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Flashcards in Psych Deck (97):
1

[Psychotic Disorders]
1. Delusions and types
2. Illusions vs hallucinations and types

1. Delusions - fixed, false beliefs against cultural norms and despite evidence to the contrary
- persecutory - most common
- ideas of reference - external stimuli perceived as personal (Eg actor on TV winking at you)
- delusions of control -- thought broadcasting, thought insertion
- delusions of grandeur - special powers
- delusions of guilt
- somatic delusions - disease or illness

2. Illusions vs hallucinations
A. Illusions - misinterpretation of existing stimulus
B. Hallucinations- sensory perception without existing stimulus
- auditory - schizo
- visual - delirium, drugs, alcohol withdrawal
- olfactory - epilepsy
- tactile - drug use, alcohol withdrawal

2

[Psychotic Disorders]
Schizophrenia
1. Types of symptoms
2. Criteria for diagnosis

Schizophrenia
1. Types of symptoms
A. Positive
- delusions
- hallucinations
- disorganized speech e.g. looseness of association, clanging, flight of idea, neologisms
- disorganized behavior e.g. catatonia

B. Negative *most impairment to QOL, most difficult to treat
- apathy / avolition
- anhedonia
- affect (flat)
- alogia
- attention - decreased

C. Cognitive - decreased executive function and working memory
- decreased size of hippocampus and amygdala

2. Criteria for diagnosis - 2+ symptoms (1 must be either delusions, hallucinations, or disorganized speech) for >1 months
- total duration >6 months
- course includes prodromal (decreased functioning), psychotic, and residual (more neg sx)

3

[Psychotic Disorders]
Schizophrenia
3. Pathophysiology via tracts (mesolimbic, mesocotical, nigrostriatal, tubuloinfundibular) and neurotransmitters
4. CT scans

Schizophrenia
3. Pathophysiology
- ↑ dopamine in mesolimbic tract --> psychotic sx
- ↓ dopamine in mesocortical tract (frontal cortex) --> negative sx, poor cognition
- nigrostriatal tract - blocked by antipsychotics --> EPS
- tubuloinfundibular tract - blocked by antipsychotics esp typicals and risperidone --> hyperprolactinemia --> gynecomastia, galactorrhea, sexual dysfunction, menstrual irregularities

- also ↑ serotonin (atypicals also antagonize 5HT)
- ↑ norepi (long-term antipsychotic use decreases norepi levels)
- ↓ GABA (which has regulatory effect on dopamine) in hippocampus
- ↓ glutamate - fewer NMDA receptors *why ketamine (NMDA antagonist) causes psych sx

4. CT shows enlarged ventricles, cortical atrophy, and decreased brain volume

4

[Psychotic Disorders]
Schizophrenia
5. Compare contrast with schizophreniform disorder, brief psychotic disorder

Schizophreniform - symptoms between 1 and 6 months
- 1/3 recover, 2/3 progress to schizophrenia or schizoaffective
tx - 6 months course of antipsychotics, supportive psychotherapy

Brief psychotic disorder - symptoms between 1 day and 1 month, eventual full return to level of functioning
- positive symptoms only (delusions, hallucinations, disorganized speech/ behavior)
- tx - antipsychotics, benzos, supportive psychotherapy

*borderline personality may have transient, stress-related psychotic symptoms but this is not brief psychotic disorder, it's attributed to their underlying personality disorder

5

[Psychotic Disorders]
Delusional disorder
1. Criteria
2. Types
3. Treatment

Delusional disorder - more common after age 40
1. Criteria - 1+ delusions for >1 month
- does not meet criteria for schizophrenia
- no bizarre behavior, functioning not impaired
- usually non-bizarre delusions

2. Types
- erotomanic
- grandiose
- somatic
- persecutory *most common
- jealous
- mixed
- unspecified

3. Treatment - difficult to treat given lack of insight and impairment
- antipsychotics
- supportive therapy but NO groups

6

[Psychotic Disorders]
Culture-specific psychoses
1. Koro
2. Amok
3. Brain fag

1. Koro - anxiety that penis will recede into body, leading to death -- in southeast asia (singapore)

2. Amok - sudden, unprovoked outbursts violence followed by suicide - in malaysia

3. Brain fag - headache, eye pain, fatigue, cognitive difficulties in male students - in Africa

7

[Psychotic Disorders]
Differentiate mood disorder with psychotic features from schizoaffective disorder

Schizoaffective - meet criteria for either major depressive or manic episode during which psychotic symptoms are also present
- but also - delusions or hallucinations for 2 weeks in absence of mood disorder symptoms
- mood sx present for majority of psychotic illness

Mood disorder with psychotic features -- better prognosis, hallucinations and/or delusions present ONLY during depressive or manic episodes
- usually mood congruent e.g. depression --> paranoia, mania --> grandiosity, invincibility
- treat MDD w psychosis --> antidepressant and antipsychotic or ECT
*remember that bipolar I may have psychotic features that occur during depressive OR manic episodes

8

[Mood Disorders]
1. Depressive episode criteria
2. Manic criteria
3. Hypomanic criteria
4. Mixed features

1. Depressive episode criteria - 5 symptoms for 2+ weeks
- depressed / sad mood + 4 SIGECAPS
- anhedonia (loss of interest) + 4 add'l SIGECAPS
SIGECAPS: sleep, interest, guilt/worthlessness, energy/fatigue, concentration, appetite, psychomotor activity (restlessness or slowness), SI

2. Manic criteria - at least 3 symptoms for 1+ week or until hospitalized
- abnormally elevated or irritable mood (if irritable, need 4 symptoms)
DIGFAST - distractibility, insomnia/impulsive behavior, grandiosity, flight of ideas/racing thoughts, activity/agitation, speech (pressured), thoughtlessness
*50% have psychotic features

3. Hypomanic criteria - no marked impairment in functioning *only psych disorder where this is true*
- no psychotic features
- at least 3 symptoms for 4+ days (4 sx if mood is irritable)

4. Mixed features - meet criteria for manic or hypomanic episode and 3+ symptoms of major depressive episode are present for 1+ week
- predominant mood state is irritability
* poorer response to lithium --> give valproic acid

9

[Mood Disorders]
Medical and substance/medication causes of
1. Depressive episode

1. Depressive episode
A. Medical -
- cardiovascular (stroke, MI)
- endocrinopathies (DM, Cushing, Addison, hypoglycemia, thyroid, calcium)
- other - Parkinsons, mono, Carcinoid, SLE
- cancer (lymphoma, pancreatic)

B. Medications
- alcohol
- barbiturates and other sedative hypnotics
- corticosteroids + levodopa (can also cause mania)
- antipsychotics
- anticonvulsants
- beta blockers
- diuretics
- sulfonamides
- withdrawal from stimulants (cocaine, amphetamines)

10

[Mood Disorders]
Medical and substance/medication causes of
2. Manic episode

2. Manic episode
A. Medical
- metabolic (hyperthyroid)
- neuro (MS, temporal lobe seizures)
- HIV

B. Medications --> bipolar
- antidepressants
- sympathomimetics
- dopamine
- corticosteroids (can also cause depression)
- levodopa (can also cause depression)
- bronchodilators
- cocaine
- amphetamines

11

[Mood Disorders]
Major depressive disorder (MDD)
1. Criteria
2. Sleep problems
3. Etiology
4. Treatment

Major depressive disorder
1. Criteria - at least one major depressive episode, no hx of mania/hypomania

2. Sleep problems
- multiple awakenings
- initial and terminal insomnia (hard to fall asleep, early morning awakening) *most common problems*
- decreased REM sleep latency, earlier cycles and longer duration
- decreased slow wave (3 and 4) sleep

3. Etiology - neurotransmitters (Decreased serotonin, 5HIAA - main 5HT metabolite- in CSF)
- HPA axis hyperactivity --> increased cortisol
- abnormal thyroid axis
- multiple adverse childhood events eg loss of parent
- genetics

4. Treatment - CBT and SSRI, try for 6- 8 weeks before another SNRI/SSRI, then another MOA (bupropion, mirtazapine)
- continuation phase tx - continue antidepressants for addl 6 months with single episode, unipolar major depression
- maintenance tx - 1-3 years for history of recurrent MDD, -
chronic (>2 years), family hx, or severe episodes
maintenance tx indefinitely - history of highly recurrent or very severe chronic MDD episodes
- hospitalization if risk for SI/HI, can't take care of themself

12

[Mood Disorders]
Describe ECT
1. Indications
2. Contraindications
3. Procedure
4. Side effects

Electroconvulsive therapy

1. Indications
- MDD - treatment resistant or w psychotic features
- acute mania
- pregnant
- emergency conditions (not eating/drinking, catatonic, actively suicidal)

2. Contraindications - none!
- relative c/i: recent MI or stroke, space-occupying brain lesion, unstably aneurysm

3. Procedure
- atropine, then general anesthesia with methohexital, then muscle relaxant succinylcholine
- induce generalized tonic clonic seizure for 30-60 sec
- 12 treatments over 3 week period or so
- d/c after symptomatic improvement, but can have monthly maintenance ECT

4. Side effects
- retrograde and anterograde amnesia, resolves within 6 months
- also headache, nausea, muscle soreness

*1st line tx for MDD w psychotic features = ECT or antipsychotic + antidepressant

13

[Mood Disorders]
Major depressive disorder
Specifiers -
1. Atypical
2. Melancholic
3. Mixed
4. Catatonia
5. Psychotic
6. Anxious distress
7. Postpartum
8. Seasonal

1. Atypical - hypersomnia, hyperphagia, reactive mood (mood brightens in response to positive events), leaden paralysis, hypersensitivity to interpersonal rejection

2. Melancholic - anhedonia, depression worse in AM, anorexia, excessive guilt

3. Mixed - manic/hypomanic symptoms present during major depressive episode

4. Catatonia - catalepsy (immobility), mutism, bizarre postures, echolalia; give ECT or benzos (lorazepam challenge test --> temporary relief w/in 10 min)

5. Psychotic - delusions/hallucinations

6. Anxious distress - restless, fearful, feeling of loss of control

7. Postpartum - during or within 4 weeks of pregnancy (as opposed to postpartum blues - which resolves w/in 2 weeks)
*give sertraline bc lowest transfer rate to infant

8. Seasonal - irritability, carb craving, and hypersomnia

14

[Mood Disorders]
Bipolar I
1. Criteria
2. Etiology
3. Treatment

Bipolar 1
1. Criteria - manic episode is only requirement (3+ DIGFAST symptoms for at least one week)
- do not need major depressive episode
- can have psychotic features (delusions/hallucinations)

2. Etiology - M=F, onset before 30
- highest genetic link of all major psychiatric disorders
- high suicide risk
- 90% have repeat episode w/in 5 years

3. Treatment - untreated --> lasts months
- pharmacotherapy -
* mood stabilizer (e.g. lithium)
*anticonvulsants (Carbamazepine, valproic acid)
*atypical antipsychotics (for acute mania; use for 6 weeks until Lithium kicks in)
*do NOT give antidepressants, may precipitate mania

- bipolar depression -- quetiapine, lurasidone, lamotrigine
- psychotherapy
- ECT for acute mania

15

[Mood Disorders]
Bipolar II
1. Criteria
2. Etiology
3. Treatment

Bipolar II
1. Criteria - 1+ major depressive episodes and at least one hypomanic episode
*if there is any full manic episode --> automatically bipolar I disorder

2. Etiology - same etiology as bipolar I
- better prognosis than bipolar I

3. Treatment - same as bipolar I
- bipolar depression -- quetiapine, lurasidone, lamotrigine

16

[Mood Disorder]
Criteria for:
1. Dysthymia
2. Cyclothymic disorder

1. Dysthymia
- at least 2 years of depressed mood (1 year in children)
- at least 2 of the following: poor concentration, hopelessness, poor or too much appetite, insomnia/hypersomnia, fatigue, low self-esteem
- never asymptomatic for >2 months
- many also meet criteria for MDD but can not have had manic/hypomanic episode (bipolar/cyclothymic respectively)

2. Cyclothymic disorder
- at least two years of alternating hypomanic symptoms (but not full hypomanic episode) and depressive symptoms (but not full MDE)
- never asymptomatic for >2 months
- no MDE, hypomanic, or manic episode
*may coexist with borderline personality disorder
*1/3 develop bipolar disorder

17

[Mood Disorder]
Criteria for:
3. Premenstrual dysphoric disorder
4. Disruptive mood regulation disorder (DMDD)

3. Premenstrual dysphoric disorder
- 5+ symptoms in the final week before menses and absent by the week postmenses:
* 1+ is affective lability, irritability, depressed mood, anxiety
* 1+ is anhedonia, anergia, appetite changes, hypersomnia/insomnia, overwhelmed, physical (breast tenderness, joint pain, bloating, weight gain)
- symptoms cause distress/impairment
- treatment: keep menstrual diary, exercise, stress reduction, SSRI (eg fluoxetine)

4. Disruptive mood regulation disorder (DMDD) - severe, persistent irritability in childhood and adolescence
- symptoms before age 10, can be diagnosed from ages 6-18
- 2+ settings (home school peers)
- at least 3 verbal and/or physical outbursts per week
- mood bw outbursts is angry/irritable
- symptoms for at least 1 year, no more than 3 months without symptoms
*cannot coexist with oppositional defiant disorder, intermittent explosive disorder, or bipolar disorder

18

Treatment for EPS:
1. Acute dystonia
2. Akathisia
3. Parkinsonism
4. Tardive dyskinesia

EPS - eps with typical antipsychotics (bc of decreased dopamine in nigrostriatal tract)

1. Acute dystonia (muscle spasms/stiffness, torticollis, oculogyric crisis, grimacing) - hours to days --> treat with anticholinergics (e.g. benztropine, diphenhydramine)

2. Akathisia (subjective feeling of restlessness) - days to weeks --> Treat with propranolol, benzos (lorazepam), or benztropine and lower antipsychotic dosage (since it is dose-dependent)

3. Parkinsonism (masklike face, bradykinesia, pill-rolling tremor, cog-wheel rigidity)- days to weeks --> treat with benztropine, amantadine

4. Tardive dyskinesia - (months to years of prolonged therapy, can also appear following dose discontinuation or reduction)
- due to D2 receptor upregulation and supersensitivity following chronic blockade
- irreversible, no definitive treatment, but switch to clozapine may help (least likely to cause EPS), along with Vitamin E or botox

*NMS can occur at any time, usually early on in treatment

19

[Anxiety Disorders]
1. Define pathologic anxiety, signs/sx
2. Substance / medication causes
3. Medical causes
4. Treatment

1. Pathologic anxiety - excessive, irrational, out of proportion to trigger or without trigger
- SOB, chest pain, palpitations, HTN, vertigo, tremors, n/v, stomach pain, diarrhea/constipation

2. Substance / medication causes
A. Withdrawal - sedative-hypnotics (benzos, barbs)
B. Intoxication - marijuana, hallucinogens (PCP, LSD, MDMA), caffeine, opioids
C. Withdrawal and intoxication - stimulants (cocaine), tobacco

3. Medical causes -
- neurologic (brain tumors, MS, HD, epilepsy, migraines)
- endocrine (carcinoid, pheo, hypoglycemia, hyperthyroid)
- metabolic (B12 deficiency, porphyria)
- respiratory (COPD, asthma, PE, pnuemonia)
- cardiovascular (CHF, arrhythmia, MI)

4. Treatment
- first-line - SSRIs, SNRIs
- also benzos, diphenydramine, hydroxyzine - for prn use
*benzos may worsen depression in comorbid MDD
- buspirone (5HT1 partial agonist) - for augmentation
- beta blockers - to control autonomic sx for panic attacks, performance anxiety

20

[Anxiety Disorders]
Criteria and treatment for:
1. Panic disorder
2. Generalized anxiety disorder

1. Panic disorder
A. Criteria - 1+ spontaneous, recurrent panic attacks without trigger followed by 1+ month of continuous worry about experiencing subsequent attacks and/or change in behavior (avoidance)
- panic attack: Da PANICS (dizziness, disconnectedness, derealization/depersonalization, palpitations/paresthesias, abdominal distress, numbness, intense fear of dying, chills/chest pain, sweating/SOB)
- comorbid with MDD and other anxiety disorders esp agoraphobia
- decreased volume of amygdalaa
B. Treatment - SSRIs and CBT
- TCAs are second line
- benzos (lorazepam ie Ativan) for prn or as bridge until long-term meds are effective
- give propranolol for treating autonomic effects of panic attacks (also performance anxiety or akathisia)
- screen for suicide risk
*increased sensitivity to lactate infusion (Causes panic sx)

2. Generalized anxiety disorder
A. Criteria - excessive anxiety/worry about various events for at least 6 months with 3+ symptoms: WARTS (wound-up, worn-out, absent-minded, restless, tense, sleepless)
- comorbid with anxiety/depressive disorders
- begins ~30 years old
B. Treatment - CBT, SSRI/SNRI, short-term benzos, augment with buspirone, exercise

21

[Anxiety Disorders]
Criteria and treatment for:
3. Agoraphobia
4. Phobias / social anxiety disorder

3. Agoraphobia
A. Criteria - intense fear/anxiety about 2+ situations due to fear of difficulty escaping e.g. bridges, crowds, buses/trains, open areas for >6 months
- fear/anxiety out of proportion to potential danger posed
- significant impairment
- frequently following traumatic event, 50% have panic attack prior to onset
B. Treatment - CBT and SSRIs

4. Phobias / social anxiety disorder
A. Criteria - >6 months irrational fear that leads to avoidance of trigger or endurance of anxiety
- specific phobia: environmental, animal, situational, blood/injection
- social anxiety phobia - fear of scrutiny by others or of negative evaluation e.g. public speaking
*most common psych disorder in women, 2nd MC in men (substance is 1st)
B. Treatment - behavioral therapy (systematic desensitization) is first line
- for social anxiety disorder, can give SSRIs (fluoxetine)
- beta blockers (propranolol) for performance anxiety subtype of social anxiety disorder

22

[Anxiety Disorders]
Criteria and treatment for:
5. Selective mutism
6. Separation anxiety disorder

5. Selective mutism
A. Criteria - failure to speak in specific situations, despite speech ability in other situations, for at least 1 month (extending beyond 1st month of school)
- starts in childhood, suffering from anxiety
B. Treatment - CBT, family therapy, SSRIs for comorbid social anxiety disorder

6. Separation anxiety disorder
A. Criteria - >1 month in children, >6 months in adults developmentally inappropriate fear/anxiety re separation from attachment figures with at least 3:
- worry about loss of figures
- reluctance to leave home, be alone, sleep alone
- physical symptoms when separated
- nightmares
*normal devlpt: stranger anxiety (~6-9 mos), separation anxiety (12-18 mos)
B. Treatment - CBT, family therapy, SSRIs

23

Triad of uncontrollable urges seen in children or adolescents

OCD, ADHD, tic disorder

24

[Anxiety Disorders]
Criteria and treatment for:
1. OCD

1. OCD
A. Criteria - obsessions and/or compulsions that are time-consuming (>1 hour/day) or cause significant distress

- obsessions - intrusive, anxiety-provoking thoughts or urges that the patient attempts to suppress, ignore, or neutralize by performing a compulsion e.g. contamination, harm/doubt, symmetry, intrusive taboo thoughts (sexual, violent)
- compulsions - repetitive behaviors or mental acts that the patient feels driven to perform e.g. cleaning, checking, ordering/counting

B. Course - mean age of onset 20 years old
- genetic component
- suicidal ideation in 50%
- structural abnormalities and increased activity of orbitofrontal cortex and caudate nucleus (dorsal striatum of the basal ganglia)

C. Treatment - combo of psychopharm + CBT
- psychopharm - SSRIs at higher doses for longer period (8-12 weeks)
- can also use clomipramine, augment with atypicals
- use cingulotomy for treatment resistant
- CBT - exposure and response prevention

25

[Anxiety Disorders]
Criteria and treatment for:
2. Body dysmorphic disorder
3. Hoarding disorder

2. Body dysmorphic disorder
A. Criteria - preoccupation with perceived defects in physical appearance not observable by others that they try to cover up with makeup, derm procedures, plastic surgery
- repetitive behaviors (grooming, skin picking) or mental acts (comparing appearance) performed in response
- significant distress or impairment
- increased prevalence with childhood abuse and neglect
B. Treatment - SSRIs or CBT to reduces OCD symptoms

3. Hoarding disorder
A. Criteria - persistent difficulty and distress discarding possessions, regardless of value
- impairment in social, occupational other areas of functioning
- begins in early teens but more prevalent in older pts, 3/4 have comorbid MDD or anxiety
B. Treatment - specialized CBT, don't need SSRI unless they also have OCD symptoms

26

[Anxiety Disorders]
Criteria and treatment for:
4. Trichotillomania
5. Excoriation disorder

4. Trichotillomania
A. Criteria - recurrent pulling of ones hair, repeated attempts to stop
- associated with stressful event, onset at puberty
B. Treatment - SSRIs, atypicals, N-acetylcysteine, lithium
- CBT (habit reversal training)

5. Excoriation disorder
A. Criteria - recurrent skin picking resulting in lesions, repeated attempts to stop
- mostly women
B. Treatment - habit reversal training, SSRIs

27

[Anxiety Disorders]
Criteria and treatment for
6. Acute stress disorder, PTSD

6. Acute stress disorder, PTSD
A. Criteria
- recurrent intrusions of reexperiencing event via nightmares, memories, dissociation (e.g. flashbacks)
- active avoidance of triggering
- 2+ of the following negative mood: dissociative amnesia (e.g. forgetting info about own life), negative feelings (fear, anger), self-blame, anhedonia, detachment
- 2+ of increased arousal: hypervigilance, startle, impaired concentration, insomnia

Acute stress disorder - trauma occurred <1 month ago, symptoms last <1 month
PTSD - trauma occurred any time in the past, symptoms last >1 month
- decreased volume of hippocampus

B. Treatment - SSRIs or SNRIs are first line along with trauma-focused CBT (exposure)
- prazosin for nightmares and paranoia
- augment with atypicals
*avoid benzos bc high rate of comorbid substance use disorder

28

[Anxiety Disorders]
Criteria and treatment for
7. Adjustment disorder

7. Adjustment disorder

A. Criteria - development of marked distress in excess of what would be expected within 3 months of identifiable stressful life event (not life-threatening --> PTSD)
- resolve within 6 months after stressor has terminated
- subtypes - depressed mood, anxiety, disturbance of conduct (eg aggression), mixed
- does not meet criteria for MDD or another disorder

B. Treatment - supportive psychotherapy *most effective*
- group therapy, pharmacotherapy
*may be chronic if stressor is chronic or recurrent

29

[Personality Disorders]
1. Criteria
2. Clusters
3. Treatment

Personality disorders
1. Criteria - pervasive, inflexible, maladaptive behavior/inner experience that deviates from culture and manifests in 2+ ways:
*cognition e.g. orphan annie
*affectivity e.g. john mcenroe
*interpersonal functioning e.g. elizabeth taylor
* impulse control e.g. lindsay lohan
- stable, onset during adolescence / early adulthood --> diagnose after age 18
- ego-syntonic (pts lack insight)

2. Clusters
Cluster A - Weird
- schizotypal, schizoid, paranoid
Clubster B - Wild
- borderline, antisocial, histrionic, narcissistic
Cluster C - Worried
- avoidant, dependent, OCPD

3. Treatment - psychotherapy e.g. CBT except borderline --> DBT

30

[Personality Disorders]
Cluster A
1. Paranoid

Cluster A
1. Paranoid - pervasive distrust and suspiciousness of others and blame problems on others with 4+ of following:
- suspicion others are cheating them
- preoccupation with loyalty
- reluctance to confide in others
- holds grudges
- perception of attacks on character
- think spouse is cheating on them (pathologically jealous)

defense mechanism --> projection
*can have transient psychosis under stressful situations
*avoid group psychotherapy

31

[Personality Disorders]
Cluster A
2. Schizoid

2. Schizoid - voluntary social withdrawal with 4+ of the following:
- no desire for close relationships
- likes solitary activities
- no interest in sex
- few if any hobbies, friends, or confidants
- indifference to praise or criticism
- flattened affect, detachment, emotional coldness

defense mechanism --> fantasy

32

[Personality Disorders]
Cluster A
3. Schizotypal

3. Schizotypal - eccentric behavior with 5+ of the following:
- ideas of reference - external stimuli perceived as personal (Eg actor on TV winking at you)
- magical thinking (bizarre fantasies, belief in telepathy, superstitions)
- suspiciousness
- unusual perceptual experiences
- odd or eccentric appearance, behavior (cults, strange religious practices)
- excessive social anxiety

33

[Personality Disorders]
Cluster B
1. Antisocial

1. Antisocial - violates rights of others since age of 15, must be 18+ to diagnose with 3+ of the following:
- unlawful acts
- deceitful, lying, manipulating others for personal gain
- lack of remorse for actions
- aggressiveness / repeated fights
- impulsivity
- irresponsibility
- disregard for safety of self or others
- onset of conduct disorder before 15

defense mechanism --> acting out

*psychopath
*more common in men with alcoholic parents
*psychotherapy ineffective

34

[Personality Disorders]
Cluster B
2. Borderline

2. Borderline - unstable relationships, affects, and behaviors with 5+ of the following:
- efforts to avoid abandonment
- unstable, intense personal relationships (likes bad boys)
- unstable self-image
- impulsive (sex, substance use, binge eating, spending)
- unstable affect / mood reactivity --> rapid mood swings
- recurrent suicidal threats or attempts
- feeling of emptiness
- inappropriate anger
- paranoid under stress --> brief psychotic episodes

defense mechanism --> splitting
*F>M, culturally bound (max in USA)
*pharmacotherapy is most useful here (SSRI and antipsychotics), also DBT (NOT CBT)
*borderline of neurosis and psychosis

35

[Personality Disorders]
Cluster B
3. Histrionic

3. Histrionic - excessive emotionality and attention-seeking with 5+ of the following:
- seductive / provocative
- center of attention
- uses physical appearance to get attention
- theatrical emotions
- easily influenced by others
- perceives relationships as more intimate than they really are

defense mechanisms - dissociation, regression

*generally more functional than borderline
*countertransference - feel bad for histrionic, mad at narcissistic

36

[Personality Disorders]
Cluster B
4. Narcissistic

4. Narcissistic - grandiosity, arrogance, and sense of superiority with 5+ of the following:
- exaggerated sense of self-importance
- preoccupation with fantasies of success, money
- belief that they are special and others are not
- requires admiration / recognition --> get depressed otherwise
- entitlement
- takes advantage of others for self-gain
- lacks empathy
- envious of others or believes others are envious of him

defense mechanism --> denial

Narcissistic = antisocial (lack of empathy, manipulation) + histrionic (need for admiration)
*both antisocial and narcissistic exploit others, but latter want status/recognition while former want material gain
*both histrionic and narcissistic want admiration, but latter make you mad while former make you pity them

37

[Personality Disorders]
Cluster C
1. Avoidant

1. Avoidant - extreme shyness and intense fear of rejection with 4+ of the following: (AFRAID)
- avoids occupation with others
- fear of embarrassment and criticism
- reserved unless certain of being liked
- always thinking rejection
- isolates / cautious of interpersonal relationships
- distanced / inhibited in new social situations bc of feeling inadequate

defense mechanism --> regression

*similar to social anxiety disorder but that involves fear of embarrassment in particular settings e.g. speaking in public, whereas avoidant is overall fear of rejection, and feeling of inadequacy

38

[Personality Disorders]
Cluster C
2. Dependent

2. Dependent - fear of separation and clingy behavior with 5+ of the following:
- difficulty making everyday decisions without reassurance
- won't disagree bc of fear of loss of approval
- needs others to assume responsibilities of life
- feels helpless when alone
- urgently seeks relationships
- preoccupied with fears of having to take care of self

*usually have one long-lasting dependent relationship, borderline and histrionic are also dependent but unable to maintain long-lasting relationships
*like histrionic, defense mechanism is regression
*difficulty with employment since they can't act independently

39

[Personality Disorders]
Cluster C
3. OCPD

3. OCPD - preoccupation with perfection and control in variety of contexts with 4+ of the following:
- preoccupation with details, lists, rules, organization
- perfectionism detrimental to completion of task
- excessive devotion to work
- will not delegate tasks
- unable to discard worthless objects
- miserly spending style
- rigid and stubborn
- excessive scrupulousness about morals/ethics

*OCPD is ego-syntonic, OCD is ego-dystonic (aware they have a problem)
*no mention of obsessions or compulsions in OCPD

40

[Substance Use Disorders]
MOA, Detection, Intoxication, and Withdrawal + treatment options:
1. Alcohol

1. Alcohol - CNS depressant

A. MOA
- activates GABA, dopamine, and serotonin receptors
- inhibits glutamate receptors, Ca2+ channels
alcohol (alcohol DH)--> Acetaldehyde (aldehyde DH) --> acetic acid

B. Detection - blood/urine testing, stays in blood for few hours; increases MCV and LFTs (AST>>ALT)

C. Intoxication - presentation based on BAL
20-50 --> decreased motor control
50-100 --> impaired judgment, coordination
100-150 --> ataxic gait
150-250 --> lethargy, n/v, memory problems
250+ --> respiratory depression, coma

D. Withdrawal - can be lethal
- 6-24 hours: irritability, insomnia, anxiety, tremor, n/v, autonomic (sweating, tachy, HTN), fever/flushed
- 12-48 hours: seizures
- 48-96 hours: delirium tremens (increased RR, HR, BP, visual and tactile hallucinations, agitation, disorientation, tremor and hyperreflexia)

41

[Substance Use Disorders]
Treatment for
1. alcohol withdrawal
2. alcohol use disorder

1. Alcohol withdrawal
- treat with benzos (chlodiazepoxide, lorazepam) and taper
- can treat symptoms (Tremor, BP, sweating) with clonidine
- antipsychotics for severe agitation
- thiamine, folic acid, multivitamins *correct hypomagnesemia

2. Alcohol use disorder
A. naltrexone - opioid receptor blocker that decreases cravings and "high" BUT will precipitate opioid withdrawal in addicted pts
- can be started while the patient is still drinking
- c/i in pts with acute hepatitis, liver failure

B. acamprosate - modulates glutamate transmission; used in pts who have stopped drinking --> post-detox for relapse prevention
*can be used in pts with liver disease but c/i in severe renal disease

C. Second-line
- disulfiram (blocks aldehyde DH enzyme) and causes flushing, n/v, headache --> use in highly motivated patients
- c/i in pregnancy, cardiac disease, psychosis
- monitor liver function

- topiramate (potentiates GABA, inhibits glutamate) - reduces cravings and decreases alcohol use

42

[Substance Use Disorders]
MOA, Detection, Intoxication, and Withdrawal + treatment options:
2. Cocaine

2. Cocaine - CNS stimulant

A. MOA - blocks reuptake of dopamine, epi, and norepi from synaptic cleft

B. Detection - UDS (+) for 2-4 days

C. Intoxication - euphoria, SNS activation (mydriasis, chills, tremors, sweating / hyperthermia)
- psychosis due to increased dopa (hallucinations either tactile e.g. formication or visual, paranoia)
*paradoxical effects - high or low BP, pulse, or psychomotor
*what can kill you --> MI, intracranial hemorrhage, stroke, arrhythmias, seizures, respiratory depression
*clinically indistinguishable from panic attack or MI

D. Withdrawal - not life threatening
- acute onset depression "cocaine crash" - constricted pupils, hunger, depression with potential SI, vivid and unpleasant dreams, fatigue

43

[Substance Use Disorders]
MOA, Detection, Intoxication, and Withdrawal + treatment options:
3. Amphetamines

3. Amphetamines - CNS stimulant

A. MOA
i. Classic - block reuptake, facilitate release of dopamine, norepi from nerve endings e.g. Ritalin (methylphenidate), methamphetamine
ii. Club drugs - release dopa, norepi AND 5-HT from nerve endings e.g. MDMA (Ecstasy) *stimulant and hallucinogen; can lead to serotonin syndrome if combined with SSRIs

B. Detection - UDS (+) for 1-3 days, but MDMA not detected on routine tox screen

C. Intoxication - mydriasis, euphoria, tachycardia, sweating, grinding teeth, skin picking (excoriation), chest pain, dehydration (from dancing in da club), rhabdo/renal failure
*meth makes you violent, psychotic (paranoid); ecstasy makes you euphoric, social, sexual and gives you bruxism, trismus
- chronic use --> psychosis, tooth decay ("meth mouth")

D. Withdrawal - crash with headache, hunger, depression, cravings *similar to cocaine*

D. Treatment
- for intoxication -- rehydrate, correct hyperthermia
- supportive for withdrawal

44

[Substance Use Disorders]
MOA, Detection, Intoxication, and Withdrawal + treatment options:
4. PCP

4. PCP - can be CNS stimulant or depressant depending on dosage

A. MOA - NMDA receptor antagonist, dopamine D2R agonist
- bath salts are similar but PCP has bath salts (eg derealization, dissociation) + stimulant effects (panic attack)

B. UDS (+) up to one week, increased CPK, AST

C. Intoxication
- nystagmus and mydriasis, ataxia
- rage / violence and high tolerance to pain
- hallucinations (visual, tactile), delusions, synesthesia
- skin dryness / erythema, muscle rigidity
- OD can cause delirium, seizures, coma, death

D. Treatment
- lorazepam for agitation, anxiety, muscle spasms, seizures
- haloperidol for severe agitation, delusions/hallucinations

E. Withdrawal - no withdrawal but you can have flashbacks for a while after, due to release of drug from lipid stores

45

[Substance Use Disorders]
MOA, Detection, Intoxication, and Withdrawal + treatment options:
5. Sedative-hypnotics

5. Sedative-hypnotics - CNS depressants

A. MOA - potentiate GABA
- Benzos - increase frequency of GABA opening
- Barbs - increase duration of GABA opening
*benzos and barbs are synergistic

B. Detection - in urine/blood for up to 3 weeks for long-acting barbs, up to 4 weeks for long-acting benzos (diazepam)

C. Intoxication - drowsiness, hypotension, slurred speech, ataxia, mood lability, impaired judgment, respiratory depression
*synergistic with EtOH, opioids (how people die)
- treatment - (barbs) alkalinize urine with sodium bicarb for renal excretion; (benzos) - flumazenil, but may cause seizures so first thing to do is d/c benzo

D. Withdrawal - life-threatening!! same as alcohol withdrawal, except occur days later than ETOH w/d and not significant increase in BP/pulse
- early rebound insomnia and increased anxiety
- treat with benzo taper

46

[Substance Use Disorders]
MOA, Detection, Intoxication, and Withdrawal + treatment options:
6. Opioids

6. Opioids - oxycodone (oxycontin), Vicodin, Percocet, heroin, codeine, dextromethorphan (higher dose --> glutamate), morphine, meperidine (demerol)

A. MOA - stimulate mu, kappa, delta opiate receptors --> anelgesia, sedation, dependence

B. Detection - UDS (+) for 1-3 days BUT methadone / oxycodone will not show up

C. Intoxication - miosis (except demerol which dilates), constipation, n/v, drowsiness, respiratory depression, seizures
- demerol, tramadol, MAOIs can cause serotonin syndrome
- give naloxone

D. Withdrawal - not life-threatening, indistinguishable from the flu --> TGIFRIDAYS:
three sx
GI (n/v)
fever
rhinorrhea/lacrimation
insomnia
dysphoria
arthralgias
yawning
sympathetic arousal (piloerection, sweating, tremor, dilated pupils)
- treat symptomatically with clonidine (can be used for heroin detox), hydroxyzine, NSAIDs, dicyclomine, zofran

E. Treatment
- methadone (long-acting agonist) - QTc prolongation --> do screening ECG
*for opiate addicted pregnant women
- buprenorphine (partial agonist) - safer bc it plateus, comes as Suboxone (adds naloxone)
- naltrexone (competitive antagonist) - good for highly motivated patients, can precipitate withdrawal w/in 1 week of heroin use

47

[Substance Use Disorders]
MOA, Detection, Intoxication, and Withdrawal + treatment options:
7. Hallucinogens

*increase BMI with normal waist circumference --> what should you think of?

7. Hallucinogens - shrooms, LSD (acid), peyote

A. MOA - LSD acts on serotonin system --> agonist at 5HT2A receptors

B. Detection - does not show up on tox screens (UDS, blood)

C. Intoxication - depression, anxiety, psychosis
- perceptual changes (hallucinations/illusions, synthesia), labile affect, dilated pupils, HTN, tachy, tremors, sweating, palpitations
- bad trip - panic, anxiety, psychotic sx (paranoia)
- tx - benzos, reassurance

D. Withdrawal - no physical dependence or withdrawal; long-term LSD use can cause spontaneous flashbacks later in life

*increase BMI with normal waist circumference --> increase muscle mass from anabolic steroids
- also gynecomastia, testicular atrophy, acne, roid rage

48

[Substance Use Disorders]
MOA, Detection, Intoxication, and Withdrawal + treatment options:
8. Marijuana

8. Marijuana

A. MOA - THC activates cannabinoid receptors that inhibit adenylate cyclase

B. Detection - UDS (+) 3 days after single use, 4 weeks in long-term users

C. Intoxication - euphoria, anxiety, perceptual disturbances (slowed time), red eyes, cotton mouth, munchies
- can induce paranoia, hallucinations, delusions
- chronic use --> asthma, immune suppression

D. Withdrawal - anxiety, restlessness, aggression, strange dreams, depression, sweating, chills, insomnia, decreased appetite
- tx is supportive and symptomatic

49

[Substance Use Disorders]
MOA, Detection, Intoxication, and Withdrawal + treatment options:
9. Inhalants
10. Caffeine
11. Nicotine

9. Inhalants - CNS depressants e.g. paint thinner, solvents, glue, whippets, nitrous oxide
A. MOA - N/A
C. Intoxication - paranoia, perceptual disturbances, dizziness, n/v, headache, neurological sequlae (nystagmus, hyporeflexia), hypoxia, stupor --> quick! lasts 15-30 min
- long-term use can cause permanent CNS damage (paralysis), myopathy, cancer, myocarditis, etc
D. Withdrawal - doesnt occur
*adolescent male whose parents say has been acting bizarrely and hasn't left his room for months --> nitrous oxide causes erections

10. Caffeine
A. MOA - adenosine antagonist --> increased cAMP
C. Intoxication - anxiety, insomnia, muscle twitching, diuresis, tachycardia
- OD --> tinnitus, agitation, cardiac arrhythmias, seizures
*differentiate from cocaine intoxication via facial flushing, GI (diarrhea/cramping); do NOT cause psychosis / aggression (only one along with nicotine that does not)
D. Withdrawal - headache, fatigue, irritability --> resolves w/in 2 weeks

11. Nicotine
A. MOA - stimulates nicotinic receptors in autonomic SNS and PSNS ganglia -- dopaminergic
C. Intoxication - insomnia, anxiety, GI motility
D. Withdrawal - cravings, anxiety, appetite, irritability
E. Treatment - varenicline (nAChR agonist) to reduce the high
- buproprion (inhibits dopa, norepi reuptake) to reduce craving

50

[Neurocognitive Disorders]
Clinical presentation, diagnosis, and treatment of:
1. Delirium

1. Delirium i.e. toxic metabolic encephalopathy, acute organic brain syndrome, acute toxic psychosis

A. Clinical - based on psychomotor activity
i. hypoactive - more common in elderly, presents as depression
ii. hyperactive (ICU psychosis)- agitation, mood lability, due to drug w/d or tox, presents as mania
iii. mixed

B. Diagnosis - decreased attention / awareness of acute onset with fluctuating course (waxing and waning) and disorganized thinking or altered consciousness
- perceptual disturbances (visual hallucinations)
- circadian rhythm disturbance
- do fingerstick, pulseox, ABG, EKG, UDS/UA, CBC/CMP

C. Treatment - treat underlying causes
- give haloperidol for agitation (decreased risk of anticholinergic side effects)
- do not give benzos which worsen delirium, except for treating alcohol withdrawal

*ICU triad = delirium, pain, agitation

51

[Neurocognitive Disorders]
Clinical presentation, diagnosis, and treatment of:
2. Alzheimer's

2. Alzheimer Disease

A. Clinical - insidious onset and subsequent gradual progressive decline in cognitive (memory, learning, language)
- personality changes, mood swings, paranoia
- getting lost in familiar places
- family is more concerned than the patient
- motor/sensory affected in late stage (death ~10 yrs post diagnosis)

B. Diagnosis -
definitely only postmortem --> extraneuronal Beta amyloid plaques and intraneuronal neurofibrillary tau tangles and progressive widespread cortical atrophy
- decreased ACh
- single gene (APP, presinilin 1 or 2) AD inheritance
- E4 is risk factor, so is Down syndrome

C. Treatment - no cure
- cholinesterase inhibitors donepezil, rivastigmine, galantamine
- NMDA receptor antagonist memantine
- antipsychotics for agitation, but associated with increased mortality

52

[Neurocognitive Disorders]
Clinical presentation, diagnosis, and treatment of:
3. Vascular dementia
4. Parkinsons

3. Vascular dementia
A. Clinical - stepwise deterioration that affects complex attention and executive functions (planning, decision-making)
- due to micro-infarcts
B. Diagnosis - evidence of vascular disease (TIAs, HTN)
- large vessel strokes (cortical)
- small vessel strokes (lacunar infarcts to subcortical)
- microvascular disease (periventricular white matter)
C. Treatment - manage risk factors to prevent future strokes

4. Parkinson's disease - degenerative disorder due to loss of dopaminergic neurons in substantia nigra and alpha-synuclein Lewy bodies
A. Clinical - TRAP, visual hallucinations, depression, apathy, paranoid delusions
B. Diagnosis - cognitive decline after motor symptoms
C. Treatment - carbidopa-levodopa and dopamine agonists
- reduce dose or give quetiapine or clozapine if psychotic symptoms arise

53

[Neurocognitive Disorders]
Clinical presentation, diagnosis, and treatment of:
5. Lewy Body dementia

5. Lewy Body dementia

A. Clinical - progressive cognitive decline
i. core features
- waxing waning cognition (attention, alertness)
- visual hallucinations (animals, small people) *don't treat if it doesn't bother patient or caregiver*
- devlpt of EPS at least one year after cognitive decline
ii. suggestive features
- REM sleep behavior disorder (violent movements in sleep eg fighting)
- antipsychotic sensitivity *avoid antipsychotics --> increased sensitivity to EPS

B. Diagnosis - definitively only postmortem
- intraneuronal Lewy bodies (alpha synuclein aggregates) in basal ganglia

C. Treatment - no cure
- cholinesterase inhibitors
- quetiapine or clozapine for psychotic symptoms, monitor for EPS and NMS *short dose for short period
- levodopa-carbidopa for Parkinsonism
- melatonin and clonazepam for REM sleep behavior disorder

54

[Neurocognitive Disorders]
Clinical presentation, diagnosis, and treatment of:
6. Frontotemporal dementia
7. Normal pressure hydrocephalus

6. Frontotemporal dementia
A. Clinical - deficits in attention, abstraction, planning, problem solving; spares memory and motor function
i. behavioral type - disinhibition, overeating, decline in executive abilities, perseveration, lack of sympathy, apathy
ii. language variant - primary progressive aphasia
*increased antipsychotic sensitivity (like with Lewy body)
B. Diagnosis - definitively only postmortem --> atrophy of frontal and temporal lobes
- presents bw 45 and 65
C. Treatment - serotonergic (SSRIs, trazodone) to reduce disinhibition, anxiety, impulsivity, repetitive behaviors, eating disorders

*HIV infection can also affect executive functioning (CD4 <200)

7. NPH
A. Clinical - wet, wobbly, wacky
B. Diagnosis - enlargement of ventricles out of proportion to cortical atrophy; clinical improvement with CSF removal via lumbar puncture
C. Treatment - ventriculoperitoneal shunt
- cognitive impairment least likely to improve

55

[Neurocognitive Disorders]
Clinical presentation, diagnosis, and treatment of:
8. Huntington's disease
9. Prion disease

8. Huntington's disease
A. Clinical - motor (chorea, bradykinesia), cognitive (executive function), psychiatric sx (depression, impulsivity, irritability, obsessions)
- increased rate of suicide
B. Diagnosis - CAG repeats encoding Huntington protein, AD inheritance (Avg age of onset = 40)
C. Treatment - symptom directed --> tetrabenazine or SGAs (atypicals)

9. Prion disease
A. Clinical - rapidly progressive cognitive decline; difficulties with concentration, memory, judgment
- myoclonus (startle reflex), akinetic mutism
- basal ganglia and cerebellum --> ataxia, nystagmus, hypokinesia
B. Diagnosis - familial (AD) - CJD, or iatrogenic
- lesions in putamen or caudate nucleus, sharp waves on EEG, or 14-3-3 proteins in CSF
C. Treatment - none

56

[Geriatric Psych]
1. Compare pseudodementia to dementia
2. Treatment of pseudodementia vs behavioral symptoms of dementia

1. Pseudodementia - 2/2 to MDD, reversible
- more acute onset
- sundowning uncommon
- often answers "idk"
- patient aware of problems
- cognitive deficits improve with antidepressants

2.
A. Pseudodementia Treatment
- low dose SSRIs
- avoid TCAs but if you do, use nortriptyline (Fewer ACh side effects
- mirtazapine - to help with depression, sleep, appetite
- methyphenidate - adjunct to antidepressants but causes insomnia, arrhythmia in cardiac patients

B. Behavioral symptoms treatment (seen in dementia)
- nonpharma tx preferred (pet, art therapy, reduce stimuli, reorient patient)
- pharma - avoid antipsychotics but can give olanzapine or quetiapine if symptoms severe, or short-term haloperidol or risperidone; avoid benzos and watch for paradoxical agitation

57

[Geriatric Psych]
1. Sleep changes in elderly
2. Age-related effects of alcohol

1. Sleep changes in elderly
- decreased REM sleep latency (reach REM faster) --> decreased stages 3 and 4 non-REM deep sleep
- decreased REM time overall
- increased stages 1 and 2 non-REM sleep
- frequent nocturnal awakenings
- prolonged sleep latency (time to fall asleep)
- earlier to bed, earlier to rise; decreased sleep overall
*avoid sedative-hypnotics, if you must give trazodone

2. Alcohol
- decreased alcohol dehydrogenase, total body water --> higher BALs
- increased CNS sensitivity
- H2 blockers also lead to higher BALs
- reserpine/nitro/hydralazine --> increased risk of hypotension

58

[Child Psych]
Criteria, etiology, and treatment for:
1. Intellectual disability

1. Intellectual disability

A. Criteria -
- deficits in intellectual functioning e.g. learning, judgment, planning
- deficits in adaptive functioning e.g. communication
- at least 2 SDs below population mean

B. Causes
- genetic - Down syndrome, Fragile X, PKU, Prader-Willi, Angelman, Williams, Rett, Cri-du-Chat
- prenatal - TORCHes (TOxo, Rubella, Cmv, HIV, HErpes, Syphilis)
- fetal alcohol syndrome (also growth retardation, smooth philtrum, thin lips)
- perinatal - anoxia, prematurity, meningitis
- postnatal - malnutrition, toxins, trauma, hypothyroid

59

[Child Psych]
Criteria, etiology, and treatment for:
2. ADHD

2. ADHD

A. Criteria - 6+ symptoms in either category:
i. inattention - easily distracted, loses things, struggles with instructions, unorganized, makes careless mistakes
ii. hyperactivity - fidgets, restless, acts as if driven by a motor, talks a lot, difficulty waiting, interrupts
- symptoms 6+ months and present in 2+ settings (home, school, work)
- onset prior to age 12, but can be dxed retrospectively in adulthood
- low self-esteem

B. Causes - multifactorial - genetics, low birth weight, smoking/ETOH during pregnancy

C. Treatment -
- 1st line are stimulants -->methylphenidate (Ritalin), dextroamphetamine (Adderall) *do not give if there is co-occurring tic disorder
- norepi reuptake inhibitor --> atomexitine
- sympatholytic alpha2 agonists --> clonidine (sedation, bradycardia), guanfacine (lower risk orthostasis)

60

[Child Psych]
Criteria, etiology, and treatment for:
3. Autism

3. Autism - ASD

A. Criteria -
- problems with social interaction and communication e.g. decreased eye contact, lack of interest in peer
- restricted, repetitive patterns of behavior or interests e.g. rituals, hand flapping, hypersensitive to sounds
* rapid deterioration of language / social skills during first 2 years of life

B. Causes - multifactorial - prenatal infections, low birth weight, genetics (Fragile X syndrome), associated with epilepsy
- increased total brain volume

C. Treatment - predictors of adult outcome are level of intellect and language impairment
- early intervention, behavioral therapy
- low dose antipsychotics (risperidone, aripiprazole) to reduce irritability, disruptive behavior

61

[Child Psych]
Criteria, etiology, and treatment for:
3. Tic Disorders
4. Elimination Disorder

3. Tic Disorders - Tourette's, provisional tic (<1 year)
tic - sudden, rapid, stereotyped movement or vocalization due to overactive D2R
A. Criteria - multiple motor and at least one vocal tics
- Tourette's: >1 year, onset prior to age 18
- provisional tic disorder - tics for <1 year
- persistent motor OR vocal tic disorder
*symptoms not required to cause significant distress to diagnose
B. Causes - genetic, psychological
- onset 4-6 yo, worst at 10-12 years old
- Tourettes comorbid with OCD and ADHD
- less white matter in prefrontal cortex
C. Treatment - habit reversal therapy
- sympatholytic alpha 2 agonists --> guanfacine, clonidine
-both typical (pimozide) and atypical (haloperidol, risperidone) antipsychotics

4. Elimination Disorder
A. Criteria
- enuresis (bed wetting) - urination 2x/week for >3 months when 5+ years old during sleep OR waking hours
- encopresis - defecation >1x/month for >3 month when 4+ years old
B. Etiology - psychosocial stressors --> 2/2 incontinence
- encopresis often related to constipation with overflow
C. Treatment - only treat if sx are distressing / impairing
- psychoeducation first (limit fluid intake, behavioral program)
- parent mgmt if child is doing it intentionally
- pharma (esp for daytime enuresis) --> desmopressin, imipramine

62

[Child Psych]
Criteria, etiology, and treatment for:
4. Oppositional Defiant Disorder
5. Conduct disorder

4. Oppositional Defiant Disorder
A. Criteria - 4+ symptoms for >6 months (with 1+ individual who is NOT a sibling)
- anger/irritable mood - loses temper, resentful
- argumentative / defiant behavior - breaks rules, argues with authority figures
- vindictiveness - at least 2x in 6 months
*does NOT involve physical aggression
B. Etiology - more common if parents have mood d/o, ODD, CD, etc or mom has depression
C. Treatment - behavior modification

5. Conduct disorder
A. Criteria - violating rights of others with >3 behaviors over last year, and >1 behavior w/in 6 mos, and no remorse or empathy:
- aggression towards people and animals
- destruction of property
- deceitfulness or theft
- serious violations - truancy, prostitution
B. Etiology - comorbid with ADHD and ODD
C. Treatment - behavior modification, parent mgmt training

63

[Dissociative Disorders]
Criteria and treatment for:
1. Depersonalization/derealization disorder
2. Dissociative amnesia

1. Depersonalization/derealization disorder
A. Criteria -
- derealization - detachment from surroundings (as if in dream or movie)
- depersonalization - detachment from body, thoughts, actions (out-of-body experience)
- reality testing remains intact and NO memory loss
B. Treatment - psychotherapy, NO meds

2. Dissociative amnesia
A. Criteria - inability to recall important autobiographical information, usually involving traumatic event
- procedural memory intact
- can be w/ or w/out fugue state - unexpected travel away from home
- can experience flashbacks, nightmares of trauma
B. Treatment - psychotherapy, NO meds used

64

[Dissociative Disorders]
Criteria and treatment for:
3. Dissociative Identity Disorder

*red flags for physical vs sexual child abuse

3. Dissociative Identity Disorder i.e. DID

A. Criteria - 2 or more distinct personality states dominating at different times
- extensive memory lapses in autobiographical info
- seen in victims of severe and chronic/childhood trauma (abuse, neglect)
- symptoms similar to borderline e.g. frequent suicide attempts
B. Treatment - psychotherapy, prazosin for nightmares, naltrexone to reduce self-mutilation

*Physical abuse - spiral bone fractures, head injuries, injuries in various stages of healing
*sexual abuse - recurrent UTIs, prepubertal bleeding, inappropriate sexual knowledge

65

[Somatic Disorders]
Criteria and treatment for:
1. Somatic Symptom Disorder
2. Conversion disorder

1. Somatic Symptom Disorder
A. Criteria - at least one somatic symptom (e.g. pain) for >6 months that causes distress
- very concerned and anxious, sx worse when stressed (are substitute for repressed impulses)
- do not intentionally produce or feign symptoms
B. Treatment - regularly scheduled visits with one PCP, address psych issues slowly

2. Conversion disorder
A. Criteria - at least one neurological symptom (motor or sensory) e.g. blindness, paralysis, paresthesia, mutism, seizures, globus sensation - not explained by neuro condition
- if affect is incongruent --> la belle indifference
B. Treatment - education about illness, CBT, PT

66

[Somatic Disorders]
Criteria and treatment for:
3. Illness anxiety disorder
4. Factitious disorder
5. Malingering

3. Illness anxiety disorder
A. Criteria - preoccupation with and anxiety about having serious illness for >6 months
- somatic symptoms not present
- most have comorbid mental disorder
B. Treatment - regularly scheduled visits with one PCP, CBT

4. Factitious disorder
A. Criteria - falsification of physical or psychological symptoms e.g. hallucinations, hypoglycemia, seizures, hematuria to assume role of sick patient
- absence of external rewards (motivation is unconscious emotional gain)
B. Treatment - collect collateral info, confront in nonthreatening manner

5. Malingering
A. Criteria - NOT considered to be mental illness; multiple vague complaints, uncooperative, symptoms improve after objective is obtained
- conscious external motivation

67

[Impulse Control Disorders]
Criteria and treatment for:
1. Intermittent explosive disorder
2. Kleptomania
3. Pyromania

1. Intermittent explosive disorder
A. Criteria -
- frequent verbal/physical outbursts that do NOT result in physical damage 2x / week for 3 months
OR
- rare outbursts resulting in physical damage >3x / year
- outbursts out of proportion to trigger and not premeditated
B. Treatment - SSRIs, mood stabilizers (lithium, anticonvulsants), CBT

2. Kleptomania
A. Criteria - failure to resist uncontrollable urges to steal objects not needed for personal use or monetary value
- tension prior | pleasure/relief while stealing | guilt and depression afterwards
B. Treatment - CBT, SSRIs
*co-occurence with bulimia (decreased serotonin)

3. Pyromania
A. Criteria - impulse to start fires to relieve tension; at least 2 episodes of deliberate fire setting
B. Treatment - none standard

68

[Eating Disorders]
Criteria, clinical (physical / labs / imaging), and treatment for:
1. Anorexia nervosa

1. Anorexia nervosa
A. Criteria - restriction of energy intake leading to low body weight (BMI < 18.5); intense fear of gaining weight and disturbed body image
i. restricting type
ii. binge eating / purging type

B. Clinical - decreased resting energy expenditure --> hypotension, bradycardia, hypothermia
i. Physical - amenorrhea, parotid enlargement, lanugo, edema, alopecia, osteopenia
i. Labs
- hyponatremia, reduced LH/FSH/estrogen
- increased amylase, BUN, cholesterol, GH, cortisol
- anemia (normocytic normochromic) and leukopenia
iii. Imaging - enlarged ventricles, QTc prolongation
*not eating triggers dopamine surge --> becomes rewarding and addicting

C. Treatment - outpatient unless medically unstable or way below ideal body weight
- CBT, family therapy
- SSRIs for comorbid depression and anxiety
*watch for refeeding syndrome (fluid retention, decreased Mg Ca Po4 --> arrhythmias, delirium, respiratory failure); slow feedings and replace electrolytes

69

[Eating Disorders]
Criteria, clinical (physical / labs / imaging), and treatment for:
2. Bulimia nervosa

2. Bulimia nervosa

A. Criteria - recurrent episodes of binge eating then compensation (vomiting, fasting, exercise) at least 1x / week for 3 months
- maintain normal weight or overweight
- usually ego-dystonic (distressing)

B. Clinical -
i. Physical - salivary gland elargement, callouses on hand, dental erosion, petechiae, peripheral edema
ii. Labs - hypochloremic hypokalemic metabolic alkalosis, metabolic acidosis (laxative abuse), elevated bicarb, hypernatremia
- increased amylase, BUN (as in anorexia)
- normal cortisol (increased in anorexia)

C. Treatment - SSRIs - fluoxetine
- therapy (CBT, group, family)

70

[Eating Disorders]
Criteria, clinical (physical / labs / imaging), and treatment for:
3. Binge-eating disorder

3. Binge-eating disorder
A. Criteria - recurrent episodes of binge eating (2 hour period, lack of control) at least 1x / week for >3 months -- no compensatory behaviors -- and with 3+ of the following:
- eating rapidly
- eating until v full
- eating when not hungry
- eating alone due to embarrassment
- feeling disgusted / depressed / guilty after eating

B. Clinical - obese patients

C. Treatment - CBT with strict diet and exercise program
- stimulants (amphetamine) - suppress appetite
- topiramate - antiepileptic associated with weight loss
- orlistat - inhibits pancreatic lipase --> decreased fat absorption

71

[Sleep-Wake Disorders]
normal sleep-wake cycle
Dyssomnias:
1. Insomnia disorder

Normal cycle -
REM sleep every 90 min, EEG as if awake, increased BP, RR< HR
non-REM is slower brain wave patterns and higher arousal thresholds

1. Insomnia disorder
A. Criteria - difficulty initiating or maintaining sleep, or awakening with inability to return to sleep
i. acute insomnia - at least 3x / week for < 3 months, usually resolves spontaneously
ii. chronic - 3 months to years
B. Treatment - CBT is first line
- benzos for short-term to reduce time to sleep and nocturnal awakening
- zolpidem, eszopiclone, zaleplon for short-term treatment
- trazodone, amitriptyline

72

[Sleep-Wake Disorders]
Dyssomnias:
2. Hypersomnolence disorder
3. Obstructive sleep apnea hypopnea

2. Hypersomnolence disorder
A. Criteria - excessive sleepiness despite 7+ hours of sleep, at least 3 x / week for >3 months, with 1+ of the following:
- recurrent sleeps in same day
- nonrestorative sleep > 9 hours
- sleep drunkenness (impaired performance after waking up)
- can be due to viral infections (EBV, HIV, GBS) or head trauma or genetics
B. Treatment - life-long therapy with modafinil or methylphenidate; atomexitine 2nd line

3. Obstructive sleep apnea hypopnea
A. Criteria - apneic episodes w cessation of breathing or reduced airflow due to upper airway collapse
- frequent awakenings due to gasping, choking; snoring
- POWERNAP: pulm HTN, other, wet sheets, erythropoiesis, reduced libido, nocturia, AM headaches, psych sx (eg depression)
*can lead to cor pulmonale, respiratory failure
B. Treatment - CPAP, BIPAP 2nd line

73

[Sleep-Wake Disorders]
Dyssomnias:
4. Central sleep apnea
5. Narcolepsy

4. Central sleep apnea
A. Criteria - 5+ central apneas per hour of sleep
- due to Cheyne-stokes breathing (crescendo-decrescendo variation in TV due to HF, stroke, renal failure)
- OR due to opioid use
B. Treatment - treat underling condition, CPAP/BIPAP, 02, acetazolamide, theophylline (promotes breathing)

5. Narcolepsy
A. Criteria - napping or lapsing into sleep at least 3x / week for >3 months associated with 1 of the following:
- cataplexy - loss of muscle tone
- ↓ hypocretin (orexin) in CSF
- ↓ REM sleep latency (via polysomnogram or multiple sleep latency test); ↓ sleep latency, ↓ sleep efficiency, ↑REM density
*hallucinations and/or sleep paralysis common
B. Treatment - scheduled naps
- daytime sleepiness --> amphetamines, methylphenidate, modafinil
- cataplexy --> sodium oxybate is 1st line; TCAs, SSRI/SNRIs

74

[Sleep-Wake Disorders]
Dyssomnias:
6. Circadian rhythm sleep-wake disorders
i. delayed sleep phase
ii. advanced sleep phase
iii. shift-work
iv. jet lag

6. Circadian rhythm sleep-wake disorders
*circadian rhythm controlled by suprachiasmatic nucleus in hypothalamus

i. delayed sleep phase - delay in sleep onset with preserved quality and duration of sleep; due to caffeine, puberty (changes in melatonin)
- treat with timed bright lights, melatonin

ii. advanced sleep phase - sleep onset and awakening earlier than desired with preserved quality and duration of sleep; due to old age
- treat with timed bright lights

iii. shift-work - 2/2 to rotating shifts
- treat with timed bright lights, modafanil

iv. jet lag - due to travel across time zones
- generally resolves on its own

75

[Sleep-Wake Disorders]
Parasomnias
Non-REM sleep behavior disorders:
1. Sleepwalking
2. Sleep terrors
3. Nightmare disorder

1. Sleepwalking
A. Criteria - occurs during non-REM slow wave sleep
- difficulty arousing, eyes open with blank stare, and amnesia of episode
B. Treatment - reassurance, condition is benign and self-limited to 1-2 years
- if refractory, low-dose benzos (clonazepam Klonopin)

2. Sleep terrors - peak at age 6
A. Criteria - sudden terror arousals w screaming / crying, during non-REM slow-wave sleep with autonomic arousal (tachycardia, tachypnea, diaphoresis, mydriasis)
- amnesia of episode and no recall of dreams
B. Treatment - same as sleepwalking (Reassurance)

3. Nightmare disorder
A. Criteria - frightening dreams in second half of sleep, awakening with vivid recall but no confusion
- occurs during REM sleep
B. Treatment - reassurance, desensitization / imagery rehearsal therapy, prazosin (for PTSD)

76

[Sleep-Wake Disorders]
Parasomnias
4. REM sleep behavior disorder
5. Restless legs syndrome

4. REM sleep behavior disorder - in second half of sleep
A. Criteria - repeated arousals during sleep with vocalization or dream-enacting behaviors e.g. talking, yelling, jerking, punching, running
*usually muscle atonia during REM
- seen with TCAs, SSRI/SNRIs, BBs; in elderly, narcolepsy; in neurodegenerative disorders (Lewy body, PD)
B. Treatment - d/c meds, clonazepam, melatonin

5. Restless legs syndrome
A. Criteria - urge to move legs due to unpleasant sensation, occurs or worsens in evening
- due to iron deficiency, genetics, drugs
B. Treatment - d/c meds, iron replacement if low ferritin, dopamine agonists (ropinirole), benzos, opioids

77

[Sexual Disorders]
1. Sexual dysfunctions
2. Gender dysphoria
3. Paraphilias

1. Sexual dysfunctions -
A. Criteria - problems with any stage of sexual response cycle (desire, arousal, orgasm, resolution) causing significant distress
- MC in males - erectile disorder, premature ejaculation
- MC in females - sexual interest disorder, orgasmic disorder
*dopamine increases libido, 5HT decreases it
B. Treatment - sex therapy, CBT, hypnosis, meds (ED --> PDE5 inhibitors and alprostadil which automatically works w/in 3 min; SSRIs for premature ejaculation, hormone replacement)

2. Gender dysphoria
A. Criteria - marked incongruence bw experienced gender and sex characteristics with desire to be of or be treated as other gender
B. Treatment - therapy, sex reassignment after 1 year of living as other gender and 1 year of hormone therapy

3. Paraphilias -
A. Criteria - unusual sexual activities > 6 months that are intense, recurrent, and interfere with daily life e.g. pedophilia, voyeurism, exhibitionism, BDSM, transvestitism
B. Treatment - CBT, social skills training, meds to decrease sex drive (SSRI, naltrexone, antiandrogens)

78

[Psychotherapies]
1. Freud's theory of the mind
2. Mature defenses
3. Neurotic defenses
4. Immature defenses

1. Freud
i. id - present at birth; unconscious, instinctual sexual/aggressive urges
ii. supergo - present by age 6; moral conscience, internalized cultural rules, ego ideal
iii. ego - present after birth; mediator bw id, supego, and environment using defense mechanisms and reality testing

2. Mature defenses - altruism, sublimation, suppression, humor

3. Neurotic defenses - controlling, displacement, intellectualization, isolation of affect, rationalization, reaction formation (doing opposite of unacceptable impulse), repression

4. Immature defenses - acting out, denial, regression, projection, splitting

79

[Psychopharm]
Side effects:
1. anticholinergic
2. antihistamine
3. antiadrenergic
4. serotonin syndrome
5. NMS
6. CYP450 inducers vs inhibitors

1. anticholinergic - hot as a hare, blind as a bat, dry as a bone, mad as a hatter (exacerbate dementia) + constipation

2. antihistamine - sedation, weight gain

3. antiadrenergic - peripheral vasodilation, orthostatic hypotension

4. serotonin syndrome - when SSRIs are combined with MAOIs, triptans, dextromethorphan (cough syrup) - overactivation of 5HT1AR --> myoclonus, flushing / diaphoresis / tremor, hyperthermia, rhabdo, renal failure, death
- need 2 week break, with fluoxetine need 5 weeks bc of long t1/2
- d/c meds and give benzos, cyproheptadine (5HT antagonist)

5. neuroleptic malignant syndrome - due to inhibition of D2R --> fever (MC sx), AMS, HTN, tremor, lead pipe rigidity ("unable to move spontaneously"), elevated WBC and CPK --> rhabdo --> AKI and hyperkalemia --> arrhythmia and death
- treat with supportive measures, bromocriptine and amantadine, lorazepam; for severe cases --> dantrolene, ECT

6. CYP450 inducers - st johns wort, carbamazepine, phenytoin, tobacco, barbs, rifampin
Inhibitors - SSRI/SNRIs

80

[Psychopharm]
Antidepressants
MOA, examples of / indications, and side effects of:
1. SSRIs
- fluoxetine
- sertraline
- paroxetine
- fluvoxamine
- citalopram
- escitalopram

1. SSRIs - for MDD, OCD, panic disorder, eating disorders, social phobia, GAD, PTSD, IBS, PMS

A. MOA - inhibit presynaptic serotonin reuptake --> increased 5HT in synaptic clefts
- increase brain plasticity --> delay to onset of effect
- NO correlation bw plasma levels and efficacy or side effects

B. Examples:
- fluoxetine - longest t1/2, 1st line for pediatric depression; can increase levels of antipsychotics and carbemazepine
- sertraline - more GI probs; preferred for breastfeeding
- paroxetine - short t/12 --> increased risk of discontinuation syndrome; teratogen - can cause atrial septal defect
- fluvoxamine - only for OCD
- citalopram - fewest drug interactions, dose- dependent QTc prolongation
- escitalopram - also QTc prolongation

C. Side effects
- GI (nausea/vomiting), insomnia, headache, anorexia / weight loss, sexual dysfunction, SIADH (rare)
- GI bleed due to platelet dysfunction (increased bleeding time) *prescribe PPI to offset
- bruxism
- black box warning for increased suicidal ideation in <25 years old
- serotonin syndrome - triptans, MDMA, MAOIs, tramadol
- can increase levels of warfarin
- discontinuation syndrome - flu-like sx; restart same drug and then taper over several weeks or fluoxetine (don't need taper bc of active metabolites)

81

[Psychopharm]
Antidepressants
MOA, examples of / indications, and side effects of:
2. SNRIs
3. Bupropion
4. Mirtazapine

2. SNRIs
A. MOA - inhibit serotonin and norepi reputake
B. Examples
- venlafaxine - for GAD + depression, and neuropathic and chronic pain; increased BP w higher doses; abrupt d/c can lead to d/c syndrome (flu-like sx, depression)
- duloxetine - for fibromyalgia + depression, neuropathic pain; can be hepatotoxic in pts with ETOH, liver dx
- dry mouth, constipation, urinary retention

3. Bupropion
A. MOA - norepi and dopamine reuptake inhibitor
B. Indications - depression, smoking cessation
C. Side effects - activating and lack of sexual side effects, but can lower seizure threshold in pts with epilepsy, eating disorders, or those taking MAOIs

4. Mirtazapine
A. MOA - alpha2 adrenergic receptor antagonist
B. Indications - major depression in pts with weight loss and insomnia
C. Side effects - sedation, weight gain, agranulocytosis (neutropenia - rare), lack of sexual side effects

82

[Psychopharm]
Antidepressants
MOA, examples of / indications, and side effects of:

5. Trazodone
6. TCAs

5. Trazodone
A. MOA - antagonist of 5HT2 receptors and inhibits reuptake
B. Indications - MDD, insomnia
C. Side effects - priapism, sedation, hypotension with higher doses

6. TCAs
A. MOA - inhibit reuptake norepi and serotonin
B. Examples / indications
- amitriptyline - migraines, neuropathic chronic pain
- imipramine - enuresis
- clomipramine - 2nd line in OCD
- doxepin - sleep aid
- notriptyline and desipramine - secondary amine, less side effects (better in elderly)
C. Side effects - coma, convulsions, cardiotoxicity (QTc prolongation, arrhythmias); can cause delirium
- lethal in OD (give sodium bicarb)
- anticholinergic, antihistaminic, antiadrenergic

83

[Psychopharm]
Antidepressants
MOA, examples of / indications, and side effects of:

7. MAOIs

7. MAOIs

A. MOA - irreversibly inhibit MAO-A and MAO-B which break down neurotransmitters
- MAO -A --> 5HT, norepi, dopa, tyramine
- MAO - B --> dopa, phenethlyamine, tyramine

B. Examples - for refractory depression, atypical subtype
- selegiline
- phenelzine
- tranylcypromine
- isocarboxazid

C. Side effects - most common is orthostasis
- hypertensive crisis with tyramine - rich foods (red wine, cheese, cured meats, fava beans) bc MAOs not able to break down norepi displaced from storage vesicles by tyramine --> HTN, photophobia, chest pain, n/v, sweating, arrhythmias, death; treat with phentolamine, nitroprusside
- serotonin syndrome
- weight gain, sexual dysfunction, sleep problems, dry mouth
- pyrodixine deficiency --> numbness, paresthesias

84

[Psychopharm]
Antipsychotics
MOA, examples of / indications, and side effects of:
1. Typical antipsychotics
incl low medium, and high potency

1. Typical, first generation antipsychotics

A. MOA - block dopamine (D2) receptors --> decreased binding of dopamine at the postsynaptic receptor

B. Examples / indications and side effects
i. Low-potency - increased antiH1, alpha1, muscarinic, highest seizure risk
- chlorpromazine - treat hiccups, cause blue-gray skin discoloration and photosensitivity, deposits in cornea
- thioridazine - irreversible retinal pigmentation
ii. midpotency - perphenazine
iii. high potency - greater EPS side effects, decreased alpha1, H1, anticholinergic side effects
- haloperidol *long acting IM form is decanoate; decreased risk anticholinergic side effects
- fluphenazine - also has decanoate form
- trifluoperazine
- pimozide - interacts with citalopram --> QTc prolongation, vtach

C. General Side effects
- antidopa (EPS, hyperPRL) --> give benztropine, diphenhydramine
- antiH1, antialpha1, antimuscarinic
- tardive dyskinesia
- NMS - more common in young males early in treatment on high potency

85

[Psychopharm]
Antipsychotics
MOA, examples of / indications, and side effects of:
2. Atypical antipsychotics
- clozapine
- risperidone
- quetiapine
- olanzapine
- ziprasidone
- aripiprazole
- lurasidone

2. Atypical antipsychotics
A. MOA - block both dopamine (D4>D2) and serotonin (5HT2) receptors
- for acute mania (bipolar), schizophrenia (+ and - sx), and also for treatment resistant depression and tic disorders
*serotonin inhibits dopamine in nigrostriatal tract --> 5HT inhibition increases dopa --> fewer EPS

B. Examples and side effects
- clozapine - treatment-refractory schizo because associated with neutropenia (weekly blood draws for first 6 mos, stop if neutrophils <1500/microliter or fever), myocarditis, seizures; lowest risk EPS but highest anticholinergic (e.g. drooling - give PTU) *only antipsychotic that decreases suicidality
- risperidone - increased risk of high prolactin
- quetiapine - sedation, hypotension; lowest risk EPS
- olanzapine - worst for weight gain, metabolic syndrome
- ziprasidone - QTc prolong, weight neutral, take w food
- aripiprazole - partial D2 agonist --> more activating (akathisia); least likely to cause QTc prolongation; weight-neutral
- lurasidone - bipolar depression, take w food

C. General side effects - less likely to cause EPS, TD, NMS
- cause anticholinergic, anthistaminic, antialpha1 side effects
- metabolic syndrome - HLD, DKA, weight gain --> measure waist circumference, BP, glucose, lipids
- elevated LFTs and ammonia - measure yearly

*atypicals used to treat behavioral sx of dementia and delirium but associated with increased risk of stroke and mortality in elderly*

86

[Psychopharm]
Mood stabilizers
MOA, examples of / indications, and side effects of:
Lithium

Lithium

A. MOA - unknown

B. Indications - 1st line in acute mania, prophylaxis for bipolar and schizoaffective disorders
- also cyclothymic, unipolar depression

C. Side effects - therapeutic dose can cause benign fine tremor (give propranolol)
- narrow TI --> check blood levels of lithium also get BMP, TFTs, UA, Ca + pregnancy test
i. acute - coarse tremor/seizures, ataxia/nystagmus, polyuria/polydipsia, n/v, diarrhea, AMS, cardiac arrhythmias (AV block, T wave flattening)
ii. chronic - nephrogenic DI, CKD, hypothyroidism, hyperparathyroidism
iii. teratogenic - Ebstein's anomaly
- metabolized by kidney -- be careful in pts with CKD

*Lithium levels increased with thiazides, NSAIDs, ACEIs, tetracyclines, metronidazole, dehydration, salt deprivation / sweating, and CKD
*Li is only mood stabilizer shown to decrease suicidality

87

[Psychopharm]
Anticonvulsants
MOA, examples of / indications, and side effects of:

1. Carbamazepine
2. Lamotrogine

1. Carbamazepine
A. MOA - blocks sodium channels and inhibits action potentials
B. Indications - mania with mixed features, rapid cycling bipolar
C. Side effects - GI, ataxia, confusion, aplastic anemia, SIADH, alopecia / acne, hepatotoxicity, SJS, teratogenic (neural tube defects)
- induces CYP450 pathway
- toxicity --> ataxia, tremor, nystagmus / diplopia, twitching, vomiting, stupor

2. Lamotrogine
A. MOA - sodium channels that modulate glutamate, aspartate
B. Indications - bipolar depression (NOT for acute mania)
C. Side effects - rash, decreases valproate levels
- SJS - widespread confluent rash with fever, WBC, affects mucosal membranes

88

[Psychopharm]
Anticonvulsants
MOA, examples of / indications, and side effects of:

3. Valproic acid
4. Topiramate

3. Valproic acid (Valproate)
A. MOA - blocks sodium channels, increases GABA
B. Indications - acute mania, mania with mixed features, rapid cycling
C. Side effects - GI distress, weight gain, PCOS, tremor, sedation, hyperammonemia
- pancreatitis - at any point
- hepatotoxicity - dose-dependent
- teratogen (neural tube defects), causes PCOS
- increases lamotrigine levels

4. Topiramate
A. MOA - also blocks sodium channels
B. Indications- used for migraine prophylaxis, pseudotumor cerebri
C. Side effects - causes weight loss, cognitive slowing (Reversible decrease in IQ), kidney stones, metabolic acidosis

89

[Psychopharm]
Anxiolytics/hypnotics
MOA, examples of / indications, and side effects of:
1. Benzodiazepines

1. Benzodiazepines - GAD, alcohol w/d, muscle spasms, seizures / status epilepticus, anesthesia e.g. conscious sedation, sleep problems e.g. insomnia and parasomnias, panic disorder

A. MOA - increase frequency of GABA opening

B. Examples
i. long-acting (t1/2 >20 hrs)
- chlordiazepoxide (Librium) - for alcohol w/d, avoid in liver disease
- diazepam (Valium) - for muscle spasms, causes euphoria
- clonazepam (Klonopin) - for anxiety, panic attacks; avoid with CKD; most potent benzo

ii. intermediate (t1/2 6-20 hrs)
- alprazolam (Xanax) - for anxiety, causes euphoria; 2nd most potent benzo
- lorazepam (Ativan) - for alcohol detox, agitation, panic attacks, and catatonia
- oxazepam - for alcohol detox
- temazepam

iii. short-acting (t1/2 <6 hours)
- triazolam - for insomnia, risk of anterograde amnesia
- midazolam (Versed) - for conscious sedation

C. Side effects - drowsiness, life-threatening w/d
- be careful - elderly -- sensitive to side effects --> confusion, ataxia, falls
- can die from respiratory depression if combined with ETHOD

*for alcoholics, give benzos NOT metabolized by liver --> lorazepam, oxazepam, temazepam

90

[Psychopharm]
Anxiolytics/hypnotics
MOA, examples of / indications, and side effects of:
2. Non-benzo hypnotics
3. Buspirone
4. Hydroxyzine

2. Non-benzo hypnotics
A. MOA - selective receptor binding to GABA-A receptor
- for short-term tx of insomnia
B. Examples - zolpidem, eszopiclone, zaleplon
- also diphenhydramine, ramelteon (MT1 and 2 agonist)
C. Side effects - anterograde amnesia, parasomnias, hallucinations

3. Buspirone
A. MOA - partial 5HT-1a agonist
B. Indications - used in combo with SSRI for GAD
C. Side effects - slow onset of action (1-2 weeks), low potential for abuse

4. Hydroxyzine
A. MOA - antihistamine
B. Indications - quick-acting, short-term anxiolytic

91

[Psychopharm]
Psychostimulants
MOA, examples of / indications, and side effects of:
1. Amphetamines
2. Atomexitine
3. Modafinil

1. Amphetamines e.g. dextroamphetamine, methylphenidate
A. MOA - CNS stimulant that induces biogenic amine
(dopa, 5HT) release from storage sites in synaptic terminals
B. Indications - ADHD, tx refractory depression
C. Side effects - weight loss, insomnia, seizures, abuse
- leukopenia, anemia with methylphenidate

2. Atomexitine
A. MOA - inhibits presynaptic norepi reuptake --> increased norepi and dopa
B. Indications - 2nd line for ADHD, hypersomnolence
C. Side effects - less abuse potential, less effective, possible increase in SI

3. Modafinil - CNS stimulant
A. MOA - dopa reuptake inhibitor, activates release of orexins and histamine
B. Indications - narcolepsy, OSA, shift work disorder
C. Side effects - abuse potential

92

[Psychopharm]
Psych side effects of the following:
1. Procainamide, quinidine
2. Albuterol
3. INH
4. Tetracyclines
5. Nifedipine, verapamil
6. Cimetidine
7. Steroids

1. Procainamide, quinidine - confusion, delirium

2. Albuterol - anxiety, confusion

3. INH - psychosis

4. Tetracyclines - depression

5. Nifedipine, verapamil (Ca2+ blockers as well as beta blockers) - depression

6. Cimetidine - depression, confusion, psychosis

7. Steroids - aggressiveness, mania, depression, anxiety, psychosis

93

[Forensic path]
1. Proving malpractice
2. Informed consent & when its not required
3. Emancipated minors

1. Malpractice - physician had duty of care --> breached it via negligence (practicing below standard of care) --> patient was harmed, directly due to this negligence

2. Informed consent - Reason for treatment, Risks/benefits, Reasonable alternatives, Refused treatment consequences
- do not need informed consent in lifesaving emergency, emancipated minors, and prevention of suicidal or homicidal behavior

3. Emancipated minors - self-supporting, in military, married, have children / pregnant --> do not need parental consent for medical decisions

94

[Forensic path]
4. What determines decisional capacity
5. Determining competence

4. Decisional capacity - communicates choice, understands condition/treatment options, acknowledges consequences of treatment options, and can weigh risks/benefits and offer reasons for decisions

5. Competence - legally determined by judge
- cannot be tried in court if not mentally competent (legally insane)
- need evil deed and evil intent to be convicted - can be not guilty by reason of insanity (NGRI)
*most important hactor in assessing risk of violence is patient's previous history of violence (also young, male, lower SES)

95

Description of sleep stages and EEG waveforms:
1. Awake (Eyes open)
2. Awake (eyes closed)
3. Non-REM sleep
N1
N2
N3
4. REM sleep

1. Awake (Eyes open) - beta (highest frequency, lowest amplitude)

2. Awake (eyes closed) - alpha

3. Non-REM sleep
N1 - light sleep, theta waves
N2 - deeper sleep, sleep spindles and K complexes; bruxism
N3 - deepest sleep, where sleepwalking, bed wetting, and night terrors occur; delta waves
4. REM sleep - muscle atonia, increased brain 02 use, where dreaming/nightmares/tumescence occur; beta waves

96

Differentiate between IED, ODD, and DMDD

These disorders cannot coexist, must pick one

IED - 3 mos *impulse control disorder
- outbursts of anger and aggression >2x/week or >3x / year (physical damage against people or property)
- don't need irritable mood bw outbursts
- grossly out of proportion to trigger

ODD - 6 mos *disruptive disorder
- anger/irritable mood
- argumentative/defiance towards authorities
- vindictiveness but no physical aggression
*associated with conduct disorder

DMDD - 12 mos *mood disorder
- verbal and/or physical temper outbursts >3x/week in 2+ settings
- irritable bw outbursts

97

Location of neurotransmitter synthesis: Ach, Dopa, GABA
norepi, 5HT

Levels during:
anxiety
depression
schizo
alzheimer
huntington
parkinson

Location of neurotransmitter synthesis:
- Ach - nucleus basalis of meynert (attention, memory, executive functions)
- dopamine - ventral tegmentum, substantia nigra (movement, rewards)
- GABA - nucleus accumbens (main inhibitor)
- norepi - locus ceruleus (stress hormone, bv, attentiveness, learning)
- serotonin - raphe nucleus (memory, emotions/moods, appetite, thermoregulation)

anxiety - 􏰀↓ GABA and 5HT, ↑ norepi
depression - ↓ dopa, 5HT, norepi
schizo - ↑ dopa
alzheimer - ↓ ACh
huntington - ↓ ACh and GABA, ↑ dopa
parkinson - ↓ dopa, ↑ ACh, 5HT