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483 Cards in this Set

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Monitoring for pts on clozapine (specifics)
ANC and WBC at baseline, then weekly for 6mo, then biweekly for 6mo, then monthly
Which pts is ziprasidone contraindicated in and when should it be tested for?
Long QT syndrome (get EKG if family Hx of SCD <40yo)
3 phases of schizophrenia
Prodromal (before first psychotic episode; withdrawn, new interests)
Psychotic
Residual (btwn episodes, negative symptoms)
Echolalia
Repeats words or phrases
Echopraxia
Mimics behavior
5 subtypes of schizophrenia
Paranoid
Disorganized
Catatonic
Residual (prominent negative symptoms)
Undifferentiated
4 dopamine pathways
Prefrontal cortical
Mesolimbic
Tuberoinfundibular
Nigrostriatal
Which dopamine pathway is responsible for negative symptoms?
Prefrontal cortical
Which dopamine pathway is responsible for positivesymptoms?
Mesolimbic
Which dopamine pathway is responsible for EPS when blocked by neuroleptics?
Nigrostriatal
Which dopamine pathway is responsible for hyperprolactinemia when blocked by neuroleptics?
Tuberoinfundibular
Two drugs of abuse that can cause acute psychosis by activating dopaminergic pathways
Cocaine
Amphetamines
2 other neurotransmitters that are increased in schizophrenia
Serotonin
Norepinephrine
Neurotransmitter that is decreased in schizophrenia
GABA (might indirectly active dopamine and NE pathways)
Changes in brain structure of schizophrenic pts seen on CT scans
Enlargement of ventricles
Diffuse cortical atrophy
4 typical neuroleptics
Chlorpromazine, thioridazine, trifluoperazine, haloperidol
How long should antipsychotics be tried before determining medication failure?
4wks
Which neuroleptics have moer EPS side effects, and which have more anticholingeric side effects?
High potency (haloperidol, trifluoperazine): EPS
Low potency (chlorpromazine, thioridazine): Anticholingeric
3 types of EPS
Dystonia, Parkinsonism, akathisia
Anticholinergic symptoms
Dry mouth, constipation, blurred vision
What is tardive dyskinesia?
Darting or writhing movements of face, tongue, head
Rx for tardive dyskinesia
Limited, but d/c offending agent and substitute atypical neuroleptic
Pt on antipsychotics with confusion, high fever, elevated BP, rigid, sweating
Neuroleptic malignant syndrome
What lab test is elevated in neuroleptic malignant syndrome
Creatine phsophokinase (CPK)
How many pts with schizophreniform disorder progress to schizophrenia or schizoaffective
2/3rds
How to differentiate schizoaffective disorder from mood disorder with psychotic features
Former has had delusions or hallucinations for 2wks in absence of mood disorder symptoms
3 most common patients who develop delusional disorder
Older (>40yo)
Immigrants
Hearing impaired
6 types of delusions
Erotomanic (love-based), grandiose, somatic, persecutory, jealous, mixed
Two ways in which delusional disorder is distinguished from schizophrenia
Nonbizarre delusions
Daily funcitoning not significantly impaired
Rx for shared psychotic disorder
Separate pt, psychoterapy, antipsychotics only if symptoms haven't improved in 1-2wks

20-40% recover upon removal from inducing person
Culture psychosis in which patient believes penis is shrinking and will disappear, causing his death
Koro (Asia)
Culture psychosis with sudden unprovoked outbursts of violence (pt has no recollection), often commits suicide afterwards
Amok (Southeast Asia)
Culture psychosis with headache, fatigue, visual disturbances in male students
Brain fag (Africa)
Mental retardation is defined as an IQ less than
70
Risk of developing antisocial PD among children w/ conduct disorder
40%
Pharma therapy for conduct disorder (2 classes of symptoms that you're treating)
Aggression: antipsychotics or lithium

Impulsivity, irritability, mood lability: SSRIs
Difference btwn ODD and conduct disorder
ODD doesn't involve violation of basic rights of others
Most common comorbid conditions with ADHD
2/3rds of pts also have conduct disorder or ODD
2 subtypes of ADHD
Inattentive

Hyperactivity-impulsivity
When does ADHD onset, and what percentage of patients have symptoms into adulthood?
By 7yo
20%
How does depression often manifest in kids?
Irritableness
3 CNS stimulants used in ADHD
Methylphenidate (Ritalin)
Dextroamphetamine (Dexedrine)
Pemoline (Cylert)
3 categories of autistic symptoms
Repetitive/ sterotyped behaviors

Impaired communication

Problems w/ social interaction
Onset of autism
Usually before 3yo
Difference between Asperger's and autism
Asperger's has normal language and cognitive development (only has the repetitive behaviors and problems with social interaction)
When do symptoms of Rett's present?
5mo-30mo get regression of head circumference and onset of hand wringing
Medical problems in Rett's include (2)
Seizures

Cyanotic spells
Mutation in Rett's
MECP2 gene (on X chromosome)
When does childhood disintegrative disorder present?
Onset 2yo-10yo (loss of previously acquired skills)
What is coprolalia
Repetition of obscene words
3 diagnostic criteria for Tourette's
Motor AND vocal tics
>1yr w/ symptoms, no tic free period >3 mo
Onset prior to 18yo
Motor tics typically involve which parts of the body?
Face and head
Which type of tic onsets later
Usually vocal (may be years after onset of motor tic)
Common comorbidity with Tourette's
OCD and ADHD
Rx for Tourette's
Haldol or pimozide
3 medical conditions to rule out before enuresis is diagnosed
Seizures
Urethritis
Diabetes
Enuresis can be further described by these two categories (2 choices for each)
Primary vs. secondary
Diurnal vs. nocturnal
Diagnostic criteria for enuresis
>2yo
2x/wk for 3mo
Outcome for majority of cases of enuresis
Spontaneously resolve by 7yo
2 pharma therapy options for enuresis
DDAVP or TCA
3 med conditions to r/o before diagnosing encopresis
Metabolic (hypothyroid)
Lower GI (fissure, IBD)
Dietary
Diagnostic criteria for encopresis
>4yo
1x/mo for 3mo
Pharma therapy for separation anxiety disorder
Low dose antidepressant
Risk of later suicide after hospitalization for MDE
15%
What % of manic pts have psychotic symptoms
75%
Predominant mood symptom in pts with mixed episodes
Irritability
4 things that differentiate hypomania from mania
>4 days (instead of >7)
No interference w/ functioning
Doesn't require hospitalization
No psychotic features
Rx for seasonal affective disorder
Light therapy
Which neuroendocrine is high in depression?
Cortisol
What % of pts with MDD eventually commit suicide?
15%
Risk of subsequent MDE after first episode?
50%
Major risk w/ monoamine oxidase inhibitors (MAOIs)?
Hypertensive crisis when used with sympathomimetics or ingestion of tyramine-rich foods (wine, beer, cheese)
Danger when combining SSRIs with MAOIs
Serotonin syndrome
Sequelae of serotonin syndrome
Autonomic instability, hyperthermia, seizures

Coma and death in severe cases
Most common side effect with MAOIs
Orthostatic hypotension
Procedure for ECT
Premed w/ atropine
General anesthesia + muscle relaxant
Generalized seizure induced by passing current of electricity across brain (unilateral or bilateral) for <1min
Time frame for initial ECT
8 treatments over 2-3 weeks
Most common side effect with ECT
Retrograde amnesia
4 subtypes of depressive disorders
Melancholic
Atypical
Catatonic
Psychotic
Characteristics of melanocholic depression
Early morning awakenings, excessive guilt, anorexia
Characteristics of atypical depression
Hypersomnia, hyperphagia, leaden paralysis, hypersensitivity to rejection
Characteristics of catatonic depressionCharac
Catalepsy (immobility), purposeless motor activity, extreme negativism/ mutism, bizarre posutres, echolalia
What is required for the diagnosis of bipolar I?
Episode of mania or mixed episode (depressive episode NOT required)
What is required for the diagnosis of bipolar II?
One or more MDEs and at least one hypomanic episode (NO history of manic episodes, otherwise is bipolar I)
Typical length of untreated manic episodes
3mo
Pharma therapy for bipolar disorder (3 options)
1) Lithium
2) Anticonvulsants (carbamazepine or valproic acid): also mood stabilizers, useful for rapid cycling and mixed episodes
3) Olanzapine
What is rapid cycling?
4 or more mood episodes in 1 year
12 side effects of lithium
Weight gain
Tremor
GI problems
Fatigue
Arrhythmia
Seizures
Goiter/ hypothyroid
Benign leukocytosis
Polyuria/ polydipsia
Alopecia
Metallic taste
Coma
Difference between MDD and dysthmic disorder
Dysthmic disorder is generally persistent (not episodic), rarely requires hospitalization
What rules out the diagnosis of dysthmia?
Psychotic features
What is double depression?
MDD with dysthmic disorder during residual periods
What is cyclothymic disorder?
Alternating periods of hypomania and periods with mild/moderate depression
Difference btwn cyclothymia and bipolar II?
No MDEs
Never symptom free for >2mo during last 2yrs
Cyclothymia often coexists with which PD?
Borderline
One third of cyclothymic pts eventually develop which diagnosis?
Bipolar disorder
Rx for cyclothymia?
Same as bipolar
Time frame for post-partum depression?
4wks to 12mo
Autonomic symptoms of anxiety (9)
Palpitations
Perspiration
Dizziness
Mydriasis
GI disturbances
Urinary urgency/frequency
Trembling
Tingling in peripheral extremities
SOB/ choking sensation
Neurotransmitters increased (1) and decreased (2) in anxiety
NE increased
GABA/ serotonin decreased
Typical duration of panic attacks
Peak in several minutes, last 25 min (rarely >1hr)
Diagnostic criteria for panic disorder
Panic attack followed by concern/ worry/ avoidance about additional attacks
Panic disorder should always be specified as
With or without agoraphobia
MI presentation with normal angiogram
Panic attack
Acute and maintenance treatment of anxiety
Benzos
SSRIs
What side effects are common in panic disorder pts taking SSRIs?
Activation side effects (anxiety symptoms that mimic those of panic)
Rx for agoraphobia associated w/ panic disorder
Usually resolves with SSRI treatment for panic disorder
Most common mental disorders in the US
Specific phobias
Best treatment for performance anxiety
Beta blockers
Rx for specific phobias
Systemic desensitization (w/ or w/out hypnosis; add benzos/beta blockers in severe cases) and supportive psychotherapy
FDA approved drug for social anxiety disorder
Paxil (paroxetine)
How to differentiate OCD from OCPD
OCD is egodystonic
4 common obsessions
Contamination
Doubt --> checking
Symmetry
Intrusive thoughts (often sexual/ violent) w/o compulsion
Rate of OCD is higher in pts with first degree relatives with this disorder
Tourette's
4 most common mental disorders
Phobias
Substance-induced disorders
Major depression
OCD
Most common trigger of OCD
Stressful life event
2 pharma options for OCD
High-dose SSRIs
TCAs (clomipramine)
Behavioral treatment option for OCD
Exposure and response prevention
3rd line therapy for refractory OCD
ECT or cingulotomy
Prognosis with PTSD
50% remain symptom free after 3mo of treatment
3 pharma options for PTSD
TCAs (imipramine and doxepin)
SSRIs and MAOIs
Anticonvulsants (for flashbacks and nightmares)
What is acute stress disorder?
Similar to PTSD, except immediately after event occurred, and symptoms last for <1mo
Treatment for acute stress disorder
Same as for PTSD
New onset psychosis in a 50yo man
Think medical condition associated psychosis
New onset psychosis in an 80yo man
Think dementia
Why should benzos be avoided in treatment of PTSD?
They are addictive, and high rates of substance abuse in PTSD pts
GAD DSM criteria requires association of at least these 3 symptoms
Restlessness
Fatigue
Difficulty concentrating
Irritability
Muscle tension
Sleep disturbance
Pharma Rx for GAD
Buspirone
Benzos (usually clonazepam or diazepam): taper quickly
SSRIs
Venlafaxine (XR)
What is an adjustment disorder?
Maladaptive behavioral or emotional symptoms within 3mo of a stressful (but not life-threatening: that is PTSD) event
By definition, when do symptoms resolve after adjustment disorder
Within 6mo after stressor has terminated
2 subtypes of anorexia
Restrictive type (often with OC traits, may vigorously exercise)
Binge eating/ purging type (associated w/ increased incidence of MDD and substance abuse)
What distinguishes anorexia from bulimia?
Low body weight for anorexia, normal to high for bulimia

Bulimia is more egodystonic
4 criteria for anorexia
Weight 15% nml
Fear of gaining weight
Disturbed body image
Amenorrhea
What is melanosis coli?
Darkened area of colon 2/2 laxative abuse
Mortality associated w/ anorexia, and 3 typical causes
10%
Starvation, suicide, electrolyte disturbance
When should anorexic pts be hospitalized?
If >20% below ideal body weight
2 good SSRIs for adjunctive Rx for anorexia
Paroxetine or mirtazapine (help increase weight gain)
Difference btwn underweight from anorexia vs. MDD
No appetite in MDD
2 types of bulimia
Purging (vomiting, laxatives, diuretics)
Nonpurging (excessive exercise or fasting)
Definition of binge eating
Excessive food intake within 2hr period accompanied by sense of lack of control
Most common electrolyte abnormality in anorexia vs bulimia
Anorexia: hypochloremic, hyperkalemic alkalosis

Bulimia: hypochloremic hypokalemic alkalosis
Pharma therapy for bulimia
SSRIs are first line, then TCAs
Classification of binge eating disorder
Eating disorder NOS
Diagnostic criteria for binge eating
Bingeing 2+ days a week for 6mo, not associated w/ compensatory behaviors, and causes distress

At least 3 of: eating v. fast, until uncomfortably full, large amts when not hungry, alone b/c of embarrassment, feeling disgusted/depressed/guilty afterward
4 neurotransmitters that can be increased in sleep disorders
Dopamine (decreased sleep time)
NE (decreased sleep time)
ACh (increased sleep time and increased REM)
Serotonin (increased sleep time esp delta sleep)
2 types of primary sleep disorders
Dyssomnias: disturbances in amt, quality, or timing of sleep
Parasomnias: abnml events in behavior or physiology during sleep
EEG waves when awake
Awake: mixed frequency, desynchronized
EEG waves when awake w/ eyes closed
Alpha waves
EEG waves in Stage 1 sleep
Loss of alpha waves
EEG waves in Stage 2 sleep
Sleep spindles and k complexes
EEG waves in Stage 3-4 sleep
Delta waves (low frequency)
EEG waves in REM sleep
Sawtooth waves
What % of sleep is REM sleep?
25%
What is REM reboun?
Increase in amt of REM sleep that occurs after a night of sleep deprivation; slow wave sleep is made up first
2 diagnostic criteria for primary insomnia
Results in daytime drowsiness or difficulty fulfilling tasks

3 or more times per wk for at least 1mo
Rx for primary hypersomnia
Amphetamines (maybe SSRIs)
6 things associated with narcolepsy
Cataplexy
Short REM latency
Sleep paralysis
Hypnagogic
Hypnopompic
Hallucinations
What are hypnagogic and hypnopompic episodes?
Hypnagogic: dream as pt is falling asleep
Hypnopompic: dream persists as pt is waking up
What is cataplexy and what often precipitates it?
Collage due to sudden loss of muscle tone

Associated w/ emotion, esp laughter
Rx for narcolepsy
Timed daily naps plus stimulant drugs

SSRIs or sodium oxalate for cataplexy
Rx for OSA vs. central sleep apnea
CPAP vs. biPAP (mechanical ventilation)
Rx for shift work sleep disorder
Light therapy
When should melatonin be given for a circadian rhythm sleep disorder?
5.5 hrs before desired bedtime
During which sleep stage do nightmares occur?
REM
Rx for nightmare disorder
Usually none (may use tricyclics or other agents that suppress REM sleep)
During which sleep stage do night terrors occur?
Stage 3-4 sleep
How to differentiate nightmares from night terrors
Nightmares: pts fully awaken and remember the episode
Rx for night terror disorder
Usually nothing (but can use low dose diazepam at bedtime)
During which sleep stage does somnambulism occur?
Stage 3-4
Peak age for prevalence of somnambulism
12yo (onset usually at 4-8yo)
Rx for somnambulism
Measures to prevent injury in surrounding environment
4 criteria for how personality disorders can manifest (pt needs at least 2/4)
CAPRI

Cognition
Affect
Personal Relations
Impulse control
3 clusters of personality disorders
A: Schizoid, schizotypal, paranoid (MAD)
B: Antisocial, borderline, histrionic, narcissistic (BAD)
C: Avoidant, dependent, obsessive-compulsive (SAD)
What is passive-aggressive personality disorder characterized as?
PD NOS
Rx of choice for PDs
Psychotherapy
How to differentiate paranoid PD from paranoid schizophrenia
Paranoid PD: no fixed delusions, no frank psychosis
Difference btwn schizoid and schizotypal
Schizoid: loner
Schizotypal: eccentric/ magical thinking
Schizotypal pts may eventually develop which disease?
Schizophrenia
9 criteria for borderline personality disorder
IMPULSIVE
Impulsive
Moody
Paranoid under stress
Unstable self image
Labile, intense relationships
Suicidal (repeatedly)
Inappropriate anger
Vulnerable to abandonment
Emptiness
For which personality disorder is pharmacotherapy most useful?
Borderline
Common defensive mechanism of histrionic patients
Regression
Difference in the underlying fear in avoidant PD vs. social anxiety disorder
Avoidant PD: fear rejection (sense of inadequacy)
Social anxiety disorder: fear embarrassment
Pt with a debilitating illness who develops dependence on a caretaker does not have dependent PD because
Onset of symptoms not before adulthood
Frequently making excuses and inefficient procrastinator is what PD?
Passive-aggressive
Lifetime prevalence of substance abuse or dependence in the US
17%
Withdrawal and tolerance are characteristics of
Substance dependence
Most commonly abused substance in the US
Alcohol (7-10% rate of alcoholism)
What neurotransmitter is responsible for the sedating effects of alcohol?
GABA
There is upregulation of which two enzymes in heavy drinkers?
Alcohol dehydrogenase (alcohol --> acetaldehyde)

Aldehyde dehydrogenase (acetaldehyde --> acetic acid)
BALs that can cause coma and respiratory depression in the novice drinker, respectively
300 mg/dL
400 mg/dL
2 types of poisonings that can present similarly to alcohol overdose
Ethylene glycol
Methanol

(all 3 cause an anion gap metabolic acidosis)
3 drugs given for acute alcohol intoxication
Thiamine
Naloxone (for any opioids that may have been ingested)
Folate
Glucose (in case their AMS is due to hypoglycemia)
3 drugs used for alcohol abuse
Disulfiram (antabuse): causes vomiting b/c inhibits aldehyde dehydrogenase
SSRIs
Naltrexone (reduces cravings)
Onset and length of alcohol withdrawal symptoms
6-24 hours
2-7 days
3 categories of alcohol withdrawal symptoms
Mild: irritable, tremor, insomnia
Moderate: diaphoresis, fever, disorientation
Severe: grand mal seizures, DTs
Symptoms of DTs
Visual or tactile halluciantions, gross tremor, autonomic instability, fluctuating levels of psychomotor activity
Mortality of untreated DTs
20%
Rx for DTs
Benzos
Drug for postwithdrawal seizures
Magnesium sulfate
Triad of Wernicke's encephalopathy (acute)
Ataxia
Confusion
Ocular abnormalities (nystagmus, gaze palsies)
Triad of Korsakoff's syndrome (chronic, irreversible)
Impaired recent memory
Anterograde amnesia
+/- confabulation (making up answers)
Order of meds given in pt with AMS and + BAL
Thiamine always BEFORE glucose, or can precipitate Wernicke-Korsakoff syndrome (b/c is a coenzyme used in carb metabolism)
3 topographic theories of psychotherapy
Unconscious, preconscious, conscious
3 structural theories of psychotherapy
Id, ego, supergo
Normal development of egos
Id at birth, ego present after birth, superego by 6yo
What is used to control instinctual urges in the ego?
Defense mechanisms
What is used to detect fantasies/ psychoses in the ego?
Reality testing
4 mature defense mechanisms
Altruism, humor, sublimation, suppression
7 neurotic defense mechanisms
Controlling, displacement, intellectualization, isolation of affect, rationalization, reaction formation, repression
What is displacement and what is an example?
Shifting emotions from an undesirable situation to one that is personally tolerable (student who is angry at his mom talks back to his teacher the next day and refuses to obey her)
What is reaction formation and what is an example?
Doing the opposite of an unacceptable impulse (man in love w/ his coworker insults her)
% of incarcerated patients who have antisocial PD?
80%
Difference btwn repression and suppression
Former is unconscious
4 immature defenses
Acting out, denial, regression, projection
What is acting out and what is an example?
Giving in to an impulse, even if socially inappropriate, to avoid the anxiety of suppressing it (man who is told his therapist is going on vacation "forgets" his last appt)
What is projection and what is an example?
Attributing objectionable thoughts or emotions to others (husband attracted to other women believes his wife is having an affair)
2 other defense mechanisms
Splitting and undoing
What is undoing and what is an example?
Attempting to reverse a situation by adopting a new behavior (man who briefly fantasizes about killing his wife by sabotaging her car takes the car in for a complete check-up)
Goal of psychoanalysis
Resolve unconscious conflicts by bringing repressed experiences/ feelings into awareness
Psychoanalysis is ____ oriented
Insight oriented
5 behavioral therapy techniques for deconditioning
Systemic desensitization, flooding and implosion, aversion therapy, token economy, biofeedback
Which technique is used in both systemic desensitization and flooding/implosion
Relaxation techniques
Difference between flooding and implosion
Real vs. imagined, respectively
Foundation of cognitive therapy
Identify and replace maladaptive thoughts w/ positive thoughts
2 common problems addressed in family therapy
Boundaries that are too permeable
Triangles (2 people forming an alliance against a 3rd)
4 types of marital therapy
Conjoint therapy, concurrent therapy (separate but same therapist), collaborative (seen individually), four-way therapy (2 therapists, common for sexual problems)
4 topics taught in DBT
Mindfulness, interpersonal effectiveness
How does cocaine cause its stimulant/reward effect?
Blocks dopamine reuptake
3 ways cocaine overdose can cause death
Arrhythmia, seizure, respiratory depression
Cause of MI/CVA in cocaine user
Vasoconstriction
Cocaine intoxication mimics
Flight or fight (sympathomimetic)
Ddx for cocaine intoxication
Amphetamines or PCP
Sedative withdrawal
How long will urine tox be positive for cocaine?
3 days (longer in heavy users
Rx for cocaine intoxication
Benzos (+ haloperidol for severe agitation/psychosis)
Rx for cocaine dependence
TCAs or dopamine agonists (amantadine, bromocriptine)
Risk of cocaine withdrawal
Really nothing: terrible crash, but not life-threatening
3 classic and 2 designer amphetamines
Dextroamphetamine (Dexedrine)
Methylphenidate (Ritalin)
Methamphetamine

MDMA (ecstasy)
MDEA (eve)
Difference between classic and designer amphetamines
Designer release serotonin (in addition to dopamine) and have hallucinogenic properties (in addition to stimulant)
How long will urine tox be positive for amphetamines
1-2 days (though many tests aren't sensitive enough)
Rx for amphetamine intox/dependence/withdrawal
All same as cocaine
Rotatory nystagmus
PCP intoxication
Which drug intoxication is most likely to cause violence
PCP
Which drug is most similar to PCP?
Ketamine
Mechanism and effect of PCP
NMDA glutamate antagonist (and dopamine activator) --> hallucinogen
Risk of PCP overdose
Seizures, coma
5 components of PCP Rx
1) Benzos or dopamine antagonists to control agitation/anxiety
2) Diazepam for spasms/seizures
3) Acidify urine w/ ammonium chloride and ascorbic acid
4) Haloperidol for severe agitation/psychosis
5) Monitor BP, temp, lytes
Ddx for PCP intoxication
Psychosis, schizophrenia
How long is a urine tox screen positive for PCP?
>1 wk
Which lab values are often elevated in PCP use?
CPK and AST
Does PCP have withdrawal symptoms
No, but pts may have flashbacks
How do benzos and barbiturates work
Potentiate GABA by increasing the frequency or duration (respectively) of chloride channel opening
Complication of benzo or barbiturate abuse
Respiratory depression
How long is a urine tox screen positive for sedatives?
1 wk
Rx for sedative overdose
Activated charcoal to prevent further absorption
Rx for benzo overdose
Flumazenil (antagonist)
Risk w/ flumazenil
Seizures
Rx for barbiturate overdose
Alkalinize urine w/ sodium bicrb to promote renal excretion
Withdrawal from sedatives
Autonomic hyperactivity, risk of life-threatening seizures
Rx for sedative withdrawal (2)
Long-acting benzo (diazepam) and valproic acid for seizures
How long is a urine tox screen positive for opiates?
12-36hrs
Triad of opioid overdose
Respiratory depression, AMS, miosis
Which opioid produces midriasis instead of miosis?
Meperidine (Demerol)
Rx for opioid withdrawal
Clonidine or buprenorphne; methadone if severe
3 hallucinogens
Mushrooms (psilocybin), mescaline, LSD
Hallucinogens don't cause
Physical dependence or withdrawal
Rx for hallucinogen intoxication
Usually just talking down pt
Use of marijuana in cancer/AIDS pts
Anti-emetic and appetite stimulant, respectively
How long is a urine tox screen positive for marijuana?
4 wks (released from adipose stores)
Inhalants are CNS ___?
Depressants
Risk w/ inhalant overdose
Respiratory depression or arrhythmias
Long-term inhalant use can damage
CNS, PNS, liver, kidney, muscle
How long is a urine tox screen positive for inhalants?
4-10hrs
Mechanism of caffeine (2)
Adenosine antagonist, so increases cAMP

Stimulant via dopaminergic effects
Caffeine intake >1 gram can cause
Tinnitus, agitation, arrhythmias
Caffeine intake >10grams can cause
Seizures or respiratory failure --> death
Neurotransmitter involved in nicotine addition
Dopamine
What is pseudodementia?
Depression in elderly --> decrease in memory and cognitive functioning
Difference btwn demented and pseudodemented pts when they don't know an answer
Demented pts confabulate
Depressed pts say "I don't know"
Sundowning is more common w/
Dementia
2 good antidepressants in elderly
SSRIs and mirtazapine
Major antidepressive side effect in elderly
Anticholinergic
Abnormal guilt may involve (3)
Hallucinations or delusions

Suicidal ideation

Duration >1yr
Sleep cycle changes in elderly (3)
Increase number of REM cycles (but no change in total duration)

Increase in Stage 1 and 2 sleep

Decrease in Stage 3 and 4 sleep
Prevalence of elder abuse
10% of pts >65yo
Baseline kidney function should be assessed in pts starting which mood stabilizer?
Lithium
Baseline EKG is required in pts starting which antipsychotic?
Ziprasidone (Geodon)
Manic presentation could be due two which two substances?
Cocaine or amphetamines
4 problems commonly associated w/ panic disorder
Depression
Aographobia
GAD
Substance abuse
How long should the intense grieving of bereavement last?
<2mo
CT scan of schizophrenic pt
Enlarged ventricles and prominent sulci
Hyperthermia, autonomic instability, muscular rigidity, altered sensorium
Neuroleptic malignant syndrome
Which drugs cause neuroleptic malignant syndrome?
Antipsychotics (dopamine antagonists)
Complication of neuroleptic malignant syndrome
Rhabdomyolysis (--> myoglobinuria --> ARF)
Rx for NMS
Dantrolene (muscle relaxant)
Dopamine agonists (bromocriptine/ amantadine)
D/c responsible drug
Supportive (fluids, cooling, alkaline diuresis)
What drugs can be used in lieu of antidepressants for MDD and in what scenario?
Psychostimulants (e.g. methylphenidate or modafinil)

Short life expectancy (before onset of efficacy of SSRI, for example)
Rx for panic attack/ panic disorder (2)
Benzos (e.g. alprazolam) for acute attack

SSRI for long-term prevention
4 dissociative disorders
Dissociative amnesia, dissociative fugue, dissociative identity disorder, depersonalization disorder
Another name for dissociative identity disorder?
Multiple personality disorder
Amnesia due to a stressful life event
Dissociative amnesia
When do pts w/ dissociative amnesia return to normal?
Minutes or days
Rx for dissociative amnesia (and dissociative disorders in general)
Hypnosis or Ativan during interview to help patient talk freely (retrieve lost memories)
What is abreaction?
Strong reaction when retrieving traumatic memories
Sudden travel away from home in which a person takes on a new identity and can't remember the past
Dissociative fugue
Difference in the amnesia between dissociative amnesia and dissociative fugue
In dissociative amnesia, pts are aware they've forgotten something
Prognosis of dissociative fugue
Hours to days or longer; afterwards pt will resume old identity and not remember fugue
Most dissociative identity disorders pts are
Women who have experienced prior trauma
Suicide rate for dissociative identity disorder
30%
What is dissociative identity disorder?
2 or more identities that take control of behaviors/ thoughts; unaware of events during prior personality states
Symptoms of dissociative identity disorder are similar to those of?
Borderline personality disorder
Persistent/ recurrent episodes of being detached from one's body or mind (like an outside observer) but w/ reality testing intact
Depersonalization disorder
Depersonalization disorder has a high comorbidity with
Anxiety/ panic
Rx for depersonalization disorder
Anti-anxiety meds or SSRIs for anxiety symptoms
What is primary gain?
Expression of unacceptable feelings as physical symptoms to avoid facing them
DSM criteria for somatization disorder
2 GI, 1 sexual, 1 neuro, and 4 pain symptoms + onset before age 30
Comorbidities w/ body dysmorphic disorder
90% depression, 70% anxiety, 30% psychosis
Rx for body dysmorphic disorder
SSRIs, no procedures
Two types of pain disorder
Acute (<6mo) or chronic (>6mo)
Ddx for pain disorder
Hypochondriasis or malingering
What must be ruled out w/ all somatoform disorders
Hypochondriasis and malingering
Intentionally producing medical or psychological symptoms to assume role of sick pt
Factitious disorder
Difference factitious disorder and malingering?
Factitious disorder involves primary gain

Malingering involves secondary gain
Commonly feigned symptoms in factitious disorder
Hallucinations, depression, fever, abdominal pain, seizures, skin lesions, hematuria
Factitious disorder w/ predominantly physical symptoms
Munchhausen syndrome
Common history of pts with factitious disorder
Child abuse or neglect
Failure to resist aggressive impulses --> assault or property destruction
Intermittent explosive disorder
Aggressiveness is associated w/ this neurotransmitter (low or high?)
Low serotonin
Rx for intermittent explosive disorder
SSRIs, anticonvulsants, lithium, propanolol
Which therapy technique often fails in intermittent explosive disorder?
Individual therapy
5 impulse control disorders
Intermittent explosive disorder
Kleptomania
Pyromania
Pathological gambling
Trichotillomania
Kleptomania is often comorbid with
Bulimia (1/4 of bulimics)
Pyromania is often present in
Mentally retarded individuals
Predisposing factors for pathologic gamgling often involve
Childhood/ family
Most effective therapy for pathologic gambling
Gamblers Anonymous
Rx for trichotillomania
SSRIs
Antipsychotics
Lithium
What is conversion disorder?
Neuro symptoms preceded by psychological stressor
Common symptoms of conversion disorder
Shifting paralysis, blindness, mutism, paresthesias, seizures, globus hystericus
Conversion syndrome in an older adult
Suspect neuro deficit
How do pts with a conversion disorder discuss their symptoms?
With calm indifference
Prognosis of conversion disorder?
Recover in 1mo
25% recur
How long must hypochondriasis persist for?
6mo
Difference between somatization and hypochondriasis
Somatization disorder pts are concerned about symptoms

Hypochondriacs are concerned about disease
5 stages of sexual response
Desire, excitement, plateau, orgasm, resolution
2 neurotransmitters that affect libido
Dopamine enhances libido
Serotonin inhibits libido
2 most common sexual disorders in women
Sexual diesire disorder
Orgasmic disorder
2 most common sexual disorders in men
Secondary erectile dysfunction
Premature ejaculation
What is second ED
Acquired after previous ability to maintain erections
Rx for female sexual arousal disorder
Release of clitoral adhesions
Rx for female orgasmic disorder
Masturbation
3 Rx methods for premature ejaculation
Squeeze technique
Stop-start technique
Use side effects of SSRIs/TCAs
3 most common paraphilias
Pedophilia, voyeurism, exhibitionism
3 paraphilias that can occur in women
Sadism, masochism, pedophilia
Sexual pleasure in men from rubbing their genitals against women in crowded areas
Frotteurism
Sexual excitement from calling unsuspecting women
Telephone scatologia
3 Rx options for paraphilias
Insight-oriented psychotherapy
Behavior therapy
Antiandrogens
Transsexuality is also known as
Gender identity disorder
Gender identity disorder is associated with an increased incidence of
MDD, anxiety, suicide
Gender identity is usually developed by age
3yo
4 exceptions to confidentiality
Subpoena
Child abuse
Tarasoff duty (harm to others)
Suicidal
How many physicians must determine need for involuntary admission?
2
Legal doctrine that allows forcible commitment
Parens patriae
Competence vs. capacity
Competence is a legal term
Capacity is a clinical term
Most important factor in predicting violence
History of violence
Criteria for not guilty by reason of insanity (3)
Mental illness, doesn't understand right from wrong, didn't understand consequences of actions at time act was committed
4 Ds fo malpractice
Dereliction (negliect) of a Duty that led Directly to Damages
2 types of damages awarded
Compensatory (for medical expenses, lost salary, physical suffering)

Punitive (to punish doctor for gross negligence)
MMSE dysfunction is below what score?
<25
Difference between impairment in dementia and delirium
Dementia: memory impairment
Delirium: sensorium impairment
Minimum workup to exclude reversible causes of dementia
CBC, Chem, TFTs, RPR, B12, folate, brain CT or MRI
Dementia w/ obesity, coarse hair, constipation
Hypothyroidism
2 types of delirium
Quiet and agitated
Rx for delirium symptoms
Quetiapine or haloperidol (avoid benzos --> confusion)
What can't you use haloperidol IV
Can cause torsades
Which has EEG changes, delirium or dementia, and what are they?
Delirium: fast waves or generalized slowing
Apraxia
Inability to perform purposeful movements
Agnosia
Inability to interpret sensations correctly (e.g. recognize things previously known)
Life expectancy of Alzheimer's
8 years after diagnosis
Neurotransmitter levels in Alzheimer's ()
Decreased acetylcholine and NE
2 classes or drugs for Alzheimer's and examples
NMDA antagonists: memantine

Cholinesterase inhibitors: donepezil (Aricept), rivastigmine (Exelon), tacrine (Cognex)
Rx for mania w/ kidney disease
Valproic acid or carbamazepine
First line for GAD
Buspirone
Rx for agitated mania
Haloperidol (acutely; lithium longterm)
Elevated cholesterol and carotene, prolonged QT, osteoporosis
Anorexia
Fever, rigidity, mental status changes, and autonomic instability
Neuroleptic malignant syndrome
Rx for neuroleptic malignant syndrome
D/c antipsychotics
ICU
Control hyperthermia
Maintain electrolyte balance
Dantrolene in severe cases
High fevers, rigidity, diarrhea, restlessness, autonomic instability
Serotonin syndrome
How long should a single MDE be treated for?
6mo following response
2 subtypes of anorexia
Restricting
Binge and purge
Pt who meets criteria for anorexia nervosa except has regular menses
Eating disorder NOS
Rx for Tourette syndrome
Typical antipsychotics (haloperidol or pimozide)
Rx for refractory enuresis
Desmopressin is first line (better safety profile)
Imipramine is second line
Two tests to get before starting lithium treatment
Creatinine
TFTs
Rx for social phobia (2)
Assertiveness training (part of CBT) and SSRI (e.g. paroxetine)
Management if only one parent consents for a treatment for a minor and the other refuses to agree?
Proceed! Only need consent from one parent or guardian
How to distinguish selective mutism and social phobia
Selective mutism: child refuses to talk
Social phobia: often 2/2 learning and communication disorders (e.g. stuttering)
When do kids usually grow out of stranger anxiety?
3yo (afterwards is generally attributable to another cause)
Who uses neurotic defense mechanisms?
Adults; usually provide short term relief
3 criteria for emancipated minor
Married
Military
Lives separately from parents and manages own finances
Abrupt cessation of what anti-anxiety med can caused generalized tonic-clonic seizures and confusion?
Alprazolam (short-acting benzo)
Methylphenidate should not be used in children younger than
6yo (safety/efficacy have not been evaluated)
Dilated pupils, HTN, tachy, psychosis
Amphetamine intoxication (similar to cocaine, but psychosis is more common with amphetamines)
Altered consciousness, respiratory depression, pinpoint pupils
Heroin intoxication
Rx for bereaved pts with continued extreme symptoms 2months after their loss
Antidepressant and psychotherapy
When might ECT be used as first line for MDD?
Severe suicidality and psychosis
Management of acutely suicidal pt whose parents want her to see her pediatrician instead of being hospitalized
Hospitalize anyway!
IVDU who contracts HCV and blames it on inadequate control of HCV within the community is an example of?
Distortion (altered perception of reality to make it more acceptable), an immature defense mechanism
Unfaithful husband who accuses his wife of infidelity
Projection (attributes unacceptable emotions to other individuals), an immature defense mechanism
Pt who was rescued from a burning building and now denies any memory of the event
Dissociation (blocking disturbing feelings form consciousness to avoid emotional upset), a neurotic defense mechanism
Magical thinking is associated with which PD?
Schizotypal
Birth defects associated w/ anticonvulsants (carbamazepine/ valproate)
Craniofacial defects
NTDs
Genital anomalies
Important diagnostic criteria for adjustment disorder (vs. normal human experience)
Functional impairment
Inheritability of bipolar disorder
High: 5-10% for first degree relatives (vs 1% for general population)
4 antipsychotics available in depot form
Haloperidol, fluphenazine (typical)
Risperidone, paliperidone (atypical)
Rx for psychosis if pt has severe EPS
Clozapine (or possibly typical antipsychotics)
Critical aspect of therapy for schizophrenics
Family therapy and keeping family conflict to a minimum
Pt w/ Hx of alcohol dependence presenting w/ auditory hallucinations and stable vitals
Alcoholic hallucinosis
Normal devt for at least 2yrs, then loss of previously acquired language, social, bowel/bladder, or play/motor skills followed by development of autistic symptoms
Childhood disintegrative disorder
How to distinguish autism from childhood disintegrative disorder
Autism symptom onset always begins before 3yo; rarely have a "regression" like in childhood disintegrative disorder, where children are normally before symptom onset
How to distinguish OCPD from OCD?
Pts with OCPD don't see it as a problem, and are more focused on perfectionism than particular obsessions/compulsions
3 subtypes of delusions
Grandiose, paranoid, somatic
4 first line and 2 second line maintenance meds for mania
Lithium, lamotrigine, olanzapine, quetiapine

Divalproex, aripiprazole
Most common side effect of ECT
Amnesia (anterograde resolves quickly, retrograde may persist)
Rare side effects of ECT (5)
Prolonged seizures, delirium, headache, nausea, skin burns
When can lithium be tapered?
For pts with one manic episode, after 1yr symptom free
When is lifelong lithium therapy recommended?
After 3 or more manic relapses
Woman who is angry with her husband and throws away his baseball card collection as retaliation is an example of
Displacement (neurotic defense mechanism): shifting of emotion associated w/ an upsetting person or object to a safer alternate object/person that represents the original
Battered woman who believes her husband is right when he says she is worthless
Introjection (immature defense mechanism): assimilating another person's attitude into one's own perspective
Person who needs to follow the rules of a game precisely may have which PD?
OCPD
Rx for adjustment disorder
Psychodynamic psychotherapy or CBT
Thing to be careful of with adjustment disorder
Timeline! If develops within 3mo of stressor and hasn't lasted >6mo, can be adjustment disorder and needs therapy, not SSRIs
Most common comorbid conditions in Tourette disorder (2)
ADHD (60%)
OCD (27%)
Rx for narcolepsy
Methylphenidate or modafinil (psychostimulants) for daytime somnolence +/- antidepressents for cataplexy
MAOI + tyramine containing food can cause
Hypertensive crisis
Stating that being fired is a "blessing in disguise" because pt can now spend more time with his family
Rationalization (neurotic defense mechanism)
Most likely atypical antipsychotic to cause EPS
Risperdal
Least likely atypical antipsychotic to cause EPS
Clozapine
Rx for fear of flying
Short acting benzo, e.g. alprazolam
Stepwise loss of function
Vascular dementia
DSM criteria for dementia
Memory impairment and at least one of: aphasia, apraxia, agnosia, diminished executive functioning
Dementia symptoms + focal neuro symptoms (hyperreflexia or paresthesias)
Vascular dementia
Diagnostic test for vascular dementia
MRI
Dementia w/ more personality/behavioral changes
Pick's disease/ frontotemporal dementia
What are Pick bodies?
Intraneuronal inclusion bodies
Prognosis of Huntington's
Death 15yrs after diagnosis
Psychotic depression, muscular hypertonicity, progressive dementia, choreiform movements
Huntington's
MRI in Huntington's shows
Caudate atrophy
2 classes of dementia w/ examples and symptoms
Cortical (Alzheimer's, Pick's, CJD): intellectual function declines

Subcortical (Huntington's, Parkinson's, NPH, multi-infarct): affective and movement symptoms
What % of Parkinson's pt develop dementia?
30%
5 causes of Parkinson's disease
Idiopathic (most common)
Traumatic
Drug-induced
Encephalitic
Familial
Pharma options for Parkinson's (5)
1) Levodopa + carbidopa (former crosses BBB, latter prevents conversion of levodopa to dopamine in periphery)

2) Amantadine (unknown)

3) Anticholinergics (for tremor)

4) Dopamine agonists (bromocriptine)

5) MAO-B inhibitors (selegiline): inhibit breakdown of dopamine
Surgical options for PD
Thalamotomy or pallidotomy if refractory
Iatrogenic cause of CJD
Corneal transplant
Dementia w/ myoclonus, EPS, LMN signs, ataxia
CJD
Prognosis/latency of CJD
Long latency btwn exposure and symptom onset, but then usually progresses to death w/in 1yr
4 other prion disease
Kuru
Gerstmann-Hraussler syndrome
Fatal familial insomnia
Bovine spongiform encephalopathy
What are prions?
Proteinaceous infectious particles, normally expressed by healthy nuerons but accumulations --> disease
EEG in CJD
Periodic sharp waves/spikes
Pathology of CJD
Spongiform changes of cerebral cortex, neuronal loss, hypertrophy of glial cells
Of triad of NPH, which is least likely to improve with shunt treatment
Dementia
Contusion w/ lucid intervals
Delirium
Best Rx for delirium after treating underlying cause
Low-dose antipsychotic
Amnestic disorders are always caused by an underlying ___ condition vs ____ condition
Medical, not psychiatric
Unusual antidepressant choice in pts who can't tolerate typicals meds, and risk of its use
Sympathomimetics (amphetamine-based): addiction potential
What must be assessed before prescribing TCAs?
Suicide risk (overdose can be lethal)
Hallmark of TCA toxicity
Widened QRS (>100 msec)
3 side effect categories of TCAs
Antihistaminic (sedation), antiadrenergic, antimuscarinic
7 examples of TCAs
Imipramine
Trimipramine
Desipramine
Clomipramine
Amitriptyline
Nortriptyline
Doxepin
Serotonin syndrome occurs from combining these two meds
SSRIs and MAOIs
Consideration when switching from SSRI to MAOI
Wait at least 2 wks to prevent serotonin syndrome
Which SSRI doesn't need a taper?
Fluoxetine/ Prozac
Which SSRI has the highest risk of GI disturbances?
Zoloft
Antidepressant also used for SAD and ADHD
Bupropion
Two low potency typical antipsychotics
Chlorpromazine and thioridazine
5 high potency typical antipsychotics
Haloperidol
Fluphenazine
Trifluoperazine
Perphenazine
Pimozide
High potency typicals have ___ EPS and ___ anticholinergic/antihistaminic side effects
More EPS

Less
Symptoms of NMS
FALTER

Fever
Autonomic instability
Leukocytosis
Tremor
Elevated CPK
Rigidity
What monitoring is required for quetiapine
Slit lamp exam q6mo to look for cataracts
Why do some atypicals have less weight gain?
Less anti-histamine action
Toxic and lethal doses of lithium
Toxic >1.5
Lethal >2
Carbamazepine is best for which two subtypes of bipolar
Rapid cycling
Mixed episodes
Carbamazepine is also used to treat which condition
Trigeminal neuralgia
3 long acting benzos (1-3 days)
Chlordiazepoxide (Librium)
Diazepam (Valium)
Flurazepam (Dalmane)
4 intermediate acting benzos (10-20hrs)
Alprazolam (Xanax)
Clonazepam (Klonopin)
Lorazepam (Ativan)
Temazepam (Restoril)
Common use for Librium
Alcohol detox
When can dystonia be life-threatening?
Dystonia of diaphragm --> asphyxiation