Psychiatry Flashcards
Positive sxs in psychotic disorders are associated with which type of receptor?
dopamine
Negative sxs in psychotic disorders are associated with which type of receptor?
muscarinic
Best initial test in patients w/ psychosis?
drug tox screen
What is the first step in management of any patient w/ an acute psychiatric condition?
determine if the patient needs hospitalization - i.e. if patient poses a risk to self or others (SI or HI)
Management of psychosis?
- If case describes bizarre or paranoid sxs –> hospitalize
- Give benzos for agitation and start antipsychotics (duration 6 mo if one time; long-term if h/o repeat episodes).
- Initiate long-term psychotherapy
Give examples of conventional HIGH potency antipsychotics.
- fluphenazine
- haloperidol
Advantages of HIGH potency antipsychotics?
- less sedating
- fewer anticholinergic effects
- less hypotension
- useful as depot injections (e.g. haloperidol decanoate, fluphenazine) for noncompliant or delirious patients
- give IM for acute psychosis when patient can’t take PO
DISadvantages of HIGH potency antipsychotics?
greatest a/w extrapyramidal sxs (EPS)
Name some low potency conventional antipsychotics.
Thioridazine, chlorpromazine
What are the advantages of low potency conventional antipsychotics?
less likely to cause EPS
What are the DISadvantages of conventional low potency antipsychotics?
greater anticholinergic effects, more sedation, more postural hypotension
Name some atypical antipsychotics.
risperidone, olanzapine, quetiapine, clozapine
What are the advantages of the atypical antipsychotics?
- drug of choice for initial therapy
- greater effect on NEGATIVE symptoms
- little or no risk of EPS
What are the disadvantages of the atypical antipsychotics?
Clozapine is reserved for treatment-resistant patients due to risk of agranulocytosis - check baseline CBC. If ok after 6 mo, can decrease monitoring to bimonthly, then monthly.
What side effects is thioridazine a/w?
- prolonged QT and arrythmias
- abnormal retinal pigmentation (after years of therapy) - get routine eye exams
What are common reasons for noncompliance with conventional low-potency antipsychotics in men? In women?
- Men: impotence, inhibition of ejaculation (alpha blocker effect)
- Women: weight gain (due to hyperprolactinemia)
Which antipsychotic has the greatest weight gain a/w it?
Olanzapine
What are good antipsychotics for insomnia?
Olanzapine, quetiapine, ziprasidone, aripiprazole
When sedation is a problem w/ antipsychotic meds, which med to try?
Risperidone
If acute dystonia 2/2 antipsychotic develops, what is the management?
- Reduce dose of antipsychotic.
- Prescribe: anticholinergics (benztropine, diphenhydramine, trihexyphenidyl)
When bradykinesia (Parkinsonism) develops 2/2 antipsychotic, what is the management?
- Reduce dose of antipsychotic.
- Prescribe: anticholinergics (benztropine, diphenhydramine, trihexyphenidyl)
When akathisia develops 2/2 antipsychotic med, what is the management?
- reduce dose
- add *beta-blockers or benzos
- switch to newer antipsychotics
If tardive dyskinesia develops 2/2 antipsychotics, what is the management?
- stop older antipsychotics
- switch to newer antipsychotics (e.g. clozapine)
If neuroleptic malignant syndrome occurs 2/2 antipsychotic, what is the managment?
stop the antipsychotic, transfer to ICU for monitoring (20% mortality!)
Tx of panic disorder?
- CBT
- relaxation training/desensitization
- meds: SSRIs (e.g. fluoxetine), benzos (e.g. alprazolam, clonazepam), imipramine, MAOIs (e.g. phenelzine)
Tx of phobic disorders? Of social phobia in particular?
Phobic disorders:
- exposure therapy (aka conditioning) –> habituation
- benzos and beta blockers helpful prior to exposure
Social phobias: exposure therapy + SSRIs, buspirone
Tx of OCD?
- behavioral psychotherapy
- pharmacotherapy: SSRIs and clomipramine (latter = a TCA)
Tx of Acute Stress Disorder (ASD) and Posttraumatic Stress Disorder (PTSD)?
- benzos acutely for anxiety
- SSRIs and other antidepressants for long-term therapy
- group counseling is most effective to prevent PTSD following traumatic event
Tx of generalized anxiety disorder?
- supportive psychotherapy (incl relaxation training, biofeedback)
- meds: SSRIs, venlaxafine (an SNRI also used for depression), buspirone, benzos
Tx of adjustment disorder w/ anxious mood?
-benzos with brief psychotherapy
Put these in order from shortest to longest half-life:
- lorazepam
- Alprazolam
- diazepam
Alprazolam (Xanax) < lorazepam (Ativan) < diazepam (Valium)
MoA of buspirone
5HT 1A receptor partial agonist
Advantages of buspirone?
can be used safely w/ other sedative-hypnotics (no additive effect), best option for people w/ occupations where driving or machinery is involved (no sedation or cognitive impairment), no withdrawal syndrome
What other conditions should you screen for when you are considering diagnosing a patient with major depressive disorder?
- Hypothyroidism (TSH, free T4)
- Parkinson’s disease
- meds: corticosteroids, beta-blockers, antipsychotics (esp. elderly), reserpine
- substance disorders
Tx of MDD?
- admit if SI/HI or paranoia
- Begin antidepressant (SSRI = tx of choice)
- Give benzos if agitated
- ECT is best choice if patient suicidal
In patients with unipolar psychotic depression, what drug combo is most effective?
antidepressant + antipsychotic
Tx for dysthymic d/o?
- do NOT hospitalize unless there is suicidal ideation
- long-term individual, insight-oriented psychotherapy
- if psychotherapy fails, trial of SSRIs
Tx of seasonal affective disorder?
phototherapy or sleep deprivation
What is rapid cycling bipolar d/o?
> 4 episodes of mania/year
Tx of bipolar disorder?
- 1st line: monotherapy w/ Li+, Lamotrigine, or risperidone (PO or IM)
- 2nd line: aripiprazole, divalproex, quetiapine, olanzapine, ?carbamazepine
- patients w/ multiple recurrences need combo therapy
- psychotherapy and CBT are always a part of it
- avoid teratogenic drugs (e.g. Li+, valproate, carbamazepine) in female patients
What problems can Li+ therapy lead to?
Ebstein’s anomaly and diabetes insipidus, hypothyroidism
What are the steps in management of acute mania?
- hospitalize
- mood stabilizers (Li+ = drug of choice)
- antipsychotics until acute mania is controlled (risperidone = drug of choice)
- IM depot phenothiazine in noncompliant severely manic patients
- antidepressants only when a h/o recurrent episodes of depression and ONLY w/ mood stabilizers
How is rapid cycling bipolar d/o managed?
gradually stop all antidepressants, stimulants, caffeine, benzos, alcohol
What other conditions predispose a patient to rapid cycling bipolar d/o?
hypothyroidism - check TSH, replace thyroid hormones if needed
What drug has been shown to prevent suicidal ideation in bipolar d/o?
lithium
If bipolar patient on lithium becomes pregnant, how do you manage?
D/C lithium, start ECT in 1st trimester, switch to lamotrigine in 2nd or 3rd trimester
Management of cyclothymia?
- psychotherapy
2. divalproex when functioning is impaired
Tx of postpartum depression?
antidepressants
Sxs of postpartum psychosis?
psychotic sxs + severe depressive sxs
Tx of postpartum psychosis?
mood stabilizers or antipsychotics + antidepressants; if patient breastfeeding, choose ECT
Tx of acutely suicidal patient?
- hospitalize (usu at least 2 weeks)
- psychotherapy and antidepressants (SSRIs are first choice)
- for acute severe risk of self-harm, treatment of choice is ECT
Indications of ECT?
- major depressive episodes unresponsive to meds
- high risk for immediate suicide
- contraindications to using antidepressant meds
- good response to ECT in past
Guidelines for Use of Antidepressants:
What antidepressant is usu first line therapy?
SSRIs - think of first for patients w/ MDD, BPD, anxiety d/os, bulimia
Guidelines for Use of Antidepressants:
Which should be avoided?
TCAs (e.g. amitriptyline) - risk of toxicity
Guidelines for Use of Antidepressants:
Which is most helpful in atypical depressive d/os?
MAOIs
Guidelines for Use of Antidepressants:
What should you do if patient does not respond to med after 8 weeks or does not tolerate SFX?
switch to another antidepressant
Guidelines for Use of Antidepressants:
For how long should you treat? Then what?
6 mo; then attempt to taper; consider long-term therapy for multiple episodes of depression
Guidelines for Use of Antidepressants:
Which med best when trying to lose or maintain weight?
Buproprion (a/w mild weight loss; but also a/w seizures)
Guidelines for Use of Antidepressants:
Which med best when trying to gain weight for the patient?
mirtazapine (a/w weight gain)
Guidelines for Use of Antidepressants:
Which med good for chronic pain?
amitriptyline
Guidelines for Use of Antidepressants:
Which med good for enuresis?
imipramine
Guidelines for Use of Antidepressants:
Which med good for severe insomnia?
trazodone (doxepin also has sedating effects)
Guidelines for Use of Antidepressants:
Which meds ok in pregnancy?
SSRIs and TCAs (except paroxetine i.e. Paxil)
Which meds a/w seizures?
bupropion, TCAs
A woman is brought into ED w/ confusion, disorientation, hypotension, tachycardia, dilated pupils, dry mucous membranes, facial flushing - which prescription med did she OD on?
TCAs - they have anticholinergic FX and are an alpha blocker
A woman is brought into ED w/ confusion, disorientation, hypotension, tachycardia, dilated pupils, dry mucous membranes, facial flushing - what is most important test to run?
EKG - look out for prolonged QRS, QT, PR. Most serious complication is Vtach, Vfib
A woman is brought into ED w/ confusion, disorientation, hypotension, tachycardia, dilated pupils, dry mucous membranes, facial flushing - which antidote should be given?
- sodium bicarb - alkalinizes the blood, uncouples TCA from myocardial sodium channels, increases extracellular Na+ concentration, improving gradient across the channel
- for mgmt of arrythmias: give lidocaine
SFX of lithium?
- acne
- weight gain
- dose-related tremors, GI distress, HA
- hypothyroidism
- polyuria 2/2 med-induced DI
SFX of carbamazepine?
agranulocytosis, sedation
SXS of Li+ OD?
-N/V, disorientation, tremors, increased DTRs, seizures
Tx of Li+ OD?
dialysis
SXS of NMS?
high fever, tachycardia, muscle rigidity, altered consciousness, autonomic dysfunction
Tx of NMS?
- ICU transfer
- D/C antipsychotic
- bromocriptine (to overcome DA receptor blockade)
- give muscle relaxants dantrolene or diazepam to reduce muscle rigidity
SXS of serotonin syndrome?
h/o SSRI use, use of migraine meds (triptan) or MAOI; agitation, hyperreflexia, hyperthermia, muscle rigidity w/ volume contraction 2/2 sweating and insensible fluid losses
Tx of serotonin syndrome
- IVF
- cyproheptadine to decrease serotonin production
- benzos to decrease muscle rigidity
Typical history of MAOI Hypertensive Crisis?
-patient w/ acute HTN, h/o MAOI use, and either antihistamines, nasal decongestants, consumption of tyramine-rich foods (cheeses, pickled foods)
Tx of MAOI hypertensive crisis?
treat as hypertensive crisis
Requirements for Dx of somatization d/o?
- 4 pain sxs
- 2 GI sxs
- 1 sexual symptom
- 1 pseudoneurologic symptom
What is conversion d/o?
when one or more neurologic symptoms that cannot be explained by any medical or neuro d/o
How long must sxs be present for dx of hypochondriasis?
6 mo
Tx of anorexia nervosa AND bulimia nervosa?
- hospitalize for IV hydration if electrolyte disturbances present
- olanzapine in anorexia patients (helps w/ weight gain)
- SSRIs (esp fluoxetine) prevents relapses
- behavioral psychotherapy
Tx of body dysmorphic d/o
high dose SSRIs
Tx of intermittent explosive d/o?
SSRIs and mood stabilizers
Tx of pathologic gambling?
group psychotherapy
Tx of personality disorders?
- psychotherapy
- For Cluster B (mood lability, dissociative sxs, preoccupation w/ rejection): mood stabilizers and antidepressants is sometimes useful
What should you order when the case describes someone with alcohol abuse?
- blood and urine tox screen
- look for secondary FX of EtOH: AST, ALT, LDH, ?GGTP
- if s/o IV drug use (e.g. track marks): HIV, hep B, hep C, PPD tests
What is the inpatient management of acute alcohol withdrawal?
- Look for withdrawal sxs.
- IV or IM thiamine and Mg2+ ASAP, B12, folate: to prevent Wernicke-Korsakoff (ataxia, nystagmus, ophthalmoplegia, amnesia)
- benzos: diazepam or chlordiazepoxide; if patient has severe liver disease, choose short-acting benzo - lorazepam or oxazepam
- no seizure PPX - treat SZs w/ diazepam
HALDOL IS NEVER THE ANSWER (REDUCES SEIZURE THRESHOLD)
What is the chronic management of EtOH dependence?
- Refer to inpatient rehab or outpatient group therapy (AA)
- Never give drug therapy without group psychotherapy
- naloxone and acamproate decrease relapse rate ONLY when given w/ psychotherapy
- disulfiram has poor compliance and hasn’t shown to be effective
Alcohol Withdrawal:
What is seen 6 hours after last drink? Tx?
- minor sxs: insomnia, tremulousness, mild anxiety, HA, diaphoresis, palpitations
- Tx: give thiamine, folate, MVI, glucose
Alcohol Withdrawal:
What is seen 12-24 hours after last drink?
-sxs: visual hallucinations, +/- auditory or tactile hallucinations
Alcohol Withdrawal:
What is seen 48 hours after last drink? Mgmt tip?
- tonic-clonic SZs
- Get CT scan if repeated seizures to r/o structural or infectious cause
Alcohol Withdrawal:
What is seen 48-96 hours after last drink?
-DELIRIUM TREMENS! (hallucinations, disorientation, tachycardia, HTN, low-grade fever, agitation, diaphoresis)
Signs/sxs of amphetamine and cocaine intoxication?
euphoria, hypervigilance, hyperactivity, weight loss, pupil dilatation, disturbed perception, stroke, MI
Tx of amphetamine and cocaine intoxication?
- short-term use of antipsychotics
- benzos
- inderal
- Vitamin C to promote excretion
Signs/sxs of amphetamine and cocaine withdrawal?
anxiety, tremors, HA, increased appetite, depression, risk of suicide
Tx of amphetamine and cocaine withdrawal?
antidepressants
Signs/sxs of cannabis intoxication?
impaired motor coordination, impaired time perception, social withdrawal, increased appetite, dry mouth, tachycardia, conjunctival redness
Tx of cannabis intoxication or withdrawal?
none!
Signs/sxs of hallucinogen (e.g. LSD) intoxication?
ideas of reference, hallucinations, impaired judgment, dissociative sxs, pupil DILATATION, panic, tremors, incoordination
Tx of hallucinogen (e.g. LSD) intoxication?
- supportive counseling
- antipsychotics
- benzos
Signs/sxs and Tx of hallucinogen (e.g. LSD) withdrawal?
None!
Signs/sxs of inhalant intoxication?
belligerance, apathy, assaultiveness, impaired judgment, blurred vision, coma, stupor
Tx of inhalant intoxication?
antipsychotics if delirious or agitated
Signs/sxs and Tx of inhalant withdrawal?
None!
Signs/sxs of opiate intoxication?
apathy, dysphoria, CONSTRICTED pupils, drowsiness, slurred speech, impaired memory, coma, death
Tx of opiate intoxication?
naloxone
Signs/sxs of opiate withdrawal?
fever, chills, lacrimation, runny nose, abd cramps, muscle spasms, insomnia, yawning, MYDRIASIS
Tx of opiate withdrawal?
clonidine, methadone or buprenorphine (opioid)
Signs/sxs of PCP intoxication?
panic reactions, assaultiveness, agitation, nystagmus, HTN, seizures, coma, hyperacusis
Tx of PCP intoxication?
- talking down
- benzos
- antipsychotics
- support respiratory function
Signs/sxs and Tx of PCP withdrawal?
none!
Signs/sxs of benzo and barbiturate intoxication?
inappropriate sexual or aggressive behavior, impaired memory or concentration
Tx of benzo and barbiturate intoxication?
flumazenil
Signs/sxs of benzo and barbiturate withdrawal?
autonomic hyperactivity (increased HR, BP, T), tremors, insomnia, seizures, anxiety, confusion, disorientation
Tx of barbiturate withdrawal?
- short-acting benzos (lorazepam or diazepam IV)
- substitute short-acting with long-acting barbiturates (chlordiazepoxide or phenobarbital)
Pharmacologic agents that cause sexual dysfunction; Name what these cause:
- alpha 1 blockers
- SSRIs
- beta-blockers
- trazodone
- DA agonists
- neuroleptics
- alpha 1 blockers: impaired ejaculation
- SSRIs: inhibited orgasm, decreased libido, impaired ejaculation
- beta-blockers: ED
- trazodone: priapism
- DA agonists: increased erection and libido
- neuroleptics: ED
Tx of paraphilias?
- individual psychotherapy and aversive conditioning
- if severe: antiandrogens or SSRIs
What is schizoaffective d/o?
schizophrenia + MOOD sxs (depression or mania) present at least 2 weeks
Tx of catatonic-type schizophenia?
benzos and/or ECT
What black box warning do the atypical antipsychotics carry re: the elderly?
may increase mortality (PNA, cardiovascular). Not FDA approved but benefits may outweigh risks.
What antidepressants are a/w weight gain? Weight loss?
- Weight gain: Mirtazapine, paroxetine, sertraline, citalopram, imipramine, amitriptyline
- Weight loss: Buproprion, fluoxetine
How long do sxs last in acute stress d/o? In PTSD?
< 1 mo; > 1 mo
What comorbidities are a/w MDD?
CAD/MI
What SFX are a/w valproic acid/valproate?
liver dysfunction (check LFTs!)
Name some SSRIs.
Fluoxetine, paroxetine, citalopram, sertraline
Name some TCAs.
imipramine, nortriptyline, amitriptyline
SFX of TCAs?
anticholinergic, orthostatic, sedative, weight gain, sexual dysfunction, prolonged QT
Name a MAOI.
phenelzine
SFX of MAOIs.
hypotension, dry mouth, GI sxs, fatigue, sedation, sexual dysfunction
When treating a patient with an antihypertensive who’s already on Li+, what to consider?
Any med/factor which decreases excretion of Li+ (e.g. diuretics [e.g. thiazides, ACE-Is, ARBs, loop diuretics, NSAIDs, ACE-Is) can precipitate toxicity. Thiazides esp have known interaction. Choose a beta-blocker or CCB instead.
What to do when transitioning a patient from SSRI to MAOI?
allow one drug-free month in between to avoid serotonin syndrome
Tx of narcolepsy?
- scheduled naps
- amphetamines (e.g. methylphenidate) if above fails
What other conditions are patients with Tourettes at risk for?
- ADHD
- OCD
Tx of Tourette syndrome?
DA receptor blockers (e.g. fluphenazine, pimozide, tetrabenazine)
