Clin Med III-Psych-Before Quiz

What are negative symptoms of schizophrenia?

Diminished social interaction (asociality)
Decreased or absent emotional expression
Flattened or restricted affect
Decreased use of speech (alogia)
Lack of motivation (avolition)
Lack of interest (anhedonia)

Describe the cognitive dysfunction in schizophrenia.

Impairments in:
-Attention
-Processing speed
-Working and declarative memory
-Abstract thinking
-Problem solving
-Understanding of social interactions

What is thought to be the pathophysiology behind schizophrenia?

-overactivity of the mesolimbic pathway --\> + symptoms
-underactivity of the mesocortical pathway triggers negative symptoms

What is a delusion and list the types?

-Fixed beliefs that will not change even with factual/conflicting evidence
-May be non-bizarre or bizarre
Types:
-*Persecutory* - one is going to be harmed/harassed by individual, group, or organization;
-*Referential* - belief that gestures, environmental cues are directed at oneself
-*Thought withdrawal or insertion* - belief that others are reading their mind, that their thoughts are being transmitted to others, or that thoughts or impulses are being imposed upon them by outside sources
-*Grandiose* - individual believes that he/she has exceptional abilities, wealth, and/or fame
-*Erotomanic* - false belief that someone is in love with him / her
-*Jealous* - belief that spouse or lover is unfaithful without evidence to support claim
-*Nihilistic* - they think a major catastrophe is about to occur
-*Somatic* - preoccupied with health and organ function

What are hallucinations?

Sensory perceptions that are not perceived by others
-Auditory (most common)
-Visual
-Olfactory
-Gustatory
-Tactile

Describe hallucinogen withdrawal.

-Hallucinogens do not have a typical withdrawal pattern.
-These drugs are considered psychologically addicting rather than physically addicting.

Describe the presentation of brief psychotic disorder.

-An acute psychotic event (i.e., sudden onset from a non-psychotic state to a clearly psychotic state ) *Lasts at least one day to less than a month*
-Manifested by psychotic symptoms: Delusions, Hallucinations, Disorganized speech, Grossly disorganized or catatonic behavior
-Preexisting personality disorders or certain medical conditions (e.g., lupus) may predispose patient to developing brief psychosis
-*may be triggered by major life stressor*
-cannot be explained by depressive or bipolar disorder with psychotic features, schizoaffective disorder, schizophrenia, or substance use disorder
-relapse is common

How is brief psychotic disorder treated?

medical supervision and short course of antipsychotic medication

Describe the presentation of delusional disorder.

-Characterized by firmly held false beliefs (delusions) persisting for at least 1 month, *without other symptoms of psychosis*-may be non-bizarre or bizarre
-Delusions remain unchanged despite person being presented with clear, reasonable evidence that the belief is false
-Generally, occurs in *middle to late adult life*
-*Psychosocial functioning is less impaired* than with schizophrenia, and typically any impairments are directly related to the delusional belief
-In the elderly is sometimes referred to as *paraphrenia* (paranoid) - May coexist with mild dementia
-can occur with paranoid personality disorder

What are the subtypes of delusional disorder?

erotomanic, grandiose, jealous, persecutory, somatic

Describe the prognosis and treatment of delusional disorder.

Prognosis:
-Severe impairment or changes in personality usually do not occur
-Gradual progression of delusional concerns may occur
-Most can remain employed provided their work does not include things related to the delusions
Treatment:
-Establishing an effective clinician-patient relationship is paramount
-Manage complications such as strained relationships or legal difficulties
-Antipsychotics may be needed in some patients
-Hospitalization may be needed if patient presents a danger

Describe the presentation of schizoaffective disorder.

-characterized by the *coexistence of psychosis and mood symptoms*
-Differentiated from schizophrenia by the presence of *\> 1 episode of depression or mania during a person's lifetime* (side note: from what I read the mood disorder is the primary problem which is not the case with schizophrenia)
-May require longitudinal assessment
Diagnostic criteria:
-Significant mood symptoms (depressive or manic) occurring for \> 50% of the total duration of illness
-Concurrent with \> 2 symptoms of schizophrenia (delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, or negative symptoms)

How is schizoaffective disorder treated?

-Combination of drugs, psychotherapy (therapy in layman's terms), and community support
-Long-term disability is common but overall better long-term prognosis than with schizophrenia
Pharmacologic treatment:
-Manic type: *2nd generation antipsychotic* +/- lithium, carbamazepine, or valproate
-Depressive type: *Begin with 2nd generation antipsychotic*. When positive psychotic symptoms are stable, add SSRI if depression persists

How is schizophreniform treated?

antipsychotics and supportive psychosocial care

Describe the presentation of schizophreniform disorder.

-*Two or more symptoms* : (must be present for at least one month )*between one month and six months*
1. *delusions*
2. *hallucinations*
3. *disorganized speech*
4. grossly disorganized or catatonic behavior
5. negative symptoms (diminished expression or avolition)
-Must have either symptom 1., 2., or 3.
-Not attributable to another psychiatric or medical disease or substance

Describe the presentation of schizophrenia.

-Most common of the psychotic disorders
-Characterized by:
•*Psychosis* (loss of contact with reality)
− Hallucinations (false perceptions)
− Delusions (false beliefs)
− Disorganized thinking and speech
− Inappropriate motor behavior (including catatonia)
•*Flattened affect* (restricted range of emotions)
•*Cognitive deficits* (impaired reasoning and problem solving)
•*Occupational and social dysfunction*
-begins in adolescence or early adulthood and continues throughout life- symptoms managed, not cured
-One or more episodes of psychotic symptoms *lasting ≥ 6 months*
-Symptoms: bizarre, unkempt appearance, decreased motor activity, withdrawn social behavior, neologisms (made up words), echolalias (repeated phrases/ words back to you), verbigeration (repetition of senseless words), word salad, flat affect, tangential thought content, delusions, distortion of reality

How is schizophrenia treated?

-Treatment consists of drug therapy, cognitive behavioral therapy, and psychosocial rehabilitation
-Early detection and early treatment improve long-term functioning
-Drug therapy: conventional (1st generation) antipsychotics and second generation antipsychotics (SGAs, "atypicals")
-ECT (Electroconvulsive therapy) is used if all else fails

Describe the stages of schizophrenia.

-Prodromal phase: May have no symptoms or may have impaired social competence, mild cognitive disorganization or perceptual distortion, a diminished capacity to experience pleasure (anhedonia), and other general coping deficiencies
-Advanced prodromal phase: withdrawal, isolation, irritability, suspiciousness, unusual thoughts, perceptual distortions, disorganization
-Early psychosis phase: active psychotic symptoms- worst
-Middle phase: episodic psychotic phase- functional deficits worsen
-Late illness phase: disability becomes stable but can vary

What are adverse events of schizophrenia?

-Suicide:
Risk factors: Young males with schizophrenia and substance use disorder, depressive symptoms, feelings of hopelessness, unemployed, recently suffering a psychotic episode or recent hospitalization, Patients with the best overall prognosis for schizophrenia (i.e., late onset and good premorbid functioning) are actually at greatest risk
-Violence
Risk factors: Substance abuse, Persecutory delusions, Command hallucinations, non-compliant with taking their meds

Describe the schizophrenic cycle.

frustration/ boredom--\> anxiety--\> withdrawal/alienation--\> hallucinations--\>
increases suicidality

How is schizophrenia diagnosed?

-Per DSM-5, must have two or more symptoms for a significant portion of a 6-month period
-Symptoms: Delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative symptoms (diminished expression or avolition)
-Must have at least one of the following: delusions, hallucinations, or disorganized speech
-Signs of disturbance *must last for \> six months*
-Prodromal or attenuated signs of illness with social, occupational, or self-care impairments evident for a 6-month period that includes 1 month of active symptoms
-Not attributable to another psychiatric or medical disease or substance

What diagnostics are performed if schizophrenia is suspected?

-check for causes of psychosis: *urine drug screen*, CBC, CMP, TSH, free T4, possibly a Cortisol level, UA, Ucx, lactic acid if WBC is increased
-CT scan- might show alterations in brain structure (e.g., enlarged cerebral ventricles, thinning of the cortex, decreased size of the anterior hippocampus and other brain regions)
-PET scan

Which antipsychotics are better at improving + symptoms?

1st generation

What are benefits of 2nd generation antipsychotics?

-more selective dopamine blocker than first generation
-Decrease likelihood of extrapyramidal (motor) adverse effects
-Greater binding to serotonergic receptors may contribute to the antipsychotic actions on positive symptoms and the adverse effect benefits

What are side effects of clozapine?

-Agranulocytosis
-clozapine is most effective SGA but contraindicated in severe heart disease due to side effect

List 2nd generation antipsychotics.

-clozapine (Clozaril)
-Risperidone (Risperdal)
-Olanzapine (Zyprexa): sedation risk
-Aripirazole (Abilify): beneficial for + and - symptoms due to partial agonist
-Quetiapine (Seroquel)
-Asenapine (Saphris)
-Lurasidone (Latuda)
-Ziprasidone (Geodon)
-Palieridone (Invega)

List common 1st generation antipsychotics.

Haloperidol (Haldol)
Chlorpromazine (Thorazine)

What are side effect of antipsychotics?

-Dry Mouth, delayed gastric emptying, esophageal reflux, ileus, delirium, acute glaucoma, orthostatic hypotension, and sexual dysfunction
-QTc prolongation: need baseline ECG and repeat ECG
-Metabolic syndrome (mostly 2nd gen): check weight, A1C, fasting blood glucose, and fasting lipid panel
-Neuroleptic malignant syndrome
-Extrapyramidal syndrome (mostly with 1st gen)

Describe the presentation of neuroleptic malignant syndrome.

-Typically develops w/in two weeks of starting or changing an anti-psychotic if it occurs - Potentially life-threatening
-Four characteristic features:
•Altered mental status (e.g., confusion, delirium, unresponsive)
•Motor abnormalities (e.g., rigidity, abnormal movements (EPS), decreased DTRs)
•Hyperthermia (temp is usually \> 38° C and often \> 40° C)
•Autonomic hyperactivity (tachycardia, arrhythmias, tachypnea, and labile hypertension)
-Labs may show Leukocytosis and elevated CK

How is neuroleptic malignant syndrome treated?

ICU, antipyretics, IV hydration, benzodiazepines, possibly adding Bromocriptine or Amantadine (Dopamine agonists). Dantrolene given for hyperthermia.

What is extrapyramidal syndrome?

-*Akathisia* - subjective craving to be in continuous motion
Tx - Benzodiazepine - Clonazepam (Klonopin) TID
-*Acute dystonia* - muscle spasms of the head, tongue, neck
Could include swallowing problems and / or chewing difficulties
Tx - Benztropine Mesylate (Cogentin) for chronic tx
- Diphenhydramine (Benadryl ) for acute event
-*Drug Induced Parkinsonism*
-*Tardive Dyskinesia* - involuntary stereotyped movements of the face, mouth , tongue, even limbs

A 25 y/o female started hearing voices in her head, seeing space aliens standing by her bedside at night, and believing aliens were experimenting on her while she slept. The symptoms lasted four months then resolved. What do you suspect is the diagnosis?

Schizopherniform disorder

A patient experienced delusions, hallucinations, and flat affect for 3 weeks following the death of his spouse but then returned to his baseline level of functioning. Which disorder did the patient likely experience?

Brief psychotic disorder

Asociality, flattened affect, alogia, avolition, and anhedonia are examples of what type of symptoms?

Negative

Overactivity of D2 receptors in the \________________ may trigger positive symptoms (hallucinations, delusions).

mesolimbic pathway

What is good sleep hygiene?

-Go to bed only when sleepy
-Use the bed and bedroom only for sleeping and sex
-If still awake after 20 minutes, leave the bedroom, pursue a restful activity (bath or meditation) and only return when sleepy
-Get up at the same time every morning regardless of the amount of sleep during the night
-Discontinue caffeine and nicotine, at least in the evening if not completely
-Establish a daily exercise regimen
-Avoid alcohol as it may disrupt continuity of sleep
-Limit fluids in the evening
-Learn and practice relaxation techniques
-Establish a bedtime ritual and routine time for going to sleep

What are the 3 major sleep disorders?

-Dyssomnia (Insomnia)
-Hypersomnia (Disorders of excessive sleepiness)
-Parasomnia (Abnormal behaviors during sleep)

What is the diagnostic criteria of insomnia disorder?

Predominant complaint of dissatisfaction with sleep quantity or quality, associated with one (or more) of the following symptoms:
-Difficulty initiating sleep
-Difficulty maintaining sleep
-Early-morning awakening with inability to return to sleep
Sleep difficulty occurs at least *3 nights/ week*, present for *at least 3 months*

What are the most common symptoms of insomnia?

-Difficulty maintaining sleep is most common single symptom of insomnia
-Difficulty falling asleep is second most common

How is insomnia treated?

•Benzodiazepine (short course) - Lorazepam (Ativan) or Temazepam (Restoril)
•Nonbenzodiazepine Sedative-hypnotics (less habit forming than BZD, still shouldn't be only tx for chronic)
-*Most commonly prescribed medications* for insomnia; provides symptom relief
-*Zolpidem (Ambien)*- short half life
-Zaleplon (Sonata)
-Eszopiclone (Lunesta)- long half life- recommended for sleep maintenance
•Orexin Receptor Antagonist - suppress wake drive, may increase depressive symptoms- Suvorexant (Blesomra)
•Melatonin receptor agonist - help with sleep onset, no abuse potential - Ramelteon (Rozerem)
•Atypical antidepressants - trazodone
•Antihistamines
•Melatonin
•Herbals (Valerian root, Chamomile, St. Johns Wort)

What herbal insomnia treatments have risks?

-potential risks associated with use (dogwood, kava kava, alcohol, and L-tryptophan) and are not recommended
-*Kava Kava may cause liver damage*

What is Kleine-Levin Syndrome?

-Characterized by hypersomnic attacks three or four times a year lasting up to 2 days, with hyperphagia, hypersexuality, irritability, and confusion on awakening
-Occurs mostly in young men
-Often been associated with antecedent neurologic insults
-Usually remits after age 40
-No pharmacological treatment

What is Hypersomnolence disorder?

•Self- reports excessive sleepiness despite a main sleep period lasting at least 7 hours, with at least one of the following symptoms at least 3x per week for at least 3 months:
-Recurrent periods of sleep or relapses into sleep within the same day
-Prolonged main sleep episode of *more than 9 hours per day* that is nonrestorative (unrefreshing)
-*Difficulty being fully awake* after abrupt awakening
•*accompanied by significant distress or impairment in cognitive, social, occupational, or other important areas of functioning*
•excessive sleep, deteriorated wakefulness, and sleep inertia; nap nearly every day
•*Sleep quality may be reported as good, but usually will be unrefreshing*
•*Sleepiness develops over a period of time [NOT an Attack]*

What is the diagnostic criteria for Narcolepsy?

•Recurrent periods of an irrepressible need to sleep, lapsing into sleep, or napping occurring within the same day. At least 3x week over past 3 months
•Presence of at least one of the following:
-Episodes of cataplexy occurring at least a few times per month- brief (seconds-minutes) episodes of loss of bilateral muscle tone while maintaining consciousness precipitated by laughter or joking
-Hypocretin deficiency (Cerebrospinal fluid Hypocretin-1 immunoreactivity values) less than or equal to 1/3 of values from healthy subjects.
-Nocturnal sleep polysomnography showing REM sleep latency less than or equal to 15 minutes, or a multiple sleep latency test showing a mean sleep latency less than or equal to 8 minutes and two or more sleep-onset REM periods
-*Tetrad of symptoms: Sudden, brief sleep attacks , Cataplexy: sudden loss of muscle tone involving specific small muscle groups or generalized muscle weakness, Sleep paralysis, Hypnagogic hallucinations: visual or auditory*
-Vivid dreams and nightmares, REM sleep behavior disorder, Nocturnal eating, Obesity, and Nocturnal sleep disruption is common and can be disabling.
-Begins in early adult life, affects both sexes equally, usually levels off in severity ~30yoa

How is hypersomnia and Narcolepsy treated?

-Treat symptoms: daily use of stimulants
-Methylphenidate 10mg PO BID
-Dextroamphetamine sulfate 10mg PO QAM
-Modafinil / Armodafinil (schedule IV)
-Imipramine - effective for cataplexy (NOT narcolepsy)

What is the diagnostic criteria of central sleep apnea?

-Evidence by polysomnography of five or more central apneas (breathing cessation \>10 seconds) per hour of sleep
-Characterized by repeat episodes of apnea/ hypopneas during sleep caused by variability in respiratory effort- disorders of ventilatory control in which respiratory events occur in periodic or intermittent pattern
-*Hyperventilation/ Hypoventilation alternating: Periodic breathing*
-Instability in ventilation and PaCO2 levels due to the high-loop gain (increased gain of the ventilatory control system)
•Idiopathic Central Sleep Apnea: Sleepiness, insomnia, and awakenings due to dyspnea in association with 5 or more central apneas per hour of sleep
•Cheyne-Stokes Respirations- Periodic crescendo- decrescendo variation in tidal volume that result in central apnea/ hypopneas that occur at least 5/ hour that are accompanied by frequent arousals; If severe, may be a poor prognostic marker and can even be seen in resting wakefulness

What does polysomnography show in a patient with sleep related hypoventillation?

episodes of decreased respiration associated with elevated CO2 levels (if unable to objectively measure CO2, then persistent low levels of hemoglobin oxygen saturation unassociated with apneic/hypopneic events may indicate hypoventilation)

What is sleep related hypoventilation?

-Present w/ sleep related complaints (insomnia, sleepiness), orthopnea, headache, shallow breathing during sleep
-Idiopathic sleep-related hypoventilation is very uncommon: Slowly progressive disorder of respiratory impairment
-Commonly associated with underlying condition: Medical, neurologic, medication use, substance- abuse disorder
-Ventilatory insufficiency: Chronic exposure to hypercapnia and hypoxemia \> vasoconstriction of pulmonary vasculature \> pulmonary htn\> R side heart failure (cor pulmonale)

-James is a 72yoM that was recently diagnosed with large right ACA stroke. He is currently in the MICU. During pre-rounds, his overnight RN informs you that his tidal volume would periodically increase and decrease resulting in cessation of breathing and that this happened multiple times overnight. He also had multiple arousals overnight and didn't appear to sleep well.
A.Obstructive Sleep Apnea
B.Idiopathic Central Sleep Apnea
C.Central Sleep Apnea with Cheyne- Stoke Respirations
D.Idiopathic Sleep Related Hypoventilation

C

What is the diagnostic criteria for circadian-rhythm sleep-wake disorder?

-Persistent or recurrent pattern of sleep disruption that is primarily due to an alteration of the circadian system or to a misalignment between the endogenous circadian rhythm and the sleep-wake schedule required by an individual's physical environment or social or professional schedule
-Sleep disruption leads to excessive sleepiness or insomnia or both
-Specify: Episodic (1-3 months), Persistent (3 months or longer), Recurrent ( 2 or more episodes occur in one year)
-Types: Delayed sleep phase, advanced sleep phase, irregular sleep-wake, non 24-hour sleep-wake, shift work

What is the diagnostic criteria NREM sleep arousal disorder?

-Recurrent episodes of incomplete awakening from sleep, usually occurring during the first third of the major sleep episode, accompanied by one of the following:
-*Sleepwalking*: Repeated episodes of rising from bed during sleep and walking about (Blank, staring face, Relatively unresponsive to communication efforts by others, Awakened only with great difficulty)
-*Sleep terrors*: recurrent episodes of abrupt terror arousals from sleep (usually beginning with panicky scream, Intense fear and signs of autonomic arousal (mydriasis, tachycardia, tachypnea, diaphoresis) at each episode, Relative unresponsiveness to efforts of others to comfort the individual during the episode)
-No or little dream imagery is recalled
-Amnesia for the episodes is present
-Episodes cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

What is the diagnostic criteria for nightmare disorder?

-*Repeated occurrences of extended, extremely dysphoric, and well remembered dreams that usually involve efforts to avoid threats to survival, security, or physical integrity and that generally occur during the second half of the major sleep episode*
-*On awakening* from the dysphoric dreams, the individual rapidly *becomes oriented and alert*
-Sleep disturbance causes clinically significant distress or impairment in social, occupational, and other important areas of functioning
-Lengthy, elaborate, story like dream that seem real and incite anxiety, fear, or other dysphoric emotions
-*Arise during REM sleep*, more likely in second half when dreaming is longer and more intense
-On awakening, nightmares are well remembered (In contrast, "bad dreams" do not awaken from sleep and are remembered only after arousing in the AM; Mild autonomic arousal)
-No vocalization or movement (due to REM sleep-related loss of skeletal muscle tone) -If talking or emoting occurs, it is brief and terminates the nightmare
-Nightmares terminated with awakening, but emotions persist and can contribute to difficulty returning to sleep and even daytime distress
-Individuals are at greater risk for suicidal ideations and suicidal attempts

What is the diagnostic criteria for REM sleep behavior disorder?

-Repeated episodes of arousal during sleep associated with vocalization and/or complex motor behaviors
-These behaviors arise during REM sleep and therefore usually occur more than 90 minutes after sleep onset, are more frequent during the later portions of the sleep period, and uncommonly occur during daytime naps
-Upon awakening from these episodes, the individual is completely awake, alert, and not confused or disoriented
-Either of the following:
•REM sleep without atonia on polysomnographic recording
•History suggestive of REM sleep behavior disorder and an established synucleinopathy diagnosis (Parkinson's disease, multiple system atrophy)
-Behaviors cause clinically significant distress or impairment in social, occupational, and other important areas of functioning (which may include injury to self or bed partner)
-Dream enacting behaviors-Behaviors often reflect motor responses to the content of action-filled or violent dreams
-Vocalizations are often load, emotion-filled, and profane
-Behaviors may be bothersome to the individual or bed partner and may result in physical injury
-Typically eyes remain closed during the event

What is the diagnostic criteria for restless leg syndrome?

•An urge to move the legs, usually accompanied by or in response to uncomfortable and unpleasant sensation in the legs, characterized by ALL of the following:
-The urge to move the legs begins or worsens during periods of rest or inactivity and is partially or totally relieved by movement
-worse in the evening or at night than during the day, or only occurs in the evening or at night
•Symptoms occur at least 3 x week for at least 3 months
•Symptoms are accompanied by significant distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning
-Uncomfortable sensations: creeping, crawling, tingling, burning, or itching
-Can delay sleep onset and awaken from sleep\= sleep fragmentation
-F\>M 1.5-2:1, RLS increases with age, Prevalence may be lower in Asian population

What is the diagnostic criteria for substance/ medication induced sleep disorder?

-Prominent and severe disturbance in sleep
-Evidence from Hx, PE, or Labs of both:
•Symptoms developed during or soon after substance intoxication or after withdrawal from or exposure to a medication
•The involved substance/medication is capable of producing the symptoms
-Disturbance does not occur exclusively during the course of a delirium
-Disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
-Note: this diagnosis should be made instead of substance intoxication or withdrawal when these symptoms predominate clinical picture and severe enough to warrant clinical attention
-Causes: Alcohol, caffeine, Cannabis, Opioids, Sedative/ Hypnotic/ Anxiolytic substances, Amphetamines and other stimulants, Tobacco

18 year old male presents to clinic in an apparent good mood. He exhibits slurred speech, excessive talking, and reveals an unsteady gait when walking. You smell alcohol on the patient's breath.
Which of the following is he exhibiting?
Intoxication
Cravings
Addiction
Tolerance
Psychosis
Withdrawal

Intoxication

What is intoxication?

A condition that follows the administration of a psychoactive substance and results in disturbances in the level of consciousness, cognition, perception, judgement, affect, or behavior, or other psychophysiological functions and responses.

What is a craving?

Very strong desire for a psychoactive substance or for the intoxicating effects of that substance.

What is addiction?

Compulsive need to use the drug repeatedly despite harm to the user

What is tolerance?

Lessened effects as a result of repeated administration

What is withdrawal?

Series of temporary physical & psychological symptoms that occur when substance use is discontinued (opposite of the effects caused by discontinued substance)

What is physical dependance?

Must take the drug to avoid withdrawal symptoms

What is physiological dependance?

Must take the drug to satisfy mental and emotional cravings

What are the effects of acute alcohol use?

-CNS depressant: low dose- depress inhibitory centers; high doses- inhibits excitatory centers
-*Acute Intoxication- Drowsiness, errors of commission, psychomotor dysfunction, disinhibition, dysarthria, ataxia, nystagmus*
-Blood level greater than 150mg/dL manifests with signs of intoxication
-Lethal blood levels range from 350-900mg/dL
-Overdosage- respiratory distress, stupor, seizures, shock syndrome, coma, and death

What are the effects of chronic alcohol use?

-Gastrointestinal - Cirrhosis of the liver, peptic ulcer disease, gastritis, pancreatitis, and carcinoma
-Cardiovascular - Hypertension, cardiomyopathy, atrial fibrillation ("holiday heart syndrome ")
-Neurological - Peripheral neuropathy leading to ataxia, Wernicke encephalopathy, Korsakoff psychosis, and structural changes in the brain leading to dementia
-Immunologic - Suppression of neutrophil function and cell-mediated immunity
-Endocrine - In males, increase in estrogen and decrease in testosterone, leading to impotence, testicular atrophy, and gynecomastia
-Obstetric - Fetal alcohol syndrome (ie, mental retardation, facial deformity, other neurologic problems)
-Psychiatric - Depression or anxiety disorders

How do we screen for alcohol use?

-CAGE questions
-AUDIT (Alcohol Use Disorders Identification Test)
-The CAGE questions should be given face-to-face, whereas AUDIT can be given as a paper-and-pencil test (and performed by clinician or self-reported by patient).

What are complications of chronic alcohol use?

•Chronic Alcohol use:
-Gynecomastia, Spider angiomata, dupuytren contractures, testicular atrophy, enlarged or shrunken liver, enlarged spleen
•Complications of alcoholism manifest as follows:
-Wernicke encephalopathy: Ataxia, ophthalmoplegia (usually lateral gaze palsy), and confusion
-Korsakoff syndrome: Anterograde and retrograde amnesia, often with confabulation and preceded by Wernicke encephalopathy
-Hepatic encephalopathy: Asterixis and confusion

What diagnostics would you run on a patient who abuses alcohol?

•Indirect:
-Aspartate aminotransferase (AST)
-Alanine aminotransferase (ALT)
-Gamma glutamyltransferase (GGT)
-Mean corpuscular volume (MCV)
-Carbohydrate-deficient transferrin (CDT)
•Direct
-Blood alcohol level
-ethyl glucuronide (EtG) can be detected in urine for up to 5 days after heavy binge drinking

Describe alcohol withdrawal.

•Withdrawal- wide spectrum- Anxiety, decreased cognition, tremulousness through increasing irritability and hyperreactivity to delirium tremens.
•DT (Delirium Tremens) or significantly symptomatic alcohol withdrawal is a *medical emergency* and should be treated on an inpatient basis.- Tachycardia & hypertension, Temperature elevation (fever), Delirium (disorientation, mental confusion)
•Less than 10% of individuals in withdrawal ever demonstrate delirium or withdrawal seizures.
•Longer term withdrawal symptoms: sleep disturbances, anxiety, depression, excitability, fatigue, and emotional volatility; may persist 3-12 months or become chronic
•Tremors, Nausea/ Emesis/ Anorexia, Diaphoresis, Agitation/ Anxiety, Headache, Seizures, Visual and auditory hallucinations, insomnia

How is alcohol intoxication managed?

-First step in treatment is brief intervention.
-A patient with an alcohol addiction may require vitamin supplementation with thiamine (200 mg), folic acid (1 mg), and a multivitamin. "banana bag"
-If the patient develops agitation or tremulousness, benzodiazepines may be needed.
-Complete abstinence is the only treatment for alcohol dependence
-Emphasize that the most common error is underestimating the amount of help needed to stop drinking
-Consider inpatient treatment if the patient has poor social support, significant psychiatric problems, or a history of relapse after treatment
-Strongly recommend Alcoholics Anonymous (AA)
-In the beginning of treatment, and perhaps ongoing, patients should remove alcohol from their homes and avoid bars and other establishments where strong pressures to drink may hinder abstinence
-Disulfiram (Antabuse): Most widely used pharmcotherapeutic treatment to prevent alcohol abuse

What are the effects of marijuana?

-Inhaled by smoking: Vaping (VALI): Vaping Associated Lung Injury
-Effects occur in 10-20 minutes and last 2-3 hours
-Two phases: mild euphoria followed by sleepiness
-*Acute state, the user has an altered time perception, less inhibited emotions, psychomotor problems, impaired immediate memory, and conjunctival injection*
-High doses produce transient psychotomimetic effects
-Frequently aggravates existing mental illness and adversely affects motor performance
-No specific treatment necessary

Describe long term use of marijuana.

-Abnormalities in the pulmonary tree; laryngitis and rhinitis are related to prolonged use, along with COPD
-EKG abnormalities are common (no chronic cardiac disease has been linked)
-Depression of plasma testosterone levels and reduced sperm counts
-Abnormal menstruation & failure to ovulate in some women
-Cognitive impairments are common
-Sudden withdrawal produces insomnia, nausea, myalgia, and irritability.

What diagnostics can be run for marijuana?

-Urine testing is reliable if samples are carefully collected and tested. Detection periods span 4-6 days in short-term users and 20-50 days in long-term users.

What are the effects of opiates?

-Heroin is by far the most commonly abused opiate.
-Other drugs of abuse in this category include methadone, morphine, codeine, oxycodone, fentanyl (China white), and black tar (a potent form of heroin).
-*Signs of intoxication are decreased respiratory rate and pinpoint pupils.* Acute complications include noncardiogenic pulmonary edema and respiratory failure.
-Snorting of heroin is a recent trend that has expanded its user base in many areas.

What are complications of chronic opiate use?

-primarily infectious and include skin abscess at an injection site, cellulitis, mycotic aneurysms, endocarditis, talcosis, HIV, and hepatitis.
-Mycotic aneurysms- aneurysm arising from bacterial infection of arterial wall
-Talcosis (talc pneumoconiosis) -Talc particles in crushed oral medications that are injected intravenously become entrapped in the pulmonary vasculature and can then move into the interstitium and cause a granulomatous reaction.

Describe opiate withdrawal.

-Withdrawal symptoms from opioids may begin just a few hours after last use- may be delayed in patients abusing long-acting opioids.- Symptoms of withdrawal usually peak around 48 hours and again at 72 hours.
-Along with a strong craving for the drug, opioid withdrawal produces yawning, tears, diarrhea, abdominal cramping, piloerection, and rhinorrhea.
-Withdrawal usually subsides after 1 week, but some heavily dependent users may have mild symptoms for up to 6 months.
-Although physically uncomfortable, opioid withdrawal *is NOT life threatening*
-Withdrawal: similar to severity of a "bout of flu", graded scale 0-4 (treatment for withdrawal initiated if Grade 2 signs develop)
•Grade 0: craving & anxiety
•Grade 1: yawning, lacrimation, rhinorrhea, perspiration
•Grade 2: previous symptoms plus mydriasis, piloerection, anorexia, tremors, hot/cold flashes, and generalized aches
•Grade 3 & 4: increase intensity of above symptoms with increased VS (Temp, BP, HR, RR)
-In withdrawal from most severe addiction, emesis, diarrhea, weight loss, hemoconcentration, & spontaneous ejaculation/ orgasm commonly occur

How is opiate withdrawal treated?

-Methadone 10mg orally & observe; recheck for signs Q4-6H with additional dosing over the first 24 hours. Total 24 hr dose, divide by 2 and administer every 12 hours with daily reduction of 5-10mg / 24 hrs.
-*Clonidine 0.1mg several times daily over 10-14 day periods both alternative or adjunct to Methadone*
-Opioid antagonist: Naltrexone- treatment for patient that has been opioid free for 7-10 days
-Buprenorphine, partial agonist, mainstay of office based treatment
-Pain: OTC analgesics or prescribed NSAIDS.
-Diarrhea: Immodium AD or diphenoxylate/atropine (Lomotil).
-Sneezing/tearing/runny nose: H1 blocking antihistamines
-Nausea/vomiting: 5-HT3 antagonists such as ondansetron or phenothiazine antiemetics such as promethazine (may also have a sedative effect).
-Tachycardia/hypertension: clonidine (also may help many of the other symptoms).
-Anxiety/insomnia: H1 blocking antihistamines.

What are the effects of cocaine?

-Acute cocaine intoxication may present with agitation, paranoia, tachycardia, tachypnea, hypertension, and diaphoresis.
-Complications of acute and chronic use can include myocardial ischemia or infarction, stroke, pulmonary edema, and rhabdomyolysis.

Describe cocaine withdrawal.

-Cocaine does not have a typical withdrawal pattern.
-These drugs are considered psychologically addicting rather than physically addicting.

What are the effects of amphetamines?

-Acute intoxication with amphetamines presents with signs of sympathetic nervous system stimulation, tachycardia, hypertension, anorexia, insomnia, and occasionally seizures.

Describe amphetamine withdrawal.

-Withdrawal can be mild to moderate with frequent, intense cravings.
-Patients may complain of depression, increased appetite, abdominal cramping, diarrhea, and headache.

Describe a hallucinogen withdrawal?

-Hallucinogens do not have a typical withdrawal pattern.
-These drugs are considered *psychologically* addicting rather than physically addicting.
-Flashbacks- mental imagery from a bad trip that is later triggered by stimuli (marijuana, alcohol, or psychic trauma)
-Treatment: short course antipsychotic (Olanzapine or Risperidone)
-Adjunct: Lorazepam or clonazepam

What are the effects of hallucinogens?

-Drugs: LSD, mescaline, psilocybin, dimethyltryptamine, and other derivatives of phenylalanine & tryptophan
Different hallucinogens present with a variety of organ system effects.
-Initial feeling of tension, followed by emotional release (laughing/ crying) (1-2 hours); perceptual distortions with visual illusions and hallucinations & occasionally fear of ego disintegration (2-3 hours); major changes in time sense and mood lability then occur (3-4 hours); feeling of detachment and sense of destiny and control (4-6 hours)
-Treatment: protection of the individual from erratic behavior--\> Haldoperidol 5mg IM may be given every several hours
-Phencyclidine (PCP) has been known to cause muscle rigidity, seizures, rhabdomyolysis, and coma.
-Anticholinergics have been associated with delirium, supraventricular tachycardia, hypertension, and seizures.
-Other hallucinogens (eg, lysergic acid diethylamide [LSD], peyote, marijuana, nutmeg) rarely cause significant physical complications

What is the drug of choice for withdrawal seizures?

Benzodiazepines

Describe tobacco use disorder.

-In developing nations, the prevalence of smoking is greater in males than females; but not the case in developed nations.
-Majority of US teens experiment with tobacco use and by age 18 years, ~20% smoke at least monthly- these often become chronic smokers.
-Individuals with lower socioeconomic status (SES) are more likely to initiate and less likely to quit tobacco use.
-\#1 preventable cause of death in the developed world!
-DSM V: Two of the diagnostic criteria within a 12-month period; then further specify severity based on number of symptoms present.
-Smoking- related morbidity occurs in more than half of tobacco users.
-*Major predictor of reversibility is duration of smoking.*
-Most medical conditions results from exposure to carbon monoxide, tar, and other non-nicotine components of tobacco.
-Most common medical diseases from smoking: cardiovascular diseases, COPD, and cancers.
-Most common psychiatric comorbidities: alcohol/substance use, bipolar, depression, anxiety, personality, and ADHD.

Describe tobacco use disorder cessation.

-More than 80% of smokers attempt to quit at some time, 60% relapse within one week. Most make multiple attempts and about 50% able to abstain. Other sources have reported an average of 8 attempts to quit before becoming successful.
-Patient Education is a critical component of smoking cessation process. Provide a description of the expected withdrawal syndrome. Encourage low calorie diet and exercise program to help with weight gain and withdrawal symptoms.
-Continue with a discussion of the possible cessation methods, which include counseling, Nicotine Replacement Therapy (NRT), antidepressant medications, behavioral training, group therapy, hypnosis.
-Nicotine Replacement Therapies:
•Transdermal nicotine patch (longer term use)
•Acute dosing/ breakthrough craving:
•Nicotine nasal spray
•Nicotine gum
•Nicotine lozenge
•Sublingual nicotine tablet
•Nicotine inhaler
-Often can combine patch with other NRT to control cravings and increase success of cessation.
-May also combine NRT with other pharmacologics: Bupropion, Nortriptyline, Clonidine

Describe the presentation of bipolar disorder.

-episodic mood shifts into mania, major depression, hypomania, and mixed mood states.
-Characterized by mania, hypomania, and major depression.
-Commonly associated with other mental health issues (anxiety disorders, substance use disorders)
-symptoms arrise at 20-25 y/o
-reduction in life expectancy and increased risk of *suicide*/ self harm

What is the diagnostic criteria of a manic episode?

◦A period of abnormal and persistently elevated or irritable mood, increased goal-directed activity and or energy *lasting at least one week* and present most of the day nearly every day
◦At least *three* of the following sx also must be present
-Increased self-esteem
-Decreased need for sleep
-Excessive talking
-Flight of ideas or racing thoughts
-Increased goal directed activity
-Excessive involvement in activities that have painful consequences
◦*Causes severe social, financial or occupational dysfunction or requires hospitalization*
◦The episode is not secondary to substance use
◦Mood is often described as euphoric, excessively cheerful, feeling "on top of the world"
◦poor judgement lack of insight, engaging in gambling, sexual promiscuity

What is the diagnostic criteria for a hypomanic episode?

◦A period of abnormal and persistently elevated or irritable mood, increased goal-directed activity & or energy lasting* 4 consecutive days* & present most of the day nearly every day
◦*Three* of the following sx also must be present
-Increased self-esteem
-Decreased need for sleep
-Excessive talking
-Flight of ideas or racing thoughts
-Increased goal directed activity
-Excessive involvement in activities that have painful consequences, sense of carelessness
◦The episode alters normal functioning when he/she is not hypomanic
◦*Does not impair social, financial or occupational functioning & does not require hospitalization*
◦Not secondary to substance use

What is the diagnostic criteria for major depression?

◦*Five* or more of the following below with either depressed mood and/or anhedonia as the major symptom for at least *2 weeks consecutively*
-Loss of weight (5% in one month) or decreased appetite nearly every day
-Insomnia or hypersomnia almost daily
-Psychomotor agitation almost daily
-Fatigue or decreased energy almost daily
-Feeling of guilt nearly daily
-Decreased ability to concentrate nearly daily
-Recurrent thoughts of death or suicidal ideations with or without plan or intent
◦Symptoms cause significant distress or impairment in function
◦Sx not secondary to substance use

Describe bipolar type I.

◦Criteria met for at least *one manic* episode
◦The mania and major depressive episodes are not better explained by another mental health diagnosis
◦Must impair occupational, social, or occupational functioning
◦Roughly 50% of patients in mania will cycle through depression afterwards
-increased risk of *suicide*
◦Comorbidities: Panic attacks, Anxiety disorder, Substance abuse disorders, Conduct disorders, Metabolic syndrome*, Migraines

What are rapid cyclers?

-those with bipolar disorder and mania/hypomania and depression with more than 4 episodes in a year

What are the functional consequences of bipolar I?

◦Lowering of SES
◦Decline in cognitive functioning
◦ETOH use disorder

Describe bipolar type II.

◦Must include *hypomania *and at least one major depressive episode
◦*DOES NOT INCLUE MANIC EPISODES*
◦Is not better explained by another disorder or medication use
◦Causes minor impairment in social, occupation or other functioning
◦Depressive episodes can follow periods of hypomania tend to be more lengthy and frequent than in BPD I
◦Impulsivity is a common feature in BPD II patients
◦Unlikely to present to office in hypomania; more likely to present with depression
◦Typically more than one cycle per year-Cycles usually decrease with increasing age

What is the prognosis of bipolar II?

◦Depression may become disabling over time
◦If rapid-cycling is present\=poorer prognosis
◦1/3 of those dx with BPD II reported *suicide* attempt

What comorbid conditions are associated with Bipolar II?

◦Anxiety disorder-most common
◦Substance use disorders
◦Eating disorder with binge eating disorder being amongst the most common of these

What is cyclothymia?

◦Hypomanic symptoms (which do not have to meet all hypomanic criteria) and periods of depression (which do not have to meet all criteria for major depression) over a period of *2 years or more*
-Less severe on either end of the spectrum but tend to persist for longer
◦Symptoms need to be present for at least half the time and not cease for more than 2 months consecutively
◦Never met criteria for hypomania, mania or major depressive disorder
◦Symptoms cause impairment in social, occupational or interpersonal relationships or functioning
◦Slower onset with progressive and persistent course
◦Pts at risk for Bipolar disorder, substance use disorder, sleep disorders, ADD or ADHD

How is severe mania treated?

◦Initiate Lithium + first or second-generation antipsychotic
◦If patient responds (50% reduction of sx in 3 weeks), continue current regimen. If not, Change the antipsychotic or Consider changing lithium to valproate
◦If patient still has refractory symptoms, then consider ECT

How is acute agitation treated?

◦May require oral and physical restraints
◦IM injection Haldol

How is milder mania or hypomania treated?

◦First-line monotherapy: Risperidone or olanzapine
◦Second-line monotx: Aripiprazole, Carbamezipine, Ziprasidone, Asenapine, Cariprazine, Haloperidol, Lithium, Paliperidone, Quietapine, Valproate
◦Treatment-resistant patients (patients who have failed 3-5 above listed drugs) Combine lithium or valproate with an antipyschotic