Psychiatry / Behavioral Medicine Flashcards
Risk factors for major depressive disorder
Family history
Female
Depressed mood or anhedonia (loss of pleasure) or loss of interest in activities with > 5 associated symptoms almost every day for at least ___ ______
2 weeks
Major Depressive Disorder
Somatic symptoms that can manifest from MDD
Constipation HA Skin changes Chest/abd pain Cough Dyspnea
Associated symptoms with MDD
- Fatigue
- Insomnia / hypersomnia
- Feelings of guilt or worthlessness
- Thoughts of suicide / death
- Weight changes
- Decreased / increased appetite
- Decreased concentration
- Indecisiveness
Presence of depressive symptoms at the same time each year - most common in the winter, due to reduction of sunlight and cold weather
Seasonal Affective Disorder
Management for Seasonal Affective Disorder
SSRIs
Bupropion
Light therapy
Shares many of the typical sx of MDD but pts experience mood reactivity (improved mood in response to positive events).
Atypical Depression
Treatment for atypical depression
MAO inhibitors
Isocarboxazid, Phenelzine, Selegiline
Characterized by anhedonia, lack of mood reactivity, depression, sleep disturbance.
Melancholia
Depression with motor immobility, stupor and extreme withdrawal
Catatonic Depression
____% of MDD pts commit suicide
15%
Screening for depression
PHQ-2 for initial screen
If positive, PHQ-9
Management of MDD
- Psychotherapy - principle therapy in mild-mod (CBT, psychoeducation)
- SSRIs often first line (SNRIs, Bupropion, Mirtazapine)
- ECT - for pts who fail medical therapy
Antidepressants should be continued for a minimum of ________ to determine efficacy
3-6 weeks
Generalized Anxiety Disorder is defined as excessive anxiety or worry for a majority of days > ________ period about various aspects of life
6 month period
Management of GAD
- SSRIs (paroxetine, escitalopram), SNRIs (venlafaxine)
- Buspirone
- Benzos (short term only), BB, TCAs
- Psychotherapy
S/E of buspirone
Does not cause sedation
Nausea, restless leg syndrome, extrapyramidal symptoms, dizziness
Social anxiety disorder is an intense fear of social or performance situations in which the person is exposed to the scrutiny of others for fear of embarrassment, for how long?
> 6 mo
Management of Social Anxiety Disorder
- SSRIs or SNRIs
- Beta blockers (may be used for performance anxiety)
- Benzos
- Psychotherapy
Panic disorder is 2-3 times more common in:
Women
Anxiety about being in places or situations from which escape may be difficult (open spaces, enclosed spaces, crowds)
Agoraphobia
Long term management of panic disorders
- SSRIs first line
- SNRIs
- CBT
Acute management of panic attacks
Benzodiazepines
Intense fear/anxiety of a specific situation, object, or place that is persistent for > 6 months. Fear is out of proportion to any real danger
Specific Phobia
Management of specific phobia
- Exposure/desensitization therapy
2. Short term benzos and BB’s in some pts
Criteria for PTSD
- Exposure to actual or threatened death, serious injury or sexual violence
- Presence of > 1 intrusion symptom
Intrusion symptoms for PTSD
- Re-experiencing
- Avoidance of stimuli associated with event
- Negative alterations in cognition and mood
- Arousal and reactivity (angry outbursts, etc)
Management of PTSD
- SSRIs first line
- MAO inhibitors
- Trazodone may be helpful for insomnia
- CBT
Criteria of insomnia disorder
- Difficulty initiating sleep, maintaining sleep, or waking up too early
- Sleep difficulties occur despite adequate opportunity and circumstances for sleep
- Patient describes daytime impairment that is attributable to sleep difficulties
Management of insomnia
- Advice regarding sleep hygiene and stimulus control
- CBT - suggested as initial management instead of medication
- Benzos, hypnotics, melatonin, doxepin, suvorexant
Refusal to maintain a minimally normal body weight fueling a relentless desire for thinness with a morbid fear of gaining weight (even though they are underweight)
Anorexia Nervosa
_____% incidence of depression associated with anorexia nervosa
60%
_____% of people diagnosed with anorexia nervosa are women
90%
Diagnosis of anorexia nervosa
- BMI < 17.5 or body weight < 85% of ideal weight
2. Labs: leukocytosis, leukopenia, anemia, hypokalemia, increased BUN (dehydration), hypothyroidism
Physical exam with anorexia nervosa
Emaciation Hypotension Bradycardia Skin/hair changes (lanugo) Dry skin Salivary gland hypertrophy Amenorrhea Arrhythmias Osteoporosis
Management of anorexia nervosa
- Medical stabilization (may need hospitalization)
- Psychotherapy - CBT, supervised meals
- SSRIs if depressed
Major difference between anorexia and bulimia nervosa
Pts with bulimia nervosa will have normal weight +/- overweight
With bulimia nervosa, binge eating must occur:
At least weekly for 3 months
Physical exam with bulimia nervosa
Teeth pitting or enamel erosion
Russell’s sign - calluses on dorsum of hand
Parotid gland hypertrophy
Labs with bulimia nervosa
Metabolic alkalosis from vomiting
Hypokalemia, hypomagnesemia
Management of bulimia nervosa
- CBT
2. Fluoxetine has shown to be helpful
> 1 manic or mixed episode which often cycles with occasional depressive episodes
Bipolar I disorder
Strongest risk factor for bipolar I disorder
Family history
Abnormal and persistently elevated, expansive or irritable mood at least 1 week with marked impairment of social/occupational function
Manic episode
Management of bipolar I disorder
- Lithium first line
- Valproic acid, carbamazepine
- Haloperidol, benzos if psychosis or agitation develops
- SSRIs, antidepressants
- Therapy, CBT, good sleep hygiene
> 1 hypomanic episode + > 1 major depressive episode. Mania or mixed episodes are absent
Bipolar II disorder
Symptoms similar to manic symptoms that is clearly different from usual nondepressed mood but does not cause marked impairment
Hypomania
Management of bipolar II disorder
Similar to bipolar I
Signs/symptoms of nicotine withdrawal
Restlessness Anxiety Irritability Sleep abnormalities Depression Nicotine craving
Management of tobacco use/dependence
- Counseling and support therapy, CBT
- Nicotine tapering therapy: gum, nasal sprays, patches, inhaler
- Bupropion - often used in combo with nicotine tapering therapy
- Varenicline (Chantix)
Symptoms of opioid intoxication
Euphoria and sedation Drowsiness Impaired social functioning Impaired memory Slow or slurred speech Nausea, vomiting, seizures, coma
Physical exam findings for opioid intoxication
- Pupillary restriction
- Respiratory depression
- Biot’s breathing
- Bradycardia
- Hypotension
Groups of quick, shallow inspirations followed by regular or irregular periods of apnea
Biot’s breathing
Seen with opioid intoxication
Symptoms of opioid withdrawal
Piloerections (goose bumps)
Pupil dilation
Flu-like sx
Diarrhea, tachycardia, N/V
Management of acute opioid intoxication
Naloxone (Narcan) - about 5 minutes IM
Management of opioid withdrawal
- Clonidine (for sympathetic sx)
- Loperamide for diarrhea
- NSAIDs for joint pain
- Methadone tapering
- Benzos may be helpful
Symptoms of alcohol withdrawal:
Tremors, anxiety, diaphoresis, palpitations, insomnia, GI sx
Seizures, hallucinations
Management of alcohol withdrawal
- May require medical treatment and hospitalization - can be potentially fatal
- IV benzos
- IV fluids, IV thiamine and magnesium, glucose, multivitamins
IV thiamine and magnesium should always be given _______ glucose administration
before
Management of alcohol intoxication
- Observation
- If known to be alcohol dependent, IV thiamine, magnesium, and glucose
- May need haloperidol if aggressive
CAGE Alcohol Screening
> /= 2 considered a positive screen
- Cutdown - have you felt the need to cutdown?
- Annoyed - have people told you they were annoyed at you when you drink?
- Guilt - have you ever felt guilty for drinking?
- Eye opener - have you needed a drink to start your day or reduce jitteriness
Management of alcohol dependence
- Psychotherapy, support (AA)
- Disulfiram can be used as deterrent
- Naltrexone - reduces alcohol craving
Strongest predictive factor of suicide
Previous attempt or threat
