Psychiatry Flashcards
pt thinks he has special powers; God given missions
Grandiose Delusion
irrational belief that can’t be changed by proof or rational arguments
Delusion
misinterpret stimulus that’s actually there (eg. think tree branch is a person)
Illusion
sensory perception in absence of external stimulus
Hallucination
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
Schizoaffective Disorder
Most effective tx for negative sxs (2)
- atypical antipsychotics
- social skills training
answers diverge from question asked but eventually return to original topic
circumstantiality
answers diverge from question asked and DO NOT return to original topic
tangentiality
no clear sequence to the thoughts presented
loose association
words strung together incoherently
word salad
pt makes up new words
neologism
drugs that cause psychosis sxs
hallucinogens (eg. PCP, LSD) stimulants (eg. cocaine, amphetamines) w/d from alcohol, benzo, barbiturates glucocorticoids anabolic steroids
neuroimaging findings in Schizophrenia
enlargement of 3rd and lateral ventricles
cortical thinning
one person’s delusion transferred to another person
Folie a Deux (Shared Psychotic Disorder)
TX: separate the 2 pts and assess degree of impairment in each
Neurotransmitters responsible for positive vs negative sxs of schizophrenia
Positive = Dopamine Negative = Muscarinic receptors
Positive Sx of Schizophrenia
Delusions (BIZARRE)
Hallucinations
Disorganized thoughts/speech
Negative Sx of Schizophrenia
Apathy Social withdrawal Flattened affect Anhedonia Poverty of thought
+ or - sxs present for 6 months
impact on social/occupational functioning
Schizophrenia
+ or - sxs present for >1 month but < 6 months
impact on social/occupational functioning
Schizophreniform Disorder
+ or - sxs present for <1 month
impact on social/occupational functioning
sxs return to baseline after 1 month
Brief Psychotic Disorder
sxs for many years (has to be at least ≥ 1 month)
no impairment in level of functioning
delusions are NONBIZARRE
Delusional Disorder
Features of Schizophrenia that suggest POOR Prognosis
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
Management of Schizophrenia
- 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
Indications for Antipsychotic Use (5)
- schizophrenia
- depression w/ psychotic features
- mania in bipolar disorder
- sedation when benzos CI
- movement disorders (eg. Huntington’s Disease and Tourrette syndrome)
what two medications should be avoided in 1st psychotic episode and why?
Olanzapine
Clozapine
They cause w. gain and metabolic adverse effects
antipsychotics increase the risk of mortality in what disease?
dementia
First choice medication for tx of schizophrenia when sedation is problem
Risperidone
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
Examples of Low Potency, Typical Antipsychotics
Chlorpromazine
Thioridazine
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)
SEs of Chlorpromazine and Thioridazine
Chlorpromazine –> deposits in Cornea
Thioridazine –> deposits in retina, prolonged QT and arrhythmias (get EKG before starting MDX)
Examples of High Potency, Typical Antipsychotics
Haloperidol Fluphenazine Trifluoperazine Loxapine Thiothixene
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
examples of long acting injectable antipsychotics
Haloperidol
Fluphenazine
Both are high potency, typical antipsychotics
These are good for ppl who are non-compliant
SE of Fluphenazine
Hypothermia
- disrupts thermoregulation and body’s shivering mechanism
which receptors are blocked by Atypical Antipsychotics?
D2 and serotonin receptors
Examples of Atypical Antipsychotics
Aripiprazole Olanzapine Quetiapine Risperidone Clozapine Ziprasidone
NOTE: Atypical antipsychotics are used to augment antidepressants in pts w/ tx-resistant depression
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
SE of risperidone
hyperprolactinemia
–> galactorrhea, amenorrhea, impotence, decreased libido
Indications for Clozapine use
Refractory cases of schizophrenia
–> if pt responded to other antipsychotics in part, then not candidate for clozapine
Schizo w/ suicidality
SEs of clozapine
agranulocytosis
- -> monitor w/ CBC before therapy and weekly during therapy
w. gain - -> monitor glucose and lipids
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
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)
Dopamine Pathways (3)
Mesolimbic Pathway (has to do w/ schizo) Nigrostriatal Pathway (has to do w/ Parkinson) Tuberoinfundibular Pathway (has to do w/ prolactin)
Effects of ↑ DA and ↓ DA in Mesolimbic Pathway
↑ DA: delusions and hallucinations
↓ DA: no (+) sxs of schizo
Effects of ↑ DA and ↓ DA in Nigrostriatal Pathway
↑ DA: chorea/tics
↓ DA: Parkinson sxs + EPS sxs
Effects of ↑ DA and ↓ DA in Tuberoinfundibular Pathway
↑ DA: inhibits prolactin release
↓ DA: releases prolactin = hyperprolactinemia sxs
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
medical causes of anxiety
hyperthyroidism pheochromocytoma excess cortisol heart failure arrhythmias asthma COPD
drug causes of anxiety
corticosteroids caffeine amphetamines cocaine withdrawal from alcohol and sedatives
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
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
Neuroimaging findings of Panic Disorder
Decreased volume of amygdala
Diseases associated w/ panic disorder
Agoraphobia Depression Bipolar Disorder Substance abuse Increased risk of suicide ideations/attempts
Tx for Panic Disorder
CBT
Relaxation training and desensitization (more useful if have agoraphobia sxs also)
SSRIs
PANIC ATTACK: Benzos
Tx of Social Anxiety Disorder
Exposure therapy
ACUTE ATTACK: Benzo
PERFORMANCE ANXIETY: B-blockers (atenolol or propranolol)
excessive poorly controlled anxiety (about EVERYTHING) that occurs daily
≥ 6 months
no precipitating factor
Generalized Anxiety Disorder
Tx for Generalized Anxiety Disorder
psychotherapy (relaxation training, biofeedback)
SSRIs/ SNRIs
buspirone (serotonin receptor partial agonist)
benzo
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
What infection can give you acute sxs of OCD?
recent grp. A strep infxn (seen in kids)
TX: SSRIs
What disorders are common in OCD pts?
Depression
Substance use
NOTE: Pts w/ Tourette syndrome often have OCD
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)
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
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
Benzos safe to use in Liver disease
“LOT”
Lorazepam
Oxazepam
Temazepam
Tx of ACUTE overdose of benzo
flumazenil
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
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)
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
Neuroimaging findings for PTSD
decreased volume of hippocampus
Survivors of Sexual Assault are at Increased Risk for what Psych Problems?
PTSD
Depression
Suicide
Which neurotransmitters are decreased in Major Depression Syndrome?
NE
Serotonin
Dopamine
depressed mood or anhedonia lasting ≥ 2 weeks
“SIGECAPS”
Major Depressive Disorder
NOTE: Adolescents get irritable mood instead of depressed mood
Medical causes of Depression
Hypothyroidism HyperPTH HIV Cancer (eg. CNS neoplasms) Stroke Parkinson's disease Alcohol use Cocaine w/d
MDX that cause Depression
Corticosteroids B-blockers antipsychotics (esp in old ppl) reserpine (antipsychotic; anti-HTN) anti-histamines benzo metoclopramide/prochlorperozine IFN-alpha
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
Tx for single episode of depression
Antidepressant for 6 months after pt responses (don’t change dose in this time)
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)
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
What about depressed pts w/ life expectancy of only 2-4 wks. What to give them?
Methylphenidate (works much faster than antidepressants)
First line SSRI in kids or teens w/ depression?
Fluoxetine
Major depression is an independent risk factor for increased morbidity and mortality in which disease?
Cardiovascular disease
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
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)
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)
depressive sxs in winter months
Seasonal Affective Disorder
TX: phototherapy or sleep deprivation
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
delusions/hallucinations develop during episodes of MDD
NO psychosis EXCEPT during depressive sxs
depression——–depression———–depression
psychosis ————————————-psychosis
MDD w/ Psychotic Features
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)
Mania Sxs
"DIG FAST" Distractibility Indiscretion Grandiosity Flight of ideas Activity increased Sleep decreased Talkative
DDX to consider for Mania
Amphetamine use
Pheochromocytoma
Hyperthyroidism
Hypomania
3 of the sxs of mania
for ONLY 4 days
don’t need hospitalization
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)
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
Management of Bipolar Depression
lamotrigine OR quetiapine (atypical antipsychotic)
NEVER use antidepressants b/c they precipitate mania
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
Maintenance Therapy for Bipolar Disorder
Li/Valproic acid/Lamotrigine + atypical antipsychotic
Rapid Cycling Bipolar
≥ 4 episodes of mania per year
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
SEs of Lamotrigine
Steven-Johnson syndrome
Toxic Epidermal Necrolysis
recurrent HYPOMANIC and depressed mood for ≥ 2 yrs
Cyclothymia
TX:
psychotherapy
divalproex (anticonvulsant)
can’t stay awake in evening (after 7PM)
social functioning difficult
get early morning insomnia due to early bedtime
Advanced Sleep Phase Syndrome
“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
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
Bereavement Presentation in Preschool Children
react w/ disbelief
may have magical thoughts that death is temporary or reversible
Bereavement Presentation in Older Children (>7 yoa)
understand finality of death
may express sadness, anxiety, anger, self-blame, regression and avoidance
<2 wks after delivery
mom mildly depressive
mom cares about baby
Postpartum Blues
TX: self-limited
2 wks - 6 mo after delivery
mom severely depressive
mom has negative thoughts about baby
Postpartum Depression
TX: antidepressants
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
Some Risk Factors for Suicide
h/o suicide threats/attempts (MOST IMPT)
FHx of suicide
white race
Age >65
Many more RFs!
Protective Factors for Suicide
social support/family connectedness (MOST IMPT)
pregnancy
parenthood
religion and participation in religious activities
Depressed pts who deteriorate after initial signs of improvement should be assessed for what?
substance use
- alcohol, stimulants, opiates –> exaggerate depressive sxs
Examples of SSRIs
sertraline fluoxetine paroxetine citalopram escitalopram fluvoxamine
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
Examples of SNRIs
venlafaxine
duloxetine
desvenlafaxine
milnacipran
SEs of SNRIs
sexual dysfxn insomnia anxiety nausea dizziness HTN (w/ venlafaxine) risk of serotonin syndrome
Examples of Atypical Antidepressants
Bupropion (NDRI)
Mirtazapine (alpha 2 adrenergic antagonist)
Trazodone
SEs of Trazodone
SEDATION
PRIAPISM
SEs of Bupropion
NO SEXUAL DYSFXN
W. LOSS
insomnia
↓ SEIZURE THRESHOLD (so don’t use MDX in ppl w/ seizure disorders or eating disorders)
SEs of Mirtazapine
SEDATION
NO SEXUAL DYSFXN
w. gain
Examples of MAOIs
phenelzine
selegiline
tranylcypromine
SEs of MAOIs
HTN CRISIS
–> occurs w/ tyramine containing foods (eg. wine, cheese), antihistamines, or nasal decongestants
TX: Treat as hypertensive crisis
Examples of TCAs
amitryptyline (for chronic pain tx)
imipramine (for enuresis tx)
nortryptyline
clomipramine
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
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
Tx of TCA Overdose
ABCs
charcoal
QRS > 100 msec = Na Bicarbonate
Seizure –> Benzo
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)
What antidepressant should be give to pt who has poor appetite, can’t sleep and is losing weight?
Mirtazapine
Sedating antidepressants
Trazodone
Mirtazapine
TCAs (not used due to other SEs)
Which antidepressants should be avoided in pts w/ seizure disorder?
Bupropion
TCAs
Which SSRI is UNSAFE in preg
Paroxetine
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
Tx of NMS
Stop antipsychotic and transfer to ICU
Dantrolene (inh. Ca release = prevents rigidity and hyperthermia)
Bromocriptine or amantadine
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
Causes of Serotonin Syndrome
SSRIs SNRIs TCAs MAOIs St.John's Wart Triptans Linezolid Levodopa
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
MDX that Increase Li Levels
Thiazide diuretics (eg. chlorthialidone)
ACEI/ ARBs
NSAIDs (EXCEPT ASP or Acetaminophen)
ABXs (eg. tetracyclines, metronidazole)
MDX that Decrease Li Levels
K-sparing diuretics (eg. spirinolactone)
Theophylline (bronchodilator)
MDX that Increase or Decrease Li Levels
Loop diuretics (eg. furosemide) CCBs (eg. verapamil or amlodipine) --> safe to use
Lithium Toxicity
Look for old pt w/ renal failure or hypoNa who is taking Li
- N/V
- Disorientation
- Tremors
- ↑ DTRs
- seizures
Tx of Lithium Toxicity
IVFs Bowel irrigation (for asympt acute overdose) Dialysis --> Li > 4 --> Li > 2.5 w/ renal failure --> ↑ Li levels despite IVFs
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
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
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
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
type of conversion disorder in which seizure behavior is due to psychological factors
hx of sexual and physical abuse is common
Psychogenic Nonepileptic Seizures
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
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
Like factitious disorder but mother making up sxs for her child
Factitious Disorder by Proxy
MUST CONTACT CHILD PROTECTIVE SERVICES
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
Tx for Factitious Disorder or Malingering
Psychotherapy
DON’T confront or accuse the pt
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
Pregnant woman w/ previous anorexia nervosa is at increased risk for what?
preterm birth IUGR hyperemesis gravidarum miscarriage post-partum depression C-section
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
Refeeding Syndrome
anabolic state ↓ Phos, Mg and K --> carb intake = insulin release = ↓ Phos, Mg, K CHF, arrhythmias delirium, seizures rhabdomyolysis
Tx for Refeeding Syndrome
replace Phos, Mg, K, thiamine and monitor electrolytes
Tx for Body Dysmorphic Disorder
SSRIs (high doses)
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
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)
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)
What other type of abuse must be reported to police?
Elder abuse
Reporting is NOT indicated for what type of abuse?
Spousal abuse
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
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
Personality Disorder:
- like schizoid PD except they also have magical thinking
- sxs not severe enough for classification of schizophrenia
Schizotypal PD
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
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
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
Personality Disorder:
- sense of self-importance
- grandiosity
- requires excessive admiration
- reacts w/ rage when criticized
Narcissistic PD
Personality Disorder:
- social inhibition
- feelings of inadequency
- want friends/affection/acceptance but fear rejection
Avoidant PD
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
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
Tx for all Personality Disorders
Psychotherapy
Alcohol dependence vs alcohol abuse
Dependence = tolerance Abuse = failure to fulfill obligations, NO tolerance
Most effective tx for alcohol abuse or prevention of relapse
Alcoholics anonymous
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
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
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
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
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
Tx for Amphetamine or Cocaine Intoxication
Benzo + O2
Long term: psychotherapy + 12 step grps (eg. cocaine anonymous)
Sxs of Amphetamine or Cocaine Withdrawal
increased appetite depression risk of suicide anxiety tremors
Sxs of Cannabis Intoxication
increased appetite
social withdrawal
conjunctival redness
impaired motor coordination and time perception
TX: nothing
Sxs of Hallucinogens (eg.LSD) Intoxication
PUPIL DILATION
hallucinations
flask backs
impaired judgement
Tx of Hallucinogens (eg.LSD) Intoxication
counseling
antipsychotics
benzo
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
Tx of Inhalants Intoxication
antipsychotics (if delirious or agitated)
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
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
Sxs of Opiate (eg. heroin, oxycodone) Withdrawal
DILATED PUPILS lacrimation runny nose abd cramps, diarrhea, N/V muscle spasms ↑ HR, BP
Tx of Opiate (eg. heroin, oxycodone) Withdrawal
Clonidine (alpha 2 agonist)
Methadone or Buprenorphine (opioid agonists)
–> ONLY FOR DETOX
–> need supervised inpatient/outpatient setting
Sxs of PCP Intoxication
agitation violence NYSTAGMUS M. RIGIDITY HTN ataxia decreased pain perception coma
Tx of PCP Intoxication
talking down
benzo (eg. lorazepam)
antipsychotics (AFTER BENZO)
mild sxs –> low stimulation environment
Sxs of Barbiturates/ Benzo Intoxication
CNS depression
resp. depression
sedation
inappropriate sexual or aggressive behavior
Tx of Barbiturates/ Benzo Intoxication
ACUTE OVERDOSE: Flumazenil
Sxs of Barbiturates/ Benzo Withdrawal
Autonomic hyperactivity (↑ HR, BP) tremors PSYCHOSIS agitation SEIZURES delirium
Tx of Barbiturates/ Benzo Withdrawal
substitute short –> long acting barbiturates
diazepam –> taper off gradually when sxs under control
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
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
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
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
mutism, stupor catalepsy posturing immobility or excessive purposeless movements echolalia
Catatonia
Tx of Catatonia
Benzos (eg. lorazepam) –> lorazepam challenge test confirms dx
ECT
Risks if Pt w/ Catatonia left untreated
malnutrition
extremely high fever
exhaustion
self inflicted injury
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)
Bupropion for Smoking Cessation
↓ post-cessation w. gain
good choice in pts w/ depression
CI in pts w/ seizure disorder or eating disorder
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
Neuroimaging findings for Autistic Spectrum Disorder
increased total brain volume
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
inattention hyperactivity (interrupt others, fidget in chairs, talk lot) interferes w/ pt's daily functioning
ADHD
- commonly associated w/ learning disabilities
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
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)
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
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
last > 1 yr
multiple motor and vocal tics (eg. head shaking, blinking, throat clearing)
seen before age 18 (begins by age 7)
Tourette Disorder
Tx of Tourette Disorder
Antipsychotic MDXs (eg. risperidone) Behavior therapy (habit reversal therapy)
Pts w/ Tourette Disorder have increased risk of developing what illnesses?
OCD and ADHD
Provisional (Transient) Tic Disorder
tics present for <1 yr
Chronic Tic Disorder
1 or more motor or vocal tics (BUT NOT BOTH) for ≥ 1 yr
