Clinical Cases Flashcards
What are the diagnostic criteria for recurrent major depressive disorder?
What are the diagnostic criteria for recurrent major depressive disorder?
2 or more episodes of major depression, categorized by 5 or more of the following symptoms, present for most of the time for at least 2 weeks: One of the symptoms MUST be depressed mood or anhedonia. Sleep changes Interest (decreased; anhedonia) Guilt (excessive), worthlessness Energy (decreased) Concentration (decreased) Appetite changes Psychomotor agitation or retardation Suicidal ideation Depressed mood *no manic, hypomanic, or mixed episode; cause distress, not caused by drugs or bereavement
What is the difference between postpartum blues and postpartum depression?
blues: sadness, strong feelings of dependency, frequent crying, and dysphoria for several days to a week; not treated like depression
depression: exceeds severity and length of blues; characterized by suicidality and severely depressed feelings; treated like major depression
A reasonable duration for continuing antidepressants is
6 to 9 months. Early discontinuation can lead to early relapse
Which of the following side effects of SSRIs tends to occur later in the treatment course:
anorgasmia, headaches, insomnia, nausea, tremor
only sexual dysfunction occurs later in the treatment course (weeks to months); the others occur earlier
The percentage of individuals with a major depressive episode who will suffer from at least one further episode, most likely within 2 to 3 years, is ___%
50-85%
When is ECT used first line in depression?
1) major depression with psychotic features
2) rapid response is required
Medical conditions that can cause depression:
1) hypothyroidism
2) multiple sclerosis
What are first-line treatment options for major depressive disorder?
SSRIs!!!!!! (fluoxetine, sertraline, paroxetine, fluvoxamine, citalopram, ecitalopram) venlafaxine duloxetine mirtazapine buproprion
What are the negative symptoms of schizophrenia?
The 5 A’s:
1) affective flattening
2) alogia (diminished flow and spontaneity of speech)
3) avolition (lack of initiative or goals)
4) anhedonia
5) attentional impairment
What are the positive symptoms of schizophrenia?
1) ideas of reference
2) grossly disorganized speech or behavior
3) delusions
4) hallucinations
The average age of onset is ________ years in men and ______ years in women
men: 18-25
women: 25-35
Medical conditions in the differential for schizophrenia:
deliria, dementias, severe hypothyroidism, hypercalcemia
NOTE: medications (steroids and anticholinergics) can cause psychotic states
In order to diagnose schizophrenia, only one psychotic symptom is needed if which are present?
1) bizarre delusions
2) auditory hallucinations
3) 2 or more voices speaking to each other
List the following in order of decreasing favorable prognosis: schizoaffective disorder, major depression with psychotic features, schizophrenia
1) major depression with psychotic features
2) schizoaffective disorder
3) schizophrenia
What must be present to satisfy criteria for panic disorder besides the recurrent, unexpected panic attacks not caused by substance abuse/meds/medical condition?
the attacks must be followed by 1 month of one of the following:
1) concerns about having an additional attack,
2) worry about the consequences of attacks, or
3) a change in behavior as a result of the attacks
fear is about having another attack; not about a particular thing
What is the treatment for panic disorder?
SSRIs (or TCAs or MAOIs) + CBT
if necessary, alprazolam on a short-term basis (short-acting benzo)
Depressed mood and a weight gain IN THE ABSENCE of an increase in appetite indicates
depression secondary to hypothyroidism
Strokes, especially in this region, commonly cause subsequent episodes of depression:
left frontal region
What is the difference between Bipolar Type I and II?
Type I: sndrome with complete manic symptoms
Type II: hypomania, characterized by depression and episodes of hypomnia (simialr to mania, but symptoms are not as severe or cause the same degree of social impairment; no usually psychotic symptoms, racing thoughts, or marked psychomotor agitation)
Diagnostic criteria for bipolar disorder:
Abnormally and persistently elevated, expansive, or irritable mood lasting at least 1 week w/ 3 or more of the following symptoms:
1) inflated self-esteem or grandiosity
2) decreased need for sleep
3) greater talkativeness
4) flight of ideas; racing thoughts
5) distractability
6) increase in goal-directed activity or psychomotor agitation
7) excessive involvement in pleasurable activities with a high potential for painful consequences
Asking about behavior during this age can help differentiate between a youth presenting with bipolar and a youth presenting with ADHD/ODD
preschool age; common to see ADHD/ODD but NOT common to see bipolar!
What is the first-line treatment for nonpsychotic mania? For psychotic mania?
Nonpsychotic: monotherapy with lithium or valproic acid. OR olanzapine, quetiapine, or risperidone
Psychotic: lithium or valproic acid AND olanzapine, quetiapine, or risperidone
What 3 findings point strongly to PCP intoxication?
1) nystagmus
2) muscle rigidity
3) numbness
Why are the following 4 things associated with adverse complications in treating PCP intoxication?
1) low potency antipsychotics
2) benzos
3) gastric lavage
4) restraints
1) low potency antipsychotics have anticholinergic effects that may worsen intoxication
2) benzos may delay excretion
3) gastric lavage can cause emesis/aspiration
4) restraints can lead to muscle breakdown
While individuals with mania and those with PCP intoxication can have hallucinations, display hostility, and have disordered thoughts/pressured speech, what is unique to PCP use vs. mania?
PCP = nystagmus
While dependence is a prominent factor in several personality disorders, including histrionic and borderline disorders, patients with dependent personality disorder tend to
- stick to one caregiver for the long term
- be less manipulative
How can you differentiate dependence associated with agoraphobia from dependent personality disorder?
dependence is not lifelong; only starts once the panic attacks or anxiety do
GAD requires 3/6 of which criteria?
1) restlessness/on edge
2) easy fatigue
3) irritability
4) difficulty concentrating
5) muscle tension
6) sleep disturbance
Why is it important that buspirone is not a benzodiazopene anxioloytic? Should buspirone be used after benzodiazepenes have been tried for anxiolysis?
it does not repress respiration (as in patients with lung disease or sleep apnea)
it works on serotonin type 1A receptors
NO! buspirone is not as effective in patients already exposed to benzos
What are the 4 first line meds for GAD?
1) SSRIs
2) buspirone
3) venlafaxine
4) benzos
Is bipolar disorder more common in women or in men?
Equal prevalence
What does “rapid cycling” mean in terms of bipolar disorder?
4 episodes within a 12 month period
What is the best psychotherapy for OCD?
Behavioral therapy involving exposure and response prevention
Pediatric autoimmune neuropsychiatric disorders, a group of disorders including oCD, have been demonstrated to occur after what kind of disease?
strep infection
Which specific SSRIs are used to treat OCD?
FLUVOXAMINE, sertraline, fluoxetine
What is the triad of Wernicke Syndrome? What is it caused by? Is it reversible or irreversible?
triad: delirium, opthalmolegia (6th nerve), ataxia
caused by thiamine (B1) deficiency
reversible! (note: Korsakoff syndrome, associated with both anterograde and retrograde amnesia and also due to thiamine deficiency, is IRREVERSIBLE)
_______________ is a medication that blocks the enzyme acetaldehyde dehydrogenase; take it to make drinking uncomfortable.
_________________ is an opioid antagonist that decreases craving for alcohol.
_____________ has shown promise in improving abstinence when used in conjunction with psych/behavior tx. Mechanism unknown.
1) disulfiram (antabuse)
2) naloxone
3) acamprosate
How do you use the CAGE to diagnose alcohol dependence?
At least 2 positive of:
Cut back? Annoyed by criticism? Guilt about drinking? Eye opener?
Schizotypal personality disorder is frequently diagnosed in females wtih
fragile X syndrome
Health risks associated with cocaine use:
TIA, stroke, seizures, MI, cardiomyopathies
Somatic treatments like antidepressants, mood stabilizers, dopamine agonists, and acupuncture have been shown to reduce cravings for which of the following: cocaine, alcohol, opiate addictions
opiate and alcohol; NOT cocaine!
Which procedure is most sensitive in establishing a diagnosis of delirium? WHat does it show?
EEG! Shows generalized slowing. Fast low voltage activity = sedative-hypnotic withdrawal. Triphasic delta waves = hepatic encephalopathy
__% of postcardiotomy patients experience delirium.
90%
Behavioral management of acute delirium includes:
- low dose of a high potency antipsychotic
- short-acting benzodiazepene
Which are the vegetative symptoms of depression? THe cognitive? The emotional?
Vegetative: sleep, appetite, energy, sexual interest
cognitive: concentration, self-esteem
emotional: crying spells
Genetic factors, loss of a parent before the age of __, and adverse early childhood experiences are significant predictors for major depression in childhood and adulthood.
loss of parents before age 11
T/F: CHildren and adolescents with normal bereavement can have hallucinatory phenomena and not have it be a psychotic depression.
True! THey often will see or hear a deceased loved one. Hostile accusatory hallucinations are what are typical of major depression with psychotic features.
In depression with psychotic features being treated with an antidepressant and antipsychotic, how long do you continue each class of meds?
antipsychotic: 3 months, then taper
antidepressant: 5 to 9 months, then taper by 33% over 2 to 3 months
In pediatric patients with depression with psychotic features, they are usually started on an SSRI and atypical antipsychotic. If that fails, what do you do? If THAT fails, then what?
1) switch to different SSRI
2) switch to different class of antidepressant OR augment with lithium or buspirone
Many children with conduct disorder have a comorbid diagnosis of
ADHD
Patients with histrionic personality disorder use the defense mechanisms ___________ and ___________ most commonly.
1) dissociation
2) repression
____________ and ______________ have demonstrated efficacy in patients with pain disorder, particularly with headaches.
1) biofeedback
2) relaxation techniques
Signs and symptoms of opioid withdrawal:
SLUD
Salivation, lacrimation, urination, and defecation
Opioid withdrawal treatment
- Clonidine (decreases hypertension, tachycardia, sweating, lacrimation, and rhinorrhea)
- Methadone
- loperamide (for loose stools)
- promethazine (for nausea and vomiting)
- ibuprofen (for muscle and joint aches)
How is atomoxetine different from methylphenidate in the treatment of ADHD?
1) lower potential for abuse
2) takes 2-3 weeks for onset of action (stimulants have rapid onset)
3) longer half-life (can control symptoms for 24 hours)
4) NOT a stimulant (duh)
Individuals with PTSD respond to which 2 classes of drugs?
1) SSRIs and 2) alpha-2 agonsits (prazosin and clonidine)
There is emerging research that starting __________ directly following a traumatic event is effective in preventing the development of PTSD.
Beta blockers, such as propanolol
Diagnostic criteria for an adjustment disorder requires that the emotional response to the specific stressor develop within __ months of the onset of the stressor and do not persist past ___ months of the stressor’s resolution.
within 3 months of stressor onset; does not last past 6 months of stressor resolution
What is “pseduologia phantastica”?
The telling of “tall tales,” or lying, commonly seen in factitious disorder
Conscious creation of symptoms is typical of which of the following? (malingering, conversion disorder, factitious disorder, somatoform disorder)
conscious symptoms: factitious (primary gain), malingering (secondary gain)
subconscious symptoms: conversion disorder, somatoform disorder
Patients with factitious disorder can also meet criteria for _________ personality disorder.
borderline
Both frequently have histories of childhood mistreatment such as physical, sexual, or emotional abuse;; neglect. Patients with BPD also act out internal psychological conflicts on an interpersonal level nad have chaotic, labile affective state seen in factitious disorder.
Night/sleep terrors occur during which type of sleep? Nightmares occur when? How else are they different?
night terrors: Delta (slow-wave) sleep; don’t remember dream, can’t be consoled
nightmares: REM, remember dream, consolable
What are examples of things that increase the frequency of sleep terror episodes?
Fever, sleep deprivation, CNS depressants
What is the difference between dyssomnias and parasomnias?
Dyssomnias = sleep difficulties with duration and type of sleep (narcolepsy, OSA, poor sleep hygiene, insufficient sleep...) Parasomnias = sleep disorders assc. with problems during the stages of sleep (sleep terrors, somnabulism, rhythmic movemetn disorder, bruxism (jaw clenching), enuresis)
Stage __ of sleep is characterized by K complexes and sleep spindles, no eye movements, and little muscle activity.
2
In stage __ of sleep, the EEG shows theata waves, muscle tone relaxes, eye movements slow and rolling.
1
“nodding off” stage of sleep
For primary enuresis, pharmacologic or extensive behavioral treatmetn should not be considered prior to which age? What kinds of treatments?
Age 7
behavioral: bell and pad (low rate of recidivism)
medical: DDAVP/desmopressin (high rate of recidivism)
imipramine (high rate of recidivism; ECG monitoring)
Sleep terrors frequently occur in the presence of which other sleep disorders?
in particular, restless leg syndrome and sleep-disordered breathing
T/F: The postpartum year is the tiem of greatest risk for first-onset depression in women, with up to 65% of all women experiencing their first episode of major depression in that time interval.
True! (Typically occur 1-6 months postpartum)
T/F: Hormone therapy, such as estrogen, has demonstrated efficacy as a treatment for major depression.
False!
When should postpartum blues resolve? When does it usually peak? What is the treatment?
peaks 3-5 days, should resolve 7-14 days after delivery
tx: reassurance and monitoring (for more severe mood episodes)
Postpartum psychosis requires what for treatment?
Antipsychotic in combination with an antidepressant or mood stabilizer, or a course of ECT
What causes the acute dystonic reaction oculogyric crisis?
contraction of superior rectus muscles bilaterally
Risk factors for acute dystonic reactions include
1) young age
2) male gender
3) high doses of antipsychotic medication
Say which population (age and gender) is most at risk for the following: 1) acute dystonic rxn, 2) neuroleptic-induced parkinsonism (resting tremor, cogwheel rigidity, bradykinesia, rabbit syndrome); 3) akathisia, 4) NMS; 5) tardive dyskinesia
1) acute dystonic: young men, high doses of meds
2) parkinsonism: old women
3) akathisia: middle-aged women
4) NMS: anyone!
5) tardive dyskinesia: old women, presence of mood disorder
Defense mechanisms in patients with narcissistic personality disorder include
1) denial
2) devaluation
3) idealization
Coprolalia:
vocal tic involving the involuntary vocalization of obscenities
How are choreiform and dystonic movements distinguished?
Dystonic movemetns are slower than the dancing, irregular nonrepeitive movemetns of choreiform movements. Dystonic movemetns are twisting interspersed with prolonged states of muscular tension
The motor component of Tourette emerges by age __ and the vocal component (grunting, sniffing, snorting, using obscene words=coprolalia) by age ___
motor: by age 7
vocal: by age 11
Tourette disorder, OCD, and _____disorder have a strong relationship and tend to run together in families.
ADHD
In Tourette disorder, GABA is decreased and dopamine is increased in ___________ (what area of the brain)
caudate nucleus
OCD, Tourette disorder, and tics are more common in children who have had a _________ infection within the last 3 months and w/ multiple infections within the last 12 months.
streptococcal
In additoin to anxiety reduction and trigger reduction, meds for treating Tourette disorder include:
alpha adrenergic agonists (clonidine, guanfacine). Note: these can reduce incidence of tics and improve impulsivity, attention, and working memory so are also used in ADHD or in treating tics for children on pscyhostimulants (either alone or in combo with atomoxetine)
2) atypical antipsychotics; risperidone
3) typical antipsychotic; haldol, pimozide (ECG changes)
_________ is an alpha arenergic agonist that activates presynaptic autoreceptors in the locus ceruleus to decrease norepinephrine release.
___________ activates postsynaptic prefrontal alpha-adrenergic cortical receptors.
Both reduce the incidence of tics and improve impulsivity, attention, and working memory.
1) clonidine
2) guanfacine
A patient on methylphenidate begins to develop tics. What course should be taken?
1) trial of atomoxetine
2) if ADHD symptoms and/or tics continue, then add clonidine or guanfacine
In PANDAS, obsessions, compulsions, and tics usually occurs in what season?
winter! in association with streptococcal infections
An individual with mainly obsessions and compulsions tends to respond to _______ (which meds), whereas a person with primarily generalized anxiety symptoms responds to ________
1) SSRIs
2) buspirone
In anorexia nervosa, patients are less than __% of expected weight due to weight loss or lack of expected weight gain
<85%
Common lab abnormalities in anorexia: K, Cl, H, albumin, liver enzymes, WBC
Which one can be used to assess extent of starvation?
K: hypokalemia Cl: hypochloremia H: metabolic alkalosis low albumin: used to assess extent of starvation elevated LFTs leukopenia with relative lymphocytosis
Anorexia nervosa is associated with gray matter loss in what region of the brain?
anterior cingulate cortex
Which type of therapy has been shown to be effective in treating anorexia nervosa as an outpatient?
family therapy: parental control over eating and gradually turning control back to adolescent
What is the most important indicator of future developmental potential in autistic children?
language development
Patients with autism spectrum disorder have (inc/dec) cortical thickness and (inc/dec) frontostriatal activation.
increased cortical thickness; decreased frontostriatal activation
What is the best therapy for avoidant personality disorder?
pscyhodyamic or cognitive behavioral psychotherapy
