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)