IMPULSIVE DISORDERS

With a focus on pyromania and kleptomania

Hicham Baba
 Impulsive disorders
• Violate the rights of others
• Bring the individual into significant
conflict with societal norms or authority figures.

• Includes

• Oppositional defiant disorder, • Kleptomania,

• Intermittent explosive disorder • Other specified and unspecified
• Conduct disorder • Disruptive, impulse-control
• Antisocial • Pathological gambling
• Pyromania • Trichotillomania
• Skin picking
Impulsive disorders
• Two extremes:
• Conduct disorder focus largely on poorly controlled behaviors that violate the
rights of others or that violate major societal norms.
• Intermittent explosive disorder focuses largely on poorly controlled emotion,
outbursts of anger that are disproportionate to the interpersonal or other
provocation or to other psychosocial stressors.
• Intermediate in impact to these two disorders is
• Oppositional defiant disorder, in which the criteria are more evenly distributed
between emotions (anger and irritation) and behaviors (argumentativeness and
defiance).
• Pyromania and kleptomania are less commonly used diagnoses characterized by
poor impulse control related to specific behaviors (fire setting or stealing) that
relieve internal tension.
• Others do not meet the criteria for one diagnosis:
• Specified disruptive, impulse-control, and conduct disorder
• there are symptoms of conduct disorder, oppositional defiant disorder, or other disruptive,
impulse-control, and conduct disorders,
• the number of symptoms does not meet the diagnostic threshold for any of the disorders,
even though there is evidence of clinically significant impairment associated with the
symptoms
 Kleptomania - Definition

• It is a recurrent failure to resist impulses

to steal objects not needed for personal use or for monetary value.

• The objects taken are often given away, returned surreptitiously, or kept

and hidden.

• Persons with kleptomania usually have the money to pay for the objects

they impulsively steal.

• The focus is not the object being stolen, rather the act of stealing itself
 Kleptomania - Epidemiology
• Estimated to be about 0.6%.

• The range varies from 3.8-24% of those arrested

for shoplifting. Some reports indicate <5%.

• The male-to female ratio is 1:3 in clinical samples

• Ages 50M vs 35F

• Women go for psych eval; Men go to prison

• The frequency of stealing ranged from less than 1

to 120 episodes a month

Kleptomania - What happens?
• 1) Mounting tension before the act,

• 2) Gratification and lessening of tension

• with or without guilt, remorse, or depression after the act.

• The stealing is not planned and does not involve others.

• Less likely to occur if immediate arrest is probable

• Some people do not assess the chance of apprehension

• Repeated arrests lead to pain and humiliation

• Guilt and anxiety occur in these people,

• Anger or feelings of vengeance are not often seen

Kleptomania – Etiology
• Tend to appear in times of significant stress

• Losses, separations, and endings of important relationships

• Psychoanalytic writers stress on:

• The expression of aggressive impulses

• Libidinal aspect

• Considerations of the act, the object stolen and the victims of the theft

• Anna Freud theorizes that the first thefts from mother's purse indicate the degree to

which all stealing is rooted in the oneness between mother and child.

• Karl Abraham wrote of the central feelings of being neglected, injured, or unwanted.
Kleptomania – Etiology
• One theoretician established seven categories of stealing in chronically

acting-out children

• 1. As a means of restoring the lost mother-child relationship

• 2. As an aggressive act

• 3. As a defense against fears of being damaged

• (perhaps a search by girls for a penis or a protection against castration anxiety in boys)

• 4. As a means of seeking punishment

• 5. As a means of restoring or adding to self-esteem

• 6. In connection with, and as a reaction to, a family secret

• 7. As excitement (lust angst) and a substitute for a sexual act

Kleptomania – Biology and Family
• Brain diseases and mental retardation

• Focal neurological signs,

• Cortical atrophy, enlarged lateral ventricles

• Disturbances in monoamine metabolism

• Serotonin, dopamine , opioid

• 7% of first-degree relatives had OCD

• Higher rate of mood disorders has been reported in family members

 Kleptomania – Diagnosis
• Attempt to resist the impulse to steal and know that the act it is wrong and senseless.

1. Sporadic with brief episodes and long periods of remission;

2. Episodic with protracted periods of stealing and periods of remission;

3. Chronic with some degree of fluctuation (relapse-remitting)

Kleptomania – Differential Diagnosis
• Ordinary theft.
• Ordinary theft (whether planned or impulsive) is deliberate
and is motivated by the usefulness of the object or its
monetary worth.
• Some individuals, especially adolescents, may also steal on a
dare, as an act of rebellion, or as a rite of passage.
• The diagnosis is not made unless other characteristic
features of kleptomania are also present.
• Kleptomania is exceedingly rare, whereas shoplifting is
relatively common
• most are teenagers and young adults who "boost" in pairs or small
groups for "kicks," as well as goods, and do not have a major
psychiatric disorder.
Kleptomania – Differential Diagnosis
• Malingering.
• individuals may simulate the symptoms of kleptomania to avoid
criminal prosecution. Invent stories that might seem believable
• Antisocial personality disorder and conduct disorder.
• deliberately undertaken for personal gain
• degree of premeditation and planning (often with others)
• threat of harm or actual violence, particularly to elude capture
• Guilt and remorse are lacking, or patients are patently insincere
• Manic episodes or drug intoxication
• Major depression with psychotic episodes
• Psychotic episodes
• delusions or hallucinations
• Major neurocognitive disorder.
Kleptomania – Treatment
• Insight oriented psychotherapy and psychoanalysis depend
on patients' motivations.
• Insight-oriented psychotherapy
• those who feel guilt and shame
• because of their increased motivation to change their behavior.
• Behavior therapy
• systematic desensitization, aversive conditioning,
• combination of aversive conditioning and altered social contingencies
• successful even when motivation was lacking.
• Drug therapy
• SSRIs, such as fluoxetine (Prozac) and fluvoxamine (Luvox)
• Tricyclic drugs, trazodone, lithium, valproate, naltrexone, and
electroconvulsive therapy
p
 Pyromania –
Epidemiology & Comorbidities
• More common in men (8:1)
• 40% are less than 18 years old
• Associated with:
• Substance abuse (esp. alcoholism)
• Affective disorders, depressive or bipolar;
• Impulse control disorders, such as kleptomania in female fire setters;
• Inadequate and borderline personality disorders
• ADHD, adjustment and learning disabilities
• Low serotonin, hypoglycemia
• Are likely to be mildly retarded
• History of antisocial traits, such as truancy, running away from
home, and delinquency
• Enuresis
• Association between cruelty to animals and fire setting
Pyromania - Diagnosis
• Make advance preparations for starting the fire
• Indifferent or derive satisfaction from destruction
 Pyromania – Differential Diagnosis

• Other causes of intentional fire setting.

• Profit, sabotage, or revenge; to conceal a crime;
• to make a political statement (e.g., an act of terrorism or protest) - arsonist
• to attract attention or recognition (e.g., setting a fire in order to discover it
and save the day).
• Fire setting may also occur as part of developmental experimentation in
childhood (e.g., playing with matches, lighters, or fire).
 Pyromania – Differential Diagnosis
• Other mental disorders.
• Conduct disorder, a manic episode, or antisocial personality
disorder (deliberate)
• In response to a delusion or a hallucination (e.g., in
schizophrenia)
• Attributable to the physiological effects of another medical
condition (e.g., epilepsy).
• Major neurocognitive disorder, intellectual disability, or sub
stance intoxication. (Alzheimer's – do not appreciate the
severity)
 Pyromania – Etiology
• Freud – sexuality (warmth and shape)
• Abnormal craving for power and social prestige
• Venting accumulated rage over frustration caused by a sense of social,
physical, or sexual inferiority.

• About patients
• Some patients with pyromania are volunteer firefighters who set fires to
prove themselves brave, to force other firefighters into action, or to
demonstrate their power to extinguish a blaze.
• Several studies have noted that the fathers of patients with pyromania were
absent from the home.
• it represents a wish for the absent father to return home as a rescuer, to put out
the fire, and to save the child from a difficult existence.
• Females trends: promiscuity without pleasure and petty stealing,
 Pyromania – Treatment
• Children – good prognosis, complete remission possible
• Adults – not as good (deny their actions, refuse to take
responsibility, are dependent on alcohol, and lack insight)

• Behavioral approaches
• Should include supervision of patients to prevent a
repeated episode of fire setting
• Incarceration may be the only method of preventing a
recurrence
• Family therapy
References
• Kaplan & Sadock's Synopsis Of Psychiatry -11E
• DSM-V