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.