Psychiatry/Behavioral Medicine Flashcards
(95 cards)
1
Q
What is anorexia nervosa?
A
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
2
Q
What are the two types of anorexia nervosa?
A
Binging/purging -laxatives/diuretics abuse -excessive exercise Restricting -eat very little -exercise to excess
3
Q
What is the tx of of anorexia nervosa?
A
- 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
4
Q
What is generalized anxiety disorder?
A
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)
5
Q
What are the symptoms of generalized anxiety disorder?
A
- 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
6
Q
What is the tx of generalized anxiety disorder?
A
- 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
7
Q
What is panic disorder?
A
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
8
Q
What is the tx for panic disorder?
A
- SSRIs: paroxetine, sertraline, fluoxetine
- Benzodiazepines: for acute attacks (watch for abuse)
- CBT (relaxation, desensitization, examining behavior consequences)
9
Q
What are the characteristics of bipolar I disorder?
A
- history of more marina than depression
- severe mood disorder with manic episodes alternating with depression; psychosis during manic episodes
10
Q
What are the characteristics of bipolar II disorder?
A
- history of more depression than mania
- low-level mania with profound depression; no psychosis
11
Q
What are the characteristics of cyclothymic disorder?
A
alternating hypomanic episodes with a long-standing low mood state (dysthymia) for at least two years
12
Q
What is bipolar I disorder?
A
- 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.
13
Q
What is the tx of bipolar I disorder?
A
- 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
14
Q
What is bipolar II disorder?
A
- 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
15
Q
What is the tx of bipolar II?
A
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
16
Q
What is cyclothymic disorder?
A
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
17
Q
What is bulimia nervosa?
A
patient who has episodes of mass eating followed by self-induced vomiting or intense exercise
18
Q
What are the characteristics of bulimia nervosa?
A
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
19
Q
What is the tx for bulimia nervosa?
A
- 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
20
Q
What is insomnia disorder?
A
difficulty initiating or maintaining sleep at least 3 times per week for 3 months
21
Q
What is major depressive disorder?
A
five or more SIEGECAPS for > 2 weeks nearly every day and at least one of the symptoms is depressed mood or anhedonia
22
Q
What is SIGECAPS?
A
- sadness
- interest/anhedonia
- guilt
- energy
- concentration
- appetite
- psychomotor activity
- suicidal
23
Q
What is the tx of major depressive disorder?
A
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
24
Q
What is panic disorder?
A
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
25
What is the tx for panic disorder?
- SSRIs: paroxetine, sertraline, fluoxetine
- benzodiazepines: for acute attacks (watch for abuse)
- CBT (relaxation, desensitization, examining behavior consequences)
26
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)
27
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
28
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
29
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
30
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
31
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
32
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)
33
What is alcohol use disorder?
a problematic pattern of alcohol use leading to clinically significant impairment or distress
34
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
35
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
36
What is the tx for alcohol withdrawal?
- thiamine, magnesium, multivitamin, dextrose (particularly if chronic alcoholism)
- benzodiazepines (if withdrawal)
37
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
38
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
39
What are the characteristics of cannabis-related disorders?
a patient who is constantly craving cannabis, has tried to stop but can't, is spending a lot of time and money obtaining it, and is having a negative impact on his life
-look for conjunctival injection in PE findings
40
What is cannabis use disorder?
- a problematic pattern of cannabis use leading to clinically significant impairment or distress, occurring within a 12-month period
- urine drug test: can detect cannabis for 4-6 days in occasional users and up to 50 days in chronic users
- chronic use of cannabis has the following complications: laryngitis, rhinitis, low testosterone, low sperm count, and COPD
41
What are the signs and symptoms of intoxication?
euphoria, anxiety, disinhibition, paranoid delusions, a perception of slowed time, conjunctival injection, impaired judgement, social withdrawal, increase appetite, dry mouth, hallucinations
42
What are the signs and symptoms of withdrawal?
irritability, depression, insomnia, nausea, and anorexia
| -most symptoms peak at 48 hours and last for 5-7 days
43
What is the tx for cannabis use disorder?
no specific treatment is required
| -symptomatic treatment only
44
What is are the characteristics of PCP?
patient is extremely aggressive and becomes enraged when sudden movements or loud sounds are made
45
What is the mechanism of PCP?
NMDA receptor antagonist - Ketamine is a similar drug
46
What are the signs and symptoms of intoxication from PCP?
belligerence, impulsiveness, fear, homicidality, psychosis, delirium, seizures, psychomotor agitation, vertical and horizontal nystagmus, tachycardia, ataxia
47
What is the tx for intoxications from PCP?
```
Pharmacologic
-antipsychotics (haloperidol)
-benzodiazepines
Further Management
-low stimulus environment
-restraints if needed to prevent the patient from hurting self/others
```
48
What are the symptoms of withdrawal from PCP?
depression, anxiety, irritability, restlessness, anergia, disturbances of thought and sleep
49
What is the tx of withdrawal from PCP?
no specific treatment - symptomatic treatment only
50
What are the characteristics of LSD?
patient wants to hurt himself
| -they say that he has "been freaking out" and seeing things that are not there
51
What is the mechanism of LSD?
action at the 5-HT receptor
52
What are the symptoms of intoxication from LSD?
- visual hallucinations and synthesis (e.g. seeing sound as color)
- marked anxiety or depression, delusions, pupillary dilation
- "bad trip" panic
53
What is the tx of LSD intoxication?
Pharmacologic
- antipsychotics (e.g haloperidol)
- benzodiazepines
- talking down, supportive counseling
54
What are the symptoms of LSD withdrawal?
- largely no withdrawal because it does not affect dopamine
| - flashbacks can occur years later
55
What is the tx of LSD withdrawal?
no specific treatment - symptomatic treatment only
56
What are inhalant-related disorders?
a young child from low socioeconomic background arrives in the ED with a headache, loss of appetite, rhinorrhea, injected sclera, dizziness, photophobia or a cough
- inhalation of certain gases found in paint, petroleum, toluene, glues, and nail polish produces the same effects of a volatile anesthetic
- the mechanism of action is unknown
57
What are the characteristics of intoxication from inhalants?
depends on the dose of inhalant sniffed
- for mild to moderate dose: the following are noted: euphoria, slurring of speech, confused state, auditory, and visual hallucinations
- physical exam: watery eyes, impaired vision, rhinorrhea, perinatal and perioral rash, headache and nausea
- for high doses: cardiopulmonary failure, liver problems, kidney problems, and bone marrow suppression
58
What are the symptoms of inhalant withdrawal?
not well characterized, no treatment
59
What is the tx for inhalants?
antipsychotics (haloperidol) if severe aggression
60
What is does a pt with opioid-related disorder look like?
pt with restlessness, mydriasis, excessive lacrimation as well as several needle puncture sites in his left antecubital fossa that are in various stages of healing
61
What is the mechanism of opioids?
mu receptor agonist - examples: morphine, heroin, methadone
62
What are the symptoms of opioid intoxication?
- constipation - no tolerance to this side effect
- respiratory depression - life-threatening
- pupillary constriction (pinpoint pupils)
- seizures (overdose is life-threatening)
- for heroin use, look for track marks (needle injections)
63
What are the symptoms of opioid withdrawal?
- anxiety, insomnia, anorexia, sweating, dilated pupils, piloerection ("cold turkey")
- fever, rhinorrhea, nausea, stomach cramps, diarrhea ("flulike" symptoms)
- yawning
- unpleasant but not life-threatening
64
What is the tx of opioid intoxication?
- naloxone/naltrexone
- opioid receptor antagonist
- opioid withdrawal is NOT fatal - it is just unpleasant
- symptomatic treatment
65
What is the tx of opioid withdrawal?
- Clonidine: alpha 2 agonist that decreases NE and sympathetic output making autonomic symptoms less intense
- Methadone (long-acting)
- Bupreonphrine + naloxone (Suboxone): can precipitate withdrawal if given too soon (partial mu agonist
- zofran for nausea/vomiting
66
What is the tx for opioid addiction?
Methadone
-typically oral
-long-acting IV opiate
-used for heroin detoxification or long-term maintenance
Suboxone (buprenorphine + naloxone)
-long-acting oral administration with fewer withdrawal symptoms than methadone
-naloxone + Buprenorphine (partial opioid agonist)
-naloxone is not active when taken orally, so withdrawal symptoms occur only if injected - intended to prevent overdose when Suboxone is injected
67
What are the characteristics of benzodiazepines?
patient with CNS depression and a history of anxiety or panic disorder
- anxiolytics are medications such as benzodiazepines used for treatment of anxiety disorders
- they have additive effects with alcohol and tend to have a cumulative effect if doses are repeated indiscriminately
68
What is the mechanism of action of benzodiazepines?
GABAa channel-increased frequency of opening
69
What are the symptoms of intoxication from benzodiazepines?
respiratory depression, hypotension, amnesia, ataxia, stupor/somnolence, coma, death
70
What are the symptoms of withdrawal from benzodiazepines?
rebound anxiety, seizures (life-threatening) and tremor-most commonly found in short-acting Benzes such as alprazolam
71
What is the tx of benzodiazepines?
treat life-threatening intoxication with flumazenil which is a competitive GABA antagonist
-treat withdrawal with long-acting Benzodiazepines such as clonazepam with an appropriate taper
72
What is the mechanism of barbiturates?
GABAa channel - increased duration of opening
73
What are the symptoms of barbiturates intoxication?
respiratory/CNS depression - can be fetal
| -does not have a depression "ceiling" in contrast to benzodiazepines
74
What are the symptoms of barbiturates withdrawal?
anxiety, seizures, delirium, similar to alcohol, life-treating cardiovascular collapse
75
What is the tx of barbiturates intoxication?
symptom management, support BP, assist respiration, intubation, and bemegride
76
What is the tx of barbiturates withdrawal?
long-acting benzodiazepines with tapes
77
What are the characteristics of a person on cocaine?
patient with pupillary dilation, aggression, diaphoresis, prolonged wakefulness, and sympathetic activation
78
What is the mechanism of cocaine?
block biogenic amine (Dopamine (DA), norepinephrine (NE) and serotonin (5-hydroxytryptamine; 5-HT)) reuptake
79
What are the symptoms of cocaine intoxication?
- mental status changes: euphoria, psychomotor agitation, grandiosity, hallucinations (including tactile), paranoid ideations
- sympathetic activation
- decrease appetite, tachycardia, pupillary dilation, hypertension, angina
- severe vasospasm
- placental infarction - vasospasm of placental vessels
- nasal septum perforation - Kiesselbach's plexus vasospasm
- stroke - CVA
- stereotyped behavior
- repetitive motions (digging through the trash)
80
What are the symptoms of withdrawal from cocaine?
- severe depression and suicidality
- hyperphagia, hypersomnolence, fatigue, malaise
- severe psychological craving
81
What is the tx of cocaine intoxication?
Antipsychotics (haloperidol)
- benzodiazepines
- antihypertensives (labetalol - need alpha-1 blockade)
- vitamin C - promotes excretion
- do not restrain patients - may result in rhabdomyoloysis
82
What is the tx of cocaine withdrawal?
- bupropion
- bromocriptine
- SSRIs for depression
83
What are examples of amphetamines?
methamphetamine, dextroamphetamine (dexedrine), methylphenidate (concerta)
84
What is the mechanism of amphetamines?
stimulates biogenic amine (dopamine (DA), norepinephrine (NE) and serotonin (5-hydroxytryptamine; 5-HT) release + decreases reuptake (high dose)
85
What are the symptoms of amphetamines intoxication?
- mental status changes: euphoria, impaired judgement, delusions, hallucinations, prolonged wakefulness/attention
- sympathetic activation: psychomotor agitation, pupillary dilation, hypertension, tachycardia, fever, cardiac arrhythmias
86
What is the tx of amphetamines?
antipsychotics (haloperidol), benzodiazepines, vitamin C (promotes excretion), antihypertensive, propranolol (BP + tachycardia control)
87
What is the mechanism of MDMA (ecstasy)?
similar to amphetamines, effects 5-HT more than dopamine, may damage serotonergic neurons
88
What are the symptoms of intoxication of MDMA?
hyperthermia and social closeness, "club drug", hyponatremia
89
What are the symptoms of withdrawal of MDMA?
mood offset for several weeks
| -no specific treatment: symptomatic treatment only
90
What are the characteristics of tobacco-related disorders?
cigarette smoking is the leading preventable cause of death in the United States
- cigarette smoking causes more than 480,000 deaths each year in the United States
- this is nearly one in five deaths
- smoking causes more deaths each year than the following causes combined:
- human immunodeficiency virus (HIV)
- illegal drug use
- alcohol use
- motor vehicle injuries
- firearm-related incidents
91
What are the symptoms of tobacco-related intoxication?
restlessness, insomnia, anxiety, arrhythmias
92
What are the symptoms of tobacco-related withdrawal?
irritability, headache, anxiety, weight gain, craving
93
What is the tx for tobacco cessation?
- bupropion
- varenicline (chantix): partial nicotine receptor agonist, mediates partial reward of nicotine yet blocks reward of nicotine
- the highest success rate of all anti-smoking drugs, particularly when stacks with nicotine patches
- nicotine administration via other routes
94
What are the characteristics of suicide?
- suicide is the 8th leading cause of death in the United States and the 3rd leading cause of death in ages 15-24 years
- in all age groups, male deaths by suicide outnumber female deaths 4 to 1
- women attempt suicide 2 to 3 times more often than men; among girls aged 15 to 19 yr, there may be 100 attempts to every 1 attempt among boys of the same age
- on average, primary care physicians encounter >6 potentially suicidal people in their practice each year
- about 77% of people who die by suicide were seen by a physician within 1 yr before killing themselves, and about 32% had been under the care of a mental health care practitioner during the preceding year
95
What are risk factors for committing suicide?
- male gender
- older
- major depression
- active substance abuse
- serious medical problems
- a recent loss (e.g of employment, relationship, death of family member)
- consider referral to emergency services
- crisis service, emergency department
