• Positive reinforcement
• Negative reinforcement
• Punishment
• Extinction

Stop reinforcement > behavior stops

(both Operant and Conditioned)

Patient projects feelings about important person onto physician

(physician seen as parent)

Physician projects feelings about important person onto patient

(patient as child)

Expressing unacceptable feelings and thoughts through actions

(Tantrums)

Temporary, drastic change in personality/memory/consciousness/motor behavior to avoid emotional stress

(Extreme forms > Dissociative Identity Disorder/Multiple Personality Disorder)

Avoiding the awareness of some painful reality

(common reaction in cancer/AIDS patients)

Transferring avoided ideas/feelings to some neutral person or object

(Mom yells at kid because husband yelled at mom)

Partially remaining at a more childish level of development

(men fixating on sports)

Modeling behavior after another person who is more powerful

(abused child identifies with abuser)

Separating feelings from ideas/events

(describing murder in graphic detail with no emotion)

Attributing an unacceptable internal impulse to an external source

(man wants another woman, thinks wife is cheating on him)

Proclaiming logical reasons for actions actually performed for other reasons, usually to avoid self-blame

(getting fired, then saying job wasn't important anyway)

REplacing a warded-off idea or feeling by an (unconsciously derived) emphasis on its opposite

(patient with libidinous thoughts enters a monastery)

Turning back the maturational clock and going back to earlier modes of dealing with the world

(children under stress like illness/punishment/birth of new sibling > start wetting the bed again)

Involuntary withhoulding an idea or feeling from conscious awareness

(not remembering a traumatic experience)

Believing that people are either all good or all bad at different times due to intolerance of ambiguity. Commonly seen in borderline personality disorder

(patient says all nurses are cold while all doctors are very nice)

Alleviating guilty feelings by unsolicited generosity toward others

(mafia boss makes large donations)

Appreciating the amusing nature of an anxiety-provoking or adverse situation

(nervous medical student jokes about the boards)

Replacing an unacceptable wish with a course of action that is similar to the wish but does not conflict with one's value system

(teenager's aggression towards father is redirected to perform well in sports)

Intentional withholding of an idea or feeling from conscious awareness (vs. repression)

(choosing to not worry about the big game until it is time to play)

Mature adults wear a SASH

Sublimination

Altruism

Suppression

Humor

Long-term deprivation:

- Decreased muscle tone

- Poor language skills

- Poor socialization skills

- Lack of basic trust

- Anaclitic depression (infant withdrawn/unresponsive)

- Weight loss

- Physical illness

The 5 W's: Weak, Wordless, Wanting (socially), Wary, and Wasting

Deprivation > 6 months can lead to irreversible changes

Severe deprivation can result in infant death

Child Abuse

(Physical Abuse - Evidence)

Healed fractures on x-ray

(Spiral fractures highly suggestive of abues)

Burns

(cigarette, scalding)

Subdural hematomes

Pattern marks/bruising

(belts, electrical cords)

Rib fractures

Retinal hemorrhage or detachment

Child Abuse

(Physical Abuse - Abuse)

Child Abuse

(Physical Abuse - Epidemiology)

Child Abuse

(Sexual Abuse - Evidence)

Genital, anal, or oral trauma

STDs

UTIs

Child Abuse

(Sexual Abuse - Abuser)

Child Abuse

(Sexual Abuse - Epidemiology)

Child Neglect

(Definition)

Failure to provide a child with adequate food, shelter, supervision, education, and/or affection

Most common form of child maltreatment

Evidence:

- Poor hygiene

- Malnutrition

- Withdrawal

- Impaired social/emotional development

- Failure to thrive

MUST be reported to local child protective services

(same as child abuse)

Attention-Deficit Hyperactivity Disorders

[ADHD]

(Time Course)

Before age 12

Continues into adulthood in as many as 50% of individuals

Attention-Deficit Hyperactivity Disorders

[ADHD]

(Characteristics)

Hyperactivity

Impulsivity

Limited attention in multiple settings

(school, home, places of worship etc.)

Normal intelligence, but difficulties in school

Attention-Deficit Hyperactivity Disorders

[ADHD]

(Time Course)

Attention-Deficit Hyperactivity Disorders

[ADHD]

(Pathophysiology)

Attention-Deficit Hyperactivity Disorders

[ADHD]

(Treatment)

Methylphenidate

Amphetamines

Atomoxetine

Behavioral interventions

(reinforcement, reward)

Repetitive and pervasive behavior violating the basic rights of others

(physical aggression, destruction of property, theft, etc.)

After age 18 > meet criteria for diagnosis of Antisocial Personality Disorder

Enduring pattern of hostile, defiant behavior toward authority figures in the absence of serious violations of social norms

(early onset)

Tourette Syndrome

(Characteristics)

Sudden, rapid, recurrent, nonrhythmic, stereotyped motor and vocal tics that persist for > 1 year

Coprolalia (involuntary obscene speech) found in 10-20% of patients

Associated with OCD and ADHD

Tourette Syndrome

(Epidemiology)

Tourette Syndrome

(Onset)

Tourette Syndrome

(Treatment)

Antipsychotics

Behavioral therapy

Separation Anxiety Disorder

(Onset)

Separation Anxiety Disorder

(Characteristics)

Overwhelming fear of separation from home or loss of attachment figure.

May lead to factitious physical complaints to avoid going to or staying at school

Separation Anxiety Disorder

(Treatment)

SSRIs

Relaxation techniques/behavioral interventions

Characteristics:

- Poor social interactions

- Communication deficits

- Repetitive/ritualized behaviora

- Restricted interests

Must present in early childhood

May or may not be accompanied by intellectual disability

Rarely accompanied by unusual abilities (savants)

More common in boys

X-linked disorder seen almost exclusively in girls

(affected males die in utero or shortly after birth)

Symptoms = Regression

(apparent around ages 1-4)

- Loss of development

- Loss of verbal abilities

- Intellectual disability

- Ataxia

- Sterotyped hand-wringing

Alzheimer Disease

(Neurotransmitter Changes)

Anxiety

(Neurotransmitter Changes)

Increased NE

Decreased GABA

Decreased 5-HT

Depression

(Neurotransmitter Changes)

Decreased NE

Decreased 5-HT

Decreased Dopamine

Huntington Disease

(Neurotransmitter Changes)

Decreased GABA

Decreased ACh

Increased Dopamine

Parkinson Disease

(Neurotransmitter Changes)

Decreased Dopamine

Increased 5-HT

Increased ACh

Schizophrenia

(Neurotransmitter Changes)

Patient's ability to know:

- Who he or she is

- Where he or she is

- Date and time

Often abbreviated as "alert and oriented x 3" (AOx3)

1) Time

2) Place

3) Person

HEADLINe

 - Head trauma

- Electrolyte/fluid imbalance

- Alcohol

- Drugs

- Low sugar (hypoglycemia)

- Infection

- Nutritional deficiencies

DARK Memories:

- Dissociative

- Anterograde

- Retrograde

- Korsakoff

Inability to remember things that occurred after a CNS insult

(no new memory)

Classic anterograde amnesia; may include some retrograde amnesia

Thiamine deficiency > destruction of mammillary bodies

Seen in alcoholics

Associated with confabulations

Inability to recall important information, usually subsequent to severe trauma or stress

May be accompanied by Dissociative Fugue

Abrupt travel or wandering during a period of dissociative amnesia

Associated with traumatic circumstances

Significant change in cognition (memory, attention, language, judgment) from previous level of functioning

Associated with:

- Abnormalities in CNS

- General medical condition

- Medications

- Substance use

Includes Delirium and Dementia

Delirium

(Characteristics)

(Delirium = changes in Sensorium)

Disorganized thinking

Hallucinations

(often visual)

Illusions

Misperceptions

Disturbance in sleep-wake cycle

Cognitive dysfunction

Often reversible

Abnormal EEG

Delirium

(Causes)

Usually secondary to other illness

- CNS disease

- Infection

- Trauma

- Substance abuse/withdrawal

- Metabolic/electrolyte disturbances

- Hemorrhage

- Urinary/fecal retention

Check for drugs with anticholinergic effects

Delirium

(Treatment)

Identify and address underlying cause

Optimize brain condition

(O2, hydration, pain, etc.)

Antipsychotics

(mainly Haloperidl)

T-A-DA approach helpful for management

- Tolerate

- Anticipate

- Don't Agitate

Delirium

(Definition)

Dementia

(Definition)

Dementia

(Characteristics)

("Dememtia" = memory loss)

Memory deficits

Aphasia, Apraxia, Agnosia

Loss of abstract thought

Behavioral/Personality changes

Impaired judgment

Increased incidence with age

Usually irreversible

EEG usually normal

Can develop into delirium

Dementia

(Causes)

Irreversible:

- Alzheimer disease

- Lewy body dementia

- Huntington disease

- Pick disease

- Cerebral infarcts

- Creutzfeldt-Jakob disease

- Chronic substance abuse (neurotoxicity)

Reversible:

- NPH

- Vitamin B12 deficiency

- Hypothyroidism

- Neurosyphilis

- HIV (partially)

- Depression (pseudodementia)

A distorted perception of reality characterized by delusions, hallucinations, and/or disorganized thinking

Can occur in patients with medical illness, psychiatric illness, or both

Perceptions in the absence of external stimuli

(seeing a light that is not actually present)

Unique, false beliefs about oneself or others that persist despite the facts

(thinking aliens are communicating with you)

Hallucination Types

(Visual)

Hallucination Types

(Auditory)

Hallucination Types

(Olfactory)

Hallucination Types

(Gustatory)

Hallucination Types

(Tactile)

Common in alcohol withdrawal

(Formication - the sensation of bugs crawling on one's skin)

Also seen in cocaine abusers

("cocaine crawlies")

Hallucination Types

(Hypnagogic)

HypnaGOgic

Occurs while GOing to sleep

Hallucination Types

(Hypnapompic)

occurs while waking from sleep

(POMPous upon waking)

Schizophrenia

(Definition)

Schizophrenia

(Characteristics)

Increased Dopaminergic activity

Increased dendritic branching

Frequent cannabis use in teens

Schizophrenia

(Diagnosis)

Requires 2 or more of the following:

(first 4 are "positive symptoms")

- Delusions

- Hallucination (usually auditory)

- Disorganized speech (loose associations)

- Disorganized or catatonic behavior

- "Negative Symptoms" (Flat affect; Social withdrawal; Lack of motivation; Lack of speech or thought)

Schizophrenia

(Cause)

Schizophrenia

(Epidemiology)

Lifetime prevalence = 1.5%

(Males = Females; Blacks = Whites)

Presents earlier in men than women

(late teens to early 20s vs. late 20s to early 30s)

Patients at increased risk for suicide

At least 2 weeks of stable mood with psychotic symptoms, plus a major depressive, manic, or mixed episode.

2 subtypes: Bipolar or Depressive

Fixed, persistent, untrue belief system lasting > 1 month

Functioning otherwise not impaired.

Example = woman who genuinely believes she is married to a celebrit when, in fact, she is not

Formerly known as Multiple Personality Disorder

Presence of 2 or more distinct identities or personality states

More common in women

Associations:

- History of sexual abuse

- PTSD

- Depression

- Substance abuse

- Borderline personality

- Somatoform conditions

Abnormal range of moods or internal emotional states and loss of control over them

Severity of moods causes distress and impairment in social and occupational functioning

Includes:

- Major Depressive disorder

- Bipolar disorder

- Dysthymic disorder

- Cyclothymic disorder

Psychotic features (delusions/hallucinations) may be present

Manic Episode

(Definition)

Distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy lasting at least 1 week.

Often disturbing to patient

Manic Episode

(Diagnosis)

Requires hospitalization or at least 3 of the following:

(DIG FAST)

- Distractibility

- Irresponsibility (seeks pleasure without regard to consequences/hedonistic)

- Grandiosity (inflated self-esteem)

- Flight of ideas (racing thoughts)

- increased goal-directed Activity or psychomotor Agitation

- decreased need for Sleep

- Talkativeness or

pressured speech

Like manic episode except mood disturbance is not severe enough to cause marked impairment in social and/or occupational functioning or to necessitate hospitalization.

No psychotic features

Lasts at least 4 consecutive days

Bipolar Disorder

(Bipolar I)

Bipolar Disorder

(Bipolar II)

Bipolar Disorder

(Characteristics)

Patient's mood and functioning usually return to normal between episodes

Antidepressants > increased mania

High suicide risk

Bipolar Disorder

(Treatment)

Mood stabilizers

(Lithium, Valproic Acid, Carbamazepine)

Atypical antipsychotics

Dysthymia and Hypomania

Milder form of Bipolar disorder lasting at least 2 years

Major Depressive Disorder

(Definition)

Major Depressive Disorder

(Diagnosis)

Episodes characterized by at least 5 of the following 9 symptoms for 2 or more weeks:

(symptoms must include patient-reported depressed mood or anhedonia and occur more frequently as the disorder progresses)

SIGE CAPSS

- Sleep disturbance

- Loss of Interest (anhedonia)

- Guilt or feelings of worthlessness

- Energy loss and fatigue

- Concentration problems

- Appetite/weight changes

- Psychomotor retardation or agitation

- Suicidal ideations

- Self-reported depressed mood

Major Depressive Disorder

(Sleep Changes)

Patients with depression typically have the following changes in their sleep stages:

- Decreased slow-wave sleep

- Decreased REM latency

- Increased REM early in sleep cycle

- Increased total REM sleep

- Repeated nighttime awakenings

- Early-morning awakening (important screening question)

Symptoms usually associated with winter season

Improves in response to full-spectrum bright-light exposure

Atypical Depression

(Characteristics)

Differs from classical forms of depression.

Characterized by:

- Mood reactivity (being able to experience improved mood in response to positive events, even if briefly)

- Reversed vegetative symptoms (hypersomnia and weight gain)

- Leaden paralysis (heavy feeling in arms and legs)

- Long-standing interpersonal rejection sensitivity

Most common subtype of depression

Atypical Depression

(Treatment)

MAO Inhibitors

SSRIs

Onset within 4 weeks of delivery

Types:

- Maternal (postpartum) "blues"

- Postpartum Depression

- Postpartum Psychosis

Incidence = 50-85%

Characteristics:

- Depressed affect

- Tearfulness

- Fatigue

Starts 2-3 weeks after delivery; usually resolves within 10 days

Treatment = Supportive

(follow-up to assess for possible postpartum depression)

Incidence = 10-15%

Characteristics:

- Depressed affect

- Anxiety

- Poor concentration

Starts within 4 weeks after delivery; lasts 2 weeks to a year or more

Treatment:

- Antidepressants

- Psychotherapy

Incidence = 0.1-0.2%

Characteristics:

- Delusions

- Hallucinations

- Confusion

- Unusual behavior

- Possible HI/SI or attempts

Usually lasts days to 4-6 weeks

Treatment:

- Antipsychotics

- Antidepressants

- Possible inpatient hospitalization

- Assessment of child safety

Normal bereavement characterized by:

- Shock

- Denial

- Guilt

- Somatic symptoms

Can have simple hallucinations (hear voice of deceased), depressive symptoms, delusions.

Durations varies, up to 6-12 months

Includes excessively intense grief

(prolonged, lasting > 6-12 months)

or grief that is delayed, inhibited, or denied

Electroconvulsive Therapy

(Indications)

Treatment for/when:

- Major Depressive Disorder refractory to other treatment

- Pregnant women with Major Depressive Disorder

- Immediate response is necessary (acute SI)

- Depression with psychotic features

- Catatonia

Electroconvulsive Therapy

(Process)

Electroconvulsive Therapy

(Adverse Effects)

Disorientation

Temporary headache

Partial anterograde/retrograde amnesia

(usually fully resolving in 6 months)

SAD PERSONS

- Sex (male)

[women try more often; men succeed more]

- Age (teenager or elderly)

- Depression

- Previous attempt

- Ethanol or drug use

- loss of Rational thinking

- Sickness (medical illness, 3 or more prescription medications)

- Organized plan

- No spouse (divorced, widowed, or single; especially if childless)

- Social support lacking

Inappropriate experience of fear/worry and its physical manifestations (anxiety) when the source of the fear/worry is either not real or insufficient to account for the severity of the symptoms

Symptoms interfere with daily functioning

Lifetime prevalence = 30% in women; 19% in men

Includes:

- Panic disorder

- Phobias

- Generalized Anxiety Disorder

Panic Disorder

(Definition)

Defined by presence of recurrent panic attacks (periods of intense fear and discomfort peaking in 10 minutes with at least 4 of the following):

PPANIICCCCSSS

- Palpitations

- Paresthesias

- Abdominal distress

- Nausea

- Intense fear of dying or losing control

- lIght-headedness

- Chest pain

- Chills

- Choking

- disConnectedness

- Sweating

- Shaking

- Shortness of breath

Panic Disorder

(Diagnosis)

Requires attack followed by 1 month (or more) of 1 (or more) of the following:

- Persistent concern of additional attacks

- Worrying about consequences of the attack

- Behavioral change related to attacks

Panic Disorder

(Cause)

Panic Disorder

(Treatment)

Cognitive behavioral therapy

SSRIs

Venlafaxine

Benzodiazepines

(risk of tolerance/physical dependence)

Fear that is excessive or unreasonable and interferes with normal function

Cued by presence or anticipation of a specific object or situation

Person recognizes fear is excessive

Treatment = Systematic desensitization

Exaggerated fear of embarrassment in social situations

(public speaking, using public restrooms)

Treatment = SSRIs

Generalized Anxiety Disorder

(Definition)

Generalized Anxiety Disorder

(Associations)

Sleep disturbance

Fatigue

GI disturbance

Difficulty concentrating

Generalized Anxiety Disorder

(Treatment)

SSRIs

SNRIs

Buspirone

Cognitive behavioral therapy

Emotional symptoms (anxiety, depression) causing impairment following an identifiable psychosocial stressor (divorce, illness) and lasting < 6 months

(> 6 months in presence of a chronic stressor)

Obsessive Compulsive Disorder

(Definition)

Recurring intrusive thoughts, feelings, or sensations (obsessions) that cause severe distress

Relieved in part by the performance of repetitive actions (compulsions)

Ego Dystonic

(vs. OCPD)

Obsessive Compulsive Disorder

(Association)

Preoccupation with minor or imagined defect in appearance, leading to significant emotional distress or impaired functioning

Patients often repeatedly seek cosmetic surgery

Post Traumatic Stress Disorder [PTSD]

(Characteristics)

Persistent reexperiencing of a previous traumatic event (war, rape, robbery, serious accident, fire)

May involve nightmares or flashbacks, intense fear, helplessness, or horror

Leads to avoidance of stimuli associated with trauma and persistently increased arousal

Post Traumatic Stress Disorder [PTSD]

(Definition)

Post Traumatic Stress Disorder [PTSD]

(Treatment)

Psychotherapy

SSRIs

Patient consciously fakes, profoundly exaggerates, or claims to have a disorder in order to attain a specific secondary (external) gain

(avoiding work, obtaining compensation)

Poor compliance with treatment or follow-up of diagnostic tests

Complaints cease after gain

(vs. factitious disorder)

Patient consciously creates physical and/or psychological symptoms in order to assum "sick role" and to get medical attention

(primary [internal] gain)

Chronic factitious disorder with predominantly physical signs and symptoms

Characterized by a history of multiple hospital admissions and willingness to receive invasive procedures

When illness in a child or elderly patient is caused by the caregiver.

Motivation is to assume a sick role by proxy.

Form of child/elder abuse

Category of disorders characterized by physical symptoms with no identifiable physical cause

Both illness production and motivation are unconscious drives. Symptoms not intentionally produced or feigned.

More common in women

Variety of complaints in one or more organ systems lasting for months to years.

Association = excessive, persistent thoughts and anxiety about symptoms

May co-occure with medical illness

Sudden loss of sensory or motor function (paralysis, blindness, mutism) often following an acute stressor.

Patient is aware of but sometimes indifferent toward symptoms ("la belle indifference")

More common in females, adolescents, and young adults

Illness Anxiety Disorder

(Hypochondriasis)

Inflexible, maladaptive, and rigidly pervasive pattern of behavior causing subjective distress and/or impaired functioning

Person is usually not aware of the problem

Usualy presents by early adulthood

Three clusters:

A = Weird

B = Wild

C = Worried

Odd or eccentric; inability to develop meaningful social relationships

No psychosis; genetic association with Schizophrenia

Weird (Accusatory, Aloof, Awkward)

Pervasive distrust and suspiciousness

Projection is the major defense mechanism

Voluntary social withdrawal

Limited emotional expression

Content with social isolation

(vs. avoidant)

Schizoid = distant

(Schizoid wants to stay away from you)

Eccentric appearance

Odd beliefs or magical thinking

Interpersonal awkwardness

Schizotypal = magical thinking

(You want to stay away from Schizotypal)

Dramatic, emotional, or erratic

Genetic association with mood disorders and substance abuse

Wild (Bad to the Bone)

Disregard for and violation of rights of others; Criminality; Impulsivity

Males > females

Must be > 18 years old and have history of Conduct Disorder before age 15

(Conduct Disorder if < 18 years old)

Antisocial = Sociopath

Unstable mood and interpersonal relationships; impulsiveness; self-mutilation; boredom; sense of emptiness

Females > males

Splitting is a major defense mechanism

Excessive emotionality and excitability

Attention seeking

Sexually provocative

Overly concerned with appearance

Grandiosity, sense of entitlement

lacks empathy and requires excessive admiration

Often demands the "best"

Reacts to criticism with rage

Anxious or fearful

Genetic association with anxiety disorders

Worried (Cowardly, Compulsive, Clingy)

Hypersensitive to rejection

Socially inhibited; timid

Feelings of inadequacy

Desires relationships with others

(vs. Schizoid)

Preoccupation with order, perfectionism, and control

Ego-Syntonic

(vs. OCD)

Submissive and clinging

Excessive need to be taken care of

Low self-confidence

1) Schizoid

2) Schizotypal

(Schizoid + Odd thinking)

3) Schizophrenic

(Greater odd thinking than Schizotypal)

4) Schizoaffective

(Schizophrenic psychotic symptoms + Bipolar or depressive mood disorder)

< 1 month = Brief Psychotic Disorder (usually stress related)

1-6 months = Schizophreniform Disorder

> 6 months = Schizophrenia

Anorexia Nervosa

(Definition)

All lead to body weight well below ideal (BMI < 17):

- Excessive dieting +/- Purging

- Intense fear of gaining weight

- Body image distortion

- Increased exercise

Seen primarily in adolescent girls

Commonly coexists with depression

Anorexia Nervosa

(Adverse Effects)

Decreased bone density

(Decreased estrogen > Osteoporosis)

Severe weight loss

Metatarsal stress fractures

Amenorrhea

Lanugo

(fine body hair)

Anemia

Electrolyte disturbances

Bulimia Nervosa

(Definition)

Binge eating +/- Purging

Often followed by self-induced vomiting or use of laxatives, diuretics, or emetics

Body weight often maintained within normal range

Seen predominantly in adolescent girls

Bulimia Nervosa

(Adverse Effects)

Parotitis

Enamel erosion

Electrolyte disturbances

Alkalosis

Dorsal hand calluses from induced vomiting

(Russel Sign)

Strong, persistent cross-gender identification

Characterized by persistent discomfort with one's sex assigned at birth > significant distress and/or impaired functioning

Affected individuals often referred to as transgender

Desire to live as the opposite sex, often through surgery or hormone treatment

(Transsexualism)

Paraphilia, not gender dysphoria

Wearing clothes (e.g., vest) of the opposite sex (cross-dressing)

(Transvestism)

Sexual Dysfunction

(Disorders)

Includes:

- Sexual desire disorder

(Hypoactive sexual desire or Sexual aversion)

- Sexual arousal disorders

(Erectile dysfunction)

- Orgasmic disorders

(Anorgasmia and Premature Ejaculation)

- Sexual pain disorders

(Dyspareunia and Vaginismus)

Sexual Dysfunction

(DDx)

- Drugs

(Antihypertensives, Neuroleptics, SSRIs, Ethanol)

- Diseases

(Depression, Diabetes, STDs)

- Psychological

(Performance anxiety)

Periods of terror with screaming in the middle of the night

Occurs during slow-wave sleep

(non-REM sleep, vs. nightmares which occur during REM sleep)

Most common in children

Cause = unknown, but triggers include:

- Emotional stress

- Fever

- Lack of sleep

Usually self-limited

Narcolepsy

(Definition)

Disordered regulation of sleep-wake cycles

Primary characteristic = excessive daytime sleepiness

Narcolepsy

(Cause)

Decreased orexin production in lateral hypothalamus

Strong genetic component

Narcolepsy

(Associations)

Hypnagogic or Hypnopompic hallucinations

Nocturnal and narcoleptic sleep episodes that start off with REM sleep

Cataplexy

(loss of all muscle tone following a strong emotional stimulus like laughter)

Narcolepsy

(Treatment)

Daytim stimulants

(Amphetamines, Modafinil)

Nighttime Sodium Oxybate

(GHB)

Maladaptive pattern of substance use defined as 2 or more of the following signs in 1 year:

1) Tolerance (need more to achieve same effect)

2) Withdrawal

3) Substance taken in larger amounts, or over longer time, than desired

4) Persistent desire or unsuccessful attempts to cut down

5) Significant energy spent obtaining, using, or recovering from substance

6) Important social, occupational, or recreational activities reduced because of substance use

7) Continued use in spits of knowing the problems that it causes

8) Craving

9) Recurrent use in physically dangerous situations

10) Failure to fulfill major obligations at work, school, or home due to use

11) Social or interpersonal conflicts related to substance use

1) Precontemplation

(not yet acknowledging that there is a problem)

2) Contemplation

(acknowledging that there is a problem, but not yet ready or willing to make a change)

3) Preparation/Determination

(getting ready to change behavior)

4) Action/Willpower

(changing behaviors)

5) Maintenance

(maintaining the behavior change)

6) Relapse

(returning to old behaviors and abandoning new changes)

Depressants

(Intoxication)

Nonspecific:

1) Mood elevation

2) Decreased anxiety

3) Behavioral disinhibition

4) Respiratory depression

Alcohol

(Intoxication)

1) Emotional lability

2) Slurred speech

3) Ataxia

4) Coma

5) Blackouts

Serum y-glutamyltransferase (GGT) = sensitive indicator of alcohol use

Lab AST value is twice ALT value

Opioids

(Drugs)

Morphine

Heroin

Methadone

Opioids

(Intoxication)

1) Euphoria

2) Respiratory depression

3) CNS depression

4) Decreased gag reflex

5) Pupillary constriction (pinpoint pupils)

6) Seizures (overdose)

Treatment:

- Naloxone

- Naltrexone

Barbiturates

(Intoxication)

Low safety margin

Marked respiratory depression

Treatment = Symptoms management

(Assist respiration; Increase BP)

Benzodiazepines

(Intoxication)

Greater safety margin

1) Ataxia

2) Minor respiratory depression

Treatment = Supportive care

- Consider Flumazenil

(competitive benzodiazepine antagonist)

Depressants

(Drugs)

Alcohol

 Opioids

Barbiturates

Benzodiazepines

Stimulants

(Intoxication)

Nonspecific:

1) Mood elevation

2) Psychomotor agitation

3) Insomnia

4) Cardiac arrhythmias

5) Tachycardia

6) Anxiety

Stimulants

(Drugs)

Amphetamines

Cocaine

Caffeine

Nicotine

Amphetamines

(Intoxication)

1) Ephoria

2) Grandiosity

3) Pupillary dilation

4) Prolonged wakefulness and attention

5) Hypertension

6) Tachycardia

7) Anorexia

8) Paranoia

9) Fever

Severe = Cardiac Arrest and Seizure

Cocaine

(Intoxication)

1) Impaired judgment

2) Pupillary dilation

3) Hallucinations (including tactile)

4) Paranoid ideations

5) Angina

6) Sudden cardiac death

Treatment = Benzodiazepines

Caffeine

(Intoxication)

1) Restlessness

2) Increased diuresis

3) Muscle twitching

Nicotine

(Intoxication)

Depressants

(Withdrawal)

Nonspecific:

1) Anxiety

2) Tremor

3) Seizures

4) Insomnia

Alcohol

(Withdrawal)

Mild = symptoms similar to other depressants

Severe = Autonomic hyperactivity and DTs

(5-15% mortality rate)

Treatment for DTs = Benzodiazepines

Opioids

(Withdrawal)

1) Sweating

2) Dilated pupils

3) Piloerection ("cold turkey")

4) Fever

5) Rhinorrhea

6) Yawning

7) Nausea

8) Stomach cramps

9) Diarrhea ("flu-like" symptoms)

Treatment:

- Long-term support

- Methadone

- Buprenorphine

Barbiturates

(Withdrawal)

Delirium

Life-threatening cardiovascular collapse

Benzodiazepines

(Withdrawal)

1) Sleep disturbance

2) Depression

3) Rebound anxiety

4) Seizures

(can be triggered by reversal with Flumazenil)

Stimulants

(Withdrawal)

Post-use "crash"

1) Depression

2) Lethargy

3) Weight gain

4) Headache

Amphetamines

(Withdrawal)

1) Anhedonia

2) Increased appetite

3) Hypersomnolence

4) Existential crisis

Cocaine

(Withdrawal)

1) Hypersomnolence

2) Malaise

3) Severe psychological craving

4) Depression/Suicidality

Caffeine

(Withdrawal)

Lack of concentration

Headache

Nicotine

(Withdrawal)

1) Irritability

2) Anxiety

3) Craving

Treatment:

- Nicotine patch, gum, lozenges

- Bupropion/Varenicline

Hallucinogens

(Drugs)

PCP

LSD

Marijuana

(Cannabinoid)

PCP

(Intoxication)

1) Belligerence

2) Impulsiveness

3) Fever

4) Psychomotor agitation

5) Analgesia

6) Vertical and horizontal nystagmus

7) Tachycardia

8) Homicidality

9) Psychosis

10) Delirium

11) Seizures

Treatment:

- Benzodiazepines

- Rapid-acting antipsychotic

LSD

(Intoxication)

1) Perceptual distortion (visual/auditory)

2) Depersonalization

3) Anxiety

4) Paranoia

5) Psychosis

6) Possible flashbacks

Marijuana

(Intoxication)

1) Euphoria

2) Anxiety

3) Paranoid delusions

4) Perception of slowed time

5) Impaired judgment

6) Social withdrawal

7) Increased appetite

8) Dry mouth

9) Conjunctival injection

10) Hallucinations

Prescription form is Dronabinol (tetrahydrocannabinol isomer)

Used as:

- Antiemetic (chemotherpy)

- Appetite stimulant (AIDS

PCP

(Withdrawal)

1) Depression

2) Anxiety

3) Irritability

4) Restlessness

5) Anergia

6) Disturbances of thought and sleep

Marijuana

(Withdrawal)

1) Irritability

2) Depression

3) Insomnia

4) Nausea

5) Anorexia

Most symptoms peak in 48 hours and last for 5-7 days

Generally detectable in urine for 4-10 days

Heroin Addiction

(Risks)

Users at increased risk for:

1) Hepatitis

2) Abscesses

3) Overdose

4) Hemorrhoids

5) AIDS

6) Right-sided endocarditis

Look for track marks (needle sticks in veins)

Heroin Addiction

(Treatments)

Methadone

Naloxone + Buprenorphine

Naltrexone

Long-acting oral opiate

Used for heroin detoxification or long-term maintenance

Partial opiate agonist

Long-acting with fewer withdrawal symptoms than Methadone

Not active when taken orally, so withdrawal symptoms occur only if injected

(lower abuse potential)

Long-acting opioid antagonist

Used for heroind relapse prevention once detoxified

Alcoholism

(Definition)

Alcoholism

(Complications)

1) Alcoholic cirrhosis

2) Hepatitis

3) Pancreatitis

4) Peripheral neuropathy

5) Testicular atrophy

Alcoholism

(Treatment)

1) Disulfiram

(to condition patient to abstain from alcohol use)

2) Naltrexone

3) Supportive care

AA and other peer support groups are helpful in sustaining abstinence

Wernicke-Korsakoff Syndrome

(Cause)

Wernicke-Korsakoff Syndrome

(Symptoms)

Wernicke Encephalopathy (Triad)

1) Confusion

2) Ophthalmoplegia

3) Ataxia

Can progress to Korsakoff Psychosis

1) Irreversible memory loss

2) Confabulation

3) Personality change

Wernicke-Korsakoff Syndrome

(Associations)

Periventricular hemorrhage

Necrosis of mammillary bodies

Wernicke-Korsakoff Syndrome

(Treatment)

Longitudinal partial thickness tear at the gastroesophageal junction caused by excessive vomiting

Often presents with hematemesis

Associated with pain (vs. esophageal varices)

Life-threatening alcohol withdrawal syndrome that peaks 2-5 days after last drinks

Symptoms in order of appearance:

1) Autonomic system hyperactivity

(Tachycardia, tremors, anxiety, seizures)

2) Psychotic symptoms

(Hallucinations, Delusions)

3) Confusion

Treatment = Benzodiazepines

ADHD

(Preferred Drugs)

Alcohol Withdrawal

(Preferred Drugs)

Anxiety

(Preferred Drugs)

SSRIs

SNRIs

Buspirone

Bipolar Disorder

(Preferred Drugs)

"Mood stabilizers"

(Lithium, Valproic acid, Carbamazepine)

Atypical Antipsychotics

Bulimia

(Preferred Drugs)

Depression

(Preferred Drugs)

SSRIs

SNRIs

TCAs

Bupropion

Mirtazapine

(especially with insomnia)

Obsessive-Compulsive Disorder

(Preferred Drugs)

SSRIs

Clomipramine

Panic Disorder

(Preferred Drugs)

SSRIs

Venlafaxine

Benzodiazepines

PTSD

(Preferred Drugs)

Schizophrenia

(Preferred Drugs)

Social Phobias

(Preferred Drugs)

SSRIs

B-blockers

Tourette Syndrome

(Preferred Drugs)

Antipsychotics

(Haloperidol, Risperidone)

CNS Stimulants

(Drugs)

Methylphenidate

Dextroamphetamine

Methamphetamine

Phentermine

CNS Stimulants

(Mechanism)

Increased catecholamines at the synaptic cleft

(especially NE and Dopamine)

CNS Stimulants

(Clinical Use)

ADHD

Narcolepsy

Appetite control

Antipsychotics [Neuroleptics]

(Drugs)

Haloperidol

Trifluoperazine

Fluphenazine

Thioridazine

Chlorpromazine

(Haloperidol + "-azines")

Antipsychotics [Neuroleptics]

(Mechanism)

Antipsychotics [Neuroleptics]

(Clinical Use)

Schizophrenia

(primarily positive symptoms)

Psychosis

Acute mania

Tourette syndrome

Antipsychotics [Neuroleptics]

(Toxicity)

Highly lipid soluble > stored in body fat > slow to be removed from body

EPS Evolution:

1) 4 hours = Acute Dystonia (muscle spasm, stiffness, oculogyric crisis)

2) 4 days = Akathisia (restlessness)

3) 4 weeks = Bradykinesia (parkinsonism)

4) 4 months = Tardive Dyskinesia

EPS Treatment = Benztropine or Diphenhydramine

Endocrine side effects

(Dopamine receptor antagonism > hyperprolactinemia > galactorrhea)

Side effects from blocking receptors:

- Muscarinic (Dry mouth; Constipation)

- a1 (Hypotension)

- Histamine (Sedation)

Chlorpromazine = Corneal deposits

Thioridazine = reTinal deposits

Antipsychotics [Neuroleptics]

(Haloperidol Toxicities)

Neuroleptic Malignant Syndrome (NMS)

- Rigidity

- Myoglobinuria

- Autonomic instability

- Hyperpyrexia

Think FEVER

(Fever, Encephalopathy, Vitals unstable, Enzymes increased, Rigidity of muscles)

Treatment = Dantrolene; D2 agonists (Bromocriptine)

Tardive Dyskinesia

- Stereotypical oral-facial movements as a result of long-term antipsychotic use

Potentially irreversible

Antipsychotics [Neuroleptics]

(High Potency)

Try to Fly High:

- Trifluoperazine

- Fluphenazine

- Haloperidol

Neurologic side effects (EPS symptoms)

Antipsychotics [Neuroleptics]

(Low Potency)

Cheating Thieves are low:

- Chlorpromazine

- Thioridazine

Non-neurologic side effects

(anticholinergic, antihistamine, and a1-blockade effects)

Atypical Antipsychotics

(Drugs)

It's atypical for old closets to quietly risper from A to Z

- Olanzapine

- Clozapine

- Quetiapine

- Risperidone

- Aripiprazole

- Ziprasidone

Atypical Antipsychotics

(Mechanism)

Not completely understood.

Varied effects on 5-HT2, Dopamine, a1, and H1-receptors

Atypical Antipsychotics

(Clinical Use)

Schizophrenia

(positive and negative symptoms)

Bipolar Disorder

OCD

Anxiety disorder

Depression

Mania

Tourette syndrome

Atypical Antipsychotics

(Toxicity)

Few EPS and anticholinergic effects that traditional antipsychotics

Olanzapine and Clozapine = significant weight gain

Clozapine:

- Agranulocytosis

(requires weekly WBC monitoring)

- Seizure

Risperidone = increased Prolactin (lactation; gynecomastia) > decraesed GnRH, LH, and FSH (irregular menstruation; fertility issues)

Ziprasidone = prolonged QT

Lithium

(Mechanism)

Lithium

(Clinical Use)

Mood stabilizer for Bipolar Disorder

(blocks relapse and acute manic events)

SIADH

Lithium

(Toxicity)

1) Tremor

2) Sedation

3) Edema

4) Heart block

5) Hypothyroidism

6) Polyuria (ADH antagonist > Nephrogenic Diabetes Insipidus)

Fetal cardiac defects include:

- Ebstein anomaly

- Malformation of the great vessels

LMNOP

Lithium side effects = Movement (tremor); Nephrogenic diabetes insipidus; hypOthyroidism; Pregnancy problems

Narrow therapeutic window > close monitoring of serum levels

Almost exclusively excreted by kidneys

(most reabsorbed at PCT following Na+ reabsorption)

Buspirone

(Mechanism)

Buspirone

(Clinical Use)

Generalized Anxiety Disorder

(I'm always anxious if the bus will be on time, so I take buspirone)

Does not cause sedation, addiction, or tolerance

Takes 1-2 weeks to take effect

Does not interact with alcohol (vs. Barbiturates, Benzodiazepines)

SSRIs

(Drugs)

Flashbacks paralyze senior citizens

- Fluoxetine

- Paroxetine

- Sertraline

- Citalopram

SSRIs

(Mechanism)

SSRIs

(Clinical Use)

- Depression

- GAD

- Panic Disorder

- OCD

- Bulimia

- Social Phobias

- PTSD

Normally takes 4-8 weeks for antidepressants to have an effect

SSRIs

(Toxicity)

Fewer than TCAs

- GI distress

- Sexual dysfunction (anorgasmia and decreased libido)

- Serotonin Syndrome with any drug that increases 5-HT (MAO inhibitors, SNRIs, TCAs)

1) Hyperthermia

2) Confusion

3) Myoclonus

4) Cardiovascular collapse

5) Flushing

6) Diarrhea

7) Seizures

Treatment = Cyproheptadine (5-HT2 receptor antagonist)

SNRIs

(Drugs)

Venlafaxine

Duloxetine

SNRIs

(Mechanism)

SNRIs

(Clinical Use)

Depression

Venlafaxine = GAD and Panic Disorders

Duloxetine = Diabetic Peripheral Neuropathy

SNRIs

(Toxicity)

Increased BP most common

Also stimulant effects, sedation, nausea

TCAs

(Drugs)

Amitriptyline

Nortriptyline

Imipramine

Desipramine

Clomipramine

Doxepin

Amoxapine

(all TCAs end in "-iptyline" or "-ipramine" except Doxepine and Amoxapine)

TCAs

(Mechanism)

TCAs

(Clinical Use)

Major Depression

OCD

(Clomipramine)

Fibromyalgia

TCAs

(Toxicity)

Tri-C's:

Convulsions; Coma; Cardiotoxicity (arrhythmias; Treatment = NaHCHO3)

- Sedation

- Respiratory depression

- Hyperpyrexia

A1-blocking effects

(Postural hypotension; Confusion; Hallucinations)

Atropine-like/Anticholinergic effects

(Tachycardia; Urinary retention; Dry mouth)

Tertiary TCAs (Amitriptyline) have more anticholinergic effects than Secondary TCAs (Nortriptyline)

[Use Nortriptyline in elderly]

Desipramine = less sedating, but higher seizure incidence

Monoamine Oxidase (MAO) Inhibitors

(Drugs)

MAO TIPS Big

- Tranylcypromine

- Isocarboxazid

- Phenelzine

- Selegiline (selective MAO-B inhibitor)

Monoamine Oxidase (MAO) Inhibitors

(Mechanism)

Nonselective MAO inhibition increases levels of amine neurotransmitters

(NE, 5-HT, Dopamine)

Monoamine Oxidase (MAO) Inhibitors

(Clinical Use)

Atypical Depression

Anxiety

Hypochondriasis

Monoamine Oxidase (MAO) Inhibitors

(Toxicity)

Hypertensive Crisis

(most notably with ingestion of Tyramine, which is found in many foods such as wine and cheese)

- CNS stimulation

Contrindicated with following to prevent Serotonin Syndrome:

- SSRIs

- TCAs

- St. John's wort

- Meperidine

- Dextromethorphan

Trazodone

Bupropion

Mirtazapine

Atypical Antidepressant; also used for smoking cessation

Mechanism = Increases NE and Dopamine via unknown mechanism

Toxicity:

- Stimulant effects (Tachycardia; Insomnia)

- Headache

- Seizure in bulimic patients

No sexual side effects

Atypical Antidepressant

Mechanism:

- a2-antagonist > increased release of NE and 5-HT

- Potent 5-HT2 and 5-HT3 receptor antagonist

Toxicity:

- Sedation (desirable in depressed patients with insomnia)

- Increased appetite/weight gain (desirable in elderly or anorexic patients)

- Dry mouth