- Responsible for the unconscious mind

- Basic instintual drives --> Sexual and aggressive

- Spans the preconscious, conscious and unconscious mind

- Associated with logic, abstraction, verbal expression, and defense mechanisms

- Individual's moral conscience based upon internalized ideals and values

- Controls the impulses of the Id

- Narcissistic: Most primitive --> Children and psychotically disturbed adults

- Immature: Socially undesirable --> Out of touch with reality --> Common in major depression and personality disorders

- Neurotic: Adults under stress --> Short-term advantages in coping but can cause long-term problems if they persist

- Mature: Emotionally healthy responses --> Provides more adaptive potential with less distortion of external perceptions

- Denial: Refusing to accept a painful reality

- Distortion: Grossly reshaping external reality to meet internal needs

- Projection: Attributing one's own unacceptable thoughts/feelings to another

- Acting out: Expression an unconscious impulse/wish through action to avoid the anxiety of suppressing that impulse

- Passive-aggression: Expressing aggression indrectly through passive actions

- Splitting: Believing people or events are all good or all bad --> Intolerance of ambiguity --> Common in split personality disorder

- Regression: Returning to an earlier, more immature developmental stage to avoid stress

- Dissociation: Drastic and temporary modification of personal identity to avoid emotional distress --> Often seen post-trauma

- Repression: Expelling or withholding an aidea or feeling from consciousness --> Post-trauma

- Intellectualization: Using intellecutual processes excessively to avoid affective expression --> Learning all about it while not dealing with the emotions about it

- Isolation: Splitting an idea from the accompanying affect and repressing it --> Isolating thoughts and feelings

- Rationalization: Offering rationales to justify attitudes, beliefs, or behavior

- Displacement: Shifting an emotion or drive from an unacceptable object or person to a more acceptable one

- Reaction formation: Transforming unacceptable impulses into exactly the opposite

- Undoing: Erasing an unacceptable event in the past by adopting acceptable behavior in the present

- Somatization: Transformation of a negative impulse or feeling into bodily symptoms

- Altruism: Performing acts that benefit others to undergo a vicarious experience

- Humor: Using comedy to overtly express feelings and thoughts without causing discomfort

- Sublimation: Altering a socially objectionable aim/object to an acceptable one

- Suppression: Purposely ignoring an unacceptable impulse or emotion or order to diminish discomfort and accomplish a task

- Insight-oriented therapy focused on uncovering the unsconscious basis of current conflicts

- Goal: Bring the unconscious into consciousness

- Techniques: Free associations, dream analysis, interpretations of transference reactions, and analysis of resistance

- 12-40 weekly sessions

- Deals with current life problems

- Insight-oriented treatment

- Uses transference and defense mechanisms to work through present problems

- Psychiatric problems (depression) result from difficulties in social roles

- Focus on helping improve current relationships

- 12-16 structured weekly sessions

- Insight into interpersonal interactions and patterns of behavior

- Multiple participants with common problems

- Leaderless (peer-led) group --> 12-step groups for AA

- Psychoeducational --> Stress management and disease specific

- Process --> Focus on members' interpersonal interactions

1. Couples

- Targets change in both parties

- Identifies repetitive dysfunctional patterns

2. Family

- Psychopathology in one family member reflects dysfunction in entire family system

- Identifies boundaries, dyads, and triangles within a family

- Effective for substance abuse, eating disorders, and child behavioral problems

- Disordered behavior is learned --> Classical and operant conditioning

- Symptoms relief is achieved by changing maladaptive behaviors into more constructive behaviors

- History, unconscious conflicts, and transference reactions are not examined

- Classical condition technique used to treat phobias

- Pairs relaxation response with increasingly fear-provoking situations

- Takes a long time

- Reciprocal inhibition

- AKA flooding

- Operant conditioning technique to treat phobias

- Direct exposure without avoidance or escape to actual or imagined stimulus

- Prevents avoidant/escape behavior to extinguish conditioned response

- Much faster than systemic desensitization

- Pairs a personally pleasurable but maladaptive behavior with an aversive stimulus

- Pairing alcohol with antibuse --> Projectile vomiting

- Based on the idea that automatic thoughts lead to emotional reactions --> Emotions lead to anxiety, fear and depression

- Focus on helping identify and correct distorted thinking about self, others, and the world

- Addresses problematic patterns of thinking 

- Combination of cognitive and behavioral techniques

- Challenges maladaptive thoughts

- Uses behavioral experiments

- Highly structured --> Here-and-now focus

- Homework between sessions

- Treatment for depression, anxiety, eating disorders, and pain

1. Psychoeducation/informational intervention

- Elicit and normalize symptoms, discuss the nature of fear, discuss 3-component model, and discuss the role of avoidance in maintaining the negative emotional response

2. Cognitive interventions

- Increase awareness of thinking patterns

- Monitor relationship between thoughts and emotional response

- Challenge thinking

- Establish adaptive thinking patterns

3. Interoceptive and situational exposures --> Exposing the patent to the particular sensations of anxiety to show them that these sensations are ok and won't hurt them

- Provide rationale for confronting feared situations

- Estabilsh hierarchy of feared situations

- Provide accurate expectations

- Repeat exposure until fear diminishes

- Attend  to the disconfirmation of fears

- Third wave CBT

- Emphasis on noticing and accepting thoughts and feelings rather than working to change them

- Revolves around mindfulness, cognitive defusion, acceptance, values, and committed action

- Treatment for depression, anxiety, chronic pain, and addictions

- Third wave CBT

- Treatment for borderline personality disorder, parasuicidal behavior and self-injurious behavior

- Combines cognitive-behavioral techniques --> Mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness

- Individual and group component

- Treatment for PTSD

- 8-15 individual 90 minute sessions

- Repeated exposure to thoughts, feelings, and situations

- Involves eduction, breathing retraining, in vivo exposure and imaginal exposure

- Treatment for PTSD

- 12 sessions conducted individually or in a group

- Tragets faulty beliefs about self, others and the world

- Incorporates education, awareness of thoughts and feelings, emotional processing of the event, challenging beliefs through cognitive restructuring, and addressing beliefs about safety, trust, power/control, esteem, and intimacy

- Multifinality: Same risk factor can eventuate in different outcomes across different people

- Equifinality: Different risk factors can lead to same outcome

- Abnormal functioning can occur at any time

- Some patterns are more likely to emerge at particular developmental periods

- "Acting in"

- Symptoms of distress are experienced internally

- Anxiety

- Depression

- Eating disorders

- "Acting out"

- Behavior is upsetting to and difficult for others

- Attention deficit hyperactivity disorder

- Oppositional defiant disorder

- Conduct disorder

- Sad mood and/or irritability

- Lack of pleasure in usual activities

- Sleep/appetite disturbance

- Poor concentration

- Suicidality

- Hopelessness

- Developmental patterns: Most common in teens and then 2x more common in women after puberty

- Mood swings with depressive episodes and manic episodes

- Manic --> Heightened energy and activity, excessively cheerful/euphoric or irritable, reduced sleep, and grandiosity

- Causal factors --> Strong heritability, neurobiological dysfunctions, stress, and vulnerability-stress models

- Treatment: Meds, family treatment, and individual treatments

- Difficulty attending to tasks

- Impulsive and overactive behavior

- 4-9% of youth --> 70% boys

- Peer dysfunction with learning/communication problems

- ADHD and school

- More than 90% of children with ADHD underachieve scholastically

- ADHD youth have more failing grades and lower GPAs

- ADHD youth are more likley to be retained, suspended, or expelled from schools

- 23-32% of ADHD youth fail to complete high school

- Only 22% are accepted to college

- Symptoms: Must be present in multiple settings --> Home, school, and peer settings

- Onset of symptoms before age 12

- At least 6 symptoms for 6 months

- Causes: Frontal lobe abnormalities, abnormal dopamine activity and family dysfunction

1. Medication

- Stimulant meds (methylphenidate)

- Safe although rare cardio events and some stunted growth possible

- AA and latinos are less likely to be assessed, to receive long acting stimulants, and tend to have more difficulties

2. Behavior Therapy

- Daily report cards (DRC)

- Organizational skills training (OST)

- Summer treatment program (STP)

- Pattern of disobedient, hostile, and defiant behavior toward authority figures

- 10% of youth

- Generally directed towards parents

- More common in males

- Causes --> Temperament and family patterns

- Treatment --> Behavioral parent training and parent-child interaction therapy (PCIT)

- Persistent pattern of behavior in which the basic rights of others or societal norms are violated

- Frequent bullying or threatening, aggression, use of weapons, physical cruelty to people or animals, stealing, forced sexual activity, fire-setting, destruction of property, truancy, and running away from home

- Early onset --> More likely to be persistent

- Adolescent onset --> More limited

- Can be primary or secondary

- Enuresis --> Wetting the bed --> Bell-and-pad technique and dry bed training for treatment

- Encopresis --> Evaluate diet and constipation issues and help the child learn to recognize bodily cues

- Impairments in social interactions

- Poor eye-to-eye gaze

- Lack of social reciprocity

- Failure to develop peer relationships

- Lack of spontaneous seeking to share enjoyment

- Impairments in communication --> Delay in or lack of language development, idiosyncratic language, and poor imitative play

- Restricted repetitive and stereotyped patterns of behavior, interests and activities --> Preoccupation with objects or parts of objects, inflexible adherence to routines or rituals, and restricted interests

- Causes: Misguided belief that personality characteristics of the parents lead to the same in the child, genetic factors, brain structure abnormalities, increased brain volume, increased white matter, and reduced temporal and frontal lobe activity during language and motor tasks

- Reduced intellectual functioning (IQ <70) in combination with poor adaptive behavior

- Reduced intellectual functioning

1. Mild --> IQ 50-70

- 80-85% of individuals

- "Educably retarded" --> Benefit from schooling

- Not recognized early on --> Early poor, understimulating environments, and inadequate parent-child interactions

- Improves with age

- Jobs tend to be unskilled or semiskilled

2. Moderate retardation --> IQ 35-49

- 10% of individuals with MR

- Receive diagnosis earlier in life

- Clear deficits in language development and play

- Benefit from vocational training --> Work unskilled jobs with supervision

3. Severe retardation --> IQ 20-34

- 3-4% of MR

- Demonstrates basic motor and communication deficits

- Other neurological dysfunction --> Seizures

- Can rarely live independently

4. Profound retardation --> IQ <20

- 1-2% of MR
- Very noticeable at birth

- Require very close, structured supervision and considerable help throughout life

- Typically part of a larger syndrome --> Cerebral palsy, etc 

- Huge barriers for adults and children in the US
- 40% with a mental disorder received treatment in the past year

- <1/3 receiving care from a mental health professional

- Only 30% of individuals with anxiety disorders get care in their first year of the disorder

- Median delay in treatment is 9-23 years 

- Physical abuse: Physical aggression directed towards the partner

- Sexual abuse: Behaviors intended to compel the partner to engage in unwanted sexual activity ranging from verbal insistence to physical force

- Psychological abuse: Coercive acts intended to produce emotional harm or threat of harm --> Can be even more harmful because it is ever present

- Behaviors that limit the other person's basic rights and freedoms

- Behaviors intended to punish the partner and increase his/her sense of insecurity in the relationship

- Behaviors that attack the partner's self-esteem

- Behaviors that make the other person feel afraid --> Threatening but verbal and non-verbal

- 1.5 million women and 834,700 men are raped and/or physically abused

- 16% of couples experience at least one act of physical abuse a year

- 10-25% of women's visits are related to physical abuse

- Medical providers only detect 2-8% of these cases

- Approximately half of women seeking primary cary report experiencing physical abuse

- More depression, PTSD, and substance abuse

- Poorer overall health and functional health

- Higher rates of injuries, chronic pain, and disability

- More neuro, musculoskeletal, cardio, GI, and GU symptoms

- Psychological abuse can be more harmful than physical abuse

- Child adjustment problems

- Social isolation of perpetrator

- Annual cost of medical care, mental health services, and lost worker productivity --> More than $8.3 billion

1. Borderline-Dysphoric

- Violence confined primarily to partner

- Psychologically distressed and emotionally volatile

- Worried that partner will leave them

- Accounts for 1/4 of all abusers

2. Generally Violent-Antisocial

- High levels of extra-familial aggression and criminality

- Antisocial personality features and substance abuse

3. Family-Only

- Least severe abuse, violence outside of the home, and criminal behavior

- Little to no psychopathology

- More than half of partner violent men report child abuse and interparental violence

- Social learning theories emphasize direct modeling and the developmet of attitudes supporting abuse

- Genetic component --> 16-22% of variance accounted  for by genetic factors

- Head injury rates range from 40-61% in abusers

- Low levels of serotonin 

- Neuropsychological studies: Abusers perform more poorly on measures of verbal intellectual ability, executive functioning, attention, learning, and memory

- Other Risk Factors: Alcohol, drug abuse, depression, information deficits, and attitudes condoning relationship abuse

- 18-74% of women who leave violent relationships return to them

- Family, friends, and care providers may become cynical and frustrated

- Stay-leave decision unfolds over time

- External barriers: Lack of information, abuser tactics, lack of financial resources, inconsistent police or court assistance, and religious counseling/guidance

- Barriers from Family/social role: Belief that a woman needs a partner to be happy, values/beliefs about abuse and controlling behavior, family of origin values, and religious values/beliefs

- Barriers from Psychological Consequences: Minimization and denial of abuse, lack of energy and poor physical and emotional health, loss of social ties, and low self-esteem/self-blame

- Importance of provider screening --> Ongoing, trusting relationship and often the first and only individuals to whom a victim may present

- Patient safety and health

- Recommend screening for all female patients

- Providers do not routinely screen for abuse

- Lack of training in domestic abuse

- Time constraints

- Awkwardness and concerns of offending patient

- Perpetrator may also be present

- Perceived lack of effective interventions --> What do I actually do if patient admits this?

- Undetectable injuries

- Embarassment and hopelessness

- Perceptions of provider helpfulness

- Fear insensitive or impersonal treatment by provider

- Fear of abuse minimization or blame

- Direct, specific and nonjudgmental questions

- Assess abuse across visits

- Avoid pressuring the patient

- Be aware of referral options and hotline numbers

- Assess abuse in as private an environment as possible

- Assess imminent danger --> Feel safe?, support system, and emergency plan

- Frequent medical visits

- Abuse of alcohol or drugs

- Noncompliance with medications or appointments

- Accident prone patient

- Delay in seeking medical attention

- Inconsistent reporting of cause of injury

- Medical history inconsistent with injuries

- No mandatory reporting unless child is involved

- Assess for child abuse and exposure to severe violence

- Document details of reported domestic abuse and related injuries

- Use patient's own words in documentation

- Document referrals

- Used to be known as hypochondriasis

- Focus is not on having a disease but rather on particular symptoms themselves

- Patients do actually have symptoms though

- No physiological cause found for these symptoms

- One or more somatic symptoms that are distressing or result in significant disruption of daily life

- Excessive thoughts, feelings or behavior related to the somatic symptoms

- Disproportionate or exaggerated thoughts

- Persistently high levels of anxiety about health symptoms

- Excessive time and energy devoted to these symptoms or health concerns

- Lasts for at least 6 months

1. Predominant pain --> Focused around pain

2. Persistent --> Marked by severe symptoms, marked impairment, and more than 6 months duration

- Anxiety focused on the possibility of having a serious disease

- No actual symptoms present or symptoms are very mild

- Call docs alot

- Take meds

- Excessive health related behaviors or maladaptive avoidance

- Present for at least 6 months

- Care seeking or care-avoidant type

- Features of anxiety and mood disorders, especially panic disorder --> Runs in families

- Preoccupied with bodily symptoms --> Disease conviction

- Reassurances from numerous doctors only has a short term effect

- Patient focuses intensely on sensations and makes sensations more intense than they really are

- Functional neurological symptom disorder by neurologists

- 2-3 times more likely in women --> Occurs in males at time of extreme stress

- Rare in mental health settings

- Physical malfunctioning such as paralysis, blindness, or difficulty speaking

- Without any physical or organic pathology to account for malfunction

- Neurodisease affecting sensory-motor systems --> Going blind, experiencing paralysis, total mutism, and seizures without EEG changes

- Precipitated by marked stress --> Soldiers exposed to combat

- Can usually function normally but seem unaware of this ability of sensory input

- Treatment: Identify and address reaction to traumatic event and remove sources of secondary gain for symptoms --> Usually resolves once trauma is addressed

- AKA Munchausen Syndrome

- Falsification of medical or psychological symptoms that can lead to others viewing the individual as more impaired --> Excessive clinical intervention

- Symptoms under voluntary control but there is no obvious reason for voluntarily producing symptoms

- Symptoms brought on to get attention

- Motivation of getting out of work --> Malingering

1. Imposed on self

- Presents themselves as ill, impaired or injured

- Deceptions might include neurological symptoms, placing blood in urine, or ingesting heparin

- 1% of hospitalized patients

2. Factitious Disorder Imposed on Others/ Munchausen syndrome by proxy

- Person presents another person as ill (usually child), impaired or injured --> Patient may put blood or feces in urine, make child ingest something, etc

- Mostly women caring for children

- Perpetrators have high rates of abuse

- Treatment: Remove the child from the environment so the child can get better

- Normalize physical sensations with CBT --> show patients how to create symptoms by focusing on specific body parts

- Provide more substantial and sensitive reassurance

- Reduce the supportive consequences of relating to significant others on the basis of somatic symptoms

- Factors such as stress, coping style, maladaptive health behaviors, poor adherence to medical recommendations, or denial of symptoms can exacerbate medical conditions

- Stress --> Increased risk for hypertension

- Depression --> Impacts the experience of pain

- Anxiety --> Exacerbates anxiety

- Denial interfering with taking care of acute chest pain

- If the psychological or behavioral symptoms develop in response to a medical condition then it's more appropriate for an adjustment disorder diagnosis

- DSM-5 Criteria: Medical symptom or condition must be present, psychological or behavioral factors adversely affect this medical condition and psychological/behavioral factors are not better explained by a mental disorder

- Recurrent, intense sexually arousing fantasies, sexual urges or behaviors generally involving:

1. Nonhuman objects

2. Suffering or humiliation of oneself or one's partner

3. Children or other non-consenting persons that occur over a period of at least 6 months

- Listed as psych disorders

- Mean onset is 19 years --> Range of 10-43 years old

- Primarily men

- 1-2 hours a day is spent in unconventional sexual behaviors with 77% leading to orgasm --> Can be very disabling and result in the inability to form relationships and keep jobs

- Typically have 3-5 paraphilias

- 50% are married

- Voyeurism>exhibitionism>transvestic fetishism>pedophilia

- Compulsive masturbation --> 70% of people with paraphilias

- Protracted promiscuity

- Pornography dependence --> 50%

- Phone sex dependence

- Watching other people undress or perform sexual acts

- "Peeping toms"

- Exposing the genitalia to unsuspecting strangers

- Streaking, etc

- Usually done in public areas where they can run away quickly if needed

- Almost 100% are men exposing to women

- Person will get aroused just thinking about exposing themselves

- Sexual arousal obstined through the contact of inanimate objects, such as shoes, women's underwear, etc

- Almost exclusively men

- Sexual activity may be directed towards the fetish itself or the fetish may be incorporated into sexual intercourse

- Rubbing your genitals against another clothed person

- Commonly occurs on subways and in elevators

- People who dress normally but ride the subway/elevator for hours a day

- Big drop off of this activity due to cell phones --> People take pictures of these people in real time now

- People are using frotteurism less and using their other paraphilia more

- Sadism: Giving physical pain and/or humiliation to others

- Masichism: Being personally humiliated and physical pain

- Usually male

- Related to rape, but rape is more aptly considered an expression of power

- Antisocial --> Gang members, will harm anyone outside their gang --> Often want to be seen as a menace

- Psychopathic --> Very cunning, charismatic and smart --> Blend in very well in society

- Most common paraphilia

- Ego dystonic --> Want to get rid of these urges but don't know how

- 10-20% of children have been molested by age 18

- At least 16 years old and at least 5 years older than victim

- Most child molestations involve genital fondling or oral sex

- 95% hetereosexual and 50% have consumed alcohol

- Female pedophiles --> 4-19% of perpetrators are women for females and 17-75% of perpetrators are female for men --> Less likely to be pursued

- Females are twice as likely as males to be sexually abused

- 6.5-27% of women report a history of sexual abuse

- 13% raped

- 3.85-16% of men reported being abused

- College students --> 22% for females and 9% for males

- Penetrative sexual abuse is highly associated with other disorders, such as anxiety, depression, eating disorders, and conduct disorders

- Sexual abusers often minimize their activity and try to make excuses

- Patient taking the step to minimization is actually a good thing --> Starting to admit things and is opening up

- Very active frontal lobes --> Very cunning and intelligent, needed for the stalking phase

- Limbic areas will light up once their victim is found --> Unthinking/savage behavior takes over

- 1-7% castration life-time recidivism rates

- Antitestosterone meds and CBT --> Lowers risk of re-offending 18-24% over 6 years

- 13-89% recidivism in 5 years

- Risk increases to 60-78% of reoffending after 6 years

- Most patients are mandated to go to treatment

- Group or individual therapy, behavioral techniques, cognitive approaches, and meds

- Depo-Provera (Medroxyprogesterone acetate)

- Cyproterone acetate --> Reduced testosterone

- SSRIs and lithium are also used

- Ingestion of a psychoactive substance in moderate amounts that does not significantly interfere with social, educational, or occupational functioning

- Examples: Drinking coffee, smoking a cigarette, having a drink with a friend, and the occasional ingestion of illegal drugs

- Cluster of cognitive, behavioral and physiological symptoms indicating that an individual continues to use the substance despite having substance-related problems

- Can be applied across many substances

- Combines both abuse and dependence

- Must specify severity --> Mild, moderate, and severe

- Substance taken in larger amounts or over a longer period of time than intended

- Persistent desire or unsuccessful efforts to cut down

- Great deal of time spent obtaining or using substance

- Cravings or strong desire to use

- Use results in a failure to fulfill major roles

- Use despite experiencing interpersonal problems

- Social, occupational, and recreational activities are given up due to substance

- Use in situations where it is physically hazardous --> While driving a car, etc

- Use despite knowledge that problems are being caused or exacerbated by use

- Tolerance evident --> Increased dose needed

- Withdrawal evident with cessation

- Mild: 2-3 characteristics within a 12 month period

- Moderate: 4-5 characteristics

- Severe: 6 or more characteristics

- Severity + Specific substance + use disorder

- Examples: Moderate heroin use disorder or severe alcohol use disorder

1. Intoxication

- Reversible substance-specific syndrome due to the recent ingestion

- Problematic behavior or changes associated with intoxication attributed to effects of the substance

- Symptoms are not attributable to another medical condition or mental disorder

- The more rapid the absorption into the blood stream the more likley to produce immediate intoxication

2. Withdrawal

- Problematic behavioral and physical changes due to the cessation or reduction in heavy and prolonged substance use

- Clinically significant distress or impairment in social, occupational or other imporant areas

- Symptoms are not attributable to another medical condition

3. Substance/Medication-Induced Mental Disorders --> Anxiety, depression, sexual dysfunction and others

- Potentially severe, usually temporary, but sometimes persistent disorders that develop in the context of the use of a substance 

- Disorders may be induced by substances that produce substance use disorders

- Most improve in days or weeks following abstinence

- Examples: Anxiety after sedative withdrawal or depression after stimulant withdrawal

- 80% of adults have consumed alcohol at some time in their lives

- 3.6% of the world's population currently have an alcohol use disorder

- 12 oz beer= 5 oz wine = 1.5 oz spirits --> 18 mL ethanol=14 g ethanol

- Description: It's initial effect is stimulation but later it reduces inhibitions, feeling of well being, and mental depression

- Delirium Tremens (DT's): Occurs on the 3rd day of withdrawal in patients who drank heavily for the past 5 years --> Life threatening (20% mortality) and consists of hand tremors, nausea, vomiting, anxiety, transient hallucinations, agitation, insomnia, and delirium tremens (body tremors)

- Tremors can begin 5-10 hours after cessation of drinking and seizures can begin 6-12 hours after

- Occurs in 1-2% of alcohol dependent individuals

- Wernicke's syndrome: Neurological disease characterized by confusion, ataxia, and ocular abnormalities

- Korsakoff's syndrome: Mental disorder characterized by memory loss, inability to form new memories, confabulation and hallucinations

- Due to thiamine (vit. B1) deficiency

- Memory loss and learning issues typically remains after repletion of thiamine

- Fetal anomalies caused by maternal consumption of alcohol during pregnancy

- Highest risk in the first trimester

- Fetal growth retardation

- Cognitive deficits --> Poor coordination and microcephaly

- Behavioral problems

- Learning difficulties

- Facial features: Skin folds at eye, low nasal bridge, short nose, small head circumference, small eye opening, small midface, thin upper lip, and underdeveloped midfacial region

- Detoxication and withdrawal --> Seizure, cardiovascular issues, and death --> Occurs 4-7 days after last drink --> Treat with BZDs and vit. B1

- Alcohol use management --> Antabuse and naltrexone --> Produces nausea with alcohol consumption

- Psychological counseling --> Family or couples therapy and alcoholics anonymous (12 step program)

- Widely prescribed in the 1930-40s to help people sleep

- Most widely abused drug by the 1950s

- Depressants of the CNS that impair or reduce the activity of the brain by acting as GABA potentiators

- Similar to BZDs

- Similar withdrawal as alcohol and other sedatives

- BZDs enhance GABA action and reduce anxiety and insomnia

- Less risk of abuse and dependence --> Safer than barbiturates but still addictive

- Advantages --> Quick onset

- Disadvantages --> Tolerance developes, dependence, and lack of long-term effectiveness

- The Hangover: Rohypnal ("Roofies") --> Induce anterograde amnesia

- Derived from the poppy flower --> Mexico is the major supplier

- May be injected or smoked

- Tolerance increases with use

- Frequent comorbidities --> HIV and Hep B

- Up to 1/3 of HIV patients are heroin users

- China white (H3) --> Off white powder that is water soluble and therefore injected

- Black Tar (H4) --> Brown, sticky, and has low boiling point and therefore smoked

- Overdose --> Treated with Naloxone (Narcan) --> Potent Mu antagonist --> Causes reversal of OD within minutes

- Medical uses: Moderate to severe pain (morphine and oxycodone) and methadone (pain management for opioid addicts)

- Detox/Withdrawal: Death from withdrawal is rare but includes depression, anxiety, and flu-like symptoms

- Treatment: Methadone, buprenorphine, or suboxone

- Most common psychoactive substance --> 90% of all Americans drink coffee

- Mechanism: Blockade of adenosine receptors (A2a) and increases cAMP and cGMP by inhibiting phosphodiesterase

- Desirable effects: Stimulant, increased alertness, concentration and energy, and bronchodilator

- Stimulates HCl secretion from gastric mucosa

- Low dose: 20-200 mgs --> Elevates mood, increases alertness, concentration, self-confidence, motivation, desire to talk to people, and mild diuretic action

- Moderate: 200-300 mgs --> 2-3 cups

- Heavy: 500-600 mgs --> 4 or more --> Jittery, insomnia, headaches, drowsiness, and unpleasant mood

- Toxic: Restlessness, jitters, anxiety, insomnia, elevated or irregular heart rate

- Lethal: 10g (>100 cups)

- Side effects: Insomnia, anxiety and agitation

- Tolerance develops

- Withdrawal: Headache, low energy, and inability to concentrate

- Therapeutic uses: Relieve fatigue, increase motor skills and alertness, adjuvant for pain relievers (increases potency of NSAIDs), asthma and COPD (bronchodilator), and weight loss

- 19.8% of all Americans smoke

- Readily crosses BBB

- CNS Effects: Stimulant, mild euphoria, increased energy and arousal, relaxation, improves attention, learning, problem solving, reaction time, appetite suppressant, and increases fat metabolism

- Peripheral effects: Autonomic arousal, increases BP and HR and stimulates GI and GU tract

- High doses: Convulsion, CNS depression, severe hypotension, arrhythmias, and blocks GI and GU musculature

- Withdrawal: Depressed mood, insomnia, irritability, anxiety, difficulty concentrating, restlessness, and increased appetite and weight gain

- Mechanisms: Nicotinic receptors --> a4b2 subtype --> High proportion in A10 pathway

- Addiction: Rate of relapse is similar to those trying to give up alcohol and heroin

- Smoking cessation programs: Change behavior and routines, brand fading, and focus on triggers, cues and the environment

- Nicotine gum or patch

- Medication: Zyban (buproprion) and varenicline (Chantix) (40% success rate) --> Partial binder to nicotine receptors

- Quitting: 80% of smokers relapse within 1 month and only 3-5% of patients remain abstinent at 6 months

- Clinical uses: Treatment of ADHD, narcolepsy, obesity and depression

- Mechanism: Similar to cocaine --> Non-catecholaminergic sympathetic amine --> Vesicular monoamine transporter blocker --> Releases monoamines at synapse and inhibits uptake

- Commonly used by people who need to stay alert or need alot of energy --> Truck drivers

- Side effects: Insomnia, irritibality, irritability, tremor, confusion, delirium, panic, suicidal tendencies, psychosis with chronic use, cardio effects, and GI tract effects

1. Crystal Meth (methamphetamine): Ingested through smoking

- Directly toxic to midbrain dopaminergic neurons

- Chronic use leads to severe structural and functional changes in the brain areas associated with emotion and memory

- May induce Parkinsonian features in chronic users

2. Ecstacy (MDMA): "Designer drug" --> Combination of amphetamine and hallucinogen

- Notoriously impure --> Often contains other chemicals

- Primary effects on serotonergic neurons

- Neurotoxic in animals --> 4 day damage to serotonin terminals is still evident 6-7 years afterwards

- Sniffed through nostrils

- "Crack" --> Smoked and is generally less pure and less expensive

- Mechanisms: Monoamine uptake inhibitor --> Potentiates and prolongs the actions of both serotonin and NE

- Effects: High is accompanied by a depressed mood that can occur within 1 hour of taking the drug

- Dysphoric feelings --> Follow the initial euphoria even when plasma concentrations are still high --> Brain starts to adapt and becomes less sensitive

- Paranoia --> Increased and irregular HR and "cocaine bugs"

- Sympathetic effects: Tachycardia, palpitations, vasoconstriction with hypertension, pupillary dilation (mydriasis), mild bronchodilation, seizures and fatal cardiac arrhythmias

- Hyperthermia: Increased heat production, impaired autonomal adjustment to heat, and impaired heat perception --> Impaired sweating and vasodilation

- Medical uses: Topical anesthetic, vasoconstrictor, and local anesthetic

- Doses: 20-50 mg --> 1-4% solution and maximum dose 200 mg --> No systemic effects

- Most commonly used illegal drug in the US

- Increased use in 12-25 year olds

- Low doses: Increases appetite, relaxation, and red eyes

- High doses: Amotivational syndrome --> Decreased desire to work and increased apathy

- Sublingual administration

- Produces unpredictable effects with trips lasting up to 12 hours

- In large enough doses --> Increased body temp, heart rate, and blood pressure, also sleeplessness and loss of appetite

- Distorts perceptions of sight, sound, and produces feelings of detachment

- Symptoms mimic schizophrenia --> Delusions, hallucinations, disordered thinking and anxiety

- Produces high BP, agitation, and very violent behavior

- Consumption of 20 mgs can cause seizure, coma and death

1. Nigostriatal (A9)

- 80% of brain dopamine

- Substantia nigra innervates striatum

- Behavioral hyperactivity

2. Mesocorticolimbic (A10)

- VTA innervates limbic and cortical areas

- Associated with nucleus accumbens

- Euphoria --> Reinforcing effects of cocaine --> Reward and positive reinforcing pathway

3. Tuberohypophysial (A12)

- Hypothalamus innervates the pituitary and median eminence

- Inhibits prolactin secretion

- ~2,000 hypocretin/orexin-producing neurons in the hypothalamus

- Project to regions involved in sleep and arousal

- Orexins --> Released during wakefulness

- Increase the activity of main brain regions involved in the promotion of wakefulness

- Helps stabilize wakefullness, prevents inappropriate transitions into REM or non-REM sleep

- Lack of the hypocretin ligands or receptor genes

- 85-90% of narcoleptic patients with cataplexy have little or no hypocretin in their CSF

- Autoimmune or neurodegenerative process results in loss of orexin neurons

- AKA provigil --> Non-amphetamine stimulant

- Promotes wakefulness but does not benefit cataplexy

- Less efficacious than amphetamines but with fewer cardiovascular side effects and less abuse potential

- Mechanism: Still under debate

- Wake-promoting effect through dopaminergic and norepinephrinergic systems

- Also involves histaminergic and orexinergic systems

- AKA Ritalin

- Improves attention and working memory and hyperkinesia

- Efficacious in 70-80% of ADHD patients

- Increases DA and NE levels

- Structurally similar to amphetamine but its effects are similar to those of cocaine

- Given orally

- AKA Strattera

- Not a stimulant but still used to treat ADHD

- Mechanism: Selectively inhibits NE transporter (NRI), blocking NE reuptake and results in increased attention and decreased impulsivity and hyperactivity

- Not likely to be abused

1. Sibutramine

- Inhibits 5-HT and NE reuptake

- No antidepressant activity

- Recently suspended for cardiovascular side effects

- Virtually no potential for abuse

2. Phentermine and Fenfluramine

- Action typical of other psychostimulants

- Phentermine --> Releases NE

- Fenfluramine --> releases 5-HT

- Taken off the market due to heart valve damage

- Sleep: 2-3 drinks can produce sleep disturbances

- Blackouts: Large doses can produce anterograde amnesias --> Alcoholic blackouts

- Hangover syndrome: Headache, thirst, nausea, cognitive impairment --> all due to mild alcohol withdrawal and dehydration

1. Low risk drinking

- Men: No more than 4 drinks a day and 14 drinks a week

- Women: No more than 3 drinks a day and 7 drinks a week

2. Binge drinking

- Consuming 5 or more standard drinks (male) or 4 or more (female) on one occasion (2 hours)

- Pattern of drinking that brings the blood alcohol levels to 0.08 grams percent or above

- Mild, moderate or severe: Based on the number of DSM criteria fulfilled for substance use disorder

3. Deep acute intoxication

- Coma, respiratory depression, and pulmonary aspiration

- Pupils are usually small

- Temperature, blood pressure, and pulse rate are decreased 

- Most is absorbed in the intestine but some is also absorbed in the mouth and stomach

- Rapid: Blood levels peak 30-60 minutes after ingestion

- Decreased by half in the presence of food, especially fatty food

- Distribution: Distributed in total body water --> Gender differences due to different proportions of total body water --> Vd=TBW(0.6-0.7L/kg)

- Metabolism: Alcohol dehydrogenase (ADH) removes most by zero order kinetics, aldehyde dehydrogenase (ALDH) oxidizes acetaldehyde to acetic acid, and CYP-4502E1 oxidizes ethanol when levels are high (first order) --> Metabolism altered by other drugs that induce or inhibit P450 enzymes 

1. Type I

- Adult-onset alcohol abuse

- No severe criminal misconduct

- Limited by the environment

- Anxious personality --> Begins drinking to reduce anxiety

2. Type II

- Males only

- Adolescent onset

- Sever criminal record

- Antisocial personality trait --> Seeking euphoric effects of alcohol

3. Ethnic Variation in Metabolism

- ADH2*2 mutation (~85%) and ALDH2 mutation (~50%) are common in Asians

- ADH2*3 mutation is common in blacks (~15%)

- Results in higher risk for alcohol induced cancers and liver disease

- GABA-A receptor agonist --> Binds a region in the transmembrane domain of a/b subunits

- NMDA receptor antagonist --> Alcohol interacts with NR1 subunit and acutely inhibits NMDA receptor functioning

- Opioid, nAChRs, Gly, 5-HT3, and other receptors

- Release of endogenous opioids --> Reduced sensation of pain --> endorphins released into VTA and Nacc

1. Disulfiram (Antibuse)

- Blocks acetaldehyde dehydrogenase --> Leads to acetaldehyde build up

- Acetaldehyde leads to nausea, vomting, headache, and chest pain only 5-10 minutes after consumption of alcohol

2. Naltrexone (Revia)

- Competitive antagonist of Mu receptor

- Reduces the euphoria and the urge to drink

- Side effect: Nausea

3. Acamprosate (Campral)

- GABA analog but acts as a NMDA receptor agonist

- Reduces cravings and relapse

- Side effect: Diarrhea

- Sources: Denatured alcohol, industrial reagent, solvent in paint removers

- Absorbed orally, by inhalation, and through the skin

- Effects: Blurry vision or blindness, acidosis due to formic acid, and CNS depression and sudden resp. depression

- Treatment: Measure blood methanol level, hemodialysis needed if >50 mg/dL, give ethanol to prevent blindness, and sodium bicarbonate to relieve acidosis

- Present in antifreeze and in heating systems

- Effects: CNS depression, hyporeflexia, tetany, cardiovascular effects, congestive heart failure, and renal oxalate crystal formation

- Metabolized to toxic aldehydes and oxalate

- Treatment: Check levels and initiate hemodialysis if too high, give ethanol, and sodium bicarbonate

- Contains cannbinol (CBN), cannabidiol (CBD), and D9-Tetrahydrocannabinol (THC)

- THC is the only one with significant psychoactive properties

- CBN has some but 1/10th of THC

- Marijuana: Dried and crumbled leaves, small stems, and flowing tops of the plants

- Hashish: Solid, prepared from resin and potency depends with concentration

- Behavioral Effects: Euphoria, relaxation, hunger, distortion of time, hallucinations (rare), and paranoia

- Cannabis "psychosis" is controversial --> Requires very large doses or just extreme vulnerability

- THC can recipitate schizophrenia in patients with history

- Physiological effects: Increased HR, vasodilation and red eye, and diminished fine motor control

- Mechanism: Structure is very similar to endogenous cannabinoids and binds to CB1 and CB2 receptors --> CB1 more prevalent in the brain --> Activated CB1 receptors in the VTA and inhibit GABA release

- Cannabinoids are released post-synaptically and move backwards across the synaptic cleft --> Effect on pre-synaptic vesicular release

- Chronic use: Effects on adolescent develoment, learning and memory, respiratory disease, immune system effects, schizophrenia, psychosis and dependence

- "Amotivational Syndrome": General apathy and indifference to social situations and activities as a result of chronic use

- Irritability

- Anger and aggression

- Anxiety and depressed mood

- Restlessness and sleep difficulty

- Decreased appetite and weight loss

- Not as severe as alcohol or opiate withdrawal but can cause significant distress

- Antiemetic effects in chemotherapy

- Appetitie promoting effects in AIDS patients

- Reduction of intraocular pressure for glaucoma

- Treatment for neuropathic pain and RA

- Reduction of spasticity in MS

- Synthetic forms: Sativex (1:1 ratio of THC and cannabidiol), nabilone (cesamet), and dronabinol (marinol)

- Irresistible urges to commit violent, harmful or ilogical acts

- Usually a chronic and lifelong condition

- May lead to serious legal and financial difficulties

- Many different forms

- More common in young men --> Late teens and early twenties

- Soft neurological signs --> Hard to know if these signs truly proceeded disorder and caused or if these are just signs of violent people who get into lots of fights

- Frequent venues conducive to anonymous violence --> Bars, concerts, sporting events and driving

- May pick a spouce who tolerates violence

- Differential: Antisocial personality disorder, substance abuse and PTSD

1. Abuser

- Mental illness

- Substance abuse

- Family history of domestic violence

- Impulsive and angry

- Usually male

- Low frustration level

- Apologetic after abuse

2. Abused

- Mental illness

- Substance abuse

- Family history of domestic violence

- Recent diagnosis of HIV --> May prompt them to be abused

- Pregnancy --> May prompt violence

- Financially dependent --> Can't really leave

- High levels of dopamine --> Aggressive behavior

- Low levels of serotonin --> Impulsive behaviors like suicide and aggression

- Testosterone reduces serotonin and correlates with aggression

- Acute treatment with haldol or BZDs

- Chronic treatment with lithium to reduce the likelihood of developing suicidal ideation --> Lowers testosterone levels

- Brain Danger areas: Limbic system, prefrontal cortex, orbitofrontal cortex, amygdala, and hippocampus

- Biological vulnerability: "Glass is half empty", irritable, and driven

- Generalized psychological vulnerability: Tendency toward lack of self-confidence, low self-esteem, and inability to cope

- Recurrent unexpected panic attacks

- Worry about future attacks or the consequences of the attack

- Substantial behavioral changes in response to the attacks

- Catastrophic thoughts: Fear of death or disability, fear of losing control/insanity, and fear of humiliation or embarrassment

- Alarm reaction --> Catastrophic misinterpretations of symptoms --> Hypervigilance to symptoms, anticipatory anxiety, and memory of past attacks --> Increased anxiety and fear

- Marked fear or anxiety about situations where escape might be difficult

- Situations are actively avoided, require presence of a companion, or are endured with intense fear or dread

- Anticipatory stress or anxiety can be the worst part of the condition

- Fear or anxiety is out of proportion to the actual danger posed by the situations

- Patients tend to avoid activities and the associated physical sensations

- Tend to avoid drinking coffee, running or dancing

- Treatment: Forcing people to experience these senstations and become more comfortable with them

- 2.7% of the US population

- Onset in most often in adolescence and early adulthood

- More common in women --> More likely to develop severe agoraphobia

- Anxiety sensitivity contributes to the maintenance of the disorder

- Excessive anxiety and worry about a number of events or activities, occuring more days that not for at least 6 months

- Worry is very pervasive and non-specific --> Seems hard to control

- Anxiety and worry is associated with at least 3 of the 6 physical symptoms:

1. Restless, keyed up, and on edge feeling

2. Easily fatigued

3. Difficulties concentrating

4. Irritability

5. Muscle tension

6. Sleep disturbance

- Efforts to control emotional responding and perceived threats by preparedness, safety behaviors, and withdrawal from significant activities

- Worry is seen as an active attempt to prevent a negative outcome

- 3.1% of the US population

- More common in women

- Associated with an earlier and more gradual onset

- Chronic course

- Prevalent among older adults

- Marked and persistent fear or anxiety about one or more social or performance situations

- Individual fears they will act in a way that will be negatively evaluated by others

- Exposure to the feared situation almost invariable provokes anxiety

- Fear is recognized as excessive or unreasonable

- Feared situations are avoided or else endured with intense anxiety or distress

- Core patterns: Self-focused attention, negative self-attention, somatic arousal, anxious apprehension, avoidance, escape, behavioral disruption of normal functioning, and skill deficits

- Most commonly begins in childhood or adolescence

- Follows an unremitting course without treatment

- 70-80% meet criteria for an additional diagnosis

- Generalized vs. nongeneralized vs. specific subtypes

- Marked and persistent fear or anxiety about a specific object or situation

- Phobic object or situation almost always provokes immediate fear and anxiety

- Phobia actively avoided or endured with intense fear and anxiety

- Fear or anxiety is out of proportion to the actual danger posed by the object or situation

- Categories: Blood-injection-injury, situational, natural environment, and animal phobias

- 8.7% overall in a given 1-year period

- 15.8% in adolescence

- Median age of onset is 7 years of age

- Runs a chronic course

- Some fears during childhood are normal

- Pathways to fear acquisition: Direct traumatic experience, vicarious learning, and informational transmission

- Prefrontal and subgenual cingulate cortices --> Emotion experience and processing --> Overactivation in anxiety disorders

- Amygdala and hippocampus: Emotional memory formation and retrieval --> Overactivation in anxiety disorders

- First line: SSRIs or SNRIs for anxiolytic effect

- Second-line: BZDs for rapid relief of symptoms, especially panic symptoms, and buspirone

- Third-line: Anticonvulsant (pregabalin), first-generation H1 receptor antagonist (Hydroxyzine), and atypical antipsychotics

- Mechanism: Positive allosteric modulator of GABA-A receptors --> Increases GABA biding

- Short term use for situational anxiety or anxiety associated with a disease or medical procedure

- Uses: Acute anxiety states, panic attacks, initial treatment with drugs having slow onset (SSRIs, etc), long-term treatment of GAD and social anxiety, and add-on therapy in long-term treatment

- Advantages: Rapid onset, few subjective side effects, minimal cardio or autonomic effects, muscle-relaxant, low overdose toxicity, and sedation

- Alprazolam --> Short acting for panic disorders, agoraphobia, and GAD

- Lorazepam --> Intermediate acting for panic disorder and GAD

- Clonazepam --> Social anxiety and GAD

- Side effects: Sedation, dizziness, weakness, cognitive impairment, anterograde amnesia, ataxia, falls, respiratory depression, and interactions with other CNS depressants

- Contraindications: Patients with major depression

- Problems: Tolerance, physical and psychological dependence, and abuse potential

- Withdrawal: Jitteriness, anxiety, palpitaitons, sweating, nausea, confusion, and seizures

- Selective Serotonin Reuptake Inhibitors (SSRIs)

- Serotonin-norepinephrine reuptake inhibitors (SNRIs)

- Atypical antidepressants

- Tricyclic antidepressants

- Monoamine oxidase inhibitors (MAOIs)

- Similar efficacy among classes --> TCAs and MAOIs not recommended due to side effects

1. Tricyclic Antidepressants

- Blocks NE and 5HT reuptake

- Autonomic side effects due to a1 and muscarinic receptor antagonism --> Dry mouth, etc

- Sedation due to H1 receptor antagonism

- Cardiac effects

2. MAO Inhibitors

- Inhibits NE, DA, and 5HT degradation

- Autonomic effects

- Tryamine-induced hypertensive crisis

- Contraindication with SSRI or SNRI use --> Risk of serotonin syndrome

- Approved for panic disorder, GAD, social anxiety, PTSD, and OCD

- Evidence based RCTs differs among the six

- All SSRIs are generally considered to be equally effective

- Have different side effects though

- Spares the effects of NE levels --> No autonomic effects

- Fluoxetine (Prozac), sertraline (Zoloft), Paroxetine (Paxil), and citalopram (Celexa)

- Side effects: Initially mimic the underlying disorder, sexual dysfunction, risk of SIADH-induced hyponatremia (rare), and serotonin syndrome

- Cognitive, autonomic, and somatic effects

- Leads to coma, hyperthermia, and tremors

- Higher risk when other 5HT-enhancing drugs --> SNRIs and MAOIs

- Four drugs in this class

- Venlafaxine --> Approved for GAD, panic disorder, and social anxiety disorder

- Side effects: Similar to SSRIs but more autonomic effects due to effect on NE --> Hypertension and greater risk of overdose

- Withdrawal: Discontinuation syndrome, CNS effects and paresthesias --> Need to taper down slowly

- Mechanism: Partial agonism of 5-HT1A receptors but true mechanism unknown

- Takes 2-4 weeks to take full effect --> Similar to SSRIs/SNRIs

- Efficacy compared to BZDs for GAD

- Advantages over BZDs: Doesn't bind GABA receptors, not sedating, minimal abuse risk, no motor impairment, little interaction with alcohol and well tolerated by the elderly

- Disadvantages: Less efficacy, slower onset, and metabolized by CYP3A4 --> Drug interactions

- SSRIs and SNRIs are first line

- 50-80% response rate after 8-12 weeks

- Begin at a low dose to reduce the risk of initial side effects, titrate up after the first week and monitor efficacy within 12 weeks

- Relapse of symptoms common after withdrawal of meds

- Treats the peripheral symptoms of anxiety but not the psychiatric symptoms

- Indications: Cardiovascular symptoms, migraine headaches, and relief of akathisia (induced by antipsychotics)

- Effective in short-term management

- Great for patients with anxiety with public speaking

- Side effects: Decreased HR and BP, weakness, fatigue, impotence, clouded sensorium, and bronchospasm

- Contraindications: Asthmatics

- Clonidine

- Indications: Hypertension, opioid withdrawal, and evidence of anxiety and panic disorder

- Tolerance may develop

- Side effects: Dry mouth, sedation/fatigue, and hypotension

- Rebound hypertension when meds stopped

- Limited efficacy for pharmacotherapy

- BZDs --> Lack of evidence

- SSRIs and SNRIs are approved for treatment

- Atypical antipsychotics --> Trials inconclusive though

- Anticonvulsants for nightmares and flashbacks

- A1 blocker (prazosin) for nightmares

- D-cycloserine --> NMDA receptor partial agonists that ay enhance the response to desensitizing exposure therapy

- Effect of SNRIs: Higher rates of remission of symptoms when patients are on SNRIs

- Enhacing extinction of fear --> D-cycloserine (NMDA agonist)

- Preventing consolidation of traumatic memory --> B-blockers and glucocorticoid receptor antagonists

- Preventing reconsolidation of traumatic memory --> Protein synthesis inhibitors, B-blockers, and NMDA receptor agonists

- Either obsessions or compulsions or both

1. Obsessions

- Intrusive and nonsensical

- Thoughts, images, or urges

- Attempts to resist or eliminate are difficult

- Symmetry (26.7%) --> Putting things in a certain order

- Forbidden thoughts or actions (21%) --> Checking, avoidance and reassurance

- Cleaning and contamination (15.9%) --> Repetitive washing, and using gloves/masks all the time

- Hoarding (15.4%) --> Collecting/saving objects with no actual or sentimental value

2. Compulsions

- Thoughts or actions

- Attempt to suppress obsessions

- Provides temporary anxiety relief --> Actually reinforces the obsession

- Children may present with compulsions without any identifiable obsessions --> Rare

- Multiple hours spent performing rituals 

- Pediatric autoimmune disorder associated with streptococcal infection

- Patients are more likely to be male

- Dramatic onset of symptosm often associated with a sore throat and fever

- Full remission between episodes of illness

- Remission of symptoms during antibiotic therapy

- Evidence of past strep infections

- Patients present with noticeable clumsiness

- Prevalence is still unknown

- 1.6-2.3% lifetime prevalence

- Median age of onset --> 19

- Earlier onset for males (13-15) and 20-24 for females

- Can present in early childhood (3-5 years)

- Checking behavior in non-clinical sample --> 10-15% of college students

1. Generalized psychological vulnerabilities

- Thought-action fusion: Equating thoughts with actions

- Believing some thoughts are unacceptable and should be suppresed may put people at greater risk for OCD --> Modeling from parents

2. Biological Vulnerabilities

- Anxious apprehension focused on recurring thoughts

- Do cognitive or behavioral rituals to neutralize or suppress thoughts

- Reduces anxiety and provides relief but reinforces thoughts and rituals

1. Pharmacotherapy

- SSRIs --> Take 8-10 weeks to take effect

- 40-60% efficacy --> Equivalent to CBT at acute and less effective than CBT at follow-up

- Inexpensive and high risk of relapse when drug discontinued

2. Psychological --> CBT

- Exposure and ritual prevention (ERP) --> Gradually reducing the number of times or amount of time washing/spitting/etc

- Reduces aversiveness of feared situations

- Patient is systematically and graduall exposed to the feard thoughts or situations

- 50-60% marked improvement, ~equivalent to meds, inexpensive, and mild relapse risk

3. Next generation of treatments

- Mindfulness-based  treatments

- Transdiagnostic treatment approach --> Unified protocol

- Adjunct treatments --> D-cycloserine (DCS)

- Minimal contact/novel treatment modalities --> Intensive treatment, therapist-guided self-help and computer-assisted CBT

- Persistent, intrusive, and horrible thougths about an aspect of one's appearance

- Accompanied by compulsive behavior such as repeatedly checking appearance by looking in the mirror

- Can also result in avoidance of mirrors all together

- Occurs in normal looking people

- Suicidal ideation and behavior are common

- Preoccupation with imagined defect in appearance

- "Ideas of reference": Thinking that everything that goes on in their world is somehow related to them and their imagined defect --> Causes considerable disruption in the patient's life

- Compulsive rituals: Excessive tanning, excessive grooming, fixation with mirrors, and avoidance of mirrors

- 33-50% of patients lack insight into this being an unreasonable source of concern

- "Muscle dysmorphia"

- Seen equally in males and females --> More severe in males

- Onset usually in the early 20s

- Most remain single and many seek out plastic surgeons --> Ultimately not helpful

- Lifelong chronic course

- Treatment: SSRIs, exposure and response prevention, and CBT --> Plastic surgeons not helpful

- Persistent difficulty discarding or parting with possessions due to a perceived need to save the items

- Items have no actual or sentimental value

- Distress associated with discarding them

- 2-5% of population --> Twice as prevalent as OCD

- Affects men and women equally

- Significant impairment

- Treatment: CBT, exposure/response prevention, exposing patients to anxiety as they throw things away, family treatment, and treatment of comorbid problems (depression)

- Urge to pull ones own hair from anywhere on the body, including the scalp, eyebrows, eyelashes, and arms

- Hair loss, distress, and significant social impairments

- 1-5% of college students --> More frequent in females

- Treatment: CBT, habit reversal training, and SSRIs

- Habit reversal training: Awareness training, development of a competing response, building motivation, and generalization of new skills

- Similar to trichotillomania except compulsion is to pick at the skin not pull out the hair

- Causes significant distress and can be physically debilitating

- US is in the bottom third of all countries for suicide rate --> Highest rates of homicide though

- Difference due to the fact that our culture frowns upon suicide

- Men are more likely to succeed at committing suicide --> 66% OD and 32% hang themselves when successful

- Women --> 50% OD, 32% hang themselves, and 18% jump when successful

- Those who OD often OD on prescription meds

- 60% of patients who committed suicide had visited their physician within 3 months

- Not caught by physicians because they tend to ask questions about it in a cursory way that prompts patients to say no

- If a patient hesitates for 1 second the answer is maybe and the answer is always yes if they pause for >3 seconds

- 15% of depressed patients and 15-20% of bipolar patients commit suicide

- 10-15% of patients with major depressive disorder commit suicide

- Mood disorders accounts for 50-70% of all suicides

- Suicide is in the top 5 for malpractice claims

- Male gender --> Men are 4x as likely to die

- Euro-American and Native American

- Active substance abuse

- Major mental illness

- Elderly

- Major depression

- Occupation: Professional

- Employment: Low satisfaction or unemployed

- Social status: Divorced or isolated

- Suicidal history: Questionable

- Female physicians are 400x more likley to commit suicide than the general population and male physicians have a 70% higher rate of suicide

- 12% of all suicides occur in hospitals

- 3-Ds of malpractice --> Damages, duty, and dereliction of duty

- Suicide is usually the 3rd to 5th most common malpractice claim

- Ask patient directly if they have current thoughts of self harm or wishes to die

- Differentiate chronic thoughts of suicie without intent or plan and suicidal thoughts with a plan and intent

- Recall that suicidal and homicidal thoughts often co-occur

- Evaluate if alcohol or drug abuse is present

- Ask about guns in the home

- Assess for history of self-harm or suicide attempts --> Methods, lethality, and frequency

- Be very cautious with males who appear depressed and deny suicidal ideation

- Assess for risk factors

- Be very careful and thorough in documentation

- Don't ever reassure or give false hope

- Try to remain neutral and continue exploring the issue

- 13% eventually successfully commit suicide

- 26% of men and 8% of women

- Stimulates serotonin, down regulates/blocks receptors for B-adrenergic and dopamine

- Works in brain-damaged, chronic psychotics, aggressive prisoners, and conduct disordered kids

- May exacerbate epilepsy in epipleptics

- Lithium is the only drug that decreases risk

- Antidepressants --> SSRIs may treat depression but may initially increase risk

- Suicide is not predictable but you can assess for risks

- Substance abuse is common in completed suicides

- Level and assess relative risk

- Check for plan and weapons

- Consult supervisor

- Document carefully

- Treat by hospitalizing, close outpatient follow-up and consider medication

- One or more symptoms of altered voluntary motor or sensory function

- Evidence of incompatibility between the symptoms reported by the patient and recognized neurological or medical conditions

- Symptoms or deficit is not better explained by another medical or mental disorder

- Symtoms or deficit causes clinically significant distress or impairment in functioning or warrants medical evaluation

- Ex. "Tourrette's" cases in 12 differen people in a small down in upstate New York --> Started developing tics but determined that they had trouble at home

- Falsification of physical or psychological signs of symptoms, or induction of injury or disease, associated with an identified deception

- Individual presents themselves to others as ill, impaired, or injured

- Deceptive behavior is evident even in the absence of obvious external rewards

- Behavior is not better explained by another mental disorder, such as delusional disorder

- New disorder in DSM-5

- Reflects persistent irritability and frequent episodes of extreme behavior dyscontrol in the form of temper tantrums in children

- Chronic severe persistent irritability --> Frequent temper tantrums 3 or more times a week

- Onset must be before age 10 but not less than 6

- Predominantly males

- Causes severe disruption in academics and family

- Different from conduct disorder

- Expression of symptoms in the final week before menses

- Symptoms improve within a few days after onset of menses and become minimal or absent in the week post-menses

- Marked mood swings, irritability, depressed mood or anxiety along with other incapacitating pysical or behavioral changes

- Ceases after menopause

- Milder symptoms of depression than in major depressive disorder

- Mildly depressed all the time --> Many patients don't seek treatment

- Associated with a higher risk of suicide because they often don't receive treatment

- Symptoms persist for at least 2 years

- Can persist unchanged for up to 20 years

- Onset typically in the 20s

- Higher likelihood of comorbin personality disorders, substance abuse disorders, and suicide attempts

- Discrete episodes of depressed mood that lasts at least 2 weeks

- Involving clear changes in affect (feeling sad), thoughts, and physical functioning (sleep disturbances and appetite)

- Includes anhedonia

- Highly unusual to present with just one episode --> Recurrent episodes

- Symptom specifiers: Anxious distress, mixed features, melancholic features, atypical features, mood congruent psychotic features, peripartum onset, and seaonsal pattern

- 80% of women experience "baby blues" as they try to cope with wakeful nights, etc

- 13-19% of new mothers experience depression that is more severe than baby blues

- Peripartum --> Time before and 6 months after birth

- Sadness, despair, tearfulness, insomnia, panic, and suicidal thoughts

- 25-50% chance of developing peripartum depression with a subsequent birth

- Risks of untreated depression: Mother --> Less compliance with prenatal care and low weight gain and baby --> preterm delivery, low birth weight, and behavior problems

- Treatments: Cognitive therapy, antidepressants, and support

- Episodes occur during certain season, primarily winter

- Must occur for 2 years with no evidence of non-seasonal depressive disorder

- Development: Increased production of melatonin, which is inhibited by sunlight and may trigger symptoms

- Prevalence is much higher in New England states

- Treatment: Phototherapy --> 2 hours of bright light per day immediately upon waking

- Women are 2 times more likely to have depression than men

1. Artifact theory: Therapists fail to detect depression in men

2. Hormon theory: Hormone changes trigger depression

3. Quality of life theory: Do women experience more stress than men? --> Face more poverty, have more menial jobs, less adequate housing, etc

4. Societal pressure theory: Women taught to seek low body weight and dissatisfaction with body image

5. Lack of control theory: Women feel less control over their lives

6. Self-Blame theory: Women more likely than men to blame their failure on lack of ability

7. Rumination theory: Rumination leads to depression and women are more likley to ruminate on things

- In bereavement, the predominant feeling is emptiness or loss of the loved one

- In bereavement, feelings are likely to decrease in intensity over days to weeks and occurs in waves associated with thoughts and reminders of the deceased

- Grief may be accompanied by postive emotions that are uncharacteristic of pervasive unhappiness

- Self-esteem is preserved

- Thoughts of death focus on the idea of joining the deceased

- Rituals, such as funerals, help us work through our losses with the support of others

- Often reoccurs at significant anniversaries and holidays

- Symptoms of bereavement that continue for more than 12 months for adults and 6 months for children

- Sadness continues to focus on the loss of the loved one though

- Common in the elderly who have been with their spouse for so long and have now lost them

- Devastating for their entire life, everything revolved around that person

- A last resort for severe depression therapy --> Chronically depressed, chronically suicidal and constantly trying to commit suicide

- Patient is anesthetized and given a muscle relaxer for the procedure

- Shock is administered to the brain for less than 1 second --> Produces a seizure and convulsions

- Patients usually receive 6-10 treatments

- Controlled studies --> 50% of patients not responding to other meds will benefit from treatment

- Side effects: Short-term memory loss and confusion

- Pulse of energy targeting a specific area of the brain

- Very promising for many neurological conditions

- Cognitive behavioral therapy --> Address cognitive errors in thinking and increased contact with reinforcing events

- Interpersonal psychotherapy --> Focuses on problematic interpersonal relationships

- Outcomes with Psychological Treatments --> Comparable to meds and effectiveness of antidepressants

- Abnormally and persistently elevated or irritable mood lasting at least 1 week and present most of the day

- 3 or more of the following must be present

1. Inflated self-esteem/grandiosity

2. Decreased need for sleep

3. More talkative/pressure to keep talking

4. Subjective experience of racing thoughts

5. Distractibility

6. Increase in goal-directed behavior

7. Excessive involvement in activities that have a high potential for painful consequences --> Shopping sprees, affairs, and bad investments

- Causes marked impairment in social/occupational functioning

- Not caused by a substance or other medical condition

- Less severe version of a manic episode

- Does not cause major impairment in functioning

- Only lasts 4 days or less

1. Abnormally and persistently elevated or irritable mood

2. Symptom requirements are the same as mania

3. Associated with a change in functioning that is uncharacteristic of the person and observable by others

- Not severe enough to cause marked impairment in social or occupational functioning

- Episode not caused by another substance

- Tendency of manic episodes to alternate with major depressive episodes

- Possible to have just one manic episode and be depressed the rest of the time

- Experience intense emotional states that represent a drastic change from their usual mood and behavior

- May also present as explosive or irritable

- Suicide risk is 15 times greater than the general population and 4 times greater than people with major depression

- Etiology: Increased prevalence with family history

- Schizophrenia and bipolar likely share a genetic origin

- Bipolar and Addiction: 56% of patients report drug or alcohol addiction --> Use drugs as a way of escaping symptoms

- Alcohol use may actually trigger a manic episode

- Types: Bipolar I, bipolar II, and cyclothymic disorder

- Alternating full major depressive and manic eposides

- AKA manic-depressive disorder

- Onset is usually 15-18 years old

- Comorbidity: Substance use disorder (~50%) and anxiety (~75%)

- Lifetime attempted suicide --> 32.4%

- Alternating major depressive and hypomanic disorder

- Average onset 19-22 years old

- Comorbidity: Substance use disorder (37%) and anxiety (75%)

- Lifetime attempted suicide --> 36.3% --> Higher lethality than bipolar I

- 10-25% of cases progress to full bipolar I disorder

- Manic and major depressive episodes are much less severe

- Symptoms must last at least 1 year for children and adolescents

- For at least 2 years, numerous periods of hypomanic symptoms that don't meet criteria for hypomania and depressive symptoms that don't meet criteria for major depressive disorder

- Patient is not without symptoms for more than 2 months

- Symptoms not better accounted for by schizophrenia, schizoaffective, schizophreniform, delusional disorder, or another schizophrenia spectrum disorder

- Causes marked impairment in social/occupational functioning

- Average onset of 12-14 years --> Predominantly female

- Chronic and lifelong condition

- Comorbidity: Substance use disorder and sleep disorder

- 15-50% risk of developing bipolar I or II disorder

1. Typical cycle: Cycles can last for days to months and typically 3 or less cycles in a year

- Some patients can have only 1 cycle a year

2.  Rapid cycling: Presence of at least 4 mood episodes in 12 months

- These people always feel the need to be on the lookout for their mood to change

- 6 or 7 cycles a year --> May last as little as 1 week at a time

- Change moods so quickly that they are at very high risk for hurting themselves

1. Substance/Medication Induced

- Induced by stimulants (amphetamines and cocaine), PCP and bath salts

2. Bipolar and related disorder due to another medical condition

- Cushing's disease, stroke, traumatic brain injury, and multiple sclerosis

1. Family therapy

- Helping families understand symptoms and develop new communication styles and coping skills

2. Skills

- Managing interpersonal and practical problems

- Learning grounding techniques (crucial for rapid cyclers)

- Recognizing and challenging thoughts

- Medication compliance --> Tough because alot of people really like the highs/manic episodes so they stop taking their meds

3. Medications

- Mood stabilizers, antipsychotics or antidepressants

- Depressed state: Very little brain activity shown on PET scan

- Manic state: Lots of brain activity --> Brain lights up

- Depression: 5-6% of the population is depressed at a given time, 10% will become depressed at some point, and reactive, endogenous, and post-traumatic forms

- VTA connections with the Nacc

- Cingulate and amydala --> Control emotions

- Adrenal gland --> Releases cortisol --> Hippocampus is very sensitive

- Cortisol can actually be toxic to neurons

- Decreased BDNF (growth factor) and CREB (signaling pathway protein to stimulate BDNF)

1. Biogenic amine theory: Decrased activity of biogenic amines in the synapses --> Low serotonin or norepinephrine leading to depression

- Serotonin is the feel good hormone --> NE may play a role in this as well in some people

2. Monoamine Theory

- Genetic mutations in tryptophan hydroxylase and polymorphisms in serotonin re-uptake transporters

- Tryptophan --> Produces serotonin

- Downstream pathways from serotonin are reduced in patients who committed suicide

1. Acute

- Increased serotonin/NE in the synapse

- Immediate increase in NTs in the synapse

- Some people feel better in a day but quite rare

2. Chronic

- Gene expression restructuring

- Increased BDNF --> Stimulates neuron growth

- Neuron growth is crucial for developing new memories and learning --> Damaged in chronic stress states

- IV anesthetic

- Stimulates AMPA receptor and inhibits NMDA receptor

- Immediate mood elevation for up to 1 week afterwards

- Relieves feelings of depression immediately

- Very addictive though! 

- Amitriptyline, imipramine, desiparamine, and clomipramine

- Mechanism: Blocks NE and 5HT reuptake and blocks G-protein coupled receptors (mACh, H1, and A1 receptors)

- Intracellular response: Delayed receptor changes, secondary messenger changes, and transcription factor chages

- Distribution: Lipophilic and protein bound --> Active metabolites and long half-lives (10- >80 hours)

- Metabolism: Hepatic

- Side effects: Sedation, orthostatic hypotension, anticholinergic effects, sexual dysfunction, and weight gain

- Overdose: Suicide, CNS excitation, and cardiac arrhythmias

- Drug interactions: P450 inducers/inhibitors, high protein binding, alcohol, sedatives, anticholinergics, sympathomimetic drugs, and MAO inhibitors

- Fluoxetine, citalopram, sertraline, paroxetine, and fluvoxamine

- Mechanisms: Block 5HT reuptake and delayed gene transcription changes

- Long half-lives (days) and active metabolites with much longer half lives

- Adverse effects: Weight gain, sexual dysfunction (loss of libido), nausea/vomiting, headache, and low risk of overdose --> Start at low dose and begin to taper up to therapeutic dose after first week to avoid side effects

- Little sedation too

- Drug interactions: P450 inhibitor and MAO inhibitor --> Serotonin syndrome

- Black Box Warning: Increased risk of suicide in teens and young adults when beginning treatment

1. Buproprion/Wellbutrin

- NE and DA re-uptake inhibitor

2. Venlafaxine/Effexor --> SNRI

- NE and 5HT re-uptake inhibitor

- Best for patients who are really tired during the day

- More peripheral side effects due to increase in NE

3. Nefazodone/Serzone

- 5HT re-uptake inhibitor and 5HT2A antagonist

- Improves sleep architecture

4. Mirtazapine/Remeron

- Alpha-2 and 5HT2A antagonist

- Improves sleep architecture

- Phenelzine, tranylcypromine, and isocarboxazid

- Mechanism: MAO-A and B inhibition, increased synaptic concentrations of monoamines and delayed therapeutic effects

- Selegiline --> MAO-B inhibitor

- Administration: Oral effect in about 1 week

- Metabolism: Acetylation metabolism --> Poor response to these drugs in slow acetylators

- Short half-lives

- Side effects: Orthostatic hypotension, weight gain (peripheral MAO inhibition), anticholinergic side effects, and serotonin syndrome

- Serotonin syndrome: Agitation, hallucinations, convulsions, and hyperprexia

- Drug interactions: Amine-containing foods (tyramine), sympathomimetics (ephedrine), TCAs, SSRIs, and opioid analgesics

- Amine containing foods --> Red wine, chocolate, aged cheese, etc --> Tyramine storm (Hypertension and tachycardia)

- Neutroceutical

- Contains very low doses of selegiline

- Hypericin

- Purity, potency, and efficacy are questionable

- Adverse effects: Photosensitivity

- Lithium carbonate

- Uses: Bipolar disorder and depression in suicidal patients --> Works REALLY well for rapid cycling bipolar patients

- Mechanism: Substitutes for sodium ion in ion channels, inhibits phosphotidyl inosytyl pathway, inhibits calcium influx through the glutamate receptor (NMDA)

- Narrow therapeutic window --> Dangerous drug

- Excretion: Urinary --> Competes with Na for reabsorption --> Kidney damage possible since Li competes with Na for reabsorption --> Monitor with BUN/Cr
- Side effects: Polyuria, tremor, nause/vomiting/diarrhea, hypothyroidism, coma and death

- Drug interactions: Affect GI motility and alter sodium levels or excretion

- Need to constantly monitor serum lithium levels --> Kidney damage and hypothyroidism occurs pretty frequently

- Lithium probably interferes with T3/T4 release via Na channel blockage

- Patient shouldn't have large shifts in fluid intake --> Can cause coma and death due to overdose and inappropriately high lithium levels

- Trauma

- Re-experiencing: Recollection, dreams and reliving

- Intrusive symptoms

- Avoidant thoughts and behaviors --> Thoughts, activities and inability to recall

- Numbing/withdrawal/anhedonia

- Increased arousal

- Negative cognitions and mood

- Alterations in arousal and reactivity

- Duration at least 1 month --> <3 months (acute) and >3 months (chronic)

- Incidence increases with increased exposure to trauma --> Highest levels in firefighters from 9/11 and combat veterans

- Exposure to life threat

- Loss and mourning

- Community disruption

- Exposure to destruction

- Personal losses

- Exposure to loss of life

- Loss of enterprise

- Information gathering --> Obtain information about needs and concerns

- Problem solving --> Increases self-mastery and enhances ability to reduce current stresses and problems

- Activity scheduling --> Reduces stresses, increases social interaction, and reduces depression

- Managing reactions --> Minimizes arousal and distress

- Helpful thinking --> Reduces maladaptive appraisals

- Healthy connections

- 15% of US adults have at least 1 personality disorder

- Males --> Antisocial

- Females --> Borderline, histrionic, and dependent

- Pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture

- Pervasive and inflexible across situations

- Onset in adolescence or early adulthood

- Stable over time, and leads to distress or impairment

- Cluster A: Paranoid, schizoid, and schizotypal --> Increased risk in relatives with schizophrenia

- Cluster B: Antisocial, borderline, histrionic, and narcissistic --> Increased risk in relatives with cluster B diagnosis and history of substance abuse

- Cluster C: Avoidant, dependent, and obsessive-compulsive

- Fearful and anxious

- Must rule out social phobia, OCD and depression

- Familial assocaition --> Anxiety disorders

1. Avoidant: Timid, wants companionship but fears rejection, socially withdrawn, and feelings of inferiority

2. Dependent: Poor self-confidence and allows others to make decisions

3. Obsessive-compuslive: Perfectionist, orderly-makes lists, indecisive, stubborn and ultimately inefficient in their actions

- Trait vs. disorder --> Trait is in patients who are still efficient in their daily life, disorder is not and causes issues in daily living

- Emotional or dramatic

- Familial association: Mood disorders, substance abuse, somatoform disorders, and bipolar disorder

- Must rule out bipolar disorder and substance abuse

1. Antisocial: No empathy or concerns for others, dishonest, criminality, but can be very charming

2. Histrionic: Attention seeking, dramatic, emotional, life of the party --> Sexually provocative, shallow, vain and unable to maintain intimate relationships

3. Narcicsistic: Pervasive pattern of grandiosity, need for admiration, and lack of empathy

4. Borderline: Erratic, unstable, intense, impulsive, seductive, feels empty, and self-injury --> Cutting behavior and splitting (good vs. evil) --> No grey zone in life

- Pervasive pattern of disregard for others

- Symptoms since at least 15 years old and shows 3 of the following:

1. Failure to conform to social norms or law

2. Deceitfulness and lying for profit or pleasure

3. Impulsivity

4. Irritability or aggressiveness

5. Reckless

6. Consistent irresponsibility

7. Lack of remorse

- Prevalence: 3% of adult population (2% males and 1% females

- Greater than 70% in males with alcohol use disorder, substance use, prisons, or other forensic settings

- Risk factors: Diagnosis of conduct disorder in childhood, family history of cluster B personality disorders, history of abuse, unstable family situation, traumatic divorce, and parents with legal problems

- All on a continuum

- Acts peculiar and/or avoids social relationships

- No psychosis

- Familial association: Psychotic illnesses

- Must rule out schizophrenia, mood disorders with psychotic features, autism, and Asperger's before making diagnosis

1. Paranoid: distrustful, suspicious, litigious, and interprets the motives of others as malevolent

2. Schizoid: Longstanding pattern of voluntary social withdrawal without psychosis, detached, and restricted emotions --> Pathological loner

3. Schizotypal: Peculiar appearance, magical thinking, and odd thought patterns and behavior --> Odd but no psychosis

1. Paranoid --> Psychotherapy, and short-course antipsychotic to treat psychosis

2. Schizoid: Psychotherapy

3. Schizotypal: Psychotherapy and somtimes low-dose antipsychotics

- Treat substance abuse and depression if it is comorbid

1. Antisocial --> Psychotherapy

2. Borderline --> Group therapy, CBT, DBT, psychotherapy and medications to maintain symptoms

3. Histrionic --> Psychotherapy

4. Narcissistic --> Psychotherapy

1. Avoidant: Psychotherapy, systematic desensitization, DBT, and antianxiety meds

2. Dependent: Group therapy, CBT, assertiveness training psychotherapy

3. Obsessive compulsive personality disorder --> Psychotherapy and CBT

- Positive symptoms: Delusions, thought disorder, hallucinations (visual and auditory), disorganized speech, and catatonia --> Best treated with meds

- Delusions are often oriented around techonology and the CIA spying on them

- Negative symptoms: Flat affect, alogia (inability to have fluent conversations with others), avolition (lack of motiviation), and anhedonia--> These symptoms have the most effect on social/occupational dysfunction and very hard to treat with meds

- Mood Symptoms: Dysphoria, suicidality and hopelessness

- Cognitive Symptoms: Impaired attention, memory and executive functioning

- Social/Occupational Dysfunction: Work, interpersonal relationships and self-care are affected

- Mainstay of treatment for schizophrenia

- Not curative --> Aimed towards symptoms, hallucinations and delusions

- Potency depends on each drug's specific selectivity and affinity for the D2 receptor

- Haloperidol: D2>D4>5HT2

- Risperidone: 5HT2>D2>D4

- Clozapine: 5HT2>D4>D2

- 17% of patients are refractory to meds

- Side effects --> Lots of patients (>60%) discontinue meds because of the side effects --> Important to titrate up and not start on the full dose

- 10-20% improve, 20-30% remain constant, and 50-60% deteriorate with time on medications

- Genetics --> ~50% in monozygotic twins and 17% in dizygotic twins

- Predisposition towards developing schizophrenia with gene copy number variation and genetic polymorphism --> Our bodies are good at keeping the sequence of genes but isn't good at keeping the number the same

- Affected genes are associated with the NMDA receptor --> Dysfunction in glutamate signaling

- Structural brain changes: Atrophy of the prefrontal cortex, superior temporal gyrus, and hippocampus/thalamus and enlarged ventricles

- Inconsistent evidence for neurochemical abnormalities --> Therapies directed towards dopamine receptors, specifically D2 receptor

- Phenothiazine, thioxanthene, and butyrophenone classes

- Chlorpromazine (low potency)

- Thiothixene (high potency)

- Haloperidol (high potency) --> Used extensively

- Potency refers to the affinity for D2 receptor

- Mainly inhibit D2 receptor

- Most important side effects are extrapyramidal symptoms

- Mechanism: D2, D3, D4 and 5HT2 anatagonists

- Lack of extrapyramidal motor side effects

- Clozapine --> 5HT2>D4>D2

- Risperidone --> 5HT2>D2>D4

- Aripiprazole --> Lowest amount of side effects

- Others: Olanzapine, quetiapine, ziprasidone, iloperidone, lurasidone, and asenapine

- Good to start patients in atypical antipsychotics because they cause less extrapyramidal symptoms and patients are more likely to be compliant with meds

- Side effects: Metabolic syndrome and weight gain

- Very expensive

- Lipophilic

- Protein bound --> >90%

- Long half lives --> 20-40 hours

- Metabolized by liver --> P450 system

- High therapeutic index --> Safe drugs

1. Extrapyramidal side effects --> Possibly due to DA receptors and only in typicals

- Akathesia --> Constantly feeling like you have to move

- Dystonia --> Treated with anticholinergics

- Parkinsonism --> Treated with anticholinergics

- Tardive dyskinesia --> Occurs in 20-40% of patients and is characterized by grimacing and lip/tongue movements

2. Sudden cardiac death/prolongation of QT interval --> High risk of torsades de pointes --> 2x increased risk

3. Weight gain and metabolic syndrome --> Present in atypicals

- Diabetes, glucose tolerance plus two of the following --> Increased BP, dyslipidemia, central obesity or BMI >30, and microalbuminuria

4. Dysphoria

5. Sedation

6. Orthostatic hypotension and anticholinergic effects --> Low potency drugs

7. Gynecomastia

8. Blood dyscrasias --> Clozapine

9. Neuroleptic malignant syndrome --> Muscular rigidity, high body temp (>42 C), and mental confusion

- Treatment for refractory schizophrenia

- Indications: Patient must have failed trials of two other antipsychotic meds

- Risk of agranulocytosis --> Blood dyscrasias

- Requires weekly CBCs at first then bi-weekly blood counts

- Parkinson's disease meds

- Sedatives

- Anticholinergics --> TCAs, etc

- Antihypertensive agents potentiated by antipsychotics --> May need to reduce doses to avoid excessive lowering and overmedication

-15-30% of patients are refractory to all meds

- Not curative --> Aimed at treating the symptoms not the root of the problem

- Unpleasant side effects --> Reduce patient compliance

- History of present illness

- Physical examination --> Including neuro exam

- Laboratory studies

- Neuroimaging

- Pay special attention to sleep, appetite, energy, concentration, and mood

- Physical exam: VS, general appearance, HEENT, skin, cardio, abdomen, neuro exam, and MSE

- Labs: CBC, metabolic panel, RPR (syphyllis), TSH, drug levels, B12, folate, and serum/urine tox screen

- Neuroimaging: CT/MRI to look for structural abnormalities, areas of ischemia, hemorrhages, enlarged ventricles, and atrophy

- EEG: Can be used to diagnose delirium, dementia, seizures and sleep disorders

1. Delirium

- Generalized theta or delta slow wave activity

- Loss of reactivity of the EEG to eye opening

2. Dementia

- Slowing of alpha activity

- Increase in slow frequency activity

3. Seizures

- Sharp waves, spikes, and paroxysmal activity

4. Sleep disorders --> REM sleep disorders

- 30 point questionnaire used to screen for cognitive impairment

- 25-30 is normal

- 21-24 is mild impairment

- 10-20 is moderate impairment

- <9 is severe impairment

- Better than the MMSE at recognizing mild cognitive imapairment or earlier stages of impairment

- >26=normal

- <26 --> Cognitive impairment

- Used in 100 countries, and translated into 36 languages

- Includes tests of executive function and abstraction

- Puts more weight on recall and attention-calculation performance and less on language

- Takes longer to administer than MMSE

- Measured by responsiveness to verbal commands and to painful stimuli in patients with suspected neurological impairment

- Evaluates: Motor and verbal response and eye opening

- Ranges from 3-15 points

- Verbal comprehension index, perceptual reasoning index, working memory index, and processing speed index

- 10 different scales --> Hypochondriasis, depression, hysteria, psychopathic deviate, masculinity/femininity, paranoia, psychasthenia, schizophrenia, hypomania, and social introversion

- Validity scales --> Adds questions that see if the patient is telling the truth or not

- Reveals maturation of visuomotor perceptions, associated with language ability and various functions of intelligence

- Observations also include physical demeanor, drawing technique, test taking behavior, and attitude

- Observe how the patient performs these tasks --> Some patients get agitated, etc

- Asked to copy all the cards

- Digit symbol substitution

- Boston naming test

- Wisconsin card sorting test

1. Dexamethasone suppression test

- About 1/2 of patients with depression ahve positive DST but not specific enough

2. IV sodium barbital assisted interviews

- Dissociative, conversion, and malingering

- "Truth serum"

3. Sodium lactate administration --> Good for diagnosing panic disorder --> Will precipitate a panic attack in someone with a panic disorder

4. Galvanic skin response --> Adjuvant for lie detector tests

1. Depression

- Hypothryoidism, anemia, stroke (left sided), meds, substance use (opioid intoxication or cocaine withdrawal), pancreatic carcinoma, Addison's disease, and Cushing's syndrome

2. Anxiety

- Hyperthryoidism, hyper/hypoglycemia, substance use disorder, cardiovascular disease, asthma, anemia, and pheochromocytoma

3. Psychosis

- AIDS dementia, Lewy Body dementia, delirium, substance use disorder (PCP and LSD), tumor, stroke (right sided), seizure, and meds (TB drugs and glucocorticoids)

- Common side effects: Depression, irritability and anxiety --> Almost everyone has some irritability

- Uncommon effects: Hypomania and psychosis

- Etiology is unclear --> Alterations in serotoninergic transmission and changes in the hypothalamic-pituitary-adrenal axis

- Pre-existing psychiatric diagnosis in 20-30% of HCV patients

- May need to prophylactically treat with meds to avoid severe psych side effects

- 50-90% may have coexistent disorder of anxiety or depression

- Somatization disorders is seen in 15-50% of patients

- Therapy: Reassurance and explanation are key and symptoms directed therapy

- Targeted IBS Therapy: Hyoscyamine (Anticholinergic and relaxes intestinal smooth muscle), tricyclic antidepressants, and SSRIs

- More common in the elderly

- Often induced by antibiotics and infections

- Can either get better or worse when patients are given BZDs --> Elderly patients tend to get worse when given BZDs --> Tend to avoid in elderly whenever possible

- Treatment: Haloperidol 2 mg IV (antagonizes dopmaine and serotonin, D4>D2>5HT2

- Haloperidol does predisposed to prolonged QT and torsades de pointes

- Haldol given IM instead of IV can be a lot better tolerated and doesn't cause long QT the way that IV does

- Haldol can produce tremor and stiffness (dyskinesia)

- Can give atypical antipsychotics at this point --> Risperidone and quetiapine --> Fewer extrapyramidal side effects