impulse control disorder final


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impulse control disorder final

  1. 1. IMPULSE CONTROL DISORDERS -Dr. Deepika Singh, 2nd Yr Resident, Dept of Psychiatry, GSMC & KEMH
  2. 2. IMPULSE CONTROL DISORDERS NOT ELSEWHERE CLASSIFIED: (1) Intermittent explosive disorder, (2) Kleptomania, (3) Pyromania, (4) Pathological gambling, (5) Trichotillomania, and (6) Impulse-control disorder not otherwise specified (NOS).
  3. 3. • • • • Epidemiology Comorbidity Etiology Diagnosis & Clinical features • Course & prognosis • Treatment
  5. 5. Epidemiology • More common in men than in women. • More in first-degree biological relatives of persons with the disorder than in the general population Comorbidity • Higher association with pyromania • Other disorders of impulse control • substance use and mood, anxiety, and eating disorders have also been associated
  6. 6. • ETIOLOGY Psychodynamic Factors: • Explosive outbursts occur as a defense against narcissistic injurious events. • Rage outbursts serve as interpersonal distance and protect against any further narcissistic injury Psychosocial Factors: • Unfavorable childhood environment • Early frustration, oppression, and hostility have been noted as predisposing factors.
  7. 7. Biological Factors • Low levels of CSF 5-HIAA have been correlated with impulsive aggression • Decreased serotonergic transmission, decreases the effect of punishment as a deterrent to behavior. • High CSF testosterone correlated with aggressiveness and violence in men
  8. 8. DSM-IV-TR DIAGNOSTIC CRITERIA • Several discrete episodes of failure to resist aggressive impulses that result in serious assaultive acts or destruction of property. • The degree of aggressiveness expressed during the episodes is grossly out of proportion to any precipitating psychosocial stressors. • 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 or a general medical condition
  9. 9. DIFFERENTIAL DIAGNOSIS • Conduct disorder: repetitive & resistant pattern of behavior, as opposed to an episodic pattern. • Antisocial and borderline personality disorders: Aggressiveness & impulsivity are part of patients' character & are present between outbursts. • Schizophrenia: patients show violent behavior in response to delusions and hallucinations, and they show gross impairments in reality testing. • Amok : It is an episode of acute violent behavior for which the person claims amnesia. Amok is distinguished from intermittent explosive disorder by a single episode and prominent dissociative features.
  10. 10. COURSE AND PROGNOSIS • It may begin at any stage of life, but usually appears between late adolescence and early adulthood • The disorder decreases in severity with the onset of middle age
  11. 11. TREATMENT • Group psychotherapy & family therapy • Goal of therapy: To have the patient recognize and verbalize the thoughts or feelings that precede the explosive outbursts instead of acting them out. • Anticonvulsants like carbamazepine, valproate and phenytoin • Selective serotonin reuptake inhibitors (SSRIs)
  13. 13. EPIDEMIOLOGY Prevalence estimated around 0.6 % Male-to-female ratio: 1:3 COMORBIDITY • High lifetime comorbidity of affective disorder (usually, but not exclusively, depression) and various anxiety disorders. • Other impulse-control disorders (notably, pathological gambling and compulsive shopping), eating & substance abuse disorders
  14. 14. ETIOLOGY • Anna Freud pointed out that the first thefts from mother's purse indicate the degree to which all stealing is rooted. • Karl Abraham wrote of the central feeling of being neglected, injured, or unwanted.
  15. 15. • One theoretician established 7 categories of stealing in chronically acting-out children: 1) As a means of restoring the lost mother child relationship 2) As an aggressive act 3) As a defense against fears of being damaged (perhaps a search by girls for a penis or a protection against castration anxiety in boys) 4) As a means of seeking punishment 5) As a means of restoring or adding to self-esteem 6) In connection with, and as a reaction to, a family secret 7) As excitement (lust angst) and a substitute for a sexual act • One or more of these can also apply to adult kleptomania
  16. 16. DSM-IV-TR DIAGNOSTIC CRITERIA FOR KLEPTOMANIA • Recurrent failure to resist impulses to steal objects that are not needed for personal use or for their monetary value. • Increasing sense of tension immediately before committing theft • Pleasure, gratification,or relief at the time of committing theft • The stealing is not committed to express anger or vengeance and is not in response to a delusion or a hallucination. • The stealing is not better accounted for by conduct disorder, a manic episode, or antisocial personality disorder.
  17. 17. ICD – 10 PATHOLOGICAL STEALING (KLEPTOMANIA) • There are two or more thefts in which the individual steals without any apparent motive of personal gain or gain for another person. • The individual describes an intense urge to steal, with a feeling of tension before the act and relief afterward
  18. 18. COURSE AND PROGNOSIS • Onset : late adolescence. • Mean age men : 50 yrs & women : 35 yrs • Course: waxes & wanes, but tends to be chronic • Prognosis with treatment can be good, but few patients come for help
  19. 19. TREATMENT • Behavior therapy, including systematic desensitization, aversive conditioning • SSRIs, such as fluoxetine & fluvoxamine, appear to be effective in some patients
  20. 20. PYROMANIA
  21. 21. EPIDEMIOLOGY • Prevalence : unknown • Male to female ratio : 8 to 1 COMORBIDITY • Substance abuse disorder & affective disorders; • Other impulse control disorders, such as kleptomania in female fire setters; • Personality disturbances, such as antisocial & borderline personality disorders. • Attention-deficit disorder and learning disabilities may be associated with childhood pyromania; • Persons who set fires are more likely to be mildly retarded than are those in the general population.
  22. 22. ETIOLOGY Psychosocial • Freud saw fire as a symbol of sexuality. • He believed the warmth radiated by fire evokes the same sensation that accompanies a state of sexual excitation, and a flame's shape and movements suggest a phallus in activity. • Some patients with pyromania are volunteer firefighters who set fires to prove themselves brave, to force other firefighters into action, or to demonstrate their power to extinguish a blaze. • The act is a way to vent accumulated rage over frustration caused by a sense of social, physical, or sexual inferiority.
  23. 23. • Several studies have noted that the fathers of patients with pyromania were absent from the home. • One explanation of fire setting is that it represents a wish for the absent father to return home as a rescuer, to put out the fire, and to save the child from a difficult existence. Biological Factors • Low CSF levels of 5-HIAA and 3-methoxy-4hydroxyphenylglycol (MHPG) - It suggests possible serotonergic or adrenergic involvement.
  24. 24. DSM IV TR : PYROMANIA • Deliberate & 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 • Pleasure, gratification, or relief when setting fires, or when witnessing or participating in their aftermath. • 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. dementia, MR, substance intoxication) • The fire setting is not better accounted for by conduct disorder, a manic episode, or antisocial personality disorder
  25. 25. • ICD – 10 PYROMANIA • There are two or more acts of fire setting without apparent motive. • The individual describes an intense urge to set fire to objects, with a feeling of tension before the act and relief afterward. • The individual is preoccupied with thoughts or mental images of fire setting or of the circumstances surrounding the act (e.g., abnormal interest in fire engines or in calling out the fire service
  26. 26. COURSE AND PROGNOSIS • Begins in childhood, the typical age of onset is unknown. • When onset is in adolescence or adulthood, the fire setting tends to be deliberately destructive. • It is episodic & may wax & wane in frequency. • Prognosis for treated children is good, and complete remission is a realistic goal. • Prognosis for adults is guarded, because they frequently deny their actions, refuse to take responsibility, are dependent on alcohol, & lack insight
  27. 27. TREATMENT • Treatment difficult because of their lack of motivation. • No single treatment has been proved effective; thus a number of modalities, including behavioral approaches, should be tried. • Because of the recurrent nature, any treatment program should include supervision of patients to prevent a repeated episode of fire setting. • In children and adolescents, treatment should include family therapy
  29. 29. EPIDEMIOLOGY • Prevalance ~ 1% • Male to female ratio: 3:1 • Family histories of pathological gamblers show an increased rate of substance abuse and depressive disorders. • A parent or influential relative of the patient often has been a problem or pathological gambler. • The family circle is likely to be competitively & materialistically oriented, evincing intense admiration for money & associated symbols of success.
  30. 30. COMORBIDITY • Mood disorders (especially, major depression and bipolarity) & substance abuse disorders ( alcohol & cocaine abuse, caffeine & nicotine dependence) • ADHD • Personality disorders ( narcissistic, antisocial & borderline personality disorders) • Other impulse-control disorders. • Although many have obsessive personality traits, full-blown OCD is uncommon.
  31. 31. ETIOLOGY Psychosocial Factors Predispose factors : • loss of a parent, separation, divorce, or desertion before child is 15 yrs of age; • inappropriate parental discipline (absence, inconsistency, or harshness); • exposure to & availability of gambling activities for adolescents; • family emphasis on material and financial symbols; and lack of emphasis on saving, planning, and budgeting.
  32. 32. Biological Factors • Subnormal MHPG concentrations in plasma, increased MHPG concentrations in the CSF, and increased urinary output of norepinephrine. • Serotonergic regulatory dysfunction • Chronic gamblers have low platelet monoamine oxidase (MAO) activity, a marker of serotonin activity. • increased cortisol levels in the saliva of gamblers while they gamble, which can account for the euphoria that occurs during the experience and its addictive
  33. 33. DSM-IV-TR PATHOLOGICAL GAMBLING A] Persistent and recurrent maladaptive gambling behavior as indicated by five (or more) of the following: 1] preoccupied with gambling (e.g., preoccupied with reliving past gambling experiences, handicapping or planning the next venture, or thinking of ways to get money to gamble) 2] needs to gamble with increasing amounts of money in order to achieve the desired excitement 3] repeated unsuccessful efforts to control, cut back, or stop gambling 4] restless irritable when attempting to cut down or stop gambling 5] gambles as a way of escaping from problems or of relieving a dysphoric mood (e.g, feelings of guilt ,anxiety, depression)
  34. 34. 6] after losing money gambler often returns another day to get even (chasing one's losses) 7] lies to family members, therapist, or others to conceal the extent of involvement with gambling 8] committed illegal acts such as forgery, fraud, theft, or embezzlement to finance gambling 9] 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
  35. 35. ICD–10 PATHOLOGICAL GAMBLING • Two or more episodes of gambling occur over a period of at least 1 year. • These episodes do not have a profitable outcome for the individual but are continued despite personal distress & interference with functioning in daily living • The individual describes an intense urge to gamble which is difficult to control and reports that he or she is unable to stop gambling by an effort of will. • The individual is preoccupied with thoughts or mental images of the act of gambling or the circumstances surrounding the act
  36. 36. COURSE AND PROGNOSIS • Begins in adolescence for men and late in life for women. • waxes and wanes, tends to be chronic. Four phases : 1] winning phase: ending with a big win, which hooks patients 2] progressive-loss phase: patients structure their lives around gambling, take considerable risks, cash in securities, borrow money, miss work, & lose jobs. 3] desperate phase: frenzied gambling with large amounts of money, not paying debts & huge loans. 4] hopeless stage: accepting that losses can never be made up, but the gambling continues because of the associated arousal or excitement.
  37. 37. TREATMENT • Gamblers Anonymous was founded in Los Angeles in 1957 and modeled on Alcoholics Anonymous (AA); it is accessible in large cities and is an effective treatment for gambling in some patients. • GA is a method of inspirational group therapy that involves public confession, peer pressure, and the presence of reformed gamblers (as with sponsors in AA) available to help members resist the impulse to gamble. • Four places in india, 2 in mumbai, 1 delhi & 1 chenai
  38. 38. • Cognitive-behavioral therapy (e.g., relaxation techniques combined with visualization of gambling avoidance) • Family therapy • Little is known about the efficacy of pharmacotherapy. One study reported that 7 of 10 patients remained completely abstinent over 8 weeks after taking fluvoxamine
  40. 40. EPIDEMIOLOGY • Prevalence 0.6 to 3.4 % • male to female ratio 1:9 • childhood type of trichotillomania occurs approximately equally in girls and boys. • It is said to be more common than the adolescent type and is generally far less serious dermatologically and psychologically. • 33 to 40 % of patients chew or swallow the hair that they pull out. Of this group, approximately 37.5 % develop potentially hazardous bezoars.
  41. 41. COMORBIDITY • Significant comorbidity is found between trichotillomania and OCD (as well as other anxiety disorders); • Tourette's syndrome; affective illness, especially depressive conditions; eating disorders; and various personality disorders particularly obsessive-compulsive, borderline, and narcissistic personality disorders. • Comorbid substance abuse disorder is not encountered as frequently as it is in pathological gambling,
  42. 42. ETIOLOGY • Disturbances in mother-child relationships, fear of being left alone, and recent object loss are often cited as critical factors contributing to the condition. • Depressive dynamics are often cited as predisposing factors, but no particular personality trait or disorder characterizes patients. • Family members of trichotillomania patients often have a history of tics, impulse-control disorders, and obsessive-compulsive symptoms
  43. 43. DSM IV TR : TRICHOTILLOMANIA • Recurrent pulling out of one's hair resulting in noticeable hair loss. • An increasing sense of tension immediately before pulling out the hair or when attempting to resist the behavior. • Pleasure, gratification, or relief when pulling out the hair. • The disturbance is not better accounted for by another mental disorder and is not due to a general medical condition (e.g., a dermatological condition). • The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
  44. 44. COURSE AND PROGNOSIS • Mean age at onset : early teens, mostly before age 17 • Course is not well known; both chronic and remitting forms occur. • An early onset (before age 6) tends to remit more readily and responds to suggestion, support, and behavioral strategies. • Late onset (after age 13) is associated with an increased likelihood of chronicity and poorer prognosis
  45. 45. • TREATMENT • Psychopharmacological methods - It includes topical steroids and hydroxyzine hydrochloride , an anxiolytic with antihistamine properties; antidepressants; serotonergic agents; & antipsychotics. • Patients who respond poorly to SSRIs may improve with augmentation with pimozide, a dopamine receptor antagonist. • Behavior therapy also helpful
  48. 48. -Originally referred to as oniomania and recognized by Emil Kraeplin and Eugen Bleuler. -Compulsive buying is not listed as a separate diagnostic category in DSM-IV-TR and ICD-10. -Epidemiology: • 1.1 to 5.9% prevalence • More common in women than in men
  49. 49. DIAGNOSTIC CRITERIA FOR COMPULSIVE BUYING • Maladaptive preoccupation with buying or shopping, or maladaptive buying or shopping impulses or behavior, as indicated by at least one of the following: – Frequent preoccupation with buying or impulses to buy that are experienced as irresistible, intrusive, and/or senseless. – Frequent buying of more than can be afforded, frequent buying of items that are not needed, or shopping for longer periods of time than intended. • The buying preoccupations, impulses, or behaviors cause marked distress, are time consuming, significantly interfere with social,occupational functioning, or result in financial problems. • The excessive buying or shopping behavior does not occur exclusively during periods of hypomania or mania.
  50. 50. • Etiology: Psychodynamic theories have implicated low self-esteem, anxiety, and the need to reduce stress as the causal factors. • Comorbid conditions: Other impulse control d/o’s (e.g. kleptomania), mood d/o’s & OCD • Course & prognosis: Onset :18 yrs However, patients do not seek treatment until their 30s, usually because they have developed serious financial problems. - Patients often try to limit their behavior but are unsuccessful.
  51. 51. TREATMENT : • Treatment of compulsive buying is difficult. • Some patients are helped with supportive therapy,& self-help groups, such as Debtors Anonymous • Pharmacological therapies include antidepressants, anxiolytics, and antipsychotics to treat any comorbid conditions. • The SSRIs have been used to limit compulsive behavior and may be of use in this condition, which has compulsive aspects
  53. 53. • Internet addiction disorder was originally proposed by Ivan Goldberg in 1995. It is however not included in the DSM IV & proposed to be included in DSM V. • Such persons spend almost all their waking hours with the computer • Their patterns of use are repetitive and constant, and they are unable to resist strong urges to use the computer or to surf the Web. • Internet addicts may gravitate to certain sites that meet specific needs (e.g., shopping, sex, and interactive games, among others).
  54. 54. Mark D. Griffiths’ 5 criteria of Internet addiction are: • Salience: Using the Internet dominates the person’s life, feelings and behaviour. • Mood modification: The person experiences changes in mood when using the Internet. • Tolerance: Increasing amounts of Internet use are needed to achieve the same effects on mood. • Withdrawal symptoms: If the person stops using the Internet, they experience unpleasant feelings or physical effects. • Relapse: The addict tends to relapse into earlier patterns of behaviour, even after years of abstinence or control.
  56. 56. • Dermatillomania (also known as neurotic excoriation, pathologic skin picking, compulsive skin picking or psychogenic excoriation) is an impulse control disorder characterized by the repeated urge to pick at one's own skin, often to the extent of causing damage. • It includes an uncontrollable urge to pick one's skin in order to seek gratification. Epidemiology • Prevalence: 1.4 to 5.4% • More common in females than males
  57. 57. ETIOLOGY: - It is a coping mechanism to deal with elevated levels of arousal or stress within the individual, & that individual has an impaired stress response. - According to psychosocial theory picking behavior is the result of repressed rage felt toward authoritarian parents COMORBIDITY: mood & anxiety disorder, substance abuse, trichotillomania, anxiety d/o, major depressive d/o, obsessivecompulsive d/o,body dysmorphic d/o
  59. 59. • Some persons repeatedly seek out sexual gratification, often in perverse ways (e.g exhibitionism) • They are unable to control their behavior & may not experience feelings of guilt after an episode of acting-out behavior. • Sometimes called sexual addiction
  61. 61. • Some persons compulsively use mobile phones to call others, friends, acquaintances, or business associates. • They justify their need to contact others by giving plausible reasons for calling; but underlying conflicts may be expressed in the behavior, such as fear of being alone, the need to satisfy unconscious dependency needs, or undoing a hostile wish toward a loved one.