Psych Clerkship Psychotic Disorders: What is the DSM Criteria for schizophrenia? A.

At least 2 of the following: Hallucinations Delusions Disorganized speech Disorganized behavior Negative Sx: alogia, avolition, attention, affect, anhedonia Only one of the preceding is needed if the delusion is bizarre (bizarre includes thought control, passivity of experience, passivity of thought -- thought-broadcasting, thought-insertion, thought-withdrawal), the auditory hallucinations involve running commentary, or there are 2 or more voices talking to each other B. Severity: Significant social and/or occupational dysfunction C. Duration: Must be present for at least 6 mos and includes at least 1 month in which there is an active-phase of sx (delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, or ideas of reference ) D. Rule out: schizoaffective disorder and mood disorder with psychotic features E. A substance or gen med condition cannot cause the sx Epi: 1% of population, avg onset 18-25 yrs in men and 25-35 yrs in women, 20-40% attempt suicide and 10% succeed What is the DDx for schizophrenia? Medical: -CNS: cerebrovascular dz, MS, neoplasm, Parkinsons dz, Huntingtons temporal lobe epilepsy, encephalitis, prion dz -Systemic: endocrinopathies (addisons/cushings dz, hyper/hypothyroidism); nutritional/vitamin def states (B12, folate, niacin), other (SLE, temporal arteritis, pophyria) Substance: medications: steroids, anti-convulsants, amantadine illicit substances: intoxication (hallucinogens, cocaine, phencyclidine (PCP), methamphetamine) or withdrawal (alcohol, benzodiazepines) psychotic: delirium/dementia bipolar disorder major depression with psychotic features brief psychotic schizophreniform schizoaffective schizophrenia delusional disorder substance-induced psychotic What is the prognosis of psychotic/mood disorders from best to worst? Mood disorder > brief psychotic disorder > schizoaffective > schizophreniform > schizophrenia How do you distinguish between schizoaffective, schizophrenia, mood disorder with psychosis? Schizophrenia: psychosis + mood sx Schizoaffective: psychosis with and without mood disorder, mood disorder is only present during psychosis Mood disorder with psychosis: psychosis ONLY with mood disorder, mood sx are present without psychosis What is the algorithm for Rx? Hospitalization Want to prevent harm Establish dx Response Rx co-morbidities

Who gets TD sx? 5% of pts on first generation 1/10 of pts on second generation clozapine 0% Describe the first generations: MOA: block D2 receptors Think: potency and efficacy! (efficacy is the same for all drugs) High potency Haldol 2mg = 100mg of Chlorpromazine Medium Potency Perphenazine 10mg = 100mg of Chlorpromazine o Perphenazine is inherently anti-cholinergic so DONT use cogentin Low Potency Chlorpromazine 100mg Side effects: o Extrapyramidal: seen with high potency traditional antipsychotics; dystonia (spasms of face, neck, and tongue) parkinsonism (resting tremor, rigidity, bradykinesia), akathisia (feeling of restlessness) Rx: beta-blocker like propranolol Rx: benztropine, amantadine, benzodiazepines o Hyperprolactinemia: galatorrhea, impotence, amenorrhea, gynecomastia (D2 inhibits PR normally so with inhibition of D2 you get PR release) o Anticholinergic sx: seen with low potency traditional antipsychotics and atypical antipsychotics (dry mouth, constipation, blurred vision) Rx: stool softener and eye drops o Tardive dyskinesia: seen in high potency anti-psychotics, darting or writhing movements of the face, tongue, and head Epi: older women after at least 6mos of medication; 50% may have spontaneous remission) Rx: discontinue offending agent and substitute atypical nueroleptics; benzodiazepines, beta blockers, cholinomimetics short term o NMS: seen with high potency anti-psychotics Describe the second generations: Drugs: clozapine, risperidone, olanzapine (zyprexa), quetiapine (seroquel), ziprasidone MOA: 5HT2 + D2 antagonists Quetiapine (Seroquel) is the cleanest 2nd generation Risperidol has high D2 activity so still get EPS and TD Clozapine and olanzapine (zyprexa) have the worst metabolic syndrome side effects Ziprasidone and aripiprazole (abilify) are the best for metabolic syndrome side effects Clozapine and quetiapine (seraquel) have the best anti-TD effects Side effects: metabolic syndrome obesity, hyperlipidemia, hypertension, glucose intolerance (worst clozapine and olanzapine = zyprexa and the best are ziprasidone and aripiprazole=abilify) What is unique about clozapine? MOA: less D2 action and more 5HT so dont have EPS and TD or prolactin side effects SE: agranulocytosis Clinical implications: CBC every week for the first 6mo and biweekly after that o Anticholinergic side effects, weight gain and metabolic syndrome, NMS What is unique about ariprazole or abilify? MOA: partial agonist so at high doses will see antagonism of 5HT and D2 (will bind to 30% of receptors and have prodopaminergic activity) and at low doses it acts like an agonist SE: less EPS effects but still see activation (insomnia) and akithesia; NO INCREASED RISK OF WEIGHT GAIN Clinical use: can be used to eliminate the negative sx of depression at low doses since has + dopamine activity but at higher doses can see avolition (lack of drive), flat affect What is unique about risperidone? MOA: more D2 action and less 5HT so still has EPS and TD and prolactin effects SE: EPS in high doses, postural hypotension, increased prolactin, weight gain, sedation, decreased concentration, PRESENT IN BREAST MILK Half-life is 3 hours in fast metabolizers and 120 in poor metabolizers When you are getting lots of TD side effects from first generation anti-psychotics what should you do? 5% of ppl will get TD from Rx Slowly withdraw from current medication and put the patient on clozapine

Do not want to stop all at once because D2 receptors have been upregulated; thus, you can end up causing tons of movement due to excess D2 receptor firing Down-titrate then cross-titrate up slowly

What causes the EPS? Seen in highly potent D2 antagonists like: haldol and trifluoperazine (lower potency such as chlorpromazine and thioridazine have primary anti-cholinergic effects) dystonia (spasms of face, neck, and tongue) Parkinsonism (resting tremor, rigidity, bradykinesia) o Parkinsons: decreased dopamine activating the D1 and D2 receptors so have less movement 1. Bradykinesia 2. Tremor 3. Rigidity 4. Postural instability (ataxia, micrographia) Huntingtons: lose neurons projecting from striatum to the GPe so it basically acts the same just uncontrolled. What happens is there is decreased inhibition on GPe increased inhibition of STN less activation GPi/STN and thus less inhibition of VL/VA resulting in hyperkinetic movements Akathisia (feeling of restlessness) MOOD DISORDERS What is a mood disorder? Mood is a description of someones internal emotional state and internal and external stimuli can change someones mood People with mood disorders have an abnormal range of moods and lose control of them What is the difference between a mood episode and disorder? Mood disorder is defined by a pattern where as mood episode is a distinct period of time What are the types of mood episodes? Major depressive episode (can be present in MDD and in bipolar I/II) Manic episode Mixed episode Hypomanic episode What are the main mood disorders? Major depressive disorder Bipolar I disorder Bipolar II disorder Dysthymic disorder Cyclothymic disorder * any of these may have psychotic features also (delusions and hallucinations) What are the criteria for Major Depressive Episode? Must have at least 5 of the following sx including 1 or 2 for at least 2 weeks: o Depressed mood o Anhedonia o Change in sleep o Decreased interest o Guilt or feelings of worthlessness o Decreased energy level o Diminished concentration o Change in appetite or body weight o Psychomotor agitation or retardation (restlessness or slowness) o Suicidal ideation *cannot be due to substance use or medical conditions and must cause significant occupational or social impairment * someone hospitalized for major depressive episode has a 15% chance of committing suicide later in life EPI: o Lifetime prevalence: 15% o 2x more likely in females o age of onset is 40 and there are no socioeconomic differences

o prevalence in elderly from 25-50% o first degree relatives are 2-3x more likely to have MDD o 2/3 of depressed ppl contemplate suicide and 10-15% are successful MDD is someone who has had at least one major depressive episode Prognosis: episodes can be self-limiting after 6-13 mos and 50% usually have another episode within 2 years; about 15% eventually commit suicide; 75% can be Rx successfully Rx: Note: all medications have same efficacy but differ in the side effect profile meds take 4-8 weeks to work Should be on meds for 6-12mos Meds alone: 60-65% improvement in sx, psychotherapy alone 60-65%, combo 70-75%, placebo 20-30% o Hospitalization if SI, HI, or cant care for self o First line--SSRIs: fluoxetine (prozac), sertraline (zoloft), paroxetine, fluvoxamine, citalopram (celexa), escitalopram MOA: inhibition of serotonin reuptake side effects are mild and include HA, GI (loose stool), 40-65% have sexual dysfunction, and rebound anxiety activation (insomnia, agitation, akathesia) o TCAs: amitriptyline, doxepin, imipramine, clomipramine (Rxs OCD features), trimipramine, desipramine (least anti-cholinergic SE), nortriptyline, protriptyline, amoxapine MOA: reduces uptake of serotonin and NE side effects include sedation, weight gain (anti-histamine effect), orthostatic hypotension (alphablockade), anticholinergic effects (dry mouth, constipation, urinary retention, blurry vision), prolongation of QT interval most lethal in overdose o MOAIs: phenelzine, isocarboxazid, selegiline, tranylcypromine MOA: inhibition of monoamine oxidase Clinical use: refractory depression SE: hypertensive crisis when used with sympathomimetics or ingestion of tyramine-rich foods (wine, beer, aged cheeses, liver, and smoked meats); risk of serotonin syndrome when in combination with SSRIs serotonin syndrome= autonomic instability, hyperthermia, and seizures, coma and death note: use anti-psychotics in patients with psychotic features note: liothyronine (T3), levothyroxine (T4), lithium, or L-tryptophan can be used to convert nonresponders to responders

When prescribing drugs to the elderly what should you look out for? Patients are more sensitive to side effects especially orthostasis and anti-cholinergic effects On lots of meds so beware of drug-drug interactions start low and go slow What are the random anti-depressants? Nefazodone: MOAserotonin antagonist + reuptake inhibitor SEsedation, hepatotoxicity, and less sexual SE Traxodone: MOAserotonin antagonist + reuptake inhibitor SEpripism prolonged erection may lead to impotence, orthostateic hypotension, sedation, can be used to manage sleep in low doses Mirtazapine: MOANE and 5HT antagonist SEweight gain and sedation no interference with sexual function Bupropion: MOA NE and dopamine reuptake inhibitors SEGI, anorexia, risk of seizures, good for helping to stop smoking, contraindicated in patients with an eating disorder or seizure disorder What is unique about fluxoetine? 1-3 day half-life = very long! If patient is having severe reaction to side effect it will take a while to leave their system What is unique about sertraline? Cause diarrhea more than others; 1 day half-life Least drug-drug interactions What is unique about citalopram? It has fewer sexual side effects What is unique about paraxotine?

More drug-drug interactions, sedation, and weight gain

What are the SSNRIs? Duloxetine treats GAD and painful diabetic neuropathy Venlafaxine treats GAD and social anxiety What is ECT? Electroconvulsive therapy: atropine is given, followed by anesthesia, and a muscle relaxant; a generalized seizure is then induced by passing a current of electricity across the brain with unilateral or bilateral electrodes that are placed on the forehead and the seizure lasts for < 1 min Thought to change neurotransmitter receptors and second messenger system in the brain 2-3x per week for a total of 6-12 Rx SE: anterograde and retrograde amnesia that can disappear after 6 mos Indications: best Rx for MDD + psychotic sx preferable to antidepressant + anti-psychotic when need immediate results, imminently suicidal, catatonic, not taking in food or fluids Clinical use: patients that have difficulty tolerating anti-depressants like the elderly or who are non-responsive to therapy; psychotic features; suicidal; refusing food or fluid, catatonic What are the unique features of depressive disorders? Melancholic 40-60% anhedonia, anorexia, early morning wakings, psychomotor disturbance, excessive guilt Catatonic immobility, echolalia, purposeless motor activity, extreme negativism or mutism, bizarre postures Atypical hyperphagia, hypersomnia, reactive mood, leaden paralysis, hypersensitivity to interpersonal rejection Psychotic10-25% of hospitalized depressions delusions and hallucinations How do you distinguish dementia from pseudodementia or MDD in the elderly? With depression the cognitive impairment may be transient and reversible with treatment During interview depressed patients may not try whereas demented patients will What are the criteria for manic episode? Period of abnormally and persistently elevated, expansive, or irritable mood lasting 1 week that includes at least 3 of the following: (4 if mood is irritable) o Distractibility o Impulsivity excessive involvement in pleasurable activities that have a high risk of neg. consequences (sexual & buying tons of shit) o Grandiosity o Flight of ideas or racing thoughts o Activity or agitation increased in goal-directed activity (social, work, sexual) o Sleep decreased sleep o Talkative pressured speech *cannot be due to substance use or medical conditions and must cause social or occupational impairment *75% have psychotic sx *manic episode is a psychiatric emergency bc of impaired judgment person is risk to themselves and others What are the criteria for mixed episode? Must have both manic episode and major depressive episode nearly every day for at least 1 week. Psychiatric emergency What is the criteria hypomanic episode? Period of abnormally elevated, expansive, or irritable mood that includes 3 of the four sx of manic episode unless irritable in which case need 4. Differences between hypomania and mania: o Mania lasts 7 days hypomania lasts 4 days o Mania causes significant social and occupational impairment hypomania does not o May need hospitalization for mania and not hypomania o Psychotic features in mania and not hypomania What is the DDx for mood disorders secondary to medical conditions? Medical causes of depressive episode:

Effects: energy, mood elevation, increased confidence, increased libido, decreased appetite Phsyiological: increased HR, BP, core temp, increasing liklihood of seizures Psych: mania, hallucinations, schizophreniform, deprssion Repetitive behaciors: pacing, bruxism, skin picking Sexual: priaprism with ejactulatory failure, impotence, compulsive masturbation, orgasmic failure o Cerebrovascular dz o Endocrinopathies: cushings, addisons, hypoglycemia, hypo/hyperthyroidism, hypo/hypercalcemia o Parkinsons dz o Mono o Cancer: lymphoma and pancreatic carcinoma o Collagen vascular dz (SLE) Medical causes of manic episode: o Metabolic (hyperthyroidism) o Neurolofical disorders (temporal lobe seizures, MS) o Neoplasm o HIV Substance-induced depressive disorder: o EtOH, anti-hypertensives o Barbituates(barbiDURate): MOA: increase duration of the opening of GABA channel by binding to the receptor; increased influx of Cl SE: 1. Interact with other drugs! Inducer of microsomal enzyme in the liver and can get crosstolerance need to give larger dose to get same reaction 2. MOOD effects and potential for abuse 3. NOT SPECIFIC widespread effects in the CNS and can depress respiration and depress vasomotor center and drop BP used in suicide attempts 4. With longterm use easier to accidently overdose bc the therapeutic index goes down ultra-short acting (thiopental redistributes to another site like to fat), short/intermediate (pentobarbital metabolized by the liver), long-acting (Phenobarbital metabolized in the liver but not as efficiently and will then be excreted by kidneys) o Corticosteroids o L-dopa o Sedative-hypnotics o Anti-convulsants o Anti-psychotics o Diuretics o Sulfonamides o Withdrawal from alcohol or cocaine Cocaine: MOA inhibits the reuptake of NE, Dopamine, and serotonin (sympathetic activation and excessive vasoconstriction) Effects: energy, mood elevation, increased confidence, increased libido, decreased appetite Phsyiological: increased HR, BP, dilated pupils; increased core temp, increasing likelihood of seizures Psych: mania, hallucinations, schizophreniform, depression Repetitive behaviors: pacing, bruxism, skin picking Sexual: priaprism with ejactulatory failure, impotence, compulsive masturbation, orgasmic failure Binge-pattern: patient will not eat or sleep and then have a post-binge crash followed by low mood, anhedonia, decreased energy, poor concentration Substance induced mania: o Corticosteroids o Sympathomimetics o Dopamine o Agonists o Antidepressants o Bronchodilators o L-dopa

What is SAD?

Seasonal affective disorder is a subtype of depression that is prevalent in the winter months and responds to Rx with light therapy

What type of sleep problems do people with MDD have? Multiple awakenings Initial and terminal insomnia (hard to fall asleep and early morning awakening) Hypersomnia REM sleep shifted to earlier in night and stages 3 and 4 are decreased What is the criteris for bipolar I disorder? Only need to have one mixed or manic episode (10-20% only have manic episodes) Epidemiology onset = 30 Prognosis is worse than MDD; only 50-60% respond to lithium and have improved sx Rx: lithium, carbamazepine, or valproic acid anticonvulsants are good for rapid cycling Olanzapine for anti-psychotics ECT works better than depression but need more Rxs What is the criteria for Bipolar II disorder? one or more major depressive episodes and at least one hypomanic episode if the patient has ever had a full manic episode they are considered to have bipolar I What should be on the ddx for children with bipolar disorder? The 1 week duration of sx in children is very important and should be followed when making the dx of mania and hypomania in children or adolescents In adolescence episodes of mania are often accompanied by psychotic features Hypomania should be differentiated from o ADHDdistractibility, impulsivity, hyperactivity persists everyday since b/f 7 yo o ODDpatient defiantly opposed others wishes o CD patient defiantly opposes social rules o Note: ADHD and ODD or CD can present like bipolar with distractibility, angry outbursts, motor agitation What is the best treatment for bipolar I disorder with psychotic features? Valproic acid or lithium and atypical antipsychotic agent Atypical antipsychotics are not teratogenic but mood stabilizers are What is the AACAPs recommendation of Rx of bipolar dz? American Academy of childrens adolescent psychiatry recommends monotherapy with traditional mood stabilizers like lithium, divalproex, and carbamazepine or the atypical antipsychotics olanzapine, quetiapine, and risperidone if no psychosis is present. If no psychosis = lithium and divalproex are first meds of choice Lithium = only FDA approved mood stabilizer > 12 yrs of age Divalproex is used for seizure disorders and has a well-established safety and risk profile for children <12 If both paranoia and though disorder should be started on both atypical antipsychotic and mood stabilizer What is divalproex? A derivative of valproic acid What is lithium? MOA: inhibits adenylate cyclase enzyme SE: o diabetes inspiduspolyuria, thirst, weight gain, polydipsia, acne o Nausea, tremor (Rx with propranolol), hypothyroidism, GI, arrhythmias, seizures, metallic taste, leukocytosis (benign increase in WBC count) o TESTING: should be done before treatment and yearly there after every 6 mos for TSH and Cr-- renal function tests (BUN, Creatinine, specific gravity), thyroid testing, fasting blood glucose, pregnancy test, ECG o Lithium levels should be measured at least every 3 mos once the patient has been stabilized on medication

What is valproic acid? MOA: opens chloride channels; unknown SE: o Thrombocytopenia, pancreatitis, weight gain, hair loss, GI, cognitive dulling o Neural tube defects in pregnancy TESTING: CBC, LFTs, pancreatic enzymes, serum hCG levels in childbearing women What is carbamazepine? MOA: inhibits repetitive firing of action potentials by inactivating Na+ channels; use-dependent SE: o N/V, slurred speech, low WBC, high LFTs, cognitive slowing, may cause craniofacial defects in newborns o TESTING: agranulocytosis CBC should be drawn every 2 weeks for the first 2 mo of Rx and thereafter once every 3 mos platelet, reticulocyte, and serum iron levels should be determined and measured yearly LFTs should be performed initially every mos for first month and then every 3 mos thereafter Potent inducer of P450 system What is the criteria for dysthymic disorder? Mild depression most of the time with no discrete episodes; rarely need hospitalization; 2 Ds 2 years of depression and 2 of the listed criteria; never asymptomatic for > 2mos and cannot have psychosis Depressed mood for majority of the time of most days for at least 2 years (in children for at least 1 year): At least 2 of the following CHASES: difficulty concentrating, hopelessness, poor appetite, decreased or increased sleep, low energy, low self-esteem During the 2 years: not been without the above sx for >2mos at a time and no major depressive disorder Note: if the patient has ever had manic or hypomania the dx would be bipolar or cyclothymic disorder EPI: lifetime prevalence 6%, 2-3x more likely in women, onset before 25 in 50% of pts Prognosis 20% develop major depression, 20% develop bipolar disorder, 25% have lifelong sx Rx: psychotherapy is most effective and antidepressants are useful when used concurrently (SSRIs, TCAs, MOAIs) o SSRIs, SNRIs, buproprion What are differences between dysthymic disorder and major depressive disorder? Dysthymic chronic and earlier onset teenage years and early adulthood What is the criteria for cyclothymic disorder? Numerous periods with hypomanic and periods of depressive sx for at least 2 years No hx of major depressive episode or manic episode Never been free from sx for > 2mos EPI: usually comorbid with borderline personality disorder; onset usually age 15-25 PERSONALITY DISORDERS What is a personality disorder? Patterns of perceiving, relating to, and thinking about the environment and oneself that are inflexible, maladaptive, and cause significant impairment in social or occupational functioning Ego-syntonic: character deficit perceived by the patient to be acceptable, unobjectionable, and consistent to the self, usually blames others for the problems that occur Ego-dystonic: inconsistent to self What is intellectualization? Things are re-hashed in an abstract, distant, emotionally barren way What is projection? Attributing unacceptable feelings, impulses, or thoughts to another person example: a pt is angry with their therapist accuses the therapist of being angry with him What are the clusters for personality disorders?

Cluster A: MAD odd or eccentric behaviors o Schizoidloner, detached, flat, restricted and generally indifferent to interpersonal relationships o Schizotypalodd, eccentric, magical thinking (association between certain acts and events), paranoid, NOT PSYCHOTIC defenses: projection, regression, fantasy o Paranoidsuspicious and distrustful with constricted affect defense: projection Cluster B: BAD dramatic or emotional o Histrionic excessively emotional, attention-seeking defense: reaction formation o Narcissisticself-important, needs admiration, dismissive feelings of others o Borderlineimpulsive unstable relationships, affective instability defense: splitting (cannot synthesize good and bad so polarize), projection o Anti-sociallacks empathy towards others, must have met criteria for CD as a child Cluster C: SAD anxious or fearful o Obsessive compulsivecompulsive, perfectionist, control freak, hyper-focused on orderliness; defense: reaction formation (unacceptable emotions and impulses manifest in the exact opposite tendency: stokholm syndrome) o Avoidant hypersensitive to criticism, socially uncomfortable, seeks out interpersonal relationships but with great discomfort (afraid of relationships but want them) o Dependent submissive, clinging, needs to be taken care of, seeks others to make decisions for them

ANXIETY DISORDERS What is the criteria for social phobia? Marked persistent fear of at least one social or performance situation in which exposure to unfamiliar people or scrutiny will occur; fears humiliation or embarrassment Exposure to the feared situations provokes anxiety that can take the form of a panic attack Knows the fear is unreasonable Avoids the feared situations so that it can interfere with normal routine Not related to general medical condition EPI: most common mental disorder 5-10% of the population; specific phobias are more common than social phobias; women>men What is the treatment of choice for social phobia? Behavioral or CBT therapy with relaxation training and progressive desensitization Pharmacotherapy: o Benzodiazepines: diazepam (valium 20-70), lorzaepam (ativan 10-70 h) clonazepam (klonopin 19-50) MOA: increase the frequency of the opening of the Cl- channel Actions: decrease REM sleep; most have long half-lives and active metabolites (TOM is short acting with highest addictive potential = triazolam, oxazepam, midazolam) Clinical use: anxiety, spasticity, status epilepticus (lorazepam, diazepam) detoxification (alcohol withdrawal-DTs) night terrors, sleepwalking SE: additive CNS depression with alcohol, less risk of respiratory depression than barbituates o Beta-blockers: Propranolol and atenolol MOA: the beta-adrenergic receptor is used just before the feared situations o SSRIs: can use escitalopram, paroxetine, sertraline o Venlafaxine: MOA: SNRI Clinical use: GAD SE: may increase blood pressure, HA, insomnia, sweating o Buspirone: MOA: stimulates 5HT receptor Clinical use: GAD SE: headache, GI, dizziness No interaction with alcohol unlike barbs and benzos Contraindicated with MOAIs and less useful if patient has used benzos o What is exposure therapy? The individual is slowly desensitized with controlled doses of the feared stimulus

What is the criteria for post-traumatic stress disorder? Follow an exposure to a traumatic event: rape, combat, car accident, natural disaster Resulting in 3 cardinal sx: o Hyperarousal: Sympathetic activation, exaggerated startle response, sleep difficulties, hypervigilance o Flashbacks o Psychic numbing and avoidance of traumatic event reminders DSM Criteria: o Person has been exposed to a traumatic event in which both of the following were present: Person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury Persons response involved intense fear, helplessness, or horror o Event is persistently re-experienced: Through persistent thoughts, images, and perceptions Dreams Acting or feeling like the event is reoccurring (illusions, hallucinations, dissociative flashbacks) An external or internal cue that sympathizes or resembles the act created intense psychological/ physiological distress o Persistent avoidance of stimuli o Persistent increased arousal Difficulty falling asleep, irritability or out-burts, difficulty concentrating o Duration > 1month o Causes significant distress or impairment in social, occupational, or other important areas of functioning o Acute: <3months o Chronic >3 months o With delayed onset: 6 months after the stressor What is the criteria for acute stress disorder? Shorter in duration: lasts for a minimum of 2 days and max of 4 weeks
What is on the DDx for PTSD? Adjustment disorder: usually in response to a milder stressor that will cause marked distress that is in excess of what would be expected from exposure to the stressor and significant impairment in social or occupational functioning OCD: intrusive thoughts that are experienced as inappropriate but are not related to a traumatic event Acute stress disorder Dissociative disorders: relieve anxiety by separating mental content from unpleasant feelings of anxiety (depersonalization, derealization) person can feel removed from his or her body or surroundings

How is fear conveyed physiologically? Visual threat info is conveyed from the Retina to the thalamus and to the amygdala (plays central role in processing the sensory stimuli in order to assess risk of threat) Also can get input from parabrachial nucleus to the PAG input to the cingulated cortex will control the amygdala from a top-down method

How do higher pathways regulate the ANS end organs? Detection of threat by the amygdala triggers a cascade activating the sympathetic nervous system for a flight-or-fight response How do hormonal systems modulate memory storage in the amygdala? Emotional events will activate the sympathetic nervous system and the HPA resulting in epi and glucocorticoids which enhance emotional memory. CLINICAL: lesions of the amygdala block memory-enhancing neuromodulatory function; Basolateral nucleus is connected to the hippocampus and neocortex and implicated in memory process. What treatments are used for PTSD? SSRIs are FDA approved but are inadequateparoxetine and sertraline; benzos are not efficacious in PTSD, Betablockers may interfere with the consolidation of traumatic memories CBT is the most successful: goal is to reduce anxiety by habituating to the traumatic memory and to restructure distorted thoughts like I could have stopped it. Alpha-2-adnergic agonists such as prazosin and clonidine have demonstrated efficacy in reducing sx COGNITIVE DISORDERS What is the diagnostic criteria for dementia? Memory impairment + one or more of the following: Aphasia, apraxia, agnosia, disturbance in executive functioning planning, organizing, sequencing, abstracting Cognitive functioning causes significant impairent with functioning that represents a declin from a previous level of functioning What are causes of dementia? Alzheimers Rx: acetylcholinesterase inhibitors donepezil, galantamine, rivastigmine, and tacrine Vascular dementia What are partial complex seizures associated with? Temporal lobe and aura that is characterized by olfactory hallucinations like smells of rubber RANDOM TERMS What is cataplexy? Intrusion of REM sleep during periods of wakefulness What is REM sleep? REM EEG: low-voltage, random, fast, and saw-toothed, period of time in which immobile, dream, have erection, heart rate and BP increased Night terrors are associated with Non-REM sleep occurring between deep sleep and REM thrashing, screaming, and autonomic arousal Rx: diazepam or valium What is catalepsy? Immobile position that is constantly maintained What is automatism? Automatic performance of unconscious symbolic meaning What is formication? Hallucinated sensation that insects are crawling on you SE of cocaine and amphetamines

CHILDHOOD DISORDERS What is childhood disintegrative disorder? Child develops bladder/bowel control, language, play all normally in the first 2 years of life, but the child loses these previously acquired skills before the age of 10 What is the criteria for ADD/ADHD? child exhibits 6 > sx that were present bf the age 7 and are present in more than 1 setting i.e. school, work, home. Inattention: o Careless mistakes o Difficulty following directions o Disorganized o Lose things o Distracted o Forgetful Hyperactivity: o Fidgeting o Squirming o Leaving ones seat o Running climbing excessively and inappropriately o Talking excessively Impulsivity: o Not waiting turn o Shouting out o Interrupting others What is the Rx? Atomoxetine, dextroamphetamine, methylamphetamine, pemoline