Flashcards in Psych 2 Deck (246):
What is the Central Reward Pathway?
Ventral Tegmental -> Nucleus Acumbens and PFC
Dopamine = Reward
What happens to the central reward pathway in the case of addiction?
Elevated dopamine levels -> downregulation of D2 receptors
What constitutes substance abuse?
1 of the following w/o meeting criteria for subs. dependence:
1. Recurrent use -> failure to meet obligations
2. Recurrent use in situations where physically hazardous
3. Recurrent substance related legal problems
4. Continued used despite persistent social/ personal problems caused or exacerbated by use of the substance.
What constitutes substance dependence?
3 or more of the following:
3. Substance taken in larger amounts or over longer period of time than intended
4. Persistend desire or unsuccessful efforts to cut down or control use
5. Great deal of time spent obtaining, using, recovering
6. Important activities given up / reduced due to use
7. Continued use despite knowlege of persistent physical/ psychological problem likely caused by substance.
Do substance dependent people always have a physiological dependence?
Tolerance / Withdrawal not necessary for dependence.
Use of substances from 3 categories (not niccotine and caffeine) - as a group meet criteria for dependence for >12 mos
Eliminated in DSM V
What effect does alcohol use have on life expectancy?
Reduces by 10 years
What constitutes moderate, at risk, and heavy drinking for males and females?
Moderate: Male: = 1 drink / day
At risk: Male: 4 drinks / day or 14 drinks / week
Female: 3 drinks / day or 7 drinks / week
Heavy: Male: 5 drinks / day or 15 drinks / week
Female: 4 drinks / day or 8 drinks / week
What is a "drink"?
1 12 oz. beer
1 5 oz. glass of wine
1.5 oz. 80 proof booze
What is a blackout and what is it associated with?
Impairment of short term memory (w/ alcohol use) in with otherwise normal intellectual and cognitive ability
Associated w/ early onset drinking, high peak BAC, head trauma, sedative hypnotic use.
Not predictive of long-term impairment.
CAGE and scoring
1. Cut down
2. Annoyed by other criticizing subs. use
2+ or yes to "eye-opener" suggestive of abuse
4 is almost diagnostic of dependence
ETOH withdrawal timeline
6-8 hrs: tremors
8-12: perceptual disturbances
72: Delerium Tremens
What is the cause of death in Delerium Tremens?
Cardiovascular collapse, hypothermia
How is Delerium Tremens treated?
Prevention of alcohol withdrawal
What is the underlying cause of Wernicke's Encephalopathy?
Alcohol related Thiamine deficiency
What is the difference between Delerium Tremens and Alcohol Induced Psychotic Disorder?
Alcohol Induced Psychosis - clear sensorium (usually associated w/ chronic alcohol use and intox or withdrawal)
-patients alert, oriented, able to pay attention
-psychosis: delusion, hallucination, disorganization
Delerium: includes disturbance of consciousness - reduced awareness of surroundings - and change in cognition
What is the first stage of ETOH liver disease?
can occur w/ a few days of heavy drinking
What is cirrhosis?
symptoms: general weakness, fatigue, anorexia, increased bleeding
What is the most common cause for hospitalization due to ETOH related medical condition?
Acute Pancreatitis - can lead to pancreatic insufficiency and pancreatic cancer
What is Mallory-Weiss syndrome?
Tear at gastroesophageal junction secondary to vomiting
What is the leading cause of nonischemic dilated cardiomyopathy
Prolonged excessive drinking
What cancers are associated with ETOH use?
oral, esophageal, laryngeal, stomach, colorectal, breast
-most associated w/ ETOH going down.
What changes in lab values are seen with alcohol use?
Elevated AST and ALT (esp. ratio - should be ~2)
elevated MCV - macrocytic anemia due to folate def.
elevated CDT (carbohydrate deficient transferin)
elevated uric acid
What concern does elevated GGT raise?
associated with recent heavy drinking. concern for withdrawal
How is ETOH overdose treated?
** no antidote **
What drugs can be used to treate ETOH withdrawal?
What is CIWA?
Clinical Institute Withdrawal Assessment
Useful in determining wether or not to include pharm in ETOH treatment.
Score <10 - drugs not indicated for use
2 Benzos used to treat alcohol withdrawal - pros and cons of each
Lorazepam: good for pts. w/ liver disease - minimal hepatic metabolism. Admin oral, SL, IM, IV
con: short half life -> frequent admin
Chlordiazepoxide: pro: longer half-life -> self-taper
con: long half-life -> liver disease. Oral only.
Whats the danger of ETOH withdrawal?
repeat withdrawal -> cognitive decline and increased severity of future withdrawal
What characterizes alcohol withdrawal seizures?
predisposition: hypokalemia, hypomagnesemia, epilepsy, previous hist. of withdrawal
manage w/ benzos. Antiepileptics may also be used.
Inhibits Aldehyde DH -> toxic accumulation of acetaldehyde -> flushing, N/V
May be no more effective than placebo
ETOH -> endogenous opioid release : affects subjective experience of alcohol use, reduces craving
Also used to treat opioid intoxication and OD
works on glutamate and GABA to "normalize" neurotransmitter system. Modulates hyperexcitability during ETOH withdrawal.
excreted by the kidney
What makes heroin a drug of abuse?
High lipid solubility - crosses BBB for rapid high
Opiate withdrawal timeline
w/in 6-8 hours after last dose
Peaks in 2-3 days
Subsides in 7-10 days
clinical triad for opioid OD
Coma, Pinpoint Pupils, Respiratory Depression
Used in OD setting
May precipitate withdrawal
Medican support: IV fluid, CV and respiratory support.
What meds can be used to treat opiate withdrawal symptoms?
Dicyclomine: diarrhea, stomach cramping
Clonidine: (a2 agonist) autonomic changes, sweating, restlessness, insomnia
Treatment for opioid dependence
Combiniation of buprenorphine and naloxone
Naloxone: prevents abuse via IV injection.
What is the value of replacement therapy in opioid addiction?
Reduces HIV spread
Who can dispense methadone and buprenorphine?
Methadone: government only
Buprenorphine: individual physicians with certification
Symptoms of SHA intoxication
SHA: Sedative, hypnotic, anxiolytic (benzo, barb, anti-psych)
Behavioral: Disinhibition, Impaired judgement/ attention/ memory, mood lability
Physical: Gait abnormality, Incoordination, Nystagmus, Slurred speech
SHA withdrawal symptoms
Behavioral: rebound anxiety, illusions, hallucinations, agitation
Physical: autonomic hyperactivity, coarse tremor, Insomnia, N/V, grand-mal seizure
What is a benzodiazepine antagonist?
How is barbiturate OD treated? Symptoms?
No antidote. Treat w/ medical support, gastric lavage, charcoal.
Symptoms: CV collapse, coma, resp. dep.
Medicinal properties of canabis
Decreased occular pressure (Narrow Angle Glaucoma)
How long after use can cannabis be detected in the urine?
What class of neurons do hallucinogenic drugs work on?
Do hallucinogens induce tolerance?
Yes - rapidly. Tolerance w/in 4 days if continual use
How is hallucinogen intoxication treated?
Benzodiazepines or antipsychotics may be used.
What is Hallucinogenic Persisting Perceptual Disorder?
Flashback - triggered by stress, sensory deprivation, other substances
Re-experiencing, after cessation of hallucinogen use, one or more of the following:
false perception of movement in peripheral vision
false flashes or intensified color perception
Macropsia / Micropsia
2 dissociative drugs. What is a disociative drug?
Also Dextromethorphan at high doses
Produces distorted perceptions of sight and sound (non-hallucinatory) and feelings of detachment from self
What is the mechanism of dissociative drugs?
Alter glutamate transmission by action at NMDA receptors
What is treatment for dissociative intoxication?
What is adderal composed of?
dextroamphetamine - amphetimine salt
What is Ritalin?
What age group is most likely to abuse stimulant drugs?
What efect does MDMA have?
Releases catecholamines as well as serotonin
Serotonin -> hallucinations
Physical symptoms of amphetimine intoxication
Arrhythmia, BP (high or low), Chest pain, chills, coma, brady- or tachycardia, weakness, N/V
Timeline for amphetamine withdrawal
peaks in 2-4 days, resolves in ~1wk
Symptoms of amphetimine withdrawal
Anxiety, Depression, Suicidality, Fatigue, Increased appetite, hyper- or insomnia, nightmares
Treatment for amphetamine abuse
Abstainance is main goal
Antipsychotics - perceptual disturbances / paranoia
Benzodiazepine - anxiety, agitation
Antidepressants - depressive symptoms
No specific medications indicated
Motiational Educational Treatment (MET)
How does cocaine work?
Blocks monoamine reuptake
Specifically blocks NET
Blocks reuptake of NE, EPI, Dopamine, and Serotonin
What substance of abuse is most associated with seizures?
What illnesses can sexual dysfunction be an indicator of?
In general - deteriorating health.
Diabetes Melitus - ED
Cardiovascular disease - ED
Hypothyroidism - loss of libido
Neurologic disease - Impaired function
What are the parts of the sexual response cycle?
What effect does depression hae on sexual function?
Loss of libido (31-77% of cases of depression)
Loss of function
What is the long - term effect of alcohol on sexual function?
HSDD in women
What are the acute and chronic effects of amphetamine on sexual function?
Acute: intensified orgasm, prolonged coitus
Chronic: inhibited sexual activity
What are the acute and chronic effects of cocaine on sexual function?
acute: increased libido, priapism (rare)
What are the effects of ecstasy on sexual function?
What medications are associated with impaired sexual function?
Cardiovascular / HTN
Is sexual dysfunction more prevalent in men or women?
4 categories of sexual dysfunction disorder
Disorders of :
What is HSDD?
Hypoactive Sexual Desire Disorder
Persistent or recurently deficient sexual fantasies
-As judged by CLINICIAN based on age, function, context of person's life
2 disorders of sexual arousal
Female sexual arousal disorder: inability to attain / maintain adequate lubrication - swelling response
Male erectile disorder: inability to attain / maintain adequate tuna spear
What are some orgasm disorders?
Female orgasmic disorder: delay or absence of orgasm w/ normal excitement phase
-wide variability of type / intensity of stimulation -> orgasm for women. Disorder judged by clinician.
Male orgasmic disorder: delay / absence of orgasm after normal excitement phase.
Premature ejaculation: ejaculation before, on, or shortly after penetration and before desired.
-judged by clinician.
Love beyond the usual
Disorder: action on or significant distress / impairment from recurrent, intense sexual urges, fantasies or behaviors involving an unusual object, activity or situation
duration of at least 6 mos.
What is fetishism?
intense sexual urge/ behavior involving inanimate objects
not limited to female garments (x-dressing) or toys
What is Frotteurism?
Intense / recurrent sexual urge / behavior involving touching / rubbing against non-consenting individual
Conditions to be met for pedophilia?
intense, recurrent desire or actual sexual activity with prepubescent child / children (usually <13)
-person at least 16 and 5years older than child
-not adolescent in ongoing sexual relationship with 12+ yr old.
Intense recurrent... heterosexual male crosdressing
How are sexual disorders and paraphilias treated?
psychotherapy is mainstay
Sex therapy and CBT for SD
Behavioral techniques (squeeze, stop-start) for some dysfunctions
Promotion of healthy lifestyle: stop smoking, diet, exercise, substance abuse treatment
What are risks of hormone use in treating HSDD?
deepening of voice
poss. breast cancer
When is hormone treatment warranted in men?
hypogonadism and low T
- goal: restore physiologic level
Drugs for male erectile disorder
PDE-5 inhibitor: prolongs action of cGMP in smooth muscle: sildenafil, tadalafil, vardenafil
Alprostadil: PGE1: intraurethral injection
Papaverine: PGE1: intracorporeal injection
What drugs may be used for premature ejaculation?
(Fucking Cock Spurts Prematurely take Serotonergic Antidepressant)
-nothing expressly approved for this application, but well tolerated.
Drugs used to treat paraphilias?
SSRI and clomipramine
What two processes are balanced in sleep?
Process S: homeostatic process
Process C: circadian arousal process
REM is independent of these
Transient and Chronic Insomnia
Transient Insomnia: over several days, short term: associated with stress, excitement, anticipation, illness, altitude, time changes
Chronic Insomnia: Multiple likely causes, but not understood.
6 screening criteria when investigating insomnia
1. poss. medical disorder
2. poss. psych. disorder (anxiety, panic)
3. sedative /hypnotic, drug use?
4. normal sleep at wrong time?
5. Legs: kick or uncomfortable at night: periodic leg movement, restless leg syndrome
6. Response to treatment for conditioned or primary insomnia? Yes: treat for insomnia
No: refer to sleep center
Primary insomnia criteria
Difficulty attaining or maintaining sleep or non-restorative sleep for 1 month
-does not occur exclusively during course of narcolepsy, breathing-related sleep disorder,parasomnia, etc.
-does not occur during course of other psych disorder
-not due to drug
Treatments for chronic insomnia
What is meant by sleep hygiene?
Regular Sleep time
Proper sleep environment
Avoidance of poorly timed alcohol / caffeine consumption
Have late-night high-tryptophan snack
What behavioral therapies can be used to treat chronic insomnia?
Sleep restriction (alone or as part of CBT, especially for elderly)
What benzodiazepines are useful in treating insomnia?
What non-benzodiazepines are useful in treating insomnia?
1. excessive daytime sleepiness
3. hypnogogic hallucinations
4. sleep paralysis
How is narcolepsy managed?
Behavioral: sleep hygiene, scheduled naps, education for pt., fam, employers, etc.
-TCA: cataplexy treatment
-stimulants: day time sleepiness
-assoc. symptoms: sodium oxybate (GHB) - special license
What are parasomnias?
Non-REM: sleep terror, sleepwalking, sleeptalking, sleep bruxism, nocturnal sleep-related eating disorder
REM: REM sleep behavior, nightmares
REFER TO SPECIALIST
Frontal Lobe Syndrome
Slowed thinking, poor judgement, decreased curiosity, social withdrawal, irritability
Due to bilateral lesion of frontal lobes due to trauma, tumor, lobotomy
What features suggest symptoms being due to a medical condition?
Unusual age of onset
Associated medical symptoms / features
No response to med. treatment
What medical condition is rapid-cycling bipolar disorder often associated with?
What are psychiactric symptoms of hypothyroidism?
Depressive: Depression, fatigue, decreased appetite, psychomotor retardation
Cognitive: Slowed mental activity
Psychotic: Hallucination, paranoid delusion (myxedema madness)
What tests should be ordered in suspected thyroid disorder?
TSH: Hypo - would be elevated; Hyper - would be low
T4: Hypo - would be depressed; Hyper - would be high
Psychiatric symptoms associated with hyperthyroidism
Restlessness, anxiety, fidgety
Tachycardia, sweating, irritability, fatigue
Hallucination, paranoid delusion
Psychiatric symptoms of hypoglycemia
anxiety, depression, fatigue
3 reasons for hypoglycemia
Malnutrition (ETOH, fasting)
Factitous disorder (self-injection of insulin)
Treatment for hypoglycemia
Psychiatric symptoms associated with Cushing's
2 causes of Cushings
Excessive ACTH secretion (pituitary)
Autosomal Recessive defect in Copper excretion -> deposition in liver, brain, cornea, kidney
What psychiatric symptoms present with Wilson's disease?
Schizophrenic, bipolar, depressive symptoms (only 10-25% of patients)
What are Kayser-Fleisher rings?
Found around edge of iris and rim of cornea due to copper deposition in Wilson's disease
How is Wilson's disease diagnosed?
Slit lamp exam - Kaiser-Fleisher rings
Blood: low ceruloplasmin (copper-carrying prot.)
Characteristics of MS
Distinct episodes of neurologic deficits
-Separated in time
-attributed to white matter lesions and demyelinated axons
What psychiatric and medical symptoms are seen in MS patients?
Major depression (common - 75% of pts), mania, psychosis
Agitation, irritability, euphoria, disinhibition, hallucination, delusion
Medical: Vary widely
-optic neuritis, cranial nerve signs, ataxia, nystagmus, motor and sensory impairment, spasticity, difficulty with bladder control / function
What CSF findings are common in MS?
elevated gamma globulin
What stage of syphilis can present with qsychologic symptoms?
Tertiary Syphilis (Neurosyphilis)
What are the symptoms of neurosyphilis (psych and med)?
early: Personality change, poor judgement/ insight, irritability, apathy, difficulty w/ calculations, decreased grooming
later: mood lability, delusions of grandeur, hallucination, disorientation, dementia
Tremor, dysarthria, hyperreflexia, ataxia, Argyll Robertson pupils (accomodate but don't react)
What part of the brain does herpes encephalitis attack?
What are the symptoms of Herpes Encephalitis (med and psych)?
Med: ABRUPT ONSET
-fever, headache, focal neuralgia (aphasia, visual field defect, hemiparesis, seizure)
Psych: ABRUBPT ONSET
-personality change, cognitive decline, hallucinations
What is treatment for herpes encephalitis?
Acyclovir and Vidarbine
* high mortality w/ and w/o treatment
<40% survive w/ treatment and have no sequelae
Describe psychosis symptoms in SLE
due to primary SLE: visual and tactile
Secondary to steroids: auditory
What is the cause of dementia in SLE?
numerous small ischemic strokes due to anti-phospholipid antibodies
What percentage of porphyria patients experience psychiatric symptoms?
90% remain normal
What is porphyria and what are some symptoms?
Defect in an enzyme involved in heme biosynthesis
Med: GI, pain, CV (HTN, tachycardia), cutaneous (photosensitivity, blisters, necrosis)
Psych: initially minor changes - anxiety, restless, insomnia
later - psychosis, agitation, delerium
What psychiatric symptoms are associated with low and high grade exposure to lead and in children?
Low: post-work fatigue, sleepiness, depression
High: impaired cognition and memory, psychosis
in Children: Intellectual impairment (IQ test), learning deficit, behavioral problems
What anemia is associated with lead exposure?
Mycrocytic hypochromic anemia
What is Niacin deficiency and what are major symptoms?
Dermatitis, Diarrhea, Delerium, Dementia, Death
Diagnostic criteria of Fibromyalgia
General pain affecting all 4 quadrants of body lasting for 3 mos.
- 11 of 18 reproducible points of pain
-4 of: gen. fatigue, sleep disturbance, headache, neuropsychiatric complaint, numbness / tingling, IBS symptoms
What psychiatric illnesses are associated with fibromyalgia?
Maj. depression, bipolar
Panic disorder, PTSD, Social phobia
How is fibromyalgia differentiated from medical disorder?
R/O everything possible. Diagnosis is process of elimination - diagnosis of EXCLUSION
Diagnostic criteria for chronic fatigue
6 mos of fatigue -> reduced activity
+ 4 psych symptoms
What drugs are approved for treatment of fibromyalgia?
What is criteria for chronic fatigue?
reduced activity for 6 months + 4 of:
Poor memory / concentration
Excessive tiredness w/ exercise
What comorbid psych disorders are associated with chronic fatigue syndrome?
Chronic Fatigue treatment
Meds for comorbid diagnosis
What are the goals of Motivational Inteviewing?
Facilitate motivation to change and leverage client's own resources for change
-Empathy and Acceptance
-Eliciting Change talk (how would your life be better if you quit...)
-Optional client driven goal setting
In regards to Motivational Interviewing and change, what is the focus of therapy?
Focus on whether to change rather than how or why
How does CBT help in treating substance abuse?
1. recognize situations where use is likely
2. avoid those situations
3. cope effectively with problematic behaviors associated with substance use
Goal of CBT in substance abuse
Restructure thoughts, beliefs, and perceptions to reduce use.
What are 3 goals of a Brief Intervention (BI)?
Listen and Understand
What percent of Americans have wanted to hurt themselves? How many do go through with it?
13.5% have had thoughts of wanting to hurt themselves
1% of those will kill selves
Static risk factors for suicide
Can't be changed:
Male, single, older, caucasian or native american, prior attempts, family history
What age groups makes the most suicide attempts?
16.9/100,000: rate increases w/ age
What lab findings have autopsies uncovered in suicides?
elevated serotonin in CSF
platelet serotonin abnormalities
What are dynamic risk factors for suicide?
Can be modified:
Psych illness, psych stressor, medical illness, acute suicidality
common psych diagnoses in suicide
Mood Disorder (40%)
Alcohol dependence (20-25%)
Severe personality disorder (20-25%)
What effect does prior academic acheivement have on suicide rates in schizophrenics?
What illnesses associate with increased suicide risk?
Cancer: 15x increase w/in 1 yr. of diagnosis
Chronic Renal Failure: 10x increase
AIDS: 7x increase
Suicide risk factors
Rational thinking loss
Social Support lacking
What is a chemical restraint?
High potency antipsychotic - haloperidol
used in cases of severe agitation when patient poses risk to self or others
What is a petition for assessment?
Allows person to be brought in for psychiatric evaluation if:
Patient is mentally ill and:
1) Serious risk to self or others
2) Has threatened to harm others
3) Unable to take care of basic needs
Tarasoff vs. Regents
If therapist determines (or shoud determine) that a patient presents threat of violence to another has duty to protect intended victim
- Must alert police or victim
Expression of psychological symptoms in physical terms
How can insurance effect somatization disorders?
Insurance that covers physical but not psychiatric symptoms fosters somatization
What is the most important management technique for somatization patients?
Follow regularly up w/ single PCP
-multiple specialists not helpful
-may refer to psychiatrist
What are the criteria for Somatization Disorder?
What is hypochondriasis?
Fear of having serious disease based on misinterpretation of symptoms.
Preoccupation persists despite appropriate evaluation and reassurance
What is conversion disorder?
presentation of neurological deficit or other GMC with associated psychologic factors.
What are pseudoseizures?
Seizures seen w/ conversion disorder - not true seizures, but unconscious origin / motivation
What percentage of conversion disorder patients will experience a recurrance of symptoms?
How many conversion disorder patients go on to receive a medical diagnosis that could explain symptoms?
What is Labelle Indifference?
Patients are undisturbed by potentially serious symptoms associated with conversion disorder.
How is body dysmorphic disorder treated?
High dose SSRI helps in 50% of cases
Cosmetic approach almost always unsuccessful
What is the origin of pain disorder?
How is pain disorder typcially treated?
SNRI and psychotherapy
What is pseudocyesis?
False belief of being pregnant associated with signs of pregnancy
symptoms are consciously produced, though for possibly subconscious reasons
Facticious disorder with predominantly physical symptoms
What is the main morbidity of factitious disorder?
Iatrogenic - procedural complications
Factitious disorder by proxy
Parent or caregiver makes child ill
If suspected - contact protective services
How does malingering differ from factitious disorder?
Conscious production of symptoms WITH motivation
-avoidance of dangerous situation, compensation, hospital stay, drugs
What personality disorder is associated with malingering?
What is the focus of treatment of personality disorder?
Not to change personality, but to understand person and work w/ traits
Disease vs. illness
Disease: pathological condition that -> group of symptoms
Illness: experience of living with disease. Reaction to body breaking down
What are the stages of dying?
Treatment goals for dying patient
Pain control and comfort
Maintain social / family function
Resolution of conflict
Achieve final goals
Competent medical care
Honest, compassionate doctor-patient relationship
What disorder has the highest mortality rate in psychiatry?
How are SSRIs used in treatment of anorexia nervosa?
Useful after weight restoration
If before - alteration of brain chemistry reduces effectiveness of future therapy
2 subtypes of bulemia
Purging: vomiting, laxative or enema abuse
Non purging: other compensatory behavior - fasting, excessive exercise
Cyproheptadine use for eating disorders
Antihistamine - increases apetite and may assist with weight gain
Use for AN ok
Should not be used for BN - appetite is normal
Is alcohol and drug use more prominent in AN or BN?
BN - up to 40% of cases
AN - around 15%
What personality disorders are associated with eating disorders?
AN: Avoidant and OCD
BN: Avoidant and Borderline
What drugs are contraindicated in AN and BN?
Bupropion: high seizure risk in eating disorders
Stimulants: abuse potential and weight loss
3 drugs that can cause weight gain
Mood stabilizers (valproic acid, lithium)
What structural features of the brain are seen in ADHD?
Reduced cortical white and gray matter volume
Decreased frontal and temporal lobe volume
Different function (in imaging studies) in caudate, frontal, anterior cingulate during tasks requiring INHIBITORY control
6 or more symptoms of inattention or hyperactivity-impulsivity
Persistant for at least 6 mos.
3 subtypes of ADHD
Predominantly inattentive: 6+ inattentive
Predominantly hyperactive-impulsive: 6+ hyperactive-impulsive
Mixed: 6+ of each type (12 total)
What is involved in evaluating ADHD?
interview child and CG
Medical eval: look at health, development, risk-factors
ADHD rating scale
Cognitive assessment: ability and achievement
Collateral reports, report cards, etc.
Criteria for Opositional Defiant Disorder
for 6 months 4+ of:
Loss of temper, arguing w/ adult, defy adult rules or requests, deliberately annoys, blames others for own misbehavior, easily annoyed by others, angry and resentful, spiteful or vindictive
What therapies are effective for ODD?
Psychosocial therapies (but NOT traditional individual or family therapy)
Parent Management Training
Collaborative problem solving, problem solving communications therapy
Criteria for Conduct Disorder
in last 6 mos 3+ of
Aggression to people or animals
Destruction of property
Deceitfulness or theft
Serious rule violations (staying out after curfew before 13, run away 2x or 1x if for a lengthy period, truancy before 13)
If over 18 and not antisocial disorder - CD
What is the treatment of choice for Conduct Disorder?
MultisystemicTherapy (MST) - only treatment to date to demonstrate long term reduction in re-arrest and incarceration
What genetic syndromes are associated with Autism?
What is Palalia?
Repeating one's own words
Complex phonic tic
What is echolalia?
Repeating someone else's words
Coplex phonic tic
What is Coprolalia?
Complex phonic tic
3 "tic" disorders
Chronic motor/vocal tic disorder
Transient tic disorder
Multiple motor and 1 or more vocal tics (not necessarily concurrent) for at least 1 year with no tic-free period lasting longer than 3 mos. Onset before 18 yoa.
Criteria for chronic vocal/motor tic disorder
Single or multiple vocal or motor tics NOT BOTH for at least 1 year, with no tic-free period of 3 months. Onset before 18
Criteria for transient tic disorder
Single or multiple vocal and/or motor tics for 4 wks - 1 year (not more). Onset before 18 yoa.
What neuroanatomic structures are involved in tics?
Corticostriatal thalamocortical abnormality
Reduced caudate volume, increased PFC volume
PET shows hypometabolism and decreased flow to ventral striatum
What is Syndenham's Chorea?
Results from childhood Strep A infection / Rheumatic fever.
Symptoms of motor tics, OCD and ADHD
Shared anatomic targets w/ Tourette's, OCD and ADHD
What is the etiology of tic generation
Increased (abnormal) activity in a population of striatal cells -> inhibition of tonically active inhibitory thalamic projection neurons -> activation of cortical motor pattern generator -> triggering of stereotyped movements (tics)
What is habit reversal training?
Patient w/ tic disorder learns to ID premonatory urge and execute other less intrusive movement
What medications can be used to treat tics?
Usually reserved unless significant impairment
D2 receptor agonists: haloperidol, pimozide, risperidone (many side effects)
a2 agonists: guanfacine, clonidine
Botulinum toxin: used for severe motor/vocal tics
What is the normal progression of continence?
Nocturnal fecal -> diurnal fecal -> diurnal bladder -> nocturnal bladder
Voiding of urine into bed or clothes 2x / week for 3+ months. At least 5 yoa chronologically or developmentally
Primary vs. secondary incontinence
Primary: never achieved continence
Secondary: achieved continence for at least 1 year
-secondary enuresis = regression
What disorders are associated w/ enuresis?
ADHD, anxiety, encopresis, developmental delay
What is the most successful treatment for enuresis?
Conditioning - enuresis alarm
What drugs may be used to help treat enuresis?
Imipramine - mechanism not understood. 40-50% efficacy w/ 50% relapse.
DDAVP - ADH analogue. Water intox w/ seizure concern.
By what age is bowel control typically established?
95% by 4, 99% by 5
What is the most significant cause of encopresis?
Constipation - inetentional or not- 75% of cases
Definition of dementia
Memory impairment + one of:
Apraxia - tasks
Agnosia - recognition (often spurs treatment_
Of what use is lab work in dementia evaluation?
Rule out reversible cause
How may neuroimaging be useful in dementia evaluation?
non-invasive detection of cortical atrophy
evidence unique metabolic changes in memory pathway
monitor therapy - follow progression of neuronal loss
What imaging study has highest specificity for Alzheimer's?
MRS: magnetic resonance spectroscopy - identify metabolite levels
When is genetic testing used in alzheimer's diagnosis?
Not routinely employed.
Used in all cases where age is s)
Apo-E4 screened for in early AD
What is delerium?
Disturbance of consciousness
Rapid onset, short duration, waxing and waning with lucid intervals
May coexist w/ dementia
Esp. in hospitalized and sick patients. s/p surgery
4 common dementias in elderly
Alzheimer's : most common - 2/3 of all
Vascular dementia: second
What NT changes are seen in AD?
-reduced activity of choline acetyltransferase
-reduced number of cholinergic receptors in late AD
-selective loss of nicotinic receptors in hippocampus and cortex
Features of LBD
Fluctuating cognition w/ increased confusion - nearly diagnostic
Lewy Bodies in cerebral cortex
What is Pick's disease?
Most common Frontotemporal Dementia
What are features of Frontotemporal Dementia?
Prominent behavior changes
Focal atrophy on neuroimaging
hypoperfusion precedes structural changes in PET
What is the standard pharmacological treatment for dementia?
Early cholinesterase inhibitor + Memantine later in treatment
Where are mutations found in familial AD?
Chromosome 21: codes APP
Chromosome 14: codes presenilin 1
Chromosome 1: codes presenilin 2
What treatments have targed amyloid and how effective are they?
Vaccine / immunotherapy
Both encountered problems in clinical trials
4 cholinesterase inhibitors
What is a MMSE and what is it used for?
Mini Mental Status Exam
Tests congnition and tracks cognitive changes
Identifies improvement or worsening and assists in screening where a baseline is known.
What does a MMSE consist of?
1. Orientation: What is the (year, date, season, day, month). Where are we (state, town, hospital, floor)
2. Registration: Ask patient to repeat three objects (1 point for each)
3. Attention and Calculation: Ask patient to count backward from 100 by sevens (stop after 5 answers)
4. Recall: Ask patient to name the 3 objects mentioned earlier
5. Language: Ask the patient to:
-Identify and name a pencil and a watch
-Repeat the phrase, "no ifs ands or buts"
-take a piece of paper in right hand and put it on the floor
-Read and obey the following, "close your eyes"
-Copy a complex diagram of interlocking pentagons
How is MMSE scored?
20-23: mild cognitive impairment
10-19: moderate dementia
0-10: severe dementia
1st line pharmacalogic for delerium?
-oral, IV (low risk of EPS), IM
-monitor EKG if QTc >450
If a causative factor for delerium is ID'd, how long after removal for resolution?
Usually 3-7 days, though up to 2 weeks
What is the effect of adding behavioral treatment to medication?
No improvement in symptoms
Improved satisfaction, internalization, social skills, reading achievement, comorbid symptoms
3 stages of ADHD pharmacotherapy
1. Titration: optimize dose/ frequency
2. Maintenance: routine monitoring
3. Termination: periodic trials off of meds should be tried.
3 first line meds for ADHD
2nd line agents for ADHD
What are contraindications for stimulant use in ADHD?
Hx of substance abuse
Active psychotic disorder
What DDIs are of concern w/ stimulant use in ADHD?
MAOI - separate use by 2 weeks to avoid HTN crisis
TCA - synergistic noradrenergic effect
Transdermal: 10mg/ 9 hr for 1 wk, then 15, etc
d-amphetamine covalently bound to L-lysine. Requires GI hydrolysis for activation.
Marketing - less abuse potential
Retrospective studies - more SE
Specific NE reuptake inhibitor
ADHD in children >6 (2nd line. 1st if stimulant contraindicated)
2D6 isozyme metabolism