Psychiatry Flashcards
1
Q
major risk factors for suicide
A
psychiatric disorders feelings of hopelessness or worthlessness impulsivity increasing age male sex access to weapons history of suicide attempts
2
Q
neurotransmitters decreased in depression
A
serotonin, norepinephrine, dopamine
3
Q
medical illnesses that can cause depressive symptoms
A
hypothyroidism hyperparathyroidism Parkinson disease stroke HIV Cancer (esp CNS neoplasms, which can mimic depression)
4
Q
Drugs known to cause depressive symptoms
A
sedatives (alcohol, benzodiazepines, antihistamines)
withdrawal from stimulants (cocaine, amphetamines)
some antihypertensives (methyldopa, clonidine, beta- blockers)
first- generation antipsychotics (haloperidol)
prochlorperazine
metoclopramide
long-term glucocorticoid use
interferon- alpha (contraindicated in depression)
5
Q
MDD with atypical features
A
mood reactivity increase appetite and weight gain hypersomnia leaden paralysis hypersensitivity to rejection responds well to MAOIs
6
Q
MDD with seasonal pattern
A
recurrent depression exhibiting a regular temporal or seasonal pattern
treatment: light therapy (10,000 lux at least 30 min/day)
7
Q
MDD with peripartum onset
A
onset during pregnancy or up to 4 weeks postpartum
8
Q
MDD with psychotic features
A
delusions or hallucinations develop during an episode of MDD
No psychosis except during depressive episodes (the depression is always present even when the psychosis isn’t_
9
Q
Schizoaffective disorder
A
baseline psychosis
mood disorder secondary to psychosis
10
Q
persistent depressive disorder (formerly known as dysthymic disorder)
A
chronic, persistent depression for at least 2 YEARS (MDD no longer precludes persistent depressive disorder as it used to in DSM4)
depressed mood plus 2 SIGECAPS symptoms
more difficult to treat than MDD
11
Q
SSRIs
A
citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline
first line for depression as well as anxiety
work in 3-4 weeks
12
Q
SNRIs
A
desvenlafaxine, duloxetine, milnacipran (fibromyalgia only), venlafaxine
13
Q
Atypical antidepressants
A
buproprion, mitrazapine, nefazodone, trazodone
14
Q
TCAs
A
amitriptyline, doxepin, imipramine, nortriptyline
15
Q
MAOIs
A
phenelzine, tranylcypromine
16
Q
side effects of SSRIs
A
sexual dysfunction insomnia/agitation weight gain risk of suicidal ideation risk of serotonin syndrome
17
Q
Serotonin syndrome
A
mental status changes: anxiety, agitation, delirium, restlessness, disorientation
autonomic excitation: diaphoresis, tachycardia, hyperthermia, hypertension, vomiting, diarrhea
Neuromuscular hyperactivity: tremor, muscle rigidity, hyperreflexia, myoclonus
ocular clonus (slow, continuous, horizontal eye movements)
spontaneous or inducible clonus
positive Babinski sign bilaterally
18
Q
Which drugs increase the risk of serotonin syndrome
A
SSRIs SNRIs MAOIs TCAs St. John's wort Tryptophan Triptans Linezolid Levodopa Stimulants (cocaine, ecstasy- MDMA, amphetamines)
19
Q
How do we treat serotonin syndrome?
A
discontinue all serotonergic agents and symptoms usually resolve in 24 hours
Supportive care to normalize vital signs
- oxygen, IV fluids, cardiac monitoring
- if medical treatment for tachycardia or HTN is needed, use short- acting agents (esmolol, nitroprusside)
Sedation with benzodiazepines
If T>41, sedation, paralysis, ET tube- mechanical cooling
- paralysis should relieve the hyperthermia, which is caused by muscle activity
- there is no benefit in using antipyretics in this scenario
If agitation despite benzodiazepine then use a serotonin inhibitor like cyproheptadine
Adter sx resolve, assess need to resume serotonergic agent
20
Q
side effects of SNRIs
A
sexual dysfunction insomnia/agitation nausea dizziness hypertension (venlafaxine) risk of serotonin syndrome
21
Q
norepinephrine dopamine reuptake inhibitor (NDRI)
A
buproprion
blocks presynaptic reuptake of NE and DA
use this to treat fatigue and hypersomnia, but not anxiety
also indicated for smokine cessation
22
Q
NDRI (buproprion) side effects
A
blocks pre-synaptic re-uptake of DA
insomnia, weight loss, lowers seizure threshold, contraindicated in anorexia, eating disorder, seizure disorder
no sexual dysfunction!
23
Q
Alpha2 antagonist- mirtazapine
A
blocks alpha 2- adrenergic receptors, which leads to increased NE release
side effects include sedation for unknown reasons, appetite stimulation, and weight gain
useful in cancer patients who have comorbid depression
24
Q
Serotonin modulators: trazadone, nefazodone, vilazodone
A
these drugs have a variety of effects on serotonin receptors (agonist/antagonist depending on the receptor subtype)
The main side effect is sedation
Trazedone can even be used as a sleep aid
priapism
25
```
TCAs:
amitriptyline
clomipramine
imipramine
nortriptyline
```
not really used much anympre
block NE and serotonin reuptake
3rd line due to poor side effect profile
```
side effects:
anticholinergic effects (amitriptyline especially)
sedation
sexual dysfunction
weight gain
dangerous in overdose
```
26
What findings are seen in TCA OD?
cardiotoxicity: tachycardia, hypotension, conduction abnormalities
CNS toxicity:sedation, obtundation, coma, seizures
antiCholinergic symptoms: mydriasis, xerostomia, ileus, urinary retention
27
MAOIs
tranylcypromine
phenelzine
inhibits MAO; increases levels of serotonin, DA, NE
not used often, due to side effects and interactions with food (tyramine builds up and stimulates autonomic nervous system)
side effects: drug- drug interactions
hypertensive crisis
28
what foods contain tyramine and should be avoided while on MAO in order to avoid hypertensive crisis?
foods that are spoiled, pickled, aged, smoked, fermented, or marinated
- fermented cheeses (cream cheese and cottage cheese are ok)
- smoked or aged meats (sausage, bologna, pepperoni, salami, smoked or pickled fish)
- chianti, most beers and wines (especially over 120 mL)
- soy sause, shrimp paste, miso soup
- sauerkraut, avocados, ripe bananas, fava beans
29
What are the indications for electroconvulsive therapy?
severe, debilitating depression refractory to antidepressants
psychotic depression
severe suicidality
depression with food refusal leading to nutritional compromise
depression with catatonic stupor
situations where a rapid antidepressant response is required (eg pregnancy)
previous good response to ECT
bipolar/mania
schizophrenia/psychosis (catatonia especially)
30
TCA that can be used to treat bedwetting in children
imipramine
31
Bipolar I disorder
at least one manic episode
| may or may not have MDD or hypomanic episodes
32
Bipolar II disorder
At least one hypomanic episode
At least one major depressive episode
Never had a manic episode
33
Manic episode
elevated, expansive, or irritable mood
increased goal- directed activity or energy
lasts at least one week
```
Distractability
Insomnia
Grandiosity
Flight of ideas
Activity/agitation
Speech
Taking risks
```
34
Manic episode versus hypomanic episode
Manic:
at least 3 DIG FAST symptoms
at least 1 week
impaired function, or requires hospitalizations, or includes psychotic features
Hypomanic episode
at least 3 DIG FAST symptoms
lasts at least 4 days
no impairment in functioning, hospitalizations, or psychosis
35
Treatment for bipolar
Lithium (unless renal failure, in which case lithium is contraindicated and valproic acid and carbamazepine are choice)
Anticonvulsants (valproate, carbamazepine, lamotrigine)
Lithium and anticonvulsants are mood stabilizers
```
Atypical antipsychotics (aripiprazole, olanzapine, quetiapine, risperidone)
ECT
```
do not use SSRIs, which can push a patient into mania. treat depression in the setting of bipolar, with mood stabilizers
36
What are side effects of lithium in treating bipolar disorder?
Teratogenesis (Ebstein anomaly)
CNS effects (depression, tremor, cognitive dulling)
Thyroid dysfunction (hyperthyroidism, hypothyroidism, euthyroid goiter)
GI effects (nausea, vomiting, diarrhea, weight gain, metallic taste changes)
Nephrogenic diabetes insipidus (polyuria, polydipsia)
37
How do we treat nephrogenic diabetes insipidus that results from lithium toxicity?
hydrochlorothiazide with amiloride
38
Ebstein anomaly
tricuspid leaflets displaced inferiorly
tricuspid regurgitation or stenosis
RV hypoplasia
+/- patent foramen ovale
39
Cyclothymic disorder
mild hypomanic symptoms that do not meet criteria for a hypomanic episode
mild depressive symptoms that do not meet criteria for a major depressive episode
symptoms are present for at least 2 YEARS (Adults), or 1 year in children
periods of normal mood last less than 2 months during that 2 year (Adult) or 1 year (child) stretch
DOES cause significant distress or impairment in social/occupational functioning
Tx: mood stabilizers, psychotherapy
40
Dissociative disorders
Dissociative identity- multiple personalities, 2 or more distinct identities/ personalities)
Depersonalization/derealization disorder- depersonalization- persistent feelings of detachment from patient's own body or thoughts, or feeling like people and things around the patient aren't real
Dissociative amnesia- amnesia for a very specific event, or generalized amnesia of patient's identity and personal life history.
May include dissociative fugue
41
Panic disorder
```
recurrent panic attacks, with abrupt onset of intense fear and anxiety accompanied by
palpitations or tachycardia
sweating
trembling/shaking
SOB
choking sensation
CP
dizziness/lightheadedness
nausea
hot flashes/chills
paresthesias
feeling of losing control
fear of dying
```
Panic attach is followed by a period of persistent worry about more panic attacks, or maladaptive behavior to prevent panic attacks. This period lasting at least one month
Treat with CBT, SSRIs, Benzodiazepines acutely (but beware addiction)
42
Generalized anxiety disorder
Excessive anxiety and worry occurring more days than not for at least 6 months
At least 3 of the following symptoms:
- hyperarousal
- difficulty concentrating
- irritability
- muscle tension
- difficulty sleeping
- fatigue
SSRIs, SNRIs, Buspirone, CBT
43
Specific phobias
marked fear out of proportion to the threat the situation poses, with avoidance of the feared exposure
exposure therapy- gradual desensitization
44
Social anxiety disorder
excessive anxiety related to social situations, with fear of being negatively evaluated by others (eg social interactions, being observed by others, performing in front of others)
Treat:
CBT, SSRI, SNRI
Benzodiazepine or beta- blocker (propanolol), as needed for performances
45
Buspirone as an anxiety medication
second- line treatment
may be used as monotherapy or in combination with SSRIs and SNRIs
Affinity for serotonin and dopamine receptors
46
Benzodiazepines as anxiety meds
increase the frequency of opening of GABA- receptor chloride channels
frequent use may lead to tolerance, dependence, withdrawal seizures
47
agoraphobia
excessive fear of being outside the home alone, using public transporation, and being in a crowd
this isn't a specific phobia
48
delusion
irrational belief that cannot be changed by proof or rational arguments
49
illusion
misinterpret a stimulus that is actually there
50
hallucinations
sensory perception in the absence of external stimulus
51
Disorganized thought
circumstantiality- answers diverge from the question asked but eventually return to the original topic
tangentiality- answers diverge from the question asked and do NOT return to the original topic. The point keeps changing, though you can see the links
Loose associations- no clear sequence to the thoughts presented
Word salad- words strung together incoherently
Neologism- new words
52
Schizophrenia:at least 2 of the following during a 1 month period (including at least 1 of the first 3)
plus social/occupational dysfunction
for a duration of at least 6 months
delusions
hallucinations (most common type is auditory)
disorganized speech
grossly disorganized or catatonic behavior
negative symptoms (flat affect, poverty of speech, lack of emotional reactivity)
53
Schizophrenia risk factors
family history
being born in late winter/early spring
maternal illness/malnutrition during pregnancy
+/- psychoactive drug use during adolescence and young adulthood
male gender
Neuroimaging- enlargement of lateral and third ventricals
cortical thinning
54
Schizophrenia negative symptoms
```
flat affect
social withdrawal
avolition/apathy
anhedonia
poverty of speech
```
55
schizotypal personality disorder
odd thoughts/behavior/appearance
| discomfort with interpersonal relationships
56
schizoid personality disorder
voluntary social isolation
57
schizoaffective disorder
psychosis with intermittent mood disorder
58
schizophrenia
psychosis that lasts at least 6 months
59
schizophreniform disorder
psychosis for less than 6 months
60
brief psychotic disorder
psychosis less than 1 month
61
Delusional disorder
delusions for one month or more
no other symptoms of shizophrenia (hallucinations, if present, are not prominent and are related to the delusion)
social/occupational function is not impaired
62
What drugs cause psychosis?
```
hallucinogens (LSD, PCP)
stimulants (cocaine, amphetamines)
withdrawal from benzodiazepines, alcohol, barbiturates
glucocorticoids
anabolic steroids
```
63
Parkinson disease
loss of dopamine- producing neurons in the substantia nigra
resulting in depigmentation,
increased ACh
increased Lewy body formation (eosinophilic inclusions of alpha- synuclein and ubiquitin proteins, with a halo around the Lewy body)
64
risk factors for PD
family history
advancing age
head trauma
MPTP metabolite, which destroys DA cells of substantia nigra
65
Parkinsonism
bradykinesia, hypokinesia, akinesia
postural instability (can't make small adjustments)
festinating gait (difficulty initiating walking)
shuffling gait to keep upright
pill- rolling tremor (while at rest)
cogwheel rigidity
mask- like facies
orthostatic hypotension (autonomic dysfunction)
cognitive dysfunction
depression
66
Huntington
```
CAG repeat on chromosome cuatro
caudate atrophy on MRI
acetylcholine and GABA are decreased
cognitive decline (dementia)
choreiform movements
cuarenta (40)= age of onset
usually fatal within 20 years of diagnosis
```
symptomatic treatment with DA antagonists (tetrabenazine), or antipsychotics (haloperidol, risperidone)
67
Personality disorder
persistent behavior that deviates significantly from cultural norms, with symptoms that lead to impaired function in society, beginning in late adolescence
and not attributable to:
drug use
medical conditions
other psych disorders
68
Cluster A personality disorders
Weird- inability to develop meaningful social relationships, also without psychosis
paranoid
schizoid
schizotypal
69
Paranoid personality disorder
long-standing suspiciousness and general distrust of others, look for clues to validate distrust
70
Schizoid personality disorder
schizoids avoid
voluntary social withdrawal
limited emotional expressions
don't smile, content with social isolation
71
schizotypal
dressed like a pickle
eccentric appearance, odd beliefs, magical thinking
interact with others awkwardly, visibly odd in their appearance
72
Cluster B personality disorders
```
wild, drama
Antisocial
Borderline
Histrionic
Narcissistic
```
73
Antisocial
disregard for rights of others, criminality
male>female
"conduct disorder" under age 18
74
Borderline
unusual variability and depth of moods
unstable moods
chaotic interpersonal relationships
impulsiveness, self- mutilation (cutting), sense of emptiness
females>males
splitting is typical
high likelihood of suicide
75
Histrionic
```
Excessive emotions
attention- seeking
seductive behavior
overly concerned with appearance
appearance can be provocative or exaggerated
```
"odd to us, but to them it looks very special"
76
Narcissistic
excessively preoccupied with personal prestige, power, vanity
lack empathy
require excessive admiration
77
Cluster C disorders
very anxious and fearful
anxiety disorders
worried, cowardly, compulsive, clingy
Avoidant
Dependent
Obsessive- compulsive
78
Avoidant
hypersensitivity to rejection
socially inhibited, timid, feelings of inadequacy
want to relate to others but don't know how
79
Dependent
psychologically dependent on other people
very low self esteem
submissive and clinging
excessive need to be taken care of
80
Obsessive- compulsive personality disorder
preoccupation with order
| concerned with perfectionism and control
81
Substance use disorder
problematic pattern of substance use that leads to significant impairment or distress
Characterized by
tolerance
withdrawal symptoms
persistent desire or unsuccessful attempts to cut down
Significant energy spent obtaining, using, or recovering from the substance
Important social, occupational, or recreational activities reduced
Continued use in spite of knowing the problems that it causes
Craving
Recurrent use in physically dangerous situations
Failure to fulfill major obligations at work, school, or home
Social or interpersonal conflicts
82
Alcohol intoxication
CNS depression, mood elevation, disinhibition, decreased anxiety and sedation, severe mental impairment, somnolence, respiratory depression
83
Alcohol withdrawal
agitation, anxiety, insomnia, tremor
84
Where does alcohol act on the brain
GABA receptor, similar to benzos
85
Treatment for alcohol intoxication
time, can be life-threatening
| anxiety, tremor, agitation, tachycardia, severe withdrawal causes DT (2-3 days after cessation)
86
Delirium tremens (DT)
2-3 days after cessation of alcohol
nightmares, agitation, disorientation, visual/auditory hallucinations, fever, hypertension, diaphoresis, seizures, autonomic hyperactivity
87
how to treat alcohol withdrawal
benzodiazepines, preferably long-acting benzodiazepines
diazepam
lorazepam
chlordiazepoxide
88
Complications of longterm alcohol use
```
liver damage
fatty change (hepatocytes)
increased GGT
increased AST and ALT
alcoholic cirrhosis
hepatitis
pancreatitis
peripheral neuropathy
testicular atrophy
aspiration pneumonia
-klebsiella
```
GI bleeding
- mallory- weiss tears
- esophageal variceal bleed
malnutrition
- b12
- Wernicke-Korsakoff due to B1 thiamine deficiency
- Wernicke is the thiamine deficiency
- Korsakoff is secondary to Wernicke
89
Wernicke encephalopathy
```
confusion
nystagmus
ophthalmoplegia
ataxia
sluggish pupillary reflexes
coma
death if untreated
```
90
Korsakoff syndrome is the fallout of Wernicke
characteristics include...
anterograde amnesia
retrograde amnesia
confabulation
hallucinations
this is due to atrophy of the mammillary bodies
treatment:
IV thiamine BEFORE glucose repletion
91
Thiamine vs glucose for the alcoholic (or malnourished) patient?
Always give thiamine before glucose to any patient with mental status changes or to any malnourished alcoholic patient
92
treatments for alcoholism recovery
```
alcoholics anonymous
naltrexone
disulfiram
topiramate
acomprosate
```
93
Benzodiazepine intoxication
```
CNS depression
decreased anxiety
disinhibition
coma
respiratory depression
```
94
Benzodiazepine withdrawal
agitation
anxiety
seizures
95
How do we treat Benzodiazepine overdose
flumazenil
96
5 stages of behavioral change
precontemplation
contemplation
preparation
97
precontemplation
patient in denial, doesn't ackowledge that there is a problem
98
contemplation
thinking about change, though they aren't ready for it yet
99
preparation
making concrete plans to change
100
action
implementing the plan
101
maintenance
the change had been made and they are ready to not go back to previous behaviors
102
Amphetamines
increase release of intracellular stores of catecholamines
103
cocaine
blocks reuptake of catecholamines (in the synaptic cleft)
104
amphetamine and cocaine intoxication
euphoria and high energy
this may lead to agitation, anxiety, insomnia
increased BP, tachycardia, cardiac arrest, stroke (cocaine), pupullary dilateion, erosions in the nose (cocaine)
105
indications for amphetamines
ADHD
| short- term weightloss
106
Amphetamine and cocaine withdrawal symptoms
depression
lethargy
weightgain
headache
107
Treat amphetamine intoxication
benzodiazepines
| haloperidol
108
treat cocaine intoxication
benzodiazepines
haloperidol
no beta blockers, because the alpha receptors will continue to be stimulated
phentolamine is an alpha blocker that could be useful
109
caffeine and nicotine intoxication
```
excitability
restlessness
diuresis (caffeine)
premature atrial contractions
premature ventricular contractions
```
110
caffeine and nicotine withdrawal symptoms
irritability
anxiety
craving
tiredness
111
Treating nicotine withdrawal
nicotine replacement
(patch, gum, lozenge)
buproprion
varenecline
112
hallucinogen intoxication
```
hallucinations
delusions
anxiety
paranoia
tachycardia
pupillary dilation
flashbacks (chronic use)
```
113
treat hallucinogen intoxication
remove patient from dangerous environment and place in a quiet dark room
antipsychotics (PO, IM)
Benzodiazepines for anxiety and agitation
114
marijuana intoxication
euphoria, sense of well-being
anxiety, paranoia, delusions
```
perception of slowed time
impaired judgment
social withdrawal
increased appetite
dry mouth
hallucinations
redness of eyes
```
115
marijuana withdrawal
irritability
insomnia
nausea
peak 4-8 hours, but still there for about a month
116
opioids (morphine, heroin, methadone)
```
CNS depression
Euphoria
n/v
constipation
pupillary constriction (miosis)
seizures
respiratory depression
```
117
Treat opioid intoxication with
naloxone
| naltrexone
118
opioid withdrawal- symptoms and treatment
```
sweating
dilated pupils
piloerection
yawning
rhinorrhea
flu-like symptoms
```
uncomfortable but not life- threatening
treat with methadone, suboxone (naloxone plus buprenorphine- this decreases withdrawal symptoms without providing a satisfying high)
119
PCP
```
belligerance
impulsiveness
agitation
nystagmus (horizontal and vertical)
homicidal ideation/ violence
psychosis
delirium
```
120
How to treat PCP intoxication
treatment: benzodiazepines, antipsychotics
121
PCP withdrawal
violence (again)
depression
anxiety
irritability
122
Anorexia
patient refuses to maintain normal body weight
risk factors- female adolescents (14-18yo especially)
high socioeconomic status
diagnosis:
distorted body image
intense fear of gaining weight
restricted caloric intake relative to energy requirements
```
features:
amenorrhea
cold intolerance and/or hypothermia
dry, scaly skin
hair loss
lanugo (fine, downy hair)
hypogonadism
osteoporosis
comorbid anxiety, OCD, depression
```
treatment:
psychotherapy
SSRI for comorbid depression or anxiety
buproprion is contraindicated (risk of seizures)
hospitalization may be required to address nutritional deficiencies and complications
123
What is refeeding syndrome?
Sudden shift from fat metabolism to carbohydrate metabolism may cause-
```
hypophosphatemia
hypokalemia
hypomagnesemia
CHF and arrhythmias
Rhabdomyolysis
Delirium
Seizures
```
124
Bulimia nervosa
Bulemics usually maintain a normal body weight
Recurrent episodes of binge eating
Inappropriate compensatory behaviors to prevent weight gain (purging, intense exercise, severe caloric restriction)
Recurrent vomiting may cause
- scarred hands
- dental erosions
- enlarged parotid glands and elevated serum amylase
- hypochloremic metabolic alkalosis
treatment:
- cognitive behavioral therapy
- pharmacotherapy: SSRIs
125
Binge- eating disorder
episodes of binge eating
no inappropriate compensatory behaviors
patients tend to be overweight/obese
treatment:
- cognitive behavioral therapy
- SSRIs, topirimate, stimulants
126
Obsessive- compulsive disorder
Obsessions: recurrent, UNWANTED, intrusive, anxiety- provoking thoughts or urges
Compulsions: repetitive behaviors or mental acts performed to relieve the anxiety caused by obsessive thought.
Diagnosis requreist hat the obsessions and compulsions are TIME- CONSUMING and cause impairment in social/occupational functioning
Treatment: cognitive behavioral therapy
Exposure and response prevention
Pharmacotherapy (SSRIs)
combination can be effective
127
Body dysmorphic disorder
preoccupation with a perceived defect in appearance
repetitive behaviors/mental acts related to perceived defects (can be internal or external)
Treatment:
avoid performing needless surgery
psychotherapy
SSRIs for refractory cases (off label use)
128
Hoarding disorder
anxiety, distress associated with getting rid of stuff
| diagnosis requires impaired social function
129
changes associated with bulimia?
hypochloremic metabolic alkalosis from vomiting
| increased amylase from salivary gland inflammation
130
Trauma disorders
PTSD
Acute stress disorder
Adjustment disorder
131
PTSD diagnosis
1. exposure to something traumatic
2. Rexperiencing the traumatic event (memories, dreams, flashbacks)
3. Avoidance of stimuli associated with the traumatic event
4. Negative changes in cognition and mood
5. Hyperarousal (irritable behavior, reckless behavior, hypervigilance, sleep disturbance)
These symptoms have to last at least 1 month
132
What are the treatment options for PTSD?
Psychotherapy, including behavioral (exposure) therapy and cognitive therapy
SSRIs are first line
Benzodiazepines should be avoided due to lack of efficacy and potential for abuse
alpha blocker (prazosin) may be used to resolve nightmares and improve sleep
no evidence to support use of TCAs, MAOIs, atypical antipsychotics, or mood stabilizers
133
acute stress disorder versus PTSD
This is like PTSD but
134
Adjustment disorders
emotional response to psychosocial stressor
-depressed mood
-anxiety
-disturbance of conduct
in any combination
- clinically significant emotional or behavioral reaction causing marked distress and/or impairment in social/occupational functioning
- symptoms develop in response to an identifiable psychosocial stressor (cancer, divorce, death of a loved one, family conflict, loss of job, moving, major life changes)
- symptoms begin within 3 months of the onset of the stressor
- symptoms disappear within 6 months of the stressor disappearing
Also, the symptoms cannot meet the criteria for another disorder
135
Somatic symptom and related disorders
conversion
somatic symptom disorder
illness anxiety disorder
factitious disorder
136
Conversion disorder
Neurological sx without recognized or medical cause
- motor: weakness/paralysis, tremor, dystonia/myoclonus, gait disorder, dysphagia, dysphonia
- sensory (numbness/paresthesias, blindness, deafness)
May or may not be the result of a specific psychological stressor
137
How to treat conversion disorder
psychotherapy, CBT, physical therapy
| find the root
138
Somatic symptom disorder
one or more somatic symptoms that is distressing or distruptive
- disproportionate and persistent thoughts about the seriousness of the symptoms
- high anxiety about health or symptoms
- excessive time and energy to symptoms or health concerns
Note: hypochondriasis no longer exists
139
Illness anxiety disorder
- preoccupation with having or acquiring a serious illness
- high level of anxiety about health
- individual performs excessive health- related behaviors
- somatic symptoms are not present
helpful to see these patients at regular intervals
140
Factitios disorder (Munchausen syndrome)
intentional induction of injury or disease, or falsification of signs/symptoms of illness
patient presents him/herself as ill or injured
deceptive behavior is present even in the absence of external reward
141
Factitious disorder imposed on another (previously known as Munchausen by proxy)
child or elder abuse,
| also in the absence of external gain
142
Malingering
not a mental disorder
| external reward desired
143
overwhelming worry about contracting a serious illness, without any signs or symptoms
illness anxiety disorder
144
overwhelming worry about the seriousness of existing physical symptoms
somatic symptom disorder
145
ADHD
decreased attention span
inability to complete tasks
forgetfulness
excessive talking and movement
for diagnosis, questionnaires are given toparents as well as 2 people who have direct contact with the student
diagnosis: 6 inattention or 6 hyperactivity/impulsivity symptoms before age 12
The symptoms limit the ability to function in social, educational, or organized settings
146
ADHD treatment
1. stimulants
methylphenidate
lisdexamfetamine
dextroamphetamine
2. atomoxetine (milder, but also helps with focusing behavior)
3. Tricyclic antidepressants:
- imipramine
- desipramine
- nortriptyline
4. buproprion
5. Clonidine alpha-2 agonist
6. eliminate foods high in caffeine and sugar
147
Common complications of ADHD stimulant medications
1. insomnia- sleep hygiene, take meds earlier, short duration formulation, clonidine at night
2. appetite suppression and weightloss- administer meds after meals rather than before
3. Tics- usually transient, choose low- moderate dose methylphenidate, which does not worsen tics
4. psychosis- discontinue (no need to taper)
5. decreased growth velocity (reassure parents that adult height is not affected. drug holidays can help with catch up growth.
148
Side effects of atomoxetine
1. increased risk of suicidality- close observation and usually discontinuation
2. liver injury (d/c without taper)
149
Tourette syndrome- therapeutic options
counseling/psychotherapy for social adjustment and coping
if interfering with necessary functions of life- anti-dopamine agents can be used
- fluphenazine
- pimozide
- tetrabenazine
(all are generally tolerated better than haloperidol)
if only focal motor or vocal tics, Botox injections into affected muscles
if impulse control problems, clonidine or SSRIs
if refractory to medical management, consider deep brain stimulation of globus pallidus, thalamus, or other subcortical target (undergoing clinical trials)
150
Autism spectrum disorder
severe, persistent impairement in interpersonal interactions
patient who is "living in his own world"
symptoms prior to age 3
lack of responsiveness to others, poor eye contact, absent social smile
impaired communication, language delay, repetative phrases
peculiar repetitive, ritualistic habits (spinning, hand flapping)
fascination with specific, seemingly mundane objects (vacuum cleaners, sprinklers)
below- normal intelligence
r/o metabolic causes
tx: behavior, speech, social, psychotherapy with peers
supervision if severe
