Panre-Psychiatry/Behavior Science Flashcards
Bipolar disorder (Level 1)?
- Bipolar Disorder 1
- Bipolar Disorder 2
- Rapid cycling
- Cyclothymic
Demographics: Men = Women, avg onset 20-30y, rare for new onset >50y
● #1 risk factor: Family hx of 1st degree relative
Bipolar Disorder Type 1
≥1 manic or mixed episodes, usually requires hospitalization
○ Depressive episodes may be occasional but not required for diagnosis
Bipolar Disorder Type 2
At least one major depressive episode (MDE) + one hypomanic episode
○ Does not meet criteria for full manic or mixed episode
Rapid cycling
Involves 4+ episodes (MDE, manic, mixed or hypomanic) in 1 year
Cyclothymic
Chronic and less severe, alternating hypomania and moderate depression
for >2 years
Sx of mania: DIG FAST
D istractibility and D ecreased need for sleep
○ I mpaired judgement and I ncreased i mpulsivity
○ G randiosity/more G oal oriented
○ F light of ideas/racing thoughts
○ A ctivities/psychomotor a gitation
○ S exual indiscretions/other pleasurable activities
○ T alkativeness/pressured speech
Dx of mania:
1+ week of persistently elevated, expansive or irritable mood + 3 “DIG
FAST” sxs
○ Psychotic symptoms also common
○ Must have significant social/occupational impairment
Hypomania:
Similar to mania but does not cause significant life impairment, no
psychotic features, does not require hospitalization
○ Period of elevated, expansive or irritable mood for at least 4 days that is
different from usual non depressed mood
○ Does not include racing thoughts or excessive psychomotor agitation
Bipolar TX?
Bipolar mania is acute emergency due to impaired judgement and concern
for self/other harm
■ Tx with hospitalization + mood stabilizers such as lithium,
carbamazepine, valproic acid
○ Bipolar depression
■ Mood stabilizers with/without antidepressants
■ Antidepressants alone can trigger mania
Child/elder abuse, Spouse/partner abuse (Level 1)
Mandatory reporter of child/elder abuse
● Be suspicious when explanation does not match injury pattern
● Have knowledge of local resources
Child Abuse: Sexual abuse:
Abuser often male who is known to victim
● S/S: Genital/anal trauma, STIs, UTIs
Child Abuse: Physical abuse:
Abuser often primary caregiver, female
● S/S: Burns in stocking glove pattern, retinal hemorrhages, subdural hematoma,
bruises, spiral fractures
Child Abuse: ● Child neglect:
Failure to provide basic needs
● S/S: Failure to thrive, malnutrition, withdrawal
Elder Abuse?
Abuser is someone with ongoing relationship, duty toward elder
● Abuse may be physical, sexual or psychological
● Also neglect or financial exploitation
Elder Abuse s/s?
Skin tears, bruising, pressure sores, spiral long bone fractures, malnutrition,
dehydration
Elder Abuse warning signs of financial exploitation? screening questions?
Change in ability to pay for medical
services, utilities, food, housing; patient who lacks capacity to consent to property
or equity transfer.
Screening questions with patient alone:
○ Do you feel safe where you live?
○ Who prepares your meals?
○ Who handles your checkbook?
Spouse/partner abuse
Women>Men
● Intimate partner violence: Actual or threatened physical, sexual or psychological
harm by current or former partner
○ Does not require sexual intimacy
○ Occurs in both heterosexual and homosexual relationships.
Spouse/partner abuse s/s?
Apparent social isolation, overly attentive/verbal partner, delay in seeking
treatment, missed appointments, inappropriate affect (jumpy, fearful, avoid eye
contact), inconsistent explanation of injuries
Spouse/partner abuse associated?
depression, suicidality, anxiety, PTSD, substance abuse, eating
disorders
Spouse/partner abuse screening questions?
Screening with SAFE questions: Ashur M. Asking About Domestic Violence: SAFE Questions.
JAMA.1993;269(18):2367
○ S tress/Safety: Do you feel safe in your relationship?
○ A fraid/Abused: Have you ever been in a relationship where you were
threatened, hurt or afraid?
○ F riend/Family: Are your friends/family aware you have been hurt?
○ E mergency plan: Do you have a safe place to go and the resources you need
in an emergency?
As providers, be non judgmental, assure appropriate confidentiality, non-hurried
discussion, reassurance that abuse is not their fault, no pressure to leave/report,
shared decision making, supportive listening
Generalized Anxiety Disorder (Level 2)
Definition: Uncontrollable, excessive anxiety or worry about multiple activities or
events that leads to significant impairment
Demographics: 2x more women>men, onset early 20s
Generalized Anxiety Disorder (Level 2) dx?
Anxiety on most days for 6+ months with 3+ somatic symptoms
○ Restlessness, fatigue, difficulty concentrating, irritability, muscle tension,
disturbed sleep
Generalized Anxiety Disorder (Level 2) tx
Short-term: Benzodiazepines
■ Side effects: ↓ duration of sleep, risk of abuse, tolerance and
dependence, disinhibition, confusion
■ Also hydroxyzine
■ 𝛃blockers
● Best for phobic disorders given before exposure
○ Long-term: Psychotherapy, cognitive behavioral therapy, medications
■ SSRIs, SNRIs
● Side effects: Nausea, somnolence, sexual dysfunction
Buspirone
● No tolerance, dependence or withdrawal
Major depressive disorder (Level 2)
Dx: Depressed mood or anhedonia along with 5+ symptoms almost every day for
most days for at least 2 weeks
Major depressive disorder (Level 2) s/s? Sig Em Caps
SIG EM CAPS
S leep insomnia or hypersomnia
○ I nterest (↓ interest or pleasure in activities)
○ G uilt (thoughts of worthlessness or inappropriate guilt)
○ E nergy ↓, fatigue
○ M ood ↓
○ C oncentration ↓
○ A ppetite and weight ↓ or ↑
○ P sychomotor agitation or retardation
○ S uicidal ideation (recurrent thoughts of death)
Symptoms must not be due to substance use, medical issues or bereavement
● Symptoms must cause distress/impairment in daily functioning
● Absence of mania or hypomania
Major depressive disorder (Level 2) RF?
Female 2x> Male, highest incidence 20-40s, FH
○ 15% commit suicide, ↑ suicide rates: White males > 45y, detailed plan,
substance abuse
Major depressive disorder (Level 2) TX?
Psychotherapy - 1st line in mild/moderate depression, cognitive behavioral
therapy (CBT)
○ SSRIs- 1st line for medicine; also SNRIs, TCAs, MAOIs; minimum 3-6 weeks
○ Electroconvulsive therapy (ECT) for pts who fail medical therapy;
transcranial magnetic stimulation (TMS)
Non-substance-related addictive disorders (Level 1)
Gambling disorder is the only DSM-5 recognized disorder
● Other behavioral addictions include pornography, sex, social media, video gaming,
shopping, food, exercise
● Screen for maladaptive behaviors similar to substance use disorder but there is
currently no specific diagnostic criteria except for gambling disorder
○ DSM 5 says “behavioral addictions…are not included because at this time
there is insufficient peer-reviewed evidence to establish the diagnostic
criteria…”
Gambling disorder dx:
Behavior leading to clinically significant impairment/distress
with 4+ sx in 1 year Extrapolate these diagnostic criteria to other behavioral
addictions, replace specific behavior for gamble/gambling
○ Need to increased amount/time gambling to achieve same excitement
○ Restless/irritable when attempting to cut down/abstain
○ Unsuccessful attempts to cut back/stop
○ Preoccupied by gambling
○ Gambles when distressed
○ Gambles even after losing money (“chasing losses”)
○ Lies about extent of gambling
○ Jeopardized or lost significant life relationship/job due to gambling
○ Relies on others for money to relieve financial stress caused by gambling
Panic disorder (Level 2) dx?
Dx: Recurrent, unexpected panic attacks (abrupt onset, peak within 10 min,
duration <60 min) with
○ At least 2 with one of the following for at least 1 mo
■ Panic attack followed by concern for future attack
■ Worry about implication of attack
■ Significant change in behavior d/t attack
○ At least 4 symptoms of panic attack
■ Tachypnea, chest pain, palpitations, diaphoresis, nausea, trembling,
dizziness, fear of dying/doom
○ Sxs not due to substance use, medical or other psychiatric condition
○ ± Agoraphobi
Panic disorder (Level 2) Demographics?
2x more women>men, average age of onset is 25y
Panic disorder (Level 2) Diff Dx?
Angina, MI, arrhythmias, hyperthyroidism, pheochromocytoma,
substance-induced anxiety, generalized anxiety disorder (GAD), PTSD
Panic disorder (Level 2) PE:
Perioral and/or acral paresthesias from hyperventilation (fairly specific to
panic attacks)
Panic disorder (Level 2)TX?
Short-term: Benzodiazepines, hydroxyzine
○ Long-term: Psychotherapy, cognitive behavioral therapy (CBT),
medications- SSRI
Post-traumatic stress disorder (Level 1)
Clinically significant stress/impairment in daily interactions due to exposure to a
life-threatening traumatic event either by: Direct experience of event
○ Witnessing event
○ Learning event happened to someone close
○ Occupational extreme or repeated exposure to details of event; Common traumatic events: Sexual assault, combat experiences, childhood abuse
Post-traumatic stress disorder (Level 1) Dx?
Presence of ≥ 1 of the following symptoms for > 1 mo:
○ Intrusion - reexperiencing event through nightmares, flashback, intrusive
thoughts
○ Avoidance of stimuli related to the event
○ Negative alterations in mood/cognitions- numbed responsiveness,
detachment, guilt, self-blame
○ Changes in arousal and reactivity- ↑ arousal, hypervigilance, exaggerated
startle, sleep disturbances, irritability, ↓ concentration
Post-traumatic stress disorder (Level 1)
SSRI, trazodone may help insomnia, CBT
Substance use disorders: illicit substances, prescription drugs, alcohol, tobacco (Level 1)
Maladaptive pattern of substance use that leads to clinically significant
impairment
○ Can be applied to most substances (not caffeine
Substance use disorders: illicit substances, prescription drugs, alcohol, tobacco (Level 1) Criteria for dx?
2 of 11 criteria within 1 year
Impaired control
■ 1. Consumption of greater amounts than intended
■ 2. Failed attempts to cut down/abstain
■ 3. Increased amount of time spent using/acquiring/recovering
■ 4. Craving
○ Social impairment
■ 5. Failure to fulfill responsibility at work/school/home
■ 6. Continued use despite recurrent social/interpersonal issues 2º to
substance
■ 7. Isolation from life activities
○ Risky use
■ 8. Use in physically hazardous situation
■ 9. Continued use despite recurrent physical/psychological issues 2º
to substance
○ Pharmacologic
■ 10. Tolerance and need for progressively larger amounts for same
effect
■ 11. Withdrawal symptoms when not using substance
Mild Dx of
Substance use disorders: illicit substances, prescription drugs, alcohol, tobacco (Level 1)
2-3 sx
Moderate: of
Substance use disorders: illicit substances, prescription drugs, alcohol, tobacco (Level 1)
4-5 sx
Severe; of
Substance use disorders: illicit substances, prescription drugs, alcohol, tobacco (Level 1)
> 6 sx
Substance use disorders labs?
✔ urine and blood tox, LFTs, ETOH
Alcohol Use Disorder risks? Dx?
Risks: Men 4x>women, FH
● Dx: CAGE questions
○ Have you ever felt the need to CUT down on your drinking?
○ Have you ever felt ANNOYED by criticism of your drinking?
○ Have you ever felt GUILT about your drinking?
○ Have you ever had to take an morning EYE opener?
Alcohol Use Disorder Withdrawal sx?
Tremor, tachycardia, delirium tremens (DTs), seizures, agitation,
hallucinations, potentially fatal
Timeline after last drink
■ 6-24 hours: Uncomplicated sxs → tremor, anxiety, diaphoresis
■ 6-48 hours: Withdrawal seizure
■ 12-48 hours: Hallucinations with normal vitals and clear sensorium
■ 2-5 days: Delirium tremens → altered sensorium, abnormal vital
signs(associated with mortality rate of up to 5%)
Withdrawal seizures: Generalized tonic-clonic, begin within 12-48 hour after the last drink, often in chronic alcoholics, age 40-50 y/o
All puts with DTS required admission and IV benzos
Withdrawal tx of Etoh use?
Benzo taper, multivitamin + folic acid, thiamine to prevent
Wernicke encephalopathy; Pts with hx of complicated withdrawal can be prophylactically tx with oral chlordiazepoxide
Long term tx of Etoh use?
Disulfiram, naltrexone, group therapy/alcoholics anonymous
Complicatons of Etoh use?
GI bleeding d/t ulcers, varices, Mallory-Weiss tears, pancreatitis,
liver disease
Tobacco use disorder
Risk factor for major pulmonary, cardiac and cancer deaths
● Withdrawal sx: Anxiety, craving, irritability, sleep changes
● Tx: Nicotine tapering therapy ± bupropion, varenicline
Opioid use disorder intoxication s/s? Withdrawal s/s?
Intoxication s/s: Euphoria and sedation, pupillary constriction, respiratory
depression, bradycardia, hypotension, N/V, flushing, constipation
● Withdrawal s/s: “Hurts all over”, non life-threatening (no seizures), lacrimation,
hypertension, pupillary dilation, piloerections, sweating, diarrhea, tachycardia
Opioid use disorder tx?
Acute intoxication: Naloxone, onset ~ 2 min IV, ~ 5 min IM
○ Withdrawal: Symptom control with clonidine, loperamide, NSAIDs,
buprenorphine + naloxone
Long term management: Methadone, suboxone
Suicide risk (Level 2) RF?
1 predictive factor: previous attempt or threat
● Always ask patients if they have a plan, access to firearms
Other risk factors: Underlying psychiatric disorders, substance abuse, family
history
Suicide risk (Level 2) Demographics?
Suicide attempts: Female > Male ○ Suicide completions: Male > Female ○ Suicide rate ↑ with age ■ #1 elderly white males ○ White > Black ○ Alone > never married > widowed > separated/divorced > married without kids > married with kids
Suicide risk (Level 2) TX?
Medical stabilization, reduction of immediate risk, safety planning, managing
underlying psychiatric illness and factors, monitoring and follow up
Narcolepsy
↓ ability to regulate sleep-wake cycles
Narcolepsy CM?
→ mins), cataplexy (emotionally-triggered transient muscle weakness), sleep paralysis &/or
hallucinations when falling asleep or awakening; usually sleep about the same number of
hours at night as most people, but have interrupted sleep
Narcolepsy Dx?
clinical; polysomnography (REM occurs at sleep onset)
Narcolepsy TX
lifestyle changes (daytime naps); CNS stimulants (eg. modafinil, methylphenidate
Parasomnias
Disruptive sleep disorders that occur during arousals from non-rapid eye movement (NREM)
or rapid eye movement (REM) sleep – can occur while falling asleep, sleeping or waking up
Parasomnias NREM dz?
often run in families & usually occur in children or adolescents; pts usually
return to sleep & are amnestic to events in the morning – most pts outgrow these conditions
by young adulthood
Parasomnias REM dz?
usually involve dream enactment & pts usually recall the dream and
associated actions – these conditions most often occur late in adult life & are associated with
degenerative brain dz
Parasomnias Dx?
clinical; polysomnography for REM sleep behavior disorder
Parasomnias TX?
Sleep hygiene
o Avoiding substance use
o Injury protection (sleeping close to floor level, removing surrounding sharp objects)
o Possibly benzodiazepines (eg. clonazepam) to promote sleep depth & continuity; also,
melatonin
o Sleep medicine consult
NREM disorders:
Somnambulism (sleep walking); Sleep (night) terrors:
Somnambulism
NREM, Sleep walking; Sitting, moving around or walking with eyes wide open, but actually still in deep NREM
sleep – may wake up during an episode & appear confused, or get back into bed without
waking; most people do not recall the event
Sleep (night) terrors
NREM; Abrupt arousal in a state of terror often screaming, crying or flailing, ↑ heart &
respiratory rates, sweating, skin flushing – pt may appear to be awake, but is confused
and unable to communicate normally; most people do not recall the event
REM disorders
REM sleep behavior disorder; Nightmares:
REM sleep behavior disorder
Vocalization (sometimes profane) & often aggressive movements (punching, kicking) that
reflect physical acting out of dreams; pts usually recall vivid dreams upon awakening
Nightmares:
Abrupt arousal in a state of fear, terror and/or anxiety brought about by vivid dreams
during sleep; pts can usually describe detailed dream content – usually due to illness,
anxiety or traumatic event
Selective serotonin
reuptake inhibitors
(SSRI) MoA?
Highly selective for
blocking serotonin reuptake
at neuronal membrane
Selective serotonin
reuptake inhibitors
(SSRI Names?
Citalopram Escitalopram Fluvoxamine Fluoxetine Paroxetine Sertraline
Selective serotonin
reuptake inhibitors
(SSRI) Indications?
#1 for depression & anxiety • Obsessive compulsive disorder (OCD) • Bulimia nervosa • Premenstrual dysphoric disorder (PMDD)
Selective serotonin
reuptake inhibitors
(SSRI) S/E?
GI upset • Sexual dysfunction • Headache Insomnia • Anxiety • Weight changes Serotonin syndrome especially if used with MAOI →
Serotonin syndrome
especially if used with MAOI → Acute altered mental status • Coma • Restlessness • Diaphoresis • Tremor • Hyperthermia • N/V • Abdominal pain • Tachycardia
Selective serotonin
reuptake inhibitors
(SSRI) CI
Avoid citalopram in patients with long QT syndrome • Avoid paroxetine in pregnancy (can cause pulmonary HTN)
Selective serotonin
reuptake inhibitors
(SSRI) Special Considerations?
Benefits: • Preferred for children • Easy dosing • Less side effects • Low toxicity in overdose
Serotonin and
norepinephrine
reuptake inhibitors
(SNRI) Names?
Desvenlafaxine
Duloxetine
Venlafaxine
Serotonin and
norepinephrine
reuptake inhibitors
(SNRI) MOA?
Inhibits serotonin,
norepinephrine & dopamine
reuptake
Serotonin and
norepinephrine
reuptake inhibitors
(SNRI) Indications?
1 for depression with
significant fatigue or pain
syndromes
• 2nd line to SSRI
Serotonin and
norepinephrine
reuptake inhibitors
(SNRI) S/e?
Similar to SSRI +
hyponatremia &
noradrenergic symptoms
Serotonin and
norepinephrine
reuptake inhibitors
(SNRI) CI ?
Cautions: • MAOI • Renal/hepatic impairment • Seizures • HTN
Serotonin and
norepinephrine
reuptake inhibitors
(SNRI) Special considerations?
Avoid abrupt discontinuation • ↑ serotonin syndrome risk when used with St John’s Wort
Tricyclic
antidepressants (TCA) Names?
Amitriptyline Clomipramine Desipramine Doxepin Imipramine Nortriptyline
Tricyclic
antidepressants (TCA) Moa?
nhibits presynaptic
reuptake of serotonin &
norepinephrine
Tricyclic
antidepressants (TCA) Indications?
Depression • Insomnia • Diabetic neuropathic pain • Post-herpetic neuralgia • Migraine • Urge incontinence • Enuresis (imipramine)
Tricyclic
antidepressants (TCA) S/e?
Anticholinergic effects (dry mouth, constipation, urinary retention, sedation) • Weight gain • Prolonged QT interval • Overdose: Na⁺channel blocker effects, wide complex tachycardia (correct with bicarbonate), ARDS, SIADH
Tricyclic
antidepressants (TCA) CI
MAOI • Recent MI • Hx of seizure • Check ECG before starting to r/o AV blocks Contraindications: • Pregnancy
Tricyclic
antidepressants (special considerations)
• Used less often due to SE & severe overdose toxicity • Non-depressed patients feel sleepy • Depressed patients have mood elevation
Mirtazapine Drug class and MOA?
Tetracyclic
compounds; Enhances central
noradrenergic &
serotonergic activity
Mirtazapine Indications
Depression
Mirtazapine S/E
Sedation • Dry mouth • Constipation • Weight gain • Agranulocytosis
Mirtazapine CI
Caution with MAOI
Mirtazapine Special Considerations?
Less sexual dysfunction
MAO inhibitors
(MAOI) Drug name and MOA
Phenelzine
Phenelzine Indications
Refractory depression
Phenelzine S/E
Insomnia • Anxiety • Orthostatic hypotension • Weight gain • Sexual dysfunction • Hypertensive urgency/ emergency (with tyramine containing foods)
Phenelzine CI
Caution + SSRI →
serotonin syndrome
• Caution + TCA →
delirium & HTN
Phenelzine Special Considerations?
Avoid tyramine containing
foods - aged/fermented
cheese, wine, beer, smoked
meats
Bupropion Drug class and MOA?
Atypical ; Inhibits neuronal uptake of
dopamine
Bupropion Indications
Depression • Smoking cessation • Attention-deficit hyperactivity disorder (ADHD) • Seasonal affective disorder (SAD
Bupropion S/E
↓ seizure threshold • Agitation • Anxiety • Restlessness • Weight loss • HTN • Headache • Dry mouth
Bupropion CI
Cautions: • Seizure disorder • Eating disorder • MAOI use • Drug/ETOH detoxification
Bupropion Special Considerations?
• Less sexual dysfunction &
GI distress than SSRI
• Avoid abrupt withdrawal
Trazodone Drug class and MOA?
Atypical;
Serotonin antagonist &
reuptake inhibitor
Indications
Depression
• Anxiety
• Insomnia
S/E
Sedation
• Priapism
Typical 1st Generation Drug class?
Butyrophenones
Phenothiazines
Butyrophenones Drug class and MOA
Typical 1st Generation ; Droperidol
Haloperidol; Blocks CNS D2 receptors
• Dopamine antagonist
Butyrophenones Indications
Psychosis • Schizophrenia (especially positive symptoms) • Tourette syndrome • Alcoholic hallucinosis • Antiemetic
Butyrophenones S/E
• Extrapyramidal symptoms (EPS) • QT prolongation • Weight gain • ↑ prolactin • Sedation
Butyrophenones CI
Liver disease
• Haloperidol CI with
Parkinson disease
• Anticoagulant use
Butyrophenones Delivery options?
IM Depot Preparations for non-compliant patients • Haloperidol q 4 wks • Fluphenazine q 2 wks
Phenothiazines Drug class and MOA
Chlorpromazine Fluphenazine Thioridazine; Blocks CNS D2 & 5HT2 receptors • Dopamine antagonist
Phenothiazines Indications
Psychosis
• Schizophrenia
• Chlorpromazine for
intractable hiccups
Phenothiazines S/E
EPS • QT prolongation • Weight gain • ↑ prolactin • Sedation • Thioridazine can cause irreversible retinitis pigmentosa
Phenothiazines CI
• Liver disease
Mood stablizers
Lithium
Carbamazepine
Lamotrigine
Valproic acid
Lithium MOA, Indications, S/E, CI, Special Considerations.
• Alters cation transport across cell membrane • Influences reuptake of serotonin and/or norepinephrine;• # 1 mood stabilizer especially in suicidal patients • Management of bipolar disorder (BPD) • Acute mania in BPD • Last drug of choice for SIADH; Lithium induced diabetes insipidus: treat with amiloride • Fine tremor: treat with propranolol • Hypothyroidism • N/V • Leukocytosis • Cardiac arrhythmias • Toxicity: ataxia, dysarthria, delirium, acute renal failure; • ↓ renal function • Pregnancy; • ↓ suicide risk • Narrow therapeutic window so must monitor blood levels • Toxicity >1.5 mEq/L
Carbamazepine MOA, Indications, S/E, CI,
Stabilizes electrical activity in the brain; • 2nd line mood stabilizer • Anticonvulsant • Trigeminal neuralgia; • Hyponatremia • Diplopia • Ataxia • Aplastic anemia • Agranulocytosis: monitor CBC; Cautions: • Gout • DM 2
Lamotrigine MOA, Indications, S/E, Special Considerations.
Stabilizes electrical activity in the brain ; • 2nd line mood stabilizer • Anticonvulsant ; • Rash/SJS • Visual disturbance; ↑ dose slowly & monitor for rash
Valproic acid MOA, Indications, S/E, CI,
Stabilizes electrical activity in the brain; • BPD • Anticonvulsant; • Pancreatitis • Hepatotoxicity • GI upset; • Pregnancy • Hepatic disease
Amitriptyline use for?
Chronic pain, Diabetic neuropathic pain
• Post-herpetic neuralgia
•
Imipramine use for
Bedwetting
Clomipramine use for
OCD
