Psychiatry Flashcards
What is anhedonia?
Loss of pleasure
How long should you wait for antidepressants to work?
minimum of 3-6 weeks
Order of treatment for depression
1) SSRI, possibly SNRI
2) Bupropion
3) TCA, MAOi
List of SSRI medications
Sertraline (Zoloft) Paroxetine (Paxil) Fluoxetine (prozac) Citalopram (Celexa) Escitalopram (Lexapro)
Presentation of Serotonin Syndrome
- AMS, seizure, coma
- Restless, diaphoretic, tremor, n/v, hyperthermia
-Increased risk with St. Johns Wart and SNRI mixing
List of SNRI medications
Venlafaxine (Effexor)
Desvenlafaxine (Pristiq)
Duloxetine (Cymbalta)
What receptors to SNRI medications work on?
Serotonin, dopamine, norepinephrine
Indications for SNRI
2nd line in depression
-Works well for patients with significant fatigue or pain syndromes in association with depression
MOA of tricyclic antidepressants
Inhibits repute of serotonin and norepinephrine
What is the definition of Bipolar 1 disorder?
At least 1 manic or mixed episode which cycles with occasional depressive episodes, major depression is not required
-Manic episode= persistantly elevated expansive or irritable mood at least 1 week with marked impairment of social function
Management of Bipolar I disorder
-MOOD STABILIZERS: LIthium 1st line, benzos 2nd line
**you can try antidepressants but they tend to precipitate mania
Definition of Bipolar II disorder
-At least one hypomanic episode with at least one major depressive episode
Hypomania=manic features that last about 4 days that DOES NOT CAUSE marked impairment in social or occupational function
Definition of panic disorder
Multiple panic attacks with the additional criteria:
- Panic attacks followed by concern about future attacks, worry about implication of attacks, or significant change in behavior from attacks
- at least 4 of 13 typical symptoms of panic attack
- S/s not due to substance use
- May have agoraphobia : anxiety about being in places where an escape may be difficult
Treatment of an Acute Panic Attack
Benzos
Treatment of panic disorder
SSRI, cognitive behavioral therapy
13 symptoms of panic attacks
- dizziness
- trembling
- Choking feeling
- Parasthesias
- Sweating
- SOB
- Chest pain
- Chills or hot flashes
- Fear of losing control
- Fear of dying
- Palpations
- Nausea
- Depersonalization
What is buspirone (buspar)?
It is an anti anxiety agent which stimulates serotonin receptors and blocks dopamine receptors. IT DOES NOT CAUSE SEDATION
ADHD Treatment options
1) Behavior Modification
2) Stimulant medications: Adderall, Ritalin
- central nervous stimulator of norepinephrine and dopamine
- High potential for abuse
3) Non-stimulant medication: Atomoxetine (Strattera):
- SNRI, less addictive
Methylphenidate
Ritalin
-stimulant used in ADHD
Amphetamine/dextroamphetamine
Adderoll
-stimulant used in ADHD
Hallmarks of ADHD
Must present before the age of 12, and be present for at least 6 months.
-The patient must demonstrate symptoms in 2 different settings, and the patient must demonstrate symptoms of Inattentiveness AS WELL AS hyperactivity
Criteria to diagnose PTSD
1) Exposure to actual or threatened death
2) At least 1 intrusion symptom:
- Re-experiencing
- Avoidance
- Negative alterations in mood
- Arousal and reactivity
Treatment of PTSD
- SSRI
- TCA
- Cognitive behavioral therapy
* May use trazadone to help insomnia
What is trazadone?
This is an antidepressant that acts as a serotonin antagonist AND reuptake inhibitor
-is a good anti anxiety, hypnotic, and helps in insomnia
What is acute stress disorder?
Similar to PTSD but it is only in the 1st month following the traumatic event and does not effect that patient chronically
Criteria for a specific phobia
Persistant fear lasting at least 6 months that is out of proportion to any real danger and everyday activities must be impaired
-Exposure therapy is the TOC
Diagnosis of anorexia
BMI under 17.5
Body weight <85% of ideal
Additional PE findings on an anorexic patient
Lanugo, dry skin, hypotension, bradycardia, amenorrhea, arrhythmias, ostoporosis
Bulimia Nervosa
Normal or overweight patient that engages in binge eating and compensatory behavior such as starvation or purging emesis
What will the pupils look like in opioid intoxication vs withdrawl?
Intoxication= constricted (narcotics are miotics) , you will also see respiratory depression
Withdrawl: dilated (mydriasis) , you will also see flu like symptoms of rhinorrhea
Medications used for tobacco dependence and their MOAs
- Nicotine tapering
- Buproprion (Zyban) antidepressant
- Varenicline (Chantix) : blocks the nicotine receptors
4 stages of alcohol withdrawl
- Increased CNS activity (6-24hrs)
- Withdrawl seizures (6-48 hrs) usually isolated event
- Alcoholic halucinosis (12-48hrs) ; NML vitals, clear sensorium
4) Dilerium Tremens (2-5 days) ; abnormal vitals, dilerious with altered sensorium
Treatment of alcohol withdrawl
1) Benzodiazepines: these potentiate GABA inhibition
2) Fluids and supplementation: Thiamine, magnesium, glucose
**be sure to replace glucose last to make sure you don’t precipitate Korsakoff syndrome
Supplementation needed for chronic alcoholics
1) IVF
2) Mg and Thiamine
3) Glucose (give after #2)
4) Multivitamins, B12, folate
Disulfiram
Antabuse
Inhibits aldehyde dehydrogenase, so the patient can’t metabolize the alcohol
What is the strongest predictive factor for committing suicide?
A previous attempt
What population has the highest suicide rate?
Elderly white males
Definition of delusional disorder
at least 1 delusion lasting at least one month in the absence of any other psychiatric symptoms
Definition of schizophreniform disorder:
schizophrenia criteria only lasting LESS THAN 6 MONTHS
Positive symptoms of Schizophrenia
Hallucinations, delusions, disorganized speech, abnormal behavior
Different types of hallucinations found in Schizophrenia
- Auditory (MC)
- Visual
- Olfactory
- Tactile ( insects on skin)
- Somatic (sensation arising form in body)
- Gustatory (tasting poisin in food)
Different types of delusions found in Schizophrenia
- Persecutory
- Reference (random events pertain to them)
- COntrol (someone else took control of them)
- Grandiose (unrealistic beliefs about oneself and abilities)
- Nihilism (exagerated belief in futility & catastrophic events
- Erotomanic (another person is in love with them)
- Jealousy (suspecting being unfaithful)
- Doubles ( a close person has been replaced by a double)
Negative symptoms of schizophrenia
Flat emotional affect, social withdrawal, lack of emotion, avolition (lack of self motivation) , lack of communication
Management of Schizophrenia
1) Antipsychotics: dopamine receptor antagonists
- 2ND GEN is best first line agent
- Risperidone, olanzapine, Quetipine
First Generation antipsychotics
Butyrophenones: Haloperidol, Droperidol
Phenothiazines: Fluphenazine (Prolixin), Perphenazine, Chlorpromazine (Thorazine), Thioridazine
1st gen antipsychotics MOA and SE
MOA: Dopamine antagonists
SE:
- Extrapyramidal s/s:
1) Dystonic reactions aka dyskinesia -Give benadryl to prevent
2) Tardive Dyskinesia: repetitive and involuntary movements
3) Parkinsonism: rigidity, tremor
- Neuroleptic Malignant Syndrome
What is neuroleptic malignant syndrome?
Life threatening disorder due to dopamine inhibition in the basal ganglia
-AMS, muscle rigidity, tremor, autonomic instability, tachycardia, hyperthermia, fever
Atypical (2nd gen) antipsychotics:
Quetiapine (seroquel)
Olanzapine (zyprexa)
Clozapine (Clozaril)
Loxapine (Loxatane)
2nd gen antipsychotics MOA, SE
MOA: Dopamine AND serotonin antagonists
SE
- less extrapyramidal s/s than first generation
- QT prolongation, weight gain
- olanzipine causes DM
- Clozapine causes agranulocytosis and myocarditis
Benzisoxazoles
Risperidone (Risperdol)
Ziprasidone (Geodon)
Benzisoxazoles MOA, SE:
MOA: partial dopamine and serotonin antagonist
SE: these increase prolactin
Quinolinones
Aripiprazole (Abilify)
Quinolinones MOA
Dopamine and serotonin receptor antagonist
Lithium MOA, SE
MOA: increases norepinephrine and serotonin receptor sensitivity
SE: HYPOTHYROID, decrease Na, increased urination and thirst, diabetes insipidus, hyperparathyroidism, arrhythmias
What is persistent depressive disorder?
chronic depressed mood for greater than 2 years
- There is no symptoms of mania, only depression
- MC in younger females
- SSRI treatment
What is cyclothymic disorder?
Less severe form of bipolar II disorder
-recurrent hypomanic s/s that don’t meet criteria for hypomania with mild depressive episodes FOR AT LEAST 2 years
What is adjustment disorder?
Emotional or behavioral response to identifiable stressor that causes a disproportionate response within 3 months and goes away around 6 months of experience
-treat with psychotherapy
What is dissociative identity disorder?
Presence of at least 2 distinct identities
- MC in women with a history of sexual abuse
- Mange with psychotherapy
What is dissociative amnesia?
Inability to recall personal information often secondary to abuse or stress
What is dissociative fugue?
Abrupt change in geographical location with loss of identity
4 major patterns of compulsions is OCD
1) Contamination
2) Pathologic doubt (forgetting to unplug iron)
3) Symmetry/precision
4) Intrusive obsessive thoughts (without compulsion)
What is the treatment for OCD ?
SSRI
What is Somatic Symptom Disorder?
Chronic condition where the patient exhibits at least 1 physical symptoms with no medical evidence for a cause
- normally present at least 6 months
- Treat with regular doctors appointments
Common presenting symptoms in somatic symptom disorder
- SOB
- Dysmenorrhea
- Burning in sexual organ
- Dysphagia
- Amnesia
- Vomiting
- Painful extremity
Illness anxiety disorder
- Formerly known as hypochondriasis
- Preoccupation with the fear that one has or will get a serious undiagnosed disease.
- Usually there are not symptoms present
What is functional neurological symptoms disorder?
- AKA conversion d/o
- neurological dysfunction suggestive of physical disorder that can’t be explained clinically and is not a result of malingering (the patient actually is experiencing)
- Motor: paralysis, aphonia, mutism, seizures
- Sensory: blindness, anesthesia, paresthesias
-Treat with psychotherapy
What is factitious disorder?
Intentional falsification of an illness on oneself or another for primary gain (sympathy) *this is a mental illness unlike malingering
- willing to undergo multiple surgeries and painful tests
- Nonspecific treatment
What is Munchausen syndrome?
old term referring to a severe form of factitious disorder
What is malingering and how does it differ from factitious disorder?
Intentional falsification of s/s for SECONDARY GAIN (finances, lawsuit, food, shelter)
*this is not a mental illness, the patient is not trying to be viewed as sick, but rather using sickness to create an advantage
Sexual abuse on a child is MC inflicted by what sex?
Male
Physical abuse on a child is MC inflicted by what sex?
Female
At what BMI is the clinical definition of obesity
30 (or weight 20% over their ideal weight)
What kind of acid/base disturbance is seen in a patient with bulimia?
Hypochloremic Metabolic alkalosis
What makes up the Cluster A personality disorders?
1) Schizoid personality d/o
2) Schizotypal personality d/o
3) Paranoid personality d/o
* These are SOCIAL detachments; weird, odd, eccentric
Schizoid personality disorder
Social withdrawal and anhedonia
MC in males
No pleasure or enjoyment from relationships or sex
Psychotherapy
Schizotypal personality disorder
Odd, eccentric, peculiar thought patterns
- Magical thinking, NO DELUSIONS (separation from schizophrenia) believes in telepathy, superstition
- Uncomfortable with close relationships
Paranoid personality disorder
Distrust and suspicion of others
What personality disorders make up cluster B?
1) Antisocial personality d/o
2) Borderline personality d/o
3) Histrionic personality d/o
4) Narcissistic personality d/o
* Wild, dramatic, impulsive, emotional
Antisocial personality d/o
Deviate from the norms or society
-MUST BE 18 to diagnose, in children this is conduct d/o
-disregard the rights of others as well as the law (often DUI)
Borderline personality d/o
Unstable, unpredictable mood and affect
- MC in females
- Mood swings, black and white thinking, impulsive self damaging behaviors
Histrionic personality d/o
overly emotional, dramatic, seductive, attention seeking behavior
-self absorbed temper tantrums
Narcissistic personality disorder
Grandiose sense of self importance but needs praise and admiration
- fragile self esteem
- considers themself special, entitled, requires extra special attention
What personality disorders are in cluster C?
1) Avoidant personality d/o
2) Dependent personality disorder
3) Obsessive compulsive personality d/o
* Anxious, worried, fearful
Avoidant personality disorder
- Desires relationships but avoids them do an inferiority complex
- Timid, shy, no self confidence
Dependent personality disorder
Dependent , submissive behacior
-constant need for reassurance, will not initiate things
Obsessive compulsive personality disorder
- Perfectionist with the need for order and control
- preoccupied with minute details
Primary signs of autism spectrum disorder
1) Social interaction difficulties (no eye contact, affection)
2) Impaired communication
3) Repetitive behaviors
Oppositional defiant disorder
-Persistant negative behavior of a child towards adults
6 months of angry mood, argumentative behaviors, and vindictiveness
Conduct disorder
Persisent pattern of behavior in a child that deviate sharply from age appropriate norms and violate the rights of others
- Violate laws, animal cruelty, deceitfulness, destruction of property
- 40% go on to develop antisocial personality disorder
Benzodiazapines used in alcohol withdrawl
- Diazepam (Valium)
- Lorazepam (Ativan)
- Chlordiazepoxide (Librium)
What must you give thiamine before glucose in alcohol withdrawal patients?
It may induce korsakoff’s syndrome (memory disorder due to lack of B1)
CAGE criteria
C-need to Cut down
A-Annoyed at you when you drink
G-Guilt about drinking
E-need for eye opener?
*at least 2 is a positive screening
Treatment options for alcohol dependence?
- Supportive
- Disulfram (Antabuse)
- Naltrexone: opiod antagonist that reduces craving and euphoria
- Gabapentin, topiramate
How long is the normal period of grief?
1 year
