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200 Cards in this Set
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Monitoring for pts on clozapine (specifics)
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ANC and WBC at baseline, then weekly for 6mo, then biweekly for 6mo, then monthly
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Which pts is ziprasidone contraindicated in and when should it be tested for?
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Long QT syndrome (get EKG if family Hx of SCD <40yo)
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3 phases of schizophrenia
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Prodromal (before first psychotic episode; withdrawn, new interests)
Psychotic Residual (btwn episodes, negative symptoms) |
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Echolalia
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Repeats words or phrases
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Echopraxia
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Mimics behavior
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5 subtypes of schizophrenia
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Paranoid
Disorganized Catatonic Residual (prominent negative symptoms) Undifferentiated |
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4 dopamine pathways
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Prefrontal cortical
Mesolimbic Tuberoinfundibular Nigrostriatal |
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Which dopamine pathway is responsible for negative symptoms?
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Prefrontal cortical
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Which dopamine pathway is responsible for positivesymptoms?
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Mesolimbic
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Which dopamine pathway is responsible for EPS when blocked by neuroleptics?
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Nigrostriatal
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Which dopamine pathway is responsible for hyperprolactinemia when blocked by neuroleptics?
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Tuberoinfundibular
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Two drugs of abuse that can cause acute psychosis by activating dopaminergic pathways
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Cocaine
Amphetamines |
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2 other neurotransmitters that are increased in schizophrenia
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Serotonin
Norepinephrine |
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Neurotransmitter that is decreased in schizophrenia
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GABA (might indirectly active dopamine and NE pathways)
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Changes in brain structure of schizophrenic pts seen on CT scans
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Enlargement of ventricles
Diffuse cortical atrophy |
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4 typical neuroleptics
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Chlorpromazine, thioridazine, trifluoperazine, haloperidol
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How long should antipsychotics be tried before determining medication failure?
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4wks
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Which neuroleptics have moer EPS side effects, and which have more anticholingeric side effects?
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High potency (haloperidol, trifluoperazine): EPS
Low potency (chlorpromazine, thioridazine): Anticholingeric |
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3 types of EPS
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Dystonia, Parkinsonism, akathisia
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Anticholinergic symptoms
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Dry mouth, constipation, blurred vision
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What is tardive dyskinesia?
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Darting or writhing movements of face, tongue, head
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Rx for tardive dyskinesia
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Limited, but d/c offending agent and substitute atypical neuroleptic
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Pt on antipsychotics with confusion, high fever, elevated BP, rigid, sweating
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Neuroleptic malignant syndrome
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What lab test is elevated in neuroleptic malignant syndrome
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Creatine phsophokinase (CPK)
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How many pts with schizophreniform disorder progress to schizophrenia or schizoaffective
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2/3rds
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How to differentiate schizoaffective disorder from mood disorder with psychotic features
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Former has had delusions or hallucinations for 2wks in absence of mood disorder symptoms
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3 most common patients who develop delusional disorder
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Older (>40yo)
Immigrants Hearing impaired |
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6 types of delusions
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Erotomanic (love-based), grandiose, somatic, persecutory, jealous, mixed
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Two ways in which delusional disorder is distinguished from schizophrenia
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Nonbizarre delusions
Daily funcitoning not significantly impaired |
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Rx for shared psychotic disorder
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Separate pt, psychoterapy, antipsychotics only if symptoms haven't improved in 1-2wks
20-40% recover upon removal from inducing person |
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Culture psychosis in which patient believes penis is shrinking and will disappear, causing his death
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Koro (Asia)
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Culture psychosis with sudden unprovoked outbursts of violence (pt has no recollection), often commits suicide afterwards
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Amok (Southeast Asia)
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Culture psychosis with headache, fatigue, visual disturbances in male students
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Brain fag (Africa)
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Mental retardation is defined as an IQ less than
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70
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Risk of developing antisocial PD among children w/ conduct disorder
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40%
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Pharma therapy for conduct disorder (2 classes of symptoms that you're treating)
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Aggression: antipsychotics or lithium
Impulsivity, irritability, mood lability: SSRIs |
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Difference btwn ODD and conduct disorder
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ODD doesn't involve violation of basic rights of others
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Most common comorbid conditions with ADHD
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2/3rds of pts also have conduct disorder or ODD
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2 subtypes of ADHD
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Inattentive
Hyperactivity-impulsivity |
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When does ADHD onset, and what percentage of patients have symptoms into adulthood?
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By 7yo
20% |
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How does depression often manifest in kids?
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Irritableness
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3 CNS stimulants used in ADHD
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Methylphenidate (Ritalin)
Dextroamphetamine (Dexedrine) Pemoline (Cylert) |
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3 categories of autistic symptoms
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Repetitive/ sterotyped behaviors
Impaired communication Problems w/ social interaction |
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Onset of autism
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Usually before 3yo
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Difference between Asperger's and autism
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Asperger's has normal language and cognitive development (only has the repetitive behaviors and problems with social interaction)
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When do symptoms of Rett's present?
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5mo-30mo get regression of head circumference and onset of hand wringing
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Medical problems in Rett's include (2)
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Seizures
Cyanotic spells |
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Mutation in Rett's
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MECP2 gene (on X chromosome)
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When does childhood disintegrative disorder present?
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Onset 2yo-10yo (loss of previously acquired skills)
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What is coprolalia
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Repetition of obscene words
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3 diagnostic criteria for Tourette's
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Motor AND vocal tics
>1yr w/ symptoms, no tic free period >3 mo Onset prior to 18yo |
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Motor tics typically involve which parts of the body?
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Face and head
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Which type of tic onsets later
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Usually vocal (may be years after onset of motor tic)
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Common comorbidity with Tourette's
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OCD and ADHD
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Rx for Tourette's
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Haldol or pimozide
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3 medical conditions to rule out before enuresis is diagnosed
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Seizures
Urethritis Diabetes |
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Enuresis can be further described by these two categories (2 choices for each)
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Primary vs. secondary
Diurnal vs. nocturnal |
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Diagnostic criteria for enuresis
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>2yo
2x/wk for 3mo |
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Outcome for majority of cases of enuresis
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Spontaneously resolve by 7yo
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2 pharma therapy options for enuresis
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DDAVP or TCA
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3 med conditions to r/o before diagnosing encopresis
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Metabolic (hypothyroid)
Lower GI (fissure, IBD) Dietary |
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Diagnostic criteria for encopresis
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>4yo
1x/mo for 3mo |
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Pharma therapy for separation anxiety disorder
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Low dose antidepressant
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Risk of later suicide after hospitalization for MDE
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15%
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What % of manic pts have psychotic symptoms
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75%
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Predominant mood symptom in pts with mixed episodes
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Irritability
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4 things that differentiate hypomania from mania
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>4 days (instead of >7)
No interference w/ functioning Doesn't require hospitalization No psychotic features |
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Rx for seasonal affective disorder
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Light therapy
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Which neuroendocrine is high in depression?
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Cortisol
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What % of pts with MDD eventually commit suicide?
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15%
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Risk of subsequent MDE after first episode?
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50%
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Major risk w/ monoamine oxidase inhibitors (MAOIs)?
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Hypertensive crisis when used with sympathomimetics or ingestion of tyramine-rich foods (wine, beer, cheese)
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Danger when combining SSRIs with MAOIs
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Serotonin syndrome
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Sequelae of serotonin syndrome
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Autonomic instability, hyperthermia, seizures
Coma and death in severe cases |
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Most common side effect with MAOIs
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Orthostatic hypotension
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Procedure for ECT
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Premed w/ atropine
General anesthesia + muscle relaxant Generalized seizure induced by passing current of electricity across brain (unilateral or bilateral) for <1min |
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Time frame for initial ECT
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8 treatments over 2-3 weeks
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Most common side effect with ECT
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Retrograde amnesia
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4 subtypes of depressive disorders
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Melancholic
Atypical Catatonic Psychotic |
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Characteristics of melanocholic depression
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Early morning awakenings, excessive guilt, anorexia
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Characteristics of atypical depression
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Hypersomnia, hyperphagia, leaden paralysis, hypersensitivity to rejection
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Characteristics of catatonic depressionCharac
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Catalepsy (immobility), purposeless motor activity, extreme negativism/ mutism, bizarre posutres, echolalia
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What is required for the diagnosis of bipolar I?
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Episode of mania or mixed episode (depressive episode NOT required)
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What is required for the diagnosis of bipolar II?
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One or more MDEs and at least one hypomanic episode (NO history of manic episodes, otherwise is bipolar I)
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Typical length of untreated manic episodes
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3mo
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Pharma therapy for bipolar disorder (3 options)
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1) Lithium
2) Anticonvulsants (carbamazepine or valproic acid): also mood stabilizers, useful for rapid cycling and mixed episodes 3) Olanzapine |
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What is rapid cycling?
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4 or more mood episodes in 1 year
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12 side effects of lithium
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Weight gain
Tremor GI problems Fatigue Arrhythmia Seizures Goiter/ hypothyroid Benign leukocytosis Polyuria/ polydipsia Alopecia Metallic taste Coma |
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Difference between MDD and dysthmic disorder
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Dysthmic disorder is generally persistent (not episodic), rarely requires hospitalization
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What rules out the diagnosis of dysthmia?
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Psychotic features
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What is double depression?
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MDD with dysthmic disorder during residual periods
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What is cyclothymic disorder?
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Alternating periods of hypomania and periods with mild/moderate depression
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Difference btwn cyclothymia and bipolar II?
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No MDEs
Never symptom free for >2mo during last 2yrs |
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Cyclothymia often coexists with which PD?
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Borderline
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One third of cyclothymic pts eventually develop which diagnosis?
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Bipolar disorder
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Rx for cyclothymia?
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Same as bipolar
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Time frame for post-partum depression?
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4wks to 12mo
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Autonomic symptoms of anxiety (9)
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Palpitations
Perspiration Dizziness Mydriasis GI disturbances Urinary urgency/frequency Trembling Tingling in peripheral extremities SOB/ choking sensation |
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Neurotransmitters increased (1) and decreased (2) in anxiety
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NE increased
GABA/ serotonin decreased |
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Typical duration of panic attacks
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Peak in several minutes, last 25 min (rarely >1hr)
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Diagnostic criteria for panic disorder
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Panic attack followed by concern/ worry/ avoidance about additional attacks
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Panic disorder should always be specified as
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With or without agoraphobia
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MI presentation with normal angiogram
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Panic attack
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Acute and maintenance treatment of anxiety
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Benzos
SSRIs |
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What side effects are common in panic disorder pts taking SSRIs?
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Activation side effects (anxiety symptoms that mimic those of panic)
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Rx for agoraphobia associated w/ panic disorder
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Usually resolves with SSRI treatment for panic disorder
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Most common mental disorders in the US
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Specific phobias
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Best treatment for performance anxiety
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Beta blockers
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Rx for specific phobias
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Systemic desensitization (w/ or w/out hypnosis; add benzos/beta blockers in severe cases) and supportive psychotherapy
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FDA approved drug for social anxiety disorder
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Paxil (paroxetine)
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How to differentiate OCD from OCPD
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OCD is egodystonic
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4 common obsessions
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Contamination
Doubt --> checking Symmetry Intrusive thoughts (often sexual/ violent) w/o compulsion |
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Rate of OCD is higher in pts with first degree relatives with this disorder
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Tourette's
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4 most common mental disorders
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Phobias
Substance-induced disorders Major depression OCD |
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Most common trigger of OCD
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Stressful life event
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2 pharma options for OCD
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High-dose SSRIs
TCAs (clomipramine) |
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Behavioral treatment option for OCD
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Exposure and response prevention
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3rd line therapy for refractory OCD
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ECT or cingulotomy
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Prognosis with PTSD
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50% remain symptom free after 3mo of treatment
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3 pharma options for PTSD
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TCAs (imipramine and doxepin)
SSRIs and MAOIs Anticonvulsants (for flashbacks and nightmares) |
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What is acute stress disorder?
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Similar to PTSD, except immediately after event occurred, and symptoms last for <1mo
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Treatment for acute stress disorder
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Same as for PTSD
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New onset psychosis in a 50yo man
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Think medical condition associated psychosis
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New onset psychosis in an 80yo man
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Think dementia
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Why should benzos be avoided in treatment of PTSD?
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They are addictive, and high rates of substance abuse in PTSD pts
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GAD DSM criteria requires association of at least these 3 symptoms
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Restlessness
Fatigue Difficulty concentrating Irritability Muscle tension Sleep disturbance |
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Pharma Rx for GAD
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Buspirone
Benzos (usually clonazepam or diazepam): taper quickly SSRIs Venlafaxine (XR) |
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What is an adjustment disorder?
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Maladaptive behavioral or emotional symptoms within 3mo of a stressful (but not life-threatening: that is PTSD) event
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By definition, when do symptoms resolve after adjustment disorder
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Within 6mo after stressor has terminated
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2 subtypes of anorexia
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Restrictive type (often with OC traits, may vigorously exercise)
Binge eating/ purging type (associated w/ increased incidence of MDD and substance abuse) |
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What distinguishes anorexia from bulimia?
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Low body weight for anorexia, normal to high for bulimia
Bulimia is more egodystonic |
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4 criteria for anorexia
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Weight 15% nml
Fear of gaining weight Disturbed body image Amenorrhea |
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What is melanosis coli?
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Darkened area of colon 2/2 laxative abuse
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Mortality associated w/ anorexia, and 3 typical causes
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10%
Starvation, suicide, electrolyte disturbance |
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When should anorexic pts be hospitalized?
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If >20% below ideal body weight
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2 good SSRIs for adjunctive Rx for anorexia
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Paroxetine or mirtazapine (help increase weight gain)
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Difference btwn underweight from anorexia vs. MDD
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No appetite in MDD
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2 types of bulimia
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Purging (vomiting, laxatives, diuretics)
Nonpurging (excessive exercise or fasting) |
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Definition of binge eating
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Excessive food intake within 2hr period accompanied by sense of lack of control
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Most common electrolyte abnormality in anorexia vs bulimia
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Anorexia: hypochloremic, hyperkalemic alkalosis
Bulimia: hypochloremic hypokalemic alkalosis |
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Pharma therapy for bulimia
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SSRIs are first line, then TCAs
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Classification of binge eating disorder
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Eating disorder NOS
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Diagnostic criteria for binge eating
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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 |
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4 neurotransmitters that can be increased in sleep disorders
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Dopamine (decreased sleep time)
NE (decreased sleep time) ACh (increased sleep time and increased REM) Serotonin (increased sleep time esp delta sleep) |
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2 types of primary sleep disorders
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Dyssomnias: disturbances in amt, quality, or timing of sleep
Parasomnias: abnml events in behavior or physiology during sleep |
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EEG waves when awake
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Awake: mixed frequency, desynchronized
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EEG waves when awake w/ eyes closed
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Alpha waves
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EEG waves in Stage 1 sleep
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Loss of alpha waves
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EEG waves in Stage 2 sleep
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Sleep spindles and k complexes
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EEG waves in Stage 3-4 sleep
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Delta waves (low frequency)
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EEG waves in REM sleep
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Sawtooth waves
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What % of sleep is REM sleep?
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25%
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What is REM reboun?
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Increase in amt of REM sleep that occurs after a night of sleep deprivation; slow wave sleep is made up first
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2 diagnostic criteria for primary insomnia
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Results in daytime drowsiness or difficulty fulfilling tasks
3 or more times per wk for at least 1mo |
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Rx for primary hypersomnia
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Amphetamines (maybe SSRIs)
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6 things associated with narcolepsy
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Cataplexy
Short REM latency Sleep paralysis Hypnagogic Hypnopompic Hallucinations |
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What are hypnagogic and hypnopompic episodes?
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Hypnagogic: dream as pt is falling asleep
Hypnopompic: dream persists as pt is waking up |
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What is cataplexy and what often precipitates it?
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Collage due to sudden loss of muscle tone
Associated w/ emotion, esp laughter |
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Rx for narcolepsy
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Timed daily naps plus stimulant drugs
SSRIs or sodium oxalate for cataplexy |
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Rx for OSA vs. central sleep apnea
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CPAP vs. biPAP (mechanical ventilation)
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Rx for shift work sleep disorder
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Light therapy
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When should melatonin be given for a circadian rhythm sleep disorder?
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5.5 hrs before desired bedtime
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During which sleep stage do nightmares occur?
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REM
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Rx for nightmare disorder
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Usually none (may use tricyclics or other agents that suppress REM sleep)
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During which sleep stage do night terrors occur?
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Stage 3-4 sleep
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How to differentiate nightmares from night terrors
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Nightmares: pts fully awaken and remember the episode
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Rx for night terror disorder
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Usually nothing (but can use low dose diazepam at bedtime)
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During which sleep stage does somnambulism occur?
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Stage 3-4
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Peak age for prevalence of somnambulism
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12yo (onset usually at 4-8yo)
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Rx for somnambulism
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Measures to prevent injury in surrounding environment
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4 criteria for how personality disorders can manifest (pt needs at least 2/4)
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CAPRI
Cognition Affect Personal Relations Impulse control |
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3 clusters of personality disorders
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A: Schizoid, schizotypal, paranoid (MAD)
B: Antisocial, borderline, histrionic, narcissistic (BAD) C: Avoidant, dependent, obsessive-compulsive (SAD) |
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What is passive-aggressive personality disorder characterized as?
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PD NOS
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Rx of choice for PDs
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Psychotherapy
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How to differentiate paranoid PD from paranoid schizophrenia
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Paranoid PD: no fixed delusions, no frank psychosis
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Difference btwn schizoid and schizotypal
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Schizoid: loner
Schizotypal: eccentric/ magical thinking |
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Schizotypal pts may eventually develop which disease?
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Schizophrenia
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9 criteria for borderline personality disorder
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IMPULSIVE
Impulsive Moody Paranoid under stress Unstable self image Labile, intense relationships Suicidal (repeatedly) Inappropriate anger Vulnerable to abandonment Emptiness |
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For which personality disorder is pharmacotherapy most useful?
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Borderline
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Common defensive mechanism of histrionic patients
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Regression
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Difference in the underlying fear in avoidant PD vs. social anxiety disorder
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Avoidant PD: fear rejection (sense of inadequacy)
Social anxiety disorder: fear embarrassment |
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Pt with a debilitating illness who develops dependence on a caretaker does not have dependent PD because
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Onset of symptoms not before adulthood
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Frequently making excuses and inefficient procrastinator is what PD?
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Passive-aggressive
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Lifetime prevalence of substance abuse or dependence in the US
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17%
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Withdrawal and tolerance are characteristics of
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Substance dependence
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Most commonly abused substance in the US
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Alcohol (7-10% rate of alcoholism)
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What neurotransmitter is responsible for the sedating effects of alcohol?
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GABA
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There is upregulation of which two enzymes in heavy drinkers?
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Alcohol dehydrogenase (alcohol --> acetaldehyde)
Aldehyde dehydrogenase (acetaldehyde --> acetic acid) |
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BALs that can cause coma and respiratory depression in the novice drinker, respectively
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300 mg/dL
400 mg/dL |
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2 types of poisonings that can present similarly to alcohol overdose
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Ethylene glycol
Methanol (all 3 cause an anion gap metabolic acidosis) |
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3 drugs given for acute alcohol intoxication
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Thiamine
Naloxone (for any opioids that may have been ingested) Folate Glucose (in case their AMS is due to hypoglycemia) |
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3 drugs used for alcohol abuse
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Disulfiram (antabuse): causes vomiting b/c inhibits aldehyde dehydrogenase
SSRIs Naltrexone (reduces cravings) |
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Onset and length of alcohol withdrawal symptoms
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6-24 hours
2-7 days |
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3 categories of alcohol withdrawal symptoms
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Mild: irritable, tremor, insomnia
Moderate: diaphoresis, fever, disorientation Severe: grand mal seizures, DTs |
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Symptoms of DTs
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Visual or tactile halluciantions, gross tremor, autonomic instability, fluctuating levels of psychomotor activity
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Mortality of untreated DTs
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20%
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Rx for DTs
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Benzos
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Drug for postwithdrawal seizures
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Magnesium sulfate
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Triad of Wernicke's encephalopathy (acute)
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Ataxia
Confusion Ocular abnormalities (nystagmus, gaze palsies) |
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Triad of Korsakoff's syndrome (chronic, irreversible)
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Impaired recent memory
Anterograde amnesia +/- confabulation (making up answers) |
