Psych Clerkship Flashcards
1
Q
Among second gen antipsychotics (Blank) is associated with the highest risk of weight gain and metabolic side effects
A
Olanzapine
- metabolic side effects: weight gain, dyslipidemia, hyperglycemia, increased risk of diabetes
—BMI, fasting glucose and lipids, BP and waist circumference should be assessed at baseline, 3 months and then annually after that
2
Q
What changes to parathyroid hormone (PTH) and calcium levels occur with lithium?
A
- Hyperparathyroidism
- Hypercalcemia
3
Q
Serotonin syndrome symptoms
A
- mental status changes (agitation, restless, confusion)
- autonomic dysregulation (rapid heart rate, high blood pressure, dilated pupils)
- Neuromuscular excitability (muscle rigidity, loss of muscle coordination, or twitching muscles)
4
Q
How is serotonin syndrome managed?
A
- discontinuation of serotonergic medications
- Hydration, cooling, and blood pressure control
- Benzos to decrease agitation and muscle contractions
- Cyproheptadine is used to decrease central serotonergic activity
5
Q
What are common options for maintenance treatment of bipolar disorder? (4)
A
- Lithium and valproate
- 2nd gen: quetiapine and anticonvulsant lamotrigine
6
Q
What is avoided in patients with bipolar I disorder due to risk of mood destabilization?
A
- antidepressant monotherapy (fluoxetine, mirtazapine, and venlafaxine)
uncharacteristically rapid response to venlafaxine within a few days (when typical response is 2-4 weeks) is another clue that someone has bipolar disorder*
7
Q
Benzodiazepines with shorter half-lives (such as BLANK) are more likely to result in symptoms of withdrawal as early as 24 hours after cessation.
—Benzo withdrawal symptoms include?
A
- Alprazolam
- seizures, tremors, anxiety, perceptual disturbances, and psychosis
8
Q
How do isolated overdose of SSRI present with?
A
- frequently asymptomatic or mild CNS depression
9
Q
Acute toxicity of lithium symptoms:
Chronic toxicity of lithium symptoms:
Treatment
A
- N/V, diarrhea
- lethargy, confusion, agitation, ataxia, tremor/fasciculations, seizure
a. IV hydration and hemodialysis if severe
10
Q
Treatment for specific phobia
A
- CBT exposure therapy - first line
- Short acting benzos (limited role, may help acutely if therapist unavailable or insufficient time)
11
Q
Bupropion and varenicline are first line pharmacologic therapies for (BLANK)
A
Smoking cessation
12
Q
What two drugs are first line treatment options for alcohol use disorders?
A
- Naltrexone - a mu opioid receptor antagonist
- Acamprosate - glutamate modulator
others
- disulfiram - can be used to give aversive symptoms
13
Q
What are the different treatment regimen for MDD vs SAD
A
MDD
1. antidepressant (eg. SSRI), CBT
SAD
1. antidepressant (eg. SSRI)+light therapy, CBT, behavioral (outdoor walks, exercise, etc)
14
Q
What are the stimulant medications for ADHD?
What are the nonstimulant medications for ADHD?
A
- Methylphenidate and amphetamine salts
- Clonidine, guanfacine, atomoxetine
15
Q
Persistant/chronic motor or vocal tic disorder
- what does this mean?
A
- Motor or vocal tics lasting >1 year, BUT NOT BOTH
- if someone has multiple motor and vocal tics for >1 year it is likely tourette syndrome
16
Q
What drug is given to treatment resistant schizophrenia and schizophrenia associated with persistent suicidality
A
Clozapine (2nd gen antipsychotic)
-has high risk of agranulocytosis which is why it is only used for treatment resistant
- only antipsychotic known to decrease risk of suicide
16
Q
What 3 medications can be used to treat opioid use disorder to decrease risk of relapse, drug overdose, and death
- what are their mechanism of action
A
- Buprenorphine - partial mu opioid agonist
- Methadone - full mu-opioid agonist
- Naltrexone - pure opioid ANTAGONIST
16
Q
Advantages and disadvantages to buprenorphine
A
A:
1. lower risk of misuse and lethal overdose
2. dose not require complete withdrawal prior to initiation
D:
1. slightly less effective at keeping patients in treatment
17
Q
Advantages and disadvantages to Methadone
A
A:
1. More effective at patient retention
2. Does not require complete withdrawal prior to initiation
D:
1. Significantly higher risk of misuse and lethal overdose
18
Q
Advantages and disadvantages to Naltrexone
A
A:
1. Does not cause physiologic dependence
D:
1. Requires complete opioid withdrawal prior to initiation
2. Increase risk of overdose with noncompliance and relapse
19
Q
What is dissociative amnesia?
A
- Inability to recall important personal information, usually of a traumatic or stressful nature
- not explained by another disorder
–> tx with psychotherapy
20
Q
- What is dissociative identity disorder?
- treatment
A
- Marked discontinuity in identity and loss of personal agency with fragmentation into >=2 distinct personality states
- associated with severe trauma/abuse
–> psychotherapy
21
Q
What is depersonalization/derealization disorder?
A
- Persistent or recurrent experiences of 1 or both:
- depersonalization (feelings of detachment from, or being an outside observer of, oneself)
- Derealization (experiencing surroundings as unreal) - Intact reality testing
-the detachment must cause daily dysfunction and not as a part of a different dx
—> tx with psychotherapy
22
Q
What MDD patients require lifelong antidepressant treatment?
A
- Patients with >=3 lifetime depressive episodes
- Severe episdoes (eg. suicide attemtps),
- Episodes lasting >=2 years
23
Dopamine receptor antagonists that cross the BBB (antiemetics such as BLANK A) and antipsychotics can cause EPSs which are... (BLANK B)
- Treated with (BLANK C)
BLANK A: prochlorperazine, metoclopramide
BLANK B: extrapyramidal symptom like sustained contraction of muscles most often impacting the neck, mouth, tongue, and extraocular muscles,
BLANK C: treat with anticholinergic agents such as diphenydramine, benztropine
24
What is the first line treatment for opioid dependent pregnant patients? (2)
1. Methadone
2. Buprenorphine
25
What side effect are SNRIs typically associated with?
dose dependent increases in diastolic and systolic blood pressure
26
From the two first line drugs for bipolar disorder, which is associated with renal disorders/malfunction?
1. Lithium - long term use has been seen with nephrogenic diabetes insipidus and chronic tubulointerstitial nephropathy
- valproate is not nephrotoxic but periodic monitoring can be done. Valproate can have hepatotoxicity though so monitor aminotransferases.
27
Manic episode
1. length of time
2. symptoms
1. >= 1 week of elevated or irritable mood and increased energy/activity
2. >=3 of the following (4 if mood is irritable only) DIGFAST mnemonic: Distractibility, Impulsivity/risky behavior, Grandiosity, Flight of Ideas,
Activity increased/pyschomotor agitation, Sleep (decreased need), Talkativeness/pressure speech
28
Brief psychotic disorder
1. time frame and what it involves
1. >= 1 days and up to a month: sudden onset with full return to function
2. psychotic symptoms (delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior)
---often develop in reaction to a marked stressor
29
Delusional Disorder
1. time frame
2. Clinical Features
3. Medication type for treatment
1. >= 1 month
2. >= 1 delusions
---other psychotic symptoms absent or not prominent
--- behavior not obviously odd/bizarre; ability to function apart from delusion's impact
3. Antipsychotics
--and supportive therapy
30
Time frame of persistent complex bereavement disorder
At least 6 months to a year after the loss
31
Major Depressive Disorder with psychotic features
- Treatment
1. Combined antidepressant and antipsychotic medication
2. ECT - especially in patients who are treatment resistant and have emergency conditions like SI, refusal to eat/drink, pregnancy
32
How long do patients stay on medication when diagnosed with schizophrenia?
Anitpsychotic medication should be maintained indefinitely in patients with schizophrenia
33
What is required to diagnose schizophrenia?
>=2 of the following (with at least 1 symptom from 1-3)
1. DELUSIONS
2. HALLUCINATIONS
3. DISORGANIZED SPEECH
4. Disorganized/catatonic behavior
5. Negative symptoms (eg. apathy, flat affect)
-Cont. impairment >= 6 months
-Significant functional decline
34
What may these point indicate (dx)
- Does not seek or respond to comfort
- poor social responsiveness, limited positive affect
- unexplained irritability/fear/sadness even during safe encounters
- toileting and sleep difficulties
- Anxiety, aggression, hyperactivity/impulsivity
Reactive attachment disorder
- arises when the normal developmental process of emotional bonding to a primary caregiver is interrupted by inconsistent or inadequate care (eg. abuse, neglect, frequent moves, etc)
- usually in children...they do not seek reassurance or respond to comfort
35
Acute clinical features of PCP (hallucinogen)
1. violent behavior
2. Dissociation
3. Hallucinations
4. Amnesia
5. NYSTAGMUS (horizontal or vertical)
6. Ataxia
36
Acute clinical features of Cocaine (stimulant)
1. Euphoria
2. Agitation/psychosis
3. CHEST PAIN
4. SEIZURES
5. Tachy/HTN
6. MYDRIASIS
37
Acute clinical features of Methamphetamine (stimulant)
1. violent behavior
2. PSYCHOSIS/DIAPHORESIS
3. Tachy/HTN
4. Choreiform movements
5. TOOTH DECAY
- sympathetic hyperactivity (mydriasis, diaphoresis, tachy, HTN)
38
Acute clinical features of Alcohol (depressant)
1. Agression
2. CONFUSION/DISORIENTATION
3. Depressed mental status
4. Respiratory depression
39
Acute clinical features of Opioids
1. Euphoria
2. DEPRESSED MENTAL STATUS
3. MIOSIS
4. RESPIRATORY DEPRESSION
5. Constipation
40
What is used to manage PCP induced emergencies? (2)
1. Benzos
2. Antipsychotics
41
What is used to manage Cocaine induced emergencies? (2)
1. Benzos
2. Antipsychotics
42
What is used to manage Methamphetamine induced emergencies? (2)
1. Benzos
2. Antipsychotics
43
What is used to manage Alcohol induced emergencies? (1)
1. Antipsychotics
44
What is used to manage Opioids induced emergencies?
1. Naloxone
45
PCP acts on what receptors?
1. NMDA receptors in the hippocampus and limbic system (causing excitatory and psychotic effects)
2. Dopamine, NE, and 5HT receptors
3. Sigma receptor complex (causing pyschotic and anticholinergic effects)
46
Adjustment disorder
1. time frame
2. what is it?
1. Develops within 3 months of an identifiable stressor of any severity and lasting no longer than 6 months once the stressor ceases
2. Symptoms are distressing and impairing but do not meet criteria for another psychiatric disorder
47
Acute stress disorder
1. time frame
2. what is it?
1. >= 3 days and < 1 month
2. Exposure to severe and life-threatening traumatic event, intrusive REMINDERS of the trauma, dissociative symptoms (altered sense of reality), and/or avoidance behavior
48
OCD
1. Clinical features
2. Treatment :med and therapy type
1. Obsessions (recurrent, intrusive, anxiety provoking thoughts, urges, or images) + Compulsions (response to obsessions with repeated behaviors or mental acts, time consuming >1 hr/day or causing significant distress or impairment
2. SSRI and CBT therapy (exposure and response prevention)
49
What treatment should be given to someone with borderline personality disorder?
1. Dialectical behavioral therapy
50
What symptoms can arise with pheochromocytoma?
1. headache
2. Tachy/palpitations
3. sweating
4. HTN
-drug resistant HTN and hyperglycemia with normal BMI
- symptoms are caused by catecholamine excess (neuroendocrine cells in adrenal medulla)
51
Postpartum blues
1. onset
2. symptoms
3. management
1. 2-3 days (resolves within 14 days)
2. Mild depression, tearfulness, irritable
3. reassurance and monitoring
52
Postpartum depression
1. onset
2. symptoms
3. management
1. within 4-6 weeks (can be up to year)
2. >= 2 weeks of mod-severe depression, sleep or appetite disturbance, low energy, pyschomotor changes, guilt, concn difficulty, SI
3. Antidepressants, psychotherapy
53
Postpartum psychosis
1. onset
2. symptoms
3. management
1. variable: days to weeks
2. delusions, hallucinations, thought disorganization, bizarre behavior
3. Antipsychotics, antidepressants, mood stabilizers; hospitalization (do not leave mother alone with infant due to risk of infantacide)
54
Neuroleptic Malignant Syndrome
1. causative agents?
2. pathophysiology?
1. Antipsychotic meds, antiemetic meds (e.g. promethazine), and withdrawal of parkinson medications
2. Central dopaminergic receptor blockade, disruption of nigrostriatal dopamine pathways
55
Neuroleptic Malignant Syndrome
1. Signs/symptoms
2. Treatment
1. fever, AMS, generalized muscle rigidity (lead pipe rigidity), autonomic instability (abnormal vital signs, diaphoresis), elevated CK +/- renal failure
2. Stop antipsychotics or restart dopamine agents.
- supportive care, ICU
- Benzos
- Bromocriptine (dopamine receptor agonists) or dantrolene (muscle relaxation) if refractory NEMS
56
Benztropine
- What kind of medication is this?
1. anticholinergic medication
- can be used to treat antipsychotic-induced extrapyramidal symptoms (e.g. dystonia- muscles contract involuntarily..stiffness)
57
What is this diagnosis?
1. Deficits in social communication and interactions with onset in early development (such as sharing emotions/interests, nonverbal communication, developing/understanding relationships)
2. Restricted, repetitive patterns of behavior (sameness/routines, intense and fixated interests, repetitive movements/speech)
3. May occur with or without language and intellectual impairment
Autism spectrum disorder
58
What antidepressant is this
1. NE and dopamine reuptake inhibitor
2. mild stimulant effects that can increase wakefulness, energy, and concn
3. approved treatment for smoking cessation
4. Help with weight loss
5. DOES NOT cause sexual side effects
6. Careful in patients with hx of bulimia nervosa/anorexia nervosa bc of potential electrolyte disturbances
1. Bupropion
- can be added onto SSRI to augment treatment
- The electrolyte disturbances can lead to prolonged QT...eventually torsades (rare)
-- can lead to decreased seizure threshold
59
Mirtazapine
1. MOA
2. Side effects
1. Antagonist of serotonergic (5HT2/5HT3) and noradrenergic (NE) receptors --> thereby increasing sympathetic tone
2. Sedating
- Increases appetite (leads to weight gain)
*used in depressive disorders, GAD, especially in underweight patients
59
What is a normal MOCA score?
>= 26/30
59
What antidepressant is this
1. Tricyclic antidepressant type
2. sedating
3. Side effect profile includes cardiotoxicity, danger in overdose
Amitriptyline
59
What antidepressant is this
1. MAOI type drug
2. Weight gain
3. Dietary restrictions and potential for severe side effects (HTN, serotonin syndrome)
4. Treat atypical depression and treatment resistant cases
Phenelzine, a MAOI
60
For those with MDD who have had partial response to first line treatment and are tolerating current medication... what strategies can be done to further tx mood symptoms?
1. adding an antidepressant with a different MOA
2. A 2nd gen antipsychotic
3. Lithium
4. Triiodothyronine
5. Psychotherapy
- Non responders would benefit from switching to a different antidepressant
61
Buspirone
1. when is this used?
1. To treat anxiety disorders
2. May be used as augmentation for MDD when augmentation with a 2nd antidepressant is ineffective
62
What antipsychotic is this?
1. 2nd generation antipsychotic
2. Risk of weight gain and metabolic adverse effects
1. Olanzapine
63
MOA of 1st vs 2nd generation antipsychotics
1. 1st gen: strong D2R ANTAGONISM
2. 2nd gen: 5HT2A and D2 ANTAGONISM
64
What are the preferred 2nd gen antipsychotics to use for Parkinson Disease psychosis?
1. Quetiapine (best option bc low D2R antagonisms, wider availability, better safety profile)
2. Clozapine (low D2R antagonism but limited use bc can induceagranuloctyosis)
3. Pimavanserin (no D2R activity but limited availability due to cost)
---if patient is experiencing psychosis then first decrease carbidopa-levodopa dose and if parkinsonism sx worsen a lot then return to regular dose and then add antipsychotics
65
Schizoaffective disorder
1. Time frame
2. Clinical criteria
1. Hx of delusions or hallucinations for >= 2 weeks in the ABSENCE of MDD or Manic episode
2. MDD or manic episode concurrent with symptoms of schizophrenia. BUT DELUSIONS/HALLUCINATIONS HAVE TO OCCUR WITHOUT MDD/MANIC S/S
- Mood episodes are recurrent/prominent and recur throughout illness
66
What medications are commonly used in the treatment of acute bipolar DEPRESSION?
1. 2nd gen antipsychotics QUETIAPINE and LURASIDONE
2. anticonvulsant LAMOTRIGINE
67
What is this disorder?
1. Intense fear of weight gain, distorted views of body weight and shape
2. BMI < 18.5 kg/m2
How do you treat it?
1. Anorexia Nervosa
2. CBT, nutritional rehab, Olanzapine if no response to the first two
68
What is this disorder?
1. Recurrent episodes of binge eating + inappropriate compensatory behavior to prevent weight gain
2. excess worrying about body shape and weight
How do you treat it?
1. Bulimia Nervous (doesnt req the vomiting aspect, just some compensatory behavior)
2. CBT, Nutritional rehab, SSRI in combo with first two
69
What is this disorder?
1. Recurrent episodes of binge eating but NO inappropriate compensatory behaviors
2. Lack of control during eating
How do you treat?
1. Binge eating disorder
2. CBT, Behavioral weight loss therapy, SSRI, Lisdexamfetamine
70
When switching from SSRI to MAOI would require how long to washout?
5 weeks due to long half life of SSRI (fluoxetine)
- washout is 2 weeks for other antidepressant
71
Adjustment disorder
1. management
1. Pyschotherapy and adjunctive pharm (short term, reserved for rapid relief of impairing symptoms like sleep aid)
72
PTSD
1. time frame
2. treatment
1. duration of clinical features >= 1 month (reexperiencing symptoms, negative cognitions and mood, sleep disturbance, etc)
2. CBT and antidepressants (eg. SNRI, SSRI)
- prazosin (alpha 1 adrenergic receptor antagonist) for nightmares
73
Specific phobia
1. treatment
1. CBT with exposure
2. short acting benzos (limited role that may help acutely if therapist unavailable or insufficient time)
74
- tremors
- agitation
- anxiety
- delirium
- psychosis
- exam findings: seizures, tachy, palpitations
This is withdrawal symptoms of...
alcohol
75
- N/V
- abdominal cramping
- diarrhea
- muscle aches
- Exam: dilated pupils, yawning, piloerection, lacrimation, hyperactive bowel sounds
This is withdrawal symptoms of...
Opioids (heroin)
76
- Tremors
- Anxiety
- Perceptual disturbances
- Pyschosis
- Insomnia
- Exam: seizures, tachy, palpitations
This is withdrawal symptoms of...
benzodiazepines
77
- Increased appetite
- Hypersomnia
- intense pyschomotor retardation
- severe depression (crash)
- Exam: no significant findings
This is withdrawal symptoms of...
stimulants
78
- Dysphoria
- Irritability/anxiety
- increased appetite
Exam: no significant findings
This is withdrawal of...
nicotine
79
- Irritability/anxiety
- depressed mood
- insomnia
- decreased appetite
-Exam: no significant findings
This is withdrawal of...
Cannabis
80
Differentiate these personality disorders
Schizoid vs antisocial vs avoidant
1. Schizoid - prefers to be alone, detached, unemotional
2. Antisocial - what comes after conduct disorder
3. Avoidant - avoidance of others due to fears of criticism and rejection
81
What is cluster A vs B vs C
A: odd/eccentric
B: dramatic/erratic
C: anxious/fearful
82
What is delayed sleep wake phase disorder?
Pronounced night-owl tendency with markedly late sleep and wake times (e.g. 2 am - 11 am)
83
Low levels of 5-hydroxyindoleacetic acid (5-HIAA) in the cerebrospinal fluid (CSF) are associated with .....
Low levels of 5-hydroxyindoleacetic acid (5-HIAA) in the cerebrospinal fluid (CSF) are associated with suicidal behavior
84
Define these key defense mechanisms
1. Displacement
1. Transferring feelings to less threatening object/person
85
Define these key defense mechanisms
1. Reaction formation
1. Transforming unacceptable feelings/impulses into the opposite
86
Define these key defense mechanisms
1. repression vs suppression
1. Repression: unconsciously blocking unwanted thoughts or feelings
2. Suppression: putting unwanted feelings aside to cope with reality
87
Define these key defense mechanisms
1. Sublimation
1. Channeling impulses into socially acceptable behaviors
88
Major depressive disorder is associated with hyperactivity of what axis in the body?
The hypothalamic-pituitary-adrenal axis resulting in increased cortisol levels
- MDD can also be seen with decreased REM sleep latency
- Decreased slow wave sleep
89
stranger anxiety
1. starts at
2. peaks at
3. resolves by age
1. 6 months
2. peaks at 8-9 months
3. resolves by age 2 years
90
Common side effects of SSRI
1. early
2. long term side effects
1. Headache, nausea, insomnia/sedation, anxiety, and dizziness
2. sexual dysfunction and weight gain
91
what ratio of aminotransferase enzymes levels indicate alcohol induced injury?
Aspartate aminotransferase/Alanine aminotransferase ratio of >= 2
92
1. For women of all ages and men age >= 65, consumption of how many drinks in a week OR in a day lead to negative health effects?
1. what about men age <65?
1. >7 drinks in a week or >3 drinks in a day
2. >14 drinks in a week
93
Disruptive mood dysregulation disorder
1. age onset
2. clinical description/diagnosis
3. treatment
1. symptoms manifest prior to age 10
2. irritable mood, repetitive temper outbursts (verbal or physical) that are out of proportion to the stimulus and inconsistent with developmental level
---> outbursts >= 3 per week
---> sx for atleast 1 year and no more than 3 months without symptoms
---> in atleast 2 settings
3. psychotherapy (parent management training)
94
Social anxiety disorder (social phobia)
1. time frame
2. treatment
1. mixed anxiety about >= 1 social situation for >= 6 months
2. SSRI/SNRI
- CBT
- Beta blocker or benzo for performance only subtype
95
- A patient with MDD has failed 2 trials of antidepressant from the same class
- Switch to an antidepressant with another MOA is preferable
1. What are the alternate meds that can be used?
1. Bupropion
2. Mirtazapine
3. SNRI
4. Serotonin modulators (e.g. vortioxetine)
---just remember each drugs side effect profile and chose best one for patient
96
clinical features:
- agitation, delirium, hallucinations, seizures
- Mydriasis, blurry vision
- Tachycardia
- Urinary retention, decreased bowel sounds
- Dry and flushed skin, dry mucous membranes, hyperthermia
what can cause this toxicity?
1. anticholinergic toxicity (overdose or combo of anticholinergic agents)
Patients suspected of anticholinergic toxicity (eg, altered mental status, tachycardia, dry skin, mydriasis, urinary retention) should have an electrocardiogram performed early in their evaluation because medications with anticholinergic properties (eg, tricyclic antidepressants) may also cause QRS interval or QTc prolongation, and other arrhythmias.
97
How to treat anticholinergic toxicity?
1. supportive care
2. activated charcoal (awake patients <2 hr of ingestion)
3. Benzo for agitation and seizures
4. Physostigmine for severe central and peripheral symptoms
98
Synthetic cathinones, commonly referred to as "bath salts," consist of a large family of amphetamine analogs.
what are their effects?
what is unique about the substance use experience?
Symptoms of intoxication include severe agitation, combativeness, psychosis, delirium, myoclonus, and, rarely, seizures. Increased sympathetic outflow may lead to significantly increased blood pressure and heart rate.
The most distinguishing feature of synthetic cathinone intoxication is the prolonged duration of effect. Delirium and psychosis due to synthetic cathinones may last up to a week
99
QRS duration >100 msec has been associated with an increased risk of arrhythmias and/or seizures and is an indication for treatment with (BLANK)
sodium bicarbonate.
100
What are negative side effects of TCA in overdose?
mental status changes, seizures, tachycardia, hypotension, cardiac conduction delay, and anticholinergic effects (eg, dilated pupils, hyperthermia, flushed and dry skin, intestinal ileus). Cardiotoxicity is due to blockade of cardiac fast sodium channels, leading to QRS prolongation and risk of developing ventricular arrhythmia (similar to class IA antiarrhythmic drugs such as quinidine). ECG should be obtained immediately and monitored frequently in suspected TCA overdose.
101
≥1 unexplained symptoms; excessive thoughts, anxiety & behaviors in response to symptoms
Somatic symptom disorder
102
1. Minimal to no symptoms; preoccupation with idea of having a serious illness
2. tx
1. Illness anxiety disorder
2. regularly scheduled visits with one PCP
- CBT
103
Neurologic symptom(s) that don't align with anatomy or pathophysiology
Conversion disorder (functional neurologic symptom disorder)
- la belle difference: patient may be surprisingly calm and unconcerned
tx: CBT and education about illness
104
Falsification of symptoms/inducing injury in the absence of obvious external rewards
Factitious disorder
105
Tourette syndrome
1. time frame/onset
2. clinical features
3. Treatment
1. Onset <18
2. Both multiple motor & ≥1 vocal tics (not necessarily concurrent, >1 year)
----Motor: facial grimacing, blinking, head/neck jerking, shoulder shrugging, tongue protrusion, sniffing
-----Vocal: grunting, snorting, throat clearing, barking, yelling, coprolalia (obscenities)
3. Behavioral therapy (habit reversal)
- Antidopaminergic agents (Tetrabenazine/dopamine depleter ;;; Antipsychotics/receptor blockers)
-Alpha 2 adrenergic receptor agonists like GUANFACINE
106
what mood stabilizer drug is known for side effect of rash or severe mucocutaneous rash of SJS
Lamotrigine - used as a mood stabilizer in bipolar disorder
107
Pharm tx of psychosis
1. Second-generation antipsychotics (eg, risperidone, aripiprazole, quetiapine, olanzapine, ziprasidone)
2. First-generation antipsychotics (eg, haloperidol)
3. Adjunctive benzodiazepines for agitation
----------------------------------
SPECIAL POP
1. Chronic nonadherence: consider long-acting injectable
2. Treatment resistance (2 failed trials): consider clozapine
108
Long face with prominent chin & forehead
Large, protruding ears
Macroorchidism
Macrocephaly
Self-injurious behavior (eg, hand biting)
Anxiety, autistic behaviors
Tall stature
Fragile X syndrome
- FMR1 MUTATION (CGG repeat expansion of FMR1)
109
Upslanting palpebral fissures
Flat nasal bridge
Epicanthal folds
Single palmar crease
Heart disease (eg, AV canal defect)
Short stature, obesity
Hearing loss
Down Syndrome
110
Schizotypal personality disorder
unusual thoughts, perceptions & behavior
111
Clozapine side effects
- seizures (tonic clonic)
- neutropenia/agranulocytosis
- myocarditis
112
Panic disorder
1. treatment
1. SSRI/SNRI and/or CBT
2. acute distress: benzodiazepines
113
What psychiatric meds can cause QT interval prolongation?
1. antipsychotics
2. TCAs
3. SSRIs
114
What changes in brain structure have been seen with schizophrenia?
1. Lateral ventricular enlargement
115
In treatment of acute psychosis and escalating agitation - what antipsychotic would be beset used?
1. olanzapine bc it can be administered IM and has rapid onset
--Valproate or carbamazepine can be used in management of bipolar disorder but require oral administration and require gradual titration over several days
116
Aripiprazole
1. type of drug
2. side effects?
1. Atypical antipsychotic (2nd gen)
2. Akathisia and impulse control problem (e.g. pathological gambling)
117
What medication used to treat bipolar disorder is not recommended during pregnancy?
1. valproate during the first trimester - risk of neural tube defects
118
What medications can be used in pregnant women - for maintenance (relapse prevention) in bipolar dx?
1. LAMOTRIGINE
2. Atypical antipsychotics (quetiapine, risperidone)
3. Lithium* there is small risk of fetal cardiac defects so last option
119
Treat of bipolar disorder
- what is used during acute depression?
Medications commonly used in the treatment of acute bipolar depression include the
1. second-generation antipsychotics quetiapine and lurasidone
2. anticonvulsant lamotrigine
120
Treat of bipolar disorder during pregnancy
- what is used during acute mania?
1. Typical antipsychotics
2. Atypical antipsychotics
121
- retrograde and anterograde amnesia
- confabulation
- apathy
- lack of insight
what is this?
- Plus alcohol use disorder
= Korsakoff synrome (a potential complication of wernicke encephalopathy)
122
- Thiamine deficiency
- encephalopathy
- ataxia
- nystagmus/oculomotor dysfunction
Wernicke encephalopathy
123
Body dysmorphic disorder
1. criteria
2. treatment
1. Preoccupation with >=1 perceived physical defect but defects not observable or appear slight to others.
- repetitive behavior or mental acts performed in response
- significant distress or impairment
- variable insight
2. Antidepressants (SSRI)
- CBT
124
acute stress disorder
1. treatment
1. trauma focused brief CBT
2. maybe meds for insomnia, intense anxiety
3. Monitor for PTSD if symptoms persist >1 month
125
What are nonopioid treatments that can be given to someone going through opioid withdrawal?
1. clonidine (alpha 2 adrenergic agonists - reduces noradrenergic hyperactivity like diaphoresis, nausea, anxiety, tachy, HTN)
2. adjunctive meds (antiemetics, antidiarrheals, benzos)
126
What are the neuropsychiatric side effects of glucocorticoids?
1. Euphoria
2. Depression
3. Hypomania or mania
4. Pyschosis
127
1. what is tardive dyskinesia
2. What can cause this?
1. Abnormal involuntary movements. Orofacial dyskinesia, limb dyskinesia, trunk dyskinesia
2. antipsychotics (greater with 1st gen) or metoclopramide
128
What are medical signs of eating disorder?
1. GI fluid loss (e.g. HYPOkalemia, Chloride depletion alkalosis, cramps)
2. Endocrine disruption (amenorrhea, osteoporosis)
3. Vomiting (e.g. dental erosions, salivary gland enlargement, subconjunctival hemorrhage)
129
What side effect of antipyschotics is dose dependent?
akithesia (restlessness that manifest as pacing or inability to sit still)
- Can decrease dose to manage akathesia PLUS beta blocker (e.g. propranolol) - works by blocking noradrenergic and serotonergic inputs on dopamine pathwasy
130
Within the typical and atypical antipsychotics...which drugs have lower tendency to cause tardive dyskinesia?
1. Quetiapine
2. Clozapine
131
Tardive dyskinesia
1. management (3)
1. Reducing antipsychotic dose
2. Using VALBENAZINE or DEUTETRABENAZINE (reversible inhibitors of VMAT2) - recently approved by FDA for use in TD
3. Switch antipsychotic for another one with lower tendency to cause TD (Clozapine, Quetiapine)
132
Wilsons disease
1. pathogenesis
2. Clinical findings
3. Tx
1. Autosomal recessive mutation in ATP7B--- leads to hepatic copper accumulation --> leaks from damaged hepatocytes and deposits in tissues
2. Hepatic issues (acute liver failure, chronic hepatitis, cirrhosis), Neuro (parkinsonism, gait disturbance), Psychiatric (depression, personality changes, psychosis)
3. Chelators (D-penicillamine, trientine), Zinc (interferes with copper absorption)
133
Patients with tourette syndrome have high rates of which comorbid conditions (2)
1. ADHD
2. OCD - develops 3-6 years after tics first appear
134
1. Pattern of excessive emotionality & attention-seeking behavior since early adulthood
2. Inappropriate, sexually seductive or provocative behavior; uses appearance to draw attention
3. Shallow, shifting, dramatic emotions
4. Impressionistic, vague speech
5. Suggestible (easily influenced)
6. Considers relationships more intimate than they really are
----what is this?
Histrionic personality disorder
135
Antipsychotic extrapyramidal effects
1. Acute dystonia (sudden, sustained contraction of the neck, mouth, tongue, and eye muscles)
- what pharmacotherapy can be used to treat?
1. Benztropine (anticholinergic antiparkinsonian)
2. Diphenhydramine
136
Antipsychotic extrapyramidal effects
1. Parkinsonism (gradual onset tremor, rigidity, and bradykinesia)
- what pharmacotherapy can be used to treat?
1. Benztropine (anticholinergic antiparkinsonian)
2. Amantadine (dopaminergic medication)
137
What are the 4 stages of piaget stages of cognitive development?
(1) sensorimotor intelligence
(2) preoperational thinking
(3) concrete operational thinking
(4) formal operational thinking.
138
Meperidine
1. type of medication
1. opioid medication
- Meperidine and tramadol are highly deliriogenic
139
If SSRI is causing sexual dysfunction what is the first method of treating this?
Decreasing SSRI dose - especially if depression in patient has been in sustained remission
140
Some studies have shown that patients with panic disorders commonly experience panic attacks in response to what?
lactate infusions
-- postulated that panic disorder develops because of catastrophic appraisals of internal body states
141
What is the management of dystonia (involuntary muscle contraction)?
- Diphenhydramine
- Benztropine (increases the availability of dopamine by blocking its reuptake and storage in central sites)
142
Management of bradykinesia (slowed movements)?
-Benztropine (increases the availability of dopamine by blocking its reuptake and storage in central sites.)
-Amantadine (antagonist of the NMDA-type glutamate receptor, increases dopamine release, and blocks dopamine reuptake)
143
Management of akathisia (restlessness)?
- reduce dose of meds
- beta blocker (propranolol)
- Benzo, or benztropine
144
Aversion technique for psychotherapy means what?
Negative resonse (e.g. shock the patient) when specific behaviors occurs
145
What is the CAGE screening?
Screen for alcohol use disorder
- Cut down
- Annoyed at people telling them to cut down
- Guilt on things they did while drunk
- Eye opener
146
-Most common inherited cause of ID
-Most common genetic cause of ID
--> Fragile x
--> Downs syndrome
147
IQ levels and description/care needed
- 50-70
- 35-50
- 20-35
- <20
1. Mild: can often live/function if provided some support
2. Moderate: Requires high amounts of supervision
3. Severe: Not independent, needs help with self-care
4. Profound: needs nursing care throughout life
148
Advanced circadian sleep-wake disorders ?
Early sleep onset, early wake time
- Tx with nighttime bright light
149
waves during stages of sleep
1. Awake (eyes open)
2. Awake (eyes closed)
3. NREM N1
4. NREM N2
5. NREM N3
6. REM
1. Beta
2. Alpha
3. Theta
4. Spindles/K spindles
5. Delta
6. Beta
150
What is SIGECAPS and how many are needed for depression?
1. Sleep
2 Interest
3. Guilt
4. Energy
5. Concentration
6. Appetite
7. Psychomotor agitation (restlessness, fidgeting)
8. Suicide
>= 5 are needed to dx depression
151
What symptoms have been seen in generalized anxiety disorder and how many are needed to diagnose?
≥1 of the following symptoms:
Restlessness; feeling on edge
Fatigue
Difficulty concentrating
Irritability
Muscle tension
Sleep disturbance
152
Acute intermittent porphyria (AIP)
- genetic inheritance pattern
- symptoms
- pathophysiology
1. autosomal dominant
2. Neuropathic sx: abdominal pain
===vomiting, constipation, sensory and motor neuropathies, tachycardia
----psychiatric sx: nonspecific and include anxiety, insomnia, restlessness, mood fluctuations, and psychotic symptoms
3. Likely related to difference in expression of altered enzymes. - These enzymes are involved in heme biosynthesis
--Often precipitated by fasting, certain meds, tobacco, and alcohol
- dx with elevated urine porphobilinogen during attack
153
Acute mania can be treated with?
First-line treatments for mania include
1. Antipsychotics (first- & second-generation)
2. Lithium (avoid in renal disease)
3. Valproate (avoid in liver disease)
4.Combinations in severe mania (eg, antipsychotic plus lithium or valproate)
154
Ziprasidone (2nd gen antipsychotic) is notable for a greater risk of (blank)
prolonging the QT interval compared to other atypical antipsychotics.
155
Bipolar I vs Bipolar II
- dx req
Bipolar I
Manic episode(s)
Depressive episodes common but not required for diagnosis
Bipolar II
Hypomanic episode(s)
≥1 major depressive episodes
156
Manic vs hypomanic episode
Manic episode
Symptoms more severe
1 week unless hospitalized
Marked impairment in social or occupational functioning or hospitalization necessary
May have psychotic features; makes episode manic by definition
Hypomanic episode
Symptoms less severe
≥4 consecutive days
Unequivocal, observable change in functioning from baseline
Symptoms not severe enough to cause marked impairment or necessitate hospitalization
No psychotic features
157
Acute risk factors for suicide
*Suicidal thoughts, plan & intent
*Presence/severity of psychiatric illness
*Impulsivity
*Hopelessness
*Psychosis/agitation
*Intoxication (disinhibition)/active substance use
*Recent psychosocial stressors
*Medical illness/pain
*Lack of social support/living alone
*Access to means (eg, weapons, medications)
158
static risk factors for suicide
Age (young adult & >70)
Sex
Attempts: female > male
Completion: male > female
Past suicide attempts
Family history of suicide/psychiatric illness
159
Treatment options for acute opioid withdrawal include
1. administration of opioid agonists (eg, low-dose methadone, buprenorphine)
2. nonopioid medications.
--> Clonidine, a central alpha-2 adrenergic agonist, is effective in blunting withdrawal symptoms by reducing noradrenergic hyperactivity. Clonidine would be particularly helpful in decreasing autonomic symptoms (ie, diaphoresis, nausea, anxiety, tachycardia, hypertension)
--> or adjunctive medications (antiemetics, antidiarrheals, benzodiazepines)
160
Neurotransmitter changes
1. Anxiety disorders
2. Depression
3. Parkinson's Disease
4. Schizophrenia
5. Huntington's Disease
6. Alzheimer's Disease
1. ANXIETY: Increased NE, Decreased GABA and 5HT
2. DEPRESSION: Decreased NE and 5HT
3. PARKINSONS DX: Decreased Dopamine
4. SCHIZOPHRENIA: Increased Dopamine
5. HUNTINGTON'S DX: Decreased GABA and Acetylcholine
6. ALZHEIMER'S DX: Decreased Acetylcholine
161
Fluvoxamine
- what kind of drug is this?
SSRI
162
Desipramine, clomipramine, amoxapine, doxepin
- What kind of drug is this?
TCA
163
TCA
1. mechanism of action?
2. side effects (3)
1. Block reuptake of NE and 5HT
--(plus some inhibition to muscarinic, histamine, and alpha adrenergic receptors)
2. Sedation (histamine)
- postural hypotension (alpha adrenergic receptors)
- anticholinergic effects (muscarinic)
164
Duloxetine, milnacipran, levomilnacipram
- What drug is this?
1. SNRIs
165
1. SSRI side effects
2. SNRI side effects
1. sexual dysfunction, weight gain
2. Hypertension, tachycardia
166
Trazodone
1. MOA
2. side effects
1. Inhibits reuptake of 5HT
- Blocks 5HT, alpha 1, and H1 receptors
2. priapism
-Sedation
-QT prolongation, etc
*used for insomnia and MDD
167
Tranylcypromine, selegiline, isocarboxazid
- what drug is this?
- MOA?
MAOIs
- inhibits monoamine oxidase A and B which leads to increased levels of 5HT, Dopamine, and Norepinephrine
168
Lithium
-side effects?
1. Tremor
2. Hypothyroidism
3. Nephrogenic diabetes insipidus (affects kidneys)
169
Trifluoperazine, loxapine, perphenazine, pimozide, thiothixene, fluphenazine, chlorpromazine, thioridazine
- what drugs are these?
Typical/first generation antipsychotics
170
Clozapine, asenapine, ilioperidone, lurasidone, and paliperidone
- what drugs are these?
Atypical/second generation antipsychotics
171
1. Risperidone side effect
1. hyperprolactinemia
172
Zolpidem
1. MOA:
2. side effects
1. GABAa receptor agonist --> decreased activity of CNS neurons
---> short term treatment of insomnia
2. Mild anterograde amnesia, hallucinations
173
Phenytoin
1. MOA
2. Clinical uses
1. Decreasing flow of Na and Ca ion across the cell membrane
2. Treat
- simple/complex PARTIAL SEIZURES
- STATUS EPILEPTICUS
- GRAND MAL SEIZURES/GENERALIZED TONIC CLONIC SEIZURES
174
Phenytoin side effects
1. Nystagmus
2. Gingival hyperplasia
3. Drug induced lupus
-teratogen (fetal hydantoin syndrome)
175
Lamotrigine
1. MOA
2. side effects
1. Block fast voltage activated sodium channels at presynaptic neuron (decreasing release of glutamate and aspartate)
2. SJS
-used for simple/complex partial seizures and generalized tonic-clonic seizures
176
Treatment for absence seizures?
Ethosuximide
177
Topiramate
- clinical uses
1. epilepsy
2. prophylaxis for migraines
178
codeine, oxycodone, meperidine, fentanyl, and dextromethorphan
-what kind of drugs are these
opioids
179
Dantrolene
- MOA
- Clinical uses (2)
1. inhibiting calcium release from the sarcoplasmic reticulum or myocytes by binding to the ryanodine receptor
2. Malignant hyperthermia
- Neuroleptic malignant syndrome
180
Tetrabenazine
1. MOA
2. clinical use
1. inhibits uptake of NE, epinephrine, dopamine, 5HT by inhibiting VMAT-2
2. Choreiform movements seen in huntingtons disease, tardive dyskinesia, tourette syndrome
181
Buspirone
1. MOA
2. clinical use
1. partial 5HT (1a) receptor agonist
2. generalized anxiety disorder
- may also be used in conjunction with SSRI to treat depression
182
Bupropion (wellbutrin)
1. MOA
2. Clinical use
3. side effects
1. inhibits reuptake of NE and Dopamine
- nicotinic antagonist
2. Depression
- Smoking cessation
3. increased risk of seizures in patients suffering from anorexia or bulimia
183
Schizophreniform disorder
1. treatment (3)
1. hospitalization if necessary
2. 6 month course of antipsychotics
3. supportive psychotherapy
184
Brief psychotic disorder
1. Treatment
1. brief hospitalization
2. supportive therapy
3. course of antipsychotics for psychosis
4. benzo for agitation
185
When are MAOIs used for depression?
During refractory depression
186
MDD w/psychotic features
1. treatment
1. 2nd gen antipsychotics
2. antidepressants
187
MDD induced catatonia
1. treatmetn
1. Lorazepam (ativan)
2. ECT
188
premenstrual dysphoric disorder
1. treatment
1. SSRIs (daily or luteal phase only)
2. oral contraceptives may reduce symptoms
189
Agoraphobia
1. treatment
1. CBT + SSRIs
*fear of places where escape may be difficult
-->= 6 months
190
Specific phobias
1. treatment
1. CBT w/exposure
191
Selective mutism
1. dx
2. treatment
1. failure to speak in specific situations for at least 1 month despite being able to. Usually starts during childhood.
2. SSRIs and CBT (esp w/comorbid social anxiety disorder)
192
Separation anxiety disorder
1. clinical uses/diagnosis
2. treatment
1. lasts for >= 4 weeks in child/adolescent and >= 6 months in adults
2. CBT, family therapy
--SSRIs can be effective as adjunct
193
General anxiety disorder
1. treatment
1. CBT
2. SSRIs or SNRIs
194
what personality disorder cannot be treated with therapy?
antisocial personality disorder
- psychotherapy is generally ineffective
195
1. How long does alcohol stay in system? (urine tox screen)
2. cocaine
3. amphetamines
4. PCP
5. Barbiturates
6. Benzos
7. Opioids
8. Marijuana
1. ALCOHOL: few hours
2. COCAINE: 2-4 days (8 days for heavy users)
3. AMPHETAMINES: 1-3 days
4. PCP: 4-7 days (OTC meds can cause false positive)
5. BARBITURATES: short acting 24 hours/long acting 3 weeks
6. BENZOS: short acting up to 5 days/long acting up to 30 days
7. OPIOIDS: 1-3 days (synthetic opioids/buprenorphine will not be detected)
8. MJ: single use 3 days but regular users up to 4 weeks
196
MOA
1. amphetamine
2. cocaine
3. PCP
1. inhibit reuptake of Dopamine and NE causing stimulant effects
2. inhibit reuptake of Dopamine, epinephrine, NE causing stimulant effect
3. inhibit NMDA glutamate receptors AND activates dopaminergic neurons
197
Alzheimer's disease
- what meds are used to slow deterioration
- what med is used for mod to severe dx
1. donepezil, rivastigmine, galantamine
- these are acetylcholinesterase inhibitors
2. amantadine (NMDA receptor antagonist)
198
Positive CSF RT-Quic assay indicates what disease?
Prion disease - Creutzfeldt-Jakob disease
- seen with startle response/myoclonus
199
Enuresis
- dx occurs 2x a week for at least 3 consecutive months
- at least 5 years old
1. Treatment
1. limit fluid intake and caffeine at night
2. urine alarm and aware system
3. First line: Desmopressin (DDAVP)
4. 2nd line: Imipramine (TCA)
200
Hypersomnolence disorder
1. diagnosis
2. tx
1. excessive sleepiness despite at least 7 hours of sleep w/
- recurrent periods of sleep within the same day
- prolonged, nonrestorative sleep more than 9 hours
- difficulty being fully awake after awakening
2. Modafinil or stimulants like methylphenidate
- atomoxetine are second line therapy
- scheduled napping
201
1. What stage of sleep does sleep walking occur in?
2. what about sleep terrors
3. nightmare disorder
1. slow wave NREM - first 1/3 of sleep - no recall/amnesia
2. slow wave NREM - no recall/amnesia
3. second half of sleep episode (REM) - vivid recall
202
Restless legs syndrome
1. tx
1. dopamine agonists (pramipexole and ropinirole, and benzos)
2. iron replacement if low
203
Describe
1. Id
2. Superego
3. Ego
1. Id: unconscious, instinctual sexual/aggressive urges and primary process thinking
2. Superego: moral conscious and ego ideal (inner image of oneself that one wants to become)
3. Ego: mediator between id and superego and external environment
204
HAM side effects
1. antihistamine
2. antiadrenergic
3. antimuscarinic
1. antihistamine - sedation, weight gain
2. antiadrenergic - hypotension
3. antimuscarinic - dry mouth, blurred vision, urinary retention, constipation, exacerbation of neurocognitive disorders
205
Ramelteon
1. MOA
2. clinical use
1. selective melatonin agonist
2. No tolerance or dependence which makes it a good sleep aid
206
What are the negative symptoms alprazolam can be associated with
1. Rebound anxiety
2. withdrawal symptoms (sympathetic hyperarousal)
207
what is a rare side effect of valproic acid?
drug induced pancreatitis
- mechanism is unknown but resolves with discontinuation of drug
208
Huntington disease
1. age of onset
2. symptoms/changes
3. when does death usually occur
1. 30-60
2. insidious onset of psychiatric (irritability, behavioral changes, depression, psychosis) and cognitive symptoms, motor symptoms (chorea, hypotonia, dystonia, loss of voluntary control))
3. People die 10-40 years after disease onset and suicide is a common cause of death
