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251 Cards in this Set
- Front
- Back
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What drugs should not be used in conjunction with MAOIs?
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SSRIs, SNRIs
buspirone |
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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 OFF benzos when transitioning to longer-term tx (eg SSRIs) |
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Long-Term Tx
General Anxiety Disorder |
lifestyle changes
psychotherapy #1 = SSRIs venlafaxine buspirone |
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Anxiolytic Medications
What are the indications for SSRIs? |
FIRST-LINE for:
GAD OCD PTSD |
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What are side effects of SSRIs?
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nausea
GI upset somnolence sexual dysfunction agitation (esp in young men) |
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Anxiolytic Medications
What are the indications for buspirone? |
GAD
OCD PTSD |
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What are side effects with buspirone
|
decr Sz threshold, esp in eating d/o
**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 (acute)
insomnia EtOH withdrawal muscle spasm night terrors sleepwalking |
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What are side effects of benzos?
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decreased sleep duration
disinhibition in young or old pts confusion in older pts |
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Side effects of flumazenil
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sedation
n/v dizziness pain at injection site |
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Clinical Presentation
Obsessions |
persistent, unwanted and intrusive ideas, thoughts, impulses or images...
...that leads to marked anxiety or distress |
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Clinical Presentation
Compulsions |
repeated MENTAL acts OR behaviors that neutralize anxiety from obsessions, and if not performed lead to mounting anxiety
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What self-realization do patients with OCD have?
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ego-dystonic
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Tx
OCD |
FIRST-LINE: SSRIs
2nd line: olanzapine CBT, exposure therapy and desensitization relaxation techniques |
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Define a panic attack.
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< 10 min period of intense FEAR or DISCOMFORT
** AT LEAST 4 somatic sx: ** tachypnea, dizziness chest pain, palpitations diaphoresis, "hot flashes," trembling nausea **fear of dying** "going crazy" depersonalization, derealization |
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What physical sx are SPECIFIC for panic attacks?
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perioral and/or acral paresthesias
(2/2 hyperventilation and low O2 saturation) |
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Short-Term Tx
Panic Disorder |
benzos for immediate relief
(eg clonazepam) taper benzos when transitioning to long-term tx |
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Long-Term Tx
Panic Disorder |
CBT
Rx 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
MAY BE SPECIFIC (public speaking, urinating in public) ... or 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
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What is specific phobia?
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anxiety provoked by exposure to or anticipation of a feared object or situation
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Tx
Specific Phobias |
CBT, exposure therapy (desensitization thru incremental exposure followed by relaxation)
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Tx
Social Phobias |
CBT
SSRIs low-dose benzos B-blockers (performance anxiety) |
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Main Features
PTSD |
Re-experiencing
Avoidance 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 |
B-blockers
a2-agonists (clonidine) |
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Long-Term Tx
PTSD |
SSRIs -- first line
buspirone TCAs MAOIs AVOID benzos (high incidence of substance abuse among patients with PTSD) |
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Causes of Dementia.
Mnemonic: "DEMENTIAS" |
D egenerative (Parkinson's, Huntington's)
E ndocrine (thyroid, parathyroid, pituitary, adrenal) M etabolic (EtOH, B12, Wilson's, hepatic, renal) E xogenous (heavy metals, CO, drugs) N eoplasia T rauma (subdural hematoma) I nfection (meningitis, encephalitis, endocarditis, neurosyphilis, HIV, prion, Lyme) A ffective disorders (pseudodementia) S troke/Structure/SLE (vascular dementia, ischemia, vasculitis, NPH) |
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What cognitive functions are affected in dementia?
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memory
orientation judgment attention |
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Diagnostic criteria for dementia.
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memory impairment ... + ... 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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w/u
Dementia |
CBC, CMP, B12, TSH
HIV UA Head CT/MRI |
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Tx
Dementia |
provide environmental cues and a rigid structure
Rx cholinesterase inhibitors low-dose antipsychotics AVOID benzos (may exacerbate disinhibition confusion) SUPPORTIVE family caregiver patient education |
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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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Major causes of delirium
I WATCH DEATH |
I nfection
W ithdrawal A cute metabolic/substance Abuse T rauma C NS Pathology H ypoxia D eficiencies E ndocrine A cute vascular/MI T oxins/drugs H eavy metals |
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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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What is the tx for refractory depression or depression with psychotic features?
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ECT
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What else can you use ECT to treat?
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intractable mania
catatonia 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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Side effect of paroxetine (SSRI) in pregnancy.
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fetal pHTN
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serotonin syndrome, describe this.
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myoclonus
mental status changes cardiovascular collapse |
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Side effect of mirtazapine.
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weight gain
sedation |
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Name 2 indications for SNRIs where an SSRI would not be helfpul
|
neuropathic pain
migraine ppx |
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cardiac side effect of venlafaxine.
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diastolic HTN
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Name 3 non-psychiatric indications for TCAs.
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neuropathic pain
migraine ppx enuresis (imipramine) |
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What is the major cardiac side effect of TCAs?
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prolonged conduction thru AV node, long QRS
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What are the common systemic side effects of TCAs?
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ANTI-CHOLINERGIC EFFECTS
dry mouth constipation urinary retention sedation |
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Name 3 MAOIs.
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phenelzine, tranylcypromine
selegiline, rasagiline (MAO-B selective) |
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Indications for MAOIs.
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atypical depression -- weight gain, hypersomnia and rejection sensitivity
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Besides therapy, Rx and ECT, what is also approved for treatment of major depression?
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transcranial magnetic stimulation (TMS)
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What are contraindications to ECT therapy?
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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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within 3 months of identifiable stressor
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Main features of normal bereavement.
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NO severe impairment or suicidality
< 6 months, resolves in 1 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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Sx of mania
DIG FAST |
D istractibility
I nsomnia (decreased need for sleep) G randiosity (increased self esteem/more Goal directed F light of ideas (or racing thoughts) A ctivities/psychomotor Agitation S exual indiscretions/other pleasurable activities T alkativeness/pressured speech |
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Average age of onset of bipolar disorder.
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early 20s
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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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Diagnosis
Bipolar Disorder |
>= 1 week of persistently elevated, expansive, or irritable mood
... + ... >= 3 DIG FAST sx (r/o drugs or GMC) |
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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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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 are 3 indications for lithium?
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acute mania
ppx in BPD augmentation in depression tx |
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Side effects of lithium
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Li
Mvmt (tremor) Nephro DI / polyuria / thirst hypOthyroid Pack on the Pounds aQne dysaRthria, Renal failure Sz Teratogenic (1st trim) |
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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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decreased renal function
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Indications for carbamazepine.
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2nd-line mood stabilizer
depression and bipolar anticonvulsant trigeminal neuralgia |
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Rare side effects 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
rash leukopenia AV block |
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Rare side effects of valproic acid.
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pancreatitis
thrombocytopenia ** fatal hepatotoxicity ** agranulocytosis |
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Common side effects of valproic acid.
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n/v
tremor sedation alopecia wt gain |
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Indications for lamotrigine.
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2nd-line mood stabilizer
anticonvulsant |
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Side effects of lamotrigine.
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blurred vision
GI distress SJS increased dose slowly to monitor for rashes |
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Characteristics of personality disorders.
Mnemonic: "MEDIC" |
Maladaptive
Enduring Deviate from norms Inflexible Can't function |
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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 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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Patients from Cluster B "wild" personality disorders.
How do you deal with these pts? |
They change the rules and demand attention. They are manipulative and demanding and will split staff members.
Be clear and consistent about boundaries/expectations |
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Patients from Cluster C "worried and wimpy"
How do you deal with these pts? |
tend to be controlling and may sabotage their tx
words may be inconsistent with actions avoid power struggles give clear recommendations, but do not push patients into decisions |
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What are the main features of schizophrenia?
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hallucinations
delusions disordered thoughts behavioral disturbances disrupted social functioning |
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Epidemiology of schizophrenia
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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?
Which parts of the brain are affected? |
dopamine dysregulation
(frontal hypoactivity, limbic hyperactivity) |
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Main characteristics of the subtype: paranoid schizophrenia.
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delusions
(often of persecution of the patient) and/or hallucinations NOTE: best overall prognosis |
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Main characteristics of the subtype: disorganized schizophrenia.
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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.
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2 OR MORE OF:
excessive motor activity immobility mutism waxy flexibility echolalia echopraxia |
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What are positive symptoms of schizophrenia?
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hallucinations (mostly auditory)
delusions disorganized speech bizarre behavior thought disorder |
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What are negative symptoms of schizophrenia?
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flat affect
decreased emotional reactivity poverty of speech lack of purposeful actions anhedonia |
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Main characteristic of schizoaffective disorders.
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schizophrenia + major mood disorder (depression or bipolar)
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Name some typical antipsychotics.
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haloperidol
fluphenazine thioridazine chlorpromazine |
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Main mechanism of typical anti-psychotics.
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blocks D2 dopamine receptors
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Indications of typical antipsychotics.
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psychotic d/o
acute agitation acute mania Tourette's syndrome |
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For pts with compliance issues, how do you treat psychotic d/o?
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depot (IM) haloperidol or fluphenazine
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Motor side effects of typical antipsychotics.
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EPS:
dystonia (torticollis) dyskinesia (pseudoparkinsonism) akathisia (restlessness) Tardive dyskinesia (involuntary mvmts) |
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Side effect of thioridazine.
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irreversible retinal pigmentaion
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What is NMS?
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muscle rigidity (elevated CK) -> rhabdo -> renal failure
autonomic instability (HTN / hypoTN) clouded consciousness |
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Tx for NMS
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*stop medication*
ICU support dantrolene or bromocriptine |
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Indications for clozapine?
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tx-resistant psychotic d/o
tardive dyskinesia (paradoxically, helps!) |
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Typical and atypical antipsychotics can cause what arrhythmia?
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prolonged QTc --> v-Tach, torsades
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Abnormal lab finding in atypical antipsychotics.
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agranulocytosis (weekly CBC)
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2 common forms of acute dystonia?
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torticollis
oculogyric crisis |
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How fast do you develop acute dystonia?
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hours
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Tx
acute dystonia |
anticholinergics (diphenhydramine, benzotropine)
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What is dyskinesia?
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pseudoparkinsonism
shuffling gait cogwheel rigidity |
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How fast do you develop dyskinesia?
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days
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Tx
dyskinesia |
anticholinergic (benztropine)
or dopamine agonist (amantadine) also, decrease dose of the antipsychotic |
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What is akathisia?
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subjective/objective restlessness
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How fast does akathisia develop?
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weeks
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Tx
akathisia |
decrease anti-psychotic
B-blockers (propranolol) |
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What is tardive dyskinesia?
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stereotypic, involuntary, painless oral-facial movements
likely from dopamine receptor sensitization from chronic dopamine blockade often irreversible |
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How fast do you develop tardive dyskinesia?
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months
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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?
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ADHD
OCD learning disorders |
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Tx
Tourette's syndrome |
haloperidol, pimozide (anti-D2)
or clonidine |
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SIGNS AND SX
Alcohol Withdrawal |
Fever, tachycardia, HTN
tremor malaise nausea sz DTs agitation |
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SIGNS AND SX
Opioid Withdrawal |
Fever
lacrimation, rhinorrhea diaphoresis dilated pupils stomach cramps, diarrhea yawning |
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SIGNS AND SX
Amphetamine Intoxication |
F, HTN, tachycardia
**PUPILLARY DILATION** diaphoresis angina arrhythmias |
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SIGNS AND SX
Cocaine Intoxication |
HTN, tachycardia
**PUPILLARY DILATION** angina, arrhthmia sudden cardiac death |
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SIGNS AND SX
PCP Withdrawal |
recurrence of intoxication sx due to reabsorption in the GI tract
sudden onset of severe, random violence |
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SIGNS AND SX
Marijuana Intoxication |
slowed sense of time
social withdrawal paranoia amotivational syndrome |
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SIGNS AND SX
Barbiturate Withdrawal |
anxiety
sz delirium life-threatening cardiovascular collapse |
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SIGNS AND SX
Benzodiazepine Intoxication |
interactions with alcohol
amnesia ataxia somnolence mild respiratory depression |
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SIGNS AND SX
Benzo withdrawal |
tachycardia, HTN
rebound anxiety, insomnia, tremor sz death |
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SIGNS AND SX
Caffeine Intoxication |
restlessness
insomnia diruesis muscle twitching arrhythmias tachy flushed face |
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SIGNS AND SX
Caffeine Withdrawal |
HA
lethargy depression wt gain irritability |
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SIGNS AND SX
Nicotine Intoxication |
restlessness
insomnia anxiety arrhythmias |
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SIGNS AND SX
Nicotine Withdrawal |
irritability
HA anxiety weight gain craving bradycardia difficulty concentrating insomnia |
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*** CONTINUE EDITING FROM HERE ***
*** *** *** *** 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 |
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What are the main sx of opiate withdrawal?
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DILATED PUPILS
everything goes up agitation anxiety insomnia diarrhea |
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Sx of cocaine overdose.
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COCAINE IS A STIMULANT!
arrhythmias increased HR and BP hyperthermia vasoconstriction |
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What causes death in cocaine overdose?
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respiratory failure
stroke cerebral hemorrhage heart failure |
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Sx of cocaine withdrawal.
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insomnia/hypersomnia
anger agitation increased appetite |
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Sx of marijuana overdose.
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social withdrawal
euphoria *conjunctival injection* dry mouth tachycardia |
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OCD VS OCPD
What is the main characteristic of OCD? |
characterized by obsessions and/or compulsions
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OCD VS OCPD
What is the main characteristic of OCPD? |
patients are excessively conscientious and inflexible
PERFECTIONIST STUBBORN |
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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 |
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What age for ADHD?
|
btw 3 and 13
M > F |
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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 |
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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) |
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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 |
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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?
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autism
Asperger's childhood disintegrative d/o Rett d/o |
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What normal social behaviors do pervasive disorder patients fail to develop?
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social smile
eye contact lack interest in relationships |
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What language delays are present in pervasive disorder patients?
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development of spoken language is delayed or absent
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What stereotype behaviors are observed in pervasive disorders?
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stereotyped speech and behavior
(hand flapping) restricted interests (preoccupation with parts of objects) |
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Describe autistic disorders.
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impaired social interaction and communication
significant language and cognitive delays characteristic repetitive or restricted behaviors |
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Describe Asperger's syndrome.
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social impairment
repetitive activities/behaviors restricted interests no marked language or cognitive delays |
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What's the difference between autism and Asperger's?
|
both are very similar
except Asperger's does not have language or cognitive delays |
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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) |
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What is Childhood disintegrative disorder?
|
severe developmental regression after > 2 yrs of normal development
eg language, motor skills, social skills, bladder/bowel control, play |
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Tx
Pervasive Developmental Disorders |
intensive special education
behavioral management *family support and counseling** SYMPTOMATIC TX neuroleptics for aggression SSRIs for stereotyped behavior |
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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 |
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Give some examples of conduct disorder.
|
AGGRESSIVE BEHAVIORS
rape robbery animal cruelty NON-AGGRESSIVE BEHAVIORS stealing lying deliberately annoying people |
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What does conduct disorder predispose to?
|
CONDUCT d/o in childhood may become ANTISOCIAL personality disorder in adulthood
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What is oppositional defiant disorder?
|
pattern of negativistic, defiant, disobedient, and hostile behavior toward AUTHORITY FIGURES
for 6 months or more |
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What are some behaviors of oppositional defiant disorders?
|
arguing
losing temper with authorities |
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What does oppositional defiant disorder become later in life?
|
conduct disorder
|
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What is the most common avoidable cause of mental retardation?
|
fetal alcohol syndrome
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What conditions are associated with MR?
|
male gender
chromosomal abnorm congenital infections teratogens inborn errors of metabolism alcohol/illicit substances during pregnancy |
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MR patients have deficits in adaptive functioning.
What are examples of adaptive functioning? |
hygiene
social skills |
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What is the primary method of preventing MR?
|
educating the public
prenatal screening |
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What is coprolalia?
|
repetition of obscene words
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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) |
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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 |
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What are signs of end-organ damage in alcoholism?
|
palmar erythema
telangiectasias |
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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** |
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What medication for alcoholic withdrawal?
|
benzodiazepine taper
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What medication for alcoholic hallucinations and psychosis?
|
haloperidol
hallucinations usually happen within 24 hrs |
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What vitamins and minerals do you provide for alcoholic patients?
|
multivitamins
folate thiamine BEFORE glucose (glucose may deplete thiamine) |
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Why administer thiamine to alcoholic patients?
|
Wernicke's encephalopathy
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What are GI complications of alcoholism?
|
GI bleeding from:
gastritis ulcers varices Mallory-Weiss tears |
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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) |
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Describe the body weight in patients with anorexia nervosa.
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BW < 85% of expected
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What are the main characteristics of anorexia nervosa?
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refusal to maintain normal body weight
intense fear of weight gain distorted body image (pts perceive themselves as fat) amenorrhea |
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There are two types of anorexia nervosa.
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RESTRICTING TYPE
(eg fast or excessive exercise) or BINGE/PURGE-EATING TYPE (eg vomit, laxatives, diuretics) |
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Signs and Sx
Anorexia Nervosa |
cachexia
BMI < 18 lanugo dry skin bradycardia lethargy hypotension cold intolerance hypothermia |
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What is lanugo?
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fine, downy hair
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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) |
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What are cardiac complications of anorexia nervosa?
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mitral valve prolapse
arrhythmias (2nd to electrolytes abnorm) bradycardia hypotension |
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What are musculoskeletal complications of anorexia nervosa?
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osteoporosis
multiple stress fractures |
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What are oral complications of eating disorders?
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dental erosions and decay
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What are GI complications of eating disorders?
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abdominal pain
delayed gastric emptying |
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What are GU complications of eating disorders?
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amenorrhea
nephrolithiasis |
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What are constitutional complications of eating disorders?
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cachexia
hypothermia fatigue electrolyte abnorm (hypokalemia, pH) |
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What are neurologic complications of eating disorders?
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seizures
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FEATURES OF COMMON PARAPHILIAS
What is exhibitionism? |
sexual arousal from exposing one's genitals to a stranger
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FEATURES OF COMMON PARAPHILIAS
What is pedophilia? |
urges or behaviors involving sexual activities with children
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FEATURES OF COMMON PARAPHILIAS
What is voyeurism? |
observing unsuspecting persons unclothed or involved in sex
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FEATURES OF COMMON PARAPHILIAS
What is fetishism? |
getting sexually aroused by objects
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FEATURES OF COMMON PARAPHILIAS
What is transvestic fetishism? |
sexual arousal from cross-dressing
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FEATURES OF COMMON PARAPHILIAS
What is frotteurism? |
touching or rubbing one's genitalia against a nonconsenting person
(common in subways) |
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FEATURES OF COMMON PARAPHILIAS
What is sexual sadism? |
sexual arousal from inflicting suffering on another
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FEATURES OF COMMON PARAPHILIAS
What is sexual masochism? |
sexual arousal from being hurt, humiliated, bound, or threatened
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Does sexual activity decrease with aging?
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NO
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What sexual changes are present in the aging male?
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requires increased stimulation for longer periods of time to reach orgasm
orgasm intensity decreases length of refractory period increases |
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What sexual changes are present in the aging female?
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estrogen levels decrease after menopause
vaginal dryness vaginal thinning (discomfort during coitus) requires estrogen vaginal suppositories or HRT or vaginal creams |
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Tx
Paraphilias |
insight-oriented psychotherapy
behavioral therapy antiandrogens (depo-provera) for hypersexual paraphilic activity |
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Describe gender identity disorder.
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1
strong, persistent cross-gender identification 2 discomfort with one's assigned sex or gender role of the assigned sex |
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What are some things that patients with gender identity disorder do?
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cross-dress
taking sex hormones pursuing surgeries to re-assign sex |
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What constitutes sexual dysfunction?
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PROBLEMS WITH
arousal desire orgasm pain |
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Recommended sleep hygiene measures
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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 |
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What is insomnia?
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sleeplessness
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Diagnosis
Primary Insomnia |
non-restorative sleep
difficulty initiating or maintaining sleep > 3 times per week for 1 month |
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Tx
Primary Insomnia |
FIRST
take good sleep hygiene measures 2ND LINE - MEDS meds for short periods of time diphenhydramine zolipidem zaleplon trazodone |
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Diagnosis
Primary Hypersomnia |
excess daytime sleepiness or nighttime sleep
> 1 month |
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Tx
Primary Hypersomnia |
FIRST-LINE
stimulants --> amphetamines SECOND-LINE antidepressants --> SSRIs |
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Clinical Manifestation
Narcolepsy |
**sleep attacks**
excessive daytime somnolence decreased REM sleep latency patients cannot avoid falling asleep > 3 mo |
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NARCOLEPSY FEATURES
What is cataplexy? |
sudden loss of muscle tone that leads to collapse
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NARCOLEPSY FEATURES
What is hypnagogic hallucinations? |
hallucinations as pt is falling asleep
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NARCOLEPSY FEATURES
What is hypnopompic hallucinations? |
hallucinations as the patient awakens
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NARCOLEPSY FEATURES
What is sleep paralysis? |
when pts first awake, they cannot move
(brief paralysis upon awakening) |
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Tx
Narcolepsy |
scheduled daily naps
plus stimulant drugs such as amphetamines |
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Tx
Cataplexy |
SSRIs
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What causes obstructive sleep apnea?
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obstruction in the respiratory passages
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What is OSA strongly associated with?
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snoring
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Risk factors for OSA
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male gender
obesity prior upper airway surgeries deviated nasal septum large uvula or tongue retrognathia |
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What is the cause of central sleep apnea?
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cease of respiratory effort
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Clinical Presentation
Central Sleep Apnea |
morning headaches
mood changes repeated awakenings during the night |
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What can one do to stop the apenic event during sleep?
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arouse the patient
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What is associated with all forms of sleep apnea?
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sudden infant death
sudden elderly death! *pulmonary HTN* HA depression increased SBP |
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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 |
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Tx
OSA in Adults |
nasal CPAP
wt loss if obese |
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Tx
OSA in Children |
usually due to tonsillar/adenoidal hypertrophy
TX surgery |
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Tx
CSA |
mechanical ventilation
BiPAP |
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What is circadian rhythm sleep disorder?
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misalignment between desired and actual sleep periods
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What are subtypes of circadian rhythm sleep disorder?
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jet-lag type
shift-work type delayed sleep-phase type unspecified |
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How do you tx jet-lag?
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usually resolves within 2-7 days without specific tx
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How do you tx the shift-work type?
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this type may respond to light therapy
exposing someone to light for a scheduled time of the day |
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What are other forms of tx for circadian rhythm sleep orders?
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oral melatonin ma be useful if given 5.5 hrs before the desired bedtime
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What are somatoform disorders?
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pts present with medically unexplained somatic symptoms
they usually have NO CONSCIOUS CONTROL over their sx |
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What are the different kinds of somatoform disorders?
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THERE AT 5 FORMS
Somatization d/o Conversion d/o Hyypochondriasis Body dysmorphic d/o Somatoform pain d/o |
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What is a factitious disorder?
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patients fabricate sx or cause self-injury to ASSUME THE SICK ROLE
they gain something out of this |
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What is Munchausen's syndrome?
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this is the fabricating of sx and injuries TO GET TESTING OR SURGERY
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What is Munchausen's syndrome by proxy?
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a "caregiver" makes someone else ill and enjoys TAKING ON THE ROLE OF THE CONCERNED ONLOOKER
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What is malingering?
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pts intentionally cause or feign sx for FINANCIAL OR HOUSING GAIN
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Clinical Presentation
Somatization Disorder |
multiple, chronic somatic sx from different organ systems
eg GI, sexual, neurologic, pain complains frequent clinical contacts and/or surgeries |
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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 |
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Clinical Presentation
Hypochondriasis |
preoccupation with having a serious disease despite medical reassurance
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Clinical Presentation
Body dysmorphic disorder |
preoccupation with an imagined physical defect or abnormality
pts often present to dermatologists or plastic surgeons |
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Clinical Presentation
Somatoform pain disorder |
the pain intensity or the pain profile is inconsistent with the physiologic process
close temporal relationship with psychological factors |
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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 |
