Behavioral Health Overview Flashcards
SIGECAPS
Sleep change Interest loss (anhedonia) Guilt (hopeless) Energy poor Concentration poor Appetite change Pschyomotor Suicide
*Dx depression need 5 or more sx in at least 2 weeks (one sx must be depressed mood or anhedonia)
Risk factors/associations w/ depression
FHx of depression, anxiety or alcohol abuse
Dx Persistent Depressive Disorder (Dysthymia)
- rules of 2’s!
1. depressed mood most days for 2 yrs
2. 2+ sx (SIGECAPS)
3. Not sx free for 2+ months in 2 yrs
Evaluation of depression
- open-ended questions
- SIGECAPS
- psychosocial questions (FHX, Social HX, physical stressors, current circumstances)
- Current support
5.*ask about manic episodes- could be BP
(have you ever had a time where you didnt sleep and didn’t miss it? ever feel too good to be true? get extremely irritable or anger?) - Ask about anxiety- worry excessively?
Screening tools: PHQ-9 Hamilton Depression Scale Beck Depression inventory Major Depression inventory Geriatric Depression Scale
TX plan for depression
- Tx physical issues
- Reassurance and education
- Therapy or lifestyle modifications
- Meds (f/u in 1 month at least needed)
- Combo
- F/U IS KEY!!
AD side effects
- GI: nausea, diarrhea, constipation
- Sedation (only SE that doesn’t go away)
- HA/ dizzy
- Dry mouth
LT: sexual, cognition (spacey), flat feeling
SSRIs from most activating to least
- Prozac (fluoxetine)
- Zoloft (sertraline)**
- Celexa (citalopram)
- Lexapro (escitalopram)**
- Paxil (paroxetine)
Common side effects w/
- Prozac (fluoxetine)
- Zoloft (sertraline)
- Celexa (citalopram)
- Lexapro (escitalopram)
- Paxil (paroxetine)
- Prozac (fluoxetine): anxiety, long half-life
- Zoloft (sertraline): not much, GI
- Celexa (citalopram): prolonged QT
- Lexapro (escitalopram): not much, sedation
- Paxil (paroxetine): sedation, wt gain, sexual, DC syndrome
Symptoms of Discontinuation Syndrome
- Sensory** (numbness, tingling)
- GI (N/V, diarrhea)
- Somatic (HA, tremor, sweating)
- Disequilibrium (dizzy)
- Sleep disturbance (excessive dreaming)
- Affective sx (irritable)
Addiction vs DC syndrome
**SSRIs are NOT addictive Addictive: -build tolerance and need higher doses -Cravings after withdrawl -use to feel "high" or altered
DC syndrome:
- No tolerance
- No cravings
- Use to feel normal
Examples of SNRIs
- Effexor XR (venlafaxine)
- Pristiq (desvenlafaxine)
- Cymbalta (duloxetine)
- Remeron (mirtazopine)
Examples of NDRIs
Wellbutrin (buproprion)
*only AD to boost NE and AD
What AD has low drug-drug interaction risk bc its an active metabolite that does not need to be metabolized in the liver?
Pristiq (desvenlafaxine)
What AD has increased serotonin effects at low doses but NE effects at high doses
Effexor XR (venlafaxine)
What AD is good for chronic pain/pain w/ depression
Cymbalta (duloxetine)
*also used to tx GAD, neuropathy, fibro
Side effects of Remeron (mirtazapine)
- weight gain
- sedation
* no sexual or GI
What AD is contraindicated with someone with a hx of seizure disorder or bulimia
Wellbutrin (bupropion)
*electrolytes are already off
1 or more delusion lasting at least 1 month WITHOUT other psychotic symptoms
Delusional disorder
What is the difference btwn
- Brief Pyschotic disorder:
- Schizophreniform disorder:
- Schizoaffective disorder:
- Schizophrenia:
- Brief Pyschotic disorder: 1+ psychotic sx w/ onset and remission in less than 1 month*
- Schizophreniform disorder: schizophrenia for less than 6 month duration*
- Schizoaffective disorder: schizophrenia + mood disturbance* (major depressive or manic)
- Schizophrenia: 6+ month* duration of illness w/ 1 month of acute sx along w/ functional decline*
Schizophrenia Dx Criteria
Need 2 or more:
- Positive Sx: hallucinations, delusions, disorganized speech/thinking
- Hallucinations ((sensory perception w/o physical stimuli)) (auditory*, visual, olfactory, tactile, somatic, gustatory)
- Delusions ((fixed belief held w. strong conviction despite evidence)) (persecutory, reference, control, Grandiose, Nihilsi, erotomanic, jealousy, doubles)
- Negative sx (caused by DA dysfunction) (flat emotional affect)
What type of delusion?
- Believes a family member or close person has been replaced by identical double
- Somebody is suspected of being unfaithful
- Exaggerated belief in the futility of everything and catastrophic events
- Believes another person is in love with them
- Unrealistic beliefs in ones powers and abilities
- person or forces is interfering w/ them, observing them or wishes harm to them
- random events take on a personal significance (directed at them)
- some agency takes control of patients thoughts, feelings and behaviors
- Doubles
- Jealousy
- Nihilism
- Erotomanic
- Grandiose
- Persecutory
- Reference
- Control
Tx of schizophrenia
- hospitalize for acute pschyotic episode
- Antipsychotics (DA receptor antagonist)
* *2nd generation “atypicals” = 1st line tx in schizophrenia (Risperidone, Olanzapine, Quetiapine
What meds are good at treating positive symptoms but are associated w/ increased extrapyramidal symptoms
1st generation antipsychotics (Haloperidol and Chlorpromazine)
extrapyramidal symptoms
rigidity, bradykinesia, tremor, akathisia (restlessness)
Examples of atypical 2nd generation antipsychotics from most sedating to least
- Olanzapine (Zyprexa)
- Quetiapine (Seroquel)
- Risperidone (Risperal)
- Geodon (Ziprasidone)
- Aripiprazole (Abilify)
- Clozapine (Clozaril)
- Loxapine (Loxatane)
*Less incidence of EPS
What antipsychotic has risk of agranulocytosis
Clozapine— need to check CBC weekly
Side effects of Lithium
- hypothyroidism
- sodium depletion
- increased urination and thirst (must drink 8-12oz water/day)
- diabetes insipidus
- hyperparathyroidism
- Seizures
- arrhythmias
- GI
* narrow therapeutic index= monitor plasma q4-8 weeks
What AD have risk for prolonged QT
- Cymbalta (duloxetine)
2. TCAs
How to dx bipolar II disorder
(hypomania) DIGFAST + 1 episode of major depression Distractibility Indiscretion/impulsivity Grandiosity Flight of ideas Activity- fun to be around/high energy Sleep Talkativeness **irritability
*Can be dx after 1 manic episode only
How to dx bipolar I disorder
DIGFAST but more severe and often has psychotic features
- Hallucinations
- Delusions
- Flight of ideas/disorganized speech
Tx of Bipolar disorder
- Mood stabilizers (often need more than 1)
- Lithium
- Depakote (divalproex, valproic acid)
- Lamictal (lamotrigine)
- Tegretol/Equetro (carbamezampine)
- Atypical antipsychotics (olanzapine, quetiapine, risperidone, aripiprazole) - Adequate sleep is KEY (benzo)
- +/- AD
- Regular routines
What med has a high risk for Steven-Johnsons syndrome in Asians so must genetic screen prior to use?
Tegretol/Equetro (carbamezampine)
*Lamictal (lamotrigine) also has high risk for SJS but not in Asians– tx mostly depression
Tx of Panic attacks
Benzos (lorazepam, aprazolam)
What is agoaphobia and how do you tx
anxiety about being in places or situations from which escape may be difficult
*seen w/ panic disorders
tx: SSRI*, cognitive behavioral therapy, benzo (acute attack)
Dx criteria for GAD
- excessive worry or anxiety a majority of days for 6+ months about various aspects of life
- 3/6 sx:
- fatigue, restlessness, poor concentration, muscle tension, sleep disturbance, irritable, shakey, HA - Cause impairement
- not due to other medical condition
Tx of GAD
- AD: SSRI or SNRI
- Buspirone (Buspar)- stimulates serotonin and blocks DA
- benzos (enhance GABA), BB, TCA
- psychotherapy (CBT)
DX social anxiety disorder
- at least 6 months of intense fear of social or performance situation in which the person is exposed to the scrutiny of others
tx of social anxiety disorder
- AD: SSRI or SNRI
- BB
- Benzo
- pscyhotherapy (CBT, insight-oriented therapy)
Single most common mental disorder
Specific phobias
Clinical manifestations of OCD
- Contamination (compulsion to wash hands)
- Pathologic doubt (forgetting to unplug iron)
- symmetry/precision (lining things up)
- Intrusive obsessive thoughts
Tx of OCD
- AD, SSRIs (higher doses), SNRIs, TCA
- CBT
- +/- Atypical antipsychotics
excessive preoccupation that 1 or more body part is deformed or an overexaggeration of a minor flaw which causes them to feel ashamed or self conscious
body dysmorphic disorder
**Poor insight and high suicide risk!
tx of body dysmorphic disorder
- educate
- SSRIs
- psychotherapy
DX criteria of PTSD
- Exposure/Stressor
- 1+ Intrusion/re-experiencing sx (dreams, flashbacks,
- 1+ Avoidance sx (avoid associated stimuli or reminders)
- 2+ Negative alterations in cognition or mood (exaggerated beliefs, “world is unsafe”, distorted blame, inability to recall, detachment, flat affect)
- 2+ arousal/reactivity sx (angry outburts, reckless, hypervililance, sleep disturbance, exaggerated startle response)
tx of PTSD
- AD: SSRI 1st line
- CBT
- Prazosin for nightmares (alpha-adrenergic blocker)
- EMDR
Acute stress disorder
similar to PTSD but sx last less than 1 month
TX: counseling/psychotherapy
What is somatic symptom disorder
chronic condition in which the patient has physical sx involving 1 or more body part but no physical cause can be found
*fears and sx disproportionate to medical findings
*often present w/ SOB, dysmenorrhea, sexual organ burning, lump in throat, amnesia, vomiting, painful extremities
tx of somatic sx disorder
regularly scheduled visits to provider to provide reassurance
what is illness anxiety disorder
(aka hypochondriasis)
-preoccupation w/ the fear or belief for at least 6 months that one has or will contact a serious, undiagnosed disease
- typically don’t have somatic sx or they are mild
- typically doctor shop
tx of illness anxiety disorder
- regularly scheduled visits to provider to provide reassurance
- SSRI
- CBT
What is Functional Neurological Symptom Disorder
aka Conversion disorder
-neurologic dysfunction suggestive of a physical disorder that cannot be explained clinically. sx cause distress or impairment
**Sx are NOT intentionally produced or feigned
(Mass hysteria)
ex. paralysis, mutism, blindness
Tx of Functional Neurological Symptom Disorder
behavioral therapy
Intentional falsification or exaggeration of signs and symptoms of medical or psychiatric illness for “PRIMARY gain” (motivation of their actions is assuming the sick role to get sympathy)
Factitious disorder
- Sx are faked or may hurt themselves to bring on sx
- may be willing or eager to undergo surgery or painful tests
Intentional falsification or exaggeration of signs and symptoms of medical or psychiatric illness for “SECONDARY gain” (ie. financial gain, food, shelter, avoid school/work/prison)
Malingering
What electrolyte and lab abnormalities are common w/ anorexia and bulimia
- Hypokalemia
- Hypomagnesemia
- Increased BUN
- Hypothyroidism
*Metabolic alkalosis from vomitting
Long pattern of voluntary social withdrawal and anhedonic introversion
“loner or hermit-like behavior”
*prefers to be alone and little enjoyment in close relationships”
-cold-flat affect
Schizoid personality disorder
MC in males and early childhood onset
Tx of:
Schizoid personality disorder and
Schizotypical Personality disorder
- psychotherapy
1. psychotherapy
- Odd, eccentric behavior and peculiar thought pattern w/o psychosis (delusions)
- inappropriate affect or speech, “magical thinking”
Schizotypical personality disorder
onset in early adulthood
Pervasive pattern of distrust and suspiciousness of others
- misinterpret the actions of others
- preoccupation w/ doubt regarding the loyalty of others
Paranoid personality disorder
tx: pscyhotherapy +/- antipsychotics if severe (haloperidol or benzo)
Behaviors deviating sharply from the norms, values and laws of society (harmful or hostile to society)
- may commit criminal acts w/ disregard to violation of laws
- inability to conform to social normal w/ disregard and violation of the rights of others
Antisocial personality disorder
begins in childhood as conduct disorder but MUST BE AT LEAST 18 to DIAGNOSE
x3 MC in males
(ex. drunk-driving common)
Unstable unpredictable mood and affect, unstable self-image and relationships
- unstable relationships but cannot tolerate being alone
- mood swings
- “black and white thinking”
- impulsivity in self-damaging behaviors
Borderline personality disorder
MC women
tx: psychotherapy
Overly emotional, dramatic, seducting
- attention seeking, self absorbed
- Temper tantrums
Histrionic Personality disorder
MC in women
TX: psychotherapy
Grandiose often excessive sense of self-importance but needs praise and admiration
-inflated self image: considers themselves special, entitled, requires extra special attention but have FRAGILE self esteem
Narcissistic personality disorder
MC in males
tx: psychotherapy
Desires relationships but avoids relationships due to inferiority complex (intense feelings of inadequacy, sensitive to criticism, fears rejection)
-timid, shy, lacks confidence
Avoidant Personality disorder
tx: psychotherapy
+/- BB or SSRI
submissive behavior (very needy and clingy)
- constantly needs to be reassured, relies on others more decision making and emotional support
- Will not initiate things
Dependent personality disorder
tx: psychotherapy
Perfectionist who require a great deal of order and control: rigid adherence to routine (rules, lists, details, lacks spontaneity)
- Change in their routine leads to extreme anxiety
- Preoccupied with minute details (may find it difficult to finish projects, hesitates to delegate work to others-avoids intimacy)
Obsessive-Compulsive Personality disorder
tx: psychotherapy
- Social interactions are difficult (emotional discomfort or detachment- avoid eye contact, no response to cuddling)
- Impaired communications
- Restricted, repetitive sterotyped behaviors and patterns
Autism spectrum disorder
Management of Autism spectrum disorder
Referral to neuropsychologic testing, behavioral modification, meds
Dx criteria of Oppositional Defiant Disorder
**often young children
6+ months of 3 of the following sx:
- Angry/irritable mood (neg attitude blames others)
- Argumentative/defiant behavior (defies authority figures, purposely annoys others)
- Vindictiveness
*persistent pattern of negative, hostile and defiant behavior towards ADULTS
Tx of Oppositional defiant disorder
tx: psychotherapy
* May progress to conduct disorder
Dx criteria of Conduct Disorder
<18y/o or otherwise antisocial personality disorder
6+ months Persistent pattern of behaviors that deviate sharply from the age-appropriate norms and violate the rights of others -Serious violation of laws -Aggressive/cruel to animals -Deceitfulness -Destruction of property
**40% develop antisocial personality disorder (after 18)
tx of ADD/ADHD
Multimodal approach
- Behavior modification
- Sympathomimetics (stimulants)
- methylphenidate (Ritalin), amphetamine/dextroamphetamine (Adderall) - Nonstimulants (atomoxetine (Straterra))
Management of Tobacco use/dependence
- Counseling/ support therapy
- Nicotine tapering therapy: gum, nasal sprays, patch, lozenges
- Bupropion (Zyban)
- Varenicline (Chantix): blocks nicotine receptors
Clinical Manifestations of Opioid intoxication
- Euphoria and sedation
- pupillary constriction
- Resp. depression
- Bradycardia
- hypotension
- NV, flushing
- constipation
Signs of Opioid withdrawal
- lacrimation
- HTN
- pruritus
- tachycardia
- NV, abdominal cramps
- piloerections* (goose bumps)
- pupil dilation (mydriasis)*
- flu-like symptoms
- rhinorrhea
Tx of acute opioid intoxication
Naloxone (narcan)
*MC used in pts w/ resp. depression
Tx of opioid withdrawal
- symptomatic control:
- Clonidine (decrease sympathetic sx)
- Loperamide for diarrhea
- NAIDS for joint pain/cramps
- Buprenorphine + Naloxone (Suboxone) - Methadone tapering
Long term treatment of dependence or detoxification of opioids
Methadone maintenance program
-Suboxone (buprenorphine + Naloxone)
SX of benzo intox
1.depression: slurred speech, slow reaction time
2. labile mood
Chronic:
1. Wernickes encephalopathy
2. Korsakoff syndrome amnesia
Tx of Benzo intox
Flumazenil
Sx of Benzo withdrawal
- increased CNS activity: tremor
- seizures, hyperreflexia
- Delirium Tremens (something crawling on them)
Sx of stimulant (cocaine or amphetamines) intox.
- euphoric mood
- aggression, agitation
- Sympathetic stimulation: HTN, pupillary dilation
Tx of stimulant (cocaine or amphetamines) intox.
Benzos
sx of stimulant (cocaine or amphetamines) intox. withdrawal
cravings hypersomnia increased appetite suicide ideation diaphoresis
sx of cannabis withdrawal
anxiety, restlessness
sx of PCP intox.
impulsiveness,
nystagmus**
sx of LSD intox.
visual hallucinations
- synesthesias (seeing sound as color)
- pupillary dilation
Sx of Alcohol withdrawal
- Increased CNS activity (tremor, diaphoresis, palpitations, sweating,)
- Withdrawal seizures (6-48 hrs after last drink)– generalized tonic-clonic type
- Alcoholic Hallucinosis (12-48hrs): clear sensorium and normal vital signs w/ visual or tactile hallucinations
- Delirium Tremens
Management of alcohol withdrawal
- Can be fatal!!
1. IV benzo- decrease CNS activity
2. IV fluids and supplementation (IV thiamine and magnesium) (prior to glucose administration) - intox may cause hypoglycemia
- Avoid meds that lower seizure threshold like bupropion, haloperidol, clonidine, BB
if glucose is giving before thiamine in someone with alcohol withdrawal, it may induce ____
Korsakoff’s syndrome
taking ____ with lithium can potentially cause a fatal neurotoxicity.
___ may increase serum lithium levels
Patients taking ___ require 50-70% reduction in lithium to maintain therapeutic levels
calcium channel blocker
potassium-sparing diuretics
ACEI
what are the two differentiating factors between mania and hypomania
- duration of sx (mania: at least a week or longer, and hypomania: at least 4 days)
- severity
what is the most frequent side effect with MAOIs
orthostatic hypotension
*wt gain, edema, insomnia, and sexual dysfunction also occurs
what are factors that lead to a better prognosis for schizophrenia and what factors lead to a worse prognosis
better: acute onset, late diagnosis, positive sx, concomitant mood distorder
worse: young age of onset, insidious onset, social isolation, fhx, negative sx
____ antipsychotic medication has been found to induce a QT interval delay in some pts- screen patients for cardiac risk factors
Ziprasidone (Geodon)
___ is characterized by symptoms of depression and hypomania for at least 2 years.
-sx are milder than regular depressive or manic episode
Cyclothymia
Sleepwalking disorders occur what part of the night?
Nightmare disorders occur what part of the night?
Sleep terrors occur what part of the night?
first half
last third
first third
what antipsychotic most frequently causes postural hypotension
Quetiapine (Seroquel)
What sleep changes occur in patients older than 65?
- redistribution of REM sleep
2. more REM episodes but shorter episodes= less total REM
A patient becomes violent and combative and given haloperidol. He first becomes managable, but then several hours later develops confusion, and inability to open mouth and high fever. What should be the initial treatment
Dantrolene
