- Preceived abnormalities of bodily structure or function that the individual finds bothersome or concerning

- Very common --> Many don't correlate with psychiatric or medical conditions

- Up to 80% of the general population reports somatic symptoms in the past 7 days

- 1/5 of the population suffers from serious, disabling, and frequently chronic somatic complaints

- PCPs encounter perplexing complaints in 40% of their patients

- Many patients have co-morbid depression and anxiety

1. DSM-IV

- Combination of pain, GI, sexual, and pseudoneurological symptoms --> Need one in each category

- Begins before age 30

- Chronic pattern

- Physical symptoms suggesting a medical condition, yet the symptoms are not fully explained by the medical condition

2. DSM-V changes --> No distinction between medically explained and unexplained symptoms

- Can be diagnosed in a patient with any distressing symptoms

- Criteria A: One or more symptom that is distressing or results in significant disruption of daily life

- Criteria B: Excessive thoughts, feelings or behaviors related to the somatic symptoms or associated health concerns --> Disproportionate and persistent thoughts about the seriousness of one's symptoms and presistently high level of anxiety

- Symptoms are presistent --> >6 months

- Types: With predominant pain and persistent

- Prevalence: Probably 5-7% but truly unknown

- Diagnosis encourages mind/body dualism

- Symptom interpretation and catastrophizing --> Increases the aversive quality of the stimuli

- Tendency to over interpret bodily sensations as signs of serious disease

- Tendency to over interpret the likelihood and/or intensity of potential negative consequences of symptoms

- Based off the common rigid assumption that being healthy is defined by the total absence of any physical sensation

- Self concepts of being bodily weak and intolerant stress

- Correlates with brain activities caused by painful stimuli in somatosensory fields of the cortex

- People who are unable to detect, name and express feelings

- Have an increased risk of developing somatic symptoms

- Each different culture has its own social norms concerning emotions

- In a culture that doesn't allow direct communication of emotional content, one available way to express emotions is through physical symptoms

- Somatic symptoms serve to notify others of emotional or psychological distress in an acceptable or non-stigmatized manner

- Association between traumatic life events and somatic symptoms

- Early lifetime adversities cause abnormalities of the biological stress response --> HPA axis

- Leads to vulnerability of the individual to develop somatic symptoms or disorders

- May also cause pts to become alexithymic

- Pre-occupation with having or acquiring a serious illness lasting for at least 6 months

- Somatic symptoms are not present or if they are present are only mild

- High level of anxiety about health and the individual is easily alarmed about personal health status

- Pt performs excessive health-related behaviors or exhibits maladaptive avoidance

- Preoccupation is not better explained by another mental disorder

- Care seeking and care avoidant types

- Functional Neurological Symptom Disorder

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

- Incompatibiilty between the symptoms and recognized neurological or medical conditions

- Not better explained by another medical or mental disorder

- Symptom/deficit causes clinically significant distress or impairment in social, occupational, or other important areas of function or warrants medical evaluation

- Specific types: Weakness, paralysis, abnormal movement, swallowing/speech problems, attacks or seizures, anesthesia or sensory loss, and specific sensory losses

- Acute: <6 months

- Associated with psychological stressor

- Hoover sign: Hip extension weakness that returns to normal with contralateral hip flexion against resistance

- Hip abductor sign: Hip abduction weakness returns to normal with contralateral hip abduction against resistance

- Tremor entrainment test: Tremor gets better when pt is distracted by being asked to move contralateral limb

- Fogging test, steropsis test, and tubular visual field test

- Vocal cord assessment and globus

- Arm drop test, midline splitting, splitting of vibration, and yes/no test

- Criteria A: medical symptom or condition is present

- Criteria B: Psychological or behavioral factors adversely affect the medical condition --> Factors influence course of the condition, factors interfere with the treatment, factors constitute additional well-established health risks, and factors influence the underlying pathophysiology

- Criteria C: Psychological and behavioral factors of criteria B are not better explained by another mental disorder

- Imposed on self or imposed on another

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

- Individuals presents themselves as ill, impaired or injured

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

- Behavior not better explained by medical or mental disorder

- Conscious and intentional production or exaggeration of symptoms for material gain, such as money, lodging, food, drugs, avoidance of military service, or escape from punishment

- False belief of being pregnant that is associated with objective signs and reported symptoms of pregnancy

- Develop empathic and trusting doctor-patient relationship

- CARE-MD: CBT, Assess, Regular visits, Empathy, Med-psych interface, and Do no harm

- Physician has a duty to educate

- Do not dispute the reality or severity of symptoms/complaints

- Establish appropriate goals and expectations

- Empathy, legitimization of feelings, partnership, support, and respect

- Always listen to patients

- Cognitive-behavioral treatment

- Biofeedback

- Relaxation training

- Group therapy

- Family therapy

- Treat any co-existing mental disorders

- Goals: Improve their functioning, recognize underlying feelings/needs, and decreasing utilization of health care resources

- TCAs, SSRIs, SNRIs, MAOIs, and atypicals

- All have the same efficacy statistically --> 33% of pts go into remission and 20-30% respond

- All require 4-6 weeks to achieve max effect

- Neurovegetative symptoms will improve before mood/anhedonia

- All have a black box warning for increased suicidality in pts up to age 24 --> Double the risk (2% --> 4%)

- Serotonin and NE re-uptake inhibitors

- First-line agents for depression

- Useful for multiple anxiety disorders too

- Concerns: GI side effects (sertraline worst), sexual side effects, P450 interactions (citalopram and escitalopram least), SSRI discontinuation syndrome (paroxetine worst), SSRI poop-out, serotonin syndrome, and SIADH

- Fluoxetine: PMDD, bulimia, metabolite norfluoxetine has 10x t1/2

- Sertraline: Fairly well tolerated

- Paroxetine: Anticholinergic and teratogenic effects --> Can also be used for premature ejaculation

- Citalopram: P450 interactions --> Black box warning for QTc prolongation --> don't use >40 mg for adults and >20 mg for elderly

- Escitalopram: S-isomer of citalopram

- Fluvoxamine: Indicated only for OCD

- Venlafaxine: Side effects are common --> Short half-life, limited P450 interactions, and NE reuptake inhibition only at higher doses

- Desvenlafaxine: Major metabolite of venlafaxine

- Duloxetine: Used for fibromyalgia and neuropathic pain --> Hepatotoxicity black box warning

- Milnacipran: Indicated only for fibromyalgia

- Norepinephrine and serotonin reuptake inhibitors via NET & SERT

- Concerns: Lethal overdose (low LD50), cardiac conduction delays, QTc prolongation, anticholinergic properties, sexual side effects, weight gain, and quite sedating

- Amitriptyline: Neuropathic pain or migraines

- Imipramine: Enuresis

- Desipramine: Least anticholinergic

- Nortriptyline: Best TCA for elderly due to minimal orthostatic hypotension

- Doxepin: Antihistaminergic --> VERY sedating

- Clomipramine: Used for OCD and most serotinergic effects

- Inhibits monoamine oxidase enzyme 

- Never a first line drug

- Concerns: Orthostatic hypotension, hypertensive crisis due to eating tyramine rich foods, serotonin syndrome (with SSRIs), and sexual side effects

- Linezolid: Antibiotic with weak MAOI properties

- Phenelzine: Can cause vit B6 deficiency

- Tranylcypromine: Methylphenidate analog

- Selegeline: Lower risk of hypertensive crisis due to MAO-B selectivity

- Wellbutrin

- NE & DA reuptake inhibition

- Can be first-line for depression and smoking cessation

- Can be activating --> Can increase anxiety

- Positives: Nominal sexual side effects, weight neutral, and has the least likelihood for manic overshoot

- Concern: Contraindicated in bulimia or epilepsy --> Lowers seizure threshold

- A2 and 5-HT antagonist

- More sedating at lower doses

- Nominal sexual side effects

- Causes a ravenous appetite

- May be a good option for pts with cancer-related weight loss or N/V due to chemo/radiation

-azodones

- Trazadone: Almost exclusively for insomnia but may cause priapism (1 in 8,000)

- Nefazodone: Black box for hepatotoxicity

- Vilazodone

- Atypical antipsychotics

- Liothyronine (T3)

- Lithium

- Buspirone

- Pindolol

- Modafinil

- Psychostimulants

- Pramipexole/ropinirole

- All with the same efficacy except for clozapine which is indicated for treatment-resistant schizophrenia

- Require 4-6 weeks for full efficacy

- Indications: Schizophrenia, delirium, behavioral disinhibition, intellectual disability, and Tourrette's

- All have a black box warning for increased mortality in elderly patients with dementia-related psychosis

- Dopamine-2(D2) receptor antagonism

- Generally only target positive symptoms

- Concerns: Neuromuscular symptoms, extrapyramidal symptoms (HP>LP), orthostatic hypotension, lower seizure threshold, anticholinergic, weight gain, QTc prolongation, and hyperprolactinemia

1. High Potency

- Haloperidol: Great for hyperactive delirium, nominal anticholinergic activity, available in depot shot, and has the least risk of QTc prolongation

- Fluphenazine: Available in depot shot

2. Low Potency --> Seldom used

- Chlorpromazine: Blue skin and photosensitivity and lenticular/corneal deposits

- Thioridazine: Black box for prolonged QTc and retinitis pigmentosa

- D1-D4 and 5-HT2 antagonism

- As efficacious as typicals and may be more efficacious at treating negative symptoms

- Mood stabilizing properties

- Can be used as adjuncts for depression

- Concerns: NMS, weight gain, type 2 diabetes, metabolic syndrome, orthostatic hypotension, less EPS, QTc prolongation

- Limited D2 anatagonism and more potent D4 antagonism

- Indications: Treatment-resistant schizophrenia and reduce suicidality in schizophrenia or schizoaffective disorders

- Black box warnings: Agranulocytosis, seizures, cardiorespiratory effects, and myocarditis

- Monitoring: Need to follow CBCs

- Side effects: Hypersalivation, very sedating, ravenous appetite/metabolic syndrome, and orthostatic hypotension

- Risperidone: Hyperprolactinemia and depot injection

- Olanzapine: Metabolic syndrome and never use IM with benzos

- Quetiapine: Risk of cataracts 

- Ziprasidone: Weight neutral and QTc prolongation

- Aripiprazole: Weight neutral but notable EPS

- Paliperidone: Depot injection

- Functions: Acute management of mania/mixed episodes and bipolar depression and maintenance 

- May be used off label to treat impulsivity, aggressive behavior, borderline personality, etc

- Lithium, valproic acid, and carbamazepine all require monitoring of therapeutic levels

- Atypical antipsychotics: Adjunctive mood stabilizers --> Quetiapine & olanzapine/fluoxetine for bipolar depression

- Oxcarbazepine, gabapentin, levetiracetam, topiramate and zonisamide

- Complicated mechanism of action --> Involves adenyl cyclase, cAMP and G-protein coupled receptors

- First line for bipolar disorder

- May decrease suicidality in bipolar patients

- Labs: B-hCG when starting, levels 0.6-1.2 mEq/L, and BUN/Cr and TSH levels

- Complicated mechanism --> Blocks Na channels and augments GABA receptors

- First line with lithium for bipolar

- More efficacious than lithium for rapid cycling and mixed episodes

- Black box warnings: Hepatotoxicity, pancreatitis, and neural tube defects

- Labs: B-hCG, 70-120 mEq/L therapeutic levels, LFTs, and CBC

- Mechanism: Blocks Na channels

- First line for bipolar disorder

- Auto-induction via CYP3A4

- Black box warnings: Aplastic anemia/agranulocytosis and SJS/TEN

- Side effects: Benign rash, vertigo, hepatotoxicity, and hyponatremia

- Labs: B-hCG, levels 4-10 mEq/L, CBC with differential, LFTs, and BUN/Cr

- Mechanism: Complicated --> Blocks Na channels

- Indications: Bipolar maintenance and bipolar depression but not effective for acute management of mania/mixed episodes

- Black box warning: SJS/TEN 

- Side effects: Dizziness, ataxia, somnolence, headache, diplopia, and GI upset

- No blood monitoring required and safe in pregnancy

- SSRIs/SNRIs --> First line for panic disorder, GAD, OCD, social phobia, and PTSD

- Busprione

- Benzodiazepines

- The Z-drugs

- Mechanism: Positive modulators of GABA-A receptor complex

- Indications: GAD, panic disorder, insomnia, seizures, alcohol withdrawal, and management of acute anxiety

- Off-label uses: Catatonia and adjunct to other mood stabilizers

- Concerns: Withdrawal or combination with opioids can be fatal, paradoxical agitation and/or disinhibition, falls in the elderly, teratogenic (cleft lip/palate), and abuse potential

- Alprazolam (12-15 hr): Acute anxiety

- Lorazepam (10-20 hr): EtOH withdrawal and catatonia

- Clonazepam (19-60 hr): Long half-life

- Oxazepam (5-10 hr): EtOH withdrawal

- Diazepam (20-50 hr): EtOH withdrawal and spasms

- Nordazepam (36-200 hr): Metabolite of diazepam

- Chlordiazepoxide (10-30 hr): EtOH withdrawal

- Temazepam (10-15 hr): Insomnia

- Triazolam (2-4 hr): Insomnia

- Lorazepam, oxazepam and temazepam are all metabolized via conjugation

- Lorazepam, oxazepma, and clonazepam don't have active metabolites

- Clonazepam often doesn't show up in standard urine tox screens

- Buspar

- Mechanism: Partial 5-HT agonist

- Indication: GAD and adjunct for MDD

- Side effects: Dizziness, nervousness and GI upset

- Non-addictive

- Mechanism: Agonist at the BZD receptor site

- Indications: Insomnia

- Zolpidem, Zaleplon, and Eszopiclone

- Mechanism: DA-reuptake inhibitor

- Available as methylphenidate or dexmethylphenidate

- 70% efficacy in treating ADHD with first trial

- Short acting: Ritalin, methylin, and focalin

- Intermediate: Metadate CD and ritalin LA

- Long-acting: Concerta, Focalin XR, and Daytrana

- Mechanism: Competitive reuptake inhibition at DAT

- Available as mixed amphetamine salts or dextroamphetamine

- 70% efficacy for ADHD

- Short acting: Adderall, Dexerdrine, and Desoxyn (methamphetamine)

- Long-acting: Adderall XR and Vyvanse

- Mechanism: Inhibits acetylaldehyde dehydrogenase

- Causes an immediate and severe negative reaction to alcohol consistent with a hangover --> Flushing of the skin, accelerated HR, N/V, SOB, throbbing headache, visual disturbance, and mental confusion

- First FDA approved med for EtOH dependence

- Long hal-life --> 60-120 hrs

- May have some use for treatment of cocaine dependence

- Mechanism: Complex and not entirely known but decreases excitatory amino acid activity

- New safer drug for alcohol dependence

- Not hepatotoxic --> Must check BUN/Cr before starting though, renally cleared and can be toxic

- TID dosing

- Few side effects

- Non-aversive --> Compared to disulfiram

- Mechanism: Full mu opioid antagonist

- FDA approved for opioid and alcohol addiction

- Alcohol: Reduces cravings and the euphoria associated with drinking

- Opioids: Blocks and leads to immediate dissociation at the Mu opioid receptor site

- Available in depot injection

- GI side effects common

- Mechanism: Full opioid antagonist

- Used for reversal of opioid overdose

- Short half-life --> Need to monitor for return of overdose effects

- Available in intranasal forms

- Mechanism: Partial mu opioid agonist

- Indication: Pain disorders and opioid use disorders when combined with naloxone

- Treats cravings without leading to a high

- Doesn't show up on a standard urine tox

- Concerns: Respiratory depression when combined with IV BZDs

- Mechanism: Full mu opioid agonist

- Indications: Pain and opioid use disorders

- Long-acting version of heroin --> Pts must come in for daily dosing

- Needs to be dispensed by licensed methadone clinic

- Side effects: Prolong QTc

- Doesn't show up on a standard urine tox

- Erikson 8 stages of psychosocial development

- Stage 1: Trust vs. mistrust (0-12 months)

- Stage 2: Autonomy vs. Shame & doubt (1-3 years) --> Establishing yourself as an individual but your parents are trying to teach you right from wrong --> Terrible 2's

- Stage 3: Initiative vs. guilt (3-5 years)

- Stage 4: Industry vs. inferiority (6-10 years) --> First time you are really surrounded by peers and the beginning of the time where you evaluate yourself compared to others

- Stage 5: Identity vs. role confusion (11-20 years) --> Developing yourself as an individual and finding your idenity

- Stage 6: Intimacy vs. isolation (20-40 years) --> Creating intimate relationships with others and creating a life

- Stage 7: Generativity vs. stagnation (40-65 years) --> Trying to give back and be generous

- Stage 8: Ego integrity vs. despair --> Looking back on your life and being happy vs. being unhappy

- Problems during any of these stages can result in pt not maturing further and can cause issues

- May present with agitation but often times is due to a medical illness, not psychiatric

- IQ is 2 standard deviations below the mean --> Below 70 --> No longer necessary in DSM-V

- Low performance at school and in activities of daily living

- Psychopharm can somtimes be used to treat disruptive behaviors, tantrums, self-injury or aggression

- FDA approved meds --> Risperidone and aripiprazole

- Marked and sustained impairment in social interactions, communication, and restricted or stereotyped behaviors, evident by age 3

- Screen for social relatedness, language development, and unusual behaviors

- Red flags: Decreased eye contact, failure to orient to name, and lack of joint attention

- Early diagnosis and intervention are important determinants of outcome

- Interventions can be intense --> 25 hours/week, 52 weeks/year

- Other characteristics: Failure to gravitate towards others, underdeveloped ability to appreciate another's mental status, half never develop functional speech, immediate echolalia (repeating statement), delayed echolalia, and motor stereotypes (hand flapping)

- Disturbances in sleeping and eating and temper tantrums when unexpected changes in routine occur

- Antipsychotics for agitation, aggression, temper outbursts, hyperactivity, and stereotypes

- SSRIs for mood, anxiety and compulsive behavior

- Atomoxetine for hyperactivity and impulsivity

- Alpha agonists for hyperactivity, impulsivity, aggression, and irritability

- Pathophysiology: Understimulated brain responds by unconsiously trying to help stimulate the brain at all times --> Excessive movements, craving coffee, etc

- Inattention and hyperactivity for at least 6 months with symptoms located at home and at school

- More frequent and severe than normal childhood behavior

- Co-morbidities: Oppositional Defiant/Conduct Disorder, anxiety, bipolar and Tourette's

- Oppositional Defiant disorder is commonly caused by inconsistent parenting

- Pts often rejected by peers due to aggressive behavior and non-compliance with rules

- 1/3 remit, 1/3 persist fully, and 1/3 persist but symptoms are reduced

- Increased risk of substance use and drug use

- Poorer prognosis if pt has poor peer relations, low IQ, adult directed aggression, and symptoms continuing into adulthood

- Treatment: Stimulants, adderall, methyphenidate, pemoline, non-stimulants (atomoxetine), and alpha 2 antagonists (clonidine)

- Must have at least 4 symptoms from the following categories:

1. Angry/irritable mood --> Often loses temper

2. Argumentative/Defiant behavior --> Argues with authority figures and adults, often deliberately annoys others and blames others for their mistakes

3. Vindictiveness --> Being spiteful or vindictive at least twice in the past 6 months

- Often times occurs due to inconsistent parenting

- Screening questions: Does your child have trouble managing feelings or behavior?

- Triggers: Significant recent stressor, peer-related conflicts, physical or sexual abuse, neglect, harsh and inconsistent parenting

- Treatment: Parent Management Training --> Reinforce positive behavior, reduce reinforcement of negative behaviors, apply consequences for dangerous/destructive behavior, make parental responses predictable, contigent and immediate

- Medications: Stimulants and atypical antipsychotics

- Episodic outbursts or verbal rages --> Can be very angry and violent

- Child returns back to normal within 30 minutes

- No persistent mood disruption outside of the outbursts

- Onset after 6 years of age

- Persistent angry/irritable mood most of the day --> Persistent mood dysfunction outside of tantrums

- Nearly every day

- May include verbal rages or destructiveness

- Onset between 6-9 years of age

- Violation of basic rights of others

- Little empathy or feelings of guilt of remorse

- New DSM V diagnosis --> Replaced dysthymia

- Depressive or irritable for at least 2 years with two of the following:

1. Poor appetite or overeating

2. Insomnia or hypersomnia

3. Low energy or fatigue

4. Low self esteem

5. Poor concentration

6. Hopelessness

- Irritable with lots of outbursts

- May have depressed or irritable mood in children

- Other symptoms: Appetite, sleep, motivation, ability to enjoy interests, energy, concentration, psychomotor retardation, hopelessness/excessive guilt, and suicidal ideation

- Evaluation: Assess for ongoing or past exposure to negative events and the environment in which depression is developing

- Younger the onset --> More likely it is to be caused by a specific environmental cause

- Mild-moderate: Psychotherapy alone (CBT and IPT)

- Moderate-severe: Medical trial with SSRIs and psychotherapy

- 30-40% remission rate with SSRIs

- Risks: Increased suicidality, behavioral activation, bleeding, and serotonin syndrome

- Half the dosing for children than adults --> Need to follow up a week later instead of the 4-6 weeks for adults

- DDx: Hyperthyroidism, caffeinism, asthma, asthma meds, lead intoxication, epilepsy, diet pills, antihistamines, and steroids

- Separation anxiety: Fears and nightmares revolve around separation and/or harm coming to care giver --> Frequently missing school and following care giver so that he/she is always in sight

- Generalized Anxiety: long list of worries and fears

- Panic disorder: May present with crying, temper tantrums, freezing up, clinging behaviors --> often misdiagnosed as a disruptive disorder since children may have difficulty articulating their fears

- PTSD: Non-specific nightmares, hypersexuality, disorganized or agitated behavior, and trauma may be replayed in child's play with toys

- Nightmares: symptoms of PTSD and separation anxiety

- Hypersexuality: DDx of PTS, bipolar mania, or normal childhood curiosity

- Treatment: SSRIs --> Start at low doses and titrate up

- DDx: ADHD and psychosis

- ADHD is chronic and bipolar is episodic

- Presentation: Manic with psychotic features and can be difficult to differentiate from primary psychotic disorder --> Usually presents first with disorganization of thoughts and then hallucinations/delusions

- Usually presents with anxiety

- Symptoms: Grandiosity, decreased need for sleep, pressured speech, flight of ideas, distractibility, increase in goal-oriented activity, excessive involvement inactivities with high potential for painful consequences

- DIGFAST symptoms

- Prodrome: Isolating from friends and bizarre behavior over the course of several months and before overt psychosis 

- Meds: Lithium for pts 12 or older for maintenance and aripiprazole, risperidone, and quetiapine down to age 10 for acute mania

- Treatment regimen: Atypical antipsychotic, antipsychotic plus mood stabilizer, or just mood stabilizer alone

- Nicotine 32%

- Heroin 23%

- Cocaine 17%

- Alcohol 15%

- Marijuana 9%

- Opioid pharmaceuticals 32% 

1. Biological

- Genetic vulnerability

- Pharmacokinetics

- Depression

- Conduct disorder/ASP

2. Pyschological

- Exposure to trauma

- Inadequate parenting

3. Social/Environmental

- Peer influences

- Poverty

- Access to drugs

- Alcohol: 12 hours

- Cocaine: 24-72 hours

- Benzodiazepines: 24-72 hours

- Heroin: 24 hours

- Methadone: 72 hours

- Buprenorphine: 72 hours

- Amphetamines: 48 hours

- Marijuana: 3-30 days depending on use

- PCP: 3-10 days

- Cocaine, amphetamines & nicotine --> Mesolimbic dopamine system

- Opioids --> Mesolimbic dopamine system

- Alcohol --> GABA, glutamate, dopamine, serotonin, and opioid peptide systems

- Cannabinoids --> Dopamine in nucleus accumbens

- Low baseline plasma B-endorphine levels --> Higher endorphine response to alcohol

- Low D-2 receptor availability --> Associated with alcohol, cocaine, heroin, methamphetamine and methylphenidate abuse

- Altered ketamine response --> Less dysphoria & more euphoria in response to NMDA antagonist

- Dopamine theory --> Drugs of abuse block the dopamine transporter and increase synaptic dopamine

- Capacity to exercise judgement ad inhibit impulses

- Determines adaptive value of pleasure recorded in nucleus accumbens

- Checks unwise urges to use drugs

- Not fully developed in adolescence

- Defective in antisocial personality

- Rare nicotine addiction if use begins after age 21 --> Prefrontal cortex is mature

- Signs: Coma, pinpoint pupils, depressed pulse and respiration, and hypothermia

- Treatment: Naloxone (narcan) 0.4 mg IV a 4 min PRN

- Monitor methadone overdose for 24-48 hours --> Long half life so may need to start on narcan IV drip since naloxone only lasts 1-4 hours

- Early Signs: Sweating, lacrimation, rhinorrhea, increased respirations, dilated pupils, yawning, agitation, and tremor

- Severe signs (48-72 hrs): Increased HR and BP, N/V, abdominal cramps, diarrhea, and insomnia

- Duration for Heroin: onset within 12-24 hours and duration 5-10 days

- Duration for methadone: Onset within 24-48 hours and duration 2-3 weeks

- Hyperactivity of noradrenergic neurons in locus coeruleus --> Increased HR, BP and respirations, increased sweating and diarrhea

- Clonidine blocks NE symptoms

- Increased GABA effects --> Reduced dopamine in nucleus accumbens --> Dysphoria, depression and craving

- Document withdrawal before treating

- Track withdrawal signs with COWS

- Do not exceed initial dose of 20 mg methadone

- May repeat in 2 hours if withdrawal increases

- Inpatients rarely require 40 mg/24hrs

- Titrate dose to avoid intoxication or withdrawal

- Detox taper --> Cut 10 mg/day down to 20 mg, then 5mg/day to zero

- Document withdrawal with COWS before 1st dose

- Day 1: Bup/Nal 4/1 mg sublingual, may redose in 2-4 hrs --> Up to 8/2

- Day 2: 8/2 to 12/3 mg SL

- Day 3: 6/1.5 mg SL --> Final dose or may taper

- Patients prefer buprenorphine over methadone or clonidine --> Makes them feel more "normal"

- Methadone is the mainstay of treatment but buprenorphine also available

- Requires proof of 1 year addiction

- 80-120 mg daily

- Best for addicts with large habits

- Metabolized by CYP3A4 --> Must monitor trough levels and aim for 400 ng/mL

- May cause prolonged QTc --> Increase dose slowly

- Analgesia needs --> Maintenance patients do experience pain and will need added opioids for pain

- High doses reduce testosterone levels

- Check for drug interactions before starting

- More likely in high doses --> >100 mg

- Patients with person and family Hx of cardiac problems 

- Patients >50 years

- Get a baseline EKG so it can be monitored throughout

- High affinity partial Mu opioid agonist --> Low overdose risk

- Kappa receptor antagonist

- Sublingual buprenorphine/naloxone tablet (suboxone)

- Can be used to treat patients >16

- Rapid stabilization of 1-2 days

- Maintenance range: 12-24 mg

- Long half life: 24-72 hour dosing

- Legal for addicts with less than 1 year addiction history

- Office-based treatment

- Prescribing requires training and CSAT/DEA waiver but can be obtained by PCPs

- Close physician monitoring necessary

- Treatment course: Abstinence prior to first dose (16 hrs for heroin, 24 hrs for sustained-release, and 36 hrs for methadone)

- PO Naltrexone: 50 mg PO daily --> Works well in very motivated and stable patients

- Must wait 3-5 days before switching over from buprenorphine --> Can induce withdrawal otherwise

- Long-acting injectable --> ER Naltrexone (Vivitrol) --> 380 mg IM every 28 days

- Average age is 30 

- 66% are male

- US has the world's highest level

- 30 million Americans have tried at least once

- <20% become regular users

- 17% risk of dependence

- No correlation between use, socioeconomic status, education or occupation

- Average user spends $637/week

- Recent trends: Major epidemic since 1980, more addictive users and less casual users, less IV use, more cocaine smokers, ~80% laced with levamisole, and 3-13% risk of agranulocytosis

- Dopamine stimulation in the nucleus accumbens normally limited by dopamine reuptake --> No longer limited with cocaine

- Cocaine blocks dopamine reuptake (DAT)

- Both 5HT synthesis and reuptake are blocked as well

- Glutamate and GABA are also likely involved

- Low depletion of dopamine in nerve terminals

- Compensatory down-regulation of post-synaptic dopamine receptors --> Tolerance

- Protracted syndrome of refractoriness to reward

- Half life: 60-90 min

- Detectable blood levels: 4-6 hrs

- Plasma cholinesterases convert to benzoylecgonine --> Inactive metabolite with t1/2 of 6-8 hrs

- BE can be detected in urine for 3-4 days after use

- Lower BE levels with nasal or IV use vs. smoking

- Cocaine HCL --> Water soluble powder done intransally or IV

- Onset: 30 sec-2 min (oral/nasal) and 15-30 secs (IV)

- Peak effect: 15-60 min (oral/nasal) and 3-5 min (IV)

- Lasts for: 40-60 min (oral/nasal) and 15-20 min (IV)

- Free Base: Solvents applied to cocaine HCL --> Produces purified base that is smoked

- Cocaine HCL that is headed with baking soda or ammonia leaving a hard paste that is then cut into rocks and smoked as a vapor

- Onset: 8-10 seconds

- Peak effect: 3-5 minutes

- Lasts for: 15 minutes

- Heroin + cocaine: Speedball

- Alcohol + cocaine: Liver esterases form cocaethylene --> Active metabolite that lasts longer (2-4 hour t1/2) and is more cardiotoxic

- Cocaine and marijuana: More intense euphoria, increased plasma levels and cardiotoxicity

- Acute: Ventricular arrhythmias and MI, seizures, CVA, asthma, hypertension, and hyperpyrexia

- Chronic: Nasal septum perforation, crack lung, sexual dysfunction, Parkinson's disease, and Tourette's Syndrome

1. Acute

- Euphoria/dysphoria

- Cocaine induced paranoia --> Short duration, drug related, unrelated to the amount used and duration of use, and possibly due to underlying vulnerability

2. Chronic

- Depression

- Anhedonia

- Lack of Motivation

- Loss of interest in sex

- Anxiety/panic attacks

- Paranoid delusions

1. Acute Intoxication

- Onset: seconds and lasts 30-60 min

- Dysphoria within hours

- Recovery: <48 hrs

- OD require life support and airway

2. Cocaine delusional disorder

- Diazepam for agitation

- Antipsychotics for delusions

- Hospitalize if suicidal or delusional

- Onset: <24 hrs

- Peak: 2-4 days

- Duration: 7-10 days

- Protracted depression and craving: 1-3 months

- Pharmacotherapy not required in mild withdrawal

- Severe: Amantadine (indirect dopamine agonist) and propranolol (B-adrenergic blocker to reduce anxiety)

- Seizures: IV daizepam

- Abstinence from all drugs including alcohol

- Individual and group psychotherapy (CBT) --> Manual-guided CBT and 12 step program

- Contingency Management/Vouchers, Behavioral Reinforcement --> Urine testing with contingencies, restrict access to money and friends

- Self-help groups

- Screen for bipolar disorder and ADHD

- Treat co-occuring disorders --> 30% depression, 11% bipolar, and 3-6% ADHD

- Disulfiram: Inhibits dopamine B-hydroxylase to reduce craving and relapse

- Baclofen: GABA-B agonist --> 20 mg TID

- Topiramate: Increases GABA and inhibits glutamate --> 25 mg PO QD and slowly increase to 200 mg QD

- Modafinil: Enhances gluatamate --> 200-400 mg PO QD

- Amantidine

- Stimulates release of dopamine and blocks reuptake

- Can be taken orally (speed), anally, smoked (crystal meth), snorted or injected

- Effects are similar to cocaine but lasts 8-24 hours

- West coast epidemic that is spreading eastward

- Long-term effects: Depletes DA, NE, and 5-HT, psychosis, depression, brain damage and weight loss

- Also results in skin lesions and tooth decay

- Treatment of overdose: Symptomatic care

- Relapse prevention: Harm reduction/CBT

- SSRIs can be used for depressive symptoms

- Low-dose atypical antipsychotics used for the psychosis

- CB-1 receptors in the brain --> Mild euphoria, relaxaion, perceptual alterations, time distortions, and enhanced sensory experiences

- CB-2 receptors in the spleen/immune system --> Reduced immune function

- Psychiatric risks: Psychological dependence, mild withdrawal symptoms, amotivational syndrome not proven, and psychosis in susceptible individuals

- Heavy daily use --> Decreased attention and learning

- Heavy use is associated with abuse of other drugs, antisocial behavior and health problems

- Becoming increasingly more potent and is the primary problem among patients seeking drug treatment in the US

- Intoxication: Panic (Benzodiazepines), mild paranoia (talk down), psychosis (haloperidol 2-10 mg), and persistent flashbacks (stop all drug use)

- Long term use management: Educate on health risks/be truthful, treat co-occuring conditions, and dependence may require intensive addiction treatment, success reported with Marinol taper

- Herbal incense

- Caused hundreds of ER visits in 2010

- Contains synthetic cannabinoid agonists with stronger affinity to the CB-1 & CB-2 receptors

- Lacks cannabidiol which has antipsychotic properties --> Higher risk of psychosis

- DEA scheduled in March of 2011

- Bind at the GABA receptor --> Increase dopamine release

- Enhance inhibitory GABA transmission causing sedation and anxiolysis

- Produces little respiratory depression --> Safe in overdose unless combined with alcohol

- Rarely a primary drug of abuse but is often combined with other drugs

- Euphoric response in individuals at risk for alcoholism

- High: Pentobarbital, alprazolam, diazepam, lorazepam, zaleplon, zolpidem, oxazepam, and diphenhydramine

- Low: Trazodone

- Symptoms similar to alcohol

- Seen after 1 month of high dose therapy after 4 months at standard doses

- Some patients have prolonged severe withdrawal, even with slow tapers

- Some patients experience a temporary intensified rebound of original anxiety symptoms

- Overdose: Flumazenil --> BZD anatagonist

- Withdrawal treatment: Slow taper of agent of dependence, substitute equivalent dose of phenobarbital and taper, substitute a long-acting BZD and taper, valproate and carbamazepine detox

- Nearly 68 million smokers in the US

- 3 million tobacco-related deaths annually worldwide --> 440,000 in the US

- 21% of Americans currently smoke

- 25% of Americans are former smokers

- Numbers of smokers are actually increasing

- Dependence Treatment: Develop a "quit day" plan, teaching coping skills, build in self-rewards, and provide written cues to reinforce abstinence

- Stimulates nAChR receptors, selective, partial a4 b2 and full a7 nACHR agonist

- FDA approved in 2006

- Reduces nicotine withdrawal symptoms

- Reduces nicotine-induced dopamine release and reward

- Blocks binding of nicotine at nAChRs

- Superior efficacy vs. placebo

- Generally well tolerated from a psychiatric standpoint but must monitor for depression/suicidal ideation

- Antidepressant acting via dopaminergic & noradrenergic mechanism and also a competitive nAChR inhibitor

- First-line treatment

- Doubles odds of long-term abstinence

- Independent of depression symptoms

- 40-44% abstinence at the end of treatment

- Approximately 50% relapse at 12 months

- First line therapy

- Doubles odds of abstinence over placebo

- Helpful with or without counseling

- All forms appear equally effective overall

- Heavy smokers, there is a dose-response curve with gum favoring high dose (4 mg)

- Dose: 20-30 mg/day --> May be a benefit to increase doses of NRT and to combinations of NRT forms

- Long acting: Transdermal patch

- Short acting: Gum, inhaler, and nasal spray

- Proper use of gum is critical

- Motivational enhancement

- Relapse prevention

- Partner support

- Guidelines are based on several large meta-analyses controlled trials

- Telephone counseling

- Physical exercise can decrease cravings and attenuate weight gain

- Maladaptive use pattern

1. Tolerance

2. Withdrawal

3. Use in larger amounts/longer periods than intended

4. Unsuccessful efforts to cut down

5. Excessive time spent taking drug

6. Important activities given up

7. Continued use despite knowledge of problems

- Qualifiers

1. +/- physiological dependence

2. Remission: Early or sustained, partial or full

- Maladaptive Use Pattern

1. Failure to fulfill major obligations

2. Recurrent use in physically hazardous situations

3. Recurrent legal problems

4. Continued use despite problems

- Proposed changes

1. Removing legal issues

2. Adds cravings

1. Carbohydrate-Deficient Transferrin (CDT) --> Most sensitive indicator of relapse --> >20 units/L in men and >26 units/L in women

2. GGT: >65 units/L in men and >50 units/L in women

3. MCV >95 in males and >100 in females

4. LFTs: AST, ALT, & Alk. Phos.

5. cAMP in WBC are 3x normal

6. Phosphatidyl ethanol in RBCs

7. Ethyl glucuronide (EtG) present 5 days in urine --> Very sensitive and may have high incidence of false positives

- Positive reinforcement

- GABA binding --> Depressant effect

- Releases dopamine & endorphines --> Postive brain reinforcement

- Antagonism at glutamate-NMDA receptors

- Activates serotonin systems

- Up-regulation of NMDA receptors excitatory neurotransmission and the primary cause of withdrawal symptoms

- Down-regulation of inhibitory GABA receptors

- Down-regulation of excitatory dopamine D2 receptors

- Increased NE activity

- CNS hyperactivity --> No opposition to alcohol induced excitatory state (NMDA hyperactivity)

- Release of CRF

- Delayed recovery of D2 receptor sensitivity after detox is associated with high risk for relapse

- Includes: Stria terminalis, amygdala, nucleus accumbens, sublenticular substantia, and innominate

- Site for primary action of alcohol in the brain

- Link sites for brain reward with emotional behavior sites

- Explains 40-60% of risk

- Manifested as low-level response to alcohol

- Associated with abnormal evoked brain wave response

- Tempermental deviations --> Cognitive, behavioral and electrophysiological abnormalities in males --> Pre-frontal-midbrain neuroaxis dysfunction

- Biological sons of alcoholic fathers are at 3-4 times risk

- Biological daughters of alcoholic fathers are at 2 times risk

- Biological daughters of alcoholic daughters are at 3-4 times risk

- Biological sons of alcoholic daughters are at normal risk as the general population

- Variants in alcohol-metabolizing enzymes

- Pre-existing serotonin defect in ealry onset alcoholism

- D2 dopamine receptor gene mutation

1. Type I/A

- Onset after 25 years

- No family history

- Equal among males and females

- No criminal history

- Reward dependence harm avoidance --> Self-medication

- Chronic use

- Good response to interactional treatment --> Treat underlying psychopathology

2. Type II/B

- Early onset

- Positive family history

- Primarily male

- Criminal history

- Low reward dependence, high novelty seeking, and low harm avoidance

- Episodic/impulsive --> Often diagnosed with antisocial personality disorder

- Good response to coping skill therapy

3. Gamma

- High psychological vulnerability to depedence

- Inability to control alcohol consumption following initiation of drinking

- Able to abstain for long periods between drinking

- Americans --> Underlying psychopathology and binge drinking

4. Delta

- Develop alcoholism under strong influence of sociocultural and economic factors

- Although able to limit the amounts of alcohol they consume per drinking occasion

- Primarily physically dependent and unable to abstain for even short periods

- Mediterranians/Europeans

- 0.05: Exhilaration and loss of inhibitions

- 0.10: Slurred speech and staggered gait

- 0.20: Euphoria and marked motor impairment

- 0.30: Confusion

- 0.40: Stupor

- 0.50: Coma

- 0.60: Respiratory paralysis --> Death

- Due to hyperactivity in locus coeruleus

- Occurs within 48-72 hours after last drink

- Prodrome: Nightmares

- Requires a drop in BAC after 3-5 years of heavy drinking to develop

- Triad: Mental confusion, tremor and hallucinations

- Seizures are also possible

- Lasts 3-10 days

- 15% mortality if left untreated

- Occurs 12-48 hours after last drink

- Can also occur during intoxication

- No delirium, tremor or hyperactivity is involved

- Hallucinations --> Auditory and paranoid

- Can become chronic --> NOT schizophrenia

- Intoxication on small amounts --> 4 oz of alcohol or less

- Automatic behavior --> Combative or violent

- Followed by sleep or amnesia

- Brain shrinkage in moderate drinkers

- High BAC levels more damaging than total amount consumed

- Females more at risk than males

- Incidence: 17% are stillborn or die shortly after birth, 20% have birth defects, and 32% show "fetal alcohol syndrome"

- Alcohol use while breast feeding --> Impairs the child's motor development but not mental development

- Long term effects --> Less than 6% can function in school, most never hold a job and average IQ is 68

- 72% have major psychiatric disorders --> ADHD, conduct disorder, mood disorders, and Tic disorder

- CIWA 8-20

- Long acting BZDs: Chlordiazepoxide (50-100 mg PO q 6-8hrs) and diazepam (10-20 mg PO q6-8 hrs)

- Short-acting BZDs: Lorazepam (2-4 mg PO q1-4 hrs)

- CIWA >20

- Diazepam 10 mg IV --> Repeat 5 mg IV q 5 min until calm

- Lorazepam 4 mg PO q 1hr, PRN --> used in pts with modeate/severe liver disease, elderly or confused patients, very ill or debilitated patients, and can be given PO, IV, or IM

- Dose: 500 mg PO qdx10 days and then give 250 mg PO QD

- Side effects: Drowsiness, headache, metallic taste, and decreased libido/potency

- Supportive counseling necessary

- Supervised dosing recommended

- Follow serial liver function tests --> Monitor for alcohol-induced hepatitis

- Rx for antabuse reaction --> Benadryl 50 mg IV or IM

- Opioid antagonist --> Blocks endogenous opioids at the mu receptor, modulates the mesolimbic dopamine system in the VTA & projections to the nucleus accumbens, and reduces alcohol craving and euphoric effect of alcohol

- Dose: 50 mg qd with meals

- Side effects: abdominal pain, decreased appetite, nausea, daytime sleepiness, fatigue, insomina, and headache

- Reversible hepatotoxicity

- Best with compliant patients

- Requires counseling or regular MD monitoring

- Decreases number of drinking day by 4%

- No major safety issues

- Long acting injectable formation --> 380 mg IM every 28 days

- Screen LFTs

- More stable plasma concentration compared to PO formulation

- Side effects: Nausea & headache, more sedation than with the oral formulation

- Best results in patients sober one week prior to starting meds

- Efficacy shown in more severe alcoholics --> Reduction in heavy-drinking days

- Anticraving medications as new standard of care

- Consider immediately post-detox for all alcoholics

- Begin 50 mg oral naltrexone after 4-5 days sobriety

- If no response after 2 weeks --> up to 100 mg

- If no or minimal response --> Add gabapentin 1200 mg/D

- If no response --> Switch to depot naltrexone

- Glutamate antagonist

- Dose: 666 mg PO TID

- Alters GABA & NMDA systems --> Restores the balance between inhibitory and excitatory pathways, attenuates acute and prolonged withdrawal, and reduces rewarding effects of alcohol

- No tolerance, withdrawal, or sedation

- Minimal side effects

- Excreted through the kidneys --> Need to check BUN/Cr before starting

- No drug-drug interactions

- Reduces the risk of relapse to 86% of the risk in placebo group

- Facilitates GABA and inhibits glutamate

- Reduced drinking and craving

- Dose: 25 mg PO QD and then increase to 100 mg TID over an 8 week period

- Side effects: Fatigue and cognitive dulling

- Pregnancy category D

- Anti-nausea drug approved in 1991

- Selective 5-HT3 blocker

- Reduced drinking in early-onset alcoholism (Type II)

- Dose: 4 ugm/kg PO BID

- Higher efficacy in individuals with the LL genotype of the 5-HTT gene

- Citalopram: Reduced drining in non-depressed male alcoholics --> No efficacy in non-depressed females

- Sertraline: REduced drinking in late-onset men, no efficacy or made drinking worse in late onset women alcoholics

- Brief interventions --> Feedback, responsibility, advice, menu, empathy, and self-efficacy

- Motivation enhancement --> Stages of change

- Cognitive therapy --> 25 sessions focusing on safety

- 12-step faciliitation --> Manualized individual therapy which focuses on resolving resistance

- Behavioral marital

- Patient-centered

- Behavioral contracting

- Self-control training

- Nausea aversion

- Social skills training

- CRA

- Medications --> Disulfiram, acamprosate, and naltrexone

- Rapidly changing demographic landscape in US

- Aging of European-origin population in the US --> Lower birth rate of americans with European roots

- Significant rise in immigration in recent decade --> Largest groups from Middle East and African nations and cultural belifs and practices vary widely from "mainstream" US

- By 2050, Euro-Americans wil lbe minority of the US population --> By 2030 amont children and adolescents and will occur by 7 years of age

- Geographic --> Rural/inner-city health professional shortage areas

- Cultural --> patient health beliefs and behaviors, traditional or religious practices, and practitioner beliefs and behaviors

- Socioeconomic --> Lack of health insurance, inability to pay out of pocket, and poor healthcare literacy

- Organizational --> Little availability of interpreter services, need for handicap/wheelchair accessibility, long appointment wait times, and public transportation failures

- 48.6 millions Americans are uninsured in 2011 --> 15.7% of the total population and 7.6 million children (9.7%) uninsured in 2011 (<19 years old)

- Those without insurance --> Native born (13.2%), Foreign born (33%)

- Demographics --> Hispanic (30.7%), African-American (20.8%), Asian-American (18.1%), American Indian (16%), and Non-Hispanic Whites (11.7%)

- Provider mistrust and fear of treatment --> Fueled by historical viases and discrimination

- Discriminatory practices and racism --> Ethnocentric care, covert prejudieces, cultural ignorance, and denial ("color blind" care)

- Differences in language and culture --> Culturally biased diagnostic tools and standardized batteries often not validated for non-English speaking population

- Less access to/lower availability of mental health services --> Less likely to receive these needed services

- those in treatment may receive lower quality of mental health care

- Under-representaiton in mental health research --> Over-respresentation in diagnosis and particularly with psychotic disorders

- Universal and culture specific elements paly a role in every disorder --> Biomedical and psychosocial

- A diverse spectrum of symptoms and syndromes manifest as a consequence of core psychopathology

- Culture influences perception of happiness, depression, and communicaiton about associated symptoms

- An appropriate awareness of specific ethnic and sociocultural factors that may be contributing to a patient's presentaiton can prevent under/over diagnosis

- Cultural assessment should be included in the formulation

- Determination of cultural identity

- Patient-centered cultural explanations

- Understanding of culture specific stressors --> Assimilation, separation, marginalization, negative identification, and cultural bereavement

- Regardless of whether the pt leaves their country on good or bad terms, there is always a sense of grieving after they leave --> They have lost everything that is familiar to them

- Higher rate of misdiagnosis of psychosis or bipolar disorder

- Receive higher dosese of antipsychotics

- More sensitive to effects of antipsychotics

- 33-50% have low actiivty of CYP2D6

- Higher risk for tardive dyskinesia with 1st gen. antipsychotics (halperidol) --> 1.8x more than Caucasians

- Respond better to TCA compared to whites

- Diverse group

- Underutilize "mainstream" mental health services

- Historic use of folk healers --> Curanderos, espiritistas, or santeros

- Seek help from non-psychiatrist physicians (PCPs)

- Receive lower daily doses (30%) of antipsychotics

- Most often seen with clozapine and respiridone

- similar relationship between oral dose of haloperidol and plasma levels among Latinos and Non-Latino whites

- Mental health issues highly stigmatized in Asian communities --> Seen as embarrassment by patients and their families

- Tend to delay psychiatric care until they become very ill

- High prevalence of enzymatic differences --> Low activities of various P450 enzymes (CYP2D6)

- High prevalence of HLA-B 1502 allele --> Acetylating enzyme

- 78-93% of Chinese and East Asians are fast acetylators --> Require lower doses of meds and show therapeutic respons at lower levels

- In some Asian and African countries, 80% of the population depend on traditional medicine for primary health care

- Herbal medicines are  the most lucrative form of traditional medicine, generating bilions of dollars in revenue

- Traditional medicine can treat various infectious and chronic conditoins

- Counterfeit, poor quality, or adulterated herbal products in international markets are a serious safety threat

- Used for sedation and anxiolysis

- Can cause fulminant liver failure

- Used for antioxidant properties thought to be anti-carcinogenic

- Associated with Stevens-Johnson Syndrome

- Can also be associated with psychosis

- Used as a sedative

- Cardiotoxic: Can lead to arrhymias and hypotension

- Used as a memory aid

- Increases bleeding risk

- Acts as a mild MAOI --> Can cause serotonin syndrome when mixed with other MAOIs or SSRIs

-Categorized as disease entities within a particular culture

- Not a voluntary behavior, not a delusion, and not a false claim made for primary(ill) or secondary gain (money)

- Widespread familiarity with the condition by members of the culture --> Complete lack of familiarity with the condition by people of other cultures (not necessarily) and condiitons recognized and treated by folk healers as dictated by cultural standards

- Symptoms occur despite lack of Western-Medicine based diagnostic criteria

- Nowadays mostly considered "relics of Imperialism"...

- DSM-5 Criteria

- Cluster of co-occuring, relatively invariant symptoms within a cultural group or community

- Syndrome need not be recognized as an "illness" within the culture

- Cultural patterns of distress MAY be recognized by an outside observer

- DSM-5 criteria

- Linguistic term referring to shared concepts of pathology among members of a cultural gorup and manner by which features of distress are expressed or communcated

- Association with specific symptoms, syndrome or perceived causes is NOT required

- May convey wide range of discomfort

- Culturally perceived causes of disease

- DSM-5

- Explanatory model provided culturally conceived etiology for distress, symptoms or illness

- Often featured within folk classificatoins of disease used by healers

- Cultural idioms of distress

- Amok: Dissociative episode characterized by a period of brooding followed by an outburst of violent, aggressive, or homicidal behavior --> Malaysia

- Pibloktoq: Arctic hysteria --> Period in women who perform irrational or dangerous acts and then have amnesia afterwards

- Latah: Abnormal behaviors occur in a patient after being startled --> Screaming, cursing, crying, dancing, and uncontrollable laughter --> Malaysia and Indonesia

- Evil eye: Belief that these amulets protect the wearer from evil sprits --> Mediterranean nations and parts of Latin America

- Rootwork: White magic or folk magic --> White/caucasian, black/African-Americans in the Southern US and Northern regions of the Caribbean

- Cultural idioms of distress

- Ataque de nervios: Uncontrollable screaming or shouting, crying, trembling, sensations of heat rising into her chest and head, dissociative experiences, and verbal and physical aggression --> Latin and South America

- Dhat: Young males are most affected by the belief that they are losing sperm and will not longer be able to conceive which can lead to premature ejaculation and impotence --> Thought to be due to excessive masturbation --> Indian Subcontinent

- Koro: Belief that the patient's penis is receding back into their body and can cause death --> Southeast Asia

- Cultural idioms of distress

- Wendigo: Morbid state of anxiety with fears of becoming a cannibal with cravings for human flesh --> Atlantic coast of North America and Algonquian Natives

- Ghost sickness: Afflicted believes that a deceased individual is possessing them and causing symptoms --> Symptoms include general weakness, loss of appetite, suffocating feelings, recurring nightmares, and a pervasive feeling of terror --> North America Natives of Navajo nation

- Bouffee Delirante: Acute or transient psychosis --> Francophone West-Africa and Haiti

- Eating Disorders: Highest prevalence in Norht American and Wetern Europe, present in cultures of abundance, relative abundance of food and media propagation of thinness as ideal

- Much higher prevalence of conversion disorder in developing nations and isolated rural US settings

- Chornic fatigue syndrome and fibromyalgia --> Almost entirely restricted to Western nations, universal cultureal norms for symptoms of fatigue and pain, more common in lower socioeconomic and education groups

- Travel madness

- Paris syndrome: Transient psychological disorder encountered by primarily Japanese tourists when visiting or vacationing in Paris --> Acute delusional state, feelings of persecution, auditory and visual halluncinations, and psychosomatic complaints (dizziness, diaphoresis, anxiety)

- Jerusalem Syndrome: Development of religiously themed obsessive ideas, delusions or psychotic-like experiences triggered by travel to Jerusalem --> Pts have no prior psychiatric history/mental illness --> Self limited and usually resolves in a few weeks or upon removal from the location

- Florence syndrome/Stendhal syndrome --> Psychosomatic symptoms produced with exposure to grand works of art --> Rapid heartbeat, dizziness, confusion and hallucinations

- DSM-5 Criteria

- 2 or more of the following for most of 1 month:

1. Delusions

2. Hallucinations

3. Disorganized speech

4. Grossly disorganized or catatonic behavior

5. Negative symptoms --> Flat affect, etc

- Social/occupational dysfunction

- Duration of at least 6 months

- Not better explained by schizoaffective or mood disorder with psychotic features

- Not due to substance use disorder or other medical condition

- ~1% lifetime prevalence worldwide

- Paranoid type: More common in the US

- Disorganized type: More common in Asia or Africa

- Age of onset: 21 in men and 27 in women (average age)

- Equal frequency in men and women

- Men generally have a poorer prognosis, more prominent negative symptoms and less response to meds than women

- Heterogeneous illness --> Defined by a constellation of symptoms

- Etiology: Multifactorial with an extremely variable course

- Social/occupational dysfunction is necessary for diagnosis

- Good treatment must address symptoms AND dysfunction

- Does not necessarily mean schizophrenia

- Can occur in MANY conditions --> Medical, neurological, and substance-induced

- Break from reality --> Inability to distinguish what is real from what is not

- Primary diagnosis demands a full medical/neurological workup

- Positive symptoms --> Delusions and hallucinations

- Negative symptoms --> Anhedonia, affective flattening, avolition, social withdrawal, and alogia

- Cognitive deficits --> Attention, memory, verbal fluency, executive functioning

- Mood symptoms --> Depression/anxiety, aggression/hostility, and suicidality

- Disorganization --> Speech and behavior

- All of these feed into functional impairments

- Functional impairments --> Work/school, interpersonal relationships, and self-care

1. Positive symptoms

- Reflective of an excess of normal functioning

- Includes --> Halluncaitons, delusions and disorganized speech/behavior

- Often linked to dysfunction in the temporal lobes --> Processing and interpretation of language, vision, and sound

2. Catatonic symptoms

- Poorly understood

- Marked reduction/excess of psychomotor activity

- Requires hospitalization and treatment with high dose BZDs and ECT

3. Negative symptoms

- Reflective of a loss of normal functioning

- Includes --> Affect flattening, alogia, avolition, abulia and asociality

- Dysfunction in the prefrontal cortex, which is involved in organization, planning, and judgement

- Hypoactivity of mesocortical pathway

- Decreased blood flow to the prefrontal cortex

- Usually intensify over time, refractory to Tx and are responsible for long term morbidity

- "Fixed false beliefs"

- Cannot be corrected by reasoning and is not culturally based

- Don't necessarily need to be bizzare

- Bizzare vs. nonbizzare --> Plausible & possibly believable

- Ex. Distinctly themed (grandiose, paranoid, somatic, and religious), delusions of thought (thought broadcasting, thought control), delusional syndromes, and culturally based

- Capgras' Syndrome: Belief that your family members have been replaced and that they are not actually your family anymore

- Cotard's Delusion: Belief that you are not actually real, that you are a ghost

- Othello syndrome: Belief that your spouse/significant other is cheating on you

- Sensory perceptions in the absence of external stimuli

- Hypothesized pathophysiology: Increased blood flow to auditory and visual cortices and dopamine/serotonin excess???

- Auditory --> Most common type

- Visual --> Uncommon but more commonly seen in delirium, alcohol detox, and other medical conditions

- Tactile --> Cocaine intoxication and alcohol withdrawal

- Olfactory -->  Temporal lobe seizures

- Gustatory --> RARE!

1. Disorganized thinking and speech

- Word salad

- Tangentiality/circumstantiality

- Perseveration of speech

- Neologisms/clang associations

- Flight of ideas --> Random, unassociated thoughts

- Loose associations --> Some association between thoughts but still pretty random

2. Disorganized behavior

- Childlike silliness (hebephrenia)

- Aimless, compulsive or bizzare behaviors

- Perseveration of behavior

- Impairments in language, executive function, attention and memory (esp. short-term)

- Best predictors of level of functioning and quality of life

- Thought to be an inherited illness --> ~40% concordance in monozygotic twins

- Abnormal genes: Dsybindin, neuregulin, COMT, and DISC-1

1. Dopamine hypothesis --> Supported by the fact that dopamine antagonists improve symptoms

- Not supported by the fact that dopamine blockade doesn't fully alleviate symptoms and decreased dopamine in the frontal lobes may actually worsen congitive symptoms

- Pathways involved: Mesolimbic (Pos.), mesocortical (Neg and cognitive), nigrostriatal (EPS side effects), and tuberoinfundibular (hyperprolactinemia)

2. Other NTs likely to be involved --> Serotonin, GABA, and glutamate

3. Structural/functional changes

- Enlarged lateral and 3rd ventricles

- Cortical gray matter atrophy

- Reduced size of temporal, frontal, and pre-frontal cortices

- Reduced blood flow and metabolic activity in the frontal cortex

4. Winter effect --> More schizophrenics are born during the winter and early spring --> High incidence of infectious diseases and mother's exposure to viruses

- Prenatal starvation due to poor maternal diet is also associated with schizophrenia

- Excessive serotonin due to long term PCP abuse --> Negative and cognitive symptoms

- Obstetric complications --> Perinatal hypoxia

- Social class and culture --> Large number in lower socioeconomic classes

- Downward Drift Hypothesis --> Affected people tend to move into lower socioeconomic classes as a result of the disease --> More favored

- Social Causation Hypothesis --> Stressors are greater in lower socioeconomic classes resulting in higher incidence --> Less favored

- Stigma associated with Dx

- Impaired insight into disease --> No agreement on problem between patient and physician

- Treatment compliance is often very poor

- Substance use is very common --> 70% nicotine dependent and ~40% alcohol dependent

- Violence risk

- Suidice risk

- Medical problems are common and often unrecognized in this population

- 15% have a good outcome

- Positive and negative symptoms gradually dissipate after the first few psychotic episodes

- Aggressive treatment --> Staying compliant with meds and avoiding alcohol/drugs

- 30% have intermediate outcome --> Plateau over time with occasional relapses

- 55% have a poorer outcome --> Steady decline in functionality

- Minimize symptoms

- Minimize medication side effects

- Prevent relapse

- Maximize functionality

- "Recovery"

- Modes of treatment --> Pharmacotherapy and psychosocial/psychotherapeutic --> Antipsychotics, family psychoeducation, and assertive community treatment (includes case workers)

- High potency (2-20 mg/day) --> Haloperidol and fluphenazine

- Mid potency (10-100 mg/day) --> Loxapine and perphenazine

- Low potency (300-800+ mg/day) --> Chlorpromazine and thioridizine

- Rigidity, tremor, bradykinesia, and masklike facies

- Management --> Lower dose, change to different drug, and add anticholinergics (benztropine or trihexylphenidine)

- Restlessness, pacing, and fidgeting --> Subjective jitteriness

- Associated with suicide

- Resembles psychotic agitation and agitated depression

- Management --> Lower dose if possible, change to different drug, and add adjunct

- Treat with BZDs or propanolol

- Side effect of typical antipsychotics

- Muscle spasm --> Oculogyric crisis, torticollis, ophisthotonis, and tongue protrusion

- Dramatic and painful

- Tx: IM/IV diphenhydramine or benztropine

- Involuntary movements, often choreoathetoid

- Often begins with the tongue or digits and progresses to the face, limbs and trunk if left untreated

- Etiology is unclear

- Incidence --> 3%/year of pts on typical antipsychotics

- Higher incidence in the elderly

- Risk factors: High doses, long duration, increased age, women, Hx of Parkinson side effects, and mood disorder

- Prevention: Minimum effective dose, use atypicals, and monitor AIMS test

- Tx: Lower dose, switch to atypical and vitamin E may be beneficial

- Fever, muscle rigidity, autonomic instability, and delirium

- Muscle breakdown indicated by increased CK levels

- Rare but life threatening

- Risk factors: High doses, high potency drugs, and parenteral administration

- Management: Stop med and supportive measures with IV fluids, cooling blankets, bromocriptine and dantrolene

- Anticholinergic side effects --> Dry mouth, constipation, blurry vision, and tachycardia

- Orthostatic hypotension

- Sedation

- Weight gain

- Neuroleptic dysphoria

- Poorer treatment response in 30% of pts

- Incomplete response in an additional 30%

- First atypical

- FDA approved in 1990

- Used only for treatment-resistant schizophrenia

- 30% response rate in the severely ill, treatment-resistant patients

- Less D2 affinity and more 5-HT receptor affinity

- Pros: Superior efficacy for positive symptoms, possible advantages for negative symptoms, much less EPS and TD, and reduced hostility and suicidality

- Cons: Agranulocytosis in 1-2%, seizure risk 4% (lowers threshold), warning for myocarditis, and causes significant  weight gain, sedation, orthostasis, tachycardia, sialorrhea, and constipation

- Lower doses needed than clozapine

- Predominantly blocks D2 and then 5-HT

- Doesn't exhibit multireceptor action

- Lacks anticholinergic activity --> Better for elderly and youth

- Cons: Increases prolactin levels --> DO NOT give in breast cancer pts

- AKA zyprexa --> #1 antipsychotic in sales

- Exhibits multireceptor action

- Good for controlling mood symptoms --> Schizophrenics with mood symptoms

- Available in a wafer --> Better compliance

- Cons: Sedation and weight gain

- Lower ratio of D2 and 5-HT2A receptor antagonism

- Lower propensity to cause EPS

- Efficacy: Equal or better than typical for positive symptoms, more effective for treatment-resistant pts (clozapine), and may be better for negative symptoms

- Pros: Lower risk of EPS and TD, possible advantages on mood and cognition

- Cons: Weight gain and metabolic syndrome with long-term use and very expensive

- Depot injections: 2 week dosing for fluphenazine and risperidone and 4 week dosing for haloperidol

- DSM-V Criteria

- Distrubance in attention and awareness

- The disturbance develops over a short period of time (hours to days), represents a change from baseline, and tends to fluctuate in severity throughout the course of the day

- Additional disturbance in cognition may be present

- Not better described by another neurocognitive disorder and not in the context of reduced level of arousal (coma)

- Not a consequence of another medical condition, substance intoxication or withdrawal

- 14-24% at hospital admission

- 6-56% incidence while in the hospital

- 31% of all ICU admissions and 81% if intubated

- Mortality rates are 22-76%

- Results in up to 4x the length of stay

- 2-7x rate of new institutionalization

- Single strongest predictor of in-hospital complications

- Strong predictor of long term loss of function

- Decreased ACh --> Anticholinergics worsen delirium

- Increased DA --> Treat with antipsychotics

- Increased inflammatory cytokines --> Sepsis/infection induced

- Increased stress (Cortisol and HPA axis)

- Causes: IWATCHDEATH --> Infectious, withdrawal, acute metabolic, trauma, CNS pathology, hypoxia, deficiencies, endocrinopathies, acute vascular, toxins/drugs, and heavy metals

- Life-threatening Causes: WHHHIMPS --> Wernicke's, hypoxia, hypoglycemia, hypertensive encephalopathy, hyperthermia/hypothermia, intracerebral hemorrhage, meningitis or encephalitis, poisoning, and status epilepticus

- Treat the underlying cause

- Workup: VS, CBC, 2x blood cultures, UA, CXR, and urine culture --> CT if all else fails

- Antipsychotics: Watch out for QTc prolongation and EPS, black box warning for increased mortality in the elderly --> Haloperidol (PO/IV/IM forms)

- Use BZDs with caution, especially in the elderly

- Valproic acid, dexmedetomidine (A2 agonist used only in ICU setting), and propofol (paralyzing pt)

- Non-pharmacological: Frequent verbal redirection/reorientation, curtains closed and lights off at bedtime, open curtains during the day, avoid BZD/anticholinergics/high-dose opioids, and use halperidol for severe agitation

- Pt seems depressed but has attention deficit

- Technically is delirium due to attention issue

- Treat with trazadone or mirtazapine

- DSM-V Criteria

- Significant cognitive decline from a baseline in one or more congnitive domains based on concerns of the individual, an informant, or clinician

- Substantial impairment in standardized neuropsychological testing

- Interferes with independence in activities of daily living

- Not delirium --> Not fluctuating or acute

- Not explained by another disorder

- Alzheimer's Disease

- Frontotemporal Dementia/Picks Disease

- Lewy Body Dementia

- Vascular Dementia

- Traumatic brain injury

- Substance/medication use

- HIV infection

- Prion disease

- Parkinson's disease

- Huntington's disease

- Rule out with head CT

- "wet, wacky, and wobbly" --> Normal pressure hydrocephalus

- Wernicke's --> Folate and B12 deficiency

- Most common form of dementia in the elderly --> 60-80%

- Estimated to affect more than 4 million Americans

- Diagnosis of older age --> Rarely diagnosed before age 60

1. Memory impairment (hippocampus) --> Recent memory goes before long-term

2. Then visuospacial function (parietal lobes) --> Getting lost and inability to draw clock

3. Executive function loss (Frontal lobes) --> Irritability, apathy, amotivation, and total dependence on others

- Psychosis can also be present

- Cholinesterase inhibitors --> Increase cholinergic transmission at the synapse --> Donepezil, rivastigmine, galatamine --> Slow progress but don't halt disease progression

- Memantine --> NMDA glutamate receptor antagonist --> Thought to be neuroprotective and involved in learning and memory

- 2nd most common type of dementia

- Step-wise decline in functioning due to successive strokes and brain tissue infarction

- Clinical manifestations depend on the location of infarcts

- Treatment: Manage vascular risk factors and prevent future strokes with anticoagulation

- Often comorbid with Alzheimer's and difficult to distinguish

- Visual hallucinations and Parkinsonian symptoms --> Pill-rolling tremor, hypokinesis, cog-wheeling rigidity, micrographia, and fenestrating gaits

- Dementia within 1 year of motor symptoms suggests Lewy body dementia

- Very sensitive to antipsychotic as they already depleted dopamine --> Can cause severe dystonia and confusion

- AKA Pick's Disease

- Focal atrophy of the frontal and temporal lobes

- Associated with Tau intraneuronal Pick bodies

- Presents at an earlier age --> Most common form of dementia before 60

- Progressive behavioral and personality changes --> Occurs first in Pick's but can occur late in another other form

- Behaviors occur earlier than in AD

- Pts are impulsive and commonly lack insight or social awareness

- Five or more of the following symptoms present during the same 2 week period and represent a change from baseline

1. Sleep

2. Interest-anhedonia

3. Guilt

4. Energy

5. Concentration

6. Appetite

7. Psychomotor slowing/agitation

8. Suicidality

- Must have either depressed mood or anhedonia along with the 5 or more symptoms

- ~7% 12 month prevalence in the US

- Lifetime prevalence is 17%

- 3x higher prevalence in 18-29 y.o. --> Higher than 60+ y.o.

- Women are 1.5-3x more likely to have than men in adulthood --> Equal prevalence between males and females in children

- Incidence peaks in the 20s in the US, but first onset in late life is not uncommon --> Average age of onset is 32 y.o.

- First degree relatives have 2-4x likelihood

- Concordance with monozygotic twins ~50%

- About 2/3 of patients will contemplate suicide --> 10-15% will die

- Episodes can last 4-12 months without treatment --> Usually will subside on their own though

- REM sleep is shifted to earlier in the night

- Stage 3 and 4 sleep is decreased

- Hyperactivity of the HPA axis is present --> Elevated cortisol levels

- Decreased brain and CSF serotonin (5-HT)

- Antidepressants are mainstay of treatment

- SSRIs and SNRIs are usually first line

- Some MDs like to start off with bupropion

- TCAs and MAOIs are only used in treatment resistant disease

- TCAs are lethal in overdose and MAOIs have the risk of hypertensive crisis when pts eat tyramine rich foods

- Adjuvant meds: Stimulants (methylphenidate), antipsychotics, and thyroid hormone

- Psychotherapy --> CBT

- ECT: 6-12 treatments over 2-4 week period --> Risk of retrograde amnesia

- Trans-cranial magnetic stimulation (rTMS)

- Light therapy

- With anxious distress

- With mixed features

- With melancholic features

- With atypical features --> Hypersomnia and hyperphagia

- With mood-congruent or mood-incongruent psychotic features

- With catatonia --> Treat with BZDs until the catatonia is broken

-  With peripartum onset

- With seasonal pattern

- Previously known as dysthymia

- 2 years of depression, 2 listed criteria, and never asymptomatic for more than 2 months

- Depressed mood for the majority of 2 years (1 year for children)

- At least two of the following:

1. Poor concentration and difficulty making decisions

2. Feelings of hopelessness

3. Poor appetite or over-eating

4. Sleep-Insomnia or hypersomnia

5. Low energy

6. Low self-esteem

- CHASES

- Double depression --> MDD episodes on top of dysthymia

- Lifetime prevalence of 6% --> 12 month prevalence of 0.5-1.0%

- Women are 2-3x more likely

- Often has an early and insidious onset and by definition a chronic course

- Onset before age 25 in >50% of patients

- Individuals whose symptoms meet depressive disorder criteria for 2 years should be given dual diagnosis of persistent depressive disorder and MDD

- Severe recurrent temper tantrums manifested verbally and/or behaviorally

- Grossly out of proportion in intensity or duration to the situation or provocation

- Tantrums are inconsistent with current developmental level and occur 3 or more times a week on average

- Mood between tantrums is persistently irritable/angry

- Symptoms are present for 12 months or more

- Cannot be asymptomatic for more than 3 months

- Persistent in at least two different settings --> School and home, etc

- Diagnosis is generally made between 6-18 y.o.

- Age of onset must be before 10 years

- Distinct period of elevated, expansive, or irritable mood and increased goal-directed activity or energy lasting at least 1 week

- Three or more DIGFAST symptoms needed:

1. Distractibility

2. Excessive involvement in activities with a high potential for painful consequences

3. Inflated self-esteem or grandiosity

4. Flight of ideas or subjective experience that thoughts are racing

5. Increased in goal-directed activity

6. Decreased need for sleep

7. More  talkative than usual or pressured speech

- 75% of patients also have psychotic symptoms

- Same DIGFAST criteria as mania

- Only needs to last 4 days

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

- Cannot necessitate hospitalization

- No psychotic features

- Full criteria are met for mania or hypomania with at least three other symptoms

1. Dysphoria or depressed mood

2. Anhedonia

3. Fatigue or loss of energy

4. Psychomotor retardation

5. Feelings of worthlessness or excessive/inappropriate guilt

6. SI

- These are the most dangerous patients --> Most likely to attempt and commit suicide

- Must meet criteria for a manic episode

- Manic episode may have been preceded by and may be followed by hypomanic or major depressive episode

- 12 month prevalence of 0.6% in the US

- Prevalence equal in men and women

- Mean age of onset is 18 y.o. but first manic episode may occur at any age

- First degree relatives are 8-18x more likely to develop

- Monozygotic twins have 75% concordance

- 90% who have a single manic episode will have recurrent mood episodes --> Episodes can be as long as 3 months if untreated

- ~15x more likely to commit suicide

- 1/4 of all completed suicides are due to bipolar disorder

- Rapid cycling --> 4 or more episodes in 1 year

- One or more major depressive episode with at least one hypomanic episode

- 12 month prevalence of 0.3%

- Women appear to be more likely to develop but it's unclear

- Average age of onset is mid 20s

- Chronic and recurrent like bipolar I

- 1/3 of patients report history of suicide attempt

- Most commonly diagnosed in period of depression

- Can be mistaken for ODD in adolescents since depression in children can present with agitation/irritability

- Milder form of bipolar II

- At least 2 years of symptoms with multiple periods of hypomanic symptoms that do not meet criteria for hypomanic episode and multiple periods with depression symptoms that don't meet criteria for MDD
- Symptoms present for at least half the time and never symptoms free for more than 2 months

- No history of MDD or mania

- Liftime prevalence of 0.4-1%

- Equal prevalence in men and women

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

- Mood stabilizers: Lithium

- Anticonvulsants: Valproic acid (depakote) and carbamazepine

- Atypical antipsychotics --> Typically used as adjuncts or to manage acute mania/psychosis

- Lithium and valproic acid are 1st line --> Most effective

- Psychotherapy: Education, supportive therapy and family therapy

- Presenting Euthymic --> Start lithium, valproid acid, or carbamazepine

- Presenting with MDD --> Get mood stabilizer up to a therapeutic level if not already --> Quetiapine and olanzapine/fluoxetine combo FDA approved for bipolar depression

- Presenting with euphoria --> Get mood stabilizer up to a therapeutic level if not already --> Lithium for plain mania, valproic acid for mania with psychotic features, and valproic acid/carbamazepine for rapid cycling

- Suicide is  the 10th leading cause of death --> 10-40 non-fatal attempts for every completed suicide

- Most critical feature is unbearable pain with no end in sight --> Often leads to hopelessness

- Sex --> Women are more likely to try, men are more likely to succeed

- Age --> More common in elderly

- Hx of depression --> Most prone in first MDD episode, especially with psychotic symptoms

- Prior attempt --> 40x but 200x risk if attempt in the last month --> Most vulnerable first 10 days after
- Recent discharge from psychiatric facility --> 300x --> Most vulnerable first 10 days after release

- Ethanol/substance use --> 20x

- Rational thinking loss --> Psychotic disorders --> 10-20x

- Lack of social support

- Organized plan

- No spouse

- Availability of lethal means to commit suicide

- Terminal Illness

- Eating disorder --> 30x

1. Depression

- CNS --> Parkinson's, AD, Wilson's, epilepsy, neoplasm, stroke, MS, infection, and TBI

- Endocrine: Hypothyroidism and hyper/hypocortisolism

- Immunological: SLE, RA, and MS
- Infection: Lyme, syphilis, and HIV

- Neoplasm: Paraneoplastic syndrome, frontal lobe tumors and pancreatic cancer

- Nutritional deficiencies: Vit B12, niacin, and folate

- Toxins: Lead and mercury

2. Mania

- CNS: Stroke, epilepsy, infections, neoplasm, TBI, MS, and SLE

- Endocrine: Hyperthyroidism and Cushing's disease

- Infections: Lyme, meningitis, HIV, and neurosyphilis

- Alcohol --> Should resolve after months of abstinence

- Stimulants --> Intoxication for mania and withdrawal for depression

- Opiates --> Soboxone can help treat

- Marijuana --> Amotivational syndrome with prolonged abuse

- Anabolic steroids --> "roid rage"

1. Depression

- Anxiolytics and CNS depressants --> BZDs and barbiturates

- CV/HTN meds: Reserpine, methyldopa, digitalis, clonidine, and B-blockers

- Interferon

- Chemo drugs

2. Mania

- Antidepressants --> Can induce mania in susceptible people

- Steroids

- Interferon

- Procainamide

- Late age of onset and sudden onset

- No personal or family history of psychiatric disease

- Abnormal labs or vitals

- Non-auditory hallucinations --> Visual without auditory first is almost ALWAYS delirium

- Haldol: IM, IV, PO --> PO vs. IV dosing is 2:1

- Ativan: IM, IV, PO

- Olanzapine: PO

- Risperidone: PO

- Benadryl: PO

- Cogentin/Benztropine: PO

- Always try to negotiate PO meds before jumping to IM or IV

- Inpatient level of care if unwilling to check themselves in or in imminent danger

- Crisis stabilization unit: Intermediate --> Pts voluntarily check in

- Referral to outpatient services

- Bipolar --> Lithium can decrease suicide risk

- Schizophrenic --> Clozapine can reduce suicide risk

- Monitor closely --> Increase rate of follow up after discharge --> Pts are most at risk the first 10 days after discharge

- Provides the psychiatrist with special skills necessary to deal with the legal system, including both civil and criminal cases

- Evaluation of competency to stand trial

- Insanity defense

- Providing court testimony

- Clinical experiences with patients in jails and prisons

- Supoenaed --> Still go through the legal department though

- If patient is suicidal

- If child or elder abuse is suspected or confirmed

- If patient is homicidal --> Tarasoff Case

- Involuntary commitment of a patient on the grounds of imminent harm to self or others, or is unable to care for themselves

- Pt must know their rights

- Pt must sign in voluntarily --> If pt doesn't, can be held for 72 hours (business days) before it goes before a court and either pt leaves or facility is able to commit pt

- Voluntary commitment

- Pt has 3 days to sign in under their own accord

- If pt doesn't sign in and pt is safe, then they can leave after 3 days

- If not, pt must go before a judge and involuntary committment can be obtained

- Legal term

- Can only be decided by a judge

- Pt has sufficient present ability to consult with his lawyer with a reasonable degree of rational understanding and whether he has a rational as well as factual understanding of the proceedings against him

- Defendant is able to adequately assist his attorney in preparing a defense

- Defendant is able to make informed decisions about trial strategy and whether or not to plead guilty or accept a plea agreement

- Clinical term

- Assessed by physicians (ANY)

- Time and task specific --> Can fluctuate

- Valid informed consent is premised on the disclosure of appropriate information to a competent patient who is permitted to make a voluntary choice

- Pt must be able to communicate a choice over time, understand relavant information, appreciate the situaiton and consequences, and reason about treatment options

- If a patient lacks capacity --> Health care proxy, advanced directives or family members can be utilized to make decisions

- Identify what is causing the impairment and try to assess and treat it if possible

- Legal concept

- Defendant claims that because of mental health problems they were not responsible for their actions

- Insanity defense is based on evaluations by forensic professionals that the defendant was incapable of distinguishing between right (legal) and wrong or appreciate the nature of his or her actions at the time of the offense

- Cannot be determined simply based on the pt being diagnosed with a mental disorder

- Criteria to determine: M'Naghten rules, irresistsable impulse, Durham/New Hampshire test, Brawner rule, Insanity defense reform act, and substantial capacity test

- In Mass: Found not guilty if at the time he lacks the substantial capacity to either appreciate the criminality of his conduct or to conform his conduct to the requirements of the law

- NOT a psychiatric disorder

- Be very careful when putting this diagnosis on patients

- Intentional production of false or grossly exaggerated physical or psychological symptoms motivated by external incentives

- Strongly suspect if: Medico-legal context, marked discrepancy between the person's claimed stress or disability and the objective findings, lack of cooperation during diagnostic evaluation, and presence of antisocial personality disorder

- Common reasons: Obtain meds, avoid punishment, obtain financial gain, and obtain room and board

- High suspicion when: Rare symptoms or symptom combinations occur, use of formal medical terms, and endorsement of all symptoms of one condition

- CNS controls affect, behavior, and cognition

- Structure and function of the central nervous system is altered by many medical disorders

- CNS alterations can lead to neuropsychiatric symptoms that can mimic primary psychiatric symptoms

- L frontal lesions tend to be associated with depression

- R frontal lesions tend to be associated with hypomania or mania

- Particular symptom may have to do with where the blood-brain barrier is most compromised and what function that area of the brain serves

- Late onset of initial presentation

- Known underlying medical condition

- Atypical presentaiton of a specific psychiatric diagnosis

- Absense of personal and family history of psychiatric illness

- Illicit drug or medication use

- Treatment resistance or unusual response to treatment

- Sudden onset of mental symptoms

- Abnormal vitals

- Waxing and waning mental status

- Syphilis

- Lupus

- HIV

- Brain tumors

- Strokes

- TBI

- Epilepsy

1.  Pathophysiology

- HIV injures neurons via indirect mechanisms --> Viral proteins (gp120 and tat) and neurotoxins from neurological immune response

- The immune response prefers subcortical structures

2. Early symptoms

- Short-term memory loss, poor coordination, slowed thinking, behavioral changes and mild motor dysfunction (ataxia and weakness)

3. Late symptoms

- Psychomotor slowing, reduced verbal output, disorientation, disinhibition, lack of awareness of illness and severe motor symptoms (weakness, hyperreflexia, bladder/bowel incontinence)

4. Risk factor

- Increased length of infection, low CD4 count, and co-infection with HCV

5. Diagnosis: Rule out all other infections via cultures, Ab titers and MRI

6. Treatment: HAART, possible formulation with greater CNS penetration

- May be reversible depending on how severe --> Should expect some improvement

1. Pathophysiology: AD neurodegenerative disorder caused by CAG expansion on chromosome 4 --> Abnormal huntingtin protein --> Protein aggregation and neuron death particularly in the caudate

2. Early symptoms

- Irritability, depression, personality changes --> May appear several years before onset of chorea

3. Late symptoms

- Chorea, dystonia, athetosis, increased rigidity/akinesia and eventual dementia

4. Diagnosis

- Genetic testing and MRI looking for caudate atrophy

5. Treatment: Symptomatic --> Tetrabenzine, neuroleptics and amantadine

1. Pathophysiology: Defiency in thiamine leading to injury in susceptible areas of the brain due to dysfunction in glucose metabolism

- Susceptible areas --> Thalamus, hypothalamus and mamillary bodies

2. Symptoms: Classic triad of confusion, ataxia, and opthalmoplegia

- Only present in 19% of patients though

3. Diagnosis: Clinical

4. Treatment: Give IV thiamine, then glucose to avoid worsening of condition

- Severe cases may progress to Korsakoff's syndrome --> Irreversible anterograde and retrograde amnesia with confabulation too

1. Pathophysiology: AD disorder in porphobilinogen deaminase enzyme --> Build up of porphyrins

2. Symptoms: Intermittent colicky abdominal pain, neurological symptoms (peripheral neuropathy), psychosis (visual hallucinations), and urine turning dark upon standing in air

- Attacks can be triggered by alcohol, barbiturates, carbamazepine, NSAIDs, valproic acid, rifampin, estrogens, high dose clonazepam, fasting, and infection

3. Diagnosis: Quantification of urinary porphobilinogens and urinary d-ALA

4. Treatment: Symptomatic --> Narcotics for pain, ondansetron, chlorpromazine, short-acting BZDs

1. Pathophysiology: Primary hyperparathyroidism or malignancy --> Also due to Paget's disease and kidney failure

2. Symptoms: N/V, abdominal pain, constipation, lethargy, altered mental status, depression, polyuria, and headache

3. Diagnosis: Serum calcium and serum ionized calcium

4. Treatment: Fluids, loop diuretics and then monitor K and Mg

1. Pathophysiology: Setting of acute or chronic liver failure --> Risk factors include cirrhosis and acute viral infection

2. Symptoms: Decreased consciousness, agitation, personality changes, and asterixis

3. Diagnosis: Ammonia levels are often increased --> EEG may be helpful

4. Treatment: Lactulose --> Binds ammonia and doesn't allow it to be absorbed

1. Cardiac Events: MI, atrial and ventricular arrhythmia, and CHF

2. Illicit substances: Cocaine or amphetamine use, LSD or PCP use, and alcohol or BZD withdrawal

3. Other Medical Conditions: PE, Asthma, COPD, hyperthyroidism, and hypoglycemia

4. Medications: Sympathomimetics, thyroid hormone, bronchodilators, stimulants, and corticosteroids

- Independent risk factors for CVD

- Patients with depressive symptoms have 1.5-3.5x increased risk for MI

- 18% of patients with asymptomatic CAD have depression

- Depression post-MI increase mortality by 4-6x

- Physiologic mechanism: Poor self care or low treatment adherence and increase in catecholamine or CRP

- Medical Conditions: Hypothyroidism, Cushing's Disease, vitamin B12 or folate deficiency, and vascular dementia

- Illicit substances: Cocaine or amphetamine withdrawal and alcohol/BZD use

- Medications: ACE inhibitors, methyldopa, reserpine, corticosteroids, and interferon

- Mechanism: Affects various receptors but hallucinogenic effects is mediated by 5-HT2A and NMDA antagonism

- Symptoms: Hallucinations, synesthesia, mood changes, hypertension, tachycardia, dizziness, loss of appetite, dry mouth, sweating, nausea, numbness and tremor

- Long-term effects: Persistent psychosis and hallucinogenic

- Severe intoxication: Malignant hyperthermia and

- Treatment: Supportive and symptomatic treatment, BZDs for agitation, and avoid antipsychotics

- Recurrent or persistent complex visual hallucinations that occur in visually impaired individuals with intact cognition and no evidence of psychiatric illness

- 10-40% of macular degeneration, glaucoma, and cataract

- After bilateral optic nerve damage due to methyl alcohol poisoning

- Liliputian hallucinations are very common

- Pts usually retain insight into the unreal nature of their hallucinations

- Treatment: Limited to reassurance of the benign nature of the hallucinations

- Pathophysiology: Autoimmune inflammatory demyelinating disease of the CNS, primarily affects women of Northern European descent --> Onset between 20-40 years

- Symptoms: Fatigue is very common, depression, mood liability and cognitive impairment, blurry vision or loss of vision, numbness, weakness, and paresthesias --> Psychosis and mania is rare

- Classification: Secondary progressive, primary progressive, progressive/relapsing

- Diagnosis: MRI + evoked potentials are used to diagnose

- Treatment: Immune modifying agents --> Cyclophosphamide, glucocorticoids, and interferon

- Pathophysiology: Decreased cerebral blood flow and decreased cerebral oxygen and glucose metabolism

- Symptoms: Depressive symptoms and lethargy combined with classic physical signs

- Diagnosis: TSH and free T4/T3

- Treatment: Thyroid hormone replacement

- Myxedema Madness: Severe hypothyroidism presenting with psychosis, delirium, depression, and cognitive impairments

- Myxedema coma: Severe hypothyroidism presenting with hypothermia and other symptoms and signs. Seizures are common

- Anxiety, restlessness, irritability, emotional lability and insomnia

- Elderly --> Apathetic thyrotoxicosis --> Apathy and depression

- Thyrotoxicosis may experience behavioral and personality changes, such as psychosis, agitation, and depression

- Eating of non-nutritive, non-food substance ~1 month

- Occasionally associated with vitamin or minteral deficiency (zinc and iron) --> Often no biological abnormality

- Comes to clinical attention following medical complications --> Intestinal obstruction, bezoar, intestinal perforation, infections or poisoning

- Associated with other mental disorders --> Intellectual disability, autism spectrum disorder, schizophrenia, and trichotillomania

- Etiology: Neglect, lack of supervision, and developmental delay increases risk

- Differential diagnosis: Anorexia nervosa, factitious disorder, and non-suicidal self-injury

- Repeated regurgitation of food several times a week and typically daily over a 1 month period

- Food is re-chewed, re-swallowed, or spit out

- Onset at any age --> Infancy to adulthood

- More common in individuals with intellectual disability

- Not associated with GI or medical condition

- Can lead to weight loss, malnutrition, and restriction of intake

- Lack of interest in eating and/or food leading to weight loss or malnutrition

- Food sensory characteristics --> Color, smell, texture, and taste

- Conditioned negative response --> Aversive experience of choking, vomiting, etc

- Most common in infancy or early childhood but can persist to adulthood

- Symptoms: Failure to thrive, dependence on enteral feeding and NOT related to lack of available

- Co-morbidities: Anxiety disorders, OCD, and neurodevelopmental disorders (ADHD, autism, and intellectual disability

- Differential: GI disease, food allergies, occult malignancies, reactive attachment disorder, autism spectrum disorder, anxiety disorders, specific phobias, anorexia nervosa, schizophrenia, ODD, MDD, and factitious disorder

- Treatment: Appetite stimulants --> May be helpful but aversions are usually more powerful than an urge to eat

- 24 million people in the US suffer from eating disorders

- Highest mortality rate of any mental disorder

- Cost of inpatient treatment can be $30,000 or more a month

- Cost of outpatient treatment, including therapy, can extend $100,000 a year

- EAT (Eating Attitude Test) --> 26 questions

- SCOFF

- Eating Disorder Screen for Primary Care

- Literally means neurotic loss of appetite

- Self induced starvation --> Fear of loosing control

- Distorted body image --> Relentless drive for thinness or morbid fear of fatness and significant misinterpretation of body and it's shape

- Weight loss is viewed as an impressive achievement and sign of extraordinary discipline

- Weight gain is perceived as an unacceptable failure of self control

- Pts often lack insight or deny the problem

- DSM- IV Criteria: Body weight <85% (BMI<18), intense fear of gaining weight, disturbance in the way in which one's body weight or shape is experienced, and amenorrhea

- Restricted type: No binge-eating or purging behavior

- Binge-eating/purging type: Pt regularly engages in binge-eating or purging behavior

- DSM-V Criteria: Criterion A focuses on behaviors like restricting calorie intake instead of total refusal and criterion D (amenorrhea) has been removed

- Lifetime Prevalence: 0.9% in women and 0.3% men

- Mean age of onset: 17

- Mortality rate --> 12x higher than the death rate of ALL causes of death for females 15-24 years old

- All ethnic and cultural groups are vulnerable

- Highest among Caucasian girls

- China and Japan --> Crisis with laxatives and fad diets

- Argentina --> 3x more eating disorders than the US

- Genetics: Decreased serotonin and obsessional/anxious traits

- Society: Western society's drive for thinness and disturbances in family system

- Psychological: Rebel from controlling parents, unable to interpret body hunger signals because of early experiences of inappropriate feeding

- Major Depression and Dysthymia (50-75%)

- Anxiety Disorders --> OCD, PTSD, and social phobia (50-75%)

- Personality Disorders or Traits (Up to 50%)

- Substance use disorders (26%)

- Bulimia

- 1/3 recover, fluctuate or are chronically ill

- Bad prognostic indicators --> Restricting subtype, lower minimal weight, later age of onset, and greater degree of body image distortion

- 30-50% of patients develop bulimia nervosa within 2 years of onset of anorexia

- Cardio: Bradycardia, orthostatic hypotension, arrhythmia, ECGs (QTc prolongation), and ST wave abnormalities

- CNS: Peripheral neuropathy, enlarged ventricles, decreased gray and white matter, and cognitive impairment

- Endocrine: Hypothermia, amenorrhea, hypokalemia, hypophosphatemia, electorlyte abnormalities, and hypercholesterolemia

- GI: Vomiting, constipation, diarrhea, parotid hyperplasia, increased serum amylase, and abnormal LFTs

- Renal: Hypokalemic nephropathy

- Hematological: Anemia and leukopenia with relative lymphocytosis

- Integument: Lanugo and carotenoderma

- Muscular: Muscular wasting and CK abnormalities

- Pulmonary: Decreased pulmonary capacity

- Reproduction: Amenorrhea, decreased serum estrogen, decreased serum testosterone, and loss of libido

- Skeletal: Osteopenia, osteoporosis, and pathological stress fractures

- Weight is 20-30% below expected weight for height --> Admit, CMP, CBC and EKG

- Forced feeding: NG and parenteral

- Refeeding syndrome --> Phos. and K --> Check daily labs x5 days

- Failed outpatient treatment --> Goal to gain 2-3 lbs/week

- Suicide screening necessary

- Caloric targets

- Bathroom restrictions

- Watch for water loading and pocket loading

- Meds can help depression, anxiety, but do not reverse the core symptoms --> SSRIs are best but none are FDA approved

- Psychological: CBT, psychodynamic therapy, and family therapy

- Interdisciplinary Team approach

- Ravenous hunger

- Preoccupation with food, overvalued fear of putting on weight, and compensatory behaviors

- DSM-IV: Recurrent episodes of binge eating, recurrent inappropriate compensatory behavior to prevent weight gain, behaviors occur >2x/week for 3 months, self-evaluation unduly influenced by body shape and weight, and does not occur exclusively during episodes of anorexia nervosa

- DSM-V Criteria: Reduce frequency of binge eating from twice to once a week

- Comorbidities: Major deression and bipolar, anxiety disorders, substance abuse disorders (33-60%), and borderline personality disorder (25-48%)

- Prognosis: Chronic but not debilitating when not complicated by electrolyte imbalance, spontaneous remission in 1-2 years, relapse rate can approach 50% in 5 year period

- Complications: Dehydration, vomiting, swelling of parotid gland, mild elevations of serum amylase, dental caries, electrolyte disturbances, Mallory-Weiss syndrome, and cardiac arrhythmias

- Treatment: Hospitalization rarely necessary, SSRIs, and CBT

- Lifetime prevalence ranges from 1-3%

- Average age of onset is 18 years

- Prognosis significantly better than anorexia

- Within 2 years of treatment --> 50-70% are symptom free

- Etiology: Increased frequency in 1st degree relatives, tend to be perfectionists, difficulties separating from caretakers, more outgoing, angry, sexual, and impulsive, and higher incidence of substance abuse

1. DMS-IV Criteria:

- Recurrent binge eating (>2x week/6 months)

- >3 of the following: eating much more rapidly, eating until uncomfortable full, eating large amounts when not feeling physically hungry, eating alone due to embarassment by how much one is eating, and feeling disgust with oneself, depressed, or guilty after overeating

- Marked distress

- Not associated with regular use of inappropriate compensatory behaviors

2. DSM-V Criteria

- Average of once a week over 3 months

3. Epidemiology: Prevalence 1.5-3%

4. Comorbidities: Bipolar disorder, MDD, anxiety, IBS, fibromyalgia, kelptomania, and bulimia

5. Treatment: SSRIs, anticonvulsants (topomax), CBT, interpersonal therapy, and pay attention to medical comorbidities

- Atypical anorexia nervosa --> Do not meet weight criteria

- Bulimia nervosa who do not binge/purge at the prerequisite frequency/duration

- Binge-eating disorder --> Low frequency and limited duration

- Purging disorder --> No binge eating behavior

- Night eating syndrome

- Altruism: Alleviating guilt through generosity to others

- Anticipation: Dealing with stress by predicting future events

- Asceticism: Eliminating pleasurable effects of experiences --> Denying one-self from pleasure for purpose of moral gain

- Humor: Appreciating humor in stress

- Sublimation: Channeling troubling thoughts/emotions into another socially acceptable form

- Suppression: Intentional dismissal of thoughts of a stressful situation to avoid stress (Differs from repression by being a conscious effort)

- Radical acceptance: Acceptance of current situation as it is, not what it should be

1. Denial: Unconsious rejection of external stimuli

2. Distortion/childish mockery: A gross reshaping of external reality to meet internal needs

3. Projection: Reducing anxiety by allowing the expression of undesirable impulses or desires without becoming consciously aware of them --> Attributing one's unacknowledged unacceptable or unwanted thoughts and emotions to another

- Acting out: Giving in to an impulse, even if it's socially unacceptable in order to avoid the anxiety of suppresing to that impulse

- Blocking: Temporarily or transiently inhibiting thinking --> Closely resembles repression and tension arises when the impulse/thought is inhibited

- Hypochondriasis: Exaggerating or overemphasizing an illness for the purpose of evasion and regression

- Introjection: Internalizing the qualities of an object --> Can obliterate the distinction between subject and object (Stockholm syndrome)

- Passive-aggression: Aggression towards others expressed indirectly or passively --> Can also be expressed through masochism, behavior, and turning against the self

- Regression: Attempting to return to an earlier phase of functioning in order to avoid tension or conflict evoked by the current level of functioning

- Schizoid fantasy: Indulging in autistic retreat in order to resolve conflict and to obtain gratification

- Somatization: Transformation of negative feelings towards others into negative feelings toward oneself, pain, illness, and anxiety --> Conversion into bodily symptoms

- Displacement: Shifting impulse to a more acceptable or less threatening target

- Dissociation: Temporary drastic modification of one's personal identity or character to avoid emotional distress

- Externalization: Projecting one's internal characteristics onto the outide world

- Intellectualization: Form of isolation by concentrating on the intellectual components of a situation so as to distance oneself from the associated anxiety-provoking emotions

- Isolation: Separation of feelings from ideas and events

- Rationalization: Convincing oneself that no wrong has been done and that all is or was alright through faulty and false reasoning

- Reaction formation: Converting unconscious wishes or impulses that are perceived to be dangerous or unacceptable into their opposites

- Repression: Unconscious attempt to repel desires towards pleasurable instincts caused by a threat of suffering if the desire is satisfied

- Undoing: Person tries to "undo" an unhealthy, destructive or otherwise threatening thought by acting out the reverse of the unacceptable

- Pervasive distrust and suspiciousness of others

- Prevalence: 0.5-2% --> Men more likely and high incidence in family members of schizophrenics

- DMS- IV Criteria: At least 4 of the following

1. Suspicion that others are exploiting or deceiving them

2. Preoccupation with doubts of loyalty or trustworthiness of acquaintances

3. Reluctance to confide in others

4. Interpretation of benign remarks as threatening or demeaning

5. Persistence of grudges

6. Perception of attacks on his or her character that are not apparent to others; quick to counterattack

7. Recurrence of suspicions regarding fidelity of spouse or lover

- Treatment: Psychotherapy but may also benefit from SSRIs or a short course of antipsychotics for transient psychosis

- Lifelong pattern of social withdrawal

- Prevalence: 7% and men are 2x more likely

- Need at least four of the following

1. Neither enjoying nor desiring close relationships (including family)

2. Generally choosing solitary activities

3. Little interest in sexual activity with another person

4. Taking pleasure in few activities

5. Few close friends or confidants

6. Indifference to praise or criticism

7. Emotional coldness, detachment, or flattened affect

- Treatment: Psychotherapy and low dose antipsychotics if transiently psychotic

- Pervasive pattern of eccentric behavior and peculiar thought patterns

- Prevalence: 3%, more prevalent in monozygotic twins

- DSM-IV Criteria: Need five or more of the following:

1. Ideas of reference

2. Odd beliefs or magical thinking, inconsistent with cultural norms --> Clairvoyance, telepathy, bizarre fantasies or preoccupations, and superstitions

3. Unusual perceptual experiences

4. Suspiciousness

5. Inappropriate or restricted affect

6. Odd or eccentric appearance or behavior

7. Few close friends or confidants

8. Odd thinking or speech

9. Excessive social anxiety

- Treatment: Psychotherapy and short course of low-dose antipsychotics

- Refuse to conform to social norms and lack remorse for their actions --> Impulsive, deceitful, and often violate the law

- Very high addictive potential

- Prevalence: 3% in men and 1% in women, higher incidence in poor urban areas and in prisoners

- DSM-IV Criteria --> Pt must be at least 18 years old, be diagnosed with conduct disorder in childhood, and three or more of the following

1. Failure to conform to social norms by committing unlawful acts

2. Deceitful/repeated lying/manipulating others for personal gain

3. Impulsivity/failure to plan ahead

4. Irritability and aggressiveness/repeated fights or assaults

5. Recklessness and disregard for safety of self or others

6. Irresponsibility/failure to sustain work or honor financial obligations

7. Lack of remorse for actions

- Treatment: Psychotherapy and pharmacotherapy with comorbid anxiety or depression --> Extremely high addictive potential in these patients so be careful!!

- Unstable moods, behaviors, and interpersonal relationships --> They feel alone in the world and have problems with self-image

- Prevalence: 1-2% and women are 2x more likely and 10% suicide rate

- DSM-IV Criteria --> Pervasive pattern of impulsivity and unstable relationships, affects, self-image, and behaviors and at least 5 of the following

1. Desperate efforts to avoid real or imagined abandonment

2. Unstable and intense interpersonal relationships

3. Unstable self-image

4. Impulsivity in at least two potentially harmful ways

5. Recurrent suicidal threats or attempts or self-mutilation

6. Unstable mood/affect

7. General feelings of emptiness

8. Difficulty controlling anger

9. Transient, stress-related paranoid ideation or dissociative symptoms

- Terribly afraid of abandonment --> Better off doing things concrete with them --> Give them presents instead of trying to have a good time with them

- Treatment: Psychotherapy and pharmacotherapy to treat psychotic or depressive symptoms

- Attention-seeking behavior and excessive emotionality

- Dramatic, flamboyant and extroverted but are unable to form long-lasting, meaningful relationships --> Often inappropriately sexual and provocative

- Prevalence: 2-3% and women are more likely

- DSM-IV Criteria --> At least 5 of the following

1. Uncomfortable when not the center of attention

2. Inappropriately seductive or provocative behavior

3. Uses physical appearance to draw attention to self

4. Has speech that is impressionistic and lacking in detail

5. Theatrical and exaggerated expression of emotion

6. Easily influenced by others or situation

7. Perceives relationships as more intimate than they actually are

- Treatment: Psychotherapy and pharmacotherapy for depressive or anxious symptoms

- Grandiosity, need for admiration, and lack of empathy beginning by early adulthood

- Prevalence: <1% 

- DSM-IV Criteria --> Five or more of the following

1. Exaggerated sense of self-importance

2. Preoccupied with fantasies of unlimited money, success, brilliance, etc

3. Believes that he or she is special or unique and can associated only with other high status individuals

4. Needs excessive admiration

5. Has sense of entitlement

6. Takes advantage of others for self-gain

7. Lacks empathy

8. Envious of others or believes others are envious of him or her

9. Arrogant or haughty

- Treatment: Psychotherapy and antidepressants or lithium as needed

- Pervasive pattern of social inhibition and an intense fear of rejection

- Prevalene: 1-10%

- DSM- IV Criteria: Pattern of social isolation, hypersensitivity, and feelings of inadequacy since early adulthood with at least 4 of the following

1. Avoids occupation that involves interpersonal contact due to fear of criticism and rejection

2. Unwilling to interact unless certain of being liked

3. Cautious of intrapersonal relationships

4. Preoccupied with being criticized or rejected in social situations

5. Inhibited in new social situations because he or she feels inadequate

6. Believes he or she is socially inept and inferior

7. Reluctance to engage in new activities for fear of embarassment

- Treatment: Psychotherapy including assertiveness training, beta blockers to control autonomic symptoms and SSRIs for depressive symptoms

- Poor self-confidence and fear separation

- Excessive need to be taken care of and allow others to make decisions for them

- Prevalence: 1% and women are more likely

- DSM-IV Criteria: Pattern of submissive and clinging behavior due to excessive need to be taken care of and at least 5 of the following:

1. Difficulty making everyday decisions without reassurance from others

2. Needs others to assume responsibilities for most areas of his or her life

3. Cannot express disagreement because of fear of loss of approval

4. Difficulty initiating projects because of lack of self-confidence

5. Goes to excessive lengths to obtain support from others

6. Feels helpless when alone

7. Urgently seeks another relationships when one ends

8. Preoccupied with fears of being left to take care of self

- Treatment: Psychotherapy and pharmacotherapy for anxiety or depression

- Pervasive pattern of perfectionism, inflexibility, and orderliness

- So preoccupied with unimportant details that they are often unable to complete simple tasks in a timely fashion

- Prevalence: Unknown, men more likely, occurs most often in the oldest child and increased incidence in 1st degree relatives

- DSM-IV Criteria: Preoccupation with orderliness, control, and perfectionism at the expense of efficiency that is persistent by early adulthood and at least 4 of the following:

1. Preoccupation with details, rules, lists, and organization such that the major point of the activity is lost

2. Perfectionism that is detrimental to completion of task

3. Excessive devotion to work

4. Excessive conscientiousness and scrupulousness about morals and ethics

5. Will not delegate tasks

6. Unable to discard worthless objects

7. Miserly

8. Rigid and stubborn

- Treatment: Psychotherapy, group therapy and behavior therapy, and pharmacotherapy may be used to treat associated symptoms

- Stubborn, inefficient procrastinators

- Alternate between compliance and defiance and passively resist fulfillment of tasks

- Frequently make excuses for themselves and lack assertiveness

- Attempt to manipulate others to do their chores, errands, and the like

- Frequently complain about their own misfortunes

- Treatment: Psychotherapy

- Brainstem --> Locus coeruleus (NE)

- Frontal lobe --> Executive functioning --> Overcomes learned response and solves problems

- Hypothalamus --> Regulates hormones and HPA axis

- Limbic system --> Scans the environment for danger

- Amydala --> Coordinates fear behaviors/response

- Hippocampus --> Regulates memory and anxiety-provoking situations

- Cortisol --> Released with stress and regulates glucose metabolism --> Affects brain functioning

- GABA

- NE --> Increased arousal and attention --> Released by caffeine, CO2/hyperventilation, and fight/flight response

- Serotonin --> GI and CNS effects --> Regulates mood/appetite/sleep and some cognition and memory

- Biological --> Genetic and neurophysio/biochemical

- Psychological --> See stimuli as being potentially threatening and have higher emotional reactivity

- Social --> Learned responses from repeated exposure to anxiety-provoking situations

- Also associated with parental overprotection, excessive criticism, and social isolation

- Older age of onset and less family/personal hx of psychiatric conditions

- Decreased availability of glucose/oxygen to the brain

- Life threatening conditions --> PE, MI --> May present initially with anxiety

- Doesn't include anxiety that exists solely with delirium

- Excessive worry more days than not for at least 6 months about a number of events or activities

- Need 3 or more of:

1. Restlessness

2. Fatigue

3. Difficulty concentrating

4. Irritability

5. Muscle tension

6. Sleep disturbance

- MDD and dysthymia are very often co-morbid with GAD --> Panic disorder too

- Treatment: SSRI, SNRI, or buspirone --> Avoid BZDs if possible 

- Marked fear/anxiety about 2 or more:

1. Using public  transportation

2. Being in open spaces

3. Being in enclosed spaces

4. Standing in line or being in a crowd

5. Being outside the house alone

- Person fears or avoids situations because of the thought that escape might be difficult or help may not be available if incapacitating/embarassing symptoms occur

- Fear out of proportion, must last 6 months or more, and causes significant distress

- Anxiety develops during or soon after use of a substance

- Substance is capable of producing anxiety

- When substance resolves, anxiety improves --> Within a month

- Intoxication: Amphetamine, cocaine, caffeine, marijuana, hallucinogens, steroids, and anticholinergics

- Withdrawal: Alcohol, sedatives, and hypnotics

- Marked fear/anxiety about social situations where an individual is exposed to possible scrutiny by others

- Situation is avoided/endured

- Symptoms last 6 months or more

- Must occur with peers and not only with adults in children

- Specify if only during public speaking/performing

- Recurrent, unexpected attacks with abrupt fear/discomfort which reaches its peak within a few minutes

- Four or more of:

1. Palpitations

2. Increased HR

3. Sweating

4. Trembling

5. SOB

6. Feeling of choking

7. CP

8. Nausea and vomiting

9. Fevers/chills

10. Parasthesias

11. Derealization

12. Depersonalization

13. Fear of losing control of going crazy

14. Fear of dying

- At least 1 attack followed by 1 month or more of persistent concern about additional attacks and/or maladaptive changes in behavior related to attack

- Consistent failure to speak in specific social situations where there is an expectation of speaking

- Interferes with communication/achievement

- Lasts at least 1 month

- Not due to lack of knowledge of spoken language, communication disorder, autism spectrum, or psychosis

- Excessive fear/anxiety re: separation from those to whom the individual is attached

- At least 3 of recurrent/persistent/excessive:

1. Distress when anticipating/experiencing separation from home or major attachment figures

2. Worry about losing figures or possible harm to them

3. Worry about experiencing event that causes separation

4. Reluctance to go places due to fear of separation

5. Fear of being alone or without figures

6. Reluctance to sleep away from figure

7. Nightmares involving separation

8. Complaints of physical symptoms when separated or anticipating separation

- Lasts 4 or more weeks for children and 6 or more months for adults

- Marked fear/anxiety about specific object/situation

- Thing is actively avoided or endured with intense fear/anxiety

- Lasts for at least 6 months

- Specify if animal, natural environment, blood injection injury, situational, and other

- Anxiety causes distress/impairment but does not meet full criteria

- Must specify reason that criteria is not fully met

- Anxiety causes distress/impairment but does not meet full criteria for other disorders

- Specific reason for criteria not being met is NOT given

- Not enough information to make specific diagnosis

- Cortisol --> Exercise, good sleep hygiene, nutrition, and meditation

- NE --> Decrease stimulants, deep breathing exercises, B-blockers (propranolol and metoprolol), and alpha-adrenergic agonists (clonidine) and antagonists (prazosin)

- Histamine --> Anti-histamines (hydroxyzine)

- Serotonin --> SSRI/SNRI, TCA, MAOI, and buspirone

- GABA --> Benzos for short term anxiety relief

- Persistent deficits in social communcation and social interaction in multiple settings: Demonstrated by deficits in all three of the following

1. Social-emotional reciprocity

2. Nonverbal communicative behaviors used for social interaction

3. Developing, maintaining, and understanding relationships

- Restricted, reptitive patterns of behavior, interests, or activities: Demonstarted by >2 of the following

1. Stereotyped or repetitive movements, use of objects or speech

2. Insistence on sameness, unwavering adherence to routines, or ritualized behavior

3. Highly restricted, fixated interests that are abnormal in strength or focus

4. Increased or decreased response to sensory input or unusual interest in sensory aspects of the environment

- Symptoms must impair function and must be present in early development

A. Acquisition and execution of coordinated motor skills is substantially below that expected for a given age and opportunity for skill learning and use

B. Motor skills defcit in A significantly and persistently interferes with activities of daily living appropriate for age

C. Onset of symptoms early in developmental period

D. Deficit not better explained by intellectual disability or visual impairment and are not attributable to a neurological condition

A. Repetitive, seemingly driven, and apparently purposeless motor behavior

B. Repetitive motor behavior interferes with social, academic or activities and may result in self-injury

C. Onset in early development

D. Not attributable to the physiological effects of a substance or neurological condition and is not better explained by another neurodevelopmental disorder

A. Multiple motor AND one or more vocal ticks that have been present for some time during the illness --> Not necessarily concurrent

B. Tics may wax and wane in frequency but have persisted for more than 1 year since first onset

C. Before the age of 18

D. Not attributable to physiological effects of a substance or another medical condition (Parkinsons/Huntingtons)

- Treatment: Clonidine or guanfacine (1st line) --> Risperidone and pimozide only for highly impairing symptoms

A. Single or multiple motor or vocal tics that have been present throughout the illness

B. Tics may wax and wane but have persisted for more than 1 year

C. Onset before 18 years

D. Not attributable to physiological effects of a substance or another medical condition

E. Cannot meet criteria for Tourrette's

A. Single or multiple vocal or motor tics

B. Tics present for less than 1 year

C. Onset before 18 years

D. Not attributable to a substance or other medical problem

E. Cannot meet criteria for Tourette's or persistent motor or vocal tic disorder

- No longer split into separate reading, mathematics, written expression, and learning disorder not otherwise specified

A. Persistent difficulties in reading, writing, arithmetic, or mathematical reasoning during formal years of school

B. Current academic skills must be well below the average range of scores in culturally and linguistically appropriate tests of reading, writing, and mathematics

C. Not better explained by developmental, neurological, sensory, or motor disorders and must significantly interfere with academic achievement, occupational performance, and activities of daily living