Everything You Ever Wanted to Know About Psychiatry…

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. Extreme anxiety  Panic disorder . peaks within 10 mins.  Generalized anxiety disorder (GAD) . typically declines within 30 mins.  Post traumatic stress disorder (PTSD) . rarely lasts >1 hr  Phobias As it pertains to the PA boards… . May/may not have identifiable trigger  Obsessive-Compulsive Disorder (OCD)

Melanie Trecartin, MS, PA-C

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1 palpitations fear of losing control  Recurrent, unexpected panic attacks  Tx tachycardia fear of dying  Abruptly occur ◦ short course benzos (alprazolam, lorazepam) sweating light-headedness  Accompanied by fear of having add’l attacks then taper benzos, start SSRI - 1st line for long trembling numbness  Fear & physical symptoms may be term tx (paroxetine, fluoxetine, sertraline, dyspnea accompanied by tingling venlafaxine (SNRI) sensation of choking ◦ feeling of impending harm/death chills or hot flashes ◦ TCA’s not as likely to be used chest discomfort ◦ fear of having heart attack/stroke derealization ◦ mild cases - relaxation or psychotherapy nausea ◦ fear of “going crazy” depersonalization

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 Persistent, excess anxiety over general life  Exposure to/witnessing a traumatic event  Age of onset 20’s events for > 6 mos  Symptoms…  R/O medical disorders (substance abuse, ◦ last greater than one month  Dx criteria: > 3 thyroid dysfunction, ETOH withdrawal) ◦ restlessness or hypervigilance ◦ develop in as little as one week or…  Tx – behavior/insight-oriented therapy + meds ◦ easy fatigability ◦ develop many years after event ◦ SSRIs, SNRIs, buspirone ◦ irritability ◦ fluctuate over time ◦ benzos as short term adjunct ◦ worsen during stressful times ◦ sleep disturbance nd ◦ TCAs may help – 2 line  ◦ muscle tension Feelings of helplessness, fear, horror that

◦ difficulty concentrating impair daily function

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 3 major elements: 1 or more: 2 or more increased arousal symptoms:

◦ re-experience trauma (flashbacks) . Persistent re-experiencing by distressing ◦ emotional numbing memories, dreams . difficulty falling or staying asleep ◦ hyperarousal . Avoids activities/places/people that remind . hyper-startle response  High co-morbidity with substance abuse of event, thinking/talking about event . irritability/angry outbursts & depression . Unable to recall important aspect of event . decreased concentration . hypervigilance  Common causes . Feelings of detachment/estrangement ◦ men: combat . Restricted range of affect, interest or anhedonia ◦ women: rape/assault . Believe future foreshortened due to event ◦ both: natural disasters

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4  Tx ◦ 1st line – SSRIs (sertraline, paroxetine) ◦ benzos reduce anxiety; trazodone for insomnia 75% 1. Anafranil 1. Anafranil ◦ TCA’s (imipramine, doxepin), MAOIs, (clomipramine) (clomipramine) anticonvulsants (carbamazepine, valproate) 2. Lexapro 2. Lexapro less often used (escitalopram) (escitalopram) 21% ◦ therapy - crisis counseling/support groups, 3. Wellbutrin 3. Wellbutrin (bupropion) (bupropion) family 0% 4% 4. Xanax (alprazolam) 4. Xanax (alprazolam)

Xanax (alprazolam) Lexapro (escitalopram) Wellbutrin (bupropion) Anafranil (clomipramine) UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013)

5  Irrational fear & persistent excess anxiety when  Fear of specific object/situation presented with object/situation  Tx ◦ animal/insects  Exposure causes immediate anxiety, can lead to ◦ desensitization/exposure therapy/flooding ◦ natural phenomena (storms, heights, water) panic attack most effective ◦ blood-injection injury (invasive procedures,  Situation or object feared & avoided or endured blood, needles, contamination) ◦ short term benzos, B-blockers as adjuncts with apprehension ◦ situational (bridges, flying, confined spaces) ◦ insight-oriented therapy, hypnosis  Pts. know fear is excessive/unreasonable ◦ other (vomiting, choking, becoming sick, death)  Interferes with daily functioning  Onset is in childhood

 Anxiety about placing self in situation in  Inciting events may include being:  Fear of social situations in which which incapacitating problem may occur & help ◦ outside the home embarrassment or humiliation may occur unavailable ◦ in a crowd  Inciting events -  Fear of being in public places where escape ◦ on a bus/train ◦ public speaking may be difficult ◦ on a bridge ◦ using public restrooms  Situations are avoided, endured with severe  Symptoms – same as panic attack ◦ eating in public distress, or faced only with a companion  50–70% have co-existing panic disorder

 F 2-3x >M

7  Tx  Obsessions – persistent, recurrent

◦ 1st line - SSRIs (paroxetine, fluoxetine, thoughts/images/impulses that are intrusive sertraline), venlafaxine (SNRI) & inappropriate resulting in anxiety ◦ 2nd line benzos, TCAs  Compulsions - ritualistic/repetitive behaviors ◦ beta-blockers (propanolol) can reduce or thoughts pts. do to relieve anxiety caused by hyperarousal & tremor with performance obsessions situations ◦ behaviors/mental acts are excessive ◦ Insight-oriented therapy, gradual exposure ◦ have no connection between events pt. is trying to avoid  Usually realize thoughts & behaviors irrational

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8  Common obsessions-compulsions Tx  20-50% have dysfunctional symptoms as adults

 Behavioral/relaxation therapy + meds  M 2-5X >F, often firstborn son . Contamination – excess hand washing, avoiding st objects presumed contaminated ◦ 1 line med - SSRIs, often higher dose than  Dx Criteria: . Doubt - worry (forget to lock door, turn off stove) normally Rx’d ◦ hyperactivity, impulsivity, or inattentiveness . Intrusive thoughts - obsessive thoughts without ◦ TCAs (clomipramine) can help manifesting before age 7 compulsion; may be sexual/aggressive  If refractory – gabapentin, venlafaxine, olanzapine, ◦ occurs in >2 settings . Symmetry - order & arrange objects, leads to clonazepam, lithium, or anti-psychotic + SSRI ◦ >6 symptoms of inattention, hyperactivity- extreme precision, slowness impulsivity, developmentally inappropriate . Other - religious obsessions, compulsive hoarding, & present >6 mos nail biting, trichotillomania, counting/repeating a phrase

9  Careless mistakes; trouble attending to details   2ndary symptoms:  Fidgets/squirms Problems sustaining attention  ◦ emotional immaturity & lability  Doesn’t follow through/complete assigned work  Leaves seat often ◦ poor social skills  Forgetful  Restlessness ◦ +/- motor incoordination  Easily distracted  Difficulty playing quietly ◦ disruptive behavior causes peer rejection,  Talking excessively  Loses items critical to assigned activities deflated self-image  Blurting out  Avoids activities requiring sustained mental ◦ don’t comply with parents’ requests  Difficulty awaiting turn effort ◦ can be explosive & irritable  Interrupts/intrudes on others  Difficulty organizing tasks

10  1st line meds – (caution: wt. loss & ↓growth with stimulants!)  >6 symptoms from these categories  At least 2 - ◦ methylphenidate (Ritalin, Concerta, Daytrana) ◦ problems with nonverbal behaviors (facial ◦ dexmethylphenidate (Focalin) ◦ amphetamine/dextroamphetamine (Adderall, ◦ impaired social interaction expression, gestures) Dexedrine) ◦ impaired communications ◦ fail to develop peer relationships ◦ atomoxetine (Strattera) selective norepinephrine ◦ repetitive stereotyped patterns of behavior & ◦ does not seek sharing of interests/enjoyment reuptake inhibitor (non-stimulant) activities with others nd  2 line/adjuncts ◦ lacks reciprocal social/emotional interaction ◦ antidepressants (guanfacine, clonidine,

imipramine, bupropion, venlafaxine)  Behavior modification, family, educational mgmt

11  Refer – Autism specialists  At least 1  At least 1  Speech & language pathologist ◦ lack of or delayed speech ◦ inflexible rituals  Audiology evaluation, +/- EEG ◦ repetitive language use  intense, rigid commitment to maintaining  Behavioral therapy ◦ lack of spontaneous, varied play activities routines  Pharmacologics nd  become agitated if routine is interrupted ◦ 2 gen. antipsychotics (risperidone, aripiprazole) for aggression/hyperactivity,  sit in specific chair, dress in certain way, mood lability; can also use haloperidol, eat specific foods carbamazepine ◦ preoccupation with parts of objects ◦ SSRIs for stereotyped/repetitive behaviors

12  Distorted body image  Egosyntonic; average age 15-30 yrs. old  Amenorrhea, emaciation (BMI < 17.5)  Restore nutritional state!  Fear of becoming fat, even though underwt.  Hypochloremia, hypokalemia, elevated BUN, metabolic  Hospitalize if >20% below expected wt.  Body wt. > 15% below normal alkalosis, hyponatremia, hypocalcemia or severe electrolyte imbalance  Amenorrhea (absence of >3 cycles)  Hypothermia, cold extremities, salivary gland  Out pt. – hypertrophy  2 types: ◦ Behavioral/family therapy  Bradycardia, arrhythmias, cardiac arrest, low BP ◦ Supervised, gradual wt. gain Restrictive Binge eating/purging  Lanugo, dry skin, peripheral edema  Pharmacologics DO NOT play major role eat very little binge/purge  Constipation, acute pancreatitis exercise to excess + laxatives ◦ (Bupropion contraindicated – lowers seizure  Leukopenia, hypercholesterolemia, anemia more withdrawn excessive exercise threshold)  Osteoporosis, muscle cramps tend to have OC +/- diuretics  Dental erosion, calluses/abrasions on back of hand traits more depression &

substance abuse

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13  Binge eating, vomiting, laxatives, diuretics,  Dental erosion/caries; calloused, abraded  Restore nutritional state! excess exercise knuckles (Russell’s sign)  SSRIs (fluoxetine, sertraline, paroxetine)  Binging causes emotional distress, feel loss  Esophagitis reduce binge/purge behaviors of control so egodystonic  Hypochloremic, hypokalemic alkalosis  Bupropion contraindicated  Normal or overweight  Hypomagnesemia, hypocalcemia  2nd line meds - TCAs, MAOIs  2 types:  Parotid gland hypertrophy  Behavioral/family/group therapy ◦ purging - self-induced vomiting +/- laxatives, diuretics, enemas  Hospitalization usually not needed ◦ non-purging - excess exercise or fasting

14  Arrested growth  Change in eating habits

 growth hormone  Marked change/frequent wt. fluctuation  Difficulty eating in social settings

 Reluctance to be weighed  plasma cortisol  Inability to gain wt.

 Depression  gonadotropins (LH, FSH)  Fatigue

 Social withdrawal

 Constipation or diarrhea  T3  School or work absence  Abnl glucose tolerance test  Susceptibility to fractures  Deceptive/secretive behavior  Abnl dexamethasone suppression  Delayed menarche

 Stealing (ie, to obtain food)

 estrogen  Hyperphosphatemia, high serum amylase  Substance abuse

 Excess exercise

15  >20% over ideal body wt. or BMI>30  Behavior modification/group therapy

 Dx criteria -  Food diaries/exercise regimen ◦ recurrent binge eating >2 days/wk for 6 mos  New eating patterns (eat slowly/not between ◦ no inappropriate wt. control meals/only when seated) ◦ >3 of following:  Tx underlying depression with SSRIs  Eating rapidly, until very full, large amounts  Others: as adjuncts when not hungry, alone out of embarrassment ◦ sympathomimetics - phentermine  feeling disgusted/depressed/guilty afterward (Adipex), benzphetamine (Didrex), orlistat (Xenical) ◦ gastric bypass

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16  Patterns of mood episodes (major depressive,  Emotional symptoms in response to identifiable  Symptoms manic, hypomanic, mixed) in which some mood stressor ◦ depressed mood, tearfulness, anxiety, impairment is present ◦ job loss, divorce, school/financial problems, palpitations, agitation, reckless driving,  Types: moving out of home/relocation, substance fighting, truancy, vandalism ◦ Adjustment abuse, becoming a parent, retirement  Tx st ◦ Major Depressive (MDD)  Symptoms within 3 mos of stressor, ending ◦ 1 line - Psychotherapy ◦ Dysthymia within 6 mos after stressor resolved ◦ Benzos, hypnotics (zolpidem), antidepressants ◦ Bipolar (types I & II)  Reaction out of proportion to stressor or (SSRI’s), briefly if warranted

impairs daily functioning

17  Sleep: insomnia/hypersomnia  Major depressive disorder (MDD) subtypes  Begin with SSRI  Interest: depressed mood, loss of interest/pleasure ◦ seasonal affective disorder (SAD)  If partial/no response after ~6 wks, re-assess ◦ melancholia  Guilt: feelings of worthlessness/guilt dx &/or increase dose ◦ atypical depression  Energy: decreased  If inadequate response ◦ catatonic depression ◦ change to another class of drugs ◦ psychotic depression  Concentration: diminished ability to think, make decisions ◦ add another med ◦ postpartum depression ◦ combine antidepressants from different classes  Appetite: weight changes  Psychotherapy

 Psychomotor: retardation/agitation  Consider ECT

 Suicide: or recurrent thoughts of death

18  Overeating & wt. gain  Fall or winter onset  Anhedonia  Oversleeping  Often remits in spring  Psychomotor retardation/agitation  Reactive mood  More common in colder climates  Anorexia, wt. loss  Leaden paralysis  Onset age 20-40 yrs  Depressed mood (esp. in morning)  Oversensitivity to interpersonal rejection  Tx –  Feelings of guilt

◦ light therapy  Sleep disturbance (early morning awakening)  Tx – ◦ SSRIs  Suicidal ideation may be present ◦ MAOIs useful (Marplan, Parnate) ◦ Bupropion ◦ SSRIs, atypical antipsychotics may help

19  Motor immobility/stupor, blurred affect  Presence of delusions or hallucinations  Onset of symptoms within 4 wks of delivery  Purposeless motor activity  Occurs in ~20% of severely depressed pts.  Tx  Extreme withdrawal, negativism  Tx ◦ Therapy plus…  Bizarre mannerisms/posturing • benzodiazepines + antidepressant for ◦ SSRIs – sertraline (Zoloft) good choice if  Echolalia/echopraxia agitation, initially breastfeeding; fluoxetine (Prozac), escitalopram

• antidepressants + 2nd gen. antipsychotic (Lexapro), venlafaxine (Effexor)  Tx ◦ Estrogen may help ◦ Benzodiazepines for maintenance ◦ ECT

◦ Valproic acid, lithium, risperidone as adjuncts

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 MAOIs, demerol, triptans, dextromethorphan st  1 line - SSRIs (fluoxetine, paroxetine, sertraline) + SSRIs can cause serotonin syndrome – rapid  SSRIs - GI upset, headache, sexual dysfunction onset:  TCAs/tetracyclics - wt. gain, orthostatic  Also effective- venlafaxine; ◦ mental status changes, restlessness hypotension, anticholinergic effects, somnolence nefazodone, bupropion, mirtazapine – least ◦ hyperthermia, diaphoresis  MAOIs - need tyramine-free diet (no wine, beer, assoc. with sexual dysfunction ◦ tremor, hypertonicity, seizures most cheeses, aged foods, smoked meats) to ◦ renal failure, coma, death

avoid HTNsive crisis  Tx  2nd line –TCAs/tetracyclics (overdose more lethal) ◦ benzodiazepines ◦ aggressive cooling  3rd line -MAOIs - least likely used ◦ cyproheptadine in severe cases

21  Electroconvulsive therapy (ECT) beneficial for ◦ severely depressed  prior attempt  poor support system  Chronic persistent mild depression ◦ unresponsive  white male  poor health  Pessimism, brooding, loss of interest, decreased ◦ intolerant of psych meds  >45 yrs old  substance abuse productivity, feelings of inadequacy, social  Safely used in elderly & pregnancy withdrawal  detailed plan  psychotic symptoms  Side effects  No psychotic or manic/hypomanic features  self-destructive  inability to accept help ◦ memory loss (temporary) pattern  MDD may develop in 10–20%, bipolar in others, ◦ postictal confusion 25% will always have symptoms  recent severe loss ◦ headache  Young adult onset

◦ nausea ◦ muscle soreness

22  >1 manic/mixed episodes, often cycle with  Depressed mood most of day, more days than not, >2 yrs (>1 yr in children/adolescents)  Antidepressants- depressive episodes  During 2 yr period, not w/o symptoms for >2 mos ◦ SSRIs 1st choice  Manic episodes - sudden mood escalation, abnormally/persistently euphoric, expansive, at a time, no major depressive episode during 1st ◦ SNRIs or irritable 2 yrs of symptoms ◦ bupropion  At least 2: ◦ may go for days without sleep ◦ TCAs ◦ poor concentration/indecisiveness ◦ excessively talkative or loud ◦ hopelessness ◦ occasionally MAOIs (last choice) ◦ socially outgoing ◦ poor appetite or overeating PLUS ◦ overly self-confident ◦ insomnia or hypersomnia  Insight-oriented, behavior, cognitive therapies ◦ hypersexual ◦ low energy/fatigue ◦ disinhibited ◦ lack self-esteem ◦ flamboyant clothing style

23  Acute mania – Lithium,* valproate, SGAs  Racing thoughts (olanzapine, aripiprazole), carbamazepine  >1 major depressive & >1 hypomanic episode  Flight of ideas  Mania maintenance - SGAs, Gabapentin,  No manic or mixed episodes  Easily distracted lamotrigine (Lamictal)  Hypomanic symptoms –  Impaired judgment  If agitation – add antipsychotics (haloperidol, ◦ similar to manic symptoms but less severe ◦ spending sprees risperidone) or benzos & less social impairment ◦ promiscuity  Depressive episodes- SSRIs, quetiapine, or olanzapine + fluoxetine ◦ usually no psychotic symptoms, racing ◦ foolish business investments  MAOIs, TCAs – least likely used thoughts, or excess psychomotor agitation ◦ psychotic symptoms (hallucinations, paranoia,  Family/group/cognitive therapy  Tx - same as bipolar I delusions) may be present ◦ lithium &/or lamotrigine (Lamictal) 1st line * narrow therapeutic window; wt. gain, tremor, nausea, excess thirst/urination, drowsiness, hypothyroidism, arrhythmias, seizures UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013)

24  Brief psychotic –  Symptoms categorized as - ◦ symptoms >1 day but <1 mos  In general - ◦ positive ◦ disordered thought content & thought processes ◦ often after catastrophic event  hallucinations, bizarre behavior, delusions ◦ perceptual disturbances (illusions, ◦ return to premorbid functioning ◦ negative hallucinations, delusions, impaired reality)  flat affect, apathy, anhedonia ◦ social, occupational function disrupted due to  Schizophreniform - affect, motivation, perception, communication ◦ same symptoms as schizophrenia  poor grooming, social withdrawal  poor eye contact, poverty of speech ◦ memory or consciousness not adversely ◦ symptoms last 1-6 mos

impacted

25  Nonbizarre delusions for >1 mos  Chronic, debilitating course  Behavior not obviously odd; daily function not  Lack insight, don’t think their behavior is abnl significantly impaired  Better prognosis if…  Subtypes of delusions - ◦ erotomanic - another person in love with them ◦ late onset ◦ somatic - having a physical/medical condition ◦ acute onset ◦ jealous - sexual partner’s infidelity ◦ obvious precipitating factor ◦ persecutory - mistreatment or persecution ◦ presence of positive symptoms ◦ grandiose - inflated self-worth, power,  Onset before age 15 or after 50 is rare knowledge

 Treatment – antipsychotics

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26  Paranoid - most common; persecutory or  Symptoms impair daily functioning grandiose delusions or auditory hallucinations  >2 in 1 mos period & continuous signs for >6 mos; hallucinations/delusions not needed for dx  Disorganized behavior - unpredictable agitation,  Catatonic – rarest; motor immobility, motor inappropriate sexual behavior, activity with no purpose, negativism or mutism, ◦ Delusions bizarre postures, waxy flexibility, stereotyped ◦ Hallucinations - auditory (most common), child-like silliness, catatonic motor behavior, movements, grimacing, echolalia or echopraxia tactile, olfactory, visual lacking self-care/hygiene  Disorganized - disorganized speech or ◦ Disorganized speech/thought processes  Negative symptoms - blunted affect, poor behavior & flat or inappropriate affect posture, lack goal-directed activities/initiative  unable to stay on topic (loose associations)  Residual - blunted affect or odd behavior  Impairment inability to hold job or maintain  unable to provide answer related to questions  Undifferentiated - delusions & hallucinations are relationships (tangential response) prominent

27  Hospitalize if suicidal, unable to care for self,  Resistant cases – clozapine or antipsychotic +  Meets criteria for major depressive, manic, or pose threat to self/others another med (benzo, carbamazepine, valproate, mixed episode, during which criteria for  1st line- serotonin & dopamine antagonists lithium) schizophrenia also met (SDAs); (risperidone, olanzapine, aripiprazole,  Behavior-oriented/group/family therapy  Hallucinations or delusions present for 2 or more ziprasidone, quetiapine, asenapine, paliperidone)  Watch for side effects! weeks without mood symptoms for negative symptoms & less side effects ◦ extrapyramidal, parkinsonian symptoms,  Better prognosis than schizophrenia, worse than  Typical neuroleptics - dopamine antagonists neuroleptic malignant syndrome, tardive dyskinesia mood disorder (haloperidol, chlorpromazine, thioridazine, - more likely with typical neuroleptics; clozapine  Tx – 2nd gen. antipsychotics loxapine, fluphenazine) best for positive may  agranulocytosis ◦ can add antidepressant/lithium/valproate symptoms ◦ ECT as adjunct for mania/depression

28  < 1 month – brief psychotic disorder 96%  1-6 months – schizophreniform disorder 1. adjustment 1. adjustment  > 6 months – schizophrenia 2. agoraphobia 2. agoraphobia

3. depression 3. depression Best  worst prognosis mood disorder->brief psychotic disorder-> 4. schizophrenia 4. schizophrenia schizoaffective disorder->schizophreniform disorder->schizophrenia 2% 2% 0%

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29  Somatization disorder  Vague physical complaints involving many organ Tx  Conversion disorder systems not explained by medical condition or  Regular visits with healthcare provider  Hypochondriasis substance use  Group/individual therapy to develop coping  Body dysmorphic disorder  Symptoms relate to GI tract, reproductive, or strategies neurologic systems; may complain of pain  Pain disorder  Minimize secondary gain  Stress causes worsening symptoms  Avoid medications/use cautiously  Low socioeconomic groups  In general - ◦ drug treatment rarely indicated  Onset < age 30; most often in adolescence ◦ goal is to improve function  Chronic, debilitating course

30  >1 neurological complaints not explained by  Shifting paralysis  F 2-5X > M medical/neuro disorder  Blindness  Most common in adolescence & young adult  Psych factors (ie, traumatic event) often  “lump in the throat” (globus hystericus)  More common in low intelligence, low precede onset/exacerbate condition  Mutism/aphonia socioeconomic groups  Symptoms –  Deafness  R/O medical cause since ~25-50% eventually ◦ paralysis, blindness, mutism  Paresthesia/anesthesia dx with neuro/medical disorders ◦ may display unexpected lack of concern to  Seizures  Tx - therapy +/- short term anxiolytics symptoms (la belle indifference )  Balance/coordination problems  Episodic, lasting few days or up to 1 mos; may remit but recur when stressed

31  Fear persists though work-up finds no cause  Preoccupation with imagined defect in physical  Preoccupation with belief/fear of  Belief is not delusional intensity, not limited to appearance/exaggerated distortion of minor flaw having/contracting a serious disease specific concern about physical appearance  Common concerns –  Normal bodily sensations falsely interpreted as  Duration of disturbance >6 mos manifestation of disease face/hair/skin/breasts/genitalia  Tx   Often co-exist with anxiety & depression High co-morbidity with depressive/anxiety ◦ Group/insight-oriented therapy disorders; linked to psychotic disorder & OCD  Course - chronic, episodic, may be exacerbated ◦ regular appts with provider for reassurance by major stressor  Stereotypes of beauty may play role ◦ meds (SSRIs) if concurrent/underlying anxiety  Tx - SSRIs reduce symptoms in >50%  Males=females; onset age 20-30 or major depressive disorder

32  Pain in >1 areas with no known cause  substance dependence = physiologic +  May describe atypical facial/low back pain, psychological headache, pelvic, other chronic pain  Symptoms not intentionally produced Impairment manifested by 3 within 1 yr period:  F 2x>M, age at onset 40-50 ◦ tolerance ◦ withdrawal  Tx - therapy, pain control prgms; SSRI’s, TCAs can be used ◦ larger amounts over longer period ◦ unsuccessful efforts to stop/decrease amount  Analgesics/sedatives not beneficial, can lead ◦ continued use despite adverse consequence to abuse/dependence

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33 Intoxication Withdrawal Slurred speech Tremors (after 8-18 hrs) Intoxication Signs/symptoms Treatment  Substance abuse - hasn’t met criteria for Euphoria Anxiety, nausea/vomiting Euphoria Ataxia/incoordination Seizures (7-38 hrs) Agitation/Aggression Benzodiazepines (diazepam, dependence but caused impairment by >1 in Facial flushing Hallucinations (within 2 days) Transient psychosis lorazepam) for agitation 1 yr period: Reduced inhibition Delirium tremens (2-5 days) Hallucinations Erratic behavior Impaired Judgment Short term antipsychotics if ◦ fails to meet home/school/work obligations Treatment Tachycardia psychotic symptoms ◦ repeatedly uses substance in hazardous Chronic abuse Benzos (diazepam, Elevated BP situations Elevated GGT, AST, ALT chlordiazapoxide) for agitation Dilated pupils Rehab/detox Increased HDL, LDH, MCV Thiamine (prevents Wernicke’s Psychotherapy ◦ recurrent substance-related legal problems Decreased LDL, BUN, RBC encephalopathy), MVI, folic acid Withdrawal Signs/symptoms volume Fatigue/depression ◦ continues use, even though results in Acne rosacea, palmar erythema Haloperidol or risperidone if Headache interpersonal/social problems Hepatomegaly hallucinations Profuse sweating Gynecomastia/testicular atrophy Disulfarim + ETOH=nausea Muscle cramps Dupuytren’s contractures Detox, AA/Alateen/Al-Anon, Hunger therapy UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013) UMDNJ PANCE/PANRE Review Course (becoming Rutgers University July 1, 2013)

34 Intoxication Signs/symptoms Treatment Euphoria Methadone OR  Onset in adolescence/early adulthood Drowsiness/Lethargy Clonidine tapering dose  CNS depressants Impaired concentration ◦ gradual withdrawal of drug  Rigid/inflexible traits cause dysfunction Hypotension, bradycardia Benzos for mild withdrawal ◦ pentobarbital or diazepam if needed In general - Slurred speech Constricted pupils NSAIDs for muscle aches  Nicotine cravings ◦ lack insight into their problems Flushing ◦ nicotine patch, nasal spray, gum, inhaler ◦ not distressed about maladaptive behavior Dicyclomine for GI distress Withdrawal Signs/symptoms ◦ bupropion (Zyban), clonidine, varenicline  Manifested by >2 Lacrimation, rhinorrhea Dependence (Chantix) ◦ affect = appropriateness of emotional response Sweating, hot/cold flashes Methadone maintenance program  Marijuana, PCP, hallucinogen withdrawal Yawning Naltrexone ◦ impulse control ◦ meds not usually needed; can use anxiolytics Hypertension, tachycardia Buprenorphine (Subutex) ◦ interpersonal relations Anxiety Buprenorphine +naloxone ◦ if psychotic symptoms from PCP, hallucinogen Nausea/vomiting/abd cramps (Suboxone) withdrawal - can use neuroleptics (haloperidol) ◦ cognition = ways of perceiving environment Muscle/joint pain Detox, psychotherapy

35  Cluster A – “MAD” odd, eccentric, weird  Emotional detachment, social withdrawal, ◦ schizoid discomfort with human interaction  Schizoid differs from… ◦ schizotypal ◦ avoidant in that schizoid prefers to be alone  No desire for close relationships ◦ paranoid ◦ schizoptypal in that latter have “magical  Chooses solitary activities  Cluster B – “BAD” emotional, impulsive, dramatic thinking” antisocial  Takes pleasure in few (if any) activities  Tx - difficult borderline  Little/no interest in sex ◦ Individual cognitive, group therapy +/- histrionic  Few/no close friends  low dose antipsychotics (olanzapine, narcissistic risperidone)  Aloof, indifferent to criticism/praise  Cluster C – “SAD” anxious, fearful  antidepressants (SSRIs or bupropion)  Constricted affect, emotional coldness ◦ avoidant  stimulants may help  Reality testing intact ◦ obsessive-compulsive

36  Ideas of reference  Disturbed thinking, perceptual distortion  differs from schizoid & avoidant -  Odd beliefs, magical thinking influences behavior  Eccentric behavior ◦ by bizarre behavior, thinking, perception, (ie, superstitiousness, clairvoyance)  Social/interpersonal deficits communication  Unusual perceptual experiences (ie, bodily illusions)  Few (if any) friends  Odd thinking & speech (vague, over-elaborate)  differs from schizophrenia -  Inner world based on magical thinking (bizarre ◦ by lack of frank psychosis but can have fantasies/preoccupations), illusions, derealization  Suspiciousness or paranoia  Inappropriate or constricted affect psychotic symptoms in times of stress  May be involved in cults, the occult, strange religious practices  Odd/peculiar behavior or appearance  differs from paranoid personality -  May progress to schizophrenia  Lack of close friends ◦ by exhibiting very odd behavior  Excessive social anxiety assoc. with paranoid fears

37  Suspects others being deceptive/exploitative  May be manifested during childhood or  Long-standing mistrust & suspiciousness  Doubt loyalty/ability to trust friends or adolescence  Often hostile, irritable acquaintances  Tx  Blame others for their difficulties  Reluctant to confide in others ◦ Therapy, social skills training +/-  Others motives thought to be malevolent  Interprets benign remarks as demeaning or threatening  antipsychotics (risperidone, olanzapine)  Feel they’ve been treated unfairly  Persistently bears grudges  antidepressants if depressive aspect  Often unsuccessful intimate relationships due  Perceives attack on character & counterattacks to jealousy  Recurrent suspicions about fidelity of  Lack warmth, restricted affect significant other

 Inability to conform to social norms >3 of following & at least 18 yrs old –  No fixed delusions or hallucinations  Disregard for rights/feelings of others . Failure to conform to social norms by breaking  Begins by early adulthood, M > F  Manipulative, deceitful, impulsive, lacking the law  Higher risk with family hx of schizophrenia & empathy . Deceitful/lying/conning others delusional disorders  On interview acts very charming, seems normal . Impulsivity/failure to plan ahead  Tx  May have abnormal EEG . Irritability & aggressiveness manifested by ◦ 1st line – individual therapy  M 3x >F, familial pattern, more common in repeated physical assaults ◦ behavioral techniques (social-skills role urban areas, prisons . Reckless disregard for safety of self/others playing)  Begins as conduct disorder . Irresponsible, unable to sustain work ◦ low dose anxiolytics/antipsychotics may reduce ◦ may be hx of physical/sexual abuse, . No remorse for actions anxiety & paranoia hurting animals, starting fires

◦ assoc. with violations of the law

39  Unstable mood/affect/behavior  1st line - therapy with socially based intervention  Impulsive  Poorly established self-image  Meds may reduce anxiety/impulsivity/aggression  Moody  Impulsivity in >2 harmful ways ($$, drugs, sex) ◦ SSRIs  Paranoid under stress ◦ lithium  Transient psychotic episodes, paranoia, or  Unstable self image dissociative symptoms ◦ valproate  Labile, intense relationships  Self-mutilation/manipulative suicide attempts ◦ carbamazepine  Suicidal  Desperate attempts to avoid abandonment ◦ 2nd gen. antipsychotics  Inappropriate anger  Feelings of emptiness  Caution - high abuse potential!  Vulnerable to abandonment  Volatile/intense relationships

 Emptiness  Inappropriate anger/difficulty controlling anger

40  Splitting - people are either all good or all bad  Needs to be center of attention  Somatization, substance disorders common  Tx - 1st line - dialectical behavior therapy (DBT)  Seductive/provocative behavior  May use defense mechanism of regression – ◦ social skills, cognitive-behavioral  Uses physical appearance to get attention revert to childlike behaviors  Meds (+ psychotherapy yields better results)  Speech lacking in detail, impressionistic ◦ antipsychotics for hostility/psychotic episodes   Dramatic/exaggerated emotions Tx ◦ antidepressants (SSRIs) to improve mood ◦ 1st line - group/individual therapy  Easily influenced by others ◦ neuroleptics can improve global functioning ◦ +/- antidepressants/anxiolytics can be used  Believes relationships are more intimate than ◦ +/- short term benzos to decrease anxiety they really are only for specific symptoms

41  Extreme sensitivity to rejection  Inflated self-image/grandiose, lacking empathy;  See themselves as unappealing consider themselves special; arrogant  Intense social anxiety, feelings of inadequacy  Tx - 1st line - psychotherapy  Sense of entitlement, fragile self-esteem; need leads to withdrawal, avoid situations where to be admired; prone to depression if criticized may be criticized  Fantasies of unlimited success, beauty,  Pharmacotherapy – rarely indicated  Shy & desire companionship but need brilliance; aging “gracefully” is difficult ◦ lithium can be used if mood swings guaranteed acceptance  Exploitative/takes advantage of others ◦ antidepressants (esp. SSRIs) can be used if  May avoid job activities involving interpersonal  mood disorder Envious of others, thinks others envious of contact due to fear of rejection him/her  Show restraint in intimate relationships for fear of rejection

42  Remember!  Social phobia, anxiety, depressive disorders  Preoccupied with orderliness/inflexible ◦ OCPD is ego-syntonic; common  Stubborn/emotionally constricted; insist others no recurrent obsessions/compulsions submit to their ways, difficulty in relationships

 Perfectionism interferes with ability to complete  Tx-1st line - social skills/assertiveness training tasks or form relationships ◦ OCD is ego-dystonic;  For specific symptoms - +obsessions/compulsions  Change in routine threatens perceived stability ◦ benzos for anxiety & causes anxiety  Tx ◦ SSRIs for anxiety/depression & may help ◦ 1st line - cognitive-behavioral therapy  Won’t delegate tasks; excess devotion to ◦ SSRIs help reduce anxiety/depression decrease rejection sensitivity work/productivity ◦ Clomipramine - 2nd line med choice  Unable to throw out worthless objects/miserly

43  Similar to PTSD - differ in onset & duration ◦ PTSD symptoms develop anytime after event & last >1 mos 82% 1. antisocial 1. antisocial  Acute stress disorder symptoms - ◦ occur within 1 mos of traumatic event 2. avoidant 2. avoidant ◦ last 2 days to 1 mos 3. schizoid 3. schizoid 4. schizotypal 4. schizotypal  Populations: ◦ motor vehicle accident survivors 9% 9% ◦ violent crime victims/witnesses 0% ◦ natural disaster survivors

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44  Exposure to traumatic event involving threat of Event re-experienced by >1:  Adjustment disorder differs - possible injury/death  recurrent dreams/images/thoughts/flashbacks ◦ by a generally non-life-threatening, less severe  During/after event, >3:  sensation of reliving event; reminders of trauma stressor, less intense pathologic response ◦ sense of numbing or detachment causes distress  Tx – same as PTSD ◦ reduced awareness of surroundings  Avoid reminders of trauma (activities/places/people) ◦ therapy/support group ◦ derealization  Excess anxiety, insomnia, irritability, poor ◦ SSRIs, TCAs, anticonvulsants, anxiolytics for concentration, hypervigilance/exaggerated startle ◦ depersonalization insomnia & irritability  Distress impairs functioning ◦ dissociative amnesia (can’t recall important  Symptoms occur - aspect of trauma) ◦ within 4 wks of event

◦ lasts >2 days & <4 wks

45  Injury not adequately explained or inconsistent with hx given  Bruises/lacerations/soft-tissue swelling, 96% dislocations/fractures, spiral fractures  Burns (doughnut-shaped, stocking-glove, 1. Acute stress disorder 1. Acute stress disorder symmetrically round) 2. Adjustment disorder 2. Adjustment disorder  Bruises or injuries with regular patterns on 3. Panic disorder 3. Panic disorder face, back, buttocks, thighs

4. Post traumatic stress 4. Post traumatic stress 4%  Internal hemorrhages, abdominal injuries, bite 0% 0% marks, injury with shape of instrument used

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46  Anxiety  Common ages 9-12  Aggressive/violent behavior  Neglect can be considered if -  Often by male known to child  PTSD ◦ minor allowed to engage in potentially  Any raises suspicion:  Depression or suicide harmful behavior (ie, ETOH consumption) ◦ evidence of sexually transmitted infection ◦ anal/genital bruises/pain/itching/trauma  Substance abuse ◦ child is unattended; in some states, leaving ◦ knowledge about sexual acts inappropriate  Poor self-esteem child < age 13 home alone for age  Dissociative disorders ◦ initiates sexual acts with others, esp. peers  Paranoid ideation ◦ exhibits sexual knowledge through play  Failure to thrive

47  Physical or sexual abuse - Watch out for caregiver with…  Psychological - ◦ bruises/puncture wounds/fractures/cuts/burns  previous hx of abuse ◦ threats/insults/verbal abuse ◦ poor hygiene/soiled clothing, hair loss in clumps  conflicting accounts of accidents ◦ refuse to allow travel, church attendance, ◦ wt. loss, poor nutrition, dehydration family visits  unwilling to agree to implementation of tx plans ◦ lack of eyeglasses/hearing aids  inappropriate defensiveness  Financial - ◦ injuries from restraints ◦ misuse of funds  Failure to allow/limits pt’s responses to ◦ genital/rectal injuries or bleeding questions  Neglect -

◦ evidence of excessive drugging ◦ withholding food/meds/clothing, routine ◦ lack of/delay seeking medical attention health care, basic necessities

48 The Abused…  Normal response to major loss  Medical attention to address physical needs  may close ranks with abuser, confront clinician  Duration of reaction depends on…  Recognition of abuse, non-threatening for ‘attempting to break up family’ questioning to determine if it occurred; ◦ suddenness of loss  who leaves abuser has greater risk of being emphasize someone cares ◦ relationship to deceased killed than one who stays  Contact numbers for referral agencies ◦ age/physical condition of deceased  suffer damage to ego defenses, may not be (legal, shelters, support groups)  Normal grief resolves within 1 yr assertive enough to believe rights were violated  Present options, allow pt. to decide  Most severe symptoms within 1st 2 mos  may think they deserved it, must accept abuse  Some develop MDD; dx not made until grief as price to pay (food, home) symptoms fail to resolve

49  Depressed mood  Decreased/increased  Anhedonia appetite or >5%  Symptoms: shock, confusion, sadness,  Inflated self-esteem,  Distractibility unintentional wt.  Excessive guilt  Impaired judgment, may numbness, guilt change over 1 mos grandiosity  May report illusions (seeing/hearing deceased)  Indecisiveness  Irritability pursue pleasurable  Decreased interest in activities with probable or deny aspects of the death  Lack of self-worth sex  Decreased need for  Insomnia/hypersomnia adverse outcomes  Hallucinations that persist, are intrusive, or  Suicidal ideation or sleep  Psychomotor agitation belief that deceased still alive is not “normal”  Difficulty with memory thoughts of death  Pressured speech  Tx – or concentration  Chronic fatigue or  Flight of ideas ◦ social contact/reassurance  Psychomotor decreased energy ◦ +/- benzos for insomnia retardation/agitation

50  Movement disorders (dystonias, bradykinesia,  Echolalia - mimicking sound akathisia, choreoathetosis) . Mod-severe wt. gain (olanzapine, clozapine)  Anhedonia  Echopraxia - mimicking behavior  Sedation . Diabetes  Delusions- erroneous beliefs based on  Weight gain . Hypercholesterolemia misinterpretation of reality such as paranoia, ideas of reference, thought broadcasting,  Temperature dysregulation/poikilothermy . Sedation  Hyperprolactinemia/galactorrhea/amenorrhea in delusions of grandeur, or delusions of guilt women & gynecomastia in men; decreased sexual . Moderate movement disorder  Hallucinations - false perceptions in any function in both . Hypotension sensory modality, such as  Postural hypotension . Hyperprolactinemia (risperidone) auditory/tactile/olfactory/visual  Sunburn . Seizures, nocturnal salivation, agranulocytosis,  Concrete thinking – thinking characterized by  Prolonged QT interval, risk of potentially fatal immediate experience rather than abstractions; myocarditis, lens opacities (clozapine) arrhythmia (with thioridazine) may be seen in schizophrenia

51  Clang associations - connections based on  Secondary Gain – use of symptoms to benefit the  Personality disorder - enduring & pervasive pattern similarities in sounds of words rather than meaning pt. (to get more attention, decreased of behavior that differs from the individual’s culture  Loosening of association - ideas have no responsibilities, avoidance of the law)  Pressured speech – rapid/accelerated/frenzied discernible connection to one another  Tolerance - either a decreased effect over time speech, difficult to interrupt; often seen in mania  Word salad - incoherent speech from extreme when same amount of substance is used or need  Primary Gain – expression of unacceptable feelings loosening of associations; may be seen in for an increased amount of a substance over time as physical symptoms in order to avoid facing them schizophrenia (esp. disorganized type) to achieve a baseline  Tardive Dyskinesia – can occur with high-potency  Neuroleptic malignant syndrome - can occur with  Withdrawal - need for substance use to relieve or antipsychotics – darting or writhing movements of high-potency antipsychotics --> confusion, high avoid physical symptoms associated with face, tongue, & head fever, elevated BP, tachycardia, “lead pipe” rigidity, deprivation of it  Tangentiality - answers become progressively less sweating, greatly elevated creatine phosphokinase  Delayed response - latency before responding; at related to the original question (CPK) levels the extreme, pt. may be mute

52  Affect – behavior that expresses emotion (ie,  Akathisia – subjective sense of restlessness with euphoria, anger, sadness); Types of disturbance:  Munchausen by proxy - form of abuse usually ◦ Blunted – severely reduced intensity of expression fidgeting, rocking from foot to foot, pacing or initiated by the mother. Symptoms made up or ◦ Flat – absence/near absence of signs of expression, being unable to sit still clinical signs are induced in a child causing often manifest as monotonous voice/immboile face  Akinesia – state of motor inhibition or reduced repeated visits to provider. Perpetrator gets ◦ Inappropriate – discordance of voice & movements voluntary motor movement attention as being an attentive, suffering with content of speech or ideation; display of parent.  Avolition – lack of initiative or goals; a negative emotion not appropriate with reality or with content  Negativism - refusal to cooperate with simple symptom of schizophrenia that it accompanies requests for no apparent reason. ◦ Labile – abnormal variability with rapid shifts in  Flight of ideas – continuous flow of rapid speech  Blocking - halt in flow of speech, unable to expression with abrupt changes from one topic to another; continue train of thought even with cueing. ◦ Restricted/constricted – reduction in expressive often seen in mania range & intensity of affect

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53  Andreason NC, Black DW. Introductory Textbook of Psychiatry. 5th edition, American Psychiatric Publishing, Inc., 2011.

 Burton, N. Psychiatry. 2nd edition, Wiley—Blackwell, 2010.  Ebert MH, Loosen PT, Nurcombe B, et al. Current Diagnosis & Treatment: Psychiatry. 2nd edition, McGraw-Hill, 2008.  Goldman HH. Review of General Psychiatry. 5th edition, Thank you and good luck! McGraw-Hill, 2000.  Sadock BJ, Sadock VA. Synopsis of Psychiatry. 10th edition,  Lippincott Williams & Wilkins, 2007.  Stead LG, Stead SM, Kaufman MS. First Aid for the Psychiatry Clerkship. 2nd edition, McGraw-Hill, 2005.

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