Psychiatry Flashcards
1
Q
What are the types of noninvasive neuromodulation and what are they used for?
A
Electroconvulsive therapy
Transcranial magnetic stimulation
Mostly for refractory depression, ECT also used for BD, schizophrenia/schizoaffective disorder, catatonia, neuroleptic malignant syndrome
2
Q
Which eating disorder is most commonly comorbid with BD?
A
Binge eating disorder
3
Q
Main treatments for binge-eating disorder?
A
Psychotherapy (esp CBT)
SSRIs (e.g. fluoxetine)
Lisdexamfetamine (amphetamine derivative), topiramate (reduce weight gain/impulsiveness)
4
Q
In the stress diathesis model, sustained elevated cortisol leads to what physical change in the brain?
Is this reversible?
A
Hippocampal shrinkage due to cortisol blocking BDNF —> emotional dysregulation, memory loss
Antidepressants + stress management can mostly reverse
5
Q
Name the first 5 individuals on the SDM hierarchy
A
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
6
Q
Who is at the bottom of the SDM hierarchy if no family can be found?
A
Public guardian and trustee (government representative)
7
Q
What act applies to both incapacity for mental health and medical treatment? Which act only applies to mental health treatment? What form is required?
A
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
8
Q
Form 1 allows what?
A
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
9
Q
What is a form 42?
A
Notice to pt they are under form 1
10
Q
Form 1 allows detention but not ____. What else do you need to issue?
A
NOT TREATMENT! (unless emergency)
Need Form 33 to provide treatment w/out consent
11
Q
What is a form 2?
A
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)
12
Q
What is a Form 3?
Who fills it out?
How is patient notified?
A
Certificate of involuntary admission (14 days)
CANNOT be filled out by same physician as Form 1
Form 30 notifies pt
13
Q
What is a Form 4? 4A?
A
After form 3 expires –> Form 4 for 1 month, 2 months then 3 months, then 4A (certificate of continuation) = 3 months
14
Q
Form 50 = confirmation of ___
Given by who to who?
A
Rights advise (given by Rights Advisor to physician who issued form 33)
15
Q
What are the 2 diff criteria for a Form 1 or 2?
A
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)
16
Q
How do you have evidence of mental disorder for Form 1 Box A?
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)
17
Q
If you use Box B criteria you must ALWAYS have a finding of ____
A
Incapacity (also issue for 33!)
+ SDM consent obtained
18
Q
What are the 3 core (positive) symptoms of psychosis?
A
1) Delusions
2) Hallucinations
3) Disorganization (speech, thought, behaviour)
19
Q
Name 4 general categories of what can cause psychosis
A
1) Primary psychotic disorder (schizophrenia, schizoaffective, etc.)
2) Mood disorders (MDD, BD)
3) Substances
4) Organic etiologies (neuro, dementia, hypothyroid, delirium, etc)
20
Q
How is orientation generally affected in psychiatric psychosis vs delirium
A
Psychosis: usually intact
Delirium: often very affected
21
Q
What can happen to sleep-wake cycle in psychiatric psychosis
A
Day-night reversal
22
Q
How are ventricles affected in schizophrenia? What other areas of the brain are affected?
A
Ventricles enlarged
Frontal lobe & cortical grey matter atrophy
23
Q
DSM-V criteria for schizophrenia
A
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
24
Q
What are the 4 dopamine pathways (+projects from where to where)
A
1) Mesolimbic (VTA of midbrain –> nucleus accumbens (ventral basal ganglia)
2) Mesocortical pathway (VTA –> frontal cortex)
3) Nigrostriatal (SN –> striatum)
4) Tuberoinfundibular (hypothalamus –> pituitary)
25
Define anasognosia
Lack of ability to perceive the reality of your own illness (lack of insight)
26
What is schizophreniform disorder?
Same as schizophrenia but 1-6 months
27
What is brief psychotic disorder?
Same as schizophrenia/schizophreniform but <1 month
28
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
29
What 3 things are assessed in the Glasgow coma scale?
1) Eye opening response
2) Verbal response
3) Motor response
30
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
31
Pathophysiological process underlying delirium
Acute encephalopathy (diffuse process in brain, no structural lesions)
32
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
33
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
34
What is sundowning?
Phenomenon where delirium usually worsens in the evening
35
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)
36
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
37
Name 4 important labs to do in delirious patient regardless of suspected etiology
CBC (anemia, WBCs)
BMP (glucose, urea/creatinine, electrolytes)
LFTs
Urinalysis
38
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
```
39
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
40
Nonpharm methods to treat/prevent delirium
Reorientation, family members, pain relief/comfort, adequate sleep (reduce noice), reduce delirium-inducing drugs, vavoid restraints
41
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)
42
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!
```
43
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
44
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
```
45
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
46
What is the difference between mania and hypomania
Duration + severity
Mania = 1+ week (unless v severe e.g. psychosis)
Hypomania = 4+ days
47
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
48
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
49
How are Bipolar I & II defined?
Type II = hypomania + at least 1 MDE
| Type I = at least 1 manic episode (MDE not required)
50
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
51
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
52
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
53
What are the main anxiety disorders?
1) GAD
2) OCD
3) Panic disorder
4) PTSD
5) Social anxiety disorder
6) Specific phobias
54
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.)
55
More correct term for antipsychotics = ?
| Difference between Typicals (old) & Atypicals (new)
Dopamine blockers (because also used as antidepressants, mood stabilizers)
Typicals: D2 blocker
Atypicals: D2 & 5HT2a, more expensive, typically less EPS
56
Dopamine blockade in schizophrenia (treatment) leads to what symptoms in the 4 pathways
Mesolimbic --> reduce positive symptoms
Mesocortical --> may increase neg symptoms!
Nigrostriatal --> EPS
Tuberoinfundibular --> hyperprolactinemia
57
Biggest ADEs of typical vs atypical antipsychotics
Typicals: EPS, anti-cholinergic, sedation
Atypicals: metabolic syndrome, strokes, QT prolongation (--> afterdepolarizations)
58
What are some side effects of clozapine?
Agranulocytosis (need very freq bloodwork!)
Sialorrhea
Constipation (co-prescribe laxatives)
Anticholinergic effects
59
What type of antipsychotics are aripiprazole & brexpirazole?
3rd gen, dopamine "balancers" (partial agonists) --> improve positive & negative
Also impacts serotonin receptors
*also have EPS
60
List 6 SSRIs by brand name
1) Prozac
2) Paxil
3) Luvox
4) Zoloft
5) Celexa
6) Cipralex/Lexapro
61
Typical antipsychotics often end in ____ or ___
Atypicals often end in ___ or ___; ___ = 3rd gen
(not always)
-ine or -ol = typicals (chlorpromazine, haloperidole)
-pine or -done = atypicals (clozapine, olanzapine, quentiapine, risperidone)
zole = 3rd gens
62
What is SSRI poop-out?
Drug that was previously working stops (not a compliance issue)
63
Fluoxetine =
Prozac (SSRI)
64
Sertraline =
Zoloft (SSRI)
65
Citalopram =
Celexa (SSRI)
66
Escitalopram =
Cipralex/Lexapro (SSRI)
67
What are SNRIs?
Selective Serotonin Norepinephrine Reuptake Inhibitors (BOTH S & N!)
68
SNRIs have what additional side effect compared to SSRIs?
Increased BP
69
What are NDRIs? What is the only drug in this class? Other purpose?
Norepinephrine/dopamine re-uptake inhibitors
Bupropion (Wellbutrin, Zyban)
Also used to treat smoking
70
Side effect pro/con of NDRIs?
Rarely impairs sexual dysfunction, little weight gain
| Can cause seizures, increased BP, stimulating
71
Duloxetine, venlafaxine = what drug class?
SNRIs
72
What type of drug is mirtazapine (Remeron)? Prominent ADE?
NaSSA (noradrenergic/specific serotonergic antidepresents)
| SEDATIVE side effect, good for depression w/ prominent INSOMNIA
73
Moclobemide (Manerix) is what type of drug? Main ADEs?
rMAOIs
(reversible inhibitors of monoamine oxidase A)
Can cause stimulation/insomnia
Less tyramine issues than MAOIs
74
Name 5 first-line classes of antidepressants
```
SSRIs
SNRIs
NDRIs
NaSSAs
rMAOI
```
75
Serious side effects of TCAs
Mania
Cardiotoxicity in overdose
Anticholinergic/CV side effects
76
What atypical antipsychotic is an option for unipolar depression?
Quentiapine
77
What is an issue with traditional MAOis?
Need to avoid all tyramine-containing foods (fermented foods etc)
Hypertensive crisis can be caused by inhibition of tyramine removal
78
What is the difference between med augmentation, combination, and switching in depression?
```
Augmentation = adding another drug that isn't an antidepressant
Combination = adding another AD
Switching = wean off then start something else
```
79
In pts with BD an AD shouldn't be prescribed before what? Why?
Shouldn't be before mood stabilizes because AD can --> manic episode
80
First line mood stabilizer. Mech of action?
Lithium
Inhibits excitatory NTs (dopamine/glutamate)
Promotes GABA-mediated neurotranmission
81
Issue with lithium
Narrow therapeutic window, need to monitor, constant salt/fluid intake
Can cause kidney ADES (polyuria/dipsia due to salts, DI, lower GFR, kidney atrophy/sclerosis)
82
Lithium toxicity can appear like..
Drunkenness
83
What are 2 anticonvulsants that can be used as mood stabilizers
Valproate & carbamazepine
84
What is the difference between valproic acid (Depakene) & divalproex (Epival)
Divalproex = 2 molecules + Na
| salt is easier on GI tract
85
Buspirone treats what?
Anxiety (anxiolytic)
| "Don't be anxious if the BUS doesn't come at ONE"
86
Idiosyncratic reaction to neuroleptics =
Neuroleptic malignant syndrome
87
Clinical features of neuroleptic malignant syndrome
Muscular rigidity, high CPK
Tachycardia & hyperthermia
Altered consciousness, dysautonomia
88
How to treat neuroleptic malignant syndrome
D/C drug, supportive care, Dantrolene (muscle relaxant)
89
Classic triad of serotonin syndrome
Neuromuscular excitability
Autonomic dysfunction
Altered mental status
90
List 4 extrapyramidal side effects
1) Parkinson-like symptoms (rigidity, bradykinesia, resting tremor, gait abnormalities)
2) Dystonia
3) Akathisia (restlessness esp in legs --> pacing, excess movement)
4) Tardive dyskinesia
91
Continuance of ideas from normal --> most abnormal
Normal
Circumstantiality (return to point, usually normal)
Tangentiality
Flight of ideas/loose associations/derailment
Incoherence/word salad
92
Between reality & delusions are....
Overvalued ideas
93
Over-sensitivity to sound =
Hyperacusis
94
What is the SCOFF screening for eating disorders
Do you make yourself SICK because you feel uncomfortably full?
Do you worry that you have lost CONTROL over how much you heat?
Have you recently lost more than ONE stone (~6.5) in a 3-month period
Do you believe yourself to be FAT when others say you are too thin?
Would you say that FOOD dominates your life?
(2+ --> likely AN or Bulimia)
95
What is a structure that can be used for the Impression/Formulation on a psych history
4 Ps: Predisposing, precipitating, perpetuating, protective
| within each, biological, psychological, social
96
2-question approach to screen for depression?
1) During the past month, have you often been bothered by feeling down, depressed, or hopeless?
2) During the past month, have you been bothered by little interest/pleasure in doing things?
97
Low risk drinking guidelines for women & men (per day, special occasions, per week)
Women: 2, 3, 10
Men: 3, 4, 15
98
DSM diagnosis of somatic symptom disorder
At least 1 somatic symptoms that is distressing (doesn't need to be "medically unexplained"
Excessive thoughts/feelings/behaviours related to somatic symptoms/health (disproportionate thinking about severity, anxiety, excessive time/energy)
6+ months
99
Components of "consultation letter" from a psychiatrist for a patient with somatic symptom disorder
- take symptoms seriously, don't say "all in your head"
- don't refer for investigation unless clear indication
- regular visits w/ same physician w/ physical exam
- reassurance + invitation to talk about personal life
100
What is conversion disorder
Neuro symptoms w/out organic explanation (not intentional) causing distress
101
What is the new term for hypochondriasis
Illness anxiety disorder
102
What is pseudocyesis
False believe you're pregnant + PHYSICAL signs of early pregnancy
103
Factitious disorder can be ___ or ____
| Goal?
Imposed on self or other
| Goal = to get med attention/sympathy though goal can be unconscious
104
OCD DMS criteria (3)
1) Presence of obsessions, compulsions, or both
2) Take >1 hour per day or cause significant distress/impairment
3) Not attributable to substance of or other medical conditions, or other mental disorder
105
For OCD diagnosis specify if...
Level of insight (into OCD believes)
| Good/fair, poor, or absent/delusional
106
Define obsession
- Recurrent thoughts/urges/images experienced as intrusive/unwanted, cause anxiety/distress
- Person attempts to ignore or suppress such thoughts or neutralize w/ an action (compulsion)
107
Define comuplsion
Repetitive behaviours/mental acts driven to perform in response to an obsession or according to rigid rules
- aimed to reduce anxiety but not realistically connected to what you're trying to neutralize
108
Main non-pharm treatment for OCD
CBT (exposure to anxiety-provoking stimuli + prevent compulsive response)
109
Cluster A personality disorders
"Odd/eccentric"
1) Paranoid
2) Schizoid (disinterest in others)
3) Schizotypal (eccentric)
110
Cluster B personality disorders
"Dramatic/erratic"
1) Antisocial
2) Borderline
3) Histrionic
4) Narcissistic
111
Main characteristics of BPD
Persistent pattern of unstable relationships, self-image, emotions (dysregulation) + impulsivity
112
Cluster C personality disorders
"Anxious/fearful"
1) Avoidant (afraid of rejection but actually want social contact)
2) Dependent
3) OCPD
113
Antisocial personality disorder if <18?
Conduct disorder
OR
Oppositional defiant disorder if only within home
114
Is BPD more prevalent in men or women?
Women more in clinic but 1:1 in genpop
115
BPD is diff than histrionic/narcissistic PDs because..
Pt sees themself as "bad"
116
Patients w/ BPD have a high risk of...
Suicide
117
Drugs to treat panic attacked
Antidepressants
Benzos work factor but more adverse effects/withdrawal; combine then taper benzo as AD kicks in
BB can control HR
118
Psychotherapy for panic disorders
Exposure therapy, CBT
119
Panic attacks turn to panic disorders based on ____
Conditioned anxiety
120
Diagnostic criteria of panic disorder
```
"STUDENTS Fear the 3Cs" (4 of 13)
Sweating
Trembling
Unsteadiness/dizziness
Derealization (feel surroundings aren't real)
Elevated HR
Nausea
Tingling
SOB
Fear of dying/going crazy
Chest pain
Choking
Chills
+ persistent worry about future attacks + maladaptive behaviour to avoid this
```
121
Difference between avoidant personality vs social phobia
| Commonality?
Avoidant can be life of party but not allow people to get close
Social phobics can't got to parties/gatherings but can have enduring close friendships
Commonality = self-esteem issues
122
Self-esteem in OCPD?
Low
123
Problematic # of drinks in one sitting for men vs women?
| Per week?
4 for women, 5 for men in one sitting
| 10 & 15 per week
124
Canada's low-risk drinking guidelines (day, special occasion, week)
Women: 2, 3, 10
Men: 3, 4, 15
125
Name 3 drugs to treat alcohol use disorder
Naltrexone
Acamprosate
Disulfiram (Antabuse)
126
How does naltrexone work for AUD? Cautions?
Blocks opioid receptor --> reduces euphoric effect of alcohol
Reduces cravings
*Causes withdrawal if pt also taking opioids, can increase liver enzymes
127
How does acamprosate work for AUD?
Antagonizes glutamate receptors to relieve subacute withdrawal symptoms (best if abstinent a few days before)
128
How does antabuse work?
inhibits alcohol dehydrogenase --> sick after you drink
| Deterrent
129
How does methadone work for opioid use disorder
Long-acting, less euphoria
130
How does buprenorphine work for opioid use disorder
Partial agonist
VERY high affinity so displaces other opioids
Less high, less withdrawal
131
How does suboxone work for OUD?
Buprenorphine + naloxone
| Naloxone only activated if injected (misuse) --> withdrawal
132
What are 2 opioid antagonists and how do they work differently for OUD?
1) Naloxone - rapid onset, short-acting (for OD)
| 2) Naltrexone - longer-acting to promote long-term abstinence (have to be off opioids at least a week first)
133
Mechanism of action of stimulants for ADHD. 2 main types?
Methylphenidate blocks dopamine/NE reuptake
Amphetamine blocks reuptake AND increase dop/NE release
both increase REGULATORY activity of brain in prefrontal cortex (stimulant paradox)
134
First line stimulants for ADHD
Methylphenidates: Concerta, Biphentin
Amphetamines: Adderall XR, Vyvanse
135
CV screening before putting someone with ADHD on stimulant
Screen based on known cardiac abnormalities, FMHx, other sympathomimetic drugs, exercise intolerance/syncope
if YES to above --> EKG
136
4 attachment style
Secure
Avoidant
Ambivalent/resistant/anxious
Disorganized
137
Diff between ODD and conduct disorder?
Conduct disorder more serious, linked to antisocial personality disorder in adulthood (violence, vandalism more serious misconduct)
ODD is more behavioural issues at home but not dangerous
