Psych MDT's Flashcards
Symptoms of PTSD
Cognitive impairment
anger
Flashbacks
Severe anxiety symptoms
Fleeing
Combative behaviors
How long must symptoms be present for PTSD
Symptoms must be present for at least four weeks following trauma for psychiatry
to make the diagnosis
Treatment of PTSD
1) Exposure therapy
2) CBT (Cognitive Behavioral Therapy)
3) EMDR (Eye Movement Desensitization and Reprocessing
Antidepressant medications (SSRIs) are the first line therapy of choice
Prazosin for nightmares
Avoid benzodiazepines due to safety and dependency issues
Sooner therapy leads to better prognosis
Five Eating disorders
(1) Anorexia nervosa
(2) Bulimia nervosa
(3) Binge eating disorder
(4) Pica
(5) Rumination disorder
What is the tool used to determine Anorexia
SCOFF: Sick, Control, One, Fat, and Food
Do you make yourself SICK because you feel uncomfortably full?
Do you worry you have lost CONTROL over how much you eat?
Have you recently lost more than ONE stone (14 pounds) in a three month period?
Do you believe yourself to be FAT when others say you are thin?
Would you say that FOOD dominates your life?
Anorexia Nervosa cause
Deficits in dopaminergic function and serotonergic function
1) Dopamine: Eating behavior, motivation and reward
2) Serotonin: Mood, impulse control, obsessive behavior
Diagnostic Criteria Anorexia Nervosa
Intense fear of gaining weight or becoming fat or persistent behavior that prevents weight gain, despite being underweight
Distorted perception of body weight and shape, undue influence of weight and shape on self-worth, or denial of the medical seriousness of one’s own low body
weight
Common physical exam findings Anorexia Nervosa
(a) Low BMI (<17.5)
(b) Emaciation
(c) Hypothermia
(d) Bradycardia
(e) Hypotension
(f) Hypoactive bowel sounds
(g) Xerosis (dry and scaly skin)
(h) Brittle hair and hair loss
(i) Lanugo body hair
(j) Abdominal distention
Recurrent episodes of binging and purging and inappropriate compensatory
behavior to prevent weight gain
Bulimia nervosa
specific behaviors of bulimia nervosa
1) Self-induced vomiting
2) Misuse of laxatives
3) Diuretic use
4) Enemas
5) Fasting
6) Excessive exercise
7) Occurring on average at least once per week for three months
Clinical findings bulimia nervosa
Mallory-Weiss syndrome
Erosion of dental enamel
ECG changes may occur
Pharyngitis
Dehydration
Eating of nonfood substances such as chalk, dirt, hair, metal, etc
Associated with iron deficiency anemia
PICA
Repeated regurgitation of food
May be rechewed,
reswallowed, or spit out
Rumination Disorder
What is substance abuse? Characterized by the triad:
(1) Psychological dependence or craving
(2) Physiologic dependence
(3) Tolerance
3rd leading preventable cause of death in the United States
Alcohol Use Disorder
Drinking risk with men and women
Men: More than 14 standard drinks per week on average More than 4 drinks on any day
Women: More than 7 standard drinks per week on average More than 3 drinks on any day
Four quick questions, for alcohol abuse
CAGE: Cut, Annoyed, Guilty, and Eye opener
a) Have you ever felt you should Cut down on your drinking?
b) Have people Annoyed you by criticizing your drinking?
c) Have you ever felt bad or Guilty about your drinking?
d) Have you ever taken a drink first thing in the morning (Eye opener) to steady your nerves or get rid of a hangover?
2 affirmative questions not a valid screening tool
Complication of alcohol use disorder that is due to a deficiency of Thiamine (B1)
Wernicke Korsakoff syndrome
Wernicke Korsakoff syndrome is broken up into two separate syndromes
Wernicke encephalopathy (WE): acute syndrome
Korsakoff syndrome: Chronic neuro condition
Wernicke encephalopathy (WE): acute syndrome quad triad
(a Encephalopathy
(b Disorientation, inattentiveness
(c Oculomotor dysfunction
(d Nystagmus most common finding
most will not have triad Most common symptom: Confusion
Korsakoff syndrome: Chronic neuro condition
Usually a consequence of WE
Causes anterograde and retrograde amnesia
More severe symptoms of alcohol withdrawal
include hallucinations and seizures as well as delirium
Mild withdraw symptoms of alcohol withdrawal
Anxiety
agitation
Restlessness
Insomnia
Tremor
Diaphoresis
Palpitations
Headache
cravings
Physical signs of alcohol withdrawal
Tachycardia, hypertension, tremor
Treatment of alcohol withdrawal
Benzos
Leading preventable cause of mortality worldwide
Tobacco Use Disorder
Nicotine withdrawal symptoms
Associated with increased appetite, weight gain, depression, insomnia, irritability, anxiety, restlessness
Treatment of nicotine withdrawal
a) Long acting: Nicotine patch
b) Short acting: Gum or lozenges available
Buproprion (Wellbutrin)
Varenicline (Chantix)
With moderate dosage, marijuana produces two phases
Mild euphoria followed by sleepiness.
treatment of choice for acute opioid intoxication
Naloxone is the treatment of choice for acute opioid intoxication
Ice” and “Speed” are both different forms of
methamphetamine.
The clinical picture of acute stimulant intoxication includes:
1) Sweating
2) Tachycardia
3) Elevated blood pressure
4) Mydriasis
5) Hyperactivity
6) Acute brain syndrome with confusion and disorientation.
18th leading cause of disability in the US
Bipolar Disorder
Bipolar disorder is a mood disorder that is characterized by three different mood states
(1) Mania
(2) Hypomania
(3) Major depression
A distinct period of abnormally or persistently elevated, expansive, or irritable mood and persistently increased activity or energy, lasting at least one week and present mods of the day, nearly every day
Mania
Three or more of the following symptoms must be present for Mania
(a) Inflated self-esteem or grandiosity
(b) Decreased need for sleep
(c) More talkative than usual or pressured speech
(d) Flight of ideas/racing thoughts
(e) Distractibility (easily distracted by stimuli)
(f) Increased goal directed activity
(g) Involvement in activities that carry negative potential (spending sprees, sexual
indiscretions)
The acronym “DIG FAST” is often used to remember the symptoms of mania
D - Distractibility
I - Indiscretions
G - Grandiosity
F - Flight of ideas
A - Activity increase
S - Sleeplessness
T – Talkativeness
Five or more of the following symptoms present during the same two week period for Major Depression
(a) Depressed mood (sad, empty, hopelessness)
(b) Diminished interest in pleasurable activities
(c) Weight loss or weight gain
(d) Insomnia or hypersomnia
(e) Psychomotor agitation (tapping, fidgeting, pacing, hand-wringing) or retardation
(reduced physical movements and slowing of thoughts)
(f) Decreased energy
(g) Guilt or feelings of worthlessness
(h) Impaired concentration
(i) Thoughts of death or thoughts of suicide
IDC management of Bipolar Disorder
Immediately refer and manage acute symptoms while awaiting referral
Haloperidol if needed prior to MEDEVAC
Maintenance therapy will usually be employed by psychiatrist with a mood stabilizer or antipsychotic
a) Lithium
b) Valproic acid
c) Lamotrigine (Lamictal)
d) Quetiapine (Seroquel)
Most common psychiatric disorder in the general population
Depression
Somatic symptoms of depression
Headache, abdominal pain, pelvic pain, back pain, other physical complaints
SIGECAPS in a pneumonic used by primary care clinicians to quickly screen for
depression when forms such as PHQ-9 are not utilized or available
O- onset cuz senior said so
S- Sleep changes: Increased during day or decreased at night
I- Interest (loss): Of interest in activities that used to interest them
G- Guilt (worthless): Depressed people tend to devalue themselves
E- Energy (lack): Common presenting symptom is fatigue
C- Concentration: Reduced concentration and cognition
A- Appetite: Usually declined appetite. Sometimes also increased
P- Psychomotor agitation: Anxious feelings or lethargic feelings
S- Suicide/death preoccupation
SSRIs: Selective Serotonin Reuptake Inhibitors examples
Fluoxetine, paroxetine, sertraline, escitalopram, citalopram
SNRIs: Serotonin- Norepinephrine Reuptake Inhibitors examples
Venlafaxine, duloxetine
Usually occurs within 12 months
Resolves within six months when the stressor is removed
Adjustment Disorder
milder and self-limited; typically develop within 2-3 days of delivery and resolve within 2 weeks.
Post-partum “blues”
Treatment of post partum depression
For mild to moderate, recommend psychotherapy such as CBT as initial treatment;
especially useful for breastfeeding moms as they won’t expose children to antidepressants.
If CBT is unsuccessful or depression is more severe, antidepressants (SSRIs, Bupropion
(Wellbutrin), Mirtazapine (Remeron)) are useful.
SSRIs: Paroxetine (Paxil) or Sertraline (Zoloft) appear to have lowest adverse effects
on infants
Characterized by excessive and persistent worrying that is hard to control, causes significant distress, and occurs more days than not for at least six months
Generalized Anxiety Disorder (GAD)
Goes “hand in hand” with other psychiatric conditions
(a) Depression
(b) Specific phobias
(c) “Medically unexplained” chronic pain
Common clinical manifestations of GAD
(a) Most do not present with “excessive worry”
1) If asked typically will admit to worrying excessively about minor matters
(b) Hyperarousal and muscle tension common
(c) Poor sleep
(d) Fatigue
(e) Difficulty relaxing
(f) Headaches
(g) Pain in the neck, shoulder, and back
Screen method for GAD
GAD 7
Treatment of Generalized Anxiety Disorder
CBT, medications, or both
1) SSRIs and SNRIs are the typical medication classes used as first line
Spontaneous, discrete episode of intense fear that begins abruptly and lasts for several minutes to an hour
Panic attack?
DSM-5 Diagnostic Criteria for Panic attack?
(a) Palpitations, pounding heart, or accelerated heart rate
(b) Sweating
(c) Trembling or shaking
(d) Sensations of shortness of breath
(e) Feelings of choking
(f) Chest pain or discomfort
(g) Nausea or abdominal distress
(h) Feeling dizzy, unsteady, light-headed, or faint
(i) Chills or heat sensations
(j) Paresthesia (numbness or tingling sensations)
(k) Derealization (feelings of unreality) or depersonalization (feeling detached from
oneself)
(l) Fear of losing control or “going crazy”
(m)Fear of dying
Common somatic symptoms of Panic attack
(a) Chest pain, shortness of breath, abdominal pain, dizziness
Treatment of panic attacks
a) Benzodiazepines
1) Clonazepam, lorazepam, diazepam, alprazolam
(b) Tend to avoid chronic use of Benzos due to addiction risk
1) Risk of withdrawal if stopped abruptly after chronic use
(2) Antihistamines such as hydroxyzine may also be tried
(3) SSRIs: Systematic reviews of clinical trials show:
(a) Reduce frequency of panic attacks
(b) Severity of anxiety
(c) Degree of phobic avoidance
(4) The SNRI, Venlafaxine, has shown similar results
SSRI’s and SNRI does not break attack only used for long term
Examples of Benzodiazepines
Clonazepam, Lorazepam, Diazepam, Alprazolam
Common symptoms for psychosis
(a) Delusions
(b) Hallucinations
(c) Thought disorganization
(d) Agitation and aggression
Delisions of psychosis may include
1) Bizarre, ie: Belief that family members have been replaced by body-doubles
2) Non bizarre, ie: Belief that spouse is cheating despite overwhelming evidence
to the contrary
(3 Eg: Belief that one is being followed or harassed by outside entity
(4 Eg: Belief that one is a billionaire
(5 Eg: Believing a famous person is in love with them
(6 Eg: Believing ones sinuses have been infested with worms
(7 Eg: Believing a dialog on TV is directed towards you
(8 Believing one’s thoughts and movements are being controlled by a
powerful outside force
five sensory modalities related to hallucinations and psychosis
Auditory (most common)
Visual
Tactile
Olfactory
Unpleasant odors
Gustatory
Treatment of psychosis
Haloperidol for acute agitation in psychosis but immediate referral is necessary
first and second generation antipsychotics
Haloperidol is a first generation
Second generation antipsychotics (also called “atypical antipsychotics) are new
and have improved side effect profile
a) Aripiprazole, risperidone, quetiapine, olanzapine
Extrapyramidal side effects should be watched for with antipsychotics:
1) Akathisia
2) Parkinsonian syndrome
3) Dystonia
4) Tardive Dyskinesia
a) Involuntary movements of the face
b) Sucking or smacking of the lips
c) Movements of the tongue
d) Facial grimacing
e) Odd movements of extremities
f) Usually occur after greater than six months of treatment on antipsychotic
Tardive dyskinesia
(1 Mask like facies, resting tremor, cogwheel rigidity, shuffling gait,
psychomotor retardation (bradykinesia)
Parkinsonian syndrome
a) Involuntary contractions of muscles
Dystonia
Motor restlessness with compelling urge to move and inability to sit still
Akathisia
Cluster B personality disorders
(a) Borderline Personality Disorder (BPD)
(b) Antisocial Personality Disorder (ASPD)
(1) Instability of interpersonal relationships, self-image, and emotions
(2) Very impulsive behaviors
Tend to misinterpret otherwise neutral events, words, or interactions as “negative”
1) Minor disagreement may elicit highly emotional response
2) Reactions of extreme anger or self-harm threats
Borderline Personality Disorder (BPD)
Pattern of socially irresponsible, exploitative, and guiltless behavior
Wide range of symptoms with criminality being common
(b) Antisocial Personality Disorder (ASPD)
Treatment of personality disorders
Social and therapeutic environments such as day hospitals, halfway houses, and self-help communities utilize peer pressures to modify the self-destructive behavior.
Operant conditioning emphasizes the recognition of acceptable behavior and its reinforcement with praise or other tangible rewards
Psychological intervention is best conducted in group settings
Hospitalization is indicated in the case of serious suicidal or homicidal danger.
Antipsychotics may be required for short periods in conditions that have temporarily
decompensated into transient psychosis (Haloperidol (Haldol), 2-5 mg orally every
3-4 hours until the patient has quieted down and is regaining contact with reality).
At least some of the symptoms must be presents before age 7.
Adults must have childhood onset (by age 12), persistent and current symptoms to be
diagnosed.
Attention-Deficit / Hyperactivity-Disorder.
Treatment of ADHA
(a) Methylphenidate (Ritalin, Concerta, Metadate)
(b) Amphetamines (Adderall ,Vyvanse)
Symptoms attributed to Post-concussion Syndrome (headache, dizziness, neuropsychiatric symptoms, and cognitive impairments) are greatest within
the first 7-10 days for the majority of patients and at one month symptoms are usually improved and often resolved.
Assessment for evaluation of suicidal ideation
Can use the Columbia-Suicide Severity Rating Scale (C-SSRS) as guide for asking questions. Answers will help identify whether someone is at risk for suicide, assess severity and immediacy of that risk, and gauge level of support that the person needs.
available for structured intervention for rescuers and survivors
involved in incidents likely to produce traumatic stress (Fire with loss of life,
suicide of shipmate, body handling duty, hostile attack, rape). As MDR always keep
a good hand on the psychological “pulse’ of the ship’s crew.
Special Psychiatric Rapid Intervention Team (SPRINT)
Mental status examination.
Physical Appearance and Behavior
(a) Grooming (poor hygiene, lack of concern with appearance, inappropriate dress)
(b) Emotional status (should demonstrate appropriate concern for the topics)
(c) Body language (should have erect posture; lack of facial expression may indicate
depression or a neurologic condition; excessive energetic movements suggest
tension, mania, etc.)
Mental status examination.
State of consciousness
Oriented to person, place, and time – gives appropriate responses to questions,
physical and environmental stimuli
Mental status examination.
Cognitive abilities
a) Evaluate as the patient responds to questions during the history taking process
(b) Mini-Mental State Exam (MMSE or Folstein Test)
Mental status examination.
Cognitive abilities
Analogies
Ask the patient to describe simple analogies first, and then more complex
analogies (i.e. similarities and/or differences)
Mental status examination.
Cognitive abilities
Abstract reasoning
1) Ask the patient to tell you the meaning of a fable, proverb, or metaphor
a) “A rolling stone gathers no moss”
Mental status examination.
Cognitive abilities
Arithmetic calculation
Writing ability
Execution of motor skills
Math problem
Write name
tie there shoe
Tested by asking the patient to listen and the repeat a sentence or a series of numbers
Immediate recall
tested by giving the patient a short time to view four or five objects, saying you will ask about them in a few minutes. Ten minutes later, ask the patient to list the objects
Recent memory
Tested by asking the patient about verifiable past events
Remote memory
Ask the patient to spell the word WORLD forward and backwards or say the days of the week
Attention Span
Ask the patient to provide solutions to hypothetical situations (i.e. finding a
stamped envelope, getting stopped by the police after driving through a red
light)
Judgement
