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
Panic disorder
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
Generalized anxiety disorder
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
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
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
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
Neuroimaging for schizophrenia
enlargement of lateral and 3rd ventricles
cortical thinning
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
Drugs known to cause psychosis
Hallucinogens - LSD, PCP Stimulants - cocaine, amphetamines Withdrawal from benzos, etOH, barbs Glucocorticoids - psychosis and mood disorders Anabolic steroids
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
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
Stages of change
Precontemplation - denial Contemplation - acknowledge there's a problem Preparation - plans to change Action - implementing the plan Maintenance
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
Benzodiazepine abuse
Increase GABA activity
Reverse toxicity - flumazenil - can induce major withdrawal and seizure
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
PCP abuse
NMDA receptor antagoinst - inhibits nicotinic acetylcholine receptors, dopamine reuptake inhibitor
Tx: benzos to sedate, antipsychotics
Alcohol abuse characteristics
Increases GABA activity
CAGE:
- cut down
- annoyance at others
- guilt over use
- eye opener
Tx intox - supportive
tx withdrawal - benzos
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
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
Delirium tremens
nightmares agitation disorientation AVH fever HTN diaphoresis seizures autonomic hyperactivity
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
Refeeding syndrome
Sudden shift from fat metabolism to carbohydrate metabolism
Hypophosphatemia! hypokalemia hypomagnesemia CHF and arrhythmias Rhabdomyolysis Delirium Seizures
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
Binge-eating disorder
Episodes of binge eating
No inappropriate compensatory behaviors
Patients tend to be overweight/obese
Tx:
CBT first line
SSRIs, topiramate, stimulants
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
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
Hoarding disorder
can’t discard things, thought of discarding causes anxiety/distress
Impaired social/occupational functioning
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
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
Acute stress disorder
like PTSD but sxs more than 3 days, but last less than 1 mo
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
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
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
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
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
Malingering
external pain - narcotics, miss work, homeless get bed for night
leave when confronted or refuse to give them what they came for
