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USMLE Step 3 - ALL > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

pt thinks he has special powers; God given missions

A

Grandiose Delusion

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2
Q

irrational belief that can’t be changed by proof or rational arguments

A

Delusion

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3
Q

misinterpret stimulus that’s actually there (eg. think tree branch is a person)

A

Illusion

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4
Q

sensory perception in absence of external stimulus

A

Hallucination

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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

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6
Q

Most effective tx for negative sxs (2)

A
  • atypical antipsychotics

- social skills training

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7
Q

answers diverge from question asked but eventually return to original topic

A

circumstantiality

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8
Q

answers diverge from question asked and DO NOT return to original topic

A

tangentiality

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9
Q

no clear sequence to the thoughts presented

A

loose association

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10
Q

words strung together incoherently

A

word salad

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11
Q

pt makes up new words

A

neologism

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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
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13
Q

neuroimaging findings in Schizophrenia

A

enlargement of 3rd and lateral ventricles

cortical thinning

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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

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15
Q

Neurotransmitters responsible for positive vs negative sxs of schizophrenia

A 
Positive = Dopamine
Negative = Muscarinic receptors
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16
Q

Positive Sx of Schizophrenia

A

Delusions (BIZARRE)
Hallucinations
Disorganized thoughts/speech

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17
Q

Negative Sx of Schizophrenia

A 
Apathy 
Social withdrawal 
Flattened affect 
Anhedonia
Poverty of thought
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18
Q

+ or - sxs present for 6 months

impact on social/occupational functioning

A

Schizophrenia

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19
Q

+ or - sxs present for >1 month but < 6 months

impact on social/occupational functioning

A

Schizophreniform Disorder

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20
Q

+ or - sxs present for <1 month
impact on social/occupational functioning
sxs return to baseline after 1 month

A

Brief Psychotic Disorder

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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

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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
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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
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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)
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25
Q

what two medications should be avoided in 1st psychotic episode and why?

A

Olanzapine
Clozapine

They cause w. gain and metabolic adverse effects

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26
Q

antipsychotics increase the risk of mortality in what disease?

A

dementia

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27
Q

First choice medication for tx of schizophrenia when sedation is problem

A

Risperidone

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28
Q

which receptors are blocked by Typical Antipsychotics and what are the 2 categories of Typical Antipsychotics?

A

Block D1 and D2 receptors

Low potency and High potency

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29
Q

Examples of Low Potency, Typical Antipsychotics

A

Chlorpromazine

Thioridazine

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30
Q

Advantages and Disadvantages of Low Potency, Typical Antipsychotics

A

Advantages:
- Less EPS sxs

Disadvantages:

  • Anticholinergic SEs (eg. dry mouth, urinary retention)
  • alpha 1 blockade (orthostatic BP)
  • anti-histamine SEs (sedating)
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31
Q

SEs of Chlorpromazine and Thioridazine

A

Chlorpromazine –> deposits in Cornea

Thioridazine –> deposits in retina, prolonged QT and arrhythmias (get EKG before starting MDX)

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32
Q

Examples of High Potency, Typical Antipsychotics

A 
Haloperidol
Fluphenazine
Trifluoperazine
Loxapine
Thiothixene
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33
Q

Advantages and Disadvantages of High Potency, Typical Antipsychotics

A

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

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34
Q

examples of long acting injectable antipsychotics

A

Haloperidol
Fluphenazine

Both are high potency, typical antipsychotics
These are good for ppl who are non-compliant

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35
Q

SE of Fluphenazine

A

Hypothermia

- disrupts thermoregulation and body’s shivering mechanism

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36
Q

which receptors are blocked by Atypical Antipsychotics?

A

D2 and serotonin receptors

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37
Q

Examples of Atypical Antipsychotics

A 
Aripiprazole 
Olanzapine 
Quetiapine
Risperidone
Clozapine
Ziprasidone

NOTE: Atypical antipsychotics are used to augment antidepressants in pts w/ tx-resistant depression

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38
Q

Advantages and Disadvantages of Atypical Antipsychotics

A

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
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39
Q

SE of risperidone

A

hyperprolactinemia

–> galactorrhea, amenorrhea, impotence, decreased libido

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40
Q

Indications for Clozapine use

A

Refractory cases of schizophrenia
–> if pt responded to other antipsychotics in part, then not candidate for clozapine
Schizo w/ suicidality

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41
Q

SEs of clozapine

A

agranulocytosis

  • -> monitor w/ CBC before therapy and weekly during therapy
    w. gain
  • -> monitor glucose and lipids
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42
Q

List Extrapyramidal SEs

A

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

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43
Q

Tx of Extrapyramidal SEs

A

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)

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44
Q

Dopamine Pathways (3)

A 
Mesolimbic Pathway (has to do w/ schizo)
Nigrostriatal Pathway (has to do w/ Parkinson) 
Tuberoinfundibular Pathway (has to do w/ prolactin)
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45
Q

Effects of ↑ DA and ↓ DA in Mesolimbic Pathway

A

↑ DA: delusions and hallucinations

↓ DA: no (+) sxs of schizo

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46
Q

Effects of ↑ DA and ↓ DA in Nigrostriatal Pathway

A

↑ DA: chorea/tics

↓ DA: Parkinson sxs + EPS sxs

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47
Q

Effects of ↑ DA and ↓ DA in Tuberoinfundibular Pathway

A

↑ DA: inhibits prolactin release

↓ DA: releases prolactin = hyperprolactinemia sxs

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48
Q

Medical illnesses to r/o before dx of schizo

A
  • hypo/hyperthyroidism (get TSH)
  • electrolyte abn (get BMP)
  • HIV (get serology)
  • syphilis (get VDRL)
  • drug intoxication (get drug screen)
  • temporal lobe epilepsy
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49
Q

medical causes of anxiety

A 
hyperthyroidism
pheochromocytoma
excess cortisol
heart failure 
arrhythmias 
asthma
COPD
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50
Q

drug causes of anxiety

A 
corticosteroids
caffeine
amphetamines
cocaine
withdrawal from alcohol and sedatives
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51
Q

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

A

Adjustment Disorder

TX: counseling

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52
Q

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

A

Panic Disorder

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53
Q

Neuroimaging findings of Panic Disorder

A

Decreased volume of amygdala

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54
Q

Diseases associated w/ panic disorder

A 
Agoraphobia
Depression
Bipolar Disorder
Substance abuse 
Increased risk of suicide ideations/attempts
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55
Q

Tx for Panic Disorder

A

CBT
Relaxation training and desensitization (more useful if have agoraphobia sxs also)
SSRIs

PANIC ATTACK: Benzos

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56
Q

Tx of Social Anxiety Disorder

A

Exposure therapy

ACUTE ATTACK: Benzo
PERFORMANCE ANXIETY: B-blockers (atenolol or propranolol)

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57
Q

excessive poorly controlled anxiety (about EVERYTHING) that occurs daily
≥ 6 months
no precipitating factor

A

Generalized Anxiety Disorder

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58
Q

Tx for Generalized Anxiety Disorder

A

psychotherapy (relaxation training, biofeedback)
SSRIs/ SNRIs
buspirone (serotonin receptor partial agonist)
benzo

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59
Q

recurrent obsessions or compulsions

pt KNOWS behavior is unreasonable

A

Obsessive Compulsive Disorder

NOTE: To dx OCD, need EITHER obsessions or compulsions; don’t need both

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60
Q

What infection can give you acute sxs of OCD?

A

recent grp. A strep infxn (seen in kids)

TX: SSRIs

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61
Q

What disorders are common in OCD pts?

A

Depression
Substance use

NOTE: Pts w/ Tourette syndrome often have OCD

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62
Q

Tx for Obsessive Compulsive Disorder

A

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)

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63
Q

general guidelines about benzo use

A

don’t change doses abruptly –> can get SEIZURES
use lowest dose possible in elderly
advice against using machinery or driving

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64
Q

Shortest to Longest Half Life of Benzos

A

Shortest to Longest Half Life:

Alprazolam
Lorazepam (can be used in IM form; esp helpful for emergency situations)
Diazepam

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65
Q

Benzos safe to use in Liver disease

A

“LOT”
Lorazepam
Oxazepam
Temazepam

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66
Q

Tx of ACUTE overdose of benzo

A

flumazenil

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67
Q

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)

A

Acute Stress Disorder

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68
Q

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)

A

Post-traumatic Stress Disorder (PTSD)

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69
Q

Tx for Acute Stress Disorder + PTSD

A

ACUTE ANXIETY: Benzo

Trauma-focused brief CBT
LONG TERM: SSRIs
NIGHTMARES: Prazosin (alpha blocker)

Most effective therapy to PREVENT PTSD = group counseling

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70
Q

Neuroimaging findings for PTSD

A

decreased volume of hippocampus

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71
Q

Survivors of Sexual Assault are at Increased Risk for what Psych Problems?

A

PTSD
Depression
Suicide

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72
Q

Which neurotransmitters are decreased in Major Depression Syndrome?

A

NE
Serotonin
Dopamine

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73
Q

depressed mood or anhedonia lasting ≥ 2 weeks

“SIGECAPS”

A

Major Depressive Disorder

NOTE: Adolescents get irritable mood instead of depressed mood

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74
Q

Medical causes of Depression

A 
Hypothyroidism 
HyperPTH
HIV
Cancer (eg. CNS neoplasms) 
Stroke
Parkinson's disease 
Alcohol use 
Cocaine w/d
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75
Q

MDX that cause Depression

A 
Corticosteroids 
B-blockers
antipsychotics (esp in old ppl) 
reserpine (antipsychotic; anti-HTN) 
anti-histamines
benzo
metoclopramide/prochlorperozine
IFN-alpha
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76
Q

Tx of Major Depressive Disorder

A

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
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77
Q

Tx for single episode of depression

A

Antidepressant for 6 months after pt responses (don’t change dose in this time)

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78
Q

Tx for multiple episodes of depression

A

maintenance therapy req’d for long time (1-3 yrs) OR for life (if episodes very severe or ≥ 3 episodes)

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79
Q

Indications for Electroconvulsive Therapy (ECT)

SE of ECT

A

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

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80
Q

What about depressed pts w/ life expectancy of only 2-4 wks. What to give them?

A

Methylphenidate (works much faster than antidepressants)

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81
Q

First line SSRI in kids or teens w/ depression?

A

Fluoxetine

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82
Q

Major depression is an independent risk factor for increased morbidity and mortality in which disease?

A

Cardiovascular disease

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83
Q

pts w/ late onset depression (after age 65) are at increased risk for developing what diseases when compared to those that present earlier?

A

Alzheimer’s Disease

Vascular dementia

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84
Q

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

A

Pseudodementia

Can detect real depression via dexamethasone suppression test (test will be abn in 50% pts w/ depression)

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85
Q

low level depression sxs that are present on most days for at least 2 years

A

Dysthmic Disorder (Persistent Depressive Disorder)

TX:
long term individual, insight-oriented psychotherapy
SSRIs (if psychotherapy fails)

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86
Q

depressive sxs in winter months

A

Seasonal Affective Disorder

TX: phototherapy or sleep deprivation

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87
Q 
mood reactivity 
increased appetite/weight 
hypersomnia
leaden paralysis (arms and legs feel heavy) 
hypersensitive to rejection
A

MDD w/ Atypical Features

TX: respond well to MAOIs and SSRIs

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88
Q

delusions/hallucinations develop during episodes of MDD
NO psychosis EXCEPT during depressive sxs

depression——–depression———–depression
psychosis ————————————-psychosis

A

MDD w/ Psychotic Features

89
Q

depression, mania or mixed sxs
distress or impaired functioning
for ≥ 1 week

A

Bipolar Disorder

Bipolar I –> mania + depression (don’t need depression for dx)
Bipolar II –> hypomania + depression (NEED BOTH)

90
Q

Mania Sxs

A 
"DIG FAST"
Distractibility 
Indiscretion 
Grandiosity 
Flight of ideas 
Activity increased
Sleep decreased
Talkative
91
Q

DDX to consider for Mania

A

Amphetamine use
Pheochromocytoma
Hyperthyroidism

92
Q

Hypomania

A

3 of the sxs of mania
for ONLY 4 days
don’t need hospitalization

93
Q

Management of ACUTE Mania

A

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
Q

Duration of Lithium Tx Guidelines

A

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
Q

Management of Bipolar Depression

A

lamotrigine OR quetiapine (atypical antipsychotic)

NEVER use antidepressants b/c they precipitate mania

96
Q

Management of Severe Mania in Pregnancy

A

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
Q

Maintenance Therapy for Bipolar Disorder

A

Li/Valproic acid/Lamotrigine + atypical antipsychotic

98
Q

Rapid Cycling Bipolar

A

≥ 4 episodes of mania per year

99
Q

SEs of Lithium

A 
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
Q

SEs of Lamotrigine

A

Steven-Johnson syndrome

Toxic Epidermal Necrolysis

101
Q

recurrent HYPOMANIC and depressed mood for ≥ 2 yrs

A

Cyclothymia

TX:
psychotherapy
divalproex (anticonvulsant)

102
Q

can’t stay awake in evening (after 7PM)
social functioning difficult
get early morning insomnia due to early bedtime

A

Advanced Sleep Phase Syndrome

103
Q

“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

A

Delayed Sleep Phase Syndrome

TX: respond to light or behavioral therapy

104
Q

Grief (Bereavement) vs Depression

A

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
Q

Bereavement Presentation in Preschool Children

A

react w/ disbelief

may have magical thoughts that death is temporary or reversible

106
Q

Bereavement Presentation in Older Children (>7 yoa)

A

understand finality of death

may express sadness, anxiety, anger, self-blame, regression and avoidance

107
Q

<2 wks after delivery
mom mildly depressive
mom cares about baby

A

Postpartum Blues

TX: self-limited

108
Q

2 wks - 6 mo after delivery
mom severely depressive
mom has negative thoughts about baby

A

Postpartum Depression

TX: antidepressants

109
Q

w/in 2-3 wks after delivery
mom has psychotic sxs + severe depressive sxs
mom has thoughts of hurting baby

A

Postpartum Psychosis

TX:
mood stabilizers or antipsychotics + antidepressants
if pt breastfeeding, do ECT instead of MDXs

110
Q

Some Risk Factors for Suicide

A

h/o suicide threats/attempts (MOST IMPT)
FHx of suicide
white race
Age >65

Many more RFs!

111
Q

Protective Factors for Suicide

A

social support/family connectedness (MOST IMPT)
pregnancy
parenthood
religion and participation in religious activities

112
Q

Depressed pts who deteriorate after initial signs of improvement should be assessed for what?

A

substance use

- alcohol, stimulants, opiates –> exaggerate depressive sxs

113
Q

Examples of SSRIs

A 
sertraline
fluoxetine
paroxetine
citalopram
escitalopram
fluvoxamine
114
Q

SEs of SSRIs

A 
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
Q

Examples of SNRIs

A

venlafaxine
duloxetine
desvenlafaxine
milnacipran

116
Q

SEs of SNRIs

A 
sexual dysfxn
insomnia
anxiety 
nausea
dizziness 
HTN (w/ venlafaxine) 
risk of serotonin syndrome
117
Q

Examples of Atypical Antidepressants

A

Bupropion (NDRI)
Mirtazapine (alpha 2 adrenergic antagonist)
Trazodone

118
Q

SEs of Trazodone

A

SEDATION

PRIAPISM

119
Q

SEs of Bupropion

A

NO SEXUAL DYSFXN
W. LOSS
insomnia
↓ SEIZURE THRESHOLD (so don’t use MDX in ppl w/ seizure disorders or eating disorders)

120
Q

SEs of Mirtazapine

A

SEDATION
NO SEXUAL DYSFXN
w. gain

121
Q

Examples of MAOIs

A

phenelzine
selegiline
tranylcypromine

122
Q

SEs of MAOIs

A

HTN CRISIS
–> occurs w/ tyramine containing foods (eg. wine, cheese), antihistamines, or nasal decongestants

TX: Treat as hypertensive crisis

123
Q

Examples of TCAs

A

amitryptyline (for chronic pain tx)
imipramine (for enuresis tx)
nortryptyline
clomipramine

124
Q

SEs of TCAs

A

ANTICHOLINERGIC EFFECTS (dry mouth, constipation, urinary retention, blurred vision)
SEDATION (anti-histamine effects)
ORTHOSTATIC HYPOTENSION (alpha 1 adrenergic blockade)
sexual dysfxn
w. gain

125
Q

Sxs of TCA Overdose

A

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
Q

Tx of TCA Overdose

A

ABCs
charcoal
QRS > 100 msec = Na Bicarbonate
Seizure –> Benzo

127
Q

What antidepressant should be given to pt concerned abt w. gain and sexual side effects

A

Bupropion

Mirtazapine also DOES NOT cause sexual side effects (BUT causes w gain)

128
Q

What antidepressant should be give to pt who has poor appetite, can’t sleep and is losing weight?

A

Mirtazapine

129
Q

Sedating antidepressants

A

Trazodone
Mirtazapine
TCAs (not used due to other SEs)

130
Q

Which antidepressants should be avoided in pts w/ seizure disorder?

A

Bupropion

TCAs

131
Q

Which SSRI is UNSAFE in preg

A

Paroxetine

132
Q

NMS Sxs

A 
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
Q

Tx of NMS

A

Stop antipsychotic and transfer to ICU
Dantrolene (inh. Ca release = prevents rigidity and hyperthermia)
Bromocriptine or amantadine

134
Q

Serotonin Syndrome Sxs

A 
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
Q

Causes of Serotonin Syndrome

A 
SSRIs
SNRIs
TCAs
MAOIs
St.John's Wart 
Triptans
Linezolid
Levodopa
136
Q

Tx of Serotonin Syndrome

A

1) D/c all serotonogenic MDXs
2) Supportive care - IVFs, O2
3) Sedation w/ benzos
3) Cyproheptadine (serotonin antagonist) if supportive measures fail

137
Q

MDX that Increase Li Levels

A

Thiazide diuretics (eg. chlorthialidone)
ACEI/ ARBs
NSAIDs (EXCEPT ASP or Acetaminophen)
ABXs (eg. tetracyclines, metronidazole)

138
Q

MDX that Decrease Li Levels

A

K-sparing diuretics (eg. spirinolactone)

Theophylline (bronchodilator)

139
Q

MDX that Increase or Decrease Li Levels

A 
Loop diuretics (eg. furosemide) 
CCBs (eg. verapamil or amlodipine) --> safe to use
140
Q

Lithium Toxicity

A

Look for old pt w/ renal failure or hypoNa who is taking Li

  • N/V
  • Disorientation
  • Tremors
  • ↑ DTRs
  • seizures
141
Q

Tx of Lithium Toxicity

A 
IVFs
Bowel irrigation (for asympt acute overdose) 
Dialysis 
  --> Li > 4
  --> Li > 2.5 w/ renal failure 
  --> ↑ Li levels despite IVFs
142
Q

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

A

Somatic Symptom Disorder

143
Q

TX of Somatic Symptom Disorder

A

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
Q

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)

A

Illness Anxiety Disorder

TX: Frequent, regular check ups

145
Q

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

A

Conversion Disorder

TX:
supportive pt-physician relationship
Psychotherapy

146
Q

type of conversion disorder in which seizure behavior is due to psychological factors
hx of sexual and physical abuse is common

A

Psychogenic Nonepileptic Seizures

147
Q

Dx and Tx of Psychogenic Nonepileptic Seizures

A

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
Q

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)

A

Factitious Disorder

149
Q

Like factitious disorder but mother making up sxs for her child

A

Factitious Disorder by Proxy

MUST CONTACT CHILD PROTECTIVE SERVICES

150
Q

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

A

Malingering

151
Q

Tx for Factitious Disorder or Malingering

A

Psychotherapy

DON’T confront or accuse the pt

152
Q

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)

A

Anorexia Nervosa

MCC of death = cardiac complications

153
Q

Pregnant woman w/ previous anorexia nervosa is at increased risk for what?

A 
preterm birth
IUGR
hyperemesis gravidarum 
miscarriage
post-partum depression 
C-section
154
Q

Tx for Anorexia Nervosa or Bulimia Nervosa

A

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
Q

Refeeding Syndrome

A 
anabolic state 
↓ Phos, Mg and K 
  --> carb intake = insulin release = ↓ Phos, Mg, K 
CHF, arrhythmias
delirium, seizures
rhabdomyolysis
156
Q

Tx for Refeeding Syndrome

A

replace Phos, Mg, K, thiamine and monitor electrolytes

157
Q

Tx for Body Dysmorphic Disorder

A

SSRIs (high doses)

158
Q 
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
A

Intermittent Explosive Disorder

TX: SSRIs and mood stabilizers

159
Q

Physical signs of child abuse

A 
bruises in diff stages of healing 
burns
lacerations 
broken bones 
shaken baby syndrome 
eye hemorrhages 
malnutrition 
female circumcision (NOT allowed in USA)
160
Q

Management of child abuse

A

1) Separate child from parents (eg. hospitalize child)

2) Call child protective services (don’t tell parents you’re doing this)

161
Q

What other type of abuse must be reported to police?

A

Elder abuse

162
Q

Reporting is NOT indicated for what type of abuse?

A

Spousal abuse

163
Q

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)
A

Paranoid PD

164
Q

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)
A

Schizoid PD

165
Q

Personality Disorder:

  • like schizoid PD except they also have magical thinking
  • sxs not severe enough for classification of schizophrenia
A

Schizotypal PD

166
Q

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
A

Histrionic PD

167
Q

Personality Disorder:

  • unstable affect, mood swings, inappropriate anger
  • unstable relationships
  • recurrent suicidal behaviors
  • defense mechanism: splitting
    • -> seeing others as all bad or all good
A

Boderling PD

TX: Dialectical behavior therapy

168
Q

Personality Disorder:

  • pt ≥ 18 yoa
  • continued antisocial or criminal acts
  • disregard for the rights of others
  • aggressiveness, lack of remorse, deceitfulness
A

Antisocial PD

If pt <18 = conduct disorder

169
Q

Personality Disorder:

  • sense of self-importance
  • grandiosity
  • requires excessive admiration
  • reacts w/ rage when criticized
A

Narcissistic PD

170
Q

Personality Disorder:

  • social inhibition
  • feelings of inadequency
  • want friends/affection/acceptance but fear rejection
A

Avoidant PD

171
Q

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
A

Dependent PD

172
Q

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)
A

Obsessive-Compulsive PD

173
Q

Tx for all Personality Disorders

A

Psychotherapy

174
Q

Alcohol dependence vs alcohol abuse

A 
Dependence = tolerance
Abuse = failure to fulfill obligations, NO tolerance
175
Q

Most effective tx for alcohol abuse or prevention of relapse

A

Alcoholics anonymous

176
Q

Acute Inpatient Management Pearls

A

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
Q

Chronic Maintenance Management for Alcohol Abuse

A

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
Q

Best screening tool to assess for unhealthy alcohol use

A

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
Q

Alcohol W/D Sxs and Timing

A

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
Q

Sxs of Amphetamine or Cocaine Intoxication

A

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
Q

Tx for Amphetamine or Cocaine Intoxication

A

Benzo + O2

Long term: psychotherapy + 12 step grps (eg. cocaine anonymous)

182
Q

Sxs of Amphetamine or Cocaine Withdrawal

A 
increased appetite
depression 
risk of suicide
anxiety 
tremors
183
Q

Sxs of Cannabis Intoxication

A

increased appetite
social withdrawal
conjunctival redness
impaired motor coordination and time perception

TX: nothing

184
Q

Sxs of Hallucinogens (eg.LSD) Intoxication

A

PUPIL DILATION
hallucinations
flask backs
impaired judgement

185
Q

Tx of Hallucinogens (eg.LSD) Intoxication

A

counseling
antipsychotics
benzo

186
Q

Sxs of Inhalants Intoxication

A
  • 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
Q

Tx of Inhalants Intoxication

A

antipsychotics (if delirious or agitated)

188
Q

Sxs of Opiate (eg. heroin, oxycodone) Intoxication

A 
CONSTRICTED PUPILS (not always seen!) 
drowsiness
resp. depression (↓ RR) 
↓ BP and bowel sounds 
unresponsive to painful stimuli 
Coma or death
189
Q

Tx of Opiate (eg. heroin, oxycodone) Intoxication

A

For Emergency –> Naloxone (opioid antagonist)

For Maintenance tx/ to prevent relapse –> Naltrexone (opioid antagonist); also used to prevent alcohol relapse

190
Q

Sxs of Opiate (eg. heroin, oxycodone) Withdrawal

A 
DILATED PUPILS 
lacrimation 
runny nose
abd cramps, diarrhea, N/V 
muscle spasms 
↑ HR, BP
191
Q

Tx of Opiate (eg. heroin, oxycodone) Withdrawal

A

Clonidine (alpha 2 agonist)
Methadone or Buprenorphine (opioid agonists)
–> ONLY FOR DETOX
–> need supervised inpatient/outpatient setting

192
Q

Sxs of PCP Intoxication

A 
agitation 
violence 
NYSTAGMUS 
M. RIGIDITY
HTN
ataxia
decreased pain perception 
coma
193
Q

Tx of PCP Intoxication

A

talking down
benzo (eg. lorazepam)
antipsychotics (AFTER BENZO)
mild sxs –> low stimulation environment

194
Q

Sxs of Barbiturates/ Benzo Intoxication

A

CNS depression
resp. depression
sedation
inappropriate sexual or aggressive behavior

195
Q

Tx of Barbiturates/ Benzo Intoxication

A

ACUTE OVERDOSE: Flumazenil

196
Q

Sxs of Barbiturates/ Benzo Withdrawal

A 
Autonomic hyperactivity (↑ HR, BP) 
tremors 
PSYCHOSIS 
agitation 
SEIZURES
delirium
197
Q

Tx of Barbiturates/ Benzo Withdrawal

A

substitute short –> long acting barbiturates

diazepam –> taper off gradually when sxs under control

198
Q

Sxs of Bath Salts (amphetamine analogs) Intoxication

A 
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
Q

Sxs of Ecstacy (synthetic amphetamine w/ hallucinogenic properties) Intoxication

A 
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
Q

Tx of Delirium

A

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
Q

Dx and Tx of Narcolepsy

A

DX: overnight polysomnography

TX:

  • naps during day
  • modafinil
  • methylphenidate (ritalin) and dextroamphetamine (effective but addictive)
  • cataplexy = SNRI (eg. venlafaxine) or SSRI/TCA
202
Q 
mutism, stupor 
catalepsy 
posturing 
immobility or excessive purposeless movements 
echolalia
A

Catatonia

203
Q

Tx of Catatonia

A

Benzos (eg. lorazepam) –> lorazepam challenge test confirms dx
ECT

204
Q

Risks if Pt w/ Catatonia left untreated

A

malnutrition
extremely high fever
exhaustion
self inflicted injury

205
Q

Long Acting and Short Acting Nicotine Replacement Therapy (NRT) for Smoking Cessation

A

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
Q

Bupropion for Smoking Cessation

A

↓ post-cessation w. gain
good choice in pts w/ depression
CI in pts w/ seizure disorder or eating disorder

207
Q

Verenicline for Smoking Cessation

A

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
Q

Neuroimaging findings for Autistic Spectrum Disorder

A

increased total brain volume

209
Q 
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
A

Autistic Spectrum Disorder

–> combines autism, Asperger’s, pervasive developmental disorder, childhood disintegrative disorder

210
Q 
inattention
hyperactivity (interrupt others, fidget in chairs, talk lot) 
interferes w/ pt's daily functioning
A

ADHD

  • commonly associated w/ learning disabilities
211
Q

Dx of ADHD

A

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
Q

Tx of ADHD

A

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
Q

pt argues w/ others
blames others for their mistakes
problems w/ authority figures
NO illegal/destructive activities

A

Oppositional Defiant Disorder

TX: teach parents child management skills; have strict clear cut rules

214
Q 
pt < 18 yoa 
rules broken
aggressive (bullying, cruelty to animals, fighting, using weapons) 
destroying property, setting fires 
steal items 
lack remorse for their actions
A

Conduct Disorder

Pt ≥ 18 yoa = antisocial personality disorder

TX: psychotherapy

215
Q

last > 1 yr
multiple motor and vocal tics (eg. head shaking, blinking, throat clearing)
seen before age 18 (begins by age 7)

A

Tourette Disorder

216
Q

Tx of Tourette Disorder

A 
Antipsychotic MDXs (eg. risperidone) 
Behavior therapy (habit reversal therapy)
217
Q

Pts w/ Tourette Disorder have increased risk of developing what illnesses?

A

OCD and ADHD

218
Q

Provisional (Transient) Tic Disorder

A

tics present for <1 yr

219
Q

Chronic Tic Disorder

A

1 or more motor or vocal tics (BUT NOT BOTH) for ≥ 1 yr

USMLE Step 3 - ALL (9 decks)

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