Psychiatry Flashcards
In-class material
What are the various tx availble for Insomnia based on the categories below? → Non-pharm → Antidepressant (2) → Anticonvulsant (1) → Non benzos (2) → Melatonin receptor agonist (1) → Benzo (2)
→ Non-pharm
Sleep hygiene
→ Antidepressant (2)
Trazodone
Mirtazapine
→ Anticonvulsant (1)
Quetiapine
→ Non benzos (2)
Zolpidem ("z-solid sleep")
Eszopiclone
→ Melatonin receptor agonist (1)
Ramelteon
→ Benzo (2) → "L & T"
Lorazepam
TemazepamParasomnias, which ones do you tx? How? + Which ones are REM vs NREM? Options: Sleepwalking REM Behavior Disorder Nightmare Disorder Sleep Terror Disorder Enuresis
Sleepwalking → nope, just education (NREM)
REM Behavior Disorder → Clonazepam (REM)
Nightmare Disorder → avoid meds (bb, TCA, etoh, clozapine, L-dopa, nicotine) (REM)
Sleep Terror Disorder → Diazepam (NREM)
Enuresis → Desmopressin (?)
Characterized by: -Sleep attacks -Cataplexy -Sleep paralysis -Hypnagogic hallucination \+ Tx?
Narcolepsy
Tx:
→Stimulant: Dextromethamphetamine
→Modafinil
→Armodafinil
Manifestation of intrusion sx (flashbacks, nightmares), avoidance sx, negative cognitive/mood alterations, hyper-arousal sx (irritability etc) w/ complete resolution in 3 weeks is categorized as what?
Acute Stress Disorder
→ PTSD sx that last < 4 weeks
Characterized by: → Perceived or actual event →Intrusion sx →Avoidance sx → Negative alteration → Hyeperarousal → Duration of sx Dx? How many under the criteria? Tx?
PTSD: → Perceived or actual event (*necessary) →Intrusion sx (> 1) →Avoidance sx (> 1) → Negative alteration (> 2) → Hyeperarousal (> 1) → Duration of sx (3 options)
Tx:
1st line Psychotherapy like TF- CBT
+
SSRI (sertraline)
ID the timelines for the 3 subtypes of PTSD?
Acute: resolution in < 3 mo
Chronic: resolution in > 3 mo
Delayed onset: > 6 mo
Russel’s Sign
Duration of sx to be diagnostic?
https://www.brainscape.com/decks/8022609/cards/quick_new_card
L/T results?
Tx?
Bulimia
Calloused knuckles
2 binge/purge per week x 3 mo
Metabolic alkalosis, ↓ K, ↓ Mg, ↓ Cl
Tx:
SSRI: Fluvoxamine or fluoxitine
Risk Factors of Substance Use Disorder
Psych disorders, PTSD, childhood trauma
Leading cause of preventable disease, disability, death
vs
3rd leading cause of preventable death in US
Tobacco
ETOH
Addiction starts with deficits in ________ & progresses into deficit in _________.
-What reinforcement is associated to each?
Impulsivity (positive/pleasure) → Compulsivity (negative/relieve an anxiety)
Characterized by the following large categories for DSM-5 criteria:
→Impaired control over use of a substance
→Social impairment
→Risky use of the substance
→Pharmacologic criteria (tolerance & withdrawal)
Substance Use Disorder
*10 possible categories of substances
of criteria needed to ID the degree of severity in SUD
→Mild
→Moderate
→Severe
Mild: 2-3
Moderate: 3-5
Severe: > 6
3 FDA approved tx for ETOH use disorder?
3 non-FDA approved tx?
Naltrexone, acamprosate, disuliram
Non-FDA:
Gabapentin, topiramate
3 tx for for Tobacco use disorder?
NRT, Varenicline, Wellbutrin
Autonomic hyperactivity (sweating, ↑ HR) Hand tremor, insomnia, anxiety N/V Transient hallucinations or illusions Seizures .... Sx of? Tx?
Alcohol use Withdrawal
Tx:
→ Thiamine, dextrose
→ Benzo vs seizures
Grades:
0: craving & anxiety
1: yawning, lacrimation, rhinorrhea, perspiration
2: previous sx + midrasis, piloerection, anorexia, tremors, hot/cold flashes, generalized aching
3/4: high intensity sx, ↑ body temp, ↑ BP, ↑ pulse, ↑ RR (resp depression)
Opioid Withdrawal
Overdose:
→resp depression, peripheral vasodilation, pinpoint pupils, pulm edema, coma, death
Risk factors for major depression
FHx of psych disorders
PMHx
Major depression diagnosis criteria
5 SIGECAPS sx
+
> 2 weeks duration
PHQ2 quesitons?
-what is PHQ9
PHQ2:
- Feeling down, depressed, hopeless?
- Little interest or pleasure?
* You can do this in a primary care setting as the 1st screening then if (+) do the PHQ9
If I have the following…
→prior attempt, plan, etoh abuse, firearms, psych dz, sudden lift in mood/antidepressant
…what am i at risk for?
HIGHEST risk of suicide
Progression of prescribing SSRIs for Major Depression
- F/u in 1-2 weeks
- If better → F/u in 6 mo → 9 mo can revaluate need
- If NOT better → change dose or med → F/u in 1-2 weeks → keep trying to change
1st line SSRI in child (2)
Fluoxetine & Escitalopram
4 Steps to do Prior to Discharging an Adolescent Who Attempted Suicide
- Caution family about drugs/etoh
- Firearms or OD drugs?
- Need a SUPPORTIVE person
- NEED a F/U apt
MC psych disorder in children
Anxiety
Mnemonic:
STUDENTS PANIC
→ How many needed to diagnose?
→Tx
Panic Attack SOB Trembling Unsteady Depersonalization Excessive HR Numb Tingling Sweating
Palpitation Abd pain Nausea Intense fear Chest pain
NEED: 4
Tx: Acute attack → Benzo
Panic Disorder
→Duration of sx to diagnose
→1st line tx
> 1 mo of concern/fear of recurrent panic attacks
1st line tx:
SSRI: sertraline, fluoxetine, paroxetine
MC co-current diagnosis w/ anxiety
Major depression (50-60% of time)
Generalized Anxiety Disorder
→Duration of sx to diagnose
→1st line tx
> 6 mo + impairment of life moments
1st line tx:
SSRI (Escitalopram, paroxetine)
→others, SNRI (venlafaxine, duloxetine) or buspirone
2 categories of sx in DSM-5 criteria for ADHD
→ID the quantity of each necessary for dx
→In what settings?
→What screening tool can be used in variable settings?
→1st line tx
→ADHD + tics
→CI of stimulants
INATTENTIVE sx (>5 adult; >6 child)
HYPERACTIVITY/IMPULSIVITY sx (>5 adult; >6 child)
Settings: > 2 Vanderbilt screening (parent, teacher etc)
Tx: Stimulants (Methylphenidate, amphetamine)
ADHD + tics: Amoxetine
CI of stimulants: Bupropion
2 categories of sx for Autism Spectrum Disorders
→How many total sx necessary for dx?
→Gold standard screening?
→GS tx?
- Social communication & interaction deficit
- Restricted & repetitive behavior, interest, activity
NEED: > 6 sx
ADOS(autism diagnostic observation schedule) + Hearing & visual screening
GS Tx:
Applied Behavioral Analysis
+/- other meds like riseperidone or aripiprazole or SSRIs
MC comorbid disorder along w/ bipolar
Anxiety (75%)
Other: ADHD, substance use disorder, eating disorders
Which meds cause the following series of SE:
A) TREMOR, weight gain, HYPOthyroidism, arrhythmia, many DDI
B) NEURAL TUBE DEFECTS, cleft lip/palate, hepatotoxic, pancreatitis
What do they tx?
A) Lithium
B) Valproate
Usually used to tx Bipolar 1/2
ID the details of the DSM-5 criteria for Bipolar 1 Disorder: →Types of episode & quantity? →Duration →Effect on life →Additional criteria & quantity?
→Types of episode & quantity?
MANIC episode (> 1)
→Duration
> 1 week
→Effect on life
Impairs function
→Additional criteria & quantity?
3 of the DIGFAST criteriaDIGFAST → what are they?
D: distractibility I: irritability G: grandiose F: flight of ideas A: activity ↑ S: sleep deficit/less need (*Usually the 1st sx) T: talkative/fast talking
Bipolar 1 vs. Bipolar 2
Tx
Mood Stabilizers: (for BP1 & hypomania in BP2)
1st line: Lithium
Other: Valproic acid, carbamazepine
Antipsychotics: (for BP1 & hypomania in BP2)
2nd generation like olanzapine
Only to subdue pt:
Haloperidol or benzodiazepine
BP2 depression: Lithium, valproate, carbamazepine, lamotrigine, atypical antipsych
BP2 mixed hypomania & depression: atypical antipsych, valproate
ID the details of the DSM-5 criteria for Bipolar 2 Disorder: →Types of episode & quantity? →Duration →Effect on life →Additional criteria & quantity?
→Types of episode & quantity?
Hypomania
Major depression
>1 episodes of each/both!
→Duration
Hypomania > 4 days
Major depression > 2 weeks
→Effect on life
Impairs function
→Additional criteria & quantity?
3 of the DIGFAST criteriaBipolar 1 vs Bipolar 2, how do they compare in terms of suicide?
Bipolar 2 has high suicide attempts but both have suicidality as a risk
Diagnostic duration for Cyclothymic Bipolar disorder?
2 years of not extremely severe depression/hypomania
Diagnostic duration of sx/presentation to diagnose either Anorexia or Bulimia?
3 months
Lanugo
Anorexia
Anorexia:
→Diagnostic weight must by _____% below expected which is about _____ standard deviations from this value
→Amenorrhea can be diagnostic at _____ months
15%
1.5
3 mo
Pharm 1st line in anorexia
Olanzapine (low dose)
Deadly complication of restoring normal weight in anorexia
Refeeding syndrome → characerized by HYPOphosphatemia & volume overload → can result in death
Solution: feeding must be slow/in small amts
Screening for anorexia
EAT 26 (96% accurate)
Types of INAPPROPRIATE COMPENSATION in bulimia (5)
- Self-induced vomiting
- Laxatives
- Diuretics
- Fasting
- Excessive exercise
Parotid swelling
Bulimia
Russel’s sign
Bulimia (calloused knuckles)
Metabolic alkalosis values form bulimia
↓ K+
↓ Mg+
↓ Cl-
*can progress to cardiac abnormalities (T-wave flattening/inversion, ST depression, QTc lengthening)
Bulimia & Binge Eating Disorder common tx?
Psychotherpay CBT
SSRI → Fluvoxamine
What risk factor makes child abuse 5 x’s more likely?
What are the other risk factors?
Poverty (5x’s greater than general pop)
Other: SUD, FHs, divorce, parental mental illness, foxter care
MC type of child abuse
Neglect
Retinal hemorrages of hyphema in baby
Shaken Baby Syndrome
Child Abuse
The general long term impact of child abuse on the victim
Overall ↓ lifespan
When is it more likely for domestic violence or a severe assault in this context to occur?
When the victim is attempting to escape their relationship
When discussing elder abuse, what age is “elder”?
> 60 yo
*A breech in the trusted relationship with the elder
During what time period is forensic evidence able to be collected from the victim?
24 hrs
“rape kit”
Sexual Abuse child victim, do you give them all abx prophylaxis?
PREpubertal + no sx → no
POSTpubertal + no sx → yes
Symptomatic → YES!
Dialectical Personality Tx
1st line tx in borderline personality disorder
CC of pt is “Aggression” what do you think of as possible causes
ADHD DMDD Intermittent Explosive Disorder TBI Seizures Autism
ODD, Conduct Disorder & Intermittent Explosive Disorder
…are all?
Impulse Control Disorders
ODD vs conduct disorder
ODD is > 6 mo of > 4 sx BUT no harming of property or ppl
Conduct disorder is > 12 mo of 3 or > 6 mo of 1 sx + YES harming in 4 categories (Aggression, destruction, deceit, serious rule violation)
ODD vs DMDD (Disrupted Mood Dysregulation Disorder)
ODD is > 6 mo of > 4 sx BUT no harming of property or ppl
DMDD is out of proportion temper tantrums > 12 mo > 3 times per week (not the pts baseline)
Intermittent Explosive Disorder vs ODD vs DMDD
Intermittent Explosive is verbal aggression OR damaging behavioral outbursts (not the pts baseline)
ODD is > 6 mo of > 4 sx BUT no harming of property or ppl
DMDD is out of proportion temper tantrums > 12 mo > 3 times per week (not the pts baseline)
Mainstay of care for somatic symptom disorders? What are they?
Psychotherapy + SINGLE provider f/u + Socialization
Illness Anxiety Disorder
Conversion Disorder
Somatization Disorder
Others that are for the pt’s personal gain: Factitious Disorder & Malingering
2 types of Illness Anxiety Disorder
→Duration of sx?
→How can it present?
- Care seeking
- Care avoidant
> 6 mo
Presents: highly focused on the idea of a sx or dx
Neurologic presentation + La belle differance
Conversion disorder
→often presents as paralysis, pseudosizure, aphonia, blindness, sensory deficit, neuro/ortho complaint
Pt complains of pain, fatigue & is preoccupied excessively w/ this sx (disproportionately) in the past 6 mo
Somatic Sx Disorder
Personality disorder MC associated w/ malingering
Antisocial personality disorder
