DSE Unit 4 Review Flashcards
Presence of physical symptoms in the absence of physical “signs”
Pain is the predominant symptom
Health Concerns play a central role in this patient’s life, to a degree that is not explainable by their physical condition
Somatic Symptom Disorder
Somatic
Relating to the body as distinct from the mind
Somatic Symptoms should have basis in the physical body, not the mind
In somatic symptom disorder, the basis is not found in the body and is therefore assumed to be in the mind.
DSM V criteria for Somatic Symptom Disorder
1+ symptom that significantly disrupts daily life
Symptoms may change but the state of “being symptomatic” lasts for at least 6 months
At least 1 of the following:
Disproportionate worry about severity not
supported by the actual severity
Persistant High Level of Health Anxiety Excessive Time & Energy devoted to Sxs Specify if PAIN is main complaint Specify if PERSISTANCE best describes Mild= 1 symptom Moderate = 2 Symptoms Severe = 3+ Symptoms
Coexists mainly with Depression, Anxiety
and the non-aggressive Personality Disorders
Somatic Symptiom Disorder
Cluster A Personality Disorders
Schitzophrenia-Delusional, Paranoid, Hallucinate
Schizoid - Asperger-ish Flat Affect, Detatched
Schitxotypal- Really Really Odd
Overvalued Ideas
Schitzotypal Personality Disorder of Cluster A
Flat Affect, Detached, Not interested in YOU
Schizoid Asperger’s - ish
Hears voices, talks back to them
Unduly suspicious
Fixed False Beliefs (aliens are coming…)
Schitzophrenia
Cluster B Personality Disorders
Antisocial
Histrionic
Narcissistic
Borderline
The criminal who violates rights of others
Without Empathy
Antisocial Personality Disorder
Must begin before Age 15 (as conduct disorder)
Watch out, these folks can be Magnetic, Compelling and charming if reeling in a victim
The Drama Queen; Everyone is her BFF
Histrionic Personality Disorder
This girl makes the wrong choice every time
She is impulsive, unstable and very fearful of abandonment (guess why)
People love her or “see through her” and find her manipulative
She is often misdiagnosed as bipolar
Borderline Personality Disorder
THERAPY (evidence based) can really help these girls (2:1 female) learn coping skills enough to turn their lives around ENOUGH.
Totally worth a try
Cluster B Personality Disorders
THE DISINHIBITED... Antisocial Histrionic Narcissistic Borderline
Lamotragine (anti seizure that Rxs anger in mood disorders) & Antipsychotics are ok to treat this cluster but NOT BENZOS - too disinhibiting for a group that is already disinhibited
Cluster B:
Borderline
Narcisistic
Antisocial
Histrionic
Lamotragine (anti seizure that Rxs anger in mood disorders) & Antipsychotics are ok to treat this cluster but NOT BENZOS - too disinhibiting for a group that is already disinhibited
Cluster B:
Borderline
Narcisistic
Antisocial
Histrionic
Grandiose, Entitled, this Pt is most obnoxious and self involved but really she craves attention because she has very low self esteem.
Narcisistic Personality Disorder
(Juliana & Draco Malfoy)
DON’T LAUGH AT THESE PTS - self esteem is too low to sustain that without resorting to extreme responses
Reality Checks may not be the best idea either - Their deflection of responsibility is borne of shame, not hubris.
Rx for Cluster Bs
Lamotragine, Abilify (antipsychotics) and Therapy but
NO BENZOS for Bs!!! Too disinhibiting !
Cluster “C” Personality Disorders
The ANXIOUS Cluster
Avoidant
Obsessive-Compulsive PD (NOT OCD)
Dependent
Perfectionistic to the point it interferes with task completion
Hoarders, Micromanagers & Work-a-holics
Obsessive Compulsive PD
Rx for Cluster Bs
Lamotragine, Abilify (antipsychotics) and Therapy
Can’t manage eating out alone, public restrooms or parties, feels INADEQUATE
Avoidant Personality Disorder
Perfectionistic to the point it interferes with task completion
Hoarders, Micromanagers & Work-a-holics
Obsessive Compulsive PD
You Can’t Shake This Friend Off
Submissive with very low self esteem
“Debbie”
Dependent PD
Rx for Anxiety & Depression
Benzos until SSRIs kick in
Can’t manage eating out alone, public restrooms or parties, feels INADEQUATE
Avoidant Personality Disorder
Use Benzos with these folks and SSRIs
An enduring pattern of inner experience & behavior that leads to distress & impairment OVER & OVER AGAIN
PERSONALITY DISORDER
REPETITION COMPULSION
divorce one abuser and marry another, compelled to keep making the same mistake. This is a “Disordered” person with a Personality Disorder. Figure out which one and refer to psychologist for testing and have him refer to an appropriate therapist.
Rx for Anxiety & Depression
Benzos until SSRIs kick in
Somatic Symptom Disorder
vs
Illness Anxiety Disorder
Somatic HAS physical symptoms + worry
Illness Anxiety HAS worry but no physical Sxs
Pt presents with unusual concern about howel movements or other vague complaint “tired heart”
No particular symptom but a great deal of concern about it
Illness Anxiety Disorder
Usually presents 20-50 yrs
Hypochondriacs
Often Obsessive-Compulsive Pers Disorder and/or Schitzophrenia
Rx for Illness Anxiety Disorder
SSRI + CBT Therapy
Somatic Symptom Disorder
Vs
Conversion Disorder
Somatic has physical Sxs but no SIGNS
Conversion has physical SIGNS that CAN BE LETHAL The mind disables the body. Prognosis is very poor. First Line Rx is education about the nature of the diagnosis, then CBT Therapy and attempt to relieve the sxs.
Chronic Stress/ HTN Anxiety/ Asthma Depression/ CAD Smoking/ COPD Obesity / Diabetes
Psychological Factors Affecting Other Medical Conditions
A DSM V Diagnosis
Chronic Stress/ HTN Anxiety/ Asthma Depression/ CAD Smoking/ COPD Obesity / Diabetes
Psychological Factors Affecting Other Medical Conditions
A DSM V Diagnosis
Mild-Won’t take HTN meds
Mod-Smokes even though SOB
Severe- Results in ER or Hospitalizatin
Extreme (too depressed to go to ER for MI)
This Pt “fakes” a physical disorder, Tampers with equipment to support the lie, Implies head trauma when they have a genetically constricted pupil etc…
FACETIOUS DISORDER
Specify if first incident (that YOU know of)
or if this is a recurring behavior.
Munchausen
Facetious Disorder IMPOSED ON SELF
Munchausen by Proxy
Facetious Disorder IMPOSED ON ANOTHER
Substance ABUSE
vs
Substance DEPENDENCE
ABUSE: Tolerance, Withdrawal, Continued Use Even w/the understanding of cost
DEPENDENCE: loss of control over use
Well Being BAC
Up to 0.05%
Getting Risky BAC
Reduced Inhibition
0.05 - 0.08%
Nausea/Vomit
Dangerous BAC
.008 - 0.15%
BAC
Stupor, Incontinence, Unable to walk unaided
0.15-0.4%
Death BAC
0.4% +
Well Being BAC
Up to 0.05%
3.75 Hrs to 0%
Nausea/Vomit
Dangerous BAC
.008 - 0.15%
Legal Limit is 0.08% 5 hrs to 0%
Coma, Shock, Death BAC
0.4% +
MUST acronym for
Alcohol Poisoning:
M (Mental Confusion)
U (Unresponsive)
S (Snoring/Gasping for Air)
T (Throwing Up)
HELP Acronym for
Alcohol Poisoning
H (Hypothermia)
E (Erratic Breathing)
L (Loss of Consciousness)
P (Pale/Bluish Skin)
ETOH Poisoning Rx:
Thiamine IV/ Banana Bag
Pump Stomach
Respirator?
Methanol Poisoning Rx
Ethanol or Fomepizole
Fomepizole also for Ethylene Glycol Poisoning
NorEpi Dopamine Reuptake Inhibitors
Bath Salts & Meth
Extreme Insomnia Jittery Self Mutilation Mutilation of others Psychotic behavior
Hyperthermia
Bath Salts & Meth
CNS Depressants
Alcohol (s)
Aerosol Huffing
Benzos - hard to overdose on these just risk of addiction
Memory Loss, Unconsciousness, Urine/Fecal Incontinence/Liver Damage & Sudden Death by suffocation or MI
Aerosol Huffing Risks
Cocaine, Amphetamine, Caffeine, Nicotine
CNS Stimulants
Dilated pupils,
Elevated BP, Pulse & Temp
Nose Bleeds/Runny Nose
Seizures
Stimulants
Specifically Cocaine, Crack & Bath Salts
Euphoria
Rapid Speech
Increased Energy & Mental Alertness
Bleeds into Paranoia & Psychosis
Methamphetamine
& to a lesser degree
the other Amphetamines
NorEpi Dopamine Reuptake Inhibitors
Bath Salts & Meth
Extreme Insomnia Jittery Self Mutilation Mutilation of others Psychotic behavior
Hyperthermia
Bath Salts & Meth
Euphoria Depressed Respirations Constipation Drowsiness Tachycardia Pin Prick Pupils (Myosis) Sleepy to unresponsive Apnea/Coma
Opiate High
Dyseuphoria Tachypnea HTN Super Focus (on getting more) Joint Aches Mydriasis Diaphoresis Insomnia Yawning (hyperrespiration)
Opiate Withdrawal
5 Ps
Drug/Alcohol Screen for pregnant women & women of childbearing age
Dopamine Releasor
Opiate
Heightened Senses
Loss of Identity
Illusions/Hallucinations
Altered Time/Distance Perception
Hallucinogens
Mushrooms
PCP
LSD
Illicit Drug relieves Asthma Sxs by relaxing bronchioles
Relieves Nausea, Migraines, Epileptic Seizure and Eye Pressure in Glaucoma, Joint Pain & Arthritis in ALS & MS
Marijuana
AUDIT screen for
Alcohol Abuse
CRAFFT
Alcohol & Drugs in Adolescents 6 questions
C Car R Relax A Alone F Forget F Family T Trouble
TWEAK
Drinking During Pregnancy screen
DAST
10 quest Drug Abuse Screen
5 Ps
Drug/Alcohol Screen for pregnant women & women of childbearing age
Antidypsotropic
Rx that supports sobriety by effecting intolerable sxs when used with alcohol or drugs or by reversing affect of drug
Antabuse Naltrexone Campral for cravings & withdrawal Methadone Suboxone
Nicotine assistance
Chantix
Wellbutrin
nicotrol
Oxycodone
Immediate Relief
Oxycontin
Sustained Relief
Street Value for 80mg Tablet is $1,000
Percocet
Oxycodone w/Tylenol
Seizure Protocol for ETOH Withdrawal
10 - 150mg Atavan IV to control agitation and prevent seizure
Seizures peak at ___ in ETOH withdrawal
24 hrs
But can begin 2 hrs after the last drink
SBRT Screen
Best Practice Primary Care Drug/ETOH Screen
Screen
Brief Intervention
Referral to
Treatment
SBRT Screen
Best Practice Primary Care Drug/ETOH Screen
Screen
Brief
Intervention
Referral to Treatment
Dilated Pupils & Tachy? Chest Pain?
Quick get ___
EKG
Cocaine & Amphetamines cause MIs
Disulfiram
Antabuse
Dilated Pupils & Tachy? Chest Pain?
Quick get ___
EKG
Cocaine & Amphetamines cause MIs
Unfortunate side effect of Chantix
Depression
Non-Suicidal Self Directed Violence
Cutters/Burners
Need “to feel”
Egoistic Suicidal Ideation
I don’t belong…
Altruisitic Suicide
Die for a Cause
Anomic Suicide
No point in going on
No point to anything
Fatalistic
No hope of change
No Point in going on
Altitude is a risk for
Suicide
Over 2,000 ft above sea-level 70% increase in suicide risk?????
Clozapine Black Box Warnings
Agranulocytosis, CNS Depression, Seizure, Bone Marrow Suppression, Myocarditis, Hypotension & Dementia
Follow w/CBC when prescribing Clozapine
Too much dopamine in the mesolimbic and too little dopamine in the mesocortical
Schitzophrenia
LSD and other hallucinogens activate Serotonin receptors in normal brains and cause hallucinations. What do we use in Schitzophrenia to quell hallucinations?
Serotonin Receptor Antagonists like
Clozapine (a NEW atypical antipsychotic)
Does NOT induce tardive dyskinesia like Risperidone. DOES cause: Weight gain, Constipation, drooling, bed wetting and bears black box warnings for : AGRANULOCYTOSIS, CNS DEPRESSION, SEIZURES…
SO.. Check CBCs regularly when on Clozapine. For these reasons, its a third line drug for Schitzophrenia even though it works better than older atypical antipsychotics.
D2 Receptor Antagonists
Antipsychotics, pines & dones Block D2
1st Gen: Haloperidol, Fluphenidol, Thiothixine
2nd Gen: Pines, Dones & Rip
Clozapine Black Box Warnings
Agranulocytosis, CNS Depression, Seizure, Bone Marrow Suppression, Myocarditis, Hypotension & Dementia
Follow w/CBC when prescribing Clozapine
DDx for Schitzophrenia
Psychotic Disorder Caused by Med. Cond
ex: Folate/B12 Deficiency
Manic Phase of Bipolar Disorder
Stimulant/Amphetamine Overdose
Schitzophrenic Symptoms less than 1 month
Brief Psychotic Disorder
Schitzo Symptoms 1 - 6 months
Schitzoaffective Disorder
Psychotic Symptoms with Mood irregularities and Schitzo Symptoms over 6 months
Schitzoprhrenia
Schitzo Symptoms 1 - 6 months
Schitzophreniform Disorder
Has Depressive or other mental comorbidity but has at least 2 weeks of pure schizophrenic symptoms
Schitzoaffective Disorder
Synapse Depletors are VMAT blockers - they reduce the monoamines secreted into synapse by blocking transport. Drugs used in Schitzophrenia:
Reserpine treats the depression, psychosis & HTN at the same time
“Serpine” venom treats HTN permanently…
Tetrabenazine - a Huntington’s drug for dyskinesia
D2 Receptor Antagonists
Antipsychotics, pines & dones Block D2
1st Gen:
2nd Gen
Use these to counteract the dyskinesia caused by blocking D2 in the Nigrostriatal Pathway when treating Schitzophrenia with 1st Gen Antipsycotics
Anticholinergics like:
Benztropine & Diphenhydramine
Side effects are Dry Mouth, Blurred Vision, Constipation
Remember, Cholinergics make you Sludgy, Anticholinergics make you dry as a bone, mad as a hatter…
Schitzophrenia is a time dependent diagnosis. Under 1 month of sxs is “Brief Psychotic Disorder” while 1-6 months is _______ and over 6 months is full on Schitzophrenia
Schitzophreniform Disorder
Schitzoaffective vs Schitzophreniform
- Affective = w/other dx but at least 2 weeks of pure full on schitzo symptoms
- Phreniform = Pure schitzo but for less than 6 months
All effective Antipsychotics block this, here
Block D2 Receptors in the mesolimbic but usually they also block in the mesocortical, bringing on parkinsonian dyskinesias
Clonzapine targets Serotonin receptors and does a great job controlling schitzo behaviors but has serious bone marrow & CNS consequences.
Blocking D2 in the MesoLimbic Pathway
Causes deceased firing and decreased Psychosis - YAY - this is the one we want, unfortunately First Generation Antipsychotics aren’t really selective. Choos 2nd Gen, Atypical Antipsychotics and if they don’t work try Abilfy or Clonzapine
All effective Antipsychotics block this, here
Block D2 Receptors in the mesolimbic but usually they also block all or several of the pathways bringing on parkinsonian dyskinesias, prolactinemia, and cognitive deficits.
Clonzapine targets Serotonin receptors and does a great job controlling schitzo behaviors but has serious bone marrow & CNS consequences.
Decrease Dopamine, decrease psychosis but you risk Increasing
Depression and dyskinesia
Too much Nor-Epi is also an issue in Schitzo
Block the monoamine transporter and you decrease both NorEpi and Dopamine
You decrease depression, decrease psychosis and decrease HTN all in one go
Reserpine
Synapse Depletors are VMAT blockers - they reduce the monoamines secreted into synapse by blocking transport. Drugs used in Schitzophrenia:
Reserpine treats the depression, psychosis & HTN at the same time
Tetrabenazine - a Huntington’s drug for dyskinesia
D2 Receptor Antagonists
Antipsychotics, pines & dones Block D2
1st Gen:
2nd Gen
Tuberoinfundibular Pathway
Blocks Prolactin secretion.
Block the D2 receptor here and prolactin gets released leading to gynecomastia and low testosterone/ED/low sperm count symptoms
Blocking D2 in the NigroStriatal Pathway
Causes tardive dyskinesias
Blocking D2 in the Mesocortical Pathway
Causes Cognitive Deficits
Blocking D2 in the MesoLimbic Pathway
Causes deceased firing and decreased Psychosis - YAY - this is the one we want, unfortunately First and Second Generation Antipsychotics aren’t really selective
All effective Antipsychotics block this, here
Block D2 Receptors in the mesolimbic but usually they also block all or several of the pathways bringing on parkinsonian dyskinesias, prolactinemia, and cognitive deficits.
Clonzapine targets Serotonin receptors and does a great job controlling schitzo behaviors but has serious bone marrow & CNS consequences.
Rare, but life-threatening, Rxn to NEUROLEPTIC MEDICATIONS LIKE ANTIPSYCHOTICS that is characterized by
fever
muscular rigidity
altered mental status, and autonomic dysfunction.
Usually occurs w/in 10 days of initiation of the neuroleptic, or after dose increases.
NEUROLEPTIC MALIGNANT SYNDROME
Too Much D2 Receptor Blocking
STOP the antipsychotic
Cool him to normal temp
Relax the muscles
Usually resolves w/in 2 weeks with supportive care, if dose was long term depot, will take a month
Can use Dantrolene to Rx muscle spasms and hyperthermia - its a D2 Agonist
D2 Agonist used to treat hyperthermia and muscle rigidity
Dantrolene
Rare, but life-threatening, Rxn to NEUROLEPTIC MEDICATIONS LIKE ANTIPSYCHOTICS that is characterized by
fever
muscular rigidity
altered mental status, and autonomic dysfunction.
Usually occurs w/in 10 days of initiation of the neuroleptic, or after dose increases.
NEUROLEPTIC MALIGNANT SYNDROME
Too Much D2 Receptor Blocking
STOP the antipsychotic
Cool him to normal temp
Relax the muscles
Usually resolves w/in 2 weeks with supportive care, if dose was long term depot, will take a month
Can use Dantrolene, to Rx muscle spasms - its a Ca+ blocker in the sarcoplasmic reticulum & prevents muscle contraction
Muscle Relaxant used to treat muscle rigidity
Dantrolene
D2/D3/D4 Agonist used to Rx hyperthermia and also Restless Leg, Parkinsons and Bipolar Disorder
Pramiprexole But…
Causes: Compulsive Gambling, eating & hypersexuality
It prefers D3 but does agonize D2 & D4
Use these to counteract the dyskinesia caused by blocking D2 in the Nigrostriatal Pathway when treating Schitzophrenia with 1st & 2nd Gen Antipsycotics
Anticholinergics like:
Benztropine & Diphenhydramine
Side effects are Dry Mouth, Blurred Vision, Constipation
Remember, Cholinergics make you Sludgy, Anticholinergics make you dry as a bone, mad as a hatter…
Choreic Movements in dyskinesia
Fast, Jerky
Blocking D2 too much causes this but so does too much Dopamine as with too much levodopa in parkinsons treatment
Athetotic Movements
Slow & Writhing
1st Gen High Potency Antipsychotics
(FGA-High Potency)
1st Gens are aka TYPICAL Antipsychotics
Haloperidol
Fluphenazine
Thiothixine
Dyskinesia, Dry Mouth, Hypotension & Sedation via H1 blockade
1st Gen Low Potency Antipsychotics
FGA-Low Potency
Chlorpromazine
Thioridazine
FGA High Pot Side effects
Dyskinesia, Dry Mouth, Hypotension & Sedation via H1 blockade
2nd Gen Antipsychotics aka
A-Typical Antipsychotics
Atypical Antipsychotic Drug MOA
Selectively Blocks Mesolimbic D2 receptors controling psychosis but leaving the others alone, reducing dyskinesia, cognitive impairment and Prolactin effects of 1st Gens
Also block Serotonin Receptors to further decrease hallucination (recall LSD antagonizes serotonin receptors and causes hallucinations)
2nd Gen Atypical Drugs for Schitzophrenia
Dones Pines Rips
Risperadone Olanzapine Ariprazole
Quetiapine
Clozapine
2nd Gen Atypical Drugs for Schitzophrenia
Dones Pines Rips
Risperadone Olanzapine Ariprazole
Quetiapine D2/D3
Clozapine Agonist
Dones make you
Twitchy
Pines make you
Fat
2nd Gen Atypical Drugs for Schitzophrenia
Dones Pines Rips
Risperadone Olanzapine Ariprazole
Quetiapine D2/D3
Clozapine Agonist
“Abilify”
Dones make you
Twitchy
Ziprasidone and Iloperidone have long QT
Pines make you
Fat & Lazy (due to sedation from H1 blockade)
aRIPrazole (Abilify) makes you
Fat, Stuffy Nose, Constipated & Twitchy
long term Brain Changes in Schitzophrenia
Grey matter/Cortical tissue atrophies
Ventricles enlarge and fill with CSF
IS PATH WARM??
Suicide Acronym
I Ideation S Substance Abuse P Purposeless-ness A Anxiety T Trapped H Hopeless W Withdrawal A Anger R Reckless M Mood Change
Rapid Onset Drug Rxn: Increases in Heart Rate, Bp and Temp with Altered Mental Status, Rhabdo, Acidosis, Seizures
Twitching, Hyper-reflexia, Renal Failure, Death
Serotonin Syndrome
May occur within minutes of elevation of serotonin levels
Lead Pipe Rigidity, Hyporeflexia, Normal Bowel Sounds
vs
Clonus, Mydriasis and Hyperreflexia and Hyperactive Bowel Sounds
Neuroleptic Malignant Syndrome has rigidity whereas Serotonin Syndrome has the clonus and hyper-reflexia.
Both have increased HR, BP and Temp as well as altered mental status and Drooling
Overdose causes cardiac arrythmias within the hour that very well may be fatal
TCAs
The brugada type QRS
