Board Vitals: Psych Extra Review Flashcards
In order to meet criteria for PTSD, how long must one have sxs for?
Sxs must last > 1month
At what age do most panic disorders begin?
Usually young adults, but can come later. To meet criteria for Panic disorder, panic attacks must be recurrent.
In what context do panic attacks first occur?
1st panic attack appears to occur “out of the blue” when the pt is doing every day things BUT there tends to be a correlation with a major life event
What is SSRI discontinuation syndrome?
SNRIs and SSRIs have short half-lives (venlafaxine, paroxetine) so can cause w/d w/ single missed dose. W/d sxs can be allevaited by tapering drug. Discontinuation sxs: ataxia, GI and flu-like sxs, headache, nausea, fatigue, excessive sweating, paresthesias, sensory and sleep disturbances, V/A hallucination, anxiety, crying spells, irritability and aggressiveness, restlessness, dysphoria, tremor, vertigo, irregular BP, dizzy
What is the onset of postpartum mood disturbances (i.e. maternal blues, depression, psychosis)?
Onset w/in 4wks of delivery
What are the preferred SSRIs in treating postpartum depression in breastfeeding mothers?
Sertraline and paroxetine levels are low to undetectable in breast milk. This is opposite to Fluoxetine, which has been shown to be the most efficacious but appears in higher levels in infants that are breast fed.
What is a bezoar?
A bezoar is a ball of swallowed foreign material (usually hair or fiber) that collects in the stomach and fails to pass through the intestines.
What is the rate of completed suicide among patients with Bipolar 1?
10-15% of Bipolar 1 patients die by suicide
For what period of time must the sxs of GAD be present in order to make the diagnosis?
At least 6 months
In rare cares, OCD and/or tic disorders has been associated with which microbial infection? Think pediatric population.
Group A strep is associated with OCD and neurological abnormalities with an abrupt prepubertal onset. PANDAS = Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections, a pediatric neurological disease in which a subset of children exhibit a rapid onset of OCD and/or tic disorders following group A beta-hemolytic streptococcal infections (S. pyogenes)
What medical conditions cause mania sxs? What drugs cause manic sxs?
Medical Conditions: CNS tumors, syphilis, delirium, encephalitis, influenza, multiple sclerosis, Q fever
Drugs: amphetamines, cocaine, isoniazid, steroids and other stimulants
What percentage of stroke victims will dependent major depression?
1/3 -1/2 of all stroke victims develop major depression and there is limited research that suggests that tx with an SSRI can reduce the rates of depression and mortality.
It is hypothesized that what brain structure might be related to the development of generalized anxiety disorder?
Amygdala
What is the typical course and prognosis for intermittent explosive disorder?
Onset usually in late teens-20s and in most cases it subsides by the time the patient is 40.
What are the common anti-cholinergic side effects of TCA’s?
Blurred vision, urinary retention, constipation, dry mouth
What are common inducers of the CYP 3A4 system?
Carbamazepine, phenytoin and oxcarbazepine
What is the lifetime prevalence rate of panic disorder?
2-5%
What percentage of people with bipolar disorder attempt suicide?
25-50% report at least one suicide attempt in their lifetime, usually occurring most commonly during a period of depression.
What is are the 2 most effective treatments for OCD?
SSRI - Fluvoxamine (Luvox) - only approved for OCD
TCA - Clomipramine
How long must sxs be present for a patient under 18 yo to be dx w/ a specific phobia?
6 months
What is the best long-term tx for GAD?
CBT + SSRI
What percentage of patients with Bipolar I disorder have more than one manic episode?
> 90%
What is referred to as “rapid cycling”?
If you have 4 or more episodes per year of a moos episodes in 1 year (major depressive, manic, mixed, etc).
Definition of sensitivity?
True Positive / (True Positives + False Negatives)
What instruments are best used to estimate IQ?
Wechsler Intelligence Scale for Children (WISC) or the Standford-Binet Intelligence Scale
What are IQ scores for children with mild, moderate, severe and profound mental retardation?
Mild retardation: 50-70
Moderate retardation: 35-49
Severe retardation: 20-34
Profound retardation:
What is Tourette disorder?
Tourette disorder is a syndrome of multiple motor and vocal tics that occur daily for at least 1 year (onset before age 18), men>women, and is associated with attention deficits and obsessive and compulsive behaviors.
What is the indication for pimozide? What will you need to monitor while patient is on this drug?
Pimozide is a high potency, 1st generation neuroleptic. MOA: Dopamine D2 receptor antagonism. Used for severe tics. Must monitor QTc with ECG.
What to patients with Tabes dorsalis present with?
Tertiary syphilis –> demyelination of dorsal columns and roots –> impaired sensation and proprioception –> sensory ataxia of lower extremities –> wide-based gait
Argyll-Robertson pupil –> pupil accomodation but no reaction to light
+ Romberg sign and absence of DTRs
What tumor should be considered in a differential diagnosis of a patient presenting with anxiety?
Pheochromocytoma: tumor of chromaffin cells, usually occurring in the adrenal medulla.
What is the necessary somatic complaint profile in order to meet criteria for Somatization disorder?
At least 4 pain sxs, 2 GI sxs, 1 sexual or reproductive sxs and 1 pseudoneurologic sxs.
What is the standard workup for delirium?
- CBC + differential
- Electrolytes + LFTs
- BUN + creatinine
- VDRL
- Vitamin B12 + folate
- Urinalysis + urine toxicology screen
- TSH
- Calcium, magnesium, phosphorus, glucose
- Peripheral oxygen saturation
- CXR, ECG, mental status and physical exam
What is the classic presentation of PCP intoxication?
Nystagmus, HTN, Tachy, decreased responsiveness to pain, muscular rigidity, violence or aggressive tendencies w/ or w/o psychotic sxs.
What is the classic presentation of cocaine withdrawal?
Intense dysphoric mood, fatigue, increased appetite, hypersomnia, unpleasant dreams and psychomotor agitation or retardation.
What is the classic presentation of marijuana intoxication?
Conjunctival injection, increased appetite, dry mouth, euphoria, impaired time perception.
What is the classic presentation of opioid withdrawal?
Pilo-erection, diaphoresis, abdominal cramps, yawning, lacrimation, muscle aches, DILATED pupils (mydriasis).
In general, drugs of abuse are more addictive if they have what characteristic?
Shorter onset of action
In general, more severe drug withdrawal syndromes are seen drugs with short or long half-lives?
Short half-lives
What percentage of patients after one manic episode will have a repeat manic episode within 5 years?
90%
What is classified under Axis I?
Mental illness including substance abuse and developmental disorders
What is classified under Axis II?
Personality disorders and mental retardation.
What benzodiazepines can be used for alcohol withdrawal with abnormal liver function tests?
Lorazepam or oxazepam (Serax) would be chosen b/c they are primarily metabolized and eliminated renally instead of through the liver.
What is the drug of choice for managing the agitated or confused patient with delirium?
Haloperidol is the drug of choice NOT thioridazine, benztropine nor diphenhydramine since they all have anticholinergic properties that exacerbate delirium. Lorazepam in older patients may have a paradoxical effect and exacerbate agitation and confusion.
What is perphenazine?
Perphenazine is a traditional neuroleptic.
A common side effect of SSRIs that may mimic a symptom of depression is?
Insomnia
What are important CYP450 inducers?
Smoking (1A2)
Carbamazepine (1A2, 2C9, 3A4)
Barbiturates (2C9)
St. John’s wort (2C19, 3A4)
What are important CYP450 inhibitors?
Fluvoxamine (1A2, 2D6, 3A4) Fluoxetine (2C19, 2C9, 2D6) Paroxetine (2D6) Duloxetine (2D6) Sertraline (2C19)
….all SSRIs ..except Duloxetine, which is a SNRI.
What is Prozac?
Prozac is Fluoxetine a SSRI.
What SSRI has the longest half-life?
Fluoxetine (Prozac) has the longest half-life so patient at a low risk of SSRI discontinuation/withdrawal syndrome.
Which SSRI is safe in pregnancy and approved for use in children?
Fluoxetine (Prozac)
What is Zoloft?
Zoloft is Sertraline a SSRI.
What is Paxil?
Paxil is Paroxetine a SSRI.
Which SSRI has the shortest half-life?
Paroxetine (Paxil) has the shortest half-life so patient at a high risk of SSRI discontinuation/withdrawal syndrome.
What are examples of serotinergic drugs that when combined with high-dose antidepressants can results in serotonin syndrome?
Cough medicine = dextromethorphan
Analgesics = meperidine, tramadol
Herbal products = St. John’s wort
Antibiotic = linezolid
What is Luvox?
Fluvoxamine is Luvox.
What is Celexa and Lexapro?
Celexa is Citalopram.
Lexapro is Escitalopram, which is more expensive than Citalopram.
What is Effexor?
Effexor is Venlafaxine a SNRI.
What is Cymbalta?
Cymbalta is Duloxetine a SNRI.
What is Wellbutrin?
Wellbutrin is Buproprion a NE-DA reuptake inhibitor used for refractory major depression + insomnia + smoking cessation BUT lowers seizure threshold.
What is Remeron?
Remeron is Mirtazapine, an alpha-adrenergic receptor antagonist. Useful in the treatment of refractory major depression, especially in patients who need to gain weight.
What are the components of the mesolimbic pathway?
Mesolimbic pathway = Reward pathway that consists of the medial orbital frontal cortex –> nucleus accumbens –> fornix –> amygdala –> hippocampus.
Mesolimbic DA pathway is responsible for the positive symptoms of SCZ.
What DA pathway is responsible for extrapyramidal symptoms?
Nigrostriatal pathway is responsible for EPS symptoms, which includes Putamen + Caudate (Striatum).
What is the known treatment for narcolepsy?
Modafinil, which is often used off-label in the treatment of hyper-somnolence and fatigue in depression.
What is donepezil indicated for and what SE should patients be warned about?
Donepezil is a centrally acting reversible acetylcholinesterase inhibitor used to treat Alzheimer’s dementia. Must warn about GI upset in setting of excess ACh.
What is Seroquel?
Quetiapine, common SE is sedation and orthostatic HYPOtension.
What is Zyprexa?
Olanzapine, common SE is weight gain.
What is Geodon?
Ziprasidone, less likely to cause weight gain.
Which atypical antipsychotic has a unique mechanism of action?
Aripriprazole (Abilify) is a partial D2 agonist.
What is Valium?
Valium is Diazepam, long acting BDZ. Used during detox from alcohol or sedative-hypnotic-anxiolytics.
What is Klonopin?
Klonopin is Clonazepam, long acting BDZ that is metabolized by the kidney.
What is Xanax?
Xanax is Alprazolam, short acting BDZ used for anxiety, including panic attacks.
What is Ativan?
Ativan is Lorazepam, intermediate acting BDZ used for panic attacks, agitation and detox BUT NOT metabolized by the liver.
What BDZs are NOT metabolized by the liver?
Lorazepam
Oxazepam
Temazepam
What are the characteristics of fetal Valproate syndrome?
Phenotypic attributes of fetal valproate syndrome include stereotypical facial features such as bifrontal narrowing, midface hypoplasia, a broad nasal bridge, a short nose with anteverted nares, epicanthal folds, micrognathia, a shallow philtrum, a thin upper lip and a thick lower lip.
What is the mechanism of lithium?
Lithium inhibits the alpha subunit of G-protein associated with cAMP.
What first generation antipsychotic has the most evidence supporting its use in pregnant women?
Haloperidol
What class of antidepressant drugs does Mirtazapine (Remeron) belong to?
Tetracyclic compound best described as a noradrenergic and specific serotonergic antidepressant.
Duloxetine (Cymbalta) should not be given to what type of patient?
Duloxetine increases hepatic transaminases and may further increase levels in patients with chronic liver disease, cirrhosis or heavy drinking.
What is one major difference in side effects between SNRIs and SSRIs?
SNRIs may cause HTN so do not use in patients with untreated or labile BP.
What EPS side effect is most commonly observed with Clozapine?
Akathisia
What is imipramine indicated for?
Imipramine is a Tricyclic Antidepressant used in childhood enuresis and panic disorder.
What is Ramelteon?
Ramelteon is a non-BDZ hypnotic that is a selective melatonin MT1 and MT2 agonist. It is used as a sleep aid.
What are two most important side effects of mirtazapine?
Sedation and weight gain.
What BDZ should be avoided in the setting of liver disease?
Clonazepam
What is biofeedback?
Process of mentally controlling physiologic parameters.
What is clonidine?
Clonidine is a alpha2-agonist used in Tourette syndrome, HTN emergencies and opioid w/d since its activity in presynaptic alpha2 autoreceptors results in decreased release of NE from Locus ceruleus (pons).
What drug is FDA approved for the treatment of suicidal behavior in SCZ and SAD?
Clozapine
What drug is known to be the treatment of choice for suicidal behavior in patients with bipolar disorder?
Lithium
What is the best time to measure plasma levels of lithium during therapy?
12hrs after the last dose
What are signs of lithium toxicity?
GI distress, tremors, acne, edema
What is a notable side effect of Ziprasidone (atypical neuroleptic)?
QT interval prolongation
What is the MOA of buspirone?
Buspirone is an 5HT-1a partial agonist. It does NOT work immediately (takes 1-2 weeks for effect).
What NT patterns are associated with anxiety?
Increase NE, decrease GABA, decrease Serotonin
What neurological pathology is associated with clozapine?
Seizures
What NT patterns are associated with depression?
Decrease in NE, decrease in 5-HT, decrease in DA
What is the classic indication for MAOIs?
Atypical depression (labile mood, sensitivity to rejection, leaden paralysis, hypersomnia, increased appetite).
Nefazodone carries a risk of what rare but serious side effect?
Black Box warning for Hepatotoxicity
What are the major adverse effects of Chlorpromazine?
Corneal deposits and blue-gray skin disColoration
What is the major toxicity of Thioridazine?
Night blindness (retinitis pigmentosa resemblance)
What cell types form the BBB?
Endothelial cells
Astrocyte end-feet
Pericytes
What NT is produced in locus ceruleus?
NE
What NT is produced in raphe nuclei?
5-HT
What is the concordance rate of bipolar 1 disorder in 1st degree relative?
10% risk if a 1st degree relative has bipolar I disorder
What is the concordance rate of bipolar 1 disorder in monozygotic twins?
70% risk of monozygotic twin has bipolar 1 disorder
What is the MOA of alcohol?
- Activates GABA and serotonin receptors in CNS
- Inhibits glutamate receptors and voltage-gated Ca2+ channels
- CNS depressant
What is the MOA of cocaine?
-Blocks DA re-uptake from synaptic cleft causing stimulant effect (recall that DA plays a role in the reward system of the brain)
What is the MOA of amphetamines?
-Block re-uptake and facilitate release of DA and NE causing stimulant effect
What is the MOA of PCP?
Antagonizes NMDA glutamate receptors
Activates DA neurons
Can have a CNS stimulant or depressant effect depending on dose taken
What is the MOA of opioids?
Stimulate opiate receptors
Effects on DA system (mediates addictive and rewarding properties)
What is the MOA of marijuana?
Stimulates cannabinoid receptors in the brain which inhibit adenylate cyclase
What is the MOA of caffeine?
Adenosine antagonist causing increase in cAMP and a stimulant effect via the DA system
What is the best treatment for Tourette disorder?
Atypical antipsychotics like risperidone
First generation antipsychotics like pimozide, haldol, fluphenazine
What is the Stanford-Binet psychological test? Subjective or Objective?
Objective IQ test for adults?
What is the Wechsler Intelligence Scale?
Objective IQ test for children?
What is the Rorschach test? Subjective or Objective?
Subjective test in which patients describe what they see in an inkblot (used to identify thought disorders and defense mechanisms)
What is the Thematic Apperception test? Subjective or Objective?
Subjective test in which the patient describes what is going on in a cartoon drawing of people.
What is the Beck Depression Inventory test? Subjective or Objective?
Objective test for depression
What is the Minnesota Multi-phasic Personality Inventory test? Subjective or Objective?
Objective test to measure personality type
What is the Halstead-Reitan Battery? Subjective or Objective?
Objective test used to determine the location and effects of specific brain lesions
What is the Luria-Nebraska Neuropsychological Battery? Subjective or Objective?
Objective test that assesses many cognitive functions as well as cerebral dominance (LT side or RT side)
