MTB 3 - Psychiatry Flashcards
What are the different time courses for schizophrenia, schizophreniform, and brief psychotic disorder?
Schizophrenia - > 6 months
Schizophreniform > 1 month but
What is the treatment for delusional disorder and schizotypal personality disorder?
Psychotherapy
What percentage of those with schizophrenia attempt suicide?
50%, 10% are successful.
For how long should you give antipsychotics after the first psychotic episode?
6 months with longterm psychotherapy
What are two other indications for antipsychotics other than treating schizophrenia?
Sedation when benzos are contraindicated.
For movement disorders like Huntington’s or Tourette’s
What are 2 pharmacologic effects a/w low-potency antipsychotics?
- alpha blockade leading to orthostatic hypotension
2. anticholinergic effects leading to urinary retention, dry mouth, blurry vision, delirium.
What are you worried about if a patient on thioridazine complains of chest pain and SOB?
Thioridazine is a/w prolonged QT and arrhythmias. Get an EKG!
What strange side effect is associated with long-term thioridazine use?
Retinal pigmentation. Routine eye exam is necessary for chronic therapy. Also impotence and inhibition of ejaculation (from the alpha-blocker effect) are seen.
What are some lesser side effects of low potency antipsychotics?
Impotence and inhibition of ejaculation (from the alpha-blocker effect) are seen. Weight gain d/t hyperprolactinemia, also galactorrhea and amenorrhea.
What are the different time courses a/w extrapyramidal symptoms?
Acute dystonia - within first week Bradykinesia (Parkinsonism) - Within weeks Akathisia - Weeks to chronic use Tardive dyskinesia - Months to years NMS - anytime
What phenomenon is commonly seen after discontinuation of antipsychotics d/t side effects?
A worsening of tardive dyskinesia.
What can be an adjunct therapy for akathisia?
Beta-blockers or benzos.
Try swtiching to a newer antipsychotic.
C/c avoidant personality d/o and social phobia
Avoidant personality d/o does not think that there is anything wrong with his behavior.
C/c the time courses of acute stress disorder and PTSD
ASD is when the symptoms occur within 1 month of the stressor and last less than 1 month
PTSD is when symptoms last longer than 1 month.
What are three important components of the diagnosis of PTSD?
- Re-experiencing of the traumatic event
- Avoidance of stimuli
- Increased arousal
What is the most effective therapy to prevent PTSD following a traumatic event?
Group psychotherapy. Benzos for actue anxiety, SSRIs can help.
What is the timeline for generalized anxiety disorder?
Excessive, poorly controlled anxiety that occurs everyday for more than 6 months.
What is the treatment for generalize anxiety disorder?
Supportive psychotherapy with relaxation training
SSRIs, venlafaxine, buspirone, and benzos.
Medications for OCD?
SSRIs and clomipramine.
What is notable about the side effect profile of buspirone that is relavant to people working a normal day?
It is the best option for people with occupations that involve operating machinery
Is there a withdrawal syndrome with buspirone?
No.
What is the time course definition of major depression?
Depressed mood and anhedonia lasting at least 2 weeks.
What is the time course definition of dysthymic disorder? What is the treatment?
Low-level depressive symptoms that persist for 2 years. Psychotherapy is best, if fails, SSRI.
You have hospitalized a patient for acute mania. What is your first drug of choice? What do you use for acute mania?
DOC: Lithium (takes 1 weeks to act)
For acute mania: antipsychotics
When do you give antidepressants to those with bipolar disorder?
Only when there is a history of recurrent depression. ONLY give with mood stabilizers (to prevent inducing mania)
What is the definition of rapid-cycling bipolar disorder? How would you treat it.
> 4 episodes of mania per year. Treat by gradually stopping all antidepressants, stimulants, caffiene, benzos, and alcohol
What drug has been shows to decrease suicidal ideation in those with bipolar disorder?
Lithium
A 32 year old pt w bipolar d/o who is on lithium has a positive pregnancy test. How do you manage her bipolar d/o going forward?
Discontinue lithium. ECT therapy is best for first trimester pats with anic episodes.
What is it called when a patient has recurrent episodes of depressed mood and hypomanic mood for at leaset 2 years? What is the treatment for this disorder? What drug is best in this disorder?
Cyclothymia. Psychotherapy is the best option. Divalproex if functioning is impaired. Divalproex is more effective than lithium.
How long do symptoms last in grief vs. depression? How long does it take pt to return to baselien level of functioning?
Grief = lasts up to one year Depression = symptoms last longer than a year
Baseline level of function
Grief = returns within 2 months
Depression = pt does not return to baseline functioning
When would you consider giving antidepressants with prolonged grief?
6 months
In what context is post-partum depression usually observed? What is the treatment?
After the second birth. The treatment is antidepressants.
In what context is postpartum psychosis usually seen?
After the first birth. Mood stabilizers or antipsychotics and antidepressants.
What sort of treatments would you consider if the patient is breastfeeding and is diagnosed with postpartum psychosis?
Avoid medications, consider ECT.
What is the beggist complaint associated with ECT therapy and what is the time course of these effects? ECT is contraindicated in patients with what medical conditions?
Transient memory loss - worsens with prolonged therapy and resolves after several weeks. ECT is contraindicated in patients with space-occupying intracranial lesions.
How long should you treat with anti-depressants following the first depressive episode?
6 months and then attempt to taper.
What drug would you consider for a patient with depression who is concerned about weight gain or sexual dysfunction? What serious adverse effect does this drug have?
Buproprion. Lowers the seizure threshold.
What drug would you consider for a patient with depression who is concerned about poor appetite, recent weight loss, or insomnia?
Mirtazepine
Depression + chronic pain = consider giving what drug?
Amitriptyline
SSRIs are safe in pregnancy except for which SSRI?
Paroxetine.
What is first line for bipolar disorder?
What is first line for rapid-cycling bipolar disorder?
What is second line for bipolar disorder?
Lithium
Divalproex (depakote)
Carbamazepine (AE: agranulocytosis and sedation)
Elderly patient with bipolar d/o w renal failure, hyponatremia w nausea, vomiting, confusion, tremors, increased DTRs, +/- seizures. What should you think about? What is the treatment?
Think lithium o/d. Treatment is dialysis.
SSRI + migraine (triptan) =/- MAOI, what are you thinking of? What is the treatment?
Serotonin syndrome.
IVF, cyproheptidine to decrease serotonin production, benzo to decrease muscle rigidity
Diagnostic criteria for somatoform disorders?
4 pain
2 GI
1 sexual
1 pseudoneurologic
How would you treat anorexia/bulemia?
Hospitalize IVF Olanzipine SSRIs (especially fluoxetine) Behavioral psychotherapy
Young female who is underweight because of food restriction +/- excessive exercise and has not had a menstrual period for 3 cycles or more. What percentage of these pts also purge?
Anorexia nervosa. 50% purge.
Young female with normal weight with frequent episodes of binge eating followed by guilt, anxiety, and self-induced vomiting, laxative, diuretics, or enema use.
Bulemia nervosa. Food restriction is not a feature of bulimia.
Bonus: what is a risk associated with prolonged ipecac syrup use?
cardiomyopathy
What is the first line treatment for body dysmorphic disorder?
SSRI
What are tests that you should order when you are considering a diagnosis of alcohol dependence?
Tox screen
To look for secondary effects of alcohol abuse: elevated GGTP, AST, ALT, LDH
HIV, HCV, HBV, PPD
What is the most effective management of alcohol abuse or the most effective way to prevent relapse?
AA
What are the symptoms a/w Wernicke-Korsakoff syndrome?
Opthalmoplegia
Ataxia
Confusion/amnesia
Nystagmus
If you are treating a patient with underlying liver disease for acute alcohol dependence, what meds would you consider? What about in a patient without liver dysfunction?
With liver dysfunction: short-acting benzos (lorazepam, oxazepam)
Without liver dysfunction: long acting (chlordiazepoxide/diazepoxide)
Naloxone and acamprosate only decrease relapse rate in alcohol dependence when given with what?
Psychotherapy
Explain the time course of the sequelae of alcohol withdrawal
6 hours: minor withdrawal - insomnia, tremors, mild anxiety, HA, diaphoresis, palpitations
12-24 hours: Alcoholic hallucinosis: visual hallucinations +/- auditory and tactile hallucinations
48 hours: Withdrawal seizures: tonic-clonic seizures
48-96 hours: Delerium tremens: hallucinations, disorientation, tachycardia, hypertension, low grade fever, agitation, diaphoresis.
In a patient with alcohol dependence, hallucinations + mental status changes, what is the (specific) diagnosis?
This is delerium tremens, NOT alcoholic hallucinosis.
