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Flashcards in Psych Deck (129):
1

HPI of sleep problems

• Duration
• Number and duration of awakenings at night
• Sleep times including bedtime, naps, and wake-up
• Symptoms of disturbed sleep: fatigue, daytime sleepiness, etc
• Stressors
• Sleep hygiene: environment, light, sounds, pets, partners
• Routine
• Caffeine intake
• Other substances: drugs, sympathomimetics
• IMPORTANT: sleep log for 2 weeks

2

ddx of sleep problems

• Anxiety
• Insomnia
• OSA
• Restless legs
• Periodic limb movements of legs
• Drug abuse/withdrawals
• Narcolepsy
• Primary hypersomnia
• Circadian rhythm disorder (shift worker, jet lag, etc)

3

theories of bipolar pathophys

? Calcium channel gating
Lithium effects sodium and calcium channels
Kindling theory
In the temporal lobes, repeated subthreshold stimulation causes a seizure like reaction in the brain hence anticonvulsants work for bipolar

4

RFs for suicide in bipolar

Single
Family history of suicide
Earlier onset BPAD
More depressive symptoms
Increasing severity of depressive sxs
Mixed state
Rapid cycling
Comorbid with anxiety and substance abuse

5

protective factors for suicide

• Social support churches, religion
• Family connectedness
• Pregnancy or parenthood though worry if they don’t want to have the baby and want to take them with them, or if they think their kids are better off without them
• Religiosity or participating in religious activities
• Thinking of or planning for future events

6

RFs for suicide in adults

• Sex
• Age
• Depression
• Previous attempt
• Ethanol abuse
• Rational thinking (or lack there of)
• Social support lacking
• Organized plan
• No spouse
• Sickness

7

RFs for suicide in kids

• Ideation – talk of suicide, looking for ways to kill self, talking or writing about death, dying or suicide not journaling after therapy—that’s what they are taught to do—parents shouldn’t read their journals!
• Substance abuse
• Purposelessness
• Anxiety – agitation and changes in sleep patterns can be only way to stop the anxiety
• Trapped – feeling no way out
• Hopelessness
• Withdrawal – isolating from friends, family and society
• Anger
• Recklessness
• Mood changes

8

bipolar dx criteria

◦ A. Distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least one week (or needing hospitalization)
◦ B. During the period of mood disturbance, 3 or more of the following sxs have persisted (4 if the mood is only irritable) and have been present to a significant degree:
• Inflated self esteem or grandiosity
• Decreased need for sleep
• More talkative than usual or pressure to keep talking
• Flight of ideas or subjective experience that thoughts are racing
• Distractibility
• Increase in goal directed activity or psychomotor agitation
• Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g. buying sprees, sexual indiscretions, reckless business investments)
◦ C. Causes marked impairment in occupational functioning or social functioning or necessitates hospitalization to prevent harm to self or others, or psychotic features
◦ D. Not due to medical reasons or drugs

9

depression labs

• TSH r/o hypothyroidism thinning hair, weight gain, cold intolerance, weight gain
• BG r/o DM thirst, polyuria
• r/o bipolar mania
• Utox
• If you think you need them: CBC, electrolytes, BUN/Cr, hepatocellular enzymes, RPR (syphilis), B12, folate, UA, EKG, MRI (stroke, brain tumor…)

10

sleep disorder pE/labs

• Epworth Sleepiness Scale
• Depression or Anxiety scales
• EKG
• Thyroid function tests
• BG
• HgA1c
• BUN
• Creatinine
• Iron

11

sleep disorder pE/labs

• Epworth Sleepiness Scale
• Depression or Anxiety scales
• EKG
• Thyroid function tests
• BG
• HgA1c
• BUN
• Creatinine
• Iron

12

ddx of mania

• Kids: PTSD, drugs etoh, caffeine, cocaine, amphetamines, heroin, meds steroids, antidepress.
• Under 50: bipolar and substance abuse ask if they have ever had mania when they are not using, may also be that they know they get manic and then use drugs
• Over 50: Organic medical cause MS, temporal lobe epilepsy
• Other causes: Endocrine hyperthyroid, cushing’s Infections HSV, HIV encephalitis, syphilis AI lupus metabolic states hypoglycemia, hypoxia

13

when does narcolepsy begin usually/

early teens or 20s

14

etiology of narcolpesy

loss of orexin signaling, genetics

15

dx and tx of narcolepsy

sleep study; tx: scheduled naps, sleep hygiene, modafinil

16

dx and tx of primary hypersomnia

compelled to sleep at innapropriate times, gets lots of sleep but does not feel refreshed (naps do not help) tx is modafinil or stimulants

17

dx and tx of insomnia

difficulty initiating, maintaining or early waking from sleep associated with IMPAIRMENT despite ADEQUATE SLEEP OPPORTUNITY

18

what comorbid conditions are with insomnia?

mental health like depression or anxiety and substance abuse

19

what is short term insomnia associated with?

stressors

20

what medications can cause insomnia?

CCBs, BBs, glucocorticoids, respiratory stimulants (saba??)

21

tx of insomnia

tx underlying psych or medical conditions, sleep hygiene, behavioral therapy (relaxation techniques), stimulus control (don't nap, bed for sleep and sex, only go to bed when sleepy, wake up at same time, get out of bed if not falling asleep), sleep restriction

22

indications for sleep study

suspecting ob. sleep apnea, narcolepsy or periodic limb movements of sleep

23

what 2 things must you do history to look for in depression?

other psych condition and other medical conditions (highly correlated)

24

what makes you suspect adolescent/childhood depression?

drop in grades, more accidents (clumsy), anxiety, social withdrawal, concentration probe, weight, irritability, neglect of appearance, HA/body aches

25

ddx of depression

endocrine (hypothyrodism), other psych illness, substance abuse, systemic illness, neuro illness (dementia, parkinson), meds

26

labs to r/o stuff in suspected depression

TSH, utox, CBC, B12, folate, CMP: glucose, BUN/cr, LFTs, electrolytes, UA, RPR, EKG, mRI

27

tx of depression

lifestyle changes (sleep hygiene, healthy diet, exercise, no substances, hobbies, relaxation) + therapy and/or medication

28

when to refer in depression

if severe, comorbid conditions, no response to tx

29

tx of adjustment disorder

social support, coping mechanisms, problem solving skills, relaxation techniques, meds

30

is bipolar common in kids?

NO very rare. think PTSD and substance abuse first.

31

difference between mania and hypomania

mania lasts at least one week, hypomania at least 4 days. mania is severe and usually requires hospitalization, hypomania does not cause impairment.

32

criteria for rapid cyclign

4 or more in a year (4 or more per day is something else--drug use, anxiety,e tc)

33

bipolar 3 definition

manic sx only on antidepressants, sx clear when meds are stopped

34

bipolar ddx

depression, substance abuse, medications (antidepressants, steroids), endrocrine (hyperthyroidism, cushings), neuro (MS, temporal lobe epilepsy, infections (syphilis, hIV), AI (lupus), metabolic states (hypoxia, hypoglycemia)

35

main RFs for suicide

major psych diagnosis, substance abuse, prior attempt, living alone, unemployed, poor health, abuse, family history, access to guns

36

psychometric testing that can be requested by primary care providers to "figure it out" from a broad perspective

neuropsychological assessment

37

who to refer to for these issues?
• Failed MMSE
• Neurodevelopmental disorders—
• Distinguish dementia from depression-
• Decision making capacity-
• Sensory processing
• determine ADHD and OT for kids
• Long term substance abuse—
• Problems with understanding language

• Failed MMSE—neuropsych testing?
• Neurodevelopmental disorders—neuropsych testing
• Distinguish dementia from depression- neuropsych testing
• Decision making capacity- neuropsych testing
• Sensory processing—OT referral
• Refer for comprehensive testing to determine ADHD and OT for kids
• Long term substance abuse—refer for functional testing
• Problems with understanding language—refer to speech language therapist

38

T or F: 99% of those who think they have memory problems have dementia

F! Most who think they have memory problems don't

39

which types of hallucinations usu have a medical cause?

olfactory and gustatory

40

false sensory perceptions occurring in any of the five senses

hallucinations

41

fixed false belief

delusion

42

ddx of psychosis

Substance induced psychosis
Mood disorder with psychotic features
Schizophrenia
Schizoaffective
Schizophreniform
Brief psychotic disorder
Delusional disorder
Psychotic disorder NOS
Pervasive Developmental disorder (autism)
Personality disorders
Delirium
Dementia
Post partum psychosis (really scary, comes on really fast)
TBI
Mental retardation
Sleep deprivation (misperceive things as brain is trying to catch up)
Shared psychotic disorder
Factitious disorder/malingering

43

T or F: there is a higher incidence of violence with persons with mental health disorders

T, HOWEVER Mental illness is not an independent predictor to violent behavior

44

RFs for schizophrenia

family member with it, family member with bipolar, advanced paternal age, winter bipolar, insults to 1st and 2nd trimester fetus, insults to perinatal period

45

which sx of schizophrenia are most responseive to meds?

positive sx (i.e. delusions, hallucaintions)

46

what are the positive sx of schizophrenia

psychosis, delusions, hallucinations

47

what are the negative sx of schizophrenia?

flat affect, loss of social drive, no personal motivation, alogia (loss of verbal expression)

48

4 sx of schiozophrenia

positive sx, negative sx, cognitive impairments (ADLs, function), and affective disorders

49

DSM criteria for schizophrenia

2 of more of these for at least one month:
Delusions
Hallucinations
Disorganized speech (e.g. frequent derailment or incoherence)
Grossly disorganized or catatonic behavior
Negative symptoms (i.e. affective flattening, alogia, or avolition)
+plus social or cognitive impairment
+signs of the disturbance for 6 months

50

disorder with mood disorder and psychotic sx

schizoaffective

51

better px of schrizophrenia

Female, significant positive/affective symptoms, good initial response to meds

52

experiencing psychological distress in the form of physical symptoms and seeking medical help for these symptoms

somatization

53

T or F: if someone is somatizing they are pretending they have the sx

F: they really think they have the sx

54

Symptoms affecting voluntary motor or sensory function suggesting a neurological disorder or other general medical illness
Clinical findings provide evidence of incompatibility between the symptoms and recognized neurological or medical conditions

converson disorder

55

Preoccupation with having or acquiring a serious illness

illness anxiety disorder

56

Preoccupation with an imagined defect in appearance or excessive concern with slight physical anomaly (not anorexia)

body dysmorphic disorder

57

difference between malingering and factitious disorder (munchausen)

malingering is faking a sx to get something, factitious is faking or causing an illness to get something for an unknown reason

58

how do you tx somatization patients?

still need PE and work ups--they still get problems

59

tx for somatiform disorders

see patients once a week in primary care to discuss sx and it puts them at ease, set limits on care (i.e. no narcotics), encourage psychotherapy, don't engage whether its mental or physical

60

psych emergency definitions

danger to themselves or others, overwhelmed and can't function,

61

critiera for hospitaliztion

imminent danger to self or others (suicide, et. or vulnerable adult or child), failing outpt tx (even if not acutely ill), not able to function in ADLs, detox

62

T or F: you must notify the person someone wants to kill every time

F: must inform them unless hospitalized for 3 days

63

biggest RFs for violence

drug use and trauma

64

best predictors of violenceq

Obsessing over an event where a person was perceived to be unfairly treated
Recent threats to act violently
Evidence of making plans to act violently
Threatening, pressured, and/or loud speech
Hypervigilance
Staring
Agitated behavior: Tremors, Sweating, Pacing, Clenching of hands and teeth

65

drugs for etoh withdrawal

ativan, librium or valium

66

drugs for benzo withdrawl

phenobarbital taper

67

sx of opiate withdrawal

Symptoms include runny nose, watery eyes, diarrhea, muscle aches/cramps, nausea, vomiting, high blood pressure

68

3 drugs commonly used in ER for psych emergencies

Haldol 1-5 mg PO/IM/IV
Ativan 1-3mg PO/IM/IV
Benadryl 25-5omg PO/IM/IV

69

when can you put someone on a hold?

if imminintely a danger to self or others

70

is it better to do a transport hold or a 72 hour hold?

transport--b/c psych can evaluate them then and 72 hour hold starts when psych says it does. 72 hour hold is taken very seriously.

71

who can write 72 hour holds?

MD, PA, NP

72

which tx is most effective for generalized anxiety?

CBT

73

how long can it take SSRIs to work for anxiety?

2-4 weeks

74

short acting benzo for anxiety

lorazepam (ativan)

75

longer acting benzo for anxiety

diazepam (valium)

76

1st line txs for generalized anxiety

SSRIs, SNRIs, benzos (for short term)

77

who should benzos not be used for for anxiety?

older adults--> risk of falls, confusion

78

TCAs that can be used for generalized anxiety

desipramine and imipramine

79

what anti-anxiety med is good for older adults and those who have a hx of substance abuse?

buspirone (b/c no tolerance develops and no effect on cognition)

80

non pharm for panic disorder

avoid caffeine, decongestants and diet pills, do CBT

81

how long does it take SSRIs ( and other antidepressants) to be effective for panic disorder?

at least 4 weeks for antigenic effect, optimal response in 6-12 wks

82

examples of first gen antipsychotics

haloperidol, chlorpromazine, perphenazin

83

examples of second generation antipsychotics

aripiprazole, asenapine, olanzapine, paliperidone, risperidone, quetiapine

84

extrapyramidal side effects of antipsychotics

parkinson like AE (cogwheel rigidity, flat effect, resting tremor), akathisia (inner restlessness), acute destinies, tardive dyskinesia

85

uncontrolled sense of inner restlessness

akathisia

86

AE of 1st gen antipsychotics

extrapyramidal side effects, anticholinergic effects, orthostatic HOTN, QT prolongation, neuroleptic malignant syndrome, agranulocytosis

87

AE of 2nd gen antipsychotics

sedation, weight gain (most with clozapine and olanzapine), hyperglycemia (most with clozapine and olanzapine), triglyceride elevations, impulse control problems

88

impulse control problems most common with which antipsychotic?

aripiprazole

89

which types of antipsychotics are the first choice for schizophrenia?

2nd generation

90

what is an adequate trial of antipsychotics for schizophrenia?

at least 6 weeks at the upper end of the dose range

91

what can happen to those with dementia on antipsychotics?

increased mortality

92

eating disorder beahviors

Starvation(withorwithoutpurging)
•Binging(with/withoutpurging)
•Purging(vomiting,exercise,laxatives)
•Chewingandspitting
•Dietpills/Laxatives/Appetitesuppressants
•Foodrules/fears
•Waterrestricting/loading
•Caloriecounting
•CompulsiveBodyChecking
•RigidTablebehaviors(cutting/smearing/slowpace)

93

common sx that bring someone into the office with an eating disorder

marked weight loss, fatigue, weakness, dizziness, syncope, irregular menses, cold intolerance, constipation, mood changes

94

T or F: in anorexia labs are often normal

T

95

when to consider a dexa in eating disorders?

if anorexia and amenorrhea for 1 year, or if poor nutrition and excessive exercise, excess soda intake, high sodium, high caffeine, smoking or etoh use

96

causes to hospitalize anorexia/bulimia

Dramatic weight changes; weight cut offs vary 500)
•Electrolyte abnormalities and unable to orally hydrate or take replacement: especially low phos(

97

model for development of eating disorders

biopsychosocial model

98

main neurotransmitter involved in reward behaviors

dopamine

99

reward area of brain

nucleus accumbens

100

RFs for drug abuse

genetics: 30-60%
environment--abuse, exposure, risk taking, peers using, lack of supervision, low perception of harm, younger age of first use, poor school achievement,

101

length of time req'd for substance use disorder

12 months

102

specifiers of substance abuse disrode

mild-severe or course: early or sustained remission (sustained after 12 months)

103

etoh intoxication signs and sx

Breath odor
Skin flushing, hypotension
Slurred speech
Lability/inappropriate behavior and emotions
Incoordination/dysmetria/ataxia
Nystagmus pupils slowed if intoxicated,
nystagmus if intoxicated
Nausea/vomiting
Seizures/coma/death

104

etoh withdrawal sx

Nausea/vomiting
Hypertension
Tachycardia
Tremor
Irritability/anxiety/insomnia
Seizures
Hallucinosis usu talking to ppl in their using scenarios
Death possible if untreated

105

what is delirium tremens?

altered mental status (global confusion)
and sympathetic overdrive high BP and pulse
which can progress to
cardiovascular collapse and death

106

intoxication of sedatives (benzos)

Fewer autonomic signs than alcohol
Somnolence
Dysarthria
Incoordination
Respiratory depression or arrest
Lethargy/coma/death

107

sedative withdrawal sx

Hypertension, tachycardia
Agitation
Tremor
Confusion
Hallucinations
Seizure higher risk than etoh
Death possible if not treated
Anxiety high, intolerable

108

tx of choice for etoh withdrawal

benzos

109

when do delirium tremens start?

usu 48-72 hours or up to 5 days after withdrawal

110

tx of benzo withdrawal

phenobarbital taper

111

opioid intoxication sx

Miosis pinpoint pupils (not reliable)
Constipation
Hypotension, bradycardia
Respiratory suppression or arrest
Somnolence, ataxia
Coma/death

112

opioid withdrawal sx

Anxiety
Nausea/vomiting
Abdominal pain
Myalgias
Diarrhea
Piloerection
Diaphoresis
Lacrimation/rhinorrhea
Hypertension/tachycardia
Yawning

113

supervised opioid withdrawal

Methadone taper (needs monitoring)
Buprenorphine (suboxone) taper (needs monitoring)
Clonidine 0.1-0.2 mg Q4-6 alpha blocker to help with HTN
Neurontin + Vistaril + Flexeril
NSAID, antidiarrheal

114

stimulant intoxication sx

Euphoria, irritability, talkativeness
Mydriasis
Hypertension, tachycardia
MI, stroke, death
Paranoia, hallucinations common
Hyperthermia, death
Hypertensive crisis, death
Pulmonary edema in smokers

115

stimulant withdrawal sx

Non-specific
“Cocaine crash” “crack nap”
Depression
Somnolence
May want to die but they probably won’t
No inpatient detoxification

116

who gets the dysphoric/paranoid and mood lability sx of cannabis intoxication more often

teens

117

sx of cannabis withdrawal

Irritability, anger, or aggression
Nervousness or anxiety
Sleep difficulty
Decreased appetite or weight loss
Restlessness
Depressed mood
At least one of the following physical
symptoms causing significant discomfort:
abdominal pain, shakiness/tremors,
sweating, fever, chills, or headache

118

who gets inpatient detox?

etoh, benzos, opiates

119

CRAFFT screening tools for kids


1. Have you ever ridden in a CAR driven by someone (including yourself) who was high or had been using alcohol or other drugs? If + stat. sig there is drug problems
2. Do you ever use alcohol or other drugs to RELAX, feel better about yourself, or fit in?
3. Do you ever use alcohol or other drugs while you are ALONE?
4. Do you ever FORGET things you did while using alcohol or other drugs?
5. Do your family or FRIENDS ever tell you that you should cut down on your drinking or drug use?
6. Have you gotten into TROUBLE while you were using alcohol or drugs?

120

T or F: there is no such thing as inpatient tx for substance abuse

tx: they have to be there voluntarily. there is housing for them and they stay there but not locked.

121

AE of naltrexone

increased LFTs, CI if liver dz or hepatitis

122

AE of acamprosate (campral)

kidney probs

123

why do you have to wait 12-24 hours before giving buprenorphine for etoh withdrawal?

it knocks some opiates off receptors and you need to wait until a while after they used to not cause severe withdrawal sx

124

for what ages can you tell parents results of tox screens?

up until age 15

125

cluster A, B and C personality disorders

A is paranoid schizoid (odd, eccentric), B is histrionic, antisocial, borderline, narcissistic (emotional, dramatic) C is anxious fearful like avoidant, dependent and OCD

126

features of paranoid personality disorder

distrust others, distrust loyalty of friends, hostile, stubborn

127

features of schizoid personality disorder

little interest in others, relationships, sex, restricted emotion, indifference to praise

128

features of schizotypal personality disorder

ideas of reference, odd thinking, magical ideas, unusual perceptual experiences, odd or eccentric behavior or appearance, social anxiety

129

management of schizotypal personality disorder

feedback, guidance, tracking errant thoughts