Clinical Psychology

Impulse Control
Disorders
A-Level Psychology

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Table of Content
01 02 03
Diagnostic Explanations Treatment and
criteria management

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 01
Diagnostic
Criteria

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Introduction
● Impulse control disorders involve build up in tension that is relieved when the person engages in a
specific behaviour, which they feel an irresistible urge to carry out.
● This pleasure experienced afterwards is short-lived, however, and the longer-term impact of these
behaviours often leads to significant distress and dysfunction, including financial and personal
losses.

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Kleptomania
● Rare condition
○ 0.6% of population
● Develop at any age
● More common in females than males
● Characteristics
○ Recurrent, irresistible urge to steal
○ Rarely do it because they want/need the item. Might even throw away or give the item to
others.
● Only 4% of a sample of shoplifters met the criteria of kleptomania (Bradford and Balmaceda, 1983)
● Thefts are often carried out unplanned, in response to a building sense of tension that is released
when item(s) are stolen (a form of negative reinforcement)
● Majority of people with kleptomania suffers from depression and anxiety due to their shame and
guilt.
● Diagnostic criteria:
○ Doctors must rule out all other possible causes of stealing such as hearing voices that are
asking them to steal.

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Pyromania
● People that have fascination with fire.
● Also fascinated by equipment for starting, accelerating and extinguishing fires, including firefighters,
fire engines and fire alarms.
○ Also fascinated by equipment for starting, accelerating and extinguishing fires, including
firefighters, fire engines and fire alarms.
● Repeatedly and intentionally light fires, but they do not always intend to cause damage.
● May feel an urge to start a fire.
● Tension builds until a fire is lit and is released once a fire has been started. Experiences pleasure as
the fire grows. Very rare condition, although between 3% and 6% of psychiatric inpatients are
thought to meet the criteria for diagnosis (Burton et al., 2012).
● Age
● A of onset: : relatively young (i.e. teenage years), with the severity of the condition increasing over
time.
●
● Risk factors
○ Boredom, stress, feelings of inadequacy, conflict at home and/or school
● Disorders such as mood substance disorders are common (90% of people with pyromania saying
they feel intensely guilty and more than 30% are suicidal). 6
Gambling disorder
● Increasingly prevalent due to the legalisation of online gambling in many countries across the world.
● Prevalence in the US: 4% (Black and Shaw, 2019).
● Also involves a build-up of tension, relieved through placing a bet regardless of the medium.
● When the new version of the ICD was published in 2018, gambling disorder was reclassified from an
impulse control disorder to an addiction disorder, alongside gaming disorder (WHO, 2018).
○ Research has demonstrated that, people who engage in excessive gambling and gaming often
show a similar profile of physical and behavioural signs and symptoms.
○ Griffiths (1993) found signs of tolerance in regular gamblers whose heart rates returned to
normal significantly faster than non-regular gamblers, following placing a bet.
■ Regular gamblers would need to gamble longer or with more money to experience the
same level of arousal as the non-regular gamblers.
○ 65% gamblers experienced withdrawal symptoms when abstaining from gambling, such as
insomnia, headaches and upset stomach, and in fact these symptoms were worse for
gamblers than people with substance addictions (Rosenthal and Lesieur, 1992).

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Gambling disorder
● To be diagnosed:
○ Must demonstrate impaired control over their gambling, such as where and when this
happens, how often and how much they bet.
○ Gambling will take priority over other activities necessary for typical daily functioning
○ Find it difficult to stop despite significant negative consequences.
○ Persistent or recurrent gambling will have been exhibited for at least 12 months (can be less in
severe and obvious cases)
○ Need to eliminate mania as the cause of excessive gambling, which can be common in people
with bipolar disorder.

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Measuring impulse control disorders
The Kleptomania Symptom Assessment Scale (K-SAS)
● Kleptomania is a relatively under-researched disorder.
● There is only one scale which measures the severity of symptoms: the Kleptomania Symptom
Assessment Scale, K-SAS.
○ 11-item self-report scale
○ Requires the respondent to consider their thoughts, feelings and actions over the past week.
○ Each item is scored from 0–4
○ The maximum score is 44;
■ Score of over 31 is said to have severe symptoms
■ Score of over 21 is classified as moderate
■ Most people with this disorder score between 22 and 37.
● Used to assess changes in severity of symptoms over time (Grant et al., 2003).

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10
Measuring impulse control disorders
Evaluating K-SAS
● Strength
○ Only takes around ten minutes to complete
○ Does not need any special training to administer or score this questionnaire
○ Covers all aspects of kleptomania, including thoughts, urges, behaviour and distress
(Hollander and Berlin, 2007).
■ Diagnosis can be made quickly, meaning the person can be referred for treatment
without delay.
○ Use of quantitative data
○ Use of a standardised procedure
■ More objective diagnosis.
● Weakness
○ Self-report questionnaire, so people may not tell the truth about their symptoms.
■ People with kleptomania are often deeply ashamed of their urges and actions, meaning
they are likely to under-report the true extent of their disorder.

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Measuring impulse control disorders
Issues and debates on K-SAS
Idiographic versus nomothetic
● Large amounts of data have been collected over the years in order that people’s scores can be
compared with normative data and judgments made about whether symptoms are mild, moderate
or severe, thus allowing people to be prioritised for treatment using relatively objective quantitative
data.
● However, this approach means that symptoms may be seen ‘out of context’, i.e there is no
explanations of why a person has been stealing. Case studies use more than one approach to
gathering data (triangulation) meaning that it is possible to gain information using idiographic
methods such as interviewing to ask open questions, which help practitioners to understand the
‘why’ as well as the ‘what’.
● For example, in Glover’s case study (Glover, 1985) the information about the woman’s husband’s
conviction for embezzlement may have helped the doctor to decide on a suitable form of therapy
for her.
● Quantitative data alone may not be as helpful in this respect, suggesting that the K-SAS should only
be one part of the information obtained about a client.
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 02
Explanation

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 Early dopamine research
Biological
explanation:
Anticipation
dopamine
Explanations Reward deficiency syndrome

Behavioural explanation:
positive reinforcement
Psychological Cognitive explanation:
explanations Miller’s feeling-state theory

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Biological explanation: dopamine
Early dopamine research
● Olds and Milner (1954) placed rats in a Skinner box with
access to a lever.
○ Pressing the lever led to electrical stimulation of
different brain regions.
○ Septal region and nucleus accumbens, both rich
in dopamine receptors, were stimulated.
○ Rats pressed the lever up to 2000 times an hour
when these areas were stimulated.
○ These regions are important reward centers as
they triggered pleasure (‘high’) in the rats.
● This is an example of operant conditioning: behavior
is repeated based on its consequences.
● Further studies (Olds, 1956) showed rats tolerated
painful shocks to press the lever.
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Biological explanation: dopamine
Anticipation
● Recent research shows animals have increased dopamine activity before performing behaviors that
were previously rewarded.
● This demonstrates classical conditioning: the sight of the lever (conditioned stimulus) causes the rat
to experience a ‘high’ (conditioned response).
● The association forms between the lever (conditioned stimulus) and electrical stimulation of the
septal region and nucleus accumbens (unconditioned stimulus).
● The euphoria (intense pleasure) is biologically caused by the release of high levels of dopamine.

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Biological explanation: dopamine
Reward deficiency syndrome
● Comings and Blum (2000): Impulse control disorders may result from low dopamine levels in brain
regions like the striatum.
● This deficiency results from an interaction between genes and environmental factors (Williams and
Potenza, 2008).
● People with impulse control disorders are more likely to carry the A1 allele, which reduces the number
of D2 dopamine receptors (Blum et al., 1996).
● Fewer D2 receptors making it harder for dopamine to bind and communicate in the brain, leading to
behaviors like fire-starting, stealing, overeating, or compulsive shopping.

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Biological explanation: dopamine
Evaluation
● Strength:
○ Supported by research evidence
■ In a study, 51% of people with gambling disorder carried the A1 allele, compared to only
25% of the general population (Comings et al., 1996; Blum et al., 1996).
■ The A1 allele was even more common in those with severe gambling symptoms.
■ This supports the role of dopamine in gambling disorder, but it is unclear if the same
applies to kleptomania or pyromania.

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Biological explanation: dopamine
Issues and debates: Application to Everyday Life
● Strength:
○ Dopamine explanation has important applications to everyday life.
■ People with Parkinson’s disease often develop impulse control disorders, especially after
treatment.
● Parkinson’s is linked to low dopamine levels and is treated with drugs that increase
dopamine (dopamine agonists) (Weintraub et al., 2006).
● This knowledge helps patients make informed decisions about their medication.
● Regular monitoring of those prescribed dopamine agonists can help prevent the
development of impulse control disorders.

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Biological explanation: dopamine
Issues and debates: Nature versus nurture
● Weakness:
○ Focusing solely on the A1 allele (nature) as a cause of impulse control disorders may overlook
the role of the environment (nurture).
■ The 'Rat Park' experiment showed that rats in poor environments were more likely to
become addicted to morphine than those in enriched environments (Alexander et al.,
1981).
■ This highlights that even if someone is genetically predisposed to addiction, the
environment plays a key role in triggering these behaviors.
■ Understanding the interaction between nature and nurture can help individuals recognize
the power of small lifestyle changes in starting their recovery journey.

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Biological explanation: dopamine
Issues and debates: Determinism versus free will
● Biological explanations tend to overlook the role of free will.
○ Although people with impulse control disorders report an uncontrollable urges to engage in
their specific compulsions, with the right support, people with impulse control disorders can,
and do, take control of their lives, actively choosing and creating environmental experiences
that support their recovery.
○ Explanations that focus too exclusively on genes and neural pathways minimise the role of
personal agency presenting a rather pessimistic viewpoint, which could be damaging to
sufferers and their families.

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Biological explanation: dopamine
Issues and debates: Reductionism versus holism
● Weakness of the biological explanations is that they tend to present an overly reductionist view, which
may mean people underestimate the role of cognitive and social factors in driving impulsive
behaviour.
○ A person may inherit certain genes that predispose them towards a dopamine deficiency,
however the expression of these genes is dictated by environmental experiences.
○ For example Archer et al. (2012) identify numerous environmental factors, including prenatal
tobacco exposure, maternal depression and childhood bullying all of which could affect the way
the developing brain responds to stress therefore indirectly increasing the probability of
impulse control disorders in later life.

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Psychological explanation
Behavioural explanation: positive reinforcement
● Skinner’s theory of operant conditioning states that behaviours that are rewarded will be repeated.
● In Olds and Milner (1954), the behaviour of the rats was rewarded using electrical stimulation of
reward pathways in the brain, resulting in compulsive lever pressing.
● In humans, the act of placing a bet, slotting a coin into a machine or scraping the surface from an
immediate-win scratch card may occasionally be reinforced by the thrill of a win, or even a near-miss
(Chase and Clark, 2010).

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Psychological explanation
Behavioural explanation: positive reinforcement
● What is more difficult to explain is why the losses, which far outweigh the wins when gambling, do not
inhibit (stop) the behaviour.
● However, this can also be explained by Skinner’s research with rats.
○ Initially, he undertook experiments where the rats were rewarded every time they pressed the
lever. This is known as continuous reinforcement.
○ Next, he experimented with partial reinforcement schedules. Here, the rats were only rewarded
for some of their lever presses.
○ The schedule that led to the highest response rate was a variable ratio schedule, whereby
rewards were unpredictable.
● Skinner believed that behaviours such as excessive gambling could be explained in the same way.

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Psychological explanation
Behavioural explanation: positive reinforcement
● Furthermore, the anticipation of a win
learned through previous experience can
also become rewarding in itself.
○ Skinner showed that this variable
ratio reinforcement schedule is highly
resistant to extinction, meaning even
in the absence of any reinforcement,
the learned behaviour persists.

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Psychological explanation
Evaluating Behavioural explanation: positive reinforcement
● Weakness:
○ Fails to acknowledge the role of negative reinforcement.
■ Impulse control disorders are characterised by building a sense of tension and anxiety
before the act, which is immediately relieved when the compulsion has been enacted.
■ This view is supported by Blaszczynski et al. (1986), who state that gambling is driven by
the desire to avoid ‘noxious physiological states and/or dysphoria mood’.
■ This is important as understanding the function of the behaviour for the individual is key
to helping the person to break the habit.

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Psychological explanation
Evaluating Behavioural explanation: positive reinforcement
● Strength:
○ The focus on nurture explains findings that cannot easily be explained by biological
explanations alone.
○ Allele 1, which codes for D2 dopamine receptors, is associated with impulse control disorders,
but not everyone who carries one or even two copies of this allele develops an impulse control
disorder as such variants only minimally increase the risk.
○ This suggests that environmental/learning experiences may also be necessary for a person with
a genetic vulnerability to actually develop an impulse control disorder

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Psychological explanation
Cognitive explanation: Miller’s feeling-state theory
● State-dependent memory
○ = When we are in a certain emotional state, we begin to retrieve memories from the last time we
were in the same state.
● Addictive memory (AM) (Miller, 2010)
○ = Memories for past experiences relating to the problem behaviour in people with impulse
control disorders.
○ Eg: When a person with pyromania feels tense and anxious, they may remember that the last
time they felt tense and anxious, they started a fire. The recall of the fire triggers recall of the
sense of euphoria associated with fire-starting (feeling-state).

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Psychological explanation
Cognitive explanation: Miller’s feeling-state theory
● Feeling-states may include sensations and thoughts as well as feelings like empowerment and control.
○ If these feelings are typically missing in a person’s life, they may be more vulnerable to
developing an impulse control disorder as the feelings are so powerful and motivating.
○ Memories can also be context-dependent, meaning specific people, objects and events may
trigger a feeling-state which triggers the compulsive behaviour
■ Eg: The sight of items associated with fire-starting may trigger a feeling-state, which
generates the irresistible urge.
■ When the person does start a fire, the same sense of relief is triggered and the memory
is strengthened and becomes a more powerful motivator for future behaviour. A sense of
shame and anxiety may quickly develop following the behaviour but unfortunately this
then triggers the feeling-state again, creating a vicious cycle.

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Psychological explanation
Evaluating Cognitive explanation: Miller’s feeling-state theory
● Weakness:
○ Most evidence to support it comes from case studies, such as that of John, a man with
gambling disorder.
■ John’s positive feeling-state was tied to a memory of winning $16,000 and he reported
positive feelings around belonging with the other people at the casino, but he also
revealed to Miller that his father used to call him a ‘loser’ and he felt that no-one liked
him. Reduction of these negative feeling-states had also become strongly associated
with gambling.
■ Case study evidence tends to be unreliable as it is often based on unstructured
interviews and cannot be generalised as John’s experiences are unique to his personal
circumstances and only relate to gambling disorder.

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Psychological explanation
Evaluating Cognitive explanation: Miller’s feeling-state theory
● Weakness:
○ Counter-argument:
■ O’Guinn and Faber (1989) have also provided detailed qualitative data from compulsive
shoppers that clearly supports the role of positive feeling-states.
● For example, ‘...the attention I got in there was incredible. She waited on me very
nicely’ and ‘I know the UPS drivers in my neighbourhood really well. They all wave
and say hello by first name.’ The participants also refer to physiological arousal and
sensations (e.g. sweating, heart racing) as they describe the process of shopping
in contrast to the pleasure of the actual purchases.
■ The social elements, such as feeling in control and ‘belonging’, can make people with low
self-esteem especially vulnerable to compulsive shopping.
● In O’Guinn and Faber (1989), self-esteem was significantly lower in the compulsive
shoppers than in a matched control group.

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Psychological explanation
Issues and debates: Individual and situational explanations
● Strength:
○ Acknowledges the role of both individual and situational factors in triggering impulsive acts.
■ The case study of John points to events in his life (e.g. his father calling him a loser) that
created negative feeling-states, which were reduced through gambling, but it also takes
into account situational factors acting on people at the time the urges arise.
■ Here, compulsive shoppers spoke of the behaviour of shop assistants and delivery
drivers who unwittingly helped to create a positive-feeling state that strengthened their
impulsive behaviour.
■ Helpful in identifying a variety of possibilities for treatment.

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 03
Treatment and
management

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 Drugs and placebo (Grant et
Biological
al, 2008)
treatment

Treatments

Covert sensitisation

Psychological Imaginal desensitisation

treatment

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Drugs and placebo (Grant et al, 2008)
Context
● Morphine connects to opioid receptors in the brain, which reduces the sensation of pain.
● When morphine (or our body’s natural endorphins) binds to these receptors, it blocks GABA.
○ GABA usually helps to control dopamine levels (dopamine is the brain chemical that makes us
feel pleasure).
○ But, with GABA blocked, dopamine levels rise a lot, which can make us feel euphoric (extremely
happy or “high”).
○ To stop this extreme dopamine increase, doctors created opioid antagonists.
■ Opioid antagonists also bind to opioid receptors, but they don’t block GABA.
■ With GABA still able to control dopamine, there’s no huge surge in dopamine—keeping
dopamine levels balanced and preventing euphoria.

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Drugs and placebo (Grant et al, 2008)
Aim and hypothesis
● Aim:
○ To investigate factors that predict the effectiveness of opiate antagonists in the treatment of
gambling disorder.
● Hypothesis:
○ Opiate antagonists would be more effective for people with a family history of alcoholism
(since they have stronger urges to gamble and euphoria in response to alcohol) compared with
people with no family history of alcoholism (weaker gambling urges and a less pronounced
response to alcohol).
○ People with less severe gambling urges may experience a placebo effect.

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Drugs and placebo (Grant et al, 2008)
Methodology
● Two randomised control trials (a meta-analysis)
○ Double-blind
○ placebo-controlled experiments
○ independent measures.
● Data collection techniques
○ Structured
○ Semi-structured interviews
○ Questionnaires
○ Psychometric tests

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Drugs and placebo (Grant et al, 2008)
Methodology
● Sample:
○ 284 American participants
○ Diagnosed with pathological gambling
■ Using:
● DSM-IV
● Scored five or more on the South Oaks Gambling Screen (SOGS)
○ 48% female
■ None were pregnant or breastfeeding and all used regular contraception.
○ There were 207 outpatients from 15 psychiatric centres who participated in a 16-week trial of
nalmefene.
○ The remaining 77 participated in an 18-week trial of naltrexone. All had gambled in the past two
weeks and gambled more than once a week. None had used either of the trial drugs before.

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Drugs and placebo (Grant et al, 2008)
Procedure
● Participants were randomly assigned to of these groups:
○ Placebo
○ Low dose (nalmefene 25mg, naltrexone 50mg)
○ Medium dose (nalmefene 50mg, naltrexone 100 mg)
○ Higher dose (nalmefene 100mg, naltrexone 150mg)

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Drugs and placebo (Grant et al, 2008)
Procedure
● Variables:
○ Comorbid diagnoses
■ Assessed using a structured interview.
○ Severity of gambling disorder symptoms
■ Assessed before and after treatment
■ Using a modified version of the Yale-Brown Obsessive-Compulsive Scale.
■ A decrease of more than 35% was classified as a positive response to treatment.
○ Daily functioning, anxiety and depression
■ Assessed using questionnaires
■ A semi-structured interview was used to collect information about family history of
psychiatric diagnoses, including alcoholism in first-degree relatives.

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Drugs and placebo (Grant et al, 2008)
Results
● Demographic
○ Average age of onset was 29, but there was an average of 11 years (range 1–40) between
starting to gamble and being diagnosed.
○ 30% had attended Gamblers Anonymous
19% had previously sought professional help for their gambling.
○ 48% played non-strategic games (eg: slots and bingo)
16% played only strategic games (eg: blackjack and poker)
36% played both non-strategic and strategic games
○ 24% met criteria for mood disorders
7% for anxiety disorders
3% for eating disorders
42% were regular tobacco user

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Drugs and placebo (Grant et al, 2008)
Results
● Response to opiate antagonists and placebos
○ Initially, the data from the two drugs were analysed separately but as the findings were so
similar, the researchers decided to analyse the data from each trial together to increase the
sample size.
○ Only family history of alcoholism was robustly associated with a positive response to
treatment outcome.
■ Stronger baseline ‘urge to gamble’ scores were mildly associated with positive treatment
response to the higher doses of both drugs.
○ Younger participants were more likely to respond positively to the placebo, which was 30%
less effective for every ten years in participant age.

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Drugs and placebo (Grant et al, 2008)
Conclusions
● Family history of alcoholism and, to a lesser extent, strength of urges to gamble are associated with a
positive response to opiate antagonists as a treatment for gambling disorder.

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Drugs and placebo (Grant et al, 2008)
Methodological strengths and weaknesses
● Strength:
○ The double-blind, placebo-controlled design, increases validity.
■ Y-BOCS test used to assess symptom severity was administered by a researcher who
was unaware of the condition to which the participant had been allocated and the
outcomes of the screening measures.
■ Had the researcher been aware of this information, differences in the way they
interacted with each participant could have unintentionally conveyed their expectations
about the efficacy of the treatment. This could have affected participants’ expectations
about the efficacy of their treatment, thus increasing the placebo effects.

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Drugs and placebo (Grant et al, 2008)
Methodological strengths and weaknesses
● Strength:
○ Sample
■ Representative of the target population
● Nalmefene participants were recruited from 15 treatment 6 centres
● Aged 19–72
● Range of people of different ethnicities, marital status and employment status
● Not applicable to naltrexone,
○ Fewer participants
○ 90% Caucasian
○ Only from one geographical area (Minnesota, USA).

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Drugs and placebo (Grant et al, 2008)
Methodological strengths and weaknesses
● Weakness:
○ Family history of alcoholism was self-reported in semi-structured interviews and so may not be
valid.
■ As this information is personal/sensitive, participants may not have accurate knowledge
regarding all of their first-degree relatives, especially if those relatives are deceased or if
they were adopted.
■ The reliance on self-reported data without checking secondary data means the
importance of family history of alcoholism may be over- or underestimated as a
predictor of positive response to opiate antagonists.
■ The use of semi-structured interviews makes this part of the study difficult to replicate
as the interviewers will have asked different questions depending on the interviewees
responses.

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Drugs and placebo (Grant et al, 2008)
Methodological strengths and weaknesses
● Weakness:
○ Grant et al. (2008) did not conduct a follow-up assessment after the 16- and 18-week trial
periods had finished.
■ Family history of alcoholism may, only have been predictive of short-term positive
effects of opiate antagonists.
■ One or more of the other variables may have been indicative of relapse/remission over
the longer term.
● This sort of data is crucial as relapse is a common feature of gambling disorder.
● Opiate antagonists stop the person experiencing euphoria and help people to
‘break the habit’ as the behaviour no longer has positive consequences. However, if
the person is not motivated to take the medication each day, they may relapse
once the trial was over and there was less support available.

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Drugs and placebo (Grant et al, 2008)
Ethics
● Approved by the institutional review board of the University of Minnesota.
● Written informed consent was provided by all participants after potential risks had been explained.
● Participants were given information about alternative treatments.
● Unlike some studies, the number of participants who received a placebo only was much lower than
the active treatment groups (1:3), meaning as many people as possible were treated without
compromising the design of the study.
● All participants were carefully screened to ensure that no-one would be at additional risk of physical
or psychological harm.
○ People with unstable medical conditions, people taking medications that could interact
negatively with the opiate antagonists and people with various psychiatric conditions and/or
suicidality were all excluded.

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Drugs and placebo (Grant et al, 2008)
Issues and debates: Application to everyday life
● These findings should help health professionals to ask questions that will help them to make more
informed decisions about the best drugs to offer to people with gambling disorders.
● Asking simple questions about family history is a quick and cheap way to gain valuable information
that will help inform the patient of the probability of a positive response to the medication.
● Opiate antagonists may still work for people without any family history of alcoholism, but it may be
helpful to use a different drug in the first instance.

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Drugs and placebo (Grant et al, 2008)
Issues and debates: Idiographic versus nomothetic
● Nomothetic approach; the objective was to draw conclusions about factors that predict the efficacy
of opiate antagonists that can be applied universally to people with gambling disorder.
○ Information about many possible factors was gathered, including age of onset, type of gambling
and tobacco use.
○ All data was quantitative (data is based on averages drawn from groups of people rather than
focusing on the unique treatment journeys of individuals)
○ Taking an idiographic approach could help to provide a more detailed understanding of the
experience of taking medication and the impact that it has on individuals and their family
members.

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Drugs and placebo (Grant et al, 2008)
Issues and debates: Reductionism versus holism
● The focus on biological factors is reductionist.
○ Without additional support to develop coping mechanisms, people may quickly relapse if they
stop taking their medication.
○ Although the behaviour may no longer feel rewarding, underpinning beliefs remain the same.
○ This suggests that pairing opiate antagonists with psychological therapies that focus on stress
management and coping skills may provide a more comprehensive treatment package.

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Covert sensitisation
Uses classical conditioning
● If behaviour can be learnt, they can also be unlearnt.
● Create unpleasant associations with the behaviour the person wishes to stop (eg., stealing, gambling
or fire-starting).

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Glover (1985)
Case History
● 56 y/o married woman
● Been stealing everyday for 14 years
● A year before her stealing began, her husband was found guilty of embezzlement
○ He received a big fine and took a new, low-paid job
○ Lost her friends (“melted away”)
○ Taken extra work to support them
● Mainly stole from supermarkets on her lunch break
● Resented her husband’s behaviour and unable to forgive him
● Been prescribed antidepressants over the years

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Glover (1985)
Symptoms
● Walking every morning with compulsive thoughts about stealing
● Attempts to resist the thought, which she found repugnant
● Giving in to the urge to steal and taking items for which she had no need, such as baby shoes
● Described her urges as “overwhelming” and wished she was “chained to a wall” to stop her from
stealing

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Glover (1985)
Methodology
● Attended 4 covert sensitisation sessions (once every two weeks)
● Previously, she tried to cure herself by imagining she was being arrested and prosecuted with her
therapist.
○ She decided to use imagery relating to vomiting.
■ Therapist encouraged her to imagine approaching items in a shop, as though she were
about to steal them, but then to imagine herself vomiting.
■ Imagine other shoppers staring at her.
■ Imagine the vomiting stopping as she replaced the items that she was about to steal.
■ Continue to do the visualisations several times a day as a homework.
● First 2 sessions
○ Muscle-relaxing medication was used to help her to fully immerse herself in the imagery
● Last 2 sessions
○ Used self-hypnosis, which she felt increased the vividness of her visualisations

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Glover (1985)
Methodology
● Therapist encouraged her to not shop without a strict ‘shopping list’.
● Therapist advised her to leave the bag that she had previously used for stealing at home.
● After two months of treatment, she had a follow-up once every three months to reassess her
progress.

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 Glover (1985)
Results
Months since Progress
therapy began

After 4 sessions over 2 Compulsion with stealing and urges to steal were reduced
months Stole on 2 occasions (took five low-value items from 4 shops) - vast improvement still

3-month follow-up Continued homework exercises several times a day

More confident to shop alone

9-month follow-up Stole a bar of soap from a chemist’s supermarket (did not relieve her tension like previously)

19-month follow-up No further relapse

More cheerful, confident, outgoing, no longer avoiding social contact due to shame, shop alone,
rarely thought about stealing
If she did think of stealing, it was no longer overwhelming (felt unwell but relieved by walking away
from the tempting items)

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Glover (1985)
Conclusions
● Impossible to know exactly which aspects of the therapy were most effective in helping the woman
to overcome her kleptomania
● The woman suggested that her urge to steal was reduced by her ability to clearly imagine the
unpleasant scenes

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Glover (1985)
Evaluation
● Weakness
○ Not representative of the population
■ Her unique experience - husband’s embezzlement
■ Her unique emotions - shame with what he has done
■ Her ability to create vivid imagery
● Strength
○ There are evidences showing that this therapy is effective with other types of client
■ 39 y/o man who had been stealing from 6 y/o

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Glover (1985)
Issues and debates: Idiographic vs nomothetic
● Uses idiographic approach
○ Uses only qualitative data
■ Readers can determine the extent to which the client’s experiences may be
transferable to other clients and therapists
● There are a lot of important details:
○ Client was highly motivated
○ Made active choices regarding vomiting instead of police involvement
○ Made active choices regarding self-hypnosis instead of relying on muscle
relaxants
■ Can be personalised to meet client’s need
■ Unable to make generalization

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Covert Sensitisation
Evaluation
Strength:
● Supported by research evidence
● Research showed that a disorder that has been around for several decade can be treated in as little
as two months
● Better than taking medication
○ Medication has side effects such as nausea, vomiting, stomach pain.
Therapy may be intense and unpleasant but only for a brief period.
○ Medication might lead to relapses after discontinuation.
Glover showed that the woman is still doing well for more than a year after the therapy ended.

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Covert Sensitisation
Evaluation
Weakness:
● Relies on the person being able to imagine scenes in detail to prompt unpleasant emotional and
physical sensations
○ People with neurodiversity might find it difficult (especially those with aphantasia - unusual
condition which means that people are unable to willfully bring images to mind)
■ Wicken et al (2021)
● People with aphantasia have flattened physiological responses when listening to
frightening stories, suggesting that this therapy would be ineffective for people
with impulse control disorders who also have aphantasia

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Imaginal desensitisation

● For people with impulse control disorders, specific environmental cues often trigger irresistible
urges to engage in compulsive behaviours.
● Imaginal desensitisation uses relaxation-based imagery to reduce the strength of these urges, by
reducing excitement and physiological arousal relating to the triggering stimulus.
● The therapy empowers the client through developing coping skills and building a sense of self
efficacy.
● It is based on McConaghy’s (1980) Behaviour Completion Mechanism, an idea which suggests that
compulsive behaviours are repeated because the person never completes a full behavioural
sequence, which leads to tension and the urge to carry out the behaviour again.
● Imaginal desensitisation works by helping the person to imagine a full behavioural sequence and all
the feelings that go with it in order to reduce urges, behaviour and the tension that reinforces the
habit.

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Imaginal desensitisation
Progressive muscle relaxation
● Sessions typically take place in a quiet room and begin with four to five minutes of PMR
○ Tensing different muscle groups while breathing in and relaxing the muscles while breathing out.
● This technique can bring about a state of relaxation that means anxiety cannot interfere with the
person’s concentration during the session.
● Once learned, it can also be applied in situations which trigger arousal and urges.
○ Example:
■ A shopping bag that has been previously used for stealing may become a cue
(conditioned stimulus).
■ Seeing the bag increases arousal and triggers the urge.
■ PMR may help the person to quickly regain a sense of calm, neutralising the urge to steal.

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Imaginal desensitisation
Guided imagery
● Used to reverse physiological arousal to the point where the stimulus no longer leads to the same
bodily response, making way for alternative, more adaptive responses.
● Can be highly personalised and scripts are typically written for each client based on their own
personal circumstances.
● Designed to evoke a range of feelings and thoughts, ultimately emphasising the negative
consequences of the behaviour.
● In a session, the person will listen to the script, either read by the therapist in person or via an
audio-recording.
○ Scripts usually comprise six scenes or stages separated by a few minutes of PMR.
○ The regular PMR helps to maintain a state of deep relaxation throughout the script.
● Therapists typically prepare two or three different scripts each focusing on a different sequence of
events linked to the target behaviour. These may focus on different triggers, venues, etc.
○ If clients have similar behaviours to previous clients, therapists may sometimes use a generic
script – that is, one that is not specific to any particular client, but may be useful in many
situations.
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Imaginal desensitisation
Designing a script
● During the initial session, the therapist will use open questions to identify typical behavioural
sequences linked to the onset of urges.
● Some environmental cues may be easy to identify, such as radio adverts for the lottery, but personal
cues, such as ‘feeling lonely’, can be more difficult.
● Clients may be asked to monitor urges before the initial discussion using handouts to identify cues.
● The therapist will then break the sequence of events into four to six scenes that lead up to the target
behaviour, such as awareness of urge, collecting required items for the behaviour, travelling to the
venue where the behaviour will take place and starting the behaviour.
● Next, the therapist will write a personalised guided imagery script of approximately 20 minutes,
including the six stages.
● This script will then be used in face-to-face sessions with the client and made into an
audio-recording for use between sessions.

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Imaginal desensitisation
Homework
● Clients are asked to participate in guided imagery two to three times a day for five to seven days,
recording their progress on specially prepared handouts provided by the therapist.
○ A minimum of 15 sessions within seven days, with each 20-minute session being completed at
the same time each day, such as first thing in the morning, late afternoon and before bed.
● The handouts are designed to track the guided imagery sessions, as well as monitoring strength of
urges and any incidents of the target behaviour.
● Clients may only have two or three face-to-face sessions with the therapist,
○ One to inform the design of the script
○ Another to practise the relaxation strategies and run through the script, plus details of how to
practise at home to greatest effect
○ One further session to check on the client’s progress and to see whether the script needs
modifying.

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Imaginal desensitisation
Blaszczynski and Nower (2003)
● Case history
○ Mary Doe was a 52-year-old, divorced, American mother of two grown-up children.
○ A bookkeeper and lived alone.
○ Her fascination with gambling began while watching her grandmother play cards as a child.
○ She started playing for money while still at school.
○ Shy and overweight, she did not socialise much but became pregnant with twins while still in
high school.
○ She did not have a boyfriend and her mother helped her raise the children.
○ When gambling was legalised in her state (Missouri, USA), she began daily visits to a local casino
after work.
○ Her losses amounted to $25,000 and caused her to imagine stealing to get money to continue
gambling.

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Imaginal desensitisation
Blaszczynski and Nower (2003)
● Treatment
○ The therapist spoke to Mary about stressors in her life that were triggering the behaviour and
explained that they would create a script to use in the guided imagery sessions.
○ They spoke together about patterns of behaviour associated with her gambling and the
therapist created one full behavioural sequence relating to her gambling but ending positively.

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Imaginal desensitisation
Blaszczynski and Nower (2003)
● Evaluation
○ Strength
■ Provides detailed qualitative data of Mary’s family and gambling history.
● Details of her losses, preferred type of gambling and age of onset
● All of which may be relevant in terms of positive response to treatment.
● This level detail is important as it will enable other therapists to make decisions
about the extent to which the findings might be transferable to their own clients.
○ Weakness
■ Do not provide any information about the success of the therapy.
■ Mary’s story is used more as an illustrative example to other therapists regarding how to
write a suitable script based on details from the case history.
■ This is important as without the findings other therapists may know how to conduct the
therapy but may not be completely convinced of its long-term efficacy and so would
need to seek further evidence before using it with their own clients.
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Imaginal desensitisation
Evaluation
● Strength
○ Supported by research evidence.
■ 80% of people with gambling disorder found long-term relief following six sessions of
this therapy (Grant et al., 2011).
■ After six months, gambling urges and behaviour were much improved compared with
pre-treatment.
■ Conclusion: Despite the reduction in hours with a therapist (due to the use of
audio-recordings), the therapy can still have long-term success. This said, there was a
small increase in symptoms at the six-month follow-up compared with immediate
post-treatment, suggesting relapse is possible without maintenance sessions or regular
practice.

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Imaginal desensitisation
Evaluation
● Strength
○ High level of client satisfaction
■ Because it is quicker and so cheaper than other types of cognitive-behavioural therapy
■ As sessions can be recorded, the therapist’s time is primarily spent interviewing clients
in order to write personalised scripts rather than delivering one-to-one therapy sessions.
■ Makes the therapy more cost-effective for both the client and the service provider, thus
increasing access to therapy for people who may not otherwise be able to afford it.

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Imaginal desensitisation
Evaluation
● Weakness
○ May not work for clients who are under-motivated or poorly organised as they may forget their
daily guided imagery sessions.
■ Specifically, the Blaszczynski and Nower (2003) study suggests that imaginal
desensitisation may be less effective for people with attention deficit disorder or
comorbid disorders, including depression.
■ That said, Grant et al. (2012) successfully treated a 17-year-old Korean-American client
with autism spectrum disorder, obsessive-compulsive disorder and kleptomania.
■ This is important as it demonstrates that therapists should make decisions based on
individual clients, building on their personal strengths, as sometimes a therapy may be
successful even for clients with complex needs, depending on the support that they
have available to them.

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Imaginal desensitisation
Evaluation
● Weakness
○ Relies on the client being able to reach a state of deep relaxation in order to fully immerse
themselves in the imagery.
■ Some clients might find this very difficult and may require medication to help them to
relax sufficiently.
■ Furthermore, the therapy takes a good deal of effort in terms of carrying out the guided
imagery sessions three times a day, if only for one week.
■ For these reasons some clients may prefer to either augment imaginal desensitisation
with anti-anxiety medication to help them to relax while conducting the guided imagery
sessions or they may simply prefer to use opiate antagonists or another drug treatment
as with drug treatments there is very minimal effort required, other than remembering to
take the medication.

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