FARR Psychiatry Flashcards
First-line pharmacotherapy for depression.
SSRIs.
Antidepressants associated with hypertensive crisis.
MAOIs.
Galactorrhea, impotence, menstrual dysfunction, and ↓ libido.
Patient on dopamine antagonist.
A 17-year-old girl has left arm paralysis after her boyfriend dies in a car crash. No medical cause is found.
Conversion disorder.
Name the defense mechanism:
■ A mother who is angry at her husband yells at her child.
■ A pedophile enters a monastery.
■ A woman calmly describes a grisly murder.
■ A hospitalized 10-year-old begins to wet his bed.
Displacement
Reaction formation
Isolation
Regression
Life-threatening muscle rigidity, fever, and rhabdomyolysis.
Neuroleptic malignant syndrome.
Amenorrhea, bradycardia, and abnormal body image in a young female.
Anorexia.
A 35-year-old man has recurrent episodes of palpitations, diaphoresis, and fear of going crazy.
Panic disorder.
The most serious side effect of clozapine
Agranulocytosis.
A 21-year-old man has three months of social withdrawal, worsening grades, flattened affect, and concrete thinking.
Schizophreniform disorder (diagnosis of schizophrenia requires ≥ 6 months of symptoms).
Key side effects of atypical antipsychotics.
Weight gain, type 2 DM, QT prolongation.
A young weight lifter receives IV haloperidol and complains that his eyes are deviated sideways. Diagnosis? Treatment?
Acute dystonia (oculogyric crisis). Treat with benztropine or diphenhydramine.
Medication to avoid in patients with a history of alcohol withdrawal seizures.
Neuroleptics.
A 13-year-old boy has a history of theft, vandalism, and violence toward family pets.
Conduct disorder.
A five-month-old girl has ↓ head growth, truncal dyscoordination, and ↓ social interaction.
Rett’s disorder.
A patient hasn’t slept for days, lost $20,000 gambling, is agitated, and has pressured speech. Diagnosis? Treatment?
Acute mania. Start a mood stabilizer (e.g., lithium).
After a minor fender bender, a man wears a neck brace and requests permanent disability.
Malingering.
A nurse presents with severe hypoglycemia; blood analysis reveals no elevation in C-peptide.
Factitious disorder (Munchausen syndrome).
A patient continues to use cocaine after being in jail, losing his job, and not paying child support.
Substance abuse.
A violent patient has vertical and horizontal nystagmus.
Phencyclidine hydrochloride (PCP) intoxication.
A woman who was abused as a child frequently feels outside of or detached from her body.
Depersonalization disorder.
A man has repeated, intense urges to rub his body against unsuspecting passengers on a bus.
Frotteurism (a paraphilia).
A schizophrenic patient takes haloperidol for one year and develops uncontrollable tongue movements. Diagnosis? Treatment?
Tardive dyskinesia. ↓ or discontinue haloperidol and consider another antipsychotic (e.g., risperidone, clozapine).
A man unexpectedly flies across the country, takes a new name, and has no memory of his prior life.
Dissociative fugue.
GAD Hx/PE:
Presents with anxiety on most days (six or more months) and with three or more somatic symptoms (restlessness, fatigue, difficulty concen-
trating, irritability, muscle tension, disturbed sleep).
GAD Tx:
Lifestyle changes, psychotherapy, medication. SSRIs, venlafaxine, and
buspirone are most often used (see Table 2.14-1). Benzodiazepines may
be used for immediate symptom relief.
I Taper benzodiazepines as soon as long-term treatment is initiated (e.g.,
with SSRIs) in light of the high risk of tolerance and dependence. Do not stop benzodiazepines “cold turkey,” as patients may develop po- tentially lethal withdrawal symptoms similar to those of alcohol with- drawal.
I Patient education is essential.
OCD Hx/PE:
Obsessions: Persistent, unwanted, and intrusive ideas, thoughts, impulses, or images that lead to marked anxiety or distress (e.g., fear of contamination, fear of harm to oneself or to loved ones) and occur despite the patient’s attempts to prevent them.
Compulsions: Repeated mental acts or behaviors that neutralize anx- iety from obsessions (e.g., hand washing, elaborate rituals for ordinary tasks, counting, excessive checking).
Patients recognize these behaviors as excessive and irrational prod- ucts of their own minds (vs. obsessive-compulsive personality disorder). Patients wish they could get rid of the ob- sessions and/or compulsions.
OCD Tx:
Pharmacotherapy (SSRIs are first-line pharmacologic treatment; see Table 2.14-1); cognitive-behavioral therapy (CBT) using exposure and de- sensitization relaxation techniques. Patient education is imperative.
Panic Disorder Hx/PE
Panic attacks are defined as discrete periods of intense fear or discomfort in which at least four of the following symptoms develop abruptly and peak within 10 minutes: tachypnea, chest pain, palpitations, dia- phoresis, nausea, trembling, dizziness, fear of dying or “going crazy,” depersonalization, or hot flashes.
Perioral and/or acral paresthesias, when present, are fairly specific to panic attacks, which produce hyperventilation and low oxygen satura- tion.
Patients present with one or more months of concern about having additional attacks or significant behavior change as a result of the at- tacks—e.g., avoiding situations that may precipitate attacks.
DDx of Panic disorder
Medical conditions: Angina, MI, arrhythmias, hyperthyroidism, vitamin B12 deficiency, pheochromocytoma.
Psychiatric conditions: Substance-induced anxiety, generalized
anxiety disorder, PTSD.
PTSD Hx/PE
Characterized by reexperiencing of the event (e.g., nightmares), avoid-
ance of stimuli associated with the trauma, numbed responsiveness (e.g., detachment, anhedonia), and ↑ arousal (e.g., hypervigilance, ex- aggerated startle) that lead to significant distress or impairment in func- tioning.
>1month
Survivor guilt, irritability, poor concentration, amnesia, personality
change, sleep disturbance, substance abuse, depression, and suicidality
may be present.
Causes of dementia—
DEMENTIAS
Degenerative diseases (Parkinson’s, Huntington’s)
Endocrine (thyroid, parathyroid, pituitary, adrenal)
Metabolic (alcohol, electrolytes, vitamin B12 deficiency, glucose, hepatic, renal, Wilson’s disease)
Exogenous (heavy metals, carbon monoxide, drugs)
Neoplasia Trauma (subdural
hematoma) Infection (meningitis,
encephalitis, endocarditis, syphilis, HIV, prion diseases, Lyme disease)
Affective disorders (pseudodementia)
Stroke/Structure (vascular dementia, ischemia, vasculitis, normal pressure hydrocephalus)
Dementia Diagnostic criteria include
memory impairment and one or more of the fol- lowing:
I Aphasia: Language impairment.
I Apraxia: Inability to perform motor activities.
I Agnosia: Inability to recognize previously known objects.
I Impaired executive function (problems with planning, organizing, and
abstracting) in the presence of a clear sensorium.
I Personality, mood, and behavior changes are common (e.g., wandering
and aggression).
Rule out treatable causes of dementia; obtain
CBC, RPR, CMP, TFTs, HIV, B12/folate, ESR, UA, and a head CT or MRI.
Dementia treatment
TREATMENT
I Provide environmental cues and a rigid structure for the patient’s daily life.
I Cholinesterase inhibitors are used to treat. Low-dose antipsychotics may be used for agitation. Avoid benzodiazepines, which may worsen disinhi- bition and confusion.
I Family, caregiver, and patient education and support are imperative.
Major causes of delirium—
I WATCH DEATH Infection Withdrawal Acute metabolic/ substance Abuse Trauma CNS pathology Hypoxia Deficiencies Endocrine Acute vascular/MI Toxins/drugs Heavy metals
Depression HISTORY/PE
Diagnosis requires depressed mood or anhedonia (loss of interest/pleasure) and five or more signs/symptoms from the SIG E CAPS mnemonic for a two-week period.
Symptoms of a depressive episode—
SIG E CAPS Sleep (hypersomnia or insomnia) Interest (loss of interest or pleasure in activities) Guilt (feelings of worthlessness or inappropriate guilt) Energy (↓) or fatigue Concentration (↓) Appetite (↑ or ↓) or weight (↑ or ↓) Psychomotor agitation or retardation Suicidal ideation
Selected depression subtypes include the following:
I Psychotic features: Typically mood-congruent delusions/hallucinations.
I Postpartum: Occurs within one month postpartum; has a 10% incidence
and a high risk of recurrence. Psychotic symptoms are common.
I Atypical: Characterized by weight gain, hypersomnia, and rejection sensitivity.
I Seasonal: Depressive episodes tend to occur during a particular season,
most commonly winter. Responds well to light therapy +/– antidepressants.
I Double depression: MDE in a patient with dysthymia. Has a poorer prognosis than MDE alone.
SSRI side effects
Sexual side effects, GI distress, agitation, insomnia, tremor, diarrhea.
Serotonin syndrome
(fever, myoclonus, mental status changes, cardiovascular collapse) can occur if SSRIs are used with MAOIs.
ECT side effects
postictal confusion, arrhythmias, headache, and anterograde amnesia.
Bipolar I
At least one manic or mixed episode (usually requiring hospi- talization).
Bipolar II
At least one MDE and one hypomanic episode (less intense than mania). Patients do not meet the criteria for full manic or mixed epi- sodes.
Bipolar Hx/PE
Symptoms of mania— DIG FAST Distractibility Insomnia (↓ need for sleep) Grandiosity (↑ self- esteem)/more Goal directed Flight of ideas (or racing thoughts) Activities/psychomotor Agitation Sexual indiscretions/ other pleasurable activities Talkativeness/pressured speech
Dx of Mania
A manic episode is one week or more of persistently elevated, expansive, or irritable mood plus three DIG FAST symptoms. Psychotic symptoms are common in mania.
Lithium side effect
Thirst, polyuria, diabetes insipidus, tremor, weight gain, hypothyroidism, nausea, diarrhea, seizures, teratogenicity (if used in the first trimester), acne, vomiting.
Bipolar treatment
lithium
carbamazepine
valproic acid
lamotrigine
Lithium toxicity
> 1.5 mEq/L; presents with ataxia, dysarthria, delirium, and acute renal failure. Avoid lithium in patients with ↓ renal function.
Characteristics of personality disorders—
MEDIC Maladaptive Enduring Deviate from cultural norms Inflexible Cause impairment in social or occupational functioning
Personality Disorder Cluster A:
“weird”
Paranoid: Distrustful, suspicious; interpret others’ motives as malevolent.
schizoid: Isolated, detached “loners.” Restricted emotional expression.
schizotypal: Odd behavior, perceptions, and appearance. Magical thinking; ideas of reference.
Personality disorder Cluster B:
“wild”
Borderline: Unstable mood, relationships, and self-image; feelings of emptiness. Impulsive. History of suicidal ideation or self-harm.
Histrionic: Excessively emotional and attention seeking. Sexually provocative; theatrical.
Narcissistic: Grandiose; need admiration; have sense of entitlement. Lack empathy.
Antisocial: Violate rights of others, social norms, and laws. Impulsive; lack remorse. Begins in childhood as conduct disorder.
Personality disorder Cluster C:
“worried and wimpy”
Obsessive-compulsive: Preoccupied with perfectionism, order, and control at the expense of efficiency. Inflexible morals, values.
Avoidant: Socially inhibited; rejection sensitive. Fear being disliked or ridiculed.
Dependent: Submissive, clingy; need to be taken care of. Difficulty making decisions. Feel helpless.
Schizophrenia
Characterized by
hallucinations, delusions, disordered thoughts, behavioral disturbances, and disrupted social functioning with a clear sensorium.
Schizophrenia onset
Peak onset is earlier in males (ages 18–25) than in fe- males (ages 25–35)
Schizophrenia subtypes
I Paranoid: Delusions (often of persecution of the patient) and/or hal- lucinations are present. Cognitive function is usually preserved. Associated with the best overall prognosis.
I Disorganized: Speech and behavior patterns are highly disordered and disinhibited with flat affect. The thought disorder is pronounced, and the patient has poor contact with reality. Carries the worst prognosis.
I Catatonic: A rare form characterized by psychomotor disturbance with two or more of the following: excessive motor activity, immobility, extreme negativism, mutism, waxy flexibility, echolalia, or echopraxia.
Positive symptoms
Hallucinations (most often auditory), delusions, disorganized speech, bizarre behavior, and thought disorder.
Negative symptoms
Flat affect, ↓ emotional reactivity, poverty of speech, lack
of purposeful actions, and anhedonia.
Extrapyramidal symptoms
acute dystonia
akithiasia
dyskinesia
tardive dyskinesia
Acute dystonia
Involuntary muscle contraction or spasm (e.g., torticollis, oculogyric crisis).
Akathisia
Subjective/objective restlessness, which is perceived as being distressing.
Dyskinesia
Pseudoparkinsonism (e.g., shuffling gait, cogwheel rigidity).
Tardive dyskinesia
Stereotypic oral-facial movements. Likely from dopamine receptor sensitization. Often irreversible (50%).
Attention deficit hyperactivity disorder
Diagnosis requires six or more symptoms from each category listed below for six or more months in at least two settings, leading to significant social and academic impairment.
Innatention: Poor attention span in schoolwork/play; poor attention to detail or careless mistakes; does not listen when spoken to; has difficulty following instructions or finishing tasks; loses items needed to complete
tasks; is forgetful and easily distracted.
Hyperactivity/impulsivity: fidgets leaves seat in classroom; runs around
inappropriately; cannot play quietly; talks excessively; does not wait turn; interrupts others.
ADHD treatment
stimulant: methyphenidate, dextroamphetamine
antidepressants
Autism spectrum Hx/PE
Characterized by abnormal or impaired social interaction and communi- cation together with restricted activities and interests, evident before age three.
Risk factors for suicide—
SAD PERSONS Sex (male) Age (older) Depression Previous attempt Ethanol/substance abuse Rational thought Sickness (chronic illness) Organized plan/access to weapons No spouse Social support lacking
