UW Flashcards
SSRI in breastfeeding
sertraline
clozapine for schizo only if fails with … (number) medications
2
somatic symptom disorder - management
regularly scheduled appointments, which establish a strong physician-patient relationship and limit diagnostic testing and subspecialty referrals
(rarely respond to reassurance)
somatic symptom disoreder - clinical features
1 or more somatic symptoms causing distress + functional impairent
- excessive thoughts or behaviors related to somatic symptoms
- more than 6 months
severe symptoms of benzo withdrawal
psychosis + seizures
folie a deux - most important frist intervention
separate the pair to disrupt the mutually reinforcing nature of the shared delucion and to enable a more careful assessment to each individual pathology
- psychiatric treatment in the dominant, the nondominant individual rarely need drugs
intermittent explosive disorder?
like antisocial but without history of conduct disorder or other fearures of antisocial
borderline - history of …… is common
childhood trauma
type of amnesia as a SE of electroconvulsive therapy
anterograde and retrodrage
retrograde persists longer
Electroconvulsive therapy - contraindications
no absolute
- increased risk if:
- severe CVD, recent MI
- space occupying brain lesion
- recent stroke, unstable aneurysm
suicidal patient - when t admit
if ideation, intnet + plan
- if ideation but no plan or intent –> ensure close follow up, treat mdifiable RF (depression etc), recruit family or friends to support, reduce acces to potentioal means
best combination for bipolar (if not controled by single drug)
lithium or valproate PLUS 2nd generation antipsychotic
evidence based monotherapy options for bipolar
lithium, valproate, quetiapine, lamotrigine
specific phobia - history and clinical features / treatment
- marked anxiety about a specific object or situation (the phobic stimulus) for more than 6 months
- common types: fear for flying, heights, animas etc)
- common 10%
- usually develops in childhood, often after traumatic events
treatment: CBT with exposure, benzo in acute
agranulocytosis - definition
complete absence of NEUTROPHILS
1st line treatment for anorexia nervosa
nutritional rehab
+
psychoterapy
anorexia nervosa - indications for hospitalization
- bradycardia (less than 40) 2. dysarhythmia 3. hypotension (less than 80/60) 4. orthostasis
- hypothermia (less than 35) 6. electrolyte disturbances 7. marked dehydration 8. organ compromise 9. BI less than 15
treatment of PCP
1st line: benzo
2nd line: haloperidol
3rd line: propofol
dextromethorphan in children can cause
hallucinations
how to seperate use of cocaine from maniac
cocaine has physical symptoms: dilated pupils, diaphoresis, tremors
Narcolepsy - diagnostic criteria
recurrent lapses into sleep or naps (at least 3 times per week for 3 months) PLUS 1 of the following: - cataplexy - low hypocretin-1 in CSF - shortened REM sellp latency
increased sensitivity to lactate infusion has been associated with
panic attacks
abnormalities in cortico-striato-thalamo-cortical circuits have been associated with
OCD
how to decrease the trisk or replapse in schizophrenia
miniimzaing conflicts and stress in home
- family psychosscial interventions are indicated
commonly abused inhalants
glue, toluene, nitrous oxide, amyl nitrite, spray paints
inhalant abuse - effects
immediate effect lats 15-25 mins
acts i CNS
- can cause dermatitis (glue sniffer;s rash) around mouth or nostrils)
liver function test may be elevated
- chronic nitrous oxide casues Vit B12 def
gender dysphoria - initial management
- assessment of safety
- support, psychoterapy (individual, family)
- referral to specialist services (medical + mental health multidisciplinary)
sleep terrors - management
reassurance
low dose of benzo at bedtime if episodes are frequent, persistent and distressing
cognitive impairment in elderly patients - ddx
- normal aging
- Major depression
- Mild neurocognitive disorder
- major neurocognitive disorder (dementia)
cognitive impairment in elderly patients - normal aging
slight decrease in fluid intelligence (ability to process new information quickly, normal functioning in daily activities
- word finding difficulty
unexplained abd pain and new onset neuropsychiatric symptoms (including neuropathies, anxiety, mood changes, psychosis)
acute intermittent porphyria
disulfiram vs naltrexone vs acamprosate as treatment of alcoholism
naltrexone –> to reduce craving (in active drinkers)
disulfiram –> in abstinent patients (2nd line)
acamprosate –> abstinent patients
naltrexone - contraidincations
liver problems
patients on opioids
acamprosate contraindications
renal failure
DDX of depressed mood
- Major depressive
- Dysthymia
- Adjustment disorder with depressed mood (within 3 months of stressor event, marked distress or/and functional impairment)
- Normal stress response
normal stress response
- not excessive or out of proportion to severit of stressor
- no significant functional impairment
how to stop a seretonergic antidepressant
gradually (with a taper)
if abrupt or rapid taper of a short HL –> psychological and physical symptoms
antidepressant discontinuation syndrome - manifestations / management
dysphoria, fatique, insomnia myalgias, flu liike, GI , tremor, neurosensory
begin within 2-4 days after the stopping of medication
- management: re-institute the same andtidepressant and taper the dose gradually over 2-4 weeks, or start fluoxetine which is long HT and stop it gradually
general anxiety disorder - when to give benzo
nondepressed patientswithout a history of substance abuse who fail to respond to or cannot tolerate antidepressants
normal aging vs dementia (major cognitive disorder) - memory loss
- in aging they can provide details about incidents of forgetfulness
- patients are more concern about memory loss
- recent memory for important events + conversations is intact
normal aging vs dementia (major cognitive disorder) - word findings difficulty
in aging is occasional WITHOUT receptive aphasia
normal aging vs dementia (major cognitive disorder) independence + functioning
- in aging they maintain independence in daily activities
- able to operate common appliances (devices)
- Maintains interpersonal social skills
- not lost in familiar territory (may have to pause briefly to reorient)
OCD -time
consuming more than 1 h / day or causing significant distress or impairment
Major depressive disorder - season
seasonal pattern characterised by seasonal onset and remission (MC fall-winter onset and spring-summer remission
treatment: bright light therapy alone or with an antidepressan
medication-induced psycotic disorder
acute onset of delusions and/or hallucinations that are temporally associated with the use of a new medication
- glucocorticoids (esp high doses) are often implicate
conversion disease - management
education about the disorder –> if not respond –> CBT
HIV-associated dementia
severe form of dementia in untreated and/or long-standing HIV and CD less than 200
- subcortical symptoms early in the course
HIV mediated dementia - number of CD4
less than 200
2ry causes of acute onset psychosis in children _ adolescents
- medical disorders: CNS injury / dysfunction, metabolic / electrolyte disturb / systemic (SLE, thyroiditis)
- Illicit substance: hallucinogen, marijuana, sympathomimetics (cocaine), alcohol withdrawal, Bath salts
- Medication SE: intoxitation or withdrawal
another SE of lithium
hyperparathyroidism
baseline studies for lithium
- urea, Cr, Ca2+, urinalysis
- Thyroid function test
- ECG coronary risk factors
How to differentiate Parksinon disease dementia from Lewy bodies
by timing of symptom onset
if parkinsonism predates cognitive impairment by more than 1 year, then is Parkinson
treat depression with Buproprion if
smoking cessation and weight loss are also goals
anorexia nervosa - Thyroid
often have low levels of T3 and/o T4 (euthyroid sick syndrome) due to body;s adaption to chronic nutritional depletion –> no thyroid replacement (dangerous for cardiac arrhythmias and osteopenia)
generalised anxiety disorder - time
6 months or more
it can be years
neuroimaging of schizophrenia
loss of cortical tissue volume with ventrical enlargement is a subset of patients with schizo, with lateral ventricular enlargement being the most widely replicatied finding
- decreased volume of amygdala and hyppocampus
autism - neuroimaging
accelerated head growth during infancy and increaesd total brain volume
OCD - neuroimaging
structural abnormalities in the orbitofrontal cortex and basal ganglia
Metabolic effects of the 2nd generation antiphsycotics - highest risk drugs / how to monitor
- Clozapine 2. Olanzapine
Baseline + regular follow-up: BMI, fastign glucose + lipids, BP, waist circumference (at 3 months and then annually)
- more frequent if DM or gained more than 5% of initial weight
Antipsychotic extrapyramidal effects - definition
- acute dystonia: sudden sustained contraction of the next, mouth, tongue and eye muscles
2 .Akathisia: subjective restlessness, inability to stil still - Parkinsonism: Gradual onset tremor, rigidity, bradykenesia
- Tardive dyskinesia: Gradual onset tremor after prolonged therapy (more than 6 months): dyskenesia of the mouth, face, trunk and extremeties
antipsychotic extrapyramidal effects - treatment
- acute dystonia: benzotropine, diphenhydramine
- akathisia: propranolol, lorazepam, benzotropine
- parkinsonism: benzotropine, amantadine
- Tardive dyskinesia: stop the drug is possible, if it is not: switch to 2nd generation (esp clozapine), valbenazine
abused drug that causes Seretonin syndrome
ecstasy
bath salts
illicid synthetic amphetamines and analogs - name 2 drugs / urine
- MDMA (ecstasy) 2. bath salt
may or may not show up as amphetamnies in routine urine toxicology
bath salts can cause
amphetaminese anaoge: seretonin syndrome. agitation, combativeness, acute psychosis, less likely hyponatremia
capacity?
patient’s ability to understand the illness, treatment options and consequences and to express a choice reflecting a preference
- communicates, understands, appreciates, rationale
diagnosis of depression - next step
evaluate for suitability (ideation, intent, plan)
treatment of ADHD in patient with history of substance abuse
atomoxetine
ADHD - CBT?
medication is generally considered as 1st line –> CBT can be added if medication is not fully effective or as monotherapy if medication is contraindicated
clonidine + guanfancine in ADHD
only in children
not effective in adults
dopamine pathways
- mesolimbinc: antipsychotic efficacy
- nigostratial: extrapyramidal symptoms
- tuberoinfundibular: hyperprolactinemia
post-stroke depression
common and underdiagnosed
increased disability and mortality
benefit from SSRI
2nd generation antipsycotics - mechanism
seretonin S2 and dopamine D2 antagonists
the added serotonin n receptor binding reduces the likelihood of extrapyramidal side effects
neuroleptic malignant syndrome - treatment
- stop antipsychotcis or restart recent dopamine agents
- supportive care (hydration, cooling, ICU
- refractory –> dantrolene or bromocriptine
the risk of lithium toxicity is increased with concurrent use of
thiazide, ACEi, tetracyclines, metronidazole, NSAID
or overdose
or volume depletion
lithium acute toxicity
GI: nausea, vomiting, diarrhea
late naurologic sequence
alcohol withdrawal syndrome - manifestations / time
- mild withdrawal: 6-24h
- seizures: 12-48h
- alcholic hallucinosis: 12-48h
- delirium tremens: 48-96h
alcohol withdrawal,mild withdrawal - time / symptoms
6-24h
anxiety, insomnia, tremors, diaphoresis, palpitations, GI, INTACT ORIENTATION
alcohol withdrawal, seizures - time and symptoms
12-48
single or multiple generalized tonic-clonic
alcohol hallucinosis - time and symptoms
12-48
visual, auditory or tactile, INTACT ORIENTATION, STABLE VITALS
delirium tremens - time and symptoms
48-96h
confusion, agiation, fever, tachycardia, hypertension, diaphoresis, hallucinations
body dysmorphic disorder - main characteristic
defects are not observable or appear slight to others
body dysmorphic disorder - treatment
- SSRI
2. CBT
personality traits vs mood disorders
mood dirorders are not for a whole life and have more symptoms
RF for prescription opiod misuese include
- younger than 45
- psychiatric disorder
- personal or family history of substance disorder
- presensce of a legal history
how to reduce the risk for prescription opioid misuse
- review of the state’s prescription drug monitoring program data
- random urine drug screens
- regular follow up are
guidelines for opioids follow up
every 3 months, and even more frequently in high risk situation
MC side effects of methylphenidate
anorexia
weight loss
insomnia
hoarding disaster?
distinct from OCD
- accumulation of a large number of possessions that may clutter living areas to the point that they are usuable –> distress when attempting to discard possessions
hoarding disorder - treatment
CBT
SSRI may be used in paralle, but with limited effect
active suicidal teenager doesn’t want to inform parents - next step
inform the parent and hospitalize the patient with or without consent
CBT - indications
- depression
- generalized anx disorder
- PTSD
- OCD
- Eating disorder
- Negative thoughts pattern
CBT - features
combines cognitive + behavioral
challenges maladaptive cognitions
targets avoidance with behavioral techniques (relaxation, exposure, behavioral modification)
effective drugs during depressive phase of bipolar
- 2nd generation antipsychotics (quetiapine, lurasidone)
- lamotrigine
mechanism of neuroleptic malignant syndrome
dopamine antagonism
parenteral nutrition - complications
- osmotic load (so ti is for more than 48 hours through central line)
- central-line associated bloodstream infection
- cholelithiasias
