Psych Flashcards
SSRI
Inhibits serotonin reuptake
Fluoxetine (Prozac) Sertraline ( Zoloft) Paroxitine (Paxil) Citalopram (Celexa) Escitalopram Vilazadone Vorioxtine Fluovoxamine
Weight gain
Abdominal upset
Sexual side effects
SIGECAPS
Sleep Interest Guilt Energy Concentration Appetite Psychomotor Suicidal thoughts
Depression criteria
5/9 x2 weeks consistently
Transmitters involved in depression
Serotonin
NE
Dopamine
Eating disorder, anorexia tx
CBT, family therapy
Supervised weight gain programs
Fluoxetine (not effective)
(SSRI)
First choice for anxiety in pregnancy
Sertraline
SSRI
SNRI
- types
- MOA
- Caution with
- SE (3)
Venlafaxine
Duloxetine
Desvenlafexine
Inhibit NE, Serotonin, dopamine reuptake
Caution in HTN and heart issues increase NE
Weight gain
Sexual side effects
GI upset
Buproprion
- type
- MAO
- SE
- Helps with
- CI
NDRI
NE and dopamine reuptake inhibitor
No weight gain or sexual side effects
Smoking cessation
CI: eating disorder and seizure disorder
TCA
- examples
- MAO
- Lethal
- SE (5)
Nortriptyine Amitriptyline Dozepin Imipramine Clomipramine Desipramine
Inhibit NE and serotonin
Lethal in overdose due to arrhythmia
Weight gain, drowsiness, hypotension, anticholinergic (red as a beet, dry as a bone, mad as a hatter)
ORTHOSTATIC HYPOTENSION
Atypical antidepressant
mirtazapine (Remeron)
- alpha 2 antagonist
- Increase NE and 5HT
- antagonizing 5HT2/3 serotonin receptors
- Sedation, WEIGHT GAIN, dry mouth
Trazondone
- priaprism side effect
- sleep inducing, anti anxiety
2nd gen antipsychotic
Abilify
partial agonist/ antagonist at dopamine receptor
DIGFAST
Distractibility irresponsibility: maxing out cards Grandiosity Flight of ideas Agitation Sleepless Thoughtless
Bipolar tx
Depakote (irritable mania)
- bad in prego
Lithium (euphoric mania)
- mood stabilizer
- bad in prego
- reduces suicide risk
Carbamazepine and valproic acid (mood stabilizer)
Lamotrigine (mood stabilizer)
Lamictal: maintenance
2nd gen antipsychotic (mania)
- Latuda (bipolar depression)
- risperidone
- aripiprazole
- olanzapine
Quetiapine [Seroquel] (bipolar depression)
Olanzapine/ Fluoxetine [Symbyax] (SSRI)
Lithium SE
Ebstein abnormality (1st trimester) - Tricuspid leaflet displaced inferiorly - RV hypoplasia - Tricuspid regurgitation or stenosis - +/- patent foramen ovale Sedation and dizziness Tremors Hypothyroid Kidney issues Acne vulgaris DM insipidus Sick sinus syndrome Heart block
High QTC
470 or 480
Dont give antipsychotic
First generation antipsychotics
First gen
- Halodol
- Fluphenazine
- Perpherazine (mid potency)
- Chlorpromazine (low) - HAM, cornea deposit
- Thioridazine (low) - HAM, retina deposit
High potency
- EPS
Low potency
- HAM
Sedation, anticholinergic, metabolic, hot dry, hypotension
Second Generation antipsychotics
Risperdal (IM) (risperidone) Invega (paliperadone) (IM) Seroquel (quetiapine) Zyprexa (olanzapine) Abilify (aripiprazole) Geodon (ziprasidone) Latuda (lurasidone) Sappharis (asenapine) Fanept (Iloperidone) Rexalti (brexpiprazole) Clozaril (clozapine)
Seroquel (quetiapine)
Low dose binds H1
300-600 bipolar
600-1200 schizophrenia
Increases QTC
QTC below 450 before prescribe
Olanzapine (zyprexa)
2nd most effect antipsycotic after clozaril
Alot of weight gain
Antipsychotic give if over weight
Abilify (aripiprazole)
Least metablic side effect of antipsychotic
Geodon ( ziprasidone)
prolongs QTC alot
Best antipsychotic for negative symptoms
Suicidality in schizophrenia
Clozapine
agranulocytosis, seizures, myocarditis, elderly standard warning, orthostatic hypotension
Excissive salivation most common
Antipsychotics with least side effect
Ability (aripiprazole)
Latuda (Lurasidone)
Geodon (ziprasidone)
Cluster A
Paranoid
- irrational suspicions and mistrust
Schizoid
- lack of interest in social relationships
Schizotypal
- odd behavior or thinking
CLuster B
Antisocial
- pervasive disregard for the law and rights of others
Borderline
- instability in relationships, self image, identify or behavior
- cut them selves
Histrionic
- pervasive attention-seeking behavior, shallow or exaggerated emotions
- bright colors, flirtatious
Narcissistic
- pervasive pattern of gradiosity
- need for admiration and lack of empathy
Cluster C
Avoidant
- social inhibition; feelings of inadequacy
Dependent
- pervasive psychological dependence on others
OCD
- rigid conformity to rules and moral codes
Indicated for depressive phase of bipolar
Quetiapine
Olanzapine/ fluoxetine
Cariprazine
Lurasidone
Drug recommend for all phase of bipolar
Quetiapine
Timeline schizophrenia
> 6 months
Timeline delusional disorder
> 1 month
Timeline for brief psychotic disorder
< 1 month
TImeline for schizophreniform disorder
1-6 months
Bugs crawling on you
Tactile hallucinations
ALcohol withdrawal or cocaine intoxication
Hallucinations when going to sleep or waking up
Narcolepsy
Schizophrenic brain (3)
Smaller
Enlarged ventricles
Thin cortex
Physiology of schizophrenia
Increased DA in mesolimbic
Decreased DA in mesocortical
Schizophrenia criteria
Psychosis
- disorganized thought
- disorganized speech
- delusions (false beliefs, tv talking to you)
- halluciinations
- illusions (misinterpret something that is actually there, coat rack is person)
Decline in functioning
> 6 months
Schizoaffective disorder
Psychotic symptoms for >2 weeks in absence of mood disorder
Mood disorder later
Neuroleptic malignant syndrome
- 5 features
- due to what NT
- due to what medication
** Not this is patient has normal vital signs**
Mental status changes (not psychosis)
- delirium
Muscle rigidity +/- tremor (lead pipe rigidity)
Hyperthermia
Rhabdomyolysis
Autonomic instability
- tachycardia, high blood pressure, tachypnea, diaphoresis
Due to dopamine
Due to antipsychotics (olanzpine)
Tx neuroleptic malignant syndrome
Dantrolene
Dopaminergic
- Bromocriptine
- Amantadine
Which antipsychotic is most closely associated iwth an increased risk of diabetes
Olanzapine
Side effect seen with increasing lithium
Tremor
Bipolar I
Manic episodes +/- major depression
Bipolar II
Hypomania episode
Episode of major depression
Tx postpartum psychosis
atypical antipsychotic
Persistent depressive disorder
> 2 years in adults
1 year in children
No more than 2 months w/o symptoms in 2 years
Stages of grief
DABGA
Denial Anger Bargaining Grieving (depression) Acceptance
Tx OCD
CBT
Antidepressant
- SSRI
(Fluoxetine, sertraline, paroxetine, citalopram)
- SNRI
( venlafaxine, desvenlafaxine, duloxetine)
Clomipramine (TCA) (not first line)
TX Anxiety
Antidepressant
Tx PTSD
Antidepressant
SNRI for fibromyalgia
Milnacipran
Chronic pain tx
Duloxetine
SNRI
Tx generalized anxiety disorder
First line - CBT - SSRI - SNRI (venlafaxine) (desvenlafaxine) (duloxetine
(Increase BP)
Enuresis Tx
Imipramine (TCA)
OCD tx
CBT
SSRI
Clomipramine (TCA)
Fibromyalgia tx
MIlnacipran (SNRI)
Amitriptyline (TCA)
Tx neuropathic pain
Amitriptyline
SE TCA
Sedation Hypotension Dizziness Anticholinergic High dose --> QT prolongation
TCA overdose signs
Tx
Cardiotoxicity
- Tachycardia, hypotension, conduction abnormalities, arrthymias
CNS toxicity
- sedated, coma, seizures
Anticholinergic
- dry mouth, ileus, urinary retention, mydraiasis, blurred vision, hyperpyrexia
Tx: Sodium bicarbonate
SSRI, TCA, MAOI, NDRI, SNRI, Serotonin modulators
Amitriptyline Bupropion Citalopram Clomipramine Doxepin Duloxetine Fluoxetine Imipramine Nefazodone Nortriptyline Paroxetine Phenelzine, Sertraline Tranylcypromine Trazodone Venlafaxine
Amitriptyline- TCA Bupropion- NDRI Citalopram- SSRI Clomipramine- TCA Doxepin- TCA Duloxetine- SNRI Fluoxetine- SSRI Imipramine- TCA Nefazodone- Serotonin modulators Nortriptyline- TCA Paroxetine- SSRI Phenelzine- MAOI Sertraline- SSRI Tranylcypromine- MAOI Trazodone- Serotonin modulators Venlafaxine- SNRI
Antidepressant the causes appetite stimulant and weight gain
Mirtrazapine
Serotonin syndrome signs
Hyperreflexia and clonus
Hyperthermia
Autonomic instability
- Cardiovascular collapse, mental status changes
Priapism
pain persistent penile erection
Trazodone, nefazodone
serotonin modulators
Patient has calustrophobia drug to give
Benzodiazepine
Antidepressant to not use in over weight
Mirtazapine
Women with daily anxiety tx
Panic attack tx
Daily= generalized anxiety disorder
give SSRI
Panic attack= benzo
Conversion disorder
tx
Unexplained loss of sensory or motor function
(Tests and PE are negative)
Paralysis
Blindness
Mutism
(Following acute stressor)
tx education about illness
Panic disorder tx
CBT
SSRI
TCA (amitryptilline
Benzo (acute only)
Specific phobia tx
Systemic desensitization
Social anxiety disorder
SSRI Beta blocker (propranolol)
BEnzodiazepines (lorazepam)
PTSD vs acute stress disorder
Tx
PTSD > 1 month
ASD < 1 month
Psychotherapy
SSRI
Adjustment disorder
Tx
Identifable psychosocial stressor
< 6 months after stressor is gone
With in 3 months of identifiable stressor but lasting no longer than 6 months once stressor ceases
5/9 SIGECAPS
TX: psychotherapy
Tx generalized anxiety disorder
> 6 months
FIrst line:
SSRI
SNRI
Second line
Benzo
Buspirone (not many side effects)
Somatic symptom disorder
tx
Complaints in > or = 1 organ system
excessive anxiety and worry
> or = 6 months
regularly scheduled visits with a single primary care physician, who should minimize unnecessary medical workups and tx
Bulimina nervosa labs
Hypokalemic
Hypochloremic
Metabolic alkalosis
Non-anion gap metabolic alkalosis w/ respiratory compensation
Metabolic acidosis (laxative abuse)
Elevated bicarbonate
Incrased BUn
Hypernatremia
Increased amylase
Tx Bulimina nervosa
SSRI (fluoxetine)
ADHD medications
1st line
- Mehtylphenidate
- Dexmethylphenidate
- Mix amphetamines
- Dextroamphetamine
2nd line
- atomoxetine (NE reuptake inhibitor)
- clonidine
- guanfacine
Hair pulling disorder
Trichotillomania
Education –> CBT –> Fluoxetine (SSRI) or Clomipramine (TCA)
Antisocial vs conduct disorder
Conduct < 18
Oppositional defiant disorder
Pattern of disobeying authority and hostile behavior
No serious violations of social norms
No disregard for rights of others
No destruction of property or cruelty to animals
Fixation
partially remaining at childish level of development
Reaction formation
Taking unacceptable thoughts and attempting to over exaggerate in opposite action
Projection
Taking unacceptable thoughts and believing that someone else has those thoughts
Displacement
Substitutes new aim/ object for something that is undesirable
man yells at family for bad day at work
Sublimation
unacceptable impulses or feelings transformed into socially acceptable actions
Suppression
Voluntarily choosing to not think about something
Medications for alcoholic
Naltrexone
Disulfiram (inhibit acetyaldehyde dehyrdogenase –> increase acetylaldehyde)
Topiramate
A camprosate
Reversal agent for benzo
Flumazenil
- blockade of GABAergic neurotransmission
Can cause seizure
Reversal agent for opioids
Naloxone
Naltrexone
Opioid withdrawal symptoms
Sweating Dilated pupils piloerection yawning Rhinorrhea Flu like
Tx:
Moderate: Clonidine (autonomic signs)
Severe: Methadone, suboxone
Amphetamine and cocaine overdose tx
Benzodiazepine (agitation)
Haloperiodol ( paranoid idealations)
Tx LSD overdose
Tx LSD reverse effects of drug
Overdose: Benzo
Reverse effects: Ziprasidone
Severe depression, HA, fatigue, insomnia/ hypersomnia, hunger
Cocaine and amphetamine withdrawal
Pinpoint pupils
N/V
Seizures
Opioid overdose
Belligerence, impulsivness, nystagmus, homicidal ideation, psychosis
PCP intoxication
HA
Anxiety depression
Nicotine or caffeine withdrawal
Anxiety, depression, delusion, hallucinations, flashblacks
LSD intoxication
Euphoria, social withdrawal, impaired judgement, hallucinations
Marjuana intoxication
Rebound anxiety, tremors, seizures, life thratening
WD from alcohol, benzo, or barb
Anxiety, piloerection, yawning, fever, rhinorhea, nausea, diarrhea
opioid withdrawal
Identification
Acting like the person you have positive thoughts towards (changing where you wear sthetoscope
Intellectualization
using logic or fact to emotionally distance onself from stressful situation
Schizophrenia tx first line
- drug
- SE of drug (2)
Risperidone
Hyperprolactinemia
Can get EPS
Tardive dyskinesia, orofacial chorea
Postpartum depression tx
CBT
SSRI
Grief lasts
< 6 months –> depression
ECT used in
Treatment refractory depression Depression with psychotic symptoms Acutely suicidality Catatonic Not eating or drinking
Agoraphobia tx
CBT
SSRI
Body dysmorphic disorder tx
CBT
Acute stress disorder tx
3 days to 1 month
Tx: CBT
Transsexualism
Desire to live as opposite sex
Through surgery or hormones
Transvestism
Paraphilia, not genderr dysphoria Wearing clothing (vest) of the opposite sex (cross dressing)
Sleep terrors
Self limited
Narcolepsy tx
Daytime stimulants
- Amphetamines
- MOdafinil
Nighttime sodium oxybate (GHB)
Tx cataplexy: sodium oxybate
Narcolepsy criteria
Recurrent lapses into sleep or naps (>= 3 times/ week for 3 months)
> = 1 of the following:
- Cataplexy : brief loss of muscle tone precipitated by strong emotions
- low CSF levels of hypocretin-1
- shortened REM sleep latency
Associated features
- Hypnagogic or hypnopompic hallucinations
- sleep paralysis
Stages of addictions (6)
- Precontemplation
- Contemplation
- Preparation
- Action
- Maintenance
- Relapse
Delirium tremens signs
Tx
2-4 days after last drink
Tachycardia Tremors Anxiety Seizurs Electrolyte disturbances Respiratory alkalosis
Tx: Benzo (chlordiazepoxide, lorazepam, diazepam)
Tourette syndrome tx
First line: aripiprazole
Antipsychotics (haloperidol, fluphenazine, pimozide)
Tetraenazine
alpha 2 agonist (guanfacine, clonidine)
Atypical antipsychotics
EPS
- hours to days
- days to months
- months to years
- tx
ADAPT
Hours to days: Acute Dystonia
(Muscle spasm, stiffness, oculogyric grisis) (prolonged involuntary gaze upward)
- Benztropine
- Diphenhydramine
Days to months: Akathiasia, Parkinsonism (restlessness, bradykinesia) - Beta blockers - Benzodiazepine (lorazepam) - Benztropine --- -Benztropine - Amantadine
Months to years: Tardive dyskinesia
(orofacial chorea)
- Valbenazine
- Deutetrabenazine
Typical antipsychotics
-azine
High potency: Try to Fly High
Trifluoperazine, Fluphenazine, Haloperiodol,
- EPS
Low potency: Cheating Thieves are low
Chlorpromazine, Thioridazine
- anticholinergic
hyperprolactinemia (amenorreha, galactorreha, gynecomastia)
Weight gain, dyslipidemia, hyperglycemia
Atypical antipsychotics
-apine, -peridone, -idone
Aripiprazole, asenapine, clozapine, olanzapine, quetiapine, iloperidone, paliperidone, risperidone, lurasidone, ziprasidone
Prolong QT Fewer EPS and anticholinergic "pines"- metabolic syndrome (weight gain, diabetes, hyperlipidemia) Clozapine: agranulocytosis Ripseridone: hyperprolactinemia (amenorreha, galactorreha, gynecomastia)
Olanzapine= obesity
LiTHIUM
Low Thyroid (hypothyroid)
Heart (Epstein anomaly)
Insipidus (nephrogenic diabetes insipidus)
Unwanted Movements (tremor)
SSRI (6)
- xetine, -alopram
Fluoxetine Fluvoxamine Paroxetine Sertraline Escitalopram Citalopram
Depression, anxiety, panic, OCD, bulimia, PTSD, premature ejacuation, premenstrual dysphoric disorder
GI distress, SIADH, sexual dysfunction
SNRI (5)
Venlafaxine Desvenlafaxine Duloxetine Levomilnacipran Milnacipran
Diabetic neuropathy, depression, anxiety,
Venlafaxine (social anxiety, panic, PTSD, OCD)
Duloxetine (fibromyalgia)
SE: Increase BP
TCA (7)
Amitriptyline Nortriptyline Imipramine Desipramine Clomipramine Doxepin Amoxapine
Depression, OCD (clom), peripheral neuropathy, chronic pain, migrane prophylaxis, Noctural enuresis (imipramine)
SE: sedation, hypotension, anticholinertic like, prolong QT
MAOI
MAO Takes Pride In Shanghai Tranylcypromine Phenelzine, Isocarboxazid Selegiline
Atypical depression
Anxeity
Parkinson (selegiline)
Clonazepam
Benzo
Tx anxiety and panic attacks
Avoid w/ renal dysfunction
Gender dysphoria
> 6 months doesnt feel like gender from birth
Flushed, hyperreflexive, diaphoratic, occasional myoclonus, disorientated, seizure
Took pill
Ecstasy
Major Depressive disorder TX
SSRI
If SSRI doesnt work
SNRI or NDRI (Buproprion)
Last resort: TCA
Patient on risperidone, increased dose now smiles less and slowed down. Mild tremor and doesnt swing arms when walking
TX
Continue Risperidone and add benztropine
anti-psychotic induced parkinsonism
Tx anticholinergic antiparkinism benztropine or amantadine
Sudden sustained contraction of neck, mouth, tongue and eye muscles
Tx
Acute dystonia
Benztropine
Diphenhydramine
Subjective restlessness, inability to sit still
Tx
Akathisia
Beta blocker (propranolol)
Benzodiazepine (lorazepam)
Benztropine
Gradual onset tremor, rigidity and bradykinesia
Tx
Parkinsonism
Benztropine
Amantadine
Gradual onset after prolonged therapy (> 6 months). Dyskinesia of the mouth, face, trunk and extremities
Tardive dyskinesia
Discontinue medication
Switch to quetiapine or clozapine
Treat with Valbenazine
Deutetrabenazine
Caused by dopamine receptor D2 upregulation and supersensitivity
Zolpidem
non-benzodiazepine sleep medication
selective receptor binding to the omega 1 receptor on the GABA-A receptor
Disruptive mood dysregulation disorder
Disproportionate verbal or physical outbursts
Onset before age 10
Persistent irritability or anger inbetween episoes
MDD physiology
Increased serum cortisol concentration
Hyperactivity of the hypothalamic pituitary adrenal axis results in rising cortisol levels
Hyperactivity of the HPA axis leads to blunted response tot he dexamethasone-suppression test
Also adrenal gland hypertrophy
A blunted response to infusion of thyrotropin release hormone
Elevated levels of thyrotropin releasing hormone in CSF
Sense of well-being and increased relaxation when thyrotropin releasing hormone is administed
Blunted response to serotonin stimulation of prolactin release
Blunted response to sleep induced stimulation of growth hormone release
Decreased amounts of somatostatin in the CSF
Patient with history of bipolar, leaves arm raised and wont talk
Catatonia
Benzodiazepines (lorazepam)
ECT
Complex motor behaviors that occur during REM sleep
Rapid eye movement behavior disorder (RBD)
Degeneration of the brainstem nuclei responsible for inhibiting spinal motor neurons during normal REM sleep
Insight orientated psychotherapy
focuses on uncovering unconscious patterns originating in childhood experiences
What is helpful in schizophrenia patients besides medication
Family intervention
CBT
Tx Lithium toxicity
Hemodialysis
Benzo overdose tx
Flumazenil
CBT treats
Depression Anxiety PTSD Panic OCD Eating disorder Negatie thoughts pattern
Interpersonal psychotherapy treats
Depression
Links symptoms to current relationship confilcts and interpersonal skill deficits
Highter functioning
Personality disorders use what treatment
Psychodynamic psychotherapy
Motivational interviewing for what
Substance use disorders
Use what for borderline personality disorders
Dialectical behavioral therapy
What what treatment modality for pain disorders
Biofeedback
Psychological features Depression Fatigue Hypersomnia Increased dreaming Hyperphagia Impaired concentration
Cocaine withdrawal
Anxiety Insomnia Tremors Tachycardia HTN
Alcohol withdrawal
Dysphoria
Myalgia
Yawning
Abdominal cramping
Opioid withdrawl
Dieting Hallucinations Abominal pain Constipation Tingling sensation in finger tips
Acute intermittent porphyria
Elevated urinary porphobilinogen levels
Painful abdomen Port wine colored urine Polyneuropathy Psylogical disturbances Precipitated by Drugs, alcohol and starvation
Alcohol withdrawal symptoms (5)
Anxiety Insomnia Tremors Tachycardia HTN
Opioid withdrawal symptoms (4)
Dysphoria (dissatifcation with life)
Myalgia (muscle pain)
Yawning
Abdominal cramping
Bipolar
Fatigue
Constipation
Myalgias
What medication
Lithium
Lithium induced hypothyroidism
TCA side effect
Constipation
Drowsiness
other anticholinergic
Social anxiety disorder main tx
Beta blockers (propranolol)
Before benzo
Gourmet meal with wine and heavy sauces
Headache
Phenelzine (MAOI)
HTN crisis
Dont eat foods with tyramine
Patient with retrograde and antegrade amnesia with intact long-term memory, alcohol use history
Korsakoff syndrome
Thiamine deficiency
Associated iwth MS
Depression
Hoarder treatment
CBT
Maybe SSRI
Intense anxiety that the penis will reced into the body, possibly leading to death
Koro
Southeast Asia (Singapore)
Sudden unprovoked outbursts of violence, often followed by suicide
Amok
Malaysia
Headache, fatigue, eye pain, cognitive difficulties and other somatic disturbances in male students
Brain fag
Africa
Mood disorders with mixed features
Irritability is predominant mood state
Poor response to lithium
Anticonvulsants such as valproic acid may be more helpful
Substance/ medication- induced depressive disorder (11)
EtOH Antihypertensives Barbiturates Corticosteroids Levodopa Sedative-hypnotic Anticonvulsants Antipsychotics Diuretics Sulfonamides Withdrawal from stimulants (cocaine, amphetamines)
Substance/ medications- induced bipolar disorder (8)
Antidepressants Sympathomimetics Dopamine Corticosteroids Levodopa Bronchodilators Cocaine Amphetamines
Tx MDD with atypical features
SSRI first line
MAOIs (phenelzine)
Anhedonia
inability to experience pleasure
Physiology in depressed patient
Decrease in CSF levels of 5-hydroxyindolacetic acid (5-HIAA) the main metabolite of serotonin
High cortisol due to hyperactivity of HPA axis
Abnormal thyroid axis
MAOI Side effect
Hypertensive crisis w/ tyramine rich foods
Serotonin syndrome when mixed with SSRI
Orthostatic hypotension
Triad for seasonal affective disorder
Irritability
Carbohydrate craving
Hypersomnia
MDD atypical features (5)
Hypersomnia Hyperphagia Reactive mood Leaded paralysis Hypersensitivity to Interpersonal rejection
Bereavement
Simple grief
Reaction to major loss
Self limiting
Last several months
Pregnant patient with manic episode tx
ECT
Patient with history of postpartum mania tx
Mood stabilizers prophylaxis
Lamotrigine
Persistent depressive disorder
Dysthymia
Two of more of: CHASES Poor Concentration or difficulty making decisions Feelings of Hopelessness Poor Appetite or overeating InSomnia or hypersomnia Low Energy or fatigue Low Self-esteem
2 years of depression
Premenstrual dysphoric disorder tx
SSRI first line daily or lutela phase tx
Delirium tremens use what
Lorazepam
Dont use Diazepam or chlordiazpoxide in patient with possible liver damage
Fetal alcohol vs downs syndrome
Fetal alcohol
- heart murmer
- low IQ
- Low height and weight
- thin upper lip
- short palpebral fissures
- smooth philtrum
- Emotional reactivity
Downs syndrome
- epicanthal folds
- upslanting palpebral fissures
- flat nasal bridge
- protruding tongue
- intellectual disability
Seizure with eyes closed, absence of self-injury, incontinence or confusion
Psychogenic nonepileptic seizure
- conversion disorder
Tx videoelectroencephalogram monitoring
Generalized tonic clonic seizures characterized by
Abrupt loss of consciousness followed by stiffening of muscles throughout the body
Rhythmic jerking of extremities
Eyes are open
Postictal confusion upon awakening
Insomnia causing significant functional impairment
Tx
Short term pharmacotherapy
Lorazepam
Anorexia criteria for hospitalization
Pulse < 40/min
BP < 80/60
hypokalemia
hypophosphatemia
Hospitalized 12 hrs afterwards psychosis and paranoid
Alcoholic hallucinosis
Depression Anxiety recent onset diabetes Decreased appetite Smoker
Pancreatic cancer
CT of abdomen
Normal aging
Word-finding aphasia
Sleep disturbance
Forgetting to take medication
ADHA treatment thats non-addictive
Atomoxetine
Clonidine and guanfacine tx ADHD in children but not adults
Manic episode treatment
Lithium
If level of creatinine high then valproate (renal failure)
Low blood pressure
2 mm pupils
constricted pupils (miosis)
Opioid intoxication
Naloxone
Naltrexone
Maintenance treatment for opioid use disorder
-blockade of opioid receptors in the endorphin system
Slower onset
Not for acute opioid intoxication
Bipolar tx with rash
Lamotrigine
mood stabilizer
Normal pupil size
2-4 mm
Specific phobia tx
CBT exposure therapy
(first line)
Benzo
Ziprasidone
Geodon
No side effects
MDD Sleep traits
Decreased REM sleep latency (the time from sleep onset until the start of the first REM sleep period
Decreased slow wave sleep
Increased total REM sleep duration
Hyperprolactinemia
Risperidone
Clozapine causes
agranulocytosis
Check for neutropenia
Risperidone MOA
Serotonin 2A and dopamine D2 receptor blockade
All second gen antipsychotics
Dopamine reuptake inhibition and stimulation of dopamine release
Stimulants for ADHD
Norepinephrine and dopamine reuptake inhibition
Antidepressant bupropion
Serotonin and norepinephrine reuptake inhibition
Venlafaxine
SNRI and TCA
Neuroleptic malignant syndrome
FEver > 40 (104)
Confusion
Muscle rigidity (generalized)
Autonomic instability (sweating, abnormal vital signs)
Elevated creatine kinase
Tx Dantrolene, bromocriptine
Physiology associated with suicidal behavior
Low levels of 5-hydroxyindoleacetic acid (5-HIAA) in CSF
Metabolite of serotonin
Hydrocephalus ex vacuo on CT
Neurodegenerative conditions (Alzheimer disease) leads to cortical atrophy
How long to take antidepressant
additional 6 months in patients with single episode of depression
Maintain at level of remission
Then taper
If patient at high risk for recurrence (>2 episodes) then maintenance for 3 years
Medication that causes seizures after abruptly stopping
Benzo
Alprazolam
Hepatotoxicity medication
Valproate (mood stabilizer)
False positive for Phencyclidine
Dextromethorphan (cough suppressant) Diphenhydramine Ketamine Tramadol Venlafaxine
False positive for Amphetamine
Atenolol
Propranolol
Bupropion
Nasal decongestants
Excessive anxiety and preoccupation with >1 unexplained symptoms
Somatic symptom disorder
Postpartum psychosis tx
Hospitalization
Anti-psychotic (2nd gen)
Delusional disorder
Does not include mood symptoms or they are brief
Avoidant personality disorder
Avoidance due to fear of criticism and rejection
Patient see repeat images of stabbing her mother
Count downs to eliminate images
OCD
Tx: SSRI
Patient with repeat abdominal pain. Negative abdodminal CT
Somatic symptom disorder
Tx: Regular scheduled visits with same provider
Alzheimer characteristics
Early short term memory loss
Language deficits
Later personality changes
Vascular dementia characteristics
Stepwise decline
Early executive dysfunction
Cerebral infarct/ deep white matter changes on neuroimaging
Frontotemporal dementia characteristics
Early personality changes
Apathy, disinhibition and compulsive behavior
Frontotemporal atrophy on imaging
Dementia with Lewy bodies characteristics
Visual hallucinations
Spontaneous parkinsonism
Fluctuating cognition
Normal pressure hydrocephalus characteristics
Ataxia early in disease
Urinary incontinence
Dilated ventricles on neuroimaging
Prior disease characteristics
Behavioral changes
Rapid progression
Myoclonus and or seizures
Patients of traumatic events are at risk for
Suicide
How to reduce long term misuse of opioids in patient
Query the prescription drug- monitoring database at each visit
Random drug urine screen
Follow up visit every 3 MONTHS
Diabetic neuropathy SSRI
Duloxetine
Neuropathic pain SSRI
Bupropion
Bipolar plus hypercalcemia medication
Lithium
Antipsychotic medication effects
- Antipsychotic efficacy the pathway effected
Decreased Dopamine in mesolimbic
Antipsychotic medication effects
- EPS pathways
Decrease in Dopamine in nigrostriatal
Antipsychotic medication effects
- Hyperprolactinemia pathway
Decrease Dopamine in tuberoinfundibular
Increased dopamine in mesolimbic
Euphoric and psychotic symptoms
Rapidly progessive dementia what is seen with labs/ imaging
Creutzfeldt-Jakob disease
Periodic sharp wave complexes on EEG
Positive 14-3-3 CSF assay
Caudate nucleus/putamen MRI findings
Spongiform changes
Neuronal loss without inflammation
Creutzfeldt Jakob disease characteristics
Tx
Rapidly progressive dementia
> 2/4
- Myoclonus (startle-induced arm jerking)
- Akinetic mutism
- Cerebellar or visual disturbances
- Pyramidal/ extrapyramidal dysfunction (hypokinesia)
Tx: None
Low alpha-synuclein
Parkinson disease
Dementia with Lewy bodies
Tx Absence seizures
Ethosuximide
Asain with facial flushing
Polymorphisms in acetaldehydre dehydrogenase, commonly found in asian populations
Early manifestations of word finding difficulties
Dominant temporal lobe
Frontotemporal dementia (FTD)
2nd generation antipsyhotic iwth QT prolongation
Ziprasidone
Ziprasidone SE
Neutral weight
QT prolongation
Quetiapine SE
Cataracts Orthostatic hypotension (Beware in elderly) Prolongation of QT
Olanzapine SE
Weight gain
Metabolic syndrome
Thiamine deficiency in alcoholics progression
Confusion, ataxia, ophthalmoplegia
–> Amnestic disorder (retrograde and anterograde)
Cant learn new information
Rationialization
Patient excusing or justifying an attitude or event by developing an alternate explanation or shifting the blame
Man speed who crashes into other drive. Other drives fault for not paying attention
Antipsychotic not working now smoking cigarettes
Hydrocarbon-induced induction of antipsychotic drug metabolism
P450 system
Olanzapine
Clozapine
Dissociative fugue
Abrupt travel or wondering associated with traumatic event
Involuntary contraction of small muscles groups like repeated contraction of fingers in one hand
Tardive dyskinesia
Increased thirst in bipolar patient
Primary polydipsia
Increase thirst
Normal serum electrolytes
Dilute urine
Drugs that induce schizophrenia
Marijuana
PCP
Ketamine
Lamotrigine SE
Mood stabilizer for bipolar
Stevens Johnson syndrome (10% of body rash)
Toxic epidermal necrosis (30% of body w/ rash)
(Rash of mucous membranes)
Valproate inhibits metabolism of lamotrigine –> accumulation
Channeling uncomfortable thoughts or emotions into more acceptable behavior
Sublimation
Acting out is always a negative reaction
Celecoxib
NSAID COX2 selective
Doesnt cause GI effects
Not for psychiatric and/or neuropathic pain
Used for inflammatory pain and osteoarthritis
Chronic alcohol use physiology
Enhancement of GABAergic neurotransmission –> downregulation of GABA RECEPTOR activity
Constipation Dry skin Weight gain Sleepiness Decrease appetite Trouble concentrating
Hypothyroidism
Brittle hair*
Addison disease characteristics
Hypotension* Weight loss Fatigue Anhedonia (inability to feel pressure) GI symptoms Hypoglycemia
Cushing syndrome characteristics
Depressed mood
Weight gain
Moon facies
Buffalo hump
Poor prognosis in schizophrenia
Onset before 25 Negative features Family hx of schizophrenia (not mood disorders) Poor social/ family support Male sex Poor functioning before onset
Opioid withdrawal 2 hrs after oral intake of drug
Buprenorphine
- partial opioid agonist
- trigger withdrawal
(Naloxone injection works 20-30 min)
Clonidine
Treat autonomic symptoms of opioid withdrawal
No role in precipitating a withdrawal syndrome
Methadone
Long acting opioid receptor agonist
Opioid maintenance therapy
Traditional opioid agonist
Doesnt cause withdrawal syndrome
Can cause QTC prolongation
- get ECG
Naloxone
Rapid acting opioid antagonist
20-30 min effect
Tx opioid overdose
IV or intranasally
Naltrexone
Competitive Opioid antagonist
Longer half-life than naloxone
Oral and IM
Precipitates withdrawal if used within 7 days of heroin use
Buprenorphine
Partial opioid agonist
Sublingual
Used in a taper dose to prevent withdrawal symptoms in opioid users
If taken after significant opioid dose can precipitate withdrawal by displacing the drug from mu opioid receptors
Can precipitate withdrawal if used too soon after full opioid agonists
Serotonin syndrome caused by
SSRI and MAOIs
St John’s wort
Meperidine
Myoclonus Hyperreflexia Rigidity Termor Seizures Flushing Hyperthermia Dilated pupils Tachycardia HTN
Night blindness
Thiordazine (retina deposit)
More common than cornea deposit in chlorpromaxine
Unconscious and repressed drives and emotions from childhood are brought to consciousness
Psychoanalysis
3x per week
for 5 years
Brief dynamic psychotherapy
High functioning patient with a focal and circumscribed area of conflict
Addressed in 10-20 sessions
High level of motivation
Cognitive therapy
Depression
Panic, OCD, somatoform
Take maladaptive and faulty views of oneself and world are source of affects and behaviors
Identify and modify cognitions
Interpersonal psychotherapy
short term tx for MDD
Depressive symptoms are interpersonal conflicts
Patients problems categorized into four areas: unresolved grief, social role disputes, social role transitions, interpersonal deficits
Focus is on the here and now. Focus on patients current dynamic conflicts rather than on childhood conflict.
Psychodynamic psychotherapy
Avoiding social situations with panic attacks
General social phobia
Avoidant personality disorder dont have panic attacks
Memantine
NMDA antagonist
Slowing down disease progression with dementia
Antagonist at NDMA receptors with pupose of reducing NMDA-medicated neurotoxicity
Donepezil
Cholinesterase inhibitors
Rivastigmine
Galantamine
Reducing destruction of ACh in synaptic cleft
Can lead to bradycardia and hypotension
Tx Dementia
Donepezil
Rivastigmine
Galantamine
(Cholinesterase inhibitors)
Memantine (NMDA antagonists)
Alprazolam
Benzo
Taper of benzo
Chlordiazepoxide
- long acting benzodiazepine to manage withdrawal
Irritability Anxiety Depression Mood lability Impair concentration/ cognition
Hypercalcemia
Hyponatremia is psychiatry
Syndrome of SIADH
SE of carbamazepine and rare SSRI
Bed wetting normal until age
5
Man who like risky behavior becomes stunt man
Sublimation
Labile affect and mood
Interpersonal difficulties
Session focus on life threatening behaviors
Therapy interfering and quality of life interfering behaviors
Weekly group for skills training in emotional regulation, distress tolerance, interpersonal effectivenss and Zen-like mindfulness
1 year commitment
Dialectical behavior therapy (DBT)
Borderline personality disorder
Interpersonal difficulties and excessive emotionality or expansive cognitive styles
Histrionic PD or narcissistic PD
Tx Psychoanalytic psychotherapy
- focus on current conflicts and dynamic patterns
Increased seizure activity w/o epileptic stressor is concern for
Psychogenic non-epileptic seizures (PNES)
Related to emotional stress
Prolactin distinguish between epileptic and psychogenic seizures
(Elevated prolactin level found in genuine seizure)
Haloperiodol
Citalopram
Methadone
Prolonged QT
Antidepressants
- Citalopram
- Escitalopram
- TCA
Antipsychotics
- Haloperiodol (highest when IV)
- Ziprasidone
- Thioridazine
Opiates
- Methadone
Anticholinergic intoxication drugs
TCA
Paroxetine
Sleep aids
Vasodilation Anhidrosis (dry) Hyperthermia (hot) Mydriasis (blind) Delirium
Increased cytochrome P450 mediated metabolism drug
Carbamazepine
Neuroleptic malignant syndrome drugs
Haloperidol
Metoclopramide
Rigidity
Fever
autonomic instability
delirium
Serotonin syndrome drugs
Dextromethorphan Tramadol Meperidine Amphetamines linezolid SSRI
Sleep techniques (10)
Avoid bed unless sleep and sex
Go to bed quickly upon experiencing sleepiness
Only go to bed when sleepy
Cant sleep in 20 min, lead bed and do relaxing activity
Avoid daytime nap
Eat at regular intervals throughout day
NO caffeine after lunch
Exercise
Wind down by reading book
Wake up same time every day
Drug for nightmares w/ SSRI
Prazosin
Nicotine withdrawal symptoms
Constipation
Irritable
Headache
Fatigue
Depression cant use SSRI, SNRI, Bupropion
Trazodone
- insomnia
First line for hypersomnia
Modafinil
Hallucinogens work on what system
Serotonin
Cocaine work on what system
Dopamine receptors
PCP works on what system
NMDA receptors
Glutamate
Amphetamines work on what system
Dopamine receptors
Ketamine works on what system
NMDA receptors
Capgras syndrome
delusional syndrome characterized by belief that a familar person is replaced by imposter
Schizophrenia
belief that the patient is entirely dead or putrefying or that parts of them (Blood, organs ) are missing or dying
Believes nothing exists
Cotard syndrome/ delusion
Shared psychotic disorder/ delusion.
Folie a deux
delusional syndrome characterized by belief that a familar person is replaced by imposter
Capgras syndrome
Belief that several different people/ strangers are actually one person
Usually familiar individual or persecutor who is in disguise or can change his/her appearance
Fregoli syndrome
Cotard syndrome/ delusion
belief that the patient is entirely dead or putrefying or that parts of them (Blood, organs ) are missing or dying
Believes nothing exists
Folie a deux
Shared delusion
Fregoli syndrome
Belief that several different people/ strangers are actually one person
Usually familiar individual or persecutor who is in disguise or can change his/her appearance
Refeeding syndrome
Food intake insulin hypophosphatemia, hypokalemia, hypomagnesemia
cardiac complications, rhabdomyolysis, seizures.
Look for fluid retention and decreased levels
- phosphorus
- magnesium
- calcium
Buspirone
Generalized anxiety disorder
Anxiolytic
Partial agonism of serotonin receptors
Doesnt caused sedation, addiction or tolerance
Doesnt not interact w/ alcohol
ADHD neurotransmitters
Dopamine
Norepinephrine
Tetrabenazine
Huntington disease
Inhibit vesicular monoamine transporter (VMAT)
Decrease dopamine vesicle packaging and release
Riluzole
ALS
Decrease glutamate excitotoxicity
Blockade of postsynaptic dopamine receptors
Antipsychotics
Global impairment of serotonergic neurotransmission
Pathophysiology of MDD
Localized loss of neurons in the caudate nucleus
Movement symptoms in Huntington’s disease
Localized loss of neurons in substantia nigra
Decrease in dopaminergic neurotransmission that causes movement symptoms of Parkinson’s disease
Drug of choice for supervised heroin withdrawal inpatient
Buprenorphine
Drug of choice for supervised opioid withdrawal taken at home
Buprenorphine/ naloxone
Nloxone component prevents abuse of buprenorphine
Heroin withdrawal acute setting
Methadone
Heroin withdrawal med in prison
Clonidine (alpha 2 adrenergic agonist)
Lofexidine
Chlordiazepoxide
Reduce anxiety and agitation due to sedative GABAergic effects
Alcohol withdrawal
Chlorpromazine
Dopamine antagonist
Originally antipsychotic no longer used dues to EPS
Reduce vomiting and diarrhea
Orthostatic hypotension Blue gray skin discoloration Corneal and lens deposits Photosensitivity Intractable hiccups
Diphenhydramine in withdrawal
Antihistamine used to manage pruritus in opioid withdrawal
Causes sedation
Ketorolac
Pain management
Potent NSAID
First line tx for tics in Tourette syndrome
Aripiprazole
(partial agonist at D2 dopamine receptors)
FDA approved: Haloperidol and pimozide
Pimozide is often correct answer on test
Habit reversal training
[Guanfacine first choice according to book?]
Patient with bipolar on lithium that wants to get pregnant
Continue medication at current dose
Labs seen with chronic alcohol abuse
Macrocytic anemia
Due to dietary folate deficiency and alcoholic effect on gastric synthesis of intrinsic factor causing deficiency in Vit B 12
Alcoholic liver enzymes
AST x2 to ALT
Diffuse cerebral atrophy
Alzheimers dementia
Lewy body dementia
Some cases of vascular dementia
Delusions of reference
Type of delusion in which the patient believes that he/she is receiving special coded message via the media
Mania
Psychotic depression
Primary psychosis
Panic disorder with agoraphobia
Avoid places from which it would be difficult to escape in the event of panic attack
MAOI
Isocarboxazid
Tranylcypromine
Phenelzine
Selegiline (selective MAO-B inhibitor)
Isocarboxazid
MAOI
HTN crisis
Tx
MAOI
Pseudoephedrine (sympathomimetics)
Tyramine
Tx: Phentolamine
Sympathomimetics
- albuterol
- terbutaline
- dobutamine
- dopamine
- epinephrine
- midodrine
- amphetamine
- cocaine
- ephedrine
SSRI discontinuation syndrome
Seen most commonly in antidepressants with shorter half lives
Fluvoxamine
Paroxetine
Venlafaxine
“Electric shocks”
Fluoxetine
- half life 4-6 days
- tx of choice
Delusion disorder
Delusions in absence of other psychiatric symptoms or functional impairment
No history of mental illness
Grandiose delusion
“grand role”
Special abilities
Mania
Schizophrenia
Belief that the patient is the subject of malice perpetrated by others
Persecutory delusions
Schizophrenia
Primary psychotic disorders
Alprazolam
Diazepam
Oral outpatient tx
Alprazolam: acute anxiety
Diazepam: alcohol withdrawal
Midazolam
Fastest acting benzo
Reduce anxiety prior to anesthesia
Emergency setting as a rapid abortive tx for status epilepticus
Temazepam
Slower onset and long duration of action
Intermittent insomnia
Tx individual episodes of panic attacks
Alprazolam
Depression NT
- Other feature
Decreased amount of Serotonin
Decreased Norepinephrine
Decrease Dopamine
Hypothalamic dysfunction
Mania NT
Increased Dopamine
Schizophrenia NT
Increased Dopamine in prefrontal cortex
OCD NT
Low Serotonin
Anxiety disorder NT
Low Serotonin
Low GABA
Benzodiazepines target
GABA
Benztropine
Improve tremor
St. Johns wort
Antidepressatn due to SSRI like effect
Bipolar I w/ rapid cycling
1 episode of mania in addition to three other mood disturbances within 1 year
Mania
Hypomania
Major depression
Mixed episode
Mania
DIGFAST
Distractibility Impulsive behavior Grandiosity Flight of ideas Activity/ agitation Sleep disturbance Talkativeness (pressured speech)
3 symptoms for 1 week or any duration if hospitalized
Bulimia labs
Decreased potassium
Elevated BUN
Normal creatinine
Increased amylase (parotid gland stimulation)
Low albumin
Dementia vs MDD
MDD
- recognize deficit
Dementia
- Poor insight
Defense mechanism which you consciously choose to not think about anxiety provoking thought
Suppression
Delusion vs illusion
Delusion
- sensory perception correct
- knew it was smoke
- belief of demons
Illusion
- subconscious misinterpretation of sensory perception
Delirum tremens characteristics
Disorientation
Memory deficits
Perceptual and language disturbances
Rapidly fluctuating symptoms
Disturbance of consciousness
(No dreams)
Muscle aches part of what withdrawal
Opioids
Vivid of unpleasent dreams part of what withdrawal
Cocaine
Cognitive triad of depression
1) Negative views about oneself
2) Negative views about the world
3) Expectation of future failure
Gambling disorder
Impulse control disorder
Tx Group psychotherapy or CBT
Inhibition of monoamine reuptake
SNRI
Bupropion
What release to feel no pain after severe injury
Endorphins
Substance P
NT that is associated w/ pain
Endocannabinoids
Provide sense of euphoria in certain situations
Tourette tx
Only tx if causing distress to child of decline in academic funcitoning
Alzheimers in brain
Neurofibrillary tangles
Alpha synuclein inclusions in neurons
Lewy dementia
Parkinson
Neurofibrillary tangles
Alzheimers
SSRI most likely to cause SSRI discontinuation syndrome
Paroxetine
Signs of schizophrenia
Delusions of thought insertion
Thought withdrawal
Thought broadcasting
Voices in discussion
Voice commentary
Audible thoughts
-hallucination in which patients thoughts are relayed back as audible voices
Schizophrenia voices
Clearly audible voices
Attempt to resist command hallucinations
Lab to check neuroleptic malignant syndrome
High levels of creatinine phosphokinase
Anticholinergic symptoms
- blurry vision
- agitation
- fever
- constipation
- urinary retention
What type of medication
TCA
- amitriptyline
Antihypertensive that can cause depression
Clonidine
Propranolol
Methyldopa
Reserpine
Antipsychotic which doesnt cause hyperprolactinemia in preexisting hyperprolactinemia
Clozapine
Slurred speech Unsteady gait Nystagmus Memory impairment Stupor Seizures
Ethanol withdrawal
Ethanol intoxication w/o seizure
Dementia
Pupillary changes (anisocoria different sized pupils)
Ataxia
Urinary incontinence
Impaired peripheral vibratory and proprioceptive sensation
Neurosyphilis
Patient w/ psychosis that recovers quickly in hospital
Delirium
Acute alcohol intoxication features
Lack of coordination
Impairment of cognition
NYSTAGMUS
Risperidone causes orthostatic hypotension by
Cross reactivity as an alpha 1 adrenergic antagonist impairing binding of norepinephrine to alpha 1 receptor
Schizophrenia brain changes
Deterioration of Hippocampus
Nefazodone
Antidepressant
SE: hepatotoxicity
MDD w/ sexual side effects and generalized anxiety
Dont use Bupropion
Nefazodone
MDD that develops psychotic features such as auditory hallucinations
Tx
Risperidone (due to high potency)
Auditory hallucination are from what part of the brain
Temporal lobe
Generalized anxiety disorder lab level
Elevated cortisol
OCD due to what part of brain
Cerebral cortex or basal ganglia
clonus=
serotonin syndrome
Lorazepam vs other benzo
Lorazepam is not metabolized by liver
Patient abruptly stops talking
Thought blocking
Person stealing thoughts
Wandering off topic during regular conversations
Derailment
Wandering off topic during an explanation or while responding to a question
Tangentiality
Rapid cycling between different ideas without direct relationship with one another
Flight of ideas
Losing track of the intended purpose of a sentence
Loss of a goal
Decreased speech, but complete sentences present
Poverty of speech
Adequate amount of speech with very little actual content
Poverty of thought
Illness anxiety disorder
Focus on obtaining a diagnosis for mild complaints that are genuine not pathological
Preoccupation with having or acquiring a serious illness
persists 6 months
tx: regular visits with one primary care physician
Delirium tx
Haloperidol
NT responsible for patients sexual dysfunction on clozapine
Anticholinergic activity
Parasympathetic
Several unrelated physical symptoms in several different systems
Somatic symptom disorder
Other features of PTSD
Sense of foreshortened future
Breathing techniques target what NT
Norepinephrine
Girl 1-4 y.o
Wringing hands
Delay in intellectual development
Rett syndrome
Alcohol changes on sleep
Decreased REM sleep
Decreased sleep latency (shorter time to fall asleep)
Increased sleep fragmentation (increased nighttime awakenings)
Pain relief tx in heroin use disorder
Ketorolac
- NSAID
- Potent
Hear colors
See tastes
Synesthesia
Visual hallucinations in those that are blind
Charles Bonnet syndrome
Neutropenia in patient
Clozapine
Carbamazepine
Carbamazepine SE
Agraulocytosis
Stevens-Johnson syndrome
Teratogenic in pregnancy
Cytochrome P450 induction
Hyponatremia
Hepatotoxicity
Drugs that induce mania or psychosis is patients with previous history of disease (6)
Corticosteriods
Thyroxine Dopaminergic anti-parkinsonian drugs Amphetamines Cocaine PCP
Drugs that induce depression in already depressed patient (8)
Corticosteriods Lidocaine Procainamide Beta blockers Reserpine Antimalarials - chloroquine - mefloquine Levetiracetam
Anticonvulsant that can exacerbate depression and anxiety
Levetiracetam
Topiramate
- what is it
- SE (2)
- Used in (2)
Mood stabilizer
Significant cognitive suppression and sedation
Useful in migraine prophylaxis and weight loss
Valproic acid
- what is it
- use in (2)
- SE (5)
Mood stablizer
Use for seizure disorder, migraine prophylaxis
Sedation, hepatotoxicity, teratogenesis, weight gain and hair loss
Epilepsy associated with psychosis
Temporal lobe epilepsy (TLE)
Major NTs in anxiety
NE
Serotonin 5HT
GABA
Most common form of psychopathology
Anxiety
If patient has a comorbid depressive disorder dont use what medications
Benzodiazepines, as they will worsen depression
Anxiety with comorbid substance abuse consider using
non-addictive anxiolytic alternatives prn such as diphenhyramine, hydroxyzine, and gagapentin
Busprione MOA
NOn-benzodiazepine anxiolytic which has partial agonist activity at serotonin receptor
Panic disorder tx
Combination of CBT and pharmacotherapy most effective
First line: SSRI
Agoraphobia duration and tx
> 6 months
CBT and SSRI
Specific phobias duration and tx
> 6 months
CBT
Selective mutism
Tx
Rare
Failure to speak in specific situations for a least 1 month
Consistent failure to speak in select social situations (school) despite speech ability in other scenarios
Tx: CBT, family therapy
SSRI
Separation anxiety disorders
- duration
- tx
Excessive and developmentally inappropriate fear/anxiety regarding separation from attachment figures
> 4 weeks in children/ adolescents
6 months in adults
TX: CBT, family therapy
Characteristics of generalized anxiety disorder (6)
associated >=3 symptoms:
Restlessness Fatigue Impaired concentration Irritability Muscle tension Insomnia
OCD tx
CBT
- exposure and response prevention
- SSRI
Second line:
- SNRI
- TCA
- Clomipramine
Hoarding tx
CBT for hoarding
SSRI can be used
Hair pulling disorder tx
SSRI
Second gen antipsychotics
Lithium
N-acetylcysteine
Specialized CBT
- Habit reversal training
Medication to stop nightmares
Prazosin
Medication to avoid in PTSD
Benzo
Tx PTSD
SSRI
Prazosin (alpha 1 antagonist)
CBT
- exposure therpy
- cognitive processing therapy
Adjustment disorder
- is what
- timeline
- tx
Non lifethreatening, stressful life event
Symptoms resolve within 6 months after stressor has terminated
Tx: Supportive psychotherapy
Group therapy
Group therapy should be avoid in what personality disorder
Paranoid personality disorder
Pharmacotherapy and tx that is useful in borderline personality disorder
Dialectical behavior therapy
- cognitive behavioral therapy
- mindful skills
- group therapy
Mood stabilizers
Antipsychotics
Antidepressants
Alcohol intoxication tx
Thiamine before glucose
Alcohol withdrawal what predisoses to seizures
Hypomagnesemia
Confabulation is part of what
Inventing stories
Korsakoff’s psychosis
Patients unaware they are making things up
Alcoholic ketoacidosis
- tx
Ketosis without hyperglycemia and a negative alcohol level
High anion gap metabolic acidosis, ketonemia, and low level of potassium, magnesium and phosphorus
Tx: Hydration with D5N5 and replacing electrolytes
Tx alcohol use disorder
First line:
Naltrexone
- Opioid receptor antagonist
- Reduces desire/ craving and the “high” associated with alcohol
- will precipitate withdrawal in patient with physical opioid dependence
Acamprosate
- modulate glutamate transmission
- used for relapse prevention in patients who have stopped drinking (post-detoxification)
- advantage is liver disease
- CI if renal disease
Second line:
Disulfiram
-blocks aldehyde dehydrogenase in liver
Topiramate
- anticonvulsant that potentiates GABA and inhibits glutamate receptors
- reduces cravings for alcohol and decreases alcohol use
Naltrexone
- Opioid receptor antagonist
- Reduces desire/ craving and the “high” associated with alcohol
- will precipitate withdrawal in patient with physical opioid dependence
Acamprosate
- modulate glutamate transmission
- used for relapse prevention in patients who have stopped drinking (post-detoxification)
- advantage is liver disease
- CI if renal disease
Topiramate
- anticonvulsant that potentiates GABA and inhibits glutamate receptors
- reduces cravings for alcohol and decreases alcohol use
Alcohol can cause what changes in labs
increased LFTs
Macrocytosis (increased in MCV)
Cocaine MOA
blocks the reuptake of dopamine, epinephrine and norepinephrine
What labs to check in PCP and amphetamine
Elevated creatine kinase.
Rhabdomyolysis
Amphetamines MOA
Release dopamine, NE and serotonin from nerve endings
Synesthesia
seen with what drug
One sensory stimulation evokes another
hearing a sound causes one to see a color
PCP
Tx barbiturates overdose
Alkalinize urine with sodium bicarbonate to promote renal excretion
Tx benzodiazpine overdose
Flumazenil
Marijuana MOA
Cannabinoid receptors in brain inhibit adenylate cyclase
Marijuana withdrawal
Irritability Anxiety Restlessness Aggression STRANGE DREAMS Depression HA Sweating Chills
Dronabinol
FDA approved form of THC
Caffeine MOA
Increasing in cyclic adenosine monophosphate (cAMP) and stimulating the release of excitatory NT
Nicoteine dependce tx
Varenicline
- alpha4beta2 nicotinic cholinergic receptor partial agonist
- mimics action of nicotine
- reduces rewarding aspects and prevents withdrawal
Bupropion
- antidepressant inhibits reuptake of dopamine and NE helps reduce cravings and withdrawal symptoms
Common causes of medication induced delirium
TCA Anticholinergics Benzo Nonbenzo hypnotics Corticosteriods H2 blockers Opioids (esp meperidine)
Opioid that doesnt cause miosis
Meperidine
Delirium on EEG
Diffuse background slowing
Delirium tremens opposite: fast EEG activity
Tool for assessing delirium
Confusion assessment method (CAM)
Medication to avoid in delirium
Benzo
Worsen delirium by causing paradoxical disinhibition or oversedation
Alzheimers disease in brain
- accumulation
- genes
Accumulation of extraneuronal beta- amyloid plaques and intraneuronal tau protein tangles assocaited iwth progressive brain atrophy
Mutation - Amyloid precursor protein - Presenilin 1 - Presenilin 2 (early onset)
Epsilon-4 variant of the apolipoprotein gene is a risk factor for developoing early onset AD
Alzheimers tx
No cure
Cholinesterase inhibitors - donepezil - rivastigmine - galantamine (may slow clinical deterioration by 6-12 months)
NMDA receptor antagonist
- memantine
Antipsychotics for agitation and aggression
- low doses
Increased difficulty in planning and decision making
Complex attention and executive functioning
Vascular disease
Lewy body disease
- brain
- features (3)
- suggesive features (3)
- biomarkers (3)
brain
- lewy bodies (alpha synuclein) and lewy neurites in the brain, primarily basal ganglia
Progressive cognitive delcine
WAXING AND WANING
Visual hallucinations
Rapid eye movement sleep behavior disorder (REM)
Suggestive features
- antipsychotic sensitivity (EPS)
- postural instability and recurrent falls
- diminished sense of smell
Biomarkers
- REM sleep without atonia
- decreased 123iodine-MIBG uptake on myocardial scintigraphy
- Reuced dopamine receptor uptake in basal ganglia vis PET or SPECT
Lewy body tx
Cholinesterase inhibitors
Quetiapine or clozapine for psychotic symptoms
Levodopa carbidopa for parkinsonism
Melatonin or clonazepam for REM sleep disorder
Tx Huntingtons
Symtoms directed tx
Tetrabenazine
Atypical (second gen) antipsychotic
Rapidly progressive cognitive decline with myoclonus
Creutzfeldt jakob disease
Features of creutzfeldt jakob disease
Ataxia
Nystagmus
Hypokinesia
Features of creutzfeldt jakob disease labs
Periodic sharp wave complexes of EEG
CSF positive for 14-3-3 protins
Lesions in the putamen or caudate nucleus on MRI
Normal aging of brain
Decreased brain weight/ enlarged ventricles and sulci
Pseudodementia tx
SSRI
If have to use TCA use nortriptyine less anticholinergic side effects
Mirtazapine can increase appetite and is also sedating (dose at bed time)
Restless leg movements due to
Dopamine imbalance
Sleep changes in elderly
Decreased REM latency
Decreased total REM
Increased amount stage 1 and 2
Decreased stage 3 and 4
Decrease sleep efficiency
(frequent nocturnal awakenings)
Decreased total sleep amount
If elderly need sedative hypnotics then use
Trazodone
K-ABC
Kaufman assessment battery for children
Intelligence test comparing intellectual capacity with acquired knowledge of patients between 2-12
WISC-R
Wechsler intelligence scale for children revised
Assesses verbal, performance and full scale IQ of patients between 6-16 years old
Difficulty acquiring and using language
Reduced vocab
Limited sentence structure
Language disorder
Difficulty producing articulate intelligible speech
Speech sound disorder
Stuttering
Childhood onset fluency disorder
ADHD
- onset
- duration
- associated with
- tx
> 6 months
Prior to age 12
Comorbid
- oppositional defiant disorder
- conduct disorder
- specific learning disorder
Methylphenidate, amphetamines
Second line:
Atomoxetine (NE reuptake inhibitor)
Alpha 2 agonist (clonidine, guanfacine)
Coprolalia
Utterance of obscene, taboo words in abrupt sharp bark or grunt
Enuresis
Recurrent bed wetting
At least 5 years old
3 months
Spontaneous remission
Psychoeducation
Limit fluid intake and caffeine at night
Urine alarm
Desmopressin (DDAVP) antidiuretic
Imipramine (TCA)
Encopresis
Recurrent defecation
3 months
4 years old
Depersonalization
tx
out of body experience
cbt
Derealization
tx
experiencing world around them in a dream or movie
Tx CBT
Medication to reduce self mutilation
Naltrexone
Intermittent explosive disorder
- criteria
- lab finding
- tx
outbursts twice weekly for 3 months
CSF shows low 5-hydroxyindoleacetic acid (5-HIAA) concentration
SSRI (fluoxetine)
Anticonvulsants
lithium
What is associated with aggressive and impulsiveness lab
Low levels of serotonin in CSF
Kleptomania comorbid with
Bulimia nervosa
Kleptomania tx
CBT
- systematic desensitization and aversive conditioning
SSRI
Naltrexone maybe
Anorexia nervousa comorbid with
OCD
Physical findings in Anorexia nervousa
Bradycardia Orthostatic hypotension Arrhythmias QTC prlongation ST-T wave changes Anemia (normocytic normochromic) Leukopenia
Enlarged ventricles and neuropathy
Muscle wasting
Amenorrhea and loss of libido
Parotid enlargement
Increased amylase levels
Hypokalemia
Elevated BUN
Increase GH
Increased CORTISOL
Lanugo (fine soft hair on body)
Hypochloremic hypokalemic alkalosis (if vomiting)
REM sleep is characterized by
Increase in
- blood pressure
- heart rate
- respiratory rate
Insomnia disorder
- criteria
- tx
3 days a week for at least 3 months
Sleep hygiene measures
CBT (first line)
Chronotherapy (bright light therapy)
Benzo (redue sleep latencya nd nocturnal awakening)
Insomnia medication with increased risk of falls in elderly
zolpidem (ambien)
Also causes cognitive impairment
Tx Sleep related hypoventilation
CPAP
Medications to stimulate/ promote breathing
- bronchodilators
- theophylline
Nightmare disorder
Recurrent frightening dreams
Vivid recall
No confusion or disorientation upon awakening
Tx: Densensitization/ imagery rehearsal therapy (IRT)
REM sleep behavior disorder tx
Clonazepam
Dopamine and serotonin effect on sex
Dopamine enhances libido
Serotonin inhibits sexual function
Tx premature ejactulation
SSRI
TCA
Frotteuristic disorder
Sexual arousal from touching or rubbing against a nonconsenting person
Voyeuristic disorder
Sexual arousal from observing an unsuspecting nude, or disrobing individual (binoculars)
Exhibitionistic disorder
Sexual arousal from exposure of one’s genitals to an unsuspecting person
Sexual masochism disorder
Sexual arousal from the act of being humiliated beaten bound or made to suffer
Sexual sadism disorder
Sexual arousal from the physical or psychological suffering of another person
Isolation of affect
Unconsciously limiting the experience of feelings or emotions associated with stressful life event in order to avoid anxiety
Undoing
Attempting to reverse a situation by adopting a new behavior
Man had fantasy of killing wift by sabotaging her car takes the car for complete check up
Homework assignments between therapy session
Set agenda
Review homework
challenge cognitive distortions
6 weeks to 6 months
CBT
Current symptoms
Dialectical behavioral therapy
once weekly individual and group tx
Reduce urges to engage in self harm behavior
Duty of warn
Tarasoff duty
Dont require consent (3)
Life saving medical emergency
Prevention of suicide or homicidal behavior
Unemancipated minor (require consent from parent)
Emanciapted minor (4)
Self supporting
In the military
Married
Have children or pregnant
Capacity vs competence
Capacity
- clinical term by physician
Competence
- legal term by judge
Parens patriae
Protecting citizens who cant care for themselves
Sixth amendment
right to counsel, a speedy trial and to confront witnesses
Fourteenth amendment
right to due process by law
M’Naghten insanity defense
Person did not understand what he/she was doing was wrong
Durham insanity defense
Criminal act resulted from mental illness
OTC drugs that can cause serotonin syndrome
St. John’s wort
dextromethorphan
CYP 450 inducers
Tobacco
Carbamazepine
Barbiturates
St. John’s wort
CYP450 inhibitors
Fluvoxamine Fluoxetine Paroxetine Duloxetine Sertraline
SSRI most associated with weight gain
Paroxetine
SSRI and MAOI
SSRI should not be used for at least 2 weeks before or after use of an MAOI
Fluvoxamine
SSRI
only for OCD
Citalopram
Escitalopram
SSRI
Dose dependent QTC prolongation
Trazodone
Nefazodone
Serotonin receptor antagonists
Tx
- MDD
- MDD w/ anxiety
- Insomnia
SE
- orthostatic hypotension
- arrhythmias
- sedation
- priapism
Nefazodone
- black box warning for liver failure
Mirtazapine
Alpha 2 adrenergic receptor antagonists
Tx MDD
Patients with weight loss and or insomnia
SE
weight gain
sedation
TCA
Tertiary amines
- Amitriptyline: chronic pain, migraines, insomnia
- Imipramine: enuresis and panic disorder
- Clomipramine: OCD
- Doxepin: Chronic pain
Secondary amines
- Nortriptyline: least likely to cause orthostatic hypotension
Desipramine
TCA overdose
Sodium bicarbonate
Factors that increase Li levels
NSAIDS
Aspirin
Thiazide diuretics
Carbamazepine
Especially useful in treating mania with mixed features and rapid-cycling bipolar disorder
Acts by blocking sodium channels and inhibiting action potentials
Valproic acid
acute mania
acute mania with mixed features
rapid cycling
Blocks sodium channels and increases GABA concentration in the brain
Lamotrigine
Bipolar depression
Steven johnson syndrome
Anxiety inducing
Sympathomimetics
Antiasthmatics
Miosis pupil size
Mydrasis pupil size
Miosis less than 2 mm
Mydrasis larger than 4 mm
What inhibits lamotrigine
Valproic acid