Test 2 Flashcards
evaluation of psychotic patient
- history (talk to family)
- mental state to establish baseline
- physical exam
- labs
- imaging (at least one head CT)
positive schizophrenia symptoms
- have to have at least 2*
- respond to antipsychotic Rx*
- disorganized speech
- bizarre behavior
- delusions
- hallucinations
- thought disorders
negative schizophrenia symptoms
- alogia (sparse speech)
- affective flattening
- anhedonia
- asociability
- apathy
- attention impairement
- less responsive to Rx*
delusion
a fixed false belief with evidence that the belief is false
hallucination
- vivid perceptual experience that occurs in absence of valid sensory stimulus
- visual, olfactory, and tactile need medical causes ruled out
catatonia
- abnormal motor behavior and periods of extreme hyperactivity and hypoactivity
- waxy flexibility
schizophrenia diagnostic criteria
- 2 characteristic symptoms of psychosis (hallucinations, delusions, disorganized speech, disorganized behavior, negative symptoms)
- lasts at least 6 months with 1 month of characteristic symptoms
- social and/or occupational dysfunction
- exclude other disorders
schizophreniform disorder
- one to six months of symptoms
- social/occupational impairment not required
schizoaffective disorder
- psychotic symptoms plus prominent mood symptoms
- two week period of psychotic symptoms without mood symptoms
delusional disorder
- delusions for at least 1 month
- no other criteria met
brief psychotic disorder
- one of the characteristic symptoms
- time range one day to one month
substance induced psychotic disorder
-hallucinations or delusions during or within one month of substance abuse
acute psychosis treatment
- one of haldol, geodon, zyprexa (or other 2nd generation antipsychotic)
- plus ativan
- sometimes benadryl or vistaril
“B-52”
long term schizophrenia treatment
- haldol first line for typical
- clozapine most effect for atypical but not used first line due to agranulocytosis
depressive type schizoaffective treatment
- 2nd generation antipsychotic
- antidepressant as adjunct
bipolar type schizoaffective long term treatment
- 2nd generation antipsychotic
- mood stabilizer as adjunct
treatment of dystonia
- cogentin
- benadryl
akathisia treatment
propranolol
benzodiazepine
benzotropine (cogentin)
tardive dyskinesia treatment
ingrezza (valbenazine)
insight oriented psychoanalysis
- increase patient’s understanding of neurosis
- uncover repressed memories
- long term
supportive psychotherapy
- therapeutic relationship for emotional support
- acute crisis
- patients with low ego strength
- vulnerable patients
cognitive behavioral therapy
- indicated for anxiety and mood disorders
- focus on patient’s maladaptive thinking
- learn new thought patterns and behaviors
dialectical behavioral therapy
- indicated for borderline personality disorder
- increase interpersonal skill and emotional regulation
- decrease self destruction
group therapy
- family
- couples
- self help
- group patients with similar diagnosis
denial
- primitive defense
- refusal to accept reality or fact
regression
- primitive defense
- reversion to earlier stage of development
acting out
- primitive defense
- extreme behavior to express thoughts or feeling
dissociation
- primitive defense
- person loses track of time and/or person and instead finds another representation of their self to continue in the moment
- common with child abuse history
compartmentalization
- primitive defense
- lesser form of dissociation where aspects of a person’s life are separated
projection
- primitive defense
- misattribution of a person’s thoughts, feelings, or impulses onto another person
repression
- intermediate defense
- unconscious blocking of unacceptable thoughts, feelings, or impulses
displacement
- intermediate defense
- redirecting of thoughts, feelings, or impulses directed at one person/object but taken out on another person/object
intellectualization
- intermediate defense
- overemphasis on thinking when confronted with an unacceptable impulse, situation, or behavior without employing any emotions
rationalization
- intermediate defense
- offering a different explanation for one’s perceptions or behaviors in the face of a changing reality
undoing
- intermediate defense
- attempt to take back an unconscious behavior or thought that is unacceptable or hurtful
sublimation
- mature defense
- channeling of unacceptable thoughts, impulses, and emotions in to favorable ones
compensation
- mature defense
- psychologically counterbalancing perceived weaknesses by emphasizing strengths in other areas
assertiveness
- mature defense
- strike a balance to speak up for themselves, express needs/opinions respectfully, and listen when spoken to
prescribing for pregnant population
- 1st: avoid/minimize medications
- 2nd: treat the mother
- evaluate risk/benefit with patient and OB team
prescribing for geriatric population
- start low and go slow
- first think drugs as cause of symptoms when diagnosing
- avoid polypharmacy
- decreased volume of distribution
- decreased metabolism
- increased AE sensitivity
SSRIs drugs
“Effective For Sadness Panic Compulsions”
- citalopram (celexa)
- escitalopram (lexapro)
- fluoxetine (prozac)
- fluvoxamine (paxil)
- sertraline (zoloft)
- paroxetine (paxil)
SSRI+ drugs
vilazadone (viibryd)
vortioxetine (trintellix)
SSRI and partial serotonin agonist
SNRI drugs
desvenlafaxine (pristiq)
duloxetine (cymbalta)
venlafaxine (effexor)
also used for peripheral pain and neuropathy
SSRI side effects
- GI upset
- sexual dysfunction
- activation/akathisia (will go away)
- mania
- SI in younger patients
- serotonin syndrome
serotonin syndrome
- potentially fatal
- can be caused by combining an SSRI/SNRI with an MAOI (should separate by 5 weeks)
- takes 24-48 hours to develop
- variable mental status
- increased muscle tone
- HTN, tachycardia, tachypnea, fever
- hyperreflexia
- mydriasis
- increased bowel sounds
serotonin syndrome treatment
- stop all serotonergic drugs
- supportive care to stabilize vitals
- benzo for sedation, relaxation
- serotonin antagonist for severe cases
bupropion (wellbutrin)
- atypical antidepressant
- do not use in patient with seizure history
- often used as adjunct with SSRI
mirtazapine (remeron)
- atypical antidepressant
- also used as sleep aid
- AE: weight gain
trazodone (desyrel)
- atypical antidepressant
- also used as sleep aid
- AE: priaprism
esketamine (spravato)
- used for treatment resistant depressant as an adjunct to other antidepressants
- patients monitored for 2 hours after dose for hallucinations
- not used in pregnancy
- AE: dissociative and perceptual changes, derealization, depersonalization, HTN
tricyclics
- 2nd/3rd line for Rx resistant depression
- OD causes fatal cardiac arrhythmias
- be aware of suicidal ideations when prescribing
- amitriptyline, clomipramine
tricyclic side effects
- cardiac toxicity (LBBB, V-tach)
- anticholinergic effects
MAOI
- use is very uncommon
- avoid tyramine containing foods due to HTN crisis
SNRI side effects
same as SSRIs plus HTN
benzodiazepine indications
- EtOH withdrawal
- anxiety disorder
- muscle relaxant
- seizure
benzodiazepine onset of action
generally one hour
benzodiazepine side effects
- sedation
- fatigue
- disinhibition
- depression
- rebound anxiety
- elderly: memory impairment, impaired performance, lowered attention span, muscle incoordination
benzodiazepine treatment concerns
- potentiate effects with alcohol
- abuse and dependence
- tolerance
buspirone (buspar)
- anxiolytic for anxiety only
- don’t cross react with alcohol or benzos
- little abuse potential
- may take 1-2 weeks to show effect with max effect 3-4 weeks
- mixed results on efficacy
hydroxyzine (vistaril, atarax)
- antihistamine
- anxiolytic
- treat agitation in alcohol detox
- adjunct for insomnia
typical antipsychotics drugs
-haldol
- prolixin
- thorazine
atypical antipsychotics
- aripiprazole (abilify)
- ziprasidone (geodon)
- risperidone (risperdal)
- quetiapine (seroquel)
- onlanzapine (zyprexa)
- clozapine (clozaril)
antipsychotic indications
- acute and chronic psychosis
- bipolar with or without psychosis
- depression with psychotic features
- resistant anxiety disorders
- impulse control disorder
- agitation in medically compromised
side effects of typical antipsychotics
- extrapyramidal symptoms
- tardive dyskinesia
- sedation
- neuroleptic malignant syndrome
- weight gain
- orthostatic hypotension
- QT prolongation
tardive dyskinesia
- involuntary muscle movements of fact, tongue, trunk
- long term side effect at 5-20 years of treatment
- higher incidence with typical antipsychotic
- treated with valbenazine
neuroleptic malignant syndrome
- result of too much dopamine and occurs over few weeks/months
- variable mental status
- increased muscle tone
- HTN, tachycardia, tachypnea, fever
- hyporeflexia
- normal pupils
- normal bowel sounds
atypical antipsychotic side effects
- weight gain
- hyperlipidemia
- DM
- clozapine = agranulocytosis
quetiapine (seroquel)
- highly sedating
- adjunct for severe depression or bipolar
- AE: orthostatic hypotension
aripiprazole (abilify)
- partial D2 antagonist
- uses: schizophrenia, bipolar, agitation, MDD
- AE: akathisia, nausea, anxiety, headache, insomnia, sedation
treatment of parkinsonian side effects
- amantadine
- levodopa
lithium
- mood stabilizer
- 1st line for bipolar mania
- narrow therapeutic index
lithium side effects
- diabetes insipidus
- renal toxicity
- tremor
- hypothyroidism
valproic acid (depakote, depakene)
- 2nd line mood stabilizer
- AE: ototoxicity, teratogenic, low platelet
propranolol use
performance anxiety
paranoid personality disorder
- cluster A
- pervasive distrust of others
- principal ego defense is projection
- Tx: CBT
schizoid personality disorder
- detached and solitary, but well functioning
- no desire for social interaction
schizotypal personality disorder
- odd beliefs, magical thinking
- suspicious or fearful of others
- avoids social interaction due to fear
antisocial personality disorder
- lack of concern or remorse
- aggressive and reckless
- mental disorder most associated with crime
antisocial personality disorder diagnostic criteria
- at least 18
- evidence of conduct disorder before 15
- occurrence of behavior is not exclusively during schizophrenia or manic episode
borderline personality disorder
- unstable relationships
- unstable self image
- anger outburst
- frequent SI/harm threats
- fear of abandonment
- Tx: dialectical behavior therapy
histrionic personality disorder
- excessive emotions, attention seeking
- seductive and provocative behavior
- shallow expression of emotion
- self dramatization
narcissistic personality disorder
- grandiose sense of self importance
- requires excessive admiration
- sense of entitlement
- exploits others
- lacks empathy
- arrogant
avoidant personality disorder
- social inhibition
- feeling inadequate
- hypersensitive to negative evaluation
dependent personality disorder
- need to be taken care of
- submissive and clinging behavior
- fear of separation
obsessive compulsive personality disorder
- perfectionism that interferes with task completion
- over conscientious, scrupulous, and inflexible
normal BMI
18.5 - 24.9
anorexia nervosa
- refusal to maintain body weight above 17.5 or 85% expected weight
- intense fear of weight gain even though underweight
- disturbance in body image
anorexia restricting type
- weight loss through dieting, fasting, excessive exercise
- no binging or purging for the last 3 months
anorexia binge/purge type
in the last 3 months recurrent binge/purge episodes
anorexia labs/results
- leukopenia
- hypokalemia
- low albumin
- amenorrhea
- lanugo
- EKG changes
anorexia treatment
- hospitalization if more than 20% below ideal body weight
- family therapy and CBT
- Rx if depressed
bulimia nervosa
- recurrent episodes of binge/purge
- at least once a week for 3 months
- maintains normal or above body weight
- dental caries, esophageal tears, parotid or salivary gland enlargement
binge eating disorder
- recurrent episodes of binge eating
- occurs weekly for at least 3 months
body dysmorphic disorder
- type of OCD
- obsession with perceived flaw in appearance
- repetitive behavior centered around that flaw
enuresis
- repeated bed wetting
- either twice a week for 3 months or significant distress
- 5 or older
- involuntary or intentional
- Tx desmopressin
encopresis
- repeated passage of feces inappropriately
- at least once a month for 3 months
- 4 or older
pica
persistent eating of non-food and non-nutritional substances
rumination
- repeated regurgitation of food
- >1 month
impaired control criteria
- larger amounts of time
- desire to reduce use
- time obtaining, using, recovering
- craving
social impairment criteria
- fail to fulfill duties
- social/interpersonal problems
- give up activities
risky use criteria
- hazardous use
- use despite physical/psychological problems
tolerance/withdrawal criteria
- tolerance
- withdrawal symptoms
severity depends on number of eleven criteria
- mild 2-3
- moderate 4-5
- severe 6 or more
early remission
no criteria for 3-12 months except craving
sustained remission
no criteria >12 months except craving
in controlled environment
access to substance restricted
alcohol use disorder
- presence of at least 2 symptoms
- mild 2-3
- moderate 4-5
- severe 6 or more
alcohol tolerance
-neuroadaptation from continued use
-need to use increased amount to achieve effect
OR
-diminished effect with continued use of same amount
alcohol intoxication
- mood lability, impaired judgement, poor coordination
- neurological impairment
- can be fatal
wernicke encephalopathy
- reversible
- acute thiamine deficiency
- triad: delirium, ocular motor dysfunction, ataxia
korsakoff syndrome
- irreversible
- chronic thiamine deficiency
- anterograde amnesia and confabulation
alcohol withdrawal
-early: anxiety, tachycardia, HTN, insomnia, headache, tremor
-grand mal seizures at 12-24 hours
-delirium tremens at 24-72 hours
altered mental status, hallucinations, autonomic instability
-life threatening
alcohol withdrawal treatment
- withdrawal assessment
- benzodiazepine
- carbamazepine
- DT treated in ICU
naltrexone
- prevent EtOH relapse
- first line
- reduce craving
- hepatoxicity at high dose
acramprosate
- prevent EtOH relapse
- first line
- renal clearance
antabuse
- prevent EtOH relapse
- blocks alcohol metabolism
CDC opioid prescribing guidelines
- nonopioid therapy preferred
- lowest dose for shortest time when prescribed
- monitor all patients closely
opioid intoxication
- pinpoint pupils
- euphoria followed by apathy
- drowsiness
- slurred speech
- memory impairment
opioid use long term effects
- constipation
- hepatitis
- HIV
- heart infection
- CNS injury
- miscarriage/neonatal withdrawal
methadone
- mu agonist
- titrated until no craving and no illicit use
- can be continued or tapered
buprenorphine (subutex)
- partial opioid agonist
- ceiling effect limits high
- long duration
- highly motivated patients who do not need high doses
suboxone
- subutex and naloxone
- discourage illicit use
naltrexone
- full opioid antagonist
- alcohol and opioid use disorder
- used under medical supervision
PCP intoxication
- unpredictability
- hallucinations
- nystagmus
PCP treatment
- benzodiazepine
- low stimulation environment
PCP tolerance/withdrawal
-typically does not occur
hallucinogen persisting perception disorder
reliving perceptual symptoms experienced while intoxicated with hallucinogen with significant distress
sedative, hypnotics, anxiolytic intoxication
similar to alcohol but less motor deficit
sedative, hypnotics, anxiolytic overdose
- CNS and respiratory depression
- treated with flumazenil
barbiturates withdrawal
potentially life threatening
benzodiazepine withdrawal
- similar to alcohol
- common detox mistake is fast taper
stimulant intoxication
- euphoria
- pupillary dilation
- cardiac arrhythmia
cocaine withdrawal
- exhaustion
- dysphoria
- lethargic
