Impulse Control Disorders Not Elsewhere Classified

Impulse Control Disorders

Failure to resist an impulse, drive or temptation to perform potentially harmful act
To self or another; physical or financial

Sense of tension/arousal before committing act Relief, pleasure, or gratification when act committed
No motivation or gain planned Distinguish between purposeful behavior
Presence of motivation & gain in aggressive act Not a lot of insight

Late adolescence to 3rd decade of life

Other Features
May or may not be present
Conscious resistance to impulse Preplanning Guilt, regret or self-reproach after committing act
Differentiates from antisocial

If addictive
Withdrawal-like symptoms may require attention

 August Aichhorn : impulsive behavior as related to a weak superego and weak ego structures associated with psychic trauma produced by childhood deprivation. Otto Fenichel : linked impulsive behavior to attempts to master anxiety, guilt, depression, and other painful affects by means of action Heinz Kohut an incomplete sense of self. He observed that when patients do not receive the validating and affirming responses that they seek from persons in significant relationships with them, the self might fragment. As a way of dealing with this fragmentation and regaining a sense of wholeness or cohesion in the self

 Donald Winnicott impulsive or deviant behavior in children is a way for them to try to recapture a primitive maternal relationship. Winnicott saw such behavior as hopeful in that the child searches for affirmation and love from the mother rather than abandoning any attempt to win her affection.

ICD
Intermittent Explosive Disorder Kleptomania Pyromania Pathological Gambling Trichotillomania Impulse-Control Disorder NOS

Psychosocial factors
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

 low cerebrospinal fluid (CSF) levels of 5hydroxyindoleacetic acid (5-HIAA) and impulsive aggression. Certain hormones, especially testosterone, have also been associated with violent and aggressive behavior temporal lobe mixed cerebral dominance ADHD . Lifelong or acquired mental deficiency, epilepsy, and even reversible brain syndromes

Making a Diagnosis
Heterogeneous & idiosyncratic group of syndromes
Do not fit in any larger group of illnesses similarly characterized by loss of control over impulses

ICD disorders so different

impossible to confuse diagnostically

Diagnostic problems
Not quite fulfill criteria for specific ICD diagnosis Occurs in context of other psychiatric symptoms/disorders Review rules of diagnostic precedence

Treatment for Impulse Control Disorders

Difficult to treat
Negative behavior inherently gratifying & reinforcing

Patience & persistence as relapse common

Build relapse into counseling

Little research available Treatment recommendations tentative Based primarily on theory & effectiveness with related disorders Importance of trusting relationship

Behavioral Techniques
Stress management Impulse control Contingency contracting
If-Then

Aversive conditioning
Discourages impulsive behavior

Overcorrection
via public confession & restitution

Assertiveness training Communication skills

Alleviates interpersonal difficulties Increases sense of control & power

Other Techniques for Treatment

Attend to correlates
Of behavior, legal, financial, occupational & family difficulties

Leisure activities & increased involvement in career & family to replace impulsive behavior Group therapy
Counteracts attraction of impulse through peer confrontation & support

Medication
Lithium or anticonvulsants Serzone Occasionally useful with pyromania & explosive
disorders

Intermittent Explosive Disorder:

Intermittent Explosive Disorder 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, Alzheimers disease). What you see: a pattern of aggressive behavior & overreacting.

Intermittent Explosive Disorder

Distinguish from purposeful behavior
Therapeutic hold act out only to be restrained bkz it is learned & only way to be touched

Discrete episodes where loss of control of results in serious assaultive acts or destruction of property
Aggressiveness grossly out of proportion to precipitating events

Does not occur during other mental disorders

Regret may follow

Generalized impulsivity/aggressive may be present between episodes Often job loss, school suspension, divorce, difficulties with relationships, accidents, hospitalizations, or incarceration More common in males Apparently rare (information is lacking)

 the presence of auras; postictal-like changes in the sensorium, including partial or spotty amnesia; and hypersensitivity to photic, aural, or auditory stimuli. High rates of fire setting in patients with intermittent explosive disorder have been reported. Other disorders of impulse control and substance use and mood, anxiety, and eating disorders have also been associated with intermittent explosive disorder

 a general medical condition, antisocial or borderline personality disorder, and substance intoxication (e.g., alcohol, barbiturates, hallucinogens, and amphetamines), epilepsy, brain tumors, degenerative diseases, and endocrine disorders. Conduct disorder the antisocial and borderline personality disorders because, in the personality disorders, aggressiveness and impulsivity are part of patients' characters and, thus, are present between outbursts.

Medication?
Lithium Carbamazepine, Valproate Or Divalproex,Phenytoin Benzodiazepines are sometimes used but have been reported to produce a paradoxical reaction Selective serotonin reuptake inhibitors (SSRIs), trazodone (Desyrel), and buspirone (BuSpar)

Differential Diagnosis
Aggressive behavior in context of many other disorders Differentiate between spoiled children Rule out Psychotic Disorders, ASPD, BPD, ODD, CD, manic episode, & Schizophrenia Consider aggressive outbursts associated with psychoactive substance-induced intoxication or substance-withdrawal Rule out Delirium, Dementia with behavioral disturbance In forensic setting, may malinger Intermittent Explosive Disorder to avoid responsibility for behavior

Treatment
Communication Skills Explore cognitions Check underlying depression & anxiety Family therapy if abuse Confidentiality problematic

Kleptomania
Recurrent failure to resist impulses to steal
objects not needed for personal use or for their monetary value

Increasing sense of tension immediately before committing theft Pleasure, gratification/relief at time of theft Stealing not committed
to express anger or vengeance Not a response to a delusion or hallucination

 As a means of restoring the lost motherchild relationship As an aggressive act As a defense against fears of being damaged (perhaps a search by girls for a penis or a protection against castration anxiety in boys) As a means of seeking punishment As a means of restoring or adding to self-esteem In connection with, and as a reaction to, a family secret As excitement (lust angst) and a substitute for a sexual act

Associated Features
Depression, anxiety, personality disturbance Awareness that act is wrong & senseless Possible eating disorders Legal, family, career, & personal difficulties

Prevalence
Rare Occurs in fewer that 5% of identified shoplifters Appears more in females May continue for years despite convictions

 Some psychoanalytic writers have stressed the expression of aggressive impulses in kleptomania; others have discerned a libidinal aspect. Those who focus on symbolism see meaning in the act itself, the object stolen, and the victim of the theft.

Differential Diagnosis
Rule out ordinary stealing R/O malingering, CD, Antisocial PD Distinguish from:
Intentional stealing during Manic Episode Stealing in response to delusions as in Schizophrenia Stealing as a result of a dementia (elderly)

Treatment -- NO controlled studies

Stress inoculation Treat depression & anxiety Family therapy Breath-holding aversion conditioning Systematic desensitization Cognitive behavioral
Monitor antecedents & sense of relief Diary of thoughts, preoccupations, impulses & behaviors

Assertiveness training
Unassertiveness may cause stealing as indirect way to strike back

Behavioral treatment

 SSRIs, such as fluoxetine and fluvoxamine appear to be effective in some patients with kleptomania. Case reports indicated successful treatment with tricyclic drugs, trazodone, lithium, valproate, naltrexone and electroconvulsive therapy.

Pyromania
Deliberate fire-setting/more than 1 time Increased tension prior to fire-setting Intense pleasure/relief during fire-setting
or as result of witnessing/participating aftermath

Fascination with, curiosity about, attraction to fire & situational contexts No typical age at onset Fire-setting incidents usually episodic
May wax & wane in frequency

Associated Features
May be regular fire-watcher, set off false alarms, show interest in fire-fighting paraphernalia, seek employment as firefighter, or as volunteer FF May be considerable advance preparation
may leave clues

Not motivated by:

monetary gain, sociopolitical ideology, anger, or revenge, or to conceal criminal activity

Not done;
to improve living circumstances in response to delusion or hallucination as result of impaired judgment

 Freud : fire as a symbol of sexuality. Other psychoanalysts have associated pyromania with an abnormal craving for power and social prestige. Some patients with pyromania are volunteer firefighters who set fires to prove themselves brave, to force other firefighters into action, or to demonstrate their power to extinguish a blaze. The incendiary act is a way to vent accumulated rage over frustration caused by a sense of social, physical, or sexual inferiority. Several studies have noted that the fathers of patients with pyromania were absent

Differential Diagnosis
Consider:
developmental experimentation with fire intentional fire-setting making a political statement attracting attention or recognition

Not in conjunction with impaired judgment associated with dementia, MR, or substance intoxication

Prevalence About 40% of arson offenses are under 18 Yet rare in childhood Juvenile fire-setting usually associated with CD, ADHD or Adjustment Disorder More often in males
Especially males with poor social skills & learning difficulties

Treatment Lacks Controlled Studies

Trustful relationship Cognitive behavioral Treat underlying depression & anxiety Parenting training/family therapy if needed Behavioral treatments
Over-correction Satiation, under controlled conditions Behavior contracting Token reinforcement Special problem-solving skills training Positive & negative reinforcement Fire safety & prevention education

Treatment
Medication Social skills training Symptom treatments Systematic Desensitization Stress inoculation Limit setting especially important
Bailing out seems to reinforce & perpetuate behavior

 Persistent & recurrent maladaptive gambling behavior with 5 of following

Pathological Gambling not manic

Preoccupied with gambling Increasing amounts of gambling Repeated unsuccessful efforts to control Restless/irritable when attempting change Cyclical gambling to escape/relieve dysphoria Chases ones losses Lies to conceal involvement Illegal acts committeed Jeopardized/lost significant relationships, jobs, career opportunities Relies on others in dire financial straits

Associated Features
Overconfident, very energetic, easily bored, big spender Prone to Gen. med. Conditions due to stress Possible distortions in thinking Over concern with approval of others Generous to the point of extravagance May be workaholic or binge worker who wait for deadlines to work Increased rates of Mood D/O, ADHD, Substance Abuse/Dependence, Antisocial, Narcissistic, PD Some correlation to marital problems 20% suicidal Hidden disorder; not easy to detect Intermittent rewards advocate denial in patient & family

Differential Diagnosis
Consideration of:
social gambling professional gambling

Is it during a Manic episode?

Not better accounted for as part of mania

Antisocial Personality Disorder

Prevalence & Predisposing Factors

Prevalence 1-3% adult population Approximately 1/3 female
Females more apt to use as depression escape Females underreport in treatment; 2-4% Gamblers Anonymous May indicate stigma to female gambling

Predisposition Inappropriate parental discipline Exposure to gambling as adolescent High family value on material/financial symbols Low family value placed on savings/budgeting

Course & Familial Pattern

Course
Typically early adolescence in male
Later in females

Familial Pattern
More prevalence if parents diagnosed

Insidious; may be yrs of social gambling before greater exposure or as stressor Regular or episodic Chronic typically Urge increases during stress, depression

Psychoanalytic theory : core character difficulties

Freud suggested that compulsive gamblers have an unconscious desire to lose, and gamble to relieve unconscious feelings of guilt. Another suggestion is that the gamblers are narcissists whose grandiose and omnipotent fantasies lead them to believe they can control events and even predict their outcome. .

Treatment
Trusting relationship Cognitive behavioral Underlying depression & anxiety Family therapy if indicated Systematic desensitization Stress inoculation Referral to Gamblers Anonymous Inpatient programs VA hospitals Limit setting Crisis management

Trichotillomania
Recurrent pulling out of hair resulting in noticeable loss Increasing sense of tension before act or attempt to resist Pleasure, gratification/relief when in act
With clinically significant distress or impairment in social, occupational, or other areas of functioning

Associated Features
Rituals
(i.e., eating hair, swallowing hair)

Denial of behavior If onset in adulthood

R/O psychotic disorders

Not occur in presence of other people (exc. Family) Social situations avoided May have urge to pull other peoples hair Nail biting, scratching, gnawing & excoriation Thumb sucking Co-occurrence of Mood Disorders, Anxiety D/O, MR Scalp most common area involved No evidence of scarring or pigmentary change May involve eyebrows, eyelashes, & beard

 The prevalence of trichotillomania may be underestimated chronic form : usually begins in early to midadolescence, with a lifetime prevalence ranging from 0.6 percent to as high as 3.4 percent in general populations F:M= 9 to 1 A patient with chronic trichotillomania is likely to be the only or oldest child in the family. A childhood type : girls = boys. It is said to be more common than the adolescent or young adult syndrome and is generally far less serious dermatologically and psychologically

 An estimated 33 to 40 percent of patients with trichotillomania chew or swallow the hair that they pull out at one time or another. Of this group, approximately 37.5 percent develop potentially hazardous bezoars. Significant comorbidity is found between trichotillomania and OCD (as well as other anxiety disorders); Tourette's syndrome; affective illness, especially depressive conditions; eating disorders; and various personality disorders particularly obsessivecompulsive, borderline, and narcissistic personality disorders

Other Factors
Precedence
No better Diagnosis Not due to Medical

Prevalence
College samples suggest 1-2% if past or current history Among children, males & females equal Among adults, more

Predisposing Factors
Psychological stress or psychoactive substance abuse May be stress related

Course
Adults report onset in early childhood Continuous or come/go Sites of hair pulling may vary over time

Treatment
Some pharmacological success
clomipramine & paroxetine

Behavior therapy for habit reversal Bitter Chinese herb solution

applied to thumb or thumb post when thumb also involved

Multimodal treatment
Address awareness of feelings, negative self-image combined with hypnosis

Relaxation techniques Mild aversive therapy Simple hypnotic suggestion

Pathological Gambling
Definition
A progressive disease An individual who has a psychologically uncontrollable preoccupation with an urge to gamble Resulting in damage to vocational, family and social interests Characterized by a chronic and progressive inability to resist the impulse to gamble An impulse control disorder in the dsm Typically a male 21 55 years old
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Gambling Types
Action gambling
Primarily at games of perceived skill Believe they can beat the house or other individuals by developing a system Preferred games
Poker Dice Cards Horse/dog racing Sports betting

Escape gambling
Primarily as a way to escape lifes challenges
Often in a hypnotic state while gambling

Does not gamble to beat the house or others Preferred games

Bingo Slot machines Video poker Lottery Scratch - offs

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Pathological Gambling Diagnosis

IN THE DSM
(MUST MEET 5 OUT OF 10 CRITERIA)

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Increase bets to sustain thrill Exhibits agitation when cutting back Chases losses Lies to conceal activity Finances bets through illegal acts Jeopardizes significant relationships Relies on financial bailout Fails in effort to control or stop Thinks constantly about gambling Preoccupied with gambling
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The Science
Pathological gambling is thought to be as a result of the dysfunction of the serotonin, noradrenergic and dopaminergic systems
Norepinephrine (arousal)
Norepinephrine is increased in the brain of patholgocal gamblers

Dopamine (reward)
Dysregulated dopamine neurotransmission

Serotonin (compulsivity)

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The Science
No specific gene is associated with pathological gambling (PG) PG subjects display a decreased activity in the frontal and orbitofrontal cortex, basal ganglia and thalamus Similar neuropathology as seen in obsessive compulsives and addictive disorders

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Gender Differences
Potenza Et Al Am J Psych
Males
Younger Cards Sports Loans And Bookies

Females
Older Lottery And Slots Credit Card Debt

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NATIONAL ADOLESCENT Review

Gambling begins at age 12 1.5% of teens age 16-17 can be classified as problem or pathological gamblers 2% can be classified as at - risk Divorce Domestic violence Child abuse or neglect
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National Adolescent Review

Children of pathological gamblers are more likely to engage in delinquent behaviors
Smoking Drinking Using drugs

Children of pathological gamblers are at increased risk of developing problem or pathological gambling

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1997 NYS Survey

Age 12 17
86% Said They Had Gambled Lifetime 15% Said They Had Gambled On A Weekly Basis

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In Primary Care Settings

6.2% of patients meet the criteria of problem or pathological gamblers These patients have an increased incidence of
Insomnia Irritable bowel syndrome Peptic ulcer disease Hypertension Migraines

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THREE PHASES OF PATHOLOGICAL

Gambling
Winning Phase Losing Phase Desperation Phase

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Winning phase Pathological Gambling

The search for action
Wins enhance selfesteem and ego Losses are rationalized as bad luck or poor advice The gambler will frequently describe the big win
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Three Phases: Winning Phase

Occasional gambling Frequent winning Excitement prior to and with gambling Increased amounts of bets Fantasies about winning The big win Unreasonable optimism
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Three Phases : Losing phase

The chase Losses become more frequent Self esteem is jeopardized Gambler borrows money to get even Hides losses and lies about where the money went

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Losing phase Pathological Gambling

Gambling alone Thinking only of gambling Cant stop borrowing money
Legal/illegal

Careless with spouse/family

Delay in paying debts Unhappy home life Unable to pay debts Bragging about wins Prolonged episodes of losing Losing time from work Personality changes Bailouts
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THREE PHASES OF PATHOLOGICAL Desperation phase

Hitting bottom
Becomes obsessed with getting even Withdrawals from family bank accounts Secret loans Panics at the thought that the gambling action will end if the credit or bailouts stop Illegal activities to support gambling
Arrests

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THREE PHASES OF PATHOLOGICAL Desperation phase:Gambling

Hitting bottom
Severe mood swings Remorse Blaming others

Rock bottom
Hopelessness Suicidal ideations or attempts Arrests Divorce Alcohol/drug involvement Emotional breakdown Withdrawal symptoms
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WITHDRAWAL SYMPTOMS IN Pathological Gamblers

Craving Restless/irritable Insomnia Headache Digestive problems Weakness Palpitations Shakes Muscle aches Breathing difficulty Sweats Chill/fever 91% 87% 50% 36% 34% 27% 26% 19% 17% 13% 12% 6%

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UNIQUE CHARACTERISTICS OF

Pathological Gambling
Gambling is a hidden addiction As long as there is money, overdose is not possible Gambling is not usually perceived as a disorder Few resources available for those affected

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Unique Characteristics Of Pathological Gambling

Gambling causes tremendous financial problems Pathological gamblers can usually function at work Gambling prevention message is not as easily accepted as a drug prevention message

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Pathological Gambling
Often occurs in conjunction with other behavioral problems Substance abuse Mood disorders Personality disorders

*National gambling impact study & 1999 national prevalence study

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Pathological Gambling
76% of pathological gamblers had a major depressive disorder with recurrent episodes in 28% Suicide risk is high (17-24%)

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Pathological Gamblers
More likely than non-pathological gamblers to report that their parents were pathological gamblers Research suggests that the earlier a person begins to gamble, the more likely he/she is to become a pathological gambler
*NATIONAL GAMBLING IMPACT STUDY & 1999 NATIONAL PREVALENCE STUDY

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Pathological Gambling And Substance Abuse

Comorbidity 30% and 50% of clients seeking treatment for problem gambling have a coexisting alcohol and/or substance abuse disorder Alcohol use replaced by gambling Clinicians miss asking

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Pathological Gambling And Substance Abuse

Many clients note that the reason they are able to maintain abstinence from their alcohol/drug problem is because they have replaced it with gambling Clients report that while in treatment for their alcohol/drug problem, no one screened them or asked them if they gambled or felt they had a problem with their gambling

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Pathological Gambling And Substance Abuse

Research institute on addictions (ria 2003)
If current alcohol dependence diagnosis 16.3 times more likely to have current gambling problem

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Pathological Gambling And Substance Abuse

84% of patients who are substance users and pathological gamblers have a diagnosis of nicotine dependence Onset of pathological gambling preceded onset of cocaine dependence in 72% of patients Onset of pathological gambling preceded onset of opiate dependence in 44% of patients Ledgerwood and downey in addict behavior 2002 found that path. Gamblers were more likely to use cocaine throughout treatment and drop out at a higher rate than non- gamblers
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Differences Between Substance Abuse And Pathological Gambling

No saturation point for a pathological gambler No urine screen/breathalyzer for a pathological gambler Bailouts easy access to money Chasing losses No differential between abuse and dependence in the gambling diagnosis Warning signs are hidden and the pathological gambler often enters treatment much later in their progression
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Associated Problems
Pathological gamblers may also have:
History of suicidal ideations/attempts Felony convictions Spouse and child abuse Unemployment

Much like many of the substance using patients

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The Pathological Gamblers Spouse

Profile
Poor self image Unrealistic expectations Caretaker Family history of gambling and/or substance abuse Angry, resentful, depressed Overachiever Often the primary person who bails the gambler out Works many jobs to make ends meet

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Diagnosis
Several screening tests are available
Lie/bet questionaire South oaks gambling screen (sogs) Warning signs in adolescents

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Lie/Bet Questionaire
Have you ever had to lie to people important to you about how much you gambled? Have you ever felt a need to bet more money?
*Yes to either indicates a pathological gambling tendency.

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Treatment
Paucity of evidence for effective treatment
Only 4 randomized controlled trials

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Treatment
Several modalities have been tried
Inpatient units
9 month residential program in england (gordon house assoc.)

Self help fellowship programs (gamblers anonymous) Cognitive behavioral methods Pharmacologic interventions

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Treatment
Addiction model includes
Structured intervention External motivation initially Psychoeducation Early abstinence Long - term sustained abstinence 12 - step self - help groups Relapse prevention Behavioral change modalities
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Treatment
Gamblers anonymous
Founded in 1957 by jim w. Open and closed meetings
Not many open meetings secondary to legal concerns

Pressure group
Not found in aa Gambler and spouse meet with oldtimers and bring in income and debt information
The group works out a budget to repay those owed money

12 steps
Similar to aa
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12 STEPS OF GA
1. We admitted we were powerless over gambling - that our lives had become unmanageable. 2. Came to believe that a Power greater than ourselves could restore us to a normal way of thinking and living. 3. Made a decision to turn our will and our lives over to the care of this Power of our own understanding. 4. Made a searching and fearless moral and financial inventory of ourselves.
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12 STEPS OF GA
5. Admitted to ourselves and to another human being the exact nature of our wrongs. 6. Were entirely ready to have these defects of character removed. 7. Humbly asked God (of our understanding) to remove our shortcomings. 8. Made a list of all persons we had harmed and became willing to make amends to them all. 9. Make direct amends to such people wherever possible, except when to do so would injure them or others.

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12 STEPS OF GA
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 Him, praying only for knowledge of His will for us and the power to carry that out. 12. Having made an effort to practice these principles in all our affairs, we tried to carry this message to other compulsive gamblers.

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Treatment
Psychotherapeutic approaches
Emphasize the reasons for gambling and confront those reasons to end the behavior Cognitive treatment focuses on challenging and correcting the patients errors in thinking
For example, exploring and understanding the illusion of control over chance events

Behavioral therapy considers pg to be a learned behavior and relies on techniques such as systemic exposure or desensitization and skill development Relaxation techniques is an example
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Treatment
Psychotherapeutic approaches
Cognitive behavioral therapy combines elements from both approaches In a university of minnesota study, almost half of the pathological gamblers said that advertisements on tv, radio and billboards could trigger the desire to gamble and that identifying and addressing these triggers is one key to successful recovery

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Treatment
Pharmacotherapy
Relatively new concept for gambling treatment Few controlled studies exist

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TreatmenT
Pharmacotherapy
Naltrexone
Inhibits dopamine in the reward area (ventral tegmental area, basal brain region)

Naltrexone trial (grant je, kim sw

ann clin psych 2002)

50 patients 90.9% responded to medication A question was raised - could better results be obtained with ssris and naltrexone in combination
Note: restrict use of over the counter analgesics as the combination of can cause an elevation in liver functions
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TREATMENT
Pharmacotherapy
Nefazodone trial
Serotonin antagonist
Hypothesis is abnormal serotonin function is the pathophysiology of poor impulse control

Started at 50mg/d in 14 subjects and increased to a maximum of 500 mg/d

12 finished the study 75% improved on several scales (obsessive, depression, anxiety)
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(Pallanti s et al j clin psych 2002)

Treatment
Pharmacotherapy Citalopram trial
Given to 15 subjects Patients reported improvement in all gambling areas (13 of 15 much improved)
Number of days spent gambling Amount of money lost gambling Preoccupation with gambling Urges to gamble

(Zimmerman et al j clin psych 2002)

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Treatment
Pharmacotherapy Paroxetine trial
Randomized, double blind placebo controlled Up to 60 mg/d Statistically greater response (decrease in gambling activity) in paroxetine group (Kim et al j clin psych 2002)
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Treatment
Pharmacotherapy
Lithium and valproate
42 non bipolar path. Gamblers Not double blind placebo controlled 60% responded in each medication group (Pallanti et al j clin psych 2002)

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Treatment
Which path. Gamblers will complete treatment?
It was found that a higher level of impulsivity at intake was associated with a higher drop out rate
(Leblond et al br j clinical psychol 2003)

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Special Case
Patients taking pramipexole, an anti parkinson medication developed gambling problems
Very small number (9 out of 529) Not sure of the etiology

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Impulse-Control NOS
May not meet any specific impulse-control disorder May not meet another mental disorder having features involving impulse control described elsewhere in manual
e.g., Substance Dependence, a Paraphillia)

South Oaks Gambling Screen

1.Indicate which of the following types of gambling you have done in your lifetime. For each type, select one of the answers provided(Not at all; Less than once a week; Once a week or more) A. Played cards for money B. Bet on horses, dogs or other animals C. Bet on sports D. Played dice games for money E. Went to the casino (legal or otherwise) F. Played the numbers or bet on lottery. G. Played bingo H. Played the stock,options, and/or commodities market I. Played slot machines, poker machines, etc J. Bowled, shot pool, played golf or some other game of skill for money. K. Pull tabs or paper games other than lotteries L. Some form of gambling not listed above (please specify)___________

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