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פסיכיאטריה Flashcards

1
Q

Schizophrenia - epidemiology

  • Frequency in general population is … [1]
  • Peak incidence age in men… [2], while in women is…[3]
  • Only…[4] present after the age of…[5]
  • People born in… [6]
  • …[7] socioeconomic levels and …[8] areas have higher tendency
    • This is explained by two hypotheses…[9][10]
  • More frequent in patients with… [11] personality disorder
A
  1. 1%
  2. 15-25
  3. 25-35
    • Late onset is considered after the age of 45
  4. 3-10%
  5. 40
    • Rarely presents before the age 10 and after the age 60
  6. Winter or early spring
  7. Lower
  8. Urbanic
  9. Downward drift hypothesis
  10. Social causation hypothesis
  11. Schizotypal
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2
Q

Schizophrenia - biological factors

  1. Dopamine theory
  2. Serotonin theory
  • Loss of…[3] in the hippocampus
  • Related to increase in…[4]
  • Decreased concentration of…[5] and…[6] receptors in the caudate, hippocampus and the pre-frontal cortex
A
  1. The main one is the dopamine theory
    • Decreased activity in the mesocortical pathway, leads to positive symptoms
    • Increased activity in the mesolimbic pathway, leads to negative symptoms
    • The tuberoinfundibular pathway and the nigrostraital pathway are related only in the way of drugs side effects
  2. Increased serotonin - leads to both negative and positive symptoms
  3. GABAgeric
  4. Glutamate
  5. Nicotinic
  6. Muscarinic
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3
Q

Schizophrenia - genetic factors

  • Risk of…[1] in sick brother
  • Risk of… [2] in child of one sick parent
  • Risk of… [3] in child of two sick parents
  • Risk of…[4] in DZ twin, while there is risk of…[5] in MZ twin
  • According to some studies, …[6] over the age…[7], while making the child is also risk factor for the child to develop schizophrenia
A
  1. 8%
  2. 12%
  3. 40%
  4. 12%
  5. 47%
  6. Father
  7. 60
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4
Q

Schizophrenia - Bleuler’s areas of life

A
  • Described as the 4A’s
    • Affect
    • Ambivalence
    • Association
    • Autism
  • Later, alogia, avolition and anhedonia were added
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5
Q

Schizophrenia - Schnider’s symptoms

A
  • Schnider’s described the characteristics of the hallucinations and the delusions of schizophrenic patients
    • Delusions of control - stealing, implanting, control of thoughts
    • Auditory hallucinations:
      • Own thoughts
      • Speaking to the patients
      • Criticizing the patient’s behavior
    • Somatic hallucinations
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6
Q

Schizophrenia - negative symptoms

A
  • Flat affect
  • Decreased emotional range
  • Cognitive decrease - blocking, low content
  • Decrease in function
  • Anhedonia
  • Apathy
  • Decreased energy
  • Abulia
  • Alogia

It has been shown that males have higher frequency of negative symptoms

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7
Q

Schizophrenia - cognitive symptoms

A
  • Defect in memory, listening and in the ability to preform tasks
  • Defective insight
  • Defective abstract thinking
  • Disorders in concentration, executive function, working memory and episodic memory
  • Considered as the most importnat prognostic factor for later immersion in society
  • Tends to have lower IQ scores than the general population
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8
Q

Schizophrenia - diagnosis (DSM-5)

A
  1. 2 or more of the following, where the one of the first 3 must be present for a significant time of one month:
    • Delusions
    • Hallucinations
    • Disorganized speech
    • Disorganized behavior (catatonic)
    • Negative symptoms
  2. Decrease in function for significant time, since the disease onset
  3. For at least 6 months
  4. No affective disorder
  5. If autism is present - hallucinations or delusion must be present
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9
Q

Schizophrenia - paranoid type

A
  • Abrupts in 20-30 - better prognosis
  • Mainly delusions (grandiosity and presecution) and hallucinations
  • There is lack of the other symptoms
  • No negative symptoms
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10
Q

Schizophrenia - disorganized type

A
  • Before the age of 25 - bad prognosis
  • Characterized by disinhibition and predominant negative symptoms
  • All the 3 need to found: disorganized speech, disorganized behavior, flat affect
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11
Q

Schizophrenia - catatonic type

A
  • At least 3 of the following:
    • Catalepsy, including waxy flexibility
    • Motor action without goal
    • Extreme negativism
    • Wired motor activity
    • Echopraxia or echolalia
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12
Q

Schizophrenia - residual type

A
  • Patients after schizophrenic abruption that are left only with the negative symptoms
  • In this stage there are no characteristics of psychosis
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13
Q

Schizophrenia - undifferentiated type

A
  • Schizophrenic patients that does not fit to any other subtype
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14
Q

Schizophrenia - post-psychotic depression

  • Occurs in…[1] of patients
  • …[2] will try to suicide, and …[3] will commit suicide
  • Criteria …[4]
A
  1. 25%
  2. 50%
  3. 10-13%
  4. 3 conditions:
    • Criteria for MDD
    • Abrupt in the residual phase of schizophrenia
    • Isnt on the background of medications or other organic disease
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15
Q

Schizophrenia - violence risk

  • Risk factors
  • Emergency treatment
  • Treatment
A
  • Higher risk, more common in patients that does not undergoing treatment
    • The most important risk factor is past violent episode
    • Other risk factors: delusion of persecution, neurological deficits
  • Acute treatment: restrication and isolation, sedation with lorazepam 1-2 mg/h
  • Anti-psychotics
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16
Q

Schizophrenia - substance addiction

  • more then…[1] have substance addiction
  • …[2] of the patients are smokers
  • …[3] are addicted to alcohol
  • …[4] consume cannabis
  • …[5] consume cocaine
A
  1. 50%
  2. >90%
    • Decrease AE’s of anti-psychotics
    • Decrease positive symptoms
    • Improves functioning
  3. 30-50%
  4. 15-25%
  5. 5-10%
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17
Q

Schizophrenia - physical co-morbidity

  • Life-expectancy is…[1] then the general population
  • Co-morbidities include…[2-6]
  • Other psychiatric co-morbidities include…[7-9]
  • Schizophrenia is found to protective against…[10], with the rate of about…[11] less then the general population
A
  1. Shorter
  2. Obesity
  3. T2DM
  4. CVD
  5. COPD
  6. HIV
    • x1.5-2.0 higher than the general population
  7. Prevasive developmental disorder (PDD)
  8. Schizoaffective
  9. MDD
  10. Rheumatoid arthritis
  11. 33%
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18
Q

Schizophrenia - prognosis

  • …[1] will be re-admitted within 2 years of the first admission
  • Within 5-10 years from the first admission only…[2] get prolonged remission
  • …[3] get remission
  • …[4] have normal lifestyle
  • …[5] have intermidate strength symptoms
  • …[6] have significant functional damage for the rest of their life
  • …[7] of the patients have bad prognosis
A
  1. 40-60%
  2. 10-20%
  3. 10-60%
  4. 20-30%
  5. 20-30%
  6. 40-60%
  7. >50%
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19
Q
A
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20
Q

Schizophrenia - suicide risk

  • The…[1] cause of death in schizophrenic patients
  • …[2] try to commit suicide, while…[3] succeed
  • Patients with…[4] prognosis have higher risk
  • The most significant risk factor is…[5], which is experienced by…[6] of the patients in any point during their life
  • Additional risk factors include…[7-9]
A
  1. Leading
  2. 50%
  3. 10-13%
  4. Good
  5. Depressive episode
  6. 80%
  7. Young age (although it is found in the bad prognosis criteria)
  8. Substance abuse
  9. Delusions
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21
Q

Schizophrenia - pharmacologic treatment

  • Drugs…[1]
  • Injections are given when…[2]
  • …[3] will get full remission
  • After psychosis, antipsychotic medications decrease the relapse rate from…[4] to…[5]
  • Maximal effect within… [6]
  • If there is no effect after…[7], …[8]
A
  1. Atypicals are the first option - risperidone or olanzapine
    • If typicals are given, perphenazine is given
  2. There is lack of compliance or in acute stage
  3. 60-70%
  4. 50-70%
  5. 15-25%
  6. 6-8 weeks
  7. 4 weeks
  8. Increase the dose or change of clozapine
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22
Q

Schizophrenia - psychosocial treatment

!!!!!!להוסיף מנקודות

A
  • Social skills - improve relations, eye contact, spontanic interactions, understanding of social interactions
  • Family treatment
  • CBT - found beneficial for supressing delusions and hallucinations
  • Psychotherapy
  • Rehabilitation
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23
Q

Schizophrenia - adjuvant therapy

A
  • Lithium - decrease psychotic signs
  • Anti-epileptics - decrease violent episodes
  • Benzodiazepines
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24
Q

Schizophreniform disorder - diagnosis (DSM-5)

A
  • Criteria A (signs), D (rule-out affective disorder) and E of schizophrenia
  • Less then 6 monthes, but more then 1 month
  • Specificy with or without good prognosis (good prognosis if 2 or more are present)
    • Acute onest (psychoitc feats. within 4 weeks of change of behavior or function)
    • Confusion in the time of psychosis
    • High function before onset
    • No flat affect
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25
Schizophreniform disorder - prognosis * ...[1] will turn to schizophrenia patients * Higher frequency of...[2]
1. 60-80% 2. Post-psychotic depression
26
Schizophreniform disorder - treatment 1. Drugs 2. Recurrent episodes 3. Catatonic symptoms or prominent depression 4. Psychothrapy
1. Antipsychotics for 3-6 months 2. Mood stabilizers - lithium, carbamazepine, valproic acid 3. Consider ECT
27
Schizoaffective disorder - epidemiology * Lifetime prevalance of...[1] * More common in...[2] gender * Age of onset in females is...[3] * Males tend to show more...[4] signs and...[5] * In the bipolar type gender division is...[6] males, and...[7] females * In the depressive type gender division is...[8] males, and...[9] females * Can have delusion or hallucinations that are... or...[10] * Important to diagnose periods of...[11] of more then...[12] * ...[13] gene is associated with both schizoaffective disorder and...[14] disorder
1. 0.5-0.8% 2. Female 3. Later 4. Anti-social 5. Flat affect 6. 50% 7. 50% 8. 33% 9. 66% 10. Mood congurent or mood incongruent 11. Delusions or hallucinations 12. 2 weeks 13. DISC1 14. Bipolar
28
Schizoaffective disorder - diagnosis (DSM-5)
* During the disease period - depressive episode/manic episode/mixed episode together with criteria A of schizophrenia * At least two weeks of only delusions/hallucinations * Affective symptoms are present in most of the time of the disease period * Rule out drugs or general medical condition
29
Schizoaffective disorder - treatment * Drugs * In manic episode * Refractory mania * Depressive episode
* Mood stabilizer, sometimes with combination of antipsychotics * Increase the dose of mood stablizers * Consider ECT * SSRI's Carbamazepine is more efficient than lithium in the bipolar subtype
30
Schizoaffetive disorder - prognosis * Better prognosis than...[1] patients * Worse prognosis than...[2] patients * Multiple...[3] signs are bad prognostic indicators
1. Schizophrenia 2. Mood disorder 3. Schizophrenic
31
Delusional disorder - epidemiology * Prevalance of...[1] * Avarage abruption age of...[2], and more common in...[3] * More common in...[4] socioeconomic state * During the years, less then...[5] will diagnosed with schizophrenia, and less then...[6] will be diagnoised with mood disorder
1. 0.2-0.3% 2. 40 3. Females 4. Low 5. 25% 6. 10%
32
Delusional disorder - risk factors * ...[1] age * ...[2] that can be physical, sensory or social * ...[3] * ...[4] socioeconomic state
1. Old 2. Isolation 3. Family history 4. Low
33
Delusional disorder - diagnosis (DSM-5)
* Delusions for at least a month * Doesnt fulfill criteria A for schizophrenia * No functional decrease, except the consequences of the delusional thoughts * If there were affective states with the delusions, their length was short in relation to the delusions * No drugs or other GMC Sepcify the delusion kind
34
Delusional disorder - prognosis * ...[1] recover, ...[2] get better, ...[3] with no change * Good prognosis when starts at...[4] age * Good prognostic indicators include: * ...[5] pre-morbid condition * ...[6] gender * ...[7] onset * Onset before the age of...[8] * ...[9] duration * ...[10], ...[11] and...[12] delusions
1. 50% 2. 20% 3. 30% 4. Young 5. Good 6. Female 7. Acute 8. 30 9. Short 10. Erotomanic 11. Persecution 12. Somatic
35
Delusional disorder - treatment * Treatment of choice * If there is no change within...[2], ...[3] * Failure of treatment, consider...[4] or...[5] * Psychotherapy
1. Antipsychotics with gradually increased dose 2. 6 weeks 3. Change to other antipsychotic 4. Mood stabilizers 5. Anti-depressents
36
Brief psychotic disorder - definition and epidemiology * Definition * More common in...[2] age, ...[3] * ...[4] countries * ...[5] socioeconomic states
1. Psychotic episode that lasts less then month and more then a day, and after which, there is full recovery and return to the premorbid function 2. Young 3. Females 4. Developing 5. Low
37
Brief psychotic disorder - diagnosis (DSM-5)
* At least one of: * Delusions * Hallucinations * Disorganized speech * Disorganized behavior * One day - one month, will full return to premorbid function * Cannot be explained by other organic of psychiatric conditions Specify if there is a stressor: brief reactive psychosis/no stressor/postpartum
38
Brief psychotic diorder - prognosis * ...[1] without major psychiatric disorders thoughout life * About...[2] will develop chronic psychiatric disease
1. 50-80% 2. 50% לפי נקודות: לרוב לא יהיו מחלות פסיכיאטריות לאחר אירוע אחד
39
Brief psychotic disorder - treatment * Drugs * Psychotherapy
* High potency antipsychotics (haloperidol) in low doses and benzodiazepines
40
Post partum psychosis * ...[1] for each 1000 deliveries * In...[2] - the first child * ...[3] had nonpsychiatric perinatal complications * More then...[4] have family of mood disorder * Symptoms have to appear...[5] after delivery * Treatment of choice [6]
1. 1/2 2. 50% 3. 50% 4. 50% 5. 4 months 6. Anti-depressents and lithium, sometimes in combination with antipsychotics
41
Catatonia - epidemiology * ...[1] related to mood disorders * ...[2] associated with schizophrenia * Specifiers
1. 25-50% (בסבב ולדימיר אמר יותר מחמישים אחוז) 2. 10% 3. 3 types: * Associated with another mental disorder * Due to another medical condition * Unspecified
42
Catatonia - diagnosis (DSM-5)
* At least 3 of the above: 1. Catalepsy 2. Waxy flexibility 3. Stupor 4. Agitation 5. Mutism 6. Posturing 7. Mannerism 8. Negativism 9. Stereotypies 10. Grimcing 11. Echolalia 12. Echopraxia 13. Rigidity (not sure!)
43
Catatonia - treatment * Treatment in...[1] * Important to take care of...[2] * Options for treatment include: * ...[3] are used, ...[4] is the gold standard * ...[5] can also be used * ...[6] can also be used
1. Hospitalization 2. Feeding and hydration. IV or NG tube can be used 3. Benzodiazepines 4. Lorazepam 5. Diazepam 6. ECT
44
Affective disorders - biologic etiology * Norepinephrine...[1] * Serotonin...[2] * Dopamine...[3] * Endocrine: * In...[4] of MDD patients there is pathologic...[5] and * ...[6] function disorders * Decreased...[7] * Disturbance in...[8] * Decreased....[9] and...[10]
1. Decreased levels are associated with depression 2. The most associated neurotransmitter - decreased levels 3. High levels of dopamine and in mania and low levels in depression 4. 50% 5. Dexamethasone supression test 6. Thyroid 7. Growth hormone 8. Melatonin 9. Sex hormones 10. Prolactin
45
Affective disorders - genetic factors * Child to a parent with mood disorder have...[1] risk to develop affective disorder * If there are 2 parents...[2] risk * MZ correlation...[3] * DZ from the same sex correlation...[4] * For depression: * Have...[5] times risk if there is depressed relative of first degree * ...[6] MZ correspondence * For bipolar disorder: * For first degree relative have...[7] times risk for an affective disorder * To...[8] of bipolar I patients have at least one parent with affective disorder * MZ correspondece is...[9]
1. 10-25% 2. 20-50% 3. 70-90% 4. 10-35% 5. 2-10 6. 50% 7. 8-18 8. 50% 9. 33-90%
46
MDD - epidemiology * Life time prevalance is...[1] * ...[2] times more common in...[3] * Avarage abruption age is...[4] * ...[5] of the patinets have their first episode before the age of...[6] * More common in...[7] * Is not related to...[8]
1. 17% 2. Twice 3. Females 4. 40 5. 50% 6. 40 7. Singles, separated or widowed 8. Socioeconomic levels
47
MDD - diagnosis (DSM-5)
1. At least 5/9, in which 1 or 2 must be present. All the symptoms must be present for at least 2 weeks: 1. Depressed mood, most of the day 2. Anhedonia 3. Change in apetite 4. Sleep disturbances 5. Psychomotor retardation 6. Loss of energy 7. Guilt 8. Decrease in concentration 9. Suicidal ideation 2. The symptoms cause significant distress or decrease in function 3. Rule out substance abuse or GMC 4. Isnt explained better with other psychiartic disorders 5. Rule out manic or hypomanic episode in the past
48
MDD - clinical features * 50% of the patients will...[1] * 97% report...[2] * 90% show signs of...[3] * 50% report...[4] * As the disease progresses, patients tend to have...[5] episodes with...[6] duration * ...[7] consider suicide, while...[8] try to suicide
1. Deny their symptoms 2. Loss of energy 3. Anxiety 4. Diurnal variation 5. More frequent 6. Longer 7. 66% 8. 10-15%
49
MDD - co-morbidity * ...[1-4] are the most frequent co-morbidities * The highest rate of associated co-morbidity is...[5], with rate of about...[6] * ...[7] is more frequent with males that have affective disorder * ...[8] are more frequent with females that have affective disorder * MDD in males is associated with...[9-12] * MDD in females is associated with...[13-16]
1. Alcoholism 2. OCD 3. Social anxiety disorder 4. Panic disorder 5. Anxiety disorder 6. 90% 7. Substance abuse 8. Eating disorders and anxiety 9. ADHD 10. Anxiety disorders 11. Alcohol dependence 12. Dysthymia 13. Schizophrenia 14. Other psychotic disorders 15. Bipolar disorder 16. Unipolar disorder
50
MDD - specifiers
* With: 1. Anxious distress 2. Psychotic features 3. Melancholic features 4. Atypical features 5. Mood congruent psychotic feats. 6. Mood incongruent psychotic feats. 7. Catatonia 8. Peripartum onset 9. Seasonal pattern
51
MDD - melancholic specifier
* Lack of mood reactivity with at least 3: 1. Depressed mood 2. Worse in the morning 3. Agitation 4. Early awakening (2h before) 5. Decreased weight 6. Severe feeling of guilt
52
MDD - atypical specifier
* Mood reactivity with at least 2 of the following: 1. Increased appetite 2. Hypersomnia 3. Leaden paralysis 4. Year long pattern of social anxiety * These patients tend to be: * Younger at onset * Severe psychomotor disturbance * Higher co-morbidity with anxiety disorders, substance abuse, dependency and somatization
53
MDD - treatment _Mild-moderate MDD_ * Start with...[1] for...[2] weeks * Partial response - augmentation with...[3-5] * No response - we need to...[6] to...[7,8] * Treatment failure is considered as lack of response after...[9] of adequate dosage * Anti-depressents effect starts within...[10] * For psychotic depression the treatment is...[11] * For atypical depression...[12] or...[13] can be given * SSRI's can be given if pregnancy with the exception of...[14] * Of the acute phase, maintenance treatment for at least...[15] is given
1. SSRI 2. 3-4 3. Lithium 4. Thyroid hormones 5. Buproprion 6. Change the drug 7. Another SSRI 8. SNRI 9. 4 weeks 10. 2-4 weeks 11. Anti-psychotic and anti-depressent 12. SSRI 13. Buproprion 14. Paroxetine 15. 6 months
54
MDD - prognosis * ...[1] will have chronic depression (2 years) * ...[2] with initial diagnosis of MDD will develop manic episode within...[3] after. The avarage age for switch is...[4] * After first episode the recurrence risk is...[5] within 6 months, while in the first 2 years is...[6], and in the next 5 years is...[7] * For...[8] will have response to therapy, from which...[9] will have total remission. * ...[10] will not have any response to therapy * During 20 years the avarage number of depressive episodes is...[11] * Duration of un-treated episode is...[12] * After first admission only...[13] will heal * The risk for complete resolution...[14] with further admissions * Stopping the drug within...[15] of its initiation, almost always leads to relapse
1. 5-10% 2. 5-10% 3. 6-10 years 4. 32 5. 25% 6. 30-50% 7. 50-75% 8. 70% 9. 30% 10. 30% 11. 5-6 12. 6-13 months 13. 50% 14. Decreases 15. 3 months
55
Bipolar disorders - epidemiology * In...[1] of population * Avarage onset age is...[2] * Gender predominance is...[3], and manic episodes are more frequent in...[4] * More common in...[5] * More common in...[6] socioeconomic state
1. 1% 2. 30 3. Equal 4. Males 5. Singles, divorced 6. High
56
Manic episode - diagnosis (DSM-5)
1. Period of abnormaly elevated mood with goal direct activity that is found for at least 1 week, for most of the day, almost everyday (or requires hospitalization) 2. In the same week at least 3/7 1. Distractibility 2. Insomnia 3. Grandiosity 4. Flight of ideas 5. Activity increase 6. Pressured speech 7. Thoughtlessness (activity that have high risk or give a lot of pleasure) 3. Significant functional disfunction 4. Rule out substance abuse or GMC
57
Bipolar I disorder - clinical features * The disease tends to start with...[1] episodes * In...[2] of the females, and in...[3] of the males * Until the first manic episode there will be about...[4] depressive episodes * Only...[5] experience only manic episodes * Manic episode tends to start...[6] and last for...[7] * If untreated it can last up tp...[8] * As the disease progresses the remission...[9] * After 5 manic episodes the remission period stabilses on...[10] * During his life, patient will have about...[11] manic episodes * In relation to MDD there is higher rate of co-morbidity with...[12] and...[13] * Higher rate of...[14] then in psychotic disorders
1. Depressive 2. 70% 3. 67% 4. 2-4 5. 10-20% 6. Rapidly 7. Weeks 8. 3 months 9. Shortens 10. 6-9 months 11. 9 12. Substance abuse 13. Anxiety 14. Catatonia
58
Bipolar I disorder - rapid cycling
* More common in females * Associated with hypothyrodisim * At least 4 episodes of mania, hypomania, depression or mixed within one year * Between each episode there is at least 2 months of remission or one episode immediately changes to another
59
Bipolar I disorder - treatment 1. Acute mania 2. Depressive episode 3. Prophylaxis 4. Rapid cycling patients
1. Antipsychotics (new generation) and mood stabilizers * Lithium, carbamazepine, valproate, clonazepam, antipsychotics 2. Anti-depressive drug, and due to risk for manic switch there is a need to add mood stabilizer * Olanzapine + fluoxetine is effient combination that does not lead to manic switch * For resistant patients - lamotrigine or ziprasedone 3. 3 options: * Lithium * Valproic acid * Cabamazepine * Lamotrigine is more efficient in treatment and prevention of depressive episodes 4. Positive outcomes with buproprion or nimodipine
60
Biploar I disorder - prognosis * ...[1] prognosis then MDD patients * ...[2] there is no recurrence of the disease * ...[3] will have manic episode within 2 years of the first episode * ...[4] will have chronic disease * In the long term * ...[5] are in good state * ...[6] in good state with multiple relapses * ...[7] in partial remission * ...[8] are chornically ill * Only...[9] have good control of the disease with lithium * Bad prognostic indicators include: * ...[10] pre-morbid working status * ...[11] abuse * ...[12] features * ...[13] signs during the episodes * ...[14] signs between the episodes * ...[15] gender
1. Worse 2. 7% 3. 50% 4. 40% 5. 15% 6. 45% 7. 30% 8. 10% 9. 50-60% 10. Bad 11. Alcohol 12. Psychotic 13. Depressive 14. Depressive 15. Male
61
Hypomanic episode - diagnosis (DSM-5)
1. Abnormaly elevated mood with goal direct activity, for at least 4 consecutive days, for most of the day, almost everyday 2. 3/7 symptoms (such as manic episode DIG FAST) 3. Decrease in function in lesser severity 4. Observable by others 5. Not severe enough to cause decrease in fucntion in social/work and does not nessciate hospitalization 6. Rule out substance abuse and GMC
62
Dysthymic disorder - epidemiology * Prevalance is...[1] * Gender prevalance is..[2] and in...[3] status, * ...[4] income * Higher prevalance in patients with first degree relative diagnosed with...[5] * Usually starts in...[6]
1. 5-6% 2. Equal 3. Single 4. Low 5. MDD 6. Childhood/adolescence
63
Dysthymic disorder - diagnosis (DSM-5)
1. Depressed mood for most of the day, indicated by the patient or by other, for at least 2 years 2. Presence while depressed of at least 2: 1. Appetite changes 2. Sleep changes 3. Low energy 4. Low self-esteem 5. Poor concentration 6. Hopelessness 3. During the period, there was no period of more then 2 months without the symptoms 4. No MDD (?) 5. No manic, hypomanic, mixed or cyclothymic disorder 6. Not part of other psychotic disturbance 7. No substance abuse or GMC 8. Distress and decrease in function
64
Dysthymic disorder - progression and prognosis * ...[1] develop symptoms before the age of...[2] * ...[3] will develop MDD * ...[4] will develop bipolar II * Less then...[5] will develop bipolar I * Only...[6] will be in remission one year after the diagnosis * ...[7] will never get full recovery
1. 50% 2. 25 3. 20% 4. 15% 5. 5% 6. 10-15% 7. 25%
65
Cyclothymic disorder - epidemiology * Prevalance is...[1] * Often is comined with...[2] * The ratio of female:male is...[3] * ...[4] is with onset in the ages of...[5] * Often in the patient's family there is a history of...[6] * ...[7] have family with bipolar I disorder
1. 1% 2. Borderline personality disorder 3. 3:2 4. 50-75% 5. 15-25 6. Substance abuse 7. 30%
66
Cyclothymic disorder - diagnosis (DSM-5)
1. Several periods of hypomania and several periods of depression that is not MDD, for at least 2 years 2. No period of more then 2 months without the symptoms 3. No episodes of MDD, mania or mixed 4. Isnt part of other psychiatric disorder 5. No substance abuse or GMC 6. Distress and decrease in function
67
Cyclothymic disorder - progression and prognosis * Symptoms start in...[1] manner, in the age of...[2] * About...[3] will develop MDD, which will lead to diagnosis of bipolar II disorder
1. Progressive 2. Early 20's 3. 33%
68
Cyclothymic disorder - treatment 1. Drugs 2. Psycho-social treatment
1. First line is mood stabilizers. * Anti-depressive treatment should be give carefully, due to the fact that 40-50% of the patients will have manic or hypomanic episodes percipitated by this treatment
69
Anxiety - etiology * Biologic etiology: * Increase in...[1] * Decrease in...[2] and...[3] of sleep * Decreased...[4] levels * Increased activity of...[5] and...[6] neurotransmitters * Increased activity in...[7-9] * Psychoanalytic: * In childhood, fear of...[10,11] * Learning: * Stress or chronic frustration leads to formation of...[12] * Mimicing...[13] * Maladaptive pattern of...[14] * Genetic: * ...[15] that are diagnosed with anxiety disorder have first degree relative with the same diagnosis
1. Autonomic, sympathetic tone 2. REM latency 3. 4th step 4. GABA 5. Serotonin 6. Dopamine 7. Temporal cortex 8. Locus ceruleus 9. Amygdala 10. Loss of loved object 11. Physical injury 12. Conditioned reaction 13. Parents 14. Cognitive thinking 15. 50%
70
Panic disorder - epidemiology * Prevalence of PD...[1], while of panic attacks is...[2] * ...[3] times more common in...[4] gender * Peak of incidence is in the age of...[5] * The anxiety disorder that have the strongest...[6] component * Identified triggers include...[7] and...[8] * 25% have focal slowing in the...[9] lobe * Kids to parents with anxiety disorder have...[10] times higher risk for developing a disorder
1. 1-4% 2. 3-5.6% 3. 2-3 4. Female 5. 25 6. Genetic 7. Divorce 8. Separation 9. Temporal 10. 4-8
71
Panic attack - criteria (DSM-5)
1. Time period of intense fear of restlessnesss, during this time there is at least 4 of the following symptoms, that develop rapidly and reach peak in 10 minutes: 1. Palpitations 2. Sweating 3. Shaking 4. Dyspnea 5. Feelings of choking 6. Chest discomfort 7. Nausea 8. Dizziness 9. Chills or heat sensations 10. Parasthesias 11. Derealization/depersonalization 12. Fear of losing control 13. Fear of dying
72
Panic disorder - diagnosis (DSM-5)
1. Recurrent, unexpected panic attacks 2. At least 1 of the attacks has been followed by at least 1 month of 1 or both of the following: 1. Persistent concern about panic attacks of their consequences 2. Significant maladaptive behavior related to the attacks 3. Not due to substance abuse or GMC 4. Not better explained by other mental disorder
73
Panic disorder - co-morbidities * ...[1] have psychiatric co-morbidity * 33% have...[2], before presentation * 66% experience PA...[3] or...[4], their...[5] diagnosis * 15% have...[6] or...[7] * 2-20% have...[8] * 15-30% have...[9] * 20% have...[10] * Another co-morbidities include...[11-13]
1. 91% 2. MDD 3. During 4. After 5. MDD 6. SAD 7. Social phobia 8. Specific phobia 9. GAD 10. PTSD 11. Ilness anxiety disorder 12. Personality disorder 13. Substance abuse
74
Panic disorder - progression and prognosis * ...[1] and...[2] progression * After treatment: * ...[3] will be without symptoms * ...[4] will have some symptoms * ...[5] will have active symptoms * ...[6] complicates the disease in...[7] * High risk for...[8] * Substance and alcohol abuse in...[9] * Patients may develop...[10] * ...[11] pre-morbid condition and...[12] duration of symptoms indicate good prognosis
1. Chronic 2. Variable 3. 30-40% 4. 50% 5. 10-20% 6. MDD 7. 40-80% 8. Suicide 9. 20-40% 10. Good 11. Short
75
Panic disorder - treatment 1. CBT 2. Drugs * Conservative approach * 2nd line * Treatment failure
1. More efficient in inducing long term remission 2. Paroxetine and alprazolam * Start with SSRI (paroxetine) and if needed also BZD * TCA (impramine/clomipramine) or MAOi * When there is no reaction to one drug family. It is possible to add mood stablizer
76
Agoraphobia - epidemiology * Prevalence of...[1] * About...[2] also have...[3] * Most of the times it is realted to...[4] * Prognosis is better when it is combined with...[5]
1. 0.6-6% 2. 75% 3. Panic disorder 4. Traumatic life event 5. Panic disorder
77
Agoraphobia - diagnosis (DSM-5)
1. Marked fear/anxiety about 2 of the following: 1. Public transportation 2. Open spaces 3. Enclosed spaces 4. Stading in line/being in crowd 5. Being outside of home 2. Fear/avoidance due to the fear that if the patient will develop panic symptoms, there will be no way to escape 3. Agoraphobic situations provoke fear/anxiety 4. Agoraphobic situations are actively avoided 5. more then 6 months 6. Fear/anxiety are out of proportion to the danger imposed 7. Distress or decrease in function 8. If another medical condition is present fear/anxiety/avoidance is clearly excessive 9. Not due to another mental disorder
78
Agoraphobia - treatment * Psychotherapy * Drugs
* Supportive, CBT * 3 options: * Benzodiazepines * SSRI's * TCA's
79
The 5 general features of phobia
1. Anxiety and stress 2. Provoked 3. Ego-dystonic 4. Avoidance 5. Anticipation
80
Specific phobia - epidemiology * Prevalence of...[1] * The most common disorder in...[2] * The 2nd most common disorder in...[3] * In the ages of...[4] the most common phobias are injections, blood, injury, nature * While in the age of...[5] the most common phobias are of situations and cicumstances * It is...[6] more common in...[7] * In...[8] there is co-morbidity with...[9],...[10] and...[11]
1. 10% 2. Females 3. Males 4. 5-9 5. 20's 6. Twice 7. Females 8. 50-80% 9. Depression 10. Anxiety 11. Substance abuse
81
Specific phobia - diagnosis (DSM-5)
1. Marked fear/anxiety aboud specific object/situation 2. Almost always provokes immediate fear/anxiety 3. Phobic object is actively avoided or endured with intesnse fear 4. Fear/anxiety is out or proportion to the actual danger 5. Fear/anxiety/avoidance is at least 6 months 6. Significant distress or decrease in function 7. Not better explained by other mental disorder Specify: type of phobia
82
Specific phobia - treatment * CBT * Psychotherapy * Drugs
* Most effective - systemic desensitization, flooding, intensive exposure * Insight oriented * Benzodiazepines, beta blockers
83
Social anxiety disorder - epidemiology * Also termed social phobia * Prevalence of...[1] * Peak incidence is in...[2] * More common in...[3] * Co-morbidity with other...[4] disorders and also with...[5] disorders * ...[6] of the patients diagnosed with...[7] * Also, co-morbidity with...[8] * There is high association with...[9]
1. 3-13% 2. Teens 3. Females 4. Anxiety 5. Affective 6. 33% 7. MDD 8. Bulemia nervosa 9. Substance abuse
84
Social anxiety disorder - diagnosis (DSM-5)
1. Marked fear/anxiety about 1 or more social situations, in which the individual is exposed to possible scrutiny by others 2. Fear that he/she will act in a way that will be negatively evaluated 3. Social situations almost always provoke fear/anxiety 4. Social situations are avoided 5. Fear/anxiety is out of proportion 6. For 6 months or more 7. Distress or decrease in function 8. Not due to drugs of GMC 9. Not better explained by other mental disorders 10. If other medical condition the fear/anxiety/avoidance is clrealy unrelated or excessive Specify: performance only
85
Social anxiety disorder - treatment 1. Psychotherapy 2. Pharmacotherapy
1. CBT, social skill training 2. First line are SSRI's * Also venlafaxine, BZD's or buspirone * In severe cases - phenelzine (MAOi) * SSRI effect starts later than MDD treatment - within 12-14 weeks * For performance disorders - BB's or short/intermediate BZD's can be given
86
GAD - epidemiology * Prevalence of...[1] * ...[2] more common in...[3] * ...[4] of ...[5] are also effected * Onset is usually in...[6]
1. 5% 2. Twice 3. Females 4. 25% 5. First degree relatives 6. Adolescense/early adulthood
87
GAD - diagnosis (DSM-5)
1. Excessive anxiety and worry occuring at least 6 months abount number of activities 2. The individual finds it difficult to control the worry 3. Anxiety and worry are associated with at least 3 of the following: 1. Restlessnesss 2. Easily fatigued 3. Difficulty concentrating 4. Irritability 5. Muscle tension 6. Sleep disturbances 4. Significant distress or decrease in function 5. Not due to substance or abuse or GMC 6. Not better explained by another mental disorder
88
GAD - co-morbidity * The mental disroder that have the highest rate with other mental disorders, this occurs in...[1] of the patients * Usually...[2],...[3],...[4] or...[5]
1. 50-90% 2. Social phobia 3. Specific phobia 4. Panic disorder 5. Depressive disorder
89
GAD - treatment * Psychotherapy * Drugs
* CBT - insight oriented, and supprotive therapy * Few options: 1. Benzodiazepines - 75% response. 2-6 weeks therapy 2. SSRI - to patinets with comorbid depression (not fluoxetine, because it increases anxiety) * Combine with BZD * 60-80% have relapse in the first year after stopping the therapy 3. Buspirone - more effective in reducing congnitive symptoms 4. SNRI (venlafaxine) - good for patients with insomnia, poor concentration, distress and muscle rigidity
90
Substance induced anxiety disorder - diagnosis (DSM-5)
1. Clinical signs of anxiety or panic attack 2. There is clues from history taking, clinical examination and lab: 1. Symptoms developed during/immediatley after/during posioning/rehab. 2. The drug is known to induce anxiety 3. Rule out another mental etiology: 1. Symptoms appeard before the use of drug 2. Present at least 1 month after stoping the drug 3. Clues of mental disroder that is not related to the drug 4. Is not present only in delirium 5. Significant distress or decrease in function
91
Anxiety disorder due to another medical condition - diagnosis (DSM-5)
1. Clinical signs of anxiety or panic attack 2. There are clues in history/physical examination/lab that the disturbance is directly due to another medical condition 3. Rule out another mental disorder 4. Is not only in the time of delirium 5. Significant distress or decrease in function
92
OCD - epidemiology * ...[1] of the general population * ...[2] gender * The avarage age of onset is...[3] * In males the age is...[4], while in females...[5] * More commmon in...[6], and in...[7] skinned * The...[8] most common frequent disorder
1. 2-3% 2. F=M * In adolescents M\>F 3. 20 4. 19 5. 22 6. Singles 7. White 8. 4th
93
OCD - genetic factors * Is about...[1] of the etiology * Relative of sick person have...[2] of having the disease, which is...[3] times more of the general population
* 40% * 35% * 3-5
94
OCD - clinical features * In more than...[1] of the patients the onset will be...[2] * ...[3] will present after...[4] * The most common obessions [5] * The most common compulsions [6] * Decrease levels of...[7] * Increased levels of...[8] * There is...[9] of the...[10], but with increased metabolism * Also increased metabolism in the...[11] lobes,...[12] and...[13]
1. 50% 2. Sudden 3. 50-70% 4. Stressful life event 5. זיהום, ספק פתולוגי, סומאטי, סימטריה, אגרסיה, מיניות 6. בדיקה, שטיפה, ספירה, צורך לשאול, סימטריה, אגרנות 7. Serotonin (low levels in the CSF) 8. Norepinephrine 9. Atrophy 10. Caudate nucleus 11. Frontal 12. Cyngulum 13. Thalamus
95
OCD - diagnosis (DSM-5)
1. Presence of obsession, compulsions or both: * Obsession defined by both conditions: 1. Recurrent and persistent behaviors that are intrusive and unwated and cause anxiety or distress 2. The patient tries to ignore or supress the behaviors or to neutralize them * Compulsions defined by both conditions: 1. Repetitive acts that the patient feel drive to preform in response to obsession 2. The acts are aimed at preventing/reducing anxiety or distress; however, this behviors are not connected in a realistic way with what designed to prevent 2. These are time consuming or cause distress or decrease function 3. Not due to substance abuse or GMC 4. Is not better explained by another mental disorder * Specifiers: * with good/fair/poor/absent insight/delusional beliefs. * Tic-related
96
OCD - comorbidity * The prevalence of MDD is...[1] * ...[2] show social phobia * ...[3] have tic disorder * Tourette's syndrome...[4] * In schizophrenic patients the prevalence of OCD is...[5]
1. 67% 2. 25% 3. 20-30% 4. 5-7% 5. 12%
97
OCD - prognosis * In more then...[1] appears abruptly, in...[2] it appears after stressor * ...[3] will show significant improvement in symptoms * ...[4] will show some kind of improvment * ...[5] will have chronic condition * Favourable prognostic factors...[6-8] * Poor prognostic factors...[9-16] * ...[17] does not influence the prognosis
1. 50% 2. 50-70% 3. 20-30% 4. 40-50% 5. 20-40% * Favorable factors: 1. Good pre-morbid condition 2. Onset after stressor 3. Episodic symptoms * Poor factors: 1. Obligation to compulsions 2. Childhood onset 3. Bizzare compulsions 4. Hospitalization 5. Concurrent MDD 6. Delusional beliefs 7. Concurrent personality disorder (schizotypal) 8. Overvalued ideas 1. Obessions
98
OCD - adult treatment 1. CBT 2. Pharmacologic * Augmentation 3. ECT
1. Have at least the same effect as pharmacologic treatment, thus, accounts for treatment of choice * Exposure and reaction prevention * Thought stopping 2. Few options: * SSRI's are the first line - given in doses of 3-4 times more then in depression, ant strat to influence with 6-8 weeks * Clomipramine (can also be used as first line) * Augmentation with stabilizers or atypical anti-psychotics in low dose, MAOi's, buspirone, SNRI's * At least 50-70% will respond to medications 3. To fully resistent disease
99
OCD - kid treatment * Pharmacotherapy * First response * Side effects
* Mainly SSRI's * Sertraline - from the age 6 * Fluoxetine - form the age of 7 * Fluvoxamine - from the age of 8 * Citalopram can also be used * The onset of the effect starts from 8-12 weeks * Nausea, agitation, tremor, insomnia, fatiuge
100
BDD - epidemiology * Prevalence of...[1] * More in...[2] gender * Disorder shows at the age...[3] * More common in...[4]
1. 2.4% 2. Female 3. 15-30 4. Singles
101
BDD - clinical features * Etiology appears to be realted to...[1] * The main complaint is...[2] with rate of...[3] * Followed by...[4] and...[5] with...[6] each * Followed by...[7] * ...[8] of the patients will isolte themselves at home * Up to...[9] will try to commit suicide
1. Lack of serotonin 2. Hair 3. 63% 4. Skin 5. Nose 6. 50% 7. Eyes 8. 33% 9. 20%
102
BDD - diagnosis (DSM-5)
1. Preoccupation with precived physical defect, that others cannot notice 2. Repetitive behaviors or mental acts as response to this precived defect 3. Significant distress or decrease in function 4. Not due to eating disorder * Specify: * Good/fair/poor/absent/delusional beliefs * With muscle dysphoria
103
BDD - comorbidity * More then...[1] expreinced episodes of...[2] * ...[3] had anxiety disorder * ...[4] had psychotic disorder
1. 90% 2. MDD 3. 70% 4. 30%
104
BDD - treatment 1. CBT 2. Drugs * Augmentation
1. The most effective therapy 2. Serotonergic products such as SSRI's, or clomipramine (TCA) are helpful in 50% of the time * Augmentation of SSRI with clomipramine, buspirone, lithium, methylphenidate or anti-psychotics
105
Hoarding disorder - epidemiology and characteristics * Prevalence of...[1] * ...[2] gender * More common in...[3] * ...[4] usually causes onset or exacerbation * ...[5] of OCD patients * ...[6] have ADHD * Familial predisposition of...[7] * Ego-...[8] * Treatment is...[9] * Symptoms can be...[10] at onset * Complete remission is...[11] * Characterized by...[12] referral to treatment
1. 2-5% 2. F=M 3. Singles 4. Traumatic life event 5. 30% 6. 20% 7. 80% 8. Syntonic 9. Resistent 10. Fluctuant 11. Rare 12. Late
106
Hoarding disorder - diagnosis (DSM-5)
1. Presistent difficulty in parting of possessions 2. Due to the need to preserve, and distress while discarding 3. Items fill and block the living areas 4. Hoarding cause distress or decrease in function 5. Not due to other medical disease 6. Is not better explained by other mental disorder * Specify: * Good/fair/poor/absent insight/delusional beliefs * With excessive acquisition
107
Trichotillomania - epidemiology * Prevalence of...[1] * More common in...[2] gender * More common in...[3] age * ...[4] chew or swallow their hair * Can be...[5] or...[6] * Good prognosis is associated with...[7] age at onset
1. 1-2% 2. Female 3. Adolescence 4. 35-40% 5. Automatic 6. Focused 7. Young!!
108
Trichotillomania - diagnosis (DSM-5)
1. Recurrent hair pulling or hair loss 2. Recurrent attempts to stop hair pulling 3. Causes distress or imapirment of function 4. No due to other medical condition 5. Is not better explained by other psychiatric disorder
109
Trichotillomania - treatment 1. Psychotherapy 2. Drugs 3. Hypnosis
1. Behavioral therapy 2. Topical steroids, SSRI's which can be augmented with pimozide
110
Excoriation - epidemiology and characteristics * Prevalence of...[1] * Onset is usually at...[2] * More common in...[3] gender * ...[4] have suicidal ideations, while...[5] attempt suicide * Treatment is...[6]
1. 1-5% 2. Adolescence 3. Female 4. 15% 5. 12% 6. Resistent
111
Excoriation - diagnosis (DSM-5)
1. Skin picking resulting in lesions 2. Recurrent attepmts to stop skin picking 3. Symptoms cause distress and impairment in function 4. Not due to substance abuse 5. Not due to other mental disorder
112
PTSD - epidemiology * Life time risk is...[1] * Life time prevalence is...[2] * ...[3] will have sub-clinical symptoms * Females...[4], males...[5] * Most commonly in...[6],...[7], and in...[8] socioeconomic level * ...[9] have at least 2 other mental disorders
1. 9-15% 2. 8% 3. 5-15% 4. 10-12% 5. 5-6% 6. Young adults 7. Singles 8. Low 9. 66%
113
PTSD - diagnosis (DSM-5)
1. Exposure to life theratening situation 1. Directly 2. Witnessing 3. Learning that the event occured to close person 4. Extreme exposure to aversive detalis (work related) 2. At least 1 intrusive symptom: 1. Intrusive distressing memories 2. Recurrent distressing dreams 3. Dissociative reactions (flashbacks) 4. Psychological response when exposed to stimuli 5. Physiological response when exposed to stimuli 3. At least 1 avoidance symptom: 1. To avoid distressing memories 2. To avoid extrenal reminders 4. At least 2 negative alterations in cognitions and mood: 1. Inability to remember important aspect of the event 2. Exaggerated negative beliefs about self/others/world 3. Distorted cognitions about the cause or consequences 4. Negative emotional state 5. Diminished interest 6. Feelings of detachment 7. inability to experience positive symptoms 5. At least 2 alterations in arousal and reactivity: 1. Irritable behavior and angry outbursts 2. Self destructive behavior 3. Hypervigilance 4. Exaggerated stratle response 5. Problems with concentration 6. Sleep disturbances 6. Duration is more then 1 month 7. Significant distress or decrease in function 8. Not due to substance abuse
114
PTSD - psychotherapy
* The main treatment of PTSD * Prolonged exposure - impolsive therapy, systemic desensitization * Stress management -relaxation * EMDR * Group and family therapy * Dynamic psychotherapy
115
PTSD - pharmacologic therapy
* SSRI's - first line. Improve all the kinds of symptoms * Other anti-depressents - buspirone, TCA's, MAOi, trazodone * Mood stabilizers - anti agressive * Anti-psychotics - when there is psychosis or vivid flashbacks * Topiramate - can help to flashbacks * Sleeping pills - not recommended but if needed, not benzo, because they lead to vivid dreams * When benzo's given acutely they increase the risk for PTSD * Low dose anti-cholinergics are more helpful
116
PTSD - prognosis * Without management: * ...[1] will heal completly * ...[2] will have mild symptoms * ...[3] will have intermediate symptoms * ...[4] will have severe symptoms * After one year of therapy,...[5] will heal completly
1. 30% 2. 40% 3. 20% 4. 10% 5. 50%
117
Acute stress disorder - diagnosis (DSM-5)
1. Exposure to life theratening event: 1. Directly 2. Witnessing 3. Learning that the event occured to close person 4. Repeated exposure to aversive detalis (work related) 2. Presence of 9 or more, from any of the following categories: 1. Intrusive symptoms: 1. Intrusive distressing memories 2. Distressing dreams 3. Dissociative reactions (flashbacks) 4. Psycological or physiological reactions in response to stimuli 2. Negative mood 1. Inability to experice positive emotions 3. Dissociative symptoms: 1. Altered sense of the reality of the surrounding/self 2. Inability to remember important aspects of the event 4. Avoidance symptoms: 1. Avoid distressing memories 2. Avoid external reminders 5. Arousal symptoms: 1. Sleep disturbance 2. Irritable behavior 3. Hypervigilance 4. Problems with concentration 5. Exaggereted stratle response 3. Duration between 3 days - 1 month 4. Significant distress or decrease in function 5. Not due to substance abuse, other mental disorder or GMC
118
Adjustment disorders - epidemiology * Prevalence of...[1] * ...[2] more common in...[3] * ...[4] of generally admitted patients, and in...[5] admitted psychiatric patients * Can appear in any age, but most commonly in...[6] * More common in...[7]
1. 2-8% 2. Twice 3. Females 4. 5% 5. 10% 6. Adolescense 7. Singles
119
Adjustment disorders - diagnosis (DSM-5)
1. Development of emotional/behavioral symptoms in response to identifiable stressor occuring within 3 month of its onset 2. Symptoms are clinically significant - at least 1 of the following: 1. Distress that is out of proportion to the stressor 2. Significant impairment in fucntion 3. The disturbance does not meet the criteria for another mental disorder, or exacerbation of preexisting mental disorder 4. Symptoms does not represent normal bereavement 5. Once the stressor is terminated the symptoms do not presist more than additional 6 months * Specify: * With depressed mood * With anxiety * With mixed anxiety and depressed mood * With disturbance of conduct * With mixed disturbance of emotions and conduct * Unspecified
120
Adjustment disorders - treatment * Psychotherapy * Drugs
* The treatment of choice, usually with crisis intervention * Better if can be avoided. * When needed: * Benzo - for anxiety * SSRI - depression * Antipsychotic - if psychosis is expected
121
Reactive attachment disorder - diagnosis (DSM-5)
1. Pattern of inhibited behavior twords adult caregiver, manifested by both: 1. Rarely seeks comfort when distressed 2. Rarely responds to comfort when distressed 2. Social and emotional disturbance manifested by at least 2 of the following: 1. Minimal social and emotional responsiveness 2. Limited positive effect 3. Episodes of unexplained irritability that are evident even during nonthreatening interactions 3. Child has experienced pattern of extreme insufficient care evidanced with at least 1 of the following: 1. Lack of having basic emotional needs 2. Repeated changes of primary caregivers 3. Unusual setting that severely limit opportunities to form stable attachments 4. Criterion C is responsible to criterion A 5. Criteria for autism spectrum disorder is not met 6. Evident before the age of 5 7. Developmental age of at least 9 months
122
Disinhibited social engagement disorder - diagnosis (DSM-5)
1. Child actively interacts with unfamiliar adults and at least 2 of the following: 1. Reduced reticence in interacting with unfamiliar adults 2. Overly familiar behavior 3. Diminished checking back with adult caregiver after venturing away 4. Willingness to go off with unfamiliar adult with minimal hesitation 2. Criterion A is not due to impulsivity 3. Experienced a pattern of extreme insufficient care, evidenced by at least 1 of the following: 1. Lack of having basic emotional needs 2. Repeated changes of primary caregivers 3. Unusual setting that severely limit opportunities to form selective attachments 4. Criterion C is responsible to criterion A 5. Developmental age of at least 9 months
123
Personality disorders - etiology * Genetic factors * Higher frequency in...[1] twins * To cluster A, there is more family history of...[2] * Biologic * Increase in...[3] hormones * Abnormal...[4] test, and...[5] test
1. MZ 2. Schizophrenia 3. Sex 4. Dexamethasone supression 5. TRH release
124
Presonality disorders - general diagnostic criteria (DSM-5)
1. Behavior/internal sensation that deviates from the norm that is accepted in the patient's culture, which is expressed in at least 2 areas: 1. Cognition 2. Affect 3. Personal function 4. Impulse control 2. Persistent pattern, which is not flexible 3. Causes significant distress and decrease in function 4. Prolonged pattern that starts in teen or early adulthood 5. Not due to other psychiartic illness 6. No substance abuse of GMC
125
Paranoid personal disorder * Incidence of...[1] * More common in...[2] gender * High rate in patients who have relatives with...[3] * Common in...[4] and...[5] * Starts in...[6] * Defend mechanism is...[7] * Some have tendency to develop...[8]
1. 2-4% 2. Male 3. Schizophrenia 4. Low SES (immigrants) 5. Deaf people 6. Early adulthood 7. Projection 8. Schizophrenia רעיונות רפרנס, דעות קדומות, defended illusions גזענות, חוסר חום אנושי
126
Schizoid personality disorder * Are not interested in...[1], described as...[2] and have...[3] * Incidence of...[4] * Tend to...[5] jobs * Does not have...[6] life
1. Social life 2. Isolated 3. Flat affect 4. 5% 5. Night/isolated 6. Sex
127
Schizotypal personality disorder * In stressful conditions can develop...[1] * In more severe cases can develop...[2] * ...[3] suicide rate * Some develop...[4]
1. Psychotic episodes 2. MDD 3. 10% 4. Schizophrenia
128
Narcissistic personality disorder * Prevalance of...[1] * Kid to parents with...[2] have higher tendency for developing these condition * Have difficulties to face...[3] * Are not...[4] to other people * Risk for...[5]
1. 6% 2. Narcisstic personality disorder 3. Crticism 4. Ampathic 5. Suicide
129
Histrionic personality disorder * Characterized by...[1] * Have...[2] behavior * Prevalance of...[3] and more common in...[4] gender * Defense mechanisms...[5,6] * Associated with...[7] and...[8] disorders
1. Excitability 2. Seductive 3. 1-3% 4. Femalee 5. Dissociation 6. Regression 7. Alcohol abuse 8. Somatic disorders
130
Borderline personality disorder * Characterized by...[1] * Prevalance of...[2] and more common in...[3] gender * Usually diagnosed before the age of...[4] * Repetitive behaviors of...[5] * Can develop short...[6] episodes * According to Otto Kernberg it is characterized by...[7-10] * The last one includes...[11] and...[12] * Tends to develop...[13] * Have risk for...[14] * Beneficial treatment method is...[15]
1. Stable instability 2. 1-2% 3. Female 4. 40 5. Self mutilation 6. Psychotic 7. Identification instability 8. Ego weakness 9. Lack of integration of the super-ego 10. Primitive defense mechanisms 11. Splitting 12. Projective identification 13. MDD 14. Suicide 15. **DBT** * **During the DBT we can expect regressions, impulsive behaviors, transference**
131
Antisocial personality disorder * Characterized by incapability to adapt to...[1] * Prevalance of...[2] and it is more common in...[3] * Higher incidence in patients with first degree relatives diagnosed with...[4] * Also, high incidence in...[5] areas * The highest incidence is seen in...[6] and...[7] abusers * Before the age of...[8] there are signs of...[9] disorder, but the diagnosis can only be made from the age of...[10] * Does not show signs of...[11] or...[12] * These patients fail to show signs of...[13] * Some have...[14] of symptoms after...[15] * Some have...[16] disorders
1. Normal social norms 2. 0.2-3% 3. Male 4. Anti-social personality disorder 5. Poor 6. Inmates 7. Alcohol 8. 15 9. Conduct 10. 18 11. Anxiety 12. Depression 13. Remorse 14. Decrease 15. Adolescense 16. Somatic
132
Dependent personality disorder * The basis is...[1] with fear of...[2] or...[3] * More common in...[4] gender and in...[5] age * Tends to develop...[6] when there is...[7] * The prognosis is...[8] * Treatment in...[9]
1. Anxiety 2. Separation 3. Isolation 4. Female 5. Young (kids) 6. MDD 7. Separation 8. Good 9. Psychotherapy - insight oriented
133
Avoidant personality disorder * Fear of...[1], this is why they tend to...[2] * Prevalance of...[3] * Babies with...[4] temperament are considered high risk for this disorder * Show increased interest for...[5] as opposed to schizoid personality disorder * Some have...[6] * Co-morbidity with...[7] and...[8] * Treatment with...[9]
1. Rejection 2. Live alone 3. 2-3% 4. Shy 5. Social interaction 6. Normal lives 7. Social phobias 8. MDD 9. Psychotherapy - encourage to engage in social activity * Also group therapy and CBT can be used
134
Obsessive compulsive personality disorder * Prevalance of...[1] * More common in...[2] gender * More common in the...[3] brother * Higher frequency in relative of patients who are diagnosed with...[4] and pepole who were raised in...[5] * According to Freud it is disorder in the...[6] phase * In interview they are...[7-9] * Defense mechanisms include...[10-14] * Some develop...[15] or...[16]
1. 2-8% 2. Male 3. Older 4. OCPD 5. Strict environment 6. Anal 7. Formal 8. Lack of sense of humor 9. Show flat affect 10. Intellectualization 11. Isolation 12. Reaction formation 13. Rationalization 14. Undoing 15. Schizophrenia 16. MDD טיפול עם באסוציאציות חופשיות No directive therapy
135
Dissociative amnesia - clinical features * Prevalence is...[1] * Sex predominence...[2] * Most commonly diagnosed at...[3] * When the amnestic episode resolves, there is high risk for...[4]
1. 2-6% 2. M=F 3. Young adulthood 4. Suicide
136
Dissociative amnesia - diagnosis (DSM-5)
1. Inability to recall personal autobiographic information 2. The symptoms cause significant distress or decrease in function 3. Not due to substance abuse or other medical/neurological disorder 4. Cannot be explained by other psychiatric disorder Specify: with dissociative fugue (travel or bewildered wandering that is associated with amnesia)
137
The 5 subtypes of dissociative amnesia
1. Localized - the most frequent. Loss of defined period of time 2. General - loss of personal history; semantic/procedural 3. Selective - loss of some part of the event, but not all of it 4. Systemized - loss of specific information category 5. Progressive - forget every new event after it happened
138
Dissociative amnesia - dissociative fugue * Specifier of dissociative amnesia * As opposed to DID, this patients...[1] * Usually lasts...[2] * After recovery there is a risk for...[3-5] * Rare disorder, with rate of...[6]
1. Forget their identity (and does not invent a new one) 2. Hours-days 3. PTSD 4. Anxiety disorder 5. Suicide 6. 0.02%
139
Dissociative amnesia - treatment
* The symptoms self resolve and usually without relapses * Try to bring back the memories as soon as possible * Interview and benzodiazepines (decrease the stress) * Hypnosis is also possible * After regained memory it is recommended to start in psychotherapy
140
DID - epidemiology * Prevelance of...[1] * ...[2] times more common in...[3] gender * The avarage diagnostic age is...[4] * ...[5] will try to commit suicide * Almost...[6] will have history of childhood traumatic event
1. 0.4-1.5% 2. 5-9 3. Female 4. 30 5. 66% 6. 100%
141
DID - diagnosis (DSM-5)
1. Distortion of the identity preception by its splitting for at least 2 different identities, expressed as lack of distinguished continuity of the preception of self, can be noted by others or by the patient 2. Repetitive difficulties to remember daily events, personal information and traumatic events 3. Symptoms cause significant distress and decrease in function 4. Does not fit to culture or personal believes 5. Not due to substance abuse or GMC
142
Depersonalization/Derealization disorder - epidemiology * Counts as the...[1] most common psychiatric disorder * ...[2] more common in...[3] gender * Usually appears before the age of...[4], and the avarage onset in the age of...[5] * Common in patients that have...[6], and...[7] * In patients that abuse...[8],...[9], and...[10] * Associated with...[11] drugs
1. 3rd (after depression and anxiety) 2. Twice 3. Female 4. 40 5. 16 6. Seizures 7. Migraines 8. Psilocybin 9. Mescaline 10. LSD 11. Anti-cholinergic
143
Depresonalization/Derealization disorder - diagnosis (DSM-5)
1. Recurring experiences of depersonalization or derealization or both 2. Due the experiences, reality test is still intact 3. Significant distress or decrease in function 4. Not due substance abuse or GMC 5. Is not due to other psychiatric disorder
144
Ganser syndrome
* Rare dissociative disorder * Response to significant stress * Answers to simple questions is almost true/absurd * Other dissociative symptoms such amnesia, conversion or fugue.
145
Somatic symptom disorder - epidemiology * ...[1] gender * More common in...[2] SES * Starts before the age of...[3], usually in...[4] * There is a relation to...[5] * In some families there is a...[6]
1. M=F 2. Low 3. 30 4. Teens 5. Violence at home 6. Genetic factor
146
Somatic symptom disorder - diagnosis (DSM-5)
1. 1 or more somatic symptom that are distressing or result in significant disruption of daily life 2. Excessive thoughts, feelings ,or behaviors related to the somatic symptoms 3. State of being symptomatic is presistent (more than 6 months) Specify: with predominent pain
147
Somatic symptom disorder - clinics * Usually the disease is...[1], which can last...[2] * The most common complaints are...[3-7] * To...[8] of the patinets there is other psychiatric disorders such as...[9-13] * Patients usually are not intersted in...[14] * Sometimes the disease is related to...[15]
1. Episodic 2. Months-years 3. Nausea and vomiting 4. Difficulty swallowing 5. Pain in hands and legs 6. Shortness of breath 7. Pregnancy and menstrual complications 8. 50% 9. MDD 10. GAD 11. Personality 12. Phobias 13. Substance abuse 14. Psychiatric treatment 15. Stress
148
Somatic symptom disorder - prognosis and treatment * Full remission...[1] * Without treatment...[2] * There is...[3] in physical disorders within...[4] years * Good prognostic factors include: * ...[5] SES * ...[6,7] which respond to therapy * ...[8] onset * Lack of...[9] and...[10] * Pharmacologic treatment...[11] * Personal and group psychotherapy can reduce by...[12] the visits to the doctor
1. Is rare 2. There will be deterioration of symptoms 3. No increase 4. 20 5. High 6. Anxiety 7. Depression 8. Sudden 9. Personality disorders 10. Associated medical disorder 11. Is not essential. Only needed for co-morbidities 12. 50%
149
Illness anxiety disorder - diagnosis (DSM-5)
1. Preoccupation with having/acquiring serious illness 2. Somatic symptoms are absent/mild or if there is another medical condition, or high risk for acquiring one, preoccupation is clearly excessive 3. High level of anxiety about health 4. Excessive health related behavior or maladaptive avoidance 5. For at least 6 months 6. Is not better explained by other psychiatric disorder Specifiy if: care-seeking type or care-avoidant type
150
Conversion disorder - epidemiology * Conversion symptoms that are not sufficient for diagnosis appears in about...[1] of the general population * Prevelance of...[2] from 100,000 * ...[3] times more common in...[4] gender * Rare before the age of...[5] or after the age of...[6] * More common in...[7] areas * People with...[8] education * The rate is higher in...[9] twins
1. 1/3 2. 11-300 3. 2 4. Female 5. 10 6. 35 7. Rural 8. Low 9. Monozygotic
151
Conversion disorder - risk factors * Living in...[1] areas * ...[2] IQ * ...[3] SES * Man who were exposed to...[4]
1. Rural 2. Low 3. Low 4. Wars
152
Conversion disorder - diagnosis (DSM-5)
1. One symptom or more in motor (voluntary) or sensoric system 2. There is no correspondense of the symptom to medical or neurological state 3. Is not better explained by other medical or psychiatric disease 4. Causes significant distress or decrease in function
153
Conversion disorder - progression and prognosis * ...[1] will eventually be diagnosed with...[2] * Spontaneous resolution within...[3] in...[4] of the cases * If the disorder is more then 6 months, the risk for resolution is...[5] * 1 year recurrence rate is...[6] * Patients are in high risk for...[7]
1. 25-50% 2. Neurological disorder 3. 2 weeks 4. 95% 5. Less than 50% 6. 20-25% 7. Suicide
154
Conversion disorder - symptom features
* Weakness/paralysis (M) * Abnormal motor movement (M) * Swallowing (M) [globus hystericus] * Speech (M) * Seizures (M) * Sensory loss (S) * Specialized sensation (S) * Mixed (M+S) The most common symptoms are paralysis, blindness and mutism
155
Conversion disorder - psychologic symptoms
* Primary gain - protects the patient from the conflict * Secondary gain - release from obligations * La belle indifference - does not pay attention to severe symptoms * Identification - unknowingly takes a model of self symptoms
156
Conversion disorder - co-morbidities * Related psychiatric disorders include...[1-3] * Associated personality disorders are...[4-7] * There is increased familial incidence of...[8]
1. MDD 2. Anxiety 3. Schizophrenia 4. OCPD 5. Hystrionic 6. Dependent 7. Anti-social 8. Conversion disorder
157
Conversion disorder - prognostic factors * Good prognostic factors: * ...[1] onset * ...[2] stressor * ...[3] treatment * ...[4] IQ * Symptoms of...[5-7] * Bad prognostic factors: * Symptoms of...[8-9]
1. Acute 2. Identifiable 3. Rapid 4. High 5. Paralysis 6. Aphonia 7. Blindness 8. Tremor 9. Seizures
158
Psychologic factors affecting other medical conditions - diagnosis (DSM-5)
1. Medical symptom or condition is present 2. Psychological or behavioral factors adversely affect the medical condition: * Influence the course of medical condition as shown by a close temporal association * Interfere with the treament of the medical condition * Constitute additional well-established health risks for the individual * Influence the underlying pathophysiology, precipitating or exacerbating symptoms or necessitating medical attention 3. Criterion B is not better explained by another mental disorders Specify: * Mild - increased medical risk * Moderate - aggravates underlying medical condition * Severe - results in medical hospitalization or emergency room visit * Extereme - results in severe, life-threatening risk
159
Kleptomania - clinical features * Prevalence of...[1] * ...[2] times more common in...[3] * The age of apperance in males is...[4], while in females is...[5] * May appear in...[6] * Co-morbidity with...[7-12] * Usually does not effect...[13]
1. 0.6% 2. 3 3. Females 4. 50 5. 35 6. Childhood 7. Mood disorders 8. Anxiety 9. Gambling disorder 10. Substance abuse 11. Excessive shopping 12. Eating disorders 13. Normal function
160
Kleptomania - diagnosis (DSM-5)
1. Failure to resistent the impulse to steal objects which are not needed and not due to their value 2. High tension before cofessing the theft 3. Feeling of satisfcation/relief while confessing about the theft 4. The act does not express anger/revenge and not due to hallucinations or delusions 5. Is not better explained by other mental disorder
161
Kleptomania - treatment * Psychotherapy * Drugs
* Few options: * Dynamic treatment and CBT * Insight oriented psychotherapy * Behavioral therapy - desensitizaton, reverse conditioning * SSRI's is the drug of choice * In addition mood stabilizers * ECT is also an option
162
Pyromania - clinical features * Male:female ratio is...[1] * Comorbidity with...[2-6] * In kids it is highly associated with...[7] * Associated with...[8] * Possible association with...[9] * If the disorder starts...[10] there is a good prognosis
1. 8:1 2. Mild retardation 3. Substance abuse (mainly alcohol) 4. MDD/bipolar disorder 5. Other impulse disorders 6. Personality disorders (borderline, anti-social) 7. ADHD and learning disability 8. Animal abuse 9. Enuresis 10. Early
163
Pyromania - diagnosis (DSM-5)
1. More then 1 case of premaditated or deliberate fire setting 2. Tension or arousal before the act 3. High intrest in fire or related situations 4. High satisifaction while setting the fire or while watching/taking part in fire setting 5. Fire setting is done without other motives, not due to delusions or hallucinations and not due to states of impaired judgement 6. Is not better explained by other mental disorder
164
Pyromania - treatment * Psychotherapy * Drugs
* The treatment is psychotherapy alone but there is no established method
165
Intermittent explosive disorder - epidemiology * More common in...[1] gender, which accounts for...[2] * Usually appears in...[3] * In most cases the severity decrease in...[4] * For diagnosis the chronologic age must be at least of...[5]
1. Male 2. 80% 3. Young age 4. Adulthood 5. 6 years old
166
Intermittent explosive disorder - etiology * Psychodynamic...[1] * Psycho-social...[2] * Biologic...[3] * Genetics...[4]
1. Defense mechanisms by narcssistic assault 2. Dependent men, rough childhood * Perinatal trauma, head injuries, encephalitis, hyperactivity 3. Decreased serotonin 4. First degree relative with MDD, addictions, impulse control disorders **הפרעה פיזיולוגית במוח, במיוחד במערכת הלימבית**
167
Intermittent explosive disorder - diagnosis (DSM-5)
1. Recurrent outburst as manifested by 1 of the following: 1. Verbal or physical aggression occuring 2 a week for at least 3 months. Physical aggression does not result in damage. 2. 3 outbursts involving damage or destruction and physical injury to other, occuring within 12 months 2. Agressiveness during the outbursts is out of proportion to the provocation 3. Outbursts are not premeditataed and not committed to achieve any objective 4. Leads to significant distress or decrease in function or associated with financial or leagal consequences 5. Chronological age is at least 6 years 6. Not better explained by other mental disorder and not due to GMC
168
Intermittent explosive therapy - treatment * Psychotherapy * Drugs * ...[1] are not recommended
* Personal psychotherapy is the treatment of choice - difficult because the patient is non compliant * SSRI's * Mood stabilizers (lithium, carbamazepine, valproate) * BB's 1. Benzodiazepines * Paradoxical reaction
169
Oppositional defiant disorder - epidemiology * Prevalence of...[1] * Starts by the age of...[2] * Before puberty...[4], while after puberty...[5]
1. 2-16% of school aged children 2. 10 3. M \> F 4. M = F
170
Oppositional defiant disorder - diagnosis (DSM-5)
1. Pattern of defiant/angry/irritable behavior/mood for at least 6 months, with at least 4 of the following happening during interaction with a person which is not a sibling 1. Angry/irritable mood: 1. Loses temper 2. Easily annoyed 3. Angry and resentful 2. Defiant behvior: 1. Argues with authority 2. Defies/refuses to comply with authority requests 3. Delibrately annoys others 4. Blames others for his behaviors/mistakes 3. Vindictiveness: 1. Vindictive for at least 2 times in the past 6 months 2. Cause significant distress to the kid and his family and decrease function 3. Does not occur in the psychosis or in affective disorder
171
Oppositional defiant disorder - clinical features * Risk factors include...[1-2] * ...[3] of the patients will have remission * Other will eventually develop...[4]
1. Child abuse/neglect 2. Strict parenthood 3. 25% 4. Conduct disorder
172
Oppositional defiant disorder - treatment * Psychotherapy * Drugs
* First line treatments include parent guidance and family treatment * Reinforce positive behavior and narrow down negative behavior * Pharmacotherapy is not indicated
173
Conduct disorder - epidemiology * More common in...[1] gender * The prevalence in males...[2], while the prevalence in females is...[3] * Higher frequency in children to parents with..[4] personality disorder and...[5] * Avarage onset in boys...[6], while the avarage onset in girls...[7] * Classified into 3 type...[8-10]
1. Male 2. 6-16% 3. 2-9% 4. Antisocial 5. Alcohol dependance 6. 10-12 7. 14-16 8. Onset before the age of 10 9. Onset after the age of 10 10. Onset in unknown age
174
Conduct disorder - etiology * Cultural-social factors...[1] * Psychological...[2] * Neurologic...[3]
1. Frequent in areas with high population * Low SES, avoidance from social acitivty, increased exposure to alcohol and drugs 2. Diffculties in regulation of emotions and lack of impulse control 3. Decrease in grey matter in the limbic system * Increased serotonin levels * Decreased levels of dopamine beta-hydroxylase Could be associated with the gene monoamineoxidase A
175
Conduct disorder - clinical features * Risk factors: * Child...[1] and...[2] * ...[3] parenthood * Exposure to...[4] * ...[5] IQ and...[6] school performance * Good prognosis when: * Happens only within...[7] * ...[8] onset * No other...[9] * ...[10] IQ
1. Abuse 2. Neglect 3. Strict 4. Alcohol 5. Low 6. Low 7. Family 8. Late 9. Psychopathology 10. Normal
176
Conduct disorder - diagnosis (DSM-5)
1. Repatitive behavior in which the basic rights of others or major social norms/rules are violated. Manifested by at least 3/15 in the past 12 months, and 1 of these is present for at least 6 months: 1. Agression: 1. Bullies 2. Initiate physical fights 3. Used a weapon 4. Physically cruel to people 5. Physically cruel to animals 6. Stolen while confronting a victim 7. Forced someone into sexual activity 2. Destruction of property: 1. Engaged in fire to cause serious damage 2. Destroyed others property 3. Deceitfulness/theft: 1. Broken into someone else house/car 2. Lies to obtain goods/favors or to avoid obligations 3. Stolen items of nontrivial value without confronting the victim 4. Violations of rules: 1. Stays out at night despite prohibitions, before the age of 13 2. Run away from home overnight at least 2 times, or once without returning to lengthy period 3. Truant from school, before the age of 13 2. Causes significant impairment in function 3. If the patient is older than 18, criteria are not met for antisocial personality disorder
177
Conduct disorder - specifiers
* With limited prosocial emotions: * Lack of remorse/guilt * Lack of empathy * Unconcerned about performance * Shallow/deficient affect
178
Conduct disorder - treatment * Psychotherapy * Pharmacotherapy
* CBT, parent guidance and child guidance * Antipsychotics - beneficial in prevention of the disease and decrease symptoms
179
ADHD - epidemiology * Prevalance of...[1] * More common in...[2] gender * ...[3] up to adolesence * ...[4] of the adolescents * ...[5] of adults * ...[6] who have been diagnosed have their symptoms in adulthood * There are screening tests like...[7] or...[8], but eventually the diagnosis is made...[9]
1. 3-7% 2. Male 3. 7-8% 4. 5% 5. 2.5% 6. 60% 7. TOVA 8. Conner 9. Clinically
180
ADHD - etiology 1. Genetics 2. Neurologic 3. Neurophysiology 4. Prenatal
1. 75% of the etiology * First degree relatives of ADHD patients have 2-9 times higher risk for developing ADHD * Association with DAT1 and DRD4 genes 2. Dopamine is the main deficient neurotransmitter * Related to locus ceruleus and the per-frontal cortex 3. Increased beta and teta waves activity is seen on EEG 4. Premature babies and for mothers who had infection during pregnancy
181
ADHD - diagnosis (DSM-5)
1. Persistent pattern of inattention or impulsivity that interfers with functioning or development * Inattention: 6 or more of the following for at least 6 months 1. Fails to give close attention 2. Difficulty in sustaining attention 3. Does not seem to listen when spoken to 4. Does not follow through instructions 5. Difficulty organizing 6. Reluctent ro engage in sustained tasks 7. Loses things 8. Easily distracted 9. Forgetful * Hyperactivity: 6 or more of the following for at least 6 months 1. Fidgets 2. Leaves sit, when expected to stay put 3. Runs/climbs in inappropriate times 4. Cant play quietly 5. Often "on the go" 6. Talks excessively 7. Blurts answer before question was finished 8. Difficulty to wait for turn 9. Intrudes on others 2. Several symptoms were present before the age of 12 3. Several symptoms are present in 2 or more settings 4. Symptoms interfere with functioning 5. In not due to other psychiatric disorder
182
ADHD - comorbidity * ...[1] will not have additional disorders * 11% will have...[2] disorder * 20% will have...[3] disorder * 14% will have signs of...[4] * 34% will have...[5] disorder * 10-90% will have...[6] * 15-19% will...[7]
1. **30% (70% with another psychiatric disorder!)** 2. Tic 3. Personality 4. Conduct 5. Anxiety 6. Sutdying disablities 7. Substance abuse
183
ADHD - stimulant treatment * The first group is...[1] * Classic...[2] * SR...[3] * LA...[4] * ...[5] is the longest acting * ...[6] is in form of transdermal patch * ...[7] contain only the active...[8] * The other group...[9] that are used only as 2nd line * The brand names...[10],...[11] * There is the prodrug form...[12] * Contraindication for stimulant treatment include...[13]
1. Methylpehnidate 2. 2-3 hours (Ritalin) 3. 4-6 hours (Ritalin SR) 4. 6-8 hours (Concerta) 5. 10-12 hours 6. Daytrana 7. Focalin 8. D+ methylphenidate 9. Amphetamines 10. Adderal 11. Attent 12. Vyvanse 13. Cardiac disorders (structural of conductive)
184
ADHD - non-stimulant treatment * ...[1] agonists, such as...[2] * Strattera (=...[3]) * Inhibits reuptake of...[4] * Begin therapy when there is...[5], or there is lack...[6] * ...[7] can also be used * ...[8] is also proved as beneficial
1. Alpha 2 2. Clonidine 3. Atomoxetine 4. Norepinephrine 5. Side effects 6. Of activity of amphetamines 7. Buproprion 8. Omgea-3
185
ADHD - treatment side effects 1. GI... 2. Psychiatric... * Worsens... 3. Neurologic... 4. Cardiovascular... 5. Ophthalmic... 6. Intoxication signs... 7. Rebound phenomenon... 8. Pregnancy...
1. Abdominal ache, decreased appetite 2. Anxiety, restlessness, difficulty sleeping, dysphoria * Anxiety disorders and psychotic disorders 3. Worsens epilepsy, tic disorder, dyskinesia * If tic disorder appears and does not resolve withub 7-10 days - psychoeducational treatment can be initiated 4. Arrythmia, tachycardia, exacerbates hypertension 5. Exacerbation of glaucoma 6. Hypertension, tachycardia, fever, delirium, psychosis, seizures 7. Irritability and hyperactivity * Slow release formulas decrease the risk 8. Avoid in first trimester * Transferred in breast milk **לא הוכח שהתרופות מביאות להאטה בצמיחה של ילדים, ילדים נוהגים לפצות על הבעיה בתקופות בהן אינם לוקחים את התרופה**
186
ADHD - progression and prognosis * In most of the cases there is...[1] * ...[2] is the most persistent symptom, while...[3] is the symptom that resolves first...[4] * Patients who have partial remission have higher risk for developing...[5]
1. Partial remission * Remission usually occurs at ages 12-20 2. Inattention 3. Hyperactivity 4. Anti-social personality disorder
187
Tourette's syndrome - general features * ...[1] per 100,000 * The motor component appears by the age of...[2] * The vocal component by the age of...[3] * ...[4] more common in...[5] gender * The avarage age of presentation is...[6] * This disorder is highly associated with...[7-10] * There is decreased volume of the...[11] * Abnormal levels of...[12] in the CSF * For diagnosis the symptoms have to start before the age of...[13] * The symptoms severity peaks at the age of...[14] and decrease thereafter
1. 4-5 2. 7 3. 11 4. 3 5. Male 6. 4-6 7. ADHD 8. OCD 9. Anxiety 10. Depression 11. Caudate nucleus 12. HVA 13. 18 * Usually presents at 4-5 14. 10-12
188
Tourettes syndrome - treatment 1. Psychotherapy 2. Pharmacotherpay
1. Psychotherpay: * Psychoeducation * Behavioral treatment - habit reversal, exposure and response prevention 2. Pharmacotherapy: * Potent antipsychotics improve the condition in 85% but due to high rate of side effect risperidone is the first line * Clonidine and atomoxetine are efficient in patients with ADHD
189
Intellectual disability - general features * Prevalance of...[1] and more common in the...[2] gender * Mild: * IQ of...[3] and educational level of up to...[4] grade * Moderate: * IQ of...[5] and educational level of up to...[6] grade * Severe: * IQ of...[7] * Profound: * IQ of...[8] * ...[9] have psychiatric co-morbidities, such as...[10-14] * High frequency of...[15] * The preferred method of treatment is...[16]
1. 1% 2. Male 3. 50-70 4. 6th 5. 35-50 6. 2nd 7. 20-35 8. \<20 9. 40% 10. ADHD 11. MDD 12. Bipolar 13. Anti-social personality disorder 14. Impulse control 15. Schizophrenia 16. Cognitive psychotherapy
190
Autistic spectrum disorder - epidemiology * Prevalance of...[1] * ...[2] times more common in...[3] * More severe in...[4] gender * In most of the patients the classic signs will appear before the age of...[5] * Have strong...[6] component
1. 1% 2. 4 3. Male 4. Female 5. 3 6. Genetic
191
Autistic spectrum disorder - co-morbidity * ...[1] delay * ...[2] will show signs of...[3] * Tends to have...[4] * Different perception of...[5]
1. Language delay * 50% will never acquire any language 2. 30% 3. Intellectual disability * ​30% - mild * 45-50% - profound * 70% with normal IQ! 4. Sensory stimuli
192
Autistic spectrum disorder - treatment and prognosis * ...[1] decrease agression and hyperactivity * ...[2] decrease obsessions and stereotypies * ...[3] can balance self mutilation when the treatments fail * ...[4] will remain with severe disability and dependency * ...[5] will have borderline employment status * ...[6] are operational and can have a stable job * Good prognosis with...[7] and...[8] at the age of...[9]
1. Risperidone 2. SSRI's 3. Lithium 4. 66% 5. 5-20% 6. 1-2% 7. IQ over 70 8. Good language skills 9. 5-7 years
193
Anorexia nervosa - epidemiology * ...[1] are females * Usually starts before the age of...[2] and rarely starts after the age of...[3] * More frequent in...[4] SES * Apperance is related to...[6] event
1. 90% 2. 17 3. 40 4. High 5. Stressful
194
Anorexia nervosa - severity * According to BMI: 1. Mild 2. Moderate 3. Severe 4. Extreme
1. \> 17 2. 16-16.99 3. 15-15.99 4. \< 15
195
Anorexia nervosa - comorbidity and clinical signs * Comorbidity: 65% - ...[1], 35% -...[2], 25%...[3] * Death rate of...[4] * Increase in...[5] and...[6] * Increase in...[7] and decrease in...[8] * Decrease in both...[9,10] * CNS changes include...[11] of the ventricles and sulci, and hyper-metabolism in the...[12]
1. MDD 2. Social anxiety disorder 3. OCD 4. 10% 5. CRH 6. Cortisol 7. TSH 8. Thyroid hormones 9. FSH 10. LH 11. Dilation 12. Caudate nucleus ## Footnote **הפרעות קצב, בעיות ויסות טמפרטורה, ל״ד ודופק, היפרכולסטרולמיה, לויוקופניה, אמנוריאה, אוסטואופורוזיס הוא הסיבוך העיקרי** **בנוסף יהיו סיבוכי הקאה**
196
Anorexia nervosa - diagnosis (DSM-5)
1. Restriction of energy intake leading to significantly low body weight in context. (Significantly low weight defined as less of the expected minimun according to age and sex) 2. Intense fear of gaining weight or being fat, or presistnent behaviors that interfer with weight gain 3. Disturbance in the body perception or lack of recognition of the seriousness of the current low body weight * Specifiers: * Binge eating/purging - repeated episodes of bing eating and detox in the last 3 months * Restrictive - without binges or purging in the last 3 months
197
Anorexia nervosa - progression and prognosis * Death is mainly due to...[1] and...[2] * ...[3] will develop...[4] within...[5] * After 10 years: * ...[6] of the paitents will have full remission * ...[7] will have parital symptoms * ...[8] will have chronic course * Good prognostic factors...[9] * Bad prognostic factors...[10]
1. Suicide 2. Arrythmias 3. 30-50% 4. Bulemia 5. 1-3 years 6. 25% 7. 50% 8. 25% 9. Appetite, good self-esteem, awareness 10. Bulemia, vomiting, laxative abuse, behvior disorders
198
Anorexia nervosa - treatment
1. Admission if possible - although most of the patients doesnt want to 2. CBT * Supervised meals, and monitor weight, electrolytes 3. Psychodynamic therapy - not for patients younger then 18 4. Family treatment 5. The are no proved drugs, should be given if there is co-morbid mental disorder * Cyproheptadine for restrictive subtype * Anti depressents and anti-psychotics are also an option
199
Bulimia nervosa - epidemiology * ...[1] of the population * ...[2] of adolescent females * ...[3] more common in...[4] gender * Sometimes the disease develops from...[5] * Onset is usually in...[6]
1. 2-4% 2. 1-3% 3. 10-20 4. Female 5. Anorexia nervosa 6. Late 20's or early 30's
200
Bulimia nervosa - comorbidity
* Affective disorders * Impulse control disorders * Cluster B personality disorders * Self mutilation * History of substance abuse **בשונה מאנורקסיה יש עוררות מינית וליבידו מוגבר. בנוסף, תפקודי תריס תקינים**
201
Bulimia nervosa - diagnosis (DSM-5)
1. Recurrent episodes of binge eating, defined as both: 1. Eating amount of food that is abnormally high in short period of time 2. Sense of lack of control while eating 2. Recurrent inappropriate compensatory behaviors in order to prevent weight gain 3. Binges and compensation occurs at least 1 time a week for at least 3 month 4. Self evaluation is influenced by body shape and weight 5. Disturbance does not occur exclusivley during episodes of anorexia nervosa * Specifiers: * Purging (80%) * Non purging type
202
Bulimia nervosa - treatment 1. Psychotherapy 2. Nutrition 3. Drugs
1. Personal/group, dynamic, CBT 2. - 3. Anti-depressents - only when there is no response to psychotherapy or comorbid depressive disorder * High dose SSRI's * Stabilizers (lithium/lamotrigine) when there is comorbid disorder
203
Bulimia nervosa - prognosis * ...[1] will recover under therapy * ...[2] recurrence rate within 5 years
1. 60% 2. 50%
204
Binge eating disorder - diagnosis (DSM-5)
1. Recurrent episodes of binge eating, characterized by both: 1. Eating high amount of food within short period of time 2. Sense of lacking control over eating during the episode 2. Binge eating episodes are associated with: 1. Eating more rapidly 2. Eating untill uncomfortably full 3. Eating large amount when not feeling hungry 4. Eating alone because feeling embarrassed by the amount 5. Feeling disgusted/guilty after the binge 3. Marked distress regarding the binge 4. Binge occurs at least once a week, for at least 3 months 5. Not associated with bulimia nervosa or anorexia nervosa
205
Binge eating disorder - co-morbidity
* MDD (+dysthemia) * Anxiety * Substance abuse * Avoidant or borderline personality disorder
206
Pica - diagnosis (DSM-5)
1. Eating of non nurishing foods for at least 1 month 2. Behavior does not correspond to developmental stage 3. Not due to cultural norms * Pathologic only in kids older than 18 months * Cannot be diagnosed in mental retardation
207
Rumination disorder - diagnosis (DSM-5)
1. Recurrent rumination for at least 1 month. The food can be swallowed again or spat out 2. Not due to other medical disorder 3. Not due to another eating disorder 4. If occurs in context of another mental disorder, the symptoms should be severe enough to require further intervention
208
Avoidant/Restrictive food intake disorder - diagnosis (DSM-5)
1. Feeding disorder that is expressed in prolonged insufficient energey consumption, that is related to at least 1 of the following: 1. Significant weight loss 2. Severe malnurishment 3. Dependecy in entral feeding or supplements 4. Impaired psychosocial dysfunction 2. Is not explained by lack of available food or cultural norms 3. Is not due to another feeding disorder and there is no signs of bad body image 4. Is not due to another GMC or mental disorder. If occurs with another mental disorder, the symptoms are severe enough to require further medical intervention
209
210
Insomnia - diagnosis (DSM-5)
1. Predominant complain with sleep, associated with at least 1 of the following: 1. Difficulty initiating sleep 2. Difficulty maintaining sleep 3. Early morning awakening with inability to return to sleep 2. Clinically significant distress or impariment in function 3. At least 3 nights per week 4. At least 3 months 5. Occurs despite adequate opportunity for sleep 6. Not due to substance abuse 7. Coexisting disorders do not explain the insomnia
211
Insomnia - treatment * Behavioral therapy * Drugs
* Deconditioning, better sleep hygiene, light therapy * Benzodiazepines, zolpidem, zaleplon * Short acting for falling asleep * Long acting for patients that wake up at night * Use no more then 2 weeks * Zolpidem is not associated with rebound insomnia
212
Hypersomnolence disorder - diagnosis (DSM-5)
1. Hypersomnolence, despite sleeping at least 7 hours, with at least 1 of the following: 1. Repeated sleeping episodes during the day 2. Nonrestorative sleeping episode of more than 9 hours 3. Difficulty being refrashed after awakening 2. At least 3 times a week for at least 3 months 3. Distress or decrease in function 4. Is not better explained by other sleeping disorder 5. Not due to substance abuse 6. Not due to other mental disorder
213
Hypersomnolence disorder - treatment
* Mainly stimulants * SSRI's which are not sedating, are beneficial in part of the cases
214
Kelin-Levin syndrome * Characterized by reapted episodes of...[1] for...[2] * Mostly in...[3] age, and...[4] gender * Associated with...[5-8] * There is...[9] after the episode * Can...[10] within few years * If medical treatment is needed...[11,12]
1. Hypersomnelance 2. Several weeks 3. Young (20's) 4. Male 5. Hypersexualism 6. Hostility 7. Hallucinations 8. Irritability 9. Amensia 10. Resolve spontaneously 11. Stimulants 12. Lithium
215
Narcolepsy - general features * Almost all patients with this disorder have...[1] on WBC's * Characterized by low levels of...[2] * Clinics include...[3-7]
1. HLA-DR2 2. Hypocretin 3. Sleeping episodes that are refreshing 4. Cateplexy - in more than 50% * Triggers include laugh, anger, physical activity, sexual arousal, fear 5. Sleep paralysis 6. Hypnogogic/hypnopompic hallucinations 7. Sleep onset REM periods - REM starts within 15 minutes after sleep is initiated
216
Narcolepsy - diagnosis (DSM-5)
1. Recurrent episodes of an irrepressible need to sleep/lapsing to sleep/napping occuring withing the same day, occuring for at least 3 nights a week for at least 3 months 2. Presence of at least 1 of the following: 1. Episodes of cataplexy defined as either of the following, occuring few times a month: 1. Long standing disease - brief episodes of loss of muscle tone with maintained consciousness that are precipitated by laughter or joking 2. Less than 6 months - spontaneous grimaces without any obvious triggers 2. Hypocretin deficiency measured in the CSF, not in the context of acute brain injury/inflammation/infection 3. Polysomnography showing REM sleep latency less than/equal to 15 minutes, or multiple sleep latency test showing mean sleep latency less/equal 8 minutes and two or more sleep onset REM periods
217
Narcolepsy - treatment
* Includes arraging sleeping times * For cataplexy the treatment is modafinil, fluoxetine or imipramine * Shortens REM
218
Non-REM parasomnias - sleepwalking * Occurs mainly at stages...[1] * Peaks at the age of..[2] * Usually there is no...[3] of the event * More common in...[4] gender * Most cases...[5]
1. N3+N4 2. 12 3. Memory 4. Male 5. Resolve spontaneously
219
Non-REM parasomnias - sleep terror * Characterized by...[1] with...[2] and...[3] * There is no...[4] of the event or the dream * ...[5] and...[6] can induce or exacerbate episodes * In children...[7]
1. Sudden awake 2. Anxiety 3. Increased autonomic function 4. Memory 5. Sleep deprivation 6. Fever 7. No treatment is needed
220
Delirium - general features * The main neurotransmitter involved in the pathophysiology is...[1] * Dysfunction in the...[2] * The main diagnostic symptoms are...[3,4] that are associated with cognitive dysfunction * Risk factors include: * ...[5] age * ...[6] gender * ...[7] drugs * ...[8] (psychiatric disorder)
1. Acetylcholine 2. Reticular formation 3. Lack of awareness 4. Attention 5. Old 6. Male 7. Anti-cholinergic 8. MDD
221
Major neuro-cognitive disorder - general features * ...[1] of elderly after 65, and...[2] after the age of 85 * The main disorders * ...[3] with...[4] * ...[5] with...[6] * ...[7] with...[8] * ...[9] have reversible condition * The main difference from minor neuro-cognitive disorder is...[10]
1. 5% 2. 20-40% 3. Alzheimer's 4. 50-60% 5. Vascular 6. 15-30% 7. Combined Alzheimer's and vascular 8. 10-15% 9. 15% 10. Lack of functioning (in major)
222
Alzheimer's disease * The main injury is the...[1] lobes * The most associated neurotransmitters are...[2,3] * Biologic changes include...[4] atrophy, and in biopsy it is possible to see...[5] and...[6] * Familial in...[7] * In early onset form there is...[8] * Treatment with...[9-11] which are...[12] drugs
1. Parieto-temporal 2. Acetylcholine 3. Norepinephrine 4. Diffuse 5. Neurofibrillary tangles 6. Amyloid plaques 7. 40% 8. Full penetration 9. Rivastigmine 10. Donepezzil 11. Memantine 12. Cholinergic (acetlycholine esterase inhibitors)
223
Vascular neuro-cognitive disorder * Age range of...[1], and it is more common in...[2] gender * Can present with...[3] * And also with...[4] and...[5]
1. 60-70 2. Male 3. Neurologic deficits 4. Dysarthria 5. Dysphagia ## Footnote **עייפות, חולשה, כאבי ראש, ממצאים פוקליים (כמו הפרעות הליכה), דיסראתריה ודיספגיה גם יכולים להופיע**
224
Neuro-cognitive disorder with Lewy bodies * Highly associated with...[1] * Core symptoms include...[2-4] * Suggested symptoms include...[5,6]
1. Visual hallucinations 2. Cognitive function fluctuations 3. Visual hallucinations 4. Spontaneous parkinsonism 5. REM-stage sleep disorder 6. Sensitivity for neuroleptics **ניפלות חוזרות, סינקופה, רגישות לתרופות אנטי-פסיכוטיות, דלוזיות סיסטמיות, פרקינסוניזם, סימנים אקסטא-פירמידליים**
225
Fronto-temporal (Pick's) dementia * ...[1] of the irreversible causes of neuro-cognitive disorders * More common in...[2] gender * Peaks at age rage of...[3] * Similiar to Alzheimer's but the...[4] is intact * Can show changes in...[5] without...[6] dysfunction * Complication is...[7], which is characterized by...[8]
1. 5% 2. Male 3. 50-60 4. Memory 5. Personality 6. Cognition 7. Kluver-Bucy syndrome 8. Disinhibition (hypersexuality, hyperorality)
226
The 12 indications for ECT (including sub-indications)
1. MDD * ​**Psychotic depression (!)** * Resistent to therapy * Catatonic * With severe suicidal ideation * With severe psychomotor retardation 2. Mania (including mixed episodes) * Resistent to therapy 3. NMS 4. Risk of the common 1st line treatment * Pregnant women with severe suicidal ideation (teratogenic effect of SSRI's) * Elderly (anti-depressents are not safe) 5. Psychotic disorders that are resistent the anti-psychotic therapy * Only effects the positive symptoms 6. Parkinson's 7. Intractable seizure disorders 8. Acute exacerbation of schizophrenia 9. OCD 10. Hypopituitarism 11. Delirium 12. Cases in which rapid intervention is cruical
227
ECT - contraindications
* There are no absolute contraindications * Relative contraindications: * Increased ICP * COPD * Severe asthma with steroid treatment * Severe vascular disease * Arryhtmias * Pacemakers * MS * Osteoporesis
228
ECT - side effects
1. Headache 2. Confusion * In 10% there is severe confusion in the 30 minutes after waking-up * Can be treated with barbiturates or BZD's 3. Delirium * Most severe after the first treatments, bilateral treatment or with background of neurological disorder * Usually resolves within days-weeks 4. Memory loss * Effects almost all the patients * Mostly resolves within 6 months
229
ECT - procedure * Unilateral * Bilateral * Treatment course * Prolonged seizures
* Midbrain, non-dominant hemisphere * Most commonly parcticed, due to lesser cognitive effects * Mostly on the right side * Both electrodes are on the temporal areas * Significant short and long term cognitive detrioration * Risk for delirium * Limited to medium strength stimulation * Fast stimulation is NOT beneficial * The series includes 12-15 treatments, in which there is about 2 treatments per week * Seizure for about 25 seconds, if prolonged (\<180s) --\> treat like status epilepticus
230
ECT - drugs combinations 1. Benzodiazepines 2. Lithium 3. Anti epileptic drugs 4. Buspirone 5. Clozapine 6. Lidocaine 7. MAOi's, TCA's and antipsychotics
1. Benzodiazepines - these treatments cancel each other * Another possibility is that BZD's will lead to prolonged seizure (50 seconds) * If there are signs of addiction - treat the addiction first * If the drug cannot be stopped - dont take the pill the night before treatment 2. Lithium - increse the risk for post-ictal delirium and prolonged seizure 3. Anti epileptic drugs - dont use them 4. Buspirone - risk for prolonged seizures 5. Clozapine - risk for prolonged seizures 6. Lidocaine - increases seizure intensity 7. Treatment with these drugs is acceptable
231
SSRI - fluoxetine (prozac) * Side effects include...[1],...[2] and...[3] * Have some...[4] and...[5] activity * Decrease the blood concentration of...[6] * Have strong effect on...[7]
1. Anxiety 2. **Weight loss** 3. Seizure 4. Anti-cholinergic 5. Anti-histaminic 6. Carbamazepine 7. CYP450
232
SSRI - fluvoxamine (favoxil) * Causes...[1] * It have...[2] effect and it is beneficial of...[3]
1. Weight gain 2. Sedative (relaxing) 3. OCD
233
SSRI - paroxetine (seroxat, paxxet) * It causes...[1] * And have...[2] side effects due to its...[3] activity * It is the most...[4] SSRI and thus it is beneficial for...[5]
1. Weight gain * The SSRI the have the highest association to weight gain 2. Anti cholinergic * The SSRI with the highest rate of anti-cholinergic side effects 3. Sedative (relaxing) 4. Panic disorder
234
SSRI - sertraline (lustral) * Side effects of...[1] and [2]
1. Anxiety 2. Diarrhea
235
SSRI - escitalopram (cipralex) and citalopram (recital) * Esticaloparm of side effects of...[1] and...[2] * For citalopram there is association with...[3]
1. Sedation 2. Weight gain 3. QTc prolongation
236
SSRI - t1/2 * From the shortest to the longest...[1-6]
From the shortest to longest: 1. Fluvoxamine 2. Paroxetine 3. Escitalopram 4. Citalopram 5. Sertraline 6. Fluoxetine
237
SSRI - GI side effects 1. Resolves usually after...[1] 2. Most commonly associated with...[2]
* GI discomfort, vomiting, nausea, anorexia, dyspepsia, diarrhea * GI side effects are the main side effect 1. Resolves usually after 2 weeks 2. Sertraline (lustral) have the most prominent GI side effects
238
SSRI - sexual dysfunction * Occurs in...[1] of the patients * Does not...[2] * Change to drug that does not effect sexual acitivity including...[3] and...[4], or add...[5]
1. 50-80% 2. Resolve 3. Mirtazapine 4. Buproprion 5. Viagra
239
SSRI - CNS side effects * Can increase...[1] in the first few weeks * Rarely and most commonly in old patients can cause...[2] * Very low rate (0.02%) of...[3] * The associated drug is...[4]
1. Anxiety (=pardoxical anxiety) 2. EPS 3. Seizures 4. Fluoxetine
240
SSRI - misc. side effects * Weight loss occurs only with...[1] the rest will cause weight gain * ...[2] that will lead to hyponatremia and delirium in old patients * Anti-cholinergic side effects with...[3] * 4% will have...[4] * Deficieny in...[5] of...[6] * Emotional...[7] * ...[8] dreams * Increased risk of...[9]
1. Fluoxetine 2. SIADH 3. Paroxetine 4. Skin rash 5. Aggregation 6. Platelets - prolonged bleeding time 7. Blunting 8. Vivid 9. Suicide attempts
241
SSRI discontinuation syndrome * Leads to...[1] disorder and...[2] discomfort * Also...[3],...[4] and...[5]. Also auras of...[6] * Accompanied with...[7] problems * Occurs in...[8] of the patients * Becuase...[9] have long t1/2 it is the treatment * When...[10] is stopped abruptly, it have the highst risk for triggering discontinuation syndrome
1. Balance 2. GI 3. Tierdness 4. Insomnia 5. Parasthesias 6. Migraine 7. Psychiatric 8. 33% 9. Fluoxetine 10. Sertraline
242
Serotonin syndrome 1. Symptoms 2. Management
1. Characterized by the 3A's: * neuromuscular hyper-Activity: clonus, hyperreflexia, hypertonia, tremor, seizures * Autonomic instability: hyperthermia, diaphoresis, diarrhea * Agitation 2. Stop the offending drug should be the first step * Supporting treatment: cyproheptadine, nitroglycerine, methysergide, chloropormazine, dentrolene, BZD * Cooling blankts * Respiratory support
243
SNRI's - 5 indications
1. MDD - effect starts within 2 weeks (faster than SSRI's) * Venlafaxine (Efexor) - for resistant MDD or MDD with anxious distress * More efficient in melancholic patients 2. GAD 3. Social anxiety 4. Panic disorder 5. Neuropathic pain - duloxetine (Cymbalta)
244
SNRI's - side effects * Frequent side effects...[1-9] * Risk of...[10] that will lead to...[11] * ...[12] is the most severe side effect. Monitro patients with pre-existing condition
1. N/V 2. Dry mouth 3. Dizziness 4. Agitation 5. Constipation 6. Weakness 7. Anorexia 8. Blurred vision 9. Sexual disorders 10. Agitation 11. Suicide 12. Hypertension
245
Mirtazapine (Miro) * Mechanism of action...[1] * Efficient in cases with prominent...[2] and...[3] * Side effects...[4-15]
1. NaSSA - noradrenergic and specific serotonergic anti-depressent * Block alpha-2 receptors * Serotonin antagonist * Block H1 receptors 2. Sleep disturbance 3. Weight gain * Used for MDD, sleeping disorders, somatic and physiologic symptoms of anxiety or distress 4. Fatigue (\>50%) 5. Dry mouth (25%) 6. Constipation (13%) 7. Increased appetite 8. Dizziness 9. Myalgia 10. Dreaming disorders (???) 11. Mania/hypomania 12. Increased cholesterol and TAG 13. Increased ALT 14. Orthostatism 15. Neutropenia * In 0.3% * Stop the medication of occurs ## Footnote **התופעות לוואי הכי חשובות הן עלייה במשקל, שינה מוגברת וניוטרופניה**
246
Bupropion (Zyban) * Mechanism of action...[1] * Does not lead to...[2-6] * Indications...[7-12] * The combination with...[13] is the most effective one aginst MDD
1. NdRI - norepinephrin-dopamine reuptake inhibitor 2. Anti-cholinergic side effects 3. Weight gain 4. Sexual dysfunction 5. Fatigue 6. Orthostatism 7. MDD 8. Bipolar disease 9. ADHD 10. Cocain intoxication 11. Smoking cessation 12. Hypoactive sexual desire disorder 13. Fluoxetine
247
Bupropion (Zyban) - side effects * Common side effects...[1-7] * Less common side effects...[8-11] * Due to dopaminergic effect it may percipitate...[12] * ...[13] when combined with risk factors such as hyperkalemia * Exacerbation of...[14] or...[15] disease * Increase...[16] in...[17] patients * Rare side effects...[18-22]
1. Tremor (the most common) 2. Headahce 3. Insomnia 4. URT complaints 5. Nausea 6. Profuse sweating 7. Constipation 8. Restlessness 9. Anxiety 10. Sleep disturbances 11. Irritability 12. Psychotic symptoms 13. Seizures 14. Liver 15. Kidney 16. Blood pressure 17. Hypertensive 18. Rash 19. Pruritus 20. Lymphadenopathy 21. Pancytopenia 22. Confusion and delirium
248
Typical anti-psychotics - high potency drugs * ...[1],...[2],...[3] and...[4] * Have low...[5], and high...[6] effects
1. Trifluphenazine 2. Fluphenazine 3. Haloperidol 4. Pimozide 5. Anti-cholinergic 6. EPS
249
Typical anti-psychotics - low potency drugs * ...[1],...[2] * Have low...[3], and high...[4] effects * ...[5], have the lowest effect of...[6], because its potency is...[7]
1. Chloropromazine 2. Thioridazine 3. EPS 4. Anti-cholinergic 5. Prephenazine 6. EPS 7. Medium
250
EPS - parkinsonism * Occurs in...[1] * After...[2] days * Most common in...[3]...[4] * Treatment
1. 15% - the most common 2. 5-90 3. Elderly 4. Females 5. Anti-cholinergics / amantadine / diphenhydramine (benedril) * When treating with anti-cholinergics caution must be used with BPH, glaucoma and patients with urinary retention
251
ESP - acute dystonia * Occurs in...[1] * Most commonly in...[2],...[3] * Prevention * Treatment
1. 10% 2. Young 3. Males 4. Anti-cholinergics / diphenhydramine (benedril) / clonazepam 5. Anti-cholinergics / anti-histamines IM/IV
252
EPS - acute akathisia * Treatment
* Consider reducing the dose or replacing the drug * Best responds to propranolol (deralin). * Can also use benzodiazepines, anti-cholinergics or cyproheptadine
253
EPS - tardive dyskinesia * Occurs in...[1] of the patients who are treated with dopamine receptor antagonist * In...[2] of the patients after 12 months, and in...[3] of the patients after 4 years * Resolves in...[4] of the cases. * Resolves in...[5] of the mild cases * Risk factors...[6-13] * Prevention * Treatment
1. 30% 2. 10-20% 3. 20-30% 4. 5-40% 5. 50-90% 6. Prolonged use 7. Typical drugs 8. Patients older than 50 9. Kids 10. Females 11. Head injuries 12. Affective disorders 13. Cognitive disorders * Treat with the lowest dose possible. Treat with atypicals (clozapine have the lesser rate) * **Decrease the dose or stop acutely the drug, and change to atypical - mainly clozapine!** **​** * The main AE's of clozapine include myocarditis, agranulocytosis, seizures * If cannot tolerate clozapine - benzo/lithium/carbamazepine
254
Neuroleptic Malignant Syndrome * ...[1] of the patients who are treated with anti-psychotics * More common in...[2] gender, and in...[3] age * Can also occur with...[4] * Higher risk when...[5] are used * Develops within...[6] and last for...[7] * Death rate of...[8] * Symptoms...[9] * Treatment...[10]
1. 0.01%-0.02% 2. Male 3. Young 4. Anti-psychotics 5. IM depot formulas 6. 24-72 hours 7. 10-14 days 8. 10-25% 9. Symptoms include: * Hyperpyrexia * Changes in conciousness - agitation, delirium, stupor, coma, catatonia * EPS - rigidity, dystonia, akinesia, mutism, akathisia * Autonomic instability - tachycardia, hypertension, tachypnea 10. Stop the offending drug * Supportive treatment (cooling) * Bromocriptine / amantadine * ECT is useful (unilateral or bilateral) * For 5-10 days
255
Typical anti-psychotics - general adverse effects * Hyper...[1] * Anti-...[2] * Orth...[3] * Anti-histaminergic...[4] * Hematologic...[5] * Cardial...[6] * Skin...[7] * Liver...[8] * Decreased...[9]
1. Prolactinemia - gynecomastia, impotence, galactorrhea, amenorrhea, anorgasmia. OSTEOPORESIS 2. Cholinergic - both central and peripheral 3. Orthostatism - due to alpha-1 blockade 4. Increased appetite and sedative 5. Mild leuckopenia, rarely, agranulocytosis 6. Prolonged PR and QT intervals 7. Photosensitive rash 8. Cholestatic jaundice 9. Seizure threshold
256
Atypical anti-psychotics * Anti-psychotic effect * Reistent to treatment
* Appears after 3 weeks with full dose * No reaction after 4-10 week with the full dose
257
Atypical anti-psychotics - metabolic syndrome
* Central obesity, increased TG, decreased HDL, increased blood fasting glucose, hypertension * Clozapine and olanzapine have the highest effect * Aripiprazole have the lowest * Aripiprazole \< quetiapine \< risperidone \< olanzapine \< clozapine
258
Atypical anti-psychotics - other adverse effects
1. Salivation - mainly due to the use of clozapine. Treat with anti-cholinergics or with clonidine * Disturbed swallowing 2. Genitourinary disturbances including impotence 3. In high dose it can exacerbate OCD
259
Atypical anti-psychotics - clozapine * Used for...[1],...[2] and...[3] * Works for...[4] that are resistent to therapy * Works also on...[5] * Is found helpful is decreasing...[6] * Adverse effects include...[7-12] * 3 Contraindications for clozapine...[13] * Does NOT increase...[14]
1. Resistent schizophrenia (3 other drugs before) 2. Severe suicidal ideations 3. Tradive dykinesia 4. 30% 5. Negative symptoms 6. Sedation 7. Suicide rate 8. Metabolic syndrome 9. Anti-cholinergic AE's including QT prolongation 10. Agranulocytosis (1-2%) 11. Decreased seizure threshold * Decrease the dose and give additional valproic acid 12. Myocarditis 13. WBC \<3500, bone marrow disorders, history of agranulocytosis with clozapine 14. Prolactin * **בחילות, הקאות, חולשה, עייפות, סחרחורת, תת ל״ד, סינקופה, טאכיקרדיה** * **שינויים בא.ק.ג** * **עלייה במשקל, בעיות במערכת העיכול - הכי נפוץ עצירות** * **אנטי-כולינרגיות** * **חולשת שרירים**
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Atypical anti-psychotics - clozapine associated agranulocytosis * Occurs in...[1] of the patients treated with clozapine * Requires intensive follow up, that include bloodworks every...[2], for the first...[3], followed by once a...[4] for...[5] * If the WBCC is...[6] and/or PMNs are...[7], we need to stop the drug immediately * If the WBCC is between...[8] and/or PMNs are between...[9] we need to...[10]
1. 1% 2. Week 3. 6 months 4. 2 weeks 5. Ever 6. \<3,000 7. \<1,500 8. 3,000-3,500 9. 1,500-2,000 10. Do intensive follow up twice/week until increase above 3500/2000
261
Atypical anti-psychotics - clozapine and contraindicated drugs * Increased risk for agranulocytosis with...[1-6] * Lithium...[7] * Past NMS...[8] * Drugs that increase its blood concentration...[9-12] * Benzodiazepines...[13]
1. Phenytoin 2. Carbamazepine 3. Sulfonamides 4. PTU 5. Benzodiazepines 6. Captopril 7. Increase the risk for seizures, confusion and movement disorders 8. Clozapine with lithium is contraindicated 9. Fluoxetine 10. Paroxetine 11. Fluvoxamine 12. Risperidone 13. Will lead to delirium
262
Atypical anti-psychotics - risperidone (risperidal)
* 3-4 times higher risk for hyperprolactinemia * The drug with the most significant risk for hyperprolactinemia * In high dose can trigger EPS * Usually used as first line ## Footnote **עלייה במשקל, בחילות, הקאות, חרדה ובעיות בזקפה**
263
Atypical anti-psychotics - olanzapine (zyprexa)
* Higher rate of H1 AE's - metabolic syndrome. * Orthostatism * Constipation * Decreased seizure threshold * Can also be used as mood stablizer
264
Atypical anti-psychotics - quetiapine (seroquell)
* Lesser motoric side effects * Have anti-cholinergic effects * Good for patients with metabolic syndrome
265
Atypical anti-psychotics - ziprezidone (geodon)
* Have risk for QT prolongation * Contraindicated in patients with long-QT syndrome or history of arrythmias * There is almost none metabolic effects * Can be used for OCD ## Footnote **כאבי ראש, בחילות, חולשה** **אין לתת עם תרופות אחרות שמאריכות מקטע קיוטי**
266
Atypical anti-psychotics - aripiprazole (Abilify) * Mechanism of action...[1] * Adverse effects...[2-6] * EPS...[7] * Does not cause...[8-11]
1. Partial agonist to dopamine receptors 2. Headache, 3. Nausea 4. Anxiety 5. Dyspepsia 6. Sleep disturbances 7. Does not lead to EPS, but leads to akathisia-like phenomenoa 8. Hyperprolactinemia 9. Weight gain (or any metabolic disorder) 10. QT prolongation 11. Diabetes
267
6 contraindications for treatment with neuroleptics **לא בטוח בכלל**
1. Severe allergic reaction 2. Interactions with drugs that will lead to CNS depression 3. Risk for seizures 4. Severe cardiac abnormalities 5. Narrow angle glaucoma 6. Tradive dyskinesia (?)
268
Anti-psychotics - long acting formulas * The 5 drugs and courses of treatment * 3 benefits
1. Halidol deconate - 1 / 1-4weeks 2. Modecate deconate (Fluphenazine) - 1 / 2weeks 3. Clopixol depot (Zuclopenthixol) - 1 / 2weeks 4. Risperidal consta - 1 / 2weeks * The only atypical drug that have long acting formulation 5. SEMAP - 1 / 1week * The only that is given PO * Good control over plasma levels * Increased compliance * Eliminating absorption disorders
269
Anti-psychotics - 4 drugs that can be give in acute setting
1. Haloperidol 2. Olanzapine 3. Ziprezidone 4. Zulopenthixol * Lasts for 3 days
270
Lithium - characteristics * Excreted by the...[1] * Have narrow...[2] * Before starting the therapy, and every...[3] - blood works for...[4],...[5],...[6],...[7],...[8] and...[9] * If there are signs of intoxication, do blood works every...[10] * Does not bind to...[11] * Obesity increases...[12]
1. Kidney 2. Therapeutic range 3. 2-6 months 4. Renal function 5. Electrolytes (calcium included) 6. Blood count 7. TSH 8. beta-HCG 9. ECG 10. Week 11. Plasma proteins 12. Elimination
271
Lithium - GI side effects
* Nausea, vomiting, diarrhea, weight gain, dyspepsia, fluid retention
272
Lithium - CNS side effects 1. Cerebellar 2. Cognitive 3. Neuron toxic syndrome
1. Postural tremor, akathisia * For tremor prevention: split doses, use long acting formulation, decrease caffeine intake, correct hypokalemia * Treated with beta-blocker 2. Dysphoria, slow response * MG like response, decreased seizure threshold, parkinsonism 3. Acute confusional state, that is sometimes non reversible, that appears with combination with anti-psychotics
273
Lithium - renal side effects
* In 33% of the patients nephrogenic DI * Intersitial fibrosis * Nephrotic syndrome ## Footnote **In the kidney lithium acts the same way as sodium - pay attention to patients that prescribed low sodium diet (cardial patients)**
274
Lithium - thyroid, parathyroid side effects
* Goiter * Hypothyroidism - more commonly in females * Treat with levothyroxin (Eltroxin) * Hyperparathyroidism --\> hypercalcemia
275
Lithium - cardial side effects
* ECG that gives picture of hypokalemia - flattening of T waves * SA node suppression - contraindicated in patients with sick sinus syndrome
276
Lithium - skin
* **Acne** * Exacerbation of psoriasis * Hair loss
277
Lithium - hematologic side effects
* Leukocytosis without clinical relevance * Rarely, thrombocytosis - thrombotic events are rare
278
Lithium - intoxication * Mild intoxication: * Blood levels of...[1] * GI signs...[2] * Neurologic signs...[3] * Moderate intoxication: * Blood levels of...[4] * GI signs...[5] * Neurologic signs...[6] * Severe intoxication: * Blood levels of...[7] * Signs...[8] * Indication for hemodialysis...[9]
1. 1.5-2.0 2. Dry mouth, vomiting, abdominal pain 3. Dizziness, ataxia, nystagmus, slurred speech, muscle weakness 4. 2.0-2.5 5. N/V, anorexia 6. Blurred vision, hyperreflexia, clonic limv movements, seizures, delirium, ECG changes, syncope, stupor, coma 7. \>2.5 8. Renal failure, oliguria, generalized seizures, death 9. When lithium levels are \>4.0
279
Lithium - teratogenicity
* Level D * 4-12% risk for Ebstein anomaly * If women is taking lithium during the pregnancy - keep the minimal possible dose * 2 weeks before delivery maintain levels of 0.6 mEq/L * Follow up on TSH for risk of fetal hypothyroidism, follow up also on the heart of the fetus * Lithium is transferred in milk
280
Lithium - drug interactions * Drugs that increase blood levels...[1-3] * Durgs that decrease blood levels...[4-8] * Contraindicated with...[9]
1. ACE inhibitors 2. Thiazides 3. NSAID's * Except aspirin and sulindac 4. Loop diuretics 5. Osmotic diuretics 6. CA inhibitors 7. Xanthines 8. Caffeine 9. CCB's
281
Valproic acid (depalept) 1. GI side effects 2. CNS 3. Weight... 4. 6 other side effects 5. Teratogenicity level * Rare side effects...[6-8]
1. Frequent in the first month of the therapy. Abdominal discomfort, jaundice 2. Sedation, tremor (reacts well to beta blockers) 3. Gain 4. Alopecia (5-15%), increased LFT's, hepatotoxicity, changes in lipid profile, polycystic ovary, SIADH 5. Level X - absolutly contraindicated 6. Thrombocytosis with decreased function - follow up with patietns taking warfarin/aspirin 7. Agranulocytosis 8. Pancreatitis * Due to relatively small amount of side effects it is the drug that is recommended for children and elderly
282
Carbamazepine (tegretol) - physiologic effects 1. Hematologic 2. Endocrine 3. Liver 4. CVS 5. Skin 6. ...-like syndrome
1. Benign leukopenia 2. SIADH, increased thyroid hormones 3. Increased liver enzymes - can interfere with other drugs metabolism 4. Contraindicated in patients with AV block 5. Rash 6. SLE
283
Carbamazepine (tegretol) - side effects 1. Hematologic 2. Liver 3. Skin 4. Pancreas 5. GI 6. CNS 7. Heart 8. Urinary tract
1. in 1:250,000 - aplastic anaemia and agranulocytosis * Blood count every 3 months in the first year * In the first months blood count every 2 weeks 2. **Hepatitis, jaundice, cholestasis** 3. Risk for SJS and TEN * When rash develops - stop the drugs immediately 4. Pancreatitis 5. Most commonly - nausea, vomiting, abdominal discomfort, dyspepsia, constipation, anorexia 6. Acute confusional state can occur when combined with neuroleptics. Also agitation, nystagmus 7. Increased conduction time --\> contraidicated in patients with AV block 8. Risk for urinary retention
284
Carbamazepine (tegretol) - precautions * Contraindications include...[1],...[2] and...[3] * Precaution with...[4],...[5] and...[6] * Tertogenicity
1. Hematologic disease 2. Liver disease 3. AV block 4. Glaucoma 5. BPH 6. Diabetes 7. Increased risk for neural tube defects, intracranial hemorrhage * Pass in milk * Lithium have favorable tertogenic profile
285
Carbamazepine (tegretol) - durg interactions * An...[1] of cytochrome p450, that will lead to...[2] in concentrations of valproate and OCP's * ...[3],...[4],...[5] increase the concentration in the blood * Blood concentration can be reduce by...[6]
1. Inducer 2. Decrease 3. Fluoxetine 4. Lamotrigine 5. Valproate 6. Auto-induction
286
Lamotrigine (lamictal) * The only anti-epileptic that is useful for...[1] * Allowed in...[2] * Side effects: * Neurologic [3] * Skin [4] * Risk factors...[5-8] * This manifestation is not...[9]
1. Depression (in the setting of bipolar disease) 2. Pregnancy (level C) 3. Tiredness, headache, ataxia, blurred vision 4. Benign rash in 8% * Risk for SJS and TEN - stop the drug when the first signs of rash are seen 1. Age \<16 2. Given with valproate 3. Quick administration 4. High initial dose 5. Dose dependent
287
Lamotrigine (lamictal) - drug interactions * ...[1] increase the concentration by...[2] * ...[3] increase the concentration by...[4] * ...[4],...[5],...[6] decrease the concentration by about...[7] * Lamotrigine itself decrease the concentration of...[8]
1. Valproate 2. 2 times 3. Sertraline 4. 25% 5. Carbamazepine 6. Phenytoin 7. Phenobarbital 8. 40-50% 9. Carbamazepine
288
Topiramate (topamax) - side effects * Idiosyncratic...[1-4] * Non dosage dependent...[5-8] * To prevent the...[9] symptoms, we increase the dosage slowly
1. Parasthesia 2. Slurred speech 3. Fatigue 4. Psychomotor retardation 5. Decrease weight and appetite 6. Renal stone formation 7. Confusion 8. Decreased concentration 9. Cognitive symptoms
289
Benzodiazepines - side effects * Mainly of...[1] * If taken with...[2] can cause...[3] and...[4] * In therapeutic range: * Can cause...[5], this is why patients should not...[6] * Risk for...[7] and...[8] there is high risk for...[9] in the elderly * Patients with...[10] are at risk for developing...[11]
1. CNS 2. Alcohol 3. Disinhibition 4. Respiratory depression 5. Sedation 6. Operate heavy mechinary 7. Ataxia 8. Diziness 9. Falls 10. Brain damage (like autism) 11. Paradoxical agitation
290
Benzodiazepines - precautions 1. Pregnancy 2. Diseases of... 3. Dont take with... 4. Precaution with...[4],...[5],...[6],...[7] and...[8]
1. Teratogenic. * Decrease fetal motility * Considered teratogenic * In the third trimester there is risk for fetal withdrawl syndrome * Passed in milk - lactation is contraindicated * D-level 2. Liver and kidney 3. Alcohol 4. COPD 5. OSA 6. Drug abuse 7. Cognitive disorders 8. Myasthenia gravis
291
Benzodiazepines - long acting * Half-life range of...[1] * 5 drugs
1. 30-100 hours 2. Diazepam (Valium) 3. Chlordiazepoxide 4. Clonazepam (Clonex) 5. Clorazepate 6. Flurazepam
292
Benzodiazepine - intermediate acting * Half-life rage of...[1] * 4 drugs
1. 8-30 hours 2. Lorazepam (Lorivan) 3. Oxazepam (Vaben) 4. Temazepam 5. Estazolam
293
Benzodiazepines - short acting * Slightly longer half-life...[1] * 1 drug...[2] * Shortest half-life of...[3] * 1 drugs...[4]
1. 10-15 hours 2. Alprazolam 3. 2-3 hours 4. Tirazolam
294
Benzodiazepines - lipid soluble * 3 drugs
1. Midazolam (not really psychiatric drug) 2. Alprazolam (xanax) 3. Diazepam (valium, assival)
295
Benzodiazepines - rapid acting drugs * 4 drugs
1. Alprazolam 2. Diazepam 3. Estazolam 4. Tirazolam
296
Benzodiazepines - discontinuation syndrome * Symptoms of...[1] * Recommended cessation of the drug...[2] * We can use...[3] * ...[4] excerbate the symptoms
1. Hyperarousal * Delirium, hypertension. tachycardia, myoclonus, agitation, tremor 2. Decrease the dose by 25% every week 3. BB's, valproic acid, carbamazepine, clonidine, sedative anti-depressent 4. Flumazenil
297
Alcohol abuse - epidemiology * ...[1] in females and...[2] in males * More in...[3] skin color, living in...[4] areas and with...[5] education * Have the strongest...[6] factor among all the abuses
1. 10% 2. 20% 3. White 4. Urban 5. High 6. Genetic
298
Alcohol abuse - general features * Symptoms correlate with...[1] * High...[2] in 60% of the patients * Increased...[3] and...[4] (liver enzymes) * ...[5] is the most sensitive * Signs of...[6] in CXR in 30% * During sleep there is...[7] in REM phase * Psychiatric co-morbidities include...[8-11] * ....[12] suicide rate
1. Alcohol blood levels 2. MCV 3. AST 4. GGT 5. GGT 6. Fractures 7. Shortening 8. Other substance abuses 9. Anti-social personality disorder 10. Mood disorders 11. Anxiety 12. 10-15%
299
Alcohol abuse - fetal alcohol syndrome * Occurs in...[1] of the mothers that abuse alcohol during the pregnancy * Include: * Pre and post-natal...[2] * ...[3]cephaly * Dysmorphism...[4,5,6] * ...[7] dislocation * ...[8] defects * In severe cases...[9] and...[10] can occur
1. 35% 2. Developmental retardation 3. Micro- 4. Small palpebral fissure 5. Thin vermilion border 6. Smooth filthrum 7. Limb 8. Heart 9. Heart-lung fistula 10. Holoprosencephaly
300
Alcohol abuse - withdrawl * Mild signs include...[6 symptoms - scheme] * Delirium tremens: * Occurs in the...[1] after withdrawl * ...[2] death rate * Symptoms [7 symptoms - scheme] * Treatment include...[3] * Second line...[4-6] * Avoid...[7] as they decrease seizure thershold
1. 72 hours 2. 20% 3. Benzodiazepines (diazepam, lorazepam) 4. Carbamazepine (tegretol) 5. Beta-blockers 6. Clonidine 7. Anti-psychotics **ההזוית מאופיינת כהזיות תחושתיות וראייה** **באחת השאלות בנקודות, ההזיות מתוארות כדליריום**
301
Wernicke-Korsakoff syndrome * Mostly in patients that abuse alcohol due to...[1] deficieny * Wernicke is...[2] and...[3] condition * Characterized by...[4-6] * Korsakoff is...[7] and...[8] condition * Characeterized by...[9,10] * Treatment is with...[11] * For Wernicke treatment is for...[12] weeks * For Korsakoff treatmet is for...[13] weeks
1. Thiamine (B1) 2. Acute 3. Reversible 4. Confusion 5. Ataxia 6. Nystagmus 7. Chronic 8. Irreversible 9. Anterograde amnesia 10. Short term memory loss 11. Thiamine 12. 1-2 13. 3-12 **בנקודות לוורניקה יש עוד סימנים:** **אופתלמופלגיה, ניסטגמוס, lateral orbital palsy, gaze palsy**, **הפרעות קורדינציה,**
302
Opiate abuse - general features * Prevalance of...[1] * Psychiatric co-morbidity include...[2-5] * ...[6] try to commite suicide * Induce their effect by binding into opiate receptors and indirectly lead to realse of...[7] * Act as CNS...[8] * Intoxication is characterized by...[9] pupils, decreased...[10] function and eventually...[11]
1. 0.1% 2. Other substance abuse 3. Anti-social personality disorder 4. Borderline personality disorder 5. Mood disorders 6. 15% 7. Dopamine 8. Depressent 9. Pin-point 10. Autonomic 11. Respiratory depression
303
Opiate abuse - withdrawl * Have the opposite effects and include...[1-3] * Characterized by increased...[4] and increased...[5] * Pupillary...[6] * Characteristic is...[7] and...[8] * ...[9]algia
1. Dysphoria 2. Anxiety 3. Restlessness 4. Autonomic function - hypertension, tachycardia, hyperthermia/hypothermia 5. Body fluid secretion - lacrimation, rhinorrhea, diarrhea 6. Dilation 7. Piloerection 8. Yawning 9. Myalgia
304
Opiate abuse - pregnancy * Withdrawl in pregnancy is not advised, only in the...[1] it is possible * ...[2] of the abusers during pregnancy have additional psychiatric disorder * If there is dependence, treat with...[3], doeses of which will need to be increased during the 3rd trimester
1. 2nd trimester 2. 90% 3. Methadone - partial agonist for u receptors will long half life (15 hours)
305
Opiate abuse - treatment * Step-wise approach * Initial step is with...[1] * Followed by...[2] * And the last step is with...[3] * In acute setting we give...[4]
1. Methadone 2. Buprenorphine - partial agonist to u and k receptors 3. Naltrexone 4. Buprenorphine
306
Stimulant abuse - general features * Cocaine, crack, amphetamines, MDMA * Prevalance of...[1] * Cocaine mechanism...[2] * In premanant use it can lead to...[3] and...[4] * When it induces psychosis, characteristic is...[5] * Co-morbidity with...[6-11] * Patients can self treat with...[12] and...[13] * Stimulants can induce...[14-17] * Life-threatening conditions include...[18,19]
1. 1.5% (M=F) 2. Reuptake inhibitor of serotonin, dopamine and NE 3. Impotance 4. Nasal perforation 5. Formication 6. MDD 7. BP2 8. Cyclothymia 9. Anti-social personality disorder 10. ADHD 11. Other substance abuse (alcohol) 12. Benzodiazepines (clonazepam) 13. Alcohol 14. Anxiety (stimulat induced anxiety disorder) 15. OCD (stimulant induced OCD) 16. Sexual dysfunction (stimulant induced sexual dysfunction) 17. Sleeping disorder (stimulant induced sleep disorder) 18. Vascular disorders (MI, stroke) 19. Seizures
307
Stimulants - withdrawl * Symptoms starts within...[1] and disappear after...[2] * ...[3] * ...[4] disorder due to...[5] * Increased...[6] * Risk for...[7] that will lead to...[8]
1. 2-3 days 2. Week 3. Tiredness 4. Sleeping 5. Nightmares 6. Appetite 7. Depression 8. Suicide
308
Stimulants abuse - treatment * Psychosis and withdrawl signs...[1] * When agitation is consider...[2] * In depression...[3,4] can be used and are more efficient than SSRI's * In hyper-activity...[5]
1. Usually mandates no treatment but supervision 2. Antipsychotics - haloperidol 3. Buproprion 4. Despiramine 5. Dizepam (Valium)
309
Cannabis abuse - general features * The...[1] most common abused substance * Up to the age of 34 it is more commonly used in...[2] and above the age of 35 it is equally used * CB1 receptors are found in the...[3-6] especially in dopaminergic cells * THC can be found in the urine...[7] days after it abuse
1. 4th 2. Whites 3. Cortex 4. Basal ganglia 5. Cerebellum 6. Hippocampus 7. 21 (due to rapid absorption in adipose tissue)
310
Cannabis abuse - symptoms * The most common sign is...[1] * Euphoria starts within...[2] and lasts for...[3] * Motor disturbance lasts...[4] after using * In posioning...[5-9] can be seen * In the long term,...[10-14]
1. Conjunctival injection 2. 30 minutes 3. 2-4 hours 4. 8-12 hours 5. In sensitivity to stimuli (colors etc...) 6. Slowed time perception 7. Orthostatism 8. Depersonalization 9. Derealization 10. A-motivational syndrome 11. Decrease seizure threshold 12. Decreased immune system activity 13. Cognitive disturbance 14. Increased risk for lung cancer/COPD
311
Cannabis abuse - withdrawl * Occurs only with...[1] cessation * Starts within...[2] * Include signs of...[3] and...[4] * Sleeping disorders with...[5] * GI signs include...[6,7] * In physical examination we can see...[8,9]
1. Abrupt 2. 1-2 weeks 3. Anxiety 4. Irritability 5. Vivid dreams 6. Abdominal pains 7. Decreased appetite 8. Tremor 9. Sweating
312
Hallucingoen abuse - LSD * Mechanism...[1] * Peak of acitivty is within...[2] and works for...[3] * Symptoms include: * ...[4] pupils * Heart...[5,6] * Vision...[7] * Decreased...[8] * Physical examination show...[9,10] * Hallucinations are characterized by increased...[11] * Hallucinations can be of...[12-14] * In posioning treat with...[15] and try to avoid...[16] * In severe psychosis...[17,18] can be used
1. Partial agoinst of the serotonin receptor 5HT2C 2. 2-4 hours 3. 12 hours 4. Dilated 5. Tachycardia 6. Palpitations 7. Blurred 8. Coordination 9. Tremor 10. Sweating 11. Sensation perception 12. הילה 13. Micropsia/Macropsia 14. Geometric hallucinations 15. BZD 16. Antipsychotics 17. Antipsychotics 18. ECT
313
Hallucinogen abuse - PCP * Mechanism...[1] * Characterized by...[2-5] * Symptoms include: * Decreased...[6] sensation * ...[7] and...[8] * Muscle...[9] * ...[10] which can in any direction * Treatment is with...[11] of the urine and...[12]
1. Antagonist for NMDA recptors (glutaminergic system) 2. Agression 3. Impulsivity 4. Agitation 5. Lack of noise tolerance 6. Pain 7. Ataxia 8. Dysarthria 9. Stiffness 10. Nystagmus 11. Acidification 12. Anti-psychotics
314
Hallucinogen persistent perception disorder
**חוויה מחדש של התסמינים שהיו בעת צריכת החומר** **פלאשבקים: עיוות ויזואלי, הלוצינציות גיאומטריות, הזיות שמיעה, תפיסה שגויה של תנועה בשדה הפריפרי, הבזקי צבע, טריילניג, מיקרופסיה, מאקרופסיה, הופעת הילה סבב עצמים**

פסיכיאטריה (3 decks)

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