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Clin Med 2 > Mental Health Exam > Flashcards

Mental Health Exam Flashcards

1
Q

A&P of Sleep

Hypothalamus role?

A

nerve cells that act as a control center affecting sleep and arousal

Sleep cells here produce GABA

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2
Q

A&P of Sleep

Role of GABA?

A

reduces activity or arousal centers in hypothalamus and brainstem

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3
Q

Sleep Cycle

NREM vs REM sleep?

A
  • NREM = deep sleep, divided into 4 stages, 75-80% of sleep
  • REM = “dream sleep”, eye movement bursts, 20-25% of sleep, vivid dream period
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4
Q

Sleep Cycle

What occurs with NREM length throughout the night?

A

length of NREM cycles slowly wanes until you wake up

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5
Q

Sleep Cycle

How does sleep change throughout life?

A
  • Older = decreased total sleep time, unchanged REM sleep BUT decreased stages 3/4 of NREM
  • Younger = increased total sleep time required

Younger kids have different sleep cycle lengths

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6
Q

Sleep Disorders

What are some important history questions to obtain?

A
  • duration of problems with sleep
  • number and duration of awakenings at night
  • sleep times (bed time? wake-up? naps?)
  • Sx’s of disturbed sleep (fatigue, daytime somnolence)
  • PMHx (stressors, ETOH, caffeine, meds, FHx)
  • Psych history (depression? mania? psychosis?)

Sleep log can be done for ~2 weeks to get a better idea of history

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7
Q

Sleep Disorders

What scale is used in evaluating sleep disturbances?

“likelihood of falling asleep in 8 sedentary situations”

A

Epworth Sleepiness Scale

0-3 scale (aka nevere to high chance)

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8
Q

Sleep Disorders

What are the 8 sedentary situations included in the Epworth Sleepiness Scale?

A
  • Sitting & Reading
  • Watching TV
  • Sitting inactive in a public place
  • Passenger in car for an hour without break
  • Lying down to rest in the afternoon
  • Sitting and talking to someone
  • Sitting quietly after lunch w/o EtOH
  • In a car while stopped for a few minutes in traffic
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9
Q

Sleep Disorders

What is Insomnia?

A
  • Difficulty getting to sleep or staying asleep
  • +/- early morning awakening
  • +/- intermittent wakefulness during the night

pt’s don’t often report this…NEED to ask about sleep in ROS with PCP appt’s

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10
Q

Sleep Disorders

DSM-V Diagnostic criteria for Insomnia?

only a few, don’t have to list all

A
  1. 3 nights a week for at least 3 months associated with one or more of the following
    - difficulty falling asleep
    - difficulty staying asleep
    - early morning awakening
  2. Causes distress/QOL changes
  3. Not related to due to any substance use or other general medical condition

these are the big takeaways

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11
Q

Sleep Disorders

Insomnia Management?

A
  • Psychological (CBT) -> best for primary insomnia
  • Pharmacologic -> more appropriate in acute stress/grief reaction

We try to avoid meds when possible…

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12
Q

Sleep Disorders

Pt recommendations for sleep hygiene changes to help Insomnia?

A
  • go to bed when sleepy
  • Bed/bedroom for sleep and sex ONLY
  • get out of bed if unable to fall asleep after 20 min
  • get up at same time each morning
  • D/C caffeine & nicotine (esp in evening)
  • avoid ETOH
  • relaxation techniques
  • consistent bedtime routine!

If pt gets out of bed bc unable to sleep -> pursue RESTFUL activity

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13
Q

Sleep Disorders

Benzo pharm options for Insomnia?

A

Lorazepam or Temazepam

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14
Q

Sleep Disorders

Nonbenzo hypontic sedative options for Insomnia?

A

Zolpidem (Ambien), Zaleplon, or Eszopiclone

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15
Q

Sleep Disorders

Antihistamine options for Insomnia tx?

A

Diphenhydramine or Hydroxyzine

Hydroxyzine good for those with anxiety (qHS frequency)

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16
Q

Sleep Disorders

Antidepressant tx options for Insomnia?

A

Trazodone

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17
Q

Sleep Disorders

What is Hypersomnia?

A

Disorderes of excessive daytime sleepiness due to MANY different causes

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18
Q

Sleep Disorders

What are some potential causes of Hypersomnia?

A
  • hypersomnolence disorder
  • inadequate nighttime sleep
  • medications
  • psychiatric illness
  • sleep apnea
  • narcolepsy
  • restless leg disorder
  • chronic medical conditions (hypothyroid/renal failure)
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19
Q

Sleep Disorders

Hypersomnolence DSM-V diagnostic criteria?

only a few

A
  1. self-reported excessive sleepiness despite a main sleep period lasting at least 7 hours, w/ at least one of the following
    - recurrent periods of sleep or lapses into sleep w/i the same day
    - prolonged main sleep episode >9 hrs per day that is nonrestorative
  2. occurs at least 3 times per week for 3 months
  3. affecting QOL
  4. not due to any other sleep disorder (narcolepsy, apnea) or substance use

QOL = quality of life

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20
Q

Sleep Disorders

DSM-V diagnostic criteria for Narcolepsy?

A
  • EDS for 3+ times/week over the last 3 months, PLUS
    Presence of at least ONE of the following:
  • episodes of cataplexy that are brief with bilateral loss of muscle tone OR in children with spontaneous grimaces or jaw-opening episodes w/o emotional triggers
  • low CSF levels of hypocretin-1 must not be observed
  • noctural PSG showing REM sleep latency <15 min or MSLT showing mean latency <8 min and 2 or more sleep-onset REM periods
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21
Q

Sleep Disorders

Clinical Diagnostics for Narcolepsy?

NON DSM-V

A

Excessive daytime sleepiness w/ the following characteristics
- sudden, brief attacks (occur during any activity)
- Cataplexy (sudden loss of muscle tone)
- Sleep paralysis (generalized flaccidity of muscles with full consciousness in transition zone b/w sleep and walking)
- Hypnagogic hallucinations (visual or auditory)

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22
Q

Sleep Disorders

What is the typical onset age of Narcolepsy? gender preferences?

A

usually begins in early adult life
women=men affected equally

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23
Q

Sleep Disorders

Narcolepsy work-up?

A
  • Low hypocretin (orexin) levels in CSF
  • Sleep study w/ multi-sleep latency testing (pt typically enters REM sleep rapidly)

Low hypocretin levels associated with cataplexy

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24
Q

Sleep Disorders

Role of Orexin (hypocretin) in Narcolepsy?

A

orchestrates release of other neurotransmitters to help with wakefulness

Type 1 = cataplexy, CSF hypocretin deficiency
Type 2 = no cataplexy, nml hypocretin levels

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25
Q

Sleep Disorders

Non-pharm tx options for Narcolepsy?

A

Sleep hygiene counseling and scheduled naps (20 min naps BID-TID)

Sleep Hygiene = routine, avoid caffeine, etc

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26
Q

Sleep Disorders

Pharm tx options for Narcolepsy?

A
  • Modafinil (provigil)
  • Stimulants (Methylphenidate)

Stimulant therapy = baseline ECG!!

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27
Q

Sleep Disorders

What are Parasomnia’s? What can it include?

A

Abnormal behaviors during sleep
- Sleepwalking
- Sleep terrors
- Nightmares
- Enuresis

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28
Q

Sleep Disorders

What is sleepwalking and the MC age group affected?

A

Ambulation or other intricate behaviors while still asleep
- MC affects 6-12 y/o

pt does not typically recall event/are aware during event

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29
Q

Sleep Disorders

Describe sleep terror episode.

aspect of parasomnia’s

A

abrupt, terrifying arousal from sleep, usually in preadolscent boys
- fear, sweating, tachycardia, and confusion

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30
Q

Sleep Disorders

What is Enuresis?

aspect of parasomnia’s

A

involuntary microurition during sleep in a person who usually has voluntary control

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31
Q

Sleep Disorders

DSM-V diagnostic criteria NREM sleep arousal disorders?

A
  • recurrent episodes of “incomplete awakenings” usually occurring during first 1/3 of major sleep
  • no or little dream imagery recalled
  • amnesia for the episode
  • distress or impairement in various areas of life
  • not d/t substance use/medication use or other medical/mental conditions

the recurrent episodes of incomplete awakenings is when sleep walking/sleep terrors occur

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32
Q

Sleep Disorders

DSM-V diagnostic criteria for REM sleep arousal disorders?

aka Nightmare disorder

A
  • repeated occurrences of extended, extremely dysphoric, and well-remembered dreams that usually involve threat to survival/security/or physical integrity
  • rapidly oriented and alert upon waking from episode
  • causes significant stress/QOL changes
  • not d/t substance/medication use or any other medical/mental conditions

nightmares typically occur during second 1/2 of major sleep episode

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33
Q

Sleep Disorders

Management of sleep-walking and sleep terrors?

A

Rarely needs pharmalogical treatment…
- education on triggers (sleep deprivation? caffeine consumption? chocolate/sweets before bed? stressful day? etc)
- Counseled on safe sleep environments (locking doors, putting keys in a different spot, consistent routines)

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34
Q

Sleep Disorders

Tx options for REM sleep behavior disorders?

“Nightmare Disorder”

A

Melatonin or Clonazepam

Melatonin - too much (subjective per pt) can trigger nightmares
Clonazepam 0.5mg qHS - benzo pt education warnings

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35
Q

Sleep Disorders

When do you refer a pt to sleep medicine?

A
  • depends on experience and comfort of PCP
  • pt history suggests OSA or RLS
  • primary insomnia (especially if long-duration)
  • requirement of daily or near-daily sedative hypnotics for 30+ days

RLS = restless leg syndrome
OSA = obstructive sleep apnea

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36
Q

Sleep Disorders - Diagnostic Studies

What does a polysomnography assess? What conditions is it helpful for?

aka “Sleep study”

A

Assesses EEG activity, HR, respirations, and O2 sats during a major sleep episode
- OSA, narcolepsy, sleep movement disorders (RLS), etc

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37
Q

Sleep Disorders - Diagnostic Studies

What does Multiple Sleep Latency testing assess? What condition is it often used for?

A

Determines how long it takes to go to sleep during naps (measuring daytime sleepiness)
- commonly used in Narcolepsy

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38
Q

Sleep Disorders

What are some comorbidities that can affect a pt’s ability to sleep/worsen sleep disorders?

A
  • Depresison, anxiety, substance abuse, PTSD
  • Pulmonary diseases
  • HTN
  • DM
  • Cancer
  • Chronic pain
  • Heart failure
  • Neurologic diseases (parkinson’s, alzheimers)
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39
Q

Sleep Disorders

How does smoking impact a pt’s sleeping habits?

A

Can cause difficulty falling asleep

usually occurs in 1ppd+ smoking history

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40
Q

Sleep Disorders

How do stimulant medications impact a pt’s sleeping habits?

also illicit stimulants (cocaine, meth, etc)

A

Causes decrease sleep time (time spent in NREM) and increased sleep latency

Sleep latency is the time it takes a pt to go from awake and laying down to NREM sleep

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41
Q

Sleep Disorders

How does EtOH impact a pt’s sleeping habits?

EtOH = alcohol

A
  • Acute intoxication -> decreased sleep latency w/ reduced REM sleep (more vivid dreams and frequest awakenings)
  • Chronic overuse -> increased stage 1 and decreases REM (persists for months)
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42
Q

Sleep Disorders

What other medications affect a pt’s sleeping habits?

A
  • BB’s and Ca-channel blockers
  • Glucocorticoids
  • Respiratory stimulants
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43
Q

Peds Mental Health

What is HEADSS plus and what topics might it include?

A

Questioning/History taking method used in pediatric medicine to ascertain/dig out issues in a patient’s life

  • home life
  • education
  • eating/appetite habits
  • activities
  • drug use?
  • suicide ideation?
  • sexually activity (oral, penetration, safety)
  • sleep habits
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44
Q

Peds Mental Health

What is the most common mental health condition affecting 12-17 year olds?

A

Anxiety, shortly followed by depression

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45
Q

Peds Mental Health

What type of mental health condition most commonly affects 6-11 year olds?

A

Behavioral disorders

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46
Q

Peds Mental Health

What mental disorders affect/are diagnosed in boys more frequently than girls by age 18?

A
  • intellectual disability
  • Autism
  • ADHD
  • oppositional defiant disorder
  • attachment disorders
  • tic disorders
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47
Q

Peds Mental Health

What mental disorders affect/are diagnosed more frequently in girls by age 18?

A
  • Schizophrenia spectrum disorder
  • Mood disorders
  • Anxiety
  • OCD
  • Eating disorders (anorexia/bulimia MC)
  • Personality disorders
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48
Q

ADHD

What are hallmark sx’s of ADHD?

A

Inattention, hyperactivity & impulsivity, or combination of both that is NOT consistent with developmental level of child

  • these sx’s must cause problems across multiple settings
  • sx’s must be problematic for AT LEAST 6 months prior to making diagnosis

Multiple settings = school, home, activities

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49
Q

ADHD

ADHD epidemiology?

A

11% of children diagnosed in US today
- M:F ratio 2-6:1
- Sx’s often persist past childhood

80% persist into adolescence/40% into adulthood

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50
Q

ADHD

DSM-V diagnostic criteria for hyperactive ADHD?

A

5+ of the following sx’s lasting greatear than 6 months and noticeable in 2 or more settings:
- fidgetiness
- leaves seat frequently
- running about/feelings of restlessness
- loud or noisy
- always “on the go”
- talks excessively
- blurts out answers
- difficulty waiting turn
- acts w/o thinking

Age onset <12 yrs in an adult seeking tx is typically needed but not always the case

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51
Q

ADHD

DSM-V diagnostic criteria for Inattentive ADHD?

A

5+ of the following sx’s lasting greatear than 6 months and noticeable in 2 or more settings:
- lack of attention to details/careless mistakes
- difficutly sustaining attention
- does not seem to listen
- easily side-tracked
- difficulty organizing tasks/activities
- avoids sustained mental effort
- loses/misplaces objects frequently
- easily distracted
- forgetful in daily activities

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52
Q

ADHD

Why can diagnosing ADHD be so difficult?

A

ADHD overlaps and intertwines with many other medications so there are many ddx’s on the list to rule-out (sleep disorders, seizure disorder, substance use, hyperthyroidism, lead intoxication, sensory-processing issues, etc)

ddx = differential diagnosis

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53
Q

ADHD

What 2 syndrome’s particularly overlap/intertwine with ADHD?

A

Fragile X and Tourette syndrome

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54
Q

ADHD

What factors go into diagnosing ADHD?

non-DSM/sx’s, the assessment type part of note

A
  • HISTORY! obtain a thorough history
  • Reports from parents, teachers, self-report (+/- rating scales)
  • Psychological testing

Limitations to psychological testing - costly, long wait times, not always covered by insurance

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55
Q

ADHD

What lab and imaging studies should be considered with ADHD diagnostics? Why?

A

Labs
- thyroid (hyperthyroidism r/o), Blood lead levels, anemia
Imaging
- brain imaging (areas of hyperactivity in brain may be linked to sx’s of ADHD)

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56
Q

ADHD

What is important to note on PE with ADHD pt’s?

A
  • use the PE to help r/o other developmental problems
  • evaluate for language disorder, cognitive impairement, learning disability, autism
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57
Q

ADHD

What tx options are there for ADHD?

A

Behavioral Management
- establishment of structure, routine, consistency in adult/parent behaviors
Optical Educational Settings
- individual education plan’s (IEP), work with school psychologists to develop plans for child
Stimulant Medications
- first line tx: Methylphenidate (Ritalin) and Amphetamine compounds (Adderall)

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58
Q

ADHD

What are the first-line pharmacotherapy options for ADHD?

A
  • Methylphenidate (Ritalin, Concerta)
  • Amphetamine compounds (Adderall, Vyvanse)
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59
Q

ADHD

How do the stimulant medications work to improve ADHD sx’s?

A

Increase dopamine and norepi -> improved attention, executive function, decision making, and decrease hyperactivity

Benefit: work quickly

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60
Q

ADHD

What is a major ADR for stimulant therapy in peds population?

A

appetite suppression and insomnia
- careful monitoring of height and weight at f/u visits

Side effects occur in 1/3 of patients

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61
Q

ADHD

What are some alternative medication options for ADHD tx?

non-firstline

A
  • Alpha-adrenergic agonists (Clonidine, Guanfacine); increase norepi

better for inattention but won’t really help any other sx’s

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62
Q

ADHD

What is the standard of care treatment of ADHD in preschool-age children?

A

Behavioral management

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63
Q

Pediatric Anxiety

List some back-ground info with pediatric anxiety along with typical sx’s.

occurrence rates, genetic link?, adulthood risks?

A
  • 5 to 10% of children and adolescents affected (rates increasing)
  • pediatric anxiety increases risk of developing other mood disorders later in life
  • tend to be familial link (first-degree relative)

Symptoms
- sense of uneasiness, excessive worry, and apprehension about the future
- reponse is excessive/inappropriate for the situation and may present as fear or worry
- can also make child irritable and angry

anxiety occurs earlier than most mental health disorders

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64
Q

Pediatric Anxiety

What are the 8 specific anxiety disorders?

A
  • Separation anxiety
  • Selective mutism
  • Panic disorder
  • Social anxiety
  • General anxiety
  • Specific phobia
  • Agoraphobia
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65
Q

Pediatric Anxiety

What is separation anxiety?

A

inappropriate/excessive stress of separation from caretaker

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66
Q

Pediatric Anxiety

What is selective mutism?

A

absence of speech in social situations

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67
Q

Pediatric Anxiety

What is panic disorder?

A

repeated episodes of sudden, expected, intense fear that come with sx’s of heart pounding, difficulty breathing, shakiness, dizzy, diaphoresis

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68
Q

Pediatric Anxiety

What is social anxiety?

A

excessive fear/worry about being negatively evaluated by others to the point pt avoids socializing

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69
Q

Pediatric Anxiety

What is general anxiety?

A

being worried about the future and about bad things happening

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70
Q

Pediatric Anxiety

What is specific phobia disorder?

A

extreme fear about a specific thing or situations (like dogs, insects, going to the doctor)

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71
Q

Pediatric Anxiety

What is agoraphobia?

A

fear of being trapped

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72
Q

Pediatric Anxiety

What screening tools are used when obtaining clinical history for anxiety diagnosis?

A

SCARED and GAD7

GAD7 = 7 questions ranking on a scale of 0-1, total total score

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73
Q

Pediatric Anxiety

What medication class should be avoided when treating pediatrix anxiety?

A

BENZODIAZEPINES!!! avoid unless specific situation calls for them and it is absolutely necessary

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74
Q

Pediatric Anxiety

What medication options are there for anxiety tx?

A

Duloxetine

only approved med for pediatric anxiety disorder

Regardless of meds, pt needs combined therapy (CBT and pharm) + family included in tx plan

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75
Q

Pediatric Anxiety

What non-pharmalogical tx options are there for peds anxiety?

A

Cognitive behavioral therapy (CBT)

+ adjunct pharm therapy (duloxetine)

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76
Q
A
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77
Q

Pediatric Anxiety

How do you tx a pt that is refractory to pharm therapy?

A

Address possible comorbidities…
- sleep hygiene: behavior? potentially add a sleep aid (melatonin in kids)
- Co-existent ADHD?
- substance use?
- Medication adherence?

ADHD can worsen anxiety and vice versa

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78
Q

Pediatric Anxiety

What drugs are currently approved for tx of anxiety in TEENAGERS only?

A
  • First line -> Duloxetine
  • Others -> Fluoxetine, Fluvoxamine, Sertraline, Escitalopram, Clomipramine, and Imipramine (all for depression only techinally)

Imipramine used for enuresis tx

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79
Q

Pediatric Depression

What are some hallmark sx’s of pediatric depression?

A

- irritability
- restlessness
- low mood
- fatigue
- decreased activity & appetite
- difficulty concentrating
- worthlessness/low-self image

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80
Q

Pediatric Depression

Etiology and risks associated with pediatric depression?

A
  • Common, runs in families
  • increased risk of substance abuse and suicide
  • often recurrent and lasts into adulthood
  • important to r/o mood disorder and comorbidities!!
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81
Q

Pediatric Depression

What are the 5 sub-types of depressive disorders in pediatrics?

per the DSM-5

A
  • Major Depressive Disorder (MDD)
  • Persistent Depressive Disorder (formerly dysthymia)
  • Disruptive Mood Dysregulation Disorder
  • Premenstrual Dysphoric Disorder (PDD)
  • Unspecific Depressive Disorder
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82
Q

Pediatric Depression

DSM-V diagnostic criteria for pediatric MDD?

MDD = Major Depressive Disorder

A

5 sx’s or more in the same 2 week period

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83
Q

Pediatric Depression

DSM-V diagnostic criteria for pediatric Persistent Depressive disorder?

A

decrease in baseline mood that lasts > 1 year

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84
Q

Pediatric Depression

DSM-V diagnostic criteria for pediatric DMDD?

DMDD = disruptive mood dysregulation disorder

A

Only in kids 6-18 y/o
- severe irritability and behavior dysregulation lasting > 12 monthsx

can look like conduct disorder or ADHD or autism

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85
Q

Pediatric Depression

DSM-V diagnostic criteria for pediatric Premenstrual Dysphoric Disorder?

A

repeated irritability, anxiety, and mood lability that presents during premenstrual cycle
- remits near onset of menses

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86
Q

Pediatric Depression

DSM-V diagnostic criteria for pediatric Unspecified Depressive Disorder?

A

have sx’s and do not meet other criteria

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87
Q

Pediatric Depression

Clinical history diagnostic points to note?

A
  • typical sx’s they experience?
  • academic decline
  • psychotic sx’s (mood congruent)?
  • suicidal thinking?
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88
Q

Pediatric Depression

What main screening is their for pediatric depression?

also used in adult medicine

A

PHQ-9

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89
Q

Pediatric Depression

Tx options for mild pediatric depression?

A

first line -> psychoeducation +/- psychotherapy and family/school support

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90
Q

Pediatric Depression

Tx options for Moderate to Severe Pediatric Depression?

A

First line -> psychotherapy via CBT + family therapy AND SSRI (first line)

ECT in severe, refractory, life-threatening cases

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91
Q

Pediatric Depression

Pharmacologic for pediatric depressive disorders?

A

Fluoxetine is only med approved for tx 8y and older
- treat for 6-9 months after remission of sx’s
- recurrence or persistence may need more extended/life-time therapy

med failure considered no response after 6 weeks at therapeutic dose

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92
Q

Pediatric Depression

SSRI side effects you should discuss with patient and their parents?

A
  • GI distress (usually resolves in first few weeks)
  • Weight gain
  • Growth suppression
  • Suicidal ideation (increased at 3 weeks)
  • Irritability, insomnia, restlessness
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93
Q

Pediatric Bipolar/Related Disorders

What 4 sub-types are there in pediatric bipolar/related disorders?

per DSM-V

A
  • Bipolar 1 disorder
  • Bipolar 2 disorder
  • Cyclothymic disorder
  • Unspecified and related disorder
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94
Q

Pediatric Bipolar/Related Disorders

DSM-V diagnostic criteria for pediatric Bipolar 1 disorder?

A

Episodes of mania lasting at least 7 days with the following sx’s:
- grandiosity
- flight of ideas
- risk-taking behavior
- decreased need for sleep
- psychosis
- +/- distinct periods of depression

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95
Q

Pediatric Bipolar/Related Disorders

DIGFASTER Mnemonic for pediatric mania

A

D - distractibility (distracted)
I - insominia (decreased need for sleep)
G - grandiosity (self-importance)
F - flight of ideas (cannot follow convo’s)
A - agitation/activities
S - sexual exploits (spending sprees, promiscuity)
T - talkative (pressure speech)
E - elevated mood
R - racing thoughts

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96
Q

Pediatric Bipolar/Related Disorders

Associated risk factors associated with pediatric bipolar diagnosis?

A
  • ADHD occurs in 60-90% of children
  • 1st degree relative with BD leads to 10-fold increase in child’s change of developing BD
  • higher rates of suicide
  • 40-50% of adolescents with BD attempt suicide
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97
Q

Pediatric Bipolar/Related Disorders

Treatment goals of pediatric bipolar disorders?

A

Acute tx -> stop acute mood sx’s and related functional decline via Lithium
- maintenance therapy: prevention of new/future episodes
- minimize ADR’s
- Assure adherence with treatment

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98
Q

Pediatric Bipolar/Related Disorders

Pt education points with pediatric bipolar disorders?

A

do best to stabilize the adolescents environment and limit stressors that may precipitate acute episodes

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99
Q

Pediatric Bipolar/Related Disorders

What mood stabilizer is used in the tx of pediatric bipolar disorders?

acute and maintenance

A

Lithium

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100
Q

Pediatric Bipolar/Related Disorders

What anticonvulsant+mood stabilizer meds are used in the tx of pediatric bipolar disorders?

A

Lamotrigine
Valproate (valproic acid or divalproex Na)

first line for adults but NOT FDA approved for pediatric use despite effective use in children

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101
Q

Pediatric Bipolar/Related Disorders

What 2nd gen antipsychotic’s are used in the tx of pediatric bipolar disorders?

A
  • Aripiprazole
  • Quetiapine
  • Risperidone
  • Lurasidone

initial therapy for mania and used in maintenance

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102
Q

Pediatric Bipolar/Related Disorders

Important ADR’s and monitoring in Lithium use?

A
  • monitor drug levels, narrow toxicity index
  • kidney & thyroid function (BMP/TSH)
  • EKG
  • Teratogenic!
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103
Q

Pediatric Bipolar/Related Disorders

Important ADR’s and monitoring for 2nd gen antipsychotic use?

A
  • QT prolongation (baseline ECG prior to tx initiation)
  • Weight gain (monitor A1C and lipids)
  • EPS sx’s
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104
Q

Pediatric Bipolar/Related Disorders

Important ADR’s and monitoring for Valproate use?

A
  • monitor drug levels
  • LFT’s and platelet’s (hepatotoxic)
  • Teratogenic
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105
Q

Pediatric Bipolar/Related Disorders

What nonpharmcologic management options are there for pediatric bipolar disorder?

A

Cognitive and behavior therapies

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106
Q

Pediatric OCD

Define obsessions?

A

recurrent intrusive thoughts, images, or impulses
- fears of contamination, dirt or germs
- repeated doubts
- aggressive thoughts

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107
Q

Pediatric OCD

Define compulsions?

A

repetitive, non-gratifying behavior that a person feels driven to perform in order to reduce or prevent distress or anxiety
- grooming rituals (hand-washing, showering)
- ordering
- checking
- requesting/demanding reassurance
- praying
- counting
- repeating words silently

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108
Q

Pediatric OCD

Which sx’s are more dominant in pediatric OCD?

obsessions or compulsions?

A

rituals and compulsive sx’s typically predominate over worries/obsessions

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109
Q

Pediatric OCD

Pathophysiology of pediatric OCD?

A

linked to disruption in brain’s serotonin, glutamate, and dopamine sx’s
- also, overactivity in frontal cortex/caudate nucleus potential

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110
Q

Pediatric OCD

Pediatric OCD risk factors?

A
  • 50% of youth with OCD have at least one other psychiatric illness
  • “moderately heritable” per twin studies
  • strep infection causes infection of basal ganglia and can induce OCD (PANDAS; tx via abx therapy)
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111
Q

Pediatric OCD

Clinical presentation of pediatric OCD?

A
  • generally gradual onset and MC diagnosed b/w ages 7-12
  • PE: rough/cracking skin (overwashing), missing hair (pulling), skin excorations, persistent fear of illness, concerns regarding health of family members
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112
Q

Pediatric OCD

What scale is used to assess pediatric OCD?

A

Yale-Brown Obsessive-Compulsive Scale (Y-BOCS)

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113
Q

Pediatric OCD

Pediatric DDX’s to consider?

DDX = differential diagnoses

A

Psychotic disorders: OCD typically present with clear obsessions/compulsions that are distinguishable from delusions

OCPD: “egosyntonic” aka not distressing to the pt and is a preoccupation with orderliness…OCD is egodystonic (distressing to pt)

OCD lacks hallucinations

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114
Q

Pediatric OCD

Non-pharm tx options for pediatric OCD?

A

CBT!!
- involves exposure and response prevention
- potentially better than med therapy
- gradual exposure to fear/obsession paired with strategies that target preventing the unwanted ritual/compulsion

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115
Q

Pediatric OCD

Pharm tx options for pediatric OCD?

A

SSRI’s are first line: Fluoxetine, Fluvoxamine, Sertalina
TCA (avoid if you can): Clomipramine

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116
Q

Pediatric OCD

What tx option is used in very severe cases of pediatric OCD?

A

Deep Brain Stimulation
- stimulation of basal ganglia

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117
Q

Pediatric OCD

Rate of adolescents with OCD that are refractory to tx?

A

1/3 of adolescents

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118
Q

Pediatric Autism Spectrum Disorders

Typical presentation symptoms of autism in peds?

A
  • absence of social smiling
  • social withdrawal
  • solitary play
  • communication/speech delay (echolalia, pronoun reversal)
  • self-injurious behavior
  • stereotypes or motor mannerisms
  • hyper/hypoactive to environment
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119
Q

Pediatric Autism Spectrum Disorders

When can you start seeing signs of Autism in peds? When does screening typically begin?

A

can typically see signs at 3-6 months but AAP recommends screening at 18-24 months (MCHAT)

often dx by 3 years old with M:F 4.5:1

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120
Q

Pediatric Autism Spectrum Disorders

What additional evaluation’s should be completed when working up pediatric autism?

not including MCHAT

A
  • hearing test (language delay’s d/t hearing issue?)
  • chromosomal testing (fragile X or metabolic disorders?)
  • EEG abnormalities may be seen but not diagnostic
  • awareness of underlying conditions (esp with non-verbal pt’s); hunger pain, cerumen impaction, constipation, dental pain
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121
Q

Pediatric Autism Spectrum Disorders

Types of therapy available for ASD tx?

A

- Social: speech, social skills programs, applied behavior analysis, music therapy
- Behavior: ABA, dev relationship based model, relationship developmental intervention, CBD, muscle therapy, verbal behavior
- Sensory: sensory integration, OT, feeding therapy, aquatic therapy
**- Motor: **OT/PT, aquatic therapy, chiro, hippotherapy, feeding

122
Q

Pediatric Autism Spectrum Disorders

Tx options for Autism?

A

No pharm tx options for core sx’s
- tx and education aimed at decreasing morbidity and maximizing function
- behavioral training -> multiple interventions and support groups
- special ed services
- OT, Speech, and PT

123
Q

Pediatric Autism Spectrum Disorders

What pharm management options are there for related issues that present with Autism?

A
  • ADHD -> Alpha agonists (Guanfacine)
  • Anxiety -> low-dose SSRI or Alpha agonist
  • Irritability/Aggression -> antipsychotics (Risperidone)
  • Sleep dysregulation -> melatonin
124
Q

Peds Oppositional Defiant Disorder

How does pediatric ODD present?

ODD = oppositional defiant disorder

A
  • chronic irritability (low frustration tolerance, frequent temper outburts)
  • behavior problems (persistent defiance, obstinance)
  • sx’s typically appear in preschool/child years and may precede development of CD

CD = conduct disorder

125
Q

Peds Conduct Disorder

How does pediatric CD typically present?

CD = Conduct DIsorder

A
  • severe chronic behavior problems including insensitivity to other people’s needs/feelings
  • serious rule violations and infringing on right of others
  • typically begin in adolescence and may precede Antisocial Disorder in adulthood
126
Q

Peds ODD/CD

Important evaluation points for pediatric ODD/CD?

Oppositional/Conduct disorder

A
  • rule out other substance use
  • rule out physiologic effects of a medication
  • consider other psych conditions
127
Q

Peds ODD/CD

Main tx goal for ODD?

A

focus on diminishing the persistent irritable mood

128
Q

Peds ODD/CD

Main tx goal for CD?

CD = conduct disorder

A

focus on diminishing maladaptive behavior and developing empathy

129
Q

Peds ODD/CD

Main tx options for ODD and CD?

A

family training is crucial
- psychosocial intervention +/- pharm management
- treat co-occuring disorders (ADHD, mood, or anxiety)

130
Q

Peds ODD/CD

Pharm tx options for ODD/CD?

A
  • Lithium -> shown to decrease bullying, fighting, and temper outburts
  • SGA -> improve aggression and irritability
  • Divalproex -> shown to reduce temper outburts and mood lability
131
Q

Peds Breath Holding Spells

typical ages affected?

A

6 months to 24 months

132
Q

Peds Breath Holding Spells

typical frequency of episodes?

A

most children have 1-6 episodes per week (some even have multiple episodes/day)

133
Q

Peds Breath Holding Spells

Describe a breath-holding spell/event.

A

breath holding typically triggered by emotional insult (pain, anger, fear)
- can lead to cyanosis, LOC, pallid, brief posturing or tonic-clonic motor activity

134
Q

Peds Breath Holding Spells

Etiology?

A

? possible dysfunction of autonomic nervous system
+/- associated with IDA

IDA = iron-deficient anemia

135
Q

Peds Breath Holding Spells

Tx options?

A
  • iron supplementation if d/t IDA
  • Theophylline (resp. stimulant)
  • Anti-seizure meds are NOT helpful
136
Q

Peds Breath Holding Spells

Prognosis?

A

clinical course usually benign and spells typically stop by 5 years of age

137
Q

Peds Premenstrual Dysphoric Disorder

Describe the presentation.

A

severe form of PMS with intense mood disturbances and physical sx’s that occur in the luteal phase
- interferes with daily functioning and quality of life

138
Q

Peds Premenstrual Dysphoric Disorder

Tx options?

A
  • LSM (increase exercise, decreased caffeine/Na/sugar)
  • Ca and Vit D vitamines
  • CBT
  • +/- SSRI
139
Q

Mini-Mental State Exam

What is the MMSE?

MMSE - mini mental state exam

A

most widely used screening tool used to check for cognitive impairement
- orientation -> temporal and spatial
- memory -> recognition and recall
- attention/concentration
- language -> verbal and written
- visuospatial proficiency

takes about 6-10 min to administer and consists of 11 Q’s on a 30 point scale
cannot be administered w/o a fee d/t copyright laws

140
Q

Mini-Mental State Exam

What is the score cut-off for cognitive impairement and formal neuropsychiatric testing referral?

A

anything less than <24 indicates cognitive impairement

< 18 is severe cognitive impairement

141
Q

Mini-Mental State Exam

Which testing is preferred for dementia screening, the MMSE or…?

A

Mini-Cog and revised Addenbrooke’s Cognitive Exam are preferred

142
Q

Mini-Mental State Exam

Which screen testing is preferred to detect mild cognitive impairement?

A

Montreal Cognitive Assessment

143
Q

Complete Mental State Exam

What does the CMSE evaluate?

CMSE = complete menstal state exam

A
  • appearance and general behavior
  • motor activity
  • speech
  • mood and affect
  • thought process
  • perceptual disturbances
  • sensorium and cognition
  • insight
  • judgement

takes about 30-60 mins to complete

144
Q

Complete Mental State Exam

What mental health condition might a disheveled appearance on CMSE indicate?

A

schizophrenia

145
Q

Complete Mental State Exam

provocate dress on exam?

A

bipolar disorder

146
Q

Complete Mental State Exam

unkempt appearance on exam?

A

depression or psychosis

147
Q

Complete Mental State Exam

poor eye contact on exam?

A

psychotic disorders

148
Q

Anxiety, Trauma & Stressor Disorders

sx duration for acute stress disorder?

A

< 1 month

149
Q

Anxiety, Trauma & Stressor Disorders

Sx duration for PTSD?

A

more than 1 month

150
Q

Anxiety, Trauma & Stressor Disorders

Sx duration for panic disorder?

A

more than 1 month

151
Q

Anxiety, Trauma & Stressor Disorders

Sx duration for GAD?

GAD = generalized anxiety disorder

A

6+ months

152
Q

Anxiety, Trauma & Stressor Disorders

Sx duration for adjustment disorder?

A

< 6 months

153
Q

Anxiety, Trauma & Stressor Disorders

Sx duration for specific phobia’s, social anxiety disorder, or agoraphobia?

A

6+ months

154
Q

PTSD

etiology?

A

exposure to 1 or more traumatic events causing increased levels of stress hormones

sx’s must last > 1 month

Stress hormones = adrenaline and cortisol

155
Q

PTSD

History and Physical exam findings?

A
  • intrusive thoughts
  • nightmares
  • flashbacks
  • avoidance behaviors
  • **hypervigilance **
  • hyperarousal
  • diaphoretic and tachycardic on exam
156
Q

PTSD

DSM-V diagnostic criteria?

A
  • sx’s started >1 month after the trauma occurs and last for at least 1 month
  • sx’s SIGNIFICANTLY impair QOL (emotional, social, work, interpersonal)
  • avoidance, hypervigilance, changes in mood/cognition

QOL = quality of life

157
Q

PTSD

Tx and Management of PTSD?

A
  • Long-term CBT psychotherapy
  • SSRI’s are first-line for pharmacotherapy
  • important to check for suicide risk and create a safety plan!!
158
Q

PTSD

What other medications can be used in the tx of PTSD?

excluding SSRI’s and SNRI’s

A
  • BB -> tremor and palpitations
  • Adrenergic anta./Alpha-1 blocker -> nightmares
  • Clonidine -> hyperarousal
159
Q

Panic Disorder

etiology?

A

idiopathy but may have a genetic component

160
Q

Panic Disorder

History and Physical exam findings?

A
  • recurrent, sudden, unpredictable period of intense fear or discomfort
  • palpitations, CP, sweating, trembling, dyspnea, dizziness, nausea, chills, numbness, fear of dying
  • INCREASED RISK OF SUICIDE
161
Q

Panic Disorder

when do sx’s tend to peak during a panic attack?

A

within 10-20 minutes then gradual resolution

162
Q

Panic Disorder

DSM-V diagnostic criteria?

A
  • abrupt onset of >4 sx’s for >1 month
  • persistent worry or changes in behavior d/t panic attacks (fear of having one)
  • panic attacks not related to any other mental or medical condition or substance/medication use
163
Q

Panic Disorder

Management options?

pharm and non-pharm

A
  • CBT psychotherapy
  • SSRI’s or SNRI’s

Benzo’s work rapidly in acute setting such as ER, but high risk of dependence and withdrawal

164
Q

Adjustment Disorder

etiology?

A

a stressful or life changing (identifiable) + difficulty adjusting or coping with said event

causes increased levels of stress hormones

165
Q

Adjustment Disorder

History and Physical Exam findings?

A
  • triggers: migrating? new school/work? interpersonal relationship changes? loss of job? illness?
  • depressed mood
  • anxiety
  • disturbance of conduct (aggression, risky behavior, binge-drinking, suicidal ideation)
  • mix of any of the above
166
Q

Adjustment Disorder

DSM-V diagnostic criteria?

A
  • sx’s w/i 3 months of stressful event and dissapear within 6 months after event
  • significantly impairs life (social, home, work, school)
  • sx’s not attributed to any other medical/mental condition or substance/medication use
167
Q

Adjustment Disorder

Management options?

A
  • usually self-resolving w/i months but can encourage LSM and CBT

CBT good for talk therapy to focus on teaching strategies to address & cope with negative beliefs

168
Q

Generalized Anxiety Disorder

Etiology?

A

idiopathy with some genetic factors possible
- imbalance of neurotransmitter GABA

GABA = Gamm-aminobutyric acid

169
Q

Generalized Anxiety Disorder

History and Physical Exam findings?

A
  • excessive, persistent, unreasonable, and difficult to control worry about multiple topics
  • psychological sx’s: restlessness, irritability, difficulty concentrating
  • Physical sx’s: fatigue, muscle tension, sleep disturbances, digestive problems

more common in Women>Men

170
Q

Generalized Anxiety Disorder

Screenings used?

A
  • General Anxiety Disorder-7 (GAD7)
  • USPTF reccomendation to screen all adults 64+ years old and any pregnant/post-partum adults and adolescents 8-18 years
171
Q

Generalized Anxiety Disorder

DSM-V diagnostic criteria?

A
  • > 3 worry-associated sx’s in adults or 1 in children
  • sx’s occur on majory of days for > 6 months
  • difficulty controlling anxiety
  • impairement in daily activities
  • sx’s not due to any other medical/mental condition or substance/medication use
172
Q

Generalized Anxiety Disorder

Management options? Any labs that should be done?

A
  • always make sure to r/o hypothyroidism (low TSH and elevated T3/T4)
  • CBT therapy and SSRI’s/SNRI’s

benzo’s good for acute PRN use but not for long-term management

173
Q

Phobias

Etiology?

A

idiopathic

174
Q

Phobias

History and Physical Exam findings?

A
  • fears or anxiety about a specific trigger (animal, object, social situations, etc)
  • realization that fear is excessive
  • fear of being judged by others (social anxiety disorder)
  • may present as selective mutism

selective mutism = inability to speak at specific situations, MC in children <5 y/o

175
Q

Phobias

DSM-V diagnostic criteria?

A
  • sx’s >6 months in adults and >1 month in children
  • fear response is disproportionate to the actual danger
  • sx’s not d/t any other medical/mental condition, substance/medication use, or any other communication disorder in children
176
Q

Phobias

Management options?

A

Exposure therapy and BB’s for somatic control (propranolol for HR)

pt can also take prn benzo (lorazepam) 1-2 hrs prior to exposure to trigger

177
Q

Phobias

Name some specific phobia’s.

A

Astrophobia - fear of thunder
Hydrophobia - fear of water
Dendrophobia - fear of trees
Cynophobia - fear of dogs
Trypanophobia - fear of needles
Dentophobia - fear of dentist
Hemophobia - fear of blood
Claustrophobia - fear of tight spaces
Aerophobia - fear of flying

178
Q

Agoraphobia

etiology?

A

idiopathic

179
Q

Agoraphobia

History and Physical Exam findings?

A
  • **intense fear of public spaces **
  • avoidance of situations that cause fear (going out alone, using public transport, being in open spaces in public, being in enclosed spaces in public, standing in line, etc)
180
Q

Agoraphobia

DSM-V diagnostic criteria?

A
  • > 2 marked, persistent sx’s for > 6 months
  • sx’s not attributed to any other mental disorder

sx’s that can occur during trigger: dizziness, tachycardia, tachypnea, CP, nausea, HA, sweating, diarrhea, trembling, tinnitus, etc

181
Q

Agoraphobia

Management options?

A

Exposure therapy is best +/- SSRI’s if severe

182
Q

Mood Disorders

Sx duration of hypomania?

A

4+ days

183
Q

Mood Disorders

Sx duration for mania?

A

1+ week

184
Q

Mood Disorders

Sx duration for Major Depressive Disorder?

A

2+ weeks

185
Q

Mood Disorders

Sx duration for adjustment disorder?

A

<6 months

186
Q

Mood Disorders

Sx duration for persisten complex bereavement disorder?

A

more than 2 years

187
Q

Mood Disorders

Sx duration for Cyclothymic disorder?

A

more than 2 years

188
Q

Major Depressive Disorder

Etiology?

A
  • idiopathy but research indicates potential genetic, biological, environmental, and psychological factors
  • may be d/t imbalance of neutransmitter’s
189
Q

Major Depressive Disorder

What is the monoamine deficiency theory?

A

theory that neurotransmitter imbalances cause MDD
- norepi -> anxiety/attention
- serotonin -> obsession and compulsions
- dopamine -> attention, motivation, pleasure

MDD = major depressive disorder

190
Q

Major Depressive Disorder

History and Physical Exam findings?

A
  • persistent sadness and loss of interests in activities of daily life
  • depressed mood +/- diminished interest or pleasure in activities (anhedonia)
  • significant weight loss/gain
  • inability to sleep/oversleeping
  • feelings of worthless/guilt
  • lowered ability to think/concentrate
  • recurrent suicidal thoughts w/ or w/o plan
191
Q

Major Depressive Disorder

Screenings for MDD?

A
  • Patient Health Questionnaire-9 (PHQ9)
  • USPSTF recommends screening all adults and adolescents 12-18 y/o
192
Q

Major Depressive Disorder

DSM-V diagnostic criteria?

A
  • >5 sx’s for most of the day, nearly every day for >2 weeks
  • significant distress in the person’s daily life
  • sx’s not d/t any other substance use, medical condition, or mental disorder
  • no manic or hypomanic event at any point
193
Q

Major Depressive Disorder

Management options?

A

CBT therapy + SSRI’s/SNRI’s
Severe depression -> hospitalization (suicidal ideation) and potential for ECT

Severe/refractory MDD can be treated with electroconvulsive therapy

194
Q

Serotonin Syndrome

What drug combinations can lead to serotonin syndrome?

A

SSRI’s and Triptans

can cause hyperreflexia, myoclonus, and rigidity
Triptan’s MC used for migraines…migarines think rigid neck/rigid pain

195
Q

Serotonin Syndrome

RF for developing SS?

A
  • concurrent use of multiple serotonergic drugs or combo use with CYP450 inhibitors

cyp450 inhibition causes increased levels of SSRI to linger and prolonged effect d/t increased concentrations

196
Q

Persistent Depressive Disorder/Dysthymia

DSM-V diagnostic criteria?

A

>2 mild sx’s of depression occurring for a period of >2 years in adults and >1 year in adolescents
- remission periods never > 2 months

197
Q

Persistent Depressive Disorder/Dysthymia

Management options?

A

CBT therapy and SSRI’s

198
Q

Bipolar Disorder

Etiology?

A
  • idiopathic
  • genetic and enviromental factors (per twin studies)
  • neurotransmitter dysregulation -> increased dopamine and serotonin transmission and norepi imbalance
199
Q

Bipolar Disorder

History and Physical Exam findings?

A
  • (+) family history of bipolar disorder
  • dramatic shifts in emotions, mood, and energy levels (moving form extreme lows to extreme highs over a period of days or weeks)
  • lows same as MDD
  • Highs or hypomanic episodes
200
Q

Bipolar Disorder

Differentiation b/w hypomania and mania?

A

timeframe…
hypomania 1-4 days
mania 4+ days

201
Q

Bipolar Disorder

High/Hypomanic episode sx’s?

A
  • excessive psychomotor activity (over-energetic, inexhaustible, diminished need for sleep)
  • elation
  • euphoric with extreme high self-esteem
  • flight of ideas (racing thoughts)
  • increased goal-oriented activity
  • pressured or accelerated speech **
    -     delusions of grandeur** (personal mission from god or supernatural powers)
  • impulsive/reckless
202
Q

Bipolar Disorder

DSM-V diagnostic criteria for BP-1?

A
  • >1 manic episode lasting 1+ week OR requiring hospitalization
  • preceded or followed by hypomania for >2 weeks
  • significant impairement in daily function
203
Q

Bipolar Disorder

DSM-V diagnostic criteria for BP-2?

A
  • depressive episodes lasting 2+ weeks AND milder hypomania for 4+ days
  • mixed episodes of depression and mania at same time
  • rapid cycling >4 episodes of depression or mania within a year
204
Q

Bipolar Disorder

DSM-V diagnostic criteria for BP-3?

BP-3 = cyclothymic disorder

A

mild hypomania sx’s cycling back and forth over a period lasting > 2 years

205
Q

Bipolar Disorder

Management options?

A
  • no cure
  • identify and tx individuals d/t high risk of suicide (admit if necessary)
  • CBT therapy + Antipsychotic medications (Quetiapine) +/- Mood stabilizer (Lithium or Valproate)
  • Avoid SSRI’s!!! they can trigger manic episodes
  • suicide risk assessment + safety plan in place
206
Q

Suicide Risk Assessment & Safety Plan

What are some topics to touch on when conducting a safety risk assessment?

A
  • presence of suicidal ideation (+/- plan? intent to act on plan? access to means?
  • firearms in home?
  • unique driver’s of the pt’s suicidal ideation?
  • protective factors (support system? pets?)?
  • past suicidal ideation or attemps?
  • intent to die (why)?
  • new/enduring psychosocial stressors
  • substance use?
207
Q

Suicide Risk Assessment & Safety Plan

What does a safety plan include?

A
  • how to manage suicide feeling when it occurs
  • what will you do if suicidal thought gets stronger
  • lists presence of protective factors
  • caring contacts
208
Q

Obsessive Compulsive Disorder

Etiology?

A

idiopathic but may have a genetic component
- potentially d/t imbalance of serotonin

209
Q

Obsessive Compulsive Disorder

History and Physical Exam findings?

A
  • MC adolescence/early adult onset
  • Obsessions (unwanted recurrent thoughts/impulses)
  • Compulsions (reptitive behavior or rituals the person feels driven to perform in a particular way)
  • pt understanding that their behavior is irrational (ego-dystonic)
210
Q

Obsessive Compulsive Disorder

DSM-V diagnostic criteria?

A

obsessions or compulsions causing marked distress, are time-consuming, and interfere with normal functioning

211
Q

Obsessive Compulsive Disorder

Management options?

A

CBT therapy and exposure/response prevention
+/- SSRI’s to treat potential underlying anxiety

212
Q

Pharmacotherapy for PTSD

SSRI’s

A

tx of choice (1st line for GAD, MDD, and PTSD)
Sertraline or Paroxetine
- sertraline therapy improved when used with adjunct exposure therapy

prescribing notes = takes 2-4 weeks to see effect

213
Q

Pharmacotherapy for PTSD

Risperidone

A

effective for women with chronic PTSD following physical, sexual, or emotional abuse

reduces intrinsic traumatic thinking and hyperarousal

214
Q

Pharmacotherapy for PTSD

Prazosin

A

a1-adrenergic receptor antagonist that reduces PTSD nightmares

fear memories reduced at amygdala

215
Q

Pharmacotherapy for PTSD

SARI’s

Trazodone

A

only useful as adjunct therapy with SSRI to treat insomnia

do NOT use as monotherapy

216
Q

Pharmacotherapy for PTSD

Monoamine Oxidase Inhibitors?

A

less re-experiencing and arousal sx’s among combat veterans
signifcant dietary, drug, and beverage restrictions

217
Q

Bipolar Spectrum

Difference between BP-1 and BP-2?

A
  • BP1 -> 1 episode of mania +/- MDD
  • BP2 -> 1 episode hypomania AND MDD
218
Q

Bipolar Spectrum

What other mental health conditions might a pt with Bipolar disorder also be diagnosed with?

A

PTSD, substance use disorder, ADHD, autism

219
Q

Bipolar Spectrum

How often should you monitor serum lithium levels? TSH and renal function during lithium therapy?

A
  • Lithium -> q1-2 weeks at start, then 3-6 months, then q6 months thereafter
  • TSH/Renal -> q2-3 months for first 6 months then q6-12 months
220
Q

Bipolar Spectrum

What monitoring should be done with Valproate?

A
  • serum valproic acid levels q1-2 weeks initially then q3-6 months
  • CBC and LFT’s monthly x 2 months then q3-12 months

teratogenic and hepatoxic

221
Q

Bipolar Spectrum

what labs should be monitored with Lamotrigine treatment?

A

CBC and LFT’s monthly x 2 months then q3-12 months thereafter

ADR = SJS, pancytopenia, aseptic meningitis, dizziness

222
Q

Bipolar Spectrum

Which typical antipsychotic medication has the highest risk for neuroleptic malignant syndrome? tardive dyskinesia?

A

Haloperidol

223
Q

Suicide Evaluation

Suicidal ideation definition?

A

thoughts of killing onself

224
Q

Suicide Evaluation

suicidal intent definition?

A

expectation or desire to die with self-injurous act

225
Q

Suicide Evaluation

Suicide attempt definition?

A

trying to take one’s own life but not successful

226
Q

Suicide Evaluation

aborted suicide attempt definition?

A

person stopped their plan to take their life mid-attempt

227
Q

Suicide Evaluation

suicide definition?

A

successfully taking one’s own life intentionally

228
Q

Suicide Evaluation

Current suicide rates?

A
  • increased 36% from 2000-2021
  • one death/11 minutes
  • men are more succesful in their attemps
229
Q

Suicide Evaluation

At risk populations for suicide?

A
  • veterans
  • tribal populations
  • adults
  • LGBT youth
  • mining/coal workers
  • people with disabilities
  • people aged 85+ (highest suicide rates)
230
Q

Suicide Evaluation

What is the MC modality of suicide?

A

firearms (more than 50%)

231
Q

Suicide Evaluation

Warning signs?

A
  • talking about feeling great guilt or shame
  • acting anxious or agitated
  • using alcohol or drugs more often
  • changing eating or sleeping habits
  • social withdrawal from friends/family/community
232
Q

Suicide Evaluation

Protective factors?

A
  • effective coping skills
  • reasons for living (family, friends, pets)
  • strong sense of cultural identity
  • support system
  • feeling connected
233
Q

Suicide Evaluation

End tx plan for following pt:
- suicide plan w/ intent to kill self or ready to act on plan

A

immediate transfer to ED for inpatient hospitalization

234
Q

Suicide Evaluation

End tx plan for following pt:
- passive ideation and pt can adhere to safety plan but patient lacks support

passive = doesn’t say they want to harm self, just go to sleep forever

A

partial hospital (day program) or intensive outpatient program (w/i 1-2 weeks)

235
Q

Suicide Evaluation

End tx plan for following pt:
- suicide plan but pt is not ready to act on plan + can adhere to safety plan AND has support

A

outpatient clinic (w/i 1-2 weeks)

236
Q

Personality Disorders - Cluster A

What personality disorders are in cluster A?

cluster A = odd/eccentric

A
  • Paranoid
  • Schizoid
  • Schizotypal
237
Q

Personality Disorders - Cluster A

DSM-V diagnostic criteria for Paranoid Personality Disorder?

A

pervasive distrust and suspiciousness of others indicated by 4+ of the following:
- suspects harm/deceit from others
- preoccupied with loyality/trustworthiness
- reluctant to confide in others
- bears grudges
- perceives attacks on character/reputation
- basically just hellllaaaa suspicious

M>F

238
Q

Personality Disorders - Cluster A

Management options for paranoid personality disorder?

A

Psychotherapy
+/- anxiolytics or short course of antipsychotics to decrease paranoia

239
Q

Personality Disorders - Cluster A

DSM-V diagnostic criteria for Schizoid personality disorder?

A

pervasive detachment from social relationships and restricted range of emotional expression indicated by 4+ of the following:
- neither desires/enjoys close relationships
- prefers solitary activities
- little or no interest in sex
- takes pleasure in few, if any, activities
- lacks close friends
- appears indifferent
- emotional coldness/detachment/flattened activity

lack of close contact does not bother the pt, MC in M>F

240
Q

Personality Disorders - Cluster A

Treatment options for Schizoid?

A

group or psychotherapy
- low does SSRI’s
- Risperidone or Olanzapine -> help flattened emotions

241
Q

Personality Disorders - Cluster A

DSM-V diagnostic criteria for Schizotypal Personality Disorder?

A

pattern of social and interpersonal deficits marked by acute discomfort and reduced capacity for close relationships in addition to cognitive/perceptual distortions and eccencentricies indicated by 5+ of the following:
- ideas of reference
- odd beliefs/magical thinking
- unusual perceptual experiences
- odd thinking/speech
- suspiciousness/paranoia
- inappropriate/constricted affect
- odd/eccentric behavior/appearance
- lack of close friends (not by choice)
- excessive social anxiety

many genetic links to schizophrenia

242
Q

Personality Disorders - Cluster A

Tx options for Schizotypal?

A

psychotherapy + social skills training (tx of choice)
- trial’s of low-dose antipsychotics
- SSRI’s to decrease anxiety if necessary

243
Q

Personality Disorders - Cluster B

What personality disorder’s are included in Cluster B?

cluster B = dramatic, emotional, erratic

A
  • antisocial
  • borderline
  • histrionic
  • narcissitic
244
Q

Personality Disorders - Cluster B

DSM-V diagnostic criteria for Antisocial personality disorder?

A

pattern of disregard and violation for the rights of others occuring since age 15 as indicated by 3+ of the following:
- trouble with the law
- deceitfulness
- impulsivity, failure to plan ahead
- irritable, aggressive -> repeated fights/assaults
- reckless disregard for safety of self/others
- consistent irresponsibility
- lack of remorse

must be 18+ y/o to diagnose with condition
strongly correlated with childhood conduct disorder
M 3x>F

245
Q

Personality Disorders - Cluster B

Tx options for Antisocial personality disorder?

A

Psychotherapy with **social based interventions **
Pharm -> SSRI’s, lithium, antipsychotics, propranolol

246
Q

Personality Disorders - Cluster B

DSM-V diagnostic criteria for Borderline Personality Disorder?

A

pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, as indicted by 5+ of the following:
- frantic efforts to avoid abandoment
- pattern of unstable/intense relationships
- impulsivity in 2+ areas (sex, substance, driving, eating)
- recurrent suicidal behavior/gestures/threats or self-harm
- affective instability, reactivity of mood
- chronic feelings of emptiness
- inappropriate intense anger
- transient paranoid ideation or severe dissociative sx’s

high incidence of MDD
Females 2x>M
can have abnml EEG

247
Q

Personality Disorders - Cluster B

Treatment options for Borderline personality disorder?

A

first line -> Dialectical behavior therapy

Pharm -> low-dose antipsychotics, SSRI’s, BZD’s, Lithium or valproate for mood stability

248
Q

Personality Disorders - Cluster B

DSM-V diagnostic criteria for Histrionic personality disorder?

A

pattern of excessive emotionality and attention seeking as indicated in 5+ of the following:
- **uncomfortable when not center of attention
- inappropriate sexual/provocative interactions with others
- rapidly shifting/shallow expression of emotions
- uses physical appearance to get attention
- speech excessively impressionistic and lacking in detail
- self-dramatizations/theatrical**
- suggestible
- considers relationships to be more intimate than they actually are

H in histrionic stands for horny

249
Q

Personality Disorders - Cluster B

Tx options for Histrionic Personality Disorder?

A

Psychotherapy is KEY (group or solo)

SSRI’s and anxiolytics less helpful than in other PD’s

250
Q

Personality Disorders - Cluster B

DSM-V diagnostic criteria for Narcissitic Personality Disorder?

A

grandiosity, need for attention, and lack of empathy indicated by 5+ of the following:
- grandiose sense of self
- fantasies of unlimited success/power/brilliance/love
- special/unique/can only be understood by other “special” people at their level
- needs excessive admiration
- interpersonally explosive
- lacks empathy
- envious of others/believes others are envious of them
- shows arrogant/haughty behavior/attitude

251
Q

Personality Disorders - Cluster B

Tx options for Narcissistic Personality Disorder?

A

Psychotherapy…medications RARELY indicated

252
Q

Personality Disorders - Cluster C

What personality disorders are in Cluster C?

cluster C = anxious/fearful

A
  • avoidant
  • dependent
  • obsessive compulsive (personality)
253
Q

Personality Disorders - Cluster C

DSM-V diagnostic criteria for Avoidant Personality Disorder?

A

social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation indicated by 4+ of the following:
- avoids occupational activities with interpersonal contact
- unwilling to get involved with people (unless certain of being liked)
- shows restraint within intimate relationships
- preoccupied with being criticized/rejected
- inhibited in new interpersonal situations d/t feelings of inadequacy
- views self as socially inept, unappealing, or inferior
- unusually reluctant to engage in new activities

254
Q

Personality Disorders - Cluster C

Tx options for Avoidant Personality Disorder?

A

First line -> Psychotherapy with social skills training, group therapy, and assertiveness training
- BB’s and SSRI’s can help anxiety/depression

255
Q

Personality Disorders - Cluster C

DSM-V diagnostic criteria for Dependent Personality Disorder?

A

pervasive and excessive need to be taken care of that leads to submissive and clinging behavior, fears of separation, as indicated by 5+ of the following:
- difficulty making daily decisions w/o others input
- needs others to assume responsibility in most major life areas
- difficulty expressing disagreement
- goes to excessive lengths for nurture/support
- feels uncomfy and helpless when alone
- urgently seeks another relationship as soon as one ends
- unrealistically preoccupied with fears of being left to take care of oneself

256
Q

Personality Disorders - Cluster C

Tx options for Dependent Personality Disorder?

A

First line -> psychotherapy w/ insight-orientated, behavioral, group, and family therapy
Pharm -> anxiolytics and SSRI’s

257
Q

Personality Disorders - Cluster C

DSM-V diagnostic criteria for Obsessive-Compulsive Personality Disorder?

A

orderliness, perfectionism, mental/interpersonal control at the expense of flexibility, openness and efficiency indicated by 4+ of the following:
- preoccupied w/ details/rules/lists/order/schedules to the extent that major point is lost
- shows perfectionism that interferes w/ task completion
- excessively devoted to work/productivity
- over conscientous, scrupulous, inflexible about morality/ethics/values
- unable to discard worn-out/worthless objects
- reluctant to delegate tasks unless submit to their exact way
- adopts miserly spending, money hoarding
- rigidity and stubborness

different from OCD because these are not obsessions/compulsions/repeated behaviors

258
Q

Personality Disorders - Cluster C

Tx options for OCPD?

A

First line -> psychotherapy and group or behavioral therapy

Pharm -> SSRI’s can help manage anxiety/depression

259
Q

Personality Disorders - Therapies

What is a fundamental treatment for ALL personality disorders?

A

psychotherapy!!!

DBT blends mindfullness and cognitive behavioral model

260
Q

Personality Disorders - Therapies

What is Cognitive Behavioral Therapy (CBT)?

A
  • Cognitive -> ID and correct maladaptive beliefs
  • Behavioral -> exercises/real experiences to facilitate sx reduction and improved functioning

often includes relaxation, education, coping skills training, stress management, or assertiveness training

261
Q

Personality Disorders - Therapies

What is Dialectical Behavioral Therapy (DBT)?

A

individual and group therapy with chronic suicidality and borderline personality disorder
- blends mindfullness and CBT to address self-awareness, interpersonal functioning, affective liability and reactions to stress

typically > once/week
good for those who struggle with emotional regulation

262
Q

Personality Disorders - Therapies

What is Psychodynamic Psychotherapy?

A

uncovers unconscious patterns of relationships with others, conflicts, and desires
- relies on developing pt insight
- based on the concept that pts past influences current situation in life

utilized for MDD, anorexia, and personality d/o

263
Q

Personality Disorders - Therapies

What is Psychoeducation?

A

combines CBT, group therapy, and education
- integrates emotional and motivational aspects to help patients cope with an illness and improve its treatment adherence and efficacy

often utilized w/ family therapy as well

264
Q

Personality Disorders - Therapies

What are relaxation therapies?

A
  • deep breathing
  • progressive muscle relaxation
  • visualization/guided imagery
  • mindfullness meditation
265
Q

Personality Disorders - Therapies

What does social skills training involve?

A

type of behavioral therapy to improve social skills in patients w/ mental health disorders or developmental disabilities
- target **specific social skills deficit **
- therapist may describe skill, explain how to carry it out and then demonstrate

266
Q

Personality Disorders - Therapies

What is group therapy?

A

** supportive network for individuals with similar challenges**
- can be numerous therapy modalities w/in group…cognitive, psychodynamic, etc

267
Q

Personality Disorders - Therapies

What is exposure therapy?

A

**graded exposure **(vs flooding, not really used) of a trigger/event/etc to reduce/control reponse and reactions
- indications include PTSD and Phobia’s

268
Q

Personality Disorders - Therapies

What is response prevention?

A

making a “choice” to not complete the behavior once trigger has occurred
- initially w/ therapist then pt’s adapt to independently
- over time, anxiety sx’s will decrease despite absence of compulsion/response

created specifically for OCD

269
Q

Neuropsychiatric testing

What is neuropsychiatric testing?

A

further testing completed by neuropsychologist after initial PCP screening tests
- assessment of neuro function integrating PMHx, labs, imaging, interviews, family collaboration, etc
- helpful in differentiating mental health from other diagnoses
- detects malingering!!!

270
Q

Schizophrenia

What are positive sx’s?

A

hallucinations (MC auditory), delusions/false beliefs, disorganization

mesolimbic system
sx’s d/t high levels of dopamine

271
Q

Schizophrenia

What are negative sx’s?

A
  • flat affect or diminished emotional expression
  • decreased motivation or interest in activities
  • anhenodia (decreased enjoyment from pleasurable activities)

mesocortical system
sx’s d/t low levels od dopamine

272
Q

Schizophrenia

What’re the “A’s” of negative sx’s?

A
  • Alogia (poverty of speech)
  • Avolition (decreased motivation)
  • Asociality (decreased interest in social interactions)
  • **Anhedonia **(decreased enjoyment from pleasurable activities)
273
Q

**Schizophrenia **

Etiology?

A
  • positive sx’s d/t increased dopamine levels in the mesolimbic pathway (motivation/desire)
  • negative sx’s d/t decreased dopamine levels in the mesocortical pathway (emotion regulation)
274
Q

Schizophrenia

History and Risk factors?

A
  • psychosis or >1 positive sx’s
  • chronic deficits in normal behavior or negative sx’s
  • cognitive impairement
  • young males (18-25) > females (25-35)
  • Fhx of schizophrenia or bipolar
  • cannabis use during adolescence
  • personal trauma
275
Q

Schizophrenia

Labs and diagnostic studies to obtain when assessing/diagnosing schizophrenia?

A
  • urine/blood tox to r/o substance intoxication
  • Mini Mental Status Exam (MMSE)
  • activities of daily living (ADL) assessment
  • ECG to establish baseline & monitor for QT prolongation prior to starting meds
  • Ventriculomegaly on CT brain
  • decreased dendritic branching on brain biopsy
276
Q

Schizophrenia

Diagnostic criteria?

A
  • >1 psychotic/positive sx’s OR >2 combined pos/neg sx’s occurring during a 1 month period
  • > 6 months of prodromal or residual sx’s
  • Progressive decline
  • Sx’s must cause significant QOL disturbance
  • other disorders must be ruled out
277
Q

Schizophrenia

What is the first line treatment for Schizophrenia?

A

Atypical (2nd gen) Antipsychotics AND CBT therapy
- Risperidone
- Ariprizaole
- Zirprasidone

278
Q

Schizophrenia

What is the 2nd line tx for Schizophrenia?

A

Typical (1st gen) antipsychotics
- Haloperidol
- Loxapine
- Prochlorperazine
- Droperidol

significantly increased risks of EPS sx’s

279
Q

Schizophrenia

What medications can treat EPS ADR sx’s associated with antipsychotic med tx?

A

Benztropine, Biperiden, Textrabenazine, or diphenhdyramine

280
Q

Schizophrenia

What are some risk-factors that can indicate poor prognosis?

A
  • age of onset (earlier is worse)
  • men
  • predominance of neg. sx’s (suicide risk)
281
Q

Schizophreniform

What is schizophreniform disorder?

A

similar to schizophrenia EXCEPT for the timeframe!!
- sx’s are present for 1-6 months

same management as schizophrenia = 2nd gen atypical antipsychotics and CBT therapy 1st line

282
Q

Brief Psychotic Disorder

What is brief psychotic disorder?

A

similar patho as schizophrenia except it presents as psychosis that may be triggered by a traumatic event or childbirth
- full return of premorbid functioning will occur

283
Q

Brief Psychotic Disorder

What is the diagnostic criteria?

A

1+ positive sx’s present by a period of 1 day to 1 month

284
Q

Brief Psychotic Disorder

Tx options?

A
  • 2nd gen atypical antipsychotics first line
  • benzo’s to ameliorate sx manifestation in acutely combative pt’s

physicial restrains associated with increased mortality, avoid

285
Q

Delusional Disorder

What are some History and Risk factors?

A
  • non-bizarre delusions
  • minimal loss of function outisde the delusion
  • lack of negative or cognitive sx’s
  • > 1 delusion for >1 month w/o meeting criteria for schizophrenia

management involves 2nd gen atypical antipsychotics

286
Q

Schizoaffective Disorder

What is schizoaffective disorder?

A
  • mood episodes (depressive, manic, hypomanic), PLUS psychosis
  • typical onset in early adult hood
  • psychosis must occur by itself for >2 weeks

first line tx -> atypical antipsychotics

287
Q

Somatic Symptom Disorder

Etiology?

A

may be the result of excessive psychological stress or increased sensitivty to pain

288
Q

Somatic Symptom Disorder

History and Risk factors?

A
  • characterized by presence of true physical sx’s (pain, fatigue, dyspnea, weakness, GI, etc)
  • +/- cognitive sx’s (worry, anxiety, thoughts about death)
  • commonly seen in ppl with hx of substance abuse, anxiety and depression
289
Q

Somatic Symptom Disorder

Diagnostic criteria?

A
  • presence of 1 or more unexplained physical sx(‘s) for 6+ months w/o explainable cause
  • sx’s disrupt pt’s daily life
  • excessive time & energy devoted to sx’s
290
Q

Somatic Symptom Disorder

Management options?

A
  • reassurance and reinforcement that medical disease has been ruled out
  • CBT
  • validity of pt’s sx’s is important!!
291
Q

Conversion Disorder

Clinical presentation?

also known as functional neurological symptom disorder

A
  • weakness, paralysis, tremors, psychological seizures, sensory disturbances (deafness/blindness) often triggered by recent emotional or physical trauma
292
Q

Conversion Disorder

Diagnostic criteria?

A

1+ neurological sx’s related to voluntary movement or sensory function (sight/hearing)

293
Q

Conversion Disorder

Management options?

A
  • clinical empathy: focus on caring>curing
  • regular f/u
  • psychotherapy (CBT)
294
Q

Illness Anxiety Disorder

Clinical Presentation?

A
  • preoccupation w/ having medical condition or developing a serious illnness
  • **no or mild somatic sx’s **
  • excessive anxiety regarding one’s health
  • don’t believe provider’s clinical w/u
    -** illness preoccupation must be present for at least 6 months**

tx caring> curing and CBT therapy

295
Q

Dissociative Disorders

What are they?

A

**disconnection or lack of continuity between the individuals and their own thoughts, memories, actions, and identity **
- helps person cope during traumatic time by switching off reality
- may last minutes to years

296
Q

Dissociative Disorders

History and Risk Factors?

A
  • psychological trauma
  • experiencing war, kidnapping, or serial medical procedures
297
Q

Dissociative Disorders

Diagnostic criteria?

A
  • all other mental disorders should be ruled out
298
Q

Dissociative Disorders

Management options?

A

CBT and Dialetical behavior therapy (DBT) are first line

299
Q

Dissociative Disorders

What is Dissociative Amnesia?

A

inability to recall information about onself, old memories, or events, or people in their lives (retrograde amnesia) following traumatic experience/event

make sure to r/o vitB1 deficiency
often self-resolving

300
Q

Dissociative Disorders

What is depersonalization/derealization disorder?

A

detachment from onself, thoughts, or actions, lack of little emotion
- can be treated with Lamotrigine

Clin Med 2 (4 decks)

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