Psych Clerkship Flashcards
Among second gen antipsychotics (Blank) is associated with the highest risk of weight gain and metabolic side effects
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
What changes to parathyroid hormone (PTH) and calcium levels occur with lithium?
- Hyperparathyroidism
- Hypercalcemia
Serotonin syndrome symptoms
- 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)
How is serotonin syndrome managed?
- 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
What are common options for maintenance treatment of bipolar disorder? (4)
- Lithium and valproate
- 2nd gen: quetiapine and anticonvulsant lamotrigine
What is avoided in patients with bipolar I disorder due to risk of mood destabilization?
- 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*
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?
- Alprazolam
- seizures, tremors, anxiety, perceptual disturbances, and psychosis
How do isolated overdose of SSRI present with?
- frequently asymptomatic or mild CNS depression
Acute toxicity of lithium symptoms:
Chronic toxicity of lithium symptoms:
Treatment
- N/V, diarrhea
- lethargy, confusion, agitation, ataxia, tremor/fasciculations, seizure
a. IV hydration and hemodialysis if severe
Treatment for specific phobia
- CBT exposure therapy - first line
- Short acting benzos (limited role, may help acutely if therapist unavailable or insufficient time)
Bupropion and varenicline are first line pharmacologic therapies for (BLANK)
Smoking cessation
What two drugs are first line treatment options for alcohol use disorders?
- Naltrexone - a mu opioid receptor antagonist
- Acamprosate - glutamate modulator
others
- disulfiram - can be used to give aversive symptoms
What are the different treatment regimen for MDD vs SAD
MDD
1. antidepressant (eg. SSRI), CBT
SAD
1. antidepressant (eg. SSRI)+light therapy, CBT, behavioral (outdoor walks, exercise, etc)
What are the stimulant medications for ADHD?
What are the nonstimulant medications for ADHD?
- Methylphenidate and amphetamine salts
- Clonidine, guanfacine, atomoxetine
Persistant/chronic motor or vocal tic disorder
- what does this mean?
- 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
What drug is given to treatment resistant schizophrenia and schizophrenia associated with persistent suicidality
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
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
- Buprenorphine - partial mu opioid agonist
- Methadone - full mu-opioid agonist
- Naltrexone - pure opioid ANTAGONIST
Advantages and disadvantages to buprenorphine
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
Advantages and disadvantages to Methadone
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
Advantages and disadvantages to Naltrexone
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
What is dissociative amnesia?
- Inability to recall important personal information, usually of a traumatic or stressful nature
- not explained by another disorder
–> tx with psychotherapy
- What is dissociative identity disorder?
- treatment
- Marked discontinuity in identity and loss of personal agency with fragmentation into >=2 distinct personality states
- associated with severe trauma/abuse
–> psychotherapy
What is depersonalization/derealization disorder?
- 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
What MDD patients require lifelong antidepressant treatment?
- Patients with >=3 lifetime depressive episodes
- Severe episdoes (eg. suicide attemtps),
- Episodes lasting >=2 years
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
What is the first line treatment for opioid dependent pregnant patients? (2)
- Methadone
- Buprenorphine
What side effect are SNRIs typically associated with?
dose dependent increases in diastolic and systolic blood pressure
From the two first line drugs for bipolar disorder, which is associated with renal disorders/malfunction?
- 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.
Manic episode
1. length of time
2. symptoms
- > = 1 week of elevated or irritable mood and increased energy/activity
- > =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
Brief psychotic disorder
1. time frame and what it involves
- > = 1 days and up to a month: sudden onset with full return to function
- psychotic symptoms (delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior)
—often develop in reaction to a marked stressor
Delusional Disorder
1. time frame
2. Clinical Features
3. Medication type for treatment
- > = 1 month
- > = 1 delusions
—other psychotic symptoms absent or not prominent
— behavior not obviously odd/bizarre; ability to function apart from delusion’s impact - Antipsychotics
–and supportive therapy
Time frame of persistent complex bereavement disorder
At least 6 months to a year after the loss
Major Depressive Disorder with psychotic features
- Treatment
- Combined antidepressant and antipsychotic medication
- ECT - especially in patients who are treatment resistant and have emergency conditions like SI, refusal to eat/drink, pregnancy
How long do patients stay on medication when diagnosed with schizophrenia?
Anitpsychotic medication should be maintained indefinitely in patients with schizophrenia
What is required to diagnose schizophrenia?
> =2 of the following (with at least 1 symptom from 1-3)
- DELUSIONS
- HALLUCINATIONS
- DISORGANIZED SPEECH
- Disorganized/catatonic behavior
- Negative symptoms (eg. apathy, flat affect)
-Cont. impairment >= 6 months
-Significant functional decline
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
Acute clinical features of PCP (hallucinogen)
- violent behavior
- Dissociation
- Hallucinations
- Amnesia
- NYSTAGMUS (horizontal or vertical)
- Ataxia
Acute clinical features of Cocaine (stimulant)
- Euphoria
- Agitation/psychosis
- CHEST PAIN
- SEIZURES
- Tachy/HTN
- MYDRIASIS
Acute clinical features of Methamphetamine (stimulant)
- violent behavior
- PSYCHOSIS/DIAPHORESIS
- Tachy/HTN
- Choreiform movements
- TOOTH DECAY
- sympathetic hyperactivity (mydriasis, diaphoresis, tachy, HTN)
Acute clinical features of Alcohol (depressant)
- Agression
- CONFUSION/DISORIENTATION
- Depressed mental status
- Respiratory depression
Acute clinical features of Opioids
- Euphoria
- DEPRESSED MENTAL STATUS
- MIOSIS
- RESPIRATORY DEPRESSION
- Constipation
What is used to manage PCP induced emergencies? (2)
- Benzos
- Antipsychotics
What is used to manage Cocaine induced emergencies? (2)
- Benzos
- Antipsychotics
What is used to manage Methamphetamine induced emergencies? (2)
- Benzos
- Antipsychotics
What is used to manage Alcohol induced emergencies? (1)
- Antipsychotics
What is used to manage Opioids induced emergencies?
- Naloxone
PCP acts on what receptors?
- NMDA receptors in the hippocampus and limbic system (causing excitatory and psychotic effects)
- Dopamine, NE, and 5HT receptors
- Sigma receptor complex (causing pyschotic and anticholinergic effects)
Adjustment disorder
1. time frame
2. what is it?
- Develops within 3 months of an identifiable stressor of any severity and lasting no longer than 6 months once the stressor ceases
- Symptoms are distressing and impairing but do not meet criteria for another psychiatric disorder
Acute stress disorder
1. time frame
2. what is it?
- > = 3 days and < 1 month
- Exposure to severe and life-threatening traumatic event, intrusive REMINDERS of the trauma, dissociative symptoms (altered sense of reality), and/or avoidance behavior
OCD
1. Clinical features
2. Treatment :med and therapy type
- 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
- SSRI and CBT therapy (exposure and response prevention)
What treatment should be given to someone with borderline personality disorder?
- Dialectical behavioral therapy
What symptoms can arise with pheochromocytoma?
- headache
- Tachy/palpitations
- sweating
- HTN
-drug resistant HTN and hyperglycemia with normal BMI
- symptoms are caused by catecholamine excess (neuroendocrine cells in adrenal medulla)
Postpartum blues
1. onset
2. symptoms
3. management
- 2-3 days (resolves within 14 days)
- Mild depression, tearfulness, irritable
- reassurance and monitoring
Postpartum depression
1. onset
2. symptoms
3. management
- within 4-6 weeks (can be up to year)
- > = 2 weeks of mod-severe depression, sleep or appetite disturbance, low energy, pyschomotor changes, guilt, concn difficulty, SI
- Antidepressants, psychotherapy
Postpartum psychosis
1. onset
2. symptoms
3. management
- variable: days to weeks
- delusions, hallucinations, thought disorganization, bizarre behavior
- Antipsychotics, antidepressants, mood stabilizers; hospitalization (do not leave mother alone with infant due to risk of infantacide)
Neuroleptic Malignant Syndrome
1. causative agents?
2. pathophysiology?
- Antipsychotic meds, antiemetic meds (e.g. promethazine), and withdrawal of parkinson medications
- Central dopaminergic receptor blockade, disruption of nigrostriatal dopamine pathways
Neuroleptic Malignant Syndrome
1. Signs/symptoms
2. Treatment
- fever, AMS, generalized muscle rigidity (lead pipe rigidity), autonomic instability (abnormal vital signs, diaphoresis), elevated CK +/- renal failure
- Stop antipsychotics or restart dopamine agents.
- supportive care, ICU
- Benzos
- Bromocriptine (dopamine receptor agonists) or dantrolene (muscle relaxation) if refractory NEMS
Benztropine
- What kind of medication is this?
- anticholinergic medication
- can be used to treat antipsychotic-induced extrapyramidal symptoms (e.g. dystonia- muscles contract involuntarily..stiffness)
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
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
- 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
Mirtazapine
1. MOA
2. Side effects
- Antagonist of serotonergic (5HT2/5HT3) and noradrenergic (NE) receptors –> thereby increasing sympathetic tone
- Sedating
- Increases appetite (leads to weight gain)
*used in depressive disorders, GAD, especially in underweight patients
What is a normal MOCA score?
> = 26/30
What antidepressant is this
1. Tricyclic antidepressant type
2. sedating
3. Side effect profile includes cardiotoxicity, danger in overdose
Amitriptyline
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
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?
- adding an antidepressant with a different MOA
- A 2nd gen antipsychotic
- Lithium
- Triiodothyronine
- Psychotherapy
- Non responders would benefit from switching to a different antidepressant
Buspirone
1. when is this used?
- To treat anxiety disorders
- May be used as augmentation for MDD when augmentation with a 2nd antidepressant is ineffective
What antipsychotic is this?
1. 2nd generation antipsychotic
2. Risk of weight gain and metabolic adverse effects
- Olanzapine
MOA of 1st vs 2nd generation antipsychotics
- 1st gen: strong D2R ANTAGONISM
- 2nd gen: 5HT2A and D2 ANTAGONISM
What are the preferred 2nd gen antipsychotics to use for Parkinson Disease psychosis?
- Quetiapine (best option bc low D2R antagonisms, wider availability, better safety profile)
- Clozapine (low D2R antagonism but limited use bc can induceagranuloctyosis)
- 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
Schizoaffective disorder
1. Time frame
2. Clinical criteria
- Hx of delusions or hallucinations for >= 2 weeks in the ABSENCE of MDD or Manic episode
- 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
What medications are commonly used in the treatment of acute bipolar DEPRESSION?
- 2nd gen antipsychotics QUETIAPINE and LURASIDONE
- anticonvulsant LAMOTRIGINE
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?
- Anorexia Nervosa
- CBT, nutritional rehab, Olanzapine if no response to the first two
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?
- Bulimia Nervous (doesnt req the vomiting aspect, just some compensatory behavior)
- CBT, Nutritional rehab, SSRI in combo with first two
What is this disorder?
- Recurrent episodes of binge eating but NO inappropriate compensatory behaviors
- Lack of control during eating
How do you treat?
- Binge eating disorder
- CBT, Behavioral weight loss therapy, SSRI, Lisdexamfetamine
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
Adjustment disorder
1. management
- Pyschotherapy and adjunctive pharm (short term, reserved for rapid relief of impairing symptoms like sleep aid)
PTSD
1. time frame
2. treatment
- duration of clinical features >= 1 month (reexperiencing symptoms, negative cognitions and mood, sleep disturbance, etc)
- CBT and antidepressants (eg. SNRI, SSRI)
- prazosin (alpha 1 adrenergic receptor antagonist) for nightmares
Specific phobia
1. treatment
- CBT with exposure
- short acting benzos (limited role that may help acutely if therapist unavailable or insufficient time)
- tremors
- agitation
- anxiety
- delirium
- psychosis
- exam findings: seizures, tachy, palpitations
This is withdrawal symptoms of…
alcohol
- N/V
- abdominal cramping
- diarrhea
- muscle aches
- Exam: dilated pupils, yawning, piloerection, lacrimation, hyperactive bowel sounds
This is withdrawal symptoms of…
Opioids (heroin)
- Tremors
- Anxiety
- Perceptual disturbances
- Pyschosis
- Insomnia
- Exam: seizures, tachy, palpitations
This is withdrawal symptoms of…
benzodiazepines
- Increased appetite
- Hypersomnia
- intense pyschomotor retardation
- severe depression (crash)
- Exam: no significant findings
This is withdrawal symptoms of…
stimulants
- Dysphoria
- Irritability/anxiety
- increased appetite
Exam: no significant findings
This is withdrawal of…
nicotine
- Irritability/anxiety
- depressed mood
- insomnia
- decreased appetite
-Exam: no significant findings
This is withdrawal of…
Cannabis
Differentiate these personality disorders
Schizoid vs antisocial vs avoidant
- Schizoid - prefers to be alone, detached, unemotional
- Antisocial - what comes after conduct disorder
- Avoidant - avoidance of others due to fears of criticism and rejection