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Emergency Medicine EOR > Psychiatry and Behavioral Medicine > Flashcards

Psychiatry and Behavioral Medicine Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

What is generalized anxiety disorder?

A

involves persistent and excessive worry pertaining to multiple events or domains that continues for 6 months or more

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2
Q

What is the tx for generalized anxiety disorder?

A
  • SSRIs: paroxetine and escitalopram; SNRIs: venlafaxine
  • Buspirone is also effective; the starting dose is 5 mg PO bid or tid, however, buspirone can take at least 2 weeks before it begins to help
  • benzodiazepines (short-term use); beta-blockers
  • psychotherapy
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3
Q

What is panic disorder?

A

characterized by recurrent unexpected panic attacks with at least a month or more of worry or avoidant behavior

  • panic disorder can occur with or without agoraphobia
  • symptoms develop abruptly and reach a peak within 10 minutes
  • palpitations, chest pain, sweating, SOB, etc.
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4
Q

What is the tx for panic disorder?

A
  • SSRIs: paroxetine, sertraline, fluoxetine
  • benzodiazepines: for acute attacks (watch for abuse)
  • CBT (relaxation, desensitization, examining behavior consequences)
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5
Q

What is phobias?

A

same as panic disorder - symptoms begin 10-15 minutes prior to stress event except in this case it is a specific stress event (i.e flying, blood, social situations, spiders etc.)

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6
Q

What is the tx for phobias?

A
  • exposure therapy (first line), teach to relax and try to understand/overcome the fear
  • SSRI + CBT
  • benzodiazepines (i.e prior to flying)
  • treat agoraphobia just as GAD with SSRIs and CBT
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7
Q

What is bipolar I disorder?

A

history of more mania than depression

-severe mood disorder with mania episodes alternating with depression; psychosis during manic episodes

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8
Q

What is bipolar II disorder?

A

history of more depression than mania

-low-level mania with profound depression; no psychosis

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9
Q

What is cyclothymic disorder?

A

alternating hypomanic episodes with a long-standing low mood state (dysthymia) for at least two years

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10
Q

What is bipolar I disorder?

A

patient who is squandering savings, destroying relationships, neglecting work activities, etc.

  • a manic episode with or without major depressive episodes
  • by the DSM, mania is described as a mood disturbance sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features
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11
Q

What is the tx of bipolar I disorder?

A

lithium is considered a first-line medication for bipolar disorder and has been more widely studied than any other maintenance treatment for bipolar disorder and is consistently supported across multiple randomized trials

  • acute mania - lithium, valproate, SGAs (olanzapine, aripiprazole), carbamazepine
  • mania maintenance - SGAs, gabapentin, lamotrigine (lamictal)
  • If agitation - add antipsychotics (haloperidol, risperidone) or benzodiazpiens
  • family/group/cognitive therapy
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12
Q

What is bipolar II disorder?

A

a patient with bouts of sadness and distractibility and an episode of decreased for sleep, a flight of ideas and buying sprees

  • at least one hypomanic episode and at least one major depressive episode
  • there has never been a manic episode
  • by DSM hypomania is described as a mood disturbance is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features
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13
Q

What is the treatment for bipolar II?

A

Lithium is considered a first-line medication for bipolar disorder and has been more widely studied than any other maintenance treatment for bipolar disorder and is consistently supported across multiple randomized trials

  • depressive episodes - SSRIs, quetiapine, or olanzapien + fluoxetine
  • MAOIs, TCAs - least likely used
  • family/group/cognitive therapy
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14
Q

What is cyclothymic disorder?

A

alternating hypomanic episodes with a long-standing low mood state (dysthymia)

  • a chronic mood disorder characterized by episodes of depression and hypomania for at least 2 years
  • this is a less intense but often longer-lasting version of bipolar disorder
  • a person with cyclothymia has both high and low mood, but never as severe as either mania or major depression
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15
Q

What is major depressive disorder?

A

a mood disorder in which a person experiences, in the absence of drugs or a medical condition, two or more weeks of significantly depressed moods, feelings of worthlessness, and diminished interest or pleasure in most activities

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16
Q

What is persistnet depressive disorder (dysthymia)?

A

mood disroder involving persistently depressed moods, with low self-esteem, withdrawal, pessimism, or despiar, present for at least 2 years, with no absence of symptoms for more than 2 months

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17
Q

What is premenstrual dysphoric disorder?

A

a disorder marked by repeasted episodes of significant depression and related symptoms during the week before menstruation

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18
Q

What is suicidal/homicidal behaviors?

A

mood disturbances, somatic omplaints, feeling hoplessness, worthlessness, helplessness

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19
Q

What is major depressive disorder?

A

5 or more SIEGECAPS for > 2 weeks nearly every day and at least one of the symptoms is depressed mood or anhedonia

  • SIGECAPS:
  • sadness
  • interest/anhedonia
  • guilt
  • energy
  • concentrration
  • appetite
  • psychomotor activity
  • suicidal
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20
Q

What is the tx for major depressive disorder?

A

SSRIS are the first line treatment

  • continue to increase dosage q3-4 wk until symptoms in remission
  • full medication effect is complete in 4-6 weeks, augmentation with 2nd medication may be necessary
  • see within 2-4 weeks of starting medication and 12wk until improvement, then monthly to monitor medication cahnges
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21
Q

What is persistent depressive disorder (dysthymia)?

A

a patient with chronic depression for two years or more

  • chronic depressions - depressive symptoms for >2 years
  • the individual has never been without the depressive symptoms in for more than 2 months at a time
  • there has never been a manic episode or a hypomanic episode
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22
Q

What is the tx for persistent depressive disorder?

A
  • SSRIs and other antidepressants
  • psychotherapy
  • physical exercise
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23
Q

What is premenstrual dysphoric disorder?

A

repeated episodes of significnt depression and related symptoms during the week before menstruation
-in the majority of menstrual cycles, at least five symptoms must be present in the final week before the onset of menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week post menses

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24
Q

What are the symptoms of premenstrual dysphoric disorder?

A

One (or more) of the following symptoms must be present:
-marked affective lability (e.g mood swings, feeling suddenly sad or tearful, or increased sensitivity to rejection)
-marked irritability or anger or increased interpersonal conflicts
-marked depressed mood, feelings of hopelessness, or self-deprecating thoughts
-marked anxiety, tension, and/or feelings of being keyed up or on edge
One (or more) of the following symptoms must additionally be present, to reach a total of five symptoms when combined with symptoms from above
-decrease interest in usual activities (work, school, friends, hobbies)
-subjective difficulty in concentration
-lethargy, easy fatigability, or marked lack of energy
-marked change in appetite; overeating or specific food cravings
-hyersomnia or insomnia
-a sense of being overwhelmed or out of control
-physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of “bloating” or weight gain

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25
Q

What is the tx for premenstrual dysphoric disorder?

A

SSRIs are first-line treatment (fluoxetine, sertraline, paroxetine, escitalopram) and can be used continuously or instituted the week prior to menses

  • birth control, low-estrogen, and diuretics may also be beneficial
  • SNRIs such as venlafaxine may also be effective in women with predominantly psychological symptoms
  • gondotropin-releasing hormone (GnRH) - SEs include accelerated bone loss and vasomotor symptoms
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26
Q

What is suicidal/homicidal behaviors?

A

suicide is the 8th leading cuase of death in the United States and the 3rd leading cause of death in ages 15-24 years

  • in all age groups, male deaths by suicide outnumber female deaths 4 to 1
  • women attempt suicid 2 to 3 times more often than men; among girls aged 15 to 19 yr, there may be 100 attempts to every 1 attempt among boys of the same age
  • on average, primary care physicians encounter >6 potentially suicidal people in their practice each year
  • about 77% of people who die by suicide were seen by a physician within 1 year before killings themselves, and about 32% had been under the care of a mental health care practitioner during the preceding year
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27
Q

What is the acess level of intent, level of lethality, and risk factors for suicide?

A
  • male gener
  • older
  • major depression
  • active substance abuse
  • serious medical problems
  • recent loss (e.g of employment, relationship, death of family members)

consider referral to emergency services
-crisis service, emergency department

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28
Q

What is delirium?

A

an acute cognitive dysfunction secondary to some underlying medical condition and is usually reversible

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29
Q

What are the characteristics of delirium?

A
  • acute and rapid deterioration in mental status (hours-days), a fluctuating level of awareness, disorientation
  • visual hallucinations are the most common type experienced by patients with delirium
  • high-risk after surgery especially in those with heart disease or diabetes
  • delirium, unlike dementia, is usually reversible
  • fall precautions - patient with delirium are six more times likely to fall
  • delirium is the most common presentation of altered mental status in the inpatient setting
  • alcohol abuse is the most common cause of delirium, specifically, delirium tremens
  • delirium is a side effect of acute hyperthyroidism known as thyroid storm
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30
Q

What is delirium vs. neurocognitive disorder (dementia)?

A

delirium is an acute, usually reversible syndrome caused by a medical condition versus neurocognitive disorder which is a long-term impaired memory disease process such as Alzheimer’s disease

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31
Q

What are the underlying organic cause of delirium?

A

UTI, pneumonia, metabolic changes, CVA, MI, TBI, medications (anticholinergics, benzodiazepines, opioids)

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32
Q

How is delirium dx?

A
  • mental status examination (MMSE)
  • labs (chemistry, B12/folate)
  • LP in a febrile, delirious patient (cerebral edema)
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33
Q

How is delirium tx?

A

treat the cause of delirium (almost always reversible) and provide supportive care, including sedation when necessary
-haloperidol for agitation/psychosis supportive

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34
Q

What is major/mild neurocogntiive disorders?

A

the previous edition of DSM-IV included a section entitled Delirium, dementia, and amnestic and other cognitive disorders which was revised in DSM-V to the broader neurocognitive disorders

  • neurocognitive disorders are described as those with a significant (major) or moderate (mild) impairment of cognition or memory that represents a marked deterioration from a previous level of function
  • the subsections include delirium and mild and major neurocognitive disorder (previously known as dementia)
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35
Q

What is major/mild neurocognitive disorders caused by?

A
  • Alzheimer’s disease
  • Frontotemporal lobar degeneration
  • Lewy body disease
  • Vascular disease
  • Traumatic brain injury
  • Substance/medication use
  • HIV infection
  • Prion disease
  • Parkinson’s disease
  • Huntington’s disease
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36
Q

How is major/mild neurocognitive disorders dx?

A

clinical - Mini-mental status examination or the Montreal cognitive assessment (MoCA)
-laboratory (TSH and B12) and imaging test (MRI or CT) are usually used to identify treatable causes

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37
Q

What is the tx for major/mild neurocogntive disorders?

A

supportive

-cholinesterase inhibitors can sometimes temporarily improve cognitive function

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38
Q

What is Alzheimer Disease?

A
  • progressive cognitive decline; most common older than age 65 years
  • loss of brain cells, beta-amyloid plaques, and neurofibrillary tangles
  • physical exam: abnormal clock drawing test
  • treatment: anti cholinesterase drugs (tacrine, donepezil)
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39
Q

What is Vascular disease?

A
  • multi-infarct
  • Treatment: blood pressure control
  • associated with arteriolosclerotic small vessel disease
  • usually correlated with a cerebrovascular event and/or cerebrovascular disease
  • stepwise deterioration with periods of clinical plateaus
  • may cause a sudden decline
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40
Q

What is frontotemporal lobar degeneration?

A

personality changes priced memory changes

-language difficulties, personality changes, and behavioral disturbances

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41
Q

What is Lewy Body disease?

A

parkinsonian symptoms

  • gradual, progressive decline in cognitive abilities
  • hallucinations and delusions, gait difficulties, and falls
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42
Q

What is substance/medications use dementia?

A

related to medication or non-prescription drug use

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43
Q

What is Creutzfeldt-Jakob disease (CJD)?

A

very rare, rapid onset

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44
Q

What is HIV infection?

A
  • cognitive decline associated with HIV infection
  • substantial memory deficits, impaired executive functioning, poor attention and concentration, mental slowing, and apathy
  • cerebral atrophy is typically evident in brain imaging
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45
Q

What is panic disorder?

A

an occurrence of three painc attack (sudden unexpected periods of intense fear or discomfort) episodes in three weeks

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46
Q

What are the characteristics of panic disorder?

A
  • at least one of the attacks has been followed by one month (or more) of one or both of the following:
  • persistent concern or worry about additional panic attacks or their consequences
  • a significant maladaptive change in behavior related to the attacks
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47
Q

What is the tx for panic disorder?

A
  • SSRIs: paroxetine, sertraline, fluoxetine
  • Benzodiazepines: for acute attacks (watch for abuse)
  • CBT (relaxation, desensitization, examining behavior consequences)
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48
Q

What is post-traumatic stress disorder?

A

the patient has experienced a traumatic event which causes an acute stress reaction
-once the symptoms persist past 1 month it is now considered post-traumatic stress disorder (PTSD)

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49
Q

What is the tx for post-traumatic stress disorder?

A

SSRIs are considered first-line along with cognitive behavioral therapy (CBT)

  • prazosin for nightmares
  • benzodiazepines, if used, should not be continued more than 2 weeks after a traumatic event
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50
Q

What is delusional disorder?

A

otherwise normal functioning person with a belief in something that does not exist but no other symptoms of schizophrenia

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51
Q

What is schizoaffective disorder?

A

psychotic disorder featuring symptoms of BOTH schizophrenia and a major mood disorder such a depression or bipolar disorder
-symtpoms may occur at the same or different times

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52
Q

What is schizophrenia?

A

psychotic disorder characterized by delusions, hallucinations, disorganized speech, and/or diminished, inappropriate emotional expression for greater than 6 months + difficulty functioning

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53
Q

What is schizophreniform disorder?

A

psychotic disorder involvign the symptoms of schizophrenia for >1 week but <6 months and no social or occupational impairment

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54
Q

What is delusional disorder?

A

otherwise normally functioning person with a belief in something that does not exist
-one or more non-bizarre delusions of thinking - such as expressing beliefs that occur in real life such as being poisoned, being stalked, being loved or deceived, or having an illness, provided no other symptoms of schizophrenia are exhibited

55
Q

What are the characteristics of delusional disorder?

A
  • no accompnaying prominent hallucinations, thought disorder, mood disorder, or significant flattening of affect
  • beliefs lasting > 1 month
  • functioning is otherwise unimpaired
56
Q

What is the tx of delusional disorder?

A
  • psychotherapy

- pharmacologic - atypial antipsychotic agents - olanzapine and risperidone

57
Q

What is schizoaffective disorder?

A

a mental health condition including schizophrenia and mood disorder symptoms

  • schizoaffective disorder is a combination of symptoms of schizophrenia and mood disorder, such as depression or bipolar disorder
  • symptoms may occur at the same time or at different times
58
Q

What are the characteristics of schizoaffective disorder?

A
  • delusions or hallucinations for 2 or more weeks in the absence of a major mood episode (depressive or manic) during the lifetime duration of the illness
  • symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of the illness
59
Q

What is the tx of schizoaffective disorder?

A
  • psychotherapy

- pharmacologic - atypical antipsychotic agents, anticonvulsants, and selective serotonin reuptake inhibitors (SSRI)

60
Q

What is schizophrenia?

A

major psychosis for greater than 6 months + difficulty functioning

61
Q

What are the characteristics of schizophrenia?

A

Two (or more) of the following, each present for a significant portion of time during 1-month period (or less if successfully treated)

  • at least one of these must be 1, 2, or 3
    1. delusions
    2. hallucinations - auditory (most common), tactile olfactory visual
    3. disorganized speech/thought processes unable to stay on topic (loose associations) unable to provide answer related to questions (tangential response)
    4. symptoms impair daily functioning
    5. disorganized behavior - unpredictable agitation, inappropriate sexual behavior, child-like silliness, catatonic motor behavior, lacking self-care/hygiene
    6. negative symptoms - blunted affect, poor posture, lack of goal-directed activities/initiative
    7. impairment inability to hold a job or maintain relationships

continuous signs of the disturbance persist for at least 6 months

62
Q

What is the tx for schizophrenia?

A
  • atypical antipsychotics: (risperidone, olanzapine, aripiprazole, ziprasideon, quetiapine, asenapine, paliperidone) for negative symptoms and fewer side effects
  • clozapine is an atypical antipsychotic that is not considered first-line because of the propensity to cause agranulocytosis
  • typical neuroleptics - dopamine antagonists (haloperidol, chlorpromazine, thioridazine, loxapine, fluphenazine) best for positive symptoms
63
Q

What is the tx for resistant cases of schizophrenia?

A

clozapine or antipsychotic + another med (Benzo, carbamazepine, valproate, lithium

  • behavior-oreinated/group/family therapy
  • watch for side effects: extrapyramidal, parkinsonina symptoms, neuroleptic malignant syndrome, tar dive dyskinesia - more likely with typical neuroleptics; clozapine may cause agranulocytosis
64
Q

What is schizophreniform disorder?

A

major psychosis for > 1 week by < 6 months and no social or occupational impairment
-schizophrenia and schizphreniform disorder are essentially the same except for the fact that the duration of symptoms found in schizophreniform disorder is longer than 1 week and less than 6 months and there is no social or occupational impairment

65
Q

What is the tx for schizophreniform disorder?

A
  • psychotherapy
  • medications: atypical antipsychotic as the usual drug of choice
  • patients who do not respond to the initial atypical antipsychotic may benefit from being switched to another atypical antipsychotic, the addition of a mood stabilizer such as lithium or an anticonvulsant, or being switched to a typical antipsychotic
66
Q

What is child abuse?

A

deliberate action that is harmful to a child’s physical, emotional, or sexual well-being

67
Q

What is domestic violence?

A

any act of violence involving family members

68
Q

What is elder abuse?

A

the physical or psychological mistreatments or neglect of elderly individuals

69
Q

What is sexual abuse?

A

Any sexual contact that is forced upon a person against his or her will

70
Q

What is child abuse?

A

injury not adequately explained or inconsistent with history given

  • bruises/laceration/soft-tissue swelling, dislocations/fractures, spiral fractures
  • burns (doughnut-shapes, stocking-glove, symmetrically round)
  • bruises or injuries with regular patterns on face, back, buttocks, thighs
  • Internal hemorrhages, abdominal injuries, bite marks, injury with shape of instrument used
71
Q

How may child abuse also manifest with?

A
  • anxiety
  • aggressive/violent behavior
  • PTSD
  • depression or suicide
  • substance abuse
  • poor self-esteem
  • dissociative disorders
  • paranoid ideation
  • failure to rhive
72
Q

When can neglect be considered?

A
  • minor allowed to engage in potentially harmful behavior (ETOH consumption)
  • child is unattended; in some states, leaving child < age 13 home alone
73
Q

What are the categories of elder abuse?

A
  • Physical or sexual abuse
  • Psychological
  • Financial
  • Neglect
74
Q

What are examples of physical or sexual elder abuse?

A
  • bruises/puncture wounds/fractures/cuts/burns
  • poor hygiene/soiled clothing, hair loss in clumps
  • loss, poor nutrition, dehydration
  • lack of eyeglasses/hearing aids
  • Injuries from restraints
  • genital/rectal injuries or bleeding
  • evidence of excessive drugging
  • lack of/delay seeking medical attention
75
Q

What are examples of psychological elder abuse?

A
  • threats/insults/verbal abuse

- refuse to allow travel, church attendance, family visits

76
Q

What are examples of financial elder abuse?

A

misuse of funds

77
Q

What are examples of neglect elder abuse?

A

withholding food/meds/clothing, routine health care, basic necessities

78
Q

What do you watch out for with a caregiver when you suspect elder abuse?

A
  • previous history of abuse
  • conflicting accounts of accidents
  • unwilling to agree to the implementation of treatment plans
  • Inappropriate defensiveness
  • failure to allow/limit pt’s responses to questions
79
Q

What is sexual abuse?

A
  • common ages 9-12 and often by a male known to the child
  • any raises suspicion:
  • evidence of sexually transmitted infection
  • knowledge about sexual acts inappropriate for age
  • Initiates sexual acts with others, peers
  • exhibits sexual knowledge through play
80
Q

What is rape?

A
  • Definition: an act of sexual aggression perpetrate on a spouse, known partner, strangers
  • Approach: hx and physical exam including genital and rectal examinations should be completed as soon after event as possible
  • rape = psychiatric emergency and legal situation; all procedures = documented, clothing saved, samples taken
  • rape kit: history, how specimen samples are collected and under what conditions and how samples should be handled to ensure evidence handled properly
  • explain the purpose of the procedure and inform what is being done
  • prevention of STD and pregnancy: prophylactic abx therapy and pt. should be given options of emergency contraception
  • counseling: pt. should talk to mental health professional ASAP + follow-up counseling
81
Q

What is alcohol-related disorders?

A

alcohol is a depressant - increases GABAa channel opening

-long-term use leads to down regulation of GABA channels (inhibitory) and up regulation of NMDA (excitatory)

82
Q

What are the symptoms of alcohol intoxication?

A

dilates pupils, clumsiness, difficulty walking, slurred speech, sleepiness, poor judgement, talkative, flirtatious, aggressive, moody, disinhibited

83
Q

What is the treatment for alcohol intoxication?

A

thiamine, folate, MVI, destrose (particularly if chronic alcoholism), and IV fluids, benzodiazepines

84
Q

What is delirium tremens?

A

(48-96 hours): autonomic instability, disorientation, hallucinations, agitation

  • suspect in a patient with unknown history followed by DT symptoms 2 days later
  • IV benzodiazepines, preferably in an ICU
85
Q

What are the addiction medications?

A
  • Disulfiram (antabuse) - inhibits acetaldehyde deydrogenase, aversive conditioning
  • 500 mg once daily for 1 to 2 weeks then decrease to the maintenance dose (range 125-500 mg once daily)
  • nor for use in persons actively drinking alcohol, avoid alcohol in other products
  • Oral Naltrexone - decreases desire
  • 50 mg once daily
  • cannot be given to patients taking opioidis
  • Extended-Release Naltrexone - decreases desire
  • 380 mg IM every 4 weeks; administer in the gluteal area with 1.5 inch 20-gauge needle
  • cannot be given to patient taking opioids
  • Acamprostate - changes brain chemistry in a way that reduces anxiety, irritability, and reslessness associated with early sobriety
  • 666 mg three times daily
  • dose reduction required with renal impairment
  • Topiramate - reduces drinking at least as well as naltrexone and acamprosate
  • begin at 25 mg daily and increase up to 150 mg BID
  • Gabapentin - decreases desire
  • begin at 300 mg once daily and increase up to 600 mg TID
86
Q

What is the tx of DT?

A

DT may be fatal and thus must be treated promptly with high-dose IV benzodiazepines, preferably in an ICU

87
Q

What is minor withdrawal?

A
  • 6 hour since last drink
  • symptoms: trembling, irritability, anxiety, headache, tachycardia, insomnia
  • management: thiamine, folate, multivitamin, dextrose, IV fluids
88
Q

What is alcoholic hallucinosis?

A
  • 12 - 24 hours since last drink
  • symptoms: visual, auditory and in some cases tactile hallucinations
  • treatment: begin benzodiazepine taper to avoid seizures
89
Q

What is a withdrawal seizure?

A
  • 48 hours since last drink
  • symptoms: tonic-clonic seizures
  • treatment: benzodiazepine taper and head CT
90
Q

What is delirium tremens?

A
  • 48 to 96 hours since last drink
  • symptoms: autonomic instability, disorientation, hallucinations, agitation
  • treatment: suspect in patient with unknown history followed by DT symptoms 2 days later and benzodiazepine taper
91
Q

What is sedative-, hypnotic-, or anxiolytic related disorder?

A

patient with CNS depression and a history of anxiety or panic disorder

  • anxiolytics are mediations such as benzodiazepines used for treatment of anxiety disorders
  • they have additive effects with alcohol and tend to have a cumulative effect if doses are repeated indiscriminately
  • the mechanism is through GABAa channel-increased frequency of opening
92
Q

What are the symptoms of intoxication from sedative-, hypnotic-, or anxiolytic related disorder?

A

respiratory depression, hypotension, amnesia, ataxia, stupor/somnolence, coma, death

93
Q

What are the symptoms of withdrawal from sedative-, hypnotic-, or anxiolytic related disorder?

A

rebound anxiety, seizures (life-threatening) and tremor-most commonly found in short-acting Benzes such as alprazolam

94
Q

What is the tx of sedative-, hypnotic-, or anxiolytic related disorder?

A

treat life-threatening intoxication with flumazenil which is a competitive GABA antagonist
-treat of withdrawal with a long-acting Benzo such as clonazepam with an appropriate taper

95
Q

What is cannabis-related disorder?

A

Binds to CB1/CB2 cannabinoid receptors

96
Q

What are the symptoms of intoxication from cannabis-related disorder?

A
  • euphoria, anxiety, disinhibition, paranoid delusions, perception of slowed time, conjunctival injection, impaired judgement, social withdrawal, increase appetite, dry mouth, hallucinations
  • amotivational syndrome
97
Q

What is the tx of intocication from cannabis-related disorder?

A
  • no specific tx

- symptomatic treatment only

98
Q

What are the symptoms of withdrawal from cannabis-related disorder?

A
  • irritability, depression, insomnia, nausea, anorexia
  • most symptoms peak in 48 hours and last for 5-7 days
  • can be detected in urine up to 1 month after last use
  • hyperemesis syndrome
  • In chronic cannabis users, individuals can experience chronic severe emesis due to down regulation of CNS cannabinoid receptors and up regulation of gut cannabinoid receptors
  • treatment: stop smoking marijuana, anti-emetics (ondansetron, metoclopramide)
99
Q

What is the tx of withdrawal from cannabis-related disorder?

A
  • no specific treatment

- symptomatic treatment only

100
Q

What are the characteristics of cocaine?

A

block biogenic amine (Dopamine (DA), norepinephrine (NE), and serotonin (5-hydroxytryptamine; 5-HT)) reuptake

101
Q

What are the symptoms of intoxication from cocaine?

A

Mental Status Change
-euphoria, psychomotor agitation, grandiosity, hallucinations (including tactile), paranoid ideations
Sympathetic activation
-decrease appetite, tachycardia, pupillary dilation, hypertension, angina
-can cause severe vasospasm
-MI - coronary vasospasm
-placental infarction - vasospasm of placental vessels
-nasal septum perforation - Kiesselbach’s plexus vasospasm
-stroke - CVA
Stereotyped behavior
-repetitive motions (eg. digging through tash)

102
Q

What is the tx of intoxication from cocaine?

A 
Pharmacologic 
-antipsychotics (haloperidol) 
-benzodiazepines
-antihypertensives (labetalol - need alpha-1 blockade) 
-vitamin C - promotes excretion 
Non-pharmacologic 
-do not restrain patients 
-may result in rhabdomyolysis
103
Q

What are the symptoms of withdrawal from cocaine?

A
  • severe depression and suicidality
  • hyperphagia, hypersomnolence, fatigue, malaise
  • severe psychological craving
104
Q

What is the tx of withdrawal from cocaine?

A

Pharmacologic

  • bupropion
  • bromocriptine
  • SSRI’s for depression
105
Q

What are amphetamines?

A

methamphetamine, dextroamphetamine (dexedrine), methylphenidate (concerta)
-simulates biogenic amine (Dopamine (DA), norepinephrine (NE) and serotonin (5-hydroxytryptamine; 5-HT) release + decrease reuptake (high dose)

106
Q

What are the symptoms of intoxication from amphetamines?

A

Mental status change
-euphoria, impaired judgement, delusions, hallucinations, prolonged wakefulness/attention
Sympathetic activation
-psychomotor agitation, pupillary dilation, hypertension, tachycardia, fever, cardiac arrhythmias

107
Q

What is the tx for intoxication from amphetamines?

A 
Pharmacologic 
-antipsychotics (haloperidol) 
-benzodiazepines
-vitamin C (promotes excretion) 
-antihypertensives
-propranolol (BP + tachycardia control) 
Non-pharmacologic 
-do not restrain patient 
-may result in rhabdomyolysis
108
Q

What is PCP?

A

Patient that is extremely aggressive and becomes enraged when sudden movements or loud sounds are made
-Mechanims: NMDA receptor antagonist - Ketamine is a similar drug

109
Q

What are the symptoms of intoxication for PCP?

A

belligerence, impulsiveness, fear, homicidality, psychosis, delirium, seizures, psychomotor agitation, vertical and horizontal nystagmus, tachycardia, ataxia

110
Q

What is the tx for intoxication from PCP?

A 
Pharmacologic 
-antipsychotics (haloperidol) 
-benzodiazepines
Further Management 
-low stimulus environment 
-restraints if needed to prevent patient from hurting self/others
111
Q

What are the symptoms of withdrawal from PCP?

A

depression, anxiety, irritability, restlessness, anergia, disturbances of thought and sleep

112
Q

What is the tx for withdrawal from PCP?

A

no specific treatment - symptomatic treatment only

113
Q

What is LSD?

A

Patent wants to hurt himself

  • they say that he has “been freaking out” and seeing things that are not there
  • mechanism: action at 5-HT receptor
114
Q

What are the symptoms of intoxication from LSD?

A
  • visual hallucinations and synesthesia (eg seeing sound as color)
  • marked anxiety or depression, delusions, pupillary dilation
  • “bad trip” panic
115
Q

What is the tx for intoxication from LSD?

A

Pharmacologic

  • antipsychotics (haloperidol)
  • benzodiazepines
  • talking down, supportive counseling
116
Q

What are the symptoms of withdrawal from LSD?

A
  • largely no withdrawal because it does not affect dopamine

- flashbacks can occur years later

117
Q

What is the treatment for withdrawal from LSD?

A

no specific treatment - symptomatic treatment only

118
Q

What is tobacco-related disorders?

A

cigarette smoking is the leading preventable cause of death in the United States

  • cigarette smoking causes more than 480,000 death each year in the United States, this is dearly one in five deaths
  • Smoking causes more deaths each year than the following causes combined:
  • Human immunodeficiency virus (HIV)
  • illegal drug use
  • alcohol use
  • motor vehicle injuries
  • firearm-related incidents
119
Q

What are the symptoms of intoxication from tobacco-related disorders?

A

reslessness, insomnia, anxiety, arrhythmias

120
Q

What are the symptoms of withdrawal from tobacco-relasted disorder?

A

irritability, headache, anxiety, weight gain, craving

121
Q

What is the treatment for cessation?

A
  • bupropion
  • Varenicline (chantix): partial nicotine receptor agonist, mediates partial reward of nicotine yet blocks reward of nicotine
  • highest success rate of all anti-smoking drugs, particularly when stacked with nicotine patches
  • nicotine administration via other routes
122
Q

What is inhalant-related disorders?

A

mechanism: unknown

123
Q

What are the symptoms of intoxication from inhalant-related disorder?

A
  • belligerence, assaultiveness
  • apathy, impaired judgment
  • blurred vision, coma
124
Q

What is the tx for intoxication from inhalant-related disorders?

A
  • no specific treatment

- antipsychotics (haloperidol) if severe aggression

125
Q

What are the symptoms of withdrawal from inhalant-related disorders?

A
  • not well characterized, no treatment

- abuse of other drugs commonly seen in these patients often from a low socioeconomic background

126
Q

What are opioid-related disorder?

A
  • mechanims: mu receptor agonist

- examples: morphine, heroin, methadone

127
Q

What are the symptoms of intoxication from opioid-related disorder?

A
  • constipation: no tolerance to this side effect
  • respiratory depression - life-threatening
  • pupillary constriction (pinpoint pupils)
  • seziures (overdose is life-threatening)
  • for heroin use, look for track marks (needle injections)
128
Q

What is the treatment of intoxication from opioid-related disorder?

A

Naloxone/naltrexone

  • opioid receptor antagonist
  • opioid withdrawal is NOT fatal - it is just unpleasant
  • symptomatic treatment
129
Q

What are the symptoms of withdrawal from opioid-related disorder?

A
  • anxiety, insomnia, anorexia, sweating, dilated pupils, piloerection (“cold turkey”)
  • fever, rhinorrhea, nausea, stomach cramps, diarrhea (“flulike symptoms)
  • yawning
  • unpleasant but not life-threatening
130
Q

What is the tx for withdrawal from opioid-related disorder?

A

Clonidine

  • alpha2 agonist that decreases NE and sympathetic output making autonomic symptoms less intense
  • methadone (long-acting)
  • buprenorphine + naloxone
  • can precipitate withdrawal if given too soon (partial mu agonist)
131
Q

What is the tx for addiction?

A

Pharmacologic

  • methadone: typically oral, long-acting IV opiate, used for heroin detoxification or long-term maintenance
  • suboxone (buprenorphine + naloxone): long-acting administration with fewer withdrawal symptoms than methadone, naloxone + buprenorphine (partial opioid agonist), naloxone is not active when taken orally, so withdrawal symptoms occur only if injected, intended to prevent overdose when Suboxone is injected
132
Q

What is suicide?

A

Suicide is the 8th leading cause of death in the United States and the 3rd leading cause of death in ages 15-24

  • in all age groups, male deaths by suicide outnumber female deaths 4 to 1
  • women attempt suicide 2 to 3 times more often than men, among girls ages 15 to 19 yr, there may be 100 attempts to every 1 attempt among boys of the same age
  • on average, primary care physicians encounter >6 potentially suicidal people in their practice each year
  • about 77% of people who die by suicide were seen by a physician within 1 yr before killing themselves, and about 32% had been under the care of a mental health care practitioner during the preceding year
133
Q

How do you access the level of intent, level of lethality, and risk factors for suicide?

A
  • male gender
  • older
  • major depression
  • active substance abuse
  • serious medical problems
  • a recent loss (e.g of employment, relationship, death of family member)

consider referral to emergency services
-crisis service, emergency department

Emergency Medicine EOR (12 decks)

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