Impulse, Eating, Sleep/wake Flashcards
Intermittent explosive disorder
Verbal/physical outbursts: 2x/week, for 3+ months
OR
Outbursts resulting in physical damage, 3+ times/year
- Not premeditated
- Out of proportion reaction to stressor
- Cause impairment or distress
Mgmt:
- SSRI (fluoxetine), mood stabilizers (anticonvulsants, lithium)
- CBT
- Group/family therapy
Kleptomania
F > M
Uncontrollable urges to steal unnecessary objects
Increasing tension right before theft
*Strongly assoc with bulimia nervosa, OCD
Mgmt:
- SSRI’s
- CBT
- Naltrexone use (may help?)
Pyromania
At least 2 epi’s of fire setting
- Highly comorbid with mood/substance disorders, gambling, conduct disorder
- Episodic epi’s that wax, wane
Mgmt:
Not really anything … CBT, SSRI, mood stab
What are the 2 types of anorexia nervosa?
- Restricting type
Has not regularly engaged in binge-eating or purging; wt loss from dieting, exercise, and/or fasting - Binge-eating/purging type
Binges —> purging (laxatives, self induced vomiting)
Sometimes will purge w/o binging
Anorexia vs. bulimia, MDD
Anorexia: low body wt + restriction of calorie intake
Bulimia: nml or over- wt; sx usually more ego-dystonic, more likely to seek help
Anorexia vs MDD:
Anorexics have a good appetite
Physical sx of anorexia
Amenorrhea Cold intolerance/hypothermia Hypotension (esp orthostasis) MVP Constipation Lanugo Alopecia Edema Dehydration Peripheral neuropathy Seizures Hypothyroidism Osteopenia Osteoporosis
Lab/imaging abn of anorexia
Enlg’ed ventricles
Decrease in gray and white matter
Peripheral neuropathy
Decreased Na, Cl, K (alkalosis if vomiting) Arrhythmia (esp QTc pr) Hypercholesterolemia Transaminitis Normocytic, normochromic aemia High BUN High GH, cortisol Low LH, FSH, sex steroid hormones (estrogen, T), glu
Tell me about anorexia!
Assoc with 3 things
Mgmt
- Assoc with OC personality traits
- Bimodal onset (13-14, 17-18 yo)
- Difficulty with separation, autonomy, struggle to gain control
Mgmt:
- CBT
- Family therapy (Maudsley)
- Supervised wt gain program
** If no improvement with standard therapy, can consider adding –> olanzapine (antipsychotic)
F/u: Refeeding syndrome
Fluid retention + low Ph, Mg, Ca
+/- resp failure, delirium, seizures, arrhythmias
(tx: replace lytes, slow feeding)
How do you dx and manage bulimia?
Binge eating: excessive food intake within 2 hrs (accompanied by lack of control)
Compensatory behaviors: vomiting, diuretics, laxatives
1+/week, duration: 3+ months
Mgmt:
1. SSRI (fluoxetine) + therapy COMBO (CBT, fam therapy, etc)
** AVOID BUPROPION **
Binge eating disorder
Dx
Mgmt
Not fixated on body wt and shape
Binges, assoc with distress
1+/week, duration: 3+ months
Usually obese
Mgmt:
- Individual psychotherapy; strict diet + exercise
- Possibly drugs for wt loss:
- Stimulants (phentermine, etc) - suppress appetite
- Topiramate, zonisimide - wt loss
- Orlistat - don’t absorb fat
What characterizes REM sleep?
Increase in
- BP
- HR
- RR
Dyssomnias
(insomnia or hypersomnia)
Dx
Mgmt
3+/week, duration: 3+ months
*Not adequately explained by comorbid moods disorders
Acute: <3 months
Chronic: 3+ months
Mgmt:
- CBT (first line for chronic insomnia)
- Sleep hygiene
- Meds:
- BZ’s (short term; falls in elderly; addiction)
- Non-BZ’s (zolpidem causes more falls in elderly, and cognitive impairment in women at high doses)
- Antidepressants - trazodone
Hypersomnolence disorder (M = F)
Dx
Etiology
Mgmt
Criteria: excessive sleepiness despite 7 hrs, with:
- recurrent pds of sleep
- prolonged nonrestorative sleep >9 hr
- difficulty being fully awake after awakening
3+/week, duration: 3+ months
Etio:
- Viral infections
- Head trauma
- Genetic (AD)
Mgmt:
1. Lifelong tx with modafinil or stimulants (methylphenidate)
(second line = atomoxetine)
2. Scheduled napping
Obstructive sleep apnea / hypopnea (M > F)
Repetitive collapse of upper airway
Polysomnography: apneic / hypopneic episodes (>15/hr)
- Excessive daytime sleepiness
- Sleep fragmentation
- Snoring
- Morning HA’s
- HTN
Mgmt:
- CPAP … or BiPAP
- Wt loss, exercise
- Surgery
Central sleep apnea
5+ central apneas/hour of sleep
(cessation of both airflow and ventilatory effort)
insomnia, daytime sleepiness
Etio:
- PRIMARY: idiopathic
- SECONDARY:
- Cheyne-Stokes breathing - sec to HF, stroke, renal failure)
- Opioid use
Mgmt:
- Treat underlying condition
- CPAP/BiPAP
- Supplemental O2
- Meds (acetazolamide, theophylline (stimulates breathing), sedative-hypnotics)
Sleep related hypoventilation
Polysomnography: decreased respiration, high CO2
Complications:
- pulm HTN
- cor pulmonale
- cardiac arrhythmias
- polycythemia
- neurocog dysfxn
- resp failure due to severe blood gas abnormalities
Mgmt:
- Tx underlying condition
- CPAP/BiPAP
- Meds to promote breathing: bronchodilators, theophylline
What is the classic narcolepsy 4 sx?
- Excessive daytime sleepiness; “sleep attacks”
- REM-relate dsleep phenomena (ie - sleep paralysis)
- Hypnagogic or hypnapompic hallucinations
- Cataplexy (NO LOC) - mild or generalized
How do you dx narcolepsy?
Excessive daytime sleepiness
Falling asleep at inappropriate times
Hallucin/sleep paralysis at beginning/end of sleep
3+/week, duration: 3+ months
At least one of:
- cataplexy (loss of muscle tone with strong emotion)
- hypocretin deficiency in CSF
- reduced REM sleep latency on polysomnography
How do you manage narcolepsy?
- Sleep hygiene
- Scheduled daytime naps
- Avoidance of shift work
Daytime sleepiness:
- amphetamines
- nonamphetamines (methylphenidate Ritalin, modafinil, sodium oxybate)
Cataplexy:
- sodium oxybate ***
- TCA’s
- SSRI/SNRI’s
Sleepwalking
Behaviors during slow wave sleep
Eyes usually open
Don’t remember dreams / + amnesia
Rarely with violent behavior
** STRONGLY assoc with fam hx
Mgmt:
1. Don’t really need. Education.
Refractory –> low dose BZ (clonazepam)
Sleep terrors
- Recurrent epi’s of sudden terror arousals (screaming/crying), occur during slow wave sleep
- Signs autonomic arousal
- Hard to wake up during episode
- Don’t remember dreams / + amnesia
END WITH: return to sleep w/o awakening
Mgmt: same as for sleepwalking (education, refractory BZ’s)
Nightmare disorder
assoc with PTSD
Second half of sleep episode
END WITH: awakening with vivid recall
- NO confusion, disorientation upon awakening
Mgmt:
1. No tx always needed. Reassurance.
2. Imagery rehearsal therapy (IRT) - mentally rehearsing modified nicer outcome of a recurrent nightmare
^^ good for PTSD recurrent nightmares
3. Meds rarely used - prazosin, antidepressants
- Non REM sleep arousal disorder
2. REM sleep behavior disorder
males, >50 yrs
- Repeated incomplete arousals; first 1/3 of sleep (sleep walking, sleep terrors)
- Repeated arousals assoc with vocalization or complex motor behavior during REM; second 1/2 of sleep
- lack of muscle atonia during REM sleep
- NO confusion, disorientation upon awakening
** Usually present with injury to bed partner
** RF: psych meds; underlying NCD
Mgmt:
- DC likely causative medication
- Clonazepam usually works
- Melatonin can help
- Ensure environmental stafety
Restless legs syndrome (F > M)
RF
Mgmt
Only occurring or worsening in evening
RF:
- strong familial component
- iron deficiency
- psych meds + medical comorbidities
Mgmt: 1. Remove any offending agents 2. Low ferritin --> iron replacement 3. FIRST LINE TREATMENT: dopamine ag's, BZ's Refractory --> low dose opioids
