Impulse Control Disorders

All answers are from DSM-IV-TR or

First and Tasmans 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 intermittent

explosive disorder
Q. List the dx criteria for intermittent
explosive disorder.

Dx criteria for intermittent

explosive 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 doesnt 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. Delirium
2. Dementia
3. Personality change due to a general
medical condition, general type
4. Substance intoxication
5. Substance withdrawal
Continued, next slide

Differential dx
6. Oppositional defiant disorder
7. Conduct disorder
8. Antisocial disorder
9. Borderline disorder
10. Mania
11. Schizophrenia
12. Tourettes
13. Anger attacks are seen sometimes as part of
MDD or panic disorder

Treatment
Q. What are the treatments?

Treatment
Ans.
Psychosocial:
Individual psychotherapies
Group psychotherapies
[Not clear why First and Tasman dont mention
Anger management per se.]
Meds [all off label]:
Mood stabilizers [Li and the anticonvulsants]
Beta blockers
SSRIs

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 aftermath
5. 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 of
pathological 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 pathological

gambling
Q. What about meds?

Meds for pathological

gambling
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 ones 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 ones 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 ones own hair?

Q. Pts who have trichotillomania pull hair
other than their own?

Only ones 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 therapys 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.