Ch. 16 Psych Flashcards
What are the three indications for involuntary hospitlization?
■ Mental illness with impaired self-control, judgment, and/or discretion
■ Dangerousness to self or others in the setting of mental illness
■ Grave disability, ie, inability to provide basic needs of food, clothing, and shelter
What are demographics that put someone at higher risk for suicide?
male gender, white race, adolescent or age > 65 years old
What are social factor that put someone at greater risk for suicide?
Divorced,
lives alone,
unemployed,
homeless,
recent personal loss,
lack of religious or community involvement,
access to firearms
What is the definition of Major Depression?
Depressed mood (or irritability in children and adolescents) and/or loss of interest or pleasure along with 4 or more of the following depressive symptoms:
■ Change in weight (unintentional) or appetite
■ Change in sleep (insomnia or hypersomnia)
■ Psychomotor agitation or retardation
■ Fatigue or loss of energy
■ Feelings of worthlessness or guilt
■ Decreased concentration or indecisiveness
■ Recurrent thoughts of death or suicide
Symptoms (1) must be present almost every day for at least 2 weeks; (2) must be associated with significant impairment in daily functioning; and (3) must NOT be due to general medical condition (eg, hypothyroidism) or substance abuse.
What is pseudodementia?
In older patients, depression may present with memory loss, inattention, social withdrawal, confusion, and poor hygiene
What is the definition of dysthymic disorder?
Persistent depressed mood for > 2 years that does not meet criteria for major depression and has no symptom-free period lasting > 2 months.
What is the mneomic for depression risk stratification screening?
Sex (male) 1
Age (< 19 or > 45 y) 1
Depression or hopelessness 2
Previous suicide attempts or psychiatric care 1
Excessive alcohol or drug use 1
Rational thinking loss 2
Separated, divorced or widowed 1
Organized or serious attempt 2
No social supports 1
Stated future intent 2
How is bipolar disorder diagnosed?
■ Symptoms
(1) must be for at least 2 weeks;
(2) must be associated with significant impairment in daily functioning; and
(3) must NOT be due to general medical condition (eg, hyperthyroidism) or substance abuse.
■ Bipolar I: One or more manic episode(s) cycling with depressive episodes
■ Bipolar II: One or more hypomanic episode(s) cycling with depressive episodes
How is a hypomanic episode defined?
characterized by symptoms of mania without marked impairment in daily function, need for hospitalization, or psychotic features.
What is first line treatment for bipolar disorder?
mood stabilizers (eg lithium, valproic acid, lamotrigine).
What is the definition of acute psychosis?
Disturbed perception of reality characterized by delusions, hallucinations, and disorganized speech or behavior.
How are delusions defined?
erroneous beliefs that involve misinterpretation of perceptions
or experiences
How are hallucinations defined?
sensory experience that exists only in the mind of the person
experiencing it; may be auditory, visual, olfactory, gustatory, or tactile
How is catatonic behavior defined?
Motor immobility and unresponsiveness to external
stimuli
What is disorganized speech?
Loosening of associations (rapid switching from topic to unrelated topic), neologisms (nonsense words invented by patient), perseverations, word salad
What are neologisms?
nonsense words invented by patient
How is disorganized behavior defined?
Unpredictable agitation and absence of goal directed behavior
How is brief psychotic disorder defined?
Psychotic symptoms lasting > 1 day but < 1 month
How is schizophrenia defined?
Psychotic symptoms present ≥ 6 months
How is delusional disorder defined?
Non-bizarre delusions (eg involving situations that
occur in real life, such as being followed, poisoned, etc) lasting > 1 month without functional impairment
How is mood disorder with psychotic features defined?
Psychosis during mood episode
only
How is schizoaffective disorder defined?
Mood episode plus psychosis, with psychosis present at least 2 weeks prior to onset of mood episode
What is a risk factor for schizophrenia?
marijuana use is an independent risk factor for schizophrenia in genetically susceptible individuals
What are positive symptoms of schizophrenia?
Delusions, hallucinations, disorganized speech, or behavior
What are negative symptoms of schizophrenia?
Flat affect, poverty of speech, social withdrawal, inability to achieve goal-directed tasks
How is schizoid personality disorder?
Voluntary social withdrawal with no signs of psychosis
How is schizotypal personality disorder defined?
Odd, magical thinking with no signs of psychosis
How is the diagnosis of schizophrenia made?
6 months of continuous signs of disturbance with at least 1 month of 2 or more active symptoms (delusions, hallucinations, disorganized speech, disorganized behavior, or negative symptoms).
Only 1 symptom is required if delusions are bizarre or hallucinations consist of a running commentary.
- must have a marked deterioration from prior level of functioning
- symptoms must not be caused by substance abuse, medication, or general medical condition.
What do you call a discrete period of sudden onset of intense apprehension, fear, terror?
Panic attack
What is the treatment for panic attacks?
Verbal deescalation/reassurance, benzodiazepines
What do you call 6 mo of persistent and excessive anxiety/worry about a broad
range of topics?
Generalized anxiety disorder
What is the treatment for GAD?
CBT, group therapy, long-acting benzodiazepines, buspirone,
SSRI
What do you call recurrent, unexpected panic attacks AND at least 1 mo of worry (or behavior modification) surrounding the attacks or over subsequent attacks?
Panic disorder
What is the treatment for panic disorder?
SSRI, short-acting benzodiazepines, β-blockers, desensitization,
“flooding” therapy (CBT)
What do you call a significant anxiety provoked by exposure to a specific feared object or situation; leads to avoidance behavior?
Phobic disorder
What is the treatment for phobic disorder?
CBT (exposure-response prevention therapy),
desensitization,
SSRI,
short-acting benzodiazepines,
β-blockers (eg, propranolol)
What is the diagnosis for someone with repetitive thoughts (obsessions) that cause marked anxiety or distress and lead to mannerisms (compulsions) that serve to neutralize and relieve anxiety?
OCD
What is the treatment for OCD?
CBT (exposure-response prevention therapy), SSRI,
clomipramine; higher doses than those for depression usually required
Your patient describes re-experiencing an extremely traumatic event associated
with symptoms of: increased arousal, hypervigilance, and
avoidance of stimuli associated with the trauma. What is the diagnosis?
Post-traumatic stress disorder
What is the treatment for PTSD?
CBT, individual/group therapy (especially helpful), SSRI, sleep
agents, long-acting benzodiazepines.
What are somatoform disorders?
conditions in which psychological stress is expressed as physical symptoms
How do somatoform disorder differ from factitious disorders?
In contrast to factitious disorders, somatoform disorder symptoms are not intentionally produced or faked.
What is La Belle Indifference?
refers to an apparent lack of concern shown by patients with conversion disorder toward
their symptoms
How is somatization disorder defined?
■ History of medically unexplained physical symptoms beginning before age 30
■ Presence of all of the following at any time during disorder: (1) 4 pain symptoms (different sites or body functions), (2) 2 gastrointestinal (GI) tract
symptoms, (3) 1 sexual symptom, and (4) 1 pseudoneurologic symptom
What is conversion disorder?
■ Abnormalities or deficits in voluntary motor or sensory function that are not medically explained (eg, pseudoseizures, pseudoparalysis, movement
disorders, blindness)
■ Symptoms do not fit an anatomic distribution or diagnosis
What is pain disorder?
Persistent pain in one or more anatomic site(s) that limits daily functioning and cannot be pathophysiologically explained
What is hypochondriasis?
■ Preoccupation with the belief that one has a serious medical disease despite medical evaluation and physician reassurance
■ Patients typically demonstrate physical symptoms disproportionate to any
apparent organic disease, conviction that they have a serious medical illness,
preoccupation with their body, and relentless pursuit of medical care, often with doctor shopping.
What is the treatment for hypochondriasis?
Acknowledge symptoms and attempt to provide reassurance via explanation of symptoms.
What do you call it when patients create symptoms to secure some external motivator such as disability, avoiding jail or work time, pain medication, etc., known as secondary gain?
malingering
What do you call it when a patient feigns or creates symptoms for primary gain of adopting the “sick role,”
with attention from nursing staff, physicians, etc.?
Munchausen Syndrome
What do you call the disorder in which an adult, most commonly the biological mother (98%), intentionally creates symptoms in a child (or rarely elderly person)
in order to have contact with health care and to assume the role of the concerned caregiver (primary gain)?
Munchausen Syndrome by Proxy
What personality disorder is characterized by pervasive distrust and suspicion that others are exploiting, harming, or deceiving him or her. Reluctant to confide in others and bears grudges easily?
Paranoid personality disorder
What personality disorder is characterized by pervasive detachment from social relationships and restricted range of emotional expression; Neither desires nor enjoys close relationships and prefers solitude?
Schizoid Personality disorder
What personality disorder is characterized by pervasive social and interpersonal deficits with reduced capacity for close
relationships along with cognitive or perceptual distortions and eccentricities, such as odd or magical thinking (Does NOT meet criteria for schizophrenia)?
Schizotypal Personality disorder
What personality disorder is characterized by pervasive and excessive emotionality and attention-seeking; Consistently uses physical appearance to draw attention to self with inappropriate provocative
behavior?
Histrionic Personality disorder
What personality disorder is characterized by pervasive inflation of self-worth, pattern of grandiosity, and need for admiration; Believes that he or she is “special” and has a strong sense of entitlement?
Narcissistic Personality disorder
What personality disorder is characterized by pervasive instability of interpersonal relationships, self-image, and affects, with marked impulsivity, emotional lability, and compromised empathy and intimacy; Often associated with recurrent suicidal behavior, gestures, and self-harm?
Borderline Personality disorder
What personality disorder is characterized by pervasive disregard for and violation of the rights of others. Marked
deceitfulness, impulsivity, aggressiveness, and reckless disregard for safety of others with lack of remorse. High prevalence of imprisonment.
Antisocial Personality disorder
What personality disorder is characterized by pervasive social inhibition, feelings of inadequacy, and hypersensitivity to negative
evaluation; Avoids interaction due to fear of criticism, disapproval, or rejection?
Avoidant Personality disorder
What personality disorder is characterized by pervasive need to be taken care of leading to submissive and clinging behavior; has difficulty making decisions without reassurance and excessive fears of being alone?
Dependent Personality disorder
What personality disorder is characterized by pervasive preoccupation with orderliness; perfectionist at the expense of
flexibility, openness, and efficiency?
Obsessive Compulsive Personality disorder
Which eating disorder is characterized by
1. Refusal to maintain body weight at or above 85% of the age-adjusted expected body weight
2. Intense fear of gaining weight or becoming fat despite being underweight
Anorexia Nervosa
What are the two types of anorexia nervosa?
restricting (eg excessive dieting, starvation),
binge eating/purging (eg vomiting, laxatives, diuretics, excessive exercise)
What is refeeding syndrome?
Reintroduction of food triggers metabolic increase with rapid consumption of already depleted electrolytes causing profound
hypophosphatemia, hypokalemia, and hypomagnesemia with severe cardiopulmonary and neurologic sequelae.
Which eating disorder is characterized by:
1. Normal weight or overweight
2. Episodes of binge eating with sense of loss of control followed by compensatory behaviors, either purging type (eg, self-induced vomiting, laxatives,
diuretics) or nonpurging type (eg, excessive exercise, fasting, dieting)
3. Binges and compensatory behavior at least twice per week for 3 or more months
Bulimia Nervosa
What is Russell sign?
callus formation over the dorsal aspect of fingers due to acidic vomit
What is first line treatment for anorexia and bulimia nervosa?
First-line treatment is psychotherapy (especially cognitive-behavioral therapy)
plus selective serotonin reuptake inhibitors (SSRIs).
Admission criteria similar to those for anorexia nervosa (see
Which antibiotic is a reversible inhibitor of MAO?
Linezolid
What are signs and symptoms of serotonin syndrome?
■ Autonomic dysfunction: Hyperthermia, diaphoresis, tachycardia, tachypnea
■ Neuromuscular symptoms: rapid onset of muscle rigidity (greater in lower
extremities), tremor, ataxia, clonus/hyperreflexia
■ CNS dysfunction: confusion/disorientation, agitation, seizures, coma
What is the treatment for serotonin syndrome?
■ Supportive care: Benzodiazepines for muscle rigidity, agitation, and seizures;
sodium bicarbonate for QRS widening > 100 milliseconds; and
intravascular (IV) fluids for rhabdomyolysis.
■ Consider cyproheptadine (5-HT2A antagonist) in severe cases.
■ Up to 25% of cases will require intubation and mechanical ventilation.
In hyperthermic patients, use a nondepolarizing agent.
What is the pathophysiology behind neuroleptic malignant syndrome?
■ Dopamine receptor blockade in hypothalamus → hyperthermia,
dysautonomia
■ Dopamine receptor
What are the signs and symptoms of neuroleptic malignant syndrome?
■ Fever and muscle rigidity (cogwheel or lead-pipe) developing over hours to days
■ Altered mental status: Lethargy, agitation, coma
■ Autonomic dysfunction: Diaphoresis, labile blood pressures, tachycardia
■ CNS dysfunction: Tremor, dysphagia, mutism, incontinence
What is the treatment for NMS?
Primary treatment is removal of the offending drug and aggressive supportive
care with IV fluids, external cooling, antihypertensive agents (consider vasodilators
to facilitate cooling), benzodiazepines for aggression, prophylactic anticoagulation, and mechanical ventilation and/or antiarrhythmic agents as needed.
use of dantrolene and dopaminergic agents such as bromocriptine and amantadine is controversial.
How can NMS be distinguished from serotonin syndrome?
NMS can be distinguished from serotonin syndrome by its lack of hyperreflexia/clonus and usually normal, rather than dilated, pupil size.
What causes extrapyramidal symptoms?
Blockade of dopamine receptors in the basal ganglia due to antipsychotic medications
What do you call intermittent, involuntary motor tics and spasms of the face, neck, back, and extremities that begins within hours of starting antipsychotic treatment?
acute dystonia
What are examples of acute dystonic reactions?
- oculogyric crisis (blepharospasm, periorbital
twitches, protracted staring episodes) and - laryngeal dystonia (potentially
life-threatening laryngospasm).
What do you call the sensation of restlessness associated with objective motor hyperactivity
that begins within days of starting treatment?
Akathisia
What is the diagnosis in someone who exhibits bradykinesia, masked faces, muscular rigidity,
resting tremor that begins within months of starting treatment?
Parkinsonian syndrome
What do you call the chronic movement disorder involving involuntary tics of the face, extremities, or trunk that begins after years of antipsychotic
treatment?
Tardive dyskinesia
(often permanent and not responsive to treatment)
What do you call the unpleasant, potentially life-threatening reaction due to elevated serum acetaldehyde that occurs in patients who consume alcohol while taking certain meds, most notably metronidazole?
DIsulfiram reaction
What is the pathophysiology behind the disulfiram reaction?
Disulfiram inhibits aldehyde dehydrogenase, preventing the breakdown of the acetaldehyde generated by the metabolism of ethanol.
What are signs and symptoms of a disulfiram reaction?
■ Skin flushing, nausea/vomiting, headache, chest pain, abdominal discomfort, diaphoresis, vertigo, palpitations, and confusion may occur within 15-30 minutes after alcohol use.
■ Severe reactions may cause hypotension, seizures, and dysrhythmias.
What is the treatment for disulfiram reaction?
Supportive care with IV fluids, antiemetics, and rarely dopamine for hypotension
Ethanol is metabolized to acetaldehyde in the liver by alcohol hydrogenase
via ____-order kinetics
zero-order kinetics
(eg, at a constant rate independent of concentration).
What is the average rate of alcohol metabolism?
10-20 mg/dL/h (up to 40 mg/dL/h in alcoholics)
_____________ is an acute, life-threatening disorder (10%-20%
mortality) caused by thiamine (vitamin B1) deficiency, most often seen in chronically malnourished patients such as heavy alcohol drinkers.
Wernicke encephalopathy
Neurological disorder with persistent anterograde
and retrograde memory impairment, apathy, and often confabulation (pathologic lying about invented memories)
Korsakoff syndrome
When giving thiamine, what else should you co-administer other than glucose?
Remember to give magnesium!
Magnesium is a cofactor required for utilization of thiamine.
In alcoholics, thiamine or glucose first?
Theoretically, one should give thiamine before glucose supplementation to avoid precipitating acute thiamine
deficiency.
How does alcoholic hallucinosis differ from delirium tremens?
Unlike delirium tremens, alcoholic hallucinosis is NOT associated with global clouding of the sensorium and vital signs are often normal.
What is the treatment for cocaine overdose?
■ Primary treatment is benzodiazepines, which restore inhibitory tone to the CNS
■ Aggressively treat hyperthermia with rapid evaporative cooling and IV fluids
■ Use nitroglycerin, nitroprusside, or phentolamine for uncontrolled
hypertension.
What drug use is commonly associated with hyponatremia?
MDMA / Ecstasy / Molly
Which opioid receptor is primary receptor for analgesia, euphoria, and addiction?
Mu receptor
Which opioid receptor is primary receptor for spinal analgesia, respiratory depression?
Delta receptors and Kappa receptors
What is the mechanism of action of PCP?
Acts as a noncompetitive antagonist of N-methyl-d-aspartate (NMDA) receptors; inhibits reuptake of dopamine, norepinephrine, and serotonin;
and acts as an anticholinergic
What are signs and symptoms of PCP use?
■ Tachycardia, hypertension, hyperthermia
■ CNS effects range from bizarre behavior, agitation, violent behavior, and
seizures to sedation, unresponsiveness, and coma.
■ Vertical, horizontal, and rotatory nystagmus is often present. Pupil size is
variable.
What street drug is associated with Mydriasis, sympathomimetic symptoms, bruxism, ataxia, dry mouth, nausea?
MDMA
What street drug is derived from fungus Claviceps purpurea?
LSD
Which benzodiazepines are renally excreted and therefore safe in liver failure patients?
oxazepam, temazepam, and lorazepam
Individual who intentionally ingest large amounts of wellpackaged product, typically for smuggling purposes.
body packer
Individual who swallows a poorly wrapped quantity of drug,
usually in an attempt to avoid arrest or detection.
Body stuffer
What is the treatment for body packers?
Treat asymptomatic patients with polyethylene glycol to expedite passage.
If rupture is suspected, obtain immediate surgical consult for
laparotomy.
What is the treatment for body stuffers?
Treat with activate charcoal (1 g/kg), close monitoring, and symptomatic treatment as in acute intoxication. Consider whole-bowel irrigation if severe toxicity is suspected.
