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Psychiatry Flashcards

1
Q

ADHD typically presents between ages?

A

Ages 3-13

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2
Q

How do you diagnose ADHD?

A

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.

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3
Q

What are the symptoms of inattention?

A
  1. Poor attention span in school work/play 2. poor attention to detail/careless mistakes
  2. difficulty following instructions and completing tasks
  3. forgetful and easily distracted.
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4
Q

Symptoms of hyperactivity/impulsivity?

A
  1. fidgets
  2. leaves seat in classroom
  3. runs around inappropriately
  4. cannot play quietly
  5. talks excessively
  6. does not wait for his/her turn
  7. interrupts others
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5
Q

Are sugar and food additives considered contributory to ADHD?

A

NO

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6
Q

Initial treatment for ADHD?

A

Behavioral modification

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7
Q

Pharmacological Stimulant treatments for ADHD?

A
  1. Methylphenidate (Ritalin)
  2. Dextroamphetamine (Dexedrine)
  3. Mixed Dextroamphetamine and Amphetamine (Adderall)
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8
Q

Non-stimulant Pharm therapy for ADHD?

A
  1. SSRI’s
  2. nortriptyline
  3. Buproprion
  4. a2 agonists - clonidine
  5. Atomoxetine (Strattera) (NeRI)
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9
Q

Autism Spectrum Disorder

A

Persistent impairment in socialization, communication, behavior more common in males.

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10
Q

How is severity of Autism Spectrum Disorder determined?

A

Based on level of support needed in psychopathological and communication and repetitive behavioral domains.

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11
Q

When you see a patient or Qstem with ASD what other disorders should you think about?

A

Rett syndrome, tuberous sclerosis, Fragile X syndrome

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12
Q

Rett Syndrome

A

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

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13
Q

Tuberous Sclerosis

A

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.

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14
Q

Fragile X Syndrome

A

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.

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15
Q

ASD is characterized by impaired social interaction, communication, with restricted activities and interests apparent by age __

A

3

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16
Q

Treatment for ASD

A

Intensive special education, behavioral management, symptom targeted medications, family support and counseling

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17
Q

What medications are used for aggression in ASD?

A

neuroleptics (antipsychotics)

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18
Q

What meds are used for stereotyped behaviors in ASD?

A

SSRIs

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19
Q

What are the disruptive behavioral disorders?

A

Conduct and Oppositional Defiant

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20
Q

ODD

A

Pattern of negative, defiant, disobedient, hostile behavior toward authority figures for more than 6 months. May progress to conduct disorder

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21
Q

Conduct disorder

A

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)

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22
Q

Conduct disorder can progress to ___ in adulthood?

A

Antisocial personality disorder

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23
Q

Treatment for ODD and conduct disorder?

A

Individual and Family Therapy

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24
Q

Most common avoidable cause of intellectual disability?

A

Fetal Alcohol Syndrome

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25
Q

Intellectual development disorders are associated with?

A
  1. male gender
  2. chromosome abnormalities
  3. metabolic disease
  4. alcohol/substance use
  5. congenital infections
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26
Q

IQ score to qualify or impaired intellectual functioning? Onset before?

A

IQ < 70; onset before age 18

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27
Q

IQ score for mild, moderate, severe, profound intellectual disability?

A

mild (IQ 50-70)- 85% of cases
moderate (35-49)
severe (20-34)
profound (< 20)

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28
Q

Primary prevention for intellectual disability?

A

Educating general public about causes

Prenatal screening

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29
Q

Treatment measures for ID?

A 
Family counseling and support
Speech and language therapy
Occupational and physical therapy
Behavioral intervention
Education assistance
Social Skills training
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30
Q

Tourette Syndrome is more common in?

A

More common in men and boys

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31
Q

Tourette Syndrome is associated with?

A

ADHD, learning disorders, OCD

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32
Q

Tourette is characterized by?

A 
Multiple motor tics (blinking, grimacing)
Vocal tics (grunting, coprolalia)- many times/day, recurrently for > 1 year with social or occupational impairment
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33
Q

Tourettes begins before?

A

Age 18

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34
Q

Coprolalia

A

Repetition of obscene words

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35
Q

Treatment for Tourette’s?

A

Dopamine receptor antagonists (haloperidol, pimozide)
OR clonidine
Behavioral therapy can be of benefit and counseling can aid in social adjustment and coping

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36
Q

What pharmaceuticals can worsen tics?

A

Stimulants

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37
Q

Schizophrenia is characterized by?

A
  1. Psychotic symptoms (hallucinations, bizarre delusions)
  2. Disorganization (thought disorder and behavioral disturbance)
  3. Negative symptoms (poverty of affect, thought, social interaction)
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38
Q

Prevalence of schizophrenia? male:female?

A

1% equal in men and women?

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39
Q

Peak onset in men/ peak onset in women?

A

Men: 18-25
Women: 25-35

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40
Q

Risk of schizophrenia is increased in people who have?

A

First degree relatives with the disease

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41
Q

% of patients that attempt/complete suicide?

A

50% attempt. 10% complete

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42
Q

Etiologic theories of schizophrenia?

A

Neurotransmitter abnormalities- dopamine dysregulation (frontal hypoactivity, limbic hyperactivity) and CT/MRI abnormalities (enlarged ventricles, decreased cortical volume)

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43
Q

How do you diagnose schizophrenia?

A

2 or more of the following characteristics are present for 6 or more months and result in social or occupational dysfunction.

  1. Positive Symptoms: hallucinations (often auditory), delusions, disorganized speech, bizarre behavior, thought disorder
  2. Negative Symptoms: flat affect, decreased emotional reactivity, poverty of speech, lack of purposeful actions, anhedonia
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44
Q

delusion

A

fixed, false, idiosyncratic belief

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45
Q

hallucination

A

perception without an existing external stimulus

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46
Q

illusion

A

misperception of an actual external stimulus

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47
Q

Differential diagnosis of psychosis?

Divide into psychotic, personality, delusional, medical

A
  1. Psychotic
    - Brief psychotic disorder
    - Schizophreniform
    - Schizophrenia
    - Schizoaffective
  2. Personality
    - Schizotypal
    - Schizoid
  3. Delusional disorder
  4. Medical/Organic/Substance Induced
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48
Q

Brief psychotic disorder

A

> 1 day and < 1 month

Usually preceded by stressors, usually without negative symptoms, no prior episodes, better prognosis

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49
Q

Schizophreniform

A

> 1 month and <6 months

Usually preceded by stressors, usually without negative symptoms, no prior episodes, better prognosis

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50
Q

Schizophrenia

A

> 6 months

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51
Q

Schizoaffective disorder

A

Schizophrenia + major affective disorder (MDD or Bipolar affective disorder)

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52
Q

Schizotypal

A

“Magical thinking”

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53
Q

Schizoid

A

“Loners”

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54
Q

Delusional Disorder

A

Persistent, fixed delusions, without disorganized thought process, hallucinations or negative symptoms of schizophrenia. Day to day functioning is typically unaffected.

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55
Q

Subtypes of delusional disorder?

A

Jealous, Paranoid, Somatic, Erotomanic, Grandiose.

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56
Q

Treatment for schizophrenia

A

Antipsychotics (atypicals are 1st line)

Supportive psychotherapy, training in social skills, vocational rehab, illness education

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57
Q

Evolution of Extrapyramidal symptoms with antipsychotic meds?

A

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)

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58
Q

High potency typical antipsychotics?

A

Haloperidol, Fluphenazin

come in depot long acting forms

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59
Q

Low potency typical antipsychotics?

A

Thioridazine, Chlorpromazine

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60
Q

Indications for typical and antipsychotics?

A

psychotic disorders, acute agitation, acute mania, tourette syndrome

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61
Q

Antipsychotics are more effective for ___ symtoms of schizophrenia based on mechanism of?

A

Positive symptoms. Block D2 receptors in limbic cortex

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62
Q

Side effects of high potency typical antipsychotics (haloperidol/fluphenazine)?

A

EPS > anticholinergic
Qtc prolongation and torsades (esp IV haloperidol)
NMS

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63
Q

Side effects of low potency typical antipsychotics (thioridazine, chlorpromazine)

A

Anticholinergic > EPS
More sedative
Greater risk of orthostatic hypotension
Thioridazine causes dose dependent Qtc prolongation and irreversible retinal pigmentation

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64
Q

Atypical antipsychotics

A

Risperidone (available in depot form), quetiapine, olanzapine, ziprasidone, aripiprazole, clozapine)

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65
Q

Indication for atypical antipsychotics?

A

1st line for schizophrenia due to less EPS and anticholinergic effects

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66
Q

Indication for Clozapine?

A

Reserved for severe treatment resistant schizophrenia and severe tardive dyskinesia

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67
Q

Side effects of Clozapine?

A

Agranulocytosis- requiring weekly CBC monitoring during first 6 mo

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68
Q

Side effects of atypical antipsychotics

A

weight gain, type II DM, metabolic syndrome, somnolence, sedation, Qtc prolonging

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69
Q

Acute dystonia

A

Onset: 4 hours. Characterized by prolonged, painful tonic muscle contraction or spasm
(torticollis- neck muscle contraction to 1 side)
(oculogyric crisis- prolonged upward gaze)

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70
Q

Treatment for acute dystonia?

A

Anticholinergics (benztropine, diphenhydramine) (acute therapy or prophylactic dosing)

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71
Q

Dyskinesia

A

Onset: 4 days. Pseudoparkinsonism with shuffling gait, cogwheel rigidity.

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72
Q

Treatment for dyskinesia

A 
Dopamine agonist (amantadine) or anticholinergic (benztropine)
Discontinue antipsychotic or lower dose if possible
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73
Q

Akathisia

A

Onset: 4 weeks. subjective/objective restlessness or agitation

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74
Q

Treatment for akathisia?

A

Decrease or discontinue antipsychotic
Beta-blocker (propranolol)
Benzos or anticholinergics may help

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75
Q

Tardive dyskinesia

A

Onset: 4 months. Stereotypic, involuntary, painless oral-facial movements. Likely from D2 receptor sensitization from chronic D2 blockade. Irreverisble 50% of time.

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76
Q

Treatment for tardive dyskinesia?

A

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)

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77
Q

Neuroleptic Malignant Syndrome

A

Can occur anytime. Fevers, muscle rigidity, autonomic instability, elevated CK and WBC, clouded consciousness.

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78
Q

Treatment for NMS?

A

Stop medication! Supportive care in ICU. Dantrolene (ryanodine receptor; decreases excitation contraction coupling) or Bromocriptine (DA agonist).

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79
Q

Diagnosing Anxiety disorder

A

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)

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80
Q

Short term treatment

A

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

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81
Q

Long term therapy

A

Lifestyle changes
Psychotherapy
Medications: SSRI (first-line), venlafaxine (SNRI), buspirone (full and partial agonist at serotonin receptors)

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82
Q

What drugs used to treat anxiety should not be used in combo with MAOIs?

A

SSRIs and Buspirone

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83
Q

Panic disorder

A

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.

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84
Q

Agoraphobia

A

“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.

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85
Q

Panic attack

A

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

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86
Q

What symptoms are fairly specific to panic attacks and cause hyperventilation/low O2 sat?

A

Perioral and or acral (peripheral) paresthesias.

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87
Q

Differential diagnosis of panic disorder?

A

Angina, MI, arrythmias, hyperthyroidism, pheochromocytoma, substance-induced anxiety, GAD, PTSD

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88
Q

Treatment for panic disorder?

A

short term: benzo

long term: SSRI (1st line), CBT, TCAs

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89
Q

Qualifier for schizoaffective disorder?

A

Need at least 2 weeks where psychotic symptoms are present without any mood symptoms.

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90
Q

Do patients recognize fear is excessive when they have a phobia?

A

YES

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91
Q

Treatment for specific phobia?

A

CBT involving desensitization through incremental exposure to feared object or situation along with relaxation techniques

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92
Q

Treatment for social phobia?

A

CBT, SSRIs, low-dose benzo, B-blocker for performance anxiety

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93
Q

Obsessions

A

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)

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94
Q

Compulsions

A

Repeated mental acts or behaviors, neutralize anxiety from obsessions. (handwashing, elaborate rituals for ordinary tasks, counting, excessive checking)

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95
Q

For patients with OCD, do they recognize behaviors as excessive and irrational?

A

YES (ego dystonic) Patients recognize obsessions and compulsions and would like to get rid of them.

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96
Q

Treatment for OCD

A

SSRIs - 1st line

CBT- exposure/desensitization

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97
Q

body dysmorphic disorder

A

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)

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98
Q

Treatment for body dysmorphic?

A

SSRIs

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99
Q

SSRIs?

A

fluoxetine, sertraline, paroxetine, citaloparm, escitalopram

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100
Q

Anxiety related indications for SSRIs?

A

GAD, OCD, panic disorder, body dysmorphic disorder, social phobia

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101
Q

SSRI side effects

A

nausea, GI upset, somnolence, sexual dysfunction, agitation

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102
Q

Buspirone indication?

Benefit related to pharmacology?

A

GAD, social phobia

No tolerance, dependence or withdrawal due to full/partial agonist

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103
Q

B-blocker indication for anxiety disorders?

side effects?

A 
Phobic disorders (give prior to exposure)
side effects: bradycardia, hypotension
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5
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104
Q

Benzodiazepines indication for anxiety?

A

acute anxiety, insomnia, alcohol withdrawal, muscle spasm, night terrors, sleep walking

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105
Q

PTSD

A

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

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106
Q

Top causes of PTSD in male patients

A
  1. sexual assualt 2. combat
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107
Q

Top causes of PTSD in female patients

A
  1. childhood abuse 2. sexual assault
108
Q

Diagnosis of PTSD?

A

characterized by following 4 symptom clusters: Symptoms must exist for > 1 month

  1. intrusion- reexperiencing event through nightmares, flashback, intrusive memory
  2. avoidance- stimuli associated with trauma
  3. negative alterations in mood/cognition (numbness)
  4. heightened arousal (hypervigilence), sleep disturbance, aggression, irritability, poor concentration
109
Q

Same symptoms as PTSD for 3 days to 1 month?

A

Acute stress disorder

110
Q

Treatment for PTSD?

A

short-term: B-blocker and a-agonist
long-term: SSRIs, buspirone, TCAs, MAOIs
Psychotherapy and support groups are useful

111
Q

Adjustment disorder

A

Clinically significant distress following a profound life change. Divorce, unemployment, financial issues, romantic break up)

112
Q

Diagnosing adjustment disorder

A

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.

113
Q

Treatment for adjustment disorder?

A

Supportive counseling. NO PHARM TREATMENT

114
Q

Causes of Dementia

Mnemonic (DEMENTIASS)

A

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

115
Q

Dementia AKA major neurocognitive disorder

A

Decline in cognitive functioning with global deficits. level of consciousness is stable. persistent and progressive course most common among those > age 85.

116
Q

2 most common causes of dementia?

A

Alzheimers (65%) and Vascular (20%)

117
Q

Diagnosis of dementia?

A

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)
118
Q

How to diagnose dementia?

A

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.

119
Q

Treatment for dementia?

A

Provide environmental cues and rigid structure for patient’s daily life.
Cholinesterase inhibitors
Low-dose antipsychotics for behavioral disturbances
AVOID BENZO

120
Q

Major causes of delerium?
Mneumonic
“I WATCH DEATH”

A 
Infection 
Withdrawal
Acute metabolic/substance abuse
Trauma
CNS pathology
Hypoxia
Deficiencie
Endocrine
Acute Vascular/MI
Toxins/Drugs
Heavy Metals
121
Q

Delirium

A

acute disturbance of consciousness with altered cognition

122
Q

Presentation of delerium

A

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)

123
Q

Is it common for delerium to be superimposed on dementia?

A

YES

124
Q

How to diagnose delerium?

A

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)

125
Q

Treatment for delerium

A

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

126
Q

Major Depressive Disorder

A

Mood disorder characterized by 1 or more major depressive episodes

127
Q

Symptoms of depressive episode?

A 
Sleep (hypersomnia/insomnia)
Interest
Guilt or feeling worthless
Energy or fatigue 
Concentration
Appetite or weight changes
Psychomotor agitation or retardation
Suicidal ideation
128
Q

Diagnosis of MDD

A

Diagnosis requires Depressed Mood or Anhedonia and five or more signs/symptoms from SIG E CAPS for a 2 week period.

129
Q

Name the depression sub-types

A
  • 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)
130
Q

Differential diagnosis of major depression.

A
  1. mood disorder due to medical condition (hypothyroidism, parkinson disease, CNS neoplasm, other neoplasms, stroke, dementias, parathyroid disorder)
  2. substance induced: drugs, alcohol, anti-HTN, corticosteroids, OCPs
  3. Adjustment disorder with depressed mood: constellation of symptoms that resemble MDE but dont meet criteria and occur within 3 months of life stressor
  4. 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
  5. Dysthymia: milder, chronic depression with depressed mood most of time for at least 2 years. often resistant to treatment.
131
Q

How long should you allow pharm to take effect for MDD? How long to continue treatment for?

A
  • 2-6 weeks

- Continue treatment for 6 months

132
Q

Treatment for MDD

A

Pharmacotherapy plus Psychotherapy

133
Q

Indication for ECT

A

Refractory depression, psychotic depression, severe suicidality, intractable mania, psychosis, safe during pregancy

134
Q

Treatment course for ECT?

A

2-3 X/week for 6-12 treatments

135
Q

Contraindications for ECT?

A

no absolute contraindications. relative contraindications include recent stroke/MI, intracranial mass, high anesthetic risk.

136
Q

How long to wait after stopping SSRI to begin MAOI treatment?

A

2 weeks. 5 weeks for fluoxetine due to longer half life.

137
Q

Differential diagnosis for postpartum disorders?

A
  1. postpartum blues: within 2 weeks of delivery. sadness, moodiness, emotional lability
  2. postpartum psychosis: 2-3 weeks post. delusions and depression. may have thoughts about harming baby.
  3. postpartum depression: 1-3 months post delivery. sadness, moodiness, emotional lability, sleep disturbances, anxiety, may have thoughts about harming baby.
138
Q

Serotonin Syndrome

A

fever, myoclonus, mental status change, cardiovascular collapse,

139
Q

Why should you avoid paroxetine in pregnancy?

A

Can cause pulmonary HTN in fetus.

140
Q

Side effects/contraindications of buproprion?

A

decrease seizure threshold, minimal sexual side effects, contraindicated in patients with eating disorders, and seizure patients

141
Q

SE/contraindications for mirtazapine?

A

weight gain, sedation

142
Q

SE trazodone?

A

highly sedating, priapism

143
Q

SNRIs

A

Venlafaxine, Duloxetine

144
Q

Indication/SE for SNRIs

A

depression, anxiety, chronic pain.

Venlafaxine: diastolic HTN

145
Q

TCAs

A

Nortriptyline, Desipramine, Amitriptyline, Imiprimine

146
Q

Indications for TCAs

A

depression, anxiety, chronic pain, migraine, enuresis (imiprimine)

147
Q

SE/contraindications to TCAs

A

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.

148
Q

MAOIs

A

Phenelzine, Tranylcypromine, Selegiline (patch form available)

149
Q

Indications for MAOIs

A

Depression (esp atypical)

150
Q

SE MAOI

A

HTN crisis if taken with high tyramine foods (aged cheese, red wine)
Sexual side effects, orthostatic hypotension, weight gain

151
Q

Bipolar disorder avg age onset?

A

20

152
Q

Bipolar I

A

involves at least 1 manic or mixed episode often requiring hospitalization

153
Q

Bipolar II

A

at least one MDE and one hypomanic episode (characterized predominantly by depression with occasional hypomanic episodes)

154
Q

Rapid cycling

A

4 or more episodes (MDE, mixed, manic, hypomanic) in 1 year

155
Q

Cyclothymic

A

chronic and less severe with alternating periods of moderate depression and hypomania for > 2 years

156
Q

Clinical presentation of mania? DIG FAST

A 
distractibility 
insomnia
grandiosity 
flight of ideas
activities/agitation
sexual indiscretion/pleasure seek
talkativeness/pressured speech
157
Q

What pharm intervention may trigger mania?

A

Antidepressant use without mood stabilizer

158
Q

How to diagnose manic episode?

A

1 week of persistently elevated, expansive or irritable mood plus three DIG FAST symptoms. Psychotic symptoms are also common with mania.

159
Q

Diagnose hypomania?

A

Similar but does not involve marked functional impairment, psychotic symptoms and does not require hospitalizations.

160
Q

Treatment for bipolar mania?

A

Acute: antipsychotics, lithium, valproate

maintenance therapy: mood stabilizer (benzo for refractory agitation)

161
Q

Treatment for bipolar depression

A

mood stabilizers with or without antidepressants

162
Q

1st line mood stabilizer? 2nd line?

A
  1. Lithium 2. Carbamazepine, Lamotrigine
163
Q

Lithium side effects

A

thirst, polyuria, diabetes insipidus, tremor, weight gain, hypothyroid, nausea, diarrhea, seizures, teratogenicity (ebstein anomaly), acne, vomiting.

164
Q

Lithium toxicity

A

narrow therapeutic window
Toxic > 1.5. Present with ataxia, dysarthria, delirium, acute renal failure. Avoid lithium in patients with decreased renal function.

165
Q

Indication for carbamazepine?

A

2nd line mood stabilizer, anticonvulsant, trigeminal neuralgia

166
Q

SE carbamazepine?

A

nausea, skin rash, leukopenia, AV block, teratogenicity (neural tube), rarely aplastic anemia (monitor CBC biweekly). SJS!

167
Q

Indications Valproic acid?

A

BPD, anticonvulsant

168
Q

SE Valproic acid

A

GI- nausea, vomit
tremor, sedation, alopecia, weight gain, teratogenicity (neural tube), pancreatitis, thrombocytopenia, fatal hepatotoxicity, agranulocytosis.

169
Q

Lamotrigine indications and side effects

A

2nd line mood stabilizer, anticonvulsant

SE: blurred vision, SJS, GI distress. increase dose slowly to monitor for rashes.

170
Q

Personality Disorders

A

One’s traits become chronically rigid and maladaptive. Onset occurs by early adulthood

171
Q

Cluster A personality disorders

A

Paranoid, Schizoid, Schizotypal

172
Q

Paranoid personality disorder

A

distrustful, suspicious, interpret others’ motives as malevolent.

173
Q

Schizoid

A

isolated, detached, “loner”, restricted emotional expression

174
Q

Schizotypal

A

odd behavior, perceptions, appearance. magical thinking. ideas of reference. (lack delusions/hallucinations that would classify them as schizophrenic)

175
Q

Cluster B personality disorders

A

Borderline, histrionic, narcissistic, antisocial

176
Q

borderline

A

unstable mood, relationships, self-image; feelings of emptiness. impulsive. history of suicidal ideation or self-harm. splitting used as a defense mechanism

177
Q

histrionic

A

excessively emotional and attention seeking. sexually provocative, theatrical.

178
Q

narcissistic

A

grandiose, need admiration, have sense of entitlement, lack empathy

179
Q

antisocial

A

violates rights of others, social norms and laws. impulsive. lacks remorse. must have prior diagnosis of conduct disorder.

180
Q

Cluster C personality disorders

A

OCPD, avoidant, dependent

181
Q

OCPD

A

preoccupied with perfectionism, order, control at the expense of efficiency. inflexible morals and values. egosyntonic. don’t feel behavior is problematic

182
Q

Avoidant

A

socially inhibited, rejection sensitive. fear of being disliked or ridiculed, yet desires to have friends and social interactions

183
Q

dependent

A

submissive, clingy, have a need to be taken care of, have difficulty making decisions, feel helpless

184
Q

Treatment for personality disorders

A

psychotherapy is mainstay of treatment

pharmacotherapy for cases with comorbid mood, anxiety, psychotic signs/symptoms

185
Q

Diagnosis of substance use disorder?

A

Meet 2 out of 11 following criteria over a 1 year period.

  1. impaired control
    - consumption of greater amounts of substance than intended
    - failure to cut back/abstain
    - increased amount of time spent acquiring, using, recovering
    - craving
  2. Social impairment
    - failure to fulfill responsibilities at work, school or home
    - continued substance use despite recurrent social/interpersonal problems
    - isolation from life activities
  3. Risky use
    - use in hazardous situations
    - recurrent use despite physical/psych problems
  4. Pharmacologic
    - Tolerance: use of progressively larger amounts to obtain same desired effect
    - Withdrawal: symptoms when not taking substance
186
Q

How do you determine severity of substance use disorder?

A

of symptoms present:
Mild: 2-3
Mod: 4-5
Severe: >6

187
Q

Diagnosis of alcohol use disorder?

A

CAGE question screening.
Vital signs for evidence of withdrawal
Increased LFTs, LDH, MCV

188
Q

CAGE

A

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

189
Q

Treatment for alcohol use disorder

A
  • 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)
190
Q

Complications from alcohol use disorder?

A

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

191
Q

Alcohol intoxication/withdrawal symptoms

A

I: disinhibition, emotional lability, slurred speech, ataxia, aggression, blackouts, hallucinations, memory impairment, impaired judgement, coma
W: tremor, tachy, hypertension, malaise, nausea, seizure, DTs, agitation

192
Q

Opioids I/W

A

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

193
Q

Naloxone and Naltrexone

A

block opioid receptors and reverse effects but beware of antagonist clearing before opioids, particularly with long acting opioids like methadone.

194
Q

Is opioid withdrawal life threatening? does it cause seizures?

A

not life threatening! does not cause seizures!

195
Q

Amphetamine I/W

A

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

196
Q

Cocaine I/W

A

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

197
Q

PCP

A

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.

198
Q

What can you give for PCP intoxication?

A

Give benzos or haloperidol for severe symptoms. Acidification of urine or gastric lavage can help to eliminate the drug.

199
Q

LSD

A

I: marked anxiety or depression, delusions, visual hallucinations, flashback, pupillary dilation, impaired judgement, diaphoresis, tachycardia, hypertension, heightened senses (colors become more intense)

W: none

200
Q

Marijuana

A

Euphoria, slowed sense of time, impaired judgement, social withdrawal, increased appetite, dry mouth, conjunctival injection, hallucinations, anxiety, paranoia, amotivational syndrome

201
Q

barbiturates

A

I: low safety margin, respiratory depression

W: Anxiety, seizures, delirium, life-threatening cardiovascular collapse

202
Q

Benzodiazepines

A

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

203
Q

caffeine

A

I: restlessness, insomnia, diuresis, muscle twitching, arrhythmias, tachycardia, flushed face, psychomotor agitation

W: headache, lethargy, depression, weight gain, irritability, craving

204
Q

Nicotine

A

I: restlessness, insomnia, anxiety, arrhythmias

W: irritability, headache, anxiety, weight gain, craving, bradycardia, difficulty concentrating, insomnia

205
Q

Anorexia Nervosa

A

severe restricting of caloric intake by fasting or excessively exercising or binge and purge (vomit, laxative, diuretic)

206
Q

Signs and symptoms of anorexia nervosa

A

cachexia, BMI < 18, lanugo, dry skin, bradycardia, lethargy, hypotension, cold intolerance, hypothermia

207
Q

Presentation of bulimia nervosa

A

for at least 1/week for 3 or more months patients have episodes of binge eating and compensatory behaviors that include purging or fasting

208
Q

Weight of anorexia vs bulemia?

A

Anorexia: >15% below expected body weight
Bulemia: normal or overweight

209
Q

Attitude toward illness between anorexia/bulemia?

A

Anorexia: not distressed by illness, so often resistant to treatment

Bulemia: typically distressed so easier to treat

210
Q

Treatment for anorexia

A

Monitor calorie intake and weight gain, hospitalize if needed. psychotherapy.

211
Q

treatment for bulemia

A

psychotherapy and antidepressants

212
Q

Two types of anorexia?

A

Restricting type.

Binge/Purge type

213
Q

Diagnostic work up for eating disorder?

A

height and weight, BMI, CBC, electrolytes, endocrine, ECG, psych eval for comorbid conditions

214
Q

Sexual changes with aging

A
  • 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
215
Q

Paraphilic disorder definition and treatment

A

Preoccupation with or engagement in unusual sexual fantasies, urges or behaviors for > 6 months with significant impairment in ones life.

Treatment: insight oriented psychotherapy

216
Q

Gender dysphoria

A

Strong persistent cross-gender identification and discomfort with ones assigned sex or gender role of the assigned sex

217
Q

List the recommended sleep hygiene measures

A
  • 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
218
Q

Primary insomnia

A

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.

219
Q

Pharmacotherapy for primary insomnia

A

Initiated with care for short periods of time (< 2 weeks)

Diphenhydramine, Zolpidem, Zaleplon, Trazodone

220
Q

Primary hypersomnia

A

Dx: excessive daytime sleepiness or nighttime sleep occuring for >1 month (cannot be attributable to medical, mental, sleep hygeine, narcolepsy, insufficient sleep)

221
Q

Tx for primary hypersomnia

A

Stimulant drugs

Antidepressants

222
Q

Narcolepsy

A

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

223
Q

Treatment for narcolepsy

A
  • schedule daily naps
  • stimulant drugs
  • SSRIs for cataplexy
224
Q

Sleep apnea

A

associated with sudden death in infants and elderly, headaches, depression, increased systolic BP, pulmonary htn

225
Q

Tx for OSA:

Tx for CSA:

A

OSA: CPAP, weight loss, tonsillar/adenoidal removal

CSA: mechanical ventilation (BiPAP), back up RR for severe cases

226
Q

Somatic Symptom Disorder

A

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

227
Q

Tx for somatic symptom disorder

A

Regularly scheduled appointments with one clinician as primary caregiver
avoid unnecessary diagnostics
psychotherapy

228
Q

Conversion disorder

A

symptoms or deficits of voluntary motor or sensory function (blind, seizure, paralysis) - incompatible with medical processes. close temporal relationship to stress or emotion.

229
Q

Dx conversion disorder:

A

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

230
Q

Tx conversion disorder

A

Psychotherapy

231
Q

Malingering

A

patients intentionally simulate illness for personal gain (financial benefit, housing)

232
Q

Factitious

A

Primary gain: assuming the sick role

233
Q

Risk factors for suicide?

SAD PERSONS

A

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
234
Q

What are the 3 main options for smoking cessation?

A
  1. Nicotine replacement therapy
  2. Varenicline (nicotinic partial ag)
  3. Buproprion
235
Q

Risks of varenicline?

A

Mood changes, suicidality, cardio events in people with pre-existing conditions

236
Q

Postpartum blues resolve within?

A

14 days

237
Q

In breastfeeding patients, which SSRI is recommended for pp depression?

A

Sertraline

238
Q

Name the 3 dopamine pathways in CNS

A

Mesocortical
Nigrostriatal
Mesolimbic
Tuberoinfundibular

239
Q

Antipsychotic med effects on mesolimbic pathway?

A

Antipsychotic efficacy

240
Q

Antipsychotic effects on nigrostriatal pathway?

A

EPS symptoms

241
Q

Antipsychotic effects on tuberoinfundibular pathway?

A

hyperprolactinemia

242
Q

What are signs and symptoms of hyperprolactinemia in men? women?

A

men: sexual dysfunction and gynecomastia
women: amenorrhea, galactorrhea, sexual dysfunction

243
Q

Eye movement desensitization and reprocessing is a form of psychotherapy used for what group of patients?

A

PTSD

244
Q

Adjustment disorder

A

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

245
Q

Name the 3 main dissociative disorders

A
  1. Depersonalization/derealization
  2. Dissociative amnesia
  3. Dissociative identity disorder
246
Q

Depersonalization/Derealization disorder

A

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
247
Q

Dissociative amnesia

A

Inability to recall important personal info usually after a traumatic, stressful experience
Not explained by another disorder

248
Q

DID

A

Marked discontinuity in identity and loss of personal agency with fragmentation into 2 or more distinct personalities. Associated with severe trauma/abuse.

249
Q

Dissociative fugue

A

amnesia of personal information combined with purposeful travel or bewildered wandering

250
Q

Atrophy of caudate is associated with?

A

Huntington’s (progressive characterized by chorea, dementia, psychotic symp)

251
Q

decreased volume of hippocampus and amygdala are associated with?

A

Schizophrenia

252
Q

accelerated head growth during infancy and increased total brain volume are found in?

A

Autism

253
Q

structural abnormalities in orbitofrontal cortex and basal ganglia found in?

A

OCD

254
Q

When should you consider treatment with Clozapine?

A

Treatment resistance: 2 failed trials of atypical antipsychotics

255
Q

NMS is likely caused by?

A

Dopamine antagonism

256
Q

Symptoms of TCA overdose

A

SEIZURES
Mental status change, tachy, hypotension, cardiac conduction delay (prolong QRS) and anticholinergic effects (dilated pupil, intestinal ileus, hot, dry skin)

257
Q

QRS duration greater than ____ is associated with increased risk of ventricular arrhythmia and seizures and is used as an indication of _____ therapy.

A

100 msec / sodium bicarb therapy

258
Q

Symptoms and timing of mild alcohol withdrawal?

A

6-24 hours. anxiety, insomnia, tremors, diaphoresis, palpitations, GI upset, intact orientation

259
Q

Symptoms and timing of seizure for alc withdrawal?

A

12-48 hours. generalized tonic clonic

260
Q

symptoms/timing for alcoholic hallucinosis?

A

12-48 hours. visual, auditory or tactile hallucinations. intact orientation. stable vitals.

261
Q

symptoms/timing for delirium tremens?

A

48-96. confusion, agitation, fever, tachy, hypertension, diaphoresis, hallucinations

262
Q

Dilsulfuram MOA

A

inhibits enzyme aldehyde dehydrogenase (acetaldehyde accumulates and patient feels ill)

263
Q

What is considered an adequate trial of SSRI?

A

Adequate dose and duration > 6 weeks.

264
Q

HIV associated dementia

A

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.

265
Q

What is a particular good choice of antidepressant in a patient with poor sleep and appetite?

A

Mirtazapine

266
Q

Why would you choose valproate over lithium for bipolar?

A

if patient has underlying kidney disease

267
Q

myalgias and arthralgias are common withdrawal symptoms from

A

opioids

Step 2 CK (26 decks)

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