244 - 6E66 Secondary impulse control syndrome

6E66 Secondary impulse control syndrome

Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders Boundary with dissociative symptoms that are precipitated by the stress of being diagnosed with a medical condition The stress of a medical diagnosis can precipitate dissociative symptoms (e.g. depersonalization, derealization). Depending on the nature of the medical condition (e.g. a life-threatening type of cancer, a potentially fatal infection) or its onset (e.g. a heart attack, a stroke, a severe injury), being diagnosed and/or having to cope with a severe medical condition can be experienced as a traumatic event, which may trigger dissociative symptoms. In the absence of evidence of a physiological link between the medical condition and the dissociative symptoms, a diagnosis of secondary dissociative syndrome is not warranted. Instead, the appropriate mental disorder can be diagnosed (e.g. adjustment disorder, depersonalization-derealization disorder). Potentially explanatory medical conditions (examples) Brain disorders and general medical conditions that have been shown to be capable of producing dissociative syndromes include: • diseases of the nervous system (e.g. encephalitis, migraine, seizures, stroke); • endocrine, nutritional or metabolic diseases (e.g. hyperglycaemia); • injury, poisoning or certain other consequences of external causes (e.g. intracranial injury); • neoplasms (e.g. neoplasms of brain). Secondary impulse control syndrome Essential (required) features • The presence of prominent symptoms that are characteristic of impulse control disorders or disorders due to addictive behaviours (e.g. stealing, fire setting, aggressive outbursts, compulsive sexual behaviour, excessive gambling) is required for diagnosis. • The symptoms are judged to be the direct pathophysiological consequence of a medical condition, based on evidence from history, physical examination or laboratory findings. This judgement depends on establishing the following. • The medical condition is known to be capable of producing the symptoms. • The course of the symptoms (e.g. onset, remission, response to treatment of the etiological medical condition) is consistent with causation by the medical condition. • The symptoms are not better accounted for by delirium, dementia, another mental disorder (e.g. an impulse control disorder or a disorder due to addictive behaviours), or the effects of a medication or substance, including withdrawal effects. • The symptoms are sufficiently severe to be a specific focus of clinical attention. 6E66 Secondary mental or behavioural syndromes associated with disorders and diseases classified elsewhere

669 Secondary mental or behavioural syndromes associated with disorders and diseases classified elsewhere Boundaries with other disorders and conditions (differential diagnosis) Boundary with primary impulse control disorder or disorders due to addictive behaviours Determining whether disturbances of impulse control are due to medical conditions classified elsewhere or are manifestations of an impulse control disorder or a disorder due to addictive behaviours is often difficult because the clinical presentations may be similar. Establishing the presence of a potentially explanatory medical condition that can cause disturbances of impulse control and the temporal relationship between the medical condition and the disturbances of impulse control is critical in diagnosing secondary impulse control syndrome. Compared to impulse control disorders or disorders due to addictive behaviours, secondary impulse control syndrome is more likely to be associated with atypical clinical features, such as a later age of onset or the presence of disturbances of impulse control in individuals who generally exhibit low levels of disinhibition or negative emotionality. Boundary with delirium and dementia Disturbances of impulse control or addictive behaviour can occur in the context of delirium or dementia. Secondary impulse control syndrome is characterized by disturbances of impulse control or addictive behaviours (e.g. aggressive outbursts, compulsive sexual behaviour) occurring in the absence of severe cognitive impairment. In contrast, delirium is characterized by fluctuating levels of consciousness and autonomic disturbances, while dementia is characterized by severe memory impairment as well as impairments in other domains of cognitive functioning. Disturbances of impulse control or addictive behaviour in the context of dementia may be recorded using one of the behavioural or psychological disturbances in dementia specifiers (e.g. agitation or aggression in dementia, disinhibition in dementia), if applicable. If the symptoms are judged to be due to the same medical condition as is causing the dementia, an additional diagnosis of secondary impulse control syndrome is not warranted. Boundary with secondary personality change Disturbances of impulse control or addictive behaviour can occur as part of secondary personality change. If the disturbances of impulse control are accompanied by other features of personality disturbance that are also judged to be due to a medical condition classified elsewhere, a diagnosis of secondary personality change should be assigned instead. Boundary with disturbances of impulse control or addictive behaviour caused by substances or medications, including withdrawal effects When establishing a diagnosis of secondary impulse control syndrome, it is important to rule out the possibility that a medication or substance is causing the symptoms instead of – or in addition to – an underlying medical condition. This involves first considering whether any of the medications being used to treat the medical condition are known to cause disturbances of impulse control or addictive behaviour at the dose and duration at which it has been administered (e.g. dopamine agonists such as pramipexole for Parkinson disease or restless legs syndrome). Second, a temporal relationship between the medication use and the onset of the symptoms should be established (i.e. the symptoms began after administration of the medication and/or remitted once the medication was discontinued). The same reasoning applies to individuals with a medical condition and disturbances of impulse control who are also using a psychoactive substance known to cause disturbances of impulse control or addictive behaviour, in the Secondary mental or behavioural syndromes associated with disorders and diseases classified elsewhere