Week 4/5 - adult externalising disorders

Question 1

What are some of the criteria for being diagnosed with Gambling Disorder (4 or more over 12 months)?

Answer 1

1. Restless/irritable
2. Preoccupied
3. Tried by can’t stop
4. Loss
5. Tolerance
6. Lying
7. Bailed out
8. Chases losses
9. Gambles to escape
   Note… mild (4-5), moderate (6-7), severe (8-9)
   - Not part of manic episode
   - Specifiers: episodic (between several months) or persistent (multiple years)

Question 2

How is gambling similar to an addiction diagnosis?

Answer 2

1. Loss of control
2. Preoccupation, urges, pathological “wanting”
3. Negative impact on major areas of life
4. Major impact on mood, judgment and insight
5. Tolerance/withdrawal

Question 3

What are some associated features/cognitive distortions we see with gambling disorder?

Answer 3

Associated features:
-	increased sensation seeking
-	deficits in decision making
-	higher motor impulsivity
-	slower contingency learning
-	more perseverative errors
-	altered punishment and reward sensitivity
-	gambling related crimes
       o	non-violent, income generating offenses
       o	illegally gained $3,000-13,000

Cognitive distortions: 
o	Chances of winning
o	Illusions of control over outcomes
o	Gambling as source of income
o	Familiarity (favourite machine)
o	Justifications regarding continued gambling
o	Estimation of skills

Question 4

What are the risk factors for developing gambling disorders?

Answer 4

• male
• young
• low ses/disadvantaged
• early exposure to gambling
• availability
• ACES (adverse childhood experiences)
• Family history
• Indigenous
• PD
• Nicotine addict
• Deviant adolescent

Question 5

What are some ways to assess for gambling:

Answer 5

QUESTIONNAIRES:

• Problem gambling severity index
• Brief problem gambling screen: 5 item, can detect low – high risk
• South oaks gambling screen: short, self-scored, 16 items
• Lie/bet questionnaire: 1 qn about lying and betting, ‘yes’ indicates GD tendency

STRUCTURED CLINICAL INTERVIEWS:

• The diagnostic interview for gambling schedule - DIGS
• The structured clinical interview for pathological gambling – SCI-PG
• The world mental health composite international diagnostic interview – WMH-CIDI
• The gambling behaviour interview – GBI
• The gambling assessment module - GAM
• Structured clinical interview for pathological gambling - SCIP

Note: structured interview benefits:

• clinical judgement
• improve accuracy of diagnosis
• include additional questions across multiple domains
• focus on impact, not just frequency and expenditure (legal, finance, social, physical, family, productivity, mental health)
• Finding out about these follow up things helps with the referral and/or treatment plan

Question 6

What are some things to be aware of when doing an gambling assessment:

Answer 6

• be aware of the shame, secrecy and stigma
• collateral information is a MUST (getting info from other sources)
• can take several sessions to get the picture
• ask for evidence (statements)
• timelines and history help differentiate between other diagnoses (like bipolar, adhd etc)

Question 7

What are the key features of impulse control disorders?

Answer 7

• a failure to resist and impulse, drive or temptation to perform an act that is harmful to the person or to others.
• Relief of mounting tension or arousal with the act
• Repetitive or compulsive engagement in the behaviour despite adverse consequences
• Diminishes control over the problematic area
• Disturbances in the ability to regulate specific impulses not attributable to other DSM-5 diagnoses

Question 8

Describe some features of pyromaniacs (diagnostic requirements):

Answer 8

• deliberate/purposeful fire setting more than once
• tension/aroused affect before the act
• fascination/interesting/curiosity/attraction with fire and its contexts (paraphernalia, uses, consequences etc).
• pleasure, gratification, or relief when setting fire or when witnessing, or participating in aftermath
• not done for monetary gain, to conceal a crime, socio-political expression, to express anger/vengeance, to improve living circumstances, in response to hallucination, etc.
• not better accounted for by other disorder (conduct, mania, APD).
• More common in males

Question 9

Describe some features of kleptomaniacs (diagnostic requirements):

Answer 9

• recurrent failure to resist impulses to steal objects that are not needed for personal use or for their monetary sale
• increasing sense of tension immediately before committing the theft
• pleasure, gratification, or relief at the time of committing the theft
• the stealing is not committed to express anger or vengeance and is not in response to a delusion or hallucination
• the stealing is not better accounted for by conduct disorder, mania or APD.
• Gender: 3-1 female-male
• Person is usually law abiding otherwise

Question 10

What are some features of intermittent explosive disorder?

Answer 10

• Recurrent behavioural outbursts
  o Verbal aggression or physical aggression (no injury/damage) twice a week for 3 months
  OR
  o 3 outbursts within a year with damage/injury
• Aggression is out of proportion
• not pre-meditated
• causes marked distress or impairment or financial/legal consequences
• At least 6 years old
• Not better explained by another disorder (conduct, mania, APD)
• Rapid onset of outbursts, which last at least 30 mins
• More common in males

Question 11

Can adults have ADHD too or is it just children? Discuss this idea.

Answer 11

• up to 70% of children/adolescents with ADHD will have symptoms into adulthood.
• 20-64 years olds have shown 4.4% prevalence
• can go unmanaged into adulthood
• some evidence that it can onset in adulthood but need some symptoms before 12 to diagnose.
• 85% of people with ADHD have comorbid disorders so diagnosis is hard
• symptoms don’t differ into adulthood, just impact age appropriate things (work failure or injury, driving problems, relationship failure, risky sexual behaviour etc).