Psychiatric Disorders - Chart Study Guide

Psychiatry/Mental Health Topics • • • • • Axis III: General medical conditions Axis IV: Psychosocial and environmental problems Axis V: Global assessment of functioning (GAF scale = 1-100) Anxiety disorders Generalize anxiety disorder • Most common anxiety disorder • 5% lifetime prevalence, • Can be treated effectively with or a combination of the two • 30-50% also meet the criteria for MDD • DSM o Excessive worry for most days for revolving around o Anxiety is difficult to control o At least three of the following: ▪ Restlessness ▪ Fatigue ▪ Difficulty concentrating ▪ Irritability ▪ Muscle tension ▪ Sleep disturbance o Anxiety does not revolve around fear of a panic attack o Causes significant distress or impairment of functioning o Not caused by meds etc Need for treatment? • Mild  (sx don’t interfere significantly with functioning), pt can forgo treatment initially, but follow the patients every 6 months to monitor • Moderate-Severe  initial treatment choice of meds or CBT can be made on basis of availability and patient preference • CBT  10-15 60 minute sessions • Meds  , no SRI has been shown to have superior efficacy o Other meds  benzos (avoid long term), pregabalin and buspirone o Other antidepressants  mirtazapine o Antipsychotic meds  SGAs (typically quetiapine) • CBT & Meds  augmentation of both has led to a greater reduction in GAD sx, patients should be on stable med dose prior to starting CBT • Avoid PRN benzos or meds with sedative effects • Encourage healthy sleep habits and limit caffeine intake Post-traumatic stress disorder (PTSD) • The complex somatic, cognitive, affective, and behavioral effects of psychological trauma • Characterized by intrusive thoughts, nightmares, flashbacks, avoidance of reminders, hypervigilance, and sleep disturbance o All of which lead to social/occupational dysfunction • Types of trauma  sexual relationship violence (33%), interpersonal-network trauma (sudden death of loved one – 30%), interpersonal violence, exposure to organized violence, participation in organized violence, other • 8% of the adult population (lower outside the US) – 60% prevalence in combat soldiers and assault victims • Pre-trauma risks o Gender (women x4) o Age at trauma o Race o Low SES o Previous trauma o Personal/family psych history o Initial severity of event • Risks Intentional trauma, native americans, refugees • Psychiatric co-morbidity is high  depression, anxiety and substance abuse • DSM o Occurs after a traumatic event associated with intense fear/horror o Persistent re-experiencing of event (nightmares, flashbacks) o May have detachment, anhedonia, restricted affect o Avoidance of thoughts/activities that may bring reminders or trauma o Increased arousal after trauma – poor concentration, hypervigilance, exaggerated startle response, insomnia, irritability o o Sx cause significant distress or social occupation/dysfunction • Tx: o (nightmares), psychotherapy, CBT, support groups, family therapy Obsessive compulsive disorder (OCD) • 2.5% prevalence – 1:1 ratio, earlier onset in males • DSM o Either obsessions OR compulsions are present o Obsessions = recurrent, persistent thoughts, impulses, or images experienced as intrusive and causing marked anxiety o Compulsions = repetitive behaviors or acts that the person feels driven to perform in response to obsessions o Person recognizes that obsessions or compulsions are excessive or unreasonable (children may not) o This , and interferes with normal functioning • Tx: o o o Clomipramine (TCA) Acute stress disorders • Develops shortly after an individual is exposed to a traumatic event • Characterized by feelings of helplessness, intense fear, and a number of dissociative sx • Panic disorder (PD) • 1-3.5% prevalence, 3:1 female/male ratio • onset in mid 20s • DSM o Required: recurrent , characterized by intense fear, palpitations/sweating/shaking/SOB/feeling of choking/chest pain/nausea/dizziness/depersonalization/fear or losing control of going crazy, fear of dying, paresthesias o Required: o At least one month of , worry about cause of attacks, significant change in behavior due to attacks o Can occur with or without agoraphobia • Tx o o Benzos can be used short term Adjustment disorders • DSM-V: development of an emotional response to a specific stressor o Clinically significant sx develop as a response to the stressor o • • Can resolve without progressing to PTSD Diagnosis: o Must occur within 4 wks, and last for a minimum of 3 days, also must have 9/14 sx in the following categories o Intrusion sx  involuntary & intrusive memories of event, distressing dreams, dissociative reactions where the individual feels as it the event is recurring, physical distress reactions to external cues that resemble an aspect of the event o Negative mood  inability to experience positive emotions o Dissociative sx  altered sense of reality of surroundings o Avoidance sx  *** • Tx: first line is trauma focused CBT (exposure based) o Different subtypes  depressed mood, anxiety, mixed anxiety and depressed mood, disturbance of conduct, unspecified Diff from depression bc depression continues after stressor is removed Treatment o Tx of choice is psychotherapy, group therapy can be helpful o o • • If the event was a traumatic stressor, relaxation techniques, changing locks on doors, etc, can be helpful ***Children will often show signs of irritability and short temper vs. depression and sadness o • Social anxiety disorder (Phobias) • The most common mental disorder in the US • An irrational fear that leads to avoidance of feared object or situation • Causes  likely a combination of genetic, behavioral, and neurochemical factors • DSM o o o o o • Exposure to the situation brings out an immediate anxiety response Situation is avoided when possible Tx o o o o Meds for specific phobias are not effective Use systemic desensitization + benzos during session Supportive psychotherapy o Eating Disorders Anorexia nervosa • Restrictive type  eat very little, vigorous exercise, withdrawn with obsessive compulsive traits • Binge/purge type  binges followed by purging, laxatives, exercise or diuretics o Melanosis coli = darkening of colon secondary to laxative abuse o Comorbid MDD or substance abuse • DSM o Body weight at least 15% below normal o Intense fear of gaining weight or becoming fat o Disturbed by body image o Amenorrhea • Management o o Refer for psychotherapy/family therapy o  atypical antipsychotics, tricyclics, Lithium, anxiolytics before eating • Prognosis o Mortality of 5-20%, average duration of illness is 6 yrs Binge eating disorder • Excessive amount of food in a 2 hr period with lack of emotional control • Emotional distress associated with overeating, no use of laxatives or vomiting, often obese • Comorbid mood or anxiety disorder • DSM o Bulimia nervosa • Purging type  use vomiting, laxatives, or diuretics to counteract binge eating • Non-purging type  use excessive exercise or fasting to counteract binge • Sx o o Embarrassed by binging o Esophagitis, dental erosion, callused knuckles, salivary gland hypertrophy o Co-morbid mood disorder, impulse control disorder, alcohol abuse • DSM o Recurrent episodes of binge eating o o Perception of self-worth is influenced by body weight and shape •  Prognosis o Better than anorexia, may relapse, half will recover All eating disorders • More common in upper/middle class families • Etiology = psych, social, biological • Screening = SCOFF • Work up = EKG, BMP, TSH, vitamin levels, DEXA •  • • • • Tx – psychotherapy, strict diet and exercise program, meds to support weight loss (stimulants, orlistat) Complication of wernicke’s - prevented with thiamine supplementation Mood disorders Major Depressive Disorder (SIG E CAPS) • Best therapy  o (sertraline, paroxetine, citalopram, fluoxetine, or fluvoxamine) o (venlafaxine, desvenlafaxine, duloxetine, levomilnacipran) ***Duloxetine can be used for painful diabetic neuropathy o Bupropiun (Wellbutrin), blocks NE and dopamine reuptake o Mirtazapine (Remeron), good for sleep • Common side effects of pharm treatment o GI symptoms, sleep disturbances, tremor, dizziness, diaphoresis, sexual dysfunction • 1 in 7 ppl will suffer from depression, women are effected twice as much as men (mean age of 40), genetics play a role, 85% lifetime recurrence, and 40% recurrence in 1 yr • DSM o Depressed mood/anhedonia >2wks o Mood is a change from baseline o Impaired fxn: social/school/work o At least 5 of these (SIG E CAPS): ▪ Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor, Suicidality • DDX o Medical  o Meds  o Psych  ▪ • • • • • • • • • ***Depression meds can worsen bipolar, ask about mania and fam hx  o Suicide rate = 15% - 2:1 female to male Peripartum depression  “baby blues” = up to a week, don’t treat as depression Other treatments o Combination of two medications o ECT – good for MDD with psychotic features or where rapid response is required o rTMS (repetitive transcranial magnetic stim) – good for pts who can’t tolerate – can be outpatient o Meds that worked in the past are likely to work again at the same dose o CBT and insight oriented therapy MDD Chronic  at least 2 yrs MDD w/ catatonic features  catatonic sx MDD w/ melancholic features  anhedonia, worse in the morning, weight loss, guilt MDD w/ atypical features  significant weight fain, hypersomnia, rejection sensitivity MDD w/ postpartum onset  within 4 wks of birth MDD w/ seasonal pattern Mania • Manic episode DSM o Must have 3 of the following: ▪ Inflated self-esteem or grandiosity, decreased need for sleep, ▪ Pressured speech, flight of ideas, ▪ Distractibility, increased goaldirected activity or psychomotor agitation o Sex, spending money, gambling o Does not meet criteria for mixed episode and not caused by medications, substance use, or medical conditions • Hypomanic episode DSM o At least of elevated /irritable mood o At least 3 sx of mania o Noticeable to others, but does not require hospitalization, no psychotic features, no marked social or occupational dysfunction (this distinguishes it from full mania) • Mixed mood episode DSM o Meets DSM criteria for manic & depressive episode for at least 1 week Bi polar I • 0.5-1.5% lifetime prevalence, Male-to-female ratio = 1:1, Suicide rate 10-15%, Strong genetic component (5-10% lifetime risk in 1st degree relative) • DSM o o Commonly accompanied by one or more MDE, but this is not needed for the dx • Classification o Describe most recent episode as manic, hypomanic, mixed, or depressive o Further classify about psychotic, catatonic, or postpartum features o Rapid cycling  presence of at least 4 mood episodes within 1 yr, o • Tx o o o ECT Use caution with antidepressants (may precipitate mania) Psychotherapy, antipsychotics if needed o Bipolar II • 0.5% lifetime prevalence, more common in females • one or more depressive episodes and at least one hypomanic episode • same tx as type I Dysthymic disorder • A more chronic, less severe depressive disorder • 6% lifetime prevalence, 3:1 female-to-male ratio • Onset usually in childhood or late adolescence • DSM o Depressed mood for most of day, more days than not, for at least 2 yrs o Presence of at least 2 or more of the following: ▪ Appetite changes ▪ Sleep changes ▪ Low energy ▪ Low self-esteem ▪ Poor concentration ▪ Hopelessness o Never been without sx for more than 2 months o No MDE during first 2 yrs • Cyclothymic disorder • Chronic cyclical episodes of mild depression and hypomania • 1% prevalence, onset between 15-25, 3:2 female-tomale ratio • DSM o Many periods of depression and hypomania for at least 2 yrs o Depressive episode cannot reach level of MDE o Cannot be sx free for more than 2 months • Tx: o Mood stabilizers – lithium, use antidepressants cautiously to avoid precipitating manic episode Sleep Disorders Insomnia • Difficulty initiating or maintaining sleep, resulting in daytime drowsiness or difficulty fulfilling tasks • Disturbance occurs 3+ times a week for at least 1 month • Exacerbated by anxiety and preoccupation with getting enough sleep Hypersomnia • At least 1 month of excessive daytime sleepiness or excessive sleep not attributable to a medical condition, meds, poor sleep hygiene, insufficient sleep, or narcolepsy • Usually beings in adolescence • Meds  Narcolepsy • Repeated, sudden attacks of sleep in the daytime for at least 3 months with associated cataplexy (collapse due to sudden loss of muscle tone during emotion/laughter), short REM latency, sleep paralysis, hallucinations while falling asleep or just waking up Management  timed daily naps, stimulant drugs, SSRIs, sodium oxalate for cataplexy Psychotic disorders Schizophrenia • Acute phase schizophrenia  phase of schizophrenia characterized by • *** (voices) • Negative symptoms  lack of emotional responses, , and avolition (decreased motivation), apathy, blunting • Positive symptoms  , ideas of reference, grossly disorganized speech, tangentiality, incoherent thoughts • DSM-V o At least two of the following have been present for ▪ Delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, negative symptoms o , this can include only negative sx or less intense positive sx o Significant social/occupational dysfunction o Rule out drugs, schizoaffective • Extreme social isolation and dysfunction • 1% of general population, for men it starts in early to mid twenties, late twenties for women • 20% attempt suicide, 5% complete it • Suicide risk factors = command AH to harm, depressive sx, substance abuse, unemployment, recent psychotic episode, hospital discharge, younger age, male gender •  • Treatment o Holistic approach ( o Often begin with second generation antipsychotics (SGA’s) because of their reduced risk of side effects o , it is also the only med with anti-suicidal properties • Nicotine is the most frequently used substance by schizophrenics, smoking induces cytochrome P450 which decreases serum levels of clozapine Classifications of schizophrenia • Paranoid type  best prognosis, preoccupation with delusions or auditory hallucinations and do not have disorganized speech, behavior, or inappropriate affect • Disorganized type  worst prognosis, prominent disorganized speech, behavior, and odd affect • Catatonic type  2 or more of the following: immobility, excessive motor activity, negativism, mutism, peculiar movements, echolalia or echopraxia • Undifferentiated type  moderate prognosis, not characterized by other types • Residual type  continued negative sx or 2+ attenuated positive sx Schizoaffective disorder • Best medication: o Depressive type: can add an antidepressant (SSRI) if this is not effective alone o Bi-polar type: can add mood stabilizer like valproic acid, lithium, or carbamazepine • Psychosocial rehab can be used • TMS is an experimental treatment • Hospitalization is not needed if the patient is not in danger to themselves or others • DSM V Criteria: o Patient must exhibit psychotic symptoms consistent with the o Psychotic sx are accompanied by prominent mood symptoms (mania or depression) at some points of the illness o o o • • • Disorder cannot be caused by substance or medical conditions Ddx: o Cocaine or amphetamine intoxication can cause manic sx, cocaine withdrawal can cause depressive sx o Steroids and antiparkinsonian medication o Schizophrenia appears similar, but the mood sx are generally more transient o Major depression and bipolar typically predate the psychoses ***Younger patients may exhibit more severe symptomology Tx ECT may be necessary for severe mood sx Schizophreniform disorder Diagnosis is deferred because 30-50% of cases may resolve or differentiate into a different diagnostic category Delusional disorder • Delusions with no other psychotic symptoms present for at least one month • “non-bizarre” delusions • behavior/functioning not significantly impaired Brief psychotic disorder • Hallucinations, delusions, disorganized behavior or speech • – Somatoform Disorders Conversion • The most common somatoform disorder – more common in women and low SES • Voluntary motor or sensory deficits that suggest a • • • Somatization • More common in females, low SES, genetic and familial predisposition •  • Paralysis, aphonia, blindness, deafness, feeling a lump in the throat, pseudoseizures Patient is surprisingly calm while describing dramatic sx ( ) Focus is ONE sx (not many as in somatization disorder) Co-morbid schizophrenia, MDD, or anxiety • • • • 50% ultimately receive an underlying medical cause • sx usually resolve in 1 month, 25% relapse Hypochondriasis • Prolonged, exaggerated concern about health and possible illness • • Waxing and waning of sx • Exacerbation when under stress • • More focused on • DSM o Fears present for at least 6 months o Fears persist despite medical evaluation o Fear based on misinterpretation of normal sx Malingering • Intentionally faking or grossly exaggerating sx for an such as avoiding work or criminal prosecutions, obtaining room and board, financial compensation, meds Munchausen Syndrome • A facitious disorder with predominantly physical complaints, often demand specific meds, highly skilled at feigning sx necessitating hospitalization Pain disorder • Pain in one or more sites associated with psychological factors that have an important role in the onset, severity, exacerbation, or maintenance of the pain • Pain not due to a medical disorder • Not intentionally produced or faked • DSM o o o o o o 2 GI sx 1 sexual sx 1 neuro sx 4 pain sx onset before age 30 cant be explained by medical condition or meds Factitious disorder • • • Frequent presentation = wound healing problems, excoriations, infection, bleeding, hypoglygemia, GI ailments Often have hx of abuse or neglect Body Dysmorphic Disorder • Imagined or exaggerated defect in physical appearance • Spend significant time trying to correct perceived flaws with make-up, derm procedures, or plastic surgery • Comorbid depression, anxiety, of psychosis • SSRI might help Munchausen Syndrome by proxy Personality Disorders Cluster A  MAD, odd and eccentric (WEIRD) Schizoid • outside immediate family Little interest in sexual activity Often functional at work as long as it does not require much interpersonal connection • Indifferent to praise or criticism • Sometimes have a rich fantasy life • Does not have “fixed delusions” • As a clinician, use a low-key, technical approach • Therapy does not work well, psychotherapy is the tx of choice, antipsychotics/antidepressants if needed Paranoid • Pervasive • Distrustful and suspicious, constricted affect • More verbally hostile than ***paranoid schizophrenia will have “fixed delusions” • Tx with psychotherapy, anxiolytics, antipsychotics if needed Cluster B  BAD, dramatic, erratic (WILD) Histrionic • • Uncomfortable when not the center of attention, inappropriate behavior, theatrical, perceives relationships as being more intimate than they really are • Tx: psychotherapy • Chronic course, may improve with age • • Antisocial • Disregard for rules, violation of rights of others, behavior since age 15 • Lacks empathy toward others, acts out, aggressive, must have met criteria for conduct disorder as a child • Failure to conform to social norms • Lack of remorse for actions • Want material gain • Tx: psychotherapy is tx of choice, caution in treating anxiety or depression as there is high addiction potential in these patients • Sx may improve with aging Cluster C  SAD, anxious and timid (WORRIED) Avoidant • • Hypersensitive to criticism, socially uncomfortable, • • • Intense fear of rejection, Comorbid depression/anxiety Tx o Psychotherapy with assertiveness training o Propranolol for autonomic anxiety sx o SSRI for depression Particularly hard in adolescence Schizotypal • , paranoid, not psychotic • Perceptual distortions, few close relationships • Tx with psychotherapy, anxiolytics, antipsychotics if needed ***Schizoid & schizotypal are more likely to develop schizophrenia or to have a first degree relative with schizophrenia Narcissistic • Grandiosity, lack of empathy • Self-important, needs admiration, dismissive of the feelings of others • Believes they are special, sense of entitlement • Arrogant/haughty • Desire status and recognition • Tx: psychotherapy, SSRI or lithium if mood disorder • Higher incidence of depression and midlife crisis Borderline • Impulsive, unstable relationships, affective instability • Unstable self-image • Frantic efforts to avoid real or imagined abandonment • Self-damaging impulsivity • Reactivity of mood, chronic feelings of emptiness • SIB • Should be treated with psychotherapy for at least 20 wks • Consider mood stabilizer, antipsychotics, consider treating comorbid PTSD or MDD with SSRIs • Remission rate of 50% after 4 yrs and 90% after 10 yrs Obsessive compulsive • Perfectionist, “control freak”, hyperfocused on orderliness • More common in men and oldest children • Appear serious, still, and formal, constricted, poor interpersonal skills, inflexibility • Excessive devotion to work, will not delegate • OCPD = ego-systonic (not aware of the problem) • Tx: Psychotherapy • Course is unpredictable, some will develop OCD, schizophrenia or MDD Dependent • Submissive, clinging, needs to be taken care of, sees others to make decisions for him/her • Tx = psychotherapy, treatment of comorbid anxiety or depression • Sx might improve with age Attention Deficit Disorder and Disruptive Behavioral Health Attention deficit hyperactivity disorder • Can be inattentive, hyperactive/impulsive, or combined) • Diagnosis  six or more sx of inattention or hyperactivity/impulsivity, present before age 12, more than one setting, significant impairment, present for >6 months o Inattention sx: careless errors, difficulty focusing, not listening, failing to follow directions, difficulty organizing tasks, avoiding tasks that require sustained mental effort, losing things, distraction, forgetfullness o Hyperactive sx: fidgety/squirmy, leaving seat, difficulty being quiet, “on the go”, excessive talking o Impulsive sx: blurting out answer, difficulty waiting for turn, interrupting • 3-5%, boys usually have hyperactive/impulsive, girls usually have inattentive • Etiology: dopaminergic and nonadrenergic tracts of the prefrontal cortex, dorsal anterior cingulate gyrus, dorsolateral prefrontal tracts • DDX  oppositional defiant disorder/conduct disorder, bi-polar early onset, lead intoxication can lead to hyperactivity, petit mal seizures can lead to poor attention (get EEG) • ***if ADHD and ODD are present it may be mistaken for bi-polar • Treatment  80% of kids will respond to stimulant medication o AEs: decreased appetite, slowed growth, insomnia, irritability, dysphoria, HA, tics o Have a rapid onset of action, wear off by the end of the day o o o o Atomoxetine: inhibitor of the presynaptic NE transporter, good alternative to stimulants, gradual onset (2-3 wks), 24 hr length of action Clonidine and guanfacine improve sleep and appetite AND help ADHD sx, can be used with stimulants or as monotherapy Bupropion & imipramine might help, worry about QTc prolongation and tic worsening Conduct disorder • • Caused by genetic and psychosocial features • Comorbid ADD and learning disorders • DSM o A pattern of behavior that involves ▪ towards people and animals • • ▪ ▪ Deceitfulness ▪ Tx  reinforcement of firm rules, psychotherapy based on behavior modification and problem solving skills o Antipsychotics or Lithium o SSRI for irritability  Oppositional defiant disorder • 20% of kids >6 • Comorbid substance abuse, mood disorders, and ADD • DSM  at least 6 months of hostile/defiant behavior with at least 4 of the following: o r o Arguments with adults o o Deliberately annoying people o o Anger and resentment o Spitefulness o Blaming others for mistakes • Tx  psychotherapy based on behavior modification and problem solving skills, parental training • Prognosis – remits in 25%, may progress to conduct disorder Paraphilias and Sexual Dysfunction Disorders  Classifications: o Hypoactive sexual desire disorder o Sexual aversion disorder o Exhibitionism; Fetishism o Sexual masochism o Pedophilia o Voyeurism (spying) • At least 6 months and impair daily functioning • Most common are pedophilia, voyeurism, and exhibitionism • Tx  insight oriented therapy, anti-androgens in men • Prognosis poor with early age of onset, comorbid substance abuse, high frequency of behavior, related arrest Prognosis good with self-referral for treatment, sense of guild associated with behavior, history of otherwise normal sexual activity in addition to the paraphilia • Other Delirium • DSM o o o o • Disturbance of consciousness with reduced ability to focus, sustain, or shift attention The change in cognition or perceptual disturbance isn’t due to dementia The disturbance develops over a short period of time (hrs to days) and fluctuates over the course of the day There is clinical evidence that the disturbance is caused by a general medical condition and/or substance use withdrawal TX o o o Treat the underlying condition Treat agitation with Haldol. Quetiapine, lorazepam, and a quiet environment with close observation Restrains may be needed Dementia • Prevalence increases with age: alzheimers is the most common (50-60%) followed by vascular dementia (13%) • DSM o The development of multiple cognitive deficits manifested by ▪ Memory impairment ▪ One or more of the following: aphasia, apraxia, agnosia, disturbance in executive functioning o The cognitive deficits cause significant social and occupational impairment and represent a significant decline from a previous level of functioning o The deficits are not the result of delirium • Tx o Treat underlying condition o Minimise CNS depressants and anticholinergic meds o Treatment of AD ▪ Mild  cholinesterase inhibitors (donepezil, galantamine, ravastigmine, tacrine) ▪ Can give vit E if no CV disease ▪ Moderate  add NMDA agonist memantine, may be neuroprotective o Treatment of vascular dementia: HTN management, aspirin • Classification o AD, vascular dementia, AIDs, head trauma, PD, HD, picks disease, creutzfeld-Jakob disease, lewy body dementia, substance induced persistent dementia • Life expectancy is 3-8 yrs • Work up o TSH, B-12, depression screen, CT, Amnestic syndrome • The amnestic disorders are a group of disorders that involve loss of memories previously established, loss of the ability to create new memories, or loss of the ability to learn new information. Substances • Tobacco o Withdrawal occurs 2-3 hrs after last cigarette, peak in 2-3 days, resolution in 1 month o Increased sx if >25 cigs a day, first cig within 30 min of waking • Alcohol o Onset in 12-24 hrs after last drink, peak at 2448 hrs o Mortality with treated DT = 5% (20% untreated) o Mild – 6-36 hrs – tremor anxiety, GI upset o Seizures – 6-48 hrs o Hallucinosis – 12-48 hrs o Delirium tremens -48-96 hrs • Cocaine o Withdrawal lasts 1-2 wks  malaise, fatigue, depression, hunger, constricted pupils, vivid dreams, psychomotor agitation and retardation o Give benzos, Haldol if severe • Amphetamine o Similar to cocaine • Sedative hypnotic o Similar to alcohol • PCP o Intoxication = impaired judgement, rotatory nystagmus, seizures, coma, rhabdo, assaultiveness, HTN, reckless o Withdrawal – no syndrome (may have flashbacks) • Inhalant (glue) o Intoxication: lethargy, nystagmus, slurred speech, respiratory depression can be fatal , belligerence, perceptual disturbances o Manage with ABCs • Opiate o Intoxication – drowsiness, N/V/C, slurred speech, constricted pupils, seizures, respiratory depression o Withdrawal  begins in 8 hrs and lasts up to 3 days, anxiety, insomnia, cramps, rhinorrhea, diarrhea, fever, chills, HTN • Hallucinogen o Pupillary dilation, give quiet room, can do benzo Dissociative disorders • Dissociative identity disorder, previously called multiple personality disorder, is usually a reaction to trauma as a way to help a person avoid bad memories. • Dissociative identity disorder is characterized by the presence of two or more distinct personality identities. Each may have a unique name, personal history, and characteristics. • Treatment is talk therapy. Substance use disorders (Substance dependence, abuse and/or withdrawal) • DSM for ABUSE o Pattern of substance use leading to impairment or distress for at least 1 year with 1+ of the following ▪ Failure to complete tasks at work, school or home ▪ Use in dangerous situations ▪ Recurrent related legal problems ▪ Continued use despite social problems • DSM for DEPENDENCE o Substance leading to impairment or distress manifested by at least 3 in a 12 month period ▪ Tolerance, withdrawal, unsuccessful efforts to cut down use, significant time used to get substance/recovering from substance, decreased activities, continued despite physical or psychological problems Sexual dysfunction • Dual sex therapy, behavior therapy, hypnosis • Treat low testosterone • Erectile disorder  yohimbine, sildenafil, vacuum pumps • Dyspareunia  gradual desensitization, muscle relaxation techniques • Vaginismus  vaginal dilators Bereavement • Bereavement is the period of grief and mourning after a death. When you grieve, it's part of the normal process of reacting to a loss. You may experience grief as a mental, physical, social or emotional reaction. Mental reactions can include anger, guilt, anxiety, sadness and despair. Acute grief reaction • Acute grief is a definite syndrome characterized by psychological and somatic symptoms: • 1. Sensations of somatic distress that occur in waves lasting for 20 minutes to an hour characterized by: Tightness in the throat. Choking. Grief • o o o o o Feelings of guilt and sadness Mild sleep disturbance and weight loss Illusions of the deceased (visual and auditory) Attempts to resume daily activities o o o o o o Severe guilt and worthlessness Significant sleep disturbance and weight loss • No attempt to resume activities SI Tricyclic antidepressants (desipramine, nortriptyline, imipramine), has anticholinergic effects (dry mouth, dry eyes, constipation), potential lethal with cardiac arrhythmias DEFINITIONS Catatonia: • A neuropsychiatric syndrome occurring in psychiatric or medical disorders that presents with three or more psychomotor sx including o Stupor, catalepsy, waxy flexibility, mutism, negativism, posturing, grimacing, mannerism, stereotypy, agitation, echopraxia, echolalia Disorganized speech • Word salad  lack of connections between words • Loose associations  lack of connections between ideas Prognosis from best to worst • Mood disorder with psychotic features  schizoaffective disorder  schizophrenia Atypical/Second Generation Antipsychotics (SGAs) • Reduced risk of side effects • ~increased efficacy in treating negative symptoms • SE: increased risk of metabolic syndrome (abdominal obesity, dyslipidemia, hyperglygemia, HTN o Clozapine and Olanzapine have the most metabolic side effects o Ziprasidone and aripiprazole have the least • Clozapine is the most effective in treating schizophrenia, but the risk of prevents it from being used as a first line drug Delusions • Fixed, false beliefs which lack cultural sanctioning  the most severe, potentially life threatening complication with altered mental status, fever, dysautonomia, and muscle rigidity Tx  immediate discontinuation of offending agent, severe cases may need and/or • Typical Antipsychotics • Higher likelihood of causes extrapyramidal symptoms (akathisia, dystonia, and parkinsonism), hyperprolactinemia, and • Acute dystonia  can be treated with anticholinergics (benztropine or diphenhydramine ) • Akathisia  (the sensation of inner restlessness), may respond to benzos or a beta-blocker (propranolol) • Parkansonian sx  can be managed by adding benztropine • Tardive dyskinesia  from long term use, hard to treat o MEDS: NMS • • • • tx with (hydration and cooling blankets) increased CPK, WBC, fever, htn, tachy movement disorder caused by antipsychotics MAOIs – block destruction of monoamines, been tyramine free diet First Gen Antipsychotics – non-selective DA-R ANTAGONISTS • Haldol –IM 30 min • Fluphenazine –IM depot • Thioridiazide – retinosis pigmentosa, QTc, less EPS • Mesoridazine - torsades • Chlorpromazine Second Gen Antipsychotics – block post-synaptic DA-R • – • – • Quetiapine – cataracts • – • Lurasidone – best at reversing metabolic syndrome • Palliperidone – comes in injection form Mood Stabilizers • Carbamezapine – SJS, OCPs/warfarin interactions, block Na channels • Valproate – increases GABA • Lithium – inhibits adenylate cyclase, hypothyroidism, DI • Lamotrigine – pregnancy C, SJS TCAs – inhibits reuptiake of serotonin and NE SSRIs – inhibit reuptake of serotonin (slight inhibition of histamine and muscarine) • Fluoxetine – longest half life, no D/C syndrome, 5 wks before MAOIs • Paroxetine – shortest half-life • Sertraline – high GI sx • Citalopram – low sexual SE • Fluvoxamine – low sexual SE • Escitalopram – low sexual SE SNRIs – inhibit serotonin and NE uptake, HTN, pain • Venlafaxine • Duloxetine • Desvenlafaxine Benzo – GABA- R agonists ADHD