Daily Archives: September 23, 2010

Impulse Control Disorders NOS


Impulse Control Disorders NOS generally include intermittent explosive disorder, kleptomania, pyromania, pathological gambling, and trichotillomania.

It would appear that the concept of “irresistible impulse” is troublesome because it is inherently tied to the observable behavior, thereby making it less than scientific.  The test suggests that the ICD implementation of the word “habit” may be useful since there is some implicit or explicit reinforcement value of the behaviors themselves.  Furthermore, NHW seem to be endorsing the use of “over-control mechanisms” since they can be investigated apart from the aggressive acts themselves.

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Over and above the issues of assessment, the documentation is extremely sparse at it relates to treatment.  The text did cite one particular cognitive-behavioral treatment course that I was interested in.  “Self-talk is often used to dissipate anger; self-monitoring can be employed to engender greater awareness of cues that evoke aggression and associated thoughts and feelings.  Modeling can be used to demonstrate effective problem solving, such as generating alternative solutions.  Role playing is designed to enable the child to better empathize with others.”  (Netherton, Holmes, & Walker, 1999, p. 455)  The above is a great place to start.  There is also some suggestion that SSRIs (antidepressants) may be of some use.

It has been suggested that Trichotillomania is a variant of obsessive-compulsive disorder (OCD).  It is important to distinguish trichotillomania from other dermatological issues like alopecia araeta and tinea capitis.  It is also important to access for attendant trichophaga (i.e., chewing and/or swallowing the hair) as this can lead to trichobezoars (hair casts in the digestive system).  Aside from the attendant bald spots, trichobezoars are probably the most serious health risk that is presented.   I don’t buy the psychosexual explanations for this disorder; they seem to be way out in left field.

Pathological gambling is an intense interest of mine, primarily because I used to deal cards at the casino.  This is where I digress into a story that I can’t resist telling.  I worked the graveyard shift, 10pm-6am at The Horseshoe Casino in Council Bluffs.  On this particular night I was dealing a “pit game” called Caribbean Stud.  It’s a “progressive” game that pays progressively larger amounts for better poker hands… and has the potential to pay huge if you get a straight flush or better (very rare).  On this night, a gentleman sat down and put 4 crisp 100 dollar bills on the table.  He asked for black chips, which was unusual for his level of buy in (it was only 4 chips!).  He proceeded to tell me that this was his last 400 dollars on his last credit card, and that if he didn’t win this game he was going to go home and “end it.”  I proceeded to put my hand up in the air, and told the manager I needed to check my schedule because I thought I worked at 2 tomorrow (code for, the guy in seat 2 is off his rocker).  I proceeded to tell the shift manager what had transpired, and they advised that “we should keep an eye on him.”  That’s it; I was disappointed by the apparent lack of caring on behalf of the casino to be honest.  That was the last night I dealt cards, just thinking about that guy reminds me why I don’t gamble… makes me sick just thinking about it.

“A plethora of etiological speculations have been offered for pathological gambing, including unconscious needs for punishment, latent homosexual propensities, and intermittent reinforcement with a “big win” early in the reinforcement schedule.”  (Netherton et al., 1999, p. 446)  I was suitably surprised that adult gamblers as a group appear to be heterogeneous, with no particular personality profile found to be characteristic.  I think this is an area where there is a definite lack of data… I have a “stereotypic gambling personality profile” in my head that just screams to be researched.

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Reference

Netherton, S. D., Holmes, D., & Walker, C. E. (1999). Child and adolescent psychological disorders: A comprehensive textbook. Oxford, NY: Oxford University Press.

Personality Disorders


As is often the case, the primary take away from this chapter is the value of early intervention.  “The hope is that such interventions in the lives of children and adolescents can, at least to some extent, prevent the later development of the more serious personality disorders of adult life, especially the antisocial disorders.”  (Netherton, Holmes, & Walker, 1999, p. 477)  The issue at hand is that it is difficult to translate the benefits of early intervention into public policy/services for those at risk… especially in cases where there is no definitive causal relationship between the childhood manifestations of the disorder and the adult versions.

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Clinicians are currently wary of diagnosing personality disorders in children due to the assumption that they are, by definition, enduring.  This may suggest that we as clinicians are suitably unwilling to deliver the gloomy prognosis due to the fact that it may in fact become a self-fulfilling prophecy.  However, evidence us abound that suggests that “early diagnosis improves the chances of appropriate treatment and education and results in a prognosis that is less gloomy than it might appear.”  (Netherton et al., 1999, p. 478)  I don’t understand what the issue is, I would call a spade a spade do our best to rectify the situation, but that’s just me.

The text suggests that “equivalence between personality disorders of childhood and those of adult life must rely on a similarity of essential symptoms and signs,” just as they do with with other disorders.  (Netherton et al., 1999, p. 479)  I found it ironic that Zeitlin found personality disorder symptoms to have greater continuity over time than diagnoses… doesn’t it seem like we are systematically mis-diagnosing children in an effort not to label them?  I am starting to get that impression.

Temperament is generally regarded as one of the “constitutional” building blocks of personality, and therefore is also loosely associated with personality disorders in young adulthood.  I was particularly interested in the nine dimensions of temperament that were deemed by Chess & Thomas’s New York Longitudinal Study (1984).  Among those dimensions were activity level, approach/withdrawal to novelty, positive or negative mood, threshold of sensitivity to stimuli, intensity of reactions, rhythmicity of biological function (what does this mean?), adaptability to novel situations and people (why double load novelty?), distractability, and persistence (how do you measure this, exactly?).  Please refer to the in-line comments, as they really speak to my questions on the how and the why regarding this particular study.

I found the following suggestion to be of value in the future when suggesting how can successfully modify or change their parenting methods: “Children are best socialized when parents use inductive, that is, reasoning methods but do so with an emotional charge.”  (Netherton et al., 1999, p. 486)  This really reminded me of the “teach around a behavior” cognitive method that we are taught as direct support professionals whom support individuals with developmental disabilities.  Matter of fact, it mirrors the kind of guidance I provide every day.

I was surprised that we as a society are not doing more with regard to home visitation programs for vulnerable mothers.  “Numerous experimental programs have shown that specially trained and supported home visitors can help poor, unmarried, young mothers to achieve better health for their babies, better educational and work status for themselves, and more sensitive and less punitive care for their children, with the result that the children have better early language skills, make better school progress, and have fewer later behavior problems, including antisocial interaction.”  (Netherton et al., 1999, p. 488)  Is anyone aware of any comparable programs like this in the Omaha area?  I think this would be a great community resource, something we should investigate?

Although it is not entirely clear at the present time whether this is still valid (since the text was written in 1999), there is a consistent theme in the NHW book.  “This disorder has been adequately explored in the adult population but it’s application to children has not been fully explored.”  I am beside myself with the number of disorders that we could substitute in the above sentence for “this disorder.”  It’s literally all of them.  The other thing I notices, and maybe this is more of a personal observation than anything… but if there is any single population that clinicians choose NOT to work with, its kids.  Why is that?

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Reference

Netherton, S. D., Holmes, D., & Walker, C. E. (1999). Child and adolescent psychological disorders: A comprehensive textbook. Oxford, NY: Oxford University Press.

Personality and Its Disorders


The most contemporary definition of the word personality delves “beneath” surface impressions “and turns the spotlight on the inner, less revealed and hidden psychological qualities of the individual.”  (Blaney & Millon, 2009, p. 551)  It would suffice to say that our current understanding of personality has changed tremendously since its Greek inception, and will likely continue to change as the field of psychology continues to develop.

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I really liked Millon’s acknowledgement that “perspectives come and go, wax and wane, even though scholars maintain that human behavior is explained by psychological laws that are pristine and eternal.”  (Blaney & Millon, 2009, p. 552)  I think the statement underscores how little we really know about the complexity of the human mind, further exemplifying how much more there is to learn and know about the constituent parts of personality and their interrelationships with each other.

I had not considered the limitations of the categorical model of personality.  It would appear that Millon is correct, “there are potentially as many types as there are individuals to be typed.”  (Blaney & Millon, 2009, p. 554)  This statement seems to lend credibility to the dimensional model where personality characteristics are expressed on a continuous gradient.  The dimensional model differs from the categorical in the respect that there are no residual cases, meaning everyone regardless of situation can be accounted for.  However, even the dimensional model cannot escape the weight of the categorical model, primarily because the dimensions themselves need to be anchored to a theory… a theory the will invariably choose dimensions to cover relevant categories or personality traits.

Prototypal models seem to be the latest trend because they acknowledge the synthesis between the categorical and the dimensional models.  “To be used successfully, however, the prototype requires (1) a willingness on the part of the professional to move flexibly between categorical and dimensional paradigms as utility requires, regarding each as what it essentially is- a clinical point of departure and nothing more and (2) valid criteria sets.”  (Blaney & Millon, 2009, p. 557)

On the whole, I was most impressed with the mathematical methods of data analysis.  I am suitably impressed with the factor models and their lack of a sharp division between normality and pathology.  Gray areas in which it is clearly a matter of opinion whether someone is “normal” or not seems to be the rule, not the exception.  This is especially true when we take multiculturalism into consideration.  I am particularly impressed with the fact that “factor models are explicitly mathematical and provide some assurance that they fuzzy domain of the social sciences can be quantified like the harder sciences of chemistry and physics.”  (Blaney & Millon, 2009, p. 558)  The limitation of the factor models is that the data chosen for inclusion must be supplied by the scientist… and the inclusion (or exclusion) of specific types of data introduces bias into an otherwise unbiased mathematical process.  I, too, am tempted by the feeling that something “real” is being uncovered by this factor model process… although I question the long term utility if there is no way to prove or disprove them as Millon suggests on page 561.

No conversation or essay on personality would be complete without discussing cognitive theories of personality and Aaron Beck.  I have to admit, the suggestion that cognitive schemas shape experience, and experience shapes behavior… is attractive.  The idea that schemas “introduce a persistent and systematic bias into the individual’s processing machinery” gives those of us that intend to practice psychoanalysis hope that maladaptive behaviors can be changed or modified… and it’s that hope that I am most attracted to.  (Blaney & Millon, 2009, p. 572)

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Reference

Blaney, P. H., & Millon, T. (2009). Oxford textbook of psychopathology (2nd ed.). New York, New York: Oxford University Press.