Test 3 Flashcards
(157 cards)
1
Q
symptoms can include delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior trouble (catatonia) with thinking and concentration, and lack of motivation (dimunition loss of function). broughout on by social or environmental that may precipitate prodromal symptoms ex. going away, substance, death
what is it? what causes it?
A
schizophrenia: biologically (10x chance of developing it). A chronic w/ chronic, relapsing remitting course w/ no cure (exacerbations and resmisions w/ further deterioration in baseline functioning after each relapse). equal men (earlier onset 10-25) and women (25-35). more likely to be born in the winter and early spring, more addicted to nicotine, and in urban settings. Exposure to viruses (prenatal exposure), malnutrition before birth or other problems, psychosocial factors.
must be 2+ of the following w/ 1, 2, or three required
. For a significant portion of the time since the onset of the disturbance, decreased level of functioningin one or more major areas (work, interpersonal relations, or self-care)
C. Continuous signs of the disturbance persist for at least 6 months.
- Must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A
- May include periods of prodromal or residual symptoms
2
Q
- Ventriculomegaly – lateral and third ventricles
- Diffuse gray matter loss
- Decreased volume in frontal and temporal cortex
- Possible thalamic volume reductions
- Reduced size of corpus callosum
what is it and what is the neurodevelopment model?
A
brain abnormalities in schizophrenia.
- Abnormal brain development begins in utero
- Based on genetic susceptibility and environmental insults
- Delayed symptom activation following adolescence-related developmental CNS changes (puberty)
- Fairly static picture thereafter
3
Q
hallucinations what kinds?
A
- Auditory- Most common – 40-80%; Frequently voices – can be music, body noises, machinery
- Visual- Often unformed
- Tactile
- Olfactory
- Gustatory
4
Q
what are delusions?
A
- Fixed, false beliefs- Present in 80% of people with schizophrenia
- Bizarre (delusionsare clearly implausible – content may not be understandable) vs. non-bizarre (delusionsare not true but are understandable & have the possibility of being true (ex – IRS after me for not paying taxes))
- Reference– random events are not random, individual involved in some way (“song on the radio is delivering a special message to me”)
- Grandiose– special significance or power
- Paranoid/persecutory– being followed, conspired against
- Nihilistic– non-existence of everything, including self (uncommon)
- Erotomanic– special relationship/in love with an individual
- Somatic– body functions or sensations
- Jealous– spouse/partner unfaithful
5
Q
What is disorganized behavior and thought?
A
- Disorganizedbehavior– observed odd or nonpurposeful movements, doing things that dont make sense
- Disorganized thought
- Tangential
- Circumstantial
- Loose associations – words make sentences, sentences don’t make sense
- Flight of ideas
- Derailment – suddenly switching topics
- Neologisms
- Word salad – words are thrown together without any sensible meaning
- Clanging – words are associated by sound (rhyming) rather than meaning
6
Q
What are the negative symptoms of schizophrenia?
A
- •Decreased expressiveness
- •Flat affect – unchanging facial expression
- •Poverty of speech
- •Thought blocking – abrupt interruption in thought before idea is finished
- •Amotivation-apathy
- •Poor grooming
- •Low energy
- •Social isolation
7
Q
What are cognitive symptoms of schizophrenia?
A
- •Impairments in multiple areas of cognition, including:
- •Processing speed
- •Attention
- •Working memory
- •Verbal learning and memory
- •Visual learning and memory
- •Reasoning/executive functioning- frontal lobe due to structural changes
- •Verbal comprehension
- •Social cognition
8
Q
What is catatonia? what other disorders is it linked to?
A
- •Catatonia– behavioral syndrome marked by an inability to move normally (not schizophrenia but associated w/ it)
- •Stupor – decreased psychomotor activity/reactivity
- •Catalepsy – passively allowing the examiner to position the body/body part
- •Waxy flexibility – slight, even resistance to positioning by the examiner – bending a candle
- •Mutism – lack of verbal response
- •Negativism – motiveless resistance to all instructions or attempts to be moved
- •Posturing – voluntarily maintaining a position of the body or a body part against gravity
- •Mannerisms – odd movements
- •Stereotypy – repetitive movements that are not goal directed – often awkward or stiff
- •Agitation or excessive motor activity – purposeless – not influenced by external stimuli
- •Grimacing
- •Echolalia – mimicking another person’s speech
- •Echopraxia – mimicking another person’s movements
- Diagnostic criteria: 3+ of the aforementioned symptoms
- Catatonia can occur in the context of many underlying psychiatric disorders, including bipolar disorder, schizophrenia, MDD, autism spectrum disorder, and delirium.
- Catatonia is typically diagnosed in an inpatient setting and occurs in up to 35% of individuals with schizophrenia, but the majority of catatonia cases involve individuals with depressive or bipolar disorders.
9
Q
What disorders can present w/ psychotic features?
A
- •Mood disorders
- •Bipolar disorder
- •MDD with psychotic features bad
- •Other psychotic disorders
- •Schizoaffective disorder
- •Delusional disorder
- •Personality disorders (next slide)
- •Schizotypal, paranoid
- •Anxiety disorders
- •OCD, PTSD
- •Other
- •Dementia
10
Q
What are the cluster A personality disorders?
A
mimic psychosis
- •Schizoid personality disorder
- •Detachment from social relationships and a restricted range of emotional expression
- •Schizotypal personality disorder
- •Eccentricities of behavior
- •Paranoid personality disorder
- •Distrust and suspiciousness such that others’ motives are interpreted as malevolent
- Key differentiating feature = psychotic disorders have a period of persistent psychotic symptoms, personality disorders do not. the same level of functioning and not at the same intensity
11
Q
What general medical conditions can also cause psychosis?
A
- •Neurological
- •Stroke
- •Seizures
- •Brain tumor
- •Parkinson’s disease
- •Endocrine
- •Thyroid/parathyroid
- •Metabolic
- •B12, folate, thiamine
- •Infectious
- •HIV, syphilis, herpes
- •Other
- •Lupus
- •Wilson’s disease (copper)
- •Delirium always has underlying medical problem changes in it are more rapid
- Medications/substances
12
Q
What are some substances that can produce psychosis?
A
- •Alcohol
- •Anabolic steroids- Testosterone
- •Analgesics- Meperidine (Demerol), indomethacin
- •Anticholinergics
- •Antidepressants- commonly triggers mania presenting as psychosis
- •Bupropion – others – trigger mania/psychosis
- •Antiepileptics
- •Antimalarial
- •Anti-parkinsonian
- •Levodopa, amantadine – increase dopamine
- •Antivirals- Acyclovir
- •Cannabinoids
- •Marijuana, synthetic (K2, spice)
- •Cardiovascular
- •Digoxin
- •Corticosteroids- should be educated about very common
- •Prednisone, dexamethasone
- •Hallucinogens
- •LSD, PCP, mushrooms, etc.
- •Inhalants
- •Interferons
- •OTC
- •Dextromethorphan, diphenhydramine
- •Stimulants
- •Adderall, cocaine, meth, diet pills, bath salts, MDMA
- •Toxins
- •Heavy metals
13
Q
What can trigger schizophrenia exacerbations?
A
- Non-adherence to treatment
- Inadequate support system
- Inadequate socialization/recreation
- Substance abuse
- High expressed emotion
14
Q
What are some factors that are favorable prognostic signs for schizophrenia?
A
- Acute onset
- Late onset
- Knownprecipitant- see more favorable prognosis
- Female
- Good/high premorbid functioning
- Few negative/cognitive symptoms
- Positive symptoms
- Good support system
15
Q
what are some factors that cause suicide in schizophrenic patients?
A
- •~20% attempt suicide
- •~5-10% complete
- •Nearly half of suicides occur within 6 months of hospital discharge
- •Most common earlyin the course of treatment during higher level of functioning and better insight
- •Risks:
- •Improving insight
- •Hopelessness
- •Higher premorbid functioning
- •Subtherapeutic medication dosage
- •Abrupt discontinuation of meds
- •Social isolation
- •Male
16
Q
What are some medical comorbidites in schizophrenia?
psychosocial complications?
A
- •Substance-related disorders
- •Anxiety – higher rates of OCD/panic disorder
- •Decreased life expectancy due to medical comorbidities
- •Weight gain
- •DM
- •Cardiovascular and pulmonary disease
- •Poor engagement in health maintenance behaviors increases the risk of chronic disease
- •Other factors: medication side effects, lifestyle, cigarette smoking, diet
- •Provider bias
- •Shared vulnerability for psychosis and medical disorders
- Socioeconomic
- Educational
- Occupational
- Legal/violence
- Medical
- Family/interpersonal
17
Q
What is the treatment of schizophrenia?
A
- •Disease management
- •Acute
- •Requires immediate attention
- •Goal: alleviate psychotic symptoms
- Untreated Can last 4-8 weeks
- May require psychiatric hospitalization if patient is deemed at risk of harming themselves or others
- chronic
- •Goals: prevent relapse, improve level of functioning
- Continuation of medications – consider monthly injectables as appropriate
- Community support
- Skills training
- Group psychotherapy
- •Acute
- •Pharmacotherapy is essential, but insufficient by itself
- •Rehabilitation/recovery
- •Coordination of care
- •Community support
18
Q
1st generation antipsychotics what are they what is their side effect?
A
- Haloperidol (Haldol)
- Chlorpromazine (Thorazine)
- Indication for intractable hiccups
- Fluphenazine (Prolixin)
- Thioridazine (Mellaril)
- Side effects:
- Extrapyramidal side effects (EPS)
- Tardive dyskinesia (TD)
- QT prolongation
- Orthostatic hypotension
19
Q
Side effects and benefits of 2nd generation antipsychotics?
A
- •Side effects
- •QT prolongation
- •Increased prolactin
- •Metabolic risks:
- •Hyperlipidemia
- •Hyperglycemia
- •Weight gain
- •Agranulocytosis – clozapine
- •Benefits:
- •Lower risk of EPS and TD
- •More effective with negative symptoms
- •Flat affect, emotional unresponsiveness, social withdrawal…
- •Lower cognitive impairment
- •Mood stabilizing properties – can be used for bipolar disorder
20
Q
what are the 2nd generation antipsychotics?
A
- Olanzapine (Zyprexa) – sedating
- Risperidone (Risperdal) – more likely to increase prolactin
- Quetiapine (Seroquel) – weight gain, sedating
- Ziprasidone (Geodon) – +QT prolongation, lower metabolic effects
- Aripiprazole (Abilify) – no QT prolongation, antidepressant augmentation, lower metabolic effects
- Clozapine (Clozaril) – agranulocytosis
- Lurasidone (Latuda) – newest, low metabolic effects, low cardiac effects
21
Q
What is special about clozapine in patients w/ schizophrenia?
A
- •Unique efficacy in treatment-resistant schizophrenia
- •Blocks receptors for several neurotransmitters, including dopamine, norepinephrine, serotonin, acetylcholine
- •AGRANULOCYTOSIS
- •Registry of patients
- •WBC differential monitoring:
- •Baseline – prior to initiating treatment
- •Weekly for 6 months
- •Every other week for 6 months
- •Every month after 1 year for the duration of treatment
- •After discontinuation, every week x 4 weeks
22
Q
similar to schizophrenia briefer symptoms lasting for 1-6 months more common in men
A
schizophreniform disorder
23
Q
- Sudden onset of psychotic symptoms:
- 1) Delusions
- (2) Hallucinations
- (3) Disorganized speech
- (4) Grossly disorganized or catatonic behavior
- Symptoms last 1 day – 1 month
- Full remission – individual returns to premorbid level of functioning
- Acute and transient
more common in women
what is it where is it seen more? what is one thing to note?
A
brief psychotic disorder
- May be seen more in:
- Individuals of low socio-economic status
- Individuals who have experienced disasters or major cultural changes (immigrants, refugees)
- Individuals who have experienced major psychosocial stressors
full return to premorbid level of functioning
One thing to note: Note: Do not include a symptom if it is a culturally sanctioned response: “for example, in some religious ceremonies, an individual may report hearing voices, but these do not generally persist and are not perceived as abnormal by most members of the individual’s community. In addition, cultural and religious background must be taken into account when considering whether beliefs are delusional.”
24
Q
- False, fixed beliefs not keeping with one’s culture
- Persist for at least 1 month
- The presence of one (or more) delusions with a duration of 1 month or longer.
- Criterion A for schizophrenia has never been met (positive symptoms)
- Functioning is not markedly impaired.
- Behavioris not obviously bizarre or odd.
A
patients are difficult to treat
25
What are the types of delusional disorder?
* Erotomanictype: Central theme of the delusion is that another person is in love with the individual.
* Grandiose type: Central theme of the delusion is the conviction of having some great (but unrecognized) talent or insight or having made some important discovery.
* Jealous type: Central theme of the individual’s delusion is that his/her spouse/lover is unfaithful.
* Persecutory type: Central theme of the delusion involves the individual’s belief that he or she is being conspired against, cheated, spied on, followed, poisoned or drugged, maliciously maligned, harassed, or obstructed in the pursuit of long-term goals.
* Somatic type: This subtype applies when the central theme of the delusion involves bodily functions or sensations.
* Mixed type: This subtype applies when no one delusional theme predominates.
Unspecified type: This subtype applies when the dominant delusional belief cannot be clearly determined or is not described in the specific types
26
* Features of both schizophrenia and mood disorders
* Schizophrenia + depression orbipolar disorder
* An uninterrupted period of illness during which there is a major mood episode (major depressive or manic) concurrent withCriterion A of schizophrenia.
* Delusions or hallucinations for 2+ weeks in the absence of a major mood episode (depressive or manic) during the lifetime duration of the illness.
* Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of the illness.
What is it? who is it most common in? what are the subtypes?
* •Psychotic symptoms and mood symptoms can exist independentlyof each other
* •Treat mood symptoms only àpsychotic symptoms still exist
* •Treat psychotic symptoms only àmood symptoms still exist
Depressive subtype more common in women
* Bipolar type: A manic episode is part of the presentation. Major depressive episodes may also occur.
* Depressive type: Only major depressive episodes are part of the presentation.
27
What is psychosomatic medicine?
* How the mind affects the body
* Patients with these disorders are often frustrated: “they told me it was all in my head”
28
What is consultation-liasion psychiatry?
* The study, practice, and teaching of the relation between medical and psychiatric disorders
* Consult on patients in medical or surgical settings and provide follow-up psychiatric treatment as needed
* Bridge between psychiatry and other specialties (education of other specialties)
* Large amount of consults on patients with psychosomatic complaints/disorders
29
* Patients believe that they have a serious undetected disease and often cannot be persuaded otherwise, even by negative workups
* Symptoms can be specific (localized pain) to nonspecific (fatigue)
* Patients may seek care from multiple doctors for the same symptoms
* More frequent in individuals with few years of education and low socioeconomic status
* More frequent in those who have recently experienced stressful life events
* Can also be associated with a history of childhood trauma or sexual abuse ex. Thoughts and feelings depressed, unconscious way or trauma
* Disproportionate and persistent thoughtsabout the seriousness of one’s symptoms
* Persistently high level of anxietyabout health or symptoms
* Excessive time and energydevoted to these symptoms or health concerns
* low threshold for physical discomfort
* social learning of "sick role" modeled after parent, level, or friend
* men and women equally 20-30
* agressive and hostile wishes toward others transferred (through repression and displacement into physical complainnts (mind-body connection))
somatic symptoms disorder- •Excessivethoughts, feelings, or behaviors related to the somatic symptoms by more than 1 of the following persistently symptomatic more than 6 months:
80% have coexisting depression or anxiety.
can be viewed as a defense against guilt, sense of innate badness, an expression of low self-esteem, sign of excessive self concern.
30
What is your differential for people w/ somatic symptom disorder?
* •General medical conditions
* •Need to rule out zebras before diagnosing somatic symptom disorder
* •Ex: AIDS, myasthenia gravis, multiple sclerosis, degenerative diseases of the nervous system, lupus, occult neoplastic disorders
* •Illness anxiety disorder-hypochrondriac
* •Fear of having a disease rather than a concern about many symptoms
* •Conversion disorder
* •Presenting symptom is loss of function (ex: of a limb)
* àSomatic symptom disorder: focus is on the distressthat particular symptoms cause
* •Panic disorder
* •Somatic symptoms and anxiety occur in acute episodes
* àSomatic symptom disorder: anxiety and somatic symptoms are more persistent
* •Delusional disorder
* •In somatic symptom disorder, beliefs are not held with delusional intensity
31
How long does somatic symptom disorder progress? What are the treamtent?
* Episodic; episodes can last for months to years with equally long symptom-free periods
* There can be an association between exacerbations and psychosocial stressors (more stress = worse symptoms)
* A good prognosis is associated with:
* •Higher socioeconomic status
* •Treatment-responsive anxiety or depression
* •Sudden onset of symptoms
* •Absence of a personality disorder
* •Absence of a related non-psychiatric medical condition
* Treatment
* •Many patients resist psychiatric treatment)- believe underlying medical cause
* •Psychotherapy
* •Treat underlying/comorbid depression/anxiety (sometimes it is enough)
* •Consider regularly scheduled physical examinations help to reassure patients that their physicians are not abandoning them and that their complaints are being taken seriously
* •Invasive diagnostic and therapeutic procedures should only be undertaken if there is objective evidence after diagnosis is made
32
pain in one or more body sites severe enough to be brought to clinical attention.
## Footnote
* Excessivethoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by 1+ of the following:
* Disproportionate and persistent thoughtsabout the seriousness of one’s symptoms
* Persistently high level of anxietyabout health or symptoms
* Excessivetime and energy devoted to these symptoms or health concerns
Somatic symptom disorder with predominant pain(previously pain disorder): this specifier is for individuals whose somatic symptoms predominantly involve pain
•Psychological factors are necessary in the genesis, severity, or maintenance of the pain, which causes significant distress, impairment, or both
Note: symptoms of irritable bowel syndrome or fibromyalgia would not satisfy the criterion necessary to diagnose somatic symptom disorder
33
* Preoccupation with having or acquiring a serious illness
* Somatic symptoms are not present or mild in intensity
* There is a high level of anxiety about health, and the individual is easily alarmed about personal health status. slightest pain or discomfort is a worse disease
* The individual performs excessive health-related behaviors(ex: repeatedly checks body for signs of illness) or exhibits maladaptive avoidance (ex: avoids doctor appointments and hospitals)
* Illness preoccupation has been present for at least 6 months, but the specific illness that is feared may change over that period of time.
what is it? what does it categorize? how do you treat it?
illness anxiety disorder
## Footnote
* Similar prevalence in males and females
* Distress does not primarily come from the physical complaint itself but rather from the anxiety about the meaning, significance, or cause of the complaint
* Concerns do not respond to appropriate medical reassurance/workup
* Can be precipitated by a major life stress or a serious but ultimately benign threat to the individual’s health
* A history of childhood abuse or of a serious childhood illness may predispose one to the development of the disorder in adulthood
* Generally thought to be chronic and relapsing similar to somatic symptom disorder
Treatment
* Patients tend to resist treatment
* Psychotherapy +/- pharmacotherapy
* Regularly scheduled examinations are more controversial; may help some patients while exacerbating fears in others
34
What is the differential diagnosis of illness anxiety disorder?
* •General medical conditions
* •Obsessive compulsive disorder
* •Illness anxiety: preoccupations are focused on having a disease presently
* •OCD: intrusive thoughts focused on fear of getting a disease in the future
* •Most individuals with OCD have obsessions or compulsions involving other concerns
* •No compulsions in illness anxiety disorder
* •Psychotic disorders
* •Illness anxiety disorder: not delusional, can acknowledge the possibility that the feared disease is not present
* •Ideas do not attain the rigidity and intensity seen in the somatic delusions occurring in psychotic disorders
* •True somatic delusions are generally more bizarre (an organ is rotting or dead)
35
* Psychoanalytic factors
* Repression of an unconscious conflict àconversion of anxiety into physical symptoms
* Learning theory
* Symptoms of illness learned in childhood àway to cope with a difficult situation
* Biological factors
* Symptoms may be caused by an excessive cortical arousal that sets off negative feedback loops between the cerebral cortex and the brainstem reticular formation àinhibits awareness of bodily sensation (can explain observed sensory deficits)
* Maladaptive personality traits are commonly associated with conversion disorder (personality disorder develop after the fact)
* There may be a history of childhood abuse and neglect
* Stressful life events are often (but not always) present
* Sensory symptoms
* Anesthesia/paresthesia common in extremities
* Symptoms can be unilateral or bilateral
* Sensory pathways intacton neurologic exam
* Motor symptoms
* Abnormal movements, gait disturbance, weakness, paralysis
* The movements generally worsen when attention is called to them
* Reflexes remain normal; no fasciculation or muscle atrophy; EMG normal
* Seizure symptoms (PNES = psychogenic non-epileptic seizures)- pseudo-seizures
* Non-epileptic seizures are common
* 1/3 of patients with PNES also have epilepsy (can have insight into both)
* Tongue-biting, urinary incontinence, and falling injuries are typically not present in PNES
* La belle indifference: inappropriately cavalier attitude toward serious symptoms; the patient seems to be unconcerned about what appears to be a major impairment
conversion disorder
* One or more symptoms of altered voluntary motor or sensory function
* Clinical findings provide evidence of incompatibilitybetween the symptom and recognized neurological or medical conditions
àNeuro symptoms with a negative neuro workup (nonepipiletpticseizures, inability to walk, etc.)
* The symptom or deficit causes clinically significant distress or impairment in functioning or warrants medical evaluation
* May account for 5-15% of psychiatric consultations in a hospital setting
* More common in women
* Onset is typically from late childhood to early adulthood
* Most common among:
* Rural populations
* Persons with little education
* Low socioeconomic groups
* Military personnel who have been exposed to combat situations
Commonly associated with comorbid diagnoses of depression and anxiety
* Course/Prognosis
* Acute onset
* Typically short duration; most symptoms remit spontaneously within 2 weeks of hospitalization
* Symptoms resolution is less than 50% in patient who have symptoms \> 6 months
* Longer duration of symptoms = less chance of recovery
* Good prognosis:
* Acute onset
* Presence of clearly identifiable stressors at the time of onset
* Short interval between onset and treatment
* Above average intelligence
* Treatment
* Psychotherapy
* Physical therapy
* Treat any underlying anxiety/depression
36
What is the differential diagnosis of conversion disorder?
* •Neurological disease
* •Needs to be ruled out
* •Somatic symptom disorder
* •The excessive thoughts, feelings, and behaviors in somatic symptom disorder are often absentin conversion disorder
* •Most of the somatic symptoms in somatic symptom disorder cannot be demonstrated to be clearly incompatible with pathophysiology (pain, fatigue); in conversion disorder, such incompatibility is requiredfor the diagnosis
* •Factitious disorder/malingering
* •In conversion disorder symptoms are NOT intentionally produced
* •Depressive disorder
* •Can have general heaviness of limbs in depression; conversion disorder loss of function is focal and prominent
* •Panic disorder
* •Paresthesias/tremors are transient in panic disorder
37
* Falsificationof physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception
* The individual presents himself or herself to others as ill, impaired, or injured
* The deceptive behavior is evident even in the absenceof obvious external rewards
* Unusual, dramatic presentation of symptoms that defy conventional medical or psychiatric understanding
* Symptoms do not respond appropriately to usual treatment or medications
* Emergence of new, unusual symptoms when other symptoms resolve
* Eagerness to undergo procedures or testing or to recount symptoms
* Reluctance to give access to collateral sources of information (i.e., refusing to sign releases of information or to give contact information for family and friends)
* Extensive medical history or evidence of multiple surgeries
* Multiple drug allergies
* Medical profession
* Few visitors
* Ability to forecast unusual progression of symptoms or unusual response to treatment
•
•
Factitious disorder imposed on self = Munchausen syndrome
Imposed on another = Munchausen by proxy
* Consider history of childhood abuse/neglect/trauma
* Course/Prognosis
* Typically intermittent episodes
* Onset is usually in early adulthood after a hospitalization for a medical or psychiatric disorder
* Lifelong hospitalizations with some patients, particularly factitious disorder imposed on self (give themselves serious infections)
* Treatment
* No specific treatment is effective
* Focus instead on management:
* Reduce the risk of morbidity and mortality
* Avoid unnecessary tests and invasive procedures
* Address underlying psychiatric diagnoses
38
What are the differential diagnosis of factitious disorder?
* •Somatic symptom disorder
* •Patient is not providing false information or behaving deceptively
* •Malingering
* •Personal gain ($$$, time off of work, etc.)
* •No personal gain in factitious disorder
* •Conversion disorder
* •No falsification of symptoms in conversion disorder
* •Borderline personality disorder
* •Self-harm without suicidal intent (cutting) is common, but no deception
* •Medical/psychiatric diagnoses
* •May still be present
39
What is it given the following:
DSM-5 Criteria:
* Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health.
* Intense fear of gaining weight or of becoming fat
* Disturbance of body image
* Lack of insight into current low body weight
Anorexia Nervosa
40
What are the two main types of Anorexia Nervosa?
What are the severity in adults?
1. Restricting type: Weight loss through dieting, fasting, and/or excessive exercise
2. Binge-eating/purging type: During the last 3 months, the individual has engaged in recurrent episodes of binge eating or purging behavior (self-induced vomiting or the misuse of laxatives, diuretics, or enemas)
Severity (adults)
* Mild: BMI ≥ 17 kg/m2
* Moderate: BMI 16–16.99 kg/m2
* Severe: BMI 15–15.99 kg/m2
* Extreme: BMI \< 15 kg/m2
41
Explain the epidemiology of Anorexia Nervosa
Explain the comorbidities of Anorexia Nervosa
Epidemiology
* Most common age of onset 14-18 years old, range 10-30 years
* Estimated to occur in 0.5-1% of adolescent girls
* 10-20x more common in females
* The prevalence of young women with some symptoms of anorexia nervosa who do not meet the diagnostic criteria is estimated to be ~5%
* More frequent in developed countries
* More common in professions that “require” thinness (modeling, elite athletics)
Comorbidities
* Depression, anxiety, OCD
42
Explain the etiology of Anorexia Nervosa
Etiology
“Genetics loads the gun, environment pulls the trigger”
* Evidence for a genetic component
* Environmental factors:
* Teasing
* Psychosocial factors
* Societal pressure
* Intensive exercise/food restriction (results will help them develop it)
* Substance abuse
43
Given these clinical features, what disorder are we speaking of?
* Onset can be related to a stressful life event (ex: leaving for college, moving, breakups)
* Intense fear of gaining weight or being fat that is not relieved by weight loss
* Peculiar behavior about food: hiding food around home, hiding food in napkins/pockets, rearranging food with poor insight into these behaviors
* Patients tend to be perfectionists
* Delayed psychosocial sexual development
* Taking a sexual history can distinguish between anorexia and belemia
* Amenorrhea
* Cold intolerance
Anorexia Nervosa
44
Given these clinical findings, what disorder are we talking about?
Physical Findings
* Bradycardia
* Hypotension
* Lanugo- fine hair growing everyone on skin
* Dry skin, scaling skin
* Dry hair- thinning, falling out
* Low body temperature/difficulty regulating
* Peripheral edema
* Body is slowing down to conserve energy
Anorexia Nervosa
45
Given the following image, what disorder are we speaking of?
Anorexia Nervosa
46
What are the cardiovascular and gastrointestinal effects of Anorexia Nervosa?
Cardiovascular effects
* Decreased cardiac output
* EKG changes
* T wave flattening/inversion (torsades)
* ST depression
* QT prolongation 🡪 risk of arrhythmias
Gastrointestinal effects
* Early satiety
* Constipation
47
Given the following information, what disorder are we referring to?
Differential Diagnoses
* Medical conditions
* Hyperthyroidism, occult malignancies, GI disease, HIV
* 🡪 Thinking about underlying causes of weight loss
* Depression
* Decreased appetite of depression can differentiate
* In depression there is no fear of obesity or body image disturbance (mood versus weight)
* Anxiety/OCD
* Many similar symptoms; with eating disorders the symptoms are only related to food
* Consider additional diagnosis of OCD only if the obsessions and compulsions are unrelated to food
* Somatization disorder
* Weight loss is typically not as severe in somatization disorder
* No fear of being overweight
* Amenorrhea is uncommon
* Schizophrenia
* May have bizarre eating habits or delusions about food, but typically about food being poisoned
* No fear of weight gain
* Bulimia nervosa
* Typically maintain near-normal body weight
Anorexia Nervosa
48
Given the course/prognosis, what is the disorder we are referring to?
Course/Prognosis
* Highly variable
* Restricting patients may be less likely to recover
* Mortality rate 5-18%
* Indicators of a favorable outcome:
* Admission of hunger (improving insight)
* Lessening of denial and immaturity
* Improved self-esteem
* ¼ of patients recover completely
* ½ are markedly improved and functioning fairly well
* ¼ are functioning poorly and chronically underweight
Anorexia Nervosa
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What are the levels of treatment for Anorexia Nervosa?
Tell the four levels then facts about each
Levels of treatment
* Medical hospitalization
* Weight loss \> 30% in 3 months or body weight less than 75% expected
* Severe metabolic changes: K \< 2.5, BUN \> 30, or other signs of dehydration would otherwise necessitate hospitalization
* HR \< 40, SBP \< 70; ekg changes (treatment team in the hospital)
* Inpatient residential treatment
* Weight \> 75th %ile
* Patient requires structure to comply with eating plan / unstable home environment
* Combo of a behavioral management approach, individual psychotherapy, family education/therapy, and psychotropic medications if indicated
* Patients must be willing participants for long-term treatment success
* Intensive outpatient care
* Medically stable, body weight at least 80% of healthy weight
* Patient goes to outpatient center daily for meals, therapy
* Outpatient care
* Body weight \> 85%ile
* Fair to good motivation
* Able to follow meal plan (eat 2/3 of meals there); supportive home structure
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What is the treatment for Anorexia Nervosa?
Psychotherapy
* Individual and family therapy
Pharmacotherapy
* Treat any underlying psychiatric comorbidities
* No serotonin synthesis with poor nutrition… SSRI wont work and wont be as efficatious🡪 Need to eat for meds to work!
* TCAs and antipsychotics have been used for weight gain
* Be aware of side effects in patients with anorexia who are already susceptible to dehydration, cardiac arrhythmias, and hypotension
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What is it given the following?
DSM-5 Criteria:
* Recurrent episodes of binge eating:
* “Eating large amounts of food in a discrete period of time that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances.”
* Lack of control, cannot stop eating
* Recurrent, inappropriate compensatory behaviors to prevent weight gain
* Self-induced vomiting
* Misuse of laxatives, diuretics, or other medications
* Fasting
* Excessive exercise
* The binge eating and inappropriate compensatory behaviors both occur at least once per week for 3 months
* Self-evaluation is highly influenced by body shape and weight
Bulimia Nervosa
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Explain the severities of Bulimia Nervosa
Explain the Epidemiology as well
* Mild: An average of 1-3 episodes of inappropriate compensatory behaviors per week.
* Moderate: An average of 4-7 episodes of inappropriate compensatory behaviors per week.
* Severe: An average of 8-13 episodes of inappropriate compensatory behaviors per week.
* Extreme: An average of 14 or more episodes of inappropriate compensatory behaviors per week.
Epidemiology
* More prevalent than anorexia nervosa
* 1-4 % of young women
* More common in women than men
* Onset is often later in adolescence or early adulthood
* Approximately 20% of college women experience transient bulimic symptoms at some point during their college years
* Can be a history of obesity leading to it,
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Given the etiology, what is the disorder we are referring to:
Etiology
* Combination of biological, social, and psychologic factors
* Increased frequency of bulimia nervosa is found in first-degree relatives of persons with the disorder
* Childhood obesity and early puberty increase risk
* Tend to be high achievers and to respond to societal pressures to be slender
* Tend to be more outgoing, angry, and impulsive than those with anorexia nervosa
* Alcohol dependence, shoplifting, and emotional lability (including suicide attempts) can be associated
Bulimia Nervosa
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Given the clinical features, what disorder are we referring to?
Clinical Features
* Lack of control during binging episodes
* Vomiting allows patients to continue eating without fear of gaining weight
* Depression or “post-binge anguish” often follows the episode guilty for eating things they ate
* The food is eaten secretly and rapidly, sometimes un-chewed, shame
* Most patients are within normal weight range
* Patients are concerned about their body image/appearance, worried about how others see them, and concerned about their sexual attractiveness
* Most are sexually active
Bulimia Nervosa
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Given the following image, what disorder are we referring to?
Also note these Medical Consequences as well:
* Gastric dilatation, pancreatitis after binging episodes
* Vomiting can lead to damaged tooth enamel, pharyngitis, esophagitis, aspiration, electrolyte abnormalities
* Swollen parotid glands
* Constipation and hemorrhoids are common
Bulimia Nervosa
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What are the following electrolyte disturbances with Bulimia Nervosa?
Diuretic abuse
Laxative Abuse
Vomiting
* Diuretic abuse
* Dehydration (NaCl, K depletion)
* Hyperaldosterone
* Renal impairment
* Laxative abuse
* Metabolic acidosis (loss of HCO3)
* Loss of Mg, zinc, Na
* Dehydration
* Vomiting
* Metabolic alkalosis (loss of HCl)
* Dehydration (loss of Na, K)
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Given the differential diagnoses, what disorder are we speaking about?
* Anorexia nervosa, binging/purging type
* Binging/purging only occurs during episodes of anorexia nervosa
* Weight differences
* “Individuals whose binge-eating behavior occurs only during episodes of anorexia nervosa are given the diagnosis anorexia nervosa, binge-eating/purging type, and should not be given the additional diagnosis of bulimia nervosa. For individuals with an initial diagnosis of anorexia nervosa who binge and purge but whose presentation no longer meets the full criteria for anorexia nervosa, binge-eating/purging type (e.g., when weight is normal), a diagnosis of bulimia nervosa should be given only when all criteria for bulimia nervosa have been met for at least 3 months.” –DSM 5
* Binge eating disorder
* No purging behaviors
* Kleine-Levin syndrome
* Rare neurological disorder
* Periodic hypersomnia lasting for 2 to 3 weeks and hyperphagia
* No preoccupation with body shape or weight
* Seasonal affective disorder
* Overeating/binging during winter months
* Not overly concerned with body shape or weight; typically no purging
* Borderline personality disorder
* Both may have impulsive behavior
* Patients with bulimia nervosa often meet criteria for borderline personality disorder
Bulimia Nervosa
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Given the course/prognosis/treatment, what is the disorder we are referring to?
* Higher recovery rates
* Treatment increases rate of recovery
* History of substance abuse and a long duration of ____ predict a worse outcome
* Mortality rate is about 2% per decade (all-cause and suicide)
Treatment:
* Eating disorder inpatient/outpatient treatment
* Psychotherapy
* Pharmacotherapy
* SSRIs may be helpful in reducing binging and purging even in the absence of a mood disorder
Bulimia Nervosa
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What is it given the following?
DSM-5 Criteria:
* Recurrent episodes of \_\_\_\_:
* Eating large amounts of food in a discrete period of time
* Lack of control during episode, cannot stop eating
* The ____ episodes are associated with 3+ of the following:
* Eating much more rapidly than normal
* Eating until feeling uncomfortably full
* Eating large amounts of food when not feeling physically hungry
* Eating alone because of feeling embarrassed by how much one is eating
* Feeling disgusted with oneself, depressed, or very guilty afterward
* Marked distress regarding binge eating is present
* The ___ eating occurs at least once per week for 3 months
Binge Eating Disorder
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•Pervasive pattern of grandiosity (in fantasy and behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by 5 or more of the following
1. Has grandiose sense of self-importance
2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
3. Believes that he/she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions).
4. Requires excessive admiration, if you treat others the same they become difficult.
5. Has a sense of entitlement
6. Is interpersonally exploitative and can become cold hearted
7. Lacks empathy; is unwilling to recognize or identify with the feelings and needs of others
8. Is often envious of others or believes that others are envious of him/her
9. Shows arrogant, haughty behaviors or attitudes
•Mostly (50~75%) are male
narcissistic
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Given the course/prognosis/treatment, what is the disorder we are referring to?
Course/Prognosis
* Little is known
* Appears to be a relatively persistent disorder
* Severe obesity is a long term effect
Treatment
* Psychotherapy is most beneficial
* Mixed results with +/- SSRI
Binge Eating Disorder
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Given the epidemiology and etiology, what disorder are we referring to?
Epidemiology
* ~2% of general population
* More common among patients with insomnia, obesity
Etiology
* Little known
* Genetic component?
* Hormonal component? Leptin, ghrelin, and cortisol have been studied
Night Eating Syndrome
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Given the following information, what syndrome are we referring to?
## Footnote
Consumption of large amounts of food after the evening meal
Little appetite during the day and insomnia
Symptoms must persist for at least 3 months
Patients are more likely to wake up during the night and to eat upon awakening
Patients believe that they can only sleep if they eat
Depressed mood is common, especially during the evening and night hours
Course and prognosis
Age of onset: late teens-late 20s
Long lasting course with periods of remission
Patients with poor sleep quality are more likely to develop diabetes, obesity, hypertension, cardiovascular disease
Treatment
Positive results with SSRIs
Light therapy effective if comorbid depression
Psychotherapy (CBT)
Night Eating Syndrome
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Given the differential diagnoses, what disorder are we speaking of?
Differential Diagnoses
* Bulimia nervosa
* No purging with binge eating disorder
* Anorexia nervosa
* No fear of weight gain with binge eating disorder
* Patients are of normal weight or obese with binge eating disorder and underweight with anorexia
* Obesity
* Obese patients without binge eating disorder have a lower caloric intake; no binging episodes
* Obese patients with binge eating disorder are emotional eaters and can have chaotic eating habits
Binge Eating Disorder
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Given the epidemiology and etiology, what is the name of this disorder?
Epidemiology
* Most common eating disorder
* Present in 50-75% of patients with severe obesity
* More common in females
Etiology
* The cause of binge eating disorder is unknown
* Impulsive and extroverted personality styles are linked to the disorder
* Link to very low calorie diets and weight cycling
* May occur during periods of stress
* May be used to reduce anxiety or depression
Binge Eating Disorder
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Given the following information, what syndrome are we looking at?
* Consumption of large amounts of food after the evening meal
* Little appetite during the day and insomnia
* Symptoms must persist for at least 3 months
* Patients are more likely to wake up during the night and to eat upon awakening
* Patients believe that they can only sleep if they eat
* Depressed mood is common, especially during the evening and night hours
* Course and prognosis
* Age of onset: late teens-late 20s
* Long lasting course with periods of remission
* Patients with poor sleep quality are more likely to develop diabetes, obesity, hypertension, cardiovascular disease
* Treatment
* Positive results with SSRIs
* Light therapy effective if comorbid depression
* Psychotherapy (CBT)
Night Eating Syndrome
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Given the following information, what disorder are we referring to?
* Recurrent purging behavior after consuming small amounts of food
* Normal weight
* Distorted view of weight/body image
* Not associated with binge eating
* Purging episodes occur at least once per week over a 3-month period
* Treatment
* Eating disorder inpatient/outpatient treatment
* Psychotherapy
Purging Disorder
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What is the definition of personality? what are some factors of personality?
The combination of characteristics or qualities that form an individual's distinctive character
* Risk takers
* Putting things away/procrastination
* Having many relationships in few years
* Like to be in spot light
* Very meticulous
* Creative/eccentric
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What are the criteria for personality disorder?
* •A. Moderate or greater impairment in personality (self/interpersonal) functioning 5/9 of the criteria. If it does not impair you does not have personality disorder
* •B. One or more pathological personality traits
* •C. Impairments in personality functioning and the individual’s personality trait expression are relatively inflexible and pervasive across a broad range of personal and social situations
* •D. Impairments in personality functioning and the individual’s personality trait expression are relatively stable across time with onsets that can be traced back to at least adolescence or early adulthood
* •E. Impairments in personality functioning and the individual’s personality trait expression are not better explained by another mental disorder
* •F. Impairments in personality functioning and the individual’s personality trait expression are not solely attributable to the physiological effects of a substance or another medical condition (e.g., severe head trauma)
* •G. Impairments in personality functioning and the individual’s personality trait expression are not better understood as normal for an individual’s developmental stage or sociocultural environments
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* : experience of oneself as a unique with clear boundaries between self and others
* especially borderline personality (don’t know who they are and what they want ) pursuit of coherent and meaningful short-term and life goals
* comprehension and appreciation of others’ experiences and motivations, how they relate
* depth and duration of connection with others many have difficulty forming it can cause self-harm (anti-social can hurt others)
what are the four elements of personality functioning?
identity
self-direction
empathy
intimacy
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What is the five factor model of personality?
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What are the three clusters and what do are they characterized by? what are the
* Cluster A: Odd, Aloof, and Eccentric ex. paranoid, schizoid, schizotypal
* Cluster B: Dramatic, Emotional, Impulsive, and Erratic ex. antisocial, borderline, histrionic, narcissistic
* Cluster C: Anxious and Fearful Ex. avoidant, dependent, OCD
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•Acceptable to the ego (don’t care because it doesn’t bother them ex. Perfectionism doesn’t bother person may bother others)
Ego syntonic
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•Adopt by trying to alter the external environment rather than themselves (because they are egosyntonicex. Cut is not a problem for them chop down rose bush rather than take care of the cut)
allopastic
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what are strong characteristics of people w/ personality disorders?
* People with personality disorders do not feel uncomfortable in regards to their personality problems. (borderline- depression and anxiety, anti-social: problems in society; avoidant- refuse to work avoid everything; schizoid- family referral from strange discussions
* They come due to other problems such as depression, anxiety, etc.
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What are the genetic etiology associated w/ the different clusters?
* Cluster A àmore likely to be related to people with schizophrenia (schizoid- premorbid condition to schizophrenia
* Cluster B àantisocial personality àrelated to alcohol use disorders, addicted to substance
* Cluster B has more relatives with mood disorders
* Histrionic personality disorder and somatization disorder- physical symptoms ex. Pain, anesthesia, moving, seizures
* Cluster C: Obsessive-compulsive traits àmore common in monozygotic twins
* Association between nurture and environment??
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What is the function of personality traits?
describe what they do and what conditions they are associated with?
Psychoanalytic approach of understanding personality disorders
Fantasy àschizoid
Dissociation àborderline, histrionic
Isolation àobsessive-compulsive
Projection àborderline (due to PTSD that dissociated projection), paranoid
Splitting (splitting, and passive agression) àborderline
Passive aggressionàborderline
Acting out (can lead to suicide)àborderline
Projective identification àborderline “I can be you” switch people, project identity and lack of identity onto you
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* Pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts as indicated by four or more of the following
* 1. Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her
* 2. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates
* 3. Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him/her
* 4. reads hidden demeaning or threatening meanings into benign remarks or events (take everything as opposite of how you mean it
* 5. Persistently bears grudges
* 6. Perceives attacks on his/her character or reputation that are not apparent to others and is quick to react angrily or to counterattack
* 7. Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner
* Not psychotic enougto meet schizophrenia but are very paranoid
* If interfering w/ normal functioning and relationship
* May become apparent in childhood and adolescence with solitariness, poor peer relationships, social anxiety, underachievement in school, hypersensitivity, etc
* In clinical samples, more often diagnosed in males
paranoid personality disorder
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•Pervasive pattern of detachment from social relationships and restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by 4 or more of the following
1. Neither desires nor enjoys close relationships, including being part of a family. Shuts out family and friends.
2. Almost always choose solitary activities and jobs, doesn’t come outside often ex. Nighttime janitor
3. Has little, if any, interest in having sexual experiences with another person
4. Takes pleasure in few, if any, activities
5. Lacks close friends or confidants other than first-degree relatives
6. Appears indifferent to the praise or criticism of others
7. Shows emotional coldness, detachment, or flattened affectivity
* Not psychotic enougto meet schizophrenia but are very paranoid
* Don’t want to share anything afraid to connect
* Bear grudges
* Take everything as opposite of how you mean it
Schizoid Personality disorder
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•Pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity of, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood and present in a variety of contexts, as indicated by 5 or more of the following:
1. Ideas of reference (excluding delusions of reference)
2. Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms
3. Unusual perceptual experiences, including bodily illusions
4. Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, stereotyped) ex. Happy when talking about sad things
5. Suspiciousness or paranoid ideation
6. Inappropriate or constricted affect
7. Behavior or appearance that is odd, eccentric, or peculiar
8. Lack of close friends or confidants other than first-degree relatives
9. Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgements about self. Anxious because of being told crazy
Can be thought as premorbid condition to schizophrenia. ~10% patients with schizotypal PD will commit suicide. Told to have history of schizophrenia but do not
Schizotypal Personality Disorder
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•Pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years, as indicated by 3 or more of the following
1. Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest
2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure
3. Impulsivity or failure to plan ahead
4. Irritability and aggressiveness, as indicated by repeated physical fights or assaults
5. Reckless disregard for safety of self or others
6. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations
7. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another
* Must be at least 18 years old
* Evidence of conduct disorder with onset before age 15 years would have to be diagnosed w/ conduct disorder before
* More in male
Antisocial Personality Disorder
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•Pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by 5 or more of the following
1. Frantic efforts to avoid real or imagined abandonment
2. Pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
3. Identity disturbance: markedly and persistently unstable self image or sense of self
4. Impulsivity in at least 2 areas that are potentially self-damaging (e.g., spending, sex, substance abuse, binge eating, reckless driving)
5. Recurrent suicidal behavior, gestures or threats or self-mutilating behavior
6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)
7. Chronic feelings of emptiness
8. Inappropriate, intense anger or difficulty controlling anger
9. Transient, stress-related paranoid ideation or severe dissociative symptoms
10. Most difficult to deal w/, impuslive, demean, and try to control you.
11. Common in females
12. Feel empty all the time, hard time deciding what she wants to do, feels that making others happy will make her happy. Ex. Assess for depression, bipolar, and schizophrenia but is personality disorder instead
13. Need to set boundaries and must say with them. If you cross boundaries become difficult to be with
borderline
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•Pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by 5 or more of the following
1. Is uncomfortable in situation in which he/she is not the center of attention
2. Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior.
3. Displays rapidly shifting and shallowing expression of emotions
4. Consistently use physical appearance to draw attention to self
5. Has a style of speech that is excessively impressionistic and lacking in detail
6. Shows self-dramatization, theatricality, and exaggerated expression of emotion
7. Is suggestible
8. Considers relationships to be more intimate than they actually are- clingy
9. Professor lockhart
histrionic personality disorder
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•Pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by 4 or more of the following
1. Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection.
2. Is unwilling to get involved with people unless certain of being liked.
3. Shows restraint within intimate relationships because of the fear of being shamed or ridiculed.
4. Is preoccupied with being criticized or rejected in social situations.
5. Is inhibited in new interpersonal situations because of feelings of inadequacy.
6. Views self as socially inept, personally unappealing, or inferior to others.
7. Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing.
avoidant
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•Pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by 5 or more of the following
1. Has difficulty making everyday decisions without an excessive amount of advise and reassurance from others.
2. Needs others to assume responsibility for most major areas of his/her life.
3. Has difficulty expressing disagreement with others because of fear of loss of support or approval that is not based on reality.
4. Has difficulty initiating projects or doing things on his/her own
5. Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant. Makes it more likely for monearily, sexually etc. taken advantage of
6. Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself/herself
7. Urgently seeks another relationship as a source of care and support when a close relationship ends.
8. Is unrealistically preoccupied with fears of being left to take care of himself/herself
•For children/adolescence, it may be developmentally appropriate for them to exhibit such behavior.notbelow age 18
dependent personality disorder
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•Pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by 4 or more of the following.
1. Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost.
2. Shows perfectionism that interferes with task completion due to self-inflicted strict standards
3. Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships
4. Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values
5. Is unable to discard worn-out worthless objects even when they have no sentimental value.
6. Is reluctant to delegate tasks or to work with others unless they submit to exactly his/her way of doing things
7. Adopts a miserly spending style toward both self and others; money=must save for future!!
8. Shows rigidity and stubbornness
9. Accepts and understands not anxious about it
•More common inmales. monk
obsessive compulsive personalit disorder
ex. ssri for OCPD
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What are the treatments for personality disorder?
* Symptom based treatment/ don’t treat disorder treat symptoms.
* Treat anxiety, psychosis, aggression, depression, etc.
* SSRI for OCPD
* Alpha-2 agonist (ex. Clonidine) to reduce aggression àalso helpful when opioid withdrawal symptoms (Antisocial PD has a lot of substance abuse problems)
* Judicial use of benzodiazepines especially in patients with substance use problems
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What are the four dissociative disorders?
dissociative identity disorder
dissociative amnesia
depersonalization/derealization disorder
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What are the positive symptoms of dissociative symptoms?
•Intrusions into awareness and behavior with accompanying losses of continuity in subjective experience ex. Can feel something
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what are the negative symptoms of dissociative symptoms?
•Inability to access information or to control mental function that normally are readily accessed or in control due to amnesia part of it because of mental function, procedural memory
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What causes dissociative disorders?
* Often induced by traumatic experiences, such as hxof physical/sexual abuse and maltreatment 90% have had it
* Derealizationdisorder- Decreased levels of serotonin
* Brain regions implicated in dissociative disorders are the amygdala (fear in trauma), hippocampus (memory of event), orbitofrontal cortex (decision making)
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•. Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession. Involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning.
–The overtness of personality states varies with individual, involving level of stress, dynamic conflicts and emotional resilience. depending upon support sysmptom
–Sense of Self: feeling of suddenly becoming depersonalized observers of their “own speech or action”.
–Sense of Agency: strong emotions, impulses, or speech/actions that without a sense of ownership or control. ex. other identity does person
–Ego-dystonic ex. original identity is distressed by having other identity and discontinuity
What is it? occurs with it?
dissociative identity disorder
* •. Recurrent gaps in the recall of everyday events, important personal information, and or traumatic events that are inconsistent with ordinary forgetting
* hard to distinguish between trauma disorders and dissociative.
* •Dependable memory: of what happened today, of well-learned skills such as how to do their job, use a compute, read, drive
* amnesia more associated w/ this. •Manifest in multiple ways, usually:
* –Gap in remote memory or personal life events
* –Lapses in dependable memory (driving car, walking, doing computer)
* –Discovery of their everyday actions and tasks that they do not recollect
* •Dissociative fugue (someone has wandering or traveling w/ no purpose and no amnesia related) can be a result of this
* C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
* D. The disturbance is not a normal part or a broadly accepted cultural/religious practice. when are they having it?
* –Usually occur recurrently, distressing, unwanted, and involuntary
* –Manifest at times and in place that violate norms of culture/religion. if occurs during and is fine less problematic
* E. Symptoms are not attributable to the physiological effects of a substance or another medical condition (EEG, seizure, etc.)
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What are some things you should look for in a person w/ dissociative identity disorder?
* •Patients with DID can undergo flashbacks, but usually have amnesia for the content of the flashback, which causes distress
* •Some patients can experience psychotic phenomena, such as Auditory Hallucinations (but experience others generally talking rather than talking to or about them listening in on them)
* •Dissociation in children unlikely to present with identity changes but rather discontinuities of experience
* –Sudden changes in identity of adolescence may be “adolescent turmoil” or early stages of another mental disorder prodrone
* •Assessing for mood symptoms in those with DID can be difficult to diagnose because moods and cognition can fluctuate, experienced in some identities but not others
* •Distinct from PTSD:
* Amnesias for many everyday and nontraumatic event
* Dissociative flashbacks are followed by amnesia of flashback content
* Disruptive intrusions into sense of self/agency
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* A. The inability to recall important autobiographical information, usually of a traumatic or stressful nature, that is inconsistent with ordinary forgetting
* B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
* C. Not attributable to the physiological effects of a substance or a neurological or other medical condition
* D. Not better explained by DID, PTSD, ASD, somatic symptom disorder, or neurocognitive disorder
–Can add specifierof dissociative fugue unable to remember what they were doing in that moment of travel
what is it? what are the different forms of amnesia?
dissociative amnesia
second criteria of identity w/out the intrusion
* •Different than permanent amnesia in that it is potentially reversible as memory has been successfully stored
* •Different forms of amnesia:
* –Localized amnesia: failure to recall events during circumscribed period of time
* •Most common form of dissociative amnesia
* –Selective amnesia: can recall some, but not all of the events during a period of time
* –Generalized amnesia: complete loss of memory’s life history
* –Systematized amnesia: loss of memory for specific category of information
* –Continuous amnesia: forgets each new event as it occurs
* •Duration of forgotten events can vary and range from minutes to decades
* •Distinct from neurocognitive disorders in that, intellectual and cognitive abilities are preserved
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individualloses memory for a specific category of information, such as memories related to one’s family, particular person, or childhood sexual abuse.
failure to recall events during circumscribed period of time. Most common form of dissociative amnesia
loss of memory for specific category of information
can recall some, but not all of the events during a period of time
complete loss of memory’s life history
forgets each new event as it occurs
Systematized amnesia
localized amneia
–Selective amnesia:
–Generalized amnesia: (rare)
–Continuous amnesia: (rare)
When amnesia extends beyond the immediate time of trauma – dx of dissociative amnesia should also be made
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experiences of unreality, detachment, or being an outside observer with respect to one’s thoughts, feelings, sensations, body, or actions . out of body experience, saw themselves experiencing something but werent there
“I have no self”, “I know I have feelings but I don’t feel them”, “My thoughts don’t feel like my own”
depersonalization
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•experiences of unreality or detachment with respect to surroundings.
person feeling in a fog, dream, or bubble
derealization
99
* A. The presence of persistent or recurrent experiences of depersonalization, derealization, or both
* B. Reality testing remains intact during depersonalization or derealizationexperiences
* C. Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
* D. Not attributable to the physiological effects of a substance or another medical condition
* E. Not better explained by another psychiatric condition
depersonalization/derealization disorder
100
–Sudden decrease or complete loss of awareness of immediate surroundings
–Profound unresponsiveness or insensitivity to environmental stimuli
dissociative trance disorder
101
–Providing approximate and vague answers with clouding of consciousness
ganser syndrome
102
–Identity disturbance due to prolonged and intense coercive persuasion. trying to dissociate themselves
"brainwashing"
103
what are the treatments for dissociative disorders?
* Psychotherapy is large component of treament for dissociative disorders, including psychodynamic and cognitive therapy
* Hypnosis often used to contain and modulate intensity, which is a tool that can be utilized by patient when learned self-hypnosis. used to contain dissociative episodes and can teach them tools of self-hypnosis.
* Treating comorbid conditions such as depression or PTSD symptoms with psychopharmacology (SSRI-helpful in dissociative and dissociative trauma, Prazosin-alpha 1- antagonist decreasing nightmares related to trauma only)
104
What are some things associated with Delirium?
* ICU psychosis
* Acute confusional State
* Acute brain failure
* Encephalopathy
* Toxic metabolic state
* Sundowning
* Organic Brain syndrome
* Cerebral Insufficiency
105
What do the following symptoms point to?
* An agitated, combative patient who does not follow instructions
* An obtunded, minimally interactive patient
* An emotionally erratic patient who makes contradictory remarks and who staff cannot logically engage
* A calm, confused patient who is suspicious and oppositional
* Lack of time frame associated w/ it
Delirium
106
These are hallmark symptoms of what?
* Abrupt onset (i.e. hours or days) time frame makes it different to psychosis (long-standing psych history slowly development of hallucinations)
* Fluctuating symptoms (waxing, waning attention and conversation)
* Difficulty sustaining attention
* Appear to have cognitive dysfunction (dementia risk factor)
* Rapid improvement when the causative factor (usually medical) is identified and eliminated
* Psychiatric Symptoms: Abnormalities of mood, perception, and behavior
* Neurologic Symptoms: tremor, asterixis, nystagmus, incoordination, urinary incontinence
Delirium
107
Given the epidemiology, what are we referring to?
* 0.4% of all people
* 1.0% in individuals over 55 (13% in those \> 85)
* 60% of nursing home residents- age and dementia (risk factors)
**Common in the medical setting**
* 5-10% of elderly in the ER
* 15-21% of all medical admissions
* 5-30% subsequent incidences of delirium during hospitalization (hospital delirious)
* 10-15% of general surgery patients (anesthesia)
* 70-87% ICU patients (medical conditions and acute care required)
Delirium
108
What are the consequences of Delirium?
* Increased length of stay
* Increased mortality and morbidity
* Perhaps between 25-75%, as high as MI and sepsis
* Prolonged cognitive difficulties (may not returned to their baseline)
* Institutionalization
109
Given the DSM-5, What are we referring to?
1. A disturbance in attention and awareness
2. The disturbance develops over a short period of time, represents a change in function, and fluctuates (waxing waning fluctuation)
3. There is a disturbance in cognition
4. memory, disorientation, language, visuospatial ability, or perception
5. A and C are not better explained by an established neurocognitive disorder (ex. Dementia)
6. Evidence from the history, PE or laboratory findings that this represents another medical condition, substance intoxication or withdrawal, toxin exposure or due to multiple etiologies.
Delirium
110
What are the DSM-5 Specifier for Delirium?
Specify etiology
Substance intoxication delirium
Substance withdrawal delirium
Medication-induced delirium
Delirium due to another medical condition
Multifactorial Delirium due to multiple etiologies
Specify characteristics
acute (hours to days) or persistent (weeks to months)
hyperactive, hypoactive or mixed
111
What are the subtypes of Delirum?
What does each subtype entail?
Hyperactive, Mixed
Hyperactive:
* Somnolent, inattentive, and uninterested
* Poor memory and cognitive abilities
* Will be described as having lapses or variable behavior
* Reduced amount and rate of speech
* Often missed because they can be left alone (and laying in bed themselves)
Mixed:
* Combination of both
Fun fact! Hypoactive and mixed account for about 80% of all cases
112
What is the confusion Assessment Method? (CAM)
Feature 1: Acute onset or fluctuating course- oriented but later on confused and disoriented
usually obtained from an informant (nurse or family member)
Feature 2: Inattention
from your evaluation, are they distractible or unable to follow the conversation
Feature 3: Disorganized thinking
rambling, confused, derailment, illogical, loose associations
Feature 4: Altered level of consciousness
normal to comatose
Must have features 1 & 2 and either 3 or 4
113
What are the levels of conciousness for Delirum?
114
Explaint the confusion assessment method for the ICU (CAM-ICU) Flowsheet
115
MMSE for Delirium
Explain what the four key questions are
Scores \< 24 have been suggested to be a threshold and be considered impairment and based on MMSe can categorize the level of dysfunction
4 key questions of the MMSE- orientation, llocation, three different objects (remember repeat), count backward, world backward, remember three words. Two objects and name them, repeat the phrase, directions for paper, write a sentence, draw this figure
* Year
* Date
* Backward spelling (“DLROW”)
* Figure copying
116
What are the etiological risks of Delirium?
* Advanced Age
* Cognitive dysfunction
* intellectual disabilities, visual impairment, depression, dementia
* Prior neuropathology
* stroke, tumor, vasculitis, trauma, history of trauma
* Major medical/surgical illness- high risk factor
* hip fracture, ICU stays,
117
What are the etiological exposures of Delirium?
* Metabolic and systemic illness
* sepsis, organ failure, electrolyte abnormalities, hypoxia, hypoglycemia, UTI
* Endocrinopathies
* CNS infections and lesions
* Nutritional deficiencies
* thiamine, niacin, B12, folate
* Intoxication and withdrawal
* Others…
* heat stoke, electrocution, sleep deprivation, MEDICATIONS
118
These medications are used to treat what?
* Anticholinergics/antihistamines- don’t give benadryl to elderly
* Analgesics
* Steroids/sympathomimetics
* Sedatives
* Anticonvulsants
* Antiarrythmics/antihypertensives
* Antibiotics (PCN, cephalosporins, quiolones)
Delirium
119
The following differential diagnosis refers to what?
Delirium
120
What is the pathophysiology of Delirium?
* Neurotransmitter hypothesis
* hypocholinergic state
* supported by deliriogenic effects of anticholinergic medications and dementia
* dopamine (and norepinephrine) excess
* supported by intoxicating effects of numerous dopaminergic agonists (seroquel) and the beneficial effects of antipsychotics
* Neuroinflammatory hypothesis
* elevated cortisol, elevated CRP, elevated procalcitonin
* alteration of the BBB and microglia activation disrupts brain function
* Hypoxia hypothesis
* disrupted oxygen supply or neurovascular coupling causing neuronal dysfunction
121
Clinical Assessment: General Principles
What are we speaking about?
* Review chart for fluctuating course, recent illness, baseline function (dementia baseline)
* Review medications including PRNs (to see if they are causing or exacerating)
* Review history of substance use, CNS pathology and mental illness (cocaine, schizophrenia)
* Gather collateral with emphasis on recent change in function (hours to days and weeks to months from family members, nurse, or other staff on the unit)
Delirium
122
Given the lab tests below, what is this for?
* Recommended tests
* Electrolytes, glucose, calcium, CBC, LFTs, UA, Utox and drug levels when appropriate
* Not necessarily recommended, but should be considered
* CXR, blood cultures, blood gasses, EEG
* Use only in appropriate cases
* Neuroimaging (structural with CT- if elderly and fall or MRI, functional with PET or SPECT)
Delirium
123
What is the management for Delirium?
* Search for the underlying cause!
* Medications only treat symptoms of agitation, not etiology.
* Minimize psychoactive medications
* Provide supportive care
* oxygen, hydration and nutrition
* positioning and mobilization
* avoid restraints
* maximize non-pharmacologic care
* Have bad sleep-wake cycle can move to room with windows and close at night to try to disrupt it more.
* The goal is an alert and manageable patent, not a sedated and lethargic patient
124
How is Delirium managed? Pharmalogically and non-pharmalogically
Non-Pharmalogically:
* Promote sleep hygiene
* visible clock, provide light cycle, avoid night time awakenings
* Low stimuli environment
* reduce IV “beeps”, move away from the nursing station
* Encourage family visits-can reorient, consistent staffing
* Minimize interrupting patient and unnecessary moves/tests
Pharmalogically
\* ONLY IF PATIENT IS DANGEROUS OF PHYSICAL/MENTAL DISCOMFORT \*
* Started w/ lowest dosea nd tritrate up if needed
* Haloperidol is first line if agitated or attacking staff. First line least anti-cholinergic.
* not if concern for Parkinson’s, Lewy body or Parkinson’s Plus syndrome
* start with 0.5 mg BID PO/IV with 0.5 mg q4 hours PRN
* IV may cause less EPS but it has a short duration of actions
* Atypical antipsychotics (no IV forms)
* Risperidone: start at 0.25-0.5 mg PO BID
* Olanzapine: start 2.5-5 mg PO BID (IM form available)
* Quetiapine/seroquel: start at 12.5-25 mg BID (often preferred given low risk of EPS, can cause orthostasis).
* All can cause metabolic syndrome if used long term and acutely disrupt glucose management complicating diabetes treatment
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Delirium vs mental illness (schizophrenia)
Differences and typical signs?
* Age of onset and history of mental illness
* Assess risk factors for delirium
* Disorientation- schizophrenia patients know who they are and what year
* Reduced level of alertness and fluctuations (waxing and waning only for delirium; schizophrenia- straight hallcuincation)
* Speech not typically dysarthric in mental illness (except in intoxication or withdrawal)
* Visual hallucinations are atypical
126
What are the differences in:
Attention
Course
Speech
Perception
Thinking
Alertness
127
Given the following, what are we speaking of?
* Disease process marked by progressive cognitive impairment in clear consciousness”
* Involves multiple cognitive domains 🡪 cause significant impairment in social and occupation functioning
* Progressive or static; permanent or reversible
* 15% of people with dementia have reversible illnesses
Epidemiology:
5% general population older than 65 years
20-40% in general population older than 85 years
15-20% in outpatient general medical practices
50% in chronic pare facilities
Dementia
128
Explain the following and List them:
Degenerative demenetias (6)
Demyelinating Diseases (1)
Misc. (4)
Drugs and Toxins associated (5)
129
Explain the following and List them:
Psychiatric (2)
Physiologic (1)
Metabolic (3)
Tumor (1)
Traumatic (2)
Infection (3)
130
What are we referring to with the following information?
* Processing of abnormal amyloid precursor protein
* Gene is found on chromosome 21
* One breakdown product of amyloid precursor protein 🡪 β/A4 protein (major constituent of senile plaques)
* Down syndrome (tisomy 21) 🡪 three copies of amyloid precursor protein gene 🡪 excessive deposition of β/A4 protein 🡪 increased risk of Alzheimer’s
* E4 genes; people with one copy 🡪 3x more frequency of Alzheimer’s
* Neurotransmitters:
* hypoactive acetylcholine and norepinephrine
* Increased stimulation of glutamate
131
Given this information, what are we referring to?
* Step wise deterioration
* Multiple areas of cerebral vascular disease
* More commonly in med with preexisting HTN or other cardiovascular risk factors step wise deterioration
* Occulsion of cerebral vessles by arteriosclerotic plaques or thromboemboli 🡪 infarction and lesions over wide areas of brain
* Physical exam: carotid bruits, funduscopic abnormalities, or enlarged cardiac chambers
* Alzheimer’s Type vs \_\_\_\_
* Stepwise deterioration- \_\_\_\_
* Risk factors for cerebral \_\_\_\_
* Focal neurological symptoms more common- \_\_\_\_
Vascular Dementia
132
Given the following, what are we referring to?
* Aka Pick’s Disease
* Atrophy in frontotemporal regions
* 5% of irreversible dementias
* More commonly in men
* Early stages: personality and behavioral changes ex. Bizarre, curse, or yell.
* Early onset; begins before age 75
Frontotemporal Dementia
133
The following indications point to what disease?
* Characterized by hallucinations, parkinsonian features, and extrapyramidal signs
* Parknsonian features: if rigidity when moving arm cogwheeling, bradykinesia (walk w/ shuffling gait), resting tremor
* Supporting features:
* repeated falls
* Syncope
* sensitivity to neuroleptics
* systematized delusions
* hallucinations in other modalities (i.e. auditory and tactile)
* Early in illness, memory symptoms may not be as prominent as attention, frontosubcortical skills, and visuospatial ability
Lewy Body Disease
134
Given the following, what are we referring to?
* Disease of basal ganglia, more commonly associated with dementia and depression
* 20-30% of patients with Parkinson’s disease have dementia
* Additional 30-40% have measurable impairment in cognitive abilities
Parkinson's Disease
135
Given the following case, what disease is this?
Mr. M, 77 years of age, came for a neurological examination because he noticed his memory was slipping and he was having difficulty concentrating, which interfered with his work. He complained of slowness and losing his train of thought. His wife stated that he was becoming withdrawn and was more reluctant to participate in activities he usually enjoyed. He denied symptoms of depression other than feeling mildly depressed about his disabilities. Two years prior, Mr. M developed an intermittent resting tremor in his right hand and a shuffling gait.
During an initial neurological examination, Mr. M's spontaneous speech was hesitant and unclear (dysarthric). Cranial nerve examination was normal. Motor tone was increased slightly in the neck and all limbs. He performed alternating movements in his hands slowly. He had a slight intermittent tremor of his right arm at rest. Reflexes were symmetrical. A neuropsychological examination was performed three weeks later. It was found that Mr. M showed impairment of memory, naming, and constructional abilities.
Parkinson's Disease
136
What catastrophic reaction is this?
* Difficulty generalizing from a single instance, forming concepts, and grasping similarities and differences among concepts. (round different between fruit not that they are fruit less abstract)
* Ability to solve problems, reason logically, and make sound judgments are compromised. Change subject and make jokes.
* Patient may be aware of intellectual deficits
* Attempt to compensate for defects by using strategies to avoid demonstrating failures in intellectual performance (i.e. change the subject, make jokes, or otherwise divert the interviewer).
* Lack of judgment and poor impulse control common in dementias that affect frontal lobes
* Ex: coarse language, inappropriate jokes, neglect of personal appearance and hygiene, and disregard for conventional rules of social conduct
Parkinson's Disease
137
What is the Montreal Cognitive Assessment (MOCA)?
* Begin at 1 and follow the pattern,
* Visuospatial/Executive
* Naming the animal
* Memory- 5 words repeat twice if get it right second time its fine
* Attention
* Language
* Abstraction
* Delayed Recall
* Orientation
138
What psychiatric and neurological changes may occur with Parkinson's?
* Personality
* Introverted- irritable
* Paranoid delusions
* Frontal and temporal involvement: irritable and explosive
* Hallucinations and Delusions
* 20-30% have hallucinations
* 30-40% have delusions (i.e. paranoid or persecutory in nature)
* Can cause physical aggression
* Mood:
* 40-50% anxiety and depression
* May exhibit pathological laughter or crying (i.e. extreme emotion) with no apparent provocation
139
What Psychosocial Determinants are associated with Parkinson's?
* Severity and course of dementia can be affected by psychosocial factors
* The greater the person’s premorbid intelligence and education, the better the ability to compensate for intellectual deficits
* Anxiety and depression can intensify and aggravate the symptoms
* Pseudodementia occurs in depressed people who complain of impaired memory, but actually have depressive disorder
* When depression is treated, the cognitive defects disappear
* Can screen for depression using PHQ-9 prior to making diagnosis of dementia should screen first to see if you that might fix it
140
What are the psychosocial therapies for Parkinson's?
* Deterioration of mental faculties 🡪 fading of patients’ identities as they recall less and less of their past 🡪 emotional reactions ranging from depression to severe anxiety to terror
* Educational and supportive psychotherapy
* Caregiver’s may struggle with guilt, grief, anger, and exhaustion as they watch a family member gradually deteriorate
* Self-sacrifice of caregivers 🡪 developing resentment suppressed because of guilty feelings it produces
* Caregivers tend to blame themselves or others’ for patient’s illness
* Clinicians can help caregivers understand the complex mixture of feelings
141
Given the following, what are we trying to treat?
* Antipsychotic drugs for delusions and hallucinations. And sleeping
* Antidepressants for depression
* Benzodiazepines for insomnia and anxiety
* Use caution as it may cause paradoxical agitation, confusion, increased falls, and increased sedation
* Avoid anticholinergic medications
* Cholinesterase inhibitors (Donepezil, rivastigmine, galantamine, tacrine)
* Slow course of memory loss in mild to moderate cognitive impairment
* Reduce inactivation of acetylcholine 🡪 produces a modest improvement in memory
* Memantine:
* Protects neurons from excessive amounts of glutamate
Parkinson's Disease
142
What is sleep defined as?
What are the types of sleep disorders?
Definition: The natural periodic suspension of consciousness during which the body is restored. Scientifically speaking, the body's metabolism decreases leading to energy conservation.
Types of Sleep Disorders:
Affect all age groups, very common complaint in the inpatient and outpatient setting. Difficult sleep in inpatient settings because of poking and prodding
* Insomnia disorders
* Hypersomnolence disorder
* Narcolepsy
* Breathing-related sleep disorders
* Circadian rhythm sleep-wake disorders
* Non-rapid eye movement (NREM) sleep arousal disorders
* Night terror disorder
* Rapid eye movement (REM) sleep behavior disorder
* Night mare disorder
* Restless leg syndrome
* Substance/medication-induced sleep disorder
143
What are the etiologies of sleep disorders?
* Poor sleep hygiene
* Anxiety
* Alcoholism
* Substance Use
* Circadian rhythm disturbance
* Medications ex. Amphetimine salts
* Caffeine
* Medical
* Epilepsy
* Hyper/hypothyroidism
* Pheochromocytoma
* Organic brain lesions- cancers
* Traumatic Brain Injuries
144
Given the following which condition are we referring to?
Dx: Patients who have a history of non-restorative sleep or difficulty initiating or maintaining sleep that is present at least 3 times a week for greater than 3 months.
Epidemiology: Affects 30% of the general population, exacerbated by anxiety. Get a good history are they anxious or worried
Tx:
* Good sleep hygiene (good regular sleep schedule, limiting caffeine intake, avoiding daytime naps in the evening, using the bedroom for sleep and sexual activity only, exercising early in the day, avoiding large meals or snacks near bed time).
* Pharmacotherapy second line therapy (for only a short duration) like melatonin, diphenhydramine (benadryl), zolpidem (Ambien), zaleplon (Sonata), and trazodone.
Primary Insomnia
145
Given the following what are we referring to?
## Footnote
Dx: Excessive daytime sleepiness or nighttime sleep that occurs for at least 3 times per week for at least 3 months. The excessive somnolence cannot be attributable to medical or mental illness, medications, poor sleep hygiene, insufficient sleep, or narcolepsy
Tx: First line stimulant drugs like amphetamines.
Antidepressants like SSRIs may be useful in some patients.
Primary Hypersomnia
146
Given the following what are we referring to?
Dx: Irresistible need for sleep and decreased sleep latency on a daily basis for at least 3 months. (may be secondary to a decrease in orexin (one of the neuropeptides responsible for sleep/wake cycle) or hypocretin). Sleep attacks are common and patients cannot avoid falling asleep. Differential must include seizure disorder, organic brain lesions or malformations (Arnold Chiari Malformation) etc.
* Cataplexy – Sudden loss of muscle tone that leads to collapse (like after laughing) or valsava maneuver and straining.
* Hypnagogic hallucinations: Occur as the patient is falling asleep .
* Hypnapompic hallucinations: Occurs as the patient is awakening.
* Sleep paralysis: Brief paralysis upon awakening can happen occasionaly to some people but if happening continually. Also do an ekg
Treatment: Scheduled daily naps plus stimulant drugs, SSRIs for cataplexy.
Narcolepsy
147
Which condition are we referring to?
Occurs secondary to disturbances in breathing during sleep that leads to excessive daytime somnolence and sleep disruptions. Etiologies can be central or peripheral
* Cental sleep apnea: occurs in which both airflow and respiratory effort sleep. This is associated with morning headaches, mood changes, and repeated awakenings during the night. Organic etiology of depression, ex. High obesity, and thick neck.
* Obstructive sleep apnea: occurs in which airflow ceases as a result of obstruction along the respiratory passages. Strongly associated with snoring. Risk factors includes male gender, obesity, prior upper airway surgery, deviated septum, large uvula, large tonsils, or tong, retrognathia (recession of the mandible).
Untreated sleep apnea can lead to headaches, sudden death in infants and the elderly, increased systolic BP, pulmonary hypertension.
* Diagnosis: sleep study (polysomnography) documents the number of arousals, obstructions and episodes of decreased O2 saturation, distinguish between OSA from CSA and identify possible movement disorders, seizures and other sleep disorders
Treatment
* OSA: Nasal continuous positive airway pressure (CPAP). Weight loss of obese. In children, most cases are due to tonsillar/adenoidal hypertrophy which is surgically corrected.
* CSA: Central sleep apnea you can uses mechanical ventilation (BiPAP; non-invasive ventilation) with backup rate for more severe cases.
Sleep Apnea
148
What does the following picture show?
Sleep Study
149
What does the following point to?
A spectrum of disorders characterized by a misalignment between desired and actual sleep. Subtypes include jet-lag type, shift-work type, delayed sleep-phase type and unspecified.
Tx
* The jet lag type usually resolves within 2-7 days without specific treatment.
* The shift work type may respond to light therapy ex. Not used in bipolar disorder can send someone into mania
* Oral melatonin may be useful if given 5.5 hours before desired bedtime.
Circadian Rhythm Sleep Disorder
150
What does the following refer to?
* Characterized as the urge to move legs accompanied by or in response to uncomfortable and unpleasant sensation in the legs. There is a voluntary response to uncomfortable feelings in legs.
* Must occur at least 3 times per week and persisted for 3 months.
* Differential diagnosis: electrolyte abnormalities (CBC CMP, potassium), low iron, arthritis, arthralgias, myalgias, positional ischemia (numbness), edema, peripheral neuropathy, radiculopathy.
* Type of REM sleep disorder.
* Family history is common
* Treatment: dopaminergic agents like pramipexole
Restless Leg Syndrome
151
Which disorder is this?
Previously known as nocturnal mycolonus.
Patient moves limbs involuntarily during sleep (unlike RLS which occurs while sleeping and while awake)
Treatment: dopaminergic agents like pramipexole can lead to relationship improver
Periodic Limb Movement Disorder
152
What does this information describe?
* Involuntary voiding of urine after age 5 which occurs twice a week for 3 months with marked impairment
* Urinary continence is normally established before age 4.
* Must rule out other conditions (urethritis, diabetes, seizures).
* Primary (child never established urinary continence)
* Secondary (manifestation occurs after a period of urinary continence, most commonly between ages 5 and 8)
* Diurnal (incudes daytime episodes)
* Nocturnal (incudes nighttime episodes)
* Most cases resolve spontaneously after age 7.
* Etiology: Genetic, small bladder, low nocturnal levels of antidiuretic hormone, psychological stress (may be a sign of abuse)
* Treatment
* Behavioral modification (bed wetting alarm; positive reinforcement- stars helps child adhere to continence and reinforcing positive behavior); first line
* Pharmacotherapy antidiruetcts (DDAVP); TCA (like imipramine).
Enuresis
153
What does this point to?
* Involuntary or intentional passage of feces in socially inappropriate places. Patient must be at least age 4. Has occurred at least once a month for 3 months
* Must rule out abnormalities like hypothyroidism, lower GI problems (anal fissure, inflammatory bowel disease), dietary factors.
* Cause: psychosocial stressors, lack of sphincter control, constipation with overflow incontinence
* Tx: psychotherapy, family therapy, behavioral therapy. Stool softener (docusate sodium)
Encopresis
154
What condition is this?
* Type of non-rapid eye movement sleep arousal disorder
* You have repeated episodes of rising from bed during sleep, blank face, relatively unresponsive to efforts to communicate to others
* Relatively common occurrence (episodes not disorder, episodies of it are common but episode is rare) in children 10-30% have had one episode, episodes range from 1-7% of adults.
Sleep Walking
155
What does this describe or refer to?
* This is also a type of non-rapid eye movement sleep arousal disorder (stage non-REM N3). You have abrupt arousals from sleep, and you have intense autonomic arousal, you have rapid breathing and sweating.
* Psychotherapy and anti-depressants helpful
Sleep Terrors (Night Terrors)
156
Which disorder is this?
* Individuals with this disorder awaken out of sleep and completely remember what occurs during their dream.
* Usually occur during REM sleep.
* Associated with PTSD.
* Treated with therapy, alpha blockers like prazosin (worry about decreases in systolic bp), 1st gen. antihistamine.
Nightmare Disorder
157
What is this very common sleep disorder?
* These are usually associated with REM-sleep disturbances.
* Alcohol
* Usually presents as insomnia time; increases late stages of non-REM sleep, and reduced REM sleep. Patients may have increased wakefulness, restless sleep, vivid and anxiety latent dreams (acutely).
* During alcohol withdraw where is an increased amount of REM sleep, and frequently vivid dreaming which is a part of alcohol intoxication.
* Chronic alcoholics complain of light fragmented sleep
* Caffeine
* Produces insomnia in a dose dependent manner (antagonizes adenosine receptors leading to wakefulness)
* Cannabis
* Acute setting may shorten sleep latency. Enhances slow wave sleep and suppressive REM sleep. Chronic uses, tolerance to the sleep-inducing effects develops. Withdrawal may lead to sleep difficulties and unpleasant dreams
* Opioids
* Initially may increase sleepiness and subjective depth of sleep, reduces REM, but with continued administration patients may have complaints of insomnia. Because of respiratory depressive effects may exacerbate sleep apnea
Substance Induced Sleep Disorder
158
What are some treatment strategies for difficulty with sleep?
* Sleep hygiene
* Making sure that patients are properly utilizing good sleep hygiene including reasonable abed times; limiting cell phone usage before bed; lights in the bedroom; utilizing the bed room for anything other than sex and sleep; caffeine usage limiting before going to bed/alcohol/other substances.
* While in the hospital its quite difficult to sleep:
* Consider trying low dose of trazodone (atypical antidepressant, w/ antihistamine and A2 using side effect of medication to benefit but utilizes the side effect (anti-histamine) to cause sedation).
* Try to avoid anti-cholinergic diphenhydramine in older adults may cause delirium; may use trazodone or low-dose of quetiapine (Seroquel watch for metabolic syndrome) or melatonin or ramelteon (melatonin receptor agonist) for mild cases.
* For severe refractory cases may use Ambien (zolpidem; GABA (gamma-aminobutyric acid)receptor antagonist) or Sonata (zaleplon; GABA-benzodiazepine receptor complex agonist) but be careful in using these agents in older adults can lead to falls and cognitive difficulty, would avoid in children.
* Benzodiazepines such as lorazepam or clonazepam (GABA agonist) may be of utility in limited cases in the hospital setting.
* Barbiturates (sensory cortex suppressants) are not commonly used to aid in insomnia. But it is possible
