PSYCHIATRY 2

Title of Lecture
Name of Lecturer/Presenters 01 Jan 2021 | S01.T01

OUTLINE Psychodynamic
● Impulse
I. General Layout B. Lists, Bullets, and → Disposition to act to decrease heightened tension caused by
Numbering the buildup of instinctual drives
II. Header and Footer → Diminished ego defenses against the drives
C. Nice-to-Know Information ● Impulse disorders
A. Header → Attempt to bypass the experience of disabling symptoms or
V. Tables, Figures, and painful affects by acting on the environment
B. Footer
Appendix
Psychoanalytic Proponents on Impulsive Behaviors
III. Main Heading August Aichhorn  Impulsive behavior as related to
A. Figures
weak superego
A. Subheading  Weak ego structures
B. Tables associated with psychic trauma
B. Subheading Font and produced by childhood
Sub-subheading VI. Review Questions deprivation
Otto Fenichel  Impulsive behavior attempts to
IV. Content Formatting VII. Citation master anxiety, guilt,
depression, and other painful
A. General Formatting VIII. References
affect by means of action
 Defense against internal danger
leading to distorted
IX. Appendix aggression or sexual
gratification
Heinz Kohut  Impulse control problems
INTRODUCTION o Gambling
● 5 conditions: o Kleptomania
→ Intermittent explosive disorder o Some paraphilic
→ Kleptomania behaviors
→ Pyromania  Related to incomplete sense
→ Oppositional defiant disorder* of self and committing the act
→ Conduct disorder* completes their idea of the self
● *Oppositional defiant disorder and conduct disorder are  Self-fragmentation
psychiatric disorders of childhood. o Non-receipt of
● Characteristics common to the group of disorders: validating and
→ Inability to resist an intense impulse, drive affirmation responses
→ Temptation to perform a particular act that is obviously that they seek from
harmful to self or to others, or both significant persons
→ Before the event: (This is the reason
▪ Mounting tension and arousal (e.g. anxiety, fear, they commit the acts
excitement) in order to get
▪ Sometimes, but not consistently mingled with conscious attention, which is a
anticipatory pleasure form of validation for
− Just by thinking about committing the act, the person the patient)
already derives pleasure  Impulsive behaviors which
→ Completion of action leads to immediate gratification and seem self-destructive is an
relief attempt at dealing with
→ Followed by conflation of remorse, guilt, self-reproach, and fragmentation and regaining a
dread sense of wholeness or
▪ May stem from obscure unconscious conflicts or cohesion in the self
awareness of the deed’s impact on others, including the Donald Winnicott  Impulsive or deviant behavior in
possibility of serious legal consequences children is a way to recapture
− E.g., kleptomania a primitive maternal
▪ Shameful secretiveness about the repeated impulse relationship
activity
 Child searches for affirmation
− It is ego syntonic but what makes it shameful are the
and love from the mother rather
consequences, otherwise if there is no social pressure,
than abandoning any attempt to
there will be no shame on the part of the patient
win affection
▪ Pervades the individual’s entire life resulting to delayed
treatment
− Patients are often brought by their family for consult Psychosocial Factors
due to their behavior ● Related to life events
● Improper models for identifications
ETIOLOGY OF IMPULSE CONTROL & CONDUCT DISORDERS ● Exposure to:
→ Violence in the home
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 → Alcohol abuse
→ Promiscuity
→ Antisocial Behavior
Biological Factors
● Limbic System: impulsive and violent activity
● Decreased CSF levels of 5-hydroxyindoleacetic acid (5-
HIAA) leads to impulsive aggression
→ 5-HIAA is a precursor of serotonin, hence remedied by
SSRIs e.g. Fluoxetine
→ Increased serotonin-binding sites
● Dopaminergic and noradrenergic systems also implicated in
impulsivity
→ benzodiazepines and anticonvulsants may serve as auxiliary
treatments
● Testosterone
→ associated with violent and aggressive behavior
→ Evidence from studies show that there is increased
aggression among those who inject testosterone
● Temporal lobe epilepsy
● Head trauma
● Other medical conditions
→ Symptoms of many individuals with disorders like irritable
bowel syndrome or fibromyalgia.
INTERMITTENT EXPLOSIVE DISORDER (IED)
DSM-5 Criteria
A. Recurrent behavioral outbursts representing a failure to
control aggressive impulses as manifested by either of the
following:
1. Verbal aggression (e.g. temper tantrums, tirades, verbal
arguments or fights) or physical aggression towards
property animals or other individuals occurring twice
weekly on average for a period of 3 months. The physical
aggression does not result in damage or destruction of
property and does not result in physical injury to animals
or other individuals.
2. Three behavior outbursts involving damage or
destruction of property and/or physical assault involving
physical injury against animals or other individuals
occurring within a 12-month period.
3. 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 people would eat in a similar period of
time under similar circumstances.
B. The magnitude of aggressiveness expressed during the
recurrent outbursts is grossly out of proportion to the
provocation or to any precipitating psychosocial stressors.
C. The recurrent aggressive outbursts are not premediated
(i.e., they are impulsive and/or anger-based and are not
committed to achieve some tangible objective (e.g. money,
power, intimidation).
D. The recurrent aggressive outbursts cause either marked
distress in the individual or impairment in occupational or
interpersonal functioning or are associated with financial or
legal consequences.
E. Chronological age is at least 6 years (or equivalent
developmental level).
F. The recurrent aggressive outbursts are not better explained
by another mental disorder (e.g. major depressive disorder,
bipolar disorder, disruptive mood dysregulation disorder, a
psychotic disorder, antisocial personality disorder, borderline
personality disorder) and are not attributable to another
medical condition (e.g. head trauma, Alzheimer’s disease) or
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the physiological effects of a substance (e.g. a drug of abuse,
a medication).
For children ages 6-18 years, aggressive behavior
that occurs as part of an adjustment disorder should
not be considered for this diagnosis.
Note: This diagnosis can be made in addition to the diagnosis of
attention-deficit/hyperactivity disorder, conduct disorder,
oppositional defiant disorder, or autism spectrum disorder when
recurrent impulsive aggressive outbursts are in excess of those
usually seen in these disorders and warrant independent clinical
attention.
GENERAL INFORMATION
● Epileptoid Personality
→ Seizure-like quality of the characteristic outburst
→ Not typical of the patient’s usual behavior
→ Suggestive of CNS damage
→ Presence of aura; postictal-like changes in the sensorium
● Discrete episode of losing control or aggressive impulse
● Can result to serious assault or destruction of property
● Grossly out of proportion to any stressors
● Described as spells or attacks appearing within minutes or
hours and regardless of duration, remits spontaneously and
quickly
● Regret or self-reproach after each episode
EPIDEMIOLOGY
● Men > women
→ Men: likely to be found in correctional institutions
→ Women: psychiatric facilities
● 2% admitted in a hospital with psychiatric services
● Common on 1st-degree biological relatives (see biological
factors)
COMORBIDITY
● Fire setting
● Substance use
● Mood disorders
● Anxiety disorders
● Eating disorders
● Triad of antisocial behavior in Pediatrics (Freud)
→ cruelty to animals
→ fire setting
→ bedwetting
EPIDEMIOLOGY
Psychodynamic
● Defense against narcissistic injury
→ When the normal or healthy narcissism is threatened, the
tendency is to activate fight or flight response.
→ If it is towards fight, then it’s intermittent explosive behavior.
● Rage outbursts
→ Employed to create interpersonal distance and protection
against any further narcissistic injury.
→ Note: when one says “nasaktan ang ego” it should
actually refer to hurting the self-esteem instead of ego. Ego
refers to the reality testing of an individual.
Psychosocial
● ● Men whose sense of masculine identity is poor ● Precedes
an episode of physical violence ● High level of anxiety,
guilt, and depression usually follows an episode ●
Unfavorable childhood environment often filled with alcohol
dependence, beatings and threats to life ● Perinatal trauma
● Infantile seizures ● Head trauma ● Encephalitis ● Minimal
brain dysfunction ● Hyperactivity
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Biologic → ↑ Substance use disorders
● Disordered brain physiology (limbic system) ● Biological relatives
● Serotonergic neurons mediate behavioral inhibition → Histories of temper or explosive outbursts
→ Decreased serotonergic transmission
▪ Serotonergic synthesis inhibition PHYSICAL EXAM & CLINICAL FINDINGS
▪ Antagonizing effects of serotonin = ↓ effect of punishment ● ↑ Incidence of soft neurological signs
as a deterrent to behavior → E.g. reflex asymmetries
▪ Low CSF 5-HIAA ● Nonspecific EEG findings
▪ High CSF testosterone concentration ● Abnormal neuropsychological testing results
● Susceptibility to accidents
Genetic/Hereditary Factors ● Magnetic Resonance Imaging (MRI)
● 1st degree relatives → may reveal changes in prefrontal cortex
→ ↑ Impulse control disorders → Loss of impulse control
→ ↑ Depressive disorders

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