Flashcards in Day 4.2 Psych Deck (161):
Distinct period of abnormal and persistently elevated, expansive, or irritable mood.
Can be happy or angry
Often disturbing to the pt, but can also be fun- v. productive
Dx of manic episode
3 or more of DIG FAST:
Grandiosity- inflated self-esteem, can be delusional
Flight of ideas- racing thoughts
Activity and agitation increased
Sleep less (decreased need)
Talkative, pressured speech
Like manic except mood disturbance doesn't interfere with social/occupational function, and doesn't need hospitalization
No psychotic features.
At least 1 manic or hypomanic episode.
(manic = bipolar I, hypomanic = bipolar II)
Always get depressive symptoms eventually.
Pt's mood/fn usu returns to normal bt episodes.
Use of anti-depressants can lead to mania (bc they increase serotonin, NE)
Engage in pleasurable activities w potentially painful consequences
High suicide risk
Rx for bipolar disorder
milder form of bipolar- hypomania, mild depression
Lithium mech and use
mech unknown, may be related to inhibition of phosphoinositol cascade
Use: mood stabilizer for bipolar disorder, blocks relapse and acute manic events
also used in SIADH
DoC for bipolar, mania
What is SIADH
Syndrome of Inappropriate(ly high) Anti-Diuretic Hormone
Excess ADH = retain water and don't urinate; serum Na+ decreases.
Toxicity of lithium
Lithium side effects:
Tremor, sedation, edema, heart block, hypothyroidism, polyuria (ADH antagonist, causes nephrogenic DI), teratogenesis (Ebstein's anomaly of the heart).
Narrow therapeutic window, requires close monitoring of serum levels
Ebstein's anomaly of the heart
Opening of tricuspid valve is directed toward the apex of the RV.
Assoc w lithium in 1st trimester and WPW
Which anti-depressants have no sexual side effects?
Bupropion (wellbutrin)- atypical antidepr NDRI
Mjr depressive episode characteristics
>2wks, need at least 5 of these and also must include pt-reported depressed mood or anhedonia:
SIG E CAPS (GAS C PIES)
Guilt/feelings of worthlessness
Psychomotor retardation/agitation (leaden/hard to get up off of couch)
Major depressive disorder- recurrent
2 or more major depressive episodes with a symptom-free interval of 2 months
Milder form of depression, 2 criteria, lasting at least two years
Seasonal affective disorder
assoc'd w winter, improves w light
Lifetime prevalence of depression
Sleep patterns of depressed pts
Decreases slow wave sleep (Stg 3&4)
Decreased REM latency (get to REM faster)
Increased REM early in sleep cycle
Increased total REM
Repeated night time awakenings
Early morning awakening (imp screening question)
characterized by hypersomnia, hyperphagia (overeating), and mood reactivity- ability to experience improved mood in response to positive events, vs persistent sadness, and psychomotor retardation (feeling like lead)
Assocd w weight gain and sensitivity to rejection
Most common subtype of depression
Rx: MAOIs, SSRIs (NOT TCAs)
What are the 3 post-partum mood disturbances, epi
Postpartum blues: 50-85%
Postpartum depression: 10-15%
Postpartum psychosis: 0.1-0.2%
Mild depression for 10days/2wks
Increased tearfulness, tiredness.
Rx supportive care, usually resolves. follow up at postpartum visit
Educate pts about this before birth! 50-85% of pts!!
Depressed affect that doesn't resolve after 2 weeks
Anx, poor concentration
A mjr depressive episode, just in the postpartum period.
Lasts 2 wks to over a year
Rx: anti-depressants, CBT, psychotherapy, supportive therapy
delusions, confusion, unusual bhvr, homicidal or suicidal ideations or attempts
High assoc w bipolar disorder
Rx antipsychotics, antidepressants, in-pt hospitalization if pt is a danger
Treatment option for mjr depressive disorder if other Rx doesn't work.
Cause painless seizure in an anesthetized pt.
Can cause disorientation and antero/retrograde amnesia (minimize by performing ECT unilaterally)
Risk factors for suicide completion
Age (teen or elderly)
Sickness (medical illness, 3+ prescriptions)
No spouse (divorced/widowed/single, esp if childless)
Social support lacking
Also, schizophrenia, access to a gun, and borderline personality disorder
Women try more, men succeed more.
List the TCAs
-ipramines and -tylines:
Imipramine, amitriptyline, desipramine, nortryptiline, clomipramine, doxepin, amoxapine.
How do TCAs work?
They block the reuptake of NE and Serotonin.
Use for TCAs
Also used for fibromyalgia (sympt improve w improved ability to sleep). Use nortriptyline for elderly pt/pt w fibromyalgia bc less side effects on ACh.
Side effects of TCAs
alpha-blocking effects (hypotension, sedation, dizziness)
atropine-like (anticholinergic) effects- tachycardia, urinary retention
Tertiary TCAs (amitriptyline) have more anticholinergic effects than Secondary TCAs (nortriptyline).
Desipramine is the least sedating and has a lower seizure threshold.
Tri-C's: convulsions, coma, cardiotoxicity (arrhythmias)
also, respiratory depression, hyperpyrexia-d/t convulsions.
Confusion and hallucinations in elderly d/t anticholinergic side effects (so use nortriptyline)
Rx: NaHCO3 for CV toxicity
List the SSRIs
How do SSRIs work?
Sertonin-specific reuptake inhibitors
Usu takes 2-3 wks for them to start working (bridge w amphetamines)
Clinical use for SSRIs
basically any anx disorder:
generalized anx disorder
can also use for atypical depression
Less toxicity than TCAs
Sexual dysfn #1 reason for discontinuation
Serotonin syndrome w any other drug that increased serotonin (eg MAOI)
What is serotonin syndrome?
caused by taking multiple drugs that increase serotonin
hyperthermia, musc rigidity (contraction), CV collapse, flushing, diarrhea, seizures
Rx: cooling and benzos 1st, then cyproheptadine (serotonin receptor antagonist)
Drugs associated with Serotonin Syndrome (so don't give these with SSRIs)
Other SSRIs, SNRIs, MAOIs
St. John's Wort, kava kava
Sibutramine (SNRI for weight loss)
dizziness, nausea, fatigue, musc aches, anx, irritibility- get all of these with short-acting SSRIs, so give long acting fluoxetine (t1/2 is 9 days) to gradually taper.
List the SNRIs
Nefadozone (no sexual side effects)
Sibutramine (for weight loss)
How do SNRIs work?
Inhibit reuptake of both serotonin and NE
What are SNRIs used for?
Velafaxine- also used in gen anx disorder
Duloxetine- used for diabetic peripheral neuropathy
Duloxetine has a greater effect on NE.
Toxicity of SNRIs
Increased BP is most common
Also, stimulant effects, sedation, nausea
Selegiline (an MAO-B inhibitor, but not an anti-depressant. used for parkinsons)
Mechanism of MAOI
Nonselective MAO inhibition, leading to increased levels of amine NTs (Dopa, NE, Epi, Serotonin) bc MAO is inhibited and doesn't break them down as usual
Clinical use for MAOIs
Toxicity for MAOIs
HTN crisis when ingesting food with tyramine (wine, cheese, beer, soy sauce, any food that's aged)
HTN crisis with Beta-agonists
Contraindicated with SSRIs or meperidine (narcotic analgesic) to prevent serotonin syndrome
MAOI washout period- wait 2 wks before starting or after finishing MAOIs to avoid any interactions w other antidepressants
What are the atypical antidepressants?
Bupropion (wellbutrin) NDRI
Mirtzapine (a tetracyclic)
Trazodone (a tetracyclic)
What atypical antidepressants are often used with SSRIs?
Buproprion (NDRI) and Trazodone
NDRI, Atypical antidepressant
Also used for smoking cessation
Increases NE and dopamine by unknown mech (so good w SSRI to increase serotonin and therefore cover all NTs)
Toxicity: stimulant effects (tachycardia, insomnia- so take in morning); headache. No sexual side effects.
Can cause seizure in bulemics or in anyone w hx of seizures or when given w anything that lowers the seizure threshold
Atypical antidepressant, tetracyclic.
Alpha2 antagonist (so increases rls of NE and serotonin), and potent serotonin receptor antagonist
Good for elderly pt w decreased appetite and insomnia (use side effects to advantage)
Toxicity: sedation, decreased appetite, weight gain, dry mouth (there are anti-histamine side effects)
Blocks NE reuptake
Toxicity: sedation, orthostatic hypotension
Atypical antidepressant, tetracyclic.
Primarily inhibits serotonin reuptake.
Used for insomnia (esp in elderly) and at high doses for antidepressant
Toxicity: sedation, nausea, priapism (trazoBONE), postural hypotension
Amytriptylline side effects
Amytriptylline = TCA
these are mostly due to amytriptylline's anti-cholinergic activity
Cyclothymia vs dysthymia
Cyclothymia - milder form of bipolar, >2 years (think cyclic)
Dysthymia - milder form of depression >2 years (D for depression)
Mech of action for benzodiazapines
facilitate GABA by increasing frequency of Cl- chnl opening
Mech of action for barbituates
Facilitate GABA by increasing duration of Cl- chnl opening
NE Dopamine Reuptake Inhibitor
Bupropion (atypical antidepressant)
MAOI (for parkinsons, not for depression)
NDRI, atypical antidepressant
Tetracyclic, atypical antidepressant
Tetracycline, Atypical antidepressant
Recurrent periods of intense fear and discomfort peaking in 10min
Must have at least 4:
Intense fear of dying/losing control
Shortness of breath
Described in context of occurance (eg panic disorder w agorophobia)
Assocd w persistent fear of having another attack
Rx for panic disorder
Rx CBT (identifying underlying thought processes), SSRIs, TCAs, benzodiazepines (only when needed- simply having them can reduce incidence), B blockers (decrease HR)
Excessive/unreasonable fear that interferes w normal function
Cued by presence or anticipation of specific object/situation (eg fear of heights)
Pt recognizes fear is excessive
Rx systematic desensitization
Social phobia (social anx disorder)
Exaggerated fear of embarassment in social situations (eg public speaking, using public restrooms)
Recurring intrusive thoughts, feelings, sensations (obsessions) that cause severe distress; relieved in part by the performance of repetitive actions (compulsions)
Ego-DYStonic: behvr is NOT consistent with one's own beliefs/attitudes (vs O-C PERSONALITY disorder)
Ego-dystonic- the pt doesn't like it
Assoc w Tourette's
Rx: SSRIs, clomipramine (TCA)
Persistent reexperiencing of prev traumatic event.
Nightmares, flashbacks, intense fear, helplessness, horror
Avoidance of stimuli assocd w trauma, persistant increased arousal
Lasts >1mo w onset any time after event. Causes significant distress or impaired fn
Rx Psychotherapy, SSRIs
Acute stress disorder
Sympt of PTSD but lasting bt 2 days to 1 mo
(Actual PTSD is >1mo)
Generalized anx disorder
Anx that doesn't fit into any other category
Uncontrollable anx that is NOT related to a specific person, situation, event.
Assoc w sleep disturbance, fatigue, difficulty concentrating
Rx: Buspirone, SSRIs, benzos
6mo in presence of a chronic stressor)
Used for Generalized Anx Disorder (>6mo)
Stims serotonin receptors
Does not cause sedation, addiction, tolerance
Does not interact w alcohol (vs barbituates, benzos, which do)
Pt consciously fakes or claims to have a disorder in order to attain a specific secondary gain (eg avoiding work, obtaining drugs)
Avoids treatment by medical personnel
Complaints stop after pt gets what they want (not the case in factitious disorder)
Motivation is conscious- pt knows why they are doing it.
Pt consciously creates physical/psychological sympt in order to assume "sick role" and to get medical attention (primary gain)
But their motivation for doing this is UNconscious- pt doesn't know why they are doing it.
Chronic factitious disorder w predominantly physical signs and symptoms.
Hx of multiple hospitalizations, willingness to receive invasive procedures
Munchausen's syndrome by proxy
Caregiver causes illness in child
Motivation is to assume a sick role by proxy
This is child abuse
Faking illness to get out of work
Imagining going through the steps of a scary exam
Systematic desensitization (somatic desensitization)
Physical sympt w no identifiable physical cause. Illness production and motivation are unconscious drives. Sympt not intentionally produced or feigned. More common in women.
Types: somatization disorder, conversion, hypochondriasis, body dysmorphic disorder, pain disorder, pseudocyesis
variety of complaints in multiple organ systems over a period of years
at least 4 pain, 2 GI, 1 sexual, 1 pseudoneurologic
motor or sensory symptoms- paralysis, blindness, mutism, pseudoseizures), often after acute stressor.
Pt is aware of sympt but unusually indifferent- la belle indifferance
preoccupation and fear of having a serious illness despite medical eval and reassurance
Body dysmorphic disorder
preoccupation w minor or imagined defect in appearance, leading to significant emotional distress/impaired functioning
Pts often repeatedly seek cosmetic surgery
prolonged pain w no physical findings
false belief of being pregnant
Motivation unconscious, creation of sympt conscious
Factitious disorder (incl munchausen's)
Motivation conscious, creation of symp conscious
Motivation unconscious, creation of sympt unconscious
enduring repetitive pattern of perceiving, relating to, thinking abt the env and oneself
exhibited in a wide range of imp social and personal contexts
inflexible, maladaptive, rigidly pervasive pattern of behavior causing subjective distress and/or impaired functioning
pt is usu not aware of problem
usu NOT dx'd in children, stable by early adulthood
can't change them.
Cluster A personality disorders
A = Weird- accusatory, aloof, awkward.
Odd, eccentric. Inability to devp meaningful social relationships
Not psychotic, but genetic assoc w schizophrenia
3 Types: paranoid, schizoid, schizotypal (ssp=scary street people)
Cluster B personality disorders
B = Wild- bad, borderline, bubbly, best
Dramatic, emotional, or erratic
Genetic assoc w mood disorders and substance abuse.
4 types: antisocial, borderline, histrionic, narcissistic
Cluster C personality disorders
C = Worried (cowardly, compulsive, clingy)
Anxious or fearful
Genetic assoc w anx disorders
3 types: avoidant, OC personality disorder (not OCD!), dependent
Borderline personality disorder
Cluster B (bad, BORDERLINE, bubbly, best)
Unstable mood and interpersonal relationships, impulsiveness, self-mutilation, suicide ideation, sense of emptiness
Splitting is a mjr defense mech (all gd or all bad)
Cluster A (accusatory, ALOOF, awkward)
Schizoid = Avoid
Voluntary social withdrawal, limited emotional expression, content w social isolation (vs avoidant, cluster c who is hps to rejection and wants relationships)
Narcissistic personality disorder
Cluster B (bad, borderline, bubbly, BEST)
Grandiosity, sens of entitlement, lacks empathy and req's excessive admiration
often demands the best and reacts to criticism with rage
Dependent personality disorder
Cluster C (cowardly, compulsive, CLINGY)
submissive and clinging
excessive need to be taken care of
Paranoid personality disorder
Cluster A (ACCUSATORY, aloof, awkward)
pervasive distrust and suspiciousness
projection is a mjr defense mech
Obsessive compulsive personality disorder
Cluster C (cowardly, COMPULSIVE, clingy)
Pre-occupation w order, perfectionism, and control. Ego-syntonic- the behavior IS consistent w own beliefs and attitudes (vs OCD, where it's not)
Avoidant personality disorder
Cluster C (COWARDLY, compulsive, clingy)
HPS to rejection, socially inhibited, timid, feelings of inadequacy
Desires relationships w others, but afraid. (vs schizoid, which avoids)
Antisocial personality disorder
Cluster B (BAD, borderline, bubbly, best)
Disregard for and violation of rights of others, criminality
if s conduct disorder
antiSOCial = SOCiopath
Cluster A (accusatory, aloof, AWKWARD)
Eccentric appearance, odd beliefs or magical thinking, interpersonal awkwardness
Schizotypal, dress like a pickle!
Cluster B (bad, borderline, BUBBLY, best)
Excessive emotionality and excitability, attention seeking, sexually provacative, overly concerned w appearance
What are the genetic associations with cluster A, B, C
B: mood disorders, substance abuse
C: anx disorders
Maladaptive pattern of substance use, 3 or more of the following signs in 1 year:
Tolerance (need more to get same effect)
Substance taken in lgr amts and over longer time than desired
Persistent desire/unsuccessful attempts to cut down
Significant energy used to obtain, use, recover from substance
Reduced number of imp social, job-related, fun activities d/t substance use
Continued use even tho know it's bad
Maladaptive pattern leading to clinically significant impairment/distress.
Sympt have NEVER met criteria for dependencs.
Recurrent use, leading to failure to fulfill mjr obligations at work/school/home
Recurrent use in physically dangerous situations
Recurrent legal problems bc of substance abuse
Keep using it in spite of persistent problems caused by use
Bhvrl, physiologic, cognitive state caused by cessation or reduction of heavy/prolonged use.
Sympt/signs often opposite of those seen in intoxication.
Serum gamma-glutamyltransferase (GGT)- sensitive indicator of alch use
Fatty chg of liver
AST = 2xALT (A Scotch & Tonic)
Rx: time! (naltrexone, disulfiram are for prevention)
Alch withdrawal is life threatening!
DTs- delirium tremens
Hallucinations (incl tactile- ants)
Rx for DTs: benzodiazapines (or alcohol)
eg morphine, heroin, methadone
pupillary constriction (pinpoint pupils)
seizures (OD is life-threatening)
Rx: naloxone, naltrexone
eg morphine, heroin, methadone
uncomfortable, but NOT life threatening like alch withdrawal)
piloerection (cold turkey)
nausea, stomach cramps, diarrha (flu-like sympt)
Rx: treat sympt; naloxone + buprenorphone (suboxone); methadone
Have a low safety margin
Rx: manage sympt (assist breathing, increase BP)
life-threatening CV collapse
Greater safety margin than barbituates.
somnolence (that's why ppl use them)
minor respi depression
additive effects w alcohol.
RX: flumazenil (competitive GABA antagonist)
Prevention of relapse in alcoholics
topiramate (anti-seizure drug)
life-threatening alch withdrawal syndrome
peaks 2-5 days after last drink
in order of appearance:
autonomic system hyperactivity (tachycardia, tremors, anx, seizures)
psychotic symptoms (hallucinations, delusions)
physiological tolerance and dependence w sympt of withdrawal (tremor, tachycardia, HTN, malaise, nausea, DTs) when intake is interrupted
complications - alcoholic cirrhosis, hepatitis, pancreatitis, peripheral neuropathy, testicular atrophy, sat night palsy (compress radial nerve), aspiration pneumonia
Alch is a diuretic, so it causes tubular dysfn and will decrease Mg2+ levels- give alcoholics Mg2+ in the ER, esp if they are having heart problems.
Seen in alcoholics.
Caused by thiamine/B1 deficiency
Triad: confusion, opthalmoplegia, ataxia (Wernicke's encephalopathy)
May progress to irreversible memory loss, confabulation, personality chg (Korsakoff's psychosis)
Assoc w periventricular hemorrhage/necrosis of mammillary bodies.
RX: IV thiamine/B1
See in alcoholism
Longitudinal lacerations at the GE junction, caused by excessive vomiting.
Often presents w hematemesis
Assoc w pain (vs esophageal varices, which bleed but are painless)
Users at incrsd risk for hepatitis, liver abscess, overdose, hemorrhoids, AIDS, right-sided endocarditis, tricuspid valve endocarditis. Many of risks are due to needle use, not heroin itself
Look for needle sticks in veins (track marks)
Will have sympt of opioid intoxication (pinpoint pupils, respi depression, coma)
Rx: Naloxone, naltrexone, methadone, suboxone
Competitively inhibit opioids
Used in cases of opioid OD
If unconscious pt in ER, often give these just in case it's OD.
long-acting oral opiate, used for heroin detox or long-term maintenance
naloxone + buprenorphine (partial agonist)
long-acting w fewer withdrawal sympt than methadone.
naloxone is not active when taken orally, so withdrawal sympt occur only if injected. (lower abuse potential)
Rx for benzo OD
What drug categories cause pupillary constriction (miosis)
Organophosphates, any Anti-AChE (stigmines)
What drug categories cause pupillary dilation (mydriasis)
Stimulants- amphetamines, cocaine
Muscarinic antagonists- atropine
Withdrawal of Opioids
Annoyed (when ppl ask you abt it)
Rx for alcoholic with hypoglycemia
Give B1/Thiamine BEFORE giving glucose.
Alcoholics have impaired gluconeogenesis- they can't generate glucose. But, if you just give them glucose, will cause Werenke-Korsakoff. So give B1 first, then can give glucose.
What's in a banana bag?
thiamine (B1), folate, multivitamines, Mg2+
give to alcoholics
Causes Wereke-Korsakoff or Beri Beri (dry/wet)
Rx for alcoholics (prophylaxis)
AA, disulfiram, etc
HBV, HAV, pneumonia, influenza vaccines
Warn abt tylenol use- 4g is toxic to liver.
Prolonged wakefulness and attn
Amphetamine and Cocaine withdrawal
severe depression, suicidality
lethargy, hypersomnulence, fatigue, malaise
stomach cramps, hunger
severe psychological craving
sudden cardiac death
Rx for cocaine OD
Restlessness, insomnia, increased diuresis, muscle twitching, cardiac arrhythmia- PACs, PVCs (premature atrial, ventricle contractions)
Headache, lethargy, depression, weight gain
Restlessness, insomnia, anx, arrhythmias- PACs, PVCs
Nicotine Withdrawal and RX
Irritability, headache, craving, weight gain
RX: nicotine replacement (gum, patch, losenge)
help prevent relapse w bupropion/varenicline
vertical and horizontal nystagmus
Rx for PCP intoxication
anergia, disturbances in thought and sleep
violence (can have with both OD and withdrawal)
marked anx or depression
flashbacks (even years later)
euphoria, anx, paranoid delusions
perception of slowed time
dry mouth, hallucinations
red eyes (conjunctivitis)
long term: social withdrawal
teens who use have incrsd risk for schizophrenia