Psychiatry Flashcards
who is a candidate for lifelong antidepressant treatment
patient with more than 3 lifetime depressive episodes, suicide attempts, or episodes lasting more than 2 years
blockage of what receptor causes extrapyramidal symptoms
D2 (antipsychotics and metoclopramide)
what is not detected by a standard urine drug screen
semisynthetic opioids
- hydrocodone
- hydromorphone
- oxycodone
synthetic opioids
- fentanyl
- meperidine
- methadone
- tramadol
man with bipolar comes in with fatigue, myalgias, constipation, and bradycardia … what do you think
lithium induced hypothyroidism (this happens in 25% of pts on lithium)
- all pts on lithium need TSH monitoring every 6-12 months
- treat with T4 supplementation (dont discontinue lithium)
if ssri doesnt work for a pt who is suffering from weight gain and sexual side effects, what do you give them?
bupropion (NDRI)
what do you give to someone who has an addictive past but is diagnosed with ADHD
Atomoxetine, nonstimulant norepinephrine reuptake inhibitor
TCA overdose
convulsions
coma
cardiotoxicity
-respiratory depression, hyperpyrexia, prolonged QT
neuroimaging in a pt with schizophrenia
larger lateral ventricles
what is the first line treatment for narcolepsy
modafinil
- nonamphetamine
- promotes wakefulness
MAOI and you drink or eat cheese
hypertensive crisis due to excess tyramine
preferred treatment for adjustment disorder (symptoms develop w/i 3 months of major stressor and cause significant impairment) and borderline personality disorder
psychotherapy
-specifically dialectical behavioral therapy for borderline personality disorder
how long do postpartum blues last
usually 2 weeks
how to treat acute opioid intoxication
naloxone
unstable mood, recurrent suicidal behavior, impulsivity, intense anger, chaotic interpersonal relationships
borderline personality disorder
what CSF findings are associated with increased risk of suicidal behavior
low concentrations of 5-HIAA in CSF
valproate side effect
hepatotoxicity
irritability, agitation, psychosis, tachycardia, hypertension, hyperthermia, diaphoresis, mydriasis
amphetamine toxicity
how to treat catatonia (when pt doesnt move even if you move their arm against gravity they will just leave it there)
benzodiazepine and/or ECT
signs of and how to treat lithium toxicity
signs –> neurologic (altered mental status, seizure, fasciculations, tremor) and gi (vomiting and diarrhea) symptoms
mild –> hydration and monitoring
prominent –> hemodyalsis
what do you think of in a pt with hand abrasions and parotid gland enlargement
bulemia nervosa
- expect to see metabolic alkalosis with hypokalemia
- also hypochloremia
3 FDA-approved first line treatments for smoking cessation
- nicotine replacement therapy
- varenicline
- bupropion
second generation antipsychotics that cause metabolic side effects
olanzapine and clozapine
what medication at high doses can cause psychosis
glucocorticoids
first line treatment for alcohol use disorders
naltrexone –> mu opioid receptor antagonist
acamprostate –> glutamate modulator
what are three chemical differences in someone with MDD
- hyperactivity of hypothalamic-pituitary-adrenal axis causing increased cortisol levels
- decreased REM latency
- decreased slow wave sleep
mirtazapine
atypical antidepressant
- a2 antagonist
- increases NE and serotonin
if pt on antipsychotic starts experiencing tardive dyskinesia refractory to valbenazine and deutetrabenazine then what do you do…
- discontinue causative medication if feasible
- switch to either quetiapine or clozapine if continued antipsychotic is required
what type of therapy has been shown to decrease relapse in pts with schizophrenia
family therapy
first line treatments for acute mania
- antipsychotics (1st and 2nd generation)
- lithium
- anticonvulsant mood stabilizers (valproate)
dhat syndrome
- somatic symptoms (fatigue, weight loss), anxiety, cultural background, and belief of losing semen during urination
- usually in south asian men
- pt mentions any type of concern of losing semen
-use a pt centered approach and ask open ended questions about what they think is going on
seizure with these factors lead to what likely diagnosis
- forced eye closure
- side-to-side head or body movements
- memory recall of the event
- lack of postictal confusion
psychogenic nonepileptic seizure (PNES)
-gold standard for dx: video electro-encephalogram of an event demonstrating lack of epileptiform activity
which antidepressant has mild stimulant effects and when would you give it
bupropion
- give to depressed pts with low energy, impaired concentration, hypersominia, and weight gain
- it can also be used to help with smoking cessation
what is the most common psychiatric complication in patients with multiple sclerosis
depression
REM sleep behavior disorder
sleep behavior disorder that involves dream enactment that occurs during REM sleep due to absence of muscle atonia
- if awakened pt becomes fully alert and recall their dreams
- in older pts this can be a sign of neurodegeneration
pt has fever, lead-pipe rigidity, mental status changes, and autonomic instability (hypertension, tachycardia, diaphoresis)
neuroleptic malignant syndrome
- can be caused by every class of antipsychotics
- creatinine kinase and WBC count may be elevated
-if supportive measures aren’t enough then use D2 blockers like bromocriptine or amantadine
macrocytosis in a pt who cant sleep and has ast:alt > 2
alcohol use disorder
once a pt with single-episode unipolar major depression has been brought back to baseline… how do you change their meds?
continuation-phase treatment
-continue their treatment for 6 months at same dose and if remission is maintained then taper gradually and discontinue
how to treat a pt with recurrent, chronic, severe episodes of depression once they finally are stable?
keep them on medication for 1-3 years or indefinitely if they have more than 3 episodes
excessive anxiety and preoccupation with 1 or more unexplained symptoms lasting at least 6 months
somatic symptom disorder
what is this pt withdrawing from…
- nausea, vomiting, abdominal cramping, diarrhea, muscle aches
- dilated pupils, yawning, piloerection, lacrimation, hyperactive bowel sounds
heroin
-pts may also have rhinorhea
if a pt has a history of bulemia or anorexia nervosa what medication is absolutely contraindicated and why
bupropion is contraindicated due to the increased risk of seizures from the electrolyte disturbances they may have
treatments for eating disorders
anorexia –> cbt, nutritional rehab, olanzapine if nothing else worked
bulemia –> cbt, nutritional rehab, ssri (fluoxetine) added
binge-eating –> cbt, behavioral weight loss therapy, ssri, lisdexamfetamine
what type of medication is contraindicated in someone taking an SSRI
monoamine oxidase inhibitor due to possible serotonin syndrome (3 As –> increased Activity, Autonomic instability, Altered mental status)
pt has depression then ends up losing a little weight and becoming hypertensive… what do you think?
SNRI, venlafaxine
-blood pressure should be monitored regularly for these pts
manic behavior (agitation, grandiosity, loud/pressured speech) + sympathetic stimulation (diaphoresis, tachycardia, hypertension, mydriasis)
cocaine intoxication
what do you give to a pt in alcohol withdrawal
lorazepam
oxazepam
temazepam
*note: you cant give chlordiazepoxide or diazepam b/c they have long half lives and build up to cause toxicity in pts with liver dysfunction
if a pt with cancer or some disorder seems depressed from it what do you do
GIVE MEDS FOR IT
-pts with medical problems have a lower threshold for when you wanna treat them for depression
preferred treatment of PCP induced agitation
benzos
what is akathesia, when do you expect to see it, and how do you treat it
akathesia –> subjective restlessness and inability to sit still
- try to keep a lookout for this if a pts psychosis gets worse or if they cant sit still after being placed on an antipsychotic
- treat by reducing antipsychotic dosage and adding propranolol, benztropine, OR a benzo
older thin pt presents with depression, anxiety, smoking history, weight loss, and recent diagnosis with DMT2… what do you think
pancreatic cancer
-get CT of abdomen
how to diagnose absence seizure
classic 3-hz spike and wave pattern on electroencephalogram
false positive UDS for amphetamines
NAP-B Nasal decongestant Atenolol Propranolol Bupropion
false positive UDS for PCP
DDD-TV-K dextromethorphan diphenhydramine doxylamine ketamine tramadol venlafaxine
at what age roughly should imaginary friends be considered abnormal
around 6 or 7, before that they are normal and a form of creative play for a child
how to tell the difference b/w risperidone or a prolactinoma in pts with history of psychosis
risperidone = prolactin level around 70-100 prolactinoma = prolactin level above 200
what other medications besides lithium can be used for bipolar disorder as mood stabilizers
valproic acid
carbamazepine
lamotrigine (titrate slowly –> can cause SJS or TEN if severe)
2nd gen antipsychotics (quetiapine and lurasidone)
wernicke-korsakoff syndrome
Wernicke encephalitis = confusion, opthalmoplegia, ataxia (classic triad)
Korsakoff syndrome = confabulation, personality change,, memory loss
*occurs in pts with alcoholism and/or thiamine (B1) deficiency
atypical features of MDD
hyperphagia, heavy feeling in limbs, hypersensitivity to rejection, and mood reactivity (ability to respond to positive events)
how can PTSD present in children
distressing dreams with vague content, traumatic themes during play, emotional dysregulation, and behavioral difficulties
explain tardive dyskinesia at a molecular level
D2 receptor upregulation and supersensitivity
when is ECT indicated for depression
treatment resistance, psychotic features, emergency conditions (pregnancy, refusal to eat/drink, imminent risk for suicide)
symptoms of cocaine w/d
depression, increased dreaming, hyperphagia, drug cravings
how to differentiate naricisstic personality from OC personality
N –> order and rigid to be perfect FOR PRAISE
OC –> order and rigid to be perfect for self
what two parkinson meds are associated with psychosis
levodopa (dopamine precursor) dopamine agonist (pramipexol) -if pt starts having psychotic symptoms then put decrease the dosage of these meds
At what CD4+ T cell count should you be concerned about HIV-associated dementia
< 200
-subcortical symptoms in early course of disease
pt presents with depressed mood, weight loss, salt cravings, and reduced body hair…. what is it and how do you diagnose it
primary adrenal insufficiency (addisons disease)
-autoimmune destruction of bilateral adrenal cortex
mineralocorticoid deficiency –> salt cravings
glucocorticoid deficiency –> psych problems (depressed mood and irritability)
androgen deficiency –> loss of libido and 2ndary sex characteristics (reduced pubic hair)
dx via cosyntropin stimulation test
clozapine side effects
agranulocytosis (neutropenia)
-only consider clozapine if the pt had 2 failed drug trials for treatment resistant schizophrenia
how to differentiate acute stress disorder from PTSD
acute stress disorder –> 3days to 1 month
PTSD –> more than 1 month
psychotic symptoms and tactile hallucinations like bugs crawling under skin
methamphetamine use disorder
pt starts fasting or taking carbamazepine, phenytoin, or rifampin then has intermittent neurovisceral attacks and abdominal pain….
acute intermittent porphyria
-dx via elevated urinary porphobilinogen
what are the negative symptoms of schizophrenia
apathy, avolition, lack of facial expression, alogia, social withdrawal, and diminished interest in relationships
how to diagnose schizophrenia
more than 2 of the following for more than 6 months
- delusions*
- hallucinations*
- disorganized speech*
- disorganized behavior
- negative symptoms
*at least one of these is required
narcolepsy and cataplexy
narcolepsy –> recurrent lapses into sleep or naps ( >3x/week for 3 months)
WITH more than 1 of the following….
1. cataplexy –> brief loss of muscle tone precipitated by strong emotion (laughter/excitement)
2. low CSF fluid levels of hypocretin-1
3. shortened REM sleep latency
Associated features
- hypnogogic or hypnopompic hallucinations
- sleep paralysis
how long after discontinuing an SSRI can you start someone on an MAOI… what happens if you dont wait long enough?
2 weeks, serotonin syndrome (3 As –> activity, autonomic, and altered mental status)
*except fluoxetine because it has a longer t1/2 you have to wait 5 weeks
what mini-mental status exam is associated with dementia
23 or lower
diagnostic criteria and treatment for dementia with lewy bodies
dx via dementia + 2 of the following features
- visual hallucinations
- parkinsonism
- fluctuating cognition
- REM sleep behavior disorder
treat with carbidopa-levodopa (parkinsonism), rivastigmine (cognitive impairment), melatonin (REM sleep behavior disorder)
—-trial of antipsychotic (risperidone) can be used for hallucinations or delusions BUT WITH CAUTION because it can cause extreme antipsychotic hypersensitivity
how to treat sleep terrors
- reassurance (usually resolve w/i 1-2 years)
- low-dose benzo if frequent, persistent, and distressing
What do you have to watch out for when giving a patient acamprostate
It’s tough on the kidneys
what type of medication is citalopram
ssri
cyclothymic disorder
chronic, fluctuating mood disturbances for many years
- more than 2 years in adults, 1 year in children
- less severe bipolar syndrome
what meds to give for premature ejacuation
SSRI topical anesthetics (lidocaine) psychotherapy/joint couples therapy
patient with schizophrenia… what should you lookout for
up to 50% of pts also have a coexisting substance use disorder so if they are in the hospital and start to have a tremor then give benzos for alcohol w/d
what are the three most serious side effects of clozapine
agranulocytosis/neutropenia
seizures
myocarditis
how to treat body dysmorphia
ssri or other antidepressants
cbt
what is chlordiazepoxide
benzo
when to wean someone off schizophrenia meds
never! maintained indefinitely including those with one 1 episode of psychosis
