Psychiatry/behavioral Flashcards
Delusional disorder
1 or more delusions lasting more than a month without other psychotic symptoms
Brief psychotic disorder
1 or more psychotic symptoms with onset and remission <1month
Schizophreniform disorder
Meets criteria for schizophrenia but duration <6month
Schizoaffective disorder
Schizophrenia with a mood disturbance
Schizophrenia
2 or more of the following:
Positive sx-hallucinations, delusions, disorganized speech/thinking, abnormal behavior
Negative sx-flat affect, social withdrawal, avolition
For 6 months or more with at least 1 month acute symptoms
Who gets schizophrenia?
MC in males with family hx, presents in early 20s
Presents in late 20s in women
1st line treatment for schizophrenia
2nd gen antipsychotics: risperidone, olanzapine, quetiapine
Typical 1st gen antipsychotics
BUTYROPHENONES: haloperidol and droperidol
PHENOTHIAZINES: fluphenazine, perphenazine, chlorpromazine, thioridazine
Side effects of antipsychotics
Extrapyramidal sx, neuroleptic malignant syndrome, QT prolongation, arrhythmias, sedation, anticholinergic sx, dermatitis, increased prolactin, weight gain
EPS and increased prolactin worse in 1st gen/typical antipsychotics
Chlorpromazine and thioridazine have less __________ symptoms but more ___________ symptoms
Extrapyramidal
Anticholinergic
Describe extrapyramidal symptoms
- dystonic reaction (intermittent spasms with sustained involuntary muscle contraction) occurs hours to days after initiating antipsychotics
- Tardive dyskinesia (akathisia) seen with long term use of antipsychotics
- Parkinsonism (rigidity, tremor, Bradykinesia)
Akathisia
Restlessness
Tx for dystonic reaction
IV diphenhydramine
Describe neuroleptic malignant syndrome (NMS)
D2 inhibition leads to mental status change, muscle rigidity, tremor, autonomic instability-tachycardia, tachypnea, hyperthermia
Tx for NMS
Stop offending agent
lower temp with cooling blankets
dopamine agonist: bromocriptine, amantadine, levodopa/carbidopa, dantrolene
When does NMS usually occur?
In young adults within 90d of antipsychotic initiation/dose increase
C/I-cautions for Haldol
Parkinson’s disease, anticoagulant use, severe cardiac disease
Describe anticholinergic symptoms
Dry mouth, blurred vision(dilated pupils), urinary retention, constipation, dry skin, flushing, tachycardia, fever, htn, and delirium
Atypical 2nd generation antipsychotics
Quetapine (Seroquel)
Olanzapine (zyprexa)
Clozapine
Loxapine
Unique side effects of clozapine
Agranulocytosis (CBC monitored weekly)
Myocarditis, QT prolongation
Seizures
Unique side effects of olanzapine
Weight gain and diabetes mellitus
Benzioxazoles
Risperidone (Risperdal)
Ziprasidond (Geodon)
Indications for benzisoxazoles
Schizophrenia, bipolar, psychosis
*Risperdal also used in Tourette’s
Indication for Abilify
Psychotic disorders
*sometimes called a 3rd generation antipsychotic
Indication for lithium
Bipolar disorder -acute mania
SE of lithium
Hypothyroidism Diabetes insipidus Hyperparathyroidism Seizures HA Tremor Sedation Arrhythmia N&V Diarrhea Weight gain
*narrow therapeutic index. Monitor q 4-8wk
Anticonvulsants used to suppress impulsive or aggressive behavior
Valproate and carbamazepine
How long must you have depressed mood/anhedonia/loss of interest in activities to be dx with MDD?
2wks
*symptoms must cause distress or impairment and mania or hyponania must be absent
Key symptom in atypical depression
Mood reactivity
Tx of atypical depression
MAO inhibitors
How prevalent is suicide in depression?
15% of pts commit suicide
Especially men 25-30 and women 40-50
Higher rates in pts with detailed plan, White males >45, and concurrent substance abuse
PHQ 2
- Little interest/enjoyment of things
2. Feeling down, depressed, or hopeless
PHQ 9
- Little interest
- Feeling down/hopeless
- Difficulty sleeping/hypersomnia
- Fatigue/low energy
- Appetite or weight changes
- Self disappointment
- Trouble concentrating
- Psychomotor changes (slow movement or speech, irritability, restlessness)
- Passive or active suicidal thoughts
Tx of MDD
1st line: SSRI or SNRI
2nd line: Bupropion or mirtazapine
3rd line: TCAs or MAO inhibitors
Continue for a minimum 3-6wk to determine efficacy
Selective serotonin reuptake inhibitors(SSRIs)
Citalopram (Celexa) Ecitalopram (Lexapro) Paroxetine (Paxil) Fluoxetine (Prozac) Sertraline (Zoloft) Fluvoxamine (Zyvox)
*1st line for depression and anxiety
SE of SSRIs
GI upset, sexual dysfunction, HA, changes in energy, anxiety, insomnia, weight changes, SIADH
Avoid using citalopram in pts with ___________.
Long QT syndrome
SSRI + MAO inhibitor =
Serotonin syndrome
SNRI + St. John’s Wart=
Serotonin syndrome
MAOI + TCA=
Delirium and hypertension
Sx of serotonin syndrome
Acute AMS seizures Restlessness Diaphoresis Tremor Hyperthermia N&V Abd pain Mydriasis Tachycardia
Serotonin Norepinephrine Reuptake inhibitors (SNRIs)
Venlafaxine (Effexor)
Desvenlafaxine (Pristiq)
Duloxetine (cymbalta)
SNRIs are particularly good first line agents for MDD in patients with ______________ or ______________
Significant fatigue
Pain syndromes
SE of SNRIs
Same as SSRIs plus htn and dizziness
Mirtazapine (Remeron)
Antidepressant with less sexual dysfunction
SE of Mirtazapine
Sedation Dry mouth Constipation Weight gain Agranulocytosis
Bupropion indication
Wellbutrin for depression *less GI distress and sexual dysfunction than SSRIs
Zyban for smoking cessation
SE of bupropion
Seizures Agitation Anxiety Restlessness Weight loss HTN HA
Bupropion C/I
Seizure disorders
Eating disorders
MAOI use
ETOH/drug detox
Tricyclics antidepressants (TCAs)
Amitriptyline Clomipramine Desipramine Doxepin Imipramine Nortriptyline
SE of TCAs
Anticholinergic, sedation, weight gain, prolonged QT
TCA overdose
Wide complex tachycardia
Neurological symptoms
ARDS
SIADH
MAO inhibitors
Non selective: phenelzine, tranylcypromine, isocarboxazid
Selective: selegiline
SE of MAOI
Insomnia Anxiety Orthostatic hypotension Weight gain Sexual dysfunction Hypertensive crisis
Pts on MAOIs must avoid these foods or it may lead to hypertensive crisis
Tyramine-containing foods
Bipolar I disorder
1 or more manic or mixed episode which often cycles with occasional depressive episodes
Strongest risk factor for bipolar I
Family history/1st degree relative
*the earlier the onset the poorer the prognosis and more likely to develops psychotic features
Mania
Abnormal & persistently elevated, expansive or irritable mood for at least 1wk with impaired function
Pharmaceutical treatment of bipolar I
1st line Mood stabilizers: LITHIUM, vampiric acid, carbamazepine
2nd line antipsychotics
Benzodiazepines can be added if psychosis or agitation develops
*antidepressants may precipitate mania
Bipolar II disorder
1 or more hypomanic disorder and 1 or more major depressive episode
Without mania or mixed episodes
Hypomania
Sx are similar to mania but no marked impairment in function
Persistent depressive disorder (dysthymia)
Chronic depressed mood in adults >2yr. Usually milder than MDD and pt is able to function
*may progress to MDD or bipolar in time. Tx same as MDD
Cyclothymic disorder
Similar to bipolar II but less severe, at least 2yr duration
Tx for acute panic attack
Benzodiazepines: lorazepam and alprazolam are 1st line
Panic disorder
Recurrent unexpected panic attacks with worry/concerns about future attacks
Symptoms of panic attack
Dizziness Trembling Choking feeling Paresthesias Sweating SOB chest pain Chills/hot flashes Fear of loading control or dying Palpitations/tachycardia Nausea or abd distress Depersonalization/derealization
Agoraphobia
Anxiety about being in places or situations from which you cannot escape
Management of panic disorder
Long term:SSRIs or SNRIs
CBT
Acute attack: benzo
Generalized anxiety disorder
Excessive anxiety about various aspects of life for >6m
Management of GAD
1st line: SSRI or SNRI
2nd: buspirone (Buspar) -May take several weeks for improvement. Does not cause sedation
3rd: Ben is, BB, TCAs
* psychotherapy
Social anxiety disorder
Persistent fear of social or performance situations that can cause panic attacks (>6m)
Tx of SAD
Antidepressants (SSRIs or SNRI)
BB (propranolol or atenolol) for performance anxiety
Benzos if treatment very infrequent
Psychotherapy
Tx of specific phobias
Exposure/desensitization therapy
*benzos or BB can be used short term in some pts
PTSD
Exposure to an inciting event and 1 or more of the following:
- Re-experiencing for >1m
- Avoidance of associated stimuli
- Negative alternations in cognition or mood
- Arousal/reactivity
Tx of PTSD
SSRIs are 1st line
2nd line: TCAs it MAOIs
Trazodone may be helpful in insomnia
CBT
Acute stress disorder
Similar to PSTD but <1m
Adjustment disorder
Disproportionate emotional or behavioral response to an identified stressor causing significant impairment in functioning
Begins w/i 3mo stressor and resolves w/i 6mo of stressor
Tx of adjustment disorder
Psychotherapy
Rule these 2 things out before dx a dissociative disorder
Seizures and brain tumors
Tx of dissociative disorders
Psychotherapy
Dissociative identity disorder
Presence of 2 or more distinct identities or states of personalities
Pts often have gaps in recall
*maybe associated with hx of sexual abuse, PTSD, or substance use
Depersonalization/derealization disorder
Persistent feelings of detachment or estrangement that cause distress
Dissociated amnesia
Inability to recall personal/autobiographical information that causes impairment in functioning
*often secondary to sexual abuse, stress or trauma
Dissociative fugue
Abrupt change in geographical location with loss of identity or inability to recall past
Obsessive-compulsive disorders
OCD, body dysmorphic disorder, hoarding, tichotillomania( hair-pulling), and excoriation disorder
OCD
Anxiety disorder characterized by obsessions (recurrent or persistent thoughts/images) and compulsions (repetitive behaviors the person feels driven to perform)
4 major OCD patterns
- Contamination
- Pathological doubt
- Symmetry/precision
- Intrusive obsessive thoughts without compulsions
Tx of OCD
Antidepressants (SSRI, TCA, or SNRI)
CBT
Body dysmorphic disorder
Preoccupation that 1 or more body parts is deformed or over exaggeration of a minor flaw
Causes shame and functional impairment
May commit repetitive acts in response
*may also have anxiety or depression
Tx of body dysmorphic disorder
Antidepressants(SSRI or TCA)
Psychotherapy
Somatic symptom disorder
Physical symptom without physical cause.
Excessive thoughts, feelings, or behaviors related to somatic sxs are distressing and can result in significant disruption.
*aka hypochondiasis and somatization disorder
Management of somatic symptom disorder
Regular visits to healthcare provider
Illness anxiety disorder
Preoccupation with fear or belief one has or will contract serious illness. Somatic sxs usually not present
*aka hypochondriac
Management of illness anxiety disorder
Regular healthcare visits
Functional neurological symptom disorder
Neurological dysfunction (motor or sensory) that can’t clinically be explained
Tends to be episodic and rescuers during times of stress
*aka conversion disorder
Tx of functional neurological symptom disorder
Physchotherapy
Pts with functional neurological symptom disorder often have…
Depression, anxiety, schizophrenia, or a personality disorder
Factitious disorder
Intentional falsification or exaggeration of signs and symptoms with motivation to assume the sick role and get sympathy
Can be self imposed or imposed on another
*considered a form of premeditated abuse if imposed on another
Things that would make you concerned that pt has factitious disorder or is malingering
- willingness or eagerness to undergo surgery or painful tests repeatedly
- extensive knowledge about medical terminology
Tx of factitious disorder
None
Münchausen syndrome
Severe factitious disorder characterized by predominance of physical symptoms, use of aliases and habitual lying
Unlike factitious disorder which is done to assume sick role and for sympathy, malingering is done with the motivation of….
Secondary gain, wether it be financial, food, shelter, avoidance of responsibility, or drug attainment
*not a mental illness
Perpetrator of child sexual abuse is often…
Male and known to pt
Perpetrator of physical child abuse is often…
Primary female caregiver
Signs of physical child abuse (7)
Cigarette burns Burns in a stocking glove distribution Lacerations Healed fxs on X-ray Subdues hematoma Multiple bruises Retinal hemorrhages
Signs of shaken baby syndrome
Retinal hemorrhages and hyphema
Signs of child neglect (4)
Malnutrition
Withdrawal
Poor hygiene
Failure to thrive
Obesity
BMI>30 or >20% over ideal weight
*50%associated with binge eating
Tx of obesity
- lifestyle modification (diet and exercise) and group therapy
- Antidepressant if underlying depression
- anti-obesity meds
- bariatric surgery
Anti obesity meds and MOA
Orlistat decreases GI fat digestion
Lorcaserin is a serotonin agonist
Anorexia nervosa
Refusal to maintain minimal normal body weight due to morbid fear of fatness
*restrictive and purging types
Anorexia is common in this population
Girls age 15-24 who are athletes or dancers
Signs of anorexia nervosa
BMI<17.5 or <85% expected body weight Hypotension Bradycardia Lanugo Dry skin Amenorrhea Arrhythmias Osteoporosis
Labs in pts with anorexia nervosa may show this
Leukocytosis Leukopenia Anemia Hypokalemia Increased BUN from dehydration Hypothyroidism
Management of anorexia nervosa
Hospitalize if <75% expected body weight
CBT with supervised meals and weight monitoring
SSRI if depressed and maybe atypical antipsychotics to cause weight gain
The major difference between anorexia nervosa and bulimia nervosa is
pts with bulimia often have a normal body weight or are overweight
Signs of self induced vomiting
Teeth putting or enamel erosion
Russell’s sign (calluses on dorsum of hand from inducing vomiting)
Parotid hypertrophy
This medication has been shown to reduce the binge-purge cycle
Fluoxetine
Cluster A personality disorders
Characterized by social detachment with weird, odd eccentric behavior
Includes: schizoid, schizotypal, and paranoid
Cluster B personality disorders
Dramatic, wild, erratic, impulsive, and emotional
Includes: antisocial, borderline, histrionic, narcissistic
Cluster C personality disorders
Anxious worried and fearful
Includes: avoidant, defendant, and obsessive-compulsive
Who has cluster A personality disorders?
They are MC in men
Schizotypal and paranoid onset is usually early adulthood
Schizoid onset is usually early childhood
Conduct disorder in childhood may progress to…
Antisocial personality disorder in adulthood
*3xMC in males
Management of cluster A personality disorders
1st line: psychotherapy
Short term low dose use of antipsychotics, antidepressants, or benzos
Describe schizoid personality disorder
Voluntary social withdrawal and anhedonic introversion
“Hermit-like behavior”/prefers to be alone
Little enjoyment if close relationships or intimacy
Describe schizotypal personality disorder
Odd, eccentric and peculiar thought patterns without psychosis/delusions
“Magical thinking”
May talk to self in public
Describe paranoid personality disorder
Pervasive pattern of distrust and suspicious of others
Bears grudges, doesn’t forgive and blames others for problems
Describe antisocial personality disorder
Deviates sharply from social norms, values, and laws
Disregard and violation of rights of others
Criminal acts, promiscuous, extremely manipulative and lacks remorse
Describe borderline personality disorder
Unstable unpredictable mood, affect, self image, and relationships
Cannot tolerate being alone/fear of abandonment
Black& white/all-or-nothing thinking
Self-damaging behaviors
Borderline personality amity disorder is MC in
Women
Describe histrionic personality disorder
Overly emotional, dramatic and seductive
Attention seeking/needs to be center of attention
Self absorbed temper tantrums
Describe narcissistic personality disorder
Grandiose excessive sense of self-importance but fragile self-esteem
Needs praise and admiration
Reacts to criticism/rejection with rage
May become depressed
Lacks empathy for others
Narcissistic personality disorder is MC in
Men
Management of cluster C personality disorders
1st line: paychotherapy
BB, anxiolytics, and antidepressants as needed
Describe avoidant personality disorder
Desires relationships but avoids them due to inferiority complex
Lacks confidence
Describe dependent personality disorder
Very needy/clingy submissive behavior
Needs constant reassurance
Will not initiate things and may volunteer for unpleasant tasks
Describe obsessive-compulsive personality disorder
Perfectionist who require great deal of control and order
Change in routine may lead to anxiety
Preoccupation with minute details
May avoid intimacy
Is autisim more common in boys or good?
Boys 4:1
Clinical manifestation of Autisim
Social interaction difficulties
Impaired communication
Restrictive, repetitive, stereotypes behaviors
Describe oppositional defiant disorder
Defiant behavior to adults characterized by irritable mood, defiant behavior and vindictiveness for at least 6m
*may progress to conduct disorder
Describe conduct disorder
Sharper deviation form age-appropriate Norns and violation of the rights of others
Social and academic difficulty
*may violate laws, be cruel to animals, destroy property, and lie
How many pts with conduct disorder eventually develop antisocial personality disorder?
40%
Onset of ADD or ADHD usually occurs when?
Before the age of 12
Tx of ADD or ADHD
Behavior modification with
Sympathomimetics/stimulants: (Methylphenidate, amphetamine/deztroamphetamine, or dexmethylpgenidate)
OR
No stimulants: (atomoxetine)
Clinical manifestations of nicotine withdrawal
Restlessness, anxiety, irritability, withdrawal, sleep abnormalities, desperation, cravings
Tx of nicotine dependence
- nicotine tapered therapy
- bupropion (zyban)
- Varenicline (Chantix)
Signs and symptoms of opioid intoxication
Euphoria Sedation Pupillary constriction Resp depression Biot’s breathing Bradycardia Hypotension
Signs of opioid withdrawal
Lacrimation N&V Hypertensioa Abd cramps Sweating Diarrhea Piloerections Pupil dilation Rhinorrgea Myalgia/joint pain
Tx for acute opioid intoxication
Naloxone (Narcan)
*IM onset of action 5min. 30-60min duration
Management of opioid withdrawal
Clinicians to decrease sympathetic symptoms
Loperamide first diarrhea
NSAIDs for joint and muscle cramps
Long term management options for opioid dependence
Methadone
Suboxone (buprenorphine and naloxone)
Tx for benzodiazepine intoxication
Flumazenil
Wernick’s encephalopathy
Triad: ataxia, confusion, oculomotor palsy
Due to thiamine/B1 deficiency caused by chronic alcohol consumption
Korsakoff syndrome
Retrograde and antegrade amnesia due to alcohol
Signs of cocaine/stimulant intoxication
Euphoric mood and psychosis
Treatment of cocaine intoxication
Benzodiazepines
When do alcohol withdrawal seizures occur?
6-48hr after last drink
*MC occurs as a single episode
When do alcoholic withdrawal hallucinations occur?
12-48hrs after last drink
*pt has clear sensorium and normal vitals
When do delirium tremendous occur?
2-5d after last drink
*altered sensorium/delirium and abn vitals(tachycardia, hypertension, and fever)
Management of alcohol withdrawal
IV benzodiazepines
IV thiamine and Mg before glucose administration
Management of alcohol intoxication
Acute intoxication - observation
IV thiamine and magnesium prior to glucose administration
Haloperidol of psychosis or severe aggression
Alcohol dependence screening
CAGE
Cutdown
Annoyed
Guilt
Eye opener
*2 or mire considered positive
Normal grief reaction
Resolved within 1yr and does not have psychosis or suicidal ideation
Types of delusions
Bizarre Non-bizarre Paranoid/persecutory Grandiose Reference (high power communication) Somatic Erotomanic (celebrity loves them) Jealous
Types of hallucinations
Auditory (commands?) Visual Tactile Olfactory Gustatory
Types of disorganized speech
Derailment Tangential Incoherent/word salad Neologism (combining words) Echolalia (repaying you back) Blocking/paucity
Psychosis differential
Substance intoxication/withdraw Meds (steroids, stimulants, anticholinergic) Delirium Dementia Hyperthyroidism CNS infection Epilepsy B12 deficiency Lupus Huntington’s Wilson’s Psychiatric disorders
DTS
Danger to self
DTO
Danger to others
MC type of elder abuse
Neglect
SSRIs with low CYP450 interactions
Sertraline and escitalopram
Pharmaceutical Tx for male hypoactive sexual desire disorder
Testosterone or bupropion
Tx for female sexual interest/arousal disorder
Lubricants
Flibanserin
Therapy
Exhibitionism
Indecent exposure/flashing
Voyeurism
Observing unsuspecting person get undressed or engage in sexual behavior
Frotteurism
Rubbing against or touching a non-consenting person
Fetishism
Sexual arousal/fantasies involving non-living objects or non-genital body parts
Masochism
Sexual arousal from being humiliated, beaten, bound, or otherwise made to suffer
Sadism
Sexual arousal from causing a non-consenting person physical or psychological harm
**associated with ASPD
