Behavioral Health Flashcards
What is first-line treatment for this condition for PMS?
Fluoxetine
When do symptoms of PMS or PMDD occur?
later luteal phase
four or five prior to menses
and remit after menses
MC affective/behaviroal sx PMS/PMDD
MC mood swings
Lab testing that should be done when working up possible PMS/PMDD
Thyroid studies
First line tx PMS/PMDD
SSRIs can be administered either
- continuously
- only during the luteal phase (start on day 14 of cycle)
- monthly only when symptomatic
Second line tx for PMS/PMDD
Oral contraceptives that contain drospirenone (progestin) best
Can also be used in adjunct with SSRI
What PMS is suggested when someone fails SSRI/oral contraception combo tx
Gonadotropin releasing hormone agonist tx such as
LEUPROLIDE
When this is done the provider usually then will “add-back therapy” with estrogen and progestin to avoid menopausal sx and osteoporosis
What is the last line tx for PMS/PMDD
surgery with oophorectomy
Tx for moderate to severe PMS/PMDD
SSRI
Oral contraceptives containing drosperinone
Continuous contraceptive containing any progestin
Alprazolam
GrRH
Ineffective tx for PMS/PMDD
progesterone
vitamin supplements
dietary restriction
What are the adverse effects of GnRH agonists?
bc of hypoestrogenism:
hot flashes, vaginal atrophy, decreased BMD
Name a med that can be used when someone with schizophrenia has an acute psychotic episode
Olanzipine
RF for schizophrenia
living in urban area immigration obstetric complications late winter or early spring birth (poss. exposure to influenza during neural tube development) increased paternal age at conception
Schizophrenia positive sx
Added to the personality: hallucinations delusions disorganized speech disorganized behavior
Schizophrenia negative sx
Take away from the personality: blunted/flat affect alogia or impoverished speech anhedonia (lack pleasure) social withdrawl
Dx of schizophrenia can be made by…
when at least two or more of the characteristic symptoms, including delusions, hallucinations, disorganized speech, disorganized behavior, and negative symptoms, are present most of the time for at least one month (or less if treated)
Dx of schizophrenia is confirmed at 6 months by….
Signs of disturbance must persist for at least six months (with at least one month of two of the five symptoms) to confirm the diagnosis. During the remainder of the six month period, the clinical manifestations may be limited to only negative symptoms or less severe positive symptoms that are not causing social or occupational dysfunction
Do antipsychotics work better on positive or negative sx of schizophrenia
positive
Which antipsychotic has the best efficacy and why is it not used first
clozapine
causes agranulocytosis
reserved for those who fail to improve or can not tolerate the other antipsychotics
Which antipsychotic is the only one effective for the negative sx of schizophrenia
cariprazine
Which generation of antipsychotics cause the least extrapyramidal SE
Second generation
What are the extrapyrimidal SE
akathisia rigidity bradykinesia tremor acute dystonic rxns
How long does it take for an antipsychotic to improve positive sx of schizophrenia
Most effect seen in first 2 weeks
Continues to improve over months
What initial intervention should you do if an antipsychotic isn’t working for your schizophrenic pt
increase the dose
Or
switch to a different antipsychotic
How do you treat a person with schizophrenia having agitated psychosis
usually works in minutes
antipsychotic med like risperidone, olanzapine, haloperidol
w/ or w/o
benzo like lorazepam
Why would benztropine of diphenhydramine be given to someone experiencing agitated acute psychosis?
To blunt the extrapyramidal SE of the antipsychotic meds
With what and for how long should you treat someone who has had a psychotic event (even just one)
antipsychotic med at lowest dose possible indefinitely
Name the first gen antipsychotics
MOA
SE
MOA: dopamine antagonists
haloperidol, fluphenazine, chlorpromazine
SE: extrapyramidal sx, sedation, anticholinergic, orthostatic hypotension, agranulocytosis, tardive dyskinesia, hyperprolactenemia, NMS, prolonged QT interval, metabolic syndromes
Define tardive dyskinesia
involuntary choreoathetoid movements of the mouth, tongue, face, extremities, or trunk
Name metabolic syndrome features
Weight gain
DM
dyslipidemia
cardiovascular disease
These two AE effects do not usually occur when using a second gen antipsychotic
extrapyramidal
tardive dyskinesia
Name some anticholinergic effects
dry mouth, constipation, urinary retention, blurred vision
What is the MOA of second gen antipsychotics
dopamine and serotonin antagonists
Tx for akathisia (motor restlessness)
benzodiazepines
Schizophrenia rapid review
Schizophrenia
≥ 2 symptoms:
Delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative symptoms
Brief psychotic disorder: < 1 month
Schizophrenia: > 6 months
Schizophreniform disorder: 1–6 months
Schizoaffective disorder: psychosis + mania or depression
Typical alcohol withdrawal sx 8 hours
anxiety 1st
Early alcohol withdrawal typical presentation
anxiety, agitation, insomnia, mild tremor, nausea
Alcohol withdrawal sx at 48 hours
prevalent tremor elevated BP, vital sign instability
What med can treat alcohol anxiety
benzo
Late alcohol withdrawal sx
autonomic instability:
seizure, delirium, LOC, altered mental status, death
How should treat alcohol withdrawal seizures
IV benzos fast acting
List the progression of alcohol withdrawal
6-12 h = tremulousness
12-48 h = hallucinations
12-48 h = seizure
>48 h = delirium tremens
What is the metabolite half life of chlordiazepoxide
3 to 100h
sedative: It can treat anxiety, alcohol withdrawal symptoms, and tremor.
Alcohol withdrawal syndrome
Alcohol Withdrawal Syndrome
Early symptoms: anxiety, nausea, restlessness
Risk of seizure
Delirium tremens may start after 48 hours
Treat with benzodiazepines
Correct nutritional deficiencies
Offer alcohol cessation support /resources
What lab values need to monitored while on lithium
thyroid function
Define bipolar manic episode
Must last at least one week
irritability, elation, expansiveness
along with at least 3 other sx of mania such as…
less need sleep, pressured speech, grandiosity, racing thoughts, easily distractible, increased pleasurable activities that inappropriate, increased goal focused activities
Define Bipolar I
alternating periods of severe depression and severe mania which can include psychosis
Define Bipolar II
alternating patterns of severe depression and a LESS severe form of mania = hypomania
FIrst line medication tx for bipolar
lithium - mood stablizer
check TSH at baseline and every 6 to 12 mos bc it can cause hypothyroid, chronic autoimmune thyroiditis, goiter
Lithium category…
D
Since lithium has a narrow therapeutic range, what are the CI
significant renal impairment, cardiovascular ds, sodium depletion, dehydration
Define autism spectrum disorder
neurodevelopmental disorder characterized by
- social communication difficulty
- intellectual disability
- repetitive, restricted interests and behaviors
Autism has a strong heritable link. Name some comorbid factors.
- ADD
- substance abuse
- OCD
What are the 2 main components of DSM-5 dx of ASD
- persistent deficits in social communication and interaction
AND - restricted, repetitive patterns of behavior, interests, or activities
Grief rxns
Grief Reaction
Stages: denial, anger, bargaining, depression, acceptance
Nonpathologic symptoms: guilt, weight loss, simple hallucinations
Pathologic symptoms: >12 months, severe functional impairment, suicidal ideation, psychotic symptoms
Anorexia nervosa: what percentage below expected body weight
15% or more below the expected body weight
Anorexia nervosa: MC age and gender
adolescence or young adult
90% female
What other behaviors/characteristic common for someone with anorexia nervosa
perfectionists
OCD
destructive relationships
parents often goal driven and over directive
Some physical features of anorexia nervosa
low body weight most obvious muscle atrophy loss of body fat Hypocellular Bone Marrow Decreased Cardiac Diameter Amenorrhea Increased Lanugo bradycardia, hypotension, constipation, dry skin leukopenia, elevated serum creatinine, low levels of LH and FSH
What ECG might you see in a pt with anorexia nervosa
hypokalemia
ST segment and T wave changes
Which gland is commonly enlarged in anorexia nervosa
parotid gland
How long does a panic attack take to peak?
10 min
What is the prevalence of panic attacks in the population
11%
Presentation of typical pt with a panic attack
Complains of: chest pain, dizziness, feeling choking, palpitations, shortness of breath
PE: hypotension, tachycardia, tachypnea, tremors, cool and clammy skin
DSM-5 dx of panic attacks
include a sudden onset of fear or discomfort accompanied by four of the following symptoms: fear of dying, fear of losing control, derealization/depersonalization, chest pain, dizziness, a feeling of choking, flushes or chills, gastrointestinal discomfort, sweating, paresthesia, dyspnea, and tachycardia.
Tx panic attacks
antidepressants; SSRIs, SNRIs
psychotherapy including CBR and exposure tx
What are the forms of exposure therapy that can be used for panic attacks?
flooding and graduated exposure
8yo, ADD, first line initial tx
amphetamine-dextroamphetamine and behavioral tx
ADD:
prevalence in children
MC in boys or girls
8-10%
boys MC
How many sx are needed to dx ADD
the Diagnostic and Statistical Manual, Fifth Edition (DSM-5), requires at least six symptoms of hyperactivity or impulsivity or at least six symptoms of inattention to make the diagnosis of attention-deficit hyperactivity disorder in children younger than 17 years of age. Children 17 years of age and older and adults require at least five symptoms of hyperactivity or at least five symptoms of inattention. Furthermore, in children and adults, these symptoms must occur often, be present in more than one setting (e.g., school, recreational activities and home), persist for at least six months, be present before the age of 12 years, and be excessive for the developmental level of the child.
4-5yo, ADD, first-line tx
behavioral tx first then can add pharm if not improved
If medicate a 4-5yo for ADD what first line drug
Methylphenidate
however in school age children medicate along with behavioral tx
Stimulants are the most effective for ADD. Name the prefered
dextroamphetamine-amphetamine
Non-stimulants can also be used for ADD but are less effective. Name 3.
atomoxetine
guanfacine
clonidine
ADHD rapid review
Attention-Deficit/Hyperactivity Disorder (ADHD)
Most common childhood behavioral disorder
Inattention + impulsivity + hyperactivity
Dx criteria:
Sx present in 2 areas of interaction
Sx must present before 12 years
Sx > 6 months
Sx maladaptive/inappropriate for child’s developmental stage
Rx: medication (most effective), behavioral modification, environmental intervention
Name the personality disorder:
no friends, never goes out, flat affect, does not desire relationships
schizoid
Describe the 3 clusters of personality disorders
A: odd and eccentric
paranoid, schizoid, schizotypal
B: dramatic, emotional, erratic
antisocial, borderline, narcissistic, histrionic
C: anxious or fearful
avoidant, dependent, obsessive compulsive personality disorders
First and second line tx for personality disorders
- psychotherapy
2. pharmacologic as adjunct
Define schizoid personality disorder per DSM-5
a pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings beginning by early adulthood. The disorder presents in a variety of contexts, as indicated by four (or more) of the following: neither desires nor enjoys close relationships (including being part of a family), almost always chooses solitary activities, has little or no interest in having sexual experiences with another person, takes pleasure in few or no activities, lacks close friends or confidants other than first-degree relatives, appears indifferent to the praise and criticism of others, and shows emotional coldness or detachment (anhedonic). Schizoid personality disorder can only be diagnosed if the symptoms are not better characterized by another psychiatric disorder.
Describe avoidant personality disorder
marked by a desire for relationships but individuals avoid those relationships due to intense feelings of inadequacy or fear of criticism. This desire contrasts with schizoid personality disorder where individuals do not desire relationships and prefer social isolation.
Describe Major depressive disorder Des
is defined by a depressed mood or anhedonia (loss of pleasure) with at least five associated depressive symptoms, including fatigue, sleep disturbances (hypersomnia or insomnia), significant weight changes, feelings of guilt, loss of interest in normally pleasurable activities, decreased concentration, psychomotor retardation (slowed speech or movement), and suicidal thoughts or ideation. The symptoms must be present for at least two weeks for major depressive disorder to be diagnosed. The patient in this vignette is socially withdrawn but does not have a depressed mood or at least five of the symptoms listed above.
Describe paranoid personality disorder
is marked by a pervasive pattern of distrust and suspiciousness of others. These individuals often misinterpret the actions of others as malevolent and are preoccupied with doubt regarding the loyalty of others. Paranoid personality disorder is also in cluster A.
schizoid rapid review
Schizoid Personality Disorder
Detachment from social relationships Restricted range of expression Solitary activities Emotionally cold/flat Avoids close relationships Pleasure in few activities
