Psychiatry Flashcards
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
what are the two most important classifications systems in psychiatry?
Diagnostic and Statistic Manual of mental disorders (DSM-5)
International classification of diseases ICD
what does the DSM 5 do?
Developed by ASA
National classification of psych only
Non-axial, numeric only
what does the ICD do
Developed by WHO
International classification
ALL diseases
Alphabet and numeric multiaxial
how many diseases and categories in DMS-5
22 Major categories
150 different diseases
whats the main difference between DSM-4 and DSM-5?
elimination of the multiaxial system
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
mental status examination - PSP
Appearance
Behavior
Speech
Mood
Tough process
Thought content
Perception
Cognition/Memory
Insight/awareness
Judgment
Bedside cognitive testing
The Montreal Cognitive Assessment (MOCA)
The Mini Mental Status Examination (MMSE)
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
The Mini Mental Status Examination (MMSE)
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
specific workup based on changes in cognition and consciousness
Lubar puncture
EEG
Brain imaging (MRI CT)
specific workup based on depression
Thyroid
Dexamethasone stimulating test
Pancreatic cancer
specific workup based on substance abuse
blood and urin toxicology
specific workup based on Dementia
Brain imaging
Carotid US with doppler
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)
types of brain imaging in psych
CT
PET
SPECT
MRI/fMRI
what is electrophysiology?
Use of electrophysiological techniques to study and understand the electrical activity of the brain and nervous system.
Types of electrophysiology?
EEG: Electroencephalography
ERPs: Event related potentials
MEG: Magnetoencephalography
TMS: Transcranial Magnetic Stimulation
ECoG: Electrocorticography
EEG: Electroencephalography
Records electric activity in the brain
Epilepsy, sleep disorders, Schizofrenia, depression
ERPs: Event related potentials
Brains processing of stimuli and cognitive functions
ADHD, Schi, mood disorders
MEG: Magnetoencephalography
Measures magnetic fields of neuronal activity
ASD, depression, OCD
TMS: Transcranial Magnetic Stimulation
Both therapy and research
Uses magnetic field to stimulate neurons
Depression
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
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)
CI of ECT
No absolute contraindications
Pregnancy and pacemakers are not a contraindication for ECT.
side effects of ECT
Retrograde more often than anterograde amnesia (typically resolves within 6 m)
Tension-type headache
Nausea
Transient muscle pain
Disorientation
Medications given in ECT
- Atropin as anticholinergic
- Succinylcholine as muscle relaxant
- Propofol as general anesthesia
The process of ECT
A generalized seizure is induced for 30-60s
Max 90s
How often is ECT given
8-12 treatments 2-3 times weekly
Sleep rTMS
repetitive transcranial magnetic stimulation for major depression. Stimulates brain cells responsible for mood control + depression
Takes about 3 - 20 min
SE of rTMS
Scalp discomfort
Lightheadedness
Headache
Tingling, Twitching, Spasms og facial muscles
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)
Bright light therapy in DSPS
Bright light delivered to the retina as soon as possible after spontaneous awakening for 30 to 90 min.
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
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.
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
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
pseudodementia
treatable disorders that mimic dementia. The most common is depression in elderly.
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
Diagnosis of Dementia
MMSE: Max score is 30 and < 24 suggests cognitive impairment
NCD dementia due to Alzheimer’s
Affects memory, learning and language
accumulation of extra-neuronal B-amyloid plaques and Tau bodies causing degeneration
Alzheimer treatment
Cholinesterase inhibitors (Rivastigmine)
NMDA receptor agonists (Memantine)
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.
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.
treatment of Lewi body dementia
Cholinesterase inhibitors for cognitive
Quetiapine/Clozapine for psychosis
Levodopa for parkinsonism
Melatonin/Clonazepam for sleep disturbance
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
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.
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
Delirium
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
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
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
Classifications of delirium
Hyperactive
Hypoactive
Mixed
treatment of delirium
First try non-pharma and fix underlying cause then try antipsychotics: Haloperidol (most commonly used) or atypical antipsychotic; Olanzapine
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
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
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
Negative symptoms of schizophrenia
Flat affect: reduced or absent emotional expression (Anhedonia)
Emotional and social withdrawal
Subtypes of schizophrenia
Early-onset schizophrenia:
Definition: onset of schizophrenia < 18 years
Catatonia:
Behavioral syndrome characterized by abnormal movements and reactivity to the environment
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.
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
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
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
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.
Schizophrenia ass with better prognosis
Late onset
Acute onset
Female gender
Good social support
Positive symptoms
Few Relapses
Schizophrenia ass with wors prognosis
Early onset
Gradual onset
Male gender
Poor social support
Negative symptoms predominate
Many relapses
Substance use
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).
