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Block 8 Week 6 Rhonda > Impulse Control - Zuchowski > Flashcards

Impulse Control - Zuchowski Flashcards

1
Q

what are the impulse control disorders?

A 
Intermittent Explosive Disorder
Kleptomania
Pyromania
Trichotillomania
Pathological Gambling
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2
Q

what areas of the brain are involved in impulse control?

A

prefrontal cortex

orbitofrontal cortex

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3
Q

You have top down (drive/brakes) and bottom up (drive/brakes)

A

top down brakes

bottom up drive

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4
Q

What are the modulations that can happen at the sensory processing stage?

A
  1. sensory distortions (drugs, alcohol, metabolic disturbance)
  2. Sensory deficits (hearing, vision, etc)
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5
Q

What are the modulations that can occur at the early information processing stage?

A
  1. culturual/social factors (perception of agression)

2. cognitive impairment (paranoid ideation, conspiracy theories)

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6
Q

which brain structures control the bottom up drive?

A

AMYGDALA
insula
hypothalamus
midbrain

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7
Q

Which brain structures control the top down brakes?

A

ORBITOFRONTAL CORTEX
PREFRONTAL CORTEX
anterior cingulate gyrus

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8
Q

TBI to what area of the brain can lead to impulse control problems?

A

left temporal lobe

will see a CT

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9
Q

T/F: epidural and chronic subdural hematomas can lead to impulse control issues

A

true

will see a CT

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10
Q

What type of dementia is associated with an early onset of explosive behavior, sexual aggression, and generally being a shit head?

A

Fronto-temporal dementia

will see an MRI; look for CORTICAL ATROPHY

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11
Q

What do you see in vascular dementia or MS that may cause impulse control issues?

A

Mutiple white matter lesions (aka plaques). This is consistent with a brain that has suffered lots of little insults to the white matter and has small vessel disease
HOWEVER, the MRI itself is not enough to Dx, a normal 80 y/o can have an MRI like this.

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12
Q

which lobe of the brain is most affected in AD?

A

parietal lobe

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13
Q

Describe the levels of serotonin and dopamine in impulse control and aggression?

A

low serotonin

high dopamine an NE

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14
Q

Serotonin, DA, and NE go to what areas of the brain?

A

Cortical structures

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15
Q

what are some of the reasons for decreased S and increased DA/NE transmission in the cortex?

A

cortical lesion (trauma or tumor)
decreased cortical volume (developmental)
orbitofrontal/cingulate cortex processing insufficiency

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16
Q

Describe the levels of GABA, glutamate, and ACh in impulse control and behavior issues?

A

reduced GABA

increased GLU and ACh

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17
Q

Where in the brain do GABA, GLU, and ACh target?

A

Limbic system

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18
Q

What are some reasons that the limbic system may have neurotransmitter imbalance?

A

hyperactivity of amygdala and limbic system
reduced amydala volume
emotional hypersensitivity
kindling

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19
Q

what area of the brain lights up when we see angry faces? Angrys scenes?

A

Faces: amygdala
Scenes: amygdala with projections to the cortex

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20
Q

What is the goal of Tx in limiting aggressive behavior?

A

First: increase serotonin

USE AN SSRI ONLY; CANNOT USE SNRI LIKE WELLBUTRIN

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21
Q

What can we give to someone who is overly aggressive from excess DA?

A

D2 blockers like antipsychotics

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22
Q

T/F: marijuana can lead to an increase in aggression

A

true; any drug that is taken at “abuse” levels that increases DA can lead to aggression

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23
Q

What are the correlations with low CSF serotonin metabolites?

A

More violent forms of aggression
Loss of impulse control
Greater risk taking
More physical wounds

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24
Q

Low serotonin is associated with reactive or proactive aggression?

A

REACTIVE aggression

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25
Q

Describe the “thresholds” that play into reactive aggression

A

Lower threshold to perceive provocation and/or

Lower threshold to respond aggressively

26
Q

What are the reasons for proactive aggression?

A

Attention, esteem of peers
Money, drugs
More “positive outcome expectancies” of aggression

27
Q

Describe the serotonin level with regard to murder in context of sex crime

A

very low

28
Q

Describe the serotonin level with regard to suicide

A

low

29
Q

Describe the serotonin level with regard to most murders

A

NORMAL serotonin

30
Q

where in the brain is there less S signaling in people with intermittent explosive disorder?

A

anterior cingulate cortex

also sig. fewer PLT serotonin binding sites

31
Q

What are the DA agonists used to treat PD and restless leg?

A

Requip

Mirapex

32
Q

What are some interesting SE of treating PD with a dopamine agonist?

A

impulse control problems:
Hypersexuality, Hyperphagia
Pathological gambling, Compulsive shopping

33
Q

T/F: PD itself is the cause of increased risk of impulse control problems

A

false, the Tx

34
Q

Which neurotransmitter is the gas and which is the brake?

A

DA is the gas

S is the brake

35
Q

What is the hallmark of intermittent explosive d/o?

A

recurrent verbal/physical aggression GROSSLY OUT OF PROPORTION TO PROVOCATION

  • not premeditated
  • no tangible objective
36
Q

the intermitent nature of the explosive d/o leads to what two issues when Rx’ing?

A

escalating med doses

irrational polypharmacy

37
Q

what type of seizure can be mistaken for explosive d/o?

A

temporal lobe seizure

38
Q

What is on your DDx for intermittent episodes of aggression?

A 
Bipolar disorder
Major depression
Panic disorder
PTSD
ADHD
Conduct disorder
Antisocial personality disorder
Borderline personality disorder
39
Q

Is proactive or reactive aggression most consistent with explosive d/o?

A

reactive

40
Q

Describe the impulse and resistance cycle of klepto and pyromania?

A 
pt feels an impulse
they resist
they have building tension
they can resist anymore
they act and they get tension and anxiety relief
41
Q

What are the criteria for pyromania?

A

Deliberate fire setting on multiple occasions
Fascination about fire
Tension/relief cycle

42
Q

People that steal or set fires do so why?)

A

NO CLEAR MOTIVE
THEY STEAL USELESS THINGS
(look for answer with no real value like salt and pepper shakers)
or set fires to reduce anxiety
(not to gain money or “cleanse the demons”)–they literally do it JUST BECAUSE

43
Q

t/f: kleptos are aware that what they do is wrong

A

true; also feel depressed and anxious about their actions

44
Q

What percent of shoplifters are kleptos?

A

25%

45
Q

what is the gender ratio of klepto?

A

female: male
3: 1

46
Q

If first onset of Sx is over 40, what do you need to rule out?

A 
medical causes 
(infx, structural, metabolic, etc)
47
Q

What are the things you should do during your initial assessment of impulse control?

A

rule out medical Dx
look for rational reason for behavior
help ID triggers
AVOID INTOXICATION

48
Q

Which SSRIs are your firstline for impulse control/aggression?

A 
Fluoxetine - Prozac
Sertraline - Zoloft
Citalopram - Celexa
Escitalopram - Lexapro
Paroxetine - Paxil
49
Q

What must you be careful of in the initial use of SSRIs?

A

possible increase in agitation and SI

50
Q

What are the non-SSRI level I treatment for impulse control?

A

Carbamazepine - Tegretol
Clozapine - Clozaril
Propanolol - Inderal

51
Q

Clozapine - Clozaril has what other positive effect?

A

anti-suicide effect

52
Q

which level I Tx has a 1-2% risk of agranulocytosis?

A

Clozapine - Clozaril

53
Q

Which drug do you use in TBI for impulse control?

A

Propanolol - Inderal

54
Q

what drugs are firstline for may shrinks but don’t have evidence?

A

Valproic Acid - Depakene

Divalproex - Depakote

55
Q

What drug is a seroternergic anxiolytic that can be used for impulse control?

A

Buspirone - Buspar

56
Q

What drug is an opiate antagonist that can be used for impulse control?

A

Naltrexone - vivitrol/Revia

CAN CAUSE ACUTE WITHDRAWAL SO BE CAREFUL

57
Q

What are the atypical antipsychotics you can use for impulse control?

A

Olanzapine - zyprexa
risperidone - risperidal
quetiapine - seroquel
ziprasidone - geodon

58
Q

Describe the angry drunk paradox when giving benzos?

A

Benzos are good for ACUTE management of agitation
but they will disinhibit the person before actually sedating them, so they get more agitated before they get better.
Answer; GIVE MORE BENZOS, then they fall asleep

59
Q

Despite lowering perceived anxiety and hostility, what do benzos do to impulsivity?

A

SIG. increases in impulsivity and aggression

poor Hx of poor impulse control predictive of disinhibitory response

60
Q

T/F: the vast majority of fire setters and assaultive people have intermitten explosive d/0

A

FALSE; they have ordinary motives! (power, revenge, money, etc)

61
Q

what is the only setting in which you should give benzos?

A

the ER

Block 8 Week 6 Rhonda (12 decks)

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