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DIT Level 2 > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

Major risk factors for suicide

A 
psych disorders
Feelings of hopelessness or worthlessness
impulsivity
advanced aged
males
access to weapons
Hx of suicide attempts
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2
Q

Medical illnesses that can cause depressive symptoms

A 
hypothyroidism
Hyperparathyroidism
parkinson dz
stroke
HIV
cancer - CNS neoplasm
Bipolar
Adjustment ds with depressed mood
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3
Q

Neurotransmitter levels in depression

A

low serotonin
low NE
low DA

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4
Q

Drugs known to cause depressive symptoms

A

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

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5
Q

MDD with atypical features

A

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)

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6
Q

MDD with seasonal pattern

A

recurrent depression exhibiting a regular temporal or seasonal pattern

Tx:
light therapy - 10,000 lux 30 min/day eye level

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7
Q

MDD with peripartum onset

A

onset during pregnancy or up to 4 weeks postpartum

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8
Q

MDD with psychotic features

A

delusions or hallucinations develop during an episode of MDD
No psychosis except during depressive episodes

Mood first, then psychosis

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9
Q

Persistent depressive disorder

A

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

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10
Q

Characteristic features of serotonin syndrome

A

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
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11
Q

Drugs increasing the risk of serotonin syndrome

A 
SSRIs
SNRIs
MAOIs
TCAs
St Johns Wort
Tryptophan
Triptans
Linezolid
Levodopa
Stimulants - cocaine, amphetamines, MDMA
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12
Q

Treatment of serotonin syndrome

A

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

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13
Q

Findings seen in TCA overdose

A

3C’s:

Cardiotoxicity - tachycardia, hypotension, conduction abnormalities

CNS toxicity - sedation, obtundation, coma, seizures

antiCholinergic sxs - mydriasis, xerostomia, ileus, urinary retention - esp in elderly

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14
Q

Management of TCA overdose

A

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

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15
Q

Foods associated with tyramine-induced hypertensive crisis with MAOIs

A

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)

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16
Q

Indications for electroconvulsive therapy

A

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)

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17
Q

Symptoms of mania (and hypomania)

A

DIGFAST

Distractibility
Insomnia - less need for sleep
Grandiosity
Flight of ideas
Activity/agitation
Speech - pressured, loud
Taking risks - drugs, sex, quit jobs, spend money
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18
Q

Treatment for bipolar disorder

A

Lithium - can’t use in renal failure

Renal failure: valproate, carbamazepine, lamotrigine (anticonvulsants)

Atypical antipsychotics: aripiprazole, olanzapine, quetiapine, risperidone

ECT- refractory

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19
Q

Potential side effects of lithium

A

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

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20
Q

Treatment for nephrogenic DI caused by lithium

A

HCTZ + amiloride

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21
Q

Features of Ebstein anomaly

A

tricuspid leaflets displaced inferiorly
RV hypoplasia
TR or TS
+/- PFO

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22
Q

Cyclothymic disorder

A

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

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23
Q

Panic disorder

A

recurrent panic attacks - abrupt onset of intense fear and anxiety accompanied by 4 sxs:

Palpitations or tachycardia
Sweating
Trembling/shaking
SOB
Choking sensation
CP
dizziness/lightheadedness
nausea
hot flashes or chills
paresthesias
Feeling of losing control/going crazy
Fear of dying

Attack followed by period of persistent worry about more panic attacks or maladaptive behaviors to prevent panic attacks, lasting at least 1 mo

24
Q

Generalized anxiety disorder

A

MC

Excessive anxiety and worry occurring more days than not for at least 6 mo

At least 3 sxs:

Restlessness/feeling "on edge" or "keyed up" - hyperarousal
difficulty concentrating
irritability
muscle tension
difficulty sleeping
fatigue
Tx: 
SSRI
SNRI
buspirone
CBT
25
Social anxiety disorder
Excessive anxiety related to social situations, with fear of being negatively evaluated by others (social interactions, being observed by others, performing in front of others) Begins in adolescence Tx: CBT SSRI SNRI Benzos or b-blockers as needed for performances -Propranolol suppresses tachycardia and fight/flight sxs
26
Diagnostic criteria for schizophrenia
at least two of the following during a one month period (including at least one of the first three) Delusions Hallucinations (MC auditory) Disorganized speech Grossly disorganized or catatonic behavior Negative symptoms - flat affect, poverty of speech, lack of emotional reactivity, social withdrawal, avolution/apathy, anhedonia, poor grooming, thought blocking Social/occupational dysfunction Duration at least 6 mo
27
Risk factors for schizophrenia
FHx born in late winter/early spring maternal illness/malnutrition during pregnancy +/- psychoactive drug use during adolescence and young adulthood (MJ, cocaine, amphetamines) Male, young
28
Neuroimaging for schizophrenia
enlargement of lateral and 3rd ventricles | cortical thinning
29
Delusional disorder
Delusions for one or more months No other sxs of schizophrenia -Hallucinations if present, not prominent and are related to the delusions Social/occupational functioning is NOT impaired
30
Drugs known to cause psychosis
``` Hallucinogens - LSD, PCP Stimulants - cocaine, amphetamines Withdrawal from benzos, etOH, barbs Glucocorticoids - psychosis and mood disorders Anabolic steroids ```
31
Neuroleptic malignant syndrome
Mental status changes - initial sxs in most - agitated delirium with confusion rather than psychosis muscle rigidity +/- tremor Hyperthermia over 38-40 C Rhabdomyolysis appearing over 1-3 days Autonomic instability - tachycardia, high/labile BP, tachypnea, diaphoresis Tx: Stop offending medication Supportive care in ICU: -IVF -lower temp - cooling blankets, ice packs in axillae, Tylenol -Reduce htn with clonidine and/or nitroprusside - cutaneous vasodilation can facilitate cooling -DVT ppx with heparin or enoxaparin -For agitation - benzos - clonazepam, lorazepam Dantrolene - prevents rigidity and hyperpyrexia by inhibiting calcium release Bromocripting or amantadine
32
Substance use disorder
Two of the following over a year: Tolerance Withdrawal sxs Persistent desire or unsuccessful attempts to cut down Significant energy spent obtaining, using, recovering from the substance Important social, occupational, or recreational activities reduced because of substance abuse Continued use in spite of knowing the problems that it causes (work, school, home) Craving Recurrent use in physically dangerous situation (driving) Failure to fulfill major obligations at work, school, or home due to use Social or interpersonal conflicts related to substance use
33
Stages of change
``` Precontemplation - denial Contemplation - acknowledge there's a problem Preparation - plans to change Action - implementing the plan Maintenance ```
34
Opioid abuse
work on mu, kappa, delta receptors Reverse toxicity - naloxone, naltrexone Treat abuse - methadone, suboxone (naloxone + buprenorphine) IV heroin risk HIV, Hep C, right endocarditis
35
Benzodiazepine abuse
Increase GABA activity Reverse toxicity - flumazenil - can induce major withdrawal and seizure
36
Amphetamines and cocaine abuse
Amphetamines - increase release of intracellular stores of catecholamines Cocaine: blocks reuptake of catecholamines (NE, epi, DA) Tx toxicity - benzos, haloperidol, phentolamine - no beta blockers - unopposed alpha worsens HTN
37
PCP abuse
NMDA receptor antagoinst - inhibits nicotinic acetylcholine receptors, dopamine reuptake inhibitor Tx: benzos to sedate, antipsychotics
38
Alcohol abuse characteristics
Increases GABA activity CAGE: - cut down - annoyance at others - guilt over use - eye opener Tx intox - supportive tx withdrawal - benzos
39
Complications of alcohol abuse
``` Elevated GGT!!! AST>ALT 2:1 Alcoholic cirrhosis, hepatitis Pancreatitis Peripheral neuropathy Testicular atrophy Aspiration pneumonia - Klebsiella Mallory-Weiss tear Esophageal varices ``` malnutrition: B2, B6, folate, b12, C, A Wernicke-Korsakoff - thiamine (B1) deficiency -Wernicke - confusion, nystagmus, ophthalmoplegia, ataxia, sluggish pupillary response, coma, death -Korsakoff - anterograde amnesia, retrograde amnesia, confabulation, hallucinations Tx: thiamine before glucose -damage to mammillary bodies and hypothalamus
40
Long term treatment of alcoholism
Group therapy - AA, CBT Naltrexone - decreases positive feelings with alcohol use Disulfiram - disulfiram reaction with alcohol - vomiting, flushing -inhibits acetaldehyde dehydrogenase -> elevated acetaldehyde Topiramate - affects glutamate receptors Acamprosate - modulates glutamate neurotransmission
41
Delirium tremens
``` nightmares agitation disorientation AVH fever HTN diaphoresis seizures autonomic hyperactivity ```
42
Anorexia nervosa
Low body weight Risk: female 14-18 High socioeconomic status Dx: distorted body image intense fear of gaining weight Restricted caloric intake relative to energy requirements ``` Features: Amenorrhea cold intolerance and/or hypothermia dry, scaly skin hair loss lanugo - fine, downy hairs hypogonadism osteoporosis comorbid anxiety, OCD, depression, SI ``` Tx: Psychotherapy Pharmacotherpay not effective -tx comorbid depression or anxiety with SSRIs Hospitalize to address nutritional deficiencies and complications
43
Refeeding syndrome
Sudden shift from fat metabolism to carbohydrate metabolism ``` Hypophosphatemia! hypokalemia hypomagnesemia CHF and arrhythmias Rhabdomyolysis Delirium Seizures ```
44
Bulimia nervosa
Normal body weight Recurrent episodes of binge eating Inappropriate compensatory behaviors to prevent wt gain - purging, intense exercise, severe caloric restriction Recurrent vomiting -> Scarred hands - Russell's sign dental erosions Enlarged parotid glands and elevated serum amylase Hypochloremic, hypokalemic, metabolic alkalosis Tx: CBT SSRIs
45
Binge-eating disorder
Episodes of binge eating No inappropriate compensatory behaviors Patients tend to be overweight/obese Tx: CBT first line SSRIs, topiramate, stimulants
46
Obsessive compulsive disorder
Obsessions - recurrent, unwanted, intrusive, anxiety-provoking thoughts or urges Compulsions - repetitive behaviors or mental acts performed to relieve the anxiety caused by the obsessive thoughts Dx requires behaviors to be time-consuming and cause impairment in social/occupational functioning Tx: CBT - exposure and response prevention SSRIs
47
Body dysmorphic disorder
preoccupation with perceived defect in appearance Repetitive behaviors/mental acts related to perceived defects Tx: avoid needless surgeries Psychotherapy SSRIs for refractory - off label use
48
Hoarding disorder
can't discard things, thought of discarding causes anxiety/distress Impaired social/occupational functioning
49
Diagnostic criteria for posttraumatic stress disorder (PTSD)
Older kids/adults Exposure to traumatic event - actual of threatened death, serious injury, sexual violence Reexperiencing traumatic event via memories, dreams, or flashbacks Avoidance of stimuli associated with traumatic event Negative changes in cognition and mood Hyperarousal - irritable behavior, reckless, behavior, hypervigilance, sleep disturbance Disturbance must last at least 1 mo
50
Treatment options for PTSD
Psychotherapy including behavioral (exposure) therapy and cognitive therapy SSRIs first line Benzos avoided - lack of efficacy and potential abuse No evidence to support TCAs, MAOIs, atypical antipsychotics, or mood stabilizers Alpha blockers - prazosin - reduces nightmares, improves sleep
51
Acute stress disorder
like PTSD but sxs more than 3 days, but last less than 1 mo
52
Adjustment disorder
Sxs: depressed mood, anxiety, distrubance of conduct Clinically significant emotional or behavioral reaction causing marked distress and/or impairment in social/occupational functioning Sxs develop in response to an identifiable psychosocial stressor - cancer, divorce, death of loved one, family conflict, loss of job, moving, major life changes Sxs begin w/in 3 mo of onset of stressor Sxs disappear within 6 mo of disappearance of stressor No pharmacotherapy Respond to CBT
53
Conversion disorder
Neuro sxs with no recognized neurological or medical cause: ``` Motor sxs: weakness/paralysis tremor dystonia/myoclonus gait disorder dysphagia dyphonia ``` Sensory sxs: numbness/paresthesias Blindness Deafness May or may not be the result of a specific psychological stressor Tx: psychotherapy and CBT PT
54
Somatic symptom disorder
One or more somatic symptoms that are distressing or significantly disruptive -may or may not be due to recognized medical condition At least one of the following: - disproportionate and persistent thoughts about the seriousness of sxs - persistently high level of anxiety about health or sxs - excessive time and energy devoted to sxs or health concerns Worry about symptoms they have
55
Illness anxiety disorder
preoccupation with having or acquiring a serious illness High level of anxiety about health Individual performs excessive health-related behaviors - repeatedly checking for signs of illness somatic sxs not present See these patients at regular intervals worry without actual symptoms
56
Factitious disorder
Intentional induction of injury or disease, or falsificaiton of s/s of illness presents as ill or injured deceptive behavior present even in absence of external reward or 2ndary gain
57
Malingering
external pain - narcotics, miss work, homeless get bed for night leave when confronted or refuse to give them what they came for

DIT Level 2 (49 decks)

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