Impulse-control disorders (ICDs) are psychological disorders characterized by the repeated inability to refrain from performing a particular action that is harmful either to oneself or others. The individual fails to resist performing a potentially harmful act and it is usually accompanied by a sense of tension or arousal before committing the act and a sense of relief or pleasure when it is committed. The hallmark in describing any of the ICDs is a tendency to gratify an immediate desire or impulse regardless of the consequences to one's self or to others.

1. IMPULSE CONTROL
DISORDERS (ICDs)
Windsor University School of
Medicine
Psychiatry Rotation
Consultant Psychiatrist – Dr. Sharon
Halliday
Presentation by:
OLADAPO SAMSON OLUWABUKOLA
TH

2. Overview
‘Throughout the past few years, ICDs
have attracted the attention of clinicians
and psychiatrists due to their impact on
the society. Interestingly enough, the
rapid advancement of technology and
its effects on the society is incriminated
to be the cause for the rise in the
prevalence of ICDs. The advent of the
Internet has created unlimited access to
gambling, shopping, porn and stock
trading; thus, the incidence of
impulsive behavior patterns has risen
sharply. Even more, new forms of
impulsive disorders have emerged such

3. Definition of terms
 Impulse-control disorders (ICDs) are
psychological disorders characterized by the
repeated inability to refrain from performing a
particular action that is harmful either to oneself
or others.
 The individual fails to resist performing a
potentially harmful act and it is usually
accompanied by a sense of tension or arousal
before committing the act and a sense of relief or
pleasure when it is committed.
 The hallmark in describing any of the ICDs
is a tendency to gratify an immediate
desire or impulse regardless of the

4. OUTLINE OF IMPULSE
CONTROL DISORDERS
(ICDs)

5. Outline of ICDs
 According to the DSM-IV-TR classification:
 Impulse control disorders not elsewhere classified:
 Intermittent explosive disorders
 Pyromania
 Kleptomania
 Pathological gambling
 Trichotillomania
 Impulse control disorders not otherwise specified:
 Impulsive compulsive self injurious disorders
 Impulsive compulsive sexual disorders
 Impulsive compulsive buying disorders
 Impulsive compulsive Internet usage disorders
 NB: there are other disorders of impulsivity but are beyond
the scope of this presentation.

6. Outline of ICDs
 Impulsivity is controlled by three major cognitive
components which are all stressful for an
individual who suffers from an impulse control
disorder. These factors are as follows:
 Failure to delay gratifications. An individual with
an impulse control disorder often takes decisions
that are aimed at seizing an immediate gain
without considering the long term unfavorable
consequences of his/her decisions and regardless
of how trivial this gain might be.
 Distractibility: failure to maintain continuous
attention on a certain task.
 Dis-inhibition: the inability to suppress behavior
in a way that is expected to be appropriate in view
of social norms and constraints.

7. Outline of ICDs
 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.

8. Incidence
 As compared to other mental disorders, impulse
control disorders were found in 8.9% (12-month
prevalence) and 24.8% (lifetime prevalence) of the
population with a greater proportion at the serious
level.
 The prevalence of impulse control disorders varies
significantly with the subtype of the disorder. For
instance, the incidence of Intermittent Explosive
Disorders (IEDs) varies according to age. Recent
studies have shown that the prevalence was
approximately 7.4% for individuals between 30 and
44 years of age, while it was only 5.7% for those
between 30 and 44 years and dropped to 4.9% for

9. Incidence
 It is rather hard to determine the prevalence of
almost all other impulse control disorders because
individuals who suffer from these disorders often
attempt to conceal their behavior from others to
prevent the “shame” of being detected. However,
pathological gambling has been extensively studied
and its prevalence is estimated to range between
1% and 3% among American adults. Pathological
gambling often starts in adolescence when the
prevalence is even higher ranging between 4% and
7%.

10. Risk factors
 Traumatic Brain Injury may result in some
individuals developing impulsive disorder. This is
particularly true when the damage has been to the
frontal cortex area.
 Substance abuse appears to be commonly
associated with impulsivity. While not all individuals
with substance abuse problems will develop impulse
control problems, research has noted a strong
correlation between the two.

11. Etiology
 Biological
 Psychological
 Social

12. Etiology – Biological
 Many investigators have focused on possible
organic factors in the impulse-control disorders,
especially for patients with overtly
violent behavior.
 Experiments have shown that impulsive
and violent activity is associated with specific
brain regions, such as the limbic system, and that
the inhibition of such behaviors is associated with
other brain regions.
 This findings led to the science of neurobiology of
ICDs

13. Etiology – Neurobiology
 The human brain is wired with natural checks and
balances that control emotions, but breakdowns in
this regulatory system appear to dramatically
heighten risk of impulsive behavior.

14. Etiology – Psychological
 An impulse is a disposition to act to decrease
heightened tension caused by the buildup
of instinctual drives or by diminished ego defenses
against the drives.
 The impulse disorders have in common an attempt
to bypass the experience of disabling symptoms or
painful affects by acting on the environment.

15. Etiology – Social
 Psychosocial factors implicated causally in impulse-
control disorders are related to 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.

16. Pathogenesis
 It has not been fully established yet how impulse
control disorders starts but the following hypothesis is
known about its pathogenesis:
 Serious head injuries and those with epilepsy have a
higher risk of developing this
 Suggested side effects of other medical conditions
 Abnormal neurological development and brain
chemistry.

17. Pathogenesis
 Impulsive behavior may be related to the interplay between several
distinct brain regions, namely the orbital frontal cortex, the anterior
cingulate cortex, and the amygdala.
 The orbital frontal cortex plays a crucial role in constraining
impulsive outbursts, while the anterior cingulate cortex recruits other
brain regions in the response to a stimulus or conflict.
 The amygdala, a tiny but highly influential portion of the brain, is
involved in the production of a fear response and other emotions.
 Over the past several years, case reports and series have noted the
onset of pathological gambling in patients with Parkinson disease
treated with levodopa (Larodopa) and dopamine agonists.
 The case reports have named dopamine receptor agonists as the
likely culprits, but the role of levodopa has been unclear and the
possibility that the symptom is a manifestation of Parkinson's
disease itself has been posited.
 The idea that pathologic gambling can be precipitated by drug
therapy challenges conventional views about complex behaviors and
the effects that drugs can have.

18. Pathogenesis

19. Pathophysiology

20. INTERMITTENT
EXPLOSIVE DISORDER
(IED)

21. IED
 Intermittent explosive disorder manifests as discrete
episodes of losing control of aggressive impulses;
these episodes can result in serious assault or the
destruction of property.
 The aggressiveness expressed is grossly out
of proportion to any stressors that may have helped
elicit the episodes.
 The symptoms, which patients may describe as spells
or attacks, appear within minutes or hours and,
regardless of duration, remit spontaneously and
quickly.

22. IED – Case Presentations
• A 31-year-old male presented with features of remaining aloof, sad,
having prominent guilt ideas and entertaining thoughts of causing self-
harm. The symptoms had developed insidiously when his wife learnt
about his extramarital affair with a known relative. After his wife left him,
the feelings of low mood became more intense and he started to
entertain suicidal thoughts. While driving his motorcycle in the night, he
met with an accident and started to bleed profusely. He tasted his own
blood and liked the smell and taste of it. Thus, the frequent incidences
of wrist cutting started so that he could suck his own blood. The act
would be preceded by a mounting tension and arousal and subsequent
relief would be noted later. He would break bottles and, with the glass
pieces, would slash his palm, wrist and feet to see and feel the blood.
He would also chew the glass pieces and the hurt caused by the glass
pieces to his cheek and lips would actually be enjoyed by the individual.
He even resorted to head banging so that the injuries caused to the
scalp would produce more blood. As his unusual behavior was noted,
he was admitted to the psychiatric center. While he was admitted to the
hospital, he remained symptomatic. He was noted to remain quiet and
aloof only to be shattered with episodic outbursts of intense anger and
aggression. He assaulted other inpatients and derived pleasure from
this fact. The episode lasted from 15 to 30 min and subsided on its own.
The individual would remember the incident, but would give no

23. IED – Case Presentations
 Kevin is diagnosed with an intermittent explosive
behavior. He was raged with anger when a friend
of him, Mike, mocked the way his hair looks. He
suddenly punched Mike hardly in the face breaking
the poor guy’s nose. This is just one of many
examples of Kevin’s unnecessary aggressive
responses. When he is really angry, his temper
builds up so fast and bursts with aggressive
actions that usually harm people around him. His
rage usually cools down in around 30 minutes after
which he sometimes even forgets that he has
harmed any one.

24. DSM-IV-TR CRITERIA
A. Several discrete episodes of failure to resist
aggressive impulses that result in serious
assaultive acts or destruction of property.
B. The degree of aggressiveness expressed during
the episodes is grossly out of proportion to any
precipitating psychosocial stressors.
C. The aggressive episodes are not better
accounted for by any other mental disorder (e.g.
Antisocial PD, Borderline PD, Conduct Disorder,
ADHD, a Manic Episode, a Psychotic Disorder),
are not due to the direct physiological effects of a
substance, or a general medical condition (e.g.
head trauma, Alzheimer’s disease).
HALLMARK: a pattern of aggressive behavior &

25. Facts and Figures
 Gender Differences: more common in men than
women
 Prevalence: rare
 Course: variable; chronic or episodic course
 Onset: childhood to the early 20’s

26. Contributing Factors
 Behavioral theory:
 Antecedents: a sense of tension or arousal
 Behavior: explosive behavior, aggressive episodes
 Immediate consequences: a sense of relief & release
 Delayed consequences: feeling upset, remorseful, regretful,
embarrassed about the aggressive behavior
 Personality factors: Generalized impulsivity or aggressiveness,
chronic anger management problems
 Childhood history of temper tantrums, impaired attention,
hyperactivity, and other behavioral difficulties
 Early learning: modeling, parenting styles, family conflict
 Biological factors: low levels of serotonin & norepinephrine,
high levels of testosterone
 Stress

27. Contributing Factors
 Some researchers have spotted a correlation between
aggressive behavior and disorders of the frontal lobe, especially
with focal orbito-frontal injury; however, in such case, according
to the DSM-IV-TR criteria, the diagnosis of intermittent explosive
disorders cannot be made. Nonetheless, a high percentage of
patients with violent behavioral patterns report history of head
trauma, mostly due to the nature of their actions, which doesn’t
coincide with the onset of their aggressive actions.
 Although the effect of trauma on the development of intermittent
explosive disorders is still not fully investigated, evidence exists
that supports the correlation between lesions in the prefrontal
cortex and impulsive patterns of aggressive behavior.
 Some evidence support the role of the reduced function of
serotonin pathways in the pathogenesis of impulsive patterns of
aggressive behavior. Moreover, some authors have reported the
increased incidence of impulsive disorders amongst children with
serotonin gene polymorphism patterns who experienced abuse,
neglect or violence.

28. Differential Diagnosis
1. Delirium
2. Dementia
3. Personality change due to a general medical condition,
general type
4. Substance intoxication
5. Substance withdrawal
6. Oppositional defiant disorder
7. Conduct disorder
8. Antisocial disorder
9. Borderline disorder
10. Mania
11. Schizophrenia
12. Tourette’s Syndrome
13. “Anger attacks” are seen sometimes as part of MDD or
panic disorder

29. Treatment – Psychosocial
 Individual psychotherapies
 Group psychotherapies
 Anger management

30. Treatment – Biological
 Medications used in the treatment of IEDs are all
off –label!
 Examples include:
 Mood stabilizers such as Lithium and the
anticonvulsants
 Beta blockers
 SSRIs

31. PYROMANIA

32. Pyromania
 Pyromania is the 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 aftermath.
 The diagnosis of pyromania necessitates the occurrence of
more than one occasion during which the patient attempts
deliberately setting fire. Moreover, the patient usually feels
stressed before setting the fire and relieved after performing
the act.
 Pyromania is extremely rare and literature data is rather
scarce.
 Incidence <1%, M>F

33. Etiology
 The exact cause for pyromania is still unclear.
Evidence suggests a multifactorial pathogenesis
which involves environmental factors,
temperamental factors and parental psychiatric
disorders. Some psychiatrists have suggested that
the cause for pyromania and most other impulse
control disorders is linked neuro-biologically, at
least in part, to substance abuse.

34. DSM-IV-TR CRITERIA
A. Deliberate and purposeful fire setting on more than one
occasion.
B. Tension or affective arousal before the act.
C. Fascination with, interest in, curiosity about, or attraction
to fire and its situational contexts (e.g. paraphernalia,
uses, consequences).
D. Pleasure, gratification, or relief when setting fires, or when
witnessing or participating in their aftermath.
E. The fire setting is not done for monetary gain, as an
expression of sociopolitical ideology, to conceal criminal
activity, to express anger or vengeance, to improve one’s
living circumstances, in response to a delusion or
hallucination, or as a result of impaired judgment (e.g. in
dementia, Mental Retardation, Substance Intoxication)
F. The fire setting is not better accounted for by Conduct
Disorder, a Manic Episode, or Antisocial Personality

35. Facts and Figures
 Age factors: although fire setting is a major problem in
childhood and adolescence, pyromania is rare; juvenile fire
setting is usually associated with ADHD, Conduct Disorder,
or Adjustment Disorder
 Prevalence: rare
 Gender differences: more common in males
 Typical age of onset: unknown
 Course: episodic; fire setting incidents may wax and wane
in frequency
 Cultural: primarily Caucasian

36. Contributing Factors
 Considerable planning and advance preparation for starting
a fire
 Reaction to fire-setting: gratification, pleasure, release
 Reaction to consequences: indifference or satisfaction
 Consequences of behavior: property damage, legal
consequences, injury &/or loss of life to fire setter or others
 Co-morbid disorders: Alcohol Abuse or Dependence
 Individual factors: poor social skills, learning difficulties,
sensation-seeking, attention-seeking
 Environmental factors: limited supervision, parental lack
of involvement, parental pathology, stressful events
 Physiological factors: low levels of Monoamine Oxidase,
diminished serotonin activity

37. Differential diagnosis
 Arson
 Psychosis
 Impaired judgment due to substance abuse
 mental retardation or dementia
 Dissocial personality disorder
 Mood disorders
 Conduct disorders
 Temporal lobe epilepsy
 Learning disability

38. Treatment – Psychosocial
 The literature focuses on treating pts with fire
setting more broadly, that is addressing other signs
of psychopathology, not just on pyromania:
 Education, including helping patients find
alternative routes to relieve tensions that have
been associated with fire-setting.
 Cognitive-Behavioural Therapy (CBT)

39. KLEPTOMANIA

40. Kleptomania
 Kleptomania is the irresistible urge to steal items that you
generally don't really need and that usually have little value.
 The essential feature of kleptomania is a 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, or kept and hidden.
Kleptomanics usually have the money to pay for the objects
they impulsively steal.
 It is crucial to differentiate kleptomania from common theft.
In kleptomania, the patient steals items that aren’t needed
in terms of use and/or their financial value. The shoplifting
behavior is neither a response to anger or revenge nor
triggered by hallucinations or delusions. Similarly to other
forms of impulse control disorders, patients with
kleptomania feel tensioned prior to performing the act of

41. Kleptomania - Case Presentation
 A 24 years old female, highly successful, single
executive from a wealthy background. She
was brought to the psychiatrist ward by the police
officer. She was accused of stealing several times
from the same shop in the same month.
She further states that the items she had stolen
were hair-chips and that she have kept them in a
box at home.
NB:
Although the thefts do not occur when immediate
arrest is probable, persons with kleptomania do
not always consider their chances of being

42. DSM-IV-TR CRITERIA
A. Recurrent failure to resist impulses to steal
objects that are not needed for personal use or
for their monetary value.
B. Increasing sense of tension immediately before
committing the theft.
C. Pleasure, gratification, or relief at the time of
committing the theft.
D. The stealing is not committed to express anger or
vengeance and is not in response to a delusion
or hallucination.
E. The stealing is not better accounted for by
Conduct Disorder, a Manic Episode, or Antisocial
Personality Disorder

43. Facts and Figures
 Gender: 66% to 80% are female
 Prevalence: occurs in less than 5% of identified
shoplifters; prevalence in general population is rare
and unknown
 Course:
 Sporadic with brief episodes & long periods of remissions;
 Episodic with protracted periods of stealing and periods of
remission;
 Chronic with some degree of fluctuation
 Onset: variable; earlier onset and treatment for
women
 Ego-Dystonic: person is aware that the behavior

44. Related & Contributing Factors
 Associated Disorders & Behaviors: compulsive shopping,
Mood Disorders (particularly depression), Eating Disorders
(particularly Bulimia Nervosa), Personality Disorders, other
Impulse Control Disorders, substance related disorders
 Childhood Experiences: stressful and tumultuous childhood,
sibling rivalries, separation from parents, neglectful parenting
 Psychoanalytic: defense against, or catharsis for, underlying
anxiety and anger
 Behavioral:
 Antecedents: tension, unpleasant feelings
 Immediate consequences: pleasure, gratification, relief
 Delayed consequences: depression, guilt, remorse; legal
problems (e.g. multiple convictions for shoplifting); family,
career, and personal difficulties

45. Differential diagnosis
 Episodes of theft occasionally occur during psychotic
illness, for example, 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.
 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 are also often prone
to stealing or some degree of shoplifting.

46. Treatment – Psychosocial
 No systematic or controlled psychosocial
treatments.
 Successful anecdotal treatments include:
 Complete abstinence from prospective stores
 Aversive conditioning
 Systemic desensitization
 Covert sensitization
 Psychodynamic therapy

47. Treatment – Biological
 Antidepressants
 Mood stabilizers such as Lithium
 Combination therapy – Antidepressants and Mood
Stabilizers
 Antipsychotics
 CNS – Stimulants
 ECT

48. PATHOLOGICAL
GAMBLING

49. Pathological Gambling
 Also known as Compulsive Gambling, it is the
uncontrollable urge to keep gambling despite the toll it takes
on your life.
 Apart from other forms of impulse control disorders,
pathological gambling is somehow correlated to substance
abuse disorders as the behavior is often associated with an
urge to increase the amount of risked money or assets to
feel satisfied which is similar to tolerance to drugs of abuse.
 Pathological gambling is usually associated with irritability
and restlessness when trying to stop gambling which is
similar to withdrawal symptoms that occur when the abused
drug is abruptly stopped. Furthermore, individuals with a
substance use disorder are at higher risk for development
of pathological gambling.
 Some studies have shown that nearly 73.2% of individuals
with pathological gambling have associated alcohol abuse
disorders, while 38.2% of pathological gamblers suffer from
other substance abuse disorders.

50. Neuro-pathology
 Functional magnetic resonance imaging (fMRI) and
brain spectroscopy have shown that the ventro-medial
prefrontal cerebral cortex, striatum and dopaminergic
neurons within the midbrain comprise the higher
centers for perception and anticipation of monetary
loss. Using the Stroop task, which is a scale of
behavioral inhibition, Potenza et al. concluded that
pathological gamblers exhibit decreased activity of the
neuronal pathways in the left ventro-medial portions of
the prefrontal cortex. Collectively, a considerable body
of evidence exists supporting the role of the ventro-
medial portions of the prefrontal cortex in the control of
pathological gambling and other behavioral patterns
that are associated with poor impulse control.

51. DSM-IV-TR CRITERIA
A. Persistent and recurrent maladaptive gambling behavior
as indicated by 5 or more of the following:
1) Is preoccupied with gambling (e.g. reliving past
gambling experiences, planning the next venture,
thinking of ways to get money to gamble with)
2) Needs to gamble with increasing amounts of money to
achieve the desired excitement
3) Has repeated unsuccessful efforts to control, cut back,
or stop gambling
4) Is restless or irritable when attempting to cut down or
stop gambling
5) Gambles as a way of escaping from problems or of
relieving a dysphoric mood (e.g. feelings of
helplessness, guilt, anxiety, depression

52. DSM-IV-TR CRITERIA
6) After losing money gambling, often returns
another day to get even (“chasing” one’s
losses)
7) Lies to family members, therapist, or others to
conceal the extent of involvement with
gambling
8) Has committed illegal acts such as forgery,
fraud, theft, or embezzlement to finance
gambling
9) Relies on others to provide money to relieve a
desperate financial situation caused by
gambling

53. Epidemiology
 A survey of 2,638 American adults concluded that the
prevalence of pathological gambling ranges between 1.3%
and 1.9%. On the other hand, some surveys have shown
that the prevalence of pathological gambling amongst
patients with substance abuse disorders is somehow higher
ranging between 10% and 18%.

54. Facts and Figures
 Gender: approximately 1/3 are female; females are more
likely to be depressed and to gamble as an escape; females
are under-represented in treatment programs & Gamblers
Anonymous
 Cultural factors: cultural variations in the prevalence and
type of gambling activities (e.g. cock fights, horse racing,
stock market, slot machines)
 Prevalence: varies depending on the availability of
gambling; <1% to 7%
 Course: regular or episodic; typically chronic; general
progression in frequency of gambling, level of
preoccupation with gambling, and amount wagered
 Onset: early adolescence for males; later for females

55. Associated and Contributing
Factors
 Distortions in thinking: denial; superstitions; overconfidence;
sense of power and control; belief that money is the cause of
& solution to all of their problems
 Personality traits: highly competitive, energetic, restless,
easily bored, generous, extravagant, overly concerned with the
approval of others, high levels of impulsivity
 Workaholics or “binge” workers
 Medical conditions associated with stress: migraines,
ulcers, hypertension
 Co-morbid psychological disorders: suicidal ideation &
attempts; ADHD; Mood Disorders; Substance Abuse or
Dependence (alcohol & nicotine); Antisocial, Narcissistic, and
Borderline Personality Disorders; other Impulse-Control
Disorders
 Abnormalities in neurotransmitter systems: 5HT, NE, D
 Stress and depression

56. Treatment – Psychosocial
 Treatment approach is like treatment for substance
dependence:
 Gamblers anonymous
 Individual psychotherapy
 Family therapy is often needed to a greater
extent than with substance dependence.
 Cognitive-Behavioural Therapy (CBT)

57. Psychosocial – Gamblers
Anonymous
 The following are the twelve steps of the Gambler’s
Anonymous model:
1. We admit that we are totally powerless over
gambling; hence, our lives had become
unmanageable.
2. We believe that we need a power that is stronger
than ours to help us restore our lives and thinking
to normal patterns.
3. We made a clear decision to turn our lives and
wills over to the care of the power that we
understand can help us.
4. We made fearless and searching moral and
financial inventories of ourselves.
5. We admit to ourselves and to others the exact

58. Psychosocial – Gamblers
Anonymous
6. We are totally ready to be helped to get rid of
these defects of character.
7. We humbly ask God (of our deep
understanding) to excise our shortcomings.
8. We listed all people whom we had previously
harmed and are willing to amend them all.
9. We will work hard to directly amend such
people, unless doing so, would harm them or
others.
10. We will continue to resort to personal inventory
whenever we are wrong, promptly admitting it.

59. Psychosocial – Gamblers
Anonymous
11. We seek by means of our meditation and
prayers our vital connection with God as we
have clearly understood Him. We pray only for
the knowledge of His good will for us and the
internal power to carry that out.
12. We made every effort to exercise all of these
principles throughout all of our affairs and we
will continue to spread this message to all other
compulsive gamblers.

60. Treatment – Biological
 The following have some support:
 Selective Serotonin Reuptake Inhibitors
(SSRIs)
 Naltrexone
 Lithium
 Carbamazepine

61. TRICHOTILLOMANIA

62. Trichotillomania
 Trichotillomania is hair loss from repeated urges to
pull or twist the hair until it breaks off. Patients are
unable to stop this behavior, even as their hair
becomes thinner.
 The criteria for the diagnosis of trichotillomania are
generally similar to obsessive compulsive disorders,
with an associated heightened tension immediately
before doing the act and a sense of gratification and/or
relief of tension after committing the act. It has been
proposed that trichotillomania should be categorized
under the new group of disorders; the obsessive
compulsive related disorders for DSM-V. Nevertheless,
some evidence denotes that trichotillomania is not
simply a form of an obsessive compulsive disorder.

63. Etiology
 Little is known about the etiology of trichotillomania. It
usually presents itself in late childhood and
adolescence. Trichotillomania is more prevalent among
women as compared to men.
 Several studies that investigated the neurobiological
mechanisms behind trichotillomania examined the
volumes of the putamen and caudate using MRI.
These regions were selected because of evidence that
they are affected in patients with obsessive compulsive
disorders and Tourette’s syndrome.
 Results showed attenuation of the volumes of the left
lenticulate and left putamen in patients with
trichotillomania as compared to normal controls.

64. DSM-IV-TR CRITERIA
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

65. Facts and Figures
 Gender differences: males and females are
equally represented among children; much more
common for females among adults
 Prevalence: unknown, but more common than
previously thought; 1-5% of college students
 Onset: early adolescence
 Course: self-limiting, continuous, or episodic

66. Contributing and Associated
Features
 Most common sites for hair pulling: scalp,
eyebrows, and eyelashes
 Triggers: relaxation, distraction, stressful
circumstances, “itch-like” sensation, being alone
 Associated behaviors: hair twirling, examining the
hair root, pulling the strand between the teeth,
eating hairs, nail biting, scratching, gnawing,
excoriation, pulling hairs from other people or
animals, pulling fibers from objects

67. Treatment – Psychosocial
 Behavior therapy’s - “habit reversal.”
 Cognitive-Behavioural Therapy (CBT)
 Hypnosis [also use in children]
 Self-help groups

68. Treatment – Biological
 Clomipramine
 SSRIs are used and have positive reports, but not in
controlled studies.
 Antipsychotics, but not in controlled studies
 Lithium used, but not is controlled study.
 One of the important features that delineate trichotillomania
from obsessive compulsive disorders is the therapeutic
response to SSRIs. Early case reports pointed to the
beneficial effects of SSRIs on the manifestations of
trichotillomania; however, placebo controlled trials failed to
detect a significant differences between the responses to
SSRIs and placebos. These results are highly contradictory
to those of many placebo controlled trials which proven
efficacy of SSRIs in the management of obsessive
compulsive disorders. A recent study concluded that the
combination of the SSRI sertraline with a special form of
cognitive behavioral therapy has a greater efficacy in the
management of trichotillomania than either line alone;

69. COMPULSIVE BUYING
DISORDER

70. Compulsive Buying Disorder
(CBD)
 Compulsive buying disorder (CBD) is characterized
by an obsession with shopping and buying behavior
that causes adverse consequences. Most people with
CBD meet the criteria for an axis II disorder.
 CBD is frequently comorbid with mood, anxiety,
substance abuse and eating disorders. Onset of CBD
occurs in the late teens and early twenties and is
generally chronic. CBD is similar to, but distinguished
from OCD hoarding and mania.
 Compulsive buying is not limited to people who spend
beyond their means, it also includes people who spend
an inordinate amount of time shopping or who
chronically think about buying things but never
purchase them.

71. Compulsive Buying Disorder
(CBD)
 Promising treatments for CBD include medication such
as selective serotonin reuptake inhibitors (SSRIs), and
support groups such as Debtors Anonymous
 Social psychology sees the compulsive buying of
consumer goods in terms of identity seeking - as an
exaggerated form of a more normal search for
validation through purchasing. Without a strong sense
of identity, pressures from the spread of materialist
values and consumer culture over the recent decades
can drive the vulnerable into compulsive shopping.

72. INTERNET ADDICTION

73. Internet Addiction Disorder
 The Internet itself is a neutral device originally
designed to facilitate research among academic
and military agencies. How some people have
come to use this medium, however, has created a
stir among the mental health community by great
discussion of Internet addiction.
 Addictive use of the Internet is a new phenomenon
which many practitioners are unaware of and
subsequently unprepared to treat.
 Some therapists are unfamiliar with the Internet,
making its seduction difficult to understand. Other
times, its impact on the individual’s life is
minimized.

74. Internet Addiction Disorder
 In 1998, Young conceptualized problematic Internet
use as a form of impulse control disorders that is
somehow similar to pathological gambling and
formulated novel criteria that are based on those of
pathological gambling. Young’s criteria were
centered on the individuals pattern of Internet
usage, types of online activities that he/she
participates in and the negative consequences that
Internet usage has on his/her aspects of life.

75. Young’s Internet Addiction Diagnositc
Questionnaire (IADQ)
 Young’s Internet Addiction Diagnostic
Questionnaire (IADQ) was the first screening tool
developed to diagnose problematic Internet use.
The IADQ included the following 8 criteria:
1. Do you have a sense of preoccupation with the
Internet (constantly think about activities you
previously engaged in online or anticipate your
next Internet use sessions)?
2. Do you get the feeling that you have to increase
the amount of time spent online to achieve
satisfaction?

76. Young’s Internet Addiction Diagnositc
Questionnaire (IADQ)
4. Do you feel depressed, restless, irritable or
moody when trying to stop or even cut down
Internet usage?
5. Do you often spend time online that is longer than
you originally intended?
6. Have you risked the loss of a serious relationship,
job or career or educational opportunities
because of your Internet use patterns?
7. Did you ever lie to your spouse, family members
or therapists to conceal your true involvement
with online activities?

77. Young’s Internet Addiction Diagnositc
Questionnaire (IADQ)
8. Do you use the cyber-world as a means of
sanctuary from problems or as a way of relief of
unpleasant moods such as feelings of guilt,
anxiety, helplessness or depression?
 The results of the questionnaire evaluated casual
Internet usage which wasn’t academically or
business related. Individuals were considered
having an Internet use problems if they positively
endorsed 5 or more of the questionnaire’s inquiries
for a period that is more than 6 months. Excessive
Internet usage, social isolation, neglect of life
responsibilities and continuous desire to conceal

78. Proposed DSM-V Criteria
 The American Psychiatric Association considered inclusion of
diagnosis of problematic Internet use in the new version of the
DSM-V. The diagnosis is a form of an impulsive compulsive
disorder that should include both online and offline computer
activities and comprises 3 subtypes; excessive gaming,
email/text messaging and sexual preoccupation. All of the
proposed variants share the following criteria:
A. Excessive use that is often accompanied by disorientation to
time and neglect of basic responsibilities.
B. Manifestations of withdrawal which include feelings of
tension, anger and/or depression when computer usage is
not possible.
C. Tolerance which involves an increasing demand for more
computer usage hours, better hardware, more advanced
software…etc.
D. Negative repercussions such as lying, arguments, social

79. Negative Consequences
 While time is not a direct function in defining Internet
addiction, generally addicted users are likely to use the
Internet anywhere from forty to eighty hours per week, with
single sessions that could last up to twenty hours. To
accommodate such excessive use, sleep patterns are
typically disrupted due to late night log-ins. The patient
typically stays up past normal bedtime hours and may
report staying on-line until two, three, or four in the morning
with the reality of having to wake for work or school at 6:00
am. In extreme cases, caffeine pills are used to facilitate
longer Internet sessions. Such sleep depravation causes
excessive fatigue often making academic or occupational
functioning impaired and may decrease one’s immune
system, leaving the patient vulnerable to disease.
Additionally, the sedentary act of prolonged computer use
may result in a lack of proper exercise and lead to an
increased risk for carpal tunnel syndrome, back strain, or
eyestrain.
 While the physical side-effects of utilizing the Internet are

80. Familial Impairment
 Young (1996) found that serious relationship problems
were reported by fifty-three percent of Internet addicts
surveyed. Marriages, dating relationships, parent-child
relationships, and close friendships have been noted to
be seriously disrupted by "net binges." Patients will
gradually spend less time with people in their lives in
exchange for solitary time in front of a computer.
 Marriages appear to be the most affected as Internet
use interferes with responsibilities and obligations at
home, and it is typically the spouse who takes on these
neglected chores and often feels like a "Cyberwidow."
Addicted on-line users tend to use the Internet as an
excuse to avoid needed but reluctantly performed daily
chores such as doing the laundry, cutting the lawn, or
going grocery shopping.

81. Academic Impairment
 The Internet has been touted as a premiere
educational tool driving schools to integrate Internet
services among their classroom environments.
However, one survey revealed that 86% of responding
teachers, librarians, and computer coordinators believe
that Internet usage by children does not improve
performance (Barber, 1997).
 Respondents argued that information on the Internet is
too disorganized and unrelated to school curriculum
and textbooks to help students achieve better results
on standardized tests.
 To further question its educational value, Young (1996)
found that 58% of students reported a decline in study
habits, a significant drop in grades, missed classes, or

82. Occupational Impairment
 Internet misuse among employees is a serious concern
among managers. One survey from the nations top
1,000 companies revealed that 55% of executives
believed that time surfing the Internet for non-business
purposes is undermining their employees’ effectiveness
on the job (Robert Half International, 1996).
 New monitoring devices allow bosses to track Internet
usage, and initial results confirm their worst suspicions.
One firm tracked all traffic going across its Internet
connection and discovered that only 23% of the usage
was business related (Machlis, 1997).
 There is growing availability of such monitoring
software as employers not only fear poor productivity,
but they need to stop the use of valuable network

83. Occupational Impairment
 Managers have been forced to respond by posting
policies detailing acceptable and unacceptable Internet
use.
 The benefits of the Internet such as assisting
employees with anything from market research to
business communication outweigh the negatives for
any company, yet there is a definite concern that it is a
distraction to many employees. Any misuse of time in
the workplace creates a problem for managers,
especially as corporations are providing employees
with a tool that can easily be misused.

84. Occupational Impairment – Case
study
 Evelyn is a 48 year old executive secretary who found
herself compulsively using chat rooms during work
hours. In an attempt to deal with her "addiction,” she
went to the Employee Assistance Program for help.
The therapist, however, did not recognize Internet
addiction as a legitimate disorder requiring treatment
and dismissed her case.
 Few weeks later, she was abruptly terminated from
employment for time card fraud when the systems
operator had monitored her account only to find she
spent nearly half her time at work using her Internet
account for non-job related tasks.

85. Occupational Impairment
 Employers uncertain how to approach Internet
addiction among workers may respond to an employee
who has abused the Internet with warnings, job
suspensions, or termination from employment instead
of making a referral to the company’s Employee
Assistance Program (Young, 1996).

86. Treatment
 There are no meta-analyses that have established the
best lines of treatment for problematic internet use.
Presently, cognitive behavioral therapeutic models are
the primarily proposed treatment strategies to manage
problematic internet use and replace it with other forms
of activities.
 Family and group therapy formats are often
encouraged to aid in the refurbishment of social
relationships and to allow family and friends engage in
the treatment plan.
 Practicing Abstinence.

87. PATHOLOGICAL LYING

88. Pathological Lying
 Pathological lying is also known as pseudologia
fantastica or mythomania.
 It is simply described as habitual and compulsive lying.
 Although somewhat controversial, pathological lying
has been defined as falsification entirely
disproportionate to any discernible end in view,
may be extensive and very complicated, and
may manifest over a period of years or even a
lifetime.
 Lying is the act of both knowingly and
intentionally/willfully making a false statement. Most
people do so out of fear. Pathological lying is
considered a mental illness, because it takes over
rational judgment and progresses into the fantasy

89. Defining Characteristics
 The defining characteristics of pseudologia fantastica
are:
 The stories told are not entirely improbable and often
have some element of truth. They are not a
manifestation of delusion or some broader type of
psychosis: upon confrontation, the teller can admit
them to be untrue, even if unwillingly.
 The fabricative tendency is long lasting; it is not
provoked by the immediate situation or social pressure
as much as it is an innate trait of the personality.
 A definitely internal, not an external, motive for the
behavior can be discerned clinically: e.g., long-lasting
extortion or habitual spousal battery might cause a

90. Defining Characteristics
 The stories told tend toward presenting the liar
favorably. For example, the person might be presented
as being fantastically brave, knowing or being related
to many famous people.
 Pseudologia fantastica may also present as false
memory syndrome, where the sufferer genuinely
believes that fictitious events have taken
place, regardless that these events are fantasies. The
sufferer may believe that he or she has committed
superhuman acts of altruism and love or has
committed equally grandiose acts of diabolical evil, for
which the sufferer must atone, or has already atoned
for in her/his fantasies.

91. SEX ADDICTION

92. Sexual Addiction
 Sexual addiction is used to describe the behavior of a
person who has an unusually intense sex drive or an
obsession with sex. Sex and the thought of sex tend to
dominate the sex addict's thinking, making it difficult to
work or engage in healthy personal relationships.
 Sex addicts engage in distorted thinking, often rationalizing
and justifying their behavior and blaming others for
problems. They generally deny they have a problem and
make excuses for their actions.
 Generally, a person with a sex addiction gains little
satisfaction from the sexual activity and forms no
emotional bond with his or her sex partners. In addition,
the problem of sex addiction often leads to feelings of guilt
and shame. A sex addict also feels a lack of control over
the behavior, despite negative consequences (financial,
health, social, and emotional).

93. Sexual Addiction & Risk Taking
 Sexual addiction also is associated with risk-taking. A
person with a sex addiction engages in various forms
of sexual activity, despite the potential for negative
and/or dangerous consequences.
 In addition to damaging the addict's relationships and
interfering with his or her work and social life, a sexual
addiction also puts the person at risk for emotional
and physical injury.
 For some people, the sex addiction progresses to
involve illegal activities, such as exhibitionism
(exposing oneself in public), making obscene phone
calls, or molestation. However, it should be noted that
sex addicts do not necessarily become sex offenders.

94. Associated/Related Behaviors
 Behaviors associated with sexual addiction include:
 Compulsive masturbation (self-stimulation)
 Multiple affairs (extra-marital affairs)
 Multiple or anonymous sexual partners and/or one-
night stands
 Consistent use of pornography
 Unsafe sex
 Phone or computer sex (cybersex)
 Prostitution or use of prostitutes
 Exhibitionism
 Obsessive dating through personal ads
 Voyeurism (watching others) and/or stalking
 Sexual harassment
 Molestation/rape

95. Treatment
 Most sex addicts live in denial of their addiction, and
treating an addiction is dependent on the person
accepting and admitting that he or she has a problem.
In many cases, it takes a significant event -- such as
the loss of a job, the break-up of a marriage, an
arrest, or health crisis -- to force the addict to admit to
his or her problem.
 Treatment of sexual addiction focuses on controlling
the addictive behavior and helping the person develop
a healthy sexuality. Treatment includes education
about healthy sexuality, individual counseling, and
marital and/or family therapy.
 Support groups and 12 step recovery programs for
people with sexual addictions (like Sex Addicts
Anonymous) also are available. In some cases,
medications used to treat obsessive-compulsive

96. 12 Steps of Sex Addicts
Anonymous
1. We admitted we were powerless over addictive
sexual behavior - that our lives had become
unmanageable.
2. Came to believe that a Power greater than ourselves
could restore us to sanity.
3. Made a decision to turn our will and our lives over to
the care of God as we understood God.
4. Made a searching and fearless moral inventory of
ourselves.
5. Admitted to God, to ourselves, and to another
human being the exact nature of our wrongs.
6. Were entirely ready to have God remove all these
defects of character.

97. 12 Steps of Sex Addicts
Anonymous
7. Humbly asked God to remove our shortcomings.
8. Made a list of all persons we had harmed and
became willing to make amends to them all.
9. Made direct amends to such people wherever
possible, except when to do so would injure them or
others.
10. Continued to take personal inventory and when we
were wrong promptly admitted it.
11. Sought through prayer and meditation to improve
our conscious contact with God as we understood
God, praying only for knowledge of God's will for us
and the power to carry that out.
12. Having had a spiritual awakening as the result of
these steps, we tried to carry this message to other
sex addicts and to practice these principles in our

98. REFERENCES
 http://www.fastceus.com/courses/Impulse_Disorders-
3CEUs.pdf
 http://www.internetandpsychiatry.com/joomla/topics/compulsi
ve-gambling/44-impulse-control-disorders.html
 http://www.psychiatrynetworks.com/impulse-control-
disorders.php
 http://www.scribd.com/doc/95092163/Impulse-Control-
Disorder
 Impulse Control Disorders by Dr. Kayj Nash Okine
 http://en.wikipedia.org/wiki/Compulsive_buying_disorder
 http://www.netaddiction.com/articles/symptoms.pdf
 http://en.wikipedia.org/wiki/Pathological_lying
 http://www.webmd.com/sexual-conditions/guide/sexual-
addiction
 http://www.ridgeviewinstitute.com/Support%20Group%20Des