Psychiatry Flashcards
Which medication for alcohol use disorder is safe to use in liver disease? Why?
Acamprosate
Renally cleared
Treatment of tardive dyskinesia
Stop offending medication if possible, if they need to be on an antipsychotic put them on Clozapine
Treatment of parkinsonism
Benztropine or amantadine
What neurotransmitter does PCP effect
Glutamate (NMDA receptors) antagonist
Triad of ADHD
inattentiveness, hyperactivity, and impulsivity IN MULTIPLE SETTINGS (ie school and home)
Cardiac effects of TCA toxicity
What is the treatment
Blockade of cardiac sodium channels
QRS and QT prolongation –> Can lead to torsades
Tx with sodium bicarb
Withdrawal: rhinorrhea and lacrimation
opioid withdrawal
What drug can be given to reverse the effects of LSD?
Atypical antipsychotics
Cyclothymic disorder
AT least 2 years of fluctuating, mild hypomanic and depressive symptoms that do not meet criteria for hypomanic episodes or major depressive episodes
What receptors does caffeine work through
Adenosine (antagonist)
Wernicke-Korsakoff syndrome:
lesion to bilateral mammillary bodies (within temporal lobes) associated with thiamine (B1) deficiency and excessive EtOH use.
Confusion, opthalmoplegia, ataxia, memory loss (retrograde and anterograde amnesia), confabulation and personality changes
o Wernicke problems come in a CAN of beer: Confusion, Ataxia, Nystagmus
Inability to learn new info
What treatment should be used in depressed geriatric patients who are unable to drink or eat, are psychotic, or are actively suicidal in order to achieve a rapid response?
ECT
Antidepressants typically take up to 6-8 weeks to be effective
Withdrawal from what drug causes depression?
Cocaine
Part of the brain implicated in ADHD
Altered activity in the dorsolateral prefrontal cortex
Tic disorder treatment
a1 agonists (clonidine, guanfacine) or antipsychotics if severe
Psychogenic polydipsia
A sensation of unquenchable thirst secondary to mania or psychosis
Dilute urine with normal electrolytes (because the kidneys can compensate just fine)
In DI – there is hypernatremia
Which drugs are the choice for sedation in emergency setting?
Lorazepam (Ativan)
Haloperidol (Haldol)
Treatment of catatonia
Benzodiazepines and/or ECT
What is required for diagnosis of Neuroleptic malignant syndrome?
Diffuse muscle rigidity
Which antipsychotic can cause retinitis?
Thioridazine (retinitis pigmentosa)
Dissociative fugue
Sudden unplanned travel accompanied by an inability to recall one’s own personal hx. Pts will often assume a new identity in this new location
Connective tissue causes of psychosis
SLE, temporal arteritis, porphyria
Medical causes of depression
o Thyroid
o Vitamin D
o Folate/B12 (hx of gastric bypass)
Features of MDD with atypical features
Symptoms and treatment
o Mood reactivity (feeling better in response to positive events)
o Leaden paralysis (patient’s arms and legs feel very heavy)
o Rejection sensitivity (sensitive to criticism)
o Hypersomnia and hyperphagia
o Treat with SSRIs (MAO inhibitors are not first line due to risk profile)
Scary side effect of Clozapine
When is Clozapine used
Leukopenia (agranulocytosis)
Used for treatment resistant schizophrenia and schizoaffective disorder
Schizophrenia vs schizophreniform disorder vs brief psychotic disorder
Schizophrenia: present for 6+ months
Schizophreniform disorder: between 1-6 months
Brief psychotic episode: less than 1 month
Medical treatment of binge eating disorder
Lisdexamfetamine: (Stimulant)
SSRI
CBT
Treatment of akathisia (Inability to sit still)
Propranolol or Benzos
Postpartum depression treatment
SSRIs for at least 6 months after resolution of symptoms
TCAs and anticholinergic toxicity symptoms
- which symptom is most specific
- which TCA is most notorious for these side effects
- which population is most often affected
Dry mouth, constipation, blurred vision, and **urinary retention
Amitriptyline
Most common in elderly patients
How does smoking affect antipsychotic medications
Nicotine increases the metabolism of antipsychotics (decreases their effectiveness)
Which med should you use in MDD with psychotic features?
SSRI (like fluoxetine) and Risperidone
1st line treatment for bedwetting in kids
- Limit fluid intake at bedtime
- Urine alarm
- Pharmacotherapy if behavioral interventions dont work
- 1st line = desmopressin
- Imipramine (TCA) – due to anticholinergic effects (causes urinary retention)
Medical management of fear of public speaking
Propranolol (B blockers)
How does tetrabenazine treatment lead to depression in Huntingtons?
It depletes dopamine from the synaptic cleft
The effects of what drug is clinically undistinguishable from schizophrenia?
PCP
Part of the brain implicated in OCD
Caudate nucleus (Basal ganglia)
What drugs act through serotonin
Hallucinogens
Which pathway causes hyperprolactinemia?
Tuberoinfundibular
Timeline of schizophrenic spectrum disease
<1 month: brief psychotic disorder
1-6 months: schizophreniform disorder
>6 months: schizophrenia
First line therapy for bipolar disorder
Lithium or Valproic acid plus a second gen antipsychotic (quetiapine) aka seroquel
Elevation of what is seen after a seizure and is used to distinguish between epileptic and psychogenic nonepileptic seizures?
Prolactin - elevated after an epileptic seizure
Naltrexone
Opioid antagonist
Decreases cravings for alcohol
Can precipitate withdrawal in opioid dependence
What is the preferred treatment of gambling disorder
Group therapy: participation in gamblers anonymous
What can benzos in the elderly cause?
Delirium
When should you expect to see seizures in alcohol withdrawal?
12-48 hours
Schizoaffective disorder
Schizophrenia + mood disorder
• Patients meet criteria for either a major depressive episode or manic episode during which psychotic symptoms consistent with schizophrenia are also met
Delusions or hallucinations for 2 weeks in the absence of mood disorder symptoms
• This is necessary in order to differentiate this from mood disorder with psychotic features
Medical management of anorexia nervosa
Fluoxetine (SSRI)
Olanzapine
Tyramine Reaction
Symptoms and meds involved
Treatment
Hypertensive crisis with HTN, blurred vision, and diaphoresis– due to build up of tyramine
If on MAOIs, need dietary restrictions (no tap beer, aged cheese, dried meat, red wine, avocado, black bananas)
Treat with phentolamine (a1 and a2 blocker)
What vitamin and electrolyte deficiencies can lead to psychosis?
B12 niacin: carcinoid syndrome, pellagra folate Calcium Sodium
When do nightmares occur?
During REM sleep, later on in the night
What are contraindications to Buproprion?
Anorexics, bulimics, and epileptics –> can cause seizures
Also has stimulant effects so it is not a good choice in people with anxiety
What drugs are used to treat OCD?
SSRIs
Clomipramine (TCA) ** technically the gold standard but has side effects
Treatment of akathisia
Beta blocker
Benzos
“For treatment of A, give Bs”
What brain changes are seen in schizophrenia
Enlargement of the ventricles
Acamprosate
Mechanism: modulates glutamate and GABA
Can be used in patients with liver disease as it is hepatically cleared
Which antipsychotic does not exacerbate symptoms of parkinsons
Clozapine
Hallucinations act through which neurotransmitter pathway?
Serotonin
Positive symptoms
hallucinations, delusions, bizarre behavior, disorganized speech
• Tend to respond better to antipsychotic medications
Acute intoxication with alcohol can cause what type of acid base disturbance
Metabolic acidosis with an elevated anion gap
Which antipsychotic is most likely to cause long QT
Ziprasidone
“Zip on over to get an EKG!”
Alcoholic with macrocytosis and peripheral neuropathy
B12 deficiency
How does the treatment of illness anxiety disorder differ from other somatic symptom disorders?
Responsive to CBT AND SSRIs
What brain tract is implicated in reward? What neurotransmitter?
Mesolimbic tract
Dopamine
Opiate withdrawal symptoms
Anxiety, N/V/D, insomnia, anorexia, fever, sweating, rhinorrhea, lacrimation, yawning
What drug(s) can be used to treat MDD with insomnia?
Mirtazapine (Remeron) – has H1 blocking traits, leading to sedation
Trazodone – H1 blockade
TCAs can also do this but they are not first line due to side effects
Which SSRI is most associated with sexual dysfunction? What should you switch them to?
Paroxetine (due to anticholinergic activity).
Switch to Sertraline
Major depressive disorder with psychotic features
When a patient presents with MDD with hallucinations and delusions that reinforce the patient’s depressive symptoms
What type of therapy is uniquely studied to be beneficial in anorexia?
Family based therapy
Workup for new onset psychosis
Utox CBC Electrolytes Tsh Liver panel CT or MRI
Which pathway is responsible for antipsychotic efficacy?
Mesolimbic
Neurotransmitter implicated in Alzheimer’s disease?
Acetylcholine
What electrolyte disturbance would you expect in anorexia nervosa
Hyponatremia
Which benzodiazepine is given to manage withdrawal symptoms from alcohol or other benzos?
Chlordiazepoxide (longer half life)
what neurotransmitter is implicated in schizophrenia?
Inc in dopamine
Refeeding syndrome
Artificial nutrition causes an increase in insulin
Inc protein synthesis, inc uptake of phosphorous, potassium, magnesium and thiamine
– Causes a dec in serum phosphorous, potassium, magnesium
Which pathway can cause extrapyramidal symptoms?
Nigrostriatal pathway
“Chronically depressed patient with at least one episode of hypomania”
Cyclothymic disorder
Which SSRI is least likely to cause withdrawal symptoms if stopped abruptly?
Fluoxetine
Withdrawal of what drugs can cause seizures?
Benzos
Booze
Barbs
Due to the upregulation of Glutamate (excitatory) to compensate for increased activation of GABA (inhibitory) by the drugs
Factitious disorder: conscious or unconscious
Conscious
Disulfiram:
Mechanism
Effects
Contraindications
inhibits aldehyde dehydrogenase –> causes vomiting, headache, flushing, acts as “punishment” for drinking
Contraindicated in pregnancy, cardiac disease, and psychosis
Issues with adherence
Dissociative fugue
Sudden unplanned travel accompanied by an inability to recall one’s own personal hx
Conversion disorder: conscious or unconscious
Unconscious
What medication for alcohol use disorder should be used in someone with kidney disease?
Naltrexone: hepatically cleared
Which second generation antipsychotics are more weight neutral?
Ziprasidone
Aripiprazole
(so your ZIPper doesnt RIP)
Workup for medical causes of psychosis
CT Head (intracranial process) HIV and RPR CBC (some leukemias can present this way) CMP (electrolytes) TSH (Thyroid disease) Utox (drug induced psychosis)
Lithium Adverse Effects
o Early toxicity = GI symptoms (N/V/D)
o Prolonged toxicity = tremor, confusion, ataxia
o Hypothyroidism: hair loss, weight gain, dry skin, constipation
o Diabetes Insipidus: polyuria, polydipsia (antagonizes ADH in the collecting duct)
Why dont you give benzos to older people
Can lead to delirium
It is disinhibiting – can cause agitation
Treatment of acute dystonia (sustained contraction of the neck, mouth, tongue, eye muscles)
Benztropine or Diphenhydramine
What illicit drug can lead to serotonin syndrome?
Ecstacy
What drugs act through GABA
Benzos, Booze, and Barbs
Time criteria for cyclothymic disorder
2 years
Agoraphobia vs social anxiety
- Social Phobia: fear of scrutiny by others or fear of acting in a humiliating or embarrassing way
- Agoraphobia: Severe anxiety that results in response to a situation or place in which a patient is concerned that it might be difficult to escape
Lithium toxicity
Very narrow therapeutic index
Acute lithium toxicity: GI symptoms (N/V/D)
Prolonged toxicity: tremor, confusion, and hyperreflexia, ataxia and seizures
What medication decreases alcohol cravings?
Acamprosate for daily drinkers
Naltrexone for binge drinkers
A patient with a recent cold presents with serotonin syndrome… what drug most likely precipitated this?
Dextromethorphan (cough syrup)
When should you expect to see delirium tremens? What is characteristic of this?
What is the treatment of DTs
after 2-4 days
*Disorientation, delusions, hallucinations
Treat with benzodiazepines
Rapid eye movement sleep behavior disorder is a suggestive feature of what disease?
Parkinson disease or Lewy Body Dementia
What antidepressant can be used for smoking cessation?
Buproprion
Treatment of body dysmorphic disorder
SSRIs and/or CBT
Features of Lewy Body Dementia
- dementia
- hallucinations: usually benign, small animals,
- Parkinsonism: masked facies, cogwheel rigidity, shuffling gait, frequent falls
- Fluctuating cognition - “sundowning”
Acute intermittent porphyria symptoms and treatment
Due to a defect in the heme synthesis pathway
o Precipitator: alcohol, starvation, CYP450 inducers o Abdominal pain o Port wine urine o Psych disturbances o Peripheral neuropathy
Treat with dextrose and heme
What drug is used for rapid cycling bipolar disorder (at leasr four mood episodes within 12 months)
Carbamazepine
Hypercalcemia
Symptoms: Stones, bones, groans, moans, thrones, and psychiatric overtones
• Stones = kidney stones
• Bones =bone pain
• Groans= lethargy, fatigue
• Moans = constipation, abdominal pain
• Thrones = polyuria and polydipsia
• Psychiatric overtones = mental status change
Which antipsychotic can decrease the efficacy of other antipsychotics when used as adjunctive therapy for depression?
Aripiprazole (partial dopamine agonist)
Why is clonipramine best for OCD compared to other TCA’s?
Inc serotonergic activity
What drug can be used to treat MDD with hypersomnolence
Bupropion (Wellbutrin) – activating, stimulant
Meds to treat neuroleptic malignant syndrome
Dantrolene- inhibits calcium ion release form the sarcoplasmic reticulum
Bromocriptine- dopamine agonist
Amantadine - an antiviral drug with dopaminergic properties
ECT
Negative symptoms
flat or blunted affect, anhedonia, apathy, alogia, and lack of interest in socialization
• Often more resistant to treatment
Which SSRI should not be started in patients with a hx of medication noncompliance? Why?
Paroxetine
Can cause severe SSRI discontinuation syndrome - dizziness, nausea, fatigue, muscle aches, electric shock sensations, anxiety
(Usually avoid this with slow tapering off of the drug)
Sleep changes in MDD
Inc in REM
Dec in slow wave “deep sleep”
Drug intoxication: nystagmus
PCP Phencyclidine
Treatment of enuresis
Desmopression Imipramine (TCA) for refractory cases
Difference in mechanism of action of barbs vs benzos
Both are GABA-A agonists
Barbs; increase DURATION of chloride channel opening
Benzos; increase FREQUENCY of chloride channel opening
fregoli syndrome
when multiple people are believed to be one person that can change appearance
Adverse effect of B blockers in elderly
centrally-acting beta blockers (carvedilol, propranolol, nadolol) can cause cognitive suppression – patients with dementia are at higher risk of this
Which anticonvulsant is safe in pregnancy?
Lamotrigine
capgras syndrome
belief that someone you know well has been replaced by an imposter
Mechanism of tardive dyskinesia
When you block dopamine receptors with antipsychotics, the brain makes more receptors are made that are more sensitive to dopamine → leads to excess movement (dopamine receptor hypersensitivity)
Hyperreflexia and myoclonus suggests what? What is the treatment?
Serotonin syndrome – treat with cyproheptadine
In NMS, you would see hyporeflexia
What receptors do opioids work through
Mu opioid receptors
Fear of crowds
Agoraphobia
What effect can alcohol have on red blood cells?
Macrocytosis
Which medication can be used in PTSD to decrease nightmares and hypervigilance
Prazosin (a1 blocker)
EKG findings in anorexia
ST dep
T wave flattening
low voltage
long QT
If a patient presents with depressive symptoms and admits to heavy alcohol use, what is the diagnosis?
Substance induced mood disorder
Kluver Bucy Syndrome
disinhibited behavior (hyperphagia, hypersexuality, hyperorality) caused by a lesion to the bilateral amygdala (within the temporal lobe)
o Can be due to ischemic stroke or trauma
o Often asociated with HSV-1
Treatment of acute mania in bipolar?
Treatment of acute depressive episodes of bipolar?
Mania: Lithium and valproic acid
Depression: Lithium and lamotrigine
Patient hospitalized for an MS flare is appropriately treated. However she then develops delusions and hallucinations. What is the likely diagnosis?
Substance induced psychosis: 2/2 steroids!
What neurotransmitter is found to be lower in the CSF of people with impulsivity/violence when compared to the general population?
Serotonin
anti-HAM effects of antipsychotics
anti-Histamine: sedation, weight gain
anti-Alpha adrenergic: orthostatic hypotension
anti-Muscarinic: dry mouth, constipation
NSAID effects on lithium levels?
NSAIDs increase lithium levels, better to use Aspirin
What antidepressant should not be started in a patient with HTN?
SNRI – can inc blood pressure
Which antipsychotic causes the most weight gain
Olanzapine
How long should a patient be treated with SSRI for depression
About 8-10 months after resolution of symptoms
