Exam 3 treatments and prognosis Flashcards
Schizophrenia Tx for Either pos/neg
and labs prior
Positive Symptoms - generally respond well to antipsychotics
Negative Symptoms - Atypical (2nd gen.) seem to work better than typical (1st gen.)
* Cariprazine (Vraylar) in particular seems to have supporting evidence
Pre-Treatment Screening - prior to starting antipsychotic drugs
- BMI, waist circumference, HR, BP, EKG
- Screen for signs of movement disorder (AIMs score)
- Labs - CBC, fasting CMP, lipids, and TFT (thyroid)
rx can be IM injection, soln, ER tab if needed
AIM for metabolic syndrome, thyroid, heart, and blood cells
How long to trial schizophrenia drugs, and prognosis
Minimum of 6 weeks trial per drug (as long as no adverse SE)
Recommended not to try high-dose therapy until 6-week trial done
about 70% with delusions or hallucinations will have a good response
30% will still have moderate to severe positive symptoms
What is Neuroleptic Malignant Syndrome?
slow onset (often 1-3 days)
Rigidity, fever, autonomic instability, altered mental status
Can lead to fatal hypertensive crisis, metabolic acidosis
Can happen with any antipsychotic
Tx - cooling measures, supportive tx, dopaminergic meds
Define tardive Dyskinesia
Tardive Dyskinesia - involuntary movements usually involving the orofacial region that disappear during sleep
(pyramid)
define Akathisia
inner restlessness leading to pacing or fidgeting
How often to check CBC for clozapine
CBC weekly x 6 mo, biweekly x 6 mo, then q 1 mo
Prognosis of Schizophrenia
Highly variable course
10% of patients eventually recover
20% of patients do not recover fully but have a good outcome
30-35% have a stable but intermediate outcome
30-40% have a deteriorating course
Significant proportion continue to have psychotic s/s
Schizophreniform Disorder
1-5 month schizophrenia
Atypical antipsychotic
Most go on to be diagnosed with schizophrenia
Secondary Psychotic Disorder
from another disorder thats not schziophrenia
1st tx by correct underlying cause.
may use antipsychotics. if agitated +/- sedatives. ppsychotherapy as well.
Schizoaffective Disorder
must have zero mood episodes for two weeks and those two weeks must have delusions or hallucinations present in order to prove that bipolar moods aren’t causing the symptoms partly.
tx - antipsychotics 1st
+/- Antidepressants, mood stabilizers
Delusional Disorder
Atypical antipsychotics (2nd gen)
2/3 recover and 20% resistant to tx
Somatic Symptom disorder
“multiple unexplained physical symptoms”
Tx- coordinate care with one PCP
Schedule frequent, routine follow-ups
Avoid new or excess diagnostic studies
Order only as objectively needed
No specific pharmaceutical management
Tx for comorbid psych disorders as appropriate
Commonly panic disorder, MDD
Psychotherapy - can reduce health expenditures by up to 50%
Functional Neurological Symptom Disorder
voluntary or motor sensory function altered.
blind or pseudoseizure
tx- Symptoms often resolve spontaneously. Education about disorder is often helpful. Refer for psychotherapy (insight oriented or behavioral)
schedule frequent follow ups
Illness Anxiety Disorder
hypochondriacs
no physical sx
Patients often decline psychiatric referral
Frequent, regular visits to reassure pts they are not being abandoned and are being taken seriously
Compassionate, tactful education on illness
Ordering diagnostic studies only when indicated by objective evidence
Therapy can be helpful, if pts are willing to go
Body Dysmorphia
- SSRIs - off-label treatment but considered first-line pharmacotherapy – to treat the anxiety OCD depressive disorder that could be causing it
- Psychotherapy - CBT, cognitive restructuring with exposure therapy
Somatic Symptom Disorder with predominant pain
massive pain response but a psychological cause even if the physical conditions are there
- alleviation of underlying psych symptoms and aggravating environmental factors
- May have to deal with opiate addiction or dependence. put on NSAIDS instead
- NSAIDs - first-line if analgesics are indicated
- Avoid opiates; if prescribed - fixed-dose rather than PRN
- Psych meds - SNRIs; TCAs also useful
Facticious Disorder
faking symptoms but NO REWARD
Single provider to coordinate care
Compassionate discussion of diagnosis
Psychotherapy - if pts agree to go
By proxy - inflicting illness on others is a criminal act and must be reported
Social work/protective agencies involved
General guidelines for:
Somatic sym disorder,
functional neurologic dis,
illness anxiety disorder
regular scheduled visits. legitamize symptoms. reassure all diseases have been r/o.
Consider psychotherapy referral.
goal of treatment is functional improvement.
SSRI, SNRI, TCA
Malingering
- difficult due to patient denial of malingering
Caution to avoid being manipulated by patient to achieve their secondary goal
Must still treat any underlying medical conditions
Restrictive Avoidant Food intake disorder
Nutritional counseling
CBT, family-based therapy
Exposure-based
Referral to speech and language pathologist
Anorexia Tx and labs
Work-up for all suspected anorexic pts
* ECG for cardiac dysrhythmias
* UA for specific gravity
* Serum labs:
* CMP - lytes, kidney and liver function, protein, glucose
* phosphorus
* magnesium
* INR
* CBC with diff
Psych meds are NOT first line
Nutritional rehabilitation, psychotherapy, medical management
To help gain weight if above doesn’t work:
2nd gen antipsychotic (olanzapine), anxiolytic (lorazepam)
SSRI may help if comorbid anxiety/depression
When to admit anorexic patient
Unstable vitals or Hypothermia (<35 C or 95 F)
End-organ complications - seizures, failure (heart, kidneys, liver, etc.)
Cardiac complications
* HR <30 bpm or <40 bpm w/hypotension or dizziness
* Cardiac dysrhythmia (other than bradycardia)
Psych complications
* Suicidal ideation with high lethality plan or suicide attempt
* Acute food refusal, very poor compliance or other acute psych emergency
Nutrition complications
* Weight <70% ideal body weight
* Marked dehydration
* Refeeding syndrome¹
