1
Q
Epidemiology of bipolar disorder? Any genetics?
A
Mood Episodes
- Epidemiology: age of onset is young adulthood, bipolar disorder usually starts with a depressive episode, most bipolar patients have more than one episode of illness
- Monozygotic concordance is high in bipolar disorder I and II
2
Q
Define the following:
- Mood episode
- Mood disorder
A
- Mood Episode: distinct periods of time in which some abnormal mood is present
- Mood Disorder: patterns of mood episodes
3
Q
For manic episode:
- What is the criteria (mnemonic)
- What is one risk factor for manic episodes?
A
- Manic episodes (psychiatric emergency)
- Criteria: a distinct period (at least 1 week) of abnormally and persistently elevated, expansive, or irritable mood
- 3 or more of the following (4 if irritability is mood): DIGFAST
- Distractibility
- Insomnia (decreased need for sleep)
- Grandiosity
- Flight of ideas
- Activity/Agitation (increased/goal-directed)
- Speech (pressured – fast talking)
- Thoughtlessness (Hedonistic interests)
- 3 or more of the following (4 if irritability is mood): DIGFAST
- Causes impairment in occupational/social activities OR requires hospitalization OR has psychotic features
- Not due to substance use or medical condition
- Risk factor: antidepressant use (i.e. SSRI)
- Criteria: a distinct period (at least 1 week) of abnormally and persistently elevated, expansive, or irritable mood
4
Q
For hypomanic episodes
- Criteria?
- Differences between manic and hypomanic (3 main ones!)
- Duration?
A
- Hypomanic episodes
- Same symptoms as manic episode (with elated, expansive, or irritable mood)
- Differences: no impairment in function, no hospitalizations, no psychotic features
- Duration: 4 days (compared to 1 week in mania)
5
Q
For mixed episodes:
- Criteria?
- Duration?
A
- Mixed episodes (both depressive and manic sx) – psychiatric emergency
- Criteria for both mania and depressive episodes are met for one week
6
Q
For bipolar I disorder:
- Criteria?
- Specifiers (many)
- Define rapid cycling subtype.
A
Bipolar I Disorder
- Presence of one or more manic/mixed manic episode
- Minor or Major Depressive Episodes MAY be present
- MAY have psychotic symptoms
- Specifiers: anxious distress, mixed features, melancholic features, atypical features, mood congruence (belief/action consistent with mood), mood incongruence (belief/action inconsistent with mood), catatonia, peripartum onset, seasonal pattern, rapid cycling
- Rapid cycling (Bipolar I or II): four or mood episodes within a year (must have a period of remission OR a switch to opposite polarity)
- Manic, hypomanic, mixed (same pole) vs depressive (opposite pole)
- Rapid cycling (Bipolar I or II): four or mood episodes within a year (must have a period of remission OR a switch to opposite polarity)
7
Q
For bipolar II:
- Criteria
A
Bipolar II Disorder
- Presence of one or more major depressive episode AND one or more hypomanic episode
- No full manic or mixed manic episodes
- Specifiers: same as Bipolar I
8
Q
For cyclothymia:
- Criteria
- Duration?
- Maximum hiatus?
A
Cyclothymia
- Criteria: numerous periods with hypomanic sx that DO NOT meet criteria for hypomanic and depressive sx or major depression
- Must be present for at least half the time with no hiatus longer than 2 months
- Criteria for major depressive, manic, or hypomanic episodes have not been met
- Duration: 2 years (1 year in children)
9
Q
What is the goal for bipolar tx?
What is the first line?
A
- Goal: treat acute sx, prophylaxis (minimize risk of switching via antidepressants)
- Lithium (gold-standard for bipolar disorder)
10
Q
For lithium:
- Use?
- Proposed MOA
- Pharmokinetics
A
- Lithium (gold-standard for bipolar disorder)
- Use: first-line (if severe, add anti-psychotics)
- Proposed MOAs:
- Interactions with cation transport process by substituting for Na+ → direct effect on NTs (i.e. serotonin, dopamine, NE, Ach) OR inhibits PIP3 pathway
- Pharmacokinetics: eliminated in kidneys (reabsorbed at PCT)
11
Q
For lithium:
- Side effects/teratogenicity?
- Toxicity effects?
- Drug interactions?
- What labs must be monitored?
A
- Lithium (gold-standard for bipolar disorder)
- Side Effect
- Teratogenicity (cardio malformations: Ebstein’s anomaly), goiter, hypotonia, CNS depression
- SE: tremor, hypothyroidism (weight gain, GI distress, fatigue), nephrogenic diabetes insipidus (ADH inhibited → polyuria), metallic taste
- Monitor: TSH, T4
- Toxicity (low therapeutic index): excessive dose, dehydration, sodium depletion, meds (thiazide diuretics, ACEis, NSAIDs, calcium channel blockers)
- Signs/sx (increasing toxicity): N/V/D → confusion, seizures, hyperreflexia → cardiac arrhythmia
- Side Effect
12
Q
For valproate:
- Use
- MOA
- SE
- Drug interactions
- Labs monitored?
A
- Valproate
- Use: less severe bipolar disorder, rapid cycling
- MOA: blockage of voltage-sensitive Na+ channel; increases GABA
- SE: HA, N/V, hepatotoxicity, teratogenicity (neural tube defects), pancreatitis, PCOS, weight gain, low platelets
- Drug interactions: weak CYP450 inhibitor (inhibits lamotrigine)
- Monitor: LFTs, coag tests
13
Q
For carbamazepine:
- Use
- MOA
- SE
- Drug interactions
- Labs monitored?
A
- Carbamazepine
- Use: rapid cycling
- MOA: block voltage-sensitive Na+ channel; decreases Glutamate
- SE: agranulocytosis, hyponatremia, induces CYP enzymes, Steven Johnsons, teratogenicity (neural tube defects), drowsiness, SIADH
- Monitor: drug concentration
14
Q
For oxycarbazepine:
- Use
- MOA
- SE
- Drug interactions
- Labs monitored?
A
- Oxcarbazepine:
- Use: rapid cycling
- MOA: block voltage-sensitive Na+ channel; decreases Glutamate
- SE: somnolence, hyponatremia
- Drug interactions: CYP inhibitor/inducer
15
Q
For lamotrigine:
- Use
- MOA
- SE
- Drug interactions
- Labs monitored?
A
- Lamotrigine
- Use: depressed phase (or lithium – antidepressants are not indicated)
- MOA: block voltage-sensitive Na+ channels; decreases Glutamate
- SE: Steven-Johnsons
- Drug interactions: affected by valproate
16
Q
What is the epidemiology of anxiety?
A
- Epidemiology: females>male, onset late teens to early adulthood, often have other psych disorders
17
Q
What are the sx of anxiety by the following systems?
- Cardiac
- Pulm
- Neuro
- Psych
- Other
A
- Symptoms of anxiety (associated with NT imbalance)
- Cardiac: palpitations, tachycardia, hypertension
- Pulmonary: SOB, choking sensation
- Neuro: dizziness, lightheadedness, hyperreflexia, mydriasis (dilation), tremors, tingling in periphery
- Psych: restlessness, butterflies
- Other: sweating, GI issues, urinary urgency, “lump in throat”, feeling of MI
18
Q
What parts of the brain are involved in anxiety?
A
- Neuroanatomy: amygdala (hyperactivated during anxiety), medial prefrontal cortex (involved), hippocampus (involved)
19
Q
Etiologies of anxiety (meds or medical?)
A
- Etiologies of anxiety
- Medical: hyperthyroidism, B12, hypoxia, neuro diseases, CVD, anemia, pheochromocytoma, hypoglycemia
- Meds: caffeine, alcohol, amphetamines, mercury, penicillin, antidepressants
20
Q
For general anxiety disorder:
- Criteria
- Duration?
A
Generalized Anxiety Disorder
- Criteria: excessive worry more days than not for at least 6 months
- Must be associated with three of the following: restlessness, easily fatigued, difficult concentrating, irritability, muscle tension, sleep disturbance
- Causes significant distress or impairment
21
Q
For panic attack:
- Criteria
- Duration?
- Seen with what disorders?
- Etiology
- Presentation
A
Panic Attack
- Description: discrete periods (10-25 minutes) of heightened anxiety and fear
- Criteria (PANICS) – 4 of any of the following: Palpitations, Abdominal distress, Numbness/Nausea, Intense fear of death, Choking/Chills/CP, Sweating/Shaking/SOB
- Can be seen in any anxiety disorder (PTSD, phobias, panic disorders, etc)
- Etiology: strong genetic component, alcohol
- Presentation: commonly present to other specialties because it presents similar to an MI
22
Q
What are provocative studies for panic attack?
A
- Etiology: strong genetic component, alcohol
- Provocative studies: Na lactate, CO2, Caffeine, MCPP (5-HT agonist), cholecystokinin, Yohimbine (alpha-2 agonist), isoproterenol (beta agonist – similar to epi/norepi)
23
Q
For panic disorder:
- Criteria?
- What are episodes chraxterized by?
A
Panic Disorder
- Criteria: at least 2 recurrent unexpected panic attacks followed-by one month with:
- Persistent worry of additional attacks, worry about implications of attacks, change in behavior due to the attacks
- Episodes must be characterized by: acute onset with no trigger, peaks and subsides within minutes, autonomic symptoms, anticipatory anxiety, and PANICS sx
- Can be present with or without agoraphobia
24
Q
What is the general definition of a phobia?
A
- General (most common anxiety disorders)
- Definition: irrational fear that leads to avoidance/escape of the feared object or situation
25
For specific (simple) phobia:
* Criteria
* Tx
* Specific (Simple) Phobias
* Criteria: marked or persistent fear that is excessive cued by presence/anticipation of a specific object or situation
* Exposure bring about an immediate out of proportion anxiety response
* Patient recognizes fear is excessive
* Interferes significantly with persons routine of function
* Situation is avoided when possible or tolerated with intense anxiety
* If patient is \< 18, the fear must last \> 6 months
* Tx: gradual systemic desensitization to feared object or situation
26
For scoial phobia (aka social anxiety disorder)
* Criteria
* Is the patient aware that their fear is excessive?
* Social Phobia (Social anxiety disorder)
* Criteria: fear of being focus of attention or behaving in an embarrassing way → leading to avoidance of social situation (i.e. public speaking, public toilets, attending parties
* Patient acknowledges fear is excessive
27
For agoraphobia:
* Criteria
* Duration
* Agoraphobia
* Criteria: marked fear or anxiety for more than 6 months about 2 of the following situations:
* Use of public transportation, being in open spaces, being in enclosed spaces, standing in line/being in crowd, being outside of home alone
* Fears or avoids these situations because escape will be difficulty
* Anxiety is out of proportion
* Situation is avoided or endured with anxiety
* Interferes with routine of function
28
For Obssessive compulsive disorder:
* Types (4 - define each)
* Criteria
* Duration
* Specifiers
* Co-morbidities
* Tx
**Obsessive Compulsive Disorder (OCD)**
* Types: Body Dysmorphic Disorder (not satisfied with appearance of body), hoarding disorder (collecting items for obsessive reason), trichotillomania (pulling body hair), excoriation disorder (picking at skin)
* Criteria: obsessions AND/OR compulsions cause marked distress, take \>1 hour/day OR cause distress/impairment in function
* Specifiers: good/fair insight (thoughts are not true), poor insight (probably true), absent insight (OCPD – not aware that thoughts/actions are crazy), tic-related
* Co-morbidities: depression
* Tx: psychosurgery (cingulatomy)
29
For Obssessive compulsive disorder:
* Epidemiology
* Define obsessive
* Define compulsion
* Define the etiologies (genetic, biological, childhood etiology\*\*)
**Obsessive Compulsive Disorder (OCD)**
* General (F=M; M earlier onset; chronic course)
* Obsessive: recurrent and intrusive thought, feeling or idea that is ego-dystonic (i.e. germs)
* Compulsion: repetitive, irresistible, time-consuming ritual that is performed in attempt to neutralize anxiety due to obsession (i.e. washing, hoarding)
* Etiologies:
* Genetics: high concordance in twins
* Biological: serotoninergic dysfunction, abnormalities in cortico-striatal-thalamic-cortical circuit, dysfunction of caudate nucleus, head injury, epilepsy
* Childhood OCD (often due to PANDAS – streptococcal autoimmune disorder of basal ganglia) – tx with penicillin, plasmapheresis
30
For PTSD:
* Criteria (mnemonic)
* Duration
**Post-Traumatic Stress Disorder (PTSD)**
* Criteria: exposure to you or a close person of actual or threatened death, serious, or sexual violence in one or more of the following ways (HARD)
* **H**yperarousal (2+ of these): problem sleeping, anger, hypervigilance, increased startle response, concertation issues
* **A**voidance of associated stimuli
* **R**e-experience of event (1+ of these): intrusive memories, nightmares, dissociative reactions, distress with cue of event (Tx: prazosin)
* **D**etachment (2+ of these): numbness of cognition or mood → diminished interest, detachment, inability to experience positive emotions, etc.
* Specifiers: dissociative (depersonalization), delayed expression (do not meet criteria until 6 months later)
* Duration: \>1 month
* Acute Stress Disorder: symptoms last \<1 month after trauma
31
Non-pharm tx for anxiety disorders
* Non-pharmacological: CBT, Desensitization, group therapy, psychotherapy
32
List tx options for anxiety disorders
antidepressants (SSRI, SNRI, TCA, MAOIs), Benzos, Z comounds, beta agonsits, 5-HT1A agonist
33
What are antidepressants used for in tx of anxiety disorders?
* Antidepressants (SSRI, SNRI, TCA, MAOI): maintenance; not acute anxiety
34
Benzodiazapine:
* Use in anxiety disorder
* MOA
* Metabolism
* Examples (short and long half life)
* SE:
* Benzodiazepines: acute anxiety, preventative if long half-life
* MOA: enhance the effect of GABA by binding on GABA A receptor → increased rush of chlorine into post-synaptic neuron
* Metabolism: well absorbed, metabolized by CYP, excreted as glucuronide conjugates in urine
* Example:
* Short half-life: alprazolam (Xanax), Triazolam, Lorazepam (Ativan)
* Long half-life: diazepam (Valium), Chlordiazepoxide (Librium)
* SE: tolerance (increased dose to produce effect), sedation, ataxia, anterograde amnesia, confusion, muscle weakness, withdrawal (anxiety, insomnia, muscle twitches/tremors, etc)
35
For "Z" compounds
* Examples
* MOA
* SE
* “Z” Compounds (Zolpidem, Zopiclone) – structurally unrelated to benzos
* MOA: same as benzodiazepines
* SE: less than benzos (no tolerance, no physical dependence, no sleep disturbance)
36
For 5-HT1A agonist
* Example
* MOA
* Disadvantage
* Advantages
* 5-HT1A agonist (i.e. buspirone)
* MOA: partial agonist for 5-HT1A receptors in brain
* Disadvantages: Slow onset of action; short half-life (needed 2-3x per day)
* Advantages: no physical dependence, no abuse potential, less sedation, less interaction with alcohol
37
Screening questions for following anxiety disorders:
* panic attack
* generalized anxiety disorders
* PTSD
* OCD
* social anxiety disorder
**Questions to Screen for Anxiety Disorders**
* Have you ever experienced a panic attack? (panic attack)
* Do you consider yourself a worrier? (General anxiety disorder)
* Have you ever had anything happen that still haunts you? (PTSD)
* Do you get thoughts stuck in your head that really bother you or need to do things over and over like washing your hands or checking things? (OCD)
* When you are in a situation that people can observe you, do you feel nervous and worry that they will judge you? (social anxiety disorder)
38
Define classic conditioning
* Classical conditioning (Pavlov’s experiment): correlating an involuntary natural response/behavior (salivation) with a conditioned/learned stimulus (bell) via pairing with an unconditioned stimulus (food)
39
# Define operant conditioning:
* Define reinforcement, punishment, exctinction
* Operant conditioning: voluntary behaviors based on punishment and reward
* Reinforcement: target behavior is followed by reward (positive reinforcement) or removal of a negative stimulus (negative reinforcement)
* Punishment: repeated application of negative stimulus (positive punishment) or removal of reward (negative punishment) to extinguish unwanted behavior
* Extinction: discontinuation of reinforcing/stimulus eventually eliminates behavior
40
Define transference and countertransference.
* Transference: patient projects feelings about formative or other important persons onto physician (i.e. psychiatrist seen as parent)
* Countertransference: doctor projects feelings about formative or other important persons onto patients (i.e. patient reminds physician of sibling)
41
Fill in the defense mechanisms
42
Fill in defense mechanisms
43
Fill in defense mechanisms
44
# Define personality disorders:
Do they have insight?
* Definition: deeply engrained inflexible patterns of relating toNext others that are maladaptive and cause significant impairment in social and occupational functioning
* Patients lack insight of their problem and sx are viewed as ego-syntonic (behaviors that are acceptable to one’s self-image)
45
What are the big 5 personality traits (mnemonic)
* “Big 5” Personality Traits (OCEAN): **O**penness to experience, **C**onscientiousness, **E**xtraversion**, A**greeableness, **N**euroticism (personality disorders have variations of these)
46
Criteria for personality disorder?
* Criteria for personality disorders:
* Pattern of behavior that deviates from culture and is manifested in at least two of the following ways:
* Cognition, affect, personal relations, impulse control
* Pattern:
* Pervasive and inflexible in a broad range of situations
* Is stable and onset during adolescence/early adulthood
* Leads to significant distress and functioning
* Not accounted by another medical condition/substance
47
Define cluster a personality disorders and what three disorders are included?
**CLUSTER A**
* Definition: odd or eccentric inability to develop meaningful relationships; no psychosis; genetic association with schizophrenia
**Paranoid (M\>F)**
**Schizoid**
**Schizotypal**
48
For paranoid disorder:
* Define
* General sx?
**Paranoid (M\>F)**
* Pervasive distrust (**A**ccusatory) and suspicious of others and profoundly cynical view of the world
* General sx: hypervigilant, unforgiving, unjustified doubts, unwarranted fear, feels threatened at all times
49
For schizoid disorder:
* Define
* General sx?
* Voluntary social withdrawal (**A**loof), limited emotional expression, content with social isolation
* Sx: cannot form relationships, loner, emotionally cold
50
For schizotypal disorder:
* Define
* Sx
**Schizotypal**
* Eccentric appearance, odd beliefs or magical thinking (interpersonal **A**wkwardness)
* Sx: illusions, weird looking, weird speech (i.e. Willy Wonka)
51
For cluster B:
* Define
* what disorders?
**CLUSTER B**
* Definition: dramatic, emotional or erratic; genetic association with mood disorders and substance abuse
* Disorders: antisocial, borderline, histrionic, narcissistic
52
For antiscoial personality disorder
* Define
* Hx
* Sx
**Antisocial (M\>F; Age\>18)**
* Disregard for and violation of rights of others with a lack of remorse, criminality, impulsivity; **B**ad
* Hx of conduct disorder (aka antisocial PD \<18y/o) before age 15
* Sx: law-breakers, reckless, lack of remorse
53
For borderline:
* Definition
* Sx
**Borderline (F\>M)**
* Unstable mood and unstable interpersonal relationships, impulsivity, self-mutilation, suicidality, sense of emptiness (**B**orderline)
* Splitting (viewing others as all good or all bad) is a major defense mechanism
* Sx: aggressive, try to avoid abandonment
54
For histrionic:
* Define
* Sx
**Histrionic**
* Excessive emotionality and excitability, attention-seeking, sexually provocative, overly concerned with appearance (**B**asic **B**itch)
* Sx: talkative, seductive
55
For narcissistic:
* Define
**Narcissistic**
* Grandiosity, sense-of-entitlement, lacks empathy, requires excessive admiration; often demands the best and reacts to criticism with rage (**B**est)
56
For CLUSTER C:
* Define
* Disorders
**CLUSTER C**
* Definition: anxious or fearful; genetic association with anxiety disorder
* Disorders: avoidant, dependent, OCPD
57
For avoidant PD:
* Definition
* Sx
**Avoidant**
* Hypersensitive to rejection; socially inhibited; timid; feelings of inadequacy; scared to develop relationships with others out of fear of embarrassment (but internally desired) (**C**owardly)
* Sx: introverted, anxious, low self-esteem, scared of being rejected
58
For dependent PD:
* Definition
* Sx
**Dependent**
* Submissive and **C**lingy; excessive need to be taken care of; low self-confidence
* Sx: reliance on others to make decisions, fear of abandonment, overly-reliant
59
For obsessive compulsive
* Definiton
* Sx
**Obsessive-Compulsive**
* Preoccupation with order, perfectionism, and control; ego-syntonic (behavior consistent with one own’s belief/attitudes) (**C**ompulsive)
* Sx: perfectionist, competitive
60
abuse definiton
and criteria
* Abuse: pattern of substance use → impairment or distress for at least 12 months with one or more of the following manifestations (WILD):
* **W**ork, school or home role obligation failure
* **I**nterpersonal or social consequences
* **L**egal problems
* **D**angerous use (i.e. while driving)
61
dependence def and criteria
* Dependence: substance use → impairment of distress manifested by 3 of the following within a 12-month period
* Tolerance (more drug is required to achieve effect)
* Withdrawal
* Using the substance more than originally intended
* Unsuccessful efforts to cut down on use
* Significant time recovering/using substance
* ↓ occupational/recreational activity secondary to substance use
* Continued use despite subsequent physical problems
62
opioids
examples, MOA for euphoria and analgesia
* Examples: morphine/codeine, oxycodone (semi-synthetic opioids), fentanyl (synthetic opioid)
* Demerol (Meperidine) dilates pupils (exception)
* Tramadol: can cause serotonin syndrome (careful with SSRI); less addiction potential
* MOA (euphoria): binds to Mu receptor → ↓ release of GABA → lack of GABA stimulation → dopamine release from neighboring neuron (Opioid = dope)
* Acts at nucleus accumbens (reward)
* MOA (analgesia): binds to Mu-GPCR→ hyperpolarization → ↓ NT → analgesia
* Acts at anterior cingulate cortex, thalamus, periaqueductal gray (pain areas)
63
opioid
toxidrome and withdrawal
tx for each
* Toxidrome (all decreases): ↓ HR/BP, ↓ RR (overdose risk), ↓ temp, ↓ pupil size (constriction), ↓ bowel sounds, ↓ sweating, euphoria
* Tx: naloxone (opioid antagonist)
* Withdrawal (opposite of toxidrome): dilated pupils, tachycardia/HTN, V/D, insomnia, sweating, craving for drug, dysphoria, piloerection (goosebumps), myalgia
* Tx (not life-threatening)
* Methadone (long-acting opioid full agonist)
* Buprenorphine (partial opioid receptor agonist)
* Naltrexone (competitive opioid antagonist)
64
cocaine
MOA, toxidrome, withdrawal
tx and complications
* MOA: dopamine reuptake inhibitor
* Toxidrome (all increases): ↑HR/BP, ↑RR, ↑Temp, ↑pupil size (dilation), ↑bowel sounds, ↑sweating
* Complications: arrhythmias, MI, respiratory distress
* Acute management for agitation: benzodiazepines or anti-psychotics (severe)
* Withdrawal (opposite of toxidrome): constricted pupils, malaise, fatigue, hypersomnolence, depression, vivid dreams, psychomotor agitation
* Tx: supportive (not life-threatening)
65
**Amphetamines**
classic MOA and designer MOA
examples for each
* Classic MOA: blocks reuptake → facilitates release of dopamine and NE from nerve endings → stimulant
* Examples: methamphetamine (“speed”, “meth”), Ritalin, Dexedrin
* Use: ADHD, narcolepsy, depression
* Substituted (designer) MOA: release of dopamine, NE, and serotonin from nerve endings → stimulant, hallucinogen
* Examples: MDMA (Ecstasy)
66
amphetamines
toxidrome
chronic complications
* Toxidrome (all increases): ↑HR/BP, ↑RR, ↑Temp, ↑pupil size (dilation), ↑bowel sounds, ↑sweating
* Chronic use can lead to tooth decay (meth mouth)
67
Sedatives
BZDs an barbituates
MOA and examples
* Benzodiazepine (BDZs) MOA – gamma unit: increases Cl- channel opening → more Cl- in post-synaptic cell → GABA potentiator
* BZDs are not lethal alone
* Examples: Diazepam (Valium), alprazolam (Xanax), Chlordiazepoxide (Librium), lorazepam (Ativan)
* Barbiturate MOA - beta unit: increases Cl- channel opening → more Cl- in post-synaptic cell → GABA potentiator
68
Sedatives
toxidrome and withdrawal
tx for each
* Toxidrome (all decreased – except eyes): ↓HR/BP, ↓RR, ↓Temp, ↓Bowel sounds, ↓Sweating, drowsiness, slurred speech, ataxia,
* Tx:
* BDZ: Flumazenil (short-acting BDZ antagonist)
* Barbiturate: Na-HCO3 (promotes renal excretion)
* Withdrawal (life threatening): HTN/tachycardia (medical emergency), hand tremor, psychomotor agitation, N/V, anxiety, irritability, sweating
* Complications: tonic-clonic seizure
* Tx: phenobarbital, clonazepam (anti-epileptics)
69
ETOH
MOA, metabolism and toxidrome
* MOA: activates GABA (alpha) and serotonin receptors in CNS → depressant
* Metabolism: alcohol → acetaldehyde (via alcohol dehydrogenase) → acetic acid (via aldehyde dehydrogenase)
* Asian glow: lack aldehyde dehydrogenase (less susceptible to dependence)
* Toxidrome
* \<50 mg/dL: impairment in skilled tasks, increased talkativeness, relaxation
* \>100 mg/dL: ataxia, hyperreflexia, impaired judgement, lack of coordination, nystagmus, slurred speech
* \>200 mg/dL: amnesia, diplopia, N/V, hypothermia, dysarthria
* \>400 mg/dL: respiratory depression, coma, and death
70
ETOH
withdrawal sx and complications
tx for some
* Delirium Tremens (DT): peaks 2-4 days after last drink; characterized autonomic hyperactivity (tachycardia/HTN, tremors, sweating, anxiety, etc)
* Tx: BZDs (Chlordiazepoxide – Librium, Lorazepam, Diazepam) → taper
* Wernicke’s encephalopathy: encephalopathy, oculomotor dysfunction, ataxia
* Korsakoff’s syndrome (chronic dz from untreated Werkicke’s):
* Pathophysiology: necrosis of mamillary bodies (often irreversible)
Sx: Retrograde/anterograde amnesia, confabulation, unaware of illness
71
* Chronic Tx for alcohol dependence
disulfiram, naltrexone, acamprosate, topiramate, gabapentin
MOA and uses
* Disulfiram
* MOA: blocks aldehyde dehydrogenase (Asian glow – flushing, N/V)
* Contraindicated in cardiac disease, pregnancy, LFTs must be monitored, adherence is low
* Naltrexone
* MOA: opioid receptor antagonist → decreases cravings and high associated with alcohol
* Acamprosate
* MOA: GABA-like agonist
* Use: post-detox; indicated in patients with liver disease
* Topiramate
* MOA: GABA potentiator
* Use: reduces cravings
* Gabapentin (only if vital signs are stable)
72
Weed
MOA and toxidrome
* MOA: THC → binding to cannabinoid receptors on presynaptic neuron → inhibition of adenyl cyclase → release of inhibitory NT (GABA)
* Toxidrome: impaired motor coordination, euphoria, anxiety, sensation of slowed time, impaired judgement, conjunctival injection (red eyes), increased appetite, dry mouth, tachycardia
* These symptoms cannot be explained by another substance or mental disorder
* Complications: Cyclic vomiting syndrome (daily vomiting relieved by showering)
* Dx: Stop marijuana use for two weeks to see if causal
73
**Anti-cholinergics**
examples, MOA, toxidrome, SE
* Examples: antihistamines (Benadryl). TCAs (Amitriptyline)
* MOA: inhibition of Ach receptor
* Toxidrome: ↑HR/BP, ↑Temp, ↑pupil dilated, ↓Bowel sounds, ↓Sweating, confusion, agitation
* SE: Hot, dry, blind, red, mad
74
hallucinogens
LSD PCP MOAs
other examples
* LSD MOA: believed to act on serotoninergic receptors
* Toxidrome: VS stable, perceptual distortion, depersonalization, anxiety, paranoia
* PCP MOA: NMDA glutamate receptor antagonist → activates dopamine release
* Toxidrome: anesthetic, dissociative, violence, impulsivity, tachycardia/HTN. Seizures
* Tx: BZDs, rapid-acting anti-psyhotics
* Other example: K2/synthetic marijuana, magic mushrooms, ketamine (anti-depressant effects), MDMA
75
caffeine
MOA, toxidrome, withdrawal
split toxidrome by amount
* MOA: adenosine antagonist → increase in cAMP → stimulant effect via dopaminergic system
* Toxidrome
* 250 mg (2 cups): anxiety, insomnia, muscle twitching, GI problems, tachycardia
* \> 1 g: tinnitus, agitation, cardiac arrhythmias
* \>10 g: death secondary to seizures/respiratory failure
* Withdrawal: headache, nausea, vomiting, depression, irritability
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nicotine
epidemiology, MOA. toxidrome, withdrawal
* Epidemiology: smoking common in patients with mental illness
* Known to increase chronic pain
* MOA: stimulates nicotinic receptors and autonomic ganglia of the SNS/PNS
* Highly addictive via the dopaminergic system
* Toxidrome: restlessness, insomnia, anxiety, increased GI motility
* Withdrawal: cravings, dysphoria, anxiety, decreased HR, increased appetite, insomnia
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nicotine tx
(4) if applicable provide MOA
* Nicotine replacement therapy (patches, gums, sprays)
* Bupropion: antidepressant (partial agonist of nAChR & inhibits dopamine reuptake → reduces withdrawal sx)
* Varenicline: antidepressant (partial agonist of nAChR → mimics nicotine → reduces withdrawal sx)
* Nortriptyline: antidepressant
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**GENERAL SOMATIC/SOMATOFORM DISORDERS**
defintion, epidemiology
* Category of disorder characterized by physical symptoms which cause significant distress and impairment; motivation of these physical sx are unconsciously produced; symptoms are not intentionally feigned
* More common in women
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**Somatic Symptoms Disorder**
criteria, duration, specifers
* Criteria: Excessive thoughts, feelings, or behaviors related to the somatic complaints (variety of body sx – pain, fatigue lasting for many years) that may occur with an actual medical illness manifested by at least ONE of the following:
* Disproportionate/persistent thoughts about seriousness of sx
* Persistent high levels of anxiety about health/sx
* Excessive time and energy devoted to sx/health concerns
* Must cause distress or disrupt daily life
* Patient must be persistently symptomatic (\>6 months)
* Specifiers: pain disorder, persistent, somatization, hypochondriasis
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**Illness Anxiety Disorder (aka hypochondriasis)**
description, duration and specifiers
* Description: preoccupation with having/acquiring a serious illness despite medical evaluation and reassurance; often excessively performs health-related behaviors
* Minimal somatic sx exist
* Must be present for at least 6 months
* Specifiers: care-seeking, care-avoidant
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**Conversion Disorder**
description, criteria, examples
* Description: patients who have a neurological symptom that cannot be explained by a medical disorder following a psychological stressor
* Criteria
* At least one neurological symptom
* Psychological factors associated with initiation or exacerbation of sx
* Not intentional feigned or produced
* Causes significant distress; not explained by another conditions
* Common examples: paralysis, blindness, mutism, seizures, paresthesias
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**Physiological Factors Affecting Other Medical Conditions**
example and criteria
* Examples: anxiety aggravating asthma, ignoring heart attack sx
* Criteria
* A medical sx or condition (other than mental disorder) is present
* Psychological/behavioral factors adversely affect the condition in the following manner:
* Delays recovery, interferes with treatment, increases health risks, or exacerbates pathophysiology/sx
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**Other Specified Somatic Symptom and Related Disorders**
criteria
* Criteria:
* Brief somatic symptom disorders (sx last \< 6 months)
* Brief illness anxiety disorder (sx last \< 6 months) OR illness anxiety disorder without health-related behaviors
* Pseudocyesis: a false belief of being pregnant due to objective signs/sx of pregnancy
84
**Unspecified Somatic Symptom and Related Disorders**
**description**
* Not meeting full criteria
* Unusual situations where there is insufficient info to make another dx
85
**GENERAL FACTITIOUS DISORDERS**
**factitious and malingering**
**define each**
* Both of the following do not exclude the presentation of a true medical diagnosis
* Factitious (primary gain): Patient consciously creates physical or psychological sx in order to assume “sick role” and to get medical attention and sympathy
* Peregrination (wandering from treatment setting to treatment setting)
* Pseudological Fantastica: fantastic liar
* Malingering (secondary gain): patient consciously fakes or exaggerates having a disorder to attain a secondary gain (i.e. avoiding work) à poor compliance with healthcare/ceases feigning after gain
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**Factitious Disorder Imposed on Self**
criteria
whats another name
* Criteria: – aka Munchausen syndrome: disorder with physical signs and sx characterized by a history of multiple hospital admissions and willingness to receive treatment
* Deceptive behavior is evident even in the absence of obvious external rewards
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**Factitious Disorder Imposed on Another**
**criteria**
* Criteria: falsification of physical/psychological sx or a disease in another person via deception
* Deceptive behavior is evident even in absence of obvious external rewards
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**Diagnostic Criteria of Delirium**
* Disturbance in attention and awareness
* Develops over a short period of time (hours to days) and tend to fluctuate in severity over the period of a day
* An additional disturbance in cognition (memory, disorientation, language, perception)
* Hallucinations, illusion, misperceptions, disturbances in sleep
* Not explained by another neurocognitive disorder
* Consequence of another medical condition, substance intoxication, or withdrawal
* Hepatic encephalopathy, alcohol withdrawals, overdose of antidepressant, secondary to UTI
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**Delirium**
**sutypes, risk factors, etiologies,**
* Subtypes: hyperactive (hyperaroused, hyperalert, agitated), hypoactive (hypoaroused, hypoalert, lethargic), mixed
* Risk Factors: age, dementia, alcohol abuse, male, sensory impairment
* Etiologies: drugs, withdrawal states, electrolyte disturbances, endocrine disturbances (glucose), nutritional issues, organ failure (liver, renal, cardiac, pulmonary), CNS infections, seizures, head injury, sepsis
90
delirium
pathophys, dx
* Pathophysiology: deficiency of Ach, elevation of dopamine/Glutamate/GABA/histamine/ serotonin/cortisol/inflammatory markers
* Dx: EEG shows diffuse slowing
91
**Treatment of Delirium**
* Environmental: changing light, correcting visual/auditory impairments, reorient to person, place, and time
* Pharmacological
* First line: haloperidol (typical psychotic)
* Benzos for withdrawal from alcohol/benzos/barbiturates or seizures
* Cholinergic meds are only indicated in cases caused by anticholinergics or antihistamines (may have secondary anticholinergic effects)
* Avoid anticholinergic drugs in treatment
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**Work-up for Dementia**
* Screen for the following: depression (pseudodementia), sleep apnea, cognitive testing, MMSE, Alzheimer Disease Assessment Scoring, check for other causes:
* MRI (stroke, MS), EEG, Metabolic (CBC, B12, glucose), Hormone levels (cortisol, testosterone), Autoimmune (ESR, ANA, thyroid), infection (HIV, Lyme, meningitis, CJD, neurosyphilis)
* Rule out pseudodementia (dementia secondary to depression/hypothyroidism)
* Pseudodementia: acute-onset dementia in which the patient is aware of their disease à treat with antidepressants
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**Dementia**
**define, reversible and irreversible etiologies**
* Definition: a decrease in intellectual function without affecting level of consciousness
* Etiology:
* Irreversible (true dementia): Alzheimer’s, Lewy Body dementia, Huntington’s, Pick disease, cerebral infract, Wilson Disease, Creutzfeldt-Jakob Disease, substance abuse, HIV, vascular dementia, progressive supra-nuclear palsy
* Reversible (presents like dementia): hypothyroidism, depression, Vit deficiency (B1/B3/B12), normal pressure hydrocephalus, neurosyphilis
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dementia
risk factors, sx, dx, complications
* Risk Factors: older age, FHx, risks associated with stroke, alcohol, head trauma, Trisomy 21 (via Alzheimers early onset)
* Sx: memory deficits, apraxia, aphasia, agnosia, loss of abstract thought, behavior/personality changes, impaired judgement
* Dx: EEG is normal, Fluorodeoxy glucose PET, atrophy on MRI/CT
* Complications: delirium
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**Treatment**
**for Alzheimers related dementia**
**name 3**
**know general MOA**
Cholinesterase inhibitors (Donepizil, galantamine, rivastigmine)
Memantine
Anti-amyloid
