Impulse Control Disorders Flashcards
Where in the brain do impulses originate from?
hypothalamus
midbrain
Anatomically, the (blank) seems to be a driving force and the (blank) seem to be inhibitory
amygdala; orbitofrontal and prefrontal cortices
Where do impulses project to?
prefrontal cortex
orbital frontal cortex
What are bottom-up drives for? Where do they come from?
signal/trigger;
amygdala, insula
What are top-down brakes for? Where do they come from?
suppression/regulation;
orbital frontal cortex, anterior cingulate gyrus
This form of dementia causes impulse control problems
frontotemporal dementia
What kind of neuromodulators contribute to poor impulse control?
low 5HT
enhanced dopamine
What can we use to increase 5HT to treat impulsivity probs?
SSRIs
What can we use to decrease dopamine to treat impulsivity probs?
anti-psychcotics (D2 antagonists)
Low levels of this metabolite correlated with more violent aggression, loss of impulse control, greater risk taking, and more physical wounds
5HT
Low serotonin is associated with low (blank) and higher (blank)
social rank; dysfunctional aggression
Response to a perceived threat or provocation
reactive aggression
What causes reactive aggression?
lower threshold to perceived provocation or lower threshold to respond aggressively
**associated with more impulsivity
Behavior that anticipates reward
proactive aggression
What things can cause proactive aggression?
attention, esteem of peers
money, drugs
more positive outcome expectancies of aggression
Describe the 5HT levels in most murderers? In suicide victims? In murders that involve sex crime?
normal in most murderers; low in suicide; very low 5HT in murders in sex crimes
Dopamine agonists
Requip (ropinirole)
Mirapex (pramipexole)
What are some conditions that arise in people put on dopamine agonists ?
pathological gambling
hypersexuality
**more dopamine, more aggression
Using the “gas” and “brake” analogy for impulse control, dopamine is the (blank), and 5HT is the (blank)
gas; brakes
Recurrent verbal or physical aggression (outbursts of aggression)
-grossly out of proportion to provocation
Not premeditated
No tangible objective (no clear reason for aggression)
Intermittent explosive disorder
Patients with intermittent explosive disorder, frequently report (blank) following the outburst
graying out or memory lapse
T/F: Intermittent episodes of aggression lead to potential for increasing med doses and irrational polypharmacy
true
What are some disorders that might be in your differential if your patient has intermittent episodes?
bipolar disorder major depression panic disorder PTSD (high emotional arousal) conduct disorder antisocial personality disorder borderline personality disorder
Which type of aggression is most consistent with intermittent explosive disorder?
reactive aggression
Failure to resist an impulse, drive, or temptation to perform an act that is harmful to the person or to others
kleptomanis (stealing) and pyromania (fire setting)
What do pts feel before acting impulsively? During the act? After the act?
building tension/arousal; pleasure, relief, gratification, relief from the urge, may not feel regret or guilt
**this is the cycle these pts feel
Deliberate fire setting on multiple occasions
Fascination about fire
Tension/relief cycle
No real motive, but to feel relief
Rare - Only 3% of those jailed for setting fires
pyromania
Failure to resist impulses to steal
**Not desired for value or use
Tension/relief cycle
Aware that act is wrong/ senseless
kleptomania
In kleptomania, are patients aware that the act is wrong/senseless? How do they feel about their actions? More common in males and females?
yes; they feel depressed and anxious about their actions; more common in females!
What is one example of kleptomania?
stealing salt and pepper shakers from a restaurant
**something useless, no financial incentive
What can you use to treat impulse control disorders?
Propranolol (Inderal) **well studied antiaggression med
SSRIs (fluoxetine, sertraline, citalopram, escitalopram, paroxetine) - increase 5HT
Carbamazepine
Clozapine - antipsychotic (decrease D2)
Can benzos be used for impulse control disorders?
not a good idea, can cause paradoxical disinhibition (angry drunk)
**inhibit the inhibitory factors…
So what happens when you give a benzo for impulse problems?
significant increase in impulsivity and aggression
Good med for recurrent impulsive violence?
propranolol
