Professional Documents
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Psychiatry
Table of Contents
Topic Psychiatric Disorders: Axis I o Psychotic Disorders o Anxiety & Adjustment Disorders o Mood Disorders o Disruptive Behavior o Adjustment Disorders in Children o Eating Disorders o Somatoform and Factitious Disorders o Substance Related Disorders o Pervasive Developmental Disorders o Delirium and Dementia o Sexual Disorders o Dissociative Disorders o Impulse Control Disorders o Chronic Pain Psychiatric Disorders: Axis II o Mental Retardation & Tourettes o Personality Disorders Psychopharmacology o Antipsychotics & Anxiolytics o Antidepressants & Mood Stabilizers Page 1 3 5 8 9 10 12 14 16 17 19 21 22 23 24 25 27 28
Psychosis: break from reality with delusions, perceptual disturbances, and/or disordered thinking
Epidemiology Timeline Symptoms Treatment 1-1.5% lifetime prev Signs persist for 6+ months Symptoms must last for 6+ months Antipsychotics: 70% improve Males=Females Age of onset below 45 2+ in 1 month Typical antipsychotic meds Men: worse prognosis : 15-25, : 25-35 Delusions: Paranoia, idea of reference, grandiosity o Block dopamine receptor (D2) Often born during 55% good outcomes Hallucinations: auditory (common), visual, tactile o Effective treat positive symptoms winter months (viral?) 45% severe deterioration Disorganized speech: content and thought process o Prominent side effects Lower SES: drift 1. Prodrome (years b4) Grossly disorganized/catatonic behavior Atypical antipsychotic meds 30-50% alcohol abuse 2. Psychosis Negative symptoms: o 1st line treatment Genetic: 50% MZ twin, 3. Residual: negative affect, anhedonia, apathy, apologia, attention o Block DA + 5-HT receptors 10% in 1 relatives symptoms between o More treat negative symptoms 1+ Social/occupational dysfunction 50% attempt suicide Ex. Work, interpersonal, self care Other drugs: Anticonvulsants, 15% complete suicide benzodiazepines, anti depressants Etiology Neurotransmitters: Dopamine (limbic system): positive symptoms. Serotonin (prefrontal cortex): negative symptoms. NE: activity (anhedonia) Brain imaging: Ventricular enlargement, cortical atrophy, hypoactivity of frontal lobes upon PET Presentation: Appearance: bizarre posture/behavior. Mood: depressed (25%), Judgment: usually deficient (violence: 12%). Orientation: oriented but attention. Neurological deficits: short-term memory deficit, unstable smooth pursuit, sensory gating ( tolerance to novel stimuli) 1. Perceptual disturbances: hallucinations (cenesthetic), usually auditory but can be visual, tactile (common in EtOH), olfactory (common in seizures) 2. Disordered thinking: inferred from speech a. Process (Form): circumstantial (circuitous), loose associations (disconnected ideas), tangentiality (never reach point), pressured (uninterruptable), perseverating, clang (related sounds make sentence), blocking (stop in middle of sentence), echolalia, neologisms, paraphasias. b. Content: delusions, insertion (others are placing thoughts in head), broadcasting (others can hear thoughts) 3. Delusions: Paranoid, Idea of reference (things are related to pt), Idea of influence, Grandeur, Guilt (I caused the holocaust) Subtypes Disorganized Prominent disorganized speech, inappropriate affect, NOT catatonic. Early onset Paranoid preoccupation with particular delusion NONE OF: disorganized speech, catatonic, inappropriate affect. Later onset Catatonic Motor immobility: catalepsy (immobile position), excessive motoric activity. Echolalia, echopraxia (mimic behavior) RAREST Undifferentiated Residual Absence of positive symptoms for some time, but still have negative symptoms Brief psychotic Secondary to medical 1+ day but <1 month with 1+ of: Hospital, meds, psychotherapy disorder condition if: prominent return to function Delusions, hallucinations, disorganized speech Good prognosis: 50-80% have no delusions Disorganized speech further psychiatric problems Delusional 0.03% 1+ months of non-bizarre Function is not impaired (vs. schizophrenia) Low dose antipsychotic disorder More women delusions Erotomatic: delusions someone is in love 50% recover long term Jealous: unfaithful partner 30% have no change Mean age: 40 Somatic: defect Schizo1/3 recover, Lasts 1-6 months, but Exclusion rules met for schizophrenia not other 3-6 months antipsychotics phreniform 2/3: go to schizophrenia return to function criteria Supportive psychotherapy SchizoLess than 1% 2 weeks of delusions/ No mood symptoms in absence of psychotic sx Concurrent antipsychotics and affective More women hallucinations in absence of MDD, manic, or mixed episode WITH symptoms of antidepressants disorder Not clear link to mood symptoms schizophrenia Schizophrenia Better prognosis than schizophrenia
PSYCHIATRY CLERKSHIP STUDY GUIDE 2009, 2011 Mark Tuttle Movement Hemiballismus is an uncontrolled swinging of an extremity. It is usually sudden, and once initiated it cannot be controlled. definitions Choreiform movements are involuntary, irregular, and jerky but lack the ballistic-like nature of hemiballismus. Athetoid movements, or athetosis, are slow, snake-like movements of the fingers and hands. Myoclonus is a sudden muscle spasm, and myotonia is prolonged muscle contraction. Common Cotard syndrome: Nihilistic, I am dead. There is no world. delusions Capgras syndrome: family members are replaced by imposters Fregoli syndrome: shapeshifter is taking form of different people. Xacodemomania: patient is inhabited by an evil spirit Folie a deux: shared delusion Cultural Koro is a traumatic fear that the penis is shrinking into the body cavity. Amok is a violent fit followed byamnesia. psychosis Pseudocyesis is the physiologic signs and symptoms of pregnancy developing inthe absence of pregnancy. Couvade syndrome occurs when the husband of a pregnant woman goes into a sort of labor. Illusions Micropsia and macropsia are misperceptions of visual stimuli. Objects appear smaller (micropsia) or larger (macropsia) than they are in reality. Palinopsia is the persistence of the visual image after the stimulus has been removed.
Adjustment Disorder
- Begins < 3 months after stressor - Ends < 6 months after stressor. (Is GAD if does not end) - Or chronic (> 6 mo) if stressor recurs/persists Lasts 6+ months Chronic and lifelong symptoms in 50% 50% completely recover
Females 2:1 45% lifetime prevalence 50-90% have MDD, phobia, panic
Panic disorder
Multiple/day 1/year Avg: 2/week 10-20% persistent 50% mild 30-40% cured
Specific phobia
Phobias are the most common mental disorders (followed by substanceinduced, MDE, OCD)
6+ months if < 18
- Anxiety brought on by specific situation o Reproducible o Versus panic disorder fear of panic attack - Patient knows fear is excessive - Anxiety brought on by fear of embarrassment o Ex. public speaking, public performance o Versus agoraphobia: fear of having panic attack in public space and unable to get help - Obsessions relieved by compulsions o 75% have obsession AND compulsion but can just be intrusive thoughts (ex. sex/violence) - Ego dystonic (have insight) (vs. OCPD) - Common: contamination, doubt, symmetry
- Acute episode: benzodiazepines - Combination of psychotherapy and pharamacotherapy o Buspirone, benzodiazepines (taper immediately), SSRI o Venlafaxine (EffexorTM) - Rule out organic cause (MI) - Acute: benzodiazepines 1. Maintenance: SSRIs 8-12 mo. a. Paroxetine (PaxilTM) b. Sertraline (ProzacTM) 2. CBT, Relaxation, biofeedback 1. Behavioral: Sys. Desensitization
a. Relaxation: Counter conditioning b.Reciporical inhibition
Social phobia
c. Not pharmacotherapy 2. Psychotherapy 1. Pharmacotherapy a. SSRI: paroxetine (PaxilTM) b. -blocker for perc. Anxiety 2. CBT: correct automatic thoughts 1. CBT: exposure and response prevention 2. SSRI (high dose) 3. TCA: clomipramine (AnafranilTM)
PSYCHIATRY CLERKSHIP STUDY GUIDE Acute Stress Disorder PTSD Length Begins within 1 month Begins anytime Lasts less than 1 month Lasts over 1 month Stressor Identifiable stressor: Death/rape/grave danger Re-experiencing, avoidance, arousal Dissociation, derealization, depersonalization
Adjustment Disorder Begins within 3 months. Lasts less than 6 months. Identifiable stressor: Not life threatening.
Generalized Anxiety Disorder 6+ months Not identifiable stressors: vague, diffuse, multiple (generalized)
Bereavement: Must be loss of a loved one Grief: Can be anything (divorce) Pathological if > 1 yr or overtly psychotic (other than seeing dead relative or wanting to join them)
Manic episode
1+ week
Average onset: 40 years 50% recur in 2 years Untreated: resolve in 612 months 2/3 suicidal ideation 15% complete suicide MZ twins: 90%
- Only need 1 manic episode (dont need MDE) - 1 hypomanic episode AND 1 MDE - Mild depression + hypomania for 2 years. No normal 2 mo. - Often coexist with borderline PD
Dysthymia 6% prevalence
- Mild depression for 2 years with no 2 months euthymic - Double depression: dysthymia + MDE - Never have psychotic features
1. SSRIs, TCAs: 70% improve Minimum 16 weeks 70% effective vs 30% placebo 2. MAOIs if refractory Stimulants in terminally ill patients ECT indications o 2-3 failed medical trials o Severe suicidality o Catatonia, malnutrition 1. Mood stabilizers: 50% improve a. Lithium b. Vaproate, carbamazepine c. Olanzapine (ZyprexaTM) 2. Supportive psychotherapy 3. Electroconvulsive therapy a. effective than in MDD 1. CBT + psychotherapy are most effective 2. Antidepressants (need 2)
Major depressive disorder o Initial insomnia o Reduced slow-wave sleep o Increased REM length o Vs. primary insomnia Early-morning awakenings: depression Rapid onset of REP depression Symptoms: 1+ month insomnia, 2 weeks for depression Other criteria for MDD Bipolar disorder manic phase o Decreased need for sleep Seasonal affective disorder o Decreased slow wave sleep o Directly related to amount of sunlight o Treat with light therapy PTSD o Difficulty remaining asleep
o Fragmented sleep o Frightening dreams, + sleep latency Psychotic disorders o Sleep deprivation increases positive symptoms of psychosis o Dream content less bizarre in psychotics o Decreased sleep efficiency Panic disorder o Sleep panic attacks, difficulty falling asleep, + body mvmt Generalized Anxiety Disorder o Decreased sleep efficiency, total sleep time o Increased sleep latency o Sleep problems may predate GA Chronic Pain o Less restorative, less deep sleep, more fragmented o Increased pain sensitivity, increased spontaneous pain
Preschool: temper tantrum Elementary: Difficult peers/ noncompliance Adolescents: Internal sense of restlessness rather than motor Adults: chronic disorganization o 20% have symptoms continuing in adulthood
6+ months
Conduct Disorder
12+ months Child-onset: before 10 years old Adolescent-onset 10+ years old
3. Multimodal a. Firm rules, consistent b. Psychotherapy behavior 4. Antipsychotics & lithium for aggression 5. SSRI for impulsivity/aggression
Treatment:
- Constitutional-temperamental factors childs behavior is not socially rewarding to parent, leads to less positive interactions vicious circle - Subpar Parenting skills leads to bad parent/child interactions vicious circle - ODD/CD children can result from violent disciplinary techniques, less monitoring of behavior, reinforce bad behavior - of variability explained by genes Parent training is best. Multimodal treatments: use school, family, community resources to clearly state/enforce behav. Expectations. Individual therapy has limited potential, doesnt address entirety of biopsychosocial model. Medication may be used to treat aggression
Disorder
Treatment
PTSD in Children
Type I (Inhibited): Do not respond in developmentally appropriate fashion to social interactions o Hypervigilant or ambivalent/contradictory Type II (Disinhibited): Varied/indiscriminant attachments Pathogenic care (1+) o Persistent disregard for childs basic emotional needs o Disregard of physical needs o Repeated changes of primary caregiver Often malnourished Weak crying response, no reciprocal smile response Tactile defensiveness Cruel to animals/siblings or other children Abuse (phys/sex): 72% show L hemisphere frontal/temporal EEG abnormalities Neglect: sensory deprivation leads to brain abnormalities 1+ month duration of disturbance Arousal symptoms (2+): Occurs months/years after event o Difficulty falling/staying asleep o Irritability or outburst of anger Re-experience symptoms, fears related to trauma event o Hypervigilence Bedwetting, separation anxiety, less interpersonally o Exaggerated startle response sensitive, less social Psychobiological More likely to be aggressive o Increased muscle tone, startle response Avoidance symptoms (3+): o Sleep disturbance o Efforts to avoid thoughts, feelings related to event o Increased catecholamine activity o Inability to recall an important aspect o Limbic system abnormalities (113%) o Markedly diminished interest o Deregulation of hypothalamic-pituitary-adrenal axis (HPA) leads to prolonged fighto Feeling detachment/estrangement or-flight responses o Restricted range of affect Loss of self-regulation, cant inhibit fight-or-flight o Sense of foreshortened future 10% lifetime Lasts 2 days 4 weeks max Exposed to traumatic event Overcome denial / avoidance, teach prevalence Must occur within 4 weeks of coping skills At least one re-experiencing event (80% of child burn trauma Pharma: SSRI, anticonvulsant, ACT 3+ of these during or afer event: victims get PTSD) PSA o Sense of numbing, detachment, absence of Note: children perceive emotion Problem-focused coping trauma differently and o Derealization o Attempt to control stressor can be more o Depersonalization o Can be most effective unless susceptible o Dissociative amnesia stressor is uncontrollable o Reduced awareness Emotion-focused coping o Attempting to reduce their own arousal and distress, stress
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30-50% recover within a few years Better prognosis if younger onset, restricter 5-10% die after 10 yrs 20% die after 20 years
Bulimia Nervosa
3% of young women 40% college females symptoms 95% female 50% anorexic get bulimia Better prognosis than anorexia 1/3 of patients are DM 1 Types: o Purge: vomiting, laxatives, diuretics o Nonpurge: excessive exercise or fast
Psychotherapy, CBT, group o Usually non-responsive SSRIs, TCAs: reduce by 50% Hospitalize if: o Suicidal o Severe metabolic disturbance
Psychotherapy Cognitive behavioral therapy (CBT) Pharmacotherapy o Stimulants: amphetamine ( appetite) o Orlistat (XenicalTM): inhibits pancreatic libase - steatorrhea o Sibutramine (MeridiaTM): inhibits reuptake of NE, 5HT, DA
PSYCHIATRY CLERKSHIP STUDY GUIDE Disorder Epidemiology Feeding Disorder of Infancy Pica 10-30% children 1-6 years 10% over 10 of institutionalized mentally retarded children Male=Female Might be nutritional insufficiency (ex. Fe) or prenatal neglect
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Timeline 1+ months Onset before 6 years old 1+ months Onset between 1-2 years. Usually remits by adolescence
Rumination Disorder
Rare-Most common in 3mo-1yr + MR children/adults 6% Male=Female (Adult = more common in males) May be genetic
1+ months
Symptoms Persistent failure to eat with decreased weight Not due to lack of available food Eating of non-nutritive substances inappropriate to childs developmental level Complications: Poisoning, anemia, intestinal obstruction, parasites DDx includes Fe/Zinc deficiency, Schizophrenia, Autism, Dwarfism, Klein-Levin syndrome (sleep for weeks wake up ravenously hungry) Repeated regurgitation Infants: weight loss, failure to thrive Adults: usually normal weight Can be: pleasure, tension-relieving, learned attention-getting DDx: gastroesophegeal reflux, Pyloric stenosis (projectile vomiting) Side effects: esophagitis, recurrent dental problems, excessive salivation, anemia, social ostracism Adults: no pain/nausea, no anatomical basis, occurs in nervous people
Treatment
Operant procedures o time out o Electric shock o Pepper sauce, lemon juice squirt on tongue o Overcorrection wash lips, use soap, use lotion o Satiation, bring in food often
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PSYCHIATRY CLERKSHIP STUDY GUIDE Disorder Epidemiology Pain disorder 2x females 75 million have chronic pain 25-50% have depression comorbid
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Symptoms Pain which is not fully accounted for by a medical or neurological condition o Can coexist with medical cause but degree of impairment not explained by medical cause 1+ anatomic site Causes distress or impairment in functioning Related to psychological factors
2% of those requesting plastic surg Male=Female 50% depressed 75% psychotic 33% housebound
Gradual onset
Belief that body is misshapen or defective in some way imagined or exaggerated Request surgery to correct perceived defect Shy, self absorbed, self-centered
Treatment Rule out: o Medical cause o Hypochondriasis o Malingering Analgesics not helpful SSRIs Nerve stimulation Biofeedback Psychotherapy Treat coexisting anxiety, depression Serotonin, antidepressants
Somatiform: patients believe they are ill Factitious: patients pretend they are ill Malingering: patients pretend they are ill with external incentives
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Drug EtOH
Sedative hypnotics
Urine
for 1 week
Opioids
Urine
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Intoxication
Nicotine
Exuberant Muscle twitching, cramps Palpitations Coma, respiratory failure at high dose
Withdrawal 75% symptomatic in 12-48 hours Headache (50%) Depressed mood, irritability Cramps, nausea
Treatment
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NOT due to psychological trauma, bad parenting, physical abuse, separation anxiety
Pervasive Developmental Disorder Aspergers Disorder Pervasive Developmental Disorder Retts Disorder More common in males More common in families where Aspergers is common ONLY in Females MECP2 gene on X chromosome Preschool motor delays School social Adults- modulation of behavior Prenatal/Perinatal: Normal Normal first 5 months 5-38 months: deceleration Lifelong impairment
head circumference growth velocity during 5-48 months Loss of previously acquired hand skills Early loss of social interaction, usually followed by subsequent improvement Severely impaired language and psychomotor development Trunk/gait problem Seizures Cyanotic spells Pervasive Males 4:1 Normal first 2 years Loss of previously acquired skills in at At least two of the following: Developmental Onset before age 10 least two areas: o Impaired social interaction o 1. Language o Impaired use of language Disorder o 2. Social skills o Restricted, repetitive, and Childhood Bowel or bladder control stereotyped behaviors and interests Disintegrative Play Disorder Motor skills Pervasive Severe, pervasive impairment in development of reciprocal social interaction and verbal/nonverbal communication. Developmental Not otherwise specified by a personality disorder or schizophrenia. Disorder NOS Sometimes called atypical autism Assessment of Medical: RULE OUT AN ORGANIC CAUSE (EX. VISION PROBLEM) Physical developmental o Maternal age & health during pregnancy, alcohol use, smoking o Somatic growth-height, weight disorders o Gestation age at birth, perinatal complications, NICU o Head circumference o Presence of infection, materal diabetes, jaundice, birth defects o Vision o Neurological, cardiac problems, parents IQ Lab testing Lab testing o Chromosomal analyses, molecular-genetic o Chromosomal analyses, molecular-genetic, toxicity, LEAD o Toxicity: lead levels Psychological evaluation Speech & language evaluation o Developmental/intelligence, behavioral observation scales
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Prodromal phase not usually diagnosed o Sleep disturbances, anxiety, irritability Hyperactivity, hypoactivity, hallucinations, fearfulness, apathy, agitation, dysphasia WHIMP Wernickes encephalopathy, Hypoxemia, Intracranial bleeding, Meningitis, Poisons
Multiple cognitive deficits and personality changes Impair social/occupational functioning. Short and long term memory problems Memory impairment and 1+ of o Aphasia: impairment of language o Apraxia: inability to perform learned movements o Agnosia: inability to correctly interpret sensory info o executive function: ex. Managing finances Causes social or occupational impairment (vs. MCI) Not exclusively during delirium Same symptoms as Alzheimers plus focal neurologic findings CT/MRI multiple lesions of cortex/subcortical structures 1. AChE inhibitors (rivastigmine) 2. NMDA antagonist (memantine) 3. PRN benzodiazepines, quetiapine(SeroquelTM)
Dementia More Males Vascular type 15-30% of all dementias Risk factors: hypertension, atrial fibrillation, CHD
Same as AD (AChE inhibit etc), treat CVD, control BP DDx: Alzheimers, TIAs if brief symptoms and RECOVER
PSYCHIATRY CLERKSHIP STUDY GUIDE Disorder Epidemiology Dementia More Males Frontotemporal 5% of all irreversible type (Picks Disease) dimentia
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Dementia 20-30% have dementia Parkinsons type 30-40% have cog impair
Normal Pressure hydrocephalus Amnestic Disorder Causes: seizure, head trauma, tumor, CV disease, MS Transient: <1month Persistent: 1+ Can be gradual/ sudden
Minutes to hours
Symptoms Primary cortical dementia Atrophy of frontotemporal regions, neuronal loss Impulsivity, irritability Hard to distinguish from Alzheimers Definite: biopsy showing spongiform change Probable: Rapid onset of dementia, burst EEG, and 2+: o Myoclonus o Cortical blindness o Ataxia, extrapyramidal symptoms o Muscle atrophy o Mutism Prodrome: lethargy, fatigue, depression Slow movements, slow thinking Cardinal signs: bradykinesia, tremor, rigid, posture Secondary subcortical dementia Degeneration of dopamine-releasing neurons in basal ganglia substantia nigra pars compacta Wet, Wacky, Wobbly Urinary incontinence, Dimentia, Ataxia Defective CSF drainage/reabsorption Inability to learn new information OR inability to recall old information Due to medical condition (Axis III) Immediate memory is INTACT Poor insight: confabulation make up answers Lack of initiative, blunted affect Causes: trauma, tumor, cv disease, alcohol use, Benzodiapines (during surg), OTC drugs Inability to learn new information AND inability to recall recent information Causes: transient vascular insufficiency, tumors, benzodiapines, migraines, embolism, arrhythmias Personal ID not lost Comorbid Wernickes Encephalopathy confusion, ataxia, ophthalmoplegia Confabulation, apathy, passivity
Treatment
NO TREATMENT
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Desire Phase Disorders Hypoactive sexual desire disorder Sexual aversion disorder
Persistent or recurrent deficiencies in or absence of sexual fantasies and desire for sexual activity Persistent or recurrent extreme aversion to, and avoidance of all genital sexual contact
Pain with before/during/after sexual intercourse without findings Involuntary spasm of outer 1/3 of vagina that interferes with sex o Also occurs with tampon insertion Inability to attain/maintain until completion of sexual activity Swelling response of female (60%) Primary: never had an erection Secondary: have had erections in past Most commonly psychological not biological cause.
Vaginismus
Gradual desensitization 1. Muscle relaxation 2. Erotic massage Vaginal dilation with fingers or device. Kegal exercises
Masturbation SS: lubricant, vaginal dilator Lysis of clitoral adhesions Yohimbine Sildenavil (Viagra) IV alprostadil Vacuum pump, ring, surgery Gradual progression to vaginal squeeze technique SSRI side effect helps LI: explain conditioned response SS: SSRIs, stop-start exercise IT: learn to self-stimulate
30% of women
PSYCHIATRY CLERKSHIP STUDY GUIDE Disorder Epidemiology Gender Identity Disorders Gender Identity Disorder Increased incidence of (transsexuality) comorbid depression, anxiety disorder, suicide
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Symptoms Strong, persistent cross gender identification Discomfort with ones own sex which causes distress or impairment Children: cross dressing, strong preference of other sex playmates Adults: stated desires, passing as other sex, conviction of being other sex, request for surgery/hormones
Treatment Treatment is a long process Psychosocial therapy: sex reassignment therapy, behavioral therapy, hormones Live as other sex for 12 months Sex reassignment surgery with long term psychotherapy Rarely become comfortable with own biology Least restrictive therapy first Psychotherapy (insight oriented) Cognitive behavioral therapy o Aversive conditioning to disrupt the learned abnormal behavior o Covert sensitization: pair images of negative consequences with sexually arousing fantasies o Victim empathy o 12-step programs Pharmacological therapy o Antiandrogens in hypersexual paraphilia in men
6+ months Poor prognosis: Early age of onset Comorbid substance abuse High frequency Law enforcement Good prognosis Self-referral Sense of guilt History of normal activity 6+ months
Normal activities taken to extremes Unusual sexual activities or fantasies Impairs functioning in 1+ areas Causes impairment in daily functioning Types: o Exhibitionism: exposure to strangers o Fetishism: inanimate objects o Necrophilia: dead people o Telephone scatologia: calling strangers o Frotterism (non-consenting) o Masochism (own suffering) o Sadism (other suffering) o Transvestic o Voyeurism Fantasies of prepubescent under 13 years For diagnosis: act on impulses and/or are distressed by fantasies o Distress not necessary
Recurrent, intense, fantasies/urges Not paraphilia Compulsive: self-stimulation, multiple partners, telephone/internet Comorbidites: substance abuse, mood disorders, anxiety disorders, impulse control Contrast with OCD: OCD compulsion is unwanted, but hypersexual are wanted
6+ months
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Dissociative Fugue
Hours-years
NOT due to medical or substance (this would be amnestic disorder) Symptoms Treatment 1. Retrieve memory to Amnesia is the only dissociative symptom present prevent recurrence Not troubled by memory loss a. Hypnosis Causes marked impairment or distress b. Amobarbital Usually triggered by a traumatic/stressful event c. Ativan Sudden travel from home with inability to remember parts of past or 2. Psychotherapy identity Often assume new identity Unaware of amnesia Causes marked impairment or distress 2+ distinct personalities which alternate control of person Each are mostly unaware of each other 1. Antianxiety PRN Recurrent feelings of detachment from self, environment, social status 2. Antidepressant PRN o Reality testing intact during episode o Feel like an outside observer Aware of symptoms, feel like they are going crazy Causes marked impairment or distress Vorbeireden: approximate answers to questions (ex. 2+2=5) Somatic symptoms Reaction to extreme stress Mimic behavior of mental illness: echolalia, echopraxia
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IMPULSE CONTROL (AXIS I): Inability to resist behavior that may be harmful to self/others. Anxiety relieved by impulse. May be remorseful or not.
Disorder Intermittent Explosive Disorder Epidemiology << 5-HT Timeline Episodes remit quickly Symptoms Impulses of assault or property destriction Out or proportion to trigger Usually feel remorseful afterward Stealing not for personal or monetary gain Pleasure derived from act of stealing Treatment 1. SSRI, anticonvulsant, lithium, propanolol 2. Group Therapy Psychotherapy not helpful 1. Insight-oriented psychotherapy 2. Behavior therapy a. Systematic desensitization b. Aversive therapy 3. SSRIs 1. Behavioral therapy 2. SSRI
Kleptomania
> of bulimics
Pyromania
< Common in MR
Pathological gambling
>1 intentional fire setting Tension before fire, relived afterward Fascination with fire Not for monetary gain or expression of anger 5+ symptoms of gambling addiction (do laterTM)
Trichotillomania
Recurrent pulling out of hair resulting in visible hair loss o Can be eyebrows, pubic hair Tension before, relieved by action Causes marked distress or impairment
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CHRONIC PAIN PAIN IS SUBJECTIVE Symptoms Pain without apparent biological cause Pain without apparent biological cause, which is MALADAPTIVE (distinguish from chronic pain) Excessive use of medications, restriction of daily activities Might be pain doesnt worsen, but individual fails to adapt/cope Factors: depression, kinesiophobia, inactivity Biological factors o Physiologic dysfunction tissue dmg o Genetics may be neurotransmitter o Gender o Pain experience based on prior pain Psychological factors most predictive o Meaning of pain o Perception of control o Coping style o Secondary gains o Pain-inactivity, pain-depression cycles Risk factors o Depression, low activity, excessive pain behavior, maladaptive congnitions, fear/avoidance o Somatization, PTSD, Age, job dissatisfaction, substance
Treatment
Psych variables (depression, anxiety) most accurate predictors, not severity of injury etc.
Prevention Return to active ASAP Take active role in own pain management Psychological testing Beck depression inventory MMPI o 1: Most pathological (CPS) o 2: V profile (CP but not mal) o 3: Chronic medical (not psyc) o 4: Normal Behavior- CBT Transition out of sick role Reduce maladaptive behavior Modify beliefs, attitudes Non-drug strategies Exercise, physical methods CBT Chiropractic, acupuncture Homeopathic, relaxation, hypnosis Ex. Thermal biofeedback for migraine o Resulted in greater reduction in headache than progressive muscle relaxation or EMG biofeedback
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Mental Retardation Subtype: Organic (Idiopathic) Subtype: PREnatal (Genetic) Subtype:PERInatal or postnatal Learning Disorder
1-3% of population 1.4x Males higher in non-white 7-15% of MR, 30-40% unknown Chromosomal: 30% severe, 4-8% mild 1.6-1.9x with mom smoker Fetal alcohol, anoxia, lead, mercury Reading disorder (3%): 3x Math disorder (5%): more Written expression (3-10%)
Onset before 18
Enuresis
Normally continent before 4 7% of 5-year olds Primary never previously continent Secondary after previously continent
Encopresis
3+ months
Must be 4+ years old Involuntary or intentional passage of feces in inappropriate places Occurs once/month for 3+ months
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Schizotypal PD 3% May remain (middle Men, more common stable severity) familially 30-50% have MDD 10% commit suicide
0.5%-2.5% Males, minorities, immigrants, relatives of schizophrenics 75% comorbid with other PD
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Histrionic PD
2-3% Female Comorbid with somatization and depression Superficial relationships <1% 50-75% MEN
Narcissistic PD
Antisocial PD
3% men, 1% women 50-75% prisoners Childhood conduct disorder. Hx of abuse, harming animals, fires 2-3% 2:1 Female Women: 3-10x likely to be victim of incest 10% suicide.
MUST begin in adolescence (15) and must be 18 at dx May or with age Get worse with age burnout. If they can survive 20s, prognosis is decent
Dependent
Avoidant
2.5% Women>men 80% comorbid PD 1% Can function Common in timid well infants Genetic predisposition 2x men Course not predictable EGO-SYNTONIC (vs. OCD)
Symptoms Treatment PERSONALITY DISORDERS - CLUSTER B (BAD) 1. Psychotherapy Theatrical expression of emotion: temper tantrums 2. Pharmacotherapy PRN Uncomfortable when not center of attention - Antidepressant Inappropriately provocative. Use physical appearance to gain attention Speech is impressionistic, lacks details Easily influenced by others Constant need for praise Use regression as a defense mechanism 1. Psychotherapy Lack of empathy. Sense of superiority. - Dont prick the bubble Takes advantage of others for self-gain (vs. antisocial for subjugation) 2. Pharmacotherapy PRN Preoccupied with fantasies of unlimited wealth, power, success Envious of others. Believes others are envious of them. Believes they are special and can only associate with high-status ppl 1. Psychotherapy NO REMORSE for harmful actions. 2. Pharmacotherapy PRN Wont conform to society: violates laws - Treat anxiety and Impulsivity, recklessness, irresponsibility depression but caution Irritability, aggression due to addictive Manipulative con men. Intelligent. Charming when first encountered personality. High risk for suicide, depression 1. Psychotherapy Unstable interpersonal relationships, self image, mood - Cognitive behavioral Desperately avoid real or perceived abandonment - Substance abuse Impulsive: sex, substance, spending 2. Pharmacotherapy PRN Recurrent suicidal thoughts and self-mutilation - Antidepressants (SSRI) Problems controlling anger - Antipsychotics Feel alone in the world Splitting defense mechanism, see as all good or all bad PERSONALITY DISORDERS - CLUSTER C (SAD) 1. Psychotherapy: independence Want others to make decisions, feel helpless when alone,Im weak 2. Pharmacotherapy Difficulty initiating projects on their own - Antidepressant Urgently seek new partner if one is lost 1. Psychotherapy WANT FRIENDSHIPS, just hard to form (vs. schizotypal/ schizoid) - Encourage interaction Fear of rejection (vs. fear of embarrassment in agoraphobia) 2. Pharmacotherapy Unable to interact unless assured that person will like them Prone to depression 1. Psychotherapy: Group Preoccupation with details such that main point of activity is lost 2. Pharmacotherapy Perfectionism detrimental to completing task - Antidepressants Will not delegate tasks. Miserly. Rigid, serioius, formal - Anxiolytics Workaholic: motivated by activity itself (vs. narcissitic by success) Hoard meaningless objects.
Antipsychotics D2+4 antag: Tx positive sx o Delusions o Hallucinations o Disorganized thought 5-HT antag: Tx negative sx o Affect o Anhedonia o Apathy o Alogia: speech o Attention
- Anti-HAM: H1, 1, Muscarinic antagonism - Advantages versus typical antipsychotics o EPS, TD o Do not prolactin levels o Increased efficacy, especially negative symptoms - Disadvantages versus typical antipsychotics o efficacious on positive symptoms o weight gain, type II DM, metabolic syndrome o More cardiotoxic (QT prolongation)
Clozapine (ClozarilTM) (strongest D4) Risperidol (RisperdalTM) Olanzepine (ZyprexaTM) Quetiapine (SeroquelTM) Ziprazidone (GeodonTM) o No weight gain (vs. all others) - Zotepine (NipoleptTM) not USA - Aripiprazole (AbilifyTM) - Amisulpride (SolianTM)
High potency
Low potency
Takes 1-2 weeks for peak therapeutic effect; only days for adverse effects. NOT drugs of abuse. - Antipychosis: mesolimbic + mesocortical pathways - Anti-HAM effects - EPS (Extra-pyrimidal): Nigrostriatal pathway (pseudoparkinsonism) o H1 R antagonist o Tx:Amantadine (SymmetrelTM), diphenhydramine (BenadrylTM), benztropine (CogentinTM) Sedation - Neuroleptic malignant syndrome (rare, anticholinergics ineffective): 20% mortality Antiemetic o Fever, autonomic labiality, leukocytosis, tremor, rigidity, CPK , rhabdomyolysis (26%) o 1 R antagonist o Tx: 1) d/c drug, 2) supportive: cooling blanket, IVF, bromocriptine or dantrolene Hypotension - Tardive dyskinesia (10-30% of chronic users) (worsened by anticholinergics) Sexual dysfunction Repetitive involuntary movement (lip smacking). Worse with longer-term antipsychotic Tx o AntiMuscarinic effects Typical atropine-like effects Hypersensitive D2 Rs; Tx with Clozapine - Weight gain - Hyperprolactinemia: Tubuloinfundibular (Less GnRH): libido, galactorrhea, amenorrhea - Liver enzyme elevation - Acute effects due to dopamine antagonism - Seizures - Chronic effects due to D2 autoreceptors decreasing dopamine release - Used in the treatment of: schizophrenia, bipolar (manic phase), delusional disorder. Class Side effects Drug Other Effects - Stronger EPS side effects (vs. atypical) - Chlorpromazine(ThorazineTM) - Less EPS (vs. high potency) TM o Acute dystonia: torticollis, oculogyric crises - Thioridazine (Mellaril ) - Strong Anti-HAM Tx: anticolinergics: benztropine (CogentinTM) - Need eye exam: o Akathisia (restlessness): o Chlorpromazine: Retinal deposits Tx: -blockers, benzodiazepines o Thiordiazine: Corneal deposits TM o Parkinsonism - Haloperidol (Haldol ) - Strong EPS (vs. low potency) TM Tx: anticholinergics (CogentinTM), - Fluphenazine (Prolixin ) - Less anti-HAM (vs. low potency) TM Trihexyphenidyl (ArtaneTM), Thiothixine ( Navane ) - Pimozide: prolonged QT syndrome Amantadine (SymmetrelTM) (releases DA), - Trifluoperazine (SterazineTM) - Haldol also tx Tourettes & Huntington TM o Perioral tremor - Perphenazine (Trilaon ) Tx: anticolinergics: benztropine (CogentinTM) - Pimozide (OrapTM) - Clozapine: only one with no EPS o Agranulocytosis (1%) o Seizures (2-5%) - Risperdol: most EPS, hyperP - Olanzepine: No hyperP - Quetiapine: cataracts o Can treat mania o Helps insomnia causes sedation - Ziprasidone: QT prolongation - Aripiprazole o weight gain o hyperprolactinemia
Principles of therapy: try 1 medication for 4 weeks. If it fails, switch to a different medication in the same class.
Anxiolytics Buspirone (BuSpar) Benzodiazepines
Serotonin-selective Reuptake Inhibitors (SSRIs) And 5-HT2A R antag Indications - MDD, PTSD - OCD, Bulemia - Panic disorder - PMS Serotonin and NE reuptake inhibitors (SNRIs) Indications - MDD - Panic/Agoraphobia - GAD MAO Inhibitors Indications (2nd line) - MDD (atypical), SAD - Social phobia - Panic disorder Mood Stabilizers Acute episodes ? and prophylaxis Other indications - Adjunct for MDD, schizophrenia - Alcoholism - Aggression/impulsivity
Takes 2-3 weeks for peak therapeutic effect; only days for adverse effects. NOT drugs of abuse. Most effective for MDD. Drug Pharmacokinetics Adverse Effects - Imipramine (TofranilTM) (NE, 5-HT) - Need to establish homeostasis: takes a - 3Cs: convulsions, coma, cardiac arrhythmias o Also treats nocturnal enuresis few weeks for effect o Wide QRS, prolonged PR, prolonged QTc - Amitriptylene (ElavilTM) (NE>5-HT) - Delay due to downregulation of - Anti-HAM o Less 1 block postsynaptic ARs and presynaptic 2Rs o Anti-H1: Sedation TM - Nortriptyline (Pamelor ) (NE) o Anti-1: Hypotension (orthostasis) - Desipramine (NorprminTM) (NE) o Anti-Muscarinic: dry mouth, blurred vision, - Doxepin (SinequanTM) constipation, urinary retention, delirium TM - Clomipramine (Anafranil ): OCD - Weight gain - Maprotiline (LudiomilTM) (NE) - Fluoxetine (ProzacTM) : preg. safe! - Delay of effect due to downregulation of - Nausea/Vomiting/Diarrhea (most common) o Treats comorbid hypersomnia 5-HT2A receptors - Agitation, akathisia, insomnia (worsened) o Only one indicated in children - Discontinuation syndrome - Sexual: libido, anorgasmia (), impotence () TM - Sertraline (Zoloft ) o Flu-like sx, vomiting, lethargy - Safe in overdose: minimal cardiotoxicity - Paroxetine (PaxilTM) o Especially with paroxetine (short t) - Serotonin Syndrome (w/ MAOIs, Li+, Carbemaz.) TM - Escitalopram (Lexapro ) o Altered mental status, diaphoresis, seizures TM - Fluvoxamine (Luvox ): OCD too o Autonomic: orthostasis, hyperthermia, diarrhea - Citalopram(CelexaTM) o Myoclonus, hypertension o Most specific for 5-HT reuptake - Avoid in pregnancy - Duloxetine (CymbaltaTM) Noradrenergic and specific serotonergic - Mirtazapine (RemeronTM): 1, 2, 5-HT2+3 antag. o Also diabetic neuropathy antidepressant (NaSSA) (no reuptake) o 2 block potentiates 5-HT1: appetite, weight - Venlafaxine (EffexorTM) o Also treats comorbid insomnia o Also treats GAD Serotonin antagonist and reuptake - Trazodone (DesyrelTM): 1 & 5-HT1A,1C,2 antagonist TM - Desvenlafaxine (Pristiq ) inhibitors (SARIs) o Short t. Priapism, orthostasis. Tx:insomnia - Amoxapine (DefanylTM) Norepinephrine-dopamine reuptake - Bupropion (WellbutrinTM, ZybanTM) o Also an antipsychotic TD inhibitors (NDRI) Tx: MDD > 8hrs old, SAD o seizure risk, no sexual side effects/wt gain - Phenelzine (NardilTM) - Inhibit MAO irreversibly - Not first-line because of interactions: - Selegiline (ZelaparTM) (MAO-B) o Long-acting (must regenerate MAO) o TCAs & SSRIs - Tranylcypromine (ParnateTM) o Need 10 day washout period before o Tyramine-rich foods (cheeses, wine, beer) - Isocarboxazid (MarplanTM) starting an SSRI, TCA o Sympathomimetics, Levodopa HTN crisis MAO-A: 5-HT, NE, DA metabolism - Inhibition of CYP450 causes interactions o Buspirone hypertension MAO-B: DA metabolism o Meperidine TM - Lithium (Lithobid ) (NE, 5-HT) - Long-term Tx for manic episodes - Lithium : Anything Na+ Li+ excretion ( Li) TM - Valproic acid (Depakote ) - Lithium o Dose-related: GI distress, tremor, and headache TM - Carbamazepine (Tegretol ) o Narrow therapeutic range: 0.7-1.2 mEq o Idiosyncratic: Arrhythmias: flat/inverted T-wave - Lamotrigine (LamictalTM) o Avoid in renal failure patients (usually benign), goiter, hypoT, leukocytosis, o Blocks IP3 cycle in NE/5-HT effects diabetes insipidus (nephrogenic), alopecia o Teratogenic: Ebstein anomaly (7.7%: 20x risk) o NSAIDs (not aspirin) availability - Valproic acid: fat, shaky, bald, yellow o Wt gain, tremor, alopecia, jaundice, pancreatitis o Teratogenic: neural tube defects
ATYPICALS