• rarely last longer than 2 MO
• Does NOT cause much functional impairment (can still go to work buy groceries ect)

Normal - guilt and sadness, mild sleep disturbance, illusions (hearing their voice); attempts to resume daily activities; Symptoms that resolves within 1 yr(worst s/s within 2 mo)

Abnormal: hallucinations, SI, no attempts to resume, smyptoms persist for more than 1 YR

Requires 5 or more for at least 2 wks:

1. Depressed mood most of the day
2. diminished interest in all activities
3. insomnia or hypersomina
4. weight changes
5. psychomotor agitiation or retardation
6. fatigue or loss of energy
7. feelings of worthlessness or excessive guilt
8. decreased concentration
9. recurrent thoughts of death or SI

 Rx: SSRI for atleast six months after one episode, more episodes involves longer maintence

Depressed mood for most of the time for at least 2 years

must have 2 of the following

1. poor appetite or over eating
2. insomnia or hypersomnia
3. low self-esteem
4. low energy
5. feelings of worthlessness
6. poor concentration

development of behaviors symptoms and responses to a stressor occuring within 3 MO of onset of the stressor and end within 6 mo of stressor(school, new job, baby, marriage)

• Distress is usually excess to what would be expected
• Usually causes significant imparment in social or occupational fxning

2x as common in females

Rx: Supportive psychotherapy (best), group therapy, some pharm if needed for insomnia, anxiety or depression

Cluster A personality disorder

charaterized by detachment from relationships and inability to express emotions

• DO NOT enjoy close relationships
• prefer keeping aloof and isolated
• Seem indifferent to praise or criticism and always choose solitary activities
• emotional coldness/detachment or flattened affect

EPI: prevalence 7%; men x2 > wo;no increased risk in pts with familial schizophrenia

pattern of odd or eccentric behavior and reduced capacity for close relationships

exhibit "magical thinking"

social anxiety

restricted affect

suspicousnes

****Course is chronic and pts can develop schizophrenia !!

show instability of interpersonal relationships and marked impulsivity swing btw devaluing and idealizing people (splitting)

demonstrate suicidal or self mutilating behavior

instability of mood w/ difficulty controling anger 

chronic feeling of emptines

unstable/intense relationships

transient/stress related paranoud ideation/dissociative sys ** can have transient psychosis

10% suicide rate, and W>M

comorbid with MDD and substance abuse

Cluster A

pattern of distrust and suspiciousness

negatively interpret actions, words and intentions

suspect others are out to harm them/deceive them

preoccupation with loyalty/fidelity

reluctance to confide

persitant grudges

m>w

 Higher incidence in family members with schizophrenia

rx: psychotherapy

presence of one or more of the following :

hallucinations

delusions, disorganized speech and behavior for atleast one day but less than a month with complete resolution of symptoms

Hallucinogen that antagonizes NMDA glutamate -R and activates DA neurons

presents w/ behavioral changes:

impulsiveness, marked agitationm impaired judgment, psychosis, paranoia, AH/VH or assults

In addition they can present with 2 or more of the following:

nystagmus, HTN or tachycardia, ataxia, dysarthria, muscle rigidity, seizure and coma

*high tolerance to pain

Rx: monitor vitals, acidify urine with ammonium chloride and asoribc acid

Bnz ir DA antagonist to control agitation and anxiety

Diazepam for muscle spasms /seizures

Haloperidol - agitation and psychosis

UDS + for 1 wk

CPK and AST are often elevated

no withdrawal but can have flashbacks

2 or more of the following:

Catalepsy, wavy flexibilty and stupor

catatonic excitment

extreme negativism or mutism

posturing, grimacing, prominent mannerisms

echipraxia or echolalia

Rx: benzo (lorazepam) or ECT

shifting of emotions associated with an unaccepatable object or idea ro another that resembles the originial in some aspect or quality

ex: after arguing with your parents; wrecking the car your parents gave you because it was a gift from your parent

reduction to more immature levels of fxning when confronted by stressful situation

recurrent involuntary voiding

atleast 2 x wk for 3 mo

age of Dx must be atleast 5 y

Rx: TCA - IMIPRAMINE

directing the force of an unacceptable impulse by suing the energy  in other. more constructive ways

Angery? go to the gym

Recurrent episodes of binge eating and lack or control over eating during the episode. Once the epsiode is over the pt often feels guilty

Compensatry behavior to prevent weight gaif after binge, like seld inducing vomiting, laxative abuse, fasting or excessive exercise

These behaviors must be occuring 2x/wk over 3 mo

BMI is normal or above normal

intentional production or feigning of physical or psychological symptoms, w/ a primary desire to assume the sick role

there are no external incentives (money or drugs)

*primary gain is the goal

Commonly feigned symptoms:

psychiatric: hallucinations, delusions

medical - fever, abdominal pain, seizures, skin lesions, and hematuria

EPI:

>5% of all hospitalized patients

>males

higher in medical/healther care workers

associated with higher intelligence, poor sense of identity and poor sexual adjustment

*many pt have hx of child abuse or neglec; repeated longterm HA are common 

RX: no effective

intentional production of false or grossly exaggerated feigning of physical or psychological symptoms, the motivation being a secondary incentive (money or drugs)

present with multiple vague symptoms, generally uncooperative and refuse to accept a good prognosis

* most common

presence of persistent intrusive thoughts - which lead to perfromance of recurrent compulsive acts in in order to allay the anxiety associated with the distrubing thoughts.

Rx: DOC -->SSRI (paroxatine) higher doses than for depression;  2nd line - TCA (Clomipramine)

EPI: 2-3% of pop, onset in early adult, associated with MDD, eating disorders, OCD personality d/o

**** higher in patient with 1st degree relatives with tourette's

Pathophys:

abnormal SE, 60% occur after stressful life event

same as schizophrenia just more than a month and less than 6 mo

• delusions
• AH/VH
• disorganized speech
• grossly disorganized behavior or catatonic behavior
• negative symptoms (3 A's affective flattening, Asociality and Alogia -poverty of speech)

EPI: 1/3 of pts recover

Rx: hospitalization, 3-6 mo of antipsychotics and therapy

requires the presence of symptoms of schizophrenia along with mood symptoms (MD episode, manic episode or mixed episode)

have had delusions or AH/VH for 2 wks in the absece of mood disorder symptoms

1. Exsposure to the event
2. re-experiencing the trauma in the form of flashbacks, nightmares or play
3. persistent avoidance of stimuli assocaited with the trauma
4. persistent symptoms of increased arousal (hypervigilant, sleep disturbances, impaired concentration)
5. S/S must persist for atleast 1 mo

High association with subsance abuse so benzo should be avoided (lorazepam )

TCA(imipramine, doxepin and nortiptyline), SSRI are often good, along with therapy

anticonvulstants can be used for nightmares and flashbacks

CBT, relaxation training ect

*1/2 remain symptom free after 3 mo of treatment

Lithium

what are the side effects?

how does is act?

inhibits inositol-1-phosphatase in neurons which enables it to treat mania, also effect sodium transport

Secreted by the kidneys, takes 5-7 day to take effect

bld levels correlate with clinical efficacy -->

theraputic range: 0.7-1.2 , toxic>1.5 and lethal >2

se: GI,

nephrotoxic (polyuria, polydipsia --> nephrogenic diabetes insipidus)

** in the elderly decrease due to decreased GFR

hypothryoid

tremors

leukocytosis

acne

psoriasus flares

hair loss

edema

TERATOGENIC (ebstein anomaly)

*does not effect liver or bone marrow

Toxic SE: altered mental status, coarse tremor, convulsions and death

Things that affect Li+

NSAIDs(decrease leverls), Asprin, Dehydration, salt deprivation, impaired renal fxn and diuretics (decreased levels)

can occur at anytime with the use of a DA antagonist

ss: altered sensorium, muscular rigidity, autonomic instability, and hyperthermia

labs: elevated CPK

FALTER (fever, autonomic

Rhabdomyolysis followed by myoglobinuria --> renal failure can occur

Rx: supportive care, aggressive cooling, and alkaline diuresis in cases of Rhabdo

Dantrolene sodium

Anorexia and pregnancy

what are they at risk for?

Cluster B

pattern of disregard and violation of the rights of others

- unlawful acts; thefts, lying, disregard for safety, lack of remorse

-aggressive, impulsive and cannot hold jobs

pt must be >18 yo w/ evidence of conduct d/o in childhood

EPI: 3%of men, higher in urban areas and jails, genetic - 5x increased risk in 1st degree relatives

Rx: psychotherapy

moa: blocks DA reuptake causing stimulant effect (reward)

intoxication: produces a euphoria, hypoTN, tachy/brady, nausea and dilated pupils; respiratory depression, seizures, arrhythmias and hallucinations (tactile)

***MI

drug screen is postitive for 3 days

Rx: Bnz for mild to mod agitation, haloperidol for severe agitation

Abuse: presents with weight loss, "strange behavior" and erythematous turbinates an nasal septums

Rx: psychotherapy, TCA and DA agonists (amantadine and bromocriptine)

Withdrawal:

crash, malaise, fatigue, depression, hunger, constricted pupils, an vivd pupils

TOC is SSRI

ex: Paroxetine

w/ psychotherapy

2ND LINE:

TCA Clomipramine

 Its primary pharmacological action is thought to be norepinephrine-dopamine reuptake inhibition. It binds selectively to the dopamine transporter, but its behavioural effects have often been attributed to its inhibition of norepinephrine reuptake It also acts as a nicotinic acetylcholine receptor antagonist.

uses: depression and anti-smoking aid

*can be used with nicotine replacement agents

CI: epilepsy, ** need to monitor BP can cause emergent HTN 

SE: can help with weight loss

X linked recessive (CCG) repeat expansions near gene called FMR1

2nd mcc of MR in males

features: long face, prominent jaw, large ears, enlarged testes, developmental delay, and MR

Tourettes

s/s and Rx

multiple motor and one or more vocal tics

tics occur frequently through out the day

Rx: older anti-psychotic drugs pimozide and haloperidol

anticholinergic

controls EPS se of antipsychotic esp dystonia and tardive dyskinesia

immature defense mechanism

express agression towards another by repeated passive failures to meet their needs

chronically giving into an impulse to avoid the tension that would result from postponement of the expression

child throwing a tantrum, yelling at your boss when you are fired (giving in to anger)

present w/in 24hrs

pts may "feel like they are dying"

s/s N/V/D muscle spasms, joint pains, abdominal cramps, rhinorrhea, lacrimation and sweating

pupillary DILATION

may have autonomic instability: HTN

Bipolar d/o

dx:

elevated or expansive mood must last for at least 1 wk

Intial tx for agitated/psychotic pt:
haloperidol

maintenance therapy with lithium for pts:

life-long maintenance for pt with three or more relapses

for a single manic episode, long term maintenance should be for at least one year (then consider tapering)

 DOC: valproate then consider lithium and carbamazepine

lifetime risk for developing mania for general population 1%, no sex difference, increased prevalence in higher socioeconomic. a high degree of prevalence seen in divorced or single individuals

incidence:

chold with one bipolar parent, sibiling or dizygotic twin: 20%

child with both bipolar parents - 60%

monozygotic twin of a person with bipolar d/o : 70%

occurs in wo 20-40 yo

sudden onset of chest pain, palpitations, nausea, anxiety and diaphoresis with negative EKG and no drug abuse

acute: benzodiazepine (alpazolam)

long term: SSRI (Paroxetine, Sertaline and Fluoxetine) or TCA w/ therapy

10-20% cont to have significant symptoms that interfere with daily fxning

50% have mild infrequent symptoms

assocated conditions:

major depression > substance dependance , social and specific phobias and OCD

Pathophys:

increased NE and decreased SE and GABA

intentional fire stting on more than one occasion

they tend to be fasinated by fires and anything realted to fires.

Its an impulse control d/o which cannot be bette accounted for by any other psychiatric or medical condition

Xanax

short acting Benzo

use: panic disorder, anxiolytic

abrupt cessation can cause severe w/drawal like tonic-clonic seizures and confusion

first line axiolytics

PROs: safe at high doses

CONs: highly addictive and cause tolerance and dependence

MOA: potentiate the effects of GABA

LONG ACTING:

Chlordiazepoxide, Diazepam (Valium)  Clonazepam (Klonopin) and Flurazepam

MEDIUM:

Lorazepam (ativan) Temazepam

Short acting:

Oxazepam, Triazolam and Alprazolam (Xanax)

BNZ, long acting

use: EtOh detox, presurgery anxiety

Temazepam - medium acting

use: insomnia

Triazolam: rapid onset use: insomnia

recurrent and progressive maladaptive gambling behavior

• preoccupied with gambling and arranging for means to indulge in it
• unable to quit
• commonly use gambling as a means to excape from their mood disturbances

persisten, excessive anxiety and hyperarousal for at least 6 mo about a number of events

difficult to control worry

must be associated with at least three:

• restlessness
• fatigue
• difficulty concentrating
• irritabilty
• muscle tension
• sleep disrubance

RX: Buspirone, Bnz (Clonazepam, Diazepam), SSRI, Venlafaxine

MOA: inihibt reuptake of NE and SE

Imipramine, Amitriptyline, Trimipramine, Nortriptyline, Desipramine, Clomipramine and Doxepin

SE: HAM

anti-hist: sedation

Antiadrenergic: CV - orthostatic hypoTN, tachy, arrythmias

Anti-muscarinic: dry mouth, constipation, urinary retention blurred vision and tachy

weight gain

lethal overdose!

3Cs: coma, convulsions and cardiotox

**** Widen QRS --> TCA toxicity -prolong conduction (do not affect contractility)

Rx: sodium bicarbonate

TCA

most serotonin specific

useful in OCD

MOA: prevent the inactivation of NE, SE and DA and tyramine by irreversibly inhibiting MAO-A/B (thus increase the amount of the transmitter in synapse)

use: refractory depression and refractory panic d/o

ex: Phenelzine, Tranylcypromine, isocrboxazid

SE: orthostatic hypoTN, drowsiness, weight gain , SEXUAL DYSFXN, dry mouth and sleep dysfxn

can also cause serotonin syndrome and HTN crisis

MOA: inhibit presynaptic serotonin pumps --> increased levels of SE in cleft

PROs: safe over dose profile, no food restriction, low SE

uses: anxiety d/o, OCD and premenstrual dysphoric d/o

ex: fluoxetine:longest half life, no need to taper

Sertraline - highest GI se

paroxetine: most SE specific, more stimulating

Fluvoxamine: only approved for OCD, short 1/2 life

Citalopram

Escitalopram

SE: sexual dysfxn (20-30%); GI upset, insomnia, HA, anorexia/weight loss, Serotonin syndrome w/ MAOIs

effexor

MOA: SE/NE Reuptake inhibitor

use: refractory depression

SE: similar to SSRIs

sexual dysfxn, GI upset, Weight loss, insomnia, HA

** can also cause elevation in BP, should not be used in pt with labile BP

NE/DA reuptake inhibitor

use: smoking cessation , seasonal affective d/o, adult ADHD

pros: lack of sexual SE - patient with sexual dysfxn (pre-exisitng or from SE) this is DOC

CONS: ** DA effects in high doses can make psychosis worse, also increases seizure risk

can cause elevated BP in patient taking nicotine replacment

CI: in patient with eating d/o or seizures, or on MAOI

MOA: SE antagonis and reuptake inhibitor

use: refractory depression

major depression with anxiety

insomnia

se: N, Dizziness, othrostatic hypotn, cardiac arrthymias sedation and priapsim

NE and 5HT antagonist

use: refractory depression esp in patient who NEED to gain weight

se: sedation, weight gains, dizziness, somnolence, tremor, and agranulocytosis

Cluster ; 2-3% W>M, more functional than Borderlines

Rx: therapy and some meds to treat depression or anxiety

• excessively emotional and attention seeking always like to be the center of attention 
• use their physical appearance to draw attention, often sexaully provocative
• exaggerate and dramatize their emotions
• demonstrate shallow expressions of emotions
• speech that is impressionistic and lacks detail
• theatrical
• easily influeced by others or situations
• perceives realtionships as more intimate than they actually are

Can have improvement with age

atypical

last drug of choice

least likely to cause movement d/o but pts must be monitored weekly with WBC-levels to check for agranulocytosis

- also decreases seizure threshold

• Complete physical exam
• skeletal survey
• coagulation profile (if multople bruises are present)
• report to CPS
• admit if necessary
• consult psychiatrist/explore family dynamics

type of impulse control d/o

1. occurence of disrete episodes of failre to resist aggressive impulses that result in serious assaults or destruction
2. degree of agressiveness expressed during an epsioe is grossly out of propprtion to any stressor 
3. dx ONLY after other mental d/o can cause agressie behavior are r/o, medical condition or substance

MOA: abnormalities in serotonergic pathway in limbic system, CSF 5-HIAA levels are often low

EPI: men>wo, late teens, early 20s

may have a history of trauma

may progress

Rx: SSRIs, anticonvulsants, lithium, and propanolol

therapy is often no very helpful

excessive preoccupation with an imagined bodily defect which causes significant fxn impairment (mood, productivity ect)

EPI:

wo>men

unmarried>married

15-20 yrs old

90% have depression; 70% have anxiety d/o;  30%psychotic d/o

Rx: SSRIs reduce symptoms in 50%

multiple medical complatins

4 pain symptoms

2 GI symptoms

1 sexual

1 psuedoneurological

EPI: 10% of patients at PCP, >F, Onset before 30yo;

50% have comorbid mental disorder

First-degree female relatives have a higher incidence

Rx: regurlalry scheduled visit

mature defense mechanism

use constructive and gratifying servie to others to decrease their own internal fears and anxiety

Does not meet with all criteria for any eating d/o

usiallly pt has anorexic behavior but normal menstural period or BMI is normal

all of the criteria for bulimia are met except for binge eating

Olanzapine

most comon SE?

obesity

DM is a concern but not as common as obesity

mcc of dementia

more common in wo v men

live 8 yrs after diagnosis

40% of pts have fmhx

clinical picture: memory impairment plus atleast ONE of the following

aphasia, apraxia, agnosia, diminished executive functioning (planing, organizing)

personality and mood changes are also common: depression, anxiety, anger and suspiciousness, can have psychotic s/s like paranoia

MOA: decreased levels of Ach (loss of noradrenergic neurons in locus ceruleus of brainstem) and NE (loss of cholinergic neurons in basal nucleus of midbrain)

Rx: memtantine (NMDA receptor antagonist)

Cholinesterase inhibitors - slow progression

ex: Tacrine, Donepezil, Rivastigmine

caused by microvascular dz in the brain - step wise loss of fxn

dz manifestations are identical to alzheimers BUT is also causes focal neurological symptoms

- hyperreflexia or paresthesias

dx: MRI

rX: supportive

rare, slowly progressive

hallmarks: aphasia, apraxia, agnosia, but also has MORE personality changes early in dz

path: atrophy of frontotemporal lobes; pick bodies (intraneuronal inclusion bodies)

no rx

AD Ch 4, trinucleotide repeat, affects basal ganglia

progressive cognitive, physical, and psychological decline --> death

onset 30-50 yo

MRI: caudate atrophy

MOA: prominent neuronal loss in substania nigra (which provides DA to basal ganglia) results in physical and cognitive impairment

30% develope dementia

characterized by:

bradykinesia, cogwheel rigidity, resting tremor, masklike faces, shufffling gait, dysarthria

50% will suffer from depression

Rx: levodopa - degraded to DA

caridopa-peripheral enzyme inhibitor, increases levels of levodopa in the CNS

Amantadine

Cogentin (Benztropine) Anticholinergic - relieves tremor

DA agonits

MAO-B inhibitors - increases levels of DA

enlarged ventricles wuth increased CSF pressure

triad:

gait disturbance

urinary incontinence

dementia** may not improve

rx: shunt

acute d/o of cognition related to impairment of cerebral metabolism

pts have an altered level of consciousness, lucid intervals, appear confused

visual hallucinations are common, often worst at night, EEG changes awareness reduced

common causes:

CNS injury or dz

systemic illness

drug abuse or withdrawl

hypoxia

fever

sensory deprovation

meds

post op

electrolytes

Avoid BNZ in delirium

Rx: treat reversible causes, antipsychotics can be helpful - quetiapine and haloperidol

CVA or mass lesion

Dx: MRI

Hypertensive encephalopathy

dx: Brain MRI/CT

drugs

dx: urine drug screen

meningitis

dx: lumbar punture

cognitive deficits in pts with major depression

s/s: sleep distrubances, decreased appetite and weight loss, feeling worthless / SI, lack of energy / interest in activities

*onset is more acute than dementia, pt often emphasizes failures and is aware of the problwm

Rx: supportive, SSRIs (LOW DOSES) ECT can be considered, Mirtazapine (good for weight gain and sedation) and methlphenidate (pt has psychomotor issues)

REM: increased in # of REM episodes but they are shorter than younger people, so total REM is about the same

stage 3,4 (deep sleep) decreases

stages 1,2 increases with more awakening

try to not give sleep aids - bad SE but if you have to give

Hydroxyzine (Vistaril) or Zolpidem (Ambien)

- less sedating than bnz

Dx:

• significantly subaverage IQ<70 or below
• deficits in adaptive skills appropriate for the age group
• onset must be before age of 18 yo

80% are mild and are able to live on their own

violation of the basic rights of others or of social norms with atleast 3 acts w/in the following in the past year:

1. agression towards others

2. destruction on property

3. deceitfullness

4. serious violation of rules

boys>girls

40% risk of developing antisocial personality d/o

increased incidence of comorbid ADHD and learning d/o, mood d/o, substance abuse and criminal behavior as an adult

6 months of negativistic, hostile and defiante behavior with at least four of the following:

1. frequent loss of temper
2. arguements with adults
3. defying adults rules
4. deliberately annoying people
5. easily annoyed
6. anger and resentment
7. spiteful
8. blaming others for their own mistakes

16-22% of children >6yo

begins by age 8

Comorbid: substance abuse, mood d/o and ADHD

25% remit

At least six s/s inovlving inattentiveness, hyperactivity ot both and most occur > 6mo

onset before 7

inattention: problems listening, concentrating, paying attention to detail, easily distracted

hyperactive: blurting out, interupting, fidgeting, leaving seat, talking

3-5% of school age children, boys>girls, most cases remit in adolescense (20% have s/s as adults)

Rx:

CNS stimulants - methyphenidate (Ritalin); dextroamphetamine (dexadrine) and pemoline (Cylert)

therapy

At least 6 s/s from following must be present

1. problems with social interaction (2): impairment of nonverbal behaviors (facial expressions); failure to develop peer relationships; failure to seek sharing; lack of emotional/social reprocity
2. Impairment in communication (1): delayed speech; repetitive use of language; lack of varied spontaneous play
3. Patterned behavior and activities(1): inflexible rituals; preoccupation with parts of objects

boys>girls, less than 1%, some familial inheritance

strong association with Fragile X, MR and seizures

70% have IQ <70

Rx: therapy, Antipsychotics (aggression, hyperactivity, mood); SSRI (repetitive behaviors)

No impairment of language

- still have a lack of nonverbal / social interaction and stereotyped/patterned behaviors BUT they are able to speek normally

Dx:

1. Normal development in first 2 yr of life
2. loss of previously aquired skills in 2: language, social, bowel or bladder cont, play or motor
3. at least 2 of the following: impaired social, language and repetitive behaviors and interest

boys>>girls

rare

Dx: multiple motor AND vocal

many times, mutliple times per day>yr

before 18 yo

<1%; boys>girls

high comorbid: OCD (27%) and ADHD (60%)

 *OCD occurs 3-6 yrs after onset of tics

MOA: impaired regulation of DA in the caudate

Rx: Haloperidol, pimozide

Extreme fear and avoidance of social situation

siginficant occupational impairment

pts often see themselves in a negative light and assume excessive responsibilty for failure or negative experience

rx: assertivness training (component of Cognitive behavioral psychotherapy) - this involves examing fearful thought and social skills training

SSRIs: like paroxetine and fluoxetine) are considered 1st line drugs in the management

requires that amnesia be the only dissociative symptom present

they are usually aware that they are haveing dificulty remembering but are not vrey troubled by it

dx:

• at least one epsisode of inablility to recall important personal info, usually involving a traumatic event or stressor
• symptoms cause sigificant distress or impairment in daily fxning 

Most common dissociative d/o, wo>men; younger>older

comorbid: depression and anxiety

Rx: most return to normal, can undergo hypnosis, can give ativan or barbituates

sudden unexpected travel away from home or work with inabilty to recal ones past

confusion about presonal identity or assumption of a new identity

symptoms cause impairment of social or occupational fxning

*** they are not aware they have forgotten anything!!

Epi: rare, reponse to stressor,

predisposing factors: head trauma, EtOH, major depression and epilepsy

dx:

• presence of two or more distinct idenitties
• atleast two of the identities recurrently take control
• inability to recall presonal info of one personality when other is dominant (large gaps)

EPI: women>>>men; prior trauma esp childhood sexual abuse, avergae age of dx =30;

comorbid: major depression, anxiety, borderline, substance abuse; 1/3 attempt suicide

usually chronic with incomplete recovery, worst prognosis of all dissociative states

persisent or recurrent feeling of detachment from oneself , enviroment

person feels separate from their bodies or mental processes

*** they are aware of the situation and often fear they are going crazy

often accompanied by anxiety or panic

EPI: 2x as common in wo; onset 15-30; comorbid: anxiety and major depression; severe stress predisposing factor

RX: psychotherapy, SSRI and antianxiety agents

present with MULTIPLE vague complaint involving MANY organ systems

long standing hx of visitng many doctors

cannot be explained by a medical disorder

dx:

at least 2 GI;

at least 1 sexual/reproductive;

at least 1 neurological

atleast 4 pain

onset <30 yo

EPI:

F 5-20x M

<1% of population- but greater in LOW socioeconomic

50% have comorbid mental illness

Chronic and debilitating, may remit only to return

Rx: no cure, regularly scheduled visits to PCP, minimize 2nd gain and medications

attempts therapy

Atleast ONE neurological symptom, onset is always preceded by psychological stressor

patient is always calm and unconcerned

NOT intentionally reproduced

causes significant impairment

Common s/s:

paralysis, blindness, mutism, paresthesias, seizures, globus hystericus

EPI:

common, 20-25%in general medical setting

2-5x more common in women

more often in early adulthood

increased incidence in LOW socioeconomic groups

HIGH comorbid: schizophrenia, major depression or anxiety

MUST r/o underlying medical condition 50% eventually receive medical dx

usually resolves w/in 1 mo, 25% will have future episodes

Rx: hypnosis or sodium amobarbital (amytal)

"insight-oriented psychotherapy" or relaxation therapy

Dx:

patients fear that they have a serious medical condition on misinterpretation of normal body symptoms

fears persist despite appropriate medical evaluation

fears present for atleast 6 mo

men=wo

average age of onset 20-30

80% have major depression or anxiety

** worries about an actual disease v somatization which is just symptoms

Rx: no cure, ONE PCP helps manage symptoms, psychotherapy is best if patient is willing

Dx:

main complaint is of pain at one or more anatomical site

cause significant distress in patients life

related to psychological factors

cannot be fully due to medical condition (pt may have a medical condition that causes them pain but is not directly caused by)

EPI:

women 2x men

30-50 yo

familial

"blue collar workers"

depression, anxiety and substance abuse is common

Rx: analgesics are not helpful (pts become dependent); SSRI, transient nerve stimulation, and *psychotherapy

Dx:

failure to resist urges to steal objects that are not needed for personal or monetary reasons

pleasure or relief from stealing

not due to anger, hallucinations, or delusions

EPI:

wo>men

5% of shoplifters

times of stress

comorbid: mood disorders, eating disorders, and OCD

usually chronic

Rx: insight orient therapy, behavior therapy and SSRIs

Dx:

• more than one episode of intentional fire setting
• tension present before the act or pleasure or relief experienced afterwards
• fascination with or attraction to fire and its uses and consequences
• purpose of fire setting not for monetary gain, expression of anger, making a politcal statement and is not due to hallucination or delusion

EPI: men>wo, mc in MR

prognosis is better in children v adults

Rx: behavior therapy, supervision, and SSRI

Affective flattenting: diminished emotional response, poor eye contact

alogia: poverty of speeck and content, poor flow of conversation

apathy: impaired grooming and hygiene, lakc of persistence

asociality: few recreation interests/activites, detached

attention: inattentivness during conversation

worst prognosis, do not respond as well to therapy

Rx: atypicals are better

Risperidone, clozapine, olanzapine, quetiapine or ziprasidone

** family therapy : patients do much better in envrioments that are calm and w/o conflict

DOC for ADHD

mild CNS stimulant

SE: loss of appetite, abdominal pain, weight loss, insomnia, tachycardia, can have minor retardation of growth.

Should not be used in children <6 y

Dx:

• body weight at least 15% below normal
• intense fear of gaining weight
• disturbed body image
• Amenorrhea 

2 types: restrictive (more often withdrawn and OCD) and binge eating/purging (more often Depressed and substance abusers)

phsyical findings: amenorreha, electrolytes - hypochloremic, hyperkalemic alkalosis) hypercholesterolemia, arrhythmias, cardiac arrest, lanugo (fine body hair) melanosis coli (darkened area of the colon) leukopenia and osteoporosis

EPI: 10-20x more common in wo, 4% of adolescents, 10-30 yo

Rx: therapy and paroxetine and mirtazapine (promotes weight gain)

- once dx is made pt may need to be hospitalized to manage electolytes and begin treatment

** patient are embarrassed by their bingeing and are overly concerned about body weight usually maintain normal body weight

2 types: purging and nonpurging

Dx:

• reccurent episodes of binge eating, recrrent, inappropriate attempts to compensate for overeating and prevent weight gain (laxatives, vomiting, diuretics)
• bing eating and compensatory behaviors occur atleast 2x a week for 3 mos

EPI: 1-3% of young females, more comon in wo

comorbid: mood disorders, impulse control, alcohol abuse/dependence

*** better prognosis than anorexia, 1/2 fully recover

Rx: therapy, SSRIs

elevated DA or NE --> decreased total sleep time

elevated Ach --> causes increased total sleep time and increased proportion of rapid eye mvt

elevated SE causes --> increased total sleep time and increased proportion of delta wave sleep

Dyssomnias: distrubances in the amount, quality or timing of sleep

Parasomnias: abnormal events in behavior or physiology during sleep

Stage I: Non REM (75% of sleep)

• eyes closed, awake ---alpha waves
• stage 1 lightest sleep --- loss of alpha waves (5%)
• stage 2 light sleep --sleep spindles and K -complexes(45%)
• stage 3-4: Deep sleep --- delta waves(25%)

Stage II REM sleep (25%)

• Cycles last 10-40 mins and occur every 90 mins - involves dreaming, lack of motor tone, erections
• waves: sawtooth waves, REM
• amount of REM sleep decreases with age
• REM rebound is an increase in amount of REM sleep that ocurs after a night of sleep deprivation. slow wave sleep is made up first.

dx:

• difficulty initiating or maintaing sleep resulting in daytime drowsiness or difficulty fulfilling task
• 3 or more times per week for atleast 1 month

EPI: 30% of pop, exterbated by anxiety and preocupation with getting enough sleep

RX: sleep hygiene

Meds: Benadryl, Ambien (zolpidem), Sonata (zaleplon), Desyrel (trazadone)

• 1 month of excessive daytime sleepiness or excessive sleep not attributed to medical condition, medication, poor sleep hygiene, insufficient sleep or narcolepsy
• begins in adolescence 

Rx: stimulants (amphentamines) are first line

SSRIs can be useful

Dx:

repeated sudden attacks of sleep in the daytime for atleast 3 months:

cataplexy

short REM latency (<10 mins)

sleep paralysis upon wakening

hypnagogic - hallucinations as pt falls asleep or wakes up

EPI:

<1% of adult population, Wo=men, may be genetic

usually have poor nightime sleep

RX: daily naps plus amphetamines and methphenidate SSRIs or sodium oxalate for cataplexy

mismatch btw circadian sleep-wake cycle and environmental sleep demands

subtypes: jet lag, shift work, delayed sleep

jet lag remits in 2-7 days

light therapy can be used for shift work

for shift life - delayed or advanced phase is better

Melatonin can be given 5 1/2 hr before desired bedtime

Nightmare d/o , sleep terror and sleep walking

Nightmare d/o - occurs during REM, recalls the nightmare

Rx: usually none but you can try TCA (supresses REM)

Night Terror: screams and intense anxiety, occur during first 1/3 f the night (stages 3, 4) Not REM

pateint do not wake and do not remmember

Epi: 1-6%, m>f , occurs in children, associated with sleepwalking

RX: small doses of diazepam (usually none!!!!)

Sleep walking: occurs during stages 3,4, never remmembered

EPI: 4-8 yrs old, more common in boys, runs in families

RX: prevent injury

Traditional Antipsychotics

Low potency

Chlorpromazine (Thorazine): deposits in lens and cornea, blue gray skin discoloration

Thioridazine (Mellaril): retinal pigmentation

MOA: block DA-R, but have a lower affinity and therefore a higher dose is often required

LOW potency = more Anti- Ach/hist SE

• Anti HAM:

histamine: sedation

alpha-adrenergic: orthostatic hypotn, cardiac abnormalities, sexual dysfunction

Antimuscarinic: (antiACH): dry mouth, tachy, urinary retention, blurry vision, constipation

• Weight gain
• elevated liver enzymes
• ophthalmologic problems
• Dermatologic
• Seizures - lowers threshold ** low potency are more likely to cause seizures
• Tardive Dyskinesia
• NMS

MOA: DA-R antagonist, low doses are required 

Haloperidol

Fluphenzine

Trifluoperazine

Perphenazine

Pimozide

SE:

EPS:

parkinsonian Rx: benztropine

akathsia: subjective anxiety and restlessness, fidgetiness RX: lower dose, change med, add propranolol

Dystonia:sustained contraction of muscles of neck, tongue, eyes Rx: benadryl, benztropin

Hyperprolactinemia: decreased libido, galactorrhea, gynecomastia, impotence, amenorrhea, osteoporosis (tuberoinfundibular path)

• Anti HAM:

histamine: sedation

alpha-adrenergic: orthostatic hypotn, cardiac abnormalities, sexual dysfunction

Antimuscarinic: (antiACH): dry mouth, tachy, urinary retention, blurry vision, constipation

• Weight gain
• elevated liver enzymes
• ophthalmologic problems
• Dermatologic
• Seizures - lowers threshold ** low potency are more likely to cause seizures
• Tardive Dyskinesia
• NMS

Dx: s/s of schizophrenia along with mood symptoms (like depression, bipolar, or mixed)

- at least 2 weeks when psyhotic symptoms are present without any mood symptoms

presents similar to cocaine but with more prominent psychotic features

present: anxiet, aggressivness agitation, pyschosis or delirium

Exam: elevated or low BP, tachycardia, bradycardia, sweating, puppilary DILATION, cardiac arrhythmias, chest pain, seizures, stroke

some studies have proven that scizophernia pt have enlarged ventricular size and prominent sulci

with decreaseed cerebral mass, hippocampal mass and temporal mass

MOA: block both DA and SE - R

SE: potential for all the same but less in theroy, rarely cause EPS, Tardive or NMS

use: 1st line most of the time, better for negative symptoms

Clozapine: AGRANULOCYTOSIS, and seizures, drooling, myocarditis Metabolic syndrome least likely to cause EPS

Olanzapine: obestiy, metabolic syndrome (hyperlipidemia, glucose intolerance, weight gain) liver toxicity *** measure LFT

Risperidone: usually first lin, most likely to cause EPS

Quetiapine(Seroquel): can be used for mania or psychosis, can be used in parkinson pts SE: less weight gain but causes cataracts in dogs...

Ziprasidone: prolonged QTC

Arispiprizole(abilify)

AGRANULOCYTOSIS, and seizures, drooling, myocarditis Metabolic syndrome least likely to cause EPS

use if pt develops tardive

Olanzapine:(Zyprexa) obestiy, metabolic syndrome (hyperlipidemia, glucose intolerance, weight gain) liver toxicity *** measure LFT

Quetiapine(Seroquel): can be used for mania or psychosis, can be used in parkinson pts SE: less weight gain but causes cataracts in dogs...

atypical antipsychotic

prolonged QTC, approved for mania

antimanics

may also be used for:

• potentiation of antidepressants in pts with major depression or refractory
• potentiation in pts with psychosis
• enchancement of abstinence from EtOH
• treatment of agression and impulsivity (dementia, intoxication, MR, personality d/o and medical conditions)

lithium, valproate and carbamazpine

anticonvulstant that is useful in rapid cycling or mixed episode of bipolar d/o

can also be used in Trigeminal neuralgia

MOA: blocks Na channels and inhibits action potentials

onset : 5-7 days

SE:skin rash, drowsiness, ataxia, slurred speech, BONE MARROW SUPRESSION - leukopenia, aplastic anemia and agranulocytosis; hypoNA; elevated LFT

** teratogenic - neural tube defects

Depakote - anticonvulsant

useful in treating mixed episodes and rapid cycling

MOA: increases levels of GABA

SE: sedation, weight gain, alopecia, hemorrhagic pancreatittis, liver tox, thrombocytopenia

Teratogenic: neural tube defects

monitor LFTs and CBC

long acting BNZ

MOA: potentiates GABA

use: EtOH detox, presurgery anxiety

Long acting BNZ

MOA: potentiates GABA

use: rapid onset, anxiety and seizure control

ALL BNZ used for insomnia

Flurazepam - long acting, rapid onset

Temazepam - intermediate acting

Triazolam - short acting, rapid onset

Xanax

short acting BNZ

MOA: potentiates GABA

use: anxiety /panic attacks

Long acting BNZ

use: panic attacks, anxiety

ativan

intermediate BNZ

panic attacks and EtOH withdrawal

Ambien

use: short term insomnia

moa: selectively binds to BNZ receptor on GABA receptor

** no anticonvulstant or muscle relaxant properties

no withdrawal SE, minimal rebound, little to no tolerance/dependence

*** warning about sleep walking, eating and driving

Zaleplon (SONATA) - shorter half life

Alternative to BNZ or venlafaxine for anxiety treatment (GAD)

slower onset of action - 1-2 wks to work

MOA: partial agonist at 5HT-1A R

** Useful in EtOhic bc is does not potentiate the CNS depression of EtOh

low abuse profile

fixed false beliefs that cannot be altered by rational arguement and cannot be accounted for by a culture

Sensory perceptions without an actual external stimulus

Auditory Hallucination: schizo

Visual: drugs

Olfactory: epilespy

Tactile: 2/2 to drug abuse and/or Etoh withdrawal

misinterpretation of external stimulus

ex: mistaking shadow for a cat

St. Johns wart and Ginseng

St Johns:used for mood, anxiety and sedative

Ginseng: is a stimulant can be used for mood and energy

Subtypes of Schizophrenia

Paranoid type: highest fxning, older age of onset

Disgorganized: poor functioning type, early onset

- must have disorganized speech, behavior, and flat affect

Catatonic: rare, motor immobility, excessive purposeless motor activity, extreme negativism, Echolalia, echopraxia

Residual type: prominent negative symptoms

1% of people over lifetime

Men present in 20s and women in 30s

strong association: substance abuse, depression (50%)

Increased DA

Theorized DA pathways:

prefrontal cortical - responsible for negative symptoms (decreased DA)

mesolimbic: positive symptoms (too much DA)

DA Pathways affected by neuroleptics:

Tuberoinfundibular: blocked DA, caused prolactinemia

Nigrostriatal: blocked DA, causing EPS

Other neurotransmitters implicated:

Elevated SE

Elevated NE

decreased GABA

Worse Prognosis:

Early onset, poor social support, Men, negativie symptoms, Gradual onset, Fmhx, many relapses, poor premobid fxn

Better Prognosis:

later onset, good social support, positive symptoms, mood symptoms, acute onset, female sex, few relapses, good premorbid fxning

period of elevated, expanisve or irritable mood that includes at least three symptoms listed for the manic episode criteria

1. last 4 days,
2. no marked impairment in social or occupational functioning
3. does not require hospitalization
4. no psychotic fxn

marked episode of depressed morr associated with loss of daily activities

May be unaware of their depressed mood or may express vauge, somatic complaints

Dx: at least one major depressive episode, no hx of manic or hypomanic

Pathophys:

Decreased levels of SE and abnormal levels of beta-adrengric

high cortisol and abnormal thyroid axis

Persistent, excessive, anxiety, and hyperarousal for atleast 6 mo

more about daily events adn activities(work, school, college, friends)

cannot control the worry

exhibit 3 of the following:

restlessness, fatigue, lack of concentration, irritability, muscle tension, sleep distrubance

epi: 4-5 % prevlence W>M

50-90% of pts with GAD have a comorbid mental d/o - MMD, phobia, or panic

chronic and fluctuating (50%) other half fully recovers

Rx: buspirone (DOC); BNZ - clonazepam, Diazepam, SSRI; Venlafaxine (XR)

behavioral therapy

Dx:

exaggerated sense of self worth,

fantasies of money, sucess and brilliance

beleives that he or she is special and unique

needs excessive admiration

sense of entitlement

takes advantage of others for self gain

lacks empathy

arrogant, haughty

envious of others or belives others are envious of them

EPI <1%

avoid occupations that involve interpersonal contact due to fear of rejection

do not interact for certain knowledge of not being liked

preoccupied with being critizied

reluctance to engage in new activities for fear of not being liked/rejected

EPI: 1-2%, increased incidence of anxiety and mood/depressive d/o

Rx: psychotherapy - assertiveness training

Beta Blocker

abuse: impairment or distress for at least 1 year with one of more:

failure to fulfill an obligation at work, school or home,

use in dangerous situations

recurrent legal problems

continued use despite social and interpersonal problems

Dependence: at least 3 of the following for 1 year

Tolerance

withdrawal

using substance more often than intended

unsiccessful efforts to cut down

significant amount of time getting, using or recovering from subtance

decreased social, occupational or recreational activites

continued use despite physical or psychological problems

prevalence:17%

M>W

MOA: activates GABA and SE -R in CNS and inhibits glutamate

Metabolized:

EtOh --> acetaldehyde (EtOH dehydrogenase)

Acetaldehyde ---> acetic acid (aldehyde dehydrogenase)

in heavy drinkers these enzymes are up regulated

in asian population there is less aldehyde dehydogenase resulting in build up of acetaldehyde and N/V flushing

Intoxication:

Acute - ABC, monitor electrolytes, and Acid/base status

obtain finger stick glucose; give thiamine, naloxone and folate

long term: AA, disulfiram (inhiits Aldehyde dehydrogenase) Naltrexone (reduces cravings) and therapy

6-24 hrs:

mild: irritable, insomnia, tremors 

moderate: diaphoresis(autonmic instability), fever, disoreintation

severe: grand mal seizure DT

DTs do not usually begin until 72 hrs

 DTs : visual or tactile hallucinations, gross tremor, autonomic instability and fluctuating levels of psychomotor activity

Rx: tapering BNZ (chlordiazepoxide, lorazepam)

Thiamine, folic acid, and a multivitamin, Mg Sulfate for post withdrawal seizures

speed, methylphenidate, dextroamphetamine, MDMA, MDEA

MOA: release DA from nerve ending, some desinger amphetamines release DA and SE resulting in a stimulant and hallucinognic effect

very similar to cocaine

s/s: sedations, slurred speech, incoordination, ataxia, mood lability, impaired judgement, nystagmus, respiratory depression  and coma or death

UDS + 1wk

Rx: ABC, activated charcoal

Barbiturates: alkalinize the urine with Sodium Bicarb to promote renal excretion

BNZ: flumazenil

Withdrawal:

autonomic hyperactivity(tachycardia, sweating) insomnia, anxiety, tremor, N/V delrium, and hallucinations, Seizures may occur and be life threatening

Rx: long acting BNZ (chlorodiazepoxide or diazepam)

tegretol or valproic acid for seizures