PSYCH EOR Flashcards
what is somatic symptom
disorder
tx
> 1 unexplained somatic sx that is distressing to the pt or leads to significant amt of disruption in life and ongoing for >6MO
In response to the sx the pt starts to have excessive thoughts, feelings and behaviors in relation to their somatic sx
tx
-after tx initiated etc
-group therapy and hypnosis
-biofeedback therapy
-social support
define conversion disorder
neuro symptoms incompatible with anatomy or pathophysiology
**Pt is not attempting to decieve—- they are concerned with real sx
what is factitious disoder
tx
IMPOSED ON SELF= MUNCHAUSEN SYNDROME
falsification of sx/inducing injury in the abscence of obvoious external rewards (this differnetiates it from malingering)
they will deceptively produce sx of a medical or psych illness or induce injury to obtain attention and get care
EX
*manipulating lab samples
*ingesting substance–insulin
*altering medical records
*inudincg illness (fecal matter into a cut to produce abscess
doing this to someone else is called FACTICIOUS DISORDER IMPOSED ON ANOTHER or MAUNCHAUSEN SYNDROME BY PROXY
tx
-conjoint confrontation by PCP and psychiatrist
-overt disclosure using tehrapy like biofeedback, self hypnosis, double blind therapy
-mauchinhousin by proxy—– child must be removed and sent to CPS
clozapine
atypical antidepressant for BP 1
olanzapine
atypical antidepressant for BP 1
risperidone
atypical antidepressant for BP 1
quetiapine
atypical antidepressant for BP 1
ziprasidone
atypical antidepressant for BP 1
gabapentin
mood stabilizers for mania
carbamazepine
mood stabilizer for mania
topiramate
mood stabilizer for mania
lithium
mood stabilizer for mania
tx for acute mania
**lithium
valproate
SGA—- olanzapine, aripirazole, carbamazepine
tx for mania maintenance
SGA
gabapentin
lamotrigine
if BP pt is acutely aggitated what is tx
haldol, risperidone or benzos
diff b/w manic and hypomanic episdoes
HYPO= does not cause impairment, no psychotic sx, and impulsivity is present
what to check before ptting pt on lithium
creatinine
lithium in pregnancy can cause?
hypothyroidism and Epstein’s anomaly (tricuspid valve issue)
BP patient who has renal dysfcuntio— what is a good drug for them?
valproate or carbamazepine
first line of tx for pregnant pt with BP
haloperiodl
mood disorder thats episodes of depression and hypomania for at least 2 years
cyclothymic disorder
less intense and often longer lasting version of BP
time line to dx cyclothymic disorder
ADULTS— 2 yers
KIDS–1 yr
*numerous periods of hypomanic sx that dont meet crteria for hypomanic episode
*numerous episodes of depressive sx that dont meet criteria for MDD
*have not been without sx for more than 2 mo at a time
tx for cyclothymic disorder
*lithium
*valproate and carbamazepine alternatives to lithium
psychotherapy
what do you need to r/o in someone showing sx of MDD
hypothryoid, addisons, cushings
fluoxetine
ssri
paroxetine
ssri
sertraline
ssri
fluvoxamine
ssri
citalopram
ssri
escitalopram
ssri
venlafaxine
ssnri
duloextine
ssnri
bupoprion
atypical antidep
nefazodone
atypcal antidep
mirtazapine
atypical antidep
trazadone
atypical antidep
amitrptiline
TCA
nortriptyline
TAC
desipramine
TCA
clomipramine
TCA
doxepin
TCA
protriptyline
tca
clmipramine
tca
imipramien
tca
pheneziine
MAOI
tranylcyproamien
MAOI
Persistent depressive disorder
-dx
-tx
*at least 2 yrs
*less acute and severe than MDD
**more chronic than MDD
TX
ssri
*fluoxetine
*paroxetine
*sertraline
*fluvoxamine
what to r/o to dx GAD
substance abuse
thyroid dysfunction
ETOH withdrawl
GAD tx
SSRI— paroxetine and escitalopram but take weeks to work
Buspirone—- low dose—- can also take 2 weeks to work and can be adjunct to SSRI
SNRIs—venlafaxine
Benzos— not long term tx but used interium until SSRI kick in
how to dx panic attacks
tx
three panic attack episodes in 3 weeks
tx
1st for long term tx–> SSRI–>paroxetine, Sertraline, Fluoxetine
BEzos for acute attacks
CBT
tx for specific phobias
tx for agoraphobia
1st line=exposure therapy
then can do SSRI + CBT
short acting benzos like alprazolam before flying for ex
tx agoraphobia jsut like GAD with SSRI + CBT
tiimeline for PTSD
tx
> 1 month
<1 month is acute stress reaction
TX
*SSRI first line with CBT
-sertralie
-paroxetine
-fluxoetine
-venlafaxine
*nightmares—prazosin
*benzos—- not for long term use bc LT use can lead to exacerbtion of sx
*dont use benzos >2 weeks after traumatic event —-use alprazolam bc its shorter actig
illness anxiety disorder
-define
-tx
-worried about having or developing a serious illness
>6 MO
somatic sx NOT present and if present its very mild
TX
-improve coping skills
-dont dismiss fears
-group/insight oriented therapy
-regular appts with provider for reassurance
-SSRI if current/underlying anxiety or MDD
Korsakoff syndorme
extreme thiamine B1 deficiency from ETOH (MC), eating disorders, chronic malnutriiton
retrograde and anterograde amnesia
preserved LT Memory
confabulation (memory fabrication w/o intent to lie)
lack of insight
MC develops in PT with hx of Wernicke encephalopathy
non benzo anxiolytic for GAD
Buspirone
*does not cause sedation
MOA: partial serotonin recep agonist and dopamine rec antagonist
often used in combo with SSRI
SE
HA, n, dizziness, restless leg syndrome, EPS
mc type of social phobia
public speaking
tx for social anxiety disorder
1st psychotherapy—-esp exposure therapy
then can add SSRI (fluoxetine, sertraline), or SNRI (venlafaxine),
+/- adjunct use benzo
situational–>can give BB for performance anxiety and public speaking like propranolol or atenolol 30-60 mins b4 speech
list some drugs that have SE fo depression
OCP
corticosteroids
ETOH
BB
interferon
amphetamines
Tx for PHQ9 scores
5-9
10-14
15-19
20-27
5-9=mild–watchful waiting, psychotherapy +/-
10-14=moderate–psychoterhapy 1st line
15-19= moderately severe–psychoterapy +/- SSRI
20-27=severe–psychotherapy + SSRI +/- ECT
tx refractory, actively suicidal, pregnant or elderly depressed pt
can try ECT
what sx must be included to be considered MDD
depressive mood or anhedonia and 4 others
-fatigue most of the day
-insomnia or hypersomnia
-feelings of guilt or worthlessness
-recurring thoughts of death/suicide
-psychomotor agiation or retardation (restlessness or slownes)
-sig wt change
-decr or incr appetite
-decr concentration
NO MANI OR HYPOMANIA
MC time for serotonin syndrome to occur
within 24 hours (esp 6) of initiation or change in SSRI, SNRI, MAOI, Buspirone, Triptans or combo of these drugs + St johns wort, MDMA, cocaine, amphetamine
PE for serotonin syndrome
Cognitive: ams, confusion, agitation, hallucinations, hypomania
autonomic instability: hyperthermia, tachycardia, diaphoresis, BP changes
GI: N/V, incr bowel sounds, diarrhea
Neurmuscular Hyperactivity: spontaneous or inducible clonus, hypertonia (INCR DTR), tremor, akathasia (restlessness)
Mydriasis (dilated)
dry mucous mem
flushed skin
tx of serotonin syndrome
stop the drug
suppportive: oxygen, IVF, benzos (for agiation, to reduce hyperthermia and correct tachycardia and HTN)
MODERATE-SEVRE:
*above + Cyproheptadine (serotonin antagonist)
DO NOT USE ANTIPYRETIS they dont help with hyperthermia ****
what is dysthymia
sx
tx
long standing depression w/o other mental health disorders and substance use
sx last at least 2 years–bassically mDDbut >2 yrs
sx begin during adolescence
tx
1st: psycotehrapy
1st line pharmaco: SSRI
2nd line: SNRI, NRI, NDRI, atypic, etc
biggest RF for suicidal/homicidal
previous attempt
mc method for suicide? homicide?
suicide=drug ingestion
homicide=guns
RF age group for homicide/suicide
45-64
pharmaacotx options for suicide/homciide ideastion inpatient
antipsychotics MC
ECT for acute suicidail patients
premestrual dysphoric disoder
timeline
tx
must occur 1 yr
tx
1: life style mods– dietary changes (decr sugar, incr protein, avoid caffeien), avoid stressful acitities, exercise, CBT
2: moodd sx: SSRI 1st choice–>Fluoxetine, Sertraline, Paroxetine, Citalopram
3: PMS longterm relief: OCPs or Leuopride (GNRH agonist)
4: PMDD–> Drospirenone (progestin medication)
timeline for BP 1 and 2
strongest RF
requiremnet for dx?
what to r/o beofr dx with BP
1
>1 week with >3 manic s/s
***major depression not requried for dx
2
>4 days depression with >1 hypomanic episode
SX
MOOD: euphoria, irritable, labile or dysphoric
THINKING: racing, flight of ideas, diroganized, easuy distracted, expanisve or grandios, impaired judgement
BEHAVIOR: hyperactivity, pressured speech, decreased need for sleep, incr impulsivity, excessive involvement in pleasure activities
+/- psychotic sx: paranoia, delusions, hallucinations,
**only needs one manic or hypomanic episode
*major dpressive episodes NT requried for dx
strongest RF=fam hx
want to R/O
1. subtance abuse
2. thyroid disorder like hyper
3. environmental toxins
wht is cyclothymia
2 years of alternating hypomanic and depressive episodes
tx for BP 1 and 2
LITHIUM**** mood stabilizer 1st line
**lithium also decrs risk if==of suicide
antivonculsants (lamotrigine, valproate, carbamazepine)
2nd gen antipsychotics
*risperidone
(quetiapine
*olanzapine
always adjunct with pschotherapy
**antidepressant monotherpay can drive them into mania
ACUTE MANIA TX
*antipsychotics–risperidone or olanzapine > Haldol
OR
*mood stabilizer like lithium or valproic acid
can use ECT for refractory
lithium
-indications
-SE
-before starting get what
-how often to check levels
-pregnancy
-caution with concomitant use of what drugs
INDS
*BP
*Acute mania (mood stab)
*schizoaffective disorder
SE
*endocrine: hypothy, nephrogenic DI, hyperparathyroidism, hypercalcemia, hypermag, NA depletion, increase thirst,
*Neuro: seizures, tremors, HA, sedation
*GI: n/v/d, wt gain
*Cardio: arrythmisa
*Heme: leukocytosis
****NARROW INDEX
-before starting tx get: EKG, chems, thryoid, beta HCG, CBC,
**lithium levels initially checked in 5 days, then every 2-3 days until therapeutic, once therapeutic—check every 4-8 weeks.
TOXIC= >1.5
preg + lithium=ebstein’s anomaly during first tri, renal and cardaic disease
CAUTION w/ use of NSAIDS, thiazide diuretics, ACEI
define hypomania
UNDER 1 week of:
*abnormal and persistenyl eelevated, expanisve or irritable mood
does not require hosp, not assoc with marked impairment, not assoc with psychotic feartures,
**need at least 3 sx affecting mood, thinking and behavior (sx otherwise sim to mania)
PMDD sx occur in wht phase of cycle
luteal
autism PE findings
*deficit sharing of emotions or interests
restricted repetitie behaviors
**thrive on routine
***fixed interest in sacking blocks
inds for clonidine
adhd
opioid withdrawl
resistnet HTN
physostigmine
antidote for antichloinergic poisoning
indications for buprenorphine
*its partial opioid agonist
*symp tx of opioid withdrawl
*ongoing maintenance threapy for opioid disorder
NOT USED FOR ACUTE INTOXICATION
Flumazenil
-inds
-se
INDS
*benzo OD
*does not reverse resp effects of benzos
*SE is seizures
key neurotrans involvd with ADHD
norepi and dopmaine
1st gen antipsychotics
-inds
-moa
-se
all types of shizo
-psychotic ideations
-drug inuded psychosis
-depression
-acute mania
1st— pos sx– hallucinations and delusions
*Clorpromazine –sedation +orthostatic hypotension
*haldol–>EPS sybdrome very common
*thioridazine–>higher incidende of QTc»>, retinitis
*fluphenazine–>comes in LA IM formula
*trifluoperazine–
*thiothixene
*loxapine
*pimozide
SE
*EPS—tarditive dyskinesia, neuropleptic malignant syndrome
*sedation
*anticholinergic sx— mydriasis, dry mucous mems, constipation
*endocrine effects— incr prolactin causing galactorhea, sexual dysfuncion, weight gain
*cardiovasc– hpotension, QTc»_space;
second gen antipsychotics
-inds
-moa
-list some
-SE generally
+ and - sx of schizophrenia
more comonly used
1st line drugs due to metabolic adverse effects vs EPS sx seen with 1st gen
MOA
blocks central dopamine and serotonin recs
THE PINES
Asenapine
clozapine–mc causes metabolic syndorme and agranulocytosis ****
*Olanzapine—-mc cause metabolic syndrome
*Quetiapine
THE DONES
*risperidone
*ziprasidone
*Lurasidone
*Paliperidone
*Iloperidone
THE PIPS AND RIP
*Aripiprazole
*Brexpiprazole
*cariprazine
SE
*less EPS, TD, NMS but causes MORE Metabolic syndrome including higher risk for DM, weight gain and sexual dysfunction
*monitor pt with cbc, lipid panel and HbA1c
what can you give pt experieincing dystonia from antipsychotics
benadryl or cogentin
*prevents
*avoid
*reduce
what can you give pt experieicng parkinsoniansm from antisychtics drugs
amantadine or anticholinergics
what is MC EPS sx
akathisia—- subjective feeling of restlessness anxiety pacing or freuqent sitting/standing
what does akathisa respond to
BB and Benzos
BB 1st then try benzo
timing for when tardive dyskinesia can develop after starting antipsychotic
YEARS
what is neuroleptic malignant syndrome
patho
tx
medical emergnecy
muscle rigidity, tremors, feever, automonitc instability, diaphoresis, delirium,
**1st gen mc
patho: increased WBC, increase CPK and increase liver enzymes lead to muscle breakdown causing autonimic instability
tx
*responds to bromocriptine (dopamine agonist)
*Dantrolene sodium– muscle relaxant that inibits CA into sarcoplastic riticuluum
MOOD STABILIZERS
-list the MC one
-MOA
-SE
-how to monitor levels
LITHIUM=MC for BP1
MOA: stimulates NMDA receptor and increases glutamate at postsynaptic neuron
SE
*nausea
*tremor
*polyuria/DI
*hypothryoid
*cardiac aryhm
*weigth gaint
*thirst
*acne
*edema
*leukocytosis
*renally cleared— watch BUN/CR
*CBC
CMP
TSH
HCG– its teratogenic
*ECG
lithium levels— narrow index
Valproic acid
-idns
anticonvulsant
radpily cycling disorders b.w mania and depression
MOA
opens cl chanels— blocks sodium and increases GABA
SE
thrombocytopenia
pancreatitis
hari loss
weight gain
GI dysfunction
neural tube defects
***teratogenic
Carbamazepine
Anticonvulsant
MOA: inhibs firing via inactivating NA chanels–potent CYP450 inducer
SE
*n/v
*agranulocytosis
*incr LFT
*slurred speech
*drowsiness
Lamotrigene
MOA: selectively binds to NA and inhibs release of glutamte
SE:
RASH–SJS
hepatitis
N/V/D
sleep dissutrbances
Gabapentin
anticonvulsant
SE: fatigue wieght gain
which SSRI has lowest risk for SSRI discontinuation syndome
Fluoxetine bc has longest 1/2 life
which SSRI least likely to cause weight gain
Sertraline
which SSRI most asso with weight gain and cardiac abnormalities
Paroxetine
which SSRI to avoid in pt with long QT
Citalopram
SSRI + what meds put pt at risk for serotonin syndrome
SSRI +cough suppressants like Dextromethorphan
or SSRI + abotive mirgraine meds like Sumatriptan
sx for serotonin sx
tx
TRAID
1. AMS
2. Automotic instability
*diaphoresis
*shivering
*tachy
*hyperthermia
3. Neuromuscular abnormalitiy
*weakness
*hyper reflexia
*myoclonus
*incoodrination
*tremos
tx
*cyproheptadine— 5HT-2 antagonist
which SSRI most likely to cause SSRI discont syndrome
sx?
paroxetine and Sertraline
bc shortler half lives
SX
F–flu like symps
I—insonia
N—-nausea
I—imbalance
S–sensory disturbances
H—-hyperarousal
neurotrans that SNRI Affect
serotoni
norepi
dopamine
all indications for SNRI
depression –2nd line
chronic pain
which SNRI used for osteoarthritis, dm pain, fibromyalgia
Duloxetine
Venlafaxine
SNRI
Anxiety and Panic disorder
SE SNRI
similar to SSRI PLUS:
-htn
-dizziness
Atomoxetine
Straterra
-norepei reuptake inhibitor
ADHD
what med can you adjucnt with olanzapine to avoid weight gain
Reboxetine
Buproprion
-MOA
MOA=block NE and dopamine from being tranps back into the cells–causing greater number of NE and dopamine to be availeble overtime
ONLY NDRI FDA approved to tx depression,
-lowers seizurre threshold*
So why we dont give to bulemia pt and epilpetict pt
Amytripltine
-cass
-inds
TCA
***also used for migraine prophylaxis
DOxepine
TCA
mipramine
TCA
imipramine
TCA
Noretryptline
TCA
sipramine
TCA
moxapine
TCA
SE of TCA
toxic triad
1. carido –QRS»>torsades
2. convulsions
3. coma
TX of TCA OD
**will cause QRS»_space;» torsades
sodium bicarb
Phenelzine
MAOI
Selegiline
MAO-B
*less chance of HTN crisis
Tranylcypromine
MAOI
SE MAOI
Contras to giving MAOI
HTN Crisis with sympathomimetics or foods high in tyramine— aged cheese, wine, beer, smoked meat, coffee, tea, chocolate
*insomina
*anxiertty
(weight gain
*orthostasis
CONTRA
*MAOI + SSRI —-serotonin syndrome
*MAOI + TCA —-delirium and HTN
Trazadone
inds
SE
avoid in who
CIs
MC used for refractory depression
SE– priapism, vasodilation, sedation,
Avoid in sickle cell pt and multiple myeloma
CI with benzo use or barbituates
pt has hx of sexual dysfnction– which antidep to give
buprobion or mirtazapine
pt has dep + difficulty sleeping or poor appetite which antidep to give
mirtazipine or paroxetine
define at risk drinking M and W
M: 4 drinks/day or 14 drinks/week
W: 3/day or 7/wk
deinfe a drink
12 oz beer
8 oz malt liquir
1.3 oz spirits
5 oz wine
sx and tx for minor etoh withdrawl
trembling, anxiety, irritability, HA, tachycardia, insomnia
tx
*thiamine
*folate
*miltivit
*dextrose
*IVF
sx and tx for etoh hallucinosis
sx
-VA and sometimes tacticle hallucinations
tx
*benzo to avoid seizure
withdrawl seizure tx
Head ct
benzo tx
DTs
-timing
-sx
-tx
48-96 hrs after last drink
autonomic instability
disorientation
hallucinations
agiation
denzo
disulfiram
do not give to pt acitvely drinking
naltrexone PO
decreaes desire to drink
cant give to pt taking opioids
list two anticonvulsants that help with ETOH stop
topiramate
gabapentin
tx for Opioid withdrawl
withdrawl is NOT LIFE THREATENING
*clonidine— methadone—-buprenirphine + nalaxone (suboxone)—zofran for n/v
what to use for diarrhea assoc opioid withdrawl sx
Dicyclomine
tx for delusional disoder
atyical antipsychotics like olanzapine and risperidone
schizoaffective disorder
depressive, manic or hypomanic episode–precedes or occurs same time with dellusions and halucinations—-these must occur for at least 2 weeks in absence of mania/hypomania/depression
schizophrneia
-sx
dif b/w schizoprhenia, schizoaffective and schizophreniform
POS SX
*hallucinations
*delusions
*disorganized speech
NEG SX
*poor affect
*anhedonia
*asociality
need at least 2 sx need to last > 6MO and at least one of the sx must be *
*delusions
*hallucinations
*disorganized speech
-grosly disorganize or catatonic behavior
-negative sx—– diminshed emotional expression or avolition
**1-6 months is schizophreniform
*no social or occupational impariment
***<1 month is schizoaffective and MC in females
schizoid personality disorder
tx
isolation, restricted emotions secondary to neglect or trauma
detached, distant, carefree, dull, bland with lack of desire to form relationships,
tx
*1st social skills training
not very responsive to drugs
schiotypal personality disorder
disturbances in thoughts , mood or perception
no close friends
eccentric behavior, magical thoughts, odd beliefs, perception distortion
can function in soceity but struggle to maintain social relationships
can develop in schizophrenia
tx
CBT 1st
shot term and low dose atyical antischioptics
lack of remorse and emptahy
pervasive pattern of disregard for onseuenes and for the rights of tehrs
anti personality disorder
aka
sociopath
sx will typically begin in early childhood with conduct disorder (<15 YO )
borderline personality disorder
“borderline” on border b/w neurosis and pschosis
unstable personal relationships, poor impulse control (spending, sexual conduct, driving, eating, SU)
sometimes sucidial threats
cant be alone– will do anything to avoid abdanoment
very common to be occuring with other disorder: SUD, eating disorder, MDD, BP
tx
1st=psychoteraphy
2nd=ssri, risperidone or naltrxone if SUD
Narcissistic personality disorder
grandiose and require admiration from others
exagertion of their own talents or accomplishments
s
ense of entitlement
expotation ofo thers
lack of empathy
arrogant
LYING*****
tx
1st therapy
2nd ssri
OCD vs OCPD
OCD
*obsessions—>recurring intrusive thoughts that cause severe distress and impairment
*compulsions–performance or repeptitive actions or rituals in an atempt to neurtralize the obsessios
assoc with tourette’s disorder
EGO DYSTONIC— behaviors are inconsistent with own beliefs and attidues (makes this diff from OCPD)
TX
*CBT
*SSRI
*1st line TCA= clomipramine
OCPD:
*preocupied with perfectonism and control—- orderliness
*lack flexiblity and openess
*perfectionist
*egocentric
*indecisive
EGO-SYNTONIC–pt is not aware of their behavior causing issues
pharmaco tx for tourettes
1st line for modrate tics
– clonidine and guanfacine
rispiridone and haloperiold for neuroplectics
aripiprazole–peds
SSRI can be used in OCD sx
DBS severe or disabiling cases
pharmacotherapy for pediphilia
IM Medroxyprogesterone acetate
Leuoprolide is 2nd line
maintain testosterone levels in males in normal female range—– <62
sadism
has to be with a NON CONSENTING adult
sexual arousal from inflicting pain or suffering on another
sexual masochism
pt finds pleasure in being humiliated–bound beaten abused etc
Masochists hurt Me
Sadists hurt Someone else
voyeuristic disorder
sexual arousal by observing a non-consenting person naked or engaging in sexual acts
must be >18 for dx
mc disorder to result in arrests
Frotteuristic disorder
paraphilia where pt aroused by rubbing up on an unwilling individual
dx needs to tuch someone at leasrt 3 times
anorexia
INTENSE FEAR OF OBESITY DESPIRTE SLENDERNESS
two types
-restrictive
-binge/purging
hx of extreme wt loss methods
-diruetics
-laxative s
-amphetamiens
-emesis
cardiac arrhytmias
»> QT
elevated BUN, edema, acidosis, hypokalemia, hypochloremic alkalosis with vomiting, hyperaldosternonsim
