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USMLE Step 1 > Psychiatry - First Aid > Flashcards

Psychiatry - First Aid Flashcards

1
Q

Psychology:

  • learning in which a natural response (salivation) is elicited by a conditioned, or learned, stimulus (bell) that previously was presented in conjunction with an unconditioned stimulus (food)
  • usually deals with involuntary responses
  • Pavlov’s classical experiments with dogs—ringing the bell provoked salivation
A

Classical Conditioning

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2
Q

Psychology:

  • learning in which a particular action is elicited because it produces a punishment or reward
  • usually deals with voluntary responses
A

Operant Conditioning

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3
Q

Operant Conditioning:

target behavior (response) is followed by desired reward (positive reinforcement) or removal of aversive stimulus (negative reinforcement)

A

Reinforcement

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4
Q

Operant Conditioning:

  • discontinuation of reinforcement (positive or negative) eventually eliminates behavior
  • can occur in operant or classical conditioning
A

Extinction

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5
Q

Operant Conditioning:

repeated application of aversive stimulus (positive punishment) or removal of desired reward (negative punishment) to extinguish unwanted behavior (Skinner’s operant conditioning quadrant)

A

Punishment

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6
Q

Psychology:

patient projects feelings about formative or other important persons onto physician (eg. psychiatrist is seen as parent)

A

Transference

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7
Q

Psychology:

doctor projects feelings about formative or other important persons onto patient (eg. patient reminds physician of younger sibling)

A

Countertransference

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8
Q

Psychology:

mental processes (unconscious or conscious) used to resolve conflict and prevent undesirable feelings (eg. anxiety, depression)

A

Ego Defenses

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9
Q

Ego Defenses:

Immature

A
  • Acting Out
  • Denial
  • Displacement
  • Dissociation
  • Fixation
  • Idealization
  • Identification
  • Intellectualization
  • Isolation of Affect
  • Passive Aggression
  • Projection
  • Rationalization
  • Reaction Formation
  • Regression
  • Repression
  • Splitting
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10
Q

Immature Ego Defenses:

  • expressing unacceptable feelings and thoughts through actions
  • A young boy throws a temper tantrum when he does not get the toy he wants.
A

Acting Out

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11
Q

Immature Ego Defenses:

  • avoiding the awareness of some painful reality
  • A patient with cancer plans a full-time work schedule despite being warned of significant fatigue during chemotherapy.
A

Denial

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12
Q

Immature Ego Defenses:

  • redirection of emotions or impulses to a neutral person or object (vs. projection)
  • A teacher is yelled at by the principal. Instead of confronting the principal directly, the teacher goes home and criticizes her husband’s dinner selection.
A

Displacement

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13
Q

Immature Ego Defenses:

  • temporary, drastic change in personality, memory, consciousness, or motor behavior to avoid emotional stress
  • patient has incomplete or no memory of traumatic event
  • A victim of sexual abuse suddenly appears numb and detached when she is exposed to her abuser.
A

Dissociation

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14
Q

Immature Ego Defenses:

  • partially remaining at a more childish level of development (vs. regression)
  • A surgeon throws a tantrum in the operating room because the last case ran very late.
A

Fixation

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15
Q

Immature Ego Defenses:

  • expressing extremely positive thoughts of self and others while ignoring negative thoughts
  • A patient boasts about his physician and his accomplishments while ignoring any flaws.
A

Idealization

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16
Q

Immature Ego Defenses:

  • largely unconscious assumption of the characteristics, qualities, or traits of another person or group
  • A resident starts putting his stethoscope in his pocket like his favorite attending, instead of wearing it around his neck like before.
A

Identification

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17
Q

Immature Ego Defenses:

  • using facts and logic to emotionally distance oneself from a stressful situation
  • In a therapy session, patient diagnosed with cancer focuses only on rates of survival.
A

Intellectualization

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18
Q

Immature Ego Defenses:

  • separating feelings from ideas and events
  • Describing murder in graphic detail with no emotional response.
A

Isolation of Affect

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19
Q

Immature Ego Defenses:

  • demonstrating hostile feelings in a nonconfrontational manner
  • showing indirect opposition
  • Disgruntled employee is repeatedly late to work, but won’t admit it is a way to get back at the manager.
A

Passive Aggression

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20
Q

Immature Ego Defenses:

  • atributing an unacceptable internal impulse to an external source (vs. displacement)
  • A man who wants to cheat on his wife accuses his wife of being unfaithful.
A

Projection

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21
Q

Immature Ego Defenses:

  • proclaiming logical reasons for actions actually performed for other reasons, usually to avoid self-blame
  • After getting fired, claiming that the job was not important anyway.
A

Rationalization

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22
Q

Immature Ego Defenses:

  • replacing a warded-off idea or feeling with an (unconsciously derived) emphasis on its opposite (vs. sublimation)
  • A patient with lustful thoughts enters a monastery.
A

Reaction Formation

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23
Q

Immature Ego Defenses:

  • involuntarily turning back the maturational clock and going back to earlier modes of dealing with the world (vs. fixation)
  • Seen in children under stress such as illness, punishment, or birth of a new sibling (eg. bedwetting in a previously toilet-trained child).
A

Regression

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24
Q

Immature Ego Defenses:

  • involuntarily withholding an idea or feeling from conscious awareness (vs. suppression)
  • A 20-year-old does not remember going to counseling during his parents’ divorce 10 years earlier.
A

Repression

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25
Q

Immature Ego Defenses:

  • believing that people are either all good or all bad at different times due to intolerance of ambiguity
  • commonly seen in borderline personality disorder
  • A patient says that all the nurses are cold and insensitive but that the doctors are warm and friendly.
A

Splitting

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26
Q

Ego Defenses:

Mature

A

Mature adults wear a SASH.

  • Sublimation
  • Altruism
  • Suppression
  • Humor
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27
Q

Mature Ego Defenses:

  • replacing an unacceptable wish with a course of action that is similar to the wish but socially acceptable (vs. reaction formation)
  • Teenager’s aggressive urges toward his parents’ high expectations are channeled into excelling in sports.
A

Sublimation

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28
Q

Mature Ego Defenses:

  • alleviating negative feelings via unsolicited generosity, which provides gratification (vs. reaction formation)
  • Mafia boss makes large donation to charity.
A

Altruism

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29
Q

Mature Ego Defenses:

  • intentionally withholding an idea or feeling from conscious awareness (vs. repression)
  • temporary
  • Choosing to not worry about the big game until it is time to play.
A

Suppression

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30
Q

Mature Ego Defenses:

  • appreciating the amusing nature of an anxietyprovoking or adverse situation
  • Nervous medical student jokes about the boards.
A

Humor

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31
Q

Infant Deprivation Effects

A
  • Long-term deprivation of affection results in:
    • failure to thrive
    • poor language/socialization skills
    • lack of basic trust
    • reactive attachment disorder (infant withdrawn/unresponsive to comfort)
    • disinhibited social engagement (infant indiscriminately attaches to strangers)
  • Deprivation for > 6 months can lead to irreversible changes.
  • Severe deprivation can result in infant death.
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32
Q

Child Abuse:

Physical Abuse

A
  • Fractures (eg. ribs, long bone spiral, multiple in different stages of healing), bruises (eg. trunk, ear, neck; in pattern of implement), burns (eg. cigarette, buttocks/thighs), subdural hematomas/retinal hemorrhages (“shaken baby syndrome”).
  • During exam, children often avoid eye contact.
  • Red flags include history inconsistent with degree or type of injury (eg. 2-month-old rolling out of bed or falling down stairs), delayed medical care, caregiver story changes with retelling.
  • Abuser is usually the biological mother.
  • 40% of deaths related to child abuse or neglect occur in children < 1 year old.
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33
Q

Child Abuse:

Sexual Abuse

A
  • genital, anal, or oral trauma
  • STIs
  • UTIs
  • Abuser is known to victim and is usually male.
  • Peak incidence is 9–12 years old.
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34
Q

Psychopathology:

  • failure to provide a child with adequate food, shelter, supervision, education, and/or affection
  • mmost common form of child maltreatment
  • presents with poor hygiene, malnutrition, withdrawal, impaired social/emotional development, and failure to thrive
  • must be reported to local child protective services
A

Child Neglect

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35
Q

Psychopathology:

  • parents perceive the child as especially susceptible to illness or injury
  • usually follows a serious illness or life-threatening event
  • can result in missed school or overuse of medical services
A

Vulnerable Child Syndrome

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36
Q

Childhood and Early-Onset Disorders:

  • onset before age 12
  • at least 6 months of limited attention span and/or poor impulse control
  • characterized by hyperactivity, impulsivity, and/or inattention in multiple settings (school, home, places of worship, etc)
  • normal intelligence, but commonly coexists with difficulties in school
  • often persists into adulthood
  • Treatment:
    • stimulants (eg. methylphenidate) +/– cognitive behavioral therapy (CBT)
    • alternatives include Atomoxetine, Guanfacine, and Clonidine
A

Attention-Deficit Hyperactivity Disorder

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37
Q

Childhood and Early-Onset Disorders:

  • characterized by poor social interactions, social communication deficits, repetitive/ritualized behaviors, restricted interests
  • must present in early childhood
  • may be accompanied by intellectual disability
  • rarely accompanied by unusual abilities (savants)
  • more common in boys
  • associated with ↑ head/brain size
A

Autism Spectrum Disorder

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38
Q

Childhood and Early-Onset Disorders:

  • repetitive and pervasive behavior violating the basic rights of others or societal norms (eg. aggression to people and animals, destruction of property, theft)
  • after age 18
  • often reclassified as antisocial personality disorder
  • treated with psychotherapy such as CBT
A

Conduct Disorder

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39
Q

Childhood and Early-Onset Disorders:

  • onset before age 10
  • severe and recurrent temper outbursts out of proportion to situation
  • child is constantly angry and irritable between outbursts
  • Treatment:
    • Stimulants
    • Antipsychotics
    • CBT
A

Disruptive Mood Dysregulation Disorder

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40
Q

Childhood and Early-Onset Disorders:

  • enduring pattern of hostile, defiant behavior toward authority figures in the absence of serious violations of social norms
  • Treatment:
    • psychotherapy such as CBT
A

Oppositional Defiant Disorder

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41
Q

Childhood and Early-Onset Disorders:

  • overwhelming fear of separation from home or attachment figure lasting ≥ 4 weeks
  • can be normal behavior up to age 3–4
  • may lead to factitious physical complaints to avoid school
  • Treatment:
    • CBT
    • Play Therapy
    • Family Therapy
A

Separation Anxiety Disorder

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42
Q

Childhood and Early-Onset Disorders:

  • onset before age 18
  • characterized by sudden, rapid, recurrent, nonrhythmic, stereotyped motor and vocal tics that persist for > 1 year
  • coprolalia (involuntary obscene speech) found in only 40% of patients
  • associated with OCD and ADHD
  • Treatment:
    • Psychoeducation
    • Behavioral Therapy
  • for intractable and distressing tics, high-potency antipsychotics (eg. Haloperidol, Fluphenazine), Tetrabenazine, α2-Agonists (eg. Guanfacine, Clonidine), or atypical antipsychotics may be used
A

Tourette Syndrome

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43
Q

Orientation

A
  • patient’s ability to know who he or she is, where he or she is, and the date and time
  • Common Causes of Loss of Orientation:
    • alcohol
    • drugs
    • fluid/electrolyte imbalance
    • head trauma
    • hypoglycemia
    • infection
    • nutritiona deficiencies
    • hypoxi
  • Order of Loss: time → place → person
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44
Q

Amnesias:

inability to remember things that occurred before a CNS insult

A

Retrograde Amnesia

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45
Q

Amnesias:

inability to remember things that occurred after a CNS insult (↓ acquisition of new memory)

A

Anterograde Amnesia

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46
Q

Amnesias:

  • amnesia (anterograde > retrograde) caused by vitamin B1 deficiency and associated destruction of mammillary bodies
  • seen in alcoholics as a late neuropsychiatric manifestation of Wernicke encephalopathy
  • confabulations are characteristic
A

Korsakoff Syndrome

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47
Q

Dissociative Disorders:

  • persistent feelings of detachment or estrangement from one’s own body, thoughts, perceptions, and actions (depersonalization) or one’s environment (derealization)
  • intact reality testing (vs. psychosis)
A

Depersonalization/Derealization Disorder

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48
Q

Dissociative Disorders:

inability to recall important personal information, usually subsequent to severe trauma or stress

A

Dissociative Amnesia

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49
Q

Dissociative Disorders:

  • formerly known as Multiple Personality Disorder
  • presence of 2 or more distinct identities or personality states
  • more common in women
  • associated with history of sexual abuse, PTSD, depression, substance abuse, borderline personality, somatoform conditions
  • may be accompanied by dissociative fugue (abrupt travel or wandering associated with traumatic circumstances)
A

Dissociative Identity Disorder

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50
Q

Psychopathology:

  • “waxing and waning” level of consciousness with acute onset
  • rapid ↓ in attention span and level of arousal
  • characterized by disorganized thinking, hallucinations (often visual), illusions, misperceptions, disturbance in sleepwake cycle, cognitive dysfunction, agitation.
  • usually 2° to other illness (eg. CNS disease, infection, trauma, substance abuse/withdrawal, metabolic/electrolyte disturbances, hemorrhage, urinary/fecal retention)
  • most common presentation of altered mental status in inpatient setting, especially in the intensive care unit and with prolonged hospital stays
  • EEG may show diffuse slowing
  • treatment is aimed at identifying and addressing underlying condition
  • use antipsychotics acutely as needed
  • avoid Benzodiazepines
  • may be caused by medications (eg. anticholinergics), especially in the elderly
  • reversible.
A

Delirium

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51
Q

Psychopathology:

  • distorted perception of reality characterized by delusions, hallucinations, and/or disorganized thought/speech
  • can occur in patients with medical illness, psychiatric illness, or both
A

Psychosis

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52
Q

Psychosis:

  • unique, false, fixed, idiosyncratic beliefs that persist despite the facts and are not typical of a patient’s culture or religion (eg. thinking aliens are communicating with you)
  • types include erotomanic, grandiose, jealous, persecutory, somatic, mixed, and unspecified
A

Delusions

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53
Q

Psychosis:

speech may be incoherent (“word salad”), tangential, or derailed (“loose associations”)

A

Disorganized Thought

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54
Q

Psychosis:

  • perceptions in the absence of external stimuli (eg. seeing a light that is not actually present)
  • contrast with illusions, misperceptions of real external stimuli
A

Hallucinations

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55
Q

Types of Hallucinations

A
  • Visual—more commonly a feature of medical illness (eg. drug intoxication) than psychiatric illness
  • Auditory—more commonly a feature of psychiatric illness (eg. schizophrenia) than medical illness
  • Olfactory—often occur as an aura of temporal lobe epilepsy (eg. burning rubber) and in brain tumors
  • Gustatory—rare, but seen in epilepsy
  • Tactile—common in alcohol withdrawal and stimulant use (eg. cocaine, amphetamines), delusional parasitosis, “cocaine crawlies”
  • Hypnagogic—occurs while going to sleep, sometimes seen in narcolepsy
  • Hypnopompic—occurs while waking from sleep (“pompous upon awakening”), sometimes seen in narcolepsy
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56
Q

Psychopathology:

  • chronic mental disorder with periods of psychosis, disturbed behavior and thought, and decline in functioning lasting ≥ 6 months (including prodrome and residual symptoms)
  • associated with ↑ dopaminergic activity, ↓ dendritic branching
  • frequent cannabis use is associated with psychosis in teens
  • Lifetime Prevalence
    • 1.5% males > females
    • African Americans = Caucasians
  • presents earlier in men (late teens to early 20s vs. late 20s to early 30s in women)
  • patients at ↑ risk for suicide
  • ventriculomegaly on brain imaging
  • Diagnosis requires ≥ 2 of the following symptoms for ≥ 1 month, and at least 1 of these should include #1–3 (first 4 are “positive symptoms”):
  1. Delusions
  2. Hallucinations—often auditory
  3. Disorganized Speech
  4. Disorganized or Catatonic Behavior
  5. Negative Symptoms (affective flattening, avolition, anhedonia, asociality, alogia)
  • Treatment:
    • Atypical Antipsychotics (eg. Risperidone) are first line
  • negative symptoms often persist after treatment, despite resolution of positive symptoms
    *
A

Schizophrenia

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57
Q

Schizophrenia:

  • ≥ 1 positive symptom(s) lasting < 1 month
  • usually stress related
A

Brief Psychotic Disorder

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58
Q

Schizophrenia:

  • ≥ 2 symptoms
  • lasting 1–6 months
A

Schizophreniform Disorder

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59
Q

Schizophrenia:

  • meets criteria for Schizophrenia in addition to major mood disorder (major depressive or bipolar)
  • to differentiate from a major mood disorder with psychotic features, patient must have > 2 weeks of psychotic symptoms without major mood episode
A

Schizoaffective Disorder

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60
Q

Psychopathology:

  • fixed, persistent, false belief system lasting > 1 month
  • functioning otherwise not impaired (eg. a woman who genuinely believes she is married to a celebrity when, in fact, she is not)
  • can be shared by individuals in close relationships (folie à deux)
A

Delusional Disorder

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61
Q

Psychopathology:

  • characterized by an abnormal range of moods or internal emotional states and loss of control over them
  • severity of moods causes distress and impairment in social and occupational functioning
  • includes major depressive, bipolar, dysthymic, and cyclothymic disorders
  • episodic superimposed psychotic features (delusions, hallucinations, disorganized speech/behavior) may be present
A

Mood Disorder

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62
Q

Psychopathology:

  • distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently ↑ activity or energy lasting ≥ 1 week
  • often disturbing to patient and causes marked functional impairment and oftentimes hospitalization
  • Diagnosis requires hospitalization or at least 3 of the following:
    • Distractibility
    • Impulsivity/Indiscretion—seeks pleasure without regard to consequences (hedonistic)
    • Grandiosity—inflated self-esteem
    • Flight of Ideas—racing thoughts
    • ↑ Goal-Directed Activity/Psychomotor Agitation
    • ↓ Need for Sleep
    • Talkativeness or Pressured Speech
A

Manic Episode

Manics DIG FAST:

  • Distractibility
  • Impulsivity/Indiscretion
  • Grandiosity
  • Flight of Ideas
  • ↑ Goal-Directed Activity/Psychomotor Agitation
  • ↓ Need for Sleep
  • Talkativeness or Pressured Speech
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63
Q

Psychopathology:

  • similar to a manic episode except mood disturbance is not severe enough to cause marked impairment in social and/or occupational functioning or to necessitate hospitalization
  • no psychotic features
  • lasts ≥ 4 consecutive days
A

Hypomanic Episode

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64
Q

Bipolar Disorder (Manic Depression)

A
  • Bipolar I—defined by presence of at least 1 manic episode +/− a hypomanic or depressive episode (may be separated by any length of time)
  • Bipolar II—defined by presence of a hypomanic and a depressive episode (no history of manic episodes)
  • Patient’s mood and functioning usually normalize between episodes.
  • Use of antidepressants can destabilize mood.
  • High suicide risk.
  • Treatment:
    • Mood Stabilizers (eg. Lithium, Valproic Acid, Carbamazepine, Lamotrigine)
    • Atypical Antipsychotics
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65
Q

Psychopathology:

  • milder form of bipolar disorder lasting ≥ 2 years
  • fluctuating between mild depressive and hypomanic symptoms
A

Cyclothymic Disorder

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66
Q

Psychopathology:

  • episodes characterized by at least 5 of the 9 diagnostic symptoms lasting ≥ 2 weeks (symptoms must include patient-reported depressed mood or anhedonia)
  • screen for history of manic episodes to rule out bipolar disorder
  • Diagnostic Symptoms:
    • Depressed Mood
    • Sleep Disturbance
    • Loss of Interest (Anhedonia)
    • Guilt or Feelings of Worthlessness
    • Energy Loss and Fatigue
    • Concentration Problems
    • Appetite/Weight Changes
    • Psychomotor Retardation or Agitation
    • Suicidal Ideations
  • Patients with depression typically have the following changes in their sleep stages:
    • ↓ slow-wave sleep
    • ↓ REM latency
    • ↑ REM early in sleep cycle
    • ↑ total REM sleep
    • repeated nighttime awakenings
    • early-morning awakening (terminal insomnia)
  • Treatment:
    • CBT and SSRIs are first line.
    • SNRIs, Mirtazapine, and Bupropion can also be considered.
    • Electroconvulsive Therapy (ECT) in treatment-resistant patients.
A

Major Depressive Disorder

SIG E CAPS:

  • Sleep Disturbance
  • Loss of Interest (Anhedonia)
  • Guilt or Feelings of Worthlessness
  • Energy Loss and Fatigue
  • Concentration Problems
  • Appetite/Weight Changes
  • Psychomotor Retardation or Agitation
  • Suicidal Ideations
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67
Q

Major Depressive Disorder:

  • often milder
  • ≥ 2 depressive symptoms lasting ≥ 2 years with no more than 2 months without depressive symptoms
A

Persistent Depressive Disorder (Dysthymia)

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68
Q

Major Depressive Disorder:

  • formerly known as Seasonal Affective Disorder
  • lasting ≥ 2 years with ≥ 2 major depressive episodes associated with seasonal pattern (usually winter) and absence of nonseasonal depressive episodes
  • atypical symptoms common (eg. hypersomnia, hyperphagia, leaden paralysis)
A

MDD with Seasonal Pattern

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69
Q

Psychopathology:

  • characterized by mood reactivity (able to experience improved mood in response to positive events, albeit briefly)
  • “reversed” vegetative symptoms (hypersomnia, hyperphagia), leaden paralysis (heavy feeling in arms and legs), long-standing interpersonal rejection sensitivity
  • most common subtype of depression
  • Treatment:
    • CBT and SSRIs are first line.
    • MAO inhibitors are effective but not first line because of their risk profile.
A

Depression with Atypical Features

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70
Q

Psychopathology:

onset during pregnancy or within 4 weeks of delivery

A

Postpartum Mood Disturbances

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71
Q

Postpartum Mood Disturbances:

  • 50–85% incidence rate
  • characterized by depressed affect, tearfulness, and fatigue starting 2–3 days after delivery
  • usually resolves within 10 days
  • Treatment: supportive
  • follow up to assess for possible postpartum depression
A

Maternal (Postpartum) Blues

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72
Q

Postpartum Mood Disturbances:

  • 10–15% incidence rate
  • characterized by depressed affect, anxiety, and poor concentration for ≥ 2 weeks
  • Treatment: CBT and SSRIs are first line
A

Postpartum Depression

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73
Q

Postpartum Mood Disturbances:

  • 0.1–0.2% incidence rate
  • characterized by mood-congruent delusions, hallucinations, and thoughts of harming the baby or self
  • risk factors include history of bipolar or psychotic disorder, first pregnancy, family history, recent discontinuation of psychotropic medication
  • Treatment:
    • hospitalization and initiation of atypical antipsychotic
    • if insufficient, ECT may be used
A

Postpartum Psychosis

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74
Q

Grief

A
  • The five stages of grief per the Kübler-Ross model are Denial, Anger, Bargaining, Depression, and Acceptance (may occur in any order).
  • Other normal grief symptoms include Shock, Guilt, Sadness, Anxiety, Yearning, and Somatic symptoms that usually occur in waves.
  • Simple hallucinations of the deceased person are common (eg. hearing the deceased speaking).
  • Any thoughts of dying are limited to joining the deceased (vs. pathological grief).
  • Duration varies widely; usually within 6–12 months.
  • Pathologic grief is persistent, causes functional impairment, and can meet criteria for major depressive episode.
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75
Q

Psychotherapy:

  • rapid-acting method to treat resistant or refractory depression, depression with psychotic symptoms, and acute suicidality
  • induces grand mal seizure while patient anesthetized
  • adverse effects include disorientation, temporary headache, partial anterograde/retrograde amnesia usually resolving in 6 months
  • no absolute contraindications
  • safe in pregnant and elderly individuals
A

Electroconvulsive Therapy

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76
Q

Suicide

A
  • Most common method in US is firearms; access to guns ↑ risk of suicide completion.
  • Women try more often; men complete more often.
  • Family history of completed suicide is another well-known risk factor.
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77
Q

Risk Factors for Suicide Completion

A

SAD PERSONS are more likely to complete suicide.

  • Sex (male)
  • Age (young adult or elderly)
  • Depression
  • Previous attempt (highest risk factor)
  • Ethanol or drug use
  • Rational thinking loss (psychosis)
  • Sickness (medical illness)
  • Organized plan
  • No spouse or other social support
  • Stated future intent
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78
Q

Psychopathology:

  • inappropriate experience of fear/worry and its physical manifestations (anxiety) incongruent with the magnitude of the perceived stressor
  • symptoms interfere with daily functioning and are not attributable to another mental disorder, medical condition, or substance abuse
  • includes panic disorder, phobias, generalized anxiety disorder, and selective mutism
  • Treatment:
    • CBT
    • SSRIs
    • SNRIs
A

Anxiety Disorder

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79
Q

Psychopathology:

  • recurrent unexpected panic attacks not associated with a known trigger
  • periods of intense fear and discomfort peak in 10 minutes with at least 4 of the following: palpitations, paresthesias, depersonalization or derealization, abdominal distress or nausea, intense fear of dying, intense fear of losing control or “going crazy,” lIght-headedness, chest pain, chills, choking, sweating, shaking, shortness of breath
  • strong genetic component
  • ↑ risk of suicide
  • Diagnosis requires attack followed by ≥ 1 month of ≥ 1 of the following:
    • persistent concern of additional attacks
    • worrying about consequences of attack
    • behavioral change related to attacks
  • symptoms are the systemic manifestations of fear
  • Treatment:
    • CBT, SSRIs, and venlafaxine are first line.
    • Benzodiazepines occasionally used in acute setting.
A

Panic Disorder

PANICS:

  • Palpitations
  • Paresthesias
  • dePersonalization or derealization
  • Abdominal distress or Nausea
  • Intense fear of dying
  • Intense fear of losing control or “going crazy”
  • lIght-headedness,
  • Chest pain
  • Chills
  • Choking
  • Sweating
  • Shaking
  • Shortness of breath
80
Q

Psychopathology:

  • severe, persistent (≥ 6 months) fear or anxiety due to presence or anticipation of a specific object or situation
  • person often recognizes fear is excessive
  • can be treated with systematic desensitization
81
Q

Phobia:

  • exaggerated fear of embarrassment in social situations (eg. public speaking, using public restrooms)
  • Treatment:
    • CBT
    • SSRIs
    • Venlafaxine
  • for performance type (eg. anxiety restricted to public speaking), use β-Blockers or Benzodiazepines as needed
A

Social Anxiety Disorder

82
Q

Phobia:

  • irrational fear/anxiety while facing or anticipating ≥ 2 specific situations (eg. open/closed spaces, lines, crowds, public transport)
  • if severe, patients may refuse to leave their homes
  • associated with panic disorder
  • Treatment:
    • CBT
    • SSRIs
A

Agoraphobia

83
Q

Psychopathology:

  • anxiety lasting > 6 months unrelated to a specific person, situation, or event
  • associated with restlessness, irritability, sleep disturbance, fatigue, muscle tension, and difficulty concentrating
  • Treatment:
    • CBT, SSRIs, and SNRIs are first line.
    • Buspirone, TCAs, and Benzodiazepines are second line.
A

Generalized Anxiety Disorder

84
Q

Psychopathology:

  • emotional symptoms (anxiety, depression) that occur within 3 months of an identifiable psychosocial stressor (eg. divorce, illness) lasting < 6 months once the stressor has ended
  • if symptoms persist > 6 months after stressor ends, it is GAD
  • symptoms do not meet criteria for MDD
  • Treatment:
    • CBT
    • SSRIs
A

Adjustment Disorder

85
Q

Psychopathology:

  • recurring intrusive thoughts, feelings, or sensations (obsessions) that cause severe distress
  • relieved in part by the performance of repetitive actions (compulsions)
  • Ego-Dystonic: behavior inconsistent with one’s own beliefs and attitudes (vs. obsessive-compulsive personality disorder, Ego-Syntonic)
  • associated with Tourette syndrome
  • Treatment:
    • CBT, SSRIs, Venlafaxine, and Clomipramine are first line
A

Obsessive-Compulsive Disorder

86
Q

Obsessive-Compulsive Disorder:

  • preoccupation with minor or imagined defect in appearance → significant emotional distress or impaired functioning
  • patients often repeatedly seek cosmetic treatment
  • Treatment: CBT
A

Body Dysmorphic Disorder

87
Q

Psychopathology:

  • experiencing a potentially life-threatening situation (eg. serious injury, rape, witnessing death) → persistent hyperarousal, avoidance of associated stimuli, intrusive re-experiencing of the event (nightmares, flashbacks), changes in cognition or mood (fear, horror, distress)
  • disturbance lasts > 1 month with significant distress or impaired socialoccupational functioning
  • Treatment:
    • CBT, SSRIs, and Venlafaxine are first line.
    • Prazosin can reduce nightmares.
A

Post-Traumatic Stress Disorder

Having PTSD is HARD.

  • persistent Hyperarousal
  • Avoidance of associated stimuli
  • intrusive Re-experiencing of the event (nightmares, flashbacks)
  • changes in cognition or mood (fear, horror, Distress)
88
Q

Psychopathology:

  • lasts between 3 days and 1 month
  • Treatment:
    • CBT
    • pharmacotherapy is usually not indicated
A

Acute Stress Disorder

89
Q

Diagnostic Criteria by Symptom Duration

90
Q

Personality:

an enduring, repetitive pattern of perceiving, relating to, and thinking about the environment and oneself

A

Personality Trait

91
Q

Personality:

  • inflexible, maladaptive, and rigidly pervasive pattern of behavior causing subjective distress and/or impaired functioning
  • person is usually not aware of problem (ego-syntonic)
  • usually presents by early adulthood
A

Personality Disorder

Three Clusters:

  • A—Weird
  • B—Wild
  • C—Worried
92
Q

Personality Disorders:

  • odd or eccentric
  • inability to develop meaningful social relationships
  • no psychosis
  • genetic association with schizophrenia
  • “weird”
A

Cluster A Personality Disorders

Cluster A: Accusatory, Aloof, Awkward

93
Q

Cluster A Personality Disorders:

pervasive distrust (Accusatory) and suspiciousness of others and a profoundly cynical view of the world

94
Q

Cluster A Personality Disorders:

  • voluntary social withdrawal (Aloof)
  • limited emotional expression
  • content with social isolation (vs. avoidant)
95
Q

Cluster A Personality Disorders:

  • eccentric appearance
  • odd beliefs or magical thinking
  • interpersonal Awkwardness
A

Schizotypal

96
Q

Personality Disorders:

  • dramatic, emotional, or erratic
  • genetic association with mood disorders and substance abuse
  • “wild”
A

Cluster B Personality Disorders

Cluster B: Bad, Borderline, flamBoyant, must be the Best

97
Q

Cluster B Personality Disorders:

  • disregard for and violation of rights of others with lack of remorse, criminality, and impulsivity
  • males > females
  • must be ≥ 18 years old and have history of conduct disorder before age 15
  • conduct disorder if < 18 years old
  • “Bad”
A

Antisocial

98
Q

Cluster B Personality Disorders:

  • unstable mood and interpersonal relationships, impulsivity, self-mutilation, suicidality, and sense of emptiness
  • females > males
  • splitting is a major defense mechanism
  • Treatment: dialectical behavior therapy
A

Borderline

99
Q

Cluster B Personality Disorders:

  • excessive emotionality and excitability, attention seeking, sexually provocative, and overly concerned with appearance
  • flamBoyant
A

Histrionic

100
Q

Cluster B Personality Disorders:

  • grandiosity and sense of entitlement
  • lacks empathy and requires excessive admiration
  • often demands the “Best” and reacts to criticism with rage
A

Narcissistic

101
Q

Personality Disorders:

  • anxious or fearful
  • genetic association with anxiety disorders
  • “worried”
A

Cluster C Personality Disorders

Cluster C: Cowardly, obsessive-Compulsive, Clingy

102
Q

Cluster C Personality Disorders:

  • hypersensitive to rejection, socially inhibited, timid, feelings of inadequacy, desires relationships with others (vs. schizoid)
  • Cowardly
103
Q

Cluster C Personality Disorders:

  • preoccupation with order, perfectionism, and control
  • Ego-Syntonic: behavior consistent with one’s own beliefs and attitudes (vs. OCD)
A

Obsessive-Compulsive

104
Q

Cluster C Personality Disorders:

  • excessive need for support
  • low self-confidence
  • patients often get stuck in abusive relationships
  • submissive and Clingy
105
Q

Psychopathology:

  • symptoms are intentional, motivation is intentional
  • patient consciously fakes, profoundly exaggerates, or claims to have a disorder in order to attain a specific 2° (external) gain (eg. avoiding work, obtaining compensation)
  • poor compliance with treatment or follow-up of diagnostic tests
  • complaints cease after gain (vs. factitious disorder)
A

Malingering

106
Q

Psychopathology:

  • symptoms are intentional, motivation is unconscious
  • patient consciously creates physical and/or psychological symptoms in order to assume “sick role” and to get medical attention and sympathy (1° [internal] gain)
A

Factitious Disorders

107
Q

Factitious Disorders:

  • also known as Munchausen syndrome
  • chronic factitious disorder with predominantly physical signs and symptoms
  • characterized by a history of multiple hospital admissions and willingness to undergo invasive procedures
  • more common in women and healthcare workers
A

Factitious Disorder Imposed on Self

108
Q

Factitious Disorders:

  • also known as Munchausen syndrome by proxy
  • illness in a child or elderly patient is caused or fabricated by the caregiver
  • motivation is to assume a sick role by proxy
  • form of child/elder abuse
A

Factitious Disorder Imposed on Another

109
Q

Psychopathology:

  • symptoms are unconscious, motivation is unconscious
  • category of disorders characterized by physical symptoms causing significant distress and impairment
  • symptoms not intentionally produced or feigned
  • more common in women
A

Somatic Symptom and Related Disorders

110
Q

Somatic Symptom and Related Disorders:

  • variety of bodily complaints (eg. pain, fatigue) lasting for months to years
  • associated with excessive, persistent thoughts and anxiety about symptoms
  • may co-occur with medical illness
  • Treatment:
    • regular office visits with the same physician in combination with psychotherapy
A

Somatic Symptom Disorder

111
Q

Somatic Symptom and Related Disorders:

  • also known as functional neurologic symptom disorder
  • loss of sensory or motor function (eg. paralysis, blindness, mutism), often following an acute stressor
  • patient may be aware of but indifferent toward symptoms (“la belle indifférence”)
  • more common in females, adolescents, and young adults
A

Conversion Disorder

112
Q

Somatic Symptom and Related Disorders:

  • also known as hypochondriasis
  • excessive preoccupation with acquiring or having a serious illness, often despite medical evaluation and reassurance
  • minimal somatic symptoms
A

Illness Anxiety Disorder

113
Q

Psychopathology:

most common in young females

A

Eating Disorders

114
Q

Eating Disorders:

  • intense fear of weight gain and distortion or overvaluation of body image leading to restriction of caloric intake and severe weight loss (BMI < 18.5 kg/m2)
  • restricting and binge/purge subtypes
  • associated with ↓ bone density (often irreversible), amenorrhea (due to loss of pulsatile GnRH secretion), lanugo, anemia, and electrolyte disturbances
  • commonly coexists with depression
  • psychotherapy and nutritional rehabilitation are first line
  • pharmacotherapy includes SSRIs for comorbid anxiety and/or depression
A

Anorexia Nervosa

115
Q

Eating Disorders:

  • ↑ insulin → hypophosphatemia, hypokalemia, hypomagnesemia → cardiac complications, rhabdomyolysis, seizures
  • can occur in significantly malnourished patients
A

Refeeding Syndrome

116
Q

Eating Disorders:

  • binge eating with recurrent inappropriate compensatory behaviors (eg. self-induced vomiting, using laxatives or diuretics, fasting, excessive exercise) occurring weekly for at least 3 months and overvaluation of body image
  • body weight often maintained within normal range
  • associated with parotitis, enamel erosion, electrolyte disturbances (eg. hypokalemia, hypochloremia), metabolic alkalosis, dorsal hand calluses from induced vomiting (Russell sign)
  • Treatment:
    • psychotherapy
    • nutritional rehabilitation
    • antidepressants (eg. SSRIs)
    • Bupropion is contraindicated due to seizure risk
A

Bulimia Nervosa

117
Q

Eating Disorders:

  • regular episodes of excessive, uncontrollable eating without inappropriate compensatory behaviors
  • ↑ risk of diabetes
  • Treatment:
    • psychotherapy such as CBT is first line
    • SSRIs
    • Lisdexamfetamine
A

Binge Eating Disorder

118
Q

Psychopathology:

persistent cross-gender identification that leads to persistent distress with sex assigned at birth

A

Gender Dysphoria

119
Q

Gender Dysphoria:

desire to live as the opposite sex, often through surgery or hormone treatment

A

Transsexualism

120
Q

Gender Dysphoria:

  • paraphilia, not gender dysphoria
  • wearing clothes (eg. vest) of the opposite sex (cross-dressing)
A

Transvestism

121
Q

Psychopathology:

  • Includes sexual desire disorders (hypoactive sexual desire or sexual aversion), sexual arousal disorders (erectile dysfunction), orgasmic disorders (anorgasmia, premature ejaculation), and sexual pain disorders (dyspareunia, vaginismus)
  • Differentials:
    • Drug Side Effects (eg. antihypertensives, antipsychotics, SSRIs, ethanol)
    • Medical Disorders (eg. depression, diabetes, STIs)
    • Psychological or Performance Anxiety (eg. nighttime erections [nocturnal tumescence])
A

Sexual Dysfunction

122
Q

Psychopathology:

  • inconsolable periods of terror with screaming in the middle of the night
  • occurs during slow-wave/deep (stage N3) sleep
  • most common in children
  • occurs during non-REM sleep (no memory of the arousal episode) as opposed to nightmares that occur during REM sleep (remembering a scary dream)
  • cause unknown, but triggers include emotional stress, fever, or lack of sleep
  • usually self limited
A

Sleep Terror Disorder

123
Q

Psychopathology:

  • urinary incontinence ≥ 2 times/week for ≥ 3 months in person > 5 years old
  • First-Line Treatment:
    • behavioral modification (eg. scheduled voids)
    • positive reinforcement
  • For Refractory Cases:
    • bedwetting alarm
    • oral Desmopressin (ADH analog; preferred over imipramine due to more favorable side effect profile)
124
Q

Psychopathology:

  • disordered regulation of sleep-wake cycles characterized by excessive daytime sleepiness (despite feeling rested upon waking) and “sleep attacks” (rapid-onset, overwhelming sleepiness)
  • caused by ↓ hypocretin (orexin) production in lateral hypothalamus
  • strong genetic component
  • Also associated with:
    • hypnagogic (just before going to sleep) or hypnopompic (just before awakening; “pompous upon awakening”) hallucinations
    • nocturnal and narcoleptic sleep episodes that start with REM sleep (sleep paralysis)
    • cataplexy (loss of all muscle tone following strong emotional stimulus, such as laughter) in some patients
  • Treatment:
    • good sleep hygiene (scheduled naps, regular sleep schedule)
    • daytime stimulants (eg. amphetamines, modafinil) and nighttime sodium oxybate (GHB)
A

Narcolepsy

125
Q

Substance Use Disorder

A

Maladaptive pattern of substance use defined as 2 or more of the following signs in 1 year related specifically to substance use:

  • Tolerance—need more to achieve same effect
  • Withdrawal—manifesting as characteristic signs and symptoms
  • substance taken in larger amounts, or over longer time, than desired
  • persistent desire or unsuccessful attempts to cut down
  • significant energy spent obtaining, using, or recovering from substance
  • important social, occupational, or recreational activities reduced
  • continued use despite knowing substance causes physical and/or psychological problems
  • Craving
  • recurrent use in physically dangerous situations
  • failure to fulfill major obligations at work, school, or home
  • social or interpersonal conflicts
126
Q

Stages of Change in Overcoming Substance Addiction

A
  1. Precontemplation—not yet acknowledging that there is a problem
  2. Contemplation—acknowledging that there is a problem, but not yet ready or willing to make a change
  3. Preparation/Determination—getting ready to change behaviors
  4. Action/Willpower—changing behaviors
  5. Maintenance—maintaining the behavioral changes
  6. Relapse—returning to old behaviors and abandoning new changes, does not always happen
127
Q

Psychiatric Emergencies:

  • Cause:
    • any drug that ↑ 5-HT.
    • Psychiatric Drugs:
      • MAO inhibitors, SSRIs, SNRIs, TCAs, Vilazodone, Vortioxetine
    • Nonpsychiatric Drugs:
      • Tramadol, Ondansetron, Triptans, Linezolid, MDMA, Dextromethorphan, Meperidine, St. John’s Wort
  • 3 A’s:
    • ↑ Activity (neuromuscular)
    • Autonomic stimulation
    • Agitation
  • symptoms of neuromuscular hyperactivity include clonus, hyperreflexia, hypertonia, tremor, and seizure
  • symptoms of autonomic stimulation include hyperthermia, diaphoresis, diarrhea
  • Treatment:
    • Cyproheptadine (5-HT2 receptor antagonist)
A

Serotonin Syndrome

128
Q

Psychiatric Emergencies:

  • Cause: carcinoid tumor of GI tract or lung
  • diarrhea, flushing, wheezing, and right heart disease (if tumor is in the gut)
  • Treatement: Octreotide
A

Carcinoid Syndrome

129
Q

Psychiatric Emergencies:

  • Cause:
    • eating tyramine-rich foods (eg. aged cheeses, cured meats, wine) while taking MAO inhibitor
  • tyramine displaces other neurotransmitters (eg. NE) in the synaptic cleft → ↑ sympathetic stimulation
  • Treatment: Phentolamine
A

Hypertensive Crisis

130
Q

Psychiatric Emergencies:

  • Causes:
    • antipsychotics + genetic predisposition
  • myoglobinuria, fever, encephalopathy, vitals unstable, ↑ enzymes (eg. ↑ CK), rigidity of muscles (“lead pipe”)
  • Treatment:
    • Dantrolene
    • Dopamine Agonist (eg. Bromocriptine)
    • discontinue causative agent
A

Neuroleptic Malignant Syndrome

Malignant FEVER:

  • Myoglobinuria
  • Fever
  • Encephalopathy
  • Vitals unstable
  • ↑ Enzymes (eg. ↑ CK)
  • Rigidity of muscles (“lead pipe”)
131
Q

Psychiatric Emergencies:

  • Cuase:
    • inhaled anesthetics, Succinylcholine + genetic predisposition
  • fever and severe muscle contractions
  • Treatment: Dantrolene
A

Malignant Hyperthermia

132
Q

Psychiatric Emergencies:

  • Cause:
    • alcohol withdrawal
    • occurs 2–4 days after last drink
    • classically seen in hospital setting when inpatient cannot drink
  • altered mental status (eg. hallucinations), autonomic hyperactivity, anxiety, seizures, tremors, psychomotor agitation, insomnia, nausea
  • Treatement:
    • Benzodiazepines (eg. Chlordiazepoxide, Lorazepam, Diazepam)
A

Delirium Tremens

133
Q

Psychiatric Emergencies:

  • Cause:
    • typical antipsychotics
    • anticonvulsants (eg. Carbamazepine)
    • Metoclopramide
  • sudden onset of muscle spasm, stiffness, oculogyric crisis that occurs within hours to days after medication use
  • can lead to laryngospasm requiring intubation
  • Treatment:
    • Benztropine
    • Diphenhydramine
A

Acute Dystonia

134
Q

Psychiatric Emergencies:

  • Cause:
    • change in lithium dosage or health status (narrow therapeutic window)
    • concurrent use of Thiazides, ACE Inhibitors, NSAIDs, or other nephrotoxic agents
  • nausea, vomiting, slurred speech, hyperreflexia, seizures, ataxia, and nephrogenic diabetes insipidus
  • Treatment:
    • discontinue lithium
    • hydrate aggressively with isotonic sodium chloride
    • consider hemodialysis
A

Lithium Toxicity

135
Q

Psychiatric Emergencies:

  • Cause: TCA overdose
  • respiratory depression, hyperpyrexia, prolonged QT interval
  • Tri-C’s:
    • Convulsions
    • Coma
    • Cardiotoxicity (arrhythmia due to Na+ channel inhibition)
  • Treatment:
    • supportive treatment
    • monitor ECG
    • NaHCO3 (prevents arrhythmia)
    • activated charcoal
A

Tricyclic Antidepressant Toxicity

136
Q

Psychoactive Drug Intoxication and Withdrawal:

  • Intoxication:
    • nonspecific, mood elevation, ↓ anxiety, sedation, behavioral disinhibition, respiratory depression
  • Withdrawal:
    • nonspecific, anxiety, tremor, seizures, insomnia
A

Depressants

137
Q

Psychoactive Drug Intoxication and Withdrawal:

  • Intoxication:
    • emotional lability, slurred speech, ataxia, coma, blackouts
    • serum γ-glutamyltransferase (GGT)—sensitive indicator of alcohol use
    • AST value is 2× ALT value
  • Withdrawal:
    • 3–36 hr: tremors, insomnia, GI upset, diaphoresis, mild agitation
    • 6–48 hr: withdrawal seizures
    • 12–48 hr: alcoholic hallucinosis (usually visual)
    • 48–96 hr: delirium tremens (DTs)
    • Treatment: Benzodiazepines
A

Alcohol

ToAST 2 ALcohol:

AST value is 2× ALT value

138
Q

Psychoactive Drug Intoxication and Withdrawal:

  • Intoxication:
    • euphoria, respiratory and CNS depression, ↓ gag reflex, pupillary constriction (pinpoint pupils), seizures (overdose)
    • most common
    • cause of drug overdose death
    • Treatment: Naloxone
  • Withdrawal:
    • sweating, dilated pupils, piloerection (“cold turkey”), fever, rhinorrhea, lacrimation, yawning, nausea, stomach cramps, diarrhea (“flu-like” symptoms)
    • Treatment:
      • long-term support
      • Methadone
      • Buprenorphine
139
Q

Psychoactive Drug Intoxication and Withdrawal:

  • Intoxication:
    • low safety margin
    • marked respiratory depression
    • Treatment:
      • symptom management (eg. assist respiration, ↑ BP)
  • Withdrawal:
    • delirium
    • life-threatening cardiovascular collapse
A

Barbiturates

140
Q

Psychoactive Drug Intoxication and Withdrawal:

  • Intoxication:
    • greater safety margin
    • ataxia
    • minor respiratory depression
    • Treatment:
      • Flumazenil (Benzodiazepine receptor antagonist, but rarely used as it can precipitate seizures)
  • Withdrawal:
    • sleep disturbance, depression, rebound anxiety, and seizure
A

Benzodiazepines

141
Q

Psychoactive Drug Intoxication and Withdrawal:

  • Intoxication:
    • nonspecific, mood elevation, psychomotor agitation, insomnia, cardiac arrhythmias, tachycardia, and anxiety
  • Withdrawal:
    • nonspecific, post-use “crash,” including depression, lethargy, ↑ appetite, sleep disturbance, and vivid nightmares
A

Stimulants

142
Q

Psychoactive Drug Intoxication:

  • euphoria, grandiosity, pupillary dilation, prolonged wakefulness and attention, hypertension, tachycardia, anorexia, paranoia, fever
  • skin excoriations with methamphetamine use
  • Severe: cardiac arrest, seizures
  • Treatment:
    • Benzodiazepines for agitation and seizures
A

Amphetamines

143
Q

Psychoactive Drug Intoxication:

  • impaired judgment, pupillary dilation, hallucinations (including tactile), paranoid ideations, angina, and sudden cardiac death
  • chronic use may lead to perforated nasal septum due to vasoconstriction and resulting ischemic necrosis
  • Treatment:
    • α-Blockers
    • Benzodiazepines
    • β-Blockers not recommended
144
Q

Psychoactive Drug Intoxication and Withdrawal:

  • Intoxication:
    • restlessness, ↑ diuresis, and muscle twitching
  • Withdrawal:
    • headache, difficulty concentrating, and flu-like symptoms
145
Q

Psychoactive Drug Intoxication and Withdrawal:

  • Intoxication:
    • restlessness
  • Withdrawal:
    • irritability, anxiety, restlessness, and difficulty concentrating
    • Treatment:
      • nicotine patch, gum, or lozenges
      • Bupropion/Varenicline
146
Q

Psychoactive Drug Intoxication:

  • hallucinogen
  • violence, impulsivity, psychomotor agitation, nystagmus, tachycardia, hypertension, analgesia, psychosis, delirium, and seizures
  • trauma is the most common complication
A

Phencyclidine (PCP)

147
Q

Psychoactive Drug Intoxication:

  • hallucinogen
  • perceptual distortion (visual, auditory), depersonalization, anxiety, paranoia, psychosis, possible flashbacks
A

Lysergic Acid Diethylamide

148
Q

Psychoactive Drug Intoxication and Withdrawal:

  • Intoxication:
    • euphoria, anxiety, paranoid delusions, perception of slowed time, impaired judgment, social withdrawal, ↑ appetite, dry mouth, conjunctival injection, and hallucinations
    • pharmaceutical form is Dronabinol: used as antiemetic (chemotherapy) and appetite stimulant (in AIDS)
  • Withdrawal:
    • irritability, anxiety, depression, insomnia, restlessness, and ↓ appetite
A

Marijuana (Cannabinoid)

149
Q

Psychoactive Drug Intoxication and Withdrawal:

  • Intoxication:
    • hallucinogenic stimulant
    • euphoria, disinhibition, hyperactivity, distorted sensory and time perception, and teeth clenching
    • life-threatening effects include hypertension, tachycardia, hyperthermia, hyponatremia, and serotonin syndrome
  • Withdrawal:
    • depression, fatigue, change in appetite, difficulty concentrating, and anxiety
A

MDMA (Ecstasy)

150
Q

Psychopathology:

  • physiologic tolerance and dependence on alcohol with symptoms of withdrawal when intake is interrupted
  • Complications:
    • alcoholic cirrhosis, hepatitis, pancreatitis, peripheral neuropathy, and testicular atrophy
  • Treatment:
    • Disulfiram (to condition the patient to abstain from alcohol use)
    • Acamprosate
    • Naltrexone (reduces cravings),
    • supportive care
    • Support groups such as Alcoholics Anonymous are helpful in sustaining abstinence and supporting patient and family.
A

Alcoholism

151
Q

Psychopathology:

  • caused by vitamin B1 deficiency
  • triad of confusion, ophthalmoplegia, and ataxia (Wernicke encephalopathy)
  • may progress to irreversible memory loss, confabulation, and personality change (Korsakoff syndrome)
  • symptoms may be precipitated by giving dextrose before administering vitamin B1 to a patient with thiamine deficiency
  • associated with periventricular hemorrhage/necrosis of mammillary bodies
  • Treatment: IV Vitamin B1
A

Wernicke-Korsakoff Syndrome

152
Q

Psychopharmacology:

ADHD

A

Stimulants

  • Methylphenidate
  • Amphetamines
153
Q

Psychopharmacology:

Alcohol Withdrawal

A

Benzodiazepines

  • Chlordiazepoxide
  • Lorazepam
  • Diazepam
154
Q

Psychopharmacology:

Bipolar Disorder

A
  • Lithium
  • Valproic Acid
  • Carbamazepine
  • Lamotrigine
  • Atypical Antipsychotics
155
Q

Psychopharmacology:

Bulimia Nervosa

156
Q

Psychopharmacology:

Depression

157
Q

Psychopharmacology:

Generalized Anxiety Disorder

A
  • SSRIs
  • SNRIs
158
Q

Psychopharmacology:

Obsessive-Compulsive Disorder

A
  • SSRIs
  • Venlafaxine
  • Clomipramine
159
Q

Psychopharmacology:

Panic Disorder

A
  • SSRIs
  • Venlafaxine
  • Benzodiazepines
160
Q

Psychopharmacology:

PTSD

A
  • SSRIs
  • Venlafaxine
161
Q

Psychopharmacology:

Schizophrenia

A

Atypical Antipsychotics

162
Q

Psychopharmacology:

Social Anxiety Disorder

A
  • SSRIs
  • Venlafaxine
  • Performance Only:
    • β-Blockers
    • Benzodiazepines
163
Q

Psychopharmacology:

Tourette Syndrome

A
  • Antipsychotics
    • Fluphenazine
    • Risperidone
  • Tetrabenazine
164
Q

Central Nervous System Stimulants

A
  • Methylphenidate
  • Dextroamphetamine
  • Methamphetamine
165
Q

Psychopharmacology:

  • ↑ catecholamines in the synaptic cleft, especially norepinephrine and dopamine
  • used for ADHD and narcolepsy
  • causes nervousness, agitation, anxiety, insomnia, anorexia, tachycardia, hypertension, weight loss, and tics
A

Central Nervous System Stimulants

166
Q

Typical Antipsychotics

A
  • Haloperidol
  • Pimozide
  • Trifluoperazine
  • Fluphenazine
  • Thioridazine
  • Chlorpromazine
167
Q

Psychopharmacology:

  • block dopamine D2 receptor (↑ cAMP)
  • used for Schizophrenia (1° positive symptoms), psychosis, bipolar disorder, delirium, Tourette syndrome, Huntington disease, and OCD
A

Typical Antipsychotics

168
Q

Typical Antipsychotics:

High Potency

A

Try to Fly High:

  • Trifluoperazine
  • Fluphenazine
  • Haloperidol

*more neurologic side effects (eg. extrapyramidal symptoms [EPS])

169
Q

Typical Antipsychotics:

Low Potency

A

Cheating Thieves are low:

  • Chlorpromazine
  • Thioridazine

*more anticholinergic, antihistamine, α1-blockade effects

170
Q

Typical Antipsychotics:

Adverse Effects

A
  • lipid soluble → stored in body fat → slow to be removed from body
  • Endocrine: dopamine receptor antagonism → hyperprolactinemia → galactorrhea, oligomenorrhea, gynecomastia
  • Metabolic: dyslipidemia, weight gain, hyperglycemia
  • Antimuscarinic: dry mouth, constipation
  • Antihistamine: sedation
  • α1-Blockade: orthostatic hypotension
  • Cardiac: QT prolongation
  • Ophthalmologic:
    • Chlorpromazine—Corneal deposits
    • Thioridazine—reTinal deposits
  • Neuroleptic Malignant Syndrome
171
Q

Extrapyramidal Symptoms

A

ADAPT:

  • Hours to Days:
    • Acute Dystonia (muscle spasm, stiffness, oculogyric crisis)
      • Treatment:
        • Benztropine
        • Diphenhydramine
  • Days to Months:
    • Akathisia (restlessness)
      • Treatment:
        • β-Blockers
        • Benztropine
        • Benzodiazepines
    • Parkinsonism (bradykinesia)
      • Treatment:
        • Benztropine
        • Amantadine
  • Months to Years:
    • Tardive Dyskinesia (orofacial chorea)
      • Treatment:
        • switch to atypical antipsychotic (eg. Clozapine)
        • Tetrabenazine
        • Reserpine
172
Q

Atypical Antipsychotics

A
  • Aripiprazole
  • Asenapine
  • Clozapine
  • Olanzapine
  • Quetiapine
  • Iloperidone
  • Paliperidone
  • Risperidone
  • Lurasidone
  • Ziprasidone
173
Q

Psychopharmacology:

  • not completely understood
  • most are D2 antagonists (Aripiprazole is D2 partial agonist)
  • varied effects on 5-HT2, dopamine, and α- and H1-receptors
  • used for schizophrenia—both positive and negative symptoms
  • also used for bipolar disorder, OCD, anxiety disorder, depression, mania, and Tourette syndrome
  • Clozapine is used for treatment-resistant schizophrenia or schizoaffective disorder and for suicidality in schizophrenia
A

Atypical Antipsychotics

174
Q

Atypical Antipsychotics:

Adverse Effects

A
  • All
    • prolonged QT interval
    • fewer EPS and anticholinergic side effects than typical antipsychotics
  • “-pines”
    • metabolic syndrome (weight gain, diabetes, hyperlipidemia)
  • Clozapine
    • agranulocytosis (monitor WBCs frequently) and seizures (dose related)
  • Risperidone
    • hyperprolactinemia (amenorrhea, galactorrhea, gynecomastia)
  • Olanzapine, ClOzapine → Obesity
175
Q

Psychopharmacology:

  • MOA not established; possibly related to inhibition of phosphoinositol cascade
  • used as mood stabilizer for bipolar disorder
  • treats acute manic episodes and prevents relapse
  • causes tremor, hypothyroidism, polyuria (causes nephrogenic diabetes insipidus), and teratogenesis
  • causes Ebstein anomaly in newborn if taken by pregnant mother
  • narrow therapeutic window requires close monitoring of serum levels
  • almost exclusively excreted by kidneys
  • most is reabsorbed at PCT with Na+
  • Thiazides (and other nephrotoxic agents) are implicated in toxicity
A

Lithium

LiTHIUM:

  • Low Thyroid (hypothyroidism)
  • Heart (Ebstein anomaly)
  • Insipidus (nephrogenic diabetes insipidus)
  • Unwanted Movements (tremor)
176
Q

Psychopharmacology:

  • stimulates 5-HT1A receptors
  • used for generalized anxiety disorder
  • does not cause sedation, addiction, or tolerance
  • takes 1–2 weeks to take effect
  • does not interact with alcohol (vs. Barbiturates and Benzodiazepines)
177
Q

Antidepressants

178
Q

Selective Serotonin Reuptake Inhibitors (SSRIs)

A
  • Fluoxetine
  • Fluvoxamine
  • Paroxetine
  • Sertraline
  • Escitalopram
  • Citalopram
179
Q

Psychopharmacology:

  • inhibit 5-HT reuptake
  • normally takes 4–8 weeks to have an effect
  • used for depression, generalized anxiety disorder, panic disorder, OCD, bulimia, social anxiety disorder, PTSD, premature ejaculation, and premenstrual dysphoric disorder
  • Adverse Effects
    • fewer than TCAs
    • GI distress
    • SIADH
    • sexual dysfunction (anorgasmia, ↓ libido)
A

Selective Serotonin Reuptake Inhibitors (SSRIs)

180
Q

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

A
  • Venlafaxine
  • Desvenlafaxine
  • Duloxetine
  • Levomilnacipran
  • Milnacipran
181
Q

Psychopharmacology:

  • inhibit 5-HT and NE reuptake
  • used for depression, general anxiety disorder, and diabetic neuropathy
  • Venlafaxine is also indicated for social anxiety disorder, panic disorder, PTSD, and OCD
  • Duloxetine is also indicated for fibromyalgia
  • causes ↑ BP, stimulant effects, sedation, nausea
A

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

182
Q

Tricyclic Antidepressants

A
  • Amitriptyline
  • Nortriptyline
  • Imipramine
  • Desipramine
  • Clomipramine
  • Doxepin
  • Amoxapine
183
Q

Psychopharmacology:

  • TCAs inhibit 5-HT and NE reuptake
  • used for major depression, OCD (Clomipramine), peripheral neuropathy, chronic pain, and migraine prophylaxis
  • nocturnal enuresis (Imipramine, although adverse effects may limit use)
  • causes sedation, α1-blocking effects including postural hypotension, and atropine-like (anticholinergic) side effects (tachycardia, urinary retention, dry mouth)
  • 3° _____ (Amitriptyline) have more anticholinergic effects than 2° _____ (Nortriptyline)
  • can prolong QT interval
  • Tri-C’s:
    • Convulsions
    • Coma
    • Cardiotoxicity (arrhythmia due to Na+ channel inhibition)
  • also causes respiratory depression and hyperpyrexia
  • confusion and hallucinations in the elderly due to anticholinergic side effects (Nortriptyline better tolerated in the elderly)
  • Treatment: NaHCO3 to prevent arrhythmia
A

Tricyclic Antidepressants

184
Q

Monoamine Oxidase Inhibitors

A

MAO Takes Pride In Shanghai.

  • Tranylcypromine
  • Phenelzine
  • Isocarboxazid
  • Selegiline (selective MAO-B inhibitor)
185
Q

Psychopharmacology:

  • nonselective _____ inhibition ↑ levels of amine neurotransmitters (norepinephrine, 5-HT, dopamine)
  • used for atypical depression, anxiety, and Parkinson disease (selegiline)
  • causes CNS stimulation and hypertensive crisis, most notably with ingestion of tyramine
  • contraindicated with SSRIs, TCAs, St. John’s wort, Meperidine, and Dextromethorphan (to prevent serotonin syndrome)
  • wait 2 weeks after stopping _____ before starting serotonergic drugs or stopping dietary restrictions
A

Monoamine Oxidase Inhibitors

186
Q

Atypical Antidepressants:

  • inhibits NE and Dopamine reuptake
  • also used for smoking cessation
  • Toxicity:
    • stimulant effects (tachycardia, insomnia)
    • headache
    • seizures in anorexic/bulimic patients
  • favorable sexual side effect profile
187
Q

Atypical Antidepressants:

  • α2-antagonist (↑ release of NE and 5-HT), potent 5-HT2 and 5-HT3 receptor antagonist and H1 antagonist
  • Toxicity:
    • sedation (which may be desirable in depressed patients with insomnia)
    • ↑ appetite
    • weight gain (which may be desirable in elderly or anorexic patients)
    • dry mouth
A

Mirtazapine

188
Q

Atypical Antidepressants:

  • primarily blocks 5-HT2, α1-adrenergic, and H1 receptors
  • also weakly inhibits 5-HT reuptake
  • used primarily for insomnia, as high doses are needed for antidepressant effects
  • Toxicity:
    • sedation
    • nausea
    • priapism
    • postural hypotension
A

Trazodone

TraZZZobone:

  • sedative
  • priapism
189
Q

Atypical Antidepressants:

  • nicotinic ACh receptor partial agonist
  • used for smoking cessation
  • Toxicity:
    • sleep disturbance
    • may depress mood
A

Varenicline

Varenicline helps nicotine cravings decline.

190
Q

Atypical Antidepressants:

  • inhibits 5-HT reuptake
  • 5-HT1A receptor partial agonist
  • used for major depressive disorder
  • Toxicity:
    • headache
    • diarrhea
    • nausea
    • ↑ weight
    • anticholinergic effects
  • may cause serotonin syndrome if taken with other serotonergic agents
A

Vilazodone

191
Q

Atypical Antidepressants:

  • inhibits 5-HT reuptake
  • 5-HT1A receptor agonist and 5-HT3 receptor antagonist
  • used for major depressive disorder
  • Toxicity:
    • nausea
    • sexual dysfunction
    • sleep disturbances (abnormal dreams)
    • anticholinergic effects
  • may cause serotonin syndrome if taken with other serotonergic agents
A

Vortioxetine

192
Q

Intravenous drug users at ↑ risk for _____.

A
  • hepatitis
  • HIV
  • abscesses
  • bacteremia
  • right-heart endocarditis
193
Q

Opioid Withdrawal and Detoxification:

long-acting oral opiate used for heroin detoxification or long-term maintenance therapy

194
Q

Opioid Withdrawal and Detoxification:

  • sublingual B_____ (partial agonist) is absorbed and used for maintenance therapy
  • N_____ (antagonist, not orally bioavailable) is added to lower IV abuse potential
A

Buprenorphine + Naloxone

195
Q

Opioid Withdrawal and Detoxification:

  • long-acting opioid given IM or as nasal spray to treat acute overdose in unconscious individual
  • also used for relapse prevention once detoxified
A

Naltrexone

Use Naltrexone for the long trex back to sobriety.

USMLE Step 1 (18 decks)

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