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IMPULSE CONTROL    DISORDERS (ICDs)     Windsor University School of              Medicine          Psychiatry Rotation  C...
Overview    ‘Throughout the past few years, ICDshave attracted the attention of cliniciansand psychiatrists due to their i...
Definition of terms Impulse-control       disorders      (ICDs)    are  psychological disorders characterized by the  rep...
OUTLINE OF IMPULSECONTROL DISORDERS      (ICDs)
Outline of ICDs According to the DSM-IV-TR classification:   Impulse control disorders not elsewhere classified:      I...
Outline of ICDs Impulsivity is controlled by three major cognitive components which are all stressful for an individual w...
Outline of ICDs Each disorder is characterized by the inability to  resist an intense impulse, drive, or temptation to  p...
Incidence As compared to other mental disorders, impulse  control disorders were found in 8.9% (12-month  prevalence) and...
Incidence It is rather hard to determine the prevalence of almost all other impulse control disorders because individuals...
Risk factors Traumatic     Brain Injury may result in some  individuals developing impulsive disorder. This is  particula...
Etiology Biological Psychological Social
Etiology – Biological Many investigators have focused on possible  organic factors in the impulse-control disorders,  esp...
Etiology – Neurobiology The human brain is wired with natural checks and balances that control emotions, but breakdowns i...
Etiology – Psychological An impulse is a disposition to act to decrease  heightened tension caused by the buildup  of ins...
Etiology – Social Psychosocial factors implicated causally in impulse- control disorders are related to early-life events...
Pathogenesis It has not been fully established yet how impulse  control disorders starts but the following hypothesis is ...
Pathogenesis Impulsive behavior may be related to the interplay between several    distinct brain regions, namely the orb...
Pathogenesis
Pathophysiology
INTERMITTENTEXPLOSIVE DISORDER       (IED)
IED Intermittent explosive disorder manifests as discrete  episodes of losing control of aggressive impulses;  these epis...
IED – Case Presentations• A 31-year-old male presented with features of remaining aloof, sad,  having prominent guilt idea...
IED – Case Presentations Kevin is diagnosed with an intermittent explosive behavior. He was raged with anger when a frien...
DSM-IV-TR CRITERIAA. Several discrete episodes of failure to resist   aggressive impulses that result in serious   assault...
Facts and Figures Gender Differences: more common in men than  women Prevalence: rare Course: variable; chronic or epis...
Contributing Factors Behavioral theory:   Antecedents: a sense of tension or arousal   Behavior: explosive behavior, ag...
Contributing Factors Some    researchers have spotted a correlation between  aggressive behavior and disorders of the fro...
Differential Diagnosis1.    Delirium2.    Dementia3.    Personality change due to a general medical condition,      genera...
Treatment – Psychosocial Individual psychotherapies Group psychotherapies Anger management
Treatment – Biological Medications used in the treatment of IEDs are all  off –label! Examples include:   Mood stabiliz...
PYROMANIA
Pyromania Pyromania is the recurrent, deliberate, and purposeful  setting of fires. Associated features include tension o...
Etiology The exact cause for pyromania is still unclear. Evidence suggests a multifactorial pathogenesis which       invo...
DSM-IV-TR CRITERIAA. Deliberate and purposeful fire setting on more than one   occasion.B. Tension or affective arousal be...
Facts and Figures Age factors: although fire setting is a major problem in    childhood and adolescence, pyromania is rar...
Contributing Factors Considerable planning and advance preparation for starting    a fire   Reaction to fire-setting: gr...
Differential diagnosis Arson Psychosis Impaired judgment due to substance abuse mental retardation or dementia Dissoc...
Treatment – Psychosocial The literature focuses on treating pts with fire setting more broadly, that is addressing other ...
KLEPTOMANIA
Kleptomania Kleptomania is the irresistible urge to steal items that you  generally dont really need and that usually hav...
Kleptomania - Case Presentation A 24 years old female, highly successful, single executive from a wealthy background. She...
DSM-IV-TR CRITERIAA. Recurrent failure to resist impulses to steal   objects that are not needed for personal use or   for...
Facts and Figures Gender: 66% to 80% are female Prevalence: occurs in less than 5% of identified  shoplifters; prevalenc...
Related & Contributing Factors Associated Disorders & Behaviors: compulsive shopping,  Mood Disorders (particularly depre...
Differential diagnosis Episodes of theft occasionally occur during psychotic  illness, for example, acute mania, major de...
Treatment – Psychosocial No systematic or controlled psychosocial  treatments. Successful anecdotal treatments include: ...
Treatment – Biological Antidepressants Mood stabilizers such as Lithium Combination therapy – Antidepressants and Mood ...
PATHOLOGICAL  GAMBLING
Pathological Gambling Also   known as Compulsive Gambling, it is the  uncontrollable urge to keep gambling despite the to...
Neuro-pathology Functional magnetic resonance imaging (fMRI) and brain spectroscopy have shown that the ventro-medial pre...
DSM-IV-TR CRITERIAA. Persistent and recurrent maladaptive gambling behavior   as indicated by 5 or more of the following: ...
DSM-IV-TR CRITERIA 6) After losing money gambling, often returns    another day to get even (“chasing” one’s    losses) 7)...
Epidemiology A survey of 2,638 American adults concluded that the prevalence of pathological gambling ranges between 1.3%...
Facts and Figures Gender: approximately 1/3 are female; females are more    likely to be depressed and to gamble as an es...
Associated and ContributingFactors Distortions in thinking: denial; superstitions; overconfidence;    sense of power and ...
Treatment – Psychosocial Treatment approach is like treatment for substance dependence:  Gamblers anonymous  Individual...
Psychosocial – GamblersAnonymous The following are the twelve steps of the Gambler’s  Anonymous model:1. We admit that we...
Psychosocial – GamblersAnonymous 6. We are totally ready to be helped to get rid of     these defects of character. 7. We ...
Psychosocial – GamblersAnonymous 11. We seek by means of our meditation and     prayers our vital connection with God as w...
Treatment – Biological The following have some support:  Selective Serotonin Reuptake Inhibitors   (SSRIs)  Naltrexone ...
TRICHOTILLOMANIA
Trichotillomania Trichotillomania is hair loss from repeated urges to  pull or twist the hair until it breaks off. Patien...
Etiology Little is known about the etiology of trichotillomania. It  usually presents itself in late childhood and  adole...
DSM-IV-TR CRITERIAA. Recurrent pulling out of one’s hair resulting in   noticeable hair lossB. An increasing sense of tens...
Facts and Figures Gender    differences: males and females are  equally represented among children; much more  common for...
Contributing and AssociatedFeatures Most common sites for hair pulling: scalp,  eyebrows, and eyelashes Triggers:     re...
Treatment – Psychosocial Behavior therapy’s - “habit reversal.” Cognitive-Behavioural Therapy (CBT) Hypnosis [also use ...
Treatment – Biological Clomipramine SSRIs are used and have positive reports, but not in  controlled studies. Antipsych...
COMPULSIVE BUYING    DISORDER
Compulsive Buying Disorder(CBD) Compulsive buying disorder (CBD) is characterized  by an obsession with shopping and buyi...
Compulsive Buying Disorder(CBD) Promising treatments for CBD include medication such  as selective serotonin reuptake inh...
INTERNET ADDICTION
Internet Addiction Disorder The Internet itself is a neutral device originally  designed to facilitate research among aca...
Internet Addiction Disorder In 1998, Young conceptualized problematic Internet use as a form of impulse control disorders...
Young’s Internet Addiction DiagnositcQuestionnaire (IADQ) Young’s      Internet     Addiction      Diagnostic  Questionna...
Young’s Internet Addiction DiagnositcQuestionnaire (IADQ)4. Do you feel depressed, restless, irritable or   moody when try...
Young’s Internet Addiction DiagnositcQuestionnaire (IADQ)8. Do you use the cyber-world as a means of   sanctuary from prob...
Proposed DSM-V Criteria The American Psychiatric Association considered inclusion of  diagnosis of problematic Internet u...
Negative Consequences While time is not a direct function in defining Internet  addiction, generally addicted users are l...
Familial Impairment Young (1996) found that serious relationship problems  were reported by fifty-three percent of Intern...
Academic Impairment The    Internet has been touted as a premiere  educational tool driving schools to integrate Internet...
Occupational Impairment Internet misuse among employees is a serious concern  among managers. One survey from the nations...
Occupational Impairment Managers have been forced to respond by posting  policies detailing acceptable and unacceptable I...
Occupational Impairment – Casestudy Evelyn is a 48 year old executive secretary who found  herself compulsively using cha...
Occupational Impairment Employers  uncertain how to approach Internet addiction among workers may respond to an employee ...
Treatment There are no meta-analyses that have established the  best lines of treatment for problematic internet use.  Pr...
PATHOLOGICAL LYING
Pathological Lying Pathological lying is also known as pseudologia  fantastica or mythomania. It is simply described as ...
Defining Characteristics The defining characteristics of pseudologia fantastica  are: The stories told are not entirely ...
Defining Characteristics The stories told tend toward presenting       the liar  favorably. For example, the person might...
SEX ADDICTION
Sexual Addiction Sexual addiction is used to describe the behavior of a  person who has an unusually intense sex drive or...
Sexual Addiction & Risk Taking Sexual addiction also is associated with risk-taking. A  person with a sex addiction engag...
Associated/Related Behaviors Behaviors associated with sexual addiction include:   Compulsive masturbation (self-stimula...
Treatment Most sex addicts live in denial of their addiction, and  treating an addiction is dependent on the person  acce...
12 Steps of Sex AddictsAnonymous1.   We admitted we were powerless over addictive     sexual behavior - that our lives had...
12 Steps of Sex AddictsAnonymous7.    Humbly asked God to remove our shortcomings.8.    Made a list of all persons we had ...
REFERENCES http://www.fastceus.com/courses/Impulse_Disorders-    3CEUs.pdf   http://www.internetandpsychiatry.com/joomla...
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Impulse-control disorders (ICDs) are psychological disorders characterized by the repeated inability to refrain from performing a particular action that is harmful either to oneself or others.
The individual fails to resist performing a potentially harmful act and it is usually accompanied by a sense of tension or arousal before committing the act and a sense of relief or pleasure when it is committed.
The hallmark in describing any of the ICDs is a tendency to gratify an immediate desire or impulse regardless of the consequences to one's self or to others.

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  1. 1. IMPULSE CONTROL DISORDERS (ICDs) Windsor University School of Medicine Psychiatry Rotation Consultant Psychiatrist – Dr. Sharon Halliday Presentation by:OLADAPO SAMSON OLUWABUKOLA TH
  2. 2. Overview ‘Throughout the past few years, ICDshave attracted the attention of cliniciansand psychiatrists due to their impact on the society. Interestingly enough, the rapid advancement of technology andits effects on the society is incriminated to be the cause for the rise in the prevalence of ICDs. The advent of theInternet has created unlimited access to gambling, shopping, porn and stock trading; thus, the incidence of impulsive behavior patterns has risen sharply. Even more, new forms ofimpulsive disorders have emerged such
  3. 3. Definition of terms Impulse-control disorders (ICDs) are psychological disorders characterized by the repeated inability to refrain from performing a particular action that is harmful either to oneself or others. The individual fails to resist performing a potentially harmful act and it is usually accompanied by a sense of tension or arousal before committing the act and a sense of relief or pleasure when it is committed. The hallmark in describing any of the ICDs is a tendency to gratify an immediate desire or impulse regardless of the
  4. 4. OUTLINE OF IMPULSECONTROL DISORDERS (ICDs)
  5. 5. Outline of ICDs According to the DSM-IV-TR classification:  Impulse control disorders not elsewhere classified:  Intermittent explosive disorders  Pyromania  Kleptomania  Pathological gambling  Trichotillomania  Impulse control disorders not otherwise specified:  Impulsive compulsive self injurious disorders  Impulsive compulsive sexual disorders  Impulsive compulsive buying disorders  Impulsive compulsive Internet usage disorders NB: there are other disorders of impulsivity but are beyond the scope of this presentation.
  6. 6. Outline of ICDs Impulsivity is controlled by three major cognitive components which are all stressful for an individual who suffers from an impulse control disorder. These factors are as follows:  Failure to delay gratifications. An individual with an impulse control disorder often takes decisions that are aimed at seizing an immediate gain without considering the long term unfavorable consequences of his/her decisions and regardless of how trivial this gain might be.  Distractibility: failure to maintain continuous attention on a certain task.  Dis-inhibition: the inability to suppress behavior in a way that is expected to be appropriate in view of social norms and constraints.
  7. 7. Outline of ICDs Each disorder is characterized by the inability to resist an intense impulse, drive, or temptation to perform a particular act that is obviously harmful to self or others, or both. Before the event, the individual usually experiences mounting tension and arousal, sometimes but not consistently mingled with conscious anticipatory pleasure. Completing the action brings immediate gratification and relief. Within a variable time afterward, the individual experiences a conflation of remorse, guilt, self- reproach, and dread.
  8. 8. Incidence As compared to other mental disorders, impulse control disorders were found in 8.9% (12-month prevalence) and 24.8% (lifetime prevalence) of the population with a greater proportion at the serious level. The prevalence of impulse control disorders varies significantly with the subtype of the disorder. For instance, the incidence of Intermittent Explosive Disorders (IEDs) varies according to age. Recent studies have shown that the prevalence was approximately 7.4% for individuals between 30 and 44 years of age, while it was only 5.7% for those between 30 and 44 years and dropped to 4.9% for
  9. 9. Incidence It is rather hard to determine the prevalence of almost all other impulse control disorders because individuals who suffer from these disorders often attempt to conceal their behavior from others to prevent the “shame” of being detected. However, pathological gambling has been extensively studied and its prevalence is estimated to range between 1% and 3% among American adults. Pathological gambling often starts in adolescence when the prevalence is even higher ranging between 4% and 7%.
  10. 10. Risk factors Traumatic Brain Injury may result in some individuals developing impulsive disorder. This is particularly true when the damage has been to the frontal cortex area. Substance abuse appears to be commonly associated with impulsivity. While not all individuals with substance abuse problems will develop impulse control problems, research has noted a strong correlation between the two.
  11. 11. Etiology Biological Psychological Social
  12. 12. Etiology – Biological Many investigators have focused on possible organic factors in the impulse-control disorders, especially for patients with overtly violent behavior. Experiments have shown that impulsive and violent activity is associated with specific brain regions, such as the limbic system, and that the inhibition of such behaviors is associated with other brain regions. This findings led to the science of neurobiology of ICDs
  13. 13. Etiology – Neurobiology The human brain is wired with natural checks and balances that control emotions, but breakdowns in this regulatory system appear to dramatically heighten risk of impulsive behavior.
  14. 14. Etiology – Psychological An impulse is a disposition to act to decrease heightened tension caused by the buildup of instinctual drives or by diminished ego defenses against the drives. The impulse disorders have in common an attempt to bypass the experience of disabling symptoms or painful affects by acting on the environment.
  15. 15. Etiology – Social Psychosocial factors implicated causally in impulse- control disorders are related to early-life events. The growing child may have had improper models for identification, such as parents who had difficulty controlling impulses. Other psychosocial factors associated with the disorders include exposure to violence in the home, alcohol abuse, promiscuity, and antisocial behavior.
  16. 16. Pathogenesis It has not been fully established yet how impulse control disorders starts but the following hypothesis is known about its pathogenesis: Serious head injuries and those with epilepsy have a higher risk of developing this Suggested side effects of other medical conditions Abnormal neurological development and brain chemistry.
  17. 17. Pathogenesis Impulsive behavior may be related to the interplay between several distinct brain regions, namely the orbital frontal cortex, the anterior cingulate cortex, and the amygdala. The orbital frontal cortex plays a crucial role in constraining impulsive outbursts, while the anterior cingulate cortex recruits other brain regions in the response to a stimulus or conflict. The amygdala, a tiny but highly influential portion of the brain, is involved in the production of a fear response and other emotions. Over the past several years, case reports and series have noted the onset of pathological gambling in patients with Parkinson disease treated with levodopa (Larodopa) and dopamine agonists. The case reports have named dopamine receptor agonists as the likely culprits, but the role of levodopa has been unclear and the possibility that the symptom is a manifestation of Parkinsons disease itself has been posited. The idea that pathologic gambling can be precipitated by drug therapy challenges conventional views about complex behaviors and the effects that drugs can have.
  18. 18. Pathogenesis
  19. 19. Pathophysiology
  20. 20. INTERMITTENTEXPLOSIVE DISORDER (IED)
  21. 21. IED Intermittent explosive disorder manifests as discrete episodes of losing control of aggressive impulses; these episodes can result in serious assault or the destruction of property. The aggressiveness expressed is grossly out of proportion to any stressors that may have helped elicit the episodes. The symptoms, which patients may describe as spells or attacks, appear within minutes or hours and, regardless of duration, remit spontaneously and quickly.
  22. 22. IED – Case Presentations• A 31-year-old male presented with features of remaining aloof, sad, having prominent guilt ideas and entertaining thoughts of causing self- harm. The symptoms had developed insidiously when his wife learnt about his extramarital affair with a known relative. After his wife left him, the feelings of low mood became more intense and he started to entertain suicidal thoughts. While driving his motorcycle in the night, he met with an accident and started to bleed profusely. He tasted his own blood and liked the smell and taste of it. Thus, the frequent incidences of wrist cutting started so that he could suck his own blood. The act would be preceded by a mounting tension and arousal and subsequent relief would be noted later. He would break bottles and, with the glass pieces, would slash his palm, wrist and feet to see and feel the blood. He would also chew the glass pieces and the hurt caused by the glass pieces to his cheek and lips would actually be enjoyed by the individual. He even resorted to head banging so that the injuries caused to the scalp would produce more blood. As his unusual behavior was noted, he was admitted to the psychiatric center. While he was admitted to the hospital, he remained symptomatic. He was noted to remain quiet and aloof only to be shattered with episodic outbursts of intense anger and aggression. He assaulted other inpatients and derived pleasure from this fact. The episode lasted from 15 to 30 min and subsided on its own. The individual would remember the incident, but would give no
  23. 23. IED – Case Presentations Kevin is diagnosed with an intermittent explosive behavior. He was raged with anger when a friend of him, Mike, mocked the way his hair looks. He suddenly punched Mike hardly in the face breaking the poor guy’s nose. This is just one of many examples of Kevin’s unnecessary aggressive responses. When he is really angry, his temper builds up so fast and bursts with aggressive actions that usually harm people around him. His rage usually cools down in around 30 minutes after which he sometimes even forgets that he has harmed any one.
  24. 24. DSM-IV-TR CRITERIAA. Several discrete episodes of failure to resist aggressive impulses that result in serious assaultive acts or destruction of property.B. The degree of aggressiveness expressed during the episodes is grossly out of proportion to any precipitating psychosocial stressors.C. The aggressive episodes are not better accounted for by any other mental disorder (e.g. Antisocial PD, Borderline PD, Conduct Disorder, ADHD, a Manic Episode, a Psychotic Disorder), are not due to the direct physiological effects of a substance, or a general medical condition (e.g. head trauma, Alzheimer’s disease).HALLMARK: a pattern of aggressive behavior &
  25. 25. Facts and Figures Gender Differences: more common in men than women Prevalence: rare Course: variable; chronic or episodic course Onset: childhood to the early 20’s
  26. 26. Contributing Factors Behavioral theory:  Antecedents: a sense of tension or arousal  Behavior: explosive behavior, aggressive episodes  Immediate consequences: a sense of relief & release  Delayed consequences: feeling upset, remorseful, regretful, embarrassed about the aggressive behavior Personality factors: Generalized impulsivity or aggressiveness, chronic anger management problems Childhood history of temper tantrums, impaired attention, hyperactivity, and other behavioral difficulties Early learning: modeling, parenting styles, family conflict Biological factors: low levels of serotonin & norepinephrine, high levels of testosterone Stress
  27. 27. Contributing Factors Some researchers have spotted a correlation between aggressive behavior and disorders of the frontal lobe, especially with focal orbito-frontal injury; however, in such case, according to the DSM-IV-TR criteria, the diagnosis of intermittent explosive disorders cannot be made. Nonetheless, a high percentage of patients with violent behavioral patterns report history of head trauma, mostly due to the nature of their actions, which doesn’t coincide with the onset of their aggressive actions. Although the effect of trauma on the development of intermittent explosive disorders is still not fully investigated, evidence exists that supports the correlation between lesions in the prefrontal cortex and impulsive patterns of aggressive behavior. Some evidence support the role of the reduced function of serotonin pathways in the pathogenesis of impulsive patterns of aggressive behavior. Moreover, some authors have reported the increased incidence of impulsive disorders amongst children with serotonin gene polymorphism patterns who experienced abuse, neglect or violence.
  28. 28. Differential Diagnosis1. Delirium2. Dementia3. Personality change due to a general medical condition, general type4. Substance intoxication5. Substance withdrawal6. Oppositional defiant disorder7. Conduct disorder8. Antisocial disorder9. Borderline disorder10. Mania11. Schizophrenia12. Tourette’s Syndrome13. “Anger attacks” are seen sometimes as part of MDD or panic disorder
  29. 29. Treatment – Psychosocial Individual psychotherapies Group psychotherapies Anger management
  30. 30. Treatment – Biological Medications used in the treatment of IEDs are all off –label! Examples include:  Mood stabilizers such as Lithium and the anticonvulsants  Beta blockers  SSRIs
  31. 31. PYROMANIA
  32. 32. Pyromania Pyromania is the recurrent, deliberate, and purposeful setting of fires. Associated features include tension or affective arousal before setting the fires; fascination with, interest in, curiosity about, or attraction to fire and the activities and equipment associated with firefighting; and pleasure, gratification, or relief when setting fires or when witnessing or participating in their aftermath. The diagnosis of pyromania necessitates the occurrence of more than one occasion during which the patient attempts deliberately setting fire. Moreover, the patient usually feels stressed before setting the fire and relieved after performing the act. Pyromania is extremely rare and literature data is rather scarce. Incidence <1%, M>F
  33. 33. Etiology The exact cause for pyromania is still unclear. Evidence suggests a multifactorial pathogenesis which involves environmental factors, temperamental factors and parental psychiatric disorders. Some psychiatrists have suggested that the cause for pyromania and most other impulse control disorders is linked neuro-biologically, at least in part, to substance abuse.
  34. 34. DSM-IV-TR CRITERIAA. Deliberate and purposeful fire setting on more than one occasion.B. Tension or affective arousal before the act.C. Fascination with, interest in, curiosity about, or attraction to fire and its situational contexts (e.g. paraphernalia, uses, consequences).D. Pleasure, gratification, or relief when setting fires, or when witnessing or participating in their aftermath.E. 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. in dementia, Mental Retardation, Substance Intoxication)F. The fire setting is not better accounted for by Conduct Disorder, a Manic Episode, or Antisocial Personality
  35. 35. Facts and Figures Age factors: although fire setting is a major problem in childhood and adolescence, pyromania is rare; juvenile fire setting is usually associated with ADHD, Conduct Disorder, or Adjustment Disorder Prevalence: rare Gender differences: more common in males Typical age of onset: unknown Course: episodic; fire setting incidents may wax and wane in frequency Cultural: primarily Caucasian
  36. 36. Contributing Factors Considerable planning and advance preparation for starting a fire Reaction to fire-setting: gratification, pleasure, release Reaction to consequences: indifference or satisfaction Consequences of behavior: property damage, legal consequences, injury &/or loss of life to fire setter or others Co-morbid disorders: Alcohol Abuse or Dependence Individual factors: poor social skills, learning difficulties, sensation-seeking, attention-seeking Environmental factors: limited supervision, parental lack of involvement, parental pathology, stressful events Physiological factors: low levels of Monoamine Oxidase, diminished serotonin activity
  37. 37. Differential diagnosis Arson Psychosis Impaired judgment due to substance abuse mental retardation or dementia Dissocial personality disorder Mood disorders Conduct disorders Temporal lobe epilepsy Learning disability
  38. 38. Treatment – Psychosocial 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 patients find alternative routes to relieve tensions that have been associated with fire-setting.  Cognitive-Behavioural Therapy (CBT)
  39. 39. KLEPTOMANIA
  40. 40. Kleptomania Kleptomania is the irresistible urge to steal items that you generally dont really need and that usually have little value. The essential feature of kleptomania is a recurrent failure to resist impulses to steal objects, not needed for personal use or for monetary value. The objects taken are often given away, returned surreptitiously, or kept and hidden. Kleptomanics usually have the money to pay for the objects they impulsively steal. It is crucial to differentiate kleptomania from common theft. In kleptomania, the patient steals items that aren’t needed in terms of use and/or their financial value. The shoplifting behavior is neither a response to anger or revenge nor triggered by hallucinations or delusions. Similarly to other forms of impulse control disorders, patients with kleptomania feel tensioned prior to performing the act of
  41. 41. Kleptomania - Case Presentation A 24 years old female, highly successful, single executive from a wealthy background. She was brought to the psychiatrist ward by the police officer. She was accused of stealing several times from the same shop in the same month. She further states that the items she had stolen were hair-chips and that she have kept them in a box at home.NB:Although the thefts do not occur when immediate arrest is probable, persons with kleptomania do not always consider their chances of being
  42. 42. DSM-IV-TR CRITERIAA. Recurrent failure to resist impulses to steal objects that are not needed for personal use or for their monetary value.B. Increasing sense of tension immediately before committing the theft.C. Pleasure, gratification, or relief at the time of committing the theft.D. The stealing is not committed to express anger or vengeance and is not in response to a delusion or hallucination.E. The stealing is not better accounted for by Conduct Disorder, a Manic Episode, or Antisocial Personality Disorder
  43. 43. Facts and Figures Gender: 66% to 80% are female Prevalence: occurs in less than 5% of identified shoplifters; prevalence in general population is rare and unknown Course:  Sporadic with brief episodes & long periods of remissions;  Episodic with protracted periods of stealing and periods of remission;  Chronic with some degree of fluctuation Onset: variable; earlier onset and treatment for women Ego-Dystonic: person is aware that the behavior
  44. 44. Related & Contributing Factors Associated Disorders & Behaviors: compulsive shopping, Mood Disorders (particularly depression), Eating Disorders (particularly Bulimia Nervosa), Personality Disorders, other Impulse Control Disorders, substance related disorders Childhood Experiences: stressful and tumultuous childhood, sibling rivalries, separation from parents, neglectful parenting Psychoanalytic: defense against, or catharsis for, underlying anxiety and anger Behavioral:  Antecedents: tension, unpleasant feelings  Immediate consequences: pleasure, gratification, relief  Delayed consequences: depression, guilt, remorse; legal problems (e.g. multiple convictions for shoplifting); family, career, and personal difficulties
  45. 45. Differential diagnosis Episodes of theft occasionally occur during psychotic illness, for example, acute mania, major depression with psychotic features, or schizophrenia. Psychotic stealing is obviously a product of pathological elevation or depression of mood or command hallucinations or delusions. Acute intoxication with drugs or alcohol may precipitate theft in an individual with another psychiatric disorder or without significant psychopathology. Patients with Alzheimers disease are also often prone to stealing or some degree of shoplifting.
  46. 46. Treatment – Psychosocial No systematic or controlled psychosocial treatments. Successful anecdotal treatments include:  Complete abstinence from prospective stores  Aversive conditioning  Systemic desensitization  Covert sensitization  Psychodynamic therapy
  47. 47. Treatment – Biological Antidepressants Mood stabilizers such as Lithium Combination therapy – Antidepressants and Mood Stabilizers Antipsychotics CNS – Stimulants ECT
  48. 48. PATHOLOGICAL GAMBLING
  49. 49. Pathological Gambling Also known as Compulsive Gambling, it is the uncontrollable urge to keep gambling despite the toll it takes on your life. Apart from other forms of impulse control disorders, pathological gambling is somehow correlated to substance abuse disorders as the behavior is often associated with an urge to increase the amount of risked money or assets to feel satisfied which is similar to tolerance to drugs of abuse. Pathological gambling is usually associated with irritability and restlessness when trying to stop gambling which is similar to withdrawal symptoms that occur when the abused drug is abruptly stopped. Furthermore, individuals with a substance use disorder are at higher risk for development of pathological gambling. Some studies have shown that nearly 73.2% of individuals with pathological gambling have associated alcohol abuse disorders, while 38.2% of pathological gamblers suffer from other substance abuse disorders.
  50. 50. Neuro-pathology Functional magnetic resonance imaging (fMRI) and brain spectroscopy have shown that the ventro-medial prefrontal cerebral cortex, striatum and dopaminergic neurons within the midbrain comprise the higher centers for perception and anticipation of monetary loss. Using the Stroop task, which is a scale of behavioral inhibition, Potenza et al. concluded that pathological gamblers exhibit decreased activity of the neuronal pathways in the left ventro-medial portions of the prefrontal cortex. Collectively, a considerable body of evidence exists supporting the role of the ventro- medial portions of the prefrontal cortex in the control of pathological gambling and other behavioral patterns that are associated with poor impulse control.
  51. 51. DSM-IV-TR CRITERIAA. Persistent and recurrent maladaptive gambling behavior as indicated by 5 or more of the following: 1) Is preoccupied with gambling (e.g. reliving past gambling experiences, planning the next venture, thinking of ways to get money to gamble with) 2) Needs to gamble with increasing amounts of money to achieve the desired excitement 3) Has repeated unsuccessful efforts to control, cut back, or stop gambling 4) Is restless or 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 helplessness, guilt, anxiety, depression
  52. 52. DSM-IV-TR CRITERIA 6) After losing money gambling, 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) Has committed illegal acts such as forgery, fraud, theft, or embezzlement to finance gambling 9) Relies on others to provide money to relieve a desperate financial situation caused by gambling
  53. 53. Epidemiology A survey of 2,638 American adults concluded that the prevalence of pathological gambling ranges between 1.3% and 1.9%. On the other hand, some surveys have shown that the prevalence of pathological gambling amongst patients with substance abuse disorders is somehow higher ranging between 10% and 18%.
  54. 54. Facts and Figures Gender: approximately 1/3 are female; females are more likely to be depressed and to gamble as an escape; females are under-represented in treatment programs & Gamblers Anonymous Cultural factors: cultural variations in the prevalence and type of gambling activities (e.g. cock fights, horse racing, stock market, slot machines) Prevalence: varies depending on the availability of gambling; <1% to 7% Course: regular or episodic; typically chronic; general progression in frequency of gambling, level of preoccupation with gambling, and amount wagered Onset: early adolescence for males; later for females
  55. 55. Associated and ContributingFactors Distortions in thinking: denial; superstitions; overconfidence; sense of power and control; belief that money is the cause of & solution to all of their problems Personality traits: highly competitive, energetic, restless, easily bored, generous, extravagant, overly concerned with the approval of others, high levels of impulsivity Workaholics or “binge” workers Medical conditions associated with stress: migraines, ulcers, hypertension Co-morbid psychological disorders: suicidal ideation & attempts; ADHD; Mood Disorders; Substance Abuse or Dependence (alcohol & nicotine); Antisocial, Narcissistic, and Borderline Personality Disorders; other Impulse-Control Disorders Abnormalities in neurotransmitter systems: 5HT, NE, D Stress and depression
  56. 56. Treatment – Psychosocial 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.  Cognitive-Behavioural Therapy (CBT)
  57. 57. Psychosocial – GamblersAnonymous The following are the twelve steps of the Gambler’s Anonymous model:1. We admit that we are totally powerless over gambling; hence, our lives had become unmanageable.2. We believe that we need a power that is stronger than ours to help us restore our lives and thinking to normal patterns.3. We made a clear decision to turn our lives and wills over to the care of the power that we understand can help us.4. We made fearless and searching moral and financial inventories of ourselves.5. We admit to ourselves and to others the exact
  58. 58. Psychosocial – GamblersAnonymous 6. We are totally ready to be helped to get rid of these defects of character. 7. We humbly ask God (of our deep understanding) to excise our shortcomings. 8. We listed all people whom we had previously harmed and are willing to amend them all. 9. We will work hard to directly amend such people, unless doing so, would harm them or others. 10. We will continue to resort to personal inventory whenever we are wrong, promptly admitting it.
  59. 59. Psychosocial – GamblersAnonymous 11. We seek by means of our meditation and prayers our vital connection with God as we have clearly understood Him. We pray only for the knowledge of His good will for us and the internal power to carry that out. 12. We made every effort to exercise all of these principles throughout all of our affairs and we will continue to spread this message to all other compulsive gamblers.
  60. 60. Treatment – Biological The following have some support:  Selective Serotonin Reuptake Inhibitors (SSRIs)  Naltrexone  Lithium  Carbamazepine
  61. 61. TRICHOTILLOMANIA
  62. 62. Trichotillomania Trichotillomania is hair loss from repeated urges to pull or twist the hair until it breaks off. Patients are unable to stop this behavior, even as their hair becomes thinner. The criteria for the diagnosis of trichotillomania are generally similar to obsessive compulsive disorders, with an associated heightened tension immediately before doing the act and a sense of gratification and/or relief of tension after committing the act. It has been proposed that trichotillomania should be categorized under the new group of disorders; the obsessive compulsive related disorders for DSM-V. Nevertheless, some evidence denotes that trichotillomania is not simply a form of an obsessive compulsive disorder.
  63. 63. Etiology Little is known about the etiology of trichotillomania. It usually presents itself in late childhood and adolescence. Trichotillomania is more prevalent among women as compared to men. Several studies that investigated the neurobiological mechanisms behind trichotillomania examined the volumes of the putamen and caudate using MRI. These regions were selected because of evidence that they are affected in patients with obsessive compulsive disorders and Tourette’s syndrome. Results showed attenuation of the volumes of the left lenticulate and left putamen in patients with trichotillomania as compared to normal controls.
  64. 64. DSM-IV-TR CRITERIAA. Recurrent pulling out of one’s hair resulting in noticeable hair lossB. An increasing sense of tension immediately before pulling out the hair or when attempting to resist the behaviorC. Pleasure, gratification, or relief when pulling out the hairD. 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)E. The disturbance causes clinically significant
  65. 65. Facts and Figures Gender differences: males and females are equally represented among children; much more common for females among adults Prevalence: unknown, but more common than previously thought; 1-5% of college students Onset: early adolescence Course: self-limiting, continuous, or episodic
  66. 66. Contributing and AssociatedFeatures Most common sites for hair pulling: scalp, eyebrows, and eyelashes Triggers: relaxation, distraction, stressful circumstances, “itch-like” sensation, being alone Associated behaviors: hair twirling, examining the hair root, pulling the strand between the teeth, eating hairs, nail biting, scratching, gnawing, excoriation, pulling hairs from other people or animals, pulling fibers from objects
  67. 67. Treatment – Psychosocial Behavior therapy’s - “habit reversal.” Cognitive-Behavioural Therapy (CBT) Hypnosis [also use in children] Self-help groups
  68. 68. Treatment – Biological Clomipramine SSRIs are used and have positive reports, but not in controlled studies. Antipsychotics, but not in controlled studies Lithium used, but not is controlled study. One of the important features that delineate trichotillomania from obsessive compulsive disorders is the therapeutic response to SSRIs. Early case reports pointed to the beneficial effects of SSRIs on the manifestations of trichotillomania; however, placebo controlled trials failed to detect a significant differences between the responses to SSRIs and placebos. These results are highly contradictory to those of many placebo controlled trials which proven efficacy of SSRIs in the management of obsessive compulsive disorders. A recent study concluded that the combination of the SSRI sertraline with a special form of cognitive behavioral therapy has a greater efficacy in the management of trichotillomania than either line alone;
  69. 69. COMPULSIVE BUYING DISORDER
  70. 70. Compulsive Buying Disorder(CBD) Compulsive buying disorder (CBD) is characterized by an obsession with shopping and buying behavior that causes adverse consequences. Most people with CBD meet the criteria for an axis II disorder. CBD is frequently comorbid with mood, anxiety, substance abuse and eating disorders. Onset of CBD occurs in the late teens and early twenties and is generally chronic. CBD is similar to, but distinguished from OCD hoarding and mania. Compulsive buying is not limited to people who spend beyond their means, it also includes people who spend an inordinate amount of time shopping or who chronically think about buying things but never purchase them.
  71. 71. Compulsive Buying Disorder(CBD) Promising treatments for CBD include medication such as selective serotonin reuptake inhibitors (SSRIs), and support groups such as Debtors Anonymous Social psychology sees the compulsive buying of consumer goods in terms of identity seeking - as an exaggerated form of a more normal search for validation through purchasing. Without a strong sense of identity, pressures from the spread of materialist values and consumer culture over the recent decades can drive the vulnerable into compulsive shopping.
  72. 72. INTERNET ADDICTION
  73. 73. Internet Addiction Disorder The Internet itself is a neutral device originally designed to facilitate research among academic and military agencies. How some people have come to use this medium, however, has created a stir among the mental health community by great discussion of Internet addiction. Addictive use of the Internet is a new phenomenon which many practitioners are unaware of and subsequently unprepared to treat. Some therapists are unfamiliar with the Internet, making its seduction difficult to understand. Other times, its impact on the individual’s life is minimized.
  74. 74. Internet Addiction Disorder In 1998, Young conceptualized problematic Internet use as a form of impulse control disorders that is somehow similar to pathological gambling and formulated novel criteria that are based on those of pathological gambling. Young’s criteria were centered on the individuals pattern of Internet usage, types of online activities that he/she participates in and the negative consequences that Internet usage has on his/her aspects of life.
  75. 75. Young’s Internet Addiction DiagnositcQuestionnaire (IADQ) Young’s Internet Addiction Diagnostic Questionnaire (IADQ) was the first screening tool developed to diagnose problematic Internet use. The IADQ included the following 8 criteria:1. Do you have a sense of preoccupation with the Internet (constantly think about activities you previously engaged in online or anticipate your next Internet use sessions)?2. Do you get the feeling that you have to increase the amount of time spent online to achieve satisfaction?
  76. 76. Young’s Internet Addiction DiagnositcQuestionnaire (IADQ)4. Do you feel depressed, restless, irritable or moody when trying to stop or even cut down Internet usage?5. Do you often spend time online that is longer than you originally intended?6. Have you risked the loss of a serious relationship, job or career or educational opportunities because of your Internet use patterns?7. Did you ever lie to your spouse, family members or therapists to conceal your true involvement with online activities?
  77. 77. Young’s Internet Addiction DiagnositcQuestionnaire (IADQ)8. Do you use the cyber-world as a means of sanctuary from problems or as a way of relief of unpleasant moods such as feelings of guilt, anxiety, helplessness or depression? The results of the questionnaire evaluated casual Internet usage which wasn’t academically or business related. Individuals were considered having an Internet use problems if they positively endorsed 5 or more of the questionnaire’s inquiries for a period that is more than 6 months. Excessive Internet usage, social isolation, neglect of life responsibilities and continuous desire to conceal
  78. 78. Proposed DSM-V Criteria The American Psychiatric Association considered inclusion of diagnosis of problematic Internet use in the new version of the DSM-V. The diagnosis is a form of an impulsive compulsive disorder that should include both online and offline computer activities and comprises 3 subtypes; excessive gaming, email/text messaging and sexual preoccupation. All of the proposed variants share the following criteria:A. Excessive use that is often accompanied by disorientation to time and neglect of basic responsibilities.B. Manifestations of withdrawal which include feelings of tension, anger and/or depression when computer usage is not possible.C. Tolerance which involves an increasing demand for more computer usage hours, better hardware, more advanced software…etc.D. Negative repercussions such as lying, arguments, social
  79. 79. Negative Consequences While time is not a direct function in defining Internet addiction, generally addicted users are likely to use the Internet anywhere from forty to eighty hours per week, with single sessions that could last up to twenty hours. To accommodate such excessive use, sleep patterns are typically disrupted due to late night log-ins. The patient typically stays up past normal bedtime hours and may report staying on-line until two, three, or four in the morning with the reality of having to wake for work or school at 6:00 am. In extreme cases, caffeine pills are used to facilitate longer Internet sessions. Such sleep depravation causes excessive fatigue often making academic or occupational functioning impaired and may decrease one’s immune system, leaving the patient vulnerable to disease. Additionally, the sedentary act of prolonged computer use may result in a lack of proper exercise and lead to an increased risk for carpal tunnel syndrome, back strain, or eyestrain. While the physical side-effects of utilizing the Internet are
  80. 80. Familial Impairment Young (1996) found that serious relationship problems were reported by fifty-three percent of Internet addicts surveyed. Marriages, dating relationships, parent-child relationships, and close friendships have been noted to be seriously disrupted by "net binges." Patients will gradually spend less time with people in their lives in exchange for solitary time in front of a computer. Marriages appear to be the most affected as Internet use interferes with responsibilities and obligations at home, and it is typically the spouse who takes on these neglected chores and often feels like a "Cyberwidow." Addicted on-line users tend to use the Internet as an excuse to avoid needed but reluctantly performed daily chores such as doing the laundry, cutting the lawn, or going grocery shopping.
  81. 81. Academic Impairment The Internet has been touted as a premiere educational tool driving schools to integrate Internet services among their classroom environments. However, one survey revealed that 86% of responding teachers, librarians, and computer coordinators believe that Internet usage by children does not improve performance (Barber, 1997). Respondents argued that information on the Internet is too disorganized and unrelated to school curriculum and textbooks to help students achieve better results on standardized tests. To further question its educational value, Young (1996) found that 58% of students reported a decline in study habits, a significant drop in grades, missed classes, or
  82. 82. Occupational Impairment Internet misuse among employees is a serious concern among managers. One survey from the nations top 1,000 companies revealed that 55% of executives believed that time surfing the Internet for non-business purposes is undermining their employees’ effectiveness on the job (Robert Half International, 1996). New monitoring devices allow bosses to track Internet usage, and initial results confirm their worst suspicions. One firm tracked all traffic going across its Internet connection and discovered that only 23% of the usage was business related (Machlis, 1997). There is growing availability of such monitoring software as employers not only fear poor productivity, but they need to stop the use of valuable network
  83. 83. Occupational Impairment Managers have been forced to respond by posting policies detailing acceptable and unacceptable Internet use. The benefits of the Internet such as assisting employees with anything from market research to business communication outweigh the negatives for any company, yet there is a definite concern that it is a distraction to many employees. Any misuse of time in the workplace creates a problem for managers, especially as corporations are providing employees with a tool that can easily be misused.
  84. 84. Occupational Impairment – Casestudy Evelyn is a 48 year old executive secretary who found herself compulsively using chat rooms during work hours. In an attempt to deal with her "addiction,” she went to the Employee Assistance Program for help. The therapist, however, did not recognize Internet addiction as a legitimate disorder requiring treatment and dismissed her case. Few weeks later, she was abruptly terminated from employment for time card fraud when the systems operator had monitored her account only to find she spent nearly half her time at work using her Internet account for non-job related tasks.
  85. 85. Occupational Impairment Employers uncertain how to approach Internet addiction among workers may respond to an employee who has abused the Internet with warnings, job suspensions, or termination from employment instead of making a referral to the company’s Employee Assistance Program (Young, 1996).
  86. 86. Treatment There are no meta-analyses that have established the best lines of treatment for problematic internet use. Presently, cognitive behavioral therapeutic models are the primarily proposed treatment strategies to manage problematic internet use and replace it with other forms of activities. Family and group therapy formats are often encouraged to aid in the refurbishment of social relationships and to allow family and friends engage in the treatment plan. Practicing Abstinence.
  87. 87. PATHOLOGICAL LYING
  88. 88. Pathological Lying Pathological lying is also known as pseudologia fantastica or mythomania. It is simply described as habitual and compulsive lying. Although somewhat controversial, pathological lying has been defined as falsification entirely disproportionate to any discernible end in view, may be extensive and very complicated, and may manifest over a period of years or even a lifetime. Lying is the act of both knowingly and intentionally/willfully making a false statement. Most people do so out of fear. Pathological lying is considered a mental illness, because it takes over rational judgment and progresses into the fantasy
  89. 89. Defining Characteristics The defining characteristics of pseudologia fantastica are: The stories told are not entirely improbable and often have some element of truth. They are not a manifestation of delusion or some broader type of psychosis: upon confrontation, the teller can admit them to be untrue, even if unwillingly. The fabricative tendency is long lasting; it is not provoked by the immediate situation or social pressure as much as it is an innate trait of the personality. A definitely internal, not an external, motive for the behavior can be discerned clinically: e.g., long-lasting extortion or habitual spousal battery might cause a
  90. 90. Defining Characteristics The stories told tend toward presenting the liar favorably. For example, the person might be presented as being fantastically brave, knowing or being related to many famous people. Pseudologia fantastica may also present as false memory syndrome, where the sufferer genuinely believes that fictitious events have taken place, regardless that these events are fantasies. The sufferer may believe that he or she has committed superhuman acts of altruism and love or has committed equally grandiose acts of diabolical evil, for which the sufferer must atone, or has already atoned for in her/his fantasies.
  91. 91. SEX ADDICTION
  92. 92. Sexual Addiction Sexual addiction is used to describe the behavior of a person who has an unusually intense sex drive or an obsession with sex. Sex and the thought of sex tend to dominate the sex addicts thinking, making it difficult to work or engage in healthy personal relationships. Sex addicts engage in distorted thinking, often rationalizing and justifying their behavior and blaming others for problems. They generally deny they have a problem and make excuses for their actions. Generally, a person with a sex addiction gains little satisfaction from the sexual activity and forms no emotional bond with his or her sex partners. In addition, the problem of sex addiction often leads to feelings of guilt and shame. A sex addict also feels a lack of control over the behavior, despite negative consequences (financial, health, social, and emotional).
  93. 93. Sexual Addiction & Risk Taking Sexual addiction also is associated with risk-taking. A person with a sex addiction engages in various forms of sexual activity, despite the potential for negative and/or dangerous consequences. In addition to damaging the addicts relationships and interfering with his or her work and social life, a sexual addiction also puts the person at risk for emotional and physical injury. For some people, the sex addiction progresses to involve illegal activities, such as exhibitionism (exposing oneself in public), making obscene phone calls, or molestation. However, it should be noted that sex addicts do not necessarily become sex offenders.
  94. 94. Associated/Related Behaviors Behaviors associated with sexual addiction include:  Compulsive masturbation (self-stimulation)  Multiple affairs (extra-marital affairs)  Multiple or anonymous sexual partners and/or one- night stands  Consistent use of pornography  Unsafe sex  Phone or computer sex (cybersex)  Prostitution or use of prostitutes  Exhibitionism  Obsessive dating through personal ads  Voyeurism (watching others) and/or stalking  Sexual harassment  Molestation/rape
  95. 95. Treatment Most sex addicts live in denial of their addiction, and treating an addiction is dependent on the person accepting and admitting that he or she has a problem. In many cases, it takes a significant event -- such as the loss of a job, the break-up of a marriage, an arrest, or health crisis -- to force the addict to admit to his or her problem. Treatment of sexual addiction focuses on controlling the addictive behavior and helping the person develop a healthy sexuality. Treatment includes education about healthy sexuality, individual counseling, and marital and/or family therapy. Support groups and 12 step recovery programs for people with sexual addictions (like Sex Addicts Anonymous) also are available. In some cases, medications used to treat obsessive-compulsive
  96. 96. 12 Steps of Sex AddictsAnonymous1. We admitted we were powerless over addictive sexual behavior - that our lives had become unmanageable.2. Came to believe that a Power greater than ourselves could restore us to sanity.3. Made a decision to turn our will and our lives over to the care of God as we understood God.4. Made a searching and fearless moral inventory of ourselves.5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.6. Were entirely ready to have God remove all these defects of character.
  97. 97. 12 Steps of Sex AddictsAnonymous7. Humbly asked God to remove our shortcomings.8. Made a list of all persons we had harmed and became willing to make amends to them all.9. Made direct amends to such people wherever possible, except when to do so would injure them or others.10. Continued to take personal inventory and when we were wrong promptly admitted it.11. Sought through prayer and meditation to improve our conscious contact with God as we understood God, praying only for knowledge of Gods will for us and the power to carry that out.12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to other sex addicts and to practice these principles in our
  98. 98. REFERENCES http://www.fastceus.com/courses/Impulse_Disorders- 3CEUs.pdf http://www.internetandpsychiatry.com/joomla/topics/compulsi ve-gambling/44-impulse-control-disorders.html http://www.psychiatrynetworks.com/impulse-control- disorders.php http://www.scribd.com/doc/95092163/Impulse-Control- Disorder Impulse Control Disorders by Dr. Kayj Nash Okine http://en.wikipedia.org/wiki/Compulsive_buying_disorder http://www.netaddiction.com/articles/symptoms.pdf http://en.wikipedia.org/wiki/Pathological_lying http://www.webmd.com/sexual-conditions/guide/sexual- addiction http://www.ridgeviewinstitute.com/Support%20Group%20Des
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