Impulse Control - Zuchowski Flashcards
what are the impulse control disorders?
Intermittent Explosive Disorder Kleptomania Pyromania Trichotillomania Pathological Gambling
what areas of the brain are involved in impulse control?
prefrontal cortex
orbitofrontal cortex
You have top down (drive/brakes) and bottom up (drive/brakes)
top down brakes
bottom up drive
What are the modulations that can happen at the sensory processing stage?
- sensory distortions (drugs, alcohol, metabolic disturbance)
- Sensory deficits (hearing, vision, etc)
What are the modulations that can occur at the early information processing stage?
- culturual/social factors (perception of agression)
2. cognitive impairment (paranoid ideation, conspiracy theories)
which brain structures control the bottom up drive?
AMYGDALA
insula
hypothalamus
midbrain
Which brain structures control the top down brakes?
ORBITOFRONTAL CORTEX
PREFRONTAL CORTEX
anterior cingulate gyrus
TBI to what area of the brain can lead to impulse control problems?
left temporal lobe
will see a CT
T/F: epidural and chronic subdural hematomas can lead to impulse control issues
true
will see a CT
What type of dementia is associated with an early onset of explosive behavior, sexual aggression, and generally being a shit head?
Fronto-temporal dementia
will see an MRI; look for CORTICAL ATROPHY
What do you see in vascular dementia or MS that may cause impulse control issues?
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.
which lobe of the brain is most affected in AD?
parietal lobe
Describe the levels of serotonin and dopamine in impulse control and aggression?
low serotonin
high dopamine an NE
Serotonin, DA, and NE go to what areas of the brain?
Cortical structures
what are some of the reasons for decreased S and increased DA/NE transmission in the cortex?
cortical lesion (trauma or tumor)
decreased cortical volume (developmental)
orbitofrontal/cingulate cortex processing insufficiency
Describe the levels of GABA, glutamate, and ACh in impulse control and behavior issues?
reduced GABA
increased GLU and ACh
Where in the brain do GABA, GLU, and ACh target?
Limbic system
What are some reasons that the limbic system may have neurotransmitter imbalance?
hyperactivity of amygdala and limbic system
reduced amydala volume
emotional hypersensitivity
kindling
what area of the brain lights up when we see angry faces? Angrys scenes?
Faces: amygdala
Scenes: amygdala with projections to the cortex
What is the goal of Tx in limiting aggressive behavior?
First: increase serotonin
USE AN SSRI ONLY; CANNOT USE SNRI LIKE WELLBUTRIN
What can we give to someone who is overly aggressive from excess DA?
D2 blockers like antipsychotics
T/F: marijuana can lead to an increase in aggression
true; any drug that is taken at “abuse” levels that increases DA can lead to aggression
What are the correlations with low CSF serotonin metabolites?
More violent forms of aggression
Loss of impulse control
Greater risk taking
More physical wounds
Low serotonin is associated with reactive or proactive aggression?
REACTIVE aggression
Describe the “thresholds” that play into reactive aggression
Lower threshold to perceive provocation and/or
Lower threshold to respond aggressively
What are the reasons for proactive aggression?
Attention, esteem of peers
Money, drugs
More “positive outcome expectancies” of aggression
Describe the serotonin level with regard to murder in context of sex crime
very low
Describe the serotonin level with regard to suicide
low
Describe the serotonin level with regard to most murders
NORMAL serotonin
where in the brain is there less S signaling in people with intermittent explosive disorder?
anterior cingulate cortex
also sig. fewer PLT serotonin binding sites
What are the DA agonists used to treat PD and restless leg?
Requip
Mirapex
What are some interesting SE of treating PD with a dopamine agonist?
impulse control problems:
Hypersexuality, Hyperphagia
Pathological gambling, Compulsive shopping
T/F: PD itself is the cause of increased risk of impulse control problems
false, the Tx
Which neurotransmitter is the gas and which is the brake?
DA is the gas
S is the brake
What is the hallmark of intermittent explosive d/o?
recurrent verbal/physical aggression GROSSLY OUT OF PROPORTION TO PROVOCATION
- not premeditated
- no tangible objective
the intermitent nature of the explosive d/o leads to what two issues when Rx’ing?
escalating med doses
irrational polypharmacy
what type of seizure can be mistaken for explosive d/o?
temporal lobe seizure
What is on your DDx for intermittent episodes of aggression?
Bipolar disorder Major depression Panic disorder PTSD ADHD Conduct disorder Antisocial personality disorder Borderline personality disorder
Is proactive or reactive aggression most consistent with explosive d/o?
reactive
Describe the impulse and resistance cycle of klepto and pyromania?
pt feels an impulse they resist they have building tension they can resist anymore they act and they get tension and anxiety relief
What are the criteria for pyromania?
Deliberate fire setting on multiple occasions
Fascination about fire
Tension/relief cycle
People that steal or set fires do so why?)
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
t/f: kleptos are aware that what they do is wrong
true; also feel depressed and anxious about their actions
What percent of shoplifters are kleptos?
25%
what is the gender ratio of klepto?
female: male
3: 1
If first onset of Sx is over 40, what do you need to rule out?
medical causes (infx, structural, metabolic, etc)
What are the things you should do during your initial assessment of impulse control?
rule out medical Dx
look for rational reason for behavior
help ID triggers
AVOID INTOXICATION
Which SSRIs are your firstline for impulse control/aggression?
Fluoxetine - Prozac Sertraline - Zoloft Citalopram - Celexa Escitalopram - Lexapro Paroxetine - Paxil
What must you be careful of in the initial use of SSRIs?
possible increase in agitation and SI
What are the non-SSRI level I treatment for impulse control?
Carbamazepine - Tegretol
Clozapine - Clozaril
Propanolol - Inderal
Clozapine - Clozaril has what other positive effect?
anti-suicide effect
which level I Tx has a 1-2% risk of agranulocytosis?
Clozapine - Clozaril
Which drug do you use in TBI for impulse control?
Propanolol - Inderal
what drugs are firstline for may shrinks but don’t have evidence?
Valproic Acid - Depakene
Divalproex - Depakote
What drug is a seroternergic anxiolytic that can be used for impulse control?
Buspirone - Buspar
What drug is an opiate antagonist that can be used for impulse control?
Naltrexone - vivitrol/Revia
CAN CAUSE ACUTE WITHDRAWAL SO BE CAREFUL
What are the atypical antipsychotics you can use for impulse control?
Olanzapine - zyprexa
risperidone - risperidal
quetiapine - seroquel
ziprasidone - geodon
Describe the angry drunk paradox when giving benzos?
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
Despite lowering perceived anxiety and hostility, what do benzos do to impulsivity?
SIG. increases in impulsivity and aggression
poor Hx of poor impulse control predictive of disinhibitory response
T/F: the vast majority of fire setters and assaultive people have intermitten explosive d/0
FALSE; they have ordinary motives! (power, revenge, money, etc)
what is the only setting in which you should give benzos?
the ER
