Psychiatry Flashcards
Attention-Deficit Hyperactivity Disorder (ADHD) (dg)
Before 12yo has ≥5 sympt from each category for ≥6mo in ≥2 settings (home/school/…) lead to signif social + academ impair
- Inatt: poor att span, poor att to details/careless mistakes, diff follow instruc/finish task, forgetful, easy distract*
- Hyperactiv/Impulsiv: fidget, leave seat in class, run around, cant play quiet, talk excess, dont wait his turn, interrupt others
ADHD (PE, ttt)
Persistent excessive inatt (esp girls) +/or hyperactiv/impulsiv (esp boys)
Betw/ 3-13yo; often familial
ttt: #1 behav modif, then pharmaco
- Psychostimulant: methylphenidate, dextroamphetamine; (side eff: insomn, irritab, ↓appetite, tic↑, ↓growth)
- Nonstimulant (SSRI, nortriptyline, bupropion) and alpha2-agonist (clonidine) and atomoxetine
Autism Spectrum Disorder (PE)
Esp boys; before 3yo
Wide variat* in IQ and severity (based on level of support needed)
AbNl/impair social interact* + communic + restrict activities/interests
Spoken language delay/absent
Stereotyp speech+behavior
Autism Spectrum Disorder (ttt)
Intensive special educat*
Behav manag
Symptom-targeted meds: neuroleptic if aggressive, SSRI for stereotyp behav
Family counseling!!!
Ass w/ Rett sd, fragile X sd, tuberous sclerosis
Disruptive behavioral disorders
Esp men/boys; Hx of abuse; ttt ptt and family
-Oppositional defiant disorder: negativistic defiant disobedient hostile behavior tow/ authority; ≥6mo
May progr to conduct dso
-Conduct disorder: persist violating basic rights of others, societal norms/rules; ≥1y. May be aggress (rape, cruelty) or nonaggress (steal, lie, annoy)
May progr to antisocial personality dso in adult
Intellectual developmental disorder
At <18yo; IQ<70 w/ def in adaptive fct* (hygiene, social skills)
Ass w/ male, chrom abNl, congen inf, teratogens, alcoh/drugs, inborn metab errors
Mild (IQ 50-70); mod (35-49); sev (20-34); profound (<20)
ttt: 1* prevent* (educat public + prenatal screen)
Family counseling/support, speech/lang therapy, physical therapy, behav interv, assist, social skills training
Tourette syndrome
Esp boys/men, starts <18yo; genetic predispo
Ass w/ ADHD, learning dso, OCD
Multiple motor tics + vocal tics, recurr for >1y
+ social/occupational impairment
ttt: dopamine recept antag (haloperidol) or clonidine
Behav therapy + counseling
CI stimulants
Schizophrenia (epidemiology, ttt)
Psychotic sympt + disorganizat* + negative sympt
1% pop; M=W; peak at 18-25yo in M and 25-35 in W
↑R if 1st relative also
Suicide: 50% attempt; 10% successful
ttt: antipsychotics + long-term follow-up
Supportive psychottt, train social skills, illness educat*
Atyp antipsy esp for negative sympt
Schizophrenia (PE)
≥2 sympt for ≥6mo w/ social/occupat dysfct*
- Positive sympt: hallucin, delus*, disorg speech, bizarre behav, thought dso
- Negative sympt: flat affect, ↓emotion, poor speech, lack of purposeful act*, anhedonia
Differential diagnosis of psychosis
- Brief psychotic disorder: >1d and <1mo
- Schizophreniform disorder: >1mo and <6mo
- Schizophrenia: >6mo
- Schizoaffective disorder: schizo + major affective dso (major depr dso or bipol dso)
- Schizotypal perso dso: magical thinking
- Schizoid perso dso: loner
- Delusional dso: persist nonbizarre fixed delus, unaffected fct
Typical antipsychotics
For psychotic disorders, acute agitat*, acute mania, Tourette, esp positive sympt of schizo
- High potency (haloperidol, fluphenazine): EPS > anticholinergic sympt; ↑QTc; TdP; neuroleptic malignant sd
- Low potency (thioridazine, chlorpromazine): anticholinergic sympt > EPS; orthostatic hypoTN; retinal pigm (thiorid)
Atypical antipsychotics
Risperidone, quetiapine, olanzapine, ziprasidone, aripiprazole, clozapine #1 ttt for schizo (↓side eff) Clozapine: sev ttt resistance
↑weight, DM2, somnolence, ↑QTc
Clozapine: agranulocytosis (CBC/wk for 6mo)
Extrapyramidal syndrome
- 4h: acute dystonia (ttt: anticholinergic)
- 4d: dyskinesia (ttt: anticholinergic or dopamine agonist; ↓or stop neuroleptic)
- 4wks: akathisia (ttt: ↓neuroleptic, give B⊖; +/- benzo or anticholin)
- 4mo: tardive dyskinesia (ttt: ↓/stop neuroleptic; clozapine; other meds)
- Anytime: neuroleptic malignant syndrome (ttt: stop med; support in ICU; dantrolene or bromocriptine)
Generalized anxiety disorder
Uncontrol excessive anxiety; multiple activities
Signif impairment/distress; M/F=1:2; early 20s
Anx most days for ≥6mo + ≥3 somatic sympt
ttt: short-term (benzo immed then taper bcz !tolerance)
Long-term: lifestyle, psychotherapy, meds (SSRI #1, venlafaxine, buspirone)
Panic disorder (PE)
Recurr unexpect panic attacks; W>M; ~25yo
+/- agoraphobia
≥1mo concern of having attacks
Intense fear/discomf + ≥4 sympt abrupt/peak in 10min (tachypn, palpit, chest pain, diaphor, N, trembl, dizzy, going crazy, deperson, hot flashes)
Panic disorder (ttt)
Short-term: benzo (immed) then taper bcz tolerance
Long-term: CBT, meds (SSRI #1, TCAs)
If ass w/ agoraphobia: ttt it also
SSRIs
Fluoxetine, sertraline, paroxetine, citalopram, escitalopram
GAD, OCD, panic disorder, depress*, anxiety
Side eff: N, GI, somnol, sex dysfct, agitat*, insomn, tremor
!!!Not w/ MAOIs (dev serotonin sd)
Buspirone and B⊖
-Buspirone: GAD, social phobia
No tolerance, dependance or withdrawal
Side eff: seizures if chronic; !!!Not w/ MAOIs
-B⊖: prior to phobic disorder
Side eff: bradycardia, hypoTN
Benzodiazepines
Anxiety, insomnia, alcohol withdrawal, M spasm, night terrors, sleepwalking
Side eff: ↓sleep durat; abuse/tolerance/dependence; disinhibit in young/old; confus*
Phobias (social and specific)
-Social: specific (speaking, urinating) or general (interact*)
Often ado
-Specific: feared object/situat*
Often childhood
Phobias (PE, ttt)
Excessive fear + avoidance
Signif distress/impairment and ⊕insight
ttt: social ph (CBT, SSRI, low-dose benzo, B⊖) Specific ph (CBT+desensitizat*, support, family psychottt)
Obsessive-compulsive disorder (OCD)
Obsess* and/or compuls; signif distress/dysfct
Late ado or early adult; W=M
Obsess: persist unwant intrusive idea/impulse: marked anxiety/distress
Compuls: repeat mental act/behav to neutralize
OCD (#dg, ttt)
OCD: ⊕insight + wants to be ttt #OCPD = personality dso: do not recognize the prob
ttt: SSRIs #1, CBT (desensitizat), educat
Body dysmorphic disorder
Preoccupat* w/ imagined or slight physical defects Imperceptible to others Signif distress/impairment Obsess* + repetitive behav ttt: SSRIs
Post-Traumatic Stress Disorder (PTSD)
Signif distress/impairment
Extreme life-threat traumatic event: direct expo, witnessing, indirect in close friend
4 sympt clusters for >1mo
Intrus* (reexperience), avoidance, negative alterat* in mood/cognit*, changes in arousal/reactivity
If >3d to <1mo: acute stress dso
PTSD (ttt)
Short-term: B⊖, alpha2-agonists (for anxiety)
Long-term: meds (SSRIs #1, … Avoid benzo), psychotherapy, support groups
Adjustment disorder
Signif distress after profound life change
But r/o other mental dso
3mo after stressor; resolv in 6mo
Anxiety, depressed mood, conduct; ↑R suicid
ttt: supportive counsel
Dementia (Major neurocognitive disorder) (PE)
Progress ↓cognit* w/ global deficits; Nl conscious
Esp Alzheimer or vascular dem
Impaired cognit* in order: Amnesia, Aphasia, Apraxia, Agnosia
Impaired executive fct*: plan, organize, abstract
+/- personality, mood, behav changes
Dementia (dg, ttt)
Dg: Hx+PE, serial MMSE
R/o treatable causes (labs, vitB12/B9, LFTs, UA, CT/MRI,…)
ttt: environmental cues for daily life
Cholinesterase inhib, family/ptt educat* + support
Low-dose antipsychotics (if aggress)
Avoid benzo
Delirium (PE)
Acute disturb conscious + altered cognit*
Hours to days; esp child/elder/hospit ptt
Wax/wane conscious + perceptual disturb (halluc, illus, delus); +/- anxiety, paranoid, stupor
Delirium (dg, ttt)
Dg: vitals, oximetry, glu, PE, neuro exam, labs, imagery
Recent meds/drugs, prior episodes, organ failure, inf
ttt: underl cause (often reversible), optimize environment, low-dose antipsychotics (agitat*/hall)
+/- physical restraint
Major depressive disorder (dg)
≥1 episodes; M/F=1:2; esp mid-20s but in elder ↑w/ age
Esp if stress or chronic illness; !!!suicide
5 subtypes: psychotic features, postpartum, atypical, seasonal, double depress*
Dg: ≥2 weeks of depressed mood or anhedonia + ≥5 signs/sympt (sleep, interest, guilt, energy, concentrat, appetite, psychomotor agitat, suicidal)
Major depressive disorder (ttt)
- Meds: 2-6wks for effect; ttt for ≥6mo
- Psychotherapy w/ meds
- Phototherapy: seasonal depress*
- Transcranial magnetic stimulation
-ECT: if refractory, psychotic depress*, sev mania or suicidality
2-3/wks for 6-12ttt
Relative CI: recent stroke/MI, intracranial mass, anesth R
Major depressive disorder (#dg)
- Mood dso due to a medical condition
- Substance-induced mood disorder
- Adjustment disorder w/ depressed mood (in 3mo of a stressor)
- Normal bereavement (<6mo, max 1y)
- Dysthymia (mild chronic depress* most of time for ≥2y)
Postpartum disorders
- PP blues: in 2wks pp; sad, moody, emot* lability; No thoughts ag bb
- PP psychosis: 2-3wks pp; delus* + depress*; may have thoughts to hurt bb
- PP depress: 1-3mo pp; depress, sleep disturb, anxiety; thoughts to hurt bb
Atypical antidepressants
Bupropion, mirtazapine, trazodone
Depress*, anxiety
Bup: seiz; so CI if seiz Hx or eating dso
Mirta: ↑weight, sedat*
Traz: sedat*, priapism
SNRIs
Venlafaxine, duloxetine
Depress*, anxiety, chronic pain
Venlaf: diastolic HTN
Tricyclic antidepressants
Nortriptylline, desipramine, amitriptylline, imipramine
Depress*, anxiety, chronic pain, migraine, enuresis (imipr)
Side eff: lethal if overdose (arrhyth) so monitor ICU x3-4d
Anticholinergic eff
MAOIs
Phenelzine, tranylcypromine, selegiline
Depress*, esp atypical
HTN crisis if taken w/ ↑tyramine food
Sexual dysfct*, orthostatic hypoTN, ↑weight
Bipolar disorder (types)
Types I (1%) and II (4%); M=W; ↑R if fam Hx ~20yo; ↑episodes w/ ↑age; !!! suicide
- BP I: ≥1 manic or mixed episode (+/- hospit)
- BP II: ≥1 MDE and ≥1 hypomanic episode
- Rapid cycling: ≥4 episodes (MDE/manic/mixed/hypomanic) in 1y
- Cyclothymic: chronic less sev, alternate hypomania and moderate depress* for >2y
Bipolar disorder (PE, dg)
Distractibility, insomnia, grandiosity, flight of ideas, psychomotor agitat*, sexual indiscretions, talkativeness
+/- psychotic features
-Manic: ≥1wk persistent elevated expansive mood + 3 sympt; signif impairment
R/o substance or medical condit*
-Hypomanic: same but no impairment, no psychotic sympt, no hospit
Bipolar disorder (ttt)
BP mania: emergency (↑R for ptt and others)
Acute ttt: antipsychotics, lithium, valproate
Mainten ttt: mood stabilizers
Benzo if refractory agitat*
BP depress*: mood stabil first +/- antidepr
!!! CI antidepr w/o mood stabilizer
ECT if refractory
Lithium
#1 for acute mania Prophylaxis in BPD, ↓R suicide
Side eff: diabetes insipidus, tremor, ↑weight, hypothyr, GI, seiz, teratogen, acne
Narrow therapeutic window
Toxicity (>1.5mEq/L): ataxia, dysarthria, delirium, acute renal failure
Carbamazepine
2 mood stabil; anticonvulsant; trigeminal neuralgia
Side eff: N, rash, leukopenia, AV block, teratogen
Rare: aplastic anemia, SJS
Valproic acid
Bipolar, anticonvulsant
Side eff: GI, tremor, sedat*, alopecia, ↑weight, teratogen
Rare: pancreatitis, thrombocytopenia, fatal hepatotoxicity, agranulocytosis
Lamotrigine
2 mood stabil; anticonvulsant
Side eff: blurred vis*, GI distress, SJS (so slowly ↑dose)
Personality disorders
Emotional + behavioral traits chronically rigid and maladaptive + social/occup impairment
Stable + predictable
Early adult
Dg: ask abt attitudes, mood variability, activities, react* to stress; deny/diff changing behavior; refuse ttt
ttt: psychotherapy (#1); meds if comorbid psychiatric ds
Cluster A (Weird)
- Paranoid: distrustful, suspicious, see other’s motives as evil
- Schizoid: isolated, detached, restricted emotional express*
- Schizotypal: odd behavior/perceptions/appearance, magical thinking
Cluster B (Wild)
- Borderline: unstable mood/relationships/self-image, feel emptiness, impulsive, suicidal ideat*/self harm
- Histrionic: excess emotional/attention seeking, sexual provocative, theatrical
- Narcissistic: grandiose, need admirat*, lack empathy
- Antisocial: violate others’ rights/social norms/law, impulsive, lack remorse (must have Hx of conduct dso)
Cluster C (Worried)
- Obsessive-compulsive: preoccupied w/ perfectionism + order + control at expense of efficiency, doesnt feel probl
- Avoidant: socially inhibited, rejection sensitive, fear of being disliked/ridiculed but desires friends/social interact*
- Dependent: submissive, clingy, need to be taken care of, feel helpless, difficulty making decisions
Substance use disorders
Most subst (except caffeine); signif impairment Dg: 2 of 11 criteria in 1y Criteria grouped into: impaired control, social impairment, risky use, pharmacologic
Tolerance and withdrawal: not needed to make dg
Severity of abuse: mild (2-3/11), mod (4-5/11), sev (>6)
Check: urine+bld toxico screen, LFTs, serum EtOH
Alcohol use disorder (dg, complications)
Esp men (4:1); 21-34yo; ⊕fam Hx Dg: screen w/ CAGE (Cut down, Annoyed by criticism, Guilty, Eye opener); monitor vitals; LFTs, LDH, MCV
Compl: pancreatitis, liver ds, DT, hallucinosis, periph neurop, Wernicke/Korsakoff, FAS, aspirat* pneumonia, trauma, ……….
Alcohol use disorder (ttt)
R/o compl, correct e- Benzo taper (withdrawal sympt) Haloperidol (psychotic sympt) Multivitamins + B9 + B1 before glucose Anticonv (if seiz Hx)
For dependence: group therapy, disulfiram, naltrexone
Long-term rehab therapy (AA)
Anorexia nervosa (RF, PE)
RF: female, ↓self-esteem, ↑socio-eco status
Ass w/ OCD, MDD, anxiety, modeling, gymnastics, ballet, running
Sev restrict KCal (fast or ↑exo) or binge+purge (vomit, laxat, diuret)
Cachexia, BMI<18, lanugo, dry skin, bradyc, lethargy, hypoTN, cold intol, hypothermia
Anorexia nervosa (dg, ttt)
Dg: BMI, CBC, e-, endocrino, ECG, intense fear of ↑weight, psychiatric eval (comorbid)
ttt: monitor KCal, hospit if necess
Psychotherapy; ttt comorbid
Ptt may resist ttt (not distressed by ds)
Medical complications of eating disorders
Constitutinal: cachexia, hypothermia, fatigue, e- Cardiac: arrhyth, sudden death, ... GI: dental eros*, abdo pain, ... GU: amenorrhea, nephrolithiasis Dermato: lanugo Hemato: leukopenia Neuro: seiz MSK: osteoporosis, stress fx
Bulimia nervosa
Esp women; ass w/ ↓self-esteem, mood dso, OCD
Dg: ≥1wk for ≥3mo of episodes (binge eat + compensatory behav of purge or fast); Nl or overweight
Dental enamel eros*, larg parotid, scars on dorsal hand
Ptt distressed so easily ttt
ttt: psychotherapy +/- antidepressants
Sexual changes with aging
Same interest in sex
Men: need ↑stimulat* for longer period to reach orgasm, ↓intensity of orgasm, ↑refractory period
Women: ↓estro, dry/thin vag, discomfort; ttt w/ HRT, estro vag suppo, vag creams
Paraphilic disorders
Preoccup w/ unusual sex fantasies/urges/behav for >6mo
Signif impairment
8 disorders characterized by: disordered courtship, disordered preferences, pleasure in inflicting/receiving pain
ttt: insight-oriented psychotherapy + behavioral therapy
Gender dysphoria (dg)
Strong persistent cross-gender identificat*
Discomfort w/ assigned sex/gender role
No intersexual disorders
Men > Women; Hx of dressing like opposite sex, taking sex hormones, surg to reassign sex
Psychiatric comorbidities
Gender dysphoria (ttt)
Educat* (culturally acceptable behav pattern)
ttt comorbid
Sex-reassign surg or hormonal ttt
Psychotherapy
Sexual dysfunction
Prob in arousal, desire, orgasm, pain
30% of pop
1/3 biological; 1/3 psycholog
ttt: dep on cause; sildenafil, bupropion; psychotherapy
Sleep disorders
1/3 of US adults; dyssomnia, insomnia
RF: female, mental/medical dso, substance abuse, adv age
Sleep hygiene: regular schedule, ↓caffeine, avoid naps, evening warm bath, bedroom (sleep/sex), exo early, relaxat*, avoid large meals
1* insomnia
30% pop; R/O physical/mental dso
Nonrestorative sleep, diff initiate/maintain sleep; ≥3 times/wk for 1 month
ttt: sleep hygiene (#1); meds (#2; for short period <2wks; diphenhydramine, zolpidem, zaleplon, trazodone)
1* hypersomnia
Excessive daytime sleepiness or nighttime sleep
For >1mo
R/O medical/mental dso, meds, poor sleep hygiene, insufficient sleep, narcolepsy
ttt: stimulant meds (#1; amphetamines)
Narcolepsy
Young adult, <30yo; may be genetic
Excess daytime somnol + ↓REM latency on daily basis for ≥3mo; sleep attacks
Ass w/ cataplexy, hypnagogic or hypnopompic hallucinations, sleep paralysis
ttt: scheduled daily naps + stimulant (amphet); SSRI (for cataplexy)
Sleep apnea (2 types)
2* to disturb breathing → excess daytime somnol + sleep disrupt* (arousal stops apnea)
- Central: airflow + resp effort cease; morning headaches, mood chang, repeat awaken at night
- Obstructive: airflow cease; snoring+++; RF (male, obes, airway surg, anatomic abNl)
Sleep apnea (dg, ttt)
Dg: polysomnography, OSA/CSA, mvt dso, seiz, other sleep dso
ttt: OSA (CPAP, ↓weight, surg in child if tonsil/adenoid hypertrophy)
CSA (BiPAP)
Circadian rhythm sleep disorder
Misalignment betw/ desired and actual sleep
Types: jet-lag, shift-work, delayed sleep, unspecified
ttt: jet-lag (self-resolut* 2-7d); shift-work (light therapy); oral melatonin if 5.5h before desired bedtime
Somatic symptom disorder
Excess thoughts/anxiety/behav by presence of somatic sympt; distress daily life +/- medical ds
High health care utilizat*
ttt: regular appointments w/ 1 Dr; psychotherapy
Conversion disorder
Def of voluntary motor/sensory fct* incompatible w/ medical ds; close time relation to sev stress/emot* Hoover sign (r/o leg paralysis); eye resist to opening in seiz; ⊖EEG; tremor disappear w/ distract*
ttt: psychotherapy
Factitious disorders and malingering
Factit: fabrication of sympt or self-injury, assume sick role (1* gain)
Factit imposed on another: caregiver makes other ill
Maling: intentionally cause sympt (2* gain), financial/housing
ttt: psychotherapy, minimal dg/ttt to avoid reinforc behav
Sexual and physical abuse (PE)
Esp women <35yo w/ marital discord, subst abuse (ptt or partner), pgnt, ↓socio-eco
Victims of childhood abuse: ↑R become adult victims
Multiple somatic complaints, fqt ER visits, unexplained injuries w/ delayed ttt, avoid eye contact, genital/anal trauma, STDs, UTIs, psychiatric prob
!!partner answers or refuses to leave room
Sexual and physical abuse (ttt)
Screen of ptt's safety Medical care Emotional support Counseling Educate abt support services + refer !!! documentation
Suicidality (RF)
30K deaths/y in US; #8 cause of death in US
RF: male, >45yo, psychiatric dso, previous attempt, Hx of psy admiss*, subst abuse, recent sev stress, fam Hx, chronic ds, no spouse/support, organized plan, weapons
Suicidality (dg, ttt)
Dg: comprehensive eval, ask directly abt suicidal ideat*/plan/weapons
ttt: emergent hospit even against ptt’s will
!!! R may ↑ after antidepr bcz ↑ energy
