Psychiatry Flashcards
What is negative reinforcement?
You remove a stimulus to increase a behavior
What is dissociation? Give an example.
A drastic, temporary modification of identity / character to avoid emotional distress
-> feel numb and detached when thinking about abusive event
What is Fixation? How does it differ from Regression? Give an example
Part of your personality remains at a more childish level of development
i.e. A surgeon handles conflicts via throwing tantrums in the operating room
vs Regression where you previously developed the ability to maturely handle problems, but INVOLUNTARILY turn back the maturational clock to earlier modes of dealing with the world (i.e. a child starts bed-wetting after new stressor).
What is identification? Give an example?
Unconscious assumption of the characteristics, qualities or traits of another person or group. This happens when you internalize the qualities of someone as part of their identity, and you want to be like them.
I.e. a child who stays up late to be like his parents
What is Isolation of Affect? Example?
Separating feelings from ideas and events
-> i.e. describing murder in graphic detail with no emotional response, as if he was describing the weather
What is reaction formation vs sublimation?
Reaction formation -> doing the opposite of an unacceptable wish or impulse. I.e. going to a monastery when you feel like having sex, overcompensating but not being genuine. (unconscious)
Sublimation -> channeling those feelings into something positive / something that does not conflict with your value system -> i.e. former cocaine addict works for a substance abuse hotline to help others after he feels like smoking da crack (conscious)
How does suppression differ from repression and denial?
Suppression is conscious
Repression and denial are not conscious
Repression involves involuntarily holding a feeling from consciousness / awarenss
Suppression is saving that feeling until you are ready to deal with it -> Voluntary
What are the longterm effects of infant stimulus depression? How long do they have to be deprived for irreversible changes?
Effects of deprivation longterm:
- Anaclitic depression - Children become susceptible to physical illness and are depressed when separated from primary caregiver
- Social / emotional deficits - poor socialization / language / trust in others
- Physical effects - failure to thrive, even death
> 6 months = irreversible changes
What is reactive attachment disorder?
Infant withdrawn / unresponsive to comfort following attachment difficulties.
Who is the normal abuser in the case of physical abuse? Where will hemorrhages / hematomas typically occur?
Usually the biological MOTHER
Subdural hematomas
Retinal hemorrhages
What is the peak incidence of sexual abuse of a child?
Age 9-12 years old
What is vulnerable child syndrome? What will result
When parents perceive the child as especially susceptible to illness / injury, usually following a serious illness or life-threatening event of child
-> can result in missed school or overuse of medical services
What are the two subtypes of ADHD and when must they be present before to make a diagnosis?
Inattentive subtype
Hyperactive / impulsive subtype
Must be present before age 12
What are first line and second line pharmacotherapies for ADHD?
First line: Stimulants - Methylphenidate and dextroamphetamine
Second line: Alpha-2 agonists - Guanfacine, Clonidine
NRI - Atomoxetine
Is oppositional behavior normal in development?
Yes, it normally peaks around age 2 (the terrible two’s)
What are the two kinds of disruptive behavior disorders (DBD)?
- Oppositional defiant disorder (ODD)
2. Conduct disorder (CD)
When does ODD start, and what do many children go on to develop?
Usually before age 8, many children will develop conduct disorder later in life
When is conduct disorder (CD) diagnosed and what is it generally?
Repetitive & persistent pattern of behavior in which basic rights of others or major age-appropriate societal norms / rules are violated
Diagnosed until 18, or after age 18 if criteria for antisocial personality disorder are not met
Do most CD adolescents develop into antisocial personality disorder? How are they related?
No, but a diagnosis of conduct disorder between age 15 is required for ASPD diagnosis
What are the three evidence-based psychosocial treatments for CD and which one shows a long-term reduction in arrest / incarceration?
- Parent Management Training
- Probleming-Solving Skills Training
(First two are same as ODD) - Multisystemic Therapy (MST) -> leads to a reduction in re-arrest. Includes involvement of school, home, justice system, etc.
There is NO indication for pharmacotherapy!!!!
When is autism typically diagnosed, and is it more common in boys or girls?
Typically diagnosed around age 4, more common in boys
-> symptoms typically noticed by 2nd year of life
Symptoms may not precipitate until the social demands exceed their capacities, or may be masked by coping techniques
What are the diagnostic features of ASD?
- Poor social interactions, social communication deficits
2. Repetitive / ritualized behaviors, and restricted interests.
How is head size associated with autism?
Macrocephaly is associated with autism (enlarged head)
What causes Rett syndrome and who gets it?
X-linked dominant MECP2 gene mutation -> homozygous lethal in males
MeCP2 gene = Methyl Cytosine-binding Protein 2 -> needed for brain development
-> cases are usually de novo, but some are rarely asymptomatic (not penetrant)
Seen in females only
What are the diagnostic features of Rett syndrome?
Encephalopathy beginning between 6 months and 2 years (normal development early)
Loss of purposeful hand movements, with stereotypic hand-wringing, ataxia, head circumference growth deceleration, loss of language skills
What are the DSM criteria of separation anxiety disorder (SAD)?
Inappropriate, excessive anxiety concerning separation from attachment figures (i.e. Meghan), lasting for >4 weeks.
Distress from separation, worry about attachment figure, refusal or fear to leave home or be alone, refusal to sleep away from home or without attachment figure. Nightmares w/separation themes common.
When does SAD usually start / originally develop?
Starts after a life stress, usually ages 7-9 years.
What are the criteria for Tourette’s Disorder (TS)? How long must the tics be present????
- 2+ motor AND 1+ vocal tics present during illness, but not necessarily at same time
- Tics must persist for greater than 1 year since onset (though the tics can change during this time)
- Must occur before age 18 (usually around age 11)
What conditions are most commonly comorbid with Tourette’s disorder?
OCD & ADHD are most commonly comorbid
What is the typical progression of tic disorders?
Simple, transient motor tics arise around age 4-6
Rostrocaudal progression of tics
Phonic tics appear ages 8-15 (does not happen in all, but if you have a phonic tic you most likely have a motor tic)
Tics severity peaks age 10-12
Waxing / waning is normal
How are tics differentiated from stereotypies?
Stereotypies - will have onset earlier than tics (before 3 years), and tend to increase when excited. Usually a feature of autism.
What is the best psychotherapy for tic disorders?
Habit Reversal Training (HRT)
-> Teaches awareness of tic, and “competing response practice” -> channel the urge into a less functionally impairing tic which cannot be seen
When is pharmacotherapy used for tic disorders and what drugs should be avoided?
Used when there is a significant impairment due to the tic, i.e. they are being bullied, or they dislocated their shoulder from the movement
Avoid stimulants like methylphenidate when treating co-morbid ADHD, which can exacerbate the tic disorder by increasing dopamine levels
What are three classes of drugs used in treatment of tic disorders?
- Alpha-2 receptor agonists - first line (clonidine, guanfacine)
- D2 receptor antagonists - neuroleptic drugs like haloperidol pimozide (typical antipsychotics mostly, since you want to inhibit the basal ganglia)
- Tetrabenazine - a VMAT2 inhibitor used for Tardive dyskinesia, Huntington’s disease, etc -> prevents basal ganglia excitation (do NOT confuse with trihexyphenidyl + benztropine)
What are the pharmacotherapies available for enuresis if there is a major functional impairment? Major risks?
Imipramine - tricyclic with anticholinergic properties, cardiac arrhythmia is a concern
DDAVP - desmopressin - reduces urine production, may lead to hyponatremia and seizure due to water intoxication
What disorder is characterized by severe and recurrent temper outbursts out of proportion to situation, being angry and irritable between outbursts? Typical treatment?
Dysruptive Mood Dysregulation Disorder (DMDD) - think Sam Yurgil
Psychostimulants - remove impulsivity
Antipsychotics - i.e. risperidone
What is PANDAS?
Abrupt onset of OCD in children following Streptococcus infection (Group A Strep)
-> analogous to Syndenham’s chorea, due to autoimmune condition
What is the order of loss of the three components of orientation?
Time, place, then person
How do you tell dissociative amnesia apart from other amnesias?
Dissociative amnesia is related to inability to recall important personal information in DISTANT memory (violates Ribot’s low) usually subsequent to severe trauma.
Patient can form new memories but doesn’t remember their past at all, very atypical. In retrograde amnesia you typically still remember things which happened a long time ago, just not more recent things which have not yet converted into longterm memory.
What is depersonalization vs derealization?
Depersonalization - sense of being outside observer of self
Derealization - subjective sense of detachment or unreality of surroundings / outside world
What is depersonalization/derealization disorder vs dissociative identity disorder?
Depersonalization/derealization - Just an alteration in subjective feeling, subject knows they are not truly detached. Does not require trauma.
-> can be a feature of PTSD / Borderline personality disorder, and thus cannot be diagnosed if better explained by these disorders.
Dissociative identity disorder - Multiple personality disorder, more common in women following a major trauma.
Is a visual or an auditory hallucination more likely to be present as part of a medical illness?
Visual hallucinations, especially human-like figures, but can be lights / shapes
Auditory hallucinations are more likely part of a psychiatric illness (i.e. Schizophrenia)
What does an EEG generally show for delirium?
Moderate to severe background slowing
What is the treatment of delirium typically based around? What is the only time benzodiazepines should be used in the treatment of delirium?
Removal of precipitating stimulus, i.e. infection / drug (i.e. anticholinergics)
May use antipsychotics like haloperidol if severe.
Benzos should only be used in delirium secondary to benzodiazepine / alcohol withdrawal
What vitamin deficiencies and endocrine deficiencies can present as dementia?
Vitamins -
B1 - (Wernicke-Korsakoff)
B3 - Pellagra (Diarrhea, dermatitis, dementia)
B12 - Subacute combined degeneration
Endocrine -
Hypothyroidism
Note: Depression may also present as pseudodementia
What is dementia now called in the DSM 5, and what are its diagnostic criteria?
Major Neurocognitive Disorder
Significant decline in 1+ cognitive domains, as assessed by clinical assessment. They interfere with daily life and do not occur exclusively in delirium or as a part of another psych disorder.
What are the major cognitive domains?
- Complex attention
- Executive function
- Learning and memory
- Language
- Perceptual-motor
- Social cognition
What are the features of “psychotic” behavior?
Delusions
Hallucinations
Disorganized speech
Disorganized and catatonic behavior
What is meant by disorganized speech?
Any change in thought process from tangential thinking, to loose associations, to total incoherence
What is flight of ideas vs loose associations?
Flight of ideas - Rapid speech about one idea to the next, but generally the listener is able to follow the thought process because the thoughts are loosely connected
Loose associations - NO associations - flow of thoughts in a completely unrelated manner, listener cannot follow. Speech may even be incoherent.
A speaker has no goal-directed associations and never gets to the desired end point when asked a question. How do you describe their speech?
Tangential
Define hallucination. How does this differ from illusion?
False sensory perception not associated with real external stimuli.
Illusion -> real external stimuli prompt a false sensory perception (thought you saw something you didn’t).
What are the names for normal sensory hallucinations which happen when falling asleep or waking up?
Falling asleep - Hypnagogic
Waking up - Hypnopompic (hopping out of bed)
What is meant by disorganized behavior?
Age inappropriate silliness, agitation, bizarre appearance, catatonia, inappropriate social behavior & outbursts of emotion
What is meant by catatonic behavior?
Decrease in reactivity Includes (possibly): 1. Negativism - resistance to instruction or doing the exact opposite 2. Rigid / bizarre posture (catalepsy) 3. Mutism 4. Lack of motor response - stupor 5. Stereotypes like grimacing, staring 6. Echolalia/Echopraxia 7. Purposeless or excessive motor activity - catatonic excitement
What symptoms are thought to be most debilitating in schizophrenia? Describe them
Negative symptoms - more difficult to treat
Includes negative clarity and tone of speech (affect flattening), emotional expression (alogia, failure to elaborate), and motivation (avolition)
Problems with social interactions (asociality), slowed movements
What are the A criteria for Schizophrenia?
Presence of 2+:
Hallucinations Delusions Disorganized speech Disorganized or catatonic behavior Negative Symptoms
At least 1 of the 2 has to come from first three (the first four are positive symptoms).
What is the remaining criteria for Schizophrenia?
Must have a decreased functioning in some aspect of life, and symptoms persist for at least 6 months which are at least prodromal, residual, attenuated, or negative symptoms of Criterion A.
What brain changes / neurological process is thought to underlie schizophrenia?
Process of errant and excessive synaptic pruning during adolescence and early adulthood may underlie brain volume decrease (causes ventriculomegaly) and prodromal impairments in emotional, cognitive, and motor function
read: DECREASED dendritic branching / synapses leads to brain atrophy and hydrocephalus ex vacuo
By what mechanism are positive and negative symptoms in schizophrenia thought to be controlled?
Mesocortical pathway (ventral tegmental area/VTA to prefrontal cortex) is thought to lead to cognitive and negative symptoms, and this is due to a decrease in dopamine.
Increased dopamine to mesolimbic pathway (VTA to NAcc) leads to positive symptoms
Why do men have a worse prognosis in schizophrenia than women?
Earlier onset (teens in men vs 20s in women)
Worse premorbid function with more cognitive impairment
Tend to have more prominent negative symptoms
Tends to not be an underlying mood disorder in men, which are easier treated
What is Schizoaffective Disorder? (Diagnostic criteria)
- Period of major depressive or manic episode
AND - Criteria A for Schizophrenia (full)
AND - 2+ week period of delusions / hallucinations in absence of major mood symptoms has occurred
What is it called if you have Schizophrenia symptoms for less than 6 months?
<1 month = Brief Psychotic Disorder
1-6 months = Schizophreniform disorder
What predisposes you to Brief Psychotic Disorder, and is it dangerous? What usually precipitates it?
Personality disorders
- > occurs in late teens and early twenties
- > very dangerous due to labile affect and high risk of suicide in this short period (psychosis)
Usually precipitated by a stressful event, and often postpartum.
What is Delusional Disorder?
Presence of delusions for >1 month in ABSENCE of otherwise bizarre behavior and functional deficits.
Hallucinations may present if in accordance to delusions
What are the diagnostic criteria for a manic episode? Include time scale.
At least 1 week of:
Distinct period of abnormally / persistently elevated or irritable mood
AND
Persistently increased goal-directed activity or energy
PLUS 3+ of:
DIGFAST Distractibility Indiscretion / Irresponsibility - excessive pleasurable activities Grandiosity - inflated self esteem Flight of ideas / racing thoughts Activity increase Sleep deficit only (decreased need for sleep) Talkativeness
How does a hypomanic episode differ from a manic episode?
Identical to manic episode except:
- Lasts at least 4 days (instead of one week)
- Less significant impairment in functioning -> just noticeable and uncharacteristic change
- NO associated psychotic symptoms
Who does BPAD 1 vs BPAD 2 preferentially affect?
BPAD 1 = equal prevalence in men and women
BPAD 2 = more women than men (remember, that’s because depression affects women more than men), typically slightly later onset
What is the diagnostic criteria for cyclothymia?
It’s literally the BPD equivalent of Persistent Depressive Disorder (dysthymia)
> 2 years, not >2 months without symptoms, hypomania and depressive symptoms which do not meet criteria for MDE (major depressive episode)
What is the diagnostic criteria for major depressive disorder? Include amount of time and number of symptoms? READ ALL OF THESE
5 or more of the following symptoms over greater than 2 weeks (twice as long as manic episode):
At least one must be: Depressed mood or loss of Interest / pleasure (anhedonia) increased or decreased
Guilt -> feeling excessively guilty or worthless
Energy -> decreased energy
Concentration -> impairment of concentration / decisionmaking
Appetite -> increased or decreased
Psychomotor retardation -> moving robotically or slowly, agitated in rare instances
Suicidality -> recurrent thoughts or attempted
What sleep abnormalities are present in MDD?
Increased sleep latency
Decreased REM latency and greater proportion of REM sleep
Repeated nighttime awakenings and terminal insomnia
What is dysthymia now called and what are its diagnostic criteria? What is the time table?
Persistent depressive disorder (PDD) Depressed mood and 2+ of HCASES H: Hopelessness C: Concentration decrease A: Appetite change S: Sleep change E: Energy decrease S: Self esteem reduction
Must be for MOST days x2 years, never without symptoms for >2 months
Not enough symptoms for MDD
What are the diagnostic criteria for atypical features in depression? Is this common?
MDE only: High mood reactivity Significant weight gain / increase of appetite with hypersomnia Leaden paralysis - feeling stiff / heavy Oversensitivity to rejection
It is the most common subtype of depression, treated monoamine oxidase inhibitors are known to be effective (2nd line).
When do postpartum mood disturbances onset? What is the least severe form and treatment?
Within 4 weeks of delivery
Lead severe form: Maternal “blues” - up to 85% of women
-> depressed affect and tearfulness starting a couple days after delivery, usually resolves within 2 weeks
Treatment is supportive only, but monitor for depression
What is the diagnostic criteria for post-partum depression? Treatment?
Includes depression / anxiety, but must last for >2 weeks (like MDE)
-> Treatment = SSRIs + CBT
What is the treatment for postpartum psychosis? What is a hallmark feature of the disease?
Psychosis + thoughts of harming baby or self, risk of infanticide
Treatment - Hospitalization with ATYPICAL antipsychotics, ECT if refractory
What are the five stages of grief?
- Denial
- Anger
- Bargaining
- Despair / Depression - give up bargaining and begin to despair
- Acceptance
Are hallucinations of the decreased speaking common in grief? What is the upper limit of normal for getting over grief?
Yes, it is common to have simple hallucinations like that
<6 months is normal. Can become pathologically persistent -> depressive episode
What are the diagnostic criteria groups for panic disorder?
- Recurrent panic attacks
or - At least 1 month of persistent concern of having another panic attack, causing behavioral change
How long must specific phobias / GAD be present for diagnosis? Give an example of a specific phobia involving public places.
> 6 months
Specific phobia example: Agoraphobia - Fear of public spaces where escape might be difficult or help unavailable
What is systemic desensitization vs graded exposure?
Graded exposure - Real life
Systemic desensitization - Carried out by a therapist
What is Flooding vs Implosion?
Flooding - real life
Implosion - Carried out by a therapist
What are the criteria for an adjustment disorder?
Emotional or behavioral symptoms in response to a stress occurring within 3 months of a stressor, which will not persist for more than 6 months after stress is removed. (>6 = generalized anxiety disorder)
Features for another psychiatric diagnosis are not present (i.e. depression)
What is the very basic definition of obsessive compulsive order (criteria)?
Presence of obsessions, compulsions, or both which are time consuming or cause significant stress / impairment in function
There are varying degrees of insight that people have. It is possible for it to be absent completely though (despite what first aid might say).
What drugs are used to treat OCD? Which TCA?
Serotonergic agents
i.e. SSRIs, and clomipramine in particular (most serotonergic of the TCAs).
How long must ADHD and oppositional defiant disorder be present for diagnosis?
> 6 months
How long must PTSD last for diagnosis? Why does this make sense?
> 1 month
It is very similar to panic disorder (avoidance of triggering stimuli), which requires >1 month for diagnosis
What are the four core features of PTSD?
PTSD is HARD
1. Hyperarousal symptoms -> exaggerated startle, irritable behavioral, sleep problems
- Avoidance behavior -> avoidance of triggers
- intrusive Rexperiencing > i.e. memories, nightmares, physiologic response
- negative mood / Distressful cognitions -> includes forgetting important aspects / distorted cognitions
What are the first line treatments for anxiety disorders in general?
SSRIs, venlafaxine (SNRI)
Those associated with acute panic episodes: benzodiazepines
How does acute distress disorder differ from PTSD? What is the treatment?
Acute stress disorder is from 3 days to 1 month after trauma, although it has the same symptoms
-> becomes PTSD after 1 month
-> basically the brief psychotic disorder of PTSD
No pharmacotherapy is indicated, just CBT
What is the difference between a personality trait and disorder?
Trait - Longstanding pattern of perceiving, relating to, and thinking about the world
Disorder - When these personal traits and behavior patterns are inflexible and maladaptive, so that they cause impairment
What are the three clusters of personality disorders?
Cluster A - Weird
Cluster B - Wild
Cluster C - Worried
What is the mnemonic for Cluster A disorders?
Cluster A - Weird - Three A’s
Accusatory - Paranoid
Aloof - Schizoid
Awkward - Schizotypal
What is the mnemonic for Cluster B disorders?
Cluster B - Wild - Four B’s
Bad - Antisocial Borderline - Borderline flamBoyant - Histrionic and the Best - Narcissitic
What is the mnemonic for Cluster C disorders?
Cluster C - Worried - 3 C’s
Cowardly - Avoidant
Obsessive-Compulsive
Clingy - Dependent
What are the common features of paranoid personality disorder? Common defense mechanism?
Person has a pervasive distrust and suspiciousness of others, interpreting motives as malevolent
-> without basis or justification
Commonly use projection
What characterizes the Schizoid personality disorder? How does it differ from Avoidant?
Detachment from social relationships and restricted range of expression of emotions in an interpersonal setting (emotions)
-> In schizoid, they actually just don’t want these relationships at all
Avoidant is just a lot like atypical depression (hypersensitivity to rejection)
What characterizes obsessive-compulsive personality disorder? What is meant when we say they are ego-syntonic?
Preoccupation with orderliness, perfectionism, and mental / interpersonal control which is at the expense of flexibility, openness, and efficiency
Ego-syntonic - they have poor inside, and their behavior is consistent with their beliefs / attitudes
What characterizes Schizotypal personal disorder?
Awkward -
Basically Schizoid personality disorder + cognitive / perceptual distortions and eccentricities of behavior
- > difference is, this person will want normal relationships a little more but feel uncomfortable with close relationships (excessive social anxiety)
- > strange thinking / paranoia, odd behavior / appearance, lack of close friends or confidants
What characterizes histrionic personality disorder?
FlamBoyant
- > excessive emotionality / attention seeking, patient is uncomfortable when not the center of attention, often seductive / provocative.
- > speech will lack detail and be impressionistic, exaggerated emotional expression, easily influenced by others and relationships are interpreted as more intimate than they actually are
How should doctors manage patients with antisocial personality disorder?
Expect to feel manipulated, and know that the patient may feign physical symptoms. Set firm limits with no nonsense, but do not try to punish them
How should you manage a patient with dependent personality disorder?
Schedule more frequent, brief appointments, recognizing the patient gains from your attention.
Set firm limits and watch for your own burnout, and realize that they may be overly-eager to accept treatment and this makes them susceptible
(similar to the treatment of somatic symptom disorders)
How should you manage a patient with obsessive-compulsive personality disorder? What type of physician treats them best?
Recognize the patient doesn’t like being sick -> loss of control
Treated best by a “scientific” physician -> detailed explanations and includes patients in decision making
Even more than narcissistic, give patient control in treatment as much as possible
What is the differenence between Malingering, factitious, and somatic symptom disorders?
Malingering - Conscious, done for external gain
Factitious - Conscious, done for internal gain (assumption of sick role)
Somatic symptom - Unconscious, not intentionally produced or feigned
What are the four somatic diagnoses when the patient will unconsciously produce their symptoms?
- Somatic symptom - preoccupation with having symptoms
- Illness anxiety - preoccupation with having disease (symptoms are minimal)
- Conversion - symptoms appear neurologic
- Pseudocyesis - thinks she is pregnant when not
What is Conversion Disorder also known as? What is it?
Also known as Functional Neurological Symptom Disorder
-> patients present with symptoms which appear neurological but without a medical cause
i.e. “Functional Amblyopia”
What typically precedes the development of a conversion disorder?
A precipitating conflict or stressor -> i.e. they saw a horrible mass shooting so they go physically blind
What is “La belle indifference”?
A symptom associated with conversion disorder, whereby the patient is inappropriately cavalier given how serious their conversion symptoms are.
“Aww im blind now, nbd it happens”
What does a good psychiatrist recommend to a PCP regarding somatic symptoms disorder in future visits?
Discuss the chronic course, low morbidity / mortality
-> explain that their symptoms are not caused by a serious disease, but do not confront them
Recommend regular appointments with a focus physical exam based on their complaints
-> reduce healthcare costs
Keep medications and procedures to a minimum unless there’s a clear indication
What is it called when your factitious disorder is predominantly physical symptoms?
Munchausen Syndrome
(vs there are other subtypes of Factitious disorder where you present with only psychological symptoms to assume the sick role)
What personality disorders are associated with anorexia nervosa? Bulimia?
Avoidant & Obsessive-Compulsive Personality Disorder
Anorexia is an OCD-related condition.
Bulimia is associated with Borderline PD.
What is the most common cause of death in eating disorders?
Cardiac arrhythmias due to electrolyte imbalance
What is a common bone finding in anorexia?
Osteoporosis - can lead to metatarsal stress fractures
What are Lanugo and Russell sign?
Lanugo - fine, babylike hair which typically occurs in anorexia
Russell sign - callouses on dorsal hand due to self-induced vomiting (purging-type anorexia, or bulimia)
What metabolic effects are seen from vomiting in bulimia and purging-type anorexia?
Hypokalemic, hypochloremic alkalosis
- > increased HCl excretion in vomit leads to increased bicarbonate uptake in the kidney to compensate for loss of Cl-
- > less H+ is able to be exchanged for K+, so not as much K+ can be reabsorbed
What is the initial treatment for AN and what should be avoided?
Gradual weight restoration -> try to return to normal weight before discharge
+
Cyproheptadine - antihistamine (sedation, weight gain) and anti-5HT (also used in the treatment of serotonin syndrome) to increase appetite
Avoid:
Refeeding syndrome - increased insulin upon introduction of carbohydrates in feeding leads to hypophosphatemia (glucose-6-phosphate formation) and cardiac arrhythmias. GO SLOWLY
Also avoid SSRIs - until weight is restored (remember we are trying to block serotonin with cyproheptidine. Sketchy actually says you shouldn’t use them at all)
What are the diagnostic criteria for bulimia nervosa?
- Recurrent binge eating with lack of self control
- Recurrent inappropriate compensatory behavior
- > could be vomiting, but often only laxatives, enemas, diuretics, meds, or even excessive exercise - Behavior must average at least 1x per week for 3 months
- Negative self-evaluation on body shape / weight gain
How is management of bulimia nervosa different than anorexia nervosa?
- Most patients can be managed as outpatients rather than inpatients, with same emphasis on therapy and SSRI / antipsychotic use.
- Bulimia patients should NOT be given cyproheptadine since their appetite is normal (vs AN)
What is binge-eating disorder? Treatment?
Recurrent binge eating WITHOUT any compensatory behaviors
CBT, SSRIs, lisdexamfetamine (stimulant which reduces appetite)
What is transvestic disorder?
Sexual arousal (paraphilia) from cross-dressing
Specify with fetishism (as well) or autogynephilia (man aroused by thinking he is a woman)
What is Fetishistic Disorder?
Arousal from nonliving objects or a highly specific focus on non-genital parts (i.e. toe)
- > object must not be a sex toy
- > Fetish objects are not clothes
What physical illnesses are correlated with impairment of sexual functioning?
Erectile dysfunction - cardiovascular illness, diabetes mellitus, MS, spinal cord injury
Decreased libido - hypothyroidism
How does cataplexy manifest in narcolepsy?
- Bilateral loss of muscle tone with maintained consciousness which is precipitated by laughing
- Jaw-opening episodes with tongue trusting or global hypotonia (spontaneous grimaces without any emotional triggers)
What are two important lab findings in Narcolepsy?**
- Hypocretin deficiency - orexin-1 is less than 110 pg/mL in CSF
- > disease is caused by decreased orexin production in lateral hypothalamus - REM sleep latency in less than 15 minutes (normal is 90 min)
What are the pharmacological treatments for narcolepsy? Behavioral?
Stimulants (methylphenidate, amphetamines, modafinil (sleep mode)) to control daytime sleepiness
Anticataplexy drugs -> sodium oxybate - (GHB, literally precursor to GABA)
Use many scheduled / planned naps
Will patients with narcolepsy feel rest after naps?
Yes - this is in contrast to hypersomnolence disorder when they will feel very tired
What are the 11 behavioral criteria for any substance use disorder in the DSM?
- More excessive use than intended
- Persistent desire to control use
- Lots of time dedicated to finding, taking, and recovering from the drug
- Craving drug
- Failure to meet obligations of life
- Recurrent social / interpersonal problems because of drug
- Activities are given up / reduced for drug
- Use of alcohol where it is hazardous (i.e. DUI)
- Continued use despite knowledge that it is causing problems
- Tolerance
- Withdrawal
What are the 6 stages to change?
- Precontemplation - Not yet acknowledging problem
- Contemplation - Acknowledging problem, but not yet ready to change
- Preparation - getting read to change behaviors
- Action / willpower - acutely changing behaviors
- Maintenance - chronically changing behvaiors
- Relapse - hopefully doesn’t happen
What is the rough timeline of withdrawal symptoms for alcohol?
6 hours - tremor
8 - 12 hours - visual hallucinations
12-24 hours - seizures
72 hours - delirium tremens (preventable)
What is Delirium tremens / its symptoms?
Delirium (confusion, disorientation) + physical symptoms of alcohol withdrawal.
Can be fatal due to cardiovascular collapse and hypothermia
(autonomic instability)
What liver enzymes suggest alcoholic liver damage vs viral hepatitis?
Elevated AST > ALT, ratio of AST:ALT is increased.
Also, elevated GGT levels
- > this makes sense because y-glutamyltransferase is a marker for ductal damage, and impairs ductal secretions
- > this is why alcohol can cause pancreatitis
What are the symptoms of Wernicke’s encephalopathy? Is it reversible? What is the main symptom of Korsakoff’s dementia?
Yes - reversible with vitamin B1
ACO Ataxia Confusion Ophthalmoplegia (lateral gaze paralysis) Vestibular dysfunction
Korsakoff’s - Anterograde amnesia compensated w/confabulation
What are the common behavioral effects of cannabis?
Decreased goal-directed mental activity, relaxation, slowed sense of time, heightened sensitivity to external stimuli (smell, sound, taste), anterograde amnesia, increased appetite
What can cannabis do to the lungs, to the psyche, and to the reproductive system?
Lungs - decreased lung capacity and increased infection risk
Psyche - Increased risk for anxiety / depression, worse mood disorders. Also increases risk for Schizophrenia.
Reproductive system - Decreased testosterone / gynecomastia. Reduced fertility
What are three definitive uses for medical marijuana?
- Anti-emetic
- Appetite stimulant
- Glaucoma - decreased IOP
What is the clinical presentation of opiate withdrawal?
Diaphoresis, diarrhea, lacrimation, vomiting, rhinorrhea
“leaking from every orifice”
-> also tachycardia and YAWNING
How does death typically occur in cocaine overdose?
Constricted blood vessels + increased heart rate -> seizure, heart attack, arrhythmias, and stroke.
Paranoia + aggressive behavior can lead to fights.
Worst effects occur when taken with alcohol.
How does longterm cocaine use affect sexual functioning?
Depletion of dopamine in brain -> increased prolactin levels -> infertility
What are two quite diagnostic physical changes for amphetamine overuse (i.e. methamphetamine or other sympathomimetics)
- Bruxism - teeth grinding
- > also seen in MDMA (ecstasy) intoxication, which is also a stimulant (+ hallucinogen) - Weight loss (appetite suppressant)
-> otherwise it looks just like cocaine use
What is one shared feature that cocaine and meth “speed” have in terms of withdrawal symptoms at night?
Cocaine - coke dreams
Meth - speed dreams
These are both really terrible nightmares.
How can an LSD trip be told apart from an acute psychotic episode?
Absence of auditory hallucinations in LSD (visual only)
What are the primary receptors affected via hallucinogens?
Serotonergic (i.e. LSD, MDMA) and NMDA (i.e. Phencyclidine - NMDA antagonism)
What is the mechanism of action of MDMA?
Amphetamine analog -> stimulant properties, but also mild hallucinogenic properties by acting on serotonergic receptors
How do kids these days typically deal with the negative effects of MDMA use?
- Pacifier - can cause bruxism (similar MoA as methamphetamine)
- Water bottles - can cause diaphoresis and increased thirst, but you this is actually BAD because MDMA is a cause of SIADH -> life-threatening hyponatremia
What is the most common cause of death in phencyclidine use? Treatment for overdose?
Remember these patients will always have violence, impulsitivity, vertical nystagmus, psychosis, and delirium
Trauma -> due to getting into violent fights, is what kills them
Give them benzos and rapid-acting antipsychotics (i.e. haloperidol).
What is the mechanism of action of Acamprosate? What is it used to treat?
Second line drug behind naltrexone for treatment of alcohol use disorder
Mechanism: NMDA antagonist, GABA-A agonist - “normalizes neurotransmitter systems”
Give a symptom of delirium tremens other than autonomic instability. What condition should you differentiate this from?
Peak 2-3 days after last drink
Respiratory alkalosis - due to hyperventilation
Differentiate this from alcoholic hallucinosis, which happens earlier (12 hr - 2 days), and mainly presents with visual > auditory hallucinations, with a much better prognosis.
