psychiatry - shelf review
TRANSCRIPT
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Psychiatry Basics:
A Shelf Review
Sonya Gabrielian
UCLA Psychiatry Clerkship
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Agenda
Psychotic Disorders
Mood Disorders
Anxiety Disorders Personality Disorders
Substance Use Disorders
Cognitive Disorders Other Disorders
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Agenda
Psychotic Disorders
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What is psychosis?
Delusions
"alse# $xed# and culturally inappropriatebelie%s that cannot be altered by rational
argu&ents
Perceptual disturbances
'allucinations and illusions
Disordered thinking Proble&s (ith thought content and
process
)
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Hallucinations
A perception *+,'OU, external sti&ulus
+llusions are &isinterpretations o% ,-U. S,+MUL+
Auditory hallucinations
,hink schi/ophrenia or other psychotic disorder 0isual or tactile hallucinations
,hink drug or alcohol intoxication1(ithdra(al
Ol%actory hallucination
,hink sei/ure disorder# e2g2# te&poral lobeepilepsy
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Dierential Diagnosis
4rie% psychotic disorder 56 day to 6 &onth7 Schi/ophreni%or& disorder 5689 &onths7 Schi/ophrenia 5:9 &onths7
Schi/oa;ective disorder Delusional disorder Depression or bipolar disorder (ith
psychosis
Substance8induced psychotic disorder Deliriu&1De&entia Psychosis secondary to general &edical
condition
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Schiophrenia
,hree key phases
Prodro&e
Decline in %unction be%ore initial psychosis2
O%ten socially (ithdra(n# irritable#
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Schiophrenia !ont"
Positive sy&pto&s
'allucinations# delusions# disorderedthought# bi/arre behavior
?egative sy&pto&s
Less
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Schiophrenia !ont"
A;ects 6B o% population
Men present earlier than (o&en
Strong genetic predisposition
Chronic and debilitating
0arious neurotrans&itters arei&plicated
Likely relationship (ith increased dopa&ine
Likely role o% elevated serotonin andnorepinephrine
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Schioaective Disorder
Patients &eet criteria %or &aor depressive#&anic# or &ixed episode during a ti&e in(hich they also &eet criteria %orschi/ophrenia
Mood sy&pto&s are present %or substantialportion o% psychotic illness
?eed to have delusions or hallucinations %or
at least (eeks (ithout &ood sy&pto&s Do not con%use schi/oa;ective disorder (ith
&ood disorder (ith psychotic %eatures
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Delusional Disorder
?onbi/arre# $xed delusions %or at least 6&onth Delusions &ay be eroto&anic# so&atic#
persecutory# grandiose ?o signi$cant %unctional i&pair&ent
Do not &eet criteria %or schi/ophrenia
O%ten occurs in patients a%ter age )Eyears
Antipsychotics are o%ten less e;ectivethan in other psychotic disorders
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Antipsychotics
,ypical neuroleptics Dopa&ine 5&ostly D7 antagonists
,reat positive sy&pto&s : negative sy&pto&s
+&portant side e;ects to &e&ori/e# (ithgreater incidence o% .PS than in atypical agents
Atypical neuroleptics Dopa&ine 5D7 and serotonin 538',7
antagonists 4etter treat&ent o% negative sy&pto&s than
typical agents
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#ypical $euroleptics
?ot as i&portant to &e&ori/e eachindividual typical agent
-e&e&ber that there are lo( and high
potency agents Potency re%ers to action on dopa&ine
receptors
Lo( potency agents reFuire bigger doses
'igh potency agents reFuire s&all doses
'igh potency agents have &ore .PS thanlo( potency agents
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Antipsychotic Side%ects
.xtrapyra&idal sy&pto&s 5.PS7 Dystonia 5spas&7 o% %ace# neck# tongue Parkinsonis&
Akathisia 5restlessness7 Anticholinergic sy&pto&s
Dry &outh# constipation# visual blurring
,ardive dyskinesia
Darting1(rithing &ove&ents o% %ace# tongue Condition can beco&e per&anent Most co&&on in older (o&en
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Atypical Antipsychotics
,ry to re&e&ber key side e;ects -isperidone 5-isperdal7
'yperprolactine&ia
Olan/apine 5yprexa7 'yperlipide&ia# (eight gain# glucose intolerance# liver
toxicity
Huetiapine 5SeroFuel7 Sedation# orthostatic hypotension
Clo/apine 5Clo/aril7 Agranulocytosis# sei/ures
iprasidone 5Geodon7 So&e association (ith H,c changes ?eed to take &edication (ith %ood
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$euroleptic &alignantSyndro'e
"AL,.- "ever 5high7 Altered &ental status Leukocytosis,achycardia1elevated blood pressure .levated CPI -igidity 5
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Agenda
Mood Disorders
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What is ('ood?)
Description o% internal e&otionalstate
Generally# people have a (ide rangeo% &ood and %eel that they haveso&e
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!o''on &ood Disorders
Maor depressive disorder
4ipolar disorder 5+ or ++7
Dysthy&ic disorder Cyclothy&ic disorder
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&a*or Depressive%pisode
"ive sy&pto&s# including depressed&ood or anhedonia# %or at least (eeks
S+G . CAPS
Sleep +nterest Guilt .nergy Concentration Appetite Psycho&otor activity Suicidal ideation
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&a*or DepressiveDisorder
At least one &aor depressiveepisode
?o history o% &ania1hypo&ania
Li%eti&e prevalence is around 63B
Depressive episodes are usually sel%8
li&ited in the long ter butantidepressant &edications are Fuitehelp%ul
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Depression Secondary to a+eneral &edical !ondition
Cerebrovascular disease
.ndocrinological abnor&alities
Cushings# AddisonJs# 'ypoglyce&ia#
'ypothyroidis 'yperthyroidis 'ypocalce&ia#'ypercalce&ia
ParkinsonJs disease
Cancer# e2g2# pancreatic &alignancy#
ly&pho&a Collagen vascular disease# e2g2# lupus
0iral illness# e2g2# &ononucleosis
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Su,stance-.nducedDepression
Alcohol
4arbiturates
4en/odia/epines
Antihypertensives# e2g2# beta8blockers
Corticosteroids
Sti&ulant# e2g2# cocaine# a&pheta&ine
(ithdra(al Anticonvulsants
Many &oreK
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#ypes of Antidepressants
Selective serotonin reuptake inhibitors5SS-+s7
Atypical agents# e2g2# dual8action
inhibitors ,ricyclic antidepressants 5,CAs7
Monoa&ine oxidase inhibitors 5MAO+s7
Aduvant &edications Sti&ulants# antipsychotics# lithiu thyroid
hor&one
)
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SSR.s
Mechanis& +nhibit presynaptic serotonin pu&ps Lead to increased availability o% serotonin in
synaptic cle%t
Advantages "airly sa%e in overdose ?o %ood restrictions
Co&&on side e;ects Gastrointestinal disturbance +nso&nia Sexual dys%unction
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SSR.s/ cont"
Used %or depressive and anxiety disorders -e&e&ber a %e( key points about each agent "luoxetine 5Pro/ac7
Longest hal%8li%e# so&e(hat activating
Sertraline 5olo%t7
'ighest rate o% G+ upset Use%ul %or elderly# least (t gain
Paroxetine 5Paxil7 Most activating agent# highest anticholinergic burden
"luvoxa&ine 5Luvox7 0ery short hal%8li%e# approved %or OCD only
Citalopra& 5Celexa7 Co&&only used given &ini&al drug8drug interactions
.scitalopra& 5Lexapro7 L8enantio&er o% citalopra so use approxi&ately hal% the dose Signi$cantly &ore expensive than Celexa
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Atypical Agents
0enla%axine 5.;exor7 Serotonin1norepinephrine reuptake inhibitor
Can increase blood pressure
*ithdra(al pheno&enon (ith
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Atypical Agents/ cont"
,ra/odone 5Desyrel7
Serotonin antagonist and reuptake inhibitor
Co&&only used to aid (ith sleep
-arely used as an antidepressant Side e;ects to re&e&ber sedation and priapis&
Mirta/apine 5-e&eron7
?orepinephrine and serotonin antagonist
O%ten used in elderly patients
Side e;ects to re&e&ber sedation and (eightgain
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#ricyclic Antidepressants0#!As1
Mechanis& +nhibit reuptake o% norepinephrine and
serotonin
+ncrease availability o% these neurotrans&ittersin the synapse
Side e;ects to re&e&ber Lethal in overdose# usually due to (idened H-S
Convulsions# co&a# cardiotoxicity
Orthostatic hypotention# tachycardia
Dry &outh# constipation# urinary retention
Sedation
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&onoa'ine 23idase.nhi,itors 0&A2.s1
+rreversibly inhibit MAO8A and MAO84
Prevent inactivation o% norepinephrine#serotonin# dopa&ine# tyra&ine
Co&&on side e;ects Orthostatic hypotension
Dro(siness
*eight gain Sexual dys%unction
Sleep dys%unction
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&A2. Side %ects toRe'e',er
Serotonin Syndro&e
Lethargy# restlessness# con%usion# ushing#diaphoresis# tre&or# &yoclonus
Can lead to hyperther&ia# rhabdo&yolysis#kidney inury# co&a# death
Usually occurs (ith MAO+ N SS-+
'ypertensive crisis Can occur i% tyra&ine is ingested (hen on
an MAO+
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&anic %pisode
Abnor&ally and persistently elevated#expansive# or irritable &ood# %or at leastone (eek
D+G "AS, 5need three o% the %ollo(ing# or
%our i% &ood is irritable7 Distractability +nso&nia Grandiosity
"light o% ideas Activity1agitation Speech 5pressured7,houghtlessness
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&ania vs" Hypo'ania
&ania Hypo'ania
Lasts > days Lasts at least ) days
Causes severe i&pair&ent ?o &arked %unctional i&pair&ent
May reFuire hospitali/ation Does not reFuire hospitali/ation
May have psychotic %eatures ?o psychosis
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&ania Secondary to a+eneral &edical !ondition
'yperthyroidis&
Multiple sclerosis
?eoplas& '+08related
Stroke
.pilepsy# e2g2# te&poral lobe sei/ures
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Su,stance-.nduced&ania
Corticosteroids
Sy&patho&i&etics
Dopa&ine agonists 4ronchodilators
Antidepressants 5controversial7
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&ood Sta,iliers
Lithiu&
Carba&a/epine 5,egretol7
0alproic Acid 5Depakote7 La&otrigine 5La&ictal7
Antipsychotics
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4ithiu'
.xact &echanis& is unkno(n
?arro( therapeutic range 5E2> 627
?eed to &onitor ,S' and Creatinine
*atch out (hen also using diuretics# AC.+#?SA+Ds
Side e;ects 'ypothyroidis&
?ephrogenic diabetes insipidus,re&or1ataxia
Polyuria# thirst
*eight gain
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2ther 'ood sta,iliers
Carba&a/epine 5,egretol7 Anticonvulsant ?u&erous side e;ects# including leukopenia# hyponatre&ia#
aplastic ane&ia# agranulocytosis# transa&initis Monitor C4C and L",s
0alproic Acid Anticonvulsant ?u&erous side e;ects# including alopecia# (eight gain#
hepatotoxicity# thro&bocytopenia Ai& %or level o% Q6EE in treat&ent o% acute &ania
La&otrigine
Anticonvulsant Must %ollo( a care%ul titration schedule "a&ous side e;ect is Steven Rohnson Syndro&e Used %or depression predo&inant bipolar disorder
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Agenda
Anxiety Disorders
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What is an3iety?
Subective experienceo% %ear and itsresultant physical
&ani%estations
?or&al and co&&onresponse to perceived
threat
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!o''on An3ietyDisorders
Generali/ed anxiety disorder Obsessive8co&pulsive disorder Panic disorder
Agoraphobia Posttrau&atic stress disorder Acute stress disorder Speci$c and social phobias Substance8induced anxiety disorder Anxiety disorder secondary to general
&edical condition
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+eneralied An3ietyDisorder 0+AD1
Persistent# excessive anxiety andhyperarousal %or at least six &onths
Anxiety surrounds daily events and
activities 0ery co&&on in general population#
especially in (o&en
Associated (ith restlessness# %atigue#
di@culty concentrating# irritability#&uscle tension# sleep disturbance
SS-+s and behavioral therapy are use%ul
)
2, i ! l i
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2,sessive !o'pulsiveDisorder
Obsession -ecurrent and intrusive thought that
causes &arked anxiety Person atte&pts to suppress thought Person reali/es that the thought is a
product o% his or her o(n &ind
Co&pulsion -epetitive behavior that person per%or&s to
respond to his or her obsession An unrealistic atte&pt to alleviate distress
caused by obsession
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2,sessive !o'pulsiveDisorder/ cont"
Several co&&on patterns o% obsessionsand co&pulsions Patterns include conta&ination# sy&&etry#
doubt and subseFuent checking# intrusions o% a
sexual or violent nature SS-+s are $rst line treat&ent
O%ten need higher8than8nor&al doses
4ehavioral treat&ent is also very i&portant .xposure and response prevention
-elaxation techniFues
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Panic Disorder
A panic attack is a brie% 5usually lessthan !E &inutes7 sudden rush o% %earand anxiety
PA?+CS Palpitations
Abdo&inal distress
?u&bness1?ausea
+ntense %ear o% death Choking# chills# chest pain
Shortness o% breath# s(eating
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Panic Disorder/ cont"
,o &eet criteria %or the actual disorder#one &ust have spontaneous recurrentpanic attacks (ithout precipitant
At least one attack &ust cause (orryabout additional attacks# or behavioralchange 5avoidance7
Usually a chronic illness# but variableseverity
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Panic Disorder/ cont"
Consider di;erential diagnosis
Drugs
Sti&ulants# ca;eine# nicotine# hallucinogens
Alcohol# opiate# ben/odia/epine (ithdra(al
Psychiatric illness
Depression# other anxiety disorders
Medical illness ?early any cardiac# pul&onary# neurological#
endocrinological abnor&ality &ay becon%used as panic
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Panic Disorder/ cont"
Acute treat&ent 4en/odia/epines
Propranolol can be used %or per%or&ance
anxiety# but is not as good %or true panic Maintenance treat&ent
SS-+s start lo( and increase slo(ly#(atching %or activation
-elaxation training
Cognitive therapy
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Agorapho,ia
De$nition "ear o% open places
O%ten# but not al(ays# develops secondary
to panic disorder ?eed to speci%y i% panic disorder is (ith
or (ithout agoraphobia
+% you treat the panic disorder#
agoraphobia o%ten resolves Agoraphobia not associated (ith panic
is &uch &ore di@cult to conFuer
)
P#SD A t St
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P#SD vs" Acute StressDisorder
P#SD Acute StressDisorder
.vent occurred any ti&e in past .vent occurred less than 6&onth ago
Sy&pto&s last &ore than one&onth
Sy&pto&s last less than one&onth
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P#SD A t St
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P#SD vs" Acute StressDisorder/ cont"
Criteria %or both disorders are the sa&e
*itness trau&atic event
Persistent re8experiencing o% event
?ight&ares "lashbacks
Avoidance o% sti&uli associated (ithtrau&a
Persistent hypervigilence1increased arousal
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P#SD A t St
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P#SD vs" Acute StressDisorder/ cont"
,reat&ent
Medication &anage&ent
SS-+s are $rst8line
Alpha86 adrenergic receptor antagonists#e2g2# Pra/osin
4ehavioral therapy
Psychotherapy nu&erous techniFues
-elaxation training
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Pho,ias
Most co&&on psychiatric disorder Speci$c phobia
.xaggerated %ear o% speci$c obect or situation 'eights# ani&als# ying# etc2
,reat (ith syste&ic desensiti/ation
Social phobia .xaggerated %ear o% social situations in (hich
hu&iliation could occur
,reat (ith SS-+s and cognitive therapy Phobias are ego8dystonic# i2e2# the person
kno(s that %ear is exaggerated
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S , t . d d A i t
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Su,stance-.nduced An3ietyDisorders
Ca;eine
A&pheta&ines
Alcohol and sedative (ithdra(al Other illicit drug (ithdra(al
Antidepressants
Carbon dioxide inhalation
Many &oreK
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to +eneral &edical
!ondition .ndocrinological abnor&alities 'yperthyroidis& 'ypoglyce&ia Pheochro&ocyto&a
?eurological disorders Sei/ure disorders 4rain tu&ors Multiple sclerosis
Cardiovascular disease Pul&onary disease
'ypoxia is anxiety provoking
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How to #reat An3iety?
-egardless o% precise disorder# usually useshort8ter& treat&ent (ith ben/odia/epines#and &aintenance treat&ent (ith SS-+s
4e %a&iliar (ith the types o%ben/odia/epines and their ti&e toonset1duration o% action
-ecogni/e abuse potential o%ben/odia/epines
4eta8blockers are use%ul %or akathisia andautono&ic e;ects o% panic1per%or&anceanxiety
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Agenda
Personality Disorders
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What is a personality
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What is a personalitydisorder?
+nexible pattern o% interaction thati&pairs social %unctioning
Patients do not have insight into their
proble&atic interaction style
Onset in adolescence1early adulthood
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#est Worthy &aterial
4e %a&iliar (ith the three clusters o%personality disorders
Ino( (hich speci$c disorders %all
into each cluster
Me&ori/e a %e( key %acts about eachdisorder# but speci$c diagnostic
criteria (ill be di@cult to test
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!luster A: (Weird)
.ccentric# (ithdra(n# border onpsychosis
Schi/oid Huiet and reclusive Do not desire close relationships
Schi/otypal
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!luster B: (Wild)
.&otional# dra&atic# o%ten (ith &ooddisorders
Antisocial Disregard %or sa%ety o% others Manipulate %or personal gain O%ten violate the la(
4orderline Desperate atte&pts to avoid abandon&ent Unstable and intense relationships -ecurrent suicidal thoughts# sel%8&utilation May
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!luster B: (Wild/) cont"
'istrionic
Attention8seeking behavior
"la&boyant and extroverted
O%ten sexually inappropriate
?arcissistic
.xaggerated sel%8i&portance
-eFuire ad&iration %ro& others
May exploit others %or sel%8gain
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!luster !: (Worried)
Anxious# %ear%ul#
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Personality Disorder#reat'ent
O%ten# patients have co8existing&ood and anxiety disorders
,reat co8occurring disorders (ith
&edication and therapy as appropriate
Personality disorders are di@cult totreat
Psychotherapy is the &ainstay o%treat&ent
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Agenda
Substance Use Disorders
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Su,stance A,use vs
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Su,stance A,use vs"Dependence
A,use Dependence
Pattern o% use leading toi&pair&ent %or at least one year
Pattern o% use leading toi&pair&ent %or at least one year
?eed one or 'ore o% %ollo(ing ?eed three or 'ore o%%ollo(ing
"ailure to %ul$ll obligations at(ork# school# ho&eUse in dangerous situations-ecurrent legal proble&s due tosubstance useContinued use despite socialpro,le's due to use
Patient !A$$2# 'eet criteriafor dependence/ as suchsupersedes a diagnosis ofa,use"
"ailure to %ul$ll obligations (ork#school# ho&e#oleranceWithdrawalActual use exceeds extended useContinued use despite 'edicalor psychological pro,le'sdue to usePersistent desire orunsuccessful eorts to cutdown on useSigni$cant ti&e spent using#getting# recovering %ro& 99
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5ey #er's
+ntoxication Signs and sy&pto&s di;er by drug o%
choice
O%ten con%used (ith (ithdra(al *ithdra(al
Substance8speci$c syndro&e due tocessation o% prolonged substance use
,olerance ?eed %or increased a&ount o% substance
to achieve desired e;ect
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Alcohol
Most co&&only abused substance
9
Alcohol
Acetaldehyde
Acetic acid
Alcohol dehydrogenase
Aldehyde dehydrogenase
Disul$ra&5Antabuse7
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Alcohol .nto3ication
.nsure A4Cs
Monitor electrolytes
Check $nger stick glucose
Consider breathaly/er or bloodalcohol level
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Alcohol Withdrawal
Can be li%e threatening Mild
+rritability +nso&nia
Mild tre&or Moderate
Disorientation "ever
Severe Autono&ic instability Sei/ures Deliriu& ,re&ens
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Deliriu' #re'ens
4egins (ithin 8! days o% alcoholcessation
'igh &ortality rate i% untreated
Deliriu& is the key characteristic Patients have altered# (axing and (aning
sensoriu&
May also have hallucinations 5visual ortactile7# psycho&otor changes#autono&ic instability
>6
#reat'ent of Alcohol
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#reat'ent of AlcoholWithdrawal
"reFuent vital sign checks vs2tele&etry
,aper doses o% ben/odia/epines
Chlordia/epoxide 5Libriu&7
Lora/epa& 5Ativan7
Dia/epa& 50aliu&7
Sei/ure precautions
Multivita&in# thia&ine# %olate
>
Wernic6e7s
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Wernic6e s%ncephalopathy
,hree key characteristics
Ataxia
Con%usion
Ocular proble&s
An acute proble& that can bereversed (ith thia&ine
Al(ays give thia&ine be%ore glucose
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5orsa6o7s Syndro'e
Chronic and o%ten irreversible
+&paired recent &e&ory
Anterograde a&nesia
Con%abulation o%ten present
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2piates
Sti&ulate opiate 5&u# kappa# delta7receptors +nvolved in analgesia# sedation# dependence
.xa&ples 'eroin
Codeine
Morphine
Methadone Meperidine
Dextroðorphan
>3
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2piate .nto3ication
Dro(siness1altered &ental status
-espiratory depression
Constipation
Constricted pupils
Can progress to co&a or death inoverdose
,reat&ent .nsure A4Cs
Can use naloxone or naltrexone i% there isrespiratory co&pro&ise
>9
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2piate Withdrawal
Craving1Anxiety
Lacri&ation
-hinorrhea
Diaphoresis Abdo&inal disco&%ort
Mydriasis
Myalgias +rritability
>>
#reat'ent of 2piate
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#reat'ent of 2piateWithdrawal
Sy&pto&atic relie% %or nausea#vo&iting# &yalgias# anxiety# andinso&nia
Clonidine -educes catechola&ine release %ro&
sy&pathetic nervous syste&
Methadone or buprenorphine &ay beconsidered %or (ithdra(al and1or&aintenance treat&ent
>
S d i i
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Sedative-Hypnotics
4en/odia/epines
Potentiate GA4A by increasing%reFuency o% chloride channel opening
4arbiturates Potentiate GA4A by increasing duration
o% chloride channel opening
>
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E
Sedative-Hypnotic
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Sedative Hypnotic.nto3ication
Dro(siness1altered &ental status
Lack o% coordination1ataxia
-espiratory depression
?ystag&us
Death or co&a in overdose#
especially in co&bination (ithalcohol
6
Sedative-Hypnotic
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Sedative HypnoticWithdrawal
Maintain A4Cs
"lu&a/enil
Short8acting ben/odia/epine antagonist
that can be used in overdose treat&ent May precipitate sei/ures
4asic principle is sa&e as alcohol
,aper ben/odia/epines# &aintain sei/ureprecautions# (atch %or autono&icinstability
2th S , t
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2ther Su,stances
*e see patients (ho abuse or &eetdependence criteria %or a host o% othersubstances
+n a test situation# ust recogni/e i% thesubstance is an
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Agenda
Cognitive Disorders
)
What is a cognitive
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What is a cognitivedisorder?
Proble& (ith &e&ory# orientation#attention# and1or udg&ent
,hree &aor categories
De&entia
Deliriu&
A&nestic disorder
3
D ti D li i
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De'entia vs" Deliriu'
De'entia Deliriu'
Me&ory i&pair&ent Sensoriu& i&pair&ent
Slo( onset 5generally7 Acute onset
Sy&pto&s are stable throughoutthe day
*axing and (aning course
Usually not reversible Usually reversible i% identi%y cause
9
D ti
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De'entia
Me&ory i&pair&ent (ithout change in level o%consciousness
May have behavioral disturbance and1orpsychosis
*atch out %or pseudode&entia# i2e2# depressed&ood that &asFuerades as de&entia ?eed to rule out reversible causes o% de&entia
461%olate de$ciency 0D-L1-P-
,hyroid abnor&alities .lectrolyte abnor&alities
>
Al h i 7 Di
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Alhei'er7s Disease
Most co&&on type o% de&entia
Progressive and linear course
O%ten have personality and &oodchanges
Pathology
?euro$brillary tangles 5,au protein7
Senile plaFues 5A&yloid protein7
Alhei'er7s Disease/
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/cont"
?eed &e&ory proble&s plus one o%the %ollo(ing
Aphasia Language di@culty
Apraxia Purpose%ul &ove&ent5
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/cont"
Assess cognition at regular intervals
Use antidepressants i% patient has truedepression
Consider lo(8dose antipsychotics to treatassociated behavioral disturbance
So&e &edications &ay slo( rate o% decline
?MDA receptor antagonists 5Me&antine7
Cholinesterase inhibitors 5Donepe/il#-ivastig&ine7
E
8ascular De'entia
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8ascular De'entia
Cognitive de$cit secondary to in%arctburden
Clinical criteria are identical to that o%Al/hei&erJs disease .tiology and progression are di;erent
Step8(ise course
?eurological de$cits are co&&on
Sa&e li&ited treat&ents as (ithAl/hei&erJs disease# but &ust alsocontrol vascular risk %actors
6
Deliriu'
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Deliriu'
"luctuating clinical course
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Deliriu'/ cont"
"irst and %ore&ost# try to identi%y theunderlying cause o% deliriu&
Until the etiology is identi$ed# can
only provide sy&pto&atic treat&ent "reFuent re8orientation
Lo(8dose antipsychotic to treat agitation
Avoid ben/odia/epines andanticholinergic agents# as these cancause paradoxical disinhibition
!
A'nestic Disorders
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A'nestic Disorders
Me&ory i&pair&ent (ithout other cognitiveproble&s associated (ith de&entia
?o alteration in consciousness
Al(ays occur secondary to &edicalcondition Sei/ures
'ypoxia
'ead trau&a
Substance use
Many &oreK
)
Agenda
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Agenda
Other Disorders
3
&ental Retardation
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&ental Retardation
Signi$cant de$cits in intellectual %unctioningand age8appropriate adaptive skills
+H is >E or belo(
Onset in childhood# be%ore age 6 years Most &ental retardation has no clear cause
So&e genetic syndro&es are i&plicated# e2g2#Do(nJs Syndro&e# "ragile # Prader *illi#
Angel&anJs Prenatal and perinatal exposures can play
signi$cant roles
9
Pervasive Develop'ental
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pDisorders
De$cits in social skills# language# behavior +&pair&ent is apparent in early childhood
Autis& Di@culties (ith social interaction
Co&&unication i&pair&ent 5non8verbal ordelayed speech7
-epetitive and stereotyped behavior
AspergerJs Disorder Si&ilar to autis but higher %unctioning
because cognitive develop&ent and languageskills are nor&al
>
Disruptive Behavioral
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pDisorders
Conduct disorder Pattern o% behavior that violates rights o%
others and de$es social nor&s
Aggression to(ard people# ani&als# property
Serious rule violation,hink precursor to antisocial personality
disorder
Oppositional de$ant disorder 5ODD7 'ostile and de$ant behavior 4ig di;erence %ro& conduct disorder is that
ODD patients do not violate the rights o% others
Attention De9cit
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Hyperactivity Disorder
Onset be%ore age seven years
4ehavior is inconsistent (ith age anddevelop&ent
Sy&pto&s involve inattentiveness#hyperactivity# or both %or 9 &onths
Mainstay o% treat&ent is C?S sti&ulants#
e2g2# ðylphenadate#dextroa&phata&ine
So&e role %or behavioral &odi$cation
%ating Disorders
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%ating Disorders
Anorexia nervosa 4ody (eight is 63B belo( nor&al +ntense and distorted body i&age preoccupation A&enorrhea
4uli&ia nervosa -ecurrent binge eating and atte&pts to
co&pensate 5vo&iting# laxatives# diuretics#and1or excess exercise7
+ntense and distorted body i&age preoccupation
4ehavioral therapy and individualpsychotherapy is &ainstay# as (ell ascontrol o% &edical co&orbidities
6EE
#he %nd
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#he %nd
GOOD LUCIT