Psychiatry Clerkship_1 Flashcards
what is the effect of NSAIDs on lithium levels?
NSAIDs ↓ lithium excretion → ↑ lithium concentrations • (except sulindac and aspirin)
psychomotor retardation is AKA what?
hypokinesia or bradykinesia
when is the term akinesia used?
in extreme cases where an absence of movement is observed
what are automatisms?
involuntary movements that occur during an altered state of consciousness and can range from purposeful to disorganized
what does pressured speech look like?
it is usually uninterruptible and the patient is compelled to continue speaking
proverb interpretation is helpful in assessing what?
whether a patient has difficulty with abstraction
vocabulary testing is useful for what?
a person’s intellectual capacity
a patient who is laughing one second and crying the next has what type of affect?
labile affect
when assessing appearance, what must you take special notice of?
- 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
what are the dimensions of speech assessment?
rate • rhythm • articulation • accent/dialect • modulation • long or short latency
what are the parameters of speech rate?
pressured • slowed • regular
what is a parameter for speech rhythm?
prosody
what is a parameter for speech articulation?
stuttering
what are the parameters for speech modulation?
loudness or softness
what are the dimensions for describing a patient’s affect?
quality • motility • appropriateness to content
what is the quality of affect?
depth and range of feelings shown
what are the parameters of quality of affect?
flat (none) • blunted (shallow) • constricted (limited) • full (average) • intense (more than normal)
what is motility of affect?
how quickly a person appears to shift emotional states
what are the parameters for motility of affect?
sluggish • supple • labile
what is described by appropriateness to content of affect?
whether the affect is congruent with the subject of conversation • parameters: appropriate– not appropriate
a patient who giggles while telling you that he set his house on fire and is facing serious charges has what type of affect?
inappropriate
a patient who remains expressionless and monotone even when discussing extremely sad or happy moments has what type of affect?
flat affect
what are the disorders of thought process?
- loosening of associations • 2. flight of ideas • 3. neologisms • 4. word salad • 5. clang associations • 6. thought blocking • 7. tangientiality • 8. circumstantiality
what is loosening of associations?
no logical connection from one thought to another
what is flight of ideas?
thoughts change abruptly from one idea to another, usually accompanied by rapid pressured speech
what are neologisms?
made up words
what is word salad?
incoherent collection of words
what are clang associations?
word connections due to phonetics rather than actual meaning
what is thought blocking?
abrupt cessation of communication before the idea is finished
what is tangentiality?
point of conversation never reached due to lack of goal directed associations between ideas; responses usually in the ballpark
what is circumstantiality?
point of conversation is enventually reached but with overinclusion of trivial or irrelevant details
what are the disorders of thought content?
- poverty of thought versus overabundance • 2. delusions • 3. suicidal and homicidal thoughts • 4. phobias • 5. obsessions • 6. compulsions
what is poverty of thoughts vs overabundance?
too few vs too many ideas expressed
what are delusions?
fixed, false beliefs that are not shared by the person’s culture and cannot be changed by reasoning
how are delusions classified?
bizarre • nonbizarre
what are phobias?
persistent irrational fears
what are obsessions?
repetitive intrusive thoughts
what are compulsions?
repetitive behaviors
what are examples of delusions?
- grandeur • 2. paranoid • 3. reference • 4. thought broadcasting • 5. religious • 6. somatic
what are delusions of grandeur?
belief that one has special powers or is someone important
what are paranoid delusions?
belief that one is being persecuted
what are reference delusions?
belief that some event is uniquely related to the patient (TV show is sending messages to the pt…etc)
what is a thought broadcasting delusion?
belief that one’s thoughts can be heard by others
what is a religious delusion?
conventional beliefs are exaggerated (jesus talks to me…etc)
what are somatic delusions?
false belief concerning body image
what is a question to use when screening for compulsions?
do you clean, check or count things repetitively?
what are hallucinations?
sensory perception that occurs in the absence of an actually stimulus
what are the major things to document about hallucinations?
sensory modality • details • if hypnogogic or hypnopompic
what are illusions?
inaccurate perception of existing sensory stimuli
what type of hallucination is an important risk factor for suicide or homicide?
auditory hallucination that instructs a patient to harm himself or others
what are the ways in which sensorium and cognition are assessed?
- consciousness • 2. orientation • 3. calculation • 4. memory • 5. fund of knowledge • 6. attention/concentration • 7. reading/writing • 8. abstract concepts
what are the possible ranges of a patient’s consciousness?
alert - drowsy - lethargic - stuporous - coma
what are the parameters of a patient’s orientation?
person • place • time
what are the parameters of measuring a patient’s calculation?
ability to add/substract
what are the 3 dimensions of assessment of a patient’s memory?
immediate (registration) • recent (short term) • remote (long term)
what is immediate memory/registration and how is it assessed?
dependent on attention/concentration and can be tested by asking a patient to repeat several digits or words
what is recent/short term memory?
events within the past few hours or days
what is fund of knowledge?
level of knowledge in the context of the patient’s culture and education
how is attention/concentration assessed?
ability to subtract serial 7’s from 100 or to spell WORLD backwards
how is reading/writing assessed?
simple sentences (make sure patient is literate)
how are abstract concepts assessed?
ability to explain similarities between objects and understand the meaning of simple proverbs
what is a patient’s insight?
the patient’s level of awareness and understanding of their problem
problems with insight include what?
complete denial of illness or blaming it on something else
how is insight described?
full • partial/limited • none
what is a patient’s judgement?
the patient’s ability to understand the outcome of their actions and use this awareness in decision making
how can judgement be described?
excellent • good • fair • poor
alcoholic hallucinosis refers to what?
hallucinations (usually visual, though possibly auditory or tactile) that develop within 12-24 hours of abstinence from etoh and resolve within 24-48 hours
how is alcoholic hallucinosis different from DTs?
in alcoholic hallucinosis there is no clouding of sensorium and vital signs are normal
what are the areas tested in the MMSE?
orientation • memory • concentration and attention • language • reading and writing • visuospatial ability
what is the general approach to the violent patient?
- 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)
what is the general approach to the delusional patient?
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
what is the general approach to the depressed patient?
offer reassurance that they can improve with appropriate therapy. inquire about suicidality → hospitalize if planning or contemplating
what are signs of increased suicide risk in a depressed patient?
feeling of hopelessness • substance abuse • hx of prior attempt
what is the most important predictor of future violence?
a prior history of violence
what is the DSM IV multiaxial classification system for diagnoses?
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
what is the GAF criterion for hospitalization?
<30
features of a GAF 1-10?
- 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
features of GAF 11-20?
- 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
features of GAF 21-30?
- 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
features of GAF 31-40?
- 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
features of GAF 41-50?
- 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
features of GAF 51-60?
- moderate symptoms: • — flat affect and circumstantial speech, occasional panic attacks • 2. moderate difficulty in social, occupational, or school functioning: • — few friends, conflicts with coworkers
features of GAF 61-70?
- 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
features of GAF 71-80?
- 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
features of GAF 81-90?
- 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
features of GAF 91-100?
- 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
what is the Minnesota Multiphasic Personality Inventory?
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
what is the Wechsler Adult Intelligence Scale (WAIS)?
- MC test for ages 16-75 • 2. Assesses overall intellectual functioning • 3. Two Parts: verbal and visuo-spatial
what is the stanford binet test?
tests intellectual ability in patients ages 2-18
what is the Thematic Apperception Test?
- test taker creates stories based on pictures of people in various situations • - used to evaluate motivations behind behaviors
what is the Rorschach test?
- interpretation of ink blots • - used to identify thought disorders and defense mechanisms
what is a very superior IQ?
> 130
what is a superior IQ?
120-129
what is a high average iq?
110-119
what is an average iq?
90-109
what is a borderline iq?
70-79
what is an iq consistent with mild MR?
50-70
what is an iq consistent with moderate MR?
35-49
what is an iq consistent with severe MR?
25-34
what is an iq consistent with profound MR?
<2
what is psychosis?
a general term used to describe a distorted perception of reality
psychosis can be a symptom of what?
schizophrenia • mania • severe depression • can be substance induced
hallucinations and delusions are also frequently observed in what?
delirium and dementia
psychosis is exemplified by what?
either delusions, hallucinations, or severe disorganization of thought/behavior
what is a nonbizarre delusion?
a belief that could be true but isn’t
what is a bizarre delusion?
a false belief that is impossible
what are the types of delusions of control?
thought broadcasting and thought insertion
what are delusions of guilt?
false belief that one is guilty or responsible for something
auditory hallucinations that directly tell the patient to perform certain acts are called what?
command hallucinations
which hallucinations are most commonly exhibited by schizophrenics?
auditory
with which conditions are visual hallucinations common?
less common with schizophrenia • may accompany drug intoxication, drug and alcohol withdrawal, or delirium
with which conditions are olfactory hallucinations common?
usually an aura associated with epilepsy
with which conditions are tactile hallucinations common?
usually secondary to drug abuse or alcohol withdrawal
what is the differential diagnosis of psychosis?
- 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
what are the medical causes of psychosis?
- CNS disease • 2. endocrinopathies • 3. nutritional/vitamin deficiency states • 4. other
what are the CNS diseases that cause psychosis?
- 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
what are the endocrinopathies that cause psychosis?
- addison/cushing • 2. hyper/hypothyroid • 3. hyper/hypocalcemia • 4. hypopituitarism
what are the nutritional/vitamin deficiency states that cause psychosis?
- B12 • 2. folate • 3. niacin
what are the other general medical conditions that cause psychosis?
- connective tissue disease • -SLE • - temporal arteritis • 2. porphyria
what are the DSM IV criteria for psychotic disorder secondary to a general medical condition?
- 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
what are the prescription medications that may cause psychosis in some patients?
- corticosteroids • 2. antiparkinson • 3. anticonvulsants • 4. antihistamines • 5. anti-cholinergics • 6. antihypertensives • - β blockers • 7. digitalis • 8. ritalin • 9. fluoroquinolones
what are the drugs of abuse that cause psychosis?
- etoh • 2. cocaine • 3. LSD, MDMA • 4. MJ • 5. BZD • 6. barbiturates • 7. PCP
what are the DSM IV criteria for diagnosis of medication/substance-use induced psychosis?
- 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
how long must a patient have symptoms to be diagnosed with schizophrenia?
6mo
what is the important workup for patient with symptoms of schizophrenia?
TSH • RPR • brain imaging
what are the positive symptoms of schizophrenia?
hallucinations • delusions • bizarre behavior • disorganized speech
what are the negative symptoms of schizophrenia?
blunted affect • anhedonia • apathy • alogia • lack of interest in socialization
what are the cognitive symptoms of schizophrenia?
impairments in attention, executive function and working memory
negative symptoms of schizophrenia contribute significantly to which problem?
social isolation of schizophrenic patients
cognitive symptoms of schizophrenia contribute significantly to what?
poor work and school performance
which symptoms of schizophrenia respond more robustly to the current antipsychotic medications?
positive symptoms
what signs are seen in catatonic schizophrenic patients?
stereotyped movement • bizarre posturing • muscle rigidity
what drug is considered when a schizophrenic patient fails both typical and atypical antipsychotics?
clozapine
symptoms of schizophrenia usually present in what phases?
- prodromal • 2. psychotic • 3. residual
what is the prodromal phase of schizophrenia?
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
what is the psychotic phase of schizophrenia?
perceptual disturbances, delusions, and disordered thought process/content
what is the residual phase of schizophrenia?
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
what are the DSM IV criteria for diagnosis of schizophrenia?
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
when is only one of the major symptoms of schizophrenia necessary for diagnosis?
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
what are the 5 A’s of schizophrenia?
negative symptoms: • 1. Anhedonia • 2. Affect- flat • 3. Alogia- poverty of speech • 4. Avolition - apathy • 5. Attention- poor
which subtype of schizophrenia is higher functioning with an older age of onset?
paranoid type
which type of schizophrenia is the poor functioning early onset subtype?
disorganized type
which type of schizophrenia is most rare?
catatonic type
for a patient to have paranoid type schizophrenia, they must meet which criteria?
- preoccupation with one or more delusions or frequent auditory hallucination • 2. no predominance of disorganized speech, disorganized or catatonic behavior, or inappropriate affect
for a patient to be diagnosed with disorganized type schizophrenia they must meet which criteria?
- disorganized speech • 2. disorganized behavior • 3. flat or inappropriate affect
for a patient to be diagnosed with catatonic type schizophrenia, which criteria must be met?
> 2: • 1. motor immobility • 2. excessive purposeless motor activity • 3. extreme negativism or mutism • 4. peculiar voluntary movements or posturing • 5. echolalia or echopraxia
paranoid type schizophrenia is characterized by what?
delusions and auditory hallucinations
disorganized type schizophrenia is characterized by what?
disorganized speech, behavior, and flat or inappropriate affect
catatonic type schizophrenia is characterized by what?
rigid posture • inappropriate or repetitive and purposeless movements • echolalia • echopraxia
residual type schizophrenia is characterized by what?
prominent negative symptoms
undifferentiated type schizophrenia is characterized by what?
doesn’t fulfill any of the other criteria
brief psychotic disorder lasts how long?
<1mo
schizophreniform disorder lasts how long?
1-6 mo
schizophrenia lasts how long?
> 6mo
the typical findings in schizophrenic patients on exam include what?
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
what is the effect of birthdate and schizophrenia?
people born in winter and early spring have a higher incidence of schizophrenia • - second trimester exposure to viral infection like influenza
what is the socioeconomic predominance of schizophrenia?
found in lower socioeconomic groups due to downward drift- have difficult holding onto job so they drift down socioeconomic ladder
schizophrenia affects what % of people over their lifetime?
1%
what is the difference in gender presentation of schizophrenia?
men: • - present 20yo • - more negative symptoms • - more impaired social functioning • women: • - present @ 30yo
what is the typical age range for presentation of schizophrenia?
rarely presents before 15 or after 55
what is the strength of the genetic predisposition to schizophrenia?
50% MZ twins • 40% risk of inheritance if both parents affected • 12% risk if first degree relative
what is the incidence of substance abuse in schizophrenia?
etoh- 30-50% • MJ- 15-20% • cocaine- 5-10%
what is postpsychotic depression?
the phenomenon of schizophrenic patients developing a major depressive disorder after resolution of their psychotic symptoms
what is akathisia?
an unpleasant, subjective sense of restlessness often manifested by the inability to sit still
what are the theorized dopamine pathways affected in schizophrenia?
prefrontal cortical • mesolimbic
what is the role of the prefrontal cortical dopamine pathway in schizophrenia?
inadequate dopaminergic activity responsible for negative symptoms
what is the role of the mesolimbic dopamine pathway in schizophrenia?
excessive dopaminergic activity responsible for positive symptoms
what are the other important dopamine pathways affected by neuroleptics?
- tuberoinfundibular • 2. nigrostriatal
what is the effect of neuroleptics on the tuberoinfundibular dopamine pathway?
blocked by neuroleptics, causing hyperprolactinemia, which may → gynecomastia, galactorrhea, menstrual irregularity
what is the effect of neuroleptics on the nigrostriatal dopamine pathway?
blocked by neuroleptics, causing EPS side effects such as tremor, slurred speech, akathisia, dystonia, and other abnormal movements
what are the other neurotransmitter abnormalities implicated in schizophrenia?
↑ serotonin • ↑ NE • ↓ GABA • ↓ level of glutamate receptors
which neuroleptics affect the ↑ serotonin in schizophrenia?
some of the atypical antipsychotics (such as risperidone and clozapine) antagonize serotonin and weakly antagonize DA
how do neuroleptics relate to the ↑ NE seen in schizophrenia?
long term use of antipsychotics has been shown to ↓ activity of noradrenergic neurons
how does ↓ GABA relate to schizophrenia?
there is ↓ expression of the enzyme necessary to create GABA in the hippocampus of schizophrenic patients
how do ↓ levels of glutamate receptors relate to schizophrenia?
schizophrenic patients have fewer NMDA receptors; this correlates with the psychotic symptoms observed with NMDA antagonists like ketamine
CT of patients with schizophrenia may show what?
enlargement of the ventricles and diffuse cortical atrophy
significant improvement is noted in what % of schizophrenics who take antipsychotic medications?
70%
what physical impairment is a predisposing factor to paranoid psychosis?
deafness
what % of schizophrenics remain significantly impaired after diagnosis?
40-50%
what % of schizophrenics function fairly well in society with medication?
20-30%
what % of schizophrenics attempt suicide?
50%
what factors are associated with a better prognosis in patients with schizophrenia?
- 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
which factors are associated with a worse prognosis in patients with schizophrenia?
- 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
- which drugs are the first generation antipsychotics?
- chlorpromazine- Thorazine • 2. thioridazine- Mellaril • 3. trifluoperazine- Stelazine • 4. haloperidol- Haldol
what is the MOA of the first generation antipsychotics?
dopamine (mostly D2) receptors
against what are the first generation antipsychotics effective?
most effective against positive symptoms with minimal impact on negative symptoms
what are the side effects of first generation antipsychotics?
extrapyramidal symptoms • neuroleptic malignant syndrome • tardive dyskinesia
which drugs are the second generation antipsychotics?
- risperidone- risperdal • 2. clozapine- Clozaril, FazaClo • 3. olanzapine- Zyprexa • 4. quetiapine- Seroquel • 5. aripiprazole- Abilify • 6. ziprosidone- Geodon
what is the MOA of the second generation antipsychotics?
these antagonize 5-HT2 receptors as well as DA receptors
what is the difference in efficacy between 1st and 2nd generation antipsychotics?
originally believed to be more effective that older antipsychotic medications, current research has shown no significant difference between 2 groups in treating NEGATIVE symptoms
what is the difference between the side effects of 2nd generation antipsychotics and 1st?
2nd have much lower incidence of EPS, but are now known to ↑ risk of metabolic syndrome
how long should 2nd generation antipsychotics be taken before efficacy is determined?
4 weeks
why is clozapine reserved for medically refractory patients?
due to ↑ risk of agranulocytosis
schizophrenic patients on atypical antipsychotics need a careful medical evaluation for what?
metabolic syndrome: • waist circumference • BMI • fasting glucose • lipids • BP
side effects of antipsychotic medications include what?
- 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
you get EPS especially with what drugs?
high potency traditional antipsychotics
what are the high potency traditional neuroleptics?
haloperidol • trifluoperazine
what symptoms make up EPS?
- dystonia (spasms) of face neck and tongue • 2. parkinsonism (resting tremor, rigidity, bradykinesia) • 3. akathisia
what is the treatment for EPS?
- antiparkinsonian agents • - benztropine, diphenhydramine • 2. BZD • 3. β blockers (specifically indicated for akathisia
which neuroleptics are more likely to cause anticholinergic symptoms?
low potency traditional antipsychotics and atypical antipsychotics
what are the low potency first gen neuroleptics?
chlorpromazine • thioridazine
what are the anticholinergic symptoms associated with antipsychotics?
dry mouth • constipation • blurred vision
what are the treatments for neuroleptic induced anticholinergic side effects?
as per symptoms- eye drops, stool softeners, etc
which types of neuroleptics are more likely to cause metabolic syndrome?
second generation antipsychotics
what is the treatment for neuroleptic induced metabolic syndrome?
- 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
what type of neuroleptics cause tardive dyskinesia?
high potency antipsychotics
what is tardive dyskinesia?
darting or writhing movements of the face, tongue, and head
what is the treatment for tardive dyskinesia?
d/c or ↓ offending agent and consider substituting an atypical antipsychotic. • BZD, β blockers, cholinomimetics can be used in the short term
what is the prognosis of tardive dyskinesia?
the movements often persist despite withdrawal of the offending agent
can atypical antipsychotics cause tardive dyskinesia ?
less commonly, but yes in some patients
what types of drugs cause NMS?
high potency antipsychotics
what is Neuroleptic malignant syndrome?
change in mental status • autonomic changes • lead pipe rigidity • sweating • ↑ CPK • leukocytosis • metabolic acidosis
what are the autonomic changes seen in NMS?
high fever • ↑BP • ↑HR
how serious is NMS?
a medical emergency that requires prompt withdrawal of all antipsychotic meds and immediate medical assessment and treatment
who can get NMS?
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
who is at a higher risk for NMS?
patients with a hx of NMS are at ↑ risk of recurrence
what are the symptoms of neuroleptic induced hyperprolactinemia?
gynecomastia, galactorrhea, amenorrhea, diminished libido, impotence
what are the hematologic effects to look out for with antipsychotic administration?
agranulocytosis may occur with clozapine, must get weekly CBC
what are the neuroleptic induced ophthalmic conditions?
- thioridazine may cause irreversible retinal pigmentation at high doses • 2. chlorpromazine can cause deposits in the lens and cornea
what are the dermatologic conditions that can occur with neuroleptic use?
rashes and photosensitivity
In which patients does tardive dyskinesia occur most often?
women after >6mo of medication
what % of patients with tardive dyskinesia see spontaneous recovery?
50%
which cardiac drugs are known to exacerbate psychosis in predisposed patients?
β blockers and digoxin
what percentage of long term hospitalized patients treated with antipsychotics end up with tardive dyskinesia?
20%
what is the prognosis for schizophreniform disorder?
1/3 recover completely • 2/3 progress to schizoaffective disorder or schizophrenia
what is the treatment for schizophreniform disorder?
hospitalization, 3-6 month course of antipsychotics, and supportive psychotherapy
if a schizophrenia presentation has not been present for 6 months, think what?
schizophreniform disorder
what are the DSM IV criteria for diagnosis of schizoaffective disorder?
- 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
what is the prognosis for schizoaffective disorder?
60-80% will progress to schizophrenia
what is the treatment for schizoaffective disorder?
- hospitalization and supportive psychotherapy • 2. medical therapy: antipsychotics and mood stabilizers; antidepressants or ECT may be indicated for tx of mood sx
does borderline personality disorder count as a brief psychotic episode?
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
what are the DSM IV criteria for diagnosis of brief psychotic disorder?
- 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
how common is brief psychotic disorder?
rare, much less common than schizophrenia
when might one expect to see brief psychotic disorder?
reaction to extreme stress such as bereavement, sexual assault, etc
what is the prognosis for brief psychotic disorder?
50-80% recovery rate • 20-50% may eventually be diagnosed with schizophrenia or mood disorder
what is the tx for brief psychotic episode
brief hospitalization • supportive psychotherapy • course of antipsychotics for psychosis itself • +/- BZDs for agitation
delusional disorder occurs more often in whom?
older patients > 40yo • immigrants • hearing impaired
what are the DSM IV criteria for diagnosing mood disorder?
- nonbizarre fixed delusions >1 mo • 2. does not meet criteria for schizophrenia • 3. functioning in life not significantly impaired
what are the types of delusions seen in delusional disorder?
- erotomantic type • 2. grandiose type • 3. somatic type • 4. persecutory type • 5. jealous type • 6. mixed type
what is the prognosis for delusional disorder?
50% full recovery • 20% ↓ sx • 30% no Δ
what is the tx for delusional disorder?
psychotherapy may be helpful • try antipsychotics even though they tend not to be effective (high potency or atypical)
what is shared psychotic disorder?
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
what is the prognosis for folie a deux?
20-40% recover upon removal from the inducing person
what is the treatment for shared psychotic disorder /folie a deux?
- separation • 2. antipsychotics if separation doesn’t resolve delusion in 1-2 weeks
what is koro?
patient believes that his penis is shrinking and will disappear causing his death
koro is unique to what culture?
asia
what is amok?
sudden unprovoked outbursts of violence of which the person has no recollection. person often commits suicide after.
amok is unique to which region/culture?
southeast asia /malaysia
what is brain fag?
headache, fatigue, and visual disturbance in male students
brain fag is unique to which region/culture?
africa
what is the prognosis of the psychotic disorders in order of best to worst?
mood disorder > brief psychotic disorder > schizoaffective > schizophreniform > schizophrenia
list the ‘schiz’ disorders and they differentiating feature
- 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
which of the ‘schiz’ disorders are personality disorders?
schizotypal and schizoid
what are mood episodes?
distinct periods of time in which some abnormal mood is present: • - depression • - mania • - mixed state • - hypomania
mood disorders include which diseases?
major depressive disorder • bipolar I • bipolar II • dysthymic disorder • cyclothymic disorder
when patients have delusions and hallucinations caused by mood disorders, they are usually what?
mood congruent
what type of psychosis is induced by depression?
paranoia and worthlessness
what type of psychosis is induced by mania?
grandiosity and invincibility
what are the DSM IV criteria for the diagnosis of MDE?
> 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
what are the symptoms of major depression?
SIG E CAPS • Sleep • Interest • Guilt • Energy • Concentration • Appetite • Psychomotor activity • Suicidal ideation
how serious is a manic episode?
psychiatric emergency; severely impaired judgement makes the patient dangerous to self and others
what are the symptoms of mania?
DIG FAST • Distractibility • Insomnia/Impulsivity • Grandiosity • Flight of Ideas • Activity/agitation • Speech (pressured) • Thoughtlessness
what are the DSM IV criteria for diagnosis of manic episode?
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
what % of manic patients have psychotic symptoms?
75%
what is a mixed episode?
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
what is a hypomanic episode?
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)
what is the difference between mania and hypomania?
- 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
what is the predominant mood state in mixed episodes?
irritability
patients in which mood episode have a poorer response to lithium?
mixed episode
what drugs may help in a mixed episode?
anticonvulsants
what are the medical causes of a depressive episode?
- 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)
what are the medical causes of a manic episode?
- metabolic (↑thyroid) • 2. neuro (temporal lobe seizure, MS) • 3. neoplasm • 4. HIV
what meds/substances induce depressive episodes?
- etoh • 2. antihypertensives • 3. barbiturates • 4. corticosteroids • 5. L-dopa • 6. sedative hypnotics • 7. anticonvulsants • 8. diuretics • 9. sulfonamides • 10. withdrawal from stimulants
which meds/substances induce mania?
- antidepressants • 2. sympathomimetics • 3. dopamine • 4. corticosteroids • 5. L-dopa • 6. bronchodilators
stroke patients are at very high risk of developing what mood disorder?
depression
what has the highest rate of suicide of any disorder?
MDD
what are the DSM-IV criteria for diagnosis of MDD?
> 1 MDE • 0 hx of manic/hypomanic episode
what is the lifetime prevalence of MDD in the USA?
16.20%
what is the average age of onset of MDD?
40
what is the gender predilection of MDD during reproductive years?
2x as prevalent in women
what is the gender predilection for MDD before menses and after menopause?
equal for men and women
what is the prevalence of MDD in the elderly?
25-50%
what is the effect of depression on mortality?
can ↑ mortality for patients with other comorbidities (DM, CVD)
what are the 2 most common sleep disturbances associated with MDD?
difficulty falling asleep and early morning waking
what are the sleep problems associated with MDD?
- multiple awakenings • 2. initial and terminal insomnia • 3. hypersomnia • 4. REM sleep shifted to earlier in night, and stages 3 & 4 ↓
what is the etiology of depression?
- 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
what is the genetic predisposition pattern in MDD?
first degree relatives 2-3x more likely to have MDD • MZT= 50-70% • DZT= 10-25%
what happens if MDE is untreated?
depressive episodes are self limiting but usually last 6-13 months
what is the pattern of MDE occurrence as MDD progresses?
epsiodes occur more frequently as disorder progresses
what percent of patients with MDD commit suicide?
15%
what % of patients with MDD respond to antidepressants?
50-60%
what combination can significantly ↑ response for severe and recurrent depression?
antidepressant + psychotherapy
what is the hamilton score?
standard measure of depression severity used in research to assess effectiveness of therapy
what life event is associated with developing MDD later?
loss of a parent before age 11
which cancer has a high association with depression?
pancreatic cancer
what fraction of patients with MDD ever receive tx?
half
when is hospitalization indicated for MDD?
if patient is at risk for suicide, homicide, or unable to care for self
how do antidepressants compare to eachother?
all antidepressants are equally effective but differ in side effect profiles
how long do antidepressants take to work?
4-8 weeks
which class of antidepressants is safer and better tolerated than other classes of antidepressants
SSRI
what are the side effects of SSRIs?
headache • gastrointestinal disturbance • sexual dysfunction • rebound anxiety
which SSRIs have activation of other neurotransmitters?
venlafaxine - effexor • duloxetine - cymbalta • bupropion - wellbutrin
which class of antidepressants is most lethal in overdose?
TCAs
what are the side effects of TCAs?
sedation, weight gain, orthostatic hypotension, anticholinergic effects
TCA’s can aggravate which cardiac condition?
prolonged QTC syndrome
MAOIs are useful in the treatment of what?
refractory depression
when is there a risk of hypertensive crisis with antidepressants?
MAOIs + sympathomimetics or ingestion of tyramine rich foods
when is there a risk of serotonin syndrome with antidepressants?
MAOIs + SSRIS
what is the most common side effect of MAOIs?
orthostatic hypotension
what is tyramine?
an intermediate in the conversion of tyrosine to NE
what are the adjunct medications that can be added to antidepressants?
stimulants • antipsychotics (if psychotic features are present) • T4, lithium, L-tryptophan (to convert nonresponders to responders)
what are the types of psychotherapy used to treat MDD?
behavioral • cognitive • supportive • psychoanalysis • family therapy
when is ECT indicated?
if patient is unresponsive to pharmacotherapy, if patient cannot tolerate pharmacotherapy, or rapid reduction of symptoms is desired
how is ECT performed?
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
patients who may not be able to tolerate the side effects include whom?
the elderly • pregnant women
what is the general course of postpartum depression?
usually resolves without medication
what are the side effects of ECT?
retrograde and anterograde amnesia, which usually disappears in 6 months • HA • nausea • muscle soreness
40-60% of hospitalized pts with MDD have what feature?
melancholic
melancholic MDD is characterized by what?
anhedonia • early morning awakening • psychomotor disturbance • excessive guilt • anorexia
atypical MDD is characterized by what?
hypersomnia • hyperphagia • reactive mood • leaden paralysis • hypersensitivity to interpersonal rejection
catatonic type MDD features include what?
catalepsy • purposeless motor activity • extreme negativism or mutism • bizarre postures • echolalia
which unique type of MDD is especially responsive to ECT?
catatonic
what fraction of hospitalized depressions is psychotic type?
10-25%
the catatonic type of major depression is usually treated with what?
antidepressants and antipsychotics concurrently
normal bereavement should not include what?
gross disorganization or suicidality
what is the kubler-ross model of grief?
denial • anger • bargaining • depression • acceptance
features of normal grief?
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
what must you always include in your differential of a psychotic patient?
bipolar
bipolar I disorder involves what?
episodes of mania and major depression
what is rapid cycling?
> 4 mood episodes in 1 year
what is the only requirement for the diagnosis of bipolar 1 disorder?
one manic or mixed episode
what percent of patients with bipolar I only experience manic episodes?
10-20%
what is the lifetime prevalence of bipolar I disorder is what?
1%
what is the gender predilection for bipolar I disorder?
M=F
what is the ethnic predilection for bipolar I disorder?
no ethnic differences seen
when is the onset of bipolar I disorder?
before 30 yo
what is the genetic risk for family members of patients with bipolar I?
first degree relatives are 8-18 times as likely to develop the illness • MZT=40-70% • DZT=5-25%
which disorder has the highest genetic link of all the psychiatric disorders?
Bipolar I
untreated manic episodes last about how long?
3mo
what is the typical course of BpID?
usually chronic with relapses; as the disease progresses, episodes may occur more frequently
what percent of individuals after one manic episode with have a repeat manic episode in 5 years?
90%
which has a worse prognosis, MDD or BpID?
BpID
what helps to ↓ risk of relapse in BpID?
lithium prophylaxis between episodes
what % of people with BpID attempt suicide?
25-50%
what % of patients with BpID die of suicide?
15%
rate of suicide is higher in BpID or MDD?
BpID
what are the side effects of lithium?
- ↑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
what is the best treatment for a manic woman in pregnancy?
ECT • - good alternative to antipsychotics • - can be used with relative safety in all trimesters
typical treatment for bipolar disorder includes what?
lithium, carbamazipine (for rapid cyclers) valproic acid
a patient with a history of pospartum mania should be treated with what in subsequent pregnancies as prophylavis?
antidepressants and lithium • - BUT relative contraindications to breast feeding
what 4 classes of drugs are the mainstays of pharmacotherapy for BpID?
- Lithium • 2. Anticonvulsants • 3. Atypical antipsychotics • 4. Antidepressants
