Disruptive, Impulse-Control, and Conduct Disorders

Disruptive, Impulse-Control, and Conduct Disorders د.وليد عزيز العميدي
Five conditions comprise the category of disruptive, impulse-control, and conduct disorders. They include two that are associated with childhood: (1) oppositional defiant disorder and (2) conduct disorder, The remaining three disorders are intermittent explosive disorder, kleptomania, and pyromania.
Each disorder is characterized by the inability to resist an intense impulse, drive, or
temptation to perform a particular act that is obviously harmful to self or others, or both. Before the event, the individual usually experiences mounting tension and arousal. Completing the action brings immediate gratification and relief. Within a variable time afterward, the individual experiences a conflation of remorse, guilt,
self-reproach, and dread.

ETIOLOGY
Psychodynamic, psychosocial, and biological factors all play an important role in impulse-control disorders; however, the primary causal factor remains unknown. Some impulse-control disorders may have common underlying neurobiological mechanisms. Fatigue and psychic trauma can lower a person s resistance to control impulses.

Psychodynamic Factors : An impulse is a disposition to act to decrease heightened tension caused by the buildup of instinctual drives or by diminished ego defenses against the drives. The impulse disorders have in common an attempt to bypass the experience of disabling symptoms or painful affects by acting on the environment.
Biological Factors : Experiments have shown that impulsive and violent activity is associated with specific brain regions, such as the limbic system. A relation has been found between low cerebrospinal fluid (CSF) levels of 5-hydroxyindoleacetic acid (5-HIAA) and impulsive aggression. Certain hormones, especially testosterone, have also been associated with violent and aggressive behavior. Some reports have described a relation between temporal lobe epilepsy and certain impulsive violent behaviors.
Psychosocial Factors
Psychosocial factors implicated causally in impulse-control disorders are related to early life events. The growing child may have had improper models for identification, such as parents who had difficulty controlling impulses. Other psychosocial factors associated with the disorders include exposure to violence in the home, alcohol abuse, promiscuity, and antisocial behavior.

INTERMITTENT EXPLOSIVE DISORDER : Intermittent explosive disorder manifests as discrete episodes of losing control of aggressive impulses; these episodes can result in serious assault or the destruction of property. The aggressiveness expressed is grossly out of proportion to any stressors that may have helped elicit the episodes. The symptoms, which patients may describe as spells or attacks, appear within minutes or hours and, regardless of duration, remit spontaneously and quickly. After each episode, patients usually show genuine regret or self-reproach, and signs of generalized impulsivity or aggressiveness are absent between episodes. The diagnosis of intermittent explosive disorder should not be made if the loss of control can be accounted for by schizophrenia, antisocial or borderline personality disorder, ADHD, conduct disorder, or substance intoxication.
The disorder appears to be more common in men than in women.
Course and Prognosis
Intermittent explosive disorder may begin at any stage of life, but usually appears between late adolescence and early adulthood. The onset can be sudden or insidious, and the course can be episodic or chronic. In most cases, the disorder decreases in severity with the onset of middle age.
Treatment
A combined pharmacological and psychotherapeutic approach has the best chance of success. Group psychotherapy may be helpful, and family therapy is useful, particularly when the explosive patient is an adolescent or a young adult. A goal of therapy is to have the patient recognize and verbalize the thoughts or feelings that precede the explosive outbursts instead of acting them out.
Anticonvulsants have long been used, with mixed results, in treating explosive patients. Lithium has been reported useful in generally lessening aggressive behavior, and carbamazepine, valproate (Depakene) have been reported helpful. Some. Benzodiazepines are sometimes used but have been reported to produce a paradoxical reaction of dyscontrol in some cases. Antipsychotics and tricyclic drugs have been effective in some cases. Selective serotonin reuptake inhibitors (SSRIs) are useful in reducing impulsivity and aggression. Propranolol (Inderal) and other ?-adrenergic receptor antagonists and calcium channel inhibitors have also been effective in some cases.

KLEPTOMANIA
The essential feature of kleptomania is a recurrent failure to resist impulses to steal objects not needed for personal use or for monetary value. The objects taken are often given away, returned back, or kept and hidden. Persons with kleptomania usually have the money to pay for the objects they impulsively steal.
As with other impulse-control disorders, kleptomania is characterized by mounting tension before the act, followed by gratification and lessening of tension with or without guilt, remorse, or depression after the act. The stealing is not planned and does not involve others. These persons may feel guilt and anxiety after the theft, but they do not feel anger or vengeance. Furthermore, when the object stolen is the goal, the diagnosis is not kleptomania; in kleptomania, the act of stealing is itself the goal.
The male-to-female ratio is 1:3 in clinical samples.
Treatment : Behavior therapy, including aversive conditioning has been reported successful, even when motivation was lacking. The SSRIs, such as fluoxetine (Prozac) and fluvoxamine (Luvox), appear to be effective in some patients with kleptomania.

PYROMANIA
Pyromania is the recurrent, deliberate, and purposeful setting of fires. Associated features include tension or affective arousal before setting the fires; fascination with, interest in, curiosity about, or attraction to fire and the activities and equipment associated with firefighting; and pleasure, gratification, or relief when setting fires or when witnessing or participating in their aftermath. Patients may make considerable
advance preparations before starting a fire. Pyromania differs from arson in that the latter is done for financial gain, revenge, or other reasons and is planned beforehand.
Treatment : No single treatment has been proved effective; thus a number of modalities, including behavioral approaches, should be tried. Because of the
recurrent nature of pyromania, any treatment program should include supervision of patients to prevent a repeated episode of fire setting. Incarceration may be the only method of preventing a recurrence.


OTHER SPECIFIED OR UNSPECIFIED DISORDERS : The disorders are classified here as compulsions because the patients feel “compelled” to act out their pathological
behavior; they cannot resist the impulse to do so.
Internet Compulsion
Also called Internet Addiction, such persons spend almost all their waking hours at the computer terminal. Their patterns of use are repetitive and constant, and they are unable to resist strong urges to use the computer. Internet addicts may gravitate to
certain sites that meet specific needs (e.g., shopping, sex, and interactive games).
Mobile or Cell Phone Compulsion
Some persons compulsively use mobile phones to call others—friends, acquaintances, or business associates. They justify their need to contact others by giving plausible reasons for calling; but underlying conflicts may be expressed in the behavior, such as fear of being alone, the need to satisfy unconscious dependency needs, or undoing a hostile wish toward a loved one.
Compulsive Sexual Behavior
Some persons repeatedly seek out sexual gratification, often in perverse ways (e.g., exhibitionism). They are unable to control their behavior and may not experience feelings of guilt after an episode of acting-out behavior. Sometimes called sexual addiction.