Clinical questions - Psychiatry Flashcards
Anorexia nervosa
less than 85% ideal body weight, amenorrhea, worried about gaining weight, excessively thin, without binge eating
Tx: Interdisciplanary team: physician, dietician, MH CBT, family therapy only SSRI if comorbid depression/anxiety Inpatient if severe malnutrition -less than 75% Ideal body wt -dehydration -elyte derangements -cardiac arrhythmias -SI or psychosis Nutritional therapy Ca/Vit D supplementation
Weight gain goals:
Inpt: 2-3 pounds/wk
Output: 0.5 - 1 pound/week
Criteria for hospitalizing a psych patient
danger to self
danger to others
unable to provide for themselves
PTSD treatment
Psychotherapy: exposure therapy, CBT
Pharmacotherapy
SSRI 1st line
other antidepressants - TCAs, MAOIs
Mood stabilizers: impulsive behavior, hyperarrousal, flashbacks
Alpha blockers - prazosin for nightmares
Atypical antipsychotics for refractory sxs
Avoid benzos - inhibit ability to process event, and addictive/abuse risk
Traditional, 1st gen, antipsychotics
Low potency:
- chlorpromazine
- thioridazine
se: anticholinergic effects
High potency:
- Haldol
- thoracenazine
se: neuroleptic malignant sn, movement disorders
Atypical, 2nd gen, antipsychotics
respirdol
quietapine
olanzapine
se: sedation, wt gain, diabetes
Tardive dyskinesia
Chorea of mouth/tongue
Side effect of traditional neuroleptics
Movement disorders seen in high potency traditional neuroleptics (halloo, throacenazine)
1st several days: acute dystonia - muscle spasm, stiffness, oculargyric crisis; torticollis
1st month: parkinsonism sxs - bradykinesia, akinesia
2nd month: akathisia - restlessness, constant movement
months to years: tardive dyskinesia - lip smacking, irreversible
Medical conditions that can cause major depression
Hypothyroidism Hyperparathyroidism - increased Ca -> depression, delirium Parkinsons Cancer - CNS neoplasm, pancreatic CA Strokes - ACA stroke esp.
Obsessive compulsive disorder
Obsession - intruding recurrent, anxiety provoking thoughts or urges
Compulsions - repetitive behavior or mental acts to relieve anxiety created by obsessive thoughts
Tx: SSRI 1st line Clomipramine (TCA) -> anticholinergic se venlafaxine (SNRI) CBT
Potential side effects of lithium
CNS effects:
- depression
- tremor
- cognitive dulling
Thyroid changes - up or down
-euthyroid goiter
GI:
- N/V/D
- metallic taste
- wt gain
Nephrogenic DI
-kidney stops responding to desmopressin (ADH) -> can’t concentrate urine -> polyuria, thirst, polydipsia
Serotonin syndrome
SSRI with MAOI, SNRI, TCA, or triptan
Mental status changes:
anxiety, agitation, delirium, restlessness, disorientation
Autonomic excitation:
diaphoresis, tachycardia, hyperthermia, HTN, N/V/D
NM hyperactivity:
Tremor, rigidity, hyperreflexia, myoclonus, ocular clonus (slow horizontal eye movements)
Major risk factors for suicide
psychiatric disorder hopelessness or worthlessness impulsivity advanced age - more successful male access to firearms prior Hx of suicide attempts
Clozapine monitoring
Used in treatment-resistant schizophrenia
Risk of agranulocytosis
Get baseline CBC then weekly for 6 months, biweekly for 6 mo then monthly
Baseline Wt, BMI, waist circumference - risk of weight gain and subsequent DM
Baseline FBG or A1c
Baseline ECG: rare myocarditis with rapid progression to CM and CHF
Weekly ESR and troponin for 4 weeks
Personality disorder characterized by controlling, perfectionistic, orderly, stubborn, possible hoarding
Obsessive compulsive disorder - rigid, organized, inflexible
Personality disorder characterized by excessive need to be taken care of, submissive and clinging behavior, low self-confidence, fears of separation and losing support
dependent PD
Personality disorder characterized by criminality, unable to conform to social norms, disregard for others’ rights, reckless disregard for safety
antisocial PD
Personality disorder characterized by grandiosity, sense of entitlement, lack of empathy
narcissistic PD
Personality disorder characterized by excessively dramatic, emotional, and extroverted, attention seeking, sexually provocative behavior, unable to maintain intimate relationships
Histrionic PD
Heroin/opioid overdose
s/s:
depressed consciousness - drowsy, slurred speech, unarrousable
Miosis - pinpoint
Resp depression -> low sats, respiratory acidosis
Tx:
Naloxone (narcan) - wears off in 2-3 minutes, keep giving it again and again if needed
Antidepressant/class that is generally 1st line tx for unipolar major depression
SSRIs
Antidepressant/class that is a good choice for depressed patient with insomnia
trazodone or mirtazapine
Antidepressant/class that is a good choice for patient who discontinued an SSRI due to sexual dysfunction
bupropion
Antidepressant/class that is a good choice for depressed patient with appetite suppression and wt loss
mirtazapine
Antidepressant/class that may help with smoking cessation
bupropion
Antidepressant/class that overdose causes sedation and life threatening arrhythmias
TCAs
Medications used to treat ADHD
ADHD: careless mistakes, easily distracted, not following instructions, frequently interrupts and blurts out answers
Stimulants:
- methylphenidate
- dextroamphetamine
Nonstimulants:
Atomoxetine (Strattera) - SNRI
Acute stress disorder vs PTSD
acute stress disorder - sxs 3 days to less than 1 mo
PTSD sxs longer than 1 mo
Both:
exposure to dramatic event
recurrent intrusive memories, dreams, flashbacks
avoidance of stimuli
altered arousal - insomnia, irritability, hyperviligence, self destructive behavior
Persistent negative change in mood or cognition - amnesia, detachement, blame self
Drugs that cause or mimic psychosis
hallucinogens - LSD, PCP Stimulants - cocaine, amphetamines Withdrawal from benzos, barbs, alcohol -> tactile hallucinations and psychosis anabolic steroids glucocorticoids
Panic disorder
recurrent unexpected panic attacks with constant worry about more panic attacks
Psychotherapy: CBT - triggers, train coping mechanisms
Meds:
SSRI
SNRI
TCA - imipramine, clomipramine - dangerous in OD, more s/e
Benzos: immediate sx relief to break attack
-> rebound anxiety and dependence
bulimia nervosa
Meds:
SSRI - fluoxetine
TCAs - desipramine, imipramine, amitriptyline
Buspirone (buspar)
Acute mania/manic episode
decreased need for sleep, increased goal directed activity, excessive spending, grandiosity, pressured speech
Mood stabilizers - alone or in combo for acute mania
Lithium
Anticonvusants - valproate, carbamazepine
Atypical antipsychotic - olanzapine, quetiapine, aripiprazole, risperidone
management of torticollis associated with antipsychotic medication
benztropine or diphenhydramine - counteract ACh at NMJ with anticholinergic drug
Psychiatric disorder: Patient with normal anatomy is convinced a part of his/her anatomy is abnormal
body dysmorphic ds
Psychiatric disorder: unexplained loss of sensory or motor function without any basis in medical or neurological condition
conversion ds
Psychiatric disorder: patient is preoccupied with the possibility of contracting a serious illness and is constantly checking his/her body for signs of illness
illness anxiety dx
Psychiatric disorder: patient produces false s/s of an illness in order to receive sympathy or medical attention
factitious ds
Generalized anxiety disorder medical treatment
1st line:
SSRI: paroxetine, sertraline, citalopram
SNRI: venlafaxine, duloxetine
2nd line: TCA: imipramine Benzos: clonazepam, diazepam - long acting -short acting risk rebound anxiety Buspirone + SSRI or SNRI
MAOI major side effect concern and dietary trigger
Hypertensive crisis
MAO inactivates catecholamines, inhibition -> increased catecholamine -> serotonin, dopamine, norepinephrine with resultant HTN
trigger - Tyramine - promotes catecholamine release
Found in aged, pickled, smoked or fermented foods
-sausage, pepperoni, salami, cheeses
-Chianti, beers/wines
-Brown bananas
-Soy sauce
Neuroleptic malignant syndrome
associated with antipsychotic drugs
s/s:
Mental status change: agitation, delirium, psychosis
Muscle rigidity -> fever, rhabdo
Autonomic dysfunction: tachycardia, labile BP, tachypnea, diaphoresis
Tx:
Stop offending medication
Supportive care in ICU - IVF, cooling blankets, icepacks
Clonidine or nitroprusside for elevated BP
Clonazepam/lorazepam for agitation prn
DANTROLINE to relax skeletal muscle - inhibits Ca release (used in NMS and malignant hyperthermia)
Withdrawal from opiates
Dysphoria - unwell, discontent Restlessness, insomnia Yawning rhinorrhea, lacrimation, diaphoresis mydriasis myalgia, arthralgia N/V/D Abd craming piloerection - "uiting cold turkey"
Features that distinguish adjustment disorder with depressed mood from major depressive disorder
Adjustment disorder has an identifiable stressor that causes emotional or behavior symptoms
-job loss, financial stress, divorce, death in family
Sxs begin within 3 months of stressor, resolves within 6 months of disappearance of stressor
disturbance does not meet criteria for MDD
Personality disorder: lifelong voluntary social withdrawal, lacks close friends, limited range of emotional expression, indifferent to the price/criticism of others
schizoid PD - schizoids avoid
Personality disorder: socially inhibited, shy, feelings of inadequacy, hypersensitive to rejection or criticism
avoidant PD
Personality disorder: social awkwardness and difficulty with personal relationships plus eccentric appearance, behavior, or thinking
schizotypal PD
Personality disorder: distrustful, suspicious, litigious
paranoid PD
Personality disorder: unstable personal relationships, unstable mood and behavior, unstable self-image, impulsiveness, suicide threats or gestures, sense of emptiness and loneliness
borderline PD
Depression management in bipolar
Mood stabilizers:
Lithium
anticonvulsants - lamotrigine (watch for rash), valproate
Atypical antipsychotic - olanzapine, quetiapine
ECT for severe depression
Indications for electroconvulsive therapy (ECT)
painless, electrode induced seizure
Refractory depression
- severe
- psychotic features
- severe SI
- refusing food, nutritional compromise
- catatonia
Rapid response necessary - pregnancy
Prior good response
Bipolar disorder/mania
Schizophrenia/psychosis esp catatonic
