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Chapter 10 Assignment

Name the six types of eating disorder and briefly define each.

Briefly define the treatment for anorexia disorder.

What are the three theories of eating disorders and briefly define each.

Name the 10 sleep disorders and briefly define each.

Briefly discuss the treatment for insomnia.

What are some of the risk factors for impulse-control disorders?

Briefly define Intermittent Explosive Disorder, Pyromania, Kleptomania, Pathological Gambling, Sexual Impulsivity, Trichotillomania , Internet Addiction and Cyber Disorders.

Define Oppositional Defiant Disorder and Conduct Disorder.

What is the difference between conduct disorder and oppositional disorder (see slide 94).

What are the treatments for oppositional defiant disorder and conduct disorder (see slides 83and 96).

Chapter 10
Feeding and Eating Disorders,
Elimination Disorders, Sleep Wake
Disorders and Disruptive, Impulsive
Control and Conduct Disorders
Feeding and Eating Disorders
Pica A. Persistent eating of nonnutritive, nonfood substances over the period of at
least 1 month. B. The eating of nonnutritive, nonfood substances the inappropriate
to the developmental level of the individual. C. The eating behaviour is not part of
a culturally supported or socially normative practice. D. If the eating behaviour
occurs in the context of another mental disorder (e.g. intellectual disability, autism
spectrum disorder) or medical condition (e.g. pregnancy), it is sufficiently severe to
warrant additional clinical attention.
Treating pica involves behaviors, the environment, and family education. One form
of treatment associates the pica behavior with negative consequences or
punishment (mild aversion therapy). Then the person gets rewarded for eating
normal foods.Mar 26, 2018
Rumination Disorder
Rumination Disorder
• Treatment. The main treatment of rumination disorder is behavioral
therapy. This may involve habitat reversal strategies, relaxation,
diaphragmatic breathing, and biofeedback. These types of therapies can
often be administered by a gastroenterologist .
Avoidant/Restrictive Food Intake
Avoidant/Restrictive Food Intake
• At the moment, the treatment for ARFID is similar to the treatment
for anorexia nervosa.
• If a child is at an extremely low weight with an irregular heart rate
or low blood pressure, they will receive treatment in a hospital. This
treatment focuses on giving enough nutrition to return the child or
teen to a healthy weight and limiting exercise.
• If a child is medically stable, they will be treated at an outpatient
eating disorders program by a team of professionals. They will
receive psychological treatment and have their weight, heart rate
and blood pressure checked regularly.
• At home, the goal is to reintroduce all the foods that a child has cut
out from their diet, for example through food chaining.
• If depression or anxiety is an underlying cause of ARFID, a child
might be prescribed medications or receive cognitive behavioural
Binge Eating Disorder
Anorexia Nervosa
1. Refuse/unable to maintain 85% of
expected weight for frame, height.
2. Intense fear of gaining weight, though
3. Distorted perception of weight or body
4. Amenorrhea (No menses)
Effects of Anorexia Nervosa
As self-starvation continues, bodily signs of
physical disturbance become more evident.
For example:
â—¼ Yellowing of the skin.
â—¼ Impaired organ functioning.
â—¼ Death (1 in 10).
Anorexia Nervosa
• Anorexia Nervosa A. Restriction of energy intake relative to
requirements, leading to a significantly low body weight in the
context of age, sex, developmental trajectory, and physical
health. Significantly low weight is defined as a weight that is
less than minimally normal or, for children and adolescents,
less than minimally expected. B. Intense fear of gaining weight
or of becoming fat, or persistent behaviour that interferes
with weight gain, even though at a significantly low weight. C.
Disturbance in the way in which one’s body weight or shape is
experienced, undue influence of body weight or shape on
self-evaluation, or persistent lack of recognition of the
seriousness of the current low body weight.
Anorexia Nervosa
• Specify whether: Restricting type: During the last three
months, the individual has not engaged in recurrent
episodes of binge eating or purging behaviour (i.e. selfinduced vomiting, or the misuse of laxatives, diuretics, or
enemas). This subtype describes presentations in which
weight loss is accomplished primarily through dieting,
fasting and/or excessive exercise. Binge-eating/purging
type: During the last three months the individual has
engaged in recurrent episodes of binge eating or purging
behaviour (i.e. self-induced vomiting, or the misuse of
laxatives, diuretics, or enemas).
• Specify current severity: Mild: BMI more than 17 Moderate:
BMI 16- 16.99 Severe: BMI 15-15.99 Extreme: BMI less than
Basal Metabolic Index: BMI Chart
Anorexia Treatment: Preliminary Treatment
Patients with anorexia nervosa require multidisciplinary treatment, involving
nutritional support, psychological counseling, and behavioral modification.
Depending on a patient’s condition, treatment may take place on an outpatient
basis, in a residential or partial hospitalization unit, or on an intensive inpatient
basis. No matter what the setting, family involvement is essential when treating
children and adolescents with anorexia nervosa (see “The Maudsley method”).
A patient’s weight usually determines how aggressive treatment should be.
Generally speaking, when an adult patient loses 15% or more of her ideal body
weight, she will require inpatient treatment or a highly structured outpatient
program. Because children and adolescents are at risk for suffering irreversible
developmental damage if they are malnourished, inpatient care may be necessary
even before they reach the 15% weight-loss threshold.
In its treatment guidelines, the American Psychiatric Association (APA)
recommends also taking other factors into account when making a decision. Items
to consider include how quickly a patient has lost weight and whether she has
developed a serious medical complication.
Anorexia Nervosa: The Maudsley method
• For children and adolescents who have suffered from anorexia
nervosa for less than three years (indicating the disorder has not
yet become chronic), the most effective therapy is based on one
developed at the Maudsley Hospital in London. This three-phase
treatment emphasizes family involvement.
• In phase 1, clinicians work with parents and siblings so that they
learn strategies to coach and encourage patients to eat more —
although the exact nutritional strategy is left up to the families. In
phase 2, as the young patients begin eating more normally and
start to gain weight, the focus shifts to identifying and changing
family dynamics that might undercut further recovery. In phase 3,
after the child has attained a healthy weight, clinicians work with
patients and families to improve relationships and to help the child
become more independent.
Anorexia Nervosa: Nutritional Therapy to
Promote Weight Gain
Patients are often severely malnourished upon entering treatment. Because
starvation affects their thinking, they are likely to be negative, obsessive, and
manipulative. At this stage, any psychotherapy that requires even minimal selfreflection is unlikely to be effective. Instead, assuming the patient is medically
stable, the immediate goal is to provide support and encourage her to gain weight.
Clinicians often combine positive reinforcement — such as praising weight gain
and linking privileges to target weights — with close monitoring, such as having
someone sit with the patient to ensure that she eats, and weighing her regularly. A
major challenge is carrying out this phase of treatment in a sympathetic, rather
than punitive, manner.
Although programs vary in their procedures, all gradually increase the amount of
calories a patient consumes and restrict excessive exercise in order to promote
weight gain. In an inpatient unit, it’s reasonable to aim for a gain of 2 to 3 pounds
per week. For outpatients, one-half to 1 pound a week is more the norm.
Patients who refuse to eat, or who are at risk of death from malnutrition, may
require nasogastric feeding. But this is generally considered a last resort. Not only
are feeding tubes coercive, they undercut the goal of therapy, which is to have the
patient stay out of medical danger and set her own objectives for a reasonably
satisfying and enjoyable life.
Anorexia Nervosa: Medication Options
Although medications are often prescribed for patients with anorexia nervosa, there’s little
evidence to support their use — either at promoting weight gain or at alleviating psychological
distress, at least during the early stages of treatment.
Antidepressants. A review by the international Cochrane Collaboration concluded that there was
not enough evidence to recommend antidepressants either for promoting weight gain or for
treating psychological symptoms in patients with anorexia nervosa. However, the APA practice
guidelines disagree on the second point, advising that combining selective serotonin reuptake
inhibitors (SSRIs) with psychotherapy may help alleviate depression, anxiety, or obsessive thinking
in some patients once they have gained weight.
Patients with anorexia nervosa should avoid taking tricyclic antidepressants and monoamine
oxidase inhibitors because they are at greater risk for adverse reactions. And the FDA has issued a
“black box” warning (its strongest advisory) for bupropion (Wellbutrin) in patients with eating
disorders, based on concerns about increased risk of seizures in this population.
Antipsychotics. Although case reports and small uncontrolled studies suggest that secondgeneration antipsychotics may help some patients with anorexia nervosa, rigorous research is
lacking. One example: The manufacturer of olanzapine (Zyprexa) funded a randomized, doubleblind, controlled study that concluded this drug was better than placebo at accelerating weight gain
and alleviating obsessions and mealtime anxiety among adult patients with anorexia nervosa. But
the study involved only 34 patients and produced only minimal benefit. At the start of the study,
both groups of women had a mean body mass index (BMI) of roughly 16, which means they were
underweight. By the end of the study, BMI had increased to 19.7 for the women taking placebo and
20.3 for those taking olanzapine — both at the low end of the normal range.
Anorexia Nervosa: Psychotherapy to Foster
Recovery and Prevent Relapse
Once patients gain enough weight to benefit from psychotherapy and behavioral interventions, the
goal of treatment is to help them to recognize distorted thinking about food, find better ways to
deal with their emotions and stress, and find ways to avoid relapse. This may take time and
persistence, for both patients and clinicians.
An ongoing challenge is to prevent relapse. Almost 50% of patients who successfully gain weight
after being treated in inpatient programs relapse within one year of being discharged. Long-term
studies are also discouraging, reporting that 50% to 73% of patients treated in academic medical
centers will continue to meet criteria for anorexia nervosa 10 years after discharge.
The evidence is strongest for using psychotherapy to improve chances of recovery in adults.
Cognitive behavioral therapy helps patients to recognize and change distorted or maladaptive
thinking about food, while interpersonal or psychodynamic therapy helps them to improve
relationships with other people.
Few studies have examined the use of medication in preventing relapse. One study suggested that
fluoxetine (Prozac) might offer a modest benefit, but it added little value above and beyond
cognitive behavioral therapy. And a subsequent study failed to replicate the findings.
Although the treatment of anorexia nervosa may seem daunting at times, it is possible for patients
to learn how to keep the most devastating symptoms under control, given enough time and a good
therapeutic relationship. Realistically, however, their attitudes about food and weight may never
return to normal, and they may have to remain vigilant about preventing relapse for the rest of
their lives.
Isabelle Caro
• Isabelle Caro (13 September 1982 – 17
November 2010) was
a French model and actress from Marseille, Fr
ance, who became well known after
appearing in a controversial advertising
campaign “No Anorexia” which showed Caro
with vertebrae and facial bones showing
under her skin in a picture by
photographer Oliviero Toscani.
Isabelle Caro
Bulimia Nervosa
• People with bulimia nervosa
alternate between eating
large amounts of food in a
short time, then compensating
for the added calories by
vomiting or other extreme
Bulimia Nervosa
Episodes of eating large amounts of food, characterized by:
1. in a 2-hour period, eating an amount much greater than
others would eat;
2. feeling a lack of control over what or how much is being
Bulimia Nervosa
PURGING TYPE – try to force out of their bodies
what they’ve just eaten by
â–ª vomiting
â–ª administering enemas
â–ª taking laxatives or diuretics
NONPURGING TYPE – try to compensate by fasting
or overexercising.
Bulimia Nervosa
• IPECAC SYRUP, if used regularly to
induce vomiting, has toxic effects
• Dental decay
• Enlarged salivary glands
• Menstrual irregularity is common.
also have toxic effects over time
• Gastrointestinal damage may
be permanent
Bulimia Nervosa
Bulimia Nervosa A. Recurrent episodes of binge eating. An episode of binge eating
is characterized by both: www.bodymatters.com.au 1. Eating in a discrete period
of time (e.g. within any 2 hour period), an amount of food that is definitely larger
than what most individuals would eat in a similar period of time under similar
circumstances; 2. A sense of lack of control over eating during the episodes (e.g. a
feeling that one cannot stop eating or control what or how much one is eating. B.
Recurrent inappropriate compensatory behaviors to prevent weight gain, such as
self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting;
or excessive exercise. C. The binge eating and inappropriate compensatory
behaviors both occur, on average, at least once a week for 3 months. D. Selfevaluation is unduly influenced by body shape and weight. E. The disturbance does
not occur exclusively during episodes of anorexia nervosa. Specify current severity:
Mild: An average of 1-3 episodes of inappropriate compensatory behaviours per
week. Moderate: An average of 4-7 episodes of inappropriate compensatory
behaviours per week. Severe: An average of 8-13 episodes of inappropriate
compensatory behaviours per week. Extreme: An average of 14 or more episodes
of inappropriate compensatory behaviours per week.
Bulimia Nervosa: Treatment
Anorexia versus Bulimia
Anorexia nervosa:
Eating disorder
characterized by an
inability to maintain
normal weight, an
intense fear of
gaining weight, and
distorted body
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Bulimia nervosa:
Eating disorder
involving alternation
between eating large
amounts of food in a
short time, then
compensating by
vomiting or other
extreme actions to
avoid weight gain.
Binge Eating Disorder
Binge-Eating Disorder A. Recurrent episodes of binge eating. An episode of binge
eating is characterized by both: 1. Eating in a discrete period of time (e.g. within
any 2 hour period), an amount of food that is definitely larger than what most
individuals would eat in a similar period of time under similar circumstances; 2. A
sense of lack of control over eating during the episodes (e.g. a feeling that one
cannot stop eating or control what or how much one is eating). B. Binge eating
episodes are associated with three or more of the following: 1. Eating much more
rapidly than normal. 2. Eating until feeling uncomfortably full. 3. Eating large
amounts of food when not feeling physically hungry. 4. Eating alone because of
feeling embarrassed by how much one is eating. 5. Feeling disgusted with oneself,
depressed, or very guilty afterwards. C. Marked distress regarding binge eating is
present. D. The binge eating occurs, on average, at least once a week for 3 months.
E. The binge eating is not associated with the recurrent use of inappropriate
compensatory behavior as in bulimia nervosa and does not occur exclusively
during the course of bulimia nervosa or anorexia nervosa. Specify current severity:
Mild: 1-3 binge eating episodes per week. www.bodymatters.com.au Moderate: 47 binge eating episodes per week. Severe: 8-13 binge eating episodes per week.
Extreme: 14 or more binge eating episodes per week.
Binge Eating Disorder Treatments
• BIOLOGICAL – Altered dopamine and serotonin
neurotransmitter systems.
• PSYCHOLOGICAL – Turn to food to escape inner turmoil and
pain; from cognitive standpoint, over time get trapped in
eating patterns.
• SOCIOCULTURAL – Dysfunctional family functioning and
societal obsession with food.
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– Cognitive/Behavioral
– Interpersonal Therapy
– Family Therapy
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Therapists have found multifamily
therapy to be particularly effective.
• Several families participate in group
sessions together.
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Sleep Wake Disorders (DSM 5)
The DSM-5 classification of sleep-wake disorders is intended for use by
general mental health and medical clinicians (those caring for adult,
geriatric, and pediatric patients)
1.Insomnia disorder
2. Hypersomnolence disorder
3. Narcolepsy
4. Breathing-related sleep disorders
5. Circadian rhythm sleep-wake disorders
6. Non–rapid eye movement (NREM) sleep arousal disorders
7. Nightmare disorder
8. Rapid eye movement (REM) sleep behavior disorder
9. Restless legs syndrome
10. Substance/medication-induced sleep disorder.
Insomnia Disorder
Insomnia Disorder Treatment
• Chronic insomnia disorder, or insomnia, affects about
10 percent of the population. It’s characterized by
difficulty falling asleep, staying asleep, and/or going
back to sleep after waking up in the early morning. This
happens at least three nights a week for a minimum of
3 months.
• Medication is typically thought of as the sole or most
effective treatment for chronic insomnia. And it can
help. Medication is convenient, fast acting, and widely
available. However, psychotherapy—particularly
cognitive behavioral therapy for insomnia (CBT-I)—is
actually the first-line treatment.
Insomnia Disorder Treatment
Challenging and changing cognitive distortions and misconceptions around sleep and its
negative daytime consequences. For example: “I can’t sleep without medication”; “I need to
stay in bed when I can’t sleep”; “Not getting at least 6 hours of sleep is horrible for my
health, and there is no way I can function at work tomorrow.”
Associating bed with sleep instead of wakefulness (called stimulus control). Individuals are
instructed to only use their bed for sleep and sex—not to read, watch TV, eat, or worry.
Individuals also work on going to bed when they’re sleepy and getting out of bed when they
can’t sleep.
Restricting the time spent in bed (called sleep restriction) and waking up at the same time
every day, regardless of how much sleep you got the night before. Individuals then gradually
increase the time spent in bed by 15 to 30 minutes (as long as their middle-of-the-night
wake-ups are minimal).
Setting healthy habits around sleep, such as cutting down on caffeine (and other substances);
not going to bed hungry; and creating a quiet, dark, comfortable environment.
Practicing relaxation techniques, such as progressive muscle relaxation and deep breathing.
Preventing a relapse, which includes identifying high-risk situations and implementing
specific strategies.
Insomnia Disorder Treatment
Medications: Medication may be helpful in managing short-term insomnia, such as
during a particularly difficult, stressful time. However, psychotherapy is typically more
effective, has very little risk, and has shown long-term effects.
– Benzodiazepines: Alprazolam (Xanax), chlordiazepoxide (Librium),
clonazepam (Klonopin), clorazepate (Tranxene), diazepam (Valium),
estazolam (Prosom), flurazepam (Dalmane), lorazepam (Ativan)
– Non-Benzodiazepines: Lunesta, Sonata, Ambien
– Antidepressants: The sedating antidepressants most commonly used to
help with sleep include Trazodone (Desyrel), Amitriptyline (Elavil),
and Doxepin (Sinequan). It should be noted that when these medications
are used for sleeping and pain relieving properties, it is in much lower
doses than when used in the treatment of depression.
– Other Sleep Medications: Ramelteon (Rozerem), a melatonin receptor
agonist, for treating trouble falling asleep. Suvorexant (Belsomra), a
selective dual orexin receptor antagonist, for treating trouble staying
asleep. Benadryl (antihistamine), valerian, tryptophan, or melatonin.
Hypersomnolence Disorder
Narcolepsy Treatment
There is no cure for narcolepsy, but medications and lifestyle modifications can
help manage the symptoms.
• Medications for narcolepsy include:
Stimulants such as modafinil (Provigil) or armodafinil (Nuvigil),
Aptensio XR, Concerta, and Ritalin.
Selective serotonin reuptake inhibitors (SSRIs) or serotonin and
norepinephrine reuptake inhibitors (SNRIs) such asfluoxetine (Prozac,
Sarafem, Selfemra) and venlafaxine (Effexor XR).
Tricyclic antidepressants such as protriptyline (Vivactil), imipramine
(Tofranil) and clomipramine (Anafranil), are effective for cataplexy.
Sodium oxybate (Xyrem). This medication is highly effective for
cataplexy. Sodium oxybate helps to improve nighttime sleep, which
is often poor in narcolepsy. In high doses it may also help control
daytime sleepiness.
Cataplexy: is a sudden and uncontrollable muscle weakness or paralysis that comes on
during the day and is often triggered by a strong emotion, such as excitement or
Sleep Apnea
Sleep Apnea
Sleep Apnea
Circadian Rhythm Sleep-Wake
• Circadian rhythm sleep disorders are caused
by desynchronization between internal sleepwake rhythms and the light-darkness cycle.
Patients typically have insomnia, excessive
daytime sleepiness, or both, which typically
resolve as the body clock realigns itself.
Diagnosis is clinical.
• EX: Jet lag, Shift workers. Etc.
Non–Rapid Eye Movement (NREM)
Sleep Arousal Disorders
• Non-Rapid Eye Movement (NREM) Sleep
Arousal Disorders occur when the brain is
partly in Non-REM sleep and partly awake
enough to perform complex activities without
any conscious awareness of them. They occur
during Slow Wave Sleep (SWS).
Non–Rapid Eye Movement (NREM)
Sleep Arousal Disorders
Non–Rapid Eye Movement (NREM)
Sleep Arousal Disorders
• No parent wants to hear their child scream in the
night. It is often a more frightening experience for
the adult than it is the child, and if it is due to a
parasomnia, the child is unaware of the event in
most cases. Parasomnias often occur in
preschool-aged children and decrease in
frequency by early adolescents. Most of the
parasomnias that occur do so in healthy children,
but the differential can include neurologic,
psychiatric, and mental disorders, so careful
observation and a good history and physical are
Non–Rapid Eye Movement (NREM)
Sleep Arousal Disorders
• Parasomnias can be divided into those that occur in nonREM (NREM) sleep and rapid eye movement (REM) sleep.
NREM parasomnias include sleep terrors and sleep walking.
These usually occur during the first third part of sleep when
the child is in stages of NREM sleep. They are called partial
or confusional arousals as they occur when transitioning
from deeper stages to lighter stages of NREM
sleep. Children who sleepwalk often have parents who did
the same when they were young. Other sleep disorders
such as obstructive sleep apnea and restless leg syndrome
can be triggers, as can gastroesophageal reflux, fever, and
sleep deprivation. Nocturnal seizures can mimic sleep
terrors and sleepwalking so careful attention must be paid
to a parent’s concerns.
Non–Rapid Eye Movement (NREM)
Sleep Arousal Disorders
• If these parasomnias are excessive or there is
concern for seizure, a sleep professional or
neurologist should be consulted. Most of
these resolve with time and reassurance from
the parents. Sleep deprivation in children and
teenagers can trigger parasomnias, so make
sure children are getting adequate sleep.
Non–Rapid Eye Movement (NREM)
Sleep Arousal Disorders
• Parasomnias that occur in REM sleep include nightmares, sleep paralysis,
and REM sleep behavior disorder (RBD). Sleep paralysis is usually seen in
young adults and is common in those with narcolepsy. RBD is usually seen
in older adults over the age of 60 but can rarely be seen in children.
• Here is a chart that might help you distinguish one parasomnia from
• Sleepwalking
– Occurs in stage 3 or 4 (delta sleep)
– Sleeper gets up and walks while literally sound
– Has poor coordination
– Clumsy but can avoid objects
– Can engage in limited conversation
– No memory of sleepwalking
Famous Sleepwalking Case
• Regina v. Parks. Kenneth Parks, a young Canadian man, was acquitted in
the 1987 murder of his mother-in-law after using the sleepwalking
defense. On the night of the death, he arose from bed, drove 14 miles to
the house of his in-laws—with whom he was said to be close—and
strangled his father-in-law until the man passed out. He bludgeoned his
mother-in-law with a tire iron and stabbed them both with a kitchen knife.
The woman died; the man barely survived. Parks then arrived at a police
station. Police said he seemed confused about what had transpired, and
they noted something odd: Parks appeared oblivious to the fact that he’d
severed tendons in both his hands during the attack. That obliviousness to
pain, along with other factors, including a strong family history of
parasomnias, led experts to testify that Parks had been sleepwalking
during the attack. Not conscious, not responsible, not guilty.
Famous Sleepwalking Case
• Pennsylvania v. Ricksgers. In 1994, Michael Ricksgers
was convicted of the murder of his wife. He claimed
he’d accidentally killed her during a sleepwalking
episode, which defense lawyers argued was provoked
by a medical condition, sleep apnea. Prosecutors
presented an alternative explanation: that Ricksgers
was upset that his wife was planning to leave him.
Ricksgers told police that he awoke to find a gun in his
hand and his wife bleeding in bed beside him. He said
that he might have dreamed about an intruder
breaking in. That didn’t sway the jury. Ricksgers was
sentenced to life in prison without parole, according to
the Associated Press.
Nightmare Disorder
Rapid Eye Movement (REM) Sleep
Behavior Disorder
• Rapid eye movement (REM) sleep behavior
disorder is a sleep disorder in which you
physically act out vivid, often unpleasant
dreams with vocal sounds and sudden, often
violent arm and leg movements during REM
sleep — sometimes called dreamenacting behavior.
Restless Legs Syndrome
• A Condition characterized by a nearly irresistible
urge to move the legs, typically in the evenings.
• Restless legs syndrome typically occurs while
sitting or lying down. It generally worsens with
age and can disrupt sleep.
• The main symptom is a nearly irresistible urge to
move the legs.
• Getting up and moving around helps the
unpleasant feeling temporarily go away. Self-care
steps, lifestyle changes, or medications may help.
Restless Legs Syndrome
Substance/Medication-Induced Sleep
Substance/Medication-Induced Sleep
Impulse-Control Disorders
Impulse-Control Disorders
The 5th Edition of the Diagnostic and Statistical Manual of Mental Disorders includes a category for
Disruptive, Impulse-Control, and Conduct Disorders.
All of the disorders in this category involve problems controlling behavior and emotions. The
disorders are typically seen in childhood or adolescence and are rarely first seen in adulthood.
The DSM-5 lists the following impulse control disorders:
Intermittent Explosive Disorder
Pyromania (characterized by irresistible urges to set fires)
Kleptomania (characterized by irresistible urges to steal various items from stores and homes)
Pathological Gambling
Sexual Impulsivity
Internet Addiction
Cyber Disorders
Oppositional Defiant Disorder (characterized by an angry and irritable mood,
argumentative/defiant behavior, and vindictiveness)
Conduct Disorder (characterized by repetitive and persistent behaviors that violate the basic rights
of other people or that violate age-appropriate societal rules)
Intermittent Explosive Disorder
• An impulse-control disorder involving an inability to hold back urges
to express strong angry feelings and associated violent behaviors.
• Over 90% have co-occurring mood disorder.
• Other co-occurring disorders include substance problems and anxiety.
Intermittent Explosive Disorder
• The DSM-5 defines pyromania as requiring the following criteria:
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).
• Urge to prepare, set, and watch fires for fun (unlike arsonists
motivated by greed or revenge).
Celebrities Caught Shoplifting
Four celebrities who have not been able to give up the instinct of shoplifting
• 1. Megan Fox
Megan Fox who has been a successful Hollywood Star has been caught often stealing from shops.
The situation went so bad that she has been banned for life from entering Walmart after she was
caught lifting lip-gloss costing only $7.
• 2. Britney Spears
Britney Spears has also been caught shop lifting on few occasions. She was caught shop lifting a
lighter from a gas station and wig from a sex shop.
• 3. Lindsay Lohan
Lindsay Lohan also falls in the category of celebrities who have indulged in shop lifting and can be
considered as Kleptomaniac. She has been caught on camera stealing jewelry costing $2,500 from a
store in Venice.
She has often been seen carrying dresses and bracelets from sets she had worked at.
• 4. Winona Ryder
Winona was accused of stealing things worth $5000 from Saks Fifth Avenue. She was caught and
fined heavily and had to face humiliation for this act.
People with kleptomania are driven by a persistent urge to steal, although their theft is not
motivated by a wish to own the object or by its monetary value. A serotonin deficiency might
underlie kleptomania. Clinicians use techniques like covert sensitization to control the urge to
steal. However, few cases come to clinical attention.
Pathological Gambling
Pathological Gambling
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Sexual Impulsivity
• Compulsive sexual behavior is sometimes
called hypersexuality,
hypersexuality disorder or sexual addiction.
It’s an excessive preoccupation
with sexual fantasies, urges or behaviors that
is difficult to control, causes you distress, or
negatively affects your health, job,
relationships or other parts of your life.
Sexual Impulsivity
• Driven to engage in frequent, indiscriminate
• Often feel bad after they engage in sex.
• May extend into violent deviance, like rape,
rape/murders, serial killing.
• Usually also have substance abuse disorder
and depression; some may have dissociative
• Trichotillomania (pronounced trik-o-till-o-MAY-nee-uh), also
referred to as “hair-pulling disorder,” is a mental disorder classified
under Obsessive-Compulsive and Related Disorders and involves
recurrent, irresistible urges to pull hair from the scalp, eyebrows,
eyelids, and other areas of the body, despite repeated attempts to
stop or decrease hair pulling.
• Hair pulling from the face can result in complete or partial removal
of the eyebrows and eyelashes, while hair pulling from the scalp
can result in varying degrees of patches of hair loss. The hair pulling
and subsequent hair loss results in distress for the person, and can
interfere with social and occupational functioning.
• For some people, the symptoms of trichotillomania are
manageable, but for others, the symptoms can be completely
â—¼ Co-occurring disorders – depression, anxiety
disorder, substance abuse, eating disorder
â—¼ Biological base – Related to OCD
(abnormalities in basal ganglia, motor control
â—¼ Behavioral base – Rooted in environmental
cues, done to relieve tension
◼ Sociocultural – The result of feeling
abandoned, neglected, emotionally
Internet Addiction
An impulse control condition in which an individual feels
irresistible need for Internet-based activities.
• Although not included in the DSM-IV-TR, Internet
addiction shares characteristics of impulse-control
Copyright © The McGraw-Hill
Companies, Inc. Permission
required for reproduction or
An informal diagnostic term for clients whose
primary clinical problem involves the
• cyber-sexual addiction
• cyber-relation addiction
• net compulsions
(e.g., online gambling, shopping, trading)
• information overload
• compulsive online game playing
Copyright © The McGraw-Hill
Companies, Inc. Permission
required for reproduction or
Oppositional Defiant Disorder and
Conduct Disorder
Oppositional Defiant Disorder
Oppositional Defiant Disorder
A. A pattern of angry/irritable mood, argumentative/defiant behavior, or
vindictiveness lasting at least 6 months as evidenced by at least four symptoms
from any of the following categories, and exhibited during interaction with at least
one individual who is not a sibling. Angry/Irritable Mood.
1. Often loses temper.
2. Is often touchy or easily annoyed.
3. Is often angry and resentful. Argumentative/Defiant Behavior
4. Often argues with authority figures or, for children and adolescents, with adults.
5. Often actively defies or refuses to comply with requests from authority figures
or with rules.
6. Often deliberately annoys others.
7. Often blames others for his or her mistakes or misbehavior. Vindictiveness
8. Has been spiteful or vindictive at least twice within the past 6 months
Oppositional Defiant Disorder
• B. The disturbance in behavior is associated with distress in
the individual or others in his or her immediate social
context (e.g., family, peer group, work colleagues), or it
impacts negatively on social, educational, occupational, or
other important areas of functioning.
• C. The behaviors do not occur exclusively during the course
of a psychotic, substance use, depressive, or bipolar
disorder. Also, the criteria are not met for disruptive mood
dysregulation disorder. Specify current severity: Mild:
Symptoms are confined to only one setting (e.g., at home,
at school, at work, with peers). Moderate: Some symptoms
are present in at least two settings. Severe: Some
symptoms are present in three or more settings.
Oppositional Defiant Disorder
Treatment for Oppositional Defiant
Conduct Disorder
Conduct Disorder
• A. A repetitive and persistent pattern of behavior in which the basic rights
of others or major age appropriate societal norms or rules are violated, as
manifested by the presence of at least three of the following 15 criteria in
the past 12 months from any of the categories below, with at least one
criterion present in the past 6 months:
1. Aggression to people and animals.
2. Destruction of Property
3. Deceitfulness or Theft
4. Serious Violation of the Rules
Aggression to People or Animals
• 1. Often bullies, threatens, or intimidates others.
• 2. Often initiates physical fights.
• 3. Has used a weapon that can cause serious physical harm to
others (e.g., a bat, brick, broken bottle, knife, gun).
• 4. Has been physically cruel to people.
• 5. Has been physically cruel to animals.
• 6. Has stolen while confronting a victim (e.g., mugging, purse
snatching, extortion, armed robbery).
• 7. Has forced someone into sexual activity.
Destruction of Property
• 8. Has deliberately engaged in fire setting with
the intention of causing serious damage.
• 9. Has deliberately destroyed others’ property
(other than by fire setting).
Deceitfulness or Theft
• 10. Has broken into someone else’s house,
building, or car.
• 11. Often lies to obtain goods or favors or to
avoid obligations (i.e., “cons” others).
• 12. Has stolen items of nontrivial value
without confronting a victim (e.g., shoplifting,
but without breaking and entering; forgery).
Serious Violation of the Rules
• 13. Often stays out at night despite parental
prohibitions, beginning before age 13 years.
• 14. Has run away from home overnight at
least twice while living in the parental or
parental surrogate home, or once without
returning for a lengthy period.
• 15. Is often truant from school, beginning
before age 13 years.
Conduct Disorder
• B. The disturbance in behavior causes clinically significant
impairment in social, academic, or occupational
• C. If the individual is age 18 years or older, criteria are not
met for antisocial personality disorder. Specify whether:
312.81 (F91.1)
– Childhood-onset type: Individuals show at least one symptom
characteristic of conduct disorder prior to age 10 years.
– Adolescent-onset type: Individuals show no symptom
characteristic of conduct disorder prior to age 10 years. 312.89
– Unspecified onset: Criteria for a diagnosis of conduct disorder
are met, but there is not enough information available to
determine whether the onset of the first symptom was before
or after age 10 years.
Conduct Disorder
• Specify if: With limited prosocial emotions: To qualify for
this specifier, an individual must have displayed at least
two of the following characteristics persistently over at
least 12 months and in multiple relationships and
settings. These characteristics reflect the individual’s
typical pattern of interpersonal and emotional
functioning over this period and not just occasional
occurrences in some situations. Thus, to assess the
criteria for the specifier, multiple information sources are
necessary. In addition to the individual’s self-report, it is
necessary to consider reports by others who have known
the individual for extended periods of time (e.g., parents,
teachers, co-workers, extended family members, peers).
Conduct Disorder
Lack of remorse or guilt: Does not feel bad or guilty when he or she does something wrong (exclude
remorse when expressed only when caught and/or facing punishment). The individual shows a
general lack of concern about the negative consequences of his or her actions. For example, the
individual is not remorseful after hurting someone or does not care about the consequences of
breaking rules.
Callous—lack of empathy: Disregards and is unconcerned about the feelings of others. The
individual is described as cold and uncaring. The person appears more concerned about the effects
of his or her actions on himself or herself, rather than their effects on others, even when they result
in substantial harm to others.
Unconcerned about performance: Does not show concern about poor/problematic performance at
school, at work, or in other important activities. The individual does not put forth the effort
necessary to perform well, even when expectations are clear, and typically blames others for his or
her poor performance.
Shallow or deficient affect: Does not express feelings or show emotions to others, except in ways
that seem shallow, insincere, or superficial (e.g., actions contradict the emotion displayed; can turn
emotions “on” or “off” quickly) or when emotional expressions are used for gain (e.g., emotions
displayed to manipulate or intimidate others).
Conduct Disorder
• Specify current severity:
– Mild: Few if any conduct problems in excess of those required to
make the diagnosis are present, and conduct problems cause
relatively minor harm to others (e.g., lying, truancy, staying out
after dark without permission, other rule breaking).
– Moderate: The number of conduct problems and the effect on
others intermediate between those specified in “mild” and
those in “severe” (e.g., stealing without confronting a victim,
– Severe: Many conduct problems in excess of those required to
make the diagnosis are present, or conduct problems cause
considerable harm to others (e.g., forced sex, physical cruelty,
use of a weapon, stealing while confronting a victim, breaking
and entering).
Conduct Disorder
Treatment for Conduct Disorder

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