Impulse Control Disorders All answers are from DSM-IV- TR or First and Tasman’s book unless otherwise noted. As of 5Mar2007
Dec 17, 2015
Impulse Control Disorders
All answers are from DSM-IV-TR or First and Tasman’s book unless otherwise noted.As of 5Mar2007
The five Impulse Control Disorders
Q. State the five DSM-IV-TR impulse control disorders.
The 5 Impulse Control Disorders
Ans.
1. Intermittent Explosive Disorder
2. Kleptomania
3. Pyromania
4. Pathological gambling
5. Trichotillomania
[of course, there is also NOS]
Dx criteria for intermittentexplosive disorder
Q. List the dx criteria for intermittent explosive disorder.
Dx criteria for intermittentexplosive disorder
Ans.1. Periodic episodes of aggression that resulted
in serious attacks on people or property.2. The degree of aggression is grossly out of
proportion to the precipitating stressor.3. Not part of another mental disorder [this is core
to the definition – but doesn’t preclude the pt having another psychiatric disorder. The other disorder should not, however, feature explosive behavior.]
Laboratory findings
Q. What are the laboratory findings?
Laboratory findings
Ans.
-- non-specific EEG findings
-- non-specific findings on neuropsych testing, e.g., trouble with letter reversal.
-- Cerebrospinal fluid has low 5-HIAA concentrations
[These findings are non-specific, i.e., found in many other disorders.]
Amok
Q. How is amok different from intermittent explosive disorder?
Amok
Ans. Amok is usually a single episode and there is amnesia for the event.
Gender
Q. Intermittent explosive disorder is more common in men or women?
Gender
Ans. Males
Prevalence
Q. What is the prevalence?
Prevalence
Ans. The official answer for this disorder is “rare.” But “rare” is partially reflecting that the signs of this disorder, for example rage, are common when people with other diagnoses are included.
Onset
Q. Usually at what ages is the onset?
Onset
Ans. Childhood till early 20s.
Differential dx
Q. List as many conditions as you can that you need to rule out?
Differential dx
Ans.1. Delirium2. Dementia3. Personality change due to a general
medical condition, general type4. Substance intoxication5. Substance withdrawalContinued, next slide
Differential dx
6. Oppositional defiant disorder7. Conduct disorder8. Antisocial disorder9. Borderline disorder10. Mania11. Schizophrenia12. Tourette’s 13. “Anger attacks” are seen sometimes as part of
MDD or panic disorder
Treatment
Q. What are the treatments?
Treatment
Ans.Psychosocial:
Individual psychotherapiesGroup psychotherapies[Not clear why First and Tasman don’t mention Anger management per se.]
Meds [all off label]:Mood stabilizers [Li and the anticonvulsants]Beta blockersSSRIs
Kleptomania
All answers, unless otherwise stated, are from DSM-IV-TR or First and Tasman.
Kleptomania criteria
Q. The criteria for kleptomania is?
Kleptomania criteria
Ans.
1. Recurrent stealing of objects that are not needed by that person.
2. Tension before stealing.
3. Relief of tension with the stealing
4. Stealing is not the result of anger, vengeance, or another psychiatric disorder
gender
Q. Gender breakdown?
Gender
Ans. Women 2:1.
Prevalence
Q. What is the prevalence?
Prevalence
Ans. Rare. <5% of shoplifters.
Course
Q. What is the age of onset and the subsequent course?
Course
Ans. Onset can be almost any age, and subsequent course is quite variable, some pts have a quite chronic course even with repeated arrests, others pts have long remissions between episodes.
Clinician attitude
Q. If such a pt is referred to you, what should your attitude be to the stealing behavior?
Clinician attitude
Ans. Provide a nonjudgmental and supportive stance.
Psychosocial treatment
Q. What are the psychosocial treatments?
Psychosocial treatment
Ans. No systematic or controlled psychosocial treatments. Successful anecdotal treatments include:-- complete abstinence from prospective stores-- aversive conditioning-- systemic desensitization-- covert sensitization-- psychodynamic therapy
Biological approaches
Q. What biological approaches have been reported to be successful?
Biological approaches
Ans.
-- antidepressants
-- mood stabilizers, including Li
-- combining the above two
-- antipsychotics
-- stimulants
-- ECT
Pyromania
Unless otherwise indicated, answers are from DSM-IV-TR or from First and Tasman.
Pyromania criteria
Q. What is the criteria needed to dx pyromania?
Pyromania
Ans. 1. Recurrent purposeless [other than tension
relief] fire setting.2. Tension or affective arousal before setting the
fire.3. Attraction to the fire and its situational context.4. Pleasure with setting the fire or its aftermath5. The fire setting is not the result of other needs
[revenge, financial gain, etc.] or the result of another psychiatric disorder.
Prevalence
Q. What is the prevalence?
Prevalence
Ans. Rare. While fire setting is common expression of other disorders in children and adolescents, pyromania is rare.
Gender
Q. Gender breakdown in pts with pyromania?
Gender
Ans. Much more common in males.
A predictor of recidivism
Q. A history of . . . . suggests there will be recidivism of the pyromania behavior?
A predictor of recidivism
Ans. Suicide attempt.
Psychosocial treatments
Q. What are the psychosocial treatments of pyromania?
Psychosocial treatments
Ans. The literature focuses on treating pts with fire setting more broadly, that is addressing other signs of psychopathology, not just on pyromania:
-- education, including helping pt find alternative routes to relieve tensions that have been associated with fire-setting.
-- CBT
Pathological gambling
The answers, unless otherwise indicated, are from DSM-IV-TR or First and Tasman.
Criteria for dx of pathological gambling
Q. Criteria, general?
Criteria for dx ofpathological gambling
Ans. While DSM-IV-TR has a five or more of ten signs, basically it is recurrent, persistent, and maladaptive gambling that disrupts personal, family or vocational pursuits, AND is not better conceptualized as part of another disorder, especially not a sign of mania.
Gender
Q. Gender breakdown?
Gender
Ans. Males 2:1.
Prevalence
Q. Prevalence of pathological gambling?
Prevalence
Ans. Quite a range depending on availability of gambling and culture: 0.3 to 7%.
Course
Q. What is the course of people with pathological gambling.
Course
Ans. For males, gambling usually begins in early adolescents but the progression into pathological gambling may take many years. Gambling usually begins later in females, but the evolving into pathological gambling takes fewer years.
Psychosocial treatments
Q. What are the psychosocial treatments?
Psychosocial treatments
Ans. Treatment approach is like treatment for substance dependence:
-- gamblers anonymous
-- individual psychotherapy
-- family therapy is often needed to a greater extent than with substance dependence. There is also a Gamblers Anon.
Meds for pathologicalgambling
Q. What about meds?
Meds for pathologicalgambling
Ans. The following have some support:
SSRIs
naltrexone
Li
carbamazepine
Trichotillomania - criteria
Q. The core criteria of trichotillomania is?
Trichotillomania - criteria
Ans. Recurrent pulling out of one’s hair that relieves tension and is not better accounted for as part of another disorder.
Trichophagia
Q. What is trichophagia?
Trichophagia
Ans. Chewing or swallowing one’s hair. Can happen in trichotillomania after the pt has pulled out the hair.
Circumstances
Q. What are the typical circumstances when trichotillomania occurs?
Circumstances
Ans. Usually alone, and some while tense and others while relaxed and “needing” a distraction.
Only one’s own hair?
Q. Pts who have trichotillomania pull hair other than their own?
Only one’s own hair?
Ans. Some pull hair of others, of pets, of sweaters, or rugs, etc.
Prevalence
Q. What is the percentage of college age students who will report this behavior as having occurred at some point in their life?
Prevalence
Ans. 1 percent.
[This answer will probably suffice for a broader question as to prevalence.]
Gender
Q. Which gender dominates?
Gender
Ans. Far more women go for treatment, but it is suspected that men rarely go for treatment even if afflicted.
Age of onset
Q. The age of onset is bimodal. What are the peaks?
Ages of onset
Ans.
5 – 8 years old
Early teens
Range: 14 months to 61 years old
Psychosocial approaches
Q. List the psychosocial approaches used with trichotillomania.
Psychosocial approaches
Ans.
-- behavior therapy’s “habit reversal.”
-- CBT
-- hypnosis [including used with children]
-- self-help groups
Meds
Q. What meds are used for trichotillomania?
Meds
Ans.
-- clomipramine
-- SSRIs are used and have positive reports, but not in controlled studies.
-- antipsychotics, but not in controlled studies
-- Li used, but not is controlled study.