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Psychiatry Flashcards

1
Q

What are 3 examples of positive Symtoms in Psychiatric disorders?

A

Disorganized speech/Behavior
Hallucinations
Delusions (Bizarre)

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2
Q

What neurotransmitter receptor is associated with Positive Symtoms in Psychiatric disorders?

A

Dopamine Receptors

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3
Q

What are 5 examples of Negative Symptoms in Psychiatric disorders?

A 
Flat affect
Apathy
Anhedonia
Social W/Drawal
Poverty of Speech
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4
Q

What neurotransmitter receptor is associated with Negative symptoms in Psychiatric disorders?

A

Acetylcholine-Muscarinic Receptors

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5
Q

What are the most effective medications for treating Negative symptoms in a Psychotic pt?

A

Atypical Antipsychotics

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6
Q

What are some common examples of Atypical Antipsychotic drugs?

A 
Risperidone
Aripriprazole
Clozapine
Olanzapine
Ziprasidone
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7
Q

What is a significant side effect of Clozapine?

A

Agranulocytosis

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8
Q

What is the criteria for dx’ing a pt with Schizophrenia?

A

1)Sx for > 1 month with interference in daily activities for >
6 months
2)Must hv at least 1 positive sx (hallucinations, delusions, disorganized speech/behavior)

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9
Q

What is the typical age of onset of Schizophrenia?

A

Males: 15-24yo
Females: 25-34yo

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10
Q

What is the most likely dx for a 19 yo male pt who presents with hallucinations and paranoid delusions for the past 2 months while away at school and his roomate reports that he refuses to leave the room to go to class bc he does not want “them” to “gain access to the decoder in his brain.)

A

Schizophreniform Disorder

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11
Q

What is the most likely dx for a 22 yo male who recently found out his girlfriend of 5 yrs was cheating on him, presents with a h/o hallucinations and paranoid delusions for the past 2 weeks while away at school and his roommate reports that he refused to leave the room to go to class bc he did not want “them” to “gain access to the decoder in his brain.” However, upon evaluation by his PCP, a week later, the sx have resolved and he has returned to his baseline?

A

Brief Psychotic Episode/Disorder

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12
Q

What is the most likely dx when there is a h/o psychotic symptoms that persist for years without interfering with the pt’s baseline function?

A 
Delusional Disorder (non-bizarre)
or Personality Disorder
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13
Q

WHat is the preferred therapy method for pts with delusional or personality disorders?

A

Psychotherapy (antipsychotics don’t really help these pts.)

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14
Q

What is the first step in management for any ACUTE psychiatric condition?

A

Determine if hospitalization required
- Pt who is at risk of harm to self or others.
Ex: suicidal/homicidal Ideations
-Pt has bizarre/paranoid symptoms

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15
Q

What is the best initial test in a pt with psychotic behavior?

A

Drug Screen

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16
Q

Besides drug screen, what additional tests should be included in the workup of a psychotic pt?

A 
TSH
Electrolytes
Serology (HIV)
VDRL (Syphilis)
Temporal Lobe Epilepsy
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17
Q

What is the greatest risk factor for progression to schizophrenia?

A

Schizophreniform Disorder

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18
Q

What is the management for an acutely psychotic pt?

A

1) Determine is hospitalization required
2) Benzodiazepine (if agitated)
3) Start Antipsychotics
4) Initiate long-term Psychotherapy

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19
Q

How long should antipsychotics be continued following an acute psychotic event?

A

6 months

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20
Q

What is the indication for long term (>6 mos) antipsychotic medications?

A

H/o recurrent episodes

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21
Q

What are the beneficial effects of Antipsychotic medications?

A

Immediate Quieting Effect in acute psychosis (any type)

Delay relapse

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22
Q

What are the indications for antipsychotic medical therapy?

A

1)Acute/Recurrent psychotic episode(s)
2)Alternative for Sedation when Benzos are
contraindicated
3)Adjunct for anesthesia
4)Movement Disorders (Huntington’s or Tourette
Syndrome)

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23
Q

What is the basis for selecting which antipsychotic medication to use?

A

Side effect profile

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24
Q

What side effects are associated with Low-Potency Typical Antipsychotic medications?

A 
Alpha Blockade:
 -Orthostatic Hypotension
Anticholinergic:
 -Blurry Vision
 -Dry Mouth
 -Urinary Retention
 -Delirium
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25
Q

What should be done for pts on low potency typical antipsychotics who present with either anticholinergic side effects or orthostatic hypotension?

A

Switch to Atypical Antipsychotic

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26
Q

What are two side effects associated with Thioridazine use?

A 
Long QT/arrhythmia
Retinal Pigmentation (long term use)
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27
Q

What is the next step in management for a pt taking Thioridazine antipsychotic and comes to the office c/o chest pain, palpitations or SOB?

A

EKG

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28
Q

What should be done for pts on chronic Thioridazine therapy?

A

Routine Eye exam (to ck for abnormal pigmentation of retina)

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29
Q

What is a common reason for non-compliance with antipsychotic medications in males?

A

Impotence/Ejaculatory Inhibition (d/t alpha blocking effects)

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30
Q

What is a common reason for non-compliance with antipsychotic medications in females and what should be monitored regulary?

A

Weight Gain (Hyperprolactinemia)

Ask about Galactorrhea and Amenorrhea

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31
Q

What must be done prior to starting a pt on Clozapine and after initiating therapy?

A

CBC w/ Diff before starting Clozapine and

Repeat CBCw/ diff WEEKLY while pt taking medication

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32
Q

What are 2 examples of High Potency Antipsychotics?

A

Haloperidol

Fluphenazine

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33
Q

What side effects are associated with High-potency Antipsychotic Use?

A

Extrapyramidal Symptoms (EPS)

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34
Q

What is the most common reason for medication non-compliance in a pt receiving Antipsychotic therapy?

A

EPS effects

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35
Q

What are some examples of EPS?

A 
Dystonia
Bradykinesia
Akathisia
Tardive Dyskinesia
Neuroleptic Malignant Syndrome (NMS)
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36
Q

What are some benefits for using High-Potency Typical Antipsychotics?

A

Less Sedating
Less Cholinergic Effects (c.w. low potency)
Less Hypotension
Can use Depot for (for noncompliant pts)
IM form for acute cases that cannot/refuse PO

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37
Q

What is a disadvantage of using High Potency Antipsychotics?

A

Highest association with EPS effects

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38
Q

What is an advantages to using Low potency Antipsychotics?

A

Less EPS effects likely

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39
Q

What is a major disadvantage to using low-potency Antipsychotics?

A

Greater Anticholinergic effects
More Sedating
More Postural Hypotension

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40
Q

What are 2 examples of Low-potency Typical Antipsychotic medications?

A

Thioridazine

Chlorpromazine

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41
Q

What are some advantages associated with Atypical Antipsychotic medications?

A

Greater Effects on Negative Symptoms

Very low/No risk of EPS effects

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42
Q

What is a disadvantage associated with Atypical Antipsychotic medications?

A

Clozapine:
-Agranulocytosis (only use for treatment -resistant
cases)
-Seizure

Olanzapine: Weight Gain

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43
Q

Which class of Antipsychotic medication is the best option for initial therapy?

A

Atypical Antipsychotic Medications (EXCEPT clozapine)

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44
Q

What is the best initial therapy for a newly dx’d schizophrenic pt who c/o insomnia?

A

Atypical Antispychotics: (all EXCEPT risperidone)

  • Olanzapine
  • Ziprasidone
  • Quetiapine
  • Aripiprazole
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45
Q

What is the next step in management for a schizophrenic pt maintained on Olanzapine for 6 mos who now c/o daytime somnolence that impairs his ability to work/maintain a job?

A

Switch to Risperidone (first choice in treating Schizophrenia when sedation is a problem)

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46
Q

What are the 6 receptors on which Risperidone has its effects?

A

Serotonin (5HT)
Dopamine (D1 and D2)
Alpha Adrenergic (Alpha 1 and Alpha 2)
Histamine(H1)

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47
Q

What is the earliest EPS side effect that can be seen in a pt started on Antipsychotic medication?

A

Acute Dystonia

  • Muscle spasms-torticollis
  • Difficulty Swallowing
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48
Q

What is the management for Acute Dystonia in a pt on antipsychotic medications?

A 
Reduce Medication Dose
Give Anticholinergics for sx relief 
   -Benztropine
   -Diphenhydramine
   -Trihexyphenidyl
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49
Q

What are two dopamine antagonists used as GI motility agents that are also associated with acute dysonia and other movement disorders, including Tardive Dyskinesia?

A

Metoclopromide

Prochlorperazine

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50
Q

How soon can a pt recently started on antipsychotic medication develop sx of Acute dystonia?

A

Within the FIRST week of use

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51
Q

What EPS side effect can typically present after several weeks after starting antipsychotic medication?

A

Bradykinesia (Parkinsonism)

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52
Q

What are the sx’s of Bradykinesia?

A 
Like Parkinson's Disease: TRAP
Tremor (resting)
Rigidity
Akinesia/Bradykinesia
Postural Instability
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53
Q

What age group are at increased risk of developing Bradykinesia subsequent to antipsychotic medication use?

A

Elderly

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54
Q

What is the management for a pt who developed bradykinesia weeks after starting antipsychotic medication?

A 
Reduce dose of medication
Give Anticholinergics:
 -Benztropine
 -Dienhydramine
 -Trihexyphenidyl
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55
Q

What is the most likely dx in a pt who c/o involuntary restlessness and feeling like they are or need to be moving and state their sx’s began about 10 weeks after starting antipsychotic medical therapy?

A

Akathisia

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56
Q

What is the management for a pt with Akathisia?

A

Reduce the dose of medications
Add Benzos or BBlockers
Switch to newer antipsychotic medication

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57
Q

What should the next step in management be when a pt with established psychotic condition develops any type of movement disorder?

A

Review Pt Medication List

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58
Q

What is the most likely dx in a pt who has been treated for Schizophrenia with antipsychotic theapy for over 2 years and now c/o chereoathetosis and involuntary movements?

A

Tardive Dyskinesia

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59
Q

What is the management for a pt with Tardive Dyskinesia?

A

Stop their current Antipsychotic
Switch to newer antipsychotic medication
Can give Benztropine

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60
Q

What should patients who develop Tardive Dyskinesia be told regarding the course of this side effect?

A

This condition tends to be irreversible

Sx’s often worsen after meds are stopped

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61
Q

When is it most likely for a pt taking antipsychotic medications to develop Neuroleptic Malignant Syndrome (NMS)?

A

Anytime

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62
Q

What are the symtoms associated with NMS?

A

FALTER:

Fever
Autonomic Instability/Altered Mental Status
Leukocytosis
Tremor
Elevated Enzymes (CPK)
Rigidity/Rhabdomyolysis
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63
Q

What is the management for NMS?

A

Stop Antipsychotic meds
Check electrolytes esp K+ and CPK
Administer Cabergoline, Bromocriptine, or Dantrolene
Transfer to ICU for monitoring

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64
Q

Which group of people are at increased risk of developing Acute Dystonia associated with antipsychotic medical therapy?

A

Young Men

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65
Q

Why are Anticholinergics the first-line medications to treat movement disorders associated with Antipsychotic medications?

A

Antipsychotics (high potency) are D2 receptor antagonists @ the Nigrostriatal Nucleus–> Increased Cholinergic output from Striatum

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66
Q

Which Antipstychotic is the most effective for treating Schizophrenia and the least likely to cause movement disorder to develop?

A

Clozapine ( but only use in pts with treatment failure/resistant sx’s)

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67
Q

What are some medications/drugs that can mimic Anxiety Disorder?(5)

A 
Corticosteroids
Cocaine
Amphetamines
Caffeine
Alcohol/Sedative  w/drawal
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68
Q

What medical conditions can mimic Anxiety Disorders?(7)

A 
Hyperthyroidism
Pheochromocytoma
Excess Cortisol
Heart Failue
Arrhythmia
Asthma
COPD
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69
Q

What is the next step in management for a pt diagnosed with adjustment Disorder?

A

Provide Counseling

Do not treat w/ medication

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70
Q

What is the most likely dx when a pt c/o several brief episodes of intense anxiety accompanied by autonomic symptoms like tachycardia, hyperventilation, dizziness, and sweating, associated with the same precipitant(s) each time and the pt has no underlying psychiatric illness?

A

Panic Disorder

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71
Q

How is Panic Disorder managed?

A

Cognitive Behavioral Therapy (CBT) and/or
Relaxation/Desensitization (esp for Agoraphobia)
Medications:
-SSRI or Benzodiazepines
-Imipramine (TCA)
-MAOi’s (phenelzine)

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72
Q

What is the most likely diagnosis in a pt presenting with persistent, unreasonable intense fear of particular situations, circumstances, or objects w/ no history of traumatic event or any other eliciting experience?

A

Phobic Disorder

Ex: Agoraphobia, Social Anxiety Disorder

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73
Q

What is the definition of Social Anxiety Disorder (Social Phobia)?

A

Persons life, activities are interrupted d/t a fear of being judged/disliked/rejected by others in various situations and avoiding these situations in order to prevent the feared outcome. Sx must be present for at least 6 months

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74
Q

What is the definition of Agoraphobia?

A

Fear/avoidance of places d/t Anxiety about not being able to escape.
More common in women

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75
Q

What is done to manage pt with Phobic Disorders?

A

Exposure Therapy w/ Benzo or BBlockers given before exposure

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76
Q

What are the benefits of Exposure Therapy?

A

Induce Habituation and Decrease Anxiety

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77
Q

What is the mechanism of action of Benzodiazepines?

A

Increased frequency of Chloride Ion influx–>increased GABAergic effects–> decreased neuron excitibility

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78
Q

What is the mechanism of action of Barbituates?

A

Increased Duration of Chloride Ion Influx–> increased Gabaergic effects–>Decreased neuronal excitability

79
Q

How are social phobia and panic disorder differentiated?

A

Social Phobia has no precipitating event

Panic Disorder has a clear precipitant ( but not a profound life altering stressor)

80
Q

What is the difference between Generalized Anxiety Disorder (GAD) and Social Phobia?

A

GAD: Anxiety/Worry about multiple things in pt’s life or the world; No single focus or event

(Note: often coexist with other anxiety disorders)

81
Q

What is the treatment for GAD?

A

Medications: SSRI’s, (also SNRI’s, Buspirone, and Benzo)
Supportive Psychotherapy:
-Ralaxation
-Biofeedback

82
Q

What medication if best to use for panic Disorder and what is the effect?

A

SSRI
Benzodiazepine (alprazolam or clonazepam)

These decrease frequency and intensity of the attack

83
Q

What medication(s) is best to use for GAD and what is the effect?

A

SSRI or SNRI
Buspirone

These decrease overall anxiety

84
Q

What medication(s) is best to use for OCD and what is the effect?

A

SSRI
Clomipramine

These medications decrease obsessional thinking

85
Q

What medication(s) is best to use for Social Phobia and what is the effect?

A

SSRI
Buspirone

These medications decrease fear associated with social situations

86
Q

What 4 facts regarding Benzodiazepines should be considered/discussed with the pt prior to initiating therapy?

A

Begin with lowest dose (esp in elderly)
Advise pt to NOT operate machinery or drive
Should NOT change dose abruptly
Half-life: Shortest——————————->Longest
Alprazolam

87
Q

What is the mechanism of action of Buspirone?

A

Serotonin (5HT1A) partial Agonist

88
Q

What are some usage/dosing benefits of using Buspirone?

A

No sedation/cognitive impairments
No additive effect/ Safe with other sedative-hypnotics
Best option for those operating machinery or drive a lot for work
No withdrawal Syndrome

89
Q

What should patients be told regarding the therapeutic effects of Buspirone?

A

Effects may take up to 1 week

90
Q

What is the definition of Obsessive Compulsive Disorder?

A

OCD:
Recurrent obsessions OR Compulsions that the individual RECOGNIZES as unreasonable/excessive.
-Obsessions provoke anxiety and are intrusive
-Compulsions are peculiar behaviors directed at
reducing the anxiety

91
Q

How can OCD be distinguished from a psychotic disorder with obsessive symptoms?

A

OCD: pt HAS Insight

Psychotic Disorder w/Obsessions: pt LACKS insight

92
Q

What is the difference between Acute Stress disorder and Post-traumatic Stress Disorder?

A

ASD: sx last 1month

93
Q

What are the key features of ASD/PTSD?

A

Re-living of the event
Avoidance/Numbing of general responsiveness
Increased Arousal

94
Q

What is the treatment for ASD/PTSD?

A

Benzos for acute anxiety sx’s

SSRIs for long term therapy and psychotherapy

95
Q

What is the most effective way to prevent PTSD following a traumatic event?

A

Group Counseling

96
Q

What are the characteristic features of Major Depressive Disorder?

A

Depressed Mood or Anhedonia
AND
Depressive Symptoms >2wks

97
Q

What are the depressive symptoms associated with Major Depressive Disorder?

A 
SIGECAPS:
Sleep changes
Interest -loss thereof
Guilt-thoughts of guilt/worthlessness
Energy-decreased energy levels
Concentration-problems concentrating/staying focused
Appetite-change in appetite/weight
Psychomotor-changes in psychomotor activity
Suicide-ideation/plan
98
Q

What conditions should be ruled out BEFORE making a dx of Depression and what should be done to do so?

A

Hypothyroidism-ck TSH
Parkinson’s Disease (clinical dx–give anti-Parkinson’s
meds)
Substance Disorder-CAGE–>counseling, detox, and
antidepressants
Medication Effect/side effect-Review med list especially
for and discontinue/switch to alternative esp if on:
-Corticosteroids, BBlockers, Antipsychotics (esp in
elderly), Reserpine

99
Q

What is the management for a pt dx’d with Major Depressive Disorder?

A

1)If Suicidal/Homicidal ideation/plan–>Hospitalization
medications (SSRI -first choince)
2)Benzo -if agitated
3)Electroconvulsive Therapy (ECT)- best choice is acutely
suicidal or if side effects of medications are a concern
(Note combination therapy with antipsychotic and antidepressant is more effective for treating major depression w/o bipolar disorder)

100
Q

What are the characteristic features associated with Dysthimic Disorder?

A

Low-level dressive symptoms/sad mood
Sx present most days for >/= 2yrs

[Note: pt can have superimposed Major Depressive Episode/Disorder]

101
Q

What is the treatment for Dysthymic Disorder?

A

Best Initial/most effective: Long-term Individual/insight-oriented Psychotherapy

102
Q

What is the next step in management if Individual/Insight-oriented Psychotherapy fails to be effective in a pt with Dysthymic Disorder?

A

Trial of SSRI

103
Q

What are the characteristics associated with Seasonal Affective Disorder?

A

Depressive Sx’s in winter and

No sx’s in the summer

104
Q

What is the treatment for Seasonal Affective disorder?

A

Phototherapy
OR
Sleep Deprivation

105
Q

What are the characteristics of associated with Bipolar Disorder?

A

Episodes of depression, mania, or both for >/=1 week resulting in distress or impairment of usual function

106
Q

What are the sx’s associated with Bipolar Disorder?

A 
Distractibility
Insomnia
Grandiosity/Goal focused
Flight of ideas
Speech is pressured/Excessive
Sexual Promiscuity

Depressed Mood
Loss of pleasure/Interests

107
Q

What are the next steps in management for a pt whose presentation resemble bipolar disorder but their hx suggests drug use or hypertension or hyperthyroidism?

A 
Drug screen (R/o amphetamine use)
or
TSH (r/o hyperthyroidism)
or
Plasma free metanephrines/VMA/ or Urine/Plasma Catecholamines (r/o Pheochromocytoma)
108
Q

What are the steps in management for a pt with bipolar disorder?

A

Hospitalize
Mood Stabilizers: Lithium (induce remission- takes 1 wk)
Antipsychotics: Risperidone (control acute mania)

Additional measures:
IM Depot Phenothiazine (if noncompliant/severely manic)
Antidepressants (iff RECURRENT DEPRESSION and must give w/Mood Stabilizers

109
Q

What is the definition of rapid cycling bipolar disorder?

A

More than 4 episodes of mania per year

110
Q

What is the most common cause of progression to Rapid Cycling Bipolar?

A

Antidepressant use

(only add antidepressants to mood stabilizer if pt has recurrent depressive episodes)

111
Q

How is Rapid Cycling Depression Managed?

A

Gradually stop all:

  • Antidepressants
  • Stimulants
  • Caffeine
  • Benzodiazepines
  • Alcohol
112
Q

What medical conditions predispose a pt to Rapid Cycling Bipolar?

A

Hypothyroidism

113
Q

What metabolic test should be done in all pts who present with Rapid Cycling Bipolar?

A

TSH–> if high, replace Thyroid Hormones

114
Q

What drug has been shown to prevent suicidal ideation in bipolar disorder?

A

Lithium

115
Q

What should be done to manage a pt with bipolar disorder undergoing maintenance therapy with Lithium, who now presents with a Positive Pregnancy Test?

A

Discontiue Lithium

ECT for manic episodes in First Trimester or Lamotrigine in 2/3 trimesters

116
Q

What are the side effects of Lithium?

A

Diabetes Insipidus

Teratogen: Ebstein Anamoly

117
Q

What are the treatment options for Bipolar Disorder?

A

First Line Monotherapy:
Lithium, Lamotrigine, Risperidone

Second-line: Aripiprazole, Quetiapine, Olanzapine, Divalproex

Pt w/ Multiple Receurrence: Combination Therapy
Arrange Psychotherapy/Cognitive Behavioral Therapy (CBT)

118
Q

What mood stablilizers/anti-seizure medications should be avoided in pregnancy?

A

Lithium
Valproate
Carbamazepine

119
Q

What are the characteristic features of Cyclothymia?

A

Multiple episodes of depressed mood with Hypomania for at least 2 yrs (mold bipolar disorder)

120
Q

What is the treatment for Cyclothymia?

A

Psychotherapy (first step)

Divalproex only if pt ability to function is impaired (works better than lithium for cyclothymia)

121
Q

What are some key factors that help distinguish normal Grief from depression?

A

Grief:

  • Sx wax and Wane
  • shame/guilt less common
  • suicidal ideation less common
  • Pt usually returns to baseline functioning within 2 ms
122
Q

What is the management for Grief?

A

Supportive Therapy

123
Q

What is the next best step in management for a pt who presents with major depressive disorder and also reports hallucinations or any other psychotic symptoms?

A

Antipsychotic Medication

Always treat worst symptom first, ie, psychosis before depression if only one option available

124
Q

What are the key features of Postpartum Blues aka “Baby Blues”?

A

Can occur after any birth
Mother cares about baby
Mild depressive sx’s
Self Limiting

125
Q

How is Post partum Blued managed?

A

No treatment, Self-limiting

126
Q

What are the key features of Postpartum Depression?

A

Usually occurs after 2nd birth
Thoughts about hurting the baby
Severe Depressive Sx
Treatment required

127
Q

What is the treatment for Postpartum Depression?

A

Antidepressants (SSRIs)

128
Q

What are the key features of Postpartum Psychosis?

A

Usually occurs asfter 1st birth
Thoughts about hurting the baby
Psychotic symptoms w/ Severe Depression
Treatment Required

129
Q

What is the treatment fot Postpartum Psychosis?

A

Mood Stabilizers
or
Antipsychotics combined with Antidepressants

130
Q

How should Postpartum Psychosis be treated in a woman who is/desires to breastfeed?

A

ECT

Avoid medications while breastfeeding

131
Q

What is the most important predictor of suicide?

A

H/o previous suicide attempt/threats in the patient

132
Q

What action(s) should be taken in an acutely suicidal pt?

A 
Take all Threats of suicide seriously
Detain/Hospitalize pt
Alway transport pt to ED with medically trained individual present
Never leave pt unsupervised
Do not Identify the pt
133
Q

What is the treatment of choice for a pt who is suicidal?

A

Antipsychotics and Antidepressnats (SSRIS first)

134
Q

What is the management for a sucicidal pt who is presenting with acute, severe risk of self harm?

A

ECT

135
Q

What are the indications for Electroconvulsive Therapy (ECT)

A

Major Deppresive episodes that fail to respond to meds
High risk for IMMEDIATE suicide
If Antidepressants are contraindicated
H/o of ECT with good response in the past

136
Q

What is the major complication associated with ECT?

A

Transient Memory Loss (worsens with prolonged therapy)

137
Q

In what type of pt is ECT use cautioned?

A

Those w/ Space-occupying Brain Lesions (ie: tumor/mets)

138
Q

Why is ECT cautioned in pts with space-occupying brain lesions?

A

ECT causes transient Increase in Intracranial Pressure

139
Q

What class of antidepressants is considered first line medciation?

A

SSRIs

140
Q

Which class of antidepressants is generally avoided d/t its side effect profile?

A

TCAs (a lot of side effects)

141
Q

Which class of antidepressants is especially useful for atypical depression?

A

MAOI’s

142
Q

What is the next step in managemnet if a pt started on Antidepressant medicantion has not received any reduction in symptoms after at least 8 wks of being compliant with his dose or the side effects are intolerable?

A

Switch to another class of Antidepressant medication

143
Q

How long should the avg pt contiune taking antidepressants?

A

About 6 mos. Can try to discontinue only after tapering the dose.

144
Q

Which pts taking Antidepressants should be considered for long term therapy?

A

Those with recurrent depressive episodes

145
Q

What is the antidepressant of choice for a pt who is concerned about weight gain and/or sexual side effects associated with certain drug classes?

A

Bupropion (causes modest wt loss)

146
Q

In which pts should Bupropion and TCAs be avoided?

A

Those with underlying Seizure disorder (ie, epilepsy)

147
Q

What is the antidepressant of choice for a pt who c/o weight loss, poor appetite, and/or insomnia?

A

Mirtazapine (associated with weight gain)

148
Q

Which antidepressant is used to treat chronic pain, especially neuropathic pain?

A

Amitriptyline

149
Q

Which antidepressant can be used to treat enuresis in children?

A

Imipramine

150
Q

Which antidepressant is often used to treat depressed pts with insomnia?

A

Trazodone (strongly sedating)

151
Q

What is a major side effect of Trazodone use?

A

Priapism

152
Q

What is the most important step to determine severity and prognosis in the management of a pt who presents with TCA overdose?

A

EKG (check for life threatening arrhythmia)

153
Q

What is the most appropriate antidepressant for an elderly pt who presents with depression and insomnia?

A

Doxepin or Trazodone

154
Q

What is the first line antidepressant for depressed pts with underlying seizure disorder?

A

SSRIs

155
Q

What is the mechanism of action of Trazodone?

A

SARI (Serotonin antagonist and reuptake inhibitor)

156
Q

What is the most likely dx in a middle-aged female pt brought to the ED with confusion and disorientation, hypotension, tachycardia, dilated pupils, dry mucous membranes, facial flushing and there is a h/o medication treated depression?

A

TCA overdose

157
Q

What is the next step in management for a pt with a TCA overdose whose EKG shows prolonged QRS and PR with sinus tachycardia?

A

Give Sodium Bicarbonate

158
Q

What is the mechanism by which Sodium Bicarb aids in treating TCA overdose?

A

Alkalinizes bld–>uncoupling of TCA from cardiac Na-channels–> restore Na flux into myocytes

Increased Extracellular Sodium–> enhances Na gradient –> increased influx of sodium –> restore normal myocardiac depolarization

159
Q

What is the next step in management for a pt who is taking Amitriptyline and presents with dry mouth and dry eyes?

A 
Discontinue Amitriptyline (very anticholinergic)
Switch to different class (ex SSRI-virtually no anticholinergic effects)
160
Q

For what conditions is Lithium considered first-line therapy?

A

Bipolar Disorder
Schizoaffective Disorder
Treatment/Prophylaxis of Mood Episodes

161
Q

What is the major reason for Lithium noncompliance?

A

Side effects

162
Q

What are the major side effects of Lithium Use?

A

Most common:

  • Acne
  • Weight Gain

Dose related: (can decrease the dose to manage these)

  • Tremors
  • GI distress
  • Headaches

Hypothyroidism
Polyuria (d/t DI)
Teratogenic
-Ebstein Anomoly (DO NOT use in first trimester)

163
Q

When should Divalproex be used to treat Bipolar disorder?

A

First-line for Rapid Cycling Bipolar Disorder

Also used when Lithium fails, is contraindicated, or impractical

164
Q

When can Carbamazepine be considered for Bipolar disorder treatment?

A

If Lithium and DIvalproex do not work or are contraindicated?

165
Q

What significant side effect results in decreased provider use of Carbamazepine?

A

Agranulocytosis

Sedation

166
Q

What is the site of action of Carbamazepine?

A

Inactivated voltage-gated Na channels (it prolongs time in this state)–> fewer channels available to open–> decreased excitatory neuronal activity

167
Q

What is a significant metabolic effect of Carbamazepine?

A

CYP450 inducer –>increases clearance of drugs that are metabolized by the liver:

  • Warfarin
  • Phenytoin
  • Valproic Acid
  • Theophylline
168
Q

What diagnosis should be suspected in an ELDERLY pt who presents with N/V,TREMORS, CONFUSION, INCREASED DTR, and/or SEIZURE, takes LITHIUM and has UNDERLYING RENAL FAILURE and HYPONATREMIA d/t vomiting, diuretics, or dehydration?

A

Lithium Toxicity

169
Q

What is the treatment of choice for Lithium Toxicity?

A

Dialysis

170
Q

By what mechanism of action does Lithium cause Nephrogenic DIabetes Insipidus?

A

Lithium accumulates at collecting ducts at Na channels–> Increased PGE2–> induction of Lysosomal degradation of Aquaporin 2 Channels–> ADH resistance

171
Q

WHat diagnosis should be suspected in a pt who RECENTLY STARTED ANTIPSYCHOTIC MEDS (esp HALOPERIDOL) or a pt with PARKINSON’S who RECENTLY STOPPED their medications now presenting with high FEVER, RIGIDITY, AUTONOMIC DYSFUNCTION, LEUKOCYTOSIS, TREMOR, TACHYCARDIA, ELEVATED CPK?

A

Neuroleptic Malignant Syndrome

Independent of dose or previous exposure

172
Q

What 3 CNS nuclei are affected by Antipsychotic medications resulting in NMS?

A

D2 receptor at:

  • Hypothalamus
  • Nigrostriatal
  • Spinal Cord
173
Q

What is the mechanism of action in the periphery, associated with antipsychotics that contributes to NMS?

A

Increase intracellular Ca release from Sarcoplasmic Reticulum–> increased force of contraction–>Rigidity and Muscle breakdown

174
Q

What is the management for NMS?

A

Transfer to ICU
Give Bromocriptine (D2 agonist)
Give Dantrolene or Diazepam (muscle relaxant)

175
Q

What diagnosis should be suspected in a pt who presents with AGITATION, HYPERREFLEXIA, HYPERTHERMIA, MUSCLE RIGIDITY, VOLUME CONTRACTION associated with SWEATING and insensible fluid losses who has a h/o SSRI use with MIGRAINE MEDICATION or MAOIs?

A

Serotonin Syndrome

176
Q

WHat is the treatment for Serotonin Syndrome?

A

IV FLuids
Cyproheptadine (decreases serotonin production)
Benzodiazepine (decrease muscle rigidity)

177
Q

What is the drug class and mechanism of action of Cyproheptadine?

A

Cyproheptadine:

  • H1 Antihistamine
  • Nonspecific 5HT1A/5HT2A antagonist–>(decrease serotonin production)
178
Q

What is the most likely diagnosis in a pt presenting with ACUTE HYPERTENSION and h/o MAOI use with ANTIHISTAMINES, NASAL DECONGESTANTS, or CONSUMPTION of CHEESE, PICKLED FOODS (or other TYRAMINE-CONTAINING FOODS), or TCA’s?

A

MAOI-induced Hypertensive Crisis

179
Q

What is the management of MAOI-induced Hypertensive Crisis?

A
  • Physical Exam (ck for papilledema)

- IV Antihypertensive medication

180
Q

What is the mechanism of action of MAOI’s?

A

Inhibit breakdown of Dietary Amines–>increased serum Tyramine levels–>depletion of Norepi form storage vesicles–>Hypertensive Crisis

181
Q

What is the first assessment that should be done prior to prescribing antidepressants ina pt dx’d with depression?

A

Assess for Suicidal ideation/plan

Note: if acutely suicidal–> hospitalize and ECT

182
Q

What is the effect of some antidepressants on suicidal tendency?

A

Can increase risk of suicidal ideation within first 2 wks of taking antidepressant

183
Q

What Personality Disorders are classified as Cluster A type?

A

Paranoid PD
Schizoid PD
Schizotypal PD

184
Q

What is the main defense mechanism employed by those with Paranoid and Schizoid PD?

A

Projection

185
Q

What is the best form of treatment for individuals with Cluster A PDs?

A

Psychotherapy

186
Q

How are Schizoid PD and Schizotypal PD distinguished?

A

Schizoid: Isolated, not interested in friends/relationships, emotionally detached/restricted–>Loners

Schizotypal: Eccentric, discomfort with social relationships, magical thinking, ideas of reference, paranoid ideation–> “Weirdos”

187
Q

What are the PD’s classified as Cluster B type?

A

Histrionic PD
Borderline PD
Antisocial PD
Narcissistic PD

188
Q

What general characteristics describe those with Cluster B PD’s?

A

Mood Lability
Preoccupation w/ Rejection
Dissociative symptoms

189
Q

What features can be used to distinguish Histrionic PD from Borderline PD?

A

Histrionic:
Sexuality/Seduction are often employed
Need to be Center of Attention

Borderline: 
     Splitting defense mechanism
     Mood swings/Marked Impulsivity
     Recurrent Suicidal behaviors, 
     inappropriate/intense anger if abandonment perceived
190
Q

What are the characteristics associated with Antisocial PD?

A 
Continuous criminal or antisocial acts
Disregard for others feelings/rights
Inability to conform to societal rules
Impulsivity
Lack of remorse
Aggression
Deceitfulness
191
Q

What treatment can be used to manage Cluster B PD’s?

A

Psychotherapy

Mood stabilizers/Antidepressants may be added

192
Q

What are the PD’s classified as Cluster C?

A

Avoidant PD
Dependent PD
Obsessive-Compulsive PD

193
Q

What are the general characteristics associated with Cluster C PD’s?

A

Anxiety
Preoccupation w/ criticism
Rigidity

Step 3 (12 decks)

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