report

1. 1
Mental Health Consultation
Patient Name: Disinhibition Facility: XXXX
Date: X-XX-XX (The under-recognized common cold of the nursing homes)
Additional history can be found elsewhere in this chart and will not be repeated here.
Reasonfor Referral: XX-year-old, white, xxxx, male… I was asked to evaluate him because of
a reported “inability to control his temper…at his last xxxx home he became angry at a
particular visitor frightening the other residents… he is not welcome to return there if his
underlying mental health issue is not brought under control”. He was admitted from the XXXX
on X-XX-XX where he was treated for xxxx.
Background Information: There was no detailed stroke history or neuroimaging available in
his record.
Current Medications: ASA, Clonazepam 0.5mg bid, Lexapro 20mg qd, Prevacid, Senokot.
Medical History: Old CVA with left hemiparesis, history of left hip fracture and pulmonary
embolism, Anxiety State, Depressive Disorder.
Mental Status Exam: He was a tall, slim, cooperative, somewhat restless, gentleman who
would become irritable but could be quickly talked down. He had left-sided hemiparesis and
could open and close his left hand with great effort. His speech was dysarthric due to left-sided
facial flattening but otherwise coherent and relevant. His affect was alternately flat versus labile.
He admitted to “getting frustrated very easily… I lose my patience quickly”. He was quick to
tear when speaking about his xxxx. He was quite interested when I explained emotional
disinhibition to him. There were no signs of psychosis or delirium. He was oriented to person,
place and time. His insight and judgment were marginal.
Findings and Recommendations: Although there is no neuroimaging nor any stroke history
available in his record, his clinical presentation points strongly towards a right middle cerebral
artery (MCA) stroke. The right middle cerebral artery supplies the right frontal lobe and part of
the temporal lobe. A large infarction in this area of the cortex could produce symptoms such as:
apathy and/or depression, anxiety and agitation, emotional and/or behavioral disinhibition,
reduced verbal output, psychomotor slowing and in some cases even paranoia and persecutory
delusions.
Disinhibition syndrome caused by cerebral impairment is a disorder of expression of emotion not
a disorder of emotion. Emotional outbursts are triggered by a trivial event and do not reflect
genuine feelings of distress (anger/depression) despite appearances. Disinhibition or emotional
incontinence is usually seen in connection with frontal systems dysfunction. Patients with
disinhibition are unable to modulate the expression of emotion; are impulsive; socially
inappropriate; show poor social judgment and display rapidly shifting moods and irritability. It is
this stroke related deficit which is responsible for Mr. Xxxx’s angry outbursts towards the
visitor, as well as, his apparent irritability and episodes of crying.

2. 2
Emotions are generated by the limbic system and kept in check by the prefrontal cortex.
An impaired pre-frontal cortex = Disinhibition
Unmodulated expression of emotion
There is no way to guarantee that he will not have an outbursts again in the future. In fact, it is
highly likely that he will. What follows are a few approaches which can moderate disinhibition
or which could be helpful with the situation at the xxxx home:
1. Medications including SSRIs such as Lexapro can help to reduce disinhibition. He is
currently taking the maximum dose of Lexapro. If in the future his disinhibition becomes
severe, the effects of Lexapro could be augmented by adding a low dose of Abilify (2 mg
qd).
2. A patient can gain some control over disinhibition by visualizing an event with the
opposite emotional content when he feels himself being overwhelmed by a particular
emotion. For example, if she appears to feel rage (actually triggered by slight frustration)
she could use visualization to picture the last time she purchased a brand-new car. She
should avoid visualizing sentimental events and possibly bringing on tears.
3. The best approach in the xxxx home would be for Mr. Xxxx to be away from the home
when the visitor who triggers his anger visits the home.
4. Staff and other residents at the xxxx home should be informed about the nature of
disinhibition so that in future they will not react to his outbursts with fear but respond by
saying the following: “We know that because of your stroke you find it difficult to control
your emotions and you are not really as angry as you seem”.
5. Stability and predictability will limit frustration and emotional outbursts. Establish a
predictable and consistent daily routine for him. Keep him busy with simple tasks but not
excessively stimulated.
6. Create a calm, soothing environment around him, tune the radio to a station with relaxing
elevator music…make the lighting soft and indirect. Keep him away from hectic, chaotic
areas and activities. Speak and move, calmly and slowly when interacting with him.
___________________________
Drew Chenelly, Psy.D.
Clinical Neuropsychologist