Psych HY Flashcards by Stephanie Escobar

Indication for Haloperidol decanoates (Intra-muscular Depo formulation)

Medicine Non-adherence in Schizophrenia
(also for homeless or limited resourced pts due to med costs)

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ECT indications and primary complication.

Psych condition & hemodynamically unstable
*Acute Psych disorder needing an immediate fix
(ex: depressed, not eating and actively suicidal)

Complication → Amnesia (anterograde or retrograde) that self-resolves

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GABA based agents MOA and their OD tx:
*Barbiturates
*Benzos
*Z-Drugs (Zolpidem, Zaleplon, Ezopiclone) → no OD tx

Barbiturates ↑ opening duration of Gabba receptors
OD tx: Sodium Bicarb (alkalinizes urine)

Benzos ↑ opening frequency of Gabba receptors
OD tx: Flumazenil (Gabba antagonist)

Z-Drugs Gabba A receptor agonist

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Buspirone Use & MOA?

2nd line agent for GAD
Partial agonist at 5HT-1A (Seretonin) receptor

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Acute manic episode tx.

Anti-psychotic + Lithium

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Patient on a mood stabilizer that has to wake up 10x a night to urinate.
dx? ppx?

NDI s/t lithium
Amiloride, Triamterene

lithium enters ENAC channels (principal cell of collecting duct) → inhibit ADH function.
Prevent by blocking ENAC Channel w/ K+ sparing diuretics

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SSRI uses:
MDD, GAD, PTSD, OCD
(4)

Pre-Menstrual Syndrome
Pre-mature ejaculation
Bulimia
Panic disorder

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SSRI with the cleanest side effect profile
(still no OK for pregnant pt tho)

Citalopram
(lonely in the city)

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Bupropion use/MOA/benefits/contraindications

MDD, Smoking Cessation
NorEpi Dopamine Reuptake Inhibitor

Weight-loss, No Sexual side effects, Smoking cessation

C/I in bulimia/anorexia or h/o seizure disorder
(Lowers seizure threshold)

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Mirtazipine use/MOA/benefits (2)

MDD, Anorexia
Alpha 2 blocker releases more Norepinephrine
Helps with sleeping & improves appetite

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SSRI that is safe in pregnancy?
Which is contraindicated in pregnancy?

Sertraline (Safe)
Paroxetine (c/i)
(parrots picking at baby’s lung - fetal HTN)

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What TCA is used in treating OCD?

Clomipramine
(2nd line agent to SSRI)

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Drug of choice for MDD in a terminally ill patient with a life expectancy of 4 weeks?

Methylphenidate
(stimulant)

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Pt on SSRIs presents with seizures and hyponatremia
dx?

SIADH s/t SSRI

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SIADH is most commonly caused by what medication?
(HY)

SSRIs

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Hyperreflexia + Myoclonus in a pt with hx of MDD
dx/tx?

Classic triad of mental status changes + autonomic dysregulation + neuromuscular hyperactivity (babinski can be +)

Serotonin Syndrome
1st line BENZOS
2nd line Cyproheptadine

(technically first is supportive tx, but not on test)

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Patient with flu-like symptoms 2 days after stopping paroxetine.
dx/NBSIM?

SSRI discontinuation syndrome
Restart old dose of SSRI → Taper off over weeks

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CBT for specific phobias.

Systematic de-sensatization

(read a book about phobia, see a picture, etc)

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CBT for PTSD.

Trauma focused Psychotherapy

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Female presents with a slashed wrist
dx/tx?

Borderline Personality Disorder
Dialectical Behavioral Therapy

(Female+ Slashing wrist= BrPD end of story)

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HY HY HY
2 drugs in psychiatry that have mortality benefits?

Lithium
Clozapine
(↓ risk of suicide)

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HY HY HY
The 4 dopaminergic pathways & how ↓Dopamine levels affects it

Nigro-striatal →

Tubero-infundibular →

Mesolimbic (↑Dopamine) →

Mesocortical →

Nigro-striatal → Extrapyramidal sxs (acute dystonia, akathisia, tardive dyskinesia)

Tubero-infundibular → Hyperprolactinemia

Mesolimbic → Positive sxs of schizo
(hallucinations, disorganized speech) Improves w/ anti-psychotics

Mesocortical → Negative sxs of schizo
(social withdrawal, flat faces) Worsen w/ anti-psychotics

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Atypical Antipsychotic treat positive sxs really well
and are _________ so they don’t worsen negative sxs as much.

serotonin 5HT antagonist

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MOA
1st Gen antipsychotics (Typical antipsychotic: haloperidol)

1st: D2 antagonist
2nd D2-4 antagonist & 5HT antagonist

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Antipsychotic that causes the side effect: Amenorrhea: metabolic syndrome (Avoid if DM/Obese pt) : Neutropenic fever: Torsades:

Amenorrhea: Respiridone Metabolic syndrome: Olanzapine Neutropenic fever: Clozapine TdP: **Ziprazidone**

AMS, T 105ºF, BP 170/100 in a patient who was recently placed on a drug regimen for diabetic gastroparesis. ± Leukocytosis or Rhabdo dx/tx?

Neuroleptic Malignant Syndrome (s/t Metoclopramide) tx: Dantrolene (Ryanodine Ca2+ channel blocker) Exposure is antipsychotic or metoclopramide

Extrapyramidal side effects and treatment: Sustained abnormal posture few days after starting Antipsychotic: Motor restlessness: Cogwheeling: Stereotypical **mouth** movements 2 years after starting **Fluphenazine** typical anti-psychotic:

**Acute dystonia** (weird face, eyes stuck looking up, neck is bent) Tx: **Benztropine** or **Diphenhydramine** **Akathisia** (Can't sit still or stop moving) Tx: **Beta blocker** (2nd line is Benzo) **Parkinsonism** (EPS: rigidity, shuffling gate, resting tremor) Tx: **Benztropine** (parking my Benz) Bromocriptine, Carbergoline (dopamine agonist) **Tardive Dyskinesia** (Weird Mouth movements) Tx: **Valbenazine** (V-mat inhibitor)

Angry, irritable, argumentative with instructors, breaks rules. No criminal behavior/ or violence

oppositional defiant d/o

Criminal behavior, forced sex, cruel to neighbor’s dog, stealing, or fighting in an **underaged** pt. Dx? Neuroanatomical association w/ this dx?: MC Complication when > 18:

Conduct d/o ↓ serotonin in CSF Cx > 18: Antisocial personality d/o

Fidgety, Forgetful 11 yo boy. Dx? Neuroanatomical association: **Genetic dz association**: First line tx: 2nd line tx: 3rd line tx:

ADHD ↓ activity of pre-frontal cortex **Fragile X syndrome** 1st → Stimulant (methyl-phenidate, dextroamphetamine) 2nd → non-stimulant (Atomoxetine) 3rd → alpha 2 agonist (Clonidine, Guanfacine)

Does not respond to social interactions (doesn't respond to name or share), poor eye contact, fixated interests. Dx?

Autism Spectrum d/o

The 2 “egos” & examples Ego Dystonic: Ego Syntonic:

Dystonic → Knowingly doing something irrational → OCD (pt is distressed by sxs) Syntonic → unknowingly doing something irrational → OCPD (pt is unbothered/proud of sxs)

Holds grudges, suspects spousal infidelity, asks you an enemy or a friend? Fears exploitation.

Paranoid personality d/o

Lacks close friends, believes in the occult/conspiracy/magical Wear yellow pants with red shirt. Kind of like an odd or weird person

Schizotypal personality d/o

Emotionally cold, indifferent reaction to praise/criticism not interested in sex/relationships/friends Seeks solitude (Loner type)

Schizoid personality d/o

Impulsive, dysfunctional relationships, radial nerve damage from slashed wrist. dx/defense mechanism?

Boderline Personality d/o Splitting (black and white thinking)

Requires admiration/attention Lacks empathy (can't see other's needs) Sense of entitlement.

Narcissistic

Adult who is Remorseless, disobeys the law, lies. In trouble with the law

Anti-Social (≤18 yo it is called Conduct d/o)

Dramatic emotions (cries easily, gets offended easily) wants to be center of attention Seductive Theatrical/Flamboyant behavior Does not usually lack empathy

Histrionic

Afraid of social criticism does not take risks/passes up good opportunities Always feels inferior to others.

avoidant social personality d/o

Stubborn, **rule oriented**, perfectionistic **devoted to the cause/no leisure** Wants everyone to do it their way Would rather do task alone if others disagree

Obsessive Compulsive Personality D/o (NOT to be confused with real OCD)

Needs reassurance for every decision problems initiating projects needs urgent companionship.

Dependent personality d/o

Anorexic pt is hemodynamically unstable request to leave ED NBSIM?

Admit to hospital (even if it against their will bc Anorexia is a psychiatric d/o)

Chronically Malnourished pt (Alcoholic, Anorexic/Bulemic, Tea/Toast Diet) dies while being given IVFs and Nourishment at hospital

hypophosphatemia s/t Re-feeding syndrome

How can you differentiate b/w bulimia nervosa and binge eating disorder?

Bulimics eat, but have a compensatory behavior (exercise, laxatives) Binge eaters do **NOT** have a compensatory behavior

ED-Antidepressant to avoid in pts w/ Eating d/o: Best CBT for anorexia on NBMEs: Best antidepressant for anorexia: Best antidepressant for bulimia:

Avoid → Bupropion CBT → Family therapy Antidepressant Anorexia → Mirtazipine Antidepressant Bulimia: → SSRI

MDD and EEG findings

↓ REM sleep Latency/Inhibition ↑ REM Sleep Same as Narcolepsy.

Pt h/o Bulimia presents w/ sudden onset, severe chest pain + pneumomediastinum. chest palpation/auscultation reveals **crepitus** dx/NBSID/tx?

Esophageal Perforation **Water** soluble contrast (**Gastrograffin** swallow) SURGERY (can be s/t Endoscopy (within 24hrs))

Outside observer to one’s thoughts. No recollection of a traumatic event.

depersonalization d/o

High anxiety about their leg pain but w/u is negative.

somatic sxs d/o (have symptom but blown out of proportion) tx: regular f/u w/same physician

Pt preoccupied with the fear of having HTN despite multiple nl BP checks. dx/tx?

illness anxiety disorder Regular physician visits w/ same clinician Has no sxs or problems but is worrying about having a dz

Neuro sxs like Pain, pinprick, fine touch loss in LLE. Not worried about sxs/Indifferent attitude during the physical exam. Neuro sxs are not consistent with a localization

Functional Neurologic d/o aka Conversion disorder (usually s/t anxiety/stress)

Hyperthermia, Rhabdomyolysis, Hyponatremic seizures, Serotonin syndrome due to ____ toxicity.

MDMA toxicity (Ecstasy pill) Takes Ecstasy pill (a seritonergic drug) & dance into hyperthermia and can't stop so muscle get damaged. Starts drinking alot of water bc feeling hot causing hyponatremia.

Pt who is clearly abusing a substance & is difficult to restrain presents with **Nystagmus**, Myoclonus and aggression/violence towards others. Dx/tx?

**Phencyclidine** (PCP) NMDA receptor antagonist tx: **Benzos** *Nystagmus separates this from cocaine or MDMA use*

Lethargic pt with Bradycardia & respiratory rate of 8 Pupils are 2mm (smallest they go) ____ Intoxication Treating intoxication: Is withdrawal fatal? **Cogwheeling/akinesia** after use → ___ toxicity damaging the **substantia nigra**

**Opioid** over-dose **Naloxone** (if it fails, try again) Withdrawal is **not** fatal, but it feels shitty Parkinsonian sxs→ **MPTP** toxicity

Pressured speech, tachycardia, mydriasis, HTN. dx/tx?

Cocaine intoxication tx: Benzo

Tachycardia, conjunctival injection, increased appetite, reduced rxn time.

Marijuana use

Tx (3) of terminal cancer pt w/ cachexia. usually s/t loss of appetite 𑁋𑁋 Tx of terminal cancer pt w/ depression 𑁋𑁋 Tx (2) of terminal cancer pt w/ Dyspnea 𑁋𑁋 Tx of chemo or cancer pt w/ nausea & emesis? what if pt has ↑ ICP

**Megestrol** (progestin analog), **Dronabinol** (cannabinoid), **Corticosteroids** 𑁋𑁋 Methylphenidate 𑁋𑁋 Opioids (Morphine) + bowel regimen 𑁋𑁋 **Ondansetron** (serotonin receptor antagonist) Adverse effect? **QT prolongation** ↑ ICP → Glucocorticoids

2 days post-op pt develops diaphoresis, tachycardia & visual **hallucinations** + **seizures**. Dx/Tx?

Alcohol withdrawal Tx: Benzos

Nystagmus, Ataxia (unable to walk right), Confusion: + Neuroanatomy: + Enzyme association: Tx: Irreversible progression:

Wernicke encephalopathy (acute, reversible) + Neuroanatomy: **Mammillary body hemorrhagic** infarction + Enzyme association: **Transketolase** does not work Tx: IV thiamine (B1) Progresses to **Korsakoff’s** (**Irreversible**) • Amnesia + Confabulation aka makes things up

Tx of ETOH use disorder (3)

Alcoholic Anonymous Acomprosate Naltrexone

82F pulling IVs, attempting to get out of bed. ± UTI. Dx: Inducing agent: Acute tx: What med to avoid:

Acute Delirium Anticholinergic Drugs (diphenhydramine, Scopolamine, TCAs) Anti-Psychotic (± **Sitter**) Avoid: Benzodiazepines (can worsen delirium)

Forgetfulness worsening & now impairs performance of activities of daily living dx/Patho?

Alzheimers ↓ AcH s/t destruction of **basal nucleus of meynart**

Alzheimers treatment (3)

AchE inhibitors * Rivastigmine * Galantamine * Donepezil

Dementia + Constantly “added” neuro deficits:

Vascular dementia

Rude language, lack of inhibition, sexually suggestive statements.

Fronto-temporal dementia (Pick’s disease)

dementia + Abnormal gait + urinary incontinence:

NPH

What kind of hydrocephalus is seen in NPH Tx strategies:

**Non-obstructive**/Communicating Hydrocephalus s/t CSF reabsorption problems in **arachnoid granulations** Tx: **VP-shunt** (**reversible cause of dementia**)

6 weeks of recurrent nightmares after being fired from role as COVID unit nurse. dx/tx? Tx of REM sleep problem?

PTSD (>1m sxs) SSRIs + **trauma focused psychotherapy** **Prazosin** for nightmares

Checks doors repeatedly to make sure they are locked. Intrusive unwanted/worrying thoughts requiring a ritual to alleviate. Dx: Pharm tx: CBT:

OCD SSRI + **Exposure & response prevention** CBT

Feels humiliated and is terrified at the thought of giving speeches. Dx/Tx (1st/2nd line) When is 1st line tx c/i?

Performance Anxiety (subtype of Social anxiety d/o) 1st line: Beta Blocker 2nd line: Benzo If pt has **Asthma** treat w/ Benzo

9 months of poor sleep, restless, impaired concentration & worrying about “multiple domains in life” dx/tx?

Generalized Anxiety d/o (≥6m sxs)

Tx (2) of panic disorder: Tx of an active panic attack?

Panic d/o: → SSRIs + CBT Panic attack? → Benzos

Major Depressive Disorder ≥5/9 on SIGECAPS for ≥ 2 weeks * Monoamine hypothesis: * Adrenal axis anomaly: * Fastest/**most effective** tx:

Monoamine hypothesis: low levels of Serotonin, Norepinephrine, & Dopamine Adrenal axis: →High cortisol Fastest/most effective tx: → **ECT (ok in pregnancy)**

Schizophrenia **neuroanatomy** abnormalities: SCZ timelines: (<1m) = (1-6m) = (≥6M) =

↑ size of lateral & 3rd **ventricles** Psychotic sxs (Hallucinations, bizarre Delusions or disorganized speech/thinking) present for: (<1m) = Acute psychotic d/o (1-6m) = **Schizophreniform** (>6M) = Schizophrenia

Most predictive factor in completing suicide. Who attempts more, M/F? Who is more successful?

Predictive → h/o prior attempt Women **attempt** more Men **succeed** more (bc more lethal methods)

27M is brought to the ED by his mom with a 2 week history of reduced oral intake. BMI is 16. PMH: MDD unresponsive to SSRIs, TCAs, & isocarboxazid Pt is muted and reluctantly responds to questions. Vitals: BP 60/40s HR 40, RR 7/min No h/o suicide attempts. NBSIM?

Admit to hospital for ECT

72M with 6 wk h/o impaired vision. Letters and lines appear “more wavy” Dx: Visual field lost first: Fundoscopic exam for Type 1: Fundoscopic exam for Type 2: Tx for Type 1: Tx for Type 2:

Macular Degeneration (age related) **HY: Wavy vision = MD** Central vision loss first → then peripheral vision loss last Fundoscopic Type 1: **Dry** Type + **Yellow deposits** (Drussen) Fundoscopic Type 2: **Wet** Type + Yellow deposits + **Neovascularization** Type 1 Tx: **Beta Carotene or Vit.K** (Antioxidants) Type 2 Tx: **VEG-F Inhibitor** (Bevazizumab or Ranibizumab)

Vision loss in a diabetic that is worse at night (problems reading signs, reading books, etc) Dx/Tx? Fundoscopic exam findings: Most important risk factor:

Cataracts tx: **Lens Replacement** Lens Opacification **Age** is BRF