Psychiatry Flashcards
(267 cards)
1
Q
ADHD typically presents between ages?
A
Ages 3-13
2
Q
How do you diagnose ADHD?
A
Require 5 or more symptoms of inattention/hyperactivity for 6 or more months in at least 2 different settings leading to significant social/academic impairments. Symptoms must be present before age 12.
3
Q
What are the symptoms of inattention?
A
- Poor attention span in school work/play 2. poor attention to detail/careless mistakes
- difficulty following instructions and completing tasks
- forgetful and easily distracted.
4
Q
Symptoms of hyperactivity/impulsivity?
A
- fidgets
- leaves seat in classroom
- runs around inappropriately
- cannot play quietly
- talks excessively
- does not wait for his/her turn
- interrupts others
5
Q
Are sugar and food additives considered contributory to ADHD?
A
NO
6
Q
Initial treatment for ADHD?
A
Behavioral modification
7
Q
Pharmacological Stimulant treatments for ADHD?
A
- Methylphenidate (Ritalin)
- Dextroamphetamine (Dexedrine)
- Mixed Dextroamphetamine and Amphetamine (Adderall)
8
Q
Non-stimulant Pharm therapy for ADHD?
A
- SSRI’s
- nortriptyline
- Buproprion
- a2 agonists - clonidine
- Atomoxetine (Strattera) (NeRI)
9
Q
Autism Spectrum Disorder
A
Persistent impairment in socialization, communication, behavior more common in males.
10
Q
How is severity of Autism Spectrum Disorder determined?
A
Based on level of support needed in psychopathological and communication and repetitive behavioral domains.
11
Q
When you see a patient or Qstem with ASD what other disorders should you think about?
A
Rett syndrome, tuberous sclerosis, Fragile X syndrome
12
Q
Rett Syndrome
A
X-linked disorder seen almost exclusively in girls (affected males typically die in utero or shortly after birth)
Symptoms become apparent between ages 1-4, including regression characterized by loss of development, loss of verbal abilities, intellectual disability, ataxia, stereotyped hand-wringing
13
Q
Tuberous Sclerosis
A
Tuberous sclerosis complex (TSC) is a rare multisystem genetic disease (Incomplete penetrance, variable expression) that causes benign tumors to grow in the brain and on other vital organs such as the kidneys, heart, liver, eyes, lungs, and skin. A combination of symptoms may include seizures, intellectual disability, developmental delay, behavioral problems, skin abnormalities, and lung and kidney disease. TSC is caused by a mutation of either of two genes, TSC1 and TSC2, which code for the proteins hamartin and tuberin, respectively. These proteins act as tumor growth suppressors, agents that regulate cell proliferation and differentiation.
14
Q
Fragile X Syndrome
A
X-linked defect affecting methylation and expression of FMR1 gene. 2nd most common cause of intellectual disability after Downs Syndrome. Associated with post-pubertal macro-orchidism, long face with a large jaw, large everted ears, autism, mitral valve prolapse.
15
Q
ASD is characterized by impaired social interaction, communication, with restricted activities and interests apparent by age __
A
3
16
Q
Treatment for ASD
A
Intensive special education, behavioral management, symptom targeted medications, family support and counseling
17
Q
What medications are used for aggression in ASD?
A
neuroleptics (antipsychotics)
18
Q
What meds are used for stereotyped behaviors in ASD?
A
SSRIs
19
Q
What are the disruptive behavioral disorders?
A
Conduct and Oppositional Defiant
20
Q
ODD
A
Pattern of negative, defiant, disobedient, hostile behavior toward authority figures for more than 6 months. May progress to conduct disorder
21
Q
Conduct disorder
A
Repetitive, persistent pattern of violating basic rights of others or age appropriate societal norms/rules for over 1 year. Behaviors can be aggressive (rape, robbery, cruelty) or non-aggressive (stealing, lying, deliberately annoying ppl)
22
Q
Conduct disorder can progress to ___ in adulthood?
A
Antisocial personality disorder
23
Q
Treatment for ODD and conduct disorder?
A
Individual and Family Therapy
24
Q
Most common avoidable cause of intellectual disability?
A
Fetal Alcohol Syndrome
25
Intellectual development disorders are associated with?
1. male gender
2. chromosome abnormalities
3. metabolic disease
4. alcohol/substance use
5. congenital infections
26
IQ score to qualify or impaired intellectual functioning? Onset before?
IQ < 70; onset before age 18
27
IQ score for mild, moderate, severe, profound intellectual disability?
mild (IQ 50-70)- 85% of cases
moderate (35-49)
severe (20-34)
profound (< 20)
28
Primary prevention for intellectual disability?
Educating general public about causes
| Prenatal screening
29
Treatment measures for ID?
```
Family counseling and support
Speech and language therapy
Occupational and physical therapy
Behavioral intervention
Education assistance
Social Skills training
```
30
Tourette Syndrome is more common in?
More common in men and boys
31
Tourette Syndrome is associated with?
ADHD, learning disorders, OCD
32
Tourette is characterized by?
```
Multiple motor tics (blinking, grimacing)
Vocal tics (grunting, coprolalia)- many times/day, recurrently for > 1 year with social or occupational impairment
```
33
Tourettes begins before?
Age 18
34
Coprolalia
Repetition of obscene words
35
Treatment for Tourette's?
Dopamine receptor antagonists (haloperidol, pimozide)
OR clonidine
Behavioral therapy can be of benefit and counseling can aid in social adjustment and coping
36
What pharmaceuticals can worsen tics?
Stimulants
37
Schizophrenia is characterized by?
1. Psychotic symptoms (hallucinations, bizarre delusions)
2. Disorganization (thought disorder and behavioral disturbance)
3. Negative symptoms (poverty of affect, thought, social interaction)
38
Prevalence of schizophrenia? male:female?
1% equal in men and women?
39
Peak onset in men/ peak onset in women?
Men: 18-25
Women: 25-35
40
Risk of schizophrenia is increased in people who have?
First degree relatives with the disease
41
% of patients that attempt/complete suicide?
50% attempt. 10% complete
42
Etiologic theories of schizophrenia?
Neurotransmitter abnormalities- dopamine dysregulation (frontal hypoactivity, limbic hyperactivity) and CT/MRI abnormalities (enlarged ventricles, decreased cortical volume)
43
How do you diagnose schizophrenia?
2 or more of the following characteristics are present for 6 or more months and result in social or occupational dysfunction.
1. Positive Symptoms: hallucinations (often auditory), delusions, disorganized speech, bizarre behavior, thought disorder
2. Negative Symptoms: flat affect, decreased emotional reactivity, poverty of speech, lack of purposeful actions, anhedonia
44
delusion
fixed, false, idiosyncratic belief
45
hallucination
perception without an existing external stimulus
46
illusion
misperception of an actual external stimulus
47
Differential diagnosis of psychosis?
| Divide into psychotic, personality, delusional, medical
1. Psychotic
- Brief psychotic disorder
- Schizophreniform
- Schizophrenia
- Schizoaffective
2. Personality
- Schizotypal
- Schizoid
3. Delusional disorder
4. Medical/Organic/Substance Induced
48
Brief psychotic disorder
> 1 day and < 1 month
| Usually preceded by stressors, usually without negative symptoms, no prior episodes, better prognosis
49
Schizophreniform
>1 month and <6 months
| Usually preceded by stressors, usually without negative symptoms, no prior episodes, better prognosis
50
Schizophrenia
> 6 months
51
Schizoaffective disorder
Schizophrenia + major affective disorder (MDD or Bipolar affective disorder)
52
Schizotypal
"Magical thinking"
53
Schizoid
"Loners"
54
Delusional Disorder
Persistent, fixed delusions, without disorganized thought process, hallucinations or negative symptoms of schizophrenia. Day to day functioning is typically unaffected.
55
Subtypes of delusional disorder?
Jealous, Paranoid, Somatic, Erotomanic, Grandiose.
56
Treatment for schizophrenia
Antipsychotics (atypicals are 1st line)
| Supportive psychotherapy, training in social skills, vocational rehab, illness education
57
Evolution of Extrapyramidal symptoms with antipsychotic meds?
4 hours: acute dystonia (sustained muscle contraction)
4 days: akinesia (impairment in voluntary movement)
4 weeks: akathesia (agitation, stress, restlessness)
4 months: tardive dyskinesia (often permanent, involuntary movement of tongue, lips, face, trunk)
58
High potency typical antipsychotics?
Haloperidol, Fluphenazin
| come in depot long acting forms
59
Low potency typical antipsychotics?
Thioridazine, Chlorpromazine
60
Indications for typical and antipsychotics?
psychotic disorders, acute agitation, acute mania, tourette syndrome
61
Antipsychotics are more effective for ___ symtoms of schizophrenia based on mechanism of?
Positive symptoms. Block D2 receptors in limbic cortex
62
Side effects of high potency typical antipsychotics (haloperidol/fluphenazine)?
EPS > anticholinergic
Qtc prolongation and torsades (esp IV haloperidol)
NMS
63
Side effects of low potency typical antipsychotics (thioridazine, chlorpromazine)
Anticholinergic > EPS
More sedative
Greater risk of orthostatic hypotension
Thioridazine causes dose dependent Qtc prolongation and irreversible retinal pigmentation
64
Atypical antipsychotics
Risperidone (available in depot form), quetiapine, olanzapine, ziprasidone, aripiprazole, clozapine)
65
Indication for atypical antipsychotics?
1st line for schizophrenia due to less EPS and anticholinergic effects
66
Indication for Clozapine?
Reserved for severe treatment resistant schizophrenia and severe tardive dyskinesia
67
Side effects of Clozapine?
Agranulocytosis- requiring weekly CBC monitoring during first 6 mo
68
Side effects of atypical antipsychotics
weight gain, type II DM, metabolic syndrome, somnolence, sedation, Qtc prolonging
69
Acute dystonia
Onset: 4 hours. Characterized by prolonged, painful tonic muscle contraction or spasm
(torticollis- neck muscle contraction to 1 side)
(oculogyric crisis- prolonged upward gaze)
70
Treatment for acute dystonia?
Anticholinergics (benztropine, diphenhydramine) (acute therapy or prophylactic dosing)
71
Dyskinesia
Onset: 4 days. Pseudoparkinsonism with shuffling gait, cogwheel rigidity.
72
Treatment for dyskinesia
```
Dopamine agonist (amantadine) or anticholinergic (benztropine)
Discontinue antipsychotic or lower dose if possible
```
73
Akathisia
Onset: 4 weeks. subjective/objective restlessness or agitation
74
Treatment for akathisia?
Decrease or discontinue antipsychotic
Beta-blocker (propranolol)
Benzos or anticholinergics may help
75
Tardive dyskinesia
Onset: 4 months. Stereotypic, involuntary, painless oral-facial movements. Likely from D2 receptor sensitization from chronic D2 blockade. Irreverisble 50% of time.
76
Treatment for tardive dyskinesia?
Discontinue or decrease dose of antipsychotic
Attempt treatment with other drugs
Consider treating with Clozapine or Risperidone
(Giving anticholinergics or decreasing neuroleptics can initially worsen tardive dyskinesia)
77
Neuroleptic Malignant Syndrome
Can occur anytime. Fevers, muscle rigidity, autonomic instability, elevated CK and WBC, clouded consciousness.
78
Treatment for NMS?
Stop medication! Supportive care in ICU. Dantrolene (ryanodine receptor; decreases excitation contraction coupling) or Bromocriptine (DA agonist).
79
Diagnosing Anxiety disorder
uncontrollable, excessive anxiety or worry about multiple activities or events that leads to significant impairment or distress. presents with anxiety on most days for 6 or more months and with 3 or more somatic symptoms (restlessness, fatigue, difficulty concentrating, irritability, muscle tension, disturbed sleep)
80
Short term treatment
Benzodiazepines: immediate symptom relief and should be tapered as soon as long term therapy is established
Never stop "cold turkey" due to potentially lethal withdrawal symptoms
81
Long term therapy
Lifestyle changes
Psychotherapy
Medications: SSRI (first-line), venlafaxine (SNRI), buspirone (full and partial agonist at serotonin receptors)
82
What drugs used to treat anxiety should not be used in combo with MAOIs?
SSRIs and Buspirone
83
Panic disorder
Recurrent, unexpected panic attacks, 2-3X more common in women. Patients present with 1 or more months of concern about having additional attacks or behavioral changes as a result of attacks.
84
Agoraphobia
"fear of the marketplace" fear of being alone in public places. fear of places/situations that may cause panic- present in 30-50% of cases of panic disorder.
85
Panic attack
Discrete period of intense fear or discomfort where at least 4 of the following symptoms develop abruptly and peak within 10 minutes.
-tachypnea, chest pain, palpitations, diaphoresis, nausea, trembling, dizziness, fear of dying, depersonalization, hot flashes
86
What symptoms are fairly specific to panic attacks and cause hyperventilation/low O2 sat?
Perioral and or acral (peripheral) paresthesias.
87
Differential diagnosis of panic disorder?
Angina, MI, arrythmias, hyperthyroidism, pheochromocytoma, substance-induced anxiety, GAD, PTSD
88
Treatment for panic disorder?
short term: benzo
| long term: SSRI (1st line), CBT, TCAs
89
Qualifier for schizoaffective disorder?
Need at least 2 weeks where psychotic symptoms are present without any mood symptoms.
90
Do patients recognize fear is excessive when they have a phobia?
YES
91
Treatment for specific phobia?
CBT involving desensitization through incremental exposure to feared object or situation along with relaxation techniques
92
Treatment for social phobia?
CBT, SSRIs, low-dose benzo, B-blocker for performance anxiety
93
Obsessions
Persistent, unwanted, intrusive ideas, thoughts, impulses, images that lead to anxiety or distress (fear of contamination, fear of harm to oneself or to loved ones)
94
Compulsions
Repeated mental acts or behaviors, neutralize anxiety from obsessions. (handwashing, elaborate rituals for ordinary tasks, counting, excessive checking)
95
For patients with OCD, do they recognize behaviors as excessive and irrational?
YES (ego dystonic) Patients recognize obsessions and compulsions and would like to get rid of them.
96
Treatment for OCD
SSRIs - 1st line
| CBT- exposure/desensitization
97
body dysmorphic disorder
characterized by preoccupation with imagined or slight defects in physical appearance that are usually imperceptible to others. leads to distress/impairment. actions and behaviors are obsessive and repetitive (mirror checks, comparisons)
98
Treatment for body dysmorphic?
SSRIs
99
SSRIs?
fluoxetine, sertraline, paroxetine, citaloparm, escitalopram
100
Anxiety related indications for SSRIs?
GAD, OCD, panic disorder, body dysmorphic disorder, social phobia
101
SSRI side effects
nausea, GI upset, somnolence, sexual dysfunction, agitation
102
Buspirone indication?
| Benefit related to pharmacology?
GAD, social phobia
| No tolerance, dependence or withdrawal due to full/partial agonist
103
B-blocker indication for anxiety disorders?
| side effects?
```
Phobic disorders (give prior to exposure)
side effects: bradycardia, hypotension
```
104
Benzodiazepines indication for anxiety?
acute anxiety, insomnia, alcohol withdrawal, muscle spasm, night terrors, sleep walking
105
PTSD
Clinically significant stress/impairment as a result of direct exposure to an extreme life-threatening traumatic event, witnessing a traumatic event, indirect exposure through learning of a life-threatening event involving a close family member or friend
106
Top causes of PTSD in male patients
1. sexual assualt 2. combat
107
Top causes of PTSD in female patients
1. childhood abuse 2. sexual assault
108
Diagnosis of PTSD?
characterized by following 4 symptom clusters: Symptoms must exist for > 1 month
1. intrusion- reexperiencing event through nightmares, flashback, intrusive memory
2. avoidance- stimuli associated with trauma
3. negative alterations in mood/cognition (numbness)
4. heightened arousal (hypervigilence), sleep disturbance, aggression, irritability, poor concentration
109
Same symptoms as PTSD for 3 days to 1 month?
Acute stress disorder
110
Treatment for PTSD?
short-term: B-blocker and a-agonist
long-term: SSRIs, buspirone, TCAs, MAOIs
Psychotherapy and support groups are useful
111
Adjustment disorder
Clinically significant distress following a profound life change. Divorce, unemployment, financial issues, romantic break up)
112
Diagnosing adjustment disorder
not severe enough to meet criteria for another mental disorder. occurs within 3 months after onset of stressor, can place person at higher risk for suicidality. Symptoms can be anxiety, depressed mood, issues in conduct. Resolves with 6 months of onset.
113
Treatment for adjustment disorder?
Supportive counseling. NO PHARM TREATMENT
114
Causes of Dementia
| Mnemonic (DEMENTIASS)
Degenerative: Parkinson, Huntington
Endocrine: thyroid, parathyroid, pituitary, adrenal
Metabolic: alcohol, electrolytes, vitamin B12, glucose, hepatic, renal, Wilson disease
Exogenous: heavy metals, carbon monoxide, drugs
Neoplasia:
Trauma:
Infection: meningitis, encephalitis, endocarditis, syphilis, HIV, prion disease, lyme disease
Affective disorder: pseudodementia
stroke/structural: vascular dementia, ischemia, vasculitis, normal pressure hydrocephalus
115
Dementia AKA major neurocognitive disorder
Decline in cognitive functioning with global deficits. level of consciousness is stable. persistent and progressive course most common among those > age 85.
116
2 most common causes of dementia?
Alzheimers (65%) and Vascular (20%)
117
Diagnosis of dementia?
memory impairment and 1 or more of the following:
- 4 A's of dementia following this order: amnesia (partial or total), aphasia (language impairment), apraxia (inability to perform motor activities), agnosia (inability to recognize previously known objects/people)
- impaired executive function
- personality, mood, behavioral changes (wandering and aggression)
118
How to diagnose dementia?
serial mini mental state exams should be performed.
| rule out treatable causes of dementia with CBC, RPR, CMP, TFTs, HIV, B12/folate, ESR, UA, head CT or MRI.
119
Treatment for dementia?
Provide environmental cues and rigid structure for patient's daily life.
Cholinesterase inhibitors
Low-dose antipsychotics for behavioral disturbances
AVOID BENZO
120
Major causes of delerium?
Mneumonic
"I WATCH DEATH"
```
Infection
Withdrawal
Acute metabolic/substance abuse
Trauma
CNS pathology
Hypoxia
Deficiencie
Endocrine
Acute Vascular/MI
Toxins/Drugs
Heavy Metals
```
121
Delirium
acute disturbance of consciousness with altered cognition
122
Presentation of delerium
acute onset of waxing and waning consciousness with lucid intervals and perceptual disturbances (hallucinations, illusions, delusions); decreased attention span, short term memory, reversed sleep wake cycle and increased symptoms at night (sundowning)
123
Is it common for delerium to be superimposed on dementia?
YES
124
How to diagnose delerium?
check vitals, pulse ox, glucose, UA, provide physical and neuro exam, check recent meds, substance use, prior episodes, organ failure, infection (occult UTI is common in elderly)
125
Treatment for delerium
Treat underlying cause (often reversible)
Normalize fluids/electrolytes
Optimize sensory environment and provide necessary and visual hearing aids
Use low dose antipsychotics (haloperidol) for agitation and psychotic symptoms
Conservative use of physical restraints may be needed to prevent harm to patient or others
126
Major Depressive Disorder
Mood disorder characterized by 1 or more major depressive episodes
127
Symptoms of depressive episode?
```
Sleep (hypersomnia/insomnia)
Interest
Guilt or feeling worthless
Energy or fatigue
Concentration
Appetite or weight changes
Psychomotor agitation or retardation
Suicidal ideation
```
128
Diagnosis of MDD
Diagnosis requires Depressed Mood or Anhedonia and five or more signs/symptoms from SIG E CAPS for a 2 week period.
129
Name the depression sub-types
- Psychotic features (typically mood congruent hallucinations/delusions)
- postpartum: within 1 month
- Atypical: weight gain, hypersomnia, rejection sensitivity
- Seasonal: depressive episodes during particular season. can respond well to light therapy with or without antidepressants
- Double depression: MDE in a patient with dysthymia (poorer prognosis than MDE alone)
130
Differential diagnosis of major depression.
1. mood disorder due to medical condition (hypothyroidism, parkinson disease, CNS neoplasm, other neoplasms, stroke, dementias, parathyroid disorder)
2. substance induced: drugs, alcohol, anti-HTN, corticosteroids, OCPs
3. Adjustment disorder with depressed mood: constellation of symptoms that resemble MDE but dont meet criteria and occur within 3 months of life stressor
4. normal bereavement: after loss of loved one. no severe impairment/suicidality. usually lasts < 6 months, should resolve w/in 1 year. may lead to MDD (illusions, hallucinations of deceased can be normal as long as patient recognizes them as such
5. Dysthymia: milder, chronic depression with depressed mood most of time for at least 2 years. often resistant to treatment.
131
How long should you allow pharm to take effect for MDD? How long to continue treatment for?
- 2-6 weeks
| - Continue treatment for 6 months
132
Treatment for MDD
Pharmacotherapy plus Psychotherapy
133
Indication for ECT
Refractory depression, psychotic depression, severe suicidality, intractable mania, psychosis, safe during pregancy
134
Treatment course for ECT?
2-3 X/week for 6-12 treatments
135
Contraindications for ECT?
no absolute contraindications. relative contraindications include recent stroke/MI, intracranial mass, high anesthetic risk.
136
How long to wait after stopping SSRI to begin MAOI treatment?
2 weeks. 5 weeks for fluoxetine due to longer half life.
137
Differential diagnosis for postpartum disorders?
1. postpartum blues: within 2 weeks of delivery. sadness, moodiness, emotional lability
2. postpartum psychosis: 2-3 weeks post. delusions and depression. may have thoughts about harming baby.
3. postpartum depression: 1-3 months post delivery. sadness, moodiness, emotional lability, sleep disturbances, anxiety, may have thoughts about harming baby.
138
Serotonin Syndrome
fever, myoclonus, mental status change, cardiovascular collapse,
139
Why should you avoid paroxetine in pregnancy?
Can cause pulmonary HTN in fetus.
140
Side effects/contraindications of buproprion?
decrease seizure threshold, minimal sexual side effects, contraindicated in patients with eating disorders, and seizure patients
141
SE/contraindications for mirtazapine?
weight gain, sedation
142
SE trazodone?
highly sedating, priapism
143
SNRIs
Venlafaxine, Duloxetine
144
Indication/SE for SNRIs
depression, anxiety, chronic pain.
Venlafaxine: diastolic HTN
145
TCAs
Nortriptyline, Desipramine, Amitriptyline, Imiprimine
146
Indications for TCAs
depression, anxiety, chronic pain, migraine, enuresis (imiprimine)
147
SE/contraindications to TCAs
Lethal with overdose due to cardiac conduction arrhythmias. (prolonged conduction through AV node. long QRS) need to be monitored in ICU for 3-4 days following overdose.
Anticholinergic effects: dry mouth, constipation, urinary retention, sedation.
148
MAOIs
Phenelzine, Tranylcypromine, Selegiline (patch form available)
149
Indications for MAOIs
Depression (esp atypical)
150
SE MAOI
HTN crisis if taken with high tyramine foods (aged cheese, red wine)
Sexual side effects, orthostatic hypotension, weight gain
151
Bipolar disorder avg age onset?
20
152
Bipolar I
involves at least 1 manic or mixed episode often requiring hospitalization
153
Bipolar II
at least one MDE and one hypomanic episode (characterized predominantly by depression with occasional hypomanic episodes)
154
Rapid cycling
4 or more episodes (MDE, mixed, manic, hypomanic) in 1 year
155
Cyclothymic
chronic and less severe with alternating periods of moderate depression and hypomania for > 2 years
156
Clinical presentation of mania? DIG FAST
```
distractibility
insomnia
grandiosity
flight of ideas
activities/agitation
sexual indiscretion/pleasure seek
talkativeness/pressured speech
```
157
What pharm intervention may trigger mania?
Antidepressant use without mood stabilizer
158
How to diagnose manic episode?
1 week of persistently elevated, expansive or irritable mood plus three DIG FAST symptoms. Psychotic symptoms are also common with mania.
159
Diagnose hypomania?
Similar but does not involve marked functional impairment, psychotic symptoms and does not require hospitalizations.
160
Treatment for bipolar mania?
Acute: antipsychotics, lithium, valproate
| maintenance therapy: mood stabilizer (benzo for refractory agitation)
161
Treatment for bipolar depression
mood stabilizers with or without antidepressants
162
1st line mood stabilizer? 2nd line?
1. Lithium 2. Carbamazepine, Lamotrigine
163
Lithium side effects
thirst, polyuria, diabetes insipidus, tremor, weight gain, hypothyroid, nausea, diarrhea, seizures, teratogenicity (ebstein anomaly), acne, vomiting.
164
Lithium toxicity
narrow therapeutic window
Toxic > 1.5. Present with ataxia, dysarthria, delirium, acute renal failure. Avoid lithium in patients with decreased renal function.
165
Indication for carbamazepine?
2nd line mood stabilizer, anticonvulsant, trigeminal neuralgia
166
SE carbamazepine?
nausea, skin rash, leukopenia, AV block, teratogenicity (neural tube), rarely aplastic anemia (monitor CBC biweekly). SJS!
167
Indications Valproic acid?
BPD, anticonvulsant
168
SE Valproic acid
GI- nausea, vomit
tremor, sedation, alopecia, weight gain, teratogenicity (neural tube), pancreatitis, thrombocytopenia, fatal hepatotoxicity, agranulocytosis.
169
Lamotrigine indications and side effects
2nd line mood stabilizer, anticonvulsant
SE: blurred vision, SJS, GI distress. increase dose slowly to monitor for rashes.
170
Personality Disorders
One's traits become chronically rigid and maladaptive. Onset occurs by early adulthood
171
Cluster A personality disorders
Paranoid, Schizoid, Schizotypal
172
Paranoid personality disorder
distrustful, suspicious, interpret others' motives as malevolent.
173
Schizoid
isolated, detached, "loner", restricted emotional expression
174
Schizotypal
odd behavior, perceptions, appearance. magical thinking. ideas of reference. (lack delusions/hallucinations that would classify them as schizophrenic)
175
Cluster B personality disorders
Borderline, histrionic, narcissistic, antisocial
176
borderline
unstable mood, relationships, self-image; feelings of emptiness. impulsive. history of suicidal ideation or self-harm. splitting used as a defense mechanism
177
histrionic
excessively emotional and attention seeking. sexually provocative, theatrical.
178
narcissistic
grandiose, need admiration, have sense of entitlement, lack empathy
179
antisocial
violates rights of others, social norms and laws. impulsive. lacks remorse. must have prior diagnosis of conduct disorder.
180
Cluster C personality disorders
OCPD, avoidant, dependent
181
OCPD
preoccupied with perfectionism, order, control at the expense of efficiency. inflexible morals and values. egosyntonic. don't feel behavior is problematic
182
Avoidant
socially inhibited, rejection sensitive. fear of being disliked or ridiculed, yet desires to have friends and social interactions
183
dependent
submissive, clingy, have a need to be taken care of, have difficulty making decisions, feel helpless
184
Treatment for personality disorders
psychotherapy is mainstay of treatment
| pharmacotherapy for cases with comorbid mood, anxiety, psychotic signs/symptoms
185
Diagnosis of substance use disorder?
Meet 2 out of 11 following criteria over a 1 year period.
1. impaired control
- consumption of greater amounts of substance than intended
- failure to cut back/abstain
- increased amount of time spent acquiring, using, recovering
- craving
2. Social impairment
- failure to fulfill responsibilities at work, school or home
- continued substance use despite recurrent social/interpersonal problems
- isolation from life activities
3. Risky use
- use in hazardous situations
- recurrent use despite physical/psych problems
4. Pharmacologic
- Tolerance: use of progressively larger amounts to obtain same desired effect
- Withdrawal: symptoms when not taking substance
186
How do you determine severity of substance use disorder?
of symptoms present:
Mild: 2-3
Mod: 4-5
Severe: >6
187
Diagnosis of alcohol use disorder?
CAGE question screening.
Vital signs for evidence of withdrawal
Increased LFTs, LDH, MCV
188
CAGE
C: cut down on drinking?
A: annoyed by criticism of drinking?
G: guilty about drinking?
E: morning eye opener?
more than 1 yes makes alcoholism likely
189
Treatment for alcohol use disorder
- rule out medical complications, correct electrolyte abnormalities
- start benzodiazepine taper for withdrawal
- add haloperidol for hallucinations and psychotic symptoms
- give multivitamins and folic acid, administer thiamine before glucose (glucose depletes thiamine) to prevent Wernicke encephalopathy
- give anticonvulsants to patients with seizure history
- group therapy, disulfuram, naltrexone can aid patients with dependence
- long-term rehab therapy (AA)
190
Complications from alcohol use disorder?
GI bleeding from gastritis, ulcers, varices, mallory weiss tears, pancreatitis, liver disease, DTs, alcoholic hallucinosis, peripheral neuropathy, Wernicke encephalopathy, Korsakoff psychosis, fetal alcohol syndrome, cardiomyopathy, anemia, aspiration pneumonia, increase trauma risk
191
Alcohol intoxication/withdrawal symptoms
I: disinhibition, emotional lability, slurred speech, ataxia, aggression, blackouts, hallucinations, memory impairment, impaired judgement, coma
W: tremor, tachy, hypertension, malaise, nausea, seizure, DTs, agitation
192
Opioids I/W
I: Euphoria leading to apathy, CNS depression, constipation, pupil constriction, Resp depression (life-threatening in overdose)
W: dysphoria, insomnia, anorexia, myalgia, fever, lacrimation, diaphoresis, dilated pupils, rhinorrhea, piloerection, nausea, vomit, stomach cramp, diarrhea, yawning
193
Naloxone and Naltrexone
block opioid receptors and reverse effects but beware of antagonist clearing before opioids, particularly with long acting opioids like methadone.
194
Is opioid withdrawal life threatening? does it cause seizures?
not life threatening! does not cause seizures!
195
Amphetamine I/W
I: psychomotor agitation, impaired judgement, hypertension, pupil dilation, tachycardia, fever, diaphoresis, anxiety, angina, euphoria, prolonged wakefulness/attention, arrhythmias, delusions, seizures, hallucinations
W: post-use crash with anxiety, lethargy, headache, stomach cramps, hunger, fatigue, depression, dysphoria, sleep disturbance, nightmares
196
Cocaine I/W
I: Psychomotor agitation, euphoria, impaired judgement, tachy, pupil dilation, hypertension, paranoia, hallucinations, "cocaine bugs", sudden death. ECG changes from ischemia (cocaine chest pain)
W: post-use crash with hypersomnolence, depression, malaise, severe craving, angina, suicidality, increased appetite, nightmares
197
PCP
I: Assaultiveness, belligerence, psychosis, violence, impulsiveness, psychomotor agitation, fever, tachycardia, vertical/horizontal nystagmus, hypertension, impaired judgement, ataxia, seizures, delirium
W: Recurrence of intoxication symptoms due to reabsorption in the GI tract. sudden onset of severe, random violence.
198
What can you give for PCP intoxication?
Give benzos or haloperidol for severe symptoms. Acidification of urine or gastric lavage can help to eliminate the drug.
199
LSD
I: marked anxiety or depression, delusions, visual hallucinations, flashback, pupillary dilation, impaired judgement, diaphoresis, tachycardia, hypertension, heightened senses (colors become more intense)
W: none
200
Marijuana
Euphoria, slowed sense of time, impaired judgement, social withdrawal, increased appetite, dry mouth, conjunctival injection, hallucinations, anxiety, paranoia, amotivational syndrome
201
barbiturates
I: low safety margin, respiratory depression
W: Anxiety, seizures, delirium, life-threatening cardiovascular collapse
202
Benzodiazepines
I: interactions with alcohol, amnesia, ataxia, somnolence, mild resp depression. (avoid using for insomnia in the elderly- can cause paradoxic agitation even in low doses)
W: rebound anxiety, seizure, tremor, insomnia, htn, tachy, death
203
caffeine
I: restlessness, insomnia, diuresis, muscle twitching, arrhythmias, tachycardia, flushed face, psychomotor agitation
W: headache, lethargy, depression, weight gain, irritability, craving
204
Nicotine
I: restlessness, insomnia, anxiety, arrhythmias
W: irritability, headache, anxiety, weight gain, craving, bradycardia, difficulty concentrating, insomnia
205
Anorexia Nervosa
severe restricting of caloric intake by fasting or excessively exercising or binge and purge (vomit, laxative, diuretic)
206
Signs and symptoms of anorexia nervosa
cachexia, BMI < 18, lanugo, dry skin, bradycardia, lethargy, hypotension, cold intolerance, hypothermia
207
Presentation of bulimia nervosa
for at least 1/week for 3 or more months patients have episodes of binge eating and compensatory behaviors that include purging or fasting
208
Weight of anorexia vs bulemia?
Anorexia: >15% below expected body weight
Bulemia: normal or overweight
209
Attitude toward illness between anorexia/bulemia?
Anorexia: not distressed by illness, so often resistant to treatment
Bulemia: typically distressed so easier to treat
210
Treatment for anorexia
Monitor calorie intake and weight gain, hospitalize if needed. psychotherapy.
211
treatment for bulemia
psychotherapy and antidepressants
212
Two types of anorexia?
Restricting type.
| Binge/Purge type
213
Diagnostic work up for eating disorder?
height and weight, BMI, CBC, electrolytes, endocrine, ECG, psych eval for comorbid conditions
214
Sexual changes with aging
- interest in sexual activity should not decrease with age
- men require increased stimulation to reach orgasm. intensity of orgasm decreases. refractory period increases.
- estrogen levels decrease after menopause, vaginal dryness and thinning, can cause discomfort
215
Paraphilic disorder definition and treatment
Preoccupation with or engagement in unusual sexual fantasies, urges or behaviors for > 6 months with significant impairment in ones life.
Treatment: insight oriented psychotherapy
216
Gender dysphoria
Strong persistent cross-gender identification and discomfort with ones assigned sex or gender role of the assigned sex
217
List the recommended sleep hygiene measures
- Establishment of regular sleep schedule
- limit caffeine intake
- avoid daytime naps
- warm baths in evening
- use of bedroom for sleep and sexual activity
- exercise early in day
- relaxation
- avoid large meals near bedtime
218
Primary insomnia
Sleep disturbance not attributable to physical or mental conditions. exacerbated by anxiety. patients preoccupied with not getting enough sleep.
Dx: history of non restorative sleep and difficulty initiating, maintaining sleep. Present at least 3X/week for 1 month.
219
Pharmacotherapy for primary insomnia
Initiated with care for short periods of time (< 2 weeks)
| Diphenhydramine, Zolpidem, Zaleplon, Trazodone
220
Primary hypersomnia
Dx: excessive daytime sleepiness or nighttime sleep occuring for >1 month (cannot be attributable to medical, mental, sleep hygeine, narcolepsy, insufficient sleep)
221
Tx for primary hypersomnia
Stimulant drugs
| Antidepressants
222
Narcolepsy
Onset occurs before age 30
Excessive daytime somnolence and decreased REM sleep latency on daily basis for at least 3 months
Sleep attacks are classic symptom.
Daytime somnolence can be associated with:
-Cataplexy: sudden loss of muscle tone that leads to collapse
-hypnagogic hallucinations: occurs when falling asleep
-hypnopompic hallucinations: occur as patient awakens
-sleep paralysis: paralyzed on awakening
223
Treatment for narcolepsy
- schedule daily naps
- stimulant drugs
- SSRIs for cataplexy
224
Sleep apnea
associated with sudden death in infants and elderly, headaches, depression, increased systolic BP, pulmonary htn
225
Tx for OSA:
| Tx for CSA:
OSA: CPAP, weight loss, tonsillar/adenoidal removal
CSA: mechanical ventilation (BiPAP), back up RR for severe cases
226
Somatic Symptom Disorder
excessive thoughts, anxiety, behaviors driven by presence of somatic symptoms. may occur with or without a medical illness present. high health care utilization is often present
227
Tx for somatic symptom disorder
Regularly scheduled appointments with one clinician as primary caregiver
avoid unnecessary diagnostics
psychotherapy
228
Conversion disorder
symptoms or deficits of voluntary motor or sensory function (blind, seizure, paralysis) - incompatible with medical processes. close temporal relationship to stress or emotion.
229
Dx conversion disorder:
unexplained by other medical or neuro causes
Hoover sign: extension of affected leg when asked to raise unaffected side (to rule out leg paralysis)
Eyes closed and resistant to open during seizure, negative simultaneous EEG
Tremor disappear with distraction
230
Tx conversion disorder
Psychotherapy
231
Malingering
patients intentionally simulate illness for personal gain (financial benefit, housing)
232
Factitious
Primary gain: assuming the sick role
233
Risk factors for suicide?
| SAD PERSONS
S: sex (male)
A: age (older)
D: depression
```
P: previous attempt
E: ethanol/substance abuse
R: rational thought
S: sickness (chronic illness)
O: organized plan/access to weapons
N: no spouse
S: social support lacking
```
234
What are the 3 main options for smoking cessation?
1. Nicotine replacement therapy
2. Varenicline (nicotinic partial ag)
3. Buproprion
235
Risks of varenicline?
Mood changes, suicidality, cardio events in people with pre-existing conditions
236
Postpartum blues resolve within?
14 days
237
In breastfeeding patients, which SSRI is recommended for pp depression?
Sertraline
238
Name the 3 dopamine pathways in CNS
Mesocortical
Nigrostriatal
Mesolimbic
Tuberoinfundibular
239
Antipsychotic med effects on mesolimbic pathway?
Antipsychotic efficacy
240
Antipsychotic effects on nigrostriatal pathway?
EPS symptoms
241
Antipsychotic effects on tuberoinfundibular pathway?
hyperprolactinemia
242
What are signs and symptoms of hyperprolactinemia in men? women?
men: sexual dysfunction and gynecomastia
women: amenorrhea, galactorrhea, sexual dysfunction
243
Eye movement desensitization and reprocessing is a form of psychotherapy used for what group of patients?
PTSD
244
Adjustment disorder
emotional or behavioral symptoms (anxiety, depression, disturbance of conduct) developing within 3 months of stressor and lasting no longer than 6 months once stressor ceases
245
Name the 3 main dissociative disorders
1. Depersonalization/derealization
2. Dissociative amnesia
3. Dissociative identity disorder
246
Depersonalization/Derealization disorder
Persistent or recurrent experiences of 1 or both:
- depersonalization (feelings of detachment from ones self. outside observer of ones self)
- derealization (experiencing surroundings as unreal)
- Intact reality testing
247
Dissociative amnesia
Inability to recall important personal info usually after a traumatic, stressful experience
Not explained by another disorder
248
DID
Marked discontinuity in identity and loss of personal agency with fragmentation into 2 or more distinct personalities. Associated with severe trauma/abuse.
249
Dissociative fugue
amnesia of personal information combined with purposeful travel or bewildered wandering
250
Atrophy of caudate is associated with?
Huntington's (progressive characterized by chorea, dementia, psychotic symp)
251
decreased volume of hippocampus and amygdala are associated with?
Schizophrenia
252
accelerated head growth during infancy and increased total brain volume are found in?
Autism
253
structural abnormalities in orbitofrontal cortex and basal ganglia found in?
OCD
254
When should you consider treatment with Clozapine?
Treatment resistance: 2 failed trials of atypical antipsychotics
255
NMS is likely caused by?
Dopamine antagonism
256
Symptoms of TCA overdose
**SEIZURES
Mental status change, tachy, hypotension, cardiac conduction delay** (prolong QRS) and anticholinergic effects (dilated pupil, intestinal ileus, hot, dry skin)
257
QRS duration greater than ____ is associated with increased risk of ventricular arrhythmia and seizures and is used as an indication of _____ therapy.
100 msec / sodium bicarb therapy
258
Symptoms and timing of mild alcohol withdrawal?
6-24 hours. anxiety, insomnia, tremors, diaphoresis, palpitations, GI upset, intact orientation
259
Symptoms and timing of seizure for alc withdrawal?
12-48 hours. generalized tonic clonic
260
symptoms/timing for alcoholic hallucinosis?
12-48 hours. visual, auditory or tactile hallucinations. intact orientation. stable vitals.
261
symptoms/timing for delirium tremens?
48-96. confusion, agitation, fever, tachy, hypertension, diaphoresis, hallucinations
262
Dilsulfuram MOA
inhibits enzyme aldehyde dehydrogenase (acetaldehyde accumulates and patient feels ill)
263
What is considered an adequate trial of SSRI?
Adequate dose and duration > 6 weeks.
264
HIV associated dementia
more likely in untreated HIV patients with CD4 count <200 and patients with long standing HIV disease. Onset is subacute and characterized by increasing apathy and impaired attention. then slowed movement and difficulty with limb movement. next memory impairment.
265
What is a particular good choice of antidepressant in a patient with poor sleep and appetite?
Mirtazapine
266
Why would you choose valproate over lithium for bipolar?
if patient has underlying kidney disease
267
myalgias and arthralgias are common withdrawal symptoms from
opioids
