Psych Block 1 Flashcards
Define Delusion
Fixed beliefs that cannot be altered despite conflicting evidence
Define Hallucination
Perception like experiences that occur w/out external stimulus
How can a provider deduce a PT has disorganized thinking?
Inferred by PTs speech-
switching from topic to topic (derailment)
vague or unrelated answers (tangentiality)
Define Catatonic Behavior
Decreased in reactivity to the environment
Resistant to instructions or lack of responses
Excessive/purposeless activity w/out cause
Dx criteria for delusional disorder
One or more delusions x 1mon or more
Criteria for Schiz has not been met
Function and behavior are not bizarre/odd
Brief manic/depressive episodes
Body dismorphic/OCD doesn’t contribute to Sx
Define Erotomanic Type
Define Grandiose Type
Another person is in love with them
Great but unrecognized talent/insight of a great discovery
Define Jealous Type
Define Persecutory Type
Delusion spouse/lover is unfaithful
Delusion of being conspired against or obstructed in pursuit of long term goals
Define Somatic Type
Define Mixed Type
Delusion involving bodily functions or sensation
No one delusional theme is dominant
Define Unspecified Type
Define a Delusion w/ Bizarre Content
Dominant delusion can’t be determined or not described as a specific type
Delusion is bizarre if clearly implausible, not understandable and not derived from ordinary life experiences
Define Delusional Disorder
Presence of one delusion for at least a month and unable to meet Schizo Dx
Function not impaired and behavior is not odd
Bipolar Sx considered mild to delusions
Not better explained
What needs to be assessed and considered prior to giving a Dx of Delusional Disorder
Sx of Cognition, Depression, and Mania
These are critical distinctions between schizo and other psych d/o
How is Delusional Disorder treated?
Prevent harm to self/others
Anti-psychotics- DOC
Antidepressants may be used in conjunction if significant depression exists
Define Brief Psychotic Disorder
At least one of:
Delusion, Hallucination, Disorganized Speech that lasts for one day but returns to normal within a month and is not better explained
Essential: sudden onset of one positive psychotic Sx
How is Brief Psychotic Disorder treated?
Prevent harm to self or others
Full medical eval and brain imaging considered in 1st episodes of psychosis
Anti-psychotics- DOC
Antidepressants can be used in conjunction
Define Schizophrenia
To make a Dx, what is required?
Range of cognitive, behavioral and emotional dysfunction w/ no single one being pathognomonic
Dx requires resence of delusion or hallucinations in absence of mood episodes
If a Dx of ASD/childhood communication disorder is made, it’s only made if ?
Prominent delusions or hallucinations are present in addition to schizophrenia Sx
What are the characteristics Sxs of schizophrenia?
A Dx requires ?
Must have 2 of 5, most of the time, for at least 1mon:
Delusions
Hallucinations
Disorganized speech
Disorganized behavior/catatonia
Negative Sx- Diminished emotional expression/avolition
Decreased level of function in one area of life
What are the suicidal risks of schizophrenic PTs?
5-6% of PTs die by suicide
20% attempt
Sometimes is a response to command hallucinations
Remains high throughout life
What is the Tx plan for Schizophrenia PTs?
Prevent harm to self or others
Medical eval and imaging during first psychosis episode
Anti-psychotics- DOC
Antidepressant may be used in conjunction
Define Insomnia
Unhappy w/ quantity or quality of one of:
Cant get to sleep
Cant stay asleep
When is Insomnia clinically significant
3 nights a week for at least 3mon and with adequate opportunity to sleep
What is the essential feature of insomnia
Unsatisfactory quantity/quality of sleep with getting to/staying asleep that frequently presents w/ non-restorative sleep w/ daytime impairment and night time difficulty
What are the non-pharmacological methods for treating insomnia?
Cognitive therapy- as effective as Zolpidem w/ benefits sustained 1yr post-treatment
Sleep hygiene
What are the pharmacological methods for treating insomnia?
Diphenhydramine Hydroxyzine Lorazepam Zolpidem- risk of amnesia Zaleplon Eszopiclone
Define Hypersomnolence Disorder
Excessive sleepiness despite 7hrs of sleep and one of:
Recurrent periods of day sleep
Prolonged non-restorative sleep of 9hrs
Difficulty being fully awake after abrupt awakening
3x/wk for 3mon
Hypersomnolence disorder may also present with what odd Sx?
Automatic behavior- driving for miles w/out memory
Long daytime napes
Sleep that develops over time VS in attacks
How is hypersomnolence disorder treated?
Encourage hygiene
Evaluate/treat comorbidities
Refer to sleep medicine specialist
Define Narcolepsy
Recurrent irrepressible need to sleep, lapsing into sleep or napping in the same day
3 x/wk x 3mon with one of:
Cataplexy
Hypocretin deficiency
Polysomnography showing dec sleep latency
Define Cataplexy
PT is awake and aware of brief episodes of sudden, bilateral loss of muscle tone precipitated by emotions
What must be present for PTs to meet Criterion B1 of Cataplexy?
Triggered by laughter/joking
Must occur a few times/mon
Not confused as weakness/after triggers (stress, anxiety)
How is Narcolepsy treated?
Stimulants- dextramphetamine sulfate
Modafinil- side effect of HA and anxiety, less abuse risk
What are the criteria to be met for a Dx of Obstructive Sleep Apnea Hypopnea
Evidence of 5 obstructive apneas/hr of sleep and either:
Snoring, gasping, breathing pause
Daytime sleepiness/fatigue
Evidence of 15 apneas/hr regardless of Sxs
Define Obstructive Sleep Apnea Hypopnea
Repeated episodes of upper airway obstruction during sleep most commonly a breathing related sleep disorder
What must be paid specific/particular attention to in Obstructive Sleep Apnea Hypopnea?
Occurring in association to snoring/breathing pauses
Findings that inc risk of Dx
How is Obstructive Sleep Apnea Hypopnea treated?
Aimed at Sx resolution and reducing comorbid conditions
PAP or dental device to reduce obstruction/inc oxygenation
Define Circadian Rhythm Sleep-Wake Disorder
Sleep disruption related to altered rhythm leading to excessive sleepiness
What are the prominent features of Circadian Rhythm Sleep-Wake Disorder?
Sleep onset insomnia
Difficult waking
Excessive early day sleepiness
What do PTs with Circadian Rhythm Sleep-Wake Disorder exhibit when they’re allowed to set their own schedules?
PTs w/ delayed sleep phase type exhibit normal sleep quality and duration for their age range
What is the treatment for Circadian Rhythm Sleep-Wake Disorder
Reorganization of rhythm Improve sleep hygiene Melatonin Zolpidem Benzodiazepine
Define Restless Leg Syndrome
Urge to move legs due to uncomfortable sensation with inc urge during rest AND urge to move is releived by movement AND urge worsens in evening/only in evening
How is Restless Leg Syndrome treated?
Some behavior therapies
Avoid aggravating factors
Fe replacement
What pharmacetuical therapies can be used for chronic Restless Leg Syndrome?
Dopamine agonist- Ropinirole FIRST LINE
Gabapentin
Low dose benzo- Clonazepam
Define Substance/Medication Induced Sleep Disorder
Sleep disurbance with both:
Starts after new medication
New med is capable of disurpting sleep
Doesn’t happen exclusively during delirium
What hand out/paper can PTs fill out to rate their sleep issues?
Epworth Sleep Scale
STOP-BANG Sleep Apnea
What does STOP-BAND stand for?
Snore
Tired
Observed breathing cessation
Pressure, treatment for HTN
BMi +35kg
Age +50
Neck >16”
Gender Male
Criteria of Bipolar 1
Elevated mood for 1 week or needing hospitalization
At least 3 of: I STAGED
Ideas Sleep Talkative Activities Goal Esteem Distractability
Severe impairment needing hospitalization/psychotic features
No effects of a substance
Criteria of Bipolar 2
Elevated mood for 4 days
At least 3 of: I STAGED
Ideas Sleep Talkative Activities Goal Esteem Distractability
Uncharacteristic behavior change observable by others
No hospitalization/Substances
What are the big/key word differences between Bipolar 1 and 2?
1= 1wk or needing hospitalization, severe impairment
2= 4 days, not severe enough for admission
Simply put, how can a Dx of Bipolar 1 be made?
Manic episode not related to something else= Dx since the essential feature is the manic episode
Characteristics of Bipolar 1
No depression/hypomania "Top of the world" Rapidly shifting emotions Delusional level of self esteem Dec need for sleep- COMMON Resistant to efforts of Tx 15x higher Suicide risk of GenPop
What is the acute management of Bipolar 1
Valproic Acid- broader safety index
Lithium- risky, x S/e/Interaction
2nd generation antipsychotic +/- Benzos- GREAT for acute management/rapid cyclers
What is the long term management of Bipolar 1 AND Bipolar 2?
First Line- stay on SAME meds that controlled acute S/Sx Second line- Lithium- dec SIs Valproate Quetiapin Lamotrigine
Simply put, how is a Dx of Bipolar 2 made?
Hypomanic episode and depressive episode= Dx
Bipolar 2 Characteristics
Recurring mood episodes- at least one depressive, one hypomanic
Typically- major depressive w/out complaint
High suicide risk, HIGHER lethality than BP1
How is Bipolar 2 treated?
Same as Bipolar 1:
Valproic Acid- broader safety index
Lithium- risky, x S/e/Interaction
2nd generation antipsychotic +/- Benzos- GREAT for acute management/rapid cyclers
Define MDD
Depressed mood or loss of interest/pleasure PLUS four x 2 wks: Sleep Interest Guilt Energy Concentration Appetite Psychomotor SI/HI
What is the common presenting complaint of MDD?
What Sx is more rare but it’s presence signifies a severe case?
Fatigue or Insomnia
Psychomotor Sxs
What is unique about MDDs suicide Hx?
What are the other risk factors that can magnify MDD?
Most completed attempts are not preceded by failed attempts
Male, alone, single, feeling hopeless
Presence of borderline personality d/o= huge inc risk
What are the variations of MDD?
Melancholic depression MDD w/ seasonal onset MDD w/ peripartum onset Dysthmia Premenstrual dysphoric d/o
What is the non-pharmacologic treatment methods for MDD?
CBT- key to good plan for depressed PTs
Electroconvulsive therapy
Phototherapy
When is electroconvulsive therapy considered for MDD PTs?
Meds can't be used Extreme suicide risk Memory disturbance HA Causes generalized seizures Works best for severe depression
What meds are used for MDD?
SSRIs
SNRI- benefit of pain control
What is used for PTs with MDD and sexual dysfunction?
PO phosphodiesterase 5 inhibitors- Sildenafil
Adjunct of Buproprion
What med is added on to PTs with MDD but have acute MI or unstable angina?
Sertraline
What are the risks of TCA use in MDD Tx?
Use w/ caution in cardiac PTs
Lowers seizure threshold
When are MAOIs used for MDD Tx?
Third in line if at all
When are stimulants used in Tx of MDD?
Effective short term Tx or refractory depression
What are the next steps in MDD Tx if initial response to meds is poor?
Reassess Dx
Trial of second meds after appropriate wash out period
What adjuncts can be given to MDD PTs going through wash out periods prior to Rx of second medication?
If you’re at this point of treatment, what is considered?
Lithium
Buspirone
Thyroid hormone
Consider specialist help and taper when coming off med
A consideration for full dosage indefinitely for MDD PT if what criteria is met?
First episode before 20 or after 50
Over 40 w/ 2 episodes
One episode after 50
3 episodes over lifetime
Define Persistent Depressive Disorder
Depressed mood most of the day, more days than not lasting for 2yrs plus two:
Appetite, sleep, energy, self esteem, concentration or hopelessness
No remission of 2mon
No mania, hypomania, cyclothymia
What is the essential feature of Persistent Depressive Disorder?
Depressive mood for 2yrs
Sx are a part of daily life and limit them from seeking help
What is the treatment plan for Persistent Depressive Disorder
Treat as MDD
What questionnaire can be filled out by PTs w/ suspected Persistent Depressive Disorder
Patient Health Questionnaire 2
Define Obsessions
Recurrent and persistent thoughts, urges or images that are experienced, intrusive and unwanted
Define Compulsion
Repetitive behaviors or mental acts that an individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly
What is the criteria for a PT to have an Obsession?
Recurrent/persistent thoughts/urges/images that are intrusive/unwanted and cause anxiety and attempts to ignore/suppress the unwanted w/ another thought/action
What is the criteria for a PT to have a Compulsion?
Repetitive behavior/mental act done in response to an obsession/according to rules
Acts aimed at preventing/reducing anxiety/stress or behaviors not realistically connected that are time consuming, clinically significant or impairing function
What specifications have to be made with OCD?
Good/fair insight- thoughts are not/probably not true
Poor insight- probably true
Absent insight/delusional- convinced they are true
What is the characteristic feature of OCD?
Presence of obsession and compulsions
Individuals with OCD tend to have ?
Dysfunctional beliefs Inflated sense of responsibility Overestimates threats Perfectionists Need to ontrol thoughts 30% have a tic in lifetime Common in males
How prevelant is suicide in OCD PTs?
SI for half of PTs
Attempts for 1/4 of PTs
What are the non-pharmacologic treatments for OCD?
Systemic desensitization
CBT
What are the pharmacologic options for treating OCD?
SSRI
Clomipramine- TCA
Define Body Dysmorphic Disorder
Perceived defects in physical appearance not observable to others
PT has performed repetitive behaviors/mental acts in response to concerns
What are the most common areas of concern in body dysmophic disorder?
Skin
Hair
Nose
Define Nidus
Area of concern in body dysmorphic disorder
What are some common repetitive behaviors seen in body dysmorphic disorder?
Comparison Checking mirrors Excessive grooming Camouflaging Seeks reassurance
What is the suicide prevalence in body dysmorphic disorder?
High in adults and adolescents
What are the non/pharmacologic treatments for body dysmorphic?
Non- therapy
Pharm- SSRIs
Clomipramine- TCA
Define Hoarding Disorder
Difficulty discarding possessions
Perceived need to save item
Distress w/ discarding
Accumulation of possessions that congests/clutters living areas
What is the essential feature of hoarding disorder?
Long standing difficulty discarding items regardless of value that is not a transient issue
How is Hoarding Disorder treated?
Difficult, CBT and SSRI
Define Trichotillomania
Hair pulling disorder most commonly in scalp, eye brow and eye lid area
What are the non-pharmaceutical ways for treating Trichotillomania
Biofeedback
Desensitization
Habit reversal
What are the pharmaceutical ways for treating Trichotillomania
In conjunction w/ Derm: Topical steroids Hydroxyzine Antidepressants Antipsychotics
Define Excoriation
Skin picking disorder usually in face, arms and hands
How is Excoriation treated?
CBT and habit reversal
Fluoxetine
Naltrexone
Define Somatic Sx
Sx associated w/ somatic nervous system
Pain, tremor, fatigue, paralysis, SoB
Define Somatization
Physical Sx that mimics a dz that isn’t there
Psychological distress felt in physical form
What is the criteria for Somatic Symptom Disorder
One somatic Sx w/ disruption to normal life
Excessive thought/feelin/behavior with at least one of:
Thoughts OOPT seriousness
High anxiety about Sx
Excessive time devoted to Sx
State of Sx continuously present
How is Somatic Symptom Disorder categorized into Mild, Moderate or Severe?
Mild- One criterion
Mod- two or more criterion
Severe- two or more criteria plus multiple somatic complaints, or one severe Sx
(persistent, anxiety, time)
What is the treatment plan for Somatic Symptom Disorder?
Non-Pharm: Social/Peer support
Pharm: Refractory cases respond to SSRI/SNRI
Don’t use medications to replace appointments
Define Illness Anxiety Disorder
Worried they MAY have/will get a serious illness w/ or w/out somatic Sxs
High anxiety about health and excessive health related behavior x 6mon
How is Illness Anxiety Disorder treated?
Same as Somatic Sx Disorder- therapy, education and support
Define Conversion Disorder
One Sx of altered voluntary motor/sensory function
Objective evidence of incompatibility between Sx and neuro disoder
What are the 3 criteria for Conversion Disorder symptoms?
Motor- weak/paralysis, tremors, abnormal posturing, speech changes
Sensory- abnormal sensation, vision/hearing changes, globus sensation
Could mimic seizure, syncope or coma
How is Conversion Disorder treated?
Non-Pharm- hypnosis
Pharm- none really help
Define Factitious Disorder
Falsified S/Sx or induced injury/dz with identified deception presenting them self as affected
Deception evident w/out sings of secondary gain
How is Factitious Disorder treated?
Early Psych- conjoint confrontation, biofeedback, self-hypnosis
Define Specific Phobia
Fear/anxiety OOPT about specific object/thing that provokes immediate fear/anxiety and occuring for +6mon
How are specific phobias treated?
Behavioral: desensitization BCT- combo of this and Rx is better than monotherapy SSRI/SNRI Gabapentin Propranolol- performance anxiety
Define Social Anxiety Disorder
Fear OOPT about social situation where they’re exposed to scrutiny and expressing anxiety Sx will be negatively evaluated
What odd characteristics can PTs w/ Social Anxiety Disorder show?
Inadequately assertive, submissive or highly controlling
How is Social Anxiety Disorder treated?
Desensitization CBT in combo w/ meds SSRI/SNRI Gabapentin Propranolol- performance anxiety
Define Panic Disorder
Unexpected panic attack w/ 4 associated Sxs that are not culturally normal- CHASTS
CC STANDS PDF
Within the last month an attack was followed by: Worrying about more attacks or maladaptive change in behavior
How is Panic Disorder treated?
Relaxation training
Desensitization- can work as well as meds
CBT w/ med combo
Anti-Depressants are DOC- SSRI/SNRI/TCA
Benzo- acute management
Propranolol- improves peripheral Sx w/out impacting motor/cognitive performance
Define Agoraphobia
OOP Anxiety in 2 of 5 situations and avoids them due to difficult escape or limited help/companion Public transportation Enclosed areas Open areas Being out of the home Standing in lines
How is Agoraphobia treated?
Peer support- groups are helpful
SSRI/SNRI
Gabapentin
Define Generalized Anxiety Disorder
Excessive worry about multiples things, more days than not, for more than 6mon and worry is difficult to control w/ 3 or more Sx (one Sx of bang);
FIRMS DC
Fatigue Irritable Restless Muscle tension Sleep disturbed Difficulty Concentrating
How is Generalized Anxiety Disorder treated
Relaxation/Desensitization CBT Antidepressants- Fist line treatment, can be anxiogenic Benzo- avoid if possible Buspirone Gabapentin Propranolol
What is the anxiety screening tool?
GAD-7
Screening tool, not Dx aid
What makes up the Psych Interview
CC HoPI Mental Status Exam AMSIT Further eval
What is the acronym for conducting a mental status exam
AMSIT Appearance, behavior Mood Sensorium Intelligence Thoughts
How is a PTs attention assessed during an interview?
Serial 7s
Spelling backward
How is a PTs intelligence/cognition or higher cognitive functions assessed during an interview?
Calculating ability
Proverb interpretation
What is assessed when analyzing a PTs thoughts, perceptions, judgement, or insight during a psych interview?
Circumstantialities Derailment Flight of ideas Neologisms Incoherence Blocking Confabulation Perseveration Echolalia Clanging
How is a PTs insight/judgement assessed during an interview?
Insight:
Parable interpretation
Interpret events of personal Hx
Judgement:
Constructional ability- clock/figure drawing
What labs/rads can be used in the psychiatric interview?
Labs- heavy metals, toxins, infection
EEG
UDS- urine drug screen
What psych tests can be performed?
IQ test PHQ-2 PHQ-9 GAD-7 ESS ADHD questionnaire
What are the EPS side effects of SSRIs?
Akathisia
Dystonias
Parkinsonian syndrome
Define Serotonin Syndrome
Triad of abnormalities:
Cognitive effects- CANA
Neuromuscular- MRHT
Autonomic dysfunction- HHDT
How is Serotonin Syndrome treated?
With drawl of agent and supportive care for anxiety/seizures w/ Benzos
What are the top 4 Sx of each part of the Serotonin Syndrome triads?
Cognitive- confusion, agitation, coma, anxiety
Neuromuscular- myoclonus, hyperflexia, rigidity, tremor
Autonomic- hyperthermia, diaphoresis, tachycardia, HTN
Which SSRI is safe for abrupt d/c due to it’s long half life?
Fluoxetine
Which SSRI has an FDA warning on it for cardiac reasons and which med doesn’t have that warning?
QT prolongations w/ Citalopram at doses higher than 40mg/day
Escitalopram- no warning
What are the two main SNRIs
Duloxetine
Venlafaxine
What are the NDRIs
Bupropion- less sex dysfunction
What are the Serotonin Receptor Antagonists
Trazodone
Mirtazapine
Nefazodone
When are specific SSRIs avoided?
Paroxetine- over weight
Citalopram- QT prolongation
Fluoxetine/Sertraline- aggitation, insomnia, pregnancy
Paroxetine- elderly
When are Circumstantialities usually seen?
When is Derailment commonly seen?
Common in pt’s with obsessions
Common in schizophrenia/mania/psychosis
Flight of Ideas are common in
Confabulation is commonly seen in
Mania
amnesia
Incoherence is commonly seen in ?
Echolalia is commonly seen in ?
schizophrenia, 24hr cable news channels
repetition of words and phrases - Autism
All meds classified as antidepressants increase ?
Concentration of NorEpi, Dopamine and/or Serotonin
What are the 3 ways antidepressants increase neurotransmitters?
What pregnancy category do they fall in?
Inhibit re-uptake
Block degredation
Increase release
Most are Category C
Where is serotonin released from?
Where does serotonin re-uptake occur?
Raphe neurons that project into limbic structures
Into presynaptic neuron
What are the 6 common SSRIs?
FF SPEC Fluoxetine Fluvoxamine Paroxetine Sertraline Citalopram Escitalopram
What are the adverse effects of taking SSRIs
GI- nausea, diarrhea, constipation CNS: agitation, tremor, panic Sexual Dysfuntion Serotonin Syndrome EPS- akathisia, dystonia, parkinsonian Sx
What SSRIs are most activating?
Who needs to avoid these and when are they taken?
Fluxetine Sertraline
Avoid PTs w/ sleep difficulty
Take in the morning
What SSRIs are most sedating?
What is the side effect of this group?
Paroxetine- worst weight gain
Fluvoxamine
All SSRIs have reports of EPS side effects, but which one has the most reports?
Paroxetine
What are the common side effects of SNRI?
SHINS Somnolence HA Insomnia Nausea Sex dysfunction,
What are the cautions/warning of TCA use?
DC SAP
Life threatening
Delirium Coma Seizure Arrhythmia Psychosis
What type of PT should not be given TCAs?
Suicidal ideations Cardiovascular issues Close angle glaucoma Urinary retention Prostate hypertrophy
What are the adverse effects of TCAs?
Anticholinergic effect- dry mouth, urine retention, constipation, blurred vision and will worsen BPH
TCA dry mouth side effect is linked to ?
Weight gain due to tendency to drink caloric beverages
PTs with which cardiovascular issues can take TCAs with caution?
Ischemic heart disease
Arrhythmia
Conduction disturbance
What are the adverse effects of taking Bupropion
HIIND
HA, Insomnia, Irritability, N/V, Dec appetite
Less sex dysfunction than other anti-depressants
What PTs are contraindicated to use Bupropion?
Seizures
Hx of anorexia/bulemia
Use/withdrawing from Benzo or ETOH
Function and use of Trazodone
Serotonin Receptor Agonist
Depression and Insomnia
Function and use of Mirtazapine
Depression w/ SSRI but has profound sedative effect
Function and use of Nefazodone
Anxious depression or when SSRIs cause too much sex dysfunction
Black Box warning- liver failure
What is taken into considereation when selecting an antidepressant
Previous response of PT/Family to antidepressants
Side effects
Interactions
Comorbid conditions
How long is an antidepressant taken before it can be considered a failure?
Full therapeutic dose for 2-8wks or up to 12wks
Response and remission while taking antidepressants means ?
50% reduction of Sx
Vortioxetine us is avoided with PTs with what primary concern?
Nausea
Avoid Mirtazapine in what PTs?
Obese
Hyperlipidemia
What are the 3 phases of antidepressant therapy?
Acute- resolve Sx
Continuation- Sx in remission w/ full dose therapy
Maintenance- long term therapy at full dose in high risk PTs to Whprevent relapses
When is depression classified as treatment resistant?
Two or more agents from different classes have been tried
What medications can be used as augmentation therapy in antidepressants?
Lithium- treatment resistant depression
Buspirone
Atypical antipsychotics
Electroconvulsive therapy
Which antidepressants are linked with pregnancy risks?
Fluoxetine- low birth weight
Paroxetine- heart defects
What are the two generations of antipsychotics available for treatment?
First Gen- typical
Second gen- atypical
Pharmacotherapy selection of antipsychotic depends on ? criteria?
PTs previous experience with antipsychotic Adverse events Concomitant conditions Medicine interactions PTs preferences
What are the typical antipsychotics?
What are the atypicals?
Cant Have Lucid Memories Try da xene
CRAPOLA IZ
What does the APA recommend when it comes to prescirbing antipsychotics?
Use Atypical first due to less EPS risk
PTs w/ preference or +Hx w/ typical may use them first
Max treatment may take 6mon
After treatment is observed, maintain for 6mon
What are the adverse reactions of antipsychotics?
Dystonia
Tardive Dyskinesia
Akathesia- most common EPS
Sex dysfunction
What is the black box warning of antipsychotics?
Inc mortality in elderly PTs w/ dimentia
Which antipsychotics are low potency typicals?
Chlorpromazine IV or PO
Thioridazine PO
Which antipsychotics are high potency typicals?
Trifluoperazine PO
Fluphenzaine IM
Haloperidol IV IM PO
Why were atypical/2nd generation antipsychotics developed?
Reduce EPS, tardive dyskinesia and improved efficacy for positive Sx (except Clozapine)
Which second generation antipsychotics are PO, IV or IM?
PO- all
IV- Aripi, Olanz
IM- Risper, Paliperi, Zipra
Most antipsychotics are pregnancy category ?
What is the catch though?
C
But, risk of EPS signs and withdrawl in neonates whose mother used antipsychs during 3rd trimester
What kind of binding do Benzos exervise?
Allosteric
Benzos are differentiated by properties, ones that have long half lives have what characteristics?
Effects last all day
Less pronounced with drawl Sx
More hangover Sx
Benzos are differentiated by properties, ones that have short half lives have what characteristics?
Quicker control of Sx
Acute management
Quick tolerance development
Breakthrough Sx- withdraw is common
Which Benzos are short acting?
TOM
Midazolam
Oxasepam
Triazolam
Which Benzos are intermediate acting?
LATE Lorazepam Alpazolam Temazepam Estazolam
Which Benzos are long acting?
CCD FQ Chlordiazepoxide Clonazepam Diazepam Flurazepam Quazepam
What are the adverse effects of using Benzos?
Daytime Hangover- especially in long half life Benzos
Rebound insomnia- if d/c abrupt
Anterograde amnesia- preferred for surgery
Benzo treatment periods should be restricted to what time frame?
3-4mon as a bridge initiation of chronic therapy
If long term use, tapered for months or even over a year
What are the with drawl Sx of Benzos?
Seizure Psychosis Disturbed sleep Tremor Nauseau Muscle ache Anxiety Depression/confusion
What is the rule for using Benzos?
Use lowest effective dose of a longer half life for the shorted period possible
What is the rescue agent of Benzos?
Flumazenil IV- short acting so may need multiple doses to reverse long acting Benzos
PTs with ? Hx should not be given Flumazenil
Seizures
What meds can be used for Bipolar Dz?
Lithium
Anticonvulsants- Divalproex, Carbamazepine, Lamotrigine, Topiramate
Antipsychotics- all atypicals for acute mania except Clozapine and Iloperiodone
Benzos- Lorazepam, Diazepam
When is Lithium for Bipolar used?
Stabilize moods during manic phase
Doesn’t work on rapid cycles- 4 or more/year
What drugs are used as adjuncts with Lithium to cover agitation or other Sx?
Antipsychotics
Benzos
When are antipsychotics d/c in Bipolar PTs?
When manic phase is resolved
What labs are performed in a pre-lithium work up?
CBC E= Renal function Thryoid function UA ECG Pregnancy
Lithium has a narrow index and requires serum blood monitoring between what ranges?
0.8-1.2mEq/L
What conditions can cause Lithium levels in the body to rise?
Dehydration Fever Vomit Crash diet Na restricted diets
When is Lithium adverse effects most common?
During initiation or after dose changes
What are the S/sx of Lithium toxicity?
Lethargy Tremor Confusion Neuro/Psych Seizure Coma Cardiac dysrhythmias Dec thyroid function
What is the thyroid risk in long term Lithium use?
Hypothyroid and TSH induced toxic goiters
What drugs interact w/ Lithium
NSAIDs
Thiazides
ACEIs
K Sparing
If Lithium toxicity occurs, what steps are taken to help the PT?
D/c Lithium
Empty stomach contents
If level was >3mEq/L= dialysis
What anticonvulsants can be used in Bipolar?
Why do these need to be used cautiously?
Valproic Acid derivatives
Carbamazepine
Lamotrigine
Topiramate
Linked to depression
When are Valproic Acid compounds, Carbamazepine and Lamotrigine more effective than Lithium?
Rapid Cycling
Comorbid substance abuse
Secondary bipolar d/o
Mixed mania
Why are Valproic Acid derivatives used in Bipolar?
Acute/prophylactic management
When is Carbamazepine used in Bipolar?
Acute mania
Maintenance therapy
Added to Lithium for PTs who have responded to monotherapy
When is Lamotrigine used for Bipolar?
Maintenance therapy
Children with a specific phobia may demonstrate ? behavior?
Crying
Tantrums
Freezing
Clinging
How is the severity of a panic attack measured?
What is the criteria for moderate and less frequent categories?
Full Sx- 4+
Limited Sx >4
Moderate: 1/wk x months
Less: two/mon x years
What are the two types of Illness Anxiety Disorder?
Care Seeking- multiples appts with multiple tests
Care avoidant- avoids hospitals and appointments
What are the differences between Illness Anxiety and Somatic Sx Disorder?
SSxD/o- Sx is present, usually more than 1, suffering is authentic, Sx state is +6mon
IAD/o- No Sxs or one mild one is present, no real suffering, illness preoccupation present +6mon
Define Cyclothymic
Chronic fluctuating mood disturbance involving numerous periods of hypomanic Sx and periods of depressive Sxs that are distinct from each other
Dx only made if criteria for MDD, manic or hypomanic episodes are not met
Define Schizoaffective Disorder
Uninterrupted period of illness
Schizophrenia criteria is met, but there is a major mood episode- pervasive depressed mood
Define Schizophreniform Disorder
Identical to schizophrenia but duration is different- at least 1 mon but less than 6mon
(episode lasts for 1-6mon)
Define Schizotypal disorder
Acute discomfort and reduced capacity for close relationships
Define Rapid Eye Movement Sleep Behavior Disorder
Vocal and/or complex motor behaviors from REM sleep suck as being attacked or escaping from danger while eyes remain SHUT
Upon awakening- individual is awake, alert and orientated
Define Non-Rapid Eye Movement Sleep Arousal Disorder
Eyes are OPEN with various levels of awareness and motor activity
Define Sleep Related Hypoventilation
Medical/neuro disorder, medication use or substance use disorder
Morning HA, fatigue, sleepiness
Define Central Sleep Apnea
Disorder of ventilatory control characterized by sleepiness, insomnia and awakening due to dyspnea with 5 or more apneas per hour
HF, stroke or renal failure
When is Bupropion used?
When is Buspropion used?
SOFPS Smoker Obese Fatigue Psychomotor slowing Sex Dysfunction
BusPro- augment antidepressant therapy
One of the adverse effects of antipsychotics is Dystonia, which means?
Define Tardive Dyskinesia
Define Akathesia
Abnormal tonicity, Severe muscle spasm of head, neck and tongue
Involuntary movement of face, mouth, tongue, trunk and limbs
Desire to be in constant motion
What are the 4 times to use Propranolol?
Specific Phobias
Social Anxiety
Panic attacks
GAD
Three drugs better for use than Lithium?
CVL
ConVuLse
