Psychiatry dx Flashcards
Definition of mania / bipolar disorder
Bipolar I- 1 manic episode
Bipolar II - hypomanic + MDD
Rapid cycling: 4 or more (MDE, manic, mixed, hypomanic) in 1 year
Cyclothymic - chronic less severe, alternating periods of hypomania and moderate depression >2 years
Manic criteria
A. Period of inc. expansive irritable mood, goal oriented activity + >1/52 of hospitalisation
B. > 3 of the following
DIGFAST
Distractability Indiscretion (sprees, promiscuous) Grandiosity / self esteem Flight of ideas / racing thoughts Activities Inc, psychomotor agitation Sleep deficit (3hours enough) Talkativeness/ pressured speech
C. Severe enough to affect function, hospitalisation, psychotic fit
D. X due to substance or medical condition
Hypomania - no marked functional impairment and no hospitalisation
Treatment: Bipolar mania is an emergency
- Acute therapy: antipsychotics, lithium, valproate
- Maintenance : mood stabilizer
- Benzodiazepines for refractory agitation
Bipolar depression : mood stabilizer with/out antidepressant
Start mood stabilizers first
NB: Antidepressant use without mood stabilizer may trigger manic episode.
Ddx of mania
Major depressive disorder Anxiety disorder GAD, PD, PTSD, other anxiety Personality disorder - borderline ADHD Substance medication induced
Definition of schizophrenia
HDNCD more than 2/5 (of which is H/D) and more than 6 months
Hallucinations Delusions Negative symptoms - 5As Catatonic/ disorganised behaviour Disorganised speech
And 1/12 active Sx w social/occupational deterioration NOT attributable to another condition
Treatment: antipsychotics and long term follow up. Supportive psychotherapy, training in social skills, rehabilitation. -ve symptoms, use atypical antipsychotics
Negative symptoms of schizophrenia (5xAs)
Affect - flat Alogia- poverty of speech Avolition - lack of motivation to start things Anhedonia - lack of interest Attention
Definition of depression
A. 2 weeks of depressed mood or anhedonia + 5 or more symptoms from the 9
SIGEDCAPS Sleep (hypersomnia or insomnia) Interest low Guilt/ worthlessness Energy low Concentration Appetite weight up/down (^ >5% /12) Psychomotor agitation or retardation Suicidal ideation \+ Depressed mood
B. Sx cause significant distress or impairment of function
C. Not attributable to physiological effects of substance/ other condition
Generally worse in the morning - early morning weakening. Diurnal variation
Treatment:
- Pharmacotherapy is effective in 50-70% of pt. Allow 2-6 weeks to take effect.
- Psychotherapy combined with antidepressants is more effective than either treatment alone
- ETC: safe highly effective for refractory depression or psychotic depression, rapid improvement needed or intractable mania. 2-3x/week. 6-12 treatments. A/E: postictal confusion, arrhythmia, headache, anterograde amnesia.
Comorbidities of depression - SADP
Somatisation and pain disorders
Anxiety disorder
Drug alcohol abuse or dependence
Personality disorder (borderline)
Definition of adjustment disorder
Onset <3 months of trigger, and resolving <6 months
Ddx of depression -MAD DSM
MEDICAL - endocrine/neuro/other- HIV
- hypothyroidism, Parkinson’s, CNS neoplasm, stroke(ACA), dementia, parathyroid disorder
ADJUSTMENT Disorder (mood disorder)
- constellation of sx match MDE but do not meet criteria. Within 3 months of stressor.
DRUG induced- COBI (CS/OCP/BB/IFA)
DYSTHYMIA. - milder chronic depression with depressed mood most of the time for at least 2 years, resistant to treatment often
SADNESS/ grief - occurs after loss of loved one. Usually <6 months. Should resolve within 1 year. May progress to MDD.
MANIC episodes with irritable mood
Characteristics of schizophrenia + Etiology + Epi
Psychotic symptoms (hallucinations, bizarre delusions) Disorganization (thought disorder, behavioural disturbance) and Negative symptoms (poverty of affect, thought and social interaction )
Epidemiology: prevalence 1%, peak onset earlier in men (18-25) and women (25-35). Men women equally affected
Etiology: Neurotransmitter abnormalities, such as dopamine dysregulation ( frontal hyperactivity and limbic hyperactivity) and brain CT and MRI (enlarged ventricles and decrease cortical volume)
Differential diagnosis of psychosis
- Psychotic disorder:
-Brief psychotic disorder: >1 day <1 month
-Schizophreniform disorder: >1 months and <6 months
(Both have the same presentation as schizophrenia but are likely preceded by stressors, no prior episodes, less -ve symptoms, better prognosis)
-Schizophrenia: >6 months
-Schizoaffective disorder: Schizophrenia + major affective disorder (major depressive disorder or bipolar affective disorder) - Personality disorder
- Schizotypal = magical thinking
- schizoid = loners - Delusional disorder
Persistent non bizarre fixed delusions without disorganized thought process, hallucinations, or negative symptoms. Day to day functioning unaffected
Definitions of delusion, hallucination, illusion
Delusion = fixed false belief (not standing with cultural/religious grounds) Hallucination = perceptions without an existing external stimulus Illusion = misperceptions of an actual external stimulus
What are the two main types of Antipsychotic medications - and under typical what two levels are there?
Typical antipsychotics:
- high potency = haloperidol, fluphenazine
- low potency = thioridazine, chlorpromazine
(MOA: primarily D2 dopamine receptor antagonists, effective for +ve symptoms of schizophrenia)
Atypical antipsychotics
- risperidone, quetiapine, olanzipine, aripiprazole, clozapine
Currently FIRST LINE FOR SCHIZOPHRENIA (fewer EPS + anti cholinergic effects) clozapine reserved for severe treatment resistance and severe tardive dyskinesia
Definition of OCD vs OCPD
Obsessive Compulsive disorder: characterized by obsession and/or compulsions. Patients RECOGNISE their obsesssion/compulsion and want to be rid of them (ego dystonic)
Obsessive Compulsive Personality Disorder: patients are excessive conscientious and inflexible. Patients DO NOT RECOGNISE their behaviour as problematic (ego syntonic)
Obsessions vs compulsions
Obsessions: persistent, UNWANTED INTRUSIVE IDEAS, thoughts, impulses or images that lead to marked anxiety or distress. (Fear of contamination, fear of harm to self)
Compulsion: REPEATED MENTAL ACTS or behaviours that neutralize anxiety from obsession. (Hand washing, rituals for ordinary tasks, counting, checking)
Definition of generalized anxiety disorder
Uncontrollable, excessive anxiety or worry about multiple activities or events that lead to significant impairment or distress on most days (6 OR MORE MONTHS) and with THREE OR MORE somatic symptoms - restlessness - fatigue - difficulty concentrating -irritability - muscle tension - disturbed sleep (
Treatment:
Short term - benzo for immediate Sx relief, taper off.
Long term - lifestyle change, psychotherapy, SSRI first line, venlafaxine, buspirone.
Definition of Panic attacks
Discrete periods of INTENSE FEAR or DISCOMFORT in which at least FOUR of the following symptoms develop abruptly and peak within 10 minutes. - tachypnea - chest pain - palpitations -diaphoresis - nausea - trembling -dizziness -FEAR OF DYING or ''going crazy'' - depersonalizations - hot flashes Perioral/a real paraesthesia is specific to panic attacks.
Patients present with ONE OR MORE MONTH of concern about having additional attacks or significant behaviour change as a result of the attacks - e.g. Avoiding situations that may precipitate attacks.
Determine if panic disorder is with/out agoraphobia - can address in treatment plan.
Treatment; Short term benzodiazepines taper off. Long term - CBT and medication (SSRI 1st line, TCA)
Definition of phobias - social and specific
Excessive or unreasonable fear and/or avoidance of an object or situation that is PERSISTENT and leads to significant DISTRESS/IMPAIRMENT in function. Pt recognizes that fear is excessive.
Social phobia: marked fear provoked by social or performance situations in which embarrassment may occur. Treatment: CBT, SSRI, low dose benzo or Beta blockers.
Specific phobia: anxiety is provoked by exposure to a feared object or situation (animal, heights, airplanes) begin in childhood. Treatment: CBT desensitization, incremental exposure, supportive, family oriented psychotherapy.
Dx and treatment of PTSD
Significant stress or impairment in day to day social/work interaction due to the result of DIRECT EXPOSURE to an extreme, LIFE THREATENING TRAUMATIC EVENT (assault, combat, accident, rape), WITNESSING a traumatic event, INDIRECT EXPOSURE through learning of a life threatening event involving family/friend, or RE- EXPOSURE to trauma related events through occupation.
Characterized by the following 4 symptom clusters
- Intrusion: reexperiencing the event through nightmares, flashback
- Avoidance: of stimuli associate with trauma
- Negative alterations in mood/cognition: Numbed responsiveness (detachment/anhedonia), guilt, self blame
- Change in arousal and reactivity - increase arousal(hypervigilance, exaggerated startle), sleep disturbance, aggression/irritable, poor concentration
Symptoms must persist for >1 month. (If for 3 days to 1 month, acute stress disorder)
Treatment:
Short term - BB and A2 agonist - clonidine
Long term- SSRI, TCA and MAOI.
Psychotherapy. And support groups
Dementia vs delirium
- attention
- onset
- corse
- consciousness
- hallucinations
- prognosis
Delirium: impaired attention, acute onset, fluctuating course ‘sundowning’, clouded consciousness, often visual tactile hallucinations, reversible prognosis.
Dementia: alert attention, gradual onset, progressive deterioration, intact consciousness, hallucinations present in advanced disease, largely irreversible.
Delirium treatment: treat underlying cause, low dose antipsychotics, environmental change (low stimulus environment, orientate to day and time, reestablish circadian rhythm)
Dementia treatment: cholinesterase inhibitors, low dose antipsychotics, environmental change.
4A of Dementia (progression of cognitive impairment)
Amnesia - partial or total memory loss
To
Aphasia - language impairment
To
Apraxia - inability to perform motor activities
To
Agnosia - inability to to recognise previously known objects/places.people
Also see impaired executive functioning in presence of clear sensorium. Personality mood and behaviour changes are common.
Causes of dementia: DEMENTIASS
Degenerative disease- Parkinson, Huntington
Endocrine (thyroid, parathyroid, pituitary, adrenal)
Metabolic (ETOH, electrolytes, Viet B12 def, glucose, hepatic, renal, Wilson)
Exogenous (heavy metal, CO, drugs)
Neoplasia
Trauma (subdural hematoma)
Infection (meningitis, encephalitis, endocarditis, syphilis, HIV< prion disease)
Affective disorder (pseudodementia)
Stroke/Structure (vascular dementia, ischemia, vasculitis, normal pressure hydrocephalus)
Causes of Delirium: IWATCH DEATH
Infection Withdrawal Acute metabolic/substance abuse Trauma CNS pathology Hypoxia Deficiencies Endocrine Acute vascular/MI Toxins/drugs Heavy metals
Definition of Dementia vs Delirium
Dementia (major neurocognitive disorder) is a decline in COGNITIVE functioning with GLOBAL DEFICITS.LEVEL OF CONSCIOUSNESS is stable. 65% Alzheimer’s disease, 20% vascular dementia.
Delirium is an acute disturbance of consciousness with ALTERED COGNITION that develops for short periods of time. Children, elderly and hospitalized patients are particularly susceptible. See a waxing waning course with lucid intervals and perceptual disturbances (hallucination, illusion, delusion) - check occult UTI in elderly
Personality disorder - MEDIC
Maladaptive Enduring Deviate from cultural norms Inflexible Cause impairment in social or occupational function
Substance misuse disorder / eating disorders / miscellaneous
/ sleep disorders somatic and related disorders / factitious and malingering / sexual abuse / suicidability
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