Disorders Not Covered In Class

1. Disorders Not Covered In Class

2. Impulse Control DisordersNot Elsewhere Classified

3. Overview of Impulse Control Disorders (Not Elsewhere Classified) Disorders include: • Intermittent Explosive Disorder • Kleptomania • Pyromania • Pathological Gambling • Trichotillomania • Impulse Control Disorder Not Otherwise Specified (NOS)

4. 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 psychological stressors • The aggressive episodes are not better accounted for by another mental disorder (e.g., Antisocial Personality Disorder, Borderline Personality Disorder, a Psychotic Disorder, a Manic Episode, Conduct Disorder, or Attention Deficit/Hyperactivity Disorder) and are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., head trauma, Alzheimer’s disease)

5. Intermittent Explosive Disorder (IED) • People with IED often describe the episodes as “spells” or “attacks” • The episode I soften preceded by a sense of tension or arousal and is immediately followed by a sense of relief • The individual often feels upset, guilty, or embarrassed by their behavior during the episode PEOPLE WITH IED FIND THE EPISODES DISTRESSING

6. Intermittent Explosive Disorder (IED) • High comorbidity with: • Mood disorders • Anxiety disorders • Eating disorders • Substance abuse • IED is not diagnosed if the episodes are a direct result of the person using a substance; however, many people abuse substances to avoid feeling the symptoms of a psychological disorder • Other impulse control disorders

7. Intermittent Explosive Disorder (IED) • IED seems to be a rare disorder, and there is no reliable information on how many people have it • Symptoms are usually better accounted for by another disorder • Higher occurrence in first degree relatives of people with IED or other impulse control disorders

8. 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 hallucination • The stealing is not better accounted for by Conduct Disorder, a Manic Episode, or Antisocial Personality Disorder

9. Kleptomania • The objects stolen are usually of little value/use to the individual • A person with kleptomania often gives away or discards the stolen objects • Occasionally they are hoarded or returned • Usually a person with kleptomania avoids stealing when immediate arrest is likely, but does not preplan thefts or fully take into account the chances of being caught • Stealing is done alone

10. Kleptomania • People with kleptomania view their behavior as “ego dystonic” • (something that is not typical of them; they realize that the impulse is coming from their own mind but do not consider it to be in line with their usual personality) • The person is aware that stealing s wrong and often fear getting caught or feel depressed or guilty about the behavior • More common in women in clinical samples • Overall prevalence is unknown, but only accounts for less than 5% of shoplifters

11. Kleptomania • Age of onset is variable • High comorbidity with: • Mood disorders • Anxiety disorders • Eating disorders • Personality disorders • Other impulse control disorders

12. 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

13. Pyromania • May make considerable advance preparation for starting a fire • May be indifferent to the consequences to life or property after fires, or may derive satisfaction from the destruction • Behaviors may lead to property damage, legal consequences, injury, or loss of life • Insufficient data about typical age of onset; unclear if there’s a relationship between fire setting in childhood and adulthood • Fully diagnosable pyromania in children is particularly rare

14. Pyromania • Pyromania is extremely rare, but is more commonly diagnosed in males • There is high comorbidity with alcohol or substance dependence and abuse

15. Pathological Gambling • Persistent and recurrent maladaptive gambling behavior as indicated by five (or more) of the following: • Is preoccupied with gambling (e.g., preoccupied with reliving past gambling experiences, handicapping or planning the next venture, or thinking of ways to get money with which to gamble) • Needs to gamble with increasing amounts of money in order to achieve the desired excitement • Has repeated unsuccessful efforts to control, cut back, or stop gambling • Is restless or irritable when attempting to cut down or stop gambling • Gambles as a way of escaping from problems or of relieving a dysphoric mood (e.g., feelings of helplessness, guilt, anxiety, depression)

16. Pathological Gambling • After losing money gambling, often returns another day to get even (“chasing” one’s losses) • Lies to family members, therapists, or others to conceal the extent of involvement with gambling • Has committed illegal acts such as forgery, fraud, theft, or embezzlement to finance gambling • Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling • Relies on others to provide money to relieve a desperate financial situation caused by gambling • The gambling behavior is not better accounted for by a manic episode

17. Pathological Gambling • Note that the symptoms described closely mirror those of physical addiction/dependence! • There are often distortions in thinking that accompany the gambling (e.g., denial, superstitions, overconfidence, or a sense of power or control) • Many pathological gamblers view money as both the cause of and solution to their problems • Frequently are highly competitive, energetic, restless, and easily bored • May be overly concerned with approval of others and generous to the point of extravagance • When not gambling are often “workaholics”

18. Pathological Gambling • Prone to general medical conditions that are associated with stress: • Hypertension • Peptic ulcer disease • Migraines • High incidence of suicidal ideation and attempts • High comorbidity with: • Mood disorders • Attention deficit/hyperactivity disorder • Substance abuse or dependence • Other impulse control disorders • Antisocial, Narcissistic, and Borderline Personality disorders

19. Pathological Gambling • Often abnormal laboratory findings: • Levels of serotonin, norepinephrine, and dopamine • Abnormalities in platelet monoamine oxidase • High levels of impulsivity on neuropsychological tests

20. Pathological Gambling • Females seem to account for 1/3 of pathological gamblers, but only 2-4% of those in treatment • Life time prevalence estimates range from .4% to 8% depending on location and age group • More common among relatives of pathological gambles and substance abusers

21. Trichotillomania • Recurrent pulling out of one’s hair resulting in noticeable hair loss • An increasing sense of tension immediately before pulling out the hair or when attempting to resist the behavior • Pleasure, gratification, or relief when pulling out the hair • The disturbance is not better accounted for by another mental disorder and is not due to a general medical condition (e.g., dermatological condition) • The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

22. Trichotillomania • Sites of hair pulling include anywhere on the body where hair may grow • May occur in brief periods scattered throughout the day or in less frequent but longer periods that can continue for hours • Hair pulling often occurs while the person is in a state of relaxation or distraction (e.g., while reading a book or watching TV.) but can also occur during stressful circumstances • For some, tension does not necessarily precede the hair pulling but is associated with attempts to resist the impulse • Some people experience an “itch like” sensation that is eased by pulling the hair

23. Trichotillomania • Hair pulling usually does not occur around other people (except family members) but social situations may be avoided • Individuals frequently try to find ways to hide their behavior or camouflage the results • Some may have impulses to pull hair from other people or objects • Associated behaviors include: • Examining the hair root • Pulling the hair strand between teeth • Eating hairs • Nail biting • scratching

24. Trichotillomania • High comorbidity with: • Mood disorders • Anxiety disorders (especially obsessive compulsive disorder) • Substance abuse • Eating disorders • Personality disorders • Mental retardation

25. Trichotillomania • Seems to be equally common among males and females in children • Among adults, more common in females • This may reflect differences in who seeks treatment among adults – the resulting hair loss may be more acceptable to an adult male than adult female due to societal norms • Overall prevalence is unclear, but it is relatively uncommon

26. This slide left blank as a divider

27. Gender Identity Disorder • A strong and persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex) In children, the disturbance is manifested by four (or more) of the following: • repeatedly stated desire to be, or insistence that he or she is, the other sex • In boys, preference for cross-dressing or simulating female attire; in girls, insistence on wearing only stereotypically masculine clothing • Strong and persistent preferences for cross-sex roles in make-believe play or persistent fantasies of being the other sex • Intense desire to participate in the stereotypical games and pastimes of the other sex • Strong preference for playmates of the other sex In adolescents and adults, the disturbance is manifested by symptoms such as a stated desire to be the other sex, frequent passing as the other sex, desire to live or be treated as the other sex, or the conviction that he or she has the typical feelings and reasons of the other sex

28. Gender Identity Disorder B. Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex In children, the disturbance is manifested by any of the following: in boys, assertion that his penis or testes are disgusting or will disappear or assertion that it would be better to not have a penis, or aversion toward rough-and-tumble play and rejection of male stereotypical toys, games, and activities; in girls, rejection of urinating in a sitting position, assertion that she has or will grow a penis, or assertion that she does not want to grow breasts or menstruate, or marked aversion toward normative feminine clothing. In adolescents and adults, the disturbance is manifested by symptoms such as preoccupation with getting rid of primary and secondary sex characteristics (e.g., request for hormones, surgery, or other procedures to physically alter sexual characteristics to simulate the other sex) or belief that he or she was born the wrong sex C. The disturbance is not concurrent with a physical intersex condition D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

29. Gender Identity Disorder • Diagnosis requires strong and persistent cross-gender identification and persistent discomfort about one’s own sex • As children, people with GID may insist that they will grow up to be the opposite sex and prefer to play with toys and take on roles typically associated with the opposite sex • Some children may refuse to attend events where they are required to dress as their biological sex • There is a high risk of social isolation because of stigma and ostracism • People with GID are at a higher risk for low self esteem and dropping out of school • There are high rates of depression and anxiety disorders among people with GID; this may be largely due to cultural reasons

30. Gender Identity Disorder • Men seem to seek treatment more often • As children, females may experience less ostracism because “tom boy” behavior is often accepted and parents are more likely to seek treatment for a son who is effeminate • Men tend to seek sex-reassignment surgery more often than women • Adults who are diagnosed with GID usually have onset of cross-gendered interests/behaviors around 2-4 years of age • Most children who express the same behaviors grow out of them and do not have GID as adults Note: GID is NOT the same as or necessarily connected with homosexuality