David C Hodgins, Nicole Peden - SciELO

1 Cognitive-behavioral treatment for impulsecontrol disordersTratamento cognitivo e comportamental paratranstornos do controle do impulsoAbstractObjectives: This paper reviews the cognitive-behavioral treatment of kleptomania, compulsive buying, and pathological : A review of the published literature was conducted. Results: Treatment research in all of these areas is limited. Thecognitive-behavioral techniques used in the treatment of kleptomania encompass covert sensitization, imaginal desensitization,systematic desensitization, aversion therapy, relaxation training, and alternative sources of satisfaction. Regarding compulsivebuying, no empirical support for treatment exists but common techniques examined were covert sensitization, exposure andresponse prevention, stimulus control, cognitive restructuring, and relapse prevention. Treatment of pathological gambling hasbeen successful in both group and individual format using techniques such as aversive therapy, systematic desensitization,imaginal desensitization and multimodal behavior therapy (which have included in vivo exposure, stimulus control, and covertsensitization) along with cognitive techniques such as psychoeducation, cognitive-restructuring, and relapse : There is a general consensus in the literature that cognitive-behavioral therapies offer an effective model forintervention for all these disorders.

2 An individualized case formulation is presented with a case study example. Clinical practiceguidelines are suggested for each : Impulse control disorders; Pathological gambling; Kleptomania; Compulsive shopping; Compulsive-behavioral treatmentResumoObjetivos: Este artigo revisa o tratamento cognitivo-comportamental da cleptomania, do comprar compulsivo e do jogo patol -gico. M todo: Revis o da literatura publicada. Resultados: A pesquisa sobre o tratamento em todas essas reas limitada. Ast cnicas cognitivo-comportamentais utilizadas no tratamento da cleptomania compreendem sensibiliza o encoberta,dessensibiliza o por imagina o, dessensibiliza o sistem tica, terapia aversiva, treino de relaxamento e fontes alternativas desatisfa o. Com rela o ao comprar compulsivo, n o existe amparo emp rico para o tratamento, mas as t cnicas avaliadas foramsensibiliza o encoberta, exposi o e preven o de resposta, controle do est mulo, reestrutura o cognitiva e preven o dereca da.

3 O tratamento do jogo patol gico teve xito tanto na terapia em grupo como individual, utilizando t cnicas tais comoterapia aversiva, dessensibiliza o sistem tica, dessensibiliza o por imagina o e terapia comportamental multimodal (incluindoexposi o in vivo, controle de est mulos e sensibiliza o encoberta), juntamente com t cnicas cognitivas, tais como psicoeduca o,reestrutura o cognitiva e preven o de reca da. Conclus es: H um consenso geral na literatura de que as terapias cognitivo-comportamentais oferecem um modelo eficaz de interven o em todos esses transtornos. Uma formula o de caso individualizada apresentada com um exemplo de estudo de caso. Sugerem-se diretrizes para a pr tica cl nica de cada : Transtornos do controle de impulsos; Jogo patol gico; Cleptomania; Comprar compulsivo; Tratamento cognitivo-comportamental1 Department of Psychology, University of Calgary, Calgary, Alberta, CanadaRev Bras Psiquiatr.

4 2008;30(Supl I):S31-40 David C Hodgins, 1 Nicole Peden1 CorrespondenceDavid C. HodginsPsychology Department, University of Calgary2500 University Dr. NWCalgary, Alberta, CanadaT2N 1N4 Phone: 403-220-3371 Fax: 403-210-9500E-mail: support: Alberta Gaming Research InstituteConflict of interests: NoneS31 Cognitive-behavioral treatment for impulse control disorders S32 Rev Bras Psiquiatr. 2008;30(Supl I):S31-40 IntroductionThis paper reviews the cognitive-behavioural treatment (CBT)of kleptomania, compulsive buying, and pathological drawing from the research literature, clinical practiceguidelines are suggested for each disorder. Both pathologicalgambling and kleptomania are classified as Impulse ControlDisorders in the DSM-IV-TR and the behaviors of compulsivebuying can be considered an Impulse Control Disorder NotOtherwise Specified.

5 These disorders share the characteristicsof the failure to resist urges to perform a harmful behavior,increasing tension or arousal that precedes the act, andpleasure or relief upon performing the research in all of these areas is limited. To date,there are no randomized clinical trials that examine thecognitive-behavioural treatment of kleptomania or compulsivebuying and few trials have been conducted with pathologicalgamblers. However, there is a general consensus in theliterature that cognitive-behavioural therapies offer an effectivemodel for intervention for all these ,3 CBT for kleptomaniaThe research on kleptomania is limited for several rates in the general population are unknown,1although among clinical samples, estimates for kleptomaniahave ranged from to Kleptomania is consideredrare with fewer than 5% of shoplifters classified as individuals with kleptomania do not present for treatmentunless they have been mandated as a result of getting A review of the literature failed to uncover anyclinical trials for CBT for kleptomania; however, several casestudies have used CBT in the treatment of kleptomania withpromising results.

6 The cognitive-behavioural techniques usedin the treatment of kleptomania encompass covert sensitization,imaginal desensitization, systematic desensitization, aversiontherapy, relaxation training, and alternative sources ofsatisfaction. CBT has largely replaced psychoanalytic andpsychodynamic therapies in the treatment of terms of individual CBT, there have been several casestudies with clients who have benefited from this early research, behavioural techniques were favored. Covertsensitization combined with exposure and response preventionwas used to treat a man with Over a four-monthperiod, the client attended seven sessions where he wasdirected to imagine stealing and the consequences of stealingsuch as being seen by a store manager, approached by security,handcuffed, put in a police car, going before the judge, andthe feelings of embarrassment. For his exposure task, he wasinstructed to go to stores and imagine that the manger andsecurity were watching him.

7 The man reported a reduction instealing behaviors, but noted no change in his urges to follow-up was use of covert sensitization in the treatment ofkleptomania is well documented in other case studies. Theeffectiveness of covert sensitization in a 30-year-old womanwith compulsive shoplifting was The client wasdirected to practice the covert sensitization technique tentimes a day and whenever she felt the urge to steal. Theclient imagined herself in a situation where she was havingan urge to steal and imagined the possible consequences ofstealing such as the process of being caught and arrested(being handcuffed, put in police car, appearing before thejudge) and having the family and neighbors find out (possiblylosing her family). Following five weekly sessions, the clientnoted that her urges were nearly diminished and after a 14-month follow-up, she reported having one lapse.

8 Of note,this study employed a thought stopping technique as a controlfor non-specific effects of the covert sensitization; followinga week of thought-stopping, the client reported an increasein the frequency, duration and intensity of shoplifting urgesand a decrease in her ability to resist the temptation. Theauthors, therefore, caution the use of thought stopping forthe treatment of sensitization was also used over four sessions witha 56-year-old woman who had a history of daily was instructed to imagine that as she approached atempting item she became increasingly nauseous, and asshe picked up the item, vomited, and was witnessed by She was also directed in stimulus control ( ,bring a shopping list when shopping and leave her usual bag for shoplifting at home). Only one lapse was reportedover a 19-month follow-up desensitization was used with two clients who werehospitalized for depression and whose kleptomania symptomsdid not respond to antidepressants or insight-oriented were taught progressive muscle relaxation andinstructed to imagine each step that led to the act of stealingwhile the therapist provided the suggestions that the client isable to identify the behavior as destructive, that the urge canbe controlled, and end the scene without one study reported on the use of systematicdesensitization in the treatment of kleptomania.

9 In that study,a 24-year-old female with kleptomania was successfully treatedover 16 sessions with systematic Multipletempting situations were used to construct a hierarchy, withitems arranged in order of increasing anxiety and probabilityof eliciting a stealing response. A ten-month follow-up revealedno incidents of cognitive-behavioral techniques have also beenexamined in the treatment of kleptomania as well. In onecase study, a 25-year-old woman, who was stealing daily,received instruction on the aversive breath holding six weekly sessions, the client was directed to hold herbreath until she felt mild pain whenever she experienced anurge to steal or an image of herself stealing. Over a 10-weekfollow-up period, the client reported three lapses, a substantialdecrease from her daily stealing different approach provided alternative sources ofsatisfaction to a client with a 20-year history of shop liftingand comorbid The client claimed that her kleptomaniawas in response to feeling depressed, as well as the need forpurpose and excitement.

10 Over a five-month period, her weeklysessions consisted of helping the patient identify activities thatwould increase self-fulfillment and provide excitement andpleasure. She was also instructed to practice relaxationtechniques. The client reported that her urges decreased andeventually disappeared, and no incidents of stealing werereported over a 2-year follow-up period. She also noted markedreduction in obsessive-compulsive and depressive study12 reported on 12 individuals with kleptomaniawho received behaviorally oriented interventions. Most patientsRev Bras Psiquiatr. 2008;30(Supl I):S31-40S33 Hodgins DC & Peden Nalthough the application of this approach to individualpatients was not There were two case studieswhere cue exposure with response prevention was subjects presented with comorbid panic disorder andagoraphobia and responded well to treatment withclomipramine, but reported no effect on their compulsivebuying.