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Flashcards in Psychiatry Deck (150):
1

major risk factors for suicide

psychiatric disorders
feelings of hopelessness or worthlessness
impulsivity
increasing age
male sex
access to weapons
history of suicide attempts

2

neurotransmitters decreased in depression

serotonin, norepinephrine, dopamine

3

medical illnesses that can cause depressive symptoms

hypothyroidism
hyperparathyroidism
Parkinson disease
stroke
HIV
Cancer (esp CNS neoplasms, which can mimic depression)

4

Drugs known to cause depressive symptoms

sedatives (alcohol, benzodiazepines, antihistamines)

withdrawal from stimulants (cocaine, amphetamines)

some antihypertensives (methyldopa, clonidine, beta- blockers)

first- generation antipsychotics (haloperidol)

prochlorperazine

metoclopramide

long-term glucocorticoid use

interferon- alpha (contraindicated in depression)

5

MDD with atypical features

mood reactivity
increase appetite and weight gain
hypersomnia
leaden paralysis
hypersensitivity to rejection
responds well to MAOIs

6

MDD with seasonal pattern

recurrent depression exhibiting a regular temporal or seasonal pattern
treatment: light therapy (10,000 lux at least 30 min/day)

7

MDD with peripartum onset

onset during pregnancy or up to 4 weeks postpartum

8

MDD with psychotic features

delusions or hallucinations develop during an episode of MDD

No psychosis except during depressive episodes (the depression is always present even when the psychosis isn't_

9

Schizoaffective disorder

baseline psychosis
mood disorder secondary to psychosis

10

persistent depressive disorder (formerly known as dysthymic disorder)

chronic, persistent depression for at least 2 YEARS (MDD no longer precludes persistent depressive disorder as it used to in DSM4)

depressed mood plus 2 SIGECAPS symptoms

more difficult to treat than MDD

11

SSRIs

citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline

first line for depression as well as anxiety

work in 3-4 weeks

12

SNRIs

desvenlafaxine, duloxetine, milnacipran (fibromyalgia only), venlafaxine

13

Atypical antidepressants

buproprion, mitrazapine, nefazodone, trazodone

14

TCAs

amitriptyline, doxepin, imipramine, nortriptyline

15

MAOIs

phenelzine, tranylcypromine

16

side effects of SSRIs

sexual dysfunction
insomnia/agitation
weight gain
risk of suicidal ideation
risk of serotonin syndrome

17

Serotonin syndrome

mental status changes: anxiety, agitation, delirium, restlessness, disorientation

autonomic excitation: diaphoresis, tachycardia, hyperthermia, hypertension, vomiting, diarrhea

Neuromuscular hyperactivity: tremor, muscle rigidity, hyperreflexia, myoclonus
ocular clonus (slow, continuous, horizontal eye movements)
spontaneous or inducible clonus
positive Babinski sign bilaterally

18

Which drugs increase the risk of serotonin syndrome

SSRIs
SNRIs
MAOIs
TCAs
St. John's wort
Tryptophan
Triptans
Linezolid
Levodopa
Stimulants (cocaine, ecstasy- MDMA, amphetamines)

19

How do we treat serotonin syndrome?

discontinue all serotonergic agents and symptoms usually resolve in 24 hours

Supportive care to normalize vital signs
-oxygen, IV fluids, cardiac monitoring
-if medical treatment for tachycardia or HTN is needed, use short- acting agents (esmolol, nitroprusside)

Sedation with benzodiazepines

If T>41, sedation, paralysis, ET tube- mechanical cooling
-paralysis should relieve the hyperthermia, which is caused by muscle activity
-there is no benefit in using antipyretics in this scenario

If agitation despite benzodiazepine then use a serotonin inhibitor like cyproheptadine

Adter sx resolve, assess need to resume serotonergic agent

20

side effects of SNRIs

sexual dysfunction
insomnia/agitation
nausea
dizziness
hypertension (venlafaxine)
risk of serotonin syndrome

21

norepinephrine dopamine reuptake inhibitor (NDRI)

buproprion

blocks presynaptic reuptake of NE and DA

use this to treat fatigue and hypersomnia, but not anxiety

also indicated for smokine cessation

22

NDRI (buproprion) side effects

blocks pre-synaptic re-uptake of DA

insomnia, weight loss, lowers seizure threshold, contraindicated in anorexia, eating disorder, seizure disorder

no sexual dysfunction!

23

Alpha2 antagonist- mirtazapine

blocks alpha 2- adrenergic receptors, which leads to increased NE release

side effects include sedation for unknown reasons, appetite stimulation, and weight gain

useful in cancer patients who have comorbid depression

24

Serotonin modulators: trazadone, nefazodone, vilazodone

these drugs have a variety of effects on serotonin receptors (agonist/antagonist depending on the receptor subtype)

The main side effect is sedation
Trazedone can even be used as a sleep aid

priapism

25

TCAs:
amitriptyline
clomipramine
imipramine
nortriptyline

not really used much anympre
block NE and serotonin reuptake
3rd line due to poor side effect profile

side effects:
anticholinergic effects (amitriptyline especially)
sedation
sexual dysfunction
weight gain
dangerous in overdose

26

What findings are seen in TCA OD?

cardiotoxicity: tachycardia, hypotension, conduction abnormalities

CNS toxicity:sedation, obtundation, coma, seizures

antiCholinergic symptoms: mydriasis, xerostomia, ileus, urinary retention

27

MAOIs
tranylcypromine
phenelzine

inhibits MAO; increases levels of serotonin, DA, NE

not used often, due to side effects and interactions with food (tyramine builds up and stimulates autonomic nervous system)

side effects: drug- drug interactions
hypertensive crisis

28

what foods contain tyramine and should be avoided while on MAO in order to avoid hypertensive crisis?

foods that are spoiled, pickled, aged, smoked, fermented, or marinated
-fermented cheeses (cream cheese and cottage cheese are ok)
-smoked or aged meats (sausage, bologna, pepperoni, salami, smoked or pickled fish)
-chianti, most beers and wines (especially over 120 mL)
-soy sause, shrimp paste, miso soup
-sauerkraut, avocados, ripe bananas, fava beans

29

What are the indications for electroconvulsive therapy?

severe, debilitating depression refractory to antidepressants
psychotic depression
severe suicidality
depression with food refusal leading to nutritional compromise
depression with catatonic stupor
situations where a rapid antidepressant response is required (eg pregnancy)
previous good response to ECT
bipolar/mania
schizophrenia/psychosis (catatonia especially)

30

TCA that can be used to treat bedwetting in children

imipramine

31

Bipolar I disorder

at least one manic episode
may or may not have MDD or hypomanic episodes

32

Bipolar II disorder

At least one hypomanic episode
At least one major depressive episode
Never had a manic episode

33

Manic episode

elevated, expansive, or irritable mood
increased goal- directed activity or energy

lasts at least one week

Distractability
Insomnia
Grandiosity
Flight of ideas
Activity/agitation
Speech
Taking risks

34

Manic episode versus hypomanic episode

Manic:
at least 3 DIG FAST symptoms
at least 1 week
impaired function, or requires hospitalizations, or includes psychotic features

Hypomanic episode
at least 3 DIG FAST symptoms
lasts at least 4 days
no impairment in functioning, hospitalizations, or psychosis

35

Treatment for bipolar

Lithium (unless renal failure, in which case lithium is contraindicated and valproic acid and carbamazepine are choice)
Anticonvulsants (valproate, carbamazepine, lamotrigine)

Lithium and anticonvulsants are mood stabilizers

Atypical antipsychotics (aripiprazole, olanzapine, quetiapine, risperidone)
ECT

do not use SSRIs, which can push a patient into mania. treat depression in the setting of bipolar, with mood stabilizers

36

What are side effects of lithium in treating bipolar disorder?

Teratogenesis (Ebstein anomaly)
CNS effects (depression, tremor, cognitive dulling)
Thyroid dysfunction (hyperthyroidism, hypothyroidism, euthyroid goiter)
GI effects (nausea, vomiting, diarrhea, weight gain, metallic taste changes)
Nephrogenic diabetes insipidus (polyuria, polydipsia)

37

How do we treat nephrogenic diabetes insipidus that results from lithium toxicity?

hydrochlorothiazide with amiloride

38

Ebstein anomaly

tricuspid leaflets displaced inferiorly
tricuspid regurgitation or stenosis

RV hypoplasia

+/- patent foramen ovale

39

Cyclothymic disorder

mild hypomanic symptoms that do not meet criteria for a hypomanic episode

mild depressive symptoms that do not meet criteria for a major depressive episode

symptoms are present for at least 2 YEARS (Adults), or 1 year in children

periods of normal mood last less than 2 months during that 2 year (Adult) or 1 year (child) stretch

DOES cause significant distress or impairment in social/occupational functioning

Tx: mood stabilizers, psychotherapy

40

Dissociative disorders

Dissociative identity- multiple personalities, 2 or more distinct identities/ personalities)

Depersonalization/derealization disorder- depersonalization- persistent feelings of detachment from patient's own body or thoughts, or feeling like people and things around the patient aren't real

Dissociative amnesia- amnesia for a very specific event, or generalized amnesia of patient's identity and personal life history.
May include dissociative fugue

41

Panic disorder

recurrent panic attacks, with abrupt onset of intense fear and anxiety accompanied by
palpitations or tachycardia
sweating
trembling/shaking
SOB
choking sensation
CP
dizziness/lightheadedness
nausea
hot flashes/chills
paresthesias
feeling of losing control
fear of dying

Panic attach is followed by a period of persistent worry about more panic attacks, or maladaptive behavior to prevent panic attacks. This period lasting at least one month

Treat with CBT, SSRIs, Benzodiazepines acutely (but beware addiction)

42

Generalized anxiety disorder

Excessive anxiety and worry occurring more days than not for at least 6 months

At least 3 of the following symptoms:
-hyperarousal
-difficulty concentrating
-irritability
-muscle tension
-difficulty sleeping
-fatigue

SSRIs, SNRIs, Buspirone, CBT

43

Specific phobias

marked fear out of proportion to the threat the situation poses, with avoidance of the feared exposure

exposure therapy- gradual desensitization

44

Social anxiety disorder

excessive anxiety related to social situations, with fear of being negatively evaluated by others (eg social interactions, being observed by others, performing in front of others)

Treat:
CBT, SSRI, SNRI
Benzodiazepine or beta- blocker (propanolol), as needed for performances

45

Buspirone as an anxiety medication

second- line treatment
may be used as monotherapy or in combination with SSRIs and SNRIs
Affinity for serotonin and dopamine receptors

46

Benzodiazepines as anxiety meds

increase the frequency of opening of GABA- receptor chloride channels

frequent use may lead to tolerance, dependence, withdrawal seizures

47

agoraphobia

excessive fear of being outside the home alone, using public transporation, and being in a crowd

this isn't a specific phobia

48

delusion

irrational belief that cannot be changed by proof or rational arguments

49

illusion

misinterpret a stimulus that is actually there

50

hallucinations

sensory perception in the absence of external stimulus

51

Disorganized thought

circumstantiality- answers diverge from the question asked but eventually return to the original topic

tangentiality- answers diverge from the question asked and do NOT return to the original topic. The point keeps changing, though you can see the links

Loose associations- no clear sequence to the thoughts presented

Word salad- words strung together incoherently

Neologism- new words

52

Schizophrenia:at least 2 of the following during a 1 month period (including at least 1 of the first 3)

plus social/occupational dysfunction

for a duration of at least 6 months

delusions
hallucinations (most common type is auditory)
disorganized speech
grossly disorganized or catatonic behavior
negative symptoms (flat affect, poverty of speech, lack of emotional reactivity)

53

Schizophrenia risk factors

family history
being born in late winter/early spring
maternal illness/malnutrition during pregnancy
+/- psychoactive drug use during adolescence and young adulthood
male gender

Neuroimaging- enlargement of lateral and third ventricals
cortical thinning

54

Schizophrenia negative symptoms

flat affect
social withdrawal
avolition/apathy
anhedonia
poverty of speech

55

schizotypal personality disorder

odd thoughts/behavior/appearance
discomfort with interpersonal relationships

56

schizoid personality disorder

voluntary social isolation

57

schizoaffective disorder

psychosis with intermittent mood disorder

58

schizophrenia

psychosis that lasts at least 6 months

59

schizophreniform disorder

psychosis for less than 6 months

60

brief psychotic disorder

psychosis less than 1 month

61

Delusional disorder

delusions for one month or more
no other symptoms of shizophrenia (hallucinations, if present, are not prominent and are related to the delusion)
social/occupational function is not impaired

62

What drugs cause psychosis?

hallucinogens (LSD, PCP)
stimulants (cocaine, amphetamines)
withdrawal from benzodiazepines, alcohol, barbiturates
glucocorticoids
anabolic steroids

63

Parkinson disease

loss of dopamine- producing neurons in the substantia nigra

resulting in depigmentation,
increased ACh
increased Lewy body formation (eosinophilic inclusions of alpha- synuclein and ubiquitin proteins, with a halo around the Lewy body)

64

risk factors for PD

family history
advancing age
head trauma
MPTP metabolite, which destroys DA cells of substantia nigra

65

Parkinsonism

bradykinesia, hypokinesia, akinesia
postural instability (can't make small adjustments)
festinating gait (difficulty initiating walking)
shuffling gait to keep upright
pill- rolling tremor (while at rest)
cogwheel rigidity
mask- like facies
orthostatic hypotension (autonomic dysfunction)
cognitive dysfunction
depression

66

Huntington

CAG repeat on chromosome cuatro
caudate atrophy on MRI
acetylcholine and GABA are decreased
cognitive decline (dementia)
choreiform movements
cuarenta (40)= age of onset
usually fatal within 20 years of diagnosis

symptomatic treatment with DA antagonists (tetrabenazine), or antipsychotics (haloperidol, risperidone)

67

Personality disorder

persistent behavior that deviates significantly from cultural norms, with symptoms that lead to impaired function in society, beginning in late adolescence

and not attributable to:
drug use
medical conditions
other psych disorders

68

Cluster A personality disorders

Weird- inability to develop meaningful social relationships, also without psychosis
paranoid
schizoid
schizotypal

69

Paranoid personality disorder

long-standing suspiciousness and general distrust of others, look for clues to validate distrust

70

Schizoid personality disorder

schizoids avoid
voluntary social withdrawal
limited emotional expressions
don't smile, content with social isolation

71

schizotypal

dressed like a pickle
eccentric appearance, odd beliefs, magical thinking

interact with others awkwardly, visibly odd in their appearance

72

Cluster B personality disorders

wild, drama
Antisocial
Borderline
Histrionic
Narcissistic

73

Antisocial

disregard for rights of others, criminality
male>female
"conduct disorder" under age 18

74

Borderline

unusual variability and depth of moods
unstable moods
chaotic interpersonal relationships

impulsiveness, self- mutilation (cutting), sense of emptiness

females>males

splitting is typical
high likelihood of suicide

75

Histrionic

Excessive emotions
attention- seeking
seductive behavior
overly concerned with appearance
appearance can be provocative or exaggerated

"odd to us, but to them it looks very special"

76

Narcissistic

excessively preoccupied with personal prestige, power, vanity
lack empathy
require excessive admiration

77

Cluster C disorders

very anxious and fearful
anxiety disorders

worried, cowardly, compulsive, clingy

Avoidant
Dependent
Obsessive- compulsive

78

Avoidant

hypersensitivity to rejection
socially inhibited, timid, feelings of inadequacy

want to relate to others but don't know how

79

Dependent

psychologically dependent on other people
very low self esteem
submissive and clinging
excessive need to be taken care of

80

Obsessive- compulsive personality disorder

preoccupation with order
concerned with perfectionism and control

81

Substance use disorder

problematic pattern of substance use that leads to significant impairment or distress

Characterized by
tolerance
withdrawal symptoms
persistent desire or unsuccessful attempts to cut down
Significant energy spent obtaining, using, or recovering from the substance
Important social, occupational, or recreational activities reduced
Continued use in spite of knowing the problems that it causes
Craving
Recurrent use in physically dangerous situations
Failure to fulfill major obligations at work, school, or home
Social or interpersonal conflicts

82

Alcohol intoxication

CNS depression, mood elevation, disinhibition, decreased anxiety and sedation, severe mental impairment, somnolence, respiratory depression

83

Alcohol withdrawal

agitation, anxiety, insomnia, tremor

84

Where does alcohol act on the brain

GABA receptor, similar to benzos

85

Treatment for alcohol intoxication

time, can be life-threatening
anxiety, tremor, agitation, tachycardia, severe withdrawal causes DT (2-3 days after cessation)

86

Delirium tremens (DT)

2-3 days after cessation of alcohol
nightmares, agitation, disorientation, visual/auditory hallucinations, fever, hypertension, diaphoresis, seizures, autonomic hyperactivity

87

how to treat alcohol withdrawal

benzodiazepines, preferably long-acting benzodiazepines
diazepam
lorazepam
chlordiazepoxide

88

Complications of longterm alcohol use

liver damage
fatty change (hepatocytes)
increased GGT
increased AST and ALT
alcoholic cirrhosis
hepatitis
pancreatitis
peripheral neuropathy
testicular atrophy
aspiration pneumonia
-klebsiella

GI bleeding
-mallory- weiss tears
-esophageal variceal bleed

malnutrition
-b12
-Wernicke-Korsakoff due to B1 thiamine deficiency
-Wernicke is the thiamine deficiency
-Korsakoff is secondary to Wernicke

89

Wernicke encephalopathy

confusion
nystagmus
ophthalmoplegia
ataxia
sluggish pupillary reflexes
coma
death if untreated

90

Korsakoff syndrome is the fallout of Wernicke

characteristics include...

anterograde amnesia
retrograde amnesia
confabulation
hallucinations

this is due to atrophy of the mammillary bodies

treatment:
IV thiamine BEFORE glucose repletion

91

Thiamine vs glucose for the alcoholic (or malnourished) patient?

Always give thiamine before glucose to any patient with mental status changes or to any malnourished alcoholic patient

92

treatments for alcoholism recovery

alcoholics anonymous
naltrexone
disulfiram
topiramate
acomprosate

93

Benzodiazepine intoxication

CNS depression
decreased anxiety
disinhibition
coma
respiratory depression

94

Benzodiazepine withdrawal

agitation
anxiety
seizures

95

How do we treat Benzodiazepine overdose

flumazenil

96

5 stages of behavioral change

precontemplation
contemplation
preparation

97

precontemplation

patient in denial, doesn't ackowledge that there is a problem

98

contemplation

thinking about change, though they aren't ready for it yet

99

preparation

making concrete plans to change

100

action

implementing the plan

101

maintenance

the change had been made and they are ready to not go back to previous behaviors

102

Amphetamines

increase release of intracellular stores of catecholamines

103

cocaine

blocks reuptake of catecholamines (in the synaptic cleft)

104

amphetamine and cocaine intoxication

euphoria and high energy

this may lead to agitation, anxiety, insomnia

increased BP, tachycardia, cardiac arrest, stroke (cocaine), pupullary dilateion, erosions in the nose (cocaine)

105

indications for amphetamines

ADHD
short- term weightloss

106

Amphetamine and cocaine withdrawal symptoms

depression
lethargy
weightgain
headache

107

Treat amphetamine intoxication

benzodiazepines
haloperidol

108

treat cocaine intoxication

benzodiazepines
haloperidol
no beta blockers, because the alpha receptors will continue to be stimulated
phentolamine is an alpha blocker that could be useful

109

caffeine and nicotine intoxication

excitability
restlessness
diuresis (caffeine)
premature atrial contractions
premature ventricular contractions

110

caffeine and nicotine withdrawal symptoms

irritability
anxiety
craving
tiredness

111

Treating nicotine withdrawal

nicotine replacement
(patch, gum, lozenge)

buproprion
varenecline

112

hallucinogen intoxication

hallucinations
delusions
anxiety
paranoia
tachycardia
pupillary dilation
flashbacks (chronic use)

113

treat hallucinogen intoxication

remove patient from dangerous environment and place in a quiet dark room

antipsychotics (PO, IM)
Benzodiazepines for anxiety and agitation

114

marijuana intoxication

euphoria, sense of well-being
anxiety, paranoia, delusions

perception of slowed time
impaired judgment
social withdrawal
increased appetite
dry mouth
hallucinations
redness of eyes

115

marijuana withdrawal

irritability
insomnia
nausea

peak 4-8 hours, but still there for about a month

116

opioids (morphine, heroin, methadone)

CNS depression
Euphoria
n/v
constipation
pupillary constriction (miosis)
seizures
respiratory depression

117

Treat opioid intoxication with

naloxone
naltrexone

118

opioid withdrawal- symptoms and treatment

sweating
dilated pupils
piloerection
yawning
rhinorrhea
flu-like symptoms

uncomfortable but not life- threatening

treat with methadone, suboxone (naloxone plus buprenorphine- this decreases withdrawal symptoms without providing a satisfying high)

119

PCP

belligerance
impulsiveness
agitation
nystagmus (horizontal and vertical)
homicidal ideation/ violence
psychosis
delirium

120

How to treat PCP intoxication

treatment: benzodiazepines, antipsychotics

121

PCP withdrawal

violence (again)
depression
anxiety
irritability

122

Anorexia

patient refuses to maintain normal body weight
risk factors- female adolescents (14-18yo especially)
high socioeconomic status

diagnosis:
distorted body image
intense fear of gaining weight
restricted caloric intake relative to energy requirements

features:
amenorrhea
cold intolerance and/or hypothermia
dry, scaly skin
hair loss
lanugo (fine, downy hair)
hypogonadism
osteoporosis
comorbid anxiety, OCD, depression

treatment:
psychotherapy
SSRI for comorbid depression or anxiety
buproprion is contraindicated (risk of seizures)
hospitalization may be required to address nutritional deficiencies and complications

123

What is refeeding syndrome?

Sudden shift from fat metabolism to carbohydrate metabolism may cause-

hypophosphatemia
hypokalemia
hypomagnesemia
CHF and arrhythmias
Rhabdomyolysis
Delirium
Seizures

124

Bulimia nervosa

Bulemics usually maintain a normal body weight

Recurrent episodes of binge eating

Inappropriate compensatory behaviors to prevent weight gain (purging, intense exercise, severe caloric restriction)

Recurrent vomiting may cause
-scarred hands
-dental erosions
-enlarged parotid glands and elevated serum amylase
-hypochloremic metabolic alkalosis

treatment:
-cognitive behavioral therapy
-pharmacotherapy: SSRIs

125

Binge- eating disorder

episodes of binge eating
no inappropriate compensatory behaviors
patients tend to be overweight/obese

treatment:
-cognitive behavioral therapy
-SSRIs, topirimate, stimulants

126

Obsessive- compulsive disorder

Obsessions: recurrent, UNWANTED, intrusive, anxiety- provoking thoughts or urges
Compulsions: repetitive behaviors or mental acts performed to relieve the anxiety caused by obsessive thought.

Diagnosis requreist hat the obsessions and compulsions are TIME- CONSUMING and cause impairment in social/occupational functioning

Treatment: cognitive behavioral therapy

Exposure and response prevention

Pharmacotherapy (SSRIs)

combination can be effective

127

Body dysmorphic disorder

preoccupation with a perceived defect in appearance

repetitive behaviors/mental acts related to perceived defects (can be internal or external)

Treatment:
avoid performing needless surgery
psychotherapy
SSRIs for refractory cases (off label use)

128

Hoarding disorder

anxiety, distress associated with getting rid of stuff
diagnosis requires impaired social function

129

changes associated with bulimia?

hypochloremic metabolic alkalosis from vomiting
increased amylase from salivary gland inflammation

130

Trauma disorders

PTSD
Acute stress disorder
Adjustment disorder

131

PTSD diagnosis

1. exposure to something traumatic
2. Rexperiencing the traumatic event (memories, dreams, flashbacks)
3. Avoidance of stimuli associated with the traumatic event
4. Negative changes in cognition and mood
5. Hyperarousal (irritable behavior, reckless behavior, hypervigilance, sleep disturbance)

These symptoms have to last at least 1 month

132

What are the treatment options for PTSD?

Psychotherapy, including behavioral (exposure) therapy and cognitive therapy

SSRIs are first line
Benzodiazepines should be avoided due to lack of efficacy and potential for abuse

alpha blocker (prazosin) may be used to resolve nightmares and improve sleep

no evidence to support use of TCAs, MAOIs, atypical antipsychotics, or mood stabilizers

133

acute stress disorder versus PTSD

This is like PTSD but

134

Adjustment disorders

emotional response to psychosocial stressor

-depressed mood
-anxiety
-disturbance of conduct
in any combination

-clinically significant emotional or behavioral reaction causing marked distress and/or impairment in social/occupational functioning

-symptoms develop in response to an identifiable psychosocial stressor (cancer, divorce, death of a loved one, family conflict, loss of job, moving, major life changes)

-symptoms begin within 3 months of the onset of the stressor

-symptoms disappear within 6 months of the stressor disappearing

Also, the symptoms cannot meet the criteria for another disorder

135

Somatic symptom and related disorders

conversion
somatic symptom disorder
illness anxiety disorder
factitious disorder

136

Conversion disorder

Neurological sx without recognized or medical cause
-motor: weakness/paralysis, tremor, dystonia/myoclonus, gait disorder, dysphagia, dysphonia
-sensory (numbness/paresthesias, blindness, deafness)

May or may not be the result of a specific psychological stressor

137

How to treat conversion disorder

psychotherapy, CBT, physical therapy
find the root

138

Somatic symptom disorder

one or more somatic symptoms that is distressing or distruptive
-disproportionate and persistent thoughts about the seriousness of the symptoms
-high anxiety about health or symptoms
-excessive time and energy to symptoms or health concerns

Note: hypochondriasis no longer exists

139

Illness anxiety disorder

-preoccupation with having or acquiring a serious illness
-high level of anxiety about health
-individual performs excessive health- related behaviors
-somatic symptoms are not present

helpful to see these patients at regular intervals

140

Factitios disorder (Munchausen syndrome)

intentional induction of injury or disease, or falsification of signs/symptoms of illness

patient presents him/herself as ill or injured

deceptive behavior is present even in the absence of external reward

141

Factitious disorder imposed on another (previously known as Munchausen by proxy)

child or elder abuse,
also in the absence of external gain

142

Malingering

not a mental disorder
external reward desired

143

overwhelming worry about contracting a serious illness, without any signs or symptoms

illness anxiety disorder

144

overwhelming worry about the seriousness of existing physical symptoms

somatic symptom disorder

145

ADHD

decreased attention span
inability to complete tasks
forgetfulness
excessive talking and movement

for diagnosis, questionnaires are given toparents as well as 2 people who have direct contact with the student

diagnosis: 6 inattention or 6 hyperactivity/impulsivity symptoms before age 12

The symptoms limit the ability to function in social, educational, or organized settings

146

ADHD treatment

1. stimulants
methylphenidate
lisdexamfetamine
dextroamphetamine

2. atomoxetine (milder, but also helps with focusing behavior)

3. Tricyclic antidepressants:
-imipramine
-desipramine
-nortriptyline

4. buproprion
5. Clonidine alpha-2 agonist
6. eliminate foods high in caffeine and sugar

147

Common complications of ADHD stimulant medications

1. insomnia- sleep hygiene, take meds earlier, short duration formulation, clonidine at night
2. appetite suppression and weightloss- administer meds after meals rather than before
3. Tics- usually transient, choose low- moderate dose methylphenidate, which does not worsen tics
4. psychosis- discontinue (no need to taper)
5. decreased growth velocity (reassure parents that adult height is not affected. drug holidays can help with catch up growth.

148

Side effects of atomoxetine

1. increased risk of suicidality- close observation and usually discontinuation
2. liver injury (d/c without taper)

149

Tourette syndrome- therapeutic options

counseling/psychotherapy for social adjustment and coping

if interfering with necessary functions of life- anti-dopamine agents can be used
-fluphenazine
-pimozide
-tetrabenazine

(all are generally tolerated better than haloperidol)

if only focal motor or vocal tics, Botox injections into affected muscles

if impulse control problems, clonidine or SSRIs

if refractory to medical management, consider deep brain stimulation of globus pallidus, thalamus, or other subcortical target (undergoing clinical trials)

150

Autism spectrum disorder

severe, persistent impairement in interpersonal interactions

patient who is "living in his own world"
symptoms prior to age 3
lack of responsiveness to others, poor eye contact, absent social smile

impaired communication, language delay, repetative phrases

peculiar repetitive, ritualistic habits (spinning, hand flapping)

fascination with specific, seemingly mundane objects (vacuum cleaners, sprinklers)

below- normal intelligence

r/o metabolic causes
tx: behavior, speech, social, psychotherapy with peers
supervision if severe