Psychiatry Flashcards
PTSD diagnostic criteria
1) Exposure to actual/threatened death, serious injury, or sexual violation in >=1 of the following ways
2) >=1 intrusive symptoms
3) >=1 avoidance symptoms
4) >=2 negative mood symptoms/dissociative symptoms
5) >=2 arousal/reactivity symptoms
- duration of above symptoms > 1 month
- clinically significant distress/impairment
- NO from substances NO from another medical condition
Acute Stress Disorder diagnostic criteria
1) Exposure to actual/threatened death, serious injury, or sexual violation in >=1 of the following ways
2) >=9 of the symptoms from any of the 5 categories: intrusive, negative mood, dissociative, avoidance, arousal
3) duration of symptoms for at least 3 days to 1 month after the trauma
4) clinically significant distress/impairment
5) NO from substance NO from another medical condition
Adjustment Disorder diagnostic criteria
1) Within 3 months of stressor, emotional/behavioral response
2) clinically significant behaviors/ symptoms as evident by >=1 of the following :
- marked distress out of proportion to severity of the stressor
- significant impairment
3) Does not meet criteria for another mental disorder
4) Does not represent bereavement
5) Once stressor or its consequence are terminated, symptoms do NOT persist more than 6 months
What are the specify of Adjustment Disorder ?
w/ depressed mood
w/ anxiety
w/ disturbance of conduct
Treatment for PTSD
** Therapy: CBT - early intervention is vital
** Reduce caffeine, alcohol, stress
** Medication: fluoxetine, paroxetine, sertraline, venlafaxine
- Second line: mirtazapine
- For nightmares: Trazodone (50-200mg) or Prazosin (1-15mg po QHS)
- continue > 8 weeks
- consider second generation atypical antipsychotics
or anticonvulsants
ADHD diagnostic criteria (DSM V)
> > Either (1) or (2): in adults only need 5 of 9 Sx
(1) >= 6 symptoms of inattention, persisted >= 6 mo that is inconsistent with developmental level, negatively impacts social, academic, occupational
(2) >= 6 symptoms of hyperactivity-impulsivity, persisted >=6 mo to a degree that is maladaptive and inconsistent with the developmental level
symptoms of eating disoder
Cardiorespiratory: palpitation, cp, sob, arrhythmia, edema, MVP
Diagnostic criteria of alcohol withdrawal syndrome
1) decreased EtOH use that has been heavy/ prolonged
2) has > or = 2 of the the following:
- autonomic hyperactivity (sweating,
tachycardia) ;
- increased hand tremor;
- insomnia;
- nausea or vomiting;
- transient visual, tactile, auditory hallucinations or illusions;
- psychomotor agitation;
- anxiety;
- tonic-clonic seizures
3) symptoms cause distress/impairment
contraindications to outpatient treatment of alcohol withdrawal syndrome
Abnormal laboratory results
Absence of a support network
Acute illness
High risk of delirium tremens
History of a withdrawal seizure
Long-term intake of large amounts of alcohol
Poorly controlled chronic medical conditions (e.g., diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure)
Serious psychiatric conditions (e.g., suicidal ideation, psychosis)
Severe alcohol withdrawal symptoms
Urine drug screen positive for other substances
symptoms of delirium tremens
severe hyperadrenergic state (i.e., hyperthermia, diaphoresis, tachypnea, tachycardia) characterized by disorientation, impaired attention and consciousness,
and visual and/or auditory hallucinations
Timing of alcohol withdrawal syndrome
12-24hrs after the last drink: tachycardia, tremors, anorexia, insomnia
24-72hrs: generalized seizures
3-5d: delirium tremens –> disorientation, fever, hallucinations
When to consider report to MOT of driving
- drinking + driving
- drove while intoxicated
- withdrawal seizure
1st meds to treat alcohol withdrawal as outpatient
anticonvulsants (not able to prevent seizure or delirium tremens)
- carbamazepine, gabapentin
Alpha-adrenergic agonist
- clonidine (s/e: Hypotension, dry mouth,
dizziness, constipation,
sedation)
contraindications to use Naltrexone or Acamprosate to treat EtOH dependence
Naltraxone:
- liver failure
- ongoing opioid use b/c risk of acute withdrawal
- can be used if pt will abstain from opioid
- ** use for abstinence OR reduction
- ** check LFTs 1,3,6 mos
Acamprosate
- severe renal impairment
- use ONLY for abstinence, does NOT reduce heavy drinking
complications of Alcohol Use Disorder
- CNS:
Wernicke encephalopathy (decreased thiamine=nystagmus, CNVI, ataxia, confusion)
Korsakoff psychosis
dementia - CVS:
HTN
cardiomyopathy
AFib
- GI cirrhosis PUD gastritis pancreatitis carcinoma
- Psycho
depression
anxiety
classes of ADHD medications
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- Amphetamine-based: Adderall, Vyvanse
- Methylphenidate-based: Biphentin, Concerta, Ritalin (short acting)
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- SNRI (selective norepinephrine reuptake inhibitor): Atomoxetine (brand: Strattera)
- Selective alpha-2a adrenergic receptor agonist: Guanfacine XR (Intuniv XR)
contraindications of ADHD medications
For psychostimulants and Atomoxetine:
Treatment with MAO inhibitors and for up to 14 days after discontinuation
Symptomatic cardiovascular disease
Glaucoma
Advanced arteriosclerosis
Untreated hyperthyroidism
Acute psychiatric conditions such as mania or psychosis
Moderate to severe hypertension
Extra caution for Atomoxetine:
Asthma
s/e of ADHD medications
- sleep disturbance
- suppressed appetite
- headache
- suppressed growth of height
- hallucination, psychotic symptoms
DDx of ADHD
- thyroid dysfunction
- hypoglycemia
- anemia
- Vit B12 deficiency
- Lead poisoning
- head trauma
- sleep disorder (OSA)
- seizure
- hearing deficit
- fetal alcohol spectrum disorder
- neurofibromatosis
- medication effect
- liver disease
diagnosis of fetal alcohol syndrome (FAS)
All of the 3 +/- confirmed maternal alcohol exposure
(1) characteristic facial anomalies (see image below) Smooth philtrum Thin, smooth vermilion border of the upper lip Midface hypoplasia Short palpebral fissures/ Microcephaly Low nasal bridge/ short nose skin folds at the corner of eyes Microphthalmia Strabismus Ptosis
(2) growth retardation (intrauterine growth restriction and failure to have catch-up growth)
(3) CNS involvement (cognitive impairment, learning disabilities, or behavioral abnormalities)
DDx of depression
- persistent depressive disorder
- adjustment disorder
- grief reaction
- bipolar
- schizoaffective disorder
- organic: substance abuse, DM, thyroid, pituitary, B12 deficiency, anemia, dementia, Parkinson’s, MS, CVA, hepatitis, OCP, BZD, beta-blockers)
initial investigations to screen depression
CBC, TSH, B12, folate, lytes, CRE, LFT +/- drug screen
Antidepressant discontinuation symptoms
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Flu-like symptoms Insomnia Nausea Imbalance Sensory disturbance Hyperarousal
s/e of SSRI
- jitteriness, H/A, GI upset, insomnia, and sexual s/e (suppressed libido)
- falls
- hyponatremia
- prolonged QT
- GI bleeds
- bone loss
- serotonin syndrome
- EPS
- neuroleptic malignant syndrome
1st line Rx for perimenopausal depression
desvenlafaxine (SNRIs)
1st and 2nd line Rx for perinatal depression
1st line: CBT, IPT
2nd line: citalopram, escitalopram, sertraline
diagnosis criteria of serotonin syndrome
Hunter’s Criteria: any of the following
- spontaneous clonus
- inducible clonus (or ocular clonus) & agitation & diaphoresis, tremor & hyperreflexia
- tremor & hyperreflexia
- hypertonia
- fever & ocular or inducible clonus
management of serotonin syndrome
- discontinue the medications
- restart with decreased dose / alternative
- ER & cyproheptadine (antihistamine)
symptoms of anticholinergic toxicity
- Visual/auditory/sensory hallucinations
- Tremulousness/myoclonic jerking
- altered mental status (delirium), Memory impairment, cognitive impairment
Tachycardia
Dilated pupils
Difficulty adjusting visual focus (lens accommodation)
Dry eyes
Constipation
Impaired stomach emptying/increased esophageal reflux
Dry mouth/impaired speech articulation
Difficulty swallowing due to lack of saliva
Decreased sweating/dry skin
Urinary retention/overflow incontinence
Difficulty starting urination/impaired bladder emptying
Rx for restless leg syndrome
1) non-ergot dopamine agonist
»_space; pramipexole
»_space; ropinirole
2) Alpha-2-delta calcium channel ligand
»_space; Gabapentin
»_space; pregabalin
Non-pharmacological mgt for restless leg syndrome
- Iron, magnesium supplement
- Stretch calves
- avoid caffeince
- massage, heat
- exercise
