Follow attached instructions due 07/17/2022 at 6pm

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Week 7: Impulse Control Disorder

Lori Sfakios

College of Nursing-PMHNP, Walden University

NRNP 6645: Psychotherapy with Multiple Modalities Practicum

Dr. Lavon Williams

October 13, 2021

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Impulse Control Disorders

Impulse control disorders are a category of disorders that involve the inability to control

emotions and behaviors. And is most evident through impulsive aggression. Disorders in this

category include intermittent explosive disorder, kleptomania, pyromania, oppositional defiance

disorder, and conduct disorder. Intermittent explosive disorder (IED) is an example that consists

of a person’s inability to control their emotions. Intermittent explosive disorder is marked by

significant psychosocial dysfunction (Patoilo et al., 2021). Serotonin function has shown to be

altered in clients with IED when compared with healthy controls (Coccaro and Grant, 2019).

Patoilo et al. (2021) were able to further support IED as a diagnosis due to the results of their

study that significantly showed a higher response of anger by those diagnosed with IED than

healthy controls and psychiatric controls. The results of their study aligned with the premise that

persons with IED are more likely to misinterpret a social situation and exhibit anger than those

without IED. The purpose of this assignment is to complete a psychiatric evaluation and

formulate a treatment plan for a client who has the diagnosis of IED

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CC: “I just need to stay sober. I am lonely and that gets me into trouble”

HPI: Client is a 63 male diagnosed with major depressive disorder, unspecified (F33.9), generalized anxiety disorder (F41.1), opioid use disorder, severe (F11.20), and intermittent explosive disorder (F63.81). He was referred to group therapy by his primary care provider (PCP). He is currently participating in a methadone treatment program and is permitted to take home his weekly supply of bottles. He was recently asked to bring his bottles in for a recall, and he could not bring in his unused doses as he had been taking more than he should. He was honest about his misuse and reported feeling depressed. He states, “I was feeling depressed after a breakup, and I was taking extra methadone to see if it would help my mood, but it didn’t.” He reports increasing anger due to the breakup and states, “My temper gets me in trouble. I pushed my girlfriend away because I get jealous and angry.” He is currently on a selective serotonin reuptake inhibitor (SSRI) for his depression and has been on weekly group psychotherapy but would like individual therapy. He denies suicidal and homicidal ideations, auditory and visual hallucinations.

Past Psychiatric History

 General Statement: The began feeling depressed and anxious around age 25.

 Caregivers (if applicable): self

 Hospitalizations: 7 previous inpatient hospitalizations- 5 for detox from opiates beginning in 1997 and 2 psychiatric hospitalizations for depression and failed suicide attempt in 2014.

 Medication trials: failed Prozac trial due to ineffectiveness

 Psychotherapy or Previous Psychiatric Diagnosis: Diagnoses include major depressive disorder, generalized anxiety disorder, and intermittent explosive disorder. Currently in group psychotherapy. Diagnosed with depression and anxiety at age 35 at which time he first started psychotherapy. He has been in and out of psychotherapy since age 35. He has history of overdose in attempt to end his life in 2014. The client has been on medication assistance treatment for his illicit substance abuse since 2007. He reports periods of sobriety from 1999-2007 then relapsed until 2007-2009 and has now been clean from opiates and heroin for 11 years and alcohol and benzodiazepines for 7 years.

Substance Current Use and History: History of cannabis abuse and opiate abuse since age 17 and heroin use at age 33, last use in 2010. Around age 50, he began abusing alcohol and benzodiazepines. He currently smokes a pack a day; denies illicit substance use, and alcohol use.

Family Psychiatric/Substance Use History:

 No known substance abuse history and no known psychiatric history

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Psychosocial History

The client is a single 63-year-old Caucasian male that grew up in Connecticut and was raised by his biological mother and father until age 3, when his parents divorced. When his parents divorced, he lived primarily with his mother. At age 17, he began using cannabis and Vicodin pills. The client dropped out of high school in the 9th grade stating, “I hated school. I never did good in school.” He then began working various part-time jobs, and then his drug use escalated. He reports constant ‘run-ins with the law because of my anger and impulsiveness.” He has a history of assaultive behaviors, domestic violence cases, and multiple breaches of peace charges. He has never been married but has been in long-term relationships and has no children. He reports feelings of depression and anxiety around age 25, and anxiety. He reports multiple detox periods and drug relapses. He has been sober for 11 years from heroin and seven years from alcohol and benzodiazepines and is in a methadone maintenance program. Currently, the client has no legal issues. He continues to go to alcoholic anonymous meetings and narcotics anonymous meetings. He has no other activities outside the home and states, ‘the meetings keep me socially connected.” He reports being up to date with annual physical examinations, yearly dental and eye exams. He is unemployed and on disability.

Medical History: hepatitis C (remission after Harvoni treatment in 2015)

Current Medications: Methadone 190mg by mouth daily for opiate addiction/relapse prevention; Vistaril 25 mg by mouth four times daily as needed for anxiety; Cymbalta 60mg by mouth daily for depression

Allergies: no known drug allergies

 Allergies: no known drug allergies  Reproductive Hx: condoms for birth control and STD prevention; currently not sexually

active.

Review of Systems

 General: The client is a well-appearing 63-year-old who denies weight loss, fatigue, chills, weakness, and insomnia.

 HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

 SKIN: denies skin rashes and itching.

 CARDIOVASCULAR: denies chest pain, chest tightness, palpitations, or chest discomfort. No palpitations or edema.

 RESPIRATORY: denies feeling short of breath, cough, or sputum.

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 GASTROINTESTINAL: denies nausea; denies vomiting, or diarrhea, abdominal pain or blood.

 GENITOURINARY: denies difficulty urinating

 NEUROLOGICAL: denies headache, fainting episodes, paralysis, ataxia, numbness, or tingling in the extremities. He reports feeling dizzy when having a panic attack.

 MUSCULOSKELETAL: denies arthralgias, joint pain, or stiffness.

 HEMATOLOGIC: denies bleeding, or bruising.

 LYMPHATICS: denies swollen or tender nodes. No history of splenectomy.

 ENDOCRINOLOGIC: denies sweating, cold, or heat intolerance; denies excessive thirst or urination

Psychiatric Review of Systems

 Mood-reports moderate depression and loneliness, denies anhedonia, denies hopelessness, denies fatigue; denies lack of motivation

 Anxiety- reports moderate anxiety related to relationship and financial stressors  Sleep-intermittent insomnia  Psychotic Symptoms-denies delusions, denies auditory hallucinations, denies visual

hallucinations  Appetite-reports good appetite, denies weight fluctuations  Behavioral-denies legal issues  Trauma-denies childhood trauma; denies sexual abuse; denies physical abuse

Objective:

Diagnostic results: 9/08/2021-urine toxicology- positive for methadone metabolites; cocaine negative; benzodiazepine negative; cannabis negative; pcp negative; amphetamine negative

Recent EKG (6/3/2021) Normal sinus rhythm

PPD (5/17/2021) 0mm induration

Last physical 11/2020- no abnormal findings, unremarkable

Assessment

Mental Status Examination

Client is a 63-year-old male that appears well for stated age. He presents with flat affect and an anxious, tense mood. His eye contact is good; speech is pressured, increase rate; thought process

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was linear, logical, and relevant. He denies suicidal ideations and can identify a safety plan should he begin to have feelings of suicidal ideations. He denies homicidal ideations. No delusional or paranoid thought processes were observed. His attention is good; recent and remote memory are intact; the client exhibits a good fund of knowledge. He denies auditory and visual hallucinations.

Differential Diagnoses

Intermittent Explosive Disorder (F63.81)

•Criteria for intermittent explosive disorder include repetitive outbursts, verbal altercations, and acts of verbal aggression that may or may not be present with physical aggression and are out of proportion to the situation. These outbursts or acts of aggression result from impulsive responses due to an inability to resist aggressive impulses and are not typically premeditated (APA, 2013). Any other mental illness can not explain the outbursts. Generalized Anxiety Disorder (F41.1)

•Generalized anxiety disorder (GAD) is described as excessive periods of worry for a period greater than six months and the person cannot control the worry. Three or more symptoms include restlessness, insomnia, irritability, muscle tension, and sleep disturbance (APA, 2013).

Major Depressive Disorder, recurrent, moderate (F33.1)

•The criteria for major depressive disorder include symptoms such as depressed mood for most of the day, loss of interest or pleasure in activities, weight loss or gain, insomnia or hypersomnia, fatigue, poor concentration, and all must be present for two weeks or more (APA, 2013). The client’s symptoms have led to occupational and social dysfunction, and in 2014 he attempted to end his life by overdosing. The client has had multiple episodes of depression lasting longer than two weeks for the last 25+ years.

Substance Use Disorder, opioid, severe (F11.20)

•Substance use disorder is characterized by a pattern of opioid use that leads to distress and dependence in the long-term. Criteria include increasing in dose and frequency of opioids with persistent desire or cravings; opioid use that interferes with social and occupational functioning; recurrent use even in dangerous situations that may put a person at risk of harm to self and others; exhibits withdrawal syndrome when stopped abruptly (APA, 2013). The client reports excessive opioid use that resulted in criminal activity to satisfy his cravings. He reports when he could no longer afford pills; he would purchase heroin. His use started around age 17 and lasted up until 11 years ago with several periods of sobriety throughout those years.

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Unspecified Attention-Deficit Hyperactivity Disorder, (F90.8)

•Unspecified attention-deficit hyperactivity disorder (ADHD) is defined in DSM 5 as a disorder that involves distress or impairment in social, academic, and occupational functioning. According to the American Psychiatric Association (2013), five or more of the following symptoms must be present:

 failure to give attention to details  difficulty concentrating  failure to complete tasks  difficulty organizing activities  does not appreciate tasks and assignments that include great mental effort  distracted by irrelevant thoughts  exhibits restlessness and difficulty staying in one position  talks excessively  interrupts others and inappropriately intrudes

Primary Diagnoses

Intermittent explosive disorder (IED) is more common than once thought and mainly due

to the failure to report anger and aggression as a priority symptom (Gelegan and Tamam, 2018).

In the case of the client, he reports anger and angry outbursts since he was a teenager. He admits

his temperament led to many negative interactions with law enforcement and many failed

relationships throughout his life. Gelegan and Tamam (2018) report that IED is more common in

males and often leads to suicidal attempts, dysfunctional relationships, and unsuccessful

employment history. The most likely diagnosis that is appropriate at this time is IED. The client

has previously been diagnosed with major depressive disorder (MDD), generalized anxiety

disorder (GAD), and substance use disorder. These disorders are frequently co-occurring with

IED. IED was the first occurring disorder for this client, and the other comorbid diagnoses did

not come until the client was over 30 years of age. He does not recall feelings of depression and

anxiety when he was a teenager. He does report a history of being a ‘hot head and short-

tempered.” MDD and GAD may elicit some labile, irritable moods; however, not to the degree

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that the client is experiencing. He does report that when he was abusing alcohol and opiates, his

anger and outbursts were increased. ADHD is most likely not an accurate diagnosis at this time.

Although there is a high prevalence of IED in clients with ADHD, there does not appear to be

sufficient data to support this diagnosis. The client reports a history of occupational and social

functioning and an ability to complete tasks when necessary. He does report impulsiveness and

poor academic functioning during childhood and adolescent years. There is a correlation between

untreated ADHD, adverse childhood experiences, IED, and early crime involvement (Barra et al.,

2020). The client reports having a ‘normal” upbringing and denies any adverse events such as

trauma or abuse.

Case Formulation and Treatment Plan

The client will continue weekly group psychotherapy and begin individual psychotherapy

for mood stabilization and his addiction. The recommended therapeutic techniques are cognitive

behavioral therapy (CBT), escape and avoidance, and motivational interviewing. Escape and

avoidance, according to Toohey (2021), are techniques for when a person is going to enter a

situation where they may be triggered. Escape and avoidance do not solve problems; however,

they diffuse situations that may elicit an aggressive response and are a short-term solution.

Motivational interviewing is a style of communication that motivates clients to commit to a

change that is a more social, and heads into a positive direction that is highly functional (Toohey,

2021). Motivational interviewing is a long-term solution. Cognitive restructuring is useful in

addressing and changing cognitive distortions, irrational beliefs, to more realistic thoughts and

beliefs that are more valid (Toohey, 2021).

The client will continue to attend his Alcoholics Anonymous and Narcotics Anonymous

meetings on an on-going basis as this has been a vital resource to his recovery. The current

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medications include an opioid antagonist as well as an antidepressant for mood, and an

antianxiolytic for his anxiety. The client currently smokes one pack of cigarettes a day. Smoking

cessation education provided. The risks of smoking tobacco products discussed, and the client is

encouraged to discontinue. The client leads a relatively sedentary lifestyle and education

provided regarding extracurricular activities such as hiking, exercising, and walking. The

benefits of getting out into the community and becoming active were provided to the client. The

client will return in one week for his next group psychotherapy session and in one month for his

medication management appointment. He will submit random urine specimens for toxicology

testing when requested by staff. A therapist will follow-up with the client to initiate weekly

psychotherapy. Contacts for emergency services including 911 and the crisis hotline, 211, have

been given. The client has been advised to call the clinic if symptoms worsen and emergency

services at any time, he does not feel safe.

Conclusion

Clients with impulse control disorders are in danger of harming themselves and others.

The use of SSRIs in combination of CBT, specifically cognitive restructuring is beneficial for

decreasing aggressive behaviors, decreasing anger, decreasing negative thoughts, and improving

functional presynaptic serotonin transporters (Coccaro and Grant, 2019).

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References

Barra, S., Turner, D., Müller, M., Hertz, P. G., Retz-Junginger, P., Tüscher, O., Huss, M., & Retz,

W. (2020). ADHD symptom profiles, intermittent explosive disorder, adverse childhood

experiences, and internalizing/externalizing problems in young offenders. European

Archives of Psychiatry and Clinical Neuroscience. https://doi-

org.ezp.waldenulibrary.org/10.1007/s00406-020-01181-4

Coccaro, E. F., & Grant, J. E. (2019). Pharmacological treatment of impulse control disorders. In

S. M. Evans & K. M. Carpenter (Eds.), APA handbook of psychopharmacology. (pp.

267–280). American Psychological Association. https://doi-

org.ezp.waldenulibrary.org/10.1037/0000133-012

Fariba K, Gokarakonda SB. Impulse Control Disorders. [Updated 2021 Jul 31]. In: StatPearls

[Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from:

https://www.ncbi.nlm.nih.gov/books/NBK562279/

Gelegen, V., & Tamam, L. (2018). Prevalence and clinical correlates of intermittent explosive

disorder in Turkish psychiatric outpatients. Comprehensive Psychiatry, 83, 64–70.

https://doi-org.ezp.waldenulibrary.org/10.1016/j.comppsych.2018.03.003

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Patoilo, M. S., Berman, M. E., & Coccaro, E. F. (2021). Emotion attribution in intermittent

explosive disorder. Comprehensive Psychiatry, 106, 152229. https://doi-

org.ezp.waldenulibrary.org/10.1016/j.comppsych.2021.152229

Rynar, L., & Coccaro, E. F. (2018). Psychosocial impairment in DSM-5 intermittent explosive

disorder. Psychiatry research, 264, 91–95. https://doi.org/10.1016/j.psychres.2018.03.077

Toohey, M. J. (2021). Cognitive behavioral therapy for anger management. In Handbook of

cognitive behavioral therapy: Applications., Vol. 2. (pp. 331–359). American

Psychological Association. https://doi-org.ezp.waldenulibrary.org/10.1037/0000219-010