ADJUSTMENT AND IMPULSE
CONTROL DISORDERS
ADJUSTMENT DISORDERS
DEFINITION
An adjustment disorder is characterized by a maladaptive
reaction to identifiable stressor that results in clinically
significant emotional or behavioral symptoms.
CLASSIFICATION
• F43.0- Acute stress reaction
• F43.1- Post traumatic stress disorder
• F43.2- Adjustment disorder
• F43.8- Other reactions to severe stress
• F43.9- Reaction to severe stress unspecified
EPIDEMIOLOGY
Adjustment disorder is thought to affect 2 to 8% of
the general population. It can affect anyone at any
age. It affects twice as many females as males.
PREDISPOSING FACTORS
I. Sociological theories
Yates suggests that, in adjustment disorders genetic
factors may influence individual risk for
maladaptive response to stress.
II. Psychosocial theories
Some proponents of psychoanalytical theory views
adjustment disorder as a maladaptive response
to stress that is caused by early childhood
trauma, increased dependency, and retarded ego
development.
III. Developmental factors
Some studies relates a predisposition to adjustment
disorders to factors such as developmental stage, timing
of the stressor, and available support systems.
When a stressor occurs, the individual doesn’t have the
developmental maturity, available systems or adequate
coping strategies to adapt, normal functioning is
disrupted, resulting in psychological or somatic
symptoms.
RISK FACTORS
Stressful life events;
• Divorce/ marital problems
• Relationships/ interpersonal problems
• Changes in situation, such as retirements, having a
baby, or going away to school.
• Adverse reactions such as losing a job, loss of loved
ones, or having financial issues
Life experiences;
• Experienced significant stress in childhood
• Have other mental health problems
• Have a number of difficult life circumstances
happening at the same time.
TYPES OF ADJUSTMENT DISORDERS
1. Adjustment disorder with depressed mood-
• Predominant depressed mood
• Fearfulness
• Feeling of hopelessness
• The individual may no longer enjoy the activities
that they did formerly.
2. Adjustment disorder with anxiety-
• Predominant manifestation is anxiety
• Nervousness
• Worry
• Problems with concentration and memory
For children, the diagnosis is usually associated with
separation anxiety from parents and loved ones.
3. Adjustment disorder with mixed anxiety and depressed mood-
Individuals with this kind of adjustment disorder
experiences both depression and anxiety.
4. Adjustment disorder with disturbance of conduct-
• Characterized by conduct in which violation of
rights of others/ major age- appropriate social
norms and rules.
• Eg; truancy, vandalism, reckless driving, fighting
and defaulting legal responsibilities.
5. Adjustment disorder with mixed disturbance of emotions and
conduct-
• Emotional disturbances
• Violation of rights of others/ major age-
appropriate social norms and rules.
6. Adjustment disorder unspecified-
• Manifestations may includes physical complaints,
social withdrawal, or work or academic inhibition
without significant depressed or anxious mood.
TREATMENT MODALITIES
Goals of treatment may includes;
To relieve symptoms associated with a stressor.
To enhance coping with stressors that cannot be
reduced or removed.
To establish support systems that maximize the
adaptation.
• Individual psychotherapy
• Family therapy
• Behavioral therapy
• Self help groups
• Crisis intervention
Psychopharmacology
• Anti- anxiety drugs
• Anti- depressants
These medications are considered as adjuncts to
psychotherapy.
NURSING MANAGEMENT
1. Dysfunctional grieving related to real/ perceived loss of any
concept of value to the individual, evidenced by
interference with life functioning, developmental
regression, or somatic complaints.
2. Impaired adjustment related to change in health status
requiring modifications in lifestyle as evidenced by inability
to problem solve or set realistic goals for the future.
IMPULSE CONTROL DISORDERS
Impulse control disorder is a class of psychiatric disorders
characterized by impulsivity, failure to resist a temptation,
an urge, or an impulse, or having the inability to not speak
on a thought.
DEFINITION
Impulse control disorders are psychological disorders
characterized by repeated inability to refrain from
performing a particular action that is harmful either to
oneself/ to others.
CLASSIFICATION- DSM IV TR
5 specific categories of impulse control disorders:
Intermittent explosive disorder
Kleptomania
Pathological gambling
Pyromania
Trichotillomania.
1. INTERMITTENT EXPLOSIVE DISORDER
DEFINITION
Intermittent explosive disorder is characterized by discrete
episodes of failure to resist aggressive impulses resulting in
serious acts or destruction of property.
- APA, 2000
EPIDEMIOLOGY
• Intermittent explosive disorder (IED) occurs most
commonly in late childhood or the teenage years.
• The disorder which is relatively rare, occurs more often in
males than in females.
PREDISPOSING FACTORS
Biological influences-
genetic-
Physiological- Perinatal trauma, infantile seizures, head
trauma, encephalitis, minimal brain dysfunction.
Psychosocial-
family dynamics-
SIGNS AND SYMPTOMS
Aggressive outbursts- feel like they can’t control their
actions during the episodes.
The aggressive outbursts are;
impulsive( not planned)
Happen rapidly after being provoked
Lasts longer tan 30 minutes
Cause significant distress.
Right before the anger outbursts, the individual may
experience-
Rage
Irritability
An increasing sense of tension
Racy thoughts
Tremors, palpitations, chest tightness.
TREATMENT MODALITIES
Individual psychotherapy
Family therapy
Psychopharmacology-
Lithium
Phenothiazines
Carbamazepines
Benzodiazepines.
2. KLEPTOMANIA
DEFINITION
Kleptomania is psychological disorder characterized by the
recurrent failure to resist impulses to steal items, even
though the items aren’t needed for personal use or for their
monetary value.
EPIDEMIOLOGY
• Onset usually in adolescence
• Rare but is thought to be more common among women
than in men.
PREDISPOSING FACTORS
Biological influences-
Brain disorders and mental retardation have been
associated with kleptomania.
Cortical atrophy on frontal region
Enlargement of lateral ventricles of brain.
Psychosocial influences-
Personal crisis
Death of a loved one.
SIGNS AND SYMPTOMS
• Inability to resist powerful urges to steal items that you
don’t need.
• Increased tension, anxiety, or arousal leading to the theft.
• Feeling pleasure, satisfaction, or relief while stealing.
• Return of urges and repetion of kleptomania cycle.
TREATMENT MODALITIES
• Insight oriented psychodynamic psychotherapy
• Behavioral therapy
Psychopharmacology-
• SSRIs
• Tricyclic antidepressants
• Lithium
• Valproate.
3. PATHOLOGICAL GAMBLING
DEFINITION
Pathological gambling is a disorder characterized by
persistent and recurrent maladaptive gambling behavior.
- APA, 2000
EPIDEMIOLOGY
• Usually begins in adolescence
• Chronic course, with periods of waxing and waning
• Common among men than women.
PREDISPOSING FACTORS
Biological influences-
Genetic-
Physiological- abnormalities in catecholamine- nor
epinephrine pathways.
Psychosocial influences-
Loss of a parent by death
Separation, divorce, or desertion
before 15 years of age.
SIGNS AND SYMPTOMS
• Lying to friends or family about gambling
• Avoid/ neglecting responsibilities
• Frequent mood swings
• Gambling to solve problems/ change mood
• Conflicts in relationships
• Seemingly irresistible urge to gambling.
TREATMENT MODALITIES
• Behavioral therapy
• Cognitive behavioral therapy
• Psychoanalysis
• ECT
Psychopharmacology-
Fluxamine
Lithium carbonate
Clomipramine
Others- antidepressants, anxiolytics.
Gambler’s Anonymous (GA)
• Organization of inspirational group therapy
• The only requirement for GA is an expressed desire to stop
gambling.
• Other groups: Gam- Anon, Gam- Anteen
4. PYROMANIA
DEFINITION
Pyromania is the inability to resist the impulse to set fires.
EPIDEMIOLOGY
• Onset usually in childhood
• Relatively rare
• Common in men than in women
PREDISPOSING FACTORS
Biological influences-
Mild metal retardation and learning disabilities
Significantly low CSF levels of 5- HIAA
Psychosocial influences-
An association is there between fire setting and sexual
gratification
Feeling of impotence and powerlessness
Poor social skills.
SIGNS AND SYMPTOMS
• Intentional, deliberate fire setting
• Tension/ arousal before fire setting
• Pleasure gratification/ release of tension after setting a fire.
TREATMENT
• Antidepressants
• Anxiolytics
• Mood stabilizers
5. TRICHOTILLOMANIA
DEFINITION
Trihotillomania is a disorder characterized by recurrent
pulling out of one’s own hair that results in noticeable hair
loss.
- APA, 2000
EPIDEMIOLOGY
• Usually begins in childhood
• Maybe accompanied by nail biting, head banging,
scratching, biting, or other acts of self mutilation.
• Relatively rare
• Common in women than in men.
PREDISPOSING FACTORS
Biological influences-
May be present as a major symptom in mental retardation,
OCD, scizophrenia, borderline personality disorder, and
depression.
Psychosocial influences-
Disturbance in mother- child relation
Fear of abandonment
Recent object loss.
SIGNS AND SYMPTOMS
• Repeated pulling of hair that causes hair loss.
• Trying multiple times to stop this behavior or do it less
often.
• Feeling that hair puling negatively affects your life
especially, work and social life.
TREATMENT MODALITIES
• Behavioral modification
• Covert desensitization
• Habit- reversal practices
• A system of rewards and punishments applied in an effort
to modify hair pulling behaviors.
Psychopharmacology-
Chlorpromazine
Amitriptyline
Lithium
Recent success with SSRIs augmented with Pimozidine has
been reported.
