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► Med Notes > Psychiatry Clerkship_1 > Flashcards

Psychiatry Clerkship_1 Flashcards

1
Q

what is the effect of NSAIDs on lithium levels?

A

NSAIDs ↓ lithium excretion → ↑ lithium concentrations • (except sulindac and aspirin)

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2
Q

psychomotor retardation is AKA what?

A

hypokinesia or bradykinesia

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3
Q

when is the term akinesia used?

A

in extreme cases where an absence of movement is observed

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4
Q

what are automatisms?

A

involuntary movements that occur during an altered state of consciousness and can range from purposeful to disorganized

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5
Q

what does pressured speech look like?

A

it is usually uninterruptible and the patient is compelled to continue speaking

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6
Q

proverb interpretation is helpful in assessing what?

A

whether a patient has difficulty with abstraction

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7
Q

vocabulary testing is useful for what?

A

a person’s intellectual capacity

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8
Q

a patient who is laughing one second and crying the next has what type of affect?

A

labile affect

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9
Q

when assessing appearance, what must you take special notice of?

A
  1. pupil size: drug intoxication/withdrawal • 2. bruises in hidden areas: ↑ suspicion for abuse • 3. needle marks: drug use • 4. eroding of tooth enamel: eating disorders • 5. superficial cuts on arms: self harm
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10
Q

what are the dimensions of speech assessment?

A

rate • rhythm • articulation • accent/dialect • modulation • long or short latency

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11
Q

what are the parameters of speech rate?

A

pressured • slowed • regular

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12
Q

what is a parameter for speech rhythm?

A

prosody

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13
Q

what is a parameter for speech articulation?

A

stuttering

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14
Q

what are the parameters for speech modulation?

A

loudness or softness

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15
Q

what are the dimensions for describing a patient’s affect?

A

quality • motility • appropriateness to content

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16
Q

what is the quality of affect?

A

depth and range of feelings shown

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17
Q

what are the parameters of quality of affect?

A

flat (none) • blunted (shallow) • constricted (limited) • full (average) • intense (more than normal)

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18
Q

what is motility of affect?

A

how quickly a person appears to shift emotional states

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19
Q

what are the parameters for motility of affect?

A

sluggish • supple • labile

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20
Q

what is described by appropriateness to content of affect?

A

whether the affect is congruent with the subject of conversation • parameters: appropriate– not appropriate

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21
Q

a patient who giggles while telling you that he set his house on fire and is facing serious charges has what type of affect?

A

inappropriate

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22
Q

a patient who remains expressionless and monotone even when discussing extremely sad or happy moments has what type of affect?

A

flat affect

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23
Q

what are the disorders of thought process?

A
  1. loosening of associations • 2. flight of ideas • 3. neologisms • 4. word salad • 5. clang associations • 6. thought blocking • 7. tangientiality • 8. circumstantiality
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24
Q

what is loosening of associations?

A

no logical connection from one thought to another

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25
Q

what is flight of ideas?

A

thoughts change abruptly from one idea to another, usually accompanied by rapid pressured speech

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26
Q

what are neologisms?

A

made up words

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27
Q

what is word salad?

A

incoherent collection of words

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28
Q

what are clang associations?

A

word connections due to phonetics rather than actual meaning

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29
Q

what is thought blocking?

A

abrupt cessation of communication before the idea is finished

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30
Q

what is tangentiality?

A

point of conversation never reached due to lack of goal directed associations between ideas; responses usually in the ballpark

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31
Q

what is circumstantiality?

A

point of conversation is enventually reached but with overinclusion of trivial or irrelevant details

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32
Q

what are the disorders of thought content?

A
  1. poverty of thought versus overabundance • 2. delusions • 3. suicidal and homicidal thoughts • 4. phobias • 5. obsessions • 6. compulsions
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33
Q

what is poverty of thoughts vs overabundance?

A

too few vs too many ideas expressed

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34
Q

what are delusions?

A

fixed, false beliefs that are not shared by the person’s culture and cannot be changed by reasoning

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35
Q

how are delusions classified?

A

bizarre • nonbizarre

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36
Q

what are phobias?

A

persistent irrational fears

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37
Q

what are obsessions?

A

repetitive intrusive thoughts

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38
Q

what are compulsions?

A

repetitive behaviors

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39
Q

what are examples of delusions?

A
  1. grandeur • 2. paranoid • 3. reference • 4. thought broadcasting • 5. religious • 6. somatic
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40
Q

what are delusions of grandeur?

A

belief that one has special powers or is someone important

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41
Q

what are paranoid delusions?

A

belief that one is being persecuted

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42
Q

what are reference delusions?

A

belief that some event is uniquely related to the patient (TV show is sending messages to the pt…etc)

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43
Q

what is a thought broadcasting delusion?

A

belief that one’s thoughts can be heard by others

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44
Q

what is a religious delusion?

A

conventional beliefs are exaggerated (jesus talks to me…etc)

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45
Q

what are somatic delusions?

A

false belief concerning body image

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46
Q

what is a question to use when screening for compulsions?

A

do you clean, check or count things repetitively?

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47
Q

what are hallucinations?

A

sensory perception that occurs in the absence of an actually stimulus

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48
Q

what are the major things to document about hallucinations?

A

sensory modality • details • if hypnogogic or hypnopompic

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49
Q

what are illusions?

A

inaccurate perception of existing sensory stimuli

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50
Q

what type of hallucination is an important risk factor for suicide or homicide?

A

auditory hallucination that instructs a patient to harm himself or others

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51
Q

what are the ways in which sensorium and cognition are assessed?

A
  1. consciousness • 2. orientation • 3. calculation • 4. memory • 5. fund of knowledge • 6. attention/concentration • 7. reading/writing • 8. abstract concepts
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52
Q

what are the possible ranges of a patient’s consciousness?

A

alert - drowsy - lethargic - stuporous - coma

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53
Q

what are the parameters of a patient’s orientation?

A

person • place • time

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54
Q

what are the parameters of measuring a patient’s calculation?

A

ability to add/substract

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55
Q

what are the 3 dimensions of assessment of a patient’s memory?

A

immediate (registration) • recent (short term) • remote (long term)

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56
Q

what is immediate memory/registration and how is it assessed?

A

dependent on attention/concentration and can be tested by asking a patient to repeat several digits or words

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57
Q

what is recent/short term memory?

A

events within the past few hours or days

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58
Q

what is fund of knowledge?

A

level of knowledge in the context of the patient’s culture and education

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59
Q

how is attention/concentration assessed?

A

ability to subtract serial 7’s from 100 or to spell WORLD backwards

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60
Q

how is reading/writing assessed?

A

simple sentences (make sure patient is literate)

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61
Q

how are abstract concepts assessed?

A

ability to explain similarities between objects and understand the meaning of simple proverbs

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62
Q

what is a patient’s insight?

A

the patient’s level of awareness and understanding of their problem

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63
Q

problems with insight include what?

A

complete denial of illness or blaming it on something else

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64
Q

how is insight described?

A

full • partial/limited • none

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65
Q

what is a patient’s judgement?

A

the patient’s ability to understand the outcome of their actions and use this awareness in decision making

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66
Q

how can judgement be described?

A

excellent • good • fair • poor

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67
Q

alcoholic hallucinosis refers to what?

A

hallucinations (usually visual, though possibly auditory or tactile) that develop within 12-24 hours of abstinence from etoh and resolve within 24-48 hours

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68
Q

how is alcoholic hallucinosis different from DTs?

A

in alcoholic hallucinosis there is no clouding of sensorium and vital signs are normal

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69
Q

what are the areas tested in the MMSE?

A

orientation • memory • concentration and attention • language • reading and writing • visuospatial ability

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70
Q

what is the general approach to the violent patient?

A
  1. avoid being alone with them • 2. notify staff of your whereabouts • 3. assess violence and homicidality • 4. notify potential victims and authorities of an imminent threat (tarasoff rule)
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71
Q

what is the general approach to the delusional patient?

A

do not directly challenge a delusion or insist that it is untrue, but do not imply that you believe it either. simply acknowledge that you understand the patient believes the delusion

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72
Q

what is the general approach to the depressed patient?

A

offer reassurance that they can improve with appropriate therapy. inquire about suicidality → hospitalize if planning or contemplating

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73
Q

what are signs of increased suicide risk in a depressed patient?

A

feeling of hopelessness • substance abuse • hx of prior attempt

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74
Q

what is the most important predictor of future violence?

A

a prior history of violence

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75
Q

what is the DSM IV multiaxial classification system for diagnoses?

A

Axis I: all dx of mental illness including substance abuse and dev. disorders, not including personality and mental retardation • Axis II: personality dx and MR • axis III: general medical conditions • axis IV: psychosocial and env problems • axis V: GAF

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76
Q

what is the GAF criterion for hospitalization?

A

<30

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77
Q

features of a GAF 1-10?

A
  1. persistent danger of severely hurting self or others: • —recurrent violence • 3. serious suicidal act with clear expectation of death • 4. persistent inability to maintain minimal personal hygiene
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78
Q

features of GAF 11-20?

A
  1. gross impairment in communication: • — largely incoherent or mute • 2. some danger of hurting self or others: • — suicide attempts without clear expectation of death, frequently violent, manic excitement • 3. occasionally fails to maintain a minimal personal hygiene: • — smears feces
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79
Q

features of GAF 21-30?

A
  1. behavior is considerably influenced by delusions or hallucinations • 2. serious impairment in communication or judgement: • — sometimes incoherent, acts grossly inappropriately, suicidal preoccupation • 3. inability to function in almost all areas: • — stays in bed all day, no job, home or friends
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80
Q

features of GAF 31-40?

A
  1. some impairment in reality testing or communication: • — speech is at times illogical, obscure, or irrelevant • 2. major impairment in several areas such as work or school, family relations, judgement, thinking, or mood: • — depressed adult avoids friends, neglects, family, unable to work. • — child frequently beats up younger children, is defiant at home, and is failing in school
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81
Q

features of GAF 41-50?

A
  1. serious symptoms: • — suicidal ideation, severe obsessional rituals, frequent shoplifting • 2. any serious impairment in social, occupational, or school functioning: • — no friends, unable to keep a job
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82
Q

features of GAF 51-60?

A
  1. moderate symptoms: • — flat affect and circumstantial speech, occasional panic attacks • 2. moderate difficulty in social, occupational, or school functioning: • — few friends, conflicts with coworkers
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83
Q

features of GAF 61-70?

A
  1. some mild symptoms: • — depressed mood, mild insomnia • 2. some difficulty in social, occupational, or school functioning: • — occasional truancy, or theft within the household, but generally functioning pretty well, has some meaningful interpersonal relationships
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84
Q

features of GAF 71-80?

A
  1. if symptoms are present, they are transient and expectable reactions to psychosocial stressors: • — difficulty concentrating after family argument • 2. no more than slight impairment in social, occupational, or school functioning • — temporarily falling behind in school work
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85
Q

features of GAF 81-90?

A
  1. absent or minimal symptoms: • — mild anxiety before an exam. generally satisfied with life. • — no more than everyday problems or concerns • — occasional arguments with family members • 2. good functioning in all areas, interested and involved in a wide range of activities, socially effective
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86
Q

features of GAF 91-100?

A
  1. no symptoms • 2. superior functioning in a wide range of activities • — life’s problems never seem to get out of hand • 3. sought out by others because of many positive qualities
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87
Q

what is the Minnesota Multiphasic Personality Inventory?

A

an objective psychological test that is used to assess a person’s personality and identify psychopathologies. mean score is 50 and the SD is 10

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88
Q

what is the Wechsler Adult Intelligence Scale (WAIS)?

A
  1. MC test for ages 16-75 • 2. Assesses overall intellectual functioning • 3. Two Parts: verbal and visuo-spatial
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89
Q

what is the stanford binet test?

A

tests intellectual ability in patients ages 2-18

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90
Q

what is the Thematic Apperception Test?

A
  • test taker creates stories based on pictures of people in various situations • - used to evaluate motivations behind behaviors
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91
Q

what is the Rorschach test?

A
  • interpretation of ink blots • - used to identify thought disorders and defense mechanisms
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92
Q

what is a very superior IQ?

A

> 130

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93
Q

what is a superior IQ?

A

120-129

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94
Q

what is a high average iq?

A

110-119

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95
Q

what is an average iq?

A

90-109

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96
Q

what is a borderline iq?

A

70-79

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97
Q

what is an iq consistent with mild MR?

A

50-70

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98
Q

what is an iq consistent with moderate MR?

A

35-49

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99
Q

what is an iq consistent with severe MR?

A

25-34

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100
Q

what is an iq consistent with profound MR?

A

<2

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101
Q

what is psychosis?

A

a general term used to describe a distorted perception of reality

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102
Q

psychosis can be a symptom of what?

A

schizophrenia • mania • severe depression • can be substance induced

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103
Q

hallucinations and delusions are also frequently observed in what?

A

delirium and dementia

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104
Q

psychosis is exemplified by what?

A

either delusions, hallucinations, or severe disorganization of thought/behavior

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105
Q

what is a nonbizarre delusion?

A

a belief that could be true but isn’t

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106
Q

what is a bizarre delusion?

A

a false belief that is impossible

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107
Q

what are the types of delusions of control?

A

thought broadcasting and thought insertion

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108
Q

what are delusions of guilt?

A

false belief that one is guilty or responsible for something

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109
Q

auditory hallucinations that directly tell the patient to perform certain acts are called what?

A

command hallucinations

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110
Q

which hallucinations are most commonly exhibited by schizophrenics?

A

auditory

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111
Q

with which conditions are visual hallucinations common?

A

less common with schizophrenia • may accompany drug intoxication, drug and alcohol withdrawal, or delirium

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112
Q

with which conditions are olfactory hallucinations common?

A

usually an aura associated with epilepsy

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113
Q

with which conditions are tactile hallucinations common?

A

usually secondary to drug abuse or alcohol withdrawal

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114
Q

what is the differential diagnosis of psychosis?

A
  1. psychosis secondary to general medical condition • 2. substance-induced psychotic disorder • 3. delirium/dementia • 4. bipolar disorder, manic/mixed episode • 5. major depression with psychotic features • 6. brief psychotic disorder • 7. schizophrenia • 8. schizophreniform disorder • 9. schizoaffective disorder • 10. delusional disorder
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115
Q

what are the medical causes of psychosis?

A
  1. CNS disease • 2. endocrinopathies • 3. nutritional/vitamin deficiency states • 4. other
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116
Q

what are the CNS diseases that cause psychosis?

A
  1. cerebrovascular disease • 2. MS • 3. neoplasm • 4. AD • 5. Parkinson’s • 6. Huntington’s • 7. tertiary syphilis • 8. temporal lobe epilepsy • 9. encephalitis • 10. prion disease • 11. neurosarcoidosis • 12. AIDS
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117
Q

what are the endocrinopathies that cause psychosis?

A
  1. addison/cushing • 2. hyper/hypothyroid • 3. hyper/hypocalcemia • 4. hypopituitarism
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118
Q

what are the nutritional/vitamin deficiency states that cause psychosis?

A
  1. B12 • 2. folate • 3. niacin
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119
Q

what are the other general medical conditions that cause psychosis?

A
  1. connective tissue disease • -SLE • - temporal arteritis • 2. porphyria
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120
Q

what are the DSM IV criteria for psychotic disorder secondary to a general medical condition?

A
  1. prominent hallucinations or delusions • 2. symptoms do not occur only during episode of delirium • 3. evidence to support medical cause from lab data, h/p
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121
Q

what are the prescription medications that may cause psychosis in some patients?

A
  1. corticosteroids • 2. antiparkinson • 3. anticonvulsants • 4. antihistamines • 5. anti-cholinergics • 6. antihypertensives • - β blockers • 7. digitalis • 8. ritalin • 9. fluoroquinolones
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122
Q

what are the drugs of abuse that cause psychosis?

A
  1. etoh • 2. cocaine • 3. LSD, MDMA • 4. MJ • 5. BZD • 6. barbiturates • 7. PCP
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123
Q

what are the DSM IV criteria for diagnosis of medication/substance-use induced psychosis?

A
  1. prominent hallucinations/delusions • 2. symptoms do not occur only during an episode of delirium • 3. evidence to support medication or substance-related cause from lab data, h/p • 4. disturbance is not better accounted for by a psychotic disorder that is not substance induced
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124
Q

how long must a patient have symptoms to be diagnosed with schizophrenia?

A

6mo

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125
Q

what is the important workup for patient with symptoms of schizophrenia?

A

TSH • RPR • brain imaging

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126
Q

what are the positive symptoms of schizophrenia?

A

hallucinations • delusions • bizarre behavior • disorganized speech

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127
Q

what are the negative symptoms of schizophrenia?

A

blunted affect • anhedonia • apathy • alogia • lack of interest in socialization

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128
Q

what are the cognitive symptoms of schizophrenia?

A

impairments in attention, executive function and working memory

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129
Q

negative symptoms of schizophrenia contribute significantly to which problem?

A

social isolation of schizophrenic patients

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130
Q

cognitive symptoms of schizophrenia contribute significantly to what?

A

poor work and school performance

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131
Q

which symptoms of schizophrenia respond more robustly to the current antipsychotic medications?

A

positive symptoms

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132
Q

what signs are seen in catatonic schizophrenic patients?

A

stereotyped movement • bizarre posturing • muscle rigidity

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133
Q

what drug is considered when a schizophrenic patient fails both typical and atypical antipsychotics?

A

clozapine

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134
Q

symptoms of schizophrenia usually present in what phases?

A
  1. prodromal • 2. psychotic • 3. residual
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135
Q

what is the prodromal phase of schizophrenia?

A

decline in function that precedes the first psychotic episode. • the patient may become socially withdrawn and irritable. • he or she may have physical complaints and/or newfound interest in religion or the occult

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136
Q

what is the psychotic phase of schizophrenia?

A

perceptual disturbances, delusions, and disordered thought process/content

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137
Q

what is the residual phase of schizophrenia?

A

occurs between episodes of psychosis. • marked by flat affect, social withdrawal, odd thinking or behavior (negative symptoms) • patients can continue to have hallucinations even with treatment

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138
Q

what are the DSM IV criteria for diagnosis of schizophrenia?

A

I. >2 x >1mo: • 1. delusions • 2. hallucinations • 3. disorganized speech • 4. grossly disorganized or catatonic behavior • 5. negative symptoms • II. must cause significant social or occupational functional deterioration • III. duration of illness >6mo • IV. symptoms not due to medical, neurological , or substance-induced disorder

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139
Q

when is only one of the major symptoms of schizophrenia necessary for diagnosis?

A

if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person’s behavior, or two or more voices conversing with eachother

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140
Q

what are the 5 A’s of schizophrenia?

A

negative symptoms: • 1. Anhedonia • 2. Affect- flat • 3. Alogia- poverty of speech • 4. Avolition - apathy • 5. Attention- poor

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141
Q

which subtype of schizophrenia is higher functioning with an older age of onset?

A

paranoid type

142
Q

which type of schizophrenia is the poor functioning early onset subtype?

A

disorganized type

143
Q

which type of schizophrenia is most rare?

A

catatonic type

144
Q

for a patient to have paranoid type schizophrenia, they must meet which criteria?

A
  1. preoccupation with one or more delusions or frequent auditory hallucination • 2. no predominance of disorganized speech, disorganized or catatonic behavior, or inappropriate affect
145
Q

for a patient to be diagnosed with disorganized type schizophrenia they must meet which criteria?

A
  1. disorganized speech • 2. disorganized behavior • 3. flat or inappropriate affect
146
Q

for a patient to be diagnosed with catatonic type schizophrenia, which criteria must be met?

A

> 2: • 1. motor immobility • 2. excessive purposeless motor activity • 3. extreme negativism or mutism • 4. peculiar voluntary movements or posturing • 5. echolalia or echopraxia

147
Q

paranoid type schizophrenia is characterized by what?

A

delusions and auditory hallucinations

148
Q

disorganized type schizophrenia is characterized by what?

A

disorganized speech, behavior, and flat or inappropriate affect

149
Q

catatonic type schizophrenia is characterized by what?

A

rigid posture • inappropriate or repetitive and purposeless movements • echolalia • echopraxia

150
Q

residual type schizophrenia is characterized by what?

A

prominent negative symptoms

151
Q

undifferentiated type schizophrenia is characterized by what?

A

doesn’t fulfill any of the other criteria

152
Q

brief psychotic disorder lasts how long?

A

<1mo

153
Q

schizophreniform disorder lasts how long?

A

1-6 mo

154
Q

schizophrenia lasts how long?

A

> 6mo

155
Q

the typical findings in schizophrenic patients on exam include what?

A

disheveled appearance • flattened affect • disorganized thought process • intact memory and orientation • auditory hallucinations • paranoid delusions • ideas of reference • concrete understandings of similarities/proverbs • lack of insight into their disease

156
Q

what is the effect of birthdate and schizophrenia?

A

people born in winter and early spring have a higher incidence of schizophrenia • - second trimester exposure to viral infection like influenza

157
Q

what is the socioeconomic predominance of schizophrenia?

A

found in lower socioeconomic groups due to downward drift- have difficult holding onto job so they drift down socioeconomic ladder

158
Q

schizophrenia affects what % of people over their lifetime?

A

1%

159
Q

what is the difference in gender presentation of schizophrenia?

A

men: • - present 20yo • - more negative symptoms • - more impaired social functioning • women: • - present @ 30yo

160
Q

what is the typical age range for presentation of schizophrenia?

A

rarely presents before 15 or after 55

161
Q

what is the strength of the genetic predisposition to schizophrenia?

A

50% MZ twins • 40% risk of inheritance if both parents affected • 12% risk if first degree relative

162
Q

what is the incidence of substance abuse in schizophrenia?

A

etoh- 30-50% • MJ- 15-20% • cocaine- 5-10%

163
Q

what is postpsychotic depression?

A

the phenomenon of schizophrenic patients developing a major depressive disorder after resolution of their psychotic symptoms

164
Q

what is akathisia?

A

an unpleasant, subjective sense of restlessness often manifested by the inability to sit still

165
Q

what are the theorized dopamine pathways affected in schizophrenia?

A

prefrontal cortical • mesolimbic

166
Q

what is the role of the prefrontal cortical dopamine pathway in schizophrenia?

A

inadequate dopaminergic activity responsible for negative symptoms

167
Q

what is the role of the mesolimbic dopamine pathway in schizophrenia?

A

excessive dopaminergic activity responsible for positive symptoms

168
Q

what are the other important dopamine pathways affected by neuroleptics?

A
  1. tuberoinfundibular • 2. nigrostriatal
169
Q

what is the effect of neuroleptics on the tuberoinfundibular dopamine pathway?

A

blocked by neuroleptics, causing hyperprolactinemia, which may → gynecomastia, galactorrhea, menstrual irregularity

170
Q

what is the effect of neuroleptics on the nigrostriatal dopamine pathway?

A

blocked by neuroleptics, causing EPS side effects such as tremor, slurred speech, akathisia, dystonia, and other abnormal movements

171
Q

what are the other neurotransmitter abnormalities implicated in schizophrenia?

A

↑ serotonin • ↑ NE • ↓ GABA • ↓ level of glutamate receptors

172
Q

which neuroleptics affect the ↑ serotonin in schizophrenia?

A

some of the atypical antipsychotics (such as risperidone and clozapine) antagonize serotonin and weakly antagonize DA

173
Q

how do neuroleptics relate to the ↑ NE seen in schizophrenia?

A

long term use of antipsychotics has been shown to ↓ activity of noradrenergic neurons

174
Q

how does ↓ GABA relate to schizophrenia?

A

there is ↓ expression of the enzyme necessary to create GABA in the hippocampus of schizophrenic patients

175
Q

how do ↓ levels of glutamate receptors relate to schizophrenia?

A

schizophrenic patients have fewer NMDA receptors; this correlates with the psychotic symptoms observed with NMDA antagonists like ketamine

176
Q

CT of patients with schizophrenia may show what?

A

enlargement of the ventricles and diffuse cortical atrophy

177
Q

significant improvement is noted in what % of schizophrenics who take antipsychotic medications?

A

70%

178
Q

what physical impairment is a predisposing factor to paranoid psychosis?

A

deafness

179
Q

what % of schizophrenics remain significantly impaired after diagnosis?

A

40-50%

180
Q

what % of schizophrenics function fairly well in society with medication?

A

20-30%

181
Q

what % of schizophrenics attempt suicide?

A

50%

182
Q

what factors are associated with a better prognosis in patients with schizophrenia?

A
  1. later onset • 2. good social support • 3. positive symptoms • 4. mood symptoms • 5. acute onset • 6. female sex • 7. few relapses • 8. good premorbid functioning
183
Q

which factors are associated with a worse prognosis in patients with schizophrenia?

A
  1. early onset • 2. poor social support • 3. negative symptoms • 4. family history • 5. gradual onset • 6. male sex • 7. many relapses • 8. poor premorbid functioning • 9. comorbid substance abuse
184
Q
  1. which drugs are the first generation antipsychotics?
A
  1. chlorpromazine- Thorazine • 2. thioridazine- Mellaril • 3. trifluoperazine- Stelazine • 4. haloperidol- Haldol
185
Q

what is the MOA of the first generation antipsychotics?

A

dopamine (mostly D2) receptors

186
Q

against what are the first generation antipsychotics effective?

A

most effective against positive symptoms with minimal impact on negative symptoms

187
Q

what are the side effects of first generation antipsychotics?

A

extrapyramidal symptoms • neuroleptic malignant syndrome • tardive dyskinesia

188
Q

which drugs are the second generation antipsychotics?

A
  1. risperidone- risperdal • 2. clozapine- Clozaril, FazaClo • 3. olanzapine- Zyprexa • 4. quetiapine- Seroquel • 5. aripiprazole- Abilify • 6. ziprosidone- Geodon
189
Q

what is the MOA of the second generation antipsychotics?

A

these antagonize 5-HT2 receptors as well as DA receptors

190
Q

what is the difference in efficacy between 1st and 2nd generation antipsychotics?

A

originally believed to be more effective that older antipsychotic medications, current research has shown no significant difference between 2 groups in treating NEGATIVE symptoms

191
Q

what is the difference between the side effects of 2nd generation antipsychotics and 1st?

A

2nd have much lower incidence of EPS, but are now known to ↑ risk of metabolic syndrome

192
Q

how long should 2nd generation antipsychotics be taken before efficacy is determined?

A

4 weeks

193
Q

why is clozapine reserved for medically refractory patients?

A

due to ↑ risk of agranulocytosis

194
Q

schizophrenic patients on atypical antipsychotics need a careful medical evaluation for what?

A

metabolic syndrome: • waist circumference • BMI • fasting glucose • lipids • BP

195
Q

side effects of antipsychotic medications include what?

A
  1. EPS • 2. anticholinergic symptoms • 3. metabolic syndrome • 4. tardive dyskinesia • 5. NMS • 6. prolonged QT +/- other ECG Δ • 7. hyperprolactinemia • 8. hematologic effects • 9. ophthalmic conditions • 10. dermatologic conditions
196
Q

you get EPS especially with what drugs?

A

high potency traditional antipsychotics

197
Q

what are the high potency traditional neuroleptics?

A

haloperidol • trifluoperazine

198
Q

what symptoms make up EPS?

A
  1. dystonia (spasms) of face neck and tongue • 2. parkinsonism (resting tremor, rigidity, bradykinesia) • 3. akathisia
199
Q

what is the treatment for EPS?

A
  1. antiparkinsonian agents • - benztropine, diphenhydramine • 2. BZD • 3. β blockers (specifically indicated for akathisia
200
Q

which neuroleptics are more likely to cause anticholinergic symptoms?

A

low potency traditional antipsychotics and atypical antipsychotics

201
Q

what are the low potency first gen neuroleptics?

A

chlorpromazine • thioridazine

202
Q

what are the anticholinergic symptoms associated with antipsychotics?

A

dry mouth • constipation • blurred vision

203
Q

what are the treatments for neuroleptic induced anticholinergic side effects?

A

as per symptoms- eye drops, stool softeners, etc

204
Q

which types of neuroleptics are more likely to cause metabolic syndrome?

A

second generation antipsychotics

205
Q

what is the treatment for neuroleptic induced metabolic syndrome?

A
  1. consider switching to a first generation antipsychotic or a more weight neutral atypical like aripiprazole or ziprasidone • 2. monitor lipids and blood glucose • 3. refer to primary car for tx of HPL, DM etc • 4. encourage diet, exercise, smoking cessation
206
Q

what type of neuroleptics cause tardive dyskinesia?

A

high potency antipsychotics

207
Q

what is tardive dyskinesia?

A

darting or writhing movements of the face, tongue, and head

208
Q

what is the treatment for tardive dyskinesia?

A

d/c or ↓ offending agent and consider substituting an atypical antipsychotic. • BZD, β blockers, cholinomimetics can be used in the short term

209
Q

what is the prognosis of tardive dyskinesia?

A

the movements often persist despite withdrawal of the offending agent

210
Q

can atypical antipsychotics cause tardive dyskinesia ?

A

less commonly, but yes in some patients

211
Q

what types of drugs cause NMS?

A

high potency antipsychotics

212
Q

what is Neuroleptic malignant syndrome?

A

change in mental status • autonomic changes • lead pipe rigidity • sweating • ↑ CPK • leukocytosis • metabolic acidosis

213
Q

what are the autonomic changes seen in NMS?

A

high fever • ↑BP • ↑HR

214
Q

how serious is NMS?

A

a medical emergency that requires prompt withdrawal of all antipsychotic meds and immediate medical assessment and treatment

215
Q

who can get NMS?

A

may be observed in any patient being treated with neuroleptic medications at any time, but is MC associated with the initiation of treatment and at a higher IV/IM dosing of high potency neuroleptics

216
Q

who is at a higher risk for NMS?

A

patients with a hx of NMS are at ↑ risk of recurrence

217
Q

what are the symptoms of neuroleptic induced hyperprolactinemia?

A

gynecomastia, galactorrhea, amenorrhea, diminished libido, impotence

218
Q

what are the hematologic effects to look out for with antipsychotic administration?

A

agranulocytosis may occur with clozapine, must get weekly CBC

219
Q

what are the neuroleptic induced ophthalmic conditions?

A
  1. thioridazine may cause irreversible retinal pigmentation at high doses • 2. chlorpromazine can cause deposits in the lens and cornea
220
Q

what are the dermatologic conditions that can occur with neuroleptic use?

A

rashes and photosensitivity

221
Q

In which patients does tardive dyskinesia occur most often?

A

women after >6mo of medication

222
Q

what % of patients with tardive dyskinesia see spontaneous recovery?

A

50%

223
Q

which cardiac drugs are known to exacerbate psychosis in predisposed patients?

A

β blockers and digoxin

224
Q

what percentage of long term hospitalized patients treated with antipsychotics end up with tardive dyskinesia?

A

20%

225
Q

what is the prognosis for schizophreniform disorder?

A

1/3 recover completely • 2/3 progress to schizoaffective disorder or schizophrenia

226
Q

what is the treatment for schizophreniform disorder?

A

hospitalization, 3-6 month course of antipsychotics, and supportive psychotherapy

227
Q

if a schizophrenia presentation has not been present for 6 months, think what?

A

schizophreniform disorder

228
Q

what are the DSM IV criteria for diagnosis of schizoaffective disorder?

A
  1. meet criteria for major depressive episode, manic episode, or mixed episode (during which criteria for schizophrenia are also met) • 2. have had hallucinations or delusions for 2 weeks in the absence of mood disorder symptoms • 3. have mood symptoms present for substantial portion of psychotic illness • 4. have symptoms not due to general medical condition or drugs
229
Q

what is the prognosis for schizoaffective disorder?

A

60-80% will progress to schizophrenia

230
Q

what is the treatment for schizoaffective disorder?

A
  1. hospitalization and supportive psychotherapy • 2. medical therapy: antipsychotics and mood stabilizers; antidepressants or ECT may be indicated for tx of mood sx
231
Q

does borderline personality disorder count as a brief psychotic episode?

A

patients with borderline may have transient, stress related psychotic experiences. these are considered part of their axis II disorder and not diagnosed as brief psychotic disorder

232
Q

what are the DSM IV criteria for diagnosis of brief psychotic disorder?

A
  1. patient with psychotic symptoms as defined for schizophrenia, but for 1-30 days • 2. symptoms must not be due to general medical condition or drugs
233
Q

how common is brief psychotic disorder?

A

rare, much less common than schizophrenia

234
Q

when might one expect to see brief psychotic disorder?

A

reaction to extreme stress such as bereavement, sexual assault, etc

235
Q

what is the prognosis for brief psychotic disorder?

A

50-80% recovery rate • 20-50% may eventually be diagnosed with schizophrenia or mood disorder

236
Q

what is the tx for brief psychotic episode

A

brief hospitalization • supportive psychotherapy • course of antipsychotics for psychosis itself • +/- BZDs for agitation

237
Q

delusional disorder occurs more often in whom?

A

older patients > 40yo • immigrants • hearing impaired

238
Q

what are the DSM IV criteria for diagnosing mood disorder?

A
  1. nonbizarre fixed delusions >1 mo • 2. does not meet criteria for schizophrenia • 3. functioning in life not significantly impaired
239
Q

what are the types of delusions seen in delusional disorder?

A
  1. erotomantic type • 2. grandiose type • 3. somatic type • 4. persecutory type • 5. jealous type • 6. mixed type
240
Q

what is the prognosis for delusional disorder?

A

50% full recovery • 20% ↓ sx • 30% no Δ

241
Q

what is the tx for delusional disorder?

A

psychotherapy may be helpful • try antipsychotics even though they tend not to be effective (high potency or atypical)

242
Q

what is shared psychotic disorder?

A

AKA folie a deux • when a patient develops the same delusional symptoms as someone they are in a close relationship with. • most are family members

243
Q

what is the prognosis for folie a deux?

A

20-40% recover upon removal from the inducing person

244
Q

what is the treatment for shared psychotic disorder /folie a deux?

A
  1. separation • 2. antipsychotics if separation doesn’t resolve delusion in 1-2 weeks
245
Q

what is koro?

A

patient believes that his penis is shrinking and will disappear causing his death

246
Q

koro is unique to what culture?

A

asia

247
Q

what is amok?

A

sudden unprovoked outbursts of violence of which the person has no recollection. person often commits suicide after.

248
Q

amok is unique to which region/culture?

A

southeast asia /malaysia

249
Q

what is brain fag?

A

headache, fatigue, and visual disturbance in male students

250
Q

brain fag is unique to which region/culture?

A

africa

251
Q

what is the prognosis of the psychotic disorders in order of best to worst?

A

mood disorder > brief psychotic disorder > schizoaffective > schizophreniform > schizophrenia

252
Q

list the ‘schiz’ disorders and they differentiating feature

A
  1. schizophrenia= lifelong psychotic disorder • 2. schizophreniform= schizophrenia < 6 mo • 3. schizoaffective= schizophrenia + mood disorder • 4. schizotypal= paranoid, magical thinking, lack of friends, social anxiety • 5. schizoid= withdrawn, lack of enjoyment from social interactions, emotionally restricted
253
Q

which of the ‘schiz’ disorders are personality disorders?

A

schizotypal and schizoid

254
Q

what are mood episodes?

A

distinct periods of time in which some abnormal mood is present: • - depression • - mania • - mixed state • - hypomania

255
Q

mood disorders include which diseases?

A

major depressive disorder • bipolar I • bipolar II • dysthymic disorder • cyclothymic disorder

256
Q

when patients have delusions and hallucinations caused by mood disorders, they are usually what?

A

mood congruent

257
Q

what type of psychosis is induced by depression?

A

paranoia and worthlessness

258
Q

what type of psychosis is induced by mania?

A

grandiosity and invincibility

259
Q

what are the DSM IV criteria for the diagnosis of MDE?

A

> 5 of the following, with #1/#2 mandatory, for > 2weeks: • 1. depressed mood • 2. anhedonia • 3. change in appetite or weight • 4. feelings of worthlessness or excessive guilt • 5. insomnia or hypersomnia • 6. diminished concentration • 7. psychomotor agitation or retardation • 8. fatigue or loss of energy • 9. recurrent thoughts of death or suicide • • sx cannot be due to substance use or medical condition • • must cause social or occupational impairment

260
Q

what are the symptoms of major depression?

A

SIG E CAPS • Sleep • Interest • Guilt • Energy • Concentration • Appetite • Psychomotor activity • Suicidal ideation

261
Q

how serious is a manic episode?

A

psychiatric emergency; severely impaired judgement makes the patient dangerous to self and others

262
Q

what are the symptoms of mania?

A

DIG FAST • Distractibility • Insomnia/Impulsivity • Grandiosity • Flight of Ideas • Activity/agitation • Speech (pressured) • Thoughtlessness

263
Q

what are the DSM IV criteria for diagnosis of manic episode?

A

A period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary) and including at least 3 of the following (4 if mood is irritable): • 1. distractibility • 2. inflated self esteem or grandiosity • 3. ↑ in goal directed activity • 4. ↓ need for sleep • 5. flight of ideas or racing thoughts • 6. more talkative or pressured speech • 7. excessive involvement in pleasurable activities that have a high risk of negative consequences • -these cannot be due to medical condition or substance abuse and must cause social or occupational impairment

264
Q

what % of manic patients have psychotic symptoms?

A

75%

265
Q

what is a mixed episode?

A

criteria are met for both manic episode and major depressive episode. these criteria must be present nearly everyday for at least a week. psychiatric emergency

266
Q

what is a hypomanic episode?

A

a distinct period of elevated, expansive, or irritable mood that includes at least of the 3 symptoms listed for manic episode (4 if mood is irritable)

267
Q

what is the difference between mania and hypomania?

A
  1. mania >7 days but hypo is >4 • 2. hypomania does not impair social or occupational function but mania does • 3. hypomania does not require hospitalization but mania does • 4. hypomania doesn’t have psychotic features but mania can
268
Q

what is the predominant mood state in mixed episodes?

A

irritability

269
Q

patients in which mood episode have a poorer response to lithium?

A

mixed episode

270
Q

what drugs may help in a mixed episode?

A

anticonvulsants

271
Q

what are the medical causes of a depressive episode?

A
  1. cerebrovascular disease (stroke, MI) • 2. endocrinopathies (DM, cushing, addison, hypoglycemia, ↑↓thyroid, ↑↓Ca) • 3. parkinson • 4. virus (IM) • 5. carcinoid syndrome • 6. cancer (lymphoma and pancreatic CA) • 7. collagen vascular disease (SLE)
272
Q

what are the medical causes of a manic episode?

A
  1. metabolic (↑thyroid) • 2. neuro (temporal lobe seizure, MS) • 3. neoplasm • 4. HIV
273
Q

what meds/substances induce depressive episodes?

A
  1. etoh • 2. antihypertensives • 3. barbiturates • 4. corticosteroids • 5. L-dopa • 6. sedative hypnotics • 7. anticonvulsants • 8. diuretics • 9. sulfonamides • 10. withdrawal from stimulants
274
Q

which meds/substances induce mania?

A
  1. antidepressants • 2. sympathomimetics • 3. dopamine • 4. corticosteroids • 5. L-dopa • 6. bronchodilators
275
Q

stroke patients are at very high risk of developing what mood disorder?

A

depression

276
Q

what has the highest rate of suicide of any disorder?

A

MDD

277
Q

what are the DSM-IV criteria for diagnosis of MDD?

A

> 1 MDE • 0 hx of manic/hypomanic episode

278
Q

what is the lifetime prevalence of MDD in the USA?

A

16.20%

279
Q

what is the average age of onset of MDD?

A

40

280
Q

what is the gender predilection of MDD during reproductive years?

A

2x as prevalent in women

281
Q

what is the gender predilection for MDD before menses and after menopause?

A

equal for men and women

282
Q

what is the prevalence of MDD in the elderly?

A

25-50%

283
Q

what is the effect of depression on mortality?

A

can ↑ mortality for patients with other comorbidities (DM, CVD)

284
Q

what are the 2 most common sleep disturbances associated with MDD?

A

difficulty falling asleep and early morning waking

285
Q

what are the sleep problems associated with MDD?

A
  1. multiple awakenings • 2. initial and terminal insomnia • 3. hypersomnia • 4. REM sleep shifted to earlier in night, and stages 3 & 4 ↓
286
Q

what is the etiology of depression?

A
  1. caused by neurotransmitter deficiency: • ↓ brain and CSF 5-HT and 5-HIAA found in depressed pts • 2. abnormal regulation of beta-adrenergic receptors • 3. ↑ cortisol • 4. thyroid disorder • 5. GABA and endogenous opioids • 6. life events • 7. genetics
287
Q

what is the genetic predisposition pattern in MDD?

A

first degree relatives 2-3x more likely to have MDD • MZT= 50-70% • DZT= 10-25%

288
Q

what happens if MDE is untreated?

A

depressive episodes are self limiting but usually last 6-13 months

289
Q

what is the pattern of MDE occurrence as MDD progresses?

A

epsiodes occur more frequently as disorder progresses

290
Q

what percent of patients with MDD commit suicide?

A

15%

291
Q

what % of patients with MDD respond to antidepressants?

A

50-60%

292
Q

what combination can significantly ↑ response for severe and recurrent depression?

A

antidepressant + psychotherapy

293
Q

what is the hamilton score?

A

standard measure of depression severity used in research to assess effectiveness of therapy

294
Q

what life event is associated with developing MDD later?

A

loss of a parent before age 11

295
Q

which cancer has a high association with depression?

A

pancreatic cancer

296
Q

what fraction of patients with MDD ever receive tx?

A

half

297
Q

when is hospitalization indicated for MDD?

A

if patient is at risk for suicide, homicide, or unable to care for self

298
Q

how do antidepressants compare to eachother?

A

all antidepressants are equally effective but differ in side effect profiles

299
Q

how long do antidepressants take to work?

A

4-8 weeks

300
Q

which class of antidepressants is safer and better tolerated than other classes of antidepressants

A

SSRI

301
Q

what are the side effects of SSRIs?

A

headache • gastrointestinal disturbance • sexual dysfunction • rebound anxiety

302
Q

which SSRIs have activation of other neurotransmitters?

A

venlafaxine - effexor • duloxetine - cymbalta • bupropion - wellbutrin

303
Q

which class of antidepressants is most lethal in overdose?

A

TCAs

304
Q

what are the side effects of TCAs?

A

sedation, weight gain, orthostatic hypotension, anticholinergic effects

305
Q

TCA’s can aggravate which cardiac condition?

A

prolonged QTC syndrome

306
Q

MAOIs are useful in the treatment of what?

A

refractory depression

307
Q

when is there a risk of hypertensive crisis with antidepressants?

A

MAOIs + sympathomimetics or ingestion of tyramine rich foods

308
Q

when is there a risk of serotonin syndrome with antidepressants?

A

MAOIs + SSRIS

309
Q

what is the most common side effect of MAOIs?

A

orthostatic hypotension

310
Q

what is tyramine?

A

an intermediate in the conversion of tyrosine to NE

311
Q

what are the adjunct medications that can be added to antidepressants?

A

stimulants • antipsychotics (if psychotic features are present) • T4, lithium, L-tryptophan (to convert nonresponders to responders)

312
Q

what are the types of psychotherapy used to treat MDD?

A

behavioral • cognitive • supportive • psychoanalysis • family therapy

313
Q

when is ECT indicated?

A

if patient is unresponsive to pharmacotherapy, if patient cannot tolerate pharmacotherapy, or rapid reduction of symptoms is desired

314
Q

how is ECT performed?

A

premedication with atropine, followed by general anesthesia and administration of a muscle relaxant. a generalized seizure is then induced by passing a current of electricity across the brain. • seizure lasts <1min • - 8 treatments over 2-3 weeks

315
Q

patients who may not be able to tolerate the side effects include whom?

A

the elderly • pregnant women

316
Q

what is the general course of postpartum depression?

A

usually resolves without medication

317
Q

what are the side effects of ECT?

A

retrograde and anterograde amnesia, which usually disappears in 6 months • HA • nausea • muscle soreness

318
Q

40-60% of hospitalized pts with MDD have what feature?

A

melancholic

319
Q

melancholic MDD is characterized by what?

A

anhedonia • early morning awakening • psychomotor disturbance • excessive guilt • anorexia

320
Q

atypical MDD is characterized by what?

A

hypersomnia • hyperphagia • reactive mood • leaden paralysis • hypersensitivity to interpersonal rejection

321
Q

catatonic type MDD features include what?

A

catalepsy • purposeless motor activity • extreme negativism or mutism • bizarre postures • echolalia

322
Q

which unique type of MDD is especially responsive to ECT?

A

catatonic

323
Q

what fraction of hospitalized depressions is psychotic type?

A

10-25%

324
Q

the catatonic type of major depression is usually treated with what?

A

antidepressants and antipsychotics concurrently

325
Q

normal bereavement should not include what?

A

gross disorganization or suicidality

326
Q

what is the kubler-ross model of grief?

A

denial • anger • bargaining • depression • acceptance

327
Q

features of normal grief?

A

illusions are common but suicidal thoughts are rare. • symptoms last < 2mo • mild cognitive disorder lasts < 1 year • can be treated with mild BZDs for sleep

328
Q

what must you always include in your differential of a psychotic patient?

A

bipolar

329
Q

bipolar I disorder involves what?

A

episodes of mania and major depression

330
Q

what is rapid cycling?

A

> 4 mood episodes in 1 year

331
Q

what is the only requirement for the diagnosis of bipolar 1 disorder?

A

one manic or mixed episode

332
Q

what percent of patients with bipolar I only experience manic episodes?

A

10-20%

333
Q

what is the lifetime prevalence of bipolar I disorder is what?

A

1%

334
Q

what is the gender predilection for bipolar I disorder?

A

M=F

335
Q

what is the ethnic predilection for bipolar I disorder?

A

no ethnic differences seen

336
Q

when is the onset of bipolar I disorder?

A

before 30 yo

337
Q

what is the genetic risk for family members of patients with bipolar I?

A

first degree relatives are 8-18 times as likely to develop the illness • MZT=40-70% • DZT=5-25%

338
Q

which disorder has the highest genetic link of all the psychiatric disorders?

A

Bipolar I

339
Q

untreated manic episodes last about how long?

A

3mo

340
Q

what is the typical course of BpID?

A

usually chronic with relapses; as the disease progresses, episodes may occur more frequently

341
Q

what percent of individuals after one manic episode with have a repeat manic episode in 5 years?

A

90%

342
Q

which has a worse prognosis, MDD or BpID?

A

BpID

343
Q

what helps to ↓ risk of relapse in BpID?

A

lithium prophylaxis between episodes

344
Q

what % of people with BpID attempt suicide?

A

25-50%

345
Q

what % of patients with BpID die of suicide?

A

15%

346
Q

rate of suicide is higher in BpID or MDD?

A

BpID

347
Q

what are the side effects of lithium?

A
  1. ↑weight • 2. tremor • 3. GI disturbance • 4. fatigue • 5. cardiac arrhythmias • 6. seizures • 7. goiter/↓thyroid • 8. leukocytosis (benign) • 9. coma • 10. polyuria ( nephrogenic DI) • 11. alopecia • 12. metallic taste
348
Q

what is the best treatment for a manic woman in pregnancy?

A

ECT • - good alternative to antipsychotics • - can be used with relative safety in all trimesters

349
Q

typical treatment for bipolar disorder includes what?

A

lithium, carbamazipine (for rapid cyclers) valproic acid

350
Q

a patient with a history of pospartum mania should be treated with what in subsequent pregnancies as prophylavis?

A

antidepressants and lithium • - BUT relative contraindications to breast feeding

351
Q

what 4 classes of drugs are the mainstays of pharmacotherapy for BpID?

A
  1. Lithium • 2. Anticonvulsants • 3. Atypical antipsychotics • 4. Antidepressants

► Med Notes (62 decks)

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