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
Prognosis for Anorexia
50% - good outcomes
25% - intermediate outcomes
25% - poor outcomes
Later age at onset, longer duration, lower minimal weight, lower body fat after weight restoration, psych comorbidities
35-55% eventually relapse
All-cause mortality - 6x higher risk of death
Medical complications - 50% of deaths
Suicide - 25% of deaths
Bulemia and labs
body weight is normal usually. problem is dehydration, low K, low Cl, and metabolic alkalosis
labs - UA and serum labs - BUN/Cr, electrolytes, LFTs, CBC with diff
tx- CBT clear advantage, and antidepressants super helpful
fluoxetine (1st line) or other SSRI
May try a TCA if no improvement on SSRIs
Buprop CI
a pool thats low in water (and Cl), with a blue banana, and baking soda
When to admit for bulemia
Unstable medical condition
Suicidal ideation or other severe psychiatric decompensation
Refusal of treatment with potential to become unstable
Bulemia prognosis
Short reduction at first (in 70%)
THEN 60% recover in long run while the rest relapse
2x mortality
1/4 to 2/4 attempt suicide
Binge Eating
Psychotherapy - first line treatment (especially CBT)
Behavioral weight loss therapy
May try using pharmacotherapy
SSRIs (first line)
* Antiepileptic (topiramate, zonisamide)
Lisdexamfetamine (Vyvanse)
Antiobesity drugs not recommended due to SE, limited efficacy in BED patients
Paranoid Personality Disorder
can try low-dose antipsychotics
If acute decompensation and frank delusions - use antipsychotics
Therapy - difficult for patients due to mistrust and suspicion
Can become overtly psychotic in short bursts of stress
Schizoid Personality Disorder
No meds unless anxiety/depression then can use antidepressants
- patients often do not feel distressed
Family/Group - can help clarify other’s expectations for pt and allow for social skill development; however pt will usually have minimal interaction
Individual - pt often does not feel necessary due to no distress; emotional detachment can limit efficacy; however may have some usefulness
Prognosis of Schizoids
Pts often have social detachment fairly early in life
Less likely to have anxiety/depression than most personality disorders
Avoiding situations that tax their social skills can help
Schizotypal Personality Disorder
- low-dose antipsychotics
-Mood stabilizers such as lithium may also be useful
Group Therapy - can help with social skill development
Pt may become disruptive or make others uncomfortable
Better Ther- Individual - supportive approach; emphasis on reality testing and recognizing cognitive distortions
Antisocial
little evidence for pharmacologic treatment
May use medication for adjunctive treatment of symptoms
Therapy - socially based interventions with others of similar temperaments and problems are tx of choice
Group - can help the patients feel a sense of
belonging
Individual - generally ineffective; CBT may be helpful
Schizotypal Prognosis
Anywhere from 10-25% progress to schizophrenia
Poor prognosis associated with paranoid ideation, social isolation, magical thinking, functional decline
BPD
Pharmacologic -
* Lithium - less anger, irritability, self-mutilation
* Carbamazepine - better behavior control, less anger and impulsivity
* Antipsychotics - less paranoia, aggression, impulses, depression
* SSRIs - less labile mood, aggression, maladaptive behavior
Group/Family Therapy - can help interpersonal problems, avoid attachment to one specific person (i.e. therapist)
Individual Therapy- Difficult; emphasis on stress tolerance, coping skills, self-management can help
Carb = control
Lithium= dagger away from me
all drugs help w/ anger.
serotonin SSRI stablilze
Antipsychotics less Paranoid
BPD Prognosis
Prognosis
Self-destructive behavior can be lethal if it progresses
Patients sometimes will “sabotage” treatment that is going well
Impulsive/dangerous behaviors usually decline in middle age
Poor prognosis → antisocial behaviors, chronic anger, over-involvement in family relations, overuse of medical facilities
Good prognosis → higher intelligence, better self-discipline, superior social supports
Histrionic Personality Disorder
Pharmacologic - little evidence; MAOIs may be helpful
Treatment for comorbid anxiety/depression (e.g., SSRIs) often useful
Group - therapy with like-minded individuals can provide a mirror for the patient’s own behavior
Couple/Marital - difficult; often don’t like to give up control in relationship
Individual - can be difficult due to patient’s labile nature and dependency
needs a beach bod and a mirror
Prognosis for Histrionic Personality Disorder
Fairly good; patients tend to improve over time regardless of treatment
Can become depressed if they feel abandoned, but often short-lived
Poorer prognosis if they meet criteria for other cluster B disorders
NPD
Pharmacologic - little data to support use of medication
Can use medication for comorbid disorders - depression, anxiety, etc.
Group - therapy with like-minded individuals can provide a mirror for the patient’s own behavior; can become difficult if pt is criticized by others
Couple/Marital - often willing to attend; therapist must take care not to solely place blame on narcissistic patient
Individual - difficult; often have high expectations of therapist and respond poorly to criticism and being confronted with their behavior
Avoidant Personality Disorder
Pharmacologic - SSRIs, MAOIs and beta blockers can all be useful to help with symptoms of anxiety
Other anxiolytics can also be useful - buspirone, BZDs
Therapy
Group - can help patient overcome fears in a controlled setting
Individual - essential to establish trust with patient as they may be reluctant to disclose personal information for fear of rejection
3B - D(isorder) SM
BDSM
Avoidant Personality Disorder - Prognosis
Pts can often adapt to their problems and show little impairment in a favorable environment
Social ineptitude and feelings of inadequacy often persist
Worse prognosis if in poor environment
Dependent Personality Disorder and prognosis
Pharmacologic - **SSRIs or TCAs **can help treat associated fatigue, malaise and anxiety, as well as in times of separation
- Therapy - patients often do not feel distressed
- Family/Couples - recruit others to reinforce patient’s attempts at autonomy
- Group - considerable benefit; helps patient try out new and more constructive interpersonal behaviors in a safe environment
- Individual - assertiveness training, decision making skills
Prognosis is good and has more empathy and trust than other disorders
OCPD Obsessive compulsive personality disorder
anal man, controlling
Pharmacologic - no strong indication for medication
SSRIs may help lessen perfectionism and associated anxiety/depression
- Therapy - patients often do not feel distressed
- Family/Couples - attempt to help patient relinquish control over others
- Group - difficult; attempt to ally themselves with the therapist and treat the other group members, who have the “real” problems
- Individual - **desires to be good patient **but has distrust and constriction, often highly critical of self or of therapy
Comorbid Insomnia
Treat underlying cause
Some antidepressants (TCAs) and anxiolytics (benzodiazepines) have SE of sedation/somnolence
Non pharm tx of insomnia
CBT IS FIRST LINE
Relaxation techniques
Meditation
Cognitive Behavioral Therapy
Regular Exercise
Sleep Hygiene
Insomnia pharm management
OTC 1st gen antihistamines - limited efficacy!
* Diphenhydramine (Benadryl, Sominex)
* Doxylamine (Unisom)
Benzodiazepine Receptor Agonists
* Zaleplon (Sonata)
* Zolpidem (Ambien)
* Eszopiclone (Lunesta)
Melatonin agonists
* Ramelteon (Rozerem)
* Melatonin (OTC supplement)
Benzodiazepines - use < 2 weeks if possible
* Temazepam (Restoril), Flurazepam (Dalmane)
* Others - alprazolam (Xanax), lorazepam (Ativan), clonazepam (Klonopin), oxazepam (Serax)
Dual Orexin Receptor Antagonists - newest class of drugs; orexin naturally promotes wakefulness
* Suvorexant (Belsomra)
* Lemborexant (Dayvigo)
* Daridorexant (Quviviq)***
* Others in development
Antidepressants
* Doxepin (Silenor), a low-dose TCA
* Trazodone (Desyrel, Oleptro)
* Mirtazapine (Remeron)
What is sleep hygiene?
Going to bed same time each night, wake up each day, even if it means not sleeping in
It means not forcing yourself to go to sleep. no reading or watching TV in bed.
keep room dark, comfortable temp, and quiet.
can try exercise 6+ hours before bedtime, a light snack near bedtime or warm drink.
No exercise within 90 mins of sleep, no caffeeine after lunch. No heavy meals within 2 hours of bed
No excess fluids right before bed.
Don’t look at your clock when awakening.
Don’t turn on the light when you get up mid sleep.
Narcolepsy
- Forced naps at regular times of day
Stimulants
* Modafinil (Provigil) - least risk of abuse/dependence
* Methylphenidate (Ritalin), dextroamphetamine (Dexedrine)
SSRIs, SNRIs
* Symptomatic tx of cataplexy, sleep paralysis, hallucinations
* Suppress REM sleep
Somnambulism
Treatment-
* Avoid fatigue
* Minimize interventions (slapping, shouting)
* Lead patient back to bed
* Protect from accidents
* No bunk beds
* Gates across stairs
* Locks on doors and windows
Sleep related bruxism
Occlusive splints → may help reduce mechanical tooth wear
Unclear if behavior itself is discouraged
Controlling anxiety may help reduce
Circadian Thythm Disorders
- Promotion of sleep hygiene
- Attempt to synchronize sleep and wakefulness with the underlying circadian rhythm
- Advanced Sleep Phase Type - Bright light in evening
- Delayed Sleep Phase Type - Bright light in early morning
- Melatonin - Can help resynchronise
- Stimulants - caffeine, modafinil
Obstructive Sleep Apnea
- Weight Loss - 10-20% of body weight - can be curative
- Strict avoidance of alcohol and hypnotic medications
- Mechanical appliances to hold jaw forward
Nasal continuous positive airway pressure (nasal CPAP)
* Given at night - Curative in many patients
* Polysomnography - usually needed to determine level of CPAP (usually 5–15 cm H2O) to stop obstruction
* Only 75% of pts continue to use after 1 yr
- Supplemental O2 - can decrease hypoxia, but may lengthen apnea duration
- Surgical repair
ADHD preschool
Behavioral interventions
only adjunct for teens
improves parent child relationship
ADHD 6 years old and up
pharm tx is 1st line
CBT not rec. as monotherapy, adjunctive
1st line - Stimulants - Methylphenidate, Amphetamines
Non stimulants- Atomoxetine, clonidine, guanifacine, antidepressants
Must have full dx assess completed and be 6 years old for pharm treatment.
2nd line - Atomoxetine, or if stims cant be used
Clonidine or guanfacine (a2 agonist)
3rd line - XR clonidine/Guanfacine, can be adjunt to stimulants. Guan has better SE
4th line - TCAs
Buproprion - helps for aggressiveness and hyperactivity only. not great evidence for ADHD.
stimulants are schedule II
methylphenidate for 6+ preschool age (thats the one that causes priaprism), and it has a less severe SE profile and less wt loss. patch form is available called daytrana.
ASD
Educational and Behavioral Interventions
Focus on social, language and adaptive skills
May use manual signing, picture exchange
Psychotherapy is often limited but can be supportive
Routine Screening and Preventative Care
Still need the same routine care as other pts of the same age
Especially be aware of dietary intake and physical activity
Complementary and Alternative Medicine
Melatonin, omega-3 fatty acids, probiotics, hyperbaric oxygen, IVIG, music therapy, yoga, massage, horseback riding
May try interventions if no harm posed to pt
Psychopharmacologic Interventions
Do not treat ASD but can help behaviors
Inattention/Hyperactivity - stimulants
* Methylphenidate (most studied)
* Other meds that may help - other stimulants, alpha agonists, atomoxetine
Maladaptive behaviors
* Antipsychotics - especially risperidone or aripiprazole
* Stimulants, SSRIs, alpha-adrenergics may also help
Anxiety or repetitive behaviors - SSRIs (fluoxetine)
Depressive symptoms - SSRI or SNRI
Dysregulated mood - atypical antipsychotic or SSRI
When is ASD prognosis poor
IQ <70, lack of joint attention by age 4 or functional speech by age 5, seizures or other comorbid conditions, severe symptoms
Rett Disorder
- Good nutrition (high-calorie, balanced diet)
- Assess oral motor function, GERD, delayed gastric emptying
- High index of suspicion of fractures
- Antiepileptic drugs for seizure patients
- Monitor QT interval
- Physical therapy for scoliosis
- Sleep hygiene and medication if needed
- PT and OT for motor dysfunction
