Psychiatry Study Guide Flashcards
(349 cards)
1
Q
What are some symptoms of complicated bereavement?
A
- Guilt
- Pervasive thoughts of death
- Preoccupation with worthlessness
- Psychomotor retardation
- Prolonged functional impairment
- Hallucinatory experiences apart from that of the deceased person
2
Q
How does bereavement different from major depression?
A
- Transient, non-psychotic hallucinatory experiences
- Crying and intense feelings of sadness/loneliness (Grief- episodes, MDD-continuous)
- Self reproach (Grief- blame focused on deceased, MDD- general negativity)
- Variable response to intervention (Grief- welcome support, MDD-social withdrawal)
3
Q
When should pharmacotherapy be employed in the setting of grief?
A
- Medications used for symptomatic relief
- Antidepressants only used if pt. is depressed (i.e. not in normal grief)
- Short-term benzodiazepines can help with sleep onset in pts. with acute grief reaction
4
Q
What is the role of psychotherapy in MDD?
A
- Primary Rx in mild depression
* Adjunctive Rx to pharmacotherapy in moderate/severe depression
5
Q
When should pharmacotherapy be used in the treatment of MDD?
A
Should be used with moderate/severe depression, especially if neurovegetative signs are present
6
Q
What are risk factors for MDD in geriatric patients?
A
- Female sex
- Loss of family and friends
- Nursing home residence
- Lower SES
- Cognitive/functional impairment
- Medical/psych comorbidities (may lead to inc. suicide attempts)
7
Q
What medical conditions can mimic depressive symptoms?
A
- Delirium
- Dementia (neurocognitive d/o)
- Frontal lobe syndromes
- Epilepsy/seizure d/o
8
Q
What types of drugs can cause sx similar to depression?
A
- EtOH
- Sedative-hypnotics
- Withdrawal from stimulant
- Anti-hypertensives
- DA-blockers (i.e. anti-psychotics, GI drugs)
9
Q
What are the diagnostic criteria for dysthymic d/o?
A
Dysphoria and depressive sx that last for most of the day most days a week occurring over 2+ years and not remitting for longer than 2 consecutive months –>dysfunction or distress
10
Q
What are examples of sx found in dysthymic d/o?
A
Requires two or more of:
- Change in appetite
- Change in sleep
- Low energy
- Poor self-esteem
- Poor concentration
- Hopelessness
11
Q
What are the outcomes of dysthymic d/o?
A
- Resolution (+ possible recurrence)
* Exacerbation to major depression
12
Q
What are risk factors for poor outcomes in dysthymic d/o?
A
- FHx
- High neuroticism scores
- Co-morbid anxiety d/o
- Dysthymia that occurs prior to onset of MDD (vs. MDD preceding dysthymia)
13
Q
What are treatments for dysthymic d/o?
A
- Antidepressants (SSRIs, TCAs)
- Psychotherapy (only if combined with pharmacotherapy)
- Hospitalization if SI present
14
Q
How can dysthymic d/o be distinguished from partially treated MDD?
A
- MDD sx are felt every day, even if partially treated
* Dysthymic sx occur on most days but not every day
15
Q
What are the features of EtOH intoxication?
A
- Psychomotor and cognitive (slurred speech, disinhibited behavior, incoordation)
- Cardiovascular (hypotension and tachycardia)
- Metabolic (hypoglycemia, lactic acidosis)
16
Q
What are the features of EtOH withdrawal?
A
- Begins within 6 hrs of cessation of consumption
- Minor sx (tremulousness, mild anxiety, GI upset, etc.)
- Moderate and severe sx (withdrawal seizures, alcoholic hallucinosis, DTs)
17
Q
What are the features of alcoholic hallucinosis?
A
- VH>AH, tactile hallucinations
- Occur over 12-48h
- Pt. has clear sensorium
18
Q
What are the features of delirium tremens?
A
- Can last 7d
- Hallucinations, disorientation, tachycardia, HTN, fever, agitation, and diaphoresis
- Risk of death
19
Q
What is the appropriate management of EtOH intoxication?
A
- Supportive (FEN)
- Benzodiazepines for psychomotor agitation
- Chemical or mechanical restraints for DTs (inc. risk of rhabdomyolysis)
20
Q
What is the best pharmacological therapy for acute EtOH withdrawal sx?
A
Benzodiazepine derivatives
21
Q
What is the history in paranoid schizophrenia?
A
- Chronic course with duration >6 mos
- Pre-morbid functioning
- Poor social skills, social withdrawal, unusual thinking
- Substance abuse may be present
22
Q
What is the history in psychosis due to cocaine?
A
- Sudden onset
- Cocaine use
- Thinking disconnected from reality
- Visual hallucinations
- Delusions
23
Q
What is the MSE in paranoid schizophrenia?
A
- Psychotic sx
- Auditory hallucinations
- Flat affect absent
- Paranoid ideas
- Ideas of reference
- Loosening of association
24
Q
What is the MSE in psychosis due to cocaine?
A
- Psychomotor agitation/slowing
- Behavioral changes
- Paranoid delusions
- Visual hallucinations
- Impaired judgment
25
What are the physical examination findings in paranoid schizophrenia?
None, aside from MSE findings
26
What are the general physical exam findings in cocaine intoxication?
Physical exam findings will be present (as compared to paranoid schizophrenia); autonomic sx, n/v, WL, weakness, resp. depression, arrhythmia, seizure, coma
27
What is the gender breakdown for SA and completion?
M>F for completion, F>M for attempts
28
What is the relationship between marital status and risk for suicide?
Divorced/widowed > Single > Married
29
What are the essential components of an assessment of suicide risk?
* Suicidal ideation
* Planning, means, and lethality
* Previous suicide attempts (cardinal 7)
* Risk factors vs. protective factors
30
When should you especially inquire about guns in the home?
In the case of any patients at increased risk for suicide
31
What is passive suicidal ideation?
When the patient refers indirectly to situation where patient is dead: "My life is not worth living anymore"
32
What is the prognosis for a single episode of depression?
40% of patients will have a good prognosis (i.e. recovery)
33
What is the percentage of patients with one episode of MDD who will have another episode?
60%; increased risk of recurrence with partial recoveries
34
What are four medical/social consequences of improper Dx and mgmt of MDD?
* Unintentional weight loss or weight gain
* Job loss of patient and/or caretaker
* Increased suicide risk
* Neglect of dependents
35
When are patients with previous SA at greatest risk for attempting again?
Greatest risk within first 2 years of attempt, especially if high lethality and precipitating/env't circumstances unch.
36
What are some examples of social supports lacking as risk factor for suicide?
* Unemployment
* Fall in SES
* Adolescent pregnancy
37
What would be an example of an organized suicide plan with some intent?
Presence of loaded firearms in the home, bought a rope for a noose, counted out pills
38
What is active suicidal ideation?
When the patient directly refers to his/her own death: "I am going to kill myself"
39
What is the lifetime prevalence, gender distribution, and peak incidence of MDD?
Lifetime prevalence is 5-20%
F:M is 2:1
Greatest incidence at 20-40, decreases >65
40
What are three factors associated with poorer prognosis in MDD?
* Very severe initial episode
* Co-existing dysthymic disorder
* Serious medical condition
41
What is the mnemonic for suicide risk factors?
```
S: Sex
A: Age (& race)
D: Depression
P: Previous attempts
E: EtOH abuse
R: Rational thinking loss
S: Social supports lacking
O: Organized suicide plan
N: No spouse
A: Access to means
S: Sickness
```
42
How does FHx of suicide increase suicide risk?
9x higher in individual with 1st degree relative who committed suicide
43
What is a biological risk factor for suicide?
Decreased 5-HIAA
44
In what age groups and races is suicide most prevalent?
* Caucasians 75-84 y/o have 2x suicide rate as those 15-24
* AA males have highest rates at 25-34 but lower than age-matched Caucasians
* Native Americans
45
What is the suicide rate in schizophrenia? What is the associative psychiatric manifestation?
* Schizophrenia has 10% suicide rate
| * Associated with depression vs command hallucinations
46
What are means of suicide that should be screened for?
Firearms, pills
47
What are the high risk patients who require assessment of suicide risk?
* Hx of past suicide attempts (mood d/o, panic d/o, schizophrenia, EtOH/substance abuse, BPD)
* Co-morbid psychiatric conditions
* Caucasians, Native Americans
* AIDS, TLE
* Terminal or severe dz
48
What are four risk factors for MDD?
* Recent stressors
* Lack of individual support system
* History of early parental loss
* Gender and FHx of depression
49
What are three features of mood disorders (MDD, bipolar d/o)?
* Uncontrollable long-term changes in predominant mood w or w/o trigger
* Sleep difficulties (early waking)
* Psychomotor slowing
50
Give an example of a neurologic medical condition that increases depression risk
Parkinson's disease
51
Give an example of a neoplastic condition that increases depression risk
Carcinoma of the pancreas (pancreatic head)
52
Give an example of a chronic medical condition which can increase depression risk
AIDS
53
To what extent does chronic illness increase suicide risk?
* AIDS (21-36x)
| * Temporal lobe epilepsy (2.5x)
54
What is parasuicidal behavior?
Any serious, non-fatal self-injurious behavior with or without SI: cutting, overdose, neglect, substance abuse
Commonly associated with BPD
55
What protective factors help reduce suicide risk?
* Family and friends
* Dependents (children, parents, pets)
* Health alliance with counselor/healthcare provider
* Job or volunteer work
* Hobbies
* Education
56
What is the percentage of people with MDD who greatly improve or fully recover within 1 year?
60%
57
What impact does depression have on medical morbidity?
Increased risk
58
Give an example of a metabolic condition that increases depression risk
Hyper/hypothyroidism
59
Give examples of drug use & poison ingestion which can increase depression risk
EtOH (drug), heavy metal poisoning (poison)
60
Give an example of an infectious agent which can increase depression risk
TB
61
How might major depression present as underlying condition in primary care?
Somatic complaints, poor concentration, irritability
62
How might major depression present in the elderly?
Frequent visits to the doctor's office
63
How does complicated bereavement differ from major depression?
* Sx of major depression may present concomitantly
| * Diagnosis not usually given unless sx are still present two months after the loss
64
How might major depression present in someone with a different race, religion, or ethnicity than yours?
May describe as somatic problems (e.g. nerves, weakness, "heartbroken") vs mood disturbance
65
What percentage of patients with MDD commit suicide?
MDD has a 15% suicide rate
66
What are 4 features of anxiety disorders (GAD, panic, OCD, PTSD, phobias)?
* Exaggerated sense of worry or panic about 2+ life circumstances w and w/o trigger
* Sleep difficulty (difficulty onset d/t anxiety)
* Weakness
* Irritability
67
How might major depression present in teenagers?
Social withdrawal, failing grades
68
What is the percentage of people who will develop chronic depression?
20%
69
What co-morbid psychiatric conditions should you look for in dysthymic d/o?
* Major depression may occur after the first 2 years of the d/o (double depression)
* Similar co-morbidities to major depression (most psychiatric diagnoses)
70
What medical concerns (acute, chronic, risk) present in EtOH intoxication and withdrawal?
* Acute: Autonomic depression, coma, inc. aspiration risk
* Chronic: Cirrhosis, variceal bleeding, HCC, hepatic encephalopathy
* Increased incidence of pneumonia, TB, alcoholic CM, HTN, GI cancer with chronic EtOH use
71
What is schizophreniform disorder?
* Presence of criterion A symptoms of schizophrenia
* Lasts >1 month but <6 mos
* May include prodromal, active, and residual phases
72
What are criterion A symptoms of schizophrenia?
* Delusions
* Hallucinations
* Disorganized speech
* Disorganized or catatonic behavior
* Negative symptoms (flat affect, avolition, paucity of speech)
73
What are the behavioral or psychological changes seen in opiate intoxication?
* Euphoria leading to
- dysphoria
- psychomotor retardation
- impaired judgment
- social/occupational dysfunction
74
What physical exam findings are seen in opiate intoxication?
* Pupillary constriction always present
* Resp. depression
* Drowsiness, coma
* Slurred speech
* Hypotension, bradycardia
* Hypothermia
* N/v
* Impaired attention/memory
75
What is the management of opiate intoxication?
* Establish an airway
| * Naloxone (0.4 mg IV) should be given immediately
76
What is the presentation of opiate overdose?
Same as intoxication but more often results in coma, respiratory depression, and death
77
What is the management of opiate overdose?
Same as intoxication
78
When do symptoms of opiate withdrawal occur?
Within 10 hours of the last dose
79
What are some symptoms of mild opiate withdrawal?
* Dysphoric mood, anxiety, and restlessness
* Lacrimation or rhinorrhea
* Pupillary dilatation, piloerection, ANS sx
* Diarrhea
* Fever
* Insomnia
* Yawning
80
What are some symptoms of severe opiate withdrawal?
* Nausea, vomiting
* Muscle aches
* Seizures
* Abdominal cramps
* Hot and cold flashes
* Severe anxiety
81
How is opiate withdrawal achieved using methadone?
Gradual withdrawal using methadone (20-80 mg/day)
82
What is the MOA and t 1/2 of methadone?
* Weak mu opiate receptor agonist
| * t 1/2=15h (longer than heroin, morphine) -->fewer intoxicant or withdrawal effects
83
What drug is used for acute opioid withdrawal symptoms?
Clonidine; treats ANS sx but does little to curb the drug craving
84
What is the MOA of clonidine?
* Centrally acting a2 receptor agonist
| * Risks of sedation and hypotension
85
What are the components of an opioid withdrawal program?
Referral to an intensive day treatment program and Narcotics Anonymous
86
What is schizoaffective d/o?
* Meets the criteria for schizophrenia and concurrently meets the criteria for a major depressive episode, manic episode, or mixed episode
* Delusions or hallucinations for 2 weeks w/o significant mood sx
87
What is schizoaffective disorder, bipolar type?
*Patient with bipolar I d/o has a two week period with psychotic sx and no mood d/o
88
How would you treat schizoaffective d/o?
* Anti-psychotics and mood stabilizers
| * ECT
89
How would you treat bipolar I disorder?
Mood stabilizers
90
When would ECT be used in the setting of depression?
* Severe depression, esp. refractory to antidepressants and/or high risk of suicide
* Pts. in which antidepressant meds are contraindicated
* Pregnant women with severe depression
91
When would ECT be used in the setting of bipolar disorder?
*Used to treat mania and depression refractory to meds and/or when immediate improvement is critical
92
When would ECT be used in the setting of acute psychosis?
When immediate resolution of psychosis is medically or psychiatrically required
93
What elements of the medical H&P must be especially considered prior to ECT?
*Neurological and cardiovascular history and exam
94
What are contraindications to ECT?
* Intracranial mass
* Recent stroke
* Recent MI
* Exceptions to contraindications when risks of no ECT outweight risk of ECT itself
95
What are risks of ECT use?
* Risk of anterograde and retrograde memory loss with respect to treatment (mostly resolves within days to weeks)
* Headaches - treat with analgesics
96
What is buspirone? Why is it preferred for use?
* Non-benzodiazepine anxiolytic agent
* Non-addicting (can be used in addicts)
* No withdrawal syndrome or tolerage
* No sedation or EtOH potentiation
97
For what anxiety d/o is buspirone effective?
* GAD
* OCD
* Augmentation of antidepressants in MDD
98
For what anxiety d/o is buspirone ineffective?
* Panic d/o
* Social phobia
* PTSD/ASD
99
What are MAOi's used for?
* Major depression with atypical features
* Social phobia
* Panic d/o with agoraphobia
100
How do MAOi's function?
* Promotes decreased degradation of monoamines
| * Effects may last up to 2 weeks after discontinuation
101
What are AEs of MAOi use?
* Hypertensive crisis
* May precipitate mania in bipolar pts.
* Sedation
* Weight gain
* Orthostatic hypotension
102
How can AEs of MAOi use be prevented?
* Titrate dose over several weeks to minimize AEs
| * Adhere to low tyramine diet
103
With which drugs are MAOi's incompatible?
* Antihistamines
* Anti-hypertensives (hypotension)
* Anesthetics (hypertensive crisis)
* SSRIs (serotonin syndrome)
104
Which MAOi can cause major morbidity and mortality?
Phenelzine
105
What is the MOA of TCAs?
* Block the reuptake of NEPI, DA, and serotonin
| * Also interacts with muscarinic, cholinergic, a1 adrenergic, histaminic receptors
106
What are AEs of TCA use? Who is most susceptible?
* Anticholinergic
* Narrow angle glaucoma
* Orthostatic hypotension
* Intraventricular conduction delays
* Long PR, QT intervals
* The elderly are most susceptible (titrate dose)
107
Which class of TCAs are better tolerated and less likely to have anticholinergic and orthostatic side effects?
*Secondary TCAs
108
What are contraindications to TCA use?
* May precipitate mania in bipolar patients
* Use with caution in pts with liver or renal dz
* Do not use with MAOis
* May cause delirium with anticholinergics
* May block the effects of anti-hypertensives
* Avoid with class 1A antiarrhythmics
109
At which receptors does clozapine primarily act?
*5-HT2, D1, D3, D4 receptor antagonist
110
Why do atypical antipsychotics (SDAs) have fewer EPS?
*Less affinity for the D2 receptor
111
What is the only FDA-approved indication for clozapine use?
Treatment resistant schizophrenia, esp. after failure of other SDAs
112
What is the major side effect of clozapine which must be monitored?
* Agranulocytosis (occurs in 1-2% within first 6 mos of treatment)
* Monitor with weekly CBC and d/c if WBC <2000
* Potentiated by carbamazepine use
113
What are the benefits of clozapine use?
* Less EPS than typical antipsychotics and other SDAs
* Efficacy against some of the negative sx
* Less increase in prolactin release
114
What are risk factors for agranulocytosis in the setting of clozapine use?
* Increased age
| * Female sex
115
What are other blood dyscrasias seen in clozapine use?
* Benign leukocytosis, leukopenia, eosinophilia, elevated ESR
* Clozapine induced seizures
116
What is the incidence of clozapine induced seizures?
5% of pts. on >600 mg/day
3-4% of pts. on 300-600 mg/day
1-2% of pts. on <300 mg/day
117
How should pts. be managed in the setting of clozapine-induced seizures?
* Temporarily d/c clozapine and initiate phenobarbital
| * Restart clozapine at 50% of previous dosage
118
What are cardiovascular AEs associated with clozapine use?
* Tachycardia due to vagal inhibition
* Hypotension and subsequent syncope
* EKG changes (usually not clinically significant)
* Paradoxical hypertension in 4% of patients
119
What are other adverse effects associated with clozapine use?
* Sedation
* Fatigue
* Sialorrhea
* Weight gain
* GI sx
* Anticholinergic effects and fever
120
Co-administration of which drug with clozapine increases risk of NMS?
Lithium
121
What drugs have a higher incidence of weight gain?
Risperidone and olanzapine
122
What is the reason for slow titration?
Potential to develop hypotension, syncope, and sedation; tolerance with slow titration
123
What is the procedure for re-initiation of clozapine following holiday >36h?
Re-titration
124
What is the consequence of sudden clozapine d/c?
Cholinergic rebound sx (diaphoresis, flushing, diarrhea, hyperactivity)
125
What is the MOA of typical antipsychotics?
DRAs; D2 antagonism > H1, a1, M1
126
What are the advantages of using atypical antipsychotics (SDAs)?
* *Less risk of adverse neurological effects (e.g. EPS)
* Less potent increase in PRL secretion
* Work on positive and negative sx
127
What is the MOA of atypical antipsychotics?
Significant activity at 5-HT receptors
128
What are the low potency typical DRAs? (50-100 mg = 100 mg CPZ)
* Chlorpromazine (Thorazine)
* Thioridazine (Mellaril)
* Mesoridazine (Serentil)
129
What are the mid potency DRAs? (10 mg=100 mg CPZ)
* Perphenazine (Trilafon)
* Loxapine (Loxitane)
* Droperidol (Inapasine)
* Molindone (Moban)
130
What are the high potency DRAs? (1-5 mg=100 mg CPZ)
* *Haloperidol (Haldol)
* Trifluoperazine (Stelazine)
* Fluphenazine (Prolixin)
* Thiothixene (Navane)
* Pimozide (Orap)
131
Why are high potency DRAs used in spite of their increased risk of EPS?
*Lower incidence of other anticholinergic, a1 antagonism as compared to low potency DRAs
132
What are the guidelines for typical antipsychotic use in schizophrenia?
All typical antipsychotics are equally efficacious
133
Which antipsychotics are best for negative sx?
Atypicals (SDAs)
134
Which SDAs are less likely to raise PRL levels?
Clozapine, olanzapine, sertindole
135
Which SDAs are anticholinergic and sedating?
Clozapine and olanzapine
136
What is the criteria for an adequate trial of DRAs?
* Lasting 6-8 weeks
| * At 1000 mg/day in CPZ equivalents
137
What is the criteria for an adequate trial of SDAs?
* Lasting 8-12 weeks
| * Pt. must have failed at least 1 typical and 2 atypicals to use clozapine
138
What are the manifestations of EPS? How are they treated?
* Parkinsonism
* Acute dystonia
* Acute akathisia
* Tardive dyskinesias
* Treat with anticholinergics (benztropine, amantadine, diphenhydramine)
139
What are other neurologic AEs of antipsychotics?
* NMS
* Epilepsy
* Sedation
* Central anticholinergic effects
140
What is the cause and manifestation of neuroleptic induced Parkinsonism?
* Blockade of DA transmission in nigrostriatal tract
* Lead-pipe, cogwheel rigidity
* Shuffling gait
141
What is the cause and manifestation of neuroleptic induced acute dystonia?
* Due to DA hyperactivity in BG when CNS levels of DRA fall between doses (esp. IM dose)
* Slow, sustained muscular contraction/spasm leading to involuntary movt.
142
What is the on the DDx for neuroleptic induced acute dystonia?
* Seizures
| * Tardive dyskinesia
143
What is the treatment for neuroleptic-induced acute dystonia?
* IM anticholinergics
| * IV/IM diphenhydramine
144
What is the cause and manifestation of neuroleptic-induced acute akathisia?
* Imbalance of NE and DA systems due to DRA
| * Subjective feeling of muscular discomfort leading to involuntary agitation, pacing, sitting/standing, dysphoria
145
How can neuroleptic-induced akathisia be managed?
* Reduce dosage of antipsychotic
| * Use propranolol, benzos, or clonidine for sx
146
What is the cause and manifestation of neuroleptic-induced tardive dyskinesia?
* DA receptor supersensitivity in BG due to chronic DA blockade
* Irregular choreoathetoid movements of head (esp. perioral), limb, trunk muscles
* Develops rapidly, stabilizes, and usually remits
147
How can TD be avoided in pts?
* Use DRAs only when necessary and at lowest effective dosages
* Use SDAs in pts. with TD: reduce movt and risk of exacerbation
148
What are the manifestations of NMS?
* Muscular rigidity and dystonia, akinesia
* Mutism
* Obtundation and agitation
* Hyperpyrexia (<107 F), sweating, tachycardia, hypertension
149
What is the timecourse of NMS?
* Evolves over 24-72 hours
| * Untreated syndrome lasts 10-14 days
150
How is NMS acutely managed?
*Supportive tx using antiparkinsonian meds, dantrolene for 5-10 days
151
How is NMS avoided in long term?
*Switch to low potency drug or SDA when treatment restarted
152
What is the cause of DRA associated epilepsy?
* Slowing and increased synchronization of EEG -->decreased seizure threshold
* Seen in low potency drugs > high-potency drugs
153
What is the cause of DRA-associated sedation? How can it be managed?
* H1 receptor blockade
* CPZ > Thioridazine > high-potency DRAs
* Dose at bedtime
154
What are some central anticholinergic effects seen in DRA use? How are they treated?
* Severe agitation
* Disorientation
* Hallucinations
* Seizures
* High fever
* Mydriasis
* May lead to stupor, coma
* Treat with physostigmine, atropine
155
Which DRAs are more cardiotoxic?
Low potency > high potency
156
What are the cardiotoxic effects of CPZ?
* QT, PR elongation
* T wave blunting
* ST depression
157
Do DRAs have an effect on incidence of sudden death in schizophrenics?
No
158
What is the cardiotoxic effect of pimozide and what is it potentiated by?
* Pimozide prolongs QT
| * Potentiated by macrolides
159
What are the cardiotoxic effects of thioridazine?
* T-wave effects
| * Malignant arrhythmias
160
At what QT duration is there increased risk for VTach/VFib
QT > 440
161
What is a possible hemodynamic side effect of antipsychotic use? How is it managed?
Orthostatic hypotension (a-adrenergic blockade, tolerance develops)
* *Epi results in worsening of hypotension (B-agonist)
* *Use pure a-adrenergic pressor (e.g. NE) for Rx
162
Which antipsychotics have the highest incidence of orthostatic hypotension?
Low potency DRAs (chlorpromazine, thioridazine, chlorprothixene), clozapine
163
What are the hematological side effects of antipsychotics?
* *Transient leukopenia (to ~3500) with DRAs
* *Agranulocytosis in 1/10000 pts (1-2% taking clozapine)
* Rare thrombocytopenic/non-thrombocytopenic purpura, hemolytic anemias, pancytopenia
164
What are the sexual side effects of antipsychotics?
* Impotence in 50% of males on DRAs
* Anorgasmia
* Dec. libido (and retrograde ejaculation) esp. thioridazine
165
What are anticholinergic side effects of antipsychotics?
* Dry mouth/nose
* Blurred vision
* Constipation
* Urinary retention
* Mydriasis
166
Which antipsychotic drugs have higher incidence of anticholinergic effects? Which drugs potentiate these effects?
* Chlorpromazine, thioridazine, mesoridazine, loxapine
| * Potentiated by TCAs
167
What are metabolic side effects of antipsychotics?
* Weight gain (DRAs, risperidone, olanzapine)
| * Endocrine (D2 blockade -->increased PRL secretion, gynecomastia/galactorrhea/sexual dysfunction/amenorrhea)
168
What antipsychotic may cause jaundice?
* 1/1000 of patients on chlorpromazine
| * Seen in 1st month of treatment
169
What are dermatologic side effects of antipsychotics? Which drugs cause them?
Seen most commonly in low-potency DRAs
* Allergic dermatitis
* Photosensitivity and blue-gray discoloration of sun-exposed skin with chlorpromazine use
170
What are ophthalmologic side effects of antipsychotics? Which drugs cause them?
* *Irreversible retinal pigmentation with >800 mg/day thioridazine (impaired night vision and possible blindness)
* *Benign eye pigmentation with 1 to 3 kg lifetime doses of chlorpromazine
171
Name an atypical antidepressant which causes lowered seizure threshold
Wellbutrin (buproprion)
<450mg/day =0.4% risk
450-600mg/day=4% risk
*Contraindicated with h/o seizures, brain injury, abnl EEG, recent EtOH withdrawal
172
Name a psychostimulant which causes lowered seizure threshold
Ritalin (methylphenidate)
| Toxicity can present with seizures
173
Name a DRA which causes lowered seizure threshold
Chlorpromazine (thorazine)
| Carries higher risk of seizures than most other typicals
174
What is a panic attack?
* Sudden onset of intense fear (anxiety), terror, apprehension, and sense of impending doom
* Lasts several minutes to hours
* Somatic sx such as palpitations, paresthesias, hyperventilation, diaphoresis, chest pain, dizziness, trembling, dyspnea
175
What is agoraphobia?
Anxiety and/or avoidance related to going places where one would feel vulnerable in the face of a panic attack or anxiety sx
176
What is generalized anxiety disorder?
* Intense pervasive worry over every aspect of life for at least 6 months
* No panic attacks or phobias
177
What is panic disorder?
* Recurrent unexpected panic attacks
| * May occur w/ or w/o agoraphobia
178
What is social phobia?
Intense fear of being scrutinized in social or public situations
179
What is major depression with anxiety?
Depressed mood with neurovegetative s/sx (SIGECAPS)
180
What is PTSD?
* Persistent re-experiences of a trauma via intrusive images, dreams, illusions, hallucinations, and flashbacks
* Hyperarousal, detachment, dissociation
181
What pharmacologic therapy is available for panic d/o?
* SSRIs, benzos, TCAs, MAOis
* Start with low dose SSRIs to prevent anxiety (avoid in hx of bipolar)
* Benzos usually used after other tx failed (avoid EtOH, 1st tri pregnancy)
* Beta blockers for sxs
182
What psychotherapeutic interventions are available for panic d/o?
* Relaxation training for panic attacks
* Systemic desensitization for agoraphobia
* Other psychotherapy, behavioral therapy, etc.
183
What is DDx of panic d/o?
* CVD, colitis, asthma, organic brain d/o, seizure d/o
* Sub abuse, w/d from sedatives, hypnotics, benzos
* Thyroid, metabolic derangements
184
What is the definition of delirium?
* Reversible state of global cortical dysfunction
* Abrupt onset with identifiable precipitant
* Variable course (waxing/waning)
185
What is the 1-year mortality rate assoc. with delirium?
>40%
186
What is the definition of dementia? What are examples?
Memory loss with 1+ cognitive defects
* Aphasia
* Apraxia
* Agnosia
* Disturbance in exec. fxn
* Usu. permanent
187
What are the most common causes of dementia?
* Alzheimer's dz
| * Vascular dz
188
What is pseudodementia?
* Typically assoc. with depression
* Prominent mood sx but memory usu. intact
* Resistant pts. are able to answer MSE questions if pushed
189
What is psychosis?
* Gross impairment of reality testing
| * Primary or secondary to another d/o
190
What is behavioral psychotherapy and what are its indications?
Changing behavior w/o considering thought process using positive or negative feedback
*Methods: systematic desensitization, flooding, implosion
191
What is cognitive psychotherapy and what are its indications?
* Focus on conscious thought processes; modify automatic thoughts
* Psych sx produced by inappropriate patterns of thought/distortions
* Indicated for mild/moderately depressed pts. w/o comorbidities
192
What is psychodynamic psychotherapy?
* Focus on the unconscious processes underlying behaviors and conscious thought
* Pt. must have high level of understanding/ego strength (not psychotic)
* Uses free association, defense interpretation, understanding transference rxns
193
What is the psych perspective on competency?
* Can only be considered re: specific task
* Can change with time and must be reassessed
* Is officially determined by court, psych. can give opinion
194
What are the components of capacity to consent to medical Tx?
* Ability to communicate a decision
* Ability to maintain a stable choice
* Understanding of relevant information
* Appreciation of potential consequences
* Ability to manipulate information (i.e. risk/benefit weighing)
195
What are the criteria for determining civil competencies (i.e. controlling finances)?
* Ability to understand situation
* Ability to manipulate information
* Ability to communicate decision
196
What are a patient's legal rights with respect to psychotropic meds?
* Pt. may refuse to take antipsychotics until court has deemed pt. incompetent with respect to this decision and approved specific Tx plan
* Case must be re-heard by court if new meds are to be added later
197
What are the elements of informed consent?
* Competency
* Disclosure of pertinent info to make adequate decision
* Voluntariness of pt. to undergo Tx, should not impact discharge
198
What is the term for treating a patient without informed consent?
A tort (battery)
199
What are exceptions to treating pts. without informed consent?
* Imminent threat of danger to pt. or others
* Pt. waives
* Therapeutic privilege (withholding info that could harm pt.)
200
What are the main differences between benzos?
* Onset of action
* Duration of action/half-life
* Potency
201
Which benzos are better suited for use as hypnotics? What are the risks of these?
* Shorter duration benzos b/c less morning sedation
| * More addicting and habit forming
202
What is the MOA of benzos?
GABA potentiation to decrease neuronal excitability
203
What are the indications for benzos?
* Anxiety d/os (panic, social phobia, GAD, adjustment d/o w/anxious mood)
* Insomnia
* EtOH withdrawal
* Seizure prophylaxis
* Pain management (off label, risk of abuse)
204
What are the clinical indications for diazepam (Valium)?
* Anxiety
* Pre-op and conscious sedation
* EtOH withdrawal
205
What are the clinical indications for clonazepam (Klonopin)?
* Prophylaxis of seizure
| * Panic d/o
206
What are the clinical indications for lorazepam (Ativan)?
* Anxiety
* Insomnia
* Pre-op sedation
207
What are the potential risks/AEs of benzo use?
* Oversedation -->dizziness, ataxia, impaired fine motor coord.
* Resp. distress, esp. when combined with other sedative-hypnotics (e.g EtOH)
* Small risk of cog. impairment
* Anterograde amnesia with rapid onset benzos
208
What are contraindications for all benzos?
* Pts. with sub abuse
* Geriatrics
* Pedi
* OB/pregnancy (Cat C, D)
* Pts. on CNS depressants, EtOH, P450 inhibitors
209
What are contraindications for diazepam, chlordiazepoxide?
* Metabolized in liver
| * Avoid in pts. with hepatic dysfunction
210
What is the contraindication for clonazepam?
* Metabolized in kidney
| * Avoid in pts. with renal failure
211
What alternatives exist for pts. who cannot safely take benzos for anxiety?
* Antidepressants
* Anticonvulsants
* Buspirone
* Antihypertensives
* Neuroleptics
212
What alternatives exist for pts. who cannot safely take benzos for insomnia?
* Sleep hygiene adjustments
* Trazodone
* TCAs
* Doxepin
* Mirtazapine
* Zolpidem
213
What are the characteristics of a conversion d/o?
* Symptoms/deficits affecting voluntary motor or sensory fxn that suggest but are not fully explained by neuro or medical condition, or sub abuse
* Symptoms are not intentionally produced or feigned
214
When is the diagnosis of conversion d/o deferred?
When presentation is explained as culturally sanctioned behavior or experience
215
What percentage of pts. with conversion d/o are later found to have true neurological illness?
21-50%
216
When does conversion d/o typically manifest?
Late adolescence or early adulthood
217
What category of illnesses are important to remain on DDx for conversion d/o even if they appear to be "pseudo-symptoms"?
Neurological illnesses; may have inconsistent presentations
218
How is conversion d/o treated?
* Insight-oriented psychotherapy
* Hypnosis
* Relaxation therapy if needed
* Most pts. spontaneously recover
219
What are the criteria for somatic sx d/o?
* One or more somatic symptoms that are distressing or result in significant disruption of daily life
* Excessive thoughts, feelings, behaviors related to somatic dx or associated health concerns
220
What is the most effective strategy for Rx of somatic sx d/o pts?
* Short, regular appointments every 4-6 weeks
* Avoid unscheduled, "as needed" appointments
* PE is done to look for signs of illness w/o being guided by pt.'s complaints
221
What is the definition of illness anxiety?
* Preoccupation with fears of having a serious disease, despite adequate medical eval and assurance
* Pts. misinterpret body sx and may border on delusional in their beliefs
222
How should a PCP deal with a hypochondriac patient?
* PCP must be willing to spend time with patient on regular basis, providing reassurance
* Be firm despite pt.'s insistence when exam does not warrant further testing
223
What are the three phases of cocaine withdrawal and Rx?
* Crash -- hospitalization + benzos, antipsychotics
* Withdrawal -- support group + DA agonists
* Extinction -- support group + drug taper/ d/c
224
What are the features of cocaine crash?
* Extreme exhaustion after binge
* Initial depression, agitation, anxiety followed by craving for sleep
* Hypersomnolence and hyperphagia
* SI is common
225
What are the features of cocaine withdrawal?
* Decreased energy, lack of interest, and anhedonia
* Sx last about 2-5 days
* Relapse is most likely at this phase
226
What are the features of cocaine extinction?
* Indefinite period during which evoked craving can occur
* Increased risk for relapse
* Moods, people, locations, or objects associated with cocaine use evoke craving
227
What are the features of benzo withdrawal?
* Asymptomatic for days and then acutely anxious
| * May have physical sx (dilated pupils, tachycardia/HTN)
228
What are the features of protracted benzo withdrawal?
* Mild withdrawal sx
* Includes anxiety, mood instability, sleep disturbance
* May be severe: paresthesias, psychosis
* Waxing/waning of sx intensity characteristic of low-dose protracted benzo withdrawal
229
What are the features of symptom rebound in benzo withdrawal?
* Transient increase in w/d sx 1-2 weeks after benzo w/d
* Intensified return of sx for which benzo was Rx
* Lasts days to weeks after discontinuation
230
What is the Rx for sx of low dose benzo withdrawal?
Phenobarbital -->taper as tolerated
231
What is the Rx for palpitations, autonomic hyperreactivity in benzo withdrawal?
* Beta blockers (propranolol)
| * A2 agonists (clonidine)
232
What are the features of acute mania?
* Period >7 days with elevated, expansive, or irritable predominant mood
* sx: DIG FAST
* May include psychotic sx (hallucinations, delusions(
* No evidence of physical or chemical cause
233
What are the features of delirium?
* Acute onset, decreased level of consciousness that waxes/wanes
* Global cognitive impairment
* Psychotic sx of paranoia, hallucinations, delusions may be present
234
What are the best tx for acute mania and long-term prophylaxis?
* Acute: antipsychotics, ECT
| * Long-term: lithium, carbamazepine, valproic acid
235
What is the best Rx for delirium?
*Find the underlying cause and correct it
236
What is the best pharmacotherapy for use in delirium?
* High potency antipsychotics (Haldol 2 mg) for short period of time
* Second line: lorazepam
237
What are limits/exceptions to confidentiality?
* Potential harm to 3rd parties
* Likelihood of harm is high
* No alternative means exist to warn/protect those at risk
* 3rd party can take steps to avoid harm
238
What are examples in which confidentiality can be broken?
* Child/elder abuse
* Impaired automobile drivers (e.g. seizure d/o)
* Suicidal/homicidal patient
* Domestic violence
239
What are medical complications of restriction-type anorexia nervosa?
* Hypothalamic dysfunction: constipation, amenorrhea, cold intolerance
* Bradycardia, hypothermia, hypotension, metabolic derangements
* Enlarged parotid glands, dry scaly skin
* Anemia
* MVP
240
What is the criteria of weight loss in anorexia nervosa?
<85% of expected weight for dx
241
What are medical complications of bulimia nervosa?
* Increased serum amylase, ALT, AST
* Abn'l dexamethasone suppression test
* Hypocalcemia or hypokalemic alkalosis
* Weakness, lethargy, ECG changes
* Parotid enlargement, knuckle calluses, dental caries
242
What are indications for hospitalization of an eating d/o pt.?
* Severe starvation and weight loss
* Hypothermia
* Hypotension
* Electrolyte imbalance
* Depressed patients with AN or BN with SI or psychosis
* Failure of outpatient Rx
243
What is the treatment for eating d/o?
* Restore pt.'s nutritional state (restore weight and metabolic balance)
* Modify pt's distorted eating behavior (individual and group therapy, increase caloric intake)
244
What are psychotropic medications used in Rx of eating d/o?
* Fluoxetine (60 mg/day)
| * Antipsychotics to treat cognitive distortions and help induce weight gain
245
What are some contraindicated medications for use in eating d/o?
* Buproprion contraindicated d/t seizure risk
| * TCAs can induce QT prolongation and increase risk of VTach, sudden death
246
What is autism spectrum disorder?
* Neurodevelopmental d/o
* Persistent impairment in reciprocal social communication and social interaction
* Restricted, repetitive patterns of behavior, interests, or activities
247
What are the criteria for meeting autism spectrum disorder?
* Sx must be present in early developmental period
* Sx must cause clinically significant functional impairment
* Disturbances are not better exaplied by ID or global developmental delay
248
How is autism spectrum disorder diagnosed?
* PCP may conduct screening tool; if positive, may warrant thorough eval
* Comprehensive evaluation by multidisciplinary team --> neurological assessment and cognitive/language testing
249
What is ADHD?
* Neurodevelopmental d/o typically presenting in childhood
| * Persistent pattern of inattention and/or hyperactivity, forgetfulness, poor impulse control, distractibility
250
What are the three subcategories of ADHD?
* Predominantly inattentive type
* Predominantly hyperactive-impulsive type
* Combined type
251
What criteria must be met for dx of ADHD?
* Some hyperactive-impulsive or inattentive sx before age 12
* Several sx present in two or more settings
* Clear evidence of functional impairment
252
How do you check a lithium level?
*Draw blood 12h after the last dose, when levels are peaking
253
What are signs of lithium toxicity?
* Diarrhea/vomiting
* Drowsiness
* Muscle weakness
* Ataxia
* Blurred vision
* Incoordination
* Diabetes insipidus
* *EKG abnl, death
* *Delirium
254
What are permanent sequelae of lithium toxicity?
Permanent neurological damage
255
What are the features of multi-infarct dementia?
* Secondary to brain cell death by infarction or hypoxia
* Deficits are irreversible but underlying vascular dz can be treated
* Mood sx must not be primary
256
What is the presentation of multi-infarct dementia?
* Focal neurological deficits
* Short term memory impairments
* Loss of executive fxn
* Paranoia
* Hallucinations
* Delusions
257
What are features of psychotic depression?
* Major depression with disturbance in reality testing
* Mood congruent psychotic sx
* Mood disturbance must precede onset of psychotic sx
* Treatment is antipsychotics w/ antidepressants, ECT
258
What are the features of schizophrenia?
* Psychotic sx social/occupational dysfunction >6 mos
* Positive sx of unusual thoughts, perceptions, behaviors
* Negative sx include a lack of motivation and isolation
259
What are the diagnostic criteria for schizophrenia?
*Need two or more of:
hallucinations, delusions, disorganized speech, grossly disorganized or catatonic behavior, or negative sx
*Psychotic sx must be of longer duration and early onset than mood disturbance
*Prodromal phase of worsening social skills, social withdrawal, unusual thinking
260
When does schizophrenia typically present?
Onset in late 20's
261
What is the treatment for schizophrenia?
Antipsychotics & mood stabilizers
262
What are features of personality disorders?
* Deeply ingrained, inflexible patterns of relating to others that are maladaptive and cause significant impairment in social or occupational functioning
* Lack insight about their problems
* Symptoms are ego syntonic
263
What are cluster A personality disorders?
* Paranoid
* Schizoid
* Schizotypal
264
What are features of paranoid personality d/o?
Distrustful, suspicious, anticipate harm and betrayal or deception, need emotional distance
265
What are features of schizoid personality d/o?
Emotionally detached, prefer to be left alone, h/o "loner," do not seek relationships
266
What are features of schizotypal personality d/o?
Odd thoughts/affect/perceptions/beliefs, few relationships, increased incidence in family members of schizophrenics
267
What are the cluster B personality disorders?
* Antisocial
* Borderline
* Histrionic
* Narcissistic
268
What are features of borderline personality d/o?
* Instability in relationships (splitting, projection, distortion)
* Self-image and affect (fragmented, unstable goals, denial)
* Poor impulse control (self-injurious or suicidal behavior)
* Frequently, Hx of trauma
269
What are features of antisocial personality d/o
* Disregard rules and laws, rarely experience remorse
| * Exploitative, liars, endanger others
270
What are features of histrionic personality disorder?
* Excessive superficial emotionality
* Powerful need for attention
* Dramatic clothing
* Exaggerated emotions
* Flirtatious, seductive, difficulty with intimacy (somatization d/o)
271
What are features of narcissistic personality d/o?
* Appears arrogant and entitled but suffers from low self-esteem
* Extravagant self-importance, demanding of attention and admiration
* No concern or empathy for others
* Low self-esteem and intense envy (co-morbid bipolar)
272
What are the cluster C personality disorders?
* Avoidant
* Dependent
* OCD
273
What are features of avoidant personality d/o?
* Desire relationships but avoids them because of anxiety produced by sense of inadequacy
* Few friends
* Hypersensitive to criticism and rejection
* Need guarantees of acceptance, social inhibition (co-morbid anxiety d/o, depression)
274
What are features of dependent personality d/o?
* Extremely needy of others for emotional support and decision making
* Continuous fear of separation, submissive and clingy (co-morbid anxiety, depression)
275
What are features of OCD?
* Need order and control, perfectionists. Attention to minutiae impairs ability to finish a project or attain goals
* Old and rigid in relationships, morally judgmental, recreation is a task
276
How would you deal with a hostile patient?
* Set limits and boundaries
| * Acknowledge hostility, contain the patient, defend self
277
How would you deal with a crying patient?
*Empathize
278
How would you deal with a cognitively-impaired patient?
*Determine Pat level
279
How would you deal with a seductive patient?
* Define role
* Set limits
* Avoid 1-1 interviews
280
How would you deal with a delusional patient?
* Don't agree with or refute delusions
* Explore inconsistencies *Genuine concern and surprise
* Agree with affect, not delusion
281
How do you report child abuse?
* Physicians obligated to report suspected abuse to DCF via phone
* Written report must follow within 48h
* Documentation and photographs are critical in suspected cases
* Child may be placed into hospital temporarily to emergency custody if s/he cannot be sent home with caregiver.
282
What is the MA statute for child abuse?
Section 51A
283
What is substance use disorder?
* Use of one or more substances leads to a clinically significant impairment or distress
* Pathological use of substance -->adverse social consequences
284
What is substance tolerance?
* A need for markedly increased amounts of substance to achieve intoxication/desired effect
* A markedly diminished effect with continued use of the same amount of substance
285
What is substance withdrawal?
Characteristic withdrawal syndrome for substance or the same or similar substance needed to avoid/relieve withdrawal symptoms
286
What medical Hx should be considered prior to starting a pt. on lithium? Why?
Hx of medical conditions that affect ADME of lithium
* Severe renal dz
* DM
* Ulcerative colitis
* Recent cardiac problems
* Drug has very narrow TI
287
What labs should be done on pt. prior to starting lithium?
* CBC
* Chem 14
* U/A
* TFTs
* Baseline hCG in reproductive age women
* New labs must be done every month for the first 3 mos, then every 3 mos
288
What are some contraindications to lithium use?
* Myasthenia gravis -->inhibits ACh release
| * Pregnancy/breast feeding -->Ebstein's anomaly
289
What are some side effects of lithium use?
* Reversible hypothyroidism (esp. women)
* T wave changes
* Nephrogenic DI
* Hypercalcemia
* Reversible leukocytosis
* Kidney damage
290
What are s/sx of lithium toxicity?
* Confusion
* Lethargy
* Severe tremors
* Muscle weakness
* Seizures
* Diarrhea
291
What are some possible causes of lithium toxicity?
* Hyponatremia (reabsorption in PT with Na+)
* NSAIDs (inc. renal PG synthesis)
* Chronic renal insufficiency
* Use of Abx such as tetracyclines, cyclosporine
292
What is tyramine?
* Naturally occurring sympathomimetic normally inactivated by MAO in the gut
* Found in matured protein foods (aged cheese, wine)
293
What is tyramine reaction?
Intake of high-tyramine foods in pt. taking MAOis may resulting in hypertensive crisis, occipital headache, risk of stroke
294
How is tyramine reaction treated?
* Nifedipine (antihypertensive)
* Regitine (alpha blocker)
* Thorazine (typical antipsychotic)
295
What is serotonin syndrome?
Excess serotonergic activity at CNS and PNS receptors
296
What drug classes cause serotonin syndrome?
* Antidepressants
* Opioids
* CNS stimulants
* 5-HT1 agonists
* Illicit drugs
297
What are the symptoms of serotonin syndrome?
* Rapid onset (mins-hrs) and fast offset
* Tachycardia, shivering, diaphoresis, mydriasis, tremor, myoclonus, hyper/hyporeflexia, hyperthermia, seizures, DIC, renal failure, metabolic acidosis
298
How do you treat serotonin syndrome?
* No antidote, supportive
* Removal of drug causes
* Administration of serotonin antagonists
299
What are the sx of anticholinergic toxicity?
* Flushing
* Dry skin/mucous membranes
* Mydriasis & loss of accomodation
* AMS
* Fever
* Sinus tachycardia
* Urinary retention
* HTN
* Myoclonic jerks
300
What is the treatment for anticholinergic toxicity?
Physostigmine salicylate
301
What is NMS?
Following neuroleptic use,
* Hyperthermia >38C
* Muscle rigidity
* AMS, tremor, tachycardia, incontinence, labile BP, metabolic acidosis, tachypnea, hypoxia, elevated CPK, diaphoresis, sialorrhea, leukocytosis
302
What are specific treatments for NMS?
* Cessation of neuroleptic drug
* Supportive care
* Lorazepam
* Amantadine
* Bromocriptine
* Dantrolene
* ECT
303
What is a hallucination?
Sensory perception without an actual external stimulus
304
What is an illusion?
Misinterpretation of an existing stimulus
305
What is a delusion?
Fixed false belief that cannot be altered by rational arguments and is not explained by cultural background
306
What is paranoia?
Mental d/o characterized by presence of systematized delusions, often persecutory, in an otherwise intact personality
307
What is ambivalence?
Coexistence of contradictory emotions, attitudes, ideas, or desires with respect to a particular person, object, or situation. Usually not fully conscious.
308
What is depersonalization?
State in which one loses feeling of one's own identity in relation to others in one's family/peer group, or loses the feeling of one's own reality
309
What is derealization?
Feeling of estrangement or detachment from one's environment
310
What are loose associations?
No logical connection from one thought to another
311
What is thought blocking?
Abrupt cessation of communication before the idea is finished
312
What is thought disorder?
* A disturbance of speech, communication, or content of thought
* Interchangeable with psychosis
313
What are ideas of reference?
Incorrect interpretation of casual incidents and external events as having direct reference to oneself
314
What is somatization?
Psychological needs are expressed in physical sx
315
What is obsession?
Recurrent and persistent thought, impulse, or image experienced as intrusive or distressing. Recognized as excessive and unreasonable.
316
What is compulsion?
* Repetitive ritualistic behavior or thoughts whose purpose is to prevent/decrease distress or an undesired event
* One feels driven to perform in response to an obsession
* Recognized as excessive and unreasonable
317
What is anhedonia?
Loss of interest in pleasurable activities
318
What is nihilism?
The delusion of the nonexistence of everything, especially the self or part of the self
319
What is narcissism?
State in which one interprets and regards everything in relation to oneself
320
What is grandiosity?
Exaggerated belief or claims of one's importance or identity
321
What is phobia?
An objectively unfounded fear that arouses a state of panic
322
What is mood?
The pervasive feeling, tone and internal emotional state of a person
323
What is affect?
Behavior that expresses a subjectively experienced emotion.
324
Describe Alzheimer's dementia
Insidious onset
| Imaging shows enlarged cerebral ventricles and cortical atrophy
325
Describe vascular dementia
Occurs abruptly, usually following a stroke
| Can include subdural hematoma
326
Describe pseudodementia
* Clues to the diagnosis of depression (e.g. weight loss, worsening sleep, crying spells)
* Treating the depression improves symptoms
327
Describe the difference between delirium and dementia
Delirium: d/o of consciousness
Dementia: impairment of memory without alteration in consciousness
328
What are the features of geriatric depression?
* More neurovegetative sx
| * Consider medical condition (L hemisphere cerebral infarct) or medication (beta blockers) as cause
329
What is the treatment for geriatric depression?
* Lower oral dose of antidepressants
| * Avoid TCAs due to risk of orthostatic hypotension
330
What is the treatment for apathetic patients with geriatric depression?
* Stimulants
| * ECT
331
What psychiatric d/o can present with psychosis?
* Schizophrenia, schizophreniform, schizoaffective
* Delirium, dementia
* Brief psychotic d/o
* Delusion d/o, shared psychotic d/o
* Major depression
* Bipolar d/o
332
What are common side effects of SSRIs?
* GI complaints (nausea, loose stools)
* Anxiety, hyperstimulation, jitters
* Insomnia
* Sexual dysfunction
* Serotonin syndrome
* May have increased suicidality in young patients
333
How long is an adequate drug trial? What are some proposed changes if there is no response?
* Drug trial should be 4-8w
| * No response in 4 w-->increase dosage or consider switching to another class
334
What is the response rate in MDD to ECT vs pharmacotherapy?
ECT: 80-90% respond
Medications: 50-75% respond
335
What are 3 domains of functional impairment?
* Work
* Social
* Family life
336
How can the severity of psychiatric illness be described?
In terms of functional domains
337
What factors make a psychiatric illness more severe?
Functional impairments in more domains
338
What are the guidelines for referral to psychotherapy?
*If pt. has SI, co-morbid personality d/o or sub abuse issuse, consider referring to psychiatrist
339
What is the standard of care for bipolar pts. in an active manic/hypomanic or depressed episode?
Psychiatrist evaluation and treatment
340
What is the standard of care for pts. experiencing psychotic disorder?
Refer to inpt. or outpt. psychiatrist
341
What is the standard of care for pts. with anxiety d/o?
* OCD, PTSD should be referred to psychiatrist or therapist; PCP can manage once med regimen is established
* Non-refractory GAD, panic d/o can be managed by a PCP
342
What is the standard of care for pts. with eating d/o?
* Referral to psychiatrist and/or therapist
| * Collaboration between PCP and psychiatrist is crucial
343
When is a section 12A indicated?
*If pt. is not hospitalized, there is a likelihood pt. will cause serious harm to themselves or others b/c of mental illness
344
What is adjustment disorder?
* Development of emotional or behavioral symptoms in response to an identifiable stressor occuring within 3 months of stressor onset
* Removal of stressor causes resolution of sx in <6 mos
345
What is the prognosis of adjustment d/o in adolescents?
* Varied outcomes
* Almost 1/2 of pts. go on to have more severe mental illness
* Adjustment d/o dx has less stigma than for more serious illnesses
346
What is the prognosis of adjustment d/o in adults?
* Good prognosis after dx
| * Represents adults with acute onset sx with no underlying psychopathology
347
What is the treatment for adjustment d/o?
* Individual therapy
* Group psychotherapy
* Can use meds for predominant sx
348
What are the diagnostic criteria for OCD?
* Presence of obsessions that pt. recognizes as product of one's mind and excessive
* Presence of compulsions that pt. sees as excessive/unreasonable
* Cause marked distress/ functional impairment
349
What is the prevalence of OCD in general population? What is the age of onset?
2-3% of general population, most will meet criteria before age 30
