Psych: stuff looked up / learned General Psych Axes (DSM) • •
• • •
Axis I: Clinical syndromes Axis II: Developmental (MR, etc) / Personality disorders (cluster A/B/C) o Cluster A (the "weird"): paranoid, schizoid/schizotypal o Cluster B (the "wild"): antisocial, borderline, histrionic, narcissitic o Cluster C (the "worried"): avoidant, dependent, OCD Axis III: Physical conditions (HIV, AIDs, brain injury, other med conditions that could be contributing) Axis IV: Psychosocial stressors Axis V: Highest level of functioning in last year and level now (how is life affected)
Personality disorders Cluster A Schizoid: Loner, flat affect, restricted emotions, indifferent to interpersonal relationships, no psychotic symptoms, not good with personal interaction, computer nerd. Use a low-key, technical approach when discussing care. Schizotypal: odd, eccentric, magical thinking, paranoid, not psychotic. Projection, regression, fantasy are defenses. Stay nonjudgmental as therapist Paranoid: distrustful / suspicious; constricted affect. Projection is defense. Try to form working alliance with patient. No true delusions / hallucinations
Cluster B Histrionic: excessively emotional, attention-seeking, theatrical, overblown speech, seductive manner. Reaction formation is defense Narcissistic: self-important, needs admiration, dismisses others' feelings, secretly low selfesteem. If they seek treatment, it's probably because they're angry that they're not getting the credit that they deserve, etc. Antisocial: no empathy, acting out, aggressive, conduct disorder as child, usually starts up by age 15, need to be 18 y/o for dx • •
Conduct disorder: 3 sx in last 12 mo, 1 in last 6 mo of: aggression toward people / animals, destruction of property, theft / deceitfulness, rule breaking (can have more than 1 in a category), need to be younger than age 18 generally Can develop somatization disorders
Borderline: impulsive, unstable relationships, affective instability, can be transiently psychotic. Splitting, projection are defenses. Dialectical behavioral therapy is specialized cognitive therapy for BPD
Cluster C OCPD: perfectionistic control freak, really into order, no obsessions or compulsions, may be really into work. Reaction formation is defense Avoidant: hypersensitive to criticism / rejection, socially uncomfortable, seeks interpersonal relationships but uncomfortable doing so, maybe a very few close friends Dependent: submissive, clingy, needs to be taken care of, wants others to make decisions Ego Defenses • • • • • • • • • • • • • •
•
Projection: pt attributes their thoughts to another (angry with therapist? accuse therapist of being angry at you!) Reaction formation: deal with emotional conflict by substituting the opposite (e.g. angry at husband? cook him a nice dinner!) Somatization: express your problems as physical complaints (form of regression - e.g. get headache when you're upset with therapist) Idealization: attribute exaggerated positive qualities to others to deal with conflict Devaluation: opposite of idealization; exaggerated negative qualities Isolation of affect: separate ideas from feelings (lose touch with feelings about an event but retain descriptive details) Rationalization: deal with emotional conflict / stressors by concealing true motivations Undoing: use words or behavior to negate / symbolically make amends for unacceptable thoughts / feelings / actions (realistically or magically associated with conflict - e.g. don't step on cracks to avoid "breaking mother's back") Acting out: use actions rather than reflections / feelings to guard against stressors / conflicts (e.g. angry? start a fight at a bar!) Dissociation: deal with conflict / stressors by breakdown of normal consciousness splitting off (e.g. feel like events are being told to someone else after son killed in car crash) Repression: disturbing stuff gets pulled into unconscious (can't remember what troubling things were said, etc) Suppression: don't deal with feelings / ideas, but still in conscious awareness (actively trying to forget) Denial: don't acknowledge conflict / stressors - arguing that they don't exist instead of dealing with them Displacement: take out impulses on less threatening target (e.g. dad was alcoholic, dtr now has conflict with boyfriends) Sublimation: acting out impulses in socially acceptable way (e.g. aggressive? be a boxer!)
Mood Disorders
Depression "SIG E CAPS" - Depression features
• • •
Sleep Interest (decreased) Guilt
•
Energy
• • • •
Concentration Appetite Psychomotor retardation Suicidal ideation
Suicide: "SAD PERSONS" (most at risk) • • •
Sex (male) Age less than 19 or greater than 45 years Depression (patient admits to depression or decreased concentration, sleep, appetite and/or libido)
• • • • • • •
Previous suicide attempt or psychiatric care Excessive alcohol or drug use Rational thinking loss: psychosis, organic brain syndrome Separated, divorced, or widowed Organized plan or serious attempt No social support Sickness, chronic disease
Bipolar Disorder Mania: "DIG FAST" • • •
Distractibility Indiscretion (DSM-IV's "excessive involvement in pleasurable activities . . . ") Grandiosity
• • • •
Flight of ideas Activity increase Sleep deficit (decreased need for sleep) Talkativeness (pressured speech)
AD / Dementia / etc
•
Dementia: multiple cognitive deficits with memory (often short-term lost 1st) and one of aphasia / apraxia / agnosia / exec fxn with functional impairment o Without the other cognitive deficits, it's just amnesia
AD • • •
APOE4: associated with increased (2x?) risk of late-onset AD (>60 y/o) APP (chr 21), presenilin 1-2: aut-dom forms, early onset AD cortical atrophy, enlarged ventricles
Pick disease: frontotemporal, pick bodies, preferential frontotemporal atrophy Vascular dementia: deep white-matter lacunar infarcts
Procedures ECT: • • •
Unilateral = less confusion / delirium afterwards; Bilateral = more powerful for sx but more confusion / delirium R. sided unilateral helps preserve language functioning afterwards Hold meds beforehand: anticonvulsants (mechanistic) and anything that can contribute to delirium
Meds Old patients may need lower doses but similar blood levels for antidepressants (less metabolism)
In hepatic disease, use benzos metabolized outside the liver (oxazepam, temazepam, lorazepam) actually metabolized by the liver via glucuronidation, which isn't dependent on "liver function" (takes a lot of liver fxn loss to lose glucuronidation capacity)
Sedation & the Agitated Patient
• •
Physical restraints are bad: increased rate of sentinel events (death / harm / etc) Chemical restraints: think B-52 o Benadryl 50 mg o 5 mg Haldol o 2 mg Ativan (lorazepam)
Bromocriptine = dopaminergic agonist. Can be used +/- dantrolene (muscle relaxant) in treatment of NMS
Thioridazine (low potency typical antipsychotic) can cause retinitis pigmentosa (loss of night vision)
Beta blockers (like Propranolol) can be used to treat akathisia, performance anxiety •
Bradycardia, hypotension, asthma exacerbation can be side-effects
Buspirone (Buspar): selective serotonin type 1A receptor agonist. As effective as diazepam in treating anxiety.
Anticholinergics (benztropine, trihexylphenidyl) used as 1st line in neuroleptic-induced parkinsonism, acute dystonia. • •
Diphenhydramine (antihistamine with anticholinergic properties) - as above + nonspecific sedation These are CNS muscarinic antagonists; side effects (peripheral anticholinergic action) blurry vision (cycloplegia), constipation, urinary retention, (central action) - sedation, delirium
Flumazenil is a benzo antagonist used in emergent benzo OD; can precipitate severe withdrawal (dangerous)
Stimulants for ADHD: watch out for decreased appetite (incl. slowed growth), insomnia at first, irritability, dysphoria, headache, tics sometimes; rapid action •
Atomoxetine is a selective NE reuptake inhibitor, used in ADHD, especially if substance abuse in family (not abusable) or tics (doesn't worsen tics) or comorbid anxiety disorders
•
Pemoline has stimulant action too, but has rare heptatotoxicity (get baseline ALT, q2wks)
Acetylcholinesterase inhibitors = donepezil, galantimine, rivistigmine, tacrine; all reversible inhibitors. • GI upset, cholinomimetic effects (bradycardia, increased gastric acid secretion) can result. • Memantine used in AD too, NMDA antagonist (less neurotoxicity) Use high potency antipsychotics in demented individuals to decrease agitation (low-potency have more anticholinergic / orthostatic side effects) Benzos Short half-life (2-10 h)
Intermediate half-life (1015h)
Long half-life (≈ 1d+) chlordiazepoxide (Librium)
temazepam* (Restoril) diazepam (Valium) triazolam (Halicon)
lorazepam* (Ativan)
oxazepam* (Serax)
alprazolam (Xanax)
clorazepale (Tranxene) flurazepam (Dalmane) halazepam (Panipam) prazepam (Centrax) Side Effects of neuroleptics • • • • •
Dystonic rxn: hours - days, treat with anticholinergics / antihistamines Parkinsonism: days - wks Akathisia: days - wks Tardive dyskinesia: years NMS: anytime
Amphetamines: generally used for ADHD, narcolepsy, depressive disorders • •
Dexedrine (dextroamphetamine), Desoxyn (methamphetamine), Ritalin (methylphenidate) affect dopaminergic system Designer amphetamines (ecstasy, etc) have serotonergic effects too
Basic Science & Anatomy Hypothalamic nuclei • • • • •
Lateral = drive to eat Venteromedial = satiety center (damaged in Prader-Willi) Anterior = sex Posterior = levels of arousal (lesion = lethargy, somnolence) Paraventricular, supraoptic = vasopressin, oxytocin
Kluver-Bucy syndrome: bilateral amygdala damage (absence of fear, hyperorality, hypersexuality, etc)
Neurotransmitters & stuff
Nuclei • • • •
Nucleus basalis - cognitive functions, memory; degenerates in Alz Dz Substantia nigra (dopamine) - degenerates in PD Raphe nuclei: serotonin, mood/pain/agression Locus ceruleus: major noradrenergic nucleus; arousal / attention / autonomic tone, connects to amygdala (threats)
Neurotransmitters:
• • • •
Serotonin: depression, OCD Dopamine: psychosis, EPS Acetylcholine: cognitive fxn, memory Norepi: anxiety disorders
Sleep:
• • • • •
Polysomnography: EEG, EOG, EMG. Stage 1: theta waves, relaxed muscle tone, "nodding off" Stage 2: K complexes, sleep spindles; no eye movements, nodding-off Delta-sleep: Low frequency, high voltage EEG waves; stages 3-4 here REM: low, fast EEG voltage; no muscle tone (cataplexy), very rapid eye movements
Sleep disorders: • •
Dyssomnia: too much / too little sleep (OSA, narcolepsy, poor hygeine) Parasomnias: during sleep or on arousal (sleep terrors, sleep walking, rhythmic movement disorder, etc)
Diagnostic tests • •
• •
MMPI: personality test (minnesota multiphasic) Projective tests: ambiguity o Rorshach: ink blots o Thematic apperception tests (TAT) - motivation (make a story about a picture) o Sentence completion (My greatest fear is...) Intelligence tests: WAIS (Weschelr Adult Intelligence Scale) is most common Neuropsych tests o Wisconsin card sorting: abstract reasoning, flexibility (sort cards) - abnl in frontal lobe dysfxn o Weschelr memory (various memory tests)
o
Visuomotor (Bender visual-motor gestalt)
Other medical conditions & psychiatry • • •
• •
•
Pancreatic cancer linked to depressive symptoms classically Psychosis in deliria, dementias, severe hypothyroid, hyperCa, syphilis, substance abuse (esp PCP) Anxiety in Graves, PE, hyperthyroid, Sjogren, some seizures o Sjogren: WBC attack moisture-producing glands. dry eyes + dry mouth + other organs. 4M in USA/yr. o Graves: up to 60% meet GAD criteria o Pheochromocytoma: can mimic panic attacks o Awaiting heart transplant: more noradrenergic tone; high incidence of panic disorder o Hypoglycemia can look like anxiety too Mania-like states: corticosteroids, levodopa, cocaine. PANDAS: Pediatric autommune neuropsych disorders a/w strep infections; includes OCDtype behavior o Get antistrep Ab titer (antistreptolysin O - ASO - titer rises 3-6 wks after infection, antistrep DNAase B - antiDNse-B - titer rises 6-8 wks later) o Use SSRI + CBT for compulsive behaviors. ?Abx use to prevent recurrence? Cardiac surgery is a big risk for delirium (90% of pts), also old age (60% nursing home residents), hosp (10-30%)
DSM Junk, etc. MDD: Most of the time for at least 2 wks, 5+ symptoms, 2+ episodes for recurrent • • •
50-80% recurrence, 15% suicide rate, usually 6-12mo episodes Vs normal bereavement: usually < 2mo after loss, diminishing with time, can even have hallucinations of deceased person (children / adolescents) but reassuring / comforting vs accusatory PMD hallucinations Psychotic MD: taper antipsychotic when psychotic sx resolve, at least 6-9 mo or more of antidepressant
Adjustment disorder: emotional response (mood sx) within 3 months of stressor, don't last longer than 6 mo after stressor resolved • •
can be anxiety, depressed mood, conduct disturbance, mixes. Often somatic complaints in kids / irritability in kids & adolescents Treat with psychotherapy (group if possible, individual, generally not meds except actue sleep help)
Postpartum blues: several days - a week, less severe than depression, present in 50-80% pts, resolves in < 14d, no treatment Postpartum depression: 65% of all women experience first MDD in 1st year after delivery.
•
Treat with SSRI, Can give antidepressant prophylaxis for next pregnancy (prior episode is #1 risk factor for postpart depression)
Postpartum psychosis: confusion, extreme mood lability, 1-2/1000 deliveries, medical emergency (hosp mom _ baby) •
SSRI (generally safe) + antipsychotic, also consider ECT; TCAs not good
Dysthymic disorder: depressed for most of day, more days than not for at least 2 yrs (1 yr for children /adolescents), not more than 2 mo without symptoms, no MDD Cyclothymia: between dysthymia & hypomania over 2 yrs Bipolar disorder, manic episode: need at least 1 wk of manic symptoms or hospitalization • • • •
70% MZ vs 20% DZ Often psychotic features if manic in children. DDx vs ADHD + ODD or CDD BP-I: full mania, BP-II: hypomania (don't meet full criteria; briefer; milder; 4d+) Rapid-cycling: 4+ episodes in 12 mo
Schizophrenia: 2+ symptoms for 1 mo or one if bizarre delusions / commenting auditory hallucinations / conversing voices, at least 6 mo with some sx (incl. negative symptoms) • • •
1% lifetime prevalence, M=F, 20-40% attempt suicide, 10% complete, M present 18-25 yo, F present 25-35 yo; women have better outcome Thought-blocking: having one's train of thought curtailed absolutely, unpleasant Ideas of reference: false beliefs that people talking about pt (often. via TV, radio, etc)
Schizoaffective disorder: psychotic symptoms like acute schiz, also must be around for 2 wks without mood symptoms as well as with mood symptoms. •
Treat with antipsychotics, often long-term (usually atypicals). Can use mood stabilizers if manic manifestations.
Schizophreniform disorder: schizophrenia that doesn't last for 6 months and no social withdrawal. Resolves or progresses to bipolar / schizophrenia Delusional disorder: non-bizarre delusions, otherwise normal, at least 1 month, often mid-life, F>M Brief psychotic disorder: often after stress or postpartum, 1 day to 1 month Panic disorder: panic attacks (4+ panic symptoms, out of the blue, episodic), recurrent, 1 mo of behavior change / worry as result. •
Treat with SSRIs / TCAs / MAOi + CBT; benzos short term only
GAD: more chronic anxiety, not attacks. A least 6 mo of symptoms for majority of the day. Also irritable, fatigued, sleep disturbed. Need 3 sx. F>M •
Treat with SSRIs/venlefaxine + CBT. Also buspirone, avoid benzos long-term.
Phobias are #1 common mental disorder in USA (5-10% population), specific > social, women > men, late childhood / early adulthood, chronic. •
Desensitization or exposure, SSRIs / benzos / venlafaxine / busipirone. Beta-blockers just before (propanolol, atenolol)
Separation anxiety (a childhood disorder) • • • •
Hard to treat; often develop depression / psychotic disorders. 18-50% develop panic disorder. Use SSRIs for mood / anxiety + relaxation + graded separation. Earlier treatment better. Don't homeschool (reinforces) At least 4 wks, onset before age 18, inappropriate anxiety about separating from home / care taker Can have somatic sx, especially in kids.
OCD: • •
2-3% lifetime; 10% o/p psych visits, 20-30% have tic history (5% Tourette's). Treat with behavioral therapy (Exposure-response prevention) and SSRIs (clomipramine 2nd line, TCA mostly acting on serotonin, but side effects)
ADHD - needs to be present in more than one setting and start before 7 yrs old, 6+ sx • • • •
Inattentive, hyperactive, and combined types Use simulants, atomoxetine (NE reuptake inhibitor, less tics associated), also buproprion, imipramine / nortriptyline / pemoline Comorbid ODD / CD is common; meds can only help if child wants to do the right thing! 70-80% respond to stimulants. Tourette Disorder: both motor & vocal tics (don't have to be at same time), for at least 1 yr without 3 months free of tics, age < 18, causes disturbance
• • • o o o
Coprolalia = potty mouth 4/5/10,000, more common in boys. Usually motor by age 7, vocal by age 11. Runs with OCD / ADHD Treat with alpha-adrenergic medicine (clonidine, guanfacine). If it doesn't work, try atypical antipsychotic (esp risperidone) Clonidine: alpha-2 agoniost, decrease NE by acting on locus ceruleus Guanfacine: activates postsynaptic prefrontal alpha-adrenergic receptors Both also used in ADHD to reduce sx - good for comorbid condition PTSD: acute if < 3mo, chronic if > 3 mo. Acute often resolve on their own; if it lasts longer than 3 mo, probably needs intervention. • •
Treat with SSRI (esp. sertraline, paroxetine) + psychotherapy (CBT), social interventions. Can use alpha-2 agonists (clonidine, prazosin) for symptoms. Benzos not helpful & risk for substance abuse.
Acute Stress Disorder (shortly after event; in first four weeks, lasting for at least 2 days) often resolves on its own
• • •
Have dissociative symptoms (3 of numbness / detatchment / lack of emotion, decreased awareness of surroundings, derealization, dissociative amnesia) with avoidance Major treatment is mobilizing social support Beta-blockers can help sx, may help prevent progression to PTSD; can use short-term hypnotic for insomnia
Somatiform disorders - take concerns seriously; regularly scheduled (not PRN) visits, no inappropriate tests. • •
•
•
Hypochondriasis: all about the disease Pain disorder: 1+ sites, primary complaint, psychological factors play role (initiate / worsen pain), at least 6 months, may be triggered past trauma o Validate pt experience, explain psych factors in pain, consider antidepressants (TCAs / SSRIs) + biofeedback, pain is chronic so focus on gradual improvement of function o Analgesics usually don't help, really avoid narcotics Somatization disorder: 4+ pain sx at different sites, 2 GI sx, one sex / repro problem, one pseudoneurologic; all over course of illness, no explanation o Needs to begin before age 30, last for several years, & cause impairment Conversion disorder: 1+ sensory / motor deficits suggesting neuro / medical illness; preceded by conflict / stress, not just pain / sex dysfxn, not part of somatiform disorder. o La belle indifference: pt unconcerned about his symptoms o Can recur; reassure that it will resolve on its own with time, pt not faking - tell pt "body responds in unusual ways" to stress sometimes
Non-somatoform disorders (consciously doing stuff to self). •
•
Factitious disorder: intentionally producing sx to assume sick role. Often borderline. Try to develop therapeutic alliance o Munchhausen is factitious disorder with repeated episodes, etc.; by proxy = induced in children by parents Malingering: intentionally producing sx for secondary gain
Bulimia Nervosa: 1% prevalence; brief purging in 5-10% young women, usually later onset than AN, even adulthood • • •
Danger: parotid glands / mouth / caries / esophageal / GI injury, dehydration from laxatives, ipecac can cause hypotension, tachycardia, arrhythmias. Check lytes (hypoCl / hypoK acidosis from emesis), amylase, mag. Treat with nutritional rehab, CBT + group + family therapy, antidepressant (usually SSRI). Mortality rate is up to 3%. Lots of relapses
Anorexia nervosa: high achievers (BN too), have to be underweight (85% ideal body wt) and amenorrheic • • •
Lanugo: fine body hair on prepubertal kids, pts with anorexia Big contribution of society, family functioning Albumin level canhelp follow nutritional status. Blood chem, ECG changes need to be monitored.
Sleep Terrors: • • •
Emotional / behavioral disorders, usually early in nightly sleep during arousal from delta (slow-wave) sleep, no memory Often in kids (3% vs 1% adults), can be increased by fever, sleep deprivation, CNS depressants; generally self-limiting (use reassurance) Often co-occur with restless leg syndrome and sleep-disordered breathing
Somnambulism: also during arousal from delta sleep (more common in kids, who have more delta sleep, & first half of night) •
Protect the kid from dangerous behaviors
Enuresis - tell the parents to be supportive, don't punish child, can use bell and pad to retrain (alarm) - but only if after age 7, occasionally desmopressin or imipramine (need ECG monitoring) • •
Primary: never a dry period Secondary: usually UTI or psychological stressor (regression with new sib)
Insomnia • •
Primary: at least 1 month, causing distress. Bad sleep hygiene, so fix it. Stimulus control (beds only for sleeping & sex, get up if can't fall asleep), relaxation therapy, take a hot bath before bed. CBT can help; reassure anxiety Ramelteon: meletonin receptor agonist, also benzos (don't use for > 2 wks), trazadone
Autism: Poor social reciprocity (verbal & non-verbal), sterotyped behaviors (purposeless, repetitive - spin toys, hand flapping) • • • • • •
Need sx < 3 y/o; often dx'd when kids put in social situations like school. 40% have MR; some can have precocity. A/w tuberous sclerosis, fragile x. Language development is best predictor of outcome. Multisystemic treatment: family education, behavior shaping, speech therapy, OT, educational training Focus on getting basic skills early so child can interact in school, etc.
Aspeberger: social impairment, restricted interests / stereotyped behavior but normal language & cognition Rett: developmental disorder: girls, normal early, then progressive encephalopathy, loss of speech, gait problems, stereotyped movements, microcephaly, poor social interaction
Dissociative disorders: generally precipitated by trauma, DDx vs dementia in older pts (more common, some past memory spared in dementia!)
Dissociative Fugue: usually brief (hours - days), can last for months, can be post-trauma / conflict, usually rapid spontaneous recovery with no recurrence. Not aware of identity; may create a new one. Dissociative Amnesia: can't recall specific information (usually about identity) but intact memory about general information; usually caused by trauma / stressful memory. no travel, no new identity created. Hx of head trauma can predispose. Dissociative identity disorder: "multiple personalities" to help deal with trauma, controversial, 2+ identities recurrently taking control Gender Identity Disorder: persistent cross-gender identification; usually have to live as opposite gender 3 mo before hormones, 1 yr before surgery Intersex Stuff •
Androgen Insensitivity Syndrome: intersex; chromosomally male but no androgen response (develop external female genitalia)
Sexual dysfunction • •
Erectile: normal nocturnal erections means ED is probably psychogenic; can also be medical (CRF, DM, malnutrition, cirrhosis, atherosclerosis, etc) and iatrogenic (antidepressants - classically SSRIs, mood stabilizers, antipsychotics) Vaginismus: involuntary muscle constriction of outer third of vagina, interferes with sexual intercourse, causes distress
Mental Retardation • • • • • •
About 1% prevalence; see table below for degrees. Self-destructive behavior can be response to painful med problems if child can't communicate Down syndrome is #1 cause of moderate to severe MR in USA (facial features, hypothonia, language + motor developmental delay, trisomy 21) Fragile X: #2 common cause of mental retardation, #1 cause of heritable MR, Xq27.3 mutation, males are moderate to severe MR, females less so PKU is another cause, can't break down phenylalanine; dietary restriction is treatment Fetal alcohol exposure too 30-40% are unknown etiology
Severity
IQ
Characteristics
Function
50Usually not detected until Mild (85% 55 to school; complete high ) 70 elementary school level
Can often live/work independently w/ social support
30Moderate 40 to Socially isolated in (10%) 50elementary school 55
Can be competent at occupational tasks in supportive setting, need high level of supervision
20Severe (3 25 to Minimal speech, poor -4%) 35motor development 40
Not independent; can do some selfcare, need extensive supervision
Profound below Absent to minimal speech, Need constant nursing care
(1-2%)
2025
poor to absent motor skills throughout life
Learning Disorders: Specific deficits in math, reading, or written expression • •
Reading most common; all twice as prevalent in boys Treat by addressing specific deficit
Substances •
Dependence (substance): need 3+ of tolerance, withdrawal sx, increased use, attempts / failure to cut down, lots of time spent getting it, less time spent doing other stuff, still using despite knowing damage Substance-induced mood disorders: If they don't resolve on their own, treat 'em like they're not substance-induced (e.g. antipsychotics, mood stabilizers, antidepressants) According to DSM, no cannibis-induced mood disorders
PCP intoxication • • • •
Phencyclidine, angel dust, horse tranq, happy leaf. piperidine like ketamine; originally anesthetic (NMDA receptor blocker), long-acting (6h short-term effects, full effect can last several days, variable behavioral changes, unpredictible), often with MJ Dysarthria, nystagmus (vertical), belligerent, hyperacusis, ataxia, muscle rigidity, can cause sz / coma, numbness, HTN / tachy Treatment: treat HTN, can acidify urine to increase excretion, hospitalize in a quiet dark room Avoid restraints (more muscle breakdown), gastric lavage (emesis / aspiration), typical antipsychotics (anticholinergic side effects make it worse). Benzos can delay excretion, so avoid those too.
Alcohol dependence: • • •
•
3-5% women, 10% men lifetime; a/w 50% homicides, 25% suicides Lab tests: elevated liver transaminases (particularly gamma-glutamyl transferase, GGT) and macrocytic anemia Wernicke: acute, reversible encephalopathy from thiamine deficiency after chronic ETOH use: delirium, opthalmoplegia (typically CN6), ataxia o give thiamine before glucose Korsakoff: usually irreversible amnesia, anterograde + retrograde with confabulation, after chronic alcohol use (thiamine deficiency)
Alcohol withdrawal: • • •
Typical stages: tremulousness / jitteriness (6-8h), psychosis / perceptual sx (8-12h), seizures (12-24h), DTs (24-72h, up to 1 wk) DTs: disorientation, tremors, elevated vital signs, fluctuating consciousness post-stoppage, can be fatal! DDx vs thyrotoxicosis, pheochromocytoma, inappropriate use of beta-agonist inhalers / sympathomimetics.
•
Use long-acting benzos (chlordiazepoxide, diazepam). Oxazepam, lorazepam are good if liver function may be compromised
Cocaine intoxication: • •
Behavioral: euphoria, bluted feelings, hypervigilance, hypersensitivity, anxiety, poor judgment, anorexia Physical: dilated pupils, autonomic instability, chills/sweating, n/v, PMA/R, chest pain / arrhythmias, confusion / sz / stupor / coma, wt loss
Cocaine withdrawal: can last 2-4 days or longer, "crash" (dysphoria, irritibility, anxiety, hypersomnia, depressive sx incl SI). •
Intox - withdrawal during lifetime of addiction can mimic bipolar disorder in the history!
Amphetamine intoxication: causes adrenergic hyperactivity (tachy, pupils dilated, hypertensive, perspiring, chills, nausea / vomiting, anorexia / wt loss, mm weakness, can have hallucinations, resp depression chest pain, arrhythmias, confusion, sz, dyskinesia, dystonia, coma can result) •
Meth gives you bad dental problems (meth mouth) + paranoia, hallucination / tics / aggression
Amphetamine withdrawal: the "crash" (anxiety, tremors, lethargy, fatigue, nightmares, headache, extreme hunger)
Opioid intoxication: apathy, PMR, constricted pupils, drowsiness Opioid withdrawal: nausea / vomiting, muscle aches, fluids from all orifices, autonomic hyperactivity, fever, dilated pupils, depressed / anxious mood, rarely life-threatening • • •
Generally, longer-acting substances give less withdrawal Ibuprofen can help muscle aches Can use clonidine for autonomic hyperactivity in acute-phase + methadone (long-acting opiate)
Psychological theories • • • •
Freud: ego psychology: id (drives / instincts), superego (right / wrong, from societal / parental morality), ego (resolves conflict / adapt to anxiety) Drive psychiatry: oral / anal / phallic / latency / genital stages of development Object relations: relationship to objects / people are more important than drives Erikson: life cycle stages. Each part of life is conflict; progress / development throughout o Trust vs mistrust (0-18mo, child depending on caretakers), autonomy vs shame (18 mo - 3 yrs; bowel / bladder function, walking), initiative vs guilt (3-5 yrs, more language / walking / explore the world), industry vs inferiority (5-13 yrs, sense of self starts developing based on things created), identity vs role confusion (13-21 yrs, adolescence, appearance to others important), intimacy vs isolation (21-40 yrs, vulnerability of intimacy vs loneliness), generativity vs stagnation (keep producing as member of society or not?), ego integrity vs despair (60 - death, accepting life course or regretting)
•
•
Cognitive distortions (cognitive therapy) o Arbitrary inference: don't have enough evidence o Dichotomous thinking: all or none o Overgeneralization: it was just one event! o Magnification / minimization: just what it sounds like Behavior theory o Modeling: learn based on observing others, imitating actions / responses o Classical conditioning: pair neutral stimulus, natural stimulus, response becomes a/w neutral stimulus o Operant conditioning: environmental events (contingencies) influence acquisition of new behaviors, extinction of existing behaviors Positive = give stimulus, negative = take stimulus away. Reinforce = make repeat behavior, punish = make stop behavior So "negative punishment" means you take a stimulus away to make someone stop a behavior, for instance
Legal Issues • • • • •
Malpractice: need negligence (broke standard of care), duty (had responsibility to pt), direct causation (negligence caused pt problem), damages (pt had a problem as a result) Informed consent: need to inform (side effects, alternatives, outcome w/o treatment), pt must be competent, and pt must give voluntary consent Involuntary commitment: right to be treated & refuse treatment unless declared incompetent Tarasoff decisions: Tarasoff I: need to warn potential victims of patients who could do them harm. Tarasoff II: need to take reasonable steps to prevent harm to 3rd party M'Naughten Rule: 1843, England, mentally ill man tried to assassinate prime minister not held responsible if mentally ill / MR and didn't understand nature of act or realize that it was wrong; controversial, basis of insanity defense.
