Psychiatry MNTH Flashcards
Criteria for Bipolar 1 diagnosis
One week of elevated or irritable mood. At least three of: Grandiosity Decreased need of sleep Talkative Flight of ideas Distractibility Impulsivity Agitation
Then needs to be serious enough for severe functional consequences/hospitalization
What is the best treatment for Mania?
Lithium
Quetiapine
Divalproex
Treatment for Bipolar 1 depression
Can you use SSRI or SSNRI?
Quetiapine
No, it can lead to a bout of mania.
What is the best pharmalogical Tx for Bipolar 1 maintenance?
Quetiapine
Lithium
Lamotrigine
How is a bipolar 2 Dx different from a bipolar 1 Dx?
Hypomania instead of mania+ the current or past depression
The hypomania must last for at least 4 days.
Same need of 3 of 7 things
Not severe enough for hospitalization.
Tx for Bipolar type 2?
Quetiapine
Lithium
Lamotrigine
What is Cyclothymia?
Numerous periods with hypomanic symptoms over at least two years.
The full criteria for hypomania or depression are never met.
Which bipolar drugs are indicated and contraindicated during pregnancy?
Quetiapine is the agent of choice
Depakote is ALWAYS contraindicated for neural tube defects
Lithium is contraindicated in the 1st trimester due to Epstein’s Anomaly
What is catatonia, how is it diagnosed, and how is it treated?
Waxy Flexibility, impulsivity, posturing, rigidity
Diagnosed with a Busch-Francis Scale and a lorazepam challenge
Treated with high-dose benzodiazepines and/or ECT (Electroconvulsive Therapy)
What is the criteria for a Dx of Major Depression?
5 of the following over a 2-week period with changes from previous function.
Sleep Disturbance Interest Decreased Guilt Energy changes Concentration Appetite or weight increase or decrease Psychomotor changes Suicidal Ideation
What is Dysthymia?
Sub clinical chronic depressive disorder lasting at least 2 years.
Doesn’t meet criteria for major depression
What is Premenstrual Dysphoric Disorder?
Meets the symptoms of Major Depression plus must be present in the final week before menses onset and improve within days of onset of menses.
What are Pharmacological and Non-pharmacological Tx for Major Depressive Disorder?
SSRIs, SSNRIs, Mirtazapine, Bupropion
Cognitive Behavioral Therapy
Psychotherapy
Transcranial Magnetic Stimulation
Electroconvulsive Therapy
Which populations are at high risk for MMD?
Postpartum Women Those with family history Advanced Age Neurological Disorders Physical Illness
DSM-5 Criteria for Schizophrenia?
Two or more of the following for at least 6 months (one must be from first 3)
Delusions Hallucinations Disorganized speech Disorganized or catatonic behavior Negative symptoms (lowered emotional expression or abolition)
Must show severe loss of function.
What are the four dopamine pathways involved with SCZ?
Mesolimbic: Increase in DA causes Positive symptoms
Mesocortical: DA hypoactivity: negative and cognitive symptoms
Nigrostriatal: Drugs- EPS and TD drug side effects
Tuberohypophyseal: Drugs- Hyperprolactinemia
Dx criteria for Schizophreniform Disorder?
Same as SCZ by for duration of 1-6 months.
What is the treatment for Psychotic disorders?
D2 Blockers
LAIs for SCZ or if you are worried about compliance
Drugs to treat specific symptoms (depression, mood, anxiety)
Criteria for a delusional disorder?
One or more delusion with a duration of at least 1 month
Criteria for SCZ not met
Function isn’t impaired outside of direct impact of delusions.
What are the types of hallucinations and which disorders are they linked with?
Auditory: Psychosis Visual: Neurological syndromes Tactile: Drug withdrawal Olfactory: CNS lesion Hypnagogic/hynapompic: Sleep disorders
What are the primary and secondary psychotic disorders?
Primary: SCZ, Delusional disorder, brief psychotic disorder
Secondary: Substance-induced, due to another medical condition.
What is a schizoaffective disorder?
An uninterrupted period of illness in which there is a major mood episode concurrent with Criterior A of schizophrenia.
Delusions or hallucinations for 2 weeks or more in the absence of a major mood episode
These are overdiagnosed.
What are the components of a mental status exam?
Appearance Attitude Speech Mood Affect Though process Though content Perceptions Cognition Insight Judgment Reliability
In a mental exam, which items are added to your ROS always?
Anxiety Mood Psychosis Substance Use- Specific SI/HI
Experiments of Harry Harlow?
Monkeys deprived of contact w/ mothers. They chose cloth over food.
Studies of Mary Ainsworth?
Strange Situation Test
- Anxious-Avoidant Insecure Attachment: Avoids or ignores caregiver, won’t explore
- Secure Attachment: Explores w/ caregiver, upset when they leave
- Anxious Resistant Insecure Attachment: Distress even before separation and hard to comfort on return
Theories of Konrad Lorenz
Imprinting
Theories of John Bowlby?
Maternal Deprivation Theory: No mother causes trouble
Built off Lorenz
What are the 8 virtues of Erik Erickson?
Hope, Basic Trust vs Basic Mistrust 0-18 months
Will, Autonomy vs Shame 1-3 years
Purpose Initiative vs guilt 3-5 years
Competence, Industry vs Inferiority 6-11 years
Fidelity, Identity vs Role Confusion 12-18 years
Love, Intimacy vs Isolation 18-40 years
Care, Generativity vs Stagnation: 40-65 years
Wisdom, Ego Integrity vs Despair: 65+
What are the 4 stages of Stage Theorists?
What are the Hallmarks of each stage?
Sensorimotor 18-24 months
- Object permanence
Preoperational 24 months to 7 years
- Symbolic thinking
Concrete operational: 7-11 years
- Acquisition of Conservation Hallmark
Formal Operational Adolescence to Adulthood
-Abstract thinking, creativity, Third eye question
What are the psychosocial stages and what changes can trauma make to them?
Whose theory is this?
Sigmund Freud
Oral 0-2 Anal 2-3 Phallic 3-7 Latency 7-11 Sexual 11+
Trauma can cause fixation or regression on or to different stages.
What are the three types of anxiety based on Freud’s theories?
Neurotic Anxiety: Worry we loose control of the Id (our compulsions)
Reality Anxiety: Fear of real world events (dog bite)
Moral Anxiety: Fear of violating our own moral principles
Define a panic attack
Abrupt onset of intense fear or discomfort that peaks in minutes with at least 4 of the following:
Palpitations Sweating Short of breath Chest pain Dizziness Paresthesias Fear of loss of control Shaking Sensations of choking Nausea Chills Fear of dying
Trypanophobia Algophobia Glossophobia Ophidiophobia Nosecomephobia Arachnophobia Coulrophobia Iatrophobia
Fear of needles Fear of pain Fear of public speaking Fear of snakes Fear of hospitals Fear of spiders Fear of clowns Fear of doctors
How much is spent on anxiety each year?
42 billion
Social Anxiety Disorder DSM-5
Marked anxiety about humiliating or emabarrassing yourself in social situations for at least 6 months.
Symptoms are out of proportion to the threat
Specific Phobia
Perisitent unreasonable excessive fear cause by the presence or anticipation of a specific object or situation
Can cause panic attacks
The object or situation is generally avoided
May become GAD
Agoraphobia
Intense anxiety to or in anticipation of entering two or more situations where the person feels stuck, unable to escape, or not able to get help
Public transport Open areas Closed areas Lines or crowds Alone outside the house
For at least 6 months, fear out of proportion
Panic Disorder DSM
What is the only single social trigger?
Recurrent unexpected panic attacks followed by one or both of the following for 1 month:
Persistent concern of having more panic attacks
Maladaptive change in behavior in response to the panic attacks
Divorce/separation
Generalized Anxiety Disorder DSM-5
Excessive anxiety and worry about a number of activities or events in multiple contexts on a near daily basis for 6 months with three of the following:
Restlessness Fatigue Poor concentration Muscle tension Irritability Sleep disturbance
Explain the Tx of GAD
Trusting relationship
Cognitive behavioral therapy
Exercise
SSRIs/Benzodiazepines
- Low dosage, slow titration
What are some medical conditions with anxiety-like symptoms?
CAD, CHF, Arrhythmia, PE Asthma, pneumonia Thyroid dysfunction, Menopause, Cushing disease, Anemia Seizure disorder Substance Abuse
What are indications and contraindications of use of Benzodiazepines in anxiety disorders?
Indications:
Rapid symptom control
Lack of effect of multiple antidepressants
Infrequent symptoms
Contraindications/Risks: Chronic opiate therapy Subastance abuse disorder Memory impairment Elderly
Criteria for PTSD
Exposure to actual physical or sexual trauma With one from each group 1. Negative alterations in mood 2. Hyperarousal: Hypervigilence 3. Avoidance 4. Intrusion symptoms: Nightmares
All more than 1 month duration with impaired function
What is the treatment for PTSD?
Psychotherapy, Exposure Therapy
SSRI, SNRI, Prazosin, Clonidine, Quetiapine, TCA
Not Benzos
Acute Stress Disorder
Criteria are the same as PTSD but apply only if 3-30 days have elapsed.
Adjustment Disorder
Emotional or behavioral symptoms in response to an identifiable stressor occurring within 3 months of the onset of the stressors.
Distress out of proportion with significant impairment.
Once the stressor is gone, the symptoms leave within 6 months.
No anhedonia, they still enjoy the things they love unlike MDD
What is the Tx for Adjustment Disorder?
Psychotherapy
No Medications
DSM-5 for OCD
Obesissions
- Persistent thoughts or urges that are unwanted and cause anxiety
- Individual attempts to ignore or suppress the thoughts by doing something
Conpulsions
- Repetitive Behaviors
- Behavior or mental acts are aimed at preventing or reducing anxiety.
Must take more than 1 hour a day and cause significant distress or impairment
What is the Tx for OCD
Exposure and Response Therapy
SSRI/SNRI
Fluoxetine, Fluvoxamine
Atypical antipsychotics, TCA, Benzos
What is the presumptive cause of OCD?
Orbitofrontal Cortex problems
DSM-5 Obsessive-compulsive personality disorder
Pervasive pattern of preoccupation with orderliness, perfectionism, mental control, at the expense of flexibility, openness, and efficiency.
- Preoccupied with details
- Excessive devotion to work
- Overconscientious
- Unable to get rid of worn out things
- Reluctant to delegate
- Adopts frugalness, money only for future catastrophe
- Stubbornness
What are the personality disorders in clusters A, B, and C
A. Paranoid, Schizoid, Schizotypd
B. Antisocial, Narcissistic, Histrionic, Borderline
C. Dependent, Avoidant, Obsessive-compulsive
Paranoid Personality
Humorless manner
Distrust: Everyone is out to get you
Affect is restricted and they appear to be unemotional
Schizoid Personality
Cold and Aloof
Use the defense of fantasy
They appear normal, speech is goal oriented, but they may answer questions in short sentences
Make up that they know people well that they haven’t seen in a long time
Schizotypal Personality
Distorted thinking
Linked with SCZ
Speech is distinctive or peculiar. They may claim to have special powers.
Use the defense of fantasy
Antisocial Personality
Composed, but have tension, irritability and rage
Complete absence of delusions or other signs of irrational thinking, “normal”
Don’t tell the truth and can’t be trusted
Show no remorse for behavior
Narcissistic Personality
Grandiose sense of self-importance
Can’t show empathy
May feign sympathy to get what they want
Histrionic Personality
Attention Seeking
Uses defenses of repression and dissociation
Seductive Behavior
May through tantrums, or accuse people when they aren’t the center of attention
Borderline Personality
Suicidal and Self Mutilitation
Chaotic sexual behavior, pansexuality
Outbursts of anger or violence
Intense and unstable relationships
Neuroses of anxiety, depression, depersonalization
Most challenging for physicians
Avoidant Personality
Hypersensitivity to rejection
Socially inhibited
Shows lack of self confidence
Not willing to enter relationships
Dependent Personality
Can’t be alone
Avoids responsibility
May stay in harmful relationships due to fear of void and loss of someone to take care of them
Obsessive-Compulsive Personality
Preoccupied with rules, neatness, and perfection
Have stiff, formal demeanor that is constricted
Things that break their routine will cause anxiety
What is the treatment for Borderline Personality Disorder?
DIALECTICAL BEHAVIOR THERAPY, TRANSFERENCE-Based psychodynamic psychotherapy
What is the best treatment model for Personality Disorders
E=MC3
Empathy, can’t cure but can Manage, Comorbidities, Countertransference, Consistent
Somatic Symptoms Disorder DSM-5
Tx
One or more somatic symptoms that are distressing or result in significant disruption of daily life for greater than 6 months.
With one of the following:
-persistent thoughts about the seriousness of symptoms
-Persistent high level of anxiety about health or symptoms
-Excessive time and energy devoted to the symptoms
Pain is the predominant somatic symptoms
Tx: CBT, regular visits
Illness Anxiety Disorder DSM-5
Preoccupation with having or acquiring a serious illness
***Somatic symptoms not present or are only mild.
High level of anxiety about their health
At least 6 months of symptoms that are better explained by any other mental disorder.
Conversion Disorder DSM-5
One or more symptoms of altered voluntary motor or sensory function:
Usually after Trauma (Abuse)*****
The symptoms cause clinically significant distress
(Visceral or motor symptoms, sensory deficits)
Fictitious Disorder DSM-5
Imposed on self
Falsification of physical or psych signs or symptoms.
The deceptive behavior is evident even in the absence of obvious external rewards
Not better explained by delusional disorder or psychotic disorder
Gain comes from going to the Dr*
Dissociative Identity Disorder DSM-5
Tx
Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession. Multiple personalities
Recurrent gaps in the recall of everyday events or personal info
Symptoms cause clinically significant distress
Not a normal part of accepted cultural or religious practice
Not from substance abuse
Tx: Psychotherapy
Dissociative Amnesia DSM-5
Tx:
Inability to recall important info, usually of a traumatic or stressful nature
Significant distress
No substance abuse
Not from any other dissociative identity disorder, PTST, or ASD.
Specified with Dissociative fugue: travel or bewildered wandering.
Tx: CBT, hypnosis, group therapy
Depersonalization/Derealization d/o DSM-5
Tx:
Presence of persistent or recurrent experiences of depersonalization, derealization, or both.
Reality testing remains intact
Clinically significant distress
Not from substance abuse or another mental disorder
Tx: SSRIs
Psychotherapy
Define Depersonalization
Derealization
Detached from body as an outside observer with respect to thoughts feelings, or body
Things around you don’t seem real (feature of PTSD)
Anorexia Nervosa DSM-5
Tx
Restriction of energy intake
Intense fear of gaining weight
Disturbance in the way in which one’s body weight or shape is experienced
***Underweight. Lower than 18.5 BMI
Hospitalization, Weight Restoration, Psychotherapy (family)
What is Refeeding Syndrome?
Seen in AN
Hypophosphatemia**
Hypocalcemia CHF Peripheral Edema Rhabdomyolysis Seizures
Bulimia Nervosa DSM-5
Tx:
Binge eating (lots within 2 hours, lack of control)
Recurrent inappropriate compensatory behaviors for weight (vomiting, exercise, laxatives)
Once a week for at least 3 months
Self-evaluation is unduly influenced by body shape and weight
Not low body weight***** Over 18.5
Tx: CBI, SSRIs
What are medical sequelae of Bulimia Nervosa?
Parotid Swelling
Dental erosion
Hypokalemic, hypochloremic metabolic acidosis
Binge-eating d/o DSM-5
Tx
Episodes of binge eating (lots in 2 hrs, loss of control)
Eating until you are uncomfortably full, once a week for 3 months
Marked distress from the eating
NO compensatory mechanisms (vomiting, laxative, enema)
Tx: CBT, SSRIs
Avoidant/Restrictive Food Intake Disorder DSM-5
Eating or feeding disturbance with one or more:
Significant weight loss <18.5 BMI
Significant nutritional deficiency
Dependence on enteral feeding or supplements
No cognitive distortions of body weight. Just doesn’t want to eat
Not explained by lack of available food or cultural practice
Not from another medical condition or mental disorder
SCOFF Screening
Screening for eating disorders
S: Sick because your full? C: Control of how much you eat? O: One stone weight loss (14 lbs) F: Fat belief when others say you are too thin? F: Food dominates your life?
Delirium DSM-5
Acute confusional state: impairment of memory, orientation, language, perception
A. Disturbance in attention
B. Develops over a short period of time that tends to fluctuate in severity during the course of a day
C. Additional disturbance in cognition (memory, disorientation, language)
D. A and C not better explained by preexisiting established neurocognitive disorder
E. Disturbance is a direct physiological consequence of another medical condition (meds)
What are the causes of delirium
Types?
Substance intoxication or withdrawal
Medication-induced
Another medical cause
Multiple etiologies
Hypoactive, hyperactive, mixed
How do you screen for delirium
Check serial 7’s, spell world backwards, ask about visual hallucinations (bugs), and the year that they are in
What are the risk factors of delirium?
Age of 65 Male Dementia Depression Immobility Functional dependence Dehydration
Which meds can cause delirium
Opioids Benzos Anticholinergics Antifungals Dopamine agonists
When should restraints be used during delirium
Only as a last resort. It should be explained to the patient. You can also use 1:1 patient monitoring
What can be used to cure delirium from
Alcohol or Benzo withdrawal
Anything else
ETOH or Benzo withdrawal: Benzos or barbiturates
Anything else: Haldo (monster QTc, check K+ and Mg+)
How many people who commit or attempt suicide have a diagnosed mental disorder?
How many have just depression?
95%
80%
How many people reported that they planned their suicide in less than 5 minutes?
75%
What are the modifiable and nonmodifiable risk factors for suicide?
Modifiable: Major depressive episode, with prominent anxiety symptoms Alcohol abuse Hopelessness Suicidal ideation and plan Access to lethal means
Nonmodifiable: Past suicide attempt Male Age over 65 Caucasian or Native American Divorced, widowed Unemployment Childhood sexual and physical abuse Alcohol dependence when facing losses Chronic neurologic illness Family history of suicide
What are protective factors from suicide?
Strong religious beliefs against suicide Strong social network Responsibility for children Hope for the future Good therapeutic alliance Positive affect
What are the types of suicidal ideation?
Passive: Morbid thinking
Active: “I want to jump in front of a bus)
How do you determine Acute risk of Suicide?
Low, Medium, High
Low: + SI but no plan or no intention
Medium: +SI and +plan but no intention; or +SI and + intention but no plan
High: +SI, +plan, and +intention to kill him/herself
What are some example of psychiatric emergencies?
Suicide Homicide/violence Medication side effects: Serotonin syndrome, NMS Malignant Catatonia Overdoses/Toxidromes Delirium Tremens
Where is the highest risk of Violence in the health care world?
ED
50% of health care providers experience violence in their careers
What is the best violence risk assessment?
Broset Violence Checklist
What are some tactics for De-escalation
What is the last line tactic?
Take and empathetic and non-judge mental stance
Allow for personal space
Don’t overreact
Pick your battles
Set limits
Validate or at least acknowledge the patient’s feelings
Offer oral medications (lorazepam, olanzapine)
Tell the pt why your are putting them in restraints, and how they can get out?
Then administer medications to reduce agitation: Haldol, lorazepam, diphenhydramine
What increases the risk of violence in patients?
Substance use doubles the risk
Mental illness itself doesn’t increase the risk.
What are the symptoms of anticholinergic toxicity?
Tx?
Red as a beet- cutaneous vasodilation Dry as a bone- anhydrosis Hot as a hare- hyperthermia Blind as a bat- blurry vision Mad as a hatter- hyperactive delirium Full as a flask- urinary retention
Tx: Physostigmine
What are the differences between NMS and Serotonin Syndrome?
SS vs NMS
Abrupt vs Gradual onset Rapid vs Prolonged course Myoclonus and tremor vs Diffuse Rigidity Increased vs Decreased Reflexes Mydriasis vs Normal
What is Malignant catatonia?
Catatonia that is hard to distinguish from NMS
Management is the same as NMS
Those with catatonia shouldn’t be given antipsychotics
What is Delirium Tremens?
Tx
Alcohol Withdrawal Syndrome
Mortality for DTs is up to 20% without Tx
Tx:
Supportive interventions
Fluids and electrolyte depletion
Benzos or phenobarb
Who are the partners in a collaborative care model?
PCP
BH care manager
Psychiatrist
Patient
What are the steps of motivational interviewing?
Engaging w/ POARS
Focusing
Evoking
Planning
POARS
Part of the engaging of motivational interviewing
P: Permission to talk O: Open-ended questions A: Affirm with positive comment R: Reflect and restate what pt. Says S: Summarize
What are the steps of Focusing in a motivational interview
Find the Factual Premise (saying they feel fine with high BP)
Find the Motivational Premise (My life is hectic)
Those are the points that the patient has to work through
Explain how Evoking is performed in a motivational interview?
Try to help the patient use elicit change talk
DARN mnemonic D: Desire A: Ability R: Reasons N: Needs
What are the steps of Planning in a motivational interview?
Mobilizing change talk
Commitment
Activation
Taking Steps
CATS
Use smart goals Specific Measurable Attainable Relevant Timely
DSM-5 Major Neurocognitive Disorder
Difference between major and minor
Evidence of significant cognitive decline in one or more:
- Learning and memory
- Language
- Executive Function
- Complex Attention
- Perceptual-motor
- Social cognition
For Major they must interfere with independence in everyday activities. Minor isn’t bad enough to interfere with those activities (paying bills, managing Meds)
Not delirium
Not MDD
What are the main types of Dementia?
What are the 2 most common types?
Alzheimer’s dementia Dementia with Levy Bodies Frontotemporal dementia Vascular dementia CJD
Alzheimer’s and Vascular
What labs do you get for a dementia work up
CBC CMP TSH Head CT HIV, RPR B12/Folate, +/- Vitamin D LFTs for hepatic dysfunction
Alzheimer’s Disease Features
Cause
Tx
Rapid Forgetting
Declarative episodic memory
Loss in the hippocampus and medial temporal lobes
B amyloid and tau protein deposits
Tx:
NO real medications to stop dementia or AD
Can use SSRI for depression and Trazodone for sleep. NO antipsychotics
Control risk factors (vascular), Acetylcholinesterase inhibitors (early AD)
-Donepezil, Galantamine, Rivastigmine
Memantine (as augmentation for severe AD) +/- Vitamine E supplementation
Frontotemporal dementia Features
Causes
Tx
Apathy and loss of empathy, Hyperorality, Compulsive behaviors, visual hallucinations, REM sleep behavior disorder
Pick Cells
Loss of frontal and temporal regions
Loss of driving
Tx:
Speech therapy, No Meds
Vascular Dementia Features
Causes
Tx
Second most common dementia
Age, HTN, DM, Hyperlipidemia, CAD, Smoking
Treat symptoms and lower Vascular problems
What is the best treatment of Levy-body Dementia visual hallucinations?
Clozapine
What are the key features of Geriatric Depression?
Low energy Sleep disruption (AM awakening) Decreased appetite Weight loss Somatic complaints/hypochondriasis
Pseduodementia
Tx
Dementia syndrome of depression
“May answer many questions with “I don’t know”
Occurs in 15% of older patients with depression
What is the Tx for depression in the elderly?
Psychotherapy
Use the Beers list!
SSRIs but be alert for hyponatremia. Meds are good Start low, go slow, but go!
ECT is a good option if 1st or 2nd line treatments fail.
