Psych - Case Files, UW, etc. Flashcards
What is the risk of recurrence of a major depressive episode if SSRIs or other treatments are discontinued?
50-85%
What are the major side effects of SSRIs?
GI sx (pain, nausea, diarrhea), sleep disturb (sedation or insomnia), tremor, dizzy, sex dysfunction
What is retinitis pigmentosa, and which psychiatric medication can cause this disorder?
Pigmentation of retina that may cause poor night vision
Side effect of first generation AP Thioridazine
What is an appropriate treatment of priapism from Trazadone?
Epinephrine injection into corpus of penis
What are contraindications for using bupropion?
Patients with eating or seizure disorder
What are symptoms of life threatening lithium overdose, and how do you best treat?
Seizures and coma
Dialysis to treat
What can be useful for excessive daytime sleepiness in shift workers?
Modafinil
What must be ruled out to make a diagnosis of schizophrenia?
Psychosis secondary to substance abuse and or general medical conditions
Schizoaffective DO and mood DO must be R/O
What symptom is most specific to a diagnosis of schizophrenia?
Bizarre delusions
What symptom is most specific to a diagnosis of schizophrenia?
Bizarre delusions
What is the immediate treatment for panic attacks? Long term treatment for panic disorder?
- Short acting benzo (alprazolam) - discontinue after initial few weeks
- SSRI + CBT
What is the definition of agoraphobia?
Anxiety about being in situations or places from which escape will be difficult, or in which help may not come if panic attack occurs
What differentiates social phobia vs. specific phobia?
Social phobia involves social or performance situations while specific involves a specific object or situation
How can ADHD be differentiated from hypo mania?
ADHD has distractibility, impulsivity and hyperactivity present on daily basis since age 7 (also look for preschool age sx)
And often oppositional defiant disorder and conduct disorder present
What needs to be monitored closely in patients taking lithium or carbamazepine?
Li - thyroid and kidney fxn
Carba - aplastic anemia or agranulocytosis
What mood stabilizers are a better option in young women of child bearing age?
Atypical APs - olanzapine risperidone seroquel
How can one differentiate schizoid PD from avoidant?
Avoidant find loneliness as ego-dystonic and strongly wish for relationships with others
Schizoid do not feel need for relationships at all
What defense mechanism is frequently seen in schizoid PD?
Intellectualization
What is the best course of therapy for major depression with psychotic features? (Especially in elderly with SI)
ECT
What medical conditions should raise caution before doing ECT?
Raised ICP, unstable angina, recent MI, electrolyte imbalance
What pharma tx can be given for anxiety associated with performance situation just before the feared situation?
Beta blockers - atenolol and propranolol
What are typical exam findings of PCP intoxication?
Angry, belligerent, dysarthria, vertical nystagmus
How does treatment for PCP intoxication vary based on the symptoms?
Benzodiazepines if psychotic symptoms not present
Haldol if severe psychosis but this may worsen anti-cholinergic side effects, hyperthermia, dystonia
What should be avoided in patients with generalized anxiety disorder?
Benzodiazepines, because habit forming and will make buspirone and to lesser extent SSRIs less effective
What are PANDAS?
Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections
Include OCD and other disorders
What is the triad of wernicke encephalopathy?
Acute reversible triad of delirium, 6th nerve palsy, ataxia, caused by thiamine deficiency
What are the CAGE questions?
Have you attempted to Cut down on drinking, Annoyed by criticism, Guilty for drinking,Eye opener
Yes to 2 or more is sensitive for EtOh dependence
What is the most sensitive test for delirium and what will it show?
EEG, generalized slowing
If delirium by EtOH or sedative hypnotic withdrawal, can show fast low voltage activity
Hepatic encephalopathy - triphasic delta waves
How do depressed youth often present to their pediatrician?
Sudden onset anger and irritability, lack of interest in fun activities, low E, poor grades
What are the key features of OCPD and how do you differentiate from OCD?
INFLEXIBLE THINKING AND BEHAVIOR - Difficulty making decisions and finishing work, blames others for problems (egosyntonic), rigid and stubborn manner
w/ OCPD there are no intrusive repetitive thoughts or ritualistic behaviors as with OCD
What are the preferred treatments for OCD?
SSRI or clomipramine are first line pharma
CBT-evoked response prevention taught to manage anxiety
What are the features of somatization disorder?
Numerous somatic complaints related to several body areas, not full explained by medical cause.
Focus is on symptoms themselves not fear of specific disease or defect
What is the best treatment for Schizoaffective DO depressive subtype?
2nd gen AP
Add SSRI only if mood sx don’t improve with AP
What should be used for treating ADHD when there are concurrent substance abuse problems? What if main meds are ineffective?
Atomoxetine
Bupropion, imipramine, nortriptyline, pemoline
What are the 5 axis’ of psychiatric diagnosis?
Axis 1: Clinical disorders (schizo, MDD)
Axis 2: Personality DO and Mental retardation
Axis 3: Physical disorders and other Gen Med conditions
Axis 4: Psychosocial problems contributing to psych prob
Axis 5: Global Assessment of Functioning
What is formication and how does it usually develop?
Hallucinated sensation that insects/snakes crawling over skin
Common SE of extensive cocaine/amphetamine use
What must be monitored in patients being treated with stimulants or atomoxetine?
Follow appetite, and monitor height and weight, because of risk of medication related growth rate changes
What is the advantage of using atomoxetine over Ritalin for ADHD? What should be avoided with Atom?
Atomoxetine begins working immediately to reduce symptoms and has longer onset of action
Don’t take on empty stomach, can cause N/V
What meds are most helpful for patients with ASD?
Hypnotics and anxiolytics in short term (beta blockers may prevent development of PTSD)
What is the defense mechanism sublimation?
Mature DM - involves satisfying socially objectionable manners in an acceptable manner (e.g. person who enjoys exerting dominance over others, becomes prison guard)
What is the difference between suppression and repression?
Suppression is a mature defensive mech and involves conscious avoidance of particular emotion/thought
Repression is immature DM and is unconscious
What are ideal characteristics for patients who are to undergo psychoanalysis?
-Age under 40, not psychotic, intelligent, stable in relationships and ADLs
What is interpersonal therapy and how is it used?
- type of psychotherapy used for Tx of depression
- focus is on the present, and specific problem areas that may interfere w/ pt self esteem and interpersonal relationships
What is the basis of the central idea behind cognitive behavioral therapy?
- Our emotions are due to our thinking (cognition)
- we may get rewarded for how we act, contributing into increase of these thoughts and actions (behavior)
What are the best treatment modalities for bulimia nervosa?
- Nutritional rehab
- CBT
- Antidepressant - SSRI (fluoxetine first, then sertraline)
What may be used by patients with bulimia to induce vomiting and what should patients be checked for?
Ipecac - can cause ipecac intoxication w/ pericardial pain, dyspnea, generalized muscle weakness; which are associated w/ HoTN, tachycardia, and ECG abnormalities
-Risk of toxic cardiomyopathy and death
What differentiates bulimia from anorexia?
Bulimia pts are less resistant to getting help, have more alcohol abuse, and have more emotional lability
-Bulimia has later onset
What drug can decrease autonomic and other sx of oops of withdrawal? MoA?
Clonidine, blocks NE neurons of locus ceruleus
What can treat sx of opioid withdrawal for patients who don’t want prescription meds?
NSAID like ibuprofen for muscle aches
Loperamide for loose stools
(Promethazine for N/V, but need script)
What are the diagnostic criteria for pain DO?
- severe distressing pain at 1 or more sites, causing fxnal impairment
- psychological factors play important part in pain
- not explained by another axis 1 DO
How can you treat patient who has overdosed on TCA?
Sodium Bicarbonate, helps with ECG abnormalities
What medication is preferred for patient with bipolar 2?
Lamotrigine - helps with depression (make sure NO mania Hx)
What antipsychotic decreases suicide risk in schizophrenia?
Clozapine
What are the signs associated with adjustment disorder?
Emotional response to specific stressor w/in 3 mo, clinically significant somatic sx, and some mood disorders (depression, anxiety, mixed, conduct DO)
What aspect of the presentation differs most with depression in adults vs Peds?
Child and adolescents more often have irritability or short temper, than sadness with depression
What other disorders occurs most along with sleep terrors?
Restless leg syndrome and sleep disordered breathing
Which medications are useful sleeping aids and how long should they be used for?
Ramelteon, Trazodone and Z-drugs
don’t use z-drugs longer than 2 weeks bc of tolerance and withdrawal symptoms
What should be the first step if seeing a new patient and suspecting somatization disorder?
Get thorough H&P and complete labs w/ blood work to r/o medical causes
What is the immediate treatment of an acute dystonic reaction?
Benztropine 2mg IM w/ repeat dose in 30min if no improvement
What is the difference between somatization and conversion DOs?
Somatization - multiple physical symptoms present for chronic length, before age of 30, not explained by any medical cause
Conversion - sx of neurologic DO w/o obvious cause or trauma (unconscious, not for external gain, internal conflict)
How can you differentiate autism spectrum DOs from Rett DO?
In Rett there is a period of normal development early on then gradual decline and loss of skills
In ASD there is evidence of disorder early on
What should be done in causes where early autism is suspected?
Full medical workup to rule out hearing/vision difficulties that may be causing poor language development
What can help to relieve some of the anxiety associated with avoidant personality DO?
Mainly CBT for APD, but SSRIs and beta-blockers can be given for anxiety
How can you differentiate autism spectrum DOs from Rett DO?
In Rett there is a period of normal development early on then gradual decline and loss of skills
In ASD there is evidence of disorder early on
What should be done in causes where early autism is suspected?
Full medical workup to rule out hearing/vision difficulties that may be causing poor language development
What can help to relieve some of the anxiety associated with avoidant personality DO?
Mainly CBT for APD, but SSRIs and beta-blockers can be given for anxiety
What is dissociative fugue?
Unexpected sudden departure from home and pt cannot recall past or identity, forges new identity; lasts hours to days, sometimes months
In setting of severe trauma or life stressor
What are predisposing factors to dissociative fugue?
Alcohol abuse, certain mood DOs, personality DOs, Hx of head trauma
What are the symptoms and time course of alcohol withdrawal?
6-8hrs: jittery and tremulous
8-12hrs: psychosis and perceptual sx
12-24hrs: seizures
24-72hrs to 1 week: DTs
What drug should be avoided in EtOH withdrawal and why?
Antipsychotics -> lower seizure threshold
What medication is preferred in the treatment of alcohol withdrawal in a patient who demonstrates poor liver function?
Lorazepam, bc metabolized solely by glucoronidation, less dependent on liver function
How can you differentiate paranoid delusions from ideations?
PD = fixed false beliefs, psychosis, require tx w/ APs
PI = paranoid personality disorder, suspiciousness NOT a Del, can be tx with reassurance
What medication can be helpful to prevent benzo withdrawal seizures in individuals prone to it?
Carbamazepine in conjunction with the benzo taper
Which benzos are more likely to cause withdrawal syndrome?
Those with shorter half lives: Alprazolam (Xanax), oxazepam, temazepam, versed
What may be a cause for anger and self destructive behavior in mentally retarded individuals?
Underlying medical condition that is causing pain
Also look for concurrent psychotic disorder that is separate from mental deficit
What two pieces of info are key in diagnosing mental retardation?
IQ score and evidence of deficits in adaptive functioning (conceptual skills, social skills, practical skills)
What is the most common cause of mental retardation?
Idiopathic or unknown
Which medications work best for agitation and psychosis from illicit drug intoxication?
Haldol and other APs
What is a patient on MAOIs consuming tyramine rich foods at risk for and what should be monitored?
Hypertensive crisis, monitor blood pressure closely
What is the treatment of akathisia?
Beta blocker or benzo
Which drugs may decrease suicidality?
Lithium and clozapine
Why do you titrate clozapine slowly?
Prevent agranulocytosis and seizures
What are the manifestations of ecstasy intoxication? What is a potentially dangerous drug interaction?
Hypertension, tachycardia, hyperthermia, hyponatremia
Can develop serotonin syndrome - autonomic dysregulation, AMS, high fever, neuromuscular irritability, and seizures (especially if pt on SSRI, MAOI, TCA etc.)
What psychological reactions do patients who ingested bath salts present with?
Amphetamine analogs - hyperactivity, combativeness, severe agitation, hyperthermia
What type of defensive mech is rationalization and what is it’s definition?
Immature - excusing an unacceptable behavior in a false but logical way, usually to avoid difficult truths
What are the main impairments present in Asperger’s syndrome?
Impairment in reciprocal social interactions and restricted interests. Desire relationships, lack awareness of social conventions. Normal language development
What are the major needs of people with OCPD?
Need for order and perfection, and to carry out activities in a extremely methodical way (usually before adulthood). These methods can severely impact life and work, resulting in missed deadlines, etc. Ego-syntonic
How can you distinguish paranoid personality disorder from delusional disorder?
PPD is characterized by a pervasive pattern of distrust and suspicion (interpersonal problems), but no persistent delusions or other psychotic symptoms
DD is >= 1 delusion for at least 1 month, can involve erotomanic, grandiose, jealous, persecutory and somatic subtypes
Which AP is least likely to cause weight gain?
Abilify
What medications are preferred for EtOH detox in patient with liver cirrhosis?
LOT - lorazepam, oxazepam, tonozepam
These are Not fully metabolized by liver
What are the main tx from dystonia side effects of APs?
AntiAch - benztropine
Anti-histamine - diphenhydramine
What drugs can interact with lithium?
Diuretics, NSAIDA besides aspirin, SSRIs, ACEI/ARB, antiepileptics
What is the preferred treatment for patient’s with mild-moderate bipolar disorder? Severe?
Atypical antipsychotics
Combo therapy with lithium/valproate + atypical AP
What’s the risk of developing bipolar d/o in pt with single parent who has bipolar? Both parents? Monozygotic twin?
10%, 60%, 70%
What is the preferred therapy for specific phobia?
Behavior therapy (exposure, systematic desensitization etc.)
What are Zuprasidone (Geodon) and Lurasidone (Latuda)? What can they be used to treat?
Z - (atypical AP) adjunct to Li or Valproate in maintenance treatment of bipolar
L - (atypical AP) treats depressive episodes of bipolar depression alone or with Li/Val
What is introjection?
immature DM, that involves incorporating another’s attitudes into one’s own perspective (victim of DM, blames partner’s aggression on themselves)
What is the best method of treatment for hypochondriasis?
Hypochondriasis occurs more commonly during times of psychological stress, therefore inquire about recent/current emotional stressors and provide brief psychotherapy
What are the order of treatments for conversion disorder?
- Education and self-help techniques to pt and family
- CBT
- Physical therapy for motor symptoms
How long should a patient who is tolerating an SSRI, but not noticing improvements, c/w the dose before considering raising it?
Go for at least 4 weeks, and if no improvement then consider increasing dose
What common side effects are seen commonly with Clozapine and Olanzapine, and what should be checked frequently?
Metabolic adverse effects - weight gain, dyslipidemia, hyperglycemia
Check fasting blood sugar and lipids, and get regular BMI, BP and waist circumference checks
What neuroimaging findings are present in schizophrenia? PTSD? OCD? Autism?
Schizo - enlargement of cerebral vesicles
PTSD - decreased hippocampal volume
OCD - orbitofrontal cortex and striatum abnormal
Autism - increased total brain volume
