Impulse Control Disorders

Impulse Control Disorders
Dr. Mohammad Hussein
November 2009

1. Impulse-Control Disorders د.محمد حسين 2-11-2009

2. 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 Disorders Control Impulse

3. Etiology Psychodynamic Factors Psychosocial Factors Biological Factors

4. Etiology…. 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 ) .

5. Etiology…. 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 )

6. Etiology…. 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 ) عروستي

7. Etiology… 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 .

8. Etiology…. 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.

9. Etiology….. 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.

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

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

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

13. Intermittent Explosive Disorder 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

14. 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

15. Epidemiology 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

16. Comorbidity 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

17. Etiology 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

18. Etiology 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

19. Etiology… 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

20. Etiology… 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

21. Diagnosis and Clinical Features 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

22. DSM-IV-TR Diagnostic Criteria for Intermittent Explosive Disorder Several discrete episodes of failure to resist aggressive impulses that result in serious assaultive acts or destruction of property. The degree of aggressiveness expressed during the episodes is grossly out of proportion to any precipitating psychosocial stressors. The aggressive episodes are not better accounted for by another mental disorder (e.g., antisocial personality disorder, borderline personality disorder, a psychotic disorder, a manic episode, conduct disorder, 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

23. Physical Findings and Laboratory Examination 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

24. Differential Diagnosis 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: 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. personality change because of a general medical condition, antisocial or borderline personality disorder ; aggressiveness and impulsivity are part of patients' characters and, thus, are present between outbursts. substance intoxication (e.g., alcohol, barbiturates, hallucinogens, and amphetamines), epilepsy, brain tumors, degenerative diseases, and endocrine disorders. Conduct disorder ; repetitive and resistant pattern of behavior, as opposed to an episodic pattern. intermittent explosive disorder

25. Course and Prognosis 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 مُتَصاعِد organic impairment can lead to frequent and severe episodes. intermittent explosive disorder

26. Treatment A combined pharmacological and psychotherapeutic approach has the best chance of success. 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

27. Treatment… Pharmacological therapy 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. 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. SSRIs , trazodone ( Trittico ), and buspirone are useful in reducing impulsivity and aggression. Propranolol ( Inderal ) and other β-blockers and calcium channel blockers →effective in some cases. intermittent explosive disorder

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

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

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

31. 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

32. The stealing is not planned and does not involve others. Although the thefts السرقات do not occur when immediate arrest is probable التوقيف الفوري محتملُ , 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

33. Epidemiology 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

34. Comorbidity 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

35. Etiology 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

36. Etiology…. 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: As a means of restoring the lost mother–child relationship 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

37. Etiology …. 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

38. Diagnosis and Clinical Features 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

39. DSM-IV-TR Diagnostic Criteria for Kleptomania Recurrent failure to resist impulses to steal objects that are not needed for personal use or for their monetary value. Increasing sense of tension immediately before committing the theft. Pleasure, gratification, or relief at the time of committing the theft. The stealing is not committed to express anger or vengeance and is not in response to a delusion or a hallucination. The stealing is not better accounted for by conduct disorder, a manic episode, or antisocial personality disorder. kleptomania

40. Differential Diagnosis 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. 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. Acute intoxication with drugs or alcohol may precipitate theft in an individual with another psychiatric disorder or without significant psychopathology. Patients with Alzheimer's disease or other dementing organic illness may leave a store without paying, owing to forgetfulness Malingering kleptomania kleptomania

41. 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. Course kleptomania

42. Prognosis 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

43. Treatment 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

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

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

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

47. 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

48. Epidemiology 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

49. Comorbidity 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

50. Etiology Psychosocial Freud saw fire as a symbol of sexuality. He believed the warmth radiated by fire evokes the same sensation that accompanies a state of sexual excitation, and a flame's shape and movements suggest a phallus in activity. 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

51. Etiology …. 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

52. Diagnosis and Clinical Features Persons with pyromania often regularly watch fires in their neighborhoods, frequently set off false alarms, and show interest in firefighting paraphernalia الملابس 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 الإستياء toward authority figures. Some fire setters become sexually aroused by the fire. pyromania

53. DSM-IV-TR Diagnostic Criteria for Pyromania Deliberate and purposeful fire setting on more than one occasion. Tension or affective arousal before the act. Fascination with, interest in, curiosity about, or attraction to fire and its situational contexts (e.g., paraphernalia, uses, consequences). Pleasure, gratification, or relief when setting fires, or when witnessing or participating in their aftermath. The fire setting is not done for monetary gain, as an expression of sociopolitical ideology, to conceal criminal activity, to express anger or vengeance, to improve one's living circumstances, in response to a delusion or hallucination, or as a result of impaired judgment (e.g., in dementia, mental retardation, substance intoxication). The fire setting is not better accounted for by conduct disorder, a manic episode, or antisocial personality disorder. pyromania

54. Differential Diagnosis 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

55. Course 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 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

56. Treatment 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

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

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

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

60. 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 تَعْرِيض للخطر or losing personal and vocational relationships because of gambling; (9) a reliance on others for money to pay off debts. pathological gambling

61. Epidemiology 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

62. Comorbidity 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

63. Etiology 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

64. Etiology…. 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

65. Etiology…. 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

66. Diagnosis and Clinical Features 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

67. Psychological Testing and Laboratory Examination 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

68. Differential Diagnosis 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

69. Course and Prognosis 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

70. Treatment 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

71. Treatment… 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

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

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

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

75. 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

76. Epidemiology 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

77. Epidemiology…. 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

78. Comorbidity 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

79. Etiology 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

80. Etiology… 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

81. Diagnosis and Clinical Features 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

82. Diagnosis and Clinical Features…. 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

83. DSM-IV-TR Diagnostic Criteria for 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

84. Pathology and Laboratory Examination 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

85. Differential Diagnosis 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

86. Course and Prognosis 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

87. Treatment 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

88. Treatment… 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

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

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

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

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

93. وشكراً