Psychiatry Flashcards
Major risk factors for suicide
psych disorders Feelings of hopelessness or worthlessness impulsivity advanced aged males access to weapons Hx of suicide attempts
Medical illnesses that can cause depressive symptoms
hypothyroidism Hyperparathyroidism parkinson dz stroke HIV cancer - CNS neoplasm Bipolar Adjustment ds with depressed mood
Neurotransmitter levels in depression
low serotonin
low NE
low DA
Drugs known to cause depressive symptoms
Sedatitives - alcohol, benzos, antihistamines
Withdrawal from stimulants - cocaine, amphetamines
Some antihypertensives - methyldopa, clonidine, b-blockers
First generation antipsychotics - haloperidol
Prochlorperazine
Metoclopramide
Long term glucocorticoid use
Interferon alpha
MDD with atypical features
MC subtype
Mood reactivity - positive reaction to positive things
Increased appetite and wt gain
Hypersomnia
Leaden paralysis
Hypersensitivity to rejections
Responds well to MAOIs (if not responded to SSRIs)
MDD with seasonal pattern
recurrent depression exhibiting a regular temporal or seasonal pattern
Tx:
light therapy - 10,000 lux 30 min/day eye level
MDD with peripartum onset
onset during pregnancy or up to 4 weeks postpartum
MDD with psychotic features
delusions or hallucinations develop during an episode of MDD
No psychosis except during depressive episodes
Mood first, then psychosis
Persistent depressive disorder
chronic, persistent depression for at least 2 years (1 yr in kids/adolescents)
Depressed mood plus at least 2 sxs
More difficult to treat than most MDD
antidepressants, once starts to lift responsive to psychotherapy
Characteristic features of serotonin syndrome
mental status changes - anxiety, agitation, delirium, restlessness, disorientation
Autonomic excitation - diaphoresis, tachycardia, hyperthermia, HTN, V/D
Neuromuscular hyperactivity - tremor, muscle rigidity, hyperreflexia, myoclonus
- spontaneous or inducible clonus
- ocular clonus: slow, continuous horizontal eye movements
- Positive Babinski sign B/L
Drugs increasing the risk of serotonin syndrome
SSRIs SNRIs MAOIs TCAs St Johns Wort Tryptophan Triptans Linezolid Levodopa Stimulants - cocaine, amphetamines, MDMA
Treatment of serotonin syndrome
Discontinue all serotonergic agents -> sxs resolve in 24 hrs
Supportive care to normalize V/S
-O2, IVF, cardiac monitoring
Esmolol or nitroprusside for tachycardia or htn prn
Sedation with benzos
Temp over 41.1 C -> sedation, paralysis, and ET tube -> mechanical cooling (ice, cooling blankets, misting fans)
- paralysis should relieve hyperthermia caused by muscle activity
- no benefit to antipyretics
If agitation despite benzos -> cyproheptadine (serotonin antagonist)
After resolution - assess need to resume serotonergic agent
Findings seen in TCA overdose
3C’s:
Cardiotoxicity - tachycardia, hypotension, conduction abnormalities
CNS toxicity - sedation, obtundation, coma, seizures
antiCholinergic sxs - mydriasis, xerostomia, ileus, urinary retention - esp in elderly
Management of TCA overdose
ABCs
Activated charcoal 1g/kg up to 50 kg (unless ileus or can’t protect airway)
continuous tele for at least 6 hours - if no problems then clear for psych eval
Frequent neuro checks
labs: drug level, BMP
ECG - check for arrhythmias
-If QRS >100 -> sodium bicarb (drug can’t bind sodium channels, prevents cardiotoxicity)
if hypotensive -> IVF, if ineffective then NE
If agitation or seizures -> benzos - but not phenytoin
Foods associated with tyramine-induced hypertensive crisis with MAOIs
spoiled, pickled, aged, smoked, fermented, or marinated
hard cheeses
Smoke/aged meats
Chianti, most beers and wines
Soy sauce, shrimp paste, miso soup
Sauerkraut, avocados, ripe bananas, fava beans
Brewer’s yeast and yeast extracts (outside of baking)
Indications for electroconvulsive therapy
severe debilitating depression refractory to antidepressants
Psychotic depression
Severe suicidality
Depression with food reversal leading to nutritional compromise
Depression with catatonic stupor
Situations where a rapid antidepressant response is required (pregnancy)
Previous good response to ECT
bipolar disorder/mania
schizophrenia/psychosis (esp catatonic)
Symptoms of mania (and hypomania)
DIGFAST
Distractibility Insomnia - less need for sleep Grandiosity Flight of ideas Activity/agitation Speech - pressured, loud Taking risks - drugs, sex, quit jobs, spend money
Treatment for bipolar disorder
Lithium - can’t use in renal failure
Renal failure: valproate, carbamazepine, lamotrigine (anticonvulsants)
Atypical antipsychotics: aripiprazole, olanzapine, quetiapine, risperidone
ECT- refractory
Potential side effects of lithium
Teratogen - Ebstein anomaly
CNS effects - depression, tremor, cognitive dulling
Thyroid dysfunction - hyperthyroidism, hypothyroidism, euthyroid goiter
GI effects - N/V/D, wt gain, metallic taste changes
Nephrogenic DI - polyuria, polydipsia
Treatment for nephrogenic DI caused by lithium
HCTZ + amiloride
Features of Ebstein anomaly
tricuspid leaflets displaced inferiorly
RV hypoplasia
TR or TS
+/- PFO
Cyclothymic disorder
Mild hypomanic symptoms do not meet criteria for hypomanic episode
Mild depressive sxs do not meet criteria for major depressive episode
Sxs present for at least 2 yrs (1 yr for kids)
Periods of normal mood last less than 2 mo
Causes significant distress or impairment in social/occupational functioning
Tx:
mood stabilizers
psychotherapy
