Psych Flashcards
Common abnormalities seen on neuroimaging in Schizophrenia patients:
Loss of cortical tissue volume
Ventricular enlargement w/lateral vent. enlargement being the most common
Decreased volume of the Hippocampus and amygdala
What neuroimaging abnormalities are a/w Huntington dx?
Atrophy of the caudate nucleus
What neuroimaging abnormalities have been a/w OCD?
Structural abnormalities in the orbitofrontal cortex and basal ganglia
What has been a/w accelerated head growth during infancy and increased total brain Vol.?
Autism
Features of Persistent complex bereavement disorder:
Aka complicated/prolonged/complex grief Prolonged grief (>12mo after loss) Difficulty accepting the death Persistent yearning for the deceased Avoidance of reminders of the deceased
What are cxs of untx’d Persistent complex bereavement disorder?
Can continue for yrs or decades.
May result in poor quality of life, increased substance use, and increased mortality d/t medical conditions or suicide.
What are the common early AEs of SSRIs?
N/D, HA, increased anxiety and insomnia or somnolence.
Pts w/ anxiety disorders are more likely to experience these and should be started on lower doses than those used to tx Depression
Often have to temporarily lower the dosage in pts who experience these.
Features of postpartum blues:
Occur in 40-48% of new mothers
Onset: 2-3d and resolves w/in 2 weeks
Have mild depression, tearfulness, and irritability
Mgmt: reassurance and monitoring
Features of post-partum depression:
Occurs in 8-15% of mothers
Onset: 4-6wks, can be up to 1yr
Have 2+ wks of moderate to severe depression, sleep/appetite changes, low E, psychomotor changes, guilt, concentration difficulty, and possibly suicidal ideation
Mgmt: antidepressants and psychotherapy
Features of postpartum psychosis:
Occurs in 0.1-0.2% of mothers
Onset: days-weeks
Have delusions, hallucinations, disorganized thoughts, bizarre behavior and possibly depressive sxs.
Mgmt: antipsychotics, antidepressants, mood stabilizers, and hospitalization – medical emergency
Have increased risk of infanticide
Contraindications to Lithium therapy:
CKD, heart disease, hyponatremia or diuretic use
Baseline studies to check before starting Lithium tx:
BUN/Cr (BMP) Ca2+ UA Thyroid fxn tests ECG in pts w/coronary risk factors Urine BhCG in women
AEs of Lithium therapy:
Acute: Tremor, ataxia, weakness, polyuria/dipsia, V/D, cognitive impairment
Chronic: Nephrogenic DI, CKD, Thyroid dysfxn, Hyperparathyroidism
What are the indications and AEs of Clozapine tx?
Indications – tx-resistant schizophrenia and schizophrenia a/w suicidality
AEs: Agranulocytosis, Seizures, Myocarditis, Metabolic syndrome
What should be given to agitated pts w/acute mania?
An antipsychotic, often needed to be given IM.
Lithium and mood stabilizers don’t have a quick enough onset of axn
What anti-PD Rxs have the greatest risk of psychosis?
The DA-agonists: Pramipexole and Ropinirole
What should be started in Parkinson pts w/psychosis?
If they fail medication adjustments then a low-potency antipsych w/minimal DA-2 R antagonism (Quetiapine, Clozapine or Pimavanserin) should be added.
Tx for specific phobia disorders:
1st line: CBT w/exposure
Short-acting benzos can be used in a limited role to help acutely
What kind of drug is Fluoxetine?
SSRI
What kind of drug is Vanlafaxine?
SNRI
What are the four criteria required to dx Schizophreniform?
1: 2+ of the following, each present for the majority of 1mo – delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, negative sxs.
2: An episode of illness >1mo but <6mo
3: Rule out schizoaffective, bipolar, and MDD w/psychotic feats.
4: Sxs can’t be attributed to substance use or another medical condition
What is schizoid personality disorder?
Social withdrawal w/out psychosis
What type of drug is Phenelzine?
MAOI – txs atypical and refractory depression and anxiety.
What type of drug is Buspirone?
An anxiolytic – txs GAD.
How are Lewy Body and Alzheimer’s dementia differentiated?
LB has an early loss of executive fxning (planning/executing tasks) w/ relatively preserved memory.
LB pts also commonly have vivid visual hallucinations early in the dx course.
What Rxs are contraindicated in LB dementia?
Neuroleptics – esp. typical antipsychs.
These can cause irreversible and severe Parkinsonism, depressed consciousness and worsening confusion/agitation.
These pts are also at increased risk for NMS w/ these Rxs.
What is often found on histo examination of a brain w/Pick disease?
Aka Frontotemporal dementia
See silver-staining, intracellular, ovoid accumulations of Tau protein – “Pick bodies”
Most common clinical presentation of atypical antipsych toxicity:
Signs of histamine & a-Adrenergic blockade, and anticholinergic toxicity.
Histamine blockade – lethargy/sedation
a-Adrenergic blockade – miosis, tachycardia, ortho HoTN, etc.
anticholinergic toxicity – dry mouth, facial flushing, confusion, etc.
** May produce false+ for TCAs on Utox – esp. Quetiapine **
What is the suggested pharmacotherapy to tx Acute dystonias caused by anti-psychs?
Benztropine
Diphenhydramine
What is the suggested pharmacotherapgy to tx Akathisia d/t anti-psychs?
BB—propranolol
Benzos—lorazepam
Benztropine
What is the suggested pharmacotherapy to tx Rx-induced Parkinsonism?
Benztropine
Amantadine
What is the suggested pharmacotherapy to tx Tardive dyskinesia?
Valbenazine
What medications may precipitate delirium?
Introduction of Opioids, benzos or anticholinergics
Elderly are especially at risk
Tx of choice for adjustment disorder:
Psychotherapy
What effects do antipsychotics have on the different DA pathways?
Anti-psychs are DA-antagonists so they block the different pathways
Mesolimbic – accounts for the therapeutic effects of antipsychotics
Nigrostriatal – EPS: acute dystonia, akathisia, parkinsonism
Tuberoinfundibular – hyperprolactinemia
How does decreased DA cause hyperprolactinemia?
DA secreted from the tuberoinfundibular pathway (which normally bind D2-Rs) inhibit prolactin release from the ant. pit. – when DA is blocked then there is no inhibition – hyperprolactinemia/gynecomastia/amenorrhea, etc.
What causes the delusions and hallucinations experienced in Schizophrenia?
Increased DA activity in the mesolimbic pathway – also responsible for the euphoria a/w drug use.
What structures are involved in each of the DA pathways?
Mesolimbic – extends from the ventral tegmental area to the limbic system
Nigrostriatal – extends from substantia nigra to the BG (involved in coordination of movement)
Tuberoinfundibular – projects from the hypothalamus to the pituitary gland
What is the classification criteria of Agoraphobia and what is it commonly associated with?
Agoraphobia must have anxiety and avoidance in 2+ situations in which it may be difficult to escape or get help. Often this develops in people with panic attacks.
Avoidance behavior and agoraphobia are best tx’d w/CBT
What are the more serious AEs of Lithium therapy?
Toxicity – N/V/D, coarse tremor, ataxia, AMS, slurred speech, renal failure, convulsions and coma
Nephrogenic DI/Renal impairment
Hypothyroidism (up to 34% F>M)
How is Lithium-induced Hypothyroidism managed?
TSH levels need to be drawn before initiating tx and then every 6-12mos.
If Hypothyroidism develops they are tx’d w/T4 – Levothyroxine
Shouldn’t dc lithium unless absolutely necessary
What is the DoC for EtOH withdrawal in the hospital setting?
Lorazepam – an intermediate acting Benzo that is safe in pts w/decreased liver fxn. bc it has no active metabolites.
Other benzos safe in liver dx and alcohol withdrawal: Oxazepam, and Temazepam. All three of these undergo phase II glucuronidation in the liver instead of phase I w/the P450s and therefore lack active metabolites harmful to the liver.
What is the DoC in Bipolar patients with possible renal dysfunction?
Valproate.
Lithium is unsafe in these pts. and can cause nephrogenic DI
Valproate though can cause hepatotoxicity and thrombocytopenia and these should be monitored.
What is reaction formation?
Transforming unacceptable feelings/impulses into the opposite.
What are the only 2 mature defense mechanisms?
Sublimation – channeling impulses into socially acceptable behaviors
Suppression – putting unwanted feelings aside to cope w/reality
Primary indications for DBT:
Borderline personality disorder.
Improves emotion regulation, distress intolerance, and mindfulness.
Decreases self harm and builds skills
What are the preferred SSRIs in terms of low-risk of Rx-interactions?
Sertraline and Escitalopram
Have especially low risk of interfering w/cardiac medications
Sxs and Exam findings of Opiate withdrawal:
Sxs – N/V/Abd cramping, diarrhea, muscle aches
Exam Findings – dilated pupils, yawning, rhinorrhea, piloerection, lacrimation, hyperactive bowel sounds
Sxs and exam findings of benzo withdrawal:
Sxs – tremors, anxiety, perceptual disturbances, psychosis, insomnia.
Exam findings – seizures, tachycardia, palpitations
What is the recommended tx for pediatric MDD?
Pharmacotherapy with SSRIs – Fluoxetine is DoC
Psychotherapy
What are the cluster A personality disorders?
Characterized as Odd/eccentric
Paranoid – suspicious, distrustful, hypervigilant
Schizoid – prefers to be a loner; detached and unemotional
Schizotypal – unusual thoughts, perceptions and behavior
What are the cluster B personality disorders?
Characterized as Dramatic/Erratic
Antisocial – disregard and violation of others rights
Borderline – chaotic relationships, abandonment fears, labile mood, impulsivity, inner emptiness, self-harm
Histrionic – superficial, theatrical, attention-seeking
What are the cluster C personality disorders?
Characterized as anxious/fearful
Avoidant – avoidance d/t fears of criticism and rejection
Dependent – submissive, clingy, needs to be taken care of
Obsessive-compulsive – rigid, controlling, perfectionistic
Antipsychotics with highest risk for Metabolic syndrome:
Clozapine
Olanzapine
When do nightmares occur?
During REM, and more frequent in 2nd half of the night.
What are the features of nightmare disorder?
Recurrent episodes of awakening from sleep w/recall of disturbing or frightening dreams.
On awakening the pt. is fully alert, remembers the dream and can usually be consoled.
When do sleep terrors occur?
During stage N3 of nREM sleep (deepest stage of sleep), more frequent in the first 3rd of the night.
What are the features of sleep terror disorder?
Incomplete awakenings, unresponsiveness to comfort and no recall of dream content.
Often have marked autonomic arousal and amnesia of the episode in the morning.
What are signs suspicious of co-ingestion/sedative-hypnotic overdose?
Severe CNS depression Bradycardia HoTN Respiratory depression Hyporeflexia
Isolated Benzo overdose typically the pts are still arousable and have normal VS.
Signs/symptoms of Neuroleptic malignant syndrome:
Fever >40C/104F
Confusion
Muscle rigidity
Autonomic instability (abnormal VS, sweating)
Tx of NMS:
Stop antipsychs/restart DA agents
Supportive care (hydration, cooling); ICU
Dantrolene or bromocriptine if refractory
Characteristic triad of Serotonin syndrome and tx:
Triad – autonomic instability, AMS, and neuromuscular irritability (hyperreflexia, myoclonus)
Tx – Cyproheptadine (a 5-HT antagonist)
Besides timeline what is one feature that differentiates Schizophrenia from Schizophreniform?
Schizophrenia requires a functional decline for diagnosis, Schizophreniform does not
What are the 3 first line tx options for smoking cessation and what are their contraindications?
1 – Transdermal patch and gum or lozenge (no contra’s)
2 – Varenicline (an a-4 B-2 nicotinic Ach-R partial agonist).
Contra’s: relative – preexisting CVD. It increases risk of CVS events in these pts.
3 – Buproprion (NE-DA reuptake inhibitor)
Contra’s: seizure disorders, active bulimia or anorexia
What are some common mood sxs of OSA?
Depressed mood, fatigue, sleep disturbance w/multiple awakenings, impaired concentration, irritability, and low mood.
What CD4 count is a/w HIV-dementia?
CD4 < 200
What are the common signs/sxs of HIV-dementia?
Onset is often subacute w/increasing apathy and impaired attn.
Subcortical (BG and NGS) dysfxn occurs early w/ sxs of slowed movement and difficulty w/smooth limb movement
Next comes significant cortical neuronal loss and memory decline.
Drugs that can increase lithium levels:
Thiazides (decrease renal clearance) ACEIs NSAIDs Tetracyclines Metronidazole
Mgmt of Lithium toxicity:
Hemodialysis for severe cases
Mgmt of Catatonia:
Benzos – Lorazepam
ECT
Key features of Frontotemporal dementia:
Early personality changes
Apathy, disinhibition and compulsive behavior (consuming the same meal daily, hyperorality – increased cig consumption).
Frontotemporal atrophy on neuroimaging
Has AD inheritance in up to 25% of cases
Key features of Dementia w/Lewy Bodies:
Visual hallucinations
Spontaneous parkinsonism
Fluctuating cognition
Most commonly used benzos for alcohol withdrawal:
Chlordiazepoxide, diazepam, and lorazepam.
Only lorazepam is safe in pts w/liver disease
Tx for Social anxiety disorder:
SSRI/SNRI
CBT
BBs or benzo for performance-only subtype
1st line options for alcohol use disorder tx:
Naltrexone – a mu-opioid R antagonist
Acamprosate – a glutamate modulator
When is Naltrexone contraindicated?
In pts taking opioids – can precipitate withdrawal
Pts w/acute hepatitis or liver failure
When is Acamprosate contraindicated?
In pts w/significant renal impairment.
What conditions are patients w/a hx of sexual abuse at increased risk for (7)?
MDD Suicidal thoughts or attempts STDs Pelvic pain Fibromyalgia Functional GI disorders Cervical cancer (thought to be linked to avoidance of pelvic exams)
Indications for ECT tx for depression:
Tx-resistant MDD
Psychotic features
Emergency conditions: pregnancy, refusal to eat or drink, imminent risk for suicide
Tx of PCP-intoxication:
Benzos for acute agitation and supportive mgmt.
Antipsychs are used 2nd line for intoxication resistant to benzo tx.
Tx of PTSD:
Trauma-focused CBT
Antidepressants – SSRIs, SNRIs
Prazosin (a-blocker) for nightmares
Which anti-psych has the highest frequency of causing Hyperprolactinemia?
Risperidone – 2nd gen
Tx of Panic disorder:
1st line/maintenance – SSRI/SNRI +/- CBT
Acute distress – benzo
Rxs often used to tx acute bipolar depression:
2nd gen antipsyhcs (Quetiapine and Lurasidone)
Anticonvulsant lamotrigine.
Others: Lithium, valproate, combo of fluoxetine + olanzapine
Indications for hospitalization in anorexia pts (6):
Bradycardia (<40 bpm)/dysrhythmia
HoTN (<80/60), orthostasis
Hypothermia (<35 C/ ~95 F)
Electrolyte disturbance/marked dehydration
Organ compromise (renal, hepatic, cardiac)
<70% expected weight (BMI < 15)
Definition of Facticious disorder:
Intentional falsification of illness in the absence of obvious external rewards.
What are some indications for Mirtazapine use in MDD?
It is a 1st line antidepressant and is preferred in pts w/poor sleep and appetite as its AEs are stimulation of appetite, weight gain and somnolence.
How long do antidepressants need to be tried before switching dose or drug?
At least 4-6 weeks
What antipsychotics have the highest potential for causing hyperprolactinemia?
High-potency 1st gens: Haloperidol and Fluphenazine
2nd gens: Risperidone and Paliperidone (risperidone metabolite)
What lab values are a/w NMS?
Leukocytosis and Increased CK (often 30k or higher)
When should long-acting injectable antipsychotics be prescribed?
Once it has been established that a patient is able to tolerate the medication in oral form, and then if repeated medication non-adherence is seen.
What are some features of Korsakoff syndrome?
Retrograde and antegrade amnesia w/intact long-term memory, confabulation, apathy, lack of insight, and hx of alcohol use disorder.
This is a potential cx of Wernicke encephalopathy, but may develop w/out sxs of an acute episode of WE.
What are the diagnostic criteria and associated sxs of Narcolepsy?
Criteria: Recurrent lapses into sleep/naps (3+ x/wk for 3mo)
1+ of the following: Cataplexy, low CSF levels of Orexin-A/Hypocretin-1, shortened REM sleep latency
Assoc. sxs: Hypnagogic or hypnopompic hallucinations, sleep paralysis
Of the 2nd gen antipsychotics, which has the highest potency?
Risperidone
What 2nd gen antipsych has the highest risk of QT prolongation?
Ziprasidone
What is a common side effect of Aripirazole?
Akathisia
What are some benefits of Quetiapine?
Can be used as monotherapy for mood stabilization
Useful for comorbid insomnia
Which 2nd gen anti-psych is approved for bipolar depression?
Lurasidone
What are the 2 high-potency 1st gen antipsychotics?
Haloperidol and Fluphenazine
Both have high incidence of EPS
Which 1st gen antipsych can be used in pediatric population and what are its AEs?
Chlorpromazine
AEs: anti-cholinergic, heavy sedation, weight gain, HoTN
What are common sxs of Valproate toxicity?
N/V ataxia, nystagmus, lethargy, coma.
Tx: hemodialysis
Valproate has DDIs related to P450 system.
What needs to be monitored in pts on Valproate?
Platelets and LFTs – can cause thrombocytopenia and hepatotoxicity
May cause benign rise in LFTs, normally acceptable up to 3x normal
Rxs that increase Lithium levels:
Diuretics – thiazides, spironolactone ACEIs/ARBs NSAIDs CCBs Abx – metronidazole, TMP-SMX, Tetracyclines
Rxs that decrease Lithium levels:
Acetazolamide
Theophylline
Caffeine (mild)
Osmotic diuretics – Mannitol
Rxs increased by Valproate:
Warfarin – increased bleeding Dilantin (Phenytoin) – increases toxicity risk Lamotrigine – increased risk of SJS Benzos – increased somnolence Alcohol – increased intoxication
Rxs that increase levels of Valproate:
Aspirin – 4x increase
Fluoxetine – 2x increase
What effects does Lithium have on EKG?
Causes flattened/inverted T-waves.
Need to check K+ levels, but if they are wnl then this is a benign change
When should Carbamazepine be prescribed?
Often helpful in mania refractory to Lithium or 2/2 neurological conditions like TBI.
Common AEs of Carbamazepine:
Neuro AEs – vertigo, ataxia, diplopia, sedation
Dose related – delayed intracardiac conduction, confusional states
Others – BMS, SIADH, DDIs (it’s a P450 auto-inducer)
What paradoxical effect does increasing doses of Carbamazepine have?
It is a p450 auto-inducer, it induces its own metabolism, so increasing the dose may actually result in lower blood levels.
Indications and AEs of Lamotrigine:
Used for Bipolar maintenance, but not helpful in acute mania.
High risk of SJS
Indications and AEs of Topiramate (Topamax):
Txs – Bulimia, Impulsivity in borderline PD, and headaches
AEs – “Dope-amax:” cognitive dulling, word-finding difficulties, concentration/memory probs.
Weight loss (good for bulimia)
Kidney stones
What SSRIs have the greatest potential of causing QT prolongation?
Citalopram and Escitalopram
Which SSRI has the greatest rate of DDIs?
Fluvoxamine – inhibits CYP1A2, 2C9, and 3A4
Fluoxetine and Paroxetine are the others with risk of DDIs
What are indications for use of Fluvoxamine?
Used for OCD and Social anxiety disorder
Also may be used to augment Clozapine levels.
Which SSRI can be used to tx Bulimia?
Fluoxetine
What are the MAOIs?
Phenelzine
Tranylcypromine (has amphetamine-like properties)
Isocarboxazid
Selegiline (Used in PD)
AEs of the MAOIs:
HoTN, Weight gain, LE edema
Serotonin syndrome
HTN crisis (can occur when taken w/meperidine or decongestants)
Which TCA can be used to tx OCD?
Clomipramine
AEs: serotonin syndrome and seizure
What are the names of the TCAs (6)?
Amitriptyline Nortriptyline Imipramine Desipramine Clomipramine Doxepin
When would combination therapy for Bipolar be indicated?
If the pt. has severe illness w/sxs such as psychosis, aggression, frequent episodes/hospitalization.
1st line combo therapy is Lithium or valproate w/a 2nd gen antipsych (Quetiapine)
What nucleus is affected in Alzheimer’s disease?
Nucleus basalis of Meynert
What nucleus would be affected to cause ballismus?
Subthalamic nucleus – only one affected will be hemiballismus
Damage to what nucleus will affect the auditory pathways?
Medical geniculate nucleus
Damage to what nucleus occurs in PD?
Substantia nigra
Damage to what nucleus causes Kluver-bucy syndrome?
Amygdaloid nucleus
What is the tx of Tourette’s w/o ADHD vs. w/comorbid ADHD?
Tourette’s w/out – Tx: DA inhibitors (Risperidone or Pimazide); 2nd line is Clonidine
Tourette’s w/ADHD 1st line is Clonidine
What area of the brain is implicated in Tourette’s?
Basal Ganglia
What is the tx of a normal Tic disorder and how does it differentiate from Tourette’s?
Tic disorder is 1+ tic.
Tourette’s requires 2+ motor tics and 1+ vocal
Tx of regular tic disorder is Clonidine or Guanfacine
Both a/w OCD
What are elderly patients at increased risk for when taking Benzos?
Adverse effects – confusion and falls
Paradoxical agitation – recurrent episodes of confusion and agitation, aggression and disinhibition typically w/in 1hr of taking a benzo.
Patients who experience this should have their benzos tapered and discontinued
What is REM sleep behavior disorder often a prodromal sign of?
Neurodegeneration in pts. w/PD or LBD
What are some serum disturbances seen in Anorexia?
Electrolyte depletion (K+, Mg2+, Na+ and PO4)
Hypercholesterolemia
Hypercarotenemia (causes yellow skin, esp. on palms)
Hypercortisolism
Low T3 and or T4 – TSH is typically norm (Euthyroid sick syndrome)
What are CVS cxs of Anorexia?
Myocardial atrophy, bradycardia, HoTN, arrhythmias
What are GI cxs of Anorexia?
Gastroparesis and Constipation
What electrolyte disturbances are common in Bulimia?
Metabolic alkalosis w/hypokalemia
Hypochloremia
Increased amylase (from salivary glands)
What is the typical onset and features of alcoholic hallucinosis?
Onset: 12-48hrs
Visual, auditory, or tactile hallucinations w/intact orientation and stable VS
What are common sxs of antidepressant discontinuation syndrome?
Sudden onset dysphoria Fatigue Insomnia Myalgias Dizziness Flu-like sxs/GI disturbance Tremor Neurosensory disturbances – electric shock/rushing sensations in the head, paresthesias, hyper-responsivity to light and noise, vivid dreams
Sxs typically start 2-4d after sudden discontinuation of meds
What CNS changes may be seen in depressed patients?
Decreased hippocampal and frontal lobe volumes
Changes in sleep architecture – decreased REM sleep latency and slow wave sleep.
What lab abnormalities might be seen in patients with MDD?
Decreased 5-HIAA in the CSF
Hypercortisolemia
What are the criteria to dx a hypomanic episode?
4+ days of elevated/irritable mood, increased energy and 3+ of the following:
Grandiosity, decreased need for sleep, talkativeness, racing thoughts, distractibility, hyperactivity, and risky behavior
How might MDMA intoxication present?
As amphetamine toxcitiy – HTN, tachy, and hyperthermia
or
Serotonin toxicity – serotonin syndrome, and hyponatremia (d/t rx-induced SIADH and xs water intake to reduce hyperthermia)
What are possibilities to give a positive reading for amphetamines on Utox?
Amphetamines
Illicit synthetic amphetamines – MDMA, bath salts
What might give a false positive for TCAs on UTox?
2nd gen antipsychs – esp. Quetiapine
How is Bipolar II diagnosed?
Hypomanic episodes and 1+ depressive episodes.
Depressive episodes not required to dx BP-I, but required for BP-II
These pts, as well as BP-I pts., have a clear and abrupt change in behavior compared to their baseline.
What is Dhat Syndrome?
Culture-bound syndrome in S. Asian cultures.
Pts believe they are losing semen through urine or xs masturbation which causes somatic sxs (wt. loss, fatigue, weakness, anxiety, etc.)
What are the criteria to dx a Manic episode?
Severe sxs lasting 1+ week (or less if requiring hospitalization before 1wk)
Marked impairment in social or occupational fxn-ing, or hospitalization
May have psychotic feats – makes episode manic by definition
Criteria to dx Cyclothymic disorder:
2+ years of fluctuating, mild hypomanic and depressive sxs that don’t meet criteria for hypomanic of MDE
Only 1yr of sxs required in children
Mnemonic to remember features of manic episode:
DIG FAST Distractibility Impulsivity/indiscretion, risky behavior Grandiosity Flight of ideas/racing thoughts Activity increased/psychomotor agitation Sleep decreased Talkativeness/pressured speech
What is Koro syndrome?
Fear of shrinking penis.
Seen predominately in Japanese
How are the pupils in heroin and cocaine use disorders?
Dilated (mydriasis) in cocaine
Constricted (miosis) in heroin.
These will become the opposite during their withdrawal phases
What is normal pupil size?
2-4mm in bright light
4-8mm in the dark
Features of cannabis intoxication:
Increased appetite Euphoria Dysphoria/panic Slow reflexes, impaired time perception Dry mouth Conjunctival injection **no changes in pupil size**
Commonly abused inhalants:
Glue Toluene (a/w paint thinners) Nitrous oxide – whip its Amyl nitrite – poppers Spray paints
What signs and sxs may be a/w inhalant abuse?
LFTs may be elevated
Chronic NO abuse can cause B12 def. – polyneuropathy
Dermatitis/glue sniffer’s rash
Cause transient euphoria and then LoC
Who is most at risk for inhalant abuse?
Boys age 14-17
What antidepressant is a/w dose-dependent HTN?
SNRI – Venlafaxine
What antidepressants are a/w HoTN at therapeutic levels?
MAOIs
What could initially present as insomnia w/microcytic anemia?
Restless leg syndrome
How is Social anxiety performance subtype tx’d if pt has asthma?
Lorazepam
Can’t give BBs to COPD or asthmatics
Features of Alcohol ketoacidosis:
Slurred speech, ataxia, AMS
Labs: High osmolar gap, increased anion gap metabolic acidosis/ketosis
Features of Methanol ingestion:
Visual blurring, central scotomata, afferent pupillary defect, AMS
Labs: High osmolar gap, increased anion gap metabolic acidosis
Features of Ethylene glycol ingestion:
Flank pain, hematuria/oliguria, CN palsies and tetany
Labs: high osmolar gap, increased anion gap metabolic acidosis, Ca-Oxalate crystals in the urine, hypocalcemia in serum
Features of Isopropyl alcohol ingestion:
CNS depression, disconjugate gaze, absent ciliary reflex
Labs: High osmolar gap, No increased anion gap or metabolic acidosis
Which of the toxic alcohols will not cause an anion gap or metabolic acidosis?
Isopropyl alcohol ingestion
What parts of the brain are affected by LBD?
Can have Lewy bodies in/damaging neurons of the substantia nigra, locus coeruleus, dorsal raphe nucleus, and substantia innominate.
What protein accumulations are seen in LBD?
Accumulations of alpha-synuclein protein.
Tx of premature ejaculation:
SSRI
One way to differentiate NMS from Serotonin syndrome:
Only NMS will have increased CK and WBCs
1st step in evaluation of a patient w/lightheadedness and suspected dehydration?
Orthostatic VS
When is encopresis considered abnormal?
> 4 years old
What does Varenicline have a black box warning against?
Increased risk of serious neuropsychiatric events, including:
Depression
Suicidal Ideation
Suicide attempt/completed suicide
Buproprion also has a black box warning against this, but Varenicline is a/w a greater risk of these events
What disorders are considered NREM sleep arousal disorders?
Sleepwalking and Sleep terrors.
Both occur during the 1st 1/3 of the night
How long must psychotic sxs be present w/o a mood disturbance to dx SZA?
2 weeks
Most common cause of acquired ataxia:
Alcoholic cerebellar degeneration
1st line therapy for hepatic encephalopathy:
Lactulose
Major defense mechanism of Paranoid PD:
Projection
