Psychiatry Flashcards
Schizophrenia spectrum
Brief Psychotic Disorder
Schizophreniform disorder
Schizophrenia (Schizoaffective disorder)
other psychotic disorders
substance/medication induced psychotic disorder
Psychotic disorder due to medicla condition
Positive symptoms of sychizophrenia
Delusions
Hallucinations
Disorganized Speech
Disorganized behavior/thought
Negative Symptoms
aPathy aLogia Affective flattening aNhedonia aTtention deficit
Symptoms of psychosis
- Perception: hallucinations, illusions
- Though content: delusions, ideas of reference, loss of ego boundaries
3, Thought process: thought blocking, neologisms, impaired abstract ability
- Form of thought
Word salad, LOA, echolalia, tangentiality, perserverations
Brief psychotic disorder
Presence of at least 1 positive symptom
- disorganized or catatonic behavior
Duration: 1 day to 1 month
Full return to premorbid functioning
W or w/o marked stressor: witness of catastrophic event/ postpartum onset
Exclusion criteria:
- substance/GMC or schizoaffective and mood disorder
Schizophreniform disorder
Two or more positive symptoms for 1 month period.
Total duration: 1- 6 months
Schizophrenia disorder
Two or more positive/negative symptoms for at least a 6 month period. At least 1 positive symptom required.
social and occupational dysfunction
Exclusion: schizoaffective/mood disorder; autism spectrum; communication d/o or substance abuse/GMC.
Schizoaffective disorder
Two or more for 1 month period (at least 1 has to be a positive symptom).
Symptoms of a major mood episode (MDD) concurrent with sx of Schizophrenia.
AND
Delusions of hallucinations for greater than or equal to 2 weeks in absence of mood episode.
Delusion disorder
- 1 month duration
- Marked impairment absent other than impact of delusions.
- Not due to substance or GMC
- Schizophrenia never diagnosed.
Types to delusions in Delusion disorder (6)
- jealous
- Persecutory
- Erotomanic (de Clerambault’s)
- Grandiose
- Somatic
- Mixed/ unspecified: Capgra’s; Fregoli, cotard
Capgra’s syndrome
Delusion that close friend or loved one is replaced by an impostor– key figure in someone’s life; usuallly spouse
May accompany functional psychoses other than schizophrenia (affective, organic d/o)
Fregoli’s syndrome
Delusion that persecutor or familiar persons can assume the guise of strangers.
(ex. The Matrix)
Cotard syndrome
Complaints of having lost possessions and status.
- loss of heart, blood, or intestines
Folie a deux
Shared Psychotic disorder
- happens when partner with delusion is suggestible and other partner is less intelligent, gullible, passive, lacking in self-esteem
Aside from delusions, the couple is not impaired.
tx: separation
Typical antipsychotics
overview
- improve positive symptoms via D2 receptor blockade (nigrostriatal tract : hyperactive)
2, high EPS/ Prolactin
- With decr potency: SOMA
Sedation, Orthostatic HypoTN, Metabolic syndrome, Anti-Ach
Atypical antipsychotics
- Improves positive and negative sx
- SOMA – sedation, Orthostatic HypoTN, Metabolic, anti-Ach
- Less so on seizure, EPS/ Prolactin
Receptors that Atypical blocks and their effect?
H1 – sedation
Alpha 1 adrenergic — OH
Metabolic syndrome ??
Muscarinic-1 — anti-ACh
Who are more likely to cause EPS
High-potency Antipsychotic > mid potency Anti-psychotic > low potency antipsychotics > Atypical
Who are the high potency Typical antipsychotics
Haloperidol/Droperidol (Haldol
Fluphenazine (Modecate)
Molindone (Moban)
Typical antisphycotic, mid potency.
EPS»_space; SOMAS
Nigrostriatal tract (DA Depletion)
Weight neutral
Thioridazine (Mellaril)
Typical antipsychotic
low potency
Phenothiazine derivative
Pigmentary rentinopathy at doses >800 mg/ day
Chlorpromazine
Typical antipsychotic
Low potency
SE: Torsades de pointes, Allergic dermatitis/ photosensitivity
Agents that cause prolonged QT:
Phenothiazine: Chlorpromazine (thorazine), Mesoridazine (Serentil)
Diphenylbutylperidine: Thioridazine (mellaril), Pimozide (Orap)
Who are the atypical antipsychotics?
- Olanzapine (Zyprexa)
- Risperidone (Risperidal)
- Quetiapine (seroquel)
- Ziprasidone (Geodon)
- Aripiprazole (Ambilify)
- Clozapine (Clozaril/ Versacloz)
- agranulocytosis
Routine morning labs for ppl on antipsyhcotics?
- fasting blood glucose, FLP
Treatment for EPS:
- increase dopamine: Amantadine (symmetrel) or Bromocriptine (Parlodel).
- Reduce Acetylcholine
- Benztropine (cogentin), Trihexphenidyl (Artane), or Benedryl but can induce delirium or sexual dysfunction
Cluster A personalities
Paranoid
Schizoid
Schizotypal
Odd or eccentric; inability to develop meaningful social relationships.
No psychosis
Genetic association with schizophrenia
Paranoid
Pervasive distrust and suspiciousness;
projection is the major defense mechanism
Schizoid
Voluntary social withdrawal. Limited emotional expression, content with social isolation (vs. avoidant).
Schizotypal
Eccentric appearing, odd beliefs/ magical thinking, interpersonal awkwardness
Cluster B personalities
Dramatic, emotional, or erratic
Genetic association with mood disorders and substance abuse
Antisocial
Borderline
Histrionic
Narcissistic
Antisocial
Disregard for and violation of rights of others,
Criminality, impulsivity
males more than females
Must be greater than or equal to 18 yo
Have hx of conduct disorder before age 15
Conduct disorder if less than 18 yo
- failure to conform to social norms – unlawful acts
- Deceitfulness/repeated lying and manipulating
- Impulsitivity
- Irritability and aggressiveness/repeated fights
- Recklessness and disregard for safety of self
- Irresponsible/failure to sustain work/ honor financial obligations
- lack of remorse for actions
Borderline
Unstable mood and interpersonal relationships Impulsivity Self-mutilation Boredom Sense of emptiness Females greater than males Splitting is a major defense mechanism ** HIGH SUICID RATE**
IMPULSIVE
Impulsive Moody Paranoid under stress Unstable self image Labile, intense relationships Suicidal Inappropriate anger Vulnerable to abandonment Emptiness
Histrionic
Excessive emotionality and excitability
Attention seeking
sexually provocative/ inappropriate
overly concerned with appearance
- Uncomfortable when not the center of atten
- Inappropriate seductive or provocative behavior
- Uses physical appearance to draw atten to self
- Has speech that is impressionistic and lacking in detail
- Theatrical and exaggerated expression of emotion
- Easily influenced by others to situation
- Perceives relationship as more intimate than they actually are
Narcissistic
Grandiosity
Sense of entitlement
Lacks empathy and requires excessive admiration
often demands the best and reacts to criticism with rage.
- exaggerated sense of self importance
- preoccupied with fantasies of unlimited money, success, brilliance
- believes he/she is “special”
- Needs excessive admiration
- Has sense of entitlement
- Takes advantage of others for self-gain
Cluster C personality
Anxious or fearful
Genetic association with anxiety disroders
Avoidant
Obsessive-compulsive
Dependent
Avoidant
hypersensitive to rejection socially inhibited timid feelings of inadequacy desires relaitonship with others
- avoid occupation that involves interpersonal contact due to fear of criticism and rejection
- unwilling to interact unless certain of being liked
- Cautious of intrapersonal relationships
- Preoccupied with being critizied or rejected in social situations
- Inhibited in new social situations b/c of feelings of inadequacy
- Believes he or she is socially inept and inferior
- Reluctant to engage in new activities for fear of embarassment
Obsessive compulsive
preoccupation with order, perfectionism and control
Ego-synotic: behavior consists with one’s own beliefs and attitudes (vs. OCD – knows they have a problem and they don’t like their illness).
Dependent
Submissive and clingy
Excessive need to be taken care of
Low self-confidence
Panic disorder
PANICS
Palpitations
Paresthesias
Abdominal distress
Nausea
Intense fear of dying or losing control; Light headedness
Chest pain, Chills, choking, disConnectedness
Sweating, Shaking, SOB, Strong genetic componenet.
Diagnosis requires attack followed by 1 month (or more) of 1 (or more) of the following:
- Persistent concern of additional attack
- Worrying about consequences of attack
- Behavioral change related to attacks
Treatment of panic disorder
CBT
SSRIs– paroxetine and sertraline
Venlafaxine
Benzodiazepines occationally used in acute setting – short course.
Anxiety Disorder
inappropriate experience of fear/worry and its physical manifestations (anxiety) incongruent with the magnitude of the perceived stressor. Symptoms interfere with daily functioning.
Treatment for anxiety
CBT
SSRIS
SNRIs
Social anxiety disorder
exaggerated fear of embarrassement in social situations (public speaking, using public restrooms)
Tx: CBT, SSRIs, and beta-blockers; systematic desensitization
Agoraphobia
Tx: CBT, SSRIs, MAOI, systematic desensitization
General anxiety disorder
anxiety >6 months unrelated to specific person, situation or event.
Tx: CBT, SSRIs (first line), SNRIs. Buspirone, TCAs, benzodiazepines are second line
Adjustment disorder
emotional symptoms (anxiety/depression), causing impairment following an identifiable psychosocial stressors (divorce/ illness) and lasting LESS THAN 6 months
- can last GREATER than 6 months IF CHRONIC STRESSOR
Tx: CBT, SSRIs
obsessive- compulsive disorder
intrusive thoughts, feelings, or sensations that cause severe stress.
Ego-centric: behavior inconsisten with one’s own beliefs and atitudes.
Associated with Tourrette syndrome.
tx: CBT, SSRIs, and clomipramine are first line.
Obsession: intrussive thought (cannot be controlled)
Compulsion: perform a task to relieve obsession
Body dysmorphic disorder
preoccupation with minor or imagined defect in appearance; significant emotional distress or impaired functioning.
ex. patient who often seeks cosmetic surgery.
Tx: CBT
Post-tramatic stres disorder
Persistent reexperiencing of a previous traumatic event.
Nightmares and flashbacks
Intense fear, helplessness, horror
Lasts > 1 month and impairs social-occupational functioning
CBT, SSRIs, and venlafaxine are first line
Acute stress disorder
3days- 1 month
Same as PTSD: nightmares, flashbacks, intense fear.
Tx: CBT; pharmacotherapy is usually not indicated.
Bipolar I disorder
at least 1 manic episode with or without hypomanic or depressive episode
tx: Mood stabilizers: lithium, Carbamazepine (tregrol) or Valproic Acid (depakote)
Olanzapine – atypical antipsychotic
Bipolar II disorder
presence of a hypomanic episode (at least 1) AND a depressive episode (at least 1)
tx: Mood stabilizers: lithium, Carbamazepine (tregrol) or Valproic Acid (depakote)
Olanzapine – atypical antipsychotic
cyclothymic disorder
dysthymia and hypomania;
milder form of bipolar disorder lasting at least 2 years
- alternating periods of hypomania and periods with mild-moderate depressive symptoms
- person never symptom free for more than 2months during those 2 years.
- may coexist with borderline personality disorder
substance abuse (4)
- failure to fulfill obligations at work, school, or home
- use in dangerous situations (i.e driving car)
- Recurrent substance-related legal problems
- Cont use despite social or interpersonal problems due to the substance use.
Substance dependence (7)
aka addiction
- tolerance
- withdrawal
- using substance more than originally intended
- Persistent desire/unsuccessful efforts to cut down
- Significant time spent in getting, using or recovering from substance
- Decreased social, occupational, or recreational activities because of substance use
- Cont use despite subsequent physical or psychological problem
treatment for long-term dependence for alcohol
- AA - alcohol anonymous/self-help group
- Disulfiram
- Psychotherapy and SSRIs
- Naltrexone – helps reduce cravings for EtOH
Delirium tremens (DTs)
starts 72 hours of cessation of drinking Visual/tactile hallucinations gross tremor Autonomic instability and fluctuating levels of psychomotor activity
Time course of alcohol withdrawal and tx
starts 6-25hrs after last drink and can last 2-7 days.
Mild: irritability, tremor, insomnia
Moderate: diaphoresis, fever, disorientation
Severe: grand mal seizures, DTs
tx: benzodiazepines, thiamine, folic acid, and multivitamin, magnesium sulfate for post-withdrawal seizures
** ALWAYS GIVE THIAMINE BEFORE GLUCOSE or Wernicke-Korsakoff syndrome may precipitate. THiamine is a precursor in carbohydrate metabolism
Wernicke-korsakoff syndrome:
A. Wernicke’s encephalopathy:
thiamine (B1) deficiency –> encephalopathy
1. ataxia
2. confusion
3. ocular abnormalities (nystagmus, gaze palsies)
*If not treated then..
B. Korsakoff’s syndrome (often irreversible)
- Impaired recent memory
- Anterograde anesia
- +/- confabulation
Cocaine intoxication tx (same tx as for amphetamines)
blocks dopamine reuptake from synaptic cleft.
Mild-moderate: Benzodiazepines Severe agitation/psychosis: Haloperidol Symptomatic support (control HTN, arrhythmias)
Tx for cocaine dependence
- psychotherapy
- TCAs
- Dopamine agonists (amantadine, bromocriptine)
symptoms of cocaine withdrawal (7)
- malaise
- fatigue
- depression
- hunger
- constricted pupils
- Vivid dreams
- psychomotor agitation or retardation
“rotatory nystagmus” for intoxication
PCP intoxication
what lab markers are elevated in PCP intoxication
CPK, AST
PCP intoxication tx: (5)
- Monitor BP, temp, electrolytes
- Acidify urine with ammonium cholride and ascorbic acid
- Benzodiazepines/ dopamine antagonists to control agitation and anxiety
- Diazepam for muscle spasms and seizures
- Haloperidol to control severe agitation or psychotic symptoms
Sedative-Hypnotic intoxication (benzos, barbituates) symptoms
- slurr speech
- incoordination
- ataxia
- mood lability
- impaired judgment
- nystagmus
- respiratory depression
- coma/death
Sedative-Hypnotic intoxication (benzos, barbituates) tx (5)
- maintain airway, breathing, and circulation.
- activated charcoal to prevent further gastrointestinal absorption
- supportive care (BP, respiratory status)
For barbituates: alkalinize urine w/ sodium bicarbonate
sedative- hypnotic withdrawal symptoms (8)
autonomic hyperactivity (tachycardia, sweating, etc) insomnia anxiety tremor nausea/vomiting delirium hallucinations seizures
treatment of sedative-hypnotic withdrawal symptoms (2)
- administer long-acting benzo (chlorodiazepoxidide or diazepam w/ tapering dose)
- Tegretol or valproic acid
classic triad of opioid overdose:
“rebels Admire Morphine”
Respiratory depression
Altered mental status
Miosis
opioid overdose tx
Naloxone, or naltrexone but keep an eye on respiratory depression
How much of caffeine do you have to take to become intoxicated? Symptoms?
250mg = anxiety, insomnia, rambling speech, flushed face, diuresis, gastron instestinal disturbance and resltessness
consumption of more than 1 gram = tinnitus, severe agitation, and cardiac arrhythmias.
Treatment of nicotine withdrawal
- behavioral counseling
- nicotine replacement therapy
- Zyban – antidepressant that helps reduce cravings
- Clonidine
What are the most common causes of dementia:
- Alzheimer’s disease
- vascular dementia
- major depression (pseudodementia)
Treatment of delirium
- rule out life-threatening causes
- treat reversible causes: hypothyroidism, electrolyte imbalance, UTI
- Antipsychotic first line: quetiapine (Seroquel) also haloperidol PO/IM *** do not use IV unless on cardiac monitor as it can cause torsades)
- Positive/negative use of benzodiazepines: can cause a paradoxical disinhibition, respiratory depression or increased risk of falls
Alzheimer’s hallmarks/ clinical manifestations
Gradual progressive decline of cognitive functions, especially memory and language. Personality changes and mood swings are very common
Memory impairment plus one of the following:
- Aphasia– d/o affecting speech and understanding
- Apraxia – inability to perform purposeful movements
- Agnosia - inability to interpret sensations correctly
- Diminished executive functioning- problems with planning, organizing and abstracting.
Vascular dementia clinical manifestations.
Vascular dementia vs. Alzheimer’s
stepwise loss of function as the microinfarcts add up
memory impairment with at least one of the following:
- Aphasia– d/o affecting speech and understanding
- Apraxia – inability to perform purposeful movements
- Agnosia - inability to interpret sensations correctly
- Diminished executive functioning- problems with planning, organizing and abstracting.
- Focal neurolgical defects: hyperreflexia/paresthesias
- Onset usually more abrupt
- Greater preservation of personalit
Pick’s Disease/ Frontotemporal Dementia
hallmarks
slowly progressing dementai
Hallmarks: Aphasia, apraxia, agnosia; personality and behavioral changes are more prominent early in disease
* Pick’s bodies
treatment of parkinson’s disease
- levodopa
- . carbidopa
- Amantadine
- Antichholingerics
- Dopamin agonists (Bromocriptine)
- MAO-B inhibitors (selegiline)
- SURGERY – thalamotomy or pallidotomy
Stages of Moarning
- Denial
- Anger (blaming others)
- Bargaining ( I’ll never smoke/ drink again if my cancer is cured)
- Depression
- Acceptance
Bereavement
feelings of severe guilt and worthlessness
Significant sleep disturbance and weight loss
Hallucination or delusions
NO attempt to resume activities
Suicidal Ideation
Symptoms persist more than 1 year (worst symptoms more than 2 months)
Dysthymic disorder
Depressed mood for at least 2 years
At least 2 of the following: poor concentration, feelings of hopelessness, poor appetite or over eating, insomnia or hypersomnia, low energey or fatigue, low self-esteem.
During the 2yr period person has not been w/o above symptoms for >2 months at a time.
No major depressive episodes
Test of children intelligence
- Kaufman intelligence battery for children (K-ABC)
- Weschler Intelligence Scale for Children-Revised (WISC-R)
- Peabody individual achievement test (PIAT)
- intelligenece test for ages 2.5 to 12
- determines intelligence quotient IQ for ages 6 to 16
- Tests academic achievement
Tourette syndrome tx:
haloperidol or pimozide (dopamine receptor antagonists)
Enuresis diagnosis and treatment
5yo or greater
occurs 2x a week at least 3 months
- behavior modification – alarm
- Antiduretics (DDAVP) or TCA (imipramine)
Encopresis criteria
Involuntary or intentional passage of feces in inappropriate places
At least 4 yo
At least once a month for 3 months
Associated with conduct d/o and ADHD
What are the dissociative disorders
Dissociative amnesia
Dissociative fugue
Dissociative identity disorder (mult per d/o)
Depersonalization d/o
Dissociative amnesia tx
Important to help patients retrieve memory. Hypnosis or administration of Ativan (lorazepam) with subsequent psychotherapy.
Women> men
onset: 30yo
Depersonalization disorder
persistent or recurrent feelings of detachment from one’s self, environment, or social situation. Pt feel separated from their bodies and mental process.
Women> men 2:1
onset: 15-30yo
Tx: antianxiety agents or SSRI to treat associated symptoms of anxiety or major depression
Somatization disorder
multiple vague complaints invovlving many organ systems. Long-standing history of numerous visits to doctors. Symptoms cannot be explained by medical disorder.
- at least on GI symptom
- At least one sexual/reproductive symptom
- at least one neurological symptoms
- At least four pain symptoms
- onset BEFORE AGE 30
- Cannot be explained by GMC or substance use
Tx: regularly scheduled visits
Conversion disorder
- At least one neurological symptom
- Psychological factors associated w/initiation or exacerbation of symptoms
- symptom not intentionally produced
- cannot be explained by medical condition or substance use
- Causes significant distress/social/functional impairment
- not limited to pain or sexual symptom
2:1 women vs men
increase in low socioeconomic groups
common symptoms: shifting paralysis blindness mutisim paresthesias seizures globus hystericus (sensation of lump in throat)
Body dysmorphic disorder tx
SSRI
Surgical/ dermatological procedures are unsuccessful in pleasing the patient.
Pain disorder
characteristics, epidemiology, treatment
- Patient main complaint of pain at one or more anatomic sites
- Pain causes significant distress in patient’s life
- Pain related to psychological factors
Average age: 30-50
Increase incidence in blue collar workers
Pts have higher incidence of major depression, anxiety d/o, and substance abuse
- SSRI, transient nerve stimulation, biofeedback, hypnosis, and psychotherapy
Intermittent explosive disorder
- Failure to resist aggressive impulses that result in assault or property destruction
- Level of aggressiveness is out of proportion to any triggering events.
onset: late teens-20’s
Men
hx of child abuse, head trauma or seizures
May progress in severity until middle age
SSRI, anti-convulsants, Lithium, Propranolol. Group/family therapy
Treatment for kleptomania
insight-oriented psychotherapy
behavior therapy (systematic desensitization and aversive conditioning)
SSRI
Anorexia nervosa tx
antidepressant – paroxetine or mirtazapine that promote weight gain
UWORLD:
- cognitive behavior therapy
- Nutritional rehabilitation
- Olanzapine if no response
Tx for narcolepsy
timed daily naps plus stimulants (amphetamines and methylphenidate)
SSRI or sodium oxalate for cataplexy: collapse due to sudden loss of muscle tone– associated with emotion particularly laughter
Nightmare disorder
- repeated awakenings with recall of extremely frightening dreams
- Occurs during REM sleep and causes significant distress
no real treatment but TCA can suppress total REM sleep
Night Terror disorder
Stage 3 or 4 of sleep (non-REM). Patients are not awake and do not remember the episodes.
High association with comorbid sleepwalking disorder.
tx: usually none, but small doses of diazepam at bedtime may be effective.
