Week 3 (everything else...) Flashcards
What is the definition of substance intoxication?
recent ingestion of a substance
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clinically significant problematic behavior and/or psychological changes attributable to the physiological effects of the substance on the CNS
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fits an intoxication syndrome profile
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not attributable to other causes
What is the definition of substance withdrawal?
prolonged use of a substance
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cessation of the substance and specific signs/symptoms associated with cessation
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signs/symptoms cause clinically significant distress or impairment
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symptoms not attributable to another cause
What factors influence intoxication and withdrawal?
timing (chronic vs. acute)
route of administration
duration of action/potency
metabolism
mechanism of action
What is the mechanism of alcohol intoxication?
interferes with membrane fluidity and affects function of ion channels and receptors
enhances nicotinic acetylcholine channels, GABA-A receptors, and increased inhibition of glutamate receptors and voltage-gated calcium channels
What are the symptoms of alcohol intoxication?
slurred speech
incoordination
unsteady gait
nystagmus
impaired memory and concentration
stupor
coma
What are the symptoms of alcohol withdrawal?
autonomic instability
nausea
vomiting
anxiety
sweats
hallucinations
tremor
headache
disorientation
What are the four stages of alcohol withdrawal?
autonomic nervous system instability (occurs 6-48 hours into withdrawal)
seizures (occurs 12-48 hours into withdrawal)
hallucinosis (arises 12-24 hours into withdrawal and lasts up to 3 days)
delirium tremens (arises 3-7 days into withdrawal)
What is ANS instability in alcohol withdrawal? What causes it?
insomnia, tremor, anxiety, agitation
GI distress, headaches, diaphoresis, palpitations
cause: surge in catecholamines that were suppressed by presence of alcohol
What type of seizures are associated with alcohol withdrawal? What causes them?
generalized tonic-clonic seizures
cause: decreased GABA-A transmission, increased glutamate NMDA receptor signaling
What types of hallucinations are associated with alcohol withdrawal? What causes them?
typically visual hallucinations with full orientation
cause: hypothesis is that it is related to increased dopamine signaling
What is delirium tremens? Who is at high risk for this?
the final stage of alcohol withdrawal in some cases
leads to delirium, perception changes, diaphoresis, agitation
higher risk: sustained use prior to withdrawal, history of delerium tremens, comorbid illness, withdrawal signs when alcohol is still in system
mortality is 15%
What are the causes of mortality associated with delirium tremens?
cardiovascular or respiratory collapse
What is the mechanism of action of sedatives, hypnotics, and CNS depressants?
agonism of the GABA-A receptor (which is coupled to a chloride ion channel)
What is the difference between mechanism of barbituates and benzodiazepines?
benzodiazepines: increase frequency of GABA-A chloride channel opening (plateaus)
barbituates: increases duration of GABA-A chloride channel opening (risk of toxicity)
What are the symptoms of sedative/hypnotic/CNS depressant toxicity?
similar to alcohol and is dose dependent
small doses: motor incoordination, impaired cognition
high doses: impaired gait, speech, nystagmus, coma/death
What are the symptoms of sedative/hypnotics/CNS depressants withdrawals?
autonomic hyperactivity, tremor, nausea, vomiting, insomnia, perceptual changes, anxiety, seizures, delirium
Which benzodiazepines carry the greatest risk of withdrawal symptoms?
ones with short half-lives (temazepam, lorazepam, alprazolam)
What is the mechanism of action of cocaine?
it inhibits the reuptake of dopamine (via dopamine reuptake transporter 1) into the presynaptic neuron
it also affects reuptake of norepinephrine and serotonin
What is the mechanism of action of amphetamines?
two mechanisms:
causes release of dopamine from vesicles in the presynaptic neuron into the cytosol
reverses the flow of dopamine reuptake transporter 1 (increases synaptic dopamine)
What parts of the brain do cocaine and amphetamines act on?
ventral tegmental areas (nucleus accumbens) and prefrontal cortex
What are the symptoms of stimulant withdrawal?
dysphoric mood, depression, fatigue, vivid/unpleasant dreams, hypersomnia, low energy, increased appetite, psychomotor changes, cognitive slowing, suicidal ideation
What are the symptoms of stimulant intoxication?
tachycardia, mydriasis, hypertension, perspiration, chills, nausea, vomiting, anorexia, psychomotor agitation or increased energy, aggression, increased libido, cardiac arrhythmias, seizures, chest pain, bruxism, decreased need for sleep, dyskinesias, dystonias, psychosis, bruxism, delirium
What is the mechanism of action of hallucinogens?
variable
some are agonists at the serotonin 2A receptor
MDMA affects serotonin and monoamines system
PCP and ketamine antagonize the glutamate NMDA receptor
What are the symptoms of PCP intoxication?
dissociation, depersonalization, derealization, vertical nystagmus, hypertension, numbness or decreased pain responses, ataxia, dysarthria, rigidity, seizures, severe aggression
What are the symptoms of hallucinogen intoxication?
hallucinations, depersonalization, derealization, ideas of reference, paranoia, anxiety, mydriasis, tachycardia, daphoresis, ataxia, vomiting, tremor, hyperreflexia, seizure, micro/macroscopia, synesthesias, light trails, intense perceptions
What is the mechanism of action of opioids?
primary effects via the mu-opioid receptor, though some secondary effects through the kappa and delta opioid receptors
What are the symptoms of opioid intoxication?
analgesia, meiosis, respiratory depression, constipation, decreased arousal, bradycardia, seizures, myoclonus
What are the symptoms of opioid withdrawal?
tachycardia, diaphoresis, anxiety, restlessness, mydriasis, myalgias, arthralgias, GI cramping/nausea, vomiting, lacrimation, rhinorrhea, tremor, yawning, irritability, piloerection
What is the mechanism of action of cannabinoids?
agonism of endogenous cannabinoid receptors
What is cyclic vomiting syndrome?
a syndrome that can result from prolonged use of cannabis
vomiting that is worse with food and relieved by hot baths
What are the symptoms of cannabis intoxication?
conjunctival injection, increased appetite, dry mouth, tachycardia, impaired motor coordination, euphoria, sense of slowed time, impaired judgement, social withdrawal
What are the symptoms of cannabis withdrawal?
irritability, anger, depression, anxiety, insomnia, disturbing dreams, anorexia, weight loss, restlessness, depression, abdominal pain, tremors, sweating, fever, chills, headache
What is the mechanism of action of tobacco?
agonists at the nicotinic acetylcholine receptor (higher affinity in the brain)
What are the symptoms of nicotine withdrawal?
irritability, frustration, anger, anxiety, difficulty concentrating, increased appetite, restlessness, depression, insomnia
What is the mechanism of action of caffeine?
antagonism of adenosine receptors
What are the symptoms of caffiene intoxication?
restlessness, nervousness, excitement, insomnia, flushing, diuresis, GI upset, rambling speech, tachycardia, inexhaustibility, agitation
What are the symptoms of caffiene withdrawal?
headache, marked fatigue, drowsiness, dysphoria, depression, irritability, difficulty concentrating, nausea, vomiting, muscle stiffness
A patient presents with vomiting, diffuse myalgias, arthralgias, diarrhea, anxiety, mydriasis, irritability, and restlessness. What is this presentation most consistent with?
a) alcohol intoxication
b) cannabinoid intoxication
c) stimulant intoxication
d) opioid intoxication
e) hallucinogen withdrawal
f) cannabinoid withdrawal
g) stimulant withdrawal
h) opioid withdrawal
h) opioid withdrawal
A patient presents with paranoia, high energy, irritability, dilated pupils, restlessness, hyperverbality, and skin excoriations? What is this presentation most consistent with?
a) alcohol intoxication
b) cannabinoid intoxication
c) stimulant intoxication
d) opioid intoxication
e) hallucinogen withdrawal
f) cannabinoid withdrawal
g) stimulant withdrawal
h) opioid withdrawal
c) stimulant intoxication
A patient presents with anxiety, restlessness, paranoia, nausea, headaches, diaphoresis, tremor, disorientation, and visual hallucinations. What is this presentation most consistent with?
a) alcohol intoxication
b) cannabinoid intoxication
c) stimulant intoxication
d) opioid intoxication
e) hallucinogen withdrawal
f) cannabinoid withdrawal
g) stimulant withdrawal
h) opioid withdrawal
i) alchol withdrawal
i) alcohol withdrawal
A patient presents with fighting, irritability, yelling, stripping off clothes, unsteady gait, agitation, paranoia, dysarthria, and vertical nystagmus. What is this presentation most consistent with?
a) alcohol intoxication
b) cannabinoid intoxication
c) stimulant intoxication
d) opioid intoxication
e) hallucinogen intoxication
f) cannabinoid withdrawal
g) stimulant withdrawal
h) opioid withdrawal
i) alchol withdrawal
j) hallucinogen withdrawal
e) hallucinogen intoxication
A patient presents with nausea and vomiting (3-4 episodes per hour) that is relieved by hot showers, weakness, difficulty focusing, signs of dehydration, injected conjunctivae, tachycardia, and dysphoric mood. What is this presentation most consistent with?
a) alcohol intoxication
b) cannabinoid intoxication
c) stimulant intoxication
d) opioid intoxication
e) hallucinogen intoxication
f) cannabinoid withdrawal
g) stimulant withdrawal
h) opioid withdrawal
i) alchol withdrawal
j) hallucinogen withdrawal
f) cannabinoid withdrawal
What is anorexia nervosa?
restriction of energy intake resulting in significantly low body weight as it relates to age/sex/development/physical health
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intense fear of gaining weight or persistent behavior interfering with weight gain
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distorted body image
What are the subtypes of anorexia nervosa?
restricting type (only restrictive behaviors)
binging/purging type (binges followed by compensatory purging)
What is bulimia nervosa?
a condition marked by recurrent episodes of binge eating followed by inappropriate compensatory behaviors to “undo” the binge episode
occurs in the setting of being normal weight or overweight
occurs at least 1x/week for at least 3 months
What are the subtypes of bulemia?
purging type (compensation is self-induced vomiting)
non-purging type (compensation is something other than vomiting)
What is binge eating disorder?
an eating disorder marked by recurrent episodes of binge eating (at least 1x/week for 3 months) in which two binges include at least three of the below features:
eating until uncomfortably full
eating alone
sense of loss of control
eating in a state of self-disgust and shame
What is orthorexia?
an obsession with eating “healthy” foods that leads to impairingrules around foods that they can eat
What is avoidant/restrictive food intake disorder?
apparent lack of interest in eating or food, avoidance based on sensory characteristics, concern about aversiveness of food
includes inability to meet nutritional needs
common in children with sensory issues
What is the gender disparity of eating disorders?
much more prevalent in women across the board
Which eating disorder has the worst prognosis?
anorexia has higher rate of remaining highly symptomatic and highest mortality rate
What psychiatric disorders commonly co-occur with anorexia?
social phobia, OCD, MDD
What psychiatric disorders commonly co-occur with bulemia?
MDD, BPD, substance abuse, anxiety disorders
What psychiatric disorders commonly co-occur with binge eating disorder??
panic disorder/agoraphobia, MDD, PTSD, personality disorders
What are the medical complications of anorexia?
bradycardia, hypotension, hypothermia, dehydration
hypoglycemia, anemia, electrolyte abnormalities (hypophosphatemia, metabolic alkalosis, hypochloremia, hypokalemia)
decreased GI motility, lanugo hair, hair loss, amenorrhea, osteopenia
What are the medical complications of bulemia?
dehydration, orthostatic hypotension
metabolic alkalosis (vomiting), metabolic acidosis (laxative abuse)
dental enamel erosion, parotid gland enlargement, esophageal tears
What are the medical complications of binge eating disorder?
obesity, diabetes, hypertension, hormone irregularities, skeletal/muscular problems
What is the social theory of eating disorders?
emphasis on social pressures and unrealistic body ideals with reinforcement from media and culture
consistent with the higher rate of eating disorders in industrialized countries
What is the family theory of eating disorders?
suggests that anorexics come from more rigid, enmeshed families
suggests that bulimics come from more disengaged and chaotic families
What is the cognitive-behavior theory of eating disorders?
the idea that even “safe” dietining can create increased cravings and increased self-punishment for lapses
restricting makes a person feel successful, purging makes a person feel less guillty after relapse or afraid of weight gain
What are the biologic theories of eating disorders?
emphasis on how satiety is biologically mediated in the brain and genetically predetermined
emphasis on how undercontrol and overcontrol impulses may have a genetic component
What is the treatment for eating disorders?
multidisciplinary approach: medical, nutrition, family therapy, individual therapy, psychiatry (group and residential)
first treatment goal: medical and nutritional stabilization, weight restoration
after stabilization, psychotherapy is the primary treatment
What are the warning signs of anorexia?
excessive weight loss
odd food rituals
lack of menstrual cycles
fine hair on face/arms/torso
wearing baggy clothing
vigorous exercise at oddhours
paleness, dizziness, fainting
What are the indications for hospitalization in anorexia nervosa?
severe malnourishment
dehydration, electrolyte imbalance (beware of refeeding syndrome)
physically threatening complications
suicidal thoughts, psychosis
acute refeeding
What medication may be effective for anorexia nervosa?
olanzapine
What medications may be beneficial for bulemia nervosa?
fluoxetine
bupropion is contraindicated due to seizure risk
What is somatic symptom disorder?
a disorder where patients have complaints in many different organ systems (often dramatically out of proportion to symptoms) that are more common in times of stress, but there is no clear explanation or identifiable disorder
What are the biggest medical complications of somatic symptom disorder?
iatrogenic (secondarily aquired) medical problems due to overly aggressive workups
What is the pain specifier subtype of somatic symptom disorder?
a subcategory of somatic symptom disorder for patients with complaints of pain where psychological factors are felt to be either partial or ocmplete basis of the onset, severity, or maintenance of the pain
What social history factors are often linked to the pain specifier subtype?
childhood maltreatment, guilt, punishment
What is conversion disorder?
A disorder with abrupt onset of neurologic symptoms (other than pain) in the setting of a normal neuro exam and workup
often follows a triggering event
may be related to abnormal brain connectivity
What is are the demographics associated with conversion disorder?
appears at any age with no gender preponderance
more common in the neurologically impaired
What is illness anxiety disorder?
a disorder where patients have persistent, unreasonable worries about specific symptoms or that they have a particular serious medical condition in absence of evidence of a known disorder
What are the goals of management in patients with somatic symptoms and related diseases?
increasing: trust in physician, understanding of causes of symptoms, ability to deal with uncertainty, functioning/activity
conservative medical management
lifestyle modification
decreasing: invasive/risky low yield procedures, doctor shopping, secondary gain, psychosocial difficulties
What demographics are associated with illness anxiety disorder?
occurs at any age without gender predominance
associated with obsessive-compulsive or paranoid traits
When should patients with somatic symptom disorders be referred to a psychiatrist?
no clear time point where this should happen
ideally the patient will have some understanding of their diagnosis in order to accept/benefit from the referral
What are the diagnostic pitfalls in conversion disorder?
presenting symptoms are usually not consistent with definable neurological disease
brain imaging/EEG can be helpful
What is the cognitive distortion in somatic symptom disorder and how is it targeted by CBT?
the cognitive distortion often involves a misreading of bodily symptoms and/or an incorrect assumption that disease condition is present
What is the general gender and age prevalence of somatization disorder?
increased rates in women
usually onset between decade following puberty and age 30
What is the differential diagnosis for somatic symptom disorder?
lupus, MS, porphyria, sarcoidosis
any psychiatric disorder
What is factitious disorder vs. malingering?
factitious disorder: intentional act of faking symptoms/disease with an unconscious motivation and a primary gain of being in a sick role (more likely to agree to invasive tests)
malingering: intentional act with a conscious motivation and a secondary gain (less likely to agree to invasive tests)
What are the DSM criteria for a paraphilic disorder?
recurrent intense sexual arousal from specific fantasies, urges, or behaviors for at least 6 months
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has acted on the urges with a non-consenting person or causes clinically significant distress or impairment
What are the types of paraphilic disorders?
fetishism, pedophilia, exhibitionism, voyeurism, masochism, sadism, frotteurism, transvestism
What is the gender and age preponderance of paraphilic disorders?
more common in men, develop in adolescence
What are the treatments of paraphilic disorders?
behavioral, cognitive, psychotropic medications, hormonal, 12-step addiction model
What are the Masters and Johnson stages of normal sexual response?
excitement: mental and physical
plateau: high level of excitement prior to orgasm
orgasm: muscular contraction
resolution: return to resting state
What are the Kaplan stages of normal sexual response?
desire
excitement
orgasm
pain
What are the gender differences in sexual responses?
men: more genitally focused, automatic, rapid and fixed
women: less genitally focused, slower, interpersonally-oriented and plastic
What physical factors can lead to sexual dysfunction?
aging
neurological, endocrine, vascular, gynecological or urological conditions
What are immediate causes of sexual dysfunction?
anxiety, lack of arousal
failure to engage in appropriate behavior, failure to communicate, partner’s sexual dysfunction
What are remote causes of sexual dysfunction?
ambivalence, depression, stress
anger, avoidance of intimacy, communication difficulties
What are the subtypes of etiologies of sexual dysfunction?
secondary to medical conditions
secondary to substances/medications