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334 Cards in this Set
- Front
- Back
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Schizophrenia
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Disorder that lasts at least 6 months and includes at least 1 month of active-phase, typically psychotic symptoms
Social and/or occupational dysfunction must be present |
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Schizophreniform disorder
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Symptomatic presentation that is equivalent to schizophrenia except the entire course of illness lasts 1-6 months and there need not be decline in function
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Schizoaffective disorder
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Mood episode and active phase symptoms of schizophrenia occur together and were preceded or followed by at least 2 weeks of delusions of hallucinations w/o mood symptoms
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Delusional disorder
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At least 1 month of non-bizarre delusions w/o other active phase symptoms of schizophrenia
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Brief psychotic disorder
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symptoms last more than one day and remit by 1 month
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Psychotic disorder due to a general medical condition
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Psychotic symptoms are judged to be a direct physiological consequence of a medical condition
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Substance-induced psychotic disorder
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Psychotic symptoms are judged to be a direct physiological consequence of drug abuse, a medication, or toxin exposure
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Schizophrenia and other psychotic disorders
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Illnesses characterized by gross impairment in reality testing and the creation of a new reality
Direct evidence of psychotic behavior is the presence of either delusions or hallucinations |
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Mood disorders
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Disturbance of pervasive and sustained emotion (mood) that color psychic life and are accompanied by elation (mania) or depression
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Major depressive disorder
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At least 2 weeks of depressed mood or loss of interest accompanied by other symptoms of depression
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Dysthymic disorder
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At least 2 years of depressed mood accompanied by additional depressive symptoms that do not meet criteria for MDD
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Bipolar I disorder
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One or more manic or mixed by MDD
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Bipolar II disorder
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One or more MDD episodes accompanied by at least one hypomanic episode
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Cyclothymic disorder
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At least 2 years of numerous periods of hypomanic symptoms and numerous periods of depressive symptoms
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Mood disorder due to a medical condition/substance abuse
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JUST KNOW AS A POSSIBILITY
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Anxiety disorders
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Disorders characterized by apprehension, tension, and unease and are often accompanied by avoidant behavior
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Panic disorder with agoraphobia
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Recurrent panic attacks with avoidance of place or situations from which escape might be difficult in the event of a panic attack
Can also have PD w/o agoraphobia |
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Specific phobia
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Anxiety provoked by exposure to feared object or situation often leading to avoidance
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Social phobia
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Anxiety provoked by social or performance situations often leading to avoidance
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OCD
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Recuurent intrusive thoughts (obesessions) which cause marked anxiety and distress and/or compulsions (acts) which serve to neutralize anxiety
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PTSD
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Re-experiencing of an extremely traumatic event accompanied by symptoms of arousal and avoidance
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Generalized anxiety disorder
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At least 6 months of persistent and excessive anxiety and worry
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Substance related disorders
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Alcohol dependence
Alcohol abuse Alcohol intoxication syndromes Alcohol withdrawal syndromes Substance intoxication syndromes Substance withdrawal syndromes |
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Anorexia nervosa
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Refusal to maintain minimally normal body weight
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Bulemia nervosa
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Binge eating followed by inappropriate compensatory behaviors
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Somatoform disorders
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Physical symptoms that suggest physical disorders for which there are no organic findings; symptoms are linked to psychological factors
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Somatization disorder
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Polysymptomatic disorder beginning before age 30 that persists for years
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Conversion disorder
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Symptoms of deficits affecting voluntary motor or sensory function; psychological factors are associated with symptoms
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Hypochondriasis
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Fear or idea of having a serious illness
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Body dysmorphic disorder
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Preoccupation with imagined or exaggerated defect in physical appearance
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Pervasive developmental disorders
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Pervasive and severe impairments in several areas of development
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Attention deficit/hyperactivity disorder
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Persistent pattern of inattention and/or hyperactivity-impulsivity
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Separation anxiety disorders
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Excessive anxiety concerning separation from home or from those to whom the person is attached
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Mood
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Sustained emotion which markedly colors behavior, affect, and thought
May not be obvious to a person when it is normal, but is certainly obvious when it is abnormal |
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Affect
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What the person is feeling at the moment and is assessed through observation and inquiry; reported affect may be incongruent with the observations
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Normal affect
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Full affective play in response to internal and external stimuli
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Restrict/blunt affect
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Diminished to minimal emotional responsiveness that is inappropriate to situation
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Flat affect
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Significant lack of responsiveness, accompanied by an expressionless voice and face
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Labile affect
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Feelings that change rapidly
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Inappropriate affect
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Feelings that are incongruent with the content being discussed
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Sexual dysfunction
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Sexual desire disorders
Sexual arousal disorders Orgasmic disorders Pain disorder |
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Form
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How is thinking organized
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Circumstantial
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Individual is unable to report with attention to useful detail before reaching the point or answering a question
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Tangential
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Individual digresses into unnecessary detail to such a degree that he or she does not answer the question, but answers another question
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Loosening of associations
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Links between thoughts are destroyed and bizarre; illogical and chaotic thinking results
"Derailment" |
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Flight of ideas
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A succession of thoughts with rapid shifting from one idea to another
The point of conversation or the answer to a question is never reached |
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Blocking
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Sudden interpretation of a train of speech before the idea has been completed
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Clanging
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The sound of a word, rather than its meaning, gives the direction to subsequent associations
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Neologism
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Creation of new words coined by a person and not understandable to others
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Perseveration
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Persistent repetition of words, ideas, or subjects, so that once a person begins to speak about aa particular subject, it continually recurs
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Obsessive thoughts
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Recurrent, persistent thoughts are experienced as intrusive and inappropriate
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Phobic preoccupation
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Fears which are often experienced as excessive, but nonetheless lead to avoidance behavior
Ex: fear of germs, fear of contamination |
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Odd or bizarre thinking
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Ideas of references, extremely superstitious or superstitions that fall short of delusional intensity
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Delusion
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Thought, idea, or belief with three characteristics
-Not true -Cannot be reasoned with -Out of harmony with the individual's educational or cultural background and surroundings; not shared by individual's cultural/religious group |
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Systematized delusion
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If certain premises are granted, one can derive a whole set of delusions that appear to have a coherent and connected organization
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Unsystematized delusion
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Beliefs appear bizarre, contradictory, and fragmented
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Schneiderian symptoms
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Delusions of thought insertion, thought withdrawal, thought broadcasting, alien control
Distinction between self and non-self is lost, person is a "puppet" |
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Hallucination
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Sensory misinterpretation which occurs without any external stimulus and is classified in terms of sensory spheres involved
Visual and auditory most common |
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Schneiderian symptoms of hallucination
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Two or more voices having conversations about the self
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Illusion
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Sensory misinterpretation which occurs with external stimuli
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Depersonalization
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Alteration in perception or experience of the self so that one feels detached, as if one was an outside observer
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Derealization
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Alteration in perception or experience of the outside world so that it seems strange or unreal
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Axis I
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Clinical syndromes
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Axis II
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Personality disorders
Mental retardation |
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Axis III
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General medical conditions
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Axis IV
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Psychosocial and environmental problems
Problems with primary support group Problems related to the social environment Educational problems Occupational problems |
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Axis V
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Global assessment of functioning (GAF)
70 - mild symptoms 60 - moderate symptoms 50 - serious symptoms 40 - behavior considerably influenced by hallucinations and delusions, or inability to function in almost all areas |
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Mental status examination
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Description - appearance, non-verbal behavior, characteristics of talk, relatedness to interviewer
Mood and affect Thought - form and content Perception Cognitive function - LOC, attention, orientation, memory, general intellectual evaulation Insight into the presence or nature of illness |
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Schizophrenia category A symptoms
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Delusions
Hallucinations Disorganized speech Grossly disorganized or catatonic behavior Negative symptoms |
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Only 1 criterion A symptom is required if...
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Delusions are bizarre or
Hallucinations consist of a voice keeping a running commentary on the person's behaviors or thoughts Two or more voices conversing with each other |
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Schizophrenia diagnosis (B-F)
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Social/occupational dysfunction
Continuous for at least 6 months including prodrome and residual Schizoaffective/mood disorder exclusion Substance/GMC exclusion Relationship to pervasive developmental disorder |
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Paranoid schizophrenia
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Preoccupation with one or more delusions ro frequent auditory hallucinations
No disorganized speech, disorganized or catatonic behavior, flat or inappropriate affect |
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Disorganized schizophrenia
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All of the following are prominent:
Disorganized speech Disorganized behavior Flat or inappropriate affect |
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Catatonic schizophrenia
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At least 2 of the following:
Motoric immobility as evidenced by catalepsy Excessive motor activity Extreme negativism Peculiarities of voluntary movement Echolalia or echopraxia |
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Undifferentiated schizophrenia
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Criterion A met, but criteria for other subtypes not met
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Bleulerian criteria
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Four A's
Affect Association (loose) Autism (preference for fantasy over reality) Ambivalence |
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Schneiderian criteria
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Delusions
Somatic hallucinations Commenting auditory hallucinations Hearing one's thoughts spoken aloud Thought broadcasting |
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Positive symptoms - functions distorted
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Hallucinations
Delusions Disorganized speech Bizarre behavior |
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Negative symptoms - functions diminished
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5 A's
Alogia - loss of fluency Affective blunting Avolition - loss of drive Anhedonia - problems with pleasure Attention impairment |
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Dopamine hypothesis (Schz.)
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Positive symptoms are due to overactivity of DA pathways
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Neurodevelopmental hypothesis (Schz.)
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Primary event(s) resulting in Schizophrenia are the result of changes in utero or in the perinatal period that disrupt the developmental aspects of brain structure and function such as myelination or synaptic pruning
-Obstetric -Environmental |
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Males with schizophrenia
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Earlier onset (3-4 years)
Poorer premorbid function Poorer outcome Minor physical anomalies Greater structural brain anomalies |
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Females with schizophrenia
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Greater temporal and spatial variations in rate of occurrence
Greater susceptibility to second trimester influenza Greater susceptibility to first trimester dietary insufficiency Difference may be related to protective effects of estrogen via DA blocking effect at D2 receptors |
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DRSC theory of schizophrenia
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Early in development, synaptogenesis creates connections randomly, with subsequent selective elimination of weaker connections based upon experience and endogenous factors
In schizophrenia, reduced synaptic density in PFC and other areas of association cortex |
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Schizophrenia treatment
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Pharmacotherapy
Individual psychotherapy Family evaluation and therapy |
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Conventional antipsychotics
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Primarily D2 blockers
More effective against (+) symptoms High incidence of serious side effects |
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Conventional antipsychotic side effects
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Tardive dyskinesia
Parkinsonian like symptoms Dystonia Akathisia Neuroleptic malignant syndrome Uninhibited prolactin secretion |
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Atypical antipsychotics
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Do not elevate prolactin
Effective against positive and negative symptoms ZA CROQ |
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Atypical antipsychotic side effects
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WASH HOH
Weight gain Anticholinergic Sedation Hyperglycemia Hyperlipidemia Orthostatic hypotension Hypercholesterolemia |
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Positive prognostic signs in schizophrenia
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Supportive family
FH of an affective disorder Premorbid history of good social relationships, school performance |
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Poor prognostic signs
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Insidious onset
FH of schizophrenia Presence of negative symptoms |
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DSM diagnosis of psychosis
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Delusions, hallucinations, disorganized speech, disorganized or catatonic behavior
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Delusional disorder
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One or more bizarre delusions that persist for a month or more
Cannot diagnose if patient has ever been diagnosed with schizophrenia Hallucinations are not prominent Psychosocial functioning is not impaired except by the direct impact of the delusion Types of delusions are few and strikingly repetitive regardless of cause Types - erotomanic, grandiose, jealous, persecutory, somatic |
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Risk factors for delusional disorder
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Increased age
Sensory impairment Family history Social isolation Recent immigration |
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Shared psychotic disorder
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Delusion that arises in someone who is involved in a close relationship with someone who already has a psychotic disorder with prominent delusions
Secondary case is usually passive, gullible, lower self esteem May resolve with separation |
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Schizoaffective disorder
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Chronic illness characterized by concurrent symptoms of schizophrenia as well as major mood disorder
Period of at least 2 weeks when delusions or hallucinations are present w/o prominent mood symptoms Mood symptoms present for a substantial portion of the total duration of the illness Negative symptoms usually less severe than in schizophrenia |
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Psychosis in mood disorders
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Hallucinations or delusions
See in severe depression and mania Usually mood congruent (delusions of persecution/guilt in depression; grandeur in mania) About 15% of MDD will develop psychosis, more common in mania |
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Psychosis in personality disorders
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Personality disorders are enduring, pervasive patterns of behavior that deviate from the cultural norm
May see transient psychotic symptoms (lasting minutes to hours) Usually paranoid delusions |
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Psychosis in delirium
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Disturbance in consciousness with change in cognition
Occurs over hours or days, fluctuates Perceptual disturbances, including hallucinations, are common May have delusional conviction of reality of hallucination Essential to determine cause |
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Psychosis in PTSD
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Symptoms develop following extreme traumatic stressor
Include reexperiencing the event, avoidance, numbing or responses, and increased arousal (anxiety, sleep problems, anger) May have hallucinations (usually auditory) and paranoid ideation in severe cases |
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Psychosis in post-partum mood disorder
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May see with major depression, bipolar disorder, or brief psychotic disorder
Usually delusions about infant or command hallucinations to harm infant Often accompanied by disorganized thoughts or behavior Occurs in 1:500-1:1000 deliveries, much more common if history of prior disorder Psychiatric emergency |
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Substance induced psychotic disorder
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Need to R/O drug use in any new onset psychosis
Many illicit drugs can cause psychosis Many legal drugs can cause psychosis in OD Drug interactions can lead to high blood levels of drugs which may lead to psychosis Prominent hallucinations or delusions that are the direct physiological effect of a substance Distinguish from primary psychosis because always associated with intoxication or withdrawal Consider in any person >35 with new onset psychosis |
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Alcohol induced psyhosis
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Can see with intoxication or withdrawal
Hallucinations are usually auditory unless delirium is present Usually associated with prolonged, heavy ingestion of alcohol Psychosis clears spontaneously, but will recur if drinking recurs |
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Delirium tremens
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Delirium superimposed on withdrawal symptoms
Often severe confusion Tactile and visual hallucinations are common May have seizures |
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Cocaine induced psychosis
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Common as part of intoxication syndrome
Usually paranoia and hallucinations (tactile or visual) Do not see with cocaine withdrawal Cocaine abuse often co-exists with a primary psychotic illness |
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Crack
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Often have visual/auditory misperceptions and then visual/auditory/tactile hallucinations
Paranoia can be extreme |
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Amphetamine psychosis
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Psychosis usually associated with high doses and long duration of use but may see after even low dose if susceptible
May not resolve for days after drug cessation and may be followed by amnesia Will become sensitized aften an episode of psychosis so even small dose may cause recurrence |
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MDMA (Ecstasy)
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Synthetic derivative of amphetamine
Selective serotonin neurotoxin - may be long lasting effects on the serotonin system Psychiatric symptoms - panic, dysphoria, paranoia After heavy use, may get longer lasting paranoia Increased vulnerability to other disorders |
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Cannibis
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High doses can induce brief psychotic symptoms
Usually persecutory delusions of auditory/visual hallucinations More common in people with underlying primary psychiatric diagnosis "Hemp insanity" more common in places with highly potent drug available Probably exacerbates schizophrenia, but not causative |
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Hallucinogens
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Hallucinogen persisting perception disorder (flashbacks) - may include visual hallucinations though usually recognized as not real
Post-hallucinogen psychotic disorder is rare and usually do not see negative symptoms as seen in schizophrenia |
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PCP
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Perceptual disturbances (lights, change in sounds, illusions) but reality testing remains intact
Occasionally see psychotic disorder, may last for up to 6 weeks after other symptoms of intoxication are gone Single low dose of PCP can rekindle symptoms in someone with schizophrenia |
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Inhalants
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Use most prevalent in teens
May see hallucinations and delusions during intoxication If in excess of what is normally seen with intoxication, diagnose substance induced psychotic disorder Controversy over whether inhalants can produce persisting psychotic state |
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Opioids
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May see prominent hallucinations or delusions with opioid intoxication or withdrawal
Prescription opiates often abused in combination with other drugs Purer form of heroin available - can be snorted |
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Medication induced psychosis
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May occur as side effect of therapeutic dosing or as a result of overdose
Highest risk are elderly, renal, and liver disease "4Anti-SCAM" |
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Psychosis due to GMC
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"STILT MVR"
Seizures (aura, TL) Trauma (subdural hematoma) Infection -HIV -Sepsis -Encephalitis Liver failure Tumor (TL) Metabolic disease -Thyroid -Adrenal -Vitamin def. Vascular disease Renal failure |
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Uremia
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Fatigue
Decreased cognitive function Confusion May get delirium and psychosis |
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Hepatic encephalopathy
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Impairment in consciousness
Often delirium with hallucinations (visual) |
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Acute intermittent porphyria
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50% have psychiatric symptoms
-Lability -Psychosis -Delirium |
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Confabulation
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Filling in gaps in memory with imaginary events
Usually momentary, may misplace true memory in time Often trying to please interviewer or hide memory loss May appear delusional but short lived, transient and varying See in amnesia, dementia, Korsakoff's (Wernicke's) |
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Pseudodementia
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See commonly in elderly
Severe psychomotor retardation Events do not register so appears to have poor memory May actually have true cognitive failure secondary to depression Also common to see depression as early response to dementia |
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Main actions of typical antipsychotics
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D2 receptor antagonists
M1 muscarinic antagonists Alpha-adrenergic antagonists H1 histaminic antagonists |
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Mesolimbic DA pathway
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Blockade of postsynaptic DA2 receptors reduces the (+) symptoms of schizophrenia
No difference in efficacy among conventional agents |
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Mesocortical DA pathway
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DA blockade causes DA def.
Results in negative symptoms and cognitive slowing DA def. may be primary or secondary |
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Nigrostriatal DA pathway
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Pathway extends from SN to BG
Part of extrapyramidal NS Reciprocal relationship between DA and ACh in BG DA blocks ACh release suppressing ACh activity DA receptor blockade results in ACh over activity Anti-cholinergic drugs help treat these movement disorders |
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EPS
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Drug induced Parkinsonism
-Shuffling gait -Muscular rigidity -Tremor -Bradykinesia Benztropine Trihexyphenidyl Amantadine Akithisia - subjective sense of inner restlessness Propanolol or benzos Dystonia - painful, involuntary muscle spasms, usually in head or neck muscles Diphenhydramine or cogentin |
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Elevated prolactin
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Galactorrhea
Amenorrhea Sexual dysfunction Weight gain |
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Anti-cholinergic side effects
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"CDC BUD"
Constipation Drowsiness Confusion Blurred vision Urinary retention Dry mouth |
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Anti-Adrenergic side effects
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"DOD"
Drowsiness Orthostatic hypotension Dizziness |
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Anti-histamine side effects
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"DW"
Drowsiness Weight gain |
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Typical antipsychotics
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Classified based upon potency and affinity for post-synaptic D2 receptors
Increased affinity leads to increased EPS |
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Phenothiazines
-Chlorpromazine -Thioridazine |
Strong anti-cholinergic SE
Weak DA effect --> decreased EPS Chlorpromazine -> blocks alpha receptors -> OH and sexual dysfunction Thioridazine -> pigmented retinopathy |
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Thioxanthines
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IM injection
Strong anti-cholinergic effects Weak DA antagonist Useful for low compliance patients - lasts for 30 days |
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Butyrophenones
-Haloperidol |
Most potent DA antagonists
Less anti-cholinergic SE |
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High potency typicals
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Haloperidol
Fluphenazine Trifluoperzine Greater association with EPS due to increased affinity |
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Neuroleptic malignant syndrome
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Muscle rigidity, fever, ANS instability, decreased level of consciousness, elevated CPK
Stop anti-psychotic Administer DA agonist and dantrolene |
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Atypical antipsychotics
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Blocks D2 and 5-HT2A receptors
Serotonin inhibits DA release Less likely to cause EPS More likely to improve negative symptoms All require monitoring for metabolic syndrome |
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Olanzapine
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Side effects - "WASH HO" weight gain, sedation, OH, anti-cholinergic SE, hyperglycemia, hyperlipidemia
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Risperidone
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Greater propensity to cause EPS - dose related
More likely to lead to hyperprolactinemia SE - "Women's SHOE" weight gain, sedation, OH, EPS, hyperprolactinemia |
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Quetiapine
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Significant blockade at H1 receptors -> sedation, weight gain
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Ziprasidone
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Split doses
QTc prolongation Less likely to cause weight gain |
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Clozapine
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Slow titration needed -> SE
Common SE - "SWIM" sedation, weight gain, increased salivation, metabolic syndrome Serious side effects - "CAS" Cardiopulmonary arrest, agranulocytosis, seizures Useful in treatment refractory patients with reduced risk of suicide and improves TD |
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Aripiprazole
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Antagonist at 5-HT2A, but partial agonist at D2 receptors
PA - block a receptor if over stimulated and stimulate same receptor when needed SE - akathisia |
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Metabolic syndrome
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Weight gain
Dyslipidemia Glucose intolerance Greatest risk - clozapine, olanzapine |
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Typical course of antipsychotic response
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First few days - agitation, psychomotor excitement
T -> H -> D Thought disorder, hallucinations, delusions Evaluate response in 3-5 weeks |
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Medical illnesses that may present as psychosis
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Head trauma
Infections Neoplasms Vascular diseases Autoimmune diseases Metabolic derangements Endocrine dysfunction Dementia Delirium Liver and renal failure |
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Features of depression
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Depressed mood
Anxiety Irritability Absence of emotion Negative perception of self, present and future Altered physiology |
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Anticipation
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Children of prodrome have disease earlier and more severely
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Assortive mating
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Non-random mating associations
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Atypical depressive symptoms
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Hypersomnia
Increased appetite Lethargy Mood reactivity |
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Atypical depression
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More frequently bipolar
Associated with mood reactivity, sensitivity to rejection, personality problems More likely to respond to SSRI or MAOI |
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Psychotic depression
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More severe
More recurrent Greater familial presence Less likely to respond to antidepressants More likely to have bipolar outcome |
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Seasonal affective disorder
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Depression begins in fall or winter
Normal mood or hypomania in spring and summer Responds to artificial bright light More frequently bipolar than non-seasonal depression |
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Medical illnesses that commonly cause depression
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"HI NAME"
Hematologic Infectious Neurologic Autoimmune Malignancy Endocrine |
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Substances that commonly cause depression
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"NASS-T"
Narcotics Alcohol Stimulants Sedatives Tranquilizers |
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Physiology of depression
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Increased CRF
Increased cortisol Due to decreased negative feedback ability of cortisol on the hypothalamus in MDD (-) response to DST Response reverses with treatment |
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Sleep in MDD
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More awakenings
Decreased REM latency Increased REM density Decreased slow wave sleep |
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Imaging in MDD
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Reduced frontal lobe volume
Loss of hippocampal volume May be due to neurotoxicity of cortisol and excitatory amino acids |
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Neurotransmitters in MDD
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NE - increased
5-HT - decresed DA - decreased ACh - increased GABA - decreased Glutamate - increased |
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Pathophysiology of MDD
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More likely due to intracellular changes
-p53 -GSK-3beta -Increased 5-HT inactivation -Downregulation of Bcl-2 -BDNF - increased by AD's |
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Mind-body interactions in MDD
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The same psychological event is more liekly to produce depression in people with vulnerable stress response systems
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Risk of chronicity in MDD
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Onset - 10-15%
>6 months - 30-40% >1 year - 50% >2 years - 95% |
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Tricyclic antidepressants
-REVIEW INDICATIONS - pg 24 |
Tertiary amines - block reuptake of both NE and 5-HT
Secondary amines - inhibit NE reuptake Side effects - anticholinergic, postural hypotension, heart block, weight gain, sudden death after AMI Risk of suicide OD -LD50 = 1 week supply Amitriptyline - migraines, chronic pain Nortriptyline - refractory MDD, migraines Imipramine - Enuresis Desipramine - refractory MDD Clomipramine - OCD |
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SSRI
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Fluoxetine - long acting
Sertraline Paroxetine - more weight gain; anti-cholinergic Fluvoxamine Citalopram Escitalopram - S-enantiomer of citalopram Side effects - sexual dysfunction, aggravation or improvement of migraine headaches, diarrhea, abdominal cramps, weight loss/gain, sedation/activation, withdrawal with paroxetine, anti-DA effect |
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Serotonin-dopamine interaction
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5-HT3R - increases DA - nausea
5-HT2R - decreases DA - Parkinsonian symptoms |
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Consequences of anti-DA effect of SSRI
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Emotional blunting
Decreased motivation and activity Memory loss Akathisia EPS Tardive dyskinesia (rare) |
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Trazodone
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5-HT2 antagonist
1/2 life - 5-8 hours Sedation common May reduce SSRI sexual dysfunction Risk of priapism |
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Nefazodone
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SRI and 5-HT2 antagonist
Does not suppress REM sleep Short half life - divided dose Anxiogenic metabolite Hepatotoxicity |
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Buproprion
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DA and NE reuptake inhibitor
No sexual or cardiac side effects First choice for PD patients with depression Risk of seizures at high doses May be helpful for ADD ad dementia |
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Venlafaxine
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Multiple NT uptake inhibitor
-5-HT at low doses -NE at moderate doses -DA at high doses Useful for severe and refractory depression Higher rate of remission than SSRI Reduces hot flashed associated with menopause XR form most common Side effects - sedation, sexual dysfunction, HTN at higher doses, withdrawal syndromes |
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Mirtazepine
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5-HT2, 5-HT3, alpha 2 antagonist
Useful for patients with weight loss, nausea, sleep disorder Side effects - weight gain, sedation Useful in cancer especially Carcinoid |
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Duloxetine
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NE and serotonin reuptake inhibitor
Useful for severe depression Side effects - nausea, sexual dysfunction, others, HTN unlikely |
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Electroconvulsive therapy
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Most effective antidepressant therapy
Usual course - 6-9 treatments CI - recent AMI, space occupying lesion |
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|
rTMS
|
Induction of localized electrical current by magnetic field
No anesthetic or sedation needed Effective as ECT in some studies, not in others |
|
|
Artificial bright light
|
Effective as AD for SAD
Minimum intensity of light 2500 lux Duration - 30 min - 2 hours Works within 3 days - 2 weeks Effect lost 3 days after treatment cessation Can induce hypomania |
|
|
Prescribing antidepressants
|
Start with low dose
If no response at all in 2-4 weeks change AD Wait up to 6-8 weeks for full effect Goal of treatment is full remission |
|
|
Best predictors of risk of depression
|
Childhood loss of a parent
FM of depression |
|
|
Bipolar disorder
|
Mania or hypomania
>99% have depressive episodes Activation alternates or mixed with depression Pathophysiolgy probably involves altered second messenger signalling and gene expression Ongoing treatment is usually necessary 20-50% of cases of depression Anticipation present Linkage studies Highest rate of substance abuse of all psychiatric illness |
|
|
Mania
|
Psychosis
Gross impairment |
|
|
Hypomania
|
Symptoms last days
No impaired functioning or psychosis No hospitalization |
|
|
Cyclothymia
|
Mild mood swings
|
|
|
Hyperthymia
|
Elevated activity
Reduced sleep Optimistic |
|
|
Bipolar I vs. II
|
Bipolar I - mania
Bipolar II - hypomana, family members have hypomania, but not mania |
|
|
Medical causes of mania and mood swings
|
"A SCRATCH"
Adrenal steroids Stimulants Cushing's disease RT sided cerebrovascular disease Antidepressants Thyroid disease Cocaine Hypercalcemia |
|
|
Evolution of bipolar mood disorders
|
Pseudounipolar depression -> recurrent depression -> mania/hypomania -> rapid/ultradian/cycling/chronicity/psychosis
|
|
|
Mood stabilizers
|
Antimanic action
Prevent recurrences of mania and depression Better against mania than depression |
|
|
Lithium
|
Advantages - once a day, AD properties, neuroprotective
Disadvantages - narrow TI, measure blood levels, long term side effects "WHite CHAIR" Hypothyroidism Weight gain Cognitive dysfunction Hyperparathyroidism Acne Interference with insulin signaling Renal damage |
|
|
Carbamazepine
|
Advantages - better tolerated than lithium, no weight gain, may improve depression, may be useful for PTSD
Disadvantages - induces metabolism of drugs (oral contraceptives), side effects "SNOBS" Sedation Neurotoxicity Occasional hypothyoidism Bone marrow suppression (rare) - agranulocytosis SIADH |
|
|
Divalproex
|
Advantages - sleep improvement, anxiolytic, anti-agressive
Disadvantages - not an AD, side effects - weight gain, sedation, hair loss, cognitive impairment, polycystic ovaries, pancreatitis |
|
|
Lamotrigine
|
Anticonvulsant
Antidepressant properties Prevents recurrences of depression but not mania Side effects - "CRIS" CNS side effects Rash Induction of mania Sedation |
|
|
Atypicals for bipolar
|
All antipsychotics have antimanic properties
Clozapine is most reliable mood stablizer in refractory bipolar disorder |
|
|
AD risky in bipolar disorder
|
Transient improvement
Increased rate of recurrence of depression Induction of hypomania |
|
|
Psychotherapy in bipolar disorders
|
Effective therapies
-IP -Social rhythms -Family focused |
|
|
Treatment of bipolar disorder
|
Mood stabilizer -> antipsychotc -> add anti-depressant -> stop anti-depressant
|
|
|
Generalized anxiety disorder
|
Excessive worry about everyday events
Global feeling of anxiety >6 months duration Restlessness Fatigued Difficulty concentrating Muscle tension Insomnia |
|
|
Panic anxiety
|
Intense, unprovoked fearfulness
Usually associated with ANS arousal Last just a few minutes Symptoms of hyperarousal W/ or w/o agoraphobia Can resemble cardiac problem |
|
|
Medical causes of anxiety
|
Endocrine
Metabolic Respiratory Cardiac Neurological |
|
|
Medications that cause anxiety
|
Stimulants
Tranquilizers - interdose withdrawal Antidepressants Beta agonists Neuroloeptics Serotonergic drugs |
|
|
Substances that cause anxiety
|
Caffeine
Stimulants Nicotine Alcohol MSG CNS depressant withdrawal Aspartame |
|
|
Psychiatric disorders associated with anxiety
|
Depression
Bipolar disorder PTSD OCD Schizophrenia Personality disorders |
|
|
Etiology of anxiety disorders
|
Indentification with anxious patient
Conditioned fear Hyperactive arousal systems -NE - locus coeruleus -Glutaminergic Deficient braking system -Serotonin -GABA Panic disorder - abnormal CO2 response |
|
|
Agoraphobia
|
Anxiety about being in situations from which escape might be difficult or embarrassing and help might not be available
|
|
|
Specific (simple) phobia
|
Marked, persistent, unreasonable fear of circumscribed objects or situations
-Animal -Natural -Situational -Blood injection - familial |
|
|
Social phobia (social anixety disorder)
|
Anxiety about hummilating oneself in social or performance situations
|
|
|
Benzodiazepine use in anxiety
|
Acute anxiety - especially cardiac pt.
Initial treatment of anxious depression Treatment of chronic anxiety in patients who do not do well with other treatments |
|
|
Pharmacology of benzos
|
Changes conformation of GABA receptor such that it increases GABA binding (lower Km)
Leads to increased Cl- --> hyperpolarization |
|
|
Inverse agonist
|
Acts on a receptor but has the reverse action as the typical agonist
|
|
|
Benzo receptor subtype effects
|
Type 1 - A
Type 2 - SCAMP Type 3 - WD |
|
|
Potency
|
High potency - smaller dose, more receptor occupancy, more intense withdrawal
Low potency - higher dose, less intense withdrawal |
|
|
Lipid solubility
|
High - drug gets into brain fast, perferable if rapid onset is needed, increased risk of dependence (buzz feeling)
Low - get into and leave brain slowly, slow onset of action, effect lasts longer after a single dose, lower abuse potential |
|
|
Half life
|
Long - less frequent dosing, more accumulation, slower onset of withdrawal
Short - dosed more frequently, less accumulation, faster onset of withdrawal |
|
|
Benzo metabolic pathways
|
Complex - diazepam, chlordiazepoxide, flurazepam
Simple - midazolam, alprazolam, lorazepam, oxazepam |
|
|
Bezodiazepine side effects
|
Sedation
Psychomotor impairment Interdose withdrawal Interactions - EtOH |
|
|
Benzo withdrawal features
|
Agitation
Confusion Delirium Tremor Myoclonus Hyperreflexia Hyperpyrexia Seizures |
|
|
BZD-1 receptor selective agents
|
Quazepam
Zolpidem Zalepon Less sedation, impairment, withdrawal |
|
|
Partial agonist
|
Not quite as good at activation as natural ligand
High natural ligand + PA --> decreased effect Low natural ligand + PA --> increased effect |
|
|
Nonselective parital BZD receptor agonists
|
Zopiclone
Eszopiclone Weaker acute effect than benzos, less dependence and withdrawal |
|
|
Alternatives to BZD agonists for anxiety
|
AD - excpet buproprion
-SSRI Buspirone Gabapentin Pregabalin Divalproex/valproate Beta blockers |
|
|
Buspirone
|
5-HT1A PA
Not sedating, no withdrawal or impairment of driving Common side effects - nausea, HA, dizziness |
|
|
Beta blockers for anxiety
|
Most useful for autonomic arousal
Propanolol for performance anxiety - sedation and sexual dysfunction |
|
|
Treatment choices for anxiety
|
Acute - benzo
Chronic - AD Substance abuse - buspirone Prominent ANS - beta blocker Pulmonary patient - buspirone, AD Behavioral treatments should always be considered |
|
|
Identification
|
Taking over and making one's own attitudes and behaviors of significant others
|
|
|
Repression
|
Removing threatening or unacceptable memories, impulses, and thoughts from awareness. The repressed material is not subject to voluntary recall
|
|
|
Denial
|
Protecting one's self from unpleasant reality by refusing to perceive it
|
|
|
Displacement
|
Emotions, ideas, or wishes are transferred from their original object and directed to a more acceptable substitute
|
|
|
Reaction formation
|
Directing overt behavior and attitude in precisely the opposite direction of one's underlying, unacceptable impulses
|
|
|
Projection
|
Attribute to others one's own unacceptable impulses, thoughts, and desires
|
|
|
Rationalization
|
Thinking up logical, socially approved reasons for our past, present, or proposed behavior
|
|
|
Isolation
|
Separating emotional components from a thought, resulting in repression of either emotion or the idea
|
|
|
Splitting
|
Perception of one's self and others as "all good" or "all bad" rather than experiencing self or others ambivalently
|
|
|
Suppression
|
A deliberate conscious effort to control and conceal unacceptable thoughts, feelings, or acts
|
|
|
Sublimation
|
Diverting basic drives or impulses into socially appropriate channels
|
|
|
Humor
|
Seeing the comic side of situations
|
|
|
Altruism
|
Taking a negative experience and turning it into a socially positive one
|
|
|
PTSD
|
Duration is >1 month
Acute - <3 months Chronic >3 months Associated with sexual abuse, physical assault, torture, accidental trauma, disasters, illness diagnosis |
|
|
Risk factors for PTSD
|
Gender
Prior trauma Prior mood and/or anxiety disorder Education |
|
|
PTSD etiology
|
Significance facilitates remembrance
Stress hormones (E, CRH, ACTH, AVP, cortisol) Amygdala - BLA Hippocampus - volume reduction |
|
|
PTSD treatment
|
CBT may speed recovery when given 2-3 weeks after exposure
SSRI - 1st line TCA - only amit. and imip. Benzos - addictive potential Anticonvulsants Antipsychotics Adrenergic modulators - alpha 2 agonists promising, beta blockers immediately post-event |
|
|
EMDR
|
Form of psychotherapy including exposure based therapy, eye movement, and recall and verbalization of traumatic memories
|
|
|
Psychiatry in primary care
|
BRIEFLY REVIEW
|
|
|
Indications for referral
|
Failure to respond to 1 or 2 med trials or 2 trials in 2 months
Hospitalization may be necessary Patient is actively suicidal Patient is psychotic Patient is bipolar Pediatric or pregnant |
|
|
SSRI - serotonin syndrome
|
From therapeutic does, OD, or drug interaction
Clonus Hyperthermia Hypertonicity AMS Dysautonomia Hyperreflexia Management - symptomatic, benzos, 5-HT2A antagonist |
|
|
Health consequences of heavy drinking
|
GI, breast cancer
Liver disease Trauma Suicide FAS |
|
|
Health risk level of alcohol consumption
|
3 drinks per day (males)
2 drinks per day (females) 5 drinks per occasion |
|
|
Alcohol abuse
|
Continued risky use despite problems over time
|
|
|
Alcohol dependence
|
Abuse + compulsive use + life centered +/- tolerance/withdrawal over time
Course persists over decades |
|
|
Alcoholism
|
Abuse or dependence
|
|
|
Risk factors for alcoholism
|
Anxiety
Depression PTSD Childhood abuse - up to 50% Risk taking behavior Altered DA/transporters |
|
|
Type 1 alcoholism
|
Milieu limited
Onset >25 Gradual course Either parent alcoholic Son or daughter Environmental and genetic risk Reward dependent; risk avoidant Anxious, depressed, needy |
|
|
Type 2 alcoholism
|
Male limited
Onset <20 Rapid course Father alcoholic Son High genetic risk Impulsive, risk takers, alterations in frontal lobe/executive center Conduct, ADHD |
|
|
Non-familial alcoholism
|
Either gender
Onset >25 Gradual No FH Either gender Environmental, acquired Various behaviors |
|
|
Pharmacology of alcohol
|
Multiple NT - opiate (pain), GABA (sedation), serotonin (mood), DA (reward)
|
|
|
Alcoholism treatment
|
AA, 12 step program
Disulfiram Thiamine - intoxication Benzos - withdrawal |
|
|
Psychological dependence
|
Habituation
Craving |
|
|
Physiological dependence
|
Tolerance
Need to continue taking the substance to prevent withdrawal |
|
|
Types of cocaine
|
Freebase - stripping cocaine of its HCl salt allowing it to vaporize at a lower temperature
Crack - mixture of cocaine HCl and NaHCO3 |
|
|
Cocaine
|
Mechanism - competitive blockade of DA reuptake via the DA transporter; blocks reuptake of NE and serotonin
Intoxication - increased HR, BP, RR, pupillary dilation OD - delirium and tactile hallucinations, seizure, hyperthermia, sudden death, stroke Withdrawal - dysphoric mood, fatigue, insomnia, increased appetite, HA |
|
|
Amphetamines
|
Mechanism - Release of DA ad NE, prevent reuptake of NE and DA, MAOIs; designer drugs - release of serotonin
Intoxication - increased alertness, insomnia, decreased appetite, euphoria, sympathetic activation Withdrawal - DEPRESSION, fatigue, sleep disturbance, psychomotor agitation |
|
|
MDMA - ecstacy
|
Amphetamine action + increased emotional openness, increased intrapersonal insight
Adverse effects are often due to adulterants or serotonin depletion MDMA may be neurotoxic |
|
|
PCP
|
Dissociative anesthetic with hallucinogenic effects
Mechanism - NMDA antagonist, activates DA neurons Intoxication - hallcinations, delirium, mania, disorientation, nystagmus, HTN, tachycardia, ataxia, dysarthria, muscle rigidity, seizures, coma Treatment - urine acidification may increase clearance, benzos, antipsychotics |
|
|
Hallucinogens
|
LSD, psilocybin, mescaline, harmine, ibogaine
Mechanism - serotonin receptor agonist Intoxication - visual distortions, illusions, altered perception, intense emotions, suggestibility increases, increased HR, pupillary dilation, tachypnea, tremors Bad trip - panic, depression, confusion, fear of insanity, impaired reality testing Treating a bad trip - benzos, reassurance Flashbacks - more likely at times of stress or fatigue LSD - 6-10 hours Psilocybin - 2-4 hours DOM - 24 hours |
|
|
Sedatives
|
Benzos and barbs
Mechanism - increase affinity of GABA receptor for GABA Intoxication - alcohol Withdrawal - potentially life threatening, autonomic hyperactivity, hallucinations, tremor, seizures, psychosis Withdrawal treatment - starting benzo ATC and tapering slowly, carbamazepine for seizure |
|
|
Opioids
|
Bind to opioid receptor found in PNS and CNS
-Mu1 - euphoria and analgesia -Mu2 - respiratory depression Tolerance - changes in the number and sensitivity of opioid receptors Opioid effects - euphoria, analgesia, pupillary constriction, apathy, drowsiness, respiratory depression, constipation (does not remit with use), slurred speech, drowsiness Withdrawal - dysphoric mood, nausea/vomiting, muscle aches, lacrimation, rhinorrhea, pupillary dilatation, diarrhea, fever, insomnia Short acting opioid - short intense withdrawal Long acting opioids - prolonged withdrawal Treatment - IV naloxone, methadone |
|
|
Methadone
|
Mu receptor agonist
Must be activated hepatically - takes about 24 hours for steady state More efficacious than morphine Close to 80% bioavailability; morphine 25% |
|
|
Anorexia nervosa
|
Refusal to maintain mininal body weight for age and height with weight loss 15% below expected body weight
Intense fear of weight gain or becoming fat Disturbance in body image Amennorhea-3 months Restricting B/P Suicide attempts rare Substance abuse rare Mortality 4-5% at 5 years |
|
|
Bulimia nervosa
|
Recurrent episodes of binge eating
Recurrent use of compensatory behaviors to prevent weight gain At least 2 binges/purges per week for 3 months Self deprecatory r/t body Purging (80%)/non-purging (20%) Suicide attempts common Substance abuse common |
|
|
Risk factors in the development of eating disorders
|
FH
Traumatic life experience Peer factors Cultural/media influences Interests Sensitizing events Chronic dieting Location (western) Gender Age (<25) Sexual orientation Racial group (W>B) |
|
|
Personality variables of eating disorders
|
3 groups
-High functioning perfectionist -Rigid and overcontrolled -Emotionally dysregulated and undercontrolled Borderline and impulsive behaviors predict poorer outcomes |
|
|
Key S&S and labs for anorexia nervosa
|
"Yellow skin"
Lanugo hair Bradycardia Hypotension Brittle hair Cyanotic and cold hands and feet Amennorrhea Edema Labs - hypercholesterolemia, QT prolongation, low WBC, low FH, FSH, estradiol, or testosterone |
|
|
Key S&S and labs for bulimia nervosa
|
Calluses on back of the hand (Russel's sign)
Salivary gland hypertrophy Dental enamel erosion Mouth ulcers GERD Barret's esophagus Melanosis coli Labs - hyperamylasemia, hypokalemia, metabolic alkalosis |
|
|
Indications for inpatient care of eating disorders
|
Body weight <75% ideal
HR <40BPM BP <90/60 Psychiatric emergency Imminent medical risk Arrested growth or development Need for NG feeding |
|
|
Eating disorder treatment
|
Psychotherapy - mainstay of treatment for eating disorders
Pharmacotherapy is highly individualized -AN - fluoxetine, olanzapine, cyproheptadine, zinc naltrexone -BN - fluoxetine, imipramine, desipramine, trazodone, pheneizine, isocarboxazid, buproprion, naltrexone BED - fluvoxamine, sertraline |
|
|
Medical complications of AN
|
Bradycardia
OH Hypothermia Metabolic alkalosis/acidosis Low potassium, sodium Hypoglycemia Leukopenia, anemia, TP, Fe2+ def. Arrhythmias Muscle loss MVP CHF (refeeding) Peripheral neuropathy Amennorrhea, infertility Cerebral atrophy Osteopenia |
|
|
Medical risks of refeeding
|
Hypophosphatemia
Hypokalemia Cardiac dysfunction Atypical abdominal pain Refeeding hepatitis |
|
|
Refeeding and weight gain
|
Starte with 1200-1500 Cal
Outpatient - .5-.9 kg/wk Inpatient - .9-1.4 kg/wk |
|
|
Somatoform disorders
|
Behavior - involuntary
Motive - unconscious MD response - give face-saving way out typically don't confront Can be contained but not cured |
|
|
Factitious disorders
|
Behavior - voluntary
Motive - unconscious MD response - confront, begin rehab Tx and refer to psychiatrist |
|
|
Malingering
|
Behavior - voluntary
Motive - conscious MD response - +/- confront, do not treat |
|
|
Factors predisposing to somatoform disorders
|
Alexithymia - lack introspective capacity
Abnormally focused attention on body |
|
|
Conversion disorder
|
"Hysteria"
Sudden loss of sensory or motor function (blindess, paralysis) Often associated with a stressful life event Patients appear relatively unconcerned Patients can have both organic pathology and conversion disorders |
|
|
Somatization disorder
|
History of multiple physical complaints (nausea, dyspnea, menstrual problems)
Onset before age 30 |
|
|
Pain disorder
|
Intense, prolonged pain not explained completely by physical disease
Patient cannot be talked out of pain The pain causes clinically significant distress or impairment Onset in 30s and 40s |
|
|
Hypochondriasis
|
Exaggerated concern with health and illness lasting >6 months
Patient goes to different physicians seeking help More common in middle and old age May respond to SSRI/CBT |
|
|
Body dysmorphic disorder
|
Normal appearing patients believe they appear abnormal
Clinically significant distress or impairment Patients may refuse to appear in public Onset usually in late teens |
|
|
Countertransferance
|
Physician's annoyance
|
|
|
Confidentiality in pediatric psych patients
|
Pre-adolescent - disclosure to parents
Adolescent - non-disclosure to parents -Disclosure to authorities only when suicidal or homicidal ideation |
|
|
Autism
|
Impaired ability to communicate
Restricted repertoire of activities and interests 70% MR Better prognosis - higher IQ, good language skills, better social skills |
|
|
Separation anxiety disorder
|
Worries
Behaviors - school refusal Physiological symptoms - nightmares, somatic complaints |
|
|
ADHD
|
Disruptive behavior disorder
Hyperactive, impulsive, distractible, inattentive Symptoms of serious Axis I disorders commonly resemble, at first, ADHD as children |
|
|
Depression in pediatrics
|
Children - irritable, aggressive, disruptive, sad, somatic complaints, tearful, poor self-esteem
Adolescents - depressed mood, decreasing school performance, social isolation, behavioral disturbances, truancy, change in sleep patterns, substance use, anhedonia, suicidal ideation |
|
|
Bipolar disorder in pediatrics
|
Risk factors - early onset MDD, FH of BD, FH of MDD w/psychosis, FH of mood disorder, pharmacologically induced mania
|
|
|
Schizophrenia in pediatrics
|
If onset is preadolescent -> first degree relative w/schizophrenia
|
|
|
Attention deficit/hyperactivity disorder
|
6/9 inattentive or hyperactive impulsive symptoms
Some symptoms that caused impairment were present before age 7 Some symptoms that cause impairment are present in 2 or more settings Must be clear evidence of clinically significant impairment in social, academic, or occupational functioning |
|
|
ADHD pathophysiology
|
Increased DAT density in adult ADHD
Anterior cingulate fails to activate in ADHD MPH blocks 50% of DAT Increased dopa was associated with subjects finding the task more interesting |
|
|
Dextroamphetamine
|
2x as potent as MPH
Increase dopa through multiple pathways |
|
|
Main adverse effects of CNS stimulants
|
"SHIRT HELPS I(S)"
Substance abuse Headaches Insomnia Rapid pulse Tics Hypertension Evening rebound Loss of appetite Possible reduction in growth velocity Stomachaches Irritability Sudden death (defect) |
|
|
Tics
|
"CAG"
Clonidine Atomoxetine Guanfacine |
|
|
Atomoxetine
|
Potent inhibitor of presynaptic NE transporter
Leads to increase in prefrontal DA NOT more efficacious than stimulants Takes 1-4 weeks for onset of therapeutic effect Black box - suicide |
|
|
Serotonin neuron in depressed state
|
Low serotonin
Upregulated receptors |
|
|
TADS study
|
Combined therapy better than all others (fluox + CBT) 71%
CBT was best treatment for suicidal ideation |
|
|
Personality
|
Relatively permanent behavioral, emotional, cognitive, and interpersonal patterns which characterize the self
|
|
|
Personality traits
|
The enduring components of personality which are exhibited in a wide range of social and personal contexts - the building blocks of personality
Spectrum Risk seeking <-----> risk aversive Impulsive <-----> planful |
|
|
Personality type
|
Certain constellations of traits tend to cluster together and form a whole which is distinguishable from other clusters of traits
|
|
|
Personality disorder
|
Personality traits which are so inflexible and pervasive that they become maladaptive and cause either significant impairment in satisfactory function, or, subjective pain and distress
PD are generally recognizable by adolescence and continue through adult life |
|
|
Structure of personality
|
Temperament - biological component
Character - social/cultural component |
|
|
Cluster A
|
Paranoid
Schizoid Schizotypal Poor interpersonal relationships Cold or aloof Odd or suspicious Socially awkward |
|
|
Cluster B
|
Histrionic
Narcissistic Antisocial Borderline Intensely emotional and reactive Often dysphoric when undistracted and alone Self-absorbed and entitled Lacks empathy for others |
|
|
Cluster C
|
Avoidant
Dependent Obsessive-compulsive Anxiety Fearfulness Have personal agendas of need for approval or acceptance which override other considerations |
|
|
Paranoid
|
Pervasive and unwarranted tendency to interpret people's actions as deliberately demeaning or threatening
Distrustful and suspicious of others - imagines motives are malevolent Easily slighted; bears grudges Socially and emotionally aloof |
|
|
Schizoid
|
Pervasive pattern of detachment from social relationships and a restricted range of emotional experience and expression
Has neither capacity nor desire for closeness Does not experience loneliness Emotionally cold and detached |
|
|
Schizotypal
|
Pervasive pattern of social and interpersonal deficits as well as cognitive or perceptual distortions and eccentricities of behavior
Odd ideas, perceptual distortions, ideas of reference Few friends because of lack of interest, social anxiety and/or eccentricities Doctor should use emotionally neutral but engaged manner |
|
|
Avoidant
|
Pervasive pattern of social inhibition, feelings of inadequacy and hypersensitivity to negative evaluation
Socially awkward and uncomfortable Excessively fearful of being embarrassed or acting foolish Inhibited in new interpersonal situations because of feeling inept or inadequate |
|
|
Dependent
|
A persavive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation
Has difficulty making decisions w/o excessive advice and reassurance Feels devastated and helpless when important relationships end Needs others to assume responsibility for major areas of life |
|
|
Obsessive-compulsive
|
A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control at the expense of flexibility, openness, and efficiency
Preoccupied with details, rules, lists, schedules Devotion to work at expense of leisure and friendship Perfectionistic, overconscientious |
|
|
Histrionic
|
A pervasive pattern of excessive emotionality and attention seeking
Needs to be center of attention Self-dramatizing, theatrical Often acts provocative and seductive |
|
|
Narcissistic
|
A pervasive pattern of gradiosity, in fantasy or behavior, need for admiration and lack of empathy
Gradiose sense of self-importance Sense of entitlement to special treatment and consideration Often envious, arrogant, haughty Lacks empathy |
|
|
Anti-social
|
A pervasive pattern of disregard for and violation of the rights of others occurring since age 15 in an individual who is at least 18
Risk taking and novelty seeking Deceitful, irresponsible, w/o remorse, guilt Often dysphoric Diagnosis of conduct disorder in those <18 Most heritable form |
|
|
Borderline
|
A pervasive pattern of instability of affects, interpersonal relationships, and self-image and marked impulsivity
Often has history of physical or sexual abuse in the past "Stably unstable" and intense interpersonal relationships Marked reactivity of mood - intense and unstable Unstable sense of self - feels chronically empty Impulsive Shows inappropriate intense anger Suicide attempts for trivial reasons Self-mutilation Splitting - primary defense |
|
|
Physical changes in the aging female
|
Decreased breast tissue
Decreased estrogen - decreased blood flow Vaginal atrophy Decreased lubrication |
|
|
Sexual changes in the aging female
|
Longer time to arousal
Longer time to lubricate Decreased engorgement of tissues Decreased intensity of orgasm |
|
|
Physical changes in the aging male
|
Decreased testosterone
Decreased sensitivity of the penis |
|
|
Sexual changes in the aging male
|
Longer time to obtain an erection
Decreased ejaculation Increased refractory period Decreased nocturnal erections Decreased desire |
|
|
Impact of illness on sexual performance
|
Prostatectomy/mastectomy/hysterectomy
DM Alcohol/drugs AMI Abdominal vascular surgery Atherosclerosis Medications Spinal cord injury |
|
|
Hypoactive sexual desire disorder
|
Persistently or recurrently deficient/absent sexual fantasy/desire for sexual activity
Causes marked distress or interpersonal difficulty |
|
|
Sexual aversion disorder
|
Persistent or recurrent extreme aversion to, and avoidance of all/almost all genital contact with a sexual partner
Causes marked interpersonal difficulty |
|
|
Female sexual arousal disorder
|
Persistent or recurrent inability to attain or maintain an adequate lubrication-swelling response of sexual excitement
|
|
|
Male erectile disorder
|
Persistent or recurrent inability to attain or maintain an adequate erection
|
|
|
ED Screenings
|
May signal underlying disease
Can be associated with morbidity Identifying ED can reveal medication and compliance issues |
|
|
Medications which may cause ED
|
Beta blockers
Thiazides Verapamil Naproxen TCA MAOI Digoxin Indomethacin H2 antagonists Narcotics Omeprazole Lithium Metaclopramide Typical antipsychotics |
|
|
Modifiable causal factors
|
Smoking
Alcohol and substance abuse Obesity Sedentary lifestyle |
|
|
Treatments for ED
|
Pump/penile ring
Yohimbine - alpha2 antagonist Alprostadil - PGE1 Silenafil, vardenafil, tadalafil - PDE5 inhibitor Implant - destroys tissue |
|
|
PDE5 inhibitors
|
Prevent conversion of cGMP to GMP
PDE5 is localized in vascular smooth muscle cells Some overlap with PDE6, PDE10 |
|
|
Orgasmic disorders
|
AD's - SSRI, some TCA
Treatment - choice of AD, dose reduction, drug holiday, add secondary pharmacological agent |
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Dyspareurnia
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Recurrent or persistent genital pain associated with sexual intercourse in either a male or female
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Vaginismus
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Recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with intercourse
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