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0

What is the Central Reward Pathway?

Ventral Tegmental -> Nucleus Acumbens and PFC

Dopamine = Reward

1

What happens to the central reward pathway in the case of addiction?

Elevated dopamine levels -> downregulation of D2 receptors

2

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.

3

What constitutes substance dependence?

3 or more of the following:
1. Tolerance
2. Withdrawal
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.

4

Do substance dependent people always have a physiological dependence?

No.
Tolerance / Withdrawal not necessary for dependence.

5

polysubstance 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

6

What effect does alcohol use have on life expectancy?

Reduces by 10 years

7

What constitutes moderate, at risk, and heavy drinking for males and females?

Moderate: Male: 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

8

What is a "drink"?

1 12 oz. beer
1 5 oz. glass of wine
1.5 oz. 80 proof booze

9

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.

10

CAGE and scoring

1. Cut down
2. Annoyed by other criticizing subs. use
3. Guilt
4. Eye-opener

2+ or yes to "eye-opener" suggestive of abuse
4 is almost diagnostic of dependence

11

ETOH withdrawal timeline

6-8 hrs: tremors
8-12: perceptual disturbances
12-24: seizures
72: Delerium Tremens

12

What is the cause of death in Delerium Tremens?

Cardiovascular collapse, hypothermia

13

How is Delerium Tremens treated?

Prevention of alcohol withdrawal
-Benzodiazapnes

14

What is the underlying cause of Wernicke's Encephalopathy?

Alcohol related Thiamine deficiency

20% mortality

15

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

16

What is the first stage of ETOH liver disease?

Steatosis
can occur w/ a few days of heavy drinking
reversible

17

What is cirrhosis?

Liver fibrosis
symptoms: general weakness, fatigue, anorexia, increased bleeding

18

What is the most common cause for hospitalization due to ETOH related medical condition?

Acute Pancreatitis - can lead to pancreatic insufficiency and pancreatic cancer

19

What is Mallory-Weiss syndrome?

Tear at gastroesophageal junction secondary to vomiting

20

What is the leading cause of nonischemic dilated cardiomyopathy

Prolonged excessive drinking

21

What cancers are associated with ETOH use?

oral, esophageal, laryngeal, stomach, colorectal, breast

-most associated w/ ETOH going down.

22

What changes in lab values are seen with alcohol use?

Elevated AST and ALT (esp. ratio - should be ~2)
elevated GGT
elevated MCV - macrocytic anemia due to folate def.
elevated CDT (carbohydrate deficient transferin)
elevated uric acid
elevated TG

23

What concern does elevated GGT raise?

associated with recent heavy drinking. concern for withdrawal

24

How is ETOH overdose treated?

Medical stabilization
IV fluid
Cardiovascular support

** no antidote **

25

What drugs can be used to treate ETOH withdrawal?

Benzodiazapines

26

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

27

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.

28

Whats the danger of ETOH withdrawal?

Autonomic instability
Seizure
repeat withdrawal -> cognitive decline and increased severity of future withdrawal

29

What characterizes alcohol withdrawal seizures?

Generalized Tonic-Clonic
predisposition: hypokalemia, hypomagnesemia, epilepsy, previous hist. of withdrawal
manage w/ benzos. Antiepileptics may also be used.

30

Disulfram

Antabuse
Inhibits Aldehyde DH -> toxic accumulation of acetaldehyde -> flushing, N/V

Adherence problem
May be no more effective than placebo

31

Naltrexone

Opioid antagonist
ETOH -> endogenous opioid release : affects subjective experience of alcohol use, reduces craving

Also used to treat opioid intoxication and OD

32

Acamprosate

works on glutamate and GABA to "normalize" neurotransmitter system. Modulates hyperexcitability during ETOH withdrawal.

excreted by the kidney

33

What makes heroin a drug of abuse?

High lipid solubility - crosses BBB for rapid high

34

Opiate withdrawal timeline

w/in 6-8 hours after last dose
Peaks in 2-3 days
Subsides in 7-10 days

35

clinical triad for opioid OD

CPR

Coma, Pinpoint Pupils, Respiratory Depression

36

Naloxone

Opioid antagonist
Used in OD setting
May precipitate withdrawal
Medican support: IV fluid, CV and respiratory support.

37

What meds can be used to treat opiate withdrawal symptoms?

Ibuprofen: pain
Dicyclomine: diarrhea, stomach cramping
Clonidine: (a2 agonist) autonomic changes, sweating, restlessness, insomnia

38

Suboxone

Treatment for opioid dependence
Combiniation of buprenorphine and naloxone
Naloxone: prevents abuse via IV injection.

39

What is the value of replacement therapy in opioid addiction?

Minimizes euphoria
Reduces crime
Reduces HIV spread

40

Who can dispense methadone and buprenorphine?

Methadone: government only
Buprenorphine: individual physicians with certification

41

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

42

SHA withdrawal symptoms

Behavioral: rebound anxiety, illusions, hallucinations, agitation
Physical: autonomic hyperactivity, coarse tremor, Insomnia, N/V, grand-mal seizure

43

What is a benzodiazepine antagonist?

Flumazenil

44

How is barbiturate OD treated? Symptoms?

No antidote. Treat w/ medical support, gastric lavage, charcoal.

Symptoms: CV collapse, coma, resp. dep.

45

Medicinal properties of canabis

Analgesia
Anticonvulsant
Anti-nausea
Appetite stimulant
Decreased occular pressure (Narrow Angle Glaucoma)

46

How long after use can cannabis be detected in the urine?

One month

47

What class of neurons do hallucinogenic drugs work on?

Serotonergic

48

Do hallucinogens induce tolerance?

Yes - rapidly. Tolerance w/in 4 days if continual use

49

How is hallucinogen intoxication treated?

Calm environment
Benzodiazepines or antipsychotics may be used.

50

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:
geometric hallucination
false perception of movement in peripheral vision
false flashes or intensified color perception
Halos
Macropsia / Micropsia

51

2 dissociative drugs. What is a disociative drug?

Ketamine
Phencycladine (PCP)
Also Dextromethorphan at high doses

Produces distorted perceptions of sight and sound (non-hallucinatory) and feelings of detachment from self

52

What is the mechanism of dissociative drugs?

Alter glutamate transmission by action at NMDA receptors

53

What is treatment for dissociative intoxication?

Calm environment
Benzodiazepines, antipsychotics

54

What is adderal composed of?

dextroamphetamine - amphetimine salt

55

What is Ritalin?

Methylphenidate

56

What age group is most likely to abuse stimulant drugs?

18-25 yrs

57

What efect does MDMA have?

Releases catecholamines as well as serotonin
Serotonin -> hallucinations

58

Physical symptoms of amphetimine intoxication

Arrhythmia, BP (high or low), Chest pain, chills, coma, brady- or tachycardia, weakness, N/V

59

Timeline for amphetamine withdrawal

peaks in 2-4 days, resolves in ~1wk

60

Symptoms of amphetimine withdrawal

Anxiety, Depression, Suicidality, Fatigue, Increased appetite, hyper- or insomnia, nightmares

61

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)
CBT
12 step

62

How does cocaine work?

Blocks monoamine reuptake
Specifically blocks NET
Blocks reuptake of NE, EPI, Dopamine, and Serotonin

63

What substance of abuse is most associated with seizures?

Cocaine

64

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

65

What are the parts of the sexual response cycle?

Desire
Excitement
Orgasm
Resolution

66

What effect does depression hae on sexual function?

Loss of libido (31-77% of cases of depression)
Loss of function

67

What is the long - term effect of alcohol on sexual function?

Impotence
Testicular Atrophy
HSDD in women

68

What are the acute and chronic effects of amphetamine on sexual function?

Acute: intensified orgasm, prolonged coitus
Chronic: inhibited sexual activity

69

What are the acute and chronic effects of cocaine on sexual function?

acute: increased libido, priapism (rare)
chronic: impotence

70

What are the effects of ecstasy on sexual function?

Increased desire
Erectile failure
Orgasmic delay

71

What medications are associated with impaired sexual function?

Antidepressant
Antipsychotic
Cardiovascular / HTN
Seizure
Cancer

72

Is sexual dysfunction more prevalent in men or women?

Women

73

4 categories of sexual dysfunction disorder

Disorders of :
Sexual desire
Sexual arousal
Orgasmic
Sexual pain

74

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

75

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

76

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.

77

Paraphilia definition

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.

78

What is fetishism?

intense sexual urge/ behavior involving inanimate objects
not limited to female garments (x-dressing) or toys

79

What is Frotteurism?

Intense / recurrent sexual urge / behavior involving touching / rubbing against non-consenting individual

80

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.

81

Transvestic fetishism

Intense recurrent... heterosexual male crosdressing

82

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

83

What are risks of hormone use in treating HSDD?

hirsutism
deepening of voice
clitoris enlargement
poss. breast cancer

84

When is hormone treatment warranted in men?

hypogonadism and low T
- goal: restore physiologic level

85

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

86

What drugs may be used for premature ejaculation?

Serotonergic antidepressants:
Fluoxetine
Clomipramine
Sertraline
Paroxetine
(Fucking Cock Spurts Prematurely take Serotonergic Antidepressant)
-nothing expressly approved for this application, but well tolerated.

87

Drugs used to treat paraphilias?

SSRI and clomipramine
Antipsychotics (rare)
Antiandrogen

88

What two processes are balanced in sleep?

Process S: homeostatic process
Process C: circadian arousal process

REM is independent of these

89

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.

90

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

91

Primary insomnia criteria

Difficulty attaining or maintaining sleep or non-restorative sleep for 1 month
-distress...
-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

92

Treatments for chronic insomnia

Sleep hygiene
Behavioral therapy
Benzo
Non-benzo

93

What is meant by sleep hygiene?

Regular Sleep time
Proper sleep environment
Wind-down time
Stimulation control
Avoidance of poorly timed alcohol / caffeine consumption
Have late-night high-tryptophan snack
Regular exercise

94

What behavioral therapies can be used to treat chronic insomnia?

CBT
Biofeedback
Sleep restriction (alone or as part of CBT, especially for elderly)

95

What benzodiazepines are useful in treating insomnia?

Triazolam
Temazepam
Estazolam
Quazepam
Flurazepam

96

What non-benzodiazepines are useful in treating insomnia?

Zolpidem
Zaleplon
Zolpidem ER
Eszopiclone
Ramelteon

97

Narcolepsy tetrad

1. excessive daytime sleepiness
2. cataplexy
3. hypnogogic hallucinations
4. sleep paralysis

98

How is narcolepsy managed?

Behavioral: sleep hygiene, scheduled naps, education for pt., fam, employers, etc.
Pharmacological:
-TCA: cataplexy treatment
-stimulants: day time sleepiness
-assoc. symptoms: sodium oxybate (GHB) - special license

99

What are parasomnias?

Non-REM: sleep terror, sleepwalking, sleeptalking, sleep bruxism, nocturnal sleep-related eating disorder
REM: REM sleep behavior, nightmares

REFER TO SPECIALIST

100

Frontal Lobe Syndrome

Slowed thinking, poor judgement, decreased curiosity, social withdrawal, irritability

Due to bilateral lesion of frontal lobes due to trauma, tumor, lobotomy

101

What features suggest symptoms being due to a medical condition?

Unusual age of onset
Atypical course
Unusual presentation
Associated medical symptoms / features
No response to med. treatment

102

What medical condition is rapid-cycling bipolar disorder often associated with?

Thyroid dysregulation

103

What are psychiactric symptoms of hypothyroidism?

Depressive: Depression, fatigue, decreased appetite, psychomotor retardation
Cognitive: Slowed mental activity
Psychotic: Hallucination, paranoid delusion (myxedema madness)

104

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

105

Psychiatric symptoms associated with hyperthyroidism

Restlessness, anxiety, fidgety
Tachycardia, sweating, irritability, fatigue
Labile mood
Hallucination, paranoid delusion

106

Psychiatric symptoms of hypoglycemia

anxiety, depression, fatigue

107

3 reasons for hypoglycemia

Malnutrition (ETOH, fasting)
Insulinoma
Factitous disorder (self-injection of insulin)

108

Treatment for hypoglycemia

Dextrose

109

Psychiatric symptoms associated with Cushing's

Depression
Mania
Anxiety
Psychosis (rare)

110

2 causes of Cushings

Excessive ACTH secretion (pituitary)
Adrenal pathology

111

Wilson's Disease

Autosomal Recessive defect in Copper excretion -> deposition in liver, brain, cornea, kidney

112

What psychiatric symptoms present with Wilson's disease?

Schizophrenic, bipolar, depressive symptoms (only 10-25% of patients)

113

What are Kayser-Fleisher rings?

Found around edge of iris and rim of cornea due to copper deposition in Wilson's disease

114

How is Wilson's disease diagnosed?

Slit lamp exam - Kaiser-Fleisher rings
Blood: low ceruloplasmin (copper-carrying prot.)

115

Characteristics of MS

Distinct episodes of neurologic deficits
-Separated in time
-attributed to white matter lesions and demyelinated axons

116

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

117

What CSF findings are common in MS?

elevated protein
elevated gamma globulin
oligoconal bands

118

What stage of syphilis can present with qsychologic symptoms?

Tertiary Syphilis (Neurosyphilis)

119

What are the symptoms of neurosyphilis (psych and med)?

Psych:
early: Personality change, poor judgement/ insight, irritability, apathy, difficulty w/ calculations, decreased grooming
later: mood lability, delusions of grandeur, hallucination, disorientation, dementia

Med:
Tremor, dysarthria, hyperreflexia, ataxia, Argyll Robertson pupils (accomodate but don't react)

120

What part of the brain does herpes encephalitis attack?

Limbic system

121

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

122

What is treatment for herpes encephalitis?

Acyclovir and Vidarbine


* high mortality w/ and w/o treatment
<40% survive w/ treatment and have no sequelae

123

Describe psychosis symptoms in SLE

due to primary SLE: visual and tactile
Secondary to steroids: auditory

124

What is the cause of dementia in SLE?

numerous small ischemic strokes due to anti-phospholipid antibodies

125

What percentage of porphyria patients experience psychiatric symptoms?

~10%

90% remain normal

126

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

127

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

128

What anemia is associated with lead exposure?

Mycrocytic hypochromic anemia

129

What is Niacin deficiency and what are major symptoms?

Pellagra

5Ds
Dermatitis, Diarrhea, Delerium, Dementia, Death

130

Diagnostic criteria of Fibromyalgia

General pain affecting all 4 quadrants of body lasting for 3 mos.

And either
- 11 of 18 reproducible points of pain
-4 of: gen. fatigue, sleep disturbance, headache, neuropsychiatric complaint, numbness / tingling, IBS symptoms

131

What psychiatric illnesses are associated with fibromyalgia?

Maj. depression, bipolar
Panic disorder, PTSD, Social phobia

132

How is fibromyalgia differentiated from medical disorder?

R/O everything possible. Diagnosis is process of elimination - diagnosis of EXCLUSION

133

Diagnostic criteria for chronic fatigue

6 mos of fatigue -> reduced activity
+ 4 psych symptoms

134

What drugs are approved for treatment of fibromyalgia?

SNRIs (Duloxetine)

135

What is criteria for chronic fatigue?

reduced activity for 6 months + 4 of:
Poor memory / concentration
Unrefreshing sleep
Excessive tiredness w/ exercise
Sore throat
Tender glands
Myalgia
Joint pain
Recent-onset headache

136

What comorbid psych disorders are associated with chronic fatigue syndrome?

GAD
Panic disorder
Depression
Somatoform disorder

137

Chronic Fatigue treatment

CBT
Exercise
Meds for comorbid diagnosis

138

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

139

In regards to Motivational Interviewing and change, what is the focus of therapy?

Focus on whether to change rather than how or why

140

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

141

Goal of CBT in substance abuse

Restructure thoughts, beliefs, and perceptions to reduce use.

142

What are 3 goals of a Brief Intervention (BI)?

Feedback
Listen and Understand
Options explored

143

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

144

Static risk factors for suicide

Can't be changed:
Male, single, older, caucasian or native american, prior attempts, family history

145

What age groups makes the most suicide attempts?

>85 yrs
16.9/100,000: rate increases w/ age

146

What lab findings have autopsies uncovered in suicides?

elevated serotonin in CSF
platelet serotonin abnormalities

147

What are dynamic risk factors for suicide?

Can be modified:
Psych illness, psych stressor, medical illness, acute suicidality

148

common psych diagnoses in suicide

Mood Disorder (40%)
Alcohol dependence (20-25%)
Severe personality disorder (20-25%)
Schizophrenia (10-15%)

149

What effect does prior academic acheivement have on suicide rates in schizophrenics?

Increased risk

150

What illnesses associate with increased suicide risk?

Cancer: 15x increase w/in 1 yr. of diagnosis
Chronic Renal Failure: 10x increase
AIDS: 7x increase

151

SADPERSONS

Suicide risk factors
Sex
Age
Depression
Prev. attempt
Ethanol
Rational thinking loss
Social Support lacking
Organized plan
No spouse
Sickness

152

What is a chemical restraint?

High potency antipsychotic - haloperidol
used in cases of severe agitation when patient poses risk to self or others

153

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

154

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

155

Somatoform disorder

Expression of psychological symptoms in physical terms

156

How can insurance effect somatization disorders?

Insurance that covers physical but not psychiatric symptoms fosters somatization

157

What is the most important management technique for somatization patients?

Follow regularly up w/ single PCP
-multiple specialists not helpful
-may refer to psychiatrist

158

What are the criteria for Somatization Disorder?

4 pain
2 GI
1 sexual
1 pseudoneurological

159

What is hypochondriasis?

Fear of having serious disease based on misinterpretation of symptoms.
Preoccupation persists despite appropriate evaluation and reassurance

160

What is conversion disorder?

presentation of neurological deficit or other GMC with associated psychologic factors.

161

What are pseudoseizures?

Seizures seen w/ conversion disorder - not true seizures, but unconscious origin / motivation

162

What percentage of conversion disorder patients will experience a recurrance of symptoms?

Only ~25%

163

How many conversion disorder patients go on to receive a medical diagnosis that could explain symptoms?

25-50%

164

What is Labelle Indifference?

Patients are undisturbed by potentially serious symptoms associated with conversion disorder.

165

How is body dysmorphic disorder treated?

High dose SSRI helps in 50% of cases
Therapy
Cosmetic approach almost always unsuccessful

166

What is the origin of pain disorder?

Psychological cause

167

How is pain disorder typcially treated?

SNRI and psychotherapy

168

What is pseudocyesis?

False belief of being pregnant associated with signs of pregnancy

169

Facticious disorder

symptoms are consciously produced, though for possibly subconscious reasons

170

Munchausen syndrome

Facticious disorder with predominantly physical symptoms

171

What is the main morbidity of factitious disorder?

Iatrogenic - procedural complications

172

Factitious disorder by proxy

Parent or caregiver makes child ill
If suspected - contact protective services

173

How does malingering differ from factitious disorder?

Conscious production of symptoms WITH motivation
-avoidance of dangerous situation, compensation, hospital stay, drugs

174

What personality disorder is associated with malingering?

Antisocial

175

What is the focus of treatment of personality disorder?

Not to change personality, but to understand person and work w/ traits

176

Disease vs. illness

Disease: pathological condition that -> group of symptoms
Illness: experience of living with disease. Reaction to body breaking down

177

What are the stages of dying?

Denial
Anger
Bargaining
Depression
Acceptance

178

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

179

What disorder has the highest mortality rate in psychiatry?

Anorexia Nervosa

180

How are SSRIs used in treatment of anorexia nervosa?

Useful after weight restoration
If before - alteration of brain chemistry reduces effectiveness of future therapy

181

2 subtypes of bulemia

Purging: vomiting, laxative or enema abuse
Non purging: other compensatory behavior - fasting, excessive exercise

182

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

183

Is alcohol and drug use more prominent in AN or BN?

BN - up to 40% of cases
AN - around 15%

184

What personality disorders are associated with eating disorders?

AN: Avoidant and OCD
BN: Avoidant and Borderline

185

What drugs are contraindicated in AN and BN?

Bupropion: high seizure risk in eating disorders
Stimulants: abuse potential and weight loss

186

3 drugs that can cause weight gain

Antipsychotics
Antidepressants (TCA)
Mood stabilizers (valproic acid, lithium)

187

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

188

ADHD criteria

6 or more symptoms of inattention or hyperactivity-impulsivity
Persistant for at least 6 mos.

189

3 subtypes of ADHD

Predominantly inattentive: 6+ inattentive
Predominantly hyperactive-impulsive: 6+ hyperactive-impulsive
Mixed: 6+ of each type (12 total)

190

What is involved in evaluating ADHD?

interview child and CG
MSE
Medical eval: look at health, development, risk-factors
ADHD rating scale
Cognitive assessment: ability and achievement
Collateral reports, report cards, etc.

191

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

192

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

193

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

194

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

195

What genetic syndromes are associated with Autism?

Fragile X
Tuberous Sclerosis

196

What is Palalia?

Repeating one's own words
Complex phonic tic

197

What is echolalia?

Repeating someone else's words
Coplex phonic tic

198

What is Coprolalia?

Speaking profanity
Complex phonic tic

199

3 "tic" disorders

Tourettes
Chronic motor/vocal tic disorder
Transient tic disorder

200

Tourette's criteria

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.

201

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

202

Criteria for transient tic disorder

Single or multiple vocal and/or motor tics for 4 wks - 1 year (not more). Onset before 18 yoa.

203

What neuroanatomic structures are involved in tics?

Basal ganglia
Corticostriatal thalamocortical abnormality
Reduced caudate volume, increased PFC volume
PET shows hypometabolism and decreased flow to ventral striatum

204

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

205

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)

206

What is habit reversal training?

Patient w/ tic disorder learns to ID premonatory urge and execute other less intrusive movement

207

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

208

What is the normal progression of continence?

Nocturnal fecal -> diurnal fecal -> diurnal bladder -> nocturnal bladder

209

Enuresis criteria

Voiding of urine into bed or clothes 2x / week for 3+ months. At least 5 yoa chronologically or developmentally

210

Primary vs. secondary incontinence

Primary: never achieved continence
Secondary: achieved continence for at least 1 year
-secondary enuresis = regression

211

What disorders are associated w/ enuresis?

ADHD, anxiety, encopresis, developmental delay

212

What is the most successful treatment for enuresis?

Conditioning - enuresis alarm

213

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.

214

By what age is bowel control typically established?

95% by 4, 99% by 5

215

What is the most significant cause of encopresis?

Constipation - inetentional or not- 75% of cases

216

Definition of dementia

Memory impairment + one of:
Aphasia
Apraxia - tasks
Agnosia - recognition (often spurs treatment_
Executive function

217

Of what use is lab work in dementia evaluation?

Rule out reversible cause

218

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

219

What imaging study has highest specificity for Alzheimer's?

MRS: magnetic resonance spectroscopy - identify metabolite levels

220

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

221

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

222

4 common dementias in elderly

Alzheimer's : most common - 2/3 of all
Vascular dementia: second
Lewy Body
Parkinson's related

223

What NT changes are seen in AD?

Cholinergic changes:
-reduced activity of choline acetyltransferase
-reduced number of cholinergic receptors in late AD
-selective loss of nicotinic receptors in hippocampus and cortex

224

Features of LBD

Confusion
Fluctuating cognition w/ increased confusion - nearly diagnostic
Lewy Bodies in cerebral cortex

225

What is Pick's disease?

Most common Frontotemporal Dementia

226

What are features of Frontotemporal Dementia?

Prominent behavior changes
Language disturbances
Focal atrophy on neuroimaging
hypoperfusion precedes structural changes in PET

227

What is the standard pharmacological treatment for dementia?

Early cholinesterase inhibitor + Memantine later in treatment

228

Where are mutations found in familial AD?

Chromosome 21: codes APP
Chromosome 14: codes presenilin 1
Chromosome 1: codes presenilin 2

229

What treatments have targed amyloid and how effective are they?

Secretase inhibitor
Vaccine / immunotherapy

Both encountered problems in clinical trials

230

4 cholinesterase inhibitors

Donepezil
Galantamine
Rivastigmine
Tacrine

231

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.

232

What does a MMSE consist of?

5 parts:
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

233

How is MMSE scored?

24-30: normal
20-23: mild cognitive impairment
10-19: moderate dementia
0-10: severe dementia

234

1st line pharmacalogic for delerium?

Haloperidol
-oral, IV (low risk of EPS), IM
-well studied
-monitor EKG if QTc >450

235

If a causative factor for delerium is ID'd, how long after removal for resolution?

Usually 3-7 days, though up to 2 weeks

236

What is the effect of adding behavioral treatment to medication?

No improvement in symptoms
Improved satisfaction, internalization, social skills, reading achievement, comorbid symptoms

237

3 stages of ADHD pharmacotherapy

1. Titration: optimize dose/ frequency
2. Maintenance: routine monitoring
3. Termination: periodic trials off of meds should be tried.

238

3 first line meds for ADHD

Stimulants
non-stimulants
a-agonists

239

2nd line agents for ADHD

TCA
Buproprion

240

What are contraindications for stimulant use in ADHD?

Hx of substance abuse
Bipolar disorder
Active psychotic disorder

241

What DDIs are of concern w/ stimulant use in ADHD?

MAOI - separate use by 2 weeks to avoid HTN crisis
TCA - synergistic noradrenergic effect

242

Methylphenidate dosing

0.3-0.6 mg/kg

Transdermal: 10mg/ 9 hr for 1 wk, then 15, etc

243

Lisdexamfetamine

d-amphetamine covalently bound to L-lysine. Requires GI hydrolysis for activation.
Marketing - less abuse potential
Retrospective studies - more SE

244

Atomoxetine

Specific NE reuptake inhibitor
ADHD in children >6 (2nd line. 1st if stimulant contraindicated)

2D6 isozyme metabolism

245

Alpha agonists used for ADHD

Guanfacine
Clonidine

IR FORMULATION OFF LABEL USE
ER formulation is FDA approved