Psych Review II

1. Charles Camp, MS IV ctcamp@buffalo.edu Psych Review II

2. Topics • Intoxication & Withdrawal • Mood Disorders – Depression and Bipolar Disorder • Eating Disorders • Anxiety Disorders • PTSD • Somatic Symptom Disorders • OCD spectrum disorders

3. Intoxication & Withdrawal Substance 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 intended • Social Impairment – not fulfilling obligations, giving up important activities • Risky Use – ignoring hazardous purchasing conditions or physical effects • Pharmacologic Dependence – tolerance, withdrawal if stop using In essence – not just physical dependence but maladaptive behaviors surrounding use

4. Intoxication & Withdrawal

5. Stimulants Mechanisms of Action: Cocaine – ↓ reuptake of DA, NE, 5HT • Smoking and injection = most addictive • Also can block nerve impulses causing local anesthetic effect Amphetamines - ↓ reuptake, ↑ release, ↓ degradation of NE and DA Ecstasy – amphetamine MoA + ↑ release of 5HT Crystal Meth - ↑ fat solubility  ↑ BBB penetration  more addictive Bath Salts – effect is similar to amphetamines

6. Stimulants Intoxication: ↑ sympathetic tone (↑HR, ↑BP, ↑RR), mydriasis, euphoria • Cocaine overdose  formications, delirium, seizure, stroke, MI • Ecstasy  ↑ emotional openness, euphoria, “afterglow” Withdrawal: malaise, fatigue, depression, SI, hypersomnia, miosis • Symptomatic treatment (not life threatening) • Ecstasy – long-term use can deplete 5HT  depression

7. Dissociative Anesthetics PCP • Mechanism – blocks NMDA glutamate receptors, activates DA receptors • Intoxication – hallucinations, nystagmus (rotatory), violence, anesthesia • Overdose – fever, rhabdomyolysis, renal failure, seizure, respiratory depression, death • Treatment – isolate, benzos, urine acidification (NOT antipsychotics – can worsen psychosis) Ketamine • Hallucinations, dissociation, profound respiratory depression

8. Hallucinogens LSD, Psilocybin, Mescaline • Mechanism – 5HT receptor agonist • Intoxication – visual distortions, intense emotions, mydriasis, tachycardia, altered sense of time/space • Hallucinogen Persisting Perception (“Bad Trip”) – acute anxiety reaction • Tx – reassure and wait, +/- benzos, antipsychotics last resort • Flashbacks can occur in times of fatigue/stress or while using other drugs • Duration: • LSD, mescaline – 6-10 hours • Psilocybin – 2-4 hours

9. Cannabinoids Marijuana (Cannabis) • Mechanism – THC binds endogenous cannabinoid receptors • Intoxication – euphoria, relaxation, conjunctival injection, paranoia, increased appetite • Withdrawal – irritability, restlessness, anxiety, depressed mood, abdominal pain K2 (Spice) • Synthetic cannabinoid, 10x more affinity for receptor than THC • More severe symptoms – hallucinations, thought disorganization, aggression

10. Sedatives Alcohol, Benzodiazepines, Barbiturates • Mechanism – potentiates the effects of GABA (CNS depressant) • Intoxication – incoordination, slurred speech, nystagmus, coma • Benzodiazepine overdose  flumazenil • Withdrawal – LIFE THREATENING! • Autonomic hyperactivity, tremor, seizures, delirium tremens (at day 2-3) • Tx – frequent vitals, benzodiazepine taper, carbamazepine

11. Sedatives Opioids – Heroin, Methadone, Buprenorphine, Naloxone, Naltrexone • Mechanism – bind opioid receptors (full and partial agonists, antagonists), most importantly the Mu receptors • Intoxication – euphoria, analgesia, respiratory depression, miosis, constipation • Overdose can be fatal  treat with naloxone (antagonist) • Withdrawal – dysphoria, nausea/vomiting, diarrhea, lacrimation, rhinorrhea, yawning, mydriasis • Treatments for dependence: • Methadone, Suboxone (buprenorphine/naloxone) – detox and maintenance • Naltrexone – maintenance only

12. Intoxication & Withdrawal Red flags for prescription drug abuse: • History of substance abuse • Resistance to changes in therapy – always seeking specific drug • Refuses to see a specialist • Early refills • Lost/stolen prescriptions • “Doctor shopping” • Deterioration at work/home • Frequent ED visits

13. Mood Disorders

14. Depression Major Depressive Episode: 5 or more of the following for ≥ 2 weeks, with loss of function: • Depressed mood • Sleep disturbance • Interest loss (anhedonia) • Guilt/Worthlessness • Energy loss • Concentration loss • Appetite change • Psychomotor agitation/retardation • Suicidal ideation • Features changes in: • Mood • Thought • Vegetative function • Epidemiology: • ~2:1 female to male • ↑ incidence • ↓ age of onset • 2-4% community prevalence Need both SIGECAPS

15. Depression • Physiologic Changes: • Dysregulated stress response, ↑ cortisol • Neuronal atrophy, neurotransmitter imbalances • Sleep: ↓ REM latency, ↓ slow wave sleep (restorative sleep) • In children: • Irritability, apathy, behavioral change • ↓ response to antidepressants • More likely to have bipolar outcome Etiology: • Genetic – 50% MZ twins, 20% DZ twins (oligogenic) • Environmental factors (i.e. loss) Course: • 50% recurrence after 1 episode • ↑ risk of recurrence with more/longer episodes

16. Depression Depression Diagnoses: • Major Depressive Disorder (MDD) –at least 1 major depressive episode (≥ 2 weeks) • MDD with Atypical Features – ↑ sleep, ↑ appetite, ↑ weight • MDD with Psychotic Features – with delusions and/or hallucinations • Tx – antipsychotic + antidepressant • Dysthymia – milder depressive symptoms for ≥ 2 years • Seasonal Affective Disorder – depression ONLY in winter, normal or hypomanic in summer • Secondary Depression: • General medical condition – hypothyroidism, pancreatic cancer, left hemisphere stroke, Parkinson’s, HIV, autoimmune disease • Medication/substances – alcohol, steroids

17. Depression Treatments for Depression: • 1st Line = SSRI’s (fluoxetine, sertraline, paroxetine, fluvoxamine, citalopram, escitalopram) – inhibit 5HT reuptake • Side effects – sexual dysfunction, GI disturbance, headaches, sedation/activation • Paroxetine – more anticholinergic, contraindicated in pregnancy • TCA’s (amitriptyline, nortriptyline, clomipramine) – NE and 5HT reuptake inhibitors • Uses – migraines, chronic pain, refractory depression (not 1st line) • Side effects – anticholinergic, orthostatic hypotension, heart block, lethal in OD • MAOI’s (phenelzine,isocarboxazid) – prevent MAO from breaking down NE, 5HT, DA, tyramine • Uses – refractory and atypical depression • CANNOT combine with SSRI’s (serotonin syndrome) or tyramine-rich foods like cheese, wine, chocolate, fava beans (hypertensive crisis)

18. Depression Treatments for Depression (continued): Trazodone – 5HT antagonist • Sedating, risk of priapism Bupropion – DA and NE reuptake inhibitor • Less sexual side effects (vs. SSRIs), risk of seizures at high doses • DA reuptake inhibition makes it first choice for depressed Parkinson’s patients Venlafaxine – 5HT, NE, DA reuptake inhibitor • Useful for depression with chronic pain • Hypertension risk, short half-life (withdrawal) Mirtazepine – 5HT and alpha2 antagonist • Causes sedation and weight gain – ideal for depressed cancer patients ECT – electroconvulsive therapy • Most effective therapy, main side effect is transient amnesia

19. Depression Principles of Treatment: • “Start low, go slow” • If no response in 4 weeks – switch to something else in same class • It can take up to 6-8 weeks for full therapeutic effect • Continue: • 8-12 months for first episode of mild depression • Indefinitely if recurrent or severe first episode Remember – antidepressants in general work by altering second messenger systems which upregulate neuroprotective genes.

20. Bipolar Disorder Mania – elevated/expansive/irritable mood with 3-4+ symptoms for ≥ 1 week: • Distractibility • Indiscretion • Grandiosity • Flight of Ideas • Activity ↑ • Sleep ↓ • Talkative (pressured speech) Hypomania – same symptom criteria as above EXCEPT: • ≥ 4 days duration • No marked functional impairment • Hospitalization not required • No psychotic features • Additional Characteristics of Mania: • Severe impairment in function • May include psychotic features • Frequently necessitates hospitalization (which confirms diagnosis regardless of symptom time frame) DIGFAST

21. Bipolar Disorder Bipolar Diagnoses: • Bipolar I – at least 1 manic episode (required) + major depressive episodes (not required) • Bipolar II – at least 1 hypomanic episode + at least 1 major depressive episode • Cyclothymia - ≥ 2 years of mood swings between hypomania and mild depressive (dysthymia) symptoms • Mixed Episode – simultaneous manic/hypomanic and depressive symptoms • Secondary Mania: • General medical condition - hyperthyroidism, right hemisphere stroke • Medications/substance – antidepressants, stimulants, steroids

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

23. Bipolar Disorder Epidemiology: • ~1% prevalence of Bipolar I • 67-100% concordance between MZ twins (risk is only dependent on biological family) • Oligogenetic When to think of Bipolar vs. Depression: • Family history! • Early (childhood) onset of depression • Atypical depression or depression with psychotic features • Highly recurrent episodes of depression • Thrill seeking, tendency towards irritability or impulsivity • Arrogance or intrusiveness, high-functioning/creative

24. Bipolar Disorder Antidepressants can unmask/worsen mania! Treatments for Bipolar Disorder = Mood Stabilizers: Lithium • Narrow therapeutic index, can improve depression • Side effects – cognitive impairment, weight gain, renal/thyroid dysfunction Carbamazepine • Better tolerated than Li, useful for rapid cycling, can improve depression • Side effects – sedation, neurotoxicity, SIADH, agranulocytosis (rare) Valproic Acid/Divalproex • Good for anxiety and anti-aggression, but no antidepressant effect • Side effects – sedation, weight gain, cognitive impairment, pancreatitis Atypical antipsychotics • Treat acute mania, possible adjunct to maintenance therapy All teratogenic

25. Mood Disorders

26. Eating Disorders • Bulimia Nervosa • Recurrent episodes of binge eating • Compensatory behavior – vomiting, laxatives • Disturbance of body image • Normal or overweight • Sense of lack of control • Feelings shame/embarrassment during/after binge • More ego-dystonic – more likely to present • Parotitis, enamel erosion, dorsal hand calluses, hypokalemic hypochloremic metabolic alkalosis • Tx– fluoxetine if comorbid depression, CBT • Binge-eating disorder • Binge-eating (at least 1x/week for 3 months) with no compensatory behavior • Normal or overweight Anorexia Nervosa • Persistent energy intake restriction • Intense fear of gaining weight • Disturbance of body image • Underweight – BMI < 17.5, < 85% expected weight • Tend to be controlling, perfectionistic, inflexible • More ego-syntonic – less likely to present themselves to treatment • ↓ HR/BP/Temp, ECG changes, electrolyte abnormalities, osteopenia, lanugo • Types: restricting, binge-eating/purging • Tx – therapy, strict weight gain programs, potential hospitalization Comorbidities – MDD, anxiety disorders, personality disorders (borderline with bulimia)

27. Suicide • Risk 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 therapy • SSRI’s – when starting there is a higher suicide risk (energy levels improve before depressed mood/suicidal thought content) • Tarasoff v. Regents = duty to warn potential victim if patient expresses threat of harm to others

28. Anxiety Disorders • Medical Causes: • PE • Arrhythmia • CHF • Delirium • Dementia • Substance Causes: • Stimulants • Caffeine • Nicotine • Alcohol • Antidepressants • Other Psych Causes: • Depression • Bipolar • Schizophrenia Generalized Anxiety Disorder –excessive worry about multiple everyday events for > 6 months • Restlessness, easily fatigued, ↓ concentration, irritability, muscle tension, sleep disturbance Panic Disorder –recurrent, unprovoked episodes of intense fear (panic attacks) • Tachycardia, sweating, SOB, CP, abdominal distress, tremor, dizziness • Anticipatory anxiety for future attacks, fear “losing control,” significant change in behavior • Peak in 10 min, last 20-30 min Agoraphobia – fear of being in situations from which escape may be difficult Specific Phobia – persistent, irrational fear of object, creature or situation Social Phobia (Social Anxiety Disorder) – anxiety about humiliating oneself in both social and performance situations

29. PTSD and ASD • Risk Factors • Female gender, younger age • Low SES, education, IQ • Intentional violent act toward you, trauma severity • Continued environmental exposures • Functional Consequences • Substance abuse • Aggression/Violence • SI, attempts • Work/marriage problems • Treatments: • CBT (1st line), EMDR • SSRI’s (1st line) sertraline, paroxetine • Benzos (very short term) • Prazosin for nightmares Post-traumatic Stress Disorder • Experiencing/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 thoughts • Avoidance – physical (people, places) or mental (thoughts, feelings) • Cognition/Mood – persistent negative emotions, detachment, distorted cognition (irrational thoughts) • Arousal/Reactivity – hypervigilance, ↑ startle response, sleep disturbance, irritability Acute Stress Disorder • Similar scenario and symptomatology to PTSD except: • Duration is 3 days – 1 month after trauma exposure

30. Neuroscience of PTSD • Amygdala – hyperactive • Hyperarousal, exaggerated emotional response to stimuli • Prefrontal cortex – hypoactive • ↓ ability to keep limbic system in check • ↓ ability to properly interpret stimulus context  behaviors become more instinctual • ↓ decreases memory consolidation which links context with stimulus • Hippocampus – small • Also impairs memory formation which properly links context to stimulus • NE hyperactivity (made in locus coeruleus) • ↑ sympathetic tone - ↑ 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 Reciprocal Changes

31. Anxiolytics Benzodiazepines (diazepam, alprazolam etc.) – acute anxiety • Potentiate GABA  neuron hyperpolarization reduce anxiety • Side effects – sedation, impaired coordination, life-threatening withdrawal Antidepressants (SSRI’s) – 1st line for chronic anxiety (i.e. GAD) Buspirone – chronic anxiety • 5HT partial agonist • Non-sedating, no withdrawal, no impairment of driving Propranolol – performance anxiety Ramelteon – melatonin receptor agonist  sleep initiation but not maintenance for insomnia Prazosin – alpha blocker that ↓ BP and improves sleep (sedating, ↓ nightmares) Non-pharmacologic treatments – relaxation training, desensitization, CBT (especially for insomnia)

32. Somatic Symptom Disorders Somatization – psychological problems communicated as physical symptoms which are otherwise medically unexplained or disproportionate • Risks – childhood illness, parental illness, childhood trauma/abuse • Consequences – ↑ health care visits, ↑ iatrogenic disease due to unnecessaryworkup, disruption of doctor-patient relationship Somatic Symptoms Disorder • 1 or more somatic symptoms that are distressing • Excessive thoughts/feelings/behaviors related to the symptoms • Disproportionate/persistent thoughts about seriousness of symptoms • Persistently high anxiety level • Excessive time/energy devoted to symptoms or health concerns • Symptom duration ≥ 6 months • Tx – regular f/u visits (i.e. monthly), set limits, minimize polypharmacy, treat common comorbid conditions appropriately (depression, anxiety disorders)

33. Somatic Symptom Disorders Illness Anxiety Disorder • Excessive/disproportionate preoccupation with having/acquiring a serious illness • High anxiety level about health, illness becomes central to identity, seek reassurance • No (or mild) somatic symptoms • Illness preoccupation present for ≥ 6 months Conversion Disorder • One or more neurologic (sensory or motor) symptoms which cannot be explained by a known neurological/medical condition • Weakness/paralysis, reduced sensation, dysarthria, limb shaking/pseudoseizures • Abrupt onset, short duration • Women > Men • “La Belle Indifference” Factitious Disorder (Münchhausen Syndrome) • Conscious falsification of physical/psych symptoms for primary gain (i.e. sick role) • No obvious external rewards (vs. malingering – falsify for secondary gain) • MünchhausenSyndrome by Proxy – falsifying symptoms of another individual

34. OCD Spectrum Disorders Obssessions – recurrent and persistent thoughts/urges/images experienced as intrusive and unwanted (i.e. ego-dystonic) and cause anxiety/distress • Common themes– contamination, fear of harming, need for symmetry, checking for reassurance Compulsions – 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 event Obsessive-Compulsive Disorder • Presence of obsessions, compulsions or both • Time consuming (> 1 hr/day) or cause significant distress or impaired functioning • MRI 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, ADHD • Tx – CBT (1st line), SSRI’s, clomipramine (TCA), surgical treatments (gamma knife, DBS)

35. OCD Spectrum Disorders Compulsive Hoarding – acquisition of and/or failure to discard useless/valueless possessions • Cluttered living space, social isolation, impaired functioning or significant distress/shame, difficulty with decision making • Can be a symptom of OCD or a stand-alone diagnosis (70-80% meet OCD criteria) • Vs. OCD – earlier symptom onset, ↑ age at presentation, ↓ insight, more treatment-resistant • Tx – same as OCD (CBT, SSRI’s) Body Dysmorphic Disorder – preoccupation with perceived physical flaws that are slight/unobservable to others • Skin, hair, nose are common preoccupations • Repetitive behaviors (grooming, mirror checking) or mental acts (comparing to others) • Often have intrusive, obsessive thoughts • Clinically significant distress or impaired function • Ideas of reference common – falsely believe people are judging/mocking them • High rates of SI and attempts

36. Questions?