PRO FORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
PRO FORMA FOR REGISTRATION OF SUBJECTS FOR
NAME OF THE CANDIDATE AND ADDRESS
Sarvodaya College Of Nursing,
Magadi Main Road,
NAME OF THE INSTITUTION
Sarvodaya College Of Nursing,
COURSE OF STUDY AND SUBJECT
1st Year Msc Nursing
Mental Health Nursing
DATE OF ADMISSION OF THE COURSE
TITLE OF THE TOPIC
“A Study To Evaluate The Effectiveness Of Structured Teaching Programme Regarding Impulse Control Disorder Among Students In Selected Colleges At Bangaluru.”
6. BRIEF RESUME OF THE INTENDED WORK
6.0 INTRODUCTION “Habit is either the best of servants or the worst of masters.” - Nathaniel Emmons A habit is a learned behavior that a person repeats so often that he or she begins to do it without even thinking about it. Certain habit can be helpful and help to achieve positive objectives. On the other hand, some habits are annoying and some can cause distress and may have harmful effects. 1
Impulse control disorders have been defined as harmful behaviors Performed in response to irresistible impulses. Impulse control Disorder is a set of psychiatric disorders including intermittent explosive disorder, compulsive buying, kleptomania, pathological gambling, pyromania, and three body focused repetitive or compulsive behaviors of trichotillomania, onychophagia and dermatillomania.2 Impulsivity, the key feature of these disorders, Can be thought of as seeking a small, short term gain at the expense Of a large, long term loss.
Intermittent explosive disorder (IED) is Characterized by extreme Expressions of anger, often to the point of uncontrollable rage, that are disproportionate to the situation at Hand. Intermittent explosive disorder affects as many as 7.3 percent of adolescents.3
Compulsive Buying is the irresistible or uncontrollable impulses to buy or shop. It is most common current and lifetime impulse control disorder.3 the estimated prevalence is approximately 16 Percent.4
Pathological gambling is continuous Preoccupation with gambling.2 The prevalence of pathological gambling in adolescence and young adulthood has been found to be two to four folds higher than in adulthood .5 In India youth population is 41.05 percent.6 In Karnataka it is 43.55 percent. 7 It is considered that more than 45 percent of youth are engaged in various gambling.
Onychophagia is repetitive and excessive nail biting. It is estimated that 28 to 33 percent of children, 44 percent of adolescents and 19 to 29 percent of young adults are nail bitters.8 In India the prevalence of oral habits is 25.5 percent.9 In Karnataka it is 29.7 percent.10 Trichotillomania refers to uncontrollable Plucking of one’s hair. Statistics show that 1 to 3 percent of population suffer from trichotillomania. However, new research shows that the rate may be 10 percent or higher. In India more common among females ( 85 %) , and belonged to urban nuclear family (70 %).11 Kleptomania is defined as the impulses to steal objects that are not acquired for personal use or monitory gain. It is presumed to be rare, prevalence is unknown. Interestingly it is more common in women than in men.12
Pyromania refers to deliberate and purposeful fire-Setting. More common in men than women and usually begins in adolescence and early adulthood in India prevalence of pyromania is unknown.13
Prevalence rate is more in case of Pathological gambling, intermittent explosive Disorder, onychophagia and compulsive buying. New researches shown that the prevalence rate of trichotillomania also increasing. Researchers have indicated that impulse Control disorders are strongly associated with mood disorders (especially Depression), anxiety disorders and substance Abuse.14 The causes of impulse control disorder might be physical or biological, psychological or emotional and cultural or societal Factors.
The prevalence of various impulse control Disorder in adolescence and young adult hood has been found to be two to four Folds higher than in adult hood. The Common treatment modalities are Psychodynamic behavioral therapies, social therapies, counseling, habit reversal, self control by creating an escape plan, family and peer support.15 Gambling anonymous Play an important role in Pathological gambling treatment. This motor behaviours markedly interferes with normal activities or result in self inflicted bodily injury and sometimes life threatening.16 Majority of the impulse control disorders is either untreated or neglected, leading to severe mental disorders. Therefore, awareness is need of the hour.
6.1 NEED FOR THE STUDY Impulse control disorder is a group of mental disorders where sufferers are frequently unable to resist the urge to do something that is harmful to themselves or others. The behaviour brings the patient some sort of satisfaction even though it may be socially unacceptable and out of character behaviour for that person.
Patient can manifest symptoms that apparently present with impulse control disorder can be part of different diagnostic rubric .The unusual presentation can lead to diagnostic difficulty as well as delay in diagnosis . It is important for the clinicians as well as public to be aware of the unusual presentation to maximize appropriate diagnosis ,early intervention and preventive measures.17 The enormous personal and social consequences of this disorder are high rate of suicidal attempts, depression, overwhelming debt, break up of relationships increased rate of legal problems and criminal behaviour.
A disproportionate amount of suicide in the world occurs in Asia, which is estimated to account for upto 60% of suicide. According to World Health Organization, China, India and Japan may account 40% of all world suicide. Pathological gambling and self-mutilation are major reasons.18
A study conducted by the Indian Council for Medical Research in Luknow and Banglore says , in India behavioural problems is an increase of approximately four percent in the past six years .19 Researchers’ show that the field of impulsive disorder is at a nascent stage of development in India. As impulse control disorder is very common in Indian adolescents and adult obviously better and more studies needed.
Impulse control statistics shows that it is more common in college student (12%-16%) and in adolescents (44.1%) especially compulsive buying behaviours. Among impulse control disorders the prevalence is more in case of compulsive buying and pathological gambling, the next is intermittent explosive disorder.2 Compulsive buying prevalence is 8.6% to 45%, where as in India nearly 45% of the youth are either pathological or problem gamblers. The prevalence of intermittent explosive disorder is 3.8%to 6.2%.2 But new research shows that the rate may be 10% or higher.
By their very nature , some impulse control disorder can result in illegal or criminal behaviour . Shoplifting that may result from kleptomania is a criminal offence. Pyromania that result in setting fire that destroy property or harm others is a criminal act . At the other end of the spectrum is trichotillomania , that may result in harm to individual but not in criminal act .Pathological gambling, while usually not a criminal act in itself , may escalate to the point where the individual must resort to illegal or criminal acts in order to support the behaviour.20 A study based on lack of impulse control and significant complication associated shows that, lack of impulse control, one of the greatest focuses should be upon the use of recreational drugs and substance abuse. That may be at the greatest risk of using alcohol, cocaine amphetamines.
One study based on neurological and environmental aspects shows that these disorders may be exacerbated by stress. In impulse control disorder, the impulse action is typically preceded by feelings of tension and excitement and followed by guilt or remorse.21
An empirical research on obstacles preventing from seeking treatment for an impulse control disorder identified the most commonly reported barriers were:-wish to handle problem by oneself, shame, embarrassment, stigma, unwillingness to admit problem, lack of knowledge about treatment options and practical issues around attending treatment.22
It is important to understand what drives our impulses and how to control them .Impulse control is important to normal functioning in all levels; physical, emotional and mental. For most individual lack of impulse control can be detrimental to not only the individual’s well being but also society in general. But once client become aware , it will be easier to control and overcome it.So awareness and prevention is important. Turn negative impulsivity into positive impulsivity is most important aspect of managing impulse control disorder.23 The investigator identified that majority of the adolescents have impulse control disorders, as the investigators came across several cases among college mates and relatives and during clinical practices which gained attention while interacting with them .Among that some habits are annoying and some can cause distress or become the focus of teasing.As per mentioned above, such habit disorder result in illegal or criminal behaviours. The investigator recognizes that most habits can be modified with a bit of efforts if people make themselves aware of what they are doing. Likewise felt the need to give awareness regarding impulse control disorders and its negative impact.
6.2 REVIEW OF LITERATURE “Review of literature provides the basis for future investigations, justifies the need for replication, throws light up on feasibility of the study, and indicates constraints of data collection and help to relate findings of one another”.
1. Literature related to incidence of impulse control disorders
Impulsive disorders are characterized by the repetitive occurrence of impulsive and uncontrolled behaviors. Behavioral dependences most often described are pathological gambling, kleptomania, trichotillomania and compulsive buying. Studies using a specific assessment scale, the South Oaks Gambling Screen, distinguished problem gambling from pathological gambling. S Data come from case reports. Prevalence of kleptomania varied between 0 and 24%. Trichotillomania prevalence rate is 0.6% among students. Studies using less restrictive diagnostic criteria found a prevalence rate of 3.4% in women and 1.5% in men. Prevalence studies of compulsive buying found the rate is high in the general population. Compulsive buying is significantly more frequent among women (90% of the cases). Study of family history of compulsive buyers showed a high frequency of alcohol-dependence disorder (20%) and depression (18%).25
A study on impulse control disorders in adolescents and children aim to examine current prevalence. Reserchers examined rates and clinical correlates of comorbid ICDs in 70 consecutive children and adolescents’ subjects. Data were obtained with structured clinical interviews. 17.1%subjects met criteria for current impulse control disorders. Pathological skin picking and compulsive nailbiting were the most common impulse control disorders with current rates of 12.8% and 10.0%, respectively.26
Compulsive buying was the most common current and lifetime impulse control disorder. Sixty-three (30.9%) of the 204 patients were diagnosed with atleast one impulse control disorder. Forty-two patients (20.6%) reported current symptoms of two impulse control disorders, 20 (9.8%) three impulse control disorders, and one (0.5%) more than three impulse control disorders. Sixty-seven patients (32.8%) were diagnosed with at least one lifetime impulse control disorder. 27
The study on the frequency of impulse control disorders (ICDs) and their association with bulimia, compulsive buying, and suicide attempts in a population of depressed inpatients. Researchers investigated ICDs using the Minnesota Impulsive Disorders Interview. Among the 31 depressed patients who met criteria for ICD (ICD+ group), found 18 cases of intermittent explosive disorder, three cases of pathological gambling, four cases of kleptomania, three cases of pyromania, and three cases of trichotillomania. Patients with co-occurring ICDs were significantly younger. Bipolar disorders were more frequent in the ICD+ group than in the ICD- group (19% versus 1.3%, p =.002), compulsive buying (51% versus 22%, p =.006) is significantly more frequent in the ICD+ group.28
A study on the prevalence of oral habits according to sex was conducted on 5554children aged 5-13 years old . These children were selected from the schools of Delhi. The sample represented the entire school-going population of Delhi in the age group of 5-13 years The results showed that the prevalence of oral habits in Delhi school going children was 25.5%. Nail biting was more common in girls when compared with boys and this difference was statistically significant (P < 0.001). 9
This epidemiological study was conducted upon 4,590 school children to find the prevalence of oral habits in Karnataka in relation to their age and sex. We noted that 29.7% of the population had habits of which 3. 1% had digit sucking, 4.6% mouth breathing, 3.02% tongue thrusting, 6.2% bruxism, 6% lip/cheek biting, 12.7% nail biting, and 9.8% pencil biting and 0. 09% masochistic habits respectively. Digit sucking, pencil biting and tongue thrust were highly prevalent among Group 1 (3-6 years) children. Mouth breathing and bruxism were significant in Group 2 (7-12 years) cases whereas lip/cheek biting and nail biting were more common in Group 3 (13-19 years) cases. Digit sucking, tongue thrust, mouth breathing and bruxism were more prevalent among the boys whereas lip/cheek biting, nail biting and pencil biting were more prevalent among the girls.10
Patients afflicted with trichotillomania (TTM) describe an overwhelming urge to pluck out specific hairs; The exact prevalence is estimates from university surveys suggest that 1.5% of males and 3.4% of females endorse clinically significant hair pulling, with .6% endorsing all diagnostic criteria of TTM . The prevalence of non-clinical hair pulling behavior is even higher, up to 15.3%, in university surveys.29
A study on trichotillomania describes the sociodemographic profile, clinical characteristics and treatment outcome of 20 children presented to the Child Adolescent Psychiatry Clinic. Most subjects were females (85%), Hindu by religion (65%), and belonged to urban nuclear family (70%). Co morbid psychiatric illness and family history of psychiatric disorders was present in 40% and 20% cases, respectively. Nearly two-third of these had associated impulse; 75% denied resistance to pluck. Children who continued treatment showed improvement.30
2. Literature related to knowledge on impulse control disorders
A cross sectional descriptive study on health seeking behavior regarding psychiatric disorders estimated that only one out of hundred get one kind of care or treatment. Very often this is because of lack of adequate health services or trained manpower in the developing countries. But lack of awareness among people regarding mental disorder is an important cause, which prevents them from seeking treatment even if available.31
Although recognized since at least the early 19th century, compulsive buying disorder is poorly understood condition that has received little systematic study. This review suggest that it is more common than realized, occur more frequently in women than in men, cause significant morbidity, are related to other psychiatric disorders (especially to one another,obsessive-compulsive disorder, and mood disorders), and often respond to available psychopharmacologic and psychological treatments. But lack of awarness regarding disease prevent from seeking treatment. 32
A study on epidemiology of behavioural dependence shows impuise control disorders, especially trichotillomania is often unrecognized.Due to lack of knowledge majority are not seeking treatment.58% of the patient have never been treated. 26
3. Literature related to causes and complications
The primary objective of the study based on consumer culture in India is to investigate the effect of irresponsible use of credit card on compulsive buying among Indian consumers on their personal finances. A survey was conducted to collect the needed data in the cities of Delhi and Hyderabad. A Sample of 250 shoppers in the shopping malls was selected for the study. The discriminant analysis using the primary data reveals that use of credit card is the significant variable that is associated most closely with compulsive buying behavior followed by anxiety attitude, income and power and prestige attitude in that order.The outcome suggests that irresponsible use of credit cards facilitates the compulsive buying behavior that ultimately is the cause for the mismanagement of personal finances.33
Research was designed specifically to examine gambling motivation among college students with a long term goal of determining why gambling is so prevalent in this population participant included 184 undergraduate college student gamblers, enrolled in introductory psychology classes at a northwestern university in the United States. The average of participants was 19.4 years, 123 males and 59 females. Participants were asked to list in rank order their top five reasons for gambling. The result reveled that most college students gamble to win money, for fun, for social reason, for excitement or just to have something to do. Over 40 percent of this sample reported monetary gain as their primary motivation for gambling.34
A case-control study of impulsive and aggressive behavior in men found that impulse control disorders increased the risk of suicide.. An analysis by age showed that risk is more specific to younger suicide victims (ages18–40). A multivariate analysis indicated that impulsive-aggressive personality disorders are independent predictors of suicide in major depression, and impulsive and aggressive behaviors seem to underlie this risk factors.35
A literature on pathological buying published during the past 15 years summarizes, pathological or compulsive buying as frequent preoccupation with buying or impulses to buy that are experienced as irresistible, intrusive, and/or senseless. The buying behavior causes marked distress, interferes with social functioning, and often results in financial problems. Studies on the phenomenology, diagnosis, classification, co morbidity, epidemiology, and treatment are presented. Psychiatric co morbidity is frequent, particularly mood, anxiety, substance use, eating, impulse control and obsessive-compulsive disorders.36
In a cross national sample, the presence of a prior mental disorder is associated with significantly increased risk of suicidal behaviors, even after controlling for socio-demographic factors, characteristics of suicidal behaviors, and country of residence. Relations are strongest across both high-, and low- and middle- the cross income countries for mood disorders (OR=3.4–5.9) and impulse-control disorders. Importantly, associations between mental disorders and suicidal behaviors are attenuated when predicting plans and attempts among ideators, with ORs decreasing to 1.0–2.1 across all categories. Among ideators, the risk of making an attempt is highest for those with impulse-control disorders, suggesting that these disorders are most strongly associated with acting on suicidal thoughts when they are present. Results also show a strong dose–response relationship between the number of mental disorders present and the risk of suicidal behaviors.37
To examine the relationship between Intermittent Explosive Disorder (IED; a psychiatric diagnosis characterized by episodes of affective aggression) and adverse physical health outcomes. A large epidemiological sample drawn from the Collaborative Psychiatric Epidemiological Surveys (N = 10,366), was used to compare participants with a lifetime diagnosis of IED (n = 929) to those without any history of IED (n = 9,437) on demographic variables (age, education, gender, race) common risk factors (smoking status, body mass index, substance use disorders, past accident or injury requiring treatment, major depression) and the presence of 12 adverse health outcomes. History of heart attacks, coronary heart disease, hypertension, stroke, lung disease, diabetes, cancer, arthritis, back/neck pain, ulcer, headaches, and other chronic pain. Logistic regression analysis controlling for demographic and other risk factors indicated that intermittent explosive disorder was associated with 9 of the 12 adverse physical health outcomes (coronary heart disease, hypertension, stroke, diabetes, arthritis, back/neck pain, ulcer, headaches, and other chronic pain). Intermittent explosive disorder may be a risk factor for several significant adverse physical health outcomes. 38
Uncontrolled anger is a contributing force in the three leading causes of adolescent death: homicide, suicide, and injuries. Anger may be one of the early warning signs which could lead to violent behavior. The purpose of this study was to examine the relationship between anger experience and expression with the potential correlates of life events, perceived social support, self-esteem, optimism, drug use, anxiety, and depressive symptoms in rural adolescents. Negative life events, anxiety, drug use, and depressive symptoms had significant positive correlations with anger. In addition, anger was found to have significant negative correlations with the adolescents' perceived family support, self-esteem, and optimism. With this knowledge, health promotion programs conducted by pediatric nurses can target anxiety, drug use, and depressive symptoms while bolstering family support, self-esteem, and optimism to promote anger management in adolescent health care.39
A survey based on gambling and other risk behavior.They found that 18% of men and 4% of women reported that gambling had led to atleast 3 negative life consequences.Students who were identified as problem gamblers, compared with other students, were signification more likely to be heavy drinkers, report negative consequences of alcohol consumption and be regular tobacco and marijuana users.Problem gambling was related to binge eating and greater use of weight control efforts.40
6.2.1 STATEMENT OF THE PROBLEM A Study To Evaluate The Effectiveness Of Structured Teaching Programme Regarding Impulse Control Disorder Among Students In Selected Colleges At Bangaluru.
1. To assess the knowledge of students regarding impulse control disorder before structured teaching programme. 2. To assess the knowledge of students regarding impulse control disorder after
Structured teaching programme 3. To evaluate the effectiveness of structured teaching programme regarding impulse control disorder among students
4. To determine the association between knowledge level of students and selected
6.3.1 OPERATIONAL DEFFINITIONS 1. Effectiveness: Refers to improvement of knowledge regarding impulse control disorder as assessed by the responses to the structured questionnaire 2.Structured Teaching Progamme: Refers to the systematically planned group instructions designed to provide information regarding Impulse Control Disorder- causes, complications, prevention and managements by using charts,flash cards,slide show for a duration of 45 minutes. 3.Impulse Control Disorder: refers to disorders distinguished by an uncontrollable tendency to commit an unplanned behavior. It includes intermittent explosive disorder, pathological gambling, onychophagia, oniomania and trichotillomania. 4.Students: Refers to both male and female studying in selected colleges at Bangalore
1. It is assumed that the students may have lack of knowledge regarding Impulse Control Disorder.
2. It is assumed that the structured teaching programme may increase the knowledge on impulse-control disorde
6.3.3 HYPOTHESIS OF THE STUDY
H1.There will be a significant improvement in knowledge of students regarding Impulse Control Disorder after structured teaching progamme than before structured teaching programme
H2.There will be significant association between the knowledge and selected demographic variables.
1. who are available at the time of data collection
2. who are willing to participate in the study
who attended any awareness programme
7. MATERIALS AND METHODS7.1 SOURCE OF DATA COLLECTION: Data will be collected from the students of selected colleges at bangalore.
7.2 METHODS OF DATA COLLECTION i.Research approach : Evaluative approach. ii.Research design : One group pre test – post test design (Quasi experimental design) iii.Setting : Selected colleges, Bangalore iv.Population : All students v.Sample : All students fulfilling inclusion criteria. vi.Sample size : 60 vii.Sampling technique : simple random sampling viii.Method of data collection : Self administered questionnaire ixTool for data collection : Structured questionnaire
x.Method of data analysis
The descriptive and inferential statistics will be use 1.Demographic variables will be analyzed by frequency and percentage of distribution. 2. The level of knowledge will be analyzed by mean and standard deviation. 3.Effectiveness of structured teaching programme on impulse control disorder will be analyzed by using paired‘t’ test. 4.Association between demographic variables and knowledge on impulse control disorder will be analyzed by using chi-square test.
xi . Duration Of The Study : 4 weeks
1. Independent Variable: Structured teaching programme on impulse control disorder. 2.Dependent Variable: Level of knowledge of students on impulse control disorder. 3.Demographic Variable: Age, Gender, Present Educational Status, Type of Family, Family History, Family Income, Religion
xiii) Projected Outcome The study will help the students to acquire knowledge regarding impulse control disorders, its negative impact and various preventive measures. It helps them to come out of such habit disorders
7.3 Does the study require any investigations or interventions to be conducted on patient or animals?
7.4 Has ethical clearance been obtained from your institution?
YES, Ethical committee’s report is enclosed
8. LIST OF REFERENCES.
1.Habit and habit disorders.Encyclopedia.com.19 Nov.2010
2.Gelder M. G, Juan J. Lopez, Nancy C. Andreasen. New Oxford Textbook of
Psychiatry. New York: Alison Langton; 2003
3.Kessler R C, Coccaro E F, Fava M .The prevalence and correlates of DSM –IV .The
national comorbidity survey replication. Arch Journal Psychiatry 2006 Jun :63(6) :
669-78 .Available From :URL: www.ncbi.nlm.nih.gov/pubmed/167548 4.Lorrin M Koran ,Ronal J ,Aboujaoude M A and Richard T .Estimated Prevalence Of
Compulsive Buying Behaviour in the United States .American Journal Psychiatry;