Impulse Disorders

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Impulse Disorders

• RCS 6931
• Steven R. Pruett, Ph.D.
• 6/5/07

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Impulse Disorders

• NOT
• Substance-Related Disorders
• Paraphilias
• Antisocial Personality Disorder
• Conduct Disorder
• Schizophrenia
• Mood Disorders

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Impulse Disorders

• This chapter in DSM-IV-TR is largely a bunch of
  leftovers.
• Not that easy make sense of these disorders.
• One common theme with these disorders is that
  they take place in accord with the patients
  wishes (ego-syntonic)
• People with these disorders either cannot or do
  not resist impulses, urges or temptations to do
  something that harms either themselves or others.

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Impulse Disorders

• Tension Release
• Typical build-up of anxiety or tension until
  pressure to act is overwhelming.
• After the act the person experiences pleasure or
  some type of relief. Remorse may follow later
  on.
• With Impulse Disorders the term mania does not
  imply having a manic episode instead it is used
  as a suffix meaning having a passion or
  enthusiasm for something.

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Impulse Disorders

• Intermittent Explosive Disorder
• Kleptomania
• Pyromania
• Pathological Gambling
• Trichotillomania
• Impulse-Control Disorder NOS

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Intermittent Explosive Disorder 312.34

• Characterized by discrete episodes of failure to
  resist aggressive impulses resulting in serious
  assaults or destruction of property.
• Relatively rare disorder even though intermittent
  violent behavior is someone common.
• Aggressiveness is grossly out of proportion to
  any provocation or stressor.

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Intermittent Explosive Disorder

• Explosive events usually associated with
  affective symptoms
• irritability/rage, increased energy, racing
  thoughts
• Usually theres a rapid onset of depressed mood
  and fatigue after explosive event.
• Some say they have tingling, tremors or
  palpitations before the explosive event.

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Intermittent Explosive Disorder

• Lab tests show lows 5-HIAA (seratonin)
  concentrations in cerebrospinal fluid some
  individuals with temper/impulsive prone
  individuals. Relationship to IED is unclear.
• Onset
• Childhood to early 20s. Mode of onset is
  usually abrupt.
• Course
• Variable chronic to episodic

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Intermittent Explosive Disorder

• Impulse control disorders may be more common
  among first-degree relatives than among the
  general population.
• Diagnostic criteria
• DSM-IV-TR p. 667
• Treatment
• Psychopharmacological
• No impulse control medication
• Mood stabilizers
• CBT
• Self-talk
• Alternative coping mechanisms
• Relaxation

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Kleptomania 312.32

• Failure to resist impulses to steal items though
  the items are not needed for personal use or for
  their monetary value.
• Tension exists before theft.
• Pleasure, gratification, relief exists during
  theft.
• Theft is not used to express anger or vengeance
  (Conduct Disorder).
• Individuals with Kleptomania know that the act of
  stealing is wrong and senseless
• Can feel fearful and guilty after the theft.
• May be associated with compulsive buying.

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Kleptomania

• 2/3 of Kleptomanics are female
• Rare only 5 of all shoplifters are Kleptomanics
• Associated with depression eating disorders
• Age at onset is variable
• Unknown if theres a familial pattern.
• Diagnostic criteria
• DSM-IV p. 669
• Treatment
• SSRIs
• Psychotherapy

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Pyromania 312.33

• Multiple episodes of deliberate/purposeful fire
  setting.
• Individuals with this condition feel a tension or
  affective arousal before setting a fire
• Interest in fire and contextual situations
• May find pleasure in being around fire
  departments, set fires to be affiliated with fire
  dept or become firefighters themselves.
• Fire setting is not done for monetary gain, or to
  express vengeance or anger.

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Pyromania

• Individuals may make considerable preparations
  for starting a fire.
• May derive satisfaction from resulting property
  destruction.
• Relationship with Alcohol Dependence or Abuse
• Pyromania in children is rare (despite the number
  of juvenile fire settings).
• Found much more often in males than females
• Course unknown.
• Diagnostic criteria
• DMS-IV-TR p. 671
• Treatment
• Behavioral modification
• CBT

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Pathological Gambling 312.31

• Persistent and recurrent maladaptive gambling
  behavior which disrupts personal, family or
  vocational pursuits.
• Cant be associated with a manic episode.
• Individuals with Pathological Gambling continue
  to gamble despite repeated attempts to stop or
  cut down on gambling.
• Can be restless or irritable when attempting to
  cut down or stop gambling.
• Gambling may be seen as a way out of problems or
  to relieve a dysphoric mood.
• Chasing ones losses.
• May lie to conceal the extent of involvement with
  gambling.
• May jeopardize relationships/opportunities
  because of gambling
• May look for a bail-out resulting from desperate
  financial situations.

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Pathological Gambling

• Cultural variations
• Cock fighting, horse races, stock market, pai
  gow.
• Females with disorder tend to be depressed and
  gamble for an escape.
• While female make up 1/3 of the population of
  pathological gamblers they represent only 2 - 4
  of individuals in Gamblers Anonymous (stigma?)
• Pathological gambling AND ETOH dependence is more
  common among the parents of pathological gamblers
  than among the general population.

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Pathological Gambling

• Prevalence influenced by availability and
  duration of the availability.
• Lifetime prevalence 0.4 to 3.4 in adults. In
  some cultures it has been as high as 7.
• 2.8 to 8 in adolescents and college students.
• Relationship to substance use disorders
• Course
• males early adolescence females later in life.
• For most the onset is insidious.
• Gambling pattern can be episodic or chronic
• General progression in frequency of gambling, the
  amount waged, preoccupation with gambling, and
  obtaining in which to gamble.
• Urge to gamble increases with periods of
  depression or stress.

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Pathological Gambling

• Diagnostic Criteria
• DSM-IV-TR, p. 674.
• Treatment
• Gamblers Anonymous
• CBT, Cognitive Behavioral Therapy
• National Council on Problem Gambling
• http//www.ncpgambling.org/
• Gamblers Anonymous
• http//www.gamblersanonymous.org/

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Trichotillomania 312.39

• Recurrent pulling out ones own hair that results
  in noticeable hair loss.
• Can include any part of body where hair grows
  (most common scalp, eyebrows eyelashes).
• Can occur during brief periods of the day or more
  sustained periods of time.
• Hair pulling often occurs during times of
  relaxation and distraction but can occur during
  stressful times.

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Trichotillomania

• Individual may experience an itch-like sensation
  in the scalp that is eased by pulling out hair.
• Diagnosis cannot be given if the individual has a
  delusion about pulling hair or have a medical
  condition/dermatological condition affecting the
  scalp etc.
• Must cause significant disturbance/distress in
  social, occupational, or other important areas of
  functioning.

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Trichotillomania

• Twirling of hair, examining follicles, pulling
  other persons hair (even dolls or carpet
  fibers), nail biting can occur.
• People with Trichotillomania may also have a mood
  disorder or anxiety disorder (e.g., OCD),
  substance use disorder, eating disorders, PDs and
  mental retardation.

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Trichotillomania

• Males Females equally represented among
  children. However, in adult it is much more
  common among Females.
• Prevalence No good data is available.
  Considered pretty uncommon
• Course pulling of hair during childhood may be
  considered a habit with self-limiting course.
  Those adults with chronic Trichotillomania report
  onset during adolescence. Can have symptoms for
  decades. Others report symptoms coming and going
  for week, months years. Sites of hair pulling
  can vary.

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Trichotillomania

• Diagnostic Criteria
• DSM-IV-TR p. 677
• Treatment
• Psychopharmacology results are disappointing.
  No single medication has much effect. Some that
  appear to have some usefulness are
• SSRIs
• Olanzapine
• Depakote
• Therapy
• Psychoanalysis does not appear work well with
  this condition
• CBT
• Self-monitoring
• Habit reversal training
• Stimulus Control

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Impulse-Control Disorder NOS 312.30

• Is to be used for any other impulse control
  disorder not somehow described in the DSM-IV.
• The manual points out that a skin picking
  disorder is not covered elsewhere.