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Impulse Control Disorders

Many psychological problems are characterized by a loss of control or a lack of control in specific situations. Usually, this lack of control is part of a pattern of behavior that also involves other maladaptive thoughts and actions, such as substance abuse problems or sexual disorders like the paraphilias (e.g. pedophilia and exhibitionism). When loss of control is only a component of a disorder, it usually does not have to be a part of the behavior pattern, and other symptoms must also be present for the diagnosis to be made.

But, there are several psychological disorders that are defined primarily by loss of control. These impulse control problems will be described here briefly:

 

Intermittent Explosive Disorder - Episodes of aggressive outbursts resulting in either destruction of property or physical assaults on others. Typically, this problem results in legal problems as well, because the individual is often charged with assault, or a domestic violence charge. 

Loss of control is an essential feature of this disorder. The individual, usually male, has had several incidents of losing control of anger, resulting in aggressive acting out, either by assaulting others, or destroying property. The degree of aggression is always out of proportion to any precipitating factors that might be present (within an argument, for example). Typically, these individuals will not take responsibility for their loss of control, instead blaming the victim, other circumstances in their life, or some third party who may have told them something or said something that "caused" their uncontrolled anger. Lack of control is a central part of the problem, and inability to accept responsibility for the aggression helps to alleviate guilt. It also prevents the individual from making any changes.

Dr. Franklin uses both behavioral and cognitive interventions of this type of control problem. In particular, anger management techniques are needed, as well as discovering a way to deflect the anger so that it can be controlled.

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Domestic Violence - Domestic violence is a particular form of Intermittent Explosive Disorder, because often these individuals only lose control within the context of a close interpersonal relationship. However, many of these individuals have a generalized anger management problem, but control it better outside their own home.  The criteria for a diagnosis of intermittent explosive disorder are almost always present in domestic violence situations, except when the violence occurs only in conjunction with substance abuse or intoxication. In those situations, the individual usually meets the criteria for a substance abuse diagnosis. Sometimes, intoxication is also a form of not accepting blame. The individual may choose to become intoxicated prior to a confrontation. This may be because of an inability to confront others.  The intoxication removes normal social restraints, and also gives the individual an excuse for loss of control.

Individuals who only lose control within relationships often attach tremendous emotional ultimatums to those relationships. If a person believes that loss of a relationship will doom them forever, then their reaction may be consistent with that belief, even if the belief is false. There are other factors influencing domestic violence that do not always occur in other social conflicts. Within a relationship, each spouse may have specific role expectations for the other spouse. That is, a man may expect his wife to behave a certain way, to think a certain way, and to respond a certain way to him. These expectations may be immature and/or irrational, although commonly held within his social group. These expectations may also serve to increase the emotional tension in the relationship, so that it surpasses his level of control. Since these expectations may not exist in other relationships, he may be able to maintain control outside of the marital relationship.

Dr. Franklin has found that the perpetrators of domestic violence rarely receive adequate psychological treatment, because they are viewed as criminals, rather than individuals with psychological problems. Because denial is often a major component of this problem, the power of the courts may act as a motivating factor to move the person into treatment, but will seldom stop the behavior without treatment.  Dr. Franklin recognizes that men who cannot control their anger have a number of psychological issues that require treatment, and that this is a mental health issue, not a criminal one. Treatment consists of behavioral self-control techniques, stress management, and cognitive therapy to change the irrational belief system that triggers the violent behavior.

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Kleptomania - This impulse control problem involves the compulsive stealing of items not needed for their monetary value. Usually, the items are not stolen to express anger or vengeance. There is usually a feeling of tension before stealing, and a sense of pleasure at the time of the theft.

A common misconception is that kleptomania is present in career thieves. This is generally not the case. Some people steal because they have no regard for the laws of society (Conduct Disorder in children and adolescents or Antisocial Personality Disorder in adults). Others may steal out of need or desperation (Adjustment Disorder with conduct disturbance).  Still others steal to support a substance abuse problem (the diagnosis would be Substance Abuse).

This is a relatively rare problem, and occurs with a much higher incidence in women than in men. It is also out of character, or as psychologists describe it, ego dystonic. This means that the person does not want to steal, and feels guilty about the behavior.  In fact, other than the focus on an illegal act, this disorder has many features in common with Obsessive Compulsive Disorder. The essential difference is that, in addition to functioning as an anxiety release, the compulsive behavior in kleptomania also results in a temporary gratification.

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Pyromania - This psychological problem primarily involves setting fires for pleasure, and experiencing a sense of relief or gratification from the experience. This does not include fires set for monetary gain, to hide criminal activity, or to express anger. The individual usually has a significant fascination with fire.

Additionally, pyromania is not diagnosed when the fire setting activity is part of another psychological problem, such as Conduct Disorder in children, or part of a psychotic process in Schizophrenia or Bipolar Disorder. This is a very rare problem, and it is usually episodic, occurring infrequently.

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Pathological Gambling - This impulse control problem consists in persistent maladaptive gambling that creates serious life problems for the individual. This is different from recreational gambling, and is diagnosed by the impact it has on your life, and by the lack of control, rather than the amount of money gambled or lost.

Individuals with this problem engage in recurrent maladaptive gambling that usually disrupts their personal life, and frequently interferes with their work as well. Some individuals develop severe financial problems, resulting in personal bankruptcy, and others engage in criminal activity to cover their financial losses (such as embezzlement). This does not include uncontrolled gambling that occurs as part of a manic episode.

There are some social differences in the pathological gambling patterns of men and women. Men usually begin a pathological gambling pattern during their teen years, while women are more likely to develop the problem when they are older.

Pathological gamblers frequently need to increase their risk to stay involved. They have often tried to stop without success, and tend to gamble as an escape from problems. In particular, they may gamble to relieve depression. They may commit illegal acts to hide their losses, and frequently "chase" their losses by making bigger bets to "get even." They may endanger their job or their family relationships because of this problem, and they will probably lie about the extent of their gambling.

Participation in Gamblers Anonymous is often helpful, but the individual should also seek psychotherapy, especially for the underlying depression.

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Trichotillomania - Pulling out your own hair habitually, to the point of seeing noticeable hair loss, and experiencing pleasure or tension relief from the behavior. This does not include hair loss as a result of medical conditions, and the disorder must result in clinical distress or impairment in life functioning.

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