Psychiatry Flashcards
major risk factors for suicide
psychiatric disorders feelings of hopelessness or worthlessness impulsivity increasing age male sex access to weapons history of suicide attempts
neurotransmitters decreased in depression
serotonin, norepinephrine, dopamine
medical illnesses that can cause depressive symptoms
hypothyroidism hyperparathyroidism Parkinson disease stroke HIV Cancer (esp CNS neoplasms, which can mimic depression)
Drugs known to cause depressive symptoms
sedatives (alcohol, benzodiazepines, antihistamines)
withdrawal from stimulants (cocaine, amphetamines)
some antihypertensives (methyldopa, clonidine, beta- blockers)
first- generation antipsychotics (haloperidol)
prochlorperazine
metoclopramide
long-term glucocorticoid use
interferon- alpha (contraindicated in depression)
MDD with atypical features
mood reactivity increase appetite and weight gain hypersomnia leaden paralysis hypersensitivity to rejection responds well to MAOIs
MDD with seasonal pattern
recurrent depression exhibiting a regular temporal or seasonal pattern
treatment: light therapy (10,000 lux at least 30 min/day)
MDD with peripartum onset
onset during pregnancy or up to 4 weeks postpartum
MDD with psychotic features
delusions or hallucinations develop during an episode of MDD
No psychosis except during depressive episodes (the depression is always present even when the psychosis isn’t_
Schizoaffective disorder
baseline psychosis
mood disorder secondary to psychosis
persistent depressive disorder (formerly known as dysthymic disorder)
chronic, persistent depression for at least 2 YEARS (MDD no longer precludes persistent depressive disorder as it used to in DSM4)
depressed mood plus 2 SIGECAPS symptoms
more difficult to treat than MDD
SSRIs
citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline
first line for depression as well as anxiety
work in 3-4 weeks
SNRIs
desvenlafaxine, duloxetine, milnacipran (fibromyalgia only), venlafaxine
Atypical antidepressants
buproprion, mitrazapine, nefazodone, trazodone
TCAs
amitriptyline, doxepin, imipramine, nortriptyline
MAOIs
phenelzine, tranylcypromine
side effects of SSRIs
sexual dysfunction insomnia/agitation weight gain risk of suicidal ideation risk of serotonin syndrome
Serotonin syndrome
mental status changes: anxiety, agitation, delirium, restlessness, disorientation
autonomic excitation: diaphoresis, tachycardia, hyperthermia, hypertension, vomiting, diarrhea
Neuromuscular hyperactivity: tremor, muscle rigidity, hyperreflexia, myoclonus
ocular clonus (slow, continuous, horizontal eye movements)
spontaneous or inducible clonus
positive Babinski sign bilaterally
Which drugs increase the risk of serotonin syndrome
SSRIs SNRIs MAOIs TCAs St. John's wort Tryptophan Triptans Linezolid Levodopa Stimulants (cocaine, ecstasy- MDMA, amphetamines)
How do we treat serotonin syndrome?
discontinue all serotonergic agents and symptoms usually resolve in 24 hours
Supportive care to normalize vital signs
- oxygen, IV fluids, cardiac monitoring
- if medical treatment for tachycardia or HTN is needed, use short- acting agents (esmolol, nitroprusside)
Sedation with benzodiazepines
If T>41, sedation, paralysis, ET tube- mechanical cooling
- paralysis should relieve the hyperthermia, which is caused by muscle activity
- there is no benefit in using antipyretics in this scenario
If agitation despite benzodiazepine then use a serotonin inhibitor like cyproheptadine
Adter sx resolve, assess need to resume serotonergic agent
side effects of SNRIs
sexual dysfunction insomnia/agitation nausea dizziness hypertension (venlafaxine) risk of serotonin syndrome
norepinephrine dopamine reuptake inhibitor (NDRI)
buproprion
blocks presynaptic reuptake of NE and DA
use this to treat fatigue and hypersomnia, but not anxiety
also indicated for smokine cessation
NDRI (buproprion) side effects
blocks pre-synaptic re-uptake of DA
insomnia, weight loss, lowers seizure threshold, contraindicated in anorexia, eating disorder, seizure disorder
no sexual dysfunction!
Alpha2 antagonist- mirtazapine
blocks alpha 2- adrenergic receptors, which leads to increased NE release
side effects include sedation for unknown reasons, appetite stimulation, and weight gain
useful in cancer patients who have comorbid depression
Serotonin modulators: trazadone, nefazodone, vilazodone
these drugs have a variety of effects on serotonin receptors (agonist/antagonist depending on the receptor subtype)
The main side effect is sedation
Trazedone can even be used as a sleep aid
priapism
TCAs: amitriptyline clomipramine imipramine nortriptyline
not really used much anympre
block NE and serotonin reuptake
3rd line due to poor side effect profile
side effects: anticholinergic effects (amitriptyline especially) sedation sexual dysfunction weight gain dangerous in overdose
What findings are seen in TCA OD?
cardiotoxicity: tachycardia, hypotension, conduction abnormalities
CNS toxicity:sedation, obtundation, coma, seizures
antiCholinergic symptoms: mydriasis, xerostomia, ileus, urinary retention
MAOIs
tranylcypromine
phenelzine
inhibits MAO; increases levels of serotonin, DA, NE
not used often, due to side effects and interactions with food (tyramine builds up and stimulates autonomic nervous system)
side effects: drug- drug interactions
hypertensive crisis
what foods contain tyramine and should be avoided while on MAO in order to avoid hypertensive crisis?
foods that are spoiled, pickled, aged, smoked, fermented, or marinated
- fermented cheeses (cream cheese and cottage cheese are ok)
- smoked or aged meats (sausage, bologna, pepperoni, salami, smoked or pickled fish)
- chianti, most beers and wines (especially over 120 mL)
- soy sause, shrimp paste, miso soup
- sauerkraut, avocados, ripe bananas, fava beans
What are the indications for electroconvulsive therapy?
severe, debilitating depression refractory to antidepressants
psychotic depression
severe suicidality
depression with food refusal leading to nutritional compromise
depression with catatonic stupor
situations where a rapid antidepressant response is required (eg pregnancy)
previous good response to ECT
bipolar/mania
schizophrenia/psychosis (catatonia especially)
TCA that can be used to treat bedwetting in children
imipramine
Bipolar I disorder
at least one manic episode
may or may not have MDD or hypomanic episodes
Bipolar II disorder
At least one hypomanic episode
At least one major depressive episode
Never had a manic episode
Manic episode
elevated, expansive, or irritable mood
increased goal- directed activity or energy
lasts at least one week
Distractability Insomnia Grandiosity Flight of ideas Activity/agitation Speech Taking risks
Manic episode versus hypomanic episode
Manic:
at least 3 DIG FAST symptoms
at least 1 week
impaired function, or requires hospitalizations, or includes psychotic features
Hypomanic episode
at least 3 DIG FAST symptoms
lasts at least 4 days
no impairment in functioning, hospitalizations, or psychosis
Treatment for bipolar
Lithium (unless renal failure, in which case lithium is contraindicated and valproic acid and carbamazepine are choice)
Anticonvulsants (valproate, carbamazepine, lamotrigine)
Lithium and anticonvulsants are mood stabilizers
Atypical antipsychotics (aripiprazole, olanzapine, quetiapine, risperidone) ECT
do not use SSRIs, which can push a patient into mania. treat depression in the setting of bipolar, with mood stabilizers
What are side effects of lithium in treating bipolar disorder?
Teratogenesis (Ebstein anomaly)
CNS effects (depression, tremor, cognitive dulling)
Thyroid dysfunction (hyperthyroidism, hypothyroidism, euthyroid goiter)
GI effects (nausea, vomiting, diarrhea, weight gain, metallic taste changes)
Nephrogenic diabetes insipidus (polyuria, polydipsia)
How do we treat nephrogenic diabetes insipidus that results from lithium toxicity?
hydrochlorothiazide with amiloride
Ebstein anomaly
tricuspid leaflets displaced inferiorly
tricuspid regurgitation or stenosis
RV hypoplasia
+/- patent foramen ovale
Cyclothymic disorder
mild hypomanic symptoms that do not meet criteria for a hypomanic episode
mild depressive symptoms that do not meet criteria for a major depressive episode
symptoms are present for at least 2 YEARS (Adults), or 1 year in children
periods of normal mood last less than 2 months during that 2 year (Adult) or 1 year (child) stretch
DOES cause significant distress or impairment in social/occupational functioning
Tx: mood stabilizers, psychotherapy
Dissociative disorders
Dissociative identity- multiple personalities, 2 or more distinct identities/ personalities)
Depersonalization/derealization disorder- depersonalization- persistent feelings of detachment from patient’s own body or thoughts, or feeling like people and things around the patient aren’t real
Dissociative amnesia- amnesia for a very specific event, or generalized amnesia of patient’s identity and personal life history.
May include dissociative fugue
Panic disorder
recurrent panic attacks, with abrupt onset of intense fear and anxiety accompanied by palpitations or tachycardia sweating trembling/shaking SOB choking sensation CP dizziness/lightheadedness nausea hot flashes/chills paresthesias feeling of losing control fear of dying
Panic attach is followed by a period of persistent worry about more panic attacks, or maladaptive behavior to prevent panic attacks. This period lasting at least one month
Treat with CBT, SSRIs, Benzodiazepines acutely (but beware addiction)
Generalized anxiety disorder
Excessive anxiety and worry occurring more days than not for at least 6 months
At least 3 of the following symptoms:
- hyperarousal
- difficulty concentrating
- irritability
- muscle tension
- difficulty sleeping
- fatigue
SSRIs, SNRIs, Buspirone, CBT
Specific phobias
marked fear out of proportion to the threat the situation poses, with avoidance of the feared exposure
exposure therapy- gradual desensitization
Social anxiety disorder
excessive anxiety related to social situations, with fear of being negatively evaluated by others (eg social interactions, being observed by others, performing in front of others)
Treat:
CBT, SSRI, SNRI
Benzodiazepine or beta- blocker (propanolol), as needed for performances
Buspirone as an anxiety medication
second- line treatment
may be used as monotherapy or in combination with SSRIs and SNRIs
Affinity for serotonin and dopamine receptors
Benzodiazepines as anxiety meds
increase the frequency of opening of GABA- receptor chloride channels
frequent use may lead to tolerance, dependence, withdrawal seizures
agoraphobia
excessive fear of being outside the home alone, using public transporation, and being in a crowd
this isn’t a specific phobia
delusion
irrational belief that cannot be changed by proof or rational arguments
illusion
misinterpret a stimulus that is actually there
hallucinations
sensory perception in the absence of external stimulus
Disorganized thought
circumstantiality- answers diverge from the question asked but eventually return to the original topic
tangentiality- answers diverge from the question asked and do NOT return to the original topic. The point keeps changing, though you can see the links
Loose associations- no clear sequence to the thoughts presented
Word salad- words strung together incoherently
Neologism- new words
Schizophrenia:at least 2 of the following during a 1 month period (including at least 1 of the first 3)
plus social/occupational dysfunction
for a duration of at least 6 months
delusions
hallucinations (most common type is auditory)
disorganized speech
grossly disorganized or catatonic behavior
negative symptoms (flat affect, poverty of speech, lack of emotional reactivity)
Schizophrenia risk factors
family history
being born in late winter/early spring
maternal illness/malnutrition during pregnancy
+/- psychoactive drug use during adolescence and young adulthood
male gender
Neuroimaging- enlargement of lateral and third ventricals
cortical thinning
Schizophrenia negative symptoms
flat affect social withdrawal avolition/apathy anhedonia poverty of speech
schizotypal personality disorder
odd thoughts/behavior/appearance
discomfort with interpersonal relationships
schizoid personality disorder
voluntary social isolation
schizoaffective disorder
psychosis with intermittent mood disorder
schizophrenia
psychosis that lasts at least 6 months
schizophreniform disorder
psychosis for less than 6 months
brief psychotic disorder
psychosis less than 1 month