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Psychiatry Flashcards

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1
Q

Treatment:

Panic disorder

A

First line

  1. Cognitive behavioral therapy
  2. SSRI
  3. SNRI

Immediate relief:
1. Benzodiazepines

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2
Q

In what panic disorder patients should you avoid using benzodiazepines?

A

Patients with a history of substance abuse.

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3
Q

Short term therapy vs. Long term therapy

Bipolar I disorder

A

Long-term maintenance pharmacotherapy is recommended to decrease the risk of recurrent mood episodes.

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4
Q

What are the clinical features of acute stress disorder (ASD)?

A
  1. Exposure to actual or threatened trauma
  2. Intrusive memories, nightmares, flashbacks with intense psychological/physiological reactions
  3. Amnesia for event/detachment (dissociative symptoms)
  4. Avoidance of reminders
  5. Negative mood
  6. Arousal with sleep disturbance
  7. Irritability
  8. Hypervigilance
  9. Exaggerated startle
  10. Impaired concentration
    Lasting more than or equal to 3 days, but less than 1 year
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5
Q

What is the drug of choice for pediatric depression?

A

Fluoxetine + Psychotherapy

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6
Q

Which antidepressant is preferred in patients with:

  1. low energy
  2. impaired concentration
  3. hypersomnia
  4. weight gain
  5. difficulty with smoking cessation
A

Buproprion

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7
Q

What are the contraindications for buproprion?

A
  1. Seizure disorders

2. Eating disorders

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8
Q

Treatment:

Agitation and aggression

A

Benzodiazepines

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9
Q

Diagnosis:

  1. agitation
  2. psychosis
  3. disorientation
  4. nystagmus
A

Phencyclidine (PCP) intoxication

Severe cases may present with: hyperthermia, ataxia, muscle rigidity, seizures and coma.

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10
Q

Treatment:

Phencyclidine (PCP) intoxication

A

First line: Parenteral Benzodiazepines (lorazepam, diazepam)
Second line: Haloperidol if resistant to benzodiazepine or Hx of seizures
Severe cases: Propofol

Patients are often too agitated to take oral medications.

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11
Q

Is urinary acidification an appropriate treatment for PCP intoxication?

A

NO! It increases the risk for acidosis and renal damage.

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12
Q

How do you differentiate alcoholic hallucinosis from delirium tremens?

A

Alcoholic hallucinosis:

  • occurs within 12-24 hours after last drink and self resolves after 48 hours
  • Sensorium is intact
  • Vital signs typically remain stable

Delirium tremens:

  • Occurs between 48-96 hours after last drink
  • presents with disorientation and global confusion
  • hallucinations, fever and autonomic hyperactivity (hyperthermia, tachycardia, hypertension & diaphoresis)
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13
Q

Treatment:

Neuroleptic malignant syndrome

A
  1. cessation of antipsychotics
  2. intensive supportive care (i.e. hydration and cooling)
  3. dopamine agonists (bromocriptine)
  4. dantrolene
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14
Q

Treatment:

Adjustment disorder

A

Psychotherapy to improve coping skills and promote a return to functioning.

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15
Q

How many SIGECAPS symptoms are required to consider a diagnosis of major depressive disorder?

A 
>/= 5 
Sleep disturbance
loss of Interest
excessive Guilt
low Energy
impaired Concentration
Appetite disturbance
Psychomotor agitation/retardation
Suicidal ideation
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16
Q

What is the differential diagnosis of depressed mood?

A
  1. Major depressive disorder
  2. Persistent depressive disorder (dysthymia)
  3. Adjustment disorder with depressed mood
  4. Normal stress response
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17
Q

Diagnose:

Adjustment disorder

A
  1. Onset within 3 months of an identifiable stressor
  2. Marked distress/functional impairment
  3. Does not meet any other DSM-5 disorder criteria
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18
Q

What is the greatest risk factor for suicide?

A

History of suicide attempt.

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19
Q

List the risk factors for suicide.

A
  1. Psychiatric disorders, prior suicide attempts
  2. Hopelessness
  3. Never married, divorced or separated
  4. Living alone
  5. Elderly white man
  6. Unemployed or unskilled
  7. Physical illness
  8. Family history of suicide, family discord
  9. Access to firearms
  10. Substance abuse, impulsivity
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20
Q

List the protective factors against suicide.

A
  1. Social support/family connectedness
  2. Pregnancy
  3. Parenthood
  4. Religion and participation in religious activities
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21
Q

Which patients are at risk for HIV dementia?

A

Patients with:

  1. Long-standing HIV (especially untreated)
  2. CD4+ cell count <200/mm3
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22
Q

What are the characteristics of HIV dementia?

A
  1. Increasing apathy
  2. Impaired attention
  3. Memory loss

Subcortical dysfunction (present early)

  1. Slowed movement
  2. Difficulty with smooth limb movement
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23
Q

What are the symptoms of opioid withdrawal?

A
  1. Myalgias
  2. GI symptoms (nausea, abdominal cramping, hyperactive bowel sounds)
  3. Piloerection
  4. Pupillary dilation
  5. Irritability
  6. Yawning
  7. Lacrimation
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24
Q

Treatment:

Obsessive-Compulsive disorder

A

First line treatment:

  1. CBT (exposure and response prevention)
  2. SSRI
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25
Treatment: Generalized Anxiety Disorder (GAD)
1. CBT | 2. SSRI or SNRI (e,g,. escitalopram)
26
Prior to recommending a treatment approach for PMS/PMDD what should be done?
Detailed menstrual diary covering 2-3 menstrual cycles.
27
Treatment: Bipolar I disorder
1. Second generation antipsychotics (eg, quetiapine, lurasidone) during the depressed phase * Avoid antidepressant monotherapy in bipolar I disorder.*
28
Which antidepressant is a good choice for a patient with: 1. Poor sleep 2. Poor appetite
Mirtazipine, it can cause drowsiness and increased appetite.
29
What are the most common side effects associated with olanzapine?
1. Weight gain (due to Histamine 1 and 5-HT2c receptor antagonism) 2. Sedation (due to histamine 1 receptor antagonism) less common: 3. Hyperglycemia 4. Dyslipidemia 5. New-onset diabetes mellitus
30
Diagnose: Cyclothymic disorder
1. Chronic mood disturbance >/= 2 years 2. Numerous episodes of hypomanic and depressive symptoms 3. sub threshold for diagnosing major depressive episode or hypomanic/manic episode
31
Which class of anti-depressants is associated with hypertensive crisis when eating tyramine rich foods?
Monamine oxidase inhibitors (eg, phenelzine) *MAOIs are typically used to treat refractory and atypical depression.*
32
When should benzodiazepines be avoided in the treatment of performance-only social anxiety disorder?
1. History of substance abuse | 2. If performance will be impaired by cognitive and sedative side effects.
33
Treatment: Performance only social anxiety disorder
1. Beta blockers: control the the autonomic response (tremors, tachycardia, diaphoresis) 2. Benzodiazepines * DO NOT use benzodiazepines if patient has a hx of substance abuse, or if performance might be affected by side effects of sedation and cognitive impairment. *
34
Treatment: Tardive dyskinesia associated with prolonged exposure to antipsychotic drugs
1. Discontinue antipsychotic drug 2. Switch to clozapine if discontinuing antipsychotic drug is not feasible 3. Treat with valbenazine
35
What is tardive dyskinesia?
Abnormal involuntary movements of the mouth, tongue, face, trunk and extremities.
36
Which antipsychotic is least likely to cause extrapyramidal symptoms?
Clozapine
37
Diagnosis: 1. Excessive daytime sleepiness 2. Cataplexy 3. REM sleep related phenomena (hypnagogic/hypnopompic hallucinations, sleep paralysis)
Narcolepsy
38
When should you expect sedative-hypnotic overdose in a patient assumed to be on a benzodiazepine?
When there are signs such as: bradycardia, hypotension, respiratory depression and hyporreflexia.
39
Treatment: Geriatric patient with major depression + psychotic features + refusal to eat and drink
Electroconvulsive therapy (ECT) *Rapid intervention is necessary in these patients.*
40
What are the indications for ECT?
1. Treatment resistance 2. Major depression with psychotic features 3. Emergency conditions (pregnancy, refusal to eat or drink, imminent risk for suicide)
41
Treatment: Drug-induced parkinsonism
1. anti-psychotic dose reduction (if feasible) 2. Benztropine 3. Amantadine
42
Which cognitive deficit acts as a fairly specific indicator of dementia as opposed to normal aging?
Getting lost in familiar territory
43
# Define: Illness anxiety disorder
Fear of having a serious illness despite few or no symptoms and consistently negative evaluations. *Illness anxiety disorder=hypochodriasis)*
44
# Define: Somatic symptom disorder
Excessive anxiety and preoccupation with >/= 1 unexplained symptoms *This typically results in high levels of medical care utilization.*
45
Diagnosis: >/= 1 delusion in the absence of other psychotic symptoms in an otherwise high-functioning individual.
Delusional disorder *Patients with personality disorders do not have persistent delusions or other psychotic symptoms.*
46
What is the primary pharmacologic neurotransmitter target for obsessive-compulsive disorder (OCD)?
Serotonin *SSRI's like fluoxetine, fluvoxamine, paroxetine, citalopram, escitalopram and sertraline are commonly used.*
47
List the normal age-related sleep changes.
1. Decreased total sleep time 2. Increased nighttime awakenings 3. Sleepiness earlier in the evening 4. Earlier morning awakening 5. Increased daytime somnolence (napping)
48
When is sleep restriction therapy indicated?
For patients with (1) insomnia who (2) spend too much nonsleeping time in bed
49
Which second generation antipsychotics are associated with the greatest risk for metabolic side effects (eg, weight gain, hyperglycemia, dyslipidemia)?
Olanzapine and clozapine *All SGA can cause metabolic syndrome, so patients should have their BMI, fasting glucose, lipids, blood pressure and weight circumference followed regularly.*
50
What organs should be monitored in patients taking lithium?
1. Kidney 2. Thyroid *Patients with renal insufficiency whorls have their dosage of lithium adjusted appropriately.*
51
What drug is associated with a risk for agranulocytosis?
Clozapine *Monitor the CBC Q6weeks
52
Which drugs are associated with hyperprolactinemia?
1. First-generation antipsychotics | 2. Risperidone (SGA)
53
Treatment: Acute dystonia due to antipsychotic treatment
1. Benztropine (anticholinergic) 2. Diphenhydramine (antihistamine) *You need drugs that have significant anticholinergic activity.* **To decrease the risk of recurrence try reducing the dosage of antipsychotic or switching to a SGA with a lower risk profile for EPS.**
54
Treatment: Akathisia 2/2 antipsychotic treatment
1. Propanolol (Beta-blocker) 2. Lorazepam (Benzodiazepine) 3. Benztropine *To decrease the risk of recurrence, try reducing the antipsychotic dosage and switching to a SGA with a lower risk profile for EPS.* **Akathisia is subjective restlessness and inability to sit still.**
55
Treatment: Parkinsonism 2/2 antipsychotic treatment
1. Benztropine 2. Amantadine *To decrease the risk of recurrence try reducing the antipsychotic dosage and switching to a SGA with a lower risk profile for EPS.* **Parkinsonism 2/2 to antipsychotic medication is a gradual-onset tremor, rigidity and bradykinesia.**
56
What are the most common side effects of ECT?
1. Anterograde amnesia 2. Retrograde amnesia 3. Fracture: VERY RARE, usually seen in patient with severe osteoporosis, but close monitoring of muscle relaxation reduces risks *Amnesia is a short lived side effect.*
57
List the absolute contraindications to ECT?
There are none.
58
What are the clinical features of sleep terrors?
1. Abrupt arousal from sleep with fear (panicked scream, terror, autosomal arousal: flushed face, sweating, tachycardia) 2. Unresponsive to comfort 3. Amnesia of the event 4. NO dream recall
59
Treatment: Sleep terrors
1. Reassurance: typically self limited after 1-2 years | 2. Benzodiazepine: low dose benzodiazepines prescribed if terrors are frequent or interfere with daytime functioning.
60
What are the risk factors for prescription opioid misuse?
1. age< 45 2. psychiatric disorder 3. personal or FHx of substance disorder 4. legal Hx
61
What measures reduce the risk of prescription misuse?
1. Review of state's prescription drug-monitoring program data 2. Random urine drug screens 3. Regular follow-up (Q3Months)
62
What are the features of cocaine withdrawal?
1. Acute depression 2. Suicidal ideation 3. Fatigue 4. Hypersomnia 5. Increased dreaming 6. Hyperphagia 7. Impaired concentration 8. Intense drug craving
63
What decreases the risk of relapse and rehospitalization in patients recently hospitalized for schizophrenia?
1. Stable home environments with decreased family stressors (Family counseling and psychoeducation)
64
Which schizophrenic patients are at higher risk for relapse?
Patients with critical, hostile or over-involved family members.
65
What are the first-line antidepressants?
1. SSRI (eg, fluoxetine) 2. SNRI (eg venlafaxine) 3. Buproprion 4. Mirtazapine 5. Serotonin modulators (eg vilazodone)
66
What conditions are survivors of sexual assault at high risk for developing?
1. PTSD 2. Depression 3. Suicidality 4. STD 5. Pelvic pain 6. Fibromyalgia 7. Functional GI disorders 8. Cervical Cancers
67
Treatment: Hoarding disorder
Cognitive-Behavioral therapy (CBT)
68
Diagnosis: 1. Euphoria 2. Rapid onset, but transient loss of consciousness 3. Perioral or perinostril rash 4. Negative urine toxicology 5. Slightly elevated LFTs
Inhalant abuse *LFTs are only slightly elevated with repeated use.* **Perioral rash is dermatitis, or glue sniffer's rash.**
69
Which neurotransmitter is dysregulated in neuroleptic malignant syndrome?
Dopamine
70
Diagnose: Panic disorder
- Recurrent and unexpected panic attacks with >/= 4 of the following: 1. Chest pain 2. Palpitations 3. SOB 4. Choking 5. Dizziness 6. Parasthesias 7. Derealization 8. Depersonalization 9. Fear of losing control or dying - Worry about additional attacks - Avoidance behavior
71
Treatment: alcohol use disorder
First line therapy: 1. Naltrexone 2. Acamprosate Second line therapy: 3. Disulfiram
72
What are the contraindications for Naltrexone in alcohol use disorder?
1. Patients taking opioids 2. Acute hepatitis 3. Liver failure
73
What are the contraindications for Acamprosate in alcohol use disorder?
1. Significant renal impairment
74
Treatment: Post-partum psychosis
Hospitalization
75
When should you screen for eating disorders in a adolescent vegetarian patient?
1. Low BMI 2. Excessively restrictive diet 3. Distorted body image
76
What are the characteristics of dissociative amnesia?
1. Inability to recall autobiographical information (personal identity or history) -OR- 2. Amnesia for a particular event Following an overwhelming or intolerable event.
77
What do you call dissociative amnesia associated with travelling or wandering?
Dissociative fugue
78
What are the clinical features of Conversion disorder?
1. Sudden onset of neurological symptoms | 2. Clinical findings incompatible with recognized neurological conditions
79
Diagnosis: 1. Altered mental status 2. Fever (104 commonly) 3. Muscle rigidity 4. Autonomic instability 5. Diaphoresis
Neuroleptic malignant syndrome *Laboratory studies indicate elevated creatine kinase and leukocytosis.*
80
How do the neuromuscular findings in serotonin syndrome differ from neuroleptic malignant syndrome?
Serotonin syndrome: hyperreflexia, myoclonus Neuroleptic malignant syndrome: rigidity
81
How is lithium excreted from the body?
Renal excretion
82
What is the drug of choice to treat ADHD in patients with a history of substance disorder?
Atomoxetine (nonstimulant) *Use this to avoid the risks of drug misuse and addiction.*
83
How long is maintenance-phase treatment with antidepressants following a first time episode of major depressive disorder to prevent relapse?
6 additional months after acute response during initial continuation-phase treatment. *If recurrent, chronic or severe (eg, suicide attempt) use maintenance therapy for 1-3 years.*
84
How can you differentiate a normal stress response from an acute stress disorder?
The absence of marked distress or significant functional impairment (eg continues to work and attend social activities) is suggestive of normal stress response.
85
Which antidepressant does not need to be tapered to prevent antidepressant withdrawal?
Fluoxetine *Half-life is 4-6 days with chronic use.*
86
What are the characteristics of benzodiazepine withdrawal?
1. Anxiety 2. Insomnia 3. Dysphoria 4. Impaired concentration 5. Psychosis* 6. Seizures* *Present in severe life-threatening cases.*
87
Diagnosis: 1. Immobility or excessive purposeless activity 2. Mutism, stupor (decreased alertness & response to stimuli) 3. Negativism (resistance to instructions & movement) 4. Posturing (assuming positions against gravity) 5. Waxy flexibility (initial resistance, then maintenance of new posture) 6. Echolalia, echopraxia (mimicking speech & movements)
Catonia
88
Treatment: Catatonia
1. Benzodiazepines (lorazepam) | 2. ECT

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