EOR - pysch Flashcards
Dx MDD
depressed mood/anhedonia w/ 5 associated symptoms almost every day for most days for @ least 2 wks. Symptoms cause clinical distress or impairment in social, occupational or other important area of fxn. Absence of mania or hypomania.
What is atypical depression? txt?
shares typical symptoms but pts experience mood reactivity (improved mood in response to positive events). Symptoms include significant weight gain/appetite increase, hypersomnia, heady/leaden feelings in arms/legs, oversensitive to personal rejection. Txt: MAO inhibitors.
melancholia affect on sleep?
(increased REM time and reduced sleep. May lead to early morning awakening or mood worse in AM).
what is catatonic depression?
motor immobility, stupor, extreme w/drawal.
Pharm txt options for MDD
SSRIs (first choice), SNRIs, bupropion + mirtazapine, TCAs and MAOIs 3rd line. Continued for minimum of 3-6wks to determine efficacy.
major depressive episode
2+weeks of major depressive symptoms.
manic episode
an emotional state characterized by a period of at least one week where an elevated, expansive, or unusually irritable mood. Feeling euphoric often w/ a directed goal. Can lead to serious consequences. Can have a break w/ reality - psychotic symptoms of delusions, hallucinations + paranoia. Can require hospitalization.
-Usually crash after the episode with depression… may take weeks to months to get out of depression. Between “phase” they are euthymic.
how many cycles per year is a typical manic episode?
2-3
hypomanic episode
at least four days of more mild mania, increased energy. Causes problems in life but not to the extent of mania + does not ever require hospitalization.
mixed episode
“manic or hypomanic episode w/ mixed features” - full criteria or manic or hypomanic episode + at least 3 depressive symptoms. (or >3 manic or hypomanic symptoms + depression)
medication options for bipolar I and II
mood stabilizers: LITHIUM!!! (also valproic acid aka depakote, carbamazepine aka tegretol)
2nd gen antipsychotics (olanzapine)
1st gen antipsychotics (haloperidol)
+ antiepileptics (quetiapine, lamotrigine aka lamictal), +benzos for agitation/pyschosis. +/- ECT, MAOIs, SSRIs, TCAs, but…. Antidepressants may precipitate mania!
how is biplar II different from bipolar I?
II: >1 hypomanic (rather than manic) episode + >1 major depressive episode. Mania or mixed are ABSENT. Does not include racing thoughts or excessive psychomotor agitation
Dx and treatment for cyclothymic d/o
Dx: recurrent hypomanic that don’t meet criteria for hypomania “cycling” w/ relatively mild depressive episodes (that dont meet MDD criteria). For at least 2 years (1 in kids). Symptom free periods dont last over 2 months at a time. No manic or mixed.
Txt: similar to bipolar I - mood stabilizers + neuroleptics.
Dx of adjustment d/o
Emotional or behavioral rxn to an IDENTIFIABLE stressor (job loss, physical illness, leaving home, divorce, etc) or an event that causes DISPROPORTIONATE response that would normally be expected w/in 3mo of stressor (does not include bereavement) + resolves w/in 6mo of stressor.
txt for adjustment d/o
psychotherapy
3 phases of schizophrenia
prodromal (or beginning), acute (or active - hallucinations, delusions, psychosis) and recovery (or residual -psychosis muted but some symptoms still present). These phases tend to occur in order and cycle throughout the course of the illness
timeline needed for Dx schizophrenia
> 6 months w/ 1month of acute symptoms along with functional decline. At least one symptom must be hallucination, delusion or disorganized speech. Must have >2 symptoms.
what are the 5 SSRIs?
citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline
what are the MC ADRs of SSRIs and which ones have the highest likliehood?
insomnia (fluoxetine - prozac, sertraline-zoloft)
orthostatic hypotension - paroxetine (paxil)
GI issues - sertraline
weight gain - paroxetine
sexual dysfunction - ALL
what are two atypical antidepressant meds?
bupropion and mirtazipine
major ADR of bupropion?
insomnia/agitation (more w/ immediate release)
what are the major ADRs of mirtazapine?
drowsiness, weight gain
what are the 5 SNRI meds?
desvenlafaxine, venlafaxine
duloxetine
levomilnacipran, milnacipran,
what is the one ADR of SNRIs?
GI toxicity (upset)
which SNRI has signficiant sexual dysfxn as an ADR?
venlafaxine
what are the 4 serotonin modulators?
nefazodone, trazodone, vilazodone, vortioxetine
what are the ADRs of the serotonin modulators and which has the most significant?
drowsiness: trazodone (also nefazodone) orthostatic hypotension: trazodone (antidepressant dose > hypnotic dose) QT prolongation: trazodone GI tox: ALL (vilazodone is the WORST) sex dysfxn: vilazodone
tricyclic and tetracyclic antidepressants (TCAs) - what drugs are they?
amitryptyline, nortryptyline, protriptyline
imipramine, clomipramine, desipramine, trimipramine,
amoxapine, doxepin, maprotline
what are the major ADRs of TCAs?
LOTS! anti-cholinergic, drowsiness, orthostatic hypotension, QT prolongation, weight gain, sexual dysfxn
what are the MAOIs?
isocarboxazid, phenelzine, selegiline, tranylcypromine
what are the major ADRs of MAOIs?
sexual dysfunction, insomnia/agitation and orthostatic hypotension (all but selegiline)
txt for persistent depressive d/o
similar to depression - psychotherapy (1st line), SSRIs. Second line - SNRIs, TCAs, MAOIs.
schizophrenia positive vs negative symptoms
positive - hallucinations, delusions
negative -flat affect, social w/drawal, avolition (lack of motivation), lack of communication/reactivity, silent, poor eye contact.
explain the different delusions one can have. .. (persucatory, reference, control, grandiose, nihilism, erotomanic, jealousy, doubles)
Delusions: fixed belief held w/ strong conviction despite evidence of the contrary.
Persecutory: person or force is interfering w/ them, observing them or wishes to harm them
Reference: random events are direct at them
Control: agency is taking control of their thoughts/feelings/behavior
Grandiose: powers/abilities
Nihilism: futility of everything + catastrophic events
Erotomanic: believe another is in love w/ them
Jealousy: suspect unfaithfulism
Doubles: believes a family member or close friend had been replaced by clone.
what are characteristics associated with a better prognosis with schizophrenia?
Late onset Family history of mood disorder Good pre-morbid hostory Positive as opposed to negative symptoms Depression Clear precipitant
2nd vs 1st generation anti-psychotics for schizophrenia: MOA, drug names, best use
2nd generation (atypical/new) are 1st line- 5HT2A/D2 antagonists. (ex/ risperidone, olanzapine, quetiapine). Clozapine in refractory cases (if not improvement w/ others in 2-6 wks).
1st generation (old/typical) 2nd line - D2 antagonists. haloperidol + chlorpromazine. better for positive symptoms
define brief psychotic episode
> 1 psychotic symptom w/ onset and remission <1 month.
schizophreniform vs schizoaffective
Schizophreniform: meets criteria for schizophrenia but <6 mo duration.
Schizoaffective: schizophrenia + mood disturbance (major depressive or manic episode)
ADR 2nd vs 1st generation anti-psychotics
2nd- metabolic ADRs ( weight gain, etc)
1st - extrapyramidal ADRs (tardive dyskinesia)
define delusional d/o
> 1 delusion lasts >1mo w/out other pyschotic symptoms +/- nonbizarre (possible but highly unlikely i.e. being poisoned). Apart from the delusion, behavior is not obviously odd or bizarre + no significant impairment of fxn. Not explained by other d/o
Dx of somatic symptom d/o
> 2 means high likelihood of somatization disorder: SOS, dysmenorrhea, burning in sexual organ, lump in throat (dysphagia), amnesia, vomiting, painful extremities.
Disproportionate thoughts, feelings or behaviors related to the somatic symptoms, high anxiety about symptoms/health, excessive time/energy devoted to symptoms/health.
med txt for body dysmorphic d/o
SSRIs (fluoxetine), TCAs (clomipramine). Psychotherapy
txt for conversion d/o
psychotherapy - behavioral
characteristics of conversion d/o
episodic, may recur w/ stress.
Motor dysfxn: paralysis, aphonia, mutism, seizure, gait abnormality, tics, weakness, swallowing
Sensory dysfxn: blindness, anesthesia, paresthesias, visual changes, deafness
factitious d/o vs malingering
Factitious d/o : intentional falsification or exaggeration of S+S for “primary gain” (assuming the sick role to get sympathy). Inner need to be seen as ill/injured but NOT for concrete personal gain. DELIBERATELY fake their symptoms. +/- personality d/o
malingering:factitious d/o BUT motivation is SECONDARY GAIN (financial - insurance, money, lawsuits), food, shelter, avoiding prison/school
Dx illness anxiety d/o (hypochondriac) + timeline
: preoccupation w/ the fear or belief one has or will contract a serious, undiagnosed dz. (despite reassurance and medical workups showing no dz). Symptoms >6mo. Somatic symptoms usually NOT present.
DSM V for personality d/o (and criteria where it manifests)
An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas:
•1. Cognition (ie, ways of perceiving and interpreting self, other people, and events)
•2. Affectivity (ie, the range, intensity, lability, and appropriateness of emotional response)
•3. Interpersonal functioning
•4. Impulse control
Cluster A personality d/o (what does it include, general txt)
social detachment w/ unusual behaviors; weird, odd, eccentric -thought disorder type
paranoid, schizoid, schizotypal
txt: pyschothereapy (1st), +/- short-term, low dose anti-pyschotics
paranoid vs schizoid vs schizotypal
paranoid - distrust/suspicion of others
schizoid - “loner/hermit”
schizotypal - “magical thinking” aka schizo w/out pyschosis
cluster B personality d/o (what does it include and general txt)
dramatic, emotional or erratic - anti-depressants
anti-social, borderline, histrionic, narcissistic
txt: psychotherapy +/- anti-depressants
borderline vs histrionic personality d/o
borderline: unstable, unpredictable mood/affect, self image/relationships. poor sense of self.
histrionic: overly emotional, dramatic, seductive. “Attention-seeking”.
cluster C personality d/os (whats included, general txt)
anxious/worried.
avoidant, dependent, OCPD
txt: psychotherapy +/- anti-anxiety meds ( BBs,) and antidepressants (SSRIs)
avoidant vs dependent personality d/o
avoidant: desires relationships but avoids due to “inferiority complex”. Timid, shy, lacks confidence.
dependent: constantly needs to be reassured, relies on others for decision making and emotional support. Will not initiate things, intense discomfort when alone. May volunteer for unpleasant tasks
depressive personality d/o
“a pervasive pattern of depressive cognitions and behaviors beginning by early adulthood and occurring in a variety of contexts.” Occurs before, during, and after major depressive episodes, making it a distinct diagnosis not included in the definition of either major depressive episodes or dysthymic disorder
sadism vs masochism
Sadism is the sexual pleasure or gratification in the infliction of pain and suffering upon another person.
masochism, the sexual pleasure or gratification of having pain or suffering inflicted upon the self, often consisting of sexual fantasies or urges for being beaten, humiliated, bound, tortured, or otherwise made to suffer, either as an enhancement to or a substitute for sexual pleasure.
Dx timeline for generalized anxiety d/o
excessive anxiety/worry most of the days >6months about various aspects of life
3 pharm options for txt anxiety d.o
SSRI, SNRI, buspar
major ADR of buspar
extrapyramidal side effects (tardive dyskinesia)
short term meds for anxiety d/o
benzos, BBs, TCAs
dx of panic attack
Episode of intense fear or discomfort that develops abruptly, peaks w/in 10min, lasts <60min. >4 of the following symptoms… (sympathetic overdrive)
txt for panic attack
benzo (lorazepam, alprazolam).
Dx panic attack disorder
At least one of the following for one month… panic attack followed by concern for future attacks, worry about implications of attacks, significant change in behavior related to attacks. Must have >4 of the 13 typical symptoms of panic.
txt options for panic attack d/o
longterm mgmt- SSRI (paroxetine, sertroline, fluoxetine) or SNRI (venlafaxine) +/- CBT or psychotherapy. Acute attack = benzo
Dx PTSD
- Direct experience
- Witnessing
- Learning the event happened to someone close
- Extreme or repeated exposure to aversive details of traumatic event (ex/ first responders collecting remains at 9/11)
Presence of >1 intrusion symptoms …
- Re-experiencing >1mo at repetitive recollections (Dreams) + dissociative rxns (flashbacks) leading to physiological distress/reactions
- Avoidance of stimuli
- Negative alterations in cognition and mood (inabilty to remember events, thinking the world is unsafe, guilt/shame, anhedonia
- arousal/reactivity
txt options for PTSD
SSRIs (1st line), TCAs (imipramine, trazodone for insomnia), MAOIs
CBT: individual + group
what is “acute stress d/o” and what are the txt options?
Similar to PTSD but more acute- symptoms <1mo + onset w/in one month of event.
Txt: counseling/psychotherapy. If persistent, txt as PTSD
social anxiety disorder (social phobia) and specific phobias need to be present how long b4 a Dx?
> 6mo
txt options for social anxiety d/o
Txt: SSRIs, SNRIs, BBs (for performance), benzos (for short term), psychotherapy (CBT, insight-oriented)
txt options for phobias
exposure/desensitization (1st line). Short-term: benzos or BBs
what are the two components of ADHD?
hyperactive/impulsive and inattentive
DSM V for ADHD Dx.. how many symptoms must they have for <17yo, for >17yo?
For children <17 years, the DSM-5 diagnosis of ADHD requires ≥6 symptoms of hyperactivity and impulsivity or ≥6 symptoms of inattention. For adolescents ≥17 years and adults, ≥5 symptoms of hyperactivity and impulsivity or ≥5 symptoms of inattention are required
txt options for ADHD: age 4-5, age >6
Age 4-5: CBT alone. Step up: methylphenidate
>6 yo: CBT + meds: stimulants (other options - atomoxetine, A2 agonists)
DSM V for oppositional defiant d/o (mild, moderate, severe)
DSM-5, at least 6months of angry and irritable, argumentative and defiant, vindictiveness. Varying severities:
Mild. Symptoms occur only in one setting, such as only at home, school, work or with peers.
Moderate. Some symptoms occur in at least two settings.
Severe. Some symptoms occur in three or more settings.
what are 4 stimulant medications?
Methylphenidate (i.e. Ritalin)
Dexmethylphenidate (i.e. Focalin)
Dextroamphetamine (i.e. dexidrine, Zenzedi, ProCentra)
Dextroamphetamine-amphetamine (i.e. adderall)
define insomnia, acute vs chronic
Insomnia refers to insufficient sleep quality or quantity due to difficulty initiating sleep, difficulty maintaining sleep, or waking up too early. Insomnia disorder is diagnosed when sleep disturbances lead to daytime dysfunction.
Acute <3 mo, Chronic >3mo
define hypersomnia
Excessive daytime sleepiness (EDS) is defined as inability to maintain wakefulness or alertness during the major waking episodes of the day. It is distinguished from fatigue, which refers to a subjective lack of physical or mental energy.
what is “arousal d/o”
Sleepwalking, confusional arousals, and sleep terrors are a mixture of NREM sleep and wake states, such that the features of the two states are combined.
often triggered by stimuli, occur after acute sleep deprivation or psychosocial stressors, and involve a variety of nonstereotyped behaviors.
MC kids + teens.
first generation anti-pyschotics
haloperidol
chlorpromazine, fluphenazine, perphenazine,
thioridazine, thiothixine, trifluoperazine
pimozide, loxapine, molindone
major ADRS of 1st generation anti-pyschotics
extra-pyramidal ADRs (akathisia/restless, parkinsonism, dystonia, tardive dyskinesia)
prolactin elevation
mild weight gain
second generation anti-pyschotics
risperidone, paliperidone, ilioperidone
ziprasidone (Geodon), lurasidone
aripiprazole (abilify), brexipiprazole,
quietapine, clozapine, Olanzapine, caripiprazine
major ADRs for second generation anti-psychotics
metabolic ADRs (weight gain, glucose abnormalities, hyperlipidemia)
which 1st gen anti-psychotics are LEAST likely to cause EPS? what is its worst ADR?
thioridazine (but increased sedation)
which 1st gen anti-pyschotics are MOST likely to cause EPS?
fluphenazine, haloperidol, pimozide, thiothixene
which 2nd generation anti-pyschotic are LEAST likely to cause metabolic ADRs?
ziprasidone (Geodon), aripiprazole (abilify)
lumateperone, pimavanserin
which 2nd generation anti-pyschotics are MOST likely to cause metabolic ADRs?
clozapine, olanzapine
also sedation
DSM -V for substance use disorder
Substance Use Disorder DSM - V
A problematic pattern of use leading to clinically significant impairment or distress is manifested by 2+ of the following within a 12-month period:
1. alcohol larger amounts/longer period
2. desire/unsuccessful efforts to cut down or control use.
3. time to obtain, use, or recover from substance’s effects.
4. Craving, tolerance, withdrawal
5. Recurrent use = failure in obligations
6. use despite social or interpersonal problems
7. Important life activities reduced because of use.
8. Recurrent use whens its physically hazardous.
9. Continued use despite physical or pysch problem caused by it
substance use disorder: Dx mild, moderate, severe
Mild – Two to three criteria
Moderate – Four to five criteria
Severe – Six or more criteria
substance abuse vs substance dependence
Substance abuse – Mild subtype of SUD
Substance dependence – Moderate to severe subtype of SUD
binge drinking
> 5 drinks on a single occasion
txt for alcohol w/drawal. what if they have DT? what meds to avoid?
IV benzos (potentiates GABA-mediated CNS inhibition), IV fluid + IV thiamine & Mg (prior to glucose), folic acid, multivitamin \+/- phenobarbitol or propofol (for delirium tremens) + haloperidol *avoid meds that lower seizure threshold
what is the peak age of child abuse?
< 1 yr
which anti-pyschotic med is LEAST likely to cause tardive dyskinesia?
Clozapine (but can cause agranulocytosis and therefore is NOT a first line)
those on lithium require monitoring of what endocrine levels?
Thyroxine: lithium can cause goiter, hypothyroidism, hyperthyroidism and autoimmune thyroiditis
first line txt for panic d/o
SSRIs (BBs are only used for performance-induced)
if you see retinal hemorrhages on infant fundoscopy, what should be the next test?
skeletal survey: retinal hemorrhages = likely “shaken baby syndrome” and skeletal survey should be done to look for other injuries of abuse
what electrolyte changes occur with anorexia nervosa
low: T3, LH, FSH, serum Ca+
high: plasma cortisol, transaminases, serum cholesterol
txt options for nicotine dependence
nicotine tapering therapy, buproprion - antidepressant (zyban) or varenicline - blocks nicotine receptors (chantix)
symptoms and PE for opiod intoxication
Opiod intoxication : euphoria + sedation → N/V, seizure, coma.
PE: pupillary constriction (narcotics are miotics), respiratory depression. Biot’s breathing, bradycardia, hypotension. Longterm = constipation
whats “biots breathing” ?
in opiod intoxication: groups of quick, shallow inspirations followed by regular or irregular periods of apnea
w/drawal from what? : lacrimation, HTN, pruritis, N/V/D, piloerections (goose bumps), pupil dilation (mydriasis), flu-like symptoms(rinhorrhea, joint pain, myalgias)
opiods
onset and duration of naloxone for opiod intox
naloxone (onset 2 mins, lasts 30-60min)
naloxone vs naltrexone
While Naloxone is used to rescue people from an opioid overdose, Naltrexone helps to prevent relapse in people who have been clean for a minimum of 7 days. The effects of Naloxone are felt immediately while Naltrexone takes some time to kick in.
txt for opiod withdrawal
w/drawal: clonidine (decr sympathetic symptoms), loperamide (for diarrhea), NSAIDs (joint pains). + buprenorphine + naloxone. Methadone-tapering +/- benzos
txt opiod addiction longterm mgmt
methadone maintenance program (suboxone + naloxone)
4 stages of alcohol w/drawal based on hrs after last drink
- uncomplicated: 6-24 hrs
- w/drawal seizures: 6-48hrs
- alcoholic hallucinosis: 12-48hrs
- delerium tremens: 2-5 days after
what is uncomplicated alcohol w/drawal
6-24 hrs after
increased CNS activity (tremors, anxiety, diaphoresis, palpitations, insomnia, GI upset. NO SEIZURE, HALLUCINATIONS, DT
alcohol w/drawal seizures, hallucinosis, DTs
w/drawal seizures: tonic-clonic type. MC as single episode
Alcoholic hallucinosis: auditory or tactile hallucinations. Clear sensorium and NORMAL VITALS
Delirium tremens: delirium (altered sensorium), hallucinations, agitation, ABNORMAL VITALS (tachy, HTN, fever). Diaphoretic.
txt of benzo intox
flumazenil
chronic alcohol use can cause what two effects
- wernicke’s encephalopathy: ataxia, confusion + oculomotor palsy (from thiamine/B1 deficiency)
- korsakoff syndrome: amnesia (retrograde and antegrade)
what is formication?
sense that “something is crawling on them” especially at night- occurs with delerium tremens
intoxication? euphoric, restless, agitated, hallucinations. skin picking, rhabdo, HTN, dilated pupils
stimulants
stimulant w/drawal S+S
craving + dysphoria, anxiety, hypersomnia, increased appetite. Nightmares, suicidal ideation, irritable.
txt for cocaine intoxication
benzos, neuroleptics, BP reduction.
intox? impulsive, homicidal, psychosis, delerium, seizures, nystagmus
PCP
intox? visual hallucinations, syntesthesias (seeing sound as color), delusions, pupil dilation
LSD
CAGE questions for alcohol dependence
Cutdown, Annoyed, Guilt, Eye opener
>2 = positive screen
alcohol abuse becomes dependence when…
withdrawal symptoms develop or tolerance
what are the 12 steps?
- admit we are powerless
- power greater than us can restore our sanity
- decide to turn our lives over to God
- made a searching and fearless moral inventory of ourselves
- admit to all the nature of our wrongs
- ready to have God remove all defects of our character
- ask God to remove our shortcomings
- make a list of those we harmed
- make amends
- continue to take inventory and admit when we are wrong
- pray and meditate
- carry these messages to all alcoholics
3 signs of child sexual abuse
genital/anal trauma, STIs, UTIs
who are the likely culprits of sexual and physical child abuse?
sexual - male who knows child
physical - female caregiver
strongest predictive factor of suicide
prior attempts or threats
what population in the US is highest risk for suicide?
older white men (but teens attempt more)
what is dementia? what does it include?
progressive, chronic intellectual deterioration of selective functions: memory loss + loss of impulse control, motor and cognitive fxns (language, disorientation, complex motor activities, inappropriate social interaction) - NOT due to delirium, meds or psych illness.
Includes: alzheimers, vascular, frontotemporal, diffuse-lewy body, Creutzfelt-Jacob.
risk factors for dementia?
age, vascular dz
pathophys of alzhemiers
loss of brain cells, amyloid deposition (senile plaques), neurofibrilliary tangles (tau protein). Cholinergic deficiency → memory, language, visuospatial changes. Normal reflexes.
Dx of alzheimers
CT: cerebral cortex atrophy
two txt options for alzheimers: what drugs are included and how do they work?
- Ach-esterase inhibitors (donepazil aka Aricept, tacrine, rivastigmine, galantamine - reverses cholinergic deficiency + symptom relief. does NOT slow dz progression.
- NMDA antagonist: Memantine - reduces glutamate exictotoxicity
why does clozapine require WEEKLY CBCs?
cause it can cause aplastic anemia
