Clinical Lectures! Flashcards
delirium
= Reversible neuropsychiatric syndrome with a specific cause
Sx:
- Fluctuating mental status (waxing/waning) - w/ disturbance in sleep/wake cycle
- Acute onset (hours to days)
- disrupted att’n
- disorganized and confused speech
- “picking at the air”
Neuro Cause?
- decreased ACh
- increased dopamine
Common causes…
- Anticholinergics, antipsychotics, opioids
- infections (UTI, URI, pneumonia, sepsis)
- fever, anemia, dehydration, thyroid problems… etc.
tx:
- order all necessary tests
- orientation!
- discontinue anticholinergic meds, use low-dose antipsychotics as necessary (haloperidol)… avoid the anticholinergic antipsychotics such as olanzapine, clozapine, chlorpromazine!
** Do NOT give benzos unless the delerium is d/t alcohol/benzo w/drawal!!!
alcohol intake?
ethyl alcohol in drinks - no higher than 12-13
1-2 drinks produces BAC of 0.25g/dL or 0.025% or .25mg%
peak BAC is in 30 mins (longer if food consumed as well) - small intestine is primary site of absorption
BAC 50-100: (2-4 drinks in short time) = BAC .05-1
- sedation, “high”, rxn time slowed
BAC 100-200
- impaired speech, slurring, impaired motor tests, clumsiness, gait disturbance,, disinhibition
BAC 200-300 - emesis, stupor
BAC 300-400: coma
BAC 500+ = resp. depression, death
management of alcohol intoxication?
Treat/prevent respiratory depression
Monitor/prevent aspiration
Give Thiamine – 100mg oral or IM
Monitor labs
effects of chronic alcoholism?
- Liver - alcoholic cirrhosis in 25%, more common in women or those w/ Hep C
- GI: pancreatitis x3 more likely, chronic gastritis, vit deficiency, w/l
- CNS:
- Peripheral neuropathy in 15%
- Cerebellar degeneration in 1%
- Wernicke’s encephalopathy – state of confusion due to thiamine deficiency
- Korsakoff’s Psychosis – longstanding memory problems and chronic confabulation occur - other:
- cancer 10x more likely
- CV: increased HTN (100% likely if drink 6-7 drinks per day)
alcohol w/drawal syndromes?
- Uncomplicated alcohol withdrawal – the “shakes”. Occurs 12 to 18 hrs after cessation of drinking and peaks at 24 to 48 hr. Can subside without treatment in 5-7 days
- Alcohol withdrawal seizures – occur 7 to 48 hr after cessation of drinking and peak at 24 to 48 hrs. Status epilepticus is rare.
- Alcoholic Hallucinosis – auditory, visual or tactile hallucinations that begin within 48 hrs of cessation of drinking. They occur with a clear sensorium, may last up to 7 days.
- Alcohol withdrawal delerium aka delerium tremens/DTs – usually begin 2-3 days after cessation of drinking, with symptoms peaking 4-5 days later. Lasts 3-5 days but may persist up to several weeks. Mortality rates of 15% have been reported.
management of alcohol w/drawal syndromes?
- Long acting benzos (diazepam, chlordiazepoxide)
- in severe liver disease, use shorter acting benzos (lorazepam and oxazepam)
- thiamine
- haloperidol/risperidone for hallucinosis
tx options to help quit alcohol?
Antabuse (disulfiram) –inhibits aldehyde dehydrogenase which leads to accumulation of acetaldehyde causing nausea, vomiting, hypotension and palpitations
Naltrexone – mu-opioid antagonist – reduces the pleasurable effects and craving for alcohol
Campral (acmprosate)- reduces craving for alcohol via glutamate receptor modulation. It also reduces the physical & emotional discomfort in alcohol cessation.
which drugs impede sexual performance?
Antipsychotics thru dopamine blocking
Antidepressants thru serotonergic activity
Others: Antihypertensives, drugs of abuse, etc
tx to female and male sex dysfunction?
Female sexual interest/arousal d/o
- Sensate focus exercises
- Sildenafil?
Male hypoactive sexual desire d/o
- Psychotherapy
- Testosterone? Bupropion (inhibits dopamine reuptake)
delayed ejaculation: sildenafil
erectile disorder: PDE-5 inhibitors
gender defs?
Genetic sex: determined at conception
Gender identity: the individual’s perception and self-awareness of being male or female
- develops early - “being trapped in wrong body”
Gender role: the behavior of an individual that identifies him/her as male or female
Sexual orientation :erotic attraction to males, females, or both. Sexual orientation is not a disorder.
gender dysphoria?
= Marked incongruence between one’s experienced/expressed gender & assigned gender
- At least 6 months duration
- Can occur with/without a disorder of sex development (congenital adrenal hyperplasia, androgen insensitivity syndrome)
- Must cause significant distress or impairment in social/occupational/other functioning
gender dysphoria in children
Strong desire to be of the other gender or insistence that one is a gender other than what has been “assigned” AND
At least 5 of the following strong desires/preferences:
For attire of the other gender
For cross-gender roles in play
For toys/games/activities stereotypically used by other gender
For playmates of the other gender
A rejection of assigned-gender toys/games/activities
Dislike of one’s sexual anatomy
Desire for primary &/or secondary sex characteristics matching one’s experienced gender
** in children must rule out other psychiatric conditions usch as psychosis and adjustment disorder **
HORMONAL/SURGICAL THERAPY IS NOT APPROPRIATE IN CHILDREN!
gender dysphoria in adults?
At least 2 of the following:
- Marked incongruence between experienced/expressed gender and one’s primary &/or secondary sex characteristics
- Strong desire to be rid of one’s primary &/or secondary sex characteristics
- Strong desire for primary &/or secondary sex characteristics of other gender
- Strong desire to be a gender other than assigned gender
- Strong desire to be treated as a gender other than assigned gender
- Strong conviction that one has typical feelings/reactions of a gender other than assigned gender
tx: therapy (1-2 years), then hormone replacement (1-2 years), then surgery maybe….
SE’s of hormone therapy:
- Estrogen: DVT, ↑ BP, thromboembolic disorders, wt gain, impaired glucose tolerance, liver abnormalities, depression
- Testosterone: Impaired liver fxn, acne, Na+ retention –> edema
Postsurgical complications:
- For genetic males: urethral stenosis, misdirected urinary streams, vaginal strictures, and rectovaginal fistulas
- For genetic females: chest wall scars and polycystic ovarian dz
paraphilic disorders?
Duration > 6 months
= Intense/persistent sexual interest in something other than a mature, consenting human partner
** Requires that the person must experience distress/impairment as a result of the paraphilia or pursuit of the paraphilia has resulted in harm to others.
Exhibitionism: Exposure of genitals to unsuspecting stranger
Transvestic fetishism: Urges/fantasies involving cross-dressing
Pedophilia: Urges/fantasies involving prepubescent children “generally ≤13yo” and individual must be at least 16 and >5 yrs older than target
Frotteurism: Touching/rubbing against a nonconsenting person
Voyeurism: Observing an unsuspecting person naked, disrobing, or having sex
Fetishism: Nonliving objects (boots, sex toys, etc)
Partialism: Exclusive focus on one part of body
Telephone scatalogia: Obscene telephone calls
Sexual masochism: Being humiliated, beaten, bound, or otherwise made to suffer
Sexual sadism: Psychological &/or physical suffering of another person
Necrophilia: Contact with corpses
Urophilia: Urine
Zoophilia: Animals
Klismaphilia: Enemas
Learning disorders
= inability to achieve in reading, writing, or math at a level consistent with one’s IQ
3 types:
- reading disorder
- mathematics
- disorder of written expression
ADHD criteria?
= pattern of extreme inattentiveness and/or restlessness
** Occurs in at least two settings for at least 6 months with onset before the age of 12 with at least 6 symptoms
three types:
- inattentive (does not pay attention to details, has trouble keeping attnetion, doesn’t seem to be listening, doesn’t follow instructions, avoids schoolwork, loses things needed for tasks, easily distracted, forgetful in daily activities… need at least 6)
- hyperactive-impulsive (fidgets w/ hands, squirms in seat, get up from seat often, runs or climbs around, trouble w/ quiet activities, talks excessively, blurts out answers early, has trouble waiting turns, interrupts)
- combined
prevalence:
- 3-10% of young & school age children
- Male-female ratio is 4:1
Etiology: multifactoral
- MRI show prefrontal cortex, basal ganglia & cerebellar abnormalities
Conduct disorder
= pattern of behavior that violates the rights of others with:
- Aggression to people & animals
- Destruction of property
- Deceitfulness or theft
- Serious violations of rules
Often become adults with Antisocial Personality Disorder (25% of women, 50% of men will go on to have PD)
Childhood onset type – starts before age 10 (worse prognosis)
Adolescent onset type – starts around age 10 and up
Oppositional Defiant disorder
= These children/teens have defiant qualities do not violate the rights of others, like is true of conduct disordered behavior.
** often lose their tempers, argue with adults and refuse to follow rules
5-10% of children. Boys > Girls
Tic disorder
Tic: A sudden, rapid, recurrent, stereotyped motor movement or vocal sound
Transient: motor AND/OR vocal nearly everyday for at least 1 mo. but less than 1 yr.
Chronic: motor OR vocal BUT NOT BOTH for at least 1 yr. AND no 3 mo. period tic free
Tourette’s: BOTH motor AND vocal for more than 1 yr. with no 3 mo. Tic free
- Motor tics usually start between ages 3-8.Vocal tics often come later
- 20% have a remission in their 20’s. Tics often decrease as the person gets older.
etiology:
- familial, OCD often
note:
Pediatric Auto-Immune Neuropsychiatric Disorders associated with Streptococcal Infections (PANDAS) occur when children develop abnormal movements, compulsions or tics, along with emotional problems after having a strep infection. (Somewhat controversial diagnosis.)
tx: atypical antipsychotics (aripiprazole, risperidone good for kids! haloperidol )
separation anxiety disorder
KEY: Excessive anxiety upon separation manifested by a least 3 sxs. For at least 4 wks. before age 18. (childhood panic disorder)
Around 9 months of age, all children are anxious when separated from their caregivers.
** They often refuse to go to school or have somatic complaints to come home or go to the nurse.
Sx:
3 Types of distress –
-Distress at being separated from home
-Worry that harm will come to the parents
-Worry that the child will be lost or separated
3 Types of behaviors –
- School refusal
- Sleep refusal
- clinging
2 type of physiological behaviors
- Nightmares
- Physical complaints, i.e. headaches, nausea, etc.
tx: return child to school ASAP!! tx anxiety or depression w/ meds, educate parents not to give in — make sure there is not another cause at school causing problems!
tx of ADHD?
SE’s: appetite suppression, irritability, exacerbation of tic sx, psychosis
- Methylphenidate (first line) - Increased postsynaptic dopamine by blocking it’s reuptake
- Amphetamine: Inhibits multiple monoamine transport systems: NE, seratonin and DA all increased
