Introduction to impulse control disorders and their treatment

Impulse control disorders (ICDs) are conditions where individuals struggle to resist urges to perform harmful actions, such as gambling disorder or kleptomania (an uncontrollable urge to steal). Effective management often combines biological and psychological approaches to reduce these urges and promote healthier behaviours.

Biological treatments for impulse control disorders

Biological treatments focus on using medications to alter brain chemistry, particularly in areas related to reward and impulse regulation. This approach is based on the idea that ICDs involve overactive dopamine systems, which drugs can modulate to restore balance.

Types of drugs used

• Selective serotonin reuptake inhibitors (SSRIs) - These medications increase levels of serotonin in the brain, helping to stabilise emotions and reduce impulsive actions.
• Mood stabilisers - Drugs that help control extreme mood swings, which can indirectly lessen the intensity of urges in ICDs.
• Topiramate - Specifically used for kleptomania, this anticonvulsant drug reduces excitability in the brain.
• Opioid antagonists - These block opioid receptors in the brain, preventing endorphins from producing the reinforcing effects that maintain compulsive behaviours.

Key study: Grant et al. (2008) on opioid antagonists

Grant et al. (2008) explored how opioid antagonists could treat gambling disorder, a type of ICD where individuals compulsively gamble despite negative consequences. The study highlighted that these drugs work by blocking the euphoria from gambling, making it less reinforcing.

Method

• This was an experimental study using randomised controlled trials with an independent measures design and double-blind procedures.
• Data were collected through structured interviews, semi-structured interviews, questionnaires, and psychometric tests.
• Independent variable - Participants were randomly allocated to low, moderate, or high doses of nalmefene or naltrexone (both opioid antagonists) or a placebo.
• Dependent variable - Changes in scores on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), a questionnaire adapted for gambling that measures the severity of urges and behaviours.
• Sample - Around 284 outpatients diagnosed with pathological gambling from 15 psychiatric centres; all had gambled in the past two weeks.
• Procedure - Initial structured interviews identified any comorbid conditions. Gambling severity was assessed with Y-BOCS. Participants then underwent a drug trial, which lasted up to 18 weeks, with follow-up measures taken afterwards.
• Controls - Participants had no prior use of these medications and were not on interacting drugs. Ethics were addressed through informed consent, minimising placebo group size, and screening to exclude those at risk of harm.

Results

• Positive outcomes were linked to three factors: a family history of alcoholism, stronger baseline urges to gamble, and older age (where placebo effects were reduced).
• Opioid antagonists were more effective for those with a family history of alcoholism and intense urges, compared to those without these traits.
• Younger participants showed improvements possibly due to placebo effects.

Conclusions

• Opioid antagonists are particularly effective for gamblers with a family history of alcoholism, as these individuals may have a stronger euphoric response to behaviours like gambling.
• Stronger urges predict better drug efficacy, while results in younger people might stem from expectation rather than the drug itself.

Evaluation

• Strengths - High validity from double-blind procedures, where researchers assessing Y-BOCS were unaware of group assignments or family histories, reducing bias. The diverse sample in the nalmefene group supports generalisability across ages and ethnicities.
• Weaknesses - Relies on self-reports for family history, which may be inaccurate due to incomplete knowledge. No long-term follow-up means we don't know if benefits persist, as family history might only predict short-term gains.

Psychological therapies for impulse control disorders

Psychological therapies, often based on cognitive-behavioural principles, aim to change thought patterns and associations linked to impulses. These methods use learning theories to create new responses.

Covert sensitisation

Covert sensitisation applies classical conditioning to link unpleasant feelings with impulsive urges. This leads to aversion, where the thought of the behaviour triggers negative emotions that suppress the impulse.

How it works:

1. Therapists guide clients to visualise disturbing images (unconditioned stimuli, like scenes of shame or disgust) that naturally evoke unpleasant responses (unconditioned responses).
2. These images are repeatedly paired with thoughts of the target behaviour (e.g., stealing or gambling).
3. Over time, the target behaviour alone emits the negative feelings, overriding the original urge.

Key study: Glover (1985) on covert sensitisation

• Aim - Glover (1985) examined covert sensitisation for kleptomania through a detailed case study.
• Method - Case study of a woman with long-term daily kleptomania. Four therapy sessions involved muscle relaxants and self-hypnosis to enhance imagery vividness, focusing on scenes like vomiting or being stared at judgmentally. She practised visualisations multiple times daily at home. Follow-ups occurred at three, nine, and nineteen months.
• Results - Urges and stealing decreased significantly. Occasional thefts no longer provided tension relief. She maintained daily visualisation exercises and gained confidence to shop alone. By nineteen months, no relapses occurred.
• Conclusions - Vividly imagining unpleasant outcomes effectively reduced stealing urges, demonstrating the therapy's potential for long-term management.
• Strength - Supported by cross-case analysis, such as Kohn and Antonuccio (2002), who treated a 39-year-old man with lifelong stealing successfully using similar methods.
• Weakness - Limited generalisability, as findings from one woman may not apply to broader populations with different demographics.

Imaginal desensitisation

Imaginal desensitisation uses guided imagery to reduce tension and urges by associating relaxation with triggers.

How it works:

1. Therapists create personalised scripts based on client interviews, identifying triggers and venues for the behaviour.
2. Clients learn progressive muscle relaxation (PMR), a technique involving tensing and relaxing muscle groups to achieve deep calm.
3. Scripts progress through six stages: initiating the urge, planning to act, arriving at the venue, generating arousal, having second thoughts with boredom/guilt, and experiencing negative outcomes or alternatives.
4. Clients practise two to three times daily for five to seven days a week, tracking progress.

Key study: Blaszczynski and Nower (2003) on imaginal desensitisation

• Aim - Blaszczynski and Nower (2003) provided guidance on using imaginal desensitisation for gambling disorder.
• Method - Case study of "Mary," a client with long-term gambling issues who lost $25,000 in casinos. The therapist developed a script based on her life stressors, divided into six stages (e.g., feeling lonely at work leading to casino visits, then shifting to boredom and guilt).
• Results - The study detailed the script but did not report long-term outcomes for Mary.
• Conclusions - Personalised scripts help therapists guide clients through relaxation and reframing, potentially reducing gambling urges.
• Strength - Provides qualitative data with a detailed example script, aiding therapists in creating effective interventions.
• Weakness - Lacks evidence on post-treatment progress, leaving uncertainty about expected outcomes.

Issues and debates in treating impulse control disorders

Treatments for ICDs raise broader psychological questions about how we approach mental health, balancing simplicity with complexity.

Reductionism versus holism

Reductionism simplifies ICDs to biological factors, like using opioid antagonists to block brain receptors, ignoring sociocultural influences. In contrast, Grant et al. (2008) adopts a holistic view by considering multiple factors like family history and urges, providing a more complete picture of treatment efficacy.

Idiographic versus nomothetic approaches

Nomothetic approaches seek general laws, as in Grant et al. (2008), which uses large samples to predict drug effectiveness across groups. Idiographic methods focus on unique cases, like Glover (1985), offering deep insights into one person's recovery without claiming broad applicability. This debate highlights the trade-off between general predictions and personalised understanding.