Psychiatry Flashcards
ADHD typically presents between ages?
Ages 3-13
How do you diagnose ADHD?
Require 5 or more symptoms of inattention/hyperactivity for 6 or more months in at least 2 different settings leading to significant social/academic impairments. Symptoms must be present before age 12.
What are the symptoms of inattention?
- Poor attention span in school work/play 2. poor attention to detail/careless mistakes
- difficulty following instructions and completing tasks
- forgetful and easily distracted.
Symptoms of hyperactivity/impulsivity?
- fidgets
- leaves seat in classroom
- runs around inappropriately
- cannot play quietly
- talks excessively
- does not wait for his/her turn
- interrupts others
Are sugar and food additives considered contributory to ADHD?
NO
Initial treatment for ADHD?
Behavioral modification
Pharmacological Stimulant treatments for ADHD?
- Methylphenidate (Ritalin)
- Dextroamphetamine (Dexedrine)
- Mixed Dextroamphetamine and Amphetamine (Adderall)
Non-stimulant Pharm therapy for ADHD?
- SSRI’s
- nortriptyline
- Buproprion
- a2 agonists - clonidine
- Atomoxetine (Strattera) (NeRI)
Autism Spectrum Disorder
Persistent impairment in socialization, communication, behavior more common in males.
How is severity of Autism Spectrum Disorder determined?
Based on level of support needed in psychopathological and communication and repetitive behavioral domains.
When you see a patient or Qstem with ASD what other disorders should you think about?
Rett syndrome, tuberous sclerosis, Fragile X syndrome
Rett Syndrome
X-linked disorder seen almost exclusively in girls (affected males typically die in utero or shortly after birth)
Symptoms become apparent between ages 1-4, including regression characterized by loss of development, loss of verbal abilities, intellectual disability, ataxia, stereotyped hand-wringing
Tuberous Sclerosis
Tuberous sclerosis complex (TSC) is a rare multisystem genetic disease (Incomplete penetrance, variable expression) that causes benign tumors to grow in the brain and on other vital organs such as the kidneys, heart, liver, eyes, lungs, and skin. A combination of symptoms may include seizures, intellectual disability, developmental delay, behavioral problems, skin abnormalities, and lung and kidney disease. TSC is caused by a mutation of either of two genes, TSC1 and TSC2, which code for the proteins hamartin and tuberin, respectively. These proteins act as tumor growth suppressors, agents that regulate cell proliferation and differentiation.
Fragile X Syndrome
X-linked defect affecting methylation and expression of FMR1 gene. 2nd most common cause of intellectual disability after Downs Syndrome. Associated with post-pubertal macro-orchidism, long face with a large jaw, large everted ears, autism, mitral valve prolapse.
ASD is characterized by impaired social interaction, communication, with restricted activities and interests apparent by age __
3
Treatment for ASD
Intensive special education, behavioral management, symptom targeted medications, family support and counseling
What medications are used for aggression in ASD?
neuroleptics (antipsychotics)
What meds are used for stereotyped behaviors in ASD?
SSRIs
What are the disruptive behavioral disorders?
Conduct and Oppositional Defiant
ODD
Pattern of negative, defiant, disobedient, hostile behavior toward authority figures for more than 6 months. May progress to conduct disorder
Conduct disorder
Repetitive, persistent pattern of violating basic rights of others or age appropriate societal norms/rules for over 1 year. Behaviors can be aggressive (rape, robbery, cruelty) or non-aggressive (stealing, lying, deliberately annoying ppl)
Conduct disorder can progress to ___ in adulthood?
Antisocial personality disorder
Treatment for ODD and conduct disorder?
Individual and Family Therapy
Most common avoidable cause of intellectual disability?
Fetal Alcohol Syndrome
Intellectual development disorders are associated with?
- male gender
- chromosome abnormalities
- metabolic disease
- alcohol/substance use
- congenital infections
IQ score to qualify or impaired intellectual functioning? Onset before?
IQ < 70; onset before age 18
IQ score for mild, moderate, severe, profound intellectual disability?
mild (IQ 50-70)- 85% of cases
moderate (35-49)
severe (20-34)
profound (< 20)
Primary prevention for intellectual disability?
Educating general public about causes
Prenatal screening
Treatment measures for ID?
Family counseling and support Speech and language therapy Occupational and physical therapy Behavioral intervention Education assistance Social Skills training
Tourette Syndrome is more common in?
More common in men and boys
Tourette Syndrome is associated with?
ADHD, learning disorders, OCD
Tourette is characterized by?
Multiple motor tics (blinking, grimacing) Vocal tics (grunting, coprolalia)- many times/day, recurrently for > 1 year with social or occupational impairment
Tourettes begins before?
Age 18
Coprolalia
Repetition of obscene words
Treatment for Tourette’s?
Dopamine receptor antagonists (haloperidol, pimozide)
OR clonidine
Behavioral therapy can be of benefit and counseling can aid in social adjustment and coping
What pharmaceuticals can worsen tics?
Stimulants
Schizophrenia is characterized by?
- Psychotic symptoms (hallucinations, bizarre delusions)
- Disorganization (thought disorder and behavioral disturbance)
- Negative symptoms (poverty of affect, thought, social interaction)
Prevalence of schizophrenia? male:female?
1% equal in men and women?
Peak onset in men/ peak onset in women?
Men: 18-25
Women: 25-35
Risk of schizophrenia is increased in people who have?
First degree relatives with the disease
% of patients that attempt/complete suicide?
50% attempt. 10% complete
Etiologic theories of schizophrenia?
Neurotransmitter abnormalities- dopamine dysregulation (frontal hypoactivity, limbic hyperactivity) and CT/MRI abnormalities (enlarged ventricles, decreased cortical volume)
How do you diagnose schizophrenia?
2 or more of the following characteristics are present for 6 or more months and result in social or occupational dysfunction.
- Positive Symptoms: hallucinations (often auditory), delusions, disorganized speech, bizarre behavior, thought disorder
- Negative Symptoms: flat affect, decreased emotional reactivity, poverty of speech, lack of purposeful actions, anhedonia
delusion
fixed, false, idiosyncratic belief
hallucination
perception without an existing external stimulus
illusion
misperception of an actual external stimulus
Differential diagnosis of psychosis?
Divide into psychotic, personality, delusional, medical
- Psychotic
- Brief psychotic disorder
- Schizophreniform
- Schizophrenia
- Schizoaffective - Personality
- Schizotypal
- Schizoid - Delusional disorder
- Medical/Organic/Substance Induced
Brief psychotic disorder
> 1 day and < 1 month
Usually preceded by stressors, usually without negative symptoms, no prior episodes, better prognosis
Schizophreniform
> 1 month and <6 months
Usually preceded by stressors, usually without negative symptoms, no prior episodes, better prognosis
Schizophrenia
> 6 months
Schizoaffective disorder
Schizophrenia + major affective disorder (MDD or Bipolar affective disorder)
Schizotypal
“Magical thinking”
Schizoid
“Loners”
Delusional Disorder
Persistent, fixed delusions, without disorganized thought process, hallucinations or negative symptoms of schizophrenia. Day to day functioning is typically unaffected.
Subtypes of delusional disorder?
Jealous, Paranoid, Somatic, Erotomanic, Grandiose.
Treatment for schizophrenia
Antipsychotics (atypicals are 1st line)
Supportive psychotherapy, training in social skills, vocational rehab, illness education
Evolution of Extrapyramidal symptoms with antipsychotic meds?
4 hours: acute dystonia (sustained muscle contraction)
4 days: akinesia (impairment in voluntary movement)
4 weeks: akathesia (agitation, stress, restlessness)
4 months: tardive dyskinesia (often permanent, involuntary movement of tongue, lips, face, trunk)
High potency typical antipsychotics?
Haloperidol, Fluphenazin
come in depot long acting forms
Low potency typical antipsychotics?
Thioridazine, Chlorpromazine
Indications for typical and antipsychotics?
psychotic disorders, acute agitation, acute mania, tourette syndrome
Antipsychotics are more effective for ___ symtoms of schizophrenia based on mechanism of?
Positive symptoms. Block D2 receptors in limbic cortex
Side effects of high potency typical antipsychotics (haloperidol/fluphenazine)?
EPS > anticholinergic
Qtc prolongation and torsades (esp IV haloperidol)
NMS
Side effects of low potency typical antipsychotics (thioridazine, chlorpromazine)
Anticholinergic > EPS
More sedative
Greater risk of orthostatic hypotension
Thioridazine causes dose dependent Qtc prolongation and irreversible retinal pigmentation
Atypical antipsychotics
Risperidone (available in depot form), quetiapine, olanzapine, ziprasidone, aripiprazole, clozapine)
Indication for atypical antipsychotics?
1st line for schizophrenia due to less EPS and anticholinergic effects
Indication for Clozapine?
Reserved for severe treatment resistant schizophrenia and severe tardive dyskinesia
Side effects of Clozapine?
Agranulocytosis- requiring weekly CBC monitoring during first 6 mo
Side effects of atypical antipsychotics
weight gain, type II DM, metabolic syndrome, somnolence, sedation, Qtc prolonging
Acute dystonia
Onset: 4 hours. Characterized by prolonged, painful tonic muscle contraction or spasm
(torticollis- neck muscle contraction to 1 side)
(oculogyric crisis- prolonged upward gaze)
Treatment for acute dystonia?
Anticholinergics (benztropine, diphenhydramine) (acute therapy or prophylactic dosing)
Dyskinesia
Onset: 4 days. Pseudoparkinsonism with shuffling gait, cogwheel rigidity.
Treatment for dyskinesia
Dopamine agonist (amantadine) or anticholinergic (benztropine) Discontinue antipsychotic or lower dose if possible
Akathisia
Onset: 4 weeks. subjective/objective restlessness or agitation
Treatment for akathisia?
Decrease or discontinue antipsychotic
Beta-blocker (propranolol)
Benzos or anticholinergics may help
Tardive dyskinesia
Onset: 4 months. Stereotypic, involuntary, painless oral-facial movements. Likely from D2 receptor sensitization from chronic D2 blockade. Irreverisble 50% of time.
Treatment for tardive dyskinesia?
Discontinue or decrease dose of antipsychotic
Attempt treatment with other drugs
Consider treating with Clozapine or Risperidone
(Giving anticholinergics or decreasing neuroleptics can initially worsen tardive dyskinesia)
Neuroleptic Malignant Syndrome
Can occur anytime. Fevers, muscle rigidity, autonomic instability, elevated CK and WBC, clouded consciousness.
Treatment for NMS?
Stop medication! Supportive care in ICU. Dantrolene (ryanodine receptor; decreases excitation contraction coupling) or Bromocriptine (DA agonist).
Diagnosing Anxiety disorder
uncontrollable, excessive anxiety or worry about multiple activities or events that leads to significant impairment or distress. presents with anxiety on most days for 6 or more months and with 3 or more somatic symptoms (restlessness, fatigue, difficulty concentrating, irritability, muscle tension, disturbed sleep)
Short term treatment
Benzodiazepines: immediate symptom relief and should be tapered as soon as long term therapy is established
Never stop “cold turkey” due to potentially lethal withdrawal symptoms
Long term therapy
Lifestyle changes
Psychotherapy
Medications: SSRI (first-line), venlafaxine (SNRI), buspirone (full and partial agonist at serotonin receptors)
What drugs used to treat anxiety should not be used in combo with MAOIs?
SSRIs and Buspirone
Panic disorder
Recurrent, unexpected panic attacks, 2-3X more common in women. Patients present with 1 or more months of concern about having additional attacks or behavioral changes as a result of attacks.
Agoraphobia
“fear of the marketplace” fear of being alone in public places. fear of places/situations that may cause panic- present in 30-50% of cases of panic disorder.
Panic attack
Discrete period of intense fear or discomfort where at least 4 of the following symptoms develop abruptly and peak within 10 minutes.
-tachypnea, chest pain, palpitations, diaphoresis, nausea, trembling, dizziness, fear of dying, depersonalization, hot flashes
What symptoms are fairly specific to panic attacks and cause hyperventilation/low O2 sat?
Perioral and or acral (peripheral) paresthesias.
Differential diagnosis of panic disorder?
Angina, MI, arrythmias, hyperthyroidism, pheochromocytoma, substance-induced anxiety, GAD, PTSD
Treatment for panic disorder?
short term: benzo
long term: SSRI (1st line), CBT, TCAs
Qualifier for schizoaffective disorder?
Need at least 2 weeks where psychotic symptoms are present without any mood symptoms.
Do patients recognize fear is excessive when they have a phobia?
YES
Treatment for specific phobia?
CBT involving desensitization through incremental exposure to feared object or situation along with relaxation techniques
Treatment for social phobia?
CBT, SSRIs, low-dose benzo, B-blocker for performance anxiety
Obsessions
Persistent, unwanted, intrusive ideas, thoughts, impulses, images that lead to anxiety or distress (fear of contamination, fear of harm to oneself or to loved ones)
Compulsions
Repeated mental acts or behaviors, neutralize anxiety from obsessions. (handwashing, elaborate rituals for ordinary tasks, counting, excessive checking)
For patients with OCD, do they recognize behaviors as excessive and irrational?
YES (ego dystonic) Patients recognize obsessions and compulsions and would like to get rid of them.
Treatment for OCD
SSRIs - 1st line
CBT- exposure/desensitization
body dysmorphic disorder
characterized by preoccupation with imagined or slight defects in physical appearance that are usually imperceptible to others. leads to distress/impairment. actions and behaviors are obsessive and repetitive (mirror checks, comparisons)
Treatment for body dysmorphic?
SSRIs
SSRIs?
fluoxetine, sertraline, paroxetine, citaloparm, escitalopram
Anxiety related indications for SSRIs?
GAD, OCD, panic disorder, body dysmorphic disorder, social phobia
SSRI side effects
nausea, GI upset, somnolence, sexual dysfunction, agitation
Buspirone indication?
Benefit related to pharmacology?
GAD, social phobia
No tolerance, dependence or withdrawal due to full/partial agonist
B-blocker indication for anxiety disorders?
side effects?
Phobic disorders (give prior to exposure) side effects: bradycardia, hypotension
Benzodiazepines indication for anxiety?
acute anxiety, insomnia, alcohol withdrawal, muscle spasm, night terrors, sleep walking
PTSD
Clinically significant stress/impairment as a result of direct exposure to an extreme life-threatening traumatic event, witnessing a traumatic event, indirect exposure through learning of a life-threatening event involving a close family member or friend
Top causes of PTSD in male patients
- sexual assualt 2. combat
Top causes of PTSD in female patients
- childhood abuse 2. sexual assault
Diagnosis of PTSD?
characterized by following 4 symptom clusters: Symptoms must exist for > 1 month
- intrusion- reexperiencing event through nightmares, flashback, intrusive memory
- avoidance- stimuli associated with trauma
- negative alterations in mood/cognition (numbness)
- heightened arousal (hypervigilence), sleep disturbance, aggression, irritability, poor concentration
Same symptoms as PTSD for 3 days to 1 month?
Acute stress disorder
Treatment for PTSD?
short-term: B-blocker and a-agonist
long-term: SSRIs, buspirone, TCAs, MAOIs
Psychotherapy and support groups are useful
Adjustment disorder
Clinically significant distress following a profound life change. Divorce, unemployment, financial issues, romantic break up)
Diagnosing adjustment disorder
not severe enough to meet criteria for another mental disorder. occurs within 3 months after onset of stressor, can place person at higher risk for suicidality. Symptoms can be anxiety, depressed mood, issues in conduct. Resolves with 6 months of onset.
Treatment for adjustment disorder?
Supportive counseling. NO PHARM TREATMENT
Causes of Dementia
Mnemonic (DEMENTIASS)
Degenerative: Parkinson, Huntington
Endocrine: thyroid, parathyroid, pituitary, adrenal
Metabolic: alcohol, electrolytes, vitamin B12, glucose, hepatic, renal, Wilson disease
Exogenous: heavy metals, carbon monoxide, drugs
Neoplasia:
Trauma:
Infection: meningitis, encephalitis, endocarditis, syphilis, HIV, prion disease, lyme disease
Affective disorder: pseudodementia
stroke/structural: vascular dementia, ischemia, vasculitis, normal pressure hydrocephalus
Dementia AKA major neurocognitive disorder
Decline in cognitive functioning with global deficits. level of consciousness is stable. persistent and progressive course most common among those > age 85.
2 most common causes of dementia?
Alzheimers (65%) and Vascular (20%)
Diagnosis of dementia?
memory impairment and 1 or more of the following:
- 4 A’s of dementia following this order: amnesia (partial or total), aphasia (language impairment), apraxia (inability to perform motor activities), agnosia (inability to recognize previously known objects/people)
- impaired executive function
- personality, mood, behavioral changes (wandering and aggression)
How to diagnose dementia?
serial mini mental state exams should be performed.
rule out treatable causes of dementia with CBC, RPR, CMP, TFTs, HIV, B12/folate, ESR, UA, head CT or MRI.
Treatment for dementia?
Provide environmental cues and rigid structure for patient’s daily life.
Cholinesterase inhibitors
Low-dose antipsychotics for behavioral disturbances
AVOID BENZO
Major causes of delerium?
Mneumonic
“I WATCH DEATH”
Infection Withdrawal Acute metabolic/substance abuse Trauma CNS pathology Hypoxia Deficiencie Endocrine Acute Vascular/MI Toxins/Drugs Heavy Metals
Delirium
acute disturbance of consciousness with altered cognition
Presentation of delerium
acute onset of waxing and waning consciousness with lucid intervals and perceptual disturbances (hallucinations, illusions, delusions); decreased attention span, short term memory, reversed sleep wake cycle and increased symptoms at night (sundowning)
Is it common for delerium to be superimposed on dementia?
YES
How to diagnose delerium?
check vitals, pulse ox, glucose, UA, provide physical and neuro exam, check recent meds, substance use, prior episodes, organ failure, infection (occult UTI is common in elderly)
Treatment for delerium
Treat underlying cause (often reversible)
Normalize fluids/electrolytes
Optimize sensory environment and provide necessary and visual hearing aids
Use low dose antipsychotics (haloperidol) for agitation and psychotic symptoms
Conservative use of physical restraints may be needed to prevent harm to patient or others
Major Depressive Disorder
Mood disorder characterized by 1 or more major depressive episodes
Symptoms of depressive episode?
Sleep (hypersomnia/insomnia) Interest Guilt or feeling worthless Energy or fatigue Concentration Appetite or weight changes Psychomotor agitation or retardation Suicidal ideation
Diagnosis of MDD
Diagnosis requires Depressed Mood or Anhedonia and five or more signs/symptoms from SIG E CAPS for a 2 week period.
Name the depression sub-types
- Psychotic features (typically mood congruent hallucinations/delusions)
- postpartum: within 1 month
- Atypical: weight gain, hypersomnia, rejection sensitivity
- Seasonal: depressive episodes during particular season. can respond well to light therapy with or without antidepressants
- Double depression: MDE in a patient with dysthymia (poorer prognosis than MDE alone)
Differential diagnosis of major depression.
- mood disorder due to medical condition (hypothyroidism, parkinson disease, CNS neoplasm, other neoplasms, stroke, dementias, parathyroid disorder)
- substance induced: drugs, alcohol, anti-HTN, corticosteroids, OCPs
- Adjustment disorder with depressed mood: constellation of symptoms that resemble MDE but dont meet criteria and occur within 3 months of life stressor
- normal bereavement: after loss of loved one. no severe impairment/suicidality. usually lasts < 6 months, should resolve w/in 1 year. may lead to MDD (illusions, hallucinations of deceased can be normal as long as patient recognizes them as such
- Dysthymia: milder, chronic depression with depressed mood most of time for at least 2 years. often resistant to treatment.
How long should you allow pharm to take effect for MDD? How long to continue treatment for?
- 2-6 weeks
- Continue treatment for 6 months
Treatment for MDD
Pharmacotherapy plus Psychotherapy
Indication for ECT
Refractory depression, psychotic depression, severe suicidality, intractable mania, psychosis, safe during pregancy
Treatment course for ECT?
2-3 X/week for 6-12 treatments
Contraindications for ECT?
no absolute contraindications. relative contraindications include recent stroke/MI, intracranial mass, high anesthetic risk.
How long to wait after stopping SSRI to begin MAOI treatment?
2 weeks. 5 weeks for fluoxetine due to longer half life.
Differential diagnosis for postpartum disorders?
- postpartum blues: within 2 weeks of delivery. sadness, moodiness, emotional lability
- postpartum psychosis: 2-3 weeks post. delusions and depression. may have thoughts about harming baby.
- postpartum depression: 1-3 months post delivery. sadness, moodiness, emotional lability, sleep disturbances, anxiety, may have thoughts about harming baby.
Serotonin Syndrome
fever, myoclonus, mental status change, cardiovascular collapse,
Why should you avoid paroxetine in pregnancy?
Can cause pulmonary HTN in fetus.
Side effects/contraindications of buproprion?
decrease seizure threshold, minimal sexual side effects, contraindicated in patients with eating disorders, and seizure patients
SE/contraindications for mirtazapine?
weight gain, sedation
SE trazodone?
highly sedating, priapism
SNRIs
Venlafaxine, Duloxetine
Indication/SE for SNRIs
depression, anxiety, chronic pain.
Venlafaxine: diastolic HTN
TCAs
Nortriptyline, Desipramine, Amitriptyline, Imiprimine
Indications for TCAs
depression, anxiety, chronic pain, migraine, enuresis (imiprimine)
SE/contraindications to TCAs
Lethal with overdose due to cardiac conduction arrhythmias. (prolonged conduction through AV node. long QRS) need to be monitored in ICU for 3-4 days following overdose.
Anticholinergic effects: dry mouth, constipation, urinary retention, sedation.
MAOIs
Phenelzine, Tranylcypromine, Selegiline (patch form available)
Indications for MAOIs
Depression (esp atypical)
SE MAOI
HTN crisis if taken with high tyramine foods (aged cheese, red wine)
Sexual side effects, orthostatic hypotension, weight gain
Bipolar disorder avg age onset?
20
Bipolar I
involves at least 1 manic or mixed episode often requiring hospitalization
Bipolar II
at least one MDE and one hypomanic episode (characterized predominantly by depression with occasional hypomanic episodes)
Rapid cycling
4 or more episodes (MDE, mixed, manic, hypomanic) in 1 year
Cyclothymic
chronic and less severe with alternating periods of moderate depression and hypomania for > 2 years
Clinical presentation of mania? DIG FAST
distractibility insomnia grandiosity flight of ideas activities/agitation sexual indiscretion/pleasure seek talkativeness/pressured speech
What pharm intervention may trigger mania?
Antidepressant use without mood stabilizer
How to diagnose manic episode?
1 week of persistently elevated, expansive or irritable mood plus three DIG FAST symptoms. Psychotic symptoms are also common with mania.
Diagnose hypomania?
Similar but does not involve marked functional impairment, psychotic symptoms and does not require hospitalizations.
Treatment for bipolar mania?
Acute: antipsychotics, lithium, valproate
maintenance therapy: mood stabilizer (benzo for refractory agitation)
Treatment for bipolar depression
mood stabilizers with or without antidepressants
1st line mood stabilizer? 2nd line?
- Lithium 2. Carbamazepine, Lamotrigine
Lithium side effects
thirst, polyuria, diabetes insipidus, tremor, weight gain, hypothyroid, nausea, diarrhea, seizures, teratogenicity (ebstein anomaly), acne, vomiting.
Lithium toxicity
narrow therapeutic window
Toxic > 1.5. Present with ataxia, dysarthria, delirium, acute renal failure. Avoid lithium in patients with decreased renal function.
Indication for carbamazepine?
2nd line mood stabilizer, anticonvulsant, trigeminal neuralgia
SE carbamazepine?
nausea, skin rash, leukopenia, AV block, teratogenicity (neural tube), rarely aplastic anemia (monitor CBC biweekly). SJS!
Indications Valproic acid?
BPD, anticonvulsant
SE Valproic acid
GI- nausea, vomit
tremor, sedation, alopecia, weight gain, teratogenicity (neural tube), pancreatitis, thrombocytopenia, fatal hepatotoxicity, agranulocytosis.
Lamotrigine indications and side effects
2nd line mood stabilizer, anticonvulsant
SE: blurred vision, SJS, GI distress. increase dose slowly to monitor for rashes.
Personality Disorders
One’s traits become chronically rigid and maladaptive. Onset occurs by early adulthood
Cluster A personality disorders
Paranoid, Schizoid, Schizotypal
Paranoid personality disorder
distrustful, suspicious, interpret others’ motives as malevolent.
Schizoid
isolated, detached, “loner”, restricted emotional expression
Schizotypal
odd behavior, perceptions, appearance. magical thinking. ideas of reference. (lack delusions/hallucinations that would classify them as schizophrenic)
Cluster B personality disorders
Borderline, histrionic, narcissistic, antisocial
borderline
unstable mood, relationships, self-image; feelings of emptiness. impulsive. history of suicidal ideation or self-harm. splitting used as a defense mechanism
histrionic
excessively emotional and attention seeking. sexually provocative, theatrical.
narcissistic
grandiose, need admiration, have sense of entitlement, lack empathy
antisocial
violates rights of others, social norms and laws. impulsive. lacks remorse. must have prior diagnosis of conduct disorder.
Cluster C personality disorders
OCPD, avoidant, dependent
OCPD
preoccupied with perfectionism, order, control at the expense of efficiency. inflexible morals and values. egosyntonic. don’t feel behavior is problematic
Avoidant
socially inhibited, rejection sensitive. fear of being disliked or ridiculed, yet desires to have friends and social interactions
dependent
submissive, clingy, have a need to be taken care of, have difficulty making decisions, feel helpless
Treatment for personality disorders
psychotherapy is mainstay of treatment
pharmacotherapy for cases with comorbid mood, anxiety, psychotic signs/symptoms
Diagnosis of substance use disorder?
Meet 2 out of 11 following criteria over a 1 year period.
- impaired control
- consumption of greater amounts of substance than intended
- failure to cut back/abstain
- increased amount of time spent acquiring, using, recovering
- craving - Social impairment
- failure to fulfill responsibilities at work, school or home
- continued substance use despite recurrent social/interpersonal problems
- isolation from life activities - Risky use
- use in hazardous situations
- recurrent use despite physical/psych problems - Pharmacologic
- Tolerance: use of progressively larger amounts to obtain same desired effect
- Withdrawal: symptoms when not taking substance
How do you determine severity of substance use disorder?
of symptoms present:
Mild: 2-3
Mod: 4-5
Severe: >6
Diagnosis of alcohol use disorder?
CAGE question screening.
Vital signs for evidence of withdrawal
Increased LFTs, LDH, MCV
CAGE
C: cut down on drinking?
A: annoyed by criticism of drinking?
G: guilty about drinking?
E: morning eye opener?
more than 1 yes makes alcoholism likely
Treatment for alcohol use disorder
- rule out medical complications, correct electrolyte abnormalities
- start benzodiazepine taper for withdrawal
- add haloperidol for hallucinations and psychotic symptoms
- give multivitamins and folic acid, administer thiamine before glucose (glucose depletes thiamine) to prevent Wernicke encephalopathy
- give anticonvulsants to patients with seizure history
- group therapy, disulfuram, naltrexone can aid patients with dependence
- long-term rehab therapy (AA)
Complications from alcohol use disorder?
GI bleeding from gastritis, ulcers, varices, mallory weiss tears, pancreatitis, liver disease, DTs, alcoholic hallucinosis, peripheral neuropathy, Wernicke encephalopathy, Korsakoff psychosis, fetal alcohol syndrome, cardiomyopathy, anemia, aspiration pneumonia, increase trauma risk
Alcohol intoxication/withdrawal symptoms
I: disinhibition, emotional lability, slurred speech, ataxia, aggression, blackouts, hallucinations, memory impairment, impaired judgement, coma
W: tremor, tachy, hypertension, malaise, nausea, seizure, DTs, agitation
Opioids I/W
I: Euphoria leading to apathy, CNS depression, constipation, pupil constriction, Resp depression (life-threatening in overdose)
W: dysphoria, insomnia, anorexia, myalgia, fever, lacrimation, diaphoresis, dilated pupils, rhinorrhea, piloerection, nausea, vomit, stomach cramp, diarrhea, yawning
Naloxone and Naltrexone
block opioid receptors and reverse effects but beware of antagonist clearing before opioids, particularly with long acting opioids like methadone.
Is opioid withdrawal life threatening? does it cause seizures?
not life threatening! does not cause seizures!
Amphetamine I/W
I: psychomotor agitation, impaired judgement, hypertension, pupil dilation, tachycardia, fever, diaphoresis, anxiety, angina, euphoria, prolonged wakefulness/attention, arrhythmias, delusions, seizures, hallucinations
W: post-use crash with anxiety, lethargy, headache, stomach cramps, hunger, fatigue, depression, dysphoria, sleep disturbance, nightmares
Cocaine I/W
I: Psychomotor agitation, euphoria, impaired judgement, tachy, pupil dilation, hypertension, paranoia, hallucinations, “cocaine bugs”, sudden death. ECG changes from ischemia (cocaine chest pain)
W: post-use crash with hypersomnolence, depression, malaise, severe craving, angina, suicidality, increased appetite, nightmares
PCP
I: Assaultiveness, belligerence, psychosis, violence, impulsiveness, psychomotor agitation, fever, tachycardia, vertical/horizontal nystagmus, hypertension, impaired judgement, ataxia, seizures, delirium
W: Recurrence of intoxication symptoms due to reabsorption in the GI tract. sudden onset of severe, random violence.
What can you give for PCP intoxication?
Give benzos or haloperidol for severe symptoms. Acidification of urine or gastric lavage can help to eliminate the drug.
LSD
I: marked anxiety or depression, delusions, visual hallucinations, flashback, pupillary dilation, impaired judgement, diaphoresis, tachycardia, hypertension, heightened senses (colors become more intense)
W: none
Marijuana
Euphoria, slowed sense of time, impaired judgement, social withdrawal, increased appetite, dry mouth, conjunctival injection, hallucinations, anxiety, paranoia, amotivational syndrome
barbiturates
I: low safety margin, respiratory depression
W: Anxiety, seizures, delirium, life-threatening cardiovascular collapse
Benzodiazepines
I: interactions with alcohol, amnesia, ataxia, somnolence, mild resp depression. (avoid using for insomnia in the elderly- can cause paradoxic agitation even in low doses)
W: rebound anxiety, seizure, tremor, insomnia, htn, tachy, death
caffeine
I: restlessness, insomnia, diuresis, muscle twitching, arrhythmias, tachycardia, flushed face, psychomotor agitation
W: headache, lethargy, depression, weight gain, irritability, craving
Nicotine
I: restlessness, insomnia, anxiety, arrhythmias
W: irritability, headache, anxiety, weight gain, craving, bradycardia, difficulty concentrating, insomnia
Anorexia Nervosa
severe restricting of caloric intake by fasting or excessively exercising or binge and purge (vomit, laxative, diuretic)
Signs and symptoms of anorexia nervosa
cachexia, BMI < 18, lanugo, dry skin, bradycardia, lethargy, hypotension, cold intolerance, hypothermia
Presentation of bulimia nervosa
for at least 1/week for 3 or more months patients have episodes of binge eating and compensatory behaviors that include purging or fasting
Weight of anorexia vs bulemia?
Anorexia: >15% below expected body weight
Bulemia: normal or overweight
Attitude toward illness between anorexia/bulemia?
Anorexia: not distressed by illness, so often resistant to treatment
Bulemia: typically distressed so easier to treat
Treatment for anorexia
Monitor calorie intake and weight gain, hospitalize if needed. psychotherapy.
treatment for bulemia
psychotherapy and antidepressants
Two types of anorexia?
Restricting type.
Binge/Purge type
Diagnostic work up for eating disorder?
height and weight, BMI, CBC, electrolytes, endocrine, ECG, psych eval for comorbid conditions
Sexual changes with aging
- interest in sexual activity should not decrease with age
- men require increased stimulation to reach orgasm. intensity of orgasm decreases. refractory period increases.
- estrogen levels decrease after menopause, vaginal dryness and thinning, can cause discomfort
Paraphilic disorder definition and treatment
Preoccupation with or engagement in unusual sexual fantasies, urges or behaviors for > 6 months with significant impairment in ones life.
Treatment: insight oriented psychotherapy
Gender dysphoria
Strong persistent cross-gender identification and discomfort with ones assigned sex or gender role of the assigned sex
List the recommended sleep hygiene measures
- Establishment of regular sleep schedule
- limit caffeine intake
- avoid daytime naps
- warm baths in evening
- use of bedroom for sleep and sexual activity
- exercise early in day
- relaxation
- avoid large meals near bedtime
Primary insomnia
Sleep disturbance not attributable to physical or mental conditions. exacerbated by anxiety. patients preoccupied with not getting enough sleep.
Dx: history of non restorative sleep and difficulty initiating, maintaining sleep. Present at least 3X/week for 1 month.
Pharmacotherapy for primary insomnia
Initiated with care for short periods of time (< 2 weeks)
Diphenhydramine, Zolpidem, Zaleplon, Trazodone
Primary hypersomnia
Dx: excessive daytime sleepiness or nighttime sleep occuring for >1 month (cannot be attributable to medical, mental, sleep hygeine, narcolepsy, insufficient sleep)
Tx for primary hypersomnia
Stimulant drugs
Antidepressants
Narcolepsy
Onset occurs before age 30
Excessive daytime somnolence and decreased REM sleep latency on daily basis for at least 3 months
Sleep attacks are classic symptom.
Daytime somnolence can be associated with:
-Cataplexy: sudden loss of muscle tone that leads to collapse
-hypnagogic hallucinations: occurs when falling asleep
-hypnopompic hallucinations: occur as patient awakens
-sleep paralysis: paralyzed on awakening
Treatment for narcolepsy
- schedule daily naps
- stimulant drugs
- SSRIs for cataplexy
Sleep apnea
associated with sudden death in infants and elderly, headaches, depression, increased systolic BP, pulmonary htn
Tx for OSA:
Tx for CSA:
OSA: CPAP, weight loss, tonsillar/adenoidal removal
CSA: mechanical ventilation (BiPAP), back up RR for severe cases
Somatic Symptom Disorder
excessive thoughts, anxiety, behaviors driven by presence of somatic symptoms. may occur with or without a medical illness present. high health care utilization is often present
Tx for somatic symptom disorder
Regularly scheduled appointments with one clinician as primary caregiver
avoid unnecessary diagnostics
psychotherapy
Conversion disorder
symptoms or deficits of voluntary motor or sensory function (blind, seizure, paralysis) - incompatible with medical processes. close temporal relationship to stress or emotion.
Dx conversion disorder:
unexplained by other medical or neuro causes
Hoover sign: extension of affected leg when asked to raise unaffected side (to rule out leg paralysis)
Eyes closed and resistant to open during seizure, negative simultaneous EEG
Tremor disappear with distraction
Tx conversion disorder
Psychotherapy
Malingering
patients intentionally simulate illness for personal gain (financial benefit, housing)
Factitious
Primary gain: assuming the sick role
Risk factors for suicide?
SAD PERSONS
S: sex (male)
A: age (older)
D: depression
P: previous attempt E: ethanol/substance abuse R: rational thought S: sickness (chronic illness) O: organized plan/access to weapons N: no spouse S: social support lacking
What are the 3 main options for smoking cessation?
- Nicotine replacement therapy
- Varenicline (nicotinic partial ag)
- Buproprion
Risks of varenicline?
Mood changes, suicidality, cardio events in people with pre-existing conditions
Postpartum blues resolve within?
14 days
In breastfeeding patients, which SSRI is recommended for pp depression?
Sertraline
Name the 3 dopamine pathways in CNS
Mesocortical
Nigrostriatal
Mesolimbic
Tuberoinfundibular
Antipsychotic med effects on mesolimbic pathway?
Antipsychotic efficacy
Antipsychotic effects on nigrostriatal pathway?
EPS symptoms
Antipsychotic effects on tuberoinfundibular pathway?
hyperprolactinemia
What are signs and symptoms of hyperprolactinemia in men? women?
men: sexual dysfunction and gynecomastia
women: amenorrhea, galactorrhea, sexual dysfunction
Eye movement desensitization and reprocessing is a form of psychotherapy used for what group of patients?
PTSD
Adjustment disorder
emotional or behavioral symptoms (anxiety, depression, disturbance of conduct) developing within 3 months of stressor and lasting no longer than 6 months once stressor ceases
Name the 3 main dissociative disorders
- Depersonalization/derealization
- Dissociative amnesia
- Dissociative identity disorder
Depersonalization/Derealization disorder
Persistent or recurrent experiences of 1 or both:
- depersonalization (feelings of detachment from ones self. outside observer of ones self)
- derealization (experiencing surroundings as unreal)
- Intact reality testing
Dissociative amnesia
Inability to recall important personal info usually after a traumatic, stressful experience
Not explained by another disorder
DID
Marked discontinuity in identity and loss of personal agency with fragmentation into 2 or more distinct personalities. Associated with severe trauma/abuse.
Dissociative fugue
amnesia of personal information combined with purposeful travel or bewildered wandering
Atrophy of caudate is associated with?
Huntington’s (progressive characterized by chorea, dementia, psychotic symp)
decreased volume of hippocampus and amygdala are associated with?
Schizophrenia
accelerated head growth during infancy and increased total brain volume are found in?
Autism
structural abnormalities in orbitofrontal cortex and basal ganglia found in?
OCD
When should you consider treatment with Clozapine?
Treatment resistance: 2 failed trials of atypical antipsychotics
NMS is likely caused by?
Dopamine antagonism
Symptoms of TCA overdose
SEIZURES
Mental status change, tachy, hypotension, cardiac conduction delay (prolong QRS) and anticholinergic effects (dilated pupil, intestinal ileus, hot, dry skin)
QRS duration greater than ____ is associated with increased risk of ventricular arrhythmia and seizures and is used as an indication of _____ therapy.
100 msec / sodium bicarb therapy
Symptoms and timing of mild alcohol withdrawal?
6-24 hours. anxiety, insomnia, tremors, diaphoresis, palpitations, GI upset, intact orientation
Symptoms and timing of seizure for alc withdrawal?
12-48 hours. generalized tonic clonic
symptoms/timing for alcoholic hallucinosis?
12-48 hours. visual, auditory or tactile hallucinations. intact orientation. stable vitals.
symptoms/timing for delirium tremens?
48-96. confusion, agitation, fever, tachy, hypertension, diaphoresis, hallucinations
Dilsulfuram MOA
inhibits enzyme aldehyde dehydrogenase (acetaldehyde accumulates and patient feels ill)
What is considered an adequate trial of SSRI?
Adequate dose and duration > 6 weeks.
HIV associated dementia
more likely in untreated HIV patients with CD4 count <200 and patients with long standing HIV disease. Onset is subacute and characterized by increasing apathy and impaired attention. then slowed movement and difficulty with limb movement. next memory impairment.
What is a particular good choice of antidepressant in a patient with poor sleep and appetite?
Mirtazapine
Why would you choose valproate over lithium for bipolar?
if patient has underlying kidney disease
myalgias and arthralgias are common withdrawal symptoms from
opioids
