Neuroleptic Malignant Syndrome (slow onset 1-3 days),
Lead pipe rigidity
Fever HTN, tachycardia
mild form of bipolar alternating hypomania and dysthymia (mild depression) for at least 2 yrs (symptom free for 2 mo. max)
Tx: Lithium, Quetiapine
4 day minimum, no social/occupational impairment, no psychotic features, no hospitalization required
Dysthymia, Time frame
depressed for at least 2 yrs (symptom free for 2 mo. max), poor concentration, hopeless, low self esteem, fatigue, insomnia, poor/excessive appetite
Serotonin Syndrome (fast onset)
d/t when MAOIs are taken with SSRIs/Serotonergic opioids; e.g. Trancypromise + Meperidine/Dextromethorphan/Tramadol
myoclonic jerks/ clonus
confusion, rhabdo, renal failure, coma
Tx: Supportive care then Cyproheptadine (serotonin antagonist)
↓ Frontal Lobe mass
impaired DA regulation in caudate
Tx. for Extrapyramidal SE of antipsychotics
How do NSAIDs affect Lithium levels?
NSAIDs ↓ Lithium levels
What is Lithium used for? Adverse effects?
Bipolar disorder and Refractory depression
AE: metal taste, hypothyroidism, polyuria
getting sick to assume sick role (1º gain)
excessive emotionality, attention seeking
acting out false/grossly exaggerated signs and symptoms for 2º gain (unemployment benefits, narcotics, money)
Extrapyramidal Symptoms (d/t typicals/atypicals i.e. Risperdal or Haldol) Rule of 4's
Rule of After 4's:
4 hrs: acute dystonia
4 days: akathisia (restlessness)
4 wks: bradykinesia
4 mo: tardive dyskinesia
Dysthymia (Persistent depressive disorder)
chronic low grade depression at least 2 yrs
Avoidant personality disorder, Tx
feels a "void" and wants to be friends, fear intimate relationships/friendships, Tx: SSRIs
Cluster A ODD personality disorders "PASS",
PAranoid: mistrust others
Schizoid: no desire for close relationships
Schizotypal: "magical thinking" and distorted cognitions/perceptions
Cluster B DRAMATIC personality disorders "BAHN"
Borderline: unstable relationships, mood swings. Tx: Dialectical behavioral (DBT)
Antisocial: violate rights of others, steals, kills with no guilt. Tx: DBT
Histrionic: attention seeking but functional. Tx: psychotherapy
Narcissistic: grandiose, need for admiration Tx: psychotherapy
Cluster C ANXIOUS personality disorders "CADO"
Avoidant: desires companionship. Tx: SSRI
Dependent: afraid of separation. Tx: psychotherapy
OCPD: rigid rules so tight they exclude friendships. Tx: psychotherapy
mature way of channeling impulses into socially acceptable behavior
When treating a single episode of Major Depression, how long should you continue antidepressants to follow a pt.'s response?
What a.a. should you avoid while on MAOIs?
Tyramine (age cheese, anchovies, red wine, cured meats, etc.)
psychosis + major Depression/Manic S&S lasting 2+ wks
i.e. Schizophrenia + either depression or bipolar disorder. That's why it has two subtypes (depression type, bipolar type)
Why can't you abruptly stop benzodiazepines like Xanax?
Hoarding is treated with?
Major Depressive Disorder, S&S, d/t?
2+ wks of 5 of 9 CISEGAPS, d/t ↓ 5HT
What would you see on PET Scan of MDD?
↓ frontal lobe blood flow
SSRIs, TCAs, MAOIs, ECT if pregnant
DIGFAST of Bipolar I
Talkative Manic Episodes last 1 wk, may have depressive episodes
Tx. Bipolar I
Lithium (mood stabilizer), Carbamazepine or Valproic Acid, Atypicals
Bipolar II (Hypomanic)
less severe DIGFAST, more prevalent, 1+ major depressive episode is required
wax and waning, worse at night, impaired cognition
Hypertensive Crisis caused by? Tx.
Taking Tyramine while on MAOIs
S&S: HTN, HA, sweating, N&V
Lithium toxicity S&S
Li > 1.5
N&V, slurred, ataxia, myoclonus, hyperreflexia
DSM IV Axis
I. mental illness + developmental disorders II. personality disorders + MR
III. medical condition
IV. psychosocial issues
V. Global Assessment of Functioning
2+ of the following for at least 1 mo: catatonia, hallucinations, delusions, (-) symptoms d/t excess DA in the Mesolimbic pathway, Tx: Atypical antipsychotics
blunt affect, anhedonia d/t deficient DA in Prefrontal Cx
What would you see on CT in Schizophrenia?
enlarged lateral ventricles and cortical atrophy
Atypical antipsychotics: DA and 5HT blockers.
Tx: for (-) symptoms
Old Closets Quietly Risper from A to Z: Olanzapine, Clozapine, Quetiapine, Risperidone, Aripiprazole, Ziprasidone
"Short-term" schizophrenia lasting 1-6 mo.
Tx: 3-6 mo of Atypical antipsychotics
Schizoaffective Disorder, Tx
Schizophrenia + Bipolar or Depression
Tx: Atypical antipsychotics, mood stabilizers, antidepressants, ECT
MAOIs [Phenelzine] MOA
blocks inactivation of NE, 5HT, DA, Tyramine
5 Stages of Grief
1. Denial, 2. Anger, 3. Bargain, 4. Depression, 5. Acceptance
Anxiety/Panic Disorder neurotransmitter changes
↑ NE, ↓ GABA and 5HT
abnormal 5HT regulation
Tx: SSRI then TCAs
ego-syntonic - don't perceive a problem
Txs. for Nicotine Dependence, MOA
Varenicline [Chantix]: prevents withdrawal S&S by affecting nicotinic cholinergic receptor
Bupropion: partial agonist at nAChR
multiple physical symptoms, multiple organ systems: 4 Pain, 2 GI, 1 Repro, 1 "Neuro"
Anorexia key labs
HypOnatremia, Alkalosis (if vomiting), ↑ Cortisol
Sleepwalking occurs during what part of sleep
Stage 3-4 Non-REM (slow wave sleep)
Tx. for Sleep Terror
Freud Structural model of the psyche
ID: unconscious sexual/aggressive urge
EGO: defense mechanisms, seeks relationships,
SUPEREGO: moral conscious
5HT Antagonists [Trazodone, Nefazodone] is used for?
blocks Na+ chan to inhibit action potentials
Tx. for Bipolar Depression
Lamictal (levels increase with Depakote administration)
potentiates GABA-A by ↑ Cl- conductivity
5HT-1A partial agonist that is often used in combo with SSRI to Tx Anxiety
short REM latency, cataplexy, hypnagogic hallucinations, sleep paralysis
Tx. Sleep hygiene/regular sleep schedule
when a patient projects onto the physician qualities that he cannot tolerate in himself
What important side effect of Haloperidol and other antipsychotics like Atypical Antipsychotics should you keep in mind?
Prolonged QT --> Torsades
Benzodiazepine and Alcohol OD
"unresponsive pt. with otherwise normal PE"
↓ mentation/obtunded, delirium Dilated pupils (mydriasis)
HypOreflexia, weakness, ataxia, HypOthermia, Mild Resp depression
Opioid (e.g. Heroin, Morphine, Meperidine, Demerol) OD?
Constricted pupils (miosis) - Opioid
Dilated pupils (mydriasis) - meth heads are always on the lookout for more!
Chest pain substernal
Dilated pupils (mydriasis)
Hallucinations and paranoia - Psychomotor agitation
Tx acute intoxication: Lorazepam or Phentolamine and ASA and O2
Dilated pupils (mydriasis)
Euphoria Hunger, dry mouth Slowed sense of time
Low safety margin
Sequelae of prolonged IV Lorazepam use? Why?
Lactic acidosis. IV Lorazepam is preserved with propylene glycol. Prolonged propylene glycol intoxication manifests as lactic acidosis.
excessive daytime sleepiness despite more than adequate nighttime sleeping and daytime napping for at least 1 mo.
EKG Hallmark of TCA OD Tx?
Wide QRS >100ms
Tx: Sodium bicarb
What do you do if a pt. is acutely suicidal?
notify police allow her to leave if she won't stay voluntarily give them hotline/crisis #s