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Psychiatry > First Pass Miss Exam 1 > Flashcards

First Pass Miss Exam 1 Flashcards

1
Q

What factors fall under social factors? (Three categories, bio-psycho-social)

A
  1. Current family relationships and interactions (not experiences, which would be psychological factors)
  2. Supports and stressors
  3. Racial, religious, socioeconomic, and cultural background -> think social determinants of health
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2
Q

What is affect?

A

The outward expression of mood -> objectively observed

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3
Q

What are the components of affect which are clinically useful?

A
  1. Variability - does it fluctuate through the interview? (labile affect)
  2. Intensity - Dysphoric vs euthymic (normal) vs euphoric
  3. Appropriateness to mood - is their self-reported mood in congruence with their affect?
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4
Q

List the 10 components of the MSE?

A 
Appearance and behavior 
Psychomotor abnormalities 
Speech 
Mood 
Affect 
Thought Process 
Thought Content 
Sensorium and Intellectual Function 
Insight 
Judgment
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5
Q

What are the components of thought content?

A

Hallucinations, delusions, illusions, recurring themes, and suicidal / homicidal ideation

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6
Q

What is formication?

A

A tactile hallucination of bugs crawling under the skin, often associated with substance withdrawal

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7
Q

A speaker has no goal-directed associations and never gets to the desired end point when asked a question. How do you describe their speech?

A

Tangential

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8
Q

What are the types of dysphoric mood?

A

Flat -> most severe dysphoria
Blunted -> mood seems a little flatter than expect
Constricted -> almost normal but still clearly less intense in feeling

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9
Q

What are the names for normal sensory hallucinations which happen when falling asleep or waking up?

A

Falling asleep - Hypnagogic

Waking up - Hypnopompic (hopping out of bed)

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10
Q

What are two types of recurring themes? What are these in general?

A
  1. Obsessions - irresistible thought or feeling which cannot be eliminated from consciousness - luke obsessing over gary
  2. Negative ruminations - i’m gonna die

These are topics so important that the interview seems to keep returning to it

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11
Q

What are the components of sensorium and intellectual functioning?

A 
Consciousness 
Orientation 
Attention and concentration 
Memory 
Abstraction 
Fund of knowledge
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12
Q

What are the two types of visual hallucinations and what is this common in?

A
  1. Formed images - i.e. people
  2. Unformed images - i.e. light flashes

Most common hallucination in psychosis due to another mental illness

(for example, Parkinson’s)

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13
Q

What are the four primary infant reflexes? When do they disappear?

A

BMR-P - 12,3,4,6

  1. Babinski - 12 months
  2. Moro - 3 months
  3. Rooting - 4 months
  4. Palmar - 6 months

Disappears like the ocular nerve numbers, 3, 4, 6 months

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14
Q

What is attachment and its significance of attachment to infancy? What are the possible effects if it is not there?

A

Emotional connection that develops between infant and primary caregiver

Effects of deprivation longterm:

  1. Anaclitic depression
  2. Social / emotional deficits - poor socialization / language / trust in others
  3. Physical effects - failure to thrive, even death
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15
Q

When does separation anxiety develop and what is it?

A

Occurs by 9 months, separation from primary caregiver gives normal anxiety - this is when object permanence starts and when the child can orient to name

Stranger anxiety begins at 6 months

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16
Q

What is the order of postural developments in infancy? From lying down to walking.

A 
Lifts head to prone by 1 month 
Rolls over by 4-5 months 
Sits and rolls by 6 months 
Crawls by 8 months 
Stands by 10 months 
Walks by 12-18 months

2-4-6-8-10-12
Head->Roll->Sit->Crawl->Stand->Walk

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17
Q

What are the toy playing milestones in infancy?

A

6 months - passes toys hand to hand - once they can sit, they can do dis
10 months - Pincer grab (thumb to finger) - think of them having to grab something to stand

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18
Q

When does gender identity set in and when is it fixed? Is it innate?

A

Begins at 18 months - you feel male or female
Fixed by 24-30 months.

Yes, majority of it is innate

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19
Q

What are the four C’s of toddlership (Child rearing working)?

A

Cruises - takes first steps by 12-18 months, runs by 24 months
Climbs stairs 18 months
Cubes stacked - 3 x age in years = 6 by two years
Cutlery - feeds self with fork and spoon - 20 months
Kicks ball - not a C, but 24 months

Runs by 2 years (same as rapproachment, parallel play, kicking ball)

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20
Q

What are the three D’s of preschool years (Don’t forget they’re still learning)?

A

Drive - can ride tricycle with 3 wheels (age 3 for three wheels)
Drawings
Dexterity - Hops on one foot by age 4, Uses buttons / grooms self by age 5, can use buttons or zippers by age 5 (full dressing of self by age 5)

REVIEW PAGE 258

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21
Q

What are the two L’s of preschool years (don’t forget they’re still Learning)?

A

Language - 3 zeros for age 3 - knows 1000 words. Can also use complete sentences by age 4.
Legends - At age 4, when can use complete sentences, can also tell complete stories.

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22
Q

What are Freud’s and Erikson’s third stage and their timing? What are the feature’s of Freud’s phase?

A

3-5 years (preschool years)
Freud - Phallic Phase
-> preoccupation with illness / injury
-> Oedipal complex -> child competes with parent to focus on parent of opposite sex

Erikson - Initiative vs Guilt

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23
Q

What are Freud’s and Erikson’s second stage and their timing?

A

Both 1-3 years (toddlerhood)

Freud - Anal phase - urges centered on controlling bowel functions / body functions (potty training)

Erikson - Autonomy vs Shame and Doubt

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24
Q

What is Piaget’s second stage and how long does it last? How is their thinking?

A

Preoperational stage 2-7 years
Child uses symbols and language
-> Thinking and reasoning are intuitive, not logical / deductive.
-> cannot understand metaphors

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25
Q

What is Piaget’s third stage and what characteristics underlie it?

A

Concrete operations, Ages 7-11 (preoperational was 2-7), ends the same year as Freud’s latency stage

Ability to understand other’s viewpoint (no longer egocentric), ability to organize / group according to characteristics of objects

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26
Q

What is Erikson’s fourth stage? Years?

A

5-13 years: Industry vs Inferiority

Child must understand his family is part of a larger society, and focuses on learning and doing

Industry - develops a sense of mastery over environment / accomplishment

Inferiority - when a child cannot master tasks

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27
Q

What are Freud’s and Erikson’s third stage and their timing? What are the feature’s of Freud’s phase?

A

3-5 years (preschool years)
Freud - Phallic Phase
-> preoccupation with illness / injury
-> Oedipal complex -> child competes with parent to focus on parent of opposite sex

Erikson - Initiative vs Guilt

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28
Q

What are the leading causes of death in people 0-1 years? 1-14 years? 15-35? 35-44?

A

0-1: Congenital malformations, premature birth, SIDS
1-14: Accidents, cancer, congenital malformations
15-35: Accidents, Homicide, Suicide
35-44: Accidents, Cancer, Heart Disease
45-64: Cancer, Heart Disease, Accidents
65+: Heart Disease, Cancer, Chronic Respiratory Disease

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29
Q

What are Freud’s and Erikson’s third stage and their timing? What are the feature’s of Freud’s phase?

A

3-5 years (preschool years)
Freud - Phallic Phase
-> preoccupation with illness / injury
-> Oedipal complex -> child competes with parent to focus on parent of opposite sex

Erikson - Initiative vs Guilt

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30
Q

What are Freud’s and Erikson’s second stage and their timing?

A

Both 1-3 years (toddlerhood)

Freud - Anal phase - urges centered on controlling bowel functions / body functions (potty training)

Erikson - Autonomy vs Shame and Doubt

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31
Q

What is Piaget’s second stage and how long does it last? How is their thinking?

A

Preoperational stage 2-7 years
Child uses symbols and language
-> Thinking and reasoning are intuitive, not logical / deductive.
-> cannot understand metaphors

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32
Q

What is Piaget’s third stage and what characteristics underlie it?

A

Concrete operations, Ages 7-11 (preoperational was 2-7), ends the same year as Freud’s latency stage

Ability to understand other’s viewpoint (no longer egocentric), ability to organize / group according to characteristics of objects

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33
Q

What is Erikson’s fourth stage? Years?

A

5-13 years: Industry vs Inferiority

Child must understand his family is part of a larger society, and focuses on learning and doing

Industry - develops a sense of mastery over environment / accomplishment

Inferiority - when a child cannot master tasks

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34
Q

What are Freud’s and Erikson’s third stage and their timing? What are the feature’s of Freud’s phase?

A

3-5 years (preschool years)
Freud - Phallic Phase
-> preoccupation with illness / injury
-> Oedipal complex -> child competes with parent to focus on parent of opposite sex

Erikson - Initiative vs Guilt

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35
Q

What are the leading causes of death in people 0-1 years? 1-14 years? 15-35? 35-44?

A

0-1: Congenital malformations, premature birth, SIDS
1-14: Accidents, cancer, congenital malformations
15-35: Accidents, Homicide, Suicide
35-44: Accidents, Cancer, Heart Disease
45-64: Cancer, Heart Disease, Accidents
65+: Heart Disease, Cancer, Chronic Respiratory Disease

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36
Q

What are the five stages of grief?

A
  1. Denial
  2. Anger
  3. Bargaining
  4. Despair / Depression
  5. Acceptance
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37
Q

What are the types of denial? Define: magical thinking, excessive fantasy, regression, withdrawal/rejection

A
  1. Magical thinking - things will be different by magic
  2. Excessive fantasy - nothing is wrong, loss is imagined
  3. Regression - make others assure them nothing is wrong, child-like
  4. Withdrawal / rejection - avoiding and rejecting those who confront them with the truth
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38
Q

How does the topographic model of the mind explain psychiatric illness? Structural model = id, ego, superego

A

Symptoms are the result of repressed memories or ideas which can be treated with lifting the repression -> memories can be recalled and symptoms resolved

Structural model - symptoms caused by conflict of the various conscious parts, and usage of defense mechanisms to resolve this

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39
Q

When is repression? How does this differ from denial and suppression?

A

Involuntary withholding of an unacceptable idea / impulse from consciousness

Denial -> Refutation of external data. Repression is denial of inner data
Suppression -> Intentional and temporary withholding of an unacceptable idea / impulse

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40
Q

What is idealization and when is it used?

A

Attributing perfect qualities to others while ignoring any flaws (to ignore negative thoughts)

  • > avoids anxiety or negative feelings such as contempt, envy or anger
  • > if you are anxious about your cancer, this might be a defense to make yourself feel like you’re in good hands
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41
Q

What is altruism and when can it be used negatively?

A

Committing oneself to the needs of other over and above one’s own needs

  • > alleviate negative feelings via unsolicited generosity
  • > can be used negatively in narcissism (want to win big prize) and guilt (remorse for bad actions)
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42
Q

How does graded exposure differ from systematic desensitization?

A

Graded exposure = doing systematic desensitization in real life.

i.e. moving through the hierarchy when you have a fear of flying by looking at pictures, then going to airport, flying on plane short trip, etc

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43
Q

What is reaction formation vs sublimation?

A

Reaction formation -> doing the opposite of an unacceptable wish or impulse. I.e. going to a monastery when you feel like having sex, overcompensating but not being genuine.

Sublimation -> channeling those feelings into something positive / something that does not conflict with your value system -> i.e. former cocaine addict works for a substance abuse hotline to help others after he feels like smoking da crack

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44
Q

What is implosion?

A

Carrying out flooding in imagined scenarios

-> Implosion is to systematic desensitization as flooding is to graded exposure

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45
Q

What type of therapy is indicated specifically for borderline personality disorder and how does it work? What is the goal?

A

Dialectical Behavioral Therapy (DBT)

Individual and group therapy which draws from CBT and supportive psychotherapies.

  • > see individuals weekly for 1 year. Taught to be mindful of present, regulate their emotions, and accept negative feelings
  • > goal is to reduce self destructive / self harm behaviors and improve interpersonal skills
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46
Q

What is the domino effect of interpersonal relationships in depression?

A

Depressive episodes are triggered, which leads to negative interpersonal encounters, which further lowers mood and social functioning
-> IPT (interpersonal therapy) can be useful to reverse this and improve mood

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47
Q

What is Milieu therapy?

A

A type of group therapy used on inpatient psych wards to help increase patients’ ability to relate to world and others

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48
Q

How does family therapy differ from individual therapy and what are its main goals?

A

Focuses on family as a unit rather than individual, knowing that the family unit attempts to maintain homeostasis

Goals:
Change maladaptive roles in the house
Improve communication
Decrease blaming / scapegoating

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49
Q

What is psychodynamic psychotherapy / what is it based on?

A

Based on Freud’s psychoanalytic theory

  • > symptoms result from early experiences with buried conflicts
  • > uncovering the unconscious results in improved self-understanding and conflicts can be resolved
  • > uncover the conflicts, repressed feelings, and issues from early life

->psychoanalysis is the more intense form of this 3-6 times per week

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50
Q

What is the typical thought process in MDD? What is the most dangerous thought content?

A

Typical -> poverty of ideation - slowed thinking and low or no thoughts, often with negative ruminations and hopelessness / helplessness

Most dangerous: psychotic depression with perceptual disturbances / command hallucinations = “you should kill your wife then yourself”

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51
Q

How does the dexamethasone suppression test for MDD work? What does it indicate?

A

Give dexamethasone

  • > in non-depressed people, coristol production is suppressed
  • > in depression, cortisol production is unchanged (increased cortisol levels in depression)

That person with positive test + diagnosed depression is more likely to have melancholia, psychotic features, and at greater risk for suicide

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52
Q

What medical condition is depression a risk factor for?

A

Cardiac events / CAD in patients with pre-existing heart condition
-> same risk for MI as LV dysfunction

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53
Q

How is full remission defined for MDD?

A

A return to patient’s baseline level of symptom severity and functioning, which correlates with a HAMD score of <7 for greater than 2 months

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54
Q

What sleep abnormalities are present in MDD?

A

Increased sleep latency

Decreased REM latency and greater proportion of REM sleep

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55
Q

How long should patient be treated in continuation phase? How often should patient be seen in continuation / maintenance phase?

A

6 months to a year on pharmacotherapy

  • > goal is to prevent relapse
  • > requires monthly visits (can go to quarterly in maintenance)

Acute phase is the time it takes to get a >50% reduction in MDD symptoms via HAMD

56
Q

What is dysthymia now called and what are its diagnostic criteria? What is the time table?

A 
Persistent depressive disorder (PDD) 
Depressed mood and 2+ of HCASES 
H: Hopelessness 
C: Concentration decrease 
A: Appetite change 
S: Sleep change 
E: Energy decrease 
S: Self esteem reduction

Must be for MOST days x2 years, never without symptoms for >2 months
Not enough symptoms for MDD

57
Q

When must symptoms be present for PMDD?

A

Premenstrual dysphoric disorder
-> in most menstrual cycles over the last year (>2 cycles), with at least 5+ symptoms during week before menses, with improvement within a few days of menses, and minimal / no symptoms a week post menses

58
Q

What are the AT LEAST 1 required symptoms of PMDD?

A

Affective lability (i.e. mood swings)
Irritability / anger / conflict
Depressed mood
Anxiety / tension

Anxiety, Depression, Anger, Lability

59
Q

What are the additional symptoms of PMDD?

A

Depression symptoms
Overwhelmed / out of control feeling
Physical symptoms - include breast tenderness, joint / muscle pain, bloating / weight gain

60
Q

What are the diagnostic criteria for a manic episode? Include time scale.

A

At least 1 week of:
Distinct period of abnormally / persistently elevated or irritable mood
AND
Persistently increased goal-directed activity or energy
PLUS 3+ of:
DIGFAST
Distractibility
Indiscretion - excessive pleasurable activities
Grandiosity
Flight of ideas / racing thoughts
Activity increase
Sleep deficit only (decreased need for sleep)
Talkativeness

So, goal-directed activity/energy + a elevated mood + DIGFAST

61
Q

What are the nonspecific brain findings in MDD? With regards to activity

A

Reduced activity in dorsolateral prefrontal cortex -> seat of reasoning = associated cognitive decline

Increased activity in amygdala and ventromedial prefrontal cortex -> leads to depressed mood and anxiety

  • > hypoactivity of the cortex overall on PET scan
  • > also has increased ventricle:brain ratio, with overall atrophy and decreased size of hippocampus (size also decreased in PTSD)
62
Q

How does a hypomanic episode differ from a manic episode?

A

Identical to manic episode except:

  1. Lasts at least 4 days (instead of one week)
  2. Less significant impairment in functioning -> just noticeable and uncharacteristic change
  3. NO associated psychotic symptoms
63
Q

What is the nonspecific brain finding for BPD?

A

Enlarged third ventricles

64
Q

How are substance induced depressive and bipolar disorders diagnosed?

A

Same criteria as medical-illness induced, except symptoms develop within 1 month of starting or withdrawing from a substance
+
evidence of association with intoxication or withdrawal and the diagnostic mood symptoms

65
Q

How are MDE criteria changed for children?

A

Depressed mood may be changed to include irritability

Weight loss may be replaced with growth retardation / lack of expected weight gains

  • > same change for PDD, and also can be >1 year
  • > same change with cyclothymia

Guess these kids’ lives are two short for >2 year diagnoses

66
Q

What are the criteria for the “anxious distress” modifier?

A 
2+ during majority of time patient is MDE or manic: 
A. Keyed up or tense 
B. Unusually restless 
C. Concentration issues due to worry 
D. Fear of something awful happening 
E. Fear of losing control

tense, restless, fear of bad things / loss of control, concentration problems

-> puts you at risk of suicide and treatment nonresponse

67
Q

What are the criteria for the “seasonal pattern” modifier?

A

Association between onset of symptoms and time of year.

During past 2 years, 2+ episodes demonstrate a pattern, with NO nonseasonal episodes. Seasonable episodes outweigh non-seasonal episodes throughout the patient’s lifetime.

68
Q

What two modifiers can only be applied to MDE, and not BPD1/2?

A

Atypical features (MAOI), melancholic features (dexamethasone risk factor)

69
Q

What are the diagnostic criteria for atypical features?

A

MDE only:
High mood reactivity
Significant weight gain / increase of appetite with hypersomnia
Leaden paralysis - feeling stiff / heavy
Oversensitivity to rejection

70
Q

What are the diagnostic criteria for melancholic features?

A

Opposite of atypical: Low mood reactivity / complete anhedonia, significant anorexia / weight loss, early morning awakening / insomnia, worse in the morning.

Marked psychomotor abnormalities.

71
Q

What is the peripartum onset modifier?

A

MDE or BPD with symptoms starting during pregnancy or within 4 weeks of delivery

72
Q

What two modifiers can be applied to BPD 1 and MDE, but not BPD2?

A

Psychotic features, catatonic features

73
Q

What are the diagnostic criteria groups for panic disorder?

A
  1. Recurrent panic attacks
    or
  2. At least 1 month of persistent concern of having another panic attack, causing behavioral change

Typical other DSM criteria

74
Q

What part of the brain is responsible for anticipatory anxiety? What types of anxiety manifestations do the following brain areas cause: prefrontal cortex? brain stem?

A

Amygdala / limbic system

Prefrontal cortex is responsible for avoidance behaviors

Brain stem: autonomic symptoms

75
Q

What, in general, are the diagnostic criteria for agoraphobia?

A

Fear of public spaces where escape might be difficult or help unavailable for greater than 6 months.

Anxiety is out of proportion to the actual threat posed, and thus these situations are avoided or endured with extreme anxiety

76
Q

How are agora and specific phobias treated with therapy? OCD?

A

Agora / specific phobias - Exposure with graded desensitization

OCD - Exposure plus response prevention

77
Q

What, in general, is social anxiety disorder? What is the normal age of onset?

A

A fear or avoidance of social / interactional situations which lasts more than 6 months, can be as small as eating / using bathroom in public

Typically in teen years

-> frequently cormorbid with depression and alcohol dependence (gotta drink to talk to people)

78
Q

What, in general, is generalized anxiety disorder?

A

Excessive anxiety and worry more days than not for at least 6 months

-> Requires associated physiological / psychological symptoms

79
Q

What types of diseases are typically on the differential diagnosis for anxiety / panic disorders?

A

Cardiovascular / respiratory dysfunction to cause the physiological symptoms, endocrine dysfunction for stress hormones, etc

80
Q

What are the four core features of PTSD? How long must they be present?

A

More than 1 month

  1. Intrusive symptoms -> i.e. memories, nightmares, physiologic response
  2. Avoidance behavior -> avoidance of triggers
  3. Negative mood / cognitions -> includes forgetting important aspects / distorted cognition
  4. Hyperarousal symptoms -> exaggerated startle, irritable behavior, sleep problems
    - > treat symptoms with pharmacotherapy
81
Q

What are two important specifiers of PTSD?

A
  1. With dissociative symptoms -> i.e. depersonalization

2. With delayed expression -> does not start until 6 months after event (i.e. holocaust victims until retirement)

82
Q

What area of the brain which regulates affect is found to be hypoactivated in PTSD?

A

medial prefrontal cortex, including orbitofrontal cortex and anterior cingulate cortex

83
Q

What are the criteria for an adjustment disorder?

A

Emotional or behavioral symptoms in response to a stress occurring within 3 months of a stressor, which will not persist for more than 6 months after stress is removed.

  • > cause marked distress out of proportion to severity / intensity of stressor
  • > cause significant impairment
  • > often comorbid with personality disorders and substance abuse
  • > treat with therapy or short-term anxiety meds
84
Q

What conditions are commonly co-morbid with OCD, and one unique one?

A

Anxiety disorders or mood disorders

Unique - up to 30% have co-morbid tic disorders, and with Tic can be used as a specifier for the OCD

85
Q

What are the noradrenergic and HPA findings in PTSD?

A

Noradrenergic - increased epinephrine concentrations in urine + downregulation of platelet alpha-2 receptors

HPA - low plasma / urinary cortisol, which cannot be stimulated easily with CRF and is enhanced suppression by dexamethasone (opposite of depression), overly-suppressed

86
Q

What is one OCD-related disorder when the prevalence in men is more than women and its diagnostic criteria basically?

A

Hoarding disorder

  • > holding onto items regardless of value, accumulating as clutter in living areas which prevents their intended use.
  • > Causes distress to discard the items
  • > think of Mr. McLeroth not being able to use the basement
87
Q

Why does hairpulling in trichotillomania continue and when does it start?

A

Typically starts in 11-13 year olds and is lifelong

-> response to negative emotions and is positively reinforced because it feels good

88
Q

What two neurosurgeries can be used for OCD?

A

Cingulotomy - bilateral lesioning of the anterior cingulate gyrus between orbitofrontal cortex (seat of wisdom) and limbic system

Capsulotomy - anterior limb of internal capsule - relay between cortical structures and thalamus

89
Q

What dirty drug is good for treating trichotillomania and OCD?

A

Clomipramine - a tricylic antidepressant

-> highly serotonergic

90
Q

What is PANDAS?

A

Abrupt onset of OCD in children following Streptococcus infection (Group A Strep)
-> analogous to Syndenham’s chorea, due to autoimmune condition

91
Q

How does acute distress disorder differ from PTSD? What is the treatment?

A

Acute stress disorder is from 3 days to 1 month after trauma, although it has the same symptoms
-> becomes PTSD after 1 month

Possible beta-blockers to prevent memory consolidation, but mostly just CBT

92
Q

What three psychiatric comorbidities are very common with anorexia nervosa?

A
  1. Depression
  2. OCD - anorexia was once thought to be part of OCD spectrum
  3. Personality disorders - Avoidant & OCD
93
Q

What personality disorders are associated with bulimia nervosa?

A

Avoidant & Borderline Personality Disorder

94
Q

What reproductive / hormonal changes occur in anorexia?

A

Low LH / FSH / TSH leads to hypothyroid symptoms as well as amenorrhea
-> Low TSH / hypothyroidism explains the comorbid depression

95
Q

What are the DSM general criteria for AN?

A
  1. Restriction of energy intake leading to low body weight or less than minimally expected for children
  2. Intense fear of gaining weight
  3. Disturbed view of own weight / shape
96
Q

What are the two subtypes of AN?

A
  1. Restricting type -> no binging and purging for last 3 months, just calorie restriction
  2. Binge-eating / Purging type -> engage in binge-eating / purging during last 3 months

People can alternate between these two

97
Q

How does Binge-eating / purging subtype of AN differ from bulimia?

A

Bulimia is not associated with a decreased overall weight and an intense fear of weight gain (just preoccupation with weight)

98
Q

What metabolic effects are seen from vomiting in bulimia and purging-type anorexia?

A

Hypokalemic, hypochloremic alkalosis

  • > increased HCl excretion in vomit leads to increased bicarbonate uptake in the kidney to compensate for loss of Cl-
  • > less H+ is able to be exchanged for K+, so not as much K+ can be reabsorbed
99
Q

What is the initial treatment for AN and what should be avoided? After recovery?

A

Gradual weight restoration -> try to return to normal weight before discharge
+
Cyroheptadine - antihistamine and anti-5HT to increase apetite

Avoid:
Refeeding syndrome - increased insulin upon introduction of carbohydrates in feeding leads to hypophosphatemia (glucose-6-phosphate formation) and cardiac arrhythmias. GO SLOWLY

SSRIs - until weight is restored

After recovery, use:
SSRIs
Cyproheptadine (for appetite)
Atypical antipsychotics

100
Q

What are the diagnostic criteria for bulimia nervosa?

A
  1. Recurrent binge eating with lack of self control
  2. Recurrent inappropriate compensatory behavior
    - > could be vomiting, but often only laxatives, enemas, diuretics, meds, or even excessive exercise
  3. Behavior must average at least 1x per week for 3 months
  4. Negative self-evaluation on body shape / weight gain
101
Q

What are the subtypes of BN?

A
  1. Purging type -> self-induced vomiting or use of laxatives as compensatory behaviors
  2. Nonpurging type -> Other inappropriate compensatory behaviors like fasting and excessive exercise are used
102
Q

How is management of bulimia nervosa different than anorexia nervosa?

A
  1. Most patients can be managed as outpatients rather than inpatients, with same emphasis on therapy and SSRI / antipsychotic use.
  2. Bulimia patients should NOT be given cyproheptadine since their appetite is normal (vs AN)
103
Q

What is purging disorder? What are they at risk for developing?

A

Recurrent purging after consuming only a SMALL amount of food in persons with normal weight and a distorted body image

At risk for developing bulimia

-> note that there is also a binge eating disorder

104
Q

Other than bupropion, what other class of medication is relatively contraindicated in eating disorders?

A

Stimulants (i.e. methylphenidate)

-> abuse potential + cause weight loss / decreased appetite

105
Q

What features of depression might make you want to learn more towards psychotherapy than pharmacotherapy?

A
  1. Presence of personality disorders

2. Psychosocial stressors -> medication cannot fix this

106
Q

What are some of the withdrawal symptoms of SSRIs?

A

Dizziness, nausea, paresthesias, anxiety, insomnia

-> must be tapered over 2-4 weeks

107
Q

Which SSRI has the most CYP interactions, and which SSRIs are known to interfere with opiates?

A

Fluvoxamine - most interactions

Fluoxetine (most activating) and paroxetine (most sedating) - interferes with effectiveness of opiates like codeine via CYP2D6 interference blocking conversion to active form

108
Q

What is the mechanism of action of mirtazapine? Include all relevant receptors and their effects

A

Noradrenergic and specific serotonergic antagonist (NaSSA)

  • blocks 5-HT2 and 5-HT3 receptors (increases 5-HT1 agonism overall), with fewer sexual / GI side effects
  • blocks alpha2 receptors - increases NE in the synapse
  • histamine antagonism - increases weight gain and sedation
109
Q

What is the mechanism of action of Vilazodone? What is its increased side effect?

A

SPARI - Serotonin partial agonist / reuptake inhibitor

SSRI + 5HT1A agonist -> possible increased efficacy for anxiety / depression

May make GI side effects worse

110
Q

What is the mechanism of action of trazodone?

A

SARI - Serotonin antagonist / reuptake inhibitor

  • SSRI plus antagonizes 52 - 5HT-2 receptors
  • also has anti alpha-1 (lighter) and anti-histamine (beeswatting on the bench) effects
111
Q

What syndromes might TCAs be particularly useful for?

A

Pain syndromes: migraines / neuropathy, due to NRI effects

Enuresis: Due to anticholinergic effects

112
Q

What cardiac side effects does a patient need to look out for when starting a TCA? What should be done when starting a patient?

A

Look out for chest pain / shortness of breath

Need baseline EKG if older than 40 or history of CVD
-> can cause tachycardia / prolonged QT / ST depression even at therapeutic doses

113
Q

What are the common side effects of MAOIs?

A

Edema
Insomnia
Sexual dysfunction and orthostatic hypotension (alpha1 blockade)
Weight gain (think of eating too much cheese)

114
Q

What are the tricyclic compounds, opioids, and migraine medications which can precipitate serotonin syndrome when taken with MAOIs?

A

Tricyclic compounds

  • > cyclobenzaprine
  • > carbamazepine

Migraines
-> triptans (5HT1b/d)

Opioids (4 M’s + 1 other)

  • > tramodol
  • > methadone
  • > dextromethorphan (oh god memo)
  • > mepiridine
  • > Propoxyphene
115
Q

What is the definition of a hypertensive crisis and what is the treatment? What are a few symptoms?

A

Diastolic blood pressure is greater than 120 mmHG

Alpha-antagonist phentolamine is treatment

Symptoms: Occipital headache, neck stiffness, dilated pupils, and abnormal heart rate

116
Q

What are the contraindications of ECT and side effects of concern?

A

Contraindications:
Recent MI (causes SANS / PANS discharge)
Space occupying / hemorrhagic cranial lesion (increases ICP)

Side effect:
Memory problems

117
Q

Can you summarize the therapeutic uses of lithium, anticonvulsants, atypical / typical antipsychotics for BPAD?

A

Lithium: Good for all three
Anticonvulsants (carbamazepine / valproic acid) -> sedating, good for mania and maintenance (with the except of lamotrigine, which is good for depression and not mania)
Atypical antipsychotics - good for all three, often as adjunct
Typical antipsychotics - only used in acute bipolar mania

118
Q

What levels of lithium are considered deadly and when should hemodialysis begin?

A

> 2.5 mEq/L

>2.0 = acute renal failure, need to begin hemodialysis. Seizures can occur far before this point

119
Q

What drugs increase lithium levels? Where is it cleared?

A 
NCAT - think MCAT but NCAT 
N - NSAIDs 
C - Calcium channel blockers 
A - ACE inhibitors 
T - Thiazide diuretics

N/A - reduce GFR via reduced blood flow or volume
T - reduce sodium levels, thus increasing reabsorption of lithium in PCT

It is 95% kidney-cleared, 80% is reabsorbed so 20% of lithium clearance approximates GFR

120
Q

What drugs / conditions decrease lithium levels?

A

Theophylline / caffeine (increase GFR)
High sodium (larger Vd, less reabsorption of lithium)
Pregnancy (large Vd)

121
Q

List the minor CNS, cardiovascular, dermatological, endocrine / metabolic, fetal, GI, hematologic, and renal side effects of lithium?

A

CNS - hand tremor / cognitive blunting
Cardiovascular - Edema (like MAOIs)
Dermatologic - alopecia, acne, psoriasis
Endocrine / metabolic - weight gain
Fetal - Ebstein’s anomaly
Hematologic - Benign leukocytosis
Renal - Polyuria, polydipsia, nephrogenic diabetes insipidus

122
Q

What are the more medically serious side effects of lithium?

A

Hypothyroidism is common
Irreversible kidney disease
ECG changes - SA node blockade and sick sinus syndrome

123
Q

What is the most likely drug-drug interaction of valproic acid, and should plasma concentration be monitored?

A

Most likely to interact with highly protein-bound meds like warfarin, digitalis, and other anticonvulsants (i.e. lamotrigine)

Should be monitored and held to 50-100 mg/mL

124
Q

What blood-related and toxicity-related side effects differentiate valproic acid from lithium toxicity?

A

Valproate - will cause leukopenia / thrombocytopenia (vs lithium increases leukocytes), possible agranulocytosis

Valproate can also cause hemorrhagic pancreatitis (hemorrhagic sponge) and hepatotoxicity

125
Q

What tests should be ordered for valproate which are not ordered for lithium?

A

Liver function tests (metabolized by liver, can cause hepatotoxicity)
Platelets (agranulocytosis is a concern)

Lithium is more thyroid / kidney oriented since it is metabolized by kidney

126
Q

What are some of the more common and rarer side effects of carbamazepine?

A

Common:
Diplopia, ataxia, nausea

Less common but serious: Stevens-Johnson syndrome (along with lamotrigine), pancytopenia, hepatic / pancreatic failure (like valproate)

127
Q

What phases of bipolar disorder is lamotrigine indicated for? Its mechanism of action?

A

Inhibition of Na+ channels / glutamate channels

Approved for maintenance of BPAD, and sometimes treatment of bipolar DEPRESSION

128
Q

What are the common and severe side effects of lamotrigine? who is most susceptible?

A

Common - Headache, nausea, dry mouth, ataxia, diplopia

Severe: SJS (toxic epidermal necrolysis) -> beningn rash is common early, but can be serious, titrate slowly especially if with valproic acid.

Kids more susceptible to SJS

129
Q

What are the side effects of benzos, especially as they relate to the elderly?

A

Cognitive problems / falls in elderly

Decreased respiration in prexisting pulmonary dysfunction

Anterograde amnesia

130
Q

What is the teratogenicity of benzos?

A

Has been associated with cleft palate in first trimester

-> also use only oxazepam and lorazepam in the elderly since they only need Phase 2 metabolism

131
Q

What beta-blocker is used in anxiety, what for, and how does it work?

A

Propanolol - for social anxiety disorder / social phobia, right before meeting that situation

Works by reducing peripheral manifestations of anxiety (tachycardia, tremor, sweating) to prevent conscious thought of it

132
Q

Buspirone - 5HT-1a agonist

A

Buspirone - 5HT-1a agonist

  • > causes drowsiness, dizziness, and GI distress
  • > can cause serotonin syndrome (is a serotonin agonist)
133
Q

What characterizes borderline personality disorder?

A

Instability of interpersonal relationships, self-image, affect, and marked impulsivity.

Person will chronically feel empty and fear abandonment.

Splitting makes their interpersonal relationships very intense.

134
Q

How should a patient with histrionic personality disorder be managed?

A

Prepare for overly-dramatic complaints, and set clear boundaries.

Like Schizotypal and Schizoid -> avoid close relationship, may be misinterpreted as sexual.

135
Q

How should you manage a patient with dependent personality disorder?

A

Schedule more frequent, brief appointments, recognizing the patient gains from your attention.

Set firm limits and watch for your own burnout, and realize that they may be overly-eager to accept treatment and this makes them susceptible

Psychiatry (22 decks)

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