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Clerkship Study > Psychiatry Study Guide > Flashcards

Psychiatry Study Guide Flashcards

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
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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)
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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
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4
Q

What is the role of psychotherapy in MDD?

A
  • Primary Rx in mild depression

* Adjunctive Rx to pharmacotherapy in moderate/severe depression

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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

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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)
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7
Q

What medical conditions can mimic depressive symptoms?

A
  • Delirium
  • Dementia (neurocognitive d/o)
  • Frontal lobe syndromes
  • Epilepsy/seizure d/o
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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)
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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

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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
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11
Q

What are the outcomes of dysthymic d/o?

A
  • Resolution (+ possible recurrence)

* Exacerbation to major depression

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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)
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13
Q

What are treatments for dysthymic d/o?

A
  • Antidepressants (SSRIs, TCAs)
  • Psychotherapy (only if combined with pharmacotherapy)
  • Hospitalization if SI present
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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

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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)
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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)
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17
Q

What are the features of alcoholic hallucinosis?

A
  • VH>AH, tactile hallucinations
  • Occur over 12-48h
  • Pt. has clear sensorium
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18
Q

What are the features of delirium tremens?

A
  • Can last 7d
  • Hallucinations, disorientation, tachycardia, HTN, fever, agitation, and diaphoresis
  • Risk of death
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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)
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20
Q

What is the best pharmacological therapy for acute EtOH withdrawal sx?

A

Benzodiazepine derivatives

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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
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22
Q

What is the history in psychosis due to cocaine?

A
  • Sudden onset
  • Cocaine use
  • Thinking disconnected from reality
  • Visual hallucinations
  • Delusions
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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
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24
Q

What is the MSE in psychosis due to cocaine?

A
  • Psychomotor agitation/slowing
  • Behavioral changes
  • Paranoid delusions
  • Visual hallucinations
  • Impaired judgment
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25
Q

What are the physical examination findings in paranoid schizophrenia?

A

None, aside from MSE findings

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26
Q

What are the general physical exam findings in cocaine intoxication?

A

Physical exam findings will be present (as compared to paranoid schizophrenia); autonomic sx, n/v, WL, weakness, resp. depression, arrhythmia, seizure, coma

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27
Q

What is the gender breakdown for SA and completion?

A

M>F for completion, F>M for attempts

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28
Q

What is the relationship between marital status and risk for suicide?

A

Divorced/widowed > Single > Married

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29
Q

What are the essential components of an assessment of suicide risk?

A
  • Suicidal ideation
  • Planning, means, and lethality
  • Previous suicide attempts (cardinal 7)
  • Risk factors vs. protective factors
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30
Q

When should you especially inquire about guns in the home?

A

In the case of any patients at increased risk for suicide

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31
Q

What is passive suicidal ideation?

A

When the patient refers indirectly to situation where patient is dead: “My life is not worth living anymore”

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32
Q

What is the prognosis for a single episode of depression?

A

40% of patients will have a good prognosis (i.e. recovery)

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33
Q

What is the percentage of patients with one episode of MDD who will have another episode?

A

60%; increased risk of recurrence with partial recoveries

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34
Q

What are four medical/social consequences of improper Dx and mgmt of MDD?

A
  • Unintentional weight loss or weight gain
  • Job loss of patient and/or caretaker
  • Increased suicide risk
  • Neglect of dependents
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35
Q

When are patients with previous SA at greatest risk for attempting again?

A

Greatest risk within first 2 years of attempt, especially if high lethality and precipitating/env’t circumstances unch.

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36
Q

What are some examples of social supports lacking as risk factor for suicide?

A
  • Unemployment
  • Fall in SES
  • Adolescent pregnancy
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37
Q

What would be an example of an organized suicide plan with some intent?

A

Presence of loaded firearms in the home, bought a rope for a noose, counted out pills

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38
Q

What is active suicidal ideation?

A

When the patient directly refers to his/her own death: “I am going to kill myself”

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39
Q

What is the lifetime prevalence, gender distribution, and peak incidence of MDD?

A

Lifetime prevalence is 5-20%
F:M is 2:1
Greatest incidence at 20-40, decreases >65

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40
Q

What are three factors associated with poorer prognosis in MDD?

A
  • Very severe initial episode
  • Co-existing dysthymic disorder
  • Serious medical condition
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41
Q

What is the mnemonic for suicide risk factors?

A 
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
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42
Q

How does FHx of suicide increase suicide risk?

A

9x higher in individual with 1st degree relative who committed suicide

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43
Q

What is a biological risk factor for suicide?

A

Decreased 5-HIAA

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44
Q

In what age groups and races is suicide most prevalent?

A
  • 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
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45
Q

What is the suicide rate in schizophrenia? What is the associative psychiatric manifestation?

A
  • Schizophrenia has 10% suicide rate

* Associated with depression vs command hallucinations

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46
Q

What are means of suicide that should be screened for?

A

Firearms, pills

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47
Q

What are the high risk patients who require assessment of suicide risk?

A
  • 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
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48
Q

What are four risk factors for MDD?

A
  • Recent stressors
  • Lack of individual support system
  • History of early parental loss
  • Gender and FHx of depression
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49
Q

What are three features of mood disorders (MDD, bipolar d/o)?

A
  • Uncontrollable long-term changes in predominant mood w or w/o trigger
  • Sleep difficulties (early waking)
  • Psychomotor slowing
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50
Q

Give an example of a neurologic medical condition that increases depression risk

A

Parkinson’s disease

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51
Q

Give an example of a neoplastic condition that increases depression risk

A

Carcinoma of the pancreas (pancreatic head)

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52
Q

Give an example of a chronic medical condition which can increase depression risk

A

AIDS

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53
Q

To what extent does chronic illness increase suicide risk?

A
  • AIDS (21-36x)

* Temporal lobe epilepsy (2.5x)

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54
Q

What is parasuicidal behavior?

A

Any serious, non-fatal self-injurious behavior with or without SI: cutting, overdose, neglect, substance abuse
Commonly associated with BPD

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55
Q

What protective factors help reduce suicide risk?

A
  • Family and friends
  • Dependents (children, parents, pets)
  • Health alliance with counselor/healthcare provider
  • Job or volunteer work
  • Hobbies
  • Education
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56
Q

What is the percentage of people with MDD who greatly improve or fully recover within 1 year?

A

60%

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57
Q

What impact does depression have on medical morbidity?

A

Increased risk

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58
Q

Give an example of a metabolic condition that increases depression risk

A

Hyper/hypothyroidism

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59
Q

Give examples of drug use & poison ingestion which can increase depression risk

A

EtOH (drug), heavy metal poisoning (poison)

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60
Q

Give an example of an infectious agent which can increase depression risk

A

TB

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61
Q

How might major depression present as underlying condition in primary care?

A

Somatic complaints, poor concentration, irritability

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62
Q

How might major depression present in the elderly?

A

Frequent visits to the doctor’s office

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63
Q

How does complicated bereavement differ from major depression?

A
  • Sx of major depression may present concomitantly

* Diagnosis not usually given unless sx are still present two months after the loss

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64
Q

How might major depression present in someone with a different race, religion, or ethnicity than yours?

A

May describe as somatic problems (e.g. nerves, weakness, “heartbroken”) vs mood disturbance

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65
Q

What percentage of patients with MDD commit suicide?

A

MDD has a 15% suicide rate

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66
Q

What are 4 features of anxiety disorders (GAD, panic, OCD, PTSD, phobias)?

A
  • Exaggerated sense of worry or panic about 2+ life circumstances w and w/o trigger
  • Sleep difficulty (difficulty onset d/t anxiety)
  • Weakness
  • Irritability
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67
Q

How might major depression present in teenagers?

A

Social withdrawal, failing grades

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68
Q

What is the percentage of people who will develop chronic depression?

A

20%

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69
Q

What co-morbid psychiatric conditions should you look for in dysthymic d/o?

A
  • Major depression may occur after the first 2 years of the d/o (double depression)
  • Similar co-morbidities to major depression (most psychiatric diagnoses)
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70
Q

What medical concerns (acute, chronic, risk) present in EtOH intoxication and withdrawal?

A
  • 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
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71
Q

What is schizophreniform disorder?

A
  • Presence of criterion A symptoms of schizophrenia
  • Lasts >1 month but <6 mos
  • May include prodromal, active, and residual phases
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72
Q

What are criterion A symptoms of schizophrenia?

A
  • Delusions
  • Hallucinations
  • Disorganized speech
  • Disorganized or catatonic behavior
  • Negative symptoms (flat affect, avolition, paucity of speech)
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73
Q

What are the behavioral or psychological changes seen in opiate intoxication?

A
  • Euphoria leading to
  • dysphoria
  • psychomotor retardation
  • impaired judgment
  • social/occupational dysfunction
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74
Q

What physical exam findings are seen in opiate intoxication?

A
  • Pupillary constriction always present
  • Resp. depression
  • Drowsiness, coma
  • Slurred speech
  • Hypotension, bradycardia
  • Hypothermia
  • N/v
  • Impaired attention/memory
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75
Q

What is the management of opiate intoxication?

A
  • Establish an airway

* Naloxone (0.4 mg IV) should be given immediately

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76
Q

What is the presentation of opiate overdose?

A

Same as intoxication but more often results in coma, respiratory depression, and death

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77
Q

What is the management of opiate overdose?

A

Same as intoxication

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78
Q

When do symptoms of opiate withdrawal occur?

A

Within 10 hours of the last dose

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79
Q

What are some symptoms of mild opiate withdrawal?

A
  • Dysphoric mood, anxiety, and restlessness
  • Lacrimation or rhinorrhea
  • Pupillary dilatation, piloerection, ANS sx
  • Diarrhea
  • Fever
  • Insomnia
  • Yawning
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80
Q

What are some symptoms of severe opiate withdrawal?

A
  • Nausea, vomiting
  • Muscle aches
  • Seizures
  • Abdominal cramps
  • Hot and cold flashes
  • Severe anxiety
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81
Q

How is opiate withdrawal achieved using methadone?

A

Gradual withdrawal using methadone (20-80 mg/day)

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82
Q

What is the MOA and t 1/2 of methadone?

A
  • Weak mu opiate receptor agonist

* t 1/2=15h (longer than heroin, morphine) –>fewer intoxicant or withdrawal effects

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83
Q

What drug is used for acute opioid withdrawal symptoms?

A

Clonidine; treats ANS sx but does little to curb the drug craving

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84
Q

What is the MOA of clonidine?

A
  • Centrally acting a2 receptor agonist

* Risks of sedation and hypotension

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85
Q

What are the components of an opioid withdrawal program?

A

Referral to an intensive day treatment program and Narcotics Anonymous

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86
Q

What is schizoaffective d/o?

A
  • 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
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87
Q

What is schizoaffective disorder, bipolar type?

A

*Patient with bipolar I d/o has a two week period with psychotic sx and no mood d/o

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88
Q

How would you treat schizoaffective d/o?

A
  • Anti-psychotics and mood stabilizers

* ECT

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89
Q

How would you treat bipolar I disorder?

A

Mood stabilizers

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90
Q

When would ECT be used in the setting of depression?

A
  • Severe depression, esp. refractory to antidepressants and/or high risk of suicide
  • Pts. in which antidepressant meds are contraindicated
  • Pregnant women with severe depression
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91
Q

When would ECT be used in the setting of bipolar disorder?

A

*Used to treat mania and depression refractory to meds and/or when immediate improvement is critical

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92
Q

When would ECT be used in the setting of acute psychosis?

A

When immediate resolution of psychosis is medically or psychiatrically required

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93
Q

What elements of the medical H&P must be especially considered prior to ECT?

A

*Neurological and cardiovascular history and exam

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94
Q

What are contraindications to ECT?

A
  • Intracranial mass
  • Recent stroke
  • Recent MI
  • Exceptions to contraindications when risks of no ECT outweight risk of ECT itself
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95
Q

What are risks of ECT use?

A
  • Risk of anterograde and retrograde memory loss with respect to treatment (mostly resolves within days to weeks)
  • Headaches - treat with analgesics
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96
Q

What is buspirone? Why is it preferred for use?

A
  • Non-benzodiazepine anxiolytic agent
  • Non-addicting (can be used in addicts)
  • No withdrawal syndrome or tolerage
  • No sedation or EtOH potentiation
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97
Q

For what anxiety d/o is buspirone effective?

A
  • GAD
  • OCD
  • Augmentation of antidepressants in MDD
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98
Q

For what anxiety d/o is buspirone ineffective?

A
  • Panic d/o
  • Social phobia
  • PTSD/ASD
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99
Q

What are MAOi’s used for?

A
  • Major depression with atypical features
  • Social phobia
  • Panic d/o with agoraphobia
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100
Q

How do MAOi’s function?

A
  • Promotes decreased degradation of monoamines

* Effects may last up to 2 weeks after discontinuation

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101
Q

What are AEs of MAOi use?

A
  • Hypertensive crisis
  • May precipitate mania in bipolar pts.
  • Sedation
  • Weight gain
  • Orthostatic hypotension
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102
Q

How can AEs of MAOi use be prevented?

A
  • Titrate dose over several weeks to minimize AEs

* Adhere to low tyramine diet

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103
Q

With which drugs are MAOi’s incompatible?

A
  • Antihistamines
  • Anti-hypertensives (hypotension)
  • Anesthetics (hypertensive crisis)
  • SSRIs (serotonin syndrome)
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104
Q

Which MAOi can cause major morbidity and mortality?

A

Phenelzine

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105
Q

What is the MOA of TCAs?

A
  • Block the reuptake of NEPI, DA, and serotonin

* Also interacts with muscarinic, cholinergic, a1 adrenergic, histaminic receptors

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106
Q

What are AEs of TCA use? Who is most susceptible?

A
  • Anticholinergic
  • Narrow angle glaucoma
  • Orthostatic hypotension
  • Intraventricular conduction delays
  • Long PR, QT intervals
  • The elderly are most susceptible (titrate dose)
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107
Q

Which class of TCAs are better tolerated and less likely to have anticholinergic and orthostatic side effects?

A

*Secondary TCAs

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108
Q

What are contraindications to TCA use?

A
  • 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
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109
Q

At which receptors does clozapine primarily act?

A

*5-HT2, D1, D3, D4 receptor antagonist

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110
Q

Why do atypical antipsychotics (SDAs) have fewer EPS?

A

*Less affinity for the D2 receptor

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111
Q

What is the only FDA-approved indication for clozapine use?

A

Treatment resistant schizophrenia, esp. after failure of other SDAs

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112
Q

What is the major side effect of clozapine which must be monitored?

A
  • 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
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113
Q

What are the benefits of clozapine use?

A
  • Less EPS than typical antipsychotics and other SDAs
  • Efficacy against some of the negative sx
  • Less increase in prolactin release
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114
Q

What are risk factors for agranulocytosis in the setting of clozapine use?

A
  • Increased age

* Female sex

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115
Q

What are other blood dyscrasias seen in clozapine use?

A
  • Benign leukocytosis, leukopenia, eosinophilia, elevated ESR
  • Clozapine induced seizures
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116
Q

What is the incidence of clozapine induced seizures?

A

5% of pts. on >600 mg/day
3-4% of pts. on 300-600 mg/day
1-2% of pts. on <300 mg/day

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117
Q

How should pts. be managed in the setting of clozapine-induced seizures?

A
  • Temporarily d/c clozapine and initiate phenobarbital

* Restart clozapine at 50% of previous dosage

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118
Q

What are cardiovascular AEs associated with clozapine use?

A
  • Tachycardia due to vagal inhibition
  • Hypotension and subsequent syncope
  • EKG changes (usually not clinically significant)
  • Paradoxical hypertension in 4% of patients
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119
Q

What are other adverse effects associated with clozapine use?

A
  • Sedation
  • Fatigue
  • Sialorrhea
  • Weight gain
  • GI sx
  • Anticholinergic effects and fever
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120
Q

Co-administration of which drug with clozapine increases risk of NMS?

A

Lithium

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121
Q

What drugs have a higher incidence of weight gain?

A

Risperidone and olanzapine

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122
Q

What is the reason for slow titration?

A

Potential to develop hypotension, syncope, and sedation; tolerance with slow titration

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123
Q

What is the procedure for re-initiation of clozapine following holiday >36h?

A

Re-titration

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124
Q

What is the consequence of sudden clozapine d/c?

A

Cholinergic rebound sx (diaphoresis, flushing, diarrhea, hyperactivity)

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125
Q

What is the MOA of typical antipsychotics?

A

DRAs; D2 antagonism > H1, a1, M1

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126
Q

What are the advantages of using atypical antipsychotics (SDAs)?

A
  • *Less risk of adverse neurological effects (e.g. EPS)
  • Less potent increase in PRL secretion
  • Work on positive and negative sx
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127
Q

What is the MOA of atypical antipsychotics?

A

Significant activity at 5-HT receptors

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128
Q

What are the low potency typical DRAs? (50-100 mg = 100 mg CPZ)

A
  • Chlorpromazine (Thorazine)
  • Thioridazine (Mellaril)
  • Mesoridazine (Serentil)
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129
Q

What are the mid potency DRAs? (10 mg=100 mg CPZ)

A
  • Perphenazine (Trilafon)
  • Loxapine (Loxitane)
  • Droperidol (Inapasine)
  • Molindone (Moban)
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130
Q

What are the high potency DRAs? (1-5 mg=100 mg CPZ)

A
  • *Haloperidol (Haldol)
  • Trifluoperazine (Stelazine)
  • Fluphenazine (Prolixin)
  • Thiothixene (Navane)
  • Pimozide (Orap)
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131
Q

Why are high potency DRAs used in spite of their increased risk of EPS?

A

*Lower incidence of other anticholinergic, a1 antagonism as compared to low potency DRAs

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132
Q

What are the guidelines for typical antipsychotic use in schizophrenia?

A

All typical antipsychotics are equally efficacious

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133
Q

Which antipsychotics are best for negative sx?

A

Atypicals (SDAs)

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134
Q

Which SDAs are less likely to raise PRL levels?

A

Clozapine, olanzapine, sertindole

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135
Q

Which SDAs are anticholinergic and sedating?

A

Clozapine and olanzapine

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136
Q

What is the criteria for an adequate trial of DRAs?

A
  • Lasting 6-8 weeks

* At 1000 mg/day in CPZ equivalents

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137
Q

What is the criteria for an adequate trial of SDAs?

A
  • Lasting 8-12 weeks

* Pt. must have failed at least 1 typical and 2 atypicals to use clozapine

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138
Q

What are the manifestations of EPS? How are they treated?

A
  • Parkinsonism
  • Acute dystonia
  • Acute akathisia
  • Tardive dyskinesias
  • Treat with anticholinergics (benztropine, amantadine, diphenhydramine)
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139
Q

What are other neurologic AEs of antipsychotics?

A
  • NMS
  • Epilepsy
  • Sedation
  • Central anticholinergic effects
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140
Q

What is the cause and manifestation of neuroleptic induced Parkinsonism?

A
  • Blockade of DA transmission in nigrostriatal tract
  • Lead-pipe, cogwheel rigidity
  • Shuffling gait
141
Q

What is the cause and manifestation of neuroleptic induced acute dystonia?

A
  • 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
Q

What is the on the DDx for neuroleptic induced acute dystonia?

A
  • Seizures

* Tardive dyskinesia

143
Q

What is the treatment for neuroleptic-induced acute dystonia?

A
  • IM anticholinergics

* IV/IM diphenhydramine

144
Q

What is the cause and manifestation of neuroleptic-induced acute akathisia?

A
  • Imbalance of NE and DA systems due to DRA

* Subjective feeling of muscular discomfort leading to involuntary agitation, pacing, sitting/standing, dysphoria

145
Q

How can neuroleptic-induced akathisia be managed?

A
  • Reduce dosage of antipsychotic

* Use propranolol, benzos, or clonidine for sx

146
Q

What is the cause and manifestation of neuroleptic-induced tardive dyskinesia?

A
  • 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
Q

How can TD be avoided in pts?

A
  • Use DRAs only when necessary and at lowest effective dosages
  • Use SDAs in pts. with TD: reduce movt and risk of exacerbation
148
Q

What are the manifestations of NMS?

A
  • Muscular rigidity and dystonia, akinesia
  • Mutism
  • Obtundation and agitation
  • Hyperpyrexia (<107 F), sweating, tachycardia, hypertension
149
Q

What is the timecourse of NMS?

A
  • Evolves over 24-72 hours

* Untreated syndrome lasts 10-14 days

150
Q

How is NMS acutely managed?

A

*Supportive tx using antiparkinsonian meds, dantrolene for 5-10 days

151
Q

How is NMS avoided in long term?

A

*Switch to low potency drug or SDA when treatment restarted

152
Q

What is the cause of DRA associated epilepsy?

A
  • Slowing and increased synchronization of EEG –>decreased seizure threshold
  • Seen in low potency drugs > high-potency drugs
153
Q

What is the cause of DRA-associated sedation? How can it be managed?

A
  • H1 receptor blockade
  • CPZ > Thioridazine > high-potency DRAs
  • Dose at bedtime
154
Q

What are some central anticholinergic effects seen in DRA use? How are they treated?

A
  • Severe agitation
  • Disorientation
  • Hallucinations
  • Seizures
  • High fever
  • Mydriasis
  • May lead to stupor, coma
  • Treat with physostigmine, atropine
155
Q

Which DRAs are more cardiotoxic?

A

Low potency > high potency

156
Q

What are the cardiotoxic effects of CPZ?

A
  • QT, PR elongation
  • T wave blunting
  • ST depression
157
Q

Do DRAs have an effect on incidence of sudden death in schizophrenics?

158
Q

What is the cardiotoxic effect of pimozide and what is it potentiated by?

A
  • Pimozide prolongs QT

* Potentiated by macrolides

159
Q

What are the cardiotoxic effects of thioridazine?

A
  • T-wave effects

* Malignant arrhythmias

160
Q

At what QT duration is there increased risk for VTach/VFib

161
Q

What is a possible hemodynamic side effect of antipsychotic use? How is it managed?

A

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
Q

Which antipsychotics have the highest incidence of orthostatic hypotension?

A

Low potency DRAs (chlorpromazine, thioridazine, chlorprothixene), clozapine

163
Q

What are the hematological side effects of antipsychotics?

A
  • *Transient leukopenia (to ~3500) with DRAs
  • *Agranulocytosis in 1/10000 pts (1-2% taking clozapine)
  • Rare thrombocytopenic/non-thrombocytopenic purpura, hemolytic anemias, pancytopenia
164
Q

What are the sexual side effects of antipsychotics?

A
  • Impotence in 50% of males on DRAs
  • Anorgasmia
  • Dec. libido (and retrograde ejaculation) esp. thioridazine
165
Q

What are anticholinergic side effects of antipsychotics?

A
  • Dry mouth/nose
  • Blurred vision
  • Constipation
  • Urinary retention
  • Mydriasis
166
Q

Which antipsychotic drugs have higher incidence of anticholinergic effects? Which drugs potentiate these effects?

A
  • Chlorpromazine, thioridazine, mesoridazine, loxapine

* Potentiated by TCAs

167
Q

What are metabolic side effects of antipsychotics?

A
  • Weight gain (DRAs, risperidone, olanzapine)

* Endocrine (D2 blockade –>increased PRL secretion, gynecomastia/galactorrhea/sexual dysfunction/amenorrhea)

168
Q

What antipsychotic may cause jaundice?

A
  • 1/1000 of patients on chlorpromazine

* Seen in 1st month of treatment

169
Q

What are dermatologic side effects of antipsychotics? Which drugs cause them?

A

Seen most commonly in low-potency DRAs

  • Allergic dermatitis
  • Photosensitivity and blue-gray discoloration of sun-exposed skin with chlorpromazine use
170
Q

What are ophthalmologic side effects of antipsychotics? Which drugs cause them?

A
  • *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
Q

Name an atypical antidepressant which causes lowered seizure threshold

A

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
Q

Name a psychostimulant which causes lowered seizure threshold

A

Ritalin (methylphenidate)

Toxicity can present with seizures

173
Q

Name a DRA which causes lowered seizure threshold

A

Chlorpromazine (thorazine)

Carries higher risk of seizures than most other typicals

174
Q

What is a panic attack?

A
  • 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
Q

What is agoraphobia?

A

Anxiety and/or avoidance related to going places where one would feel vulnerable in the face of a panic attack or anxiety sx

176
Q

What is generalized anxiety disorder?

A
  • Intense pervasive worry over every aspect of life for at least 6 months
  • No panic attacks or phobias
177
Q

What is panic disorder?

A
  • Recurrent unexpected panic attacks

* May occur w/ or w/o agoraphobia

178
Q

What is social phobia?

A

Intense fear of being scrutinized in social or public situations

179
Q

What is major depression with anxiety?

A

Depressed mood with neurovegetative s/sx (SIGECAPS)

180
Q

What is PTSD?

A
  • Persistent re-experiences of a trauma via intrusive images, dreams, illusions, hallucinations, and flashbacks
  • Hyperarousal, detachment, dissociation
181
Q

What pharmacologic therapy is available for panic d/o?

A
  • 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
Q

What psychotherapeutic interventions are available for panic d/o?

A
  • Relaxation training for panic attacks
  • Systemic desensitization for agoraphobia
  • Other psychotherapy, behavioral therapy, etc.
183
Q

What is DDx of panic d/o?

A
  • CVD, colitis, asthma, organic brain d/o, seizure d/o
  • Sub abuse, w/d from sedatives, hypnotics, benzos
  • Thyroid, metabolic derangements
184
Q

What is the definition of delirium?

A
  • Reversible state of global cortical dysfunction
  • Abrupt onset with identifiable precipitant
  • Variable course (waxing/waning)
185
Q

What is the 1-year mortality rate assoc. with delirium?

186
Q

What is the definition of dementia? What are examples?

A

Memory loss with 1+ cognitive defects

  • Aphasia
  • Apraxia
  • Agnosia
  • Disturbance in exec. fxn
  • Usu. permanent
187
Q

What are the most common causes of dementia?

A
  • Alzheimer’s dz

* Vascular dz

188
Q

What is pseudodementia?

A
  • Typically assoc. with depression
  • Prominent mood sx but memory usu. intact
  • Resistant pts. are able to answer MSE questions if pushed
189
Q

What is psychosis?

A
  • Gross impairment of reality testing

* Primary or secondary to another d/o

190
Q

What is behavioral psychotherapy and what are its indications?

A

Changing behavior w/o considering thought process using positive or negative feedback
*Methods: systematic desensitization, flooding, implosion

191
Q

What is cognitive psychotherapy and what are its indications?

A
  • 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
Q

What is psychodynamic psychotherapy?

A
  • 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
Q

What is the psych perspective on competency?

A
  • 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
Q

What are the components of capacity to consent to medical Tx?

A
  • 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
Q

What are the criteria for determining civil competencies (i.e. controlling finances)?

A
  • Ability to understand situation
  • Ability to manipulate information
  • Ability to communicate decision
196
Q

What are a patient’s legal rights with respect to psychotropic meds?

A
  • 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
Q

What are the elements of informed consent?

A
  • Competency
  • Disclosure of pertinent info to make adequate decision
  • Voluntariness of pt. to undergo Tx, should not impact discharge
198
Q

What is the term for treating a patient without informed consent?

A

A tort (battery)

199
Q

What are exceptions to treating pts. without informed consent?

A
  • Imminent threat of danger to pt. or others
  • Pt. waives
  • Therapeutic privilege (withholding info that could harm pt.)
200
Q

What are the main differences between benzos?

A
  • Onset of action
  • Duration of action/half-life
  • Potency
201
Q

Which benzos are better suited for use as hypnotics? What are the risks of these?

A
  • Shorter duration benzos b/c less morning sedation

* More addicting and habit forming

202
Q

What is the MOA of benzos?

A

GABA potentiation to decrease neuronal excitability

203
Q

What are the indications for benzos?

A
  • 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
Q

What are the clinical indications for diazepam (Valium)?

A
  • Anxiety
  • Pre-op and conscious sedation
  • EtOH withdrawal
205
Q

What are the clinical indications for clonazepam (Klonopin)?

A
  • Prophylaxis of seizure

* Panic d/o

206
Q

What are the clinical indications for lorazepam (Ativan)?

A
  • Anxiety
  • Insomnia
  • Pre-op sedation
207
Q

What are the potential risks/AEs of benzo use?

A
  • 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
Q

What are contraindications for all benzos?

A
  • Pts. with sub abuse
  • Geriatrics
  • Pedi
  • OB/pregnancy (Cat C, D)
  • Pts. on CNS depressants, EtOH, P450 inhibitors
209
Q

What are contraindications for diazepam, chlordiazepoxide?

A
  • Metabolized in liver

* Avoid in pts. with hepatic dysfunction

210
Q

What is the contraindication for clonazepam?

A
  • Metabolized in kidney

* Avoid in pts. with renal failure

211
Q

What alternatives exist for pts. who cannot safely take benzos for anxiety?

A
  • Antidepressants
  • Anticonvulsants
  • Buspirone
  • Antihypertensives
  • Neuroleptics
212
Q

What alternatives exist for pts. who cannot safely take benzos for insomnia?

A
  • Sleep hygiene adjustments
  • Trazodone
  • TCAs
  • Doxepin
  • Mirtazapine
  • Zolpidem
213
Q

What are the characteristics of a conversion d/o?

A
  • 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
Q

When is the diagnosis of conversion d/o deferred?

A

When presentation is explained as culturally sanctioned behavior or experience

215
Q

What percentage of pts. with conversion d/o are later found to have true neurological illness?

216
Q

When does conversion d/o typically manifest?

A

Late adolescence or early adulthood

217
Q

What category of illnesses are important to remain on DDx for conversion d/o even if they appear to be “pseudo-symptoms”?

A

Neurological illnesses; may have inconsistent presentations

218
Q

How is conversion d/o treated?

A
  • Insight-oriented psychotherapy
  • Hypnosis
  • Relaxation therapy if needed
  • Most pts. spontaneously recover
219
Q

What are the criteria for somatic sx d/o?

A
  • 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
Q

What is the most effective strategy for Rx of somatic sx d/o pts?

A
  • 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
Q

What is the definition of illness anxiety?

A
  • 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
Q

How should a PCP deal with a hypochondriac patient?

A
  • 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
Q

What are the three phases of cocaine withdrawal and Rx?

A
  • Crash – hospitalization + benzos, antipsychotics
  • Withdrawal – support group + DA agonists
  • Extinction – support group + drug taper/ d/c
224
Q

What are the features of cocaine crash?

A
  • Extreme exhaustion after binge
  • Initial depression, agitation, anxiety followed by craving for sleep
  • Hypersomnolence and hyperphagia
  • SI is common
225
Q

What are the features of cocaine withdrawal?

A
  • Decreased energy, lack of interest, and anhedonia
  • Sx last about 2-5 days
  • Relapse is most likely at this phase
226
Q

What are the features of cocaine extinction?

A
  • Indefinite period during which evoked craving can occur
  • Increased risk for relapse
  • Moods, people, locations, or objects associated with cocaine use evoke craving
227
Q

What are the features of benzo withdrawal?

A
  • Asymptomatic for days and then acutely anxious

* May have physical sx (dilated pupils, tachycardia/HTN)

228
Q

What are the features of protracted benzo withdrawal?

A
  • 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
Q

What are the features of symptom rebound in benzo withdrawal?

A
  • 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
Q

What is the Rx for sx of low dose benzo withdrawal?

A

Phenobarbital –>taper as tolerated

231
Q

What is the Rx for palpitations, autonomic hyperreactivity in benzo withdrawal?

A
  • Beta blockers (propranolol)

* A2 agonists (clonidine)

232
Q

What are the features of acute mania?

A
  • 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
Q

What are the features of delirium?

A
  • Acute onset, decreased level of consciousness that waxes/wanes
  • Global cognitive impairment
  • Psychotic sx of paranoia, hallucinations, delusions may be present
234
Q

What are the best tx for acute mania and long-term prophylaxis?

A
  • Acute: antipsychotics, ECT

* Long-term: lithium, carbamazepine, valproic acid

235
Q

What is the best Rx for delirium?

A

*Find the underlying cause and correct it

236
Q

What is the best pharmacotherapy for use in delirium?

A
  • High potency antipsychotics (Haldol 2 mg) for short period of time
  • Second line: lorazepam
237
Q

What are limits/exceptions to confidentiality?

A
  • 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
Q

What are examples in which confidentiality can be broken?

A
  • Child/elder abuse
  • Impaired automobile drivers (e.g. seizure d/o)
  • Suicidal/homicidal patient
  • Domestic violence
239
Q

What are medical complications of restriction-type anorexia nervosa?

A
  • Hypothalamic dysfunction: constipation, amenorrhea, cold intolerance
  • Bradycardia, hypothermia, hypotension, metabolic derangements
  • Enlarged parotid glands, dry scaly skin
  • Anemia
  • MVP
240
Q

What is the criteria of weight loss in anorexia nervosa?

A

<85% of expected weight for dx

241
Q

What are medical complications of bulimia nervosa?

A
  • 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
Q

What are indications for hospitalization of an eating d/o pt.?

A
  • Severe starvation and weight loss
  • Hypothermia
  • Hypotension
  • Electrolyte imbalance
  • Depressed patients with AN or BN with SI or psychosis
  • Failure of outpatient Rx
243
Q

What is the treatment for eating d/o?

A
  • Restore pt.’s nutritional state (restore weight and metabolic balance)
  • Modify pt’s distorted eating behavior (individual and group therapy, increase caloric intake)
244
Q

What are psychotropic medications used in Rx of eating d/o?

A
  • Fluoxetine (60 mg/day)

* Antipsychotics to treat cognitive distortions and help induce weight gain

245
Q

What are some contraindicated medications for use in eating d/o?

A
  • Buproprion contraindicated d/t seizure risk

* TCAs can induce QT prolongation and increase risk of VTach, sudden death

246
Q

What is autism spectrum disorder?

A
  • Neurodevelopmental d/o
  • Persistent impairment in reciprocal social communication and social interaction
  • Restricted, repetitive patterns of behavior, interests, or activities
247
Q

What are the criteria for meeting autism spectrum disorder?

A
  • 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
Q

How is autism spectrum disorder diagnosed?

A
  • PCP may conduct screening tool; if positive, may warrant thorough eval
  • Comprehensive evaluation by multidisciplinary team –> neurological assessment and cognitive/language testing
249
Q

What is ADHD?

A
  • Neurodevelopmental d/o typically presenting in childhood

* Persistent pattern of inattention and/or hyperactivity, forgetfulness, poor impulse control, distractibility

250
Q

What are the three subcategories of ADHD?

A
  • Predominantly inattentive type
  • Predominantly hyperactive-impulsive type
  • Combined type
251
Q

What criteria must be met for dx of ADHD?

A
  • Some hyperactive-impulsive or inattentive sx before age 12
  • Several sx present in two or more settings
  • Clear evidence of functional impairment
252
Q

How do you check a lithium level?

A

*Draw blood 12h after the last dose, when levels are peaking

253
Q

What are signs of lithium toxicity?

A
  • Diarrhea/vomiting
  • Drowsiness
  • Muscle weakness
  • Ataxia
  • Blurred vision
  • Incoordination
  • Diabetes insipidus
  • *EKG abnl, death
  • *Delirium
254
Q

What are permanent sequelae of lithium toxicity?

A

Permanent neurological damage

255
Q

What are the features of multi-infarct dementia?

A
  • 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
Q

What is the presentation of multi-infarct dementia?

A
  • Focal neurological deficits
  • Short term memory impairments
  • Loss of executive fxn
  • Paranoia
  • Hallucinations
  • Delusions
257
Q

What are features of psychotic depression?

A
  • 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
Q

What are the features of schizophrenia?

A
  • Psychotic sx social/occupational dysfunction >6 mos
  • Positive sx of unusual thoughts, perceptions, behaviors
  • Negative sx include a lack of motivation and isolation
259
Q

What are the diagnostic criteria for schizophrenia?

A

*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
Q

When does schizophrenia typically present?

A

Onset in late 20’s

261
Q

What is the treatment for schizophrenia?

A

Antipsychotics & mood stabilizers

262
Q

What are features of personality disorders?

A
  • 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
Q

What are cluster A personality disorders?

A
  • Paranoid
  • Schizoid
  • Schizotypal
264
Q

What are features of paranoid personality d/o?

A

Distrustful, suspicious, anticipate harm and betrayal or deception, need emotional distance

265
Q

What are features of schizoid personality d/o?

A

Emotionally detached, prefer to be left alone, h/o “loner,” do not seek relationships

266
Q

What are features of schizotypal personality d/o?

A

Odd thoughts/affect/perceptions/beliefs, few relationships, increased incidence in family members of schizophrenics

267
Q

What are the cluster B personality disorders?

A
  • Antisocial
  • Borderline
  • Histrionic
  • Narcissistic
268
Q

What are features of borderline personality d/o?

A
  • 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
Q

What are features of antisocial personality d/o

A
  • Disregard rules and laws, rarely experience remorse

* Exploitative, liars, endanger others

270
Q

What are features of histrionic personality disorder?

A
  • Excessive superficial emotionality
  • Powerful need for attention
  • Dramatic clothing
  • Exaggerated emotions
  • Flirtatious, seductive, difficulty with intimacy (somatization d/o)
271
Q

What are features of narcissistic personality d/o?

A
  • 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
Q

What are the cluster C personality disorders?

A
  • Avoidant
  • Dependent
  • OCD
273
Q

What are features of avoidant personality d/o?

A
  • 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
Q

What are features of dependent personality d/o?

A
  • Extremely needy of others for emotional support and decision making
  • Continuous fear of separation, submissive and clingy (co-morbid anxiety, depression)
275
Q

What are features of OCD?

A
  • 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
Q

How would you deal with a hostile patient?

A
  • Set limits and boundaries

* Acknowledge hostility, contain the patient, defend self

277
Q

How would you deal with a crying patient?

A

*Empathize

278
Q

How would you deal with a cognitively-impaired patient?

A

*Determine Pat level

279
Q

How would you deal with a seductive patient?

A
  • Define role
  • Set limits
  • Avoid 1-1 interviews
280
Q

How would you deal with a delusional patient?

A
  • Don’t agree with or refute delusions
  • Explore inconsistencies *Genuine concern and surprise
  • Agree with affect, not delusion
281
Q

How do you report child abuse?

A
  • 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
Q

What is the MA statute for child abuse?

A

Section 51A

283
Q

What is substance use disorder?

A
  • Use of one or more substances leads to a clinically significant impairment or distress
  • Pathological use of substance –>adverse social consequences
284
Q

What is substance tolerance?

A
  • 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
Q

What is substance withdrawal?

A

Characteristic withdrawal syndrome for substance or the same or similar substance needed to avoid/relieve withdrawal symptoms

286
Q

What medical Hx should be considered prior to starting a pt. on lithium? Why?

A

Hx of medical conditions that affect ADME of lithium

  • Severe renal dz
  • DM
  • Ulcerative colitis
  • Recent cardiac problems
  • Drug has very narrow TI
287
Q

What labs should be done on pt. prior to starting lithium?

A
  • 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
Q

What are some contraindications to lithium use?

A
  • Myasthenia gravis –>inhibits ACh release

* Pregnancy/breast feeding –>Ebstein’s anomaly

289
Q

What are some side effects of lithium use?

A
  • Reversible hypothyroidism (esp. women)
  • T wave changes
  • Nephrogenic DI
  • Hypercalcemia
  • Reversible leukocytosis
  • Kidney damage
290
Q

What are s/sx of lithium toxicity?

A
  • Confusion
  • Lethargy
  • Severe tremors
  • Muscle weakness
  • Seizures
  • Diarrhea
291
Q

What are some possible causes of lithium toxicity?

A
  • Hyponatremia (reabsorption in PT with Na+)
  • NSAIDs (inc. renal PG synthesis)
  • Chronic renal insufficiency
  • Use of Abx such as tetracyclines, cyclosporine
292
Q

What is tyramine?

A
  • Naturally occurring sympathomimetic normally inactivated by MAO in the gut
  • Found in matured protein foods (aged cheese, wine)
293
Q

What is tyramine reaction?

A

Intake of high-tyramine foods in pt. taking MAOis may resulting in hypertensive crisis, occipital headache, risk of stroke

294
Q

How is tyramine reaction treated?

A
  • Nifedipine (antihypertensive)
  • Regitine (alpha blocker)
  • Thorazine (typical antipsychotic)
295
Q

What is serotonin syndrome?

A

Excess serotonergic activity at CNS and PNS receptors

296
Q

What drug classes cause serotonin syndrome?

A
  • Antidepressants
  • Opioids
  • CNS stimulants
  • 5-HT1 agonists
  • Illicit drugs
297
Q

What are the symptoms of serotonin syndrome?

A
  • Rapid onset (mins-hrs) and fast offset
  • Tachycardia, shivering, diaphoresis, mydriasis, tremor, myoclonus, hyper/hyporeflexia, hyperthermia, seizures, DIC, renal failure, metabolic acidosis
298
Q

How do you treat serotonin syndrome?

A
  • No antidote, supportive
  • Removal of drug causes
  • Administration of serotonin antagonists
299
Q

What are the sx of anticholinergic toxicity?

A
  • Flushing
  • Dry skin/mucous membranes
  • Mydriasis & loss of accomodation
  • AMS
  • Fever
  • Sinus tachycardia
  • Urinary retention
  • HTN
  • Myoclonic jerks
300
Q

What is the treatment for anticholinergic toxicity?

A

Physostigmine salicylate

301
Q

What is NMS?

A

Following neuroleptic use,

  • Hyperthermia >38C
  • Muscle rigidity
  • AMS, tremor, tachycardia, incontinence, labile BP, metabolic acidosis, tachypnea, hypoxia, elevated CPK, diaphoresis, sialorrhea, leukocytosis
302
Q

What are specific treatments for NMS?

A
  • Cessation of neuroleptic drug
  • Supportive care
  • Lorazepam
  • Amantadine
  • Bromocriptine
  • Dantrolene
  • ECT
303
Q

What is a hallucination?

A

Sensory perception without an actual external stimulus

304
Q

What is an illusion?

A

Misinterpretation of an existing stimulus

305
Q

What is a delusion?

A

Fixed false belief that cannot be altered by rational arguments and is not explained by cultural background

306
Q

What is paranoia?

A

Mental d/o characterized by presence of systematized delusions, often persecutory, in an otherwise intact personality

307
Q

What is ambivalence?

A

Coexistence of contradictory emotions, attitudes, ideas, or desires with respect to a particular person, object, or situation. Usually not fully conscious.

308
Q

What is depersonalization?

A

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
Q

What is derealization?

A

Feeling of estrangement or detachment from one’s environment

310
Q

What are loose associations?

A

No logical connection from one thought to another

311
Q

What is thought blocking?

A

Abrupt cessation of communication before the idea is finished

312
Q

What is thought disorder?

A
  • A disturbance of speech, communication, or content of thought
  • Interchangeable with psychosis
313
Q

What are ideas of reference?

A

Incorrect interpretation of casual incidents and external events as having direct reference to oneself

314
Q

What is somatization?

A

Psychological needs are expressed in physical sx

315
Q

What is obsession?

A

Recurrent and persistent thought, impulse, or image experienced as intrusive or distressing. Recognized as excessive and unreasonable.

316
Q

What is compulsion?

A
  • 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
Q

What is anhedonia?

A

Loss of interest in pleasurable activities

318
Q

What is nihilism?

A

The delusion of the nonexistence of everything, especially the self or part of the self

319
Q

What is narcissism?

A

State in which one interprets and regards everything in relation to oneself

320
Q

What is grandiosity?

A

Exaggerated belief or claims of one’s importance or identity

321
Q

What is phobia?

A

An objectively unfounded fear that arouses a state of panic

322
Q

What is mood?

A

The pervasive feeling, tone and internal emotional state of a person

323
Q

What is affect?

A

Behavior that expresses a subjectively experienced emotion.

324
Q

Describe Alzheimer’s dementia

A

Insidious onset

Imaging shows enlarged cerebral ventricles and cortical atrophy

325
Q

Describe vascular dementia

A

Occurs abruptly, usually following a stroke

Can include subdural hematoma

326
Q

Describe pseudodementia

A
  • Clues to the diagnosis of depression (e.g. weight loss, worsening sleep, crying spells)
  • Treating the depression improves symptoms
327
Q

Describe the difference between delirium and dementia

A

Delirium: d/o of consciousness
Dementia: impairment of memory without alteration in consciousness

328
Q

What are the features of geriatric depression?

A
  • More neurovegetative sx

* Consider medical condition (L hemisphere cerebral infarct) or medication (beta blockers) as cause

329
Q

What is the treatment for geriatric depression?

A
  • Lower oral dose of antidepressants

* Avoid TCAs due to risk of orthostatic hypotension

330
Q

What is the treatment for apathetic patients with geriatric depression?

A
  • Stimulants

* ECT

331
Q

What psychiatric d/o can present with psychosis?

A
  • Schizophrenia, schizophreniform, schizoaffective
  • Delirium, dementia
  • Brief psychotic d/o
  • Delusion d/o, shared psychotic d/o
  • Major depression
  • Bipolar d/o
332
Q

What are common side effects of SSRIs?

A
  • GI complaints (nausea, loose stools)
  • Anxiety, hyperstimulation, jitters
  • Insomnia
  • Sexual dysfunction
  • Serotonin syndrome
  • May have increased suicidality in young patients
333
Q

How long is an adequate drug trial? What are some proposed changes if there is no response?

A
  • Drug trial should be 4-8w

* No response in 4 w–>increase dosage or consider switching to another class

334
Q

What is the response rate in MDD to ECT vs pharmacotherapy?

A

ECT: 80-90% respond
Medications: 50-75% respond

335
Q

What are 3 domains of functional impairment?

A
  • Work
  • Social
  • Family life
336
Q

How can the severity of psychiatric illness be described?

A

In terms of functional domains

337
Q

What factors make a psychiatric illness more severe?

A

Functional impairments in more domains

338
Q

What are the guidelines for referral to psychotherapy?

A

*If pt. has SI, co-morbid personality d/o or sub abuse issuse, consider referring to psychiatrist

339
Q

What is the standard of care for bipolar pts. in an active manic/hypomanic or depressed episode?

A

Psychiatrist evaluation and treatment

340
Q

What is the standard of care for pts. experiencing psychotic disorder?

A

Refer to inpt. or outpt. psychiatrist

341
Q

What is the standard of care for pts. with anxiety d/o?

A
  • 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
Q

What is the standard of care for pts. with eating d/o?

A
  • Referral to psychiatrist and/or therapist

* Collaboration between PCP and psychiatrist is crucial

343
Q

When is a section 12A indicated?

A

*If pt. is not hospitalized, there is a likelihood pt. will cause serious harm to themselves or others b/c of mental illness

344
Q

What is adjustment disorder?

A
  • 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
Q

What is the prognosis of adjustment d/o in adolescents?

A
  • 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
Q

What is the prognosis of adjustment d/o in adults?

A
  • Good prognosis after dx

* Represents adults with acute onset sx with no underlying psychopathology

347
Q

What is the treatment for adjustment d/o?

A
  • Individual therapy
  • Group psychotherapy
  • Can use meds for predominant sx
348
Q

What are the diagnostic criteria for OCD?

A
  • 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
Q

What is the prevalence of OCD in general population? What is the age of onset?

A

2-3% of general population, most will meet criteria before age 30

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