פסיכיאטריה Flashcards
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
- 1%
- 15-25
- 25-35
- Late onset is considered after the age of 45
- 3-10%
- 40
- Rarely presents before the age 10 and after the age 60
- Winter or early spring
- Lower
- Urbanic
- Downward drift hypothesis
- Social causation hypothesis
- Schizotypal
Schizophrenia - biological factors
- Dopamine theory
- 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
- 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
- Increased serotonin - leads to both negative and positive symptoms
- GABAgeric
- Glutamate
- Nicotinic
- Muscarinic
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
- 8%
- 12%
- 40%
- 12%
- 47%
- Father
- 60
Schizophrenia - Bleuler’s areas of life
- Described as the 4A’s
- Affect
- Ambivalence
- Association
- Autism
- Later, alogia, avolition and anhedonia were added
Schizophrenia - Schnider’s symptoms
- 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
Schizophrenia - negative symptoms
- 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
Schizophrenia - cognitive symptoms
- 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
Schizophrenia - diagnosis (DSM-5)
- 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
- Decrease in function for significant time, since the disease onset
- For at least 6 months
- No affective disorder
- If autism is present - hallucinations or delusion must be present
Schizophrenia - paranoid type
- Abrupts in 20-30 - better prognosis
- Mainly delusions (grandiosity and presecution) and hallucinations
- There is lack of the other symptoms
- No negative symptoms
Schizophrenia - disorganized type
- 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
Schizophrenia - catatonic type
- At least 3 of the following:
- Catalepsy, including waxy flexibility
- Motor action without goal
- Extreme negativism
- Wired motor activity
- Echopraxia or echolalia
Schizophrenia - residual type
- Patients after schizophrenic abruption that are left only with the negative symptoms
- In this stage there are no characteristics of psychosis
Schizophrenia - undifferentiated type
- Schizophrenic patients that does not fit to any other subtype
Schizophrenia - post-psychotic depression
- Occurs in…[1] of patients
- …[2] will try to suicide, and …[3] will commit suicide
- Criteria …[4]
- 25%
- 50%
- 10-13%
- 3 conditions:
- Criteria for MDD
- Abrupt in the residual phase of schizophrenia
- Isnt on the background of medications or other organic disease
Schizophrenia - violence risk
- Risk factors
- Emergency treatment
- Treatment
- 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
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
- 50%
- >90%
- Decrease AE’s of anti-psychotics
- Decrease positive symptoms
- Improves functioning
- 30-50%
- 15-25%
- 5-10%
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
- Shorter
- Obesity
- T2DM
- CVD
- COPD
- HIV
- x1.5-2.0 higher than the general population
- Prevasive developmental disorder (PDD)
- Schizoaffective
- MDD
- Rheumatoid arthritis
- 33%
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
- 40-60%
- 10-20%
- 10-60%
- 20-30%
- 20-30%
- 40-60%
- >50%


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]
- Leading
- 50%
- 10-13%
- Good
- Depressive episode
- 80%
- Young age (although it is found in the bad prognosis criteria)
- Substance abuse
- Delusions
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]
- Atypicals are the first option - risperidone or olanzapine
- If typicals are given, perphenazine is given
- There is lack of compliance or in acute stage
- 60-70%
- 50-70%
- 15-25%
- 6-8 weeks
- 4 weeks
- Increase the dose or change of clozapine
Schizophrenia - psychosocial treatment
!!!!!!להוסיף מנקודות
- Social skills - improve relations, eye contact, spontanic interactions, understanding of social interactions
- Family treatment
- CBT - found beneficial for supressing delusions and hallucinations
- Psychotherapy
- Rehabilitation
Schizophrenia - adjuvant therapy
- Lithium - decrease psychotic signs
- Anti-epileptics - decrease violent episodes
- Benzodiazepines
Schizophreniform disorder - diagnosis (DSM-5)
- 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
Schizophreniform disorder - prognosis
- …[1] will turn to schizophrenia patients
- Higher frequency of…[2]
- 60-80%
- Post-psychotic depression
Schizophreniform disorder - treatment
- Drugs
- Recurrent episodes
- Catatonic symptoms or prominent depression
- Psychothrapy
- Antipsychotics for 3-6 months
- Mood stabilizers - lithium, carbamazepine, valproic acid
- Consider ECT
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
- 0.5-0.8%
- Female
- Later
- Anti-social
- Flat affect
- 50%
- 50%
- 33%
- 66%
- Mood congurent or mood incongruent
- Delusions or hallucinations
- 2 weeks
- DISC1
- Bipolar
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
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
Schizoaffetive disorder - prognosis
- Better prognosis than…[1] patients
- Worse prognosis than…[2] patients
- Multiple…[3] signs are bad prognostic indicators
- Schizophrenia
- Mood disorder
- Schizophrenic
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
- 0.2-0.3%
- 40
- Females
- Low
- 25%
- 10%
Delusional disorder - risk factors
- …[1] age
- …[2] that can be physical, sensory or social
- …[3]
- …[4] socioeconomic state
- Old
- Isolation
- Family history
- Low
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
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
- 50%
- 20%
- 30%
- Young
- Good
- Female
- Acute
- 30
- Short
- Erotomanic
- Persecution
- Somatic
Delusional disorder - treatment
- Treatment of choice
- If there is no change within…[2], …[3]
- Failure of treatment, consider…[4] or…[5]
- Psychotherapy
- Antipsychotics with gradually increased dose
- 6 weeks
- Change to other antipsychotic
- Mood stabilizers
- Anti-depressents
Brief psychotic disorder - definition and epidemiology
- Definition
- More common in…[2] age, …[3]
- …[4] countries
- …[5] socioeconomic states
- 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
- Young
- Females
- Developing
- Low
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
Brief psychotic diorder - prognosis
- …[1] without major psychiatric disorders thoughout life
- About…[2] will develop chronic psychiatric disease
- 50-80%
- 50%
לפי נקודות: לרוב לא יהיו מחלות פסיכיאטריות לאחר אירוע אחד
Brief psychotic disorder - treatment
- Drugs
- Psychotherapy
- High potency antipsychotics (haloperidol) in low doses and benzodiazepines
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]
- 1/2
- 50%
- 50%
- 50%
- 4 months
- Anti-depressents and lithium, sometimes in combination with antipsychotics
Catatonia - epidemiology
- …[1] related to mood disorders
- …[2] associated with schizophrenia
- Specifiers
- 25-50% (בסבב ולדימיר אמר יותר מחמישים אחוז)
- 10%
- 3 types:
- Associated with another mental disorder
- Due to another medical condition
- Unspecified
Catatonia - diagnosis (DSM-5)
- At least 3 of the above:
- Catalepsy
- Waxy flexibility
- Stupor
- Agitation
- Mutism
- Posturing
- Mannerism
- Negativism
- Stereotypies
- Grimcing
- Echolalia
- Echopraxia
- Rigidity (not sure!)
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
- …[3] are used, …[4] is the gold standard
- Hospitalization
- Feeding and hydration. IV or NG tube can be used
- Benzodiazepines
- Lorazepam
- Diazepam
- ECT
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]
- Decreased levels are associated with depression
- The most associated neurotransmitter - decreased levels
- High levels of dopamine and in mania and low levels in depression
- 50%
- Dexamethasone supression test
- Thyroid
- Growth hormone
- Melatonin
- Sex hormones
- Prolactin
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]
- 10-25%
- 20-50%
- 70-90%
- 10-35%
- 2-10
- 50%
- 8-18
- 50%
- 33-90%
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]
- 17%
- Twice
- Females
- 40
- 50%
- 40
- Singles, separated or widowed
- Socioeconomic levels
MDD - diagnosis (DSM-5)
- At least 5/9, in which 1 or 2 must be present. All the symptoms must be present for at least 2 weeks:
- Depressed mood, most of the day
- Anhedonia
- Change in apetite
- Sleep disturbances
- Psychomotor retardation
- Loss of energy
- Guilt
- Decrease in concentration
- Suicidal ideation
- The symptoms cause significant distress or decrease in function
- Rule out substance abuse or GMC
- Isnt explained better with other psychiartic disorders
- Rule out manic or hypomanic episode in the past
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
- Deny their symptoms
- Loss of energy
- Anxiety
- Diurnal variation
- More frequent
- Longer
- 66%
- 10-15%
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]
- Alcoholism
- OCD
- Social anxiety disorder
- Panic disorder
- Anxiety disorder
- 90%
- Substance abuse
- Eating disorders and anxiety
- ADHD
- Anxiety disorders
- Alcohol dependence
- Dysthymia
- Schizophrenia
- Other psychotic disorders
- Bipolar disorder
- Unipolar disorder
MDD - specifiers
- With:
- Anxious distress
- Psychotic features
- Melancholic features
- Atypical features
- Mood congruent psychotic feats.
- Mood incongruent psychotic feats.
- Catatonia
- Peripartum onset
- Seasonal pattern
MDD - melancholic specifier
- Lack of mood reactivity with at least 3:
- Depressed mood
- Worse in the morning
- Agitation
- Early awakening (2h before)
- Decreased weight
- Severe feeling of guilt
MDD - atypical specifier
- Mood reactivity with at least 2 of the following:
- Increased appetite
- Hypersomnia
- Leaden paralysis
- 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
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
- SSRI
- 3-4
- Lithium
- Thyroid hormones
- Buproprion
- Change the drug
- Another SSRI
- SNRI
- 4 weeks
- 2-4 weeks
- Anti-psychotic and anti-depressent
- SSRI
- Buproprion
- Paroxetine
- 6 months
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
- 5-10%
- 5-10%
- 6-10 years
- 32
- 25%
- 30-50%
- 50-75%
- 70%
- 30%
- 30%
- 5-6
- 6-13 months
- 50%
- Decreases
- 3 months
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%
- 30
- Equal
- Males
- Singles, divorced
- High
Manic episode - diagnosis (DSM-5)
- 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)
- In the same week at least 3/7
- Distractibility
- Insomnia
- Grandiosity
- Flight of ideas
- Activity increase
- Pressured speech
- Thoughtlessness (activity that have high risk or give a lot of pleasure)
- Significant functional disfunction
- Rule out substance abuse or GMC
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
- Depressive
- 70%
- 67%
- 2-4
- 10-20%
- Rapidly
- Weeks
- 3 months
- Shortens
- 6-9 months
- 9
- Substance abuse
- Anxiety
- Catatonia
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
Bipolar I disorder - treatment
- Acute mania
- Depressive episode
- Prophylaxis
- Rapid cycling patients
- Antipsychotics (new generation) and mood stabilizers
- Lithium, carbamazepine, valproate, clonazepam, antipsychotics
- 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 options:
- Lithium
- Valproic acid
- Cabamazepine
- Lamotrigine is more efficient in treatment and prevention of depressive episodes
- Positive outcomes with buproprion or nimodipine
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
- Worse
- 7%
- 50%
- 40%
- 15%
- 45%
- 30%
- 10%
- 50-60%
- Bad
- Alcohol
- Psychotic
- Depressive
- Depressive
- Male
Hypomanic episode - diagnosis (DSM-5)
- Abnormaly elevated mood with goal direct activity, for at least 4 consecutive days, for most of the day, almost everyday
- 3/7 symptoms (such as manic episode DIG FAST)
- Decrease in function in lesser severity
- Observable by others
- Not severe enough to cause decrease in fucntion in social/work and does not nessciate hospitalization
- Rule out substance abuse and GMC
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]
- 5-6%
- Equal
- Single
- Low
- MDD
- Childhood/adolescence
Dysthymic disorder - diagnosis (DSM-5)
- Depressed mood for most of the day, indicated by the patient or by other, for at least 2 years
- Presence while depressed of at least 2:
- Appetite changes
- Sleep changes
- Low energy
- Low self-esteem
- Poor concentration
- Hopelessness
- During the period, there was no period of more then 2 months without the symptoms
- No MDD (?)
- No manic, hypomanic, mixed or cyclothymic disorder
- Not part of other psychotic disturbance
- No substance abuse or GMC
- Distress and decrease in function
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
- 50%
- 25
- 20%
- 15%
- 5%
- 10-15%
- 25%
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%
- Borderline personality disorder
- 3:2
- 50-75%
- 15-25
- Substance abuse
- 30%
Cyclothymic disorder - diagnosis (DSM-5)
- Several periods of hypomania and several periods of depression that is not MDD, for at least 2 years
- No period of more then 2 months without the symptoms
- No episodes of MDD, mania or mixed
- Isnt part of other psychiatric disorder
- No substance abuse or GMC
- Distress and decrease in function
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
- Progressive
- Early 20’s
- 33%
Cyclothymic disorder - treatment
- Drugs
- Psycho-social treatment
- 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
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
- Autonomic, sympathetic tone
- REM latency
- 4th step
- GABA
- Serotonin
- Dopamine
- Temporal cortex
- Locus ceruleus
- Amygdala
- Loss of loved object
- Physical injury
- Conditioned reaction
- Parents
- Cognitive thinking
- 50%
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
- 1-4%
- 3-5.6%
- 2-3
- Female
- 25
- Genetic
- Divorce
- Separation
- Temporal
- 4-8
Panic attack - criteria (DSM-5)
- 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:
- Palpitations
- Sweating
- Shaking
- Dyspnea
- Feelings of choking
- Chest discomfort
- Nausea
- Dizziness
- Chills or heat sensations
- Parasthesias
- Derealization/depersonalization
- Fear of losing control
- Fear of dying
Panic disorder - diagnosis (DSM-5)
- Recurrent, unexpected panic attacks
- At least 1 of the attacks has been followed by at least 1 month of 1 or both of the following:
- Persistent concern about panic attacks of their consequences
- Significant maladaptive behavior related to the attacks
- Not due to substance abuse or GMC
- Not better explained by other mental disorder
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]
- 91%
- MDD
- During
- After
- MDD
- SAD
- Social phobia
- Specific phobia
- GAD
- PTSD
- Ilness anxiety disorder
- Personality disorder
- Substance abuse
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
- Chronic
- Variable
- 30-40%
- 50%
- 10-20%
- MDD
- 40-80%
- Suicide
- 20-40%
- Good
- Short
Panic disorder - treatment
- CBT
- Drugs
- Conservative approach
- 2nd line
- Treatment failure
- More efficient in inducing long term remission
- 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
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]
- 0.6-6%
- 75%
- Panic disorder
- Traumatic life event
- Panic disorder
Agoraphobia - diagnosis (DSM-5)
- Marked fear/anxiety about 2 of the following:
- Public transportation
- Open spaces
- Enclosed spaces
- Stading in line/being in crowd
- Being outside of home
- Fear/avoidance due to the fear that if the patient will develop panic symptoms, there will be no way to escape
- Agoraphobic situations provoke fear/anxiety
- Agoraphobic situations are actively avoided
- more then 6 months
- Fear/anxiety are out of proportion to the danger imposed
- Distress or decrease in function
- If another medical condition is present fear/anxiety/avoidance is clearly excessive
- Not due to another mental disorder
Agoraphobia - treatment
- Psychotherapy
- Drugs
- Supportive, CBT
- 3 options:
- Benzodiazepines
- SSRI’s
- TCA’s
The 5 general features of phobia
- Anxiety and stress
- Provoked
- Ego-dystonic
- Avoidance
- Anticipation
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]
- 10%
- Females
- Males
- 5-9
- 20’s
- Twice
- Females
- 50-80%
- Depression
- Anxiety
- Substance abuse
Specific phobia - diagnosis (DSM-5)
- Marked fear/anxiety aboud specific object/situation
- Almost always provokes immediate fear/anxiety
- Phobic object is actively avoided or endured with intesnse fear
- Fear/anxiety is out or proportion to the actual danger
- Fear/anxiety/avoidance is at least 6 months
- Significant distress or decrease in function
- Not better explained by other mental disorder
Specify: type of phobia
Specific phobia - treatment
- CBT
- Psychotherapy
- Drugs
- Most effective - systemic desensitization, flooding, intensive exposure
- Insight oriented
- Benzodiazepines, beta blockers
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]
- 3-13%
- Teens
- Females
- Anxiety
- Affective
- 33%
- MDD
- Bulemia nervosa
- Substance abuse
Social anxiety disorder - diagnosis (DSM-5)
- Marked fear/anxiety about 1 or more social situations, in which the individual is exposed to possible scrutiny by others
- Fear that he/she will act in a way that will be negatively evaluated
- Social situations almost always provoke fear/anxiety
- Social situations are avoided
- Fear/anxiety is out of proportion
- For 6 months or more
- Distress or decrease in function
- Not due to drugs of GMC
- Not better explained by other mental disorders
- If other medical condition the fear/anxiety/avoidance is clrealy unrelated or excessive
Specify: performance only
Social anxiety disorder - treatment
- Psychotherapy
- Pharmacotherapy
- CBT, social skill training
- 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
GAD - epidemiology
- Prevalence of…[1]
- …[2] more common in…[3]
- …[4] of …[5] are also effected
- Onset is usually in…[6]
- 5%
- Twice
- Females
- 25%
- First degree relatives
- Adolescense/early adulthood
GAD - diagnosis (DSM-5)
- Excessive anxiety and worry occuring at least 6 months abount number of activities
- The individual finds it difficult to control the worry
- Anxiety and worry are associated with at least 3 of the following:
- Restlessnesss
- Easily fatigued
- Difficulty concentrating
- Irritability
- Muscle tension
- Sleep disturbances
- Significant distress or decrease in function
- Not due to substance or abuse or GMC
- Not better explained by another mental disorder
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]
- 50-90%
- Social phobia
- Specific phobia
- Panic disorder
- Depressive disorder
GAD - treatment
- Psychotherapy
- Drugs
- CBT - insight oriented, and supprotive therapy
- Few options:
- Benzodiazepines - 75% response. 2-6 weeks therapy
- 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
- Buspirone - more effective in reducing congnitive symptoms
- SNRI (venlafaxine) - good for patients with insomnia, poor concentration, distress and muscle rigidity
Substance induced anxiety disorder - diagnosis (DSM-5)
- Clinical signs of anxiety or panic attack
- There is clues from history taking, clinical examination and lab:
- Symptoms developed during/immediatley after/during posioning/rehab.
- The drug is known to induce anxiety
- Rule out another mental etiology:
- Symptoms appeard before the use of drug
- Present at least 1 month after stoping the drug
- Clues of mental disroder that is not related to the drug
- Is not present only in delirium
- Significant distress or decrease in function
Anxiety disorder due to another medical condition - diagnosis (DSM-5)
- Clinical signs of anxiety or panic attack
- There are clues in history/physical examination/lab that the disturbance is directly due to another medical condition
- Rule out another mental disorder
- Is not only in the time of delirium
- Significant distress or decrease in function
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
- 2-3%
- F=M
- In adolescents M>F
- 20
- 19
- 22
- Singles
- White
- 4th
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
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]
- 50%
- Sudden
- 50-70%
- Stressful life event
- זיהום, ספק פתולוגי, סומאטי, סימטריה, אגרסיה, מיניות
- בדיקה, שטיפה, ספירה, צורך לשאול, סימטריה, אגרנות
- Serotonin (low levels in the CSF)
- Norepinephrine
- Atrophy
- Caudate nucleus
- Frontal
- Cyngulum
- Thalamus
OCD - diagnosis (DSM-5)
- Presence of obsession, compulsions or both:
- Obsession defined by both conditions:
- Recurrent and persistent behaviors that are intrusive and unwated and cause anxiety or distress
- The patient tries to ignore or supress the behaviors or to neutralize them
- Compulsions defined by both conditions:
- Repetitive acts that the patient feel drive to preform in response to obsession
- 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
- Obsession defined by both conditions:
- These are time consuming or cause distress or decrease function
- Not due to substance abuse or GMC
- Is not better explained by another mental disorder
- Specifiers:
- with good/fair/poor/absent insight/delusional beliefs.
- Tic-related
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]
- 67%
- 25%
- 20-30%
- 5-7%
- 12%
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
- 50%
- 50-70%
- 20-30%
- 40-50%
- 20-40%
- Favorable factors:
- Good pre-morbid condition
- Onset after stressor
- Episodic symptoms
- Poor factors:
- Obligation to compulsions
- Childhood onset
- Bizzare compulsions
- Hospitalization
- Concurrent MDD
- Delusional beliefs
- Concurrent personality disorder (schizotypal)
- Overvalued ideas
- Obessions
OCD - adult treatment
- CBT
- Pharmacologic
- Augmentation
- ECT
- Have at least the same effect as pharmacologic treatment, thus, accounts for treatment of choice
- Exposure and reaction prevention
- Thought stopping
- 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
- To fully resistent disease
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
BDD - epidemiology
- Prevalence of…[1]
- More in…[2] gender
- Disorder shows at the age…[3]
- More common in…[4]
- 2.4%
- Female
- 15-30
- Singles
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
- Lack of serotonin
- Hair
- 63%
- Skin
- Nose
- 50%
- Eyes
- 33%
- 20%
BDD - diagnosis (DSM-5)
- Preoccupation with precived physical defect, that others cannot notice
- Repetitive behaviors or mental acts as response to this precived defect
- Significant distress or decrease in function
- Not due to eating disorder
- Specify:
- Good/fair/poor/absent/delusional beliefs
- With muscle dysphoria
BDD - comorbidity
- More then…[1] expreinced episodes of…[2]
- …[3] had anxiety disorder
- …[4] had psychotic disorder
- 90%
- MDD
- 70%
- 30%
BDD - treatment
- CBT
- Drugs
- Augmentation
- The most effective therapy
- 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
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
- 2-5%
- F=M
- Singles
- Traumatic life event
- 30%
- 20%
- 80%
- Syntonic
- Resistent
- Fluctuant
- Rare
- Late
Hoarding disorder - diagnosis (DSM-5)
- Presistent difficulty in parting of possessions
- Due to the need to preserve, and distress while discarding
- Items fill and block the living areas
- Hoarding cause distress or decrease in function
- Not due to other medical disease
- Is not better explained by other mental disorder
- Specify:
- Good/fair/poor/absent insight/delusional beliefs
- With excessive acquisition
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
- 1-2%
- Female
- Adolescence
- 35-40%
- Automatic
- Focused
- Young!!
Trichotillomania - diagnosis (DSM-5)
- Recurrent hair pulling or hair loss
- Recurrent attempts to stop hair pulling
- Causes distress or imapirment of function
- No due to other medical condition
- Is not better explained by other psychiatric disorder
Trichotillomania - treatment
- Psychotherapy
- Drugs
- Hypnosis
- Behavioral therapy
- Topical steroids, SSRI’s which can be augmented with pimozide
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]
- 1-5%
- Adolescence
- Female
- 15%
- 12%
- Resistent
Excoriation - diagnosis (DSM-5)
- Skin picking resulting in lesions
- Recurrent attepmts to stop skin picking
- Symptoms cause distress and impairment in function
- Not due to substance abuse
- Not due to other mental disorder
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
- 9-15%
- 8%
- 5-15%
- 10-12%
- 5-6%
- Young adults
- Singles
- Low
- 66%
PTSD - diagnosis (DSM-5)
- Exposure to life theratening situation
- Directly
- Witnessing
- Learning that the event occured to close person
- Extreme exposure to aversive detalis (work related)
- At least 1 intrusive symptom:
- Intrusive distressing memories
- Recurrent distressing dreams
- Dissociative reactions (flashbacks)
- Psychological response when exposed to stimuli
- Physiological response when exposed to stimuli
- At least 1 avoidance symptom:
- To avoid distressing memories
- To avoid extrenal reminders
- At least 2 negative alterations in cognitions and mood:
- Inability to remember important aspect of the event
- Exaggerated negative beliefs about self/others/world
- Distorted cognitions about the cause or consequences
- Negative emotional state
- Diminished interest
- Feelings of detachment
- inability to experience positive symptoms
- At least 2 alterations in arousal and reactivity:
- Irritable behavior and angry outbursts
- Self destructive behavior
- Hypervigilance
- Exaggerated stratle response
- Problems with concentration
- Sleep disturbances
- Duration is more then 1 month
- Significant distress or decrease in function
- Not due to substance abuse
PTSD - psychotherapy
- The main treatment of PTSD
- Prolonged exposure - impolsive therapy, systemic desensitization
- Stress management -relaxation
- EMDR
- Group and family therapy
- Dynamic psychotherapy
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
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
- 30%
- 40%
- 20%
- 10%
- 50%
Acute stress disorder - diagnosis (DSM-5)
- Exposure to life theratening event:
- Directly
- Witnessing
- Learning that the event occured to close person
- Repeated exposure to aversive detalis (work related)
- Presence of 9 or more, from any of the following categories:
- Intrusive symptoms:
- Intrusive distressing memories
- Distressing dreams
- Dissociative reactions (flashbacks)
- Psycological or physiological reactions in response to stimuli
- Negative mood
- Inability to experice positive emotions
- Dissociative symptoms:
- Altered sense of the reality of the surrounding/self
- Inability to remember important aspects of the event
- Avoidance symptoms:
- Avoid distressing memories
- Avoid external reminders
- Arousal symptoms:
- Sleep disturbance
- Irritable behavior
- Hypervigilance
- Problems with concentration
- Exaggereted stratle response
- Intrusive symptoms:
- Duration between 3 days - 1 month
- Significant distress or decrease in function
- Not due to substance abuse, other mental disorder or GMC
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]
- 2-8%
- Twice
- Females
- 5%
- 10%
- Adolescense
- Singles
Adjustment disorders - diagnosis (DSM-5)
- Development of emotional/behavioral symptoms in response to identifiable stressor occuring within 3 month of its onset
- Symptoms are clinically significant - at least 1 of the following:
- Distress that is out of proportion to the stressor
- Significant impairment in fucntion
- The disturbance does not meet the criteria for another mental disorder, or exacerbation of preexisting mental disorder
- Symptoms does not represent normal bereavement
- 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
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
- When needed:
Reactive attachment disorder - diagnosis (DSM-5)
- Pattern of inhibited behavior twords adult caregiver, manifested by both:
- Rarely seeks comfort when distressed
- Rarely responds to comfort when distressed
- Social and emotional disturbance manifested by at least 2 of the following:
- Minimal social and emotional responsiveness
- Limited positive effect
- Episodes of unexplained irritability that are evident even during nonthreatening interactions
- Child has experienced pattern of extreme insufficient care evidanced with at least 1 of the following:
- Lack of having basic emotional needs
- Repeated changes of primary caregivers
- Unusual setting that severely limit opportunities to form stable attachments
- Criterion C is responsible to criterion A
- Criteria for autism spectrum disorder is not met
- Evident before the age of 5
- Developmental age of at least 9 months
Disinhibited social engagement disorder - diagnosis (DSM-5)
- Child actively interacts with unfamiliar adults and at least 2 of the following:
- Reduced reticence in interacting with unfamiliar adults
- Overly familiar behavior
- Diminished checking back with adult caregiver after venturing away
- Willingness to go off with unfamiliar adult with minimal hesitation
- Criterion A is not due to impulsivity
- Experienced a pattern of extreme insufficient care, evidenced by at least 1 of the following:
- Lack of having basic emotional needs
- Repeated changes of primary caregivers
- Unusual setting that severely limit opportunities to form selective attachments
- Criterion C is responsible to criterion A
- Developmental age of at least 9 months
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
- MZ
- Schizophrenia
- Sex
- Dexamethasone supression
- TRH release
Presonality disorders - general diagnostic criteria (DSM-5)
- Behavior/internal sensation that deviates from the norm that is accepted in the patient’s culture, which is expressed in at least 2 areas:
- Cognition
- Affect
- Personal function
- Impulse control
- Persistent pattern, which is not flexible
- Causes significant distress and decrease in function
- Prolonged pattern that starts in teen or early adulthood
- Not due to other psychiartic illness
- No substance abuse of GMC
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]
- 2-4%
- Male
- Schizophrenia
- Low SES (immigrants)
- Deaf people
- Early adulthood
- Projection
- Schizophrenia
רעיונות רפרנס, דעות קדומות, defended illusions
גזענות, חוסר חום אנושי
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
- Social life
- Isolated
- Flat affect
- 5%
- Night/isolated
- Sex
Schizotypal personality disorder
- In stressful conditions can develop…[1]
- In more severe cases can develop…[2]
- …[3] suicide rate
- Some develop…[4]
- Psychotic episodes
- MDD
- 10%
- Schizophrenia
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]
- 6%
- Narcisstic personality disorder
- Crticism
- Ampathic
- Suicide
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
- Excitability
- Seductive
- 1-3%
- Femalee
- Dissociation
- Regression
- Alcohol abuse
- Somatic disorders
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]
- Stable instability
- 1-2%
- Female
- 40
- Self mutilation
- Psychotic
- Identification instability
- Ego weakness
- Lack of integration of the super-ego
- Primitive defense mechanisms
- Splitting
- Projective identification
- MDD
- Suicide
-
DBT
- During the DBT we can expect regressions, impulsive behaviors, transference
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
- Normal social norms
- 0.2-3%
- Male
- Anti-social personality disorder
- Poor
- Inmates
- Alcohol
- 15
- Conduct
- 18
- Anxiety
- Depression
- Remorse
- Decrease
- Adolescense
- Somatic
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]
- Anxiety
- Separation
- Isolation
- Female
- Young (kids)
- MDD
- Separation
- Good
- Psychotherapy - insight oriented
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]
- Rejection
- Live alone
- 2-3%
- Shy
- Social interaction
- Normal lives
- Social phobias
- MDD
- Psychotherapy - encourage to engage in social activity
- Also group therapy and CBT can be used
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]
- 2-8%
- Male
- Older
- OCPD
- Strict environment
- Anal
- Formal
- Lack of sense of humor
- Show flat affect
- Intellectualization
- Isolation
- Reaction formation
- Rationalization
- Undoing
- Schizophrenia
- MDD
טיפול עם באסוציאציות חופשיות
No directive therapy
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]
- 2-6%
- M=F
- Young adulthood
- Suicide
Dissociative amnesia - diagnosis (DSM-5)
- Inability to recall personal autobiographic information
- The symptoms cause significant distress or decrease in function
- Not due to substance abuse or other medical/neurological disorder
- Cannot be explained by other psychiatric disorder
Specify: with dissociative fugue (travel or bewildered wandering that is associated with amnesia)
The 5 subtypes of dissociative amnesia
- Localized - the most frequent. Loss of defined period of time
- General - loss of personal history; semantic/procedural
- Selective - loss of some part of the event, but not all of it
- Systemized - loss of specific information category
- Progressive - forget every new event after it happened
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]
- Forget their identity (and does not invent a new one)
- Hours-days
- PTSD
- Anxiety disorder
- Suicide
- 0.02%
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
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
- 0.4-1.5%
- 5-9
- Female
- 30
- 66%
- 100%
DID - diagnosis (DSM-5)
- 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
- Repetitive difficulties to remember daily events, personal information and traumatic events
- Symptoms cause significant distress and decrease in function
- Does not fit to culture or personal believes
- Not due to substance abuse or GMC
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
- 3rd (after depression and anxiety)
- Twice
- Female
- 40
- 16
- Seizures
- Migraines
- Psilocybin
- Mescaline
- LSD
- Anti-cholinergic
Depresonalization/Derealization disorder - diagnosis (DSM-5)
- Recurring experiences of depersonalization or derealization or both
- Due the experiences, reality test is still intact
- Significant distress or decrease in function
- Not due substance abuse or GMC
- Is not due to other psychiatric disorder
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.
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]
- M=F
- Low
- 30
- Teens
- Violence at home
- Genetic factor
Somatic symptom disorder - diagnosis (DSM-5)
- 1 or more somatic symptom that are distressing or result in significant disruption of daily life
- Excessive thoughts, feelings ,or behaviors related to the somatic symptoms
- State of being symptomatic is presistent (more than 6 months)
Specify: with predominent pain
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]
- Episodic
- Months-years
- Nausea and vomiting
- Difficulty swallowing
- Pain in hands and legs
- Shortness of breath
- Pregnancy and menstrual complications
- 50%
- MDD
- GAD
- Personality
- Phobias
- Substance abuse
- Psychiatric treatment
- Stress
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
- Is rare
- There will be deterioration of symptoms
- No increase
- 20
- High
- Anxiety
- Depression
- Sudden
- Personality disorders
- Associated medical disorder
- Is not essential. Only needed for co-morbidities
- 50%
Illness anxiety disorder - diagnosis (DSM-5)
- Preoccupation with having/acquiring serious illness
- Somatic symptoms are absent/mild or if there is another medical condition, or high risk for acquiring one, preoccupation is clearly excessive
- High level of anxiety about health
- Excessive health related behavior or maladaptive avoidance
- For at least 6 months
- Is not better explained by other psychiatric disorder
Specifiy if: care-seeking type or care-avoidant type
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
- 1/3
- 11-300
- 2
- Female
- 10
- 35
- Rural
- Low
- Monozygotic
Conversion disorder - risk factors
- Living in…[1] areas
- …[2] IQ
- …[3] SES
- Man who were exposed to…[4]
- Rural
- Low
- Low
- Wars
Conversion disorder - diagnosis (DSM-5)
- One symptom or more in motor (voluntary) or sensoric system
- There is no correspondense of the symptom to medical or neurological state
- Is not better explained by other medical or psychiatric disease
- Causes significant distress or decrease in function
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]
- 25-50%
- Neurological disorder
- 2 weeks
- 95%
- Less than 50%
- 20-25%
- Suicide
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
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
Conversion disorder - co-morbidities
- Related psychiatric disorders include…[1-3]
- Associated personality disorders are…[4-7]
- There is increased familial incidence of…[8]
- MDD
- Anxiety
- Schizophrenia
- OCPD
- Hystrionic
- Dependent
- Anti-social
- Conversion disorder
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]
- Acute
- Identifiable
- Rapid
- High
- Paralysis
- Aphonia
- Blindness
- Tremor
- Seizures
Psychologic factors affecting other medical conditions - diagnosis (DSM-5)
- Medical symptom or condition is present
- 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
- 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
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]
- 0.6%
- 3
- Females
- 50
- 35
- Childhood
- Mood disorders
- Anxiety
- Gambling disorder
- Substance abuse
- Excessive shopping
- Eating disorders
- Normal function
Kleptomania - diagnosis (DSM-5)
- Failure to resistent the impulse to steal objects which are not needed and not due to their value
- High tension before cofessing the theft
- Feeling of satisfcation/relief while confessing about the theft
- The act does not express anger/revenge and not due to hallucinations or delusions
- Is not better explained by other mental disorder
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
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
- 8:1
- Mild retardation
- Substance abuse (mainly alcohol)
- MDD/bipolar disorder
- Other impulse disorders
- Personality disorders (borderline, anti-social)
- ADHD and learning disability
- Animal abuse
- Enuresis
- Early
Pyromania - diagnosis (DSM-5)
- More then 1 case of premaditated or deliberate fire setting
- Tension or arousal before the act
- High intrest in fire or related situations
- High satisifaction while setting the fire or while watching/taking part in fire setting
- Fire setting is done without other motives, not due to delusions or hallucinations and not due to states of impaired judgement
- Is not better explained by other mental disorder
Pyromania - treatment
- Psychotherapy
- Drugs
- The treatment is psychotherapy alone but there is no established method
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]
- Male
- 80%
- Young age
- Adulthood
- 6 years old
Intermittent explosive disorder - etiology
- Psychodynamic…[1]
- Psycho-social…[2]
- Biologic…[3]
- Genetics…[4]
- Defense mechanisms by narcssistic assault
- Dependent men, rough childhood
- Perinatal trauma, head injuries, encephalitis, hyperactivity
- Decreased serotonin
- First degree relative with MDD, addictions, impulse control disorders
הפרעה פיזיולוגית במוח, במיוחד במערכת הלימבית
Intermittent explosive disorder - diagnosis (DSM-5)
- Recurrent outburst as manifested by 1 of the following:
- Verbal or physical aggression occuring 2 a week for at least 3 months. Physical aggression does not result in damage.
- 3 outbursts involving damage or destruction and physical injury to other, occuring within 12 months
- Agressiveness during the outbursts is out of proportion to the provocation
- Outbursts are not premeditataed and not committed to achieve any objective
- Leads to significant distress or decrease in function or associated with financial or leagal consequences
- Chronological age is at least 6 years
- Not better explained by other mental disorder and not due to GMC
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
- Benzodiazepines
- Paradoxical reaction
Oppositional defiant disorder - epidemiology
- Prevalence of…[1]
- Starts by the age of…[2]
- Before puberty…[4], while after puberty…[5]
- 2-16% of school aged children
- 10
- M > F
- M = F
Oppositional defiant disorder - diagnosis (DSM-5)
- 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
- Angry/irritable mood:
- Loses temper
- Easily annoyed
- Angry and resentful
- Defiant behvior:
- Argues with authority
- Defies/refuses to comply with authority requests
- Delibrately annoys others
- Blames others for his behaviors/mistakes
- Vindictiveness:
- Vindictive for at least 2 times in the past 6 months
- Angry/irritable mood:
- Cause significant distress to the kid and his family and decrease function
- Does not occur in the psychosis or in affective disorder
Oppositional defiant disorder - clinical features
- Risk factors include…[1-2]
- …[3] of the patients will have remission
- Other will eventually develop…[4]
- Child abuse/neglect
- Strict parenthood
- 25%
- Conduct disorder
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
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]
- Male
- 6-16%
- 2-9%
- Antisocial
- Alcohol dependance
- 10-12
- 14-16
- Onset before the age of 10
- Onset after the age of 10
- Onset in unknown age
Conduct disorder - etiology
- Cultural-social factors…[1]
- Psychological…[2]
- Neurologic…[3]
- Frequent in areas with high population
- Low SES, avoidance from social acitivty, increased exposure to alcohol and drugs
- Diffculties in regulation of emotions and lack of impulse control
- 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
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
- Abuse
- Neglect
- Strict
- Alcohol
- Low
- Low
- Family
- Late
- Psychopathology
- Normal
Conduct disorder - diagnosis (DSM-5)
- 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:
- Agression:
- Bullies
- Initiate physical fights
- Used a weapon
- Physically cruel to people
- Physically cruel to animals
- Stolen while confronting a victim
- Forced someone into sexual activity
- Destruction of property:
- Engaged in fire to cause serious damage
- Destroyed others property
- Deceitfulness/theft:
- Broken into someone else house/car
- Lies to obtain goods/favors or to avoid obligations
- Stolen items of nontrivial value without confronting the victim
- Violations of rules:
- Stays out at night despite prohibitions, before the age of 13
- Run away from home overnight at least 2 times, or once without returning to lengthy period
- Truant from school, before the age of 13
- Agression:
- Causes significant impairment in function
- If the patient is older than 18, criteria are not met for antisocial personality disorder
Conduct disorder - specifiers
- With limited prosocial emotions:
- Lack of remorse/guilt
- Lack of empathy
- Unconcerned about performance
- Shallow/deficient affect
Conduct disorder - treatment
- Psychotherapy
- Pharmacotherapy
- CBT, parent guidance and child guidance
- Antipsychotics - beneficial in prevention of the disease and decrease symptoms
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]
- 3-7%
- Male
- 7-8%
- 5%
- 2.5%
- 60%
- TOVA
- Conner
- Clinically
ADHD - etiology
- Genetics
- Neurologic
- Neurophysiology
- Prenatal
- 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
- Dopamine is the main deficient neurotransmitter
- Related to locus ceruleus and the per-frontal cortex
- Increased beta and teta waves activity is seen on EEG
- Premature babies and for mothers who had infection during pregnancy
ADHD - diagnosis (DSM-5)
- Persistent pattern of inattention or impulsivity that interfers with functioning or development
- Inattention: 6 or more of the following for at least 6 months
- Fails to give close attention
- Difficulty in sustaining attention
- Does not seem to listen when spoken to
- Does not follow through instructions
- Difficulty organizing
- Reluctent ro engage in sustained tasks
- Loses things
- Easily distracted
- Forgetful
- Hyperactivity: 6 or more of the following for at least 6 months
- Fidgets
- Leaves sit, when expected to stay put
- Runs/climbs in inappropriate times
- Cant play quietly
- Often “on the go”
- Talks excessively
- Blurts answer before question was finished
- Difficulty to wait for turn
- Intrudes on others
- Inattention: 6 or more of the following for at least 6 months
- Several symptoms were present before the age of 12
- Several symptoms are present in 2 or more settings
- Symptoms interfere with functioning
- In not due to other psychiatric disorder
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]
- 30% (70% with another psychiatric disorder!)
- Tic
- Personality
- Conduct
- Anxiety
- Sutdying disablities
- Substance abuse
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]
- Methylpehnidate
- 2-3 hours (Ritalin)
- 4-6 hours (Ritalin SR)
- 6-8 hours (Concerta)
- 10-12 hours
- Daytrana
- Focalin
- D+ methylphenidate
- Amphetamines
- Adderal
- Attent
- Vyvanse
- Cardiac disorders (structural of conductive)
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
- Alpha 2
- Clonidine
- Atomoxetine
- Norepinephrine
- Side effects
- Of activity of amphetamines
- Buproprion
- Omgea-3
ADHD - treatment side effects
- GI…
- Psychiatric…
- Worsens…
- Neurologic…
- Cardiovascular…
- Ophthalmic…
- Intoxication signs…
- Rebound phenomenon…
- Pregnancy…
- Abdominal ache, decreased appetite
- Anxiety, restlessness, difficulty sleeping, dysphoria
- Anxiety disorders and psychotic disorders
- Worsens epilepsy, tic disorder, dyskinesia
- If tic disorder appears and does not resolve withub 7-10 days - psychoeducational treatment can be initiated
- Arrythmia, tachycardia, exacerbates hypertension
- Exacerbation of glaucoma
- Hypertension, tachycardia, fever, delirium, psychosis, seizures
- Irritability and hyperactivity
- Slow release formulas decrease the risk
- 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
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]
- Partial remission
- Remission usually occurs at ages 12-20
- Inattention
- Hyperactivity
- Anti-social personality disorder
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
- 4-5
- 7
- 11
- 3
- Male
- 4-6
- ADHD
- OCD
- Anxiety
- Depression
- Caudate nucleus
- HVA
- 18
- Usually presents at 4-5
- 10-12
Tourettes syndrome - treatment
- Psychotherapy
- Pharmacotherpay
- Psychotherpay:
- Psychoeducation
- Behavioral treatment - habit reversal, exposure and response prevention
- 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
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%
- Male
- 50-70
- 6th
- 35-50
- 2nd
- 20-35
- <20
- 40%
- ADHD
- MDD
- Bipolar
- Anti-social personality disorder
- Impulse control
- Schizophrenia
- Cognitive psychotherapy
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%
- 4
- Male
- Female
- 3
- Genetic
Autistic spectrum disorder - co-morbidity
- …[1] delay
- …[2] will show signs of…[3]
- Tends to have…[4]
- Different perception of…[5]
- Language delay
- 50% will never acquire any language
- 30%
- Intellectual disability
- 30% - mild
- 45-50% - profound
- 70% with normal IQ!
- Sensory stimuli
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]
- Risperidone
- SSRI’s
- Lithium
- 66%
- 5-20%
- 1-2%
- IQ over 70
- Good language skills
- 5-7 years
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
- 90%
- 17
- 40
- High
- Stressful
Anorexia nervosa - severity
- According to BMI:
- Mild
- Moderate
- Severe
- Extreme
- > 17
- 16-16.99
- 15-15.99
- < 15
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]
- MDD
- Social anxiety disorder
- OCD
- 10%
- CRH
- Cortisol
- TSH
- Thyroid hormones
- FSH
- LH
- Dilation
- Caudate nucleus
הפרעות קצב, בעיות ויסות טמפרטורה, ל״ד ודופק, היפרכולסטרולמיה, לויוקופניה, אמנוריאה, אוסטואופורוזיס הוא הסיבוך העיקרי
בנוסף יהיו סיבוכי הקאה
Anorexia nervosa - diagnosis (DSM-5)
- 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)
- Intense fear of gaining weight or being fat, or presistnent behaviors that interfer with weight gain
- 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
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]
- Suicide
- Arrythmias
- 30-50%
- Bulemia
- 1-3 years
- 25%
- 50%
- 25%
- Appetite, good self-esteem, awareness
- Bulemia, vomiting, laxative abuse, behvior disorders
Anorexia nervosa - treatment
- Admission if possible - although most of the patients doesnt want to
- CBT
- Supervised meals, and monitor weight, electrolytes
- Psychodynamic therapy - not for patients younger then 18
- Family treatment
- 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
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]
- 2-4%
- 1-3%
- 10-20
- Female
- Anorexia nervosa
- Late 20’s or early 30’s
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
Bulimia nervosa - diagnosis (DSM-5)
- Recurrent episodes of binge eating, defined as both:
- Eating amount of food that is abnormally high in short period of time
- Sense of lack of control while eating
- Recurrent inappropriate compensatory behaviors in order to prevent weight gain
- Binges and compensation occurs at least 1 time a week for at least 3 month
- Self evaluation is influenced by body shape and weight
- Disturbance does not occur exclusivley during episodes of anorexia nervosa
- Specifiers:
- Purging (80%)
- Non purging type
Bulimia nervosa - treatment
- Psychotherapy
- Nutrition
- Drugs
- Personal/group, dynamic, CBT
- -
- 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
Bulimia nervosa - prognosis
- …[1] will recover under therapy
- …[2] recurrence rate within 5 years
- 60%
- 50%
Binge eating disorder - diagnosis (DSM-5)
- Recurrent episodes of binge eating, characterized by both:
- Eating high amount of food within short period of time
- Sense of lacking control over eating during the episode
- Binge eating episodes are associated with:
- Eating more rapidly
- Eating untill uncomfortably full
- Eating large amount when not feeling hungry
- Eating alone because feeling embarrassed by the amount
- Feeling disgusted/guilty after the binge
- Marked distress regarding the binge
- Binge occurs at least once a week, for at least 3 months
- Not associated with bulimia nervosa or anorexia nervosa
Binge eating disorder - co-morbidity
- MDD (+dysthemia)
- Anxiety
- Substance abuse
- Avoidant or borderline personality disorder
Pica - diagnosis (DSM-5)
- Eating of non nurishing foods for at least 1 month
- Behavior does not correspond to developmental stage
- Not due to cultural norms
- Pathologic only in kids older than 18 months
- Cannot be diagnosed in mental retardation
Rumination disorder - diagnosis (DSM-5)
- Recurrent rumination for at least 1 month. The food can be swallowed again or spat out
- Not due to other medical disorder
- Not due to another eating disorder
- If occurs in context of another mental disorder, the symptoms should be severe enough to require further intervention
Avoidant/Restrictive food intake disorder - diagnosis (DSM-5)
- Feeding disorder that is expressed in prolonged insufficient energey consumption, that is related to at least 1 of the following:
- Significant weight loss
- Severe malnurishment
- Dependecy in entral feeding or supplements
- Impaired psychosocial dysfunction
- Is not explained by lack of available food or cultural norms
- Is not due to another feeding disorder and there is no signs of bad body image
- 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


Insomnia - diagnosis (DSM-5)
- Predominant complain with sleep, associated with at least 1 of the following:
- Difficulty initiating sleep
- Difficulty maintaining sleep
- Early morning awakening with inability to return to sleep
- Clinically significant distress or impariment in function
- At least 3 nights per week
- At least 3 months
- Occurs despite adequate opportunity for sleep
- Not due to substance abuse
- Coexisting disorders do not explain the insomnia
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
Hypersomnolence disorder - diagnosis (DSM-5)
- Hypersomnolence, despite sleeping at least 7 hours, with at least 1 of the following:
- Repeated sleeping episodes during the day
- Nonrestorative sleeping episode of more than 9 hours
- Difficulty being refrashed after awakening
- At least 3 times a week for at least 3 months
- Distress or decrease in function
- Is not better explained by other sleeping disorder
- Not due to substance abuse
- Not due to other mental disorder
Hypersomnolence disorder - treatment
- Mainly stimulants
- SSRI’s which are not sedating, are beneficial in part of the cases
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]
- Hypersomnelance
- Several weeks
- Young (20’s)
- Male
- Hypersexualism
- Hostility
- Hallucinations
- Irritability
- Amensia
- Resolve spontaneously
- Stimulants
- Lithium
Narcolepsy - general features
- Almost all patients with this disorder have…[1] on WBC’s
- Characterized by low levels of…[2]
- Clinics include…[3-7]
- HLA-DR2
- Hypocretin
- Sleeping episodes that are refreshing
- Cateplexy - in more than 50%
- Triggers include laugh, anger, physical activity, sexual arousal, fear
- Sleep paralysis
- Hypnogogic/hypnopompic hallucinations
- Sleep onset REM periods - REM starts within 15 minutes after sleep is initiated
Narcolepsy - diagnosis (DSM-5)
- 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
- Presence of at least 1 of the following:
- Episodes of cataplexy defined as either of the following, occuring few times a month:
- Long standing disease - brief episodes of loss of muscle tone with maintained consciousness that are precipitated by laughter or joking
- Less than 6 months - spontaneous grimaces without any obvious triggers
- Hypocretin deficiency measured in the CSF, not in the context of acute brain injury/inflammation/infection
- 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
- Episodes of cataplexy defined as either of the following, occuring few times a month:
Narcolepsy - treatment
- Includes arraging sleeping times
- For cataplexy the treatment is modafinil, fluoxetine or imipramine
- Shortens REM
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]
- N3+N4
- 12
- Memory
- Male
- Resolve spontaneously
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]
- Sudden awake
- Anxiety
- Increased autonomic function
- Memory
- Sleep deprivation
- Fever
- No treatment is needed
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)
- Acetylcholine
- Reticular formation
- Lack of awareness
- Attention
- Old
- Male
- Anti-cholinergic
- MDD
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]
- 5%
- 20-40%
- Alzheimer’s
- 50-60%
- Vascular
- 15-30%
- Combined Alzheimer’s and vascular
- 10-15%
- 15%
- Lack of functioning (in major)
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
- Parieto-temporal
- Acetylcholine
- Norepinephrine
- Diffuse
- Neurofibrillary tangles
- Amyloid plaques
- 40%
- Full penetration
- Rivastigmine
- Donepezzil
- Memantine
- Cholinergic (acetlycholine esterase inhibitors)
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]
- 60-70
- Male
- Neurologic deficits
- Dysarthria
- Dysphagia
עייפות, חולשה, כאבי ראש, ממצאים פוקליים (כמו הפרעות הליכה), דיסראתריה ודיספגיה גם יכולים להופיע
Neuro-cognitive disorder with Lewy bodies
- Highly associated with…[1]
- Core symptoms include…[2-4]
- Suggested symptoms include…[5,6]
- Visual hallucinations
- Cognitive function fluctuations
- Visual hallucinations
- Spontaneous parkinsonism
- REM-stage sleep disorder
- Sensitivity for neuroleptics
ניפלות חוזרות, סינקופה, רגישות לתרופות אנטי-פסיכוטיות, דלוזיות סיסטמיות, פרקינסוניזם, סימנים אקסטא-פירמידליים
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]
- 5%
- Male
- 50-60
- Memory
- Personality
- Cognition
- Kluver-Bucy syndrome
- Disinhibition (hypersexuality, hyperorality)
The 12 indications for ECT (including sub-indications)
- MDD
- Psychotic depression (!)
- Resistent to therapy
- Catatonic
- With severe suicidal ideation
- With severe psychomotor retardation
- Mania (including mixed episodes)
- Resistent to therapy
- NMS
- Risk of the common 1st line treatment
- Pregnant women with severe suicidal ideation (teratogenic effect of SSRI’s)
- Elderly (anti-depressents are not safe)
- Psychotic disorders that are resistent the anti-psychotic therapy
- Only effects the positive symptoms
- Parkinson’s
- Intractable seizure disorders
- Acute exacerbation of schizophrenia
- OCD
- Hypopituitarism
- Delirium
- Cases in which rapid intervention is cruical
ECT - contraindications
- There are no absolute contraindications
- Relative contraindications:
- Increased ICP
- COPD
- Severe asthma with steroid treatment
- Severe vascular disease
- Arryhtmias
- Pacemakers
- MS
- Osteoporesis
ECT - side effects
- Headache
- Confusion
- In 10% there is severe confusion in the 30 minutes after waking-up
- Can be treated with barbiturates or BZD’s
- In 10% there is severe confusion in the 30 minutes after waking-up
- Delirium
- Most severe after the first treatments, bilateral treatment or with background of neurological disorder
- Usually resolves within days-weeks
- Memory loss
- Effects almost all the patients
- Mostly resolves within 6 months
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
ECT - drugs combinations
- Benzodiazepines
- Lithium
- Anti epileptic drugs
- Buspirone
- Clozapine
- Lidocaine
- MAOi’s, TCA’s and antipsychotics
- 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
- Lithium - increse the risk for post-ictal delirium and prolonged seizure
- Anti epileptic drugs - dont use them
- Buspirone - risk for prolonged seizures
- Clozapine - risk for prolonged seizures
- Lidocaine - increases seizure intensity
- Treatment with these drugs is acceptable
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]
- Anxiety
- Weight loss
- Seizure
- Anti-cholinergic
- Anti-histaminic
- Carbamazepine
- CYP450
SSRI - fluvoxamine (favoxil)
- Causes…[1]
- It have…[2] effect and it is beneficial of…[3]
- Weight gain
- Sedative (relaxing)
- OCD
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]
- Weight gain
- The SSRI the have the highest association to weight gain
- Anti cholinergic
- The SSRI with the highest rate of anti-cholinergic side effects
- Sedative (relaxing)
- Panic disorder
SSRI - sertraline (lustral)
- Side effects of…[1] and [2]
- Anxiety
- Diarrhea
SSRI - escitalopram (cipralex) and citalopram (recital)
- Esticaloparm of side effects of…[1] and…[2]
- For citalopram there is association with…[3]
- Sedation
- Weight gain
- QTc prolongation
SSRI - t1/2
- From the shortest to the longest…[1-6]
From the shortest to longest:
- Fluvoxamine
- Paroxetine
- Escitalopram
- Citalopram
- Sertraline
- Fluoxetine
SSRI - GI side effects
- Resolves usually after…[1]
- Most commonly associated with…[2]
- GI discomfort, vomiting, nausea, anorexia, dyspepsia, diarrhea
- GI side effects are the main side effect
- Resolves usually after 2 weeks
- Sertraline (lustral) have the most prominent GI side effects
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]
- 50-80%
- Resolve
- Mirtazapine
- Buproprion
- Viagra
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]
- Anxiety (=pardoxical anxiety)
- EPS
- Seizures
- Fluoxetine
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]
- Fluoxetine
- SIADH
- Paroxetine
- Skin rash
- Aggregation
- Platelets - prolonged bleeding time
- Blunting
- Vivid
- Suicide attempts
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
- Balance
- GI
- Tierdness
- Insomnia
- Parasthesias
- Migraine
- Psychiatric
- 33%
- Fluoxetine
- Sertraline
Serotonin syndrome
- Symptoms
- Management
- Characterized by the 3A’s:
- neuromuscular hyper-Activity: clonus, hyperreflexia, hypertonia, tremor, seizures
- Autonomic instability: hyperthermia, diaphoresis, diarrhea
- Agitation
- Stop the offending drug should be the first step
- Supporting treatment: cyproheptadine, nitroglycerine, methysergide, chloropormazine, dentrolene, BZD
- Cooling blankts
- Respiratory support
SNRI’s - 5 indications
- 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
- GAD
- Social anxiety
- Panic disorder
- Neuropathic pain - duloxetine (Cymbalta)
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
- N/V
- Dry mouth
- Dizziness
- Agitation
- Constipation
- Weakness
- Anorexia
- Blurred vision
- Sexual disorders
- Agitation
- Suicide
- Hypertension
Mirtazapine (Miro)
- Mechanism of action…[1]
- Efficient in cases with prominent…[2] and…[3]
- Side effects…[4-15]
- NaSSA - noradrenergic and specific serotonergic anti-depressent
- Block alpha-2 receptors
- Serotonin antagonist
- Block H1 receptors
- Sleep disturbance
- Weight gain
- Used for MDD, sleeping disorders, somatic and physiologic symptoms of anxiety or distress
- Fatigue (>50%)
- Dry mouth (25%)
- Constipation (13%)
- Increased appetite
- Dizziness
- Myalgia
- Dreaming disorders (???)
- Mania/hypomania
- Increased cholesterol and TAG
- Increased ALT
- Orthostatism
- Neutropenia
- In 0.3%
- Stop the medication of occurs
התופעות לוואי הכי חשובות הן עלייה במשקל, שינה מוגברת וניוטרופניה
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
- NdRI - norepinephrin-dopamine reuptake inhibitor
- Anti-cholinergic side effects
- Weight gain
- Sexual dysfunction
- Fatigue
- Orthostatism
- MDD
- Bipolar disease
- ADHD
- Cocain intoxication
- Smoking cessation
- Hypoactive sexual desire disorder
- Fluoxetine
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]
- Tremor (the most common)
- Headahce
- Insomnia
- URT complaints
- Nausea
- Profuse sweating
- Constipation
- Restlessness
- Anxiety
- Sleep disturbances
- Irritability
- Psychotic symptoms
- Seizures
- Liver
- Kidney
- Blood pressure
- Hypertensive
- Rash
- Pruritus
- Lymphadenopathy
- Pancytopenia
- Confusion and delirium
Typical anti-psychotics - high potency drugs
- …[1],…[2],…[3] and…[4]
- Have low…[5], and high…[6] effects
- Trifluphenazine
- Fluphenazine
- Haloperidol
- Pimozide
- Anti-cholinergic
- EPS
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]
- Chloropromazine
- Thioridazine
- EPS
- Anti-cholinergic
- Prephenazine
- EPS
- Medium
EPS - parkinsonism
- Occurs in…[1]
- After…[2] days
- Most common in…[3]…[4]
- Treatment
- 15% - the most common
- 5-90
- Elderly
- Females
- Anti-cholinergics / amantadine / diphenhydramine (benedril)
- When treating with anti-cholinergics caution must be used with BPH, glaucoma and patients with urinary retention
ESP - acute dystonia
- Occurs in…[1]
- Most commonly in…[2],…[3]
- Prevention
- Treatment
- 10%
- Young
- Males
- Anti-cholinergics / diphenhydramine (benedril) / clonazepam
- Anti-cholinergics / anti-histamines IM/IV
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
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
- 30%
- 10-20%
- 20-30%
- 5-40%
- 50-90%
- Prolonged use
- Typical drugs
- Patients older than 50
- Kids
- Females
- Head injuries
- Affective disorders
- 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
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]
- 0.01%-0.02%
- Male
- Young
- Anti-psychotics
- IM depot formulas
- 24-72 hours
- 10-14 days
- 10-25%
- Symptoms include:
- Hyperpyrexia
- Changes in conciousness - agitation, delirium, stupor, coma, catatonia
- EPS - rigidity, dystonia, akinesia, mutism, akathisia
- Autonomic instability - tachycardia, hypertension, tachypnea
- Stop the offending drug
- Supportive treatment (cooling)
- Bromocriptine / amantadine
- ECT is useful (unilateral or bilateral)
- For 5-10 days
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]
- Prolactinemia - gynecomastia, impotence, galactorrhea, amenorrhea, anorgasmia. OSTEOPORESIS
- Cholinergic - both central and peripheral
- Orthostatism - due to alpha-1 blockade
- Increased appetite and sedative
- Mild leuckopenia, rarely, agranulocytosis
- Prolonged PR and QT intervals
- Photosensitive rash
- Cholestatic jaundice
- Seizure threshold
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
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
Atypical anti-psychotics - other adverse effects
- Salivation - mainly due to the use of clozapine. Treat with anti-cholinergics or with clonidine
- Disturbed swallowing
- Genitourinary disturbances including impotence
- In high dose it can exacerbate OCD
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]
- Resistent schizophrenia (3 other drugs before)
- Severe suicidal ideations
- Tradive dykinesia
- 30%
- Negative symptoms
- Sedation
- Suicide rate
- Metabolic syndrome
- Anti-cholinergic AE’s including QT prolongation
- Agranulocytosis (1-2%)
- Decreased seizure threshold
- Decrease the dose and give additional valproic acid
- Myocarditis
- WBC <3500, bone marrow disorders, history of agranulocytosis with clozapine
- 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
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%
- Week
- 6 months
- 2 weeks
- Ever
- <3,000
- <1,500
- 3,000-3,500
- 1,500-2,000
- Do intensive follow up twice/week until increase above 3500/2000
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]
- Phenytoin
- Carbamazepine
- Sulfonamides
- PTU
- Benzodiazepines
- Captopril
- Increase the risk for seizures, confusion and movement disorders
- Clozapine with lithium is contraindicated
- Fluoxetine
- Paroxetine
- Fluvoxamine
- Risperidone
- Will lead to delirium
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
עלייה במשקל, בחילות, הקאות, חרדה ובעיות בזקפה
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
Atypical anti-psychotics - quetiapine (seroquell)
- Lesser motoric side effects
- Have anti-cholinergic effects
- Good for patients with metabolic syndrome
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
כאבי ראש, בחילות, חולשה
אין לתת עם תרופות אחרות שמאריכות מקטע קיוטי
Atypical anti-psychotics - aripiprazole (Abilify)
- Mechanism of action…[1]
- Adverse effects…[2-6]
- EPS…[7]
- Does not cause…[8-11]
- Partial agonist to dopamine receptors
- Headache,
- Nausea
- Anxiety
- Dyspepsia
- Sleep disturbances
- Does not lead to EPS, but leads to akathisia-like phenomenoa
- Hyperprolactinemia
- Weight gain (or any metabolic disorder)
- QT prolongation
- Diabetes
6 contraindications for treatment with neuroleptics
לא בטוח בכלל
- Severe allergic reaction
- Interactions with drugs that will lead to CNS depression
- Risk for seizures
- Severe cardiac abnormalities
- Narrow angle glaucoma
- Tradive dyskinesia (?)
Anti-psychotics - long acting formulas
- The 5 drugs and courses of treatment
- 3 benefits
- Halidol deconate - 1 / 1-4weeks
- Modecate deconate (Fluphenazine) - 1 / 2weeks
- Clopixol depot (Zuclopenthixol) - 1 / 2weeks
- Risperidal consta - 1 / 2weeks
- The only atypical drug that have long acting formulation
- SEMAP - 1 / 1week
- The only that is given PO
- Good control over plasma levels
- Increased compliance
- Eliminating absorption disorders
Anti-psychotics - 4 drugs that can be give in acute setting
- Haloperidol
- Olanzapine
- Ziprezidone
- Zulopenthixol
- Lasts for 3 days
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]
- Kidney
- Therapeutic range
- 2-6 months
- Renal function
- Electrolytes (calcium included)
- Blood count
- TSH
- beta-HCG
- ECG
- Week
- Plasma proteins
- Elimination
Lithium - GI side effects
- Nausea, vomiting, diarrhea, weight gain, dyspepsia, fluid retention
Lithium - CNS side effects
- Cerebellar
- Cognitive
- Neuron toxic syndrome
- Postural tremor, akathisia
- For tremor prevention: split doses, use long acting formulation, decrease caffeine intake, correct hypokalemia
- Treated with beta-blocker
- Dysphoria, slow response
- MG like response, decreased seizure threshold, parkinsonism
- Acute confusional state, that is sometimes non reversible, that appears with combination with anti-psychotics
Lithium - renal side effects
- In 33% of the patients nephrogenic DI
- Intersitial fibrosis
- Nephrotic syndrome
In the kidney lithium acts the same way as sodium - pay attention to patients that prescribed low sodium diet (cardial patients)
Lithium - thyroid, parathyroid side effects
- Goiter
- Hypothyroidism - more commonly in females
- Treat with levothyroxin (Eltroxin)
- Hyperparathyroidism –> hypercalcemia
Lithium - cardial side effects
- ECG that gives picture of hypokalemia - flattening of T waves
- SA node suppression - contraindicated in patients with sick sinus syndrome
Lithium - skin
- Acne
- Exacerbation of psoriasis
- Hair loss
Lithium - hematologic side effects
- Leukocytosis without clinical relevance
- Rarely, thrombocytosis - thrombotic events are rare
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]
- 1.5-2.0
- Dry mouth, vomiting, abdominal pain
- Dizziness, ataxia, nystagmus, slurred speech, muscle weakness
- 2.0-2.5
- N/V, anorexia
- Blurred vision, hyperreflexia, clonic limv movements, seizures, delirium, ECG changes, syncope, stupor, coma
- >2.5
- Renal failure, oliguria, generalized seizures, death
- When lithium levels are >4.0
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
Lithium - drug interactions
- Drugs that increase blood levels…[1-3]
- Durgs that decrease blood levels…[4-8]
- Contraindicated with…[9]
- ACE inhibitors
- Thiazides
- NSAID’s
- Except aspirin and sulindac
- Loop diuretics
- Osmotic diuretics
- CA inhibitors
- Xanthines
- Caffeine
- CCB’s
Valproic acid (depalept)
- GI side effects
- CNS
- Weight…
- 6 other side effects
- Teratogenicity level
- Rare side effects…[6-8]
- Frequent in the first month of the therapy. Abdominal discomfort, jaundice
- Sedation, tremor (reacts well to beta blockers)
- Gain
- Alopecia (5-15%), increased LFT’s, hepatotoxicity, changes in lipid profile, polycystic ovary, SIADH
- Level X - absolutly contraindicated
- Thrombocytosis with decreased function - follow up with patietns taking warfarin/aspirin
- Agranulocytosis
- Pancreatitis
- Due to relatively small amount of side effects it is the drug that is recommended for children and elderly
Carbamazepine (tegretol) - physiologic effects
- Hematologic
- Endocrine
- Liver
- CVS
- Skin
- …-like syndrome
- Benign leukopenia
- SIADH, increased thyroid hormones
- Increased liver enzymes - can interfere with other drugs metabolism
- Contraindicated in patients with AV block
- Rash
- SLE
Carbamazepine (tegretol) - side effects
- Hematologic
- Liver
- Skin
- Pancreas
- GI
- CNS
- Heart
- Urinary tract
- 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
- Hepatitis, jaundice, cholestasis
- Risk for SJS and TEN
- When rash develops - stop the drugs immediately
- Pancreatitis
- Most commonly - nausea, vomiting, abdominal discomfort, dyspepsia, constipation, anorexia
- Acute confusional state can occur when combined with neuroleptics. Also agitation, nystagmus
- Increased conduction time –> contraidicated in patients with AV block
- Risk for urinary retention
Carbamazepine (tegretol) - precautions
- Contraindications include…[1],…[2] and…[3]
- Precaution with…[4],…[5] and…[6]
- Tertogenicity
- Hematologic disease
- Liver disease
- AV block
- Glaucoma
- BPH
- Diabetes
- Increased risk for neural tube defects, intracranial hemorrhage
- Pass in milk
- Lithium have favorable tertogenic profile
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]
- Inducer
- Decrease
- Fluoxetine
- Lamotrigine
- Valproate
- Auto-induction
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]
- Depression (in the setting of bipolar disease)
- Pregnancy (level C)
- Tiredness, headache, ataxia, blurred vision
- Benign rash in 8%
- Risk for SJS and TEN - stop the drug when the first signs of rash are seen
- Age <16
- Given with valproate
- Quick administration
- High initial dose
- Dose dependent
- Risk for SJS and TEN - stop the drug when the first signs of rash are seen
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]
- Valproate
- 2 times
- Sertraline
- 25%
- Carbamazepine
- Phenytoin
- Phenobarbital
- 40-50%
- Carbamazepine
Topiramate (topamax) - side effects
- Idiosyncratic…[1-4]
- Non dosage dependent…[5-8]
- To prevent the…[9] symptoms, we increase the dosage slowly
- Parasthesia
- Slurred speech
- Fatigue
- Psychomotor retardation
- Decrease weight and appetite
- Renal stone formation
- Confusion
- Decreased concentration
- Cognitive symptoms
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]
- CNS
- Alcohol
- Disinhibition
- Respiratory depression
- Sedation
- Operate heavy mechinary
- Ataxia
- Diziness
- Falls
- Brain damage (like autism)
- Paradoxical agitation
Benzodiazepines - precautions
- Pregnancy
- Diseases of…
- Dont take with…
- Precaution with…[4],…[5],…[6],…[7] and…[8]
- 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
- Liver and kidney
- Alcohol
- COPD
- OSA
- Drug abuse
- Cognitive disorders
- Myasthenia gravis
Benzodiazepines - long acting
- Half-life range of…[1]
- 5 drugs
- 30-100 hours
- Diazepam (Valium)
- Chlordiazepoxide
- Clonazepam (Clonex)
- Clorazepate
- Flurazepam
Benzodiazepine - intermediate acting
- Half-life rage of…[1]
- 4 drugs
- 8-30 hours
- Lorazepam (Lorivan)
- Oxazepam (Vaben)
- Temazepam
- Estazolam
Benzodiazepines - short acting
- Slightly longer half-life…[1]
- 1 drug…[2]
- Shortest half-life of…[3]
- 1 drugs…[4]
- 10-15 hours
- Alprazolam
- 2-3 hours
- Tirazolam
Benzodiazepines - lipid soluble
- 3 drugs
- Midazolam (not really psychiatric drug)
- Alprazolam (xanax)
- Diazepam (valium, assival)
Benzodiazepines - rapid acting drugs
- 4 drugs
- Alprazolam
- Diazepam
- Estazolam
- Tirazolam
Benzodiazepines - discontinuation syndrome
- Symptoms of…[1]
- Recommended cessation of the drug…[2]
- We can use…[3]
- …[4] excerbate the symptoms
- Hyperarousal
- Delirium, hypertension. tachycardia, myoclonus, agitation, tremor
- Decrease the dose by 25% every week
- BB’s, valproic acid, carbamazepine, clonidine, sedative anti-depressent
- Flumazenil
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
- 10%
- 20%
- White
- Urban
- High
- Genetic
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
- Alcohol blood levels
- MCV
- AST
- GGT
- GGT
- Fractures
- Shortening
- Other substance abuses
- Anti-social personality disorder
- Mood disorders
- Anxiety
- 10-15%
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
- 35%
- Developmental retardation
- Micro-
- Small palpebral fissure
- Thin vermilion border
- Smooth filthrum
- Limb
- Heart
- Heart-lung fistula
- Holoprosencephaly
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
- 72 hours
- 20%
- Benzodiazepines (diazepam, lorazepam)
- Carbamazepine (tegretol)
- Beta-blockers
- Clonidine
- Anti-psychotics
ההזוית מאופיינת כהזיות תחושתיות וראייה
באחת השאלות בנקודות, ההזיות מתוארות כדליריום

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
- Thiamine (B1)
- Acute
- Reversible
- Confusion
- Ataxia
- Nystagmus
- Chronic
- Irreversible
- Anterograde amnesia
- Short term memory loss
- Thiamine
- 1-2
- 3-12
בנקודות לוורניקה יש עוד סימנים:
אופתלמופלגיה, ניסטגמוס, lateral orbital palsy, gaze palsy, הפרעות קורדינציה,
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]
- 0.1%
- Other substance abuse
- Anti-social personality disorder
- Borderline personality disorder
- Mood disorders
- 15%
- Dopamine
- Depressent
- Pin-point
- Autonomic
- Respiratory depression
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
- Dysphoria
- Anxiety
- Restlessness
- Autonomic function - hypertension, tachycardia, hyperthermia/hypothermia
- Body fluid secretion - lacrimation, rhinorrhea, diarrhea
- Dilation
- Piloerection
- Yawning
- Myalgia
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
- 2nd trimester
- 90%
- Methadone - partial agonist for u receptors will long half life (15 hours)
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]
- Methadone
- Buprenorphine - partial agonist to u and k receptors
- Naltrexone
- Buprenorphine
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]
- 1.5% (M=F)
- Reuptake inhibitor of serotonin, dopamine and NE
- Impotance
- Nasal perforation
- Formication
- MDD
- BP2
- Cyclothymia
- Anti-social personality disorder
- ADHD
- Other substance abuse (alcohol)
- Benzodiazepines (clonazepam)
- Alcohol
- Anxiety (stimulat induced anxiety disorder)
- OCD (stimulant induced OCD)
- Sexual dysfunction (stimulant induced sexual dysfunction)
- Sleeping disorder (stimulant induced sleep disorder)
- Vascular disorders (MI, stroke)
- Seizures
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]
- 2-3 days
- Week
- Tiredness
- Sleeping
- Nightmares
- Appetite
- Depression
- Suicide
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]
- Usually mandates no treatment but supervision
- Antipsychotics - haloperidol
- Buproprion
- Despiramine
- Dizepam (Valium)
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
- 4th
- Whites
- Cortex
- Basal ganglia
- Cerebellum
- Hippocampus
- 21 (due to rapid absorption in adipose tissue)
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]
- Conjunctival injection
- 30 minutes
- 2-4 hours
- 8-12 hours
- In sensitivity to stimuli (colors etc…)
- Slowed time perception
- Orthostatism
- Depersonalization
- Derealization
- A-motivational syndrome
- Decrease seizure threshold
- Decreased immune system activity
- Cognitive disturbance
- Increased risk for lung cancer/COPD
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]
- Abrupt
- 1-2 weeks
- Anxiety
- Irritability
- Vivid dreams
- Abdominal pains
- Decreased appetite
- Tremor
- Sweating
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
- Partial agoinst of the serotonin receptor 5HT2C
- 2-4 hours
- 12 hours
- Dilated
- Tachycardia
- Palpitations
- Blurred
- Coordination
- Tremor
- Sweating
- Sensation perception
- הילה
- Micropsia/Macropsia
- Geometric hallucinations
- BZD
- Antipsychotics
- Antipsychotics
- ECT
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]
- Antagonist for NMDA recptors (glutaminergic system)
- Agression
- Impulsivity
- Agitation
- Lack of noise tolerance
- Pain
- Ataxia
- Dysarthria
- Stiffness
- Nystagmus
- Acidification
- Anti-psychotics
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