Psychiatry Flashcards
generalized anxiety disorder (GAD): definition, dx criteria, tx
persistent, excess anxiety over general life events > 6mo
Dx:
- restlessness
- easy fatigue
- irritable
- sleep distrubance
- muscle tension
- difficulty concentrating
Tx: behavior therapy + meds
- 1st line: SSRI, SNRI, busprione
- benzo for short-term adjust only
panic attack: definition, dx criteria, tx
extreme anxiety or intense fear
- lasts 5-20 min
- may or may not have identifiable trigger
- accompanied by 1 mo of fear of additional attack or change behavior due to fear of attack
tx: therapy + meds
- short-course benzos (lorazepam) then start SSRI for long-term tx
- propranolol not as effective as SSRIs
- mild: relaxation, psychotherapy
phobias
irrational fear and persistent excess anxiety when presented with object or situation
- causes immediate anxiety, panic attack
- interferes with daily functioning
specific phobia
fear of specific object/situation lasting at least 6 months
- onset in childhood
- animals, insects, heights, blood, needles, contamination, confined spaces, choking, becoming sick, etc.
Tx:
- 1st line: desensitization/ exposure therapy/ flooding
- Short-term benzos, b-blockers
social phobia
fear of social situations
- onset in adolescents
- public speaking
- using public bathrooms
- eating in public
agoraphobia
anxiety about placing self in situation in which problem may occur and help will be unavailable
- fear of public places (bus, crowd, cinema)
- situations often avoided
- often experience panic attack
Tx: therapy + meds
- 1st line: SSRI, SNRI
- beta-blockers (propanolol) for performance-related situations
obsessive-compulsive disorder (OCD): definition
obsessions: persistent, recurrent thoughts that are intrusive and inappropriate resulting in anxiety
compulsions: ritualistic/repetitive behaviors or thoughts pts do to relieve anxiety
- may have no connection b/t event pt is trying to avoid
most people realize that thoughts and behaviors are irrational
obsessive-compulsive disorder (OCD): common examples, tx
contamination: hand washing
doubt: worry (forget to lock door, turn off stove)
symmetry: extreme precision
other: nail biting, trichotillomania (hair pulling), skin picking, counting
Tx: therapy + meds
- SSRI (higher dose)
- exposure therapy
body dysmorphic disorder
preoccupation w/ imagined defect in physical appearance
- exaggerated distortion of minor flaw
- common: face, hair, skin, breasts, genitalia
Tx:
- CBT + SSRI
- delusional: add 2nd generation antipsychotic
post traumatic stress disorder (PTSD): definiton and sxs
exposure to actual or threatened death or serious injury; learning about event occurring to friend or family
- feel helpless, fear, horror than impair daily fx
sx:
- KEY: last > 1 month
- occur 1 week to yrs after event
- fluctuate over time
post traumatic stress disorder (PTSD): 4 elements, common causes
4 major elements:
- re-experince trauma (dreams, memories, flashbacks)
- avoid reminders
- sxs of hyperarousal (hyper-startle response, anger outburst, hyper vigilance)
- emotional numbing (blame self or others, persistent negative state, anhedonia, feel detached)
common causes:
- men: combat
- women: rape/assault
- natural disasters
post traumatic stress disorder (PTSD): tx
Therapy + meds
- 1st line: SSRIs
- SNRIs
- benzos reduce anxiety; trazodone for insomnia
- prazosin for nightmares
- therapy: support groups, family
adjustment disorder: definition and example stressors
emotional symptoms in response to identifiable life stressor (not life-threatening)
- sxs w/in 3 months of stressor and ending w/in 6 months after stressor resolves
- reaction out of proportion to stressor / impairs daily functioning
ex. stressors:
- job loss, school or finance problems, moving, substance abuse, booming parents, retirement, legal issues
adjustment disorder: sxs, tx
sxs:
- depressed mood, tearful, anxiety, palpitations, agitation, reckless driving, fighting, vandalism, difficult functioning at work
tx:
- 1st line: psychotherapy
- benzos, hypnotics (zolpidem): briefly
- SSRI if depression present
acute stress disorder: definition, populations affected
like PTSD, but with different onset and duration
= may be a pre-cursor to PTSD
acute stress d/o:
- occurs within 1 mo of traumatic event
- lasts 3 days - 1 month
populations affected:
- motor vehicle accident survivors
- violent crome victims/witnesses
- natural disaster survivors
acute stress disorder: tx
similar to PTSD
- therapy/support group
- short course benzo (for severe anxiety)
- +/- SSRI, TCAs, anticonvulsants, anxiolytics for insomnia and irritability if warrented
attention-deficit disorder (ADD or ADHD): characteristics, dx criteria
male (2-5x>F), 1st born son
- 20-50% have dysfunctional sxs as adult
- underdeveloped part of brain
Dx criteria:
- hyperactivity, impulsivity, or inattentiveness (developmentally inappropriate for > 6 mo)
- MUST manifest prior to age 12
- MUST occur in 2 or more settings
attention-deficit disorder (ADD or ADHD): tx
1st line: stimulants
- methylphenidate (Ritalin, Concerta)
- dexmethylphenidate (Focalin)
- amphetamine (Adderall)
Note: wt. loss and dec growth as SE of stimulants!
Behavior modification, family, educational managment
autistic disorder: characteristics
> 6 sxs from these categories:
- impaired social interaction
- impaired communication
- repetitive stereotypes patters of behavior and activities (inflexible rituals, hypo or hype sensory)
Note: more common with boys; genetic component; evident prior to age 3
autistic disorder: management
Behavioral therapy
- 1st line
Refer: autism specialist
Speech and language pathology
Audiology testing and EEG (many have seizure d/o)
Meds:
- 2nd generation antipsychotics (for aggressive behavior)
anorexia nervosa: definition, grades, 2 types
distorted body image; fear of becoming fat even though underweight
- egosyntonic: behaviors consistent with ideal image (person does not see anything wrong)
- Mild: BMI>17
- Moderate: BMI 16-17
- Severe: BMI 15-16
2 types:
- restricting: eat very little, excessive exercise, OC traits, withdrawn
- binge eating/purging: use of laxatives and/or diuretics, depression and substance abuse
anorexia nervosa: findings and complications
amenorrhea electrolyte abnormalities hypothermia cardiac abnormalities: bradycardia, arrhythmia lanugo (hair on body) osteoporosis
anorexia nervosa: management
restore nutritional state and electrolyte abnormalities
- hospitalize if severely under weight or severe electrolyte imbalance
Outpatient:
- behavior/family therapy
- supervised, gradual weight gain
Meds: DO NOT play major role
- 2nd gen. antipsychotics (may promote wt gain and reduce cognitive distortion
- Bupropion (Wellbutrin) contraindicated: lowers sz threshold due to electrolyte disturbance
bulimia nervosa: characteristics
binge eating and purging (vomit, laxatives, diuretics)
- at least 1 day/wk for 3 months
- severity based on number of binge/purge episodes/week
- rapid fluctuations in weight
Egodystonic: binging causes emotional distress
Person normal or overweight
- BMI>18
bulimia nervosa: physical findings
Fluctuating weight Dental erosions Russell's sign: abraded knuckles (from self-induced purging) esophagitis acid-base disturbance: - hypokalemia alkalosis - hypo-mag, hypo-Ca++ Parotid gland enlargement (chipmunk cheeks) Gastric distention Cardiac arrhythmias
bulimia nervosa: management
restore nutrition/metabolic state
Meds:
- 1st line: SSRIs: reduce binge/purge behaviors
- Bupropion (Wellbutrin) contraindicated
Behavior/family/group therapy
- hospitalization usually not needed
eating disorders: general endocrine problems, somatic signs, behavioral signs
Endocrine issues:
- inc growth hormone, cortisol
- dec LH, FSH, estrogen
- dec T3
- abnormal glucose and dexamethasone suppression
Somatic signs:
- arrested growth
- fatigue
- constipation or diarrhea
- susceptible to fractures
- delayed menarche
Behavior:
- reluctance to be weights
- depression
- substance abuse
obesity / binge-eating disorder
BMI>30 or :20% over ideal body weight
dx criteria:
- binge eating > 1/week for 3 months
- no purging
- sense of lack of control when eating
- eating rapidly, eating when not hungry
- feeling disgusted/guilty afterwards
obesity - tx
1st line: behavior modifications / group therapy
- new eating patterns
DEPRESSION is often alongside obesity
- tx with SSRIs
Surgery: gastric bypass
major depressive disorder - criteria
Depressed mood / anhedonia + 5+ of the following sx for >2 weeks S: sleep (high or low) I: interest G: guilt E: energy C: concentration A: appetite P: psychomotor (retardation/agitation) S: suicide
major depressive disorder - tx
SSRI
- start low and go slow
- give 6 wks (and then reassess dx or inc. dose)
SNRI, TCA
- can switch drug class
- can combine drugs from different classes
Psychotherapy
Consider ECT
seasonal affective disorder - definition, tx
fall or winter onset
20-40 y/o females
Tx:
- light therapy
- SSRIa
- Bupropion
postpartum depression - definition, tx
onset of sxs within 4 wks of delivery
Tx:
- therapy +
- SSRI (note: sertraline (Zoloft) best for breastfeeding)
- estrogen may help
disruptive mood dysregulation disorder (DMDD) - definition, tx
- aka conduct disorder
- called antisocial if > 18 y/o
severe temper tantrums > 3 times/wk for 12 months
- kids age 6-18
- sad, irritable, angry almost evert day
- occurs in at least 2 settings
Tx:
- therapy (individual and family)
- +/- SSRI, stimulants
- 2nd generation anti-psychotics (risperidone or ambilify) for aggression
premenstrual dysphoric disorder (PMDD) -definition, tx
severe PMS
- start week before menses (luteal has) and go away with menstruation
- severe enough to affect work, daily activities, relationships
- sadness, despair, tension, low energy
- bloating, breast tenderness, H/A, muscle pain
Tx:
- SSRI
- OCP (low dose estrogen)
serotonin syndrome
severe side effect that can occur with too much serotonin
- usually due to drug combos: SSRI + MAOI + demerol + triptans + dextromethorphan
sxs:
- rapid onset
- metal status changed
- hyperthermia, diaphoresis
- tremor, hypertonicity (clonus), seizures
- renal failure, coma, death
Tx:
- STOP serotonin drugs
- benzodiazapines
- IV hydration and aggressive cooling
dysthymic disorder / persistent depressive disorder - criteria and tx
chronic, persistent mild depression
- mores days than not for > 2 yrs, not w/o sx for > 2 mo, no major depressive episode
- loss of interest, dec. productivity, social withdrawal, lack self esteem, poor concentration
- NO psychotic or manic features
- young adult onset
Note: can develop major depressive disorder or bipolar
Tx:
- SSRI + therapy
bipolar I disorder - criteria
> 1 manic episode, often cycles with depressive episodes
- Bipolar I has psychotic features / more severe
- Often requires hospitalization
D: distracted I: impulsive G: grandiosity F: flight of ideas A: activity (high energy, agitation) S: dec. ned for sleep T: talkative
Psychotic symptoms: hallucinations, delusions
bipolar I and II disorder - tx
Begin tx with a mood stabilizer
- typical 1st line is lithium or Depakote
Note: refer to specialist
bipolar II disorder
at least 1 major depressive and 1 hypomanic episode
- less severe than bipolar I
- hypomanic sxs are milder than manic sxs
- no “manic” episodes
- no psychotic sxs
Brief Psychotic Disorder
symptoms last 1-30 days but then person returns to complete normal functioning
- usually in the context of a severe stressor / traumatic event
Schizophreniform Disorder
Note: almost the same as schizophrenia
- precursor for schizophrenia
- duration 1-6 months and may be able to still function
- typically lead to full blown schizophrenia
Schizoaffective Disorder
schizophrenia with mood disorder (BPD, depression) on top of it
- look for psychotic symptoms when mood issues NOT present to differentiate from mania or psychotic depression
Delusional Disorder
having a delusion and nothing else; absence of other schizophrenia symptoms
- delusion of at least 1 month (ex. someone put chip in my brain – but still functioning)
- person still functioning
tx: antipsychotics
schizophrenia - 3 categories of sxs
Manifests in teens and 20s with gradual onset of sxs
- must last for 6 months or more
- severe enough to disrupt social and occupational fx
positive sxs:
- hallucinations (auditory common)
- delusions (false ideas asked on incorrect perceptions of reality)
negative sxs:
- emotional blunting
- flat affect
disorganized sxs:
- loose associations
- word salad (talking but words do not make any sense)
- neologisms (made up words)
- thought blocking (getting stuck)
- catatonia (strange postures)
- echolalia (repeating back what someone said to them)
- bizarre behavior often related to delusions/hallucinations
schizophrenia - treatment
- Antipsychotic medications (higher doses of the atypicals usually tried first – higher than for BPD, etc.)
- Referral to community mental health center (which has prescribers, therapists, groups, help with jobs/functioning etc.)
- Support groups for patient and/or caregivers
- Prognosis is typically poor compared to other mental health conditions
- Note: high rate of suicide
somatic symptom disorders vs. factitious disorder vs. malingering
somatic symptom disorders: not conscious or intended (physical sxs that defy medical w/u)
- somatic disorder
- conversion disorder
- illness anxiety disorder
Factitious Disorders: person is doing something intentionally (faking or causing an illness); limited or no external gain (attention seeking / likely begin hospitalized)
Malingering: intentional for external gain (money, time off work)
somatic symptom disorder - definition, tx
sxs relate to many systems: GI, reproductive, neuro, pain, cardiac
- sxs and fears are disproportionate to objective medical findings
- numerous negative work-ups from variety of health care providers; several hrs a week in appts
Tx:
- thorough W/U
- assure pt you take them seriously
- regularly scheduled appointments with the same provider can provide reassurance (Key!!)
- CBT, relaxation
conversion disorder
physical symptoms that can’t be explained physiologically; neurological W/U normal
- symptoms: include blindness, seizures, paralysis, deafness, fainting, ticks
- patients may have unexpected lack of concern to sxs
Tx: therapy, reassurance, reduce stress
- remission rate is high
Illness anxiety disorder - definition, tx
6+ months of fear or belief that one has acquired or might acquire a serious illness
- layman’s term: hypochondriac
- few or no physical symptoms; extreme anxiety and worry
Tx:
- SSRI’s and CBT (cognitive behavior therapy); similar to OCD
ETOH - labs in chronic abuse
elevated GGT (1st sign), AST, ALT - AST:ALT 2:1
inc. HCL, LDH, MCV
dec. LDL, BUN, RBC volume
ETOH - withdrawal signs and tx
tremors: 10-18hr anxiety, N/V seizures: 7-48 hrs hallucinations: within 2 days delirium tremens: 2-5 days
tx:
- benzos (diazapam) from agitation
- thiamine (prevents Wernicke’s encephalopathy)
- multi-vitamin, folic acid
- haloperidol or risperidone: hallucinations
- naltrexone: reduced cravings
stimulants (amphetamines, cocaine) - intoxication, withdrawal, tx
intoxication:
- euphoria
- aggression
- psychosis, hallucinations
- tachycardia, elevated BP, dilated pupils
withdrawal:
- fatigue, depression, hunger
- H/A, seating, muscle cramps
tx:
- benzodiazepines for agitation
- short-term antipsychotics for psychotic sxs
- rehab / detox
opioids (heroin, morphine, oxycodone) intoxication, withdrawal, tx
intoxication:
- euphoria
- drowsy, lethargy
- hypotension, bradycardia
- constricted pupils
withdrawal:
- lacrimation (tears), rhinorrhea
- sweating, yawning
- muscle aches
- hypertension, tachycardia, anxiety
tx:
- methadone
- benzos for mild w/drawal
- NSAIDS for muscle aches
opioid dependence therapy
- methadone (full opioid agonist) maintenance program
- buprenorphine + naloxone (suboxone, partial opioid agonist)
- Naltrexone (opioid antagonist - interrupts reward pathway; approved for tx of alcohol and/or opiate use disorder)
nicotine - tx
best: combo of counseling and meds
nicotine replacement therapy: patch, gum, nasal spray
Buproprion (Zyban): atypical antidepressant with unrelated anti-smoking activity
• Long-term abstinence rates similar to NRT (~19%)
• Start 1-2 weeks before quit date and continue 7-12 weeks after
• Can use patches with this
Varenicline (Chantix) – blocks pleasure of smoking
• Partial nicotine receptor agonist/antagonist
• Short-term quit rates higher than NRT, but long-term probably similar (~19%)
• Start week before quitting, 3 months of treatment
• Cannot use patches with this
personality disorders - general characteristics
DS begin at birth
Traits become rigid and non-adaptive to situations
- often may not notice PD until situation where it is not appropriate
- traits interfere with daily functioning, ability to succeed in life or meet expected goals
- traits cause serious problems with interpersonal relationships, serious problems to others
Common shared characteristics among personality disorders:
- skewed/distorted sense of self
- low frustration tolerance
- often blame others, has “victim” mentality
- often has POOR/NO insight into personality issues
antisocial personality disorder
lack of empathy, aggressive, cruel w/ lack of regret / remorse, disregard for safety of self and others
- repeat violation of others; blaming others; brain: cannot read others’ emotions like others can
- antisocial disorder once 18 y/o and older (conduct beforehand)
avoidant personality disorder
fear of rejection (sensitive), loner
- people want to have relationships, but afraid of being rejected
borderline personality disorder
common, inconsistency / unstable “frenemy”, emotional instability, easily frustrated
- people all good or all bad
- needy, attention-seeking, push boundaries – want to feel special (call after hours); can get upset
- behave similarly to all sexes
- difficult to treat: get on nerves of provider; confused with bipolar disorder
dependent personality disorder
dependent, indecisive, obsequious, people pleaser, helpless
- often see marriages where wife is completely dependent on husband (decisions, going everywhere)
- lack of ability to participate in shared-decision making; often has person w/ them who makes decisions
histrionic personality disorder
provocative or seductive behavior, attention seeking, relationships considered more intimate than they are → sexual, women trying to get attention from men
- can make medical staff uncomfortable, exaggerate sxs and difficulties
narcissistic personality disorder
self centered, entitled, demanding / want special treatment; lacking empathy for others
- ex. President Trump (extreme reaction to criticism; cannot admit to being wrong)
obsessive-compulsive personality disorder
“just right” – compulsions are efforts to get rid of obsessions, repetitive behaviors
- rigidity around rules, neatness, cleanliness, order
Note: OCD realize they have strange behaviors vs. OCPD who wonders why others do not think way they do
paranoid personality disorder
distrust, suspicious mistrust, think everyone is out to get them (everything seen through lens of suspicion); these people do not have a lot of friends
- difficult for pt to trust provider
schizoid personality disorder
lack feelings and emotions, cold, indifferent, do not find joy in anything
- do not want to have relationships with people – lack of interest; seek jobs where they do not interact w/ people; lack of intimate relationships
schizotypal personality disorder
hard time having close relationships (b/c so odd), odd beliefs or magical thinking (“eccentric”), somewhat psychotic beliefs
- like schizophrenia, but no decline in fx
grief reaction / bereavement
sxs: shock, confusion, sadness, numbness
- may report illusions (seeing or hearing deceased)
- person maintains hope that things will get better (vs. major depressive disorder)
Tx:
- therapy, reassurance
- +/- benzos for insomnia, SSRIs, anti-depressants
neuroleptic malignant syndrome
caused by dopamine blockade
- can occur with high potency antipsychotics
- confusion, high fever, elevated BP, tachycardia
- “lead-pipe” rigidity
- sweating, elevated CPK levels
munchausen by proxy
form of abuse initiated by parent
- make up sxs in child causing repeated visits to provider
- parent gets attention being attentive, suffering parent
