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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
Q

FGA and SGA side effects: weight gain/metabolic syndrome (highest risk, lowest risk, spectrum)

A

Highest: low-potency FGA, Clozapine, Olanzapine
High (++): quetiapine, risperidone/paliperidone
Middle (+): high-potency FGA
Lowest: aripiprazole, ziprasidone

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26
Q

Advantages - Aripiprazole

A
  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
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27
Q

Disadvantages - Aripiprazole

A
  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&raquo_space; Sedation]
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28
Q

Uses of Aripiprazole?

A
  • Antipsychotic
  • MDD adjunct
  • Acute mania
  • BP Maintenance

NOT BP Depression

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29
Q

Advantages - Olanzapine

A
  1. Extensive clinical experience
  2. Formulations: LAI + disintegrating + IM
  3. Superior retention in BP maintenance treatment
30
Q

Disadvantages - Olanzapine

A
  1. Highest risk of metabolic syndrome/weight gain, sedation, anticholinergics (among SGAs)
  2. Liver irritation
  3. High cost
31
Q

Uses of Olanzapine?

A
  • Antipsychotic
  • Acute mania
  • BP Maintenance
  • BP Depression
32
Q

Advantages - Quetiapine

A
  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
Q

Disadvantages - Quetiapine

A
  1. Longer dose titration
  2. Moderate risk of weight gain, high anticholinergic effects, increased sexual side effects
  3. Moderate to high cost
34
Q

Uses of Quetiapine?

A
  • Antipsychotic
  • BP maintenance monotherapy
  • BP Depression
  • Psychosis in DLB, Parkinson’s
35
Q

Advantages of Risperidone?

A
  1. Extensive clinical experience
  2. Formulations: LAI, disintegrating, liquid
  3. Relatively low cost
36
Q

Disadvantages of Risperidone?

A
  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
Q

Uses of Risperidone?

A
  • Antipsychotic
  • Acute mania
  • BP Maintenance
38
Q

Advantages of Paliperidone?

A
  1. No hepatic metabolism (useful in liver disease)

2. LAI

39
Q

Disadvantages of Paliperidone?

A
  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
Q

Advantages - Ziprasidone?

A
  1. Low risk of weight gain and sexual dysfunction
  2. Relatively low cost
  3. IM injection
41
Q

Disadvantages - Ziprasidone?

A
  1. 2x daily dosing
  2. Must take with food
  3. Most likely SGA to cause QTC prolongation
42
Q

Uses - Ziprasidone

A
  • Antipsychotic
  • Moderate/mild mania or hypomania, NOT acute mania
  • BP Maintenance
43
Q

LAI - 4?

A

Aripiprazole
Olanzapine
Risperidone
Paliperidone

44
Q

Disintegrating - 5?

A 
Aripiprazole
Asenapine
Clozaine
Olanzapine
Risperidone
45
Q

IM - 3?

A

Aripiprazole
Olanzapine
Risperidone

46
Q

Advantages - high-potency FGA (Haldol)?

A
  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
Q

Disadvantages - high-potency FGA?

A
  1. Relative to low-potency, increased risk of EPS/TD
48
Q

Advantages - low-potency FGA (Chlorpromazine)?

A
  1. Inexpensive
  2. Relatively decreased risk of EPS/TD
  3. Used for intractable hiccups
  4. Very sedating
49
Q

Disadvantages - low-potency FGA?

A
  1. Relatively increased risk of sedation, weight gain, anticholinergics, orthostatic hypotension
  2. Increased risk of QTC prolongation
50
Q

General Advantages - FGA?

A

-1x daily dosing

51
Q

General Disadvantages - FGA?

A
  • 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
Q

Advantages - Clozapine?

A
  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
Q

Disadvantages - Clozapine?

A
  1. High cost
  2. Agranulocytosis (requires monitoring)
  3. AE - v. sedating, v. anticholinergic, sialorrhea, decreased seizure threshold, myocarditis, increased weight
54
Q

Rx - Bipolar Disorder, Severe Manic Episode

A

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
Q

General principles - treating Bipolar Disorder?

A

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
Q

Rx - Bipolar Disorder, Moderate/Mild Manic Episode or Hypomanic Episode

A
  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
Q

Rx - Bipolar Disorder, Maintenance Rx

A
  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
Q

Rx - Bipolar Depression

A
  • Symbyax (fluoxetine + olanzapine)
  • Li
  • Lamotrigine (!)
  • Lamotrigine + Li
  • Depakote
  • SGAs (quetiapine, lurasidone, cariprazine, olanzapine)
  • ECT

NO FGAs
Avoid antidepressant monotherapy

59
Q

Advantages - Lithium?

A
  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
Q

Disadvantages - Lithium?

A
  1. Avoid in renal disease
  2. Narrow therapeutic window
  3. AE - tremor
61
Q

Monitoring - Lithium?

A

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
Q

Advantages - Depakote

A
  1. Rapid loading (improvement in 3+ days)
  2. Decreased risk of relapse
  3. Ideal pt: irritable, angry, SUD, mixed features
63
Q

Disadvantages - Depakote

A
  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
Q

Monitoring - Depakote?

A
  • Check a level 12 hours after last dose, or 18 hours if ER
  • Labs: LFTs, CBC (platelets), pregnancy test
  • Level: 50-100
65
Q

Advantages - Lamotrigine

A
  1. Decreased risk of relapse (~16%)
  2. Can use for maintenance treatment or BP depression
  3. No weight gain or sedation
66
Q

Disadvantages - Lamotrigine

A
  1. Rash/SJS
  2. Increases if with Depakote
  3. Never for acute mania
67
Q

Disadvantages - Carbamazepine

A
  1. Teratogenic (cleft lip/palate)
  2. Black box - agranulocytosis, aplastic anemia
  3. Autoinduction
  4. Hyponatremia
  5. Substrate/inducer

(Labs - LFTs, CBC)

68
Q

Advantages - Bupropion?

A
  • 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
Q

Disadvantages - Bupropion?

A

Risk of seizure at high doses
Less effective for anxiety
Onset of therapeutic action delayed for 2-4 weeks

70
Q

Advantages - mirtazapine?

A

Less/no GI side effects
Almost immediate therapeutic effect on insomnia and anxiety
No CYP450 effects

71
Q

Disadvantages - mirtazpine?

A

Weight gain

Psychiatry Clerkship (8 decks)

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