Extras from UWorld Flashcards
(127 cards)
1
Q
Major Depressive Episode
A
1) 5 of the following 9: Sleep disturbances, appetite change, low energy, psychomotor changes, low mood, anhedonia, guilt, focus/concentration issues, SI
2) Low mood or anhedonia MUST be there
3) May occur in response to a variety of stressors, including loss of loved ones
4) Duration over 2 weeks
5) Social and occupational dysfunction
6) Suicidality related to hopelessness and worthlessness
If ANY patient meets criteria for MDE, it’s MDE. REGARDLESS of what the stressor was.
2
Q
What type of depression is more common in elderly patients?
A
Melancholic
Anhedonia, absent mood reactivity, depressed mood worse in morning, insomnia or early-morning waking, loss of appetite with weight loss, excessive guilt, psychomotor agitation or retardation
3
Q
Atypical depression
A
Involves hypersomnia, increased appetite, rejection sensitivity, and leaden paralysis (heavy limbs)
4
Q
Grief Reaction
A
1) Normal rxn to loss
2) Feelings of loss and emptiness are dominant (as opposed to persistent depressed mood or anhedonia)
3) Symptoms revolve around the deceased
4) Functional decline less severe than in MDE
5) Worthlessness, self-loathing, guilt and suicidality less common
6) Sad feelings are more specific to deceased
7) Thoughts of dying involve joining the deceased
8) Intensity decreases over time (weeks to months)
5
Q
Primary insomnia
A
Isolated symptom of difficulty falling or staying asleep.
6
Q
Persistent Depressive Disorder (Dysthymia)
A
1) Chronic depressed mood for at least 2 years (1 year in kids/adolescents)
2) No symptom-free period for more than 2 months
3) at least 2 of these:
(a) Poor appetite or overeating
(b) Insomnia or hypersomnia
(c) Low energy or fatigue
(d) Low self-esteem
(e) Poor concentration or difficulty making decisions
(f) Feelings of hopelessness
Specificers
1) With Pure dysthymic syndrome - criteria for MDE never met
2) With intermittent MDEs
3) With persistent major depressive episodes. Criteria for MDE met throughout previous 2 years
Tx includes antidepressants, psychotherapy or a combo
7
Q
Adjustment Disorders in summary
A
Characterized by increased anxiety, depression or disturbed behavior that develops in response to a stressor.
Symptoms must develop within 3 months of an identifiable stressor and last no more than 6 months after it ends
In Adjustment Disorder with depressed mood, the full criteria for MDE are not met. If full criteria is met, then by DEFINITION, it is NOT Adjustment Disorder
8
Q
Transference
A
Patient projects feelings about formative or other important persons onto physicians (Psychiatrist is seen as a parent)
9
Q
Countertransference
A
Doctor projects feelings about formative or other important persons onto patient (patient reminds doctor of younger sibling)
10
Q
Acting out
A
Immature
Expressing unacceptable feelings and thoughts through actions
Ex - tantrums
11
Q
Denial
A
Immature
Avoiding the awareness of some painful reality
Ex - Common in newly diagnosed AIDS and Cancer patients
12
Q
Displacement
A
Immature
Transferring avoided ideas and feelings to a neutral person or object (vs projection)
Ex - mom yells at her child bc her husband yelled at her
13
Q
Dissociation
A
Immature
Temporary, drastic change in personality, memory, consciousness, or motor behavior to avoid emotional stress
Ex - Extreme forms can result in dissociative identity disorder
14
Q
Fixation
A
Immature
Partially remaining at a more childish level of development (vs regression)
Ex - Adults fixating on video games
15
Q
Identification
A
Immature
Modeling behavior after another person who is more powerful (though not necessarily admired)
Ex - Abused child identifies with abuser
16
Q
Isolation (of affect)
A
Immature
Separating feelings from ideas and events
Ex - describing murder in graphic detail with no emotional response
17
Q
Passive aggression
A
Immature
Expressing negativity and performing below what is expected as an indirect show of opposition
Ex - Disgruntled employee is repeatedly late to work
18
Q
Projection
A
Immature
Attributing an unacceptable internal impulse to an external source (vs displacement)
Ex - A man who wants another woman thinks his wife is cheating on him
19
Q
Rationalization
A
Immature
Proclaiming logical reasons for actions actually performed for other reasons, usually to avoid self-blame
Ex - After getting fired, claiming that the job was not important anyway
20
Q
Reaction formation
A
Immature
Replacing a warded-off idea or feeling by an (unconsciously derived) emphasis on its opposite (vs sublimation)
Ex - A patient with libidinous thoughts enters a monastery
21
Q
Regression
A
Immature
Turning back the maturational clock and going back to earlier modes of dealing with the world (vs fixation)
Ex - Seen in kids under stress such as illness, punishment or birth of new sibling (bedwetting in a previously toilet-trained child when hospitalized)
22
Q
Splitting
A
Immature
Believing that people are either all good or all bad at different times due to intolerance of ambiguity. Commonly seen in BPD
Ex - A patient says that all the nurses are cold and insensitive but that the doctors are warm and friendly
23
Q
Altruism
A
Mature
Alleviating negative feelings via unsolicited generosity
Ex - Mafia boss makes large donation to charity
24
Q
Humor
A
mature
Appreciating the amusing nature of an anxiety-provoking or adverse situation
Ex - nervous medical student jokes about the boards
25
Sublimation
Mature
Replacing an unacceptable wish with a course of action that is similar to the wish but does not conflict with one's value system (vs reaction formation)
Ex - teenager's aggression toward his father is redirected to perform well in sports
26
Suppression
Mature
Intentionally withholding an idea or feeling from conscious awareness (vs repression); temporary
Ex - Choosing to not worry about the big game until it is time to play
27
Firearm injury
Risk factors
1) Male adolescent
2) Behavior or psychiatric problems
3) Impulsive, violent or criminal behavior
4) Low socioeconomic status
Prevention
1) REMOVE ALL FIREARMS FROM HOME
2) Store firearms unloaded
3) Lock firearms and ammunition in separate containers
28
How can you tell the difference btw medication-induced delirium and medication-induced psychotic disorder
Delirium will not have a normal cognitive exam. Delirium has fluctuating cognitive impairments such as poor attention and disorientation
Med-induced psychotic disorder associated with delusions and/or hallucinations that are temporarily associated with the use of a new med and rapid onset of symptoms while med is being used. Steroids at high doses are often to blame
29
Specific Phobia
History and clinical features
1) Marked anxiety about a specific object or situation (the phobic stimulus) for more than 6 months
2) Common types: Flying, heights, animals, injections, blood
3) Avoidance behavior (bridges, elevators, refusing work requiring travel)
4) Common. 10% of population
5) Usually develops in childhood, can develop after traumatic event
Treatment
1) BEHAVIORAL THERAPY - exposure, systemic desensitization is treatment of choice
2) short acting benzos may help acutely (therapist unavailable, insufficient time) but have limited role
30
Eye movement desensitization and reprocessing treatment
A complex method of psychotherapy that integrates therapy with eye movements. It is helpful for PTSD
31
Increased suicidality in adolescent patients on antidepressants
Slight increase. FDA issues warning for patients age 18-24. They should be informed about the small risk of becoming suicidal during initial antidepressant treatment
Depression itself is associated with increased suicide risk though.
Must weigh the risks. Benefits of meds for moderate to severe depression outweigh risks. Do not withhold antidepressant treatment bc of this slight increased risk.
Monitor patients closely for worsening depression and suicidality at start of therapy
32
Interpersonal therapy
Duration - time limited
Typical patient - Relationship conflicts, life role transitions, grief
Focus - "The here and now," Current relationships and conflicts
33
Supportive psychotherapy
Duration - ongoing
Typical patient - Lower functioning, in crisis, psychotic, cognitively impaired
Focus
1) Therapist as guide
2) Reinforce coping skills
3) Listen and foster understanding
4) Build up adaptive defense mechanisms
34
Psychodynamic psychotherapy
Duration - ongoing
Typical patient - higher functioning, persistent patterns of dysfunction, more neurotic
Focus
1) Unconscious conflicts cause symptoms
2) Explore past relationships/conflicts
3) Utilize transference
4) Break down defense mechanisms
35
Motivational interviewing
Duration - variable
Typical patient - Substance use disorder
Focus
1) Address ambivalence to change
2) Nonjudgmental
3) Enhance motivation to change
4) Acknowledge resistance
36
CBT
Duration - time limited
Typical patient - persistent maladaptive thoughts, avoidance behavior, ability to participate in homework
Focus
1) Identify and chalenge maladaptive thoughts
2) Change emotions and behavior coming from thoughts
3) Behavioral techniques (breathing, exposure, goal-setting, visualization)
Anxiety, mood, personality, somatic symptom, and eating disorders
37
DBT
Duration - Variable
Typical patient - Borderline personality, self injury
Focus
1) Acceptance and change
2) Improve emotion regulation, mindful awareness, distress tolerance
3) Manage self harm
4) Group therapy component
38
Biofeedback
Duration - variable
Typical patient - Prominent physical responses accompany psychiatric symptoms
Focus
1) Improve awareness and control over physiological reactions
2) Lower stress levels
3) Integrate mind and body
39
Abrupt discontinuation of Alprazolam
Xanax
Associated with significant withdrawal symptoms such as generalized seizures and confusion.
Short half life
40
Depersonalization/Derealization disorder
1) Persistent or recurrent experiences of 1 or both:
(a) Depersonalization (feelings of detachment from, or being an outside observer of, one's self)
(b) Derealization (experiencing surroundings as unreal)
2) Intact reality testing
41
Dissociatie amnesia
1) Inability to recall important personal info, usually of a traumatic or stressful nature
2) Not explained by another disorder (substance use, PTSD)
Can't remember autobiographical info. Localized or selective amnesia for a specific period or event or generalized amnesia for personal identity or life history.
Onset very sudden and preceded by overwhelming or intolerable events.
Specifier "with dissociative fugue" is used when amnesia is associated with seemingly purposeful travel or bewildered wandering
42
Dissociative Identity Disorder
1) Marked discontinuity in identity and loss of personal agency with fragmentation into 2 or more distinct personality states
2) Associated with severe trauma/abuse
43
Bipolar disorder treatment
It is a highly recurrent disease that requires maintenance pharm.
In patients not adequately controlled with monotherapy (Lithium, valproate, quetiapine, lamotrigine) and/or severe features (psychosis, aggression, high risk of suicide, frequent episodes with marked impairment requiring hospitalizations) then combo therapy may be needed.
First line is Lithium or Valproate combined with a second-generation antipsychotic (quetiapine)
Avoid antidepressants - may precipitate mania. If antidepressant is used for an acute depressive episode, it should be slowly tapered and D/C'd during maintenance therapy
44
MDMA
Ecstasy/Molly. 3,4-methylenedioxy-methamphetamine.
Mild hallucinogen properties.
Can cause increase in synaptic NE, Dopamine, and Serotonin. Neurotoxic maybe with long-term use
Intox - HTN, tachy, hyperthermia, serotonin syndrome**, hyponatremia, and death, seizures, coma
Not detected by routine urine tests even tho it is an amphetamine
45
When is lifelong lithium indicated?
When there is a severe course
Highly recurrent episodes, suicide attempts, severe symptoms, and impairment requiring hospitalization.
46
How to D/C lithium
Slowly over weeks to months. Frequently monitor to identify early signs and symptoms of recurrence
47
Social Anxiety Disorder (Social phobia)
Diagnosis
1) marked anxiety about 1 or more social situations for 6 or more months
2) Fear of scrutiny by others, humiliation, embarrassment
3) Marked impairment (social, academic, occupational)
4) Subtype specificer - Performance only
Tx
1) SSRI/SNRI
2) CBT
3) B-blocker* or benzo for performance-only type (as needed to control autonomic response - the tachy and sweating)
48
Antipsychotic med effects in dopamine pathways
Dopamine antagonism
1) Mesolimbic - Antipsychotic efficacy
2) Nigrostriatal - EPS - acute dystonia, akathisia, parkinsonism
3) Tuberoinfundibular - Hyperprolactinemia (amenorrhea, galactorrhea, gynecomastia, sexual dysfunction)
49
Patient fails SSRI. Now what?
An adequate dose and duration of at least 6 weeks is needed to declare failure
If 1 fails, either use a different SSRI or another first-line antidepressant with dif mechanism (SNRI like venlafaxine)
Another option is augmenting with second agent (particularly useful in patients with some benefit but incomplete improvement from SSRI) and either adding or switching to psychotherapy
50
Switching from SSRI to MAOI
Requires 5 week washout period to lower risk of serotonin syndrome
51
Treatment of depressive symptoms in cancer patients
Initial step is ensuring appropriate pain control
Combination of psychotherapy and SSRI should be tried
Low threshold for starting antidepressants in cancer patients given generally low risk of side effects and the large potential benefit
52
Somatic Symptom Disorder
Clinical features
1) 1 or more somatic symptoms causing distress and functional impairment
2) Excessive thoughts or behaviors related to somatic symptoms
(a) Unwarranted, persistent thoughts about seriousness of symptoms
(b) Persistent anxiety about health or symptoms
(c) Excessive time and energy devoted to symptoms
3) 6 or more months in duration
Management
1) Regularly scheduled visits with same provider
2) Limit unnecessary workup and specialist referrals
3) Legitimize symptoms but make functional improvement the goal
4) Focus on stress reduction and improving coping strategies
5) mental health referral if patient will accept
53
NMS
Signs/Symptoms
1) Fever sometimes above 40C
2) AMS
3) Muscle rigidity (generalized)
4) Autonomic instability - tachy/dysarhythmias, labile BPs, tachypnea, diaphoresis
5) May see rhabdo and leukocytosis too
Precipitating factors
1) Antipsychotics (typical and atypical)
2) Antiemetics (promethazine, metoclopramide)
3) Antiparkinson (dopamine agonists) med withdrawal
4) Infection
5) Surgery
Treatment
1) Stop neuroleptics or restart dopamine agents
2) Supportive care (hydration, cooling)
3) Dantrolene or bromocriptine
Most often seen with high potency first generation antipsychotics but can occur with all. May develop over 1-3d with delirium often the first sign
54
Distinguishing NMS from Serotonin Syndrome
Serotonin Syndrome is characterized by neuromuscular irritability (tremor, hyperreflexia, myoclonus), rather than rigidity seen in NMS
Fever in SS is not as high as in NMS
GI symptoms are more common (vomiting, diarrhea) in SS
55
How long is long enough between stopping MAOI and switching to SSRI?
2 weeks is sufficient
56
Common side effect of mirtazepine
Weight gain
57
Borderline Personality Disorder
Diagnostic criteria
Pervasive pattern of unstable relationships, self-image, and affects and marked impulsivity, with 5 or more of the following:
1) Frantic efforts to avoid abandonment
2) Unstable and intense interpersonal relationships
3) Markedly and persistently unstable self-image
4) Impulsivity in 2 or more areas that are potentially self-damaging
5) Recurrent suicidal behaviors or threats of self-mutilation (cutting)
6) Affective instability (marked mood reactivity)
7) Chronic feelings of emptiness
8) Inappropriate and intense anger
9) Transient stress-related paranoia or dissociation
Treatment
1) Primary treatment is psychotherapy - best evidence is for DBT but many are effective
2) Adjunctive pharm to target mood instability and transient psychosis (second gen antipsychotic, mood stabilizers)
3) Antidepressants if comorbid mood or anxiety disorder
58
Comorbidities commonly associated with Panic Disorder
Major depression, bipolar, agoraphobia, and substance abuse
59
Panic Disorder
1) Recurrent and unexplained panic attacks
2) At least 1 attack followed by 1 or both of the following for more than 1 month:
(a) Worry about additional attacks or consequences
(b) Changes in behavior related to attacks (avoidance)
3) Panic attacks not attributable to another mental illness or substance abuse
Patient must have more than 1 full symptom unexplained attack to meet diagnosis
Tx:
1) Immediate - benzos
2) Long-term- SSRI/SNRI and/or CBT
60
Schizoaffective Disorder
DSM-5
1) Major depressive or manic episode concurrent with symptoms of schizophrenia
2) Lifetime history of delusions or hallucinations for 2 or more weeks in the ABSENCE of major depressive or manic episodes
3) Mood symptoms are present for majority of illness
4) Not due to substances or another medical condition
Ddx
1) Major depressive or bipolar disorder with psychotic features - psychotic symptoms occur exclusively during mood episodes
2) Schizophrenia - mood symptoms present for relatively brief periods
61
Ddx of depressed mood
MDD
1) At least 2 weeks
2) At least 5 of symptoms: Depressed mood and SIGECAPS
3) Significant functional impairment
4) No lifetime history of mania
5) Not due to drugs or medical condition
Adjustment Disorder with depressed mood
1) Identifiable stressor
2) Onset within 3 months of stressor
3) Marked distress
4) Significant functional impairment
5) Does not meet criteria for another DSM-5 disorder
6) Tx of choice is psychotherapy (improving coping skills and promoting a return to functioning)
Normal stress response
1) Not excessive or out of proportion to severity of stressor
2) No significant functional impairment
62
Guidelines for lithium therapy
Indications - mania due to bipolar disorder
Contraindications
1) CKD
2) Heart disease
3) Hyponatremia or diuretic use
Baseline studies
1) BUN, Cr, Ca, UA
2) TFTs
3) ECG in patients with coronary risk factors
```
Adverse effects
(A) acute
1) Tremor, ataxia, weakness
2) Polyuria, polydipsia
3) Vomit, diarrhea
4) Cognitive impairment
```
(B) Chronic
1) Nephrogenic DI
2) Thyroid dysfunction
3) Hyperparathyroidism
Monitor drug levels every 6-12 months and 5-7 days after any dose changes or after starting other meds that can interact with Li
63
Common drugs affecting lithium levels
1) Diuretics
2) NSAIDs, except aspirin
3) SSRIs
4) ACEIs and ARBs
5) Antiepileptics (carbamazepine, phenytoin)
64
Shared psychotic disorder (Folie a deux)
Rare manifestation of delusional disorder in which the same delusion is present in individuals who share a close relationship.
Usually, the dominant individual in the pair becomes delusional and transfers the delusion onto the second, more passive, person who may or may not meet full criteria for delusional disorder
Most appropriate course of action is to separate the pair to break the chain of reinforcing each other's beliefs.
The dominant one who first had the delusion usually requires psych treatment (sometimes inpatient), whereas the other one requires treatment only sometimes
65
Tarasoff decision
Doctors have duty to warn or protect an individual who is being threatened by a patient.
66
Hoarding Disorder
Accumulation of a large number of possessions that may clutter living areas to the point that they are unusable
Patients experience intense distress when attempting to discard possessions regardless of their actual value
Social isolation due to embarrassment may also occur
Tx - CBT. SSRIs are sometimes tried bc of their efficacy in OCD, but effectiveness in hoarding without OCD is limited. Consider SSRIs has a good adjunctive for comorbid depression or anxiety
67
GAD
1) Excessive worry, anxiety (multiple issues) for at least 6 months
2) Difficult to control
3) At least 3 of these:
(a) restlessness/feeling on edge
(b) Fatigue
(c) Difficulty concentrating
(d) irritability
(e) Muscle tension
(f) Sleep issues
4) Significant distress/impairment
5) Not due to substances, another mental disorder or medical condition
Tx
1) CBT
2) SSRIs or SNRIs
68
Acute Mania
Clinical Features
1) Elevated, irritable, labile mood
2) Increased energy and activity, decreased need for sleep
3) Pressured speech, racing thoughts, distractible
4) Grandiosity, risky behavior
5) Marked impairment, may have psychotic symptoms
Management
1) Antipsychotics (first and second gen)
2) Lithium (avoid in renal disease)
3) Valproate (avoid in liver disease)
4) Combo in severe mania (antipsychotic plus lithium or valproate)
5) Adjunctive benzos for insomnia, agitation
Severe mania - psychotic features, aggressive behavior, risk of harm to self or others
Lithium and valproate are not the best immediate treatment bc they take a while to build up in blood
Avoid antidepressants bc they can precipitate mania
69
What is a significant side effect of lamotrigine?
It is an AED. It is used for bipolar depressive episodes (not manic)
Most significant side effect rash that can develop into SJS in 0.1% of patients
70
Alcohol withdrawal
Tremors, agitation, anxiety, delirium, psychosis
Exam - seizures, tachy, palpitations
71
Benzo withdrawal
Tremors, anxiety, perceptual disturbances, psychosis, insomnia
Exam - seizures, tachy, palpitations
Long acting will have longer course (clonazepam) of withdrawal
72
Heroin withdrawal
N/v, abdominal cramping, muscle aches
Exam - Dilated pupils, yawning, piloerection, lacrimation, hyperactive bowel sounds
Can present 6-12hrs after stopping and peak 36-72h later. May continue for several days. Not life threatening
73
Stimulant withdrawal (cocaine, amphetamine)
Increased appetite, hypersomnia, intense psychomotor retardation, severe depression (crash)
Exam - No significant findings
74
Nicotine withdrawal
Dysphoria, irritability, anxiety, increased appetite
Exam - No significant findings
75
Abrupt discontinuation of an antidepressant
Discontinuation syndrome
Fatigue, HA, myalgias, paresthesias (electric shock)
Most likely in shorter acting ones like paroxetine and venlafaxine
76
Key features of somatic symptom and related disorders
1) Somatic symptom disorder - excessive anxiety and preoccupation with 1 or more unexplained symptoms
2) Illness Anxiety Disorder (hypochondriasis) - Fear of having a serious illness despite few or no symptoms and consistently negative evaluations
3) Conversion Disorder (Functional neurologic symptom disorder) - Neuro symptom incompatible with any known neurologic disease; often acute onset associated with stress
4) Factitious Disorder - Intentional falsification or inducement of symptoms with goal to assume sick role
5) Malingering - Falsification or exaggeration of symptoms to obtain external incentives (secondary gain)
77
Pathologic gambling
Likely dx in person with chronic history of gambling and an inability to stop. Significant financial losses and damaged relationships are common consequences of the behavior
78
Risperidone vs aripiprazole (prolactin effects)
Risperidone is known to have high frequency of prolactin elevation due to dopamine blockade in tuberoinfundibular pathway (typically 25-100, prolactinoma will be like above 200). Note: Risperidone (along with 1st generation) is the atypical antipsychotic most likely to cause EPS (best tx is to replace it with alternative antipsychotic)
Aripiprazole is a dopamine antagonist AND a partial D2 agonist. Less likely to cause hyperprolactinemia
79
Delusional Disorder
Clinical
1) at least 1 delusion for at least 1 month
2) Other psych symptoms ABSENT or not prominent
3) Ability to function apart from delusion; behavior not obviously bizarre or odd
4) Subtypes: Erotomanic, grandiose, jealous, persecutory and somatic
Ddx
1) Schizophrenia - other psych symptoms present (hallucinations, disorganization, negative symptoms); greater functional impairment
2) Personality disorders - pervasive pattern of suspiciousness (paranoid), grandiosity (narcissistic), or odd beliefs (schizotypal) but no clear delusions. In schizotypal they may have superstitions or clairvoyance but their beliefs are not held with delusional conviction
Tx
1) Antipsychotics
2) CBT
80
OCPD
Longstanding preoccupation with orderliness and perfectionism. To maintain a sense of control, they become so preoccupied with details and rigid rules that the major point of the activity is lost.
Perfectionism often interferes with task completion as they perseverate and repeatedly check for possible mistakes.
Stubbornness, excessive devotion to work, inability to delegate tasks to others and a miserly spending style are also seen. Ego-syntonic with little insight. I.e. this isn't a problem.
81
Management of Antisocial Personality Disorder
1) Psychotherapy for milder forms (monitor for manipulation of therapeutic relationship)
2) Treat co-morbid psych disorders (substance use, depression)
82
Alcohol withdrawal syndrome
1) Mild withdrawal - anxiety, insomnia, diaphoresis, palpitations, GI upset, intact orientation. 6-24h since last drink
2) Seizures - Single or multiple generalized tonic-clonic. 12-48h since last drink.
3) Alcoholic hallucinosis - Visual, auditory, or tactile; intact orientation; stable vital signs. 12-48h since last drink. Look for this shortly after hospitalization. This context of a hospital puts it more likely than brief psychotic disorder.
4) DT - Confusion, agitation, fever, tachycardia, HTN, diaphoresis, hallucinations. 48-96h since last drink.
83
Brief psychotic disorder
More than 1 day. Less than 1 month. Full return to function.
84
Schizophreniform
More than 1 month but less than 6. Same symptoms as schizophrenia. Functional decline not required.
85
Clozapine treatment guidelines
Indications
1) Treatment-resistant schizophrenia (poor response to at least 2 antipsychotic trials)
2) Schizophrenia associated with suicidality
Adverse effects
1) Agranulocytosis
2) Seizures
3) Myocarditis
4) Metabolic Syndrome
86
Atypical antipsychotic with least weight gain
Ziprasidone (only haldol showed less)
87
When should benzos be used in treatment of GAD?
Nondepressed patients without a history of substance abuse who fail to respond to or cannot tolerate antidepressants
88
ECT
Conditions treated
1) Unipolar and bipolar depression
2) Catatonia
3) Bipolar mania
Specific indications
1) Treatment resistance
2) Psychotic features present
3) Emergency conditions - pregnancy, refusal to eat or drink, imminent risk for suicide
4) Pharm contraindicated due to comorbid medical illness or poor tolerability
5) History of ECT response
Safety
1) No absolute contraindications!!!
2) Increased risk if severe CV disease or recent MI, space-occupying brain lesion, recent stroke or unstable aneurysm
89
Homicide risk factors
1) Young male
2) Unemployed
3) Impoverished
4) Access to firearms*** (most important risk factor to address)
5) Substance abuse
6) Antisocial personality disorder
7) History of violence or criminality
8) History of childhood abuse
9) Impulsivity
90
Metabolic effects of second generation antipsychotics
Metabolic Syndrome
1) Weight gain
2) Dyslipidemia
3) Hyperglycemia (including new-onset diabetes)
Highest risk drugs
1) Clozapine
2) Olanzepine
Monitoring guidelines include baseline and routine follow-up of:
1) BMI
2) Fasting glucose and lipids
3) BP
4) Waist circumference
Baseline then again at 3 months then again annually. Earlier and more frequent if more than 5% weight gain or for patients with diabetes.
91
Mechanism of second generation antipsychotics
Serotonin 2A and dopamine D2 antagonism. The added serotonin receptor binding reduces likelihood of EPS effects
92
Length of antidepressant treatment
Patients with single episode of MDD who respond to acute tx should continue tx for an additional 4-9 months (continuation phase treatment). There is a higher risk of relapse in patients who stop sooner. The dose should be maintained at the level that achieved remission and not be reduced (the dose that gets them well keeps them well)
Maintenance phase treatment is continuing past the continuation phase. 1-3 years of maintenance is appropriate for patients with a history of multiple episodes (recurrent MDD), chronic episodes (2 or more years), strong FHx, or severe episodes (suicide attempt)
Patients with highly recurrent (3 or more lifetime episodes) and very severe, chronic MDEs should continue indefinitely
93
When should parents of adolescents with psychiatric problems be notified?
When patient is a risk to self or others
When starting psychotropic medication
94
Antidepressant classification of major drugs
SSRIs
1) Fluoxetine
2) Paroxetine
3) Sertraline
4) Citalopram
5) Escitalopram
6) Fluvoxamine
SNRIs
1) Venlafaxine
2) Desvenlafaxine
3) Duloxetine
NDRI (NE and Dopa reuptake inhib)
1) Bupropion (does not cause weight gain, no sexual side effects, activating effects)
TCA (for treatment-refractory patients who failed multiple drug classes)
1) Amitriptyline
2) Nortriptyline
MAOI
1) Phenelzine
2) Tranylcypromine
Other
1) Mirtazapine (watch out for sedation and weight gain)
2) Trazodone (used mostly for insomna related to depression. Watch out for priapism)
3) Vortioxetine
95
What do you do if a patient fails 2 trials of an SSRI?
Switch to dif mechanism of action
96
Manic episode (DSM)
At least 1 week (unless hospitalized) of persistently elevated or irritable mood and increased energy/activity
At least 3 of the following (4 if mood is irritable)
1) Less need for sleep
2) Grandiosity
3) Pressured speech
4) Racing thoughts (flight of ideas)
5) Distractibility
6) Hyperactivity/psychomotor agitation
7) Risky behavior (spending, investments, sex)
Marked impairment typically needing hospitalization
Psychotic features may be present
Note on tx: In depressed phase, antipsychotics are still useful. If antidepressants are needed they should be used in combination with mood stabilizers
97
Most common side effects of olanzepine
Sedation (antagonism at histamine receptor)
Weight gain (antagonism at histamine H1 receptor and 5-HT2c receptors)
98
Lorazepam vs chlordiazepoxide for alcohol withdrawal
IV Lorazepam (intermediate duration) is preferred in hospital setting. It is safer in patients with possible liver disease and has no active metabolites
Chlordiazepoxide is long acting with multiple active metabolites. Less preferred in medically hospitalized patients or in patients with liver disease
99
Disulfiram
Used as behavioral deterrent in high-functioning alcoholic patients who desire long-term abstinence. Buildup of acetaldehyde makes patient feel ill when ingested.
Inhibits aldehyde dehydrogenase
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DSM 5 schizophrenia
At least 2 of these:
1) Delusions
2) Hallucinations
3) Disorganized behavior
4) Negative symptoms (decreased emotional expression, avolition)
Social/occupational dysfunction
Duration of at least 6 months
Rule out other medical, psych, or substance use
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Acute stress disorder
Intrusive re-experiencing, hyperarousal, and avoidance symptoms lasting at least 3 days and less than 1 month following exposure to life-threatening, traumatic event.
(PTSD is when it lasts at least 1 month)
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Body dysmorphic disorder
1) Preoccupations with at least 1 perceived physical defect
2) Defects are not observable or appear slight to others
3) Repetitive behavior or mental acts performed in response to the preoccupation
4) Significant distress or impairment
5) Specify insight (good, poor, absent/delusional beliefs)
Tx - medication (usually SSRI) or psychotherapy. NOT surgery.
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When is mirtazepine a good choice for depression?
When patient has poor sleep and/or has low appetite
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Autism spectrum disorder
Multiple, persistent deficits in social communication and interactions currently or by history involving:
1) Social-emotional reciprocity
2) Nonverbal communicative behaviors
3) Developing, maintaining and understanding relationships
Restricted, repetitive patterns of behavior currently or by history
1) Repetitive motor movements
2) Insistence on sameness or inflexible adherence to routines
3) Fixated interests of abnormal intensity or focus
4) Adverse responses to sensory input
Onset in early developmental period
May occur with or without language and intellectual impairment
Tx
1) Early diagnosis and early intervention is crucial!!! -starting by age 2 or 3 improves outcomes
2) Comprehensive, multimodal treatment (speech, behavioral therapy, educational services)
3) Adjunctive pharm for psych comorbidities
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Narcolepsy treatments
1) Modafinil and armodafinil address excessive, uncontrollable daytime sleepiness. Modafinil is a novel stimulant. These are the preferred meds in narco tx
2) Amphetamine stimulants have traditionally been used. Not currently first line due to risk of abuse, potential tolerance and significant side effects
3) Sodium oxybate (Xyrem) reduces cataplexy. Due to potential for abuse and illicit use, both sodium oxybate and amphetamines are regulated as controlled substances
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Bipolar and Related Disorders
Both manic and hypomanic require 3 of the DIGFAST (4 if irritable mood). The defining features of each are below:
Manic episode
1) Symptoms more severe
2) 1 week unless hospitalized
3) Marked impairment in social or occupational functioning or hospitalization needed
4) May have psychotic features, makes episode manic by definition.
Hypomanic episode
1) Symptoms less severe
2) At least 4 consecutive days
3) Unequivocal, observable change in functioning from patient's baseline
4) Symptoms not severe enough to cause marked impairment or necessitate hospitalization
5) No psychotic features
Bipolar 1
1) Manic episode
2) Depressive episodes common, but not required for dx!
Bipolar 2
1) Hypomanic episode
2) At least 1 major depressive episode required
Cyclothymic disorder
1) At least 2 years of fluctuating, mild hypomanic and depressive symptoms that do not meet criteria for hypomanic episodes or major depressive episodes
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Management of suicidality
High imminent risk (ideation, intent and plan)
1) Ensure safety - hospitalize immediately, involuntary if needed
2) Remove personal belongings and objects in room that may present self harm risk
3) Constant observation and security may be required to hold against will
High non-imminent risk (ideation, intent but no plan to act in near future)
1) Treat modifiable risk factors (underlying depression, psychosis, substance abuse)
2) Recruit family or friends to support patient
3) Reduce access to potential means (secure firearms, medications)
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Victims of sexual assault are at increased risk for what?
PTSD, Depression, SI, suicide attempts, medical problems (STD, pelvic pain, fibromyalgia, functional GI disorders, cervical cancer)
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How can you decrease the risk of relapse in schizophrenia?
Minimize conflict and stress in the home
Family psychosocial interventions are indicated for patients with a recent psychotic episode who have significant ongoing contact with family members
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Assessment of decision making capacity
1) Communicates a choice - patient able to clearly indicate preferred treatment option
2) Understands info provided - patient understands condition and treatment options
3) Appreciates consequences - patient acknowledges having condition and likely consequences of treatment options, including no treatment
4) Rationale given for decision - patient able to weigh risks and benefits and offer reasons for decision
Patients with psychiatric diagnoses CAN give informed consent if they meet these criteria too.
Competency is up to the courts. Not providers.
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Tx of conversion disorder
First line - education and self help techniques
Second line - CBT
PT for motor symptoms
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Neuroimaging findings in psychiatric disorders
1) Autism - Increased total brain volume
2) OCD - Orbitofrontal cortex and striatum abnormalities
3) Panic Disorder - Decreased volume of Amygdala
4) PTSD - Decreased hippocampal volume
5) Schizophrenia - Enlargement of cerebral ventricles
Structural imaging is often performed in new-onset psychosis to rule out stuff. Do not need in someone with known psychotic disorder
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MAOI plus tyramine
Hypertensive crisis
Tyramine is found in aged cheeses, aged/cured meats, aged/fermented soy products, overripe fruit, some alcoholic beverages
Tyramine is a sympathomimetic monoamine that can facilitate release of other sympathomimetic monoamines such as adrenaline. Tyramine metabolism is inhibited by MAOIs, which causes an increased sympathomimetic (adrenergic) effect that can result in sever hypertensive crisis
Presents first as HA but can lead to intracranial bleeding, stroke and death
(MAOI + SSRI is serotonin syndrome, NOT hypertensive crisis)
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Eating disorder treatments
1) Anorexia - CBT, nutritional rehab, Olanzepine if no response to the others
2) bulimia - CBT, Nutritional rehab, SSRI (fluoxetine) often in combo with the rest
3) Binge eating disorder - CBT, behavioral weight loss therapy, SSRI, Lisdexamfetamine/topiramate
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Age related sleep changes
May frequently awaken from sleep and spend less time sleeping overall. Nap during day. Period of deep sleep (stage 4) becomes shorter and eventually disappears
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Postpartum blues
1) prevalence - 40-80%
2) Onset - 2-3d (resolves within 10d)
3) Symptoms - Mild depression, tearfulness, irritability
4) Tx - Reassurance and monitoring
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Postpartum depression
1) Prevalence - 8-15%
2) Onset - within 4w
3) Symptoms - Moderate to severe depression, sleep or appetite disturbance, low energy, psychomotor changes, guilt, concentration difficulty, suicidal ideation
4) Tx - Antidepressants, psychotherapy
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Postpartum psychosis
1) Prev - 0.1-0.2%
2) Onset - variable. Days to weeks
3) Symptoms - Delusions, hallucinations, thought disorganization, bizarre behavior. Symptoms of mood disorder are also common
4) Tx - Antipsychotics, antidepressants. Do NOT leave mom alone with infant (risk of infanticide)
This is a medical emergency! Acute management involves hospitalization to ensure safety, antipsychotic meds and treatment of underlying disorder (most people with postpartum psychosis are Bipolar).
It is vital to mobilize family to care for newborn and ensure mom is never left alone with baby
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Inhalant abuse
Usually occurs in boys age 14-17 and may involve multiple household chemicals. Effects are rapid and transient but can be life-threatening. Users also display characteristic perioral skin changes (glue sniffer's rash)
No drug paraphernalia found
Not included in most tox screens. Rapidly eliminated.
Brief transient euphoria and LOC seen
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Greatest risk factor for suicide attempt
Prior suicide attempt
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Secondary causes of acute-onset psychosis in kids and adolescents
Medical disorders
CNS injury/dysfunction
1) Trauma
2) Space occupying lesion
3) Stroke
4) Infection
5) Epilepsy
6) Cerebral hypoxia
Metabolic/lyte disturbances
1) Urea cycle disorders
2) Acute intermittent porphyria
3) Wilson Disease
4) Renal/liver failure
5) Hypoglycemia
6) Sodium, Calcium, Magnesium issues
Systemic disorders
1) SLE
2) Thyroiditis
Illicit substances
1) Hallucinogens (PCP, LSD, Ketamine)
2) Marijuana
3) Sympathomimetics (Cocaine, amphetamines)
4) Alcohol withdrawal
5) Bath salts
Medication side effects
1) anticholinergic intox (Diphenhydramine, scopolamine)
2) Serotonin Syndrome
3) Amoxicillin/erythromycin/clarithromycin intox
4) Anticonvulsant intox
5) Corticosteroid intox
6) Isoniazid intox
7) Baclofen withdrawal
8) Benzo withdrawal
Moral: Sudden onset psychosis in a child or adolescent is rare. Think secondary causes.
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Arthralgia and sudden onset psychosis with hematuria and proteinuria in 14 year old girl
SLE!
Classic malar rash often absent
Check ANA titers. If positive, confirm with anti-smith, anti-dsDNA, anti-U1 ribonucleoprotein
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Treatment of akathisia
Lower dose of antipsychotic and administer propranolol or lorazepam
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Kleptomania
Clinical features
1) Rare impulse control disorder with typical onset in adolescence
2) Repetitive failure to resist impulses to steal
3) Stolen objects of little value
4) Increasing tension prior to theft, pleasure or relief when committing theft
5) Stolen objects given away, discarded, or returned; guilt and remorse are common
Ddx
1) Shoplifting - theft for personal gain, much more common
2) Antisocial personality disorder - general pattern of antisocial behavior
3) Bipolar disorder, manic episode - impulsivity, impaired judgment
4) Psychotic disorders - stealing in response to delusions, hallucinations
Tx - CBT, SSRIs, opioid antagonists, Li, anticonvulsants
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Benzos in the elderly
Use sparingly due to increased risk of adverse effects
As people age, they metabolize benzos differently/more slowly. More likely to experience confusion and increased risk of falls.
Also, paradoxical agitation - recurrent episodes of confusion and agitation shortly after taking benzo dose
Paradoxical agitation - increased agitation, confusion, aggression, and disinhibition, typically within an hour of benzo. This is uncommon, but it is important to recognize since increasing benzo dose would make this worse
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What is terazosin?
Alpha blocker.
Can cause orthostatic hypotension or syncope, esp with the first dose.
Not associated with cognitive impairment or agitation
use with caution in elderly.
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When are long acting injectable antipsychotics useful?
Patients who have responded to oral medication in the best but who are noncompliant
Patients with unstable illness who live alone and have poor social support systems, poor insight, and frequent med noncompliance are good candidates
