Psychiatry (p348-373) Flashcards
In evaluating a psych pt, what must first always be ruled out?
drug abuse
What should be the approach to treatment of psych disorders?
Combination tx with psychotherapy and pharmacologic tx
What are some criteria to hospitalization?
Danger to self
danger to others
Unable to care for self
Syndrome of repeated major depressive episodes
Major depressive disorder
What is the criteria for major depressive disorder?
2 depressive episodes to continue for greater than 2 weeks each seperated by atleast 2 months or greater.
What is psychodynamic therapy?
understanding self and inner conflicts
what is cognitive behavioral therapy?
recognizing negative thought or behavior and altering thinking/behavior accordingly
What is interpersonal therapy?
Examines relation of sx to negative/absent relationships with others
What is the indication for Electroconvulsive treatment?
refractory cases
What are the side effects of TCAs
orthostatic hypotension
prolonged QRS
When does seritonin syndrome occur?
MAOI interaction with SSRIs, meperidine or pseudoephedrine
When might hypertensive crisis occur in a pt on MAOi’s?
If they eat tyramine rich foods (wine and cheese)
What side effect is mirtazapine associated with?
agranulocytosis
Major depressive symotoms that continue for a duration of minimum 2 years.. .diagnosis?
Dysthymic disorder
Tx as you would MDD
Older adult whose partner just died, sx less than 2 months…diagnosis?
More than 2 months? Dx?
2 mos = MDD
Pt with increased energy, decreased need to sleep, pressured speech, hypersexuality, impulsivity, spending large amounts of money, outrageous activity. Dx?
Bipolar disorder (manic depression) – seen more in young people. whereas MDD is for people in 40s
How long must episodes last to be classified as bipolar?
> 1 week
What is the difference between bipolar I and II?
I = manic episode with or without depressive episodes
II = depressive episodes with hypomanic episodes but by definition the absence of manic episodes
What is rapid cycling and what can it be precipitated by?
4 episodeds in 12 months, can be precipitated by anti depressants
What is the 1st and 2nd line for bipolar disorder?
Valproate is 1st line
Lithium 2nd
Why must lithium levels be frequently checked?
Toxicity can cause tremor and polyuria from nephrogenic diabetes inspidus
Side effect of valproate and carbamazepine
Blood dyscrasias
What are the 2 biggest culprits of drug induced mania?
Dx?
Rx?
Cocaine and amphetimenes
Dx with Urine or serum tox screen
Tx: Ca channel blockers for acute autonomic sx
False sensory perception not based on a real stimulus
Hallucination
False interpretation of external reality
Delusion
When is hospitalization indicated for hallucinations or delusions?
When voice telling pt to hurt themselves or others or if condition is disabling enough to the point where pt cannot care for themselves
What is the time frame differences between schizophrenia, schizophreniform and brief psychotic disorder?
schizophrenia >6 months continuously
schizophreniform 1-6months
brief psychotic disorder 1 day to 1 month with full recovery to baseline functioning
Schizoaffective definition
mood disorder + schizophrenia
What kind of delusions do people with delusional disorder have?
non bizarre delusions
Pts acutely not oriented to person, time or places. Severity waxes and wanes
Delirium
Paranoid delusions + feeling of bugs crawling on skin (formication) is a sign of..
cocaine and amphetamine use
What drug was used if pt has visual, taste touch or olfactory hallucinations?
LSD and PCP
What class of drugs are chlorpromazine and haldoperidol?
Typical antipsychotics
What class of drugs are clzapine, respiridone and olanzapine
Atypical antipsychotics
Younger pt less than 25 yrs with MI like sx, escalate for 10 mins, last about 30 mins.Dx? Tx?
Panic disorder, dx made by exclusion
SSRI, SnRI, if you need asap, Benzos
Cognitive behavioral training, respiratory relaxation training
Sustained muscle spasm anywhere in the body, but often in the neck jaw or back, lasting 4hrs to 4 days. Dx? Tx?
Acute dystonia
Tx: IV diphenhydramine
Cog wheel rigidity, shuffling gait, resting tremor lasting 4 days to 4 mos. Dx? Tx?
Parkinsonism
Tx: Benztropine
Involuntary irregular movements of head, tough, lips, limbs and trunk. Lasts 4 mos - 4 years
Tardive dyskinesia
Tx: change meds or decrease doses immediately
Subjective sense of discomfort, restlessness, pacing, sitting down and getting up. Dx? tx?
Akathisia
Tx: lower medication doses
Life threatening muscle rigidity –> fever, increased BP/HR, rhabdomyolysis over 1-3 days. Can easily be misdiagnosed as a psycotic sx. Labs can show increased WBC, CK, transaminases, plasma myoglobin. Dx? Tx?
Malignant Neuroleptic syndrome
Tx: immediately stop drug, give Dantrolene (stops Ca release into cells), Cool patient to prevent hyperpyrexia
Fear of being in situations where escaping would be very difficult should a panic attack arise. Dx? Tx?
Agoraphobia
Tx: Exposure desensitization = exposure to noxious stimulus in crements while undergoing concurrent relazation tx. Also, B-blocker for prophylaxis
Recurrent thoughts
Obsessions
Recurrent act
Compulsions
Obsessive thought creates anxiety and compulsion relieves that anxiety. Commonly includes cleanliness/contamination. Pt recognizes the absurdity of the obsessions. Dx? Tx?
Obsessive Compulsive disorder
SSRI (1st line) or Clomipramine
CBT
Obsessive thought creates anxiety and compulsion relieves that anxiety. Commonly includes cleanliness/contamination. Pt sees nothing wrong with obsessions. Dx?
Obsessive compulsive personality disorder
Pt s/p traumatic violent event and relives the moment through conscious thoughts and dreams. Avoids public places and activities. Depression, moodiness, difficulty concentrating. Dx?
What is acute form of this
Post traumatic stress disorder
Acute form = acute stress disorder (seen in victims of sexual assault)
Tx: SSRI
What drug should you be cautious of giving PTSD pt?
Careful of giving benzodiazepines bc high association between substance abuse and PTSD
What are the 2 approaches of psychotherapy?
Prolonged exposure treatment: relieving the experience
Cognitive processing therapy: attacking the source vs. controlling the sx
Worry for most days for atleast 6 months, irritability and inability to concentrate. Insomnia, fatigue, restlessness. SOCIAL DYSFUNCTION (affecting school, job, marital strain). Dx? Tx?
Generalized anxiety disorder
Tx: psychotherapy bc chronicity of probleml, biofeedback and relaxation techniques are good
Pharm: B blocker
Paranoid, schizoid and schizotypal personalities thought of as weird or eccentric. Cluster ___
A
Borderline, antisocial, histrionic, narcissistic personalities thought of as wild, dramatic and agressive. Cluster ___
B
Avoidant, dependent, obsessive compulsive thought of as shy and nervous. Cluster ___
C
Transforming unacceptable feeling into actions, often loud ones (tantrums). What ego defense?
Acting out
Contstructivev service to others that brings pleaseure and personal staisfaction. What ego defense?
Altruism
Refusal to accept external reality because it’s too life threatening. What ego defense?
Denial
Redirection of some emotion from a real source to substitute person or object. What ego defense?
Displacement
Overt expression of ideas and feelings (especially those that are unpleasant to focus on or too terrible to talk about) that gives pleasure to others ie jokes about someone close to you just dying. What ego defense?
Humor
Patterning behavior after someone elses. What ego defense?
Identification
Explaining away the unreasonable in form of logic. What ego defense?
Intellectualization
Identifying with some idea or object so deeply that it becomes part of that person. What ego defense?
Introjection
Attributing unacceptable thoughts, feelings, behaviors and motives to others. What ego defense?
Projection
Personality disorder where pt negatively misinterprets actions of other. Projection is often ego defense. No fixed delusions or hallucinations. Dx?
Paranoid disorder cluster A
Personality disorder where pt is socially withdrawn, no close emotional ties, but can still recognize reality. Dx?
Schizoid cluster A
Personality disorder where pt believes in concepts not considered real by the rest of society (magic, clairvoyance) Often related to schizophrenics. Ego defense is fantasy. Dx?
Schizotypal cluster A
Personality disorder where pt violates the rights of others, break the law, seductive. Must have exhibited behevaiors while young (15) but actual dx can only be made as adult 18 yrs. Dx?
What would this dx be if child?
Antisocial. cluster B
Conduct disorder
Personality disorder where pt is volatile, swing wildly between idealizing and devaluing. Ego defense is splitting (people are very good or very bad). Have the ability to disassociate. Self destructive behavior. Dx?
Borderline personality disorder cluster B
Personality disorder where pt requires attention of everyone, uses sexuality and physical appearance to get it. Use disassociateion and repression. Dx?
Histrionic cluster B
Personality disorder where pt feels entitled because they are best and everyone else is inferior. dx?
Narcissistic cluster B
Personality disorder where pt can do very little on their own, nor can they be alone. Dx?
Dependant Cluster C
Personality disorder where pt feels inadequate and are extremely sensitive to negative commments. Reluctant to try new things. fear of embarassment.
Avoidant Cluster C
Personality disorder where pt is preoccupied by detail, rules, regulations, neatness. ego defense is isolation, putting up walls of self restraint and detail orientation that keep away any sign of emotional affect. Dx?
Obsessive compulsive Cluster C
Making the unreasonable seem acceptable. What ego defense?
Rationalization
Set aside unconscious feelings and express exact opposite feelings. What ego defense?
Reaction formation
Resorting to child like behaviro often seen in hospital. What ego defense?
Regression
Taking instinctive drives like sex and funneling that energy into a socially acceptable behavior like studying, behavior or emotion. What ego defense?
Sublimation
The conscious process of pushing thoughts into the preconscious. The conscious decision to delay paying attention to an emotion or need in order to cope with present reality. What ego defense?
Suppression
Lack of conscious manipulation of somatic sx. Dx?
Somatoform disorder
Consciously faking or manipulating sx for purpose of assuming the “sick” role but not for material gain. Dx?
Factitious disorder
Consciously faking sx for purpose of material gain. Dx?
Malingering
Factitious disorder with predominantly physical (not psychologic) sx/ Dx?
Munchhausen syndrome
pt claims nonexistant sx in someone else under his/her care. Ie parent brings in “sick” child. Dx?
Munchhausen syndrome by proxy.
Whats the treatment of factitious disorder?
Nearly impossible.
Often female pts
Somatization disorder
Tx: continuity of care - schedule regular appointments.
Pt with neurologic sx, not consciously faked ie. sensory defecits, stcking and glover sesory deficit begins exactly at wrist. Pt rarely gets hurt and all studies indicate intact neurologic pathways. Dx? Tx?
Conversion disorder - identify stressor
Tx: supportive, sx resolve
Preocupation with sz, pt does not complain of many sx, but misinterprets them as evidence of something serious. Dx? Tx?
Hypochondriasis
Tx: regular visits to MD, but try not to order labs/imaging. Psychotherapy.
Pt with concern with body, usually picks one feature and imagines deficits that other people don’t see. Dx? Tx?
Body dysmorphic disorder.
SSRI can help, surgery not recommended.
Review psychological tests chart
p. 363
Child
Autism
Autism without the langauge impairment. Dx?
Asperger’s syndrome
Vaccines cause autism. T or F?
FALSE
How do preschool children present with depression? Treatment?
hyperactive and agressive.
Tx: SSRI is controversial, family Tx is a major consideration.
Child who is bit too attached to his parents or any other figures in his life. Child is worried something will happen to these beloved figures. Dx? Tx?
Seperation anxiety disorder.
Tx: dednsensitizing tx, in some cases imipramine is used.
How do you differentiate oppositional defiant vs conduct disorder? Tx?
Bark vs. bite
Oppositional - pt argumentative, tempermental, esp with people they know.
Conduct - bully others, start fights, violate/destroy property.
Tx: strict rule setting and expected consequences
Inability to focus or perform tasts completely, easily distracterd by random stimuli.
Attention defict sx
Child is unable to sit still, talks excessively, and can never wait his turn in games.
Hyperactivity sx
Before what age do sx need to be present to diagnose ADHD?
Before age 7
What is the tx for ADHD?
Methylphenidate.
Children with ADHD have a higher liklihood of developing what adult disorders?
Conduct disorder and antisocial personality
Pt with involuntary tics, sterotyped repetitive movements or vocalizations present for >1 year. Dx? Tx?
Tourette’s syndrome
Haldoperidol
What is coprolalia?
Vocal tics in tourettes that are often obscene or socially unacceptable.
Psychotherapy not helpful.
Eating disorder where pt has decreased self worth and body image. Pt is 85% below expected body weight.
Anorexia
Why does amenorrhea occur in anorexic pts?
Because of weight loss
Eating disorder characterized by binge eating where pt has normal BMI.
Bulimia
What 2 physical findings are suggestive of purging?
abrasions over knuckles, dental erosions
How to treat eating disorders?
Hospitalize anorexic to get pt’s weight back to normal.,
Monitor electrolytes
Psychotherapy
How can you screen for alcoholism?
CAGE questionaire
C- cut down
A- annoyed about being asked about drinking
G- guilty for drinking
E - eye opener need a drink in the morning
Pt with agitation, irritability, decreased appetitie, dormications, cardiac arrythmia or infarction, stroke, seizure and nosebleeds. What is pt intoxicated with? Tx?
Cocaine/amphetamine
Tx: benzodiazepine for sz
Ca channel blockers for ischemia
Pt with intense fleeting euphoria, decreased memory.. Triad of decreased consciousness, pinpoint pupils, and respiratory depression should always lead to a suspicion of ______. Dx? tx?
Heroin/opiods
Tx: naloxone to reverse acute intoxication
Withdrawl - tx with a long methadone taper
Pt with intense psychosis, violence, rhabdomyolysis, hyperthermia. Intoxication with…? Tx?
PCP
Tx with supportive, benzos or haldoperidol for psychosis
Pt with sensation enchanced, color richer, music more profound,tastes heightened. Intoxication with? Treatment?
Intox with LSD, supportive treatment
______ identity is based on biology
Sexual
______ identity is based on self-perception
Gender
What age do children have a firm conception of their gender identity?
age 3
A pt seemingly possess different personalities that can each take control at a given time. Pt hx might include childhood trauma. Dx? Tx?
Dissociative disorder (Multiple personality disorder)
Tx focuses on gradual integration of these personalities
Syndrome of forgetting a great deal of personal information
Amnesia
Syndrome of sudden travel to another place, with inability to remember the past and confusion of present identity.
Fuge
Do amnesia or fuge involve shifting between different identities?
No
Any behavioral or emotional sx that occurs in response to stressful life events in excess of what is normal. Dx requires sx within 3 months of stressor and must disappear within 6 months of stressor disappearing. Dx?
Adjustment disorder
Pt unable to reisist the drive to peform certain actions harmful to themselves or others. These people feel anxiety before the action and gratification afterwards
Impulse control disorders
Discrete EPISODES of agressive behavior far in excess of any possible stressor. Dx?
Intermittent explosive disorder
Impulse to steal. Often feels guilty after.
Kleptomania
Purposeful fire setting. Often fascination. Dx?
Pyromania
Pt with hair pulling, causing observable hair loss.
Trichotillomania
What are 2 normal types of sleep?
REM and NREM
What is stage 1 of sleep characterized by?
Alpha waves and then theta waves
Stage 2 sleep is characterized by..?
Sleep spindles
Stage 3 and 4 sleep is characterized by..?
Delta wave sleep (most difficult to wake from)
What is REM sleep characterized by?
Dreaming
Unable to fall asleep or stay asleep recurrently over a 1 mo period.
Insomnia
Difficulties with sleep is called…
Dyssomnias
Recurrent sleep attachs associated with REM sleep and day dreaming.
Narcolepsy
Periods of apnea occuring during sleep
Sleep apnea
What are the 3 types of sleep apnea?
Obstructive: increased inspiratory effor that fails to result in decerased airflow
Mixed obstructive/central: periods of no inspiratory effor followed by inspiratory effect that is obstructed by collapse of oropharyngeal airway.
Central: loss of inspiratory effort
What is pickwickian syndrome?
central alvelolar hypoventillation.
What is the triad of sx for pickwickian syndrome?
somnolence, obesity and erythrocytosis
Child with suddenly sitting up in bed with diaphoresis, tachycardia and feeling frightened. Not fully awake. Pt goes to sleep after episode. Dx?
Night terror
During what phase of sleep do night terrors occur?
NREM
During what stage of sleep do nightmares occur?
REM sleep
Pt gets out of bed and wanders around. No memory of events. Occurs in NREM sleep. Dx?
Sleepwalking
Pt with irresistable urge to move limbs. Can be primary with no known cause or secondary to iron deficiency, dopamine deficiency or hypothyroidism. Dx? tx?
Restless leg syndrome.
Dx with labs to r/o underlying cause.
Tx: dopamine antagonist and treat underlying cause.
