BMED II Week 2

How does re-deployment affect risk of PTSD?

W/ each deployment, risk of developing PTSD goes up 15%

Highest suicides per capita

White males over age of 65: 36 per 100,000 Average is 11 per 100,000

What age groups are more likely to dissociate?

Younger (negative correlation w/ age; higher age, less likely to dissociate)

Who is most at risk for increased suicidal thoughts due to SSRIs?

Younger age (under 25) When over 25 usually will decrease suicidality

Psychosis

a symptom, not an illness or diagnosis; condition in which thoughts, feelings, affective response, ability to recognize reality and ability to communicate and relate to others are sufficiently impaired to interfere grossly w/ capacity to deal w/ reality; characteristics of psychosis are *impaired reality testing, hallucinations, delusions, and illusions*

Intermediating-acting benzos?

(5-24h) Estazolam, Alprazolam, Lorazepam, Temazepam, Oxazepam

Short-acting benzos?

(<5h) Triazolam & Midazolam

What are the long-acting benzos?

(>24h) Chlordiazepoxide, Diazepam, Clobazam, others

Clinical consequences of 5-HT reuptake blockade

(SSRI) Anti-depressant effect GI disturbances Sexual dysfunction Impaired cognition

Medications used in delirium

*Antipsychotics* (great for helping sleep @ night) Cholinesterase inhibitors (not really used) Don't use benzo's unless their delirium is due to benzo withdrawal

Personality disorders w/ highest increased risk for violence

*Antisocial Personality Disorder* (low empathy, disrespect of authority, frustration intolerance, low anxiety, less impulsive and more calculated - will figure out when is the best time to attack) *Borderline Personality Disorder* (impulsive, drug/etoh use, emotional deregulation, real/imagined rejection) *Paranoid personality disorder* (frequently premeditated, partial loss of contact w/ reality, exaggerated reactions, distorted interpretations) *Narcissistic personality d/o* (victims generally known to perpetrator; violence in response to narcissistic injury)

Gender Dysphoria

*Distress* due to lack of match between one's experienced gender and gender assigned at birth; Interventions may include psychotherapy to address mental health symptoms (high comorbidity w/ depression, anxiety) and assist w/ related stressors; assistance in altering gender expression/gender role; hormone therapy; gender affirmation surgeries Treatments improve mental health status

Escitalopram (Lexapro)

*Most selective* of the SSRIs; relatively flat-dose response curve; potency of blocking 5-HT comparable to sertraline

Postpartum psychosis

0.1-0.2% incidence; within first month postpartum; disorientation, confusion, delusions, hallucinations, rapid mood cycling

Risk factors for suicide

1 risk factor can override all protective factors Previous attempts, lack of support system, mood d/o (depression, anxiety [PTSD], bi-polar), substance abuse, a plan, means to complete plan, chronic pain, multiple psycho-social stressors, no plans for future, impulsive or risky behaviors, statements of hopelessness/despair

Suicidal assessment

1) Eliciting suicidal ideas and intent 2) Eliciting risk factors 3) Clinical decision making

What are the criteria for PTSD

1) Stressor 2) Intrusive symptoms (recurrent and involuntary - nightmares, dissociative reactions, prolonged distress after exposure to traumatic reminders) 3) Avoidance 4) Negative alterations in cognition and mood after traumatic event (2 required - dissociative amnesia, persistent, negative beliefs about oneself or world, distorted blame, negative trauma-related emotions, diminished interest, feeling alienated, constricted affect) 5) Alterations in arousal and reactivity (2 required - irritable/aggressive, self-destructive/reckless, hypervigilance, exaggerated startle response, problems in concentration, sleep distrubance) 6) Persistence for more than a month 7) Funcitonal significance 8) Exclusion (not due to meds, substance, illness)

Clinical features of dissociative identity disorder

1/3-1/2 experience auditory hallucinations; often have amnestic quality for alternative personalities; transition from one personality to another is abrupt

M'Naughten Rule

1st famous legal defense for insanity; english woodcutter shot and killed secretary to prime minister - was acting on paranoid delusions; rule created a presumption of sanity unless "at time of committing act, the accused was laboring under such a defect of reason from disease of mind, as not to know nature and quality of act he was doing or that he did not know it was wrong"

PHQ-2 Screen for Depression

2 questions: Over the past 2 weeks, how often have you been bothered by the following problems: 1) Little interest or pleasure in doing things 2) Feeling down, depressed, or hopeless If yes to either, refer for more comprehensive evaluation

Mirtazapine (Remeron)

5-HT and NE release enhanced (via alpha2 receptor antagonism); 5-HT2 and 5-HT3 block

Serotonin hypothesis of schizophrenia

5-HT in midbrain dorsal raphe nucleus; 5HT1, 5HT2a, 5HT3 are relevant in schizophrenia; serotonin regulates dopaminergic neurons (most likely inhibitory effect on dopamine function); second gen or atypical antipsychotics are 5-HT2a antagonists and particularly effective for negative symptoms probably a combo of dopamine and serotonin problems

Nefazodone (Serzone)

5-HT2 blocker, weaker 5-HT and NE reuptake blocker

Postpartum blues

70-80% incidence; within first week postpartum and ends by day 14; tearfulness, anxiety, insomnia, mood instability

Course of dissociative amnesia

75% of cases last between 24 hours and 5 days; usually recover quickly and completely w/out treatment; many pts display propensity towards amnesia in setting of a trauma (Every time water is running, the pt dissociates (had trauma related to water).) Recommend seizure work-up in these pts

Other evaluation tools for alcohol use?

AUDIT-C; SBIRT (screening, brief intervention, and referral to tx)

Clinical course of delirium

Abrupt or acute onset (within hours to 1-2 days); fluctuation in symptom severity (waxing and waning; typically worse at night)

Testing for frontal lobe

Abstraction, judgment, executive abilities (planning, sequencing, goal-directed behavior) Ask for similarities between classes, proverb interpretation for abstraction Ask "what would you do if..." to assess judgment Serial hand sequences, clock drawing for executive abilities

Medications for AD

Acetylcholinesterase inhibitors for mild-moderate AD (Galantamine, Donepezil, Rivastigmine, Tacrine); slows progression Glutamate Receptor (NMDA) Antagonist (memantine); slows cell damage Non-FDA approved interventions: anti-inflamm agents, anti-oxidative agents, statins, immune system modulators

Romantic love & the brain

Activates VTA, which is rich in dopamine; caudate nucleus also active (which is active in OCD) Love is neurobiologically an addiction (dopamine) and an obsession (caudate nucleus)

Clinical course of PTSD

Acute - within 30 days Delayed - after 6 months Usually symptoms decrease over time, but can develop chronic PTSD, and spontaneous recovery is unusual in these cases. Symptoms can return years later w/ new stress or the right trigger

Risk factors for delirium

Advanced age; male gender; medical illness; underlying neurological disorders (i.e. dementia); prior episode(s) of delirium, substance use disorders, poor nutritional status (i.e. low albumin), prolonged hospitalization, medication exposure

Lowest suicides per capita

African-American females over age of 65

Denial of the specific (interviewing technique)

After denial of generic question, ask a series of questions about specific methods; force pt to deny each specific method "Have you thought about shooting yourself?" "Have you thought about overdosing?"

Gerstmann Syndrome

Agraphia, Acalculia, Right-left disorientation, and finger agnosia Found in dysfunction of *left inferior parietal lobule*

Ketamine

All the previous drugs require several weeks to become therapeutic. However, ketamine can cause a rapid anti-depressant effect. Ultimate effects probably due to impact on structural plasticity of the brain (thru change in glutamate; leads to synaptogenesis) - ketamine is a *glutamate receptor antagonist* Used off-label; not FDA approved for depression

Sedative/Hypnotics

All will induce sleep at high doses; benzos as sedative hypnotics can: decrease latency of sleep onset, diminish number of awakenings, increase sleep duration due to marked prolongation of stage 2 NREM sleep, decrease duration of REM sleep, decrease duration of slow wave sleep (stages 3/4) Don't ever prescribe more than one benzo, just decide whether want to give short, intermed or long acting

Fear conditioning in the brain

Amygdala; links fear response to previously neutral object; recognizes emotive expression; perpetuate negative emotions Amygdalar hyperactivity mediates anxious and depressive states*

Amyloid Precursor Protein

Amyloid precursor protein spans the cell membrane. Normally gets clipped and released into extracellular space (normal). Don't really know function; in Alzheimer's bad beta-amyloid starts accumulating, forms plaques and causes damage.

What could you use in PTSD if have mood-swings, irritability, aggression, family hx of bipolar disorder?

Anticonvulsant or mood stabilizer Valproate or lithium (valproate better tolerated) may help stabilize

Medications that can cause sexual dysfunction

Antihypertensives/antihistamines (decrease lubrication, ED) SSRIs (drive, orgasm) Benzodiazepines (impair orgasm) Opioids (like heroine; hypogonadism, premature ejaculation)

How do you test attention and concentration?

Attention - forward digits span (numbers @ one per second and patient repeats list - do 5); impaired in delirium and advanced dementia Concentration - serial subtraction (7 from 100 and continue); words or months backwards

How can you change the environment to help a pt w/ delirium?

Avoid interruption of sleep; room close to nursing station; sitter; clocks/calendars for frequent reorientation; adequate lighting; sensory aids (i.e. if they need hearing aids, glasses, etc.)

Efficacy of atypical anti-psychotics

Basically all the same efficacy, but clozapine may be slightly more efficacious But basically all the same is the main takeaway

Tx female orgasmic disorder

Bibliotherapy to improve knowledge of sexual functioning; masturbation; estrogen or testosterone; sensate focus

Triple vulnerabilities

Biological, generalized psychological, and specific psychological (learning what's dangerous)

Neuropsychiatric hx

Birth history Developmental history Handedness Ictal events (seizures; prodrome, aura, ictus, aftermath) History of head injury (amnesia?) Alcohol/drug use Mild cognitive impairment Appetitive functions (sleep, appetite, sex, hyperphagia, hyposexuality) Aggression Occupational hx (head blows, heavy metal exposure) Family hx Personality change (sexual drive, exaggeration of traits, temporal lobe epilepsy, Alzheimer's, subcortical dementias)

Why are benzodiazepines safer that barbiturates/alcohol?

Ceiling response is lower; easier to commit suicide w/ barbiturates and EtOH; although it is very dangerous to use benzos w/ EtOH

Which benzodiazepines have active metabolites?

Chlordiazepoxide, Diazepam, Prazepam, Clorazepate, Alprazolam, Triazolam, Flurazepam Desmethyldiazepam, an active metabolite, has a half life of several days!

Wilson Disease

Chromosome 13; ceruloplasmin deficiency (copper accumulation in body > cirrhosis, Kayser-Fleischer rings, etc)

Disorders of thought process

Circumstantiality, tangentiality, flight of ideas, derailment (loose associations), thought blocking, fragmentation, word salad Thought process: how ideas are produced & organized

Treatment of PTSD

Cognitive behavioral psychotherapy and prolonged exposure psychotherapy Exposure and CBT very important to treatment Two meds approved: Sertraline (zoloft) and paroxetine (paxil)

Progression of Alzheimer's

Cognitive symptoms > loss of ADLs > behavior problems > nursing home placement > death (dehydration, malnutrition, infection)

Common consistent in suicide is life-long___________.

Coping patterns

CAGE Questionnaire

Cut down on drinking? Annoyed by criticizing drinking? Guilty about your drinking? Eye-opener? 2 or more positive reponses suggest sufficient evidence of alcohol abuse at some point during life > further investigation

What receptor do typical antipsychotics have an affinity for?

D2 dopamine receptors

Pathophysiology of Delirium

Decreased cholinergic activity (leads to deficits in information processing, arousal, attention/ability to focus) Excess dopamine (source of agitation, delusions, pychosis)

PET scan of brain w/ Alzheimer's

Decreased glucose metabolism

Frontotemporal dementias

Degeneration of frontal and/or temporal lobes; leads to changes in personality/social behavior and/or aphasia; common cause of early onset dementia in 6th decade Clinical features do not predict neuropathology

HPA Axis and depression

Depressed patients have excessive HPA axis activity; hypercortisolemia due to increased expression of CRH and reduced feedback inhibition When treated, HPA axis will improve impairment in HPA axis and pts will start feeling better

Biogenic Amine Deficiency Theory of Affective Disorders

Depression is result of reduced levels of biogenic amines in CNS; discrepancies: some antidepressants do not block transport of 5-HT or NE, and are not MAO (break down serotonin, dopamine) inhibitors; therapeutic response to antidepressant drug required *2-3 weeks* to fully manifest, whereas maximum inhibition of biogenic amine transport occurs w/in a few hours

What disorders are associated w/ negative affect?

Depression, GAD, panic disorder/agoraphobia, OCD, social phobia

Uses of tricyclic antidepressants

Depression, neuropathic pain, enuresis, panic disorder

What mood disorder is highly comorbid w/ DID?

Depression; 70% of DID patients have attempted suicide

Kaplan's 3 Stage Model of Sexual Response

Desire (interest in sex) Excitement (body responds physically to sexual arousal) Orgasm (release of sexual tension, intense pleasure)

Clinical features of delirium

Diffuse cognitive impairment (attention, memory impaired, disorientation, executive dysfunction); thought disturbances (disorganized); language disturbances (dysgraphia, difficulty finding words); perceptual disturbances (misperceptions, hallucinations (visual >> auditory); psychomotor abnormalities; sleep-wake cycle disturbances; delusions (usually paranoid and not systematized); affective lability

Dissociative Identity Disorder

Disruption of identity from 'presence of two or more distinct personality states' accompanied by alterations in affect, behavior, consciousness, memory, perception, cognition, or sensory/motor function; recurrent inability to recall everyday events or important personal information that is too extensive to be explained by ordinary forgetfulness; symptoms not due to substance or general medical condition; cause distress/impairment

Delirium Diagnosis

Disturbance in *attention* and *awareness*; disturbance develops over a short period of time, is distinctly different from baseline, and tends to *fluctuate* throughout the day; has additional disturbance in *cognition* (like memory deficit, disorientation, language, visuospatial ability, or perception)

Dopamine hypothesis of schizophrenia

Dopamine hyperactivity in nigrostriatal, mesolimbic, and mesocrotical tracts; hyperactivity of dopamine receptors trigger psychosis (*D2* family is the hyperactive one - in the limbic & striatum); isn't the full answer but probably contributes (if was the full answer, then antipsychotics that block D2 would be the answer)

How do SSRIs affect the brain?

Down-regulated B-adrenergic and a2-adrenergic receptors; chronic antidepressants also affect 5-HT systems Acute SSRI elevates 5-HT in dorsal raphe nucleus and increases activation of 5-HT1a receptors Results in decreased firing rate of 5-HT neurons, counteracting effects of SSRI in forebrain Chronic SSRI normalizes raphe 5-HT neuron activity due to downreg of 5-HT1a receptors Ability of SSRIs to elevate serotonergic transmission in forebrain is then expressed unimpeded BASICALLY: Acutely, an SSRI decreases the firing of action potential fro serotonergic neurons. After chronic, there is a downregulation of 5-HT1a receptors and have increased firing rate and more serotonin being released. Uptake is also attenuated.

What can cause delirium?

Drugs and toxins, infections (e.g. sepsis), metabolic derangements, brain disorders (CNS infections, seizures, traumatic brain injury, psych disorders), systemic organ failure, physical disorders (burns electrocution, hyper/hypothermia)

SNRIs

Duloxetine (cymbalta), Milnacipran (Savella), Venlafaxine (effexor), Desvenlazfaxine (pristiq) Serotonin-norepinephrine reuptake inhibitors

What stage of life is extra attention important?

Early stage - this is neuroprotective; also breast fed kids have less anxiety and more resilience

Electroconvulsive therapy (ECT)

Effective in depression (severe, suicidal, stupor, 1st trimester because can't have meds), mania, schizophrenia (catatonia, treatment-resistant); MOA is unknown; for response, seizures are necessary but not sufficient; leads to downregulation of pre-synaptic serotonergic and adrenergic receptors, increased GABA; right unilateral ultrabrief pulse ECT as effective as bilateral reuglar-pulse ECT w/out cognitive effects; higher stimulus dose > better efficacy Contraindications: intracranial tumor, recent stroke Side effects: headaches, bodyaches, confusion, short term amnesia

Use of restraints in violent pts

Emergency use only if patient is danger to self/others; only used when less restrictive interventions have been ineffective; must be ordered by licensed independent practitioner; document ongoing need; cannot be punitive or for convenience or substitute for active treatment

Norepinephreine affects...

Energy, interest, motivation

Tarasoff Case

Ex-boyfriend of Tatiana Tarasoff said he was going to kill her; psychologist ordered him detained, but police interviewed him and let him go as he 'changed his attitude'; he later stabbed and killed Tarasoff; she nor her family were warned Tarasoff ruling: I - court rules duty to warn II - appeals court rules duty to protect

What can slow cognitive impairment/prevent AD?

Exercise, cognitive stimulation, mediterranean diet, social engagement, social stimulation, stress reduction, healthy sleep pattern, smoking cessation

Presenting suicide events

Explore presenting suicide events (method, how serious was action & intent, how feel about not completing, well-planned or impulsive, stress, alcohol, drugs, interpersonal, hopeless, why failed?)

Recent events

Explore recent suicide events; past 2 months; what other ways, behavioral incidents, gentle assumptions, symptom amplification, how intense?, how serious has progression been?

Protective factors for suicide

Family, spirituality, lack of means to carry out plan, lack of substance use, therapeutic alliance w/ health care professionals, statements indicating reasons or living, parent w/ children

Suicide risk assessment

Feeling hopeless? Suicidal thoughts in past 1 week? Drug or alcohol abuse in past 1 week? Moderate to severe level of stress?

Factors for better outcomes in schizophrenia

Female, presence of affective symptoms, and paranoid type

Who gets dissociative amnesia most?

Females > Males More common in adolescents and young adults

What is beneficial about atypical antipsychotics?

Fewer extrapyramidyl effects; somewhat more effective against negative symptoms than older drugs; better because only occupy striatal D2 receptors at 30-50% (better to prevent extrapyramidal symptoms)

How do you localize lesion sin linguistic syndromes?

Finger naming & right-left discrimination (point to right shoulder, point to right knee)

Treatment selection in PTSD

First line = evidence based psychotherpay over medication (Prolonged Exposure Therapy or Cognitive Processing Therapy or Eye movement desensitization and reprocessing); all of these are superior to control PTSD symptoms

Which SSRI(s) have active metabolites?

Fluoxetine (half life 1-4 days) and Norfluoxetine (half life 7-15 days)

SSRIs

Fluoxetine, Paroxetine, Sertraline, Fluvoxamine, Citalopram *Fluoxetine* is the prototype; selectively blocks serotonin (5HT) uptake; 70% of depressed pts will respond to SSRI at end of 6 weeks (4-6 weeks until effects evident); better tolerated and lower toxicity than TCAs Do not inhibit muscarinic or alpha adrenergic receptors Withdrawal response following cessation of chronic therapy can include recrudescence of depressed symptoms, headache

Supportive psychotherapy

For pts experiencing crisis or stress; restore former level of functioning; reassurance, guidance, explanation, suggestion

Language Cortex

Front = Broca's Area; if damaged, have broken, interrupted speech (Broca's, motor, production aphasia) Back = Wernicke's area if damaged, cannot understand speech/instruction (Wernicke's, sensory aphasia) Middle = if damaged will have conduction aphasia (cannot repeat speech)

Trichotillomania D/O

Hair-pulling; recurrent pulling out of one's hair, resulting in hair loss; repeated attempts to decrease or stop; causes significant impairment

What anti-psychotic is the worst in terms of extrapyramidal symptoms?

Haloperidol

Obsessive-Compulsive Disorder

High comorbidity w/ some level of depression A. Either obsessions or compulsions or both B. Obsessions or compulsions are time-consuming (e.g. take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning C. Obsessive-compulsive symptoms are not attributable to physiological effects of substance or condition D. Disturbance not better explained by symptoms of another mental disorder

What is the single greatest predicting factor for pt violence?

History of violent behavior Substance abuse is also strongly predictive of violent behavior

Exploration of immediate suicide events

Ideation during interview itself; anticipation of suicidal thoughts after leaving? develop a crisis plan (what to do if thoughts happen); ask if would be willing to make a safety contract (this is an assessment tool, not something to rely on); plans for future, reasons for living

Mild cognitive impairment

If of amnestic subtype, represents early stage of Alzheimer's; preserved general cognitive and social functioning; conversion rate to AD = 10-15% per year; pts are independent, not demented

What 4 fundamental personality dimensions predict violence in pts w/ personality disorders?

Impulse control, affect regulation, threatened egotism/narcissism, paranoid thinking/personality style

Serotonin affects...

Impulsivity, sex, appetite, aggression

What effect do benzodiazepines have on GABAa receptor?

Increase frequency of opening by acting as a positive allosteric modulator (binds to a different site compared w/ GABA); when GABAa receptor is bound by benzo, the channel opens and allows Cl- to flow into the cell > membrane hyperpolarization (an inhibitory potential)

Cognitive-Behavior Therapy Assumptions

Individuals are active processors of info; individuals recognize that there are reciprocal influences among cognitive emotional, behavioral, and physiological processes, and these processes are influenced by environment; individual must become active in tx

Risk factors for worse outcomes in schizophrenia

Insidious onset (comes on slowly), younger age of onset, negative symptoms, disorganized type and poor premorbid functioning

Seclusion in violent pts

Involuntary confinement to a room where pt cannot leave; emergency use only when pt danger to self/others; must be ordered by a licensed independent practitioner; document ongoing need; cannot be punitive or for convenience

How does alcohol affect suicidal thinking?

It lowers inhibitions, impairs judgment, leads to impulsivity, increases depression, leads to loss of emotional regulation Risk factor

When is contracting for safety helpful?

It's not; it's an outdated concept Develop a safety plan instead - trigger/relapse symptoms, self-initiated interventions, community support system, formal intervention

What gene is linked to schizophrenia

It's probably polygenic, but C4A is strongly linked C4A codes for complement factors; higher levels of C4A expression > greater risk of schizophrenia; these increased levels may result in excessive developmental synaptic pruning

Exposure to what toxin can influence violent behavior?

Lead

How does stress affect your body?

Leads to increased cortisol levels and decreased immunity > increased risk of cancer/infection Also, depression is an independent risk factor for CAD Stress also causes brain atrophy

Buproprion (Wellbutrin, Zyban)

Little influence on reuptake of NE or 5-HT; does not inhibit MAO adverse effects: seizures, CNS stimulation and insomnia weakly inhibits dopamine uptake, some effect to enhance release Produces 25% occupancy of DAT after therapeutic regimen Also used for smoking cessation

Which benzodiazepines do NOT have active metabolites?

Lorazepam

What neurobiological factors influence violent behavior?

Low serotonin (5HT) implicated in increased violence to self and others Alcohol transiently increases 5HT levels, but chronic drinking ultimately lowers 5HT levels

Atypica/Second Gen antipsychotics

Loxapine, Clozapine, Risperidone, Quetiapine, Olanzapine, Ziprasidone, Aripiprazole

Depression in pregnancy

MDD - 10-15% incidence; occurs within 1st month postpartum and can last for a year; depression, guilt, anxiety, fear of harm to baby, obsessions

GABA (gamma-amino-butyric acid)

Major inhibitory neurotransmitter in the brain (40% of neurons are GABAergic); ubiquitous distrubtion of both interneurons and projectino neurons; ionotropic & metabotropic; ionotropic receptors (GABAa) regulate a chloride ion channel to hyperpolarize neurons

Cognitive impairment in schizophrenia

May be due to failure to properly coordinate pyramidal neurons; will also have negative & positive symptoms

Course of dissociative fugue

May last a few hours to several years, but most episodes last *few days to few months* Prognosis varies; better w/ short duration

Chemical restraint in violent pts

Medication used to control behavior or restrict pt's freedom of movement and that medication is not a standard tx for pt's condition; generally not allowed and considered inappropriate use of medication; acceptable to medicate pt to treat symptoms w/ medications that are standard tx for their condition CANNOT say "Ativan prn for aggression" because that is a chemical restraint

What areas of the brain do antipsychotics act on?

Mesolimbic & mesocortical pathways - antipsychotic effect Nigrostriatal path - motor side effects Tuberoinfundibular - stimulation of prolactin release, galactorrhea Chemoreceptor trigger zone - antiemetic

What is the central channel of reward?

Mesolimbic dopamine system Include VTS and nucleus accumbens

Genetic predispositions to violence

Monoamine oxidase (MAOA) gene Tryptophan hydroxylase (TPH) gene (regulates serotonin levels)

Targets for anti-depressant and anti-obsessional drugs

Monoamine transporters Serotonin transporter

Factitious Disorder

Motivation is the *assumption of sick role*

Clinical features of impending violence

Motor control is the best predictor of impending physical violence; psychomotor agitation, especially pacing, and most especially approach-avoidance pacing, indicate high risk Posture (tense), Speech (loud, angry), Reflex (increased startle reflex)

Post-traumatic stress disorder

Must have direct exposure to death, threatened death, or actual or threatened serious injury, or actual or threatened sexual violence (direct, witnessed, indirect (learning that something violent/accidental happened to close relative/friend), or can be repeated exposure) Re-experiencing, Avoidance, Hypervigilance (RAH)

Psychological causes of sexual dysfunction

Negative affect (anxiety, depression, relationship conflict, negative views of sex), Negative cognitions, Distraction, lack of awareness of own sexual processes, lack of education about normal sexual functioning

Alzheimer's Disease

Neurodegenerative disorder, unk cause; commonest cause of dementia; affects older adults; progressive brain degeneration beginning in *temporoparietal area*, irreversible, fatal Earliest symptoms = memory impairment, followed by other cognitive dysfunction Impacts ADLs, functioning, emotions, behaviors

Is the stressor the only thing that's important in development of PTSD?

No - the reaction to stress is equally as important

What is the role for benzodiazepines in PTSD?

None

Why does Beta amyloid form in AD?

Normally the amyloid precursor protein is snipped by alpha secretase. In AD, b-secretase and gamma-secretase kick in. These cut in the wrong place and is not good for you. Dangerous and toxic. Not only the plaques damage the brain, but the oligomers (small fragments) are also very toxic to the brain.

What receptor do atypical antipsychotics have an affinity for?

Not D2 dopamine receptors; Important to remember that Loanzapine and Aripiprazole and Clozapine have ability to block 5-HT2a, which the typical first gen anti-psychotics don't.

Treatment of paraphilic d/o's

Nothing really works that well Cognitive-behavioral: orgasmic reconditioning, aversive treatment, relapse prevention Drug: physical or chemical castration, SSRIs to reduce sex drive; treat relevant psych cconditions Social control: incarceration, intensive supervision probation

What is responsible for producing acetylcholine in the brain?

Nucleus basalis of Meynert; becomes dysfunctional in Alzheimer's > decreased Ach and declining memory/awareness

Chronic illnesses/medical conditions and sexual dysfunction

Obesity, Diabetes, Multiple sclerosis, thyroid disorders (reduce desire), chronic pain, spinal cord injuries

Medical interventions that can help w/ violent patients

Offer nicotine replacement Offer medications to 'take the edge off' Benzodiazepines (lorazepam) Antipsychotics (Haldol, Thorazine, Olanzapine) Mood stabilizers (Divalproex)

Effectiveness of antipsychotics

Olanzapine has highest efficacy, but all others are basically the same, but also has side effects of weight gain, diabetes risk, worsening lipid profile; not first line antipsychotic Good for resistant pts

Prefrontal cortex and amygdala

PFC applies 'brakes' to the amygdala A lesion of the *medial PFC* will reduce the ability to extinguish fears People w/ anxiety disorders have reduced activity in prefrontal cortex

Which SSRI has the most potent anticholinergic effect?

Paroxetine

Predictors of PTSD after trauma

Per-traumatic dissociation, persistent hyper-arousal, low cortisol, severity, intensity, chronicity (hostage, spouse, child abuse)

MSE findings in psychosis

Perception altered (hallucinations, illusions, pseudhallucinations) Thought alterations - both form (circumstantiality, tangentiality, flight of ideas, derailment, word salad, thought block) and content (delusions, overvalued ideas) Behavior changes (e.g. catatonia, catatonia, poor impulse control, anger, agitation, stereotypes)

Hoarding Disorder

Persistent difficulty discarding or parting w/ possessions regardless of actual value; difficulty due to perceived need to save items and/or distress assoc w/ discarding them; leads to accumulation of possessions that congest and clutter active living areas and compromise their intended use; significant distress

What happens if you activate the medial prefrontal cortex?

Person becomes fearless/decreased anxiety

Typical/First Generation Antipsychotics

Phenothiazine derivatives: chlorpromazine, thioridazine, trifluoperazine, perphenazine, fluphenazine Thioxanthene derivatives: thiothixene, *haloperidol*

Which symptoms in schizophrenia are most amenable to anti-psychotics?

Positive symptoms (hallucinations, delusions, agitation) - by blocking D2 dopamine receptor

Possible AD vs Probable AD vs Definitive AD

Possible = meets DSM criteria w/out positive biomarkers Probable = meets DSM criteria with positive biomarkers Definitive = meets probable AD criteria w/ *histopathologic evidence*

Depersonalization/Derealization Disorder

Presence of one or both: 1) depersonalization (experiencing unreality/detachment/outside observe to oneself); 2) derealization (unreality/detachment w/ respect to one's surroundings) *Reality testing intact*; Disturbance not due to substance/medical condition; cause distress/impairment

Chronological Assessment of Suicide Events (CASE) Approach

Presenting suicide Events > Recent Events > Past Events > Immediate Events

Phases of schizophrenia

Prodromal: beginning of deterioration; mild symptoms Active: symptoms become increasingly apparent Residual: return to prodromal levels (1/4 of pts fully recover, 3/4 continue to have residual probs)

What is the therapy of choice for depression?

Psychotherapy (CBT, IPT, Psychodynamic, Group Tx)*** Will be a question

Treatment of dissociative amnesia

Psychotherapy (restore missing memories into conscious states) Drug assisted interview (sodium amobarbital given IV) Hypnosis

Treatment of dissociative fugue

Pt helped to recall events preceding fugue, sometimes thru hypnosis or sodium amobarbital interview

Treatment of Depersonalization/Derealization Disorder

Pts often refractory to intervention; treating accompanying psychiatric conditions, such as depression or anxiety, may help; as w/ dissociative disorders, exploration of past traumatic events can be useful

Obsession

Recurrent and persistent thoughts, urges, or images that are experienced at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety/stress The individual attempts to ignore or suppress such thoughts, urges, images or neutralize w/ action (i.e. performing compulsion)

Premature ejaculation

Recurrent orgasm and ejaculation before desired (minimal stimulation); unable to control; can cause embarrassment and social isolation

Excoriation D/O

Recurrent skin picking resulting in skin lesions; repeated attempts to decrease or stop; pulling cause significant impairment

How can the MMSE help you localize a lesion?

Registration of objects (frontal) WORLD backwards (frontal) "No ifs, ands, or buts" (L frontal) Calculations: Serial 7's (L parietal) Three-stage command (L parietal) Write a sentence (L parietal) Copy design (R parietal) Recent orientation (temporal) Recall of objects (L temporal) "Close your eyes" (L temporal) Recognizing a pen and a watch (occipital & temporal)

Compulsion

Repetitive behaviors (hand washing, ordering, checking) or mental acts (praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession, or according to rules that must be applied rigidly; the behaviors or mental acts aimed at preventing or reducing anxiety/distress

Types of tremors

Rest tremor - parkinsonism Postural tremor - anxiety, lithium, caffeine, asthma meds, hereditary essential tremor Coarse postural tremor: metabolic encephalopathy

Minor physical anomalies on neuropsych exam

Reveals something about fetal life; 4 or more is a pointer of deviant development; can have Small head, flat midface, smooth philtrum, underdeveloped jaw, thin upper lip, short nose, small eye openings, low nasal bridge - clues that something went wrong in-utero.

Sertraline (Zoloft)

SSRI Indications: PTSD, PMDD, OCD in children Most dopamine transporter blocking potency; intermed half-life w/ no active metabolites; linear pharmacokinetics; lower potential for drug-drug interactions; relatively fewer side-effects (watch for GI)

Paroxetine (Paxil)

SSRI Indications: social phobia, others Significantly more anti-Ach affinity, and more anti-Ach side effects; intermed half-life, no active metabolites; potential for drug-drug interactions a concern; worst side effect profile and highest rates of sexual dysfunction Available in sustained release

Citalopram (Celexa)

SSRI One indication - depression Low potency at 5-HT reuptake blockade; linear dose-response curve; intermed half-life, no active metabolites; linear pharmacokinetics; fewer side effects at low doses; lower potential for drug-drug interactions

Pharmacotherapy of OCD

SSRI's are first line (Fluoxetine, Paroxetine, Sertraline, Fluvoxamine) Combine w/ cognitive behavior therapy & exercise (exercise is awesome because it releases dopamine and serotonin PLUS endorphins)

Fluoxetine (Prozac)

SSRI; indicated for depression, bulimia, geriatric depression, PMDD (premenstrual dysphoric disordere); longest half-life; fewer side effects; potential for drug-drug interactions is a concern Inexpensive

medications for suicidal patients

SSRIs (safer for ppl who may try to overdose), Clozapine (can be specifically anti-suicidal for people with schizophrenia; this is an anti-psychotic)

Adverse effects of benzos

Sedation, CNS depression (worse if combined w/ EtOH), behavioral disinhibition (irritability, excitement, aggression, rage), psychomotor & cognitive impairment (coordination, attention [driving], poor visual-spatial ability, ataxia, confusion) Overdose (fatalities extremely rare w/ benzos alone) CNS & respiratory depression if combined w/ alcohol, barbiturates, narcotics, TCAs

What is associated w/ low propensity to produce extrapyramidal symptoms (motor stuff like tardive dyskinesia)?

Selectivity for 5HT2A receptors Clozapine, Risperidone, Olanzapine, Ziprasidone

Medications for PTSD

Serotonin drugs (SSRIs) work best; avoid catecholamine anti-depressants Acute PTSD responds better to SSRIs than chronic PTSD Sertraline or Paroxetine Use if you started psychotherapy and it's not helping enough

Which SSRI is the most potent dopamine reuptake blocker?

Sertraline

Symptom amplification (interviewing technique)

Since pts downplay, set an upper limit high enough in questioning "What percent of day are you thinking of suicide? 90%, 75%, 50%?"

Cognitive Therapy

Situation > Thinking (cognition) > Mood Want to correct cognitive errors so mood doesn't go bad (catastrophic thinking, all-or-nothing, shoulds, musts, mind reading, labelling, personalizations, overgeneralization, magnification, minimization)

What disorders are associated w/ positive affect?

Social phobias and depression

Acute Dystonia

Spastic Retrocollis, Torticollis Spasm of muscles, tongue, face, neck, back; may mimic a seizure; maximal risk at 1-5 days; treatment = antiparkinsonian agents (but not l-dopa)

Dissociative Fugue

Specifier for dissociative amnesia and is NOT a separate diagnosis; apparently purposeful travel or bewildered wandering that is associated w/ amnesia for identity or for other important autobiographical information (traveling around and 'come to' at a certain point) Basically dissociative amnesia + travel Ddx: brain pathology; drug induced fugues

Tau protein

Stabilizing protein that keeps the transport system working in neurons; accumulates in Alzheimer's disease when it "goes bad", which means it is *hyperphosphorylated*. Tubules start falling apart, hyperphosphorylated Tau starts clumping in neurons and causes damage; these clumps damage the neuron enough that it breaks and tau exits neuron and can damage outside the neuron Causes neurofibrillary tangles

Stage of Lewy Body Dementia

Stage 1 & 2: Starts in brainstem and causes autonomic and olfactory disturbances Stages 3 & 4: lewy bodies creep up and lead to sleep and motor disturbances Stage 5 & 6: cause emotional and cognitive disturbances

Civil Commitment

States have different procedures for civil commitment to treatment for mental health; through civil courts, not criminal court; can commit a pt for: danger to self, danger to others, inability to care for basic human needs IF above is due to mental illness (or in some states substance dependence) Has to be 'least restrictive alternative' Starts as inpatient care usually; can get court order to continue outpatient care for 90 days, can renew indefinitely (sometimes in 180 day increments) Can also court order meds, but varies by state

Stress response in the brain

Stress > increased glucocorticoids and decreased BDNF > atrophy/death of neurons

Biomarkers for Alzheimer's Disease

Structural imaging - will have medial temporal lobe atrophy, *hippocampal atrophy*, *enlarged ventricles*, widened sulci, overall decrease in volume Functional imaging - *reduced glucose* metabolism in temporoparietal regions; *reduced blood flow* in temporoparietal regions

Non-benzodiazepines that act at the benzodiazepine receptor

Structurally different from benzodiazepines, but they have similar function (similar pharmacological profile - bind to exact same site on GABA A receptors) Imidazopyridines (Zaleplon, Zolpidem) and Cyclopyrrolone (eszopiclone) The "Z-drugs"

Malingering

Symptoms feigned for reasons other than sick role, such as to avoid criminal or financial responsibilities; may express symptoms only when they feel they are being observed or heard, may refuse physician to have collateral interviews w/ others

Behavior therapies

Systematic desensitization, Flooding (expose all at once, good for OCD), Response prevention, Shaping (successive approximations to desired behavior reinforced, often used in autism/ID), contingency management (reinforced behavior; every time they have a negative drug test or something they get a reward), social skills training (used in schizophrenia), biofeedback, yoga/meditation

How do different depression treatments affect frontal cortex?

TMS and anti-depressants activate frontal cortex CBT and ECT decreases activity of frontal cortex Together this helps depression but you would think you'd just want to activate. Brain is complex- some areas you need hypoactive, some areas you need more active.

Tricyclic antidepressants

Tertiary amines (have active metabolites): Amitryptiline, Imipramine, Doxepin Secondary amines: Desipramine, Nortriptyline, Protriptyline Block both serotonin and NE uptake Adverse effect profile is worse than SSRIs

How do psychotropics change stress response?

They increase serotonin and NE and BDNF; they decrease glucocorticoids > increased survival and growth of neurons

OCD & the brain

Think BASAL GANGLIA; often symptoms of OCD are seen in other disorders that affect basal ganglia (Tourette's, Parkinson's, Sydenham's chorea)

Shame attenuation (interviewing technique)

Those w/ shame and guilt; communicate positive regard/understanding; 'did you need to lie to protect yourself?'

Clinical features of Depersonalization/Derealization Disorder

Transient depersonalization is common; events not considered pathological pts describe feeling like they are a robot or they feel like they are living in a movie Most episodes last from hours to weeks, can be chronic Ddx: depression, substances, brain pathology (seizures, migraines, discrete lesions)

What is required from the diet to synthesize serotonin in mammals?

Tryptophan

Vagus Nerve Stimulation (VNS)

Vagus has 80% afferents to brain, portal to brainstem, limbic, cortex; requires surgical implantation of device in chest wall and wire in neck; brain is stimulated thru vagus nerve in neck; approved for chronic recurrent treament-resistant depression

Structural abnormalities in schizophrenia

Ventricular enlargement; Hypofrontality (esp *dorsolateral prefrontal cortex)

Coercive paraphilias

Voyeuristic, Exhibitionistic, Frotteuristic, Pedophilic

Life Threatening Etiologies of Delirium

W (Wernicke's Encephalopathy; Withdrawal) H (hypoglycemia, hypoxia, hypoperfusion of CNS, hypertensive crisis) I (infections, intracranial processes) M (metabolic derangements, meningitis) P (Poisons) S (seizures)

CBT and prefrontal cortex

ability to master difficult circumstances and gain control resides in prefrontal cortex; CBT helps reframe negative thinking into positive and utilizes PFC

Neurocognitive disorders

acquired cognitive decline in one or more domains; mild = tasks need more effort or time; major = can be major mild, or major moderate , or major severe Major mild NCD = IADL starts to go away - like cooking, driving, writing check book Major moderate NCD = ADL starts to away - brushing teeth, showering, going to the bathroom Beyond = severe

What is the most selective SSRI? Most potent?

aka monamine uptake inhibitors Escitalopram is most selective (as reflected by higher NE/5HT ratio) Paroxetine is the most potent (as indicated by lower Ki value)

Benzodiazepines

all have similar structure; used clinically as anxiolytics, hypnotics, anticonvulsants, myorelaxants, preanesthetics Alprazolam, Chlordiazepoxide, Clonazepam, Clorazepate, Diazepam, Flurazepam, Flunitrazepam (Rohypnol - date rape drug), Lorazepam, Oxazepam, Prazepam, Triazolam, etc

Flumazenil

an antagonist of the GABAa receptor; binds to same site as benzodiazepines (e.g. diazepam); used to treat overdose of benzo's by acting as a competitive antagonist; remember, flumazenil is a competitive antagonist of benzo's, not of GABA Can precipitate withdrawal; not effective against barbiturate or ETOH overdose

Iloperidone

an atypical antipsychotic; high affinity for D2 and 5-HT2a receptors; high affinity for a1 adrenergic receptors; responsible for high incidence of postural hypotension HERG channel blocker Schizophrenic pts show similar discontinuation and relapse rates as those pts treated w/ haloperidol Low incidence of extrapyramidal effects; clinically sig weight gain

Dissociative Amnesia

an inability to recall important autobiographical information, usually of a traumatic nature, that is is inconsistent w/ ordinary forgetting; disturbance not due to a substance or other condition; symptoms cause significant distress/impairment May be global (total loss of autobiographical info) or episodic (pts cannot recall specific episodes of behavior or traumatic experiences); experience may include traumatic events, sexual or criminal behaviors, self-mutilation, marital or financial crisis; pt is alert and aware of loss of memory (may be indifferent to it) Differentials: organic syndromes, factitious disorder, malingering

Aripiprazole (Abilify)

antagonist at 5HT2a receptors; partial agonist @ D2 receptors; low incidence of extrapyramidal adverse effects; 75 hour half life

Effects of antipsychotic drugs

antipsychotic effect, antiemetic effect, reduced temp regulation, lowering of seizure threshold, increased prolactin release

Damage to MEDIAL frontal lobe

apathetic syndrome; not motivated to do anything

Gentle Assumption (interviewing technique)

assum behavior has occurred; don't ask "do you..." or "have you...?"; instead ask "How often do you..." or "What other...?"

Acceptance and Commitment Therapy (ACT)

assumes that normal psychological processes of human mind are often destructive, and create psychological suffering for all of us at some point; our suffering is due to our use of language and our attempts to control our internal experiences 1. Determine values and goals 2. Identify Unwanted Inner Experiences (negative thoughts) 3. Eliminate (things done/not done to ease unwanted inner experiences - maladaptive coping strategies like isolation) 4. Committed Action (what small behavior would you be willing to do that is consistent w/ values even in presence of negative thoughts? something kind, brave, bold, valued)

Male hypoactive sexual desire disorder

at least 6 month lack of interest in and desire for sexual activity

Female sexual interest/arousal disorder

at least 6 months, lack of or significant decline in sexual desire and arousal; not diagnosed if just a "desire discrepancy" (less desire than partner)

5-HT receptors

at the serotonergic synapse; all are G-protein coupled except 5-HT3, which is ligand gated

Adverse effects of TCAs

atropine-like side effects (dry mouth, constipation, blurred vision, mydriasis, metallic taste, urine retention) Orthostatic hypotension (due to a1-AR blockade) Drowsiness, sedation, weight gain (due to histamine-receptor block)

Lurasidone

atypical antipsychotic blocks D2 and 5-HT2a receptors w/ preferential binding to D2/3 dopamine receptors High affinity for 5-HT1a receptors Adverse effects: akathisia, EPS, hyperprolactinemia, sedation

Huntington disease

autosomal dominant; chromosome 4; caudate atrophy, chorea, psychosis

Negative symptoms in schizophrenia

avolition (decreased motivation), alogia (lack of speech), anhedonia (inability to feel pleasure), affective flattening

Theories of suicide

basically boils down to issue of connected-ness and feeling disconnected

de Clerambault's syndrome

believe someone (usually of high social status) is in love w/ them

Delusional parasitosis

believe they are infested w/ parasites.

Extrapyramidal symptoms

bradykinesia, rigidity, variable tremor, masked facial expression, shuffling gait Due to antagonism of D2 receptors in striatum most likely Tx: antiparkinsonian agents helpful (benztropine, trihyxlphenidyl)

Hyposmia, Anosmia on neuropsych exam

can be seen in Alzheimer's disease, multiple sclerosis, Parkinson's, TBI

Non-verbal amnesia

can't recall pictures; right temporal lobe

What populations has the highest percentage of PTSD occurrence?

children & battered women prevalence in women is 10%

ApoE

clears b-amyloid normally; people w/out AD get some b-amyloid, but it's cleared out by ApoE and lipoprotein transport system; need SLEEP to get rid of amyloid; People w/ Alzheimer's get worse in the evening because B-amyloid accumulates throughout the day (then usually is cleared when we sleep)

Schizoaffective d/o

concurrent mood episodes and symptoms of schizophrenia; presence of delusions or hallucinations for *2 weeks* in absence of mood episodes; major mood episode be present for a majority of disorder's total duration after criterion A has been met

CBT

coping skills learned, not innate; automatic and may require conscious effort; use cognitive skills to *cope* w/ an objectively stressful event; identify and change irrational thinking patterns

Schizophrenia

criterion A: 1 month of active phase symptoms (at least 2): *delusions, hallucinations, disorganized speech*, disorganized behavior, negative symptoms; must have at least one of the three core positive symptoms (delusions, hallucinations, disorganized speech); total duration *6 months* + social/functional impairment

Orbitofrontal cortex

critical for social function and adherence to external rules that govern behavior; has inhibitory input to the amygdala; assesses value of objects as to internal needs; selects objects of high value and inhibits response to others of less value When damaged > *impulsivity*, *antisocial behavior*, and *lack of empathy*

SPECT scan in Alzheimer's

decreased blood flow

Female orgasmic disorder

delay in or absence of orgasm following a normal process of arousal occurring during 75-100% of sexual encounters; not diagnosed if can orgasm only from clitoral stimulation; only diagnosed if causes significant distress

Delusional d/o

delusions for *1 month*; erotomanic, grandiose, jealous, persecutory, somatic, mixed type; symptoms not better explained by something else

Brief psychotic disorder

delusions, hallucinations, disorganized speech or disorganized behavior w/ duration of 1-30 days; full return of premorbid functioning; only need ONE symptoms; onset must be within 2 weeks of a stressor and return to normal w/in 30 days

Omega sign and Veraguth's folds

depression

Anterior Left hemispheric brain lesions

depression; pessimism, hopeless, helpless, tearful, sad, suicidal

Insomnia

difficulty w/ initiation, maintenance, duration or quality of sleep that results in impairment of daytime functioning; chronic insomnia is that lasting more than 1 month; more common in women, older adults, pts w/ chronic medical & psychiatric conditions Consequences: fatigue, mood disturbances, occupational difficulties, reduced quality of life

Pupils & neuropsych exam

dilated: anticholinergic delirium small: opiate intoxication argyll-robertson pupils: small, irregular, not reactive to light, reactive w/ accomodation (neurosyphilis) Kayser-Fleischer corneal ring: wilson's disease

Generalized psychological vulnerability

diminished sense of control; control is huge; environment can turn on genetic vulnerability; parents who allow kids to explore their world and learn to cope w/ unexpected environmental events enhance sense of control in kids (good)

Dopamine affects...

drive, motivation, sex, appetite, aggression

Sleep-deprivation therapy

elevation of mood if pt w/ depression is kept awake for whole night; in bipolar can cause hypomania; unclear mechanism (endogenous antidepressant substance when awake?)

Past events

exploration of past suicide events; only info that can change decision; what was most serious past suicide attempt? current similar? triggers similar? how many previous? when was most recent outside of past 2 months?

Treatment of DID

extended psychotherapy 4 approaches to treatment: 1) integrate the alters 2) seek harmony between the alters 3) leave alters alone and focus on 'here and now' adaptation 4) ignore the alters, regard them as 'artifacts' and treat other symptoms No pharm treatments helpful in reducing dissociation (benzos make it worse), but antipsychotics sometimes helpful in treating disorganized thoughts/hallucinations

Hemiagnosia

fail to correctly dress one half o body - contralateral to damaged hemisphere; unilateral neglect

Hallucinations

false sensory perception not assoc w/ real external stimuli; auditory is most common; can also be visual, commands, olfactory, somatic/tactile, gustatory

Capgras syndrome

feel that spouse is an imposter (replaced by someone else)

Risk factors for PTSD

female gender, child abuse or neglect, prior hx of psychiatric illness, history of trauma or stress, family history of psychiatric illness, borderline personality d/o, neuroticism, genetic liability

Noncoercive paraphilias

fetishistic disorder (inanimate objects) Transvestic d/o (sexual arousal achieved by cross-dressing) Sexual sadism d/o (recurrent and intense sexual arousal form physical/psychological suffering of another person) Sexual masochism d/o (sexual arousal achieve thru being on receiving end of behaviors listed above)

Clozapine

first atypical antipsychotic; few extrapyramidal effects; affinity for D2 dopamine and 5-HT2a serotonin receptors; modest inhibitor of SNAT2, which increases synaptic glycine levels leading to increased activation of NMDA receptors Very efficacious for positive and negaitve symptoms Also *lowers suicide risk*; no extrapyramidal symptoms; no tardive dyskinesia Side effects: lowers seizure threshold, *black box warning = agranuloscytosis*

Delusions

fixed false belief that is unshakeable even when contrary evidence based on fact is presented; inconsistent w/ religious, cultural, or subcultural norms, not resisted by pt, subjective certainty to pt; types: somatic delusion, grandeur, reference, erotomania

Light therapy

for seasonal affective disorder; morning exposure to bright light for 30 min daily effect seen in 1-2 weeks

Vascular neurocognitive disorder

from cerebrovascular disease; hypertension is a risk factor; small and medium sized blood vessels; Binswanger disease is classic (tiny stroked in brain due to HTN)

Specific Psychological Vulnerabilities

function of early learning where anxious apprehension is focused on potentially dangerous specific objects or events; learning what is dangerous Panic d/o - unexplained somatic sensations are dangerous Specific phobia - particular object/situation dangerous Social phobia - potential social evaluation is dangerous OCD - thoughts, images, or urges equated w/ dangerous actions

What happens in brain of someone w/ Alzheimer's

get plaques, tangles, neuron destruction, cholinergic deficit (Ach deficient)

Genetics of late onset AD

greater than 99%; ApoE e4 allele on chromosome 19; one copy increases risk 3.5 fold; 2 copies increases risk 10-20 fold

Lewy Body Dementia

hallmark = lewy bodies w/ neuronal loss a-synuclein pathology (usually a normal synaptic protein involved in vesicle formaiton) Lew bodies form and contain pink intracytoplasmic neuronal inclusions of aggregated *insoluble a-synuclein* Pathology of a-synuclein can spread from cell to cell Don't give antipsychotics to these pts because they are exquisitely sensitive

Indicators of psychosis

hallucinations, delusions, formal thought d/o and disorganized speech, disorganized behavior (such as catatonia), negative symptoms

Orbital prefrontal cortex

has a critical role in goal-directed behaviors; pleasure seeking

EEG in delirium

helpful to confirm dx; usually have generalized slowing; low voltage fast activity in alcohol or sedative-hypnotic withdrawal

Pharmacokinetics of benzodiazepines

hepatic CYP450 metabolism; undergo hepatic oxidation and/or conjugation Cross the placenta & detectable in breast milk Many have active metabolites w/ half-lives greater than parent drug (e.g. Diazepam, active metabolite is desmethyldiazepam and oxazepam and have t1/2 20-80 hours)

Generalized biological vulnerabilities

high strung, nervous emotional runs in families; high neuroticism and low extroversion important vulnerability for anxiety; genetic basis; may not be turned on depending on whether you have exposure to psychological vulnerability

MRI of brain w/ Alzheimer's

hippocampal atrophy, enlarged ventricles, atrophy overall

Common emotion in suicide

hopelessness

Neurobiology of PTSD

hyperarousal of symp nervous system Noradrenegic, HPA, serotonergic, glutamatergic, thyroid, endogenous opioid, and other systems affected Reduced volume of hippocampus and anterior cingulate Excessive amygdala activity and reduced activation of prefrontal cortex & hippocampus

Treatment of delirium

identify & reverse reason(s) for delirium; reduce psychiatric or behavioral symptoms of delirium (environmental manipulation; medication)

Frontal lobe

important for executive functioning

Temporal lobe

important for memory

Parietal lobe

important for sensation

Occipital lobe

important for vision

Tx of erectile d/o

improve health; vacuum pumps; medications (testosterone, vasodilating meds), surgical techniques (penile implant), sensate focus, reducing thrusting/partner superior position

Damage to ORBITOFRONTAL lobe

impulsive, socially inappropriate words/activities, labile mood - *disinhibition*

Erectile disorder

inability to achieve or maintain an erection until completion of sexual activity during 75-100% of sexual encounters for 6 months

Acalculias

inability to do simple addition/multiplication; lesions of left posterior hemisphere in inferior parietal regions

Temporal lobe epilepsy indications

increased religiosity, short temper, hyposexuality

Olanzapine

inhibits 5-HT2a and D2 receptors (and a-adrenergic and muscarinic receptors); less extrapyramidal effects; *does NOT appear to cause agranulocytosis*; lowers seizure threshold; weight gain

Risperidone

inhibits D2 and 5-HT2a receptors; extrapyramidal effects at higher doses;

Paraphilic disorder

intense and persistent sexual interest other than genital stimulation or preparatory fondling w/ phenotypically normal, physically mature, consenting human partners; can involve non-human objects, suffering or humiliation of self or partner or children/other non-consenting person Only diagnosed if causes distress or dysfunction and/or involves coercion Desire persistent, compulsive, chronic; can be occasional or be the only way individual can experience sexual arousal almost never in females except masochism and pedophilia (rare)

Stimulus for suicide

intolerable psychological pain

Behavioral activation

key to changing how people feel is helping them change what they do; structure and schedule activities that follow a plan not a mood; change will be easier when starting small; emphasize activities that are naturally reinforcing, be a coach! emphasize problem solving approach

Junction between frontal and parietal

language cortex (esp on left side of head)

Nonfluent aphsia

lesions of anterior left hemisphere; short utterances, dysprosodia (Broca's area; motor aphasia)

Impaired comprehension

lesions of posterior left hemisphere (Wernicke's area; sensory aphasia)

Genetics of early onset AD

less than 1% of all AD pts; age of onset <65 years Autosomal dominant inherited gene mutations of B-amyloid production or metabolism; APP (chromosome 21), presenilin-1 (chromosome 14), presenilin-2 (chromosome 1)

Adverse effects of antipsychotics

loss of accomodation, dry mouth, difficulty urinating, constipation (due to muscarinic blockade) orthostatic hypotension, impotence, failure to ejaculate (a-adrenoreceptor blockade) parkinson's syndrome, akathisia, dystonia (dopamine receptor blockade) Tardie dyskinesia (supersentivity of dopamine receptors) Toxic-confusional state (muscarinic blockade) Amenorrhea, galactorrhea, infertility, impotence (dopamine receptor blockade), weight gain

Ziprasidone

low extrapyramidal effects; low antimuscarinic effects; low sedative action; low hypotensive effects; QT prolongation

Molecular biomarkers for Alzheimer's

low levels of B-amyloid42 in the CSF (because it's all accumulating in brain); increased CSF tau and phospho-tau; psoitive amyloid PET

Symptoms of Alzheimer's disease

memory impairment most common; declarative episodic memory of specific events; recent events dependent on hippocampus, entorhinal cortex; cannot recall w/ cues; need another person to give you reliable hx Executive dysfunciton (organization, planning, multiasking) Anosognosia (poor insight) Apathy, social disengagement, irritability Behavioral (aggression, wandering, psychosis) Apraxia (dressing, eating, self-care tasks) Olfactory dysfunction Sleep disturbances Seizures, myoclonus, primitive reflexes, incontinence

Causes of dissociative fugue

memory loss is secondary to painful psychological conflict, in which pt has limited emotional resources to confront defenses include: repression, denial, dissociation

Reward center of the brain

mesolimbic and mesocortical pathways

Imitation behavior

mimics gestures of examiner despite instructions - frontal lobe disease

Illusion

misperception or misinterpretation of real external sensory stimuli (seeing a hose and thinking it's a snake)

Hypoactive Frontal cortex

more likely to be depressed

Delusions of persecution

most common; feel mocked, insulted, watched, poisoned

Akathisia

motor restlessness, not anxiety or 'agitation' maximal risk at 5-60 days Tx: reduce dose or change antipsychotic; antiparkinsonian agents; diphenhydramine; benztropine

GABAa Receptor

multiple subunits; span cell membrane to form chloride ion channel; when benzo or z-drug binds, they increase the FREQUENCY of opening of this channel; barbiturates bind to a different site and increase the DURATION of channel opening

Neuroleptic malignant syndrome

muscle rigidity, stupor, hyperthermia, unstable blood pressure, myoglobinemia; can be fatal Max risks weeks after starting and can persist for days after stopping Mech: rapid antagonism of dopamine receptors may contribute Tx: stop anti-psychotic immediately; dantrolene or diazepam as muscle relaxants or bromocriptine

Emergency Protective Custody

must be detained by a law enforcement officer; provider can hold a patient until law enforcement arrives; pt must be evaluated by a mental health professional w/in a certain time frame (36 hours in Nebraska)

Substance abuse and sexual dysfunction

nicotine (reduces desire, vasocongestion, testosterone levels) Cocaine/amphetamines (impair orgasm & erection) Marijuana (long-term use decreases desire) Alcohol (impairs orgasm in males; long-term use reduces testosterone)

Consequences of insomnia

nighttime experience; daytime complaints, quality of life, absenteeism, decreased productivity, increased healthcare costs, societal burden, future health risks, increased fall risk

Wernicke's Encephalopathy

often have paralysis of the eye muscles; thiamine deficiency causes this

Tardive dyskinesia

oral-facial dyskinesia (widespread choreoathetosis or dystonia) max risk: after months or years of tx; worse on withdrawal mech: dopamine receptor supersensitivity (up-regulation) Tx: prevention crucial; tx unsatisfactory

Genito-Pelvic Pain/Penetration D/o

pain assoc w/ intercourse (usually during but can be before or after); may involve vaginal pain, or pain in other areas

Abulia/Akinetic Mutism

pathological slowness or absence of spontaneity, delayed response, no effort made; cerebral disease; can do the telephone test (won't talk to you, but if no one is questioning them and the telephone rings, they will run and answer it)

Genetics of schizphrenia

polygenic; inherit a vulnerability

Pedophilic d/o

preference for sexual involvement w/ prepubescent children; not all perpetrators of childhood sexual abuse are pedophiles

Over-valued ideas

preoccupation that can come to dominate & ruin a person's life but can understand where it came from - like body image distortion in anorexia Can usually be reassured (not unshakeable like a delusion)

Body Dysmorphic Disorder

preoccupation w/ one ore more perceived defects or flaws in physical appearance that are not observable or appear slight to others; at some point, individual has performed repetitive behaviors (mirror checking, obsessive grooming, skin picking) or mental acts (comparing appearance to others); preoccupation causes distress/impairment; appearance preoccupation not better explained by concerns w/ body fat or weight in an individual whose sx meet diagnostic criteria for eating d/o

Habituation

process during which person stops responding to a stimulus because it is no longer new; one of the reason that exposure therapy works

Clinical features of lewy body dementia

progressive dementia; fluctuating cognition; visual hallucinations; Parkinsonian symptoms; sensitivity to neuroleptics; REM sleep behavior disorder; falls, autonomic dysfunction

Double Bind theory of schizophrenia (expressed emotion)

proposed that schizophrenic symptoms are an expression of social interactions (esp w/ family) in which the individual is repeatedly exposed to conflicting injunctions, without having the opportunity to adequately respond to those injunctions, or to ignore them; schizophrenia often linked to family stress "expressed emotion" - family members frequently express criticism and hostility and intrude on each other's privacy

Tx of female arousal issues

psychoeducational techniques (education about sexual functioning, restructure negative thoughts, sensate focus) Lifestyle changes Technologies (lubricant, clitoral vacuum pump) Medications (alprostadil, estrogen replacement)

Dissociation

psychologically induced loss of memory, consciousness, identity, or perception of the environment

Psychiatric conditions w/ increased risk for violence

psychosis, bipolar disorder, intermittent explosive disorder, conduct disorder, oppositional defiant disorder, dementia

Negative symptoms in psychosis

refer to loss of normal function; four major clinical subgroups = affective, communicative conational, and relational Blunted affect, speech ay be reduced in quantity and information; patient may show lack of drive/goal-directed behavior (conational) like poor grooming; interest in social activities/relationships reduced Differentiate from people w/ depression - in psychosis you aren't sad, just detached

Downward drift hypothesis

refers to the link between socioeconomic status and schizophrenia (occurs in all groups, but more frequent in lower socioeconomic status); stress of poverty cause the disorder or the disorder causes victims from higher social levels to fall and remain at lower levels ("downward drift")

Clinical interventions for suicidal patients

safety issues, removal of means (GUNS), hospitalization; provide support; pay attention to affect; regular framework for tx to provide stability; treat underlying cause

MOCA

screens for cognition; score of > 26 is normal

Defenses used in dissociative amnesia

secondary to painful psychological conflict; use following defenses: repression (unconscious blocking of disturbing impulses from awareness), denial, dissociation (separation and independent functioning of one group of mental processes from others)

Effects of TCAs

sedation, relieve depression, elevate mood in depressed pts (delayed), antimuscarinic effects, alpha-adrenergic blockade (a1) Variety of targets; affinity for different targets leads to adverse effect profile

Purpose of suicide

seek a solution

Delirium tremens

severe form of alcohol withdrawal that results in sudden and severe mental status changes; usually occurs around 72 h after last drink

What is thought to cause DID?

severe psychological and physical abuse (most often sexual) in childhood that leads to profound need to distance self from horror & pain; leads to unconscious splitting off of different aspects of original personality, each personality expressing some necessary emotion or state the original personality does not dare express; the dissociated selves become a long term, ingrained method of self-protection from perceived emotional threats

Frotteuristic d/o

sexual arousal achieved by 'touching and rubbing against a nonconsenting person'

Exhibitionistic d/o

sexual arousal achieved by displaying genitals to unsuspecting others

Voyeuristic D/o

sexual arousal achieved by observing unsuspecting others naked or engaged in grooming or sexual activity

Quetiapine

similar to olanzapine; assoc w/ cataracts

Schizophreniform disorder

similar to schizophrenia except for duration of *1 month to 6 months*; don't need impairment of function for dx

Behavior incident (interviewing technique)

specific facts, details; try to anchor pt in specific memory (how many pills? what did you do next?); no opinions or impressions, just a verbal video

Paranoia

spectrum: normal vigilance > hypervigilance > paranoid personality > delusional d/o > paranoid schizophrenia; projection is main ego defense (substitutes and external threat for an internal fear or threat); paranoid themes = being followed, monitored, having things stolen, being poisoned, having integrity, problems w/ authority

Brain-Derived neurotrophic Factor

stimulates nerve cell growth; anti-depressants work in part by boosting BDNF and stimulating cell growth; but if you have too much can cause anxiety

Tx of premature ejaculation

stop-start technique; squeeze technique (squeeze the penis when feel like going to ejaculate); SSRIs (tend to delay ejaculation, but may decrase desire)

Hippocampus

stores memory and gives it back when you need it; interacts w/ amygdala in encoding of emotional memories Size/volume of hippocampus is important

Anxiolytics

strategy for tx is to reduce anxiety w/out causing sedation; often use benzodiazepines Can also be used as hypnotics Include: Benzodiazepines, 5-HT1a receptor agonists, SSRIs, SNRIs Take 2-4 weeks before anxiolytic effects manifest

Z drugs

structurally unrelated but as effective as benzos; Zolpidem and Zaleplon, Eszopiclone Metabolized by CYP450; short half-lives No active metabolites Reduce dose in pts w/ hepatic dysfunction Don't drive the day after taking zolpidem ER

Basal ganglia

subcortical structures usually assoc w/ movement and motor control; disruption of BG leads to disorders like Huntington's, Parkinson's, hemiballisumus; Treatment interventions for OCD decrease BG activity in responders, but the role remains unclear

Treatment of desire disorders

switch med if appropriate; tesosterone replacement for both men and women; estrogen replacement therapy for women; psychosocial interventions (masturbation, increasing fantasy, cognitive-behavioral depression tx)

Polymorphism of 5-HTT gene and depression

the short allele > more vulnerability to depression long allele > less vulnerability to depression

Phantom boarder delusion

think someone is living in their house

Treatment of sexual disorders

trauma treatment sensate focus (touch each other just for purpose of arousal, focus away from intercourse) kegel exercises Flibanserin (supposed to help w/ sexual dysfunction in women, but it's super duper shitty and doesn't work)

Etiology of Dissociation Theories

traumatic experience strongly correlated; children more prone to dissociation; link between dissociative states and hypnosis (more hypnotizable); neurochemical and pharmacologic agents may be related (LSD, PCP, ketamine induce dissoc episodes, as do benzos), serotonin dysregulation may contribute

Tx of sexual pain

treat medical causes (UTI); estrogen replacement therapy, lubricant, kegels, relaxation vagina dilator different positions

Normal pressure hydrocephalus

triad of neurocognitive impairment, urinary incontinence, and magnetic gait enlarged ventricles; if you put a shunt in, their dementia reverses

Verbal amnesia

trouble remembering words; left temporal lobe

Apraxia

unable to execute learned movements despite intact motor and comprehension (combing hair, etc) Very broad area has to be damaged test by asking to pantomime combing, brushing

Anosognosia

unaware of deficit; right parietal lesions denying left hemiparesis

Deep-brain stimulation (DBS)

use electrodes to stimulate brain electrically and 'knock-out' function temporarily thru hyper-polarization; replaced brain surgery for OCD and depression

Transcranial Magnetic Stimulation (TMS)

uses coil resting on scalp to create brief potent magnetic field - passes thru skull; magnetic field then encounters nerve cells and induces ELECTRICAL current to flow in them; prefrontal repetitive TMS produces immediate and long-term changes in mood circuits FDA-approved for depression Adverse effects: scalp discomfort, rarely seizures Therapeutic w/out seizure

Utilization behavior

uses objects around as if required of him/her; feel they are obligated to do something w/ everything in your office; may drink out of your coffee cup

Right hemispheric brain lesions

usually get *mania*; grandiosity, pressured speech, risk-taking behaviors, uncritical optimism

Trazodone (Desyrel)

weak inhibition of serotonin uptake; partial agonist at some postsynaptic serotonin receptors and some antagonist activity at presynaptic receptors; half life 6-11 hours; adverse effects include sedation dizziness, hypotension, nausea somewhat unpredictable in treating depression