Psychiatry 1 Flashcards
1
Q
What are the clinical features of persistent depressive disorder (dysthymia)?
A
Chronic depressed mood for 2+ years (1 year in children/adolescents) No symptom-free period for >2 months Presence of 2+ of the following: 1. Poor appetite or overeating 2. Insomnia or hypersomnia 3. Low energy or fatigue 4. Low self-esteem 5. Poor concentration or difficulty making decisions 6. Feelings of hopelessness
2
Q
What are the 3 specifiers for persistent depressive disorder (dysthymia)?
A
- With pure dysthymic syndrome - criteria for major depressive episode never met
- With intermittent major depressive episodes
- With persistent major depressive episodes (criteria for major depressive episode met throughout previous 2 years)
3
Q
Patients with ___ personality disorder exhibit a lifelong pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.
A
Avoidant
4
Q
What are the characteristics of chronic fatigue syndrome (aka systemic exertion intolerance disease)?
A
Relatively sudden onset of overwhelming fatigue, often associated with an infection such as mononucleosis
5
Q
What is cyclothymic disorder?
A
2+ years of numerous periods with fluctuating subclinical/mild hypomanic and depressive symptoms that do not meet the full criteria for hypomanic or major depressive episodes
6
Q
In bipolar manic episodes, the predominant mood may be ___ rather than elevated or euphoric.
A
Irritable
7
Q
Patients with bipolar disorder may exhibit ___ and ___ that are difficult to distinguish from ADHD.
A
Distractibility; hyperactivity
8
Q
Diagnostic criteria for anorexia nervosa?
A
Significantly low weight
Fear of weight gain
Distorted view of body weight and shape
9
Q
CV complications of anorexia nervosa?
A
Myocardial atrophy, bradycardia, hypotension, arrhythmias
10
Q
Renal complications of anorexia nervosa?
A
Poor urinary concentration, dehydration
11
Q
Neurological complications of anorexia nervosa?
A
Seizures, cognitive impairment
12
Q
Dermatological complications of anorexia nervosa?
A
Dry skin, lanugo
13
Q
Gynecological complications of anorexia nervosa?
A
Amenorrhea, infertility
14
Q
GI complications of anorexia nervosa?
A
Gastroparesis, constipation
15
Q
Hematologic complications of anorexia nervosa?
A
Cytopenia
16
Q
Other complications of anorexia nervosa?
A
Electrolyte depletion, osteopenia, hypercholesterolemia, hypercarotenemia
17
Q
What causes edema in anorexia nervosa?
A
Nutritional deficiency (commonly seen in the ankles and around the eyes)
18
Q
What causes osteopenia in anorexia nervosa?
A
Various endocrine abnormalities, hypercortisolism, GH resistance
19
Q
What electrolyte abnormalities may be seen in anorexia nervosa?
A
Magnesium, potassium, sodium, and phosphate may be normal or depleted
Hypokalemia due to self-induced vomiting is a common feature in patients with the binge-eating/purging subtype
20
Q
What causes hypercarotenemia in anorexia nervosa?
A
Due to excessive consumption of low-calorie, carotene-rich foods with impairment in hepatic clearance
21
Q
Euthyroid sick syndrome is commonly seen in anorexia nervosa due to the body’s adaptation to chronic nutritional depletion - what are the levels of T3/T4 and TSH?
A
Low levels of T3 and/or T4; TSH is usually normal or low
22
Q
Indications for lithium therapy?
A
Acute mania
Bipolar maintenance
23
Q
Contraindications to lithium therapy?
A
Chronic kidney disease
Heart disease
Hyponatremia or diuretic use
Pregnancy (teratogenic)
24
Q
What baseline studies should be performed when starting lithium therapy?
A
BUN, Creatinine, Ca2+, urinalysis
Thyroid function tests
EKG in patients with coronary risk factors (DM, HTN, smoking)
Pregnancy test (women of childbearing age)
25
Acute adverse effects of lithium?
```
Course tremors, ataxia, weakness
Polyuria, polydipsia
N/V, diarrhea
Cognitive impairment/altered mental status
Weight gain
```
26
Chronic adverse effects of lithium?
Nephrogenic DI
Chronic kidney disease
Thryoid dysfunction (most often hypothyroidism)
Hyperparathyroidism with hypercalcemia
27
What type of medication is bupropion?
Antidepressant
| NE and DA reuptake inhibitor
28
Contraindications to bupropion use?
Seizure disorders (seizures are a potential AE, especially at high doses)
Bulimia and anorexia nervosa (Eating disorders can cause electrolyte abnormalities that can precipitate seizures)
Recent use of MAOIs (past 2 weeks) - risk of HTN crisis
29
What common antidepressant side effects are not commonly seen with bupropion?
Weight gain
| Sexual dysfunction
30
Compare memory loss seen in normal aging vs. dementia.
Normal aging: pt can provide details about incidents of forgetfulness, pt is concerned about memory loss, recent memory for important events and conversations is intact
Dementia: cannot remember specific instances of forgetfulness, family is more concerned than patient, has notable decline in memory for recent important events and conversations
31
Compare word-finding difficulty seen in normal aging vs. dementia.
Normal aging: occasional (expressive aphasia), no receptive aphasia
Dementia: frequent, with substitutions, some receptive aphasia
32
Compare independence and functioning seen in normal aging vs. dementia.
Normal aging: maintains independence in ADLs, is able to operate common appliances, maintains interpersonal social skills, does not get lost in familial territory (may have to pause briefly to reorient)
Dementia: becomes dependent on others for ADLs, is unable to operate common appliances, loses interest in social activities, can get lost for hours in familiar territory while driving or walking
33
___ is a stimulant that produces increased energy, decreased appetite, and reduced need for sleep. Those who abuse this drug often have mood changes and weight loss secondary to decreased appetite.
Cocaine
34
What is a common physical finding in individuals who snort cocaine?
Erythema of the nasal mucosa
35
In addition to mood disturbances, list 4 other psychiatric complications of cocaine use.
Anxiety
Panic attacks
Grandiosity
Psychosis (delusinos and hallucinations)
36
___ involves lack of interest and avoidance of eating based on the sensory characteristics of food, with typical onset in infancy or early childhood.
Avoidant/restrictive food intake disorder
37
Abuse of what drug should be suspected in an individual with weight loss, behavioral changes, and erythema of the nasal mucosa?
Cocaine
38
What is acute intermittent porphyria (AIP)?
Hereditary disorder involving alterations in heme biosynthesis; characterized by intermittent neurovisceral symptoms
39
What presentation suggests AIP?
New onset of psychiatric and neurologic abnormalities, accompanied by unexplained acute abdominal pain and a family history of similar symptoms
40
Clinical manifestations of acute intermittent porphyria?
```
Abdominal pain (most common symptom) - neuropathic (tenderness may not be present)
Vomiting, constipation, sensory and motor neuropathies, tachycardia
Psychiatric symptoms may be nonspecific and may include anxiety, insomnia, restlessness, mood fluctuations, and psychotic symptoms
```
Acute symptoms may last for days to weeks and usually resolve between attacks
Age of onset - 30s or 40s
41
Lab abnormality in acute intermittent porphyria?
Elevated urinary porphobilinogen
42
Findings in Lyme disease?
Erythema migrans, nonspecific systemic symptoms, carditis (earlier)
Arthritic symptoms (later)
Common neurologic manifestations of Lyme disease include radiculopathies, meningitis, and cranial neuropathies
43
What is Wilson disease?
Disorder of copper transport, leading to copper accumulations that cause hepatic, psychiatric, and neurologic dysfunction
Findings include dysarthria, dystonia, tremor, parkinsonism, and copper deposits in the cornea (Kayser-Fleischer rings)
Depression is the most common psychiatric manifestation
44
The National Institute on Alcohol Abuse and Alcoholism has found evidence of negative health effects for women of all ages and men age 65+ who consume ___ drinks in a week or ___ in a day.
8+; 4+
| men <65: 15+, 5+
45
What lab abnormalities may be seen in a patient with alcohol use disorder?
Abnormal liver enzymes (AST/ALT ratio 2:1 or higher)
| Macrocytosis
46
Individuals with alcohol use disorder frequently seek primary care due to ___ and/or ___ symptoms from mild withdrawal.
Sleep disturbance; anxiety (use alcohol to fall asleep; as the blood alcohol level drops, CNS hyperarousal occurs and results in awakenings)
47
What is a frequent complication of Parkinson disease?
Psychotic symptoms (most commonly visual hallucinations and paranoid delusions)
48
What is the strongest predictor of nursing home placement in patients with Parkinson disease?
Psychotic symptoms
49
Although PD psychosis can occur as a result of the underlying disease process, the risk increases in patients treated with ___ medications (give examples).
Dopaminergic medications
Dopamine agonists (pramipexole, ropinirole) have a greater risk than the dopamine precursor and gold-standard medication arbidopa-levodopa
50
Treatment of PD psychosis?
Dose reduction of antiparkinson medication
Medication substitution
Addition of a low-potency antipsychotic medication
51
Give examples of low-potency antipsychotics used to treat PD psychosis.
Quetiapine, cloazpine, pimavanserin
| Minimal dopamine-2 receptor antagonism
52
Why should antipsychotics with more potent dopamine-2 receptor antagonism (haloperidol, risperidone) be avoided in PD psychosis?
Highest risk of EPS and will worsen Parkinson symptoms
53
___, an antiviral, and ___, an MAOI are both dopaminergic agents used in the treatment of PD.
Amantadine; selegiline
54
Clinical features of a specific phobia?
Marked anxiety about a specific object or situation (phobic stimulus) for >6 months
Avoidance behavior
Usually develops in childhood, often after a traumatic event
55
Prevalence of specific phobias?
10% of population
56
Treatment of specific phobias?
CBT with exposure (first-line)
| Short-acting benzodiazepines
57
Compare panic attacks that occur in panic disorder vs. specific phobias.
In contrast to panic disorder, panic attacks in specific phobia are always triggered by the phobic stimulus and do not occur unexpectedly
58
What is HIV-associated dementia?
Potentially severe neurocognitive disorder, more likely to be present in untreated HIV patients with a CD4+ cell count of <200/mm^3 and in patients with long-standing HIV disease
59
Pathophysiology of HIV-associated dementia?
Macrophage-mediated signaling pathways and associated toxicity may lead to neuronal dysfunction
60
Presentation of HIV-associated dementia?
Onset is typically subacute and characterized by increasing apathy and impaired attention
Early subcortical dysfunction leading to slowed movement and difficulty with smooth limb movement
Significant cortical neuronal loss and memory decline
61
How can the risk of developing HAD be decreased?
Antiretroviral therapy (resuming treatment may improve HAD symptoms)
62
Diagnostic criteria for ODD?
Recurrent pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness for 6+ months
Behaviors must be excessive compared to normative, age-appropriate behaviors and observed during interactions with individuals other than siblings
Argues with adults, defies authority figures, refuses to follow rules
Deliberately annoys others
Blames others for own mistakes or misbehavior
Easily annoyed, angry, resentful, or vindictive
Not due to another mental disorder
63
Rx - ODD?
Parent management training
Psychotherapy (anger management, social skills training)
NO pharmacotherapy, but assess for comorbid ADHD and treat if present
64
What is a common condition comorbid with ODD?
ADHD
65
The diagnosis of antisocial personality disorder is not made in individuals under age ___.
18
66
How is ODD different from Conduct Disorder?
CD involves more severe violations of basic rights
67
Although benzodiazepines are often prescribed for patients with insomnia and/or anxiety, they should be used sparingly in the elderly - why?
Due to increased risk of adverse effects; as people age, they metabolize benzos more slowly and are more likely to experience confusion and increased risk of falls. Another adverse effect is paradoxical agitation.
68
What are the characteristics of paradoxical agitation?
Increased agitation, confusion, aggression, and disinhibition, typically within an hour of administration
69
Why should terazosin (alpha blocker) be used cautiously in the elderly?
It may cause orthostatic hypotension or syncope, especiallyw ith the first dose
70
Discuss elements of the assessment for suicide risk (SAD PERSONS).
Sex
Age
Depression
```
Previous attempt
EtOH (or other substance) use
Rational thought loss (psychosis)
Social support lacking
Organized plan
No spouse or significant other
Sickness or injury
```
71
Define high imminent risk of suicide.
Ideation, intent, and plan
72
Define high non-imminent risk of suicide.
Ideation, intent, but no plan to act in the near future
73
Management of high imminent risk of suicide?
Ensure safety: hospitalize immediately (involuntarily if necessary)
Remove personal belongings and objects in room that may present self-harm risk
Constant observation and security may be required to hold against will
74
Management of high non-imminent risk of suicide?
Ensure close follow-up
Treat modifiable risk factors (underlying depression, psychosis, substance abuse, pain)
Recruit family or friends to support patient
Reduce access to potential means (secure firearms, medications)
75
True or false - significant concern about the patient's immediate safety overrides any "promises" made about agreeing to outpatient treatment.
True (especially when there is no established therapeutic alliance or relationship between patient and physician)
76
True or false - there is evidence that a "no-harm" contract is effective in reducing suicide.
False - there is little evidence that a "no-harm" contract is effective in reducing suicide
77
Common symptoms of alcohol withdrawal?
Tremors, agitation, anxiety, delirium, psychosis
78
Common symptoms of benzodiazepine withdrawal?
Seizures, tremors, anxiety, perceptual disturbances, psychosis, insomnia, psychomotor agitation, dysphoria
79
Common physical exam findings seen in alcohol and benzodiazepine withdrawal?
Seizures, tachycardia, palpitations
80
Common symptoms of heroin/opioid withdrawal?
Nausea, vomiting, abdominal cramping, diarrhea, muscle aches (myalgias, arthralgias),
81
Common physical exam findings seen in heroin/opioid withdrawal?
Dilated pupils, yawning, piloerection, lacrimation, hyperactive bowel sounds, rhinorrea, diaphoresis
Afebrile, alert and oriented
82
Common symptoms of stimulant (eg, cocaine, amphetamines) withdrawal?
Increased appetite, hypersomnia, intense psychomotor retardation, severe depression ("crash"), fatigue, vivid dreams
Minimal physical symptoms
83
Common symptoms of nicotine withdrawal?
Dysphoria, irritability, anxiety, increased appetite
84
Common symptoms of cannabis withdrawal?
Irritability, anxiety, depressed mood, insomnia, decreased appetite
85
Common physical exam findings of stimulant/nicotine/cannabis withdrawal?
No significant findings
86
Discuss the time course of opioid withdrawal symptoms.
Symptoms present within 6-12 hours (short-acting), can peak within 36-72 hours, and may continue for several days
24-48 hours after the last dose of lacrimation
87
Discuss the time course of alcohol withdrawal symptoms.
Develops 6-24 hours after the last drink, delirium tremens 2-4 days after the last drink if untreated
88
Benzodiazepine withdrawal presents with symptoms similar to alcohol withdrawal, but with less...
...predictability in time of onset and duration of symptoms.
89
___-acting benzodiazepines are likely to have later onset and a longer course of withdrawal symptoms.
Long (withdrawal from short-acting benzos can occur as early as 24 hours after cessation)
90
Diphenhydramine is an antihistamine with ___ effects. Withdrawal symptoms are rare - what would these be?
Anticholinergic; cholinergic rebound symptoms such as bradycardia and miosis
91
Compare a manic vs. hypomanic episode.
Manic:
Symptoms more severe
1 week unless hospitalized
Marked impairment in social or occupational functioning or hospitalization necessary
May have psychotic features; makes episode manic by definition
Hypomanic:
Symptoms less severe
4+ consecutive days
Unequivocal, observable change in functioning from patient's baseline
Symptoms not severe enough to cause marked impairment or necessitate hospitalization
No psychotic features
Both require elevated/irritable mood and increased energy, plus 3 symptoms (or 4 if mood is irritable)
92
Define Bipolar I.
Manic episodes
| Depressive episodes common but not required
93
Define Bipolar II.
Hypomanic episodes
| 1+ major depressive episodes
94
Diagnosis of hypomanic/manic episodes?
Requires elevated/irritable mood and increased energy + 3 of the following (or 4 if mood is irritable):
```
DIGFAST
Distractibility
Impulsivity (high-risk behaviors)
Grandiosity (delusions)
Flight of ideas/racing thoughts
Activity (increased goal-directed activity/psychomotor agitation)
Sleep (decreased need)
Talkativeness/pressured speech
```
95
How is a manic episode differentiated from a hypomanic episode in general?
Severity of symptoms, duration, and degree of functional impairment
96
If ___ symptoms are present, an episode is manic by definition.
Psychotic
97
What types of drugs are more likely to induce manic symptoms during intoxication?
Stimulants and cocaine
98
What is clozapine?
Second-generation antipsychotic used in treatment-resistant schizophrenia and schizoaffective disorder (failed 2+ antipsychotic trials), and in schizophrenic and schizoaffective patients with recurrent suicidality
99
Significant/key adverse affect of clozapine that requires monitoring?
Risk of neutropenia and life-threatening agranulocytosis (complete absence of neutrophils) in ~1% of patients
Regular monitoring of ANCs before dispensing the drug
100
Additional AE of clozapine?
Weight gain, metabolic syndrome, seizures, ileus, myocarditis, hypotension
LEAST likely (compared to other antipsychotics) to cause EPS, has not been shown to cause TD
101
List 7 primary indications for CBT.
```
Depression
GAD
PTSD
Panic disorder
OCD
Eating disorders
Negative thought patterns
```
102
Features of CBT?
Evidence-based, standardized modality of psychotherapy that targets persistent maladaptive thought patterns and behaviors
Combines cognitive and behavioral therapy
Challenges maladaptive cognitions
Targets avoidance with behavioral techniques (relaxation, exposure, behavior modification)
103
List 1 primary indication for interpersonal psychotherapy.
Depression
104
Features of interpersonal psychotherapy?
Links symptoms to current relationship conflicts and interpersonal skill deficits
105
List 2 primary indications for supportive psychotherapy.
1. Lower functioning; psychotic disorders
| 2. Patients in crisis
106
Features of supportive psychotherapy?
Maintains hope; provides encouragement
| Reinforces coping skills, adaptive defenses
107
List 2 primary indications for psychodynamic psychotherapy.
1. Higher functioning
| 2. Personality disorders
108
Features of psychodynamic psychotherapy?
Builds insight into unconscious conflicts and past relationships
Uses transference
Breaks down maladaptive defenses
109
List 1 primary indication for motivational interviewing.
SUDs
110
Features of motivational interviewing?
Nonjudgmental; acknowledges ambivalence and resistance
| Enhances intrinsic motivation to change
111
List 1 primary indication for DBT.
Borderline personality disorder
112
Features of DBT?
Improves emotion regulation, distress tolerance, mindfulness
| Decreases self-harm, builds skills
113
List 1 primary indication for DBT.
Prominent physical symptoms; pain disorders
114
Features of Biofeedback?
Improves control over physiological reactions to emotional stressors
115
Victims of sexual assault are at increased risk for what medical problems?
Major depression, contemplation of suicide, suicide attempts
STDs, pelvic pain, fibromyalgia, functional GI disorders, cervical cancer (may be linked to an avoidance of pelvic examinations)
116
___ personality disorder is characterized by a lifelong pattern of unstable interpersonal relationships, emotions, and self-identity through a range of contexts.
Borderline
117
Survivors of sexual assault are at high risk for developing ___, ___, and ___.
PTSD; depression; suicidality
118
Features of intoxication with phenchyclidine (PCP)?
Dissociative anesthetic causes hallucinations, dissociative feelings, agitation, confusion, tachycardia, and nystagmus (any time)
Can lead to psychotic and violent behavior, diminished pain perception, and subsequent physical injury
119
Onset and duration of action of PCP?
Rapid onset
| Duration < 8 hours
120
Symptoms of high dose PCP intoxication?
Severe HTN, seizures, rigidity, and life-threatening hyeprthermia
121
Features of alcohol intoxication?
Disinhibition, disorientation, horizontal nystagmus, slurred speech, unsteady gait
122
Features of cocaine intoxication?
Elevated BP and HR, euphoria, increased alertness
123
Features of Jimson weed intoxication?
Anticholinergic atropine-containing plant, manifests as anticholinergic poisoning
Hallucinations/delirium, hyperthermia, tachycardia, nonreactive mydriasis, dry and red skin
124
Features of lysergic acid diethylamide (LSD) intoxication?
Visual hallucinations and illusions, euphoria or dysphoria, and depersonalization, mild HTN and tachycardia
Orientation is often intact
125
Features of methamphetamine intoxication?
Severe psychomotor agitation, hallucinations, tachycardia, HTN
126
Duration of action of methamphetamine?
<20 hours (longer than PCP)
127
True or false - bipolar I disorder is a lifelong illness that requires maintenance pharmacotherapy to reduce the risk of recurrent mood episodes.
True
128
If a patient with bipolar I disorder insisted on stopping lithium, what would be the first step in management? If he refused all pharmacotherapy?
Cross-taper to another antimanic agent; slowely taper over weeks to months and frequently monitor for early signs and symptoms of recurrence
129
Upper end of therapeutic lithium level range?
1.2+ mmol/L
