First Pass Miss Exam 2 Flashcards
What are the two subtypes of ADHD, and how many symptoms do you have to have in that category in order to qualify for that subtype (or combined = affected by both)
Inattentive subtype
Hyperactive / impulsive subtype
Need at least 6 for children and 5 for adults
Must be present at least 6 months, symptoms first appearing before 12 years of age
What areas of the brain seem to have lower activity in ADHD? What neurotransmitters are affected?
Prefrontal cortex (impulse control) Caudate & Globus pallidus (basal ganglia, motor control)
Neurotransmitters include dopamine and NE
What things are commonly cormorbid with ADHD?
ODD/CD
Learning disability
Anxiety / Mood disorders
What are first line, second line, and third line pharmacotherapies for ADHD?
First line: Stimulants - Methylphenidate and dextroamphetamine
Second line: Alpha-2 agonists - Guanfacine, Clonidine
NRI - Atomoxetine
Third line: TCAs, Bupropion
What are the important side effects of stimulants?
Appetite suppression / weight loss -> may lead to growth delay
Mood disturbance in withdrawal -> will realize they are hungry
Elevated HR / BP
Can cause insomnia if taken at night, also GI / headache
What are some other indications for stimulants?
Exogenous obesity and binge-eating disorder (appetite suppressant)
Adjunct for Obstructive Sleep Apnea
Narcolepsy (treats insomnia via keeping you awake)
What are some conditions which may be mis-diagnosed at ADHD (on the differential)?
Anxiety -> will be fidgety
Depression -> lack of motivation
BPAD -> looks like hypomanic symptoms
Conduct disorder -> playing with scissors might look like conduct disorder but actually be ADHD
What are atomoxetine’s drug interactions of concern?
Metabolized by CYP2D6 - increased levels with paroxetine, fluoxetine, and TCAs
What is the mechanism of action of alpha agonists in ADHD?
Enhance NE input from locus coeruleus and stimulate post-synaptic alpha 2A receptors -> improves functional connectivity of prefrontal cortex networks
side effects include the pre-synaptic effects:
Drowsiness / sedation
Decreased BP / pulse -> discontinuation = rebound hypertension, tachycardia, anxiety / panic attacks
Take 4-6 weeks to work (same as Atomoxetine)
Give a couple key biological, individual, family, and social/school risk factors for development of DBDs?
Biology - male sex, perinatal complications, genetic
Individual - Below average IQ, reading problems, aggression / ADHD
Family - Parental antisocial behavior, single parent w/ lack of supervision, excessive control, early motherhood
Social - Peer rejection / being bullied / victimized, low SES, exposure to media violence
What are the three categories for ODD diagnosis? How long must it be present?
For >6 months - pattern of negativistic / hostile / defiant behavior
- Angry / Irritable Mood
- Argumentative / Defiant Behavior
- Spiteful / Vindictive
Basically: Mood, Behavior, and Vindictive behavior
Usually starts before age 8, average age 6
What is the treatment for ODD? What is most important?
There is NO pharmacotherapy
- > Early treatment via psychosocial therapies MUST involve parents
- > Individual or family therapy NOT effective
- -> Parent Management Training or Problem Solving Collaboration / Communication therapy is indicated*
When is conduct disorder diagnosed and what is it generally?
Repetitive & persistent pattern of behavior in which basic rights of others or major age-appropriate societal norms / rules are violated
Diagnosed until 18, or after age 18 if criteria for antisocial personality disorder are not met
What are the four categories of misconduct in conduct disorder?
TARD: Theft, aggression, rules violation, destruction of property
- Aggression towards people & animals
- Destruction of property
- Deceitfulness or theft
- Serious violations of rules (parental or school)
What are three specifiers of conduct disorder?
- Childhood onset -> at least one criteria before age 10
- Adolescent onset -> absence of criteria before age 10
- With limited prosocial emotions -> lack of remorse, guilt, empathy, shallow affect, and unconcern about performance
What are the three evidence-based psychosocial treatments for CD and which one shows a long-term reduction in arrest / incarceration?
- Parent Management Training
- Probleming-Solving Skills Training
(First two are same as ODD) - Multisystemic Therapy (MST) -> leads to a reduction in re-arrest. Includes involvement of school, home, justice system, etc.
What conditions are most frequently comorbid with ODD / CD?
ADHD (10x) Major Depression (7x) Substance Abuse (4x) -> although behavior must not be CAUSED by substance use
What are the three levels of ASD severity?
Level 1 - least severe, requires some support. Will have decreased interest in social interactions and difficulties switching between activities, with poorer independence
Level 2 - requires substantial support, marked deficits, reduced or abnormal social responses, and repeated behaviors are obvious to casual observer
Level 3 - Most needy, very limited social interactions / social responses, restricted behavior interferes with functioning in all spheres
What are the diagnostic features of ASD?
- Poor social interactions, social communication deficits
2. Repetitive / ritualized behaviors, and restricted interests.
What neurobiological abnormalities are known to be associated with ASD? One important environmental exposure?
Neurobiological - EEG abnormalities & seizure disorders
Environmental - Fetal exposure to valproate
Poor prognosis involves ASD associated with grand mal seizures.
What are the typical avenues to accomplish the treatment goals of ASD?
Language remediation for speech delay -> speech therapy
Educational interventions -> classroom changes
**Applied Behavior Analysis (ABA) ** -> teach them learning
OT/PT, and sensory integration therapy
How can ASD social developmental deficits be seen in childhood and adults?
Childhood - Difficult playing with peers due to awkward / inappropriate social behavior, cannot detect feelings of others
Adults - lack of relationships
What is an example of hypo / hyper-reactivity to the environment?
Apparent indifference to pain / temp (wont even care if they bang their head)
Will have adverse response to specific sounds, or be fascinated by lights / movement
What is Asperger’s basically?
A subset of ASD, with no language or intellectual impairment, but clearly marked decrease in social interactions which can lead to teasing / bullying
What causes Rett syndrome and who gets it?
X-linked dominant MECP2 gene mutation -> homozygous lethal in males
MeCP2 gene = Methyl Cytosine-binding Protein 2 -> needed for brain development
-> cases are usually de novo, but some are rarely asymptomatic (not penetrant)
Seen in females only
Encephalopathy beginning between 6 months and 2 years (normal development early)
Loss of purposeful hand movements, with stereotypic hand-wringing, ataxia, head circumference growth deceleration, loss of language skills
What are the common manifestations of social or pragmatic communication disorder?
Deficits in using appropriate communication for context / listener needs. Cannot understand the implied meaning or multiple meanings of words and phrases very well.
Sometimes when things are said, you mean to imply many things “We are going to the store, remember it’s raining” -> need them to infer you need to put on your raincoat, etc. They have difficulty understanding whats not explicitly stated.
What are the pharmacological treatments of ASD for?
Targeting specific symptoms / common comorbidities
If aggression -> Risperidone
SSRIs for comorbid depression / anxiety
Stimulants for comorbid ADHD
How is restricted, repetitive behavior characterized in ASD?
- Stereotyped / repetitive movements and in use of objects / speech - stereotypies
- Insistence on sameness, inflexibility / ritualized behavior - i.e. extreme distress at small changes
- Highly restricted, fixated interests which are abnormal in intensity / focus -> way too focused on one thing, possible savantism
- Hypo/hyper reactivity to environment
What are three types of complex vocal tics which may involve speaking? There are three words for these.
- Palilalia - repeating one’s own words
- Echolalia - repeating someone else’s words
- Coprolalia - Obscenities uttered (rare)
What are the criteria for Tourette’s Disorder (TS)?
- 2+ motor AND 1+ vocal tics present during illness, but not necessarily at same time
- Tics must persist for greater than 1 year since onset (though the tics can change during this time)
- Must occur before age 18
What is a provisional tic disorder?
Single or multiple motor tick and/or vocal tics
Any tics presenting for <1 year since onset, before age 18
What neuroanatomic abnormalities occur in TS?
Basal ganglia dysfunction, with defective cortical input to striatum, and thalamocortical abnormalities.
-> small caudate volumes, larger PFC, increased dopamine (D1 for direct pathway = GalphaS) receptor density in striatum in general to make them hypermobile
What is the typical progression of tic disorders?
Simple, transient motor tics arise around age 4-6
Rostrocaudal progression of tics
Phonic tics appear ages 8-15 (does not happen in all, but if you have a phonic tic you most likely have a motor tic)
Tics severity peaks age 10-12
Waxing / waning is normal
What is the best psychotherapy for tic disorders?
Habit Reversal Training (HRT)
-> Teaches awareness of tic, and “competing response practice” -> channel the urge into a less functionally impairing tic which cannot be seen
What are three classes of drugs used in treatment of tic disorders?
- Alpha-2 receptor agonists - first line (clonidine, guanfacine)
- D2 receptor antagonists - neuroleptic drugs like haloperidol, risperidone, and pimozide (typical antipsychotics mostly)
- Botox - for very severe motor / vocal
What are the typical etiologies of primary vs secondary enuresis and what does this mean? Which is more common?
Primary - never gained continence -> usually due to maturational delay. Represents 80% of patients.
Secondary enuresis - lost continence after at least 1 year of continence -> usually due to a stressor. Less common, starts between 5-8
What is the DSM diagnosis of enuresis? What developmental must be met?
Involuntary or intentional voiding into bed or clothes, at least 2x a week for >=3 consecutive months, or presence of distress / impairment
Developmental age >= 5 years (better than 90% will have bladder control by this point)
What are the pharmacotherapies available for enuresis if there is a major functional impairment? Major risks?
Imipramine - tricyclic with anticholinergic properties, cardiac arrhythmia is a concern
DDAVP - desmopressin - reduces urine production, may lead to hyponatremia and seizure due to water intoxication
Best treatment: Enuresis alarm
What condition must be ruled out before making a diagnosis of encopresis and starting normal treatment?
Psychogenic megacolon
pathology:
- > children hold feces voluntarily or because of defecation pain
- > rectal distention leads to loss of rectal tone / desensitization
- > children do not need to defecate -> leads to OVERFLOW encopresis
- > need GI to decompact the bowel for treatment
What is the DSM criteria for encopresis? What must you specify?
Involuntary or intentional passage of feces at least 1x per month for at least 3 months
-> chronological age of at least 4 (vs 5 with enuresis)
-> must specify if due to overflow incontinence or not
What are the DSM criteria of separation anxiety disorder (SAD)?
Inappropriate, excessive anxiety concerning separation from attachment figures (i.e. Meghan), lasting for 1 month (>4 weeks).
Distress from separation, worry about attachment figure, refusal or fear to leave home or be alone, refusal to sleep away from home or without attachment figure. Nightmares w/separation themes common.
Starts after a life stress, usually ages 7-9 years.
What is the DSM criteria for selective mutism?
For >1 month (not the first month of school), failure to speak in specific social situations despite speaking in others. Interferes with function, not simply due to language / developmental issue
-> explains high incidence of social phobia / anxiety later in life
Why does encopresis typically arise?
Arises usually as secondary encopresis (>1 yr of continence) with constipation and excessive fluid overflow (overflow incontinence) -> will be small liquid stool. Often precipitated by life events and in reaction to a stressor / anxiety.
Can also be primary due to lack of proper toilet training.
This is opposite to enuresis which tends to arise as primary, secondary is less common. (It’s unlikely that you will have never figured out how to hold your poops).
What is considered moderate, at risk, and heavy drinking for males? This is, number of drinks per day. Females?
Moderate = 2 drinks a day
At risk = 4+ drinks a day
Heavy = 5+ drinks a day
Females is 1 less than this in all categories.
What is the rough timeline of withdrawal symptoms for alcohol?
6 hours - tremor
8 - 12 hours - visual hallucinations
12-24 hours - seizures
72 hours - delirium tremens (preventable)
What liver enzymes suggest alcoholic liver damage vs viral hepatitis?
Elevated AST > ALT, ratio of AST:ALT is increased.
Also, elevated GGT levels
What are the most common features of Cannabis Withdrawal Syndrome?
3+ behavior symptoms: Decreased appetite, Irritability, Sleep difficulty
+
1+ physical symptoms: like sweating, tremors, headache
Can opiate withdrawal be fatal and how long does it last?
Q.
Can opiate withdrawal be fatal and how long does it last?
A.
Lasts 7-10 days, peaking at 2-3 days
NOT fatal (like delirium tremens would be)
Remember: Nicotine withdrawal peaks at 2-3 days as well, but lasts 1-3 months! gg!
What are the common behavioral effects of cannabis?
Decreased goal-directed mental activity, relaxation, slowed sense of time, heightened sensitivity to external stimuli (smell, sound, taste), anterograde amnesia, increased appetite
How does cocaine cause stroke?
Major vasoconstriction -> nonhemorrhagic cerebral infarct
- > can also cause hemorrhagic
- > also liable to cause MI / arrhythmias due to myocardial ischemia from vasoconstriction + sympathetic hyperstimulation
What are two quite diagnostic physical changes for amphetamine overuse (i.e. methamphetamine or other sympathomimetics)
- Bruxism - teeth grinding
- Weight loss (appetite suppressant)
-> otherwise it looks just like cocaine use
How can an LSD trip be told apart from an acute psychotic episode?
Absence of auditory hallucinations in LSD (visual only)
Does a withdrawal syndrome exist for hallucinogens? How do they differ from dissociative drugs?
NO
Differ from dissociative drugs because they expand your consciousness
Dissociative drugs distort your consciousness and detach you from it
Both will act on NMDA receptors
What is the mechanism of action of MDMA?
Amphetamine analog -> stimulant properties, but also mild hallucinogenic properties by acting on serotonergic receptors
How do kids these days typically deal with the negative effects of MDMA use?
- Pacifier - can cause bruxism (similar MoA as methamphetamine)
- Water bottles - can cause diaphoresis, dehydration, and hyperthermia
- > can lead to hyperthermia, heart, kidney failure due to extreme heat stroke
What can cannabis do to the lungs, to the psyche, and to the reproductive system?
Lungs - decreased lung capacity and increased infection risk
Psyche - Increased risk for anxiety / depression, worse mood disorders
Reproductive system - Decreased testosterone / gynecomastia. Reduced fertility
What is the medical name of roofies and its mechanism of action? How long do effects last?
Rohypnol - Flunitrazepam
Mechanism of action - GABA-A agonist, similar to other benzos. 7-10x as potent as diazepam, with effects lasting 4-6 hours