Psych Flashcards
(238 cards)
1
Q
Anxiety diagnosis
A
AND I C REST Anxious, worried No control Duration >6mo of 3 or more of: - Irritability - Concentration impairment - Restlessness - Energy decreased - Sleep impairment - Tension in muscles
2
Q
GAD-7 scores
A
5 = mild 10 = moderate 15 = severe
3
Q
Best evidence-based treatment for anxiety
A
Cognitive behavioural therapy
4
Q
Main brain structure involved in anxiety
A
Amygdala
5
Q
Panic disorder diagnosis
A
STUDENTS FEAR the 3Cs Sweating Trembling Unsteadiness/dizziness Derealization/depersonalization Excessive heart rate Nausea Tingling SOB Fear of dying Chills, chest pain, choking
6
Q
Treatment duration for panic disorder
A
Up to 1 year after symptoms resolve
7
Q
Pharmacological choices for panic disorder
A
SSRIs
SNRIs
Benzos for short-term use
Often require higher doses for longer period of time than depression
8
Q
Prognosis of panic disorder
A
6-10yrs post-treatment:
30% well
40-50% improved
20-30% no change or worse
9
Q
Agoraphobia diagnosis
A
Marked fear or anxiety about 2 or more of: - using public transport - being in open spaces - being in enclosed places - standing in line or being in a crowd - being outside of home alone avoids these situations situations provoke fear or anxiety lasting >/=6mo Impairs functioning
10
Q
First line pharmacological treatment for anxiety
A
SSRI and SNRIs
11
Q
Second line pharmacological treatment for anxiety
A
Buspirone (TID dosing)
Bupropion
12
Q
First line treatment for phobic disorders
A
CBT
13
Q
Genetics and specific phobias
A
Tends to run in families
Blood-injection injury type phobias has high familial tendencies
14
Q
Paroxetine
A
SSRI
- Paroxetine (Paxil) 20mg daily (take in morning), increase by 10mg/d at 1 week intervals
- Typically 20-50mg/d, but no greater benefit seen with doses >20mg
15
Q
Sertraline
A
SSRI
* Sertraline (Zoloft) 25mg daily, increase by 25-50mg at intervals of >/= 1-2 wks
* Typically 50-150mg/d, max dose of 200mg/d
Safest in pregnancy and breastfeeding
16
Q
Citalopram
A
SSRI
- Citalopram (Celexa) 10mg daily, increase by 10mg at >/= 1 week intervals
- Typically 40mg/d for adults = 60yrs and 20mg/d for adults >60yrs
17
Q
Escitalopram
A
SSRI
- Escitalopram (Cipralex) 10mg daily, increase >/=1 wk intervals
- Max 20mg daily
18
Q
Venlafaxine
A
SNRI
* Venlafaxine (Effexor) 37.5mg daily, increase by = 75mg/d increments at >/=4d intervals
* Typically increase to 75mg after 4-7d
* Typically 75-225mg daily, max 225mg/d
19
Q
Duloxetine
A
SNRI
- Duloxetine (Cymbalta) 60mg daily or 30mg daily, increase by 30mg increments at >/= 1wk intervals
- Typically 60mg daily, max 120mg/d
20
Q
Panic disorder associated with ___ in 50% of cases
A
Agoraphobia
21
Q
Social anxiety disorder/social phobia is most commonly associated with
A
Substance abuse
1/2-3/4 of patients with SAD have co-occuring mental, drug or alcohol problems
22
Q
Having social anxiety disorder increases your likelihood of depression by
A
~2-4x
23
Q
Multiple personality syndrome and depersonalization has been strongly associated with
A
Hx of childhood sexual abuse
24
Q
Nihilistic delusions
A
Belief that things do not exist; a sense that everything is unreal
25
Suicide risk factors
```
SAD PERSONS
Sex (male)
Age >60
Depression
Previous attempts
Ethanol abuse
Rational thinking loss
Suicide in family
Organized plan
No spouse/support
Serious illness
```
26
Most common psychiatric disorders a/w completed suicide
Mood (bipolar > depression)
| Alcohol abuse
27
Schizoprehnia dx
2 or more of the following, for at least 1 month, with at least one being one of the first three:
-Delusions
-Hallucinations
-Disorganized speech
-Grossly disorganized or catatonic behaviour
-Negative symptoms
Continuous signs of disturbance persist for at least 6 months
Decreased level of fxn
28
Echopraxia
Imitates movements and gestures of others
29
Schizophrenia linked to...
Substance related disorders
Anxiety disorders
Reduced life expectancy secondary to medical comrbidities
30
Antipsychotics
Risperidone
Aripiprazole
Haloperidole
Paliperidone
31
Last resort antipsychotic
Clozapine
32
Schizophrenia tx duration
At least 1-2yrs after first episode
| At least 5yrs after multiple episodes
33
Schizophreniform d/o
Same criteria is schizophrenia but for at least 1 month and <6months
Return to baseline
60-80% progress to schizophrenia
34
Sex differences for schizophrenia
Male = female
Female dx later in life with bimodal distribution
Men = 10-25y.o,
Women = 25-35y.o.
35
Schizophreniform d/o
Same criteria is schizophrenia but for at least 1 month and <6months
Return to baseline
60-80% progress to schizophrenia
36
Schizophreniform epidemiology
Common in young adults/teens
Men >> women (5x)
Less common than schizo (<<1%)
37
Tx for schizophreniform d/o
Brief course of antipsychotic drugs (3-6mo)
38
Brief psychotic disorder
```
One or more of the following, with at least one being one of the first three:
- Delusions
- Hallucinations
- Disorganized speech
- Grossly disorganized behaviour
More than 1d, less than 1 mo
Eventual return to premorbid level of functioning
~50% go onto develop chronic psych
```
39
Schizoaffective d/o
Major mood eps CONCURRENT with Criterion A of schizo
Delusions/hallucinations for 2 or more weeks WITHOUT major mood eps during duration of illness
Major mood eps symptoms present for majority of total duration of active portions of illness
40
Schizoaffective epidemiology
```
Bipolar = equal in men and women, more common in young
Depression = 2x more common in females. more common in older
```
41
Schizoaffective tx
Tx appropriate symptoms
BPD --> mood stabilizers
Depression --> SSRIs
Psychotics --> antipsychotics
42
Delusional d/o
>/= 1 delusion for 1 month or longer
Do not meet criterion A of schizo
Fxn not markedly impaired
Mania or major depressive epis brief relative to duration of delusions
43
Most freq subtype of delusional d/o
Persecutory
44
Depression
```
5 or more of the following symptoms for at least 2 weeks, with at least 1 being depression or decreased interest:
Suicidal thoughts
Interest decrease
Guilt
Energy low
Concentration difficulty
Appetite change
Psychomotor changes
Sleep issues
```
45
Mania
```
1 week period of elevated mood AND increased energy/goal-directed energy plus 3 of the following:
DIGFAST
- Distractibility
- Indiscretion
- Grandiosity
- Flight of ideas
- Activity increased
- Sleep decreased
- Talkativeness
```
46
Hypomanic episode
Mania but duration is >/= 4d and severity is not enough to cause marked impairment in social or occupational functioning
47
Mixed features mood disorder
While meeting full criteria for major drepressive episode, pt has on most days >/=3 criteria for manic episode
OR while meeting full criteria for manic/hypomanic episode, ptient has on most days >/= 3 criteria for depressive episode
48
Major depressive disorder
Presence of a MDE
Not better accounted for by schizoaffective d/o, not superimposed on schizophrenia, schizphreniform, delusional or psychotic d/o
No hx of manic episode or hypomanic
49
Fastest and most effective tx for MDD
ECT
50
1st line pharmacotherapy for MDD
SSRI: Sertraline, Escitalopram
SNRI: Venlafaxine
NaSSA: Mirtazapine
51
Typical response to antidepressants
Physical symptoms improve at 2wk
Mood/cognition by 4wk
If no improvement after 4wk at highest tolerated therapeutic dosage --> alter regimen
52
Persistent depressive disorder
```
Depressed mood for most of the day, for more days than not for >/= 2 yr
Presence of >/=2 of:
Sleep changes
Eating changes
Energy low
Self-esteem low
Poor concentration
Feelings of hoeplessness
Never without these symptoms during the 2 yr period for >2mo
```
53
Primary treatment for persistent depressive disorder
Psychotherapy
54
Postpartum blues
Normal
No psychotropic meds needed
Transient (2-4d postpartum, up to 10d)
Mild depression, mood instability, anxiety, decreased concentration
Usually mild or absent: feeling of inadequacy, anhedonia, thoughts of harming baby, suicidal thoughts
55
Major depressive disorder with peripartum onset
| Postpartum Depression
MDD with onset during pregnancy or within 4wk following delivery
Typically lasts 2-6mo
Residual symptoms can last up to 1yr
56
Tx of MDD with peripartum onset
Psychotherapy
SSRI (safe short-term while breastfeeding)
If symptoms severe, consider ECT
57
Bipolar I Disorder
At least one manic episode
Commonly accompanied by at least 1 MDE but not required for dx
Usually MDE first, manic episode 6-10yrs after
Average age of first manic episode = 32yo
58
Bipolar II Disorder
At least 1 MDE, 1 hypomanic episode and no manic episodes
59
Bipolar treatment: Mania
Lithium
Anticonvulsants (divalproex, carbamazepine)
Antipsychotics
ECT if resistant
*MONOTHERAPY WITH ANTIDEPRESSANTS SHOULD BE AVOIDED
60
Agent with proven efficacy in preventing suicide attempts and completions
Lithium
61
Bipolar treatment: Depression
```
Lithium
Lurasidone (atypical antipsychotic)
Quetiapine (atypical antipsychotic)
Lamotrigine (anticonvulsant)
Antidepressants (only WITH mood stabilizer)
ECT
```
62
Cyclothymia
- At least 2yrs (1 yr in children/adolescents), numerous periods with hypomanic symptoms that do not meet criteria for hypomanic episode and numerous periods with depressive symptoms that do not meet criteria for major depressive episode
- Hasn't been without symptoms for more than 2mo at a time
63
Panic Disoder
```
Recurrent unexpected attacks - abrupt surge of fear or intense discomfort reaching peak within MINUTES during which time 4 or more of the following occur:
STUDENTS FEAT THE 3 Cs
- Palpitations, pounding heart, high HR
- Sweating
- Trembling/shaking
- Blurred vision
- Light-headedness
- Chills or heat sensations
- Paresthesias
- Derealization
- Fear or losing control
- Fear of dying
- Sensation of SOB or smothering
- Feelings of choking
- CP or discomfort
- Nausea
At least one attack followed by 1 mo or more of one or both of:
- persistent corn or worry about more panic attacks or their consequences
-Significant maladaptive change in behaviour related to attacks
```
64
Tx for Panic d/o
CBT
SSRI
SNRI
Tx for up to 1yr after symptoms resolve to avoid relapse
65
Anxiety vs depression tx
Anxiety often requires tx for longer and at higher doses than depression
66
Agoraphobia
```
At least 2 of more of the following:
- fear of open spaces
- fear of line ups
- fear of enclosed spaces
- fear of public transport
- fear of being outside of house alone
Fear for 6mo or more
```
67
Phobic disorder
Marked and persistent (>6mo) fear that is excessive or unreasonable, cued by presence or anticipation of a specific object or situation
68
Social anxiety disorder
Marked and persistent (>6mo) fear of social or performance situations in which one is exposed to unfamiliar ppl or to possible scrutiny by others; fearing he/she will act in a way that may be humiliating or embarassing
69
Obsessive Compulsive disorder
Presence of obsessions, compulsions or both
Obsessions: Recurrent and persistent thoughts, urges, or images that are intrusive and unwanted, cause anxiety, individual attempts to ignore or suppress thoughts
Compulsions: repetitive behaviours or mental acts that individual feels driven to perform in response to obsession. Behaviours meant to prevent/reduce anxiety or prevent some dreaded event but they are not connected realistically
70
Risk factors for OCD
```
Neuro dysfunction
Family hx
Adverse childhood experiences
Exposure to traumatic events
Group a strep infection (PANDAS)
```
71
Tx for OCD
CBT (exposure with response prevention)
SSRIs/SNRIs (12-16wk trials, higher dosages than used for depression), adjunctive antipsychotics (risperidone)
Clomipramine (TCA)
72
Body dysmorphic disorder
Preoccupation with >/=1 perceived flaws in physical appearance not observed by others
Repetitive behaviours or mental acts related to appearance
73
PTSD
```
TRAUMA
Traumatic event
Re-experience the event
Avoidance of stimuli associated with trauma
Unable to function
More than a month
Arousal increased
+ negative alterations in cognition and mood
```
74
PTSD tx
Psychotherapy, CBT
SSRI
Prazosin (treating disturbing dreams and nightmares)
Adjunctive atypical antipsychotics (risperidone, quetiapine)
Eye movement desensitization and reprocessing (EMDR)
75
Adjustment disorder
Emotional or behavioural symptoms in response to an identifiable stressor(s) occurring within 3mo of onset of stressor(s)
Once stressor has terminated, symptoms do not persist for more than an additional 6mo
76
Adjustment disorder tx
Brief psychotherapy
| Benzodiazepine for significant anxiety
77
Antipsychotic options for delirium tx
Low doses of haloperidol IV or IM
| Risperidone, olaznapine
78
Dementia
Significant cog decline from previous performance in 1 or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual-motor or social cognition) based on both individual/clinician/family and standardized testing
79
Most common form of dementia
Alzheimer's
80
Classic feature of alzheimer's
Predominantly memory and learning issues
81
Classic feature of Lewy body dementia
Recurrent soft visual hallucinations
Autonomic impairment (falls, hypotension)
EPS/Parkinsonian features (cogwheeling, bradykinesia, resting tremor)
Does not respond well to pharmacotherapy
Fluctuating degree of cognitive impairment
82
Classic feature of vascular disease
Focal neurological signs
| Abrupt onset
83
Pharmacological therapy for dementia
Mild-severe dz: Indirect holinesterase inhibitors
Mod-severe dz: Non-competitive NMDA receptor antagonist
Low-dose antipsychotics
84
Cholinesterase inhibitors x3
Donepezil (Aricept)
Rivastigmine
Galantamine
85
NMDA receptor antagonist x 1
Memantine
86
Low dose antipsychotics that can be used for dementia behavioural symptoms
Risperidone
| Quetiapine
87
MOCA score
26/30 or above is considered normal
88
Indications for ECT as 1st line tx
```
Acute suicidal ideation
MDE with psychotic features
Tx resistant depression
Catatonia
Prior favourable response
Repeated med failures
Rapidly deteriorating physical status
During pregnancy
Patient choice
```
89
3 most common causes of dementia in pts over 65
Alzheimer's
Vascular
Mixed vascular and Alzheimer's
90
Hallmark neuropathology in alzheimer's
Amyloid deposits
Neurofibrillary tangles
Neuronal loss esp in cortex and hippocampus
Synaptic loss
91
Hallmark neuropathology in frontotemporal dementia
Atrophy in frontotemporal regions
| Neuronal pick bodies (masses of cytoskeletal elements) hence AKA Pick's disease
92
Criteria for substance use disorder
PEC WITH MCAT
- use despite Physical or Psychological problems
- failures in important External roles (work/school/home)
- Craving or strong desire to use substance
- Withdrawal
- continued use despite Interpersonal problems
- Tolerance needing to use more substance to get same effect
- use in Hazardous situations
- More substance used or for longer period than intended
- unsuccessful attempts to Cut down
- Activities given up due to substance
- excessive Time spent on using or finding substance
93
CAGE questionnaire
ever felt the need to Cut down on drinking
ever felt Annoyed at criticism of your drinking
ever felt Guilty about your drinking
Eye opener
Men: score >/= 2 is +ve
Women: score >/= 1 if +ve
94
Drinking guidelines
Men: 3 or less/d (= 15/wk)
Women: 2 or less/d (= 10/wk)
Elderly: 1 or less/d
95
CIWA basic protocol
Diazepam PRN until CIWA <10
Thiamine x 3d
If >65 or hx of liver dz --> lorazepam instead
Haloperidol if hallucinations present or atypical antipsychotics (olanzapine, risperidone)
96
Wernicke-Korsakoff Syndrome
EtOH-induced amnestic disorders due to thiamine deficiency
97
Wernicke's encephalopathy
```
Acute and reversible
Triad of:
Oculomotor dysfunction (ie. nystagmus)
Gait ataxia
Confusion
Tx: Thiamine 100mg PO OD x 1-2wk
```
98
Korsakoff's syndrome
Chronic and only 20% reversible with tx
Anterograde amnesia and confabulations
Can't occur during acute delirium or dementia
Must persist beyond usual duration of intoxication/withdrawal
Tx: Thiamine 100mg PO BID/TID x 3-12mo
99
Pharmacological tx for EtOH use disorder
Naltrexone
Acamprosate
Disulfiram
100
Naltrexone
Opioid antagonist
Reduces high a/w EtOH, moderately effective in reducing cravings, frequency or intensity of EtOH binges
Long half life
Can be used while pt is still drinking
101
Acamprosate
NMDA glutamate receptor antagonist
Useful in maintaining abstinence
Doesn't help with decreasing cravings
102
Disulfiram
Prevents oxidation of alcohol (blocks acetaldehyde dehydrogenase --> acetaldehyde accumulates --> toxic reaction = vomiting, tachycardia, death)
Prescribed only when tx goal is abstinence
103
Naloxone/Narcan
Opioid antagonist
Used for life-threatening CNS/respiratory depression in opioid overdose
Short half-life
Induces opioid withdrawal symptoms
104
Opioid-use disorder tx
```
Methadone = opioid agonist
Buprenorphine = mixed agonist-antagonist
Suboxone = buprenorphine + naloxone
```
105
ECG findings of cocaine OD
Prolonged QRS
106
Cocaine OD tx
IV diazepam to control sz
| Beta blockers NOT recommended b/c of risk from unopposed alpha-adrenergic stimulation
107
Date rape drugs
GHB
Flunitrazepam (roofies)
Ketamine
108
MDMA MOA
Acts on serotonergic and dopaminergic pathways
109
Gamma hydroxybutyrate MOA
Biphasic dopamine response (inhihibition then release)
110
Flunitrazepam (Roofies) MOA
Strong benzos
111
Ketamine MOA
NMDA receptor antagonist
112
Malingering
intentional production of false or exaggerated symptoms, motivated by secondary gain/external reward
113
Factitious disorder
Intentional production or feigning of physical or psychological signs not motivated by secondary gain but may seek sympathy
114
Conversion disorder
>/= 1 symptoms or deficits affecting voluntary motor or sensory function that mimic a neurological disorder (ie. local paralysis, double vision, sz)
115
Depersonalization
Experiences of detachment from oneself, feelings of unreality, or being an outside observer to one's thoughts, feelings, speech, and actions (can feature distortions in perception including time, as well as emotional and physical numbing)
116
Derealization
Experiences of unreality or detachment with respt to surroundings
117
Non-rapid eye movement sleep arousal disorders
Incomplete awakening from sleep
Complex motor behaviour without conscious awareness Amnesia regarding episodes
Includes symptoms of: sleep walking, sleep terrors
118
Rapid eye movement sleep behaviour disorder
Arousal during sleep a/e vocalization and/or complex motor behaviours
Rapid orientation and alertness on awakening
119
Gender dysphora
Distress from conflict btwn one's experienced/expressgend denger and one's assigned gender
120
Anorexia nervosa
1. intake/weight (energy intake less than requirements, weight less than expected/normal)
2. fear/behaviour
3. perception
121
Reasons to admit for anorexia nervosa
```
<65% standard body weight (<85% if teen)
Hypovolemia requiring IVF
HR <40bpm
Abnormal serum chemistry
Actively suicidal
```
122
Refeeding syndrome
Severe shifts in fluid/lytes due to metabolic response of refeeding in severely malnourished pt
Hypophosphatemia
CHF
Cardiac arrhythmias
Delirium
Death
Tx: slow, supplemental phosphorus, close lyte follow, cardiac status
123
Bulimia Nervosa
A. Recurrent epis of binge eating (eating more than a typical person would during that time and having a sense of lack of control over eating)
B. Recurrent inappropriate compensatory behaviour to prevent weight gain
C. A and B happen at least once a week for 3 mo
D. Self eval is influenced by body shape and weight
E. Disturbance does not occur exclusively during episodes of AN
124
Russell's sign
Knuckle callus from self-induced vomiting
125
Bulimia vs anorexia for pharmaco meds
Bulimia has some evidence for SSRIs (ie. fluoxetine)
| Meds of little value for anorexia
126
Binge-eating disorder
- Recurrent epis of binge eating
- Epis associated with 3 or more of:
* Eating more rapidly than normal
* Eating alone b/c embarrassed
* Feeling gross with oneself afterwards
* Eating until uncomfortably full
* Eating large amounts when not hungry
- Marked distress regarding binge eating
- Occurs ~1x/wk for 3mo
- NOT associated with recurrent use of inappropriate compensatory behaviour
127
Avoidant/restrictive food intake disorder
Eating disturbance to extent of persistent failure to meet appropriate nutritional and/or energy needs --> significant weight loss/growth failure and nutritional deficiencies
Does not involve disturbances in body image
128
Important lytes in eating disorders
KPMg
potassium
Phosphate
Magnesium
129
Cluster A Personality D/O
Odd or eccentric cluster
Paranoid
Schizoid
Schizotypal
130
Personality D/O with familial associations
Schizotypal
Antisocial
Borderline
131
Paranoid Personality D/O
```
4 or more of:
SUSPECT
- Spousal infidelity suspected
- Unforgiving
- Suspicious that others are exploiting or deceiving them
- Perceives attacks on character, counterattacks quickly
- Enemy or friend?
- Confiding in others is feared
- Threats perceived in benign events
```
132
Schizotypal Personality D/O
```
Acute discomfort with and reduced capacity for close relationships and cognitive or perceptual distortions and eccentricities of behaviour
5 or more of:
ME PECULIAR
- Magical thinking
- Experiences unusual perceptions
- Paranoid ideation
- Eccentric behaviour/appearance
- Constricted or inappropriate affect
- Unusual thinking/speech
- Lacks close fiends
- Ideas of reference
- Anxiety in social situations
- Rule out psychotic or pervasive developmental d/o
```
133
Schizoid personality d/o
Detachment from social relationships and restricted range of expression of emotions in interpersonal settings
4 or more of DISTANT
-Detached/flat affect, emotionally cold
-Indifferent to praise or criticism
-Sexual experiences of little interest
-Tasks done solitarily
-Absence of close friends
-Neither desires not enjoys close friendships (including family)
-Takes pleasure in few activities (if any)
134
Cluster B Personality Disorders
```
Dramatic, emotional, erratic cluster
Antisocial
Borderline
Histrionic
Narcissistic
```
135
Borderline Personality D/O
```
Instability of interpersonal relationships, self image and affects, marked impulsivity
5 or more of:
DESPAIRER
- Disturbance of identity
- Emotionally labile
- Suicidal behaviour
- Paranoia or dissociation
- Abandonment (fear of)
- Impulsive in at least 2 areas that are self-damaging
- Relationships unstable
- Emptiness (feelings of)
- Rage (inappropriate)
Tends to fizzle out as pts age
10% suicide rate
```
136
Narcissistic PD
```
Grandiosity, need for admiration and lack of empathy
5 or more of :
GRANDIOSE
- Grandiose
- Requires attention
- Arrogant
- Need to be special
- Dreams of success and power
- Interpersonally exploitative
- Others (unable to recognize needs of)
- Sense of entitlement
- Envious
```
137
Antisocial PD
```
Disregard for and violation of rights others since 15y.o.
3 or more of:
CORRUPT
- Cannot conform to law
- Obligations ignored
- Reckless disregard for safety
- Remorseless
- Underhanded (deceitful)
- Planning insufficient (impulsive)
- Temper (irritable and aggressive)
Must be at least 18
A/W conduct d/o with onset before age 15
```
138
Histrionic personality d/o
Excessive emotionality and attention seeking
5 or more of:
PRAISE ME
- Provocative or seductive behaviour
- Relationships considered more intimate than they are
- Attention (need to be centre of)
- Influenced easily
- Style of speech (lacking detail, impressionistic)
- Emotions (rapidly shifting, shallow)
- Make up (physical appearance)
- Emotions exaggerated
139
Familial association of cluster B personality disorders with
Mood disorders
140
Familial association of cluster C personality disorders with
Anxiety disorders
141
Cluster C Personality Disorders
Anxious, fearful cluster
Avoidant
Dependent
Obsessive-compulsive
142
Avoidant Personality Disorder
Social inhibition, inadequacy and hypersensitivity to negative evaluation
4 or more of:
CRINGES
-Criticism or rejection preoccupies thoughts in social situations
-Restraint in relationships d/t fear of shame
-Inhibited in new relationships
-Needs to be sure of being liked before engaging socially
-Gets around occupational activities with need for interpersonal contact
-Embarassment prevents new activity
-Self-viewed as unappealing or inferior
143
Obsessive compulsive personality disorder
```
Orderliness, perfectionism and mental and interpersonal control
4 or more of:
SCRIMPER
- Stubborn
- Cannot discard worthless objects
- Rule obsessed
- Inflexible
- Miserly
- Perfectionistic
- Excludes leisure d/t devotion to work
- Reluctant to delegate to others
```
144
Dependent personality disorder
Submissive and clinging behaviour and fears of separation
5 or more of:
RELIANCE
- Reassurance required
- Expressing disagreement difficult
- Life responsibility assumed by others
- Initiating projects difficult
- Alone
- Nurturance (goes to excessive lengths to obtain)
- Companionship sought urgently when relationship ends
- Exaggerated fears of being left to care for self
145
Attachment types
Secure
Insecure avoidant
Insecure ambivalent/resistent
Disorganized
146
Secure attachment style
Healthy, good enough parenting
Child learns that they will get attention when they need help
60% of children
Mentally healthy adolescents and adults
147
Insecure - avoidant attachment style
Emotionally rejecting parenting style
Child learns they will not receive attention when they need help and try to avoid expressing distress/do not seek parents for help
20% of children
May be at higher risk of behaviour d/o
Emotionally inhibited adults but still live fulfilling lives
148
Insecure - ambivalent attachment style
Inconsistent parenting
Seek caregiver for help but difficult to soothe
Show increased distress in face of stressors
More problems in relationships as teens/adults
Increased risk of future psych d/o (esp anxiety)
149
Disorganized-inhibited or disinhibited attachment style
Scary or fearful caregiver
Unable to organize strategy for seeking help
Inhibited --> child won't go to anyone for help --> reactive attachment d/o
Disinhibited --> child will go to anyone for help --> disinhibited social engagement d/o
HIGHEST RISK for later developing psychopathology
150
Disruptive mood dysregulation disorder
Severe developmentally inappropriate recurrent verbal or behavioural temper outbursts at least 3x/wk
Symptom onset before age 10, lasts for 12mo with no more than 3 consecutive mo free from symptoms
Supersedes dx of ODD if both criteria are met
151
Bipolar d.o in teens
Higher proportion have mixed presentation and psychotic symptoms
152
Autism spectrum Disorder
Persistent deficits in social communication and interaction manifested in 3 areas:
1. social-emotional reciprocity
2. Non-verbal communicative behaviours
3. Developing, maintaining and understanding relationships
Restricted, repetitive patterns of behaviour manifested by 2 or more of: stereotyped or repetitive motor movements, insistence on sameness, restricted fixated interests, hyper/hyporeactivity tosensory input
153
ADHD
A. Inattention AND/OR hyperactivity-impulsivity that interferes with fxning or development
- Inattention: 6 or more of (for at least 6 months)
* Fails to pay close attention to details
* Difficulty staying focused
* Does not listen when spoken to
* Doesn't follow instructions
* Avoids tasks that requires sustained mental effort
* Loses things necessary for tasks
* Easily distracted by extraneous stimuli
* Forgetful in daily activities
- Hyperactivity and impulsivity: 6 or more of (for at least 6months) or 5 or more if older teen/adult
* Fidgets with or taps hands/feets
* Leaves seat when not supposed to
* runs or climbs a lot/feels restless
* unable to play or engage in leisure activities quietly
* On the go, acting as if driven by motor
* talks excessively
* blurbs out answers
* can't wait his/her turn
* interrupts or intrudes on others
Symptoms present before age 12
Symptoms present in 2 or more settings
154
ADHD - 1st line pharmacologic tx
CNS STIMULANTS
- Methylphenidate
- Dextroamphetamine
- Dextroamphetamine and amphetamine salt combos
155
Methylphenidate
Ritalin, Concerta, Biphentin (small granules that can be sprinkled into food)
Dopamine AGONIST
156
Dextroamphetamine
Dexedrine, Vyvanse
| Dopamine AGONIST
157
Dextroamphetamine and amphetamine salt combos
Adderall
158
ADHD - 2nd line pharmacologic tx
Atomoxetine (Straterra) - NE reuptake inhibitor
159
ADHD 3rd line pharacologic tx
Adjunct nonstimulants (ie. guanfacine, clonidine. buproprion)
160
Oppositional defiant disorder
```
M=F after puberty
At least 6mo
at least 4 symptoms from any of the categories when interacting with at least 1 person who is not a sibling:
- Angry or irritable mood
- Argumentative/defiant behaviour
- Vindictiveness
ODD kids ARE BRATS
Annoying
Resentful
Easily annoyed
Blames others
Rule breakers
Argues with adults
Temper
Spiteful/vindictive
```
161
Conduct disorder
```
M:F = 4-12:1
>/=3 criteria in past 12mo and >/=1 in past 6mo
TRAP
Theft
Rule breaking
Aggression
Property destruction
If >18yo, consider antisocial PD
```
162
Intermittent Explosive Disorder
Recurrent behavioural outbursts representing failure to control aggressive impulses in children age >/= 6 manifested as either
verbal or physical aggression >/=2x/wk for 3mo
3 outbursts involving physical damage to another person, animal, piece of property in last 12mo
163
Mesolimbic DA pathway and schizophrenia
High DA causes positive symptoms of schizophrenia
164
Mesocortical DA pathway and schizophrenia
Low DA causes negative symptoms of schizophrenia
165
Nigrostriatal DA pathway and schizophrenia
Low DA causes EPS
166
Tuberoinfundibular DA pathway and schizophrenia
Low DA causes hyperprolactinemia
167
Typical antipsychotic MOA
Block postsynaptic DA receptors (D2 )
168
Atypical antipsychotic MOA
Block postsynaptic DA receptors AND serotonin (5HT2) or presynaptic dopaminergic terminals, triggering DA release and reversing DA blockade in some pathways
169
Common typical antipsychotics
Haldol
Fluphenazine
Loxapine
170
Common atypical antipsychotics
```
Risperidone
Paliperidone
Olanzapine
Aripiprazole
Quetiapine (seroquel)
Clozapine
```
171
Most effective antipsychotic for tx resistant schizophrenia
Clozapine
172
Antipsychotic with hghest risk of EPS
Risperidone
173
Neuroleptic malignant syndrome
Due to strong DA blockade
Mental status changes then fever, autonomic reactivity, rigidity
Develops over 25-72h
174
Neuroleptic malignant syndrome labs
Elevated creatine phosphokinase
Leukocytosis
Myoglobinuria
175
Neuroleptic malignant syndrome tx
```
Supportive
D/C antipsychotic
Hydration
Cooling blankets
Dantrolene (muscle relaxant)
Bromocriptine (DA agonist)
```
176
Dystonia
Acute or tardive
Sustained abnormal posture, torsions, twisting, contraction of muscle groups
Tx: Benztropine or diphenhydramine (anticholinergics)
IV if severe, PO if mild
177
Akathisia
Acute or tardive
Motor restlessness, crawling sensation in legs
Tx: Lorazepam, propranolol or diphenhydramine
178
Pseudoparkinsonism
Acute only
Tremor, rigidity (cogwheeling), akinesia, postural instability
Tx: Benzotropine or amantadine (NMDA antagonist, DA reuptake inhibitor)
179
Dyskinesia
Tardive only
Purposeless, constant movements involving facial and mouth musculature
Tx: No good tx, may try clozapine
DO NOT give anticholinergics, may worsen the condition
180
Anticholinergics and EPS
Do not routinely rx with antipsychotics
| Rx only if at high risk for acute EPS or if acute EPS develops
181
Fluoxetine
Prozac
Most activating SSRI (recommend taking in AM)
Does NOT require taper due to long half-life
Most useful in children
182
Wellbutrin
Bupropion
Starting dose 100mg
Therapeutic dose 300-450
NDRI (NE and DA)
Pros: no weight gain or sexual dysfunction
Cons: Sz at high doses
C/I: Seizure disorders, bulimia nervosa, anorexia nervosa, MAOI use in psat 2 wks
183
Amitriptyline
TCA
| Useful for OCD
184
MAOI
Phenelzine
Useful for moderate/severe depression that doesn't respond to other antidepressants
Needs MAOI diet (avoid foods with tyramine - cheese, cured meats, aged soy, overripe fruits, EtOH)
Tyramine metabolism is inhibited by MAOI --> sympathomimemtic response (HTN crisis)
185
Mirtazapine
NaSSA
Useful for depression with prominent features of insomnia, agitation or cachexia
Does not cause appetite suppression
Infrequently causes sexual disturbance
186
Anticholinergic S/E
```
Mad as a hatter
Red as a beet
Blind as a bat
Dry as a bone
Hot as a hare
```
187
Serotonin syndrome
Due to over-stimulation of serotonergic system
Nausea, diarrhea, palpitations, chills, restlessness, confusion, lethargy --> myoclonus, hyperthermia, rigor and hypertonicity
188
Discontinuation syndrome
Most commonly with paroxetine, fluvoxamine, venlafaxine
189
Common mood stabilizers
```
1st line:
Lithium
Lamotrigine
Divalproex
2nd line:
Carbamazepine
```
190
Lithium monitoring
Before starting: UA, BUN/Cr, thyroid function, ECG if heart disease
Serum levels every 5-7d until therapeutic (wait 12h post dose)
Then monitor monthly
Then q2-3mo
Monitor thyroid function, Cr q6mo and UA q1y
191
Acute mania tx
Lithium
DIvalproex
Carbamazepine
NOT lamotrigine
192
Lamotrigine monitoring
No therapeutic plasma level established, titrate based on response
Slow titration due to risk of SJS
A/E: SJS, fever, swollen glands, severe muscle pain, bruising, headache, neck stiffness, vomiting, confusion, increased sensitivity to light
193
Divalproex monitoring
Monitor serum levels q5-7d until therapeutic
| LFTs weekly x 1mo then monthly then q2-3mo due to risk of liver dysfunction
194
Divalproex drug interaction
OCP
195
Carbamazepine monitoring
Monitor serum levels q5-7d until therapeutic
| Weekly blood counts for first month due to risk of agranulocytosis
196
Carbamazepine drug interaction
OCP
197
Lithium toxicity
Clinical dx as toxicity can occur at therapeutic levels
Caused by OD, fluid loss, concurrent illness, NSAIDs or diuretics
N/V/D, ataxia, slurred speech, poor coordination, polyuria, drowsiness, myoclonus, tremor, UMN signs, sz, delirium, coma
Tx: D/c for several days and restart at low dose when level falls to non-toxic range, saline infusion, hemodialysis if high levels, coma, shock, severe dehydration, failure to respond to tx after 24h or deterioration
198
Benzo MOA
Strengthen binding of GABA to receptors --> decreased neuronal activity
199
Benzo antagonist for OD
Flumazenil
200
Buspirone MOA
Partial agonist of 5-HT1A receptors
201
Benzodiazepines safe in pts with impaired liver function
LOT
Lorazepam
Oxazepam
Temazepam (should be avoided)
202
ECT
Induction of generalized sz using electrical impulse through scalp electrodes while pt is under general anesthesia with muscle relaxant
203
Repetitive transcranial magnetic stimulation (rTMS)
Focal electrical currents in select brain circuits using magnetic induction
204
Form 1
Right to hospitalize pt for psych assessment against his/her will
Valid for 72h
205
Form 2
Right to bring pt in for psych assessment against his/her will
Valid for 7d
206
Form 3
Certificate of involuntary admission to facility
Completed by any MD other than MD who completed Form 1
Valid for 14d
207
Form 4
Certificate of renewed involuntary admission
First: 1mo
Second: 2mo
Third: 3mo (Max)
208
Form 5
Change to informal/voluntary staus
209
Risperidone
Atypical antipsychotic of choice if wanting to avoid sedation
210
Narcolepsy
Excessive daytime sleepiness
Cataplexy (emotion causes physical collapse)
Hypnagogic hallucinations
Sleep paralysis
211
Narcolepsy tx
Methylphenidate and other stimulant drugs
212
Tourette syndrome
Common genetic neuro disorder manifested by motor and phonic tics with childhood onset
Symptoms must occur for more than 1yr
Tics = involuntary, sudden, brief, intermittent movements or utterances that present with irresistible urge before and relief after
213
Treatment for tics
Alpha2-adrenergic drugs (Clonidine, Guanfacine)
Antipsychotics (risperidone best studied)
Botox
Psychotherapy
214
Antipsychotics and galactorrhea
DA RESTRICTS prolactin release
Antipsychotics decrease DA --> increased prolactin --> galactorrhea (+menstrual irregularities, infertility)
Most commonly seen with first gen antipsychotics (haldol, fluphenazine) and 2nd gen (risperidone and paliperidone)
215
Somatic symptom disorder
At least 4 pain symptoms, GI distress, Sexual problems and pseudoneurological symptoms
Begins before age 30
216
Bipolar tx duration
Indefinite tx with mood stabilizer
| Kindling phenomenon = episodes occur more frequently, more severe and less responsive to tx if tx is stopped
217
Early morning awakening - depression or anxiety?
Depression
218
Difficulty falling asleep - depression or anxiety?
Anxiety
219
Apprehensive expectations or feelings of dread - depression or anxiety?
Anxiety
220
Voyeuristic disorder
Sexually aroused by watching someone who is disrobing, naked or engaged in sexual activity
221
Exhibitionistic disorder
Involves exposing the genitals in order to become sexually excited or having strong desire to be observed by other ppl during sexual activity
222
Transient tic disorder
AOO 7yo
Vocal and/or motor tics which occur several tism a day for a minimum of 4 wks, however, no logner than 12mo
Dx CANNOT be made if pt has EVER had a hx of Tourette's
223
Acute stress disorder
>/= 3d and =1mo following trauma
| If >1mo, then becomes PTSD
224
Most common S/E a/w Olanzapine
Weight gain
225
Psych drug a/w diabetes insipidus
Lithium
226
Amenorrhea from prolactin elevation most commonly seen with
Palliperidone
| Risperidone
227
Atypical antipsychotic monitoring
```
Metabolic adverse effects:
BMI
Fasting plasma glucose
Lipids
BP
Waist circumference
Baseline, at 3mo then annually
Olanzapine and clozapine pose greatest risk
```
228
Lithium C/I
CKD --> use Valproate instead
Heart disease
Hyponatremia or diuretic use
229
Common drugs affecting lithium levels
```
Diuretics
NSAIDs, EXCEPT ASA
SSRI
ACEi/ARB
Antiepileptics
```
230
Wellbutrin C/I in what medical condition
Epilepsy
| Lowers sz threshhold
231
Psych med known to cause hypothyroidism
Lithium
Baseline thyroid function tests should be mesaured prior to starting Li therapy and monitored 3mo after starting and 6-12mo thereafter
232
Recurrence of depression
6x risk boys, 4x risk in girls
Recurrence more common with family hx
Mean # episodes over lifetime is 5-6
233
Mean # episodes of bipolar over lifetime
8-9
234
Indications for long-term tx of depression
2 depressive episodes within 5 years
3 prior episodes
Severe psychotic depression, serious suicide attempt
Review afte r3-5yrs
235
Long-term tx depression
All antidepressants and lithium continued at dose to manage acute episode
236
Management of hypertension in AD patients
Beta blockers
237
Capgras Syndrome
Belief that someone familiar has been replaced by an imposter
238
Catatonia treatment
Benzodiazepines
