Psychiatry Flashcards
major risk factors for suicide
psychiatric disorders feelings of hopelessness or worthlessness impulsivity increasing age male sex access to weapons history of suicide attempts
neurotransmitters decreased in depression
serotonin, norepinephrine, dopamine
medical illnesses that can cause depressive symptoms
hypothyroidism hyperparathyroidism Parkinson disease stroke HIV Cancer (esp CNS neoplasms, which can mimic depression)
Drugs known to cause depressive symptoms
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)
MDD with atypical features
mood reactivity increase appetite and weight gain hypersomnia leaden paralysis hypersensitivity to rejection responds well to MAOIs
MDD with seasonal pattern
recurrent depression exhibiting a regular temporal or seasonal pattern
treatment: light therapy (10,000 lux at least 30 min/day)
MDD with peripartum onset
onset during pregnancy or up to 4 weeks postpartum
MDD with psychotic features
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_
Schizoaffective disorder
baseline psychosis
mood disorder secondary to psychosis
persistent depressive disorder (formerly known as dysthymic disorder)
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
SSRIs
citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline
first line for depression as well as anxiety
work in 3-4 weeks
SNRIs
desvenlafaxine, duloxetine, milnacipran (fibromyalgia only), venlafaxine
Atypical antidepressants
buproprion, mitrazapine, nefazodone, trazodone
TCAs
amitriptyline, doxepin, imipramine, nortriptyline
MAOIs
phenelzine, tranylcypromine
side effects of SSRIs
sexual dysfunction insomnia/agitation weight gain risk of suicidal ideation risk of serotonin syndrome
Serotonin syndrome
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
Which drugs increase the risk of serotonin syndrome
SSRIs SNRIs MAOIs TCAs St. John's wort Tryptophan Triptans Linezolid Levodopa Stimulants (cocaine, ecstasy- MDMA, amphetamines)
How do we treat serotonin syndrome?
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
side effects of SNRIs
sexual dysfunction insomnia/agitation nausea dizziness hypertension (venlafaxine) risk of serotonin syndrome
norepinephrine dopamine reuptake inhibitor (NDRI)
buproprion
blocks presynaptic reuptake of NE and DA
use this to treat fatigue and hypersomnia, but not anxiety
also indicated for smokine cessation
NDRI (buproprion) side effects
blocks pre-synaptic re-uptake of DA
insomnia, weight loss, lowers seizure threshold, contraindicated in anorexia, eating disorder, seizure disorder
no sexual dysfunction!
Alpha2 antagonist- mirtazapine
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
Serotonin modulators: trazadone, nefazodone, vilazodone
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
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
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
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
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
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)
TCA that can be used to treat bedwetting in children
imipramine
Bipolar I disorder
at least one manic episode
may or may not have MDD or hypomanic episodes
Bipolar II disorder
At least one hypomanic episode
At least one major depressive episode
Never had a manic episode
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
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
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
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)
How do we treat nephrogenic diabetes insipidus that results from lithium toxicity?
hydrochlorothiazide with amiloride
Ebstein anomaly
tricuspid leaflets displaced inferiorly
tricuspid regurgitation or stenosis
RV hypoplasia
+/- patent foramen ovale
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
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
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)
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
Specific phobias
marked fear out of proportion to the threat the situation poses, with avoidance of the feared exposure
exposure therapy- gradual desensitization
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
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
Benzodiazepines as anxiety meds
increase the frequency of opening of GABA- receptor chloride channels
frequent use may lead to tolerance, dependence, withdrawal seizures
agoraphobia
excessive fear of being outside the home alone, using public transporation, and being in a crowd
this isn’t a specific phobia
delusion
irrational belief that cannot be changed by proof or rational arguments
illusion
misinterpret a stimulus that is actually there
hallucinations
sensory perception in the absence of external stimulus
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
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)
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
Schizophrenia negative symptoms
flat affect social withdrawal avolition/apathy anhedonia poverty of speech
schizotypal personality disorder
odd thoughts/behavior/appearance
discomfort with interpersonal relationships
schizoid personality disorder
voluntary social isolation
schizoaffective disorder
psychosis with intermittent mood disorder
schizophrenia
psychosis that lasts at least 6 months
schizophreniform disorder
psychosis for less than 6 months
brief psychotic disorder
psychosis less than 1 month
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
What drugs cause psychosis?
hallucinogens (LSD, PCP) stimulants (cocaine, amphetamines) withdrawal from benzodiazepines, alcohol, barbiturates glucocorticoids anabolic steroids
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)
risk factors for PD
family history
advancing age
head trauma
MPTP metabolite, which destroys DA cells of substantia nigra
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
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)
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
Cluster A personality disorders
Weird- inability to develop meaningful social relationships, also without psychosis
paranoid
schizoid
schizotypal
Paranoid personality disorder
long-standing suspiciousness and general distrust of others, look for clues to validate distrust
Schizoid personality disorder
schizoids avoid
voluntary social withdrawal
limited emotional expressions
don’t smile, content with social isolation
schizotypal
dressed like a pickle
eccentric appearance, odd beliefs, magical thinking
interact with others awkwardly, visibly odd in their appearance
Cluster B personality disorders
wild, drama Antisocial Borderline Histrionic Narcissistic
Antisocial
disregard for rights of others, criminality
male>female
“conduct disorder” under age 18
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
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”
Narcissistic
excessively preoccupied with personal prestige, power, vanity
lack empathy
require excessive admiration
Cluster C disorders
very anxious and fearful
anxiety disorders
worried, cowardly, compulsive, clingy
Avoidant
Dependent
Obsessive- compulsive
Avoidant
hypersensitivity to rejection
socially inhibited, timid, feelings of inadequacy
want to relate to others but don’t know how
Dependent
psychologically dependent on other people
very low self esteem
submissive and clinging
excessive need to be taken care of
Obsessive- compulsive personality disorder
preoccupation with order
concerned with perfectionism and control
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
Alcohol intoxication
CNS depression, mood elevation, disinhibition, decreased anxiety and sedation, severe mental impairment, somnolence, respiratory depression
Alcohol withdrawal
agitation, anxiety, insomnia, tremor
Where does alcohol act on the brain
GABA receptor, similar to benzos
Treatment for alcohol intoxication
time, can be life-threatening
anxiety, tremor, agitation, tachycardia, severe withdrawal causes DT (2-3 days after cessation)
Delirium tremens (DT)
2-3 days after cessation of alcohol
nightmares, agitation, disorientation, visual/auditory hallucinations, fever, hypertension, diaphoresis, seizures, autonomic hyperactivity
how to treat alcohol withdrawal
benzodiazepines, preferably long-acting benzodiazepines
diazepam
lorazepam
chlordiazepoxide
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
Wernicke encephalopathy
confusion nystagmus ophthalmoplegia ataxia sluggish pupillary reflexes coma death if untreated
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
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
treatments for alcoholism recovery
alcoholics anonymous naltrexone disulfiram topiramate acomprosate
Benzodiazepine intoxication
CNS depression decreased anxiety disinhibition coma respiratory depression
Benzodiazepine withdrawal
agitation
anxiety
seizures
How do we treat Benzodiazepine overdose
flumazenil
5 stages of behavioral change
precontemplation
contemplation
preparation
precontemplation
patient in denial, doesn’t ackowledge that there is a problem
contemplation
thinking about change, though they aren’t ready for it yet
preparation
making concrete plans to change
action
implementing the plan
maintenance
the change had been made and they are ready to not go back to previous behaviors
Amphetamines
increase release of intracellular stores of catecholamines
cocaine
blocks reuptake of catecholamines (in the synaptic cleft)
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)
indications for amphetamines
ADHD
short- term weightloss
Amphetamine and cocaine withdrawal symptoms
depression
lethargy
weightgain
headache
Treat amphetamine intoxication
benzodiazepines
haloperidol
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
caffeine and nicotine intoxication
excitability restlessness diuresis (caffeine) premature atrial contractions premature ventricular contractions
caffeine and nicotine withdrawal symptoms
irritability
anxiety
craving
tiredness
Treating nicotine withdrawal
nicotine replacement
(patch, gum, lozenge)
buproprion
varenecline
hallucinogen intoxication
hallucinations delusions anxiety paranoia tachycardia pupillary dilation flashbacks (chronic use)
treat hallucinogen intoxication
remove patient from dangerous environment and place in a quiet dark room
antipsychotics (PO, IM)
Benzodiazepines for anxiety and agitation
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
marijuana withdrawal
irritability
insomnia
nausea
peak 4-8 hours, but still there for about a month
opioids (morphine, heroin, methadone)
CNS depression Euphoria n/v constipation pupillary constriction (miosis) seizures respiratory depression
Treat opioid intoxication with
naloxone
naltrexone
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)
PCP
belligerance impulsiveness agitation nystagmus (horizontal and vertical) homicidal ideation/ violence psychosis delirium
How to treat PCP intoxication
treatment: benzodiazepines, antipsychotics
PCP withdrawal
violence (again)
depression
anxiety
irritability
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
What is refeeding syndrome?
Sudden shift from fat metabolism to carbohydrate metabolism may cause-
hypophosphatemia hypokalemia hypomagnesemia CHF and arrhythmias Rhabdomyolysis Delirium Seizures
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
Binge- eating disorder
episodes of binge eating
no inappropriate compensatory behaviors
patients tend to be overweight/obese
treatment:
- cognitive behavioral therapy
- SSRIs, topirimate, stimulants
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
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)
Hoarding disorder
anxiety, distress associated with getting rid of stuff
diagnosis requires impaired social function
changes associated with bulimia?
hypochloremic metabolic alkalosis from vomiting
increased amylase from salivary gland inflammation
Trauma disorders
PTSD
Acute stress disorder
Adjustment disorder
PTSD diagnosis
- exposure to something traumatic
- Rexperiencing the traumatic event (memories, dreams, flashbacks)
- Avoidance of stimuli associated with the traumatic event
- Negative changes in cognition and mood
- Hyperarousal (irritable behavior, reckless behavior, hypervigilance, sleep disturbance)
These symptoms have to last at least 1 month
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
acute stress disorder versus PTSD
This is like PTSD but
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
Somatic symptom and related disorders
conversion
somatic symptom disorder
illness anxiety disorder
factitious disorder
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
How to treat conversion disorder
psychotherapy, CBT, physical therapy
find the root
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
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
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
Factitious disorder imposed on another (previously known as Munchausen by proxy)
child or elder abuse,
also in the absence of external gain
Malingering
not a mental disorder
external reward desired
overwhelming worry about contracting a serious illness, without any signs or symptoms
illness anxiety disorder
overwhelming worry about the seriousness of existing physical symptoms
somatic symptom disorder
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
ADHD treatment
- stimulants
methylphenidate
lisdexamfetamine
dextroamphetamine - atomoxetine (milder, but also helps with focusing behavior)
- Tricyclic antidepressants:
- imipramine
- desipramine
- nortriptyline - buproprion
- Clonidine alpha-2 agonist
- eliminate foods high in caffeine and sugar
Common complications of ADHD stimulant medications
- insomnia- sleep hygiene, take meds earlier, short duration formulation, clonidine at night
- appetite suppression and weightloss- administer meds after meals rather than before
- Tics- usually transient, choose low- moderate dose methylphenidate, which does not worsen tics
- psychosis- discontinue (no need to taper)
- decreased growth velocity (reassure parents that adult height is not affected. drug holidays can help with catch up growth.
Side effects of atomoxetine
- increased risk of suicidality- close observation and usually discontinuation
- liver injury (d/c without taper)
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)
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
