NEUROPSYCH Flashcards
Categories of Psychiatric Disorders
- Neurodevelopmental disorders
- Neurocognitive disorders
- Personality disorders
- Psychosis
- Depressive Disorders
- Bipolar Disorders
- Anxiety diorders
- Trauma or stressor related diorders
- Substance use disorders
- Somatic symptom and related disorders
Obsessive compulsive Disorders
Neurodevelopmental disorders
Inborn conditions of the CNS
Includes:
- ADHD
- ASD
- Intellectual Disability
- Specific Learning Disorders
ADHD
- Inattention
- Hyperactivity and/or
- impulsitivity
ASD
Social impairment and sterotypic behaviors
Intellectual Disability
impairments in adaptive functioning + documented subpar intellect, usually via IQ testing
Specific Learning Disorder
formerly called dyslexia
Neurocognitive Diorders
Conditions affecting the CNS that impacts a person’s cognitive capacity, which includes memory, language, attention, perception, and executive functons. formerly called dementia describes a long term cognitive decline
Delirium
Neurologic diagnosis of encephalopathy - a global disruption off brain function
Personality disorders
enduring pattern of inner experience and behavior that is inflexible, pervasive, causes distress or dysfunction, and is stable in late adolescence/early adulthood onwards.
Cluster A (odd and eccentric)
tendency towards psychosis; may represent prodrome or residual symptoms of schizophrenia
- Paranoid
- Schizoid
- Schizotypal
Paranoid
suspicious and distrubing
Schizoid
detached and lacking in emotion
Schizotypal
distorted and magical thinking
Cluster B (“emotional and erratic’)
tendency towards Mood disorders
- Histrionic
- Narcissistic
- Antisocial
- Borderline
Histrionic
attention seeking and emotional
Narcissistic
self important, lacking in empathy, needing admiration
Antisocial
disregard for laws and rights of others; with evidence of conduct disorder before 15 years of age
Borderline
unstable sense of self; tends to be impulsve; associated with self-harm, turbulent relationships, and emotional outbursts
Cluster C (“fearful and ansious”)
tendency towards anxiety disorders
- dependent
- avoidant
- obsessive
- compulsive
Dependent
clingy and submissive
Avoidant
socially inhibited with feelings of inadequacy
Obsessive compulsive
perfectionist and rigid
Anxiety Disorders
Can include 2 phenomenoms:
- fear, which is mediated by the amygdala and is connected to the sympathetic nervous system
- worrying, which is a cognitive processess mediated by the cortico-striatal pathway
Panic Disorders
presence of 1 panic attack + 1 month of more of persistent worrying or maladaptive change in behavior in response to the attack
Panic Attack
A panic attack is a spontaneous episode of anxiety characterized by a combination of psychological and physiologic symptoms
Psychological:
- derealizaion,
- fear of losing control
Physiologic:
- palpitations
- tachycardia
- trembling
- shortness of breath
- choking
- chest pain,
- nausea
- abdominal distress
- dizziness
- chills/heat sensation
Generalized Anxiety Disorder
Excessive anxiety and worry occuring for most days than not in a span of at least 6 months restlessness, being easily fatigue, difficulty concentrating or mind going blank, irritability, muscle tension, and sleep disturbances
Agoraphobia
Modifier for a panic disorder but is now a stand alone diagnosis marked fear or anxiety in situations where escape is deemed diffcicult
Social anxiety disorder
Consistent fear or anxiety about social situations in which the individual is subject to the possibility of scrutiny by others
Acute stress disorder and PTSD
exposure to actual or threatened death, serious injury, or sexual violence.
- Intrusion symptoms: memories, dreams
- negative mood/ cognitive changes - inability to experience positive emotions
- Dissociative symptoms - depersonalization, derealiation
- avoidance symptoms -
- Arousal symptoms - sleep disturbancem irritability, angry outbursts, hypervigilance, problem with concentration, exaggerated startle response
Acute: 3 days to 1 month
Post traumatic:
more than 1 month, involves more long term negative alterations to cognitive schemes and mood and may be delayed in manifestation
Adjustment disorder
refers to the development of out-of-proportion emotional or behavioral symptoms in response to an identifiable stressor (not necessarily life threatening) within 3 months of its onset.
Modifiers:
- with depressed mood
- with anxiety
- with mixed anxiety and depressed mood
- With disturbance of conduct
Conversion disorder or functional neurological symptom disorder
development of neurologic deficits incompatible with recognized neuromedical conditions
Illness Anxiety disorder
formerly called hypochondriasis, this involves preoccupation with having serious illness despite having minimal symptoms
OCD
Obsessions are recurrent, intrusive, specific, and distressing thoughts bringing about anxiety to a patient
Compulsions are repetitive actions, whether mental or actual, which the patient cannot stop doing and is usually a way for him or her to control the anxiety brought about by obsessions. It is usually not a logical response to the content of the obsession.
Absolute psychiatric indications for admission
- Harm to self
- Harm to others
- Non-compliance to medications
- Social Emergencies
Psychosis
- Hallucinations
- Delusions
- Disorganized Behavior
- Disorganized speech
- Negative sx: Flattening of affect, avolition, alogia, extreme social withdrawal
**2 out of 5 symptoms must be fulfilled for a psychotic disorder
Pathophysiology of psychosis
Result of dopamine dysregulation in the brain.
Dopamine is influenced by serotonin and glutamate
Positive Symptoms: Increased Dopamine in the MESOLIMBIC TRACT
Negative symptoms: DECREASED DOPAMINE in the MESOCORTICAL TRACT
Dopamine is also found in the nigrostriatal tract - blockafe causes EPS
Dopamine also inhibits prolactin release in the TUBEROINFUNDIBULAR TRACT - blockade causes hyperprolactinemia which leads to amenorrhea-galactorrhea syndrome and gynecomastia
Brief psychotic episodes
1 day to 1 month
Usually bot not always, an isolated episode associated with a stressor. Not usually associated with negative symptoms
Tx: short course antipsychotics
Schizophreniform
1 month to 6 months
around 2/3 progress into schizophrenia
Schizophrenia
greater than 6 months with 1 month of active symptoms
More likely to see negative symptoms.
More likely to have gradual cognitive and functional decline related to chronic neurodegenerative process
Tx; Log-term maintenance with anti-psychotics
Schizoaffective disorder
2 or more weeks of psychotic symptoms alone with the eventual development of a major mood episode (fulfills criteria for MDD/bipolar) still in the temporal context of the psychosis
classified as depressed type or bipolar type
usually treated with a combination of antipsychotics and antidepressant/mood-stabilzier
Delusional disorder
psychosis which is only has delusions as its primary symptom.
It more commonly involves non-bizarre delusions
Substance or medication induced psychosis
MAP and other stimulant withdrawal
cannabis
steroid
Psychosis secondary to another medical condition
can arise from epilepsy, sle.
Treatment for psychosis
use of antipsychotic medication
Psychotherapy
Psychosocial intervention
Anti-psychotics
Dopmanine receptor antagonists
Serotonin and dopamine antagonists (atypical)
Dopamine receptor anataonists or typical anti psychotics
- haloperidol
- chlorpromazine
- fluphenaine
- flupenthixol decanoate or depot drugs
injected monthly
Side effects: EPS, Akathisia, tardive dyskinesia, Neuroleptic malignant syndrome (NMS)
Akithisia
subjective feeling of restlessness
tardive dyskinesisa
a hyperkinetic disorder due to upregulation of D2 receptors resulting from chronic DRA use
Neuroleptic malignant syndrome
(“FEVER”)
- Fever
- Encephalopathy
- Vitals Unstable
- Elevated muscle enymes
- Rigidity
Serotonin and dopamine antagonists (SDA) or atypical antipsychotics
- Risperidone
- olanzapine
- quetiapine
- clozapine
- amisulpride
- aripiprazole
- asenapine
- paliperidone
MORE EFFECTIVE FOR NEGATIVE SYMPTOMS
side effects: Metabolic syndrome, sedation, with less EPS
Clozapine can lower seizure threshold and has idiosyncratic reaction of AGRANULOCYTOSIS.
Olanzapine, known for having the highest weight gain
Depression
at least 5 of nine symptoms for a span of atleast 2 weeks
TWO CORE SYMPTOMS.
- Depressed mood
- Anhedonia or inability to find pleasure in anything
THREE PSYCHOLOGICAL SYMPTOMS
- Recurrent thoughts of death or suicidality
- feelings of worthlessness or inappropriate guilt
- Difficulty on concentration
FOUR SOMATIC or BODY RELATED SYMPTOMS
- Disturbances in appetite or weight
- Disturbance in sleep
- Psychomotor retardation or agitation
- Fatigue
Pathophysiology of Depression
Hypofunctioning of the serotonegc, dopaminergic, and norepinehrinergic circuits of the brain Not necessarily just a lack of those NT
Psychological and social factors play a big role in depression and may be the ones responsible for the biological changes in the brain especially in those genetically vulnerable through epigentic and neurohormonal factors
Subtypes of major depression:
- with atypical features
- with melancholic features
- with anxious distress
- with psychotic features
- with catatonia
- with postpartum onset
- with seasonal pattern
Teatment of Depression
Mild: Psychotherapy
Moderate or Severe: combined pharmacology and psychotherapy
Severe: Electroconvlsive therapy
Antidepressants
- SSRI
- TCA
- MAO
SSRI
- Escitalopram
- setraline
- fluoxetine
- paroxetine
*Duloxetine: SNRI
Side effects: GI disturbances, headcahe, restlessness
TCA
- Imipramine
- clomipramine
- amytryptylline
Side effects: Prolongation of the QT interval in the ECG, leading to arrhythmias
MAO
Isocarboxazid
Side effects: Combining this with tyramine-containing food such as cheese will cause hypertensive crisis.
Bipolar 1 Disorder
diagnosed if the patient has a single manic episode.
A depressive episode preceding or following the manic episode is common. but is NOT necessary for diagnos
Manic episode
when a person has abnormally and persistently elevated expansive or irritable mood for a period of atleast 1 week + 3 symptoms.
symptoms of Mania: Mood elevation or irritability +
- inflated self-esteem or grandiosity
- decreased need for sleep
- Pressured speech
- Flight of ideas or racing thoughts
- Distractability
- Increased goal-directed activity or psychomotor agitation
- Excessive involvement in activities with high potential for adverse consequences
Bipolar 2 disorder
diagnosed if the patient has at least one hypomanic episode + at least one Major depressive episode
hypomanic episode
same symptoms of mania but is not severe enough to warrant hospitalization or severe functional impairment, minimum of 4 days duration
Pathophysiology of Bipolar
dysregulation of the monoamine neurotransmitters which include dopamine, serotonin, and norepinephrine overlap with elevated dopamine psychosis - some psychotic episodes
does not involve cognitive and functional decline.
There is return to baseline functioning during the interim, at least in the microbiological aspect
treatment for bipolar disorder
Mood stabilizers are the first line treatments for bipolar disorder. However, this is commonly augmented with atypical antipsychotics
For pregnant: ATYPICAL antipsychotics
Antidepressants are used with caution. (push into manic episode)
Psychotherapy
Mood Stabilziers
- Lithium
- Valproic Acid
Lithium
Modulatory effects on intracellular secondary messengers of monoamine neurons
Cheap but effective but has a narrow therapeutic range (0.8 to 1.2 mEqs)
Toxicity: Gi disturbances, tremors, delirium, acne, weight gain, diabetes insipidus, hypothyroidism, kidney damge and teratogenesis
Valproic Acid
Antiepileptic drug that prevents overfiring of monoamine neurons by stabilizing the membrane
Wider Tx range than lithium, but is also teratogenic: neural tube anomalies
Delirium
neurobehavioral sequelae of a physiologic derangement that affects global brain functions, should always be ruled out of patients with psychiatric symptoms
corresponds to the neurologic diagnosis of encephalopathy
Features of Delirium
Disturbance in sensorium and cognition.
- May be hyperactive or hypoactive type
- Changes in sensorium (drowsiness reversed sleep-wake pattern) are seen in severe cases
- Impairment in attention and presence of disorientation
- May involve psychotic symptoms
- May result to agitation
Tends to develop over short period of time (acute) and tends to fluctuate throgh the day.
Common precipitants of Delirium
- Uremia
- hepatic encephalopathy
- Hypoxia, including severe anemia
- Metabolic derangements (electrolytes, glucose, etc.) Sepsis
- Substance toxicity/withdrawal, including anesthetics
Treatment for delirium
Treat underlying etiology
Psychotropics are given to control the delirium
Atypicals: low doses Benzodiazepines for anxiolysis and sedation
Substance Related Disorders
assess three dimensions.
- Acute Effects
- Pattern of substance Use
- Underlying psychiatric disorder
Wernicke Korsakoff syndrome
- ophthalmoplegia
- confusion
- ataxia
caused by thiamine deficiency from chronic alcoholism
Characterize Substance Use disorder
- Tolerance
- Withdrawal
- craving
- Failed attempts to cut down
- taken in larger amounts or longer
- Great deal of time is spent to obtain the substance
- Failure to fulfill major role obligations at work,school
- Important occupations are given up because of substance use
- Recurrent use in situations where it is physically hazardous
- Use of continued despite knowledge of having persistent or recurrent physical or psychological problem
- Continued use despite social problems
Mild Use disorder
2-3 symptoms
Moderate use disorder
4-5 symptoms
Severe use disorder
6 or more
Early remission of use disorder
3-12 months off the substance
Sustained remission of use disorder
greater than 1 year
Chlorpromazine
Antipsychotics (typical)
200mg, 1 tab HS to BID
Fluphenazinedecanoate
Antipsychotics (depot drug)
25mg/ml, 1mL IM every month
Flupentixol
Antipsychotics (depot drug)
20mg/ml, 1ml IM every month
Biperiden
Antipsychotics for EPS/akathisia
2 mg tab, 1 tab OD PRN
Risperidone
Antipsychotics (ATYPICAL)
2mg tab, 1 tab HS to BID
Olanzepine
Antipsychotics (ATYPICAL)
10mg tab, 1 tab HS to BID
Clozapine
Antipsychotics (ATYPICAL)
100mg tab, 1-3 tabs HS or divided through the day (slow uptitrated, for treatment resistant psychosis)
serial CBCs must be done
Escitalopram
Antidepressants
10 mg tab, 1 tab OD
Setraline
Antidepressants
50 mg tab, 1 tab OD
Fluoxetine
Antidepressants
20 mg tab, 1 tab OD`
Sodium Valproate + Valproic Acid
Bipolar 1
500mg tab, 1 tab BID to TID
Lithium carbonate
Bipolar 1
450mg tab, 1 tab BID
Haloperidol LActate
for agitation
5mg +/- diphenhydramine 50 mg cocktail IM PRN
**Diphen may cause delirium in geriatrics because of anticholinergic effects
Haloperidol lactate
For delirium
5mg IV PRN
Clonazepam
for insomnia
2mg tab, 1/4 to 1/2 tab PRN
*requires yellow prescription
Diphenhydramine
For insomnia
50mg tab, 1/2 to 1 tab HS PRN
Quetiapine
for insomnia
25 mg tab, 1 tab HS
Neurotransmitter primarily involved in the reward pathway?
Dopamine
Group of signs and symptoms occurring when a substance is reduced in amount after heavy and prolonged use
Withdrawal state
Lifetime prevalence of alcohol dependence
14%
At least 2 years of alternating depression and hypomanic episodes
Cyclothymia
DSM -5 Criteria for Manic Episode
DSM-5 criteria for hypomania
DSM-5 criteria for Major depressive episode
DSM-5 Bipolar I
DSM 5- Panic Disorder
DSM-5 Acute stress disorder
Which class of medication is the preferred long term treatment for panic disorder?
Antidepressants
Timeline for Acute Stress Disorder
3 days to 1 month
If there is a decrease in the dopamine levels in the tuberoinfundibular area, what will maifers?
Breast enlargement among male patients
DSM 5 -MDD
Clonazepam relieves anxiety symptoms by…
acting on the GABA receptor complex
What receptor does escitalopram acts on?
Serotonin
What receptor does risperidone acts on?
Dopamine and serotonin
What receptor does Donepezil acts on?
Acetylcholine
What receptor does Desvenlafaxine acts on?
Serotonin and Norepinephrine
What receptor does haloperidol acts on?
Dopamine
Most depressive disorders begin by age:
18-25
Which pathway is affected with the patient with schizophrenia manifests with impaired cognitive functions?
Mesocortical pathway
Decreased dopamine activity in this tract produces negative symptoms of schizophrenia
mesocortical
The EPS side effects of medications for schizophrenia is caused by blocking the receptors in the…
nigrostriatal pathway
Which receptors/do most of the atypical antipsychotics block?
5HT2A and D2
Drug of choice for agitated psychotic patients
Haloperidol + Diphenhydramine
Strongest predictor of violence
Past history of violence or criminal behavior
Strongest risk factor for suicide
Past suicide attempts
According to WHO, DALY stands for?
Disability Adjusted Life years
What is the most important neurotransmitter involved in the etiology of seizures?
GABA
Most common cause of Dementia?
Alzheimer’s disease
