Behavioral Medicine

alcohol intoxication symptoms and screening

• slurred speech

• ataxia

• impaired judgment

AUDIT-C (frequency), CAGE-AID

alcohol withdrawl and treatment

• Tremors

• tachycardia

• hypertension

• Delirum tremens

Benzos

delerium tremens and treatment

48-96 hours after etoh use

• extreme confusion

• severe tremors

• hallucinaitons

• agitation

• fever

• autonomic hyperactivity

Benzos→ diazepam, lorazepam

alcohol abuse treatment

• CBT

• Naltrexone

• Acamprosate

• Disulfiram

opioid intoxication and overdose treatment

• pin point pupils

• respiratory depression

• decreased level of conciousness

Naloxone

opioid withdrawl and treatment

• yawning

• Lacrimation

• rhinorrhea

• muscle aches

• Diarrhea

• Piloerection

• Possible dilated pupils

buprenorphine, suboxone, methadone

stimulant intoxication and overdose treatment

• euphoria

• agitation

• tachycardia

• hypertension

• psychosis

• decreased appetite

• parranoia

• irratibilty

• lack of sleep

• dilated pupils

benzos + labatalol for htn

stimulant withdrawl

• fatigue

• depression

• hypersomnia

• increase appetite

cannabis intoxication

• anxiety

• parnoia

• altered perceptions

• psychosis

cannabis withdrawl

• irrritability

• sleep disturbances

• decreased appetite

benzos (sedatives) intoxication and overdose

• CNS depression

• slurred speech

• unsteady gait

• sedation

• confusion

• drowsiness

maybe Flumzenil

benzo withdrawl

• Anxiety

• Life threatening seizures

Clonazepam (long acting) taper, or diazepam

Ecstasy/MDMA MOA

Increases dopamine and norepinephrine

Ecstasy/MDMA Symptoms

• euphoria

• Increased empathy

• Seizures

• Hyperthermia

• Hypertension

• Tremor

• Jaw clenching

• Hyponatremia (excess water intake SIADDH)

Benzos

Cholinergic toxicity

Organophosphate, onepezil, rivastigmine

• Pinpoint pupils

• Diaphoretic

• Diarrhea

• Bradycardia

• Hypotension

• Confusion

• Seizures

SLUDGE (salivation, lacrimation, ruination deification, GI cramps, emesis)

Atropine

Anticholinergic toxicity

TCA, H1 blockers, antipsychotics, benzotropine

• hot (as a hare)

• Dry (as a bone)

• Red (as a beet)

• Mad (as a hater)

• hyperthermia

• Dilated pupils

• Delirium

• Tachycardia

Physostigmine

LSD intoxication MOA

Increased activity in serotonin receptors

what portion of the brain is affected in ADHD?

orbitofrontal cortex

• emotional processing and motivationfor executive function

ADHD medications

Non stimulant→ Straterra (atomoxetine) SNRI, hepatotoxic, SI, glaucoma, pheo

Guanfacine (intuniv) alpha 2 adrenergic receptor agonist, children/adolescents, hypotension, sedation

Wellbutrin, seizures

Clonidine→ adjunct therapy

Stimulant → Ritalin (methylphenidate) blocks uptake of dopamine and norepinephrine

Adderall

first generation antipsychotics medications

• haloperidol (haldol) → less sedation

• Fluphenazine (prolixin)

• Trifluperazine (Stelazine)

• Thiothxene (Navane)

• Pimozide (Orap)

• Loxapine (Loxitane)

• Perphenazine (Trilafon)

• Chlorpromazine (Thorazine) → more sedation

• Thioridazine (Mellaril)

EPS

second generation antipsychotics medications

• risperadone (risperdal)

• Olanzapine (zyprexa)

• Quntiapine (seroquel) → bipolar with dominant depression

• Clozapine (clozaril) treatment resistant schizophrenia, agranulocytosis

• Arpiprazole (abilify)

• Ziprasidone (geodon)

• Paliperidone (invega)

• Asenapine (saphris)

• Iloperidone (fanapt)

• Lursidone (latuda)

• Cariprazine (vraylar)

• Brexpiprazole (rexulti)

metablic syndrome

QT prolongation

Increase prolactin

Neuroleptic Melignant syndrome and treatment

Fever

Encephalopathy

Vitals unstable

Elevated enzymes (CK due to rhabdo)

Rigidity

Treatment: Dantrolene, bromocriptine, amatadine, benzotropine (also in young Parkinson’s, avoid in glaucoma and BPH)

acute dystonia

muscle contractions

Benzotropine

akathisia

restlessness

parkinsons

• bradykinesia

• rigitidy

• tremor

• shuffling gait

Tardive dyskinesia

involuntary repetive movements, irreversible

• lip smacking

• tongue rolling

SRRI

• Fluoxetine (Prozac) → OCD, decreased discontinuation syndrome

• Sertraline (Zoloft)

• Citalopram (Celexa) → QT prolongation

• Escitalopram (Lexapro)

• Paroxetine (Paxil) → avoid in pregnancy

• Fluvoxamine (Luvox)

GI upset

Weight changes

SSRI discontinuation syndrome

• dizziness

• Flu-like symptoms

• Irritability

Slow taper

*fluoxetine (prozac) → long half life so decreased syndrome

Seratonin syndrome

SSRI, SNRI, MAOI, linezolid, triptans, tramadol, lithium, St. John wort, ecstasy (MDMA)

• Mental status change within hours

• Hyperthermia

• Tachycardia

• Hypertension

• Diaphoresis

• Diarrhea

• Hyperreflexia

• Cloud

• Tremor

• Myoclonus

• Increase CK

• Metabolic acidosis (lactic acidosis)

Benzos+ cyproheptadine

SNRI MOA

Uptake of serotonin and norepinephrine

SNRI drugs

• Venlafaxine (Effexor)→ htn

• Desvenlafaxine (Pristiq)

• Dulxetine (Cymbalta)

• Levomilnacipran (Fetzima)

• Milnacipran (Savella)

Watch for htn

Good for neuropathy, fibromyalgia, chronic pain, withdrawal symptoms are short

SARIs (serotonin antagonist and reuptake inhibitors) MOA

• Blocks 5-HT2 receptors

• Weakens serotonin reuptake inhibition

SARIs Drugs and uses

• Trazadone (Desyrel)

insomnia (off label), depression

SA→ Sedation, orthostatic, and priapism

MAOIs (monoamine oxidase inhibitors) MOA

Blocks monoamine oxidase causing increase in serotonin, dopamine, and norepinephrine

MAOI drugs

• Phenelizne (Nardil)

• Tranylcypromine (Parnate)

• isocardoxazid (marplan)

• Selegiline (emsam)

AVOID Tyramine (aged cheese and meat) = hypertensive crisis

2 week washout when switching to or from MAOI!

TCA MOA

Block reuptake of serotonin and norepinephrine + muscarinic receptors, alpha 1 receptors, and histamine receptors

TCA drugs

• Amitrptyline (Elavil)

• Nortriptyline (Pamelor)

• Imipramine (tofranil)

• Desirpramine (Norpramin)

• Clomipramine (Anafranil)

• Rermeron (mirtazapine) → sedation

SA→ anticholinergic (dry mouth, constipation, urinary retention, blurry vision), QT prolongation

TCA overdose

• Confusion

• Coma

• Convulsions

• Cardiotoxicity

Sodium bicarbonate

Valproic acid (depakene or depakote)

Bipolar

• SE→ Hepatotoxic, thrombocytopenia,

• Teratogenic→ neural tube defects (spina bifida)

Lithium

Bipolar

• Hypothyroidism

• Nephrogenic diabetes insipidus, hyponatremia

• Leukocytosis

• CKD

• Teratogenic

Be aware of ACE, ARBS, thiazides, nsaids bc increase concentration by reducing renal clearance

Lamotreigene(lamictal)

Decreases glutamate release

Bipolar depression maintenance therapy

Can be used in pregnancy

SE→ SJS (slow titration)

Carbamazepine (Tegretol)

Blocks sodium channels

Bipolar, seizures

Used in pregnancy + folate acid

SA→ agranulocytosis, aplastic anemia, SIADH, hepatotoxic

Topiramate (Topamax)

Off label bipolar adjunct

SE→ cognitive slowing, kidney stones, metabolic acidosis

Teratogenic → cleft lip

Clonazepam (klonapin)

Facilitates GABA transmission

Benzo long acting

Seizures, anxiety (off label), panic disorders, agitation

SE→ drowsiness, respiratory depression, ataxia, cognitive slowing

OCD medication treatment

• Fluoxetine

Conversion disorder (functional neurological symptom disorder) vs somatic symptom disorder

Conversion → symptoms not explained by medical or neuro condition and not intentional produced

• Most commonly after emotional event

Somatic symptom disorder → physical complaints associated with anxiety or depression for 6 months. Excessive thoughts about somatic symptoms

Early ejaculatoin treatment

SSRI, sertaline

Pseudocyesis

Somatic symptom disorder

Autism brain findings

• Increase total brain volume

• increased volume of corpus callosum

• increased amygdala

• Increased extra-axial fluid

• Smaller cerebellum

Auditory hallucinations MRI findings

Decreased size of temporal lobe

Visual sensations MRI findings

Infarct of superior occipital lobe

Schizophrenia brain MRI

Decreased size of prefrontal cortex

Fear and anxiety brain MRI

Increased activity of amygdala

Sleep wake disorders brain MRI

Decreased activity of suprachiamstic nucleus

Dopamine

Cravings and pleasure

Vasopressin

Aggression and bonding behavior

Oxytocin

Affectionate hormone

Recent strep infection with OCD symptoms

PANDAS w/wo tics

Depression brain MRI

• Decreased volume in prefrontal cortex

• decreased volume of hippocampus

• decreased volume of amygdala

• Enlargement of volume of lateral ventricles

• Decreased volume of basal ganglia

Avolition

Lack of motivation in goal directed activity

• Negative symptom of schizophrenia

Negative symptoms

• blunted affect

• Reduced speech

• Lack of motivation (avolition)

• Inability to feel pressure

• Social withdrawal (asociality)

GAD neurotransmitters

Increases inhibitory effects of gamma aminobutyric acid

How does nicotine work in the body when smoking cigarettes?

Nicotine binds to nicotinic acetylcholine receptors causing release of dopamine norepinephrine, serotonin, endorphins, and acetylcholine

• acetylcholine receptor agonist

Somatic symptom disorder may have history of what?

History of substance abuse

Erotomanic type

Person of high status is in love with you

Persecutory type

Being attacked, harassed, or conspired against

SSRI in pregnancy

Sertaline (Zoloft)

What is associated with panic attacked?

Derealization

Anorexia/bulimia electrolyte abnormalities

• hypochloremia (vomiting)

• Hypokalemia

• Hyponatermia

• Hypoglycemia

• Metabolic acidosis (vomiting) (alk if laxatives)

Refeeding syndrome electrolyte abnormalities

• Hypophosatemia

• Hypokalemia

• Hypomagnesemia

Caudate nucleus

Approach and attachment behaviors

Hippocampus

Formation of memories

Nucleus accubens

Reward pathway

Oritofrontal cortex

Recognition of pleasurable activities

Immature defense mechanisms

• acting out

• Denial

• Displacement→ transferring feelings to less threatening object/person

• Intellectualization→ focusing on non emotional aspects to avoid distressing feelings

• Passive aggression → avoiding conflict by expressing hostility convertly

• Projection→ atttributting one’s own feelings onto others

• Rationalization→ justifying behavior to avoid difficult truths

• Reaction formation→transforming. Unacceptablefeelings/impulses into the opposite

• Regression→ reverting to earlier developmental stage

• Splitting→ experiencing a person/situation as either or all positive or negative

Mature defense mechanisms

• altruism → deriving pleasure from helping others, often at a personal cost

• Humor

• Sublimation→ channeling impulses into socially acceptable behaviors

• Suppression

What is flumzenil used for?

Benzo overdose to reduce sedation

When would you start SSRI with illness anxiety disorder?

Comorbid panic disorder

Who is at highest of completing suicide?

• Older white men

• Prior attempts at suicide

SSRI safe in pregnancy?

• Zoloft

• Lexpro

• Sometimes Prozac

SSRI to avoid in pregnancy

• Paxil

What condition is pressured speech in?

Bipolar or manic

(May be in schizophrenia)

Which is the opioid receptor

Mu opioid receptor

Which neurotransmitter change occurs in schizophrenia?

Increase in dopamine

What EKG finding would you find in anorexia?

QT prolongation due to hypocalcemia and Hypokalemia

Circumstantially

Irrelevant information with much detail

Derailment

Loose associations and sentences that do not make sense

Ideas of reference

Abnormal thought content thinking there is a message especially for you

• schizophrenia

Thought broadcasting

Thinking your thoughts are being broadcasted over the media

Retrospective falsification

Memory is being filtered through a persons present emotional state

What can you use to asses before treatment?

Working alliance inventory

What fracture is highly suspicious for non accidental trauma in pediatrics?

• Posterior rib fracture

• Metaphysical fracture (growth plate)

• Skull fracture

• Scapular fracture

• Sternal fracture

• Transverse long bone fracture

What SSRI has least sexual/weight gain side effects? Most?

Least is lexapro

Most is Paxil or Fluvoxamine

Anorexia treatment

Olanzapine

Bulimia treatment

SSRI (Prozac)

Order of stages or grief

1. Denial

2. Anger

3. Bargaining

4. Depression

5. Acceptance