Psychiatry Flashcards
Treatment for acute psychosis in an emergency setting:
4 options
1) Haloperidol 5 mg IM +/- lorazepam 2 mg
2) Loxapine PO +/- Lorazepam
3) Olanzapine PO/IM
4) Risperidone
What is trichotillomania?
Hair-pulling disorder
Most effective antypsychotic drug and its classification
Clozapine, atypical
Side effects of Clozapine, routine blodwork when using this drug
Agranulocytosis Anticholinergic activityh Cardiomyopathy Myocarditis * Check CBC because of the risk of agranulocytosis
Name some typical antipsychotics (6 drugs)
Haloperidol Fluphenazine Zuclopenthixol Perphenazine Loxapine Chlorpromazine
Name some atypical antypsychotics (8 drugs)
1) Risperidone
2) Paliperidone
3) Olanzapine
4) Asenapine
5) Ziprasidone
6) Aripiprazole
7) Quetiapine
8) Clozapine
Clusters of personality disorders
Cluster A: “Mad” personality disorders
Cluster B: “Bad” personality disorders
Cluster C: “Sad” personality disorders
Cluster A personality disorders: characteristics, family history and typical defence mechanisms
(Cluster A: “Mad” personality disorder)
Characteristics: Patient seems odd, eccentric and withdrawn
Family history of psychotic disorders
Defence mechanisms: intellectualization, projection, magical thinking
Which personality disorders belong to Cluster A personality disorders? (3 disorders)
BONUS point for the mnemonic!
Cluster A: “Mad” personality disorder
1) Paranoid personality disorder (SUSPECT)
2) Schizotypal personality disorder (ME PECULIAR)
3) Schizoid personality disorder (DISTANT)
Which personality disorders belong to Cluster B personality disorders? (4 disorders)
BONUS point for the mnemonic!
Cluster B: “Bad” personality disorders.
1) Borderline personality disorder (IMPULSIVE)
2) Narcissistic personality disorder (GRANDIOSE)
3) Antisocial personality disorder (CORRUPT)
4) Histrionic personality disorder (ACTRESSS)
Which personality disorders belong to Cluster C personality disorders? (3 disorders)
BONUS point for the mnemonic!
Cluster C: “Sad” personality disorders.
1) Avoidant personality disorder (CRINGES)
2) Obsessive-compulsive personality disorder (SCRIMPER)
3) Dependent personality disorder (RELIANCE)
Cluster B personality disorders: characteristics, family history and typical defence mechanisms
Cluster B: “Bad” personality disorders.
Characteristics: Patient is dramatic, emotional, inconsistend
Family history of mood disorders
Defence mechanisms: Denial, acting out, regression, splitting, projective identification, idealization/devaluation
Cluster C personality disorders: characteristics, family history and typical defence mechanisms
Cluster C: “Sad” personality disorders
Characteristics: Patient is anxious and fearful
Family history of anxiety disorders
Defence mechanisms: isolation, avoidance hypochondriasis
Characteristic of dependent personality disorder
Pervasive and excessive need to be taken care of, excessive fear of separation, clinging and submissive behaviors.
Difficulty making everyday decisions.
Useful to set regulated treatment schedule (regular, brief visits) and being firm about in between issues. Encourage patient to do more for themselves, engage in own problem-solving.
Characteristics of Obsessive-Compulsive Personality Disorder
Preoccupation with orderliness, perfectionism, and mental and interpersonal control. Is inflexible, closed-off, and inefficient.
Characteristics of Avoidant Personality Disorder
Timid and socially awkward with a pervasive sense of inadequacy and fear of criticism. Fear of
embarrassing or humiliating themselves in social situations so remain withdrawn and socially
inhibited
Characteristics of Histrionic Personality Disorder
Attention-seeking behaviour and excessively emotional. Are dramatic, flamboyant, and extroverted. Cannot form meaningful relationships. Often sexually inappropriate
Characteristics of antisocial personality disorder
Lack of remorse for actions, manipulative and deceitful, often violate the law. May appear charming on first impression. Pattern of disregard for others and violation of others’ rights must be present before age 15; however, for the diagnosis of ASPD patients must be at least 18. Strong association with Conduct Disorder, history of trauma/abuse common
Characteristics of narcissistic personality disorder
Sense of superiority, needs constant admiration, lacks empathy, but with fragile sense of self. Consider themselves “special” and will exploit others for personal gain
Characteristic of borderline personality disorder
Unstable moods and behaviour, feel alone in the world, problems with self-image. History of repeated suicide attempts, self-harm behaviours. Inpatients commonly report history of sexual abuse. Tends to fizzle out as patients age.
Characteristic of schizoid personality disorder
Neither desires nor enjoys close relationships including being a part of a family; prefers to be alone. Lifelong pattern of social withdrawal. Seen as eccentric and reclusive with restricted affect
Characteristic of schizotypal personality disorder
Pattern of eccentric behaviours, peculiar thought patterns
Characteristics fo paranoid personality disorder
Pervasive distrust and suspiciousness of others, interpret motives as malevolent. Blame problems on others and seem angry and hostile.
Name the types of delusions (7) and explain them
1) Persecutary delusions: Others are trying to harm them
2) Delusions of grandeur: Believes that they have special powers, talents or abilities
3) Somatic delusions: Belief that they have a physical disorder/defect
4) Delusions of reference: Interpreting publicly known events/celebreties as having a direct reference to them.
5) Nihilistic delusions: Belief that things do not exist, are meaningless or nothing is real
6) Erotomania: belief that another is in love with them
7) Religious: receiving instructions/powers from a higher being, believes to be a higher being
Symptoms of TCA overdose + findings on ABG
Palpitations, chest pain, hypotension, arrhythmias, decreased mental status, respiratory depression, increased temperature, flushing, dilated pupils.
ABG: Acidosis and hypoxia
Tourette’s syndrome: preferred medications (2 options)
Dopamine-receptor-blocking agents are most effective.
Pimozide (antipsychotic)
Clonisine (alpha 2 agonist)
5 risk factors for delirium
1) Impaired vision/hearing
2) Dehydration
3) Immobility
4) Cognitive impairment
5) Sleep deprivation
Symptoms of serotonin syndrome
1) Mental status: anxiety, restlessness
2) Increased autonomic activity: tachycardia, hypertension, fever, shivering, diaphoresis
3) Increased neuromuscular activity: tremor, rigidity
Causes of serotonin syndrome
SSRI+SNRI SSRI/SNRI+MAOI SSRI/MAOI+tryptophan MAOI+meperidine Tramadol+MAOI/SSRI
Treatment of serotonin syndrome
Supportive treatment.
(Benzodiazepines)
Cyproheptadine - serotonin antagonist (not used often)
Indications to use electroconvulsive treatment (6)
1) Depression: poor response to antidepressants, psychotic features, catatonic features, when medications may be unsafe or rapid response is needed
2) Catatonia: refractory, severe or life-threatening
3) Schizophrenia: acute symptoms with poor response to antipsychotics, catatonia, history of NMS
4) Mania: refractory, severe or life-threatening situation
5) Personal or family history of good response to ECT
6) Inconclusive evidence for OCD
Antidepressant for children
Fluoxetine (SSRI), is the only indicated drug for patients aged 8-17 years
Indications for methylphenidate. Also class of drug + trade name
1) ADHD
2) Narcolepsy
3) Terminal patients with depression (decreased mood and suicidal thoughts with short life expectancy)
4) Fatigue in MS patients
It’s a CNS stimulant. AKA Ritalin
Management of a patient with a high risk of suicide
1) Hospitalization (if he/she refuses - complete form for involuntary admission)
2) Do not leave alone, remove dangerous objects from the room.
Difference between brief psychotic, schizophreniform disorders and schizophrenia
Time
< 1 month: Brief psychotic disorder
1-6 months: Schizophreniform disorder
> 6 months: Schizophrenia
Symptoms of psychosis and how many are needed
Criterion A for Schizophrenia (psychotic symptoms) 2 or more are needed:
1) Delusions
2) Hallucinations
3) Disorganized speech
4) Grossly disorganized or catatonic behaviour
5) Negative symptoms (diminished emotional expression or avolition)
Differentiate the psychotic disorders (symptoms and duration) (7 disorders)
- Psychotic symptom = Criterion A symptoms
1) Brief psychotic disorder: 1 + psychotic symptom for < 1 month
2) Schizopheniform disorder: Psychotic symptoms 1-6 months
3) Schizophrenia: psychotic symptoms >6 months
4) Schizoaffective disorder: psychotic symptoms + major mood episode (but > 2 weeks psychotic without mood symptoms). durations >1 month
5) Delusional disorder: Non-bizarre delusions (+/- hallucinations) >1 month
6) Substance-induced psychotic disorder: delusions/hallucinations that resolves <1 mo after drug use
7) Secondary to mood disorder: Mood symptoms are dominant + delusions/hallucinations
Investigations for psychotic patients
- CBC, electrolytes, creatinine, glucose, urinalysis, urine drug screen, TSH, vitamin B12
- Baseline before antipsychotics: LFTs, fasting lipids, HbA1C, ECG
- If indicated clinically: infectious work-up, inflammatory markers, brain imaging
Management of schizophrenia (groups of drugs + psychosocial)
1) Antipsychotics. Adjunctives: Mood stabilizers (for aggression/impulsiveness), Anxiolytics, ECT.
2) Psychotherapy, CBT, Assertive community treatment
3) Social skills training, employment programs, disability benefits
4) Housing.
Duration of pharmacological treatment for schizophrenia
1-2 years after first episode
At least 5 years after multiple episodes
Medical work-up for mood disorders
Physical exam
CBC, extended electrolytes, renal, liver and thyroid function tests, drug screen
Medication list
Additional: B12 in elderly, neurological consultation, chest X-ray, ECG, head imaging
Difference between a full manic episode and hypomanic episode
Hypomanic episode lasts > 4 days. Does not cause marked impairment in social/occupational function
If the patient has psychotic features: this is a manic episode
Risk factors for major depressive disorder (7)
1) Sex: female
2) Family history of depression, alcohol abuse, suicide attempt or completion
3) Childhood experiences: Loss of parent before 11 yrs, negative home environment (abuse, neglect)
4) Personality: neuroticism, insecure, dependent, obsessional
5) Recent stressors: Illness, financial, legal, relational, academic
6) Lack of intimate, confiding relationships or social isolation
7) Low socioeconomic status
Treatments for major depressive disorder (pharmacological groups + nonpharmacological) (6)
1) Lifestyle: aerobic exercises, mindfulness-based stress reduction
2) Pharmacological: SSRIs, SNRIs, other antidepressants
3) Somatic: ECT. rTMS (repetitive transcranial magnetic
stimulation) . Phototherapy
4) Psychological: Individual (e.g CBT), group or family therapy
5) Social: Vocational rehabilitation, social skills training
6) Experimental: magnetic seizure therapy, deep brain stimulation, ketamine
Difference between major depressive disorder and persistent depressive dis order
Persistent depressive disorder lasts for > 2 years with less than 2 continuous months without depressive symptoms.
Risk factors for postpartum depression (major depressive disorder with peripartum onset) (8)
1) Previous history of mood disorder
2) Family history of mood disorder
3) Stressful life events
4) Unemployment
5) Marital conflict
6) Lack of social support
7) Unwanted pregnancy
8) Colicky or sick infant
Treatment of postpartum depression (major depressive disorder with peripartum onset)
1) Psychotherapy (CBT or IPT - interpersonal therapy)
2) SSRIs (safe for breastfeeding short-term, long-term unknown)
3) If severe or with psychotic symptoms: ECT
Which disorder is strongly associated with sleep walking?
Thyrotoxicosis
Which NSAIDs can be used with Lithium?
Aspirin and sulindac
Common interactions with lithium
1) NSAIDs, ACE-inhibitors and thiazides increase serum levels of lithium.
2) Mannitol and aminophylline decrease serum levels of lithium.
3) Anticonvulsants: additive neurotoxicity
4) Neuroleptics: additive extrapyramidal side effects
5) Lithium increases duration of action of NM-blocking agents
6) Increases risk of delirium with ECT (pause lithium before ECT)
Disorders associated with persistent depressive disorder
Major depression Social phobias Personality disorders Cerebrovascular accidents MS AIDS PMS Hypothyroidism
Treatment for Tourette’s disorder
Fluphenazine, pimozide Tetrabenazine Clonidine Clonazepam Deep brain stimulation
What is the difference between Bipolar 1 and Bipolar 2?
Bipolar 1: More manic episodes. Requires at least 1 manic episode for diagnosis.
Bipolar 2: Hypomanic episodes instead of manic episodes. Requires 1 major depressive episode, 1 hypomanic episode, and 0 manic episodes.
Risk factors of bipolar disorder:
1) Family history of major mood disorder
2) These characteristics of major depressive episode (MDE): Age <25 yrs, several MDEs, psychotic symptoms, onset postpartum, anxiety, antidepressant failure, early
impulsivity and aggression, substance abuse, cyclothymic temperament
Medications for bipolar disorder
Lithium
Lamotrigine
Lurasidone
Seroquel
Treatment for manic episode:
Lithium (mood stabilizer), divalproex (anticonvulsant), carbamazepine (antiepileptic, 2nd line), 2nd gen antipsychotics, ECT, benzodiazepines
Prevention of mania
Lithium, divalproex, carbamazepine (2nd line), SGA (second generation antipsychotics).
Lower doses than when treating an manic episode
Treatment of bipolar depression
The 4 Ls: Lithium, lurasidone, quetiapine (seroqueL), lamotrigine.
Antidepressants (never as monotherapy in bipolar)
ECT
First line drug for treating depression in Bipolar type 2:
Quetiapine (seroqueL)
What is cyclothymia
Periods of hypomanic an depressive symptoms, that do not meet the criteria for full hypomanic episode or major depressive episodes. For diagnosis this state has to last for 2 yrs, never more than 2 months without symptoms
General treatment for cyclothymia
Mood stabilizers
Psychotherapy
Avoid antidepressants in monotherapy
Treat comorbid substance use disorder
Bupropion is contraindicated in which patients and why
Bulimia and anorexia due to higher incidence of seizures
What is anxiety associated with?
Depression
Substance abuse
Workup of patient presenting with symptoms of anxiety
Routine: Physical exam, CBC, electrolytes, thyroid function test, ECG.
Additional screening: Extended electrolytes, vit B12, folate, chest x-ray, head imaging, neurological consultation. Other tests to exclude differential diagnoses
Risk factors of Anxiety disorders
- Somatic: Endocrine disorders (hyperthyroidism), respiratory conditions (asthma, COPD), CNS conditions (temporal lobe epilepsy, substances/medications, chronic medical illness.
- Family history
- Personal previous anxiety or mood disorder
- Female
- early childhood trauma, current stress, early parental loss
Treatment for panic disorder
CBT
1st line: SSRIs: fluoxetine, citalopram, esscitalopram, proxetine, setraline fluvoxamine. SNRIs: Venlafaxine
2nd line: Mirtazapine, MAOIs, benzodiazepines
Diagnostic criteria for agoraphobia
Marked fear for at least 2: public transport, open spaces, being in enclosed places, being in a crowd/standing in line, being outside alone
Treatment for generalized anxiety disorder
1) Lifestyle: Avoid alcohol and caffeine. Sleep hygiene
2) CBT, relaxation techniques, mindfulness
3) SSRIs, SNRIs, pregabalin
4) 2nd line: benzodiazepines
Common comorbidities to OCD
Anxiety disorders Depression Obsessive-compulsive personality disorder Tic disorders Body dysmorphic disorder Trichotillomania Excoriation disorder
Risk factors for OCD (5)
1) Neurological dysfunction
2) Family history
3) Adverse childhood experiences
4) Traumatic events
5) Group A streptococcal infection
Pharmacological treatment of OCD
SSRIs/SNRIs: 12-16 weeks trials, higher doses than in depression Clomipramine Adjunctive antipsychotics (risperidone)
Disorders related to OCD
1) Body dysmorphic disorder
2) Hoarding disorder
3) Trichotillomania (hair-pulling disorder)
4) Excoriation disorder (skin-picking disorder)
What is body dysmorphic disorder?
Preoccupation with 1 + flaws in physical appearance not observed by others. Repetitive behaviors
Which disorders must be excluded before diagnosing hoarding disorder? (8)
1) Brain injury
2) Cerebrovascular disease
3) Prader-Willi syndrome
4) OCD
5) MDD (major depressive disorder)
6) Psychotic disorder (delusions)
7) Neurocognitive disorder
8) ASD (restricted interests) (autism spectrum disorder)
What is excoriation disorder?
Skin-picking disorders
What is the difference between acute stress disorder and PTSD?
Time. Acute stress disorder: 3 days after trauma, up to 1 month. May be a precursor to PTSD .
PTSD: Symptoms for more than 1 month
PTSD: Treatment
CBT, trauma therapy.
Eye movement desensitization and reprocessing (EMDR).
Pharmacological: 1st line: Fluoxetine, paroxetine, sertraline (SSRIs), venlaflaxine XR (SNRI).
Prazosin - nightmares (alpha 1 receptor blocker)
Benzodiazepines - acute anxiety
Adjunctive atypical antipsychotics - risperidone, olanzapine
What is adjustment disorder?
Acute emotional/behavioral symptoms that resemble less severe versions of other psychiatric conditions. Occurs due to difficulty dealing with stressful live event/situations. Does not last more than 6 months after the stressor is removed.
Risk factors of poor bereavement outcomes
Poor social supports
Unanticipated death or lack of preparation for death
Highly dependent relationship with deceased
High initial distress
Other concurrent stresses and losses
Death of a child
Pre-existing psychiatric disorders (esp depression and separation anxiety)
Symptoms that may indicate abnormal grief or presence of major depressive disorder
Excessive guilt
Excessive thoughts if death/worthlessness
Marked psychomotor retardation, functional impairment
Hallucinatory experiences other than hearing the voice/transiently seeing the image of the deceased person.
Pervasive dysphoria, absence of mood reactivity.
Risk factors for delirium
Polypharmacy, infection, dehydration, immobility, malnutrition, bladder catheters.
Hospitalization (of frail and surgical patients). Previous delirium, nursing home residents, old age (esp males), severe illness, resent anesthesia or surgery.
pPre-existing neurologic or neurocognitive disorder, substance abuse, past psychiatric illness
Work up of delirious patient
CBC + differential. Electrolytes (+ ca2+,mg2+, po43-), glucose, BUN, Cr, TSH/T4, LFTs, vit B12, folate, albumin, urinalysis, urine C&S.
If indication: ECG, CXR, head CT/MRI, toxicology/heavy metal. VDRL, HIV, LP, blood cultures, EEG
Treatment of delirium
Manage underlying cause
Reorient and optimize the environment
Low dose haloperidol. Or risperidone, olanzapine, quetiapine, aripiprazole.
Benzodiazepines are only used in substance withdrawal delirium.
Minimize drugs with anticholinergic effects.
How to preform the “Mini Cog” rapid assessment
3 words immediate recall
Clock drawn to 10 past 11
3 words delayed recall
Difference between Alzheimer’s, frontotemporal degeneration, Lewy body disease, vascular disease, normal pressure hydrocephalus (NPH)
Alzheimer’s disease: Memory and learning issues
Frontotemporal degeneration: language type (early preservation), behavioral type (apathy, disinhibition, self-neglect)
Lewy body disease: recurrent, soft visual hallucinations (e.g rabbits), autonomic impairment (falls, hypotension), EPS, poor response to pharmacy, fluctuating degree of cognitive impairment
Vascular disease: Vascular risk factors, focal neurological signs, abrupt onset, stepwise progression
NPH: abnormal gait, early incontinence, rapidly progressive
Do you have to inform the Ministry of Transportation about a demented person’s inability to drive?
Yes
Pharmacological therapy for dementia
Cholinesterase inhibitors (donepezil, rimestigmine, galantamine). NMDA receptor antagonist (memantine). Low-dose antipsychotics (risperidone, aripripazole), escitalopram (SSRI), trazodone: for behavioral or emotional symptoms.
Which screening questionnaire would you use for alcohol use disorders?
CAGE.
Ever felt the need to Cut down on your drinking?
Ever felt Annoyed at criticism of your drinking?
Ever feel Guilty about your drinking?
Ever need a drink first think in the morning? (Eye opener)
Symptoms of delirium tremens
Autonomic hyperactivity (diaphoresis, tachycardia, increased respiration) Hand tremor Insomnia Psychomotor agitation Anxiety Nausea/vomiting Tonic-clonic seizures Visual/tactile/auditory hallucinations Persecutory delusions
Stages of alcohol withdrawal
1: 4-12 h. tremor, sweating, agitation, anorexia, cramps, diarrhea, sleep disturbance, anxiety, insomnia, headache.
2: 12-24h: alcoholic hallucinosis: visual, auditory, olfactory or tactile hallucinations.
3: 24-48 h: Seizures - tonic-clonic, non-focal, and brief.
4: 48-72 h: delirium tremens, confusion, hallucinations, delusions, agitation, tremors, autonomic hyperactivity (fever, tachycardia, HTN).
Management of alcohol withdrawal
According to CIWA-A scale:
Diazepam 20 mg every 1-2 h until CIWA-A <10. If >65 yrs, severe liver or respiratory disease: lorazepam
Thiamine 100 mg IM, then 100 mg PO OD for 3d.
Hallucinations: Haloperidol
Hydration and nutrition.
Brain disorders caused by alcohol overuse and causes of these disorders
Wernicke-Korsakoff syndrome because of thiamine deficiency.
Wernicke’s encephalopathy (acute, reversible): Triad - oculomotor dysfunction (nystagmus), gait ataxia, confusion
Korsakoff’s syndrome (chronic, 20 % reversible): Anterograde amnesia, confabulation. Must persist beyond intoxication/withdrawal
Pharmacological treatment for alcohol use disorder
Naltrexone (opioid antagonist): reduce the “high”, cravings, can be started while still consuming.
Acamprosate (NMDA glutamate receptor antagonist): Maintaining abstinence and decreasing cravings.
Disulfiram (antabuse): toxic and potentially fatal reaction if patient drinks alcohol.
