Psychiatry Flashcards
What are the types of noninvasive neuromodulation and what are they used for?
Electroconvulsive therapy
Transcranial magnetic stimulation
Mostly for refractory depression, ECT also used for BD, schizophrenia/schizoaffective disorder, catatonia, neuroleptic malignant syndrome
Which eating disorder is most commonly comorbid with BD?
Binge eating disorder
Main treatments for binge-eating disorder?
Psychotherapy (esp CBT)
SSRIs (e.g. fluoxetine)
Lisdexamfetamine (amphetamine derivative), topiramate (reduce weight gain/impulsiveness)
In the stress diathesis model, sustained elevated cortisol leads to what physical change in the brain?
Is this reversible?
Hippocampal shrinkage due to cortisol blocking BDNF —> emotional dysregulation, memory loss
Antidepressants + stress management can mostly reverse
Name the first 5 individuals on the SDM hierarchy
1) Guardian
2) POA for personal care
3) Representative from consent/capacity board
4) Spouse (incld common law and “most important primary person in both individuals’ lives)
5) Child/parent
Who is at the bottom of the SDM hierarchy if no family can be found?
Public guardian and trustee (government representative)
What act applies to both incapacity for mental health and medical treatment? Which act only applies to mental health treatment? What form is required?
Mental Health Act only to mental health
Health Care Consent Act to both
Form 33 ONLY REQUIRED FOR MENTAL HEALTH; for medical, rights advisor doesn’t need to be notified, the HCP can tell the pt
Form 1 allows what?
You have 7 days to apprehend pt
Can be detained for psych evaluation for 72 hours at a schedule 1 facility
Physician signing form must have seen pt in the last 7 days
What is a form 42?
Notice to pt they are under form 1
Form 1 allows detention but not ____. What else do you need to issue?
NOT TREATMENT! (unless emergency)
Need Form 33 to provide treatment w/out consent
What is a form 2?
Same conditions as form 1 but issued by Justice of the Peace
Allows police to bring personal to hospital but doesn’t authorize detainment (doc needs to issue form 1)
What is a Form 3?
Who fills it out?
How is patient notified?
Certificate of involuntary admission (14 days)
CANNOT be filled out by same physician as Form 1
Form 30 notifies pt
What is a Form 4? 4A?
After form 3 expires –> Form 4 for 1 month, 2 months then 3 months, then 4A (certificate of continuation) = 3 months
Form 50 = confirmation of ___
Given by who to who?
Rights advise (given by Rights Advisor to physician who issued form 33)
What are the 2 diff criteria for a Form 1 or 2?
Box A: Risk of harm to self or others PLUS evidence of a mental disorder
Box B: need to treat (had past effective treatment for mental disorder that could result in serious harm to self/others, current episode likely to be same)
How do you have evidence of mental disorder for Form 1 Box A?
1) Past/Present Test: evidence of risk/danger (HPI, history)
2) Future Test: evidence to support findings of mental disorder causing the risks above (MSE etc)
If you use Box B criteria you must ALWAYS have a finding of ____
Incapacity (also issue for 33!)
+ SDM consent obtained
What are the 3 core (positive) symptoms of psychosis?
1) Delusions
2) Hallucinations
3) Disorganization (speech, thought, behaviour)
Name 4 general categories of what can cause psychosis
1) Primary psychotic disorder (schizophrenia, schizoaffective, etc.)
2) Mood disorders (MDD, BD)
3) Substances
4) Organic etiologies (neuro, dementia, hypothyroid, delirium, etc)
How is orientation generally affected in psychiatric psychosis vs delirium
Psychosis: usually intact
Delirium: often very affected
What can happen to sleep-wake cycle in psychiatric psychosis
Day-night reversal
How are ventricles affected in schizophrenia? What other areas of the brain are affected?
Ventricles enlarged
Frontal lobe & cortical grey matter atrophy
DSM-V criteria for schizophrenia
2 or more of the following present 1+ months: hallucinations, delusions, disorganized speech/behaviour, apathy/affective flattening
+Marked decline in social/occupational functioning
6+ months duration
What are the 4 dopamine pathways (+projects from where to where)
1) Mesolimbic (VTA of midbrain –> nucleus accumbens (ventral basal ganglia)
2) Mesocortical pathway (VTA –> frontal cortex)
3) Nigrostriatal (SN –> striatum)
4) Tuberoinfundibular (hypothalamus –> pituitary)
Define anasognosia
Lack of ability to perceive the reality of your own illness (lack of insight)
What is schizophreniform disorder?
Same as schizophrenia but 1-6 months
What is brief psychotic disorder?
Same as schizophrenia/schizophreniform but <1 month
Name 7 different Levels of Consciousness categories
1) Alertness
2) Somnolence (easily aroused)
3) Lethargy
4) Obtundation
5) Stupor (need STRONG external stimulus)
6) Coma (eyes closed, no response, weak/absent reflexes, but preserved ABCs unlike braindeath)
7) Delirium
What 3 things are assessed in the Glasgow coma scale?
1) Eye opening response
2) Verbal response
3) Motor response
What are decorticate and decerebrate responses? Which is worse?
Abnormal posturing responses to noxious stimuli
Decorticate = upper body flexion (better) = damage to corticospinal tracts above midbraine
Decerebrate = upper body extension (worse) = upper pontine damage
Both have legs extended + feet plantar flexed
Pathophysiological process underlying delirium
Acute encephalopathy (diffuse process in brain, no structural lesions)
Common etiologies of delirium
Infections
Withdrawal Acute metabolic disorders (AKI, liver failure, electrolytes) Trauma CNS pathology (stroke, tumor) Hypoxia (anemia, HF, COPD, PE)
Deficiencies (B12, folate, thiamine) Endocrine (DKA, hyper/hypothyroid, adrenal crisis) Acute CV collapse/MI Toxins/drugs Heavy metals
Also: ongoing constipation, urinary retention, pain, vision/hearing loss, dehydration
What is oxybutynin and how does it relate to delirium?
It’s a muscarinig antagonist used to treat urge incontinence
Anticholinergics are a RF for delirium
What is sundowning?
Phenomenon where delirium usually worsens in the evening
How is psychomotor activity affected in delirium?
May be hypoactive (esp in elderly), hyperactive/agitated (esp in substance use/withdrawal), or mixed (most common in gen pop)
Confusion Assessment Method (CAM) for assessing delirium
1) Acute onset change in mental status, fluctuating
2) Inattention
AND
3) Altered consciousness (hypervigilant or decreased)
OR
4) Disorganized thinking
Name 4 important labs to do in delirious patient regardless of suspected etiology
CBC (anemia, WBCs)
BMP (glucose, urea/creatinine, electrolytes)
LFTs
Urinalysis
Based on the possible etiologies of delirium, what other tests might you order
CT/MRI head, EEG, LP CXR ECG/echo B12, folate, thiamine Urine/serum toxicology Cultures TSH, cortisol
Delirium is reversible when the underlying condition is treated but…
May sometimes persist for several weeks after correction, potentially requiring hospital admission for that time
Nonpharm methods to treat/prevent delirium
Reorientation, family members, pain relief/comfort, adequate sleep (reduce noice), reduce delirium-inducing drugs, vavoid restraints
Meds to treat delirium if nonpharm measures insufficient and posing risk to self/others
1) Antipsychotics (esp HALOPERIDOL)
2) Benzos (lorazepam) - ONLY for pts w/ alcohol or benzo withdrawal (antipsychs have seizure risk)
Definition of Binge-Eating Disorder
Recurrent binge eating w/out purging at least once per week for 3 months Lack of control over amount of food consumed w/ at least 3 of: - eating must faster - eating until uncomfortably full - when not physically hungry - alone because embarrassed - feeling disgusted/guilty/depressed Market distress!
DSMV definition of Major Depressive Order (9 traits)
At least 5 (mood and/or anhedonia MUST be present) nearly every day for 2 weeks: (SIG ME CAPS)
Sleep
Interest (anhedonia)
Guilt/worthlessness feelings
Mood (depressed)
Energy (fatigue)
Concentration difficulties
Appetite changes
Psychomotor activity changes
Suicidal ideation
Definition of Dysthymia (Persistent Depressive Disorder)
1) Depressed mood for most of day, more days than not, 2+ years (never 2 months w/out in this period)
HE’S SAD
Hopelessness Energy (low) Self esteem (low) Sleep (more or less) Appetite changes Decision-making/concentration impaired
After how much time does grief meet criteria for diagnosis? What is this disorder called?
Persistent Complex Bereavement Disorder
>6 months for youth
>12 for adults
*Diff than MDD because focused on the loss, generally not suicidal. But diff than grief because of more emptiness, loss of joy in other things, numbness, etc that doesn’t pass
What is the difference between mania and hypomania
Duration + severity
Mania = 1+ week (unless v severe e.g. psychosis)
Hypomania = 4+ days
What are the symptoms characterizing mania/hypomania (7)
3+ of the following: DIGFAST
Distractibility
Indiscretion (risk-taking)
Grandiosity (increased confidence)
Flight of ideas
Agitation (psychomotor)/activity increased
Sleep need reduced
Talkative
Why do pts need treatment for hypomania?
It’s generally actually pleasant but you need to stabilize mood because of MDEs which are often much more frequent
How are Bipolar I & II defined?
Type II = hypomania + at least 1 MDE
Type I = at least 1 manic episode (MDE not required)
Define cyclothymic disorder
2+ years (1 year in children/adolescents) periods of hypomanic & depressive symptoms that never meet criteria for hypomania, mania, or MDE
Symptoms present at least half the time and never absent for 2+ months within the 2 eyars
60% of patients with MDD have a comorbid..
Anxiety (or related) disorder
also 1/3 of anxiety pts suffer form MDD!
(diff stat: 80% of patients with anxiety disorders during the course of their illness will present with secondary depression)
EITHER WAY VERY COMORBID
What is the criteria for GAD?
Excessive & hard-to-control anxiety/worry most days for 6+ months
WATCHERS Worry, Anxiety (required) 3+ of: Tension (muscles) Concentration difficult or mind going "blank" Hyperarousal/irritability Energy (easily fatigued) Restlessness Sleep disturbance
*+Distress/impairment
What are the main anxiety disorders?
1) GAD
2) OCD
3) Panic disorder
4) PTSD
5) Social anxiety disorder
6) Specific phobias
6 criteria of PTSD
TRAUMAS
1) TRAUMA Exposure to actual or threatened death, serious injury, or sexual violence (direct, witnessing, learning about it)
2) REEXPERIENCING - Intrusion symptoms associated with the events (dreams, flashbacks, physiological reactions)
3) AVOIDANCE Persistent avoidance of associated stimuli
4) UNABLE to function
MONTH (lasts >1 month)
5) AROUSAL - Altered arousal/reactivity (incld sleep disturbance)
6) SELF - Negative alterations in cognitions/mood (negative beliefs, distorted cognitions, detachment, anhedonia, memory issues, etc.)
