Disorders of Behavior and Impulse Control

1
Disorders of Behavior and Impulse Control

• Test Results
• Read Article
• Lecture

2
Overview

• Substance Abuse
• Sleep
• Sexual and Sexual Identity
• Eating

3
Substance-Related Disorders

• The core concept of the group is the occurrence
  of adverse social, behavioral, psychological, and
  physiological effects caused by seeking or using
  one or more substances.

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Evans (1998)

• 30 of population with drug dx
• 5.3 million people
• 6 million children from homes with substance dx
  is diagnosable
• 75 to 85 other mental disorder
• 54 prison inmates substance dx
• Deaths
• 350 per day due to nicotine dependence
• 150 alcohol
• 15 other

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DSM

• DSM I
• Alcoholism and Drug Addiction
• Sociopathic personality disorders
• DSM III
• Move toward specific classes of substances

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12 Classes of Abused Substances (p.193)

• Alcohol
• Inhalants
• Amphetamines
• Nicotine
• Caffeine
• Opioids
• Cannabis

• Phencyclidine
• Cocaine
• Sedatives, Hypnotics or Anxiolytics
• Hallucinogens
• Other or Unknown Substances

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DEFINITIONS

• Anxiolytic - medications that relieve anxiety
  (benzodiazepines)
• Macropsia perceptual state wherein objects seem
  larger than they are
• Micropsia perceptual state wherein objects seem
  smaller than they are
• Psychomotor agitation abnormal increase in
  physical and emotional activity
• Rush an immediate high that occurs shortly
  after substance ingestion
• Tolerance needing increased amounts of a
  substance to achieve intoxication or desired
  effect
• Withdrawal physical symptoms that occur after
  stopping or reducing the consumption of a
  substance
• Page 193 Table of drug effects

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Psychoactive Substance Use Disorders

• Examples
• Substance Dependence
• P. 197
• Continued use of substance despite substance
  related problems.
• Typically involves physiological dependence
• Substance Abuse
• P. 199
• Maladaptive pattern of substance use leading to
  distress
• Each substance area can be either Dependence or
  Abuse e.g.
• Alcohol Dependence 303.90
• Alcohol Abuse 305.00
• Once you qualify for Dependence rule-out Abuse
• Substance Induced Disorders
• Substance Intoxication
• Substance Withdrawal

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Specifiers

• With / Without physiological dependence
• Tolerance or Withdraw
• Early Full Remission
• No criteria for 1 month
• Early Partial Remission
• 1 or more criteria but not full
• Sustained Full Remission
• No criteria for 12 months
• Sustained Partial
• 1 or more but not full criteria for 12 months
• Contextual Specifiers
• Agonist Therapy prescribed meds, no criteria 1
  month
• Controlled Environment -

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Substance-Induced Disorders

• Substance Intoxication (p. 201)
• Substance Withdrawal (p. 202)
• Substance-Related Disorder NOS (e.g., p. 223)
• Substance-Induced Mental Disorders (p. 209)
• Delirium, Dementia, Amnestic Disorder, Psychotic
  Disorder, Mood Disorder, Sexual Dysfunction,
  Sleep Disorder, Anxiety Disorder (p. 479)

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Necessary Clinical Information

• Identity of substance(s) used
• History of substance(s) used
• History of substance use emergencies and
  treatment
• Cognitive impairment (e.g., confusion,
  disorientation, impaired attention)
• Physiological signs (e.g., hypertension,
  hypotension, tachycardia)

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• Psychomotor agitation or retardation
• Changes in mood, perception, and thought
• Changes in personality, mood, anxiety
• Urine drug screening, blood alcohol level
• Changes in social or family life
• Current and past legal problems

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Making a Diagnosis

• Does the patient admit to using a substance?
• Does the patient have abnormal physiological
  signs or symptoms?
• Does the patient have a history of substance
  abuse?
• Has the patient experienced recent related legal
  problems?
• Does the patient have maladaptive behavioral or
  psychological changes?

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Key Diagnostic Points

• Substance Dependence diagnoses distinguished by
  evidence of either tolerance or withdrawal
• Two main categories used in diagnosing dependence
  include physiological effects and resulting
  behavioral problems
• Pupillary dilation is a sign of intoxication with
  some stimulants (e.g., cocaine) and a sign of
  withdrawal with some depressants (e.g., opioids)
• Psychopathology occurring within 1 month after
  substance use may be etiologically related to the
  substance use

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• A 38 year old mother of 4 was referred to a
  counselor by her priest, to whom she had confided
  that every few months she was subject to intense
  fits of rage in which she struck her children and
  threw things at her husband, sometimes needing to
  be physically restrained. The children had
  learned to run off to their rooms and lock the
  doors when she began to rant "Did you do your
  homework?" or "Look at this messy house!" She
  had overheard them referring to her to their
  father as "crazy Mommy" and "looney." Her
  husband would not talk to her for several days
  after such an incident. The client herself felt
  very guilty and ashamed. Detailed questioning
  revealed that each episode was apparently
  associated with the client's sneaking only "a
  swallow or two" from a bottle of bourbon she kept
  hidden from her husband in the trunk of her car.

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Diagnosis

• Axis I 305.00

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Sleep Disorders

• Disturbance in the process of sleep that causes
  clinically significant distress or impairment in
  social, occupational, or other important areas of
  functioning.

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Definitions

• Apnea cessation of breathing
• Cataplexy sudden loss of muscle tone usually
  associated with intense emotion
• Dyssomnia disturbance in the amount, quality,
  or timing of sleep
• Hypersomnia excessive amount of sleep
• Insomnia difficulty initiating and maintaining
  sleep
• Parasomnia disorders in which abnormal events
  occur during sleep
• Somnambulism - sleepwalking

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Dyssomnias

• Disorders of initiating or maintaining sleep or
  of excessive sleepiness characterized by
  disturbance in the amount, quality, or timing of
  sleep.
• Primary Insomnia p. 604 Primary
• Hypersomnia p. 609

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• Narcolepsy p. 615
• Breathing-Related Sleep Disorder p. 622
• Circadian Rhythm Sleep Disorder p. 629
• Dyssomnia NOS p. 629

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Necessary Clinical Information

• Insomnia or Hypersomnia
• Daytime napping
• Nightmares or bad dreams
• Substance abuse
• Sleep medication
• Excessive daytime sleepiness
• Work schedule
• Travel schedule
• Medical problems that might interfere with sleep
• Snoring
• Unusual sleep behavior (e.g., sleepwalking,
  episodes of terror)

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Parasomnias

• Disorders characterized by abnormal behavioral or
  physiological events occurring in association
  with sleep, specific sleep stages, or sleep-wake
  transitions.
• Nightmare Disorder (p. 634)

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• Sleep Terror Disorder (p. 639)
• Sleepwalking Disorder (p. 644)
• Parasomnia NOS (p. 644)

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Other Sleep Disorders

• Insomnia Related to Another Mental Disorder (p.
  650)
• Hypersomnia Related to Another Mental Disorder
  (p. 650)
• Sleep Disorder Due to a General Medical Condition
  (p. 654)
• Substance-Induced Sleep Disorder (p. 660)

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Key Diagnostic Features

• The diagnosis of Insomnia and Hypersomnia Related
  to Axis I or Axis II disorder is made when the
  patient has a sleep disturbance related to a
  psychiatric disorder but the disturbance is
  sufficiently severe to warrant independent
  treatment
• Excessive daytime sleepiness and loud snoring are
  defining features of Breathing-Related Sleep
  Disorder (sleep apnea)

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• The diagnosis of Insomnia and Hypersomnia Related
  to Axis I or Axis II disorder is made when the
  patient has a sleep disturbance related to a
  psychiatric disorder but the disturbance is
  sufficiently severe to warrant independent
  treatment
• Excessive daytime sleepiness and loud snoring are
  defining features of Breathing-Related Sleep
  Disorder (sleep apnea)

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• A 19 year old military recruit is referred to the
  counselor after walking in his sleep in his
  barracks on three occasions. He walked in his
  sleep as a young child, as did one of his
  sisters, but ha snot done so since about age
  five. He says he is not aware of this behavior
  and does not recall any dream associated with it.
  there is no personal history of significant
  dysphoria, maladjustment, or other psychiatric
  symptoms, and no family history of psychiatric
  disorder (except for sleepwalking). He has been
  doing well in Basic Training and does not want a
  medical discharge. His physical examination,
  including neurological workup and EEG, is
  negative.

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Diagnosis

• Axis I -

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Sexual and Gender Identity Disorders

• The core concept of the group is difficulty in
  the expression of normal sexuality (Fauman,
  1994 p. 284). The sexual disturbance results in
  significant distress or impairment in social,
  occupational, or other important areas of
  functioning.

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Sexual Desire Disorders

• Hypoactive Sexual Desire Disorder (p. 541)
• Sexual Aversion Disorder (p. 542)

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Sexual Arousal Disorders

• Female Sexual Arousal Disorder (p. 544)
• Male Erectile Disorder (p. 547)

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Orgasmic Disorders

• Female Orgasmic Disorder (p. 549)
• Male Orgasmic Disorder (p. 552)
• Premature Ejaculation (p. 554)

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Sexual Pain Disorders

• Dyspareunia (p. 556)
• Vaginismus (p. 558)

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• Sexual Dysfunction Due to a General Medical
  Condition (p. 561)
• Substance-Induced Sexual Dysfunction (p. 565)
• Sexual Dysfunction NOS (p. 565)

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Paraphilias

• Recurrent, intense sexually arousing fantasies,
  sexual urges or behaviors with a specific focus
  lasting at least 6 months.
• Distinguished from some other disorders because,
  in some cases (e.g., Frotteurism), the diagnosis
  is made if the client has acted on the urges
  regardless of whether the client indicates that
  the symptoms have caused marked distress.

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• Exhibitionism (p. 569)
• Fetishism (p. 570)
• Frotteurism (p. 570)
• Pedophilia (p. 572)
• Sexual Masochism (p. 573)

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• Sexual Sadism (p. 574)
• Transvestic Fetishism (p. 575)
• Voyeurism (p. 575)
• Paraphilia NOS

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• Gender Identity Disorder (p. 581)
• Gender Identity Disorder NOS (p. 582)
• Sexual Disorder NOS (p. 582)

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Necessary Clinical Information

• History of cross-dressing
• Current preferences for sexual partner (e.g.,
  age, sex)
• Current sexual desire
• Problems with arousal
• Problems with orgasm
• Pain associated with sex

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• Current and past sexual fantasies
• Use of objects associated with the opposite sex
  for arousal
• Gender Identity
• Unusual sexual activity (e.g., voyeurism,
  frotteurism)
• Coercion or humiliation in the sexual act

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Impulse Control Disorders Not Otherwise Classified

• Core concept of the diagnostic group is the
  repeated expression of impulsive acts that lead
  to physical or financial damage and often result
  in a sense of relief or release of tension.

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Impulse Control Disorders Not Otherwise Classified

• Intermittent Explosive Disorder (p. 667)
• Kleptomania (p. 669)

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• Pathological Gambling (p. 674)
• Pyromania (p. 671)
• Trichotillomania (. 677)
• Impulsive Control Disorder NOS (p. 677)

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Necessary Clinical Information

• Repeated episodes of stealing not motivated by
  monetary gain or vengeance
• Unexplained hair loss in unusual areas of the
  body
• Repeated financial difficulties in a person who
  appears to make adequate money
• Repeated gambling
• Sudden episodes of violence that are not
  warranted by the obvious stressor
• Repeated episodes of fire setting not motivated
  by monetary gain or vengeance

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Key Diagnostic Points

• Objects stolen in Kleptomania are not needed for
  personal use or monetary gain
• In Kleptomania, Pyromania, and Trichotillomania
  there is a sense of tension before the act, and
  pleasure, gratification, or relief after the act.

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• Craig was a hardworking student who began
  gambling in high school and found it exciting.
  Eventually he concentrated his gambling on horse
  races and tried to develop a system to beat the
  betting odds. His initial betting was restrained
  and judicious and he had modest winnings. One
  day, after he had established a successful dental
  practice, Craig won a substantial amount of
  money. After that his pattern of gambling
  changed. He became convinced that he could not
  lose and needed to bet more and more to maintain
  the initial excitement he had felt while
  gambling. Craig became careless and started to
  lose money, but responded by betting more money
  in an attempt to get even or recoup his losses.
  He tried to stop several times but in each
  instance he became irritable and restless and
  finally returned to gambling. Soon the gambling
  began to interfere with his practice and he began
  using the money he needed for the mortgage and
  other bills to pay his gambling debts. When his
  wife confronted him about the money, he lied to
  her. Eventually, as he became desperate, Craig
  borrowed from friends and loan sharks to finance
  his gambling.

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Diagnosis

• Axis I

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Eating Disorders

• The core concept of the group includes
• Obsessive concern about becoming overweight or
  fat
• Distorted body image
• Inability to appropriately control food intake to
  maintain a healthy body weight
• Fluctuation of self-evaluation dependent on
  perceived body shape or weight.

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Definitions

• Anorexia loss of appetite accompanied by
  inability to eat
• Binge excessive eating beyond the amount
  necessary to satisfy normal appetite
• Purge emptying the stomach by induced vomiting
  or the bowels by induced evacuation with enemas
  or laxatives

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Necessary Clinical Information

• Current and past weight
• Current and past patterns of eating
• Current and past feelings about food
• Unusual eating rituals
• Current and past appetite
• History of dieting
• Current and past feelings about weight

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• Medical illnesses
• Current medications and abused substances
• Psychiatric illnesses (e.g., Major Depression)
• Episodes of binge eating
• Psychological conflicts related to
  self-evaluation (self-esteem)
• Relationship between weight and patients
  self-esteem
• Family history of Eating Disorder

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EATING DISORDERS

• ANOREXIA NERVOSA (p. 589)
• BULIMIA NERVOSA (p. 594)
• EATING DISORDER NOS (p. 594)

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• Eight-year-old Tim was referred by a pediatrician
  who asked for an emergency evaluation because of
  a serious weight loss during the past year. Tim
  is extremely concerned about his weight and
  weighs himself daily. He complains that he is
  too fat, and if he does not lose weight, he cuts
  back on food. He has lost ten pounds in the past
  year and still feels that he is too fat, though
  it is clear that he is underweight. In
  desperation, his parents have removed the scales
  from the house as a result, Tim is keeping a
  record of the calories that he eats daily. He
  spends a lot of time on this, checking and
  rechecking that he has done it just right. In
  addition, Tim is described as being obsessed with
  cleanliness and neatness. Currently he has no
  friends because he refuses to visit them, feeling
  that their houses are "dirty" he gets upset whey
  another child touches him. He is always checking
  whether he is doing things the way they "should"
  be done. He becomes very agitated and anxious
  about this. He has to get up at least two hours
  before leaving for school each day in order to
  give himself time to get ready. Recently, he
  woke up at 130 in the morning to prepare for
  school.

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Diagnosis

• Axis I