Psych Flashcards

Question

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

Answer 1

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

Answer 2

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

Answer 3

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

Answer 4

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

Answer 5

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

Answer 6

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

Answer 7

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

Answer 8

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

Answer 9

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

Answer 10

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

Answer 11

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

Answer 12

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

Answer 13

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

Answer 14

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

Answer 15

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

Answer 16

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)

Answer 17

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

Answer 18

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

Answer 19

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

Answer 20

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

Answer 21

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

Answer 22

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

Answer 23

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

Answer 24

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

Answer 25

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

Answer 26

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

Answer 27

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

Answer 28

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

Answer 29

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

Answer 30

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

Answer 31

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

Answer 32

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

Answer 33

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

Answer 34

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

Answer 35

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)

Answer 36

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

Answer 37

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

Answer 38

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

Answer 39

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

Answer 40

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

Answer 41

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

Answer 42

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

Answer 43

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

Answer 44

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

Answer 45

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)

Answer 46

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

Answer 47

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

Answer 48

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

Answer 49

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

Answer 50

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

Answer 51

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)

Answer 52

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

Answer 53

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)

Answer 54

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

Answer 55

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

Answer 56

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)

Answer 57

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

Answer 58

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

Answer 59

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

Answer 60

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

Answer 61

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*

Answer 62

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

Answer 63

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

Answer 64

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

Answer 65

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

Answer 66

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

Answer 67

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

Answer 68

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

Answer 69

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

Answer 70

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)

Answer 71

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

Answer 72

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

Answer 73

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 ```

Psych Flashcards

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