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347 Cards in this Set
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What drugs should not be used in conjunction with MAOIs?
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SSRIs
buspirone |
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What is General Anxiety Disorder?
|
uncontrollable and excessive anxiety or worry about things
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Patient Population
General Anxiety Disorder |
M:F 1:2
early 20s |
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Clinical Presentation
General Anxiety Disorder |
6+ months of anxiety
3 OR MORE SOMATIC SX: restlessness fatigue difficulty concentrating irritability muscle tension disturbed sleep |
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Short-Term Tx
General Anxiety Disorder |
Benzos for immediate sx relief
taper benzos when transitioning to longer-term tx (eg SSRIs) do not stop benzos "cold turkey" --> lethal withdrawal sx similar to alcohol withdrawal |
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Long-Term Tx
General Anxiety Disorder |
lifestyle changes
psychotherapy MEDS SSRIs -- first line venlafaxine buspirone |
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What are all the anxiety disorders?
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General Anxiety Disorder
Obsessive-Compulsive Disorder Panic Disorder PTSD Phobias |
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Anxiolytic Medications
What are the indications for SSRIs? |
FIRST-LINE FOR:
General Anxiety Disorder OCD PTSD |
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What are samples of SSRIs?
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fluoxetine
sertraline paroxetine citalopram escitalopram |
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What are side effects of SSRIs?
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nausea
GI upset somnolence sexual dysfunction agitation |
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Anxiolytic Medications
What are the indications for Buspirone? |
Generalized anxiety disorder
OCD PTSD |
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What are side effects with buspirone
|
sz with chronic use
**no tolerance, dependence, or withdrawal** |
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Anxiolytic Medications
What are the indications for beta-blockers? |
performance anxiety
PTSD |
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Anxiolytic Medications
What are the indications for benzodiazepines? |
anxiety
ionsomnia alcohol withdrawal muscle spasm night terrors sleepwalking |
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What are side effects of benzos?
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decreased sleep duration
risk of abuse, tolerance and dependence disinhibition in young or old patients (disinhibition means lack of restraint) confusion |
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Anxiolytic Medications
What are the indications for Flumazenil? |
antidote to benzo intoxication
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How does flumazenil work?
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blocks GABA sites
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Side effects of flumazenil
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resedation
NV dizziness pain at injection site |
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Why is OCD an illness?
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bc these obsessions and/or compulsions lead to significant stress and dysfunction in social or personal areas
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Clinical Presentation
Obsessions |
persistent, unwanted and intrusive ideas, thoughts, impulses or images
that leads to marked anxiety or distress (eg fear of contamination, fear of harm to oneself or to loved ones) |
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Clinical Presentation
Compulsions |
repeated mental acts or behaviors that neutralize anxiety from obsessions
(eg hand washing, elaborate rituals for ordinary tasks, counting, excessive checking) |
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What self-realization do patients with OCD have?
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they realize that these behaviors are excessive and irrational products of their own minds
they wish they could get rid of their obsessions and compulsions |
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Tx
OCD |
FIRST-LINE
SSRIs COGNITIVE-BEHAVIORAL THERAPY (CBT) using exposure and desensitization relaxation techniques |
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What are panic disorders?
|
recurrent and unexpected panic attacks
agoraphobia is present in 30-50% (feeling that you are in a environment you cannot escape) (or fear of being alone in a public space) |
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Define a panic attack.
|
discrete periods of intense FEAR or DISCOMFORT
lasts < 10 min HAS AT LEAST 4 SOMATIC SX: tachypnea chest pain palpitations diaphoresis nausea trembling dizziness **fear of dying** "going crazy" hot flashes depersonalization |
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What physical sx are specific for panic attacks?
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perioral and/or acral paresthesias
this produces hyperventilation and low O2 saturation |
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How long do patients usually have panic attack?
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1 or more months
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Short-Term Tx
Panic Disorder |
benzos for immediate relief
(eg clonazepam) avoid long-term use to avoid addiction and tolerance taper benzos when transitioning to long-term tx |
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Long-Term Tx
Panic Disorder |
CBT
cognitive behavioral therapy MEDS SSRIs -- first line TCAs |
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Can alprazolam (Xanax) be used for panic disorders?
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Yes, but it has such a short-half life that pts can go into withdrawal within the same day of taking it
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What is a social phobia?
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marked fear provoked by social or performance situations in which embarrassment may occur
IT MAY BE SPECIFIC public speaking urinating in public GENERAL social interaction |
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When do social phobias normally begin in life?
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adolescence
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When do specific phobias normally begin in life?
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childhood
eg fear or heights |
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What is specific phobia?
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anxiety provoked by exposure to a feared object or situation
eg animals, heights, airplanes |
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Tx
Specific Phobias |
CBT
desensitization thru incremental exposure to it followed by relaxation |
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Tx
Social Phobias |
CBT
SSRIs low-dose benzos beta-blockers (performance anxiety) |
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What causes PTSD?
|
exposure to an extreme life-threatening traumatic event that evoked intense fear, helplessness or horror
eg assault, combat, witnessing a violent crime |
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Main Features
PTSD |
Re-experiencing of the event
(eg nightmares) Avoidance of the stimuli associated with trauma Numbed responsiveness eg detachment, anhedonia Increased Arousal eg hypervigilance, exaggerated startle |
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How long must PTSD be present for it to be a disorder?
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> 1 month
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Short-Term Tx
PTSD |
beta-blockers
alpha2-agonists (clonidine) |
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Long-Term Tx
PTSD |
MEDS
SSRIs -- first line buspirone TCAs MAOIs avoid benzos if you can --> to prevent addiction as there is a high incidence of substance abuse among patients with PTSD OTHER TX psychotherapy support groups |
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Which patient population should not be given benzos?
|
substance people patients
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Top cause of PTSD in males.
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rape
combat |
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Top cause of PTSD in females.
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childhood abuse
rape |
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Causes of Dementia.
DEMENTIA |
Degenerative diseases (Parkinson's, Huntington's)
Endocrine (thyroid, parathyroid, pituitary, adrenal) Metabolic (alcohol, lytes, Vit b12 def, glucose, hepatic, renal, Wilson's disease) Exogenous (heavy metals, CO, drugs) Neoplasia Trauma (subdural hematoma) Infection (meningitis, encephalitis, endocarditis, syphilis, HIV, prion, Lyme) Affective disorders (pseudodementia) Stroke/Structure (vascular dementia, ischemia, vasculitis, NPH) |
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What cognitive functions are affected in dementia?
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memory
orientation judgement attention |
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What is the level of consciousness in dementia patients?
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the LOC is stable
(vs delirium, which is not) however, cognitive function is affected |
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Diagnostic criteria for dementia.
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memory impairment
and 1 or more of the following: THE 4 A'S OF DEMENTIA amnesia aphasia apraxia (inability to perform tasks) agnosia (inability to recognize previously known objects) IMPAIRED EXECUTIVE FUNCTION planning organizing abstracting OTHERS personality mood behavior |
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Diagnosis
Dementia |
MMSE
RULE OUT OTHER CAUSES full labs hiv ua Head CT/MRI |
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Tx
Dementia |
provide environmental cues and a rigid structure for the patient's daily life
MEDS cholinesterase inhibitors low-dose antipsychotics (eg agitation) avoid benzos (may exacerbate disinhibition confusion) SUPPORTIVE family caregiver patient education |
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DELIRIUM VS DEMENTIA
What is the level of attention? |
DELIRIUM
impaired (fluctuating) DEMENTIA usually alert |
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DELIRIUM VS DEMENTIA
What is the onset? |
DELIRIUM
acute DEMENTIA gradual |
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DELIRIUM VS DEMENTIA
What is the course of the disease? |
DELIRIUM
fluctuating from hr to hr "sundowning" DEMENTIA progressive deterioration |
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DELIRIUM VS DEMENTIA
How is the patient's consciousness? |
DELIRIUM
clouded DEMENTIA intact |
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DELIRIUM VS DEMENTIA
Are there hallucinations? |
DELIRIUM
often visual or tactile DEMENTIA 30% of pts have hallucinations |
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DELIRIUM VS DEMENTIA
What is the prognosis? |
DELIRIUM
reversible DEMENTIA mostly irreversible |
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DELIRIUM VS DEMENTIA
What is the treatment for delirium? |
tx underlying cause
low-dose antipsychotics environmental changes |
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DELIRIUM VS DEMENTIA
What is the treatment for dementia? |
cholinesterase inhibitors
low-dose antipsychotics environmental changes |
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Major causes of delirium
I WATCH DEATH |
Infection
Withdrawal Acute metabolic/substance Abuse Trauma CNS Pathology Hypoxia Deficiencies Endocrine Acute vascular/MI Toxins/drugs Heavy metals |
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What is delirium?
|
acute disturbance in the consciousness and cognition
develops over a very short period of time |
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Clinical Presentation
Delirium |
waxing and waning consciousness with lucid intervals
PERCEPTUAL DISTURBANCES hallucinations illusions delusions OTHERS decreased attention span decreased short-term memory reversed sleep-wake cycle increased sx at night (sundowning) |
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How is it like interacting with delirious patients?
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they can be:
combative anxious paranoid stuporous |
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How do you tx agitation and psychotic sx?
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haloperidol or other antipsychotics
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How do you prevent harm to others or self?
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physical restraints
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Give examples of mood disorders.
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major depressive disorder
bipolar |
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Symptoms of a depressive episode
SIG E CAPS |
Sleep (hypersomnia or insomnia)
Interest Guilt (feeling of worthlessness or inappropriate guilt) Energy (decreased) or fatigue Concentration decreased Appetite/Weight -- increased or decreased Psychomotor agitation/retardation Suicidal ideation |
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Mnemonic for TCA toxicity
Tri-C's |
Convulsions
Coma Cardiac arrhythmias |
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SUBTYPES OF DEPRESSION
What psychotic features might be present in depression? |
typically mood-congruent delusions/hallucinations
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SUBTYPES OF DEPRESSION
Describe postpartum depression. |
within 1 mo postpartum
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SUBTYPES OF DEPRESSION
What are atypical sx of depression? |
weight gain
hypersomnia rejection sensitivity |
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SUBTYPES OF DEPRESSION
What are seasonal sx? |
depressive episodes tend to occur during a particular season
(most commonly winter) responds well to light therapy and anti-depressants |
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What is the tx for refractory depression or depression with psychotic features?
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ECT
electroconvulsive therapy |
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What else can you use ECT to treat?
|
intractable mania
psychosis |
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What are adverse effects of ECT?
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postictal confusion
arrhythmias HA anterograde amnesia |
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What are indications for SSRIs?
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depression
anxiety |
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Side effect of paroxetine (SSRI) in pregnancy.
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can cause pulmonary HTN in the fetus
so avoid this drug in pregnancy |
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SSRI's can cause serotonin syndrome, describe this.
|
F
myoclonus mental status changes cardiovascular collapse can occur if SSRIs are combined with MAOIs, illicit drugs or herbals |
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Name 3 atypical anti-depressants.
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bupropion
mirtazapine trazodone |
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Indications for the atypical anti-depressants.
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same as for SSRIs:
depression anxiety |
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Side effects of bupropion.
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*decreases sz threshold*
minimal sexual side effects |
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Bupropion is contraindicated in what 2 situations?
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1 - pts with sz disorders
2 - pts with eating disorders |
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Side effect of mirtazapine.
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weight gain
sedation |
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Side effect of trazodone.
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highly sedating
priapism (erect penis cannot relax) |
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Serotonin–norepinephrine reuptake inhibitors
Name 2 kinds of SNRIs. |
Serotonin–norepinephrine reuptake inhibitors
venlafaxine duloxetine |
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Serotonin–norepinephrine reuptake inhibitors
What are the indications for SNRIs? |
depression
anxiety chronic pain |
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Side effect of velafaxine.
|
diastolic HTN
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Name 4 kinds of tricyclic antidepressants.
|
nortriptyline
desipramine amitriptyline imipramine |
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Indications for TCAs.
|
depression
anxiety d/o chronic pain migraine HA enuresis (imipramine) |
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What is the major cardiac side effect of TCAs?
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lethal with overdose --> arrhythmias
prolonged conduction thru AV node long QRS |
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What are the systemic side effects of TCAs?
|
ANTI-CHOLINERGIC EFFECTS
dry mouth constipation urinary retention sedation |
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Name 3 kinds of MAOIs.
|
phenelzine
tranylcypromine selegiline |
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Indications for MAOIs.
|
depression
(esp atypical depression -- weight gain, hypersomnia and rejection sensitivity) |
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Besides meds and ECT, what is also approved for treatment of major depression?
|
transcranial magnetic stimulation
(TMS) |
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What is an effective tx for those with seasonal depression?
|
phototherapy
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What are contraindications to ECT therapy?
|
recent MI/stroke
intracranial mass high anesthetic risk (relative) |
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What are the features of an adjustment disorder with depressed mood?
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a constellation of sx that resemble an depressive episode (SIG E CAPS) but does not meet the criteria for it
occurs within 3 months of an identifiable stressor |
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Main features of normal bereavement.
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occurs after the loss of a loved one
no severe impairment or suicidality lasts < 6 months, resolves in a year may lead to MDD that requires tx |
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Time of onset of postpartum blues.
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within 2 weeks of delivery
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Time of onset of postpartum psychosis.
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2-3 weeks after delivery
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Time of onset of postpartum depression.
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1-3 months post delivery
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Whats the difference between postpartum blues and postpartum psychosis?
|
in blues, you do not have thoughts of hurting the baby
in psychosis, you do! |
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What are the main sx of postpartum depression?
|
also has thoughts of hurting the baby, as in psychosis
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Sx of mania
DIG FAST |
Distractibility
Insomnia (decreased need for sleep) Grandiosity (increased self esteem/more Goal directed Flight of ideas (or racing thoughts) Activities/psychomotor Agitation Sexual indiscretions/other pleasurable activities Talkativeness/pressured speech |
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Average age of onset of bipolar disorder.
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early 20s
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Definition of Bipolar I.
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at least 1 manic or mixed episode
(usually requiring hospitalization) |
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Definition of Bipolar II.
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at least 1 major depressive episode and 1 hypomanic episode
(less intense than mania -- pts do not meet the criteria for full mania) |
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Define the rapid cycling subtype of bipolar disorder.
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4 or more episodes in 1 year
(MDE, manic, mixed, hypomanic) |
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Define the cyclothymic subtype of bipolar disorder.
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chronic and less severe
with alternating periods of hypomania and moderate depression for > 2 years |
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What are the main clinical sx of bipolar disorder?
|
excessive engagement in pleasurable activities
(eg excessive spending or sexual activity) reckless behaviors psychotic features |
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What is one interesting note about use of antidepressants in bipolar disorder?
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anti-depressant use may trigger manic episodes
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Diagnosis
Bipolar Disorder |
1 manic episode is 1 week or more of persistently elevated, expansive, or irritable mood
PLUS 3 DIG FAST symptoms (sx must not be due to drugs or medical condition) |
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Acute Tx
Bipolar mania |
A PSYCHIATRIC EMERGENCY!!
owing to impaired judgment and great risk of harm to self and others **antipsychotics** |
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Maintenance Tx
Bipolar mania |
mood stabilizers
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How do you treat refractory agitation in bipolar pts?
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benzos
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Tx
Bipolar depression |
mood stabilizers +/- antidepressants
START MOOD STABILIZERS FIRST to avoid inducing mania |
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How do you treat refractory bipolar depression?
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ECT
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What is a first-line mood stabilizer?
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lithium
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What are the indications for lithium use?
|
acute mania
ppx in BPD for augmentation in depression tx |
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Side effects of lithium
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thirst
polyuria DI tremor wt gain hypothyroidism NV diarrhea sz acne |
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Is lithium a teratogen?
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yes, in the first trimester
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What are the sx of lithium toxicity?
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> 1.5 mEq/L
ataxia dysarthria delirium acute renal failure |
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When should you avoid lithium?
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avoid in pts with decreased renal function
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Indications for carbamazepine.
|
2nd-line mood stabilizer
depression and bipolar anticonvulsant trigeminal neuralgia |
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Rare side effect of carbamazepine.
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aplastic anemia
(monitor CBC weekly) SJS |
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Common side effects of carbamazepine.
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nausea
skin rash leukopenia AV block |
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Indications for valproic acid.
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bipolar
anticonvulsants |
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Rare side effects of valproic acid.
|
pancreatitis
thrombocytopenia **fatal hepatotoxicity** agranulocytosis |
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Common side effects of valproic acid.
|
GI side effects (NV)
tremor sedation alopecia wt gain |
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Indications for lamotrigine.
|
2nd-line mood stabilizer
anticonvulsant |
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Side effects of lamotrigine.
|
blurred vision
GI distress SJS increased dose slowly to monitor for rashes |
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Which two mood stabilizers can cause SJS?
|
carbamazepine
lamotrigine |
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Characteristics of personality disorders.
MEDIC |
Maladaptive
Enduring Deviate from cultural norms Inflexible Cause impairment in social or occupational functioning |
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Define personality.
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an individual's set of emotional and behavioral traits that are stable and predictable
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Tx
Personality Disorders |
**psychotherapy mostly**
meds if they have comorbid mood, anxiety or psychotic signs |
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What are the Cluster A "weird" personality disorders?
|
paranoind
schizoid schizotypal |
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What are the Cluster B "wild" personality disorders?
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borderline
histrionic narcissistic antisocial |
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What are the Cluster C "worried and wimpy" personality disorders?
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obsessive-compulsive
avoidant dependent |
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Characteristics of PARANOID personality disorder.
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distrustful
suspicious interpret others' motives as malevolent |
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How can doctors deal with pts that are paranoid?
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be clear, honest, noncontrolling and nondefensive
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Characteristics of SCHIZOID personality disorder.
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isolated
detached "loners" restricted emotional expression |
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Characteristics of SCHIZOTYPAL personality disorder.
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odd behavior
odd perceptions odd appearance **magical thinking** ideas of reference |
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Characteristics of BORDERLINE personality disorder.
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unstable mood
unstable relationships unstable self-image feelings of emptiness impulsive hx of suicidal ideation or self-harm |
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Characteristics of HISTRIONIC personality disorder.
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excessively emotional
attention seeking sexually provocative theatrical |
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Characteristics of NARCISSISTIC personality disorder.
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grandiose
need admiration have sense of entitlement lack empathy |
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Characteristics of ANTISOCIAL personality disorder.
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violate rights of others, social norms and laws
impulsive lack remorse BEGINS IN CHILDHOOD AS CONDUCT DISORDER |
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Patients from Cluster B "wild" personality disorders.
They change the rules and demand attention. They are manipulative and demanding and will split staff members. How do you deal with these pts? |
be clear and consistent about boundaries and expectations
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Characteristics of OBSESSIVE-COMPULSIVE personality disorder.
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preoccupied with perfectionism, order and control at the expense of efficiency
inflexible morals and values |
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Characteristics of AVOIDANT personality disorder.
|
socially inhibited
rejection sensitive FEAR BEING DISLIKED OR RIDICULED |
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Characteristics of DEPENDENT personality disorder.
|
submissive
clingy have a need to be taken care of have difficulty making decisions feels helpless |
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Patients from Cluster C "worried and wimpy" tend to be contorlling and may sabotage their tx. Words may be inconsistent with actions.
How do you deal with these pts? |
avoid power struggles
give clear recommendations, but do not push patients into decisions |
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What is a hallucination?
|
perception without an existing stimulus
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What is an illusion?
|
misperception of an actual external stimulus
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What is a delusion?
|
a fixed and false belief
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What are the main features of schizophrenia?
|
hallucinations
delusions disordered thoughts behavioral disturbances disrupted social functioning |
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Age of onset of schizophrenia
|
M = F
M 18-25 F 25-35 increased incidence of those born in winter or early spring |
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What is the pathogenesis of schizophrenia?
|
dopamine dysregulation
(frontal hypoactivity and limbic hyperactivity) |
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Main characteristics of the subtype: paranoid schizophrenia.
|
delusions
(often of persecution of the patient) and/or hallucinations NOTE: has the best overall prognosis |
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Main characteristics of the subtype: disorganized schizophrenia.
|
speech and behavior are highly disordered and disinhibited
flat affect poor contact with reality WORSE PROGNOSIS |
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Main characteristics of the subtype: catatonic schizophrenia.
|
2 OR MORE OF:
excessive motor activity immobility extreme megativism mutism waxy flexibility echolalia echopraxia |
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What are positive symptoms of schizophrenia?
|
hallucinations (mostly auditory)
delusions disorganized speech bizarre behavior thought disorder |
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What are negative symptoms of schizophrenia?
|
flat affect
decreased emotional reactivity poverty of speech lack of purposeful actions anhedonia |
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Diagnosis of schizophrenia.
|
6 or more months of positive or negative sx
with social or occupational dysfunction |
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Tx
Schizophrenia |
anti-psychotics
long-term follow-up |
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Duration of brief psychotic disorder.
|
< 1 month
|
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What are negative symptoms of schizophrenia?
|
flat affect
decreased emotional reactivity poverty of speech lack of purposeful actions anhedonia |
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Duration of schizophreniform disorder.
|
> 1 mo but < 6 mo
|
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|
Diagnosis of schizophrenia.
|
6 or more months of positive or negative sx
with social or occupational dysfunction |
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Duration of schizophrenia.
|
> 6 mo
|
|
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Tx
Schizophrenia |
anti-psychotics
long-term follow-up |
|
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Main characteristic of schizotypal personality disorders.
|
magical thinking
|
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Duration of brief psychotic disorder.
|
< 1 month
|
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Main characteristic of schizoid personality disorders.
|
loners
|
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Duration of schizophreniform disorder.
|
> 1 mo but < 6 mo
|
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Main characteristic of schizoaffective disorders.
|
schizophrenia + major mood disorder (depression or bipolar)
|
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Duration of schizophrenia.
|
> 6 mo
|
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Main characteristic of schizotypal personality disorders.
|
magical thinking
|
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Main characteristic of schizoid personality disorders.
|
loners
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Main characteristic of schizoaffective disorders.
|
schizophrenia + major mood disorder (depression or bipolar)
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Name some typical antipsychotics.
|
haloperidol
fluphenazine thioridazine chlorpromazine |
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Name some atypical antipsychotics.
|
clozapine
risperidone quetiapine olanzapine ziprasidone aripiprazole |
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Main mechanism of typical anti-psychotics.
|
blocks D2 dopamine receptors
|
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Indications of typical antipsychotics.
|
psychotic d/o
acute agitation acute mania Tourette's syndrome |
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Typical antipsychotics has better effect on positive or negative sx?
|
positive
|
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For pts with compliance issues, how do you treat?
|
use depot shots
haloperidol and fluphenazine come in depot preparations |
|
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Motor side effects of typical antipsychotics.
|
EXTRAPYRMIDAL SX
dystonia (torticollis) dyskinesia (pseudoparkinsonism) akathisia (restlessness) Tardive dyskinesia (involuntary mvmts) |
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|
Anticholinergic side effects of typical antipsychotics.
|
dry mouth
urinary retention constipation |
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Side effect of thioridazine.
|
irreversible retinal pigmentaion
|
|
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What is neuroleptic malignant syndrome?
|
F
muscle rigidity autonomic instability elevated CK clouded consciousness SIDE EFFECT OF TYPICAL ANTIPSYCHOTICS |
|
|
Tx for NMS
|
*stop medication*
ICU support dantrolene or bromocriptine |
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Atypical anti-psychotics are first-line tx for what?
|
schizophrenia
(bc of lower EPS and anticholinergic effects) |
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|
Clozapine is an atypical antipsychotic used in which situation?
|
severe tx resistance
severe tardive dyskinesia |
|
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Typical and atypical antipsychotics can cause what arrhythmia?
|
prolonged QTc
|
|
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Abnormal lab finding in atypical antipsychotics.
|
agranulocytosis
monitor weekly CBC (esp clozapine) |
|
|
What is acute dystonia?
|
prolonged muscle contraction/spasm
torticollis oculogyric crisis |
|
|
How fast do you develop acute dystonia?
|
hours
|
|
|
Tx
acute dystonia |
ACUTE THERAPY
anticholinergics (benzotropine or diphenhydramine) |
|
|
What is dyskinesia?
|
pseudoparkinsonism
shuffling gait cogwheel rigidity |
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|
How fast do you develop dyskinesia?
|
days
|
|
|
Tx
dyskinesia |
anticholinergic
(benztropine) or dopamine agonist (amantadine) also, decrease dose of the antipsychotic |
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What is akathisia?
|
subjective/objective restlessness
|
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|
How fast does akathisia develop?
|
weeks
|
|
|
Tx
akathisia |
decrease anti-psychotic
try beta-blockers (propanolol) |
|
|
What is tardive dyskinesia?
|
stereotypic, involuntary, painless oral-facial movements
likely from dopamine receptor sensitization from chronic dopamine blockade often irreversible |
|
|
How fast do you develop tardive dyskinesia?
|
months
|
|
|
Tx
tardive dyskinesia |
discontinue the drug
maybe change to clozapine or risperidone GIVING ANTICHOLINERGICS OR DECREASING NEUROLEPTICS MAY INITIALLY WORSEN TARDIVE DYSKINESIA. |
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Tourette's syndrome is associated with what other conditions?
|
ADHD
OCD learning disorders |
|
|
Features of tourette's syndrome
|
MOTOR TICS
blinking grimacing VOCAL TICS grunting coprolalia |
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|
Tx
Tourette's syndrome |
dopamine receptor blockers
(haloperidol, pimozide) or clonidine |
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|
SIGNS AND SX
Alcohol Intoxication |
disinhibition
emotional lability slurred speech ataxia aggression blackouts hallucinations memory impairment impaired judgment coma |
|
|
SIGNS AND SX
Alcohol Withdrawal |
tremor
tachycardia HTN malaise nausea sz DTs agitation |
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|
SIGNS AND SX
Opioid Intoxication |
euphoria leading to apathy (indifference)
CNS depression constipation **PUPILLARY CONSTRICTION** respiratory depression (life-threatening) |
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|
Is opioid withdrawal life-threatening?
|
no
and it does not cause seizures just hurts all over |
|
|
SIGNS AND SX
Opioid Withdrawal |
dysphoria
insomnia anorexia myalgias F lacrimation diaphoresis dilated pupils rhinorrhea piloerection NV stomach cramps diarrhea yawning |
|
|
SIGNS AND SX
Amphetamine Intoxication |
psychomotor agitation
imparied judgment HTN **PUPILLARY DILATION** tachy F diaphoresis anxiety angina euphoria prolonged wakefulness/attention arrhythmias delusions sz hallucinations |
|
|
SIGNS AND SX
Amphetamine Withdrawal |
postuse "crash"
anxiety lethargy HA stomach cramps hunger fatigue depression/dysphoria sleep disturbance nightmares |
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|
SIGNS AND SX
Cocaine Intoxication |
euphoria
impaired judgment tachy **PUPILLARY DILATION** HTN paranoia hallucinations "cocaine bugs" sudden death EKG = ISCHEMIC |
|
|
SIGNS AND SX
Cocaine Withdrawal |
postuse "crash"
hypersomnolence depression malaise severe craving angina suicidality increased appetite nightmares |
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|
SIGNS AND SX
PCP Intoxication |
ASSAULTIVENESS
belligerence psychosis violence impulsive **vertical/horizontal nystagmus** |
|
|
SIGNS AND SX
PCP Withdrawal |
recurrence of intoxication sx due to reabsorption in the GI tract
sudden onset of severe, random violence |
|
|
SIGNS AND SX
LSD Intoxication |
marked anxiety or depression
delusions visual hallucinations flashbacks pupillary dilation impaired judgment diaphresis tachy HTN heightened senses |
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|
SIGNS AND SX
Marijuana Intoxication |
euphoria
slowed sense of time impaired judgment social withdrawal increased appetite dry mouth conjunctival injection hallucinations paranoia amotivational syndrome |
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|
SIGNS AND SX
Marijuana Withdrawal |
none
|
|
|
SIGNS AND SX
Barbiturate Intoxication |
low safety margin
respiratory depression |
|
|
SIGNS AND SX
Barbiturate Withdrawal |
anxiety
sz delirium life-threatening cardiovascular collapse |
|
|
SIGNS AND SX
Benzodiazepine Intoxication |
interactions with alcohol
amnesia ataxia somnolence mild respiratory depression |
|
|
SIGNS AND SX
Benzo withdrawal |
rebound anxiety
sz tremor insomnia HTN tachy death |
|
|
SIGNS AND SX
Caffeine Intoxication |
restlessness
insomnia diruesis muscle twitching arrhythmias tachy flushed face |
|
|
SIGNS AND SX
Caffeine Withdrawal |
HA
lethargy depression wt gain irritability craving |
|
|
SIGNS AND SX
Nicotine Intoxication |
restlessness
insomnia anxiety arrhythmias |
|
|
SIGNS AND SX
Nicotine Withdrawal |
irritability
HA anxiety weight gain craving bradycardia difficulty concentrating insomnia |
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|
What are the main sx of opiate overdose?
|
**OPIOIDS ARE DEPRESSANTS**
PINPOINT PUPILS RESPIRATORY DEPRESSION everything slows down BP goes down HR goes down Temp goes down bowel sounds decreased Dry skin |
|
|
What are the main sx of opiate withdrawal?
|
DILATED PUPILS
everything goes up agitation anxiety insomnia diarrhea |
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|
Sx of cocaine overdose.
|
COCAINE IS A STIMULANT!
arrhythmias increased HR and BP hyperthermia vasoconstriction |
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|
What causes death in cocaine overdose?
|
respiratory failure
stroke cerebral hemorrhage heart failure |
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|
Sx of cocaine withdrawal.
|
insomnia/hypersomnia
anger agitation increased appetite |
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|
Sx of marijuana overdose.
|
social withdrawal
euphoria *conjunctival injection* dry mouth tachycardia |
|
|
OCD VS OCPD
What is the main characteristic of OCD? |
characterized by obsessions and/or compulsions
|
|
|
OCD VS OCPD
What is the main characteristic of OCPD? |
patients are excessively conscientious and inflexible
PERFECTIONIST STUBBORN |
|
|
OCD vs OCPD
Which patient recognizes that their disorder is a problem? |
OCD patients realize that it's a problem
(ego-dystonic) OCPD don't realize it (ego-syntonic) |
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|
What are the main features of ADHD?
|
inattention
hyperactivity impulsive |
|
|
What age for ADHD?
|
btw 3 and 13
M > F |
|
|
ADHD
What are the sx of inattention? |
1
poor attention span in schoolwork/play 2 poor attention to detail or careless mistakes 3 does not listen when spoken to 4 difficulty following instructions or finishing tasks 5 loses items needed to complete tasks 6 forgetful and easily distracted |
|
|
ADHD
What are the sx of hyperactivity/impulsivity? |
1
FIDGETS 2 leaves seat in classroom 3 runs around inappropriately 4 cannot play quietly 5 talks excessively *6* does not wait for his/her turn 7 interrupts others |
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|
Tx
ADHD |
INITIAL - NON-PHARMACOLOGIC
behavior modification PSYCHOSTIMULANTS methylphenidate dextroamphetamine ANTI-DEPRESSANTS SSRIs nortriptyline bupropion ALPHA2-AGONISTS clonidine |
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|
Side effects of methylphenidate or psychostimulants in general.
|
insomnia
irritability decreased appetite tic exacerbation decreased growth velocity (normalizes when growth is stopped) |
|
|
Review of EPS
What is the onset and the 4 signs of EPS? 4 and A |
4 and A
4 hours - acute dystonia 4 days - akinesia 4 weeks - akathisia 4 months - tardive dyskinesia |
|
|
What are the 3 main features of pervasive developmental disorders?
|
impaired social interaction
impaired communication delayed behavior ALSO restricted activities and interests *onset before age 3* |
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|
Pervasive developmental disorder is a group of disorders. What are the 4 disorders?
|
autism
Asperger's childhood disintegrative d/o Rett d/o |
|
|
What normal social behaviors do pervasive disorder patients fail to develop?
|
social smile
eye contact lack interest in relationships |
|
|
What language delays are present in pervasive disorder patients?
|
development of spoken language is delayed or absent
|
|
|
What stereotype behaviors are observed in pervasive disorders?
|
stereotyped speech and behavior
(hand flapping) restricted interests (preoccupation with parts of objects) |
|
|
Describe autistic disorders.
|
impaired social interaction and communication
significant language and cognitive delays characteristic repetitive or restricted behaviors |
|
|
Describe Asperger's syndrome.
|
social impairment
repetitive activities/behaviors restricted interests no marked language or cognitive delays |
|
|
What's the difference between autism and Asperger's?
|
both are very similar
except Asperger's does not have language or cognitive delays |
|
|
What is Rett disorder?
|
genetic disorder in females
progressive neurodegenerative disorder born fine for the first 5 months, but then start developing growth impairment (eg language, head growth, coordination) |
|
|
What is Childhood disintegrative disorder?
|
severe developmental regression after > 2 yrs of normal development
eg language, motor skills, social skills, bladder/bowel control, play |
|
|
Tx
Pervasive Developmental Disorders |
intensive special education
behavioral management *family support and counseling** SYMPTOMATIC TX neuroleptics for aggression SSRIs for stereotyped behavior |
|
|
What is conduct disorder?
|
repetitive, persistent pattern of violating:
1 - the basic rights of others or 2 - age-appropriate societal norms or 3 - rules for 1 year or more |
|
|
Give some examples of conduct disorder.
|
AGGRESSIVE BEHAVIORS
rape robbery animal cruelty NON-AGGRESSIVE BEHAVIORS stealing lying deliberately annoying people |
|
|
What does conduct disorder predispose to?
|
CONDUCT d/o in childhood may become ANTISOCIAL personality disorder in adulthood
|
|
|
What is oppositional defiant disorder?
|
pattern of negativistic, defiant, disobedient, and hostile behavior toward AUTHORITY FIGURES
for 6 months or more |
|
|
What are some behaviors of oppositional defiant disorders?
|
arguing
losing temper with authorities |
|
|
What does oppositional defiant disorder become later in life?
|
conduct disorder
|
|
|
What is the most common avoidable cause of mental retardation?
|
fetal alcohol syndrome
|
|
|
What conditions are associated with MR?
|
male gender
chromosomal abnorm congenital infections teratogens inborn errors of metabolism alcohol/illicit substances during pregnancy |
|
|
MR patients have deficits in adaptive functioning.
What are examples of adaptive functioning? |
hygiene
social skills |
|
|
What is the primary method of preventing MR?
|
educating the public
prenatal screening |
|
|
What is coprolalia?
|
repetition of obscene words
|
|
|
What is the criteria for substance abuse?
|
1 OR MORE OF THE FOLLOWING IN 1 YEAR:
1 failure to fulfill responsibilities at work/school/home 2 use of substances in physically hazardous situations (eg driving while intoxicated) 3 legal problems during time of substance use 4 continued use despire recurrent social/interpersonal problems 2nd to effects of such use (eg frequent arguments with spouse over abuse) |
|
|
What is the criteria for substance dependence?
|
3 OR MORE IN 1 YEAR:
1 TOLERANCE use progressively larger amts to obtain same effect 2 WITHDRAWAL SX when not taking the substance OTHERS - failed attempts to cut down or abstain - significant time spent obtaining it - isolation from life activities - consumption of greater amts than intended |
|
|
What are signs of end-organ damage in alcoholism?
|
palmar erythema
telangiectasias |
|
|
CAGE Questionnaire
|
1 CUT
have you ever felt the need to cut down on your drinking? 2 ANNOYED Have you ever felt annoyed by criticism of your drinking? 3 GUILTY Have you ever felt guilty about drinking? 4 EYE OPENER Have you ever had to take a morning eye opener? **more than 1 "yes" answer makes alcoholism likely** |
|
|
What medication for alcoholic withdrawal?
|
benzodiazepine taper
|
|
|
What medication for alcoholic hallucinations and psychosis?
|
haloperidol
hallucinations usually happen within 24 hrs |
|
|
What vitamins and minerals do you provide for alcoholic patients?
|
multivitamins
folate thiamine BEFORE glucose (glucose may deplete thiamine) |
|
|
Why administer thiamine to alcoholic patients?
|
Wernicke's encephalopathy
|
|
|
What are GI complications of alcoholism?
|
GI bleeding from:
gastritis ulcers varices Mallory-Weiss tears |
|
|
What are organ complications in alcoholism?
|
pancreatitis
liver disease DTs Wernicke's / Korsakoff's psychosis cardiomyopathy aspiration pna increased risk of trauma (eg subdural hematoma) |
|
|
Describe the body weight in patients with anorexia nervosa.
|
BW < 85% of expected
|
|
|
What are the main characteristics of anorexia nervosa?
|
refusal to maintain normal body weight
intense fear of weight gain distorted body image (pts perceive themselves as fat) amenorrhea |
|
|
There are two types of anorexia nervosa.
|
RESTRICTING TYPE
(eg fast or excessive exercise) or BINGE/PURGE-EATING TYPE (eg vomit, laxatives, diuretics) |
|
|
Signs and Sx
Anorexia Nervosa |
cachexia
BMI < 18 lanugo dry skin bradycardia lethargy hypotension cold intolerance hypothermia |
|
|
What is lanugo?
|
fine, downy hair
|
|
|
Tx
Anorexia Nervosa |
INITIALLY
monitor caloric intake to restore nutritional status and stabilize weight THEN focus on weight gain ONCE STABLE initiate psychotherapy (individual, family, group) |
|
|
What are cardiac complications of anorexia nervosa?
|
mitral valve prolapse
arrhythmias (2nd to electrolytes abnorm) bradycardia hypotension |
|
|
What are musculoskeletal complications of anorexia nervosa?
|
osteoporosis
multiple stress fractures |
|
|
What are oral complications of eating disorders?
|
dental erosions and decay
|
|
|
What are GI complications of eating disorders?
|
abdominal pain
delayed gastric emptying |
|
|
What are GU complications of eating disorders?
|
amenorrhea
nephrolithiasis |
|
|
What are constitutional complications of eating disorders?
|
cachexia
hypothermia fatigue electrolyte abnorm (hypokalemia, pH) |
|
|
What are neurologic complications of eating disorders?
|
seizures
|
|
|
FEATURES OF COMMON PARAPHILIAS
What is exhibitionism? |
sexual arousal from exposing one's genitals to a stranger
|
|
|
FEATURES OF COMMON PARAPHILIAS
What is pedophilia? |
urges or behaviors involving sexual activities with children
|
|
|
FEATURES OF COMMON PARAPHILIAS
What is voyeurism? |
observing unsuspecting persons unclothed or involved in sex
|
|
|
FEATURES OF COMMON PARAPHILIAS
What is fetishism? |
getting sexually aroused by objects
|
|
|
FEATURES OF COMMON PARAPHILIAS
What is transvestic fetishism? |
sexual arousal from cross-dressing
|
|
|
FEATURES OF COMMON PARAPHILIAS
What is frotteurism? |
touching or rubbing one's genitalia against a nonconsenting person
(common in subways) |
|
|
FEATURES OF COMMON PARAPHILIAS
What is sexual sadism? |
sexual arousal from inflicting suffering on another
|
|
|
FEATURES OF COMMON PARAPHILIAS
What is sexual masochism? |
sexual arousal from being hurt, humiliated, bound, or threatened
|
|
|
Does sexual activity decrease with aging?
|
NO
|
|
|
What sexual changes are present in the aging male?
|
requires increased stimulation for longer periods of time to reach orgasm
orgasm intensity decreases length of refractory period increases |
|
|
What sexual changes are present in the aging female?
|
estrogen levels decrease after menopause
vaginal dryness vaginal thinning (discomfort during coitus) requires estrogen vaginal suppositories or HRT or vaginal creams |
|
|
Tx
Paraphilias |
insight-oriented psychotherapy
behavioral therapy antiandrogens (depo-provera) for hypersexual paraphilic activity |
|
|
Describe gender identity disorder.
|
1
strong, persistent cross-gender identification 2 discomfort with one's assigned sex or gender role of the assigned sex |
|
|
What are some things that patients with gender identity disorder do?
|
cross-dress
taking sex hormones pursuing surgeries to re-assign sex |
|
|
What constitutes sexual dysfunction?
|
PROBLEMS WITH
arousal desire orgasm pain |
|
|
Recommended sleep hygiene measures
|
1 - establish a regular sleep schedule
2 - limit caffeine intake 3 - avoid daytime naps 4 - warm baths in evening 5 - restrict bedroom use for sleep/sex only 6 - exercise early in day 7 - relaxation techniques 8 - avoid eating before sleeping |
|
|
What is insomnia?
|
sleeplessness
|
|
|
Diagnosis
Primary Insomnia |
non-restorative sleep
difficulty initiating or maintaining sleep > 3 times per week for 1 month |
|
|
Tx
Primary Insomnia |
FIRST
take good sleep hygiene measures 2ND LINE - MEDS meds for short periods of time diphenhydramine zolipidem zaleplon trazodone |
|
|
Diagnosis
Primary Hypersomnia |
excess daytime sleepiness or nighttime sleep
> 1 month |
|
|
Tx
Primary Hypersomnia |
FIRST-LINE
stimulants --> amphetamines SECOND-LINE antidepressants --> SSRIs |
|
|
Clinical Manifestation
Narcolepsy |
**sleep attacks**
excessive daytime somnolence decreased REM sleep latency patients cannot avoid falling asleep > 3 mo |
|
|
NARCOLEPSY FEATURES
What is cataplexy? |
sudden loss of muscle tone that leads to collapse
|
|
|
NARCOLEPSY FEATURES
What is hypnagogic hallucinations? |
hallucinations as pt is falling asleep
|
|
|
NARCOLEPSY FEATURES
What is hypnopompic hallucinations? |
hallucinations as the patient awakens
|
|
|
NARCOLEPSY FEATURES
What is sleep paralysis? |
when pts first awake, they cannot move
(brief paralysis upon awakening) |
|
|
Tx
Narcolepsy |
scheduled daily naps
plus stimulant drugs such as amphetamines |
|
|
Tx
Cataplexy |
SSRIs
|
|
|
What causes obstructive sleep apnea?
|
obstruction in the respiratory passages
|
|
|
What is OSA strongly associated with?
|
snoring
|
|
|
Risk factors for OSA
|
male gender
obesity prior upper airway surgeries deviated nasal septum large uvula or tongue retrognathia |
|
|
What is the cause of central sleep apnea?
|
cease of respiratory effort
|
|
|
Clinical Presentation
Central Sleep Apnea |
morning headaches
mood changes repeated awakenings during the night |
|
|
What can one do to stop the apenic event during sleep?
|
arouse the patient
|
|
|
What is associated with all forms of sleep apnea?
|
sudden infant death
sudden elderly death! *pulmonary HTN* HA depression increased SBP |
|
|
Diagnosis
Sleep Apnea |
sleep study
polysomnography document the # of arousals, obstructions and episodes of decreased O2 saturations distinguishes OSA from CSA and identifies possible movement disorders or sz or other |
|
|
Tx
OSA in Adults |
nasal CPAP
wt loss if obese |
|
|
Tx
OSA in Children |
usually due to tonsillar/adenoidal hypertrophy
TX surgery |
|
|
Tx
CSA |
mechanical ventilation
BiPAP |
|
|
What is circadian rhythm sleep disorder?
|
misalignment between desired and actual sleep periods
|
|
|
What are subtypes of circadian rhythm sleep disorder?
|
jet-lag type
shift-work type delayed sleep-phase type unspecified |
|
|
How do you tx jet-lag?
|
usually resolves within 2-7 days without specific tx
|
|
|
How do you tx the shift-work type?
|
this type may respond to light therapy
exposing someone to light for a scheduled time of the day |
|
|
What are other forms of tx for circadian rhythm sleep orders?
|
oral melatonin ma be useful if given 5.5 hrs before the desired bedtime
|
|
|
What are somatoform disorders?
|
pts present with medically unexplained somatic symptoms
they usually have NO CONSCIOUS CONTROL over their sx |
|
|
What are the different kinds of somatoform disorders?
|
THERE AT 5 FORMS
Somatization d/o Conversion d/o Hyypochondriasis Body dysmorphic d/o Somatoform pain d/o |
|
|
What is a factitious disorder?
|
patients fabricate sx or cause self-injury to ASSUME THE SICK ROLE
they gain something out of this |
|
|
What is Munchausen's syndrome?
|
this is the fabricating of sx and injuries TO GET TESTING OR SURGERY
|
|
|
What is Munchausen's syndrome by proxy?
|
a "caregiver" makes someone else ill and enjoys TAKING ON THE ROLE OF THE CONCERNED ONLOOKER
|
|
|
What is malingering?
|
pts intentionally cause or feign sx for FINANCIAL OR HOUSING GAIN
|
|
|
Clinical Presentation
Somatization Disorder |
multiple, chronic somatic sx from different organ systems
eg GI, sexual, neurologic, pain complains frequent clinical contacts and/or surgeries |
|
|
Clinical Presentation
Conversion Disorder |
sx or deficits of voluntary motor or sensory function incompatible with a medical process
eg blindness, seizure-like movements, paralysis there is a close temporal relationship to a stress or intense emotion |
|
|
Clinical Presentation
Hypochondriasis |
preoccupation with having a serious disease despite medical reassurance
|
|
|
Clinical Presentation
Body dysmorphic disorder |
preoccupation with an imagined physical defect or abnormality
pts often present to dermatologists or plastic surgeons |
|
|
Clinical Presentation
Somatoform pain disorder |
the pain intensity or the pain profile is inconsistent with the physiologic process
close temporal relationship with psychological factors |
|
|
Risk factors for suicide.
SAD PERSONS |
Sex (male)
Age (older) Depression Previous attempt Ethanol/substance abuse Rational thought Sickness (chronic illness) Organized plan/access to weapons No spouse Social support lacking |
