Kk&s Ch.25 Impulse Control Nos

Front 1

Describe Impulse control ds in general

Back 1

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. These feelings may stem from obscure unconscious conflicts or awareness of the deed's impact on others (including the possibility of serious legal consequences in syndromes such as kleptomania). Shameful secretiveness about the repeated impulsive activity frequently expands to pervade the individual's entire life, often significantly delaying treatment.

Front 2

Name 4 Impulse-Control Ds NOS

Back 2

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

Front 3

What can lower person's resistance to control impulses

Back 3

Fatigue,
incessant stimulation, and
psychic trauma can lower a person's resistance to control impulses.

Front 4

Heinz Kohut considered many forms of impulse-control problems, including gambling, kleptomania, and some paraphiliac behaviors, to be related to

Back 4

an incomplete sense of self. He observed that when patients do not receive the validating and affirming responses that they seek from persons in significant relationships with them, the self might fragment. As a way of dealing 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. Kohut's formulation has some similarities to Donald Winnicott's view that impulsive or deviant behavior in children is a way for them to try to recapture a primitive maternal relationship. Winnicott saw such behavior as hopeful in that the child searches for affirmation and love from the mother rather than abandoning any attempt to win her affection.

Front 5

Psychosocial factors implicated causally in impulse-control disorders are related to

Back 5

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.

Front 6

Experiments have shown that impulsive and violent activity is associated with specific brain regions such as ?

Back 6

such as the limbic system, and that the inhibition of such behaviors is associated with other brain regions.

Front 7

A relation has been found between (HIGH or LOW) cerebrospinal fluid (CSF) levels of 5-hydroxyindoleacetic acid (5-HIAA) and
?

Back 7

LOW

impulsive aggression

Front 8

Which hormones assoc with aggression?

Back 8

testosterone

Front 9

Neuro problems associated with aggression?

Back 9

Some 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

Front 10

A high incidence of (left, right, mixed) cerebral dominance may be found in some violent population

Back 10

MIXED

Front 11

Which NT most linked to impulse control ds?

Back 11

onsiderable 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

Front 12

(CNS REGIONS) levels of 5-HIAA are (DECREASED OR INCREASED), and serotonin-binding sites are (DECREASED, INCREASED) in persons who have committed suicide.

Back 12

Brainstem and CSF levels of 5-HIAA are decreased, and serotonin-binding sites are increased in persons who have committed suicide.

Front 13

What else is associated with adult Impulse control ds?

Back 13

ADHD
MR
EPileps
Brain Syndromes

Front 14

In intermittent explosive ds do people show regret after the event? between?

Back 14

yes, no aggression inbetween

Front 15

The diagnosis of intermittent explosive disorder should not be made if the loss of control can be accounted for by ?

Back 15

schizophrenia,
antisocial or borderline personality disorder,
ADHD, conduct disorder, or
substance intoxication.

Front 16

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 associated features suggest the possibility of an epileptoid state

Back 16

the presence of auras; postictal-like changes in the sensorium, including partial or spotty amnesia; and hypersensitivity to photic, aural, or auditory stimuli.

Front 17

Any genetic link to IED?

Back 17

yes, more common in first-degree biological relatives of persons with the disorder than in the general population.

Front 18

IED Comorbidity?

Back 18

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

Front 19

Psychodynamic explanation of Explosive outbursts

Back 19

Psychoanalysts have 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.

Front 20

IED more common in large or small men?

Back 20

Large men with poor masculine id
sense of being useless, impotent

Front 21

Predisposing factors to IED?

Back 21

Predisposing factors in infancy and childhood include perinatal trauma, infantile seizures, head trauma, encephalitis, minimal brain dysfunction, and hyperactivity. Workers who have concentrated on psychogenesis as causing episodic explosiveness have stressed identification with assaultive parental figures as symbols of the target for violence. Early frustration, oppression, and hostility have been noted as predisposing factors. Situations that are directly or symbolically reminiscent of early deprivations (e.g., persons who directly or indirectly evoke the image of the frustrating parent) become targets for destructive hostility.

Front 22

Some investigators suggest that disordered brain physiology, particularly in the ??? is involved in most cases of episodic violence

Back 22

limbic system,

Front 23

relationship of serotonin and aggression?

Back 23

Compelling evidence indicates that serotonergic neurons mediate behavioral inhibition. Decreased serotonergic transmission, which can be induced by inhibiting serotonin synthesis or by antagonizing its effects, decreases the effect of punishment as a deterrent to behavior. 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.

Restoring serotonergic activity by administration of L-tryptophan or drugs that increase synaptic serotonergic levels appears to restore control of episodic violent tendencies

Front 24

(LOW OR HIGH) levels of CSF 5-HIAA have been correlated with impulsive aggression.

Back 24

LOW

Front 25

(LOW OR HIGH) CSF testosterone concentrations are correlated with aggressiveness and interpersonal violence in men

Back 25

HIGH

Front 26

In IED, does one episode = ds?

Back 26

NO

Front 27

in IED any neuro signs?

Back 27

eurological examination sometimes reveals soft neurological signs, such as left-right ambivalence and perceptual reversal. Electroencephalographic (EEG) findings are frequently normal or show nonspecific changes.

Persons with the disorder have a 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.

Front 28

What tests to order in IED?

Back 28

Blood chemistry (liver and thyroid function tests, fasting blood glucose, electrolytes), urinalysis (including drug toxicology), and syphilis serology may help rule out other causes of aggression. Magnetic resonance imagery (MRI) may reveal changes in the prefrontal cortex, which is associated with loss of impulse control.

Front 29

What might you see with IED on MRI?

Back 29

Magnetic resonance imagery (MRI) may reveal changes in the prefrontal cortex, which is associated with loss of impulse control.

Front 30

DDX of IED?

Back 30

The diagnosis of intermittent explosive disorder can be made only after disorders associated with the occasional loss of control of aggressive impulses have been ruled out as the primary cause. These other disorders include psychotic disorders, personality change because of a general medical condition, antisocial or borderline personality disorder, and substance intoxication (e.g., alcohol, barbiturates, hallucinogens, and amphetamines), epilepsy, brain tumors, degenerative diseases, and endocrine disorders.

Front 31

How compare IED to conduct ds?

Back 31

Conduct disorder is distinguished from intermittent explosive disorder by its repetitive and resistant pattern of behavior, as opposed to an episodic pattern.

Front 32

How compare IED to ASPD?

Back 32

Intermittent explosive disorder differs from the antisocial and borderline personality disorders because, in the personality disorders, aggressiveness and impulsivity are part of patients' characters and, thus, are present between outbursts

Front 33

How compare IED to Sz?

Back 33

In paranoid and catatonic schizophrenia, patients may display violent behavior in response to delusions and hallucinations, and they show gross impairments in reality testing.

Front 34

IED vs mania?

Back 34

Hostile patients with mania may be impulsively aggressive, but the underlying diagnosis is generally apparent from their mental status examinations and clinical presentations.

Front 35

Amok vs IED

Back 35

Amok is an episode of acute violent behavior for which the person claims amnesia. Amok is usually seen in southeastern Asia, but it has been reported in North America. Amok is distinguished from intermittent explosive disorder by a single episode and prominent dissociative features

Front 36

Tx for IED?

Back 36

Group psychotherapy may be helpful, and family therapy is useful, particularly when the explosive patient is an adolescent or a young adult.

Front 37

One goal of therapy for Impulse DS?

Back 37

A goal of therapy is to have the patient recognize and verbalize the thoughts or feelings that precede the explosive outbursts instead of acting them out

Front 38

Rx for IED?

Back 38

nticonvulsants have long been used, with mixed results, in treating explosive patients. Lithium (Eskalith) has been reported useful in generally lessening aggressive behavior, and carbamazepine, valproate (Depakene) or divalproex (Depakote), and phenytoin (Dilantin) have been reported helpful. Some clinicians have also used other anticonvulsants (e.g., gabapentin [Neurontin]).

Front 39

IED and Benzo?

Back 39

Benzodiazepines are sometimes used but have been reported to produce a paradoxical reaction of dyscontrol in some cases.

Front 40

IED and Antipsychotics?

Back 40

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.

Front 41

IED and antidepressants?

Back 41

Selective serotonin reuptake inhibitors (SSRIs), trazodone (Desyrel), and buspirone (BuSpar) are useful in reducing impulsivity and aggression.

Front 42

IED and other?

Back 42

Propranolol (Inderal) and other β-adrenergic receptor antagonists and calcium channel inhibitors have also been effective in some cases. Some neurosurgeons have performed operative treatments for intractable violence and aggression. No evidence indicates that such treatment is effective.

Front 43

Persons with kleptomania usually don't have or do have

the money to pay for the objects they impulsively steal.

Back 43

do have

Front 44

Kleptomania ... is stealing planed? if caught how feel? goal of ?

Back 44

The stealing is not planned and does not involve others. Although the thefts do not occur when immediate arrest is probable, 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 or vengeance. Furthermore, when the object stolen is the goal, the diagnosis is not kleptomania; in kleptomania, the act of stealing is itself the goal.

Front 45

More males or females shoplift?

Back 45

females, 3 to 1 males

Front 46

Kleptomania comorbidity?

Back 46

Patients with kleptomania are said to have a high lifetime comorbidity of major affective illness (usually, but not exclusively, depressive)

and various anxiety disorders.

Associated conditions also include other impulse-control disorders (notably, pathological gambling and compulsive shopping), eating disorders, and substance abuse disorders, alcoholism in particular.

Front 47

One theoretician established seven categories of stealing in chronically acting-out children:

Back 47

*
As a means of restoring the lost mother–child relationship
*
As an aggressive act
*
As a defense against fears of being damaged (perhaps a search by girls for a penis or a protection against castration anxiety in boys)
*
As a means of seeking punishment
*
As a means of restoring or adding to self-esteem
*
In connection with, and as a reaction to, a family secret
*
As excitement (lust angst) and a substitute for a sexual act

Front 48

bio factors associated with kleptomania?

Back 48

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

Front 49

Kleptomania and family ds?

Back 49

In one study, 7 percent of first-degree relatives had obsessive-compulsive disorder (OCD). In addition, a higher rate of mood disorders has been reported in family members.

Front 50

In one study of patients with kleptomania, the frequency of stealing ranged from less than ? episodes a month

Back 50

1 to 120

Front 51

DDX of kleptomania?

Back 51

Mood Ds,
Sz
ASPD
EtOH intox/abuse
Alzeimeres

Front 52

Kleptomania onset usually?

Back 52

childhood

Front 53

Kleptomania usual onset?

Back 53

teens

Front 54

Tx for kleptomania

Back 54

Insight Psychdynamc Tx
Behavior Tx
SSRIs ... Prozac, Luvox

Case reports indicated successful treatment with tricyclic drugs, trazodone, lithium, valproate, naltrexone and electroconvulsive therapy

Front 55

Pyromania comorbidity?

Back 55

Pyromania is significantly associated with

substance abuse disorder (especially alcoholism);
affective disorders, depressive or bipolar;
other impulse control disorders, such as kleptomania in female fire setters; and

various personality disturbances, such as inadequate and borderline personality disorders.

Attention-deficit disorder and learning disabilities may be conspicuously associated with childhood pyromania; this constellation frequently persists into adulthood.

Persons who set fires are more likely to be mildly retarded than are those in the general population. Some studies have noted an increased incidence of alcohol use disorders in persons who set fires.

Fire setters also tend to have a history of antisocial traits, such as truancy, running away from home, and delinquency.

Enuresis has been considered a common finding in the history of fire setters, although controlled studies have failed to confirm this.

Studies, however, have found an association between cruelty to animals and fire setting.

Childhood and adolescent fire setting is often associated with ADHD or adjustment disorders.

Front 56

Pyromania psychosocial theory?

Back 56

Several studies have noted that the fathers of patients with pyromania were absent from the home. Thus, one explanation of fire setting is that it represents a wish for the absent father to return home as a rescuer, to put out the fire, and to save the child from a difficult existence

Front 57

Describe Bio factors assoc with Pyromania

Back 57

LOW 5HIAA
LOW MHPG
LOW GLUCOSE

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. The presence of reactive hypoglycemia, based on blood glucose concentrations on glucose tolerance tests, has been put forward as a cause of pyromania

Front 58

Pyromania clinical features?

Back 58

Commonly associated features include alcohol intoxication, sexual dysfunctions, below-average intelligence quotient (IQ), chronic personal frustration, and resentment toward authority figures. Some fire setters become sexually aroused by the fire

Front 59

Pyromania vs conduct/aspd?

Back 59

When fire setting occurs in conduct disorder and antisocial personality disorder, it is a deliberate act, not a failure to resist an impulse.

Front 60

Prognosis for children vs adults?

Back 60

good for kids
gaurded for adults because
-- they frequently deny their actions, refuse to take responsibility, are dependent on alcohol, and lack insight.

Front 61

Tx of pyromania

Back 61

Jail
Support
Behavior Tx
.... no much evidence of tx

Front 62

DSM criteria for gambling

Back 62

(1) a preoccupation with gambling; (2) the 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) the commission of illegal acts to finance gambling; (8) jeopardizing or losing personal and vocational relationships because of gambling; and (9) a reliance on others for money to pay off debts

Front 63

Although comprehensive worldwide statistics have yet to be compiled, excellent local studies all point to a XX percent rate of problem gamblers in the general population and an approximate YY percent rate of individuals meeting the requirements for pathological gambling.

Back 63

3 to 5%
1%

Front 64

Family histories of pathological gamblers show an increased rate of

Back 64

substance abuse (particularly alcoholism) and depressive disorders

Front 65

gambling comorbidty?

Back 65

Significant comorbidity occurs between pathological gambling and mood disorders (especially, major depression and bipolarity) and substance abuse disorders (notably, alcohol and cocaine abuse and caffeine and nicotine dependence).

Comorbidity also exists with ADHD (particularly in childhood),

various personality disorders (notably, narcissistic, antisocial, and borderline personality disorders), and other impulse-control disorders.

Although many pathological gamblers have obsessive personality traits, full-blown OCD is uncommon.

Front 66

Several factors may predispose persons to develop the disorder:

Back 66

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.

Front 67

Psychoanalytic views of gambling?

Back 67

unconsciuos desire to lose to relieve guilt
narciss grandiosity ... i can control predict events

Front 68

bio factors assoc with gambling?

Back 68

hese theories have centered on both serotonergic and noradrenergic receptor systems. Male pathological gamblers may have subnormal MHPG concentrations in plasma, increased MHPG concentrations in the CSF, and increased urinary output of norepinephrine. Evidence also implicates 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.

Front 69

hese theories have centered on both serotonergic and noradrenergic receptor systems.
Male pathological gamblers may have(high,low) MHPG concentrations in plasma, (high,low) MHPG concentrations in the CSF, and (high,low) urinary output of norepinephrine. Evidence also implicates serotonergic regulatory dysfunction in the pathological gambler. Chronic gamblers have (high,low) platelet monoamine oxidase (MAO) activity, a marker of serotonin activity, also linked to difficulties with inhibition.

Back 69

hese theories have centered on both serotonergic and noradrenergic receptor systems. Male pathological gamblers may have subnormal MHPG concentrations in plasma, increased MHPG concentrations in the CSF, and increased urinary output of norepinephrine. Evidence also implicates 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.

Front 70

Gamblers attitude?

Back 70

They commonly have the attitude that money is both the cause of, and the solution to, all their problem

Front 71

Gambling lab abn?

Back 71

Males with the disorders have shown abnormalities in platelet MAO activity.

Patients with pathological gambling often display high levels of impulsivity on neuropsychological tests.

German studies have demonstrated increased cortisol levels in the saliva of gamblers while they gamble, which can account for the euphoria that occurs during the experience and its addictive potential.

Front 72

DDX of patho gambling?

Back 72

Mania
ASPD

Front 73

Four phases of patho gambling?

Back 73

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, with patients frenziedly gambling with large amounts of money, not paying debts, becoming involved with loan sharks, 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.

Front 74

Tx of gambling? drop out rate?

Back 74

Gamblers Anony
high

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.

CBT
Fam Tx

Front 75

Rx for gambling?

Back 75

Tx comorbidity

One study reported that 7 of 10 patients remained completely abstinent over 8 weeks after taking fluvoxamine. Also, case reports indicate successful treatment with lithium and clomipramine (Anafranil).

Front 76

What is a trichobezoar?

Back 76

swallowing hair

Front 77

Trichotillomania severe form begins when? more likely to be eldest, youngest or middle child?

Back 77

mid teens
eldest or only child

Front 78

Trichotillomani f-male ratio?

Back 78

9 to 1 except = in childhood

Front 79

Trichotillomania and comorbidity?

Back 79

Significant comorbidity is found between trichotillomania and OCD (as well as other anxiety disorders);

Tourette's syndrome;
affective illness, especially depressive conditions;
eating disorders; and various personality disorders—particularly
obsessive-compulsive,
borderline, and
narcissistic personality disorders.


Comorbid substance abuse disorder is not encountered as frequently as it is in pathological gambling, kleptomania, and other disorders.

Front 80

trichotillomania onset is XX% of time associatd with stressful situation?

Back 80

>25%

Front 81

etiology of trichotillomania

Back 81

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.

Front 82

genetic relationship in trichotillomania?

Back 82

Family members of trichotillomania patients often have a history of tics,

impulse-control disorders, and

obsessive-compulsive symptoms, further supporting a possible genetic predisposition.

Front 83

Trichotillomania .... most common region?

Back 83

scalp

Front 84

trichot hair loss pattern?

Back 84

Hair loss is often characterized by short, broken strands appearing together with long, normal hairs in the affected areas.

Front 85

How can you confirm clinical dx of tricho?

Back 85

punch biopsy of scalp

Front 86

what to do if suspect bezoar?

Back 86

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.

Front 87

DDX of Tricho?

Back 87

OCD
Factious ds
Malingering
mvmt disorders
alopecia areata and tinea capiti

Front 88

mean age of trich onset?

Back 88

early teens before 17

Front 89

tricho ... which is worse, onset before age 6 or after age 13

Back 89

after age 13

Front 90

Tx for trichotillomania

Back 90

topical steroids and hydroxyzine hydrochloride (Vistaril),
an anxiolytic with antihistamine properties;
antidepressants;
serotonergic agents; and
antipsychotics.

Front 91

Rx for Tricho?

Back 91

Current evidence strongly points to the efficacy of drugs that alter central serotonin turnover. 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 cited the possible effect of the drug on aggression, impulsivity, and mood instability as an explanation. Lithium also possesses serotonergic activity.

Case reports indicate successful treatment with buspirone, clonazepam (Klonopin), and

trazodone. In one placebo-controlled study, patients taking
naltrexone had a reduction in symptom severity.

Front 92

Psych Tx for trichotillomania?

Back 92

Successful behavioral treatments, such as biofeedback, self-monitoring, covert desensitization, and habit reversal, have been reported, but most studies have been based on individual cases or a small series of cases with relatively short follow-up periods. Further controlled study of the treatments is warranted.

Chronic trichotillomania has been treated successfully with insight-oriented psychotherapy.

Front 93

Define impulse and compulsion

Back 93

An impulse is a tension state that can exist without an action;
a compulsion is a tension state that always has an action component.

Front 94

Compulsive buying comorbid with?

Back 94

other disorders of impulse control (e.g., kleptomania), mood disorders, and OCD

Front 95

mobile phone compulsion justification?

Back 95

They justify their need to contact others by giving plausible reasons for calling; but underlying conflicts may be expressed in the behavior, such as fear of being alone, the need to satisfy unconscious dependency needs, or undoing a hostile wish toward a loved one, among others (e.g., “I just want to make sure you are OK.”