Impulse Control, Eating, Sleep, Sexual disorders Flashcards
What is impulse control disorders?
disorder characterized by an inability to resist reactions towards internal/external stimuli without considering the consequences (ie harm to self or others)
What are the 4 core qualities of impulse control disorders?
1) repetitive or compulsive engagement in behavior despite adverse consequences
2) little control over the behavior
3) anxiety/craving experienced PRIOR to the behavior
4) relief or satisfaction DURING or AFTER completion of the behavior
What is intermittent explosive disorder (based on DSM)?
recurrent outbursts of aggression that result in assault against people or property; response is out of proportion to the inciting event/stressor
Intermittent explosive disorder is more common in…
men, late teens
Treatment of Intermittent explosive disorder?
PALS: propranolol anticonvulsants Lithium SSRIs
What is kleptomania (based on DSM)?
uncontrollable urges to steal objects that are NOT needed for personal use/monetary reasons; objects are normally given or thrown away, returned, or hoarded
pleasure or relief is experienced while stealing
who tends to be kleptomanics?
women, esp during times of stress
kleptomania is highly comorbid with:
mood disorders
eating disorders
OCD
kleptomania prognosis
chronic
1/4 of these types of patients are also comorbid with kleptomania
bulimia nervosa
kleptomania treatment
insight-oriented psychotherapy
systematic desensitization/aversive conditioning
SSRIs
what is pathological gambling (based on DSM)
at least 5 symptoms of gambling
- preoccupation with it
- lying to hide it
- committing legal acts to finance it
- jeopardizing relationships or job because of it
- relying on others to financially support it
- need to gamble with increasing $$ to achieve pleasure
- done to escape problems or relieve dysphoria
- returning to gambling to reclaim losses
- unsuccessful with cutting down
- restlessness or irritability when attempting to cut down
pathological gambling is highly comorbid with
mood d/o
anxiety d/o
OCD
(possible ADHD)
treatment of pathological gambling?
gambler’s anonymous
What is trichotillomania?
what triggers the behavior?
recurrent, repetitive, intentional pulling out of one’s hair causing visible hair loss;
tension is experienced before the hair pulling, with immediate relief or pleasure afterwards
trigger: the texture of the hair
who does trichotillomania usually happen in?
women
trichotillomania is comorbid with…
OCD/OCPD
mood disorders
borderline personality disorder
trichotillomania treatment
SSRI
antipsychotics
lithium
N-acetylcysteine
What is pyromania (based on DSM)?
- at least 1 episode of deliberate/impulsive fire setting with pleasure, gratification, or relief from tension/arousal experienced when setting the fire
- patient has a fascination with, interest in, curiosity about, or attraction to fire
who usually has pyromania?
males, late adolescents
treatment for pyromania?
behavior therapy
supervision
SSRIs
What type of cardiovascular changes may a patient with anorexia nervosa present with? 7
bradycardia orthostatic hypotension arrhythmias QTc prolongation ST-T wave changes cardiomyopathy mitral valve prolapse
What type of lab changes may a patient with anorexia nervosa present with? 5
anemia (normocytic, normochromic) leukopenia increased LFTs elevated BUN decreased albumin
What type of neurological changes may a patient with anorexia nervosa present with? 5
enlarged ventricles decreased G/W matter cognitive impairment peripheral neuropathy seizures
What type of endocrine changes may a patient with anorexia nervosa present with? 6
hypoglycemia hypothyroidism increased GH increased cortisol amenorrhea due to decreased LH/FSH and estrogen, testosterone
What type of physical changes may a patient with anorexia nervosa present with? 5
parotid enlargement (with increase amylase levels)
languo hair/alopecia
muscle wasting
cold-intolerance
bone fractures (due to osteopenia/osteoporosis)
What type of electrolyte changes may a patient with anorexia nervosa present with? 3
hypochloremic hypokalemic alkalosis (if vomiting)
hyponatremia
hypokalemia
2 types of anorexia nervosa?
restrictive type
binge-eating/purging type
DSM V for anorexia nervosa?
BMI < 17.5 kg/m2 or < 85% of ideal body weight)
intense fear of gaining weight
distorted body image
(note DSM IV has amenorrhea)
How do you differentiate btwn anorexia nervosa and MDD as the cause of significant weight lost in a patient?
anorexia nervosa - patients have GOOD appetite but will starve themselves due to distorted body image; PREOCCUPIED with food but do not eat it themselves
MDD - patients have POOR appetite, which causes the weight-loss; NO INTEREST in food
What is the refeeding syndrome?
Edema and decreased levels of PO4, Mg, and Ca that occurs when a severely malnourished patient is refed too quickly
“Must Carefully Pour Everything”
prognosis of patients with anorexia nervosa?
poor: chronic/relapsing illness
mortality is cumulative (starvation, suicide, or cardiac failure)
rates of suicide in patients with anorexia nervosa
57x greater than normal
Treatment for patients with anorexia nervosa 3
1) food…
2) low-dose atypical antipsychotics - treat excessive preoccupation with weight/food
3) benzodiazepines - administered prior to meals to reduce pre-prandial anxiety
Why have SSRIs not been shown to work in patients with anorexia nervosa?
because anorexia nervosa is believed to be due to an inadequate dietary intake of tryptophan, which is the precursor of serotonin
What is bulimia nervosa
binge eating combined with behaviors intended to counteract weight gain
- vomiting
- laxatives
- enemas
- diuretics
- excessive exercise
two types of bulimia nervosa?
purging type - vomiting, laxatives, enemas, diuretics
non-purging type - excessive exercising, fasting
What is bulimia nervosa as defined by DSM
≥ 2x/week for 3 months of recurrent episodes of binge eating + recurrent attempts to compensate for over-eating/prevent weight gain
What type of physical changes may a patient with bulimia nervosa present with? 6
parotid gland enlargement dental erosions/caries callouses/abrasions on dorsum of hand petechiae peripheral adema esophagitis
What type of electrolyte changes may a patient with bulimia nervosa present with? 1
hypochloremic hypokalemic alkalosis
metabolic acidosis (laxative abuse)
increased HCO3, Na, BUN, amylase
decreased Mg/K
What type of hormonal changes may a patient with bulimia nervosa present with? 2
∆ TH, cortisol homeostasis
bulimia nervosa is highly comorbid with…
mood disorders anxiety disorders impulse control disorders substance abuse childhood abuse increased cluster B, C personality disorders
What is IPECAC?
used to cause vomiting
What does anorexia and bulimia nervosa have in common?
at risk of developing CARDIAC ARRHYTHMIAS due to electrolyte disturbances (ie hypokalemia)
prognosis of bulimia nervosa?
chronic relapsing illness, but better prognosis than anorexia nervosa
only SSRI that is FDA-approved for bulimia nervosa
fluoxetine
best treatment for bulimia nervosa?
SSRI (fluoxetine) + group therapy
why do you want to avoid buproprion in bulimics?
lowers seizure threshold!!
What is binge-eating disorder?
patients who binge eat and suffer emotional distress over it but do NOT try to control their weight (via purging or restricting calories) and are NOT fixated on their body shape/weight
Making the binge-eating disorder diagnosis according to DSM
recurrent binge-eating episodes in a 2-hour period
binge-eating occurs at least 2 days/week for 6 months
not associated with compensatory behaviors (vomiting, laxatives, etc)
Treatment for binge-eating disorder?
individual psychotherapy
behavioral therapy
strict diet
exercise program
What can you use to promote weight loss in patients with binge-eating disorder?
1) stimulants (phentermine, amphetamine) to suppress appetite
2) orlistat - inhibits pancreatic lipase, thus decreasing the amount of fat absorbed from the GI tract
3) sibutramine - inhibits reuptake of NE, serotonin, and dopamine
Awakening from what part of the sleep cycle is associated with vivid dream recall?
REM
∆ btwn dyssomnias and parasomnias? Examples of each?
dyssomnias - disorders that make it difficult to fall or remain asleep (insomnia) or excess daytime sleepiness (hypersomnia) that result in insufficient, excessive, or altered timing of sleep
- 1˚ insomnia
- OSA
- narcolepsy
- idiopathic hypersomnia
- kleine-levin syndrome
- circadian rhythm sleep disorder
parasomnias - unusual behaviors or experiences that occur during sleep and is often associated with sleep disruption
- sleep walking
- sleep terror
- nightmare disorder
- REM sleep behavior disorder
What are dyssomnias? 6
disorders that make it difficult to fall or remain asleep (insomnia) or excess daytime sleepiness (hypersomnia) that result in insufficient, excessive, or altered timing of sleep
- 1˚ insomnia
- OSA
- narcolepsy
- idiopathic hypersomnia
- kleine-levin syndrome
- circadian rhythm sleep disorder
What are parasomnias? 4
unusual behaviors or experiences that occur during sleep and is often associated with sleep disruption
- sleep walking
- sleep terror
- nightmare disorder
- REM sleep behavior disorder
What type of sleep disorder is 1˚insomnia
dyssomnia
How is 1˚ insomnia diagnosed (based on DSM)?
difficulty of initiating or maintaining sleep, or non-restorative sleep, for at least 1 month
(note: patients are so preoccupied with getting enough sleep and the fact that they are not doing so further increases their frustration and inability to sleep)
∆ btwn acute and chronic 1˚ insomnia? (include timing and prognosis)
acute: 1-4 weeks, usually resolves spontaneously
chronic: >1 month, increase risk of psychiatric illness
First-line of treatment for 1˚insomnia? What should you be careful of in these patients?
Benzodiazepines - reduces sleep latency and nocturnal awakenings
be careful of: tolerance, addiction, daytime sleepiness, rebound insomnia, and falls/confusion in the elderly
What are some non-benzodizepine treatments for 1˚insomnia? What should you be careful of in these patients?
These are benzodiazepine-receptor agonists:
Zolpidem (ambien)
eszopiclone (lunesta)
zaleplon (sonata)
be careful of: tolerance, daytime sleepiness, and orthostatic hypotension
why should you be weary of prescribing Zolpidem (ambien) to the elderly? 2
increased risk of falls
may induce cognitive impairment
What are some antidepressants that can be prescribed for 1˚insomnia? What should you be careful of in these patients?
trazodone
amitriptyline
doxepin
be careful of: sedation, dizziness, psychomotor impairments
What are other Rx (other than benzo, non-benzo, and antidepressants) that can be prescribed for 1˚insomnia? What should you be careful of in these patients?
Ramelteon - melatonin receptor agonist - helps with sleep onset latency with little effect on wakefulness during th emiddle of the night
REM is characterized by what physiological changes? EEG?
increased BP
increased HR
increase RR
EEG: brain wave patterns resemble that of an aroused person
What is obstructive sleep apnea? what is it caused by? risk factors? 3
chronic breathing-related disorder caused by repetitive collapse of the upper airway (with subsequent reduction in blood O2 sat)
risk factors:
- obesity
- increased neck circumference
- airway narrowing
symptoms of obstructive sleep apnea?
excess daytime sleepiness snoring apneic episodes (gasping, choking) non-refreshing sleep morning HA
Treatment of obstructive sleep apnea?
CPAP
weight loss/exercise
surgery
What is the narcolepsy triad?
1) Excess daytime sleepiness
2) REM-sleep related phenomena (inability to move during transition from sleep -> wakefulness
3) Hallucinations (hypnagogic, hypnopompic)
4) Cataplexy
CHER is a narcoleptic
What is cataplexy?
sudden loss of bilateral muscle tone evoked by strong emotions w/o loss of consciousness; may affect the voice, face, arms, or generalized of narcoleptics
pathophysiology of narcolepsy?
loss of hypocretin neurons
pharmacotherapy for excess daytime sleepiness that narcoleptics have?
- amphetamines (d-amphetamine, meth-amphetamine)
- non-amphetamines (methylphenidate, modafinil, sodium oxymbate)
pharmacotherapy for cataplexy that narcoleptics experience?
sodium oxybate
What is idiopathic hypersomnia?
excess daytime sleepiness + prolonged nocturnal sleep episodes, and frequent irresistible urges to nap
(ie they get enough sleep, but are still constantly fatigued)
What type of sleep disorder is obstructive sleep apnea?
dyssomnia
What type of sleep disorder is narcolepsy?
dyssomnia
What type of sleep disorder is idiopathic hypersomnia?
dyssomnia
What type of sleep disorder is kleine-levin syndrome?
dyssomnia
What type of sleep disorder is circadian rhythm sleep disorder
dyssomnia
What type of sleep disorder is sleep walking?
parasomnia
What type of sleep disorder is sleep terror?
parasomnia
What type of sleep disorder is nightmare disorder?
parasomnia
What type of sleep disorder is REM sleep behavior disorder?
parasomnia
What is the Kleine-levine syndrome
disorder characterized by recurrent HYPERsomnia with episodes of daytime sleepiness with
- hyperphagia
- hypersexuality
- aggression
(sounds like kluver bucy)
What is the circadian rhythm sleep disorder?
how is it normally treated?
intrinsic defect in the circadian pacemaker or impaired entrainment (ø light or other time-signaling stimuli)
bright light phototherapy (BLP) +/- meltaonin
4 subtypes of circadian rhythm sleep disorder? What are they treated with?
delayed sleep phase disorder: BLP + melatonin
advanced sleep phase disorder: BLP
shift-work disorder: BLP + modafinil
jet-lag disorder
What coordinates the circadian rhythmicity?
suprachiasmic nucleus (SCN)
What are some features of sleep-walking?
simple-complex behaviors (sitting up in bed eating, walking outdoors) that are initiated during slow-wave sleep and result in walking during sleep
When part of the sleep cycle does sleep-walking occur?
slow-wave sleep (delta-wave)
Are the eyes of sleepwalkers open or closed?
usually open, with a “glassy look”
What happens if you wake a sleepwalker? Will they remember the sleep walking incident the next day?
they’re confused, and will not remember anything (amnesia); will sometimes be very violent
(same as sleep terror)
What are some of the risk factors associated with sleep-walking? 8
sleep hygiene (deprivation, irregular schedules) stress hyperthyroidism OSA seizures migraine Rx Mg deficiency
What Rx can you use to treat sleep walking?
1) clonazepam
2) benzodiazepine receptor agonists (Zolpidem (ambien), Eszopiclone (lunesta), Zaleplon (sonata))
3) TCAs
What are sleep terrors, and what part of the sleep cycle do they normally occur?
What are some of the physiological symptoms that occur?
sudden arousal with screaming from what appears to be in a state of complete terror
slow-wave sleep (delta-wave)
sympathetic hyperactivation: tachycardia, tachypnea, diaphoresis, increased muscle tone
When part of the sleep cycle does sleep-terrors occur?
slow-wave sleep (delta-wave)
What happens if you wake a kid who is in the middle of a sleep terror episode? Will they remember the sleep walking incident the next day?
they’re confused and disoriented, and will not remember anything (amnesia); will sometimes be very violent
(same as sleep walking)
What are some of the risk factors associated with sleep terrors?
**Fever Nocturnal asthma GERD Sleep deprivation CNS-stimulating Rx (amphetamines) Other sleep disorders
prognosis of sleep terrors?
benign and self-limited
treatment of sleep terrors?
- reassurance (the disorder itself is benign and self-limited)
- low-dose, short-acting benzodiazepines (clonazepam, diazepam) in adults with refractory cases
- sleep hygiene
What is a nightmare disorder, and what part of the sleep cycle do they normally occur?
What are some of the physiological symptoms that occur?
- recurrent frightening dreams that causes one to wake up with vivid recall
- no confusion or disorientation
treatment for nightmare disorders?
imagery rehearsal therapy (IRT) - see pg 161 for description
What is REM sleep behavior disorder, and what part of the sleep cycle does it normally occur?
muscle atonia during REM sleep + complex motor activity with onset of dreams (ex: talking, yelling, limb jerking, walking/running, punching)
risk factors for REM sleep behavior disorder?
Older age (60-70 yo) Rx: TCA, SSRI, MAOi Narcolepsy Brainstem lesions Dementia
primary treatment of REM sleep behavior disorder?
clonazepam
What are some factors that increase libido?
Dopamine Testosterone Alcohol (suppresses inhibitions) Marijuana (suppresses inhibitions) Cocaine (stimulates dopamine R) Amphetamines (stimulates dopamine R)
MAD-CAT (think of a cat in heat; last letter of each word are biological factors)
What are some factors that decrease libido?
Serotonin
Progesterone
Alcohol (chronic use)
Narcotiecs
How do cocaine and amphetamines increase libido?
it stimulates dopmaine receptors
How do alcohol and marijuana increase libido?
suppresses inhibitions
What are some general medical conditions that can cause sexual dysfunction?
- atherosclerosis (causes ED from vascular occlusions)
- diabetes (causes ED from vascular ∆s and peripheral neuropathy)
- pelvic adhesions (causes dyspareunia)
What are some medications that can cause sexual dysfunction?
All the "anti-x" antihypertensives anticholinergics antidepressants (esp SSRI) antipsychotics (affect dopamine levels)
What is hypoactive sexual desire disorder?
How is it treated?
ø or deficiency of sexual desire or fantasies
treated with testosterone (for M and F) and estrogen
What is sexual aversion disorder?
avoidance of genital contact with a sexual partner
most common sexual disorder in women?
sexual desire disorder
orgasmic disorder
most common sexual disorder in men?
ED
premature ejaculation
How do you tell physiological vs. physical sexual disorder in men?
if he can have erections in the AM, during masturbation, or with other sexual partners, it is of a PSYCHOLOGICAL problem (rather than a physical etiology)
What is the female sexual arousal disorder?
inability to maintain lubrication until completion of the sex act
What is the female orgasmic disorder?
inability to have an orgasm after a normal excitement phase
What is the male orgasmic disorder?
achieves orgasm with great difficulty
What is premature ejaculation?
How is it treated?
ejaculation earlier than desired time (before or immediately upon entering the vagina)
What is dyspareunia?
How does this differ than vaginismus?
dyspareunia - genital pain at any time during intercourse
vaginismus - vaginal pain during insertion of the penis/object due to involuntary muscle contraction of the outer third of vagina
What is dual sex therapy and when is it useful?
uses the concept of the marital unit/couple as the target of therapy to address sexual problems
How is behavior therapy useful for treating sexual dysfunction?
sexual dysfunction is approached as a LEARNED MALADAPTIVE BEHAVIOR and therefore uses systemic desensitization where patients are progressively exposed to increasing levels of stimuli that provoke their anxiety
What can you use to treat ED?
which one requires sexual stimulation to achieve an erection? which one does not?
sildenafil (phosphodiesterase 5-inhibitor) - requires sexual stimulation
alprostadil (injected into corpus cavernosa or transurethrally); does not require sexual stimulation to work
What can you use to treat premature ejaculation?
SSRI
TCAs
both prolong the time from stimulation to orgasm
How do you treat hypoactive sexual disorder?
testosterone (for M and F)
estrogen
What are paraphilia disorder according to DSM (include duration)
engagement or preoccupation in unusual sexual urges/fantasies that are considered abnormal by society for at least 6 months that causes impairment in daily functioning
∆ btwn transsexual and transvestite?
transsexual - person who believes that they are trapped in the body of the wrong gender
transvestite - heterosexual male who dresses in female clothing
What is a common treatment for paraphilias?
aversion therapy - used to disrupt the abnormal behavior
What constitutes a pedophile according to DSM (age specific)?
engagement of sexual acts with children < 13 yo; person must be at least 16 yo and ≥ 5 years older than the child
What is frotterurism?
sexual pleasure from touching or rubbing against a non-consenting person
What is voyeurism?
watching unsuspecting nude individuals (often with binoculars) in order to obtain sexual pleasure
What is exhibitionism?
exposure of one’s genitals to strangers
What is sadism?
sexual excitement from hurting/humiliating another (giving end)
What is fetishism?
sexual preference for inanimate objects (shoes, panty hose)
What is transvetic fetishism?
person who is sexually aroused by dressing up as a member of the opposite gender; does NOT mean that they are homosexual
What is masochism?
sexual excitement from being humiliated or beaten (receiving end)
What is necrophilia?
sexual pleasure from engaging in sexual activity with dead people
What is telephone scatologia?
sexual excitement from calling unsuspecting women and engaging in sexual conversation with them
What is autoerotic asphyxiation?
sexual activity while simultaneously restricting blood flow to the brain
good prognostic factors for paraphilias?
self-referral for treatment sense of guilt associated with the act history of normal sexual activity normal intelligence stable adult relationships
poor prognostic factors for paraphilias?
referral by others (ie law enforcement agencies) no sense of guilt about the act presence of another paraphilia early age of onset comorbid substance abuse high frequency of behavior
What is gender identity disorder?
AKA transsexuality - subjective feeling that one was born the wrong sex
may dress as the opposite sex, take sex hormones, undergo sex-change operation
When do cross-gender behaviors in children with gender identity disorder usually begin?
before age 3, when gender identity is established
gender identity disorder is usually comorbid with…
MDD
anxiety disorders
suicide
What determines (+) outcomes of sex-reassignment surgery for a patient with gender identity disorder?
living in the desired sex role for at least
- 3 months before HORMONAL reassignment
- 12 months before SURGICAL reassignment
