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1
Q

Is there life threatening withdrawal for cocaine?

A

No

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2
Q

reaction formation

A

a neurotic defense mechanism- doing the opposite of what you think- a man is mean to a wife he loves

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3
Q

dissociation

A

defense mechanism- unclear if mature, neurotic, or immature
- dealing with stress by temporarily eliminating a perception of themselves or their environment to avoid a problem- as in amnesia

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4
Q

suppression

A

mature defense mechanism that means that you purposely ignore an unacceptable impulse or emotion in order to diminish discomfort and accomplish a task

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5
Q

controlling defense mechanism

A

a neurotic defense mechanism in which you regulate situations and events of external environment in order to relieve anxiety

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6
Q

intellectualization defense mechanism

A

avoiding negative feelings by excessive use of intellectual functions and focusing on irrelevant details or inanimate objects- eg: man dying of colon cancer explains the pathophysio of the disease to a 12 yo son
- reasoning is used to block confrontation with an unconscious conflict

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7
Q

repression vs. suppression

A 
suppression= mature defense mechanism- don't think about something in order to get thru a task- *conscious
repression= neurotic defense mechanism where you prevent a thought or feeling from entering consciousness- *unconscious
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8
Q

acting out

A

immature defense mechanism- giving into an impulse even if socially inappropriate in order to avoid the anxiety of suppressing that impulse

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9
Q

denial

A

immature defense mechanism- not accepting reality that is too painful

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10
Q

regression

A

immature DM- performing behaviors from an earlier stage of development in order to avoid tension associated with current phase of development

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11
Q

projection

A

attributing objectionable thoughts or emotions to others
immature DM
eg- man who is attracted dot other women believes that his wife is having an affair

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12
Q

undoing defense mechanism

A

attempting to reverse a situation by adopting a new behavior

eg: man who fantasizes briefly about killing his wife with a car takes the car for a complete checkup

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13
Q

what is goal of psychoanalysis

A

resolve unconscious conflicts by bringing repressed experience and feelings in awareness and integrating them into patients conscious experience

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14
Q

patient has repressed feelings of abandonment by her father and becomes angry when her therapist is late for the appt- this is an example of which D.M.

A

transference

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15
Q

what type of therapy uses free association

A

psychoanalysis- bring unconscious to conscious

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16
Q

CBT

A
  • 6 wks to 6 mo
  • focus on current symptoms by examining the connection between thoughts and behaviors
  • identify and challenge maladaptive thoughts like overgeneralization, catastrophizing, etc
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17
Q

supportive psychotherapy

A

for lower functioning people- psychotic, cognitively impaired

  • work with therapist to build up defense mechanisms and reinforce coping skills
  • help make patient feel safe
  • not insight oriented
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18
Q

psychodynamic psychotherapy

A

in higher functioning people- explore past relationships and conflicts and break down defense mechanisms

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19
Q

what type of therapy for borderline

A

DBT- acceptance and change
improve emotional regulation and distress tolerance
component of group therapy

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20
Q

drug for hoarding?

A

SSRI

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21
Q

adjustment disorder

A

stressful life event-> maladaptive behavioral or emotional symptoms

  • symptoms begin within 3 months and end within 6 months
  • they must cause significant impairment in daily functioning or interpersonal relationships
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22
Q

adjustment disorder vs. PTSD

A

AD: event is not life threatening
PTSD: event is life threatening

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23
Q

what therapy is good for adjustment disorder

A

supportive psychotherapy

- pharmacotherapy for associated symptoms like insomnia, anxiety, or depression

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24
Q

what drugs can be used for OCD

A 
clomipramine (TCA)
fluoxetine (SSRI)
fluvoxamine (luxov) (SSRI)
paroxetine (paxil) (SSRI)
sertraline (zoloft) (SSRI)
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25
Q

which antipsychotic increases prolactin levels the most. what does this lead to

A

risperodone

-> galactorrhea, amenorrhea, breast tenderness

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26
Q

schizotypal vs. schizoid

A

schizoid= social detachment and restricted emotion- do not enjoy close relationships with others, indifferent to praise or criticism

shizotypal= reduced capacity for closed relationships and magical thinking with bizarre fantasies

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27
Q

avoidant PD vs. schizoid

A

avoidant= hypersensitive to criticism. want friendships but stay away bc they fear ridicule
schizoid- don’t care about criticism or praise

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28
Q

schizophreniform vs. schizophrneia

A

schizophrenia> 6mo

schizophreniform: 1-6 mo

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29
Q

delusional disorder critera

A

nonbizzare fixed delusions from >1mo
does not meet criteria for schizophrenia
fucntioning in life not signifciantly impaired

common in >40, immigrants, and hearing impaired

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30
Q

persecutory delusional disorder vs. paranoid personality disorder

A 
PDD= can still function in life. non bizarre delusions
PPD= pervasive pattern of interpersonal problems but no persistent delusions or other psychotic symptoms
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31
Q

which antidepressant can help smoking cessation

A

buproprion

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32
Q

adjustment disorder with depressed mood vs. normal stress response

A

adjustment disorder with depressed mood requires significant functional impairment

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33
Q

what do you give to prevent alcohol withdrawal permanent damage

A

thiamine to prevent wernicke’s encephalopathy, which can progress to korsakoff syndrome

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34
Q

a patient after days in hospital becomes anxious, diaphoretic, and tachycardic. what do you suspect and what do you give

A

you suspect alcohol withdrawal
6-24 hrs: anxious, diaphoretic, tachycardic

12-48 hours- you worry about seizures, alcoholic hallucinxsis (vitals stable at this point)

48-96 hrs: DT: confusion, tachycardia, fever, agitation, diaphoresis

give tapered librium (and also phenytoin for seizures)

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35
Q

dilsulfiram

A

drug used to prevent alcohol addiction long term

- inhibits alcohol dehydrogenase, making patients feel sick when they have alcohol

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36
Q

will all people with seizures get delirium tremens

A

1/3 of them will

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37
Q

how many die of DT

A

15-25% mortality if untreated

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38
Q

wernickes vs korsakoff

A

wernicke first: acute and can be revered with thiamine. ataxia, confusion, ocular abnormalities (nystagmus gaze palsy)

korsakoff: chronic amnestic syndrome
reversible in only 20% of patients
anterograde amnesia
confabulation- making up answers when memory has failed

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39
Q

how to treat cocaine withdrawal

A

its not deadly

treatment is supportve

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40
Q

how does PCP work

A

antagonize NMDA glutamate receptors
activates dopaminergic neurons
can lead to psychosis

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41
Q

conversion disorder

A

neuro symptoms incompatible with any near disease- often associated with stress

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42
Q

factitious disorder vs. malingering

A

malingering = falsification or exagerating to obtain external incentives

factitious= intenitonal falsification with goal to assume sick role

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43
Q

illness anxiety disorder

A

fear of having a serious illness in spite of no symptoms and consistently negative evaluations

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44
Q

somatic symptom disorder

A

excessive anxiety and preoccupation with 1 or more unexplained symptoms

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45
Q

genetics of bipolar

A

one of strongest genetic components of all psych disorders

  • first degree relative: 10%
  • both parents: 60%
  • monozygotic twin: 70%-90%
  • general population: 1%
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46
Q

remission vs. response phase

A

remission: absence of morbid symptoms- return to preillness state of health
response: 50% reduction in baseline level of severity

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47
Q

which atypical antipsychotic is most likely to cause EPS? how do you counter them?

A

risperidone.

counter with anticholinergic like benztropine

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48
Q

how do you treat akathisia from antipsychotics

A

give propranolol

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49
Q

panic disorder

A

panic attacks with no obvious precipitant
- causes at least of month of persistent concern about attacks, changing behavior based on attacks, and worry about implications of such an attack

comorbid with depression a lot of the time and agoraphobia*

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50
Q

what kind of meds to use in depressed terminally ill patients

A

methylphenidate if short life expectancy

SSRI if longer life expectancy

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51
Q

displacement

A

defense mechanism - immature
dispalce feelings from one thing to another thing

eg: your boss yelling at you- taking it out by yelling at your secretary

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52
Q

disociative fugue

A

sudden unexpected travel away from one’s home in addition to an inability to recall things from one’s past

  • unaware of new identity or amnesia
  • seem relatively not stressed

associated with traumatic event, alcohol

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53
Q

medication for GAD

A

SSRI like escitolopram
SNRI like venlafaxine
non benzo anxiolytic like buspirone (slow onset: 1-2 weeks)

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54
Q

what is most common side effect o olanzipine

A

weight gain- because it blocks histaminergics (H1) and 5HT2C receptors.
also diabetes, but not as common as weight gain

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55
Q

ODD vs conduct disorder

A

ODD does not have aggression toward people or animals and conduct disorder does

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56
Q

drugs from bipolar 1

A

mood stabilizer and antipsychotic

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57
Q

elderly person with severe depression with psychotic interest, loss of interest, excessive guilt, sleep and appetite disturbance, and auditory hallucinations. SSRI ineffective. Not eating or drinking. What to do?

A

try ECT. it is an evidence based treatment for treatment refractory MDD. this is an emergency- not eating or drinking. also if pregnant or if suicide risk. it was have a rapid response, unlike drugs. it is safe alone and it can be used in conjunction with other medications.patients are given general anesthesia and an general tonic clonic seizure is induced.

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58
Q

what is a mixed episode of bipolar? treatment?

A

irritability is the predominant mood state. lithium is usually not effective. try an anticonvulsant like depakote (valproic acid)- these also work for rapid cycling mania

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59
Q

how long do you give ECT for

A

discontinued after symptomatic improvement. usually 8-12 sessions given 3 times weekly. monthly maintenance is given to preevent relapse of symptoms.

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60
Q

side effects of ECT

A

muscle soreness, headaches, amnesia, confusion. bilateral electrode placements decrease the number of treatments needed but increase memory impairment and confusion.

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61
Q

what drug for manic patient with increased creatinine

A

check kidney function. if not good, don’t give lithium- give valproic acid.

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62
Q

time period of adjustment disorder

A

it is emotional or behavioral symptoms that develop within 3 months of exposure to an identifiable stressor and rarely last more than 6 months after the stressor ends.

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63
Q

treatment of choice for adjustment disorder

A

psychodynamic psychotherapy or brief cognitive psychotherapy. these 2 methods focus on developing coping mechanisms and improving the individuals response to and stated about stressful situations

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64
Q

NMS?

A

NMS is rare but potentially lethal side effect of antipsychotic (Atypical and typical) medications (dopamine antagonists)
- 20% mortality rate if untreated

hyperthermia, autonomic instability, muscular rigidity

rhadbomyolosis-> myoglobinuria- AKI

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65
Q

how to treat NMS

A

take off of neurlopetic

supportive care: aggressive cooling, antipyretics, fluid/electrolyte repletion, alkaline diuresis (in case of rhabdomyolysis)

pharm: dantrolene sodium (muscle relaxant) and/or dopamine agonist bromocriptine

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66
Q

can people who get NMS be treated with neuroleptic later on in life

A

yes

it is not an allergic rxn

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67
Q

side effects of NMS (pnemonic)

A 
F: fever
A: autonomic instability (tachycardia, labile HTN, diaphoresis)
L: leukocytosis
T: tremor
E: elevated creatinine phosphokinase (CPK)
R: rigidity (lead pipe rigidity)
E: excessive sweating (diaphoresis)
D: delirium
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68
Q

lead pipe rigidity

A

pathological resistance to passive extension of a joint- constant throughout range of motion

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69
Q

what is the biggest predictor of suicide

A

prior suicide attempt

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70
Q

PCP intoxication symtpoms

A 
RED DANES
R: rage
E: erythema
D: dilated pupils
D: Delusions
A: amnesia
N: Nystagmus
E: excitation
S: skin dryness
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71
Q

which drug has effect of nystagmus

A

PCP, sedative hypnotics, inhalants

rotary nystagmus is pathognomonic for PCP

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72
Q

PCP vs LSD intoxication

A

they present similarly

agitation and aggression more common in PCP

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73
Q

which 2 drugs give tactile and visual hallucinations

A

PCP and cocaine

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74
Q

drug to counter acute dystonic rxn

A

benztropine or diphenhydramine (benadryl)

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75
Q

alcohol hallucinosis

A

12-24 hours after last drink

auditory, visual, tactile hallucinations with normal vital signs and intact sensorium

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76
Q

how to treat social anxiety disorder

A

Generalized:
SSRI/SNRI, CBT

performance:
benzo or beta blocker

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77
Q

schizoaffective disorder vs. bipolar disorder with psychotic features

A

schizoaffective: lifetime history of delusions or hallucinations for >2 weeks in the absence of major depressive or manic episode (they may also have them concurrently)

major depressive or bipolar with psychotic features: psychotic symptoms occur exclusively during mood episodes

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78
Q

persistent depressive disorder (dysthymia)

A

depressed mood for most days for at least 2 years

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79
Q

can dysthymia ever have psychotic features?

A

no. if a person has delusions or hallucinations with depression, consider another diagnosis like major depression with psychotic features aschizoaffective, etc

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80
Q

what is the first line treatment for specific phobia

A

behavioral treatment

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81
Q

bipolar I vs. bipolar II

A

bipolar I has manic episodes and does not require depressive period.
bipolar II has hypomanic and at least one depressive episode

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82
Q

manic versus hypomanic

A

manic: >7 days unless hospitalized, may have psychotic features
hypomanic: >4 days, no psychotic features

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83
Q

what is cyclothymic disorder

A

at least 2 years of fluctuating mild hypomanic and depressive symptoms that do not meet criteria for hypomanic episodes or major depressive episodes

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84
Q

what is the most likely atypical antipsychotic to cause EPS? least likely?

A

risperidone is most likely. clozapine is least likely.

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85
Q

if a person on MAOI eats aged cheese, what should you monitor

A

blood pressure because they can have a hypertensive crisis

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86
Q

what is the most common side effect of MAOi

A

orthostatic hypertension

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87
Q

which 2 drugs have the greatest risk of weight gain and diabetes

A

clozapine and olanzipine

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88
Q

what are signs of amphetamine intoxication

A

agitiation, irritability, paranoia, or delirium

can also have cardiac arrhythmia, seizures, hypothermia, and intracerebral hemorrhage

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89
Q

can you do a lab test for amphetamine intoxication

A

no- diagnosis is clinical

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90
Q

what medication can cause seizures in withdrawl

A

xanax

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91
Q

how long to continue antidepressant aftera single episode of major depression

A

treat for 6 months following patients response

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92
Q

concordance of depression in twins

A

50-70% for monozygotic
10-25% for dizygotic
first degree relatives 2-3 x more likely to get it

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93
Q

how to treat dysthymic disorder

A

antidepressants, cognitive therapy, inside oriented psychotherapy

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94
Q

medication for a first depressive episode

A

SSRIs are indicated for 6 mo-year and then can be discontinued as per the patients request

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95
Q

risk of depressive episode after first untreated episode? risk of suicide

A

50% in 2 years

15% of depressive patients commit suicide

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96
Q

what % of patients with MDD show a response to antidepressants?

A

50-60%

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97
Q

what are medical causes of manic episode?

A

hyperthyroidism, neuro:seizures, frotno tempoeralsclerosis, neoplasms, HIV infection

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98
Q

can you give antidepressants to manic patient

A

no- they can make mania worse

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99
Q

what do you give rapid cycling mania

A

mood stabilizers like depakote and carbamazapine

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100
Q

mixe episode

A

criteria ar emet for manic and MDD every day for at least a week

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101
Q

can you give antipsychotics for mania

A

yes- they are often give as adjunct to mood stabilizers

mania can have psychosis (delusions)

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102
Q

bipolar I vs. bipolar II

A

bipolar II cannot have manic phase. it just hypomanic phases and MDE.

bipoalr II- have manic episode. does not need MDE to meet criteria.

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103
Q

what treatment for refractory life threatening acute mania

A

ECT may be indicated

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104
Q

how long do untreated manic episodes last

A

3 months

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105
Q

what percent of people with bipolar commit/die from suicide? compared to MDD

A

more than MDD> 25% commit and 15% die

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106
Q

how common is relapse in bipolar? how to prevent it

A

90% of people with one manic episode will have another within 5 years

treat by interim lithiumprophylaxis

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107
Q

which gender has earlier onset of bipolar? outcome

A

men. worse outcome when earlier onset

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108
Q

what drug OD would present with confused, agitated, delirious, obtunded, low BP, regular HR, warm dry flushed skin, dllated pupils, distended bladder

A

anticholinergic- high potency neuroleptics (antipsychotics), antihistamines, mostly TCA*

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109
Q

what are TCAs used for

A

depression, neuropathic pain, migraines

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110
Q

what do you give for lithium toxicity

A

kayexalate chelator

cant use lavage to treat it

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111
Q

what should you give delirious patient

A

only give benzo if delirious from alcohol withdrawal

otherwise NEVER because it can make it worse. give a low dose of an antipsychotic like haldol.

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112
Q

SSRi side effects due to 5HT3 receptor

A

GI system. over stimualtion -> diarrhea, nausea, and vomiting

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113
Q

SSRI side effects due to 5HT2C

A

CNS- overstim-> anxety and mental agitation

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114
Q

SSRi side effects due to 5HT2A

A

CNS, spinal cord, over stimualton-> anxiety, mental agitation, akathisia, insomnia, myoclonus, sexual dysfunction

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115
Q

what does demerol do to pupils

A

it is an exception to opioids producing miosis. demerol dilates pupils.

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116
Q

how to stop sexual disfunction from risperdal

A

give a little bit of ability with it- binds to D2 more strongly?

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117
Q

how can mood and psychosis congruency help diagnosis

A

mood congruent- bipolar

mood incongruent- psychosis

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118
Q

can benadryl cause anticholinergic?

A

yes. it is mostly antihistamine but it can also cause anti-cholinergic

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119
Q

what can you give in anticholingeric OD

A

physostigmine- cholinesterase inhibitor

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120
Q

why are TCA OD so lethal

A
  1. anticholinergic-> prolong qtc-> torsade
  2. antiarrythmic-> mess up rhythm
  3. anti-a-adrenergic-> drop BP

also other effects like serotonin syndrome

anticholinergic-> slows down its own absorption-> makes you think that patient is better, but then another bolus gets absorped

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121
Q

columbia suicide severity screen test

A

wish to be dead, suicidal thoughts, suicidal thoughts with method, SI, SI with specific plan

tests history of attempts

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122
Q

how long to keep on antidepressant after suicide attempt? after 2?

A

1 attempt: >1 year

more than 1 attempt: even longer, bc it icnreases risk

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123
Q

how do SSRIs work

A

block uptake->

more serotonin binds to 5ht1a receptor

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124
Q

what serotonin receptors do atypical antipsychotics block

A

5HT2a (and 2c)

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125
Q

5Ht2 blockade -> dopamine?

A

increases dopamine

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126
Q

SSRI and akathisia?

A

can cause it

increase action 5HT2 receptor-> decrease dopamine-> increase receptors for dopamine-> akathisia (?)

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127
Q

what do you use if SSRI isn’t effective

A

try SNRI like effexor

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128
Q

risk of effexor

A

increase mania

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129
Q

MAOi process of working

A

look up
also in gut- processes tyramine- over tyramne-> tyramine

also can’t take anything sympathomimetic- sudafed, etc

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130
Q

treatment refractory depression highly atypical (and def not bipolar variant) what drug?

A

MAOI is a good variant

eg: selegiline

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131
Q

buproprion mechanism

A

antagonism of presynaptic norepinephrine and dopamine reuptake pumps
weight gain, no sexual side effects

less likely to flip people into mania

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132
Q

trazadone mechansims

A

serotonin antagonism and reuptake inhibitor

no weight gain even though 5HT2 blocker

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133
Q

mirtazapine mechanism

A

alpha 2 blocker-> disinhibition of NE and SE.

also stimulate alpha 1 somatodendritic receptors on serotonin neurons.

can cause weight gain and sedation

works in a diff way than ssri and snri- can add to them and i can be synergistic

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134
Q

serotonin and platelet

A

need serotonin for platelets
anything that inhibits serotonin messes up platelets-> increases bleeding like GI bleeding or surgical bleeding

wan people, if on aspirin

remeron (mirtazapine) does not have that problem

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135
Q

rational approach to ssri

A

start ssri.
if partial response -> increase dose
if still partial-> augmentation strategies based on side effects and anticipated response. welbutrin, buspar, remora, lamictal, lithium, atypical antipsychotic. thyroid hormone.

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136
Q

what antidepressants do not cause mania

A

ECT and thyroid hormone

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137
Q

what is most common substance and psych comorbidity

A

nicotine and schizophrenia

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138
Q

which personality disorder is most likely to have substance abuse

A

antisocial

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139
Q

what test allows you to monitor depressive symptoms with the greatest validity

A

beck depression inventory

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140
Q

what test would you use to assess for memory impairments in the setting of ECT

A

Brown-Peterson task- evaluates short term memory

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141
Q

what test would you use to test in schizophrenic ability to organize and correctly process information

A

wisconsin card sorting test- sort cards of pictures and symbols according to a variety of different criteria that change over time without the patient knowing. tests a patients ability to switch sets, reason abstractly, and solve problems.
executive functions-frontal lobes (dorsolateral frontal lobes)

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142
Q

MMPI-2

A

most widely used test in evaluation of personality structure. evaluates attitudes about the test which helps determne validity of test. must be scored by experienced evaluator.

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143
Q

how to calculate IQ

A

divide mental age by chronological age and then multiply by 100

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144
Q

patient with damage to right parietal lobe. which test to assess damage?

A

rey-osterrieth test. assess visual nonverbal memory. people with right parietal lesions show abnormalities in copying the figure by neglecting the items int he left visual field.

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145
Q

deja entendu vs deja vu

A

deja entendu= feeling that one is hearing something one has heard before

deja vu= sensation that one is seeing something one has not seen before

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146
Q

transference vs. countertransference

A 
transference= feelings patient has about therapist (based on past)
countertrasnference= therapists feelings about patient (based on past)
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147
Q

how to interpret rorsach test?

A

exner comprehensive system- limited in validity and requires highly trained examiners

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148
Q

test to ask friends or family of the patient to assess the ability of the patient to function in his or her usual environemnt

A

blessed rating scale

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149
Q

how to preoperatively test hemispheric dominance in an 18 year old left handed woman with a history of seizure disorder who is about to undergo surgery to remove a seizure focus in th let hemishere

A

wada test-

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150
Q

what stage of sleep do night terrors occur

A

deep sleep: stage 3-4

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151
Q

separation anxiety disorder versus reactive attachment disorder

A

sep. anx.: usually after 7- maybe after a stressful event; reactive attachment disorder: experience marked lack of social relatedness, usually before age 5

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152
Q

copralalia

A

excessive repetition of obscene words, often seen in tourettes

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153
Q

how to treat enurisis

A

DDAVP or TCA like imipramine

DDAVP stop neurosis for 7ish hours- can cause headache and slight hyponatremia

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154
Q

approximate comorbidity of childhood anxiety disorders and MDD

A

50%

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155
Q

most common side effect of fluoxetien

A

GI- nausea

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156
Q

what is first line treatment for Tourette’s

A

clonidine (intermediate acting benzo) (first line)

used to be high potency antipsychotics (these are more effective but have worse side effects)

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157
Q

what is the most common initial symptoms of tourettes? what is necessary to diagnose tourettes?

A

eye tics such as blinking. need multiple motor tics and one or more vocal tics at some point. onset before 18. tics must be present almost every day for a year with no tic free period greater than 3 months.

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158
Q

what is most common predisposing factor for MR?

A

early altercations in embryonic development (chromosomes, alcohol)

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159
Q

what type of medication is most likely to unmask an underlying predisposition to developing tics?

A

stimulants

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160
Q

what blood abnromality do you see in anorexia nervosa

A

hypercholesterolemia.

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161
Q

are there brain changes in anorexia nervosa?

A

yes- increased ventricular- brain ratio on imaging

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162
Q

what criteria to meet paranoid schizophrenia

A

highest functioning type. oldest age of onset.

  1. preoccupation with one or more delusions or frequent auditory hallucinations
  2. no predominance of disorganized speech, disorganized or catatonic behavior, or inappropriate affect
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163
Q

how to best differentiate between mania and ADHD in children

A

low self esteem in ADHD, euphoria in mania

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164
Q

when can children conceptualize death

A

between 7 and 10

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165
Q

what medication for panic disorder?

A

SSRI

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166
Q

when is rubella-> physical/mental defects in fetus

A

first trimester

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167
Q

what do you think if you see an 8 yo boy with erythematous chapped hands and otherwise normal phsycial

A

OCD- from excessive washing

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168
Q

twin concordance of schizophrenia

A

50%

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169
Q

belief that people have been replaced by imposters

A

capgras

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170
Q

postpartum depression with depression, mood lability, delusions, hallucinations is usually a result of

A

bipolar

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171
Q

what characterizes shizophrenia catatonic type

A

must meet 2 of the following
- motor immobility
- excessive purposeless motor activity
- ectreme negativism or mutism
peculiar voluntary movements or posturing
- echolalia or echopraxia
–it has been going down in recent years and it is the least common of all of them.

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172
Q

what has the strongest genetic link in all the psych illnesses

A

bipolar 1
carries a worse prognosis than unipolar depression but a higher percentage of patients with bipolar are eventually treated

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173
Q

woman with terrible anxiety, diaphoretic, tachycrdic, dialed pupils, stomach pain

A

think porphyra

174
Q

lab findings in anorexia

A 
increase BUN
hyperkalemic alkalosis
hypercholesterolemia
leukopenia
ostoeposrosis
175
Q

what are chances that a person with MDD will fail to suppress cortisol levels in a dexamethasone suppression test

A

50%

176
Q

person getting a pill for a chronic mood disorder. side effects of dry mouth, trouble urinating, occasional dizziness when she gets out of bed

A

TCA ike imipramine

not prozac

177
Q

clinical triad of normal pressure hydrocephalus

A
  1. gait disturbance
  2. urinary inontinence
  3. dementia, mild, with insidious onset.

this is reversible cause of dementia

178
Q

GGT in alcoholism? AST and ALT? anemia?

A

increased GGT;

AST/ALT increase; macrocytic anemia

179
Q

can delusional in delusional disorder be bizarre

A

no

180
Q

acute stress disorder versus PTSD

A

ASD= trauma 4 weeks ago

181
Q

old lady coming from hospital with fluctuating results on MSE

A

delirium not dementia. dementia is more stable. dementia= memory impairment, delirium= sensorium impairment

182
Q

SSRI at 5HT3 receptor side effect

A

GI system. overstimulation leads to diarrhea, nausea, and vomiting

most common side effect of SSRI

183
Q

SSRI at 5HT2C receptor side effect

A

CNS. overstimulation leads to anxiety and and mental agitation

184
Q

SSRI at 5HT2A side effect

A

CNS: spinal cord; overstimulation-> anxiety and mental agitation, akathisia, akathisia, insomnia, myoclonus, and sexual disfunction

185
Q

how to treat panic disorder? prognosis?

A

start SSRIs slowly- sertraline(Zoloft) and paroxetine (Paxil). . they are more prone to get panic symptoms from activation of 5HT2A/C. ultimately need higher doses than you do for depression

  • relapses common with discontinuation of therapy.
  • 10-20% have signifiant symptoms that inferrer with fair functioning
  • 50% have mild infrequent symptoms
  • 30-40% remain symptom free after treatment
186
Q

How to qualify for GAD

A
  • excessive worry and anxiety that is difficult to control for >6 months
  • must include 3 of the following- restlessness, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbance
  • very common- 45% lifetime prevalence
  • 50-90 % have coexisting disorder
187
Q

patient is in an acute manic episode. what should you give? (no counter indications here)

A

lithium + anticonvuslant (carbamazepime or valproic acid). maybe add an atypical antipsychotic (olanzipine, quietiapine, ziprasidone (Geodon)) as adjunct for acute mania

don’t give benzo bc they are addicting

188
Q

side effects of lithium for

  1. pregnant women
  2. person with CHF
  3. person with pain
  4. person with kidney disease, heart disease, thyroid disease
A
  1. ebstein’s abnormality-abnormal parts of tricuspid valve, abnormality of great vessels
  2. caution with thiazide diuretics, ACE inhibitors
  3. caution with NSAIDS
  4. prob bad idea-> causes long term nephrotoxicity, cardiac arrhythmia and T wave flattening, thyrotoxcity
189
Q

monitoring for lithium?

A

YES. levels should be obtained twice weekly until stable. then they should be obtained once every 1-3 months.

therapeutic levels for acute mania are: 0.6-1.2 mEq/L
>1.5: toxic
>2.0: lethal

190
Q

how can carbamazepine (tegretol) cause toxicity and death

A
  • it inhibits neuron depolarization (by binding to Na/K channel) and decreases glutamate release and is anticholinergic
  • toxicity: prolong QRS-> predispose patients to ventricular arrythmias and hypotension
  • OD: antagonizes adenosine receptors-> proconvulsant
  • OD: acute liver failure
191
Q

what is mechanism of valproic acid

A

inhibits Na/Ca channels-> boost GABA-> decrease glutamate

192
Q

what percent of depressed patients respond to placebo? what percent respond (within 2-4 weeks) to SSRI

A
  • 30%

- 70%

193
Q

disorganzied schizophrenia? how does it respond to treatment?

A

it is pronounced and severe through disorder that is relatively unresponsive to neuroleptics

194
Q

how to treat narcolepsy?

A

methylphenidate-> inhibit REM sleep cycles

- TCAs as adjunctive are sometimes shown to be good adjuncts with methylphenidate

195
Q

infarct of right vs. left hemisphere vs diffuse bilateral frontal injury

A

left infarct: depression;
right infarct: euphoria, inappropriate indifference, mania;
diffuse bilateral frontal injury: OCD

196
Q

what are sleep changes seen in depressed patients

A
  • increased sleep latency (difficulty falling asleep), early morning awakening, less REM sleep latency (REM sleep occurs earlier in the night)
197
Q

cotard syndrome

A

delusion that nothing exists (nihilism) or that the patient hissed does not exist. the person may believe her body is dead.

198
Q

what is fomication? who has it?

A

tactile hallucintion in which one has the sensation of bugs crawling on or under the skin. it can be seen in cocaine intoxication or alcohol withdrawal. `

199
Q

neurovegetative signs

A

physiological signs of depression such as changes in sleep, bowel habits, and weight

200
Q

brain of schizophrenic

A

shrunken hippocampus, parahippocampal gyrus, amygdala

201
Q

ideas of reference

A

idea that others are focusing on you in some positive or negative way- seen in paranoid schizophrenia

202
Q

TCA OD-> hallucinations, pulling out IV lines

A

gives benzo like lorazepam (short half life);

NOT neuroleptic- more hypotensions;

203
Q

person with weight gain,hypersomnia, and mood reactivity and depression. what do you give?

A

this is atypical depression. give phenelzine (MAO).

204
Q

patient with alcohol withdrawal and elevated transaminases

A

normally you would give long acting like chlordiazepoxide (librium). however, that is metabolized in the liver. use something like oxazepam or lorezapam or temezepam (LOT) which undergo glucuronidation before the liver

205
Q

what is the most likely mechanism for the delayed therapeutic response of SSRI

A

still not really known for sure- maybe down regulation of postsynaptic 5HT2 binding sites

206
Q

what is the most common serious side effect of NMS

A

rhabdomyologsis-> renal failure

207
Q

long term consequence of high dose thioridazine (mellaril) (unique)

A

retinal pigmentation-> blindness

208
Q

what is the most potent anxiolytic benzo

A

clonazepam (klonopin) long half life and high potency

209
Q

what should you target in children suffering from tourette disorder

A

dopamine D2 receptor (halloo) anatognism; also maybe alpha2agonist

210
Q

what is the only medication that may improve symptoms of TD

A

clozapine

211
Q

how to best treat borderline (drugs)?

A

SSRI and antipsychotics

212
Q

mechanism of action of trazodone and nefazadone

A

selective antagonism as 4HT reuptake pumps PLUS 5HT2A blockade. the blockade at 5HT2A prevents side effects of overstimulating 5HT2A (anxiety, mental agitation, akathisia, insomnia, myoclonus, sexual disfunction). questionably treats severe illness BUT it can be used as an adjunct to help with sleep in severely depressed patients

213
Q

how can lithium in normal doses affect EKG

A

it can flatten the T wave. not clinically signficant. lithium toxicity can cause sinus node disfunction and AV block

214
Q

clozapine is efficacious because of its action at which recpeotr

A

D4, especially in limbic system. D4 receptors may mediate psychotic symptoms and may also potentiate NMDA receptor. it also has activity at 5HT2 receptor (other neuroleptics lack this). it also works at D1, D2, histamine 1, alpha 1.

215
Q

which antidepressant causes orthostatic hyotension?

A

TCA- like imipramine. notriptyline has the least orthostatic hypertension of the TCAs

216
Q

what to give an 85 year old patient who has become combative, yelling, punching staff, and pulling out IVs. what to give her

A

low dose antipsychotic like risperidone are very effective at reducing agitation in delirious patients. benzos can be used for agitation in delirium but they can overly sedate or conversely disinhibit the patient further

217
Q

mechanism of mirtazapine

A
  • antagonism of central alpha-2 auoreceptors and subsequent disinhibition of NE and SE
  • stimulation of alpha 1 receptors on serotonin neurons-> boost 5HT release
218
Q

what is counterindication to TCA use

A

ECG changes. it slows cardiac conduction like prolonged QT, winding of QRS, bundle branch block,

219
Q

what can you give for PTSD

A

SSRI; clonidine (alpha 2 adrenergic agonist) for symptoms of fear and palpitations

220
Q

what can you give to help with sialorrhea from clozaril

A

anticholinergic like propylthiouracil

221
Q

what is flumazanil

A

benzo antagonist. should not be given until you get history because it can decrease seizure threshold.

222
Q

how do you medically detox from heroin

A

clonidine. central alpha 2 antagonist. suppressed sympathetic response to heroin withdrawal and helps to control agitation and autonomic instability (elevated BP and HR). DOES NOT take away craving.

223
Q

what should you monitor for in low dose risperidone

A

orthostatic hypotension

224
Q

how to treat impotence? who can’t get this drug? what is opposite of this drug

A

yohimbine (central alpha 2 antagonist). should not be used in patients with cardiac or renal disease bc it can cause elevated BP and HR. opposite of this is clonidine (central acting alpha2 agonist)

225
Q

dopamine and prolactin? impact of antipsychotics

A

dopamine inhibits prolactin. antipsychotics inhibit dopamine-> increase prolactin.

226
Q

what type of drug is most dangerous when it is abruptly withdrawn

A

sedative hypnotics

227
Q

which bipolar drug can cause pancreatitis

A

valproic acid

228
Q

which antidepressant can cause serotonin discontinuation syndrome

A

only paxil really has a short enough half life to cause serotonin discontinuation syndrome

229
Q

which antipsychotics are available in a depot injection

A

risperdal and haldol

230
Q

which drug can cause a lot of peeing

A

lithium can cause nephrogenic diabetes insidious-> lots of peeing

231
Q

someone on clozaril gets increase in resting HR and a sinus tachycardia. do you need to stop medication?

A

no. give propranolol

232
Q

what are the least likely antipsychotics to cause weight gain and diabetes?

A

least likely= aripiprazole and ziprasadone. next likely= risperidone and quetiapine. most likely=olanzipine and clozapine.

233
Q

which mood stabilizer doesnt cause weight gain

A

lamictal

234
Q

what do you see in brain scan of panic dsorder

A

overactive locus coerulus and amygdala

235
Q

time course of dysthymia vs. GAD

A

GAD: >6 months
dysthymia: 2 yrs

236
Q

what medicine to use for bipolar with substance abuse

A

depakote. works faster. can do IV. anti-epileptic. wider therapeutic window. treats mixed and rapid cycling (common with SUD). it also helps with impulsivity. but not good bc its metabolized by the liver.

237
Q

methadone vs heroin

A

opiate agonist. much slower acting. not as likely to cause addiction. not in withdrawal and you don’t experience cravings. just need to take it once a day. need to use in clinic.

238
Q

suboxone

A

buprenorphine + naloxone. buprenorphine- partial agonist- risk of OD is decreased- less use of OD and less use of misuse. can give prescription. naloxone- can’t do anything unless injected, but if you try to inject something, it will be safety measure.

239
Q

naltrexone

A

orally bioavailable versus of naloxone. blocks opiate receptors. use in alcohol addiction, opiate addition. more long term.

240
Q

4 drugs for alcohol withdrawal

A

acamprosate (regualtes GABA and glutamate- works in someone who is newly sober), disulfiram (blocks enzymes that metabolize alcohol- make you feel sick), naltrexone (alcohol also works at opiod receptors). topamax- potentiates GABA and inhibits glutamate.

241
Q

what is contraindication for ECT

A

history of MI, history of intracranial space occupying lesion

242
Q

what would you use to treat depression in a patient with diabetes and a lot pain

A

dulexetine (cymbalta). SNRI. Serotonin and Norepinephrine reuptake inhibitor. treats depression and also approved for diabetic neuropathy.

243
Q

which 3 antidepressants do not cause sexual disfunction

A

buproprion, mirtazapine, nefazadone

244
Q

what lab changes do you see in bulimia

A

hypokalemic, hypochloremic alkalosis, high serum amylase, hypo magnesia. normal thyroid function.

245
Q

what are symptoms of opiate withdrawal

A

yawning, muscle aches, diarrhea, laceration, rhinorea, fever, mildly elevated vital signs

246
Q

how does cocaine work

A

blocks dopamine reuptake

247
Q

patient complains of diffuse muscle pain and vague abdominal ramps she continually yawns, blows her nose, and has goose bumps.

A

opiate withdrawal

248
Q

patient with increased tactile perceptions, diaphoretic, high bp, trismus, bruxism, hyperthermia and diaphoreses and sucking a pacifier

A

MDMA intoxication, drug paraphernalia include pacifiers, popsicle sticks, candy necklaces, to help avoid bruxism (grinding of teeth)

249
Q

what is classical presentation of Wernicke

A

ACE. A- ataxia, C- confusion, E- eye movement

250
Q

how to treat schizotypal that is affecting life negatively

A

low dose neuroleptic

251
Q

a woman being treated for major depression is brought to the ED unconscious after drinking wine with BP=220/110. how to treat?

A

hypertensive crisis from MAOI+wine. give iV alpha blocking agent. can also be seen with occipital headache, stiff neck, nausea, vomiting, sweating

252
Q

does clozapine affect prolactin

A

no- unlike typical antipsychotics

253
Q

what are medical causes of mania

A

thyrotoxicosis (hyperthyroidism), cushing disease, hypoglycemia, electrolyte disorders, substance abuse and withdrawal, nutritional deficinies, steroid use, anticholinergic agents, CNS insults

254
Q

what tests attention in the MSE

A

perform digit recall

255
Q

amok

A

culture bound syndrome of malayan origin in which there is a violent or furious outburst of homicidal intent. prodromal brooding, a homicidal outburst, persistence in reckless killing without apparent motive, claim of amnesia. common in young men whose selfesteen has been injured. person often commits suicide afterward.

256
Q

what are 4 types of EPS? how to treat?

A
  1. acute dystonic rxn. (4 hr) 2. akathisia.(4 day) 3. pseudoprkinsonism. (4 week) 4. tardive dyskinesia (4 mo)

treat with anticholinergic like benztropine, antihistamine, benzodiazepine, dopamine agonist

do not give parkinsonism l dopa! that will make psychosis worse.

257
Q

how to treat NMSMS

A
  1. STOP medication 2. D2 agonist like bromocriptine, dantrolene sodium
258
Q

which antipsychotic can cause jaundice and purple gray rash over sun exposed areas?

A

chlorpromazine

259
Q

which atypical is weight neutral but prlongs QTC? which atypical is weight neutral but causes akathisia?

A

QTC prolongation: ziprazadone; akathisia: arapriprazole

260
Q

which atypical is most likely to cause orthostatic hypotension? what else can it cause.

A

quietiapine. it has alpha blocking properties. also cataracts.

261
Q

polysomnogram of depressed patient

A

decreased REM latency and more REM overall

262
Q

which medications might cause depression

A

beta blockers, IFN, amethyldopa, OCPs, ETOH, cocaine/amp withdrawal, opiates

263
Q

medical causes of depression

A

HIV, hypothyroidism, porphyra, uremia, lyme, cushings, liver dz, huntingtons, MS, lupus, L-MCA stroke

264
Q

which SSRI has the most drug-drug interactions? which has fewest?

A

most: paroxetine (p450 metabolism in liver). least: citalopram.

265
Q

which SSRI is most likely to cause headache, dizziness, irritability, and fatigue upon abrupt dicontinuation

A

sertaline and fluvox have shortest half lives and are most likely to cause serotonin discontinuation syndrome

266
Q

what SSRI should you avoid in hypertensive patients? what homeopathic med can’t you take this srug with?

A

venlafaxine. also can’t take it with st. johns wort.

267
Q

how do you treat hypertensive crisis from MAO and bad diet

A

discontinue. treat with IV alpha blocker like phentolamine

268
Q

75 yo patient with symptoms of mania. what is it likely?

A

not bipolar- too late. in older patients, think medical causes. right MCA stroke.

269
Q

how do you treat lithium overdose.

A

fluid rescusitation. dialysis if levels are >4 or if kidney disease

270
Q

bipolar- taking meds. gets agranulocytosis. which drug was taken?

A

carbamazepime.

271
Q

bipolar in preggos? how to treat?

A

ECT and benzos

272
Q

bipolar + increase AFP in a 20 week preggo. what drug were they taking?

A

valproic acid or carbamazepime. they cause neural tube defects-> increased AFP. repro age female should eat 4g folate daily

273
Q

what s the most common side effect of carbamezpime

A

rash (can progress to stevens johnson syndrome)

274
Q

therapeutic levels of valpric acid and carbamzepime

A

VP: 6-12
Carb: 60-120

275
Q

who can’t you give benzos to

A

drug addiction history, COPD, restrictive lung disease

276
Q

somatization disorder criteria

A

onset before age 30. 4 pain sxs, 1 GI sx, 1 sexual sx, 1 pseudoneuro sx

277
Q

how does dantrolene sodium work

A

dissociates excitation-contraction coupling in skeletal muscle by decreasing intracellular calcium, inducing skeletal muscle contraction. used for rigidity from NMS

278
Q

how does bromocriptine work

A

stimulates dopamine receptors, inhibits anterior pituitary prolactin secretion (dopamine agonist). used for NMS. also for hyperprolactinemia.

279
Q

dyssomnia vs. parasomnia

A

dyssomnia: disturbance in amount, quality, or timing of sleep
parasomnia: abnormal events in behavior or physiology during sleep

280
Q

how long is REM cycle? how often does it happen? REM as you get older? REM after sleep deprivation?

A

REM cycle is 10-40 minutes every 90 minutes. amount of REM decreases with age. REM rebound is an increase in the amount of REM after sleep deprivation

281
Q

what labs do check in restless leg syndrome

A

iron level. creatinine. treat with dopamine agonist

282
Q

treatment for narcissistic PD

A

indiviudal therapy- they don’t do well in group therapy. kind of have to buy into narcissism in treatment.

283
Q

social phobia vs. avoidant personality disorder

A

avoidant PD is more pervasive. social phobia is fear of embarrassment. avoidant is fear of rejection and a sense of inadequacy.

284
Q

antisocial PD vs narcissitic PD

A

both exploit others. antisocial PD wants material gain or subjugation of others. Narcissistic PD become depressed when they don’t receive the recognition they think they deserve.

285
Q

EEG findings of delirium and psychosis.

A

psychosis EEG is normal. delirium is diffuse background slowing of background rhythm

286
Q

alzheimers on MMSE

A

can’t remember 3 words, even with promptin

287
Q

genes of alzheimers

A

APP (on chr 21- thats why people with down syndrome get more alzheimers) and Apo E E2

288
Q

treatment of alzheimers

A

donazepil, memantidine (NMDA receptor antagonist- second line- add as an adjunctive), rivastigmine, galantamine (diarrhea). acetylcholinesterase inhibitors-> give more acetylcholine in synapse.

289
Q

what are the three most common causes of dementia

A

alzheimers (50-60%); vascular dementia (10-20%), major depression (pseudo dementia)

290
Q

minimum workup to exclude reversible causes of dementia

A

CBC, electrolytes, TFTs, VDRL/RPR, B12 and folate levels, brain CT or MRI

291
Q

dementia + stepwise increase in severity + focal neurologic signs

A

multi-infarct dementia. do CT/MRI

292
Q

dementia + cogwheel rigidity+ resting tremor

A

lewy body dementia or parkinsons. tests= clinical

293
Q

dementia+ obesity+ coarse hair + constiption+ cold intolerance

A

hypothyroidism. test T4, TSH.

294
Q

dementia + diminished position/vibratory sense + megaloblasts on CBC

A

vitamin B12 deficinecy. test b12

295
Q

dementia + tremor + abnormal LFT + kayser fleischer rings

A

wilsons disease. test for ceruloplasmin

296
Q

dementia + diminished position and vibration senses + Argyll Robertson Pupils

A

(argyll robinson pupils: accommodation response present, response to light absent)- neurosyphilis. test cerebrospinal fluid fluorescent treponemal antibody absorption test (CSF FTA-ABS) or CSF VDRL

297
Q

alzheimers criteria

A

memory impairment plus at least one of the following. aphasia, apraxia, agnosia (can’t recognize things that were previously known), diminished executive function (plan, organize, abstract)

298
Q

alzheimers physiology

A

loss of noradrenergic neurons in locus coerulus-> decreased acetylcholine.
loss of cholinergic neurons in basal nucleus of meynert of midbrain-> decreased norepinephrine

299
Q

path of alzheimers

A

gross: diffuse atrophy with enlarged ventricles and flattened sulci. microscopic: senile plaques of amyloid protein, neurofibrillary tangles from Tau proteins, neuronal and synaptic loss

300
Q

picks disease/frontotemporal dementia vs alzheimers

A

very similar. FTD has more personality and behavioral changes. intraneuronal inclusion bodies (Pick bodies).

301
Q

dementia vs. pseudodementia sympotms

A

sundowning common in dementia but not in pseudo (more confusion at night). dementia- guess at answers (confabulate), pseudo- answers i don’t know. pseudo- aware of problems

302
Q

how to treat picks disease/FTD

A

treat behavioral problems with olanzipine

303
Q

lewy body dementia symptoms.

A

hard to tell form parkinsons. shuffling gait. key= fluctuations in consciousness and visual hallucinations

304
Q

what do you give lewy body dementia

A

not antipsychotics or benzos- paradoxical rxn occurs.

305
Q

pristiq

A

desvenlafaxine. good at menopause. snri

306
Q

wellbutrin side effects besides seizures

A

anxiety bc its activating

307
Q

how does mirtazapine work

A

block alpha 2 receptor- disinihibit SE and NE. same effect as SNRI but diff function (SNRI blocks repute of SE and NE)

308
Q

which antidepressant if nauseous on chemo

A

mirtazapine. blocks 2a nd 2c and 3. doesnt block 1a. get all therapeutic effects of antidepressant but without sexual disfunction an nausea. you also histamine receptor.

309
Q

what is the therapeutic level of nortryptiline

A

50-150

310
Q

which MAOI is similar to buproprion

A

tranylcipramine

311
Q

can you use trazadone with a MAOi

A

yes- they work at diff receptors

312
Q

why does eating tyramine with MAOI bad

A

MAO blocks MAOa (degrade monoamines) and MAOb ( degrade tyramine)

313
Q

what if you see triphasic bursts on eeg

A

CJD

314
Q

how long since last drink do you see tonic clonic seizures

A

avg 12-48 hours. bimodal peak at 8 and 48.

315
Q

reflexes in alcohol withdrawal?

A

there is hyperreflexia

316
Q

what is the most specific test for ETOH consumption in the past 10 days

A

carbohydrate deficient transferin. also increased GGT. AST/ALK>2

317
Q

what symptoms do you expect in opiate withdrawal

A

joint and muscle pain, photophobia, goosebumps, diarrhea, tachycardia, HTN, GI cramps, dilated pupils, anxiety/depression (Juicy- things get wet)

318
Q

how to treat opiate withdrawal.

A

treat symptoms. clonidine for autonomic sxs. ibuprofen for muscle cramps. loperamide for diarrhea,

319
Q

when do kids begin to think abstractly

A

around 11. formal operational starts.

320
Q

what is the most common cause of inherited MR

A

fragile X

321
Q

methylphenidate vs. amphetamine

A

methylphenidate blocks DA reuptake. amhetamine (adderall) blocks DA/NE reuptake and stimualtes release. both have side effects of anorexia, nausea, increased HR and BP, stunted growth

322
Q

how long do you need sxs for conduct disorder? for ODD?

A

CD: 6 mo. ODD:1 yr

323
Q

normal grief vs. abnormal grief in bereavement

A

normal: 1 year. Normal: hallucinations. abnormal: hallucinations or delusions. no attempt to return to life, significant sleep disturbance or weight loss

324
Q

after administering an anti cholinesterase, patient gets nausea, vomiting, and seizure. what to give?

A

atropine= anticholinergic

325
Q

patient with HIV is depressed, low energy and hopeless. what to give?

A

medically ill patients with depressive disorders may respond to psychostimulants- rapid onset of action and rapid clearance are beneficial

326
Q

signs of inhalant intoxication? OD?

A

intoxication- impaired judgment, belligerence, impulsivity, perceptual disturbance, lethargy, dizziness, nystagmus, tremor, muscle weakness, hyporeflexia, ataxia, slurred speech, euphoria, stupor, or coma. OD may be fatal secondary to respiratory depression or arrythmias. Long term use may cause permanent damage to CNS, PNS, liver, kidney, and muscle.

327
Q

staring into space and euphoria. which drug?

A

PCP

328
Q

what bipolar treatment can cause hair loss

A

divalproex sodium

329
Q

a woman in labor with schizophrenia is acutely psychotic. what medicine is pretty safe?

A

haldol. high dose antipsychotic (typical)

330
Q

A 16 year old girl with abdominal cramps, confusion, palpitations, and muscle twitching

A

nicotine intoxication

331
Q

which SSRI may increase blood pressure at higher doses. what is its mechanism of action?

A

SNRI like venlafaxine. It inhibits the repute of serotonin and at higher doses, inhibits norepinephrine.

332
Q

which SSRi inhibits the repute of serotonin most specifically

A

citalopram

333
Q

what is called when one thinks that others can hear his thoughts

A

thought broadcasting. in schizophrenia

334
Q

nymphomania vs satyriasis

A

nymphomania in women and satyriasis in men. both mean insatiable sexual desire.

335
Q

competence vs. capacity

A

competence= legal term and can only be decided by a judge. capacity= clinical term assessed by physicians

336
Q

criteria for capacity

A
  1. can communicate a choice or preference. 2. understands the relevant info regarding treatment-purpose, risks, benefits, and alternatives- can explain this info to you. 3. appreciates the situation and potential consequences 4. can logically manipulate info and reach logical communication
337
Q

tangential vs flight of ideas

A

flight of ideas is a very fast stream of tangential thoughts

338
Q

delusions are in which part of MSE

A

they are a disturbance in thought content

339
Q

childhood disintegrative disorder

A

normal development first 2 years of life. then loss of previously acquires skill sin language, social skills, etc. onset age 2-10. cause unknown. B:F 4:1.

340
Q

physiology of most delirium in elderly from medicines

A

delirium related to blockage of acetylcholinergic receptors. Ach is related to memory processes in the brain.

341
Q

what percent of patients with complex partial epilepsy experience psychotic symptoms at some time

A

20%

342
Q

blockade of which NT in an elderly person would most likely result in a cognitive decline

A

ACH

343
Q

which sign is most closely associated with lithium toxicity

A

abdominal pain

344
Q

can you take antipsychotics during ECT

A

yes. they lower seizure threshold which can even make the ECT more effectvie

345
Q

how does clozapine affect glucose

A

it increases liver gluconeognesis.

346
Q

do you need weight gain to get diabetes after taking zyprexa or clozapine?

A

no- some just get diabetes without weight gain

347
Q

should you put patient on clozapine or zyprexa on prophylactic metformin

A

yes you can. studies show that it does work- but it might not work in real life as much as in studies

348
Q

how do we augment antidepressant when it doesnt work

A

add a little antipsychotic. we don’t know how effective this is but its standard practice and its public health issue- both cause weight gain

349
Q

which antidepressants are more weight gaining

A

the ones that are more anti-histaminic (maybe)

350
Q

what medications can offset weight gain

A

amphetamines (but cause tarry stools), topamax,

351
Q

weight loss with welbutrin?

A

avg weight loss is about 4 lbs

352
Q

benzo withdrawal?

A

not necessarily autonomic sxs. can feel sxs of anxiety

353
Q

can you use SNRI for anxiety?

A

yes- even though its activating, they’ve been shown to be very effective

354
Q

which benzo for prophylaxis of panic attacks an anxiety

A

klonopin

355
Q

what determines how quickly a benzo takes effect

A

lipid solubility. doesnt have to do with how quickly metabolized

356
Q

is benzo OD (w/o comorbidities) lethal?

A

yes. just do supportive treatment. could use flumzenil but usually just use that for benzo users in ECT

357
Q

what is mechanism of buspar

A

serotinin 1A partial antagonist. some dopamine properties as well.

358
Q

what is tourettes comorbid with

A

OCD

359
Q

child with ADHD and OCD and a tic- what meds

A

not stimulant- that can make tics worse.

360
Q
  • atomexetine (strattera)
A

norepinephrine reuptake inhibitor used to treat ADHD

361
Q

what type of dementia looks like delirium

A

vascular- it gets worse very quickly

362
Q

downside of depot antipsychotics

A

if they have NMS- you can’t get rid of it quickly

363
Q

lithium OD

A

not thyrotox, kidney tox (thats long term side effects). tremors, stomach pain

364
Q

name five high potency antipsychotics

A

halopridol, fluphanezine, pimozide, thithixene, trifluoperazine

365
Q

name five mid potency antipsychotics

A

perphanazine, molindine, loxapine

366
Q

name three low potency antipsychotics

A

chlorpromazine, mesoridazine, thioridazine

367
Q

what typical antipsychotics have IM forms available? depot?

A

IM: haloperidol, fluphanezine, perphanizine. depot: haloperidol, fluphanezine.

368
Q

what parts of body can tradeoff dyskinesia be

A

involuntary choreoathetoid movements of face, neck, trunk, and extremities

369
Q

how can parkinsonism be treated from antipsychotics (4)

A

anticholinergics, dopaminergric agents (amantidine) or beta blockers

370
Q

seizures and antipsychotics

A

typical antipsychotics lower seizure threshold

371
Q

can antipsychotics affect skin?

A

yes. dermatitis and photosensitivity

372
Q

which pathways do atypicals affect

A

block D2 in mesolimbic: efficacious against positive symptoms. block D2 in mesocortical tract-> worsen negative sxs. block D2 in nigrostriatal->EPS, block D2 in tuberoinfundibulnar-> hyperprolactinemia

373
Q

what is mechanism of action of atypical antipsychotics (exact receptors).

A

D2 blockade and serotonin 2A blockade. also block muscarinic, alpha-adrenergic, and histamine-1 to varying degrees.

374
Q

atypicals and mania

A

atypicals (with the exception of clozapine) have recently won indications for acute mania. olanzipine and arapiprazole are indicated for prophylaxis of recurrent mania or bipolar maintenance.

375
Q

which receptors does olanzipine work at

A

like clozapine, wide antagonism at 5HT2A, D1, D2, D4, H1, muscarinic, and alpha 1

376
Q

which atypicals have an IM form? dissolvable tab? depot?

A

IM: risperidone, olanzipine, ziprasadone. depot: risperidone. dissolavable tab: risperidone, olanzapine

377
Q

which receptors does quietiapine work at

A

antagonist at 5HT2A, D2, Alpha-1, alpha-2, H1.

378
Q

which receptors does ziprasadone work at

A

antagonist at 5HT1A, 5HT2A, D2, D3, monoamine reuptake pumps (NE, 5HT, DA)

379
Q

which receptors does aripiparzole work at

A

antagonist at 5HT2A, partial agonist at D2 and 5HT1A.

380
Q

which atypical is a metabolite of risperidone?

A

paliperidone (Invega). possibly less EPS than risperidone.

381
Q

Which atypical antipsychotic can be given for depression?

A

Aripiprazole. It is antagonist at 5HT2A AND partial agonist at D2 and 5HT1A.

382
Q

mechanism of action of typical CNS stimulants vs. novel ones

A

typical: stimulate alpha and beta adrenergic receptors-> release dopamine and norepinephrine from presynaptic terminals. novel: mechanism not clear for monadical. atomoxetine is related to selective inhibition of repute of norepinephrine.

383
Q

side effects of novel vs. typical CNS stimulants

A

both have anxiety, anorexia, insomnia

typical: tachycardia, drug dependence, HTN, cardiac arrhythmia, cardiovascular collapse.
novel: dizziness, rhinitis, sexual dysfunctions. atomocetine: suicidal ideation and severe liver injury

384
Q

which stimulants can be given or narcolepsy

A

typical CNS stimulants. modanifil (provigil). not atomoxetine.

385
Q

ADHD with narrow angle glaucoma. what to give?

A

modanifil (provigil). not atomoxetine or typical.

386
Q

which stimulant can you coadminister with MAOI

A

NONE

387
Q

what is pemoline

A

CNS stimulant.

388
Q

can you give lamotrigine with valproic acid

A

not really- there are boosted blood levels

389
Q

which two mood stabilizers are ineffective as mono therapy for mania

A

gabapentin and topiramate

390
Q

do you need blood monitoring for oxcarbazepine (trileptal)

A

no- compared to carbamexepine, it has much less potential for hematologic, dermatologic, and hepatotoxicity

391
Q

which mood stabilizer can cause nephrolithiasis

A

topiramate

392
Q

what do you need to monitor on valproic acid? for carbamezpine? lithium?

A

all: therapeutic blood monitoring
VP: blood count, liver, and pancreatic function testing.
carb: blood count, liver, metabolic function testing.
lithium: thyroid and kidney monitoring

393
Q

how does gabapentin work? where is it excreted

A

GABAergic. excreted renally so caution in renal disease.

394
Q

which mood stabilizer can be rapidly loaded for quicker therapeutic effect

A

valproic acid

395
Q

adverse effects of valproic acid versus carbamazepine

A

both: nausea, vomiting, diarrhea, sedation, lightheadedess, tremor, cognitive blunting, weight gain.
carb: electrolyte abnormalities (hyponatremia), anticholinergic, .
VP: hair loss

396
Q

serious adverse effects of carbamazepine vs. VP

A

both: thrombocytopenia.
Carb:blood dycrasias (aplastic anemia, agranulocytosis,), hepatotox.
VP: hemorrhagic pancreatitis hepatotoxicity polycystic ovaries

397
Q

OD for carbazempine for VP

A

both: tremor, coma, and death

398
Q

Adverse effects of MAOi vs TCA

A

Both: orthostatic hypotension, sexual dysfunction, weight gain, mania in bipolar

TCA: anticholinergic (dry mouth, constipation, blurry vision, urinary retention, confusion, ECG changes), seizures, sedation

MAOI: myoclonus, muscle pains, parasthesias, insomnia

399
Q

Serious side effects in TCA vs MAOI

A

TCA: cardio toxicity (slow cardiac conduction-> arrhythmia, AV block), neurotox (tremor and ataxia; in OD, agitation, delirium, coma, death)

MAOI: tyramine induced HTN crisis

400
Q

Mechanism of action of TCA

A

Antagonism at 5HT and NE pre synaptic re-uptake pumps. Also block muscarinic, alpha adrenergic, and histamine 1 receptors

401
Q

Tertiary amines vs secondary amines

A

Tertiary amines have greater HAM blockade. Newer secondary amines have fewer side effects and are less sedating, and are safer in OD

402
Q

What are 5 tertiary amines

A

Amitryptiline (elavil), clomipramine (anafranil), doxepin (sinequan), trimipramine (surmontil), imipramine(tofranil)

403
Q

Which atypicals can be used for adjunctive treatment for depression

A

Aripiprazole and quitiapine

404
Q

Which two atypicals can be used for bipolar depression

A

Latuda and quetiapine

405
Q

What is side effect of ziprasadone to worry about

A

Possible increased risk of QT prolongation

406
Q

What are 3 secondary amines

A

Desipramine (norpramin), nortryptyline (Pamelor), protryptiline (vivactil)

407
Q

Which TCA is least anticholinergic

A

Desipramine (norpramin)- secondary TCA

408
Q

Which TCA causes least orthostatic hypotension

A

Nortyptiline (Pamelor)

This is the demethylated version of amitryptaline (elavil)

409
Q

Uses for amitryptaline vs doxepin

A

Both are for pain and insomnia. Amytryptiline is for headache. Doxepin is for anxiety.

410
Q

Which MAOI has fewer dietary restrictions s

A

Transdermal selegeline

411
Q

What are three MAOIs

A

Phenylzine, tranylcypramine, transdermal selegeline

412
Q

How long do you have to wait after MAOI before starting ssri

A

2 weeks

413
Q

Mechanism of action of SNRI

A

Selective antagonism of NE and 5HT reuptake pumps. No HAM- kosher

414
Q

What happens when you discontinue SNRI

A

You can get headache, dizziness, irritability, and fatigue (just like with discontinuation of SSRI)

415
Q

What are serious side effects of mirtazapine

A

Agranulocytosis and other blood dyscrasias

416
Q

mechanism of action of benzos

A

binding site on GABA(A) receptor-> potentiates GABA by causing increased FREQUENCY of chloride channel openings

417
Q

what are three long half life benzos

A

clonazepam, diazepam (valium), chlordiazepoxide (librium)

418
Q

what are three nonbenzo anxiolytics

A

buspirone, hydrozyzine (sedating antihistamine), propranolol (beta blocker)

419
Q

how do nonbenzo hypnotics work

A

all but diphenhydramine and ramelteon are GABAergic

420
Q

which nonbenzo hypnotic leads to progressive tolerance and dependence

A

zolpidem (ambien) and zaleplon (sonata)

421
Q

which nonbenzo hypnotic can you dose in the middle of the night

A

zalpeplon (sonata)- it is short acting

422
Q

which GABAergic nonbenzo hypnotic does not yield tolerance

A

eszopiclone (Lunesta)

423
Q

ramelteon?

A

agonist at melatonin MT-1 and MT-2 receptors, thought to normalize circadian rhythms

424
Q

which nonbenzo hypnotics cause GI probs

A

zolpidem: nausea, vomiting, GI distress.
zaleplon: dizziness and dyspepsia

425
Q

hydrozyzine versus diphenhydramine

A

hydrozyzine is more for situational anxiety, diphenydramine is more for sleep

426
Q

what non chart drugs for ADHD

A

guanfacine and clonidine

427
Q

what drugs cause QT prolongation

A

typicals, TCAs, ziprasadone,

428
Q

which mood stabilizers treat mania

A

lithium, carbamazepine, VP

429
Q

how is clozapine dosed and monitored

A

12.5 mg daily BID + 25/50mg daily-> target to 200-450 mg daily-> + 100 mg/day-> max is 900 mg/day

430
Q

how often do you monitor clozapine

A

first 6 months: weekly monitoring.
months 6-12: monitor every 2 weeks.
after 12 months, you monitor every 4 weeks

Psych (7 decks)

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