Psych Flashcards
When is postpartum psychosis?
Within 2 weeks of childbirth
Most often seen in those with bipolar disorder
Acute stress disorder timeline
Within 1 month of traumatic event
Adjustment disorder timeline
Starts within 3 months of stressor, ends within 6 months of stressor ending
Delusional disorder definition
> =1 month delusions without other psychotic or mood symptoms
Vascular dementia strategic stroke locations
Medial frontal, medial temporal, thalamus
Malignant catatonia
Autonomic instability (like NMS) but with posturing and waxy flexibility
How long to continue antidepressant in MDD?
Single episode: continuation-phase treatment for additional 6 months after symptoms controlled
> =2 episodes, persistent residual symptoms: maintenance treatment for 1-3 years
> =3 episodes, chronic episodes (>=2yr), strong FHx, or severe: maintenance indefinitely
Bipolar II vs borderline personality disorder: timeframe
Bipolar II: discrete periods lasting weeks
Personality disorder: labile mood states that last hours-days; lifelong pattern of identity disturbance
Bipolar major depression - treatment
Lurasidone or quetiapine (2nd-generation anti-psychotics)
Alternatives:
Lithium, valproate, lamotrigine, or olanzapine + fluoxetine
Medications to avoid with bipolar disorder
Antidepressant monotherapy - if necessary, use in combination with mood stabilizers (e.g. lithium, valproate, 2nd gen antipsychotics)
Borderline personality disorder - firstline treatment
Dialectical behavior therapy
Schizoid personality disorder
Lifelong pattern of behavior characterized by lack of desire for and detachment from social relationships and restricted emotions
Sleepwalking
Sleep terrors
REM sleep behavior disorder
Nightmare disorder
Sleepwalking and sleep terrors are during slow-wave (N3), non-REM sleep; longer period of confusion before becoming fully alert, do not recall concurrent dreams
REM sleep behavior disorder occurs in latter half, awakened easily and alert and oriented, in older adult men and may be sign of neurodegeneration and possible later onset of Parkinson or dementia with Lewy bodies
Nightmare is vivid recall of disturbing dream content without motor activity
Depersonalization/derealization disorder
Dissociative amnesia
Dissociative identity disorder
Depersonalization/derealization: intact autobiographical memory but feelings of unreality/detachment
Dissociative amnesia: typically sudden and preceded by overwhelming or intolerable events; localized amnesia for particular event or generalized for personal identity and history
Dissociative identity disorder: requires >=2 distinct personality states; associated with severe trauma/abuse
PTSD length
> 1 month (vs acute stress disorder, which is >=3d and <=1 month
Dialectical behavioral therapy
Borderline personality disorder
Improves emotion regulation, distress tolerance, mindfulness
Decreases self-harm; builds skills
Psychodynamic therapy
For higher functioning patients; personality disorders
Builds insight into unconscious conflicts and past relationships
When is electroconvulsive therapy used for MDD with psychotic features?
Rapid response in case of severe suicidality or refusal to eat/drink
Persistent depressive disorder (dysthymia)
> =2 years with >=2 symptoms
No symptom-free period for >2 mo
Specifiers:
with pure dysthymic syndrome - never major depressive episode
with intermittent major depressive episodes
with persistent major depressive episodes (criteria met throughout previous 2 years)
Bulimia nervosa - drug of choice
Fluoxetine
How does somatic symptom disorder differ from illness anxiety disorder?
Significant somatic symptoms, as opposed to concern with the idea of having a serious illness
Dissociative identity disorder - treatment
Long-term, trauma-focused psychotherapy
Difference in auditory hallucinations between dissociative identity disorder and psychotic disorder
DID - voices perceived as inside patient’s head
Psychotic - voices seem from outside of head
How long for schizophrenia diagnosis?
Impaired functioning >=6 mo
Episodes of acute psychosis and negative symptoms
Panic disorder - acute and long-term treatments
Acute: Benzo (e.g. lorazepam)
Long-term: SSRI/SNRI and/or CBT
Medication for sedation
Benzos
Haloperidol
Haloperidol + lorazepam can achieve more rapid sedation in severely agitated, combative patients
Kleptomania
Impulse control disorder with typical onset in adolescence - steal objects of low monetary value or not needed for personal use (as opposed to shoplifting)
Tend to feel guilt or shame afterward and want to return or give away item
Medication-induced dystonia - signs
Sudden, sustained contraction of muscles, most often impacting neck, mouth, tongue, and extraocular muscles
May be associated with other extrapyramidal effects
Anticholinergics will help treat
Differentiate medication-induced dystonia (dopamine antagonists, antipsychotics) with serotonin syndrome (serotonin antagonists)
Serotonin syndrome is more pronounced in extremities (e.g. spontaneous clonus, hyperreflexia) with prominent autonomic hyperactivity (e.g. hyperthermia, hypertension)
Lithium-enhanced physiologic tremor vs lithium toxicity tremor
Physiologic: symmetric, limited to hands/upper limbs, occurs when medication started or increased; nonprogressive and often decreases
Toxicity: Irregular, coarse, multiple parts of body +/- GI or neuro symptoms
Essential tremor
Action tremor - more pronounced at end of goal-directed movements and improves with rest
Typically older patients or FHx
Akathisia
How to manage?
Most common extrapyramidal symptoms associated with antipsychotic medication
Dose-dependent effects
Management:
1. Cautiously reduce antipsychotic dosage
2. Change to alternative antipsychotic
3. Add beta-blocker (e.g. propranolol - block noradrenergic and serotonergic inputs on dopamine pathways), anticholinergic (e.g. benztropine), or less commonly benzo
Common sites of dystonia (related to antipsychotic or dopamine antagonist)
Head and neck small muscles
Oculogyric crisis - forced upward gaze deviation
Torticollis (stiff neck)
Blepharospasm (blinking, other eyelid movements that you can’t control)
Trismus
Narcolepsy definition
Recurrent lapses into sleep or naps (>= 3x/week for 3 months)
> =1 of following:
1. Cataplexy - brief loss of muscle tone precipitated by strong emotion
2. Low CSF orexin A/hypocretin-1
3. Shortened REM sleep latency
May come with hypnagogic or hypnopompic hallucinations, sleep paralysis - these are intrusions of REM sleep phenomena
Narcolepsy workup
- Polysomnography - to rule out other sleep disorders
- Multiple sleep latency test - demonstrates decreased sleep latency and sleep-onset REM periods
Histrionic personality disorder
Excessive emotionality and attention-seeking since early adulthood
Inappropriate, sexual, provocative behavior
Suggestible (easily influenced)
Considers relationships more intimate than they really are
Narcissistic personality disorder
Want to be center of attention but without emotional displays
Lack of empathy
Interpersonal exploitation
Intermittent explosive disorder
Intermittent verbal or physical aggressive behavior that is disproportionate to the objective triggering offense
Treat with CBT and SSRIs
Persistent complex bereavement disorder (complicated grief)
Persistent yearning for deceased and prolonged emotional pain related to loss, accompanied by maladaptive, ruminative thoughts and dysfunctional behaviors
Bulimia nervosa vs binge eating vs anorexia nervosa
Bulimia nervosa: inappropriate compensatory behavior; treat with fluoxetine
Binge eating: no compensatory behaviors; lisdexamfetamine, topiramate
Anorexia: BMI <18.5; olanzapine if no response to first-line treatments
How long must binge and compensation last to make diagnosis of bulimia nervosa?
Each at least once a week for 3 months
Borderline vs intermittent explosive disorders
Borderline - anger and rage occurs in context of unstable relationship, related to underlying fears of abandonment; also suicidal, empty feeling, etc.
Disruptive mood dysregulation disorder vs intermittent explosive
DMDD requires onset before age 10 and persistent irritability or anger between episodes; diagnosis not made after age 18
Eccentric behaviors and odd beliefs
Schizotypal disorder
No fixed delusions or frank hallucinations, paranoia not of delusional proportions
Requires ruling out psychotic disorders
Schizotypal personality disorder vs schizoid vs schizophrenia
Schizotypal - eccentric behaviors, odd beliefs, magical thinking
Schizoid - socially detached, “loners”; do not have odd thinking or perceptual distortions
Schizophrenia - delusions, hallucinations, disorganized speech/behavior, negative symptoms
When is electroconvulsive therapy immediately indicated in MDD?
Emergency:
1. Suicide risk
2. Not eating or drinking
3. Pregnancy
Non-emergency:
1. Treatment resistance
2. Psychotic features
Premenstrual dysphoric disorder (PMDD) diagnosis
Prospective daily ratings for >=2 cycles demonstrating a symptom-free period in the follicular phase
Subconjunctival hemorrhage can be a sign of what psych disorder?
Anorexia or bulimia nervosa - from intraabdominal pressure from vomiting
Tourette syndrome - treatment
Habit reversal training
Antidopaminergic: tetrabenazine (dopamine-depleting), antipsychotics
a2-agonists
Social anxiety disorder treatment - difference between performance-only version
Performance-only: beta-blocker or benzo PRN instead of SSRI
Treatment for nightmares in PTSD
Prazosin - decreases adrenergic hyperactivity seen
Bipolar medication that isn’t teratogenic
Lamotrigine
OCD treatment alternative to SSRI
Clomipramine (TCA)
Dementia - sequence of medications
- Cholinesterase inhibitors: Donepezil, rivastigmine, or galantamine
- NMDA antagonist: Memantine
Which SSRI should be avoided in pregnancy?
Paroxetine - cardiac defects in 1st trimester, pulmonary HTN in 3rd trimester
