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Disorders of Behavior and Impulse Control

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Title: Disorders of Behavior and Impulse Control


1
Disorders of Behavior and Impulse Control
  • Test Results
  • Read Article
  • Lecture

2
Overview
  • Substance Abuse
  • Sleep
  • Sexual and Sexual Identity
  • Eating

3
Substance-Related Disorders
  • The core concept of the group is the occurrence
    of adverse social, behavioral, psychological, and
    physiological effects caused by seeking or using
    one or more substances.

4
Evans (1998)
  • 30 of population with drug dx
  • 5.3 million people
  • 6 million children from homes with substance dx
    is diagnosable
  • 75 to 85 other mental disorder
  • 54 prison inmates substance dx
  • Deaths
  • 350 per day due to nicotine dependence
  • 150 alcohol
  • 15 other

5
DSM
  • DSM I
  • Alcoholism and Drug Addiction
  • Sociopathic personality disorders
  • DSM III
  • Move toward specific classes of substances

6
12 Classes of Abused Substances (p.193)
  • Alcohol
  • Inhalants
  • Amphetamines
  • Nicotine
  • Caffeine
  • Opioids
  • Cannabis
  • Phencyclidine
  • Cocaine
  • Sedatives, Hypnotics or Anxiolytics
  • Hallucinogens
  • Other or Unknown Substances

7
DEFINITIONS
  • Anxiolytic - medications that relieve anxiety
    (benzodiazepines)
  • Macropsia perceptual state wherein objects seem
    larger than they are
  • Micropsia perceptual state wherein objects seem
    smaller than they are
  • Psychomotor agitation abnormal increase in
    physical and emotional activity
  • Rush an immediate high that occurs shortly
    after substance ingestion
  • Tolerance needing increased amounts of a
    substance to achieve intoxication or desired
    effect
  • Withdrawal physical symptoms that occur after
    stopping or reducing the consumption of a
    substance
  • Page 193 Table of drug effects

8
Psychoactive Substance Use Disorders
  • Examples
  • Substance Dependence
  • P. 197
  • Continued use of substance despite substance
    related problems.
  • Typically involves physiological dependence
  • Substance Abuse
  • P. 199
  • Maladaptive pattern of substance use leading to
    distress
  • Each substance area can be either Dependence or
    Abuse e.g.
  • Alcohol Dependence 303.90
  • Alcohol Abuse 305.00
  • Once you qualify for Dependence rule-out Abuse
  • Substance Induced Disorders
  • Substance Intoxication
  • Substance Withdrawal

9
Specifiers
  • With / Without physiological dependence
  • Tolerance or Withdraw
  • Early Full Remission
  • No criteria for 1 month
  • Early Partial Remission
  • 1 or more criteria but not full
  • Sustained Full Remission
  • No criteria for 12 months
  • Sustained Partial
  • 1 or more but not full criteria for 12 months
  • Contextual Specifiers
  • Agonist Therapy prescribed meds, no criteria 1
    month
  • Controlled Environment -

10
Substance-Induced Disorders
  • Substance Intoxication (p. 201)
  • Substance Withdrawal (p. 202)
  • Substance-Related Disorder NOS (e.g., p. 223)
  • Substance-Induced Mental Disorders (p. 209)
  • Delirium, Dementia, Amnestic Disorder, Psychotic
    Disorder, Mood Disorder, Sexual Dysfunction,
    Sleep Disorder, Anxiety Disorder (p. 479)

11
Necessary Clinical Information
  • Identity of substance(s) used
  • History of substance(s) used
  • History of substance use emergencies and
    treatment
  • Cognitive impairment (e.g., confusion,
    disorientation, impaired attention)
  • Physiological signs (e.g., hypertension,
    hypotension, tachycardia)

12
  • Psychomotor agitation or retardation
  • Changes in mood, perception, and thought
  • Changes in personality, mood, anxiety
  • Urine drug screening, blood alcohol level
  • Changes in social or family life
  • Current and past legal problems

13
Making a Diagnosis
  • Does the patient admit to using a substance?
  • Does the patient have abnormal physiological
    signs or symptoms?
  • Does the patient have a history of substance
    abuse?
  • Has the patient experienced recent related legal
    problems?
  • Does the patient have maladaptive behavioral or
    psychological changes?

14
Key Diagnostic Points
  • Substance Dependence diagnoses distinguished by
    evidence of either tolerance or withdrawal
  • Two main categories used in diagnosing dependence
    include physiological effects and resulting
    behavioral problems
  • Pupillary dilation is a sign of intoxication with
    some stimulants (e.g., cocaine) and a sign of
    withdrawal with some depressants (e.g., opioids)
  • Psychopathology occurring within 1 month after
    substance use may be etiologically related to the
    substance use

15
  • A 38 year old mother of 4 was referred to a
    counselor by her priest, to whom she had confided
    that every few months she was subject to intense
    fits of rage in which she struck her children and
    threw things at her husband, sometimes needing to
    be physically restrained. The children had
    learned to run off to their rooms and lock the
    doors when she began to rant "Did you do your
    homework?" or "Look at this messy house!" She
    had overheard them referring to her to their
    father as "crazy Mommy" and "looney." Her
    husband would not talk to her for several days
    after such an incident. The client herself felt
    very guilty and ashamed. Detailed questioning
    revealed that each episode was apparently
    associated with the client's sneaking only "a
    swallow or two" from a bottle of bourbon she kept
    hidden from her husband in the trunk of her car.

16
Diagnosis
  • Axis I 305.00

17
Sleep Disorders
  • Disturbance in the process of sleep that causes
    clinically significant distress or impairment in
    social, occupational, or other important areas of
    functioning.

18
Definitions
  • Apnea cessation of breathing
  • Cataplexy sudden loss of muscle tone usually
    associated with intense emotion
  • Dyssomnia disturbance in the amount, quality,
    or timing of sleep
  • Hypersomnia excessive amount of sleep
  • Insomnia difficulty initiating and maintaining
    sleep
  • Parasomnia disorders in which abnormal events
    occur during sleep
  • Somnambulism - sleepwalking

19
Dyssomnias
  • Disorders of initiating or maintaining sleep or
    of excessive sleepiness characterized by
    disturbance in the amount, quality, or timing of
    sleep.
  • Primary Insomnia p. 604 Primary
  • Hypersomnia p. 609

20
  • Narcolepsy p. 615
  • Breathing-Related Sleep Disorder p. 622
  • Circadian Rhythm Sleep Disorder p. 629
  • Dyssomnia NOS p. 629

21
Necessary Clinical Information
  • Insomnia or Hypersomnia
  • Daytime napping
  • Nightmares or bad dreams
  • Substance abuse
  • Sleep medication
  • Excessive daytime sleepiness
  • Work schedule
  • Travel schedule
  • Medical problems that might interfere with sleep
  • Snoring
  • Unusual sleep behavior (e.g., sleepwalking,
    episodes of terror)

22
Parasomnias
  • Disorders characterized by abnormal behavioral or
    physiological events occurring in association
    with sleep, specific sleep stages, or sleep-wake
    transitions.
  • Nightmare Disorder (p. 634)

23
  • Sleep Terror Disorder (p. 639)
  • Sleepwalking Disorder (p. 644)
  • Parasomnia NOS (p. 644)

24
Other Sleep Disorders
  • Insomnia Related to Another Mental Disorder (p.
    650)
  • Hypersomnia Related to Another Mental Disorder
    (p. 650)
  • Sleep Disorder Due to a General Medical Condition
    (p. 654)
  • Substance-Induced Sleep Disorder (p. 660)

25
Key Diagnostic Features
  • The diagnosis of Insomnia and Hypersomnia Related
    to Axis I or Axis II disorder is made when the
    patient has a sleep disturbance related to a
    psychiatric disorder but the disturbance is
    sufficiently severe to warrant independent
    treatment
  • Excessive daytime sleepiness and loud snoring are
    defining features of Breathing-Related Sleep
    Disorder (sleep apnea)

26
  • The diagnosis of Insomnia and Hypersomnia Related
    to Axis I or Axis II disorder is made when the
    patient has a sleep disturbance related to a
    psychiatric disorder but the disturbance is
    sufficiently severe to warrant independent
    treatment
  • Excessive daytime sleepiness and loud snoring are
    defining features of Breathing-Related Sleep
    Disorder (sleep apnea)

27
  • A 19 year old military recruit is referred to the
    counselor after walking in his sleep in his
    barracks on three occasions. He walked in his
    sleep as a young child, as did one of his
    sisters, but ha snot done so since about age
    five. He says he is not aware of this behavior
    and does not recall any dream associated with it.
    there is no personal history of significant
    dysphoria, maladjustment, or other psychiatric
    symptoms, and no family history of psychiatric
    disorder (except for sleepwalking). He has been
    doing well in Basic Training and does not want a
    medical discharge. His physical examination,
    including neurological workup and EEG, is
    negative.

28
Diagnosis
  • Axis I -

29
Sexual and Gender Identity Disorders
  • The core concept of the group is difficulty in
    the expression of normal sexuality (Fauman,
    1994 p. 284). The sexual disturbance results in
    significant distress or impairment in social,
    occupational, or other important areas of
    functioning.

30
Sexual Desire Disorders
  • Hypoactive Sexual Desire Disorder (p. 541)
  • Sexual Aversion Disorder (p. 542)

31
Sexual Arousal Disorders
  • Female Sexual Arousal Disorder (p. 544)
  • Male Erectile Disorder (p. 547)

32
Orgasmic Disorders
  • Female Orgasmic Disorder (p. 549)
  • Male Orgasmic Disorder (p. 552)
  • Premature Ejaculation (p. 554)

33
Sexual Pain Disorders
  • Dyspareunia (p. 556)
  • Vaginismus (p. 558)

34
  • Sexual Dysfunction Due to a General Medical
    Condition (p. 561)
  • Substance-Induced Sexual Dysfunction (p. 565)
  • Sexual Dysfunction NOS (p. 565)

35
Paraphilias
  • Recurrent, intense sexually arousing fantasies,
    sexual urges or behaviors with a specific focus
    lasting at least 6 months.
  • Distinguished from some other disorders because,
    in some cases (e.g., Frotteurism), the diagnosis
    is made if the client has acted on the urges
    regardless of whether the client indicates that
    the symptoms have caused marked distress.

36
  • Exhibitionism (p. 569)
  • Fetishism (p. 570)
  • Frotteurism (p. 570)
  • Pedophilia (p. 572)
  • Sexual Masochism (p. 573)

37
  • Sexual Sadism (p. 574)
  • Transvestic Fetishism (p. 575)
  • Voyeurism (p. 575)
  • Paraphilia NOS

38
  • Gender Identity Disorder (p. 581)
  • Gender Identity Disorder NOS (p. 582)
  • Sexual Disorder NOS (p. 582)

39
Necessary Clinical Information
  • History of cross-dressing
  • Current preferences for sexual partner (e.g.,
    age, sex)
  • Current sexual desire
  • Problems with arousal
  • Problems with orgasm
  • Pain associated with sex

40
  • Current and past sexual fantasies
  • Use of objects associated with the opposite sex
    for arousal
  • Gender Identity
  • Unusual sexual activity (e.g., voyeurism,
    frotteurism)
  • Coercion or humiliation in the sexual act

41
Impulse Control Disorders Not Otherwise Classified
  • Core concept of the diagnostic group is the
    repeated expression of impulsive acts that lead
    to physical or financial damage and often result
    in a sense of relief or release of tension.

42
Impulse Control Disorders Not Otherwise Classified
  • Intermittent Explosive Disorder (p. 667)
  • Kleptomania (p. 669)

43
  • Pathological Gambling (p. 674)
  • Pyromania (p. 671)
  • Trichotillomania (. 677)
  • Impulsive Control Disorder NOS (p. 677)

44
Necessary Clinical Information
  • Repeated episodes of stealing not motivated by
    monetary gain or vengeance
  • Unexplained hair loss in unusual areas of the
    body
  • Repeated financial difficulties in a person who
    appears to make adequate money
  • Repeated gambling
  • Sudden episodes of violence that are not
    warranted by the obvious stressor
  • Repeated episodes of fire setting not motivated
    by monetary gain or vengeance

45
Key Diagnostic Points
  • Objects stolen in Kleptomania are not needed for
    personal use or monetary gain
  • In Kleptomania, Pyromania, and Trichotillomania
    there is a sense of tension before the act, and
    pleasure, gratification, or relief after the act.

46
  • Craig was a hardworking student who began
    gambling in high school and found it exciting.
    Eventually he concentrated his gambling on horse
    races and tried to develop a system to beat the
    betting odds. His initial betting was restrained
    and judicious and he had modest winnings. One
    day, after he had established a successful dental
    practice, Craig won a substantial amount of
    money. After that his pattern of gambling
    changed. He became convinced that he could not
    lose and needed to bet more and more to maintain
    the initial excitement he had felt while
    gambling. Craig became careless and started to
    lose money, but responded by betting more money
    in an attempt to get even or recoup his losses.
    He tried to stop several times but in each
    instance he became irritable and restless and
    finally returned to gambling. Soon the gambling
    began to interfere with his practice and he began
    using the money he needed for the mortgage and
    other bills to pay his gambling debts. When his
    wife confronted him about the money, he lied to
    her. Eventually, as he became desperate, Craig
    borrowed from friends and loan sharks to finance
    his gambling.

47
Diagnosis
  • Axis I

48
Eating Disorders
  • The core concept of the group includes
  • Obsessive concern about becoming overweight or
    fat
  • Distorted body image
  • Inability to appropriately control food intake to
    maintain a healthy body weight
  • Fluctuation of self-evaluation dependent on
    perceived body shape or weight.

49
Definitions
  • Anorexia loss of appetite accompanied by
    inability to eat
  • Binge excessive eating beyond the amount
    necessary to satisfy normal appetite
  • Purge emptying the stomach by induced vomiting
    or the bowels by induced evacuation with enemas
    or laxatives

50
Necessary Clinical Information
  • Current and past weight
  • Current and past patterns of eating
  • Current and past feelings about food
  • Unusual eating rituals
  • Current and past appetite
  • History of dieting
  • Current and past feelings about weight

51
  • Medical illnesses
  • Current medications and abused substances
  • Psychiatric illnesses (e.g., Major Depression)
  • Episodes of binge eating
  • Psychological conflicts related to
    self-evaluation (self-esteem)
  • Relationship between weight and patients
    self-esteem
  • Family history of Eating Disorder

52
EATING DISORDERS
  • ANOREXIA NERVOSA (p. 589)
  • BULIMIA NERVOSA (p. 594)
  • EATING DISORDER NOS (p. 594)

53
  • Eight-year-old Tim was referred by a pediatrician
    who asked for an emergency evaluation because of
    a serious weight loss during the past year. Tim
    is extremely concerned about his weight and
    weighs himself daily. He complains that he is
    too fat, and if he does not lose weight, he cuts
    back on food. He has lost ten pounds in the past
    year and still feels that he is too fat, though
    it is clear that he is underweight. In
    desperation, his parents have removed the scales
    from the house as a result, Tim is keeping a
    record of the calories that he eats daily. He
    spends a lot of time on this, checking and
    rechecking that he has done it just right. In
    addition, Tim is described as being obsessed with
    cleanliness and neatness. Currently he has no
    friends because he refuses to visit them, feeling
    that their houses are "dirty" he gets upset whey
    another child touches him. He is always checking
    whether he is doing things the way they "should"
    be done. He becomes very agitated and anxious
    about this. He has to get up at least two hours
    before leaving for school each day in order to
    give himself time to get ready. Recently, he
    woke up at 130 in the morning to prepare for
    school.

54
Diagnosis
  • Axis I
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