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Psychiatry > Extras from UWorld > Flashcards

Extras from UWorld Flashcards

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.

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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

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3
Q

Atypical depression

A

Involves hypersomnia, increased appetite, rejection sensitivity, and leaden paralysis (heavy limbs)

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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)

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5
Q

Primary insomnia

A

Isolated symptom of difficulty falling or staying asleep.

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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

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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

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8
Q

Transference

A

Patient projects feelings about formative or other important persons onto physicians (Psychiatrist is seen as a parent)

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9
Q

Countertransference

A

Doctor projects feelings about formative or other important persons onto patient (patient reminds doctor of younger sibling)

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10
Q

Acting out

A

Immature

Expressing unacceptable feelings and thoughts through actions

Ex - tantrums

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11
Q

Denial

A

Immature

Avoiding the awareness of some painful reality

Ex - Common in newly diagnosed AIDS and Cancer patients

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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

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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

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14
Q

Fixation

A

Immature

Partially remaining at a more childish level of development (vs regression)

Ex - Adults fixating on video games

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15
Q

Identification

A

Immature

Modeling behavior after another person who is more powerful (though not necessarily admired)

Ex - Abused child identifies with abuser

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16
Q

Isolation (of affect)

A

Immature

Separating feelings from ideas and events

Ex - describing murder in graphic detail with no emotional response

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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

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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

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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

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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

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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)

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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

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23
Q

Altruism

A

Mature

Alleviating negative feelings via unsolicited generosity

Ex - Mafia boss makes large donation to charity

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24
Q

Humor

A

mature

Appreciating the amusing nature of an anxiety-provoking or adverse situation

Ex - nervous medical student jokes about the boards

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25
Q

Sublimation

A

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

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26
Q

Suppression

A

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

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27
Q

Firearm injury

A

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

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28
Q

How can you tell the difference btw medication-induced delirium and medication-induced psychotic disorder

A

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

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29
Q

Specific Phobia

A

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

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30
Q

Eye movement desensitization and reprocessing treatment

A

A complex method of psychotherapy that integrates therapy with eye movements. It is helpful for PTSD

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31
Q

Increased suicidality in adolescent patients on antidepressants

A

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

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32
Q

Interpersonal therapy

A

Duration - time limited

Typical patient - Relationship conflicts, life role transitions, grief

Focus - “The here and now,” Current relationships and conflicts

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33
Q

Supportive psychotherapy

A

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

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34
Q

Psychodynamic psychotherapy

A

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

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35
Q

Motivational interviewing

A

Duration - variable

Typical patient - Substance use disorder

Focus

1) Address ambivalence to change
2) Nonjudgmental
3) Enhance motivation to change
4) Acknowledge resistance

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36
Q

CBT

A

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

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37
Q

DBT

A

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

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38
Q

Biofeedback

A

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

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39
Q

Abrupt discontinuation of Alprazolam

A

Xanax

Associated with significant withdrawal symptoms such as generalized seizures and confusion.

Short half life

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40
Q

Depersonalization/Derealization disorder

A

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

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41
Q

Dissociatie amnesia

A

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

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42
Q

Dissociative Identity Disorder

A

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

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43
Q

Bipolar disorder treatment

A

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

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44
Q

MDMA

A

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

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45
Q

When is lifelong lithium indicated?

A

When there is a severe course

Highly recurrent episodes, suicide attempts, severe symptoms, and impairment requiring hospitalization.

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46
Q

How to D/C lithium

A

Slowly over weeks to months. Frequently monitor to identify early signs and symptoms of recurrence

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47
Q

Social Anxiety Disorder (Social phobia)

A

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)

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48
Q

Antipsychotic med effects in dopamine pathways

A

Dopamine antagonism

1) Mesolimbic - Antipsychotic efficacy
2) Nigrostriatal - EPS - acute dystonia, akathisia, parkinsonism
3) Tuberoinfundibular - Hyperprolactinemia (amenorrhea, galactorrhea, gynecomastia, sexual dysfunction)

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49
Q

Patient fails SSRI. Now what?

A

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

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50
Q

Switching from SSRI to MAOI

A

Requires 5 week washout period to lower risk of serotonin syndrome

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51
Q

Treatment of depressive symptoms in cancer patients

A

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
Q

Somatic Symptom Disorder

A

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
Q

NMS

A

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
Q

Distinguishing NMS from Serotonin Syndrome

A

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
Q

How long is long enough between stopping MAOI and switching to SSRI?

A

2 weeks is sufficient

56
Q

Common side effect of mirtazepine

A

Weight gain

57
Q

Borderline Personality Disorder

A

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
Q

Comorbidities commonly associated with Panic Disorder

A

Major depression, bipolar, agoraphobia, and substance abuse

59
Q

Panic Disorder

A

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
Q

Schizoaffective Disorder

A

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
Q

Ddx of depressed mood

A

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
Q

Guidelines for lithium therapy

A

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
Q

Common drugs affecting lithium levels

A

1) Diuretics
2) NSAIDs, except aspirin
3) SSRIs
4) ACEIs and ARBs
5) Antiepileptics (carbamazepine, phenytoin)

64
Q

Shared psychotic disorder (Folie a deux)

A

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
Q

Tarasoff decision

A

Doctors have duty to warn or protect an individual who is being threatened by a patient.

66
Q

Hoarding Disorder

A

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
Q

GAD

A

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
Q

Acute Mania

A

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
Q

What is a significant side effect of lamotrigine?

A

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
Q

Alcohol withdrawal

A

Tremors, agitation, anxiety, delirium, psychosis

Exam - seizures, tachy, palpitations

71
Q

Benzo withdrawal

A

Tremors, anxiety, perceptual disturbances, psychosis, insomnia

Exam - seizures, tachy, palpitations

Long acting will have longer course (clonazepam) of withdrawal

72
Q

Heroin withdrawal

A

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
Q

Stimulant withdrawal (cocaine, amphetamine)

A

Increased appetite, hypersomnia, intense psychomotor retardation, severe depression (crash)

Exam - No significant findings

74
Q

Nicotine withdrawal

A

Dysphoria, irritability, anxiety, increased appetite

Exam - No significant findings

75
Q

Abrupt discontinuation of an antidepressant

A

Discontinuation syndrome

Fatigue, HA, myalgias, paresthesias (electric shock)

Most likely in shorter acting ones like paroxetine and venlafaxine

76
Q

Key features of somatic symptom and related disorders

A

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
Q

Pathologic gambling

A

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
Q

Risperidone vs aripiprazole (prolactin effects)

A

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
Q

Delusional Disorder

A

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
Q

OCPD

A

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
Q

Management of Antisocial Personality Disorder

A

1) Psychotherapy for milder forms (monitor for manipulation of therapeutic relationship)
2) Treat co-morbid psych disorders (substance use, depression)

82
Q

Alcohol withdrawal syndrome

A

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
Q

Brief psychotic disorder

A

More than 1 day. Less than 1 month. Full return to function.

84
Q

Schizophreniform

A

More than 1 month but less than 6. Same symptoms as schizophrenia. Functional decline not required.

85
Q

Clozapine treatment guidelines

A

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
Q

Atypical antipsychotic with least weight gain

A

Ziprasidone (only haldol showed less)

87
Q

When should benzos be used in treatment of GAD?

A

Nondepressed patients without a history of substance abuse who fail to respond to or cannot tolerate antidepressants

88
Q

ECT

A

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
Q

Homicide risk factors

A

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
Q

Metabolic effects of second generation antipsychotics

A

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
Q

Mechanism of second generation antipsychotics

A

Serotonin 2A and dopamine D2 antagonism. The added serotonin receptor binding reduces likelihood of EPS effects

92
Q

Length of antidepressant treatment

A

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
Q

When should parents of adolescents with psychiatric problems be notified?

A

When patient is a risk to self or others

When starting psychotropic medication

94
Q

Antidepressant classification of major drugs

A

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
Q

What do you do if a patient fails 2 trials of an SSRI?

A

Switch to dif mechanism of action

96
Q

Manic episode (DSM)

A

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
Q

Most common side effects of olanzepine

A

Sedation (antagonism at histamine receptor)

Weight gain (antagonism at histamine H1 receptor and 5-HT2c receptors)

98
Q

Lorazepam vs chlordiazepoxide for alcohol withdrawal

A

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
Q

Disulfiram

A

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

100
Q

DSM 5 schizophrenia

A

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

101
Q

Acute stress disorder

A

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)

102
Q

Body dysmorphic disorder

A

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.

103
Q

When is mirtazepine a good choice for depression?

A

When patient has poor sleep and/or has low appetite

104
Q

Autism spectrum disorder

A

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

105
Q

Narcolepsy treatments

A

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

106
Q

Bipolar and Related Disorders

A

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

107
Q

Management of suicidality

A

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)

108
Q

Victims of sexual assault are at increased risk for what?

A

PTSD, Depression, SI, suicide attempts, medical problems (STD, pelvic pain, fibromyalgia, functional GI disorders, cervical cancer)

109
Q

How can you decrease the risk of relapse in schizophrenia?

A

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

110
Q

Assessment of decision making capacity

A

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.

111
Q

Tx of conversion disorder

A

First line - education and self help techniques

Second line - CBT

PT for motor symptoms

112
Q

Neuroimaging findings in psychiatric disorders

A

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

113
Q

MAOI plus tyramine

A

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)

114
Q

Eating disorder treatments

A

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

115
Q

Age related sleep changes

A

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

116
Q

Postpartum blues

A

1) prevalence - 40-80%
2) Onset - 2-3d (resolves within 10d)
3) Symptoms - Mild depression, tearfulness, irritability
4) Tx - Reassurance and monitoring

117
Q

Postpartum depression

A

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

118
Q

Postpartum psychosis

A

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

119
Q

Inhalant abuse

A

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

120
Q

Greatest risk factor for suicide attempt

A

Prior suicide attempt

121
Q

Secondary causes of acute-onset psychosis in kids and adolescents

A

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.

122
Q

Arthralgia and sudden onset psychosis with hematuria and proteinuria in 14 year old girl

A

SLE!

Classic malar rash often absent

Check ANA titers. If positive, confirm with anti-smith, anti-dsDNA, anti-U1 ribonucleoprotein

123
Q

Treatment of akathisia

A

Lower dose of antipsychotic and administer propranolol or lorazepam

124
Q

Kleptomania

A

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

125
Q

Benzos in the elderly

A

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

126
Q

What is terazosin?

A

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.

127
Q

When are long acting injectable antipsychotics useful?

A

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

Psychiatry (8 decks)

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