Exam 2 Beth Flashcards
1
Q
Screen everyone even low risk
A
Har from false positive-expense, harm , and mental trauma
2
Q
Mood disorders
A
Ok
Depressive, anxiety, and bipolar related
3
Q
Mood disorders genetic
A
Can be-always get family history
Especially bipolar-50% have a first degree relative with a mood disorder
-LOOK FOR FAMILY HISTORY WITH BIPOLAR
10-25% of mood disorder have first degree relative for mood disorder
4
Q
NT with mood
A
NE, dopamine, 5-HT, GABA , glutamate
Glutamate NMDA-excitatory
GABA-inhibitory NT, site of benzodiazepines
Dopamine down in depression, high in mania
NE down regulate beta receptors, nor Adrenergic function abnormal in depression
5-HT decreased in depression SSRI proved effective as anti depression
5
Q
Life and environmtal psychocosial
A
Death grandparent, parent before 11, death spouse or child, unemployment,
6
Q
Major depressive
A
2 weeks at least 5 with at least 1 being depressed mood or loss of interest or pleasure
7
Q
Manic
A
Abnormally and persistently elevated expansive or irritable mood lasting at least 1 week with at least 3 of the following
8
Q
Hypomanic episode
A
Similar to manic last 4 days must not include psychotic features
BIPOLAR TYPE II associated
9
Q
Diagnosis major depressive disorder
A
Diagnosis requires presence of one or more major depressive episodes and absence of manic, hypomanic, or mixed
10
Q
Grief (bereavement) vs depression
A
Grief 2 months-2years
Following loss of a lover one , symptoms similar to major depressive, should not include hallucinations/delusions or impairment of function
NO HALLUCINATIONS?DELUSIONS or impairment of function
11
Q
Kubler Ross stage of grief
A
Denial Anger depression bargaining acceptance
12
Q
Treat grief
A
Not antidepressants
13
Q
Treat major depressive disorder
A
hospitalization
Somatic therapies=TCA, MOA inhibitors, SSRI, SNRI, mirtazapine
ECT
Trans racial magnetic stimulation
14
Q
Triazolopyridines trazadone
A
Priapism
Cheap
Help sleep
Don’t use
15
Q
ECT
A
Treatment resistant depression
Short term memory loss common
Good treatment response
16
Q
Transcranial magnetic stimulation
A
Newer treatment in doctors office
17
Q
Ketamine
A
Causes dissociative anesthesia
NMDA antagonist
Overdose-panic attacks and aggressive
Works well AMAZING
18
Q
Spravato
A
Nasal ketamine like
Nasal spray given in health care setting NO GO HOME rapid acting antidepressant
$$$$$$$$$$
19
Q
Persistent depressive disorder/ dysthymic
A
Depressed mood for most of day for 2 years in duration for adults and 1 year for kids that has not been severe enough to meet criteria for major depressive episode
During 2 years cannot be w/o six for >2 months at a time
Smoldering depressed
20
Q
Treat dysthymic
A
SSRI, SNRI, MAOI, CBT
21
Q
Seasonal depression
A
Onset and remission of major depressive episode at characteristic time
Fall
Sleep more and eat more fatigues
22
Q
Treat seasonal depression
A
Light therapy
23
Q
Premenstrual dysphoric disorder
A
Moor instability 1 week before menses for 1 year
Treat with exercise, diet, relaxation,
24
Q
Bipolar 1
A
At least one manic or mixed episode and a depressive
Don’t need a major depressive episode
To diagnose, if have a manic call them this
Worse prognosis MDD
25
Bipolar II
At least 1 major depressive and one hypomanic more common than I
NO MANIC
26
Treat bipolar
Lithium, valorous acid mood stsabilizers
27
Cyclothymic disorder
Dysthymic disorder with intermittent hypomanic periods
Over 2 years (1 for kids), experiences repeated episodes of hypomanic and depression (not severe enough to meet criteria for major depressive disorder)
28
Treat cyclothymic disorder
Mood stabilizing
Antidepressants precipitate manic-diagnose bipolar from giving an antidepressant
Support
29
Substance related
Bipolar and major depressive disorders either due to substance induced or withdrawal of drugs
30
Anxiety disorder symptoms psychological
Apprehension, worry, doom gloom, hyper vigilant (also PTSD) ,cant concentrate, derealization
31
Somatic symptoms anxiety
HA, dizziness, lightheaded, palpitations, lump in throat , restlessness, SOB, dry mouth, sweating
32
Physical signs anxiety disorders
Diaphoresis, cool clammy skin, tachycardia, flushing, hyper reflex is, tremor, fidgeting
33
Generalized anxiety
Everything in general bothers u
34
Panic disorder
Recurrent unexpected panic stacks
At least one attacked followed by 1 months or one or more
-persistent concern about additional attacks
Worry about implications of attack or its consequences
Significant change in behavior related to the stack
35
Panic atttack
Discrete period of intense fear or discomfort, in which four or more of the rolling g develop PEAK IN 10 min
36
Who has panic disorder
Women
37
Agoraphobia
Situations cant get out by scared gonna have a panic attack so stay home
Associated with panic disorder
38
Social phobia
Avoid social situations for about 6 months
Feel embarrassed or humiliated/uncomfortable when talking to others
Feel they’re hanging on every word
Shy kids being teased=worry about talking to you
If patients this social anxiety
Usually starts 3-5th grade shy kids can get social phobia
39
Social phobia hand shake
Super wet hand scared about interaction
40
Generalized anxiety disorder
Excessive anxiety and worry (apprehensive expectation) occurring more days than not for at least 6 months, for most day, about a number of events or activities
Difficult to control the worry
```
The anxiety and worry are associated with at least 3 for 6 months
-restlessness or feeling on edge
Easily fatigued
Difficulty concentrating
Irritability
Muscle tension
Sleep disturbance
```
41
OCD
Recurrent and persistent thoughts, impulses, or images experienced as intrusive and inappropriate and causing marked anxiety or distress
Not simply excessive worries about real like issues
Person attempts to ignore or suppress these thoughts
Recognizes them as a produce of mind
Compulsions-repetitive behaviors or mental acts, aimed at preventing or reducing distress
Recognized obsessions or compulsions unreasonable
Obsessions and compulsions interfere with functioning
42
OCD vs ersonality disorder
OCPD-don’t know have problem
OCD-know their compulsion and obsessions re not reasonable most of the time
43
ptSd
```
Re experience traumatic event
Avoidance
Increased arousal
Nightmares
Flashbacks
```
Negative cognitions-persistent and disrobed sense of blame or self or others, estrangement from others, markedly diminished interest in activities, inability to remember key aspects
HAS OT BE FOR OVER A MONTH
44
Acute stress disorder
Less than 1 month
45
Treat PTSD
SSRI
CBT
Increased risk of substance abuse
-avoid addictive Rex such as benzodiazepines
46
Arachnophobia
Spiders
47
Iatrophobia
Fear of doctors
48
Acrophobia
Fear of heights
49
Treat anxiety w
Supportive therapy
Psychodynamic psychotherapy
CBT
SSRI***** serotonin anxiety NT, SNRI, TCA, MAOI, buspirone, benzodiazepines, antipsychotics
50
Eating disorders
Suicidal
| Bulimia and anorexia
51
Anorexia
Restriction of energy intake lower body weight don’t think anything is wrong with them
Distorted perception fo body weight and shape undue influence of weight and shape on self worth or denial of the medical seriousness of ones body weight
52
Types of anorexia N
Restricting type
Binge eating purging type
53
Restricting type
3 months of no binging or purging
Excessive exercise, fasting, dieting
54
Binge eating purging type
4 months of binging and purging behavior
| Self induced vomiting , misuse of laxatives, diuretics, enemas
55
Binge eating purging not bulemia
NOT OVERWEIGHT in anorexia N binge eating type
56
AN
Not delusional it is their reality
Deny conceal or express through somatic or old symptoms
Dress a way to hide weight loss
57
Complications AN
Cardiac-bradycardia hypotension QT dispersion, cardiac atrophy and mitral valve prolapse
Amenorrhea, decreased libido
Osteoporosis
Gastroparesis and constipation
Dehydration, hypokalemia, hypophosphatemia, hypomg
58
AN medical complications
Respiratory muscle atrophy
Anemia, leukopenia, thrombocytopenia,
Brain atrophy
Ceros is, lanugo, carotenoid Emma, acrocyanisis, seborrheic dermatitis,
Re feeding syndrome-DO NOT rehydrate or feed beyond capacity this is serious complication
59
Comorbidity AN
OCD anxiety disorders
Impulse control
Personality disorders
Obsessive-compulsive, avoidant, dependent, narcissistic, paranoid, borderline
Perfectionist, narcissistic
60
Treat AN
Interdisciplinary team , rehab psychotherapy, ALWAYS ASK ABOUT SUICIDALITY, what
61
Pharm AN
Antidepressants gain weight
Start low doses due to increased risk of side effects
Avoid bupronion** by increase seizure risk with binging and purging and TCA for cardio toxicity
Caution with antipsychotics and antidepressants with risk of QT prolongation
62
BN
Recurrent episodes of binge eating,eating a lot
Not underweight
Recurrent inappropriate compensatory behavior
Sel evaluation is unduly influenced by body shape and weight
Disturbance does not occur exclusively during an AN
63
Considerations BN
Depressed, conceal binge eating and purging, fearful of weight gain, don’t necessarily want to be thin bu don’t want to be fat
64
Medical complications BN
Dehydration, hypokalemia, hypochloremia, metabolism alkalosis
Mallory Weiss syndrome, calluses on back of hand, esophageal rupture, parotid and submandibular gland hypertrophy, abdominal pain and bloating and constipation
Tooth enamel erosions
Parotid big by salivating
65
Comorbidity BN
Anxiety, mood , substance disorder
Treat those
66
Treat BN
CBT, pharmacotherapy,
Monitor for medical complications
Nutritional rehab is used to help counsel patients about eating habits to help control
67
CBT BN
Other ways to cope with dysphoria
Helps!
Best when combined with pharmacotherapy y
Improve self esteem
68
BN pharmacotherapy
Less effective than CBT alone, but best if used in combination**
Avoid bupropion
SUICIDALITY always when start on antidepressant
69
Black box warning 18-24 antidepressants
Suicide
70
Pharmacotherapy BN
Fluoxetine SSRI* first line
71
Flyvoxamine
OCD and second line BN
72
Binge eating disorder
Episodes of binge eating in a 2 hour period and cant stop eating and feel lack of control
Rapid, not hungry, eat alone, disgust after binge eating
Episodes occur on average for once a week for at least 3 months!
No regular compensatory behavior
73
Treat BED
CBT, focuse on earth coping skill, deal with body image
Vyvanse(lisdexamfetamine dimesylate) is the first and only medication approved to treat moderate to severe binge eating disorder in adults also indicated for ADHD
74
Pharmacotherapy BED
Less effective than psychotherapy , but less expense and time
Psychotherapy best bet
75
Gender dysphoria
Gender in congruence
Strong desire to be another gender in kids
Adults-desire to rid of ones sexual characteristics I, desire to be other gender, desire to be treated as other gender
76
Treat gender dysphoria
Multidisciplinary approach
Access to high quality
77
Treat gender dysphoria
Not meds
Talk, therapy so become comfortable in skin
Transfer of patients from adolescent to adult services is important
78
Geriatric psychiatry
Now dsm5 shows mild cognitive impairment-go into room forget why in there
79
Dsm5 changes
Mild cognitive impairment along with major
80
modest cognitive decline
Just change and ppl notice but doesn’t interfere with capacity of life
See more but not debilitating
81
Special considerations when treating geriatric patients
Multiple comorbidities
Unusual presentation of illness
More degenerative. Diseases and cancer
Differentiate normal aging from disease
Under reporting
Purpose of treatment
Medication start low and go high
82
Lewy body dimentia
Progressive disorder-neurocognitive deficits, memory, learning new things but also parkinsons like symptoms shuffling rigid falling and severe memory problems and visual hallucinations
83
Risk factor Alzheimer’s
Female, family history, head trauma, downs
84
Dementia reversible causes
Drug induced, thyroid, metabolic disorders, hematoma, hydrocephalus
85
Symptoms dementia
Depression
```
Memory loss
Sadness
Social withdrawal
Disorientation
Personality changes
Inappropriate behavior
Psychotic symptoms
Agitation
```
86
Pseudodementia
Problems depression but there is something else going on, not a 6 moth progressive illness
Get depression under control and memory gets better!
Depression presents as memory loss
87
Most important dementia
H and P
For progression, comorbidity, neurological, mental exam, functional status, neuropsychological testing, labs-b12, folate, CBC, camp, hba1c, ct mri, pet
88
Neuropsych testing
If on fence and done mental status exam and family says cognitive decline
Impulsive, erratic, and memory isn’t too bad
Want to get a baseline of how bad memory is11 neuropsych testing on fence with anything of any psychiatric diagnosis
Closes thing to a blood test
BASE LINE neurocognitive funciton
89
B12
Numbness ataxic fatigue depressed
90
Pet scan
For diagnosing dementia but insurance rarely cover it
91
Treat dementia
Case treat
Rule out otherpsychiatric and Neuro conditions
Avoid anticholinergic medications which can impair cognitive function, especially in elderly (benadryl, hydroxyzine)******** horrible on cognition
These meds slow progression and no cure. -donepezil acetylcholinesterase inhibitor, memantine NMDA antagonist
92
Treat psychosis in dementia
Antipsychotics
But black bock in psychosis in elderly patients with dementia
Olanzapine, aripiprazole, risperidone, quetiapine
Increase risk of sudden death -just says isn’t his pop twice likely for sudden death
These patients advanced dementia and medically compromised anyways but this is on all drugs packages
Start lowest dose shortest period of time possible by will get Parkinson’s
93
Psychosis due to delirium
Third most common cause of psychosis in elderly outpatients
| And high risk mortality in delirium for 1 year
94
Delirium
Visual hallucinations and disoriented and happens over night or a few days
Dementia months
95
UTI and delirium
Septic
96
Constipation and delirium
Totally
97
Psychosis due to major depressive disorder with psychotic features
Psychosis in old
Somatic troubles, persecution, depressed
98
Treat psychotic depression
ECT
99
Treat psychosis due to Alzheimer’s type dement
Antipsychotics
100
Psychosis due to Alzheimer’s type dementia
Most common diagnosis accounting for psychosis in old
Believe spouse is cheating on them
Paranoid
Patients believe items stolen from them
Abandoned
Their spouse and children are disloyal to them
Usually delusions of paranoid nature
101
Substance abuse
Old prone to abuse prescription drugs and alcohol
Why do physicians miss substance abuse in old???
Unaware of the high prevalence rate
Unaware of increased impact certain substances have on the elderly
Uncomfortable-doctors Amy not be comfortable in screening elderly
Maintain a high index of suspicion When popping pills of drinking a lot and always ask about it
102
Risk factors for substance abuse in elderly
Female, single separated, absence of hobbies, health concerns, possible pharmacokinetic changes that take place in older individuals may lead to an increased potential for abuse of benzodiazepines or opiates
103
Long use of substances like benzodiazepines
Fall, cognition impairment, depression and other mood alterations, sleep alteration, balance and vestibular problems, delirium, increase risk for developing other medical conditions
104
Lorazepam old person
Delirium and confusion
105
Treat substance abuse in old
Treat withdrawal
Can’t go cold turkey with intense-alcohol, benzos and barbiturates can kill u if u do this
Alcohol->delirium tremendous and death
106
How go off alcohol barbiturates and benzodiazepines
Gradual taper is also an effective way to treat benzodiazepine dependence in older persons
107
Treat alcohol withdrawal
Benzodiazepines (diazempan)
Gabapentin and valorous acid
108
Treat substance abuse in older
Inform patients! This increases compliance!
More education less medication
Educate about what’s going on
CBT 12 step program
109
Is depression common in old ppl
Yup
110
Primary causes depression
Deteriorating health
Cognitive decline
Loss of independence
Loss of spouse and friends
111
Signs symptoms depression old
Anxiety, fatigue and hypersomnolence, somatic complaints, cognitive impairment, weight loss, insomnia , anhedonia, agitation, less evident symptoms in the affective mood domain
112
Major depression meds
Not one indicated
113
Are you a burden to your family
Red flag for suicide
114
Avoid diphenhydramine in old
Serotoninsyndrome
115
Dementia vs depression
Depression have insite are of memory loss goo thin
116
Treat depression
CBT SSRI-but worry hyponatremia and insomnia
117
Mirtazapine
Increases appetite
118
SSRI
Falls, GI, serotonin syndrome
119
Bupronion
Seizures
120
TCA
Caution cardiac
121
Venlafaxins and fluoxetine
Often used with comorbidity pain conditions
122
Nortriptyline
Amazing TCA use caution inc radial though
123
Mesolimbic
Positive symptoms
124
Mesocortical
Negative symptoms
125
Nigrostriatal pathway
EPS and TD
126
Tuberoinfundibular pathway
Hyperprolactinemia
127
Indications for antipsychotics
```
Psychosis
Suicidal behavior (clozapine)
```
MDD
Bipolar, Tourette’s,
128
First generation antipsychotics/typical
```
Chlorpromazine
Fluphenazine
Haloperidol
Thioridazine
Thiothixene
```
129
Second generations ntipsychotics/atypical
```
Aripiprazole
Clozapine
Olanzipine
Quetiapine
Risperidone
Ziprasidone
```
130
Main difference between agent groups
Reduction in movement disorder SE
131
First generation MOA
Block dopamine type 2 D2 post synaptic receptors
D2>5HT2
Also muscarinic receptors, histamines receptors, alpha Adrenergic receptors, which cause SE
132
Muscarinic effects
```
Dry mouth
Constipation
Urnary retention
Blurred vision
Sedation
```
133
Alpha Adrenergic effects
Orthostatic hypotension
| Dizziness/syncope
134
Histamine receptors
Sedation
135
Other effects typical antipsychotics
QT prolongationa nd seizure
136
Dopamine associated AE first gen
Hyperprolactinemia (tuberoinfundibular)
-amenorrhea/galctorrhea/gynecomastia/decreased libido
Extrapyramidal symptoms /tar dive dyskinesia (nigrostriatal)
Acute aka this is/dystopia/Parkinsonism like
Tar dive dyskinesia
137
Low potently first gen
More sedation, hypotension and seizure threshold reduction
Chlorpromazine
Thioridazine
138
High potency are
More movement and endocrine
Fluphenazine
Haloperidol
Thiothixene
139
Treat dopamine associated AE for extrapyrimidal symptoms
Anticholinergic agents-benztropine and trihexyphenidyl
Antihistamine-diphenhydramine (Benadryl)
140
Treat tar dive dyskinesia
Selective vesicular monoamine transporter 2 inhibitor
Valbenazine
Deutetrabenzaine
141
Second generation MOA
Block D2 and 5HT2a
142
Name 2nd gen
```
Aripiprazole
Clozapine
Olanzapine
Quetiapine
Risperidone
Ziprasidone
```
143
Do 2nd gen block more D2 or 5HT2a
5HT2a
144
MOA 2nd gen
5HT2a antagonism in PFC theorized to increase DA transmission in mesocortical path
May contribute to improved negative and cognitive symptoms
Reduced ep she
145
Side effects 2nd
Diabetes, weight gain, CVD, dyslipidemia
146
Rare at 2nd gen
QT prolongation ecg changes
Negative inotropic actions
-greater risk for women, old and on antiarrhythmics**
Stroke
-greater risk in elderly with dementia (increase all cause mortality with all antipsychotics)
147
Clozapine AE rare
Agranulocytosis
Monitor WBC, REMS program
148
Olanzapine AE
Drug induced hypersensitivity
149
Antipsychotics NMS
Rare fatal, severe Parkinson’s like
150
Treat NMS
Dantrolene
151
Dantrolene MOA
Block ryanodine receptor and get peripheral muscle relaxation
152
Antipsychotics moniting
Guidelines recommend determining in all patients a few things
-serum glucose, lipids, weight , blood pressure, waist circumference and personal/family history of metabolic and CV disease
153
What is critical for antipsychotic drugs
Adherence!
154
Non adherence antipsychotics how fix
Long acting injectable agents can manage
LAIA
Risperidone, olanzapine, aripiprazole, paliperidone
155
How long get effects antipsychotics
2-3 weeks
156
Max benefit (remission)
Several months
157
After dose escalation or switching agents, combination antipsychotic therapy may be necessary clinciallly
Acute agitation-injectable and ODT or SL versions
MDR -clozapine
Psychotic with antisuicidal thoughts
-clozapine
158
LO
Key features of psychosis and characteristic symptoms of schizophrenia
Epidemiology, etiologies, neurophysiology of psychotic disorders
Guidelines for management
Diagnostic criteria
159
Schizophrenia
Many disorders
Positive symptoms better prognosis
Negative symptoms poor prognosis
Very poor: negative symptoms, poor cognitive younger, poor support
160
Prodromal symtpoms
Before or few close friends, schizoid , minimal social activities
161
Schizophrenia etiology
In monozygotic only40-50%
Multiple genes, epigenetics, early life complications, labor delivery and neonatal life
1.5-2 fold increase for early life complication
Genes and env
162
So what drive schizophrenia
Integration between genomic risk and ELC driven by fetal genome and independent of gene-env interactions
Genes highly and differentials expressed in placenta drive the interaction between polygenic risk scores esp resp infections
Influenza virus during 1st trimester more likely to get this
163
Maternal URI
Yes schizophrenia
Mom get flu shot omg
164
Dopamine and schizophrenia
Mesolimbic areas and hypoactive dopamine transmission in prefrontal cortex
Dopamine also dysregulates brain regions including amygdala and prefrontal cortex which are important for emotional processing
165
PET scan schizophrenia where hyperactive
Mesolimbic-hippocampus
166
Positive symptoms
Delusions, hallucinations, disorganized thinking, grossly disorganized or abnormal motor behavior
167
Negative symptoms
Diminished emotional expression-poor response to treatment
Abolition-poor response to treatment
Alogia
Anhedonia
Asociality
168
Nihilism delusion
Belief things aren’t real
169
Most common schizophrenia hallucinations
Auditory
170
Hypnagogic and hypnopompic
Not psychosis, or schizophrenia
Narcolepsy, related to temporal lobe dysfunction, seizure activity
171
Types of disorganized thinking
Tangential
Derailment
Incoherent word salad
172
Catatonic behavior
Decreased reactivity to env
Put arm somewhere and stays there
173
Catatonic excitement
Purposeless and excessive motor activity without obvious cause
Walking around eating from dumpster lack of interaction
Presume schizophrenia
174
Negativism
Resistance to instructions
175
Inappropriate bizarre posture
Waxy
176
Mutism and stupor and repeated stereotyped movements
Year all of the schizophrenia out on the stress
177
Negative symptoms
Alogia-diminished speech
Anhedonia-decreased ability to have pleasure
Asociality-lack of interest in social interactions
178
Main neg symptoms
2 neg symptoms-dismissed emotional expression, abolition
179
Neg symptoms
Morbidity
180
Diagnose schizophrenia
2 or more for 1 month at least one the first 3
```
Delusions
Hallucinations
Disorganized speech
Grossly disorganized or catatonic behavior
Negative symptoms
```
Kid not achieving function and adult going down hill
But these signs and symptoms must go on for 6 months -must get 1 month of criterion a , 1 month needs prominent
181
What rule out for schizophrenia
Autism, neurodevelopment disorders and other things
182
Catatonic type of schizophrenia
At least 2:
Motoric immobility as evidenced by catalepsy or stupor
Excessive motor activity (apparently purposeless and not influenced by external stimuli)
Extreme negativism or mutism
Peculiarities of voluntary movement such as posturing, stereotyped movements, prominent mannerisms or prominent grimacing, exholalia or achopraxia
183
Echolalia
Repeat stuff that u say
184
Schizophrenia and suicide
5-6% commit suicide
Single leading cause of death in them
Greatly increased with substance use, comorbidity major depression and previous high functioning
Usually near illness onset
185
Work up schizophrenia
Labs, drug screen, imaging, ct/mri, neurological, eeg
186
Delirium
Acute medical illness affects the brain, with psychotic symptoms
Consider with schizophrenia onset
187
Mood disorders may mistake schizophrenia
Manic, major depressive, psychotic, schizoaffective
188
Treat acute psychosis
Hospital if needed for patient safety and stabilization may need court order
IM injections for haloperidol, fluphenazine, lorazepam
189
Treat stabilization phase
Consider converting to newer atypical antipsychotics
190
Treat aintenance phase
Keep patients free from symtpoms while avoiding incapacitation side effects
191
Treat poor responders
Relapses in patients whose schizophrenia was once under control but no longer respond
192
Second generation antipsychotics for schizophrenia
Clozapine-agranulocytosis mainly bipolar
Risperidone-increased prolactin
Olanzapine-weight gain, diabetes
Quetiapine-weight gain, excessive sedation, less risk tardive
Ziprasidone-QT prolongation
193
Behavioral therapy for schizophrenic and psychotic
Behavior management
-how get stuff that goes int he freezer into the freezer
Insite oriented is detrimental!!!! Not psychotherapy more agitated and disturbed
ECT-if better lack of diagnostic clartiy
194
Delusional disorder
Delusions 1 motnh or longer
Not get criteria for schizophrenia
Functioning ok and not weird
Not from other things like substances
195
Brief psychotic disorder
At least 1 day but less than 1 month duration of episodes
At least one of
Delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior
All day for 1 day at least
196
If longer than 1 month
Not brief psychotic disorder
197
Schizophreniform disorder
Two of these for sig time in 1 month at least 1 must be
```
Delusion
Hallucination
Disorganized speech
Grossly disorganized or catatonic behavior
Negative symptoms
```
At least 1 month but less than 6 months
198
Schizoaffective
Uninterrupted period of illness which major mood episode with criterion A of schizophrenia
Major mood episode-can be depression or mania concurrent it’s it
Delusions or hallucinations for 2 or more weeks in absence of a major mood episode
199
Major depressive
Severe what psychosis high risk suicide hospitalize them
When depression better psychosis is gone
200
Substance/medication induced psychotic disorder
Delusions and hallucinations (one or both)
Criterion a develop during or soon after substance intoxication or withdrawal or after exposure to a med
Involved substance/med is capable of producing the symtpoms in criterion a
ABOUT 1 month or more suspect another disorder has been triggered by the drug and is now diagnosable not better explained by other things
201
Catatonic disorder
Ok
202
Persistent auditory hallucinations, delusions with significant overlapping mood episodes, attenuated psychosis syndrome, delusional symptoms in partner of individual with delusional disorder
Other specified schizophrenia spectrum
203
Persistent auditory hallucinations
In absence of other features
204
Delusions with significant overlapping mood episodes
Mood and delusion
205
Attenuated psychosis syndrome
Psychotic like symptoms below threshold
206
Delusional symptoms in partner of individual with delusional disorder
Yup
207
What ear there
Other specified schizophrenia spectrum
208
Schizoid
Very introverted and voluntarily withdraws from social interactions
209
Schizotypal
Schizoid symptoms and magical thinking and odd behavior
210
Schizophrenia
Schizotypal and psychosis
211
Schizoaffective
Schizophrenia and mood disorder
212
Schizophrenia and violence
Not more likely to kill ppl
If antisocial, borderline, paranoid, content of auditory hallucinations, substance abuse, impulsive, talking about violence, history of violence can be very dangerous
213
Personality disorders
Inflexible and maladaptive
And everyone else in the family doesn’t act like this
Misperception world around them and react bad
214
Diagnose personality disorder
Over 18
Stable
Enduring pattern not better accounted for as manifestation
Enduring pattern is not due to the direct physiological effects of substance or medical condition
215
Who don’t diagnose with personality disorder
Young
216
A
Paranoid personality disorderL irrational suspicions and mistrust of others
Ppl exploiting or deceiving them
Distrust can get erratic and aggressive and agitated with ppl around them
217
Cluster a schizoid
Lack of interest in in social
Don’t do much for fun
Few friends
218
Schizotypal A
Odd behavior or thinking
Vague circumstantial speech
Social anxiety
Magical thinking
Don’t like being around ppl=like being along
219
B
Bad dramatic, errratic
Antisocial personality disorder-
Borderline
Histrionic
Narcissistic
220
Antisocial
Pervasive disregard for law and rights of others
No responsibly
Blame other ppl for their problems
No remorse
Men
Risk for anxiety disorders, substance abuse, somatization disorder, pathological gambling
221
Borderline
Black white thinking, instability in relationships, self image identity and behavior
```
Frantic efforts to avoid expected abandonment
Unstable and intense interpersonal relationships
Unstable self image
Impulsive
Recurrent SUICIDALITY
Cutting
Sex substance abuse
Self mutliating
```
Feel empty hate themselves and hate everyone else
Transient paranoia or dissociation
WOMEN
Male borderline-lethal
Super manipulative-immature personality traits. Teddy bear and tweety bird sign
Need to set rigid boundaries with these patients
Constant reminders of patient guidelines and responsibilities
Will often split staff members.providers against each other
Victims of sex abuse or emotional abuse
Have high rate of comorbidity major depression
222
Histrionic
Pervasive attention seeking behavior including inappropriate sexual seductiveness and shallow or exaggerated emotions
NEED ATTENTION
Quite dramatic and sexual
Emotionally labeled
Vague and impressionistic speech highlighted
La belle indifference-indifferent detachment, while describing dramatic physical symtpoms
Somatotropin too
223
Narcissistic
Pervasive pattern of grandiosity, need for admiration and lack of empathy
```
Exaggeration of talents and accomplishments
Sense entitlement
Exploitation o fathers
Surgeon
Enzy of others
Arrogant, haughty attitude
```
Anorexia nervous, substance abuse, depression
224
Cluster c
Anxious or fearful
Avoidant personality disorder
Dependent
Obsessive compulsive
225
Avoidant personality disorder
Social inhibition, feelings of inadequacy, extreme sensitivity to negative evaluation and avoidance
Not schizoid by desire relationships
Shy but not odd
Paralyzed by their fear nd sensitivity into social isolation
226
Avoidant personality disorder
Can’t make decisions without guidance and reassurance
Seeking another relationship
Can’t initiate activities
227
OCD
Preoccupied with perfectionism and control
Lack flexibility or openness
Preoccupations interfere with their efficiency despite their focus on tasks
Scrupulous and inflexible
Things have to be done my way
228
Dissociative identity disorder
Two or more identities
Women and sexual abuse
229
Treat psychodynamic psychotherapy
Examines way patient perceive events
Assumption that perceptions are shaped by early life
Identify perceptual distortions and their historical sources
Facilitate the development of more adaptive modes of perception and response
Frequency from several times a week to once a month; it makes use of transference
230
Treat CBT
Deals with how ppl think about their world and their perception of it
Limited to episodes of 6-20 weeks, once weekly
231
Group psychotherapy
Interpersonal psychopathology to display itself among peer patients
Usually once weekly over a course that Amy range from several months
232
Dialectical behavior therapy-FOR BORdERLINE
Skills based therapy developed
Borderline
Stable sense of self
Reduce impulsive erratic self destrucive behavior
Manual based therapy is on the development of coping skills to improve affective stability and impulse control and on reducing self harmful behavior
233
Borderline
I hate u don’t leave me
Sometimes I act crazy
234
Meds
Not curative
235
Why no MAOI
Don’t want overdose
236
SSTU
Safe fir them
237
Meds borderline
Less effective than in patients with uncomplicated major depression
238
Valproic acid
Bipolar
239
If try multiple meds and they don’t change
Personality disorder
They are poly pharmacy
Ask about suicide
Don’t get them no too much
240
Complications personality disorder
Suicide
Substance
Injury
Depression
Hoomicide-paranoid esp
241
Prognosis
A b better with age
C older worse
242
Worst prognosis
B
| Susceptible to problems of substance abuse impulse control and suicidal behavior ,which may shorten their lives
243
Psychosomatic medicine
Ok
244
Psychosomatic assumptions
Unit of mind and body
Psychological factors
Influenced complementary and alternative medicine as well as behavioral medicine
Holistic approach to medicine
245
Stress theory
Circumstance that disturbs or is likely to disturb the normal physiological or psychological functioning of a person.
Stimulation of autonomic nervous system particularly the sympathetic nervous system
Tachycardia up CO
246
SLE
Psychiatric symptoms
Supportive psychotherapy can help patients acquire knowledge and maturity to cope and promote positive interactions
Psychosis
247
MS
Anxiety, euphoria, Mania
248
Seizure disorder
Complex partial seizures cause sensory distortions, violence, belligerence
Confusion, psychosis, dissociative symptoms, catatonic like, bizarre nahavior
249
CV
Type A, hostility anger, mental stress
Also depression, sudden cardiac death, HTN,
250
Asthma
SOB anxiety disorder/panic disorder
251
Thyroidhyper
Heat intolerance, excessive sweating, diarrhea, weight loss, tachycardia, palpitations, vomiting, fine tremor, hyperactivity, short attention span, impaired recent memory
Nervousness, excitability, irritability, irritability, pressured speech, insomnia, psychosis, visual hallucinations
252
Hypo
Cole intolerance, dry skin, constipation, weight gain
Lethargy, depressed personality change, paranoia
253
Diabetes
Depression!!!!!
Frustration, loneliness, dejection
Get thyroid panel
254
Hyponatremia
Thirst, stupor, coma, seizures
Confusion, lethargy, personality changes
Geriatric!
255
Thiamine defines
Poor concentration, confusion, confabulation.
Alcoholics
256
Coral in b21
Pallor dizziness, peripheral neuropathy, dorsal column signs, ataxia
Irritability inattentativeness, psychosis, dementia
257
PUD
Psychological stress
258
UC
Dependent personality
259
Crohn
Per existing panic disorder
260
TCA
Anticholinergic effects
261
SSRI
GI
262
Pancreatic carcinoma
Weight loss, abdominal pain, depression, lethargy, anhedonia, apathy, decreased energy
263
Acute intermittent porphyria
An pain, fever, nausea, or minting, constipation
Acute depression, agitation, paranoia, Vidal hallucinations
264
Hepatic encephalopathy
Asterisks, hyperreflexia, spider angioma, palmar erythema, ecchymosis, liver enlargement
Euphoria, disinhibition psychosis, depression
265
Atopic dermatitis, psoriasis
Depression
266
Frontal lobe tumor
Mood changes, irritability, facetiousness, impaired judgement, impaired memory, delirium, loss of speech, losss of smell
267
Occipital lobe tumor
Aural, visual hallucinations
Smell something burning
Olfactory
268
TBI
Head trauma
Confusion, personality changes, memory impairment
269
Treat
Self observation, cognitive restructuring, relaxation, mindfulness
270
The study, practice, and teaching of the relation between medical and psychiatric disorders
So sultan ion liaison psychiatry
271
Delirium
Hospital acquired confusion
Psychosis
This is temporary and reversible
272
Delerium vs emdntia
Reversible and acute onset
Don’t know what hey are or where they are
273
Who don’t get benzodiazepines
Old ppl
274
How prevent delirium
Keep noise down at night
Avoid benzodiazepines
Cognitive stimulation
275
PCP
Elevated BP, tachycardia, nystagmus, muscular rigidity, vomiting
Agitation with blank state, anxiety, stupor aggression, panic, bizarre bahevior
276
LSD
Sympathetic excess
Sensory distortion
277
Corticosteroids
Mania, psychosis (hallucinations0
If COPD get IV steroids get delirious psychotic and manic
278
Benzodiazepines
Sedation, paradoxical agitation
Avoid in elderly with delirium
279
Anti Parkinson’s
Psychotic symptoms, mania, anxiety
CBT cause dopamine release
280
Antidepressants
Mania anxiety, insomnia
281
COPD gets treatment what cause symptoms
IV steroids
282
Diabetes nausea and vomiting and depression how treat
Sertraline
| -
283
Lithium
Bipolar
284
Lorazepam
Anxiety
285
Olanzapine
Schizophrenia and bipolar
286
Bupropion
Nicotine withdrawal
287
Imipramine
Enuresis
288
Duloxetine
Diabetic peripheral neuropathy, fibromyalgia, and chronic musculoskeletal pain
289
Duloxetine
Stress incontinenee
290
General antidepressants MOA
Block serotonin and be re uptake by sert, net, or both
291
Ssri
Citalopram, escitalopram, fluoxetine, paroxetine, sertraline, fluvoxamine
292
Snri
Duloxetine, milnacipran, venlafaxine
293
Tca
Amitriptyline, clomipramine, imipramine
294
5ht modulators
Nefazodone, trazodone, vortioxetine
295
Atypical
Amoxapine, bupropion, mirtazapine, vilazodone, maprotiline
296
Maoi
Phenalzine, selegiline
297
SSRI for ocd/sad
Fluvoxamine
298
Snri (and TCA)
Selectively inhibit the presynaptoc reputable of serotonin via sert and ne via net
299
Tertiary amine tca
Inhibit ne/serotonin equally
300
2 amines TCA
Inhibit NE>serotonin
301
3 tca
Amitryptline, clomipramine, doxepin, imipramine
302
Secondary amines
Amoxapine, desipramine, nortriptyline
303
Snri
All tca
| Desvenlafaxine, duloxetine, venlafaine, levomilnacipran
304
Snri and da
Amoxapine
305
TCA always block other receptors
Ok
306
TCA-based SNRA impact 3 key non efficacy related receptors
Histamine, muscarinic, a1
307
Amitriptyline indication
Relied of symptoms of depression
308
Contraindications amitriptyline
Hypersensitivity, MOAI (hypertensive crisis, convulsion and death)
309
Black box warning amitriptyline
Suicide,
310
Interactions amitriptyline
P450 2d6 drug metabolizes
311
Tri cyclic agents toxic
Coma, cardio toxicity, convulsions
312
Cardiovascular tca ae
Tachycardia, orthostatic hypotension, dysrhythmias
313
Anticholinergic
Dry. Mouth, urinary retention/constipation
| Blurred vision
314
CNS TCA system ae
Sedation/fatigue. Dizziness/seizures
315
Amitryptiline
Seizures, sedation, cardiac
316
Clomipramine
Seizures*, sedation , cardiac
317
Doxepin
Seizures, sedation, cardiac
318
Imipramine
Seizures, sedation, cardiac
319
Trimipramine
Seizures, sedation, cardiac effects
320
Amoxapine indications
Depression with neurotic or reactive depressive disorders and endogenous and psychotic depression.
Depression with anxiety and agitation
321
Onset amoxapine
Rapid. Four to seven days get effect
322
Contraindications
Hypersensitivity, MOAI, hyperpyretic crises, convulsions, deaths if MOAI and TCA together
323
Warning amoxapine
Suicide risk in MDD, worse depression suicide
324
Use amoxapine with caution
Urinary retention, angle closure glaucoma, increased intraocular pressure. CVD TCA can cause sinus tachycardia, Arrhythmias
325
Amoxapine, despiramine, maprotiline, nortriptyline, protriptyline
No GI, sex, cardiac
326
Indications SSRI-escitalopram
MDD
327
Warning BBW escitalopram
Suicide with MDD< worse depression,
328
Discontinuation SSRI
Taper
329
MAOI and SSRI
Fatal reactions can occur with hyperthermia, rigidity, myoclonus, autonomic instability, fluctuations of vital signs and mental status
330
SSRI MOA
SERT inhibit reputable of serotonin
331
SSRI
```
Citalopram
Escitalopram
Fluoxetine
Paroxetine
Sertraline
Vilazodonevortioxetine
```
332
SSRI and other receptors
Less impact on histamine, muscarinic and Adrenergic receptors, fewer side effects than TCA
333
Ae SSRI
CNS, sexual dysfunction, weight gain, acute withdrawal reactions, flu like symptom
334
Rare AE ssri
QT prolongation, hyponatremia, serotonin syndrome, sweating, hyperreflexia, aka this is/myoclonus, shivering
SUICIDALITY-kids young adults
335
Opioid and antidepressants
CNS reactions alled serotonin syndrome
336
Drug drug SSSRI
Cyp450
Most is fluoxetine (strong inhibitor)
Least is citalopram and sertraline (mild inhibitors)
337
Citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, venlafaxine
GI, sexual
338
Ae atomoxetine
None
339
Mirtazapine, nefazodone, trazodone
Sedation
340
Phenelzine MAOI
None
341
Tranylcypromine
None
342
Selegiline MAOI
None
343
5 Rs’ of antidepressant efficiency
Response >50% reduction ins ymptoms from baseline -partial response>25% reduction but <50% reduction in symptoms from baseline
Remission-symptoms free
Recovery-2-6 months of ongoing remission but before recovery
Recurrence-return of symtpoms after recovery
344
General antidepressant efficacy
Work after 3-8 weeks
Goal is remission/recovery
Minority reach remission with a single agent
345
What do if don’t respond to one after 8 weeks
Switch to a different MOA
If partial response aff another agent
346
Mono therapy
For unipolar, not depressive phase of bipolar
347
How get off antidepressants
Slow titration downward is recommended
348
Mood stabilizers
Lithium
Carbamazepine, lamotrigine, divalproate/valproic acid
349
Mood stabilizers
All except lithium were originally approved as anti seizure medications
350
Lithium MOA
Inhibits calcium dependent and depolarization provoked release of NE and DA
Inhibits receptor blockers and substances known to stimulate and inhibit G protein synthesis/actions
Interfere with inhibitory G protein and stimulators to keep inactive
351
A lithium
Nephrogenic diabetes insipidus
Polyuria polydypsia
352
Lithium and diuretics
Preferential na loss and li reabsorption
ESP thiazides
353
Acei and lithium
Linisopril
354
NSAIDs and lithium
Alter renal perfusion
355
Narrow therapeutic agent
.6-1
356
Lithium indications
Acute maintenance treatment of mania/bipolar I disorder
Augmentation in unipolar depressive patients with inadequate response to antidepressant therapy
357
Off label lithium
Reduced risk suicide and all cause mortality in patients with mood disorders
358
3 anti seizure mood stabilizers
Carbamazepine
Valproic acid/divalproex
Lamotrigine
359
Uses indications mood stabilizers anti seizure
Divalproex for acute bipolar I without psychotic features 50-125 mcg/ml
Carbamazepine for acute maintenance treatment of acute mania an dmxed episodes (bipolar I)
Lamotrigine for maintenance of bipolar I and II
360
Carbamazepine is what
Major cyp450 inducer
361
HYPOPHOSPHATEMIA in alcoholic patient from decreased absorption
Due to poor dietary intake of both phosphate and vitamin D
Due to binding of dietary phosphate by antacids given to treat recurring gastritis (calcium carbonate)
Reduced net intestinal phosphate absorption, which may be induced by chronic diarrhea
362
Increased urinary phosphate in alcoholic with hypophosphatemia
Hypereparathyroidism induced by vitamin D defiency
363
Alcohol and hypophosphatemia
Get vitamin D levels
Can cause proximal tubule dysfunction so don’t get reabsorption
364
Look for hypophosphatemia when who comes in
Alcoholic eating disorder or get severe damage
365
Dextrose containing solution in alchohol
Stimulate insulin promote phosphate uptake into cells
Get acute respiratory alkalosis from alcohol withdrawal which stimulated I traced intracellularl phosphofructokinase andicnreases glycolysis and movement of phosphate into cells
366
What is low phosphate
1mg/dL
367
What do when alcoholic patient admitted to hospital
PHOSPHATE monitoring
368
Treat hypophosphatemia
Not necessarily symptomatic I f less than 2mg/dL
369
What happens if hypophosphatemia alcoholic
Myopathy due to both phosphate depletion and alcohol toxicity, and are at risk for clinically significant rehab do Yoshi’s
370
Acute alcoholic myopathy
CK
Alcohol can cause muscle damage
Starvation decreases alcohol metabolism and results in increased blood alcohol levels
371
Thiamine defiency related encephalopathy
Thiamine defiency
We Ricky is acute syndrome require int emergent treatment o prevent death and neurological morbidity
Korsakoff-chronic neurological condition that usually occurs as a consequence of WE
372
Thiamine
Cofactors for enzymes in energy metabolism
Transketolase
Alpha ketoglutarate DH
Pyruvate DH
Thiamine requirements depend on metabolic rate with the greatest need during periods of high metabolic demand and high glucose intake
This manifest by the precipitation of wet icky encephalopathy
373
Add glucose
Stimulate pathway and whole body use thiamine and use up faster than and cells dependent on glycolysis are going to be deprived
374
Triad of wear ice
Encephalopathy, oculomotor dysfunction-nystagmus, gait ataxia
375
Commonly affected areas of thiamine defiency
Third ventricle, aqueduct, fourth ventricle, mammillary Brodie, cerebellum
Global
376
Enlarged ventricles
Korsakoff
377
Less frequently effected areas wernicke k
Hippocampus-medial temporal lobe
378
Lab wernicke
No lab study
Thiamine blood level not accurate by don’t know how much reservoir-liver and can release cant measure reservoir
379
Treat WE
Immediate parent earl thiamine
Glucose without thiamine worse
Thiamine before glucose
380
Prevent WE
Don’t give glucose loading with unsuspected thiamine defiency
Give thiamine before
381
Take home medical emergency
Thiamine initiated immediately
382
We
Anterograde and retrograde
Medial temporal lobes
Alcohol abusers
KS may result from a. Series of sub clinical or unrecognized episodes of WE
383
Extrapyrminla syndrome from anti[sychotic drugs
Acute dystopia reactions
Drug induced parksonism
Akasithisa
Antipsychotic induced catatonic
Tardive dyskinesia
384
Tardive dyskinesia
Fasciculations of the tongue , lingual facial hyperkinesis, choreathetotic movements of the extremities and trunk
385
Acute systolic reactions
Sudden tonic contractions fo muscles of tongue, neck, back, mouth, eyes
386
Dru induced Parkinsonism
Cogwheel rigidity, bradykinesia, tremor, loss of postural reflexes, mask like fancies
387
Akasthisia
Motor restless, may involve the entire body
388
Antipsychotic induced catatonic
Withdrawal mutism motor abnormalities
389
Tardive dyskinesia
Fasciculations fo the tongue, lingual facial hyperkinesis, choreathetotic movements of the extremities and trunk
390
Neuroleptic malignant syndrome
Muscular rigidity, fever, autonomic instability, altered level of consciousness
391
Tardive dyskinesia
Medication induced hyperkinetic movement disorder goes for a month after discontinuation
Involuntary movements of patients face, mouth, trunk common
Chores, at hero’s is, stereotyped behavior, dystopia, akathisia, tics, respiratory dyskinesia, tremor
392
AIMS
Abnormal involuntary movement scale for tardive dyskinesia
393
When else see tardive dyskinesia
Withdrawal emergent
-children <1 month following discontinuation antipsychotic drug
Withdrawal dyskinesia TD
-dyskinesia in adults that occurs immediately after discontinuing or reducing the dose of a dopamine receptor blocking agent
Masked TD
-tardive movements that resolve when a dopamine receptor blocking agent is resumed or its dose is increased
394
All dopamine receptor blocking agents
Can cause TD
395
Anything block dopamine can cause TD
Antidepression No cause it
First second gen antipsychotics, metoclopramide, prochlorperazine, chlorpromazine
396
Do antidepressants cause TD
No
397
Who get TD
Ppl who get EPS early on
398
Dopamine hypothesis
TD
399
5 ht2a hypothesis
Polymorphism in 5HT2a receptor gene have been linked to susceptibility to TD
400
Clozapine
Serotonin antagonist with strong binding to 5HT2a/2c receptor
Lower incidence TD
Favorable effect on TD
401
GABA hypothesis
Chronic treatment with antipsychotic drugs get persistent dyskinesia and gaba metab
402
Treat TD
Stop drug
Switch 1st to 2nd generation
Use benzodiazepines, Botox, valbenazine, or tertrabenazine
403
Ginkgo balboa extract
Treat TD egb-761
404
Anticholinergic drugs for TD
Benztropine
Ineffective or may exacerbate
Sometimes helpful for ameliorating Tardive dystonia but tardive dyskinesia worse
So know diffference between dystonia and dyskinesia
