Psych COMAT Flashcards
What is the path and diagnosis of GAD?
Path: chronic, insidious
Presentation: constant state of worry involving most things on most days >/= 6 months duration with >/= 3 somatic changes.
What are somatic changes to look out for when diagnosing GAD?
changes in sleep, changes in weight, irritability, and decreased concentration
What is the treatment of GAD?
psychotherapy»_space; meds (SSRIs, buspirone)
panic attacks are abortive with benzodiazepines (but they should not be prescribed in patients with GAD because they can become dependent on them)
What is the path and diagnosis of panic disorder? What is the PANIC STUDENTS mnemonic?
Path: acute, overt Diagnosis: not caused by another disorder (usually women in their 20s with no medical history to account for another cause) STUDNETS PANIC: SOB Trembling Unsteady Depersonalization Excessive HR Numbness Tingling Sweating
Palpitations Abdominal pain Nausea Intense fear of death Chest pain
What conditions should be ruled out when diagnosing panic attacks in a new pt?
Rule out ACS with EKG/troponings, rule out hyperthyroidism with TSH, rule out asthma with history/wheezing
What is the treatment for panic disorder?
meds > psychotherapy (CBT works)
Abortive treatment = benzodiazepines
What is the criteria for diagnosing phobia?
exaggerated and/or irrational usually against a specific object or situation
What are examples of a specific phobia?
heights, flying, spiders, clowns, snakes
What are examples of a social phobia?
public speaking, public peeing
How can you overcome phobias?
CBT - flooding (quick, not as long lasting) and desensitization (takes longer, lasts longer)
also usually use benzos
What is intermittent explosive disorder? (Path, action, patient)
Path: stressor can be anything (usually someone violating their personal space)
Action: violence (usually disproportionate to stressor)
Patient: men > women, decreases with age
What are the two types of intermittent explosive disorder, and how are they different?
Mild (no harm): two outbursts per week that continue for 3 months
Severe (harm present): 3 outbursts over the course of 12 months
What is the treatment for intermittent explosive disorder?
Meds don’t work, therapy is not very beneficial (OME recommends building a relationship with the person and figuring out something that works for that person)
What is the stressor and action for someone with kleptomania? Patient?
Stressor: object
Action: stealing (usually somethin of little to no value)
Patient: women > men
What are actions after stealing associated with kleptomania?
guilt/remorse after stealing, which makes them give the object away, hoard it away, or return it
What is the treatment for kleptomania?
meds and therapy are not very effective; need to coach to give item back
Stressor, action, patient, diagnostic criteria, treatment for pyromania?
stressor: increase sexual arousal
action: set fires in order to increase sexual arousal
patient: men > women
diagnosis: >/= 2 occasions of setting fires
treatment: meds/therapy don’t help
OCD path,
path: obsessions: anxiety provoking (internal, intrusive, unwanted, thoughts or preoccupations); compulsions: anxiety reducing (behavior or ritual)
What are some common obsessions and their compulsions?
safety -> checking
contamination -> washing/cleaning
asymmetry -> putting things in order, counting
What is the treatment for OCD?
psychotherapy > medications
Types of therapy: CBT
Medications: SSRIs
preoccupation/obsession, convulsion, and unsafe effect of hoarding disorder?
preoccupation/obsession: throwing things away
compulsion: keep things (usually trash)
unsafe effect: unsafe environment
preoccupation/obsession, convulsion, and unsafe effect of body dysmorphic disorder?
preoccupation/obsession: some part of the body (skin, hair, nose, breast)
compulsion: check appearance, unnecessary surgeries
unsafe effect: none
(female disease)
preoccupation/obsession, convulsion, and unsafe effect of muscle dysphoria?
preoccupation/obsession: increasing muscle size
compulsion: excessive exercise, use anabolic steroids
unsafe effect: rhabdomyolysis -> ARI; roid rage
(male disease)
(any question about copper or testicular atrophy, think this)
preoccupation/obsession, convulsion, and unsafe effect of trichotillomania?
preoccupation/obsession: anything
compulsion: pull out hair
unsafe effect: alopecia; hair at varying lengths
(r/o fungus, bezoar -> eats hair, leading to small bowel obstruction
What are common stressors leading to PTSD?
actual death, threatened death, combat, raped, abused/neglected
What are possible exposures leading to PTSD?
experienced (self), witnessed (others), learned (loved one), repeated exposure to aftermath (EMTs, firefighters, police officers)
What are the five components to PTSD?
intrusion, mood change (depressed), dissociation, avoidance, arousal (hyper-vigilance)
Duration of PTSD symptoms > 3 days but < 6 months is what diagnosis?
acute stress disorder
Duration of PTSD symptoms > 6 months is what diagnosis?
PTSD
What is the treatment for PTSD?
psychotherapy (group therapy, survivor groups), meds (SSRIs), benzos for panic attacks
What are patients with PTSD at risk for without treatment?
mood disorders and substance abuse
What is the stressor in reactive attachment disorder (RAD) and disinhibited social engagement disorder (DSED)?
abuse/neglect in infancy
What is the difference between RAD and DSED?
same trigger, but RAD they end up pairing too little with others; DSED they end up pairing too much (there is no difference between a friend and a stranger)
When can RAD and DSED be diagnosed?
< 5 years old, must r/o autism
What is the treatment of RAD and DSED? What are possible complications of poor treatment?
treatment = teaching the caregiver how to parent better and provide coping skills complications = mood, anxiety, or substance abuse disorders, learning disability
Describe adjustment disorder.
non life-threatening stressor that leads to a change in mood (but does not meet criteria for a mood disorder). onset must be within 3 months of the stressor and the duration is < 6 months (no psychotic features, no SI/HI)
What is the diagnostic criteria of major depressive disorder?
depressed mood or anhedonia for duration >/= 2 weeks AND 5 SIGECAPS
What does SIGECAPS stand for?
Sleep Interest Guilt Energy Concentration Appetite Psychomotor Suicidal ideation
What is the treatment for major depressive disorder with suicidal ideations with a plan and means to carry out said plan?
hospitalization
What is the treatment for major depressive disorder with suicidal ideations without a plan and/or means to carry out said plan?
safety conract
What is the treatment for major depressive disorder without suicidal ideations?
SSRI or SNRI for 1-2 months before deciding to add another med; psychotherapy (combo), ECT in refractory, catatonia, or psychosis
What SIGECAPS findings would you expect for atypical depression? How is this different than typical depression?
increased sleep, decreased interest, increased guilt, decreased energy, increased appetite, decreased psychomotor, +/- suicide; different than typical depression with sleep and appetite
Bipolar I pathology, diagnosis, symptoms?
path: manic-predominant diagnosis; "E" + 3 Sx for >/= 1 week Distractibility Insomnia Grandiosity Flight of ideas Agitation Sexual exploits Talkative Elevated mood Racing thoughts R/O: stimulants, Bipolar II, cyclothymia
How do you treat someone with Bipolar I that is manic in the ED?
Chronic = mood stabilizers (benzos if need sedated) = Lithium (1st line), Valproic acid (2nd line), Carbamazepine/Lamotrigine (3rd line) Antipsychotic = quetiapine (4th line)
Bipolar II presentation, diagnosis?
hypomania + major depressive episode
R/o: catatonia, Bipolar I
What is cyclothymia?
lesser version of Bipolar II
Dysthmia presentation, diagnosis, treatment?
depressed mood within 2 year period or longer, duration never more than 2 months at a time
R/O hypothyroidism with TSH
Tx with SSRI
What are the five stages of death and dying?
Denial, Depression, Bargaining, Anger, Acceptance (for dying and survivors)
In what situations is PTSD/ASD due to death/dying more likely?
when loss is unexpected and/or violent (Sx; anxiety, fear)
What is criteria for diagnosis of adjustment disorder in relation to death and dying?
adjustment disorder cannot be diagnosed in the setting of bereavement
onset, duration, focus, course, behaviors, reason for suicide, and treatment of grief
onset: anytime
duration: <12 months (since loss of person)
focus: diseased (dysphoria, guilt, anhedonia normal)
course: depressed mood waxes and wanes; able to imagine a time in the future when they will be happy
behaviors: talking to deceased, praying at deceased, visiting graveside, catching a glimpse of deceased (normal as long as there is the insight to know they are still deceased)
reason for suicide: deceased (to be with them, trade places, etc)
treatment: does not need treatment
describe persistent complex bereavement disorder including onset an duration.
onset: >6 months after
duration: >/= 12 months
A mix between grief and major depressive disorder.
onset, duration, focus, course, behaviors, reason for suicide, and treatment of major depressive disorder
onset: anytime
duration: >/= 12 months
focus: pervasive and global, affects rest of life (dysphoria, guilt, anhedonia)
course: persistent depressed mood; cannot imagine a time when they will be happy again
behaviors: related to hallucinations (auditory, visual), psychotic features (usually lack insight)
reason for suicide: thinking about self (despondent and hopeless)
treatment: SSRI, SNRI
baby blues - baby, onset, duration, symptoms, treatment
baby: 1st baby, mom cares about baby
onset: within 2 weeks
duration: within 2 weeks
symptoms: depressed mood
treatment: no treatment
post-partum depression - baby, onset, duration, symptoms, treatment
baby: 1st baby, mom doesn’t care about baby (still wants baby to live)
onset: within 1 month
duration: ongoing without tx
symptoms: SIGECAPS
treatment: SSRIs
post-partum psychosis - baby, onset, duration, symptoms, treatment
baby: not usually 1st baby, mom fears baby and is likely to kill it
onset: within first month
duration: ongoing without tx
symptoms: psychosis-predominant
treatment: anti-psychotics
What is the proposed pathophys of positive symptoms in schizophrenia?
increased dopamine
What is the proposed pathophys of negative symptoms of schizophrenia?
increased serotonin
What is the diagnostic criteria for schizophrenia?
> /= 2 symptoms and one must be 1-3:
1. delusions (looking for persecution or grandiosity)
2. hallucinations (generally auditory)
3. disorganized speech
4. disorganized behavior (stop grooming, stop leaving house)
5. negative symptoms (flat affect, poverty of speech/movement, anhedonia, cognitive delay)
R/o drugs, determine duration, and +/- mood disorder (can change the diagnosis)
What is the treatment for schizophrenia?
antipsychotics
Schizophrenia duration and treatment time period
duration: > 6 months
treatment: lifelong
Brief psychotic disorder duration and treatment time period
duration: > 1 day, < 1 month
treatment: 1 month (if it persists, probably schizophrenia)
Schizophreniform duration and treatment time period
duration: > 1 month, < 6 months
treatment: 3-6 months
Schizoaffective disorder criteria, duration, and treatment time period
PSYCHOSIS + mood
duration: > 6 months
treatment: treat mood disorder first
Describe delusional disorder.
delusions that are not bizarre and do not cause impairment (do not meet 1-3 criteria of schizo)
Use gentle confrontation (their delusion is more likely to impair someone else than themselves)
What meds would you choose for a normal compliant schizophrenic patient?
atypicals (quetiapine, olanzapine, risperdol) - atypicals work on both dopamine and serotonin in the brain, less side effects than typicals
What meds would you choose for a schizophrenic patient who is combative in the ED?
typicals - haloperidol, (do not use olanzapine with combative patient)
What meds would you choose for a noncompliant schizophrenic patient?
depot form (once a month injection) haloperidol
What meds would you choose for a schizophrenic patient when all else fails?
clozapine (first atypical med made, almost always works, but can cause agranulocytosis so you have to try all other meds first)
What condition can all antipsychotics cause and what is the treatment?
neuroepileptic malignant syndrome (fever, rigidity, elevated CK, on antipsychotic); treat with dantrolene
What electrolyte abnormalities would you expect with bulimia nervosa hyperemesis type?
hypokalemia, hypomagnesemia, metabolic alkalosis
What electrolyte abnormalities would you expect with bulimia nervosa laxative type?
metabolic acidosis
Bodyweight, self-image, anxiety, method, signs/symptoms, hospitalization, treatment, f/u for anorexia nervosa?
body weight: underweight
self-image: decreased
anxiety: fearing becoming fat or being fat (no insight into actual weight)
method: restriction
signs/symptoms: malnourished (hypothyroid but thin - lanugo, amenorrhea, cold intolerance, emaciated)
hospitalizations: when anorexia is extreme (BMI < 16)
treatment:
inpatient: force feeds, IV fluids
outpatient: antipsychotics (1st line), + CBT
f/u: OCD, MDD -> SSRI/SNRI
bodyweight, self-image, anxiety, method, signs/symptoms, hospitalization, treatment, f/u for bulimia nervosa?
body weight: normal
self-image: decreased
anxiety: binge (insight into this being bad/shameful, so they purge)
method: binge -> purge
signs/symptoms: normal patient (signs of emesis/laxative purging)
hospitalizations: very rarely requires
treatment: SSRI/SNRI + CBT
f/u: NEVER use buproprion (increased risk of seizure)
What is the difference between binge eating disorder and bulimia nervosa?
binge eating disorder - +binging, negative purging, +obesity
What are the cluster A personality disorders?
paranoid, schizoid, schizotypal
What are the cluster B personality disorders?
borderline, histrionic, narcissistic, anti-social
What are the cluster C personality disorders?
avoidant, dependent, obsessive-compulsive
Diagnostic criteria of dissociative identity disorder
> /= 2 distinct identity states
What will you see in the patient vs others in dissociative identity disorder?
patient: memory gaps/blackout, severe trauma history, other dissociative symptoms
others: paradoxical behaviors (women having changes in sexual preferences and drug use), can see appearance change
Look for another psych diagnosis
What is the difference between depersonalization and derealization?
depersonalization - from the body (out-of-body, deja-vu)
derealization - from environment (experiencing things as if in a dream)
Look for intact reality testing (not psychotic); usually occur in a nonsevere trauma to an adolescent
What is the diagnostic criteria for catatonia?
> /= 3 of the following symptoms:
1A. stupor
2A. cata-lepsy (able to put patient in whatever position you want)
3A. waxy flexibility
4A. negativism
5A. mutism
1B. stereotypy (same movement over and over again)
2B. agitation/grimace
3B. echolalia/echopraxia (copy what you say/do)
A = retarded/decreased symptoms
B = excited/increased symptoms
How do you clinically diagnose catatonia? What are risks to watch out for with this diagnosis?
diagnostic criteria + if you give lorazepam and it goes away
At risk for malnutrition (monitor with albumin), DVT (use LMWH/compression devices), rhabdomyolysis -> renal failure (check CK)
precipitant and symptoms of malignant catatonia?
precipitant: will have a psychiatric disease, but no medication caused it
symptoms: rigidity (lead pipe rigidity -> muscle breakdown -> elevated CK; resistance to movement) + dysfunctional autonomic nervous system (increased HR, BP, temp)
precipitant and symptoms of neuroeplileptic malignant syndrome?
precipitant: psychiatric illness; antipsychotic medication
symptoms: rigidity (lead pipe rigidity -> muscle breakdown -> elevated CK; resistance to movement) + dysfunctional autonomic nervous system (increased HR, BP, temp)
precipitant and symptoms of serotonin syndrome?
precipitant: psychiatric illness; treated with SSRIs
symptoms: rigidity + dysfunctional autonomic nervous system
precipitant and symptoms of malignant hyperthermia?
precipitant: halothane gas, no psych disorder
symptoms: family hx of reaction to anesthesia, rigidity + dysfunctional autonomic nervous system
Grade and function of a child with IQ > 70?
grade n/a
live, work, ADLs independently
Grade and function of a child with IQ 50-70?
6th grade
work and ADLs, live with someone/group home
Grade and function of a child with IQ 35-49?
3rd grade
ADLs (cannot work/live independently)
Grade and function of a child with IQ 20-34?
pre-school
need help with ADLs
Aspects of impaired social communication in autism spectrum disorder?
impaired in:
- social reciprocity
- social relationships
- nonverbal communication
- joint attending
Aspects of restricted/repetitive behavior in autism spectrum disorder?
- stereotyping (repeating actions - stacking objects, lining objects up)
- sameness (sticking to strict routine)
- restricted interests (fixation)
- change in sensory perception
Diagnostic criteria for diagnosing ADHD
Must have impulsivity and inattention symptoms
Must have symptoms in >/= 2 settings
Onset of symptoms age 7-12
Duration: >/= 6 months
Treatment of ADHD?
Stimulants - methylphenidate or amphetamine salts
Special education
Train parents on how to handle the children
R/o absence seizures (treat with carbamazepine)
Tic Disorders: association, presentation, diagnosis
association: OCD, ADHD
presentation: physical or vocal tic (not usually words, never swearing)
diagnosis: before age 18 with duration > 1 year
What is the treatment of tic disorders?
D2 antagonists (antipsychotics - usually low potency, including aripiprazole) Cognitive behavioral therapy
Eneuresis cause/treatment < 7 yo and never dry
< 7 and never dry -> normal, train them
Treatment: positive reinforcement, water restriction, alarm blankets, can use DDAVP (vasopressin), but that is probably the wrong answer on the test
Eneuresis workup in a child who was previously dry
get a UA and ultrasound ->
If + UA and - ultrasound: infection, common in girls as they begin to toilet train (Abx and correct behavior)
If - UA and + ultrasound -> anatomical defect (surgery)
If - UA and - ultrasound -> regression (new sibling, new place -> normal, think about abuse if no precipitating cause)
What is the difference between conduct disorder and oppositional defiant disorder?
conduct disorder harms peers and fights authority (criminal behavior)
oppositional defiant disorder gets along with peers but fights authority (acting out)
What do you expect to see in a child with conduct disorder? What is the treatment?
bullying (hurt animals, use torture/cruelty, force sex), destruction (fires, lying, cheating, stealing), violation of rules (truancy, running away >/= 2 times, defiant behavior)
Tx: juvenile detention
What do you expect to see in a child with oppositional defiant disorder? What is the usual cause of this?
cause: incongruent parenting
Expect: no bullying, no harming animals, no cruelty/torture, + lying, cheating, and stealing, + defiance
What is the treatment for oppositional defiant disorder?
teach the parents how to parent (unifying front)
What are the SSRIs? What are the common side effects?
(es)citalopram, fluoxetine, paroxetine, sertraline
side effects: sexual dysfunction, including decreased libido and prolonged ejaculation
What are the SNRIs? What are the benefits to using these over SSRIs?
(des)venlafaxine, duloxetine
tend to be better and cleaner, but more expensive
What is a positive side effect of buproprion? When is it contraindicated?
Good with: helping patients quit smoking without causing weight gain, no sexual dysfunction side effects
Contraindicated: in bulimia patients because it decreases the seizure threshold
What are the serotonin modulators? What are the side effects/alternate uses?
mirtazapine, trazodone
Trazodone causes excessive sleepiness, can be used as a sleep aid; can cause priapism
Mirtazapine - appetite stimulant
What are the tricyclic antidepressants? What are they useful to treat? What are the side effects?
“-triptyline”, imipramine, donepin
Not used to treat depression; can treat eneuresis in children, neuropathic pain (diabetic neuropathy)
Side effects: “3 C’s” - convulsions, cardiac toxicity, coma
What are the MAOIs? When are they used?
selegiline, phenylzine
Not used to treat depression
Can be used in hypertensive emergency, especially when the patient drinks wine or eats cheese
Which classes of antidepressants are not used for treating depression anymore?
TCAs and MAOIs
What is the rule of 6’s for antidepressants?
>/= 6 weeks at dose >/= 6 months at effective dose >/= 6 weeks of washout
What is lithium used to treat? What are the side effects?
One of the first line medications for treatment of mania
Side effects: teratogen, narrow therapeutic index, nephrotoxic, nephrogenic diabetes insipidus
What is valproate used to treat? What are the side effects?
One of the first line medications for treatment of mania
Side effects: spina bifida, pancreatitis, decreased platelets, agranulocytosis
What is quetiapine used for? What are the side effects?
2nd line treatment for mania
Side effects: eight gain, QTc -> EKG, somnolence
What is lamotrigine used for? What are the side effects?
2nd line treatment for mania
Generally safe side effect profile
What is carbamazepine used for? What else can it treat?
3rd line going forward; historically a 2nd line treatment
Used for treatment of trigeminal neuralgia and absence seizures in children
What are the short-acting benzodiazepines?
lorazepam and alprazolam
What is the treatment for benzodiazepine withdrawal?
diazepam, chlordiazepoxide
What are psychotic positive symptoms regulated by? (area of brain)
mesolimbic D2C-R (dopamine)
What are psychotic negative symptoms regulated by? (NT)
5HT3 (serotonin)
Typical (FGA) Antipsychotics MOA, side effect
MOA: mesolimbic, D2-C-R antagonists
Side effects: increased potency = increased extrapyramidal symptoms
Names of typical antipsychotics
Potent: - haloperidol - fluphenazine Less potent: - thioridazine - chlorpromazine
Atypical antipsychotics (SGA) MOA and side effects
D2C-Receptor antagonists AND 5HT3-receptor antagonists
Side effects: less extrapyramidal symptoms than FGA
Names of atypical antipsychotics with respective side effect
Most common: Quetiapine - somnolence (can be used to treat insomnia & bipolar mania) Olanzapine - metabolic syndrome Risperidone - extrapyramidal symptoms Less common: Aripiprazole Ziprasidone
ALL: have problems with QTc prolongation and ACh side effects
Clozapine - why is it not used regularly? side effect? how to get on it?
agranulocytosis; can get diagnosed if have failed 2 other antipsychotics (best one but last resort)
What type of antipsychotic would you use for a normal, compliant patient?
atypical (SGA) antipsychotic PO
What type of antipsychotic would you use for an agitated patient in the ER?
IM olanzapine or haloperidol
What type of antipsychotic would you use for a patient with dysphagia?
oral dissolving tablets - olanzapine and risperidone
What type of antipsychotic would you use for a chronically noncompliant patient?
depot form - olanzapine and risperidone
Extra pyramidal symptoms (4)
Akasthesia - feeling of restlessness (treat by decreasing dose, beta blocker, or anti-ACh meds ((benztropine/diphenhydramine)))
Acute dystonia - contraction of major muscle group - oculogyric crisis or torticollis (treat with Anti-ACh meds as above)
Dyskinesia - bradykinesia/Parkinsonism (treat with anti-ACh)
Tardive dyskinesia - chronic, life-long; grimacing, jaw-moving, tongue-moving (nothing to do for it) (usually on medication for 6 months before getting it)
What does the CRAFFT mnemonic mean?
used for a substance abuse screening for adolescents.
C- car (using while driving)
R - relax (using to relax)
A - alone (using alone)
F - friends (losing friends over using)
F - forget (forget stuff you’ve done while losing)
T - trouble
Stages of change
- pre-contemplative - denial
- contemplative - accepted problem
- preparation - first steps (thinking, etc)
- action - behavior change
- maintenance - sustain behaviors
Who is at a higher risk of alcohol addiction?
male > females 3:1; native Americans and alaskan natives
What are signs of acute alcohol or benzodiazepine withdrawal?
diastolic HTN, tachycardia tremor diaphoresis agitation confusion (delirium tremens) seizure
What is the treatment for acute alcohol/benzodiazepine withdrawal?
benzo taper (chlordiazepoxide, diazepam) + rapid-acting benzos as needed (alprazolam, lorazepam)
What substance is this describing intoxication of?
slurred speech, disinhibition, ataxia, blackouts, memory loss, impaired judgement
alcohol intoxication
What substance is this describing withdrawal of?
tremor, tachycardia, HTN, seizures, psychosis
alcohol OR benzodiazepine withdrawal
What substance is this describing intoxication of?
delirium in elderly, respiratory depression and coma (with increased dose), amnesia
benzodiazepine intoxication
What substance is this describing intoxication of?
euphoria, pupil constriction, respiratory depression, and potential tract marks
opiate intoxication
What substance is this describing withdrawal of?
yawning, lacrimation, N/V, hurting everywhere, sweating
opiate withdrawal
What substance is this describing intoxication of?
psychomotor agitation, HTN, tachycardia, dilated pupils, psychosis, angina/HTN crisis
cocaine intoxication
What substance is this describing withdrawal of?
depression, suicidality
cocaine withdrawal - also “cocaine bugs”
What drug/antidote to give for a cocaine withdrawal?
supportive care or benzos; alpha blocker then beta blocker
What substance is this describing intoxication of?
overheat (fever, tachycardia) and water intoxication, pupillary dilation, psychosis
MDMA intoxication
What substance is this describing intoxication of?
aggressive psychosis, vertical horizontal nystagmus, impossible strength, blunted senses
PCP intoxication
What substance is this describing withdrawal of?
severe random violence
MDMA withdrawal
What substance is this describing intoxication of?
rarely seen, hallucinations, flashbacks, heightened senses
LSD intoxication
What substance is this describing withdrawal of?
flashbacks
LSD withdrawal
What substance is this describing intoxication of?
tired, slowed reflexes, conjunctivitis, the munchies, overdose brings paranoia
marijuana intoxication
What substance is this describing intoxication of?
tachycardia, HTN, pressured speech, flight of ideas
amphetamine intoxication
What EEG changes do you expect to see in stage I of sleep?
theta waves, absent alpha waves
What EEG changes do you expect to see in stage II of sleep?
K-complexes and sleep spindles
What EEG changes do you expect to see in stage III of sleep?
delta
What EEG changes do you expect to see in REM sleep?
beta waves
What is sleep latency? In what conditions is sleep latency affected?
sleep latency is time from bed -> stage I of sleep
Increased in insomnia
decreased in sleep deprivation (OSA and alcohol)
What is REM latency? In what conditions is REM latency affected?
REM latency is time from stage I -> REM (usually 40 minutes)
decreased in narcolepsy
decreased in sleep deprivation (OSA and alcohol)
What is REM rebound?
The amount of REM you get significantly increases when you deprive the body of REM sleep
What affect do the neurotransmitters serotonin, ACh, norepinephrine, and dopamine have on sleep? (NT specifically, not necessarily medications)
increase serotonin -> increase sleep
increase ACh -> increase dreaming
increase norepinephrine -> increased arousal/awakeness
increase dopamine -> increased arousal/awakeness
What effects does GABA have on sleep? How can GABA be stimulated?
GABA -> decrease sleep latency, decrease NREM stage III
GABA is stimulated by alcohol, nonspecific benzodiazepines, and newer benzodiazepines type 1 (zolpidem)
Nightmares - stage, characteristics, age, treatment
will be in REM, no tone, easy to wake up, will remember, any age, no treatment (try to reduce stressors causing nightmares) (alcohol and benzos might decrease this, but SHOULD NOT BE USED)
Night terrors - stage, characteristics, age, treatment
NREM Stage III, has tone, appear awake to others, does not remember, parents will complain about this in their child, no treatment (reassurance, it will go away)
Obstructive Sleep Apnea cause, presentation/patient, diagnosis, treatment
Cause: excess tissue/fat -> obstructs airway
Pt: daytime somnolence, obese, snoring, large tongue, short neck
Dx: polysomnography -> looking for >/= 15 apneas/hr or five or more apneas + snoring
Tx: CPAP = PEEP, lose weight if due to obesity
Central Sleep Apnea cause, diagnosis, treatment
Cause: respiratory drive forgets to breathe -> CO2 accumulation; can be caused by opiates, over oxygenation in COPD, stroke, idiopathic (most common)
Dx: polysomnography
Tx: BiLevel or BiPAP
Narcolepsy cause, patient/presentation, diagnosis, treatment
Cause: startle -> rapid REM and loss of tone
Pt: decreased sleep latency, 3x/week for 3 months, wake refreshed, cataplexy (could wake up paralyzed), hypnogogic and hypnopompic (hallucinations while going to sleep and waking from sleep, respectively)
Dx: polysomnography
Tx: lifestyle modification (teach to take scheduled naps), can treat with stimulants
Insomnia
Path: trouble sleeping (falling asleep and staying asleep)
Dx: 3x/week for 3 months
Ask - sleep duration (>6 hours -> normal sleep or jet lag) -> reorient or use phototherapy
(<6 hours -> could have insomnia)
Ask - sleep hygiene (if good -> primary insomnia)
Tx: diphenhydramine, trazodone (SSRI), quetiapine, BZD1 (zolpidem)
What would you tell someone when advising on sleep hygiene?
To Do: use bed only for sex and sleep, lights off
Avoid: stimulants (caffeine, amphetamines, etc), avoid exercise and alcohol
What are the criteria for diagnosis of gender dysphoria?
identity is not congruent with assignment AND it causes distress; duration must be > 6 months
Needs one:
- Identity not congruent with assignment
- Desire to be or be treated like the opposite sex
- Desire to be rid of secondary sex characteristics (and be asexual)
- Believes they are the opposite sex
What is the treatment for gender dysphoria?
psychotherapy (in order to obtain gender reassignment surgery)
What do you expect to find in a patient’s history who has a somatiform disorder?
multiple doctors, many tests, anxiety disorder or major depressive disorder, multiple surgeries
What should be ruled out prior to a diagnosis of somatiform disorder?
r/o organic causes
r/o factitious disorder
r/o malingering
What is the treatment for somatiform disorder?
psychotherapy
having ONE physician that controls boundaries, number of visits, tests ordered, etc.
illness anxiety disorder symptoms, preoccupation, motivation
symptoms: NONE
preoccupation: acquiring illness despite reassurance
motivation: absolutely unwanted
symptom somatic disorder
symptoms: pain or fatigue
preoccupation: somatic symptom +/- real medical dx (but complaint will be disproportionate to diagnosis)
motivation: unwanted
conversion disorder
symptoms: neurologic complaint or life stressor
preoccupation: NONE; won’t harm self (gets paralyzed when something terrible happens but won’t trip and fall down the stairs while paralyzed)
motivation: unwanted
factitious disorder
symptoms: ANY
preoccupation: to achieve attention or fulfill a role
motivation: intentionally deceive
malingerring
symptoms: ANY
preoccupation: secondary gain (money, insurance, freedom)
motivation: intentionally deceive
What neurotransmitter can be decreased with deep breathing techniques to aid in nightmares?
norepinephrine (modulates flight or fight) - deep breathing stimulates the vagus nerve, thus stimulating parasympathetic activity
Is sublimation a mature, immature, or neurotic defense mechanism? What is it?
mature; patient channels displeasing impulses and desires into constructive and positive actions
Ex: a man who likes cutting and blood becomes a butcher at a local store
Is suppression a mature, immature, or neurotic defense mechanism? What is it?
mature; a patient recognizes an uncomfortable situation, but consciously or semiconsciously minimizes thoughts of the stressor by trying to ignore it or temporarily postpone it.
Ex: a mother tries to ignore her fear of flying so she can travel to see her daughter get married
Is displacement a mature, immature, or neurotic defense mechanism? What is it?
neurotic; patient substitutes the real stressor for one which is less threatening. Problematic feelings are transferred from her ear target to a harmless victim or inanimate object.
Ex: A man who is angry at his therapist for confronting him about a maladaptive behavior returns home and yells at his wife.
Is intellectualization a mature, immature, or neurotic defense mechanism? What is it?
neurotic; patient avoids the emotional consequences of the stressor by focusing on the intellectual and inanimate details of the stressor.
Ex: A woman who fears that she may have colon cancer spends her time researching new treatments rather than maximizing her time with her family and friends.
Is rationalization a mature, immature, or neurotic defense mechanism? What is it?
neurotic; involves the patient excusing or justifying an attitude or event by developing an alternate explanation or shifting the blame.
Ex: a man who is driving above the speed limit crashes his car into the one adjacent to his on the highway - he blames the accident on the other driver for not paying attention
Is reaction formation a mature, immature, or neurotic defense mechanism? What is it?
neurotic; reaction formation occurs when an unacceptable impulse is turned into its opposite.
Ex: a person who dislikes someone acts overly friendly toward them to hide their true feelings
Is acting out a mature, immature, or neurotic defense mechanism? What is it?
immature; patient expresses an unconscious thought or feeling through an impulsive action (allows them to avoid the anxiety caused by acknowledging the thought or feeling)
Ex: a woman who is angry and frustrated because she may have cancer goes out drinking and starts spending money excessively
Is projection a mature, immature, or neurotic defense mechanism? What is it?
immature; patient takes his or her own feelings and switches ownership of those thoughts to another. (thinks what he/she secretly feels is what another person is feeling).
Ex: a woman resents her younger sister, so, instead she accuses her younger sister of resenting her.
What psychiatric symptoms do you expect to see in serotonin discontinuation syndrome?
anxiety, agitation, irritable mood, insomnia, nightmares, poor concentration
What neurologic symptoms do you expect to see in serotonin discontinuation syndrome?
headache/migraines, dizziness/lightheadedness, vertigo, weakness, tremor, ataxia, paresthesias, “rushing” sensations in head, “electric-shock” sensations in head
What somatic symptoms do you expect to see in serotonin discontinuation syndrome?
flu-like symptoms (fatigue, malaise, myalgia), GI distress (nausea, vomiting, diarrhea, abdominal pain)
What is the action of buprenorphine and what is it used for?
partial agonist at opioid receptors; it is commonly used as maintenance therapy to prevent opioid withdrawal
In a bulimia nervosa patient, you expect to see decreased potassium, elevated BUN, normal creatinine, and elevation of what enzyme?
salivary amylase due to repetitive parotid gland stimulation
In conversion disorder, does the patient have psychological distress about their illness, yes or no?
no, conversion disorder is characterized by loss or alteration of physical function that may resemble somatic illness, but it caused by underlying psychopathology. It often occurs after a significant psychological stressor and develops suddenly. A key factor is an absence of psychological distress int he presence of a significant complaint
What is a specific phobia? How is it different than agoraphobia?
A specific phobia involves a fear of any specific situation that cannot be account for by any other diagnosis, including agoraphobia, social phobia, OCD, or separation anxiety disorder.
What is psychoanalysis?
intensive form of therapy based on the concept that psychopathology is a result of repressed and unconscious feelings (regression, transference, free association, identifying and challenging defense mechanisms, and interpretation of unconscious drives and thoughts)
What are the symptoms of MDMA intoxication? How is it treated?
MDMA = an amphetamine; intoxication - first euphoria, friendliness, and feelings of love -> then mood disorder, most often with manic or mixed features -> then seizures, autonomic hyperactivity, and agitation; prevention of seizures and autonomic hyperactivity is mediated by benzodiazepines (lorazepam or diazepam)
What is the treatment for catatonia?
benzodiazepines, primarily lorazepam
What is the MOA of memantine? When is it used?
NMDA receptor antagonist (prevents gluatamate-associated neurotoxicity); approved for the treatment of Alzheimer’s dementia either alone or in combo with cholinesterase inhibitors
What is the MOA of galantamine, rivastigmine, and donepezil?
cholinesterase inhibitors (not to be used in combo with one another)
What does anticholinergic toxicity look like?
delirium, fever, tachycardia, flushing, dry mucous membranes, and constipation
What is a side effect of lamotrigine?
sevens-johnson syndrome
What is a side effect of topiramate?
cognitive suppression and sedation
What are some side effects of valproic acid?
sedation, hepatotoxicity, teratogenesis, weight gain, hair loss
What is a side effect of levetiracetam?
nonspecific psychiatric adverse effects (can exacerbate depression, anxiety, irritability, and psychosis)
How does neurosyphilis present? How do you check for it?
dementia, pupillary changes, ataxia, urinary incontinence, and impaired peripheral vibratory and proprioceptive sensation; check rapid plasma reagin
What type of epilepsy can be confused with schizophrenia?
temporal lobe epilepsy (particularly complex partial seizures due to involvement of the hippocampus)
What is an example of acute dystonia?
torticollis
What is an example of akathisia?
restless leg syndrome
What movements will you commonly see with tardive dyskinesia?
repeated grimacing, grunting, or other muscle movements (repeated hand movements)
Is altruism a mature, immature, or neurotic defense mechanism? What is it?
mature; the patient “lives vicariously” through helping others.
Ex: a rich banker who once dreamt of becoming a painter now gives money to struggling artists
Is humor a mature, immature, or neurotic defense mechanism? What is it?
mature; patient uses comedy to acknowledge and express feelings about the stressful situation.
Ex: an obese man who has a MI jokes that he needs to join a TV show in which he would be forced to lose weight.
Is denial a mature, immature, or neurotic defense mechanism? What is it?
immature; patient refuses to accept, and fully rejects, an aspect of reality.
Ex: a man who has a MI states that the lab tests are incorrect and he simply has indigestion.
What psychiatric symptoms can those with multiple sclerosis present with?
depression, anxiety, bipolar disorder
specific phobias are described by the patient as being excessive and unreasonable. True or false?
true
What are the four side effects of lithium?
- fine tremor (Tx with propranolol)
- hypothyroidism (Tx with levothyroxine)
- diabetes insipidus (stop medication or amiloride)
- direct nephrotoxicity
What are the five side effects of carbamazepine?
- hyponatremia secondary to SIADH
- agranulocytosis
- Stevens-Johnson syndrome
- neural tube defects in developing fetuses
- cytochrome P450 induction
What are the two side effects specific to olanzapine?
weight gain and metabolic syndrome
What are the 4 side effects of valproid acid?
- weight gain
- hepatotoxicity
- thrombocytopenia
- neural tube defects
What neurotransmitter is affected in ADHD?
norepinephrine (tx with stimulants, norepinephrine reuptake inhibitors)
What neurotransmitters are affected in major depression?
serotonin, norepinephrine, dopamine (treat with SSRIs, SNRIs, and NDRIs)
What neurotransmitter is affected in mania?
dopamine (Tx with antipsychotics)
What neurotransmitter is affected in schizophrenia?
dopamine (Tx with antipsychotics)
What neurotransmitter is affected in OCD?
serotonin (Tx with SSRIs)
What neurotransmitters are affected in anxiety disorders?
serotonin (SSRIs), GABA (benzodiazepines)
What does the prodromal phase of schizophrenia consist of and how long does it last?
prodromal phase of schizophrenia usually lasts for several months before development of psychotic symptoms; characterized by social isolation, decreased speech, decreased motivation, poor interest in activities, and blunting of affect
patient swill describe at least 3 months of chronic diffuse muscle pain that varies in severity and location, but is constantly present in some area of the body - what is it?
fibromyalgia
What other symptoms/disorders is fibromyalgia associated with?
fatigue, sleep disturbance, other features of major depressive disorder
What is the treatment for fibromyalgia?
TCAs (amitriptyline, nortriptyline)
What is the difference between major depressive disorder with atypical features and typical features?
physical symptoms are more prominent than psychological symptoms in atypical vs typical MDD (particularly increased sleep and increased appetite)
Two of the following four symptoms must be exhibited: increased sleep, increased appetite, hypersensitivity to psychosocial rejection, and leaden paralysis
What is the treatment for major depressive disorder with atypical features?
first line is still SSRIs, but MAOIs are particularly effective
What drug is commonly known for causing cognitive suppression?
topiramate (dose-dependent impairments in memory, executive function, psychomotor activity, and speech fluency)
What are the two biggest symptoms/complaints with separation anxiety disorder?
children develop severe anxiety or somatic symptoms when forced to go to school or separate from their parents for any reason; stomachaches are the most common manifestation of the somatic complaints. Child often sleeps with their parents
What is known to be a poor prognostic factor in patients with schizophrenia?
presence of negative symptoms (blunted affect, poor motivation, apathy, social withdrawal, decreased speech, and poverty of speech or thought)
Is controlling a mature, immature, or neurotic defense mechanism? What is it?
neurotic; patient manages the external environment instead of addressing the actual stressor.
Ex: a single father insists that his children line up for inspection three times a day to ensure perfection in the home.
Is repression a mature, immature, or neurotic defense mechanism? What is it?
neurotic; patient unconsciously blocking and avoiding awareness of the stressor.
Ex: a woman forgets that she called her boyfriend three times earlier in the day
Is regression a mature, immature, or neurotic defense mechanism? What is it?
immature; patient reverts to an earlier developmental state, often with childlike behaviors and emotions.
Ex: a woman throws a temper tantrum when confronted with an uncomfortable idea
What are the general rules regarding antipsychotics and pregnancy?
- maintenance of therapy, even if teratogenic (a relapse of psychotic symptoms would be worse for baby)
- if starting a new medication, lamotrigine is 1st line.
- If starting a new medication, risperidone and quetiapine are second-line
Is anticipation a mature, immature, or neurotic defense mechanism? What is it?
mature; addressing a future concern by preparing for it in an appropriate manner.
Ex: A person who is concerned about a future nuclear attack prepares by purchasing a family bomb shelter
Is undoing a mature, immature, or neurotic defense mechanism? What is it?
neurotic; addressing an unacceptable thought or behavior by attempting to do the opposite.
Ex: a cigarette company executive donates money to lung cancer research
What is Cotard syndrome?
the delusional belief that the individual’s own body or body parts are dead or dying (can expand to include the belief the world is also dead or unreal). Acutely, it is most likely seen in schizophrenia or severe depressive episode. Chronically, associated with Alzheimer’s.
What is Capgras syndrome?
delusion that a familiar person/relative has been replaced by an imposter who shares the same appearance. Commonly associated with schizophrenia but can be a sign of dementia, head trauma, malignancy
What is delusional disorder?
at least 1 month of non-bizarre delusions that do not significantly impair daily functioning.
What is Fregoli syndrome?
belief that several different people/strangers are actually one person, usually a familiar individual or persecutor, who is in disguise or can change his/her appearance
Which benzodiazepines are safe to use in a patient with advanced liver disease to treat delirium tremens?
lorazepam and oxazepam (in healthy patients, diazepam and chlordiazepoxide are the drugs of choice)
What is the cognitive triad of depression?
States that depression is characterized by:
- negative views about oneself
- negative views about the world
- expectation of future failure
Which antipsychotics are best for treating delirium?
high-potency: haloperidol (preferred), fluphenazine, risperidone, paliperidone, ziprasidone, aripiprazole
What is first line treatment for neuroleptic malignant syndrome?
benzodiazepines, bromocriptine (direct dopamine agonist), or dantrolene
What is the treatment for serotonin syndrome?
benzodiazepines or cyproheptadine
What is the antidote for TCA toxicity?
sodium bicarbonate
What is an effective treatment for pain disorder with depressed mood?
duloxetine (and other SNRIs)
