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Psych Clerkship Flashcards

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1
Q

What are the components of the Mental Status Exam - 14

A

ABC STAMP LICKER

  1. Appearance (gender/race/appears age/healthy/grooming)
  2. Behavior (psychomotor mvmnt + behavior toward u)
  3. Content of thought (is pt thinking about obssesions/phobias/delusions)
  4. Speech (talkative/monotonous/mute/loud/rapid)
  5. Thought process (logical?/rambling?/rate of idea flow?)
  6. Affect (full/guarded/inappropriate2mood/blunted)
  7. Mood ( “What is ur mood today? - happy/sad/angry..” )
  8. Perception (Derealization?/Depersonalization?/Hallucinations?)
  9. Level of consciousness (alert,stupor,somnolent)
  10. Insight & judgement (good/fair/impaired)
  11. Cooperation
  12. Knowledge & cognition (MMSE score?/ A/O /Memory w/recall?/able to Abstract think?/concentration?)
  13. Endings (suicidal, homocidal)
  14. Reliability
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2
Q

What would you expect diagnostic appearance of a Major Depression pt to be - 3

A
  1. ⬇︎Body wt
  2. poor grooming
  3. poor hygiene
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3
Q

What would you expect diagnostic appearance of an Anorexia Nervosa pt to be - 3

A
  1. ⬇︎Body wt
  2. baggy clothes
  3. Lanugo -image

Tx = Fluoxetine

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4
Q

What is echopraxia

A

repetitive imitation of mvmnts of another person

EchoLALIA = repetitve imitation of verbiage of another person

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5
Q

What is sterotyping

A

isolated purposeless mvmnt performed reptitively

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6
Q

What is alexithymia

A

Pt can NOT describe their mood

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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

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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

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9
Q

What are the different ways you can describe Thought Process during mental status exam? - 5

A

ABC S(T)AMP LICKER

  1. Logical
  2. Circumstantial (heavily includes details that have lil relevance to the point)
  3. Tangential (doesn’t directly address point or finishes it and tlks about topics easily brought to mind)
  4. Flight-Of-Ideas (Tangenital + Racing Thoughts)
  5. Looseness of Assocation-image (connection between ideas it not clear and topic changes cant be followed)
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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!”

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11
Q

What is formication

A

feeling bugs crawling under skin

common in Cocaine users!! lol

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12
Q

What is hallucinosis

A

pt knows their hallucinations aren’t real

Common in Alcoholics

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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?

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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!

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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

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16
Q

What is the diagnostic clinical criteria for Panic Disorder? - 3

A
  1. Recurrent Panic Attacks
  2. Unexpected Panic Attacks
  3. 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*
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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

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18
Q

Tx for Panic Disorder - 6

A

CBT (can be used alone)(breathing technique, exposure therapy) +/-

  1. SSRI (1st line rx)
  2. SNRIs
  3. Benzo short term
  4. TCA
  5. MAOi
    * Similar to Social Phobic Anxiety Disorder tx*
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19
Q

What is the diagnostic clinical criteria for Agoraphobia? - 2

A
  1. Fear & Avoidance OOP of ≥ 2 / 5 agora situations - image
  2. Fear & Avoidance OOP are > 6 months

LIKE WITH ANY PYSCH DO, Fear & Avoidance OOP –> distress and functional impairment

OOP = Out Of Proportion

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20
Q

What is the diagnostic clinical criteria for Generalized Anxiety Disorder (GAD)? - 2

A

Excessive anxiety….

  1. includes ≥ 3 / 6 of anxiety sx - waTCHERS
  2. ≥ 6 months

LIKE WITH ANY PYSCH DO, sx –> distress and functional impairment

OOP = Out Of Proportion

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21
Q

Demographic (sex and age) for Generalized Anxiety Disorder - 2

A

Women between 20-47

90% Occurs with MDD/GAD/OCD!!!!

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22
Q

How is GAD associated with pharmacotherapy cessation?

A

60-80% of GAD pts relapse within 1st year after stopping pharmacotherapy

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23
Q

Tx for Generalized Anxiety Disorder -9

A
  1. CBT
  2. SSRI (1st line rx)
  3. SNRI (1st line rx)
  4. TCA (2nd line rx)
  5. Benzo
  6. Buspirone
  7. Lyrica
  8. Mirtazapine
  9. Trazodone
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24
Q

What is the diagnostic clinical criteria for PTSD? - 3

Lifetime prevalence = 8% and more common in Women

A
  1. All 4 sx categorymet - image
  2. sx > 1 month
  3. Exposure done via Direct (single or repeated), Witnessed, occurred to close fam/friend
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25
Q

What is the diagnostic clinical criteria for Acute Stress Disorder? - 3

A

image

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26
Q

Risk factors for developing PTSD? - 7

Lifetime prevalence = 8% and more common in Women

A
  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
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27
Q

When considering PTSD in military members, what should be on the ddx? - 5

Lifetime prevalence = 8% and more common in Women

A
  1. TBI
  2. Military Sexual Trauma
  3. Re-exposure 2/2 multiple deployments
  4. Civilian life readjustment
  5. Substance Abuse
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28
Q

Tx for PTSD -13

A
  1. CBT
  2. Exposure therapy
  3. EMDR (Eye Mvmnt Desensitization & Reprocessing)
  4. Anger Mngmt
  5. SSRI (1st line rx) -_P_aroxetine and _S_ertraline (PT_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
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29
Q

What is the diagnostic clinical criteria for Obsessive Compulsive Disorder?

A

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

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30
Q

What comorbidities is OCD associated with? - 5

Male = Female in prevalence

A
  1. MDD
  2. Substance Dependence
  3. Anorexia
  4. Schizophrenia
  5. Tourettes
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31
Q

OCD tx - 6

A
  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)
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32
Q

In Hoarding Disorder, pts accumulate possessions and cause functionally impairing clutter

When in untreated pts are these areas typically cleaned?

A

ONLY when intervention by 3rd parties is made

Medical causes and other disorders should ALWAYS be ruled out before diagnosing psych conditions

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33
Q

Diagnostic clinical criteria for Social Phobic Anxiety Disorder - 2

A
  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

Tx similar to Panic Disorder tx

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34
Q

Diagnostic clinical criteria for Specific Phobia - 2 ; Tx?

A
  1. Specific objects or locations provoke IMMEDIATE fear/anxiety OOP –> active avoidance
  2. sx ≥ 6 mo

Tx = Exposure Therapy

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35
Q

Describe these Cultural Syndromes:

Ataque de nervios

Dhat Syndrome

Khyal Cap

Kufingisisa

A
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36
Q

Describe these Cultural Syndromes:

Susto

Taijin Kyofusho

Maladi Moun

A
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37
Q

What are the _____ organic causes of Anxiety

Endocrine - 5

Cardiovascular - 5

A

Substances can also induce Anxiety

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38
Q

What are the _____ organic causes of Anxiety

Metabolic - 5

Neurological - 7

A
  • Metabolic includes the “Zebras”*
  • Substances can also induce Anxiety*
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39
Q

Which substances are known for inducing Anxiety - 8

A
  1. Cocaine
  2. Amphetamines
  3. Caffeine
  4. CTS (CorTicoSteroids)
  5. Hallucinogens (Cannabis, PCP)
  6. Inhalants
  7. Theophylline
  8. Thyroid hormones
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40
Q

Common side effects of SSRI - 8

A
  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)!

​SSRI DC –> Nausea/HA/Dizziness/Lethary/FluLikeSx

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41
Q

Serotonin Syndrome Clinical Presentation (8)

A

“Serotonin gave me the SHIVERS!”

Shivering

[Hyperreflexia & Myoclonus]

INC Temp

[Vital sign instability] (tachycardia vs. tachypnea vs. HTN)

Encephalopathy (Confusion vs. Agitation)

Restlessness

Sweating

Italicized = Triad Sx

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42
Q

How do you treat Refractory Serotonin Syndrome

Serotonin Syndrome comes from SSRI PLUS another med that synergistically ⬆︎Serotonin

A

Cyproheptadine

(antihistamine with anti-serotonergic properties)

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43
Q

Describe Neuroleptic Malignant Syndrome

A

RARE SE of Any Dopamine Blocker (Antipsychotics vs. GI meds) that –> FEVER

  • [Fever > 40C]
  • Encephalopathy (PRESENTS FIRST)
  • Vitals unstable (⬆︎ HR / RR / ⬇︎BP from autonomic dysfunction)
  • Enzymes (⬆︎CPK AND WBC)
  • Rigitidy ⬆︎
  • NMS should develop within 30 days but most is within 1 week. Also has good pgn*
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44
Q

What’s the best way to approach treatment for [Neuroleptic Malignant Syndrome]

A

Treat Rigiditiy with Dantrolene (inhibits Ca+ release from sk. muscle sarcoplasmic reticulum)

+

supportive care

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45
Q

What is the diagnostic criteria for ADHD? - 3

A
  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)

as usual, sx must be functionally impairing and not 2/2 substance or other condition

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46
Q

Diagnostic criteria for Cyclothymic disorder - 4

A
  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
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47
Q

What is the clinical criteria for hypomanic episodes

A
  1. Elevated or irritable mood 4< x <7 days PLUS
  2. ≥3 Classic BIPOLAR sx
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49
Q

What is the clinical criteria for Manic episodes

A
  1. Elevated or irritable mood ≥ 7 days PLUS
  2. ≥3 Classic BIPOLAR sx
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50
Q

Diagnostic criteria for Bipolar II ? - 3

A
  1. Major Depressive Episodes +
  2. hypomanic episode +
  3. NOT functionally impairing
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51
Q

Diagnostic criteria for Persistent Depressive Dysthymia disorder - 2

A
  1. at least 2 / 6 of SIGECA
  2. CONSTANT for 2 years (no relief > 2 mo)

Major Depressive Episodes may also occur with this

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53
Q

Diagnostic criteria for Bipolar I ? - 2

A
  1. Manic episode +/- major depressive episodes
  2. Functionally impairing vs psychosis vs hospitalization
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54
Q

What are the drug culprits that cause Serotonin Syndrome (when synergistically combined with an SSRI)? -7

A
  1. Tramadol
  2. Triptans
  3. Linezolid
  4. MAOI
  5. Ondansetron
  6. Metoclopramide
  7. MDMA
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55
Q

Relationship between Benzodiazepines and pregnant women

A

NO BENZOS FOR PREGGOS!

Benzodiazepines are Class D

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56
Q

Hoarding disorder tx

A

CBT targeting hoarding behaviors

Consider adding SSRI only if there’s also depression / anxiety

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57
Q

How should you manage Autism? - 3

A
  1. Early dx & tx
  2. Multimodal tx (speechTherapy/CBT/education)
  3. Antipsychotic adjunct
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58
Q

What are the signs of Cocaine intoxication? - 6

A
  1. MyDriasis (Pupils Wide Open on coke!)
  2. Chest Pain –> Arrhythmia and MI
  3. Seizures
  4. Hyperthermia
  5. sexual dysfunction
  6. psychosis
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59
Q

What are the signs of Amphetamine intoxication? - 5

A
  1. Psychosis +/- delirium
  2. Agitation
  3. MyDriasis
  4. Tachycardia
  5. HTN
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60
Q

Which rx agents cause false positive amphetamine results on urine tox? - 3

A
  1. pseudophedrine
  2. Buproprion
  3. Selegiline (also comes as transdermal)
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61
Q

How long does opioid withdrawal typically last?

A

3-5 days

Sweating/Lacrimation/Rhinorrhea/Myalgia/Diarrhea

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62
Q

Phencyclidine (AKA ___) is a __(MOA)___ and main toxication signs are what?-4

A

PCP (Hallucinogenic dissociative anesthetic = [NMDA Glutamate R Blocker])! ;

  1. [Vertical Nystagmus]
  2. Violence
  3. HTN
  4. Hyperthermia
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63
Q

[LSD ergoline] main toxication sign is _____

A

frightening Visual Hallucinations

even while sober, pts may reexperience this

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64
Q

[Phencyclidine PCP] and Ketamine are both _____ with similar effects. What’s the main differences?-2

A

Hallucinogenic Dissociative anesthetics

  1. Ketamine is short lived
  2. Keamine causes blunted behavior (i.e.impaired consciousness) while PCP causes violent behavior
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65
Q

What is Eye movement desensitization and reprocessing treatment? ; What is it indicated for?

A

Integration of eye mvmnts with therapy ; PTSD

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66
Q

Tx for Mania or hypomania - 5

A

Treat Bipolar pts b4 they go BALD + Car!

  1. Benzos (ONLY AS ADJUNCT)
  2. AntiPsychotics (1st AND 2nd Generation)
  3. Lithium **
  4. DepakOte **
  5. [Carbamazepine Tegretol]
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67
Q

Buspirone MOA ; indication

A

Buspirone = [5HT1a partial agonist]; GAD; [slow onset] and [lacks muscle relaxant/anticonvulsant properties]

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68
Q

What are the cons of Buspirone? - 3

A
  1. slow onset
  2. lacks muscle relaxant properties
  3. lacks anticonvulsant properties
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69
Q

Describe Shift work sleep disorder

A

Recurrent sleep interruption 2/2 shift work –> daytime sleepiness, difficulty initiating sleep, difficulty maintaining sleep

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70
Q

Describe Trichotillomania is ; what’s a serious complication of this?

A

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

Related to OCD and has ⬆︎morbidity in those with hx or fam hx of OCD

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71
Q

Trichotillomania tx

A

CBT - habit reversal training

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72
Q

MDMA MOA

A

synthetic amphetamine that ⬆︎synaptic “SND” Serotonin, NorEpi, Dopamine

Can cause Serotonin Syndrome when taken with SSRI!! MDMA may also cause hypOnatremia

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73
Q

In pts with TCA overdose, what’s the most important vital to monitor and why?

A

QRS duration ; QRS > 100 msec –>⬆︎Vt arrhythmias and seizures (tx: NaHO3)

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74
Q

What comorbidities is GAD associated with? - 4

Male = Female in prevalence

A
  1. MDD
  2. Substance Dependence
  3. Social phobic anxiety disorder
  4. Panic disorder
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75
Q

What is the precaution with using Benzos in PTSD pts? - 2

A
  1. may cause Disinhibition in PTSD pts
  2. Dependency

only has limited positive effect

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76
Q

What comorbidities is PTSD associated with? - 5

Female > men in prevalence

A
  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
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77
Q

Which diagnostic tools are used in-office to make PTSD dx?

A
  1. Primary Care PTSD screen
  2. PTSD checklist (PCL)
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78
Q

Which sex is more likely to have PTSD? ; What is lifetime prevalence in general population?

A

WOMEN are twice as likely ; 8%

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79
Q

What % of PTSD pts also have substance abuse disorder?

A

50%

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80
Q

PCP and Amphetamine intoxication presentations may be similar

How can you tell them apart? - 2

A
  1. PCP will show up in urine tox x 8 days
  2. PCP has multidirectional nystagmus
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81
Q

Signs and symptoms of MDMA intoxication - 3

A
  1. Hyperthermia
  2. Seizures
  3. Delirium
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82
Q

Teens who develop significant acute changes in behavior should be assessed for what potential factors? - 4

A
  1. Psychosocial stressors
  2. Trauma (physical or sexual)
  3. Substance use
  4. Psych disorders

Don’t just throw drugs at them! Do detailed eval

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83
Q

Borderline personality disorder pt typically have a remote hx of what?

A

PESSP

CHILD ABUSE

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84
Q

When is it ok for Bipolar pts to discontinue their rx therapy if they’ve had ≥ 2 Manic episodes? ; Explain

A

NEVER!!

It is a lifelong illness requiring maintenance rx for years (and forever in severe bipolar pts)

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85
Q

Tardive Dyskinesia is an EPS component caused by ____ blockers. ; What’s the antidote for it?-4

  • EPS = (T)ADD sx*
  • (T)ardive Dyskinesia is not EPS*
A

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

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86
Q

What makes up the ExtraPyramidal Symptoms? - 4

A

EPS = (T)ADD sx

  1. Tardive dyskinesia (tx=switch to clozapine)
  2. Akathisia
  3. Dystonia
  4. Drug-induced Parkinsonism
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87
Q

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?

A

EKG (Lithium causes dysrhythmias in CAD pts)

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88
Q

Tx for Somatic Symptom disorder

Depression is a common CoMorbidity and Females > Males in prevalence

A

Regularly scheduled Med visits (Goal: Improve functionality)

DO = preocupation with unexplained (but proven to be benign) medical sx

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89
Q

Somatic Symptom disorder CP

Depression is a common CoMorbidity and Females > Males in prevalence

A

preocupation with unexplained (but proven to be benign) medical sx +/- pain and/or persistence

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90
Q

What is Functional Neurological Symptom Disorder? ; tx?

A

unexplained neurological deficits 2/2 emotional stressors ; EDUCATION about the Disorder!

  • AKA CONVERSION DISORDER*
  • Be sure to specifiy deficit, whether > or < 6 mo and what stressor was*
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91
Q

Jimson Weed Poisoning clinical presentation - 7

A

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
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92
Q

Malignant Hyperthermia etx ; Which pts are susceptible?

A

After giving [inhaled anesthestics and/or succinylcholine] (to genetically predisposed pts (AUTO DOM)) –> [Fever & Muscle Rigidity soon after surgery with Unstable Vitals]

Malignant = Muscle Rigiditiy

Malignant = Unstable Vitals

Hyperthermia = Fever

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93
Q

Malignant Hyperthermia Tx

A

Dantrolene

TREAT PROMPTLY! AS THIS IS LIFE THREATENING CONDITION!

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94
Q

Malignant Hyperthermia clinical presentation - 3

A
  1. Malignant = Malignant Unstable Vitals
  2. Malignant = Muscle Rigidity
  3. Hyperthermia = Fever
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95
Q

Disulfiram MOA ; indication

Disulfiram is AKA AntAbuse

A

inhibits aldehyde dehydrogenase ; thwarts urge to drink EtOH by causing horrible rxn (NV/HA/Flushing) when EtOH is consumed

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

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96
Q

Naltrexone is 1st line tx for alcohol use disorder and can be taken while pt is still drinking

When is Naltrexone contraindicated? - 3

A
  1. Liver Failure
  2. Acute Hepatitis
  3. Pt currently uses opioids

It CAN be used in mild liver dysfunction

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97
Q

Acamprosate MOA ; indication

dose: 2T of 333mg TID

A

GABA analog ; Maintains Alcohol abstinence once its reached by ⬇︎cravings (1st line rx)

Renal excreted so Be sure to monitor renal function and SE = Diarrhea

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98
Q

What behaviors from a toddler regarding sex are medically concerning? - 4

A
  1. precocious sexual knowledge
  2. preoccupation with masturbating
  3. excessive talk about sexuality
  4. simulating oral/anal/genital2genital contact

curiousity with their own or other children’s genitals is normal

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99
Q

Indications for Buproprion - 5

A
  1. Depression
  2. Smoking cessation
  3. ADHD
  4. Sexual Dysfunction 2/2 SSRI
  5. hypersomnia 2/2 atypical depression
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100
Q

What are 3 major precautions to remember with SSRIs?

A
  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
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101
Q

What are the main physical things that change from normal aging - 4

A
  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)
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102
Q

90% of Alzheimer’s pts are what age?

A

≥ 65 yo

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103
Q

Alzheimer’s tx - 7 ; Which medication should be used last?

A

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)
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104
Q

When treating the Depression/Anxiety in Alzheimer’s pts, which SSRI should you avoid?

A

paroxetine

if sx persist, use ACEI

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105
Q

When treating the Psychosis in Alzheimer’s pts, which antipsychotics should be used? - 4

A

Risperidone = Quetiapine > Olanzapine=Aripiprazole

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106
Q

What’s unique about the clinical presentation of Vascular dementia?

A

step-wise deterioration (usually because of recurring CVA/TIA)

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107
Q

Dementia with Lewy Bodies (DLB) CP - 3

A

DLB at the DMV

  1. Dementia confusion periodically
  2. MichaelJFox Parkinsonism (PARK + hamp) tht does NOT respond to dopaminergic tx and has early falls and presyncopal episodes
  3. Visual Hallucinations (brightly colored 3D subjects)
  • will be more symmetric than regular Parkinson’s and is sensitive to neuroleptics*
  • Lewy Body= [LABS (Lewy α-synuclein BodieS)] that are Eosinophilic intracytoplasmic accumulations*
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108
Q

What is the important thing to remember regarding the treatment of psychosis in pts with Dementia with Lewy Bodies (DLB) ?

A

DLB at the DMV

IT IS POORLY SENSITIVE TO D2 BLOCKER NEUROLEPTICS SO DON’T USE THEM!

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109
Q

Huntington’s Dz Clinical Presentation (2)

A
  • “Hunting 4​ food is way too aggressive & dancey”*
    1st: Aggressive Dementia w/ strange behavior
    2nd: Dance-like Chorea mvmnts
  • AUTO DOM = Affects BOTH sexes equally!!*
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111
Q

Etx of Frontotemporal Pick’s Dementia ; CP-2

A

Prounouced Frontal & Temporal lobe atrophy –> [Socially inappropriate Behavior] + aphasia

OCCURS MORE IN FEMALES!!!

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112
Q

A: Demographic of Frontotemporal Pick’s Dementia?

B: Mode Of Inheritance

A

A: 50-60 yo Females (Alzheimer = > 60)

B: Auto Dominant

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113
Q

[Creutzfeldt Jakob Dz] CP - 2

A

[RAPIDLY Progressive Dementia] + [STARTLE Myoclonus] –> DEATH

Can be Acquired vs. Inherited

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114
Q

Dx for Creutzfeldt Jakob disease - 6

A
  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
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115
Q

Openly discuss Limbic Encephalitis

A
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116
Q

What is the CAM score used for? ; Describe its criteria

A

CAM score = Diagnosis Delirium and differentiates it from Dementia/Depression

AIDA: Requires A and I, but only either D vs. A

Acute onset and fluctuating

Inattention (spell “world” backwards & forward)

Disorganized thinking (rambling/illogical)

Altered level of consciousness (intermittently not alert?)

Also can use Dementia Rating Scale for this

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117
Q

What type of EEG changes are noticed in Delirium pts? - 4

A
  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)

33-67% of Delirium is missed 2/2 “expected” to occur, assumed to be depression, ignored for bigger issues or lack of screening

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118
Q

Most Delirium pts (90%) are what demographic? - 3

A
  1. CA pts
  2. MICU
  3. Post-Cardiac surgery pts
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119
Q

Risk factors for Delirium - 9

A
  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
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120
Q

What type of EEG changes are noticed in Delirium Tremens pts? - 2

A
  1. low voltage but…
  2. FAST activity
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121
Q

What are Non-Rx ways to prevent Agitation in Delirius pts -5

A
  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)
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122
Q

What are Rx ways to ⬇︎Agitation in Delirius pts -4

A
  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
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123
Q

Which rx is most optimal for Anorexia Nervosa

A

Fluoxetine

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124
Q

Difference between Tourette and [Chronic Tic DO]

A

Tourette = [Motor AND Vocal Tics BOTH] for ≥ 1 year

These sx must occur before 18 yo and tx = Antipsychotics vs Alpha 2 R agonist vs CBT

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125
Q

Tx for Tourette’s and Chronic Tic Disorder - 6

A
  1. CBT Habit Reversal Training
  2. Clonidine - alpha 2 R agonist
  3. Guanfacine - alpha 2 R agonist
  4. Risperidone
  5. Haloperidol
  6. Pimozide antipsychotic

Antipsychotics are more effective

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126
Q

Side effects of ADHD stimulants - 4

A
  1. ⬇︎Appetite –> Wt loss
  2. Insomnia
  3. Tachycardia
  4. Tics (in children AND RARE)
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127
Q

Buproprion MOA - 2

A

Buproprion is a NDRI

NorEpi and Dopamine reuptake inhibitor

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128
Q

Why is Mirtazapine a good choice for depressed pts who are losing weight and can’t sleep

A

It’s SE includes ⬆︎appetite/wt gain and somnolence

Wt gain is > in Women before menopause and usually not problem if hasn’t occured within 1st 6 wks

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129
Q

There are 4 Dopamine D2 pathways in the brain

Name the pathways ; what overall effect do they have when activated?

A

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)

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131
Q

Which antipsychotic actually has a dual blockade effect? ; Which 2 receptors does it block?

A

Risperidone ;

  1. D2 R blocker
  2. Serotonin 2A R blocker (helps to ⬇︎EPS side effects)
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132
Q

S/S of Opioid withdrawal - 7

A
  1. Sweating
  2. Lacrimation
  3. Rhinorrhea
  4. Myalgia
  5. Diarrhea
  6. Yawning
  7. MyDriasis

These last for 3-5 Days

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133
Q

Which comorbidities is Tourette’s associated with? - 2

A
  1. OCD (develops within ~5 years of tic onset)
  2. ADHD
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134
Q

Describe the clinical tool used to assess whether a pt is seriously contemplating suicide

A

SAD PERSONS

Each is worth 1 point and [normal _3_ <–(outpt tx)–_8_ –> Hospitalize now!]​

Sex Male (be sure to ask about in-house guns!)

Age external to 19-45

Depression or other psych dx

Previous attempt hx (STRONG RISK FACTOR!)

EtOH or substance abuse

Rational thinking impaired (delusions, hallucinations)

Social support lacking or suicidal fam hx

Organized plan

No significant Other

Sickness physically (i.e. chronic pain)

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135
Q

What is the strongest single risk factor for suicide

A

previous suicide attempt

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136
Q

Diagnostic clinical criteria for Disruptive Mood Dysregulation disorder - 3

A
  1. Frequent Temper Outburst
  2. Severe irritability
  3. Poor Frustration tolerance
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137
Q

What type of psychiatric side effects does CTS (CorTicoSteroids) have? - 4

A

Steroids Make People Depressed!

  1. Suicidality
  2. Mania
  3. Psychosis
  4. Depression
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138
Q

AntiSocial Personality disorder is essentially Charlie Sheen

What is the nuance for diagnosing this disorder in regards to age of onset?

A

ASPD pts must have had conduct DO before 15 yo, with a continuance into adulthood

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139
Q

What regimen, for maintenance therapy, is considered in Bipolar pts who DON’T respond to monotherapy maintenace?

A

Treat Bipolar pts b4 they go B(AL)D!

A + [L or D]

[Antipsychotic 2ND GEN] + [Lithium or Depakote]

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140
Q

Tx for Major Depression with psychotic features - 2

A
  1. ECT > antipsychotic ➕
  2. Antidepressant

​Use ECT in elderly as it is more rapid acting

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141
Q

Suicide is the ___ (1st/2nd/3rd/4th) leading cause of death

A

4th

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142
Q

What are the strongest predictors of suicide? - 2

A

psychiatric illness > # of substances abused

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143
Q

What are the steps of Suicide Risk Assessment? - 5

A
  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

⬇︎Dynamic RF and ⬆︎protective factors

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144
Q

When should you document a Suicide Risk Assessment? - 3

A
  1. 1st psych assessment/admission
  2. prior to inpatient d/c
  3. any suicidal behavior/ideation

Document risk level, basis for risk level, plan for reducing risk and firearm assessment

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145
Q

What are the 3 C’s of addiction?

A
  1. Compulsion to use
  2. Control is lost
  3. Continues despite consequences
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146
Q

Which demographics has the highest suicide rates? - 2

A
  1. Age > 65 of the LAW [Latinos/Asians/Whites]
  2. Age < 25 of African Americans and Native Americans

Of this, Native Americans and Whites commit the most as a group

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147
Q

Lifetime prevalence for prior suicide attempts

A

~28%

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148
Q

Name the common suicidal Protective factors - 8

A
  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
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149
Q

What are rx treatments for Suicide - 4

A
  1. Antidepressants
  2. Lithium
  3. ECT for short term reduction only
  4. Clozapine for schizophrenia & schizoaffective only
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150
Q

What should be targeted during psychotherapy for Sucidal pts? - 3

A
  1. Circumstantial issues
  2. Manage high risk sx (hopelessness & anxiety)
  3. treat high Depression and other Psych illnessess
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151
Q

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”?

A

Cont Antidepressant rx for additional 4-9 months once remission is reached and then d/c

  • 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*
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152
Q

[T or F] Pt confidentiality should be maintained even when a pt is having Active suicidal ideation

A

FALLLSEE!!!!

Active (i.e. plans to hang themself) suicidal or homocidal ideation warrants breaking confidentiality and informing parents or whomever

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153
Q

Is Parental consent required for hospitalization? ; what about psychotropic medications?

A

NO, not required for hospitalization if pt is harm to self or others ; YES required for psych meds

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154
Q

3 SGAs that cause the greatest weight gain

A

“i Cause Obesity”

iLoperidone / Clozapine / Olanzapine

Clozapine & Olanzapine cause Sedation & [Metabolic Syndrome X] as well so monitor Fasting glucose and lipids!

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155
Q

Which SGA causes the MOST metabolic syndrome SEs (2)

A

Clozapine and Olanzapine

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156
Q

A: High binding SEs of Olanzapine (2)

B: Which Receptors are blocked (2)

A

A:

  1. Wt. Gain
  2. Metabolic Syndrome

B: [A1 adrenergic] / H1

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157
Q

Tx for Kleptomania - 5

A
  1. CBT
  2. SSRI
  3. Opioid R Blockers
  4. Lithium
  5. Anticonvulsants
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158
Q

MAOi MOA ; indications-2

A

inhibit catabolism of SEND (Serotonin/Epi/NorEpi/Dopamine)

  1. refractory depression
  2. atypical depression
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159
Q

Foods containing ____ can be have a dangerous interaction with MAOIs

What is the rxn when these two mix?

A

Tyramine ; HYPERTENSIVE CRISIS 2/2 sympathetic activation!

This will first present as a HA

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160
Q

Explain what Cognitive Behavioral Therapy is

A

Therapy that changes cognitive distortions (i.e. overgeneralization, catastrophizing, minimalizing positive events)

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161
Q

Explain what Biofeedback therapy is

A

Uses signals from body (HR, temperature, BP) as indicators of emotional distress and teaches this to pts to control their responses

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162
Q

Explain what Dialectical behavioral therapy is - 3 ; What disorder is this specifically used for?

A

Targets

  1. emotional dysregulation
  2. self-destructive
  3. suicidal behaviors

Borderline Personality DO

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163
Q

In Motivational Interviewing, therapist focus on pt’s motivation for change and ambivalence

What illness is this usually used to treat?

A

Substance Abuse DO

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164
Q

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?

A

waTCHERS

Worry / Anxiety that –> to…

  1. Tension in muscles
  2. Concentration ⬇︎
  3. Hyperarousal IRRITABILITY
  4. Energy ⬇︎
  5. Restlessness/on edge
  6. Sleep disturbance
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165
Q

Contraindications for Buproprion - 4

A
  1. Seizure hx
  2. Bulimia nervosa
  3. Anorexia Nervosa
  4. Use of MAOI within prior 2 weeks
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166
Q

Tx for Anorexia Nervosa - 5

A
  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)
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167
Q

How is Anorexia Nervosa associated with thyroid dysfunction? ; Should this be medically addresed with supplement?

A

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

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168
Q

Clinical presentation of REM sleep behavior disorder ; What could this indicate if it occurs reoccurs frequently?-2

A

Physical Dream Enactment during REM sleep (latter part of the night) ; Parkinson’s or DLB

Pt kicking, talking and pushing you off the bed while they’re dreaming

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169
Q

Describe Sleep terrors and sleepwalking

A

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

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170
Q

What is the difference between Sleep Terror and Nightmare disorder?

A

In NightMares, you’ll reMember the Dream!

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171
Q

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?

A

≥ 6 weeks

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172
Q

Most common side effect of ElectroConvulsive Therapy (ECT)

A

Transient Amnesia

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173
Q

What are the primary electrolyte disturbances seen in Anorexia or Bulimia Nervosa - 3

A
  1. ⬆︎Amylase
  2. ⬇︎K+
  3. ⬇︎Cl
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174
Q

Antipsychotics (___ generation) can be used to treat the depressive phase of Bipolar disorder

Which 2 are the best to be used?

A

Treat Bipolar pts b4 they go BALLD!

2nd generation Antipsychotics for Bipolar Depression =

Quetiapine and Lurasidone

175
Q

In the context of substance abuse, what are the 4 types of recovery?

A
  1. Clinical (absence of sx/usage)
  2. Social
  3. Economic
  4. Personal
176
Q

Diagnostic clinical criteria for Substance Dependence - 7

A

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
Q

The highest prevalence of Substance use disorders occurs in which psych illnesses? - 3

A

[AntiSocial 84%] > [Bipolar 60%] > [Schizophrenia 47%]

178
Q

What constitutes “a drink”? - 3

A
  1. 1 oz of 100 proof liquor (50% EtOH)
  2. 12 oz beer
  3. 4 oz wine
179
Q

S/S of Alcohol Withdrawal -10

these sx PEAK during 2nd day of abstinence and resolve by day 5

A

PAST NITE

Psychomotor agitation

Anxiety Irritability

Seizures

Tremor & DELIRIUM TREMENS

NV

Insomnia

Transient Hallcuinations

Excitable autonomics (⬆︎HR, BP)

180
Q

Describe Delirium Tremens-5 ; when does DT onset?

A

Further progression of Excitable autnomics =

  1. ⬆︎ HR
  2. ⬆︎ BP
  3. fever
  4. hallucinations
  5. Tremulousness –> Death

Onsets 2 days post last EtOH (when withdrawal sx peak)

181
Q

An alcoholic likely needs to be hospitalized in what situations? - 5

A
  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
Q

What is the interpretation of the CIWA protocol? - 3

A

Mild <— 9 —Moderate— 21 —> SEVERE

  • Mild withdrawal tx = support, reassurance and q4 checks*
  • Moderate withdrawal tx = Benzos*
  • S**EVERE withdrawal tx = ⬆︎Benzo, Thiamine, Fluids in ICU*
183
Q

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

A

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 Excitable autnomics
  5. Clonidine for Excitable autonomics
  6. Anticonvulsants for Seizures

The more withdrawals a pt has, the harder it is each time to treat

184
Q

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

A

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
Q

What are the single loading dose options for treating EtOH withdrawal? - 6

A
186
Q

Which Benzos are safe to use in pts with liver disease, elderly or dementia? - 3

A

These handicapped pts need a LOT of help

  1. Lorazepam
  2. Oxazepam
  3. Temazepam

Short half life & no active metabolities

187
Q

What are the Benzo dose options for treating Seizures associated with EtOH withdrawal? - 3

A
188
Q

Naltrexone is more than likely to be hepatotoxic in which situations? - 2

Naltrexone is available as monthly depot injection

A
  1. Obese pts
  2. [Higher Doses > 100 mg/day]

Naltrexone is available as monthly depot injection

189
Q

What is the major metabolite of crack cocaine? ; How long is it detectable in the blood?

A

BenzoyLEcGonine ; 3 days

190
Q

S/S of Amphetamine and Cocaine withdrawal - 4

A

Amphetamine/Cocaine withdrawal hits HARD

  1. Hungry
  2. Angry irritable
  3. Rest a lot w/unpleasant dreams
  4. Depressed (can mimic MDD vs Bipolar)

can last up to 9 days

191
Q

Opioids binds to Receptors located where in the body? - 3

A
  1. Brain
  2. Spinal Cord
  3. GI Tract

Opioids act on Dopamine, GABA and Glutamate systems

192
Q

Which is more lipid soluble (and thus more potent) between Heroin and morphine?

A

HEROIN

People start using opioids in mid 20s but become hooked by their 30s-40s

193
Q

Most of the time, pts obtain Pain Relievers from where?

A

Friend/Relative (who themself gets it from 1 doctor)

194
Q

What are the functions of the Mu Opioid receptors? - 5

A

Mu are the main CARDS

  1. Constipation
  2. Analgesia
  3. Respiratory Depression
  4. Dependence
  5. Sedation
195
Q

What are the functions of the Kappa Opioid receptors? - 3

A

Kappas are just SAD

  1. Sedation
  2. Analgesia
  3. Diuresis
196
Q

What are the functions of the Delta Opioid receptors?

A

possibly analgesia

197
Q

What is the clinical symptom triad for Opioid Overdose?

A

CPR!

  1. Comatose
  2. Pinpoint pupils
  3. Respiratory Depression

Immediately give Naloxone 0.4 mg IV or IM x 5 prn

198
Q

What is the dose of Naloxone to be given for Opioid Overdose?

A

Naloxone 0.4 mg IV or IM x 5 prn

199
Q

When does Heroin withdrawal occur? ; When does Heroin withdrawl subside?

A

6-8 hrs post last dose and peaks or 2nd day ; Subsides in 1 week

200
Q

Buprenorphine MOA - 2 ; Route of administration?

Buprenorphine + Naloxone = Suboxone

A

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
Q

During opioid dependence tx, which drug is more superior between Methadone and Buprenorphine?

A

Methadone ≥ 80 mg/day has SUPERIOR outcomes to daily Buprenorphine

Therefore, use Buprenorphine for mild-moderate (usually PO) opioid dependence only

202
Q

Which Blood pressure med is used to treat opioid withdrawal? ; Which sx does it treat? - 3

A

Clonidine ;

  1. NVD
  2. Cramps
  3. Sweating
203
Q

What is CAGE and how is it interpreted?

A

CAGE = Determines EtOH abuse; ≥ 2 positive answers = EtOH abuse/dependence and 1 positive answer warrants further eval

  1. ever tried to Cut back on drinking?
  2. Angry when someone criticizes ur drinking?
  3. Guilty about how much you drink?
  4. need an Eye opener in morning to prevent withdrawal/calm nerves?
204
Q

Dx Criteria for Illness Anxiety disorder

Males = Females

A

EXCESSIVE anxiety about having or acquiring an actual illness but pt has few or no sx that –> abnormal health-related behaviors

these pts may either seek OR avoid medical care

205
Q

What are the triggers of Sleep Terrors/Walking - 4

A
  1. Sleep Deprivation
  2. Stress
  3. illness
  4. meds affecting CNS
206
Q

Diagnostic criteria for Adjustment disorder with depressed mood - 4

A
  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

Tx = CBT

207
Q

[Drug-induced parkinsonism] is an EPS component caused by ____ blockers. ; What’s the antidote for EPS sx?-6

  • EPS = (T)ADD sx*
  • (T)ardive Dyskinesia is not EPS*
A

Dopamine R blockers;

  1. Lorazepam (TADD)-use only acutely
  2. Clozapine (use for Tardive Dyskinesia even tho only 50% respond)
  3. Propranolol (use for Akathisia)
  4. Benztropine (DD)
  5. Trihexyphenidyl (DD)
  6. Diphenhydramine (DD)
  • Obviously ⬇︎ (not d/c) D2 blocker as well*
  • EPS = TADD sx*
208
Q

What is the half life of Fluoxetine?

A

1 week!

209
Q

Which SSRI is most likely to cause weight gain

A

Paroxetine

210
Q

How long should a Doc wait to start an SSRI after discontinuing a MAOI?

This is to avoid Serotonin Syndrome SHIVERS

A

2 weeks

211
Q

SSRIs with short half lives need to be tapered

Which 2 SSRIs are in this group?

A

Paroxetine and FluVoxamine

212
Q

What are the NTS blocked by Venlafaxine? - 3

A
  1. NorEpi
  2. Serotonin
  3. Dopamine (only at > 375 mg/day)
213
Q

How is Venlafaxine related to perimenopausal women?

A

Although it causes sweating SE, it actually ⬇︎ hot flashes

214
Q

Compared to SSRI/SNRI, Buproprion is less effective at treating _____ and ____

A

Anxiety and ADHD

Onset of Buproprion = 2-4 weeks

215
Q

Which drug is helpful in treating hypersomnia (> 10 hrs/night) that possibly occurs in atypical depression

A

Buproprion

Buproprion can also ⬇︎ weight in any pt

216
Q

Mirtazapine MOA - 3

A
  1. PreSynpatic alpha 2 R blocker –> ⬆︎Serotonin & Norepi
  2. POSTsynpatic Serotonin R Blocker
  3. POSTsynpatic Histamine R Blocker

Mirtazapine works on anxiety and insomnia almost immediatley

217
Q

The GI Side effects from SSRI/SNRI can actually be relieved with what other antidepressant?

A

Mirtazapine (via 5HT3 R blockade)

218
Q

The tertiary amine TCA (amitriptyline) is metabolized to a secondary amine TCA named _____

A

Nortriptyline

TCAs are more effective than SSRI in depression tx for MEN

219
Q

The tertiary amine TCA (imipramine) is metabolized to a secondary amine TCA named _____

A

Desimipramine

TCAs are more effective than SSRI in depression tx for MEN

220
Q

Which class of antidepressants are catabolized by Cyto2D6?

A

TCAs

221
Q

Which class of antidepressantss inhibit Cyto2D6?

A

TCAs

222
Q

What are the effects of TCA blockade on:

H1 Receptors - 2

M1 Receptors - 2

A1 Receptors - 3

A
  1. H1 histamine R: sedation, weight gain
  2. M1 muscarinic R: sedation, confusion
  3. a1 adrenergic R: sedation, orthostatic hypotension, dizziness
223
Q

FGA antipsychotics are divided into 2 categories based on what?

A

low potency vs high potency are based on D2 R binding affinity

224
Q

Name the 3 anticholinergic meds that are used to counter EPS

A
  1. Diphenhydramine
  2. Benztropine
  3. Trihexyphenidyl
225
Q

Dosage for injectable forms of Haloperidol & Fluphenazine in treating Schizophrenia

A

1 injection IM q2-4 weeks

226
Q

Chlorpromazine MOA - 4

A
  1. D2 blocker (Remember that so is ProChlorperazine)
  2. Histamine R Blocker
  3. Muscarinic R Blocker
  4. A1 R Blocker
227
Q

Which antipsychotic can be used to treat intractable hiccups

A

Chlorpromazine

228
Q

Which FGA has the greatest risk of dose dependent QT prolongation

A

Thioridazine

SGA = Ziprasidone

229
Q

Name the antipsychotics that have long acting injectable formulations - 6

A

FOPRAH

  1. Fluphenazine
  2. Olanzapine (not used often)
  3. Paliperidone
  4. Risperidone
  5. Aripiprazole
  6. Haloperidol
230
Q

Which SGA has the least likelihood of EPS? ; This makes it idea to treat what condition?

A

Quetiapine ; Parkinson’s diseases (includes DLB)

231
Q

3 SGAs most likely to cause Sedation

A

“i Cause Obesity”

iLoperidone / Clozapine / Olanzapine

Clozapine & Olanzapine cause Sedation & [Metabolic Syndrome X] as well so monitor Fasting glucose and lipids!

232
Q

Which SGA has the greatest risk of dose dependent QT prolongation

A

Ziprasidone

  • must be taken c food or > 50% wont be absorbed*
  • FGA = Thioridazine*
233
Q

Aripiprazole MOA ; associated side effect?

A

partial dopamine R agonist ; Akathisia

    • 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
Q

Which SGA is approved for MDD adjunct tx

A

Aripiprazole

can NOT use for Bipolar depression adjunct tx

235
Q

Why is slow dose titration necessary for Clozapine

A

it can induce Seizures

236
Q

Name the 4 most metabolically neutral antipsychotics

A

ALAZ, I’m neutral!

  1. Aripiprazole
  2. Lurasidone
  3. Asenapine
  4. Ziprasidone (must be taken c food or > 50% wont be absorbed)
237
Q

Abrupt stop of Clozapine actually –> rebound psychosis

When is it ok to abrupt stop Clozapine? - 2

A
  1. WBC < 2K OR
  2. Absolute neutrophils < 1K
238
Q

a1 R blockade is associated with orthostatic hypotension

Which antipsychotics cause dose dependent Orthostatic hypotension - 5

A

makes ur BP QCRIP

  1. Quetiapine
  2. Clozapine
  3. Risperidone
  4. Iloperidone
  5. Paliperidone
239
Q

Which antipsychotic side effect it being shown?

A

OculoGyric crisis

240
Q

Which antipsychotic causes dry mouth AND salivation lol?

A

Clozapine

241
Q

SGAs work mostly by blocking what 2 receptors

A
  1. D2
  2. 5HT-2A
242
Q

How many D2 Receptors need to be blocked before antipsychotic effect can take place?

A

60%

243
Q

How many D2 Receptors need to be blocked before major side effects (EPS, hyperprolactin) occur from antipsychotics?

A

80%

only 60% is needed for antipsychotic therapy

244
Q

Which antiemetics are D2 R Blockers? - 4

A
  1. Prochlorperazine
  2. Promethazine
  3. Metaclopramide
  4. Droperidol
245
Q

about 75% of schizophrenia pts do this activity which actually ⬆︎ metabolism of antipsychotics

A

SMOKE CIGARETTES!

246
Q

Which drugs are approved for Bipolar Depression? - 5

A
  1. Quetiapine
  2. Lurasidone
  3. Lamotrigine
  4. Lithium
  5. Symbyax (olanzapine-fluoxetine)

this can be with adjunctive antidepressants but not monotherapy

247
Q

Which 2 SGAs need to be taken with food?

A

Eat ur PZ with ur antipsychotics

  1. Paliperidone (also available in injectable form)
  2. Ziprasidone (also most likely to cause QT prolongation)
248
Q

Which demographic is most at risk for dystonia from D2 R Blockers

A

Young Males

249
Q

Which bipolar subtype presents with mixed features

A

1 AND 2

Mixed = Manic + Major Depression Simultaneously in the same week x 1 week

250
Q

How much more than the hypomanic state are Bipolar 2 pts in depressed state?

A

15 x more

251
Q

Which bipolar subtype is mistaken for cyclothymic disorder sometimes

A

2

252
Q

In which bipolar subtype are pts more likely to have a hypomanic episode

A

1

Remember: Bipolar 1 can have hypomanic episodes too

253
Q

Which bipolar subtype is gender equal in frequency

A

1

Bipolar 2 data is unclear

254
Q

In Bipolar pts, If the first mood disturbance is a manic episode, what is the % risk of having future mood episodes?

A

85%

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
Q

What is the % risk of an identical twin developing Bipolar disorder if the other twin has it

A

70

50% for Schizophrenia

256
Q

How many Manic episodes does a Bipolar pt typically have in a lifetime

A

~10 (1 episode q2 years)

257
Q

At what age does Bipolar 1 typically onset? ; What about Bipolar 2?

A

18 ; mid20s

258
Q

What is the risk of having future major depressive episodes after having the first one?

A

50%

259
Q

Which Bipolar medications should be avoided in liver disease pts? - 3

A
  1. Lithium (also avoid in renal disease pts)
  2. Depakote
  3. Symbyax (olanzapine component)

also avoid in Obese pts

260
Q

Which Bipolar medications have the capability of rapid loading –> improvement within 3 days - 3

A
  1. Lithium
  2. Depakote
  3. Symbyax (olanzapine component)
261
Q

Lithium and Depakote monotherapy can be used in Bipolar pts

Which %:

respond well

partially respond

respond poorly

A

rule of 3s!

1/3 respond well

1/3 partially respond

1/3 respond poorly

262
Q

What are the first line tx options for acute severe mania - 2

A
  1. Antipsychotics + Lithium
  2. Antipsychotics + DepokOte
263
Q

Officially, how many manic episodes are needed before you consider maintenace tx in bipolar pts

A

2

and most of the time, after only one episode

264
Q

Treatment with which bipolar medication actually ⬇︎ suicide

A

Lithium

265
Q

Which Bipolar medications should be avoided in obese pts? - 3

A
  1. Lithium (also avoid in renal disease pts)
  2. Depakote
  3. Symbyax (olanzapine component)

also avoid in Liver dz pts

266
Q

What happens if Lithium is abruptly stopped (d/c over days)

A

affective switch to Mania

be sure to d/c lithium gradually 6-12 days after first euthymic visit

267
Q

Since these type of antidepressants were introduced, studies have shown an ⬆︎ switch rate & an ⬆︎ in the number of rapid cycling cases

A
  1. TCAs
  2. SNRIs
268
Q

Antidepressant monotherapy is contraindicated in which bipolar subtype?

A

1

269
Q

Which antidepressant carries the least risk of inducing a manic episode?

A

Buproprion

fyi: if antidepressants are used for bipolar depression be sure to d/c after the depression has resolved

270
Q

Which psychotrophic medication has the most narrow therapeutic index?

A

Lithium

fyi: give dialysis if Lithium > 4 meQ which = is life threatening

271
Q

What amount of DepokOte is given to rapid load a pt?

A

1500 mg

Lithium and Symbyax can also be rapidly loaded

272
Q

What % of bipolar pts ends by suicide

A

16%

20x risk of general population (similar to MDD)

273
Q

Which Bipolar sx usually indicates onset of new manic episode

A

awOke = ⬇︎need for sleep

274
Q

What is more common, Mania –> Depression or Depression –> Mania

A

Mania –> Depression occurs 60% of time

275
Q

Typically, pt must have elevated mood episodes (with impaired function) for ___ week before they’re considered Manic

When is there an exception to this?

A

if pt is hospitalized

276
Q

TCAs and SNRIs increase risk of bipolar disorder rapid cycling

What is rapid cycling?

A

≥ 4 mood episodes in 1 year

Mood episodes = MDD, Manic, Mixed or Hypomanic

277
Q

What are the risk factors for Bipolar disorder Rapid cycling? - 4

Rapid cycling = ≥ 4 mood episodes in 1 year

A
  1. TCAs
  2. SNRIs
  3. Female
  4. Thyroid abnormality

5-15% of Bipolar 1 pts have rapid cycling

278
Q

Although stimulants treat ADHD, what happens if you give a stimulant to a Bipolar pt?

A

induces mania

279
Q

What other things need to be ruled out before diagnosing Schizophrenia - 6

A
  1. Other psych disorders
  2. Mood disorders
  3. childhood developmental disorders
  4. general med condition
  5. substance induced
  6. personality disorders
280
Q

clinical presentation of Catatonia - 5

A
  1. EchoLalia/praxia
  2. Mutism
  3. Waxy flexibility (resistance to repositioning)
  4. Catalepsy (limbs remain fixed and immobile)
  5. negativism

  • Possibly* Catatonic Agitation
  • Tx = Lorazepam vs ECT*
281
Q

In schizophrenia, describe the timing of onset for negative sx - 3

A
  1. Present early during illness (during Prodrome)
  2. Worsen druing active periods
  3. Do NOT respond well to antipsychotics
282
Q

What % of schizophenic pts get married?

A

~35%

283
Q

What % of schizophenic pts have a single active episode?

A

10%

30% have intermittent course and 60% have chronic course

284
Q

When should the trough be drawn after last dose of Lithium ; When do you confirm therapeutic levels?

A

12 hours after last dose ; 5 days after start

285
Q

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?

A

85%

286
Q

In Schizophrenia, what is important to remember regarding age of onset between males and females?

A

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
Q

Schizophrenia pts have a life expectancy of ___ years because of this disease?

A

48-53 y/o ; Cardiovascular

Ironically, Schizophrenia cost more than all CA combined!

288
Q

What % of schizophenic pts live independently?

A

33%

289
Q

Why is the schizophrenia course typically worst for males than females?

A

males develop dz earlier

290
Q

Other than clozapine, if a schizophrenia pt does not respond to antipsychotics by ___ weeks than they won’t ultimately work by 4 weeks ?

A

2 weeks

291
Q

Why is it ok to give lower doses of Antipsychotics to schizophrenia pts who have active phase first?

A

they have ⬆︎sensitivity to medication side effects

292
Q

Within the FGAs potency (high potency vs low potency) has ⬆︎ risk of anticholinergic side effects but ⬇︎ risk of EPS?

A

low

Dry mouth, urinary hesitancy, hyperthermia, blurred vision

293
Q

What do Clozapine and Lithium have in common?

A

Both ⬇︎ Suicidality

along with antidepressants & ECT

294
Q

Name the indications for Clozapine - 5

A
  1. Persistence of positive sx
  2. Failure of ≥ 2 Antipsychotic trials
  3. Co-Morbid substance abuse
  4. Recurrent Suicidality
  5. Recurrent Violence
295
Q

What % of dopamine receptors are blocked when FGA side effects kick in?

A

75-80

296
Q

What % of dopamine receptors need to be blocked in the mesoLimbic tract in order to have antipsychotic effect

A

65

297
Q

Which EPS sx should u be concerned about in the > 70 y/o demographic

A

Tardive Dyskinesia (if > 2 years taking drug, 50% develop TD)

298
Q

Which 2 SGAs do NOT cause EPS

A
  1. Clozapine
  2. Quetiapine - is used to treat Parkinson’s/DLB
299
Q

In the CATIE study, this SGA was shown to be highly likely to have pt compliance?

A

Olanzapine

also has HIGHEST risk for metabolic syndrome/obesity & is very sedating

300
Q

Which SGA is safe to give to Liver failure pts because it doesn’t require hepatic metabolism

A

Paliperidone

avoid in renal failure pts

301
Q

This SGA has very low risk of EPS or agranulocytosis but can cause metabolic syndrome

A

Quetiapine

302
Q

Major side effects of Clozapine - 8

A
  1. Dry Mouth
  2. Salivation
  3. Metabolic Syndrome
  4. obesity
  5. Sedation
  6. Myocarditis
  7. Seizures (so titrate up slowly!)
  8. Agranulocytosis
303
Q

In Schizophrenia, positive sx are correlated with hospitalization but not ______

A

functional improvement

remember, negative sx and cognitive sx only improve midly w/tx and is only with SGAs

304
Q

In Schizophrenia, negative sx are correlated with ____

A

functional improvement

remember, negative sx and cognitive sx only improve mildly w/tx and is only with SGAs

305
Q

In Schizophrenia, what sx are correlated with functional impairment? -2

A

Negative sx & Cognitive sx

present from early age and are also poorly responsive to meds

306
Q

In Schizophrenia, what contributes most to Criteria B Social Occupation Dysfunction

A

Cognitive sx decline

present from early age and are also poorly responsive to meds

307
Q

In schizophrenia, what is the downward drift hypothesis?

A

Cognitive decline early in age –> ⬇︎[Work/Interpersonal/SelfCare] –> Overall Social Occupational dysfunction –> Downward drift into the Lower Socioeconomic class

308
Q

Which sex is more likely to have schizophrenia?

A

EQUAL!

males have ⬆︎ severity 2/2 earlier onset

309
Q

What is the peak age of onset of Schizophrenia in males? ; in females?

A

Males = 15/18-25 ;

Females = 25-35/45

310
Q

Lifetime prevalence of Schizophrenia

A

1%

311
Q

What is the % risk of an identical twin developing Schizophrenia if the other twin has it

A

50

70% for Bipolar

312
Q

[T or F] Schizophrenia is caused by a combination of genes

A

TRUE!

313
Q

For Schizophrenia, prenatal risk factors occur in the ___ trimester ; Name the major risk factors associated with schizophrenia development? - 6

A

2nd trimester;

  1. viral infection
  2. winter births
  3. Starvation
  4. Toxin exposure
  5. anoxia
  6. Advanced PATERNAL age
314
Q

For maintenance tx of Bipolar Disorder, lithium levels should be between ______

A

~0.7-4 mEq/L

TSH, BUN/Cr, Lithium level should be drawn twice a year

315
Q

At what Lithium level should Dialysis be used for toxicity ; What risk factors make this more likely? - 3

A

> 4 mEq/L ;

  1. Renal impairment
  2. hypOnatremia
  3. Dehydration
316
Q

Which test need to be done on young males before starting Depakote? - 2

A
  1. LFTs
  2. Platelets (ASA can accelerate platelet drop)
317
Q

What is important to remember regarding pts taking BOTH Depakote AND Lamotrigine?

A

Lamotrigine needs to be cut in half

this is because Depakote actually ⬆︎ Lamotrigine’s serum level x 2

318
Q

Depakote has a serious hepatotoxic side effect

Who’s most at risk for this?

A

< 2 yo

319
Q

In regards to side effects, what is the difference between DepakOte and Depakene?

A

Depakene –> GI Side effects

320
Q

Ironically, DepakOte is indicated as px for _____, even though this is also one of its side effects

A

HA

321
Q

For DepakOte, trough for IR should be drawn ____ hours after last dose ; trough for ER should be drawn ____ hours after last dose

A

12 ; 18

322
Q

What happens if ASA is given with DepakOte?

A

⬇︎platelets

323
Q

Explain autoinduction of Carbamazepine

A

After first few weeks of taking Carbamazepine, its half life will ⬇︎ by more than 50% due to autoinduction

324
Q

What are the 2 black box side effects of Carbamazepine?

A
  1. Agranulocytosis
  2. Aplastic Anemia
325
Q

Because Carbamazepine is a substrate AND inducer of cytochrome ____, how does it affect birth control?

A

3A4 ; ⬇︎birth control –> pregnancy

326
Q

Which electrolyte is often low in pts taking Carbamazepine?

A

sodium (2/2 SIADH)

327
Q

What 2 side effects does Lithium, Depakote, Quetiapine and Olanzapine have that Lamotrigine does NOT have?

A
  1. Wt Gain
  2. Sedation
328
Q

Rash is a side effect of Lamotrigine

What is the % risk of developing benign rash? ; SEVERE rash? ; Steven’s Johnson Syndrome?

A

10 ; 0.3 ; 0.02-0.1

329
Q

DepakOte/Depakene Side Effects - 7

A

“Grab a Coat..you’ve got GNATTTS!

  1. Gain in wt
  2. NVD
  3. Alopecia
  4. Thrombocytopenia at high doses, worst w/ASA
  5. Tremor
  6. TERATOGENIC
  7. Sedation

Get LFTs and Platelets before giving

330
Q

Which psychotropics are used in maintenance tx of Bipolar disorder - 5

A

Treat Bipolar pts b4 they go BALLD + Car!

Antipsychotics - OAQRZ only

Lamotrigine

Lithium

Depakote

Carbamazepine

331
Q

Which SGA has a long half life of 75 hours but takes 2 weeks to reach steady state

A

Aripiprazole

332
Q

What happens when Risperidone is used at high doses (_____)? - 2

A

High Risperidone= ≥6 mg –> acts like FGA and has ⬆︎EPS

333
Q

Which 2 SGAs are the least likely to cause metabolic syndrome

A
  1. Aripiprazole
  2. Ziprasidone
334
Q

How long does a single marijuana joint stay in the urine

A

4 days

335
Q

What % of weed smokers become dependent

A

10

but remember weed is anti-inflammatory, convulsant and emetic

336
Q

Why is Burproprion used in smoking cessation

A

mimics some of the effects of nicotine

337
Q

Varenicline MOA

A

long acting partial agonist of A4B2NAR

338
Q

Which TCA is used as 2nd line smoking cessation agent

A

Nortriptyline

339
Q

When does Nicotine withdrawal occur? ; WHen does it peak? ; how long does it last

A

1 day ; 2-3 days ; 2-3 weeks

340
Q

How are opioids related to EtOH

A

Opioids enhances the midbrain release of dopamine by EtOH

341
Q

Naltrexone MOA

A

mu opioid R blocker

342
Q

What lab value should be monitored in pts on Acamprosate? ; What’s the main side effect of this drug?

dose: 2T of 333mg TID

A

Renal excreted so Be sure to monitor renal function and SE = Diarrhea

343
Q

Name the drugs in the phenylAlkylamine hallucinogen drug class - 3

A
  1. MDMA - has neurotoxic effects
  2. DOM
  3. Mescaline
344
Q

What is Sudden Sniffing Death

A

Inhaled volatile hydrocarbons –> Cardiac Arrhythmias –> Death

345
Q

How long does PCP stay in the urine

A

8 days

346
Q

Which ilicit is most commonly involved in ER visits

A

Cocaine

347
Q

50% of people who stop smoking develop nicotine withdrawal. What are the s/s? - 3

A
  1. irritability
  2. anxiety
  3. ⬇︎Concentration

only 5% never relapse again

348
Q

In medicine, what are the measurements of what “a drink” is? - 3

A
  1. 1.5 oz shot
  2. 4-6 oz wine
  3. 12 oz beer
349
Q

What is the most common ilicit drug used across all age groups

A

marijauna

350
Q

How long does opioids stay in the urine

A

12 - 36 hours

351
Q

What % of IV opioid users develop Hep C?

A

90

352
Q

Which 2 s/s of Opioid withdrawal are more severe and not seen very often

A
  1. Piloerection
  2. Fever

pupil Dilation is commonly seen in withdrawal

353
Q

Although Cocaine users use ____ as a sedative for their side effects, Amphetamine users use ___ as a sedative agent

A

Cocaine=EtOH ; Amphetamine=Marijuana

354
Q

Name a reliable sign of stimulant withdrawal

A

bradycardia

355
Q

Stimulants stay in the hair for how many days

A

90

356
Q

What is a Speedball

A

Cocaine + Heroin

357
Q

In terms of EtOH use, what is positive reinforcement? ; What is negative reinforcement?

A

positive= enjoying the buzz/high from EtOH –> more drinking

vs

negative = having withdrawal sx –> more drinking

358
Q

How long does it take substance use disorder to resolve after removing the substance and its withdrawal sx subside

A

< 1 month

359
Q

People with alcoholic parents are ___times as likely to become alcoholics as well

A

4x

360
Q

Elevation of which 2 lab values indicates alcoholism (and is used to monitor abstinence and relapse)

A
  1. GGT
  2. Carbohydrate Deficient Transferrin

MCV can be used to detect history of alcoholism but not monitoring

361
Q

Below is Criterion A for Substance Use Disorder. Which does Cravings belong to?

Impaired Control

Social Impairment

Risky use

Pharm Criteria

A

Impaired Control

362
Q

PCP can induce psyhotic disorders, delirium, anxiety and ____ disorders

A

Mood

363
Q

Between Cocaine intoxication and withdrawal, which is associated with onset of mood disorder

A

BOTH

364
Q

Between Cocaine intoxication and withdrawal, which is associated with onset of psychotic disorder

A

Intoxication

365
Q

Inhalants and ______ do not cause withdrawal

A

Hallucinogens

366
Q

What are the 3 Ps of Personality Disorder

A
  1. Pervasive
  2. Persistent
  3. Pernicious
367
Q

Personality Disorders manifest in ≥ 2 of what categories (4) ; When should these onset by?

A
  • Interpersonal function
  • Affect
  • Cognition
  • Impulse control

PD should onset by teen/young adult

368
Q

Textbook definition of Personality Disorder

A

Dysfunctional amplification of normal personality traits

369
Q

Strategies for dealing with Cluster B pts - 4

For all Clusters, never personalize pt’s behavior

A
  1. Empathize with pt’s fears
  2. Be consistent
  3. set limits
  4. Verbalize that you want to help & satisfy reasonable request

Beware of Countertransference

370
Q

Strategies for dealing with Cluster A pts - 4

For all, never personalize pt’s behavior

A
  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

Beware of Countertransference

371
Q

Strategies for dealing with Cluster C pts - 4

For all, never personalize pt’s behavior

A
  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

Beware of Countertransference

372
Q

4 major risk factors for Anorexia Nervosa

Refusal to maintain body wt ≥ normal BMI

A
  1. Genetics (56% biological / 44% environmental)
  2. Obstetrical complications
  3. Female Athletes
  4. Dieting

anorexia pts are at risk of renal disease

373
Q

Time Criteria for Bulimia Nervosa

A

Binge eating followed by Purge occurs…

  1. twice a week
  2. x 3 months
374
Q

4 major causes of death in eating disorders

A
  1. Starvation
  2. Cardiac Arrhythmias
  3. Suicide
  4. GI Dilation –> Rupture
375
Q

Best way to treat Anorexia is food!!! but also treat comorbidity

List the Refeeding complications - 4

A
  1. Hyperburn
  2. Edema
  3. Constipation
  4. GI Dilatation
376
Q

tx for Bulimia Nervosa - 4

A
  1. SSRIs - higher dose
  2. Topiramate
  3. Zofran
  4. CBT
377
Q

Time Criteria for Binge Eating disorder - 3

Men = Women in prevalence

A
  1. Binges without purging twice a week
  2. x 6 months
  3. Distress over the binging

Tx = CBT + WtLossProgram

378
Q

What are predictors of outcome for Bulimia pts -2

A
  1. Duration of illness at start of tx = BEST PREDICTOR
  2. Lack of response to CBT by 6th session = poor pgn
379
Q

How long are Anorexia pts hospitalized usually? ; What about Bulimia pts?

A

2 weeks (or until wt restoration) ; 1 week

380
Q

Lifetime prevalence of MDD

A

12-18%

381
Q

[T or F] There is a genetic component to MDD

A

TRUE!

pts with fam hx of MDD have 2x the risk of getting it

382
Q

What are the highest risk factors for MDD - 3

A
  1. Early parental loss
  2. postpartum
  3. Negative life events = HIGHEST
383
Q

What is the Kindling theory

A

With each episode of depression or mania, you become more susceptible to future mood episodes with weaker triggers

384
Q

List the 5 outcomes of Depression tx

A
385
Q

___% of pts after first MDD episode recover if they receive adequate care

What CoMorbid factors retard MDD recovery? - 4

A

80%

  1. psychosis
  2. prominent anxiety
  3. personality disorder
  4. MDD sx are VERY severe
386
Q

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?

A

Initial Somaticizer

387
Q

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?

A

Facultative Somaticizer

388
Q

What are the adverse considerations between SSRIs and Pregnant Women? - 6

A
  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
Q

Describe the proposed role of the 3 NTS

NorEpi / Serotonin / Dopamine

A
390
Q

Complementary Rx for MDD - 2

A
  1. Omega 3 fatty acids
  2. Exercise
391
Q

What does “MDD with mixed features” imply

A

There are some hypomanic sx also

392
Q

What is Melancholic Depression - 4

A

SEVERE Depression thats

  1. likely biological
  2. loss of pleasure
  3. loss of reactivity to pleasurable things
  4. ≥3 of image
393
Q

In MDD, what are the % chances of reoccurence if pt had only 1 episode? what about 2 episodes? 3 episodes?

A

1 - 50% chance MDD will reoccur

2 - 90%

≥3 = 95%

394
Q

What type of changes are observed in newborns with a mother depressed during pregnancy?

A

⬆︎in-utero Cortisol exposure –> newborn R Amygdala ∆ which –> ⬆︎risk for MDD, cognitive and physical defects since neurogenesis is downregulated by cortisol

neurogenesis is upregulated by exercise, learning environment, estrogen, antidepressants

395
Q

What is the association between inflammation and Depression

A

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
Q

Which part of the insula is liked to translating visceral experiences into subjective feeling states

A

ANTERIOR

397
Q

How does Exercise biochemically treat depression

A

Exercise –> FNDC5 production in muscle cells which –> release into blood as IRisin –> IRisin stimulates [Brain Derived Neutrophic Factor] –> AntiDepression/Learning/Memory

398
Q

How is Depression associated witih Cardiac disease - 2

A
  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
Q

What are good prognositc factors for Illness Anxiety Disorder - 5

A
  1. High SES
  2. Sudden onset
  3. CoMorbid Depression/Anxiety are tx-responsive
  4. NO coexisting Personality DO
  5. NO coexisting med condition
400
Q

In Functional Neurological Symptom Disorder, what is La Belle Indifference?

A

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
Q

In Functional Neurological Symptom Disorder, what is the rule of one-thirds?

A
  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
Q

General pgn for Functional neurological symptom disorder

A

90-100% have initial sx resolve within [first few days-1 month] and 75% DON’T have another episode

403
Q

Factitious Disorder presents in _____ and usually last _____

A

early adulthood ; lifelong possibly

404
Q

What is Pseudocyesis

A

false belief of being pregnant associated w/objective s/s of pregnancy!

falls under “Other” Somatic Sx Disorders

405
Q

Bipolar Epidemiology

Age of onset?

Which gender predominates Bipolar 1?

Which gender predominates Bipolar 2?

A

Age = 19-21

Bipolar 1 = MALES = FEMALE

Bipolar 2 = FEMALE

most bipolar pts are single/divorced

406
Q

What is the % risk of an dizygotic twin developing Bipolar disorder if the other twin has it

A

20%

407
Q

What is the % risk of a family member developing Bipolar disorder if a 1st degree relative has it

A

15%

ESPECIALLY IF MOM

408
Q

Bipolar disorder has many gene overlap with ____ disorder. What electrolyte channel is implicated in these disorders?

A

Schizophrenia ; Ca+ channel signaling dysfxn

409
Q

What is the % risk Bipolar pts relapse if Mania was their 1st episode? ; What if depression was their 1st episode?

A

85 ; 50

410
Q

What regimen, for maintenance therapy, is considered in Bipolar pts who DON’T respond to monotherapy maintenace?

A

Treat Bipolar pts b4 they go B(A-LD)!

A + [L or D]

[Antipsychotic 2ND GEN] + [Lithium or Depakote]

411
Q

Even after 1 Manic episode, Lithium should be continued for _____ and then if effective, adjuvant meds can be d/c’d after ___ over _____

A

9-24 mo. ; 4-6 wks ; 1-3 mo.

If after 2nd Manic episode = cont Lithium indefinitely

412
Q

How long does Depakote take to improve acute mania? What about Carbamazepine?

A

3 days ; 1-2 wks

413
Q

What constitutes MDD with atypical features - 4

A

MDD + ≥ 2 of:

  1. Wt Gain
  2. Hypersomnia
  3. Leaden Paralysis (heavy arms/legs)
  4. Long standing sensitivity to rejection

Tx = MAOI

414
Q

Which Dopamine Receptor subtypes are highly correlated with psychotic activity? ; Which subtype is not found in the EPS pathways?

A

D2-4 ; D4

SGAs have high affinity for D4

415
Q

How long does it take antipsychotics to reach peak plasma when given IM? ; what about when given PO?

A

30 min ; 1-4 hours

only 10% of these are unbound which = only 10% cross blood brain barrier

416
Q

In Schizophrenia, Functional deterioration mostly occurs when?

A

During ACTIVE Episodes

remember, only negative sx and cognitive sx respond poorly to meds

417
Q

The order to which pts are prescribed antipsychotics follows an algorithm

List the 6 stages of the AntiPsychotic Algorithm

A
  • 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
Q

Clozapine trial requires more time than others

Explain the regimen - 3

A
  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

usually effective for 30-50% tx refractory pts

419
Q

Clozapine is obvi used for refractory psychosis

When is Clozapine also considered? - 5

A
  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

usually effective for 30-50% tx refractory pts

420
Q

FGA antipsychotics are divided into 2 categories based on D2 R binding affinity

In regard to side effects, what’s unique about Low potency FGAs?-3

A
  1. ⬇︎EPS due to ⬆︎Anticholinergic effects
  2. Highly SEDATING
  3. QT prolongation

LOW potency FGAs have LOW risk for EPS

421
Q

Which antipsychotic has a disintegrating tablet formulation

A

Olanzapine

422
Q

Which antipsychotic is most effective for negative sx

A

Clozapine

423
Q

What is the blood drawing schedule for Clozapine - 3

A
  1. Weekly x 6 months
  2. Then BiWeekly x 6 months
  3. Then montly
424
Q

What should you remember regarding SGAs and elderly pts

A

All SGAs have black box warning of ⬆︎mortality in [elderly w/dementia-related psychosis]

425
Q

How should you proceed with tx after a pt develops Neuroleptic Malignant Syndrome

A

30% have recurrent NMS with restart but most pts can be safely restarted with precautions

426
Q

[T or F] In schizophrenia tx, start with lowest effective dose and then tirtate up

A

FALSE!

Use Continous FULL-dose antipsychotic tx in schizophrenia only

427
Q

Most common psychotropics to cause Sedation - 6

A

Quit Crying, FOLD & sleep

  1. Quetiapine
  2. Clozapine
  3. FGAs
  4. Olanzapine
  5. Lithium
  6. Depakote
428
Q

Which anti-HTN med is used to treat smoking cessation

A

Clonidine

Psych Clerkship (1 decks)

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