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Final Flashcards

1
Q

What is imipramine used for

A

Enuresis

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2
Q

What are the SSRIs

A

Citalopram, escitalopram, fluoxetine, paroxetine, sertraline, fluvoxamine

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3
Q

What are the SNRIs

A

Duloxetine, Milanacipran, venlafaxine

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4
Q

What are the TCAs

A

Amtriptyline, clomipramine, imipramine

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5
Q

What are the 5HT modulators

A

Nefazodone, trazodone, vortioextine

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6
Q

What are the atypical (tetracyclics/unicyclics)

A

Amoxapine, bupropion, mirtazapine, vilazodone, maprotiline, despiramine, nortriptyline, protriptyline

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7
Q

What are the MAOIs

A

Phenelzine, selegiline, isocarboxaxid, trancypromine

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8
Q

What is the SSRI that is only for OCD/SAD

A

Fluvoxamine

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9
Q

What antidepressant is a SNRI and dopamine antagonist

A

Amoxapine

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10
Q

What are the NDRIs(noradrenergic dopamine reuptake inhibitors)

A

Bupropion

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11
Q

Which SSRI is a partial agonist on 5HT1A

A

Vilazodone

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12
Q

Which SSRI is a partial agonist on 5HT1B and agonist on 5HT1A and antagonist on 5HT1D

A

Vortioxetine

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13
Q

What is the MOA of SNRIs

A

Selectively inhibit pre-synaptic reuptake of serotonin via SERT and NE via NET

  • tertiary amines inhibit both 5HT/NE equally
  • secondary amines inhibit NE>5HT
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14
Q

What are the tertiary vs secondary amine SNRIs (TCAs)

A
  • tertiary: amitriptyline, clomipramine, doxepin, imipramine

- secondary: amoxapine, desipramine, nortriptyline

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15
Q

What do TCA based SNRIs have additional affects on

A

Histamine (H1), muscarinic, alpha1 - block all of them

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16
Q

What are the features of amitriptyline

A

Antidepressant with sedative effects; contraindicated in patients with hypersensitivity; dont give with MAOI (causes hyperpyretic crises, convulsion and death); *increasd risk of suicide

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17
Q

What are the toxic effects of TCAs

A

Coma, cardiotoxicity (conduction abnormalities - quinidine like effect), convulsions

-tachycardia, orthostatic hypotension, dysrhythmias, dry mouth, urinary retention, constipation, blurred vision, increased IOP, sedation

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18
Q

What are the negative effects of the NE reuptake inhibitors - tertiary amine TCAs

A

Seizures, sedation, hypotension, anti-ACH, weight gain, sexual effects, cardiac effects

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19
Q

What are the features of amoxapine

A

Indicated for relief of depression in patients with neurotic or reactive depressive disorders as well as psychotic and endogenous depression; depression accompanied by anxiety or agitation; *more rapid onset than amitriptyline or imipramine; dont give with MAOI; increased risk of suicide

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20
Q

What are the side effects of the tetracyclics/unicyclics

A

Sexual and cardiac effects; NO GI effects

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21
Q

What are the features of escitalopram

A

Indicted for treatment of major depressive disorder; increased suicide risk; taper*; dont give with MAOI

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22
Q

What is the MOA of SSRIs

A

Selective inhibition of reuptake of serotonin via SERT

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23
Q

Do SSRIs or TCAs have fewer side effects

A

SSRIs

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24
Q

What are the side effects of SSRIs

A

Sedation, sexual dysfunction, weight gain in adults, loss in kids, acute withdrawal reactions (flu-like sx)

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25
Q

What are the rare toxic side effects of SSRIs

A

QT prolongation, hyponatremia, serotonin syndrome (sweating, hyperreflexia, akathisia/myoclonus, shivering/tremors), increased suicide (highest risk in kids)

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26
Q

What are the common features btw neuroleptic malignant syndrome (caused by antipsychotics) and serotonin syndrome

A

Both present with HTN, tachy, hyperthermia , hypersaivation, diaphoresis, coma

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27
Q

What are the differences btw neuroleptic malignant syndrome and serotonin syndrome

A
  • neuroleptic: pallor, stupor, alert, lead pipe rigidity in all mm, hyporeflexia, normal pupils, normal or decreased bowel sounds
  • serotonin: agitated, increased m tone esp in LE, hyperreflexia, clonus, dilated pupils, hyperactive bowel sounds
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28
Q

What SSRIs have the most vs least drug interactions

A
  • most: fluoxetine

- least: citalopram and sertraline

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29
Q

What are the side effects of SSRIs

A

GI effects, sexual effects, cardiac effects

NO seizures NO sedation

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30
Q

Which atypical antidepressants have sedative effects

A

Mirtazapine, nefazodone, trazodone

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31
Q

What is the only negative side effect of MAOI

A

Sexual dysfunction

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32
Q

What are the 5R’s of general antidepressant efficacy

A
  • response: >50% reduction in sx from baseline; partial response = >25% but <50%
  • remission: sx free
  • recovery: 2-6 months of ongoing remission; not cured
  • relapse: return of sx after remission but before recovery
  • recurrence: return of sx after recovery
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33
Q

What should you do if a patient doesn’t respond to an antidepressant in 8 weeks

A

Switch to another with different MOA

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34
Q

What should you do when stopping any antidepressant

A

Slow titration

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35
Q

What are the mood stabilizers

A
  • anti-seizure: carbamazepine, lamotrigine, divalproate/valproic acid
  • misc: lithium
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36
Q

What are the actions of lithium

A

Inhibits calcium dependent depolarization provoked release of NE and DA, inhibits receptor blockers and substances known to stimulate and inhibit Gprotein synth (can affect both Gs and Gi - inactivate them both)

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37
Q

What are the side effects of lithium

A

Polyuria (nephrogenic DI), tremor, mental confusion (take at bedtime), thyroid goiter (inhibits iodination of thyroid hormone leading to hypothyroidism), leukocytosis (stimulates M-CSF), seizures and serotonin syndrome

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38
Q

What are the drug interactions of lithium

A
  • diuretics: Na loss and Li reabsorption, esp thiazides
  • ACEIs esp lisinopril
  • NSAIDs

Narrow therapeutic agent

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39
Q

What are the indictions for lithium

A

Acute and maintenance treatment of mania/bipolar disorder; augmentation in unipolar depressive patients with inadequate response to antidepressant

Off label - reduced risk of suicide and all cause mortality in patients with mood disorders

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40
Q

What are the uses for anti-seizure meds in mood disorders

A

Divalproex used for acute bipolar I; carbamazepine used for acute and maintenance treatment of acute mania and mixed episodes; lamotrigine used for maintenance of bipolar disorder

*carbamazepine is CYP450 inducer

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41
Q

What does sensitivity and specificity describe

A

Accuracy of test result

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42
Q

What does the positive and negative predictive value predict

A

Accuracy of diagnosis based on known test result

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43
Q

What is diagnostic accuracy

A

Describes collective accuracy of all correct test results

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44
Q

What is sensitivity

A

How accurately a test can correctly detect presence of disease when the disease is present; TP/(TP+FN) x 100; or TP/all diseased x 100; *highly sensitive test has low false negative

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45
Q

What is specificity

A

How accurately a test can correctly detect absence of dz when the disease is absent; TN/(FP+TN)x100 or TN/all nondiseased x100; highly specific test has low false positive rate

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46
Q

What is a positive predicative value

A

How accurately a positive test correctly predicts presence of a disease; percentage of TP in patients with a positive test; TP/(TP+FP) x 100

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47
Q

What is negative predictive value

A

How accurately a negative test correctly predicts the absence of dz; % of TN in patients with negative test; TN/(FN+TN)x100

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48
Q

What is diagnostic accuracy

A

Percentage of all correctly identified patients out of total number of screened patients; (TP+TN)/(TP+FP+FN+TN) x 100

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49
Q

What is a likelihood ratio

A

Ratio of probability (%) of given test result for person with dz / probability of same test result for person without disease

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50
Q

How do you calculate likelihood ratio positive

A

sensitivity/(1-specificity)

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51
Q

How do you calculate likelihood ratio negative

A

(1-sensitivity)/specificity

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52
Q

What should the likelihood ratios be

A

LR+ should be >10 to demonstrate the test is most beneficial
LR- should be <0.1 to demonstrate the test is most beneficial

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53
Q

What is validity

A

Ability to discern between those that do and dont have dz; internal: reflect what was being assessed; external: applicable to other populations

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54
Q

What is reliability

A

Ability of test to give same result on repeat use; analogous to reproducibility/consistency *valid test is always reliable; reliable test not always valid

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55
Q

What are the most common psych illnessses

A

Mood disorders

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56
Q

What happens to dopamine with diff mood disorders

A

Decreased in depression, increased in mania

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57
Q

What happens to 5HT in depression

A

Decreased

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58
Q

What is major depressive episode

A

At least 5 of the following for 2 weeks with at least either depressed mood or loss of interest/pleasure: depressed mood most of day, markedly diminished interest, significant weight loss or gain, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feeling worthlessness or guilt, diminished concentration, recurrent thoughts of death or suicide

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59
Q

What is a manic episode

A

Abnormally and persistently elevated or irritable mood lasting at least 1 week with at least 3 of: inflated self esteem or grandiosity, decreased need for sleep, more talkative, flight of ideas, distractability, increased goal oriented behavior, excessive involvement in pleasurable activities

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60
Q

What is hypomanic episode

A

Less severe than manic; only need to last 4 days and can’t include psychotic features

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61
Q

What is major depressive disorder

A

Requires presence of 1 or more major depressive episodes and absence of manic, hypomanic, or mixed episodes

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62
Q

What is normal grief

A

Similar sx to depressive disorder; doesn’t include hallucinations, delusions or impairment of function; denial -> anger -> bargaining -> depression -> acceptance

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63
Q

What is the treatment for major depressive disorder

A

Hospitalization, TCAs, MAOI, SSRI, triazolopyridines (trazodone), bupropion, SNRIs, Mirtazapine

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64
Q

What is used for treatment resistant depression

A

ECT; no absolute contraindications

Ketamine 4-6 infusions over 2-3 weeks

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65
Q

What is spravato

A

Esketamine; nasal spray

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66
Q

What is persistent depressive disorder (dysthymia)

A

Depressed mood for most of the day for at least 2 years for adults and 1 year for children that is not severe enough to meet major depressive disorder; *cannot be without sx for >2 months; can occur simultaneously with major depression

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67
Q

What is the treatment for dysthymia

A

SSRIs, SNRI, MAOI; CBT

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68
Q

What is premenstrual dysphoria disorder

A

Anxiety, depression, irritability week before menses;; treat - exercise, diet, relaxation therapy; SSRI during cycle or 2 weeks preceding

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69
Q

What is bipolar I disorder

A

Single manic episode needed to diagnose; depressive usually presents first but not necessary for dx; worse prognosis than MDD

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70
Q

What is bipolar II

A

At least 1 major depressive episode and one hypomanic episode in the absence of any manic or mixed episodes; more prevalent than bipolar I

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71
Q

What is the treatment for bipolar

A

Mood stabilizers* - lithium, valproic acid, carbamazepine

Second gen antipsychotic - pines, risperidone, ziprasidone, lurasidone, aripiprazole

Lamotrigine for bipolar with depression

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72
Q

What is cyclothymic disorder

A

Dysthymia with intermittent hypomanic episodes; over 2 years (1 year for kids) experiences repeated episodes of hypomanic and depression - treat with mood stabilizers and psychotherapy

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73
Q

What are the psychological sx of anxiety disorders

A

Apprehension, worry, sense of doom, hypervigilence, ,difficulty concentrating, derealization (world seems strange)

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74
Q

What is panic disorder

A

Recurrent unexpected panic attacks and at least one attack followed by 1 month of one or more : persistent concern about more attacks, worry about implications of attacks, significantly change in behavior related to attacks

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75
Q

What is a panic attack

A

Discrete period of intense fear or discomfort - need 4 of the following within 10 min and <25 min: palpitations, sweating, trembling, SOB, chest pain, dizzy, fear off losing control, paresthesias, chills or hot flashes

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76
Q

What is panic disorder

A

More in women 25 years; *genetic

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77
Q

What is agoraphobia

A

Fear of being in a situation where you cant escape

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78
Q

What is social phobia

A

Fear, anxiety, avoidance for 6 or more months;

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79
Q

What is generalized anxiety disorder

A

Excessive anxiety and worry occuring more days than not for 6 months most of the day; difficult to control; assoc with at least 3: restlessness or feeling on edge, easily fatigued, difficulty concentrating, irritability muscle tension, sleep disturbance

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80
Q

What are the related OCD disorders

A

Hoarding, trichotillomania (hair pulling), excoriation, substance medication induced

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81
Q

What is the diff between OCPD and OCD

A

OCPD they dont perceive they have a problem, OCD know they have a problem

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82
Q

What are the negative cognitions seen with PTSD

A

Persistent and distorted sense of blame of self or others, estrangement from others, markedly diminished interest in activities, inability to remember key aspects of event

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83
Q

What is the duration of sx for PTSD

A

More than 1 month

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84
Q

How do you treat PTSD

A

SSRIs, cognitive processing therapy *avoid benzos b/c increased risk of addiction

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85
Q

What does SIG E CAPS stand for

A

Sleep, interest, guilt, energy, concentration, appetite, psychomotor, suicidal ideation

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86
Q

What is DIG FAST mnemonic

A

For manic; distractability, inflated self esteem, grandiosity, flight of ideas, activity speech, thoughtlessness

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87
Q

What are the first line options for major depressive disorder

A

SSRIs - bupropion, venlafaxine, and mirtazapine

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88
Q

Does bullimia or anorexia have a higher suicide rate

A

Bulemia

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89
Q

What is anorexia

A

Restriction of energy intake relative to requirements leadin to low body weight , intense fear of gaining weight, distorted perception of body weight

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90
Q

What are the types of anorexia

A
  • restricting: 3 months of no binging or purging; excessive exercise, fasting, dieting
  • binge-eating/purging: 3 months of binging and purging; use of laxatives, diuretics
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91
Q

Is the distortion of body image in anorexia a delusion

A

No; idea overvaluation

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92
Q

What are the complications of anorexia

A

Bradycardia, hypotension, QT dispersion, cardiac atrophy, mitral prolapse, amenorrhea, decreased libido, osteoporosis hypothermia, euthyroid, hypoglycemia, gastroparesis, constipation, dehydration, hypokalemia, hypophosphatemia, hypomagnesemia, resp atrophy, pancytopnia, brain atrophy, lanugo, carotenoderma, acrocyanosis, seorrheic derm

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93
Q

What is refeeding syndrome

A

Do not rehydrate or feed patients beyond current capacity

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94
Q

How much should AN patients gain

A

Inpatient: 2-3
Outpatient: .5-1

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95
Q

What meds should you avoid in eating disorders

A

Bupropion (seizures), and TCAs (cardiotoxicity)

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96
Q

What drugs can you give to treat eating disorders

A

Only given if failing other treatment; olanzapine; lorazepam before meals

97
Q

What is bulimia

A

Recurrent episodes of binge eating with compensatory behavior to prevent weight gain at least 2 times per week for 3 months; can be normal weight, overweight, underweight; dont want to become thin - just dont want to be fat

98
Q

What are the complications of bulimia

A

Hypokalemia, hypochloremia, metabolic alkalosis; hypotension, tachycardia, Mallory-Weiss, parotid hypertrophy, consipation; tooth erosion, scars and callus on dorsum for hand (russels sign)

99
Q

What is the treatment of choice for bulimia

A

CBT; must be emotionally stable; combine with pharmacotherapy; goals - increase self esteem, decrease emphasis on thinness, eliminate dietary restraint, create regular pattern of eating

100
Q

What are the drugs used for bulimia

A
  • first line: fluoxetine
  • second line: other SSRIs at dose higher than used for MDD (sertraline or fluvoxamine)
  • third: TCAs, topiramate, trazadone, MAOI
101
Q

What is binge eating disorder

A

Binge eating within 2 hours - feel like they lack control of eating; Need 3 of : eating large amounts when not hungry, eat rapidly, eels uncomfortably full, eats alone due to embarrassment, guilt, depression, disgusting after binging;; occur once a week for at lest 3 months

102
Q

What is first line treatment for binge eating

A

Psychotherapy

103
Q

What is the only drug used for binge eating disorder

A

Vyvanse (lisdexamfetamine)

104
Q

What is mild NCD

A

Modest cognitive decline but does not interfere with capacity for independence

105
Q

What are the types of dementia

A
  • Alzheimer’s: female, family hx, head trauma, downs
  • vascular: male, advanced age, HTN
  • progressive: pick’s (frontotemporal), Lewy body
  • reversible causes - drug induced, thyroid dz, metabolic disorders, NPH
106
Q

What are the sx of dementia

A
  • depression: in geriatrics look for weight loss, anxiety, social withdrawal) - pseudementia
  • memory loss
  • difficulty performing tasks
  • disorientation
  • personality changes
  • inappropriate behavior
  • psychotic sx
  • agitation
107
Q

What is the most important in evaluating dementia

A

H & P

108
Q

What does neuropsych testing do

A

Establishes baseline for dementia

109
Q

What labs should you order in suspected dementia

A

Endocrine, B12, folate, CBC,CMP, HbA1C

110
Q

What is the treatment for dementia

A

Attempt to determine cause (rule out other psych conditions, drugs, metabolic, trauma), treat comorbid conditions, *donepezil (AChE inhibitor) and memantine (NMDA antagonist) *AVOID ANTICHOLINERGIC MEDS (benedryle, hydroxyzine)

111
Q

What is the black box warning in using antipsychotics in elderly

A

Increased risk of sudden death with olanzapine, aripiprazole, risperidone, quetiapine

112
Q

What can cause psychosis due to delirium in the elderly

A

Inappropriate drug use, withdrawal, infection, constipation, CV, intracranial stroke, seizures, hemorrhage, sleep deprivation

113
Q

What is psychosis due to major depressive disorder with psychotic features in elderly

A

Somatic troubles, persecution, guilt, poor self estee

114
Q

What is the most common psychosis in elderly outpatients

A

Alzheimer’s type dementia; delusions usually paranoid - items being stolen, cheating on them

115
Q

What are the risk factors for substance abuse in the elderly

A

Female, single or divorced, absence of socialization, Health Concners

116
Q

What is the major depression criteria in elderly

A

Anhedonia or depressed mood for 2 weeks and 4 or more of the following: feeling of worthlessness fatigue, decreased concentration, psychomotor agitation, insomnia or hypersomnolence weight or appetite changes, recurrent thoughts of suicide or death

117
Q

What do the scores on the geriatric depression scale indicate

A

> 5 depression, >10 always indicative of depression

> 5 indicates follow up comprehensive assessment ; use caution with dementia - cant remember

118
Q

What medication should you avoid in the elderly

A

Diphenhydramine - can cause serotonin syndrome

119
Q

How do you differentiate between dementia and depression in the elderly

A

Mental status exam - focus on your patients “insight” - depressed patients with will have insight; dementia patients have little insight

120
Q

How do you treat depression in the elderly

A

CBT, exercise, diet, socialization, meds

121
Q

How long is the initial anti depressant trial

A

4-6 weeks

122
Q

What are the SSRI side effects

A

Serotonin syndrome, increase risk of falls, insomnia, agitation, GI effects

123
Q

What is the main side effect of mirtazapine

A

Increased appetite

124
Q

What comorbid conditions are venlafaxine and duloxetine (SNRIs) used for

A

Pain

125
Q

What does trazodone do

A

Promotes sleep; use in low doses

126
Q

What are the first generation antipsychotics

A

Chlorpromazine, fluphenazine, haloperidol, thioridazine, thiothiene; also called typical

127
Q

What are the second generation antipsychotics

A

Aripiprazole, clozapine, olanzapine, quetiapine, risperidone, ziprasidone

128
Q

What is the main diff btw first and second generation antipsychotics

A

Second gen has less movement disorder side effects

129
Q

What antipsychotic is used for suicidal behavior

A

Clozapine

130
Q

What causes positive vs negative sx in schizophrenia

A

Positive - overactivity of mesolibmic

Negative: mesocortical dysfunction

131
Q

What does D2 antagonism induce

A

Extrapyramidal sx (pseudoparkinsonism); also increases prolactin levels

132
Q

What is the MOA of first gen antipsychotics

A

Blocks D2 post synaptic receptors (D2»5HT); also block muscarinic receptors, histamine receptors, alpha adrenergic receptors, D2 in nigrostriatal and tuberoinfundiblar pathways

133
Q

What are the side effects of first gen antipsychotics

A

Anticholinergic, orthostatic hypotension, dizziness, sedation, QT prolongation and seizurse

134
Q

At what percentage of D2 occupancy do antipsychotics start causing EPS

A

78%

135
Q

What are the diff categories of first gen antipsychotics

A
  • low potency: more sedation, hypotension and seizure threshold reduction - chlorpromazine and thioridazine
  • high potency: more movement disorder and endocrine effects - fluphenazine, haloperidol, thiothixene
136
Q

What are the treatments for extrapyramidal symptoms

A

Anticholinergic: benztropine and trihexyphenidyl
Antihistamine: diphenhydramine

For acute and maintenance

137
Q

What are the treatments for tardive dyskinesia

A

Selective vesicular monoamine transporter 2 (VMAT2) inhibitors; block release of DA from synapse; valbenazine and deutetrabnazine

138
Q

What is the MOA of second gen antipsychotics

A

Block D2 and 5HT2A; 5HT2A»>D2; 5HT2A antagonism in PFC increases DA in mesocortical pathway - improves negative and cognitive sx and reduces EPS

139
Q

What are the side effects of second gen antipsychotics

A

Weight gain, hyperglycemia, insulin resistance, hyperlipidemia, QT prolongation, negative inotropic actions (greater in women, elderly and those on antiarrythmics), stroke (increased with all antipsychotics)

140
Q

Which second gen antipsychotics have the most weight gain assoc

A

Clozapine and olanzapine

141
Q

What is a side effect specific to clozapine

A

Agranulocytosis

142
Q

What syndrome is olanzapine assoc with

A

DRESS - drug induced eosinophilia; assoc with reactivation of latent HSV

143
Q

What is neuroleptic malignant syndrome

A

Potential fatal severe Parkinson’s like movement disorder with wide spread m contraction; hyperthermia, dehydration, rhabdo, altered mental status *treat with dantrolene

144
Q

What is the monitoring protocol for second gen antipsychotics

A

BMI (every time), BP, fasting glucose, lipid; ***Determine baseline in all patients - glucose, lipids, BMI, BP

145
Q

How can you manage non-adherence to antipsychotics

A

Long acting injectablee agents (LAIAs) every 2-12 weeks
1st gen - haloperidol, fluphenazine
Second gen: risperidone, olanzapine, aripiprazole, paliperidone

146
Q

What combination antipsychotic therapies are given

A
  • psychotic depression - olanzapine/fluoxetine

- mania with psychotic features - lithium/anticonvulsant

147
Q

What is give for acute agitation

A

Injectable and ODT or SL versions

148
Q

What is given for multi drug resistant dz

A

Clozapine

149
Q

Which second generation have hyperprolactinemia

A

Risperidone, ziprasidone

150
Q

Which second gen is the greatest risk for EPS

A

Risperidone

151
Q

Which second gen has the most risk for sedation

A

Clozapine (also anticholinergic and orthostatic hypotension)

152
Q

Which first gens have orthostatic hypotension

A

Chlorpromazine, thioridazine

153
Q

What second gen has the least effect on BMI

A

Ziprasidone

154
Q

What are examples of psychosomatic medicine

A
  • mood disorder afffecting recovering from MI
  • psych sx exacerbating asthma
  • personality traits or coping style ie - denial of need for surgery with cancer
  • maladaptive health behaviors
  • stress related phys responses (exerbaction of HTN, ulcer, HA)
155
Q

What are the responses to stress

A

Catecholamines, serotonin release; glucocorticoids enhance serotonin function, increased dopaminergic transition, ACTH release, increases CV function, inhibits growth, reproduction and immunity

156
Q

What MSK disorders can present with psych sx

A

SLE
MS (anxiety, euphoria, mania)
Seizure disorder (confusion, dissociative states, psychosis)

157
Q

What psych illnesses can present with CV complaints

A

Depression, anxiety, type A, anger, increase risk of coronary a disease

158
Q

What endocrine problems can cause psych sx

A
  • hyperthyroidism - nervousness, pressured speech, insomnia, hallucinations
  • hypothyroidism: lethargy, depression, personality change, paranoia
  • DM: frustration, loneliness, depression
  • pheochromocytoma - anxiety
159
Q

What metabolic issues can present with psych sx

A
  • Hyponatremia: med sx (excessive thirst, polydipsia), confusion, lethargy, personality changes
  • thiamine def
  • B12 def: irritability psychosis, dementia
160
Q

What GI problems can present with psych sx

A

UC - increased dependent personalities; crohns increased panic disorder; SSRI has highest effect on GI tract (diarrhea), TCA - constipation and dry mouth

161
Q

What hepatic/pancreatic dz can present with psych sx

A
  • pancreatic cancer
  • acute intermittent porphyria: ab pain, fever, peripheral neuropathy; depression, paranoia, visual hallucinations
  • hepatic encephalopathy: euphoria, psychosis, depression
162
Q

What integumentary dz can present with psych sx

A

Atopic derm, psoriasis, urticaria

163
Q

What are the treatments for psychosomatic disorders

A
  • self observation - daily diary to keep records of stressors
  • cognitive restructuring
  • relaxation exercises
  • mindfulness
164
Q

What interventions can be implemented to mitigate risk factors of delirium

A

Use clocks, calendar, windows, conigitve stimulation (visits from family during day), facilitate physio sleep AVOID BENZO

165
Q

What can corticosteroids cause

A

Mania, psychosis (hallucinations)

166
Q

What can antiparkisons meds cause

A

Psychotic sx

167
Q

What indicates a poor prognosis of schizophrneia

A

Negative sx, poor suppports, younger onset, poor cognitive performance, insidious onset

168
Q

What is the neurophys of schizophrenia

A

Hyperactive dopamine in mesolimbic and hypoactive dopamine in PFC

Also affects cingulate, hippocampus (overactive), and amygdala

169
Q

What are the positive sx of schizophrenia

A

Delusions, hallucinations, disorganized thinking, grossly disorganized motor behavior (includes Catatonia)

170
Q

What are the negative schizophrenia sx

A

Diminished emotional expression, avolition, alogia, anhdonia, asociality

171
Q

What are delusions

A

Fixed beliefs not amendable to change in light of conflicting evidence

Can be persecutory, grandiose, referential, erotomanic, nihilistic, somatic

172
Q

What are the most common hallucinations in schizophrenia

A

Auditory

173
Q

What are the types of hallucinations that are not indicative of psychosis

A

Hypnagogic (occur while falling asleep) or hypnopompic (while waking up)

174
Q

What are the types of disorganized thinking

A

Tangentiality, derailment, loose associations, word salad

175
Q

What is the diff btw catatonic behavior and excitement

A

Behavior: decrease in reactivity to environment
Excitement: purposeless and excessive motor activity without obvious cause

176
Q

What are types of disorganized motor behavior

A
  • negativism: resistance to instructions
  • inappropriate or bizarre posture: waxy flexibility
  • mutism and stupor - lack of verbal and motor response
  • repeats stereotyped. Movements - staring, grimacing, mutism, echoing
177
Q

What are the types of negative sx in schizo

A
  • diminished emotional expression: decreased eye contact, intonation
  • avolition: decrease in motivated self-initiated purposeful activities
  • alogia: diminished speech output
  • anhedonia: decreased ability to experience pleasure
  • asociality: lack of interest in social interactions
178
Q

What is the diagnostic criteria for schizophrenia

A

2 or more of the following for most of 1 month (at least 1 of first three) - delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative sx; for at least 6 moths

179
Q

What is schizophrenia catatonic type

A

Dominated by 2 of the following - motoric immobility, excessive motor activity, extreme negativism or mutism, peculiarities of voluntary movement, echolalia or echopraxia

180
Q

What are the treatments for schizophrenia

A
  • acute psychosis - hospitalization; IM haloperidol, fluphenazine, lorazepam
  • stabilization phase: atypical antipsychotics
  • maintenance
  • poor responders
181
Q

What are the antipsychotics used for schizophrenia

A
  • clozapine
  • risperidone: increased prolactin
  • olanzapine
  • quetiapine: weight gain, sedation, less TD
  • ziprasidone: loss weight gain, QT prolongation
  • iloperidone
  • aripiprazole
182
Q

What can you give for catatonic disorder

A

Benzo

183
Q

What is delusional disorer

A

Presence of one or more delusions for at least 1 months; does not meat criteria for schizo; functioning not impaired, behavior not bizarre;

184
Q

What can be your ddx for delusional disorder

A

Alzheimers, Huntington’s, brain tumor, complex partial seizure, strokes

185
Q

What is brief psychotic disorder

A

Presence of 1 or more (must be first three): delusions, hallucinations, disorganized speech, grossly disorganized behavior for at least 1 day but less than a month

186
Q

What is schizophrenifor disorder

A

2 or more for 1 month but less than 6(from schizophrenia criteria)

187
Q

What is schizoaffective disorder

A

Major mood episode with criterion A of schizophrenia; delusions or hallucinations for 2 or more weeks in absence of mood episode

188
Q

What is other specified schizophrenia spectrum and other psychotic disorder

A

Causes significant distress but does not meant criteria
Persistent auditory hallucinations in absence of any other features, delusions with significant overlapping mood episodes
-attenuated psychosis syndrome: psychotic like sx below threshold
-delusional sx in partner of individual with delusional disorder

189
Q

What is schizoid

A

Very introverted and voluntarily withdraws from social interactions

190
Q

What is schizotypal

A

Schizoid sx + magical thinking and odd behavior

191
Q

What are the risk factors for violence in schizophrenic patients

A

Antisocial, borderline, hx of violence (if violent in ED, use restrains, seclusion, lorazepam and haloperidol IM), paranoid, content of auditory hallucinations, substance abuse, impulsivity, talking about violence

192
Q

What can cause hypophosphatemia in alcoholics

A

Decreased intake of phosph, PPIs, chronic diarrhea, increased phosphate excretion due to vitamin D def (secondary hyperPTH)

193
Q

How can alcohol withdrawal cause hypophosphatemia

A

Acute resp alkalosis -> stimulates intracellular phosphofructokinase which increases glycolysis

194
Q

How do you treat hypophosphatemia

A
  • oral if 1-1.9
  • IV if <1 and switch to oral when >1.5
  • stop when >2
195
Q

What are alcoholics with hypophosphatemia at risk for

A

Rhabdo

196
Q

Which enzymes are thiamine a cofactor for

A

Transketolase, alpha-ketoglutarate DH, pyruvate DH

197
Q

What is the triad of wernicke encephalopathy

A
  • encephalopathy; disorientation
  • oculomotor dysfunction: nystagmus, lateral rectus palsy
  • gait ataxia

*confusion most common

198
Q

What are the affected areas in wernicke encephalopathy

A

Third ventricle, aqueduct, 4th ventricle, mammillary bodies, dorsomedial thalamus, locus ceruleus, periaqueductal gray, ocular motor nuclei, vestibular nuclei, cerebellum

199
Q

What are EPSs

A
  • acute dystonic reactions: suddenly tonic contractions of tongue, neck, back, mouth
  • drug induced Parkinsonism
  • akathisia: motor restlessness
  • antipsychotic-induced catatonia: withdrawal, mutism
  • tardive dyskinesia: fasciulations of tongue, lingual-facial hyperkinesias, choreoathetotic movments
200
Q

What is tardive dyskinesia

A

Med induced hyperkinetic movement disorder that persisted for a least a month after discontinuing agent; chorea, athetosis, stereotyped behaviors, dystocia, akathisia, tics, resp dyskinesia, tremor

201
Q

What is AIMS

A

Abnormal involuntary movement scale

202
Q

What drugs can cause TD

A

All dopamine blocking agents; metoclopramide, prochlorperazine, chlorpromazine, antidepressants

203
Q

What drug has the highest incidence of causing TD

A

Paliperidone and risperidone; lowest for pimavanserine, quetiapine and clozapine

204
Q

Who is at higher risk for TD

A

Older, heavy smokers, DM; polymorphism in 5HT2A receptor gene

205
Q

What is the treatment for TD

A

Switch to second gen - clozapine and quetiapine have ameliorating effects; not in US but ginkgo biloba extract (EGb-761)

206
Q

What is a personality disorder

A

Inflexible maladaptive and pervasive pattern of behavior causing distress, impaired functioning; usually not aware of problem

207
Q

What is the diagnostic criteria for personality disorders

A

Enduring pattern on inner experience and behavior that deviates from expectations of culture manifested in 2 or more of the following areas: cognition, afffect, interpersonal functioning, impulse control

208
Q

Who do we NOT diagnose with a personality disorder

A

Under 18 - in order to do so, sx must be present for at least 1 year; antisocial personality disorder cannot be diagnosed at all under 18

209
Q

What are the cluster A personality disorders

A

Weird; paranoid, schizoid, schizotypal

210
Q

What is paranoid personality disorder

A

Irrational suspicions and mistrust of others; hidden meaning in remarks, spouse is unfaithful, risk for agoraphobia, major depression, OCD and substance abuse

211
Q

What is schizoid personality disorder

A

Lack of interest in social relationships, indifferent to praise or criticism of others, little pleasure in activities, lacks close friends

212
Q

What is schizotypal personality disorder

A

Odd behavior or thinking, ideas of reference (public messages are for them), vague speech, excessive social anxiety that does not diminish with familiarity, idiosyncratic perceptual experiences or bodily illusion

213
Q

What are the cluster B personality disorders

A

Dramatic, emotional, erratic; antisocial, borderline, histrionic, narcissistic

214
Q

What is histrionic personality disorder

A

Pervasive attention seeking behavior

215
Q

What are people with antisocial personality disorder at risk for

A

Anxiety, substance abuse, somatization disorder, pathological gambling

216
Q

What usually causes borderline personality disorder

A

Victims of sexual or emotional abuse; have high rate of comorbid depression

217
Q

What disorder is histrionic personality disorder associated with

A

Somatoform

218
Q

What is la belle indifference

A

Indifferent detachment while describing dramatic physical sx; seen in histrionic

219
Q

What are people with narcissistic personality disorder at risk for

A

Anorexia, substance use, depression

220
Q

What are cluster C personality disorders

A

Anxious or fearful; avoidant personality disorder, dependent, OCPD

221
Q

What is avoidant personality disorder

A

Social inhibition, feelings of inadequacy, extreme sensitivity to negative evaluation and avoidance of social interaction

222
Q

What is dependent personality disorder

A

Pervasive psychological dependence on others; difficulty making decisions; difficulty expressing disagreement; urgent seeking for another relationship when on has ended

223
Q

What is OCPD

A

Rigid conformity to rules, moral codes and excessive orderliness, stubborn, inflexible about morality, ethics; more in men than women

224
Q

What is dissociative identity disorder

A

2 or more distinct identities or personality states; more in women; assoc with hx of sexual abuse

225
Q

What are the treatments for personality disorders

A

Psychodynamic psychotherapy; examines way they perceive events; CBT; group psychotherapy, dialectical behavior therapy (borderline - coping skills to improve stability and impulse control); meds - SSRIs, valproic acid for impulse control

226
Q

Which personality disorders increase risk for homicide

A

Paranoid and antisocial

227
Q

What is the prognosis of personality disorders

A

Cluster C become exaggerated later in life; A and B tone down but B has worst prognosis

228
Q

What are SSRI vs SNRI used for

A

SSRI: bulemia, social anxiety
SNRI: diabetic neuropathy, fibromyalgia

229
Q

What is duloxetine used for

A

Diabetic neuropathy, fibromyalgia, stress incontinence

230
Q

What is imipramine metabolized to

A

Desipramine

231
Q

Which SSRI has the most drug-drug interactions (CYP450)

A

Fluoxetine; least is vortioxetine and escitalopram

232
Q

What is the “quinidine” like effect of TCAs

A

Slows phase 0 depolarization and conduction velocity wide QT

233
Q

what are the SARAs

A
  • 2 act like SSRIs and also block alpha 1 and 5HT2: trazodone and nefazodone (also H1 block)
  • 1 blocks presynpatic alpha2 on NE and serotonergic neurons and blocks 5HT2/3: mirtazapine - no SERT/NET activity
234
Q

What are the side effects of SARAs

A
  • sedation - trazodone and mirtazapine
  • orthostatic hypotension - trazodone
  • weight gain - mirtazapine
235
Q

Which MAOI is selective

A

Selegiline (antidepressant form is patch)

236
Q

What is the major concern with MAOIs

A

Hypertensive crises - needed for tyramine metabolism which can increase cathecholamines

237
Q

Which SNRI has the most sexual dysfunction

A

Venlafaxine

238
Q

What re the withdrawal syndrome for antidepressants

A

Flu like, insomnia, nausea, imbalance, sensory disturbances, hyperarousal

239
Q

How does lithium work

A

Inhibits dopamine transmission , NMDA downregulation

Psych (2 decks)

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