Psychiatry Flashcards
FDA approved first-line drugs for smoking cessation treatment
- Nicotine replacement therapy→transdermal patch, gum, lozenge, inhaler, nasal spray►↓nicotine withdrawal symptoms
- Varenicline→alpha 2, Beta 4 nicotinic acetylcholine receptor partial agonist►↓nicotine cravings (associated with mood changes, suicidality, CV events)
- Bupropion→norepinephrine and dopamine reuptake inhibitor►smoking cessation aid
Most common comorbid conditions in Tourette syndrome
- Attention-Deficit hyperactivity disorder (ADHD)
- Obsessive-compulsive disorder (OCD)
Probable side effects of some over-the-counter cold preparations and why?
Because they may contain:
- Antihistamines (diphenhydramine, doxylamine)→anticholinergic►confusion and hallucinations
- Alpha-adrenergic agents (pseudoephedrine, phenylephrine)→sympathomimetic►agitation and psychosis
- Dextromethorphan→NMDA antagonist►dissociative symptoms and hallucinations
*Effects seen in combination, excess or prescribed doses in sensitive individuals
Which is the most common method to commit suicide? Why is important?
- Firearms (men and women)
- Ask about access to guns (avoid access in patients with suicide ideation)
How can you differentiate primary psychiatric disorders from chronic methamphetamine abuse?
Methamphetamine abuse:
- Persistent psychosis→Visual and tactile hallucinations are more common in substance-induced psychotic disorder
- Weight loss
- Dental problems (“meth mouth”)→brown discoloration, tooth decay, cracked teeth
- Excoriations due to chronic skin picking
Main features of delusional disorder
- ≥1 Persistent delusion and no other prominent psychotic symptoms (hallucinations, negative symptoms, disorganization)
- Functioning is not markedly impair
Key to differentiate personality disorders (paranoid, schizoid and schizotypal) from delusional disorder
Personality disorders do not have delusions
Common early side effects of SSRIs in anxiety disorder patients? What to do?
- Stimulating effects: new-onset anxiety in nonsocial situations, insomnia
- Temporary reduction in dosage
*Should generally start with lower doses than usual (depressive disorders)→Half normal starting dose and gradual increase
Early side effects of SSRIs
Nausea, diarrhea, increased anxiety or insomnia (activating or stimulating effects), somnolence
How do you differentiate schizoaffective disorder from bipolar disorder or major depressive disorder with psychotic features?
- Psychotic symptoms in major depressive or bipolar disorder occur exclusively during mood episodes
- Schizoaffective disorder =>2 weeks of delusions or hallucinations without major depressive or manic episode
Dominant person’s delusion transferred to a more submissive partner
Shared psychotic disorder (folie á deux)
First measure to approach shared psychotic disorder
Separate the individuals to determine the degree of impairment in each
*Also Tx to break the cycle of mutual reinforcement
Pharmacology treatment for aggressive autism spectrum disorder
Risperidone or Aripiprazole
First and second line of treatment for Attention Deficit Hyperactivity Disorder
- First line: Methylphenidate, Dextroamphetamine (Affect noradrenergic and dopaminergic pathways)
- Second line:
- Atomoxetine (NE reuptake inhibitor)
- Clonidine, Guanfacine (alpha-2 agonists)→↑Cognition and attention in prefrontal cortex (limited use in adults)
Pharmacology treatment for Tourette disorder
- Dopamine-depleting agents→tetrabenazine►VMAT-2 inhibitor►↓monoamines uptake
- Preferred over dopamine-blocking agents; not cause tardive dyskinesia
- Dopamine antagonists (Antipsychotics)→Haloperidol, Pimozide, Risperidone
- Alpha-2 agonist→Clonidine
Best alternative in a patient with depression and neuropathic pain
Duloxetine→SNRI
*Also tricyclic antidepressant (amitriptyline)
Best indications of Bupropion in a patient with major depressive disorder
- Fearful of weight gain with SSRI
- Fearful of sexual side effects or SSRI-induced sexual side effects
- Smoker trying to quit
Indications of Electroconvulsive therapy in depression
- Initial therapy did not work
- Severe depression associated with psychotic symptoms
When do you use Mirtazapine for major depressive disorder? How does it work?
Patient with insomnia and weight loss (appetite-stimulating)
*α2-antagonist→↑release NE, 5-HT, potent 5-HT2, 5-HT3 receptor antagonist, H1 antagonist→antidepressant and sedative effects
Treatment for acute mania with severe symptoms
Atypical antipsychotics→shorter onset of action►Olanzapine, Lurasidone, Quetiapine, etc
Treatment of acute mania
Lithium, Valproic Acid, Atypical antipsychotics
Best treatment for depression
Electroconvulsive therapy
Which disorder may develop in adulthood the children with disruptive mood dysregulation disorder (DMDD)?
Depression or Anxiety
What is the Disruptive mood dysregulation disorder (DMDD)?
Severe recurrent verbal (scream) or behavioral (physical aggression) outbursts out of proportion of the situation + persistent irritability, angry mood between outbursts for >1 year
Contraindication of Bupropion
Eating disorders and seizure disorders (↓Seizure threshold)
Mania or Hypomania treatment during pregnancy
- Typical antipsychotics (eg, haloperidol)
- Electro Convulsive Therapy for severe or refractory mania
Characteristic polysomnographic finding in Major Depressive Disorder. Which are other sleep findings?
- ↓REM sleep latency (time from sleep onset until the start of first REM sleep period)►biomarker of depression
- ↓Slow-wave sleep (deep sleep), ↑REM sleep duration and density, disruptions in sleep continuity
How can you differentiate postpartum depression from postpartum blues?
- Postpartum depression➡onset since 4 wks, function impairment
- Postpartum blues➡onset in days, self-limited to 2 wks, milder symptoms, no function compromised
Treatment of postpartum depression
SSRI (Sertraline preferable during lactation) + Psycotherapy
Treatment options of Tardive Dyskinesia
- ⬇Antipsychotic dose
- Valbenazine, Deutetrabenazine➡reverse inhibitors of the vesicular monoamine transporter 2 (VMAT2)
- Switching (cross-tapering) to an antipsychotic with lower tendency for TD➡Quetiapine, Clozapine
First step in patients with depression
Screen for suicidal risk➡ indicates appropriate treatment setting and frequency of follow-up care
- Plan and intent to act➡Hospitalization
- Ideation without a specific plan or intent➡intensive outpatient treatment
*Screen before initiating antidepressants drugs
Side effects of atypical antipsychotics
- “pines” (Olanzapine, Clozapine, etc)➡⬆risk of weight gain, metabolic syndrome, diabetes
- “dones” (Risperidone, Lurasidone, etc)➡⬆risk of movement disorders (Risperi-), cardiac conduction problems (Ziprasi-)
- Aripiprazole➡compulsive behavior (gambling)
Specific side effects of Clozapine, what you must watch during treatment? What is its main indication?
- Agranulocytosis (monitor WBCs frequently), seizures (dose-related), myocarditis
- Resistant schizophrenia or schizoaffective disorder, and for suicidality in schizophrenia
What is the first-line treatment for alcohol abstinence?
Naltrexone (block μ-opioid receptor)➡⬇the craving for alcohol
*Given to patients who are still drinking
First-line treatment for acute bipolar depression
- Second-generation antipsychotics: Quetiapine, Lurasidone
- Lamotrigine, Lithium, Valproate, combination olanzapine + fluoxetine
*Avoid first-line antidepressants (fluoxetine)➡⬆risk inducing mania or hypomania
Medications options for Binge eating disorder. What is the most effective treatment option?
- SSRI, Lisdexamfetamine, Topiramate
- Cognitive-behavioral therapy
What is the paradoxical agitation adverse effect of benzodiazepines? Which is the management?
- Recurrent episodes of ⬆ agitation, confusion, aggression, and disinhibition within one hour of administration
- Taper and discontinuation
*⬆Risk in elderly
Treatment for Major depressive disorder with psychotic features
- Nonemergency➡Antidepressant + antipsychotic (Ex, sertraline + risperidone)
- Emergency (severe suicidality, refusing to eat, dehydration)➡Electroconvulsive therapy (ECT)
*Antipsychotic monotherapy or antidepressant monotherapy is not well effective
Maintenance treatment for severe bipolar disorder with frequent mood episodes
First-line combination therapy: Lithium or Valproate + second-generation antipsychotic (ex, quetiapine)
Best next step when patients have no significant response or unacceptable tolerability with first-line antidepressant trial
- Switch to a different antidepressant rather than augmentation with a second agent
- Add second agent in partial response with first drug and without side effects
*Decision-based upon specific depressive symptoms and side effects; Ex: SSRI (no response and/or sexual dysfunction)🔄Bupropion
Treatment for ADHD
- 4–5 years of age: Best initial treatment➡Behavior therapy. Add drugs if no improvement
- ≥ 6 years of age: Best initial treatment: Pharmacologic therapy + behavior therapy
■ First line: CNS stimulants (methylphenidate, dextroamphetamine)
■Alternatives: Nonstimulants
*Atomoxetine (norepinephrine reuptake inhibitor): Might be first-line to avoid side effects of CNS stimulants
*Clonidine/guanfacine (α2-agonist) [limited use in adults], bupropion, TCAs
What is selective mutism?
Refusal to speak in a specific social situation (Ex, school)
*Dx requires >1 month. Considered Anxiety disorder, frequently comorbid with social anxiety disorder
What abnormality in the CSF of depressive patients with suicidal behavior you may find?
⬇Hydroxyindoleacetic acid (5-HIAA)➡associated with suicidal behavior
*Primary metabolite of serotonin➡ modulates mood and behavior
Marker of narcolepsy in the CSF
⬇Hypocretin-1/Orexin-A
What is the REM sleep behavior disorder?
Complex motor behaviors during REM sleep
- Degeneration of brainstem nuclei that inhibits spinal motor neurons during REM sleep➡⬇or❌muscle atonia▶dream enactment
- Latter half of the night in older adult men
- Easy to awake alert and oriented, recall the dreams
Which diseases might be associated with REM sleep behavior disorder (RBD)?
Prodromal sign of α-synuclein neurodegenerative disorders➡ Parkinson’s disease, dementia with Lewy bodies, multiple system atrophy
*Look for other signs/symptoms of neurodegeneration▶subtle motor deficits (slowed gait), anosmia, constipation
What type of sleep disorders are sleep terrors and sleepwalking? How do you identify them?
- Non-REM sleep arousal disorder
- Younger patients, slow-wave (N3) non-REM sleep
- First third of the sleep period, long period of confusion, do not recall concurrent dreams
Antipsychotics with the highest potential to cause infertility
- First-generation: Haloperidol, fluphenazine
- Second generation: Risperidone, palliperidone (metabolite of risperidone)
Dopamine-2 receptor blockers➡⬆Prolactin➡menstrual irregularities, galactorrhea, infertility
Antipsychotics with lower probability to produce infertility
- Aripiprazole (partial DR2 agonist)
- Quetiapine (low potency DR2 antagonist)
*Less likely to produce hyperprolactinemia
Type of tremor associated with lithium side effects vs lithium toxicity
- Lithium side effect▶Physiologic tremor: fine action tremor that worsens with stress (⬆sympathetic activity or medications), symmetric, upper limbs➡⬆iron accumulation in substantia nigra
- Lithium toxicity▶irregular, coarse tremor in multiple parts of the body + GI or more neurologic symptoms (require dialysis)
Treatment of choice for alcohol withdrawal in patients with significant liver disease
- Benzodiazepines without active metabolites and with hepatic metabolism via phase II glucuronidation instead of cytochrome P450 oxidation
- Oxazepam, temazepan, lorazepan (IV presentation)
Inability to restrain aggressive impulses resulting in verbal or physical aggression that is out of proportion of the provocation, impulsive outburst episodes lasting <30 minutes with immediate relief followed by remorse, dysphoria and embarrassment
Intermittent explosive disorder
*Impulse-control disorder
First-line treatment for obsessive-compulsive disorder (OCD)
- SSRI (Fluoxetine, Fluvoxamine, Sertraline)
- Cognitive-behavioral therapy (CBT)
Clinical presentation of cocaine withdrawal
Acute onset depression with pronounced fatigue (crash) following a period of increased energy (high)
- Severe depression with suicidal ideation
- Psychomotor slowing
- Hypersomnia
- ⬆dreaming
- Hyperphagia
- ❌concentration
- Intense drug craving
Pharmacologic therapy for patients with alcohol use disorder
- First line:
- Naltrexone (mu-opioid receptor antagonist)➡contraindicated in liver disease and opioid use
- Acamprosate (glutamate modulator)➡preferred in liver disease or opioid use (requires adjustment in renal failure)
- Second line
- Disulfiram (aldehyde dehydrogenase inhibitor)➡second-line therapy in highly motivated patients
Physical examination and laboratory findings suggesting heavy alcohol use
Macrocytic anemia, AST:ALT >2:1, parotid gland enlargement
Most common deficient minerals in patients with alcohol use disorder
- Hypomagnesemia
- Zinc
- Iron
*Relative hyponatremia and hypocalcemia can happen as well but less common
Treatment for posttraumatic stress disorder-related nightmares
Prazosin▶⬇adrenergic hyperactivity➡⬇nightmares frequency
*Helpful as an adjunct to SSRI and SNRI
Best next step when a patient has responded to oral antipsychotic but relapses frequently due to medication nonadherence
Long-acting injectable antipsychotic
Treatment for Body dysmorphic disorder
- SSRI (first line), eg, Escitalopram. Typically significantly high doses
- Cognitive-behavioral therapy
Best next step if office urine drug screen comes out positive for PCP, and patient is taking control prescription correctly and refuses to be using recreational drugs or PCP
Obtain additional urine study➡Confirmatory testing (gas chromatography with mass spectroscopy)
*Common OTC (dextromethorphan, diphenhydramine, ibuprofen) can cause false-positive for PCP [might forget to reveal]
Best next step for a patient with the first trial of SSRI failure, and history of bulimia nervosa
- SNRI (Venlafaxine) if had adequate first trial (adequate dose ≥ 6 weeks)
- Bupropion is wrong because increases the risk of seizures in patients with active or historical bulimia or anorexia (potential electrolyte disturbance)
Most commonly associated inherited syndrome with autism spectrum disorder
Fragile X syndrome
*Unstable trinucleotide (CGG) repeat expansion in the FMR1 gene on the X chromosome
Best next step in an acutely psychotic patient who already received an antipsychotic dose and persists with agitation. Patient has an ECG with QTc interval 505ms.
- Given the potential class effect of antipsychotics on the QTc interval (increasing risk of dysrhythmias), benzodiazepine should be used (Lorazepam)
- Physical restraints only is wrong, they should be accompanied by chemical sedation
Polysomnography finding characteristic for Narcolepsy
Decreased REM latency
*Decreased REM density is wrong, it has Increased REM density
