Psych Tips, Techniques and Treatment Options Flashcards
What is a good way to close a patient encounter
Ask the patient what their goal was for the visit
Generally how should you diagnose personality disorders
Unless a patient meets every single wicket for a disorder, use the diagnosis of Personality Disorder NOS
What treatment options should be considered when treating depression and an unresolved neurovegitative state
Consider using Buproprion first, and then adding adderall on later.
What are some common drugs that need to be titrated up and down
SSRI SNRI Benzodiazepines Lamictal Topamax Beta blockers
When should you consider do genetic testing for medical treatment in psych?
consider in patients who are low responders and have sensitivity problems with a few different classes.
Generally not beneficial in patients that have tried many different classes already
What is the benefit of using an anxiolytic over a benzodiazepine when treating anxiety
Benzo’s will only mask the problem, while anxiolytics have the ability to correct the problem.
What should you do if a patient is sensitive to a medication after beginning treatment
Switch to a different medication and start on a low dose. Titrate up slowly
What determines the interval between visits
Disease progression, patient stability and support group determines intervals.
4-6 weeks after initiating a medical change or unstable patient.
2-3 months if the patient is showing improvements but not at target
4-6 months if the patient is stable and has met or is near target
What is a good medication to start for a patient with anxiety?
Anxiety is closely related to Serotonin levels so initiate therapy with an SSRI.
If the patient is also experiencing depression, start with the lowest possible dose and titrate up slowly.
What psychiatric effect does antihypertensive medications have?
May cause depression
What cardiac effect does anti-depressants cause
Arrhythmias
If a patient is depressed and anxious but is experiencing negative sexual side effects from an SSRI, what is a good alternative
Mirtazipine
What is a serious complication of trazadone
Priapism in 1%
How is trazadone used medically
Commonly used as an adjunct of treatment with bupropion. It is also used to assist patients in sleeping
It is mainly used to treat anxiety and depression
How do you treat fibromyalgia and depression
Initiate treatment with an SNRI. Consider adding an SSRI after the SNRI has been maxed.
Be sure to monitor for symptoms of seratonin syndrome
What is a limiting side effect of duloxetine
comorbid liver disease
When adjusting dose of lamictal, what should the patient look for
a Rash. There is the potential to develop Steven-Johnson Syndrome (SJS)
Nefazadone. No longer used in the US do to what side effect
Liver dysFunction
Contraindicated in patients with a comorbid liver disease
what is the mnemonic for dementia
(DEMENTIAS) Degenerative disease Endocrine Metabolic Exogenous Neoplasm Trauma Infection Affective Disorder Stroke/Structure
what is the mnemonic for delerium
(I WATCH DEATH) Infection Withdrawal Acute metabolic/Abuse of substance Trauma CNS pathology Hypoxia Deficiencies Endocrine Acute vascular / MI Toxins or drugs Heavy metals
what is the mnemonic for a depressive episode
(SIG E CAPS) Sleep Interest Guilt Energy Concentration Appetite Psychomotor agitation or Retardation Suicidal ideation
what is the mnemonic for TCA toxicity
“Tri C’s”
convulsions
coma
cardiac arrhythmia
what is the mnemonic for mania
(DIG FAST) Distractability insomnia Grandiosity Flight of ideas Activities / Psychomotor agitation Sexual indiscretions talkativeness or pressured speech
what is the mnemonic for a personality disorder
(MEDIC) Maladaptive Enduring Deviate from cultural norms Inflexible Causes impairment in social or occupational functioning
what is the mnemonic for the evaluation of EPS
"4 and A" 4 hours: acute dystonia 4 days: Akinesia 4 weeks: Akathisia 4 months: Tardive dyskinesia
what is the mnemonic for the features of substance abuse
(WITHDraw IT) 3 or more in a 12 month period
Withdrawal
Interest or important activities decreases
Tolerance
Harm
Desire to cut down
Intended time or amount exceeded
Time spent with or for substance increased
what is the screening tool for alcoholism?
“CAGE Questionnaire”
- have you ever felt the need to cut down on drinking ?
- have you ever felt annoyed by criticism of your drinking?
- have you ever felt guilty of your drinking?
- have you ever had to have a morning “eye opener”?
answer of yes to more than one makes alcoholism likely
what is the mnemonic for the risk factors associated with suicide
(SAD PERSONS) Sex (male) Age (older) Depression Previous attempt Ethanol or substance abuse Rational thought Sickness Organized plans and access to weapons No spouse Social support lacking
Can antihypertensive medications cause depression
yes
What cardiac side effect is associated with several antidepressants
May cause arrhythmia
If a patient is sensitive to the sexual side effects associated with SSRI’s, what medication should be considered
mirtazipine
What is the major side effect of trazodone
Priapism
1% of population
When is trazodone indicated
Anxiety and depression
Can be used as an adjunct therapy with buproprion to assist with insomnia (increases sleep duration)
What is key consider when prescribing duloxetine
Comorbid liver disease use with caution.
What is the most serious side effect of lamictal
Rash. Can develop Steven Johnson Syndrome
When should you use nefazodone
not in the US. It is contraindicated with liver disease
What are the common side effects of topamax
Skinny and stupid (trouble finding words/speaking)
What tends to happen with depressed and anxious periods of increased stress
Generally their symptoms will decrease
What psychological conditions are generally associated with outburst
- Bipolar
- Anxiety
- ADHD
- Drug Side Effects
What drug is known to decrease seizure threshold
Buproprione
What can be used to help reduce racing thoughts at bed time
Neurontin
Is GAD always associated with Panic Disorders
NOPE, anxiety attacks are the key feature not necessarily generalized
If Lamictal is insufficient in treatment what is a good complimentary medication to add
Abilify
What is the drug of choice (gold standard) for anxiety and depression
Prozac (fluoxetine)
What affect does lap bands and gastric by-pass surgeries have on anti-depressants
Lap bands have a limited effect
Gastric Bypass will tend to have a greater effect
If a patient has bouts irritability, what other conditions should be considered
Anxiety
acute dystonia
neurological movement disorder, in which sustained muscle contractions cause twisting and repetitive movements or abnormal postures.[
akinesia
the inability to initiate movement due to difficulty selecting and/or activating motor programs in the central nervous system
a result of severely diminished dopaminergic cell activity in the direct pathway of movement.
akathesia
characterized by unpleasant sensations of inner restlessness that manifests itself with an inability to sit still or remain motionless
Tardive dyskinesia
characterized by repetitive, involuntary, purposeless movements. Some examples of these types of involuntary movements include grimacing, tongue protrusion, lip smacking, puckering and pursing of the lips, and rapid eye blinking.
What is atypical depression
similar to MDD but is characterized by reversed vegetative symptoms, namely over-eating and over-sleeping, and separately by interpersonal rejection sensitivity.
What are the primary drugs used for depression
SSRI
SNRI
TCA
What are the primary drugs for atypical depression
MAOI
SSRI’s
What can be used for depression with insomnia
Mirtazipine
Name the MAOI’s generally used for depression
phenelzine
tranylcypromine
isocarboxazid
what is the mechanism for Buproprion
Norepinephrine - dopamine reuptake inhibitor
what kind of plasma levels should be drawn with carbamazepine
during the first three months weekly CBC’s should be drawn.
Liver function tests every 6 months
what kind of plasma levels should be drawn with valproate
serum valproate levels (therapeutic 45-50mg/mL)
LFT’s every 6-12 months
What are the 3 classifications of the causes of mental illness
Biologic
psychological
Environmental
What is included in Axis I
clinical syndromes (organic mental disorders)
What is included on Axis II
Personality disorders and Mental Retardation
What additional lab work is needed with Clozapine
weekly CBC for 6 months followed by every other week CBC’s for 6 months
What is included on Axis III
General medical conditions
What is included on axis IV
Psychosocial and environmental problems (stressors)
What is included on Axis V
Global assessment of function
How is GAF determined
a numeric scale (0 through 100) used by mental health clinicians and physicians to rate subjectively the social, occupational, and psychological functioning of adults, e.g., how well or adaptively one is meeting various problems-in-living. The scale is presented and described in the DSM-IV-TR on page 34.
100 - no problems
40 - suicide idealation
10 - danger to hurting others or self
What are the positive symptoms associated with Schizophrenia
delusions
hallucinations
catatonia
agitation
What are the negative symptoms associated with Schizophrenia
affective flattening apathy social withdrawal anhedonia poverty of thought content of speech
What is required for diagnosis of Schizophrenia
Two of the following for most of 1 month (group A)
- Delusions
- Hallucinations
- Disorganized speech
- Grossly disorganized or catatonic behavior
- Negative symptoms
Marked social or occupational disturbance
Duration of at least 6 months of persistent symptoms such as attenuated forms of group A symptoms or negative symptoms
substance use, medical conditions and associated mood disorders ruled out
What are the subtypes of schizophrenia
Paranoid disorganized Catatonic Undifferentiated Residual
What is catatonic schizophrenia
clinical picture dominated by 2 of the following
a. motoric immobility as evidenced by catalepsy or stupor
b. excessive motor activity
c. extreme negativism or mutism
d. peculiarities of voluntary movement such as posturing, stereotyped movements, prominent mannerisms, or prominent grimacing
e. echolalia or echopraxia
What is the effect of GABA for psychiatric disorders
plays an inhibitory role with dopaminergic neurons.
GABA may be responsible for terminating or controlling the activity with in the dopamine system
1. Low levels of GABA are found early in the course of schizophrenia
2. Benzodiazepines, which work in part as GABA agonists can relieve some symptoms of schizophrenia in some patients
3. Baclofen, a GABA receptor Antagonist can exacerbate symptoms of schizophrenia
What is the theory behind using D2 blockers with schizophrenia
Dopamine receptros, particularly D2 receptors, are found in abnormal numbers in the brains of persons with schizophrenia.
How is glutamate affected in patients with schizophrenia
Glutamate levels are reduced in the CSF of persons with schizophrenia. In addition, glutamate receptor antagonist such as phencyclidine can cause schizophrenia-like symptoms
Glutaminergic neurons interact with both serotonergic and dopaminergic systems
What are two types of catatonic posturing
catatonic rigidity
wavy flexibility
What is a brief psychotic episode
Duration of schizophrenia like symptoms for one day but less than one month
What is schizopheniform disorder
schizophrenia like symptoms for more than one month but less than 6 months
What is schizoaffective disorder
schizophrenia with mania or major depression
- Subtype Bipolar
- Subtype Depressive
Which group of antipsychotic medication is associated more with anticholinergic side effects
low potency
Due 1st generation antipsychotics effect more of the positive or negative symptoms
Primarily positive but less effect on chronic well organized delusions
How do you treat the side effect of an acute dystonia
benztropine (1-2mg IM)
Diphenhydramine (25-50mg IV or IM)
What is the mechanism of benztropine
anticholinergic
How do you treat the side effect of akathisia
May respond to antiparkinsonian agents.
If the patient responds poorly to these agents, consider:
propranolol, benzodiazepines, vitamin E
What are the antiparkinsonian agents
Amantadine (Symmetrel) Benztropine (Cogentin) Biperiden (Akineton) Diphenhydramine (Benadryl) Trihexyphenidyl (Artane)
Buspirone is used to treat what
Antianxiety
Buproprion is used to treat what
depresssion
What is the mechanism for buspirone
binds to serotonin and dopamine receptors
Hydroxyzine can be used to treat what psychiatric disorder
Anxiety
Name the Atypical Antipsychotics
aripiprazole asenapine clozapine iloperidone olanzapine paliperidone Quetiapine Risperidone Ziprasidone
Name the conventional Antipsychotics
Chlorpromazine Thioridazine Fluphenazine Perphenazine Trifluoperazine Thiothixine Haloperidol Loxapine Molindone
What are the neurochemical factors associated with mood disorders
NE
Dopamine
5-HT
GABA
What is the proposed neurochemical cause of mania
increase NE activity
Name 2 dopaminergic agents that can be used to treat depression
Methylphenyldate
Modafinil
What is the duration of symptoms for a MDE
2 weeks
What is the duration of symptoms for a Manic episode
1 week
What defines a mixed episode
patient satisfies criteria for both manic episode and MDE over a 1 week period
What defines a hypomanic episode
Duration only needs to last 4 days and the symptoms of mania are milder
What is the duration of symptoms needed to diagnose dysthymia
2 years for adults
1 year for children and adolescents
What is a cyclothymic disorder
dysthymic disorder with intermittent hypomanic periods.
Chronic illness of at least 2 years in duration
Name the mood disorder modifiers
Severity (presence or absence of psychosis) Remission Catatonic features Melancholia Atypical features of depress Postpartum onset
What are mood stabilizers used in the treatment of Bipolar
Lithium Valproate Carbamazepine Second generation antipsychotics Lamotrigine Benzodiazepines for mania and sedation Anticonvulsants (oxcatbazepine, topiramate, gabapentin, tigabine)
What are the side effects of lithium
tremor sedation nausea polyruria polydipsia memory problems weight gain hypothyroidism
How is Lithium excreted
renally;
monitor clearance and therapeutic levels in pts with reduced kidney function
What are some side effects of Carbamazepine
blurred vision ataxia nausea fatigue hyponatremia asymptomatic leukopenia
RARE BUT SERIOUS
AGRANULOCYTOSIS
SJS
PANCREATITIS
What is the pharmacological treatment of OCD
SSRI’s
What is the duration required to diagnose GAD
6 months
What is the duration of symptoms required to diagnose panic disorder
1 month
What 2 SSRI’s have an FDA approval for PTSD
Sertraline
Paroxetine
SSRI’s are less effective against combat related PTSD
What is aphasia
impairment or loss of language function
What is apraxia
inability to execute previously learned complex motor behaviors such as bathing, dressing, driving, or drawing
What is agnosia
failure to recognize or identify previously known objects
What defines cortical dementia
characterized by the early appearance fo aphasia, difficulties with calculation and memory loss.
Disturbances of speech and psychomotor behavior are less predominant
What defines subcortical dementia
is characterized by the early appearance of problems with executive functioning and recall, dysarthria, motor skill impairment, and personality changes.
These symptoms can occur in the absence of significant aphasia
What is the pathology behind huntington’s disease
progressive neurodegenerative disease that involves loos of GABAnergic neurons of the basal ganglia.
Manifest y choreoasthetosis and dementia
what is cataplexy
complete loss of muscle tone associated with narcolepsy and atonic seizures
what defines myoclonic seizures
muscle contraction with out loss of consciousness
What are the 4 types of generalized seizures
tonic clonic
atonic
Absence
myoclonic
What are the 2 types of partial seizures
Simple partial
Complex partial
What defines simple partial seizures
manifested by motor, sensory or autonomic disturbances depending on the location of the seizure focus
What defines complex partial seizures
disturbances of consciousness, including decreased awareness and alteration of cognition, emotion and sensory experience
may resemble symptoms of dissociative fugue
Define beriberi
thiamine deficiency
Wet beriberi: pt present with high-output cardiac failure,
Dry beriberi: peripheral neuropathy with bilateral distal impairment of motor and sensory skills and reflexes
Cerebral Beriberi: CNS damage with motor and cognitive impairments
Define pelagra
nicotinic acid deficiency
Caused by alcohol dependence, vegetarian diets, starvation
Symptoms include dermatitis, diarrhea, peripheral neuropathies, cognitive deficits, and personality changes that progress to delirium
Psychiatric symptoms of hyperparathyroid disorders
muscular weakness, anxiety and personality changes. Delirium, seizures and death can occur with a parathyroid storm
Psychiatric symptoms associated with hypoparathyroid disorder
increased excitability, transient parathesias, crampon, twitching, tetany and seizures
Hypothyroid disorder is also known as
myxedema
Psychiatric presentation of AIP
acute intermittent porphyria
abdominal pain, motor neuropahties and mental disturbances that range from personality changes to psychotic symptoms and delirium.
What are egosyntonic symptoms
patients do not recognize that anything is wrong with them that needs to be changed. They view existing disturbances as being the result of the worlds being out of step with with them.
Name the Cluster A personality disorders
Schizoid
paranoid
schizotypal
Name the cluster B personality disorders
histrionic
narcissistic
antisocial
borderline
Name the cluster C personality disorders
Avoidant
dependent
Obsessive-Compulsive Personality D/O
What is the progression to antisocial
conduct disorder
oppositional defiant
Antisocial
How do you distinguish avoidant from schizoid
avoidant personality has the fear of rejection yet still wants friends
Schizoid does not want friends
What defines conversion disorder
subjective symptoms unexplained by physical findings
Often the patient will show little concern to the symptoms
Modeling is common
what defines body dysmorphic disorder
unusual attention to and /or preoccupation with symptoms, organs, and body parts
what defines somatization disorder
four pain symptoms
two GI symptoms
one sexual symptom
One pseudoneurologic symptom
What defines hypochondriasis
preoccupation with fears of having a serious disease due to a misinterpretation of a bodily symptom
What is a dissociative fugue
sudden, unepected travel away from home or place of work with an inability to recall one’s past and confusion about personal identity or assumption of a new identity
What is dissociative amnesia
inability to recall important personal information, usually of traumatic or stressful nature, too extensive to be accounted for by ordinary forgetfulness
What is a dissociative identity disorder
involves the presence of two or more distinct personalities or personality states which recurrently take control of the person’s behavior
What is a depersonalization disorder
persistent or recurrent experiences of detachment from one’s body or mental processes
What differentiates malingering from factitious disorder
malingering has a motive. Both have deliberate cause of symptoms
What are the stages of sexual response
I: desire
II: Excitement
III: Orgasm
IV: Resolution
What is sexual identity
individuals’ biologic make up including chromosome configuration, genitalia, hormone levels, and after puberty the secondary sex characteristics
What is gender identity
a person’s self-identification as male or female which usually occurs by age of 2-3 years
What is sexual orientation
the object of an individuals sexual desire
What is frotteurism
characterized by touching or rubbing against a nonconsenting person
What is klismphilia
arousal from enemas
What is telephone scatologia
arousal from making obscene phone calls
What sexual effect can dopaminergic medications have
increases libido
What body weight is required for diagnosis of anorexia
85% of ideal weight
What are the two subtypes of anorexia
Restricting
Binge/purge
What are the abnormal associated findings of anorexia
Peripheral edema Lanugo hair development Skin changes Lowered metabolic rate Decrease total brain volume
What medications are indicated for anorexia
Cyproheptadine (apetite stimulation)
Fluoxetine (after weight has returned)
What are associated findings in bulimia nervosa
ingestion of high calorie food bingeing episodes occur in secret wide fluctuations in weight persistent overconcern with weight and body shape attempts to lose weight Lengthy phases of normal eating
What are some medical complications of bulimia nervosa
metabolic abnormalities parotid gland swelling dental erosions menstrula irregularities gastic dilation and rupture chronic sore throats and esophagitis anemia Neropsychiatric symptoms (seizures, neuropathies)
How will a patient present with Neuroleptic malignant syndrome
altered mental status muscle rigidity hyperthermia diaphoresis tachycardia elevated blood pressure
LABS:
Elevated CPK
Leukocytosis
What is used for the treatment of NMS
stop the offending agent Fluids Cooling blankets dantrolene ECT if pharmocotherapy fails
How will a patient present with Serotonin Syndrome
myoclonus mental status changes akathisia diaphoresis tremor hyperreflexia mydriasis diarrhea headache autonomic instabilities
What is the treatment for serotonin syndrome
Stop the offending agent
supportive care
control agitation with benzodiazepine
Cyproheptadine can be given in moderate cases to control symptoms
What is pica
persistent (for a period of atleast 1 month) eating of nonfood products
What symptoms should cause you to suspect lead poison in a child
suspected in any child who has an encephalopathy or who exhits unusual behavior (irritability, anorexia, decreased activity)
What is rumination disorder
a potentially fatal disorder that is characterized by the regurgitation of previously ingested food followed by rechewing of the foot.
Onset is typically in the first year of life, but in mentally retarded individuals may be delayed until adult hood
What is anaclitic depression
infants that have failure to thrive after being removed from their between 9 and 12 months of age
What is reactive detachment disorder
The child has impaired social interactions that are due to pathologic parenting and not due to an autism spectrum disorder.
Two types:
inhibited type: the child does not initiate or respond appropriately socially and may avoid contact or approach and then avoid contact
Disinhibited type: children are overly familiar with strangers
What is autistic disorder
the child is relatively unresponsive to other hum beings, demonstrates bizarre responses to the environment, and has unusual language development.
Most commonly before the age of 3.
What 3 things are required to diagnose autism
Social interactional deficits
Communicative deficits
Behavioral deficits
What are the 3 subtypes of ADHD
inattentive type
hyperactive-impulsive type
combined type
What is the pharmacological treatment for oppositional defiant disorder in patients with ADHD
Stimulants
atomoxetine
clonidine
What is the medical treatment for tourettes
dopamine blocking agents
Clonidine
Guafacine
What is PANDAS
Pediatric autoimmune neuropsychiatric disorders associated with streptococcal group A
abrupt onset in early childhood of OCD symptoms
What is somnambulism
sleep walking
onset between 4 and 8. peaks at 12
what is somniloquy
sleep talking
how are night terrors characterized
- inconsolability of the child during the event
- absence of recall of the content of the dream
- absence of recall of the event the following morning
What is the treatment for narcolepsy
modafinil
What is primary nocturnal enuresis
Bed wetting
parasomnia that occurs during stages 3 and 4 sleep
What is primary diurnal enuresis
Bed wetting
parasomnia that occurs during the waking hours
What is secondary enuresis
unrinating at inappropriate time and places that develops after one year of good bladder control
What is encopresis
fecal incontinence beyond the period when bowel control should normally have developed
define dementia with lewy bodies
cytoplasmic inclusions found in cells of the sbstantia nigra in patients with idiopathic parkinson disease
what are lewy bodies
round inclusions composed of a-synuclein, found intracellulary in substantial nigra cells and in the locus ceruleus, nucleus basalis of Meynert, dorsal raphe nuclei, and dorsal motor nucleus of CN X
what is the pharmacological treatment for dementia
acetylcholinesterase inhibitors
NMDA receptor antagonist
What is parkinsons dementia
degenerative disease caused by the loss of dopaminergic neurons in the substantia nigra
What effect does anticholinergic medications have on dementia and cognition
exacerbates symptoms of dementia
Avoid anti-cholinergic medications in the elderly
What is the mechanism of cyproheptadine
Anti histamine
