Psych Flashcards
HPI of sleep problems
- Duration
- Number and duration of awakenings at night
- Sleep times including bedtime, naps, and wake-up
- Symptoms of disturbed sleep: fatigue, daytime sleepiness, etc
- Stressors
- Sleep hygiene: environment, light, sounds, pets, partners
- Routine
- Caffeine intake
- Other substances: drugs, sympathomimetics
- IMPORTANT: sleep log for 2 weeks
ddx of sleep problems
- Anxiety
- Insomnia
- OSA
- Restless legs
- Periodic limb movements of legs
- Drug abuse/withdrawals
- Narcolepsy
- Primary hypersomnia
- Circadian rhythm disorder (shift worker, jet lag, etc)
theories of bipolar pathophys
? Calcium channel gating
Lithium effects sodium and calcium channels
Kindling theory
In the temporal lobes, repeated subthreshold stimulation causes a seizure like reaction in the brain hence anticonvulsants work for bipolar
RFs for suicide in bipolar
Single Family history of suicide Earlier onset BPAD More depressive symptoms Increasing severity of depressive sxs Mixed state Rapid cycling Comorbid with anxiety and substance abuse
protective factors for suicide
- Social support churches, religion
- Family connectedness
- Pregnancy or parenthood though worry if they don’t want to have the baby and want to take them with them, or if they think their kids are better off without them
- Religiosity or participating in religious activities
- Thinking of or planning for future events
RFs for suicide in adults
- Sex
- Age
- Depression
- Previous attempt
- Ethanol abuse
- Rational thinking (or lack there of)
- Social support lacking
- Organized plan
- No spouse
- Sickness
RFs for suicide in kids
- Ideation – talk of suicide, looking for ways to kill self, talking or writing about death, dying or suicide not journaling after therapy—that’s what they are taught to do—parents shouldn’t read their journals!
- Substance abuse
- Purposelessness
- Anxiety – agitation and changes in sleep patterns can be only way to stop the anxiety
- Trapped – feeling no way out
- Hopelessness
- Withdrawal – isolating from friends, family and society
- Anger
- Recklessness
- Mood changes
bipolar dx criteria
◦ A. Distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least one week (or needing hospitalization)
◦ B. During the period of mood disturbance, 3 or more of the following sxs have persisted (4 if the mood is only irritable) and have been present to a significant degree:
• Inflated self esteem or grandiosity
• Decreased need for sleep
• More talkative than usual or pressure to keep talking
• Flight of ideas or subjective experience that thoughts are racing
• Distractibility
• Increase in goal directed activity or psychomotor agitation
• Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g. buying sprees, sexual indiscretions, reckless business investments)
◦ C. Causes marked impairment in occupational functioning or social functioning or necessitates hospitalization to prevent harm to self or others, or psychotic features
◦ D. Not due to medical reasons or drugs
depression labs
- TSH r/o hypothyroidism thinning hair, weight gain, cold intolerance, weight gain
- BG r/o DM thirst, polyuria
- r/o bipolar mania
- Utox
- If you think you need them: CBC, electrolytes, BUN/Cr, hepatocellular enzymes, RPR (syphilis), B12, folate, UA, EKG, MRI (stroke, brain tumor…)
sleep disorder pE/labs
- Epworth Sleepiness Scale
- Depression or Anxiety scales
- EKG
- Thyroid function tests
- BG
- HgA1c
- BUN
- Creatinine
- Iron
sleep disorder pE/labs
- Epworth Sleepiness Scale
- Depression or Anxiety scales
- EKG
- Thyroid function tests
- BG
- HgA1c
- BUN
- Creatinine
- Iron
ddx of mania
- Kids: PTSD, drugs etoh, caffeine, cocaine, amphetamines, heroin, meds steroids, antidepress.
- Under 50: bipolar and substance abuse ask if they have ever had mania when they are not using, may also be that they know they get manic and then use drugs
- Over 50: Organic medical cause MS, temporal lobe epilepsy
- Other causes: Endocrine hyperthyroid, cushing’s Infections HSV, HIV encephalitis, syphilis AI lupus metabolic states hypoglycemia, hypoxia
when does narcolepsy begin usually/
early teens or 20s
etiology of narcolpesy
loss of orexin signaling, genetics
dx and tx of narcolepsy
sleep study; tx: scheduled naps, sleep hygiene, modafinil
dx and tx of primary hypersomnia
compelled to sleep at innapropriate times, gets lots of sleep but does not feel refreshed (naps do not help) tx is modafinil or stimulants
dx and tx of insomnia
difficulty initiating, maintaining or early waking from sleep associated with IMPAIRMENT despite ADEQUATE SLEEP OPPORTUNITY
what comorbid conditions are with insomnia?
mental health like depression or anxiety and substance abuse
what is short term insomnia associated with?
stressors
what medications can cause insomnia?
CCBs, BBs, glucocorticoids, respiratory stimulants (saba??)
tx of insomnia
tx underlying psych or medical conditions, sleep hygiene, behavioral therapy (relaxation techniques), stimulus control (don’t nap, bed for sleep and sex, only go to bed when sleepy, wake up at same time, get out of bed if not falling asleep), sleep restriction
indications for sleep study
suspecting ob. sleep apnea, narcolepsy or periodic limb movements of sleep
what 2 things must you do history to look for in depression?
other psych condition and other medical conditions (highly correlated)
what makes you suspect adolescent/childhood depression?
drop in grades, more accidents (clumsy), anxiety, social withdrawal, concentration probe, weight, irritability, neglect of appearance, HA/body aches
ddx of depression
endocrine (hypothyrodism), other psych illness, substance abuse, systemic illness, neuro illness (dementia, parkinson), meds
labs to r/o stuff in suspected depression
TSH, utox, CBC, B12, folate, CMP: glucose, BUN/cr, LFTs, electrolytes, UA, RPR, EKG, mRI
tx of depression
lifestyle changes (sleep hygiene, healthy diet, exercise, no substances, hobbies, relaxation) + therapy and/or medication
when to refer in depression
if severe, comorbid conditions, no response to tx
tx of adjustment disorder
social support, coping mechanisms, problem solving skills, relaxation techniques, meds
is bipolar common in kids?
NO very rare. think PTSD and substance abuse first.
difference between mania and hypomania
mania lasts at least one week, hypomania at least 4 days. mania is severe and usually requires hospitalization, hypomania does not cause impairment.
criteria for rapid cyclign
4 or more in a year (4 or more per day is something else–drug use, anxiety,e tc)
bipolar 3 definition
manic sx only on antidepressants, sx clear when meds are stopped
bipolar ddx
depression, substance abuse, medications (antidepressants, steroids), endrocrine (hyperthyroidism, cushings), neuro (MS, temporal lobe epilepsy, infections (syphilis, hIV), AI (lupus), metabolic states (hypoxia, hypoglycemia)
main RFs for suicide
major psych diagnosis, substance abuse, prior attempt, living alone, unemployed, poor health, abuse, family history, access to guns
psychometric testing that can be requested by primary care providers to “figure it out” from a broad perspective
neuropsychological assessment
who to refer to for these issues? • Failed MMSE • Neurodevelopmental disorders— • Distinguish dementia from depression- • Decision making capacity- • Sensory processing • determine ADHD and OT for kids • Long term substance abuse— • Problems with understanding language
- Failed MMSE—neuropsych testing?
- Neurodevelopmental disorders—neuropsych testing
- Distinguish dementia from depression- neuropsych testing
- Decision making capacity- neuropsych testing
- Sensory processing—OT referral
- Refer for comprehensive testing to determine ADHD and OT for kids
- Long term substance abuse—refer for functional testing
- Problems with understanding language—refer to speech language therapist
T or F: 99% of those who think they have memory problems have dementia
F! Most who think they have memory problems don’t
which types of hallucinations usu have a medical cause?
olfactory and gustatory
false sensory perceptions occurring in any of the five senses
hallucinations
fixed false belief
delusion
ddx of psychosis
Substance induced psychosis Mood disorder with psychotic features Schizophrenia Schizoaffective Schizophreniform Brief psychotic disorder Delusional disorder Psychotic disorder NOS Pervasive Developmental disorder (autism) Personality disorders Delirium Dementia Post partum psychosis (really scary, comes on really fast) TBI Mental retardation Sleep deprivation (misperceive things as brain is trying to catch up) Shared psychotic disorder Factitious disorder/malingering
T or F: there is a higher incidence of violence with persons with mental health disorders
T, HOWEVER Mental illness is not an independent predictor to violent behavior
RFs for schizophrenia
family member with it, family member with bipolar, advanced paternal age, winter bipolar, insults to 1st and 2nd trimester fetus, insults to perinatal period
which sx of schizophrenia are most responseive to meds?
positive sx (i.e. delusions, hallucaintions)
what are the positive sx of schizophrenia
psychosis, delusions, hallucinations
what are the negative sx of schizophrenia?
flat affect, loss of social drive, no personal motivation, alogia (loss of verbal expression)
4 sx of schiozophrenia
positive sx, negative sx, cognitive impairments (ADLs, function), and affective disorders
DSM criteria for schizophrenia
2 of more of these for at least one month:
Delusions
Hallucinations
Disorganized speech (e.g. frequent derailment or incoherence)
Grossly disorganized or catatonic behavior
Negative symptoms (i.e. affective flattening, alogia, or avolition)
+plus social or cognitive impairment
+signs of the disturbance for 6 months
disorder with mood disorder and psychotic sx
schizoaffective
better px of schrizophrenia
Female, significant positive/affective symptoms, good initial response to meds
experiencing psychological distress in the form of physical symptoms and seeking medical help for these symptoms
somatization
T or F: if someone is somatizing they are pretending they have the sx
F: they really think they have the sx
Symptoms affecting voluntary motor or sensory function suggesting a neurological disorder or other general medical illness
Clinical findings provide evidence of incompatibility between the symptoms and recognized neurological or medical conditions
converson disorder
Preoccupation with having or acquiring a serious illness
illness anxiety disorder
Preoccupation with an imagined defect in appearance or excessive concern with slight physical anomaly (not anorexia)
body dysmorphic disorder
difference between malingering and factitious disorder (munchausen)
malingering is faking a sx to get something, factitious is faking or causing an illness to get something for an unknown reason
how do you tx somatization patients?
still need PE and work ups–they still get problems
tx for somatiform disorders
see patients once a week in primary care to discuss sx and it puts them at ease, set limits on care (i.e. no narcotics), encourage psychotherapy, don’t engage whether its mental or physical
psych emergency definitions
danger to themselves or others, overwhelmed and can’t function,
critiera for hospitaliztion
imminent danger to self or others (suicide, et. or vulnerable adult or child), failing outpt tx (even if not acutely ill), not able to function in ADLs, detox
T or F: you must notify the person someone wants to kill every time
F: must inform them unless hospitalized for 3 days
biggest RFs for violence
drug use and trauma
best predictors of violenceq
Obsessing over an event where a person was perceived to be unfairly treated
Recent threats to act violently
Evidence of making plans to act violently
Threatening, pressured, and/or loud speech
Hypervigilance
Staring
Agitated behavior: Tremors, Sweating, Pacing, Clenching of hands and teeth
drugs for etoh withdrawal
ativan, librium or valium
drugs for benzo withdrawl
phenobarbital taper
sx of opiate withdrawal
Symptoms include runny nose, watery eyes, diarrhea, muscle aches/cramps, nausea, vomiting, high blood pressure
3 drugs commonly used in ER for psych emergencies
Haldol 1-5 mg PO/IM/IV
Ativan 1-3mg PO/IM/IV
Benadryl 25-5omg PO/IM/IV
when can you put someone on a hold?
if imminintely a danger to self or others
is it better to do a transport hold or a 72 hour hold?
transport–b/c psych can evaluate them then and 72 hour hold starts when psych says it does. 72 hour hold is taken very seriously.
who can write 72 hour holds?
MD, PA, NP
which tx is most effective for generalized anxiety?
CBT
how long can it take SSRIs to work for anxiety?
2-4 weeks
short acting benzo for anxiety
lorazepam (ativan)
longer acting benzo for anxiety
diazepam (valium)
1st line txs for generalized anxiety
SSRIs, SNRIs, benzos (for short term)
who should benzos not be used for for anxiety?
older adults–> risk of falls, confusion
TCAs that can be used for generalized anxiety
desipramine and imipramine
what anti-anxiety med is good for older adults and those who have a hx of substance abuse?
buspirone (b/c no tolerance develops and no effect on cognition)
non pharm for panic disorder
avoid caffeine, decongestants and diet pills, do CBT
how long does it take SSRIs ( and other antidepressants) to be effective for panic disorder?
at least 4 weeks for antigenic effect, optimal response in 6-12 wks
examples of first gen antipsychotics
haloperidol, chlorpromazine, perphenazin
examples of second generation antipsychotics
aripiprazole, asenapine, olanzapine, paliperidone, risperidone, quetiapine
extrapyramidal side effects of antipsychotics
parkinson like AE (cogwheel rigidity, flat effect, resting tremor), akathisia (inner restlessness), acute destinies, tardive dyskinesia
uncontrolled sense of inner restlessness
akathisia
AE of 1st gen antipsychotics
extrapyramidal side effects, anticholinergic effects, orthostatic HOTN, QT prolongation, neuroleptic malignant syndrome, agranulocytosis
AE of 2nd gen antipsychotics
sedation, weight gain (most with clozapine and olanzapine), hyperglycemia (most with clozapine and olanzapine), triglyceride elevations, impulse control problems
impulse control problems most common with which antipsychotic?
aripiprazole
which types of antipsychotics are the first choice for schizophrenia?
2nd generation
what is an adequate trial of antipsychotics for schizophrenia?
at least 6 weeks at the upper end of the dose range
what can happen to those with dementia on antipsychotics?
increased mortality
eating disorder beahviors
Starvation(withorwithoutpurging) •Binging(with/withoutpurging) •Purging(vomiting,exercise,laxatives) •Chewingandspitting •Dietpills/Laxatives/Appetitesuppressants •Foodrules/fears •Waterrestricting/loading •Caloriecounting •CompulsiveBodyChecking •RigidTablebehaviors(cutting/smearing/slowpace)
common sx that bring someone into the office with an eating disorder
marked weight loss, fatigue, weakness, dizziness, syncope, irregular menses, cold intolerance, constipation, mood changes
T or F: in anorexia labs are often normal
T
when to consider a dexa in eating disorders?
if anorexia and amenorrhea for 1 year, or if poor nutrition and excessive exercise, excess soda intake, high sodium, high caffeine, smoking or etoh use
causes to hospitalize anorexia/bulimia
Dramatic weight changes; weight cut offs vary 500)
•Electrolyte abnormalities and unable to orally hydrate or take replacement: especially low phos(
model for development of eating disorders
biopsychosocial model
main neurotransmitter involved in reward behaviors
dopamine
reward area of brain
nucleus accumbens
RFs for drug abuse
genetics: 30-60%
environment–abuse, exposure, risk taking, peers using, lack of supervision, low perception of harm, younger age of first use, poor school achievement,
length of time req’d for substance use disorder
12 months
specifiers of substance abuse disrode
mild-severe or course: early or sustained remission (sustained after 12 months)
etoh intoxication signs and sx
Breath odor Skin flushing, hypotension Slurred speech Lability/inappropriate behavior and emotions Incoordination/dysmetria/ataxia Nystagmus pupils slowed if intoxicated, nystagmus if intoxicated Nausea/vomiting Seizures/coma/death
etoh withdrawal sx
Nausea/vomiting Hypertension Tachycardia Tremor Irritability/anxiety/insomnia Seizures Hallucinosis usu talking to ppl in their using scenarios Death possible if untreated
what is delirium tremens?
altered mental status (global confusion)
and sympathetic overdrive high BP and pulse
which can progress to
cardiovascular collapse and death
intoxication of sedatives (benzos)
Fewer autonomic signs than alcohol Somnolence Dysarthria Incoordination Respiratory depression or arrest Lethargy/coma/death
sedative withdrawal sx
Hypertension, tachycardia Agitation Tremor Confusion Hallucinations Seizure higher risk than etoh Death possible if not treated Anxiety high, intolerable
tx of choice for etoh withdrawal
benzos
when do delirium tremens start?
usu 48-72 hours or up to 5 days after withdrawal
tx of benzo withdrawal
phenobarbital taper
opioid intoxication sx
Miosis pinpoint pupils (not reliable) Constipation Hypotension, bradycardia Respiratory suppression or arrest Somnolence, ataxia Coma/death
opioid withdrawal sx
Anxiety Nausea/vomiting Abdominal pain Myalgias Diarrhea Piloerection Diaphoresis Lacrimation/rhinorrhea Hypertension/tachycardia Yawning
supervised opioid withdrawal
Methadone taper (needs monitoring)
Buprenorphine (suboxone) taper (needs monitoring)
Clonidine 0.1-0.2 mg Q4-6 alpha blocker to help with HTN
Neurontin + Vistaril + Flexeril
NSAID, antidiarrheal
stimulant intoxication sx
Euphoria, irritability, talkativeness Mydriasis Hypertension, tachycardia MI, stroke, death Paranoia, hallucinations common Hyperthermia, death Hypertensive crisis, death Pulmonary edema in smokers
stimulant withdrawal sx
Non-specific “Cocaine crash” “crack nap” Depression Somnolence May want to die but they probably won’t No inpatient detoxification
who gets the dysphoric/paranoid and mood lability sx of cannabis intoxication more often
teens
sx of cannabis withdrawal
Irritability, anger, or aggression Nervousness or anxiety Sleep difficulty Decreased appetite or weight loss Restlessness Depressed mood At least one of the following physical symptoms causing significant discomfort: abdominal pain, shakiness/tremors, sweating, fever, chills, or headache
who gets inpatient detox?
etoh, benzos, opiates
CRAFFT screening tools for kids
- Have you ever ridden in a CAR driven by someone (including yourself) who was high or had been using alcohol or other drugs? If + stat. sig there is drug problems
- Do you ever use alcohol or other drugs to RELAX, feel better about yourself, or fit in?
- Do you ever use alcohol or other drugs while you are ALONE?
- Do you ever FORGET things you did while using alcohol or other drugs?
- Do your family or FRIENDS ever tell you that you should cut down on your drinking or drug use?
- Have you gotten into TROUBLE while you were using alcohol or drugs?
T or F: there is no such thing as inpatient tx for substance abuse
tx: they have to be there voluntarily. there is housing for them and they stay there but not locked.
AE of naltrexone
increased LFTs, CI if liver dz or hepatitis
AE of acamprosate (campral)
kidney probs
why do you have to wait 12-24 hours before giving buprenorphine for etoh withdrawal?
it knocks some opiates off receptors and you need to wait until a while after they used to not cause severe withdrawal sx
for what ages can you tell parents results of tox screens?
up until age 15
cluster A, B and C personality disorders
A is paranoid schizoid (odd, eccentric), B is histrionic, antisocial, borderline, narcissistic (emotional, dramatic) C is anxious fearful like avoidant, dependent and OCD
features of paranoid personality disorder
distrust others, distrust loyalty of friends, hostile, stubborn
features of schizoid personality disorder
little interest in others, relationships, sex, restricted emotion, indifference to praise
features of schizotypal personality disorder
ideas of reference, odd thinking, magical ideas, unusual perceptual experiences, odd or eccentric behavior or appearance, social anxiety
management of schizotypal personality disorder
feedback, guidance, tracking errant thoughts
