Psych Review II Alyssa Norman, MS4 - PowerPoint Presentation

1. Psych Review IIAlyssa Norman, MS4aherman@buffalo.edu

2. Intoxication & WithdrawalSubstance Use Disorder – problematic pattern of substance use leading to significant impairment or distress over 12 month period involving:Impaired Control – can’t cut down, taking more than intendedSocial Impairment – not fulfilling obligations, giving up important activitiesRisky Use – ignoring hazardous purchasing conditions or physical effectsPharmacologic Dependence – tolerance, withdrawal if stop using

3. Intoxication & WithdrawalStimulantsSedativesHallucinogensDissociative AnestheticsCannabinoidsCocaineAlcoholLSDPCPMarijuanaAmphetaminesBenzodiazepinesPsilocybinKetamineK2Crystal MethBarbituatesMescalineMDMA(Ecstasy)OpioidsBath Salts

4. StimulantsMechanisms of Action:Cocaine –  reuptake of DA, NE, 5HTSmoking and injection = most addictiveAlso block nerve impulses causing local anesthetic effectAmphetamines –  reuptake,  release,  degradation of NE and DAEcstasy – amphetamine MoA +  release of 5HTCrystal Meth – fat solubility  BBB penetration  more addictiveBath Salts – effect is similar to amphetamines

5. StimulantsIntoxication – sympathomimetic ( HR, BP, RR), mydriasis, euphoriaCocaine overdose  formications, delirium, seizure, stroke, MIEcstasy  emotional openness, euphoria, “afterglow”Withdrawal – malaise, fatigue, depression, SI, hypersomnia, miosisSymptomatic treatmentEcstasy – long-term use can deplete 5HT  depression

6. Dissociative AnestheticsPCPMoA: blocks NMDA glutamate receptors, activates DA receptorsIntoxication: hallucinations, nystagmus, violence, anesthesiaOverdose: fever, rhabdo, renal failure, seizure, respiratory depression, deathTreatment: isolate, benzos, urine acidification (NOT antipsychotics – can worsen psychosis)KetamineHallucinations, dissociation, profound respiratory depression

7. HallucinogensLSD, Psilocybin, MescalineMoA – 5HT receptor agonistIntoxication – visual distortions, intense emotions, mydriasis, tachycardia, altered sense of time/spaceHallucinogen Persisting Perception (“Bad Trip”) – acute anxiety reactionTx – reassurance and wait, +/- benzos, antipsychotics last resortFlashbacks can occur in times of fatigue/stress or while using other drugsDurationLSD, mescaline: 6-10 hrsPsilocybin – 2-4 hrs

8. CannabinoidsMarijuana (Cannabis)MoA – THC binds endogenous cannabinoid receptorsIntoxication – euphoria, relaxation, conjunctival injection, paranoia, increased appetiteWithdrawal – irritability, restlessness, anxiety, depressed mood, abdominal painK2 (Spice)Synthetic cannabinoid, 10x more affinity for receptor than THCMore severe sxs – hallucinations, thought disorganization, aggression

9. SedativesAlcohol, Benzodiazepines, BarbituatesMoA – potentiates the effects of GABA (CNS depressant)Intoxication – incoordination, slurred speech, nystagmus, comaBenzo overdose  flumazenilWithdrawal – LIFE THREATENING!!!!Autonomic hyperactivity, tremor, seizures, DTs (day 2-3)Tx – frequent vitals, benzo taper, carbamazepine

10. SedativesOpioids – Heroin, Methadone, Buprenorphine, Naloxone, NaltrexoneMoA – bind opioid receptors (most importantly the Mu receptors)Full agonist: highly reinforcing, most common to abuseHeroin, methadone, oxycodonePartial agonists: activates at lower levels, less reinforcingBuprenorphineAntagonist: occupies without activating, not reinforcing, blocks and displaces agonistsNaloxone, naltrexone

11. OpioidsIntoxication – euphoria, analgesia, respiratory depression, miosis, constipationOverdose can be fatal  treat with naloxone (antagonist)Single naloxone lasts 1-4hrs Withdrawal – dysphoria, craving, nausea/vomting, diarrhea, lacrimation, rhinorrhea, yawing, mydriasisTreatments for dependenceMethadone: used for detox and maintenance, long half-lifeSuboxone (buprenorphine/naloxone) – detox and maintenanceNaltrexone – maintenance only

12. Mood Disorders

13. DepressionMajor Depressive Episode (MDE) – 5 or more of the following for ≥ 2 weeks, with loss of function:Depressed mood*Sleep disturbanceInterest lost (anhedonia)*Guilt/worthlessnessEnergy lossConcentration lossAppetite changePsychomotor agitation/retardationSuicidal Ideation*Need both(SIGECAPS)Features changes in:MoodThoughtVegetative functionEpidemiology:~2:1 female to maleIncreased incidenceDecreased age of onset2-4% community prevalenceEtiologyGenetic EnvironmentalCourse50% recurrence after 1 episodeRisk of recurrence increases with more/longer episodes

14. DepressionPhysiologic Changes:Dysregulated stress response (cortisol)Neuronal atrophy, NT imbalancesSleep:  REM latency,  slow wave sleep (restorative sleep)In children:Irritability, apathy, behavioral changeLess of a response to antidepressantsMore likely to have bipolar outcome

15. Depression DiagnosesMajor Depressive Disorder (MDD) – at least 1 major depressive episode (≥ 2 weeks)MDD with atypical features: increased sleep, increased appetite, weight gainMDD with psychotic features: w/ delusions and/or hallucinationsTx – antipsychotic + antidepressantDysthymia – milder depressive symptoms for ≥ 2 yearsSeasonal Affective Disorder – depression ONLY in winter, normal or hypomanic in springSecondary Depression:General medical condition – hypothyroidism ,pancreatic cancer, left hemisphere stroke, Parkinson's, HIV, autoimmuneMedication/substance – alcohol, steroids

16. Treatments for Depression1st Line = SSRIs (fluoxetine, sertraline, paroxetine, fluvoxamine, citalopram, escitalopram) – inhibit 5HT reuptakeSide effects – sexual dysfunction, GI disturbance, headaches, sedation/activationParoxetine – more anticholinergic, contraindicated in pregnancyTCAs (amitriptyline, nortriptyline, clomipramine) – NE and 5HT reuptake inhibitorsUses: migraines, chronic pain, refractory depression (not 1st line)Side effects: anticholinergic, orthostatic hypotension, heart block, lethal in ODToxicity: Cardic, CNS/Convulsions, ComaMAOIs (phenelzine, isocarboxazid) – prevent MAO from breaking down NE, 5HT, DA and tyramineUses – refractory and atypical depressionCANNOT combine with SSRIs (serotonin syndrome) or tyramine-rich foods (cheese, wine, chocolate, fava beans (HTN crisis)

17. Treatments for DepressionTrazodone – 5HT antagonistSedating, risk of priapismBuproprion – DA and NE reuptake inhibitorLess sexual side effects (vs. SSRIs), risk of seizures at high dosesDA reuptake inhibition makes it first choice for depressed Parkinson’s patientsVenlafaxine – 5HT, NE, DA reuptake inhibitorUseful for depression with chronic painHypertension risk, short half-life (withdrawal)Mirtazepine – 5HT and alpha2 antagonistCauses sedation and weight gain –ideal for depressed cancer patientsECT – electroconvulsive therapyMost effective therapy, main side effect is transient amnesia

18. Principles of Treatment“Start low, go slow”If no response in 4 weeks switch to something else in same classIt can take up to 6-8 weeks for full therapeutic effectContinue8-12 months for first episode of mild depressionIndefinitely if recurrent or severe first episodeRemember – antidepressants in general work by altering second messenger systems with up-regulate neuroprotective genes

19. Bipolar DisorderMania – elevated/expansive/irritable mood with 3-4+ symptoms for ≥ 1 weekDistractibilityIndiscretionGrandiosityFlight of ideasActivity increasedSleep decreasedTalkative (pressured speech)Hypomania – same symptom criteria as above EXCEPT:≥ 4 days durationNo marked functional impairmentHospitalization not requiredNo psychotic featuresAdditional Characteristics of Mania:Severe impairment in functionMay include psychotic featuresFrequently requires hospitalization (which confirms diagnosis regardless of symptom time frame)

20. Bipolar DiagnosesBipolar I – at least 1 manic episodes (Required) + major depressive episode (not required)Bipolar II – at least 1 hypomanic episode + at least 1 major depressvive episodeCyclothymia - ≥ 2 years of mood swings between hypomania and mild depressive (dysthymia) symptomsMixed Episode – simultaneous manic/hypomanic and depressive symptomsSecondary Mania:General medical condition – hyperthyroidism, right hemisphere strokeMedications/substance – antidepressants, stimulants, steroids

21. Remember Schizoaffective Disorder?Schizoaffective Disorder – concurrent symptoms of schizophrenia and mood disorder but with at least 2 weeks of psychotic symptoms in the absence of mood symptomsIn mood disorders with psychotic features, psychosis never occurs outside the context of the mood symptoms (mood symptoms are causing the psychosis)If mood symptoms disappear, but psychosis remains for at least 2 weeks on their own = Schizoaffective disorder

22. Bipolar DisorderEpidemiology~1% prevalence of Bipolar I67-100% concordance between MZ twins (risk only dependent on biological family)OligogeneticWhen to think of Bipolar vs. DepressionFamily hxEarly (childhood) onset of depressionAtypical depression or depression w/ psychotic featuresHighly recurrent episodes of depressionThrill seeking, tendency towards irritability or impulsivityArrogance or intrusiveness, high-functioning/creative

23. Treatment for Bipolar DisorderAka. Mood StabilizersLithium*Narrow therapeutic index, can improve depressionSide effects – cognitive impairment, weight gain, renal/thyroid dysfunctionCarbamazepine*Better tolerated than Li, useful for rapid cycling, can improve depressionSide effects – sedation, neurotoxicity, SIADH, agranulocytosis (Rare)Valproic Acid/Divaplroex*Good for anxiety and anti-aggression, but no antidepressant effectSide effects – sedation, weight gain, cognitive impairment, pancreatitis Atypical antipsychotics Treat acute mania, possible adjunct to maintenance *Teratogenic

24. SuicideRisk factors: previous attempt, substance abuse, mental illness, firearms in the home, elderly, military personnel Native American > White > Asian, Hispanic, Black Females attempt more (3:1), males complete more (4:1) Firearms = most common in U.S. and most lethal Hospitalize (involuntarily if necessary), begin appropriate therapySSRI’s – when starting there is a higher suicide risk (energy levels improve before depressed mood/suicidal thought content)

25. Eating DisordersAnorexia NervosaPersistent energy intake restrictionIntense fear of gaining weightDisturbance of body imageUnderweight – BMI < 17.5, < 85% expected weightTend to be controlling, perfectionistic, inflexible More ego-syntonic – less likely to present themselves to treatment ↓ HR/BP/Temp, ECG changes, electrolyte abnormalities, osteopenia, lanugoTypes: restricting, binge-eating/purgingTx – therapy, strict weight gain programs, potential hospitalizationBulimia NervosaRecurrent episodes of binge eatingCompensatory behavior – vomiting, laxatives, excessive exerciseDisturbance of body imageNormal or overweightSense of lack of controlFeelings shame/embarrassment during/after bingeMore ego-dystonic – more likely to present Parotitis, enamel erosion, dorsal hand calluses, hypokalemic hypochloremic metabolic alkalosisTx – fluoxetine if comorbid depression, CBTBinge-eating disorderBinge-eating (at least 1x/week for 3 months) with no compensatory behaviorNormal or overweight

26. Gender Dysphoria A marked incongruence between one’s experienced/expressed gender and assigned gender for ≥ 6 months duration, with ≥2 of the following:Marked incongruence between one’s experienced/expressed gender and primary +/or secondary sex characteristicsStrong desire to be rid of one’s primary +/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed genderStrong desire for the primary +/or secondary sex characteristics of the other genderStrong desire to be of the other genderStrong desire to be treated as the other genderStrong conviction that one has the typical feelings and reactions of the other genderAssociated with clinically significant distress or impairment in social, occupational or other important areas of functioning

27. Gender Dysphoria - Differential Transvestic Disorder – cross dressing behavior generates sexual excitement or distress/impairment without drawing primary gender into questionBody Dysmorphic Disorder – individual focuses on alteration or removal of specific body part perceived to be abnormal (not because it represents assigned gender)

28. Anxiety DisordersGeneralized Anxiety Disorder – excessive worry about multiple everyday events for > 6 monthsRestlessness, easily fatigued, concentration, irritability, muscle tension, sleep disturbancePanic Disorder – recurrent, unprovoked episodes of intense fear (panic attacks)Tachycardia, sweating, SOB, CP, abdominal distress, tremor, dizzinessAnticipatory anxiety for future attacks, fear “losing control”, significant change in behaviorPeak in 10 mins, last 20-30 minsAgoraphobia – fear of being in situations from which escape may be difficultBeing outside the home, in a crowd or in line, bridges tunnels, on a bus, train or carSpecific Phobia – persistent, irrational fear of object, creature or situationSocial Phobia (Social Anxiety Disorder) – anxiety about humiliating oneself in both social and performance situationsMedical CausesPEArrhythmiaCHFDeliriumDementiaSubstance CausesStimulantsCaffeineNicotineAlcoholAntidepressantsOther Psych ConditionsDepressionBipolarSchizophrenia

29. PTSD and ASDPost-traumatic Stress DisorderExperiencing/witnessing/learning of a traumatic event, with ≥ 1 month of symptoms (onset at any time) from the following clusters + functional impairment:Intrusion – flashbacks, nightmares, distressing thoughtsAvoidance – physical (people, places) or mental (thoughts, feelings)Cognition/Mood – persistent negative emotions, detachment, distorted cognition (irrational thoughts)Arousal/Reactivity – hype vigilance,  startle response, sleep disturbance, irritability Acute Stress DisorderSimilar scenario and symptomatology to PTSD except:Duration is 3 days – 1 month after trauma exposureRisk factors:Female gender, younger ageLow SES, education, IQIntentional violent act toward you, trauma severityContinued environmental exposuresFunctional Consequences:Substance abuseAggression/violenceSI, attemptsWork/marriage problems Treatments:CBT (1st line), EMDRSSRI’s (1st line) sertraline, paroxetineBenzos (Very short term)Prazosin for nightmares

30. Neuroscience of PTSDAmygdala – hyperactive Hyperarousal, exaggerated emotional response to stimuliPrefrontal cortex – hypoactive ability to keep limbic system in check ability to properly interpret stimulus context  behaviors become more instinctual memory consolidation which links context to stimulusHippocampus – smallAlso impairs memory formation which properly links context to stimulusNE hyperactivity (made in locus coeruleus)Increased sympathetic tone – increased HR, BP, startle response, hyperarousal HPA axis dysregulation on the locus coeruleus  high levels of stress hormones (i.e. cortisol) fail to provide feedback inhibition  continues to drive up NE levels

31. AnxiolyticsBenzodiazepines (diazepam, alprazolam, etc) – acute anxietyPotentiate GABA  neuron hyperpolarization  reduce anxietySide effects – sedation, impaired coordination, life-threatening withdrawalAntidepressants (SSRIs) – 1st line for chronic anxiety (i.e. GAD)Buspirone – chronic anxiety5HT partial agonistNon-sedating, no withdrawal, no impairment of drivingPropranolol – performance anxietyPrazosin – alpha blocker that  BP and improves sleep (sedating, nightmares)Non-pharmacologic treatments – relaxation training, desensitication, CBT (especially for insomnia)

32. Somatic Symptom DisordersSomatization – psychological problems communicated as physical symptoms which are otherwise medically unexplained or disproportionateRisks – childhood illness, parental illness, childhood trauma/abuseConsequences – increase health care visits, increase iatrogenic disease due to unnecessary workup, disruption of doctor-patient relationshipSomatic Symptom Disorder1 or more somatic symptoms that are distressingExcessive thoughts/feelings/behaviors related to the symptomsDisproportionte/persistend thoughts about seriousness of symptomsPersistently high anxiety levelExcessive time/energy devoted to symptoms or health concernsSymptom duration ≥ 6 monthsTx – regular f/u visits (i.e monthly), set limits, minimize polypharmacy, treat common comorbid conditions appropriately (depression/anxiety disorders)

33. Somatic Symptom DisordersIllness Anxiety DisorderExcessive/disproportionate preoccupation with having/acquiring a serious illnessHigh anxiety level about health, illness becomes central to identity, seek reassuranceNo (or mild) somatic symptomsIllness preoccupation present for ≥ 6 monthsConversion DisorderOne or more neurologic (sensory or motor) symptoms which cannot be explained by a known neurological/medical conditionWeakness/paralysis, reduced sensation, dysarthria, limb shaking/pseudo seizuresAbrupt onset, short durationWomen > men“La Bell Indifference” Factitious Disorder (Munchhausen Syndrome)Conscious falsification of physical/psych symptoms for primary gain (i.e sick role)No obvious external rewards (vs. malingering – falsify for secondary gain)Munchhausen Syndrome by proxy – falsifying symptoms of another individual

34. OCD Spectrum DisordersObsessions – recurrent and persistent thoughts/urges/images experienced as intrusive and unwanted (ego-dystonic) and cause anxiety/distressCommon themes – contamination, fear of harming, need for symmetry, checking for reassuranceCompulsions – repetitive behaviors (washing, checking) or mental acts (counting, repeating) that the individual feels driven to perform to alleviate anxiety from obsessions or prevent a dreaded eventObsessive-Compulsive DisorderPresence of obsessions, compulsions or bothTime consuming (>1hr/day) or causes significant distress/impaired functionMRI findings – increased metabolic activity in orbitofrontal cortex, limbic structures, caudate, and thalamus (regulate emotions, impulse inhibition and judgment)M=F, younger in males, 80-87% MZ concordance, childhood onset comorbid with Tourette’s Syndrome, ADHDTx – CBT (1st line), SSRIs, clomipramine (TCA), surgical treatments (gamma knife, DBS)

35. OCD Spectrum DisordersCompulsive Hoarding – acquisition of and/or failure to discard useless/valueless possessionsCluttered living space, social isolation, impaired functioning or significant distress/shame, difficulty with decision makingCan be symptom of OCD or a stand-alone dx (70-80% meet OCD criteria)Vs. OCD – earlier symptom onset,  age at presentation, insight, more tx-resistantTx – same as OCD (CBT, SSRIs)Body Dysmorphic Disorder – preoccupation with perceived physical flaws that are slight/unobservable to othersSkin, hair nose are common preoccupationsRepetitive behaviors (grooming, mirror checking) or mental acts (comparing to others)Often have intrusive, obsessive thoughtsClinically significant distress or impaired functionIdeas of reference common – falsely believe people are judging/mocking themHigh rates of SI and attempts