Psychiatry Flashcards
General anxiety disorder dx, tx
6+ months
3+ somatic signs
Worry about multiple entities
Causes dysfunction
Benzos ==> eventually taper
- SSRI’s
- Buspirone
- SNRI
Benzo overdose tx w/ mechanism
Flumazenil
Competitive GABA antagonist
Obsessive compulsive disorder dx, tx*
Obsessions: persistent, unwanted ideas
Compulsions: repeated acts to relieve anxiety
Ego-dystonic (aware of absurdity)
- SSRI
- CBT
Panic disorder dx, associations, tx
Discrete moment of fear
4+ signs: tachypnea, palpitations, sweating, chest pain, nausea, fear of dying, depersonalization
1+ month of fear over recurrence causing behavior change
*Must screen for agoraphobia
*Depression, bipolar, substance abuse
- Acute: Benzo (taper if needed)
1. SSRI
1. CBT
Phobia disorders dx, tx*
Excessive fear leading to dysfunctional avoidance
Ego-dystonic
*1. CBT ==> first-line for SINGLE phobia like flying!
*2. Beta blocker or benzo if situational
Rarely SSRI
Post-traumatic stress disorder dx, subtype*, tx
s/p threatening event
Avoidance, hypervigilance, numbed responsiveness
sx for 1+ month
*Acute-stress disorder: PTSD lasting < 1 month
Short term:
Beta-blockers
Alpha-agonists
Long-term:
SSRI
Support groups
Dementia dx, tx
Memory impairment plus 1+ sx: [4A's] Amnesia Aphasia (language impairment) Apraxia (motor impairment) Agnosia (recognition impairment) Executive dysfunction Personality change STABLE CONSCIOUSNESS (unlike delirium)
Cholinesterase inhibitors
Antipsychotics
Environmental cues
AVOID benzodiazepines!
Delirium dx, tx
Waxing/waning consciousness (unlike dementia)
Altered cognition
Perceptual disturbances
Worsening at night
2/2 underlying medical cause!!! ==> find it!
Environmental cues
Antipsychotics
Major depressive disorder dx, subtypes*, tx** including refractory cases
2+ weeks Depressed mood or anhedonia and... 4+ SIGECAPS Sleep change Interest loss Guilt/worthlessness Energy loss Concentration loss Appetite increase/decrease Psychomotor agitation/retardation Suicidality
Psychotic
Post-partum (within 1 month)
Seasonal
*Dysthymia: milder but 2+ years
Bereavement: gradually waning with time, generally less severe, less self-loathing
*Persistent complex bereavement: 1+ year of depression with symptoms ALL focused on deceased
Adjustment disorder: 2/2 event, doesn’t meet MDD criteria, impairs functioning, lasts >1 month but > 6 months ==> psychotherapy instead of SSRI
- SSRI ==> expect 4-6 weeks for change; continue minimum 6 months if effective without severe side effects ==> switch class after 2 refractory attempts*
- ECT if refractory
ECT s/e*
*Anterograde amnesia
Headache, nausea, skin burns
Bipolar disorder dx, relevant features, subtypes, tx
1+ week of elevated, irritable mood plus 3+ DIGFAST mania criteria: Distractibility Irresponsibility Grandiosity Flight of ideas Agitation (psychomotor) Sleep decrease Talkative (pressured speech)
SSRI's may trigger Psychotic episodes common Suicide risk! Rule out substance abuse 10% risk if parent or sibling has it*
1: manic episode
2: depressive episode + hypomanic episode
Rapid cycling: 4+ episodes of any in one year
Cyclothymic: alternating episodes for 2+ years
*Acute mania:
antipsychotics [haloperidol] & hospitalize
*Long-term:
Mild bipolar: mood stabilizer or atypical antipsychotic mono therapy
Severe bipolar: mood stabilizer [lithium] + antipsychotic
Bipolar II:
Mood stabilizer first, then possibly antidepressant (afterward to prevent inducing mania)
Antipsychotics mechanism, names, side-effects*
Typicals: BLOCK D-2 receptor
Haloperidol, fluphenazine, chlorpromazine
Extrapyramidal (see flashcard)
Anticholinergic (dry mouth, urinary retention, constipation)
NMS (fever, rigidity, CK elevation) ==> dantrolene or bromocriptine
Prolacinemia 2/2 dopamine blockade*
Seizures
QT prolongation
Atypicals: D-2* and serotonin receptor blockage
Ziprazidone, quetipine, risperidone, olanzipine, aripiprazole, clozapine, fluphenazine (depot…for non-compliant)
Prolactinemia 2/2 dopamine blockade*
Weight gain* (especially olanzipine and clozapine ==> monitor glucose and lipids)
QT prolongation
Risperidone: most likely to cause extrapyramidal sx
**Clozapine only: tardive dyskinesia, agranulocytosis (weekly CBC)
Antidepressant names, s/e*, contraindications
SSRIs-
Fluoxetine, citalopram etc.
Sexual, GI etc.
MAO-i ==> serotonin syndrome; pregnancy
Atypicals-
*Bupropion: seizures ==> contraindicated in epileptics and anorexia
Mirtazipine: sedation
Trazodone: sedation, priapism
SNRIs-
Venlafaxine, duloxetine
Hypertension
TCAs-
Nortriptyline, amitryptiline, desipramine
“Tri-C”: seizure, coma, dry mouth, dilated pupils, widened QRS ==> reverse with sodium bicarb**
MAO-i-
Selegiline, tranylcypromine, isocarboxazid
Hypertensive* crisis 2/2 tyramines (wine, cheese)
SSRI’s ==> serotonin syndrome
Mood stabilizer names, s/e, contrandications
Lithium
DI, hypothyroid* (test thyroid function before initiating)
Fetal: ASD & Ebstein’s tricuspid anomaly
Toxicity > 1.5 ==> ataxia, renal failure (always see Cr if stem gives CBC)
Carbamazepine
SJS, aplastic anemia
Valproic acid
Agranulocytosis, pancreatitis, hepatotoxicity
Lamotrigine
SJS
Post-partum disorder ddx
“Blues”:
Within 2 weeks
Sadness
No harm thoughts
Psychosis: 2-3 weeks post-delivery Depression Delusions Possible harm thoughts
Depression:
1-3 months post-delivery
Psychosis
+ harm thoughts
Personality disorders general characteristics, clusters with subtypes*, tx
"MEDIC" Maladaptive Enduring Deviant Inflexible Causing social impairment
“Weird, Wild, Worried Wimp”
CLUSTER A
Paranoid
Schizoid: isolated loners
Schizotypal: magical thinking, ideas of reference (seeing reference in everyday media)
CLUSTER B
Borderline: unstable relationships, self-harm history, manipulative, splitting*
Histrionic: excessively emotional, sexual
Narcissistic: entitled, lacking empathy
Antisocial: violates others without remorse; conduct disorder as child
CLUSTER C* OCD: perfectionist, ego-syntonic Avoidant*: fear of rejection, inadequacy, isolation DESPITE desire for friendship (unlike schizoid*) Dependent*: submissive, clingy ---- Psychotherapy
Schizophrenia age, dx*, subtypes** with prognosis, ddx, tx
Males: 18-25
Females: up to 35
*6+ months
2+ of following:
Positive symptoms: hallucinations, delusions (fixed, false belief), disorganized speech, bizarre behavior ==> more treatment sensitive
Negative symptoms: flat affect, poverty of speech, anhedonia
Paranoid: delusions, hallucinations, intact cognition ==> best prognosis
Disorganized: flat affect, disordered speech and behavior ==> worst prognosis
Catatonic: motor defects, echolalia, echopraxia, mutism
- Brief pyschotic < 1 month
- Schizophreniform < 6 months
- Schizoaffective = schizophrenia plus mood disorder features (i.e. mania, depression*)
Antipsychotics: atypicals are first line due to fewer side effects
Extrapyramidal side-effect symptoms, tx
DYSTONIA
Immediate onset tonic muscle contraction
Anticholinergics: benztropine*, diphenhydramine
DYSKINESIA
Days-later onset of pseudoparkinsonism (bradykinesia, masked facies, tremor)
Anticholinergic: benztropine*
Dopaminergic: amantadine
AKATHISIA
Weeks-later restlessness
Beta blockers or anticholinergic
TARDIVE DYSKINESIA*
Months-later stereotypical hyperkinetic oral-facial movement 2/2 dopamine blockade
Anticholinergics or decreasing dose may worsen
Often irreversible
ADHD dx, tx
6+ months
2+ settings
6+ symptoms of inattention and/or hyperactivity
Methylphenidate (ritalin)
Amphetamines
Antidepressants
Rett disorder presentation
Females only
Progressive impairment after 5 months of normal development
Childhood disintegrative disorder presentation
Regression after 2 years of normal development
Conduct disorder dx
1+ year
Violating rights of others
Progresses to antisocial disorder
Oppositional defiant dx
6+ months
Negative, defiant behavior towards authority
May progress to conduct disorder
Retardation IQ scores
Mild: 50-70
Moderate: 35-50
Severe: 20-34
Profound: <20
Tourette’s dx, associations, tx
< 18 y/o
1+ year
Motor tics
Vocal tics (coprolalia = obscene word repetition)
ADHD
OCD*
Antipsychotic*
Substance abuse dx
1+ year of 1 or more: Failure to fulfill responsibilities Use in hazardous situations Legal problems Recurrent use despite social problems
Substance dependence dx
1+ year of 3+ of following: Tolerance (more to obtain desired effect) Withdrawal sx Failed attempts to cut down Significant time spent obtaining Isolation Consumption of greater amounts than intended Continued use despite problems 2/2 drug
Alcoholism dx, withdrawal signs*, tx hospital and long-term
2+ "CAGE" Cutting back need Annoyed when criticized Guilty Eye opener
6 hrs: anxiety, palpitations ==> 1-2 days: seizures, hallucinations ==> 2-4 days: DT’s fever, hypertension, tachycardia, hallucinations
HOSPITAL
Benzo taper
Multivitamins w/ folic acid
Thiamine before glucose (glucose depletes thiamine, thus prevents Wernicke’s)
LONG-TERM
Disulfiram or naltrexone
Signs of substance abuse* and withdrawal* with reversal agents
OPIOIDS
Pupil constriction, respiratory depression
Dilated pupils, pain, sweating, GI upset* ==> no seizures & not life-threatening
Naloxone or naltrexone
AMPHETAMINES
Pupil dilation, agitation, seizures
Anxiety, lethargy
Haloperidol
COCAINE
Pupil dilation, cardiac ischemia, agitation
Lethargy, anxiety
Haloperidol
PHENCYCLIDINE (PCP)*
Combativeness*, vertical/horizontal/rolling nystagmus
None
Benzo or haloperidol
LSD*
Anxiety, delusion, hallucination, pupil dilation
Less aggression and more pronounced hallucinations than PCP*
Anorexia vs bulimia dx, complications**, pill to avoid, when to hospitalize*
< 85% expected body weight
Ego-syntonic (delusion as fat)
Dental erosions, enlarged parotids, dorsal scars
Bradycardia, hypotension, lanugo (fine, soft hair)
Subtypes: restrictive or binge & purge
Osteoporosis* Elevated cholesterol Amenorrhea Mitral valve prolapse Stress fractures Arrhythmia Mortality > 10% 2/2 suicide or medical complications **Small for gestational age...even if only formerly anorexic!
Normal - overweight
3+ months of 2x/week of binging ==> purge/fasting
Ego-dystonic (aware of problem)
Dental enamel erosions, enlarged parotids, dorsal scars
Lower mortality
More easily treatable
Similar complications
—-
Bupropion decreases seizure threshold ---- Hypokalemia Bradycardia BMI < 18
Sexual interest change with age:
None
Primary insomnia dx, tx
1+ month
3x / week
Unrestful sleep
NOT caused by medical or psychiatric condition
- good sleep hygiene (limit caffeine, sleep schedule, am exercise, nighttime bath etc)
- <2 week of sleep aids: diphenhydramine, zoldipem, trazadone
Narcolepsy dx, features, tx
> 3 months
Decreased REM
Sleep attacks
Cataplexy loss of muscle tone
Hypnogogic/pompic hallucination
Sleep paralysis
Scheduled naps
Stimulants
Sleep apnea types, tx
Central: both airflow and respiratory effort cease
Peripheral: obstruction 2/2 obesity, tongue, etc
Central: bipap
Peripheral: cpap
Somatoform disorder definition, types, tx
Unconscious production of sx
- Somatization
Female»_space;> male
Chronic complaints of multiple organs: GI, neurologic, pain, sexual
Frequent physician visits*
1.5 Somatic symptom disorder (maybe different than above?)
1+ somatic complaints, including pain
>6 months
Causing severe impairment
- Conversion
Usually 2/2 stressful event
Implausible severe sensory/motor dysfunction (blind, seizure, paralysis)…often indifferent to them “la belle indiference”
Self-resolving - Hypochdriac/”illness anxiety disorder”
Male = female
Debilitating concern despite NO REAL SYMPTOMS* and REASSURANCE
Frequent apt - Body dysmorphic
Female slightly more
Debilitating self image concern
SSRI may help; repeat appointments; reassurance doesn’t help*
Fictitious disorder definition, types*
Cognizant fabrication of sx
- Munchausen*: for primary gain of sick role; often health workers
- Munchausen by proxy: fabricating sx in another person also for primary gain
- Malingering*: fabrication for secondary gain (pain seeking, $$)
Abuse signs, sequelae, tx
Late-presentation of illness
Frequent ER visits
Shifty behavior or partner
PTSD
Suicide attempt
Document everything!!
Suicide risks, dx, tx
SAD PERSONS Sex (males complete; females attempt more) Age (>45!!!) Depression / mental disorder Previous attempt Ethanol/substance Rational thought Sickness (chronic) Organized plan / access No spouse Social support dirth
Ask DIRECTLY
If endorsing ==> immediate hospitalization (even against will)
SSRI increase risk early by increasing energy…observe
Trichtillomania dx, tx
Pulling hair to relieve anxiety
No underlying derm condition
Delusional disorder dx*
1+ month
1+ delusion
No other psychotic symptoms
Otherwise well-functioning
Normal ages for imaginary friends*
2-6
Folie a deux dx, tx
One person’s delusion becomes shared by another close relation
Interview separately
Defense mechanisms
Do them once finished
Defiant teenager workup*
Interview together and separately with parents
*Toxicology screen
HIPAA stuff to know*
Information may be released by verbal or written consent
Information may be released over the phone without proof of identity
Neuroimaging findings in psychiatric disorders*
Autism: increased total volume Schizophrenia: enlarged ventricles PTSD: smaller hippocampus Panic disorder: smaller amygdala OCD: orbitofrontal cortex changes
Kleptomania dx, tx
Anxiety-induced urge to steal
Often small value
Regret post-stealing
*CBT
Best option for patients refusing treatment*
Ask why!!
Hospice referral criteria*
<6 month prognosis
Vaginismus/pelvic pain/penetration disorder dx*
6+ months
Pain or tenseness with penetration
Causing significant impairment
Buproprion indications, s/e
Atypical antidepressant
Smoking cessation aid
==> if patient is depressed and wants to quit, this may be best option*
Decreases seizure threshold!
Contraindicated with MAO-i
When its okay to proceed with emergency procedure without consent*
No living will or advanced directives
Patient is not able to provide consent
*Even if Jehova’s witness, according to family
Dissociative fugue vs dissociative amnesia*
Fugue: TRAVEL, amnesia, unable to identify self
Amnesia: forgetting important life events usually 2/2 stressor
When minors can receive confidential, parental consent-free care*
STD
Pregnancy
Mental illness
Emancipated minor 13+: armed services, marriage, a parent*, living alone or financial independence
Pediatric sexual abuse signs*
TRIAD:
Sudden behavioral change
Unstable economic background
Parent with substance abuse
Breaking bad news approach*
SPIKES
Setting up: privacy, ask if family are desired
Perception: assess understanding of medical situation
Invitation: how much they want to know
Knowledge: warn of bad news and drop the bomb
Empathy
Strategy
Reporting HIV or other STD to cuckolded partner*
Encourage partner to do it… but explain that health department will notify the partner if not
When to discontinue lithium in bipolar patients*
1 episode: after 2 stable years
2 episodes: many years, if not lifetime
Circumstantiality vs. tangentiality*
Circumstantial: eventually returns to topic
Tangential: deviates totally
Mother vs fetus ethics*
Mother has autonomy over fetus as long as she has capacity
