First Aid Flashcards
Definition of Generalized Anxiety Disorder
uncontrollable, excessive anxiety or worry about multiple activities or events that leads to significant impairment or distress. male:female is 1:2, clinical onset is in early 20s. Presents with anxiety on most days (6 or more months) with 3 or more somatic symptoms (restlessness, fatigue, difficulty concentrating, irritability, muscle tension, disturbed sleep.
short term therapy for generalized anxiety disorder
benzodiazepines. taper once long term therapy is established (i.e. with SSRIs) in view of high risk of tolerance and dependance
dangers of stopping benzos “cold turkey” when treating GAD short term
may develop potentially lethal withdrawal symptoms similar to alcohol withdrawal
Long term therapy for generalized anxiety
lifestyle changes, psychotherapy, medications (SSRIs are first line, venlafaxine, buspirone), patient education
5 anxiolytic meds
SSRIs, Buspirone, Beta blockers, Benzodiazepines, Flumazenil
Side effects of SSRIs
Nausea, GI upset, somnolence, sexual dysfunction, agitation
side effects of Buspirone
seizures with chronic use. no tolerance, dependence or withdrawal
Beta Blocker side effects
bradycardia, hypotension
Benzodiazepines side effects
decreased sleep duration, risk of abuse, tolerance, and dependence, disinhibition in young or old patients; confusion
MOA of Flumazenil
competitive antagonist at GABA receptor
Side effects of Flumazenil
resedation, nausea, dizziness, vomiting, and pain at the injection site.
how to OCD patients generally present
to a nonpsychiatrist- i.e. to a dermatologist with a skin complaint 2/2 overwashing hands
difference btwn OCD and OCPD
OCD: patient recognizes these behaviors as excessive and irrational products of their mind. they wish they could get rid of the obsession and/or compulsion
Treatment for OCD
Pharmacotherapy (SSRIs are first line pharmacologic treatment), cognitive behavioral therapy (CBT) using exposure and desensitization relaxation techniques. patient education is imperative.
Definition of panic disorder
characterized by recurrent, unexpected panic attacks. two to three times more common in females than in males. agoraphobia is present in 30-50% of cases. average age of onset is 25
Definition of a panic attack
defined as discrete periods of intense fear or discomfort in which at least 4 of the following symptoms develop abruptly and peak within 10 minutes: tachypnea, chest pain, palpitations, diaphoresis, nausea, trembling, dizziness, fear of dying or ‘going crazy’, depersonalization, or hot flashes.
perioral and/or acral paresthesias
fairly specific to panic attacks. produce hyperventilation and low O2 saturation
Panic disorder patients present with symptoms for how long
1 or more months of concern about having additional attacks or significant behavior change as a result of attacks.
panic disorder therapy
short term: benzos (avoid long term use cause of addiction or tolerance), taper once tx (i.e. SSRIs). long term: CBT, SSRIs, TCAs
do patients with phobias recognize that their fear is excessive?
yes
PTSD treatment
short term: beta blockers, alpha agonists (i.e. clonidine). Long term: SSRIs are first line, buspirone, TCAs and MAOIs may be helpful. bEnzos are used but should be avoided if possible. psychotherapy and support groups are useful.
definition of a cognitive disorder
affects memory, orientation, judgement, and attention.
Dementia
a decline in cognitive functioning with global deficits. level of consciousness is stable (vs. delerium). Prevalence is highest among those greater than 85 years old. common cause is alzheimers and vascular dementia.
other causes of dementia (DEMENTIA)
Degenerative diseases (parkinsons, huntingtons), endocrine (thyroid, parathyroid, pituitary, adrenal), metabolic (alcohol, electrolytes, vitamin B12 deficiency, glucose, hepatic, rengal, wilson’s disease), exogenous (heavy metals, carbon monoxide, drugs), neoplasia, trauma (subdural hematoma), infection (meningitis, encephalitis, endocarditis, syphilis, HIV, prions, lyme), affective disorders (pseudodementia), stroke/structure (vascular dementia, ischemia, vasculitis, normal pressure hydrocephalus).
Diagnosis of dementia
memory impairment and 1 or more of: the 4 As of dementia (progression of cognitive impairment follows this order- Amnesia, aphasia, apraxia, agnosia), impaired executive function (problems with planning, organizing, and abstracting in the presence of a clear sensorium, personality/mood/behavior changes, often become more confused later in the day and at night.
Rule out treatable causes of dementia. get what labs
CBC, RPR, CMP, TFTs, HIV, B12/folate, ESR, UA, head CT or MRI.
avoid benzos in dementia because
may exacerbate disinhibition and confusion
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
Major Depressive Disorder
characterized by 1 or more major depressive episodes. the male-to-female ratio is 1:2. onset is usually in mid 20s, in elderly, prevalence increases with age. chronic illness and stress increase risk. approximately 2-9% of patients die by suicide.
SIGECAPS
sleep (hyper or insomnia), interest, guilt, energy, concentration, appetite, psychomotor agitation or retardation, suicidal ideation
diagnosing major depressive disorder
depressed mood or anhedonia and 5 or more of SIGECAPS for a 2 week period.
TCA toxicity
three Cs: Convulsions, Coma, Cardiac Arrhythmias
what % of patients with MDD respond to medication
50-70% (allow 2-6 weeks to take effect, treat for 6 months.
most effective treatment regimen for MDD
psychotherapy combined with antidepressants is more effective than either alone
ECT
safe, highly effective and often lifesaving therapy that is reserved for refractory depression or psychotic depression, or if rapid improvement in mood is needed
adverse effects of ECT
post ictal confusion, arrhythmias, headache, and anterograde amnesia
how long to wait to start an MAOI if patient was on fluoxetine? other SSRIs?
5 weeks for fluoxetine, 2 weeks for other SSRI
Bipolar type I
involves at least 1 manic episode or mixed episode (usually needing hospitalization)
Bipolar type II
At least 1 MDE and 1 hypomanic episode
rapid cycling type bipolar
4 or more episodes (MDE, manic, mixed, or hypomanic) in 1 year
cyclothymic type bipolar
chronic and less severe, with alternating periods of hypomania and moderate depression for more than 2 years.
symptoms of mania (screening for bipolar)
DIG FAST (distractability, insomnia, grandiosity, flight of ideas, activity/psychomotor agitation, sexual indiscretions, talkativeness/pressured speech
SSRIs (examples, indications, side effects)
Fluoxetine, sertraline, paroxetine, citalopram, fluvoxamine. for depression, anxiety. has 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, illicit drugs, or herbal medications.
Atypical Antipsychotics (examples, indications)
Bupropion, mirtazapine, trazodone. for depression, anxiety.
Bupropion side effects
decreased seizure threshold, minimal sexual side effects. contraindicated in patients with eating disorders and seizure patients
Mirtazapine side effects
weight gain, sedation
Trazodone side effects
highly sedating, priapism
SNRIs (examples, indications, side effects))
venlafaxine, duloxetine. for depression, anxiety, chronic pain. Venlafaxine can cause diastolic hypertension
TCAs (examples, indications, side effects)
nortriptyline, desipramine, amitriptyline, imipramine. Depression, anxiety disorder, chronic pain, migraine headaches, enuresis. Lethal with overdose owing to cardiac conduction arrhythmias (i.e. prolonged conduction through the AV node, long QRS). monitor in the ICY for 3-4 days following an OD. Anticholinergic effects (Dry mouth, constipation, urinary retention, sedation).
MAOIs (examples, indications, side effects)
Phenelzine, tranylcypromine, selegiline. for depression, especially atypical. Side effects: hypertensive crisis if taken with high tyramine foods (aged cheese, red wine). sexual side effects, orthostatic hypotension, weight gain.
Manic Episode
manic episode is 1 week or more of persistently elevated, expansive, or irritable mood plus 3 DIG FAST symptoms. psychotic symptoms are common in mani.
Treatment of Bipolar Mania
acute therapy: antipsychotics. maintenance therapy- mood stabilizers. use benzodiazepines for refractory agitation.
Treatment of bipolar depression
mood stabilizers +/- antidepressants. start mood stabilizers FIRST to avoid inducing mania. ECT may be used if refractory. In patients with severe depression or bipolar II with predominantly depressive features, antidepressant treatment can be augemented with low dose lithium
Characteristics of a personality disorder
MEDIC: Maladaptive, eduring, deviate from cultural norms, inflexible, cause impairment in social or occupational functioning.
Lithium (indications and side effects)
first line mood stabilizer. used for acute mania (in combo with antipsychotics) for ppx in BPD, and for augmentation in depression treatment. Side effects: thirst, polyuria, diabetes insipidus, tremor, weight gain, hypothyroidism, nausea, diarrhea, seizures, teratogenicity (first trimester), acne, vomiting. narrow therapeutic window. toxicity > 1.5 mEQ/L
Carbamazepine (indications and side effects)
second line mood stabilizer, anticonvulsant, trigeminal neuralgia, Side effects: skin, rash, leukopenia, AV block. Rarely aplastic anemia (monitor CBC weekly). SJS
valproic acid (indications and side effects)
for BPD, anticonvulsant. Side effects: GI, tremor, sedation, alopecia, weight gain. rarely: pancreatitis, thrombocytopenia, fetal hepatotoxicity, and agranulocytosis.
Lamotrigine (indications and side effects)
second line mood stabilizer, anticonvulsant. side effects: blurred vision, GI distress, SJS. increase dose slowly to monitor for rashes
personality disorder clusters A B and C
Weird, Wild, Wimpy (alphabetical)
cluster A disorders
Paranoid, Schizoid, Schizotypal
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
Cluster B disorders
Borderline, histrionic, narcissistic, antisocial
Borderline personality disorder
unstable mood, relationships, and self image. feelings of emptiness. impulsive. history of suicidal ideation or self-harm.
Histrionic personality disorder
excessively emotional and attention seeking. sexually provocative, theatrical
Narcissistic personality disorder
grandiose; need admiration; have sense of entitlement, lack empathy
Antisocial personality disorder
Violate rights of others, social norms, and laws. Impulsive; lack of remorse. Begins in childhood as conduct disorder
Cluster C disorders
Obsessive-compulsive, avoidant, dependent
Obsessive-compulsive disorder
Preoccupied with perfectionism, order, and control at the expense of efficiency. inflexible morals and values.
Avoidant personality disorder
socially inhibited, rejection sensitive. Fear being dislike or ridiculed
Dependent personality disorder
submissive, clingy, have a need to be takenc are of. Have difficulty making decisions. Feel helpless
Schizophrenia (etiology)
Dopamine dysregulation (frontal hypoactivity and limbic hyperactivity), and bran abnormalities on CT and MRI (enlarged ventricles and decreased cortical volume.
Subtypes of schizophrenia
Paranoid, disorganized, catatonic
Paranoid type schizophrenic
delusions and/or hallucinations are present. cognitive function is usually preserved. Associated with the best overall prognosis
Disorganized type schizophrenic
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
Catatonic type schizoprenia
rare form characterized by psychomotor disturbance with 2 or more of the following; excessive motor activity, immobility, extreme negativsm, mutism, waxy flexibility, echolilia, or echopraxia
Schizophreniform disorder
symptoms of schizophrenia with a duration of less than 6 months
positive schizo symptoms
hallucinations, delusions, disorganized speech, bizarre behavior, and thought disorder
negative schizo symptoms
flat affect, decreased emotional reactivity, poverty of speech, lack of purposeful actions, anhedonia.
schizoaffective disorder
combines the symptoms of schizophrenia with a major affective disorder (MDD or BPD)
delusion v. hallucination v. illusion
Delusion: fixed false idiosyncratic belief. Hallucination- perception without an existing external stimulus. illusion: misperception of an actual external stimulus
Treatment of schizophrenia
antipsychotics, long term follow up. supportive psychotherapy, training in social skills, vocational rehabilitation, and illness education may help
ADHD
persistent pattern of excessive inattention and/or hyperactivity/impulsivity. more common in males; typically presents between ages 3 and 13. often shows a familial pattern. Diagnosis requires 6 or more symptoms from each category listen below for 6 or more months in at least 2 settings
Typical antipsychotics (examples, indications, side effects)
Haloperidol, droperidol, fluphenazine, thioridazine, chlorpromazine. Psychotic disorders, acute agitation, acute mania, tourette’s syndrome. Thought to be more effective for positive symptoms of schizophrenia. primarily block D2 receptors. For patients in whom compliance is a problem, consider depot forms of haloperidol, fluphenazine, etc.
DMS IV criteria for schizophrenia
two or more must be present for at least 1 month: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative symptoms (flattened affect etc). Must cause significant social or occupational functional deterioration, duration of illness fora t least 6 months (including prodromal or residual periods in which above criteria may not be met), symptoms not due to medical, neurological, or substance-induced disorder
genetic predisposition to schizophrenia
50% concordance rate among monozygotic twins, 40% risk if both parents have schizophrenia, 12% if one first degree relative is affected
what pathway is responsible for negative schizophrenia symptoms
prefrontal cortical
what pathway is responsible for positive symptoms of schizophrenia
mesolimbic
what pathway is blocked by neuroleptics that causes hyperprolactinemia
tuberoinfundibular
what pathway causes extrapyramidal side effects when blocked by neuroleptics
nigrostriatal
CT scans of patients with schizophrenia often show
enlargement of the ventricles and diffuse cortical atrophy
neurotransmitter abnormalities implicated in schizophrenia
elevated serotonin (risperidone and clozapine antagonize serotonin and dopamine), elevated norepinephrine (long term antipsychotic use decreases activity of noradrenergic neurons), and decreased GABA
better prognostic factors in schizophrenia
later onset, good social support, positive symptoms, mood symptoms, acute onset, female sex, few relapses, good premorbid functioning
worse prognostic factors in schizophrenia
early onset, poor social support, negative symptoms, family history, gradual onset, male sex, many relapses, poor premorbid functioning (social isolation)
Typical antipsychotics/neuroleptics
chlorpromazine, thioridazine, trifluoperazine, haloperidol. D2 antagonists. better at treating positive than negative symptoms. important side effects and sequelae (EPS, NMS, TD)
Atypical neuroleptics/antipsychotics
Risperidone, clozapine, olanzapine, quetiapine, aripiprazole, ziprosidone. Antagonize 5-HT2 receptor as well as dopamine. better at treating negative symptoms. lower incidence of EPS.
EPS
dystonia- spasms of neck, face, tongue. parkinsonism (resting tremor, rigidity, bradykinesia), akathisia (feeling of restlessness)
Treatment of EPS
antiparkinsonian agents (benztropine, amantadine, etc), benzodiazepine
two antipsychotics with highest incidence of EPS
haloperidol and trifluoperazine
antipsychotics with more anticholinergic side effects
chlorpromazine and thioridazine
Tardive Dyskinesia (and tx)
darting or writhing movements of face, tongue, and head. d/c offending agent and substitute atypical. benzodiazepines, beta blockers, and cholinomimetics may be used short term. often persists despite withdrawal of agent.
Neuroleptic malignant syndrome
confusion, high fever, elevated BP, tachycardia, “lead pipe” rigidity, sweating, and greatly elevated creatine phosphokinase.
Schizophreniform V. Schizophrenia
schizophreniform: symptoms have lasted between 1 and 6 months. schizophrenia: symptoms more than 6 months.
Schizoaffective disorder
meet criteria for either major depressive episode, manic episode, or mixed episode. have had delusions or hallucinations for 2 weeks in the absence of mood disorder symptoms, have mood symptoms present for substatial portion of psychotic illness, not due to medical illness
Brief psychotic disorder
1 day to 1 month.
delusional disorder criteria
nonbizarre, fixed delusions for at least 1 month, does not meet criteria for schizophrenia, functioning in life not significantly impaired.
schizotypal
paranoid, odd or magical beliefs, eccentric, lack of friends, social anxiety, criteria for true psychosis are not met
schizoid
withdrawn, lack of enjoyment from social interactions, emotionally restricted
Major depressive episode criteria
must have at least 5 of following symptoms for at least a 2 week period: depressed mood, anhedonia, change in appetite or weight, worthlessnes or guilt feelings, insomnia or hypersomnia, diminished concentration, psychomotor agitation or retardation (restlessness or slowness), fatigue or loss of energy, recurrent thoughts of death or suicide.
manic episode criteria
period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week and including at least three of the following: distractibility, inflated self esteem or grandiosity, increase in goal directed activity, decreased need for sleep, flight of ideas/racing thoughts, more talkative or pressured speech (rapid and uniterruptible), excessive involvement in pleasurable activities that have a high risk of negative consequences (i.e. buying sprees, sexual indiscretions)
DIG FAST
distractibility, insomnia, gradiosity, flight of ideas, activity/agitation, speech (pressure), thoughtlessness
possible medical conditions that can cause depressive episodes
cerebrovascular disease, endocrinopathies (cushings, addisons, hypoglycemia, hyper/hypothyroid, hyper/hypocalcemia), parkinson’s, viral illnesses (mono), carcinoid syndrome, cancer (lymphoma, and pancreatic cancer), collagen vascular disease (i.e. lupus).
possible medical conditions that can cause manic episodes
metabolic (hyperthyroidism), neurological disorders (temporal lobe seizures, multiple sclerosis, neoplasms, HIV infection
medication/substances that can induce depressive episodes
EtOH, anti-HTN, barbiturates, corticosteroids, levodopa, sedative-hypnotics, anticonvulsants, antipsychotics, diuretcs, sulfonamides, withdrawal from psychostimulants
medication/substances that can induce mania
corticosteroids, sympathomimetics, dopamine agonists, antidepressants, bronchodilators, levodopa
SSRI side effects
headache, GI disturbance, sexual dysfunction, rebound anxiety
TCA side effects
most lethal in OD, sedation, weight gain, orthostatic hypotension, anticholinergic effects, can aggravate prolonged QT
MAOI side effects
hypertensive crisis when used with sympathomimetics or ingestion of tyramine rich foods (wine, beer, cheese, liver, and smoked meats). Serotonin syndrome when combined with SSRIs. most common side effect is orthostatic hypotension (tyramine is an intermediate in the conversion of tyrosine to NE.
serotonin syndrome
autonomic instability, hyperthermia, seizures. coma or death may result.
ECT is performed by premedication with
atropine
how to treat catatonic depression
with antidepressants and antipsychotics concurrently
Bipolar I disorder criteria
occurrence of one manic or mixed episode (10 to 20% of patients experience only one manic episode). btwn manic episodes they may have euthymia, MDD, dysthymia, or hypomanic episodes, but none required for dx
rapid cycling definition
occurrence of four or more mood episodes in 1 year (major depressive, manic, mixed, etc)
treatment of bipolar
lithium, anticonvulsants (carbamazepine or valproic acid)- also mood stabilizers, especially useful for rapid cycling bipolar disorder. Olanzapine- typical antipsychotic
side effects of lithium
weight gain, tremor, GI disturbances, fatigue, arrhythmias, seizures, goiter/hypothyroidism, leukocytosis (benign), coma, polyuria, polydypsia, alopecia, metallic taste
