Impulse control disorder happens when a person often unable to resist the sudden, forceful urge to do something that may violate the rights of others or conflict with societal norms. These impulsive behaviors may occur repeatedly, quickly and without consideration of the consequences of the actions.

1. JUHIN J
2nd YEAR MSC(N)

2. OBJECTIVES
At the end of this session, you will get clear understanding about;
• What is meant by impulse control disorder
• Epidemiology of impulse control disorder
• Classification of impulse control disorder
• Intermittent explosive disorder
• Kleptomania
• Pyromania
• Trichotillomania
• Nursing process

3. INTRODUCTION
Impulse control disorder happens
when a person often unable to resist the sudden,
forceful urge to do something that may violate
the rights of others or conflict with societal
norms.
These impulsive behaviors may occur
repeatedly, quickly and without consideration of
the consequences of the actions.

4. EPIDEMIOLOGY
• The lifetime prevalence rate for intermittent explosive disorder is
estimated to be around 5 to 8 percent; more common in men.
• The prevalence rate of kleptomania is 0.6%; more common in female
(1:3).
• Pyromania is more in men than women.

5. CLASSIFICATION
Intermittent explosive
disorder
Pyromania
Kleptomania
Trichotillomania

6. INTERMITTENT EXPLOSIVE DISORDER
• Patients with intermittent explosive disorder have discrete
episodes of losing control of their aggressive impulses.
• These episodes can result in severe assault or destruction
of property.
• The episodes appear within minutes or hours, lasting for
less than 30 minutes.
• The episodes can have serious psychosocial
consequences, including job loss, interpersonal
relationship problems, school expulsion, divorce,
automobile accidents, or jail.
• After each episode, patients usually show genuine regret
or guilt.

7. ETIOLOGY - IED
➢ Genetic: -
• First degree biological relaitves
➢ Childhood: -
• Childhood exposure to violence
• Child neglect
• Aversive childhood parenting
• Physical abuse in childhood
➢ Physical: -
• Prefrontal cortical dysfunction
• Disordered brain & limbic
system
➢ Biological: -
• High CSF testosterone
concentrations
• Antiandrogenic agents

8. COMORBIDITY - IED
• More than 80% meet the criteria of another psychiatric disorder
• Increased risk of self-harm
COURSE & PROGNOSIS - IED
• Begin at any age of life, usually appears between late adolescence and early
adulthood.
• Onset - Sudden or insidious
• Course - Episodic or chronic
• More common in men than women

9. CLINICAL MANIFESTATION - IED
The key feature of this disorder is an aggressive outburst that has a
rapid onset.
• Persistently repeated maladaptive behavior
• Failure to resist the impulse
• Preceded by a period of tension
• Followed by a period of release

10. DIAGNOSTIC EVALUATION - IED
➢ History collection: -
▪ Developmental history
▪ Family history
▪ Social history
▪ Psychiatric history
▪ Previous episode
▪ Past experience- alcohol use disorder,
violence and emotional instability.
➢ Mental status examination: -
▪ Anxiety
▪ Guilt
▪ Depression
➢ Laboratory examination: -
▪ Biochemistry – Liver and thyroid
function test, fasting blood glucose
▪ Urinalysis- drug toxicology
▪ Syphilis serology
➢ MRI -
▪ May reveal changes in the prefrontal
cortex which is associated with loss of
impulse control

11. DIAGNOSTIC CRITERIA - IED
• Significant distress and impairment of functioning
• Discrete episodes of failing to resist aggressive impulses resulting in serious
assaultive acts or property destruction
• Degree of aggressiveness grossly out of proportion to provocation or stressor
• Not better accounted for by another psychiatric disorder; not a direct
physiologic effect of a substance or general medical condition

12. MANAGEMENT- IED
➢ Pharmacological:-
▪ Beta-blockers(Propranolol, metoprolol)
▪ Anti convulsants (Carbamazepine,
Valproic acid)
▪ Antidepressants (Tricyclics, SSRI)
▪ Lithium
▪ Antianxiety agents (Lorazepam,
Alprazolam, Buspirone)
▪ Phenytoin
➢ Non- Pharmacological: -
▪ Group psychotherapy
▪ Family therapy
▪ Cognitive behavior therapy

13. KLEPTOMANIA
• In kleptomania, individuals cannot resist the urge to
steal, and they independently steal items that they
could easily afford.
• These items are not particularly useful or wanted. The
underlying issue is the act of stealing.
• They feel tensed before the act, followed by gratification
and lessening of tension after the action.
• The theft is not planned and does not involve others.
• They may feel guilt and anxiety after the theft, but they
do not feel anger or vengeance.

14. ETIOLOGY - K
➢ Genetic: -
• First degree relatives with
alcohol use disorder
• Relatives with OCD
➢ Neurotransmitters:-
• Serotonin
• Dopamine
➢ Physical: -
• Brain damage
• Head trauma
• Frontal lobe lesions
• Cortical atropy
➢ Psychological: -
• Anxiety & Stress
• Dementia

15. COMORBIDITY - K
• High lifetime comorbidity of major mood and anxiety disorders
• Reported with high rates of suicide
COURSE & PROGNOSIS - K
• Begin in childhood
• Onset - adolescence
• Course - chronic
• Frequency of stealing- one to multiple episodes/ month
• More common in women

16. CLINICAL MANIFESTATION - K
The essential feature of kleptomania is recurrent, intrusive, and
irresistible urges or impulses to steal unneeded objects.
• Persistently repeated maladaptive behavior
• Failure to resist the impulse
• Preceded by a period of tension
• Followed by a period of release

17. DIAGNOSTIC CRITERIA - K
• Recurrent failure to resist impulse to steal object that is not needed
• Increased tension before theft
• Pleasure, gratification, or relief at time of theft
• Theft not related to anger or vengeance; not in response to delusion or
hallucination
• Not better accounted for by another psychiatric disorder

18. MANAGEMENT- K
➢ Pharmacological:-
▪ Antidepressants (SSRI, Tricyclics)
▪ Trazadone
▪ Lithium
▪ Valproate
▪ Naltrexone
➢ Non- Pharmacological: -
▪ Behavior therapy
▪ Insight oriented Psychotherapy
▪ Psychoanalysis
▪ Cognitive behavior therapy
▪ ECT

19. PYROMANIA
• Patients with pyromania repeatedly and deliberately set
fires.
• They feel an urge to do this and feel relief or pleasure
after doing this.
• They typically are fascinated with all aspects of fires.
• They may make considerable preparations before starting
the fire.
• Their curiosity is evident, but they show no guilt.
• They may gain satisfaction from the resulting
destruction.
• They leave apparent clues.

20. ETIOLOGY - P
Less number of studies
➢ Neurotransmitters: -
• Serotonin
• Nor-epinephrine
➢ Psychological:-
• Substance use disorders

21. COMORBIDITY - P
• Significantly associated with substance use disorder, affective disorders,
depressive/ bipolar
• Reported to have increased suicidal thoughts
COURSE & PROGNOSIS - P
• Start setting fires in adolescence or younger adulthood
• Frequency and intensity- increase over time or wax & wane
• Course – Unknown, few studies suggest that it may be chronic
• Mostly in men with weaker social skills and learning difficulties

22. CLINICAL MANIFESTATION - P
The essential feature of pyromania is setting fire,
• Persistently repeated maladaptive behavior
• Failure to resist the impulse
• Preceded by a period of tension
• Followed by a period of release

23. DIAGNOSTIC CRITERIA - P
• Multiple episodes of deliberate and purposeful fire setting
• Fascination with, interest in, curiosity about, or attraction to fires
• Pleasure gratification or tension relief with fire starting, watching its effects
or participating in aftermath
• Not done for monetary gain; expression of ideology, anger, or vengeance;
concealing criminal activity; improving living conditions; or as a response to
hallucination or delusion
• Not better accounted by another psychiatric disorder

24. MANAGEMENT- K
➢ Pharmacological:-
▪ SSRI
▪ Lithium
▪ Naltrexone
▪ Valproate
▪ Carbamazepine
▪ Clonazepam
▪ Olanzapine
➢ Non- Pharmacological: -
▪ Problem solving skill training
▪ Parenting training
▪ Cognitive behavior therapy
▪ Behavior contracting with token
reinforcement
▪ Relaxation exercises

25. TRICHOTILLOMANIA
• Trichotillomania is chronic, self-destructive hair pulling
those results in noticeable hair loss, usually in the
crown, occipital, parietal areas, eyebrows and
eyelashes.
• The patient has an increase in tension immediately
before pulling out the hair or when attempting to resist
the behavior. After the hair is pulled, the person feels a
sense of relief.
• A hair-pulling session can last several hours, and the
individual may ritualistically eat the hairs or discard
them.
• Hair ingestion may result in the development of a hair
ball, which can lead to anorexia, stomach pain,
obstruction. Instead of pain, these persons experience
pleasure and tension release.

26. ETIOLOGY - T
Very less number of studies
• Unknown
• Alteration of brain activity
• Obsessive compulsive disorder

27. COURSE & PROGNOSIS - T
• Onset – Children before 5 years of age and in adolescence
• In children, often occurs along with thumb-sucking
• Progression of the condition appears to be unpredictable

28. DIAGNOSTIC CRITERIA - T
• Recurrent pulling of one's hair with subsequent hair loss
• Brief episodes throughout day or sustained periods of hours
• Increased during stress and relaxation periods
• Increased tension immediately before act and with attempts to resist urge
• Gratification, pleasure, or relief with act
• Not better accounted for by another psychiatric disorder; not the effect of a
general medical condition

29. MANAGEMENT- T
➢ Pharmacological:-
▪ SSRI- Clomipramine, Imipramine
▪ Dopamine agonist - Haloperidol

30. NURSING PROCESS
Ineffective
coping
• Some text here
• Some text here
Low self
esteem
• Some text here
• Some text here
Sleepless
ness
• Some text here
• Some text here
Ineffective
impulse
control
• Some text here
• Some text here
Risk for
violence
• Some text here
• Some text here

31. 1. Risk for injury related to, dysfunctional family system, possible genetic and
psychological influences.
Outcome criteria: Client will not harm others or the property of others.
Nursing Interventions:
• Convey an accepting attitude towards the patient.
• Maintain a low level of stimuli(low lighting, few people, low noise level) in patient’s
environment.
• Remove all potentially dangerous objects from the patient’s environment.
• Maintain and convey a calm attitude.
• Help patient to recognize the signs that tension can be increased.
• Explain the patient, in what way staffs will intervene after explosive behavior occur to protect
patient and others. (Tranquilizing medications, restrains, isolation)
• Administer medications as per order.

32. 2. Ineffective impulse control related to internal or external stimuli as
evidenced by a pattern of rapid, unplanned reactions.
Outcome criteria: Client will verbalize adaptive ways to cope with stress
Nursing Interventions:
• Support client in his/her effort to control impulse.
• Ensure that a non-judgemental attitude is conveyed and criticism of the behavior is avoided.
• Assist the patient in habit-reversal therapy(HRT).
• Keep immediate surrounding low stimuli(dim lighting, few people).
• Practice stress management techniques: deep breathing, meditation, stretching, physical
exercise, listening to soft music.
• Offer support and encouragement when setbacks occur.

33. 3. Ineffective coping related to, possible hereditary factors, physiological
alterations, dysfunctional family or unresolved developmental issues.
Outcome criteria: Client will be able to delay gratification and use adaptive coping
Nursing Interventions:
• Help client gain insight into his/her own behaviors.
• Talk about past behaviors with client.
• Discuss behaviors that are acceptable by societal norms and those they are not.
• Work with the client to increase the ability to delay gratification
• Help client to identify and practice more adaptive strategies for coping with stressful life
situations.

34. SUMMARY

35. REFERENCES
Books:
• Lalitha.(2015). Mental Health and Psychiatric Nursing. P. 438
• Norman, Lee, Carol. Psychiatric Nursing (5th Edition). P. 461-465
• Kaplan Sadock’s Synopsis.(2022). (12th ed.). P. 1758-1778
• Louise Rebraca.(2012). Basic Concepts of Psychiatric Mental Health Nursing (8th ed.). P. 621-623
• Subash Indra Kumar.(2014). Psychiatry and Mental Health Nursing. P. 647-663
Journals:
• Journal of endocrinological investigation, Increased prevalence of impulse control disorder symptoms
in endocrine diseases treated with dopamine agonists: a cross-sectional study, Vol 44(8), 2021, P.
1699-1706
• Journal of Neurology, Neurosurgery & Psychiatry, Sleep and REM sleep behaviour disorder in
Parkinson’s disease with impulse control disorder, Vol 89, 2018, P. 305-310

36. SUMMARY