Emma Holiday Review Flashcards
What has to go on for at least 6 months for it to be schizophrenia?
ANY symptoms
Not just positive symptoms. Usually the negative symptoms predate the positive symptoms (this is what produces the schizophrenia prodrome!)
Most common type of schizophrenia
Paranoid type
It also has the best prognosis!
Schizophrenia statistics
Prevalence 0.5-1%
Twin-twin Concordance 50%
Sibling: 10%
Positive symptoms in schizophrenia are due to. . .
. . . too much dopamine in the mesolimbic tract
Negative symptoms of schizoprenia are due to. . .
. . . not enough dopamine in the mesocortical tract
This is why 1st generation antipsythotics (which have greater effect in the mesocortical tract) cause so many EPS! 2nd generation avoid these dopamine receptors.
Brain dopamine pathways
Blocking the mesolimbic reduces psychotic symptoms.
Blocking the mesocortical produces negative symptoms.
Blocking the nigrostriatal produces extrapyramidal symptoms.
Blocking the tuberoinfundibular produces hyperprolactinemia.
Will treating a patient in a brief psychotic episode with antipsythotics prevent progression to schizoprenia?
No
__ is often the treatment for psychotic depression
ECT is often the treatment for psychotic depression
Is ECT safe in pregnant patients?
YES
Therapy for different delusional disorders
Erotomanic -> psychotherapy. If they are functional, don’t necessarily need antipsychotic. If not, you should put them on an atypical.
Two most potent antipsythotics
- Haloperidol
- Fluphenazine
They also have the most EPS and other off-target dopaminergic effects (hyperprolactinemia, etc)
Injectable antipsychotics
Fluphenazine decanoate
Haloperidol decanoate
Risperidone decanoate
Low-potency 1st generation antipsychotics
Lower off-target dopaminergic effects, BUT also have anticholinergic effects and antihistaminergic effects
Sedating and may precipitate delirium, dry mouth, etc.
Includes chlorpromazine (Thorazine) and thioridazine
Chlorpromazine side effect
Can cause anticholinergic/antihistaminergic effects
Also, can cause sun-exposed “purple-gray” skin rash (hypersensitivity dermatitis) and jaundice/liver disease
Thiaridazine side effects
Prolonged QTc
Pigmentary retinopathy
Treatment for dystonia
- Discontinue offending agent
- Either benztropine or diphenylhydramine
Treatment for akathisia
Benzo
OR
Propranolol
Treatment for drug-induced parkinsonism
Often with anticholinergics in young patients (benztropine, trihexyphenidyl, biperiden, sometimes diphenylhydramine)
2nd line: Bromocriptine, amantadine
Antipsychotics less likely to cause tardive dyskinesia
Clozapine
Patients who develop TD may be switched to this
Which atypical agent has the highest risk of EPS and hyperprolactinemia?
Resperidone
Weight-neutral antipsychotics
Ziprasidone (also QTc prolonging!)
Aripiprazole (also causes akathisia!)
Atypical most associated with weight gain
Olanzapine
Atypical most associated with orthostasis
Quetiapine
Also an alpha-1 blocker
Like buproprion, this antipsychotic also decreases the seizure threshold
Clozapine
In addition to causing agranulocytosis in some patients
Depression’s effects on sleep cycle
Shortened REM latency period
More frequent REM
So. . . more REM overall, ergo less deep/restfull sleep/stage3-4 sleep.
Depression in a patient with abdominal pain, joint pain, and a photosensitive rash
Depression secodary to porphyria cutanea tarda
___ stroke can produce symptoms of depression
Left MCA stroke can produce symptoms of depression
Which SSRI has the most drug-drug interactions?
Paroxetine
Which SSRI don’t you have to taper when stopping?
Fluoxetine
Long half-life due to metabolite norfluoxetine
SSRI with fewest drug-drug interactions
Citalopram
Contraindications for buproprion
- Seizures:
- Epilepsy
- Bulimia nervosa
- Recurrent DTs or benzo withdrawals
You can’t take __ with St. John’s Wart
You can’t take an SNRI (venlafaxine) with St. John’s Wart
Can cause hypertensive crisis
Treating a tyramine-MAOi-induced hypertensive crisis
An IV alpha blocker is effective at treating the hypertensive crisis
Like prazosin or related drug
Treatment of tricyclic toxicity
Charcoal if you get them in time
Sodium bicarbonate to help with excretion
Depressive symptoms, but sleep more and eat more (tather than less) with “leaden paralysis” in the morning
Atypical depression
Treat with CBT +/- SSRIs. MAOis more considered in treatment for this condition, but still not first-line.
Twin-twin concordance rate for bipolar disorder
90%
One of THE most heritable psychiatric conditions
___ stroke can procude manic symptoms.
Right ACA stroke can procude manic symptoms.
Lithium toxicity is classically precepitated by. . .
. . . most NSAIDs
With the exceptions of Aspirin and Sulindac
“Prolonged QRS” in drug toxicity
TCA toxicity
“Flattened T waves” or “Interveted T waves” or “U waves” (like hypolakemia) in drug toxicity
Lithium toxicity
Lithium levels vs antidote
< 4, fluids and watch
>4, dialysis
MOST common side effects of lithium
GI side effects and acne
Therapeutic range of lithium
0.6-1.2
How do we treat bipolar in pregnancy?
Benzodiazepines
Since lithium
Elevated AFP can mean ___ with respect to psychiatric medications
Can mean presence of an NTD in patients on valproate or carbamazepine
Therapeutic range of valproate (for bipolar)
6-12
Contraindications to benzodiazepines
Hx of addiction
COPD, Restrictive lung disease (decraesed respiratory drive)
Order of pharmacologic interventions for GAD
- None! Therapy only.
- SSRI or SNRI
- Buspirone
- Pregabalin
- Benzodiazepines
Trick question about OCD treatment
The gold standard is still clomipramine (TCA).
But the first line is SSRIs.
Read your prompt carefully.
PTSD 1st line
SSRIs + CBT
+ prazosin if nightmares are present
Adjustment disorder is, by definition, . . .
. . . out of proportion to what you would expect
Comorbidities of somatic symptom disorder
Often anxiety and/or depression on Axis I
Very high prevalence of personality disorder on Axis II
___ is elevated following a true seizure and can help differentiate seizures from PNES
Prolactin is elevated following a true seizure and can help differentiate seizures from PNES
Simple factitious disorder vs Munchausen syndrome
Simple factitious: They are just lying for no clear gain/to take on sick role. They do not induce real disease in themself (I have a headache).
Munchausen syndrome: They lie AND induce symptoms in themselves (inject faeces, take laxatives, etc).
“V code”
List of DSM “conditions” that are not pathological diagnoses, but are often on the differential. Include:
Bereavement
Malingering
Russel’s sign
Callouses on the knuckles from repeated indentation by the incisors
Present in patients with bulimia or anorexia with orally-induced purging behavior
Vitals of a patient with anorexia
Bradycardia, hypotensive, hypothermic
Loss of volume, inability to maintain body temperature
Dyssomnia Not Otherwise Specified
Encompasses periodic leg movement disorder (random kicking motions with sleeping) and restless leg syndrome (feeling creepy crawlies)
Treatment for restless leg syndrome
Dopamine agonists: Ropinirole, pramipexole
What do you need to observe on sleep study to diagnose OSA?
>10 hypoapneic or apneic events per hour
Are sleep attacks diagnostic of narcolepsy?
NO!
You also need EITHER: hypogogic/hypnopompic hallucinations OR cataplexy
Treatment of paranoid personality disorder
Low dose antipsychotic
It is one of the “personality” disorders that is actually a thought disorder, like schizotypal.
Most common comorbid conditions with histronic personality disorder
- Substance use
- Eating disorder
Patients with narcissistic personality do NOT do well with ___
Patients with narcissistic personality do NOT do well with group therapy
The biggest risk factor for delirium is. . .
. . . advanced age
This is an even bigger risk factor than underlying dementia!!!! They love to ask you to choose between them. Suprisingly, advanced age is more important than whether or not the patient is demented.
EEG to distinguish delirium vs psychosis
Diffuse EEG slowing in delirium, normal EEG in psychosis (unless they have temporal lobe epilepsy!)
Why do patients with Down’s syndrome have a higher incidence of Alzheimer’s?
APP is on chromosome 21
Memantine mechanism
NMDA antagonist
Weirdly enough, same with PCP and anti-NMDAR antibodies!
NMDA is a glutamate receptor activated ion channel
Pick bodies
Seen in Pick’s disease aka Frontotemporal dementia
Silver-staining bodies within neurons
Best treatment for Frontotemporal Dementia
Olanzapine
Best drug to treat behavioral disturbance
EEG hallmark of Creutzfeld-Jakob disease
Triphasic bursts
Alcohol is metabolized by __ order kinetics
Alcohol is metabolized by zero order kinetics
In other words, a certain fixed amount is metabolized per unit time, not a fixed percentage.
As a result the more you drink/higher your ABV is, the longer it takes to clear.
What do you do before naloxone in an opioid overdose?
Intubate
If a patient is being admitted for opioid detox and is in withdrawal, you treat with. . .
. . . symptomatic therapy, NOT methadone. If they are there to withdraw, then let them withdraw.
This involves clonidine and agents to help with symptoms.
However, if they are there for some other reason and happen to withdraw, THEN you give methadone.
If you suspect that a patient is presenting with acute cocaine or amphetamine toxicity, what is the FIRST test you order? What is the SECOND test?
FIRST, get an EKG. An arrhythmia or vasospasm is how this patient will die.
SECOND, get a u-tox. This will confirm your diagnosis.
Never give __ to a patient with cocaine toxicity
Never give beta blockers to a patient with cocaine toxicity
Calcium channel blockers are fine.
The time when death is permanent/concrete operational
7 years
Piaget stages
Average and SD of IQ
Average: 100
SD: 15
2 SD below 100 (70) is where mild retardation begins. Then the degree goes up for every z-score.
You need symptoms for ___ to receive a Dx of conduct disorder
You need symptoms for 6 months to receive a Dx of conduct disorder
“Most effective” vs “First line” medications for tic disorders
“Most effective” = haloperidol
“First line” = clonidine (OR tetrabenazine if this is available, but not in the US!)
Reactive attachment disorder
Needs not met by caregiver early in development
Difficulty forming emotional connections, hypervigilance, decreased positive emotions
___ and ___ are child behavioral disorders related to food both of which may indicate lead poisoning
Rumination disorder and pica are child behavioral disorders related to food both of which may indicate lead poisoning
