PASS Behavioral.pdf

Chapter Eleven: Behavioral Science or Psychiatry Chapter Sections: I. II. III. IV. V. VI. VII. VIII. IX. The Ups and the Downs Major Depressive Disorder Bipolar Disorder Anxiety Disorders Trauma and Stressor Related Disorders Schizophrenia Spectrum and Other Psychotic Disorders Personality Disorder...

Chapter Eleven: Behavioral Science or Psychiatry Chapter Sections: I. II. III. IV. V. VI. VII. VIII. IX. The Ups and the Downs Major Depressive Disorder Bipolar Disorder Anxiety Disorders Trauma and Stressor Related Disorders Schizophrenia Spectrum and Other Psychotic Disorders Personality Disorders Somatic Symptom and Related Disorders Dissociative Disorders X. XI. XII. XIII. XIV. XV. XVI. Defense Mechanisms Feeding and Eating Disorders Sexual Dysfunctions and Paraphilic Disorders Disruptive Impulse-control and Conduct Disorders Sleep-Wake Disorders Pediatric Disorders Neurodevelopmental Disorders Neurocognitive Disorders When studying behavioral science, it quickly becomes clear that much of it feels abstract. That is because, in psychiatry, there are often no clear-cut tests to rule in or out a disease. This leaves us in unfamiliar territory when compared to other medical specialties. Instead of objective, physically fact-based diagnosis, behavioral science must often rely on findings that can seem subjective. The following are some of the currently used Diagnostic categories in Behavioral Science (DSM-5): • • • • • • • • Depressive Disorders Bipolar and Related Disorders Anxiety Disorders Obsessive-Compulsive and Related Disorders Trauma and Stressor Related Disorders Schizophrenia Spectrum and other Psychotic Disorders Personality Disorders Somatic Symptom and Related Disorders • • • • • • • 294 Dissociative Disorders Feeding and Eating Disorders Sexual Dysfunctions, Gender Dysphoria and Paraphilic Disorders Disruptive, Impulse control and Conduct Disorders Sleep-Wake Disorders Neurodevelopmental Disorders Neurocognitive Disorders Behavioral Science or Psychiatry The Ups and the Downs There are two simple patterns found in psychiatric illness: the ups and the downs. REMEMBER Euthymia: normal mood The “DOWNS” This includes slowed mentation, slowed movement, bradycardia, excessive sleepiness, constipation, fatigue, mental dullness. The patient’s mood and all the body’s processes are depressed. Sadness: Normal FEELING Situational and controlled depression In the absence of the event, person looks and feels normal. Grief: Sadness surrounding the death or loss of someone or something of great importance to the person. This is subjective; something important to one person may not be important to another person. Grief Sadness, despair, mourning Fatigue or low energy Tears Loss of appetite Poor sleep Poor concentration Happy and sad memories Mild feelings of guilt Gradually, these feelings remit as the individual regains his/her equilibrium. Depression Worthlessness Exaggerated fatigue Loss of interest Agitation Powerlessness Helplessness Suicidal thoughts Exaggerated guilt These feelings are unremitting, daily functioning at home and work are impaired. 295 Behavioral Science or Psychiatry 5 Stages of Grief 1. 2. 3. 4. 5. Denial: The person does not want to face the truth (i.e., parents of a dead child) Anger: The blame game Bargaining: Wishful thinking. Offerings to God to change the situation. Depression and guilt: Feelings of intense sadness, decreased sleep Acceptance: Accepting the reality of the situation REMEMBER Fantasy is a type of denial. Example: Parent keeps the room the same way the child liked it before he died, as if the child will be coming back. Based on current guidelines, Major Depressive Disorder can be diagnosed in a bereaving patient if 3 criteria are present: 1. 2. 3. Dysfunction Suicidal ideas Feelings of worthlessness Treatment of Grief: • • • Empathy: “I know how you feel”. This only works if you, as the physician, have gone through something similar. If you have not, it may come across as if you are patronizing them. Hope: Giving hope gives strength to the patient. If you cannot empathize, refer to a support group. If you cannot do either, show COMPASSION. Supportive Psychotherapy REMEMBER “Functional” means that the person is still able to carry on with their life and can accomplish their activities of daily living. 296 Behavioral Science or Psychiatry Melancholy: • • Dark, deeper type of sadness Shades, blinds closed, incense burning Persistent Depressive Disorder (Dysthymia): Criteria for diagnosis • • • Depressed mood for most of the day for at least 2 years. A functionally depressed patient. Presence, while depressed, of 2 or more of the following: o appetite or overeating o insomnia or hypersomnia o low energy or fatigue o low self-esteem o concentration or difficulty making decisions o Feelings of hopelessness o There has never been a manic or a hypomanic episode, and criteria have never been met for cyclothymic disorder. Treatment: Psychotherapy, SSRI’s if indicated *If full criteria for a major depressive episode have been met at some point during the current episode of illness, they should be given a diagnosis of Major Depressive Disorder. REMEMBER Mania = loss of normal daily functioning Hypomania = still functional Cyclothymia: • • • Low level depression with occasional periods of hypomania for at least 2 years Milder form of Bipolar II Disorder Treatment: Antimanic drugs (Lithium, Valproate, Carbamazepine), and Psychotherapy *Under current guidelines, Persistent Depressive Disorder (Dysthymia) is categorized under Depressive Disorders and Cyclothymia is under Bipolar and Related Disorders. 297 Behavioral Science or Psychiatry Major Depressive Disorder Diagnostic criteria: Five (5) or more of the following symptoms have been present during the same 2week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure (anhedonia) SIG E CAPS 1. 2. 3. 4. 5. 6. 7. 8. 9. Depressed mood Sleep disturbance Loss of Interest Guilt or feelings of worthlessness Loss of Energy Diminished ability to Concentrate Appetite or weight loss/gain Psychomotor agitation/retardation Suicidal thoughts Sleep disturbance in MDD: • • • • Excessive sleepiness Short bursts of REM-go in and out quickly More REM overall but still do not feel well rested Early morning awakenings Common medical conditions that can cause depression: • • • • • • Endocrine disorders (Hyper/Hypothyroidism) Parkinson's disease Stroke Dementia Pseudo dementia Medications (B-blockers, Steroids) 298 REMEMBER Pseudo dementia: • • • Like dementia but is a depressive disorder Has intact memory Rx: SSRI’s Behavioral Science or Psychiatry Atypical Depression • • • • • Mood reactivity (on and off) Hypersomnia Hyperphagia Hypersensitive to rejection Treatment: SSRI’s, MAOIs Seasonal Affective Disorder • • Periods of mild depression that present in fall and winter months Treatment: Phototherapy, relocation Premenstrual Dysphoric Disorder (PMDD) • • • Symptoms begin in the final week before menses, starts to improve in the days after onset of menses and are absent in the postmenstrual weeks during the past year. At least one of 5 or more required symptoms must be marked: lability of affect, irritability, depressed mood or hopelessness or self-depreciation, or marked anxiety or tension. Treatment: SSRI’s (1st line), OCP (2nd line–if not trying to get pregnant) Postpartum Depression Postpartum Blues Postpartum “Baby Blues” Depression Postpartum Psychosis Onset Occurs after birth and lasts up to 2 weeks Occurs within 1 month of birth and symptoms may persist Occurs within 1 month of birth and symptoms may persist Does mother care for baby? Yes May have thoughts about hurting the baby May have thoughts about hurting the baby Symptoms Mild depressive Severe depressive Severe depressive and psychotic symptoms Treatment Self-limited; No treatment necessary Antidepressants Antidepressants and mood stabilizers or antipsychotics 299 Behavioral Science or Psychiatry Management of MDD • • • • The main NT involved is Serotonin followed by Norepinephrine. Neurotransmitters involved in mood disorders are norepinephrine (NE), serotonin (5HT), and dopamine (D). Epinephrine, a hormone, can also be involved. Once treatment is initiated, it takes 4 weeks for levels of neurotransmitters to go back to baseline. Patient feels better (subjectively) in 6-8 weeks REMEMBER Suicide is most prevalent in the first 90 days of treatment because patient gives up if they do not understand that it takes time for symptoms to be alleviated. • • • Complete treatment is between 6-9 months The following are the percentages of the incidence of depression given to a population according to a given risk factor: General population: 1-3%  Elderly: 1 risk factor =10 %  Elderly patient in the hospital: 2 risk factors =50%  Elderly patient in the nursing home: 3 risk factors = >90% Question Why is being in a nursing home associated with increased risk for depression? Surveys have shown that patients in nursing homes fear a loss of their autonomy. Therefore it is important to treat these patients with compassion. REMEMBER Suicide Risk Factor: Previous attempt (#1) Protective factors: • • Parenthood/Pregnancy Strong support network (community service, religion, family) 300 Behavioral Science or Psychiatry Antidepressants 1. 2. 3. 4. 5. Selective Serotonin Reuptake Inhibitors (SSRI’s) Serotonin-Norepinephrine Reuptake Inhibitors (SNRI’s) Tricyclic antidepressants (TCA’s) Monoamine Oxidase inhibitors (MAO’s) Atypical antidepressants REMEMBER Assessment of suicide risk: SAD PERSONS Sex (male) Age (young/elderly) Depression Previous attempts Ethanol or drug use Rational thinking loss REMEMBER Catecholamines (D, NE, and E) are all made from phenylalanine and tyrosine Social support lacking Organized plan No spouse Sickness Serotonin Syndrome Serotonin syndrome is characterized by opposing effects such as tachycardia followed by bradycardia, or diarrhea followed by constipation, and hyperthermia followed by hypothermia. This is a result of excessive serotonin in the CNS. A triad of mental status changes, autonomic hyperactivity and neuromuscular abnormalities is seen. Hyperreflexia and myoclonus also seen. Management of Serotonin Syndrome: • • Sympathetic Symptoms o Cyproheptadine: 5HT receptor blocker Parasympathetic symptoms o Octreotide: Somatostatin analog REMEMBER Caffeine also increases serotonin levels in the CNS, which explains why people drink coffee to stay awake Carcinoid syndrome occurs secondary to carcinoid tumors. A carcinoid tumor is a neuroendocrine, GI tumor that releases serotonin. 301 Behavioral Science or Psychiatry SSRI SNRI MOA • Inhibits 5-HT reuptake • INDICATIONS • • • • • • Depression OCD PTSD ADD/ADHD PMDD Generalized Anxiety Disorder Eating disorders Panic and phobic disorders including social phobia • • • • • • • • Inhibits 5-HT and NE reuptake Depression Generalized Anxiety Disorder Panic disorder Social anxiety disorder PTSD OCD Diabetic neuropathy Fibromyalgia Sexual dysfunction (anorgasmia) GI distress SIADH Prolonged QT interval • • • Hypertension Sedation Nausea Fluoxetine Paroxetine Fluvoxamine Sertraline Citalopram Escitalopram • Venlafaxine Desvenlafaxine Duloxetine Levomilnacipran Milnacipran • • ADVERSE EFFECTS • • • • • DRUGS • • • • • • • • • Tricyclic antidepressants (TCA): Amitriptyline, nortriptyline, imipramine, desipramine, clomipramine, doxepin, amoxapine MOA: Inhibit 5-HT and NE reuptake Indications: • • • • • • Major Depression OCD (Clomipramine) Chronic pain/neuropathy (Amitriptyline) Nocturnal enuresis (Imipramine) Migraine prophylaxis Nortriptyline and Desipramine best for elderly patients (short half-life) 302 Behavioral Science or Psychiatry Adverse Effects: • • • • • • Increase Dopamine (mania) Anticholinergic (urinary retention, tachycardia, dry mouth, hyperthermia) Block α1 receptors (orthostatic hypotension) Block AV nodal conduction (prolong QT) Block Na⁺ channels (arrhythmia, seizures) Block Histamine receptors (sedation) Management of TCA overdose: Fluids and NaHCO₃ Monoamine Oxidase Inhibitors (MAOIs): Tranylcypromine, Phenelzine, Isocarboxazid, (MAO-A); Selegiline (MAO-B inhibitor) MOAI: Block the degradation of Amine neurotransmitters leading to increased levels of dopamine, 5-HT and NE. MAO is present in the presynaptic terminal of sympathetic nerve fibers and their levels increase with age. Indications: • • • REMEMBER Atypical depression Parkinson’s disease (Selegiline) Social anxiety disorder Selegiline is unique for blocking MAO-B. B for BRAIN: used in the treatment of Parkinson’s disease. Adverse Effects: • • Hypertensive crisis: Tyramine present in cheese and wine triggers a release of catecholamines leading to sympathetic stimulation Contraindicated with SSRI’s, TCA’s, dextromethorphan, and St. Johns wart as it can precipitate Serotonin Syndrome. * If it is necessary to switch from MAOI’s to SSRI’s, wait for 2 weeks as it takes 10-14 days to regenerate the enzyme. REMEMBER COMT is in the postsynaptic terminal 303 Behavioral Science or Psychiatry REMEMBER Tyramine, which is found in wine and cheese, can cause a severe reaction in a person taking MAOIs. Atypical Antidepressants Trazodone: • • • MOA: Blocks 5-HT2 reuptake; blocks α1 adrenergic and blocks H1 receptors. Indication: Insomnia Adverse effects: Sedation, priapism, and orthostatic hypotension REMEMBER SE: Trazadone: priapism Mirtazapine: • • • TrazoBONE MOA: Antagonist at presynaptic α2 adrenergic receptors (increases NE and serotonin); antagonist at 5-HT2 and 5-HT3 serotonin receptors and antagonist at H1 receptors Indication: Depression, Generalized Anxiety Disorder, and tension headaches Adverse effects: Sedation, dry mouth, increased appetite, and weight gain Bupropion: • • • • MOA: Inhibits reuptake of Dopamine and NE Indication: Depression, Seasonal Affective Disorder, ADHD, Smoking cessation Does not have sexual side effects Adverse effects: Seizures (esp. in anorexic and bulimic patients), headache, and insomnia Varenicline: • • • MOA: Partial agonist at nicotinic ACh receptor Indication: Smoking cessation Adverse effects: Mood disturbance 304 Behavioral Science or Psychiatry Vortioxetine: • • • • MOA: Inhibits reuptake of 5-HT (serotonin), agonist at 5-HT₁ and antagonist at 5-HT₃ Indication: Major Depressive Disorder Adverse effects: Nausea, abnormal dreams, sexual dysfunction, and anticholinergic effects Can cause serotonin syndrome if taken with other serotonergic drugs Bipolar Disorder Mania: Diagnostic criteria • • A distinct period of abnormally and persistently elevated, expansive, or irritable mood, activity or energy lasting at least 1 week and present most of the day At least 3 of the following symptoms DIGFAST 1. 2. • Distractibility Irresponsibility/Engagement in high-risk activities (sexual indiscretions, buying sprees) 3. Grandiosity 4. Flight of ideas 5. Activity increases/ Psychomotor Agitation 6. Sleep decreased 7. Talkativeness Mood disturbance severe enough to cause an impairment in normal functioning Hypomania: Milder form of mania but the individual is functional, lasts at least 4 consecutive days. Bipolar I: Mania +/- depression Bipolar II: Hypomania + depression Treatment of Bipolar Disorder Mood Stabilizers: Does not bring you up; does not bring you down 305 Behavioral Science or Psychiatry Lithium (Li+) • • MOA: Lithium stabilizes the cell, so it does not depolarize Adverse effects: o Hyponatremia (Li+ looks like Na+, so it can get in the way of Na+) o Hypothyroidism (it competes with Iodine) o Nephrogenic Diabetes Insipidus (blocks ADH receptors in the kidney) o Teratogen (Ebstein’s anomaly in newborn) o Tremors REMEMBER Use caution in a patient that is hyponatremic prior to administration of Lithium REMEMBER Lithium and Demeclocycline can block ADH receptors and cause Nephrogenic DI Valproic Acid • • • MOA: Blocks sodium and calcium channels. Adverse effects: o Bone marrow suppression (blocks folate) o Hepatitis o Neural tube defects (in pregnancy) Pancreatitis REMEMBER Folate antagonists can cause neural tube defects, megaloblastic anemia, and bone marrow suppression. 306 Behavioral Science or Psychiatry Carbamazepine • • MOA: Blocks sodium and calcium channels Adverse effects: o Agranulocytosis o Hepatotoxic o P-450 inducer The “Ups” Anxiety Disorders Anxiety disorders have both psychological and physiological symptoms. Psychological: excessive worry, hypervigilance, restlessness, difficulty concentrating, and sleep disturbances. REMEMBER Insight: Being aware that a problem exists Physiological: autonomic hyperactivity (tachycardia, hypertension, sweating) and motor tension. Phobic disorder • • Individuals who suffer from intense fear or anxiety when exposed to specific objects or situations. o Agoraphobia- Fear of certain places, situations, or open spaces o Social phobia - fear of social situations (stage fright) o Specific phobias - animals (spiders), environment (heights, germs), bodily (blood/shots), situational (flying, dentist) Treatment: o CBT / Systematic desensitization o Desensitization is the best way to treat a patient with a specific phobia. This means multiple exposures to the stimulus which will, over time, become less provoking to the patient. o SSRI’s, buspirone, β-blockers 307 Behavioral Science or Psychiatry Clinical Correlation Buspirone • • • • • Partial agonist at serotonin 5-HT1A receptor Pre-synaptic dopamine (D2, D2, D4) receptor antagonist Partial α receptor agonist Increases firing in locus coeruleus →↑NE Metabolized by CYP -450 Panic Disorder • • • • Recurrent unexpected panic attacks. These are attacks of intense anxiety that are accompanied by an accelerated heart rate, pounding heart beats, chest pain, sweating, shortness of breath, nausea, dizziness, chills, feeling of being detached from oneself and fear of dying. The patient also experiences persistent worry or fear of having a panic attack and often changes behaviors and routines to avoid panic attacks. Treatment: SSRI’s (1st line), alprazolam (acute), imipramine, and MAOI’s Generalized Anxiety Disorder • • Excessive worry and anxiety occurring for at least 6 months and causing an impairment in normal functioning. It is also associated with at least 3 of the following: 1. Restlessness 2. Fatigue 3. Difficulty concentrating 4. Irritability 5. Muscle tension 6. Sleep disturbance Treatment: SSRI’s, buspirone, venlafaxine, benzodiazepines 308 Behavioral Science or Psychiatry Obsessive-Compulsive Disorder (OCD) • • • • OCD is characterized by recurrent obsessions or compulsions that are recognized by the person as excessive or unreasonable. Obsessions: anxiety inducing thoughts, commonly concerning contamination, doubt, guilt, aggression, and sex Compulsions: Repetitive behaviors (hand washing, checking) or mental acts (praying, counting) that the person feels driven to perform in response to an obsession, that are aimed at reducing anxiety Treatment: CBT, SSRI’s, clomipramine Body Dysmorphic Disorder • • Preoccupation with an imagined defect in appearance. The preoccupation causes significant emotional distress and impairment in functioning. Treatment: CBT Trauma and Stressor Related Disorders Adjustment Disorder • • • • Emotional or behavioral symptoms that develop in response to an identifiable stressor within 3 months of the onset of the stressor. The symptoms do not represent Bereavement The symptoms do not persist more than 6 months after the termination of the stressor Treatment: CBT, SSRI’s Acute Stress disorder (ASD) and Post-traumatic Stress Disorder (PTSD) • • • • ASD: Specific fear behaviors that lasts from 3 days to 1 month after a traumatic event (physical attack, abuse, active combat, sexual violence, accidents). May experience flashbacks or may block out parts of the event. PTSD: When these last longer than 1 month. Also associated with: o Reexperiencing of the traumatic event: dreams, flashbacks o Avoidance of associated stimuli  Increased arousal: anxiety, hypervigilance Depression and emotional lability Treatment: CBT, SSRI’s, venlafaxine (Prazosin for nightmares) 309 Behavioral Science or Psychiatry When the Brain Plays Tricks on You... Schizophrenia Spectrum and Other Psychotic Disorders Schizophrenia • • • Increased Dopamine Schizophrenia is a disorder in which a person will experience gross deficits in reality testing, manifested with at least 2 or more of the following for more than 6 months o Delusions o Hallucinations (mostly auditory) o Disorganized or catatonic behavior o Negative symptoms (flat affect, mutism) Treatment: Antipsychotics REMEMBER Tactile hallucination and formication can also be seen in alcohol withdrawal and cocaine intoxication. REMEMBER Catatonia is a neurogenic immobility Brief Psychotic Disorder • The above symptoms are present for more than 1 day and less than 1 month Schizophreniform Disorder • The above symptoms are present for more than 1 month but less than 6 months 310 Behavioral Science or Psychiatry Schizoaffective Disorder • An uninterrupted period of illness during which there is a major mood episode (major depressive or manic) The occurrence of delusions or hallucinations must be in the absence of any serious mood symptoms for at least 2 weeks Symptoms that meet criteria for a major mood episode (major depressive or mania) are present for the majority of the illness • • Two types: Bipolar type: Depressive and manic episodes Depressive type: Only depressive episodes Delusional Disorder Delusion: A single, falsely held belief despite proof to the contrary. • • • • Diagnosis requires the presence of delusions for at least 1 month No impairment in function The patient has not met criteria for schizophrenia Types: erotomaniac, grandiose, jealous, persecutory, somatic, mixed, unspecified Antipsychotics • Primarily works on Dopamine receptors (D2, D4) Dopamine 1. 2. 3. 4. 5. Mesolimbic & Mesocortical tracts: hallucinations and vomiting Nigrostriatal tract (basal ganglia): increases initial movement Infundibular tract: inhibits release of Prolactin Gives the patient the feeling of being “high” Mediates urges 311 GnRH amenorrhea PRH galactorrhea Behavioral Science or Psychiatry Typical Antipsychotics (D2 antagonists) Phenothiazines (strong anticholinergic and weak D2 blockade) • • • • • Chlorpromazine: also inhibit α1 receptors, decrease BP Thioridazine: causes pigment retinopathy Fluphenazine: strong EPS, available in depot form that lasts for 30 days Promethazine: anti-emetic in children Prochlorperazine: anti-emetic in adults Thioxanthenes (strong anticholinergic and weak D2 blockade) • Thiothixene: available in depot form Butyrophenone (most potent D2 blockade, mild anticholinergic) • • Haloperidol: weak anticholinergic, best for acutely psychotic or delirious patients Droperidol Atypical Antipsychotics (D4>D2, 5-HT2 antagonists) • • • Good for negative symptoms Older antipsychotics have a higher incidence of extrapyramidal symptoms (EPS) Newer ones have minimal to no EPS symptoms Drug Adverse Effect Risperidone (D2, 5-HT2) Hyperprolactinemia Olanzapine Metabolic syndrome (Diabetes, wt. gain) Quetiapine Cataracts, little effect on weight Ziprasidone Prolonged QT Aripiprazole Weight gain, mild Clozapine Agranulocytosis, lower seizure threshold Lurasidune 312 Behavioral Science or Psychiatry Extrapyramidal Syndromes (EPS) If the patient develops a movement disorder secondary to antipsychotic medication, the drug must be discontinued. It is important to note that tardive dyskinesia and akathisia may persist after discontinuation of medication and can become debilitating. Acute Dystonia (4hr) • • • • • Akinesia=Dyskinesia Bradykinesia꓿ Parkinsonian (4d-4wks) Sustained contraction of a muscle group Torticollis Opisthotonos Tics Rx: Anticholinergics (Benztropine, trihexyphenidyl), antihistamines (Diphenhydramine) • • Akathisia (4wks-4mo) • • • Stiffness, Parkinson-like symptoms Rx: Anticholinergics, Antihistamines Tardive Dyskinesia (4mo-4yrs) Restlessness Inability to stop movement. Rx: β-blocker • • • Facial grimacing, tongue protrusion, lip smacking, puckering Choreoathetoid movement of the head, limbs, and trunk Rx: D/c current antipsychotic, switch to risperidone or clozapine, anticholinergics Clinical Correlation Torticollis is a form of dystonia when the head is in a sustained contraction to one side Opisthotonos is sustained contraction of the back muscles resulting in arched position Tic is a sustained contraction of one muscle 313 Behavioral Science or Psychiatry Clinical Correlation Tremors Resting: Parkinson Dz (supinator and pronator muscles fighting each other over control of initiation of movement) Intention: Cerebellar dysfunction, Alcohol intoxication Essential: Always present. Worsens with movement. Alcohol (↑GABA) can slow it down. Rx: Propranolol (β- blocker) Neuroleptic Malignant Syndrome (NMS) • • Neuroleptic Malignant Syndrome (NMS) occurs when there is uncoupling in the ETC caused by a neuroleptic drug. This causes hyperthermia due to inability to release heat. And, since ATP is not produced, the muscles are unable to relax. This leads to muscle damage which is reflected in laboratory findings such as high LDH and potassium, high AST and ALT, myoglobin, troponin, and CPK which have leaked out of the cells. It is important to recognize this since it is life-threatening. Treatment: o Antihistamines are the cheapest treatment for movement disorders because of their anticholinergic action. Why? Muscle contractions are CHOLINERGIC, so an anticholinergic will prevent the muscle from contracting. o Dantrolene, which stabilizes the sarcoplasmic reticulum and therefore allows the calcium to be sequestered. Clinical Correlation Clinical Correlation NMS is similar to Malignant Hyperthermia (MH) in that is seen in patients treated with anesthesia. 314 Benztropine has the same effect as antihistamines but is more expensive. Behavioral Science or Psychiatry Comparing the “CRISIS” Syndromes HYPERTENSIVE CRISIS MALIGNANT HYPERTHERMIA Why: Why: • MAOI user consumes substances with increased tyramine • ↑Tyramine → ↑NE release → vasoconstriction (α1) • • • Presentation: • HTN → Stroke → Death Autosomal Dominant Genetic variation of Skeletal muscle ryanodine receptor → ↑Calcium release → ↑contractions → ↑heat Most commonly seen with succinylcholine Presentation: • S/Sx similar to pheochromocytoma, cocaine and amphetamine overdose • • • Rx: • Phenoxybenzamine, phentolamine • Acute sympathetic Sx can be treated with a short acting benzodiazepine • ↑Temp Muscle rigidity, muscle breakdown, ↑K HTN, ↑HR Rx: • • Dantrolene Cooling, ice bath NEUROLEPTIC MALIGNANT SYNDROME Why: SEROTONIN SYNDROME Why: • Overdose on antipsychotics • SSRI + MAOI • Blockade of α, M, H, D receptors • SSRI + Meperidine/St. John’s wort • Presentation: • Presentation: • Rhabdomyolysis (↑CPK) • ↑Temp • ↑Temp • Muscle aches • Autonomic instability • CV collapse (hyper/hypotension) Rx: Rx: • • Dantrolene Phenylephrine (α1 agonist) to bring up BP if needed. Do not use Epi (β2) 315 • Cyproheptadine • Prevention: o MAOI → SSRI, window of 15 days o SSRI → MAOI, window of 30 days Behavioral Science or Psychiatry Treatment of “Ups” The goal is to slow down the brain by enhancing GABA. The stimulation of GABA receptors triggers the opening of chloride (Cl⁻) channels and drives the membrane potential in the reverse direction, which inhibits the cell from depolarizing. Both benzodiazepines and barbiturates increase Cl⁻ in the cell, but in different ways Benzodiazepines: Increases the frequency of opening Cl⁻ channels Barbiturates: Increases the duration of opening Cl⁻ channels Adverse Effects • • • • Sedation Lethargy Bradycardia Miosis Benzodiazepines Flurazepam: Longest acting. Avoid in children and elderly. Fat soluble. Alprazolam: Short acting, half-life of 4-6 hours. REMEMBER Triazolam: Helps elderly to initiate sleep. “TRY”azolam (Triazolam) TRY to sleep (initiate) Temazepam: Helps maintain sleep in patients who have frequent nocturnal awakenings. TeMAzepam: MAintain Midazolam: 30-45 min, shortest acting. Used in short procedures where patient needs to be awake and cooperative, i.e., endoscopy. Causes anterograde amnesia so that patient does not remember trauma experienced during procedure. 316 Behavioral Science or Psychiatry Lorazepam: Used to treat anxiety in middle age women (group with the highest anxiety). Has a half-life of 8 hours, so it can be taken either in the first half of the day or second half, depending on when the anxiety is worst for the patient. REMEMBER Both Diazepam and Lorazepam can be used to treat Status Epilepticus Clonazepam: Only benzodiazepine that has been indicated in the past for the treatment of absence seizures. Also used for restless leg syndrome. However, the drug of choice for restless leg syndrome is pramipexole or ropinirole. Chlordiazepoxide: Used in treating Delirium Tremens Management of Benzodiazepine Overdose Flumazenil: Flumazenil works by blocking the benzodiazepine receptor. The benzodiazepine receptor is not for GABA itself. But it is located next to the receptor. It enhances the receptor without blocking it. Barbiturates Phenobarbital: DOC for generalized seizures in children because it is the least toxic over the long-term when compared to other seizure medications. Thiopental: Shortest acting; used in general anesthesia to quiet patient down before anesthesia kicks in. Secobarbital: Most abused on the streets. Amobarbital Pentobarbital 317 Behavioral Science or Psychiatry Personality Disorders The 4 defining features of personality disorders: 1) 2) 3) 4) Distorted thinking patterns Problematic emotional responses Over- or under-regulated impulse control Interpersonal difficulties 1) Cluster “A” Paranoid • • Distrusting and suspicious of everything Multiple obsessive beliefs and fears Schizoid • • • • • Conscious decision by a person to be socially withdrawn Lack affect Like to be by themselves Get violent if you invade their personal space e.g., a recluse living in a cave shoots at an intruder Schizotypal • • • • Prefer to be by themselves Are not apprehensive if approached Very awkward and have magical thinking Like to entertain themselves 2) Cluster “B” Antisocial vs. Conduct • • • • • A person who lies, cheats, steals, or destroys property without remorse Behavior outside of the social norm May occur as a result of chaotic upbringing or when parents do not set limits early on in life Called conduct disorder up to the age of 18 e.g., commonly seen in boys raised by a single mother 318 Behavioral Science or Psychiatry Borderline • • • • Unstable mood; sense of emptiness; impulsive In their mind everything is black or white (either they hate you or love you) Use “splitting” as a defense mechanism e.g., If you cannot see a child for an earache, the parent ends up hating you (allow patient to see another doctor) Histrionic • • Sexually provocative; openly flirtatious person “Marilyn Monroe syndrome” Narcissistic • • • • Think they are the best and better than other people Think the world revolves around them Sense of entitlement Sensitive to criticism 3) Cluster “C” Avoidant • • Deal with problems by avoiding them Afraid of rejection Obsessive-compulsive • • • A person who is anal retentive about how everything must be done Has a need to be orderly, a perfectionist, and in control Differentiate from OCD which consists of obsessions that are followed by compulsive acts 319 Behavioral Science or Psychiatry Dependent • • • • Requires excessive need for reassurance Clingy, submissive and needs to be taken care of Lacks self-confidence e.g., popular male athlete needs to be told how good he is everyday Somatic Symptom and Related Disorders Conversion Disorder (Functional Neurological Symptom Disorder) • • • • • • Neurological manifestation that occurs as a result of an internal struggle More common in women than men Usually occur after a stressful event Persistent change in sensory or motor function e.g., child walks in on mother and father having sex and goes blind e.g., girlfriend loses function of her legs after boyfriend threatens to break up with her Illness Anxiety Disorder (formerly Hypochondriasis/Somatoform) • • • • • • • Obsesses about one illness Has been preoccupied with illness for at least 6 months Patient has no or minimal somatic symptoms Highly anxious about health Patient repeatedly checks health status Running tests helps to calm the patient down e.g., man who had a brother die at age 42 of an MI has multiple visits to the hospital or ER as he approaches the same age Somatic Symptom Disorder • • • • • • • Subconscious Need to be present for at least 6 months Patient believes he/she has a new illness every time he visits the doctor Patient will consent to multiple tests/procedures Can coexist with a medical disorder Patient requires regular visits to the doctor for constant reassurance Psychotherapy may be helpful 320 Behavioral Science or Psychiatry Factitious Disorder (formerly Munchausen) • • Conscious Can be predominantly psychological, physiological symptoms, or both Factitious Disorder Imposed on Another (formerly Munchausen by proxy) • Making up psychological or physiological symptoms in another Dissociative Disorders Dissociative Identity Disorder • • • • • • • Person creates a new personality with something they cannot handle Inability to explain how a person got somewhere or acquired something “Lost time”, “flashbacks” or “out of body” experiences Inability to recall large memories from childhood Handwriting and functional changes (disabled → highly functioning) Feelings of detachment from body or thoughts Formerly called Multiple Personality Disorder Dissociative Amnesia • • • • • • Temporary loss of recall memory caused by disassociation Voluntary or involuntary Often arises from traumatic childhood events Often comorbid with PTSD e.g., a homeless patient in the ER who cannot recall anything from their past Dissociative fugue is a subtype: temporary or permanent loss of ones' personal identity or the development of a new identity; involves travel Depersonalization/Derealization Disorder • • Depersonalization: (does not recognize oneself in the mirror) o Detachment from emotions o Distorted body image o Loss of sensation in parts of the body o Feeling unreal or like a spectator in their own lives Derealization: (living in a dream) o Feeling detached from their surrounding 321 Behavioral Science or Psychiatry o Feeling like general life events are unreal o Visual distortions Defense Mechanisms Your subconscious trying to protect your conscious; may be mature or immature 1) Immature Passive Aggressive • • • A person who does by not doing e.g., a woman expects a man to know that she is mad at him e.g., a patient comes late for an appointment repeatedly Denial • • Where you do not face the truth e.g., the 1st stage of grief; parents want to run more tests in a child who is dying already Fantasy • • • • A form of denial Pretentious action Magical thinking e.g., parent keeps child’s room as is, after the child has died Isolation of Affect • • • A form of denial Isolating feelings for the benefit of someone else e.g., husband wants to stay strong for his wife who is dealing with an emotional situation (death, loss of job, etc.) 322 Behavioral Science or Psychiatry Repression • • Subconsciously putting away feelings or emotions e.g., girl represses thoughts of childhood sexual abuse Regression • • • Reverting to an infantile way of acting e.g., throwing a tantrum e.g., an older man curling up in the fetal position next to his mother Projection • • • Putting your thoughts into someone else Used heavily in advertising (e.g., projecting sexually provocative images to sell things) e.g., husband who is craving ice cream asks wife if she would like to have some ice cream Displacement • • Taking your feelings out on someone or something else e.g., a man who is mad at his boss comes home and kicks the dog Undoing • • Doing the exact opposite of what you used to do e.g., an arsonist becomes a firefighter Reaction Formation • • Reacting opposite to how you feel e.g., a person who feels sad acting extra bubbly while at work Counterphobic Behavior • • • • e.g., a person who has a fear of heights takes up bungee jumping Imitation A person wants to be like someone else May be positive or negative 323 Behavioral Science or Psychiatry Identification • • Modeling behavior after another who is perceived to be more powerful e.g., when you dress like someone else Idealization • • • Feeling that everything must be ideal e.g., person dates a someone with poor character because they feels they can change them to their ideal boyfriend/girlfriend e.g., woman feels as though every man she dates must be like her father Idolization • • Exaggeration of the positive attributes and minimization of the imperfections or failings e.g., child wears shoes of a famous athlete because he thinks it will make them play like that athlete Sexualization • • Making something sexual out of everything that happens e.g., man views a tree swaying as a woman with nice hips Transference • • • Type of projection Patient projects to doctor feelings they have toward someone else Countertransference is when doctor projects feelings towards the patient (this is always negative!) Rationalization vs. Justification • • Rational explanations are used to justify unacceptable attitudes, beliefs, or behaviors e.g., not passing the test is attributed to the test being too difficult 324 Behavioral Science or Psychiatry Intellectualization • • Intellectual reasoning is used to block confrontation with an unconscious conflict e.g., a person diagnosed with terminal illness focuses on learning everything about the disease in order to avoid distress and remain distant from reality 2) Mature Suppression • • • Consciously putting away of an emotion e.g., not laughing out loud when thinking of a joke while sitting in church e.g., a someone not retaliating against a person who they recognize from a childhood school fight Humor • • Learning to laugh at yourself e.g., telling a joke to diffuse a situation in which a fight is about to occur Altruism • • Putting others before yourself e.g., Mother Teresa going to India to help the needy Sublimation • • • • Making something positive out of something negative e.g., someone who likes to fight becomes a boxer e.g., a person starts a fund in the name of a friend who died recently e.g., mother donates organs of child who recently died Philanthropy • Monetary giving to those less fortunate 325 Behavioral Science or Psychiatry Feeding and Eating Disorders Feeding and Eating Disorders Anorexia Nervosa Diagnostic criteria (Low BMI) • • • • Bulimia Nervosa Diagnostic criteria (Normal BMI) Persistent restriction of food intake leading to significantly low body wt. An intense fear of gaining wt. or of becoming fat, or persistent behavior that interferes with wt. gain Disturbance in perception of one’s body wt. Denial of seriousness of condition Treatment • • • • Recurrent episodes of binge eating Self-induced vomiting, misuse of laxatives/diuretics, fasting or excessive exercise Occurs at least once a week x 3 months Self-evaluation is unduly influenced by body shape and wt. (attempts to conceal behavior) Treatment • Hospitalize, correct electrolytes • Behavioral therapy • SSRI • • Cognitive and behavioral therapy SSRI Sexual Dysfunctions and Paraphilic Disorders Remember that what two consenting adults do behind closed doors is considered “normal”. Paraphilic Disorders Pedophile • Any sexual pleasure derived from children • e.g., touching, watching, etc. 326 Behavioral Science or Psychiatry Urophile • Sexual pleasure derived from being urinated upon Coprophilia • Sexual pleasure derived from being defecated on Necrophile • Sexual pleasure derived from a dead corpse • More common in women Transvestite • Sexual pleasure derived from dressing up as the opposite sex • Person does NOT want to be the opposite sex, only likes to dress up Fetishism • Sexual pleasure derived from an inanimate object • e.g., they like it when their sexual partner wears high heel shoes Frotteurism • Sexual pleasure derived from rubbing up against fully clothed people • e.g., patient rubbing up against people while riding on the subway Sadism • Sexual pleasure derived from inflicting pain upon someone else Masochism • Sexual pleasure derived from having pain inflicted upon yourself 327 Behavioral Science or Psychiatry Voyeurism • Sexual pleasure derived from watching others have sex, but without their permission Exhibitionism • Sexual pleasure derived from exposing your genitalia to others Beastophilia • Sexual pleasure derived from having sex with animals Gender Dysphoria • Incongruence between the gender the patient sees themselves as and their classified gender assignment • An intense need to do away with his/her primary or secondary sex features • An intense desire to have the primary or secondary features of the other gender • A deep desire to transform into another gender Sexual Dysfunctions: Male or Female Sexual Interest/Arousal Disorder • • • • Absence or reduction of an interest in sexual activity Absence of sexual or erotic thoughts Disinclined to initiate sexual acts with partner No sense of pleasure during sexual acts Female Orgasmic Disorder • Reduced intensity, delay, infrequency, or absence of orgasm Genito-Pelvic Pain/Penetration Disorder • Tightening of the vaginal muscle resulting in the inability to penetrate • Pain or a burning sensation when penetration is attempted 328 Behavioral Science or Psychiatry • A decrease in or absent desire to have intercourse • Voluntary avoidance of sexual activity • An intense phobia or fear of pain Premature Ejaculation • Consistently ejaculating within one minute or less of vaginal penetration Disruptive Impulse-control and Conduct Disorders Intermittent Explosive Disorder • Episodes of aggressiveness that result in assaultive acts or destruction of property • These episodes are out of proportion to the degree of stressor Kleptomania • Recurrent failure to resist impulses to steal objects that they do not need • Increased anxiety before the act and release of anxiety after the act Pyromania • Deliberate fire setting on more than one occasion • There is anxiety before the act and release of anxiety after the act sometimes followed by fascination and gratification Trichotillomania • Pulling ones’ own hair, resulting in hair loss • There is anxiety before the act and release of anxiety after the act Pathologic Gambling • Recurrent and persistent gambling with a preoccupation to gambling • A need to gamble with more money, illegal acts to finance gambling • Loss of relationships due to gambling *Oppositional Defiant Disorder and Conduct Disorder will be discussed under Pediatrics 329 Behavioral Science or Psychiatry Sleep-Wake Disorders Review-Stages of Sleep NonREM • Slowing of EEG rhythms • ↑muscle tone • Absence of eye movements Stages Stage 1 EEG Features • Brief (0-7 min) Alpha and theta waves • Easily woken Stage 2 Sleep spindles and k complexes • • Lasts about 20 min HR Stage 3 Delta waves • Stage 4 (Delta sleep) Delta waves • Transitional period between light and deep sleep Hardest to be awakened Body repairs muscles and tissues Stimulates growth Boosts immune function Bedwetting and sleep walking happen at the end of Stage 4 sleep Stages 3 &4 tends to disappear in the elderly • • • • • REM • About 90 min after initially falling asleep and can last up to an hour • 5-6 REM cycles on average/night • Lengthens as night progresses Saw tooth waves 330 • • • • • • Dreams Eye movement ↑RR Sexual arousal Muscles relaxed Brain is active Behavioral Science or Psychiatry Sleep-Wake Disorders Sleep Neurotransmitters Serotonin: ↑; Initiates sleep Acetylcholine: ↑ Norepinephrine: Dopamine: ↑; arousal and wakefulness • • • • Other Substances That Affect Asleep • • • • • • • • Tryptophan: ↑total sleep Benzodiazepines: Stage 4, ↑ latency Barbiturates: REM Alcohol intoxication: REM Alcohol withdrawal: REM rebound Dopamine agonist: arousal Dopamine antagonists: arousal MDD: ↑REM, REM latency Sleep Disorders Narcolepsy • • • • • • • Excessive daytime sleepiness > 3 months Patients feel refreshed after awakening Cataplexy: sudden loss of muscle tone precipitated by sudden emotion or loud noise Hypnagogic and Hypnopompic hallucinations: Hallucinations as the patient is going to sleep or waking up Sleep paralysis Hypocretin or Orexin Treatment: Amphetamines, Modafinil Restless Legs Syndrome • • • • • • Urge to move the legs accompanied by uncomfortable sensations which are partially relieved by movement (while resting or at night) 3 nights/week for at least 3 months Leads to functional disability Are not accounted for by another medical condition Are not caused by medications, drugs, or alcohol Treatment: Dopamine agonists (pramipexole) 331 Behavioral Science or Psychiatry Parasomnias Sleep walking (Somnambulism) • Happens in Stage 3 and 4 • Usually ends in awakening and confusion • May return to sleep without memory of the occurrence Nightmare Disorder • Occurs during REM sleep • Memory of the event upon awakening • Increased during stress Sleep terrors • Occurs during Stage 3 and 4 • Wakes up screaming in the middle of the night • No memory of the event Pediatric Disorders-Neurodevelopmental Disorders Autism Spectrum Disorder • • • • • Usually before 3 years of age Persistent deficits in social communication and social interaction Deficits in developing, maintain and understanding relationships Repetitive activities, movements, or speech (lining up of toys) +/- intellectual disability Attention-Deficit Hyperactivity Disorder (ADHD) • • • • • • Symptoms appear before age 12 Should be present for at least 6 months Hyperactivity and impulsivity Present at school and home Talks excessively and out of turn and interrupts frequently Treatment: Stimulants (amphetamines), clonidine 332 Behavioral Science or Psychiatry Oppositional Defiant Disorder • Persistent pattern of hostile and defiant behavior toward authority figures Conduct Disorder • • Aggression toward people and animals, destruction of property, theft If over age 18, classified as Antisocial Personality Disorder Tourette’s Syndrome • • • • • • Onset before age 18 Present for > 1 year Associated with ADHD, OCD Motor tics: twitching of face/trunk, pacing, spinning Vocal tics: grunting, coprolalia Treatment: Antipsychotics (haloperidol, pimozide), clonidine Rett Syndrome • • • Seen in girls MECP2 mutation Normal development followed by regression between ages 1-5. Disruptive Mood Dysregulation Disorder • • • • Onset before age 10 and present for at least 12 months Verbal or aggressive outbursts that are out of proportion to trigger Outbursts occur at least 3 times/wk. and at two different locations Mood is irritable and unhappy between outbursts 333 Behavioral Science or Psychiatry Neurocognitive Disorders Neurocognitive Disorders Delirium • • • • • • Dementia Acute onset Caused by infections, electrolyte disorders, lung, liver, kidney, brain diseases, and drugs Fluctuating course Altered level of consciousness Disorientation Hallucinations • • Rx: Treat underlying condition antipsychotics if needed, benzodiazepines for Delirium tremens 334 • • • • • Insidious onset Caused by neurodegenerative disorders (Alzheimer’s, Parkinson, Huntington, Picks disease, Downs Synd., Alcohol, Creutzfeldt-Jacob) Can also have delirium Chronic Personality changes Aphasia, apraxia, agnosia +/- Hallucinations Rx: Supportive