Psych Clerkship Flashcards
1
Q
What are the components of the Mental Status Exam - 14
A
ABC STAMP LICKER
- Appearance (gender/race/appears age/healthy/grooming)
- Behavior (psychomotor mvmnt + behavior toward u)
- Content of thought (is pt thinking about obssesions/phobias/delusions)
- Speech (talkative/monotonous/mute/loud/rapid)
- Thought process (logical?/rambling?/rate of idea flow?)
- Affect (full/guarded/inappropriate2mood/blunted)
- Mood ( “What is ur mood today? - happy/sad/angry..” )
- Perception (Derealization?/Depersonalization?/Hallucinations?)
- Level of consciousness (alert,stupor,somnolent)
- Insight & judgement (good/fair/impaired)
- Cooperation
- Knowledge & cognition (MMSE score?/ A/O /Memory w/recall?/able to Abstract think?/concentration?)
- Endings (suicidal, homocidal)
- Reliability
2
Q
What would you expect diagnostic appearance of a Major Depression pt to be - 3
A
- ⬇︎Body wt
- poor grooming
- poor hygiene
3
Q
What would you expect diagnostic appearance of an Anorexia Nervosa pt to be - 3
A
- ⬇︎Body wt
- baggy clothes
- Lanugo -image
Tx = Fluoxetine
4
Q
What is echopraxia
A
repetitive imitation of mvmnts of another person
EchoLALIA = repetitve imitation of verbiage of another person
5
Q
What is sterotyping
A
isolated purposeless mvmnt performed reptitively
6
Q
What is alexithymia
A
Pt can NOT describe their mood
7
Q
What are the different ways you can describe Affect during mental status exam?
A
ABC ST(A)MP LICKER
Affect = outward manifestations of emotional state
8
Q
What is pressured speech? ; Which pts with mental illness exhibit this?
A
ABC (S)TAMP LICKER
rapid and difficult to interrupt (verbally runs you over!) ; Mania
9
Q
What are the different ways you can describe Thought Process during mental status exam? - 5
A
ABC S(T)AMP LICKER
- Logical
- Circumstantial (heavily includes details that have lil relevance to the point)
- Tangential (doesn’t directly address point or finishes it and tlks about topics easily brought to mind)
- Flight-Of-Ideas (Tangenital + Racing Thoughts)
- Looseness of Assocation-image (connection between ideas it not clear and topic changes cant be followed)
10
Q
Describe referential delusions
A
random events are of some special significance
“the Cubs lost, so that’s a signal the alien invasion is coming!”
11
Q
What is formication
A
feeling bugs crawling under skin
common in Cocaine users!! lol
12
Q
What is hallucinosis
A
pt knows their hallucinations aren’t real
Common in Alcoholics
13
Q
What are the different ways you can ask about judgement during mental status exam?
A
ABC STAMP L(I)CKER
judgement:
-If u were in a crowded movie theater and smelled smoke, what would u do? AND what would u like to do (or have done) in ur current situation?
14
Q
When describing Perception during a mental status exam, define the terms Derealization and Depersonalization
A
ABC STAM(P) LICKER
- Derealization = perceives objects in the world to be unreal (bigger vs smaller vs strange)
- Depersonalization = perceives self to be detached from body (like in a dream)
These typically occur together!
15
Q
What is the lifetime prevalence of Anxiety Disorders in the U.S.?
A
25%
Many of these pts go to docs who are NOT psychiatrist
16
Q
What is the diagnostic clinical criteria for Panic Disorder? - 3
A
- Recurrent Panic Attacks
- Unexpected Panic Attacks
- At least 1 attack is followed by ≥1 mo. of 1 or both of below:
- persistent worry of having another panic attack
- huge behavior changes to try and avoid future panic attacks
4. ≥ 4 of Panic Attack sx - image - And obvs can’t be 2/2 drugs or other condition*
17
Q
Demographic for Panic Disorder - 2 ; What is this group at risk for?
A
Women in the late teens/early 20s ; Death from Stroke vs MI
Usually Occurs with MDD/GAD/OCD
18
Q
Tx for Panic Disorder - 6
A
CBT (can be used alone)(breathing technique, exposure therapy) +/-
- SSRI (1st line rx)
- SNRIs
- Benzo short term
- TCA
- MAOi
* Similar to Social Phobic Anxiety Disorder tx*
19
Q
What is the diagnostic clinical criteria for Agoraphobia? - 2
A
- Fear & Avoidance OOP of ≥ 2 / 5 agora situations - image
- Fear & Avoidance OOP are > 6 months
LIKE WITH ANY PYSCH DO, Fear & Avoidance OOP –> distress and functional impairment
OOP = Out Of Proportion
20
Q
What is the diagnostic clinical criteria for Generalized Anxiety Disorder (GAD)? - 2
A
Excessive anxiety….
- includes ≥ 3 / 6 of anxiety sx - waTCHERS
- ≥ 6 months
LIKE WITH ANY PYSCH DO, sx –> distress and functional impairment
OOP = Out Of Proportion
21
Q
Demographic (sex and age) for Generalized Anxiety Disorder - 2
A
Women between 20-47
90% Occurs with MDD/GAD/OCD!!!!
22
Q
How is GAD associated with pharmacotherapy cessation?
A
60-80% of GAD pts relapse within 1st year after stopping pharmacotherapy
23
Q
Tx for Generalized Anxiety Disorder -9
A
- CBT
- SSRI (1st line rx)
- SNRI (1st line rx)
- TCA (2nd line rx)
- Benzo
- Buspirone
- Lyrica
- Mirtazapine
- Trazodone
24
Q
What is the diagnostic clinical criteria for PTSD? - 3
Lifetime prevalence = 8% and more common in Women
A
- All 4 sx categorymet - image
- sx > 1 month
- Exposure done via Direct (single or repeated), Witnessed, occurred to close fam/friend
25
What is the diagnostic clinical criteria for Acute Stress Disorder? - 3
*image*
26
Risk factors for developing PTSD? - 7
## Footnote
*Lifetime prevalence = 8% and more common in Women*
1. Substance abuse
2. Violence, Mood or Anxiety med hx (self or family)
3. Suicidal Ideation/attempts
4. Work or Marriage problems
5. Homelessness
6. Prior trauma
7. Female
27
When considering PTSD in **military** members, what should be on the ddx? - 5
## Footnote
*Lifetime prevalence = 8% and more common in Women*
1. TBI
2. Military Sexual Trauma
3. Re-exposure 2/2 multiple deployments
4. Civilian life readjustment
5. Substance Abuse
28
Tx for PTSD -13
1. CBT
2. Exposure therapy
3. EMDR (Eye Mvmnt Desensitization & Reprocessing)
4. Anger Mngmt
5. **SSRI (1st line rx) -*******_P_**aroxetine and **_S_**ertraline (**_P_**T_S_D)***
6. Prazosin (nightmare sx) -*alpha 1 NorEpi postsynpatic R Blocker*
7. SNRI
8. TCA
9. Clonidine (hyperarousal sx)
10. Propranolol (hyperarousal sx)
11. SGAs
12. Mood Stabilizers
13. Anticonvulsants
29
What is the diagnostic clinical criteria for Obsessive Compulsive Disorder?
Obessions/Compulsions or both that \> 1 hr/day AND/OR
LIKE WITH ANY PYSCH DO, sx HAVE to --\> distress and functional impairment
*Obessesion=Contamination, Symmetry, Somatic, Violence, Sex, Religion*
30
What comorbidities is OCD associated with? - 5
## Footnote
*Male = Female in prevalence*
1. **MDD**
2. Substance Dependence
3. Anorexia
4. Schizophrenia
5. Tourettes
31
OCD tx - 6
1. CBT
2. Exposure & Response prevention
3. **SSRIs-higher doses than anxiety tx (1st line rx)**
4. Clomipramine TCA (2nd line rx) - consider after 2 failed trials of SSRI
5. SNRI (3rd line rx)
6. SGAs (augmenting agent)
32
*In Hoarding Disorder, pts accumulate possessions and cause functionally impairing clutter*
When **in untreated pts** are these areas typically cleaned?
ONLY when intervention by 3rd parties is made
## Footnote
*Medical causes and other disorders should ALWAYS be ruled out before diagnosing psych conditions*
33
Diagnostic clinical criteria for Social Phobic Anxiety Disorder - 2
1. Fear/Anxiety OOP about Social situations that could --\> **scrutiny or humiliation** by others (giving speech/meeting new peeps/eating/drinking)
2. Fear/Anxiety ≥ **6 mo**
## Footnote
*Tx similar to Panic Disorder tx*
34
Diagnostic clinical criteria for Specific Phobia - 2 ; Tx?
1. Specific objects or locations **provoke IMMEDIATE fear/anxiety OOP** --\> active avoidance
2. sx ≥ **6 mo**
Tx = Exposure Therapy
35
Describe these Cultural Syndromes:
Ataque de nervios
Dhat Syndrome
Khyal Cap
Kufingisisa
36
Describe these Cultural Syndromes:
Susto
Taijin Kyofusho
Maladi Moun
37
What are the **\_\_\_\_\_** organic causes of Anxiety
**Endocrine** - 5
**Cardiovascular** - 5
*Substances can also induce Anxiety*
38
What are the **\_\_\_\_\_** organic causes of Anxiety
**Metabolic** - 5
**Neurological** - 7
* Metabolic includes the "Zebras"*
* Substances can also induce Anxiety*
39
Which substances are known for inducing Anxiety - 8
1. Cocaine
2. Amphetamines
3. Caffeine
4. CTS (CorTicoSteroids)
5. Hallucinogens (Cannabis, PCP)
6. Inhalants
7. Theophylline
8. Thyroid hormones
40
Common side effects of SSRI - 8
1. GI distress (there are MORE serotonin R in the GI tract!)
2. SIADH
3. Wt Gain
4. ⬇︎Libido
5. Sedation
6. Dry Mouth
7. HA
8. **induces mania/hypomania/rapid cycling in Bipolar pts if monotherapy (SNRIs does this also)!**
## Footnote
*****SSRI DC --\> Nausea/HA/Dizziness/Lethary/FluLikeSx*
41
**Serotonin Syndrome** Clinical Presentation (8)
"Serotonin gave me the **SHIVERS**!"
***S**hivering*
[**H**yperreflexia & Myoclonus]
**I**NC Temp
*[**V**ital sign instability] (tachycardia vs. tachypnea vs. HTN)*
***E**ncephalopathy (Confusion vs. Agitation)*
**R**estlessness
**S**weating
*Italicized = Triad Sx*
42
How do you treat *Refractory* Serotonin Syndrome
## Footnote
*Serotonin Syndrome comes from SSRI PLUS another med that synergistically ⬆︎Serotonin*
Cyproheptadine
(antihistamine with anti-serotonergic properties)
43
Describe Neuroleptic Malignant Syndrome
RARE SE of Any Dopamine Blocker (Antipsychotics vs. GI meds) that --\> **FEVER**
- [**F**ever \> 40C]
- **E**ncephalopathy (PRESENTS FIRST)
- **V**itals unstable (⬆︎ HR / RR / ⬇︎BP from autonomic dysfunction)
- **E**nzymes (⬆︎CPK AND WBC)
- **R**igitidy ⬆︎
* NMS should develop within 30 days but most is within 1 week. Also has good pgn*
44
What's the best way to approach treatment for [Neuroleptic Malignant Syndrome]
Treat Rigiditiy with Dantrolene (inhibits Ca+ release from sk. muscle sarcoplasmic reticulum)
+
supportive care
45
What is the diagnostic criteria for ADHD? - 3
1. Sx present for **at least 6 mo.** AND inappropriate for dvpmental age
2. Sx **start** **between 6-12 yo** and not after 12 yo
3. Evident in **2 or more settings** (school/work/home)
## Footnote
*as usual, sx must be functionally impairing and not 2/2 substance or other condition*
46
Diagnostic criteria for Cyclothymic disorder - 4
1. Fluctuating mood episodes (hypomania \<---\> depression)
2. ≥ 2 years
3. no sx relief for \> 2 mo.
4. **BUT does not meet full criteria for hypomanic or MDD episodes**
47
What is the clinical criteria for **hypomanic** episodes
1. Elevated or irritable mood 4\< x \<7 days PLUS
2. ≥3 Classic BIPOLAR sx
49
What is the clinical criteria for **Manic** episodes
1. Elevated or irritable mood **≥ 7 days** PLUS
2. ≥3 Classic BIPOLAR sx
50
Diagnostic criteria for Bipolar II ? - 3
1. Major Depressive Episodes +
2. **hypo**manic episode +
3. NOT functionally impairing
51
Diagnostic criteria for Persistent Depressive Dysthymia disorder - 2
1. at least 2 / 6 of **SIGECA**
2. CONSTANT for 2 years (no relief \> 2 mo)
## Footnote
*Major Depressive Episodes may also occur with this*
53
Diagnostic criteria for Bipolar I ? - 2
1. **Manic** episode +/- major depressive episodes
2. Functionally impairing vs psychosis vs hospitalization
54
What are the drug culprits that cause Serotonin Syndrome (when synergistically combined with an SSRI)? -7
1. Tramadol
2. Triptans
3. Linezolid
4. MAOI
5. Ondansetron
6. Metoclopramide
7. MDMA
55
Relationship between Benzodiazepines and pregnant women
**NO BENZOS FOR PREGGOS!**
## Footnote
*Benzodiazepines are Class D*
56
Hoarding disorder tx
CBT targeting hoarding behaviors
## Footnote
*Consider adding SSRI **only** if there's also depression / anxiety*
57
How should you manage Autism? - 3
1. **Early dx & tx**
2. Multimodal tx (speechTherapy/CBT/education)
3. Antipsychotic adjunct
58
What are the signs of Cocaine intoxication? - 6
1. MyDriasis (*Pupils Wide Open on coke!*)
2. Chest Pain --\> Arrhythmia and MI
3. Seizures
4. Hyperthermia
5. sexual dysfunction
6. psychosis
59
What are the signs of Amphetamine intoxication? - 5
1. Psychosis +/- delirium
2. Agitation
3. MyDriasis
4. Tachycardia
5. HTN
60
Which rx agents cause false positive amphetamine results on urine tox? - 3
1. pseudophedrine
2. Buproprion
3. Selegiline (also comes as transdermal)
61
How long does opioid withdrawal typically last?
3-5 days
## Footnote
*Sweating/Lacrimation/Rhinorrhea/Myalgia/Diarrhea*
62
Phencyclidine (AKA \_\_\_) is a \_\_(*MOA*)\_\_\_ and main toxication signs are what?-4
PCP (Hallucinogenic dissociative anesthetic = [NMDA Glutamate R Blocker])! ;
1. [Vertical Nystagmus]
2. Violence
3. HTN
4. Hyperthermia
63
[LSD ergoline] main toxication sign is \_\_\_\_\_
*frightening* Visual Hallucinations
## Footnote
even while sober, pts may reexperience this
64
[Phencyclidine PCP] and Ketamine are both _____ with similar effects. What's the main differences?-2
Hallucinogenic Dissociative anesthetics
1. Ketamine is short lived
2. Keamine causes blunted behavior (i.e.impaired consciousness) while PCP causes violent behavior
65
What is Eye movement desensitization and reprocessing treatment? ; What is it indicated for?
Integration of eye mvmnts with therapy ; PTSD
66
Tx for Mania or hypomania - 5
Treat Bipolar pts b4 they go **BALD** + Car!
1. **B**enzos (ONLY AS ADJUNCT)
2. **A**ntiPsychotics (1st AND 2nd Generation)
3. **L**ithium \*\*
4. **D**epakOte \*\*
5. [Carbamazepine Tegretol]
67
Buspirone MOA ; indication
Buspir**one** = [5HT**1**a partial agonist]; GAD; [slow onset] and [lacks muscle relaxant/anticonvulsant properties]
68
What are the cons of Buspirone? - 3
1. slow onset
2. lacks muscle relaxant properties
3. lacks anticonvulsant properties
69
Describe Shift work sleep disorder
Recurrent **sleep interruption** 2/2 shift work --\> daytime sleepiness, difficulty initiating sleep, difficulty maintaining sleep
70
Describe Trichotillomania is ; what's a serious complication of this?
compulsive **Hair pulling DO** in which pt attempts to stop pulling hair out of scalp, eyebrows and eyelashes but can't. ; Possibly leads to trichophagia (swallowing hair) which --\> bowel obstruction
## Footnote
*Related to OCD and has ⬆︎morbidity in those with hx or fam hx of OCD*
71
Trichotillomania tx
CBT - habit reversal training
72
MDMA MOA
synthetic amphetamine that ⬆︎synaptic "SND" **S**erotonin, **N**orEpi, **D**opamine
## Footnote
*Can cause Serotonin Syndrome when taken with SSRI!! MDMA may also cause hypOnatremia*
73
In pts with TCA overdose, what's the most important vital to monitor and why?
**QRS duration** ; QRS \> 100 msec --\>⬆︎Vt arrhythmias and seizures (tx: NaHO3)
74
What comorbidities is GAD associated with? - 4
## Footnote
*Male = Female in prevalence*
1. **MDD**
2. Substance Dependence
3. Social phobic anxiety disorder
4. Panic disorder
75
What is the precaution with using Benzos in PTSD pts? - 2
1. may cause Disinhibition in PTSD pts
2. Dependency
## Footnote
*only has limited positive effect*
76
What comorbidities is PTSD associated with? - 5
## Footnote
*Female \> men in prevalence*
1. **MDD (65% of PTSD pts have this also)**
2. Substance Dependence (50% of PTSD pts have this also)
3. Somatization DO
4. Suicide
5. Aggression
77
Which diagnostic tools are used *in-office* to make PTSD dx?
1. Primary Care PTSD screen
2. PTSD checklist (PCL)
78
Which sex is more likely to have PTSD? ; What is lifetime prevalence in general population?
**WOMEN** are twice as likely ; 8%
79
What % of PTSD pts also have substance abuse disorder?
50%
80
*PCP and Amphetamine intoxication presentations may be similar*
How can you tell them apart? - 2
1. PCP will show up in urine tox x 8 days
2. PCP has multidirectional nystagmus
81
Signs and symptoms of MDMA intoxication - 3
1. Hyperthermia
2. Seizures
3. Delirium
82
Teens who develop significant acute changes in behavior should be assessed for what potential factors? - 4
1. Psychosocial stressors
2. Trauma (physical or sexual)
3. Substance use
4. Psych disorders
## Footnote
*Don't just throw drugs at them! Do detailed eval*
83
Borderline personality disorder pt typically have a remote hx of what?
**PESSP**
CHILD ABUSE
84
When is it ok for Bipolar pts to discontinue their rx therapy if they've had ≥ 2 Manic episodes? ; Explain
NEVER!!
It is a **lifelong** illness requiring maintenance rx for years (and forever in severe bipolar pts)
85
Tardive Dyskinesia is an EPS component caused by ____ blockers. ; What's the antidote for it?-4
## Footnote
* EPS = (T)ADD sx*
* (T)ardive Dyskinesia is not EPS*
Dopamine R blockers;
1. **Switch to Clozapine** (even tho only 50% respond to it)
2. 50% of pts naturally have relief within 3 mo of d/c Dopamine R blocker
3. Benzo ACUTELY
4. ⬆︎Dopamine R blocker actually **temporarily** ⬇︎Tardive Dyskinesia ACUTELY
*Obviously ⬇︎ (not aruptly d/c) D2 blocker as well*
86
What makes up the ExtraPyramidal Symptoms? - 4
*EPS = (T)ADD sx*
1. **T**ardive dyskinesia (tx=switch to clozapine)
2. **A**kathisia
3. **D**ystonia
4. **D**rug-induced Parkinsonism
87
*In addition to TSH, BUN/Creatinine and urinalysis labs...*
What other test should be ordered before starting pts needing Lithium **if they have CAD risk**?
EKG (Lithium causes dysrhythmias in CAD pts)
88
Tx for Somatic Symptom disorder
## Footnote
*Depression is a common CoMorbidity and Females \> Males in prevalence*
Regularly scheduled Med visits (*Goal: Improve functionality*)
## Footnote
*DO = preocupation with unexplained (but proven to be benign) medical sx*
89
Somatic Symptom disorder CP
## Footnote
*Depression is a common CoMorbidity and Females \> Males in prevalence*
preocupation with unexplained **(but proven to be benign)** medical sx +/- pain and/or persistence
90
What is Functional Neurological Symptom Disorder? ; tx?
unexplained neurological deficits **2/2 emotional stressors** ; EDUCATION about the Disorder!
## Footnote
* AKA CONVERSION DISORDER*
* Be sure to specifiy deficit, whether \> or \< 6 mo and what stressor was*
91
Jimson Weed Poisoning clinical presentation - 7
*Jimson Weed = AntiCholinergic*
"Blind as a bat, mad as a hatter, red as a beet, hot as a hare, dry as a bone, the bowel & bladder lose their tone, and the heart runs alone....." = The AntiCholinergic 7
1. Blind as a bat = [**MyDriasis and [cycloplegia** (blurry vision especially when focusing on near objects)]
2. Mad as a hatter= **Agitation & Hallucinations**
3. Red as a Beet = **Cutaneous flushing** despite vasoconstriction
4. Hot as a hare = **Hyperthermia** from ⬇︎ ability to sweat
5. Dry as a bone= **DEC Secretions** (including sweat)
6. **Bladder & Bowel lose their tone**
7. Heart runs alone = No vagal tone at SA --\> **Tachycardia**
92
Malignant Hyperthermia etx ; Which pts are susceptible?
After giving [**inhaled anesthestics** and/or **succinylcholine**] (to genetically predisposed pts (AUTO DOM)) --\> [Fever & Muscle Rigidity soon after surgery with Unstable Vitals]
## Footnote
**M**alignant = **M**uscle Rigiditiy
**Malignant** = Unstable Vitals
**Hyperthermia** = Fever
93
Malignant Hyperthermia Tx
Dantrolene
## Footnote
*TREAT PROMPTLY! AS THIS IS LIFE THREATENING CONDITION!*
94
Malignant Hyperthermia clinical presentation - 3
1. **Malignant** = Malignant Unstable Vitals
2. **M**alignant = **M**uscle Rigidity
3. **Hyperthermia** = Fever
95
Disulfiram MOA ; indication
## Footnote
*Disulfiram is AKA AntAbuse*
inhibits aldehyde dehydrogenase ; **thwarts urge to drink EtOH** by causing horrible rxn (NV/HA/Flushing) when EtOH is consumed
## Footnote
*ONLY give to NON-IMPULSIVE INTELLIGENT, normal liver pts who will be abstinent and HIGHLY motivated as this lingers in system for 2 weeks after dose*
96
*Naltrexone is 1st line tx for alcohol use disorder and can be taken while pt is still drinking*
When is Naltrexone contraindicated? - 3
1. Liver Failure
2. Acute Hepatitis
3. Pt currently uses opioids
## Footnote
*It CAN be used in mild liver dysfunction*
97
Acamprosate MOA ; indication
## Footnote
*dose: 2T of 333mg TID*
GABA analog ; **Maintains** Alcohol abstinence once its reached by ⬇︎cravings (1st line rx)
## Footnote
*Renal excreted so Be sure to monitor renal function and SE = Diarrhea*
98
What behaviors from a toddler regarding sex are medically concerning? - 4
1. precocious sexual knowledge
2. preoccupation with masturbating
3. excessive talk about sexuality
4. simulating oral/anal/genital2genital contact
## Footnote
*curiousity with their own or other children's genitals is normal*
99
Indications for Buproprion - 5
1. Depression
2. Smoking cessation
3. ADHD
4. Sexual Dysfunction 2/2 SSRI
5. hypersomnia 2/2 atypical depression
100
What are 3 major precautions to remember with SSRIs?
1. **induces mania/hypomania in Bipolar pts!**
2. **⬆︎**suicidality within first 2 weeks in young adults
3. SSRI Discontinuance --\> Nausea/HA/Dizziness/Lethargy/FluLikeSx/Zapping
101
What are the main *physical* things that change from normal aging - 4
1. Fragmented sleep w/⬇︎ of stage 4
2. ⬇︎Muscle mass
3. ⬇︎deep tendon reflexes
4. Brain wt ⬇︎ by 85% w/frontal & temporal affected most (plus lipofuscin granules, senile amyloid plaques)
102
**90**% of Alzheimer's pts are what age?
≥ 65 yo
103
Alzheimer's tx - 7 ; Which medication should be used last?
CLAV --\> HANDU
1. Donepezil - *AChnesterase inhibitor*
2. Tacrine - *AChnesterase inhibitor*
3. Rivastigmine - *AChnesterase inhibitor*
4. Galantamine - *AChnesterase inhibitor*
5. Memantine - *NMDA R Blocker: **USE LAST***
6. Respite Care for Caregivers (ex: Adult day program)
7. SGAs - Quetiapine vs Risperidone (for acute psycosis)
104
When treating the Depression/Anxiety in Alzheimer's pts, which SSRI should you **avoid**?
paroxetine
## Footnote
*if sx persist, use ACEI*
105
When treating the Psychosis in Alzheimer's pts, which antipsychotics should be used? - 4
Risperidone = Quetiapine \> Olanzapine=Aripiprazole
106
What's unique about the clinical presentation of Vascular dementia?
**_step-wise_** deterioration (usually because of recurring CVA/TIA)
107
Dementia with Lewy Bodies (DLB) CP - 3
DLB at the **DMV**
1. **D**ementia confusion periodically
2. **M**ichaelJFox Parkinsonism (PARK + hamp) tht **does NOT respond to dopaminergic tx** and has early falls and presyncopal episodes
3. **V**isual Hallucinations (brightly colored 3D subjects)
* will be more symmetric than regular Parkinson's and is sensitive to neuroleptics*
* Lewy Body= [**LABS** (**L**ewy **α**-synuclein **B**odie**S**)] that are Eosinophilic intracytoplasmic accumulations*
108
What is the important thing to remember regarding the treatment of psychosis in pts with Dementia with Lewy Bodies (DLB) ?
DLB at the **DMV**
IT IS POORLY SENSITIVE TO D2 BLOCKER NEUROLEPTICS SO DON'T USE THEM!
109
Huntington's Dz Clinical Presentation (2)
* "Hunting 4 food is way too **aggressive** & **dancey**"*
1st: **Aggressive** Dementia w/ strange behavior
2nd: **D****ance**-like Chorea mvmnts
* AUTO DOM = Affects BOTH sexes equally!!*
111
Etx of Frontotemporal Pick's Dementia ; CP-2
Prounouced Frontal & Temporal lobe atrophy --\> [**Socially inappropriate** Behavior] + aphasia
## Footnote
*OCCURS MORE IN FEMALES!!!*
112
A: Demographic of Frontotemporal Pick's Dementia?
B: Mode Of Inheritance
A: 50-60 yo Females (Alzheimer = \> 60)
B: Auto Dominant
113
[Creutzfeldt Jakob Dz] CP - 2
[**RAPIDLY** Progressive Dementia] + [STARTLE Myoclonus] --\> DEATH
## Footnote
*Can be Acquired vs. Inherited*
114
Dx for Creutzfeldt Jakob disease - 6
1. [PRNP prion protein] genetic testing
2. EEG Biphasic vs Triphasic **sharp wave complexes**
3. Postmortem brain biopsy
4. ⬆︎CSF 14-3-3 proteins
5. MRI Cortical Ribbons
6. MRI basal ganglia hyperintensity
115
Openly discuss Limbic Encephalitis
116
What is the CAM score used for? ; Describe its criteria
CAM score = **Diagnosis Delirium** and differentiates it from Dementia/Depression
***AIDA:** Requires A and I, but only either D vs. A*
**A**cute onset and fluctuating
**I**nattention (spell "world" backwards & forward)
**D**isorganized thinking (rambling/illogical)
**A**ltered level of consciousness (intermittently not alert?)
*Also can use Dementia Rating Scale for this*
117
What type of EEG changes are noticed in Delirium pts? - 4
1. Background slowing
2. poor organization of background rhythm
3. loss of reactivity to opening/closing eyes
4. Triphasic waves (especially hepatic encephalopathy or sepsis delirium)
## Footnote
*33-67% of Delirium is missed 2/2 "expected" to occur, assumed to be depression, ignored for bigger issues or lack of screening*
118
Most Delirium pts (90%) are what demographic? - 3
1. CA pts
2. MICU
3. Post-**Cardiac** surgery pts
119
Risk factors for Delirium - 9
1. Age (elderly)
2. Pre-exisiting cognitive impairment
3. Meds
4. Neuro insults (CVA/TIA)
5. Pain
6. Nutrition
7. Smoking/Nicotine **withdrawal**
8. Perioperative factors
9. Genetics
120
What type of EEG changes are noticed in Delirium **Tremens** pts? - 2
1. low voltage but...
2. FAST activity
121
What are **Non**-Rx ways to prevent Agitation in Delirius pts -5
1. DC Delirum-causing meds (*Benzo, Benadryl*)
2. No restraints
3. Normalize Sleep
4. Reorientation (*Write Date on the message board*)
5. Correct Derangements (*dehydration, metabolic*)
122
What are **Rx** ways to ⬇︎Agitation in Delirius pts -4
1. Haloperidol (Monitor K, Mg, QTc)
2. SGAs if pt had TBI (**Although antipsychotics ⬆︎stroke/sudden death risk in dementia pts**, Haloperidol ⬇︎recovery abilities if pt is s/p TBI)
3. Benzos for EtOH/sedative withdrawal
4. Anticonvulsants if postictal
123
Which rx is most optimal for Anorexia Nervosa
Fluoxetine
124
Difference between Tourette and [Chronic Tic DO]
Tourette = [Motor **_AND_** Vocal Tics BOTH] for ≥ 1 year
## Footnote
*These sx must occur before 18 yo and tx = Antipsychotics vs Alpha 2 R agonist vs CBT*
125
Tx for Tourette's and Chronic Tic Disorder - 6
1. CBT Habit Reversal Training
2. Clonidine - alpha 2 R agonist
3. Guanfacine - alpha 2 R agonist
4. **Risperidone**
5. Haloperidol
6. Pimozide antipsychotic
## Footnote
*Antipsychotics are more effective*
126
Side effects of ADHD stimulants - 4
1. ⬇︎Appetite --\> Wt loss
2. Insomnia
3. Tachycardia
4. Tics (in children AND RARE)
127
Buproprion MOA - 2
*Buproprion is a NDRI*
**NorEpi** and **Dopamine** reuptake inhibitor
128
Why is Mirtazapine a good choice for depressed pts who are losing weight and can't sleep
It's SE includes ⬆︎appetite/wt gain and somnolence
## Footnote
*Wt gain is \> in Women before menopause and usually not problem if hasn't occured within 1st 6 wks*
129
*There are 4 Dopamine D2 pathways in the brain*
Name the pathways ; what overall effect do they have when activated?
Stimulation of....
**Mesolimbic** = Psychosis
**MesoCortical** = Activated Affect (loss of MesoCortical --\> negative sx)
**Nigrostriatal** = Mvmnt Coordination
**Tuberoinfundibular** = INHIBITS Prolactin when activated (*if blocked --\> infertility from hyperprolactinemia*)
131
Which antipsychotic actually has a **dual** blockade effect? ; Which 2 receptors does it block?
Risperidone ;
1. D2 R blocker
2. Serotonin 2A R blocker (helps to ⬇︎EPS side effects)
132
S/S of Opioid withdrawal - 7
1. Sweating
2. Lacrimation
3. Rhinorrhea
4. Myalgia
5. Diarrhea
6. Yawning
7. MyDriasis
## Footnote
*These last for 3-5 Days*
133
Which comorbidities is Tourette's associated with? - 2
1. OCD (develops within ~5 years of tic onset)
2. ADHD
134
Describe the clinical tool used to assess whether a pt is seriously contemplating suicide
**SAD PERSONS**
## Footnote
*Each is worth 1 point and* *[normal **_3_** \<--(outpt tx)--**_8_** --\> Hospitalize now!]*
**S**ex Male (be sure to ask about in-house guns!)
**A**ge external to 19-45
**D**epression or other psych dx
**P**revious attempt hx (STRONG RISK FACTOR!)
**E**tOH or substance abuse
**R**ational thinking impaired (delusions, hallucinations)
**S**ocial support lacking or suicidal fam hx
**O**rganized plan
**N**o significant Other
**S**ickness physically (i.e. chronic pain)
135
What is the strongest single risk factor for suicide
previous suicide attempt
136
Diagnostic clinical criteria for Disruptive Mood Dysregulation disorder - 3
1. Frequent Temper Outburst
2. Severe irritability
3. Poor Frustration tolerance
137
What type of psychiatric side effects does CTS (CorTicoSteroids) have? - 4
**S**teroids **M**ake **P**eople **D**epressed!
1. **S**uicidality
2. **M**ania
3. **P**sychosis
4. **D**epression
138
*AntiSocial Personality disorder is essentially Charlie Sheen*
What is the nuance for diagnosing this disorder in regards to age of onset?
ASPD pts must have had conduct DO **before 15 yo**, with a continuance into adulthood
139
What regimen, for maintenance therapy, is considered in Bipolar pts who DON'T respond to monotherapy maintenace?
Treat Bipolar pts b4 they go **B(****AL****)D**!
**A** + [**L or D]**
[**A**ntipsychotic 2ND GEN] + [**L**ithium or **D**epakote]
140
Tx for Major Depression **with psychotic features** - 2
1. ECT \> antipsychotic ➕
2. Antidepressant
## Footnote
*Use ECT in elderly as it is more rapid acting*
141
Suicide is the ___ (*1st/2nd/3rd/4th)* leading cause of death
4th
142
What are the strongest predictors of suicide? - 2
**psychiatric illness** \> # of substances abused
143
What are the steps of Suicide Risk Assessment? - 5
1. Reduce RF for suicide-*static vs _dynamic_* (SAD PERSONS)
2. Enhance protective factors
3. Directly inquiry about Suicide (Ideation, Attempts, Plan, Intent)
4. Risk level determination
5. DOCUMENT
## Footnote
*⬇︎Dynamic RF and ⬆︎protective factors*
144
**When** should you document a Suicide Risk Assessment? - 3
1. 1st psych assessment/admission
2. prior to inpatient d/c
3. any suicidal behavior/ideation
## Footnote
*Document risk level, basis for risk level, plan for reducing risk and firearm assessment*
145
What are the 3 C's of addiction?
1. **C**ompulsion to use
2. **C**ontrol is lost
3. **C**ontinues despite consequences
146
Which demographics has the highest suicide rates? - 2
1. Age \> 65 of the **LAW** [**L**atinos/**A**sians/**W**hites]
2. Age \< 25 of African Americans and Native Americans
## Footnote
*Of this, Native Americans and Whites commit the most as a group*
147
Lifetime prevalence for prior suicide attempts
~28%
148
Name the common suicidal Protective factors - 8
1. Family
2. religion
3. life satisfaction
4. Reality testing ability (i.e. No psychosis/AVH)
5. good coping skills
6. social support
7. good therapeutic relationship (usually w/outpt MD)
8. good problem solving skills
149
What are rx treatments for Suicide - 4
1. Antidepressants
2. Lithium
3. ECT **for short term reduction only**
4. Clozapine **for schizophrenia & schizoaffective** **only**
150
What should be targeted during psychotherapy for Sucidal pts? - 3
1. Circumstantial issues
2. Manage high risk sx (hopelessness & anxiety)
3. treat high Depression and other Psych illnessess
151
*A pt has a **single** episode of major depression but responds well to antidepressant SSRI tx*
What do you do when he asked to stop the SSRI since he's now feeling "great"?
Cont Antidepressant rx for **additional 4-9 months** once remission is reached and then d/c
## Footnote
* This is called continuation phase tx*
* Pt with multiple episodes of MDD should cont SSRI for additional 1-3 years after reaching remission and indefinitely if their depression is SEVERE*
152
[T or F] Pt confidentiality should be maintained even when a pt is having Active suicidal ideation
FALLLSEE!!!!
## Footnote
Active (i.e. plans to hang themself) suicidal or homocidal ideation warrants breaking confidentiality and informing parents or whomever
153
Is Parental consent required for hospitalization? ; what about psychotropic medications?
NO, not required for hospitalization if pt is harm to self or others ; YES required for psych meds
154
3 SGAs that cause the greatest **weight gain**
"**i** _**C**ause_ _**O**besity_"
**i**Loperidone / _**C**lozapine_ / _**O**lanzapine_
***C**lozapine & **O**lanzapine cause Sedation & [Metabolic Syndrome X] as well so monitor Fasting glucose and lipids!*
155
Which SGA causes the **MOST** metabolic syndrome SEs (2)
Clozapine and Olanzapine
156
A: **High** binding SEs of Olanzapine (2)
B: Which Receptors are blocked (2)
A:
1. Wt. Gain
2. Metabolic Syndrome
B: [A1 adrenergic] / H1
157
Tx for Kleptomania - 5
1. CBT
2. SSRI
3. Opioid R Blockers
4. Lithium
5. Anticonvulsants
158
MAOi MOA ; indications-2
inhibit catabolism of **SEND** (**S**erotonin/**E**pi/**N**orEpi/**D**opamine)
1. refractory depression
2. atypical depression
159
Foods containing ____ can be have a dangerous interaction with MAOIs
What is the rxn when these two mix?
Tyramine ; **HYPERTENSIVE CRISIS** 2/2 sympathetic activation!
## Footnote
*This will first present as a HA*
160
Explain what Cognitive Behavioral Therapy is
Therapy that **changes cognitive distortions** (i.e. overgeneralization, catastrophizing, minimalizing positive events)
161
Explain what Biofeedback therapy is
Uses signals from body (HR, temperature, BP) as indicators of emotional distress and teaches this to pts to control their responses
162
Explain what Dialectical behavioral therapy is - 3 ; What disorder is this specifically used for?
Targets
1. emotional dysregulation
2. self-destructive
3. suicidal behaviors
Borderline Personality DO
163
In Motivational Interviewing, therapist focus on pt's motivation for change and ambivalence
What illness is this usually used to treat?
Substance Abuse DO
164
*Diagnostic clinical criteria for Generalized Anxiety Disorder consist of a ≥6 month time period of ≥3 out of 6 major sx*
What are the 6 GAD sx?
wa**TCHERS**
## Footnote
Worry / Anxiety that --\> to...
1. **T**ension in muscles
2. **C**oncentration ⬇︎
3. **H**yperarousal IRRITABILITY
4. **E**nergy ⬇︎
5. **R**estlessness/on edge
6. **S**leep disturbance
165
Contraindications for Buproprion - 4
1. Seizure hx
2. Bulimia nervosa
3. Anorexia Nervosa
4. Use of MAOI within prior 2 weeks
166
Tx for Anorexia Nervosa - 5
1. **Nutritional rehab**
2. CBT
3. Hospitalization if vitals unstable
4. Fluoxetine if refractory to #1-3
5. Olanzapine if refractory to #1-3 (⬇︎obsessive thoughts and ⬆︎ wt)
167
How is Anorexia Nervosa associated with thyroid dysfunction? ; Should this be medically addresed with supplement?
pts with **anorexia** nervosa naturally have ⬇︎levels of T3 and T4 2/2 body's adaption to chronic nutritional depletion ; T3 and T4 will return ON THEIR OWN with refeeding so DO NOT REPLACE
168
Clinical presentation of REM sleep behavior disorder ; What could this indicate if it occurs reoccurs frequently?-2
**Physical Dream Enactment** during REM sleep (latter part of the night) ; Parkinson's or DLB
## Footnote
*Pt kicking, talking and pushing you off the bed while they're dreaming*
169
Describe Sleep terrors and sleepwalking
**non**-REM sleep arousal disorders that occurs in younger pts during first trimester of sleep period with **NO MEMORY** of the dreams and pt can NOT be awakened during episode
*often results in Sleep awakenings*
170
What is the difference between Sleep Terror and Nightmare disorder?
In Night**M**ares, you'll re**M**ember the Dream!
171
*Depressed pt has been on an SSRI "for a while" and doesn't see much improvement*
What constitutes an adequate "trial" of SSRI before switchin to SNRI?
≥ 6 weeks
172
Most common side effect of ElectroConvulsive Therapy (ECT)
Transient Amnesia
173
What are the primary electrolyte disturbances seen in Anorexia or Bulimia Nervosa - 3
1. ⬆︎Amylase
2. ⬇︎K+
3. ⬇︎Cl
174
Antipsychotics (\_\_\_ generation) can be used to treat the depressive phase of Bipolar disorder
Which 2 are the best to be used?
Treat Bipolar pts b4 they go **BALLD**!
2nd generation Antipsychotics for Bipolar *Depression* =
Quetiapine and Lurasidone
175
In the context of substance abuse, what are the 4 types of recovery?
1. Clinical (absence of sx/usage)
2. Social
3. Economic
4. Personal
176
Diagnostic clinical criteria for Substance **Dependence** - 7
Maladaptive pattern of substance use consisting of **≥3 of the following in a 1 year period**:
1. Tolerance
2. Withdrawal
3. Desire to control/cut down is ineffective
4. Substance taken in larger amnts or over longer period of time than intended
5. Significant amount of time spent in activities needed to obtain the substance
6. Other important social activities are given up 2/2 substance
7. Use is continued despite knowledge of consequences it presents
177
The highest prevalence of Substance use disorders occurs in which psych illnesses? - 3
[**AntiSocial 84%**] \> [Bipolar 60%] \> [Schizophrenia 47%]
178
What constitutes "a drink"? - 3
1. 1 oz of 100 proof liquor (50% EtOH)
2. 12 oz beer
3. 4 oz wine
179
S/S of Alcohol Withdrawal -10
## Footnote
*these sx PEAK during 2nd day of abstinence and resolve by day 5*
**PAST NITE**
## Footnote
**P**sychomotor agitation
**A**nxiety Irritability
**S**eizures
**T**remor & DELIRIUM TREMENS
**N**V
**I**nsomnia
**T**ransient Hallcuinations
**E**xcitable autonomics (⬆︎HR, BP)
180
Describe Delirium Tremens-5 ; when does DT onset?
Further progression of **E**xcitable autnomics =
1. ⬆︎ HR
2. ⬆︎ BP
3. fever
4. hallucinations
5. Tremulousness --\> Death
Onsets 2 days post last EtOH (when withdrawal sx peak)
181
An alcoholic likely needs to be hospitalized in what situations? - 5
1. Documented hx of Severe EtOH abuse and ⬆︎tolerance
2. Pt has severe psych DO
3. hx of withdrawal seizures
4. hx of Delirium Tremens
5. Concurrent abuse of other substances
182
What is the interpretation of the CIWA protocol? - 3
Mild \<--- **_9_** ---Moderate--- **_21_** ---\> SEVERE
## Footnote
* Mild withdrawal tx = support, reassurance and q4 checks*
* Moderate withdrawal tx = Benzos*
* S**EVERE withdrawal tx = ⬆︎Benzo, Thiamine, Fluids in ICU*
183
*Pts going through **mild** EtOH withdrawal sx (CIWA ≤9) should be treated with support. reassurance and q4 checks*
What is the tx for SEVERE EtOH withdrawal sx (CIWA ≥ 21)? - 6
IN ICU SETTING...
1. [⬆︎Benzos PO vs IV **only** (No IM should be used, especially if benzo is Diazepam or ChlorDiazepoxide)]
2. Thiamine B1
3. IVF
4. Propranolol for **E**xcitable autnomics
5. Clonidine for **E**xcitable autonomics
6. Anticonvulsants for **S**eizures
*The more withdrawals a pt has, the harder it is each time to treat*
184
*Pts going through **mild** EtOH withdrawal sx (CIWA ≤9) should be treated with support. reassurance and q4 checks*
What is the tx for Moderate EtOH withdrawal sx (CIWA 10-20)? - 5
Benzos PO vs IV **only**
1. Lorazepam 2mg OR
2. Diazepam 10mg OR
3. ChlorDiazepoxide 50mg ➕
4. Thiamine B1
5. IVF
*The more withdrawals a pt has, the harder it is each time to treat*
185
What are the single loading dose options for treating EtOH withdrawal? - 6
186
Which Benzos are **safe** to use in pts with liver disease, elderly or dementia? - 3
These handicapped pts need a **LOT** of help
1. **L**orazepam
2. **O**xazepam
3. **T**emazepam
*Short half life & no active metabolities*
187
What are the Benzo dose options for treating **S**eizures associated with EtOH withdrawal? - 3
188
Naltrexone is more than likely to be hepatotoxic in which situations? - 2
## Footnote
*Naltrexone is available as monthly depot injection*
1. Obese pts
2. [Higher Doses \> 100 mg/day]
## Footnote
*Naltrexone is available as monthly depot injection*
189
What is the major metabolite of crack cocaine? ; How long is it detectable in the blood?
BenzoyLEcGonine ; 3 days
190
S/S of Amphetamine and Cocaine withdrawal - 4
Amphetamine/Cocaine withdrawal hits **HARD**
1. **H**ungry
2. **A**ngry irritable
3. **R**est a lot w/unpleasant dreams
4. **D**epressed (can mimic MDD vs Bipolar)
*can last up to 9 days*
191
Opioids binds to Receptors located where in the body? - 3
1. Brain
2. Spinal Cord
3. GI Tract
## Footnote
*Opioids act on Dopamine, GABA and Glutamate systems*
192
Which is more **lipid** soluble (and thus more potent) between Heroin and morphine?
HEROIN
## Footnote
*People start using opioids in mid 20s but become hooked by their 30s-40s*
193
Most of the time, pts obtain Pain Relievers from where?
Friend/Relative (who themself gets it from 1 doctor)
194
What are the functions of the Mu Opioid receptors? - 5
Mu are the main **CARDS**
1. **C**onstipation
2. **A**nalgesia
3. **R**espiratory Depression
4. **D**ependence
5. **S**edation
195
What are the functions of the Kappa Opioid receptors? - 3
Kappas are just **SAD**
1. **S**edation
2. **A**nalgesia
3. **D**iuresis
196
What are the functions of the Delta Opioid receptors?
possibly analgesia
197
What is the clinical symptom triad for Opioid Overdose?
**CPR!**
1. **C**omatose
2. **P**inpoint pupils
3. **R**espiratory Depression
*Immediately give Naloxone 0.4 mg IV or IM x 5 prn*
198
What is the dose of Naloxone to be given for Opioid Overdose?
Naloxone 0.4 mg IV or IM x 5 prn
199
When does Heroin withdrawal occur? ; When does Heroin withdrawl subside?
6-8 hrs post last dose and peaks or 2nd day ; Subsides in 1 week
200
Buprenorphine MOA - 2 ; Route of administration?
## Footnote
*Buprenorphine + Naloxone = Suboxone*
mixed - partial opioid R agonist AND blocker:
1. only partial agonist of [Mu CARD R] and
2. blocks [Kappa SAD R]
sublingual (even tho Naloxone is better absorbed parenterally)
201
During opioid dependence tx, which drug is more superior between Methadone and Buprenorphine?
**Methadone** **≥ 80 mg/day** has SUPERIOR outcomes to daily Buprenorphine
## Footnote
*Therefore, use Buprenorphine for mild-moderate (usually PO) opioid dependence only*
202
Which Blood pressure med is used to treat opioid withdrawal? ; Which sx does it treat? - 3
Clonidine ;
1. NVD
2. Cramps
3. Sweating
203
What is CAGE and how is it interpreted?
CAGE = Determines EtOH abuse; ≥ 2 positive answers = EtOH abuse/dependence and 1 positive answer warrants further eval
1. ever tried to **C**ut back on drinking?
2. **A**ngry when someone criticizes ur drinking?
3. **G**uilty about how much you drink?
4. need an **E**ye opener in morning to prevent withdrawal/calm nerves?
204
Dx Criteria for Illness Anxiety disorder
## Footnote
*Males = Females*
EXCESSIVE anxiety about having or acquiring an actual illness **but pt has few or no sx** that --\> abnormal health-related behaviors
## Footnote
*these pts may either seek OR avoid medical care*
205
What are the triggers of Sleep Terrors/Walking - 4
1. Sleep Deprivation
2. Stress
3. illness
4. meds affecting CNS
206
Diagnostic criteria for Adjustment disorder with depressed mood - 4
1. [≤ 4 SIGeCAPSS s/s] within 3 mo. of acute stressor that --\>
2. **functionally impairing**
3. and resolves within 6 mo. after stressor ends
4. NOT 2/2 an other more specific disorder
## Footnote
*Tx = CBT*
207
[Drug-induced parkinsonism] is an EPS component caused by ____ blockers. ; What's the antidote for EPS sx?-6
## Footnote
* EPS = (T)ADD sx*
* (T)ardive Dyskinesia is not EPS*
Dopamine R blockers;
1. Lorazepam (**T****A****DD**)-use only acutely
2. Clozapine (use for **T**ardive Dyskinesia even tho only 50% respond)
3. Propranolol (use for **A**kathisia)
4. Benztropine (**DD**)
5. Trihexyphenidyl (**DD**)
6. Diphenhydramine (**DD**)
* Obviously ⬇︎ (not d/c) D2 blocker as well*
* EPS = TADD sx*
208
What is the half life of Fluoxetine?
1 week!
209
Which SSRI is most likely to cause weight gain
Paroxetine
210
How long should a Doc wait to start an SSRI after discontinuing a MAOI?
## Footnote
*This is to avoid Serotonin Syndrome SHIVERS*
2 weeks
211
*SSRIs with short half lives need to be tapered*
Which 2 SSRIs are in this group?
Paroxetine and FluVoxamine
212
What are the NTS blocked by Venlafaxine? - 3
1. NorEpi
2. Serotonin
3. Dopamine (**only at \> 375 mg/day**)
213
How is Venlafaxine related to perimenopausal women?
Although it causes sweating SE, it actually ⬇︎ hot flashes
214
Compared to SSRI/SNRI, Buproprion is less effective at treating _____ and \_\_\_\_
Anxiety and ADHD
## Footnote
*Onset of Buproprion = 2-4 weeks*
215
Which drug is helpful in treating hypersomnia (\> 10 hrs/night) that possibly occurs in atypical depression
Buproprion
## Footnote
*Buproprion can also ⬇︎ weight in any pt*
216
Mirtazapine MOA - 3
1. PreSynpatic alpha 2 R blocker --\> ⬆︎Serotonin & Norepi
2. POSTsynpatic Serotonin R Blocker
3. POSTsynpatic Histamine R Blocker
## Footnote
*Mirtazapine works on anxiety and insomnia almost immediatley*
217
The GI Side effects from SSRI/SNRI can actually be relieved with what other antidepressant?
Mirtazapine (via 5HT3 R blockade)
218
The tertiary amine TCA (amitriptyline) is metabolized to a secondary amine TCA named \_\_\_\_\_
Nortriptyline
## Footnote
*TCAs are more effective than SSRI in depression tx for MEN*
219
The tertiary amine TCA (imipramine) is metabolized to a secondary amine TCA named \_\_\_\_\_
Desimipramine
## Footnote
*TCAs are more effective than SSRI in depression tx for MEN*
220
Which class of antidepressants are catabolized by Cyto**2D6**?
TCAs
221
Which class of antidepressantss inhibit Cyto**2D6**?
TCAs
222
What are the effects of TCA blockade on:
H1 Receptors - 2
M1 Receptors - 2
A1 Receptors - 3
1. H1 histamine R: **sedation**, weight gain
2. M1 muscarinic R: **sedation**, confusion
3. a1 adrenergic R: **sedation**, orthostatic hypotension, dizziness
223
FGA antipsychotics are divided into 2 categories based on what?
low potency vs high potency are based on **D2 R binding affinity**
224
Name the 3 anticholinergic meds that are used to counter EPS
1. Diphenhydramine
2. Benztropine
3. Trihexyphenidyl
225
Dosage for **injectable** forms of Haloperidol & Fluphenazine in treating Schizophrenia
1 injection IM q2-4 weeks
226
Chlorpromazine MOA - 4
1. D2 blocker (*Remember that so is ProChlorperazine*)
2. Histamine R Blocker
3. Muscarinic R Blocker
4. A1 R Blocker
227
Which antipsychotic can be used to treat intractable hiccups
Chlorpromazine
228
Which FGA has the greatest risk of dose dependent QT prolongation
Thioridazine
## Footnote
*SGA = Ziprasidone*
229
Name the antipsychotics that have long acting injectable formulations - 6
**FOPRAH**
1. **F**luphenazine
2. **O**lanzapine (not used often)
3. **P**aliperidone
4. **R**isperidone
5. **A**ripiprazole
6. **H**aloperidol
230
Which SGA has the least likelihood of EPS? ; This makes it idea to treat what condition?
Quetiapine ; Parkinson's diseases (includes DLB)
231
3 SGAs most likely to cause Sedation
"**i** _**C**ause_ _**O**besity_"
**i**Loperidone / _**C**lozapine_ / _**O**lanzapine_
***C**lozapine & **O**lanzapine cause Sedation & [Metabolic Syndrome X] as well so monitor Fasting glucose and lipids!*
232
Which SGA has the greatest risk of dose dependent QT prolongation
Ziprasidone
## Footnote
* must be taken c food or \> 50% wont be absorbed*
* FGA = Thioridazine*
233
Aripiprazole MOA ; associated side effect?
partial dopamine R agonist ; **A**kathisia
## Footnote
* - In low DA receptor stimulation environment, binds D2 R with HIGH AFFINITY & has partial agonist effect
- In high DA stimulation environment, exerts blocking action*
234
Which SGA is approved for **MDD** adjunct tx
Aripiprazole
## Footnote
***can NOT use for Bipolar depression adjunct tx***
235
Why is slow dose titration necessary for Clozapine
it can induce Seizures
236
Name the 4 most metabolically neutral antipsychotics
**ALAZ**, I'm neutral!
1. **A**ripiprazole
2. **L**urasidone
3. **A**senapine
4. **Z**iprasidone *(must be taken c food or \> 50% wont be absorbed)*
237
Abrupt stop of Clozapine actually --\> rebound psychosis
When is it ok to **abrupt stop** Clozapine? - 2
1. WBC \< 2K OR
2. Absolute neutrophils \< 1K
238
a1 R blockade is associated with orthostatic hypotension
Which antipsychotics cause dose dependent Orthostatic hypotension - 5
makes ur BP **QCRIP**
1. **Q**uetiapine
2. **C**lozapine
3. **R**isperidone
4. **I**loperidone
5. **P**aliperidone
239
Which antipsychotic side effect it being shown?
OculoGyric crisis
240
Which antipsychotic causes dry mouth AND salivation lol?
Clozapine
241
SGAs work mostly by blocking what 2 receptors
1. D2
2. 5HT-2A
242
How many D2 Receptors need to be blocked before antipsychotic effect can take place?
60%
243
How many D**2** Receptors need to be blocked before major side effects (EPS, hyperprolactin) occur from antipsychotics?
80%
## Footnote
*only 60% is needed for antipsychotic therapy*
244
Which antiemetics are D2 R Blockers? - 4
1. Prochlorperazine
2. Promethazine
3. Metaclopramide
4. Droperidol
245
about **75%** of schizophrenia pts do this activity which actually ⬆︎ metabolism of antipsychotics
SMOKE CIGARETTES!
246
Which drugs are approved for Bipolar Depression? - 5
1. Quetiapine
2. Lurasidone
3. Lamotrigine
4. Lithium
5. Symbyax (olanzapine-fluoxetine)
## Footnote
*this can be with adjunctive antidepressants but not monotherapy*
247
Which 2 SGAs need to be taken with food?
Eat ur **PZ** with ur antipsychotics
1. **P**aliperidone (also available in injectable form)
2. **Z**iprasidone (also most likely to cause QT prolongation)
248
Which demographic is most at risk for dystonia from D2 R Blockers
Young Males
249
Which bipolar subtype presents with **mixed** features
1 AND 2
## Footnote
*Mixed = Manic + Major Depression Simultaneously in the same week x 1 week*
250
How much more than the hypomanic state are Bipolar 2 pts in depressed state?
15 x more
251
Which bipolar subtype is mistaken for cyclothymic disorder sometimes
2
252
In which bipolar subtype are pts more likely to have a hypomanic episode
1
## Footnote
*Remember: Bipolar 1 can have hypomanic episodes too*
253
Which bipolar subtype is gender equal in frequency
1
## Footnote
*Bipolar 2 data is unclear*
254
In Bipolar pts, If the first mood disturbance is a manic episode, what is the % risk of having future mood episodes?
85%
## Footnote
*fyi: the more manic episodes a pt has, the longer they'll become and the shorter the interepisode will become. And Mania --\> Depression occurs 60% of the time*
255
What is the % risk of an identical twin developing Bipolar disorder if the other twin has it
70
## Footnote
*50% for Schizophrenia*
256
How many Manic episodes does a Bipolar pt typically have in a lifetime
~10 (1 episode q2 years)
257
At what age does Bipolar 1 typically onset? ; What about Bipolar 2?
18 ; mid20s
258
What is the risk of having future major depressive episodes after having the first one?
50%
259
Which Bipolar medications should be avoided in liver disease pts? - 3
1. Lithium (**also avoid in renal disease pts**)
2. Depakote
3. Symbyax (olanzapine component)
## Footnote
*also avoid in Obese pts*
260
Which Bipolar medications have the capability of rapid loading --\> improvement within 3 days - 3
1. Lithium
2. Depakote
3. Symbyax (olanzapine component)
261
**L**ithium and **D**epakote monotherapy can be used in Bipolar pts
Which %:
respond well
partially respond
respond poorly
rule of 3s!
1/3 respond well
1/3 partially respond
1/3 respond poorly
262
What are the first line tx options for **acute severe mania** - 2
1. **A**ntipsychotics + **L**ithium
2. **A**ntipsychotics + **D**epokOte
263
Officially, how many manic episodes are needed before you consider maintenace tx in bipolar pts
2
## Footnote
*and most of the time, after only one episode*
264
Treatment with which bipolar medication actually ⬇︎ suicide
Lithium
265
Which Bipolar medications should be avoided in obese pts? - 3
1. Lithium (**also avoid in renal disease pts**)
2. Depakote
3. Symbyax (olanzapine component)
## Footnote
*also avoid in Liver dz pts*
266
What happens if Lithium is **abruptly** stopped (d/c over days)
affective switch to Mania
## Footnote
*be sure to d/c lithium gradually 6-12 days after first euthymic visit*
267
Since these type of antidepressants were introduced, studies have shown an ⬆︎ switch rate & an ⬆︎ in the number of rapid cycling cases
1. TCAs
2. S**N**RIs
268
Antidepressant **monotherapy** is contraindicated in which bipolar subtype?
1
269
Which antidepressant carries the least risk of inducing a manic episode?
Buproprion
## Footnote
*fyi: if antidepressants are used for bipolar depression be sure to d/c after the depression has resolved*
270
Which psychotrophic medication has the most narrow therapeutic index?
Lithium
## Footnote
*fyi: give dialysis if Lithium \> 4 meQ which = is life threatening*
271
What amount of DepokOte is given to rapid load a pt?
1500 mg
## Footnote
*Lithium and Symbyax can also be rapidly loaded*
272
What % of bipolar pts ends by suicide
16%
## Footnote
*20x risk of general population (similar to MDD)*
273
Which Bipolar sx usually indicates onset of new manic episode
aw**O**ke = ⬇︎need for sleep
274
What is more common, Mania --\> Depression or Depression --\> Mania
Mania --\> Depression occurs 60% of time
275
Typically, pt must have elevated mood episodes (with impaired function) for ___ week before they're considered Manic
When is there an exception to this?
if pt is hospitalized
276
*TCAs and SNRIs increase risk of bipolar disorder rapid cycling*
What is rapid cycling?
≥ 4 mood episodes in 1 year
## Footnote
*Mood episodes = MDD, Manic, Mixed or Hypomanic*
277
What are the risk factors for Bipolar disorder Rapid cycling? - 4
## Footnote
*Rapid cycling = ≥ 4 mood episodes in 1 year*
1. TCAs
2. SNRIs
3. Female
4. Thyroid abnormality
## Footnote
*5-15% of Bipolar 1 pts have rapid cycling*
278
Although stimulants treat ADHD, what happens if you give a stimulant to a Bipolar pt?
induces mania
279
What other things need to be ruled out before diagnosing Schizophrenia - 6
1. Other psych disorders
2. Mood disorders
3. childhood developmental disorders
4. general med condition
5. substance induced
6. personality disorders
280
clinical presentation of Catatonia - 5
1. EchoLalia/praxia
2. **Mutism**
3. **Waxy flexibility** (resistance to repositioning)
4. **Catalepsy** (limbs remain fixed and immobile)
5. negativism
## Footnote
* Possibly* Catatonic Agitation
* Tx = Lorazepam vs ECT*
281
In schizophrenia, describe the timing of onset for negative sx - 3
1. Present **early** during illness (during Prodrome)
2. Worsen druing active periods
3. Do NOT respond well to antipsychotics
282
What % of schizophenic pts get married?
~35%
283
What % of schizophenic pts have a single active episode?
10%
## Footnote
*30% have intermittent course and **60% have chronic course***
284
When should the trough be drawn after last dose of Lithium ; When do you confirm therapeutic levels?
12 hours after last dose ; 5 days after start
285
***Schizophrenic Prodrome is a negative prognostic sign** lasting several months-years and occurs before 1st psychotic episode*
What % of schizophrenic pts actually have a prodrome?
85%
286
In Schizophrenia, what is important to remember regarding **age of onset** between males and females?
The peak age of onset (mode = 25 y/o) is the same, **but the average age is different** because females have second peak after 40
287
Schizophrenia pts have a life expectancy of ___ years because of this disease?
48-53 y/o ; Cardiovascular
## Footnote
*Ironically, Schizophrenia cost more than all CA combined!*
288
What % of schizophenic pts live independently?
33%
289
Why is the schizophrenia course typically worst for males than females?
males develop dz earlier
290
**Other than clozapine**, if a schizophrenia pt does not respond to antipsychotics by ___ weeks than they won't ultimately work by 4 weeks ?
2 weeks
291
Why is it ok to give lower doses of Antipsychotics to schizophrenia pts who have active phase first?
they have ⬆︎sensitivity to medication side effects
292
Within the FGAs potency (high potency vs low potency) has ⬆︎ risk of anticholinergic side effects but ⬇︎ risk of EPS?
low
## Footnote
*Dry mouth, urinary hesitancy, hyperthermia, blurred vision*
293
What do Clozapine and Lithium have in common?
Both ⬇︎ Suicidality
## Footnote
*along with antidepressants & ECT*
294
Name the indications for Clozapine - 5
1. Persistence of positive sx
2. Failure of ≥ 2 Antipsychotic trials
3. Co-Morbid substance abuse
4. Recurrent Suicidality
5. Recurrent Violence
295
What % of dopamine receptors are blocked when FGA side effects kick in?
75-80
296
What % of dopamine receptors need to be blocked in the mesoLimbic tract in order to have antipsychotic effect
65
297
Which EPS sx should u be concerned about in the **\> 70 y/o** demographic
Tardive Dyskinesia (if \> 2 years taking drug, 50% develop TD)
298
Which 2 SGAs do **NOT** cause EPS
1. Clozapine
2. Quetiapine - *is used to treat Parkinson's/DLB*
299
In the CATIE study, this SGA was shown to be highly likely to have pt compliance?
Olanzapine
## Footnote
*also has HIGHEST risk for metabolic syndrome/obesity & is very sedating*
300
Which SGA is safe to give to Liver failure pts because it doesn't require hepatic metabolism
Paliperidone
## Footnote
*avoid in renal failure pts*
301
This SGA has very low risk of EPS **or agranulocytosis** but can cause metabolic syndrome
Quetiapine
302
Major side effects of Clozapine - 8
1. Dry Mouth
2. Salivation
3. Metabolic Syndrome
4. obesity
5. Sedation
6. **Myocarditis**
7. **Seizures (so titrate up slowly!)**
8. **Agranulocytosis**
303
In Schizophrenia, positive sx are correlated with hospitalization but not \_\_\_\_\_\_
functional improvement
## Footnote
*remember, negative sx and cognitive sx only improve **midly** w/tx and is only with SGAs*
304
In Schizophrenia, negative sx are correlated with \_\_\_\_
functional improvement
## Footnote
*remember, negative sx and cognitive sx only improve **mildly** w/tx and is only with SGAs*
305
In Schizophrenia, what sx are correlated with functional impairment? -2
Negative sx & Cognitive sx
## Footnote
*present from early age and are also poorly responsive to meds*
306
In Schizophrenia, what contributes most to Criteria B Social Occupation Dysfunction
Cognitive sx decline
## Footnote
*present from early age and are also poorly responsive to meds*
307
In schizophrenia, what is the downward drift hypothesis?
Cognitive decline early in age --\> ⬇︎[Work/Interpersonal/SelfCare] --\> Overall Social Occupational dysfunction --\> **Downward drift** into the Lower Socioeconomic class
308
Which sex is more likely to have schizophrenia?
EQUAL!
## Footnote
males have ⬆︎ severity 2/2 earlier onset
309
What is the peak age of onset of Schizophrenia in males? ; in females?
Males = 15/18-25 ;
Females = 25-35/45
310
Lifetime prevalence of Schizophrenia
1%
311
What is the % risk of an identical twin developing Schizophrenia if the other twin has it
50
## Footnote
*70% for Bipolar*
312
[T or F] Schizophrenia is caused by a combination of genes
TRUE!
313
For Schizophrenia, prenatal risk factors occur in the ___ trimester ; Name the major risk factors associated with schizophrenia development? - 6
2nd trimester;
1. viral infection
2. **winter births**
3. Starvation
4. Toxin exposure
5. anoxia
6. Advanced PATERNAL age
314
For maintenance tx of Bipolar Disorder, lithium levels should be between \_\_\_\_\_\_
~0.7-4 mEq/L
## Footnote
TSH, BUN/Cr, Lithium level should be drawn twice a year
315
At what Lithium level should Dialysis be used for toxicity ; What risk factors make this more likely? - 3
\> 4 mEq/L ;
## Footnote
1. Renal impairment
2. hypOnatremia
3. Dehydration
316
Which test need to be done on young males before starting Depakote? - 2
1. LFTs
2. Platelets (ASA can accelerate platelet drop)
317
What is important to remember regarding pts taking BOTH Depakote AND Lamotrigine?
Lamotrigine needs to be cut in half
## Footnote
*this is because Depakote actually ⬆︎ Lamotrigine's serum level x 2*
318
Depakote has a serious hepatotoxic side effect
Who's most at risk for this?
\< 2 yo
319
In regards to side effects, what is the difference between DepakOte and Depakene?
Depakene --\> GI Side effects
320
Ironically, DepakOte is indicated as px for \_\_\_\_\_, even though this is also one of its side effects
HA
321
For DepakOte, trough for IR should be drawn ____ hours after last dose ; trough for ER should be drawn ____ hours after last dose
12 ; 18
322
What happens if ASA is given with DepakOte?
⬇︎platelets
323
Explain autoinduction of Carbamazepine
After first few weeks of taking Carbamazepine, its **half life will ⬇︎ by more than 50%** due to autoinduction
324
What are the 2 black box side effects of Carbamazepine?
1. Agranulocytosis
2. Aplastic Anemia
325
Because Carbamazepine is a substrate AND inducer of cytochrome \_\_\_\_, how does it affect birth control?
**3A4** ; ⬇︎birth control --\> pregnancy
326
Which electrolyte is often low in pts taking Carbamazepine?
sodium (2/2 SIADH)
327
What 2 side effects does Lithium, Depakote, Quetiapine and Olanzapine have that Lamotrigine does NOT have?
1. Wt Gain
2. Sedation
328
Rash is a side effect of Lamotrigine
What is the % risk of developing benign rash? ; SEVERE rash? ; Steven's Johnson Syndrome?
10 ; 0.3 ; 0.02-0.1
329
DepakOte/Depakene Side Effects - 7
"Grab a *Coat*..you've got **GNATTTS**!
1. **G**ain in wt
2. **N**VD
3. **A**lopecia
4. **T**hrombocytopenia at high doses, worst w/ASA
5. **T**remor
6. **T**ERATOGENIC
7. **S**edation
*Get LFTs and Platelets before giving*
330
Which psychotropics are used in maintenance tx of Bipolar disorder - 5
Treat Bipolar pts b4 they go B**ALLD** + Car!
## Footnote
**A**ntipsychotics - OAQRZ only
**L**amotrigine
**L**ithium
**D**epakote
Carbamazepine
331
Which SGA has a long half life of 75 hours but takes 2 weeks to reach steady state
Aripiprazole
332
What happens when Risperidone is used at high doses (\_\_\_\_\_)? - 2
High Risperidone= ≥6 mg --\> acts like FGA and has ⬆︎EPS
333
Which 2 SGAs are the least likely to cause metabolic syndrome
1. Aripiprazole
2. Ziprasidone
334
How long does a single marijuana joint stay in the urine
4 days
335
What % of weed smokers become dependent
10
## Footnote
*but remember weed is anti-inflammatory, convulsant and emetic*
336
Why is Burproprion used in smoking cessation
mimics some of the effects of nicotine
337
Varenicline MOA
long acting partial agonist of A4B2NAR
338
Which TCA is used as **2nd line** smoking cessation agent
Nortriptyline
339
When does Nicotine withdrawal occur? ; WHen does it peak? ; how long does it last
1 day ; 2-3 days ; 2-3 weeks
340
How are opioids related to EtOH
Opioids enhances the midbrain release of dopamine by EtOH
341
Naltrexone MOA
mu opioid R blocker
342
What lab value should be monitored in pts on Acamprosate? ; What's the main side effect of this drug?
## Footnote
*dose: 2T of 333mg TID*
Renal excreted so Be sure to monitor renal function and SE = Diarrhea
343
Name the drugs in the phenylAlkylamine hallucinogen drug class - 3
1. MDMA - **has neurotoxic effects**
2. DOM
3. Mescaline
344
What is Sudden Sniffing Death
Inhaled volatile hydrocarbons --\> Cardiac Arrhythmias --\> Death
345
How long does PCP stay in the urine
8 days
346
Which ilicit is most commonly involved in ER visits
Cocaine
347
50% of people who stop smoking develop nicotine withdrawal. What are the s/s? - 3
1. irritability
2. anxiety
3. ⬇︎Concentration
## Footnote
**only 5% never relapse again**
348
In medicine, what are the measurements of what "a drink" is? - 3
1. 1.5 oz shot
2. 4-6 oz wine
3. 12 oz beer
349
What is the most common ilicit drug used across all age groups
marijauna
350
How long does opioids stay in the urine
12 - 36 hours
351
What % of IV opioid users develop Hep C?
90
352
Which 2 s/s of Opioid withdrawal are more severe and not seen very often
1. Piloerection
2. Fever
## Footnote
*pupil Dilation is commonly seen in _withdrawal_*
353
Although Cocaine users use ____ as a sedative for their side effects, Amphetamine users use ___ as a sedative agent
Cocaine=EtOH ; Amphetamine=Marijuana
354
Name a reliable sign of stimulant withdrawal
bradycardia
355
Stimulants stay in the **hair** for how many days
90
356
What is a Speedball
Cocaine + Heroin
357
In terms of EtOH use, what is positive reinforcement? ; What is negative reinforcement?
positive= enjoying the buzz/high from EtOH --\> more drinking
vs
negative = having withdrawal sx --\> more drinking
358
How long does it take substance use disorder to resolve after removing the substance and its withdrawal sx subside
\< 1 month
359
People with alcoholic parents are \_\_\_times as likely to become alcoholics as well
4x
360
Elevation of which 2 lab values indicates alcoholism (and is used to monitor abstinence and relapse)
1. GGT
2. Carbohydrate Deficient Transferrin
## Footnote
*MCV can be used to detect **history** of alcoholism but not monitoring*
361
Below is Criterion A for Substance Use Disorder. Which does **Cravings** belong to?
## Footnote
Impaired Control
Social Impairment
Risky use
Pharm Criteria
Impaired Control
362
PCP can induce psyhotic disorders, delirium, anxiety and ____ disorders
Mood
363
Between Cocaine intoxication and withdrawal, which is associated with onset of mood disorder
BOTH
364
Between Cocaine intoxication and withdrawal, which is associated with onset of psychotic disorder
Intoxication
365
Inhalants and ______ do not cause withdrawal
Hallucinogens
366
What are the 3 Ps of Personality Disorder
1. **P**ervasive
2. **P**ersistent
3. **P**ernicious
367
Personality Disorders manifest in ≥ 2 of what categories (4) ; When should these onset by?
- Interpersonal function
- Affect
- Cognition
- Impulse control
PD should onset by teen/young adult
368
Textbook definition of Personality Disorder
Dysfunctional amplification of normal personality traits
369
Strategies for dealing with Cluster B pts - 4
## Footnote
*For all Clusters, never personalize pt's behavior*
1. Empathize with pt's fears
2. Be consistent
3. set limits
4. Verbalize that you want to help & satisfy **reasonable** request
## Footnote
*Beware of Countertransference*
370
Strategies for dealing with Cluster A pts - 4
## Footnote
*For all, never personalize pt's behavior*
1. PROVE TRUST WITH ACTIONS (not words)
2. Straightforward explanations
3. Don't challenge distortions until firm rapport is built
4. Include family for ⬆︎ pt compliance
## Footnote
*Beware of Countertransference*
371
Strategies for dealing with Cluster C pts - 4
## Footnote
*For all, never personalize pt's behavior*
1. **Empathize** with pt's fears
2. Share the decision making (don't tell them what to do)
3. In avoidant & dependent, verbalize ur willing to care for them
4. Avoid power struggles with OCPD
## Footnote
*Beware of Countertransference*
372
4 major risk factors for Anorexia Nervosa
## Footnote
*Refusal to maintain body wt ≥ normal BMI*
1. Genetics (56% biological / 44% environmental)
2. Obstetrical complications
3. Female Athletes
4. Dieting
## Footnote
*anorexia pts are at risk of renal disease*
373
Time Criteria for Bulimia Nervosa
**Binge eating** followed by **Purge** occurs...
1. twice a week
2. x 3 months
374
4 major causes of death in eating disorders
1. Starvation
2. Cardiac Arrhythmias
3. Suicide
4. GI Dilation --\> Rupture
375
Best way to treat Anorexia is food!!! but also treat comorbidity
List the Refeeding complications - 4
1. Hyperburn
2. Edema
3. Constipation
4. GI Dilatation
376
tx for Bulimia Nervosa - 4
1. SSRIs - higher dose
2. Topiramate
3. Zofran
4. **CBT**
377
Time Criteria for Binge Eating disorder - 3
## Footnote
*Men = Women in prevalence*
1. Binges **without purging** twice a week
2. x 6 months
3. Distress over the binging
## Footnote
*Tx = CBT + WtLossProgram*
378
What are predictors of outcome for Bulimia pts -2
1. **Duration of illness at start of tx = BEST PREDICTOR**
2. Lack of response to CBT by 6th session = poor pgn
379
How long are Anorexia pts hospitalized usually? ; What about Bulimia pts?
2 weeks (or until wt restoration) ; 1 week
380
Lifetime prevalence of MDD
12-18%
381
[T or F] There is a genetic component to MDD
TRUE!
## Footnote
*pts with fam hx of MDD have 2x the risk of getting it*
382
What are the **highest** risk factors for MDD - 3
1. Early parental loss
2. postpartum
3. **Negative life events = HIGHEST**
383
What is the Kindling theory
With each episode of depression or mania, you become more susceptible to future mood episodes with weaker triggers
384
List the 5 outcomes of Depression tx
385
\_\_\_% of pts after first MDD episode recover if they receive adequate care
What CoMorbid factors retard MDD recovery? - 4
80%
1. psychosis
2. prominent anxiety
3. personality disorder
4. MDD sx are VERY severe
386
Only 15% of MDD pts are Psychologizers
If a pt answers "Depression" to, "What is Causing your somatic sx?", what type of MDD pt are they?
**Initial** Somaticizer
387
Only 15% of MDD pts are Psychologizers
If a pt answers "YES" to, "Could nerves/worry be contributing to your sx", what type of MDD pt are they?
**Facultative** Somaticizer
388
What are the adverse considerations between SSRIs and Pregnant Women? - 6
1. slight miscarriage⬆︎ (but no more than any other depressed woman)
2. ⬆︎early delivery
3. ⬆︎perinatal complications / neonatal adaption syndrome
4. ⬆︎Craniofacial disfiguration in Paroxetine
5. ⬆︎Autism if 1st trimester exposure
6. Sertraline has some passage in breast milk **but safe** unless child gets GI sx
389
Describe the proposed role of the 3 NTS
NorEpi / Serotonin / Dopamine
390
Complementary Rx for MDD - 2
1. Omega **3** fatty acids
2. Exercise
391
What does "MDD **with mixed features**" imply
There are some hypomanic sx also
392
What is Melancholic Depression - 4
SEVERE Depression thats
1. likely biological
2. **loss of pleasure**
3. **loss of reactivity to pleasurable things**
4. ≥3 of image
393
In MDD, what are the % chances of reoccurence if pt had only 1 episode? what about 2 episodes? 3 episodes?
1 - 50% chance MDD will reoccur
2 - 90%
≥3 = 95%
394
What type of changes are observed in newborns with a mother depressed during pregnancy?
⬆︎in-utero Cortisol exposure --\> **newborn R Amygdala ∆** which --\> ⬆︎risk for MDD, cognitive and physical defects since neurogenesis is downregulated by cortisol
## Footnote
*neurogenesis is upregulated by exercise, learning environment, estrogen, antidepressants*
395
What is the association between inflammation and Depression
pts with early life adversities may develop MDD more easily when experiencing stressors like obesity and this --\> tx refractory depression --\> may need anti-inflammatories
396
Which part of the insula is liked to translating visceral experiences into subjective feeling states
ANTERIOR
397
How does Exercise biochemically treat depression
Exercise --\> FNDC5 production in muscle cells which --\> release into blood as **IRisin** --\> IRisin stimulates [Brain Derived Neutrophic Factor] --\> AntiDepression/Learning/Memory
398
How is Depression associated witih Cardiac disease - 2
1. SSRIs can be used as px for cardiac disease
2. Depression is risk factor for developing cardiac disease
3. Depression is risk factor for developing DM in elderly
399
What are good prognositc factors for Illness Anxiety Disorder - 5
1. High SES
2. Sudden onset
3. CoMorbid Depression/Anxiety are tx-responsive
4. NO coexisting Personality DO
5. NO coexisting med condition
400
In Functional Neurological Symptom Disorder, what is La Belle Indifference?
Pt has Lack of concern regarding neuro sx associated with their conversion disorder (i.e. they don't care that their arm is paralyzed)
401
In Functional Neurological Symptom Disorder, what is the rule of one-thirds?
1. 1/3 are REdiagnosed with an acutal neuro dx
2. 1/3 have real co-existing seizures **with** their pseudoseizures
3. 1/3 maintain only a dx of pseudoseizures
402
General pgn for Functional neurological symptom disorder
90-100% have initial sx resolve within [first few days-1 month] and 75% DON'T have another episode
403
Factitious Disorder presents in _____ and usually last \_\_\_\_\_
early adulthood ; lifelong possibly
404
What is Pseudocyesis
false belief of being pregnant associated w/objective s/s of pregnancy!
## Footnote
*falls under "Other" Somatic Sx Disorders*
405
Bipolar Epidemiology
Age of onset?
Which gender predominates Bipolar 1?
Which gender predominates Bipolar 2?
Age = 19-21
Bipolar 1 = MALES = FEMALE
Bipolar 2 = FEMALE
*most bipolar pts are single/divorced*
406
What is the % risk of an dizygotic twin developing Bipolar disorder if the other twin has it
20%
407
What is the % risk of a family member developing Bipolar disorder if a 1st degree relative has it
15%
## Footnote
*ESPECIALLY IF MOM*
408
Bipolar disorder has many gene overlap with ____ disorder. What electrolyte channel is implicated in these disorders?
Schizophrenia ; **Ca+** channel signaling dysfxn
409
What is the % risk Bipolar pts relapse if Mania was their 1st episode? ; What if depression was their 1st episode?
85 ; 50
410
What regimen, for maintenance therapy, is considered in Bipolar pts who DON'T respond to monotherapy maintenace?
Treat Bipolar pts b4 they go **B(****A-L****D)**!
**A** + [**L or D]**
[**A**ntipsychotic 2ND GEN] + [**L**ithium or **D**epakote]
411
Even after 1 Manic episode, Lithium should be continued for _____ and then if effective, **adjuvant meds** can be d/c'd after ___ over \_\_\_\_\_
9-24 mo. ; 4-6 wks ; 1-3 mo.
## Footnote
*If after 2nd Manic episode = cont Lithium indefinitely*
412
How long does Depakote take to improve acute mania? What about Carbamazepine?
3 days ; 1-2 wks
413
What constitutes MDD **with atypical features** - 4
MDD + ≥ 2 of:
1. Wt Gain
2. Hypersomnia
3. Leaden Paralysis (heavy arms/legs)
4. Long standing sensitivity to rejection
*Tx = MAOI*
414
Which Dopamine Receptor subtypes are highly correlated with psychotic activity? ; Which subtype is **not** found in the EPS pathways?
D2-4 ; D4
## Footnote
*SGAs have high affinity for D4*
415
How long does it take antipsychotics to reach peak plasma when given IM? ; what about when given PO?
30 min ; 1-4 hours
## Footnote
*only 10% of these are unbound which = only 10% cross blood brain barrier*
416
In Schizophrenia, Functional deterioration mostly occurs when?
During ACTIVE Episodes
## Footnote
*remember, only negative sx and cognitive sx respond **poorly** to meds*
417
The order to which pts are prescribed antipsychotics follows an algorithm
List the 6 stages of the AntiPsychotic Algorithm
* *should give at least 4 wks before moving to next stage. If \> 12 wks on one stage, move on.*
* *If pt does NOT have 25%⬇︎ in sx within first 2 wks = outcome will be poor by 4 wks*
* *First episode pts require lower antipsychotic dosing and have ⬆︎risk for side effects*
418
Clozapine trial requires more time than others
Explain the regimen - 3
1. 1st 4 wks is for initial titration
2. Then requires at least 12 wks for therapeutic trial
3. Cont for up to 12 more wks before moving to next stage
## Footnote
*usually effective for 30-50% tx refractory pts*
419
Clozapine is obvi used for refractory psychosis
When is Clozapine also considered? - 5
1. Suicidality in schizophrenia/schizoaffective
2. Violence in schizophrenia/schizoaffective
3. Substance Abuse
4. *Consider* in pts with positive sx \> 2 years
5. ***GIVE*** in pts with positive sx \> 5 years
## Footnote
*usually effective for 30-50% tx refractory pts*
420
FGA antipsychotics are divided into 2 categories based on D**2** R binding affinity
In regard to side effects, what's unique about Low potency FGAs?-3
1. **⬇︎EPS** due to ⬆︎Anticholinergic effects
2. Highly SEDATING
3. QT prolongation
## Footnote
*LOW potency FGAs have LOW risk for EPS*
421
Which antipsychotic has a disintegrating tablet formulation
Olanzapine
422
Which antipsychotic is most effective for negative sx
Clozapine
423
What is the blood drawing schedule for Clozapine - 3
1. Weekly x 6 months
2. Then BiWeekly x 6 months
3. Then montly
424
What should you remember regarding SGAs and elderly pts
All SGAs have black box warning of ⬆︎mortality in [elderly w/dementia-related psychosis]
425
How should you proceed with tx after a pt develops Neuroleptic Malignant Syndrome
30% have recurrent NMS with restart but most pts can be safely restarted with precautions
426
[T or F] In schizophrenia tx, start with lowest effective dose and then tirtate up
FALSE!
## Footnote
Use Continous **FULL**-dose antipsychotic tx in schizophrenia only
427
Most common psychotropics to cause Sedation - 6
**Q**uit **C**rying, **FOLD** & sleep
1. **Q**uetiapine
2. **C**lozapine
3. **F**GAs
4. **O**lanzapine
5. **L**ithium
6. **D**epakote
428
Which anti-HTN med is used to treat smoking cessation
Clonidine
