Psychiatry

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Psychiatry
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  1. diagnostic criteria for Schizophrenia
    a. The presence of at least two of five characteristic positiveor negative symptoms for at least 1 month:

    delusions,hallucinations, disorganized speech, grossly disorganizedor catatonic behavior, or negative symptoms

    —only need one of five if the delusions are bizarre or a voice or voices are keeping running commentary on the person’s behavioror

    • b. Deterioration in social, occupational, and interpersonal relationships
    • c. Continuous signs of the disturbance for at least 6 months (can include prodromal or residual symptoms like amotivation)
    • d. Schizoaffective disorder and mood disorder with psychotic features have been ruled oute.
  2. Schizophrenia important points
    1%, M=F, M earlier onset than F

    Average age at onset: men, 21 years (17-27 years); women, 27 years (17-37 years), Onset before age 10 and after age 45 are uncommon

    Hallmark:Positive symptoms: delusions, hallucinations, bizarre behavior

    Negative symptoms: blunting of affect, autism, ambivalence, social withdrawal, poverty of speech

    Subtypes: Paranoid (best prognosis), disorganized, catatonic, undifferentiated, residual

    At least 6 months of symptoms
  3. Fregoli syndrome
    Identifies a familiar person in various other people he or she encounters; even if nophysical resemblance
  4. Negative symptoms in Schizophrenia
    • 1) Alogia: speech that is empty or with decreased spontaneity
    • 2) Affective blunting: sparsity of emotional reactivity
    • 3) Avolition: unable to initiate or complete goals
    • 4) Other common negative symptoms: anhedonia (unable to experience pleasure), inability to concentrate or “attend,” inappropriate affect, poor hygiene
  5. Other symptoms and associations in Schizophrenia and risk of suicide
    Abnormalities of eye movements (increased frequencyof blinking and abnormal saccades during test of smooth pursuits)

    Decreased stage IV sleep

    Up to 25% may have shown schizoid traits before schizophrenia developed

    Tend to be less interested in sexual activity

    Up to 10% of schizophrenics commit suicide withinfirst 10 years of their illness

    Up to 20% of schizophrenics drink excessive amounts of water, which may lead to chronic hyponatremia and possible water intoxication
  6. Subtypes of schizophrenia
    paranoid, disorganized, catatonic,undifferentiated, residual

    • Paranoid (best outcome)
    • a) Presence of delusions (often persecutory)
    • b) Frequent auditory hallucinations
    • c) Onset of illness (late 20s or 30s) later than other subtypes
    • d) More likely to marry and have children

    • Disorganized
    • a) Display disorganized, nonproductive behaviors and demonstrate disorganized speech patterns, Can act silly or childlike
    • b) Exhibit flat or inappropriate affect; grimacing is common
    • c) Delusions and hallucinations are less organized

    • Catatonic
    • a) According to DSM-IV-TR, must have at least two of the following:
    • i) Motoric immobility (catalepsy, stupor)
    • ii) Excessive motor activity
    • iii) Stereotypies, Echolalia, echopraxia

    Undifferentiated: these patients do not satisfy criteria for any other schizophrenia subtype

    Residual: according to DSM-IV-TR, these patients no longer have any major psychotic symptoms but still exhibit evidence of the illness, with negative symptoms or at least 2 other odd or eccentric behaviors or perceptual experiences

  7. Indicators of good outcome in schizophrenia
    • a) Acute onset, short duration, no previous psychiatric history, no FH
    • b) Mood symptoms present, sensorium clouded
    • c) No OCDs, no assaultiveness
    • d) Premorbid functioning good, high socioeconomic class
    • e) Married, good psychosexual functioning
    • f) Normal findings on neuroimaging
  8. Ideas of reference
    Belief that one is the topic or subject of media or other people’s thoughts orconversations
  9. Loose associations
    Rapid shift from one unrelated topic to another
  10. Perseveration
    Thinking about something over and over
  11. Tangentiality
    Thoughts begin in logical fashions, then getfurther off track
  12. Thought blocking
    Train of thought stops, usually because of hallucinations
  13. Schizophrenia Genetics
    Twin studies: nearly 50% monozygotic, 17% dizygotic

    Chromosomes implicated: 3p, 5q, 6p, 6q, 8p, 10p,13q, 15q, 18p, 22q

    Trinucleotide repeat (CAG/CTG) on chromosomes17 & 18
  14. Neuroanatomical findings on imaging in schizophrenia
    a. Most consistent finding is ventricular enlargement,especially third and lateral ventricles

    b. Selective reduction in size of frontal lobe, basal ganglia, thalamus, and limbic regions, including the hippocampus and medial temporal lobe

    c. Sulcal widening, especially frontal and temporal areas

    f. Increased incidence of: Cavum septum pellucidum and Partial callosal agenesis
  15. Functional neuroimaging in schizophrenia
    a. Hypofrontality

    • b. PET studies: anatomic substrate for visual hallucinationsin schizophrenia
    • 1) Inferotemporal cortex is responsible for visual recognition of objects and faces
    • 2) Basal ganglia output (primarily substantia nigra pars reticulata) to infero-temporal cortex with relay in ventral-anterior thalamic nucleus—influences visual processing and causes altered visual perception (hallucinations) as a result of increased dopaminergic activity in basal ganglia (may also be the mechanism of hallucinations in parkinsonian syndromes sensitive to dopaminergic agents [diffuse Lewy body disease more so than idiopathic Parkinson disease])
  16. Neuropathology schizophrenia
    • a. Decreased cell density in the dorsomedial nucleus of thalamus
    • b. Displacement of interneurons in frontal lobe cortex
    • c. Developmental issues
    • 1) History of injury at birth may contribute to developmentof schizophrenia
    • 2) Season of birth: more schizophrenics are born in earlyspring or winter
  17. Five types of dopamine receptors: D1, D2, D3, D4,D5
    • a) D1: located in cerebral cortex and basal ganglia
    • b) D2: located in striatum
    • c) D3 and D4: high concentration in the limbicsystem
    • d) D5: located in thalamus, hippocampus, andhypothalamus
  18. Neurochemical considerations in schizophrenia
    • Dopamine: excessive dopaminergic activity in mesolimbic areas
    • Serotonin: hyperactivity
    • Norepinephrine: hyperactivity
    • γ-Aminobutyric acid (GABA): loss of GABAergic neurons in hippocampus (decreased GABA, increased dopamine)
  19. Treatment of schizophrenia
    1) First line, atypicals (may improve neurocognitive impairment in schizophrenia): risperidone (Risperdal),olanzapine (Zyprexa), quetiapine (Seroquel), ziprasidone(Geodon), aripiprasole (Abilify)

    2) Second line: clozapine

    3) Typicals (may worsen neurocognitive functioning)
  20. Schizophrenia: Associated Neurologic Manifestations
    • - Ventricular enlargement
    • - Frontal lobe abnormality
    • - Cerebellar vermis atrophy
    • - Decreased volume: basal ganglia, limbic areas, hippocampus, thalamus, temporal regions, parahippocampal gyrus
    • - Hypofrontalility: frontal lobe dysfunction
    • - Increased D2 receptor density in striatum & nucleus accumbens
    • - Abnormal saccadic eye movements
    • - Primitive reflexes
  21. Schizophreniform Disorder in a glance
    • - Like schizophrenia but duation <6 months (1-6 m)
    • - 66% progress to schizophrenia/schizoaffective disorder
    • - Prevalence: 0.2%
    • - M=F
    • - Depression is often comorbid: increases risk of suicide
    • - Clinical management and psychosocial interventions: same as for schizophrenia
  22. Schizoaffective Disorder
    - Prominent mood symptoms and at least 2 weeks of psychotic symptoms in the absence of mood symptoms

    - Prognosis: better than schizophrenia, but worse than major depression

    • Prevalence: <1%
    • Suicide risk: 10%
  23. Delusional Disorder
    - Rare

    - Nonbizarre delusions for 1 or more months (persecutory type is more common)

    - Functioning is not impaired, behavior is not odd

    - Consider atypical antipsychotic agent, SSRIs can be helpful, even apart from depression

    - Psychosocial interventions
  24. Brief Psychotic Disorder
    At least one of the following symptoms for 1 or more days but less than 1 month: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior

    often precipitated by a stressor, may occur withoutan apparent antecedent

    Factors associated with good prognosis: sudden onset, short duration, severe stressor, prominent mood symptoms, maintenance of affective reactivity, prominent confusionat peak of psychosis

    50% to 80% completely recover, and in the other 20% to 50% schizophrenia or a mood disorder may be diagnosed
  25. Criteria for MDD
    Need five symptoms for 2 weeks, must also have depressed mood or anhedonia

    • “SIG E CAPS” (useful mnemonic for depression)
    • S—sleep disturbance
    • I—loss of interest
    • G—guilt
    • E—loss of energy
    • C—loss of concentration
    • A—appetite change (gain/loss)
    • P—psychomotor agitation/retardation
    • S—suicidal ideations

    Chronic if full criteria are met for at least 2 years—clinically challenging!
  26. Postpartum onset specifier for depression
    • - Onset of episode within 4 weeks post partum
    • - High rate of recurrence, 30% to 50%
    • - 1:500 to 1:1,000 births
  27. Atypical feature specifier of MDD
    • a) Mood reactivity: brightens in response to positive events and
    • b) At least two of the following: considerable weight gain or increased appetite, hypersomnia, leaden paralysis, long-standing interpersonal rejection sensitivity
  28. Major Depression: Epidemiology
    • - Prognosis usually good
    • - Suicide (10%-15%): completers (M>F), attempters (F>M) - Prevalence: 10%-25% for F, 5%-12% for M
    • - Peak age: 18-44 years
  29. Major Depression Neurotransmitters and Genetics
    -Neurotransmitters: low levels of serotonin, norepinephrine, dopamine in limbic areas

    - Genetics: 50% concordance rates in monozygotic twins, 10%-25% in dizygotic twins

    - Sleep: shortened latency of first rapid eye movement (REM) period, increased length of first REM period, increased REM density, increased REM sleep first part of night
  30. Suicide Risk Factors
    • - Previous suicide attempts
    • - Older
    • - Substance abuse
    • - h/o rage, violence
    • - Male
    • - White
    • - Socially isolated
    • - FH of suicide
    • - Jewish/Protestant
    • - Failing health or chronic illness
  31. Disorders associated with depression
    • - Cancer (especially pancreatic): 25%
    • - Dementia: 11% of patients with Alzheimer’s
    • - Seizure disorders: up to 60% of patients
    • - Nutritional factors associated with depression: B12, folate, thiamine

    - Cerebrovascular: depression often develops after stroke, especially left hemisphere brain injury or subcortical strokes and disorders

    • - 50% of Parkinson’s patients
    • - 40% Huntington’s disease
  32. Medications cause MDD
    β-blockers, diuretics, corticosteroids, birth control pills with progesterone, cimetidine, disulfiram, sulfonamides, reserpine, methyldopa, glucocorticoids, BZD, barbiturates, digitalis, clonidine, phenytoin
  33. Neuroanatomy and structural neuroimaging in MDD
    • - Hypothalamus: functioning is decreased in depression
    • Depression linked to hypothalamic-pituitary-adrenalaxis and cortisol secretion abnormalities
    • Depression linked to hypothalamic-pituitary thyroid axis and thyroid hormone secretion abnormalities

    - Basal ganglia: higher incidence of depression in patients with Parkinson’s disease

    • - Anterior left hemisphere strokes --> dysphoria
    • - Right hemisphere strokes --> euphoria

    - Depressed patients may have increased number of focal signal hyperintensities in the white matter

    • - have smaller caudate nuclei and frontal lobes
  34. Dysthymic Disorder
    Depressed mood at least 2 years

    “I’ve been depressed all my life”
  35. Double depression
    major depressive disorder + dysthymia
  36. Manic episode: overview of DSM-IV-TR criteria
    - At least 1 week of persistently elevated, expansive, or irritable mood (less duration if hospitalization is required)

    - At least three (four if mood is only irritable) of the following: DIG FAST, distractibility, insomnia, grandiosity, flight of ideas, activities increased, pressured speech, thoughtlessness
  37. Mixed episode: overview of DSM-IV-TR criteria
    Criteria met for manic episode and major depressiveepisode except duration is at least 1 week
  38. Hypomanic episode vs. Manic episode
    At least 4 days of persistently elevated, expansive, or irritable mood

    Not severe enough to cause impaired functioning
  39. Epidemiology of Bipolar
    • a. Bipolar I disorder: lifetime prevalence is 1.0%, M=F
    • - Early onset is associated with more psychotic issues
    • - Peak manic episodes occur in summer
    • - Early onset associated with increased psychotic issues
    • - Episodic, noncurable, variable course and outcome
    • - First episode between 20-25 years old
    • - Highest rate of suicide completion is 15%-50%
    • - Divorce rate 3 times higher
    • - Untreated manic episode may last 3 to 4 months and Untreated depressive episode may last 6 to 9 months

    b. Bipolar II disorder: lifetime prevalence is 0.5%

    c. Cyclothymic disorder: lifetime prevalence is 0.7%
  40. Cyclothymic Disorder
    a. At least 2 years of periods of hypomania and periods of depressive symptoms that do not meet criteria for major depressive episode (1 year for children and adolescents)

    b. Never without symptoms for more than 2 months at a time

    c. No major depressive episode, manic episode, or mixed episode present during first 2 years of disturbance
  41. Generalized Anxiety Disorder Criteria:
    • - At least 6 months of excessive anxiety
    • - At least three of the following: restlessness, easily fatigued, poor concentration, irritability, muscle tension, sleep disturbance
    • - Causes marked impairment
    • - Chronic, fluctuating course
    • - Prevalence: 4%-7%, F>M, onset in early 20s
  42. Generalized Anxiety Disorder - Comorbidities
    • - 62% in major depressive disorder, 37% in alcohol dependence
    • - Increases suicide risk in patients with major depressivedisorder
  43. Genetic Factors in Generalized Anxiety
    • - 25% of first-degree relatives of a patient with generalized anxiety disorder have the disorder
    • - Twin studies: genetic factors have a role, but nongenetic factors may be more important
  44. Panic attack: overview of DSM-IV-TR criteria
    a. Intense fear

    b. At least four of the following: pounding heart, sweating, trembling, shortness of breath, feelings of choking, chest pain, nausea, dizziness, de-realization, loss of control, fearof dying, paresthesias, chills or hot flashes
  45. Panic disorder: overview of DSM-IV-TR criteria
    • a. Recurrent panic attacks
    • b. At least 1 month of concern about having additional attacks
    • c. Absence of agoraphobia (panic disorder without agoraphobia) or presence of agoraphobia (panic disorder with agoraphobia)
  46. Panic Disorder Highlightes:
    • “PANIC”
    • P—palpitations
    • A—abdominal distress, anxiety
    • N—nauseaI—increased perspiration, intense dread/doom
    • C—chest pain, chills, choking, lost control

    • Episodes: 5-30 minutes
    • Prompts frequent emergency department visits, unnecessary work-up

    Prevalence: 2%-3% in F, 0.5%-1.5% in M

    Onset in mid-20s, usually chronic or lifelong

    30% recover fully

    45% concordance monozygotic twins, 15% dizygotic twins

    Increased catecholamine levels

    Locus ceruleus likely affected
  47. false suffocation alarm
    the brain Carbon dioxide hypersensitivity in panic attack. it is a theory.
  48. Specific Phobias
    Most common of phobia disorders

    Types: animal; blood, injection, injury; situational;natural environment; other

    • - Situations or objects are avoided, causes marked impairment in function
    • - At least 6 months in duration (if younger than 18 years)
    • - Bimodal age of onset: childhood and early adulthood

    • - Benzodiazepines, propranolol
    • - Cognitive-behavioral therapy, biofeedback, exposure therapy
  49. Obsessive-Compulsive Disorder (OCD) - afew notes
    20% to 35% of relatives of patients with obsessivecompulsivedisorder have the disorder

    May be observed in context of head trauma, epilepsy, Sydenham’s chorea, Huntington’s disease

    Some patients have decreased caudate size

    Hypermetabolism in frontal cortex

    Prognosis is better if obsessions only; Prognosis is worse if yielding to compulsions
  50. PTSD - DSM criteria
    a. Exposure to traumatic event—must have both of the following:

    • 1) Experienced or confronted with actual or threatened death or injury to self or others
    • 2) Response involved intense fear, helplessness, horror

    • b. Traumatic event is reexperienced in at least one of the following:
    • 1) Recurrent and intrusive recollections of the event
    • 2) Recurrent and distressing dreams of the event
    • 3) Acting or feeling as if event were recurring
    • 4) Intense psychologic distress at exposure to triggers or cues related to the event

    • Symptom onset can be immediate or delayed
    • Intensity waxes and wanes (anniversaries of trauma maybe worse).Can be chronic, lasting 40+ years
  51. PTSD and sleep
    Decreased rapid eye movement latency in stage IV sleep
  52. Neurotransmitter pathway in PTSD
    - Noradrenergic pathways implicated (e.g., increased levels of epinephrinein veterans with posttraumatic stress disorder and in sexually abused girls)

    - 5HT pathways implicated: decrease in 5HT produces anxiety

    - Hypothalamic-pituitary-adrenal axis can be affectedby high levels of arousal
  53. somatization disorder and PTSD
    High rates of somatization disorder in patients with posttraumaticstress disorder
  54. Acute Stress Disorder vs. PTSD
    Exposure to traumatic event

    • Duration: at least 2 days and less than 4 weeks
    • Must occur within 4 weeks after the traumatic event
  55. Abuse vs. dependence
    • Abuse: during 12 months, at least 1 of following:
    • Failure at social obligations due to drug use
    • Legal problems
    • Use despite having social problems

    • Dependence: during 12 months, at least 3 of following:
    • Tolerance,
    • increased amounts needed
    • Withdrawal
    • Much time spent obtaining the drug
  56. “A drink”
    • 12 g pure alcohol = 1.5 oz 80-proof = 5 ozwine = 12 oz beer or wine cooler
  57. “Moderate drinking”
    2 or less drinks/day for menyounger than 65 (≤1 drink/day for non-pregnant women and anyone >65 years)
  58. If you can smell alcohol on the person’s breath, the likelylevel is greater than .......
    0.125%
  59. Blood alcohol concentration and symptoms in non-dependent persons
    1) 0.05%: “feeling good”, a bit disinhibited
  60. 2) 0.05% to 0.10%: problems thinking, more uncoordinated, considered mildly intoxicated
  61. 3) 0.1% to 0.2%: noticeably intoxicated, having greater difficulty with cognition, exhibiting slurred speech and unsteadiness or ataxia
  62. 4) 0.2% to 0.4%: often unconscious, with lowering of core body temperature; poor respiratory effort; hypotension; can progress to coma and death
  63. 5) 0.4% to 0.5%: death rate as high as 50%; death is often secondary to respiratory failure or asphyxiation
  64. CAGE Questions for Alcohol Dependence
    • C—tried to cut down?
    • A—annoyed when others say cut back?
    • G—feel guilty about your drinking?
    • E—Need an eye-opener?

    • “Yes” for 2 of 4 = 70%-80% indicative of dependence
    • “Yes” for 4 of 4 = 100% indicative of dependence
  65. Marchiafava-Bignami disease,
    Marchiafava-Bignami disease is a progressive neurological disease characterized by corpus callosum demyelination and necrosis and subsequent atrophy.

    It is classically associated with chronic alcoholics and sometimes nutritional deficiencies.

  66. Alcoholic myopathy
    painful, swollen muscles with increased creatinine phosphokinase level, also muscle weakness is common
  67. 53-year-old alcoholic man affected by Marchiafava-Bignami disease. A, Multiple cavitations and atrophy of corpus callosum are noted (arrows) on sagittal T1-weighted images. B, Axial FLAIR image shows cavitations of splenium of corpus callosum
  68. Positional alcohol nystagmus
    Positional alcohol nystagmus (PAN) is nystagmus (visible jerkiness in eye movement) produced when the head is placed in a sideways position. PAN occurs when the specific gravityof the membrane space of the semicircular canals in the ear differs from the specific gravity of the fluid in the canals because of the presence of alcohol.

    • in details:
    • When a person consumes alcohol, the alcohol is carried by the bloodstream and diffused into the water compartments of the body. Normally, the specific gravity of a canal membrane is the same as the specific gravity of the surrounding fluid. Because of this, even though the Earth's gravity is a constant force of acceleration, the semicircular canals do not respond to it. Alcohol has a lighter specific gravity than water. When alcohol enters the canal membrane via capillaries, the specific gravity of the membrane is lower than that of the surrounding fluid. The alcohol does diffuse from the membrane to the fluid, but it does so very slowly. While the specific gravity of the membrane is lower than the specific gravity of the extracellular fluid, the hair cells on the membrane become responsive to the Earth's gravity[1]. This is the condition of PAN I.

    PAN I is characterized by a nystagmus to the right when the right side of the head is down. It is typically present during a rising and peak Blood Alcohol Concentration (BAC), and becomes noticeable at around 40 mg/dL (.04% BAC).
  69. Disulfiram function
    Alcohol dehydrogenase breaks down alcohol to acetaldehyde, then aldehyde dehydrogenase breaks down acetaldehyde to acetic acid

    Disulfiram (Antabuse) blocks aldehyde dehydrogenase,thus build up of toxic acetaldehyde.

    Asians also have lower levels of alcohol dehydrogenase and aldehyde dehydrogenase, leading to greater potential for intoxication with small amounts of alcohol
  70. Amphetamine intoxication
    Euphoria, blunting, anxiety, tension, anger, impaired judgment and functioning

    At least two of the following: tachycardia or bradycardia, pupillary dilation, change in blood pressure,perspiration or chills, nausea or vomiting, weightloss, psychomotor agitation or retardation, weakness,respiratory depression, chest pain, arrhythmias,confusion, seizures, dyskinesias, dystonias,coma
  71. Amphetamine withdrawal
    Dysphoric mood

    and at least two of the following occurring within hours or days after discontinued use or reduced amount of amphetamine after prolongedand heavy use:

    • a) Fatigue
    • b) Vivid, unpleasant dreams
    • c) Insomnia or hypersomnia
    • d) Increased appetite
    • e) Psychomotor agitation or retardation
  72. Serious complications of Amphetamine (speed, ice, meth, crank, crystal, go-fast,go, zip, Chris)
    • - Seizures with acute intoxication
    • - Ischemic infarction and intracerebral hemorrhagic complications:may occur as a result of acute hypertension,vasoconstriction, and reversible vasospasm of the cerebralvasculature.
    • - Movement disorders related to alteration of dopaminergic transmission: may yield (or exacerbate) akathisia,chorea, dystonia, tics, myoclonus. Repetitive chewingand tooth grinding were identified in the 1960s as characteristicobservations in patients abusing amphetamines
  73. Cannabis intoxication
    psychologic changes surrounding use

    Often accompanied by uncontrollable laughter, memory impairment, decreased attention span, poor insight and judgment, distorted sensory perceptions, decreased coordination, depression, increased blood pressure and pulse rate, sedation, conjunctival injection, dry mouth,increased appetite and thirst, hypothermia, occasional“bad trips” (anxiety, panic attacks, paranoia, depersonalization,delusions, hallucinations)

    Can be “spiked”: phencyclidine or cocaine may beadded by users to amplify the effect

    Does not produce physical dependence, thus no withdrawal syndrome

    Can be found in urine drug screen up to 30 days after chronic use
  74. Cannabis and seizure
    There are scattered reports of both the anticonvulsant and proconvulsant properties of cannabis
  75. “amotivational syndrome” in Cannabis
    Chronic use leads to “amotivational syndrome”: apathy,inattentiveness, flat affect
  76. Clinical management of Cannabis intoxication
    Allow sleep, “talk down,” benzodiazepines, neuroleptics
  77. Cocaine intoxication
    - psychologic changes surrounding use

    - At least two of the following: tachycardia or bradycardia, pupillary dilation, (all the symptoms are similar to amphetamines)
  78. Cocaine withdrawal
    • - Dysphoric mood
    • - At least two of the following: fatigue, vivid dreams,insomnia or hypersomnia, increased appetite, psychomotor retardation or agitation (Similar to amphetamine)
  79. Other neurologic complications of Cocaine
    similar to amphetamines

    • Ischemic or hemorrhagic stroke
    • - Mechanism is likely a combination of acute hypertension,vasospasm and vasoconstriction of cerebral vasculature(arterial occlusion), and platelet aggregation

    • - Possible association with antiphospholipid antibodies
    • - Cardiac complications of cocaine use such as cardiomyopathy, myocardial infarction, or cardiac arrhythmias may predispose to cardioembolic cause ofstrokes
    • - Unlike amphetamines, this drug has not been established to cause CNS vasculitis
    • - Asymptomatic subcortical white matter T2-hyperintenselesions are also more commonly observed incocaine users

    Movement disorders related to alteration of dopaminergic transmission (as with amphetamines)

    Acute seizures (as with amphetamines)
  80. Macropsia
    objects within an affected section of the visual field appear larger than normal

    Macropsia has a wide range of causes, from prescription and illicit drugs, to migraines and (rarely) complex partial epilepsy
  81. Tx for LSDs and other hallucinogens
    Haloperidol + lorazepam is effective

    Hallucinogenic effect is likely produced by release of 5HT
  82. Inhalants (glue sniffing, sniffing, huffing) intoxication
    - psychologic changes surroundinguse

    - dizziness, nystagmus, incoordination, slurred speech, unsteady gait, lethargy, depressed reflexes, psychomotor retardation, tremor, generalized muscle weakness, blurry or double vision, coma, euphoria
  83. Inhalant clinical findings
    • - auditory, visual, tactile hallucinations
    • - Anxiety
    • - Physical signs might include “glue sniffers rash” aroundmouth or nose
    • - Pulmonary findings: airway irritation, increased airway resistance
    • - CNS and peripheral nervous system findings (can be permanent): weakness, neuropathy, cerebral atrophy, cerebellar degeneration, white matter lesions
    • - Hepatitis, chronic renal failure, bone marrow suppression
    • - “Sudden sniffing death”:
  84. Smoking and med blood level
    Smoking increases metabolism of many prescription medications; smoking cessation can lead to worrisomeincreases in blood levels of those medications
  85. neurologic complications of opioids
    • a. Opioid-related movement disorders (uncommon, casereports)
    • 1) Dyskinesias (observed with fentanyl)
    • 2) Oculogyric crisis and generalized dystonia (intranasalheroin)
    • 3) Myoclonus (chronic use of meperidine)
    • 4) Tremor and chorea (methadone)

    b. Seizures: meperidine has been shown to lower seizure threshold

    c. No evidence of long-term cognitive impairment
  86. Phencyclidine intoxication
    impaired judgmentor function shortly after use

    Within an hour after use, at least two of the following: vertical or horizontal nystagmus, hypertension or tachycardia, numbness or decreased pain sensation, ataxia, dysarthria, muscle rigidity, seizures or coma, hyperacusis

    Can see bizarre behaviors, myoclonic jerks, confusion,disorientation, coma, seizures
  87. Classic test for degree of dependence: pentobarbital challenge test
    is used for phenobarbital or BZD dependence:

    • 1) First, give 200 mg of pentobarbital by mouth
    • 2) In 1 hour, check for signs of intoxication (slurred speech, incoordination,unsteady gait, nystagmus, impaired memory or atten)
    • 3) If no signs of intoxication, give another 100 mg of pentobarbital and recheck in 1 hour; repeat until signsof intoxication or maximum of 500 mg
    • 4) When patient shows signs of mild intoxication, total amount given is the total daily dose
    • 5) Convert to phenobarbital by giving 30 mg phenobarbital for each 100 mg of pentobarbital given and divide that total into four daily doses for administration (similarly one may convert to a benzodiazepine such as diazepam using equivalence tables and proceed with a taper)
    • 6) Taper by about 10% per day which will complete detoxification in 10 to 14 days
  88. Nitrous oxide abuse
    Intoxication: light-headedness, floating sensation, confusion,paranoia
  89. PERSONALITY DISORDERS
    Cluster A “odd or eccentric” (paranoid, schizoid, schizotypal)

    Cluster B “dramatic, emotional, erratic” (antisocial, borderline, histrionic, narcissistic)

    Cluster C “fearful, anxious” (avoidant, dependent, obsessive-compulsive)
  90. Tx for paranoid personality
    Few seek treatment; often they are forced into it by family or legal system

    Challenge is building trust and a collaborative working relationship

    Provider should be open, honest, and maintain strict boundariesd. Breaking or bending rules can lead these patients to litigatione.

    Maintain calm when met with anger or hostility

    Group therapy often should be avoided because the patients tend to mis-interpret statements made by group members
  91. schizoid personality
    social detachment and limited emotional reactivity
  92. schizotypal personality disorder
    Characterized by discomfort with close relationships, cognitive and/or perceptual distortions, and eccentric behaviors and beliefs

    one step closer to schizophrenia

    • Often seen in females with fragile X syndrome
  93. antisocial personality disorder
    Must be at least 18 years oldd. Previous history of conduct disorder before age 15
  94. avoidant personality disorder
    Characterized by extreme sensitivity to rejection, shyness, need for uncritical acceptance

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