Impulse Control - Zuchowski Flashcards by Rhonda Mittenzwei

what are the impulse control disorders?

Intermittent Explosive Disorder
Kleptomania
Pyromania
Trichotillomania
Pathological Gambling

How well did you know this?

Not at all

Perfectly

what areas of the brain are involved in impulse control?

prefrontal cortex

orbitofrontal cortex

How well did you know this?

Not at all

Perfectly

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

top down brakes

bottom up drive

How well did you know this?

Not at all

Perfectly

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

sensory distortions (drugs, alcohol, metabolic disturbance)
Sensory deficits (hearing, vision, etc)

How well did you know this?

Not at all

Perfectly

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)

How well did you know this?

Not at all

Perfectly

which brain structures control the bottom up drive?

AMYGDALA
insula
hypothalamus
midbrain

How well did you know this?

Not at all

Perfectly

Which brain structures control the top down brakes?

ORBITOFRONTAL CORTEX
PREFRONTAL CORTEX
anterior cingulate gyrus

How well did you know this?

Not at all

Perfectly

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

left temporal lobe

will see a CT

How well did you know this?

Not at all

Perfectly

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

true

will see a CT

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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.

How well did you know this?

Not at all

Perfectly

which lobe of the brain is most affected in AD?

parietal lobe

How well did you know this?

Not at all

Perfectly

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

low serotonin

high dopamine an NE

How well did you know this?

Not at all

Perfectly

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

Cortical structures

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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

reduced GABA

increased GLU and ACh

How well did you know this?

Not at all

Perfectly

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

Limbic system

How well did you know this?

Not at all

Perfectly

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

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

How well did you know this?

Not at all

Perfectly

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

Faces: amygdala
Scenes: amygdala with projections to the cortex

How well did you know this?

Not at all

Perfectly

What is the goal of Tx in limiting aggressive behavior?

First: increase serotonin

USE AN SSRI ONLY; CANNOT USE SNRI LIKE WELLBUTRIN

How well did you know this?

Not at all

Perfectly

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

D2 blockers like antipsychotics

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

What are the correlations with low CSF serotonin metabolites?

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

How well did you know this?

Not at all

Perfectly

Low serotonin is associated with reactive or proactive aggression?

REACTIVE aggression

How well did you know this?

Not at all

Perfectly

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