Disorders Flashcards
Nigrostriatal tract
substantia nigra –> striatum (CN + putamen), D2-R
- EPS symptoms
Mesolimbic tract
ventral tegmental area of midbrain –> limbic system, D4-R
hyperactivity = positive sx
Mesocortical tract
VTA –> frontal cortex and cingulate & prefrontal gyri
hypoactivity = neg sx, low mood, poor cognition
tuberoinfundibular tract
hypothal –> pituitary
dopamine suppresses PRL … so dop antag = hyperPRL
Symptoms of hyperPRL
galactorrhea
gynecomastia
amenorrhea
Group at greatest risk of hyperPRL from antipsychotics = adolescent males
What are the positive & negative sx?
POSITIVE: delusions, hallucinations, disorganized speech and behavior
NEGATIVE: anhedonia, avolition, apathy, alogia (poverty of speech), affect flattening, attention deficit
Hallucination vs illusion
Hallucination: NO external stimulus
Illusion: misperception of external stimulus
What are Schneider’s first rank symptoms?
- Audible thoughts
- Voices commenting
- Voices arguing, discussing
- Somatic passivity (passive recipient of bodily sensations from outside forces)
- Thought broadcasting, insertion and withdrawal
- Delusional perceptions (normal perception, followed by a delusional interpretation)
What are Schneider’s second rank symptoms?
- Sudden delusional thoughts
- Perceptual disturbances
- Perplexity
- Depressive and euphoric feelings
- Emotional impoverishment
What is a delusion?
What are the different kinds of delusions?
Fixed, false belief, which is not a shared cultural belief
“JPEGS”
- Jealous
- Persecutory (most common) - think they will be subject to hostile treatment
- Erotomanic (de Clerambault’s) - that someone usually of higher SES is in love with you
- Grandiose
- Somatic - includes delusional parasitosis
- Unspecific
- Mixed
Ideas of reference - belief that cues in external environment are uniquely directed towards them
What are the disorders similar to schizophrenia?
How do they differ?
- Brief Psychotic Disorder
>/= 1 positive sx
duration: between 1 day - 1 month - Schizophreniform
SAME except duration: 1-6 months
3. Schizophrenia Causes lifestyle dysfunction. 2 + of the following, with at least one of the first three: -- delusions -- hallucinations -- disorg speech -- grossly disorg or catatonic behavior -- neg sx duration: > 6 months **intact orientation **lack of insight into their disease
- Schizoaffective disorder
schizophrenia with concurrent MDD sx, with at least 2 weeks of hallucinations/delusions W/O MDD sx
–> 2 subtypes: bipolar, depressive
Which substances can causes psychosis?
Intoxication and withdrawal?
- intoxication of all substances EXCEPT: caffeine, opioids, nicotine “CON”
- withdrawal of alcohol, sedatives, hypnotics “ASH”
What are the 3 phases of schizophrenia?
- Prodromal - decline in functioning (socially withdrawn, physical complaints, declining school/work performance, irritable, newfound interest in religious cult)
- Psychotic - perceptual disturbances (illusion, hallucin), delusions, disordered throught process/content
- Residual - occurs following an episode of active psychosis … mild hallucinations or delusions, social withdrawal, neg sx
Describe the characteristics of neuroleptic malignant syndrome.
- change in mental status
- autonomic instability (high fever, labile BP, tachycardia, tachypnea, diaphoresis)
- “lead pipe” rigidity
- elevated CPK
- leukocytosis
- metabolic acidosis
Medications: Weight gain risk
HIGHEST: olanzapine, clozapine
MEDIUM: Wellbutrin (bupropion), Cymbalta (duloxetine)
NEUTRAL: ziprasidone, aripiprazole
What is “rapid cycling” ?
Best treatment?
4 + mood episodes in one year
(major depressive, manic, hypomanic)
tx = mood stabilizers: carbamazepine, valproic acid
Define bipolar disease I and II.
Bipolar I: only requirement = manic episodes
highest genetic link
tx = lithium (decreased suicide risk), mood stabilizers (c, va), atypical antipsychotics (r, o, q, z)
Bipolar II: MDD + hypomania
*likely better prognosis than bipolar I
tx = same as above
What does the “atypical features” specifier for MDD denote?
Hypersomnolence Hyperphagia Reactive mood Leaden paralysis Hypersensitivity to interpersonal rejection
“CHASES” of dysthymia?
poor Concentration Hopelessness poor Appetite or overeating inSomnia or hypersomnia low Energy low Self-esteem
*for most days, for 2 years
*has not been w/o above sx for >2 months at a time
*never had a hypomanic or manic episode
tx = psychotherapy + pharmacology
Criteria for cyclothymic disorder?
- hypomanic sx (NOT hypomania) + mild depression for at least 2 years
- must not have been sx free for >2 months
- NO hx MDD episode, hypomania, manic episode
*approx 1/3 eventually develop bipolar I or II
tx = antimanic agents: mood stabilizers or atypicals
Define criteria for disruptive mood dysregulation disorder (DMDD)
- Severe, recurrent verbal/physical outbursts out of proportion to situation.
- Outbursts 3+ times/week, inconsistent with developmental level
- Angry/irritable mood between outbursts
- at least 1 year, no >3 months w/o sx
- at least 2 settings
- dx made bw ages 6-18 BUT sx must have started at <10 years old
- no hypomania/mania episodes >1 day or MDD
- not due to substance/medical condition
- high rates of comorbidity
tx = psychotherapy (ie parent mgmt training)
other meds to treat primary sx (SSRIs, atypicals, stimulants)
Substances
- PCP (hallucinogen): NYSTAGMUS, violent behavior, dissociation, hallucin, amnesia, ataxia
- LSD (hallucinogen): VISUAL HALLUCIN, dysphoria/panic, tachycardia/HTN
- Cocaine (stimulant): CP, SEIZURES, MYDRIASIS, agitation/psychosis, tachy/HTN
- Methamphetamine (stimulant): violent behavior, psychosis, diaphoresis, tachy/HTN, choreiform movements, tooth decay
* bath salt* –> mydriasis/tachy/HTN, agitation, violent behavior - Marijuana (psychoactive): CONJ INJECTION, increased appetite, dysphoria/panic, slow reflexes/impaired time perception, dry mouth … psychomotor impairment (can last for 1 day)
- Heroin (opioid): triad: DEPRESSED MENTAL STATUS, MIOSIS, RESP DEPRESSION, constipation
*all of euphoria except methamphetamines and PCP
How can you dx borderline personality disorder?
pervasive pattern of unstable relationships, self-image, affects, marked impulsivity, WITH 5+:
- frantic efforts to avoid abandonment
- unstable, intense interpersonal relationships
- markedly and persistently unstable self-image
- impulsivity in 2+ areas that are potentially self damaging
- suicidal behavior/ self mutilation
- mood instability
- chronic feelings of emptiness
- inapprop and intense anger
- transient stress-related paranoia or dissociation
tx =
- PSYCHOTHERAPY (best)
- ATYPICALS, MOOD STABILIZERS for mood reactivity/transient psychosis
- ANTIDEP’s if comorbid mood/anxiety disorder
*common: hx childhood trauma
PTSD
trauma and sx <1 month = Acute Stress Disorder
sx for >1 month = PTSD
immediately after trauma or with delayed expression
- INTRUSIVE sx (thoughts, nightmares, flashbacks)
- AVOIDANCE of triggering stimuli
- MOOD CHANGES
- DISSOCIATION
- 2+ sx of INCREASED AROUSAL: hypervigilance, exag startle response, irritability/angry outbursts, insomnia
*50% PTSD recover within 3 months
What are tx options for PTSD?
- SSRIs or SNRIs
- Prazosin (alpha 1 antag) - nightmares, hypervigilance
- if severe: augment with atypicals
- psychotherapy (ie - cognitive processing therapy) asap after stressor
Define ego-dystonic and ego-syntonic.
Ego-dystonic: it bothers the person
Ego-syntonic: it doesn’t bother the person
Personality disorder criteria
CAPRI
Cognition
Affect
Personal Relations
Impulse control
Cluster A
schizoid: eccentric, reclusive (VOLUNTARY social withdrawal), little interest in sexual activity with another person, taking pleasure in few activities, few close friends, indifference to praise/criticism, flattened affect/emotional coldness
schizotypal: eccentric … 5+: ideas of reference (thinking insignif things have personal significance), odd beliefs, magical thinking, inapprop/restricted affect, suspiciousness, excess social anxiety
paranoid: distrustful, tend to blame their own problems on others, characterized as frequently jealous, reluctance to confide in others, persistence of grudges
Paranoid PD vs. Schizophrenia, Social isolation
PPD:
no fixed delusions, not frankly psychotic
*CAN be transiently psychotic in stressful situations
Ask others in close contact with the person, who can identify the person as excessively suspicious
Schizoid vs. Schizophrenia, Schizotypal, Avoidant
SPD:
no fixed delusions or hallucinations
no magical thinking; not the same level of odd behavior/thought/perception
PREFER to be alone
Schizotypal vs. Schizophrenia
not frankly psychotic, no fixed delusions
*CAN be transiently psychotic
What is magical thinking?
Belief in telepathy or clairvoyance
Bizarre fantasies, preoccupations
Belief in superstitions
Cluster B
antisocial (M > F): violate the rights of others w/o showing guilt, exploitive, break rules to meet their own needs, lack empathy, impulsive, skilled at social cues & can appear charming at first, fail to accept responsibility for their own behavior, assault others, arrogant
- REQUIRE hx conduct disorder (<15 yrs), and be dx’ed with this at age >18 yrs
- Hx abuse, hurting animals, starting fires
- Men with alcoholic parents
borderline (F > M): unstable, intense interpersonal relationships; fear abandonment, poorly formed ID, aggression, impulsive, hx suicide/self-mutilation, transient stress-related psychosis
- Tx: Dialectical behavior therapy (DBT)
- Often split (good vs bad)
histrionic (F > M): attn-seeking, excessive emotionality, dramatic extroverted; unable to form long-lasting meaningful relationships, sexually inappropriate/provocative
*Regression (revert to childlike behaviors)
narcissistic: sense of superiority, need for admiration, lack of empathy, sense of entitlement, exploitive BUT fragile self esteem
* Greater risk of midlife crisis (emphasis on youth and power)
Borderline vs. Bipolar II, Histrionic
vs bipolar II: mood swings are rapid, brief, moment-to-moment reactions to perceived environ or psychological triggers
vs histrionic: more likely to suffer from depression, brief psychotic episodes, attempt suicide
(histrionic pts usually more functional)
Antisocial vs Narcissistic, Intermittent Explosive Disorder
NPD: want status/recognition … if don’t get it, they become depressed
Antisocial: want material gain, or simply dominance of others
*both exploit others
IED: usually no hx of conduct disorder, do not routinely engage in illegal activities
(can only dx IED in absence of antisocial disorder)
Cluster C
avoidant: social inhibition, intense fear of rejection, hyperSn, avoid jobs with interpersonal contact
(DESIRE companionship but extremely shy)
*Overlap with social anxiety disorder
dependent (F > M): poor self-confidence, fear of separation, need to be taken care of, difficulty making everyday decisions, need others to assume responsibilities, difficulty expressing disagreement, feels helpless when alone
OCPD (M > F): perfectionism, inflexibility, orderliness; unable to finish simples tasks on time; appear stiff, serious, formal with constricted affect; professionally successful but poor interpersonal skills. Unable to discard worthless objects, miserly spending style, stubborn.
Avoidant vs.
Schizoid
Social anxiety disorder
Dependent personality disorder
vs. schizoid: desire to be social but are shy
vs social anxiety disorder:
- if sx (fear, avoidance) been a chronic thing and part of patient’s entire life - personality.
- but if it’s fear in a particular setting - SAD.
vs DPD:
- both cling to relationships.
- avoidant pts are slow to get involved, whereas DPD pts actively/aggressively seek relationships
Dependent PD vs. Borderline
DPD: long-lasting relationships
Borderline / histrionic: dependent on people but unable to maintain a longterm relationship
OCPD vs OCD, Narcissisicism
vs OCD: no recurrent o or c
OCPD: ego-syntonic
OCD: ego-dystonic
vs narcissisicism:
- both involve assertiveness and achievement
- narcissisicism: motivated by status
- OCPD: motivated by the work itself
Which substances can induce depressive disorder?
Alcohol Antihypertensives Barbiturates Steroids Levodopa Sedative-hypnotics Anticonvulsants Antipsychotics Diuretics Sulfonamides Withdrawal from stimulants (cocaine, etc)
Which substances can induce bipolar disorder?
antidepressants sympathomimetics (ie - phenylephrine) dopamine steroids levodopa bronchodilators cocaine / amphetamines
Procainamide, quinidine Albuterol Isoniazid Tetracycline Nifedipine, verapamil Cimetidine Steroids
Procainamide, quinidine: confusion, delirium
Albuterol: anxiety, confusion
Isoniazid: psychosis
Tetracycline: depression
Nifedipine, verapamil: depression
Cimetidine: depression, confusion, psychosis
Steroids: aggressiveness/agitation, mania, depression, anxiety, psychosis
What is:
reactive attachment disorder
disinhibited social engagement disorder
abuse/neglect in infancy
RAD: pairs too little
DSED: pair too much (overly bonding; cannot diff between stranger and family)
dx: <5 years old … r/o autism
tx: tell caregiver how to parent better OR get kid to place where it can happen
f/u: mood disorder, substance disorders … learning disabilities
Adjustment disorder
Non life-threatening stressor –> mood changes
(lose child, lose your job, etc)
onset: within 3 months of stressor
duration: < 6 months
- more severe reaction than expected
mood change that doesn’t qualify for a mood disorder (no SI, HI) –> generally don’t need treatment
First line tx, MDD with psychotic features
Combination therapy: antidepressant + antipsychotic
or
ECT
Catatonia
- sx of retarded vs excited
- treatment
- 3 things for f/u
Mood / Bipolar»_space;> Schizophrenia (modifier of illness)
Dx: 3+ of:
- Retarded catatonia: stupor, catalepsy (can put pt in any position you want), waxy-flexibility, negativitism (resistance to ideas etc), mutism, immobility
- Excited catatonia: stereotypy (repetitive mvmts), agitation/grimace, echolalia, echopraxia
Dx: Treat with Lorazepam … if goes away, that’s the dx.
** antipsychotics WORSEN catatonia
F/u:
- Malnutrition –> albumin
- DT ppx (DVT??)
- Rhabdo –> ARF (check elevated CK)
Malignant catatonia (psych disorder ++ NO meds)
NMS (psych disorder ++ antipsychotic induced)
SS (psych disorder ++ SSRI or w.e. induced)
Malignant hyperthermia (NO psych disorder ++ halothane/anesthesia induced)
Sx:
- Lead pipe rigidity:
- muscle breakdown –> high CK
- strong resistance to mvmt - ANS dysfunction:
- HTN
- tachy
- fever
Social anxiety disorder
fears related to being publically scrutinized, embarassed, or neg judged in a social context
vs GAD: where there are multiple worries
vs panic disorder: where there are
- unexpected panic attacks
- patient’s fear is specifically related to the panic sx
vs specific phobia: where stimulus is not related to social anxiety
What are some augmentation strategies, if someone’s having a partial response to their current anti-depressant medication?
What if they’re a nonresponder?
- add anti-depressant with a different MOA
- add an atypical (aripiprazole)
- add lithium
- add T3
- psychotherapy
Nonresponder: change to a diff med
MDD vs normal grief
MDD:
- persistent sadness, anhedonia
- excessive guilt
- self critical ruminations
- suicidality
- feelings of worthlessness and hopelessness
What is persistent complex bereavement disorder?
Aka complicated grief
- persistent yearning for deceased
- prolonged emotional pain related to loss (6-12 mo)
- impaired functioning
- complicating features:
- maladaptive rumination
- dysfunctional behavior (ie - excessively seeking proximity to deceased thru objects)
Side effects of lithium?
CI?
Acute: tremor, ataxia, AMS, n/v, diarrhea + polyuria, polydipsia, weakness
Chronic: nephrogenic DI, CKD, thyroid dysfxn (usually hypo), hyperparathyroidism (hyperCa)
CI: CKD, CVD, hyponatremia or diuretic use
*esp first tri pregnancy
What labs would you want to get before starting lithium?
BMP TFT Ca UA pregnancy test ECG if have CAD risk factors
Indications for ECT?
treats: depression, bipolar mania, catatonia
- treatment resistant
- psychotic features
- emergencies (SI, refusal to eat)
- CI to pharmacotherapy
- pregnancy if can’t use meds
- hx of ECT response
- no absolute CI
What are the side effects of ECT?
Retrograde + anterograde amnesia
Anterograde: resolves w/in 2 wks of being done
Retrograde: may persist longer
What can you use to treat the depressive phase of bipolar?
lamotrigine
quetiapine
Primary diagnostic features of conduct disorder?
Deceitfulness or theft (lying, stealing)
Deliberate property damage (vandalism, setting fires)
Aggression, cruelty towards ppl/animals
Serious violation of rules (truancy, running away)
3+ for >12 months. lack of remorse
Tx:
- CBT
- Fam therapy
- Parent mgmt training
Conduct disorder vs ODD
ODD: angry/irritable mood + defiant behavior toward authority figures
NO stealing or aggression towards people
Somatic symptom disorder
vs
Panic disorder
Somatic symptom disorder: physical sx are persistent over time
Panic disorder: more acute attacks
What are the sleep changes in depression?
Early morning awakening
Multiple awakenings
Decreased REM latency
Decreased restorative sleep
Lewy body dementia - what can happen when you use anti-psychotics in these patients?
- autonomic dysfunction (orthostatic hypotension)
- Parkinsonism (bc blocking dopamine)
- AMS
