Impulse Disorders

ANOREXIA NERVOSA is an eating disorder characterized by obsessional weight loss without an identifiable
organic cause.
A. Diagnostic criteria (Table 10-1)
В. Clinical features and associated findings
1. Onset. The average age of onset of the illness is 13 to 14 years; the onset often is preceded by a period of mild
obesity or mild dieting.
2. Behavioral features are varied, but commonly include:
a. Overactivity
b. Obsessions and rituals connected with food and food preparation
c. Purging (self-induced vomiting, diuretic abuse, laxative abuse)
d. Secretiveness
e. Extreme behavioral rigidity and inflexibility
f. Cognitive preoccupations and distortions regarding body image and weight
3. Associated findings that accompany the onset of illness are listed in Table 10-2. In general, these findings reflect
metabolic slowing, fluid and electrolyte disturbances, alterations in multiple endocrinologic axes, and organic brain
symptoms. In addition, three personality styles are classically cited as preceding the onset of anorexia nervosa.
a. Obsessive-compulsive (perfectionistic). An individual who is perfectionistic about other areas of life may focus
this compulsivity on eating as well.
b. Histrionic individuals overly sexualize relationships because of conflicts about sexuality. Such conflicts may
also play a role in the etiology of anorexia nervosa (see I D 2 a).
c. Schizoid or schizotypal individuals are prone to odd behavior and are, therefore, more likely to have unusual
eating behavior.
4. Clinical subgroups.
Some research suggests that anorexia nervosa is a syndrome that can be subclassified. Subclassification may be
useful prognostically and, possibly, in treatment. There are four subgroups:
a. The anorexia nervosa subgroup is characterized by strict self-starvation
b. Patients with anorexia accompanied by bulimia may form a distinct subgroup. These patients seem to be more
extroverted, present with the disorder later in life, and have a worse prognosis than patients who indulge only in
persistent self-starvation.
с Vomiters may form another subgroup; they tend to herald a more chronic course with a poorer prognosis.
d. Male anorectics may form yet another distinct subgroup.
5. Medical complications (Table 10-3)
Epidemiology. Anorexia nervosa is 10 to 20 times more common in girls than in boys; within the United States and
Western Europe, approximately 1 in 200 adolescent girls is affected. The disorder is more common in Western
cultures. Caucasians have the highest rate of anorexia nervosa, particularly girls from Jewish and Italian families.
Middle- and upper-class families are at the greatest risk. The disorder is increasing in prevalence, probably as a
result of the high value placed on thinness in Western societies.
Etiology and pathogenesis. Although no single cause is known, various biologic and psychological factors are
implicated in the etiology of anorexia nervosa.

Biologic factors. Certain mental disorders, endocrine abnormalities, and genetic problems occur with
increased frequency in anorectic patients.
a. Temperament. Many anorectics are high achievers with above average intelligence. Many also tend
toward rigid self-control and affective constriction. Interpersonal conflict is more likely to be expressed
through passive- aggressive modalities than through direct confrontation.
b. Mental disorders. Unipolar and bipolar mood disorders occur at a greater rate in anorectics than in
the general population. These disturbances tend to occur later in life and probably are not the underlying
cause of anorexia nervosa. The risk for suicide is increased in anorectic patients.
с Endocrine disorders
(1) Alterations in catecholamine activity at various central nervous system (CNS) sites could account
for some of the clinical features of the illness. Because much of this activity normalizes after weight gain,
causality is difficult to determine.
(2) An alteration in normal hypothalamic-pituitary function may account for some of the endocrine
abnormalities that occur in anorexia.
d. Genetic disorders. Some twin studies suggest a possible genetic role in the transmission of anorexia
nervosa.
Psychological factors. Three theories have been proposed in the etiology of anorexia nervosa.
a. Fear of sexuality. A classic theory holds that anorectics have a fear of impregnation and an
accompanying fantasy that impregnation occurs orally. They defend themselves against pregnancy by not
eating. A corollary to this theory is that affected adolescents fear sexuality, menarche, and pregnancy, and
starve themselves to remain prepubertal.
b. Parent-child conflict. The transactional theory purports that a series of parent-child interactions may
cause slight changes in the family system, which, in turn, may lead to a new and more deviated set of
interactions. The child's request not to eat or refusal to eat is overridden by the parent's need to feed the
child. Eventually, the child cannot regulate her own eating and becomes dependent on her environment
for cues concerning this and other areas of self-regulation.
с Dysfunctional family. The family system model also considers parent-child interactions and asserts
that family systems seek to maintain a dynamic equilibrium. Changes in any part of the system cause
disequilibrium and require compensatory changes elsewhere in the system. An adolescent's attempt to
begin the process of separation and emancipation in an overinvolved family or to exert developmentally
appropriate autonomy and self-control in a rigid, autocratic family is seen as disrupting the family system.
Therefore, the regression of the child from normal adolescent strivings to a preadolescent developmental
posture (through the symptoms of anorexia nervosa) represents an accommodation within the family
system, resulting in a more tenable, albeit pathologic, equilibrium.
(1) The mother-daughter relationship could play a role in the etiology. Mothers of anorectic girls often
are controlling, allowing their daughters little autonomy. Mothers of anorectic girls may also be fragile in
terms of feminine identity and self- esteem, perceiving their pubescent daughters as competitive and
threatening. Regression of the child to a prepubertal body morphology may serve to relieve this
disequilibrating force in the family system.
(2) Fathers of anorectics often are obsessive- compulsive. They may participate in quasi-weight- control
activities, such as distance running, and may transmit their attitudes about weight to their daughters.
("Obligate running" among males has been considered by some to be a male equivalent to anorexia
nervosa.) Fathers of anorectic girls also may be fearful of their own sexual impulses toward their
daughters, which are heightened by the girls' pubertal development.
rrerential diagnosis Medical conditions. The differential diagnosis for unexplained weight loss in adoles-
cence is included. An adequate medical assessment must include consideration of each of the following:
a. Addison's disease may present as weight loss, anorexia (loss of
appetite), vomiting, and electrolyte and endocrine abnormalities (low sodium concentration, high potas-
sium concentration, and suppressed serum cortisol levels). Listlessness and depression are common
findings, in contrast to the hyperactivity of anorexia nervosa.
b. Hypothyroidism may present as intolerance to cold, constipation, bradycardia, low blood pressure,
and skin changes similar to those seen in anorexia nervosa (i.e., dry, scaling skin). Obsessional food
handling, weight loss (and accompanying fear of weight gain), and hyperactivity are not usual, however.
c. Hyperthyroidism presents as elevated vital signs, hyperactivity, and, sometimes, weight loss.
However, patients with hyperthyroidism usually are not obsessive about food.
d. Any chronic illness (e.g., Crohn disease, ulcerative colitis, rheumatoid arthritis, tuberculosis) can
cause progressive weight loss but should be readily identifiable as a physical disorder.
e. Neoplasms, especially central nervous system (CNS) tumors (e.g., tumors of the hy-pothalamus
or third ventricle), can cause endocrine malfunction with accompanying weight loss of either a primary or
secondary nature. Other symptoms of the tumor, such as visual disturbances or panhypopituitarism,
should be evident.
f. Superior mesenteric artery syndrome can cause vomiting and anorexia. The mechanism apparently
involves compression of the duodenum by the superior mesenteric artery, particularly when the patient is
supine and especially in individuals who are thin. When found concomitantly with anorexia nervosa, it
often is difficult to ascertain whether superior mesenteric artery syndrome is primary (causative) or
secondary to the weight loss of anorexia nervosa.
2. Psychiatric conditions
a. Schizophrenia. Although schizophrenics may be delusional about food, the delusions are more
bizarre than those seen in anorectics (e.g., "there's poison in this" versus "this will make me fat"). Other
features of schizophrenia should be present.
b. Bulimia nervosa involves binge eating, usually followed by some form of purging, in a patient who
otherwise maintains her weight.
c. Depression often is accompanied by anorexia. In this case, the anorexia is a so-called "vegetative"
sign of depression, and a depressed mood usually is pronounced.
d. Hysterical noneating can be distinguished by the absence of a morbid concern with weight and
calories.
Treatment
1. Medical assessment. The anorectic patient must be protected from the potentially lethal
complications of starvation, i.e., metabolic disturbances, fluid and electrolyte disturbances, and cardiac
dysrhythmias. Medical management always begins with assessment for and treatment of potentially life-
threatening medical complications of the disorder. Intervention for a medical emergency sometimes is
necessary; therefore, immediate assessment requires a determination of how much weight has been lost
and over what period of time, as well as an assessment of cardiac, metabolic, and hydration status. Only
when medical stability has been attained does treatment for the underlying psychologic disorder begin.
2. Psychotherapeutic modalities
a. Individual therapy. Psychotherapy usually is a useful adjunct to other treatment modalities but rarely
is effective alone. Psychoanalysis can be particularly ineffective in anorexia nervosa if it is the only
treatment intervention. Both therapies can foster a regression in patients, which, in treatment, is useful
only when the patient has the ability and strength to pull out of the regression at the end of the session.
Neither treatment provides enough structure for the patient; anorectics may need to be watched and
instructed for most of the day. (1) Initially, the therapeutic work should be aimed at forming an alliance
with the pa-
Impulse Disorders I 241
tient to work on particular problems. The foci need not include weight or eating habits so long as
physiologic stability is maintained.
(2) Gaps in the patient's ego should be clarified. For example, when the patient is obviously angry about
something but is unaware of this, her affect can be pointed out to her.
(3) Transference reactions should be interpreted if and when they interfere with the patient's ability to
work on and talk about her problems.
(4) An empathic stance should be maintained with the patient at the same time that issues of
physiologic stability and compliance with medical treatment are treated as nonnegotiable. A close
partnership must be maintained among the patient, the psychiatrist, and the primary care physician in the
collaborative management of these patients.
b. Hospifalization. In some cases, the patient cannot be treated effectively within the dysfunctional home
environment, and adequate, less restrictive alternatives are not available. Out-of-home placement is
indicated if the patient loses weight despite outpatient intervention, if the patient is suicidal, or if vomiting
and purging are causing acid-base, electrolyte, or cardiac complications.
(1) Therapeutic approach reflects the understanding that anorectics have a propensity to deny and
conceal the severity of their condition.
(a) Careful attention must be paid to the accuracy of weight measurements. Serial weights should be
obtained at the same time of day, on the same scale, in the same garb (preferably a hospital gown only),
and after voiding. Attempts to pad weight artificially by drinking large quantities of water or concealing
objects on the body are typical of anorectics.
(b) Splitting (pitting one staff member against another) and manipulations concerning eating are
common and should be discussed at staff meetings and with the patient. Flexibility among members of
the treatment team with regard to the treatment plan is important. These patients can be extraordinarily
manipulative.
(2) Behavioral techniques may be necessary with refractory adolescents.
(a) The patient should be weighed every other day. Urine should be
monitored regularly for ketones, sometimes as often as daily before each meal.
(b) Alimentation should be provided by a nasogastric tube if the patient
steadfastly refuses to eat, and should be readministered if the food is vomited. Hy-peralimentation may
be provided through a central intravenous line if these measures fail.
(c) Patient privileges (e.g., freedom to leave the ward versus
confinement in a locked unit) should be tied to the behavioral approach and commensurate with the
patient's ability to regulate her own activity and eating. Such a program may take the following form:
(i) The patient's weight, not the eating behavior, amount of exercise, or vomiting, should be the target
symptom. Reinforcers should be tied to weight fluctuation.
(ii) Once the patient is stable medically and has some weight reserve, urine can be monitored for
ketones before each meal as part of a behavioral treatment approach. Monitoring ketones provides
information about starvation state, provides the patient with immediate feedback, and offers her the
opportunity to alter her starvation state immediately. If the patient's urine contains ketones, her activities
and privileges should be completely restricted until her urine reverts to normal.
с Group therapy. Peer interaction and feedback should be sought and emphasized, because adolescents often pay
more attention to their peers than to adults. Adolescents respond to peers with more trust and less suspicion, such
that the perception of empathy is enhanced. In addition, the realization that others share the same symptoms helps
adolescents feel less isolated. Although many types of groups have been used, self-help groups have been increasing
in number and prominence. d. Family therapy. Some form of family intervention is nearly always indicated,
espe-
i
242 Chapter 10 IF
daily for adolescents. Styles of family interaction should be clarified, and projections and vicarious
pleasures that family members derive from the patient's symptoms should be interpreted and
restructured. Individual therapy for either or both of the parents may be indicated; when marital issues
contribute to the symptomatology of the child, marital therapy for the parents may also be indicated.
Parent education concerning the normal developmental tasks and transitions of adolescence may be
necessary. In general, the family should be allied with the staff, working toward the patient's improvement,
and not with the patient to her detriment. e. Medications. There is no pharmacologic treatment for
anorexia nervosa. Medications may be useful therapeutic adjuncts, but only when targeted at specific,
underlying symptoms.
(1) Cyproheptadine may be of some value because it has appetite-stimulating
properties,
(2) Antidepressants may benefit when depressive symptoms are prominent.
(3) Likewise, prominent anxiety symptoms may respond to anxiolytics.
(4) When eating and food preparation are excessively ritualized, or other
symptoms of obsessive- compulsive disorder (OCD) are present, anti-OCD agents may prove beneficial.
(5) Because of potentially severe side effects, antipsychotic medication
should be used only when the patient suffers from a psychotic illness.
G. | Prognosis. On average, 30%-40% of patients have a relatively complete recovery; 30% or more
demonstrate partial improvement (some may undergo a period of obesity); and up to 30%-40% continue
to demonstrate bizarre eating habits, weight loss, and a severe disease course.
1. Positive prognostic indicators include early onset of disease, decreased
denial of a problem, gainful employment, and admitting to feeling hungry.
2. Negative prognostic indicators include a long disease course; a schizoid
personality; and recurrent bulimia, vomiting, and laxative abuse.
3. Mortality rates are reported to be 5%-15%. Death, when it occurs, is due to
electrolyte abnormalities, suicide, cardiac dysrhythmias, or, possibly, sudden rehydration and weight gain.
BULIMIA NERVOSA. Bulimia nervosa is characterized by ravenous overeating followed by guilt, depression, and
anger at oneself for doing so. During the episode, a sense of lack of control over eating exists, despite which there is
no significant loss of weight below the normal for age and size.
A.J Diagnostic criteria are listed in Table 10-4. Bulimia nervosa patients fall into two distinc categories:
1. Patients with the purging type engage in regular vomiting and use of diuretics or
cathartics
2. Patients with the nonpurging type compensate for high-calorie binges with subsequent
caloric restriction or exercise; they do not regularly purge.
B. I Clinical features and associated findings
1. Onset. Bulimia nervosa is most commonly a disorder of adolescent and young
adult ff males.
2. Behavioral features. Individuals with bulimia nervosa have an increased frequency с
mood and anxiety symptoms and of substance abuse and personality disorders. Othe symptoms of impulsivity, such
as stealing, are common. Stealing may be necessary t: support an expensive eating habit.
3. Associated findings are listed in Table 10-5.
4. Medical complications are listed in Table 10-6.
Impulse Disorders I 243
DSM-IVCriteria for Bulimia Nervosa
vpes ("purging" and "nonpurging") sodes of bingeing, characterized by:
on of a quantity of food that exceeds what a normal person would eat during a given od, under similar
circumstances, and
г not having control over eating during the episode
ppropriate weight-controlling behavior (e.g., self-induced vomiting, use of cathartics, xercise)
inappropriate weight-controlling behavior, both at least twice weekly for 3 months
n unduly influenced by body shape and weight
Joes not occur exclusively during episodes of anorexia nervosa

Associated Findings in Bulimia Nervosa

igh-calorie food
odes occur in secret
ions in weight
rconcern with weight and body shape
)se weight (through dieting, exercise, or use of cathartics, diuretics, enemas)
odes terminated by sleep, abdominal pain, social interruption, or self-induced
es of normal eating
ABLE 10-6. Medical Complications of Bulimia Nervosa
Metabolic abnormalities (e.g., hypokalemia, hypochloremic alkalosis)
Parotid gland swelling
Dental erosion and caries
Menstrual irregularities
Gastric dilatation and rupture
Chronic sore throats and esophagitis
Anemia
logy. Bulimia nervosa is primarily a disorder of adolescent girls and probably is mon, existing in gradations from mild
(perhaps a variant of normal) to severe. :e may be as high as 5%-10% of college-age females. The disorder is many
times imon in females than in males.
Very little is known about the cause of the disorder, although several theories n proposed.
^logical theories
imia could be caused by a need to take in something orally—perhaps as a substi-on for some degree of maternal
deprivation.
244 I Chapter 10 II D

b. Some children of short stature fantasize that eating ravenously can help
them grow.
c. Bulimia has been described in children with psychogenic dwarfism
(retarded growth due to emotional neglect).
d. Bulimia could be a disorder of self-regulation. There are high rates of
coexistent substance abuse and stealing.
2. Biologic theories. A lesion of the satiety center in the hypothalamus could contribute to bulimia, but
no such lesion has yet been defined or discovered.
E. I Differential diagnosis
1. Prader-Willi syndrome is characterized by continuous overeating, obesity,
mental retardation, hypogonadism, hypotonia, and diabetes mellitus. It apparently is a genetic syndrome,
but the mode of transmission is unknown. It is thought to be due to a hypothala-mic lesion.
2. Kliiver-Bucy syndrome. Objects are examined by mouth, and
hypersexuality and hyper-phagia are characteristic. Visual agnosia, compulsive licking and biting, and
hypersensi-tivity to stimuli are common as well. The condition may result from temporal lobe dysfunction.
3. Kleine-Levin syndrome manifests as hyperphagia and hypersomnia, both
of which occur in spurts of 2 to 3 weeks at a frequency of 2 or 3 cycles per year. Loss of sexual inhibitions
may occur as part of the syndrome. This disorder is more common in boys and appears to represent a
limbic or hypothalamic dysfunction.
4. Hypothalamic lesions should be considered.
5. Anorexia nervosa. A component of anorexia nervosa may be binge eating,
but simple bulimia nervosa does not include significant weight loss.
6. Binge eating in obesity. In obesity, bingeing represents a pattern of
overeating, is not terminated by purging, and is not accompanied by a preoccupation with body shape.
7. Epileptic seizures
8. CNS tumors
F. I Treatment. Long-term efficacy of any one treatment modality has not been
established. Bu-
limia traditionally has been viewed largely as a treatment-resistant condition. However, mixed modality
treatment appears to offer promising results.
1. Individual psychotherapies of psychodynamic, behavioral, and cognitive
orientations have been variably helpful. Individual therapy that combines elements of the various
therapeutic orientations in conjunction with supportive group psychotherapy offers promising results.
2. Medications are not universally indicated. Drugs that have been reported to
be useful, however, include selective serotonin reuptake inhibitors (SSRI) and tricyclic antidepres-sants,
monoamine oxidase inhibitors, lithium, carbamazepine, and phenytoin.
3. Hospitalization is indicated for the management of serious medical
complications, for relentless bingeing and purging (several times daily), and for the severely depressed or
suicidal bulimic patient.

ШГ
OTHER IMPULSE CONTROL
DISORDERS. Eating disorders
may be recognized as falling
within a broader spectrum of
disorders of self-regulation or
impulse control, which also
includes substance-related
disorders and paraphilias. The
following disorders also fall
within this spectrum and are
clustered within the Diagnostic
and Statistical Manual of Mental
Disorders, 4th edition (DSM-IV)
as impulse control disorders not
elsewhere classified.
AJ Intermittent explosive
disorder
Impulse Disorders I 245
1. Diagnostic criteria
a. Repeated, discrete episodes of loss of behavioral control
characterized by aggression toward persons or property are the hallmark of this disorder. Most
commonly, the aggression toward persons assumes the form of a physical assault, whereas aggression
toward property manifests as destruction of property.
b. Precipitating events may be variably present or absent but, when
present, are disproportionately insignificant when compared with the extent of the aggressive behav-
ioral outburst.
c. Whether the disorder exists independently from the conditions that
must be ruled out in a differential diagnosis is controversial. Consequently, the condition may best be
considered a characteristic symptom constellation deriving from multiple etiologies, rather than as
a distinct and discrete disorder.
2. Epidemiology. Intermittent explosive disorders apparently are more
common in men than in women. Men with these disorders reportedly are more likely to be seen in cor-
rectional facilities, whereas women are more likely to be seen in mental health facilities.
3. The differential diagnosis includes a variety of psychological and organic
etiologies. Regardless of the etiology, victimization by or exposure to violence and aggressive behavior
likely contributes to the expression of this symptom constellation.
a. Psychological etiologies may include personality disorders
(especially antisocial and borderline), psychotic disorders (schizophrenia), mood disorders (manic
episodes), and disruptive behavior disorders (especially conduct and attention deficit hyperac-tivity).
b. Organic etiologies may include seizures (especially with temporal lobe
foci), psy-choactive substance intoxication, structural lesions (trauma, infarct, tumor, hemorrhage,
abscess), normal pressure hydrocephalus, CNS infection, metabolic disorders (hypoglycemia), and
hormone disturbances (elevated androgen levels).
4. Treatment is best aimed at the underlying condition(s).
a. Incarceration, institutionalization, seclusion, and restraint have
all been employed, although these measures likely control rather than alter aggressive behaviors.
b. Behavior modification techniques have met with only modest
success, as have conventional psychotherapies.
c. Various psychosurgical procedures have been applied, although
currently these are used rarely and are reserved for the most dangerous and refractory cases.
d. A variety of medications have also been used with some symptomatic
benefit. Mood stabilizers (e.g., lithium), anticonvulsants (e.g., phenytoin, carbamazepine, valproic acid), p-
blockers (e.g., propranolol), minor and major tranquilizers (e.g., benzodi-azepines, neuroleptics), and,
more recently, SSRIs (e.g., fluoxetine, sertraline, paroxe-tine) have been used with favorable responses
in appropriately selected cases.
B. I Kleptomania
1. Diagnostic criteria
a. Multiple episodes of impulsive stealing in the presence of
pertinent negatives are the
hallmark of this disorder. Specifically, the stealing is not:
(1) For monetary value or to satisfy a personal need
(2) An expression of anger, retribution, or retaliation
(3) Symptomatic of an underlying psychotic disorder (in response to a
hallucination or delusion)
b. Individuals experience a mounting sense of tension or anxiety
before the stealing episode. Pleasure, then, is derived from easing this internal tension and anxiety
after gratifying the impulse to steal, not from the object(s) stolen. This contrasts sharply with shoplifting,
robbery, burglary, and other stealing behaviors where the secondary gain derives from the object(s)
stolen rather than from the impulse gratification itself. In fact, it is common for the objects stolen in
kleptomania to be hidden, stored, discarded, returned, or given away.
2. Epidemiology and etiology. Kleptomania is believed to be extremely rare,
and more com-
246 Chapter 10 III В
mon in females than in males. Many reported cases must be carefully evaluated - " the secondary gain afforded by conscious attempts to avoid
criminal prosecution -gering). Because the disorder is rare, little is known of its epidemiology or its etlc .
a. Organic etiologies related to behavioral disinhibition have been suggested :: main poorly defined.
b. Psychological etiologies have been suggested, largely by psychoanalytic the who tend to view the behavior as an
attempt to restore wishes, drives, and \: that were lost, or at least frustrated, during infancy and childhood. These the remain poorly defined.
3. Treatment. The literature is largely devoid of systematically controlled treatment y. and, instead, includes mostly single-case, anecdotal reports of
either psychoana " behavioral therapeutic modalities. There is no clearly defined role for pharmacc" in this disorder, except in cases in which an
underlying organic state has been icier*
С I Pyromania
1. Diagnostic criteria
a. Multiple episodes of willful and intentional fire setting in
the presence of per: negatives are the hallmark of this disorder. Specifically, the fire setting is
not:
(1) For financial gain (e.g., insurance reimbursement)
(2) An act of sociopolitical insurrection
(3) One of a series of related criminal activities
(4) An act of vandalism or an expression of retaliation or revenge
(5) A symptom of an underlying psychotic disorder
b. Individuals experience a mounting sense of tension or
anxiety before the fire-settm episode, which sometimes may be in the form of a building
sexual tension and exclfe1» ment (pyrolagnia). Relief of tension and anxiety, or sexual
pleasure, is derived when the fire-setting impulse is gratified as well as during the aftermath of
the fire setting.
с Afflicted individuals maintain an obsessional preoccupation with fire, in much the same way individuals with
eating disorders maintain obsessional preoccupations w№ food.
2. Epidemiology. Pyromania is a rare disorder that accounts for only a fraction of al ! -of
fire setting. The disorder appears to be more common in males than in females, с childhood onset is common.
Individuals with pyromania appear to lack empathic re:>; nition of the physical destructiveness of their actions and the
consequences of thei-1■:-tions to its victims.
3. Etiology. Specific etiology tends to be obscured by the rarity of the disorder.
a. An underlying organic factor is suggested by long- standing observations of high
rates of fire setting in organically impaired populations. This correlation has not beer specifically evaluated within the
pyromania subset of the fire-setting population however.
b. Psychological theorists have focused on the intrapsychic representation and
mea of fire. Such theories have emphasized issues related to sexuality, power, rage, and aggression as
psychodynamic determinants, which may underlie this disorder.
4. Treatment. The nature of the disorder is such that "treatment" most often occurs in penJ
institutions. No systematically controlled studies have been done to describe the differential efficacies of various
treatments that have been applied in this population. There % no clearly defined role for pharmacotherapy in this
disorder unless an underlying organic state has been identified.
D. I Pathological gambling
1. Diagnostic criteria. As with alcohol consumption, some degree of gambling is viewed falling within a wide
spectrum of normality. a. The chronic, progressive, and maladaptive nature of the gambling behavior is the
hallmark of this disorder, as evidenced by:
\NSWERS AND EXPLANATIONS

г
ч
" e answer is A [II E 1-3]. The Prader-Willi не is characterized by ravenous :ing and is accompanied by obesity,
'etardation, and hypotonia. It is proba-т to a hypothalamic lesion. Examining r by mouth, hypersexuality, and hyper-
are attributed to the Kluer-Bucy syn-and overeating and hypersomnia are ~ed with the Kleine-Levin syndrome.
seating interspersed with lengthy phases '«arma! eating may be seen in bulimia ner-u and may be associated with
wide fluctu-n weight. The constellation of in-appetite, weight loss, and heat "ance suggests hyperthyroidism.
e answer is D [III С 2, 3 a]. The motive - setting in pyromania is specifically not :ondary gain (e.g., to access
insurance :s), as an act of terrorism or political in-rtion, or as an act of vandalism amid a illation of delinquent
behaviors. Neither " response to psychotic delusions or corn-auditory hallucinations. Rather, the mo-r fire setting in
pyromania is tension ration and reduction, often of a sexual r Tension is relieved and/or sexual plea-ratified only by
indulging the impulse to -5, and its aftermath.
*e answer is С [/ F 1, G 3]. Anorexia ner-•iinav be a life-threatening illness. Sign if i-i mortality accompanies this
condition, '"1 commonly due to the metabolic or car-c complications secondary to starvation. '"first intervention with
anorectic patients «wys is an assessment of the medical state few ing blood for serum electrolyte deter-unation,
followed by supportive or emer-""ку medical intervention, such as starting twenous feeding. Too-rapid hydration or P
gain should be avoided because it may further complications and even death, igh-protein and carbohydrate diet
adminis-1ed by nasogastric tube would not correct ill and electrolyte problems quickly. Evalua-w and treatment of the
individual and family "atnics are always secondary to emergency cGical management.
- The answer is A [/// introduction]. Impulse itrol disorders broadly include eating disorders, substance-
related disorders, paraphilias,
and a cluster of "other" impulse control disorders including intermittent explosive disorder, kleptomania, pyromania,
pathological gambling, and trichotillomania. Paraphilias are sexual impulses involving non-human objects, suffering
or humiliation, or children or other non-consenting individuals. Gender identity disorders, by contrast, involve cross-
gender identification rather than sexual behavioral impulses. Parasomnias are sleep disorders not related to
voluntary impulses. Behavioral impul-sivity may be a symptom of many personality disorders and disruptive behavior
disorders; however, in these conditions it is just one in a broad spectrum of symptoms, and not the defining
characteristic.
5. The answer is D [Table 10-6, I E]. Frequent exposure of the teeth, parotid salivary
gland, and esophagus to gastric acid (as occurs in the purging type of bulimia nervosa) can result in irritation,
inflammation, and damage to each of these tissues. Individuals with Addison's disease may present with weight loss,
but it occurs in conjunction with hyperkalemia rather than hypokalemia. Superior mesenteric artery syndrome can
cause vomiting and anorexia, but usually after substantial weight loss. Anorexia nervosa cannot be diagnosed until
weight is at or below 85% of ideal body weight. Rumination disorder, in which food is repeatedly regurgitated and re-
chewed, is an uncommon disorder of infancy and early childhood that rarely progresses into adulthood except in
individuals with mental retardation or pervasive developmental disorders.
6. The answer is В [III Л 1 b, 2]. Multiple etiologies, including psychologic and organic
states, likely underpin this disorder. Environmental precipitants are only variably present, but, when present, they are
disproportionately minor when compared with the extent of the aggressive behavioral outburst. Nonetheless,
precipitants may not be identifiable with each explosive outburst. Regardless of the underlying etiology, exposure to
violence and aggression likely contributes to the behavior. Elevated androgen levels have been implicated in some
cases.
7. The answer is A [/// В 1 b, 2]. Kleptomania is believed to be an extremely rare disorder.
It
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