Psychiatry/Behavioral Medicine Flashcards
What is anorexia nervosa?
patients who refuses to eat due to fear of being overweight
- intense fear of becoming fat, even though underweight, frequent weight checks and denial of emaciated state
- weight <85% of ideal body weight
- anorexia nervosa can be distinguished from bulimia nervosa by body mass <17 or bodyweight < 85% of ideal body weight
- the highest suicide rate of eating disorders
What are the two types of anorexia nervosa?
Binging/purging -laxatives/diuretics abuse -excessive exercise Restricting -eat very little -exercise to excess
What is the tx of of anorexia nervosa?
- restore nutritional state
- hospitalization - if weight is <75% expected body weight
- psychotherapy - behavioral therapy
- pharmacologic - SSRIs
- have added benefit of causing weight gain
- have not been proven to be effective in anorexia nervosa
- have some efficacy in bulimia nervosa
What is generalized anxiety disorder?
excessive anxiety and worry occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance)
What are the symptoms of generalized anxiety disorder?
- the individual finds it difficult to control the worry
- the anxiety is associated with three (or more) of the following six symptoms:
- restlessness or feeling keyed up or on edge
- being easily fatigued
- difficulty concentrating or mind going blank
- irritability
- muscle tension
- sleep disturbances (difficulty falling or staying asleep, or restless, unsatisfying sleep)
- the anxiety causes clinically significant distress or impairment
- the disturbance is not attributable to the physiological effects of a substance or another medical condition
- the disturbance is not better explained by another mental disorder
What is the tx of generalized anxiety disorder?
- SSRIs: paroxetine and escitalopram; SNRIs: vanlafaxine
- buspirone is also effective; the starting dose is 5 mg PO bid or tid, however, buspirone can take at least 2 weeks before it begins to help
- benzodiazepines (short-term use), beta-blockers
- psychotherapy
What is panic disorder?
an occurrence of three panic attack (sudden unexpected periods of intense fear or discomfort) episodes in three weeks
- at least one of the attacks has been following by one month (or more) of one of the both of the following:
- persistent concern or worry about additional panic attacks or their consequences
- a significant maladaptive change in behavior related to the attacks
What is the tx for panic disorder?
- SSRIs: paroxetine, sertraline, fluoxetine
- Benzodiazepines: for acute attacks (watch for abuse)
- CBT (relaxation, desensitization, examining behavior consequences)
What are the characteristics of bipolar I disorder?
- history of more marina than depression
- severe mood disorder with manic episodes alternating with depression; psychosis during manic episodes
What are the characteristics of bipolar II disorder?
- history of more depression than mania
- low-level mania with profound depression; no psychosis
What are the characteristics of cyclothymic disorder?
alternating hypomanic episodes with a long-standing low mood state (dysthymia) for at least two years
What is bipolar I disorder?
- patient who is squandering savings, destroying relationships, neglecting work activities, etc.
- a manic episode with or without major depressive episodes
- by the DSM, mania is described as a mood disturbance sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
What is the tx of bipolar I disorder?
- lithium is considered a first-line medication for bipolar disorder and has been more widely studied than any other maintenance treatment for bipolar disorder and is consistently supported across multiple randomized trials
- acute mania - lithium, valproate, SGAs (olanzapine, aripiprazole), carbamazepine
- mania maintenance - SGAs, gabapentin, lamotrigine (Lamictal)
- if agitation - add antipsychotics (haloperidol, risperidone) or benzodiazepines
- family/group/cognitive therapy
What is bipolar II disorder?
- a patient with bouts of sadness and distractibility and an episode of decreased need for sleep, a flight of ideas, and buying sprees
- at least one hypomanic episode and at least one major depressive episode
- there has never been a manic episode
- by DMS hypomania is described as a mood disturbance is not severe enough to caused marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features
What is the tx of bipolar II?
lithium is considered a first-line medication for bipolar disorder and has been more widely studied than any other maintenance treatment for bipolar disorder and is consistently supported across multiple randomized trials
- depressive episodes - SSRIs, quetiapine, or olanzapine + fluoxetine
- MAOIs, TCAs - least likely used
- family/group/cognitive therapy
What is cyclothymic disorder?
alternating hypomanic episodes with a long-standing low mood state (dysthymia)
- a chronic mood disorder characterized by episodes of depression and hypomania for at least 2 years
- this is a less intense but often longer-lasting version of bipolar disorder
- a person with cyclothymia has both high and low mood, but never as severe as either mania or major depression
What is bulimia nervosa?
patient who has episodes of mass eating followed by self-induced vomiting or intense exercise
What are the characteristics of bulimia nervosa?
frequent binge eating with to without purging
- purging commonly performed by self-induced vomiting resulting in - metabolic alkalosis, urinary chloride <20 mEq, and volume depletion
- may abuse laxatives/diuretics
- may exercise excessively
- patients are disturbed by their behavior
- binging and compensatory behaviors occur at least once a week for 3 months
- on exam look for these classic physical findings: scar on knuckles, swollen parotid glands + dental erosions + normal weight + hypokalemia
What is the tx for bulimia nervosa?
- first, you must restore the nutritional state
- fluoxetine 60 mg PO once day is recommended (this dose is higher than that typically used for depression)
- SSRIs used alone often reduce the frequency of binge eating and vomiting
- second-line medications: TCAs, MAOIs
- behavioral/family/group therapy
What is insomnia disorder?
difficulty initiating or maintaining sleep at least 3 times per week for 3 months
What is major depressive disorder?
five or more SIEGECAPS for > 2 weeks nearly every day and at least one of the symptoms is depressed mood or anhedonia
What is SIGECAPS?
- sadness
- interest/anhedonia
- guilt
- energy
- concentration
- appetite
- psychomotor activity
- suicidal
What is the tx of major depressive disorder?
SSRIs are the first-line treatment - although both TCA and MAOI classes of antidepressants are often helpful in depression, the SSRI class is associated with less morbidity, and drugs in this class are generally considered first-line treatment
- continue to increase dosage q 3-4 weeks until symptoms in remission
- the full medication effect is complete in 4-6 weeks
- augmentation with 2nd medication may be necessary
- see within 2-4 weeks of starting mediation and q2wk until improvement, then monthly to monitor medication changes
What is panic disorder?
an occurrence of three panic attack (sudden unexpected periods of intense fear or discomfort) episodes in three weeks
- at least one of the attacks has been followed by one month (or more) of one or both of the following:
- persistent concern or worry about additional panic attacks or their consequences
- a significant maladaptive change in behavior related to the attacks
What is the tx for panic disorder?
- SSRIs: paroxetine, sertraline, fluoxetine
- benzodiazepines: for acute attacks (watch for abuse)
- CBT (relaxation, desensitization, examining behavior consequences)
What is post traumatic stress disorder?
the patient has experienced a traumatic event that causes an acute stress reduction
-once the symptoms persists past 1 month it is now considered post-traumatic stress disorder (PTSD)
What is the treatment for posttraumtic stress disorder?
- SSRIs are first-line
- cognitive behavioral therapy (CBT)
- prazosin for nightmares
- benzodiazepines, if used, should not be continued more than 2 weeks after a traumatic event
What is a specific phobia?
excessive and persistent fear of a specific object, situation, or activity that is generally not harmful
- lasts for 6 months or more
- patients know their fear is excessive, but they can’t overcome it
- these fears cause such distress that some people go to extreme lengths to avoid what they fear
- examples are fear of flying or fear of spiders
What is the tx for specific phobias?
treat with exposure therapy (first line), teach to relax and try to understand/overcome the fear
- SSRI + CBT
- benzodiazepines (i.e. prior to flying)
- treat agoraphobia just as GAD with SSRIs and CBT
What are the characteristics of spouse or partner violence, physical?
this category should be used when non accidental acts of physical force that result, or have reasonable potential to result, in physical harm to an intimate partner or that evoke significant fear in the partner have occurred during the past year
- nonaccidental acts of physical force include shoving, slapping, hair pulling, pinching, restraining, shaking, throwing, bitting, kicking, hitting with the fist for an object, burning, poisoning, applying force to the threat, cutting off the air supply, holding the head underwater, and using a weapon
- acts for the purple of physically protecting oneself or one’s partner are excluded
What are the characteristics of spouse or partner violence, sexual?
this category should be used when forced or coerced sexual acts with an intimate partner have occurred during the past year
- sexual violence may involve the use of physical force or psychological coercion to compel the partner to engage in the sexual act against his or her will, whether or not the act is completed
- also included in this category are sexual acts with an intimate partner who is unable to consent
What are the characteristics of spouse of partner neglect?
partner neglect is any egregious act or omission in the past year by one partner that deprives a dependent partner of basic needs and thereby results, or has reasonable potential to result, in physical or psychological harm to the dependent partner
-this category is used in the context of relationships in which one partner is extremely dependent on the other partner for care or for assistance in navigating ordinary daily activities - for example, a partner who is incapable of self-care owing to substantial physical, psychological/intellectual, or cultural limitations (e.g inability to communicate with others and manage everyday actives due to living in a foreign culture)
What is alcohol use disorder?
a problematic pattern of alcohol use leading to clinically significant impairment or distress
What is alcohol intoxication?
- recent ingestion of alcohol
- clinically significant problematic behavioral or psychological changes (e.g inappropriate sexual or aggressive behavior, mood lability, impaired judgement) that developed during, or shortly after, alcohol ingestion
- one (or more) of the following signs or symptoms developing during, or shortly after, alcohol use:
- slurred speech
- incoordination
- unsteady gait
- nystagmus
- impairment in attention or memory
- stupor or coma
What are the characteristics of alcohol withdrawal?
- cessation of (or reduction in) alcohol that has been heavy and prolonged
- two (or more) of the following, developing within several hours to a few days after the cessation of (or reduction in) alcohol use:
- autonomic hyperactivity (e.g sweating or pulse rate greater than 100 bpm)
- increased hand tremor
- insomnia
- nausea or vomiting
- transient visual, tactile, or auditory hallucinations or illusions
- psychomotor agitation
- anxiety
- generalized tonic-clonic seizures
What is the tx for alcohol withdrawal?
- thiamine, magnesium, multivitamin, dextrose (particularly if chronic alcoholism)
- benzodiazepines (if withdrawal)
What are the addiction medications?
-disulfiram (Antabuse) - inhibits acetaldehyde dehydrogenase, aversive conditioning
-500 mg once daily for 1-2 weeks then decrease to the maintenance dose (range 125-500 mg once daily)
-nor for use in persons actively drinking alcohol; avoid alcohol in other products
-Oral naltrexone - decreases desire
-50 mg once daily
-cannot be given to patients taking opioids
-Extended - release naltrexone - decreases desire
-380 mg IM every 4 weeks; administer in the gluteal area with 1.5 inch 20-gauge needle
-cannot be given to patients taking opioids
Acamprosate - changes brain chemistry in a way that reduces anxiety, irritability, and restlessness associated with early sobriety
-666 mg three times daily
-dose education required with renal impairment
Topiramate - reduces drinking at least as well as naltrexone and acamprosate
-begins at 25 mg daily and increases up to 150 mg BID
-Gabapentin - decreases desire
-begins at 300 mg once daily and increase up to 600 mg TID
What is the tx of DT?
DT may be fatal and thus must be treated promptly with high-dose IV benzodiazepines, preferably in an ICU
