Psychiatry Lange and qbank

Schizophrenia epi

- 1% of pop - men: onset ~20 - women: onset ~30 - Men have more negative symptoms and more impaired social functioning - genetics: 50% concordant with monozygotic twins, 40% inheritance with 2 parents, 12% risk with 1st degree relative - Substance abuse, EtOH in 30-50%; cannabis (15-20%) and cocaine (5-10%) - Post-psychotic depression

Epi of MDD

- 16.2% of pop - Average onset ~40 - 2x women > men in reproductive years, but equivalent before menopause and pre-menarche - No ethnic or socioeconomic differences - Prevalence in elderly from 25-50% - Can increase mortality in those with comorbid medical conditions

Risk factors for delirium

- Age - preexisting brain damage - Prior hx of same - DM - Male - Cancer - Sensory impairment

Sleep probs in MDD

- Awakenings - Initial and terminal insomnia - Hypersomnia - REM shifted to earlier in night and stages 3 and 4 of sleep decrease

Leading theory on depression

- Decreased serotonin. Decreased 5-HIAA (primary metabolite thereof) found in CSF. - abnormal b-adrenergic activity shown as well - High cortisol and hyperactivity of hypothalmic-pituitary axis - abnormal thyroid axis - psychosocial - genetics: 1st degree relatives are 2-3x more likely to have MDD. 50-70% concordance in monozygotic twins. 10-25 in fraternal.

Epi of phobias

- Most common mental disorders - at least 5-10% afflicted - specific phobia is more common than social onset as early as 5yo and old as 35yo for situational. - Average onset for social phobias is mid-teens - Women are 2x more likely to have specific phobia, but social is =ly likely.

Bipolar epi

- lifetime prevalence is 1% - men and women equally effected - onset usually before age of 50 - First degree relatives are 8-18x more likely to develop the illness - 40-70% concordance rates for twins; 5-25% for dizygotic - Highest genetic link of all major psychiatric disorders

Epidemiology

- more prevalent than bipolar I - Slightly more common in women - Onset before age 30 - Frequently misdiagnosed as unipolar depression

Bipolar course and prognosis

- untreated manic episodes last ~3months - chronic with relapses - worse prognosis than MDD - 25-50% attempt suicide and 15% die by suicide -> significantly higher than MDD.

DSM IV for dysthymia and treatment

1. Depressed mood for the majority of the time, most days for at least 2 years (in children and adolescents for at least 1 year) 2. At least two of the following: - Poor concentration or difficulty making decisions - Feelings of hopelessness - Poor appetite or overeating - Insomina or hypersomnia - Low energy or fatigue - Low self-esteem 3. During the 2 year period - Not been without above symptoms for >2 months at a time - No major depressive episode - Never manic or hypomanic (bipolar or cyclothymia) Tx: cognitive therapy and insight-oriented psychotherapy with concurrent anti-depressants

DSM criteria for delirium

1. Disturbance of consciousness (i.e. reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention. 2. A change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia. 3. Acute onset and fluctuating symptoms tx: Seroquel or haloperidol (most studied)

DSM for personality disorders in general

1. Pattern of behavior/inner experience that deviates from the person's culture and is manifested in two ore more of the following ways: - Cognition - Affect - Personal relations - Impulse control 2. The pattern: - Pervasive and inflexible in a broad range of situations. - Stable and has onset no later than adolescence or early adult-hood. - Significant distress in functioning - Not medical/substance

DSM for dementia

1. multiple cognitive deficits manifested by both: - memory impairment (learning or recall) - One or more of the following: > aphasia, apraxia, agnosia, disturbance in executive functioning (planning, organizing, sequencing, abstracting) 2. significant decline from prior baseline and impairment 3. Do not occur exclusively in the setting of delirium. Associated: psychosis (delusions, and hallucinations) in 30% demented patients depression and anxiety in 40-50% Personality changes

DSM for specific phobias and social phobia and tx

1. persistent excessive fear borught on by a specific situation or object. 2. Exposure brings immediate anxiety response 3. Patient recog. that fear is excessive 4. Situation is avoided when possible or tolerated with intense anxiety. 4. if under 18 duration must be at least 6 months. Social phobia if related to social settings in which pt. might be embarrassed or humiliated by other people. Tx: behavior therapy -> systematic desensitization and or flooding. Pharm tx not effective, except as adjunct benzos or b-blocker during desensitization social phobia: paroxetine is approved for treatment of social anxiety disorder - b-blockers for performance anxiety

DTs

15-25% mortality men 4x > women sx: delirium, hallucinations, gross tremor, autonomic instability Can use carbamazepine or valproic acid taper. ***confabulations/false memories associated with Korskoff's psychosis

DSM IV for schizophrenia

2 or more: 1. delusions 2. hallucinations 3. negative symptoms (5 A's: anhedonia, affect, attention, avolition, alogia) 4. grossly disorganized or catatonic behavior 5. disorganized speech *only one of above needed if bizarre hallucinations or running auditory hallucinations, or 2 or more voices conversing - Significant distress or impairment in func - >6 months duration - Not due to medical issue or substance Subtypes: - Paranoid: delusions and AH - Disorganized: as expected - catatonic: rare; motor immobility, purposeless motor activity, extreme negativism or mutism, echolalia or echopraxia - undifferentiated - Residual: prominent negative sx with minimal positive sx

Epi of OCD

2-3% prevalence onset in early adulthood with = gender associated with MDD, eating disorders, Tourette's, and OCPD. - Rate is higher in patient with first-degree relatives who have Tourette's.

Epi for GAD, prognosis and tx

45% lifetime prevalence women 2x more likely Onset before 20 50-90% of patients with coexisting mental disorder, especially MDD, phobias, or panic disorder Prognosis: lifelong, fluctuating in 50%, others will recover with years of therapy Tx: comination psychotherapy (CBT) and pharmacotherapy: inc. SSRIs and short term benzos.

DSM IV for brief psychotic

50-80% recovery rate 20-50% progress to schizophrenia 1 day to 1 month Not borderline (borderline pts. may have transient stress related experiences

Epi for dysthymia

6% lifetime prevalence 2-3 times more common in women Onset before 25 in 50% of patients 25% will go on to develop major depression

MDD course and prognosis

6-13 months if untreated and not fatal (15% of patients commit suicide). Episodes increase in frequency as illness progresses.

DSM IV for schizoaffective

60-80% progress to schizophrenia - Meet criteria for either MDD, mania, or mixed episode comorbid with schizophrenia sx - Delusions or hallucinations for 2wks in absence of mood sx Tx: supportive psychotherapy, antipsychotics and mood stabilizers, anti-depressants or ECT.

Epi for cyclothymic

<1% prevalence May coexist with borderline Onset 15-25 course: chronic with 1/3 eventually diagnosed with bipolar.

Caffeine

>10g is fatal 2/2 seizures and resp. depression >1 gram causes severe agitation and cardiac arrhythmias W/d: HA, fatigue drowsiness. Occurs in 50-75% of users.

DSM for PTSD

A diagnosis of PTSD is made for patients older than age six years who meet all of the following DSM-5 criteria [75]: ●A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: •1. Directly experiencing the traumatic event(s). •2. Witnessing, in person, the event(s) as it occurred to others. •3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental. •4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (eg, first responders collecting human remains; police officers repeatedly exposed to details of child abuse). Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related. ●B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: •1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In children older than six years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed. •2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). Note: In children, there may be frightening dreams without recognizable content. •3. Dissociative reactions (eg, flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Note: In children, trauma-specific reenactment may occur in play. •4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). •5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). ●C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following: •1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). •2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). ●D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: •1. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs). •2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world, for example: -"I am bad'' -"No one can be trusted'' -"The world is completely dangerous" -"My whole nervous system is permanently ruined" •3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others. •4. Persistent negative emotional state (eg, fear, horror, anger, guilt, or shame). •5. Markedly diminished interest or participation in significant activities. •6. Feelings of detachment or estrangement from others. •7. Persistent inability to experience positive emotions (eg, inability to experience happiness, satisfaction, or loving feelings). ●E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: •1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. •2. Reckless or self-destructive behavior. •3. Hypervigilance. •4. Exaggerated startle response. •5. Problems with concentration. •6. Sleep disturbance (eg, difficulty falling or staying asleep or restless sleep). ●F. Duration of the disturbance (Criteria B, C, D, and E) is more than one month. ●G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. ●H. The disturbance is not attributable to the physiological effects of a substance (eg, medication, alcohol) or another medical condition.

OCDP

A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: (1) is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost (2) shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met) (3) is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity) (4) is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification) (5) is unable to discard worn-out or worthless objects even when they have no sentimental value (6) is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things (7) adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes (8) shows rigidity and stubbornness Tx: therapy Course: unpredictable, may resolve, develop OCD, schizoP or MDD

Paranoid personality disorder

A. A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: •1. Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her. •2. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates. •3. Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her. •4. Reads hidden demeaning or threatening meanings into benign remarks or events. •5. Persistently bears grudges (ie, is unforgiving of insults, injuries, or slights). •6. Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack. •7. Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner. ●B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, or another psychotic disorder and is not attributable to the physiological effects of another medical condition. Tx: therapy and maybe anti-anxiety

Avoidant personality disorder

AFRAID Avoids occupation with others Fear of embarrassment and criticism Always thinking rejection Isolates Distances, unless sure liked Pervasive pattern of social inhibition and intense fear of rejection. Avoid situations where they might be rejected. At least 4 of following: 1. Avoids occupation that involves interpersonal contact due to a fear of criticism and rejection 2. Unwilling to interact unless certain of being liked 3. cautious of interpersonal relationships 4. Preoccupied with being criticized or rejected in social situations 5. Inhibited in new social situations because he or she feels inadequate 6. Believes he or she is socially inept and inferior 7. Reluctant to engage in new activities for fear of embarrassment epi: 1-10% prevalence Sex ratio unknown Course: usually chronic particularly difficult during adolescence increased incidence of anxiety and depressive disorders If support system fails, patient is left very susceptible to depression, anxiety and anger Tx: - psychotherapy including assertiveness training is most effective. - Beta blockers for autonomic sx of anxiety and SSRIs for major depression.

Vascular dementia

APOe4 also is risk factor. Stepwise loss of cognition. Cholinesterase inhibitors have been used successfully in patietns with vascular dementia

Substance abuse/dependence

Abuse: At least 12 months: Work impairment Interpersonal impairment Legal problems Dangerous use Dependence: 12mo with at least 3 1. TOlerance - increased dose to achieve desired effect or diminishing effect with same dose. 2. WIthdrawal - development of substance-specific syndrome due to the cessation of substance use that has been heavy and prolonged. 3. Using substance more than originally intended 4. Persistent desire or unsuccessful efforts to cut down on use 5. Sig. time spent obtaining, using or recovering 6. Decreased social, occupational or rec actibvies because of substance use. 7. Continued use despite physical or psych problems epi: 17% over lifetime for abuse or dependence men > women

Pathophysiology of schizophrenia

Affected dopamine pathways: - Prefrontal: inadequate dopa; causes negative sx - Mesolimbic: excessive dopa; positive sx - Tubuloinfundibular: hyperprolactinemia - Nigrostriatal: EPS

DSM for cyclothymic

Alternating periods of hypomania and periods with mild and moderate depressive symptoms - Numerous periods with hypomanic symptoms and periods with depressive symptoms for at least 2 years - Never have been symptom free for >2months during those 2 years - No hx of major depressive episode or manic episode.

Snohomish county's #1 export...

Amphetamines: Block reuptake and facilitate release of dopamine and NE from nerve endings, causing a stimulant effect. SSX: mydriasis, increased libido, diaphoresis, respiratory depression, chest pain. - chronically: acne and accelerated tooth decay. Substituted amphetamines: MDMA/ecstasy - Release dopamine, NE and serotonin from nerve endings. - stimulant and hallucinogenic properties - Serotonin syndrome is possible if combined with SSRIs Clinical SSX: similar to cocaine - overdose can cause hyperthermia, dehydration and rhabdomyolysis -> renal failure. - Withdrawal: prolonged depression and can cause psychosis. Tx: correct electrolyte abnormalities and treat hyperthermia.

Pharmacotherapy for depression

Antidepressants: SSRIs: - 50-60% of people respond - venlafaxine, duloxetine and bupropion have activation of other NTs (NE mostly) TCAs: - Most lethal in overdose - sfx: sedation, weight gain, orthostatic hypotension, and anticholinergic effects. Can aggravate prolonged QTc MAOIs: - Useful for refractory depression and atypical depression - risk of HTN crisis with tyramine (intermediate in conversion of tryosine to NE) containing foods and sympathomimetics - risk of serotonin syndrome if used with SSRIs - Most common sfx is orthostatic hypotension Adjunct medications: - Stimulants may be used in terminally ill or refractory sx - Antipsychotics in those with psychotic sx - thyroid hormone, lithium or L-tryptophan (serotonin precursor) may be added to convert non-responders to responders. ECT: - indicated if patient is unresponsive to pharmacotherapy or if rapid reduction in risk is indicated - Is safe and may be used in combination with pharmacotherapy - Premedicated with atropine followed by general anaesthesia and muscle relaxant - 8 tx over 2-3 weeks - Retrograde and anterograde amnesia is common, but usually regress within 6 months.

Histrionic personality disorder

Attetnion-seeking behavior and excessive emtotionality. Dramatic, flamboyant and extroverted but unable to form long-lasting, meaningful relationships. Often sexually inappropriate and provocative. Criteria: - Pattern of above by early adulthood - 5 of following: 1. Uncomfortable when not the center of attention 2. Inappropriately seductive or provocative behavior 3. uses physical appearance to draw attention to self 4. Has speech that is impressionistic and lacking in detail 5. Theatrical and exaggerated expression of emotion 6. Easily influenced by others or situation 7. Perceives relationships as more intimate than they actually are. Epi: - 2-3% prevalence - Women > men Tx: Psychotherapy with adjunct pharm for associated depressive or anxious symptoms.

Prognostic factors of schizophrenia

Better prog: - later, acute onset - positive sx - mood sx - female - good premorbid func. Worse prog: (opposite of above) - early, gradual onset - negative sx - no mood sx - male - poor premorbid functioning

She don't lie, she don't lie, she don't lie.... Cocaine

Blocks dopamine reuptake fro mthe synaptic cleft, causing a stimulant effect. Intoxication: euphoria, autonomic instability, mydriasis, psychomotor agitation, tachy or brady, diaphoresis. Dangerous: resp. depression, seizurs, arrhythmias, paranoia and hallucinations (esp. tactile) -> as direct sympathomimetic, it inhibits the fight or flight response. Deadly: vasoconstrictive effect may result in MI or stroke. MGMT: Supportive - mild to mod: reassurance and benzos - severe agitation or psychosis -> antipsychotics - Temp >102 is medical emergency and tx with ice back, cooling etc Withdrawal: Abrupt abstinence is NOT life-threatening - produces 'crash': depression, hunger, miosis, vivid dreams, psychomotor agitation or retardation and can cause SI. - Resolves w/in 18hrs, but in chronic use may last for weeks with peak in a few days

Symptoms of anxiety

CV: palpitations, tachycardia, HTN Pulm: SOB, choking sensation Neuro: Dizziness, light-headedness, hydriasis, hyperreflexia, tremors, tingling in peripheral extremities Psychological: pacing, 'butterflies' Other: sweating, GI, urinary urgency and frequency

Medication or substance-induced anxiety disorders

Caffeine and theophylline Amphetamines Alcohol and sedative withdrawal Mercury or arsenic Organophosphate or benzene Penicillin Sulfa Sympathomimetics Anti-depressants

DSM IV for delusional disorder

Criteria: - non-bizarre, fixed delusions for at least 1 month - Does not meet schizoP criteria - Functioning NOT significantly impaired Types of delusions: - erotomanic - grandiose - somatic - persecutory - jealous - mixed

Medical causes of depressive or manic episode

Depressive: - CVA - Endocrinopathies (Cushings (hypercortisolism)/Addison's (primary adrenal insufficiency), - Parkinsons - Viral (i.e. Mono) - Carcinoid - Cancer (esp. lymphoma, or pancreatic) - Collagen vasc diseases (SLE) Manic: - Hyperthyroidism - Neurological (temporal lobe seizures, MS) - Neoplasms - HIV

Mood disorders 2/2 substances

Depressive: - EtOH - AntiHTN - Barbituates - Corticosteroids - Levodopa - Sedative-hypnotics - Anti-convulsants - Antipsychotics - Diuretics - Sulonamides - W/d from psychostimulants (cocaine, meth) Manic: - Antidepressants - Sympathomimetics - Dopamine - Corticosteroids - levodopa - Bronchodilators (albuterol)

Panic attacks

Discrete periods of heightened anxiety and fear that classically occur in patients with panic disorder, but can also be seen with other anxiety disorders (phobic and PTSD) - peak within 10 minutes and usually last <25 minutes. - Must have 4 of following: 1. Palpitations 2. sweating 3. shaking 4. SOB 5. choking sensation 6. nausea or abdo distress 7. light-headedness 8. chest pain 9. derealization (feeling out of reality) 10. depersonalization (feeling detached from oneself) 11. fear of losing control or 'going crazy' 12. fear of dying 13. numbness or tingling, 14. chills or hot flashes Tx: SSRIs that start low and slowly increased as can cause anxiety in of themselves. - best is SSRIs with paroxetine and sertraline (2-4wks) and higher doses are required than for depression. - clomipramine and imipramine also - Benzos good immediately - tx for 8-12 months as relapse is common after cessation - Non-pharm: biofeedback, relaxation training, cognitive tx, and insight-oriented psychotherapy.

Medications for alcohol dependence and lx monitoring for detection of recent prolonged drinking

Disulfiram (antabuse) - blocks aldehyde dehydrogenase - contraindicated in severe cardiac disease, pregnancy and psychosis - monitor LFTs - Use in highly motivated pts. as adherence is poor. naltrexone (vivitrol) - opioid receptor blocker - works by decreasing desire/craving and "high" associated with alcohol - greater benefit seen in pt. with family history of alcohol abuse - will precipitate withdrawal in patients with physical opioid dependence Acamprosate (camprol) - Structurally similar to GABA and thought to inhibit the glutamatergic system - should be started postdetoxification for relapse prevention - Can be used in patietns with liver disease -> this is main advantage but - CI in patients with severe renal disease Topiramate - anticonvulsant that potentiates GABA and inhibits glutamate receptors. - reduces cravings for alcohol. *AST:ALT ratio >2:1 and elevated GGT (gamma-glutamyl transpeptidase) suggest excessive alcohol use. At risk for heavy drinking men >4/day or 14/week and women 3day/7wk

Sfx of anti-psychotics expanded

EPS - dystonia (spasms) of face, neck and tongue - Parkinsonism (resting tremor, rigidity, bradykinesia) - Akathisia (feelings of restlessness) - Tx: antiparkinsonian agents (benxtropine, diphenhydramine), benzos, and beta-blockers (for akathisia) *** also consider decreasing dosage of anti-psychotics! Metabolic syndrome: - HTN, HLD, abdominal obesity, insulin resistance -> increased risk of CVD, stroke, DMII - tx: consider switching to 2nd gen 'weight neutral' anti-psychotic such as aripiprazole or ziprasidone. Monitor lipids, glucose. Anticholinergic sx: - Esp. low potency traditional and atypicals - dry mouth, constipation, blurred vision - tx: symptomatic tx TD (high potency antipsychotics) - tx: discontinue offender; benxos, beta-blockers or cholinomimets short term. - atypical neuroleptics can cause as well NMS - autonomic instability (high fever, HTN, tachy) - "lead pipe" rigidity - diaphoresis - increased CPK - leukocytosis - metabolic acidosis - tx: stop offending agent, neurolepic agents (IM or IV) Prolonged QT, hyperprolactinemia -> galactorrhea, amenorrhea, decreased libido and impotence retinal pigmentation (thioridazine and chlorpromazine) derm effects

Schizophrenia NT abnormalities

Elevated serotonin and NE Decreased GABA ( enz. needed to synthesize) in hippocampus Decreased glutamate receptors and NMDA receptors re: efficacy of ketamine

Agoraphobia

Fear of being alone in public places - often 2/2 panic attacks - often resolves when coexisting panic disorder (50-75% of patients) is treated. But if not associated with panic disorder, is chronic and debilitating.

Inhalants

Generally CNS depressants Effects: psychosis (paranoid), lethargy, vomiting, nystagmus headache, ataxia, hyporeflexia and slurred speech. Intoxication lasts minutes, stupor may last hours OD: may be fatal 2/2 respiratory depression or cardiac arrhythmias Long-term use may cause permanent CNS damage (inc. impaired memory, epilepsy and reduced IQ) as well as dmg to PNS, liver, kidney, heart and muscle. Tx: ID substance, some may require chelation

Normal grief vs. depression

Grief: - illusions are common, suicidal thoughts rare - lasts <2 months - tx with benzos for sleep Depression: - hallucinations and delusions are common - >2 months - mild cog. disorder lasts for >1 year - tx: anti-depressants, mood stabilizers or ECT.

Clusters

Honey nut A: schizoid, schizotypal, and paranoid - eccentric, peculiar or withdrawn - familial association with psychotic disorders B: antisocial, borderline, histrionic and narcissistic - emotional, dramatic or inconsistent - association with mood disorders C: avoidant, dependent, OCPD - anxious or fearful - familial association with anxiety disorders Personality disorder NOS: don't fit nicely in above categories, and includes passive-aggressive and depressive.

Medical causes of anxiety

Hyperthyroidism B12 deficiency Hypoxia Neurological disorders (MS, epilepsy, brain tumors etc) CV disease Anemia Pheo Hypoglycemia Also associated with: mitral valve prolapse, asthma, PE, angina and anaphylaxis. *more than 40% of pt. presenting with chest pain and with normal EKG may have panic disorder

Opiates

In addition to opioid receptors, also increase dopaminergic action in reward pathway - prescription opioids are more commonly abused Clinical: - drowsiness, constipation, nausea, vomiting - slurred speech, constricted pupils, seizures - meperidine and MAOIs coadministration may cause serotonin syndrome (muscular rigidity, hyperthermia, confusion, hyper or hypotension). Tx: ABCs, and naloxone, but may cause severe withdrawal -> supportive.

Hallucinogens

LSD is believed to act on the serotonergic system. Hallucinogens do not cause physical dependence or withdrawal and rarely cause psychological dependence. SSx: labile affect, dilated pupils, tachycardia, HTN, hyperthermia, tremors - last usually 6-12hrs tx: supportive and symptomatic based Heavy, chronic LSD use may cause flashbacks

Lewy body dementia

Lewy neurites = aggregations of alpha-synuclein in the brain, primarily in basal ganglia. Clinical manifestations: CORE FEATURES - Waxing and waning of cognition - Visual hallucinations -> usually vivid, colorful and well-formed images of animals or people. - Parkinsonism (w/o exposure to neuroleptics) is a core feature - Sensitive to neuroleptics (paranoid delusions common as well) Diagnosis: > Onset of dementia within 12 months of parkinsonism symptoms. > if dementia begins more than 12 months after Parkinson's symptoms it is classified as Parkinson disease dementia. Tx: Symptomatic only - cholinesterase inhibitors for hallucinations - clonazepam for sleep - dopamine agonists, psychostimulants may improve cognition or psychomotor slowing - atypical neuroleptics useful for stopping delusions and agitation.

Differences between hypomania and mania

Mania: - at least 7 days - severe impairment - may necessitate hospitalization - may have psychotic features Hypomania: - at least 4 days - no marked impairment - no hosp - no psychotic features

Unique types and features of depressive disorders

Melancholic: - 40-60% with major depression - Anhedonia, early morning awakenings, pscyhomotor disturbance, excessive guilt and anorexia Atypical: - hypersomnia - hyperphagia - reactive mood - leaden paralysis - hypersensitivity to interpersonal rejection Catatonic: - catalepsy - purposeless motor activity, - extreme negativism or mutism - bizarre postures - echolalia or echopraxia - esp. responsive to ECT Psychotic: - 10-25% of hospitalized depressions. Characterized by the presence of delusions or hallucinations.

Second-generation antipsychotics

MoA: 5-HT2 and dopamine receptor antagonists Treat: No sig. difference in tx of negative sx Sfx: Lower incidence of EPS, but known for increasing risk of metabolic syndrome. Clozapine for those who have failed multiple antipsychotic trials due to increased risk of agranulocytosis

First-generation antipsychotics

MoA: D2 antagonists Treat: positive sx Sfx: EPS, NMS, and TD

Mary Jane

MoA: cannabinoid receptors in the brain inhibit adenylate cyclase. withdrawal: irritability, anxiety, restlessness, depression, decreased appetite tx: supportive and symptomatic

DSM IV for major depressive disorder

Must have at least five of following symptoms for at least 2 wk period and must include #1 or 2: 1. depressed mood. 2. anhedonia 3. change in appetite or body weight 4. feelings of worthlessness or excessive guilt 5. insomnia or hypersomnia 6. diminished concentration 7. psychomotor agitation or retardation 8. fatigue or loss of energy 9. recurrent thoughts of death or suicidality Sleep Interest Guilt Energy Concentration Appetite Psychomotor Suicidality

Dependent personality disorder

OBEDIENT Obsessive about approval Bound by other's decisions Enterprises are rarely started; low self-confidence Difficult to make own decisions Invalid feelings while alone Engrossed with fears of self-reliance Needs to be in relationship Tentative about decisions Poor self confidence and fear of separation. Excessive need to be taken care of and allow others to make decisions for them. They feel helpless when left alone. 5 of following: 1. Difficulty making everyday decisions 2. Needs others to assume responsibilities 3. Cannot express disagreement because of fear of loss of approval 4. Difficulty initiating projects because of lack of self-confidence 5. Goes to excessive lengths to obtain support from others 6. Feels helpless when alone 7. Urgently seeks another relationship when one ends 8. Preoccupied with fears of being left to take care of self. epi: - ~1% - women> men Course: - usually chronic - sx may decrease with age +/or therapy - difficulties with employment due to inability to act independently - prone to depression

DSM IV for BPII

One or more major depressive episode and at least one hypomanic episode. IF EVER a full manic episode then the diagnosis is Bipolar I. More common than BPI.

Bipolar 1 DSM IV

Only requirement is one manic episode

Personality disorders in a nutshell

Paranoid: pervasive distrust and suspiciousness of others, pathologically jealous. Schizoid: Recluses who don't like social interaction Schizotypal: magical thinking without hallucinations

DSM for generalized anxiety disorder

Persistent excessive hyper-arousal and anxiety about general daily events. Often present with somatic complaints. Must be associated with 3 of the following: - restlessness - fatigue - muscle tension - sleep disturbance - irritability - difficulty concentrating

Bipolar treatment

Pharmacotherapy: - Long-term lithium reduces suicide risk, but OD is 25% due to low TI. - Anticonvulsants (carbamazepine or valproate) are esp. useful for rapid cycling and mized episodes though associated with increased risk of suicide. - Atypical antipsychotics (olanzapine, quetiapine and ziprasidone) are effective both as monotherapy and adjunct for acute mania. - avoid anti-depressants as may induce mania ECT: - works well for mania - more tx needed than for depression

Tx of personality disorders (if any)

Psychotherapy and group therapy

DSM for panic disorder and tx

Recurrent panic attacks with no obvious precipitant, average of 2x per week. Usually last between 20-30 minutes and anticipatory anxiety common b/w attacks To qualify, at least one of attacks must be followed by a minimum of 1 month of following - persistent concern of repeat attacks - worry about implications of the attack (losing control, 'going crazy') - Significant change in behavior Tx: SSRI/SNRI is first line. Alprazolam/short acting benzos for acute events. *always specify if with agoraphobia or without

Confusion Assessment Method Diagnostic Algorithm

Requires criteria 1+2 and either 3 or 4. 1. Acute change in mental status and fluctuating course 2. Inattention 3. Disorganized thinking 4. AMS (including hyperalert)

PTSD tx

SSRIS, TCAs (imipramine, doxepin). Anticonvulsants for flashbacks and nightmares Also, CBT, support groups and EMDR

Narcissistic personality disorder

Sense of superiority, need for admiration and lack of empathy. Consider themselves "special" and will exploit others to their own gain. Despite grandiosity, have low self-esteem. 5 or more of following: 1. Exaggerated sense of self-importance. 2. Preoccupation with fantasies of unlimited money, success, brilliance, etc 3. Believes that he or she is "special" or unique and can associate only with other high-status individuals. 4. Needs excessive admiration. 5. Has sense of entitlement. 6. Takes advantage of others for self-gain. 7. Lacks empathy. 8. Envious of others or believes others are envious of him or her. 9. Arrogant or haughty. Epi: <1% Tx: - higher incidence of depression and midlife crises since these pt. put so much value on youth and power. - Psychotherapy or group therapy tx of choice. - Antidepressants or lithium as needed for other sx

DDx for dementia

So many things, but remember: Lyme HIV dementia malnutrition (b12, folate, thiamine) Wilson's Lead tox Neurosyphilis!!!!!!!!!!!!!!!!!!!

Pathological anxiety vs. normal and NTs involved

Sx interfere with daily functioning. NTs: increased NE, and decreased GABA and serotonin

Acute stress disorder vs PTSD

Symptoms (like PTSD) within 1 month, and last for maximum of 1 month.

Depression with atypical features

The DSM-IV-TR defines Atypical Depression as a subtype of Major Depressive Disorder with Atypical Features, characterized by: Mood reactivity (i.e., mood brightens in response to actual or potential positive events) At least two of the following: - Significant weight gain or increase in appetite; - Hypersomnia (sleeping too much, as opposed to the insomnia present in melancholic depression); - Leaden paralysis (i.e., heavy, leaden feelings in arms or legs); - Long-standing pattern of interpersonal rejection sensitivity (not limited to episodes of mood disturbance) that results in significant social or occupational impairment. - Criteria are not met for With Melancholic Features or With Catatonic Features during the same episode.

Lx for every initial psychiatric workup?

VDRL, TSH, B12

Wernicke's encephalopathy and Korsakoff syndrome

Wernicke's encephalopathy: - caused by thiamine deficiency resulting from poor nutritional intake. - Acute and reversible with thiamine - SSX: ataxia (broad based gait), confusion, ocular abnormalities (nystagmus, gaze palsies). If left untreated may progress to Korsakoff syndrome: - chronic amnestic syndrome - reversible in only ~20% of patients - SSx: impaired recent memory, anterograde amnesia, compensatory confabulation (unconsciously making up answers when memory has failed).

Opioid dependence treatment and withdrawal treatment

Withdrawal: - dysphoria - insomnia - lacrimation, rhinorrhea, yawning - piloerection - mydriasis - craving Tx: - clonidine for moderate, NSAIDS - severe: detox with methadone or buprenorphine (alone) - Monitor withdrawal with COWS Tx for dependence: - methadone: causes QTC prolongation; safe(r) in pregnancy - Buprenorphine: partial agonist; 1/2 suboxone - naltrexone: antagonist. Other half suboxone -> for highly motivated pts.

EtOH MoA, tx

activates GABA and seotonin and inhibits glutamate and voltage-gated calcium channels. CNS depressant *acetaldehyde dehydrogenase decreased in asian pops. THus less conversion of acetaldehyde to acetic acid. *Metabolic acidosis with increased anion gap tx: 1st: ABCs 2nd: thiamine + folate (re: wernike's) 3nd: benzos acutely

DSM IV for schizophreniform

as schizophrenia, but duration <6mo

Etio of OCD, tx, and course

associated with abnormal regulation of serotonin - higher in first-degree relatives and monoxygotic twins - Medical: associated with head injury, epilepsy, basal ganglia disorder and postpartum conditions - onset triggered by stressful life event in ~60% of patients Tx: SSRIs at higher than normal doses, and TCAs if resistant. Behavioral tx as effective, but best tx is both. also exposure response treatment (ERP). Also relaxation techniques. - ECT and cingulotomy as last option. Course: 20-40% remain significantly impaired. 30% show significant improvement.

DSM IV for manic episode

at least 1 week, or any duration if hosp. is necessary and 3 of following: 1. Distractibility 2. Inflated self-esteem or grandiosity 3. increase in goal directed activity (sexually, work or social) 4. decreased need for sleep 5. talkative or pressured speech 6. excessive involvement in pleasurable activities that have a high risk of negative consequences. 7. Flight of ideas or racing thoughts 75% have psychotic symptoms.

Cluster C

avoidant, dependent, OCPD. Appear anxious and fearful.

Sedative-hypnotics

benzos, barbituates, zolpidem, zaleplon, gamma-hydroxybutyrate (GHB), meprobamate and others. Benzos: - increase frequency of chloride channel openings thus potentiating the effects of GABA. Barbituates: - Use for tx of epilepsy and as anesthetics. - increase duration of Cl channels thus potentiating GABA effects. - At high doses barbituates act as direct GABA agonists - synergistic with other CNS depressants. *barbituates have the highest mortality rate of any drug withdrawal* Clinical: - drowsiness, confusion, slurred speech, hypotension, ataxia, mood lability impaired judgement. - synergistic with other CNS depressants - dependence and may cause depressive symptoms. Tx: - ABCs, and supportive care - Activated charcoal and GI lavage to prevent further GI absorption (if drug was ingested in prior 4-6hrs) FOR BARBITUATES ONLY: alkalinize urine with sodium bicarbonate to promote renal excretion FOR BENZOS ONLY: Flumazenil in overdose (very short acting BDZ antagonist, use with caution as may precipitate seizures. Withdrawal: - abrupt abstinence after chronic use can be life-threatening. -> short acting agents are more likely to cause dependence and withdrawal symptoms. Clinical presentation: - same as EtOH withdrawal inc tonic-clonic seizures. Tx: - benzo taper - Carbamazepine or valproic acid taper may be used for seizure prevention.

Urine t1/2 for various drugs

cocaine 2-4 days amphetamines 1-3 days PCP 3-8 days with elevated cpk and AST sedative-hypnotics (benzos, barb) = depends on druge - pentobarb 24hrs - phenobarb 3wks - lorazepam 3days - diazepam 30days opiotds 2-3 days MJ - 3 days with single use; 4 weeks with chronic use

DSM IV for folie a deux

induced psychotic disorder delusions are transmitted from one individual to another

Bereavement

last 2 months Sx: crying spells, problems sleeping and trouble concentrating at work. - should not include suicidality or gross disorganization

Depressive personality disorder

lifelong traits of depressed-like state. Pessimistic, self-doubting, chronically unhappy and distressed

Quick and easy distinguishing features

schizophrenia: lifelong, >6mo schizophreniform: <6 mo schizoaffective: (personality disorder) paranoid, odd or magical beliefs, social anxiety, lack of friends Schizoid: (personality disorder), withdrawn, lack of enjoyment from social interactions and emotionally restricted.

Nicotine

stimulates nicotinic ACh receptors in autonomic ganglia of sympathetic and parasympathetic NS. Highly addictive through effects on dopaminergic system. Leading cause of preventable morbidity and mortality w/d: intense cravings, increased GI motility, poor concentration, bradycardia, increased appetite and insomnia. Tx: 1. Varenicline: alpha4beta2 nicotinic receptor (nAChR) partial agonist that mimics action of nicotine and prevents withdrawal symptoms 2. Bupropion (as Zyban): also partial agonist at nAChR receptors and inhibitor of dopamine reuptake. Behavior counseling should be part of every treatment.

Passive aggressive personality disorder

stubborn, inefficient procrastinators, alternate b/w compliance and passive resistance of fulfillment of tasts Manipulate others to do their taskes and complain about own misfortunes

EtOH withdrawal

sx: anxiety, diaphoresis, nausea, vomiting, tachy, HTN, psychomotor agitation, seizures, hallucinations, delirium Sx begin w/in 6-24hrs and last 2-y days. With seizures b/w 6-48hrs peaking around 13-24hrs Hypomagnesemia may predispose to seizures -> thus give Mg if low. Tx: seizures with benzos

What to give in AMS 2/2 alcohol use before glucose?

thiamine, as glucose will increase thiamine uptake and may precipitate Wernicke's encephalopathy

PCP

tx: bunch o benzos and minimal stimulation -> dark room. Will have nystagmus. MoA: dissociative, hallucinogenic drug that antagonizes N-methyl-D-aspartate receptors and activates dopaminergic neurons. It can have stimulant or CNS depressant effects, depending in the dose taken. - usually dipped or sprinkled on cigarettes and smoked - ketamine is similar to PCP but less potent -> sometimes used as date rape drug as odorless and tasteless. Clinical: **rotary nystagmus is pathonomonic for PCP intoxication* - muscle rigidity, high tolerance topain, depersonalization, hallucinations, synaesthesia, tachy, NYSTAGMUS - OD can cause seizures coma and even death Tx: - monitor vitals - sensory deprivation - benzos for anxiety/agitation - haloperidol for severe agitation or psychotic symptoms. W/d: - no syndrome, but release from fat stores can cause recurrence of intoxication symptoms.

Epi of anxiety

women 30% men 19% More common in higher socioeconomic groups

Alzheimer's

women 3x as compared with men, and presence in 1st degree relative increases risk 4x. - Decreased ACh due to loss of noradrenergic neurons in the basal ceruleus and decreased choline acetyltransferase. Major susceptibility is APOe4 gene (apolipoprotein e4) - homozygotes are 50-90% likely to have dementia by 85 - heterozygotes have 45% chance by 85 - vs. 20% chance in general population Amyloid hypothesis: excess of AB peptides either by overproduction or diminished clearance. - APP, presenelin I and II patients are lifelong over producers of AB peptides. Post-mortem: - Gross: diffuse atrophy with enlarged ventricles and flattened sulci. - microscopic: Senile plaques and NF tangles - Neuritics plaques, but not neurofibrillary tangles correlate with severity of dementia. Tx: No cure or truly effective treatment. Cholinesterase inhibitors - approved for mild to mod - will slow cog. decline for 6-12 months - examples: Tacrine, donepexil, rivastigmine, galantamine NMDA antagonists: - for mod-severe disease - memantine

Schizoid

●A. A pervasive pattern of detachment from social ●A. A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: •1. Neither desires nor enjoys close relationships, including being part of a family. •2. Almost always chooses solitary activities. •3. Has little, if any, interest in having sexual experiences with another person. •4. Takes pleasure in few, if any, activities. •5. Lacks close friends or confidants other than first-degree relatives. •6. Appears indifferent to the praise or criticism of others. •7. Shows emotional coldness, detachment, or flattened affectivity. ●B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder and is not attributable to the physiological effects of another medical condition. Tx: therapy and anti-psychotics for tx for comorbid conditions.

Antisocial

●A. A pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years, as indicated by three (or more) of the following: •1. Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest. •2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure. •3. Impulsivity or failure to plan ahead. •4. Irritability and aggressiveness, as indicated by repeated physical fights or assaults. •5. Reckless disregard for safety of self or others. •6. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations. •7. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another. ●B. The individual is at least age 18 years. ●C. There is evidence of conduct disorder with onset before age 15 years. ●D. The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or bipolar disorder. Epi: 3% of men and 1% of women - poor urban areas and prisoners - no racial difference - somatic complaints, MDD and substance abuse often comorbid. Tx: DBT and behavioral therapy best choice - pts. have high addiction potential

Borderline

●A. A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: •1. Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.) •2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. •3. Identity disturbance: markedly and persistently unstable self-image or sense of self. •4. Impulsivity in at least two areas that are potentially self-damaging (eg, spending, sex, substance abuse, reckless driving, binge eating). (Note: Do not include suicidal or self mutilating behavior covered in Criterion 5.) •5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior. •6. Affective instability due to a marked reactivity of mood (eg, intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days). •7. Chronic feelings of emptiness. •8. Inappropriate, intense anger or difficulty controlling anger (eg, frequent displays of temper, constant anger, recurrent physical fights). •9. Transient, stress-related paranoid ideation or severe dissociative symptoms. ●B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations. ●C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning. ●D. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood. ●E. The enduring pattern is not better explained as a manifestation or consequence of another mental disorder. ●F. The enduring pattern is not attributable to the physiological effects of a substance (eg, a drug of abuse, a medication) or another medical condition (eg, head trauma). Epi: - 2x in women - suicide 10% - 1-2% Prog: - increased risk of suicide - coexisting depression/substance abuse. Tx: DBT with adjunct pharmacological tx for psychotic or depressive symptoms.

Schizotypal

●A. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive A. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: •1. Ideas of reference (excluding delusions of reference). •2. Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (eg, superstitiousness, belief in clairvoyance, telepathy, or "sixth sense"; in children and adolescents, bizarre fantasies or preoccupations). •3. Unusual perceptual experiences, including bodily illusions. •4. Odd thinking and speech (eg, vague, circumstantial, metaphorical, overelaborate, or stereotyped). •5. Suspiciousness or paranoid ideation. •6. Inappropriate or constricted affect. •7. Behavior or appearance that is odd, eccentric, or peculiar. •8. Lack of close friends or confidants other than first-degree relatives. •9. Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self. ●B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder. Tx: Therapy. Low-dose antipsychotics if necessary -> may help decrease social anxiety and suspicion in social relationships.