Psych rotation Flashcards
(310 cards)
1
Q
Class and mechanism of mirtazapine? Uses?
A
Tetracyclic antidepressant
Noradrenergic and serotonergic mechanisms; NOT A REUPTAKE INHIBITOR
Depression
Anxiety disorders
Induce sleep
2
Q
What is ideas of reference?
A
False beliefs that, for example, TV, radio, performer, song, or newspaper article refers to oneself
3
Q
Pt started on lithium. You might see a benign increase in ________. They also have a tremor. How can you help the tremor?
A
Benign increase in WBC
Propanolol can may help with tremor
4
Q
Normal grief feelings of guilt, sadness, appetite changes, illusions usually abate after _______ (time)
A
Usually abate after 6 months of the loss
Pt’s ability to function appropriately in their life is preserved
5
Q
What is complicated grief?
A
Complicated/prolonged grief:
- Persists for at least 6 months + 4/8 symptoms:
- Difficulty moving on with life
- Numbness/detachment
- Bitterness
- Agitation
- Feeling that life is empty without deceased
- Trouble accepting loss
- Feeling the future holds no meaning without deceased
- Difficulty trusting others since loss
6
Q
Age related effects of alcohol?
A
Decreased alcohol dehydrogenase –> increased BAL with less drinks compared to younger adults
Increased CNS sensitivity to alcohols
7
Q
Isoniazid + alcohol use can lead to increased risk of _____
A
Increased risk of hepatotoxicity
Alcohol + acetaminophen, isoniazid, or phenylbutazone
8
Q
Antihistamines + alcohol use can lead to increased _____
A
Sedation
Alcohol with these can cause sedation: Antihistamine Benzos TCAs Narcotics Barbiturates
9
Q
Drinking alcohol with what other drug can lead to higher BALs?
A
Alcohol + H2 blockers –> Higher BALs
10
Q
Alcohol + long acting hypoglycemics –> ?
A
Nausea/vomiting
11
Q
Most common psych disorder in elderly?
A
MDD
12
Q
Most Alzheimers patients experience delusions. T/F?
A
True
Delusions are reported in up to 70% of Alzheimers
13
Q
Most dementia patients experience hallucinations. T/F? Are they mostly auditory or visual?
A
False
Hallucinations can be seen in up to 33% of dementia pts
Mostly VISUAL
14
Q
Visual hallucinations early in dementia suggest a dx of _____
A
Lewy body dementia
DO NOT GIVE ANTIPSYCHOTICS
15
Q
If you have to use antipsychotics in elderly, which meds?
A
Quetiapine or olanzapine with severe symptoms
Short term haloperidol or risperidone
16
Q
If sedative hypnotics are used in the elderly, what drugs are used?
A
Trazodone
Hydroxyzine
(safer than the more sedating benzos)
17
Q
What is K-ABC? WISC-R?
A
K-ABC: intelligence test for children 2-12
WISC-R: Determines IQ for ages 6-16
18
Q
What defines intellectual disability/mental retardation?
A
- Significantly subaverage IQ of
19
Q
Mental retardation affects males more than females. T/F?
A
True
Men are affected 1.5x as often as females
*85% of MR are mild cases (IQ 55-70)
20
Q
What are the different categories of MR?
A
1-2% Profound / IQ
21
Q
What are prenatal causes of MR?
A
TORCH infections
Toxo, other (syphilis, AIDS, alcohol/drugs), rubella, CMV, herpes simplex
22
Q
Perinatal causes of MR?
A
Anorexia Prematurity Birth trauma Meningitis Hyperbilirubinemia
23
Q
Postnatal causes of MR?
A
Hypothyroidism Malnutrition Toxin exposure Trauma Psychosocial causes
24
Q
Genetic causes of MR?
A
Down syndrome Fragile X syndrome (2nd most common cause of MR) PKU Prader Willi Angelman Williams syndrome Tuberous sclerosis
25
Most common inherited form of mental retardation?
Fragile X
| FMR1 gene defect on X chromosome, M>F
26
Most common of learning disorders?
Reading, boys may be more affected than girls
27
What is ADHD? What are the types?
Inattention and/or hyperactivity and impulsivity greater than expected for age
Three types:
Predominantly inattentive
Predominantly hyperactive-impulsive
Combined
28
How do you dx ADHD?
At least 6 sx of either inattentiveness, hyperactivity, or both
- Persisted for at least 6 months
- Sx present to a degree that is maladaptive
- Onset prior to age 7
29
ADHD is more prevalent in boys. Does it go into adulthood?
Up to 60% of childhood cases will have sx into adulthood (impulsivity > hyperactivity)
30
First line treatment for ADHD?
CNS Stimulants
- Methylphendiate (Ritalin, Concerta, Focalin, Metadate)
- Dextroamphetamine (Dexedrine, DextroStat)
- Amphetamine salts (Adderall)
31
First line for ADHD cant be used. What else can you use?
If first line cant be used, use ALPHA-2 AGONISTS
- Clonidine
- Guanfacine
* can be used at adjuvant therapy to stimulants
32
What disorder can atomoxetine used for?
ADHD; non stimulant that is FDA approved
33
CNS stimulants are good long term options for ADHD. T/F?
False; long term efficacy is controversial
34
Boys > Females in autistic disorder, T/F?
True
| Boys are 3-4x more likely than girls
35
Autism is associated with ______
Mental retardation (70% meet criteria of
36
Autism phenotypic findings? Genetic component?
May have higher peripheral serotonin levels
Increased head size
Persistent primitive reflexes
Abnormalities in EEG findings
YES genetic component; siblings have 22x risk vs general population
37
Two most important predictors of adult outcome in those with autism?
Level of intellectual functioning AND communicative competence
38
Childhood disintegrative disorder is associated with:
- Abnormal EEG findings
- Seizure disorder
- Various medical conditions like Landau-Kleffner, neurolipidoses, mitochondrial deficits, metachromatic leukodystrophy, CNS infection
39
What is tourettes?
Most severe tic disorder
- Multiple daily motor tics
- One or more vocal tics
- Onset before 18
* **Vocal tics may appear many YEARS after motor tic
40
What are the types of vocal tics seen in Tourettes?
Coprolalia - repetitive speaking of obscene words
| Echolalia - exact repetition of words
41
How do you dx tourettes?
- Onset before 18
- Motor and vocal tics both present at some point, not attributable to CNS disease
- Tics occur many times a day, almost every day for >1 year
- No tic free period >3 months
- Change in anatomic location and character of tics over time
42
Describe course of sx of someone with Tourettes?
Sx peak in severity between 8-12 years old, decrease with puberty
Decrease sx/asymptomatic by adulthood
43
Tourettes has a high comorbidity with ______
OCD (40%)
| ADHD (50%)
44
Neurochemical factors that contribute to Tourettes?
Impaired regulation of dopamine in caudate nucleus
| and possibly impaired regulation of endogenous opiates and the noradrenergic system
45
Tx of Tourettes?
When tics become a source of impairment:
- Atypicals (e.g. risperidone)
- Alpha-2-agonists (e.g. clonidine, guanfacine)
- SEVERE? Use typicals (e.g. haloperidol, pimozide)
46
Do you have to be worried about withdrawal with antidepressants?
```
YES
Most antidepressants have a withdrawal phenomenon
- Dizziness
- Headaches
- Nausea
- Insomnia
- Fatigue
TAPER, depending on dose and half life
```
47
Regarding SSRIs there is no relationship between plasma levels and efficacy or side effects.
TRUE
| No relationship!
48
Why are SSRIs the most commonly prescribed antidepressant?
- Low incidence of side effects, resolve with time
- No food restrictions
- Much safer in OD
49
Which SSRI do you give to a pregnant women?
Fluoxetine
50
Which SSRI is also approved for use in children?
Fluoxetine
51
Schizophrenia prevalence in men vs women?
Men and women similarly affected
Men present around 20 and have more negative sx and more social impairment
Women present around 30
52
How does season affect schizophrenia?
People born in winter or early spring have a higher incidence of schizophrenia for unknown reasons
53
Should you screen for substance abuse in those with schizophrenia? If so, what?
Yes, substance abuse comorbid
Alcohol (most common)
Cannabis
Cocaine (least)
54
What is the downward drift hypothesis?
People with schizophrenia are unable to function well in society --> enter lower socioeconomic groups --> lower socioeconomic groups have higher rates of schizophrenia
55
What would you expect to see on CT of schizophrenia pt?
Enlarged ventricles
| Diffuse cortical atrophy
56
Ketamine mechanism? How does it relate to those with schizophrenia?
NMDA antagonist (glutamate receptor)
In schizophrenics, they have lower # of NMDA receptors; correlates with psychotic symptoms observed with ketamine
57
NE, Serotonin, dopamine, GABA levels in schizophrenics?
Dopamine: increased
Serotonin: increased
NE: increased
GABA: decreased (decreased expression of the enzyme necessary to create GABA in the hippocampus)
58
How does onset of schizophrenia relate to prognosis?
Earlier onset and gradual onset = poor prognosis
| Later onset and acute onset = better prognosis
59
How do positive or negative sx relate to prognosis?
Positive sx = better prognosis
| Negative sx = poor prognosis
60
Mood symptoms in people with schizophrenia is associated with better or worse prognosis?
Mood sx associated with BETTER prognosis
61
Mechanism of typical and atypical neuroleptics?
Typical: D2 antagonist
Atypical: 5-HT2 and dopamine receptor antagonist
62
What kind of lab tests would you order for someone on atypical antipsychotics?
FBG
Lipids
BP, waist circumference, BMI
--> METABOLIC SYNDROME (increased risk with atypicals)
63
Beta blockers and _____ are known to exacerbate psychosis in predisposed patients
Beta blockers and digoxin
64
Prognosis of schizophreniform disorder?
Remember 1-6 months; >6mo is schizophrenia
1/3 recover completely
2/3 progress to schizoaffective or schizophrenia
65
Prognosis for schizoaffective disorder?
60% progress to schizophrenia
66
What is a brief psychotic disorder?
Psychotic sx just like in schizophrenia
| Sx last from 1 DAY to 1 MONTH
67
Delusional disorder occurs more in _____ population
Older (>40)
Immigrants
Hearing impaired
68
Bizarre or nonbizarre delusions in delusional disorder?
NONbizarre delusions for at least 1 month (bizarre delusions are found in schizophrenia)
(cant meet criteria for schizophrenia, functioning in life not significantly impaired)
69
Folie a deux is also known as _______ and it's characterized by:
Induced Psychotic Disorder
| - Pt develops same delusional sx as someone he or she is in a close relationship with
70
Can someone have a manic episode for less than a week?
Yes if they are hospitalized, it can be any length of time
Otherwise, at least for one week
Persistently elevated, expansive, or irritable mood
71
Mixed manic/depressive episode is a psychiatry emergency. T/F?
True; same with manic episode
| - Severely impaired judgement makes patient dangerous to self and others
72
MDD prevalence in men vs women?
Equal before menses and after menopause
| Women 2x likely in reproductive years
73
Sleep changes in MDD?
- REM shifted to earlier in night
- Decreased stage 3/4 sleep
- Hypersomnia
- Multiple awakenings
- Initial and terminal insomnia (hard to fall asleep and wake up)
74
How does dexamethasone relate to MDD?
High cortisol is associated with MDD
| - Hyperactivity of HPA axis as shown by failure to suppress cortisol by dexamethasone suppression test
75
Death of a parent before age 11 is associated with later development of ______.
MDD
| So is pancreatic cancer
76
Neurotransmitter change in MDD?
Decreased brain and CSF 5-HT and 5-HIAA
77
How long do depressive episodes last if untreated in MDD?
Usually self limited
| last 6-13 months
78
Which class of antidepressants is most lethal in OD?
TCAs
79
Side effects of SSRIs?
GI disturbances
Sexual dysfunction
Headache
Rebound anxiety
80
TCA side effects?
```
Orthostasis
Weight gain
Sedation
Anticholinergic effects
Can aggravate QTc prolongation
```
81
MAOI is used for _______ and has a major side effect of _____
Refractory depression
| Orthostasis
82
Postpartum depression usually resolves without medication. T/F?
True
83
When is ECT used?
Unresponsive to pharmaco
Can't tolerate pharmaco (pregnant, elderly)
Desire rapid reduction in sx (e.g. suicide risk)
84
During ECT, premedication with ______, then give ____ and ____
Premed with atropine, give anesthesia (propofol, ketamine, etc), muscle relaxant (succinylcholine)
85
Side effects of ECT
Retrograde and anterograde amnesia (usually disappears within 6 mo)
Headache, nausea, muscle soreness
86
Pharmacotherapy and psychotherapy is more effective in treating depression than either treatment alone. T/F?
TRUE
87
Atypical features of depression? Tx?
Mood reactivity (mood brightens in response to positive events)
Leaden paralysis (legs feel heavy)
Hypersomnia
Hyperphagia
Hypersensitivity to interpersonal rejection
If atypical depression? Use MAOI!
88
Dysthymia can never have psychotic features. T/F?
TRUE
| If they have delusions or hallucinations with "depression" consider another dx like MDD or schizoaffective
89
High potency antipsychotic associated with heart block, ventricular tachycardia, etc?
Pimozide
90
Low potency antipsychotic that can cause bluish skin discoloration?
Chlorpromazine
- can also cause photosensitivity
- used to treat N/V and intractable hiccups
91
Mechanism for how antipsychotics cause hyperprolactinemia?
Blocks dopamine activity in tuberoinfundibular pathway --> prolactinemia --> galactorrhea, gynecomastia, amenorrhea, sexual dysfunction
92
Adjustment disorder prevalence in men vs women
Occurs 2x more in women
93
When should you think adjustment disorder?
Stressful life event --> maladaptive behavior/emotional sx that begin within 3 months, resolve by 6 months
--> causes significant impairment in daily functioning and interpersonal relationships
94
Tx of adjustment d/o?
Supportive psychotherapy!!!!!
Group therapy
Meds for symptoms like insomnia, anxiety, depression, etc
95
Common comorbidities of panic attacks?
```
MDD
Bipolar
Agoraphobia
Substance abuse
*Also linked to a higher rate of suicide attempts or ideation
```
96
How long does bereavement last?
Sx usually last up to 2 months
97
Hoarding disorder is treated with cognitive behavioral therapy and ____
SSRIs
98
What is panic disorder? Acute treatment? Long term?
Recurrent and unexpected panic attacks with 4 or more of things like palpitations, sweating, sob, chest pain, dizziness, fear of dying, etc
Immediate: benzos
Long term: SSRIs, SNRI, and/or cognitive behavioral therapy
99
First line treatment for specific phobia?
Specific phobia: fears specific object or situation
First line: BEHAVIORAL THERAPY (via exposure therapy)
*short acting benzos like lorazepam or alprazolam are effective in alleviating anxiety acutely but not first line for phobia because outweighed by rebound anxiety, dependence and cognitive impairment
100
How do you treat anorexia?
FOOD
Behavioral therapy, family therapy, weight gain programs
Low dose 2nd gen antipsychotics (e.g. olanzapine) may treat preoccupation with weight gain and food, can help cause weight gain
Benzos before meals for preprandial anxiety
101
How do you treat bulimia?
Antidepressants + therapy
- SSRIs are FIRST LINE; Fluoxetine is the only FDA approved one
- Therapy: CBT, interpersonal psychotherapy, family therapy, group therapy
102
First line for OCD?
SSRIs (high doses)
| TCAs (clomipramine)
103
Functional neuroimaging of pts with social phobia (social anxiety disorder) shows MORE activity in ______
Amygdala
| Insula
104
Performance anxiety is often successfully treated with:
beta blockers
| atenolo, propanolol
105
How to treat social phobia?
Psychotherapy/desensitization
Severe? Some pharmacological:
- SSRIs
- Benzos
- Venlafaxine
- Buspirone (can augment treatment when used adjunctively with SSRIs)
106
Specific phobias are more common than social phobias. T/F? Specific phobias are more common in men vs women? T/F?
True, specific > social
| False, women > men
107
PCP intoxication physical findings?
```
Nystagmus
Dysarthria
Hyperacusis
Hypertension or tachycardia
Muscle rigidity
Ataxia
Seizures or coma
Numbness
```
Behavioral manifestations are very UNPREDICTABLE; can be sociable one minute and extremely violent the next.
108
PCP intoxication tx?
If nonpsychotic:
- Benzos for muscle spasms, seizures, sedation, agitation, anxiety
If agitated or psychotic:
- Antipsychotics (haldol is popular, or atypical antipsychotics)
- AVOID typical low potency antipsychotics because can increased PCP-induced hyperthermia, dystonia, anticholinergic effects and lower seizure threshold
109
Non pharm intervention for PCP intoxication?
Place in room away from stimulation, dark room
Avoid physical restraints because risk of muscle breakdown (but might need restraints initially)
110
What other drug is commonly used with PCP?
Marijuana; PCP often added to marijuana cigarettes; do UDS!
111
Chances of getting bipolar disorder is a first degree relative has it? What if both parents have it? What if your monozygotic twin has it? Dizygotic twin? General population?
```
1st degree: 5-10%
Both parents: 60%
Mono twin: 70%
Dizygotic twin (same as 1st degree): 5-10%
General population: 1%
```
112
First line for acute mania?
Antipsychotics
or Mood stabilizers (Lithium, Valproate, Carbamazepine)
**But mood stabilizers need gradual titration over several days for therapeutic blood levels so it would be less effective in controlling pts acute agitation
113
When should you think somatization disorder?
Multiple organ systems
Chronic
Onset BEFORE age 30
Seen multiple doctors
114
Tx of somatization disorder?
Regularly scheduled PCP visits with limited medical workup
Be slow with psychology, will likely refuse MH referral
115
Somatization disorder, conversion disorder, hypochondriasis are all more common in women vs men. T/F?
False; somatization and conversion are more in WOMEN
| Hypochondriasis MEN = WOMEN
116
When would you see la belle indifference?
See it in conversion disorder where patients are calm and unconcerned when describing their symptoms
117
Common symptoms of conversion disorder?
```
Shifting paralysis
Blindness
Paralysis
Paresthesia
Mutism
Seizures
Globus hystericus (sensation of lump in throat)
```
118
Most patients with conversion disorder resolve spontaneously. T/F?
```
True
Tx may include
- Insight oriented psychotherapy
- Hypnosis
- Relaxation therapy
```
119
Hypochondriasis has to last for _____ (time)
At least 6 months; preoccupation with fear of having or contracting serious disease, based on misinterpreting bodily symptoms
120
Good prognostic factors for someone with hypochondriasis?
Higher SES
Treatment responsive anxiety or depression
Absence of comorbid medical conditions and personality disorders
121
How do you treat hypochondriasis?
Regularly scheduled visits to PCP
Comorbid anxiety or depression? Treat with SSRI or other psychotropic
CBT is the most useful of psychotherapies
122
Body dysmorphic disorder; seen in what kind of patient? onset?
Women > men
Unmarried > married
Onset between 15-20yo; usually gradual onset
123
Surgical/dermatological interventions are often successful in body dysmorphic disorder. T/F?
False!
124
How do you treat body dysmoprhic d/o?
NOT surgical/dermatological
| SSRI's helpful in 50%
125
How do you define acute vs chronic pain disorder?
6 month
| Pain often coexists with medical condition but is not directly caused by it or not FULLY accounted for by it
126
Tx for pain disorder?
```
SSRIs
Biofeedback
Hypnosis
Psychotherapy
***DO NOT USE ANALGESICS; not helpful and pts become dependent on them
```
127
_____ can exacerbate the sx of pain disorder
MDD
128
What is primary gain?
Sx as an unconscious defense against unacceptable INTERNAL conflicts
- Self justification for various actions or lack of action
129
What is secondary gain?
Sx that provide unconscious external benefits (attention from others, decreased responsibilities, avoidance of law)
Malingering is NOT secondary gain because its CONSCIOUS external benefit
130
Munchhausen syndrome is also known as _____ and is:
Aka factitious disorder
| - Predominantly physical complaints
131
Factitious disorder is higher in _____ (population)
```
Hospital/health care workers
Higher intelligence
Poor sense of identity
Poor sexual adjustment
Many pts have history of child abuse or neglect
```
132
How do you treat factitious disorder?
Collect collateral
Collab with PCP to avoid unnecessary procedures
Avoid early confrontation (will leave AMA and get hospitalized elsewhere)
*Repeated and long term hospitalization is common
133
Intermittent explosive disorder tx?
```
SSRI- esp fluoxetine
Anticonvulsants
Mood stabilizers - lithium
Antipsychotics
Propanolol
```
Individual psychotherapy is INEFFECTIVE and DIFFICULT
134
Low levels of _____ have been associated with impulsiveness and aggression
Serotonin
135
1/4 of bulimia patients have comorbid _____
Kleptomania
136
Majority of shoplifters have kleptomania. T/F?
False; less than 5% of shoplifters have kleptomania
137
How do you treat kleptomania?
Insight-oriented psychotherapy
Behavior therapy such as desensitization, aversive conditioning
SSRIs
maybe naltrexone
138
People with kleptomania experience guilt when they steal. T/F
True
| Pleasure is from stealing; often report intense guilt and shame
139
Comorbid conditions of those with klepto?
Mood disorders
Eating disorders
OCD
*Klepto more in women, but severity of sx equal in men vs women
140
Pt has pathological gambling; what other disorders might they have?
Increased incidence of:
- Mood disorders
- Anxiety disorders
- OCD
141
Most people with pathological gambling recover without treatment. T/F?
False; 1/3 recover without treatment
142
Predisposing factors to pathological gambling?
Loss of a parent during childhood
Inappropriate discipline from parent in childhood
ADHD
Lack of family emphasis on budgeting
143
Most effective treatment for pathological gambling?
Participating in gamblers anonymous (12-step)
After 3 months of abstinence from gambling, insight-oriented psychotherapy may be attempted
144
Trichotillomania is more common in men vs women. T/F?
False; more in women
145
Trigger for trichotillomania behavior?
TEXTURE of the hair
146
Pts with trichotillomania have an increased incidence of comorbid:
Borderline personality disorder
OCD
OCDP
Mood disorders
147
Tx for trichotillomania?
SSRIs
Antipsychotics
Lithium
148
Onset and prognosis of pyromania?
Onset is late adolescence
Prognosis better in children vs adults
*w/ tx, children recover completely
149
Tx of pyromania?
Behavior therapy
Supervision
SSRI
150
____ (hormone) is often increased in anorexia
Cortisol
151
Bulimia patient with laxative abuse...alkalosis or acidosis?
Metabolic acidosis
152
Lab findings in bulimia to look for?
```
Increased BUN, amylase
Hypernatremia
Hypochloremia hypokalemic alkalosis
Altered thyroid hormone and cortisol homeostasis
*Metabolic acidosis (laxative abuse)
```
153
Physical findings in bulimia?
```
Russell's sign
Sialadenosis (enlarged parotid glands)
Dental erosions
Petechiae
Peripheral edema
Aspiration
```
154
Comorbid disorders associated with bulimia?
Mood disorders
Anxiety disorders
Impulse control disorders
Prevalence of cluster B and C personality disorders!
155
Bulimia has a better prognosis compared to anorexia. T/F?
True
156
Most people with bulimia fully recover with treatment. T/F?
1/2 recover fully with treatment
| 1/2 have chronic course with fluctuating sx
157
Tx for binge eating?
Individual psychotherapy and behavioral therapy + strict diet and exercise
Pharmacotherapy can be used adjunctively to promote weight loss:
- Stimulants to suppress appetite (phentermine, amphetamine)
- Orlistat (inhibits pancreatic lipase)
- Sibutramine (inhibits reuptake of NE, serotonin, dopamine)
158
Pathophysiology of narcolepsy?
Linked to loss of hypothalamic neurons that contain hypocretin
May have autoimmune component
159
Kleine-Levin syndrome?
Rare; recurrent hypersomnia with episodes of daytime sleepiness + hyperphagia, hypersexuality, aggression
Sx:
- Insomnia
- waking up at inappropriate times
- headaches, difficulty concentration, frequent performance errors, increased reaction times
160
Nightmare disorder?
Recurring nightmares, awakens with vivid recall, NO confusion or disorientation with wakening
Higher in women
161
Tx of nightmare disorder?
IRT; imagery rehearsal therapy
- mental imagery to modify the outcome of of a recurrent nightmare; writing down improved outcome then mentally rehearsing it in a relaxed state
- severe? may use antidepressants
162
GAD first line tx?
SSRI, SNRI
Tx for GAD includes CBT, meds, or both.
163
First line for generalized social anxiety disorder? Performance social anxiety?
(Marked anxiety about 1 or more social situations for >6mos, fear of scrutiny, humiliation, embarrassment, avoid social situations, marked impairments)
Generalized:
- SSRI/SNRI first line
- CBT first line
Performance only:
- Benzo or propanolol 30-60min before
- CBT
- *Avoid benzos if substance abuse or sedation is not desired
164
Difference between risperidone and aripiprazole?
Risperidone is a dopamine and serotonin antagonist --> can cause weight gain and hyperprolactinemia (amenorrhea, galactorrhea)
Aripiprazole is a PARTIAL AGONIST of D2 receptors so no galactorrhea
165
Youth presents to pediatrician with complaints of sudden onset of anger and irritability, sudden poor grades, lack of interest in fun activities and decreased energy. Dx?
Depression
| - Pt might stay up late by wanting to watch TV but actually has trouble falling asleep
166
MAO-A and MAO-B deactivates?
MAO-A: Serotonin
MAO-B: NE, Epi
Both: Dopamine and tyramine
167
MAOI?
Phenelzine
Isocarboxazid
Tranylcypromine
168
ODD vs CD?
ODD: negative behavior pattern
| but offenses do NOT typically cause significant harm to others or involve violations of major societal norms
169
How to treat CD?
Multisystemic treatment approach
- combines well-coordinated plan to help parents develop new skills at home like parent-child interaction training, to help the relationship between parents/caregivers and the child
Also
- Teach classroom social skills
- Encourage communication between teachers and parents
Meds:
- stimulants (--> leads to less aggression and impulsiveness)
- atypicals may be helpful in controlling aggression
170
Many children with CD have a comorbid dx of ____
ADHD
171
CD sx categories?
```
Aggression toward people or animals
Destruction of property
Deceitfulness or theft
Serious rule violation
*At least 3 of the sx in the last 12 months with at least one occurring the last 6 months
```
172
Definition of antisocial personality disorder?
Pervasive disregard for and violation of rights of others starting by age 15
Dx if the sx appear AFTER THE AGE OF 18
173
Conduct disorder is more common in children of parents with ______
Antisocial personality disorder
| Alcohol dependence
174
Side effects of tertiary amine TCAs vs secondary amine TCAs?
Tertiary amine TCAs:
- Highly anticholinergic
- More sedating
- More lethal in OD
Secondary amine TCAs:
- Less anticholinergic
- Less sedating
175
Name the tertiary amine TCAs and uses of each
CAID
Clomipramine - OCD (most serotonin specific)
Amitriptyline - Migraines, chronic pain, insomnia
Imipramine - Enuresis, panic disorder (IM form available)
Doxepin - Chronic pain, sleep aid in low doses
176
Name the secondary amine TCAs and uses of each
Nortriptyline - chronic pain (less like to cause orthostasis)
Desipramine - more activating, least sedating, least anticholinergic
177
TCA OD treatment?
Sodium Bicarbonate
178
Name the tetracycline antidepressants
Amoxapine - metabolite of loxapine (antipsychotic), similar side effect profile to typical antipsychotics
Maprotiline - higher rates of seizures, arrhythmia, fatality in OD
179
How much TCA can cause an overdose?
As little as a 1 week supply (1-2g)
180
Three C's (complications) of TCAs?
Cardiotoxicity
Convulsions
Coma
181
Side effects of TCAs?
HAM, weight gain, sex problems
- - anti-Histaminic: sedation
- - anti-Adrenergic: CV side effects, orthostasis, arrhythmias, ECG changes, seizures (avoid in pts with preexisting conduction problems or recent MI)
- - anti-Muscarinic: exacerbation of narrow angle glaucoma, dry mouth, urinary retention, tachycardia, blurred vision, constipation
- - Weight Gain
- - Serotonergic effects: ED problems in men, anorgasmia in women
182
TCAs are highly protein bound and lipid soluble. T/F?
True; thus can interact with other meds that are highly protein bound
Also, side effects of TCAs are due to TCAs lack of receptor specificity and interaction with other receptors
183
Pt has atypical depression but does not want to be put on a dietary restriction if put on an MAOI. What do you use?
Selegiline (Emsam patch)
| *MAOI that does not require dietary restrictions when used in low dosages
184
Describe the course of serotonin syndrome
Initially:
- Lethargy
- Restlessness
- Confusing
- Flushing/diaphoresis
- Tremor
- Myotonic jerks
May progress to:
- hyperthermia, hypertonicity, rhabdomyolysis, renal failure, convulsions, coma, death
185
How do you treat serotonin syndrome?
Discontinue meds
CCB (oral nifedipine)
If carefully monitored, can try chlorpromazine or phentolamine
186
Pt needs to be switched from an SSRI to MAOI. How do you approach this
Wait at least 2 weeks before switching
| If switching from fluoxetine, wait at least 5-6 weeks
187
Side effects of MAOI other than possible serotonin syndrome? Which is most common?
Most common - orthostasis
- Drowsiness
- Weight gain
- Dry mouth
- Sleep dysfunction, sex dysfunction
- Paresthesias (in people with pyridoxine deficiency, tx with B6)
188
Pts on clozapine should get ____ tests at a frequency of ____ for risk of _____
WBC tests
Weekly for first 6 months of treatment, can decrease in frequency after that
Risk of agranulocytosis
189
Tests to order when prescribing/monitoring someone on lithium?
Lithium levels
Thyroid
Creatinine
190
Studies show an increased risk of ____ and ____ when atypical antipsychotics are used in the eldery
All cause mortality
| Stroke
191
Mesolimbic pathway includes which structures? How does this relate to antipsychotics?
Nucleus accumbens
Fornix
Amygdala
Hippocampus
Antipsychotics target mesolimbic dopamine pathway to treat the positive sx of schizophrenia
192
Antipsychotic thats less likely to cause tardive dyskinesia?
Clozapine
193
Neuroleptic malignant syndrome is characterized by ? Seen mostly in ?
```
FALTERED
Fever
Autonomic instability (tachy, labile htn, diaphoresis)
Leukocytosis
Tremor
Elevated CPK
Rigidity (lead pipe)
Excessive sweating
Delirium
```
Young males early in treatment with either typicals or atypicals
194
NMS is treated with things like amantadine or bromocriptine. T/F?
False
Discontinue meds, supportive therapy
Amantadine, bromocriptine, dantrolene are infrequently used because of side effects and unclear efficacy
195
Pt is on a haldol for 5 years. What are the pts chances of getting tardive dyskinesia?
5%
| - 1% per year they are on typical antipsychotics
196
Lab tests to order if you suspect NMS?
Liver enzymes (elevated), jaundice
197
If patient develops NMS from a certain antipsychotic, they can no longer use that drug at a later date. T/F?
False, doesnt prevent pt from restarting the same neuroleptic later
198
Low potency antipsychotics are more likely to lower seizure thresholds. T/F
True
199
In general, how do side effects of atypicals compare to typical antipsychotics?
Atypicals have a less chance of causing EPS, NMS, Tardive dyskinesia
200
Atypicals are used to treat:
```
Schizophrenia (negative sx)
Acute mania
Bipolar
Adjunctive for unipolar depression
Sometimes for personality disorders
```
201
Ziprasidone is an atypical used when you want to avoid _____ (side effect)
Weight gain
| - less likely to cause weight gain
202
Side effects of aripiprazole?
D2 partial agonist so it can be more activating (akathisia)
- also less sedating
- less potential for weight gain
203
What drug is a metabolite of risperidone?
Paliperidone
204
Side effects of risperidone?
Can cause increased prolactin
Orthostasis, reflex tachycardia
Consta = long acting injectable form
205
____ is the only antipsychotic to decrease risk of suicide
Clozapine
206
When MUST you stop clozapine use in a pt?
When absolute neutrophil count drops below 1500/ul
207
____ (antipsychotic) is associated with hypersalivation and can develop myocarditis
Clozapine
- Associated with hypersalivation
- Myocarditis can develop
- ONLY antipsychotic to be more efficacious, decrease risk of suicide
- LESS likely to cause tardive dyskinesia
- MORE anticholinergic effects than other typicals or high potency typicals
208
Side effects of seroquel?
Sedation
| Orthostasis
209
Labs to order with atypical antipsychotic use?
Think metabolic syndrome
- lipids, glucose, BMI, etc
LFT - monitor yearly for elevation and ammonia
QTc prolongation
210
_____ is the only mood stabilizer shown to decrease suicidality
Lithium
211
Prior to initiating someone on lithium, what tests do you want?
```
Basic chemistries
CBC
ECG
Thyroid
Pregnancy test
*Lithium is metabolized by kidney so adjust and monitor if pt has renal dysfunction
```
212
Onset of action of lithium?
5-7 days
213
Normal, toxic, and lethal range of lithium?
.6-1.2 normal
>1.5 toxic
>2 lethal
214
Factors/meds that affect lithium levels?
```
NSAIDs - decrease
Dehydration - increase
Salt loss/sweating - increase
Salt deprivation - increase
Impaired renal function - increase
Aspirin
Diuretics, esp thiazides
```
215
Before starting pt on carbamazepine, what tests should you order? Onset of action?
CBC and LFT, monitor regularly
| Onset: 5-7 days
216
Carbamazepine use?
Mixed episodes and rapid-cycling bipolar disorder
*Less effective for depressed phase
Management of trigeminal neuralgia
217
Carbamazepine mechanism?
Blocks Na+ channels, inhibits AP
218
Side effects of carbamazepine?
GI and CNS are most common (ataxia, sedation, confusion)
SJS
Leukopenia, aplastic anemia, agranulocytosis, etc
Teratogenic (neural tube)
P450 interactions; causes AUTOINDUCTION (inducing its own metabolism) so requires increasing doses
219
Valproic acid tests? Normal range?
CBC and LFT monitor regularly
50-150 micrograms/mL
Check levels after 3-5 days
220
Lamotrigine mechanism? How does it relate to valproate?
Works on sodium channels that modulate glutamate and aspartate
Valproate will increase lamotrigine levels
Lamotrigine will decrease valproate levels
221
Pregabalin and gabapentin have little efficacy in bipolar disorder. T/F?
True
Gabapentin: adjunctively used for sleep, anxiety
Pregabalin: GAD, fibromyalgia
222
Oxcarbazepine vs carbamazepine?
Oxcarazepine is as effective for mood disorders
- better tolerated
- less risk of rash and hepatic toxicity
223
Topiramate use? Side effects?
Use: Impulse control disorder and anxiety
Side effects:
- Weight loss (beneficial)
- Kidney stones
- Hypochloremic, non-anion gap metabolic acidosis
- limited use because of cognitive slowing
224
Main side effects of valproate
Hepatotoxicity or benign liver enzyme elevations
Increased ammonia
Teratogen
Pancreatitis
-----
GI side effects, weight gain, sedation, alopecia, thrombocytopenia
225
Benzos are relatively safer in OD than barbiturates. T/F?
True
226
Short acting benzos? (half life
Triazolam - for insomnia
| Midazolam
227
Intermediate acting benzos (half life 6-20hrs)
A LOT
Alprazolam - for anxiety, panic attacks (SHORT onset of action --> euphoria, high abuse potential)
Lorazepam - for panic attacks, agitation, alcohol detox, sedative-hypnotic-anxiolytic detox
Oxazepam - for alcohol detox, sedative-hypnotic-anxiolytic detox
Temazepam - decreasingly used for insomnia due to dependence
228
Long acting benzos (half life >20hrs)
Diazepam (has rapid onset) - for alcohol detox, sedative-hypnotic-anxiolytic detox, seizures
Clonazepam - for anxiety, panic attacks; AVOID WITH RENAL DYSFUNCTION
229
Side effects of benzos
Impairment of intellectual functioning
Reduced motor coordination (CAREFUL WITH ELDERLY)
Anterograde amnesia
Drowsiness
230
When is informed consent NOT required?
Lifesaving medical emergency
Prevention of suicidal or homicidal behavior
UNemancipated minors receiving obstetric care, STD treatment, or substance abuse tx
231
Minors are considered emanicipated if they are:
Married
In the military
Have children
Self supporting
232
What is police power?
Protecting citizens from each other (supports involuntary commitment)
233
What is parens patriae?
Protecting citizens who can't care for themselves (supports involuntary commitment)
234
Lawyers are not required to report child abuse. T/F?
True
| Doctors ARE required
235
What is tenting and how does it relate to the sexual response cycle?
Desire
Excitement - tenting (elevation of uterus in pelvis); increase in BP, pulse, nipple erection
Plateau - contraction of outer 1/3 of vagina, enlargement of upper 1/3 vagina
Orgasm
Resolution
236
Being male is a risk factor for developing PTSD. T/F?
```
False;
Risk factors:
- Female
- Low SES
- Low education
- Previous psych illness
```
237
Treatment of PTSD?
Multimodal (pharm + psychotherapy + social interventions)
SSRIs or SNRIs
- Paroxetine, sertraline (reduces the sx clusters of reexperience, avoidance hyperarousal in esp noncombat related PTSD)
TCAs and MAOIs for treating the reexperiencing sx
*SSRis are usually first adminsitered at a low dose and titrated up to max dose as tolerated
238
How to determine patient for decisionality?
Understand relevant information regarding treatment (purpose, risk, benefits)
Appreciate appropriate weight of and impact of the decision
Logically manipulate the information to make a decision
Communicate a choice or preference
239
What is the 6th amendment? 14th amendment?
6th: Right the counsel and to confront witnesses
14th: Right to due process of law
240
Which mental illness/disorder has the highest risk of violence towards self/others?
Other substance abuse/dependence other than alcohol - 16x risk
```
Alcohol abuse/dependence 12x
Bipolar 5x
Depression 5x
Schizophrenia 2-5x (controversial)
Mental illness increased risk of violence
```
241
Expert witness standards; Daubert? Frye?
Daubert: Judge decides if evidence is based on relevant and reliable science
Frye: Evidence must be generally accepted by the appropriate scientific community
242
Signs for detecting malingering?
```
Antisocial personality disorder
Substance abuse
Hx of working in medical field
Atypical presentation
"textbook" description of the illness
Sx only present when patient knows they are being observed
```
243
How does alcohol, marijuana, cocaine, amphetamines, narcotics affect libido?
Alcohol and marijuana: increase by suppressing inhibitions
Cocaine and amphetamines: increase by stimulating dopamine receptors
Narcotics: inhibit
***Alcohol long term DECREASES libido
244
Testosterone increases libido in women. T/F?
True; in both men and women
245
How does serotonin affect sexual function? Progesterone?
Serotonin INHIBITS sexual function
Progesterone INHIBITS sexual function in men and women by blocking androgen receptors
246
Most common sexual disorders in women? Men?
Women:
- Sexual desire disorder
- Orgasmic disorder
Men:
- Secondary erectile disorder
- Premature ejaculation
247
What is hypoactive sexual desire disorder?
Absence or deficiency of sexual desire/fantasies (more common in women)
*No problem having or sustaining erection, no problem reaching orgasm
248
Male erectile disorder? Female sexual arousal disorder?
Male erectile disorder:
- Impotence; primary (never had one) or secondary (previously able to)
- Psychological etiology if they have erections in the morning, during masturbation or with sexual partners
Female sexual arousal disorder:
- Inability to maintain lubrication until completion of sex act ( high prevalence, 33% of women)
249
Male orgasmic disorder?
MUCH LESS COMMON than impotence or premature ejaculation
- Achieves orgasm with great difficulty, if at all
250
Female orgasmic disorder?
Inability to have an orgasm after a normal excitement phase (30% of women)
251
Sexual aversion disorder?
Avoidance of genital contact with a sexual partner
252
Vaginismus?
Involuntary contractions of outer 1/3 of vagina upon insertion of penis, object
Higher incidence in high SES, strict religious upbringing
253
Dyspareunia? Associated with?
Genital pain BEFORE, DURING, or AFTER sexual intercourse
Much higher incidence in women; associated with vaginismus
254
What is dual sex therapy and what are its goals?
Marital unit meets with male and female therapist for a 4-way session to identify sexual problems
Goals:
- Sexual at-home exercises
- Heightening sensory awareness
- Increase levels of sexual contact
SHORT TERM therapy
255
Hypnosis is most useful as primary treatment. T/F?
False; most often used as adjunct with other therapies
Most useful is anxiety also present
256
____ is injected into the penis (which location?) and causes an erection in 2-3 minutes. Does this drug require sexual stimulation to achieve erection?
Alprostadil
Injected into corpus cavernosa or transurethral
No sexual stimulation needed
257
How to treat premature ejaculation?
SSRIs and TCAs
| Increases time between stimulation and orgasm
258
Hypoactive sexual desire disorder, how do you treat? Men vs women?
Testosterone in men to replace low levels of T
| Low doses in women may increase libido
259
How do you treat vaginal dryness?
Estrogen replacement may improve vaginal dryness and atrophy in hypoestrogenemic women
260
Tx for end-stage impotence?
Surgical insertion of semirigid or inflatable tubes into corpus cavernosa
261
Mechanical tx of male orgasmic disorder? Female orgasmic disorder?
Male orgasmic disorder: gradual progression for extra to intravaginal ejaculation
Female orgasmic disorder: masturbation, sometimes with vibrator
262
Vaginismus tx?
Regular dilation of vagina with fingers or dildo
263
What are paraphilias?
Sexual disorders of engagement of unusual sexual activities and/or preoccupation with unsual sexual
264
Paraphilia tx?
Aversion therapy
265
Sadism vs masochism?
Sadism - humiliating others
| Masochism - being humiliated
266
Three most common types of paraphilia?
Pedophilia
Voyeurism
Exhibitionism
267
Of all major psych disorders, which has highest genetic link?
Bipolar I
* Concordance of monozygotic twins with bipolar is 40-70%; for dizygotic 5-25%
* First degree relatives of bipolar are 8-18x more likely to develop illness
268
Best treatment for manic pregnant women?
ECT
269
Long term treatment of lithium increases suicide risk. T/F?
FALSE
Long term lithium use DECREASES suicide risk
*Note: other mood stabilizers like carbamazepine or valproic acid are associated with INCREASED suicide risk
270
Two most commonly used substances in terms of substance abuse?
Alcohol and nicotine
271
Abuse vs Dependence?
```
Abuse --> think WILD
Work, school, home role obligation failure
Interpersonal or social consequences
Legal troubles
Dangerous use
```
Dependence --> impairment/distress within a 12 month period of things like
- tolerance, withdrawal, using more than intended, persistent desire to quit, failed attempts to quit, continued use despite physical/psychological problems
272
Is it possible to have substance dependence without physiological dependence?
YES
| Meaning without withdrawal or tolerance
273
```
How long is each present in urine (i.e. produce a positive UDS)?
Cocaine
Amphetamine
PCP
Barbiturate (short and long acting)
Benzos (short and long acting)
Opioids
Marijuana (heavy and single use)
```
Cocaine: 2-4 days
Amphetamine: 1-3 days
PCP: 3-8 days; CPK and AST are often elevated
Barbiturate/short like pentobarbital: 24 hours
Barbiturate/long like phenobarbital: 3 weeks
Benzo/short like lorazepam: 3 days
Benzo/long like diazepam: 30 days
Opioids: 2-3 days (methadone and oxycodone will be negative on general screen so order a separate panel!)
Marijuana/heavy use: 4 weeks
Marijuana/single use: 3 days
274
Alcohol mechanism of action?
Activates GABA receptors
Activates serotonin receptors
Inhibits glutamate receptors
Inhibits voltage gated calcium channels
275
Alcohol, methanol and ethylene glycol can cause what metabolic disturbances?
Metabolic acidosis with increased anion gap
276
How to do you treat alcohol intoxication?
ABCs, glucose, electrolytes, acid base status
Thiamine to prevent/treat Wernickes Encephalopathy
Folate
CT to r/o subdural hematoma or other brain injury
277
Attempted suicided is associated with:
Mental illness
Young females
Alcoholism
278
Gi evacuation is NOT indicated in alcohol overdose. T/F?
Can be done if significant amount of EtOH was consumed in the preceding 30-60 minutes
279
Anorexia can be a s/s of alcohol withdrawal syndrome. T/F?
True
280
Seizures can happen in alcohol withdrawal. When do they occur and peak?
Generalized tonic clonic seizures occur at 6-48 hours after cessation
Peak 13-24hours
281
Hypo/hypermagnesemia can predispose to seizures.
HYPOmagnesemia
282
When do etoh withdrawal sx begin and how long do they last?
Begin 6-24 hours
| Last 2-7 days
283
Only 5% of hospitalized etoh withdrawal pts develop DTs and if left untreated has a 15-25% mortality rate. T/F
True
284
DTs occur equally in men and women. T/F
False
| DTs 4-5x higher in men
285
DT sx? Tx? When does it start?
delirium
hallucinations (often visual, can be tactile)
gross tremor
autonomic instability
fluctuating levels of psychomotor activity
Tx? Phenytoin or Benzo; use antipsychotics and temporary restraints for severe agitation
Start: usually 24-72hrs, usually within a week
286
_____ is associated with Korsakoff's psychosis
Confabulation
| Pt is unaware they are making this up
287
Disulfuram is contraindicated in
Severe cardiac disease
Pregnant
Psychosis
288
AST:ALT >2 suggests excessive alcohol use. T/F?
True
289
Naltrexone mechanism?
Opioid receptor blocker, reduces craving/desire
| Greater benefit seen in those with family hx of alcoholism
290
Acamprosate mechanism?
Structurally similar to GABA (thought to inhibit glutaminergic system)
Should be started POST-detox for relapse preventionin patients who have stopped drinking
291
Glucose before thiamine or thiamine before glucose in alcoholics?
Thiamine before glucose, otherwise wernicke korsakoff syndrome may be precipitated
292
Major benefit of using acamprosate? Contraindication?
Can be used in those with liver disease
| Contraindicated in severe renal disease
293
Topiramate mechanism and use?
Anticonvulsant that potentiates GABA and inhibits glutamate receptors
Reduces cravings for alcohol
294
Wernickes encephalopathy?
Long term complication of alcohol intake
Caused by B1/thiamine deficiency from poor nutrition
Sx:
- Ataxia, broad based
- Confusion
- Eye abnormalities (nystagmus, gaze palsies)
Untreated? Can progress to Korsakoff syndrome
295
What is korsakoff syndrome?
```
Chronic amnestic state
- Impaired recent memory
- anterograde amnesia
- compensatory confabulation (memory fails so you lie)
only reversible in 20%
```
296
What does cocaine intoxication look like?
- euphoria, heightened self esteem
- dilated pupils,
- nausea, weight loss, chills, sweating
- tachy or brady, hyper or hypotension, psychomotor agitation or depression
- hallucinations (esp. tactile), paranoia
- respiratory depression
- seizures, arrhythmia
- vasoconstrictive may result in MI or stroke
297
Signs of cocaine withdrawal? Can you abruptly stop using?
Abrupt abstinence is NOT life threatening
- post-intoxication crash!
- malaise, fatigue, depression, somnolence
- psychomotor agitation or depression
- hunger
- constricted pupils
- vivid dreams
298
How long does cocaine withdrawal last? Tx?
Mild-moderate use: resolve within 18 hours
Heavy chronic use: weeks, peak in several days
***Heavy use may cause AMPHETAMINE PSYCHOSIS that mimics schizophrenia
Tx: supportive
299
Amphetamine mechanism?
Blocks reuptake and facilitates release of dopamine and NE --> stimulant effect
Substituted/designer amphetamines: release dopamine, NE and serotonin from nerve endings --> stimulant and hallucinogenic effect
***Serotonin syndrome possible if combined with SSRI
300
Physical findings of chronic amphetamine use?
Tooth decay
| Acne
301
Sx of amphetamine abuse?
```
Dilated pupils
Increased libido
Perspiration
Respiratory depression
Chest pain
```
302
Rotary nystagmus is pathognomonic for?
PCP intoxication
303
PCP intoxication sx?
```
RED DANES
Rage
Erythema (skin)
Dilated pupils
Delusions
Amnesia
Nystagmus
Excitation
Skin dryness
```
304
OD of amphetamine sx? Tx?
Hyperthermia
Dehydration
Rhabomyolysis --> renal failure
Tx: rehydrate, correct electrolytes, treat hyperthermia
305
Amphetamine withdrawal sx?
Prolonged depression
| Possible psychosis
306
PCP mechanism? Relationship to ketamine?
```
NMDA antagonist (glutamate receptors)
Activates dopaminergic neurons
```
Ketamine is less potent; used as date rape as its tasteless and odorless
307
Cocaine and PCP are similar in that they both can cause _____ hallucinations
Tactile and visual hallucinations
308
Withdrawal sx of PCP?
None
| Might get "flashbacks" of sx from lipid stores releasing drug
309
What is meperidine and its unique properties?
Meperidine = Demerol = synthetic opioid analgesic
Dilates pupils, does NOT constrict pupils like other opioids
Meperidine + SSRI --> Serotonin syndrome
310
Tx of opioid withdrawal?
Moderate sx:
- Clonidine for autonomic s/s of withdrawal
- NSAIDs for pain
- Dicyclomine for ab pain
Severe sx:
- Detox with buprenorphine or methadone
