Impulse Control Disorders

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 mingled with conscious
anticipatory pleasure.
Completing the action brings immediate gratification and relief.
Within a variable time afterward, the individual experiences a
remorse ‫ندم‬, guilt, self-reproach, and dread

Etiology
1. Psychodynamic Factors
2. Psychosocial Factors
3. Biological Factors

Etiology….
1. Psychodynamic Factors
Impulse is a disposition ‫الترتيب‬ to act to decrease heightened tension
caused by the buildup of instinctual drives or by diminished ego
defenses against the drives.
Attempt to bypass the experience painful affects by acting on the
environment.
Weak superego and weak ego structures associated with psychic
trauma produced by childhood deprivation (August Aichhorn) .

Etiology….
1. Psychodynamic Factors…..
impulsive behavior linked to attempts to master anxiety, guilt,
depression, and other painful affects by means of action.
such actions defend against internal danger and produce a distorted
aggressive or sexual gratification (Otto Fenichel)

Etiology….
1. Psychodynamic Factors…..
Related to an incomplete sense of self.
when patients do not receive the validating and affirming responses
that they seek from persons in significant relationships with
them, the self might fragment.
with this fragmentation and regaining a sense of wholeness or
cohesion in the self, persons may engage in impulsive behaviors
that to others appear self-destructive….
(Heinz Kohut)
‫ستي‬‫و‬‫عر‬

Etiology…
2. Psychosocial Factors
Related to early-life events.
The growing child may have had improper models for identification,
such as parents who had difficulty controlling impulses.
include exposure to violence in the home, alcohol abuse,
promiscuity, and antisociabehavior.

Etiology….
3. Biological Factors
Experiments have shown that impulsive and violent activity is
associated with specific brain regions, such as the limbic
system, and inhibition of such behaviors is associated with
other brain regions.
A relation found between low (CSF) levels of 5-hydroxyindoleacetic
acid (5-HIAA) and impulsive aggression.
Certain hormones, especially testosterone, associated with violent
and aggressive behavior.

Etiology…..
3. Biological Factors…..
Reports have described a relation between temporal lobe epilepsy
and certain impulsive violent behaviors, as well as an
association of aggressive behavior in patients who have
histories of head trauma with increased numbers of emergency
room visits and other potential organic antecedents.
Evidence indicates that the serotonin neurotransmitter system
mediates symptoms evident in impulse-control disorders.
The dopaminergic and noradrenergic systems have also been
implicated in impulsivity.
Symptoms can continue into adulthood in persons whose disorder
has been diagnosed as childhood ADHD.

(1) intermittent explosive disorder,
(2) kleptomania,
(3) pyromania,
(4) pathological gambling,
(5) trichotillomania, and
(6) impulse-control disorder not otherwise specified (NOS).

impulse-control disorders:
(2) kleptomania,
(3) pyromania,

discrete episodes of losing control of aggressive impulses; result in
serious assault or the destruction of property.
The aggressiveness expressed is out of proportion to any stressors
elicit the episodes.
The symptoms, appear within minutes or hours remit spontaneously
and quickly.
After each episode, patients show genuine regret or self-reproach,
Signs of generalized impulsivity or aggressiveness are absent
between episodes.
intermittent
explosive
disorder

The term epileptoid personality has been used to convey the seizure-
like quality of the characteristic outbursts, which are not typical of
the patient's usual behavior, and to convey the suspicion of an
organic disease process, for example, damage to the central
nervous system.
Several features suggest the possibility of an epileptoid state:
 the presence of auras;
 postictal-like changes in the sensorium, including partial or spotty
amnesia;
 and hypersensitivity to photic, aural, or auditory stimuli.
intermittent
explosive
disorder

• underreported.
• more common in men than in women.
• The men are likely to be found in correctional institutions and the
women in psychiatric facilities.
• more common in first-degree biological relatives of persons with
the disorder than in the general population.
• Many factors other than a simple genetic explanation may be
responsible.
intermittent
explosive
disorder

 High rates of fire setting in patients with intermittent explosive
disorder have been reported.
 Other disorders of impulse control
 substance use
 mood, anxiety, and eating disorders
intermittent
explosive
disorder

 Psychodynamic Factors
Psychoanalysts suggested that explosive outbursts occur as a defense
against narcissistic injurious events.
Rage outbursts serve as interpersonal distance and protect against
any further narcissistic injury.
intermittent
explosive
disorder

 Psychosocial Factors
patients described as physically large, but dependent, men whose
sense of masculine identity is poor. A sense of being useless and
impotent or of being unable to change the environment often
precedes an episode of physical violence, and a high level of
anxiety, guilt, and depression usually follows an episode.
An unfavorable childhood environment often filled with alcohol
dependence, beatings, and threats to life is usual in these
patients.
Predisposing factors include: perinatal trauma, infantile seizures,
head trauma, encephalitis, minimal brain dysfunction, and
hyperactivity. Early frustration, oppression ‫الظلم‬, and hostility have
been noted as predisposing factors.
intermittent
explosive
disorder

 Biological Factors
disordered brain physiology, particularly in the limbic system, is
involved
evidence indicates serotonergic neurons mediate behavioral inhibition.
The restoration of serotonin activity, by administering serotonin
precursors such as L-tryptophan or drugs that increase synaptic
serotonin levels, restores the behavioral effect of punishment
Low levels of CSF 5-HIAA have been correlated with impulsive
aggression.
High CSF testosterone concentrations are correlated with
aggressiveness and interpersonal violence in men.
Antiandrogenic agents have been shown to decrease aggression.
intermittent
explosive
disorder

 Familial and Genetic Factors
First-degree relatives of patients with intermittent explosive disorder
have higher rates of impulse-control disorders, depressive disorders,
and substance use disorders.
Biological relatives were more likely to have histories of temper or
explosive outbursts than the general population.
intermittent
explosive
disorder

history-taking reveal:
• several episodes of loss of control associated with aggressive
outbursts
• childhood atmosphere of alcohol dependence, violence, and
emotional instability.
• Patients' work histories are poor; job losses, marital difficulties, and
trouble with the law.
• Most patients have sought psychiatric help in the past but to no avail
‫فائدة‬.
• Anxiety, guilt, and depression usually follow an outburst, but this is
not a constant finding.
• Neurological examination reveals soft neurological signs, such as left-
right ambivalence and perceptual reversal.
• EEG findings are frequently normal or show nonspecific changes.
intermittent
explosive
disorder

A. 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 another
mental disorder (e.g., antisocial personality disorder, borderline
personality disorder, a psychotic disorder, a manic episode,
conduct disorder, ADHD disorder) and are not due to the direct
physiological effects of a substance (e.g., a drug of abuse, a
medication) or a general medical condition (e.g., head trauma,
Alzheimer's disease).
intermittent
explosive
disorder

 high incidence of soft neurological signs (e.g., reflex
asymmetries), nonspecific EEG findings, abnormal
neuropsychological testing results (e.g., letter reversal
difficulties), and accident susceptibility.
 Blood chemistry (liver and thyroid function tests, fasting blood
glucose, electrolytes), urine alysis (including drug toxicology), and
syphilis serology may help rule out other causes of aggression.
 (MRI) may reveal changes in the prefrontal cortex, which is
associated with loss of impulse control.
intermittent
explosive
disorder

• The diagnosis made only after disorders associated with the
occasional loss of control of aggressive impulses have been ruled
out as the primary cause.
• other disorders include:
1. psychotic disorders, patients may display violent behavior in response to
delusions and hallucinations, and they show gross impairments in reality testing.
mania may be impulsively aggressive, but the underlying diagnosis is generally
apparent from their mental status examinations and clinical presentations.
2. personality change because of a general medical condition,
3. antisocial or borderline personality disorder; aggressiveness and impulsivity are
part of patients' characters and, thus, are present between outbursts.
4. substance intoxication (e.g., alcohol, barbiturates, hallucinogens, and
amphetamines),
5. epilepsy, brain tumors, degenerative diseases, and endocrine disorders.
6. Conduct disorder ; repetitive and resistant pattern of behavior, as opposed to an
episodic pattern.
intermittent
explosive
disorder

Begin at any stage of life, usually appears between late adolescence
and early adulthood.
Onset can be sudden or insidious.
The course can be episodic or chronic.
decreases in severity with the onset of middle age, but heightened
‫د‬ِ‫ع‬‫صا‬َ‫ت‬ُ‫م‬ organic impairment can lead to frequent and severe
episodes.
intermittent
explosive
disorder

A combined pharmacological and psychotherapeutic approach has
the best chance of success.
I. Psychotherapy
 Psychotherapy is difficult,
 because of their angry outbursts. Therapists may have
problems with countertransference and limit-setting.
 Group psychotherapy may be helpful, and family therapy is
useful
 A goal of therapy : have the patient recognize and verbalize
the thoughts or feelings that precede the explosive
outbursts instead of acting them out.
intermittent
explosive
disorder

II. Pharmacological therapy
A. Anticonvulsants.
 Lithium, carbamazepine, valproate or divalproex, and phenytoin have been reported helpful.
 other anticonvulsants (e.g., gabapentin .
 Benzodiazepines are sometimes used but have been reported to produce a paradoxical reaction
of dyscontrol in some cases.
B. Antipsychotics
 (e.g., phenothiazines and serotonin-dopamine antagonists) and tricyclic drugs have been
effective in some cases, but clinicians must then question whether schizophrenia or a mood
disorder is the true diagnosis.
 With a likelihood of subcortical seizure-like activity, medications that lower the seizure threshold
can aggravate the situation.
C. SSRIs, trazodone (Trittico), and buspirone are useful in reducing impulsivity and
aggression.
D. Propranolol (Inderal) and other β-blockers and calcium channel blockers
→effective in some cases.
intermittent
explosive
disorder

impulse-control disorders:
(2) kleptomania,
(3) pyromania,
intermittent
explosive
disorder

(2) kleptomania
(3) pyromania,

 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 ‫في‬
‫السر‬ , or kept and hidden.
 Persons with kleptomania usually have the money to pay for the
objects they impulsively steal.
 As with other impulse-control disorders, kleptomania is
characterized by mounting tension before the act, followed by
gratification and lessening of tension with or without guilt,
remorse, or depression after the act.
kleptomania

 The stealing is not planned and does not involve others.
 Although the thefts ‫السرقات‬ do not occur when immediate arrest is
probable ‫التوقيف‬
‫الفوري‬
ُ
ُ‫ل‬‫محتم‬ , persons with kleptomania do not
always consider their chances of being apprehended, although
repeated arrests lead to pain and humiliation.
 These persons may feel guilt and anxiety after the theft, but they
do not feel anger.
 when the object stolen is the goal, the diagnosis is not
kleptomania; in kleptomania, the act of stealing is itself the goal.
kleptomania

 The prevalence is not known,
 but it is estimated to be about 0.6%.
 The range varies from 3.8 to 24 % of those arrested for
shoplifting.
 DSM-IV-TR reports that it occurs in fewer than 5% of identified
shoplifters.
 male:female ratio → 1:3 in clinical samples.
kleptomania

has a high lifetime comorbidity of major affective illness (usually,
but not exclusively, depressive) and various anxiety disorders.
also include;
 other impulse-control disorders:(pathological gambling and
compulsive shopping),
 eating disorders, and
 substance abuse disorders, alcoholism in particular.
kleptomania

 Psychosocial Factors
symptoms appear in times of significant stress, e.g; losses,
separations, and endings of important relationships.
Psychoanalytic writers have stressed the expression of aggressive
impulses in kleptomania;
others have discerned a libidinal ‫شهواني‬ aspect. Those who focus on
symbolism see meaning in the act itself, the object stolen, and the
victim of the theft.
Analytic writers have focused on stealing by children and adolescents.
Anna Freud pointed out that the first thefts from mother's purse
indicate the degree to which all stealing is rooted in the oneness
between mother and child.
kleptomania

 Psychosocial Factors….
Karl Abraham wrote of the central feeling of being neglected, injured,
or unwanted. One theoretician established seven 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
kleptomania

….
 Biological Factors
Brain diseases and mental retardation have been associated with
kleptomania, as they have with other disorders of impulse control.
Focal neurological signs, cortical atrophy, and enlarged lateral
ventricles have been found in some patients.
Disturbances in monoamine metabolism, particularly of serotonin,
have been postulated.
 Family and Genetic Factors
7 % of first-degree relatives had obsessive-compulsive disorder (OCD).
higher rate of mood disorders has been reported in family members.
kleptomania

 The essential feature: recurrent, intrusive, and irresistible urges or
impulses to steal unneeded objects.
 Pt may also be distressed about the possibility or actuality of
being apprehended and may manifest signs of depression and
anxiety.
 Patients feel guilty, ashamed, and embarrassed.
 Often have serious problems with interpersonal relationships and
often show signs of personality disturbance.
 Frequency of stealing ranged from less than 1 to 120 episodes a
month.
 Most patients with kleptomania steal from retail stores, but they
may also steal from family members in their own households.
kleptomania

A. 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 a hallucination.
E. The stealing is not better accounted for by conduct disorder, a
manic episode, or antisocial personality disorder.
kleptomania

1. psychotic illness, e.g. 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.
2. Antisocial personality disorder:
 premeditation ‫تعمد‬ and planning,
 often executed with others.
 Involves the threat of harm or actual violence.
 Guilt and remorse are distinctively lacking.
3. Acute intoxication with drugs or alcohol may precipitate theft in an
individual with another psychiatric disorder or without significant
psychopathology.
4. Patients with Alzheimer's disease or other dementing organic
illness may leave a store without paying, owing to forgetfulness
5. Malingering kleptomania
kleptomania

 Begin in childhood, although most children and adolescents who
steal do not become kleptomaniac adults.
 onset generally is late adolescence.
 female are more likely to present for psychiatric evaluation or
treatment than are male.
 Men are more likely to be sent to prison.
 Men →50 ys ,women→35 ys
 course →waxes and wanes, but tends to be chronic. Persons
sometimes have bouts of being unable to resist the impulse to
steal, followed by free periods that last for weeks or months.
kleptomania

• Serious impairment and complications secondary to being caught
• the disorder impairs a person's social or work functioning.
• The prognosis with treatment can be good, but few patients
come for help of their own accord.
kleptomania

• Because true kleptomania is rare, reports of treatment tend to be
individual case descriptions or a short series of cases.
• Insight-oriented psychotherapy and psychoanalysis have been successful,
but depend on patients' motivations.
• Those who feel guilt and shame may be helped by insight-oriented
psychotherapy because of their increased motivation to change their
behavior.
• Behavior therapy, including systematic desensitization, aversive
conditioning, and a combination of aversive conditioning and altered
social contingencies.
• SSRIs, such as fluoxetine (Prozac) and fluvoxamine (faverin), are effective
in some patients.
• Case reports →tricyclic drugs, trazodone, lithium, valproate, naltrexone
and electroconvulsive therapy
kleptomania

pyromania
(1) intermittent explosive disorder
(2) kleptomania,,
(3) pyromania,

• 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
• Patients may make considerable preparations before starting a
fire.
pyromania

• No information is
• only a small percentage of adults who set fires can be classified as
having pyromania.
• male to female ratio of approximately 8 to 1.
• More than 40 % of arrested arsonists ‫الحارقون‬ are younger than 18
years of age.
pyromania

significantly associated with :
 substance abuse disorder (especially alcoholism);
 affective disorders, depressive or bipolar;
 other impulse control disorders, such as kleptomania in female fire
setters;
 personality disturbances, such as inadequate and borderline
personality disorders.
 Attention-deficit disorder and learning disabilities associated with
childhood pyromania.
 Persons who set fires are more likely to be mildly retarded than are
those in the general population.
 Childhood and adolescent fire setting is often associated with
ADHD or adjustment disorders.
pyromania

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.
 Other psychoanalysts have associated pyromania with an
abnormal craving for power and social prestige.
 Fire is a way to vent accumulated rage over frustration caused
by a sense of social, physical, or sexual inferiority.
pyromania

….
Biological Factors
 Significantly low CSF levels of 5-HIAA and 3-methoxy-4-
hydroxyphenylglycol (MHPG) have been found in fire setters,
which suggests possible serotonergic or adrenergic
involvement.
 presence of reactive hypoglycemia, based on blood glucose
concentrations on glucose tolerance tests, has been put forward
as a cause of pyromania.
pyromania

• Persons with pyromania often regularly watch fires in their
neighborhoods, frequently set off false alarms, and show interest in
firefighting paraphernalia ‫المالبس‬
‫الخاصة‬
‫بمكافحي‬
‫الحرائق‬
• Their curiosity is evident, but they show no remorse and may be
indifferent to the consequences for life or property.
• Fire setters may gain satisfaction from the resulting destruction;
frequently, they leave obvious clues.
• Commonly associated features include:
 alcohol intoxication,
 sexual dysfunctions,
 below-average intelligence quotient (IQ),
 chronic personal frustration,
 resentment ‫اإلستياء‬ toward authority figures.
• Some fire setters become sexually aroused by the fire.
pyromania

A. 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 disorder.
pyromania

• Fascination of young children with matches, lighters, and fire as
part of the normal investigation of their environments.
• fire acts of sabotage ‫التخريب‬ carried out by political extremists
• Paid torches, or arsonists.
• Conduct disorder & antisocial personality disorder; it is a
deliberate ‫متعمد‬ act, not a failure to resist an impulse.
• schizophrenia or mania; may set fires in response to delusions or
hallucinations.
• Patients with brain dysfunction (e.g., dementia), mental
retardation, or substance intoxication may set fires because of a
failure to appreciate the consequences of the act.
pyromania

• Begins in childhood
• But the typical age of onset of pyromania is unknown.
• Fire setting in pyromania is episodic and may wax and wane in
frequency.
• Prognosis for treated children is good, and complete remission is
a realistic goal.
• The prognosis for adults is guarded, because they frequently deny
their actions, refuse to take responsibility, are dependent on
alcohol, and lack insight.
pyromania

• Little has been written about the treatment of pyromania, and treating
fire setters has been difficult because of their lack of motivation.
• No single treatment has been proved effective;
• behavioral approaches, should be tried.
• treatment program should include supervision of patients to prevent a
repeated episode of fire setting.
• Incarceration ‫السجن‬ may be the only method of preventing a recurrence.
Behavior therapy can then be administered in the institution.
• Children; must be treated with the utmost seriousness. Intensive
interventions should be undertaken when possible, but as therapeutic
and preventive measures, not as punishment. In the case of children and
adolescents, treatment of pyromania or fire setting should include family
therapy.
pyromania

(2) kleptomania,
(3) pyromania,
(4) pathological gambling

• characterized by persistent and recurrent maladaptive gambling
that causes economic problems and significant disturbances in
personal, social, or occupational functioning.
• Aspects of the maladaptive behavior include:
(1) a preoccupation with gambling;
(2) need to gamble with increasing amounts of money to achieve the desired
excitement;
(3) repeated unsuccessful efforts to control, cut back, or stop gambling;
(4) gambling as a way to escape from problems;
(5) gambling to recoup losses;
(6) lying to conceal the extent of the involvement with gambling;
(7) illegal acts to finance gambling;
(8) Jeopardizing ‫يض‬ ِ
‫ر‬ْ‫ع‬َ‫ت‬
‫للخطر‬ or losing personal and vocational relationships because of
gambling;
(9) a reliance on others for money to pay off debts.
pathological
gambling

• 3 to 5 % rate of problem gamblers in the general
• 1 % →pathological gambling.
• The typical patient:
 pathological gambling cuts across every ethnic, class, age, and occupational divide
(casino personnel, are most consistent heavy players and losers).
 normal and pathological gambling has risen, especially in locales with legalized
gaming.
 noted in the poor, notably poor minorities; adolescents; elderly retirees; and
women.
 1/3 now is female: It has been suggested that women are gambling more because
an increased presence in the workplace gives them more cash.
 Family histories of pathological gamblers show an increased rate of substance
abuse (particularly alcoholism) and depressive disorders.
 The family circle is likely to be competitively and materialistically oriented, evincing
intense admiration for money and associated symbols of success. In this respect,
compulsive gambling has been called the dark side of the American dream.
pathological
gambling

• Significant comorbidity;
 mood disorders
 substance abuse disorders (alcohol and cocaine abuse and caffeine
and nicotine dependence).
• ADHD
• personality disorders (narcissistic, antisocial, & borderline
personality disorders),
• other impulse-control disorders.
• obsessive personality traits, full-blown OCD is uncommon.
pathological
gambling

Psychosocial Factors
• Psychoanalytic theory has focused on a number of core
character difficulties.
• Freud suggested that compulsive gamblers have an
unconscious desire to lose, and gamble to relieve
unconscious feelings of guilt.
• Another suggestion is that the gamblers are narcissists whose
grandiose and omnipotent fantasies lead them to believe
they can control events and even predict their outcome.
• Learning theorists view uncontrolled gambling as resulting
from erroneous perceptions regarding control of impulses.
pathological
gambling

Several factors may predispose persons to develop the
disorder:
• loss of a parent by death, separation, divorce, or desertion before
a child is 15 years of age;
• inappropriate parental discipline (absence, inconsistency, or
harshness);
• exposure to, and availability of, gambling activities for
adolescents; a family emphasis on material and financial symbols;
and a lack of family emphasis on saving, planning, and budgeting.
pathological
gambling

Biological Factors
 Male pathological gamblers may have:
 subnormal MHPG concentrations in plasma,
 increased MHPG concentrations in the CSF,
 increased urinary output of norepinephrine.
 serotonergic regulatory dysfunction in the pathological
gambler.
 Chronic gamblers have low platelet monoamine oxidase (MAO)
activity, a marker of serotonin activity, also linked to difficulties
with inhibition..
pathological
gambling

• pathological gamblers often appear overconfident, somewhat
abrasive, energetic, and free-spending.
• They often show obvious signs of personal stress, anxiety, and
depression.
• They commonly have the attitude that money is both the cause of,
and the solution to, all their problems.
• usually forced to lie to obtain money and to continue gambling.
• make no serious attempt to save money.
• likely to engage in antisocial behavior to obtain money.
• Their criminal behavior is typically nonviolent.
• Complications include alienation from family members and
acquaintances, the loss of life accomplishments, suicide attempts, and
association with fringe and illegal groups. Arrest for nonviolent crimes
may lead to imprisonment.
pathological
gambling

• abnormalities in platelet MAO activity. Patients
• high levels of impulsivity on neuropsychological tests.
• increased cortisol levels in the saliva of gamblers while they
gamble, which can account for the euphoria occurs during the
experience and its addictive potential.
pathological
gambling

• Social gambling; occurs with friends, on special occasions, and
with predetermined acceptable and tolerable losses.
• manic episode ; history of a marked mood change and the loss of
judgment preceding the gambling.
• Antisocial personality disorder may have problems with gambling.
When both disorders are present, both should be diagnosed.
pathological
gambling

• begins in adolescence for men and late in life for women.
• The disorder waxes and wanes and tends to be chronic.
• Show Four phases;
1. The winning phase, ending with a big win, equal to about a year's salary,
which hooks patients. Women usually do not have a big win, but use
gambling as an escape from problems.
2. The progressive-loss phase, in which patients structure their lives around
gambling and then move from being excellent gamblers to being stupid ones
who take considerable risks, cash in securities, borrow money, miss work,
and lose jobs.
3. The desperate phase ‫مستميت‬, with patients frenziedly ‫بشراهة‬ gambling with
large amounts of money, not paying debts, becoming involved with loan
‫قروض‬, writing bad checks, and possibly embezzling.
4. The hopeless stage of accepting that losses can never be made up, but the
gambling continues because of the associated arousal or excitement. The
disorder may take up to 15 years to reach the last phase, but then, within a
year or two, patients have deteriorated totally.
pathological
gambling

• Gamblers seldom come forward voluntarily to be treated.
• Legal difficulties, family pressures, or other psychiatric complaints
bring gamblers to treatment.
• GA was founded in Los Angeles in 1957 and modeled on Alcoholics
Anonymous (AA); it is accessible, at least 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
available to help members resist the impulse to gamble.
• The dropout rate from GA is high
pathological
gambling

• hospitalization may help by removing patients from their
environments.
• Insight-oriented psychotherapy should not be sought until patients
have been away from gambling for 3 months. At this point, patients
who are pathological gamblers may become excellent candidates
for this form of psychotherapy.
• Family therapy is often valuable.
• Cognitive-behavioral therapy (e.g., relaxation techniques combined
with visualization of gambling avoidance)
• Little is known about the efficacy of pharmacotherapy
pathological
gambling

impulse-control disorders.
(2) kleptomania,
(3) pyromania,

impulse-control disorders.
(2) kleptomania,
(3) pyromania,
(5) trichotillomania

(2) kleptomania,
(3) pyromania,
(5) trichotillomania

• chronic disorder characterized by repetitive hair pulling, driven by
escalating tension and causing variable hair loss that is usually—
but not always—visible to others.
• Known at least as far back as the 12th century.
• “trichotillomania” was coined by a French dermatologist, Francois
Hallopeau, in 1889.
trichotillomania

• The prevalence underestimated because of accompanying shame
and secretiveness.
• The diagnosis encompasses at least two categories of hair pullers
differing in incidence, severity, age of presentation, and gender
ratio. Other subsets may exist.
• The potentially most serious, chronic form of the disorder usually
begins in early to mid- adolescence, with a lifetime prevalence
ranging from 0.6 % to as high as 3.4 % in general populations and
with a female to male ratio as high as 9 to 1.
trichotillomania

• The number of men may actually be higher, because men are even
more likely than women to conceal hair pulling.
• A patient with chronic trichotillomania is likely to be the only or
oldest child in the family.
• A childhood type of trichotillomania occurs approximately equally in
girls and boys, more common than the adolescent or young adult
type.
• 33 to 40 % of patients with chew or swallow the hair that they pull
out at one time or another. Of this group, approximately 37.5 %
develop potentially hazardous bezoars.
trichotillomania

• Significant comorbidity with OCD (as well as other anxiety
disorders)
• Tourette's syndrome.
• affective illness, especially depressive conditions.
• eating disorders.
• personality disorders—particularly obsessive-compulsive,
borderline, and narcissistic personality disorders.
• Comorbid substance abuse disorder is not encountered as
trichotillomania

• its onset has been linked to stressful situations in more than ¼
cases.
• Disturbances in mother-child relationships, fear of being left
alone, and recent object loss are often cited as critical factors
contributing to the condition.
• Substance abuse may encourage development of the disorder.
• Depressive dynamics are often cited as predisposing factors, but
no particular personality trait or disorder characterizes patients.
Some see self-stimulation as the primary goal of hair pulling.
trichotillomania

• Biologically determined substrate may reflect inappropriately
released motor activity or excessive grooming behaviors.
• Biological theories pointed to metabolic differences in the
serotonin and opioid systems.
• Family members often have a history of tics, impulse-control
disorders, and obsessive-compulsive symptoms, further
supporting a possible genetic predisposition.
trichotillomania

• Before engaging in the behavior, patients
experience an increasing sense of tension and
achieve a sense of release or gratification from
pulling out their hair.
• All areas of the body may be affected, most
commonly the scalp Other areas involved are
eyebrows, eyelashes, and beard; trunk, armpits,
and pubic area are less commonly involved
• Hair loss is often characterized by short, broken
strands appearing together with long, normal
hairs in the affected areas.
• No abnormalities of the skin or scalp are
present.
trichotillomania

• Hair pulling is not reported to be painful,
although pruritus and tingling may occur in the
involved area.
• Complications: trichobezoars, malnutrition, and
intestinal obstruction.
• Patients usually deny the behavior and often try
to hide the resultant alopecia.
• Head banging , nail biting, scratching, gnawing,
excoriation, and other acts of self-mutilation
may be present.
trichotillomania

A. Recurrent pulling out of one's hair resulting in noticeable hair
loss.
B. An increasing sense of tension immediately before pulling out the
hair or when attempting to resist the behavior.
C. Pleasure, gratification, or relief when pulling out the hair.
D. 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 distress or
impairment in social, occupational, or other important areas of
functioning.
trichotillomania

• If necessary, the clinical diagnosis can be confirmed by punch
biopsy of the scalp.
• In patients with a trichobezoar, blood count may reveal a mild
leukocytosis and hypochromic anemia due to blood loss.
• Appropriate chemistries and radiological studies should also be
performed, depending on the bezoar's suspected location and
impact on the gastrointestinal (GI) tract.
trichotillomania

• Hair pulling may be a wholly benign condition
• OCD;.
 As with OCD, trichotillomania is often chronic and recognized by patients as undesirable.
 Unlike those with OCD, patients with trichotillomania do not experience obsessive
thoughts, and the compulsive activity is limited to one act, hair pulling.
• Factitious disorder: physical signs and symptoms actively seek medical
attention and the patient role and deliberately simulate illness toward
these ends.
• Patients with stereotypic movement disorder; do not seem distressed
by their behavior.
• alopecia areata and tinea capitis; biopsy may be necessary to
distinguish
trichotillomania

• Onset:
The mean age at onset: is in the early teens, most frequently
before age 17, but onsets have been reported much later in life.
• course;
• both chronic and remitting forms occur.
 An early onset :remit more readily and responds to suggestion, support, and behavioral
strategies.
 Late onset: associated with an increased likelihood of chronicity and poorer prognosis
• 1/3 of persons presenting for treatment report a duration of 1
year or less,
• whereas in some cases, the disorder has persisted for more than
two decades.
trichotillomania

• Treatment usually involves psychiatrists and dermatologists.
• Psychopharmacological methods that have been used to treat
psychodermatological disorders include:
 topical steroids and hydroxyzine hydrochloride (Vistaril),
 an anxiolytic with antihistamine properties;
 antidepressants; serotonergic agents;
 and antipsychotics.
trichotillomania

• Whether depression is present or not, antidepressant agents can
lead to dermatological improvement.
• Patients who respond poorly to SSRIs may improve with
augmentation with pimozide (Orap), a dopamine receptor
antagonist.
• A report of successful lithium treatment for trichotillomania
• Successful behavioral treatments: biofeedback, self-monitoring,
covert desensitization, and habit reversal, have been reported
• Chronic trichotillomania: insight-oriented psychotherapy.
trichotillomania

:
impulse-control disorders
(2) kleptomania,
(3) pyromania,

:
impulse-control disorders
(2) kleptomania,
(3) pyromania,
(6) impulse-control disorder not
otherwise specified (NOS).

impulse-control disorder not otherwise
specified (NOS).
• Compulsive Buying
• Internet Compulsion
• Mobile Phone Compulsion
• Compulsive Sexual Behavior

Impulse Control Disorders

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