Week 9 Flashcards
Clinical Manifestations of LSD
perceptual distortions: micropsia/macropsia. Derealization, depersonalization. Visual hallucinations. Synesthesia.
Euphoria or lability. Ego fragmentation.
Unmasking psychiatric vulnerabilities
Mechanism of LSD
unsure. Serotonergic system (5HT-2 Receptor!), but not exclusively.
Clinical Sx PCP (standard/low dose)
Dissociation/Disconnection. Euphoria (peaceful floating). Oblivious to surroundings. Flat affect (schizophrenia-like). Unresponsiveness.
Mechanism of PCP
NMDA receptor antagonist. Blocks glutamate. Also monoamines, sigma, other receptors.
Clinical Sx MDMA
Euphoria, loving. Loss of boundaries. Disinhibition/decreased defensiveness. Intimacy. Perceptual/cognitive distortions (apathy). Increased anxiety.
BP, heart rate, dry mouth, bruxism, fever/dehydration(?)
Mechanism of MDMA
increased vesicular release of dopamine and 5HT (not well characterized)
factors increasing drug use
perceived risk; supply
route of admin LSD
oral. Powder, solution, blotting paper.
Tx LSD trip
Ride the wave. Support. Benzos if extremely anxious.
Route of admin PCP
Dipped and smoked.
Clinical Sx high-dose PCP
Slurred speech, nystagmus(!), rolling gait, numbness, disturbing depersonlization, distortions of body image/consistency, space/time, perceptual disturbances.
Hyperacusis, amnesia, hostility, excess salivation w/o gag reflex, risk of coma/convulsions/death.
Regular PCP use consequences
neuro/cognitive dysfunction for 2-3 wks. (“zombies”)
Tx PCP trip
Reassurance NOT EFFECTIVE. Benzo for seizure prophylaxis. Antipsychotic for extreme paranoia. Acidification of urine to increase excretion in extreme cases. Gastric suction for coma.
Route of admin MDMA
oral.
consequences of chronic MDMA use
permanent destruction of 5HT pathways (?)–>depression
Tx of MDMA high
support, prevent dehydration.
Anticholinergic administration
rarely taken intentionally. Usually accidental iatrogenic.
anticholinergic clinical manifestations
delirium. Waxing and waning of consciousness, impulsivity, impaired judgment, hallucinations, dysphoria. Can be subtle.
Treatment of delirium
stop offending agents (e.g. anticholinergics). Physical/chemical restraint (anti-psychotic, not benzo!). Gastric lavage.
Huffing
inhalation of volatile hydrocarbons (amyl/butyl nitrates = poppers)
Clinical manifestations of huffing
stimulation/disinhibition. Nystagmus. Incoordination. Perceptual distortions. Frank hallucinations?
Mechanism of huffing
GABA-A ? not known
chronic use of huffing
CNS damage: demyelination/cerebellar atrophy.
Sex breakdown of schizophrenia
higher incidence in men, but equal prevalence
Cognitive deficits in schizophrenia
1-2 SDs below norm. Verbal/visual learning/memory, attention, speed of processing, executive function
Negative symptoms of schizophrenia
alogia, flat affect, anhedonia, avolition, asociality
Treatment outcomes of schizophrenia (patterns, prognostic factors)
1/3 Treatment refractory
1/3 episodic relapse
1/3 good response
Good prognosticators: later/abrupt onset, shorter duration, better premorbid function, better support, paucity of negative Sx, female, adherence.
Schizophrenia etiology
neurodevelopmental disorder: vulnerability x environment.
heritable, but no high-contribution genes.
3rd trimester development (flu, nasal cavity)
Dopamine hypothesis of schizophrenia
too much DA leads to inappropriate salience attributed to random stimuli. (antipsychotics block D2)
glutamate hypothesis of schizophrenia
NMDA antagonists (PCP, ketamine) mimic both positive and negative Sx. NMDA blockade of interneuron leads to loss of inhibitory tone-->loss of synchrony of cortical areas NMDA hypomorphs are reasonable model for schizophrenia.
Anorexia Nervosa criteria
A: 85% body weight
B: intense fear of gaining weight, even though underweight
C: Disturbance in body weight/shape experience or lack of recognition
D: Absence of 3 consecutive menstrual cycles
Anorexia nervosa onset
following crisis, loss of self-esteem. Dieting to “take control”
Serotonin might play a role.
Anorexia nervosa Tx
impatient if indicated. SSRIs not useful. atypical antipsychotics might be.
Very hard to treat. Boot camp rehab and psychotherapy. Bring parents in before returning to independent eating (controversial)
Bulimia Nervosa criteria
A: recurrent episodes of binging B: recurrent compensatory behavior C. Binge/compensation 1/wk for 3 months D. self evaluation unduly influenced by weight and shape E. Does not occur during AN
Bulimia Nervosa neurobio
less activation of fronotstriatal areas—> less impulse control
Bulimia Nervosa course
May occur in all weights. First occurrence usually in response to caloric deprivation while dieting
Bulimia Nervosa complications
erosion of enamel, hypokalemia–> weakness, lethargy, arryhthmias, parotid gland enlargement.
Bulimia Tx
fluoxetine (SSRI), CBT (alone not sufficient for many patients). Only eating disorder where pharm Tx indicated
Binge Eating Disorder criteria
A. Binging + lack of control B. Associated binging practices C. Marked distress D Frequency E. not associated with compensatory behavior, not AN or BN
Neuro of Binge Eating
similar to cocaine. Food addiction?
Tx of BED
CBT and behavioral weight control equivalent for reducing binging. BWC superior for reducing weight
Night eating syndrome
25% of food intake. 2/wk. distress
Leading preventable cause of death in US
smoking
Pharm of nicotine
NAchR modulated Da release presynaptically and response of post-synaptic neuron
Interventional therapy for nicotine addiction
Brief advice is pretty good relative to behavior therapy
Pharm therapy for nicotine
replacement therapy, bupropion SR, varenicline (partial agonist)
Only antipsychotic that works on negative Sx of schizophrenia
clozapine (but has AE of agranulocytosis)
Dexamethasone suppression test
Exogenous steroid: should be able to suppress (feedback)
Dysregulation of HPA –> failure to suppress (anxiety, depression). Only works for severe melancholic depression (2/3 depression overall)
Benzos vs SSRIs for GAD
Benzos treat symptoms!! (GABA). To treat underlying disorder, need SSRIs! First-line is SSRI, sometimes with “benzo-bridge.”
Prescribe benzo for situational anxiety only (e.g. flight phobia), where treating underlying disorder would be exposure therapy
