Impulse Control Disorders-Zuchowski Flashcards
Which disorders include the symptom of impulsivity?
ADHD Tourette's/OCD Developmental Disorders PTSD Substance Use Diosrder Cluster B Personality Diosrders Bipolar Spectrum **Impulse Control Disorders
Which impulse control disorders are included in DSMV?
Intermittent Explosive Disorder
Kleptomania
Pyromania
Which 2 impulse control disorders were excluded from DSMIV-V transition?
trichotillomania–now OCD-like categorization
Pathological gambling–now substance like addition
Where does hunger originate from?
satiety center in hypothalamus
fMRI would show which part of the brain light up when you see anger?
amygdala in the medial temporal lobe
Describe the pathway for stimuli-impulses–regulation.
orbitofrontal cortex: stimulus perceived
TO prefrontal cortex OR hypothalamus/midbrain
cyclic communication
Describe in a different way the pathway of stimulus-response.
stimulus/challenge (provocative)
sensory processing: hearing/vision loss, sensory distortions (drugs)
early info processing/cognitive appraisal: cultural social factors, paranoid ideation etc.
TOP DOWN BRAKES: suppression/regulation
BOTTOM UP DRIVES: signal, trigger
Which parts of the brain are involved in top down brakes? bottom up drive?
top down brakes: orbital frontal cortex, anterior cingulate gyrus
bottom up drive: amygdala, insula
What are some MRI-revealed reasons for impulsivity?
frontal lobe damage-debris, epidural hematoma, subdural hematoma
cortical atrophy-vascular dementia, Alzheimer’s
Which NT would dominate in a patient with higher impulsivity, higher aggression? Cortical system?
reduced serotonin
enhanced dopamine, NE
IN THE CORTICAL SYSTEM
Which NT would dominate in a patient with higher impulsivity, higher aggression? Limbic system
reduced GABA
enhanced glutamate
enhanced acetylcholine
Which meds would you theoretically use to correct a low serotonin or a high dopamine ?
low serotonin–SSRIs
high dopamine–antipsychotics
If you have low CSF serotonin what is this correlated with?
More violent forms of aggression
Loss of impulse control
Greater risk taking
More physical wounds
What are the social links w/ low serotonin?
Low serotonin = low social rank, higher dysfunctional aggression
T/F Appropriate” aggression used to maintain social dominance associated w/ low serotonin levels.
False.
What is reactive aggression?
– response to a perceived threat or provocation
Lower threshold to perceive provocation and/or
Lower threshold to respond aggressively
**you’re looking at me funny-i’m gonna cut you
What is proactive aggression?
Proactive aggression – behavior that anticipates a reward
Attention, esteem of peers
Money, drugs
More “positive outcome expectancies” of aggression
**i want to go out & kill someone for money or fun.
What are the serotonin levels for murderers, suicide, murder in context of sex crime?
murder w/ sex crime: very low serotonin
suicide: low serotonin
most murderers: normal serotonin
Which anatomic/NT things were found in patients with intermittent explosive disorder?
less serotoninergic innervation in anterior cingulate cortex
fewer platelet serotonin binding sites
What is a possible aggravator for hypersexuality, hyperphagia, pathologic gambling, compulsive shopping?
dopamine agonists
** used in Parkinson’s & RLS
Ex: Ropinirole & pramipexole
patients w/ PD on dopamine agonists had aggravation of these characteristics
Using the “gas” and “brake” analogy for impulse control, which statement is most accurate?
A) Dopamine is the brake, serotonin the gas
B) GABA is the gas, serotonin the brake
C) Dopamine is the gas, glutamate is the brake
D) Dopamine is the gas, serotonin the brake
D.
What is intermittent explosive disorder?
Recurrent verbal or physical aggression
-grossly out of proportion to provocation
Not premeditated
No tangible objective
Patients frequently report memory lapse or a “graying out” during outburst
What is a risk with the intermittency of intermittent explosive disorder?
escalating med doses or irrational polypharmacy tempting.
What is the differential for intermittent episodes?
Bipolar disorder Major depression Panic disorder PTSD ADHD Conduct disorder Antisocial personality disorder Borderline personality disorder
Which type of aggression is most consistent with intermittent explosive disorder? A) Reactive aggression B) Proactive aggression C) Both D) Neither
A
What are the core features of kleptomania & pyromania?
failure to resist an impulse, drive, or temptation to perform an act that is harmful to another person
What happens before, during, and after the act for a person with kleptomania or pyromania?
before: individual feels an increasing sense of tension or arousal
during: individual experiences pleasure, gratification, or relief
after: a sense of relief from the urge; may or may not feel regret, self reproach or guilt
What is pyromania?
Deliberate fire setting on multiple occasions
Fascination about fire
Tension/relief cycle
Rare - Only 3% of those jailed for setting fires
A man says he has kleptomania. Which of the following is most consistent with that dx?
A) Stealing money
B) Stealing drugs from a dealer
C) Purse snatching
D) Stealing salt and pepper shakers from restaurants
D
What is kleptomania?
Failure to resist impulses to steal
Not desired for value or use
Tension/relief cycle
Aware that act is wrong/ senseless
Patients are aware that act is wrong/ senseless
Feel depressed and anxious about actions
Rare in general population but up to 25% of shoplifters
More common in females (3:1)
Woman has been arrested repeatedly for arson. consistent with what motive? revenge against ex husband arson for profit to relieve anxiety to cleanse a home from demons
to relieve anxiety
What is involved in the initial assessment of impulse control disorders?
First onset of symptoms over age 40 – must carefully rule out a general medical cause (e.g. infectious, structural, metabolic, hormonal).
Look for rational alternative motive for behavior (but remember that human motivation is often complex)
Try to help identify triggers for behavior
Strongly advise to avoid intoxication
Level 1 evidence-randomized & controlled trials
proven treatment for impulse control disorders?
SSRIs: just watch out for increase in agitation & suicidal ideation at the beginning
Carbamezepine
Clozapine: antisuicide, watch out for agranulocytosis
propranolol
What are some Level III treatments for impulse control disorders?
valproic acid 1st line divalproex 1st line buspirone: serotonergic anxiolytic naltrexone: opiate antagonist atypical antipsychotics: olanzapine risperidoen quetiapine ziprasidone
Should you use benzos for impulse control disorders?
NO
sedating GABA promoting
sometimes good for agitation
but paradoxical disinhibition: angry drunk syndrome possible
could inhibit the inhibitory centers of the brain!
Can benzos be helpful in agitated ER patients w/ IV access?
yes, can increase dose for inhibition
A woman presents with recurrent impulsive violence following a traumatic brain injury. Which of the following is the best first line treatment? A) Antipsychotic like haloperidol B) Benzodiazepine like alprazolam C) Antidepressant like bupropion D) Beta blocker like propranolol
D. Level 1
but NOT C b/c not an SSRI & not first line & could increase agitation
Which anatomy regions are the gas & brake?
Gas: amygdala
Brake: orbital frontal & prefrontal cortex
Which NTs are the gas & brake?
Gas: dopamine
Brake: Serotonin, GABA
When a patient has symptom onset after age 40…what should you do?
look for a general medical cause
T/FVast majority of shoplifters, fire setters and assaultive people will have “ordinary” motives
True.
T/F Except in acute management (ER or inpatient setting) avoid benzodiazepines
True.
