Download Impulse Control Disorders Not Elsewhere Classified

Disorders Not Covered In Class
Impulse Control Disorders
Not Elsewhere Classified
Overview of Impulse Control Disorders
(Not Elsewhere Classified)
Disorders include:
• Intermittent Explosive Disorder
• Kleptomania
• Pyromania
• Pathological Gambling
• Trichotillomania
• Impulse Control Disorder Not Otherwise
Specified (NOS)
Intermittent Explosive Disorder
A. Several discrete episodes of failure to resist aggressive
impulses that result in serious assaultive acts or
destruction of property
B. The degree of aggressiveness expressed during the
episodes is grossly out of proportion to any precipitating
psychological stressors
C. The aggressive episodes are not better accounted for by
another mental disorder (e.g., Antisocial Personality
Disorder, Borderline Personality Disorder, a Psychotic
Disorder, a Manic Episode, Conduct Disorder, or Attention
Deficit/Hyperactivity Disorder) and are not due to the
direct physiological effects of a substance (e.g., a drug of
abuse, a medication) or a general medical condition (e.g.,
head trauma, Alzheimer’s disease)
Intermittent Explosive Disorder (IED)
• People with IED often describe the episodes as
“spells” or “attacks”
• The episode I soften preceded by a sense of
tension or arousal and is immediately followed by
a sense of relief
• The individual often feels upset, guilty, or
embarrassed by their behavior during the
episode
PEOPLE WITH IED FIND THE EPISODES DISTRESSING
Intermittent Explosive Disorder (IED)
• High comorbidity with:
– Mood disorders
– Anxiety disorders
– Eating disorders
– Substance abuse
• IED is not diagnosed if the episodes are a direct result
of the person using a substance; however, many people
abuse substances to avoid feeling the symptoms of a
psychological disorder
– Other impulse control disorders
Intermittent Explosive Disorder (IED)
• IED seems to be a rare disorder, and there is
no reliable information on how many people
have it
– Symptoms are usually better accounted for by
another disorder
• Higher occurrence in first degree relatives of
people with IED or other impulse control
disorders
Kleptomania
A. Recurrent failure to resist impulses to steal objects that
are not needed for personal use or for their monetary
value
B. Increasing sense of tension immediately before
committing the theft
C. Pleasure, gratification, or relief at the time of committing
the theft
D. The stealing is not committed to express anger or
vengeance and is not in response to a delusion or
hallucination
E. The stealing is not better accounted for by Conduct
Disorder, a Manic Episode, or Antisocial Personality
Disorder
Kleptomania
• The objects stolen are usually of little value/use
to the individual
– A person with kleptomania often gives away or
discards the stolen objects
– Occasionally they are hoarded or returned
• Usually a person with kleptomania avoids stealing
when immediate arrest is likely, but does not
preplan thefts or fully take into account the
chances of being caught
• Stealing is done alone
Kleptomania
• People with kleptomania view their behavior as
“ego dystonic”
• (something that is not typical of them; they realize that the
impulse is coming from their own mind but do not consider
it to be in line with their usual personality)
• The person is aware that stealing s wrong and
often fear getting caught or feel depressed or
guilty about the behavior
• More common in women in clinical samples
• Overall prevalence is unknown, but only accounts
for less than 5% of shoplifters
Kleptomania
• Age of onset is variable
• High comorbidity with:
– Mood disorders
– Anxiety disorders
– Eating disorders
– Personality disorders
– Other impulse control disorders
Pyromania
A.
B.
C.
Deliberate and purposeful fire setting on more than one occasion
Tension or affective arousal before the act
Fascination with, interest in, curiosity about, or attraction to fire
and its situational contexts (e.g., paraphernalia, uses,
consequences)
D. Pleasure, gratification, or relief when setting fires, or when
witnessing or participating in their aftermath
E. The fire setting is not done for monetary gain, as an expression of
sociopolitical ideology, to conceal criminal activity, to express
anger or vengeance, to improve one’s living circumstances, in
response to a delusion or hallucination, or as a result of impaired
judgment (e.g., in dementia, mental retardation, substance
intoxication)
F. The fire setting is not better accounted for by conduct disorder, a
manic episode, or antisocial personality disorder
Pyromania
• May make considerable advance preparation for
starting a fire
• May be indifferent to the consequences to life or
property after fires, or may derive satisfaction from the
destruction
• Behaviors may lead to property damage, legal
consequences, injury, or loss of life
• Insufficient data about typical age of onset; unclear if
there’s a relationship between fire setting in childhood
and adulthood
– Fully diagnosable pyromania in children is particularly rare
Pyromania
• Pyromania is extremely rare, but is more
commonly diagnosed in males
• There is high comorbidity with alcohol or
substance dependence and abuse
Pathological Gambling
A. Persistent and recurrent maladaptive gambling behavior
as indicated by five (or more) of the following:
1.
2.
3.
4.
5.
Is preoccupied with gambling (e.g., preoccupied with reliving
past gambling experiences, handicapping or planning the next
venture, or thinking of ways to get money with which to
gamble)
Needs to gamble with increasing amounts of money in order
to achieve the desired excitement
Has repeated unsuccessful efforts to control, cut back, or stop
gambling
Is restless or irritable when attempting to cut down or stop
gambling
Gambles as a way of escaping from problems or of relieving a
dysphoric mood (e.g., feelings of helplessness, guilt, anxiety,
depression)
Pathological Gambling
6.
After losing money gambling, often returns another day to
get even (“chasing” one’s losses)
7. Lies to family members, therapists, or others to conceal
the extent of involvement with gambling
8. Has committed illegal acts such as forgery, fraud, theft, or
embezzlement to finance gambling
9. Has jeopardized or lost a significant relationship, job, or
educational or career opportunity because of gambling
10. Relies on others to provide money to relieve a desperate
financial situation caused by gambling
B. The gambling behavior is not better accounted for
by a manic episode
Pathological Gambling
• Note that the symptoms described closely mirror those
of physical addiction/dependence!
• There are often distortions in thinking that accompany
the gambling (e.g., denial, superstitions,
overconfidence, or a sense of power or control)
• Many pathological gamblers view money as both the
cause of and solution to their problems
• Frequently are highly competitive, energetic, restless,
and easily bored
• May be overly concerned with approval of others and
generous to the point of extravagance
• When not gambling are often “workaholics”
Pathological Gambling
• Prone to general medical conditions that are associated
with stress:
– Hypertension
– Peptic ulcer disease
– Migraines
• High incidence of suicidal ideation and attempts
• High comorbidity with:
–
–
–
–
–
Mood disorders
Attention deficit/hyperactivity disorder
Substance abuse or dependence
Other impulse control disorders
Antisocial, Narcissistic, and Borderline Personality disorders
Pathological Gambling
• Often abnormal laboratory findings:
– Levels of serotonin, norepinephrine, and
dopamine
– Abnormalities in platelet monoamine oxidase
– High levels of impulsivity on neuropsychological
tests
Pathological Gambling
• Females seem to account for 1/3 of
pathological gamblers, but only 2-4% of those
in treatment
• Life time prevalence estimates range from .4%
to 8% depending on location and age group
• More common among relatives of
pathological gambles and substance abusers
Trichotillomania
A. Recurrent pulling out of one’s hair resulting in noticeable
hair loss
B. An increasing sense of tension immediately before pulling
out the hair or when attempting to resist the behavior
C. Pleasure, gratification, or relief when pulling out the hair
D. The disturbance is not better accounted for by another
mental disorder and is not due to a general medical
condition (e.g., dermatological condition)
E. The disturbance causes clinically significant distress or
impairment in social, occupational, or other important
areas of functioning
Trichotillomania
• Sites of hair pulling include anywhere on the body where
hair may grow
• May occur in brief periods scattered throughout the day or
in less frequent but longer periods that can continue for
hours
• Hair pulling often occurs while the person is in a state of
relaxation or distraction (e.g., while reading a book or
watching TV.) but can also occur during stressful
circumstances
• For some, tension does not necessarily precede the hair
pulling but is associated with attempts to resist the impulse
– Some people experience an “itch like” sensation that is eased by
pulling the hair
Trichotillomania
• Hair pulling usually does not occur around other people
(except family members) but social situations may be
avoided
• Individuals frequently try to find ways to hide their
behavior or camouflage the results
• Some may have impulses to pull hair from other people or
objects
• Associated behaviors include:
–
–
–
–
–
Examining the hair root
Pulling the hair strand between teeth
Eating hairs
Nail biting
scratching
Trichotillomania
• High comorbidity with:
– Mood disorders
– Anxiety disorders (especially obsessive compulsive
disorder)
– Substance abuse
– Eating disorders
– Personality disorders
– Mental retardation
Trichotillomania
• Seems to be equally common among males
and females in children
– Among adults, more common in females
• This may reflect differences in who seeks treatment
among adults – the resulting hair loss may be more
acceptable to an adult male than adult female due to
societal norms
• Overall prevalence is unclear, but it is
relatively uncommon
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Gender Identity Disorder
A.
A strong and persistent cross-gender identification (not merely a desire
for any perceived cultural advantages of being the other sex)
In children, the disturbance is manifested by four (or more) of the
following:
1.
2.
repeatedly stated desire to be, or insistence that he or she is, the other sex
In boys, preference for cross-dressing or simulating female attire; in girls,
insistence on wearing only stereotypically masculine clothing
3. Strong and persistent preferences for cross-sex roles in make-believe play or
persistent fantasies of being the other sex
4. Intense desire to participate in the stereotypical games and pastimes of the
other sex
5. Strong preference for playmates of the other sex
In adolescents and adults, the disturbance is manifested by symptoms such as a
stated desire to be the other sex, frequent passing as the other sex, desire to live
or be treated as the other sex, or the conviction that he or she has the typical
feelings and reasons of the other sex
Gender Identity Disorder
B. Persistent discomfort with his or her sex or sense of inappropriateness in
the gender role of that sex
In children, the disturbance is manifested by any of the following: in boys,
assertion that his penis or testes are disgusting or will disappear or assertion that
it would be better to not have a penis, or aversion toward rough-and-tumble play
and rejection of male stereotypical toys, games, and activities; in girls, rejection of
urinating in a sitting position, assertion that she has or will grow a penis, or
assertion that she does not want to grow breasts or menstruate, or marked
aversion toward normative feminine clothing.
In adolescents and adults, the disturbance is manifested by symptoms such
as preoccupation with getting rid of primary and secondary sex characteristics
(e.g., request for hormones, surgery, or other procedures to physically alter sexual
characteristics to simulate the other sex) or belief that he or she was born the
wrong sex
C. The disturbance is not concurrent with a physical intersex condition
D. The disturbance causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
Gender Identity Disorder
• Diagnosis requires strong and persistent cross-gender identification
and persistent discomfort about one’s own sex
• As children, people with GID may insist that they will grow up to be
the opposite sex and prefer to play with toys and take on roles
typically associated with the opposite sex
• Some children may refuse to attend events where they are required
to dress as their biological sex
• There is a high risk of social isolation because of stigma and
ostracism
– People with GID are at a higher risk for low self esteem and dropping
out of school
– There are high rates of depression and anxiety disorders among
people with GID; this may be largely due to cultural reasons
Gender Identity Disorder
• Men seem to seek treatment more often
– As children, females may experience less ostracism because
“tom boy” behavior is often accepted and parents are more
likely to seek treatment for a son who is effeminate
– Men tend to seek sex-reassignment surgery more often than
women
• Adults who are diagnosed with GID usually have onset of
cross-gendered interests/behaviors around 2-4 years of age
– Most children who express the same behaviors grow out of
them and do not have GID as adults
Note: GID is NOT the same as or necessarily connected with
homosexuality