Disorders Flashcards
1
Q
Nigrostriatal tract
A
substantia nigra –> striatum (CN + putamen), D2-R
- EPS symptoms
2
Q
Mesolimbic tract
A
ventral tegmental area of midbrain –> limbic system, D4-R
hyperactivity = positive sx
3
Q
Mesocortical tract
A
VTA –> frontal cortex and cingulate & prefrontal gyri
hypoactivity = neg sx, low mood, poor cognition
4
Q
tuberoinfundibular tract
A
hypothal –> pituitary
dopamine suppresses PRL … so dop antag = hyperPRL
5
Q
Symptoms of hyperPRL
A
galactorrhea
gynecomastia
amenorrhea
Group at greatest risk of hyperPRL from antipsychotics = adolescent males
6
Q
What are the positive & negative sx?
A
POSITIVE: delusions, hallucinations, disorganized speech and behavior
NEGATIVE: anhedonia, avolition, apathy, alogia (poverty of speech), affect flattening, attention deficit
7
Q
Hallucination vs illusion
A
Hallucination: NO external stimulus
Illusion: misperception of external stimulus
8
Q
What are Schneider’s first rank symptoms?
A
- Audible thoughts
- Voices commenting
- Voices arguing, discussing
- Somatic passivity (passive recipient of bodily sensations from outside forces)
- Thought broadcasting, insertion and withdrawal
- Delusional perceptions (normal perception, followed by a delusional interpretation)
9
Q
What are Schneider’s second rank symptoms?
A
- Sudden delusional thoughts
- Perceptual disturbances
- Perplexity
- Depressive and euphoric feelings
- Emotional impoverishment
10
Q
What is a delusion?
What are the different kinds of delusions?
A
Fixed, false belief, which is not a shared cultural belief
“JPEGS”
- Jealous
- Persecutory (most common) - think they will be subject to hostile treatment
- Erotomanic (de Clerambault’s) - that someone usually of higher SES is in love with you
- Grandiose
- Somatic - includes delusional parasitosis
- Unspecific
- Mixed
Ideas of reference - belief that cues in external environment are uniquely directed towards them
11
Q
What are the disorders similar to schizophrenia?
How do they differ?
A
- Brief Psychotic Disorder
>/= 1 positive sx
duration: between 1 day - 1 month - Schizophreniform
SAME except duration: 1-6 months
3. Schizophrenia Causes lifestyle dysfunction. 2 + of the following, with at least one of the first three: -- delusions -- hallucinations -- disorg speech -- grossly disorg or catatonic behavior -- neg sx duration: > 6 months **intact orientation **lack of insight into their disease
- Schizoaffective disorder
schizophrenia with concurrent MDD sx, with at least 2 weeks of hallucinations/delusions W/O MDD sx
–> 2 subtypes: bipolar, depressive
12
Q
Which substances can causes psychosis?
Intoxication and withdrawal?
A
- intoxication of all substances EXCEPT: caffeine, opioids, nicotine “CON”
- withdrawal of alcohol, sedatives, hypnotics “ASH”
13
Q
What are the 3 phases of schizophrenia?
A
- Prodromal - decline in functioning (socially withdrawn, physical complaints, declining school/work performance, irritable, newfound interest in religious cult)
- Psychotic - perceptual disturbances (illusion, hallucin), delusions, disordered throught process/content
- Residual - occurs following an episode of active psychosis … mild hallucinations or delusions, social withdrawal, neg sx
14
Q
Describe the characteristics of neuroleptic malignant syndrome.
A
- change in mental status
- autonomic instability (high fever, labile BP, tachycardia, tachypnea, diaphoresis)
- “lead pipe” rigidity
- elevated CPK
- leukocytosis
- metabolic acidosis
15
Q
Medications: Weight gain risk
A
HIGHEST: olanzapine, clozapine
MEDIUM: Wellbutrin (bupropion), Cymbalta (duloxetine)
NEUTRAL: ziprasidone, aripiprazole
16
Q
What is “rapid cycling” ?
Best treatment?
A
4 + mood episodes in one year
(major depressive, manic, hypomanic)
tx = mood stabilizers: carbamazepine, valproic acid
17
Q
Define bipolar disease I and II.
A
Bipolar I: only requirement = manic episodes
highest genetic link
tx = lithium (decreased suicide risk), mood stabilizers (c, va), atypical antipsychotics (r, o, q, z)
Bipolar II: MDD + hypomania
*likely better prognosis than bipolar I
tx = same as above
18
Q
What does the “atypical features” specifier for MDD denote?
A
Hypersomnolence Hyperphagia Reactive mood Leaden paralysis Hypersensitivity to interpersonal rejection
19
Q
“CHASES” of dysthymia?
A
poor Concentration Hopelessness poor Appetite or overeating inSomnia or hypersomnia low Energy low Self-esteem
*for most days, for 2 years
*has not been w/o above sx for >2 months at a time
*never had a hypomanic or manic episode
tx = psychotherapy + pharmacology
20
Q
Criteria for cyclothymic disorder?
A
- hypomanic sx (NOT hypomania) + mild depression for at least 2 years
- must not have been sx free for >2 months
- NO hx MDD episode, hypomania, manic episode
*approx 1/3 eventually develop bipolar I or II
tx = antimanic agents: mood stabilizers or atypicals
21
Q
Define criteria for disruptive mood dysregulation disorder (DMDD)
A
- Severe, recurrent verbal/physical outbursts out of proportion to situation.
- Outbursts 3+ times/week, inconsistent with developmental level
- Angry/irritable mood between outbursts
- at least 1 year, no >3 months w/o sx
- at least 2 settings
- dx made bw ages 6-18 BUT sx must have started at <10 years old
- no hypomania/mania episodes >1 day or MDD
- not due to substance/medical condition
- high rates of comorbidity
tx = psychotherapy (ie parent mgmt training)
other meds to treat primary sx (SSRIs, atypicals, stimulants)
22
Q
Substances
A
- PCP (hallucinogen): NYSTAGMUS, violent behavior, dissociation, hallucin, amnesia, ataxia
- LSD (hallucinogen): VISUAL HALLUCIN, dysphoria/panic, tachycardia/HTN
- Cocaine (stimulant): CP, SEIZURES, MYDRIASIS, agitation/psychosis, tachy/HTN
- Methamphetamine (stimulant): violent behavior, psychosis, diaphoresis, tachy/HTN, choreiform movements, tooth decay
* bath salt* –> mydriasis/tachy/HTN, agitation, violent behavior - Marijuana (psychoactive): CONJ INJECTION, increased appetite, dysphoria/panic, slow reflexes/impaired time perception, dry mouth … psychomotor impairment (can last for 1 day)
- Heroin (opioid): triad: DEPRESSED MENTAL STATUS, MIOSIS, RESP DEPRESSION, constipation
*all of euphoria except methamphetamines and PCP
23
Q
How can you dx borderline personality disorder?
A
pervasive pattern of unstable relationships, self-image, affects, marked impulsivity, WITH 5+:
- frantic efforts to avoid abandonment
- unstable, intense interpersonal relationships
- markedly and persistently unstable self-image
- impulsivity in 2+ areas that are potentially self damaging
- suicidal behavior/ self mutilation
- mood instability
- chronic feelings of emptiness
- inapprop and intense anger
- transient stress-related paranoia or dissociation
tx =
- PSYCHOTHERAPY (best)
- ATYPICALS, MOOD STABILIZERS for mood reactivity/transient psychosis
- ANTIDEP’s if comorbid mood/anxiety disorder
*common: hx childhood trauma
24
Q
PTSD
A
trauma and sx <1 month = Acute Stress Disorder
sx for >1 month = PTSD
immediately after trauma or with delayed expression
- INTRUSIVE sx (thoughts, nightmares, flashbacks)
- AVOIDANCE of triggering stimuli
- MOOD CHANGES
- DISSOCIATION
- 2+ sx of INCREASED AROUSAL: hypervigilance, exag startle response, irritability/angry outbursts, insomnia
*50% PTSD recover within 3 months
25
What are tx options for PTSD?
1. SSRIs or SNRIs
2. Prazosin (alpha 1 antag) - nightmares, hypervigilance
3. if severe: augment with atypicals
4. psychotherapy (ie - cognitive processing therapy) asap after stressor
26
Define ego-dystonic and ego-syntonic.
Ego-dystonic: it bothers the person
| Ego-syntonic: it doesn't bother the person
27
Personality disorder criteria
CAPRI
Cognition
Affect
Personal Relations
Impulse control
28
Cluster A
schizoid: eccentric, reclusive (VOLUNTARY social withdrawal), little interest in sexual activity with another person, taking pleasure in few activities, few close friends, indifference to praise/criticism, flattened affect/emotional coldness
schizotypal: eccentric ... 5+: ideas of reference (thinking insignif things have personal significance), odd beliefs, magical thinking, inapprop/restricted affect, suspiciousness, excess social anxiety
paranoid: distrustful, tend to blame their own problems on others, characterized as frequently jealous, reluctance to confide in others, persistence of grudges
29
Paranoid PD vs. Schizophrenia, Social isolation
PPD:
no fixed delusions, not frankly psychotic
*CAN be transiently psychotic in stressful situations
Ask others in close contact with the person, who can identify the person as excessively suspicious
30
Schizoid vs. Schizophrenia, Schizotypal, Avoidant
SPD:
no fixed delusions or hallucinations
no magical thinking; not the same level of odd behavior/thought/perception
PREFER to be alone
31
Schizotypal vs. Schizophrenia
not frankly psychotic, no fixed delusions
| *CAN be transiently psychotic
32
What is magical thinking?
Belief in telepathy or clairvoyance
Bizarre fantasies, preoccupations
Belief in superstitions
33
Cluster B
antisocial (M > F): violate the rights of others w/o showing guilt, exploitive, break rules to meet their own needs, lack empathy, impulsive, skilled at social cues & can appear charming at first, fail to accept responsibility for their own behavior, assault others, arrogant
* REQUIRE hx conduct disorder (<15 yrs), and be dx'ed with this at age >18 yrs
* Hx abuse, hurting animals, starting fires
* Men with alcoholic parents
borderline (F > M): unstable, intense interpersonal relationships; fear abandonment, poorly formed ID, aggression, impulsive, hx suicide/self-mutilation, transient stress-related psychosis
* Tx: Dialectical behavior therapy (DBT)
* Often split (good vs bad)
histrionic (F > M): attn-seeking, excessive emotionality, dramatic extroverted; unable to form long-lasting meaningful relationships, sexually inappropriate/provocative
*Regression (revert to childlike behaviors)
narcissistic: sense of superiority, need for admiration, lack of empathy, sense of entitlement, exploitive BUT fragile self esteem
* Greater risk of midlife crisis (emphasis on youth and power)
34
Borderline vs. Bipolar II, Histrionic
vs bipolar II: mood swings are rapid, brief, moment-to-moment reactions to perceived environ or psychological triggers
vs histrionic: more likely to suffer from depression, brief psychotic episodes, attempt suicide
(histrionic pts usually more functional)
35
Antisocial vs Narcissistic, Intermittent Explosive Disorder
NPD: want status/recognition ... if don't get it, they become depressed
Antisocial: want material gain, or simply dominance of others
*both exploit others
IED: usually no hx of conduct disorder, do not routinely engage in illegal activities
(can only dx IED in absence of antisocial disorder)
36
Cluster C
avoidant: social inhibition, intense fear of rejection, hyperSn, avoid jobs with interpersonal contact
(DESIRE companionship but extremely shy)
*Overlap with social anxiety disorder
dependent (F > M): poor self-confidence, fear of separation, need to be taken care of, difficulty making everyday decisions, need others to assume responsibilities, difficulty expressing disagreement, feels helpless when alone
OCPD (M > F): perfectionism, inflexibility, orderliness; unable to finish simples tasks on time; appear stiff, serious, formal with constricted affect; professionally successful but poor interpersonal skills. Unable to discard worthless objects, miserly spending style, stubborn.
37
Avoidant vs.
Schizoid
Social anxiety disorder
Dependent personality disorder
vs. schizoid: desire to be social but are shy
vs social anxiety disorder:
- if sx (fear, avoidance) been a chronic thing and part of patient's entire life - personality.
- but if it's fear in a particular setting - SAD.
vs DPD:
- both cling to relationships.
- avoidant pts are slow to get involved, whereas DPD pts actively/aggressively seek relationships
38
Dependent PD vs. Borderline
DPD: long-lasting relationships
| Borderline / histrionic: dependent on people but unable to maintain a longterm relationship
39
OCPD vs OCD, Narcissisicism
vs OCD: no recurrent o or c
OCPD: ego-syntonic
OCD: ego-dystonic
vs narcissisicism:
- both involve assertiveness and achievement
- narcissisicism: motivated by status
- OCPD: motivated by the work itself
40
Which substances can induce depressive disorder?
```
Alcohol
Antihypertensives
Barbiturates
Steroids
Levodopa
Sedative-hypnotics
Anticonvulsants
Antipsychotics
Diuretics
Sulfonamides
Withdrawal from stimulants (cocaine, etc)
```
41
Which substances can induce bipolar disorder?
```
antidepressants
sympathomimetics (ie - phenylephrine)
dopamine
steroids
levodopa
bronchodilators
cocaine / amphetamines
```
42
```
Procainamide, quinidine
Albuterol
Isoniazid
Tetracycline
Nifedipine, verapamil
Cimetidine
Steroids
```
Procainamide, quinidine: confusion, delirium
Albuterol: anxiety, confusion
Isoniazid: psychosis
Tetracycline: depression
Nifedipine, verapamil: depression
Cimetidine: depression, confusion, psychosis
Steroids: aggressiveness/agitation, mania, depression, anxiety, psychosis
43
What is:
reactive attachment disorder
disinhibited social engagement disorder
abuse/neglect in infancy
RAD: pairs too little
DSED: pair too much (overly bonding; cannot diff between stranger and family)
dx: <5 years old ... r/o autism
tx: tell caregiver how to parent better OR get kid to place where it can happen
f/u: mood disorder, substance disorders ... learning disabilities
44
Adjustment disorder
Non life-threatening stressor --> mood changes
(lose child, lose your job, etc)
onset: within 3 months of stressor
duration: < 6 months
* more severe reaction than expected
mood change that doesn't qualify for a mood disorder (no SI, HI) --> generally don't need treatment
45
First line tx, MDD with psychotic features
Combination therapy: antidepressant + antipsychotic
or
ECT
46
Catatonia
- sx of retarded vs excited
- treatment
- 3 things for f/u
Mood / Bipolar >>> Schizophrenia (modifier of illness)
Dx: 3+ of:
- Retarded catatonia: stupor, catalepsy (can put pt in any position you want), waxy-flexibility, negativitism (resistance to ideas etc), mutism, immobility
- Excited catatonia: stereotypy (repetitive mvmts), agitation/grimace, echolalia, echopraxia
Dx: Treat with Lorazepam ... if goes away, that's the dx.
** antipsychotics WORSEN catatonia
F/u:
1. Malnutrition --> albumin
2. DT ppx (DVT??)
3. Rhabdo --> ARF (check elevated CK)
47
Malignant catatonia (psych disorder ++ NO meds)
NMS (psych disorder ++ antipsychotic induced)
SS (psych disorder ++ SSRI or w.e. induced)
Malignant hyperthermia (NO psych disorder ++ halothane/anesthesia induced)
Sx:
1. Lead pipe rigidity:
- muscle breakdown --> high CK
- strong resistance to mvmt
2. ANS dysfunction:
- HTN
- tachy
- fever
48
Social anxiety disorder
fears related to being publically scrutinized, embarassed, or neg judged in a social context
vs GAD: where there are multiple worries
vs panic disorder: where there are
1. unexpected panic attacks
2. patient's fear is specifically related to the panic sx
vs specific phobia: where stimulus is not related to social anxiety
49
What are some augmentation strategies, if someone's having a partial response to their current anti-depressant medication?
What if they're a nonresponder?
1. add anti-depressant with a different MOA
2. add an atypical (aripiprazole)
3. add lithium
4. add T3
5. psychotherapy
Nonresponder: change to a diff med
50
MDD vs normal grief
MDD:
- persistent sadness, anhedonia
- excessive guilt
- self critical ruminations
- suicidality
- feelings of worthlessness and hopelessness
51
What is persistent complex bereavement disorder?
Aka complicated grief
- persistent yearning for deceased
- prolonged emotional pain related to loss (6-12 mo)
- impaired functioning
- complicating features:
- - maladaptive rumination
- - dysfunctional behavior (ie - excessively seeking proximity to deceased thru objects)
52
Side effects of lithium?
CI?
Acute: tremor, ataxia, AMS, n/v, diarrhea + polyuria, polydipsia, weakness
Chronic: nephrogenic DI, CKD, thyroid dysfxn (usually hypo), hyperparathyroidism (hyperCa)
CI: CKD, CVD, hyponatremia or diuretic use
*esp first tri pregnancy
53
What labs would you want to get before starting lithium?
```
BMP
TFT
Ca
UA
pregnancy test
ECG if have CAD risk factors
```
54
Indications for ECT?
treats: depression, bipolar mania, catatonia
1. treatment resistant
2. + psychotic features
3. emergencies (SI, refusal to eat)
4. CI to pharmacotherapy
5. pregnancy if can't use meds
6. hx of ECT response
* no absolute CI
55
What are the side effects of ECT?
Retrograde + anterograde amnesia
Anterograde: resolves w/in 2 wks of being done
Retrograde: may persist longer
56
What can you use to treat the depressive phase of bipolar?
lamotrigine
| quetiapine
57
Primary diagnostic features of conduct disorder?
Deceitfulness or theft (lying, stealing)
Deliberate property damage (vandalism, setting fires)
Aggression, cruelty towards ppl/animals
Serious violation of rules (truancy, running away)
3+ for >12 months. *lack of remorse*
Tx:
1. CBT
2. Fam therapy
3. Parent mgmt training
58
Conduct disorder vs ODD
ODD: angry/irritable mood + defiant behavior toward authority figures
NO stealing or aggression towards people
59
Somatic symptom disorder
vs
Panic disorder
Somatic symptom disorder: physical sx are persistent over time
Panic disorder: more acute attacks
60
What are the sleep changes in depression?
Early morning awakening
Multiple awakenings
Decreased REM latency
Decreased restorative sleep
61
Lewy body dementia - what can happen when you use anti-psychotics in these patients?
1. autonomic dysfunction (orthostatic hypotension)
2. Parkinsonism (bc blocking dopamine)
3. AMS
