Impulse Control Disorders-Zuchowski Flashcards
What are the 5 Impulse Control Disorders?
- Intermittent Explosive Disorder
- Kleptomania
- Pyromania
mpulses such as hunger originate in the (blank)
This impulse can be put off, but its drive will increase with time.
satiety center of the hypothalamus
Impulses to fear and reactions to anger occur in the (blank). If you see anger being physically manifested how does this affect your amygdala?
amygdala
even more so!! (i.e seeing an angry face doesnt light up your amygdala as much as seeing an angry person grabbing someone)
The (blank) structure such as the hypothalamus is the main region where impulses arise. These impulses are then modulated by specific areas of the (blank, blank and blank) typically resulting in (blank).
mid brain structure
cortex; the prefrontal cortex and the orbital frontal cortex
processing and suppression
The mid brain structure such as the hypothalamus is the main region where impulses arise. These impulses are then modulated by specific areas of the cortex; the prefrontal cortex and the orbital frontal cortex. When it gets here, what happens to the impulse?
information is sent for cognitive appraisal where the impulse can either be stopped or driven.
Sensory processing can be affected by many factors such as ….?
sensory deficits or distortions, cultural/social factors and level of cognition or cognitive impairment.
(blank) function in the suppression and regulation of impulse (acts as the breaks)
The Orbital Frontal (and anterior cingulate gyrus)
The (blank and blank) are the “bottom up” signals and work to drive the impulse.
amygdala and insula
What are brain disorders with secondary impulse control problems?
a. Trauma to the frontal lobes
b. Presence of epidural hematomas
c. Dementia’s, particularly Frontal Temporal Dementia
d. Vascular dementia can also show signs of impulse control dysregulation depending on what areas are affected.
T or F
Levels of neuromodulators effect impulse control
T
Low (blank) and enhanced (blank) are associated with poor impulse control and aggressive behavior.
serotonin dopamine (and norepinephrine)
Low serotonin and enhanced dopamine (and norepinephrine) are associated with poor impulse control and aggressive behaviors. These neuromodulators have their effects primarily on the (blank) brain circuitry and abnormal levels of these neuromodulators are associated with conditions such as (blank……)
cortical
- cortical lesion (trauma, tumor),
- decreased cortical volume
- orbitalfrontal/cingulate cortex processing inefficiency
(blank) GABA, (blank) glutamate and (blank) acetylcholine are also associated with poor impulse control
These neurotransmitters have their effects primarily on the (blank) and can cause what?
Reduced
enhanced
enhanced
limbic system
- hyperactivity of the amygdala and limbic system
- reduced amaygdalar volume
- emotional hypersensitivity
- kindling
Low CSF serotonin levels are correlated with what?
- more violent forms of aggression
- loss of impulse control
- greater risk taking
- more physical wounds
(blank) is associated with low social rank, and higher dysfunctional aggression
Low serotonin
“appropriate” aggression used to maintain social dominance was not associated with (blank) in monkeys
low serotonin levels
What is reactive aggression?
What happens if you have poor impulse control?
What is an example of this?
response to a perceived threat or provocation
-lower threshold to perceive provocation and/or lower threshold to repond aggressively
PTSD
What is proactive aggression?
Is it associated with poor impulse control?
a behavior that anticipates reward such as attention, esteem of peers, money and drugs and is associated with a thought process that aggression will result with a “positive outcome” i.e bullying
It is not associated with impulse control.
If you commit a murder in the context of a sex crime, what are your serotonin levels like?
What about a murderer without a sex crime?
What about for people who commit suicide?
Very low serotonin
Normal serotonin
Low serotonin
What are serotonin levels like in patients with intermittent explosive disorder?
less serotonergic innervation in the anterior cingulate cortex AND pnts have fewer platelet serotonin binding sites
What do physiological disorders do you use dopamine agonists for and what are some dopamine agonists?
Parkinsons and restless leg syndrome
Ropinirole (requip) and Pramipexole (mirapex)
Research has shown that certain impulse control problems can result from the use of dopamine agonists, what are these?
How did we figure this out?
- hypersexuality
- hyperphagia
- pathological gambling
- compulsive shopping
We compared parkinsons patients behavior on dopamine agonists with parkinsons patients not on dopamine.
(PD itself does not appear to increase risk of impulse control problems)
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) Dopamine is the gas, serotonin the brake
What is this:
-Recurrent verbal or physical aggression
(grossly out of proportion to provocation)
-Not premeditated
-No tangible objective
-Intermittency leads to potential for escalating meds doses and/or irrational polypharmacy
-Patients frequently report memory lapse or a “graying out” during outburst
Intermittent Explosive Disorder
What is the differential diagnosis of 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) Reactive aggression
What are the essential featuers of kleptomania and pyromania?
How do kleptomaniacs and pyromaniacs feel before they commit the act?
- Failure to resist an impulse, drive, or temptation to perform an act that is harmful to the person or to others
- The individual feels an increasing sense of tension or arousal
How do kleptomaniacs and pyromaniacs feel at the time of commiting the act?
How do they feel after the act?
- the individual experience pleasure, gratification, or relief
- the individual experiences a sense of relief from the urge, the individual may or may not feel regret, self-reproach, or guilt
What is this:
Deliberate fire setting on multiple occasions
Fascination about fire
Tension/relief cycle
Is it common?
pyromania
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) Stealing salt and pepper shakers from restaurants
What is this:
- failure to resist impulses to steal
- not desired for value or use
- tension/relief cycle
- aware that act is wrong/senseless
Kleptomania
What is this:
- patients are aware that act is wrong/senseless
- feel depressed and anxious about actions
- rare in general population but up to 25% of shoplifters
Who is it more common in?
Kleptomania
More common in females (3:1)
WHen do you typically see the first onet of symptoms for impulse control disorders? What must your rule out? What should you identify and what should you advise these individuals to avoid?
age 40
general medical cause (infectious, structural, metabolic, hormonal) or a rational motive for behavior
- triggers
- avoid intoxication
Midbrain (amygdala and insula) and deeper brain structures (Blank) impulses and the cortex and anterior cingulate gyrus (blank) impulses
drive
suppress
What would be good drugs to lessen aggregration induced by impulsivity?
SSRIs cuz they can increase serotonin or anytipsychotics cuz they are D2 antagonists
What seizure disorder is mistaken for impulse control disorder?
temporal lobe seizure
Do we like benzos? Why not? when can you use them?
HOw do you overcome the disinhibition paradoxical effect?
no, cuz they can cause paradoxical inhibition due to a time lag and their ability to inhibit the inhibitiory centers of the brain leading to excitation.
- for acute management of agitation in ER setting
- Give them more IV benzos and they will fall asleep
When people with impulse control disorder take benzos how do they subjectively think they feel? what do other people see?
decreased PERCEIVED anxiety and hostility
-significant increase in impulsivity and aggression were observed
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) beta blocker like propranolol
What are the three types of CBT for klepto/pyromania?
- Covert sensitization
- Aversion therapy
- Systematic desensitization
What is this an example of:
picture stealing or setting a fire and then facing negative consequences, such as getting caught
covert sensitization
What is this an example of:
practice mildly painful techniques, such as breath holding until uncomfortable, when having urge to steal
Aversion therapy
What is this an example of:
using relaxation techniques while picturing CONTROLLING urges to steal
systematic desensitization
Anatomically, the (blank) seems to be a driving force and the (blank) and (blank) seem to be inhibitory
amygdala
orbital frontal
prefrontal cortices
Impulsivity itself is (blank)
non-specific
T or F
Vast majority of shoplifters, fire setters and assaultive people will have “ordinary” motives
AND not have disorders
T
T or F
Except in acute management (ER or inpatient setting) avoid benzodiazepines
T
