Psychiatry Flashcards
1
Q
What are 3 examples of positive Symtoms in Psychiatric disorders?
A
Disorganized speech/Behavior
Hallucinations
Delusions (Bizarre)
2
Q
What neurotransmitter receptor is associated with Positive Symtoms in Psychiatric disorders?
A
Dopamine Receptors
3
Q
What are 5 examples of Negative Symptoms in Psychiatric disorders?
A
Flat affect Apathy Anhedonia Social W/Drawal Poverty of Speech
4
Q
What neurotransmitter receptor is associated with Negative symptoms in Psychiatric disorders?
A
Acetylcholine-Muscarinic Receptors
5
Q
What are the most effective medications for treating Negative symptoms in a Psychotic pt?
A
Atypical Antipsychotics
6
Q
What are some common examples of Atypical Antipsychotic drugs?
A
Risperidone Aripriprazole Clozapine Olanzapine Ziprasidone
7
Q
What is a significant side effect of Clozapine?
A
Agranulocytosis
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)
9
Q
What is the typical age of onset of Schizophrenia?
A
Males: 15-24yo
Females: 25-34yo
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
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
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
13
Q
WHat is the preferred therapy method for pts with delusional or personality disorders?
A
Psychotherapy (antipsychotics don’t really help these pts.)
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
15
Q
What is the best initial test in a pt with psychotic behavior?
A
Drug Screen
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
17
Q
What is the greatest risk factor for progression to schizophrenia?
A
Schizophreniform Disorder
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
19
Q
How long should antipsychotics be continued following an acute psychotic event?
A
6 months
20
Q
What is the indication for long term (>6 mos) antipsychotic medications?
A
H/o recurrent episodes
21
Q
What are the beneficial effects of Antipsychotic medications?
A
Immediate Quieting Effect in acute psychosis (any type)
Delay relapse
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)
23
Q
What is the basis for selecting which antipsychotic medication to use?
A
Side effect profile
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
25
What should be done for pts on low potency typical antipsychotics who present with either anticholinergic side effects or orthostatic hypotension?
Switch to Atypical Antipsychotic
26
What are two side effects associated with Thioridazine use?
```
Long QT/arrhythmia
Retinal Pigmentation (long term use)
```
27
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?
EKG
28
What should be done for pts on chronic Thioridazine therapy?
Routine Eye exam (to ck for abnormal pigmentation of retina)
29
What is a common reason for non-compliance with antipsychotic medications in males?
Impotence/Ejaculatory Inhibition (d/t alpha blocking effects)
30
What is a common reason for non-compliance with antipsychotic medications in females and what should be monitored regulary?
Weight Gain (Hyperprolactinemia)
Ask about Galactorrhea and Amenorrhea
31
What must be done prior to starting a pt on Clozapine and after initiating therapy?
CBC w/ Diff before starting Clozapine and
| Repeat CBCw/ diff WEEKLY while pt taking medication
32
What are 2 examples of High Potency Antipsychotics?
Haloperidol
| Fluphenazine
33
What side effects are associated with High-potency Antipsychotic Use?
Extrapyramidal Symptoms (EPS)
34
What is the most common reason for medication non-compliance in a pt receiving Antipsychotic therapy?
EPS effects
35
What are some examples of EPS?
```
Dystonia
Bradykinesia
Akathisia
Tardive Dyskinesia
Neuroleptic Malignant Syndrome (NMS)
```
36
What are some benefits for using High-Potency Typical Antipsychotics?
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
37
What is a disadvantage of using High Potency Antipsychotics?
Highest association with EPS effects
38
What is an advantages to using Low potency Antipsychotics?
Less EPS effects likely
39
What is a major disadvantage to using low-potency Antipsychotics?
Greater Anticholinergic effects
More Sedating
More Postural Hypotension
40
What are 2 examples of Low-potency Typical Antipsychotic medications?
Thioridazine
| Chlorpromazine
41
What are some advantages associated with Atypical Antipsychotic medications?
Greater Effects on Negative Symptoms
| Very low/No risk of EPS effects
42
What is a disadvantage associated with Atypical Antipsychotic medications?
Clozapine:
-Agranulocytosis (only use for treatment -resistant
cases)
-Seizure
Olanzapine: Weight Gain
43
Which class of Antipsychotic medication is the best option for initial therapy?
Atypical Antipsychotic Medications (EXCEPT clozapine)
44
What is the best initial therapy for a newly dx'd schizophrenic pt who c/o insomnia?
Atypical Antispychotics: (all EXCEPT risperidone)
- Olanzapine
- Ziprasidone
- Quetiapine
- Aripiprazole
45
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?
Switch to Risperidone (first choice in treating Schizophrenia when sedation is a problem)
46
What are the 6 receptors on which Risperidone has its effects?
Serotonin (5HT)
Dopamine (D1 and D2)
Alpha Adrenergic (Alpha 1 and Alpha 2)
Histamine(H1)
47
What is the earliest EPS side effect that can be seen in a pt started on Antipsychotic medication?
Acute Dystonia
- Muscle spasms-torticollis
- Difficulty Swallowing
48
What is the management for Acute Dystonia in a pt on antipsychotic medications?
```
Reduce Medication Dose
Give Anticholinergics for sx relief
-Benztropine
-Diphenhydramine
-Trihexyphenidyl
```
49
What are two dopamine antagonists used as GI motility agents that are also associated with acute dysonia and other movement disorders, including Tardive Dyskinesia?
Metoclopromide
| Prochlorperazine
50
How soon can a pt recently started on antipsychotic medication develop sx of Acute dystonia?
Within the FIRST week of use
51
What EPS side effect can typically present after several weeks after starting antipsychotic medication?
Bradykinesia (Parkinsonism)
52
What are the sx's of Bradykinesia?
```
Like Parkinson's Disease: TRAP
Tremor (resting)
Rigidity
Akinesia/Bradykinesia
Postural Instability
```
53
What age group are at increased risk of developing Bradykinesia subsequent to antipsychotic medication use?
Elderly
54
What is the management for a pt who developed bradykinesia weeks after starting antipsychotic medication?
```
Reduce dose of medication
Give Anticholinergics:
-Benztropine
-Dienhydramine
-Trihexyphenidyl
```
55
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?
Akathisia
56
What is the management for a pt with Akathisia?
Reduce the dose of medications
Add Benzos or BBlockers
Switch to newer antipsychotic medication
57
What should the next step in management be when a pt with established psychotic condition develops any type of movement disorder?
Review Pt Medication List
58
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?
Tardive Dyskinesia
59
What is the management for a pt with Tardive Dyskinesia?
Stop their current Antipsychotic
Switch to newer antipsychotic medication
Can give Benztropine
60
What should patients who develop Tardive Dyskinesia be told regarding the course of this side effect?
This condition tends to be irreversible
| Sx's often worsen after meds are stopped
61
When is it most likely for a pt taking antipsychotic medications to develop Neuroleptic Malignant Syndrome (NMS)?
Anytime
62
What are the symtoms associated with NMS?
FALTER:
```
Fever
Autonomic Instability/Altered Mental Status
Leukocytosis
Tremor
Elevated Enzymes (CPK)
Rigidity/Rhabdomyolysis
```
63
What is the management for NMS?
Stop Antipsychotic meds
Check electrolytes esp K+ and CPK
Administer Cabergoline, Bromocriptine, or Dantrolene
Transfer to ICU for monitoring
64
Which group of people are at increased risk of developing Acute Dystonia associated with antipsychotic medical therapy?
Young Men
65
Why are Anticholinergics the first-line medications to treat movement disorders associated with Antipsychotic medications?
Antipsychotics (high potency) are D2 receptor antagonists @ the Nigrostriatal Nucleus--> Increased Cholinergic output from Striatum
66
Which Antipstychotic is the most effective for treating Schizophrenia and the least likely to cause movement disorder to develop?
Clozapine ( but only use in pts with treatment failure/resistant sx's)
67
What are some medications/drugs that can mimic Anxiety Disorder?(5)
```
Corticosteroids
Cocaine
Amphetamines
Caffeine
Alcohol/Sedative w/drawal
```
68
What medical conditions can mimic Anxiety Disorders?(7)
```
Hyperthyroidism
Pheochromocytoma
Excess Cortisol
Heart Failue
Arrhythmia
Asthma
COPD
```
69
What is the next step in management for a pt diagnosed with adjustment Disorder?
Provide Counseling
| Do not treat w/ medication
70
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?
Panic Disorder
71
How is Panic Disorder managed?
Cognitive Behavioral Therapy (CBT) and/or
Relaxation/Desensitization (esp for Agoraphobia)
Medications:
-SSRI or Benzodiazepines
-Imipramine (TCA)
-MAOi's (phenelzine)
72
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?
Phobic Disorder
| Ex: Agoraphobia, Social Anxiety Disorder
73
What is the definition of Social Anxiety Disorder (Social Phobia)?
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
74
What is the definition of Agoraphobia?
Fear/avoidance of places d/t Anxiety about not being able to escape.
More common in women
75
What is done to manage pt with Phobic Disorders?
Exposure Therapy w/ Benzo or BBlockers given before exposure
76
What are the benefits of Exposure Therapy?
Induce Habituation and Decrease Anxiety
77
What is the mechanism of action of Benzodiazepines?
Increased frequency of Chloride Ion influx-->increased GABAergic effects--> decreased neuron excitibility
78
What is the mechanism of action of Barbituates?
Increased Duration of Chloride Ion Influx--> increased Gabaergic effects-->Decreased neuronal excitability
79
How are social phobia and panic disorder differentiated?
Social Phobia has no precipitating event
| Panic Disorder has a clear precipitant ( but not a profound life altering stressor)
80
What is the difference between Generalized Anxiety Disorder (GAD) and Social Phobia?
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
What is the treatment for GAD?
Medications: SSRI's, (also SNRI's, Buspirone, and Benzo)
Supportive Psychotherapy:
-Ralaxation
-Biofeedback
82
What medication if best to use for panic Disorder and what is the effect?
SSRI
Benzodiazepine (alprazolam or clonazepam)
These decrease frequency and intensity of the attack
83
What medication(s) is best to use for GAD and what is the effect?
SSRI or SNRI
Buspirone
These decrease overall anxiety
84
What medication(s) is best to use for OCD and what is the effect?
SSRI
Clomipramine
These medications decrease obsessional thinking
85
What medication(s) is best to use for Social Phobia and what is the effect?
SSRI
Buspirone
These medications decrease fear associated with social situations
86
What 4 facts regarding Benzodiazepines should be considered/discussed with the pt prior to initiating therapy?
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
What is the mechanism of action of Buspirone?
Serotonin (5HT1A) partial Agonist
88
What are some usage/dosing benefits of using Buspirone?
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
What should patients be told regarding the therapeutic effects of Buspirone?
Effects may take up to 1 week
90
What is the definition of Obsessive Compulsive Disorder?
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
How can OCD be distinguished from a psychotic disorder with obsessive symptoms?
OCD: pt HAS Insight
| Psychotic Disorder w/Obsessions: pt LACKS insight
92
What is the difference between Acute Stress disorder and Post-traumatic Stress Disorder?
ASD: sx last 1month
93
What are the key features of ASD/PTSD?
Re-living of the event
Avoidance/Numbing of general responsiveness
Increased Arousal
94
What is the treatment for ASD/PTSD?
Benzos for acute anxiety sx's
| SSRIs for long term therapy and psychotherapy
95
What is the most effective way to prevent PTSD following a traumatic event?
Group Counseling
96
What are the characteristic features of Major Depressive Disorder?
Depressed Mood or Anhedonia
AND
Depressive Symptoms >2wks
97
What are the depressive symptoms associated with Major Depressive Disorder?
```
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
What conditions should be ruled out BEFORE making a dx of Depression and what should be done to do so?
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
What is the management for a pt dx'd with Major Depressive Disorder?
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
What are the characteristic features associated with Dysthimic Disorder?
Low-level dressive symptoms/sad mood
Sx present most days for >/= 2yrs
[Note: pt can have superimposed Major Depressive Episode/Disorder]
101
What is the treatment for Dysthymic Disorder?
Best Initial/most effective: Long-term Individual/insight-oriented Psychotherapy
102
What is the next step in management if Individual/Insight-oriented Psychotherapy fails to be effective in a pt with Dysthymic Disorder?
Trial of SSRI
103
What are the characteristics associated with Seasonal Affective Disorder?
Depressive Sx's in winter and
| No sx's in the summer
104
What is the treatment for Seasonal Affective disorder?
Phototherapy
OR
Sleep Deprivation
105
What are the characteristics of associated with Bipolar Disorder?
Episodes of depression, mania, or both for >/=1 week resulting in distress or impairment of usual function
106
What are the sx's associated with Bipolar Disorder?
```
Distractibility
Insomnia
Grandiosity/Goal focused
Flight of ideas
Speech is pressured/Excessive
Sexual Promiscuity
```
Depressed Mood
Loss of pleasure/Interests
107
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?
```
Drug screen (R/o amphetamine use)
or
TSH (r/o hyperthyroidism)
or
Plasma free metanephrines/VMA/ or Urine/Plasma Catecholamines (r/o Pheochromocytoma)
```
108
What are the steps in management for a pt with bipolar disorder?
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
What is the definition of rapid cycling bipolar disorder?
More than 4 episodes of mania per year
110
What is the most common cause of progression to Rapid Cycling Bipolar?
Antidepressant use
| (only add antidepressants to mood stabilizer if pt has recurrent depressive episodes)
111
How is Rapid Cycling Depression Managed?
Gradually stop all:
- Antidepressants
- Stimulants
- Caffeine
- Benzodiazepines
- Alcohol
112
What medical conditions predispose a pt to Rapid Cycling Bipolar?
Hypothyroidism
113
What metabolic test should be done in all pts who present with Rapid Cycling Bipolar?
TSH--> if high, replace Thyroid Hormones
114
What drug has been shown to prevent suicidal ideation in bipolar disorder?
Lithium
115
What should be done to manage a pt with bipolar disorder undergoing maintenance therapy with Lithium, who now presents with a Positive Pregnancy Test?
Discontiue Lithium
| ECT for manic episodes in First Trimester or Lamotrigine in 2/3 trimesters
116
What are the side effects of Lithium?
Diabetes Insipidus
| Teratogen: Ebstein Anamoly
117
What are the treatment options for Bipolar Disorder?
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
What mood stablilizers/anti-seizure medications should be avoided in pregnancy?
Lithium
Valproate
Carbamazepine
119
What are the characteristic features of Cyclothymia?
Multiple episodes of depressed mood with Hypomania for at least 2 yrs (mold bipolar disorder)
120
What is the treatment for Cyclothymia?
Psychotherapy (first step)
| Divalproex only if pt ability to function is impaired (works better than lithium for cyclothymia)
121
What are some key factors that help distinguish normal Grief from depression?
Grief:
- Sx wax and Wane
- shame/guilt less common
- suicidal ideation less common
- Pt usually returns to baseline functioning within 2 ms
122
What is the management for Grief?
Supportive Therapy
123
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?
Antipsychotic Medication
| Always treat worst symptom first, ie, psychosis before depression if only one option available
124
What are the key features of Postpartum Blues aka "Baby Blues"?
Can occur after any birth
Mother cares about baby
Mild depressive sx's
Self Limiting
125
How is Post partum Blued managed?
No treatment, Self-limiting
126
What are the key features of Postpartum Depression?
Usually occurs after 2nd birth
Thoughts about hurting the baby
Severe Depressive Sx
Treatment required
127
What is the treatment for Postpartum Depression?
Antidepressants (SSRIs)
128
What are the key features of Postpartum Psychosis?
Usually occurs asfter 1st birth
Thoughts about hurting the baby
Psychotic symptoms w/ Severe Depression
Treatment Required
129
What is the treatment fot Postpartum Psychosis?
Mood Stabilizers
or
Antipsychotics combined with Antidepressants
130
How should Postpartum Psychosis be treated in a woman who is/desires to breastfeed?
ECT
| Avoid medications while breastfeeding
131
What is the most important predictor of suicide?
H/o previous suicide attempt/threats in the patient
132
What action(s) should be taken in an acutely suicidal pt?
```
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
What is the treatment of choice for a pt who is suicidal?
Antipsychotics and Antidepressnats (SSRIS first)
134
What is the management for a sucicidal pt who is presenting with acute, severe risk of self harm?
ECT
135
What are the indications for Electroconvulsive Therapy (ECT)
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
What is the major complication associated with ECT?
Transient Memory Loss (worsens with prolonged therapy)
137
In what type of pt is ECT use cautioned?
Those w/ Space-occupying Brain Lesions (ie: tumor/mets)
138
Why is ECT cautioned in pts with space-occupying brain lesions?
ECT causes transient Increase in Intracranial Pressure
139
What class of antidepressants is considered first line medciation?
SSRIs
140
Which class of antidepressants is generally avoided d/t its side effect profile?
TCAs (a lot of side effects)
141
Which class of antidepressants is especially useful for atypical depression?
MAOI's
142
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?
Switch to another class of Antidepressant medication
143
How long should the avg pt contiune taking antidepressants?
About 6 mos. Can try to discontinue only after tapering the dose.
144
Which pts taking Antidepressants should be considered for long term therapy?
Those with recurrent depressive episodes
145
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?
Bupropion (causes modest wt loss)
146
In which pts should Bupropion and TCAs be avoided?
Those with underlying Seizure disorder (ie, epilepsy)
147
What is the antidepressant of choice for a pt who c/o weight loss, poor appetite, and/or insomnia?
Mirtazapine (associated with weight gain)
148
Which antidepressant is used to treat chronic pain, especially neuropathic pain?
Amitriptyline
149
Which antidepressant can be used to treat enuresis in children?
Imipramine
150
Which antidepressant is often used to treat depressed pts with insomnia?
Trazodone (strongly sedating)
151
What is a major side effect of Trazodone use?
Priapism
152
What is the most important step to determine severity and prognosis in the management of a pt who presents with TCA overdose?
EKG (check for life threatening arrhythmia)
153
What is the most appropriate antidepressant for an elderly pt who presents with depression and insomnia?
Doxepin or Trazodone
154
What is the first line antidepressant for depressed pts with underlying seizure disorder?
SSRIs
155
What is the mechanism of action of Trazodone?
SARI (Serotonin antagonist and reuptake inhibitor)
156
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?
TCA overdose
157
What is the next step in management for a pt with a TCA overdose whose EKG shows prolonged QRS and PR with sinus tachycardia?
Give Sodium Bicarbonate
158
What is the mechanism by which Sodium Bicarb aids in treating TCA overdose?
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
What is the next step in management for a pt who is taking Amitriptyline and presents with dry mouth and dry eyes?
```
Discontinue Amitriptyline (very anticholinergic)
Switch to different class (ex SSRI-virtually no anticholinergic effects)
```
160
For what conditions is Lithium considered first-line therapy?
Bipolar Disorder
Schizoaffective Disorder
Treatment/Prophylaxis of Mood Episodes
161
What is the major reason for Lithium noncompliance?
Side effects
162
What are the major side effects of Lithium Use?
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
When should Divalproex be used to treat Bipolar disorder?
First-line for Rapid Cycling Bipolar Disorder
| Also used when Lithium fails, is contraindicated, or impractical
164
When can Carbamazepine be considered for Bipolar disorder treatment?
If Lithium and DIvalproex do not work or are contraindicated?
165
What significant side effect results in decreased provider use of Carbamazepine?
Agranulocytosis
| Sedation
166
What is the site of action of Carbamazepine?
Inactivated voltage-gated Na channels (it prolongs time in this state)--> fewer channels available to open--> decreased excitatory neuronal activity
167
What is a significant metabolic effect of Carbamazepine?
CYP450 inducer -->increases clearance of drugs that are metabolized by the liver:
- Warfarin
- Phenytoin
- Valproic Acid
- Theophylline
168
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?
Lithium Toxicity
169
What is the treatment of choice for Lithium Toxicity?
Dialysis
170
By what mechanism of action does Lithium cause Nephrogenic DIabetes Insipidus?
Lithium accumulates at collecting ducts at Na channels--> Increased PGE2--> induction of Lysosomal degradation of Aquaporin 2 Channels--> ADH resistance
171
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?
Neuroleptic Malignant Syndrome
| Independent of dose or previous exposure
172
What 3 CNS nuclei are affected by Antipsychotic medications resulting in NMS?
D2 receptor at:
- Hypothalamus
- Nigrostriatal
- Spinal Cord
173
What is the mechanism of action in the periphery, associated with antipsychotics that contributes to NMS?
Increase intracellular Ca release from Sarcoplasmic Reticulum--> increased force of contraction-->Rigidity and Muscle breakdown
174
What is the management for NMS?
Transfer to ICU
Give Bromocriptine (D2 agonist)
Give Dantrolene or Diazepam (muscle relaxant)
175
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?
Serotonin Syndrome
176
WHat is the treatment for Serotonin Syndrome?
IV FLuids
Cyproheptadine (decreases serotonin production)
Benzodiazepine (decrease muscle rigidity)
177
What is the drug class and mechanism of action of Cyproheptadine?
Cyproheptadine:
- H1 Antihistamine
- Nonspecific 5HT1A/5HT2A antagonist-->(decrease serotonin production)
178
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?
MAOI-induced Hypertensive Crisis
179
What is the management of MAOI-induced Hypertensive Crisis?
- Physical Exam (ck for papilledema)
| - IV Antihypertensive medication
180
What is the mechanism of action of MAOI's?
Inhibit breakdown of Dietary Amines-->increased serum Tyramine levels-->depletion of Norepi form storage vesicles-->Hypertensive Crisis
181
What is the first assessment that should be done prior to prescribing antidepressants ina pt dx'd with depression?
Assess for Suicidal ideation/plan
| Note: if acutely suicidal--> hospitalize and ECT
182
What is the effect of some antidepressants on suicidal tendency?
Can increase risk of suicidal ideation within first 2 wks of taking antidepressant
183
What Personality Disorders are classified as Cluster A type?
Paranoid PD
Schizoid PD
Schizotypal PD
184
What is the main defense mechanism employed by those with Paranoid and Schizoid PD?
Projection
185
What is the best form of treatment for individuals with Cluster A PDs?
Psychotherapy
186
How are Schizoid PD and Schizotypal PD distinguished?
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
What are the PD's classified as Cluster B type?
Histrionic PD
Borderline PD
Antisocial PD
Narcissistic PD
188
What general characteristics describe those with Cluster B PD's?
Mood Lability
Preoccupation w/ Rejection
Dissociative symptoms
189
What features can be used to distinguish Histrionic PD from Borderline PD?
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
What are the characteristics associated with Antisocial PD?
```
Continuous criminal or antisocial acts
Disregard for others feelings/rights
Inability to conform to societal rules
Impulsivity
Lack of remorse
Aggression
Deceitfulness
```
191
What treatment can be used to manage Cluster B PD's?
Psychotherapy
| Mood stabilizers/Antidepressants may be added
192
What are the PD's classified as Cluster C?
Avoidant PD
Dependent PD
Obsessive-Compulsive PD
193
What are the general characteristics associated with Cluster C PD's?
Anxiety
Preoccupation w/ criticism
Rigidity
