Psychiatry Flashcards
1
Q
pt thinks he has special powers; God given missions
A
Grandiose Delusion
2
Q
irrational belief that can’t be changed by proof or rational arguments
A
Delusion
3
Q
misinterpret stimulus that’s actually there (eg. think tree branch is a person)
A
Illusion
4
Q
sensory perception in absence of external stimulus
A
Hallucination
5
Q
mood sxs present for significant portion of the illness
BUT delusions/hallucinations occur for ≥ 2 wks in absence of mood sxs (eg. depressive or manic episode)
mood disorder ONLY occurs during psychosis
Mood sxs + psychosis———————Mood sxs + psychosis
Psychosis ONLY
A
Schizoaffective Disorder
6
Q
Most effective tx for negative sxs (2)
A
- atypical antipsychotics
- social skills training
7
Q
answers diverge from question asked but eventually return to original topic
A
circumstantiality
8
Q
answers diverge from question asked and DO NOT return to original topic
A
tangentiality
9
Q
no clear sequence to the thoughts presented
A
loose association
10
Q
words strung together incoherently
A
word salad
11
Q
pt makes up new words
A
neologism
12
Q
drugs that cause psychosis sxs
A
hallucinogens (eg. PCP, LSD) stimulants (eg. cocaine, amphetamines) w/d from alcohol, benzo, barbiturates glucocorticoids anabolic steroids
13
Q
neuroimaging findings in Schizophrenia
A
enlargement of 3rd and lateral ventricles
cortical thinning
14
Q
one person’s delusion transferred to another person
A
Folie a Deux (Shared Psychotic Disorder)
TX: separate the 2 pts and assess degree of impairment in each
15
Q
Neurotransmitters responsible for positive vs negative sxs of schizophrenia
A
Positive = Dopamine Negative = Muscarinic receptors
16
Q
Positive Sx of Schizophrenia
A
Delusions (BIZARRE)
Hallucinations
Disorganized thoughts/speech
17
Q
Negative Sx of Schizophrenia
A
Apathy Social withdrawal Flattened affect Anhedonia Poverty of thought
18
Q
+ or - sxs present for 6 months
impact on social/occupational functioning
A
Schizophrenia
19
Q
+ or - sxs present for >1 month but < 6 months
impact on social/occupational functioning
A
Schizophreniform Disorder
20
Q
+ or - sxs present for <1 month
impact on social/occupational functioning
sxs return to baseline after 1 month
A
Brief Psychotic Disorder
21
Q
sxs for many years (has to be at least ≥ 1 month)
no impairment in level of functioning
delusions are NONBIZARRE
A
Delusional Disorder
22
Q
Features of Schizophrenia that suggest POOR Prognosis
A
male sex early age on onset gradual onset no precipitating factors negative sxs poor premorbid functioning (MOST IMPT) FHX of schizophrenia poor support system single, divorced, or widowed status disorganized or deficit subtype
23
Q
Management of Schizophrenia
A
- pt has bizarre or paranoid sxs –> hospitalize pt
- pt agitated –> give benzos
- start antipsychotics (give for 6 months)
- -> long term antipsychotics only necessary for h/o repetitive episodes
- start psychotherapy
24
Q
Indications for Antipsychotic Use (5)
A
- schizophrenia
- depression w/ psychotic features
- mania in bipolar disorder
- sedation when benzos CI
- movement disorders (eg. Huntington’s Disease and Tourrette syndrome)
25
what two medications should be avoided in 1st psychotic episode and why?
Olanzapine
Clozapine
They cause w. gain and metabolic adverse effects
26
antipsychotics increase the risk of mortality in what disease?
dementia
27
First choice medication for tx of schizophrenia when sedation is problem
Risperidone
28
which receptors are blocked by Typical Antipsychotics and what are the 2 categories of Typical Antipsychotics?
Block D1 and D2 receptors
Low potency and High potency
29
Examples of Low Potency, Typical Antipsychotics
Chlorpromazine
| Thioridazine
30
Advantages and Disadvantages of Low Potency, Typical Antipsychotics
Advantages:
- Less EPS sxs
Disadvantages:
- Anticholinergic SEs (eg. dry mouth, urinary retention)
- alpha 1 blockade (orthostatic BP)
- anti-histamine SEs (sedating)
31
SEs of Chlorpromazine and Thioridazine
Chlorpromazine --> deposits in Cornea
| Thioridazine --> deposits in retina, prolonged QT and arrhythmias (get EKG before starting MDX)
32
Examples of High Potency, Typical Antipsychotics
```
Haloperidol
Fluphenazine
Trifluoperazine
Loxapine
Thiothixene
```
33
Advantages and Disadvantages of High Potency, Typical Antipsychotics
Advantages:
- FEWER Anticholinergic SEs (eg. dry mouth, urinary retention)
- FEWER alpha 1 blockade (orthostatic BP)
- FEWER anti-histamine SEs (sedating)
- can take IM and some in depot injection form
Disadvantages:
- EPS sxs
34
examples of long acting injectable antipsychotics
Haloperidol
Fluphenazine
Both are high potency, typical antipsychotics
These are good for ppl who are non-compliant
35
SE of Fluphenazine
Hypothermia
| - disrupts thermoregulation and body's shivering mechanism
36
which receptors are blocked by Atypical Antipsychotics?
D2 and serotonin receptors
37
Examples of Atypical Antipsychotics
```
Aripiprazole
Olanzapine
Quetiapine
Risperidone
Clozapine
Ziprasidone
```
NOTE: Atypical antipsychotics are used to augment antidepressants in pts w/ tx-resistant depression
38
Advantages and Disadvantages of Atypical Antipsychotics
Advantages:
- best choice for initial therapy
- best effect on negative sxs
- FEWER anticholinergic SEs
- FEWER EPS sxs
Disadvantages:
- W. gain (increased risk for DM and metabolic syndrome - so monitor glucose and lipids)
- -> highest risk w/ olanzapine
- -> second highest risk w/ clozapine
- -> least risk w/ aripiprazole or ziprasidone
39
SE of risperidone
hyperprolactinemia
| --> galactorrhea, amenorrhea, impotence, decreased libido
40
Indications for Clozapine use
Refractory cases of schizophrenia
--> if pt responded to other antipsychotics in part, then not candidate for clozapine
Schizo w/ suicidality
41
SEs of clozapine
agranulocytosis
- -> monitor w/ CBC before therapy and weekly during therapy
w. gain
- -> monitor glucose and lipids
42
List Extrapyramidal SEs
1) Acute dystonia (w/in days)
- -> sustained muscle contractions (eg. torticollis)
2) Parkinsonism (w/in wks)
- -> bradykinesia, akinesia, rigidity, tremors, mask like facies
3) Akathisia (w/in wks - mo)
- -> restlessness, compulsion to move
4) Tardive dyskinesia (w/in mo - yrs)
- -> choreoathetosis (writhing movements) of tongue, face, neck, trunk, limbs
- -> lip smacking
- -> irreversible
- -> NOTE: chronic use of DA antagonists (eg. metoclopramide) can result in tardive dyskinesia
43
Tx of Extrapyramidal SEs
1) Acute dystonia
- -> decrease dose
- -> benztropine (anticholinergic) or diphenhydramine
2) Parkinsonism
- -> decrease dose
- -> benztropine (anticholinergic) or amantadine
3) Akathisia
- -> decrease dose
- -> B-blockers or benzo
4) Tardive dyskinesia
- -> d/c older antipsychotic
- -> start newer antipsychotic (eg. clozapine)
44
Dopamine Pathways (3)
```
Mesolimbic Pathway (has to do w/ schizo)
Nigrostriatal Pathway (has to do w/ Parkinson)
Tuberoinfundibular Pathway (has to do w/ prolactin)
```
45
Effects of ↑ DA and ↓ DA in Mesolimbic Pathway
↑ DA: delusions and hallucinations
| ↓ DA: no (+) sxs of schizo
46
Effects of ↑ DA and ↓ DA in Nigrostriatal Pathway
↑ DA: chorea/tics
| ↓ DA: Parkinson sxs + EPS sxs
47
Effects of ↑ DA and ↓ DA in Tuberoinfundibular Pathway
↑ DA: inhibits prolactin release
| ↓ DA: releases prolactin = hyperprolactinemia sxs
48
Medical illnesses to r/o before dx of schizo
- hypo/hyperthyroidism (get TSH)
- electrolyte abn (get BMP)
- HIV (get serology)
- syphilis (get VDRL)
- drug intoxication (get drug screen)
- temporal lobe epilepsy
49
medical causes of anxiety
```
hyperthyroidism
pheochromocytoma
excess cortisol
heart failure
arrhythmias
asthma
COPD
```
50
drug causes of anxiety
```
corticosteroids
caffeine
amphetamines
cocaine
withdrawal from alcohol and sedatives
```
51
normal reaction after change in person's life (eg. divorce, breaking up w/ gf, migration)
sxs occur w/in 3 months of stressor and go away w/in 6 months of removing the stressor
Adjustment Disorder
TX: counseling
52
brief, some UNEXPECTED attacks of intense anxiety w/ autonomic sxs (eg. tachycardia, hyperventilation, dizziness, sweating)
episodes occur regularly
have obvious PRECIPITANT
pt worries about having more attacks and changes behavior to prevent them
Panic Disorder
53
Neuroimaging findings of Panic Disorder
Decreased volume of amygdala
54
Diseases associated w/ panic disorder
```
Agoraphobia
Depression
Bipolar Disorder
Substance abuse
Increased risk of suicide ideations/attempts
```
55
Tx for Panic Disorder
CBT
Relaxation training and desensitization (more useful if have agoraphobia sxs also)
SSRIs
PANIC ATTACK: Benzos
56
Tx of Social Anxiety Disorder
Exposure therapy
ACUTE ATTACK: Benzo
PERFORMANCE ANXIETY: B-blockers (atenolol or propranolol)
57
excessive poorly controlled anxiety (about EVERYTHING) that occurs daily
≥ 6 months
no precipitating factor
Generalized Anxiety Disorder
58
Tx for Generalized Anxiety Disorder
psychotherapy (relaxation training, biofeedback)
SSRIs/ SNRIs
buspirone (serotonin receptor partial agonist)
benzo
59
recurrent obsessions or compulsions
| pt KNOWS behavior is unreasonable
Obsessive Compulsive Disorder
NOTE: To dx OCD, need EITHER obsessions or compulsions; don't need both
60
What infection can give you acute sxs of OCD?
recent grp. A strep infxn (seen in kids)
TX: SSRIs
61
What disorders are common in OCD pts?
Depression
Substance use
NOTE: Pts w/ Tourette syndrome often have OCD
62
Tx for Obsessive Compulsive Disorder
Behavioral psychotherapy (exposure and response prevention therapy)
SSRIs
--> need high doses, prolonged trials and gradual up titration
Clomipramine (TCA)
--> if SSRIs don't work
--> many SEs (anticholinergic, ↓ BP, cardiac conduction delay)
63
general guidelines about benzo use
don't change doses abruptly --> can get SEIZURES
use lowest dose possible in elderly
advice against using machinery or driving
64
Shortest to Longest Half Life of Benzos
Shortest to Longest Half Life:
Alprazolam
Lorazepam (can be used in IM form; esp helpful for emergency situations)
Diazepam
65
Benzos safe to use in Liver disease
"LOT"
Lorazepam
Oxazepam
Temazepam
66
Tx of ACUTE overdose of benzo
flumazenil
67
sxs last < 1 month
severe anxiety sxs that follow life-threatening event:
--> re-experience traumatic event
--> avoid stimuli associated w/ event
--> increased arousal (sleep disturbances, hyper-vigilance, emotional detachment, concentration difficulties, irritability, amnesia)
Acute Stress Disorder
68
sxs last > 1 month
severe anxiety sxs that follow life-threatening event:
--> re-experience traumatic event
--> avoid stimuli associated w/ event
--> increased arousal (sleep disturbances, hyper-vigilance, emotional detachment, concentration difficulties, irritability, amnesia)
Post-traumatic Stress Disorder (PTSD)
69
Tx for Acute Stress Disorder + PTSD
ACUTE ANXIETY: Benzo
Trauma-focused brief CBT
LONG TERM: SSRIs
NIGHTMARES: Prazosin (alpha blocker)
Most effective therapy to PREVENT PTSD = group counseling
70
Neuroimaging findings for PTSD
decreased volume of hippocampus
71
Survivors of Sexual Assault are at Increased Risk for what Psych Problems?
PTSD
Depression
Suicide
72
Which neurotransmitters are decreased in Major Depression Syndrome?
NE
Serotonin
Dopamine
73
depressed mood or anhedonia lasting ≥ 2 weeks
| "SIGECAPS"
Major Depressive Disorder
NOTE: Adolescents get irritable mood instead of depressed mood
74
Medical causes of Depression
```
Hypothyroidism
HyperPTH
HIV
Cancer (eg. CNS neoplasms)
Stroke
Parkinson's disease
Alcohol use
Cocaine w/d
```
75
MDX that cause Depression
```
Corticosteroids
B-blockers
antipsychotics (esp in old ppl)
reserpine (antipsychotic; anti-HTN)
anti-histamines
benzo
metoclopramide/prochlorperozine
IFN-alpha
```
76
Tx of Major Depressive Disorder
If pt has ACTIVE suicidal ideations --> admit to hospital
If pt agitated --> give benzos
```
Interpersonal psychotherapy
SSRIs (FIRST LINE) --> take 4-6 wks to work
SNRIs
Buproprion
ECT
```
77
Tx for single episode of depression
Antidepressant for 6 months after pt responses (don't change dose in this time)
78
Tx for multiple episodes of depression
maintenance therapy req'd for long time (1-3 yrs) OR for life (if episodes very severe or ≥ 3 episodes)
79
Indications for Electroconvulsive Therapy (ECT)
SE of ECT
pt acutely suicidal
MDD not responsive to MDXs
for pts worried about side effects from MDXs
pts w/ psychotic depression
depression w/ malnutrition or catatonic stupor (old pt that doesn't eat or drink)
Bipolar D
Schizophrenia
safe in preg pts (for depression or mania)
SE: retrograde amnesia
80
What about depressed pts w/ life expectancy of only 2-4 wks. What to give them?
Methylphenidate (works much faster than antidepressants)
81
First line SSRI in kids or teens w/ depression?
Fluoxetine
82
Major depression is an independent risk factor for increased morbidity and mortality in which disease?
Cardiovascular disease
83
pts w/ late onset depression (after age 65) are at increased risk for developing what diseases when compared to those that present earlier?
Alzheimer's Disease
| Vascular dementia
84
old depressed pt presents w/ memory loss
pt overly concerned abt memory loss
pt seeks help themselves
can mimic Alzheimer's Disease
CT head normal
Pseudodementia
Can detect real depression via dexamethasone suppression test (test will be abn in 50% pts w/ depression)
85
low level depression sxs that are present on most days for at least 2 years
Dysthmic Disorder (Persistent Depressive Disorder)
TX:
long term individual, insight-oriented psychotherapy
SSRIs (if psychotherapy fails)
86
depressive sxs in winter months
Seasonal Affective Disorder
TX: phototherapy or sleep deprivation
87
```
mood reactivity
increased appetite/weight
hypersomnia
leaden paralysis (arms and legs feel heavy)
hypersensitive to rejection
```
MDD w/ Atypical Features
TX: respond well to MAOIs and SSRIs
88
delusions/hallucinations develop during episodes of MDD
NO psychosis EXCEPT during depressive sxs
depression--------depression-----------depression
psychosis -------------------------------------psychosis
MDD w/ Psychotic Features
89
depression, mania or mixed sxs
distress or impaired functioning
for ≥ 1 week
Bipolar Disorder
Bipolar I --> mania + depression (don't need depression for dx)
Bipolar II --> hypomania + depression (NEED BOTH)
90
Mania Sxs
```
"DIG FAST"
Distractibility
Indiscretion
Grandiosity
Flight of ideas
Activity increased
Sleep decreased
Talkative
```
91
DDX to consider for Mania
Amphetamine use
Pheochromocytoma
Hyperthyroidism
92
Hypomania
3 of the sxs of mania
for ONLY 4 days
don't need hospitalization
93
Management of ACUTE Mania
1) Hospitalize
2) STOP ALL ANTIDEPRESSANTS
3) Lithium (mood stabilizer)
- -> if kidneys compromised, use valproic acid or carbamazepine instead
- -> prevents suicidal ideation!!!
4) Risperidone (antipsychotic)
Noncompliant, severely manic pt --> IM depot phenothiazine (antipsychotic)
94
Duration of Lithium Tx Guidelines
If had 1 episode of acute mania --> Li for 1 yr
If had ≥ 2 episodes of acute mania --> Li for many yrs
- if there is FHx or episodes were SEVERE = lifetime Li therapy
If had ≥ 3 relapses --> lifetime Li maintenance therapy
95
Management of Bipolar Depression
lamotrigine OR quetiapine (atypical antipsychotic)
NEVER use antidepressants b/c they precipitate mania
96
Management of Severe Mania in Pregnancy
Safest = haloperidol (antipsychotic)
Avoid Li, valproate, carbamazepine
--> Li can cause Ebstein's anomaly
ECT:
- -> effective BUT try IF haloperidol fails OR
- -> if pt at risk of hurting her self or fetus
97
Maintenance Therapy for Bipolar Disorder
Li/Valproic acid/Lamotrigine + atypical antipsychotic
98
Rapid Cycling Bipolar
≥ 4 episodes of mania per year
99
SEs of Lithium
```
Ebstein's anomaly
Diabetes insipidus
Thyroid problems (hypo/hyper)
--> tx hypothyroidism w/ T4 and continue Li
Metallic taste in mouth
Acne
W. gain
GI distress
Headaches
```
NOTE: perform Cr and TFTs before starting Li
Therapeutic Range: 0.8-1.2 mEq/L
100
SEs of Lamotrigine
Steven-Johnson syndrome
| Toxic Epidermal Necrolysis
101
recurrent HYPOMANIC and depressed mood for ≥ 2 yrs
Cyclothymia
TX:
psychotherapy
divalproex (anticonvulsant)
102
can't stay awake in evening (after 7PM)
social functioning difficult
get early morning insomnia due to early bedtime
Advanced Sleep Phase Syndrome
103
"night owls"
problems going to sleep at normal time (eg. before midnight)
sleep is normal when they are allowed to set their own schedule (eg. during weekends when pt not at work)
starts in adolescence
Delayed Sleep Phase Syndrome
TX: respond to light or behavioral therapy
104
Grief (Bereavement) vs Depression
Grief:
- sxs wax and wane
- shame and guilt LESS common
- suicidal ideation LESS common
- sxs typically last <6 months
- returns to baseline level of functioning w/in 2 months
- hear voices of the deceased; want to join them (hallucinations normal in grief)
TX: supportive therapy
Depression:
- sxs PERVASIVE and UNREMITTING
- shame and guilt COMMON
- suicidal ideation COMMON
- sxs continue for > 1 yr
- does not return to baseline level of functioning
TX: antidepressants
105
Bereavement Presentation in Preschool Children
react w/ disbelief
| may have magical thoughts that death is temporary or reversible
106
Bereavement Presentation in Older Children (>7 yoa)
understand finality of death
| may express sadness, anxiety, anger, self-blame, regression and avoidance
107
<2 wks after delivery
mom mildly depressive
mom cares about baby
Postpartum Blues
TX: self-limited
108
2 wks - 6 mo after delivery
mom severely depressive
mom has negative thoughts about baby
Postpartum Depression
TX: antidepressants
109
w/in 2-3 wks after delivery
mom has psychotic sxs + severe depressive sxs
mom has thoughts of hurting baby
Postpartum Psychosis
TX:
mood stabilizers or antipsychotics + antidepressants
if pt breastfeeding, do ECT instead of MDXs
110
Some Risk Factors for Suicide
h/o suicide threats/attempts (MOST IMPT)
FHx of suicide
white race
Age >65
Many more RFs!
111
Protective Factors for Suicide
social support/family connectedness (MOST IMPT)
pregnancy
parenthood
religion and participation in religious activities
112
Depressed pts who deteriorate after initial signs of improvement should be assessed for what?
substance use
| - alcohol, stimulants, opiates --> exaggerate depressive sxs
113
Examples of SSRIs
```
sertraline
fluoxetine
paroxetine
citalopram
escitalopram
fluvoxamine
```
114
SEs of SSRIs
```
sexual dysfxn
insomnia
anxiety
w. gain
nausea
risk of suicidal ideation
risk of serotonin syndrome
```
GI sxs and insomnia common at beginning of therapy but improve over time so continue MDX
NOTE: if no improvement w/ 1 SSRI, change to another SSRI. If still no improvement, change to different MDX class
115
Examples of SNRIs
venlafaxine
duloxetine
desvenlafaxine
milnacipran
116
SEs of SNRIs
```
sexual dysfxn
insomnia
anxiety
nausea
dizziness
HTN (w/ venlafaxine)
risk of serotonin syndrome
```
117
Examples of Atypical Antidepressants
Bupropion (NDRI)
Mirtazapine (alpha 2 adrenergic antagonist)
Trazodone
118
SEs of Trazodone
SEDATION
| PRIAPISM
119
SEs of Bupropion
NO SEXUAL DYSFXN
W. LOSS
insomnia
↓ SEIZURE THRESHOLD (so don't use MDX in ppl w/ seizure disorders or eating disorders)
120
SEs of Mirtazapine
SEDATION
NO SEXUAL DYSFXN
w. gain
121
Examples of MAOIs
phenelzine
selegiline
tranylcypromine
122
SEs of MAOIs
HTN CRISIS
--> occurs w/ tyramine containing foods (eg. wine, cheese), antihistamines, or nasal decongestants
TX: Treat as hypertensive crisis
123
Examples of TCAs
amitryptyline (for chronic pain tx)
imipramine (for enuresis tx)
nortryptyline
clomipramine
124
SEs of TCAs
ANTICHOLINERGIC EFFECTS (dry mouth, constipation, urinary retention, blurred vision)
SEDATION (anti-histamine effects)
ORTHOSTATIC HYPOTENSION (alpha 1 adrenergic blockade)
sexual dysfxn
w. gain
125
Sxs of TCA Overdose
3 C's:
- cardiotoxicity (↑ HR, ↓ BP)
- CNS toxicity (sedation, seizures)
- antiCholinergic sxs (mydriasis, urinary retention --> d/c MDx and put catheter)
NOTE: urgent step = checking EKG for QRS prolongation
126
Tx of TCA Overdose
ABCs
charcoal
QRS > 100 msec = Na Bicarbonate
Seizure --> Benzo
127
What antidepressant should be given to pt concerned abt w. gain and sexual side effects
Bupropion
Mirtazapine also DOES NOT cause sexual side effects (BUT causes w gain)
128
What antidepressant should be give to pt who has poor appetite, can't sleep and is losing weight?
Mirtazapine
129
Sedating antidepressants
Trazodone
Mirtazapine
TCAs (not used due to other SEs)
130
Which antidepressants should be avoided in pts w/ seizure disorder?
Bupropion
| TCAs
131
Which SSRI is UNSAFE in preg
Paroxetine
132
NMS Sxs
```
AMS (confusion)
Autonomic dysfxn (↑ HR, ↓ BP, ↑ RR, ↑ temp)
Muscle problems (lead pipe rigidity, bradykinesia, ↑ CPK, rhabdomyolysis)
```
NOTE: Look for pt who recently started taking ANTIPSYCHOTICS or Parkinson pt who stopped Levodopa
133
Tx of NMS
Stop antipsychotic and transfer to ICU
Dantrolene (inh. Ca release = prevents rigidity and hyperthermia)
Bromocriptine or amantadine
134
Serotonin Syndrome Sxs
```
AMS (agitation, delirium)
Autonomic dysfxn (↑ HR, ↑ BP, ↑ temp)
--> vomiting, diarrhea, diaphoresis
Muscle problems (clonus, hyperkinesis, tremors, ↑ DTRs)
--> ocular clonus = slow, continuous, horizontal eye movements
```
NOTE: Look for h/o ANTIDEPRESSANT use
135
Causes of Serotonin Syndrome
```
SSRIs
SNRIs
TCAs
MAOIs
St.John's Wart
Triptans
Linezolid
Levodopa
```
136
Tx of Serotonin Syndrome
1) D/c all serotonogenic MDXs
2) Supportive care - IVFs, O2
3) Sedation w/ benzos
3) Cyproheptadine (serotonin antagonist) if supportive measures fail
137
MDX that Increase Li Levels
Thiazide diuretics (eg. chlorthialidone)
ACEI/ ARBs
NSAIDs (EXCEPT ASP or Acetaminophen)
ABXs (eg. tetracyclines, metronidazole)
138
MDX that Decrease Li Levels
K-sparing diuretics (eg. spirinolactone)
| Theophylline (bronchodilator)
139
MDX that Increase or Decrease Li Levels
```
Loop diuretics (eg. furosemide)
CCBs (eg. verapamil or amlodipine) --> safe to use
```
140
Lithium Toxicity
Look for old pt w/ renal failure or hypoNa who is taking Li
- N/V
- Disorientation
- Tremors
- ↑ DTRs
- seizures
141
Tx of Lithium Toxicity
```
IVFs
Bowel irrigation (for asympt acute overdose)
Dialysis
--> Li > 4
--> Li > 2.5 w/ renal failure
--> ↑ Li levels despite IVFs
```
142
Physical sxs w/o medical explanation
Interere w/ pt's life
disproportionate/persistent thoughts about seriousness of sxs
persistently increased anxiety abt health/sxs for ≥ 6 mo
excessive time devoted to these sxs or health concerns
Somatic Symptom Disorder
143
TX of Somatic Symptom Disorder
Maintain single physician as primary caretaker
Schedule brief monthly visits
Schedule individual psychotherapy (do after establishing pt-physician relationship)
Avoid dx testing
Avoid hospitalization
144
preoccupation w/ having or acquiring serious illness despite FEW/NO SXS (SOMATIC SXS NOT PRESENT)
increased anxiety about health
excessive health related behaviors (eg. repeatedly checking signs of illness)
Illness Anxiety Disorder
TX: Frequent, regular check ups
145
1 or more neurological sxs that cannot be explained by any medical or neurologic disorder (eg. mutism, blindness, paralysis, anesthesia/paresthesia)
pt unconcerned about impairment
Conversion Disorder
TX:
supportive pt-physician relationship
Psychotherapy
146
type of conversion disorder in which seizure behavior is due to psychological factors
hx of sexual and physical abuse is common
Psychogenic Nonepileptic Seizures
147
Dx and Tx of Psychogenic Nonepileptic Seizures
DX:
Video electroencephalogram (Gold Stnd Test)
--> combines simultaneous extended EEG monitoring w/ video capture of clinical events
--> NO abn seen on test
TX:
Get psych evaluation and stop any antiepileptics
148
pt has seen many doctors and visited many hospitals
has lot of medical knowledge (eg. health care worker)
demands tx
have NO EXTERNAL GAIN by assuming sick role
may inject insulin to cause hypoglycemia
may inject urine, sputum, feces or milk into skin or bld stream to cause infxns (polymicrobial)
Factitious Disorder
149
Like factitious disorder but mother making up sxs for her child
Factitious Disorder by Proxy
MUST CONTACT CHILD PROTECTIVE SERVICES
150
pt makes up sxs to avoid something or for possible gain (eg. to avoid criminal prosecution, to seeks shelter, MDXs)
see more frequently in prisoners or military personnel
Malingering
151
Tx for Factitious Disorder or Malingering
Psychotherapy
| DON'T confront or accuse the pt
152
young female UNDERWEIGHT
exercises too much or restricts food lot
may purge
has calluses on hands, cavities, amenorrhea, lanugo hair, osteoporosis, dry scaly skin
↓ BP, ↓ HR
EKG changes (from ↓ K)
Anorexia Nervosa
MCC of death = cardiac complications
153
Pregnant woman w/ previous anorexia nervosa is at increased risk for what?
```
preterm birth
IUGR
hyperemesis gravidarum
miscarriage
post-partum depression
C-section
```
154
Tx for Anorexia Nervosa or Bulimia Nervosa
Hospitalize (to give IVFs and correct electrolytes)
Nutritional rehabilitation and behavioral psychotherapy
--> watch out for refeeding syndrome
--> try 1st before giving MDXs
Olanzapine (in anorexia nervosa to help w/ w. gain)
SSRIs to prevent relapse of bulimia nervosa (NOT for anorexia nervosa)
--> never give Bupropion b/c it decreases seizure threshold
155
Refeeding Syndrome
```
anabolic state
↓ Phos, Mg and K
--> carb intake = insulin release = ↓ Phos, Mg, K
CHF, arrhythmias
delirium, seizures
rhabdomyolysis
```
156
Tx for Refeeding Syndrome
replace Phos, Mg, K, thiamine and monitor electrolytes
157
Tx for Body Dysmorphic Disorder
SSRIs (high doses)
158
```
pt age >6
episodes of aggression out of proportion to stressor
--> occur 2x/wk for 3 months
may be h/o head trauma
urine toxicology negative
```
Intermittent Explosive Disorder
TX: SSRIs and mood stabilizers
159
Physical signs of child abuse
```
bruises in diff stages of healing
burns
lacerations
broken bones
shaken baby syndrome
eye hemorrhages
malnutrition
female circumcision (NOT allowed in USA)
```
160
Management of child abuse
1) Separate child from parents (eg. hospitalize child)
| 2) Call child protective services (don't tell parents you're doing this)
161
What other type of abuse must be reported to police?
Elder abuse
162
Reporting is NOT indicated for what type of abuse?
Spousal abuse
163
Personality Disorder:
- pt distrustful and suspicious
- often confused w/ paranoid schizo
- defense mechanism: projection
- -> attributing one's own thoughts to others (eg. husband w/ thoughts of infidelity accuses his wife of being unfaithful)
Paranoid PD
164
Personality Disorder:
- pt emotionally distant
- disinterested in having friends --> like being by themselves
- defense mechanism: projection
- -> attributing one's own thoughts to others (eg. husband w/ thoughts of infidelity accuses his wife of being unfaithful)
Schizoid PD
165
Personality Disorder:
- like schizoid PD except they also have magical thinking
- sxs not severe enough for classification of schizophrenia
Schizotypal PD
166
Personality Disorder:
- colorful, exaggerated behavior and excitable
- use of physical appearance to draw attention to self
- sexually seductive
- defense mechanism: regression
- -> reverting to earlier developmental stage
Histrionic PD
167
Personality Disorder:
- unstable affect, mood swings, inappropriate anger
- unstable relationships
- recurrent suicidal behaviors
- defense mechanism: splitting
- -> seeing others as all bad or all good
Boderling PD
TX: Dialectical behavior therapy
168
Personality Disorder:
- pt ≥ 18 yoa
- continued antisocial or criminal acts
- disregard for the rights of others
- aggressiveness, lack of remorse, deceitfulness
Antisocial PD
If pt <18 = conduct disorder
169
Personality Disorder:
- sense of self-importance
- grandiosity
- requires excessive admiration
- reacts w/ rage when criticized
Narcissistic PD
170
Personality Disorder:
- social inhibition
- feelings of inadequency
- want friends/affection/acceptance but fear rejection
Avoidant PD
171
Personality Disorder:
- submissive and clinging behavior
- need to be taken care of
- worry about abandonment
- inability to assume responsibility
- fear of being alone
- defense mechanism: regression
- -> reverting to earlier developmental stage
Dependent PD
172
Personality Disorder:
- preoccupied w/ orderliness, perfectionism, control
- have no insight of their problem and don't want to change (vs. OCD where pt has insight and wants to change but can't)
Obsessive-Compulsive PD
173
Tx for all Personality Disorders
Psychotherapy
174
Alcohol dependence vs alcohol abuse
```
Dependence = tolerance
Abuse = failure to fulfill obligations, NO tolerance
```
175
Most effective tx for alcohol abuse or prevention of relapse
Alcoholics anonymous
176
Acute Inpatient Management Pearls
1) prevent Wernicke-Korsakoff
- -> give IV thiamine before glucose
2) Benzo
- -> chlordiazepoxide or diazepam (LONG ACTING)
- -> pt has severe liver disease = short acting benzo (eg. lorazepam, oxazepam - part of "LOT")
3) DON'T give seizure ppx or haldol
177
Chronic Maintenance Management for Alcohol Abuse
AA + MDXs
- Naltrexone (opioid antagonist) + acamposate + psychotherapy = decreased relapse
- -> decreases craving and heavy drinking
- -> CI in pts taking opioids and in those w/ liver failure and acute hepatitis
- Disulfiram = poor compliance
178
Best screening tool to assess for unhealthy alcohol use
single item screening
- how many times in the past year have you had 5 (4 for women) or more drinks in a day?
- -> if ≥ 1 day = positive
CAGE questionnaire no longer recommended
179
Alcohol W/D Sxs and Timing
Minor w/d sxs (6 hrs after last drink)
- tremulousness, anxiety, diaphoresis, palpitations, insomnia, headache
- Thiamine + folate + multivitamin + glucose
Alcoholic Hallucinosis (12-24 hrs after last drink)
- visual/auditory or tactile hallucinations
- good vitals and NO AMS
Withdrawal Seizure (48 hrs after last drink)
- tonic-clonic seizures
- get CT scan for repetitive seizures to r/o other causes
Delirium Tremens (48-96 hrs after last drink)
- hallucinations
- unstable vital signs (↑HR, ↑BP, fever)
- disorientation
- agitation
180
Sxs of Amphetamine or Cocaine Intoxication
red turbinates/nasal septum (from snorting cocaine)
"meth mouth" = tooth decay
loss of appetite = weight loss
autonomic hyperactivity (↑ HR, BP, sweating)
PUPIL DILATION
anxiety, insomnia
formication (bugs crawling sensation) --> get skin picking = skin excoriations
Cocaine-Induced MI
--> give ASP, NG, CCBs (NO B-blockers), IV benzo
181
Tx for Amphetamine or Cocaine Intoxication
Benzo + O2
Long term: psychotherapy + 12 step grps (eg. cocaine anonymous)
182
Sxs of Amphetamine or Cocaine Withdrawal
```
increased appetite
depression
risk of suicide
anxiety
tremors
```
183
Sxs of Cannabis Intoxication
increased appetite
social withdrawal
conjunctival redness
impaired motor coordination and time perception
TX: nothing
184
Sxs of Hallucinogens (eg.LSD) Intoxication
PUPIL DILATION
hallucinations
flask backs
impaired judgement
185
Tx of Hallucinogens (eg.LSD) Intoxication
counseling
antipsychotics
benzo
186
Sxs of Inhalants Intoxication
- common in boys ages 14-17
- rapid effect (15-45 min)
- rapidly eliminated from body --> DON'T SHOW UP ON DRUG SCREEN
- ↑ LFTs w/ repeated use
```
perioral rash ("glue snifer's rash")
brief transient euphoria
belligerence/ assaultiveness
apathy
LOC or death
```
187
Tx of Inhalants Intoxication
antipsychotics (if delirious or agitated)
188
Sxs of Opiate (eg. heroin, oxycodone) Intoxication
```
CONSTRICTED PUPILS (not always seen!)
drowsiness
resp. depression (↓ RR)
↓ BP and bowel sounds
unresponsive to painful stimuli
Coma or death
```
189
Tx of Opiate (eg. heroin, oxycodone) Intoxication
For Emergency --> Naloxone (opioid antagonist)
| For Maintenance tx/ to prevent relapse --> Naltrexone (opioid antagonist); also used to prevent alcohol relapse
190
Sxs of Opiate (eg. heroin, oxycodone) Withdrawal
```
DILATED PUPILS
lacrimation
runny nose
abd cramps, diarrhea, N/V
muscle spasms
↑ HR, BP
```
191
Tx of Opiate (eg. heroin, oxycodone) Withdrawal
Clonidine (alpha 2 agonist)
Methadone or Buprenorphine (opioid agonists)
--> ONLY FOR DETOX
--> need supervised inpatient/outpatient setting
192
Sxs of PCP Intoxication
```
agitation
violence
NYSTAGMUS
M. RIGIDITY
HTN
ataxia
decreased pain perception
coma
```
193
Tx of PCP Intoxication
talking down
benzo (eg. lorazepam)
antipsychotics (AFTER BENZO)
mild sxs --> low stimulation environment
194
Sxs of Barbiturates/ Benzo Intoxication
CNS depression
resp. depression
sedation
inappropriate sexual or aggressive behavior
195
Tx of Barbiturates/ Benzo Intoxication
ACUTE OVERDOSE: Flumazenil
196
Sxs of Barbiturates/ Benzo Withdrawal
```
Autonomic hyperactivity (↑ HR, BP)
tremors
PSYCHOSIS
agitation
SEIZURES
delirium
```
197
Tx of Barbiturates/ Benzo Withdrawal
substitute short --> long acting barbiturates
| diazepam --> taper off gradually when sxs under control
198
Sxs of Bath Salts (amphetamine analogs) Intoxication
```
severe agitation
combativeness
delirium
psychosis
MYOCLONUS
↑ HR, BP
```
* **prolonged effects (days-wks) --> "remain psychotic for a week" (vs. PCP where sxs are short lived and PCP found on drug screen)
* **not found on routine drug screen
199
Sxs of Ecstacy (synthetic amphetamine w/ hallucinogenic properties) Intoxication
```
euphoria, dissociated
increases sexual drive
flushed, diaphoretic
↑ HR, BP, hyperthermia
↓ Na
seizure
coma or death
```
* **Combining ecstacy w/ SSRIs/serotonin drugs = serotonin syndrome risk
* **not found on routine drug screen
200
Tx of Delirium
Mild = frequent reorientation of pt
Severe w/ agitation/psychotic sxs = antipsychotics (eg. haloperidol)
Avoid benzos in elderly (unless delirium is from alcohol w/d)
Avoid physical restraints
201
Dx and Tx of Narcolepsy
DX: overnight polysomnography
TX:
- naps during day
- modafinil
- methylphenidate (ritalin) and dextroamphetamine (effective but addictive)
- cataplexy = SNRI (eg. venlafaxine) or SSRI/TCA
202
```
mutism, stupor
catalepsy
posturing
immobility or excessive purposeless movements
echolalia
```
Catatonia
203
Tx of Catatonia
Benzos (eg. lorazepam) --> lorazepam challenge test confirms dx
ECT
204
Risks if Pt w/ Catatonia left untreated
malnutrition
extremely high fever
exhaustion
self inflicted injury
205
Long Acting and Short Acting Nicotine Replacement Therapy (NRT) for Smoking Cessation
Long Acting NRT (eg. nicotine patch) and Short Acting NRT (eg. nasal spray, gum, lozenge, inhaler)
↓ cravings and daytime w/d sxs
long acting can be combined w/ short acting
safe in all pts (even preg pts)
206
Bupropion for Smoking Cessation
↓ post-cessation w. gain
good choice in pts w/ depression
CI in pts w/ seizure disorder or eating disorder
207
Verenicline for Smoking Cessation
Verenicline = partial nicotine receptor agonist
better than NRT or bupropion
increased risk of cardiac events
possible increased risk of depression or suicide
--> thus considered 2nd line for those w/ MDD or h/o suicide
208
Neuroimaging findings for Autistic Spectrum Disorder
increased total brain volume
209
```
prior to age 3
severe, persistent impairment in interpersonal interactions
poor eye contact
absence of social smile
lack of responsiveness to others
language delay
repetitive behaviors (eg. head banging)
fascination over particular objects
below average intellect
```
Autistic Spectrum Disorder
--> combines autism, Asperger's, pervasive developmental disorder, childhood disintegrative disorder
210
```
inattention
hyperactivity (interrupt others, fidget in chairs, talk lot)
interferes w/ pt's daily functioning
```
ADHD
- commonly associated w/ learning disabilities
211
Dx of ADHD
before age 12
sxs present in 2 different settings
need sxs for >6 months
2/3 pts can have sxs (esp. impulsivity and inattentiveness) that persist into adulthood
212
Tx of ADHD
CHILD AGE ≥ 6:
First line: methylphenidate (ritalin) and dextroamphetamine
--> takes few wks to see effects
--> before starting stimulants, pt needs cardiac hx/physical cardiac exam, baseline weight and vitals
--> SEs: insomnia, decreased appetite, tics
--> stimulant therapy does NOT increase risk of substance use disorder
Second line: clonidine (alpha 2 agonist)
Third Line: atomoxetine (NE reuptake inh) - non-stimulant
Parent-Child Behavioral Therapy used w/ MDXs
CHILD AGE 3-5:
First line: behavioral therapy
Second line: MDXs (ONLY if therapy doesn't work or sxs worsening)
213
pt argues w/ others
blames others for their mistakes
problems w/ authority figures
NO illegal/destructive activities
Oppositional Defiant Disorder
TX: teach parents child management skills; have strict clear cut rules
214
```
pt < 18 yoa
rules broken
aggressive (bullying, cruelty to animals, fighting, using weapons)
destroying property, setting fires
steal items
lack remorse for their actions
```
Conduct Disorder
Pt ≥ 18 yoa = antisocial personality disorder
TX: psychotherapy
215
last > 1 yr
multiple motor and vocal tics (eg. head shaking, blinking, throat clearing)
seen before age 18 (begins by age 7)
Tourette Disorder
216
Tx of Tourette Disorder
```
Antipsychotic MDXs (eg. risperidone)
Behavior therapy (habit reversal therapy)
```
217
Pts w/ Tourette Disorder have increased risk of developing what illnesses?
OCD and ADHD
218
Provisional (Transient) Tic Disorder
tics present for <1 yr
219
Chronic Tic Disorder
1 or more motor or vocal tics (BUT NOT BOTH) for ≥ 1 yr
