Clinical questions - Psychiatry Flashcards by Autumn Brubaker

Anorexia nervosa

less than 85% ideal body weight, amenorrhea, worried about gaining weight, excessively thin, without binge eating

Tx:
Interdisciplanary team: physician, dietician, MH
CBT, family therapy
only SSRI if comorbid depression/anxiety
Inpatient if severe malnutrition
-less than 75% Ideal body wt
-dehydration
-elyte derangements
-cardiac arrhythmias
-SI or psychosis
Nutritional therapy
Ca/Vit D supplementation

Weight gain goals:
Inpt: 2-3 pounds/wk
Output: 0.5 - 1 pound/week

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Criteria for hospitalizing a psych patient

danger to self
danger to others
unable to provide for themselves

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PTSD treatment

Psychotherapy: exposure therapy, CBT

Pharmacotherapy
SSRI 1st line
other antidepressants - TCAs, MAOIs
Mood stabilizers: impulsive behavior, hyperarrousal, flashbacks
Alpha blockers - prazosin for nightmares
Atypical antipsychotics for refractory sxs

Avoid benzos - inhibit ability to process event, and addictive/abuse risk

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Traditional, 1st gen, antipsychotics

Low potency:

chlorpromazine
thioridazine
se: anticholinergic effects

High potency:

Haldol
thoracenazine
se: neuroleptic malignant sn, movement disorders

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Atypical, 2nd gen, antipsychotics

respirdol
quietapine
olanzapine

se: sedation, wt gain, diabetes

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Tardive dyskinesia

Chorea of mouth/tongue

Side effect of traditional neuroleptics

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Movement disorders seen in high potency traditional neuroleptics (halloo, throacenazine)

1st several days: acute dystonia - muscle spasm, stiffness, oculargyric crisis; torticollis

1st month: parkinsonism sxs - bradykinesia, akinesia

2nd month: akathisia - restlessness, constant movement

months to years: tardive dyskinesia - lip smacking, irreversible

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Medical conditions that can cause major depression

Hypothyroidism
Hyperparathyroidism - increased Ca -> depression, delirium
Parkinsons
Cancer - CNS neoplasm, pancreatic CA
Strokes - ACA stroke esp.

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Obsessive compulsive disorder

Obsession - intruding recurrent, anxiety provoking thoughts or urges
Compulsions - repetitive behavior or mental acts to relieve anxiety created by obsessive thoughts

Tx:
SSRI 1st line
Clomipramine (TCA) -> anticholinergic se
venlafaxine (SNRI)
CBT

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Potential side effects of lithium

CNS effects:

depression
tremor
cognitive dulling

Thyroid changes - up or down
-euthyroid goiter

GI:

N/V/D
metallic taste
wt gain

Nephrogenic DI
-kidney stops responding to desmopressin (ADH) -> can’t concentrate urine -> polyuria, thirst, polydipsia

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Serotonin syndrome

SSRI with MAOI, SNRI, TCA, or triptan

Mental status changes:
anxiety, agitation, delirium, restlessness, disorientation

Autonomic excitation:
diaphoresis, tachycardia, hyperthermia, HTN, N/V/D

NM hyperactivity:
Tremor, rigidity, hyperreflexia, myoclonus, ocular clonus (slow horizontal eye movements)

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Major risk factors for suicide

psychiatric disorder
hopelessness or worthlessness
impulsivity
advanced age - more successful
male
access to firearms
prior Hx of suicide attempts

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Clozapine monitoring

Used in treatment-resistant schizophrenia
Risk of agranulocytosis

Get baseline CBC then weekly for 6 months, biweekly for 6 mo then monthly
Baseline Wt, BMI, waist circumference - risk of weight gain and subsequent DM
Baseline FBG or A1c
Baseline ECG: rare myocarditis with rapid progression to CM and CHF
Weekly ESR and troponin for 4 weeks

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Personality disorder characterized by controlling, perfectionistic, orderly, stubborn, possible hoarding

Obsessive compulsive disorder - rigid, organized, inflexible

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Personality disorder characterized by excessive need to be taken care of, submissive and clinging behavior, low self-confidence, fears of separation and losing support

dependent PD

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Personality disorder characterized by criminality, unable to conform to social norms, disregard for others’ rights, reckless disregard for safety

antisocial PD

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Personality disorder characterized by grandiosity, sense of entitlement, lack of empathy

narcissistic PD

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Personality disorder characterized by excessively dramatic, emotional, and extroverted, attention seeking, sexually provocative behavior, unable to maintain intimate relationships

Histrionic PD

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Heroin/opioid overdose

s/s:
depressed consciousness - drowsy, slurred speech, unarrousable
Miosis - pinpoint
Resp depression -> low sats, respiratory acidosis

Tx:
Naloxone (narcan) - wears off in 2-3 minutes, keep giving it again and again if needed

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Antidepressant/class that is generally 1st line tx for unipolar major depression

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SSRIs

Antidepressant/class that is a good choice for depressed patient with insomnia

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trazodone or mirtazapine

Antidepressant/class that is a good choice for patient who discontinued an SSRI due to sexual dysfunction

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bupropion

Antidepressant/class that is a good choice for depressed patient with appetite suppression and wt loss

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mirtazapine

Antidepressant/class that may help with smoking cessation

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bupropion

Antidepressant/class that overdose causes sedation and life threatening arrhythmias

TCAs

Medications used to treat ADHD

ADHD: careless mistakes, easily distracted, not following instructions, frequently interrupts and blurts out answers Stimulants: - methylphenidate - dextroamphetamine Nonstimulants: Atomoxetine (Strattera) - SNRI

Acute stress disorder vs PTSD

acute stress disorder - sxs 3 days to less than 1 mo PTSD sxs longer than 1 mo Both: exposure to dramatic event recurrent intrusive memories, dreams, flashbacks avoidance of stimuli altered arousal - insomnia, irritability, hyperviligence, self destructive behavior Persistent negative change in mood or cognition - amnesia, detachement, blame self

Drugs that cause or mimic psychosis

``` hallucinogens - LSD, PCP Stimulants - cocaine, amphetamines Withdrawal from benzos, barbs, alcohol -> tactile hallucinations and psychosis anabolic steroids glucocorticoids ```

Panic disorder

recurrent unexpected panic attacks with constant worry about more panic attacks Psychotherapy: CBT - triggers, train coping mechanisms Meds: SSRI SNRI TCA - imipramine, clomipramine - dangerous in OD, more s/e Benzos: immediate sx relief to break attack -> rebound anxiety and dependence

bulimia nervosa

Meds: SSRI - fluoxetine TCAs - desipramine, imipramine, amitriptyline Buspirone (buspar)

Acute mania/manic episode

decreased need for sleep, increased goal directed activity, excessive spending, grandiosity, pressured speech Mood stabilizers - alone or in combo for acute mania Lithium Anticonvusants - valproate, carbamazepine Atypical antipsychotic - olanzapine, quetiapine, aripiprazole, risperidone

management of torticollis associated with antipsychotic medication

benztropine or diphenhydramine - counteract ACh at NMJ with anticholinergic drug

Psychiatric disorder: Patient with normal anatomy is convinced a part of his/her anatomy is abnormal

body dysmorphic ds

Psychiatric disorder: unexplained loss of sensory or motor function without any basis in medical or neurological condition

conversion ds

Psychiatric disorder: patient is preoccupied with the possibility of contracting a serious illness and is constantly checking his/her body for signs of illness

illness anxiety dx

Psychiatric disorder: patient produces false s/s of an illness in order to receive sympathy or medical attention

factitious ds

Generalized anxiety disorder medical treatment

1st line: SSRI: paroxetine, sertraline, citalopram SNRI: venlafaxine, duloxetine ``` 2nd line: TCA: imipramine Benzos: clonazepam, diazepam - long acting -short acting risk rebound anxiety Buspirone + SSRI or SNRI ```

MAOI major side effect concern and dietary trigger

Hypertensive crisis MAO inactivates catecholamines, inhibition -> increased catecholamine -> serotonin, dopamine, norepinephrine with resultant HTN trigger - Tyramine - promotes catecholamine release Found in aged, pickled, smoked or fermented foods -sausage, pepperoni, salami, cheeses -Chianti, beers/wines -Brown bananas -Soy sauce

Neuroleptic malignant syndrome

associated with antipsychotic drugs s/s: Mental status change: agitation, delirium, psychosis Muscle rigidity -> fever, rhabdo Autonomic dysfunction: tachycardia, labile BP, tachypnea, diaphoresis Tx: Stop offending medication Supportive care in ICU - IVF, cooling blankets, icepacks Clonidine or nitroprusside for elevated BP Clonazepam/lorazepam for agitation prn DANTROLINE to relax skeletal muscle - inhibits Ca release (used in NMS and malignant hyperthermia)

Withdrawal from opiates

``` Dysphoria - unwell, discontent Restlessness, insomnia Yawning rhinorrhea, lacrimation, diaphoresis mydriasis myalgia, arthralgia N/V/D Abd craming piloerection - "uiting cold turkey" ```

Features that distinguish adjustment disorder with depressed mood from major depressive disorder

Adjustment disorder has an identifiable stressor that causes emotional or behavior symptoms -job loss, financial stress, divorce, death in family Sxs begin within 3 months of stressor, resolves within 6 months of disappearance of stressor disturbance does not meet criteria for MDD

Personality disorder: lifelong voluntary social withdrawal, lacks close friends, limited range of emotional expression, indifferent to the price/criticism of others

schizoid PD - schizoids avoid

Personality disorder: socially inhibited, shy, feelings of inadequacy, hypersensitive to rejection or criticism

avoidant PD

Personality disorder: social awkwardness and difficulty with personal relationships plus eccentric appearance, behavior, or thinking

schizotypal PD

Personality disorder: distrustful, suspicious, litigious

paranoid PD

Personality disorder: unstable personal relationships, unstable mood and behavior, unstable self-image, impulsiveness, suicide threats or gestures, sense of emptiness and loneliness

borderline PD

Depression management in bipolar

Mood stabilizers: Lithium anticonvulsants - lamotrigine (watch for rash), valproate Atypical antipsychotic - olanzapine, quetiapine ECT for severe depression

Indications for electroconvulsive therapy (ECT)

painless, electrode induced seizure Refractory depression - severe - psychotic features - severe SI - refusing food, nutritional compromise - catatonia Rapid response necessary - pregnancy Prior good response Bipolar disorder/mania Schizophrenia/psychosis esp catatonic

Clinical questions - Psychiatry Flashcards

(48 cards)