Learning in which a natural response is elicited by a conditioned stimulus that previously was presented in conjunction with an unconditioned stimulus. Ex. Pavlov's dogs
Classical conditioning usually deals with...
learning in which a particular action is elicited becasue it produces a punishment or reward
Operant conditioning usually deals with...
desired reward produces action (mouse presses button to get food)
target behavior (response) is followed by removal of averse stimulus (mouse presses button to turn off continuous loud noise)
repeated application of aversive stimulus extinguishes unwanted behavior
discontinuation of reinforcement (positive or negative) eventually eliminates the behavior. Can occur in operant or classical conditioning
pt projects feelings about formative or other importnat persons onto physician (ex. psychiatrist is seen as a parent)
doctor projects feelings about formative or other important persons onto pt (ex. pt reminds physician of younger sibling)
expressing unacceptable feelings and thoughts through actions Ex. tantrums
temporary, drastic change in personality, memory, consciousness or motor behavior to avoid emotional stress ex. extreme forms can result in dissociative identity disorder
avoiding the awareness of some painful reality ex. a common rxn in newly diagnosed AIDS and cancer pts
transferring avoided ideas and feelings to some neutral person or object Ex. mother yells at her child bc her husband yelled at her
partially remaining at a more childish level of development Ex. men fixating on sports games
modeling behavior after another person who is more powerful ex. abused child identifies with abuser
separating feelings from ideas and events ex. describing murder in graphic detail with no emotional response
attributing an unacceptable internal impulse to an external source ex. a man who wants another woman thinks his wife is cheating on him
proclaiming logical reasons for actions actually performed for other reasons, usually to avoid self-blame Ex. after getting fired, claiming that the job was not important anyway
replacing a warded-off idea or feeling by an (unconsciously derived) emphasis on its opposite ex. a pt with libidinous thoughts enters a monastery
turning back the maturational clock and going back to earlier modes of dealing with the world ex. seen in children under stress (illness, punishment, new sibling) - bedwetting in a previously toilet-trained child
involuntary witholding an idea or feeling from conscious awareness Ex. not remembering a conflictual/traumatic experience; pressing bad thoughts into the unconscious
believing that people are either all good or all bad at different times due to intolerance of ambiguity ex. pt says that all nurses were cold/insensitive but the doctors were warm/friendly
Splitting is often seen in...
borderline personality disorder.
alleviating guilty feelings by unsolicited generosity towards others Ex. mafia boss makes large donation to charity
appreciating the amusing nature of an anxiety-provoking or adverse situation Ex. nervous med student jokes about boards
replacing an unacceptable wish with a course of action that is similar to the wish but does not conflict with one's value system Ex. teen's aggression toward his father is redirected to perform well in sports
intentional witholding of an idea or feeling from conscious awareness ex. choosing not to worry about the big game until it is time to play
Long-term deprivation of affection in infants leads to...
-decreased muscle tone -poor language skills -poor socialization skills -lack of basic trust -anaclitic depression -weight loss -physical illness
Deprivation in an infant for more than 6 months can...
lead to irreversible changes. Severe deprivation can result in death.
The main physical abuser of children is usually...
the biological mother and usually occurs before the age of 3.
Peak age of sexual abuse in children
9-12 (signs: genital, anal or oral trauma, STDs, UTIs)
Evidence of physical abuse
-healed fractures on x-ray (esp. spinal) -burns -subdural hematomas -pattern marks/bruising -rib fractures -retinal detachment/hemorrhage
The most common form of child maltreatment is...
child neglect which is the failure to provide a child with food, shelter, supervision, education and affection.
Evidence of child neglect
-poor hygiene -malnutrition -withdrawal -impaired social/emotional development -FTT
Attention Deficit Hyperactivity Disorder (ADHD)
-onset before 12 -poor impulse control -normal intelligence but has difficulty in school
ADHD is associated with...
decreased frontal lobe volume/metabolism
Treatment for ADHD
-methylphenidate -amphetamines -atomoxetine -behavioral interventions
-repetitive, pervasive behavior violating the basic rights of others (physical aggresion, property destruction, theft)
After the age of 18, many with conduct disorder will meet the criteria for...
antisocial personality disorder.
Oppositional Defiant Disorder
-enduring pattern of hostile, defiant behavior toward authority figures in the absence of serious violations of social norms
-onset before 18 -sudden, rapid, recurrent, nonrhythmic, stereotyped motor and vocal tics that persist for more than 1 year
involuntary obscene speech. Seen in only 10-20% of those with Tourette's.
Tourette's is associated with...
OCD and ADHD.
Treatments for Tourette's
-antipsychotics -behavioral therapy
Separation anxiety disorder
-onset 7-9 yrs -overwhelming fear of separation from home or loss of attachment figure -may lead to factitious physical complaints to avoid going to school
Treatment for Separation anxiety disorder
-SSRIs -relaxation/behavioral interventions
Pervasive developmental disorders are characterized by...
difficulties with language and failure to acquire or early loss of social skills.
Pervasive developmental disorders
1. Autism spectrum disorder 2. Rett Disorder
Autism is characterized by...
poor social interactions, communication deficits, repetitive behaviros and restricted interests.
Autism must present in...
early childhood and may or may not be accompanied by intellectual disability. More common in boys.
-X-linked disorder almost exclusively in girls -symptoms appear at 1-4 yrs old -regression, loss of development and verbal abilities -ataxixa -intellectual disability -sterotyped hand-wrigning
Alzheimer NT changes
Anxiety NT changes
increased NE decreased GABA and serotonin
Depression NT changes
decreased NE, serotonin and dopamine
Huntington NT changes
decreased GABA and ACh increased dopamine
Parkinson NT changes
decreased dopamine increased serotonin and ACh
Schizophrenia NT changes
Common causes of loss of orientation
-alcohol/drugs -fluid/electrolyte imbalance -head trauma -hypoglycemia -infxn -nutritional deficiencies
Order of loss of orientation
1st - time 2nd - place last - person
inability to remember things that occurred before a CNS insult
inability to remember things that occured after a CNS insult (no new memories)
-classic anterograde amnesia caused by thiamine deficiency and the associated destruction of mammillary bodies -seen in alcoholics and associated with confabulations
inability to recall important personal information, usually subsequent to severe trauma or stress
Dissociative amnesia may be associated by...
dissociative fugae (abrupt travel or wandering during a period of dissociative amnesia)
-significant changes in cognition (memory, attention, language, judgement)
Cognitive disorder includes...
delirium and dementia.
-waxing and waning level of consciousness with acute onset -rapid decrease in attention span and level of arousal -disorganized thinking, hallucinations, illusions, misperceptions, disturbance in sleep, cognitive dysfunction -abnormal EEG
Delirium is usually secondary to...
another illness: -CNS disease -infxn -trauma -substance abuse/withdrawal -metabolic/electroly disturbances -hemorrhage -urinary/fecal retention
If a patient has delirium, check for...
drugs with anticholinergic effects. Usually reversible.
Dementia is a...
gradual decrease in intellectual ability or cognition without affecting levels of consciousness.
Dementia is characterized by...
memory deficits, aphasia, apraxia, agnosia, loss of abstract thought, behavioral/personality changes, impaired judgement. (EEG usually normal)
A patient with dementia can develop...
delirium. Ex. a pt with AD who develps pneumonia is at increased risk for delirium.
Irreversible causes of dementia
-Alzheimer disease -Lewy body dimentia -Huntington disease -Pick disease -cerebral infarcts -Creutzfeldt-Jakob disease -chronic substance abuse
Reversible casues of dementia
-NPH -vitamin B12 deficiency -hypothyroidism -neurosyphilis -HIV
In elderly pts, depression may present...
like dementia (pseudodementia).
a distorted perception of reality characterized by delusions, hallucinations, and/or disorganized thinking
perceptions in the absence of external stimuli (seeing a light that is not actually present)
unique, false beliefs about oneself or others that persist despite the facts (thinking aliens are communicating with you)
words and ideas are strung together based on sounds, puns or loose associations
Visual hallucinations are more commonly a feature of...
medical illness (drug intoxication) than psychiatric illness.
Auditory hallucinations are more commonly a feature of...
psychiatric illness (schizophrenia) than medical illness.
Olfactory hallucinations often occur as...
an aura of psychomotor epilepsy and in brain tumors.
Tactile hallucinations are common in...
alcohol withdrawal (formicatin = sensation of bugs crawling on one's skin); also seen in cocaine abuse.
Hypnagogic hallucinations occurs...
while going to sleep.
Hypnopompic hallucinations occur...
when waking from sleep.
Schizophrenia is a...
chronic mental disorder with periods of psychosis, disturbed behavior and thought, and decline in functioning that lasts more than 6 months.
Schizophrenia is associated with...
increased dopaminergic activity and decreased dendritic branching.
Diagnosis of Schizophrenia requires 2 or more of the following:
1. delusions 2. hallucinations 3. disorganized speech (loose associations) 4. disorganized or catatonic behavior 5. negative symptoms (flat affect, social withdrawal, lack of motivation, lack of speech/thought)
Brief sychotic disorder
less than one month, usually stress related
at least 2 wks of stable mood with psychotic symptoms plus a major depressive, manic or mixed episode
In teens, psychosis/schizophrenia is associated with...
frequent cannabis use.
Schizophrenia presents in men...
earlier (late teens to early 20s) than women (late 20s to early 30s).
fixed, persistent, untrue belief system lasting more than one month Ex. woman who genuinely believes she is married to a celebrity
Dissociative Identity Disorder
presence of 2 or more distinct identities or personality states; more common in women
Dissociative Identity Disorder is associated with...
hx of sexual abuse, PTSD, depression, substance abuse, borderline personality disorder and somatoform conditions
persistent feelings of detachment or estrangement from one's own body, thoughts, perceptions and actions (depersonalization) or one's environment (derealization)
characterized by an abnormal range of moods or internal emotional states and loss of control over them; severity of mood causes distress and impairment in social and occupational functioning
Mood disorders include...
major depressive disorder, bipolar disorder, dysthymic disorder and cyclothymic disorder
distinct period of abnormally, persistently elevated, expansive or irritable mood and increased activity/energy lasting at least one week
Diagnosis of Manic episode requires hospitalization or at least three of the following:
manics DIG FAST 1. Distractibility 2. Irresponsibility 3. Grandiosity 4. Flight of Ideas 5. increase in goal-directed Activity/psychomotor Agitation 6. decreased need for sleep 7. Talkativeness
like manic episode except mood disturbance is not severe enough to cause marked impairment in social and/or occupational functioning or to necessitate hospitalization; lasts at least 4 consecutive days
Bipolar I is defined by...
the presence of at least 1 manic episode with or without a hypomanic or depressive episode.
Bipolar II is defined by...
the presence of a hypomanic and a depressive episode.
Between episodes in bipolar, pts mood and functioning usually...
returns to normal.
Use of antidepressants can lead to...
increased mania. High suicide risk in bipolar.
Treatment for Bipolar
-mood stabilizers (lithium, valproic acid, carbamazepine) -atypical antipsychotics
-dysthymia and hypomania -milder form of bipolar lasting at least 2 yrs
In major depressive disorder (MDD), episodes usually last...
MDD episodes are charachterized by at least 5 of the following 9 symptoms for 2 or more weeks
-sleep disturbance -loss of interest (anhedonia) -guilt or feelings of worthlessness -energy loss and fatigue -concentration problems -appetite/weight changes -psychomotor retardation or agitation -suicidal ideations -depressed mood
Pts with depression typically have the following changes in their sleep stages:
-decreased slow wave sleep -decreaesd REM latency -increased REM early in sleep cycle -increased total REM -repeated nighttime awakenings -early-morning awakening
Persistent, depressive disorder (dysthymia)
depression, often milder, lasting at least 2 yrs
Seasonal affective disorder
symptoms usually associated with winter season; improves in response to full-spectrum bright-light exposure
Atypical depression is characterized by...
mood reactivity, reversed vegetative symptoms (hypersomnia and weight gain), leaden paralysis, and interpersonal rejection sensitivity
Treatment of Atypical Depression
-MAO inhibitors -SSRIs
Postpartum mood disturbances has onset within...
4 wks of delivery
Maternal (postpartum) blues are characterized by...
depressed affect, tearfulness, and fatigue starting 2-3 days after delivery.
Maternal blues usually resolves...
within 10 days. Treatment is supportive and requires follow-up.
Postpartum depression is characterized by...
depressed affect, anxiety and poor concentration starting within 4 wks after delivery. It lasts 2 wks to a year or more.
Postpartum psychosis is characterized by...
delusions, hallucinations, confusion, unusual behavior and possible homicidal/suicidal thoughts/attempts. Usually lasts days to wks.
Pathologic grief is...
normal bereavement characterized by shock, denial, guilt and somatic symptoms. Duration varies (up to 6-12 months). May experience simple hallucinations (ex. hearing name called).
treatment option for MDD refractory to other treatment and pregnant women with MDD; also considered when immediate response is necessary, in depression with psychotic features and for catatonia.
a relatively painless seizure in an anesthetized pt.
Adverse effects of ECT include...
disorientation, temporary HA and partial amnesia (resolves).
Risk factors for suicide completion
SAD PERSONS -sex (male) -age (teen or elderly) -depression -previous attempt -ethanol or drug use -loss of rational thinking -sickness -organized plan -no spouse -social support lacking
Symptoms of anxiety disorder will...
interfere with daily functioning.
Anxiety disorder includes...
panic disorder, phobias, and generalized anxiety disorder.
Panic Disorder is defined by...
the presence of recurrent panic attacks (periods of intense fear and discomfort peaking in 10 min with at least 4 of the following): 1. palpitations 2. paresthesias 3. Abdominal distress 4. Nausea 5. intesnse fear of dying or losing control 6. light-headedness 7. chest pain 8. chills 9. choking 10 disconnectedness 11. sweating 12. shaking 13. shortness of breath *strong genetic component
Treatment for Panic Disorder
-behavioral therapy -SSRIs -venlafaxine -benzodiazepines
Diagnosis of Panic Disorder requires an attack followed by 1 month of at least 1 of the following:
1. persistent concern of additional attacks 2. worrying about the consequences of the attack 3. behavioral change related to the attacks
Specific phobias can be treated with...
Types of specific phobia
-social anxiety disorder -agoraphobia
Social Anxiety Disorder can be treated with...
exaggerated fear of open or enclosed places, using pulbic transportation, being in line or in crowds or leaving home.
Generalized anxiety disorder is a pattern of...
uncontrollable anxiety for at least 6 months that is unrelated to a specific person, situation or event.
Generalized anxiety disorder is associated with...
sleep disturbance, fatigue, GI disturbance and difficulty concentrating.
Treatment for Generalized Anxiety Disorder
-SSRIs -SNRIs -Buspirone -Cognitive behavioral therapy
Ego dystonic obsessive-compulsive disorder is...
inconsistent with one's own beliefs and attitudes.
Treatment of OCD
In PTSD, the disturbance lasts...
more than one month causing significant distress, negative cognitive alterations and/or impaired functioning.
Treatment of PTSD
Acute stress disorder lasts...
between 3 days and 1 month.
patient consciously fakes, profoundly exaggerates or claims to have a disorder in order to attain a specific secondary (external) gain (avoiding work or obtaining compensation)
Pts who are malingering have...
poor compliance with treatment and follow-up tests and their complaints stop after the gain.
pt consciously creates physical and/or psychological symptoms in order to assume "sick role" and to get medical attention (primary (internal) gain)
Chronic factitious disorder with predominantly physical signs and symptoms
Munchausen Syndrome is characterized by...
a history of multiple hospital admissions and willingness to receive invasive procedures
Munchausen Syndrome by proxy
when illness in a child or elderly pt is caused by the caregiver; motivation is to assume a sick role by proxy
Somatic symptom, etc. is a category of disorders characterized by...
physical symptoms with no identifiable phyical cause; both the illness production and motivation are unconscious drives; symptoms are not intentionally produced or feigned
-sudden loss of sensory or motor function, often following an acute stressor; pt is aware of but sometimes indifferent toward symptoms (la belle indifference)
Illness anxiety disorder (hypochondriasis)
preoccupation with and fear of having a serious illness despite medical evaluation and reassurance
Cluster A Personality Disorders (Weird)
1. Paranoid 2. Schizoid 3. Schizotypal (Accusatory, Aloof, Awakward)
Cluster A Personality Disorders Features
-odd/eccentric -inability to develop meaningful social relationships -no psychosis -genetic association with schizophrenia
Paranoid Personality Disorder
pervasive distrusta nd suspiciousness; projection is the major defense mechanism
Schizoid Personality Disorder
Voluntary social withdrawal, limited emotional expression, content with social isolation
Schizotypal Personality Disorder
eccentric appearance, odd beliefs or magical thinking, interpersonal awkwardness
Cluster B Personality Disorder Features
-dramatic, emotioinal or erratic -genetic association with mood disorders and substance abuse
Antisocial Personality Disorder
-disregard for and violation of rights of others, criminality, impulsivity *must be older than 18 and have a hx of conduct disorder before age 15
Borderline Personality Disorder
-unstable mood and interpersonal relationships -impulsiveness -self-mutilation -boredome -sense of emptiness **more common in females
A major defense mechanism of borderline personality disorder is...
Histrionic personality disorder
excessive emotionality and excitability attention seeking sexually provocative overly concerned with appearance
Narcissistic personality disorder
-grandiosity -sense of entitlment -lackes empathy and requires excessive admiration -often demands the "best" and reacts to criticism with rage
Cluster C personality disorder features
-anxious or fearful -genetic association with anxiety disorders
Avoidant Personality Disorder
-hypersensitive to rejection, socially inhibited, timid, feelings of inadequacy, desires relationships with others
Dependent Personality Disorder
-submissive and clinging -excessive need to be taken care of -low self-confidence
Anorexia is associated with...
decreased bone density metatarsal stress fractures amenorrhea lanugo anemia electrolyte disorders
The osteoporosis seen in anorexia is partly due to...
decreased estrogen over time.
Bulimia nervosa is associated with...
parotitis enamel erosion electrolyte disturbances alkalosis dorsal hand calluses (Russel sign)
DDx for Sexual Dysfunction Disorders include:
-drugs (antihypertensives, neuroleptics, SSRIs and ethanol) -diseases (depression, diabetes, STDs) -psychological (performance anxiety)
Sleep terror disorder occurs during...
slow-wave sleep, non-REM (thus, no memory upon arousal); most commonly in children.
Nightmares occur during...
REM sleep (and thus, you have a memory of it).
Triggers of sleep terror disorder include...
emotional stress, fever or lack of sleep.
disordered regulation of sleep-wake cycles with the primary characteristic being excessive daytime sleepiness. *strong genetic component
Narcolepsy is caused by a decrease in...
orexin production in the lateral hypothalamus.
Narcolepsy is associated with (3):
1. hypnagogic/hypnopompic hallucinations 2. nocturnal and narcoleptic episodes that begin with REM 3. cataplexy
loss of all muscle tone following a strong emotional stimulus, such as laughter)
Treatment for Narcolepsy:
-daytime stimulants (amphetamines, modafinil) -nighttime sodium oxybate (GHB)
Substance use disorder is defined as a maladaptive pattern of substance use defined as 2 or more of the following signs in one year:
-tolerance -withdrawal -substance taken in larger amounts or over longer time, than desired -persistant desire/unsuccessful attempts to cut down -significant energy spent obtaining, using or recovering from substance -importnat social, occupational or recreational activities reduced -continued use in spite of the knowledge that it causes a problem -craving -recurrent use in physically dangerous situations -failure to fulfill major obligations at work, school, home -social/interpersonal conflicts
6 Stages of Change in overcoming substance abuse
1. Precontemplation 2. Contemplation 3. Preparation/determination 4. Action/willpower 5. Maintenance 6. Relapse
Nonspecific symptoms of intoxication with a depressant
-mood elevation -decreased anxiety -sedation -behavioral disinhibition -respiratory depression
Nonspecific symptoms of withdrawal from a depressant
-anxiety -tremor -seizures -insomnia
-alcohol -opioids -barbituates -benzodiazepines
Symptoms of alcohol toxicity
-emotional lability -slurred speech -ataxia -coma -blackouts
A sensitive indicator of alcohol use is...
serum gamma-glutamyltransferase (GGT).
Symptoms of alcohol withdrawal
-if severe, can cause autonomic hyperactivity and DTs
Treatment for DTs from alcohol withdrawal
Symptoms of opioid intoxication
-euphoria -respiratory/CNS depression -decreased gag reflex -pupillary constriction -seizure
Treatment for Opioid intoxication
Symptoms of Opioid withdrawal
-sweating -dilated pupils -piloerection -fever -rhinorrhea -yawning -nausea -stomach cramps -diarrhea
Treatment for opioid withdrawal
Symptoms of Barbituate intoxication
-low safety margin -marked respiratory depression
Treatment of Barbituate intoxication
-assist respiration -increase BP
Symptoms of Barbituate withdrawal
-delirium -CV collapse
Symptoms of benzodiazepine intoxication
-greater safety margin -ataxia -minor respiratory depression
Treatment of benzodiazepine intoxication
supportive; consider flumazenil (competitive benzodiazepine antagonist)
Symptoms of withdrawal from Benzodiazepines
-sleep disturbance -depression -rebound anxiety -seizure
Nonspecific symptoms of stimulant intoxication
-mood elevation -psychomotor agitation -insomnia -cardiac arrhythmias -tachycardia -anxiety
Nonspecific symptoms of stimulant withdrawal
-post-use "crash" including depression, lethargy, weight gain and headache
1. amphetamines 2. cocaine 3. caffeine 4. nicotine
Symptoms of Amphetamine intoxication
-euphoria -grandiosity -pupillary dilation-prolonged wakefulness and attention -HTN -tachycardia -anorexia -paranoia -fever -severe: cardiac arrest, seizure
Symptoms of Amphetamine Withdrawal
-andhedonia -increased appetite -hypersomnolence -existential crisis
Symptoms of Cocaine Intoxication
-impaired judgement -pupillary dilation -hallucinations -paranoid ideations -angina -sudden cardiac death
Treatment of Cocaine intoxication
Symptoms of cocaine withdrawal
-hypersomnolence -severe psychologic craving -depression/suicide
Symptoms of caffeine intoxication
-restlessness -increased diuresis -muscle twitching
Symptoms of caffeine withdrawal
-lack of concentration -HA
Symptoms of nicotine intoxication
Symptoms of nicotine withdrawal
-irritability -anxiety -craving
Treatment for nicotine withdrawal
-nicotine patch, gum, etc. -buproprion/varenicline
-PCP -LSD -Marijuana
Symptoms of marijuana intoxication
-belligerence -impulsiveness -fever -psychomotor agitation -analgesia -nystagmus -tachycardia -homicidality -psychosis -delirium -seizures
Treatment for PCP intoxication
-benzodiazepines -rapid acting antipsychotic
Symptoms of PCP withdrawal
-depression -anxiety -irritability -restlessness -anergia -disturbances of thought and sleep
Symptoms of LSD intoxication
-perceptual distortion -depersonalization -anxiety -paranoia -psychosis
Symtpoms of marijuana toxicity
-euphoria -anxiety -paranoid delusions -perception of slowed time -impaired judgment -social withdrawal -increased appetite -dry mouth -conjunctival injection -hallucinations
Prescription form of marijuana is...
Dronabinol which is used as antiemetic (chemo) and appetite stimulant in AIDS.
Symptoms of marijuana withdrawal
-irritability -depression -insomnia -nausea -anorexia *most peak at 48 hrs and last 5-7 days
Marijuana is generally detectable in the urine for...
Heroin addicted pts are at increased risk for...
hepatitis, abscesses, overdose, hemorrhoids, AIDS, and right-sided endocarditis.
If you suspect heroin addiction, look for...
track marks (needle sticks in vein).
Treatment for heroin addiction
-Methadone -Naloxone + Buprenorphine -Naltrexone
Methadone is a...
long-acting oral opiate; used for heroin detoxification
Naloxone + Buprenorphine is a...
partial opioid agonist; long-acting with fewer withdrawal symptoms than methadone
a long-acting opioid antagonist used for relapse prevention once a pt is detoxified from heroin
Complications of Alcoholism (5)
1. alcoholic cirrhosis 2. hepatitis 3. pancreatitis 4. peripheral neuropathy 5. testicular atrophy
Treatment for Alcoholism
Wernicke-Korsakoff syndrome is caused by..
thiamine deficiency. It has a triad of confusion, ophthalmoplegia and ataxia. May progress to irreversible memory loss, confabulation and personality change.
Wernicke-Korsakoff is associated with...
periventricular hemorrhage/necrosis of the mammillary bodies.
Treatment for Wernicke-Korsakoff is...
IV vitamin B1 (thiamine).
Mallory-Weiss Syndrome is...
longitudinal, partial thickness tear at the GE junction caused by excessive vomiting. Often presents with hematemesis. Associated with pain.
Delirium tremens is...
a life-threatening alcohol withdrawal syndrome that peaks 2-5 days after the last drink.
Symptoms of Delirium tremens in order of appearance
-autonomic system hyperactivity (tachycardia, tremors, anxiety, seizures) -psychotic symptoms (hallucinations, delusions) -confusion
Treatment for Delirium tremens
Preferred drug for ADHD
Preferred drug for alcohol withdrawal
Preferred drugs for anxiety
-SSRIs -SNRIs -Buspirone
Preferred drugs for bipolar
-mood stabilizers (lithium, valproic acid, carbamazepine) -atypical antipsychotics
Preferred drug for bulimia
Preferred drugs for depression
-SSRIs -SNRIs -TCAs -Bupropion -Mirtazapine (esp. with insomnia)
Preferred drugs for OCD
Preferred drugs for panic disorder
-SSRIs -venlafaxine -benzodiazepines
Preferred drug for PTSD
Preferred drug for schizophreina
Preferred drug for social phobias
Preferred drug for tourette's
-antipsychotics (haloperidol, risperidone)
CNS Stimulants (4)
1. methylphenidate 2. dextroamphetamine 3. methamphetamine 4. phentermine
Mechanism of CNS Stimulants
-increase catecholamines at the synaptic cleft, esp. NE and DA.
Clincial use of CNS stimulants
ADHD Narcolepsy Appetite control
Antipsychotics (neuroleptics) (5)
1. Haloperidol 2. Trifluoperazine 3. Fluphenazine 4. Thioridazine 5. Chlorpromazine
Mechanism of Antipsychotics
All typical antipsychotics block dopamine D2 receptors (increase cAMP).
Clinical use of antipsychotics
-schizophrenia (mainly + symptoms) -psychosis -acute mania -Tourette's
Antipsychotics are very slow to be removed from the body because...
they are highly lipid soluble and are stored in body fat.
Toxicity of antipsychotics
-extrapyramidal system effects (dyskinesias) -endocrine side effects (galactorrhea) -dry mouth, constipation (from blocking muscarinic receptors) -hypotension (from blocking alpha-1 receptors -sedation (from blocking histamine receptors)
Neuroleptic malignant syndrome
toxicity of antipsychotics causing rigidity, myoglobinuria, autonomic instability and hyperpyrexia
Treatment forNeuroleptic malignant syndrome
-dantrolene -D2 agnoists (bromocriptine)
toxicity of antipsychotics casuing oral-facial movements
High potency antipsychotics
-Trifluoperazine, Fluphenazine, Haloperidol *these cause neurologic side effects (EPS system)
Low potency antipsychotics
-Chlorpromazine, Thioridazine *these cause non-neurologic side effects
Chlorpromazine can also cause...
Thioridazine can cause...
Haloperidol can also cause...
NMS or tardive dyskinesia.
Evolution of EPS side effects
-4 hr acute dystonia -4 day akathisia -4 wk bradykinesia -4 month tardive dyskinesia
Atypical Antipsychotics (6)
1. Olanzpaine 2. Clozapine 3. Quetiapine 4. Risperidone 5. Aripiprazole 6. Ziprasidone
Clinical use of atypical antipsychotics
-schizophrenia (+ and - symptoms) -Bipolar -OCD -anxiety disorder -depression -mania -tourette's
Olanzapine/Clozapine may cause...
significant weight gain.
Clozapine may cause...
agranulocytosis (requires weekly WBC monitoring) and seizure.
Risperidone may increase...
prolactin (lactation/gynecomastia) leading to decreased GnRH, LH and FSH (irregular menstruation/fertility).
prolong the QT interval.
Clinical use of Lithium
-mood stabilizer for bipolar disorder -blocks relapse and acute manic episodes -SIADH
Toxicity of Lithium
-tremor -sedation -edema -heart block -polyuria -teratogenesis
Lithium causes polyuria because...
it is an ADH antagonist causing nephrogenic DI.
Fetal cardiac defects from lithium include...
Ebstein anomaly and malformation of the great vessels.
stimulates 5-HT(1A) receptors
Use of Buspirone
-generalized anxiety disorder (1-2 wks to take effect) (does not interact with alcohol)
1. Fluoxetine 2. Paroxetine 3. Sertraline 4. Citalopram
Mechanism of SSRIs
5-HT specific reuptake inhibitors
Use of SSRIs
-depression -GAD -Panic disorder -OCD -bulimia -social phobias -PTSD
Toxicity of SSRIs
-GI distress -sexual dysfunction -serotonin syndrome w/ any drug that increases 5HT (MAO inhibitors, SNRIs, TCAs)
-hyperthermia -confusion -myoclonus -CV collapse -flushing -diarrhea -seizures
Serotonin Syndrome is treated with...
Cyproheptadine (5-HT2 receptor antagonist)
For SSRIs to start taking effect, it takes...
Mechanism of SNRIs
inhibit 5-HT and NE reuptake
Use of SNRIs
depression -Venlafaxine also for GAD and panic disorder -Duloxetine also for diabetic peripheral neuropathy
Toxicity of SNRIs
increased BP stimulant effects sedation nausea
Tricyclic Antidepressants (7)
1. amitriptyline 2. nortriptyline 3. imipramine 4. desipramine 5. clomipramine 6. doxepin 7. amoxapine
block reuptake of NE and 5-HT
Uses of TCAs
-depression -OCD (clomipramine) -fibromyalgia
Toxicity of TCAs
-sedation -alpha-1 blocking effects (postural hypotension) -atropine-like effects (anticholinergic - tachycardia, urinary retention, dry mouth) -convulsions -coma -cardiotoxicity -respiratory depression -hyperpyrexia
Tertiary TCAs (amitriptyline) have more...
anticholinergic effects than secondary TCAs (nortriptyline) have.
Desipramine is less...
sedating but has higher seizure incidence.
In the elderly, TCAs can cause...
confusion and hallucinations due to anticholinergic side effects (use nortriptyline).
Treatment for cardiotoxicity from TCAs
Monoamine oxidase inhibitors (4)
1. Tranylcypromine 2. Phenelzine 3. Isocarboxazid 4. Selegine (slective MAO-B inhibitor)
Mechanism of MAO inhibitors
inhibition of MAO leading to increased levels of amine neurotransmitters (NE, 5-HT, DA)
use of MAO inhibitors
-atypical depression -anxiety -hypochondria
Toxicity of MAOIs
-hypertensive crisis (typically w/ ingestion of tyramine) -CNS stimulation
MAOIs are contraindicated with...
SSRIs TCAs St. John's wort Meperidine Dextromethorphan
1. Buproprion 2. Mirtazapine 3. Trazodone
NE and DA
Besides depression, buproprion is also used for...
Toxicity of Buproprion
-stimulant effects -HA -seizure in bulimic pts
-alpha2-antagonist (increased release of NE and 5-HT) -potent 5-HT2 and 5-HT3 antagonist
Toxicity of Mirtazapine
-sedation -increased appetite -weight gain -dry mouth
-blocks 5-HT2 and alpha1-adrenergic receptors
Trazodone is primarily used for...
Toxicity of Trazodone
sedation nausea priapism postural hypotension