Impulse Control Disorders-Zuchowski

Question 1

What are the 5 Impulse Control Disorders?

Answer 1

• Intermittent Explosive Disorder
• Kleptomania
• Pyromania

Question 2

mpulses such as hunger originate in the (blank)

This impulse can be put off, but its drive will increase with time.

Answer 2

satiety center of the hypothalamus

Question 3

Impulses to fear and reactions to anger occur in the (blank). If you see anger being physically manifested how does this affect your amygdala?

Answer 3

amygdala

even more so!! (i.e seeing an angry face doesnt light up your amygdala as much as seeing an angry person grabbing someone)

Question 4

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).

Answer 4

mid brain structure

cortex; the prefrontal cortex and the orbital frontal cortex

processing and suppression

Question 5

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?

Answer 5

information is sent for cognitive appraisal where the impulse can either be stopped or driven.

Question 6

Sensory processing can be affected by many factors such as ….?

Answer 6

sensory deficits or distortions, cultural/social factors and level of cognition or cognitive impairment.

Question 7

(blank) function in the suppression and regulation of impulse (acts as the breaks)

Answer 7

The Orbital Frontal (and anterior cingulate gyrus)

Question 8

The (blank and blank) are the “bottom up” signals and work to drive the impulse.

Answer 8

amygdala and insula

Question 9

What are brain disorders with secondary impulse control problems?

Answer 9

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.

Question 10

T or F

Levels of neuromodulators effect impulse control

Answer 10

T

Question 11

Low (blank) and enhanced (blank) are associated with poor impulse control and aggressive behavior.

Answer 11

serotonin
dopamine (and norepinephrine)

Question 12

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……)

Answer 12

cortical

• cortical lesion (trauma, tumor),
• decreased cortical volume
• orbitalfrontal/cingulate cortex processing inefficiency

Question 13

(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?

Answer 13

Reduced
enhanced
enhanced

limbic system

• hyperactivity of the amygdala and limbic system
• reduced amaygdalar volume
• emotional hypersensitivity
• kindling

Question 14

Low CSF serotonin levels are correlated with what?

Answer 14

• more violent forms of aggression
• loss of impulse control
• greater risk taking
• more physical wounds

Question 15

(blank) is associated with low social rank, and higher dysfunctional aggression

Answer 15

Low serotonin

Question 16

“appropriate” aggression used to maintain social dominance was not associated with (blank) in monkeys

Answer 16

low serotonin levels

Question 17

What is reactive aggression?
What happens if you have poor impulse control?
What is an example of this?

Answer 17

response to a perceived threat or provocation

-lower threshold to perceive provocation and/or lower threshold to repond aggressively

PTSD

Question 18

What is proactive aggression?

Is it associated with poor impulse control?

Answer 18

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.

Question 19

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?

Answer 19

Very low serotonin
Normal serotonin
Low serotonin

Question 20

What are serotonin levels like in patients with intermittent explosive disorder?

Answer 20

less serotonergic innervation in the anterior cingulate cortex AND pnts have fewer platelet serotonin binding sites

Question 21

What do physiological disorders do you use dopamine agonists for and what are some dopamine agonists?

Answer 21

Parkinsons and restless leg syndrome

Ropinirole (requip) and Pramipexole (mirapex)

Question 22

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?

Answer 22

• 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)

Question 23

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

Answer 23

D) Dopamine is the gas, serotonin the brake

Question 24

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

Answer 24

Intermittent Explosive Disorder

Question 25

What is the differential diagnosis of intermittent episodes?

Answer 25

``` Bipolar disorder Major depression Panic disorder PTSD ADHD Conduct disorder Antisocial personality disorder Borderline personality disorder ```

Question 26

``` Which type of aggression is most consistent with intermittent explosive disorder? A) Reactive aggression B) Proactive aggression C) Both D) Neither ```

Answer 26

A) Reactive aggression

Question 27

What are the essential featuers of kleptomania and pyromania? How do kleptomaniacs and pyromaniacs feel before they commit the act?

Answer 27

- 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

Question 28

How do kleptomaniacs and pyromaniacs feel at the time of commiting the act? How do they feel after the act?

Answer 28

- 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

Question 29

What is this: Deliberate fire setting on multiple occasions Fascination about fire Tension/relief cycle Is it common?

Answer 29

pyromania | rare, only 3% of those jailed for setting fires

Question 30

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

Answer 30

D) Stealing salt and pepper shakers from restaurants

Question 31

What is this: - failure to resist impulses to steal - not desired for value or use - tension/relief cycle - aware that act is wrong/senseless

Answer 31

Kleptomania

Question 32

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?

Answer 32

Kleptomania More common in females (3:1)

Question 33

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?

Answer 33

age 40 general medical cause (infectious, structural, metabolic, hormonal) or a rational motive for behavior - triggers - avoid intoxication

Question 34

Midbrain (amygdala and insula) and deeper brain structures (Blank) impulses and the cortex and anterior cingulate gyrus (blank) impulses

Answer 34

drive | suppress

Question 35

What would be good drugs to lessen aggregration induced by impulsivity?

Answer 35

SSRIs cuz they can increase serotonin or anytipsychotics cuz they are D2 antagonists

Question 36

What seizure disorder is mistaken for impulse control disorder?

Answer 36

temporal lobe seizure

Question 37

Do we like benzos? Why not? when can you use them? | HOw do you overcome the disinhibition paradoxical effect?

Answer 37

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

Question 38

When people with impulse control disorder take benzos how do they subjectively think they feel? what do other people see?

Answer 38

decreased PERCEIVED anxiety and hostility | -significant increase in impulsivity and aggression were observed

Question 39

``` 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 ```

Answer 39

D) beta blocker like propranolol

Question 40

What are the three types of CBT for klepto/pyromania?

Answer 40

- Covert sensitization - Aversion therapy - Systematic desensitization

Question 41

What is this an example of: | picture stealing or setting a fire and then facing negative consequences, such as getting caught

Answer 41

covert sensitization

Question 42

What is this an example of: | practice mildly painful techniques, such as breath holding until uncomfortable, when having urge to steal

Answer 42

Aversion therapy

Question 43

What is this an example of: | using relaxation techniques while picturing CONTROLLING urges to steal

Answer 43

systematic desensitization

Question 44

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

Answer 44

amygdala orbital frontal prefrontal cortices

Question 45

Impulsivity itself is (blank)

Answer 45

non-specific

Question 46

T or F Vast majority of shoplifters, fire setters and assaultive people will have “ordinary” motives AND not have disorders

Answer 46

T

Question 47

T or F | Except in acute management (ER or inpatient setting) avoid benzodiazepines

Answer 47

T