Psychiatry 2 Flashcards
1
Q
Clinical features of delusional disorder?
A
1+ delusions for 1+ months
Other psychotic symptoms are absent or not prominent
Behavior is not obviously odd/bizarre; ability to function apart from delusion’s impact
2
Q
What are the subtypes of delusional disorder?
A
Erotomanic, grandiose, jealous, persecutory, somatic
3
Q
DDx - delusional disorder
A
- Schizophrenia (other psychotic symptoms present, such as hallucinations, disorganization, negative symptoms + greater functional impairment)
- Personality disorders (paranoid - pervasive pattern of suspiciousness, narcissistic - grandiosity, schizotypal - odd beliefs, but no clear delusions)
4
Q
Treatment of delusional disorder?
A
- Antipsychotics
2. CBT
5
Q
Clinical features of brief psychotic disorder?
A
Sudden onset of 1+ psychotic symptoms lasting 1+ days, but less than 1 month; full return to function
Excluded if the symptoms are better explained by the effects of a medication or medical illness
6
Q
Characteristics of personality disorders?
A
Long-standing patterns of interpersonal problems but no persistent delusions or other psychotic symptoms
7
Q
Widespread distrust and suspiciousness are characteristic of ___ personality disorder.
A
Paranoid
8
Q
Patients with ___ personality disorder exhibit eccentric behavior and odd beliefs or magical thinking; their beliefs are not held with delusional conviction.
A
Schizotypal
9
Q
Patients with ___ personality disorder often display pervasive emotionality or the need to be the center of attention.
A
Histrionic
10
Q
Medications commonly used to treat acute bipolar depression?
A
Second-generation antipsychotics (quetiapine and lurasidone) and the anticonvulsant lamotragine
[Lithium, valproate, and combined olanzapine/fluoxetine have also demonstrated efficacy]
11
Q
Why should antidepressant monotherapy generally be avoided in patients with bipolar I disorder?
A
Risk of precipitating mania, development of rapid cycling, increased mood cycle frequency
(If necessary, antidepressants should be used in combination with mood stabilizers as these appear to decrease the risk of an anti-depressant-induced switch from depression to mania)
12
Q
Define rapid cycling.
A
4+ mood episodes/year
13
Q
True or false - haloperidol is a first-generation antipsychotic that has not shown efficacy in treating bipolar depression.
A
True
14
Q
High-dose glucocorticoids, often given for allergic, inflammatory, or autoimmune conditions, may cause ___, typically during the first week of treatment, but can occur at any time. What other symptoms can it cause?
A
Glucocorticoid-induced psychosis; manic or depressive symptoms
15
Q
Symptoms of cannabis use?
A
Euphoria, perceptual changes, increased appetite, red eyes, slowed reflexes, dizziness, and impaired coordination
16
Q
What is the core feature of delirium?
A
Fluctuating cognitive impairment, such as poor attention and disorientation
17
Q
What are the characteristic features of medication-induced psychotic disorder?
A
Acute onset of delusions and/or hallucinations that are temporally associated with the use of a new medication
18
Q
Diagnosis of dementia with Lewy bodies (DLB)?
A
Dementia plus 2+ of the following: Visual hallucinations Parkinsonism Fluctuating cognition REM sleep behavior disorder
19
Q
Treatments for dementia with Lewy bodies?
A
Carbidopa-levodopa (Parkinsonism) Cholineserase inhibitors (eg, rivastigmine; cognitive impairment) Melatonin (REM sleep behavior disorder) [Trial of antipsychotic medication may be indicated in patients with functionally impairing visual hallucinations or delusions]
20
Q
Why must antipsychotics be prescribed with caution in DLB?
A
Extreme antipsychotic hypersensitivity of patients with DLB; may cause worsening confusion, parkinsonism, and autonomic dysfunction
21
Q
Which antipsychotic is known for stronger dopamine receptor antagonism relative to other second-generation antipsychotics?
A
Risperidone
22
Q
When antipsychotics are indicated in the treatment of DLB, evidence favors what? What should be avoided entirely?
A
Low-potency second-generation antipsychotics (eg, quetiapine); first-generation antipsychotics
23
Q
Diagnosis of schizophreniform disorder?
A
1+ month, but <6 months, same symptoms as schizophrenia, functional decline not required
Symptoms of schizophrenia (2+): delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms
24
Q
Diagnosis of schizophrenia?
A
6+ months, with 1+ months of active symptoms, can include prodromal and residual periods, requires functional decline
25
Diagnosis of schizoaffective disorder?
Major depressive or manic episode with concurrent active-phase symptoms of schizophrenia + lifetime history of 2+ weeks of delusions or hallucinations in the absence of prominent mood symptoms
Mood episodes are prominent and recur throughout illness
Not due to substances or another medical condition
26
DDx - psychotic disorders
1. Brief psychotic disorder (1 day to <1 month, sudden onset, full return to function)
2. Schizophreniform disorder (1 month to <6 months, schizophrenia symptoms, no functional decline required)
3. Schizophrenia (6+ months with 1+ months active symptoms, requires functional decline)
4. Schizoaffective disorder (mood episode with concurrent active-phase symptoms of schizophrenia + 2+ weeks of delusions or hallucinations in the absence of prominent mood symptoms)
5. Delusional disorder (1+ delusions and 1+ month, no other psychotic symptoms, normal functioning except for direct impact of delusions)
27
Age of onset of the psychotic features of schizophrenia?
Between late teens and mid-30s
28
When the diagnosis of schizophreniform disorder is made without waiting for the patient to recover, it is specified as ___. If symptoms persist >6 months, the diagnosis is changed to ___.
Provisional; schizophrenia
29
Clinical features of PTSD?
Exposure to life-threatening trauma
Nightmares, flashbacks, intrusive memories
Avoidance of reminders, amnesia for event
Emotional detachment, negative mood, decreased interest in activities
Sleep disturbance, hypervigilance, irritability
Increased startle response
Duration 1+ months
30
Treatment of PTSD?
Trauma-focused CBT
Antidepressants
Prazosin for nightmares
31
What increases risk for PTSD in military veterans?
Repeated deployments
Longer duration
Higher severity of combat exposure
32
Clinical features of panic disorder?
Recurrent, spontaneous, unexpected panic attacks with 4+ of the following:
```
Chest pain, palpitations, SOB, choking
Trembling, sweating, nausea, chills
Dizziness, paresthesias
Derealization, depersonalization
Fear of losing control or of dying
```
1+ months of worry about additional attacks or avoidance behavior
Dx requires that at least some of the episodes are untriggered or unexpected
33
Treatment of panic disorder?
First-line/maintenance: SSRI/SNRI and/or CBT
| Acute distress - benzodiazepines
34
When is anxiety disorder due to another medical condition diagnosed?
When the panic attacks are a direct physiological consequence of another medical condition (eg, hyperthyroidism, pheochromocytoma, arrhythmias, asthma)
35
Clinical features of GAD?
6+ months of persistent worry and anxiety about multiple issues
Difficult to control
3+ of the following symptoms: restlessness or feeling on edge, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbance
Significant distress or impairment
Not due to substances, another mental disorder, or a medical condition
Does not feature unexpected panic attacks
36
Following stabilization of acute symptoms, patients with bipolar disorder require maintenance treatment to delay or prevent recurrence of new mood episodes. Common first-line mood stabilizers?
Lithium
Valproate
Other options - quetiapine and lamotrigine
37
Why is lithium contraindicated in patients with renal dysfunction?
Lithium is excreted unchanged by the kidneys and may build up to toxic levels when used in patients with renal dysfunction
Long-term use has also been associated with nephrogenic DI and chronic tubulointerstitital nephropathy
38
True or false - topiramate has not demonstrated efficacy in acute or maintenance treatment of bipolar disorder.
True
39
What three things should be evaluated in a suicide risk assessment?
Ideation
Intent
Plan
40
What information should be included when evaluating suicidal ideation?
Passive (wish to die, not wake up) vs. active (thoughts of killing self)
Frequency, duration, intensity, controllability
41
What information should be included when evaluating suicidal intent?
Strength of intent to attempt suicide
Ability to control impulsivity
Determine how close patient has come to acting on a plan (rehearsal, aborted attempts)
42
What information should be included when evaluating suicide plan?
Specific details (method, time, place, access to means, preparations)
Lethality of method
Likelihood of rescue
43
What should be done for all patients presenting with depression?
Careful screening for suicide risk
44
Signs and symptoms of neuroleptic malignant syndrome?
```
Fever >40 C (104 F) common
Confusion/mental status changes/delirium
Muscle rigidity (generalized, lead pipe)
Autonomic instability (abnormal vital signs - HTN, tachycardia, sweating)
```
CK and WBC may be elevated
45
Treatment of neuroleptic malignant syndrome?
```
Stop antipsychotics or restart dopamine agents
Supportive care (hydration, cooling); ICU
Dantrolene (direct-acting muscle relaxant) or bromocriptine/amantadine (reverse dopamine blockade) if refractory
```
46
What medications can cause NMS?
More commonly associated with high-potency first-generation antipsycsyndromeotics (eg, haloperidol), but can occur with every class, including second-generation
47
NMS should be differentiated from ___.
Serotonin syndrome
48
Signs and symptoms of serotonin syndrome?
Hyperthermia (usually not as high as NMS)
Autonomic instability
Mental status changes
Prominent GI symptoms
Neuromuscular irritability (hyperreflexia, myoclonus, tremor, NOT lead-pipe rigidity)
49
Cause of serotonin syndrome?
Typically due to a combination of serotonergic medications or the interaction of these medications and MAOIs (eg, phenelzine)
50
Compare NMS and SS.
NMS has a higher fever
SS has prominent GI symptoms and neuromuscular irritability (hyperreflexia and myclonus), NO lead-pipe rigidity
Both have autonomic instability and mental status changes
51
Characteristics of catatonia?
Syndrome of marked psychomotor disturbance with decreased motor activity, lack of responsiveness during interview, and posturing
Not associated with high fevers
52
What causes malignant hyperthermia?
Volatile anesthetics or succinylcholine
53
Dx - MDD?
2+ weeks
5+ of 9 symptoms - depressed mood and SIGECAPS
Significant functional impairment
No lifetime history of mania
54
Dx - adjustment disorder with depressed mood?
Onset within 3 months of identifiable stressor
Resolve 6 months after the stressor ends
Marked distress and/or functional impairment
Does not meet criteria for another DSM-5 disorder
55
DDx - depressed mood?
1. MDD
2. Dysthymia
3. Adjustment disorder with depressed mood
4. Normal stress response (not excessive or out of proportion to severity of stressor, no significant functional impairment)
56
SIGECAPS?
```
Sleep disturbance
Interest (loss of)
Guilt (excessive)
Energy (low)
Concentration (impaired)
Appetite disturbance
Psychomotor agitation/retardation
Suicidal ideation
```
57
Rx of choice for adjustment disorder?
Psychotherapy (developing coping mechanisms and improving the individual's response to and attitude about the stressful situation)
58
Clinical features of MDD with psychotic features?
Depressive episode is accompanied by delusions and/or hallucinations, typically with depressive themes (eg, deserving punishment, worthlessness, nihilism)
Psychotic features occur ONLY during the major depressive episode
59
First-line treatment of MDD with psychotic features?
Combination pharmacotherapy with an antidepressant and antipsychotic OR ECT
60
Clinical features of illness anxiety disorder?
Excessive concern about having a serious, undiagnosed general medical condition
61
Clinical features of somatic symptom disorder?
Excessive anxiety and thoughts about the seriousness of 1+ somatic symptoms lasting for 6+ months
62
Clinical features of persistent complex bereavement disorder (aka complicated grief)/
Depressive symptoms with sadness centering on the loss of a loved one; characterized by intense yearning for the deceased
63
What is tardive dyskinesia?
Involuntary movement disorder associated with dopamine-blocking agents
Characteristic movements include orofacial dyskinesias (rhythmic movements of the face, lips, and tongue) and choreoathetoid movements of the trunk and extremities
64
Pathophysiology of tardive dyskinesia?
Dopamine D2 receptor upregulation and supersensitivity resulting from chronic blockade of dopamine receptors
(Other hypotheses include an imbalance between D1 and D2 receptor effects in the basal ganglia as well as excitotoxic destruction of GABA neurons in the striatum)
65
Tardive dyskinesia is most commonly associated with...?
Prolonged use of antipsychotic medications
Typically seen in patients with chronic psychotic disorders
Also common for it to worsen or first appear following antipsychotic dose reduction or discontinuation
More common with first-generation, can also occur with second-generation such as risperidone
66
Cauadate nucleus atrophy is associated with?
Huntington disease
67
What is Huntington disease?
Inherited progressive neurodegenerative disorder characterized by choreiform movements, psychiatric symptoms, and dementia
68
The ___ area is a region in the midbrain that contains a high density of dopamine-releasing neurons, which project to the ___ (nucleus) and modulate reward pathways.
Ventral tegmental area; nucleus accumbens
69
Separation anxiety commonly develops at what age? Time course/prognosis?
9-18 months; Tends to improve with time, but can recur during times of transition that require separation
70
When is parent-child relational problem diagnosed?
When conflict in the parent-child relationship is beyond that seen in normal development and causes significant distress requiring clinical intervention
71
Clinical features of separation anxiety disorder?
Extreme and persistent anxiety with separation and excessive worry about losing major attachment figures
May have physical symptoms, repeated nightmares involving the theme of separation, difficulty sleeping alone, and school refusal
72
What is stranger anxiety?
Fear of being around unknown people rather than fear of separation from parents and can occur with the parents in the room
73
Stranger anxiety is developmentally appropriate beginning around age ___.
6-12 months
74
True or false - although confidentiality should be maintained whenever possible to facilitate rapport and encourage trust, if an adolescent patient is at risk of harm to self others, safety becomes more important and confidentiality must be broken in order to facilitate treatment.
True
75
True or false - parental consent is not required for emergency hospitalization of a minor.
True
76
What types of medications are effective in alcohol use disorder treatment?
Medications that target the reinforcing effects of alcohol by modulating opioid and glutamate function
77
First-line treatment medications for alcohol use disorder?
Naltrexone (mu-opioid receptor antagonist)
Acamprosate (glutamate modulator)
78
Discuss the efficacy of naltrexone in treating alcohol use disorder.
Shown to decrease alcohol craving, reducing heaving drinking days, and increase days of abstinence
79
True or false - naltrexone cannot be initiated until the patient stops drinking.
False - it can be initiated while the patient is still drinking
80
When is naltrexone contraindicated?
Patients taking opioids (can precipitate withdrawal)
| Those with acute hepatitis or liver failure
81
When is acamprosate contraindicated?
Significant renal failure
82
Mechanism of buprenorphine?
Opioid partial agonist
83
Uses of buprenorphine?
Opioid use disorder
| Pain management
84
Uses of valproate?
Epilepsy
| Bipolar affective disorder
85
First-line treatments for smoking cessation?
Bupropion
| Varenicline
86
Rx of moderate to severe alcohol withdrawal?
Benzodiazepines (eg, chlordiazepoxide)
87
Mechanism of disulfiram?
Aldehyde dehydrogenase inhibitor that causes an unpleasant physiologic reaction (tachycardia, flushed skin, headache, N/V) when alcohol is consumed
88
What should disulfiram be used to treat alcohol use disorder?
Abstinent patients who are not actively drinking
| Highly motivated or taking the medication in a supervised setting to avoid skipping a dose when alcohol is desired
89
Clinical features of acute distress disorder?
Exposure to actual or threatened trauma
Intrusive memories, nightmares, flashbacks with intense psychological/physiological reactions
Amnesia for event, detachment, avoidance of reminders
Negative mood
Arousal with sleep disturbance, irritability, hypervigilance, exaggerated startle, impaired concentration
Lasting 3+ days and no longer than 1 month
90
Management of acute stress disorder?
Trauma-focused, brief CBT (first-line)
Consider pharmacotherapy for insomnia, intense anxiety
Monitor for development of PTSD
91
An adequate antidepressant trial is generally considered to be at least ___.
4-6 weeks (+adequate dose)
92
Compare the prevalence of postpartum blues, depression, and psychosis.
Blues - 40-80%
Depression - 8-15%
Psychosis - 0.1-0.2%
93
Compare the onset of postpartum blues, depression, and psychosis.
Blues - 2-3 days (resolves within 14 days)
Depression - typically within 4-6 weeks, can be up to 1 year
Psychosis - variable (days to weeks)
94
Compare the symptoms of postpartum blues, depression, and psychosis.
Blues - mild depression, tearfulness, irritability
Depression - 2+ weeks of moderate to severe depression, sleep or appetite disturbance, low energy, psychomotor changes, guilt, concentration difficulty, suicidal ideation
Psychosis - delusions, hallucinations, thought disorganization, bizarre behavior
95
Compare the management of postpartum blues, depression, and psychosis.
Blues - reassurance and monitoring
Depression - antidepressants, psychotherapy
Psychosis - antipsychotics, antidepressants, mood stabilizers; hospitalization, do not leave mother alone with infant (risk of infanticide)
96
Among antidepressants, ___ are commonly used as first-line therapy in treatment-naive patients as they have demonstrated efficacy and tolerability in postpartum depression.
SSRIs
97
In breastfeeding patients, what antidepressant is preferred, as levels in infants are usually undetectable?
Sertraline
98
List 9 risk factors for homicide.
1. Young male
2. Unemployed
3. Impoverished
4. Access to firearms
5. Substance abuse
6. Antisocial personality disorder
7. History of violence or criminality
8. History of childhood abuse
9. Impulsivity
99
What are the most commonly used weapon in youth homicide in the US?
Firearms
100
True or false - all patients, including children, vulnerable adults, and the elderly, should be given the opportunity to speak with the physician alone and tell their story in their own words.
True
101
Clinical features of sleep terrors (type of parasomnia that occurs during NREM sleep)?
Abrupt arousals from sleep (panicked scream, terror, autonomic arousal, unresponsive to comfort)
Little or no dream recall
Cannot be fully awakened
Amnesia for episodes
102
Management of sleep terrors?
Reassurance that sleep terrors are not dangerous and usually resolve spontaneously within 1-2 years
Low-dose benzodiazepine at bedtime if episodes are frequent, persistent, and distressing
103
Sleep terrors are most commonly seen in children age ___, with a peak incidence at age ___.
2-12; 5-7
104
How do nightmares differ from sleep terrors?
In contrast to sleep terrors, nightmares usually occur in the latter half of sleep when REM occurs and are associated with complete awakening and dream recall
105
Desmopressin and imipramine are used in the treatment of ___.
Nocturnal enuresis
106
How are sleep terrors diangosed?
Clinically
107
Diagnostic criteria of borderline personality disorder?
Pervasive pattern of unstable relationships, self-image and affects, and marked impulsivity with 5+ of the following:
1. Frantic efforts to avoid abandonment
2. Unstable and intense interpersonal relationships
3. Markedly and persistently unstable self-image
4. Impulsivity in 2+ areas that are potentially self-damaging
5. Recurrent suicidal behaviors or threats of self-mutilation
6. Mood instability (marked mood reactivity)
7. Chronic feelings of emptiness
8. Inappropriate and intense anger
9. Transient stress-related paranoia or dissociation
108
Rx - Borderline personality disorder?
Primary treatment - psychotherapy (several types effective, best evidence for DBT)
Adjunctive pharmacotherapy to target mood instability and transient psychosis (second-generation antipsychotics, mood stabilizers)
Antidepressants if comorbid mood or anxiety disorder
109
A history of ___ is common in patients with borderline personality disorder.
Childhood trauma (physical and sexual abuse and neglect)
110
___ to the primary caregiver may underlie the unstable relationships and fears of abandonment commonly seen in borderline personality disorder.
Insecure attachment
111
If present, psychotic symptoms in borderline personality disorder are ___ and ___.
Transient; stress-related
112
Describe the affect typically seen in borderline personality disorder.
Intense, labile, or angry
113
Clinical features of narcolepsy?
Recurrent lapses into sleep or naps (3+ times/week for 3 months)
1+ of the following:
Cataplexy (emotionally triggered loss of muscle tone)
Low CSF levels of hypocretin-1/orexin-A
Shortened REM sleep latnecy
Associated features:
Hypnagogic/hypnopompic hallucinations
Sleep paralysis
114
Treatment of narcolepsy?
Sleep hygiene and scheduled naps
Avoidance of alcohol and drugs that cause drowsiness
Medication to promote wakefulness may be necessary when sleepiness impairs daily functioning; first-line is Modafinil (nonamphetamine medication that promotes wakefulness)
If significant cataplexy, may benefit from REM-sleep suppressing drugs (antidepressants and sodium oxybate)
115
Uses of pramipexole?
Treat symptoms of Parkinson disease and restless legs syndrome
116
Why can antipsychotic medications cause hyperprolactinemia?
Dopamine is a prolactin-inhibitng factor; medications cause dopamine blockade in the tuberoinfundibular pathway
117
Symptoms of hyperprolactinemia?
Gynecomastia
Galactorrhea
Menstrual dysfunction
Decreased libido
118
What second-generation antipsychotic is known to have a high frequency of prolactin elevation?
Risperidone
119
Why is aripiprazole less likely to cause hyperprolactinemia?
It is both an antagonist and partial agonist of D2 receptors
120
DDx - galactorrhea
Antipsychotic use
Galactocele (benign milk collection in lactating women due to blocked duct)
Hypothyroidism (also presents with lethargy, dry skin, cold intolerance)
PCOS (hyperandrogenism - acne, hirsutism, menstrual irregularities)
Prolactinomas (headaches, visual disturbances, very high prolactin levels)
121
DDx - schizoaffective disorder?
1. Major depressive disorder with psychotic features
2. Bipolar disorder with psychotic features
(#1 and #2 - psychotic symptoms occur exclusively during mood episodes)
3. Schizophrenia (mood symptoms may be present for a relatively brief period)
122
List the EPS of antipsychotics in order of onset.
1. Acute dystonia
2. Akathisia
3. Parkinsonism
4. Tardive dyskinesia (gradual onset after prolonged therapy; >6 months)
123
Define acute dystonia.
Sudden, sustained contraction of the neck, mouth, tongue, and eye muscles
124
Define akathisia.
Subjective inner restlessness, inability to sit still
In severe cases, patients may become extremely distress, resulting in increased agitation and overall global worsening
125
Define parkinsonism.
Gradual-onset tremor, cogwheel rigidity, bradykinesia, shuffling gait, masklike facies
126
Define tardive dyskinesia.
Dyskinesia of the mouth, face, trunk, and extremities
127
Clinicians must differentiate akathisia from worsening psychotic agitation, as akathisia is ___.
Dose dependent (efforts to target restlessness and agitation by increasing the antipsychotic dose were ineffective)
128
First steps in management of akathisia?
Cautiously reducing antipsychotic dosage and/or adding a beta blocker (eg, propranolol), an anticholinergic (eg, benztropine), or a benzo (eg, lorazepam)
129
How does propranolol work in managing akathisia?
Likely blocks noradrenergic and serotonergic inputs on dopamine pathways
130
Why are benzos not first-line treatment for akathisia in patients with schizophrenia?
Associated with increased mortality
131
Rx acute dystonia?
Benztropine (anticholinergic)
| Diphenhydramine
132
Rx parkinsonism?
Benztropine (anticholinergic)
| Amantadine
133
Rx tardive dyskinesia?
Valbenazine
134
List 11 risk factors for suicide.
1. Psychiatric disorders and prior suicide attempts
2. Hopelessness
3. Never married, or divorced/separated
4. Living alone
5. Elderly white man
6. Unemployed or unskilled
7. Physical illness
8. Family history of suicide, family discord
9. Access to firearms
10. Substance abuse
11. Impulsivity
135
List 4 protective factors against suicide.
1. Social support/family connectedness
2. Pregnancy
3. Parenthood
4. Religion/participation in religious activities
136
Strongest single factor predictive of suicide?
Prior suicide attempt
137
What is often the first symptom of NMS?
Delirium
