EOR Topics to Review Flashcards
Tx of choice for BPD in pregnant patients?
Atypical antipsychotics (b/c mood stabilizers are all CI d/t being teratogens)
If you HAVE to choose a mood stabilizer, lamotrigine is the best
how long do sx have to be present to make a diagnosis of delusional disorder?
1 month
(sx include: usually NONBIZARRE delusions that do not impair functioning and cannot be attributed to a different medical condition)
Erotomanic delusions
Belief that another person is in love with the individual
Grandiose delusions
Conviction of having some great talent or insight
Jealous delusions
Delusion that partner is unfaithful when they have no reason/evidence to do so
Persecutory delusions
Belief that they are being conspired against, spied on, poisoned, etc.
Somatic delusions
Delusions about bodily functions or sensations
Bizarre delusions
Content is clearly implausible, not understandable and not derived from ordinary life experiences (eg. government placed a chip in brain)
Schizophrenia risk factors
- Male sex
- Born in late winter or early spring (March)
- Living in industrialized communities
- Cannabis use!!!! HUGE ONE
- Paternal age > 50
- Pregnancy complications: Maternal infection, malnutrition, hemorrhage, hypoxia or ABO incompatibility
Delusion of reference
Belief that a random event in life is specifically directed at an individual (i.e. news reporting speaking directly to someone)
Nihilistic delusion
Belief that one is dead or their body is breaking down
Paranoid delusion
Persistent false beliefs that others are out to get them
Which 2nd gen antipsychotics cause the LEAST weight gain
Lurasidone, aripiprazole, ziprasidone
Main ADR of 2nd gen antipsychotics + monitoring parameters
- Metabolic changes (diabetes, hyperlipidemia)
- QTc prolongation
Monitor with fasting BG or an A1C, lipid panel
First line treatment of delusional disorder
2nd gen antipsychotics such as aripiprazole (adjunctive psychotherapy, CBT an option)
Clozapine ADRs
- Cardiotoxic: causes mitral valve incompetence, cardiomyopathy, myocarditis, QT prolongation, can cause bradycardia and orthostatic hypotension/syncope, cardiac arrest
- PE
- Agranulocytosis (rec that pts have > 1500 neutrophil count before starting clozapine), therefore MONITOR WITH WEEKLY CBC
Clozapine indications?
Patients who are refractory to MANY other antipsychotic treatment options or display persistent self injurious or suicidal behaviors
Risperidone ADRs
- Hyperprolactinemia, gynecomasstia
- Extrapyramidal sx (though less frequent than 1st gen)
Which antipsychotic is most well known for causing weight gain?
Olanzapine
(THINK: “O” in olanzapine stands for rOund)
Most concerning ADRs of 1st gen antipsychotics
EPS, tardive dyskinesia with chronic use
Treatment for acute dystonia after administration of first generation antipsychotic
Diphenhydramine (benadryl) – balances cholinergic and dopaminergic activity to help correct dopamine imbalance caused by antipsychotic administration
Can also use benztropine
Hallmark findings of neuroleptic malignant syndrome
Fever
Lead pipe (muscle) rigidity
AMS
Autonomic instability
What is verbigeration?
Compulsive repetition of seemingly meaningless words/phrases w/o regard to stimuli
Difference between verbigeration and echolalia?
Verbigeration = random repetition
Echolalia = repetition of words uttered by someone else, usually during conversation/interview with patient
Tangential speech
Patient discusses many unrelated topics, never arrives at an appropriate answer
Circumstantial speech
Patient discussed many unrelated topics BEFORE arriving at the appropriate answer
Neologisms
Creation of new idiosyncratic words
Which 2nd gen antipsychotic has highest potential for misuse and is the most sedating?
Seroquel (quetiapine)
***avoid in patients with history of substance abuse
Which of the following is the most common substance used by patients with schizophrenia?
A) Tobacco
B) Cocaine
C) Alcohol
D) Cannabis
A – up to 90% of patients
Treatment of EPS
Depends on manifestation of EPS symptoms:
- Parkinsonian EPS symptoms: treat with amantadine or benztropine (though increased risk in pts with glaucoma or cognitive impairment)
- Dystonia (involuntary muscle contractions): treat with diphenhydramine, hydroxyzine
- Akathisia (feeling/motor restlessness): treat with propranolol
Distinguishing schizoaffective disorder versus schizophrenia
Presence of manic or depressive episode indicates schizoaffective disorder
Presentation of synthetic cannabinoids
Anxious: diaphoretic, hypertension (or hypo), tachycardia (or brady), angina, N/V
Psychotic: delusions, paranoia, hallucinations, AMS, avoidance of eye contact
Can also present w extreme muscle rigidity c/w rhabdo
Why cant you detect synthetic cannabinoids on drug screen?
Structurally dissimilar from naturally occurring marijuana, only detectable on a liquid/gas chromotography mass spectrometry
What is the indication for lamotrigine?
Maintenance management of BPD II, helps stabilize mood fluctuations
NOT USED FOR ACUTE MANIA MANAGEMENT
Which mood stabilizers can cause neural tube defects?
Valproate and carbamazepine (though stronger association for valproate)
Which mood stabilizer requires hla testing (in patients of Asian descent)?
Carbamazepine (and also lamotrigine) b/c it looks at likelihood of developing SJS or TEN
Which mood stabilizer is suicide protective?
Lithium
Treatment options for acute manic episode
Antipsychotic (olanzapine, seroquel) + lithium
antipsychotic + valproate if lithum is CI (i.e. in CKD)
No valproate in patients trying to become pregnant d/t teratogenicity, also avoid in pts with chronic liver injury d/t hepatotoxicity
ADRs of valproate
N/V, hair loss, easy bruising, weight gain
RARE but SERIOUS: pancreatitis, hepatotoxicity (elevated LFTs), TCP – monitor LFTs every 6-12 mos
Which mood stabilizer is associated with cardiovascular abnormalities including Ebstein’s anomaly?
Lithium
BPD I versus BPD II diagnostic criteria
BPD I: mania (sx for > 1 week OR manic sx requiring hospitalization) +/- depressive sx
BPD II: hypomania (sx for at least 4 days) that does NOT result in marked social impairment + AT LEAST ONE major depressive episode
Which mood stabilizers can cause SJS/TEN?
Lamotrigine and carbamazepine
What meds can INCREASE lithium levels?
ACEi, NSAIDs, thiazides, tetracyclines and metronidazole
Which SSRI is considered to be the most sedating?
Paroxetine (Paxil)
THINK: paroxetine makes you fat and sleepy
Biggest ADR of citalopram
QT prolongation
(THINK: It takes a LONG (QT) time to get out of the CITy(alopram)
Best treatment for social anxiety disorder with FREQUENT sx?
CBT, SSRI (sertraline)
Propranolol or lorazepam can be used if sx are infrequent or for single occurrences
GAD treatment algorithm
1st line for long term mgmt: SSRI (lexapro, zoloft) or SNRI (venlafaxine)
Acute: can augment SSRI/SNRI with buspirone and/or benzos
Pts refractory to SNRI/SSRIs can be started on long term benzos assuming no history of substance misuse
When can you use buspirone as adjunctive therapy for GAD?
In patients with partial response to SSRIs (i.e. has been on sertraline for 6 months with only mild improvement)
When is CBT versus SSRIs considered first line for phobias?
CBT with real world exposure therapy always first line UNLESS pt has social phobia – then manage with long term SSRI, adjunctive buspirone and/or benzos
What is the SADPERSONS mnemonic?
Good for assessing suicide risk
Sex (M > F)
Age (< 19 or > 45)
Depression or hopelessness
Previous attempts – STRONGEST INDICATOR!!!
Excessive alcohol use
Rational thinking impaired
Separated or divorced marital status
Organized or serious attempt previously
No social support (aka isolation)
Stated future intent
> /= 6 means HIGH RISK
MDD risk factors
- First degree relative with history of depression
- Childhood trauma (sexual, physical, emotional)
- Separated/widowed/divorced
- F > M
- Recent life stressors (family death, divorce, job loss, etc.)
- Postpartum status
ADRs of mirtazapine
Most notable: weight gain, sedation (opposite of SSRIs)
When is mirtazapine indicated for treating depression?
Pts who have insomnia or sexual dysfunction 2/2 SSRIs
Serotonin syndrome treatment
- D/c offending agent
- Benzos (2 mg lorazepam) for short term sedation
- Cyproheptadine (serotonin agonist)if unresponsive or only mildly responsive to benzos
Serotonin syndrome classic triad of presentation
- AMS (agitated, anxious)
- Neuromuscular excitation (CLONUS, DTR hyperreflexia, tremors, akathisia)
- Increased sympathetic activity (tachycardia, hypertension, diaphoresis, mydriasis)
Which SSRI has the longest half life?
Fluoxetine (Prozac) and therefore has the lowest risk of SSRI discontinuation syndrome
What are the 5 C’s of TCAs?
Chubby (weight gain occurs d/t histamine blockage, which causes an increase in appetite)
Cardiotoxic (pro-arrhythmic, orthostatic hypotension)
Cutie (QTc prolonged)
Convulsions (decreases seizure threshold)
AntiCholinergic (dry mouth, erythema/flushing, urinary retention, constipation, tachycardia)
TCA MOA
Nonselective inhibition of NE and serotonin reuptake (also impacts 5HT receptors, alpha 1, anticholinergic, histamine and Na+ channels)
What are the MAO inhibitors?
Tranylcypromine
Isocarboxazid
Phenelzine
Selegiline
(THINK: TIPS)
Major ADRs of MAO inhibitors?
LARGE risk of serotonin syndrome
Also risk of hypertensive crisis, need to eliminate tyramine rich foods from diet (fermented foods)
***need to wait 2 weeks before starting and after stopping these meds to make dietary changes to avoid SS or hypertensive crisis
How do you transition to MAO use?
Need to have completely been off antidepressants for 2 weeks prior to starting a MAO inhibitor (avoid SS and hypertensive crisis)
***unless fluoxetine, which must be d/c 5 weeks prior
Absolute CI to ECT?
Brain tumor leading to increased ICP
Protective factors against suicide?
Higher SES
Pharmacologic: clozapine for individuals with schizophrenia + recurrent attempts; lithium for individuals with BPD + recurrent attempts
LITHIUM IS SUICIDE PROTECTIVE!
Best two SSRIs for pts who are breastfeeding?
Sertraline (zoloft) and paroxetine (Paxil)
Distinguishing MDD and PDD?
If MDD lasts for more than 2 years, is refractory to treatment and is present more days than not, it is considered PDD now
When is bupropion used as first line for depression tx?
In patients who have a history of sexual dysfunction or have concomitant tobacco use or have coexisting neuropathic pain
(THINK: if you want to BUMP and GRIND, use bupropion)
How do long do pts need to be treated with SSRIs and psychotherapy for PDD?
Indefinite amount of time
How long do grief symptoms have to last to be considered complicated bereavement?
More than 12 months
Core features of narcissistic personality disorder?
- Grandiosity
- Inflated but fragile self image
- Manipulative/exploitative and superficial relationships
- Need for admiration (often avoid situations – promotions, jobs, etc. – that would make them open to criticism)
What are the cluster C personality disorders?
THINK: anxious and fearful, sometimes sad
Avoidant
Dependent
Obsessive compulsive
THINK: ADO is in cluster C
Treatment of choice for borderline personality disorder?
DBT!!!
Pharmacologics not really indicated as 1st line, fluoxetine can be used as adjunct for patients with co-existing depression
Major difference between oppositional defiant disorder and conduct disorder
Pts with conduct disorder purposely harm others, animals without remorse for others
How to differentiate bipolar versus borderline?
Bipolar sx last longer (at least a week) and are typically less labile, versus extreme fluctuations in mood throughout a single day with borderline
T or F: OCPD is marked by obsessions and compulsions
FALSE, this is more c/w OCD. OCPD is more focused on being perfect and rigid routines at the expense of own happiness and interpersonal relationships
Cluster B personality disorders
THINK: dramatic, emotional and erratic
Histrionic
Borderline
Narcissistic
Antisocial
When do you use pharmacologic treatment for schizotypal personality disorder?
When trying to address severe disorganization and/or inattention
Pharmacologic treatment of choice for schizotypal disorder?
Quetiapine (also helps decrease anxiety)
Examples of the clinical manifestations of schizotypal personality disorder?
Ideas of reference (i.e. thinking Magic 8 ball is talking to pt specifically)
Poor hygiene practices
Chronic history of being nervous, distrustful, shy
Disorganized/messy
Lack of attention to detail
What are the cluster A personality disorders?
THINK: Odd and eccentric
Paranoid
Schizotypal
Schizoid
When is pharmacotherapy useful in patients with antisocial personality disorder?
In patients with SEVERE AGGRESSION – can offer 2nd gen antipsychotics (i.e risperidone or quetiapine)
Which antipsychotics are ok to use in kids with autism?
Risperidone and aripiprazole
What happens to cholesterol levels in anorexia nervosa?
Total cholesterol increases as a result of increased HDL production as a cardioprotective mechanism
Which 2nd gen antipsychotic has the highest likelihood of causing tardive dyskinesia?
Risperidone
Describe tardive dyskinesia
Hyperkinetic movement disorder that has a DELAYED ONSET and appears after prolonged antipsychotic use
- Repetitive facial movements (chewing, lip smacking) is common
Panic disorder risk factors
- Smoking during childhood
- Sexual or physical abuse during childhood
- Neuroticism personality trait
- Family history of panic disorder
Delusional disorder versus paranoid personality disorder?
Paranoid personality = paranoia is more generalized and can wax/wane
Delusional = specific/focused nature of delusions on one certain thing
What is the MCC of oral leukoplakia
Tobacco use
Oral leukoplakia = painless white patch with well defined IRREGULAR BORDERS on tongue, not able to be scraped off – must confirm diagnosis with a biopsy
THC (delta 9 tetrahydrocannabinol) MOA
Partial agonist at the cannabinoid 1 and 2 receptors
Cannabinoid 1 receptors are responsible for controlling the body’s brain reward system, and stimulation of these receptors is what can cause marijuana abuse
What is the best pharmacologic option in a patient with ADHD who has history of substance or alcohol use disorder?
Atomoxetine (want to avoid stimulants like amphetamines or methylphenidate)
What is akathisia?
Feeling of or true motor restlessness that is not relieved with movement
How do you treat akathisia?
Cautious reduction of antispychotic dose OR if dose can’t be reduced, treat with BBs, benztropine or benzos
Which antipsychotics have the lowest risk of TD?
Quetiapine and clozapine
Loose associations
Switching from one topic to another inappropriately, a/w schizophrenia
What is the dose relationship when starting an SSRI for GAD versus MDD?
Dose for GAD should be HALF of what the starting dose is for MDD
1st line pharm treatment for PCP intoxication
Benzos, midazolam in particular because it is so fast acting
Cooling
IV fluids
Treatment of narcissistic personality disorder
Contract between patient and provider on acceptable communication
Pharmacologic intervention if pt is physically aggressive can be warranted (mood stabilizers)
Psychotherapy is FIRST LINE
What med is a first line treatment of mild to moderate body dysmorphic disorder?
Fluoxetine (in combination with CBT)
What substance should you think of if pt has bad breath or body odor when sx arise?
Solvent inhalation
Oppositional defiant disorder versus conduct disorder
Oppositional doesn’t typically involve violence, more focused on vindictiveness and an angry/irritable mood
Conduct = complete disregard for others, laws, authority, etc.
Cyclothmic disorder diagnostic criteria
Multiple hypomanic episodes that are never gone for more than 2 months over at least a 2 year period; sx cause psychosocial impairment
like a more mild form of BPD
What labs should you order to r/o physiologic causes of panic attacks and to make an accurate diagnosis of panic disorder?
TSH, CMP, CBC (looking for anemia, infection, hyperthyroidism, hypoglycemia or lyte imbalance)
Cannot make panic disorder diagnosis without ruling physiologic causes out first! Diagnosis of exclusion
First line therapy for males with pedophilic disorder
IM medroxyprogesterone or leuprolide acetate (hormonal therapies that decrease testosterone production and libido)
Depression and/or mania sx + hallucinations, delusions should make you think…
Schizoaffective disorder
T or F: if a patient has an episode where all of the elements of schizophrenia are met, but the symptoms do not persist for at least 6 months, it is considered schizophreniform disorder
True
Timeline for schizophreniform disorder
Sx for more than 1 month but less than 6 months
Oppositional defiant disorder often coexists with…
ADHD (~50%)
T or F: The presence of people is the root of the development of fear/anxiety for those with social anxiety disorder
True. These pts would feel more comfortable in the same situation if people were NOT present, versus in agoraphobia regardless of whether or not people are at a venue, they are still anxious because their fear is being unable to escape or leave should they have a panic attack
What is the greatest contributor to increased likelihood of relapse after being treated for MDD?
Childhood maltreatment
Risk of recurrence is greatest within the first few months after treatment
Key word to clue you into opiate withdrawal
Increased lacrimation, yawning
When would ECT be considered first line for BPD treatment?
If pt has major depressive episode with malignant catatonia (decreased response to external environment, signs of autonomic instability)
Bupropion inhibits the reuptake of which neurotransmitters?
Dopamine and norepinephrine
What must you do before starting methylphenidate?
Full cardiac eval
Vicarious acquisition versus direct bias versus informational transmission as modes of developing phobias
Vicarious acquisition = observing or seeing someone react to something
Informational transmission = hearing anecdotes about other people
Direct bias = fear develops after inciting event happens to you
Treatment of choice for pain mgmt in patients with hx of opioid use disorder?
1st line long term treatment = opioid agonist (such as buprenorphine or methadone) + naloxone
***this is ok to use in pregnancy
What substance is excessive yawning associated with?
Opioid withdrawal
Difference in MOA between benzos and barbituates (both sedatives)?
Benzos: increase FREQUENCY of chloride channel opening (to allow for hyperpolarization more often)
Barbituates: increase DURATION of chloride channel opening (to allow for longer hyperpolarization periods)
THINK: Ben wants it to happen more often, but Barb wants it to last longer
What intoxication should you think of with tactile hallucinations?
Cocaine or methamphetamine intoxciation (think of stimulants with this presentation, more a/w cocaine but could be either)
Which substance should you think of with rotatory nystagmus?
Phencyclidine (PCP)
THINK: the cycl in phencyclidine signals that the eyes move in a circular motionW
What should you think of when you hear bruxism in regards to substances?
MDMA or meth
Bruxism = grinding, clenching or mashing teeth together
THINK: bruxisMMMM – the M substances
What substance should you think of when you see miosis, aka pinpoint pupils?
Opioid intoxication OR stimulant withdrawal
What substance should you think of with excessive thirst?
MDMA intoxication (d/t serotonergic effects, hyponatremia)
Potentially life threatening AE of methadone?
QT prolongation – progression to Torsades
Other non life-threatening AEs: constipation, sweating, drowsiness, peripheral edema
Methadone is a long acting opioid agonist that acts on mu receptors
Treatment of choice for cannabis withdrawal
Mild sx - none (encourage relaxation techniques)
Moderate to severe - dronabinol or gabapentin
Common ADRs of varenicline?
Nausea/vomiting
HA
Insomnia
Abnormal dreams!!!
MOA: decreases cravings and withdrawal sx by blocking nicotinic ACh receptors and stimulating dopamine activity to a lesser degree than nicotine does
Benzo withdrawal sx
Hyperacusis and photosensitivity!!
Seizures in prolonged instances
Autonomic instability (HTN, tachycardia, tachypneic, febrile)
N/V
What medication is used to treat benzo overdose/intoxication?
Think severe respiratory slowing, constipation, lethargy, etc.
Flumazenil
What medication class should you avoid in the sitting of cocaine intoxication?
Beta blockers – c/f extreme HTN and coronary artery vasoconstriction with unopposed alpha adrenergic stimulation
Complications of acute and chronic inhalant use
Acute: think CARDIAC – vent tachydysrhythmias, myocarditis, sudden cardiac death
Chronic: leukoencephalopathy, myeloneuropathy, hepatotoxicity
What are the two naturally occurring opioids?
Morphine and opium – important to know bc these are the only opioids that will show up positive on a routine drug screen (i.e. urine drug testing)
Qualifications for “risky” alcohol use based on gender
Males: >/= 5 drinks per day or >/= 15 per week
Females: >/= 4 drinks per day or >/= 8 per week
Mild alcohol withdrawal symptoms
Tachycardia
Diaphoresis
Tremors
N/V
Anxiety
Mild agitation
Insomnia
Alcohol craving
HA
Once hallucinations, seizures, DTs present = moderate to severe withdrawal
Wernicke Korsakoff presentation triad (vitamin B1, aka thiamine, deficiency, common in alcoholics)
Ophthalmoplegia or oculomotor dysfunction
Encephalopathy (AMS)
Gait ataxia
Alcohol withdrawal treatment based on CIWA scores
< 8 (mild) = no benzos needed
9 -15 (moderate) = benzos q2h
>/= 16 (severe) = benzos hourly
How do you treat HTN 2/2 amphetamines?
Lorazepam = 1st line
Nitroprusside, phentolamine = 2nd line
What 2 oral medications can help discourage alcohol use?
Naltrexone and disulfiram
T or F: Bupropion is the first line treatment for smoking cessation in pregnant patients
FALSE. First line tx = behavioral interventions, no evidence that bupropion is effective during preg
MC manifestation of cannabis withdrawal
Insomnia/disturbed sleep – can be treated with zolpidem
Best treatment for acute opioid withdrawal
Symptom control – antidiarrheals, antiemetics, antipyretics, CLONIDINE for HTN, IV lorazepam
Treatment of malingering
Subtle confrontation
Treatment of somatic symptom disorder
FIRST = regularly scheduled follow ups
CBT or DBT once pt is ready to make behavioral changes
Illness anxiety disorder versus somatic symptom disorder
Illness anxiety = fixed on developing a certain disease or medical condition; may or may not have sx, MILD somatic sx if at all present. More focused on future worsening of health
Somatic symptom = sx are the MAIN CC/core finding
Difference between factitious and malingering
Factitious = intentional falsification without apparent secondary/external gain; tx = psychotherapy
Malingering = falsification with goal of secondary gain, often will not consent to diagnostic testing; tx = subtle confrontation
First line treatment of PTSD
CBT ALONE, can add pharmacotherapy (SSRI, SNRI) if refractory
What is the new term for Munchausen by proxy?
Medical child abuse (aka factitious disorder imposed on someone else)
What’s the most common manifestation of adjustment disorder?
Maladaptive behaviors (alcohol or substance use to relieve anxiety)
Pharmacologic treatment for insomnia
If refractory to CBT and practicing good sleep hygiene, can try DOXEPIN, which is long acting and helps people stay asleep
Short acting options (the Z drugs: zaleplon, zolpidem, eszopiclone) are used to help initiate sleep
Which of the following is a common predisposing factor in the development of PTSD?
A) Being married
B) Female sex
C) Higher SES
D) Older age at time of trauma
B
- Being married hasn’t been shown to increase risk of developing PTSD
- Lower SES increases risk, not higher
- Younger age at time of trauma increases risk, not older (the idea is that you have better coping skills at this time)
which 2 SSRIs are best for treating OCD?
Paroxetine (Paxil) and sertraline (Zoloft)
What is the role of clomipramine in treating OCD?
Used as a second line therapy if pts are unresponsive to CBT and SSRIs (sertraline, paroxetine)
Which SSRI is used to treat body dysmorphic disorder?
Fluoxetine
1st line tx for ODD
Assess psychosocial situation and parent training, THEN initiate CBT
Common causes of low nitric oxide levels leading to ED?
Diabetes
Smoking
Testosterone deficiency – usually will also be a/w decreased libido and loss of E
Most potent risk factor for development of female sexual arousal disorder?
History of sexual abuse (doubles the likelihood of development)
Most common fetishes?
Feet, hair, women’s underwear, shoes and toes
Indications for admission 2/2 anorexia nervosa
- Vital signs unstable (HR < 40, bradypnea, orthostatic hypotension, BP < 80/60)
- BMI < 15
- Cardiac dysrhythmias (prolonged PR interval)
- Moderate to severe refeeding syndrome
- Medical emergencies: syncope, seizure (BUPROPION CI IN THESE PTS), hypoglycemia, electrolyte disturbance, cardiac or liver failure, pancreatitis
Diff between bulimia and binge eating disorder
No compensatory behaviors in binge eating disorder
Complications of binge eating disorder versus bulimia
Binge eating:
- T2DM!!!
- HTN
- Hypercholesterolemia
- Obesity
Bulimia:
- Colonic dysmotility 2/2 laxatives or enemas
- Hypokalemia and other electrolyte imbalances d/t vomiting
Which personality disorder is most closely associated with bulimia?
Borderline personality disorder
Most important initial treatment for anorexia
Nutritional counseling and rehabilitation
Anorexia versus restrictive food intake disorder
Anorexia = low body weight, aversion to food out of fear of body changes/weight gain!!
Restrictive food intake disorder = low body weight, lack of interest in food or aversions to certain characteristics of food. NO distorted body image or intense fear of gaining weight
Which personality disorder is MC associated with anorexia?
OCPD
ADRs of stimulants
Growth suppression, weight loss – monitor weight and height routinely
Insomnia
Blurred vision
Motor tic development
Social withdrawal
Mild increases in HR and BP – monitor routinely
Monitoring parameters: 1 month after starting meds, and then q3 months once on a stable dose
ADHD diagnostic criteria
Must have 5 or more sx of inattention OR hyperactivity
Methylphenidate MOA
Blocks reuptake of norepinephrine and dopamine into presynaptic neurons
At what age do you screen for autism?
18-24 months (per American Academy of Pediatrics) with the M-CHAT tool
Moderate risk: score 3-7, administer second stage of M-CHAT
High risk: 8 or higher, immediate referral for diagnostic evaluation
How is the sympathomimetic toxidrome (cocaine, methamphetamine) different than the anticholinergic toxidrome?
Anticholinergic will have dry skin and hypoactive bowel sounds
Oral leukoplakia versus squamous cell carcinoma of the tongue
Squamous cell = often larger (> 2 cm) and on the lateral border of the tongue
Oral leukoplakia = often smaller, on top of the tongue
Both painless white patches with irregular borders
Common ADRs of lithium
Nausea, tremors, polyuria, weight gain, loose stools, thirst
What SSRIs are used in OCD?
Sertraline or paroxetine in combination with CBT OR fluvoxamine
What is used to treat benzo withdrawal?
Think: tremors, agitation, nausea, diaphoresis, tachycardia, anxiety
Long acting benzo (diazepam) and then tapering
Naloxone versus naltrexone
Naloxone = narcan, used for opioid overdose
Naltrexone = helps treat both alcohol use disorder AND opioid use disorder
Wernicke Korsakoff presentation and treatment
Ophthalmoplegia (i.e. LR palsy), gait ataxia, confusion/amnesia
Treat with IV THIAMINE administration because it develops d/t deficiency with long term alcohol use
Beyond 2:1 AST:ALT ratio, what lab indicates alcohol use disorder?
Elevated GGT, macrocytosis, low serum albumin (d/t malnourishment)
What is the role of benzos in treating opioid withdrawal?
If patients are put into iatrogenically induced opioid withdrawal (i.e. given narcan/naloxone for opioid intoxication), benzodiazepines like lorazepam can be used to help manage subsequent sx development. do NOT give these pts opioid agonists in the withdrawal phase, would need a really high dose that can cause euphoria!!!
Meds and vaccines to give to patients who are sexually assaulted
- HIV medication
- Hep B vaccine
- HPV vaccine
How does depression impact the anatomy of the brain?
Decreases hippocampal and frontal lobe volume, increases-ventricular:brain ratio
Is GABA inhibitory or excitatory?
Inhibitory – when GABA levels are decreased, anxiety results
Is frequent conflict over trivial matters more associated with borderline or dependent personality disorder?
Borderline
Treatment for severe suicidal ideation
ECT
Preferred medication to switch to for management of BPD if initial antipsychotic regimen is no longer tolerated/failed?
Lithium (therapeutic levels are 0.8-1.2)
Best treatment for cannabis use disorder?
CBT
Best therapy for opioid use disorder/patients trying to quit that have been unsuccessful with behavioral attempts?
Buprenorphine + naloxone (narcan)
***Buprenorphine has a lower risk of overdose than methadone b/c it has less adverse cardiac effects, and should be used first line
Which of the following is most specific for delirium tremens?
A) Disorientation
B) HR of 108
C) Seizures
D) Visual hallucinations
A – you can see all of the other options earlier on in alcohol withdrawal (tachy very early on, seizures 6-48 hours after last drink, hallucinations 12-48 hours after last drink) but AMS and disorientation is not until much later on in DTs (develops > 48 hours after last drink)
What are general labs you should get in patients with personality disorders?
STI testing d/t poor impulse control
May also want to get hepatitis C testing d/t increased risk of substance abuse
How long should patients with GAD be on an SSRI before considering discontinuing if they have a good response?
12 months if pts have a robust response, then can taper off the medication
Best tool to assess for ADHD in adults?
diagnostic interview for attention deficit hyperactivity disorder in adults
Which SSRI is indicated in OCPD?
Fluvoxamine
T or F: Cigarette smoking is a known risk factor for MDD
False
Imipramine medication class
TCA
What’s the timeline for the disappearance of postpartum blues?
Usually by 2 weeks postpartum – if persistent, now termed postpartum depression
What is a common comorbid condition with panic disorder?
MDD
