Psych Flashcards
First line Rx for depression
SSRI
Antidepressants associated with HTN crisis
MAOI
Galactorrhea, impotence, menstrual dysfunction, and dec libido
DA antagonist
17 yo female left arm paralysis after boyfriend dies in car crash. No medical reason
Conversion disorder
Defense mechanism: Mother who is angry at her husband yells at her child
Displacemtn
Defense mechanism: Pedophile enters monastery
Reaction formation
Woman calmly describes grisly murder
Isolation
Hospitalized 10 yo begins to wet his bed
Regression
Life threatening mm rigidity, high fever, rhabdo
NMS - neuroleptic malignant syndrome
Amenorrhea, low body weight (<85%), bradycardia, abnormal body image in young woman
Anorexia
35 yo man recurrent episodes of palpitations, diaphoresis, fear of going crazy
Panic disorder
Most serious side effect of clozapine
Agranulocytosis
21 yo man has 3 months of social withdrawal, worsening grades, flattened affect, concrete thinking
Schizophreniform disorder (schizophrenia needs >6 mo)
Key side effect atypical
Weight gain, DM II, QT prolongation
Young weight lifter receives IV haloperidol and complains eyes are deviated sideways, Dx. Tx
Acute dystonia (oculogyric crisis) Tx benztropine or diphenhydramine
MEds to avoid in pts with hx alcohol withdrawal seizures
NEuroleptics
13 yo boy has hx of theft, vandalsim, violence toward family pets
Conduct disorder–assoc with antisocial personality disorder
5 mo old girl dec head growth, truncal discoordination, dec social interaction
Rett’s disorder–loss of milestones is commonly described
Pt hasnt slept for days, lost $20,000 gambling, agitated, pressured speech. Dx? Tx
Acute mania. Start with mood stabilizer - Li
After minor fender bender, man wears neck brace and requests permanent disability
Malingering
Nurse presents with severe hypoglycemia. blood analysis reveals no elevation C peptide
Factitious disorder (Munchausen)
Pt continues to use cocaine ager being in jail. losing job, not paying child support
Substance abusse
Meds to avoid in pts with PTSD
Benzodiazepines - high addiction potential
Violent pt w/ vertical and horizontal nystagmus
PCP
Woman was abused as child frequently feels outside of or detached from her body
Depersonalization disorder
Schizophernic pt takes haloperidol for 1 yr and develops uncontrollable tongue movements. Dx Tx
Tardive dyskinesia
Dec or discontinue haloperidol and try another antipsych (risperdone, cloazpine)
Man with major depressive disorder counseled to avoid tyramine rich food with new med
MAOI
DSM IV - category I
Clinical psych disorders - mood, anxiety, substance, delirium
DSM IV- category II
PD and developmental disorders - BPD and mental retardation
DSM IV - category III
MEdical conditions - encephalopthy, neoplasm, HIV
DSM IV - psychosocial stresses
Support structures, social environment, occupational factors
DSM V - global assessment of functioning
100 pt scale that describes how well pt has functioned in society
Mood vs affect
Mood - subjective
Affect - way person expresses his or her state of mind
Insight vs judgment
Insight: pts awareness of problems and their affect on daily life (pre contemplation–>contemplation–>action–>maintenance)
Judgment - response to a situation
Awareness of time, place, identity
Orientation
Ability to retrieve mentally stored information
Memory
Ability to maintain attention to task
Concentration
Major Depressive Disorder
Which characteristics essential for Dx?
SIG E CAPS Sleep disturbance - insomnia Interest loss Guilt Energy reduction - fatigue Concentration impairment Appetite changes Psychomotor disturbances Suicidal ideation NEED 5
Either Depressed mood or anhedonia
Time frame to Dx MDD
> 2 weeks
NT involved in depression
5HT, NE, DA
Risks for successful suicide attempt
age>45 violent behavior drug use prior attempt plan male recent loss depression unemployed widowed, single, divorced
Bereavement - time line, major criteria
6 months
DO NOT AFFECT ABILITY TO FUNCTION
Depression after loss of loved one
Time line
S/S
> 6 months
Detachment, bitterness, inability to accept life without the deceased, agitation, distrust
Dysthymic disorder
Define
Time line
> 2 yrs - depressed on more days than not, no hx MDD -Hopelessness -Change sleep -Change appetite -Fatigue -Inability to concentrate -Low self esteem NEED 2 w/ depressed mood
Bipolar I vs II
I: depression with 1+ manic
II: depression with 1+ hypomanic
Mania vs hypomania
Mania: > 1 wk-->DIG FAST; affects ability to function -Distractibility -Insomnia -Grandiosity -Flight of idea -Activity -Speech pressured -Taking risks NEED 3
Hypomania 4 or more days - does not impair ability to fcn
Tx bipolar
Mood stabilizers - lithium, lamotrigine, atopyicals
Lithium first line mania
SSRI
Mechanism
Use
SE
Block 5HT reuptake
First line: depression; also for anxiety and PTSD
Sexual dysfcn, increase SI in adolescents
fluoxetine, sertaline, paroxetinee citolapram, escitolopram
SNRI
Mechanism
Use
SE
Inhibits 5HT and NE reuptake
1st line depression with comorbid neuro pain
2nd line if fail SSRI
HTN, insomnia/sedation, nausea, constipation, dizziness
Venlafazine, Duloxetine
TCA
Mechanism
Use
SE
Block NE and 5HT reuptake - like SNRI; also hit alpha and muscarinic
2nd line depression used if comorbid neuro pain
Easy to OD, fatal 5x therapeutic dose; QT prolong, sedate, weight gain, sexual, antichol Sx
Imipramine, amitryptiline, desipramine, nortiptyline
MAOI
Mechanism
Use
SE
Block MAO to inhibit deamination of 5HT, NE, and DA
2nd line depression; used Tx depression with neuro Sx or refractory
Dizziness, tyramine = HTN crisis, dry mouth,
Phenelzine, Isocarboxazid, tranylcypromine, selegiline
Buproprion
Mechanism
Use
SE
DA and NE
Depression with fatigue and concentration problems; smoking
NO SEXUAL DYSFCNl weight loss, HA
Trazodone
5ht
Depression with insomnia
Sedation, priapism, seizure high dose, hypotension
Mitrazapine
alpha 2 and 5HT blockade
Depression with insomnia
Dry mouth, weight gain, sedation
St Johns Wort
Mechanism
Use
SE
Decrease reuptake 5HT, NE, DA
First line in Europe, alternative in us
MANY DRUG INTERACTIONS
Rapid cycling hypomania with mild depression > 2 yrs without period of normal mood > 2months
Cyclothymia - Tx mood stabilizer
How to precipitate mania in bipolar disorder
Taking antidepressants without mood stabilizer
Behavioral or mood changes within 3 months of stressful event and impait ability to finction
Time frame of beginning and ending
Tx
Adjustment disorder with depressed mood
begin within 3 months of event and end 6 months after end of sterssor
Tx: psychTx, antidepressants
Organic disorder associated with panic disorder
MCP
Agorophobia also
Dx of panic attacks requires
Hx of recurrent episodes plus persistent fear that will happen again
Tx panic attacks
PsychTx, SSRI, SNRI
TCA 2nd line
Tx specific phobia
PsychTx to desensitize
Tx social phobia
PsychoTx Beta blockers SSRI MAOI if refractory BDZ for anxiety
Major necessity for OCD Dx
Impairs daily life
Pt recognizes sx and wants to get rid of them
Tx OCD
PsychoTx
SSRI or clomipramine
Vivid dreams or recurrent intrusive thoughts, detachment, avoidance, guilt
PTSD
Dx requires exposed to traumati event, Sx of reliving event (dreams or thoughts), increased arousal (insomnia, irritable, difficulty concentrationg)
Dx PTSD requires
Dx requires exposed to traumatic event, Sx of reliving event (dreams or thoughts), increased arousal (insomnia, irritable, difficulty concentrationg) lasting > 1month if acut e>3 months if chronic
Tx PTSD
SSRI
MAOI
Mood stabilizer
PsychoTx
Time line generalized anxiety disorder
> 6 months
Dx of GAD requires
Excessive anxiety for most days
Impairment of ability to fcn
> 6 months
GAD Tx
PsychoTx
Anxiolytics (BDZ, Buspirone)
SSRI and SNRI promising prospect
How much BDZ need to OD
Tx OD
> 1000x dose
FLumazenil
BDZ
Mechanism
Indications
SE
Increase GABA inhibition of neural firing
Alprazolam- rapid onset and short half life = break panic attacks
Clonazepam and diazepam - prolonged
SE: sedation, confusion; withdrawal (alprazolam)
Buspirone
Mechanism
Indications
SE
DA and 5HT
Anxiety in which abuse or sedation is a concern
HA, dizzy, N
Schizophrenia puts pt at risk for
Substance abuse
Suicide
Risk factor shcizophrenia
FH, maternal malnutrition or illness, homeless and indigent
Positive Sx schizophrenia
Delusion Hallucination Disorganized thought and behavior thought broadcasting ideas of reference
Negative Sx schizophrenia
Social withdrawal Flat affect Apathy Anhedonia Lack of motivation
Cognitive Sx schizophrenia
Attention deficits
Inability to organize or form abstract thought
Poor memory
Dx schizophrenia requires
2_ Sx for at least 1 month in 6 month period; impaired social fcn > 6 months
Tx schizophrenia
Antipsychs (atypicals, neuroleptics)
PsychoTx
Good vs bad outcome schizophrenia
Good: due to substance abuse or mood disorder, positive sx, good uspport
Bad: negative Sx, motor or sensory signs, poor support
Subtype of schizophrenia: excessive paranoia, hallucination and ideas of reference severe
Paranoid
Subtype of schizophrenia: rigid posturing, poor response to stimuli, poor interaction
Catatonic
Subtype of schizophrenia: flat affect, disorganized speech, inappropriate and disorganized behavior
Disorganized
Subtype of schizophrenia: does not fit into other categories
Undifferentiated
Subtype of schizophrenia: previously dx schizophrenia with resolition of + Sx but - Sx remain
Residual
Atypical antipsych
Mechanism
Use
SE
block DA and 5HT
1st line psych disorders; Clozapine is best but agranulocytosis
Antichol effect, arhythmia, seizure
Clozapine, Risperidone, Olanzapine, Sertindole, Quetiapine, Ziprasidone, Paliperidone, Airpiprazole
High potency neuroleptics
Mechanism
Use
SE
Block D2
Strong + Sx, emergency control psychosis or agitation, 2nd line maintenance
EPS (dystonia, PDism, akinesia, akahisia), TD, sexual, hyperprolactinemia, NMS, seizures = FEWER ANTICHOL SE
Haloperidol, Droperidol, Fluphenazine, Loxapine, Thiothixene, Perphenazine, Trifluoperazine
Low potency neuroleptics
Mechanism
Use
SE
Block D2
Strong _ Sx, 2nd line maintenance
Fewer EPS but more antichol (confusion,constipation, urinary retention, hypotension)
Thioridazine, chlorpromazine
Sx similar to schizophrenia but last >1 month and <6 months
Schizophreniform
Mood disorder and psychotic Sx, not meet criteria for either one; requires presence of psychotic Sx during normal mood for > 2 wks
Schizoaffective
Presence of 1+ realistic delusion >1 month without psychotic Sx, fcn normally, unrealistic delusions - schizophreniform or schizophrenia
Delusional
Sudden onset psych Sx < 1month
Brief psychotic
Second pt accepts and becomes involved in delusions of pt with pre-existing delusions
Shared psychotic/ folie a deuz
Personality trait vs PD
trait: mild signs of PD but can fcn normally in society
Cluster A PD
odd or eccentric - WEIRD
- Paranoid
- Schizoid
- Schizotypal
Cluster B PD
Dramatic or emotional - Wild
- Antisocial
- Borderline
- Histrionic
- Narcissistic
Cluster C PD
Anxious or fearful - wimpy or worried
- Avoidant
- Dependent
- Obsessive compulsive
persistent distrust of others, others actions interpreted as harmful or deceptive, reluctant to share info, misinterpret comments, angry reaction, suspicion partner infidelity
Paranoid
Low dose antipsych
Inability to form close relationships, social detachment emotionally restricted, anhedonia, flat affect, no sexual interests
Schizoid
Antipsych
Paranoia, idea of reference, eccentric and inappropriate behavior, social anxiety, disorganized speech, odd beliefs
Shizotypal
Low dose antipsych or anxiolytic
Aggressive behavior toward ppl and animals, destroy property, illegal activity, pathologic lying, irritability, isk taking, lack of responsibility, lack of remorse for actions, >18, hx conduct
Antisocial
Structured environment, psych Tx
Unstable relationships, feelings of emptiness, fear of abandonment, poor self esteem, impulsivity, mood lability, SI, inappropriate irritability, paranoia, splitting, women
Borderline
SSRI, mood stabilizer, low dose antipsych
Dire need for attention, inappropriate sexual behavior, emotional lability, shallow relationships, dramatic speech, uses appearance to draw attention to self, easily influenced by others, believes relationships are more intimate than they are
Histrionic
Grandiosity, fantasies of success, manipulation of others, expectation of admiration, arrogance sense of entitlement, lacks empathy, envious of others
Narcissistic
Fear of criticism and embarrassment, social withdrawal, fear of intimacy, poor self esteem ,reluctance to try new activities, preoccupied by fear of rejection, feelings of inadequacy are inhibitory
Avoidant
Difficulty making decisions, fear of responsibility, difficulty expressing disagreement, lack of confidence in judgment, need for others support, fear of being alone, requires constant close relationships
Dependent
Preoccupied with details, perfectionist, excessively devoted to work, inflexible in beliefs, difficulty working with others, hoard worthless objects, stubbornness
Obsessive compulsive
Does not recognize behavior as problematic
Repetitive use of substance that results in negative consequences
Substance abuse
Physical adaptation to repetitive substance use in which abrupt cessation or antagonist causes withdrawal
Physical dependence
Perceived need for given substance because of its associated positive effect or because of fear of effects from lack of use
Psychological dependence
Chronic substance use leading to physical and psychological dependence, development of tolerance, feelings of loss over use, significant amount of time devoted to procuring substance
Addiction
CAGE
Cut down on usage
Annoyance over others suggestion to stop useage
Guilt over usage
Eye opener
Refuse to maintain normal body weight, amenorrhea, cold intolerance, hypothermia, dry skin, lanugo hair, bradycarda
Tx
Anorexia nervosa
Inpt to gain weight
PsychoTx
No pharm unless associated depression then SSRI
Hypophosphatemeia, cardiovascular collapse, rhabdomyolysis, confusion, seizures
Refeeding syndrome - sudden shift from fat to card metabolism in anorexics who resume eating
Feel lack of control over eating behavior, normal body weight; binding and compesnation episodes at least 2x per week for 3 months
S/S: dental enamel erosion, scars on harnds, parotid enlargment, oligomenorrhea
Tx
Bulimia
PsychoTx
SSRI, TCA, buspirone
Needed for somatization disorder
2 GI
1 sex
1 pseduoneuro
Pain multiple body sites
Sensory or neuro deficits following stress, no medical condition
Conversion disorder
Tx pain diosrder
TCA and SSRI
Pt imagines physical defect in distinct body region, present to dermatologist or plastic surgeon to improve, continues to imagine defect after Tx
Body dysmorphic disorder
Factitious vs malingering
Malingering: benefit pt
Factitious: no benefit
Sundowning
Deterioration of behavior during evening hours in pts with dementia
Acute onset, fluctating change in cognition and behavior, oriented only to self, flight of idea/disorganizd, short term memory impaired, reversible if find underlying cause
Delirium
Gradual onset, sundowning, normal level of consciousness, orientation impaired, thought production impoerished, few psychotic features, memory - short and long term impaired, irreversible
Dementia
4 types dementia
AD
PD
Vascular - w/ neuro Sx
Alcohol- aphasias
Tx dementia
Cholinesterase inhibitors - donepezil, rivastigmine, galantamine to slow decline
Therapy
Drugs that can worsen dementia and delerium
BDZ and antichol
3 types ADHD
Inattentive: decreased attention span, difficulty following instruction
Hyperactivity: inappropriate activity
Impulsivity: interrupts,
Dx ADHD
Must exhibit Sx in multiple settings
Repetitive disruptive and antisocial behavior that violates others rights and social norms
Dx requires
Conduct disorder
Need 1 critera < 10 yrs of age and 3 >10 yrs of age
Dx Tourette’s requires
presence tics >1 yr and begins before 21
Similar to conduct but not illegal or destructive activities
Oppositional defiant
Severe, persistent impairment in interpersonal interactions, communication and social activities
Autism
4 As of dementia
Amnesia
Apraxia - motor inability
Anosia- recognize inability
Aphasia
Subtypes MDD
Psychotic features
Postpartum - 1 month
Atypical: weight gain, hypersomnia, rejection sensitivity
SEasonal: winter, light Tx
Double depression: major depressive episode with dysthymia
TCA toxicity
3c
Convulsions
Coma
Cardiac arrhythmias
SSRI and MAOI dosing
DC SSRI 2 wks before starting MAOI
If Fluoxetine wait 5 wks
Postpartum depression within 2 weeks of delivery - sadness, moodiness, emotional lability without thoughts of hurting baby
Postpartum blues
Postpartum depression 2-3 wks after delivery w/ delusion and depression; may have thoughts of hurting baby
Postpartum psychosis
Postpartum depression 1-3 months post delivery; also sleep disturbances and anxiety with thoughts of hurting baby
Postpartum depression
Characteristics of PD
MEDIC Maladaptive Enduring Deviate from cultural norms Inflexible Cause impairment in social or occupational functioning
Lithium
Use
SE
First line mood stabilizer - acute mania, trophy in BPD, augmentation in depression
SE - DI, hypothyroidism, seizures, teratogen 1st trimester, acne, vomiting; Li toxicity >1.5 ==ataxia, dysarthria, delirium ARF
Carbamazepine
Use
SE
2nd line mood stabilizer, anticonvulsant, trigeminal neuralgia
SE-skin rash, leukopenia, AV block, aplasti anemia, SJS
Valproic acid
Use SE
BPD, anticonvulsant
GI, sedation, alopecia, weight gain, pancreatitis, agranulocytosis, etc
Lamotrigine
Use
SE
2nd line mood stabilizer
Anticonvulsant
Blurred vision, SJS - inc dose slowly and monitor for rashes
Fixed false idiosyncratic belief
Delusion
Perception without existing external stimulus
Hallucination
Misperception of actual external stimulus
Illusion
Things with Schiz
Schizophreniform 1-6 months Schizophrenia - > 6 months Schizoaffective - Schizophrenia + Major affective disorder Schizotypal - PD with magical thinking Schizoid - PD = loner
Evolution of EPS
4 hours= Acute dystonia
4 days- Akinesia
4 weeks - akathisia
4 months - Tardive dyskinesia
Prolonged painful mm contraction or spasm
Dystonia- tx w/ antichol (benztropine or diphenhydramine)
Pseudoparkinsinism
Dyskinesia - Tx antichol or DA ag (amantadine)
Subjective/objective restlessness that is perceived as being distressing
Akathisia - Tx beta blocker (propranolol_
Stereotypic involuntary painless oral facial movements
Tardive dyskinesia
Tx - dec neuroleptic dose; antichol may worsen
Autism like disorder of social impairment and repetitive activities, behaviors, interests WITHOUT cognitive or language delays
Aspergers
Severe developmental regression after >2 yrs of normal development
Childhood disintegrative disorder
IQ to judge mental retardation
50-70 mild
35-49 severe
<20 profound
Tremor, tachycardia, HTN, malaise, nausea, seizures, DT, agitation - withdrawal?
Alcohol withdrawal
Dysphoria, insomnia, anorexia, myalgias, fever, lacrimation, diaphoresis, dilated pipils, rhinorrhea, piloerection, nausea, vomiting, stomach cramps, diarrhea, yawning
Opiod withdrawal - not life threatening
Anxiety, lethargy, HA< stomach cramps, hunger, fatigue, depression/dysphoria, sleep disturbances, nightmares
Amphetamine withdrawal
Recurrence of intoxication sx due to reabsorption in GI tract, sudden onset seer, random violence
PCP withdrawal
Anxiety, seizures, delirium, life threatening CV collapse
Barbs
Rebound anxiety, seizures, tremor, insomnia, HTN, tachycardia, death
BDZ withdrawal
Irritability, HA, anxiety, weight gain, craving, bradycardia, difficulty concentrating, insomnia
Nicotine withdrawal
Sedation, depression, psychomotor retardation, fatigue, anhedonia
Cocaine withdrawal
disinhibition, emotional lability, slurred speech, ataxia, aggression, blackouts, hallucinations, memory impairment, impaired judgment, coms
Alcohol intoxication
Euphoria leading to apathy. CNS depression, constipation, MIOSIS, resp depression (life threatening)
Opiod intoxication
Tx nalaxone and naltrexone - may need to redose if long acting opiod
Psychomotor agitation, impaired judgment, HTN, MYDRIASIS, tachycardia, fever, diaphoresis, anxiety, angina, euphoria, prolonged wakefulness/attention, arrhythmias, delusions, seizures, hallucinations
Amphetamine intoxication
Can give Haloperidol if severe agitation
Psychomotor agitation, euphoria, impaired judgment, tachycardia, MYDRIASIS< HTN, paranoise, hallucinations, :bugs”, sudden death - EKG shows ischemia
Cocaine intoxication
Tx with haloperidol
Assaultiveness, belligerence, psychosis, violence, vertical or horizontal nystagmus, HTN, ataxia, seizures, delirium
PCP intoxication
Tx: BDZ or haloperidol
Marked anxiety or depression, delusions, visual hallucinations, flashbacks, MYDRIASIS, impaired judgment, diaphoresis, tachycardia, HTN, heightened senses
LSD intoxication
Euphoria, slowed sense of time, impaired judgment, social withdrawal, inc appetite, dry mouth, conjunctival injection, hallucinations, paranoia, amotivational syndrome
Marijuana intoxication
respiratory depression - low safety margin
Barbs
Interactions with alcohol, amnesia, ataxia, somnolence, mild resp depression
BDZ intoxication
Restlessness, insomnia, diuresis, mm twitching, arrhythmia, tachycardia, flushed face, psychomotor agitation
Caffeine intoxication
Restlessness, insomnia, anxiety, arrhythmias
Nicotine intoxication
Med to avoid in eating disorders because associated with lowering seizure threshold
Buproprion
Hypnagogic vs hypnopompic hallucinations
Gogic: going to sleep
Pompic: waking up
Tx Narcolepsy
Amphetamines, scheduled naps, SSRI for cataplexy
Central vs obstructive sleep apnea
Central: both airflow and resp effort cease – morning HA common
Obstructive: airflow ceases 2/2 obstruction - snoring, obesity, male gender, deviated nasal septum,
Complications of sleep apnea
Sudden death HA Depression inc SP Pulm HTN
TX Central vs Obstructive sleep apnea
CSA: BiPAP
OSA: CPAP
Risk factors for suicide
SAD PERSONS
Sex- male A - age >45 Depression Previous attempt Ethanol..substance abuse Rational thought Sickness-chronic illness Organized plan/access to weapons No spouse Social support lacking
Antipsych med that causes retinal pigments deposits
Thioridazine
Antipsych med that causesjaundice and photosensitivity
Chlorpromazine
Atypical antipsych: weight gain, sedation, hypotension, dry mouth
Olanzapine
Atypical antipsych: sedation, orthostatis hypotension, akathisia, weight gain, dry mouth
Quetiapine
Atypical antipsych: nausea, weakness, QT prolongation
Ziprasidone
Atypical antipsych: HA, nausea, akathisia, tremor, constipation
Aripripazole
Atypical antipsych: PDism, dystonia, dyskinesia, akathasia, QT prolongation
Paliperidone
Atypical antipsych: orthostatic hypotension, weight gain, metabolix syndtome, sedation, constipation
Clozapine
Reversible amnesia for personal identity; unplanned travel or wandering. Does remember event upon returning
Dissociative fugue
Somatiform vs factitious
Somatiform: do not inttentionally create Sx
Factitious: create Sx