Final Flashcards
sleep recommendations for adults
at least 7 hours each night
definition of sleep
physiological state of relative unconsciousness and inaction of voluntary muscles
REM sleep
- 4-6 episodes per night
- period almost total muscle atonia
- nocturnal erections
- dreaming
NREM stage 1
- slow rolling eye movements
- theta waves
NREM stage 2
spindles and K complexes
NREM stage 3 and 4
- delta waves
- recovery, growth hormone secretion, immune function
- blood perfusion, metabolic rate, and temperature drop
- sleep walking and night terrors
sleep regulation
- circadian biological clock regulates timing of sleep and wakefulness
- diurnal
sleep efficiency and aging
- efficiency decreases with age
- efficiency defined as time asleep versus time in bed
effects of sleep deprivation
- decreased cognition
- decreased performance
- decreased perceptions
- increased carbohydrate cravings
- possible insulin resistance
insomnia criteria
- dissatisfaction with sleep quality or quantity
- causes significant distress or impairs function
- sleep difficulty at least 3 nights per week
- sleep difficulty present at least 3 months
- not caused/explained by another condition
three different types of insomnia
- inability to fall asleep
- inability to maintain sleep
- early morning awakening
psychophysiological insomnia
- somatized tension and learned sleep preventing associations
- associated decreased functioning during wakefulness
insomnia history and physical
- complete sleep history
- medical and psych assessment
- substance use
- labs
- sleep diary
- possible sleep study/actigraphy
polysomnography (sleep study)
- indicated if suspected sleep apnea, periodic limb movements, or parasomnias; insomnia treatment failure
- not indicated for routine insomnia because of insomnia variability
diphenhydramine/doxylamine sleep aid
- no prescription and inexpensive
- limited studies, residual effects from long T1/2, probable tolerance with repeated nightly use
melatonin
- questionable hypnotic effect
- not regulated by DEA
- reports of depression
- better at affecting circadian patterns
sedating antidepressants
- no defined hypnotic dose
- few studies on efficacy in treated insomnia unrelated to depression
- poor side effect profile
benzodiazepines for sleep
- good hypnotic effects
- potential for abuse
- reduces stage 3/4
- rebound insomnia
- elderly ADE: anterograde amnesia, cognitive/psychomotor degradation
zolpidem (ambien)
- rapid sleep onset
- does not affect sleep architecture
- half life 2.5 hours
- minimal side effects and drug interactions
zaleplon (sonata)
- rapid onset
- half life one hour
- no effect on sleep architecture
- can be used if 4 hours left to sleep
- unknown habit forming potential
- minimal side effects and drug interactions
eszopiclone (lunesta)
- rapid sleep onset
- longer half life
- good for chronic use and maintenance insomnia
narcolepsy
excessive sleepiness associated with
- cataplexy
- sleep paralysis
- hypnagogic hallucinations
- nocturnal sleep disruption
narcolepsy testing
- multiple sleep latency test shows low sleep onset latency and 2+ sleep onset REM
- low hypocretin in CSF
narcolepsy treatment
modafinil (provigil)
- no effect on total sleep time
- no suppression of REM
narcolepsy treatment sodium oxybate (xyrem)
- anti cataplexy
- taken at bedtime and reduces daytime sleepiness
parasomnia
- unwanted events during sleep
- nightmare disorder
- non REM: sleepwalking, sleep terrors
- REM: acting out dreams
restless legs criteria
"urge" Urge to move legs Rest exacerbates symptoms Getting up improves symptoms Evening brings worsening onset
Sleep apnea types
- obstructive (most common)
- non obstructive
sleep apnea criteria
-sleep study shows
5+ apneic episodes with symptoms
or
15+ episodes without symptoms
sleep apnea treatment
- lose weight
- avoid alcohol, nicotine, sleep Rx
- CPAP
- dental appliance
- surgery
paraphilic disorder
individual primarily seeks sexual gratification through means considered abnormal by society
disorders of sexual orgasm
- female orgasmic disorder
- premature ejaculation
- delayed ejaculation
disorders of sexual arousal
- erectile disorder
- dyspareunia (pain associated with intercourse)
- vaginismus (involuntary muscle contraction of outer 1/3)
disorders of sexual desire
-male/female hypoactive sexual desire disorder
paraphilic disorder criteria
-feel personal distress about desire or -have desires that cause other's distress; involve unwilling persons; involve persons who can't give consent and occurred over a period of 6 months
exhibitionist
compulsive exposure of genitals
fetishistic
sexual gratification through objects
frotteuristic
touching/rubbing against another person
pedophilic
activity with prepubescent child
sexual masochism
arousal from being made to suffer
sexual sadism
arousal from another person’s suffering
voyeuristic
observing another who is naked or engaged in sexual activity
child development
biological and psychological changes that occur in human beings between birth and end of adolescence that progresses from dependency to increasing autonomy
ADHD criteria
- persistent pattern of inattention and/or hyperactivity (6 symptoms and 6 months)
- symptoms present before age 12
- symptoms in 2 or more settings
- symptoms interfere with functioning
ADHD stimulants
- ritalin, focalin, dexedrine, adderall, vyvanse
- schedule II
- dopamine reuptake blockers
ADHD non stimulant
-strattera
stimulant adverse effects
- loss of appetite
- anorexia
- insomnia
- increased BP
- psychosis
- sudden cardiac death
autism spectrum disorder screening
18 and 24 months
autism spectrum criteria
- persistent deficits in social communication and interaction
- restricted repetitive patterns of behavior, interests, or activities
- symptoms present in early development
- symptoms cause significant impairment
- no other better explanation
intellectual disability
- deficits in intellectual functioning
- deficits in adaptive functioning
- classed as mild, moderate, severe, or profound
oppositional defiance disorder criteria
- pattern of angry/irritable mood, argumentative/defiant behavior, vindictiveness
- lasts at least 6 months
- at least 4 symptoms
- causes impairment in social, academic, or occupational functioning
conduct disorder
repetitive and persistent violation of age-appropriate societal norms, rules, or basic rights of others
- aggression to people and animals
- destruction of property
- deceitfulness or theft
- serious violations of rules
disruptive mood dysregulation disorder
- severe recurrent tantrums that are inconsistent with development level “walking on eggshells”
- must be present in two settings
tourette’s syndrome criteria
- multiple motor tics
- one or more vocal tics
- tics persisted more than 1 year
- onset prior to 18
tourette’s treatment
- block dopamine receptors
- habit reversal training
tourette’s comorbid conditions
- OCD
- ADHD
physical child abuse signs/symptoms
- unexpected injuries
- bite marks
- multiple fractures over time
- antisocial behavior
- fear of adults
- burns with symmetrical edges
child sexual abuse signs/symptoms
- not age appropriate interest/knowledge
- nightmares and/or bed soiling
- fear of a particular person
- drastic change in appetite or behavior
emotional child abuse signs/symptoms
- depression
- hostility
- eating disorder
- social withdrawal
- apathy or hopelessness
neglect child abuse signs/symptoms
- dirty/unbathed
- extreme hunger
- unsuitable clothing for weather
- lack of apparent supervision
child abuse reporting
- suspicion: DHHS
- serious non accidental trauma: police
delirium
acute onset of a transient confused state due to an identifiable cause
delirium criteria
- disturbance of attention and awareness
- disturbance develops over short period of time and fluctuates during the day
- disturbance in cognition
- evidence that cause is physiological consequence of medical condition
delirium etiology
“I WATCH DEATH”
- Infection
- Withdrawal
- Acute metabolic
- Trauma
- CNS pathology
- Hypoxia
- Deficiencies
- Endocrine
- Acute vascular
- Toxins or drugs
- Heavy metals
delirium types
- hyperactive (combative, agitated, restless)
- hypoactive (lethargic, sedated, stupor)
- mixed
Hypoactive often mistaken for depression
diagnosis of neurocognitive disorder
- cognitive decline in 1 or more domains
- interferes with everyday activities
- impairment documented by neuropsychological testing
- chronic and progressive
Alzheimer’s disease common cause
- neurofibrillary tangles
- senile plaques
- massive loss of synapses correlates with cognitive decline
alzheimer’s risk factors
#1 age #2 genetics
alzheimer’s protective factors
- physical activity
- social activity
- cognitive activity
- diet
alzheimer’s treatment
- donepezil/aricept (stimulate cholinergic)
- memantine/namenda (NMDA receptor agonist)
- vitamin E
slow decline, no reversal
somatic system disorder criteria
one of the following
- disproportionate, persistent thoughts about symptom seriousness
- persistent high anxiety about health/symptoms
- excessive time/energy devoted to health/symptoms
state persists for >6 months
somatic symptom disorder treatment
- validate
- biofeedback
- regular visits
- no narcotics
- therapy
- SSRI, SNRI, TCA helpful
illness anxiety disorder criteria
- preoccupation with having/acquiring serious illness
- zero or mild somatic symptoms
- if risk legit exists then preoccupation is excessive
- high anxiety about health
- care seeking or care avoiding type
- illness preoccupation > 6 months
illness anxiety disorder treatment
- take serious
- regular visits
- no inappropriate tests ordered
- CBT
- SSRI
conversion disorder
- one or more symptoms of altered voluntary motor or sensory function
- clinical findings incompatible with symptoms
conversion disorder cause/treatment
- often caused by stressor
- symptoms typically resolve on their own
- educate patient
- CBT
- PT
factitious disorder criteria
- pathologic lying
- falsification of physical or psychological symptoms
- recurrent, feigned, or simulated illness
- deception evident even when no obvious external rewards
malingering
lying about medical need in order to avoid responsibility or for external gain
dissociative identity disorder
- 2 or more distinct personality states
- gaps in recall of everyday events
- may be caused by trauma
dissociative amnesia
- inability to recall important self-information
- can be selective or generalized information
dissociative fugue
- apparently purposeful travel or bewildered wandering
- associated with amnesia of identity
depersonalization disorder
-experiences of detachment or unreality with respect to one’s thoughts, feelings, or actions
derealization disorder
-experiences of detachment or unreality with respect to surroundings or own body
adjustment disorder
- situational depression
- symptoms start < 3 months after stressful event
- symptoms last no longer than 6 months
grief
prolonged grief disorder
- overlapping symptoms with depression
- responds to social contact
- not usually helped by antidepressant
- self limited, usually 2-12 months
remission
- partial 3-12 months
- full greater than 12 months
Lithium monitoring
- narrow therapeutic index
- level every 3 days until stable and then every 3 months
- desirable range 0.5-1.5 but in practice 0.8-1.2 mEq/L
- 1st line drug for bipolar
- toxic to kidneys at high dose
clozapine monitoring
- risk of agranulocytosis (decreased WBC)
- CBC with differential weekly for first 6 months and then every 2 weeks
diagnose MDD
- constant symptoms for at least 2 weeks
- 5 of the SIGECAPS and one must be lost of interest
CAGE questionnaire
Cut down on drinking
Annoyed when asked about drinking
Guilty about drinking
Eye opener in the morning
panic disorder
- recurrent, unexpected panic attacks (2 or more)
- concern about additional attacks
- worry about the implications of the attack or significant change in behavior related to the attacks
panic disorder treatment
- SSRIs are first choice
- benzodiazepine (simultaneous with SSRI then taper)
- TCAs (alternative but more AE and lower safety profile)
treat 8-12 months after symptoms controlled
OCD treatment
-SSRIs are first choice but higher dosages are commonly required
persistent depressive disorder
- chronic state of subclinical depression exhibited by a depressed mood for most of the days for at least 2 years
- can’t go more than 2 months without symptoms
- no previous manic episodes
- don’t meet criteria for MDD
manic episode
distinct period of abnormal and persistently elevated, expansive, or irritable mood lasting at least 1 week (or any duration if hospitalization is needed)
hypomania episode
- distinct period different from usual non-depressed mood lasting at least 4 days
- does not impair functioning and no psychotic features
Bipolar I criteria
- at least one manic episode
- symptoms not explained by another disorder
- psychosis, marked impairment daily life, hospitalization
Bipolar II criteria
- one hypomania
- one major depressive episode
- symptoms not explained by another disorder
- no psychosis or life altering impairement
cyclothymic disorder
- for at least 2 years (1 yr kids)
- numerous periods of hypomanic symptoms that don’t meet hypomania criteria
- numerous periods of depressive episodes that don’t meet MDD criteria
- symptoms present at least half the time and not absent for more than 2 months
schizophrenia diagnostic criteria
- 2 characteristic symptoms of psychosis (hallucinations, delusions, disorganized speech, disorganized behavior, negative symptoms)
- lasts at least 6 months with 1 month of characteristic symptoms
- social and/or occupational dysfunction
- exclude other disorders
schizophreniform disorder
- one to six months of symptoms
- social/occupational impairment not required
schizoaffective disorder
- psychotic symptoms plus prominent mood symptoms
- two week period of psychotic symptoms without mood symptoms
delusional disorder
- delusions for at least 1 month
- no other criteria met
brief psychotic disorder
- one of the characteristic symptoms
- time range one day to one month
substance induced psychotic disorder
-hallucinations or delusions during or within one month of substance abuse
SSRIs drugs
“Effective For Sadness Panic Compulsions”
- escitalopram (lexapro)
- fluoxetine (prozac)
- fluvoxamine (paxil)
- sertraline (zoloft)
- paroxetine (paxil)
- citalopram (celexa)
SSRI+ drugs
vilazadone (viibryd)
vortioxetine (trintellix)
SSRI and partial serotonin agonist
SNRI drugs
desvenlafaxine (pristiq)
duloxetine (cymbalta)
venlafaxine (effexor)
also used for peripheral pain and neuropathy
SSRI side effects
- GI upset
- sexual dysfunction
- activation/akathisia (will go away)
- mania
- SI in younger patients
- serotonin syndrome
serotonin syndrome
- potentially fatal
- can be caused by combining an SSRI/SNRI with an MAOI (should separate by 5 weeks)
- takes 24-48 hours to develop
- variable mental status
- increased muscle tone
- HTN, tachycardia, tachypnea, fever
- hyperreflexia
- mydriasis
- increased bowel sounds
bupropion (wellbutrin)
- atypical antidepressant
- do not use in patient with seizure history
- often used as adjunct with SSRI
mirtazapine (remeron)
- atypical antidepressant
- also used as sleep aid
- AE: weight gain
trazodone (desyrel)
- atypical antidepressant
- also used as sleep aid
- AE: priaprism
esketamine (spravato)
- used for treatment resistant depressant as an adjunct to other antidepressants
- patients monitored for 2 hours after dose for hallucinations
- not used in pregnancy
- AE: dissociative and perceptual changes, derealization, depersonalization, HTN
tricyclics
- 2nd/3rd line for Rx resistant depression
- OD causes fatal cardiac arrhythmias
- be aware of suicidal ideations when prescribing
- amitriptyline, clomipramine
tricyclic side effects
- cardiac toxicity (LBBB, V-tach)
- anticholinergic effects
MAOI
- use is very uncommon
- avoid tyramine containing foods due to HTN crisis
SNRI side effects
same as SSRIs plus HTN
benzodiazepine side effects
- sedation
- fatigue
- disinhibition
- depression
- rebound anxiety
- elderly: memory impairment, impaired performance, lowered attention span, muscle incoordination
buspirone (buspar)
- anxiolytic for anxiety only
- don’t cross react with alcohol or benzos
- little abuse potential
- may take 1-2 weeks to show effect with max effect 3-4 weeks
- mixed results on efficacy
hydroxyzine (vistaril, atarax)
- antihistamine
- anxiolytic
- treat agitation in alcohol detox
- adjunct for insomnia
typical antipsychotics drugs
-haldol
- prolixin
- thorazine
atypical antipsychotics
- onlanzapine (zyprexa)
- risperidone (risperdal)
- clozapine (clozaril)
- aripiprazole (abilify)
- quetiapine (seroquel)
- ziprasidone (geodon)
side effects of typical antipsychotics
- extrapyramidal symptoms
- tardive dyskinesia
- sedation
- neuroleptic malignant syndrome
- weight gain
- orthostatic hypotension
- QT prolongation
neuroleptic malignant syndrome
- result of too much dopamine and occurs over few weeks/months
- variable mental status
- increased muscle tone
- HTN, tachycardia, tachypnea, fever
- hyporeflexia
- normal pupils
- normal bowel sounds
atypical antipsychotic side effects
- weight gain
- hyperlipidemia
- DM
- clozapine = agranulocytosis
quetiapine (seroquel)
- highly sedating
- adjunct for severe depression or bipolar
- AE: orthostatic hypotension
aripiprazole (abilify)
- partial D2 antagonist
- uses: schizophrenia, bipolar, agitation, MDD
- AE: akathisia, nausea, anxiety, headache, insomnia, sedation
lithium
- mood stabilizer
- 1st line for bipolar mania
- narrow therapeutic index
lithium side effects
- diabetes insipidus
- renal toxicity
- tremor
- hypothyroidism
valproic acid (depakote, depakene)
- 2nd line mood stabilizer
- AE: ototoxicity, teratogenic, low platelet
paranoid personality disorder
- cluster A
- pervasive distrust of others
- principal ego defense is projection
- Tx: CBT
schizoid personality disorder
- detached and solitary, but well functioning
- no desire for social interaction
schizotypal personality disorder
- odd beliefs, magical thinking
- suspicious or fearful of others
- avoids social interaction due to fear
antisocial personality disorder
- lack of concern or remorse
- aggressive and reckless
- mental disorder most associated with crime
antisocial personality disorder diagnostic criteria
- at least 18
- evidence of conduct disorder before 15
- occurrence of behavior is not exclusively during schizophrenia or manic episode
borderline personality disorder
- unstable relationships
- unstable self image
- anger outburst
- frequent SI/harm threats
- fear of abandonment
- Tx: dialectical behavior therapy
histrionic personality disorder
- excessive emotions, attention seeking
- seductive and provocative behavior
- shallow expression of emotion
- self dramatization
narcissistic personality disorder
- grandiose sense of self importance
- requires excessive admiration
- sense of entitlement
- exploits others
- lacks empathy
- arrogant
avoidant personality disorder
- social inhibition
- feeling inadequate
- hypersensitive to negative evaluation
dependent personality disorder
- need to be taken care of
- submissive and clinging behavior
- fear of separation
obsessive compulsive personality disorder
- perfectionism that interferes with task completion
- over conscientious, scrupulous, and inflexible
anorexia restricting type
- weight loss through dieting, fasting, excessive exercise
- no binging or purging for the last 3 months
anorexia binge/purge type
in the last 3 months recurrent binge/purge episodes
bulimia nervosa
- recurrent episodes of binge/purge
- at least once a week for 3 months
- maintains normal or above body weight
- dental caries, esophageal tears, parotid or salivary gland enlargement
alcohol use disorder
- presence of at least 2 symptoms
- mild 2-3
- moderate 4-5
- severe 6 or more
wernicke encephalopathy
- reversible
- acute thiamine deficiency
- triad: delirium, ocular motor dysfunction, ataxia
korsakoff syndrome
- irreversible
- chronic thiamine deficiency
- anterograde amnesia and confabulation
