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MCC Part 1 > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

Define psychosis

A

Interruption from reality

  • may affect thought process, thought content, behaviours and/or perceptions
  • manifested by delusions, hallucinations, disorganized thoughts and behaviours, or failed reality testing
  • > sx not dx
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2
Q

Define delusion

A

Fixed false beliefs that fall outside cultural norms

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3
Q

What is schizophrenia characterized by?

A
  • positive sx - delusions, hallucinations
  • negative sx - affective blunting, anhedonia, abolition, alogia
  • cognitive impairment - attention, concentration, processing speed, learning, memory, executive function
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4
Q

Age of onset of psychosis in schizophrenia?

A

late teens to mid-30s

- earlier for men

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5
Q

Genetic risk of schizophrenia?

A

50% when both parents affected

60-84% monozygotic twins

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6
Q

Environmental factors re: schizophrenia?

A
  • perinatal events
  • obstetric complications
  • social stressors
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7
Q

Neurotransmitters re: schizophrenia

A
  • hyperdopaminergic state in D2 striata system = + sx
  • hypodopaminergic state in prefrontal D1 system = cognitive deficits
  • monoamine receptors (serotonin, histamine, muscarinic, alpha-adrenergic) = - sx
  • Ach related to high use of tobacco
  • glutamate and GABA related to some behavioural and cognitive sx
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8
Q

Most common anatomical finding in schizophrenia?

A
  • enlargement of the ventricles
    +/- reduced frontal lobe activation
  • functional circuit disruption (vs. localized dysfunction)
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9
Q

Ddx psychosis -> psychotic disorders

A
  • schizophrenia
  • shizophreniform
  • brief psychotic disorder
  • delusional disorder
  • schizoaffective disorder
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10
Q

Ddx psychosis

A

Psychiatric

  • psychotic
  • mood + psychotic features (MDD, bipolar I)
  • OCD
  • mental retardation
  • autism spectrum
  • personality (Schizotypal, schizoid, borderline, paranoid)
  • malingering, factitious

Substances/medications

  • substance abuse
  • rx medications (e.g. steroids)
  • toxins

General medical conditions

  • CNS - lesions, infections, seizures, strokes
  • Systemic illness - autoimmune, metabolic, endocrine, vitamin deficiency, sepsis
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11
Q

Baseline investigations for schizophrenia

A
  • CBC, lytes, Cr, BUN, LFTs, TSH
  • fasting plasma glucose
  • lipid panel
  • toxicology screen
  • syphilis, HIV

+/- head CT, MRI (re: structural brain abnormalities)
ECG
clinical screening for chromosome 22q11

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12
Q

Timeline re: brief psychotic vs. schizophreniform vs. schizophrenia

A 
<1mo = brief psychotic disoder
1-6mo = schizophreniform disorder
>6mo = schizophrenia
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13
Q

Diagnosis for pt with only delusions but not much functional impairment?

A

Delusional disorder

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14
Q

Diagnosis for pt with psychosis plus mood sx with periods lasting at least 2wk of only psychosis and no mood BUT mood sx at least half the time of illness?

A

Schizoaffective disorder

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15
Q

Diagnosis for pt with psychosis plus mood sx but NO periods of at least 2wk of only psychosis and no mood?

A

Depression with psychosis

Bipolar I with psychosis

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16
Q

Criteria A for schizophrenia

A

At least 2 of the following:

  • delusions
  • hallucinations
  • disorganized speech
  • disorganized behaviour
  • -> at least 1 mo and with impairment lasting at least 6mo
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17
Q

Atypical antipsychotic advantages vs. disadvantages

A
  • less chance of extrapyramidal sx and tardive dyskinesias

- increased metabolic s/e

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18
Q

When can clozapine be tried?

A
  • after 2 failed trials of different antipsychotics (6-8wk optimized therapeutic dose)
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19
Q

What is the most efficacious medication to treat schizophrenia? What are the s/e?

A

Clozapine

- regular and consistent monitoring re: agranulocytosis, seizures, myocarditis

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20
Q

Typical antipsychotics

  • indications
  • CI
  • adverse
A

High potency - haloperidol

  • indications: positive sx, pregnancy
  • CI: preexisting movement disorder/ TD
  • adverse: higher risk EPS/TD; hyperprolactinemia

Low potency - chlorpromazine, thioridazine

  • indications: positive sx
  • CI: preexisting movement disorder/ TD
  • adverse: lower risk EPS/TD; postural hypotension, sedation, anticholinergic (blind as a bat, mad as a hatter, dry as a bone, red as a beet, hot as a hare)
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21
Q

Atypical antipsychotics

  • indications
  • CI
  • adverse
A
  • E.g. olanzapine, resperidone, clozapine, quetiapine, aripiprazole
  • indications: positive or negative or cognitive sx; preexisting movement disorders sensitivity (quetiapine or clozapine); treatment refractory (clozapine); suicidality (clozapine)
    CI: diabetes (relative)
  • adverse: low risk EPS/TD; weight gain/ hyperglycemia/ hyperlipidemia/ diabetes/ sedation; agranulocytosis (clozapine - need weekly CBC x6mo then >biweekly CBC); prolonged QT interval (esp. quetiapine - need ECG monitoring)
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22
Q

Psychosocial treatment for management of psychotic/ thought disorders?

A

Supportive therapy

CBT

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23
Q

Define mania

A

Period of severe and sustained elevated mood that leads to disturbed behaviour and function
+/- psychotic sx
hypomania if elevation in mood less severe or more brief

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24
Q

Prevalence bipolar disorder and median age of onset

A

Bipolar I = 0.6%
Bipolar II = 0.4%
Subthreshold disorders = 1.4%

Median age of onset 25yr

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25
Q

Ddx mania/hypomania

A

Psychiatric

  • Bipolar disorders (bipolar I or II; cyclothymic)
  • MDD
  • Anxiety
  • Psychotic disorders (schizophrenia, schizoaffective, delusional disorder)
  • ADHD
  • Borderline PD

Substance/medication-induced

  • substances (stimulants, EtOH, hallucinogens)
  • medications (antidepressants, dopamine agonists, steroids)

General medical conditions

  • infectious (HIV, tertiary syphilis)
  • neurological (stroke, traumatic brain injury, tumor, seizures, multiple sclerosis)
  • systemic (hyperthyroid, thryotoxicosis, Cushing, SLE)
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26
Q

Investigations mania

A
  • CBC, lytes, BUN, Cr, LFTs, TSH
  • fasting blood glucose
  • B12/folate
  • urinalysis, urine drug screen

+/- neurologic consultation
CXR
ECG
CT

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27
Q

Dx mania

A
  • abnormally and persistently elevated, expansive or irritable mood and increased goal-directed activity or energy for at least 1wk (or any duration if hospitalized)

at least 3 sx (4 if mood only irritable) - GSTPPAID

  • grandiosity
  • sleep decreased
  • talkativeness
  • pleasure activities with painful consequences
  • pressured speech
  • activity level increased
  • ideas (flight of)
  • distractible

mood causes marked impairment
sx not due to substance or medical condition
- evidence for bipolar I if sx after treatment or drugs but sx continued after tx d/c

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28
Q

Dx hypomania

A
  • criterion 1 of manic episode met but duration at least 4d
  • criteria 2 and 4 manic episode met
  • episodes associated with uncharacteristic decline in functioning observable by others
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29
Q

Bipolar I vs II Disorder

A

Bipolar I

  • one manic episode, commonly accompanied by MDE but not MDE not required
  • not due to schizophrenia, schizophreniform, schizoaffective, delusional or other psychotic disorder

Bipolar II

  • at least one MDE and at least one hypomanic episode without past manic episode
  • condition not schizophrenia, schizophreniform, schizoaffective, delusional or other psychotic disorder
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30
Q

Dx cyclothymia

A
  • numerous periods of hypomanic and depressive sx but not meeting criteria for MDE for at least 2yr (one year in kids, adolescents), never without sx more than 2mo
  • no MDE, no manic or mixed episodes and no evidence of psychosis
  • not due to general medical condition or substances
  • sx cause clinically significant distress or impairment
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31
Q

Pharm tx mania

A
  • risperidone
  • olanzapine
  • aripiprazole
  • asenapine
  • ziprazidone
  • resperidone IM
  • divalproex
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32
Q

Pharm tx mania and depression

A

Lithium

Quetiapine

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33
Q

Pharm tx depression in bipolar

A
  • Lamotrigine
  • (Lithium or Divaproex) + (SSRI or bupropion)
  • Olanzapine + SSRI
  • Lithium + Divalproex
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34
Q

Is depression the leading cause of disability worldwide?

A

Yes

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35
Q

Define mental disorder

A
  • syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion, regulation, or behaviour that reflects a dysfunction in the psychological, biologic, or developmental processes underlying mental functioning
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36
Q

Main neurotransmitters involved in depression?

A
  • serotonin
  • norepinephrine
  • dopamine
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37
Q

Main neuropeptides in depression? Roles?

A
  • somatostatin
  • neuropeptide Y
    Act as cotransmitters
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38
Q

Ddx depression

A

Psychiatric

  • depressive disorders (MDD, persistent depressive disorder, premenstrual dysphoric disorder)
  • bipolar disorders (bipolar I and II, cyclothymic)
  • psychotic disorders
  • adjustment disorder with depressed mood
  • dementia

Bereavement

Substance of medication induced

  • medications
  • substances (EtOH, CNS depressants; stimulant withdrawal)

General medical conditions
- chronic illness, endocrine (adrenal, thyroid), malignancy, metabolic (electrolyte, vitamins), neurologic (MS, stroke, tumor)

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39
Q

Suicide risk factors

A 
SAD PERSONS
- sex male
- age
- depression
- previous attempt
- ethanol or drugs
- rational thinking loss
- separated, divorced, widowed
- organized plan
- no social support
- stated future intent (e.g. suicide note)
\+acute risk factors
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40
Q

Depression investigations

A
  • CBC, lytes, BUN, Cr, LFTs, fasting blood glucose, TSH
  • toxicology/ drug screen (alcohol, cannabis, opioid, amphetamines/ stimulant, cocaine withdrawal or intoxication)
  • urinalysis, urine drug screen

+/- neurologic consult
CXR
ECG
CT

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41
Q

Dx MDD

A

At least 5 sx (MSIGECAPS) with at least one of depressed mood or anhedonia presented within same 2wk period with change from previous functioning:

  • mood depressed
  • sleep increased or decreased
  • interest decreased (anhedonia)
  • guilt
  • energy decreased
  • concentration decreased
  • appetite decreased or increased
  • psychomotor agitation or retardation
  • suicidal ideation

Sx cause clinically significant distress or impairment
Sx not due to physiologic effects of substance of GMC
Sx not better accounted for by other psychiatric disorders

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42
Q

Specifiers MDD

A
  • with anxious distress (two or more: feeling tense, restless, concentration problems, worry something awful might happen, worry lose self-control)
  • with mixed features (three or more manic or hypomanic sx)
  • with melancholic features (loss of pleasure in all activities, inability to react to pleasurable stimuli + specific sx)
  • with atypical features (reactive mood + increased sleep, eating)
  • with mood-congruent psychotic features (delusions and/or hallucinations has depressive theme)
  • with mood-incongruent psychotic features (delusions and/or hallucinations present not depressive themes)
  • with cataonia (motoric immobility, excess motor activity, negativism, mutism, peculiar movements, echolalia, echopraxia)
  • with peripartum onset (during pregnancy or within 4wk delivery)
  • with seasonal pattern (particular time of year, full remission at particular time of year, in last 2yr)
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43
Q

Predominant affect MDD vs. grief

A

MDD - depressed mood, inability to anticipate happiness or pleasure
Grief - emptiness and loss

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44
Q

Dx persistent depressive disorder

A

Depressed mood for most of day, depressed more days than not, at least 2yr

At least two while depressed

  • poor appetite or overeating
  • insomnia or hypersomnia
  • low energy or fatigue
  • low self-esteem
  • poor concentration or difficulty in making decisions
  • feelings of hopelessness

During 2yr period never been without sx for more than 2mo at a time

Never been manic episode, mixed episode, or hypomanic episode; never met criteria for cyclothymic disorder

Disturbance not because persistent psychotic disorder

Sx not due to substance of GMC

Sx cause clinical distress or impairment

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45
Q

Pharm management depressed mood

A
  • Escitalopram (allosteriod serotonin reuptake inhibitor)
  • Sertraline (SSRI)
  • Venlafaxine (SNRI)
  • Duloxetine (SNRI)
  • Milncipran (SNRI)
  • Mirtazapine (alpha2-adrenergic agonist, 5HT antagonist)
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46
Q

Psychological management depressed mood

A
  • CBT
  • ITP
  • other therapies have less evidence for efficacy
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47
Q

Define remission and recovery

A

Remission - 2wk - 2mo with no or very few sx

Recovery is absence of sx (no more than one to two) for 2mo or more

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48
Q

Define suicide

A

Act of intentionally terminating one’s own life

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49
Q

Progression of suicidal behaviour

A

Ideation -> plan -> intent

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50
Q

Ddx suicidal ideation

A

Psychiatric

  • mood disorder (depression, bipolar)
  • psychotic disorder (schizophrenia)
  • substance use disorder
  • personality disorder (borderline and antisocial)
  • anxiety disorder (more common with panic disorder)
  • delirium (altered level of consciousness, can lead to increase in suicidal behaviour)

Psychosocial stressors

  • adverse childhood experience
  • change in marital status
  • change in employment
  • lacking social support

Other
- chronic medical conditions (CF, cancer, cirrhosis, etc)

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51
Q

Age demographics with highest risk of suicide?

A

Age >65yr = highest risk

Age 16-19 yr = second highest risk

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52
Q

Male vs. female completed and attempted suicide?

A

M > F (3:1) in completed suicide

F > M (4:1) in attempted suicide

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53
Q

Suicide workup investigations

A
  • CBC, lytes, BUN, Cr, fasting blood glucose, LFTs, TSH, toxicology/ drug screen (alcohol, cannabis, opioid, amphetamine/ stimulant or cocaine withdrawal or intoxication)
  • urinalysis, urine drug screen

+/- neurologic consult, CXR, ECG, CT, EEG

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54
Q

Treatment suicidal patient

A

Underlying disorder
depression most common
- antidepressants
- antipsychotics

psychotherapy, rehab programs, detox programs

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55
Q

Do you need consent from the patient to treat acute agitation?

A

No

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56
Q

Carter vs. Canada ruling (Feb 5 2015)?

A
  • Canadian adults who are competent and suffering intolerably and permanently have the right to doctor’s help in dying (then suspended ruling x12mo)
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57
Q

What is anxiety?

A

Human adaptive reaction to external threats by activating sympathetic NS fight-or-flight

  • alerting signal warning of impending danger
  • unpleasant, vague feeling of apprehension and often autonomic arousal sx
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58
Q

What is fear? vs. anxiety?

A

Alerting signal to something known, external or definite

vs. anxiety is often unknown, internal and vague

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59
Q

When is anxiety pathological?

A
  • fear out of proportion to severity of threat

- social and/or occupational functioning impaired

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60
Q

What brain structures responsible for coordinating fear and storing memory for future exposure to same stimuli? Neurotransmitters involved?

A

Amygdala and hippocampus

- Dopamine, serotonin, glutamine, GABA

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61
Q

Ddx anxiety

A

Psychiatric

  • anxiety disorders (specific phobia, panic disorder, agoraphobia, generalized anxiety)
  • depression
  • somatization disorder
  • depersonalization disorder
  • OCD/related disorders
  • trauma and stress related disorders (acute stress disorders, PTSD)

Substance-induced

Medical

  • hyperthyroid, hypothyroid
  • cardiac (MVP, schema, arrhythmia)
  • DM
  • vestibular nerve disease
  • pheochromocytoma
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62
Q

Diagnosis: pt with specific object cue that brings on anxiety >6mo and impairs function?

A

Specific phobia

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63
Q

Diagnosis: pt with specific situational cue that brings on anxiety >6mo and impairs function?

  • fear negatively evaluated in social situations
  • fear of anxiety about situations where difficult escape
A
  • social = Social anxiety disorder

- fear of difficult escape = agoraphobia

64
Q

Diagnosis: pt with sx of panic (autonomic sx) with >=1 mo worry about having another panic attack and/or behaviours to avoid panic attack

A

Panic disorder

65
Q

Diagnosis: pt with excessive worry and anxiety about numerous things for most days at least 6mo and >=3 sx (feeling keyed up, fatigue, concentration issues, irritability, muscle tension, sleep disturbance)

A

Generalized anxiety disorder

66
Q

Diagnosis: pt with recurrent or unwanted thoughts or repetitive behaviours or mental acts that are time consuming and impairing

A

Obssessive-compulssive disorder

67
Q

Workup for anxiety disorders and why

A 
CBC - r/o anemia, infection 
lytes - r/o lyte imbalance 
BUN, Cr - r/o renal failure
fasting blood glucose - r/o hyper/hypo glycemia
TSH - r/o hyper/hypothyriodism
Urinalysis - street drugs
68
Q

Biological tx anxiety disorders

A

SSRIs - first line
- may initially exacerbate anxiety, start low and go slow
SNRIs - first line
Mirtazapine
Benzodiazepines
- often in emergency tx
- caution: sedation, cognitive effects, dependence
- abrupt withdrawal may be dangerous (seizures, DTs)
TCAs
MAOIs
Buspirone
- generalized anxiety efficacy (not for panic)

69
Q

Psychological tx anxiety disorders

A

CBT

Behavioural (exposure) therapy

70
Q

Define delusion of control

A
  • delusional belief one’s actions, behaviour, or feelings are not under personal control or own doing, but imposed by external force
71
Q

Define delusion of guilt or sin

A
  • delusional believe of responsibility for tragedy or disaster to which there is no personal connection
72
Q

Define delusion of grandiosity

A
  • delusional belief of special power, taken, abilities, or identity
73
Q

Define delusion of jealousy

A
  • with little or no evidence, person believes one’s sexual partner is unfaithful
74
Q

Define delusion of mind reading

A
  • delusional belief that people can read one’s mind or know one’s thoughts
    (note different from thought broadcasting)
75
Q

Define delusion of persecution

A
  • delusional belief that one is in danger, being followed or monitored, harassed or conspired against
76
Q

Define delusion of reference

A
  • delusional belief that ordinary, insignificant comments, objects or events refer to or have special meaning for the patient
77
Q

Define delusion of replacement

A
  • delusional belief that someone important to the patient has been replaced by a double
78
Q

Define erotomania

A
  • delusional belief that one is loved, perhaps secretly, by another person; usually other person is higher status that pt
79
Q

Define nihilistic delusion

A
  • delusional belief that the person, a part of the person’s body, or the world does not exist
80
Q

Define somatic delusion

A
  • delusional belief that one’s body is diseased or changed
81
Q

Define thought broadcasting

A
  • delusional belief that as thoughts occur they escape from the person’s head and can be heard by others
82
Q

Define thought insertion

A
  • delusional belief that thoughts are not one’s own, but have been placed there by some person, group, or force from the outside
83
Q

Define thought withdrawal

A
  • delusional belief that one’s thoughts have been removed or taken away by someone or something from the outside
84
Q

Hypnogogic vs. hypnopompic hallucination

A
  • hypnogogic - when pt falling asleep as is pseudo-hallucination; only significant to dx abnormal sleep states (not psychopathological)
  • hypnopompic - analogous to hypnogogic but occurs upon awakening
85
Q

Types of affect?

A
  • blunted
  • constricted
  • flat (more severe than blunted)
  • inappropriate
  • labile
86
Q

Ddx psychiatric causes weight loss re: eating disorders

A
  • anorexia nervosa
  • bulimia nervosa
  • pica
  • avoidant/restrictive food intake disorder
87
Q

Signs of purging?

A

Teeth: enamel erosion, chipped/ ragged, dental caries

Salivary gland hypertrophy (parotid)

88
Q

Signs of starvation?

A

Lanugo hair (fine downy)
Emaciation
Peripheral edema

89
Q

Investigations re: eating disorders?

A
  • r/o medical illness
  • r/o physiologic comorbidities induced by eating disorder

CBC, basic and extended lytes, LFTs, TSH, ECG

90
Q

Dx anorexia nervosa

A
  • Persistent restriction of energy intake vs. requirements = significantly low body weight (less than minimally expected)
  • Intense fear of gaining weight or becoming fat, persistent behaviour that interfere with weight gain
  • distorted self-perception, overvalued significance of body weight and shape on self-evaluation, or lack of insight into significance of low body weight

Specify:

  • restricting type: in past 3mo no binge eating or purging
  • binge-eating purging type: in past 3mo has recurrent binge eating or purging behaviour
Mild = BMI >17
Moderate = BMI 16-16.9
Severe = BMI 15-15.9
Extreme = BMI <15
91
Q

Dx bulimia nervosa

A
  • Recurrent episodes of binge eating, consuming more than normal person and which is accompanied by sense of lack of control
  • Recurrent inappropriate compensatory behaviours to prevent weight gain (vomiting, laxatives, excessive exercise, restricting intake)
  • Self-evaluation is unduly influenced by body shape and weight
  • Episodes of inappropriate compensatory behaviours occur on average:
    1-3x/wk (mild)
    4-7x/wk (moderate)
    8-13x/wk (severe)
    >14x/wk (extreme)
92
Q

Dx: pt with normal body weight, episodes of binge eating but no purging behaviours?

A

Binge-eating disorder

93
Q

Dx pt with low body weight but no fear of gaining weight or behaviours to prevent weight gain?

A

Unspecified eating disorder

94
Q

Dx patient eating non-food substances?

A

Pica

95
Q

Dx weight loss but no preoccupation with body weight/ image?

A

Avoidant/ restrictive food intake disorder or unspecific eating disorder

96
Q

Management eating disorders

A
  • outpatient psychotherapy is cornerstone
    -> CBT
  • SSRI and antipsychotics limited role
    some evidence SSRI with bulimia (decrease binge and purging episodes)
  • combo SSRIs + psychotherapy best
  • manage complications (e.g. osteoporosis)
97
Q

Epidemiology substance use problems?

A

10% population

- up to 50% psychiatric disorders

98
Q

10 classes of drugs in DSM-V?

A
  • EtOH
  • caffeine
  • cannabis
  • hallucinogens
  • inhalants
  • opioids
  • sedatives, hypnotics, anxiolytics
  • stimulants
  • tobacco
  • other (or unknown) substances
99
Q

Neurotransmitters involved with brain reward system (i.e. substance abuse)?
Brain areas involved?

A
  • Opioid
  • Dopamine
  • GABA

Mesolimbic, hippocampus, amygdala, thalamo-orbitofrontal, anterior cingulate, frontal cortex regions

100
Q

Genetic factors with any substance use disorders?

A

EtOH

101
Q

Anticholinergic toxidrome

A
  • Blind as a bat, dry as a bone, hot as a hare, red as a beet, mad as a hatter

Substances

  • antihistamines
  • antiparkinson
  • antipsychotics
  • benztropine
  • carbamazepine
  • TCAs

Sx

  • agitation
  • delirium
  • hallucination
  • memory loss
  • urinary retention
  • visual disturbance

Signs

  • HTN
  • hyperthermia
  • tachycardia
  • flushing
  • mydriasis
  • decreased bowel sounds
  • seizures
102
Q

Cholinergic toxidrome

A

Substances

  • anticholinesterase inhibitors
  • insecticides
  • nerve gases

Sx

  • confusion
  • lacrimation/ salivation
  • vomiting
  • diarrhea
  • increased urination

Signs

  • bradycardia
  • hypotension
  • hypothermia
  • diaphoresis
  • miosis
  • seizures
103
Q

Opioid and sedative-hypnotic toxidromes

A

Substances

  • opioids
  • benzodiazepines
  • EtOH
  • sedatives/hypotics

Sx

  • altered mental status
  • confusion
  • delirium
  • coma

Signs

  • hypotension
  • hypothermia
  • respiratory depression
  • miosis (opioids)
  • hyporeflexia
104
Q

Neuroleptic malignant syndrome

A

Substances

  • antipsychotics
  • levodopa
  • lithium
  • desipramine
  • phenelzineu

Sx

  • fever
  • diaphoresis
  • muscles cramps and stiffness
  • tremors
  • agitation
  • delirium
  • coma

Signs

  • hypertensive crisis
  • muscle rigidity
  • rhabdomyolysis
  • elevated WBC
  • elevated CPK
  • metabolic acidosis
105
Q

Serotonin syndrome

A

Substances

  • antidepressants: SSRI, SNRI, MAOI, TCA, bupropion, trazodone, mirtazapine
  • opioids: fentanyl, meperidine, oxycodone, tramadol
  • amphetamines
  • cocaine
  • methylphenidate
  • LSD

Sx

  • diaphoresis
  • diarrhea
  • headache
  • agitations
  • hallucinations
  • coma

Signs

  • hypertension
  • hypethermia
  • mydriasis
  • hyperreflexia
  • myoclonus
  • clonus
106
Q

Sympathomimetic toxidrome

A

Substances

  • amphetamines
  • caffeine
  • cocaine
  • ephedrine/ pseudoephedrine
  • LSD
  • PCP

Sx

  • diaphoresis
  • n/v
  • anxiety
  • delusions
  • paranoid

Signs

  • hypertension
  • tachycardia
  • mydriasis
  • hyperreflexia
  • seizures
107
Q

Substance use disorders investigations

A
  • serum and urine toxicology screens
  • CBC + differential, lytes, BUN, Cr, LFTs, TSH, fasting plasma glucose, lipid panel, etc.
  • communicable diseases (hepatitis, syphilis, HIV)
    +/- ECG, EEG, CT head, MRI
108
Q

Treatment EtOH use disorder

A

CIWA protocol
- diazepam 20mg PO q1-2h or 2-5mg IV/min until sx abate
- if elderly, liver impairment, severe asthma or resp failure -> use lorazepam 1-2mg PO/SL tid-qid
+/- anti epileptics if seizure
antipsychotics if hallucinations
supportive care re: hydration and sx management

109
Q

Treatment opioid use disorder

A
  • Naloxone 2mg bolus IV/IM/SL/SC
    increase by 2mg increments until sx abate (max 10mg)

methadone for detox and maintenance

110
Q

Treatment tobacco use disorder

A

Nicotine replacement therapies

  • patch (7-21mg)
  • gum (2mg q1h - max 20 pieces per day)
  • lozenge (1mg q1h - max 20/d)
  • inhaler (4mg - max 12/d)

Varenicline
Bupropion

111
Q

Treatment __ use disorders

cannabis, stimulants, hallucinogens, caffeine, implants, sedatives, hypnotics, anxiolytics

A
  • supportive care for hydration and sx management for acute intoxication or withdrawal
  • GI decontamination
  • benzodiazepine for seizures or agitation
  • b-blockers for HTN
  • vasopressors for hypotension
  • anti arrhythmic for dysrythmias
  • antipsychotics for psychotic sx
112
Q

Substance use disorders psychological and social tx options?

A
  • many psychological tx (motivational interviewing, CBT, DBT, etc.)
  • social tx: detox centres, residential tx centres, etc, AA, Narcotics anonymous, etc.
113
Q

What are neurodevelopment disorders as per DSM-V?

A
  • developmental deficits that result in impairment in personal, social, academic, or occupational functioning
114
Q

What is intellectual disability?

A
  • objectively confirmed deficits in intellectual function and deficits in adaptive functioning with onset during developmental period
115
Q

What week GA does brain development begin?

A

3rd wk GA

- continues to late adolescence/ early adulthood

116
Q

When are fundamental structures of brain established by in wk GA?

A

By end of embryonic period (8th wk GA) with growth and refinement through fetal development

117
Q

In utero vs. postnatal causes of DD?

A

In utero:
- disruption of gene expression (trisomy 21, fragile X)
- environmental input (FASD, congenital infection)
Postnatal:
- CP, postnatal infection
re: brain development continues after birth

118
Q

What medical disorders are prevalent in DD?

A
  • cardiac disease: CAD, congenital
  • respiratory disease: aspiration pneumonia, OSA
  • GI: GERD, GI/feeding issues
  • neurologic: seizures/epilepsy, early onset dementia
  • endocrine: hypothyroidism, hypogonadism
119
Q

What is cerebral palsy?

A
  • static neurological condition characterized by motor and occasionally intellectual impairment
  • brain injury before completion of neurodevelopment (first 2 years of life)
120
Q

Health surveillance in pt with down syndrome?

A

Each visit: sx celiac disease; OSA screen; cervical spine positioning precautions; sx myopathy

Annual: TSH, hemoglobin, audio logic exam, exam for acquired mitral/aortic valve disease

q3yr: ophthalmologic assessment for cataracts, refractive errors, corneal thinning or haze

121
Q

Down syndrome: etiology, investigations

A

etiology

  • sporadic trisomy 21 in 95% cases
  • unbalanced translocation 3-4%, 25% of these familial
  • mosaicism 1-2%

inv
- FISH study - positive result followed by chromosomal analysis for translocations

122
Q

Dx pt with: small head, flattened facial features, protruding tongue, upward slanting eyes, single palmar crease, short fingers

A

Down syndrome

123
Q

Fragile X: etiology, investigations

A

etiology
- CGG trinucleotide repeat of FMR1 gene on X chromosome

inv
- PCR to assess trinucleotide repeats

124
Q

Dx pt with: long face, long ears, hyper extensible joints, macroorchidism, flat feet, ADHD, autism, speech delay, social anxiety

A

Fragile X

125
Q

Cerebral palsy: etiology and investigations

A

etiology

  • non progressive neurological condition resulting from brain injury prenatally or in first 2yr life
  • 70-80% prenatal of unknown cause
  • 10-20% postnatal from infections of brain trauma

inv
- clinical dx based on history, physical exam, exclusion of progressive neurologic disorders

126
Q

Dx pt with: hyperreflexia, hypertonia, scissors gait, toe walking (70-80% presentations)
+/- global developmental and physical dysfunction or isolated disturbances of gait, cognition or sensation

A

Spasticity - cerebral palsy

127
Q

Dx pt with: slow, writhing movements (10-20% presentations)

+/- global developmental and physical dysfunction or isolated disturbances of gait, cognition or sensation

A

Athetosis - cerebral palsy

128
Q

Dx pt with: wide-based gait, intention tremor (5-10% presentations)
+/- global developmental and physical dysfunction or isolated disturbances of gait, cognition or sensation

A

Ataxia - cerebral palsy

129
Q

Fetal alcohol syndrome/ spectrum disorder: etiology and investigations

A

etiology

  • syndrome: combination of characteristic physical and CNS abnormalities
  • spectrum disorder: range of effects resulting from alcohol exposure

inv
- confirmed maternal EtOH exposure and characteristic facial, growth, CNS, and/or cognitive impairment
FAS without confirmed EtOH exposure dx if facial anomalies, growth retardation and CNS abnormalities all present

130
Q

Dx pt with: short palpebral fissures, flat upper lip, flattened philtre, flat mid face
+ growth retardation
+ microcephaly, structural CNS abnormalities, neurologic hard/soft signs
+ behavioural/cognitive difficulties

A

Fetal alcohol syndrome/ spectrum disorder

131
Q

Autism spectrum disorder: etiology and investigations

A

etiology

  • definitive etiology not established
  • 15% associated with known genetic mutation
  • environmental risk factors include advanced paternal age, low birth weight, fetal exposure to valproate

inv
- clinical dx using caregiver interviews, questionnaires and clinical observation tools

132
Q

Dx pt with: deficits in social communication/ interaction and restricted, repetitive behaviours, interests or activities
+ specify if accompanying intellectual impairment or language impairment

A

Autism spectrum disorder

  • without language deficit previously Aspergers
133
Q

Do you need objective standardized intelligence testing to dx intellectual disability with DSM-V?

A

Yes

134
Q

Management of behaviour problems with DD?

A
  • behavioural/ psychological interventions (first line)
  • all psychotropic medications (with confirmed psych disorder - depression, anxiety, ADHD)
  • atypical antipsychotics - attempt use <72h
  • Resperidone for ASD control of behaviour
135
Q

Define sexual dysfunction & categories

A

disturbance in sexual interest, arousal or achieving orgasm

  • male erectile dysfunction
  • female orgasmic disorder
  • female sexual interest/arousal disorder
  • male hypoactive sexual desire disorder
136
Q

Define sexual paraphilia

A
  • sexual arousal, fantasies, sexual urges or behaviour involving nonhuman objects, suffering or humiliation of oneself or one’s partner, children or others
  • often pt has more than one paraphilia
  • women 5%
137
Q

Define gender dysphoria

A
  • strong and persistent cross-gender identification with repeated stated desire or insistence that one is opposite sex
    children vs. adolescents and adult criteria
  • gender identity set by age 2-3 yr
138
Q

Subtypes of sexual paraphilia

A
  • exhibitionism
  • fetishism
  • frotteurism
  • voyeurism
  • pedophilia
  • sexual masochism
  • sexual sadism
  • transvestite fetishism
  • paraphilia NOS (necrophilia, zoophilia, coprophilia, urophilia)
139
Q

Gender dysphoria lab work

A

CBC, lytes, BUN, Cr, fasting blood glucose, LFTs, TSH, toxicology/ drug screen (EtOH, opioid, amphetamines/ stimulants, cocaine withdrawal/ intoxication)
FSH/LH, GH

140
Q

Gender dysphoria tx

A
  • testosterone to control sexuality, fantasies, behaviour
  • antiandrogenic drugs to reduce sex drive in men (s/e)
  • SSRIs and lithium to reduce impulse control problems and/or sexual obsessions
  • psychostimulants to augment SSRIs (paraphilia disorder)
  • psychotherapy
141
Q

What are PDs?

A
  • enduring pattern of inner experience and behaviour that deviates markedly from expectations of culture; manifested in 2+ cognition, affect, interpersonal functioning and impulse control
  • inflexible and pervasive across range of situations
142
Q

Paranoid PD dx

- cluster A (mad)

A 
SUSPECT >=4
Spouse fidelity suspected
Unforgiving and bearing grudges
Suspicious of others
Perceives attack on his/her character not apparent to others and reacts quickly
Enemy or friend
Confides in others feared
Threats perceived in benign events
143
Q

Schizoid PD dx

- cluster A (mad)

A 
SOLITARY >=4 (negative sx)
Shows emotional coldness to others
Omits from social events
Lacks friends
Involved in solitary activities 
Takes pleasure in few activities
Appears indifferent from praises and criticism
Restricts from close relationship
Yanks himself or herself from social interactions
144
Q

Schizotypal PD dx

- cluster A (mad)

A 
ME PECULIAR >=5 (ideas of reference)
Magical thinking or odd beliefs
Experiences unusual perceptions
Paranoid ideation
Eccentric behaviour/ appearance
Constricted/inappropriate affect
Unusual (odd) thinking and speech
Lacks close friends
Ideas of reference
Anxiety in social situations
Rule out psychotic disorders and pervasive developmental disorder
145
Q

Antisocial PD dx

- cluster B (bad)

A 
CORRUPT >=3 (criminal aggressive)
Conformity to law lacking
Obligations ignored
Reckless disregard for safety of self or others
Remorse lacking
Underhandedness (deceitful, lies, cons)
Planning deficit (impulsive)
Temper (irritable, aggressive)
146
Q

Borderline PD dx

- cluster B (bad)

A 
AM SUICIDE >=5 (affect lability suicide)
Abandonment 
Mood instability
Suicide and/or self-harming behaviour
Unstable and intense relationship
Impulsivity (self-damaging areas)
Can't control anger
Identity disturbance
Dissociative sx
Emptiness
147
Q

Histrionic PD dx

- cluster B (bad)

A

PRAISE ME >=5 (centre of attention, emotional lability)
Provocative or sexually seductive behaviour
Relationship considered more intimate than they are
Attention (uncomfortable when not centre)
Influenced easily
Style of speech (impressionistic, lacks details)
Emotional liability and shallowness
Make up (physical appearance used to draw attention)
Exaggerated emotions (theatrical)

148
Q

Narcissistic PD dx

- cluster B (bad)

A

SPECIAL >=5 (self-importance, entitlement)
Special - believes special and unique, status (high)
Preoccupied with fantasies of unlimited success, power, brilliance, beauty or ideal love
Entitlement (strong sense), envious
Conceited (grandiose sense of self-importance)
Interpersonal exploitation
Arrogant
Lacks empathy

149
Q

Avoidant PD dx

- cluster C (sad)

A

AVOIDER >=4 (social phobia)
Avoid occupational activities
View self as inept, unappealing or inferior
Occupies with fear of rejection or criticism in social situations
Inhibits from new interpersonal relationships
Difficulty initiating new projects due to lack of self confidence
Embarrassment prevents new activity or taking personal risks
Restraints in intimate relationships due to fear of being shamed

150
Q

Dependent PD dx

- cluster C (sad)

A

DEPENDENT >=5 (separation anxiety)
Difficulty making everyday decisions without advice and reassurance form others
Excessive length to obtain nurturance and support
Preoccupied with thoughts of taking care of self
Exaggerated fears of being left to care for self
Needs others to assume responsibility for most major areas of life
Difficulty in expressing disagreement
Ending one relationship immediately and seeking urgently for another
Not able to initiate projects due to lack of self-confidence
Take care of me is motto

151
Q

Obsessive-Compulsive PD dx

- cluster C (sad)

A

LAW FIRMS >=4 (obsessive-compulsive behaviour)
Loses point of activity due to preoccupation with details
Ability to complete tasks compromised by perfectionism
Worthless objects unable to discard
Friendships and leisure activities excluded due to preoccupation with work
Inflexible, scrupulous, overly conscientious on ethics, values or morality; not accounted for by religion or culture
Reluctant to delegate unless others submit to exact guidelines
Miserly toward self and others
Stubbornness and rigidity

152
Q

Excessive daytime sleepiness vs. fatigue

A
  • daytime sleepiness: inability to stay alert during day; falling asleep inappropriately during day (e.g. driving)
  • fatigue: subjective lack of energy
153
Q

STOP BANG screen for OSA

A
  • snoring
  • tired
  • observed apneas
  • blood Pressure
  • BMI >35kg/m2
  • age >60
  • neck circumference >40cm
  • male Gender
    >=3 -> high risk
154
Q

Define fatigue

A
  • state of extreme weariness
155
Q

Categories of abuse

A
  • physical
  • sexual
  • emotional/ psychological
  • economic
    elderly + abandonment, neglect and self-neglect

MCC Part 1 (22 decks)

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