UW 2 Flashcards
switching from fluoxetine to MAIi
wait 5 weeks to prevent seretonin syndrome (fluoxetine has long HT)
seretonin syndrome - treatment
- stop all seretonergic medications
- supportive care, sedation with benzo
- refractory –> cyproheptadine)
switch to clozapine if extrapyramidal symptoms under antipsychotics
only if tardive dyskinesia
REM sleep behavior disorder
complex motor behaviours that occur during REM
- dream enactment can occur if the muscle atonia that usually accompanies REM sleep is absent or incomplete
- latter of the night (higher % of REM)
- very transient confusion after awake
- recall heir dreams but not movements
- older adult men
- may be prodromal for Parkinson or Lewy
depression refractory to 1 SSRI - next step
try a 2nd SSRI (then other drugs) change class if 2 dif medication of the same class do not work
Best predictor of complication after TCA overdose
QRS longer than 100 msec
best initial therapy for major depression
SSRI with CBT
gambling disorder diagnosis is based on 4 or more of the following
- gambling when distressed
- depressed or anxious
- increased gambling to achieve the desired excitement
- frequently returning to gambling to recover past losses
- preocppation with gambling
- irritability and distress when trying to cut back on gambling
- repeated unsuccessful attempts to cut back
- trying to conceal the extend behaviors
- damaging relationships or jeopardizing employment
- relying on others to make up for financial loses
start SSRI for Major depression - when to stop them
if single episode of major depression –> continue for additional 6 months following acute response to reduce the risk of relapse
with chronic, recurrent or severe episodes –> 1-3 years
cancer patient with depression - what to say
offer treatment (don't say it is normal: it will negatively affect the treatment)
post traumatic stress disorder - treatment
- trauma focused CBT
- SSRI or SNRI
- prazosin for nightmares
drug of choice in pediatric depression
fluoxetine
Pharmacotherapy of psycjosis
- antipsychotics 2nd generation
- adjunctive benzo for agitation
- chronic nonadherence: lonsider long actinve injectable
- Treatment resistance (2 failed trials): consier clozapine
oppositional defiant disorder - time
at least 6 months
patient with acute mania and psychosis - best initial treatment
antipsychotic
causes of FP amphetamine urine test
selegiline, bupropion, decongestant pseudoephedrine
kelptomania - characteristics
stolen objects have little value
- increasing tension prior to theft –> pleasure or relief after
- guilt or remorse are common
- stolen objects given away, discharged or returned
kleptomania vs shoplifting
shoplifting is much more common, theft for personal gain
- In kleptomania, ovewrwhelming fellings of tension r anxiety precede impulses and are releived with the act of theft (guilty and shame)
kleptomani treatment
CBT oreientation focusing on techniques to resist and manage urges and anxiety
medications: SSRI, opiod antagonists, lithium, anticonvulsants
new onset (childhood) schizo - characteristic
poor prognosis
schizophreniform vs schizophrenia beside duration
only schizophrenia requires functional decline
antipsychitics vs prolactinoma regarding levels of prolactin
prolactinoma: more than 200
medications: 25-100
medications that decreases lithium levels
theophylline
K+ sparing diuretics
treatment of bipolar in renal failure
valproate
Marchiafava-Bgnami disease
dementia, motor dysfunction, dyrsarthria
- severe damage to the corpus callosum and surrounding white matter in the contex of chronic alcohol use disorder and malnutrition
Korsakoff - kind of amnesia / another characteristics)
retrograde and anterograde with intact long memory
sometimes develops without Wernicke - normal neurological examination
catatonia?
syndrome seen in severe psychiatric and medical illness and is characterized by immobility, mutism, posturing
Lorazepam and electroconvulsive therapy are the treatments of choice
antipsychotics - long QT?
only ziprasidone in very high doses
some chronic methammphetamine users can develop
persistent psychosis: difficult to distinguish from primary psychiatric disorders –> visual and tactile hallucinations tend to be more common in substance-induced psychotic disorders –> long term management with CBT and antipsychotics
narcolepsy - treatment
- sleep hygiene and scheduled naps
- if leepiness impairs daily functioning na dposes safety risks –> modafinil (nonamemphetamine medication)
- if significant cateplexy –> antidepressants and sodium oxybat
immediate treatment of depression with SSRI –>
it is not depression –> its bipolar
borderline - treatment
1st line: dialectical
- adjunctive pharmacotherapy to target mood instability + transient psychosis (2nd feneration antipsychotics, mood stabilizers)
- antidepressants if comorbid mood or anxiety disorder
alcohol withdrawal - which benzo
lorazepam (intermediate HT and does not metabolized by liver)
adjustment disorder
emotional or behavioral symptoms that develop within 3 months of exposure to an identifiable stressor and rarely last more than 6 months (no criteria for major depression)
- treatment: psychotheray
nightmare disorder
recurrent episodes of awakening from sleep with recall of highly disturbing and frightening dream content
- full alert on awakening
- usually consoled
another SE of marijuana overdose
dry mouth
tachycardia
slow reaction time
transient global amnesia
anterograde amnesia fro time and place that resolve in 24 h
dissociative amnesia
isolated impairment in autobiographical memory
- if the amnesia is accompanied by travel or wandering, the specifier of “with dissociative fugue” is given
long acting antipsychotics are administered IM every
2-4 wks
benzo should be used with extreme caution in the elderly due to
increased risk of cognitive imairment, falls, and paradoxical agitation
(be careful –> don’t increase the dose if the patient is agitated)
partial response to an antidepressant
add an antidepressant with a different mechanism of action, 2nd gen antipsychotic, lithium, T3 or psychoterapy)
persecutory delusions m - example
being poisoned, harassed, plotted against
delusional disorder - treatment
antipsychotics
CBT
adequate duration of an antidepressant trial is generally considered to be
6 wks
Dissociative identity disorder - association
with childhood trauma –> chronic auditory hallucinations that have venn present since childhood and are perceived as inside the patien;s head (vs psychotice, in which voices seem to come from outside)
dissociative identity disorder - treatment
long-term focused psychotheray
psychiatric drug that can cause liver toxicity
valproate
esp the first 6 months
(check Liver enzymes before initiation of treatment and then monitor)
in addition to hepatotoxicity, valproate can cause
thrombocytopenia, alopecia, tremor
normal age related sleep changes
- decreased total sleep time
- increased nighttime awakenings
- sleepiness earlier in the evening with earlier morning awaking
- increased daytime somnolence (napping)
patients with chronic alcohol abuse frequently seep primary care due to
sleep disturbance and anxiety from mild withdrawal is in this patient
- use alcohol to fall asleep, but the blood alcohol level drops, CNS hyper-arousal occurs and results in awakening
how to differentiate nhistrionic vs narcisistic
histrionic have greater capacity for interpersonal relationships and do not display emotional coldness or lack of empathy)
neuroleptic malignant symptom - time to happen
in the 1st 2 wks
hypertnesive crisis after MAOi can results in
headache (can present like)
- stroke/intracranial bleeding/death
clozapine SE
- neutropenia
- metabolic syndrome
- myocarditis
- seizures
the greatest RF in completing homicide
firearms
homicide RFs / (strongest)
- young male
- unemployed
- impoverished
- access to firearms (STRONGEST)
- substance abuse
- history of violence or criminality
- impuslivity
- history of childhood abuse
tamoxifen in male
in people taking steorids to treat gynecomastia
methamphetamine - acne or baldness
maybe due to skin picking
marijuana - another symptom
gynecomastia
psychogenic non epileptic seizure?
type of conversion disorder commonly misdiagnosed as a seizure disorder
- features suggestive include FORCED EYE CLOSURE, SIDE TO SIDE HEAD OR BODY MOVEMENTS, MEMORY RECALL OF THE EVENT, LACk OF POSTICTAL CONFUSION
gold standard for diagnosis: video electroencephalogram of an event demonstrating lack of epiliptiform activity
somatic symptoms disorder - management
regularly sceduled vistis with the same provider, avoiding unnecessary diagnostic testing and specialists referrals, exploring the role of psycholosocial stresors, promote stress deuction and healthy behaviors
- refractory: CBT, SSRI
alcohol withdrawal syndrome - manifestations per time
mild withdrawal: 6-24
seizures: 12-48
alcholic hallucinosis: 12-48
DT: 48-96
DT - time + manifestation
48-96
- confusion, agitation, fever, tachycardia, hypertension, diaphoresis, hallucinations
Delayed sleep-wake phase disorder
circadian rhythm disorder characterizedby inability to fall assleep at traditional bedtimes –> sleep-onset insomnia and excessive sleepiness –> sleep normally if allowed to follow their internal circadian rhythm and sleep until late morning
special characteristic og bath satls
long time effect
- may be toxicology (-)
HIV-associated neurocognitive disorder - manifestations
- Impaired memory + attention/concentration
- personality + behavior changes
- motor symptoms (eg. ataxia, slowed movement
HIV - associated neuroognitive disorder - RFs
long standing HIV
older than 50
CD less than 200
sleep disturbances are commonly seen in
depression (new onset of insomnia in elderly patients with depressed symptoms –> think about major depressive disorder)
anorexia nervosa - complications
- cardiovascular: Myocard atrophy, bradycardia, hypotension, arrhythmias
- renal: poor urinary concentration, dehydration
- neurological: seizures, cognitive impairment
- dermatological: dry skin, lanugo
- gynecological: amenorrhea, infertility
- GI: gastroparesis, constipation
- hematological: cytopenias
- other: electrolyte depletion, osteopenia, hypercholesterolemia, hypercarotenemia
over the counter cold preparation containing antihistamine in children can cause
hallucinations + confusion
survicors of sexual assault are at high risk for developing
PTSD
depression
suitability
social anxiety disorder (social phobia) - diagnosis
- marked anxiety about 1 or more social situations for 6 or more months
- fear
- avoid social situations
- marked impairment
- SUB-TYPE SPECIFIER: Pperformance only
Social anxiety disorder (social phobia) - treamtent
SSRI/SNRI
CBT
beta blockers or benzo for performance -only subtype
dissociative idenntity disorder - treatment
trauma-focused psychotherapy
2nd generation antipsychotic drug associated with hyperprolactinemia
risperidone
acute dystonia - treatment
- benzotropine
2. diphenidramine
akathisia - treamtent
- propranolol
- benzotropnine
- lorazepame
parkinsonism - treatment
- benzotropine
2. amantadine
tardive dyskinesia -ttreatment
valdenazine
major depression who fail to respond to an initial SSRI trial
consider switch to another 1st line antidepressant (SSRI, bupropion, mirtazapin, Seretonin modulators)
adeqate duration of SSRI
6 wks
SSRI - suitability
slightly higher risk if under 25
the risk of suicide from depression is higher
lamotrigine - rash
up to 10% (and steven Johnson in ot Toxic epdiermal necrolysis in 0.1%
- any occurence of rash during lamotrigine –> immediate stop the drug
Hoover sign
impaired flexion/extension strength of the hip with intact extension on contralateral hip flexion –> incompatible with known nerve pathways -> maybe conversion
how long before antidepressnats should be stoped before MAOI
2 weeks
- exception is fluoxetine: 5 wks
initial apporach to patients presenting with symptoms after a trumatic incident
educate them on the range that will normalize their experience
trama focused CBT is indicated if prersistent symptoms
panic disorder treatment
immediate: benzo
long erm: SSRI/SNRI +/or CBT
risperidone - mechanism of action
seretonin 2A + dopamine D2 antagonists
- the added seretonin receptor binding reduces the likelihood of extrapyramidal SE
benzo withdrawal
abrupt discontinuation of benzo can result in a potentially life-threatening withdrawal syndrome: anxiety, insomnia, tremors, psychosis, seizures
- mild withdrawal may be difficult to distinguish from reemergence of the underlying disorder
intermittent explosive disorder
recurrent episodes of impulsive verbal or physical aggression
- unplanned and out of proportion to the provocation
disruptive mood dysregulation disorder
disroportionate verbal or physical outbursts
- diagnosis requires onset before 10 and persistent irritability or anger in-between episodes
electroconvulsive - indications
- treatment resistance
- psychotic features
- emergency conditions (pregnancy, refusal to eat or drink, imminent risk for suicide
severe or refractory anorexia nervosa
olanzapine
contraidication of haloperodol
seizure disorder
