Step 2 Psych Flashcards
How is Tourettes D/O dx’d? What pharm options do you have? What comorbid conditions are associated?
Dx = multiple motor and vocal tics that cause relief for at least one year before 18 yo; can wax and wane.
Pharm therapy is indicated when the d/o interferes with daily living; first gen anti psych rx haloperidol and pimozide are FDA approved but b/c of potential SEffx (QTc prolong), 2nd gen are preferred (esp. Risepridone)
Associated with OCD
What factors make a person more predisposed to lifetime therapy for Bipolar Mood D/O? What med has been shown to decrease suicide, relapse, and hospitalization in these pts?
Fam hx, >3 episodes, severe episodes
LITHIUM!
What would you do and give a patient who recently started an antipsychotic and is experiencing hyperthermia, muscle rigidity, autonomic instability, and altered sensorium? What’s happening? What are you watching out for as a possible complication?
Give Dantrolene Sodium, a direct muscle relaxant and immediately stop the neuroleptic, it’s causing Neuroleptic Malignant Syndrome.
Can also continue supportive care with cooling, antipyretic meds, electrolyte and fluid repletion.
Look out for Rhabdomyolysis as evidenced by elevated CPK levels - give alkaline diuresis for suspected rhabdo to prevent acute renal failure.
Describe Reaction Formation, Sublimation, Splitting and Suppression.
1) Reaction Formation = neurotic mech = doing the exact opposite of what makes you mad (i.e. being furious with homeless people but volunteering at a homeless center)
2) Sublimation = mature mech = downgrading an instinctive response and doing something that is acceptable (go boxing when you want to punch someone out of anger)
3) Splitting = “all good” or “all bad” mentality
4) suppression = avoiding an uncomfortable idea by occupying yourself with other things
What are the two 1st line trmts for Generalized Social Anxiety D/O?
CBT and SSRI
Dx psychosis for:
1) < 1 month
2) > 1 month but < 6 months
3) > 6 months
1) Acute Psychosis
2) Schizophreniform
3) Schizophrenia
What’re the +/- sympt of Schizophrenia?
Pos: delusions, hallucinations, bizarre behavior, thought disorder (respond well to antipsychotics)
Neg: Flat affect, anhedonia, alogia, poor attention, avolition (respond poorly to typical anti psych meds but better response found with atypical anti psych meds)
Schizophrenia predictors of bad/good outcome:
Bad Outcome: fam hx, early onset, neg sympt, poor support, no precipitating factors, and MOST IMPORTANTLY poor premorbid functioning
Good Outcome: MOST IMPORTANTLY good premorbid functioning, late onset, positive sympt, good support, married
Does psychotherapy help outcomes in Schizophrenia?
YES
What to watch out for with high potency (Haloperidol), low potency (Chlorpromazine), and Atypicals (Risperidone, Olanzapine, Aripiprazole, Paliperidone, Quetiapine, and Ziprasidone)?
1) EPS
2) Autonomic Dysfxn
3) Less incidence of auto dysfxn than above
*Auto Dysfxn = anticholinergic (dry mouth, urinary retention, blurry vision, mydriasis) / alpha blockade (orthostatic hypotension) / antihistamine effects (sedation)
Define acute dystonia, who does it predominate in, trmt?
In the first couple of hrs - days of anti psych meds, MALES predominately, develop muscle stiffness (torticollis, opisthotonus, oculogyric eye crisis, etc) - treat with antihistamines (diphenhydramine) or anticholinergic (benztropine, trihexphenidyl)
Give ______ for akathisia.
Beta-blockers (occurs days after meds given)
How do you treat parkinsonism s/p anti psych meds?
Most commonly presents in older woman months after trmt started - treat the same as acute dystonia. (2/2 to dopamine blockade by meds)
What do you do with a pt p/w Tardive Dyskinesia?
Occurs many months to years s/p trmt - no definitive treatment except for taking them off the meds and consider switching to atypical.
Galactorrhea, impotence, menstrual dysfxn, and decreased libido can result from anti psych meds b/c….
They block/inhibit dopamine and dopamine is a prolactin-inhibiting hormone.
Side Effects of:
1) Thioridazine
2) Clozapine
3) Chlorpromazine
4) Olanzapine
5) Quetiapine
6) Ziprasidone
7) Aripiprazole
8) Paliperidone
1) Retinal pigment deposits
2) Agranulocytosis which is why you monitor WBC’s
3) Photosensitivity and jaundice
4) Wt gain, hypotension, sedation dry mouth (AVOID in overtly overweight patients BC HIGH INCID OF DM and WT GAIN)
5) Sedation, orthostatic hypotension, akathisia, wt gain, dry mouth
6) Nausea, weakness, QT prolongation (AVOID IN PATIENTS W/ CONDUCTION D/O)
7) HA, nausea, akathisia, tremor, constipation
8) Parkinsonism, dystonia, dyskinesia, akithisia, QT prolongation
Trmt for acute mania in BP d/o vs. BP depression?
1) Lithium, valproic acid, and atypical antipsychotic
2) Lithium, Lamotrigine
- WATCH THE KIDNEYS WITH Lithium
Side Effects of Lithium, Valproic Acid, and Carbamazepine:
1) Kidney dysfunction (diabetes insipidus), thyroid dys, tremor, CNS probs
2) Liver Dys
3) Bone marrow suppression = aplastic anemia & SIADH
Differentiate BP I, BP II and Cyclothymia:
BP I is mania with depression, BP II is hypomania w/ depression (no psychosis w/ mania and no effect on occupation), vs. 2 yr hx of hypomania and mild depression WITHOUT full-blown manic or major depressive states
T/F: When pt’s symptoms begin to improve from depression. they are at an increased likelihood of suicide?
Yes - they might get enough energy to do it!
Age groups most likely to commit suicide?
> 65 yrs old; age 15-24 experiencing highest increase in rate
Define dysthmia:
Depressed mood on most days for more than 2 years w/o episodes of major depression, mania, or psychosis
What to give a pt with a possible TCA-induced arrhythmia? (prolonged QRS complex)
Sodium Bicarbonate - would see hyperthermia, seizures, hypotension, anticholinergic effects including dilated pupils, flushed dry skin, and intestinal ileus
When would you consider giving MAOI’s? What two med classes to not prescribe with?
May be good for atypical depression (hyperphagia/hypersomnia) when it doesn’t respond to other meds. DONT GIVE WITH SSRI’s or MEPERIDINE!!!!
What side effect is feared by men with Trazodone?
Priapism
What distinguishes normal grief from pathologic grief?
Normal: generally, up to 1 yr of normal SIGECAPS, yearning for lossed person >1 yr, searching for deceased too, hallucinations with insight that they are hallucinations
Abnormal: suicidal ideation, psychomotor retardation, and feelings of worthlessness
Agoraphobia is associated with what psych d/o?
Panic D/O
Drug consideration for GAD…
Buspirone = slow onset, nonsedating, nonaddictive
SSRI’s = use if concurrent depressive sympt
BZD = warning with addiction and sedation
Differentiate b/w Somatization D/O, Conversion D/O, Hypochondriasis, and Body Dysmorphic D/O
Somatization D/O is when a pt has multiple vague symptoms in different organ symptoms with no precipitating factor for many years and negative work up
Conversion D/O occurs with a specific factor and a unexplainable neurological symptom
Hypochondriasis is when the pt persistently believes something is wrong despite negative w/u
Body Dysmorphic D/O whereby a pt is fixated on a physical defect that doesn’t exist or is hugely blown out of proportion
Differentiate b/w somatiform, factitious, and malingering d/o’s…
Somatiform d/o comprises symptoms that are not made up by the patient, it’s an unconscious process. Factitious d/o is where the pt actually creates the illness or the symptoms to assume the “role of the pt” but NO secondary gain. Malingering happens when pts intentionally create their symptoms in attempts of secondary gain!
What is classically associated with a history of childhood abuse?
Dissociative Identity D/O
Difference b/w Schizoid, Avoidant, Antisocial and Borderline Personality D/O’s?
Schizoid - alone and WANT to be alone
Avoidant - avoid social environments but WANT to have friends
Antisocial - past hx of Conduct D/O; set fires, cruel to animals, lie and have no remorse for their actions, male predominance
Borderline - unstable moods, behaviors, and relationships. Look for splitting!!! Might have micro psychotic episodes.
Dx: pt has decreased latency to REM sleep, cataplexy, hypnagogia and hypnopompic…Trmt?
Narcolepsy. Modafinil
MCC’s of mental retardation?
MC preventable cause = Fetal Alcohol Syndrome
MC overall = Down Syndrome
Male-specific cause = Fragile X
How to differentiate autism from Asperger Syndrome?
Asperger’s has intact language skills with the impairment of social activities and restricted interests. VS Autism w/ all three: impaired social interactions, impaired verbal and nonverbal communication, and restricted interests.
Seffx of Atomoxetine…
It’s an SNRI and may cause cardiovascular events and suicidal thinking
Kids with Separation Anxiety D/O complain of…” “
That something will happen to themselves or their parents when they are away - compensate by doing something that prohibits the separation
Anorexia’s three dx criteria:…. Feared complication?
(1) Body wt at least 15% BELOW normal (2) Fear of gaining wt and (3) ammenorrhea. Fear electrolyte imbalances, arrhythmias, and infections.
Encopresis is normal until 4 and enuresis until age 5. Trmt for refractory cases of enuresis?
Try conservative mgmt first with rewards, positive disciplining, etc. R/O medical problem. Can give Desmopressin or Imipramine for refractory cases.
MC elicit drug of abuse?
Marijuana
Name that drug use!
Intoxication: euphoria, analgesia, drowsy, miosis, constipation, and CNS depression - resp. depression = overdose.
Withdraw: diarrhea, goosebumps, abd pain/cramping.
Trmt?
Opiods (Heroin)
Give Naloxone to prevent resp. depression
Methadone and Buprenorphine can be used to reduce ACUTE withdrawal sympt.
Pt take a substance that causes VISUAL hallucinations, mydriasis, tachycardia, diaphoresis, “flashbacks” or a “bad trip”….dx? Trmt?
Dx = LSD or hallucinogenic mushrooms.
Trmt = Reassurance or BZD, or antipsychotic.
Hallmarks of presentation: extreme aggression, vertical/horizontal nystagmus, muscle rigidity, convulsions, coma, and schizophrenia=like sympt. Trmt?
PCP. Acidify the urine to help with excretion.
How to treat overdose of BZD?
Flumazenil. Treat on inpatient with long-acting BZD and then slowly taper to decrease chance of cardiac collapse or seizure. ENSURE THIS IS ACUTE OVERDOSE AND NOT CHRONIC DEPENDENCE - could cause seizures in this circumstance
What contraindication exist for bupropion?
Seizure hx or eating d/o or anything that could predispose to an electrolyte abnormality that might cause a seizure b/c the med decreases seizure threshold
What distinguishes Schizoaffective D/O from BP or MDD?
The mood and psychosis can co-occur together, but for Schizoaffective D/O, the psychosis must be present w/o mood symptoms for > 2weeks. VS there others where psychosis only occurs during the manic or depressive states with nothing in between, euthymic.
Which dopamine pathways are affected from the following:
1) antipsychotic efficacy
2) EPS
3) Hyperprolactinemia
1) Mesolimbic
2) Nigrostriatal
3) Tuberoinfundibular
What medications are classically associated with Malignant Hyperthermia?
Halothane and Succinylcholine
Acute confusion, extreme hyperthermia (>105) tachycardia, and coagulopathic bleeding after heavy work in direct, hot sun = ??? Other complications of this?
Exertional Heat Stroke - further complicates include ARDS, renal failure, rhabdo
Types of Mental Retardation:
1) Little to no speech, very limited ability to manage self care
2) Needs continuous supervision and care
3) Reaches 2nd grade level of education, needs help in mildly stressful events
4) Reaches 6th grade level of education, can work and live independently
1) Severe (IQ 20 - 40)
2) Profound (
Dx: Progressive encephalopathy, microcephaly, hand wringing, loss of speech, ataxia, and psychomotor retardation?
Rett Disorder
Dx: Normal development for two years then marked regression in functioning, decreases in language, social, motor and bladder function are common. Repetitive and stereotyped behaviors are noted.
Childhood Disintegrative D/O
The dx of ADHD requires symptoms to occur in how many locations? Medical trmt?
2 locations (school and home). Methylphenidate and Dextroamphetamine have side effects which is why Atomoxetine is a good drug to try first.
What is the MCC of depression-like medical illness? MCC neurological associations are what two things?
Hypothyroidism. Dementia and Parkinsons.
Trmt for patient with depression and neuropathic pain?
Duloxetine
Trmt for patient with depression and extreme fear of weight gain or sexual side effx?
Bupropion
When would you should electroconvulsion therapy?
Maybe try if refractory to multiple medications or the depression was far more severe and associated with psychotic features. Or if suicidal
Manic is differentiated by hypomanic by?
One week’s duration of symptoms and its influence of daily living
*Bipolar normally starts off with depression
T/F : Antipsychotics can be 1st line trmt in Bipolar trmt if the pt is experiencing extreme acute manic episode?
True
How to treat someone with hypomanic episodes and mild depressive episodes that have occurred for more than 2 years?
Lithium, valproic acid or carbamazepine
When to give meds for a “sad” postpartum mother?
Postpartum Depression = occurs within 1 - 3 months of birth and complains of depressed mood and may experience negative feelings toward the baby. If less than 2 weeks, postpartum blues can be treated supportively.
Common psych drug classes and their Seffx:
1) TCA’s
2) MOAI
3) SNRI
4) Lithium
5) Valproic
6) Lamotrigine
1) Amitriptyline/Nortriptyline/Imipramine - hypotension and arrhythmias
2) Phenelzine, Tranylcypromine, Isocarboxazid - red wine, aged cheese and chocolate can cause increase in tyramine and cause hypertension
3) Venlafaxine, Desvenlafaxine, Duloxetine - Hypertension and Blurry vision
4) Diabetes insipidus, renal failure, tremors, weight gain, leukocytosis, ataxia, abnormal reflexes
5) Tremors, alopecia, hepatotoxic, hyponatremia
6) Steven’s Johnson Syndrome or TEN
Treatment of Schizophrenia: medication considerations…acutely psychotic, need IM….noncomplient pt…..refractory to previous rx’s
Olanzipine or Ziprasidone
Long acting agent = Risperidone
Clozapine = do not respond to adequate trial of typical or atypical antipsychotic meds - never use as first line
2 atypical antipsychotics less likely to cause weight gain, diabetes, and metabolic syndrome…
Ziprasidone and Aripiprazole
Panic attack vs. Panic D/O trmt?
Alprazolam (BZD) vs. SSRI respectively
PTSD vs. Acute Stress D/O. Trmt?
PTSD = sympt > 1 month of reliving the event, nightmares, anger outbursts, hypervigilence
Acute Stress D/O = more than 2 days of sympt but < 1 month
Trmt = Paroxetine and Sertraline = 1st line while Prazosin is used to treat nightmares
Antianxiety med considerations…
1) Emergency situation, need IM
2) Addiction is of concern
3) Alcohol Withdrawal
1) Lorazepam
2) Clonazepam (longer half life)
3) Chlordiazepoxide, Oxazepam, Lorazepam
Additional pharm trmt for alcohol abuse…
Disulfuram (acetaldehyde dehydrogenase inhibitor), Acamprosate, and Naltrexone (opiod receptor antagonist)
Trmt for fibromyalgia?
SSRI
Adjustment D/O timeline…
Maladaptive reaction to identifiable stressor (NLy less traumatic) - symptoms of anxiety depression or conduct disturbances occur within 3 months of incident and remit by 6 months
*treat with psychotherapy
What personality d/o may have short lived psychotic episodes?
Borderline and Schizotypal
Cataplexy, as seen in narcolepsy may be precipitated by…
loud noise or emotions
Medical trmt of insomnia…
Zolpidem, Zaleplon, or Eszopiclone (Z’s)
Trmt of premature ejaculation?
SSRI
People sexually abused w/ PTSD are at higher risk of??
Suicide ideality and attempts most importantly but also STIs, depression, pelvic pain, fibromyalgia, and functional GI problems
Options for a stable pt with an IUFD?
Expectant management or induction of labor - increased risk of DIC and chorio with expectant management.
*Fibrinogen levels are normally higher in pregnancy
You’d see pulsus bisferiens (two strong systolic peaks of the aortic pulse from left ventricular ejection with an interrupted mid systolic dip) in what two d/o’s?
Aortic regurg w/ or w/o AS
Hypertrophic Obstructive Cardiomyopathy
Kids with recurrent middle ear infections, observable skin debris, and granulation tissue in the ear canal should be worked up for?
Cholesteatomas - can have pockets whereby granulation tissue and skin debris accumulates causing persistent ear drainage despite antibiotic use.
Complications = hearing loss, cranial nerve palsies, vertigo, and bran abscess or meningitis.
Common findings seen in pts with anorexia nervosa:
Osteoporosis, elevated cholesterol and carotene levels, Prolonged QT interval, Euthyroid Sick Syn, HPA dysfunction, hyponatremia to excessive water drinking unless purging is present
Trmt of Anorexia nervosa and bulimia?
Anorexia = CBT, nutritional rehab and Olanzapine if unresponsive to first two trmt modalities
Bulimia = CBT, nutritional rehab, and SSRI
Statin/Lipid recommendations:
If you’re more than 40?
Lifestyle + statin therapy to reduce CVD
What would you start with a patient who is a young non-smoker with persistent cough? 3 common causes?
Psot-nasal drip (s/p URI), GERD, and asthma. Can start a first generation antihistamine (chlorpheniramine) or combo (brompheniramine and pseudo ephedrine)
What is the MCC of chronic mitral regurg in developed countries?
MVP = displaced apical impulse, holosystolic murmur, and third heart sound
First line treatment for acute mania depend on…
They are antipsychotics and mood stabilizers like valproic acid, carbamazepine, and lithium….but EXTREME agitation and psychosis would benefit from a second generation antipsychoptic like Risperidone first b/c it acts fast!
Abrupt withdrawal of BZD’s cause?
Seizures and confusion.
Neuroimaging findings on:
1) Autism
2) OBCD
3) Panic D/o
4) PTSD
5) Schizophrenia
1) Increased total brain volume
2) Orbitofrontal cortex
3) Amygdala
4) Decreased hippocampal volume
5) enlarged cerebral ventricles
Bipolar I vs II?
I does not require depression episode like BP II does.
AV block, bradycardia, hypotension, wheezing, and cardiogenic shock = what intox?
Beta blockers - ADMINISTER ATROPINE AND FLUIDS FIRST, THEN GLUCAGON IF REFRACTORY
____ is the MC middle ear pathology in patients with immunodeficiency?
Serous otitis media = non-infectious effusion
