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Psychiatry Clerkship > Video OSCE > Flashcards

Video OSCE Flashcards

1
Q

Broad differential diagnosis - psychotic, mood, anxiety, other

A

Psychotic:

  • Schizophrenia
  • Schizophreniform
  • Brief Psychotic Disorder
  • Schizoaffective Disorder
  • Delusional Disorder
  • Psychosis NOS

Mood

  • Bipolar I (+/- mixed ft.)
  • Bipolar II (+/- mixed ft.)
  • Bipolar I or II with psychotic ft.
  • Bipolar NOS
  • Cyclothymic
  • MDD (+/- fixed ft.)
  • MDD with psychotic ft.
  • Dysthymic
  • Adjustment disorder
  • Bereavement

Anxiety

  • OCD
  • GAD
  • PTSD
  • Acute Stress Reaction
  • Panic Disorder
  • Social Phobia
  • Specific Phobia
  • Agoraphobia
  • BDD
  • Hoarding

Other

  • ADHD
  • Personality disorder
  • Dementia/Delirium
  • Somatoform
  • Eating

Any: substance-induced, 2/2 medical condition

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2
Q

Diagnostic criteria - Schizophrenia?

A

A. 2+ symptoms (1 must be positive)

B. 1 month of A criterion within 6 months of signs/symptoms

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3
Q

Diagnostic criteria - Schizophreniform?

A

> 1 month, <6 months

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4
Q

Diagnostic criteria - Brief Psychotic Disorder?

A

<1 month

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5
Q

Diagnostic criteria - Schizoaffective Disorder?

A
  • Meets A criteria for schizophrenia + criteria for MDD or BP
  • Delusions or hallucinations occur for 2 weeks WITHOUT mood symptoms
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6
Q

Diagnostic criteria - Delusional Disorder?

A

1+ delusions for 1+ months, function not significantly impaired outside of the delusions, but people notice

Never meet A criteria for schizophrenia

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7
Q

Diagnostic criteria - Bipolar I Disorder?

A

Elevated, expansive, or irritable mood
3+ symptoms (4+ if irritable mood) for 1+ weeks (also meets criteria if hospitalized or psychotic symptoms <1 week)
Symptoms:
Distractibility
Insomnia (decreased need for sleep)
Grandiosity (or elevated self-esteem)
Flight of ideas
Activity/Agitation (increased goal-directed activity, PMA)
Speech (pressured speech or increased quantity)
Thoughtlessness (risky behavior)

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8
Q

Diagnostic criteria - Bipolar II Disorder?

A 
Hypomanic episode (manic criteria, but 4-6 days) + MDD episode at some point in patient's history
Less severe impact on patient's functioning
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9
Q

Diagnostic criteria - Bipolar Disorder with mixed features

A

I - Mania criteria met with some depressive symptoms

II - Hypomania criteria met with some depressive symptoms OR MDD criteria met with some manic symptoms

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10
Q

Diagnostic criteria - Bipolar Disorder with psychotic features

A

Bipolar criteria met + hallucinations or delusions

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11
Q

Which illnesses require ruling out several serious psych problems?

A

Schizophrenia (r/o schizoaffective, MDD or BP with psychotic features)

Bipolar (r/o schizoaffective, schizophrenia, schizophreniform, delusional disorder, any psychotic illness)

MDD (r/o schizoaffective, schizophreniform, schizophrenia, delusional disorder, manic episode/hypomanic episode)

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12
Q

Diagnostic Criteria - Cyclothymic Disorder?

A

Hypomania + depressive symptoms (never meeting full criteria for an episode) for 2+ years, never symptom free for >2 months

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13
Q

Diagnostic criteria - MDD?

A

5+ symptoms (must including depressed mood or anhedonia) for 2+ weeks

Depressed mood
Marked anhedonia
Weight loss/gain, appetite decrease/increase
Insomnia/hypersomnia
PMA/R
Fatigue/loss of energy
Feeling worthless, excessive/inappropriate guilt
Diminished ability to think/concentrate, indecisiveness
Recurrent thoughts of death or suicide

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14
Q

Diagnostic criteria - MDD with mixed features?

A

MDD criteria + some hypomanic symptoms

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15
Q

Diagnostic criteria - MDD with psychotic features?

A

MDD criteria + hallucinations or delusions

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16
Q

Diagnostic criteria - Dysthymia?

A

Depressed mood + 2 other symptoms for 2+ years, not symptom free for >2 months

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17
Q

Diagnostic criteria - Adjustment Disorder?

A

Symptoms develop within 3 months of the start of the stressor, symptoms go away within 6 months after the stressor ends

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18
Q

General treatment algorithm for Schizophrenia/Psychotic Disorders + general principles?

A
  1. SGA (aripiprazole, risperidone, ziprasidone)
    - If partial response - continue dose or increase for 4 more weeks
    - No response - #2
  2. Different SGA or FGA
  3. Clozapine trial
  4. Clozapine + SGA or FGA
  5. New FGA or SGA
  6. 2 FGAs, 2 SGAs, or FGA + SGA
  • Continuous full dose treatment to prevent relapse
  • All first-line SGAs equally effective and equally tolerated
  • Minimum of 4 weeks at therapeutic dose for SGA
  • Minimum of 12 weeks at therapeutic dose for Clozapine + 4 week titration
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19
Q

FGA and SGA side effects: EPS (highest risk, lowest risk, spectrum)

A

Highest: high-potency FGA
Lowest: Clozapine (0) (also quetiapine v. low)

High potency FGA > Low-potency FGA > Risperidone/Paliperidone > Aripiprazole/Olanzapine/Quetiapine/Ziprasidone > Clozapine (0)

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20
Q

FGA and SGA side effects: Hyperprolactinemia (highest risk, lowest risk, spectrum)

A

Highest: Risperidone/Paliperidone/Low-potency FGA/Clozapine

All others: +/-

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21
Q

FGA and SGA side effects: Anticholinergic (highest risk, lowest risk, spectrum)

A

Highest: Low-potency FGA and Clozapine
High (++): olanzapine, quetiapine
Lowest: high-potency FGA, aripiprazole, risperidone/paliperidone, ziprasidone

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22
Q

FGA and SGA side effects: Orthostatic hypotension (highest risk, lowest risk, spectrum)

A

Highest: Low-potency FGA and Clozapine
High (++): olanzapine, quetiapine
Middle (+): risperidone/paliperidone
Lowest: aripiprazole, ziprasidone

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23
Q

FGA and SGA side effects: qTc prolongation (highest risk, lowest risk, spectrum)

A

Highest (++): Low-potency FGA
Middle (+): Clozapine, ziprasidone, high-potency FGAs
Lowest: aripiprazole, olanzapine, quetiapine, risperidone/paliperidone

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24
Q

FGA and SGA side effects: sedation (highest risk, lowest risk, spectrum)

A

Highest: low-potency FGA, Clozapine, quetiapine
High (++): olanzapine
Middle (+): High-potency FGA, risperidone/plaiperidone
Lowest: aripiprazole, ziprasidone

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25
FGA and SGA side effects: weight gain/metabolic syndrome (highest risk, lowest risk, spectrum)
Highest: low-potency FGA, Clozapine, Olanzapine High (++): quetiapine, risperidone/paliperidone Middle (+): high-potency FGA Lowest: aripiprazole, ziprasidone
26
Advantages - Aripiprazole
1. Unique MOA (partial agonist) 2. Formulations: LAI, disintegrating, IM 3. Long-half life 4. Minimal risk of weight gain/metabolic syndrome, lowest risk of QTC prolongation, lowest sexual side effects
27
Disadvantages - Aripiprazole
1. Unique MOA (partial agonist) - transitioning to/from D2 antagonists can lead to worsening symptoms 2. Long-half life (2 weeks to steady state) 3. Moderate-high cost 4. Most likely to cause akathisia among SGAs [5. Insomnia >> Sedation]
28
Uses of Aripiprazole?
- Antipsychotic - MDD adjunct - Acute mania - BP Maintenance NOT BP Depression
29
Advantages - Olanzapine
1. Extensive clinical experience 2. Formulations: LAI + disintegrating + IM 3. Superior retention in BP maintenance treatment
30
Disadvantages - Olanzapine
1. Highest risk of metabolic syndrome/weight gain, sedation, anticholinergics (among SGAs) 2. Liver irritation 3. High cost
31
Uses of Olanzapine?
- Antipsychotic - Acute mania - BP Maintenance - BP Depression
32
Advantages - Quetiapine
1. Lowest EPS risk 2. Very low risk of agranulocytosis 3. Rapid onset of action 4. 1x daily dosing 5. Very sedative 6. Decreases recurrence of bipolar depression episodes
33
Disadvantages - Quetiapine
1. Longer dose titration 2. Moderate risk of weight gain, high anticholinergic effects, increased sexual side effects 3. Moderate to high cost
34
Uses of Quetiapine?
- Antipsychotic - BP maintenance monotherapy - BP Depression - Psychosis in DLB, Parkinson's
35
Advantages of Risperidone?
1. Extensive clinical experience 2. Formulations: LAI, disintegrating, liquid 3. Relatively low cost
36
Disadvantages of Risperidone?
1. Highest EPS risk among SGAs (increase dose, increase risk) 2. Hyperprolactinemia risk 3. Moderate risk of weight gain 4. Highest risk of sexual side effects among SGAs
37
Uses of Risperidone?
- Antipsychotic - Acute mania - BP Maintenance
38
Advantages of Paliperidone?
1. No hepatic metabolism (useful in liver disease) | 2. LAI
39
Disadvantages of Paliperidone?
1. Cannot use in kidney disease 2. EPS/Prl/Lb side effects 3. Must be taken with food 4. Highest risk of sexual side effects among SGAs
40
Advantages - Ziprasidone?
1. Low risk of weight gain and sexual dysfunction 2. Relatively low cost 3. IM injection
41
Disadvantages - Ziprasidone?
1. 2x daily dosing 2. Must take with food 3. Most likely SGA to cause QTC prolongation
42
Uses - Ziprasidone
- Antipsychotic - Moderate/mild mania or hypomania, NOT acute mania - BP Maintenance
43
LAI - 4?
Aripiprazole Olanzapine Risperidone Paliperidone
44
Disintegrating - 5?
``` Aripiprazole Asenapine Clozaine Olanzapine Risperidone ```
45
IM - 3?
Aripiprazole Olanzapine Risperidone
46
Advantages - high-potency FGA (Haldol)?
1. Inexpensive 2. Haldol - IM, PO, IV, depot 3. Relative to low potency, decreased risk of sedation, weight gain, anticholinergics 4. Can be used in Tourette's syndrome
47
Disadvantages - high-potency FGA?
1. Relative to low-potency, increased risk of EPS/TD
48
Advantages - low-potency FGA (Chlorpromazine)?
1. Inexpensive 2. Relatively decreased risk of EPS/TD 3. Used for intractable hiccups 4. Very sedating
49
Disadvantages - low-potency FGA?
1. Relatively increased risk of sedation, weight gain, anticholinergics, orthostatic hypotension 2. Increased risk of QTC prolongation
50
General Advantages - FGA?
-1x daily dosing
51
General Disadvantages - FGA?
- Extensive CYP450/liver metabolism - Increased risk of CV events, especially in older patients with dementia - Risk of NMS and agranulocytosis - Risk of sexual side effects and hyperprolactinemia
52
Advantages - Clozapine?
1. Prevents suicide 2. Treatment resistant schizophrenia 3. Useful if SUD, persistent psychotic symptoms 4. No EPS, in fact can treat TD/EPS 5. Most effective drug for negative symptoms
53
Disadvantages - Clozapine?
1. High cost 2. Agranulocytosis (requires monitoring) 3. AE - v. sedating, v. anticholinergic, sialorrhea, decreased seizure threshold, myocarditis, increased weight
54
Rx - Bipolar Disorder, Severe Manic Episode
Always Combination Therapy 1. Li or Depakote + antipsychotic (aripiprazole, FGA, olanzapine, quetiapine, risperidone) -NOT ziprasidone, carbamazapine, lamotragine 2. Switch Li or Depakote 3. Switch antipsychotic 4. Refractory (4-6 tries): Li or Depakote + Clozapine or ECT
55
General principles - treating Bipolar Disorder?
Goal: remission with no more than 1-2 mild symptoms and no psychosis - Treat for at least 2 weeks before trying a new medication - Treat for 9-24 months; if 2+ episodes, always maintenance
56
Rx - Bipolar Disorder, Moderate/Mild Manic Episode or Hypomanic Episode
1. Monotherapy (Li, Carbamazepine, Depakote, Antipsychotic - all including ziprasidone) - If antipsychotic, start with risperidone or olanzapine 2. Try another mono 3. Refractory (3-5) - Li or Depakote + antipsychotic
57
Rx - Bipolar Disorder, Maintenance Rx
1. Acute Rx 2. Li > Depakote . Quetiapine > Lamotrigine 3. Olanzapine, aripiprazole, risperidone 4. Asenapine, carbamazepine, oxcarbazepine, paliperidone If frequent relapse: Li or Depakote + antipsychotic (including ziprasidone) or ECT
58
Rx - Bipolar Depression
- Symbyax (fluoxetine + olanzapine) - Li - Lamotrigine (!) - Lamotrigine + Li - Depakote - SGAs (quetiapine, lurasidone, cariprazine, olanzapine) - ECT NO FGAs Avoid antidepressant monotherapy
59
Advantages - Lithium?
1. Most widely studied 2. Decreased risk of relapse (30%), recurrences less severe 3. Decreases suicide 4. Ideal pt: euphoric, positive family history, no substance use, no rapid cycling, few episodes
60
Disadvantages - Lithium?
1. Avoid in renal disease 2. Narrow therapeutic window 3. AE - tremor
61
Monitoring - Lithium?
Lab - TSH, BUN/Cr, Pregnancy test, EKG if >50 years old Check a level after 5 days, 12 hours after last dose Level: 0.6-0.8
62
Advantages - Depakote
1. Rapid loading (improvement in 3+ days) 2. Decreased risk of relapse 3. Ideal pt: irritable, angry, SUD, mixed features
63
Disadvantages - Depakote
1. Teratogenic 2. Avoid in liver disease 3. Thrombocytopenia (risk increases with aspirin) 4. AE - tremor, GI (generic form), HA 5. Increases Lamotrigine level
64
Monitoring - Depakote?
- Check a level 12 hours after last dose, or 18 hours if ER - Labs: LFTs, CBC (platelets), pregnancy test - Level: 50-100
65
Advantages - Lamotrigine
1. Decreased risk of relapse (~16%) 2. Can use for maintenance treatment or BP depression 3. No weight gain or sedation
66
Disadvantages - Lamotrigine
1. Rash/SJS 2. Increases if with Depakote 3. Never for acute mania
67
Disadvantages - Carbamazepine
1. Teratogenic (cleft lip/palate) 2. Black box - agranulocytosis, aplastic anemia 3. Autoinduction 4. Hyponatremia 5. Substrate/inducer (Labs - LFTs, CBC)
68
Advantages - Bupropion?
- Treat cravings from nicotine - No sexual side effects/can treat this AE in SSRIs - Helpful in treating hypersomnia - May cause weight loss (or at least stay weight neutral)
69
Disadvantages - Bupropion?
Risk of seizure at high doses Less effective for anxiety Onset of therapeutic action delayed for 2-4 weeks
70
Advantages - mirtazapine?
Less/no GI side effects Almost immediate therapeutic effect on insomnia and anxiety No CYP450 effects
71
Disadvantages - mirtazpine?
Weight gain

Psychiatry Clerkship (8 decks)

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