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Impulse Control Disorders

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Category: Psychology

Autor: reviewessays 20 December 2010

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IMPULSE CONTROL DISORDERS

Many of the self-control disorders involve disturbances in the ability to regulate an impulse - an urge to act. People with impulse control disorders act on certain impulses involving some potentially harmful behavior that they cannot resist. Impulsive behavior in and of itself is not necessarily harmful; in fact, we all act impulsively upon occasion. Usually our impulsive acts have no ill effects, but in some instances they may involve risk. Consider the following two examples. While walking through a clothing store, a young woman decides on the spur of the moment to charge an expensive sweater which is over her budget; she may regret her decision later, but few serious consequences will result. Were she to use all her financial resources to buy an expensive sports car, the consequences would be considerably more serious. Neither of these situations is as threatening as that of another woman, who invites a man she has just met at a singles bar to her apartment where they have unprotected sex--a behavior that puts her at serious risk. People with impulse control disorders repeatedly engage in behaviors that are potentially harmful, feeling unable to stop themselves, and experience mg a sense of desperation if they are thwarted from carrying out their impulsive behavior.

Impulse control disorders have three essential features. First, people with these disorders are unable to stop from acting on impulses that are harmful to themselves or others. Some people attempt to fight their impulses and others give in when they feel the urge to act. The act can be spontaneous or planned. Second, before they act on their impulse, people with these disorders feel pressured to act, experiencing tension and anxiety that can only be relieved by following through on their impulse. Some people with these disorders experience a feeling of arousal that they liken to sexual excitement. Third, upon acting on their impulse, they experience a sense of pleasure or gratification, also likened to the release of sexual tension.

Individuals with impulse control disorders are not usually conflicted at the moment of choosing to engage in the behavior. Conflict, regret, and remorse, if they do occur, appear afterwards.

KLEPTOMANIA

You may have heard the term kleptomaniac used to describe a person who shoplifts or takes things from other people's houses. People with the impulse control disorder called kleptomania do not take things on a whim or out of economic necessity, but because they are driven by persistent urges to steal.

If you thought that a kleptomaniac was someone driven to acquire possessions, it may surprise to to learn that people with this impulse control disorder are driven by the desire to steal, not the desire to have. The main motivation for their behavior is an urge to release tension. The act of stealing provides this release and gives the kleptomaniac a temporary thrill, even though the individual regards the urge to steal as unpleasant, unwanted, intrusive, and senseless. Kleptomaniacs steal just about anything, although the most common objects include food, clothes, jewelry, cosmetics, records, toys, pens and paper, and, in some cases, money. While most kleptomaniac steal from a store or workplace, for some the behavior is limited to stealing from a particular person, perhaps someone about whom they feel intense feelings of attraction or jealousy. Keep in mind that it is not the intrinsic value of these objects that motivates the kleptomaniac to steal, but rather the act of stealing itself. In fact, most kleptomaniacs are perplexed about what to do with their acquired items. Some hoard the objects, as in the case of a woman whose closet was overflowing with thousands of inexpensive plastic combs and brushes taken over the course of several years. Others give away the items, or may even throw them in the trash. This lack of interest in the stolen items is the main feature that differentiates a typical shoplifter or burglar from a kleptomaniac.

• Theories and treatments

Although kleptomania is a fascinating psychological disorder, it has received relatively little attention from researchers, perhaps because relatively few cases come to professional attention except for those referred to forensic psychologists. Clinicians usually become aware of a person's kleptomania only when the individual is in treatment for some other psychological problem such as an anxiety disorder, psychoactive substance abuse, eating disorder, or mood disorder (Bradford & Balmaceda, 1983; McElroy et al., 1991). The fact that most kleptomaniacs seen in a clinical context also suffer from another psychological disorder raises some interesting questions. Is it possible that kleptomanic behavior is a symptom of some other disorder, possibly biologically caused? With this possibility in mind, some researchers have speculated that a serotonin deficiency might underlie kleptomania, an idea that is supported by the fact that the medication fluoxetine (Prozac), which increases serotonin in the nervous system, has been found to reduce kleptomanic behavior (McElroy et al., 1991).

In addition to pharmacological interventions, behavioral treatments are also used to help individuals control their urge to steal. In covert sensitization, the client is insstructed to conjure up aversive images during the act of stealing (Glover, 1985). For example, a kleptomaniac may be instructed to conjure up disgusting images, such as vomit, when the compulsion to steal is emerging. Alternatively, the client may be instructed to use thought-stopping techniques, in which dramatic internal cries to resist thinking about the stealing behavior serve to prevent the person from following through on the urge.

PATHOLOGICAL GAMBLING

Gambling is a common feature of everyday life. Even if you do not consider yourself a "gambler," you have probably bought a raffle ticket, scratched off the disk on a game card in a cereal package, sent a card in the mail to a sweepstakes contest, bet on your home team, or wagered a dollar with a friend that your answer to a test question was correct. Perhaps you have been to a gambling casino, where you played the slot machines or sat at the blackjack table for an hour or two. lf you have had any of these experiences, you know thrilling it can be to see your bet pay off. People who are troubled by pathological gambling have an urge to gamble that is much stronger than that of the average person, (ten end up spending their entire lives in pursuit of big wins.

• Characteristics of pathological gambling

During the late 1980s the sports world was taken by the story that one of the leading baseball figures of all time, Pete Rose, had been betting thousands of dollars a day on baseball games. Admitting his guilt, Rose publicly acknowledged that he was unable to control his gambling, despite his banishment from baseball. Pete Rose's problem brought attention to a disorder with which few Americans had been familiar.

Pathological gamblers feel unable to resist the betting impulse. Obsessed with a desire to gamble, they spend their money recklessly and engage in extreme behaviors such as lying cheating and stealing in an effort to fuel their habit. lf for some reason they are prevented from gambling, they become restless and irritable. Some pathological gamblers try desperately to stop hut find themselves unable to resist, deceiving themselves and others that if they can just recoup their losses, they will stop--a dream that never comes true. In the process, their family and work lives deteriorate as financial and legal problems resulting from their losses overtake them. Some pathological gamblers become so distraught by feelings of hopelessness that they contemplate or even commit suicide. You can evaluate your own propensity for this problem by considering how you would respond to questions from the South Oaks Gambling Screen (Lesieur & Blume, 1987) shown in Table 1 below.

It is easy to be oblivious to the prevalence and seriousness of pathological gambling unless the problem has personally touched your life. Statistics show, however, that recent growth of the number of people who have this disorder has been dramatic; thus the possibility of encountering someone with this problem at some point in your life may be greater than you think. Pathological gambling is becoming a serious problem in U.S. society; it is estimated that this disorder affects from 1 to 4 million adults (Nadler, 1985), or 3 percent of the adult population, with a greater proportion of men than women having this problem (Volberg & Steadman, 1988). Some experts believe that the increasing incidence of pathological gambling is directly related to the tremendous growth of legalized gambling enterprises. For example, state lotteries became tremendously popular during the 1980s, as did off-track betting; furthermore, the availability of casino gambling on the East Coast enticed many people who otherwise would not have had access to this form of gambling. In 1987, Americans legally bet almost $184 billion, an eleven-fold increase in little more than a decade (Gambino & Stein, 1989); in a mere 4 years the figure had risen to approximately $286 billion (Finch, 1991).

In addition to the destructive effects of pathological gambling on the individual's life, this behavior erodes the well-being of families. In an unusual survey of spouses (mostly wives) attending a national meeting of Cam-Anon (an organization analogous to Al-Anon), a number of serious problems were identified in the families of pathological gamblers, leading the vast majority to regard themselves as "emotionally ill" (Lorenz & Shuttlesworth, 1983). Many of these spouses had resorted to dysfunctional coping behaviors such as excessive drinking, smoking, under- or over-eating, and impulsive spending. Almost half of these women reported that they had experienced emotional, verbal, or physical abuse, and 12 percent said they had at attempted suicide. The children were also affected by the father’s pathological gambling; one-quarter had significant behavioral or adjustment problems in school or at home, or were involved in drug or alcohol abuse, crime, or gambling related activities. Virtually all individuals surveyed reported that their husband's gambling had caused severe financial problems that necessitated borrowing money from family, friends, or creditors. In extreme cases, they were forced to apply for welfare payments to support their families.

Clearly, although U.S. society presents many opportunities for gambling, not everyone who gambles becomes a pathological gambler. How does such a seemingly harmless pastime develop into a compulsive, self-destructive pattern? According to the late psychiatrist Robert L. Custer, who in 1974 established the first clinic for treatment of pathological gambling in the United States, a person becomes a pathological gambler through a series of stages in which gambling progresses from a relatively harmless sport to a total focus of life (Custer, 1982). In the first stage, the individual is simply a recreational gambler who enjoys gambling a social activity. The person's behavior, at this point, is indistinguishable from the gambling patterns shown by ordinary individuals who stop when they begin to lose, or set a time or spending limit on their gambling. Movement into the next stage, which is the beginning of a pathological gambling pattern, occurs when the individual begins to start winning. At this point, the gambler starts to gain an identity as a "winner," and the more often that success is encountered in gambling, the more this identity becomes reinforced.

During the early winning stage, the individual gains gambling skills, making it possible to enhance whatever luck is experienced with greater knowledge of the various strategies involved in winning. If at this point the person encounters a big win, a gain of large amounts of money in one bet, the gambler becomes propelled into a pattern of ‘addiction’ which inevitably becomes almost impossible to break. This event is so reinforcing, both financially and psychologically, that the individual becomes possessed with the need to reexperience it. The gambler is now convinced of the possession of unique good fortune and gambling skills, and starts to make riskier and more expensive bets. However, inevitably the luck does not hold out, and the person begins to lose. Whatever money was gained from the big win disappears as the losses begin to outweigh the gains. Keeping the person going is the fictitious belief that if the big win could only be repeated, all troubles would be over.

The gambler even may promise to stop after landing another big win. At this point, the individual begins to “chase” or bet more and more to recoup earlier loses. As the desperation mounts, the individual is fully launched into an intensive and all-consuming enterprise. And precisely because of this desperation, the gambler suffers a loss of judgment and bets unwisely.

In the doomed search for another big win, a cycle becomes established in which the pathological gambler has periodic wins that maintain an unreasonable optimism, but these gains never erase the debt, because for every win experienced, continued gambling leads to heavier losses. In time, the gambler's physical, psychological, and financial resources are depleted and the person considers drastic action such as suicide, running away, or embarking on a life of crime.

• Theories and treatments

We have just seen the stages that are thought to lead from recreational to pathological gambling. These stages seem to involve some of the same factors that play a role in alcohol and drug addiction, in that the individual continually seeks pleasure from a behavior that, although leading to trouble, possesses strong reward potential. The perpetual pursuit of the big win is much like the alcohol-dependent person's search for stimulation and pleasurable feelings through alcohol use, though there are some significant differences between the two. Spending money is not inherently pleasurable as is taking a psychoactive substance; also, gamblers are not reinforced during every gambling venture, whereas alcoholics do receive reinforcement each time they drink (Rachlin, 1990).

Despite these differences, both alcohol dependence and pathological gambling are addictive behaviors, and researchers continue to explore why many pathological gamblers also have substance abuse disorders (McCormick et al., 1987). Perhaps this connection-rests on the fact that like some substance abusers, pathological gamblers are looking for sensations that are new and exciting (Blaszczynski, et al., 1986). Gamblers easily become bored (Rosenthal, 1986) and crave excitement, what they call “being in action.” They are excited by the risk of losing as well as by the thrill of winning -- experiences that add to the reinforcing value of gambling.

In addition to a proneness to addiction, what other factors account for certain people becoming pathological gamblers? Several interesting personality characteristics are common to pathological gamblers; for example, male gamblers tend to be compulsive and antisocial; women with this disorder are more commonly dependent, submissive, passive-aggressive (Peck, 1986). Pathological gamblers are also narcissistic and aggressive (Dell et. al., 1981), looking to succeed through unconventional means (Tabel et al., 1986). In the survey of Gam-Anon members (Lorenz & Shuttlesworth, 1983), the wives’ description of their husbands also provide some interesting insight into the personality of the pathological gambler. Almost all the wives said they saw their husbands as liars who were irresponsible, uncommunicative, insincere, and impulsive.

In addition to these personality characteristics, it has been suggested that a large number of pathological gamblers suffer from mood disorders; in fact, there is mounting evidence that points to pathological gambling as related to mood disorder (McElroy et al., 1992). Researchers investigating the possible role of biological factors in pathological gambling have come across some interesting characteristics in people with this disorder. For example, pathological gamblers show more norepinephrine activity (Roy et al., 1988) and a greater likelihood of EEC abnormalities (Goldstein et al., 1985) than comparison subjects.

Interestingly enough, pathological gamblers believe that they are in control of the random aspects of gambling (Dickerson & Adcock, 1987). For example, when playing slot machines, pathological gambler switch machines regularly, raking time to examine a slot machine before playing on it. They carefully study facets of the machine that are unnoticed by others, such as the machine's position in a row of slot machines or how the handle feels. Mistakenly convinced that they can control the probabilities that affect the outcome of their bets, they develop grandiose ideas that lead them to become convinced of their ultimate success.

In some instances, an individual's pathological gambling may be sustained by a disturbed marital relationship. The husband's gambling may allow his wife to blame marital conflicts on her husband's gambling rather than on her own problems. Or, a husband may inadvertently urge his wife to bet if he shares her false optimism that she will magically have a big win (Gaudia, 1987). Even if a non-gambling spouse attempts to break away from the marriage, this may be made difficult by the gambler's threats or false promises. In the survey of Cam-Anon spouses, wives of pathological gamblers indicated that they had difficulty carrying through on their intent to withhold money from their husbands, and although more than three-quarters of them had indicated their desire to break out of the marriage, many remained with their spouses because they loved them and hoped they would improve. Interestingly, almost one-fifth of the wives in this study came from families in which a parent had been a pathological gambler (Lorenz & Shuttlesworth, 1983)

Like individuals who are alcohol dependent, pathological gamblers deny the extent of their difficulties and tend not to seek treatment. When they do, it is out of desperation, feeling that they have no choice because of serious financial, legal, and family problems. Even then, they must be confronted with the grave nature of their gambling problem. This approach is used in groups such as Gamblers Anonymous where members penetrate the wall of denial among each other (Franklin & Ciarrocchi, 1987).

Behavioral methods similar to techniques for treating alcohol dependence are the most commonly used. In aversive conditioning, the most frequently used behavioral method, the individual receives an unpleasant but not painful electric shock to the fingers after reading a series of phrases about gambling (McConaghy et al., 1983). For the in vivo exposure method, the individual is taken by the therapist to a gambling casino or club but allowed only to watch and not to gamble. Another method, which appears to have the greatest long-term effectiveness (McConaghy et al., 1991), is imaginal desensitization. In this form of treatment, clients are told to imagine scenes in which they feel tempted to gamble and to relax as they imagine each successive behavior involved in this particular scene. The desensitization in this procedure is comparable to that used in treating people with phobias, in that the individual learns to substitute the usual response to this situation with a new response that replaces the problem behavior. By substituting relaxation for arousal in these situations, they learn to avoid becoming distressed when not allowed to gamble, and come to recognize that they have the ability to control their addiction.

PYROMANIA

The sight of fire is fascinating to many people. If a building is on fire, most passersby skip and watch while it is brought under control. Candles and fireplaces are commonly regarded as backdrops to a romantic or intimate evening. For the very small percentage of the population who have the impulse control disorder called pyromania, fascination with fire goes beyond this normal degree of interest and becomes a compulsive and dangerous urge to set fires deliberately.

• Characteristics of pyromania

As is true with all impulse control disorders, people with pyromania cannot restrain themselves from acting on strong and compelling urges; in this case the urges involve the intense desire to prepare set, and watch fires. Before the fire, these people become tense and aroused, and upon setting the fire they experience intense feelings of pleasure, gratification, or relief. Their behavior is not motivated by financial or criminal motives, as in the case of an arsonist who reaps monetary gain through insurance fraud.

Pyromania is a rare disorder; even among fire starters, only 2 to 3 percent would be considered to be pyromaniacs (Crossley & Guzman, 1985). As with pathological gambling, pyromania is more common in males, with most showing the first signs of a pathological interest in fire during childhood (Jacobson, 1985). In numerous cases, sexual arousal has been reported to play a role in compulsive fire-setting behavior (e.g., Bourget & Bradford, 1987; Quinsey et al., 1989), pointing to the possibility that in some cases pyromania might actually be appropriately regarded as a paraphilic, fetishistic behavior. However, little systematic research has been conducted to confirm this notion.

• Theories and treatments

Most individuals with pyromania are afflicted with one or more other problems or disorders, and in most cases the disorder is rooted in childhood problems and firesetting behavior. In efforts to understand how patterns of uncontrollable firesetting begin, and in an attempt to develop early intervention programs, researchers have conducted extensive studies of firesetting in children, who set two out of every five fires (Wooden, 1985). A firesetting child does not necessarily grow up to become a pyromaniac; firesetting behavior among children and adolescents emerges from various sets of issues. Wooden (1985) delineated four types of childhood firesetters: curious youngsters who accidentally start fires while playing with matches, older problem-ridden youth who seem to be crying out for attention and help, delinquents who use fire to act out against authority, and a group with severe psychological disturbance who go on to chronic firesetting in adulthood. Among these extreme cases, Wooden delineated two personality types: the impulsive neurotic and the borderline psychotic. The impulsive neurotic is impatient, almost hyperactive, and prone to destruction and thievery. The borderline psychotic experiences mood swings, intense anger, numerous phobias, and a proneness toward violence. One of the most famous cases of an individual who engaged in this extreme form of firesetting behavior was David Berkowitz, the confessed “Son of Sam” serial murderer who was reported to have set more than 2,000 fires in New York City during a 3-year period in the mid-1970s.

Other research on children who get caught up in recurrent firesetting behavior tells us more about how these children differ from their peers (Kolko & Kazdin, 1988, 1989a, 1989b). Firesetting children have a compelling attraction to and curiosity about fire, which commonly develops as a result of their observation and modeling of adult firesetting behavior. They know more about what it takes to get fires started, and they usually have an impressive knowledge of combustible materials. In addition, family issues, particularly those pertaining to discipline, are influential factors. Parents of firesetting children are more likely to use unpredictable disciplinary styles ranging from harsh discipline to ineffective mild punishment (Kolko & Kazdin, l 989a). Child-parent relationships are commonly characterized by inconsistency, emotional disturbance, and abuse, resulting in the development of conduct-disordered behavior including firesetting (Lowenstein, 1989).

The possibility of biological contributions to pyromania is suggested by research showing lower levels of serotonin and norepinephrine in people with this disorder (Roy et al., 1988; Virkkunen et al., 1987).

Most individuals with pyromania avoid treatment, so clinicians are likely to see only those who are caught and are ordered to obtain professional help. People who are apprehended for serious firesetting are sent either to prison or to a psychiatric hospital, depending on the circumstances of their arrest and the ensuing legal proceedings. Ideally, some form of treatment will be provided regardless of the placement of the firesetter.

As there is little information on biological treatments, the most commonly employed psychological intervention for pyromania relies on behavioral principles. The most well-known of these is the graphing technique, initially developed for treating children who engage in firesetting (Bumpass, 1989). In following this method, the clinician and client construct a graph that corresponds to the individual's history of behaviors, feelings, and experiences associated with firesetting. Presumably, a visual presentation of the chronological history of this behavior enables the client to become aware of cause-effect relationships, and to become attuned to signals that the compulsion to set fires is about to strike. In response to the signal, the individual can substitute more appropriate ways to discharge tension. This technique has been effective in helping many individuals stop their firesetting, but it is only the preliminary component of a therapy that should then focus on developing more insight into this dangerous behavior.

SEXUAL IMPULSIVITY

People with sexual impulsivity are unable to control their sexual behavior, engaging in frequent and indiscriminate sexual activity. This disorder has gained widespread attention since the early 1980s, largely through the publication of a book called Out of the Shadows: Understanding Sexual Addiction by Comes (1983).

• Characteristics of sexual impulsivity

Sexual impulsivity is sometimes referred to as compulsive sexuality or sexual addiction, but these terms are misnomers (Barth & Kinder, 1987), because the main feature of the disorder involves neither a true compulsion nor an addiction, but rather a lack of control over sexual impulses. People with this disorder are preoccupied with sex, feeling uncontrollably driven to seek out sexual encounters which they later regret. This drive is similar to that reported in other disorders of self-control, involving a state in which the individual is transfixed by the need for sex. Often, sexual impulsivists engage in many sexual encounters in a brief period of time, even at the risk of disease or arrest.

As is true for other disorders of impulse control, the uncontrollable behavior of sexual impulsivists interferes with their ability to carry out normal social and occupational roles. They feel a great deal of distress about their behavior, and following sexual encounters they are likely to feel dejected, hopeless, and ashamed. Although a few sexual impulsivists are consumed by the constant need to masturbate, most seek out partners, usually people they do not know and do not remain involved with any longer than the anonymous sexual encounter.

The most detailed investigation of sexual impulsivity was conducted with a male homosexual and bisexual sample (Quadland, 1985). In this group, sexual impulsivists averaged more than 29 partners per month and more than 2,000 different sexual encounters over their lifetimes. They frequently sought sex in public settings and used alcohol or drugs with sex, and they typically had a history of few long-term relationships.

• Theories and treatments

The most tenable explanations for the development of sexual impulsivity incorporate elements of family systems and behavioral theory. Sexual impulsivity can result from either unduly restrictive attitudes toward sex or as a result of neglect and abuse in the family (Coleman, 1987). Families with extremely restrictive outlooks on sexuality foster guilt with regard to pleasure-seeking behaviors. The child becomes secretive and anxious about his or her developing sexuality. One reaction to this emotional atmosphere is to develop sexual dysfunctions, such as sexual aversion disorder. At the other extreme, the child may react by acting out in sexual ways. The more the parents attempt to repress the child's sexuality, the more the child is driven to engage secretly in sexual pursuits. By the time such children have grown into adolescence, sexual pursuit has become an uncontrollable part of their lives.

In cases of childhood neglect and abuse, the abused child feels sad and lonely, and looks to sex as a temporary relief from emotional pain. The unhappy child comes to associate sexuality with escape from a neglecting or abusing family member. Because sexual gratification is such a powerful reinforcement, it is very difficult to break the association between escape from unhappiness and sexual release. In time, the child learns to rely on sexuality and other mind-numbing activities such as overeating or substance abuse. As an adult, such an individual can become addicted to drugs or alcohol as well as sex (Schwartz & Brasted, 1985).

It is possible that some cases of sexual impulsivity are caused by abnormally high levels of testosterone that lead the individual to become hypersexual (Berlin & Meinecke, 1981; Gagne, 1981). Clearly, given the role of physiology in sexual response, biological factors are important to consider in understanding cases of sexual impulsivity.

Treatment for sexual impulsivity involves a combination of components derived from insight-oriented, behavioral, and family systems approaches. Insight-oriented therapy focuses on bringing to the surface the individual's underlying conflicts that motivate the behavior. These conflicts include resolving nonsexual problems through sexual means, needing reassurance, and feeling insecure about one’s sex role (Weissberg & Levay, 1986). Behavioral techniques, include aversive covert conditioning, in which the individual is trained to associate unpleasant images with inappropriate sexual behavior (McConaghy et al., 1985). Other techniques include behavioral contracting, substitution of alternative forms of activity, and methods to bolster the individual's low self-esteem (Schwartz & Brasted, 1985). The inclusion of family or couples therapy is important for clients whose excessive sexual behavior occurs in the context of long-term close relationships. This approach focuses on improving the communication between the client and the client's partner and restructuring their relationship to correct dysfunctional patterns of interaction that are enacted in the sexual domain (Sprenkle, 1987).

In cases involving sexual victimization of other people, antiandrogenic medication is sometimes used to reduce the individual 's testosterone level. This method involves some of the same concerns that are present in the treatment of sex offenders.

As with other disorders involving impulse control, group therapy seems to be useful in the treatment of sexual impulsivity (Quadland, 1985). The elements of a successful group approach include peer support, confrontation, and availability of an alternate social network.

TRICHOTILLORNANIA

The urge to pull out one's hair, which becomes a compulsion in people with the rare disorder called trichotillomania, may seem bizarre and far removed from the realm of everyday human behavior. In our culture, many women are self-conscious about facial hair and go to some trouble to remove it. However, for some people the act of hair-pulling develops a compulsive quality, causing them to become so preoccupied with pulling off their hair that they are oblivious to the fact that they may actually be marring their appearance.

• Characteristics of trichotillomania

Like people with other disorders of impulse control, the person with trichotillomania experiences an increasing sense of tension which is temporarily relieved by the act of hair-pulling. This problem occurs most often among women and girls, usually beginning in childhood or adolescence (Muller, 1987). People with this disorder feel unable to resist the urge to pull hair, regardless of the fact that their behavior results in bald patches and in lost eyebrows, eyelashes, armpit hair, and pubic hair. In extreme cases, some individuals swallow the hair after they have pulled it out, risking the danger that it will solidify in the stomach or intestines.

Despite physical evidence suggesting intentional hair pulling, people with this disorder tend to deny that they are engaging in the behavior. But still, they cannot resist the urges to pluck their hair. As a result, dermatologists rather than mental health professionals are typically the ones who discover the disorder. The usual scenario involves a parent bringing the child to the dermatologist because of the child's mysterious hair loss. Upon examination, the dermatologist may notice many short, broken hairs around the bald areas on the skin, indicating the hairs have been plucked. In other cases it is not a dermatological concern that brings clinical attention, but some other psychological problem; people with trichotillomania also tend to have mood, anxiety, substance abuse, and eating disorders (Christenson et al., 1991), and may come to the attention of a clinician because of one of these problems.

Although relatively few cases of trichotillomania have been officially recorded, this disorder is apparently more common than clinicians realized even as recently as the 1970s. At that time, approximately 8 million Americans were estimated to have the disorder (Azrin & Nunn, 1978). During the late 1980s, discussion of the topic appeared in newspaper articles and on talk shows, resulting in many more people coming forward to acknowledge that they suffered from this problem. Interestingly, in one experimental study comparing different treatment methods, the subjects were obtained when they called the National Institute of Mental Health after seeing the disorder described on the ABC television program 20/20 (Swedo et al., 1989).

• Theories and treatments

Trichotillomania is an intriguing disorder that is not well understood, although proponents of the major models have put forth some hypotheses about why this behavior would begin and become so resistant to change. Proponents of the biological perspective have suggested that trichotillomania is a variant of obsessive-compulsive disorder. This notion is supported by the facts that in both disorders behavior is driven by anxiety or tension, and that people with this disorder respond to various medications including lithium (Christenson et al., 1991) and antidepressants (Pollard et al., 1991), particularly clomipramine, an antidepressant that reduces obsessional symptoms (Swedo et al., 1989). While medication are effective in reducing hair-pulling behavior, their long-term effectiveness has not yet been demonstrated; furthermore, people are understandably reluctant to take medication for years when effective psychological interventions are available.

From a psychological perspective, trichotillomania is seen is as originating in disturbed parent-child relationships; an upset child who feels neglected, abandoned, or emotionally overburdened may resort to this behavior in an attempt to gain attention or to derive a disturbed form of gratification (Krishnan et al., 1985). Although this is a tenable hypothesis it does not explain why the behavior becomes so firmly established and maintained. From a behavioral perspective this pattern develops because the individual learns to associate hair-pulling behavior with relief from tension.

Behavioral treatments for people with trichotillomania fall into five categories: enhanced awareness of the behavior, reinforcement, aversive conditioning, relaxation or hypnotic techniques, and substitution with other behaviors (Ratner, 1989). In procedures geared toward enhancing awareness, the individual is encouraged to become more consciously attentive to hair-pulling behavior; this can be accomplished by keeping a record of each incident, by talking aloud about the behavior while pulling out hairs, or by asking family members to point out times when the individual is engaging in the behavior. By heightening awareness of the habit, it is assumed that the individual will develop the ability to stop the behavior before the occurrence of a hair-pulling episode.

Reinforcement techniques follow those used with any behavior a person is working to extinguish; for example, praising the individual for successful abstinence from the behavior or for improved appearance due to cessation of hair-pulling can strengthen the individual's resolve to change this behavior. Aversive techniques may involve instructing the individual to administer some unpleasant stimulus at the point of awareness of the behavior, perhaps snapping a taut rubber band worn around the wrist as punishment for hair-pulling (Stevens, 1984).

Although general relaxation techniques have not been particularly effective in helping people stop hair-pulling, more specific techniques involving hypnosis have shown promise. Effective hypnotic methods are those aimed at increasing awareness of the habit, sensitivity to the unpleasant aspects of this behavior, and the individual's feelings of personal self-control (Ratner, 1989).

Another behavioral technique involves the substitution of a more acceptable behavior such as hand-clenching for the hair-pulling (Tarnowski et al., 1987). This approach is based on the idea that if the individual is doing something that is physically incompatible with hair-pulling each time the urge arises, this more acceptable behavior will aid in the extinction of the less desirable behavior of hair-pulling. Moving beyond straight behavioral techniques to those involving cognitive-behavioral principles, some experts urge the individual to initiate inner dialogues in order to provide a warning of situations in which the behavior is likely to occur (Ratner, 1989).

INTERMITTENT EXPLOSIVE DISORDER

As is true for the other disorders of impulse control, intermittent explosive disorder involves an inability to hold back an urge that other people experience but have no serious problem restraining. The urge, in this case, is to express strong angry feelings and associated violent behaviors.

• Characteristics of intermittent explosive disorder

The behaviors found in people with intermittent explosive disorder are occasional bouts of extreme rage in which the individual becomes assaultive or destructive without serious provocation. During these episodes, these people can cause serious physical harm to themselves, other people, and property. While in the midst of an episode, they feel as if they are under a spell and some have even used terms that suggest that it is like a seizure state. Just prior to the outburst, they may feel an impending sense that something is about to happen, an experience that has been compared to the aura, or anticipatory state, that people with epilepsy experience prior to a seizure. Between episodes, people with intermittent explosive disorder show no signs of being unusually impulsive or temperamental. This rare disorder is more common among men, some of whom are imprisoned for their destructive or assaultive behavior. Women with this disorder are more likely to be sent to a mental health facility for treatment.

• Theories and treatments

Many features of intermittent explosive disorder suggest that biological factors play an important determining role, possibly in combination with environmental factors (Hamstra, 1986). For example, as we noted earlier, people with this disorder report an aura experience just prior to their outbursts similar to that of people with epilepsy. However, epilepsy does not account for this impulse control disorder (Leicester, 1982), so there must be other explanations. In one study, people diagnosed with intermittent explosive disorder were found to have abnormal patterns of insulin secretion (Virkkunen, 1986). Lower levels of serotonin and norepinephrine have also been reported (Linnoila et al., 1983; Virkkunen et al., 1989). Other features supporting a biological explanation are the unpredictability of the outbursts and the apparent lack of externally precipitating events.

Because of the belief that biology plays a central role in causing this disorder, clinicians have looked to somatic treatments (Mattes, 1985), usually augmented by behavioral interventions. In recommending medications for this disorder, clinicians turn to those used in treating aggression (Lion, 1989). For example, benzodiazepines have been used to reduce explosive behaviors in people with certain personality disorders. Medications that alter norepinephrine metabolism, including lithium and a category of medications called beta blockers, can also reduce aggressive behaviors (Eichelman, 1988).