Psychiatry Flashcards
Ziprasidone is an antipsychotic that has high risk of what particular side effect
QT prolongation
If family members of very very Ill patient don’t want to allow withdrawal of care, what can we do
Reframe discussion to become about NEOT (no escalation of treatment)
Three care philosophies about end of life care
NEOT, time limited trial, withdrawal of care
General diagnosis for pyromania
Fire setting on more than one occasion. Tensions relived when setting fire, no external gain.
Patient wants help quitting opioids. Recently taken them.
Methadone or buprenorphine. Both agonists and can decrease cravings. Not naltrexone, since it’s an antagonist an requires a period of detox prior. Not clonidine, since this is just to help reduce ANS symptoms in withdrawal (not the craving)
Patient ODd on methadone. Given naloxone, and gets better. Can we discharge?
No, need a couple of days of observation. Naloxone is short acting and methadone is long acting. Sooo when naloxone wears off, the effects of methadone will return
Most effective anti psychotic for Tx resistant SCZ
Clozapine
Aside from dialectical behaviour therapy, what else can be given for mood swings in BPD
Mood stabelisers
Main psych complication of MS
Depression
Can GCs cause psychosis
Yes
Treatment for binge eating disorder
CBT, SSRI (consider lisdexamfetamine or topiramate)
Treatment for bipolar is it’s severe (patient is aggressive, has multiple episodes etc.)
Combo therapy: Li (or other mood stabiliser) and an 2nd gen antipsychotic
SAD therapy
light therapy, with or without SSRI (if moderate or severe)
When to give benzos over SSRIs for panic disorder
If it’s acute, can give, also second line for long term. Careful in druggy people due to addiction risk
Can adjustment disorder be from traumatic origin
No,,,, don’t make my mistake
REM sleep disorder vs Sleep terror
Sleep terrors are nonREM. Sleep terror has way more confusion, occurs earlier in sleep, seen in younger patients and they don’t dream so vividly. REM sleep disorder is the opposite of this
Dx criteria for ADHD
More than 6mo, of 6or more symptoms. In 2 or more settings. Signs Begins before 12 (6*2 Rule)
Language delay and no compensation from other forms of communication
Autism
Cortisol l levels in depression
High
Alcohol withdrawal vs PCP intox
Alcohol withdrawal ,or stepwise and includes tremors and less likely nystagmus
List as many cannabis withdrawal side effects
Sleep issue, irritable, depressed, anxiety, weight loss and low appetite, abdomen pain, headache, tremor, fever, sweating
Adolescent SCZ key points
More hallucinations than delusions. They often name their delusions (friend, henry etc.). Worse Px.
What is the main prognostic indicator for autism
Language development, because it is based on social interaction
Why do we have to do audiometry before diagnosing autism
Since hearing impairment can present similarly
Describe the activities of daily living element to intellectual disability
ADL helps determine severity of intellectual disability. ADL and intellectual deficits are the two domains of intellectual disability. Mild disability patients are independent, Moderate intellectual disability patients would need a little help for ADL, severe intellectual disability patients would need significant support for ADL, profound intellectual disability patients would need full support for ADL
What is the most common chromosomal, preventable, inherited causes of intellectual disability
Downs, fetal alcohol syndrome, fragile X syndrome respectively
What is psychosis
Hallucinations +/- delusions, with no insight
Schizophreniform and brief psychotic disorder are less likely to have which symptoms than schizophrenia
Negative symptoms
When is resistance to antiphsycotics considered
When two drugs or more have been attempted without improvement of symptoms
Main difference between drealizatiom/depersonalisation and psychosis
Psychosis don’t have insight
Abnormalities on brain imaging in patients with OCD,
specifically in the orbitofrontal cortex and basal ganglia. The cortico-striato–thalamo-cortical (CSTC) circuits have been implicated in the pathophysiology of the disorder.
Out of OCD and OCPD, which patient recognise their behaviour is irrational
OCD Patients recognize their behaviors as excessive and irrational (vs obsessive-compulsive personality disorder [OCPD]
Kleptomania
An OCD-related disorder. Where someone has the compulsion to steal, for no really reason
Hairs in different stages of growth and different lengths….. sign of what?
Trichotillomania
List some OCD related disorders
Trichotillomania, hoarding disorder, excoriation disorder, kleptomania, body dysmorphia
Out of dementia and pseudo dementia… who is more concerned about it?
Patients with dementia are usually not concerned about their cognitive decline and are often accompanied to the doctor visit by a family member or friend (vs major depressive disorder [MDD]/pseudodementia)
Is parental consent 100% needed if the paed has suicidal. Ideation
Minors with suicidal ideation should be hospitalized involuntarily with or without parental consent (although parental consent is preferred).
Which vessel stroke is associated with depression
ACA
Rule of two for dysthymia
2 or more of the symptoms, for 2 or more years. With no period of more than 2 mo free of symptoms
Features of atypical depression
Characterized by weight gain, hypersomnia, and rejection sensitivity.
Which SSRI should be avoided in pregnancy . Why?
Paroxetine. Cardiac and pulmonary ,malformations in 1st and 3 rd trim resp
How long should be left before Starting MAOI after SSRI. And special case if SSRI was fluoxetine
Discontinue SSRIs at least 2 weeks before starting an MAOI. Wait 5 weeks if the patient was on fluoxetine due to its long half-life.
What is double depression
Double depression: Diagnosed if patient meets criteria for MDD during dysthymic
periods.
3 key features of adjustment disorder
Event is not life-threatening.
Symptoms present within 3 months after onset of the stressor. Adjustment disorder
resolves within 6 months after event is over.
Adjustment disorder causes social or occupational dysfunction, as opposed to a normal
stress reaction.
What is premenstraul dysphoric disorder and how is it similar to dysthymia
Premenstrual dysphoric disorder (PMDD) presents the same as dysthymia, but the symptoms in PMDD are cyclic, whereas dysthymia is present all the time.
How is pin point pupils not always sensitive for opioid intox
Pinpoint pupils are not always a reliable sign of opioid ingestion, because co-ingestions can lead to normal or enlarged pupils. Also look for a ↓ respiratory rate, track marks, and ↓ breath sounds
Is prior opioid abuse a CI to use opioids for pain relief in hospital settings
In the appropriate clinical setting, prior substance abuse is not a contraindication to the use of opioids in pain management and requires a nonjudgmental environment and shared decision makin
Alcohol withdrawal
6-24 hours:
12-24 hours:
12-48 hours:
48-96 hours:
6-24 hours: Anxiety, tremor, tachycardia, HTN
12-24 hours: Hallucinations
12-48 hours: Seizures
48-96 hours: DTs, fever, agitation, HTN, hallucinations
Opioid withdrawal symptoms, is it life threatening, what’s the Mx
Dysphoria, insomnia, anorexia, myalgias, fever,
lacrimation, diaphoresis, dilated pupils, rhi-
norrhea, piloerection, tachycardia, nausea,
vomiting, stomach cramps, diarrhea, yawning
Opioid withdrawal is not life-threatening, “hurts
all over” and does not cause seizures; it can be
treated with buprenorphine or methadone
Symptoms of glue and solvent abuse
Tachycardia; nystagmus; tremor; ataxia; slurred speech; uncon-
sciousness followed by drowsiness and headache; perioral
rash, common among adolescents
Short duration of action
Long-term use can lead to irreversible CNS damage and poly-
neuropathy (due to vitamin B, deficiency)
Some key ways to distinguish between amphetamine and cocaine intoxication
Amphetamine is taken by mouth, and can commonly cause meth mouth (poor dentition). Cocaine is typically snorted, and can cause red matters turbinates and perforated septum. Cocaine is much shorter acting (around 30 minutes), where is amphetamine is more long-acting (several hours).
Patient with PCP intox… suddenly symptoms recur after recovering for a few hours
Recurrence of intoxication symptoms caused by
reabsorption in the Gl tract; sudden onset of
severe, random violence
LSD vs PCP vs ecstasy symptoms
LSD more hallucinationogenic, but does not alter vital signs much. PCP is more dissociative (with some hallucinations too), and causes major vital sign change. Ecstasy causes heightened senses and increased emotional liability (euphoria), and elevated muscle tone (bruxism) and elevated heat excertion.
CAGE questions for alcohol use disorder
- Have you ever felt the need to Cut down on your drinking?
- Have you ever felt Annoyed by criticism of your drinking?
- Have you ever felt Guilty about drinking?
- Have you ever had to take a morning Eye opener?
Delerium tremens….. vs alcohol hallucinosis
48-96 hours since last drink
Autonomic instability (hyperadrenergic state;
1 blood pressure [BP], T heart rate (HR])
Disorientation, agitation
Hallucinations
12-24 hours since last drink
Visual, auditory, and tactile hallucinations
Benzos/ barbiturates withdrawal is similar to alcohol…. Which is the main difference
Alcohol withdrawal usually causes autonomic instability
Avoid pure Bb’s in which intoxication?
Cocaine. Unopposed Alpha can cause worsened HTN
Issue with buspirone and MOAI
Like SSRIs, buspirone should not be used in conjunction with monoamine oxidase inhibitor
Increased sensitivity to lactate infusion is seen in which disorder
Panic disorder
Which area of the brain is associated with OCD
The cortico-striato–thalamo-cortical (CSTC) circuits have been implicated in the pathophysiology of the disor
OCD vs OCPD…. Who recognises their disorder as problematic
OCPD…. Not sure if this is true
Suicidal minors. Do they need parental consent to hospitalise
Minors with suicidal ideation should be hospitalized involuntarily with or without parental consent (although parental consent is preferred).
Older people usually complain of which aspects of MDD
Somatic symptoms more
Anorexia versus bulimic patience, who are distressed and who are not distressed about the illness
Bulimic patients are usually distressed (make sense because they compensate). Anorexic patients usually not distressed
Normal sexual changes with aging in men
Increased stimulation needed to reach orgasm, decrease intensity of orgasm, longer refractory period before next orgasm
Normal sexual changes with aging in women
Vaginal dryness, some coitus discomfort,
Patients with gender dysphoria are At increased risk of which psychiatric diseases
Depression, anxiety, substance abuse, personality disorders
What are some sleep Hygiene measures
Sleep schedule, limit caffeine, avoid napping, warm baths in evening, his bedroom for sleeping six only, exercise early in the day, relaxation techniques, avoid large meals near bed
What is Hoover sign in relation to conversion disorder
If it involves leg paralysis in conversion disorder. Asked the patient lying down to lift up the unaffected leg, if the affected leg extends, this could rule out true leg paralysis
Patient having seizure. Eyes are closed and resistant to opening. Thoughts?
Could be conversion disorder
Risk factors for suicide
Previous attempt (main risk factor), male, above 45, psychiatric comorbidities, history of hospitalisation for psychiatrist issue, history of violent behaviour, substance abuse, recent stressor, poor social support, family history
Adults between 45 and 64 versus adults between 18 and 25. Who is more likely to die from the suicides, who has a higher risk of thoughts an attempt suicide
In that order
Protective factors for suicide
Social support, good family network, religious, pregnant, parenthood
Antidepressants and suicide risk, what’s the link
Impatience less than 24, all antidepressant medications have a blackbox warning for increased suicide risk
Age above or below 17 and the Dx of ADHD
Less than 17: diagnosis required 6 or more symptoms
Above 17: 5 or symptoms
But the symptoms must start above 12 years of age
Best initial Tx for ADHD. Consider if 6 or older/or younger
Behavioural only if your younger
Older, you should do both Pharma and behavioural
Rather than amphetamines…. Which non addictive medication can I give instead for ADHD
Atomexitine…. No addiction potential ato
Is decreasing sugar intake ever a proper option for ADHD.
No
Two domains of autism and then ADHD
Disorder in social interaction, and communition. Then restricted and repetitive patterns.
Inattention and hyperactivity for ADHD
Which psych disorder does DMDD most likely to become in adulthood
Depression
DMDD cannot be diagnosed before what age
6
Is IDD (intellectual development disorder) the same as specific learning disorders
No, recall we need both domains of IDD. Not just isolated learning disorder (reading, math etc.)
We know tetrabenazine e is good for Tourette’s. What other medications are good
Antipsychotics or alpha 2 agonists
Persistent motor tics for over one year. Is this Tourette’s
Only if vocal tics also.
Some facts on separation anxiety disorder
Fear of separation from attachment figure or home. Remember it’s normal around 1yo-1.5yo. But if extends or is really bad, then look for SAD. Need at least three of the main signs
Separation anxiety disorder Tx
CBT, family therapy
Patient refusing to speak in certain circumstances…. What is this a sign of?
Selective mutism. Not always autism
Can ODD progress to conduct disorder
Yes
Main time frame difference between ODD and DMDD
ODD for 6mo. DMDD for 1year
Two domains of intellectual developmental disorder
Intellectual deficit and adaptive function deficits (activities of daily living help)
Main diagnostic criteria for Tourette’s
Multiple motor tics and one or more phonic tics. More than 1 year. Recurrent. Dx before 18
Best initial Tx for Tourette’s
Habit reversal and behavioural therapy. Then try meds like tetrabenazine
Caviat with SCZ Dx
Two or more of the 4 symptoms we know. But at least one is halluc, delu, disorganised speech
Main schizoaffective element to Dx
SCZ Dx, but has also got concmittent mood disorder most of the time. Need psychosis for >2 weeks and no mood
Do we needs day to day dysfunction for diagnosis of delusional disorder
No
Patient is timid and introverted before getting SCZ symptoms. Does this affect Px
Yes, worsens it
Worse atypical for causing hyperprolactinemia
Risperidone (Perry got the Rizz with those boobs)
Worse atypical for causing QT prolongations
Ziprasidone (QT Zebra)
Best atypical for causing least hyperprolactinemia
Aripiprazole (Avi not so good with the boobs) since it’s weirdly a partial agonist
Thioridazine and chlorpromazine . Mention these fellas
They are the less powerful typical antipsychotics. More antiCh than EPS. So they can sedate, orthostasis is etc. And recall these guys do the eye side effects
Dx this:
24 year old women, 2mo ago became isolated, heard voices, slept poorly, felt sad. Now her mood is better but she still hears voices
Schizoaffective. I’m these Qs, keep a look out for a SCZ p with a weird amount of mood issues…. Then see if fits the two weeks no mood criteria
Catatonia
Posturing, mutism, immobile. Give either benzos or ECT
Patient with tardive Dyskinesia. Dose of antipsych decreased… and it gets worse. Normal? What to do?
Fairly normal. Try valbenazine or deutetrabenazine
When to give dantrolene vs benztropine
Give dantrolene for NLMS. Benztropine is usually used for acute dystonia, or akathisia, or dyskinesia after anti psych
Dissociation disorders main Tx
PsychTx. And relevant meds for comorbs
Buspirone use for GAD?
Less sexual side effects than SSRI… (like bupronorphrine also has…. But we use this where?)
Buspirone same risk for SeroT syndrome (ie.wait 2 weeks after discontinue, to start MAOI)
Yes. Same risk
Panic disorder extra details on Dx
Recurrent attacks and at least 1mo:
Persistent worry, maladaptive behaviour.
Name the somatic symptoms of GAD to look out for
Wound up, (Absent minded) Low conc, Worn out, Restless, muscle Tension, Sleep issue, (usually need around 3)
Worry WARTS
Other than SSRI, what is the main alternative Med for OCD
Clomipramine TCA (Chloe was OCD)
Trichotillomania hair follicle finding
Hair in different phases of growth
Excessive cosmetic procedures may be a sign of which psych disorder
Body dysmorphic disorder (a type of OCD). And we should discourage them from getting these procedures (obviously don’t dismiss their complaints though).
Tx of all OCDs
CBT and SSRI
Top PTSD causes in women and men
Women: child abuse and sexual assault
Men: sexual assault and war
CBT and SSRI are great for PTSD. But what’s also good non pharma
Eye movement desense and reprocessing.
15-25 year olds. Main causes of death
Unintentional injury, then suicide
PEP for HIV we give in RAPE victim
Tenofovir emtricitabine and integrase inhibitor
In order to Dx illness a society disorder what needs to be present (other than the obvious)
Maladaptive behaviour. Repeat self checks, uses the healthcare system l a lot, avoids hospital, etc.
Random key fact 🔑
Pseudo epilepsy can occur together with seizure disorder
Primary insomnia Dx (times)
Three or more times a week, for at least one month
For primary insomnia, After good sleep hygiene (our first line), what is our second lines
Psychotherapy or CBT for insomnia. Pharma (anti H or the Z drugs) for <2 weeks at a time
Best Tx for primary Hypersomnia
CNS stimulant
Narcolepsy rule of three
Symptoms occur for at least threee times a week, for at least 3 months
Tx overview for narcolepsy
Scheduled naps, and amphetamine or modafinil. SSRI for cataplexy
What is the confusion assessment method
CAM score, to check for delirium. Acute onset/fluctuating course, in attention, disorganised thinking, altered mental status, need first and second and then either third or fourth
Why is there a blackbox warning for load of psychotics in older adults for delirium
Increase mortality
Adjustment disorder has to be within how many months of stressor
3
In a patient breathing who has illusions or hallucinations of the deceased. What’s the main wait to see whether this is normal or psychosis
Patient will be aware that there are hallucinations, and will have insight 
Contrast the time of onset between postpartum blues and depression
Blues usually within two weeks of delivery, where is postpartum depression is usually months after delivery
What’s the rule of sex when talking about SSRIs
Allow up to 6 weeks to take affect. Once a cheat permission need to keep going with the medication for six months. Allow two weeks washout before starting MAOI
Bupropion
Buspirone
The former is a depression medication. With less sexual side effects, but decrease seizure threshold
The latter is an anxiety medication, which also has less sexual side effects
Why should paroxetine be avoided in pregnancy
First trimester causes cardiac defects, Saif third trimester causes pulmonary hypertension
Main medication for atypical depression
MAOI
Other than patients with a seizure disorder, buproprion is contraindicated in what else
Waiting disorder
What’s phenelzine
MAOI
What’s tranylcypromine
MAOI
Those with two or more episodes of MDD should have what
Maintenance antidepressant therapy
We know that SSRIs need a two week wash out before MAOI. However watch the exception with fluoxetine
Fluoxetine requires five weeks (F equals F)
Best treatment for dysthymia
Psychotherapy. If resistant then can add some medication
Main difference between adjustment disorder a normal stress reaction
Adjustment disorder will have social and occupational dysfunction. Normal stress reaction wont
What is premenstrual dysphoric disorder
Essentially dysthymia but symptoms of cycle with the menstrual cycle
Ropinirole may cause what symptoms
Mania like
Symptom duration diagnosis for:
Dysthymia or cyclothymia
2 years
Symptom duration diagnosis for:
Narcolepsy
3 mo
Symptom duration diagnosis for:
Panic disorder (length of underlying symptoms)
One month
Symptom duration diagnosis for:
PTSD
One month
Symptom duration diagnosis for:
GAD
6mo
Symptom duration diagnosis for:
Delusional disorder
1mo
Symptom duration diagnosis for:
DMDD
1yr
Symptom duration diagnosis for:
Tic disorder
1 year
Symptom duration diagnosis for:
ODD
6mo
Symptom duration diagnosis for:
ADHD
6mo
Symptom duration diagnosis for:
Adjustment disorder
Less than 6mo
Lithium side-effect profile, other than the ones you know
Tremor, weight gain, GI side-effects, ataxia,. Contraindicated in low renal function, sodium depression, significant CVD
After lithium, which is the second line mood stabiliser
Lamotrigone
Main contraindication for valproic acid
Liver disease.
General idea for when you treat mild compared to severe mania
Mild can just give an atypical antipsychotic. More severe you give the mood stabiliser plus or minus in antipsychotic
Mania in pregnancy treatment
Typical antipsychotic. Or ECT
If a patient has all the signs of opioid overdose, but the people is a normal. What can you be thinking of
That this may just be a poo ingestion with something that causes mydriasis. So if they have low respiratory Drive, track marks, et cetera go with it
Deletion tremendous after how long of withdrawal
48hr
How to treat your opioid intoxication. What is given as a short acting antagonist, which is given as a long acting antagonist prevent relapse
Naloxone and naltrexone respectively
Withdrawal from opioids obviously not life-threatening, but can be treated with what. Consider if mild or severe
Anti emetics or anti diahrrea if mild. Buprenorphine or methadone if severe cravings. Clonidine if severe ANS
Long-term use of inhalants can cause which deficiency
B12 according to you first aid.
Cocaine cause the sensation of water under the skin
Bugs
Best initial treatment for alcohol abstinence
Naltrexone best, can start while patient still drinking. And long-term rehabilitation. Can also consider disulfiram
We all know that alcohol hallucinosis is up to 48 hours after. Where is delirium tremens is after 48 hours. What is the main difference in the symptom
The former has usually visual hallucinations, but no delirium. May have some autonomic instability two. The latter has hallucinations, autonomic instability, delirium, potentially seizures
President should we avoid in anorexia and bulimia
Bupropion, just because seizure risky so high
Anorexics versus bulemics , which are more distressed about their symptoms
Anorexics
Can we give naltrexone if somebody is using heroin currently
No. We need a full opioid free period, and naltrexone could cause withdrawal. So give methadone instead
Other than tetrabenazine, what’s the other options for Tourette’s
Antipsychotics
When is biofeedback needed
Usually in chronic pain disorders
