A. The fact that this patient has gone from euphoric and psychotic (the hallucination about the President) to depressed and unresponsive in only 1 hour, combined with the findings of dilated pupils and erythema (redness) of the nose (from snorting the drug), indicate that this patient has used cocaine. The major mechanism of action of cocaine is to block reuptake of dopamine, thereby increasing its availability in the synapse. Increased availability of dopamine is involved in the “reward” system of the brain and accounts for some of the euphoric effects of stimulants such as cocaine.
B. Tiredness and headache are seen with withdrawal from stimulants. Although increased appetite can be seen in withdrawal from all stimulants, intense hunger is most commonly seen in withdrawal from amphetamines. Withdrawal from sedatives such as alcohol and benzodiazepines or opioids such as heroin do not include these symptoms. There are no significant physical withdrawal symptoms from PCP.
D. This constellation of symptoms, including excessive salivation, lacrimation (tearing eyes), sweating, rapid heart rate, restlessness, and agitation, indicate that the child’s mother is a heroin addict and that the child is in withdrawal after birth.
E. Withdrawal from benzodiazepines is associated with tremor, insomnia, and anxiety. Respiratory depression and sedation are associated with use of, not withdrawal from, sedative agents.
D. Elevated levels of cotinine, a metabolite of nicotine, are found in the urine of smokers. Benzoylecgonine is a cocaine metabolite, and elevated gamma-glutamyltransferase is found in the body fluids of heavy alcohol users. Elevated levels of serum glutamic-oxaloacetic transaminase and creatinine phosphokinase, reflecting muscle damage, may be found with use of PCP.
A. Caffeine tends to increase blood pressure.
E. Psychosis and long-term effects may occur with PCP use.
A. Weight gain commonly occurs following nicotine withdrawal.
A. Marijuana is the most frequently abused illegal drug in the United States.
C. Appetite may increase with marijuana use.
C. Amphetamines reduce appetite and have been used as diet pills.
D. Benzodiazepines are used as sedatives, muscle relaxants, anesthetics, and tranquilizers; they are not used as antihistamines.
E. Sedation, analgesia, decreased respiratory drive, and euphoria may result from opiate use.
B. Korsakoff’s syndrome is associated with long-term use of alcohol.
D. Women are often more secretive about their use of alcohol than men.
C. Lacrimation, nausea, sweating, and vomiting are associated with heroin withdrawal.
B. Withdrawal from benzodiazepines is associated with insomnia, tremor, and anxiety.
B. The history of insomnia indicates that this patient may have been given a prescription for secobarbital (Seconal). His depression may have resulted from using this drug in a suicide attempt.
J. PCP use, like other hallucinogens, results in feelings of altered body states.
C. Paranoia, agitation, and aggressiveness, tachycardia, hypertension, and nasal inflammation all indicate that this patient was using cocaine.
G. The presence of HIV as well as signs of sedation and euphoria indicate that this patient is an intravenous heroin abuser.
C. Illegal drug use is most common in people ages 18-25.
D. This chronic pain patient is at high risk for depression but at relatively low risk for drug addiction. Pain patients tend to be undermedicated, and this patient is more likely receiving to little rather than too much pain medication. Psychological therapies can be of significant benefit to chronic pain patients. This patient’s expression of pain is related not only to the extent of his pain, but to religious, cultural, and ethnic factors.
D. Cultural, religious, and ethnic factors can influence a patient’s expression of pain and the responses of the support system of the patient to the pain.
A. Chronic pain is a commonly encountered complaint of patients. Chronic pain, which is associated with depression, substance abuse, childhood neglect and abuse, and stress can be treated with anti-depressants and phenothiazines.
D. Although medication is the preferred method of treatment, behavior modification and deconditioning have been used to treat pain caused by cancer or chronic diseases. For pain relief in chronic diseases, the medication schedule should be separated from the experience of pain (i.e., medication should be scheduled at regular intervals rather than given on demand). Many patients are undermedicated even though they are at low risk for addiction.
B. Patients with chronic pain benefit from psychotherapy and behavioral therapy by needing less pain medication, becoming more mobile, and showing increased attempts to return to their normal lives.
D. Patients with narcissistic or borderline personality disorders and patients with hypochondriasis and depression are at risk for developing chronic pain syndrome.
A. This man has a dysphoric mood (loss of interest in activities and decreased interest in food and sexual activity) as well as suicidal ideation, and he is therefore probably experiencing a major depressive episode. Sleep in major depression is associated with a shift in REM from the last to the first part of the sleep cycle, long first REM period, reduced slow-wave sleep, shortened REM latency, and greater percentage of REM.
C. Delta waves characterize sleep stages 3 and 4 (slow-wave sleep), which is also associated with episodic body movements, somnambulism, night terrors, and enuresis. Delta sleep is the deepest, most relaxed stage of sleep. Clitoral erection, paralysis of skeletal muscles, nightmares, and increased brain oxygen use occur during REW sleep.
E. Sleep in elderly patients, like this 85-year-old, is characterized by increased nighttime awakenings, decreased REM sleep, decreased delta sleep (stages 3 and 4), and decreased total sleep time. All of these changes could result in the daytime sleepiness that this patient demonstrates.
B. The most appropriate intervention for this student who is having problems falling asleep is to recommend a fixed wake-up and bedtime schedule; that is, he should go to sleep at about the same time on weekdays and weekends. Late bedtimes on weekends can make it difficult to fall asleep earlier on weekdays, leading to daytime sleepiness and impairment in functioning. Benzodiazepines are not appropriate for this student because of their high abuse potential and possibility of causing daytime sedation. These agents also decrease sleep quality by reducing REM and delta sleep. Exercise should be done early in the day; if done before bedtime, it can be stimulating and cause wakefulness. A large meal before bedtime is more likely to interfere with sleep than to help sleep. Although many lay people believe that milk helps induce sleep, this effect has never been proved scientifically.
C. This child demonstrates sleep terror disorder, which occurs in delta sleep and is characterized by screaming during the night and the inability to be awakened or to remember these experiences in the morning. In contrast, nightmare disorder occurs during REM sleep in which the child wakes up and can relate the nature of his frightening dreams. Kleine-Levin syndrome is usually seen in adolescents and involves recurrent periods of hypersomnia and hyperphagia, each lasting 1-3 weeks. In sleep drunkenness, a patient cannot come fully awake after sleep. In circadian sleep disorder, sleeping and waking occur at inappropriate times.
A. Shortening of REM latency is seen in narcolepsy; it also occurs in depression.
C. ACh is involved in increasing REM sleep.
C. REM sleep is characterized by penile and clitoral erection.
B. Non-REM sleep is associated with decreases in blood pressure, pulse, and respiration, and with calmness and episodic body movements.
D. Major depression is associated with reduced slow-wave sleep, shortened REM latency, greater percentage of REM, shift in REM from the last to the first part of the night, and long first REM period.
D. Patients with mania frequently have a reduced need for sleep rather than hypersomnolence.
C. Slow-wave sleep is associated with enuresis, somnambulism, night terrors, and no memory of the arousal.
C. Drugs that increase brain dopamine produce wakefulness; dopamine blockers tend to increase sleep time. Patients with Alzheimer’s disease have reduced slow-wave sleep and REM sleep.