Psych COMAT Flashcards
1
Q
What is the path and diagnosis of GAD?
A
Path: chronic, insidious
Presentation: constant state of worry involving most things on most days >/= 6 months duration with >/= 3 somatic changes.
2
Q
What are somatic changes to look out for when diagnosing GAD?
A
changes in sleep, changes in weight, irritability, and decreased concentration
3
Q
What is the treatment of GAD?
A
psychotherapy»_space; meds (SSRIs, buspirone)
panic attacks are abortive with benzodiazepines (but they should not be prescribed in patients with GAD because they can become dependent on them)
4
Q
What is the path and diagnosis of panic disorder? What is the PANIC STUDENTS mnemonic?
A
Path: acute, overt Diagnosis: not caused by another disorder (usually women in their 20s with no medical history to account for another cause) STUDNETS PANIC: SOB Trembling Unsteady Depersonalization Excessive HR Numbness Tingling Sweating
Palpitations Abdominal pain Nausea Intense fear of death Chest pain
5
Q
What conditions should be ruled out when diagnosing panic attacks in a new pt?
A
Rule out ACS with EKG/troponings, rule out hyperthyroidism with TSH, rule out asthma with history/wheezing
6
Q
What is the treatment for panic disorder?
A
meds > psychotherapy (CBT works)
Abortive treatment = benzodiazepines
7
Q
What is the criteria for diagnosing phobia?
A
exaggerated and/or irrational usually against a specific object or situation
8
Q
What are examples of a specific phobia?
A
heights, flying, spiders, clowns, snakes
9
Q
What are examples of a social phobia?
A
public speaking, public peeing
10
Q
How can you overcome phobias?
A
CBT - flooding (quick, not as long lasting) and desensitization (takes longer, lasts longer)
also usually use benzos
11
Q
What is intermittent explosive disorder? (Path, action, patient)
A
Path: stressor can be anything (usually someone violating their personal space)
Action: violence (usually disproportionate to stressor)
Patient: men > women, decreases with age
12
Q
What are the two types of intermittent explosive disorder, and how are they different?
A
Mild (no harm): two outbursts per week that continue for 3 months
Severe (harm present): 3 outbursts over the course of 12 months
13
Q
What is the treatment for intermittent explosive disorder?
A
Meds don’t work, therapy is not very beneficial (OME recommends building a relationship with the person and figuring out something that works for that person)
14
Q
What is the stressor and action for someone with kleptomania? Patient?
A
Stressor: object
Action: stealing (usually somethin of little to no value)
Patient: women > men
15
Q
What are actions after stealing associated with kleptomania?
A
guilt/remorse after stealing, which makes them give the object away, hoard it away, or return it
16
Q
What is the treatment for kleptomania?
A
meds and therapy are not very effective; need to coach to give item back
17
Q
Stressor, action, patient, diagnostic criteria, treatment for pyromania?
A
stressor: increase sexual arousal
action: set fires in order to increase sexual arousal
patient: men > women
diagnosis: >/= 2 occasions of setting fires
treatment: meds/therapy don’t help
18
Q
OCD path,
A
path: obsessions: anxiety provoking (internal, intrusive, unwanted, thoughts or preoccupations); compulsions: anxiety reducing (behavior or ritual)
19
Q
What are some common obsessions and their compulsions?
A
safety -> checking
contamination -> washing/cleaning
asymmetry -> putting things in order, counting
20
Q
What is the treatment for OCD?
A
psychotherapy > medications
Types of therapy: CBT
Medications: SSRIs
21
Q
preoccupation/obsession, convulsion, and unsafe effect of hoarding disorder?
A
preoccupation/obsession: throwing things away
compulsion: keep things (usually trash)
unsafe effect: unsafe environment
22
Q
preoccupation/obsession, convulsion, and unsafe effect of body dysmorphic disorder?
A
preoccupation/obsession: some part of the body (skin, hair, nose, breast)
compulsion: check appearance, unnecessary surgeries
unsafe effect: none
(female disease)
23
Q
preoccupation/obsession, convulsion, and unsafe effect of muscle dysphoria?
A
preoccupation/obsession: increasing muscle size
compulsion: excessive exercise, use anabolic steroids
unsafe effect: rhabdomyolysis -> ARI; roid rage
(male disease)
(any question about copper or testicular atrophy, think this)
24
Q
preoccupation/obsession, convulsion, and unsafe effect of trichotillomania?
A
preoccupation/obsession: anything
compulsion: pull out hair
unsafe effect: alopecia; hair at varying lengths
(r/o fungus, bezoar -> eats hair, leading to small bowel obstruction
25
What are common stressors leading to PTSD?
actual death, threatened death, combat, raped, abused/neglected
26
What are possible exposures leading to PTSD?
experienced (self), witnessed (others), learned (loved one), repeated exposure to aftermath (EMTs, firefighters, police officers)
27
What are the five components to PTSD?
intrusion, mood change (depressed), dissociation, avoidance, arousal (hyper-vigilance)
28
Duration of PTSD symptoms > 3 days but < 6 months is what diagnosis?
acute stress disorder
29
Duration of PTSD symptoms > 6 months is what diagnosis?
PTSD
30
What is the treatment for PTSD?
psychotherapy (group therapy, survivor groups), meds (SSRIs), benzos for panic attacks
31
What are patients with PTSD at risk for without treatment?
mood disorders and substance abuse
32
What is the stressor in reactive attachment disorder (RAD) and disinhibited social engagement disorder (DSED)?
abuse/neglect in infancy
33
What is the difference between RAD and DSED?
same trigger, but RAD they end up pairing too little with others; DSED they end up pairing too much (there is no difference between a friend and a stranger)
34
When can RAD and DSED be diagnosed?
< 5 years old, must r/o autism
35
What is the treatment of RAD and DSED? What are possible complications of poor treatment?
```
treatment = teaching the caregiver how to parent better and provide coping skills
complications = mood, anxiety, or substance abuse disorders, learning disability
```
36
Describe adjustment disorder.
non life-threatening stressor that leads to a change in mood (but does not meet criteria for a mood disorder). onset must be within 3 months of the stressor and the duration is < 6 months (no psychotic features, no SI/HI)
37
What is the diagnostic criteria of major depressive disorder?
depressed mood or anhedonia for duration >/= 2 weeks AND 5 SIGECAPS
38
What does SIGECAPS stand for?
```
Sleep
Interest
Guilt
Energy
Concentration
Appetite
Psychomotor
Suicidal ideation
```
39
What is the treatment for major depressive disorder with suicidal ideations with a plan and means to carry out said plan?
hospitalization
40
What is the treatment for major depressive disorder with suicidal ideations without a plan and/or means to carry out said plan?
safety conract
41
What is the treatment for major depressive disorder without suicidal ideations?
SSRI or SNRI for 1-2 months before deciding to add another med; psychotherapy (combo), ECT in refractory, catatonia, or psychosis
42
What SIGECAPS findings would you expect for atypical depression? How is this different than typical depression?
increased sleep, decreased interest, increased guilt, decreased energy, increased appetite, decreased psychomotor, +/- suicide; different than typical depression with sleep and appetite
43
Bipolar I pathology, diagnosis, symptoms?
```
path: manic-predominant
diagnosis; "E" + 3 Sx for >/= 1 week
Distractibility
Insomnia
Grandiosity
Flight of ideas
Agitation
Sexual exploits
Talkative
Elevated mood
Racing thoughts
R/O: stimulants, Bipolar II, cyclothymia
```
44
How do you treat someone with Bipolar I that is manic in the ED?
```
Chronic = mood stabilizers (benzos if need sedated) = Lithium (1st line), Valproic acid (2nd line), Carbamazepine/Lamotrigine (3rd line)
Antipsychotic = quetiapine (4th line)
```
45
Bipolar II presentation, diagnosis?
hypomania + major depressive episode
| R/o: catatonia, Bipolar I
46
What is cyclothymia?
lesser version of Bipolar II
47
Dysthmia presentation, diagnosis, treatment?
depressed mood within 2 year period or longer, duration never more than 2 months at a time
R/O hypothyroidism with TSH
Tx with SSRI
48
What are the five stages of death and dying?
Denial, Depression, Bargaining, Anger, Acceptance (for dying and survivors)
49
In what situations is PTSD/ASD due to death/dying more likely?
when loss is unexpected and/or violent (Sx; anxiety, fear)
50
What is criteria for diagnosis of adjustment disorder in relation to death and dying?
adjustment disorder cannot be diagnosed in the setting of bereavement
51
onset, duration, focus, course, behaviors, reason for suicide, and treatment of grief
onset: anytime
duration: <12 months (since loss of person)
focus: diseased (dysphoria, guilt, anhedonia normal)
course: depressed mood waxes and wanes; able to imagine a time in the future when they will be happy
behaviors: talking to deceased, praying at deceased, visiting graveside, catching a glimpse of deceased (normal as long as there is the insight to know they are still deceased)
reason for suicide: deceased (to be with them, trade places, etc)
treatment: does not need treatment
52
describe persistent complex bereavement disorder including onset an duration.
onset: >6 months after
duration: >/= 12 months
A mix between grief and major depressive disorder.
53
onset, duration, focus, course, behaviors, reason for suicide, and treatment of major depressive disorder
onset: anytime
duration: >/= 12 months
focus: pervasive and global, affects rest of life (dysphoria, guilt, anhedonia)
course: persistent depressed mood; cannot imagine a time when they will be happy again
behaviors: related to hallucinations (auditory, visual), psychotic features (usually lack insight)
reason for suicide: thinking about self (despondent and hopeless)
treatment: SSRI, SNRI
54
baby blues - baby, onset, duration, symptoms, treatment
baby: 1st baby, mom cares about baby
onset: within 2 weeks
duration: within 2 weeks
symptoms: depressed mood
treatment: no treatment
55
post-partum depression - baby, onset, duration, symptoms, treatment
baby: 1st baby, mom doesn't care about baby (still wants baby to live)
onset: within 1 month
duration: ongoing without tx
symptoms: SIGECAPS
treatment: SSRIs
56
post-partum psychosis - baby, onset, duration, symptoms, treatment
baby: not usually 1st baby, mom fears baby and is likely to kill it
onset: within first month
duration: ongoing without tx
symptoms: psychosis-predominant
treatment: anti-psychotics
57
What is the proposed pathophys of positive symptoms in schizophrenia?
increased dopamine
58
What is the proposed pathophys of negative symptoms of schizophrenia?
increased serotonin
59
What is the diagnostic criteria for schizophrenia?
>/= 2 symptoms and one must be 1-3:
1. delusions (looking for persecution or grandiosity)
2. hallucinations (generally auditory)
3. disorganized speech
4. disorganized behavior (stop grooming, stop leaving house)
5. negative symptoms (flat affect, poverty of speech/movement, anhedonia, cognitive delay)
R/o drugs, determine duration, and +/- mood disorder (can change the diagnosis)
60
What is the treatment for schizophrenia?
antipsychotics
61
Schizophrenia duration and treatment time period
duration: > 6 months
treatment: lifelong
62
Brief psychotic disorder duration and treatment time period
duration: > 1 day, < 1 month
treatment: 1 month (if it persists, probably schizophrenia)
63
Schizophreniform duration and treatment time period
duration: > 1 month, < 6 months
treatment: 3-6 months
64
Schizoaffective disorder criteria, duration, and treatment time period
PSYCHOSIS + mood
duration: > 6 months
treatment: treat mood disorder first
65
Describe delusional disorder.
delusions that are not bizarre and do not cause impairment (do not meet 1-3 criteria of schizo)
Use gentle confrontation (their delusion is more likely to impair someone else than themselves)
66
What meds would you choose for a normal compliant schizophrenic patient?
atypicals (quetiapine, olanzapine, risperdol) - atypicals work on both dopamine and serotonin in the brain, less side effects than typicals
67
What meds would you choose for a schizophrenic patient who is combative in the ED?
typicals - haloperidol, (do not use olanzapine with combative patient)
68
What meds would you choose for a noncompliant schizophrenic patient?
depot form (once a month injection) haloperidol
69
What meds would you choose for a schizophrenic patient when all else fails?
clozapine (first atypical med made, almost always works, but can cause agranulocytosis so you have to try all other meds first)
70
What condition can all antipsychotics cause and what is the treatment?
neuroepileptic malignant syndrome (fever, rigidity, elevated CK, on antipsychotic); treat with dantrolene
71
What electrolyte abnormalities would you expect with bulimia nervosa hyperemesis type?
hypokalemia, hypomagnesemia, metabolic alkalosis
72
What electrolyte abnormalities would you expect with bulimia nervosa laxative type?
metabolic acidosis
73
Bodyweight, self-image, anxiety, method, signs/symptoms, hospitalization, treatment, f/u for anorexia nervosa?
body weight: underweight
self-image: decreased
anxiety: fearing becoming fat or being fat (no insight into actual weight)
method: restriction
signs/symptoms: malnourished (hypothyroid but thin - lanugo, amenorrhea, cold intolerance, emaciated)
hospitalizations: when anorexia is extreme (BMI < 16)
treatment:
inpatient: force feeds, IV fluids
outpatient: antipsychotics (1st line), + CBT
f/u: OCD, MDD -> SSRI/SNRI
74
bodyweight, self-image, anxiety, method, signs/symptoms, hospitalization, treatment, f/u for bulimia nervosa?
body weight: normal
self-image: decreased
anxiety: binge (insight into this being bad/shameful, so they purge)
method: binge -> purge
signs/symptoms: normal patient (signs of emesis/laxative purging)
hospitalizations: very rarely requires
treatment: SSRI/SNRI + CBT
f/u: NEVER use buproprion (increased risk of seizure)
75
What is the difference between binge eating disorder and bulimia nervosa?
binge eating disorder - +binging, negative purging, +obesity
76
What are the cluster A personality disorders?
paranoid, schizoid, schizotypal
77
What are the cluster B personality disorders?
borderline, histrionic, narcissistic, anti-social
78
What are the cluster C personality disorders?
avoidant, dependent, obsessive-compulsive
79
Diagnostic criteria of dissociative identity disorder
>/= 2 distinct identity states
80
What will you see in the patient vs others in dissociative identity disorder?
patient: memory gaps/blackout, severe trauma history, other dissociative symptoms
others: paradoxical behaviors (women having changes in sexual preferences and drug use), can see appearance change
Look for another psych diagnosis
81
What is the difference between depersonalization and derealization?
depersonalization - from the body (out-of-body, deja-vu)
derealization - from environment (experiencing things as if in a dream)
Look for intact reality testing (not psychotic); usually occur in a nonsevere trauma to an adolescent
82
What is the diagnostic criteria for catatonia?
>/= 3 of the following symptoms:
1A. stupor
2A. cata-lepsy (able to put patient in whatever position you want)
3A. waxy flexibility
4A. negativism
5A. mutism
1B. stereotypy (same movement over and over again)
2B. agitation/grimace
3B. echolalia/echopraxia (copy what you say/do)
A = retarded/decreased symptoms
B = excited/increased symptoms
83
How do you clinically diagnose catatonia? What are risks to watch out for with this diagnosis?
diagnostic criteria + if you give lorazepam and it goes away
At risk for malnutrition (monitor with albumin), DVT (use LMWH/compression devices), rhabdomyolysis -> renal failure (check CK)
84
precipitant and symptoms of malignant catatonia?
precipitant: will have a psychiatric disease, but no medication caused it
symptoms: rigidity (lead pipe rigidity -> muscle breakdown -> elevated CK; resistance to movement) + dysfunctional autonomic nervous system (increased HR, BP, temp)
85
precipitant and symptoms of neuroeplileptic malignant syndrome?
precipitant: psychiatric illness; antipsychotic medication
symptoms: rigidity (lead pipe rigidity -> muscle breakdown -> elevated CK; resistance to movement) + dysfunctional autonomic nervous system (increased HR, BP, temp)
86
precipitant and symptoms of serotonin syndrome?
precipitant: psychiatric illness; treated with SSRIs
symptoms: rigidity + dysfunctional autonomic nervous system
87
precipitant and symptoms of malignant hyperthermia?
precipitant: halothane gas, no psych disorder
symptoms: family hx of reaction to anesthesia, rigidity + dysfunctional autonomic nervous system
88
Grade and function of a child with IQ > 70?
grade n/a
| live, work, ADLs independently
89
Grade and function of a child with IQ 50-70?
6th grade
| work and ADLs, live with someone/group home
90
Grade and function of a child with IQ 35-49?
3rd grade
| ADLs (cannot work/live independently)
91
Grade and function of a child with IQ 20-34?
pre-school
| need help with ADLs
92
Aspects of impaired social communication in autism spectrum disorder?
impaired in:
1. social reciprocity
2. social relationships
3. nonverbal communication
4. joint attending
93
Aspects of restricted/repetitive behavior in autism spectrum disorder?
1. stereotyping (repeating actions - stacking objects, lining objects up)
2. sameness (sticking to strict routine)
3. restricted interests (fixation)
4. change in sensory perception
94
Diagnostic criteria for diagnosing ADHD
Must have impulsivity and inattention symptoms
Must have symptoms in >/= 2 settings
Onset of symptoms age 7-12
Duration: >/= 6 months
95
Treatment of ADHD?
Stimulants - methylphenidate or amphetamine salts
Special education
Train parents on how to handle the children
R/o absence seizures (treat with carbamazepine)
96
Tic Disorders: association, presentation, diagnosis
association: OCD, ADHD
presentation: physical or vocal tic (not usually words, never swearing)
diagnosis: before age 18 with duration > 1 year
97
What is the treatment of tic disorders?
```
D2 antagonists (antipsychotics - usually low potency, including aripiprazole)
Cognitive behavioral therapy
```
98
Eneuresis cause/treatment < 7 yo and never dry
< 7 and never dry -> normal, train them
Treatment: positive reinforcement, water restriction, alarm blankets, can use DDAVP (vasopressin), but that is probably the wrong answer on the test
99
Eneuresis workup in a child who was previously dry
get a UA and ultrasound ->
If + UA and - ultrasound: infection, common in girls as they begin to toilet train (Abx and correct behavior)
If - UA and + ultrasound -> anatomical defect (surgery)
If - UA and - ultrasound -> regression (new sibling, new place -> normal, think about abuse if no precipitating cause)
100
What is the difference between conduct disorder and oppositional defiant disorder?
conduct disorder harms peers and fights authority (criminal behavior)
oppositional defiant disorder gets along with peers but fights authority (acting out)
101
What do you expect to see in a child with conduct disorder? What is the treatment?
bullying (hurt animals, use torture/cruelty, force sex), destruction (fires, lying, cheating, stealing), violation of rules (truancy, running away >/= 2 times, defiant behavior)
Tx: juvenile detention
102
What do you expect to see in a child with oppositional defiant disorder? What is the usual cause of this?
cause: incongruent parenting
Expect: no bullying, no harming animals, no cruelty/torture, + lying, cheating, and stealing, + defiance
103
What is the treatment for oppositional defiant disorder?
teach the parents how to parent (unifying front)
104
What are the SSRIs? What are the common side effects?
(es)citalopram, fluoxetine, paroxetine, sertraline
| side effects: sexual dysfunction, including decreased libido and prolonged ejaculation
105
What are the SNRIs? What are the benefits to using these over SSRIs?
(des)venlafaxine, duloxetine
| tend to be better and cleaner, but more expensive
106
What is a positive side effect of buproprion? When is it contraindicated?
Good with: helping patients quit smoking without causing weight gain, no sexual dysfunction side effects
Contraindicated: in bulimia patients because it decreases the seizure threshold
107
What are the serotonin modulators? What are the side effects/alternate uses?
mirtazapine, trazodone
Trazodone causes excessive sleepiness, can be used as a sleep aid; can cause priapism
Mirtazapine - appetite stimulant
108
What are the tricyclic antidepressants? What are they useful to treat? What are the side effects?
"-triptyline", imipramine, donepin
Not used to treat depression; can treat eneuresis in children, neuropathic pain (diabetic neuropathy)
Side effects: "3 C's" - convulsions, cardiac toxicity, coma
109
What are the MAOIs? When are they used?
selegiline, phenylzine
Not used to treat depression
Can be used in hypertensive emergency, especially when the patient drinks wine or eats cheese
110
Which classes of antidepressants are not used for treating depression anymore?
TCAs and MAOIs
111
What is the rule of 6's for antidepressants?
```
>/= 6 weeks at dose
>/= 6 months at effective dose
>/= 6 weeks of washout
```
112
What is lithium used to treat? What are the side effects?
One of the first line medications for treatment of mania
| Side effects: teratogen, narrow therapeutic index, nephrotoxic, nephrogenic diabetes insipidus
113
What is valproate used to treat? What are the side effects?
One of the first line medications for treatment of mania
| Side effects: spina bifida, pancreatitis, decreased platelets, agranulocytosis
114
What is quetiapine used for? What are the side effects?
2nd line treatment for mania
| Side effects: eight gain, QTc -> EKG, somnolence
115
What is lamotrigine used for? What are the side effects?
2nd line treatment for mania
| Generally safe side effect profile
116
What is carbamazepine used for? What else can it treat?
3rd line going forward; historically a 2nd line treatment
| Used for treatment of trigeminal neuralgia and absence seizures in children
117
What are the short-acting benzodiazepines?
lorazepam and alprazolam
118
What is the treatment for benzodiazepine withdrawal?
diazepam, chlordiazepoxide
119
What are psychotic positive symptoms regulated by? (area of brain)
mesolimbic D2C-R (dopamine)
120
What are psychotic negative symptoms regulated by? (NT)
5HT3 (serotonin)
121
Typical (FGA) Antipsychotics MOA, side effect
MOA: mesolimbic, D2-C-R antagonists
| Side effects: increased potency = increased extrapyramidal symptoms
122
Names of typical antipsychotics
```
Potent:
- haloperidol
- fluphenazine
Less potent:
- thioridazine
- chlorpromazine
```
123
Atypical antipsychotics (SGA) MOA and side effects
D2C-Receptor antagonists AND 5HT3-receptor antagonists
| Side effects: less extrapyramidal symptoms than FGA
124
Names of atypical antipsychotics with respective side effect
```
Most common:
Quetiapine - somnolence (can be used to treat insomnia & bipolar mania)
Olanzapine - metabolic syndrome
Risperidone - extrapyramidal symptoms
Less common:
Aripiprazole
Ziprasidone
```
ALL: have problems with QTc prolongation and ACh side effects
125
Clozapine - why is it not used regularly? side effect? how to get on it?
agranulocytosis; can get diagnosed if have failed 2 other antipsychotics (best one but last resort)
126
What type of antipsychotic would you use for a normal, compliant patient?
atypical (SGA) antipsychotic PO
127
What type of antipsychotic would you use for an agitated patient in the ER?
IM olanzapine or haloperidol
128
What type of antipsychotic would you use for a patient with dysphagia?
oral dissolving tablets - olanzapine and risperidone
129
What type of antipsychotic would you use for a chronically noncompliant patient?
depot form - olanzapine and risperidone
130
Extra pyramidal symptoms (4)
Akasthesia - feeling of restlessness (treat by decreasing dose, beta blocker, or anti-ACh meds ((benztropine/diphenhydramine)))
Acute dystonia - contraction of major muscle group - oculogyric crisis or torticollis (treat with Anti-ACh meds as above)
Dyskinesia - bradykinesia/Parkinsonism (treat with anti-ACh)
Tardive dyskinesia - chronic, life-long; grimacing, jaw-moving, tongue-moving (nothing to do for it) (usually on medication for 6 months before getting it)
131
What does the CRAFFT mnemonic mean?
used for a substance abuse screening for adolescents.
C- car (using while driving)
R - relax (using to relax)
A - alone (using alone)
F - friends (losing friends over using)
F - forget (forget stuff you've done while losing)
T - trouble
132
Stages of change
1. pre-contemplative - denial
2. contemplative - accepted problem
3. preparation - first steps (thinking, etc)
4. action - behavior change
5. maintenance - sustain behaviors
133
Who is at a higher risk of alcohol addiction?
male > females 3:1; native Americans and alaskan natives
134
What are signs of acute alcohol or benzodiazepine withdrawal?
```
diastolic HTN, tachycardia
tremor
diaphoresis
agitation
confusion (delirium tremens)
seizure
```
135
What is the treatment for acute alcohol/benzodiazepine withdrawal?
benzo taper (chlordiazepoxide, diazepam) + rapid-acting benzos as needed (alprazolam, lorazepam)
136
What substance is this describing intoxication of?
| slurred speech, disinhibition, ataxia, blackouts, memory loss, impaired judgement
alcohol intoxication
137
What substance is this describing withdrawal of?
| tremor, tachycardia, HTN, seizures, psychosis
alcohol OR benzodiazepine withdrawal
138
What substance is this describing intoxication of?
| delirium in elderly, respiratory depression and coma (with increased dose), amnesia
benzodiazepine intoxication
139
What substance is this describing intoxication of?
| euphoria, pupil constriction, respiratory depression, and potential tract marks
opiate intoxication
140
What substance is this describing withdrawal of?
| yawning, lacrimation, N/V, hurting everywhere, sweating
opiate withdrawal
141
What substance is this describing intoxication of?
| psychomotor agitation, HTN, tachycardia, dilated pupils, psychosis, angina/HTN crisis
cocaine intoxication
142
What substance is this describing withdrawal of?
| depression, suicidality
cocaine withdrawal - also "cocaine bugs"
143
What drug/antidote to give for a cocaine withdrawal?
supportive care or benzos; alpha blocker then beta blocker
144
What substance is this describing intoxication of?
| overheat (fever, tachycardia) and water intoxication, pupillary dilation, psychosis
MDMA intoxication
145
What substance is this describing intoxication of?
| aggressive psychosis, vertical horizontal nystagmus, impossible strength, blunted senses
PCP intoxication
146
What substance is this describing withdrawal of?
| severe random violence
MDMA withdrawal
147
What substance is this describing intoxication of?
| rarely seen, hallucinations, flashbacks, heightened senses
LSD intoxication
148
What substance is this describing withdrawal of?
| flashbacks
LSD withdrawal
149
What substance is this describing intoxication of?
| tired, slowed reflexes, conjunctivitis, the munchies, overdose brings paranoia
marijuana intoxication
150
What substance is this describing intoxication of?
| tachycardia, HTN, pressured speech, flight of ideas
amphetamine intoxication
151
What EEG changes do you expect to see in stage I of sleep?
theta waves, absent alpha waves
152
What EEG changes do you expect to see in stage II of sleep?
K-complexes and sleep spindles
153
What EEG changes do you expect to see in stage III of sleep?
delta
154
What EEG changes do you expect to see in REM sleep?
beta waves
155
What is sleep latency? In what conditions is sleep latency affected?
sleep latency is time from bed -> stage I of sleep
Increased in insomnia
decreased in sleep deprivation (OSA and alcohol)
156
What is REM latency? In what conditions is REM latency affected?
REM latency is time from stage I -> REM (usually 40 minutes)
decreased in narcolepsy
decreased in sleep deprivation (OSA and alcohol)
157
What is REM rebound?
The amount of REM you get significantly increases when you deprive the body of REM sleep
158
What affect do the neurotransmitters serotonin, ACh, norepinephrine, and dopamine have on sleep? (NT specifically, not necessarily medications)
increase serotonin -> increase sleep
increase ACh -> increase dreaming
increase norepinephrine -> increased arousal/awakeness
increase dopamine -> increased arousal/awakeness
159
What effects does GABA have on sleep? How can GABA be stimulated?
GABA -> decrease sleep latency, decrease NREM stage III
| GABA is stimulated by alcohol, nonspecific benzodiazepines, and newer benzodiazepines type 1 (zolpidem)
160
Nightmares - stage, characteristics, age, treatment
will be in REM, no tone, easy to wake up, will remember, any age, no treatment (try to reduce stressors causing nightmares) (alcohol and benzos might decrease this, but SHOULD NOT BE USED)
161
Night terrors - stage, characteristics, age, treatment
NREM Stage III, has tone, appear awake to others, does not remember, parents will complain about this in their child, no treatment (reassurance, it will go away)
162
Obstructive Sleep Apnea cause, presentation/patient, diagnosis, treatment
Cause: excess tissue/fat -> obstructs airway
Pt: daytime somnolence, obese, snoring, large tongue, short neck
Dx: polysomnography -> looking for >/= 15 apneas/hr or five or more apneas + snoring
Tx: CPAP = PEEP, lose weight if due to obesity
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Central Sleep Apnea cause, diagnosis, treatment
Cause: respiratory drive forgets to breathe -> CO2 accumulation; can be caused by opiates, over oxygenation in COPD, stroke, idiopathic (most common)
Dx: polysomnography
Tx: BiLevel or BiPAP
164
Narcolepsy cause, patient/presentation, diagnosis, treatment
Cause: startle -> rapid REM and loss of tone
Pt: decreased sleep latency, 3x/week for 3 months, wake refreshed, cataplexy (could wake up paralyzed), hypnogogic and hypnopompic (hallucinations while going to sleep and waking from sleep, respectively)
Dx: polysomnography
Tx: lifestyle modification (teach to take scheduled naps), can treat with stimulants
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Insomnia
Path: trouble sleeping (falling asleep and staying asleep)
Dx: 3x/week for 3 months
Ask - sleep duration (>6 hours -> normal sleep or jet lag) -> reorient or use phototherapy
(<6 hours -> could have insomnia)
Ask - sleep hygiene (if good -> primary insomnia)
Tx: diphenhydramine, trazodone (SSRI), quetiapine, BZD1 (zolpidem)
166
What would you tell someone when advising on sleep hygiene?
To Do: use bed only for sex and sleep, lights off
| Avoid: stimulants (caffeine, amphetamines, etc), avoid exercise and alcohol
167
What are the criteria for diagnosis of gender dysphoria?
identity is not congruent with assignment AND it causes distress; duration must be > 6 months
Needs one:
1. Identity not congruent with assignment
2. Desire to be or be treated like the opposite sex
3. Desire to be rid of secondary sex characteristics (and be asexual)
4. Believes they are the opposite sex
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What is the treatment for gender dysphoria?
psychotherapy (in order to obtain gender reassignment surgery)
169
What do you expect to find in a patient's history who has a somatiform disorder?
multiple doctors, many tests, anxiety disorder or major depressive disorder, multiple surgeries
170
What should be ruled out prior to a diagnosis of somatiform disorder?
r/o organic causes
r/o factitious disorder
r/o malingering
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What is the treatment for somatiform disorder?
psychotherapy
| having ONE physician that controls boundaries, number of visits, tests ordered, etc.
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illness anxiety disorder symptoms, preoccupation, motivation
symptoms: NONE
preoccupation: acquiring illness despite reassurance
motivation: absolutely unwanted
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symptom somatic disorder
symptoms: pain or fatigue
preoccupation: somatic symptom +/- real medical dx (but complaint will be disproportionate to diagnosis)
motivation: unwanted
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conversion disorder
symptoms: neurologic complaint or life stressor
preoccupation: NONE; won't harm self (gets paralyzed when something terrible happens but won't trip and fall down the stairs while paralyzed)
motivation: unwanted
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factitious disorder
symptoms: ANY
preoccupation: to achieve attention or fulfill a role
motivation: intentionally deceive
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malingerring
symptoms: ANY
preoccupation: secondary gain (money, insurance, freedom)
motivation: intentionally deceive
177
What neurotransmitter can be decreased with deep breathing techniques to aid in nightmares?
norepinephrine (modulates flight or fight) - deep breathing stimulates the vagus nerve, thus stimulating parasympathetic activity
178
Is sublimation a mature, immature, or neurotic defense mechanism? What is it?
mature; patient channels displeasing impulses and desires into constructive and positive actions
Ex: a man who likes cutting and blood becomes a butcher at a local store
179
Is suppression a mature, immature, or neurotic defense mechanism? What is it?
mature; a patient recognizes an uncomfortable situation, but consciously or semiconsciously minimizes thoughts of the stressor by trying to ignore it or temporarily postpone it.
Ex: a mother tries to ignore her fear of flying so she can travel to see her daughter get married
180
Is displacement a mature, immature, or neurotic defense mechanism? What is it?
neurotic; patient substitutes the real stressor for one which is less threatening. Problematic feelings are transferred from her ear target to a harmless victim or inanimate object.
Ex: A man who is angry at his therapist for confronting him about a maladaptive behavior returns home and yells at his wife.
181
Is intellectualization a mature, immature, or neurotic defense mechanism? What is it?
neurotic; patient avoids the emotional consequences of the stressor by focusing on the intellectual and inanimate details of the stressor.
Ex: A woman who fears that she may have colon cancer spends her time researching new treatments rather than maximizing her time with her family and friends.
182
Is rationalization a mature, immature, or neurotic defense mechanism? What is it?
neurotic; involves the patient excusing or justifying an attitude or event by developing an alternate explanation or shifting the blame.
Ex: a man who is driving above the speed limit crashes his car into the one adjacent to his on the highway - he blames the accident on the other driver for not paying attention
183
Is reaction formation a mature, immature, or neurotic defense mechanism? What is it?
neurotic; reaction formation occurs when an unacceptable impulse is turned into its opposite.
Ex: a person who dislikes someone acts overly friendly toward them to hide their true feelings
184
Is acting out a mature, immature, or neurotic defense mechanism? What is it?
immature; patient expresses an unconscious thought or feeling through an impulsive action (allows them to avoid the anxiety caused by acknowledging the thought or feeling)
Ex: a woman who is angry and frustrated because she may have cancer goes out drinking and starts spending money excessively
185
Is projection a mature, immature, or neurotic defense mechanism? What is it?
immature; patient takes his or her own feelings and switches ownership of those thoughts to another. (thinks what he/she secretly feels is what another person is feeling).
Ex: a woman resents her younger sister, so, instead she accuses her younger sister of resenting her.
186
What psychiatric symptoms do you expect to see in serotonin discontinuation syndrome?
anxiety, agitation, irritable mood, insomnia, nightmares, poor concentration
187
What neurologic symptoms do you expect to see in serotonin discontinuation syndrome?
headache/migraines, dizziness/lightheadedness, vertigo, weakness, tremor, ataxia, paresthesias, "rushing" sensations in head, "electric-shock" sensations in head
188
What somatic symptoms do you expect to see in serotonin discontinuation syndrome?
flu-like symptoms (fatigue, malaise, myalgia), GI distress (nausea, vomiting, diarrhea, abdominal pain)
189
What is the action of buprenorphine and what is it used for?
partial agonist at opioid receptors; it is commonly used as maintenance therapy to prevent opioid withdrawal
190
In a bulimia nervosa patient, you expect to see decreased potassium, elevated BUN, normal creatinine, and elevation of what enzyme?
salivary amylase due to repetitive parotid gland stimulation
191
In conversion disorder, does the patient have psychological distress about their illness, yes or no?
no, conversion disorder is characterized by loss or alteration of physical function that may resemble somatic illness, but it caused by underlying psychopathology. It often occurs after a significant psychological stressor and develops suddenly. A key factor is an absence of psychological distress int he presence of a significant complaint
192
What is a specific phobia? How is it different than agoraphobia?
A specific phobia involves a fear of any specific situation that cannot be account for by any other diagnosis, including agoraphobia, social phobia, OCD, or separation anxiety disorder.
193
What is psychoanalysis?
intensive form of therapy based on the concept that psychopathology is a result of repressed and unconscious feelings (regression, transference, free association, identifying and challenging defense mechanisms, and interpretation of unconscious drives and thoughts)
194
What are the symptoms of MDMA intoxication? How is it treated?
MDMA = an amphetamine; intoxication - first euphoria, friendliness, and feelings of love -> then mood disorder, most often with manic or mixed features -> then seizures, autonomic hyperactivity, and agitation; prevention of seizures and autonomic hyperactivity is mediated by benzodiazepines (lorazepam or diazepam)
195
What is the treatment for catatonia?
benzodiazepines, primarily lorazepam
196
What is the MOA of memantine? When is it used?
NMDA receptor antagonist (prevents gluatamate-associated neurotoxicity); approved for the treatment of Alzheimer's dementia either alone or in combo with cholinesterase inhibitors
197
What is the MOA of galantamine, rivastigmine, and donepezil?
cholinesterase inhibitors (not to be used in combo with one another)
198
What does anticholinergic toxicity look like?
delirium, fever, tachycardia, flushing, dry mucous membranes, and constipation
199
What is a side effect of lamotrigine?
sevens-johnson syndrome
200
What is a side effect of topiramate?
cognitive suppression and sedation
201
What are some side effects of valproic acid?
sedation, hepatotoxicity, teratogenesis, weight gain, hair loss
202
What is a side effect of levetiracetam?
nonspecific psychiatric adverse effects (can exacerbate depression, anxiety, irritability, and psychosis)
203
How does neurosyphilis present? How do you check for it?
dementia, pupillary changes, ataxia, urinary incontinence, and impaired peripheral vibratory and proprioceptive sensation; check rapid plasma reagin
204
What type of epilepsy can be confused with schizophrenia?
temporal lobe epilepsy (particularly complex partial seizures due to involvement of the hippocampus)
205
What is an example of acute dystonia?
torticollis
206
What is an example of akathisia?
restless leg syndrome
207
What movements will you commonly see with tardive dyskinesia?
repeated grimacing, grunting, or other muscle movements (repeated hand movements)
208
Is altruism a mature, immature, or neurotic defense mechanism? What is it?
mature; the patient "lives vicariously" through helping others.
Ex: a rich banker who once dreamt of becoming a painter now gives money to struggling artists
209
Is humor a mature, immature, or neurotic defense mechanism? What is it?
mature; patient uses comedy to acknowledge and express feelings about the stressful situation.
Ex: an obese man who has a MI jokes that he needs to join a TV show in which he would be forced to lose weight.
210
Is denial a mature, immature, or neurotic defense mechanism? What is it?
immature; patient refuses to accept, and fully rejects, an aspect of reality.
Ex: a man who has a MI states that the lab tests are incorrect and he simply has indigestion.
211
What psychiatric symptoms can those with multiple sclerosis present with?
depression, anxiety, bipolar disorder
212
specific phobias are described by the patient as being excessive and unreasonable. True or false?
true
213
What are the four side effects of lithium?
1. fine tremor (Tx with propranolol)
2. hypothyroidism (Tx with levothyroxine)
3. diabetes insipidus (stop medication or amiloride)
4. direct nephrotoxicity
214
What are the five side effects of carbamazepine?
1. hyponatremia secondary to SIADH
2. agranulocytosis
3. Stevens-Johnson syndrome
4. neural tube defects in developing fetuses
5. cytochrome P450 induction
215
What are the two side effects specific to olanzapine?
weight gain and metabolic syndrome
216
What are the 4 side effects of valproid acid?
1. weight gain
2. hepatotoxicity
3. thrombocytopenia
4. neural tube defects
217
What neurotransmitter is affected in ADHD?
norepinephrine (tx with stimulants, norepinephrine reuptake inhibitors)
218
What neurotransmitters are affected in major depression?
serotonin, norepinephrine, dopamine (treat with SSRIs, SNRIs, and NDRIs)
219
What neurotransmitter is affected in mania?
dopamine (Tx with antipsychotics)
220
What neurotransmitter is affected in schizophrenia?
dopamine (Tx with antipsychotics)
221
What neurotransmitter is affected in OCD?
serotonin (Tx with SSRIs)
222
What neurotransmitters are affected in anxiety disorders?
serotonin (SSRIs), GABA (benzodiazepines)
223
What does the prodromal phase of schizophrenia consist of and how long does it last?
prodromal phase of schizophrenia usually lasts for several months before development of psychotic symptoms; characterized by social isolation, decreased speech, decreased motivation, poor interest in activities, and blunting of affect
224
patient swill describe at least 3 months of chronic diffuse muscle pain that varies in severity and location, but is constantly present in some area of the body - what is it?
fibromyalgia
225
What other symptoms/disorders is fibromyalgia associated with?
fatigue, sleep disturbance, other features of major depressive disorder
226
What is the treatment for fibromyalgia?
TCAs (amitriptyline, nortriptyline)
227
What is the difference between major depressive disorder with atypical features and typical features?
physical symptoms are more prominent than psychological symptoms in atypical vs typical MDD (particularly increased sleep and increased appetite)
Two of the following four symptoms must be exhibited: increased sleep, increased appetite, hypersensitivity to psychosocial rejection, and leaden paralysis
228
What is the treatment for major depressive disorder with atypical features?
first line is still SSRIs, but MAOIs are particularly effective
229
What drug is commonly known for causing cognitive suppression?
topiramate (dose-dependent impairments in memory, executive function, psychomotor activity, and speech fluency)
230
What are the two biggest symptoms/complaints with separation anxiety disorder?
children develop severe anxiety or somatic symptoms when forced to go to school or separate from their parents for any reason; stomachaches are the most common manifestation of the somatic complaints. Child often sleeps with their parents
231
What is known to be a poor prognostic factor in patients with schizophrenia?
presence of negative symptoms (blunted affect, poor motivation, apathy, social withdrawal, decreased speech, and poverty of speech or thought)
232
Is controlling a mature, immature, or neurotic defense mechanism? What is it?
neurotic; patient manages the external environment instead of addressing the actual stressor.
Ex: a single father insists that his children line up for inspection three times a day to ensure perfection in the home.
233
Is repression a mature, immature, or neurotic defense mechanism? What is it?
neurotic; patient unconsciously blocking and avoiding awareness of the stressor.
Ex: a woman forgets that she called her boyfriend three times earlier in the day
234
Is regression a mature, immature, or neurotic defense mechanism? What is it?
immature; patient reverts to an earlier developmental state, often with childlike behaviors and emotions.
Ex: a woman throws a temper tantrum when confronted with an uncomfortable idea
235
What are the general rules regarding antipsychotics and pregnancy?
1. maintenance of therapy, even if teratogenic (a relapse of psychotic symptoms would be worse for baby)
2. if starting a new medication, lamotrigine is 1st line.
3. If starting a new medication, risperidone and quetiapine are second-line
236
Is anticipation a mature, immature, or neurotic defense mechanism? What is it?
mature; addressing a future concern by preparing for it in an appropriate manner.
Ex: A person who is concerned about a future nuclear attack prepares by purchasing a family bomb shelter
237
Is undoing a mature, immature, or neurotic defense mechanism? What is it?
neurotic; addressing an unacceptable thought or behavior by attempting to do the opposite.
Ex: a cigarette company executive donates money to lung cancer research
238
What is Cotard syndrome?
the delusional belief that the individual's own body or body parts are dead or dying (can expand to include the belief the world is also dead or unreal). Acutely, it is most likely seen in schizophrenia or severe depressive episode. Chronically, associated with Alzheimer's.
239
What is Capgras syndrome?
delusion that a familiar person/relative has been replaced by an imposter who shares the same appearance. Commonly associated with schizophrenia but can be a sign of dementia, head trauma, malignancy
240
What is delusional disorder?
at least 1 month of non-bizarre delusions that do not significantly impair daily functioning.
241
What is Fregoli syndrome?
belief that several different people/strangers are actually one person, usually a familiar individual or persecutor, who is in disguise or can change his/her appearance
242
Which benzodiazepines are safe to use in a patient with advanced liver disease to treat delirium tremens?
lorazepam and oxazepam (in healthy patients, diazepam and chlordiazepoxide are the drugs of choice)
243
What is the cognitive triad of depression?
States that depression is characterized by:
1. negative views about oneself
2. negative views about the world
3. expectation of future failure
244
Which antipsychotics are best for treating delirium?
high-potency: haloperidol (preferred), fluphenazine, risperidone, paliperidone, ziprasidone, aripiprazole
245
What is first line treatment for neuroleptic malignant syndrome?
benzodiazepines, bromocriptine (direct dopamine agonist), or dantrolene
246
What is the treatment for serotonin syndrome?
benzodiazepines or cyproheptadine
247
What is the antidote for TCA toxicity?
sodium bicarbonate
248
What is an effective treatment for pain disorder with depressed mood?
duloxetine (and other SNRIs)
