Psychiatry Flashcards by Sabrina Maleki

hat is the purpose of systems of classification in psychology?

Distinguish one psych disorder from another
Predict potential outcomes
Provide a common language among health professionals

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what are the two most important classifications systems in psychiatry?

Diagnostic and Statistic Manual of mental disorders (DSM-5)
International classification of diseases ICD

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what does the DSM 5 do?

Developed by ASA
National classification of psych only
Non-axial, numeric only

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what does the ICD do

Developed by WHO
International classification
ALL diseases
Alphabet and numeric multiaxial

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how many diseases and categories in DMS-5

22 Major categories
150 different diseases

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whats the main difference between DSM-4 and DSM-5?

elimination of the multiaxial system

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the psychiatric interview

Safe environment
Open-end questions
Personal data
Chief complaint
Source of information
Prior Illnesses
Past psych history
Family psych history/drugs used
Substance use
Medications/allergies
Development history
Social history

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mental status examination - PSP

Appearance
Behavior
Speech
Mood
Tough process
Thought content
Perception
Cognition/Memory
Insight/awareness
Judgment

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Bedside cognitive testing

The Montreal Cognitive Assessment (MOCA)
The Mini Mental Status Examination (MMSE)

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The Montreal Cognitive Assessment (MOCA)

make a line from number to letter i desending order
Drav the figure you see
Make a clock with numbers and set a time
Name the animals
Give some words and tell the pat to remember
repeat the numbers back to me
say 3 number and par say it backwards
every time I say letter A you tap your hand
Count backwards by 7 from 100
I read sentences you repeat
say as many word as you can from on letter
I say two words and you tell me how they are connected

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The Mini Mental Status Examination (MMSE)

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Routine lab tests in psychiatry

CBC
Blood chemistry (el, glu, Ca, Mg)
Liver function test
Kidney function test
Thyroid
VDRL syphilis
Urinalysis and urin toxicology
ECG
CT in psychosis
Vit B12 and Folate
HgA1c

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specific workup based on changes in cognition and consciousness

Lubar puncture
EEG
Brain imaging (MRI CT)

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specific workup based on depression

Thyroid
Dexamethasone stimulating test
Pancreatic cancer

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specific workup based on substance abuse

blood and urin toxicology

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specific workup based on Dementia

Brain imaging
Carotid US with doppler

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indications for neuroimaging in psychiatry

New onset psychosis
Acute changes in mental status
New neurological defect
Dementia-characteristics
Degenerativ disorders (Huntington)
Chronic CNS infection (HIV, TB, Neurosyphilis)

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types of brain imaging in psych

CT
PET
SPECT
MRI/fMRI

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what is electrophysiology?

Use of electrophysiological techniques to study and understand the electrical activity of the brain and nervous system.

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Types of electrophysiology?

EEG: Electroencephalography
ERPs: Event related potentials
MEG: Magnetoencephalography
TMS: Transcranial Magnetic Stimulation
ECoG: Electrocorticography

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EEG: Electroencephalography

Records electric activity in the brain
Epilepsy, sleep disorders, Schizofrenia, depression

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ERPs: Event related potentials

Brains processing of stimuli and cognitive functions
ADHD, Schi, mood disorders

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MEG: Magnetoencephalography

Measures magnetic fields of neuronal activity
ASD, depression, OCD

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TMS: Transcranial Magnetic Stimulation

Both therapy and research
Uses magnetic field to stimulate neurons
Depression

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what does ECT do

Electroconvulsive therapy uses a small electric current to produce a generalized cerebral seizure under generalized anesthesia in an attempt to reset brain function. It affects cellular mechanism of memory and mood

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Indications for ECT

Depression (most common)
MDD with psychotic features
Schizoaffective disorder
Schizophrenia with catatonia
Highly suicidal or pregnant depressed patients (not usually first-line)

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CI of ECT

No absolute contraindications
Pregnancy and pacemakers are not a contraindication for ECT.

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side effects of ECT

Retrograde more often than anterograde amnesia (typically resolves within 6 m)
Tension-type headache
Nausea
Transient muscle pain
Disorientation

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Medications given in ECT

Atropin as anticholinergic
Succinylcholine as muscle relaxant
Propofol as general anesthesia

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The process of ECT

A generalized seizure is induced for 30-60s
Max 90s

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How often is ECT given

8-12 treatments 2-3 times weekly

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Sleep rTMS

repetitive transcranial magnetic stimulation for major depression. Stimulates brain cells responsible for mood control + depression
Takes about 3 - 20 min

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SE of rTMS

Scalp discomfort
Lightheadedness
Headache
Tingling, Twitching, Spasms og facial muscles

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Bright light treatment

daily exposure to a light intensity of 5000–10,000 lux used to shift sleep pattern. Very important with the timing of the treatment.
Used in delayed sleep phase syndrom (DSPS)

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Bright light therapy in DSPS

Bright light delivered to the retina as soon as possible after spontaneous awakening for 30 to 90 min.

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Neurocognitive disorders and their 3 categories based on DSM

group of disorders defined by decline form a previous level of cognitive function
DSM categories
Major NCD (Demetia)
Minor NCD
Delirium

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Diagnostic criteria for mild neurocognitive disorder (mild cognitive impairment)

Diagnostic criteria are similar to dementia, with the following differences:
Cognitive deficits are less severe, do not interfere with everyday life.
Patients are typically aware of their deficits.

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what are the 6 cognitive domains that can be affected in neurocognitive disorders?

Complex attention
Executive function
Learning and memory
Language
Perceptual-motor skills
Social cognition

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DSM-5 diagnostic criteria of Dementia

Significant cognitive decline seen by self, clinician or informer
Interfers with daily activity and progress to total dependance
NOT due to delirium or other psychological conditions like depression or schizofrenia

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pseudodementia

treatable disorders that mimic dementia. The most common is depression in elderly.

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NCD etiology

Alzheimer disease (> 50% of dementia cases)
Parkinson disease
Dementia with Lewy bodies
Cerebrovascular disease
Prion disease
Normal pressure hydrocephalus
Wernicke‑Korsakoff syndrome
Syphilis
HIV

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Diagnosis of Dementia

MMSE: Max score is 30 and < 24 suggests cognitive impairment

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NCD dementia due to Alzheimer’s

Affects memory, learning and language
accumulation of extra-neuronal B-amyloid plaques and Tau bodies causing degeneration

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Alzheimer treatment

Cholinesterase inhibitors (Rivastigmine)
NMDA receptor agonists (Memantine)

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NCD dementia due to vascular dementia

Cognitive decline 2nd to vessel stroke or microvascular disease affecting the white matter. Long term reduced blood to brain casing ischemia and tissue damage. liquification of the brain.

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NCD dementia due to Lewi body dementia

Lewi body accumulation in the brain, primarily in BG. increase and decrease in cognition. Affects alertness and attention. Visual hallucinations and Parkinsonism seen.

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treatment of Lewi body dementia

Cholinesterase inhibitors for cognitive
Quetiapine/Clozapine for psychosis
Levodopa for parkinsonism
Melatonin/Clonazepam for sleep disturbance

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NCD dementia due to frontotemporal dementia

Degeneration of frontal lobe tissue seen on imaging. Types are: Behavioral: change of personality and behavior or Language type, difficulty with speech and comprehension. Use SSRI’s

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NCD dementia due to Prion disease

Encephalopathy due to infectious protein particles. No treatment, dies within 1 year. Basal ganglia and cerebellar dysfunction. Must diagnose with biopsy.

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NCD dementia due to Hydrocephalus

Enlarged ventricle due to CSF obstruction. Triad of gate, urinary incontinence and cognitive. Treatment is lumbar puncture or ventriculoperitoneal shunt

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Delirium

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5 major categories of delirium by DSM-5

1) Substance intoxication delirium
2) Substance withdrawal delirium
3) Medication-induced delirium
4) Delirium due to another medical condition
5) Delirium due to multiple etiologies

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epidemiology of delirium

Up to 50% of hospitalized elderly patients develop delirium
Associated with high mortality rates; up to 40% of individuals die within 1 year

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Etiology of delirium MANY

Metabolic diseases
- Most common: metabolic encephalopathy
- Liver or kidney failure
- Diabetes mellitus (diabetic ketoacidosis)
- Hyperthyroidism or hypothyroidism
- Vitamin deficiencies (vitamin B12 deficiency, folic acid deficiency, thiamine deficiency)
- Electrolyte abnormalities
Infection
- UTIs (most common cause in older patients)
- Pneumonia
CNS pathology
Drugs (drug-induced + toxic encephalopathy)
- Anticholinergics
- Benzodiazepines, barbiturates
- Antihistamines (particularly in older patients)
- Opioids
- Recreational drugs (intoxication/withdrawal)
- Alcohol use disorder and alcohol withdrawal
- Heavy metals
Cardiorespiratory conditions
- Hypoxia
- Acute cardiovascular disease
- Dehydration
Other
- Constipation
- Urinary retention
- Major surgery
- Trauma
- Pain

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Classifications of delirium

Hyperactive
Hypoactive
Mixed

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treatment of delirium

First try non-pharma and fix underlying cause then try antipsychotics: Haloperidol (most commonly used) or atypical antipsychotic; Olanzapine

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Etiology of schizophrenia

Genetic factors: risk significantly increased if relatives are also affected
Environmental factors
Stress and psychosocial factors
Frequent use of cannabis during early teens

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Pathophysiology of Schizofrenia

*Dysregulation of neurotransmitters
- ↓ Dopamine in prefrontal cortical pathway: negative s
- ↑ Dopamine in mesolimbic pathway: positive s
*Structural and functional changes to the brain
- Enlarged lateral and third ventricles
- ↓ Volume of hippocampus and amygdala

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positive symptoms of schizophrenia

Psychosis
- Hallucinations and/or illusions (auditory hallucinations are most common)
- Delusions, e.g., grandiosity, ideas of reference, paranoia, persecutory delusions
- Disorganized speech: loose associations, word salad

Abnormal motor behavior
- Catatonia

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Negative symptoms of schizophrenia

Flat affect: reduced or absent emotional expression (Anhedonia)
Emotional and social withdrawal

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Subtypes of schizophrenia

Early-onset schizophrenia:
Definition: onset of schizophrenia < 18 years

Catatonia:
Behavioral syndrome characterized by abnormal movements and reactivity to the environment

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DSM-5 diagnostic criteria for Schizophrenia

DSM-5 diagnostic criteria
At least TWO of the following symptoms must be present, with at least ONE of these from the first three symptoms listed:
1. Delusions
2. Hallucinations
3. Disorganized speech

+ Catatonia
+ Negative symptoms

Symptoms persist for ≥ 1 month.
Symptoms must cause social, occupational, or personal functional impairment lasting ≥ 6 months.

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Early onset schizophrenia

Clinical features
1) History preceding the onset of psychosis
- Poor social, academic, occupational function
- Substance use, esp. cannabis

2) Hallucinations (mainly auditory) occur more commonly than delusions.
In young children, hallucinations should be differentiated from age-appropriate imaginative activity

Prognosis: more severe than adult-onset, worse outcomes the earlier the onset of symptoms

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DDx for schizophrenia

Schizophreniform disorder
Brief psychotic disorder
Schizoaffective disorder
Delusional disorder
Shared psychotic disorder
Schizotypal personality disorder
Mood disorders with psychotic features
Substance-induced psychotic disorder

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Prognosis of schizophrenia

Predictive factors for a favorable course:
- Strong treatment adherence
- Older age at onset
- Strong network of social support
- Rapid onset of symptoms
- Few negative symptoms

Predictive factors for an unfavorable course
- Family history
- Early onset of disease
- Poor network of social support
- Slow onset of symptoms
- Many negative symptoms

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Treatment-resistant schizophrenia

Definition: persistent positive symptoms (i.e., delusions, hallucinations, and/or disorganized speech) despite trials of ≥ 6 weeks of 2 different antipsychotics at therapeutic doses
Clozapine is the drug of choice for treatment-resistant schizophrenia.

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Schizophrenia ass with better prognosis

Late onset
Acute onset
Female gender
Good social support
Positive symptoms
Few Relapses

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Schizophrenia ass with wors prognosis

Early onset
Gradual onset
Male gender
Poor social support
Negative symptoms predominate
Many relapses
Substance use

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Prognosis of schizophrenia response to meds

40-60% of patients remain significantly impaired after their diagnosis. only 20-30% functions well in society.

Pharma treatment in schizophrenia

1st gen AS: Fluphenazine, Haloperidol
2nd gen AS: Aripiprazole, Clozapine, Olanzapin, Quetiapine, Risperioden
ECT treatment
Behavioral therapy

1st gen AS properties

Primarily D2 antagonists
* Treat positive symptoms, with minimal impact on negative symptoms
* Side effects:
o Extrapyramidal symptoms
o Neuroleptic malignant syndrome (NMS)
o Tardive dyskinesia

2nd gen AS properties

Antagonize serotonin receptors (5-HT2) as well as dopamine receptors (D4 > D2)
* Side effects:
o Lower incidence of extrapyramidal side effects
o Higher rates of metabolic syndrome
* Medications should be taken for at least 4w
* Clozapine is highly effective in treating psychosis but carries a considerable risk of
agranulocytosis

what is the mood affecting disorders

group of illnesses that describe serious changes in the emotional status that can interfere with day-to-day activities (e.g., working, studying, eating, and sleeping).

name the major mood affecting disorders

Major depressive disorder
Bipolar disorder
Suicide
The menstrual cycle and menstrual cycle abnormalities (Premenstrual syndrome)

Defiene Major depressive disorder

Episodic mood disorder primarily characterized by depressed mood and anhedonia lasting for at least two weeks

clinical symptoms of MMD

Depressed mood
Anhedonia
Feelings of guilt, worthlessness, or hopelessness
Low energy levels
Difficulty concentrating
Changes in appetite and weight (increased or decreased)
Sleep disorders (insomnia or hypersomnia)
Psychomotor agitation or retardation
Suicidal thoughts

subtypes of MDD

Major depressive disorder with seasonal pattern
Major depressive disorder with atypical features
Major depressive disorder with psychotic features
Persistent depressive disorder (dysthymia)
Peripartum depression

Diagnostic criteria of MDD

5 or more of 9 listed, for at least 2 weeks, with at least 1 of the symptoms being depressed mood or anhedonia
1. Depressed mood for most of the day, almost every day (in children, can manifest with irritability)
2. Sleep disturbance (insomnia or hypersomnia)
3. Anhedonia
4. Feelings of worthlessness or disproportionate guilt
5. Fatigue or loss of energy
6. Diminished concentration, cognition, and ability to make decisions (pseudodementia)
7. Weight change due to appetite change
8. Psychomotor changes (observed by others)
- Agitation
- Retardation
- Suicidal ideation

If diagnosing MDD when should you consider bipolar disease?

Bipolar disorder: should be considered in treatment-resistant depression or unexpected responses to antidepressants (e.g., manic or hypomanic symptoms)

neurotransmitters involved in MMD

Epinephrine
Dopamine
Seretonine

Anhedonia

the inability to experience joy or pleasure.

Major depressive disorder with seasonal pattern

o Seasonal affective disorder, winter depression
o Occurs in a yearly, season-specific pattern
o Diagnostic criteria: symptoms must be present for > 2 consecutive years and
for the majority of years in a lifetime
o Treatment: bright light therapy

Major depressive disorder with atypical pattern

o Most common variant of MDD
▪ Increased appetite or overeating
▪ Hypersomnia
▪ Leaden paralysis (heavy feeling)
▪ Interpersonal rejection sensitivity that leads to social and occupational impairment
▪ Mood reactivity: brightening of mood in response to positive events
o Treatment:
▪ 1st line: CBT with or without SSRIs

SSRI’s

Escitalopram (Cipralex)
Citalopram
Sertraline (Zoloft)
Fluoxetine (Fontex)
Paroxetin (Seroxat)
Fluvoxamine
Voritoxetine

Major depressive disorder with psychosis

▪ Psychotic features: which are mood-congruent (the content is consistent with the depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment)
▪ Psychotic features occur only alongside a major depressive episode
o Treatment: Antidepressants + antipsychotics
▪ In severe cases → ECT

Persistent depressive disorder (dysthymia)

Milder form of MDD
▪ Poor appetite or overeating
▪ Insomnia or hypersomnia
▪ Low energy
▪ Low self-esteem
▪ Poor concentration
▪ Feelings of hopelessness
o Diagnostic criteria:
▪ Depressed mood in addition to > 2 of the clinical features mentioned above
▪ The symptoms are present most of the day, for > 2 years in adults

Peripartum depression

Develops within 4 weeks following delivery
Symptoms must be present for at least 2 weeks to confirm the diagnosis.

Cognitive behavioral therapy

A talking therapy that can help you manage your problems by changing the way you think and behave

SNRI’s

Venlaflaxin (Efexor)
Duloxetin (Cymbalta)

Other atypical antidepressants

Mirtazapine
Mianserin
Reboxetin
Miklobemid
Bupropion

when do we use ECT in depression?

Resistant/unresponsive to pharmacotherapy
Cannot tolerate pharmacotherapy (pregnancy)
Rapid reduction of symptoms is required (immediate suicide risk)

things to do to exclude organic cause of depression?

Thyroid test
Urine toxicology
Neuroimaging

why do we take a urine sample in depression?

Depressive symptoms may be associated with certain drugs, e.g., benzodiazepine use, amphetamine or cocaine withdrawal.

why should we always rule out bipolar disease in depression

Patients with bipolar disorder who are treated with antidepressants without a mood stabilizer are at increased risk of manic symptoms.

SSRI and MAO-I

MAOIs should not be combined with SSRIs/SNRIs or tricyclic antidepressants, because this may lead to serotonin syndrome. Stop SSRI and have a 2 week washout before smarting MAO-I

Post partum blues

Develops within the first few days of delivery
Usually resolve spontaneously within 2 weeks.

Bipolar disorder

Bipolar disorder is a psychiatric condition characterized by episodes of mania (or hypomania) and major depression, interspersed with periods of normal mood and functioning

average age on onset bipolar disease

at 20 years of age

Lifetime prevalence

General population: 1–3%
First-degree relative with bipolar dis: up to 10%
Monozygotic twin: 40–70%

Etiology of bipolar disease

Multifactorial origin
- Strong genetic component
↑ Paternal age → ↑ mutations during spermatogenesis
Triggers
- Psychosocial stress
- Medications (e.g., dexamethasone)
- Childhood traumatic experiences
- Sleep disturbances
- Physical illness

Manic/hypomanic episode in BP

Characterized by an elevated mood
Symptoms include:
- Intense prolonged happiness (several days)
- Irritability
- Overconfidence, risky behavior (overspending)
- Decreased need for sleep
- Hypersexuality
- Psychotic features

Major depressive episode in BP

Characterized by a depressed mood
Symptoms include:
- Anhedonia
- Fatigue, sleep disturbances
- Frequent reports of pain, e.g., headache or stomach ache
- Lack of interest in activities that were previously enjoyed
- Feelings of worthlessness or guilt
Suicidal ideation

Types of bipolar disorder

Bipolar I disorder:
- At least 1 episode of mania.
- Major depressive or hypomanic episodes usually occur but are not required for diagnosis.

Bipolar II disorder:
At least one episode of hypomania and one major depressive episode; no previous episodes of mania (distinguishing feature from bipolar I)

subtypes of BP disease

Rapid cycling
Cyclothymia
Substance/medication-induced bipolar disease

Racing cycle bipolar diseases

Patients affected by rapid cycling have 4 or more episodes of depression, mania, or hypomania occurring in a single year.

Cyclothymia BP disease

Persistent instability of mood involving numerous periods of depressive symptoms and periods of hypomanic symptoms
Symptoms are not sufficiently severe or persistent enough to diagnose bipolar disorder (symptoms never meet the criteria for a major depressive or hypomanic episode)
Symptoms last at least 2 years, are present at least half of the time, and are never absent for more than 2 months at a time.

Hypomania

A mood state characterized by ≥ 4 consecutive days of persistently elevated, expansive, and/or irritable mood with ≥ 3 of the following:
- Inflated self-esteem
- decreased need for sleep
- pressured speech
- flight of ideas
- distractibility
- increased goal-directed activity

Unlike in mania, the episode is not severe enough to cause hospitalization

Substance/medication-induced bipolar disease

elevated mood after intake of:
Alcohol
Phencyclidine
Amphetamine
Cocaine
Benzodiazepines
Glucocorticoids (e.g., dexamethasone)

what test should always be done in patients presenting with mani?

Always do a urine drug screening in patients presenting with mania to rule out acute intoxication (e.g., with amphetamines)

General diagnosis of bipolar disorder

≥ 3 of the following:
*Increased goal-directed activity (sexually, at work, socially) or psychomotor agitation
*Increased talkativeness or pressure to keep talking
*Flight of ideas or racing thoughts
*Excessive involvement in risky activities that can potentially lead to negative consequences (e.g., compulsive shopping, indiscreet sexual behavior, impulsive financial investments)
*Decreased need for sleep
*Heightened self-esteem or grandiosity
*Distractibility

Diagnosis of BP disorder I

Bipolar I disorder: ≥ 1 confirmed episode of mania > 7 days

Diagnosis of BP II

Bipolar II disorder: ≥ 1 confirmed episode of hypomania > 4 days AND ≥ 1 major depressive episode AND absence of any manic episodes

how to know the difference between a manic and hypomanic episode

A key difference between mania and hypomania is the intensity of the symptoms. Symptoms of mania are much more intense than those of hypomania, result in significant dysfunction, and manic patients often require hospitalization.
If psychotic symptoms are present, the episode is by definition manic, not hypomanic.

DDx i BP disease

Endocrine disorders: hypercortisolism (Cushing)
Autoimmune disorders: multiple sclerosis
Neurological disorders, e.g., stroke, traumatic brain injury, delirium

two phases of treatment in regards to BP disease

Acute treatment: resolution of mania and psychosis (if present) in order to prevent harm to the patient and/or others

Maintenance therapy: prevention of manic episodes, reduction of suicide risk, improvement in social functioning

Acute management of agitation in BP disease

Use rapid-acting intramuscular atypical antipsychotics (e.g., olanzapine, aripiprazole) or benzodiazepines (e.g., lorazepam).

Treatment of acute mania in BP disease: Mild

Monotherapy with:
Lithium
Valproic acid
Atypical antipsychotics (olanzapine, quetiapine)

Treatment of acute mania in BP disease: severe

Combination therapy
Mood stabilizer (lithium OR valproic acid) + antipsychotic (quetiapine, risperidone, haloperidol)

Lithium danger

Narrow therapeutic index and doses should be individualized according to serum levels and clinical response; an overdose may result in life-threatening lithium toxicity. Lithium is contraindicated in patients with renal dysfunction.

what is an anxiety disorder?

Broad spectrum of conditions characterized by excessive and persistent fear:
- Anxiety (the anticipation of a future threat)
- Worry (apprehensive expectation)
- Avoidance behavior.

types of anxiety disorders

Generalized anxiety disorder (GAD)
Panic disorder
Specific phobias
Agoraphobia
Social anxiety disorder (SAD)
Substance/medication-induced anxiety disorder

Etiology of anxiety disorders

Neurobiological factors
- Disruption of the serotonin system
- Dysfunction of GABAergic inhibitory transmission
Substance use: medication-induced anxiety
Environmental and developmental factors
- Stress
- Smoking (risk factor for panic disorder)
- Psychological trauma, esp. during childhood
Other medical conditions:
- Endocrine disease (e.g., hyperthyroidism)
- Cardiovascular disorders
- Respiratory illness (asthma)
- Neurological diseases ( encephalitis)

Define generalized anxiety disorder?

Anxiety that is prolonged, excessive, persistent (> 6 months), and caused by various aspects of daily life instead of a single specific situation or object

Clinical presentation of GAD

Diagnosis is confirmed if the following symptoms occur more days than not for at least 6 months
*(≥ 1 symptom in children, ≥ 3 in adults)
- Nervousness, restlessness
- Irritability
- Muscle tension
- Somnolence, fatigue
- Concentration difficulties
- Insomnia

differentiate GAD for MMD

Individuals with GAD tend to be more concerned with the future.
Individuals with MMD are more past-oriented.
Mood swings and suicidal ideation are uncommon in GAD.

treatment og GAD

1st: psychotherapy, pharmacotherapy, or both
Psychotherapy: CBT, relaxation therapy
Pharmacotherapy: SSRIs/SNRI for 12 months

Second-line
TCAs
Benzodiazepines used until SSRIs take effect but should never be used for long-term
Buspirone

Define panic attack

An abrupt episode of intense fear associated with physical and cognitive symptoms

Acute panic attacks peak within several minutes and involve ≥ 4 of the following cognitive and/or somatic symptoms:

Fear of dying
Palpitations, tachycardia, or pounding heart
Sweating or diaphoresis
Trembling or shaking
Shortness of breath or smothering sensation
Choking sensation
Chest pain or tightness
Abdominal discomfort or nausea
Dizziness, light-headedness, or faintness
Chills or feeling hot
Paresthesia’s

Tx panic attack

Reassurance
Deep breathing
Short-acting benzodiazepine (e.g., alprazolam) if nonpharmacological intervention fails

Define panic disorder

Definition: recurrent spontaneous and unexpected panic attacks that often occur without a known trigger

Etiology of panic disorder

Strong genetic disposition
Associated conditions
- Agoraphobia
- Substance use
- Depression
- Bipolar disorder

Dx of panic disorder

Recurrent panic attacks, at least one of which is followed by ≥ 1 of the following:
Persistent concern about having another attack
Persistent concern about the consequences of another panic attack (e.g., losing control)
Significant maladaptive behavioral changes in response to the attacks (e.g., avoiding a situation in which a previous attack occurred)
The panic attacks are not attributable to:
- Effects of a medication or substance
- Another mental disorder

Tx of panic disorder

CBT
Antidepressant: SSRIs, SNRIs (venlafaxine) TCAs
Benzodiazepines may be used until antidepressants take effect.

Define specific phobia disorder

Persistent (≥ 6 months) and intense fears of one or more specific situations or objects.
Always occurs during encounters with the phobic stimulus but may already surge in anticipation of an encounter

common phobias

Animal: spiders (arachnophobia), insects (entomophobia), dogs (cynophobia)
Natural environment: heights (acrophobia), storms (astraphobia)
Blood-injection-injury: blood (hematophobia), needles (belonephobia), dental procedures (odontophobia), fear of injury (traumatophobia)
Situational: enclosed places (claustrophobia), flying (aviophobia)
Other: fear of vomiting (emetophobia), the number 13 (triskaidekaphobia), costumed characters (masklophobia), fear of clowns (coulrophobia)

Tx of phobia

CBT
Benzo

Define Agoraphobia

Pronounced fear or anxiety of being in situations that are perceived as difficult to escape from or situations in which it might be difficult to seek help

Clinical presentation of Agoraphobia

Fear, anxiety, or even panic attacks over a period of ≥ 6 months in ≥ 2 of the following 5 situations:
- Using public transportation
- Being in open spaces
- Being in enclosed places
- Standing in line or being in a crowd
- Being outside of the home alone
- Active avoidance of these settings unless a companion is present
- Fear can become so severe that the affected individual feels unable to leave the house.

Define substance/medication-induced anxiety disorder

Prominent anxiety or panic attacks within 1 month of use of, or withdrawal from, a substance/medication that is capable of inducing anxiety symptoms

etiology of substance/medication-induced anxiety disorder

Alcohol
caffein
Amphetamine

Define somatoform disorder

Now called somatic syndrom disorder. Having physical symptoms that aren’t explained by any known physical or mental disorder

clinical presentation of somatoform disorder

Multiple physical symptoms that cause significant distress
A history of extensive (and fruitless) diagnostic testing and medical procedures
A preoccupation with their symptoms and health concerns for ≥ 6 months
Symptoms may be related to an existing medical condition.

Dx of somatoform disorder

All of the following DSM-5 diagnostic criteria must be met:
≥ 1 somatic symptom (e.g., heartburn, fatigue, headache, pain) that causes significant distress
Excessive thoughts, feelings, or behaviors related to the somatic symptoms or health concerns, manifesting as ≥ 1 of the following:
- Disproportionate and constant thoughts of symptom severity
- Constant and significant anxiety about symptoms or general health
- Excessive amounts of time and energy spent attending to symptoms or health concerns
Duration: ≥ 6 months

Tx of somatoform disorder

Minimize unnecessary studies and procedures.
Schedule regular visits with the same physician.
Psychotherapy: primarily CBT

Define Conversion disorder

Conversion disorder is also known as functional neurological symptom disorder.
Patients present with neurological symptoms that cannot be fully explained by a neurological condition.
Patients may be calm and unconcerned when describing their symptoms

Age of onset: ∼ 10–35 years of ag

Clinical presentation of conversion disorder

Functional paralysis
Psychogenic nonepileptic seizures
Functional dystonia
Functional tremor
Functional visual disturbances
Functional hearing loss

what is common to see on different physical exams of a patient with conversion disorder?

Inconsistent examination findings are common in conversion disorder; signs elicited during one examination may not always be present when using a different method.

Dx of conversion disorder

All of the following DSM-5 diagnostic criteria must be met:
≥ 1 neurological symptom (altered motor or sensory function): e.g., paralysis, muscle spasms, blindness, mutism, lump in throat, weakness, gait disorder

Clinical features:
Are incompatible with any recognized neurological or medical condition
Cannot be better explained by another medical disorder
Symptoms cause significant distress or psychosocial impairment or require medical evaluation

Tx of conversion disorder

If present, ensure comorbid neurological conditions are well-managed.
Physical therapy
Cognitive-behavioral therapy

Define Illness anxiety disorder

Previously known as hypochondriasis

Persistent preoccupation with having or developing a serious illness despite no concerning findings on multiple medical examinations

Somatic symptoms are usually absent or mild, but patients spend large amounts of time and energy obsessing over their health and the possibility of developing a disease.

Dx of Illness anxiety disorder

All the following DSM-5 diagnostic criteria must be met:
Preoccupation with having or developing an illness
Absent or mild somatic symptoms
Significant anxiety about health
The patient exhibits:
Excessive health-related behaviors (e.g., constantly checking for signs of illness)
OR incongruent avoidance behaviors (e.g., avoiding screening tests, doctor’s appointments, attending hospital)

Duration: ≥ 6 months

Symptoms are not better explained by another mental disorder.

Tx of Illness anxiety disorder

Minimize unnecessary studies and procedures
Schedule regular visits with the same primary care physician
Cognitive behavior therapy

Define Alcohol use disorder

chronic illness in which an uncontrolled pattern of alcohol leads to significant physical, psychological and social impairment or distress

Etiology of AUD

Genetic factors
Neurobiological factors
Psychosocial factors

Classificatio of AUD

Light to moderate
Heavy
Binge

Light to moderate AUD

♀: ≤ 1 standard drink a day
♂: ≤ 2 standard drinks a day

Heavy AUD

♀: ≥ 4 drinks per day or ≥ 8 drinks per week
♂: ≥ 5 drinks per day or ≥ 15 drinks per week

Binge drinking

consumption within a 2-hour period of ≥ 4 standard drinks for women and ≥ 5 standard drinks for men

AUD screening

AUDIT-C
CAGE test (cut, annoyed, guilt)

Lab tests confirming regular heavy alcohol use

Blood alcohol level
Liver AST level x2 higher then ALT (Al-hep)
Carbohydrate deficient transferrin
Malnutrition and BM damage
Phosphatidylethanol (PEth)

Test confirmation of regular heavy alcohol use

Phosphatidylethanol (PEth): a collection of phospholipids that are formed following exposure to alcohol
The half-life of PEth correlates to the amount and frequency of alcohol intake.
Can be detected for up to 28 days since the last drink in individuals with regular heavy alcohol use

pharmacotherapy of alcohol use

Naltrexone
Disulfiram (antabus)
Acamprosate
Topamirate/Gabapentin

long term complications of alcohol AUD

Wernicke’s encephalopathy
Korsakoff syndrom
Liver cirrhosis
HHC
GI bleeding
Chronic pancreatitis
Cardiomyopathy
Electrolyte abnormalities

Alcohol withdrawal syndrom

6–24 hours after cessation or reduction
Autonomic symptoms (e.g., palpitations, sweating, tachycardia, elevated blood pressure, hyperthermia)
Anxiety, insomnia, vivid dreams
Tremor, hyperreflexia
Headaches
Anorexia, nausea, vomiting

Alcohol withdrawal seizure

8–48 hours after cessation or reduction
Clinical features
Usually brief, generalized tonic-clonic seizures
Often a single episode

Alcohol-induced psychotic disorder (alcoholic hallucinosis) [2][3]

12–24 hours after cessation or reduction
Clinical features
Consciousness is usually intact.
Vital signs may be normal.
Auditory and/or visual hallucinations are common
Delusions
Duration: 24–48 hours after onset

Alcohol withdrawal delirium (delirium tremens)

Definition: persistent alteration of consciousness and sympathetic hyperactivity due to alcohol withdrawal

Onset: usually 72–96 hours after cessation of or reduction in alcohol consumption

Clinical presentation of delirium tremens (AUD)

Tachycardia
Hypertension
Anxiety
Nausea
Sweating
Psychomotor agitation (fidgeting, restlessness)
Alcohol withdrawal seizures can occur
Insomnia
Rest and intention tremor (first high then low frequency)
Duration: usually 2–3 days; may be lethal

treatment of alcohol withdrawal seizures

Alcohol withdrawal seizures: Immediately administer IV benzodiazepines.

Alcohol-induced psychotic disorder treatment

Consider low-dose antipsychotics (e.g., haloperidol, risperidone) in combination with benzodiazepines (not as monotherapy).

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