Impulse Control Disorders

Question 1

Where in the brain do impulses originate from?

Answer 1

hypothalamus

midbrain

Question 2

Anatomically, the (blank) seems to be a driving force and the (blank) seem to be inhibitory

Answer 2

amygdala; orbitofrontal and prefrontal cortices

Question 3

Where do impulses project to?

Answer 3

prefrontal cortex

orbital frontal cortex

Question 4

What are bottom-up drives for? Where do they come from?

Answer 4

signal/trigger;

amygdala, insula

Question 5

What are top-down brakes for? Where do they come from?

Answer 5

suppression/regulation;

orbital frontal cortex, anterior cingulate gyrus

Question 6

This form of dementia causes impulse control problems

Answer 6

frontotemporal dementia

Question 7

What kind of neuromodulators contribute to poor impulse control?

Answer 7

low 5HT

enhanced dopamine

Question 8

What can we use to increase 5HT to treat impulsivity probs?

Answer 8

SSRIs

Question 9

What can we use to decrease dopamine to treat impulsivity probs?

Answer 9

anti-psychcotics (D2 antagonists)

Question 10

Low levels of this metabolite correlated with more violent aggression, loss of impulse control, greater risk taking, and more physical wounds

Answer 10

5HT

Question 11

Low serotonin is associated with low (blank) and higher (blank)

Answer 11

social rank; dysfunctional aggression

Question 12

Response to a perceived threat or provocation

Answer 12

reactive aggression

Question 13

What causes reactive aggression?

Answer 13

lower threshold to perceived provocation or lower threshold to respond aggressively

**associated with more impulsivity

Question 14

Behavior that anticipates reward

Answer 14

proactive aggression

Question 15

What things can cause proactive aggression?

Answer 15

attention, esteem of peers
money, drugs
more positive outcome expectancies of aggression

Question 16

Describe the 5HT levels in most murderers? In suicide victims? In murders that involve sex crime?

Answer 16

normal in most murderers; low in suicide; very low 5HT in murders in sex crimes

Question 17

Dopamine agonists

Answer 17

Requip (ropinirole)

Mirapex (pramipexole)

Question 18

What are some conditions that arise in people put on dopamine agonists ?

Answer 18

pathological gambling
hypersexuality

**more dopamine, more aggression

Question 19

Using the “gas” and “brake” analogy for impulse control, dopamine is the (blank), and 5HT is the (blank)

Answer 19

gas; brakes

Question 20

Recurrent verbal or physical aggression (outbursts of aggression)
-grossly out of proportion to provocation
Not premeditated
No tangible objective (no clear reason for aggression)

Answer 20

Intermittent explosive disorder

Question 21

Patients with intermittent explosive disorder, frequently report (blank) following the outburst

Answer 21

graying out or memory lapse

Question 22

T/F: Intermittent episodes of aggression lead to potential for increasing med doses and irrational polypharmacy

Answer 22

true

Question 23

What are some disorders that might be in your differential if your patient has intermittent episodes?

Answer 23

bipolar disorder
major depression
panic disorder
PTSD (high emotional arousal)
conduct disorder
antisocial personality disorder
borderline personality disorder

Question 24

Which type of aggression is most consistent with intermittent explosive disorder?

Answer 24

reactive aggression

Question 25

Failure to resist an impulse, drive, or temptation to perform an act that is harmful to the person or to others

Answer 25

kleptomanis (stealing) and pyromania (fire setting)

Question 26

What do pts feel before acting impulsively? During the act? After the act?

Answer 26

building tension/arousal; pleasure, relief, gratification, relief from the urge, may not feel regret or guilt **this is the cycle these pts feel

Question 27

Deliberate fire setting on multiple occasions Fascination about fire Tension/relief cycle No real motive, but to feel relief Rare - Only 3% of those jailed for setting fires

Answer 27

pyromania

Question 28

Failure to resist impulses to steal **Not desired for value or use Tension/relief cycle Aware that act is wrong/ senseless

Answer 28

kleptomania

Question 29

In kleptomania, are patients aware that the act is wrong/senseless? How do they feel about their actions? More common in males and females?

Answer 29

yes; they feel depressed and anxious about their actions; more common in females!

Question 30

What is one example of kleptomania?

Answer 30

stealing salt and pepper shakers from a restaurant **something useless, no financial incentive

Question 31

What can you use to treat impulse control disorders?

Answer 31

Propranolol (Inderal) **well studied antiaggression med SSRIs (fluoxetine, sertraline, citalopram, escitalopram, paroxetine) - increase 5HT Carbamazepine Clozapine - antipsychotic (decrease D2)

Question 32

Can benzos be used for impulse control disorders?

Answer 32

not a good idea, can cause paradoxical disinhibition (angry drunk) **inhibit the inhibitory factors...

Question 33

So what happens when you give a benzo for impulse problems?

Answer 33

significant increase in impulsivity and aggression

Question 34

Good med for recurrent impulsive violence?

Answer 34

propranolol