Miscellaneous Disorders

Question 1

Substance abuse

Answer 1

Requres 1 or more of the following in 1 year:

1) Failure to fulfill responsibilities at work, school, or home
2) use of substances in physically hazardous situations (driving)
3) Legal problems during time of substance use
4) Continued substance use despite recurrent social or interpersonal problems secondary to the effects of such use (frequent arguments with spouse over the substance use)

Question 2

Substance dependence

Answer 2

Requires 3 or more of the following in 1 year:

1) Tolerance and use of progressively larger amounts to obtain the same desired effect
2) Withdrawal symptoms when not taking the substance
3) Failed attempts to cut down use or abstain from the substance
4) Significant time spent obtaining the substance (visiting many doctors to get pain pills)
5) Isolation from life activities
6) Consumption of greater amounts of the substance than intended
7) Continued substance abuse despite recurrent physical or psych problems secondary to effect of substance use

“WITHDraw IT”

3 or more of 7 within 12 month period

Withdrawal
Interest of Important activities given up or reduced
Tolerance
Harm (physical and psychosocial) with use
Desire to cut down/control
Intended time/amount exceeded
Time spent obtaining/using is increasing

Question 3

Pinpoint pupils

Answer 3

Not always a reliable sign of opioid ingestion bc coingestions can lead to normal or enlarged pupils. Also look for a decreased RR, track marks, and reduced breath sounds.

Question 4

Dx/Tx of substance abuse/dependence

Answer 4

1) Substance use is often denied or underreported so seek out collateral info from family and friends
2) Check urine and blood tox screens, LFTs, and serum EtOH
3) Detox - usually 5-10 days, mostly in hospital settings
4) Rehab - usually 28 days or more with focus on relapse prevention techniques

AA

NA

Disulfiram (acetaldehyde dehydro inhibitor), naltrexone (opioid receptor antagonist) and acamprosate

Question 5

Alcoholism

Answer 5

More common in men (4x more) and in those 21-34, although incidence in females is rising. Associated with positive FHx

Question 6

Dx alcoholism

Answer 6

Look for palmar erythema or telangiectasias as well as for other signs of end-organ complications

Screen with CAGE. More than 1 yes answer makes it likely. Monitor vitals for evidence of withdrawal.

Labs may show increased LFTs, LDH, and MCV

Question 7

Tx of alcoholism

Answer 7

1) Rule out med complications; correct lytes
2) Start benzo taper for withdrawal symptoms. Add haldol for hallucinations and psychotic symptoms
3) Give multivitamins and folic acid; administer thiamine before glucose (which depletes thiamine) to prevent Wernicke Encephalopathy
4) Give anticonvulsants to patients with a seizure history
5) Group therapy, disulfiram, or naltrexone can aid patients with dependence
6) Long term rehab (AA)

Question 8

Complications of alcoholism

Answer 8

1) GI bleeding from gastritis, ulcers, varices, Mallory-Weiss
2) Pancreatitis, liver disease, DTs, alcoholic hallucinosis, peripheral neuropathy, Wernicke’s, Korsakoff psychosis, fetal alcohol syndrome, cardiomyopathy, anemia, aspiration pneumonia, increased risk of sustaining trauma (subdural hematoma)

Question 9

CAGE

Answer 9

1) Have you ever felt the need to Cut down on drinking?
2) Have you ever felt Annoyed by criticism of your drinking?
3) Have you ever felt Guilty about drinking?
4) Have you ever had to take a morning Eye opening?

Question 10

Alcohol intox and withdrawal

Answer 10

1) Intox - Talkative, sullen, gregarious, moody, disinhibited.

Tx - mechanical ventilation if severe

2) Withdrawal - Tremors, hallucinations, seizures, tachy, DT.

Tx - Benzos, thiamine, multivitamins, folic acid

Question 11

Amphetamines and cocaine (also bath salts) intox and withdrawal

Answer 11

1) Intox - Euphoria, hypervigilence, autonomic hyperactivity, weight loss, pupillary dilation, perceptual disturbances

tx - antipsychotics and/or benzos and /or antihypertensives

2) Withdrawal - Anxiety, tremulousness, HA, increased appetite, depression, risk of suicide, nightmares

Tx - Bupropion and/or bromocriptine

Question 12

Opioids (also desomorphin - krokodil) intox and withdrawal

Answer 12

1) Intox - Apathy, CNS depression, constipation, pupillary constriction, respiratory depression (life threatening in OD), slurred speech, coma, death, dysphoria

Tx - Naloxone

2) Withdrawal - Fever, chills, lacrimation, abdominal cramps, muscles spasms, diarrhea, insomnia, myalgias, diaphoresis, nausea, vomiting, yawning

Tx - Clonidine, methadone or buprenorphine

Question 13

PCP intox and withdrawal

Answer 13

1) Intox - Belligerence, psychomotor agitation, violence, nystagmus (vertical/horizontal), HTN, seizures, tachycardia, impaired judgment, ataxia, delirium

Tx - Antipsychotics and/or benzos and/or talking down

2) Withdrawal - None (sometimes recurrence of intox symptoms due to reabsorption in GI tract; sudden onset of severe, random violence)

Tx - NA

Question 14

Hallucinogens intox and withdrawal

Answer 14

1) Intox - Ideas of reference, perceptual disturbances, possible increase in psychosis, impaired judgment, tremors, incoordination, dissociative symptoms

LSD - marked anxiety or depression, visual hallucinations, pupils dilated, diaphoresis, tachy, HTN, heightened senses (colors more intense)

Tx - Antipsychotics and/or benzos and/or talking down

2) Withdrawal - None

Tx - NA

Question 15

Marijuana intox and withdrawal

Answer 15

1) intox - Euphoria, slowed sense of time, impaired judgment, social withdrawal, increased appetite, dry mouth, conjunctival injection, hallucinations, anxiety, paranoia, amotivational syndrome

Tx - consider antipsychotics if patient is psychotic (K2, Spice)

2) Withdrawal - None usually, but sometimes irritability, anger, anxiety, sleep problems, restlessness, appetite problems

Tx - Symptomatic

Question 16

Barbiturates intox and withdrawal

Answer 16

1) Intox - low safety margin; respiratory depression

2) Withdrawal - Anxiety, seizures, delirium, life-threatening CV collapse

Question 17

Benzo intox and withdrawal

Answer 17

1) Intox - Interactions with alcohol, amnesia, ataxia, somnolence, mild respiratory depression (avoid using for insomnia in elderly; can cause paradoxical agitation even in low doses)
2) Withdrawal - rebound anxiety, seizures, tremor, insomnia, HTN, tachycardia, death

Question 18

Caffeine intox and withdrawal

Answer 18

1) Intox - Restlessness, insomnia, diuresis, muscle twitching, arrhythmias, tachycardia, flushed face, psychomotor agitation
2) Withdrawal - HA, lethargy, depression, weight gain, irritability, craving

Question 19

Nicotine intox and withdrawal

Answer 19

1) Intox - restlessness, insomnia, anxiety, arrhythmia

2) Withdrawal - Irritability, HA, anxiety, weight gain, craving, bradycardia, difficulty concentrating, insomnia

Question 20

Inhalants intox and withdrawal

Answer 20

1) Intox - Belligerence, apathy, aggression, impaired judgment, stupor or coma

Tx - antipsychotics

2) Withdrawal - None

Tx - NA

Question 21

Anorexia Nervosa history and exam

Answer 21

Risk factors include female, low self esteem, high socioeconomic status. Also associated with OCD, MDD, anxiety, and careers/hobbies such as modeling, gymnastics, ballet, running

1) Body weight is less than 85% of expected
2) Patients present with refusal to maintain normal body weight, and intense fear of weight gain, a distorted body image (patients perceive themselves as fat) and amenorrhea
3) Patients restrict (severely restricting caloric intake by fasting or by exercise) or binge and purge (vomit, lax, diuretics)

4) Signs/symptoms include cachexia, BMI below 18, lanugo, dry skin, bradycardia, lethargy, hypotension, cold intolerance, and hypothermia (below 95)

Question 22

Dx of anorexia

Answer 22

Measure height and weight, check BMI, check CBC, lytes, endocrine levels, and ECG. Perform a psych eval to screen for comorbid conditions

Question 23

Tx of anorexia

Answer 23

Hospitalization to prevent dehydration, starvation, lyte imbalances and death

Psychotherapy

Behavioral therapy

SSRIs have been used to promote weight gain

Initially, monitor caloric intake to restore nutritional status and to stabilize weight THEN focus on weight gain

Question 24

Complications of anorexia

Answer 24

1) MVP, arrhythmias (secondary to lytes), hypotension, bradycardia, amenorrhea (missing 3 straight cycles), nephrolithiasis, osteoporosis*, multiple stress fractures, pancytopenia, thyroid abnormalities
2) Mortality from suicide or medical complications is more than 10%

Very resistant to treatment. Deny health risks associated with their behavior

Question 25

Bulimia nervosa history and exam

Answer 25

More in women. Associated with lower self esteem, mood disorders and OCD

1) Patients have normal weight or are overweight. For at least 2 times a week for 3 or more months, patients have episodes of binge eating and compensatory behaviors that include purging or fasting.
2) Patients are usually ashamed an conceal their behavior
3) Signs include dental enamel erosion, enlarged parotid glands, and scars on dorsal hand surfaces. Usually normal body weight

Question 26

Tx of bulimia

Answer 26

Psychotherapy focuses on behavior mods and body image. Antidepressants may be effective for both depressed and nondepressed patients.

Does NOT require hospitalization unless severe lyte issue

SSRIs and therapy

Question 27

Medical complications of eating disorders

Answer 27

1) Overall - Cachexia, hypothermia, fatigue, lyte issues (hypoK, pH issues)
2) Cardiac - arrhythmias, sudden death, hypotension, bradycardia, prolonged QT
3) GI - dental erosions and decay, abdominal pain, delayed gastric emptying
4) GU - Amenorrhea, kidney stones
5) Other - Derm (lanugo), heme (Leukpenia), neuro (seizures), MSK (osteoporosis, stress fractures)

AVOID BUPROPION IN THESE PATIENTS

Question 28

Binge Eating Disorder

Answer 28

Recurrent episodes of binge eating that occur at least 3 times per week for more than 3 months.

Patients are overweight, and usually lack a sense of control over their eating habits.

Binge eating episodes associated with eating faster than usual, eating until feeling uncomfortably full, eating large amounts of food in absence of hunger, eating alone, and feeling disgusted afterward

Tx - Topiramate! SSRIs may have limited benefit. Psychotherapy is indicated (CBT, interpersonal, DBT)

Question 29

Eating Disorder NOS

Answer 29

When patients don’t meet criteria for either anorexia or bulimia nervosa

1) Criteria for anorexia present in girls but menstruation is normal
2) Anorexic patient with normal weight
3) Use of compensatory behavior after eating normal amounts of food

Question 30

Sexual changes with aging

Answer 30

1) Interest in sex usually does not decrease with age
2) Men usually require increased stimulation of genitalia for longer periods to reach orgasm. Intensity of orgasm diminished. Length of refractory period is longer.
3) Women, estrogen levels decrease after menopause, leading to vaginal dryness and thinning which may cause discomfort during sex. May be treated with HRT, estrogen vaginal suppositories or other vaginal creams

Question 31

Impotence

Answer 31

Persistent or recurrent inability to attain or maintain an erection until completion of sexual act

Tx - rule out medical causes or medication, psychotherapy, couples sexual therapy

Question 32

Premature ejaculation

Answer 32

Ejaculation before penetration or just after penetration usually due to anxiety

Tx - psychotherapy, behavioral mods (stop and go, squeeze), SSRIs

Question 33

Genitopelvic pain disorder (Dyspareunia)

Answer 33

Pain associated with sexual intercourse, not diagnosed if due to medical condition

Tx - psychotherapy

Question 34

Penetration disorder (Vaginismus)

Answer 34

Involuntary constriction of the outer third of vagina preventing penile insertion

Tx - psychotherapy, dilator therapy

Question 35

Paraphilias

Answer 35

1) Preoccupation with or engagement in unusual sexual fantasies, urges, or behaviors for more than 6 months with clinically significant impairment in one’s life. Includes criminal sex offenders. Almost always in men. Usually begins before or during puberty
2) Tx - insight-oriented psychotherapy and behavioral therapy. Antiandrogens (depo-provera) or SSRI have been used for hypersexual paraphilic activity

Question 36

Gender dysphoria

Answer 36

Characterized by persistent discomfort and sense of inappropriateness regarding the patient’s assigned sex

Gender identity disorder will manifest by wearing the opposite gender’s clothing, using toys assigned to opposite sex, play with opposite-sex children when young, and feeling unhappy about the person’s own sexual assignment.

Patients will take hormones when older to deepen voice, if female, or soften voice if male. Women may bind their breasts and men may hide their penis and testicles. Seen more frequently in young men.

Tx - sexual reassignment if approved. Individual psychotherapy

Question 37

Risk factors for sleep disorders

Answer 37

1) Female gender
2) Presence of mental and medical disorders
3) Substance abuse
4) Advanced age

Question 38

Primary insomnia

Answer 38

Affects up to 30% of the general population. Causes sleep disturbance that is not attributable to physical or mental conditions. Often exacerbated by anxiety and patients may become preoccupied with getting enough sleep

Dx: Patients present with history of nonrestorative sleep or difficulty initiating or maintaining sleep that is present at least 3 times per week for 1 month.

Tx:

1) First line therapy includes initiation of good sleep hygiene measures
2) Pharm is considered second line and should be started with care for short periods of time (less than 2 weeks). Pharm agents include diphenhydramine, zolpidem (ambien), zaleplon (sonata), and trazodone (Desyrel)

Question 39

Primary hypersomnia

Answer 39

Dx: Diagnosed when a patient complains of excessive daytime sleepiness or nighttime sleep that occurs for more than 1 month. The excessive somnolence cannot be attributable to medical or mental illness, meds, poor sleep hygiene, insufficient sleep, or narcolepsy

Tx:

1) First line therapy includes stimulant drugs such as amphetamines
2) Antidepressants such as SSRIs may be useful for some

Question 40

Recommended sleep hygiene measures

Answer 40

1) Establishment of a regular sleep schedule
2) Limiting of caffeine intake
3) Avoidance of daytime naps
4) Warm baths in the evening
5) Use of the bedroom for sleep and sex only
6) Exercising early in the day
7) Relaxation techniques
8) Avoidance of large meals near bedtime

Question 41

Narcolepsy

Answer 41

May affect up to 0.16% of the population. Onset typically occurs by young adulthood, generally before age 30. Some forms of narcolepsy may have genetic component.

Dx:

1) Manifestations include excessive daytime somnolence and reduced REM sleep latency on a daily basis for at least 3 months. Sleep attacks are the class symptom; patients cannot avoid falling asleep
2) Characteristic excessive sleepiness may be associated with the following: Cataplexy - sudden loss of muscle tone that leads to collapse. Hypnagogic hallucinations - Occur as patient is falling asleep. Hypnopompic hallucinations - occur as patient awakens. Sleep paralysis - brief paralysis upon awakening

Tx: Treat with a regimen of scheduled daily naps plus stimulant drugs such as amphetamines; give SSRIs for cataplexy

Modafinil (used to maintain alertness)

can include methylphenidate and dextroamphetamine

Gamma-hydroxybutyrate can be given at bedtime to induce symptoms of narcolepsy and contain them at night

Question 42

Sleep apnea

Answer 42

1) occurs secondary to disturbances in breathing during sleep that lead to excessive daytime somnolence and sleep disruption. Etiologies can be either central or peripheral
2) Central sleep apnea: A condition in which both airflow and respiratory effort cease. CSA is linked to morning HAs, mood changes, and repeated awakenings during the night
3) OSA: Airflow ceases as a result of obstruction along the respiratory passages. OSA strongly associated with snoring. Risk factors are male, obesity, prior upper airway surgeries, a deviated nasal septum, a large uvula or tongue, and retrognathia (recession of mandible)
4) In both forms, arousal results in cessation of the apneic event.
5) Associated with sudden death in infants and elderly, HA, depression, increased systolic BP, and pulmonary HTN

Question 43

Dx of sleep apnea

Answer 43

Sleep studies (polysomnography) document the number of arousals, obstructions, and episodes of reduced O2 saturation; distinguish OSA from CSA; and identify possible movement disorders, seizures, or other sleep disorders

Question 44

Tx of sleep apnea

Answer 44

1) OSA - nasal continuous positive airway pressure (CPAP). Weight loss if obese. In kids, most cases are due to tonsillar/adenoidal hypertrophy which is corrected surgically

Avoid sedatives and alcohol

2) CSA - mechanical ventilation (BiPAP) with a backup rate for severe cases

Question 45

Circadian Rhythm Sleep Disorder

Answer 45

1) A spectrum of disorders characterized by a misalignment between desired and actual sleep periods. Subtypes include jet-lag type, shift-work type, delayed sleep-phase type, and unspecified.
2) Tx of jet lag: usually resolves within 2-7 days without specific treatment
3) Shift-work type may respond to light therapy
4) Oral melatonin may be useful if given 5.5 hours before the desired bedtime

Question 46

Somatoform disorders

Answer 46

Patients have no conscious control over symptoms. There are 5 major types:

1) Somatization Disorder
2) Conversion Disorder
3) Hypochondriasis
4) Body Dysmorphic Disorder
5) Somatoform Pain Disorder

Question 47

Somatization Disorder

Answer 47

Multiple, chronic somatic symptoms from different organ systems with multiple GI, sexual, neuro, and pain complaints

Frequent clinical contacts and/or surgeries; significant functional impairment

Male to female ratio is 1 to 20! Onset usually before age 30

Schedule regular appointments with identified primary caregiver who maintains communication with consultants and specialists; psychotherapy

Question 48

Conversion Disorder

Answer 48

Symptoms or deficits of voluntary motor or sensory function (blindness, seizure-like movements, paralysis) incompatible with medical processes. Close temporal relationship to stress or intense emotion

More common in young females and in lower socioeconomic strata and less educated groups

Usually resolves spontaneously, but psychotherapy may help

Question 49

Hypochondriasis

Answer 49

Preoccupation with or fear of having a serious disease despite medical reassurance, leading to significant distress/impairment. Often involves history of prior physical disease.

Men and women equal, Onset is in adulthood

Manage with group therapy and schedule regular appointments with the patient’s primary caregiver

Question 50

Body dysmorphic disorder

Answer 50

Preoccupation with an imagined physical defect or abnormality that leads to significant distress/impairment. Patients often present to dermatologists or plastic surgeons

Has a slight female predominance. May be associated with depression

SSRIs may help

Question 51

Somatoform Pain Disorder

Answer 51

The intensity or profile of pain symptoms is inconsistent with physiologic processes. Close temporal relationship with psychological factors.

More common in women. Peak onset is at 40-50 years old. May be associated with depression

Treatment includes rehab (PT), psychotherapy, and behavioral therapy. Analgesia is usually not helpful. TCAs and SNRIs (venlafaxine and duloxetine) may be therapeutic

Question 52

Factitious Disorders

Answer 52

Patients fabricate symptoms or cause self-injury to assume the sick role (primary gain). More common in women.

Question 53

Munchausen’s Syndrome

Answer 53

Form of chronic factitious disorder in which patients fabricate physical signs and symptoms, leading to unnecessary testing or surgery. Common among health care workers.

Question 54

Munchausen by proxy

Answer 54

A “caregiver” makes someone else ill and enjoys taking on the role of the concerned onlooker

Question 55

Malingering

Answer 55

Patients intentionally cause or feign symptoms for secondary gain of financial benefit or housing

Question 56

Sexual and physical abuse

Answer 56

1) Most frequently affects women under 35 who fill the following criteria:
(a) Experiencing marital discord and are substance abusers or have a partner who is a substance abuser
(b) Are pregnant, are of low socioeconomic status, or have obtained a restraining order

2) Victims of childhood abuse are more likely to become adult victims of abuse

3) Hx/PE:
(a) Patients typically have multiple somatic complaints, frequent ER visits, and unexplained injuries with delayed medical treatment. They may also avoid eye contact or act afraid or hostile
(b) children may exhibit precocious sexual behavior, genital or anal trauma, STDs, UTIs, and psych problems
(c) Other clues include a partner who answers questions for the patient or refuses to leave the exam room

4) Tx: Perform a screening assessment of the patient’s safety domestically and in their close personal relationships. Provide medical care, emotional support, and counseling; educate the patient about support services and refer appropriately. Documentation is crucial.

Sexual abusers are usually male and are often known to the victim (and are often family members)

Question 57

Risk factors for suicide

Answer 57

SAD PERSONS

1) Sex (male)
2) Age (older than 45)
3) Depression (or other psych issues like psychosis)

4) Previous attempt (or history of violent behavior)
5) Ethanol/substance abuse
6) Rational thought
7) Sickness (chronic illness)
8) Organized plan/access to weapons
9) No spouse
10) Social support lacking

PLUS family history of suicide

Women are more likely to attempt. Men more likely to succeed (more lethal means used)

Question 58

Dx and Tx of suicidality

Answer 58

1) Perform comprehensive psych eval
2) Ask about FHx, previous attempts, ambivalences toward death, and hopelessness
3) Ask DIRECTLY SI, intent, and plan, and look for available means

Tx: A patient who endorses suicidality requires emergent inpatient hospitalization even against their will. Suicide risk may increase after antidepressant therapy is initiated bc a patient’s energy to act on suicidal thoughts can return before the depressed mood lifts.