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Dx Criteria for
Psychosis secondary to a general medical condition (3)
1) Prominent hallucinations
2) Symptoms occur outside delirium
3) Evidence to support medical cause from lab data, hx, or physical
Dx Criteria for
Psychosis secondary to medication or substance abuse (4)
1) Prominent hallucinations
2) Symptoms occur outside delirium
3) Evidence to support medication or substance-related cause from lab data, hx, or phyiscal exam
4) Disturbance is not better accounted for by a psychotic disorder that is not substance-induced
Dx Criteria for
Schizophrenia (4)
1) Two of: Delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, negative symptoms
2) Must cause significant social or occupational functional impairment
3) 6 month duration
4) Sx not due to medical, neurological, or substance induced disorder
Dx Criteria for
Schizophrenia (4)
1) Two of: Delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, negative symptoms
2) Must cause significant social or occupational functional impairment
3) 6 month duration
4) Sx not due to medical, neurological, or substance induced disorder
Dx Criteria for
Schizophreniform disorder
Schizophrenia symptoms for 1-6 months
Dx Criteria for
Brief Psychotic Episode
Schizophrenia symptoms lasting 1 day to 1 month
Dx Criteria for
Schizoaffective disorder (3)
1) Have a major depressive, manic, or mixed episode while also meeting criteria for schizophrenia
2) Hallucinations or delusions at least 2 weeks prior to onset of mood disorder
3) Have mood symptoms present for substantial portion of psychotic illness
Dx Criteria for
Delusional disorder (2)
1) Non-bizarre, fixed delusions for at least 1 month
2) Functioning in life not significantly impaired
Difference between bizarre and non bizarre delusions
Non-Bizarre: Beliefs that are false but which are plausible
Bizarre: Basically everything else
*Bizarre delusions are pathognomonic for schizophrenia
Diagnostic Criteria for
Major Depressive Episode (8)
SIG E CAPS
Depressed mood and at least four of the following for 2 weeks:
1) Sleep - Increased/decreased
2) Interest - Anhedonia
3) Guilt - Feelings of worthlessness or guilt
4) Energy - Decreased energy
5) Concentration - Diminished concentration
6) Appetite - Increased or decreased
7) Suicidal ideation
Diagnostic Criteria for
Manic Episode
DIG FAST
A period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week and including at least 3 of the following (4 if mood is only irritable):
1) Distractibility
2) Insomnia - Decreased need for sleep
3) Grandiosity - or Inflated self-esteem
4) Flight of ideas - or Racing thoughts
5) Activity/Agitation - Increase in goal directed activity (social, sexual, or work)
6) Speech - Pressured speech or talkativeness
7) Thoughtlessness - Excessive activities of indiscretion
Diagnostic Criteria for
Mixed Episode
Meets requirements for both depressive and manic episode
Diagnostic Criteria for
Manic Episode
Meets criteria for a manic episode and:
1) Lasts at least 4 days
2) Does not markedly impair social or occupational functioning
3) Does not require hospitalization
4) No psychotic features
Diagnostic Criteria for
Major Depressive Disorder
At least 1 major depressive episode
Diagnostic Criteria for
Seasonal Affective disorder
Major depressive episodes happen during the winter months
Dx
Irritability, Carbohydrate drawing, and Hypersomnia
Seasonal Affective disorder
Drug cause of serotonin syndrome
An SSRI (usually fluoxetine) with an MAOI
Dx
Major depression with anhedonia, early morning awakenings, psychomotor disturbance, excessive guilt, and anorexia
Melancholic Major Depressive disorder
Dx
Major depression with hypersomnia, hyperphagia, reactive mood, leaden paralysis, and hypersensitivity to interpersonal rejection.
Atypical Major Depressive disorder
Dx
Major depression with immobility (catalepsy), purposeless motor activity, extreme negativism or mutism, bizarre postures, and echolalia
Catatonic Major Depressive disorder
Dx
Major depression with delusions or hallucinations
Psychotic Major Depressive disorder
Dx
Schizophrenia with
1) preoccupation with delusions or auditory hallucinations
2) No predominance of disorganized speech, behavior, of inappropriate affect
Paranoid Schizophrenia
Dx
Schizophrenia with
1) Disorganized speech
2) Disorganized behavior
3) Flat or inappropriate affect
Disorganized Schizophrenia
Dx
Schizophrenia with at least 2 of:
1) Motor immobility
2) Excessive purposeless motor activity
3) Extreme negativism or mutism
4) Peculiar voluntary movements or posturing
5) Echolalia or echopraxia
Catatonic Schizophrenia
Dx
Schizophrenia with
1) Prominent negative symptoms with minimal positive symptoms
Residual type Schizophrenia
Dx
Schizophrenia with
Multiple subtypes or none
Undifferentiated Schizophrenia
Diagnostic Criteria for
Bipolar I Disorder
1) At least 1 manic or mixed episode
2) Can be euthymic, depressed, or hypomanic between frank manic episodes
3) May have psychotic features during either depressive or manic episodes
Diagnostic Criteria for
Bipolar II Disorder
1) At least 1 major depressive episode
2) At least 1 hypomanic episode (manic episode excludes)
Diagnostic Criteria for
Rapid cycling
4 or more manic episodes within 1 year
Diagnostic Criteria for
Dysthymic disorder (3)
1) Depressed mood for the majority of time of most days for 2 years (in children 1 year)
2) 2 of the following: Poor concentration, hopelessness, poor appetite or overeating, insomnia or hypersomnia, low energy, low self-esteem
3) No euthymia of more than 2 months, and no major depressive episode or (hypo)manic episode
Diagnostic Criteria for
Double Depression
Dysthymic disorder punctuated by major depressive episodes
Diagnostic Criteria for
Cyclothymic disorder
1) Numerous periods with hypomanic symptoms and periods with depressive symptoms for at least 2 years
2) No symptom free period greater than 2 years
Diagnostic Criteria for
Minor Depressive disorder
Chronic euthymia punctuated by periods of depressive symptoms that do not meet Major Depressive episode
Sx of anxiety
Palpitations
Perspiration
Dizziness
Mydriasis (pupil dilation)
GI discomfort
Urinary frequency and urgency
Diagnostic Criteria for
Panic Attack (6)
PANICS
Palpitations
Abdominal discomfort
Numbness/Nausea
Intense fear of death
Choking, Chills, Chest pain
Sweating, Shaking, SOB
Diagnostic Criteria for
Panic Disorder (2)
1) Spontaneous recurrent panic attacks with no obvious precipitant
2) At least 1 month of persistent concern about having additional attacks, a significant change in behavior related to attacks
Must specify with or without Agoraphobia
3 common substances that exacerbate anxiety
Caffeine
Nicotine
Marijuana
Tx for
Panic Disorder
Paroxetine (Paxil)
or
Sertraline (Zoloft)
Benzos acutely (better than beta blockers)
Diagnostic Criteria for
Agoraphobia (2)
1) Anxiety about being in places from which escape is difficult or where help is not readily available
2) Above are avoided, endured with severe distress, or with a companion
Diagnostic Criteria for
Specific Phobia
1) Excessive fear brought on by specific situation or object
2) Exposure to situation or object brings about an immediate anxiety response
3) Pt recognizes fear is excessive
4) Situation is avoided or endured with severe anxiety
5) If pt less than 18, duration must be at least 6 months
Diagnostic Criteria for
Social Phobia
A specific phobia to social settings in which the pt might be embarrassed or humiliated in front of other people
Tx for
Specific Phobia
Systematic desensitization
(Beta blockers or benzos acutely in early desensitization)
Tx for
Social Phobia
Paroxetine


Beta-blockers for performance anxiety
CBT useful adjunct
Diagnostic Criteria for
Obsessive-Compulsive disorder
1) Either obsessions or compulsions
a. Obsessions:
i. Recurrent and persistent intrusive thoughts thoughts or impulses
ii. Attempts to suppress thoughts
iii. Pt realizes thoughts are of own making
b. Compulsions
i. Repetitive behaviors that reduce distress from obsession, but no realistic link between behavior and distress
2. Pt has insight that obsessions and compulsions are unreasonable and excessive
3. Obsessions are distressful, time consuming, or significantly interfere with daily functioning
Common obsessions and compulsions:
1) Contamination and washing
2) Doubt and rechecking
3) Symmetry
4) Intrusive thoughts wihtout compulsions
.
Tx for
OCD
High dose SSRI
Diagnostic Criteria for
Posttraumatic Stress disorder (6)
1) Having experienced or witnessed a traumatic event.
2) Persistent reexperiencing of event (dreams, flashbacks, recurrent recollections)
3) Avoidance of stimuli associated with event
4) Numbing of responsiveness (diminished affect)
5) Persistent increased arousal (difficulty sleeping, anger, startle response, difficulty concentrating)
6) At least 1 month duration of sx
Diagnostic Criteria for
Acute Stress disorder
PTSD sx that last last than 1 month after event
Diagnostic Criteria for
Generalized Anxiety disorder (3)
1) Excessive anxiety and worry about daily events and activities for at least 6 months most days of the week
2) Difficult to control the worry
3) At least 3 of : Restlessness, Fatigue, Difficulty concentrating, Irritability, Muscle tension, Sleep disturbance
Diagnostic Criteria for
Adjustment disorder
1) Emotional or behavioral sx within 3 months of a stressful event that is not life threatening (i.e. divorce):
a. Abnormally elevated distress that impairs daily functioning
2) Not bereavement
3) Last no longer than 6 months after event
Diagnostic Criteria for
Personality Disorder
1) Pattern and behavior/inner experience that deviates from the person's culture and is manifested in two or more of the following ways:
1. Cognition
2. Affect
3. Personal relations
4. Impulse control
2) The pattern:
1. Is Pervasive and inflexible in a broad range of situations
2. Is Stable and has an onset no later than adolescence or early adulthood
3. Leads to significant distress in functioning
4. Is not accounted for by another mental/medical illness or by substance use
Diagnostic Criteria for
Paranoid Personality Disorder
General distrust of others with 4 or more of the following:
1) Suspicion without evidence that others are exploiting or deceiving him or her
2) Preoccupation with doubts of loyalty or trustworthiness of acquaintances
3) Reluctance to confide in others
4) Interpretation of benign remarks as threatening or demeaning
5) Persistence of grudges
6) Perception of attacks on his or her character that are not apparent to others; quick to counterattack
7) Recurrence of suspicions regarding fidelity of spouse or lover
No fixed delusions or frank hallucinations
Diagnostic Criteria for
Schizoid Personality Disorder
A pattern of voluntary social withdrawal and restricted range of emotional expression with 4 or more of the following:
1) Neither enjoying nor desiring close relationships (including family)
2) Generally choosing solitary activities
3) Little if any interest in sexual activity
4) Taking pleasure in few or no activities
5) Few or no close friends or confidants
6) Indifference to praise or criticism
7) Emotional coldness, detachment, or flattened affect
Diagnostic Criteria for
Schizotypal Personality Disorder
Eccentric behavior, cognitive or perceptual distortions, and discomfort with close relationships with 5 or more of the following:
1) Ideas of reference
2) Odd beliefs or magical thinking, inconsistent with cultural norms
3) Unusual perceptual experiences (e.g. bodily illusions)
4) Suspiciousness
5) Inappropriate or restricted affect
6) Odd or eccentric appearance or behavior
7) Few close friends or confidants
8) Odd thinking or speech
9) Excessive social anxiety
Diagnostic Criteria for
Antisocial Personality Disorder
Disregard for others for others and violation of the rights of others since before age 15 with hx of conduct d/o. Pt must be 18 with 3 or more of the following:
1) Failure to conform to social norms by committing unlawful acts
2) Deceitfullness/repeated lying/manipulating others for personal gain
3) Impulsivity/failure to plan ahead
4) Irritability and aggressiveness/repeated fights or assaults
5) Recklessness and disregard for safety of self or others
6) Irresponsibility/failure to sustain work or honor financial obligations
7) Lack of remorse for actions
Diagnostic Criteria for
Borderline Personality Disorder
5 of the following: IMPULSIVE
Impulsive
Moody
Paranoid under stress
Unstable self image
Labile, intense relationships
Suicidal
Inappropriate anger
Vulnerable to abandonment
Emptiness
Diagnostic Criteria for
Histrionic Personality Disorder
Excessive emotionality and attention seeking with 5 of the following:
1) Uncomfortable when not center of attention
2) Inappropriately seductive or provocative behavior
3) Uses physical appearance to draw attention to oneself
4) Has speech that is impressionistic and lacking in detail
5) Theatrical and exaggerated expression of emotion
6) Easily influenced by others or situation
7) Perceives relationships as more intimate than they actually are
Diagnostic Criteria for
Borderline Personality Disorder
5 of the following: IMPULSIVE
Impulsive
Moody
Paranoid under stress
Unstable self image
Labile, intense relationships
Suicidal
Inappropriate anger
Vulnerable to abandonment
Emptiness
Diagnostic Criteria for
Narcissistic Personality Disorder
Grandiosity, need for admiration, lack of empathy with 5 of the following:
1) Exaggerated sense of self-importance
2) Preoccupied with fantasies of unlimited money, success, brilliance, etc.
3) Believes that he or she is special or unique and can associate only with other high status individuals
4) Needs excessive admiration
5) Has sense of entitlement
6) Takes advantage of others for self-gain
7) Lacks empathy
8) Envious of others or believes others are envious of him or her
9) Arrogant or haughty
Diagnostic Criteria for
Histrionic Personality Disorder
Excessive emotionality and attention seeking with 5 of the following:
1) Uncomfortable when not center of attention
2) Inappropriately seductive or provocative behavior
3) Uses physical appearance to draw attention to oneself
4) Has speech that is impressionistic and lacking in detail
5) Theatrical and exaggerated expression of emotion
6) Easily influenced by others or situation
7) Perceives relationships as more intimate than they actually are
Diagnostic Criteria for
Avoidant Personality Disorder
Social inhibition, hypersensitivity, and feelings of inadequacy with 4 of the following:
1) Avoids occupation that involves interpersonal contact due to a fear of criticism and rejection
2) Unwilling to interact unless certain of being liked
3) Cautious of intrapersonal relationships
4) Preoccupied with being criticized or rejected in social situations
5) Inhibited in new social situations because he or she feels inadequate
6) Believes he or she is socially inept and inferior
7) Reluctant to engage in new activities for fear of embarrassment
Diagnostic Criteria for
Narcissistic Personality Disorder
Grandiosity, need for admiration, lack of empathy with 5 of the following:
1) Exaggerated sense of self-importance
2) Preoccupied with fantasies of unlimited money, success, brilliance, etc.
3) Believes that he or she is special or unique and can associate only with other high status individuals
4) Needs excessive admiration
5) Has sense of entitlement
6) Takes advantage of others for self-gain
7) Lacks empathy
8) Envious of others or believes others are envious of him or her
9) Arrogant or haughty
Diagnostic Criteria for
Dependent Personality Disorder
Submissive and clinging behavior due to excessive need to be taken care of with 5 of the following:
1) Difficulty making everyday decisions without reassurance from others
2) Needs others to assume responsibilities for most areas of his or her life
3) Cannot express disagreement because of fear of loss of approval
4) Difficulty initiating projects because of lack of self-confidence
5) Goes to excessive lengths to obtain support from others
6) Feels helpless when alone
7) Urgently seeks another relationship when one ends
8) Preoccupied with fear of being left to take care of self
Diagnostic Criteria for
Avoidant Personality Disorder
Social inhibition, hypersensitivity, and feelings of inadequacy with 4 of the following:
1) Avoids occupation that involves interpersonal contact due to a fear of criticism and rejection
2) Unwilling to interact unless certain of being liked
3) Cautious of intrapersonal relationships
4) Preoccupied with being criticized or rejected in social situations
5) Inhibited in new social situations because he or she feels inadequate
6) Believes he or she is socially inept and inferior
7) Reluctant to engage in new activities for fear of embarrassment
Diagnostic Criteria for
Obsessive-Compulsive Personality Disorder
Preoccupation with orderliness, control, and perfectionism at the expense of efficiency with 4 of the following:
1) Preoccupation with details, rules, lists, and organization such that the major point of the activity is lost
2) Perfectionism that is detrimental to the completion of task
3) Excessive devotion to work
4) Excessive conscientiousness and scrupulousness about morals and ethics
5) Will not delegate tasks
6) Unable to discard worthless objects
7) Miserly
8) Rigid and stubborn
OCD is ego-dystonic
OCPD is ego-systonic
Diagnostic Criteria for
Dependent Personality Disorder
Submissive and clinging behavior due to excessive need to be taken care of with 5 of the following:
1) Difficulty making everyday decisions without reassurance from others
2) Needs others to assume responsibilities for most areas of his or her life
3) Cannot express disagreement because of fear of loss of approval
4) Difficulty initiating projects because of lack of self-confidence
5) Goes to excessive lengths to obtain support from others
6) Feels helpless when alone
7) Urgently seeks another relationship when one ends
8) Preoccupied with fear of being left to take care of self
Diagnostic Criteria for
Obsessive-Compulsive Personality Disorder
Preoccupation with orderliness, control, and perfectionism at the expense of efficiency with 4 of the following:
1) Preoccupation with details, rules, lists, and organization such that the major point of the activity is lost
2) Perfectionism that is detrimental to the completion of task
3) Excessive devotion to work
4) Excessive conscientiousness and scrupulousness about morals and ethics
5) Will not delegate tasks
6) Unable to discard worthless objects
7) Miserly
8) Rigid and stubborn
OCD is ego-dystonic
OCPD is ego-systonic
Diagnostic Criteria for
Substance Abuse
Impairment or distress for at least 1 year with 1 of the following:
1) Failure to fulfill obligations at work, school, or home
2) Use in dangerous situations
3) Recurrent substance-related legal problems
4) Continued use despite social or interpersonal problems
Diagnostic Criteria for
Substance dependence (7)
3 in a 12 months period:
1) Tolerance
2) Withdrawal
3) Using substance more than originally intended
4) Desire or inability to cut down
5) Significant time spent getting, using, or recovering from substance
6) Decreased social, occupational, or recreational activities bc of use
7) Continued use despite subsequent physical or psychological problems
Tx for
Acute Alcohol intoxication (5)
1) Airway, breathing, circulation
2) FSG to r/o hypoglycemia
3) Thiamine to prevent wernicke's encephalopathy
4) Naloxone to reverse effects of any opioids
Dx
Insomnia, anxiety, tremor, irritability, anorexia, tachycardia, hyperreflexia, hypertension, fever, seizures, hallucinations, delirium
EtOH withdrawal
Timeline of EtOH withdrawal
Onset: 6-24 hours from last drink
DTs: with 72 hours
Tx for
EtOH withdrawal
1) Benzos
2) Thiamine, folic acid, and a multivitamin
3) Magnesium sulfate for postwithdrawal seizures
Dx
Ataxia, Confusion, Ocular abnormalities (nystagmus)
Wernicke's encephalopathy (thiamine Vit B12 deficiency)
Dx
Impaired recent memory, anterograde amnesia, confabulation
Korsakoff's syndrome (untreated Wernicke's encephalopathy of thiamine deficiency)
Dx
Nausea, dilated pupils, weight loss, psychomotor agitation, chills, and sweating.
Cocaine intoxication
Acute medical complications of cocaine intoxication (2)
MI (from vasospasm)
CVA
Tx for
Cocaine intoxication
1. Mild to moderate agitation
2. Severe agitation or psychosis
1. Mild to moderate agitation - Benzos
2. Severe agitation or psychosis - Haloperidol
Dx
Dysphoria, malaise, fatigue, depression, hunger, constricted pupils, vivid dreams, psychomotor agitation or retardation.
Cocaine withdrawal
Tx for
Cocaine withdrawal
Nothing
Diagnosis, withdrawal, and treatment of what drug class is identical to that of cocaine?
Amphetamines
Method of action of
PCP and Ketamine
NMDA (glutamate) antagonists and dopamine agonists
Dx
Recklessnes, impulsiveness, impaired judgment, assaultiveness, rotatory nystagmus, hypertension, tachycardia, muscle rigidity, and high tolerance to pain.
PCP or Ketamine intoxication
Dx
Rotatory nystagmus
PCP intoxication
Date rape drug
GHB
Dx
Drowsiness, slurred speech, incoordination, ataxia, mood lability, impaired judgment, nystagmus, respiratory depression.
Sedative or Hypnotic Intoxication
Tx for
Benzo intoxication (3)
1) ABCs
2) Activated charcoal
3) Flumazenil
Tx for
Barbiturate Intoxication (3)
1) ABCs
2) Activated charcoal
3) Sodium bicarb to alkalinize urine to promote renal excretion
Tx for
Benzo or barbiturate withdrawal (2)
1) Long acting benzo taper (CWA protocol)
2) Tegretol or Valproic acid for seizure control
Dx
Tachycardia, sweating, insomnia, anxiety, tremor, n/v, delirium, hallucinations.
Not EtOH related
Benzo or Barbiturate withdrawal
Dx
Drowsiness, n/v, constipation, slurred speech, constricted pupils, seizures, and respiratory depression.
Opiate intoxication
Difference between opiates and opioids
Opiates are naturally occuring (morphine), opioids are synthetic (fentanyl)
Tx for
Opiate intoxication
ABCs
Tx for
Opiate overdose
Naloxone
Tx for
Long term opiate dependence
Methadone or suboxone
What is the only opiate that dilates pupils?
Demerol (Meperidine)
"Demerol dilates pupils"
Dx
Dysphoria, insomnia, lacrimation, rhinorrhea, yawning, weakness, sweating, piloerection, n/v, fever, dilated pupils, muscle ache.
Opiate withdrawal
Tx for
Opiate withdrawal
Moderate -
Severe -
Moderate - Clonidine or Buprenorphine
Severe - Methadone taper
Dx
Perceptual changes, papillary dilation, tachycardia, tremors, incoordination, sweating, palpitations.
Hallucinogen intoxication
Tx for
Hallucinogen intoxication
Talking down pt, possibly antipsychotics
Dx
Euphoria, impaired coordination, mild tachycardia, conjunctival injection, dry mouth, increased appetite.
Marijuana intoxication
Dx
Impaired judgment, belligerence, impulsivity, perceptual disturbances, lethargy, nystagmus, tremor, muscle weakness, ataxia, slurred speech, euphoria, stupor, or coma.
Inhalant intoxication
Tx for
Inhalant intoxication
ABCs
Tx for
Marijuana intoxication
None
Dx
Anxiety, insomnia, twitching, rambling speech, flushed face, diuresis, GI discomfort, and restlessness.
Caffeine intoxication
Dx
Tinnitus, severe agitation, and cardiac arrhythmias.
Caffeine overdose
Dx
Headache, n/v, drowsiness, anxiety or depression.
Caffeine withdrawal
Dx
Improved attention, improved mood, decreased tension, insomnia, restlessness, anxiety, GI discomfort.
Nicotine intoxication
Dx
Craving, dysphoria, anxiety, increased appetite, irritability, insomnia.
Nicotine withdrawal
Minimum workup to exclude reversible causes of dementia (6)
15% of dementia
1) CBC
2) Panel 7
3) Thyroid function tests
4) RPR
5) B12 and folate
6) Brain CT or MRI
Dx
Dementia with stepwise increase in severity and focal neurological signs
Multi-infarct dementia
Dx study for
Multi-infarct dementia
Head CT/MRI
Dx
Dementia, cogwheel rigidity, resting tremor
Lewy body dementia or
Parkinson's disease
Dx
Dementia, atraxia, urinary incontinence, dilated cerebral ventricles
Normal pressure hydrocephalus
(Wild, wet, and wobbly)
Dx study for
Normal pressure hydrocephalus
Head CT/MRI
Dx
Dementia, obesity, coarse hair, constipation, cold intolerance
Hypothyroidism
Dx
Dementia, diminished position and vibration sensation, megaloblasts on CBC
Vitamin B12 deficiency
(Posterior column disease)
Dx
Dementia, tremor, abnormal liver function tests, Kayser-Fleischer rings
Wilson's disease
(Too much copper)
Dx
Dementia, diminished position and vibration sensation, Accomodation Response Present, response to light absent
Neurosyphilis
Argyll-Robertson pupils (Accomodation Response Present but response to light absent)
ARP, get it
Two types of delirium
Quiet delirium: Depressed, failure to thrive
Agitated: Pulling out lines, may be hallucinating
Tx for
Delirium
Quetiapine (seroquel) or
Haloperidol
Differential Diagnosis for
Delirium
AEIOU
Alcohol
Electrolytes
Iatrogenic (medications)
Oxygen hypoxia (bleeding, pulmonary cause)
Uremia/hepatic encephalopathy
Dx Criteria for
Alzheimer's Dementia (4)
Memory impairment plus 1:
1) Aphasia - Disorder of language affecting speech and understanding
2) Apraxia - Inability to perform purposeful movements
3) Agnosia - Inability to interpret sensations correctly (i.e. inability to recognise an object)
4) Diminished executive functioning - problems with planning, organizing, and abstracting
Neurophysiologic chagnes in
Alzheimer's Dementia (2)
1) Decreased ACh (due to loss of noradrenergic in Locus Ceruleus of brainstem)
2) Decreased Norepi (due to loss of cholinergic neurson in Basal Nucelus of Meynert)
Microscopic changes in
Alzheimer's Dementia
1) Senile plaques from amyloid Beta protein
2) Neurofibrillary tangles from Tau protein
Tx for
Early Alzheimer's Dementia
Donepezil (Aricept)
Cholinesterase inhibitor
Tx for
Anxiety in dementia
Low dose, short acting benzos
Tx for
Agitation or psychosis in dementia
Quetiapine
Dx Criteria for
Vascular Dementia (4)
Memory impairment with 1)
1) Aphasia
2) Apraxia
3) Agnosia
4) Diminished executive functioning
Dx Criteria for
Mild Cognitive Impairment
Normal daily function but abnormal memory functioning relative to age
Dx
Aphasia, apraxia, agnosia, with personality and behavior changes usually before memory impairments
Frontotemporal Dementia (Pick's Dementia)
Microscopic finding in
Frontotemporal Dementia
Pick bodies (tau protein)
Dx
Progressive dementia, bizare choreiform movements, muscular hypertonicity
Huntington's Disease
Dx
Bradykinesia, cogwheel rigidity, resting tremor, masked facies, shuffling gait, dysarthria
Parkinson's Disease
Neurophysiology of
Parkinson's Disease
Neuronal loss in Substantia Nigra causing decreased Dopamine to Basal Ganglia
Tx for
Parkinson's Disease
Levodopa and Carbidopa
Dx
Rapidly progressive dementia, 6-12 months after onset of sx, startle myoclonus and possibly ataxia and fasciculations.
Creutzfeld-Jakob
Dx Criteria for
Creutzfeld-Jakob
1) Rapidly progressive dementia
2) Periodic generalized sharp waves on EEG
3) At least 2 of:
a. Myoclonus
b. Cortical blindness
c. Ataxia, pyramidal signs, or EPS
d. Mutism
Tx
Normal Pressure Hydrocephalus
Shunt to decrease ICP
(Yes, contrary to name the pressure is elevated)
Dx
Delirium with hemiparesis or other focal neurological signs and symptoms
CVA or mass lesion
Dx
Delirium, elevated blood pressure, papilledema
Hypertensive encephalopathy
Dx
Delirium, dilated pupils, tachycardia
Drug intoxication
Dx
Delirium, fever, nuchal rigidity, photophobia
Meningitis
Dx
Delirium, tachycardia, tremor, thyromegaly
Thyrotoxicosis
Dx
Impairment of memory without other cognitive impairment or altered consciousness.
Amnestic disorder
(Hypoglycemia, CVA, seizure, MS, etc)
Dx
Decreased muscle mass/increased fat, decreased brain mass with enlarged ventricles, impaired vision and hearing, minor forgetfullness
Normal Aging
Stages of Dying (5)
1) Denial
2) Anger
3) Bargaining
4) Depression
5) Acceptance
Dx
Memory and cognitive impairment, emphasizes failures, no sundowning, patient has insight.
Pseudodementia
i.e. Depression in the elderly
Tx for
Depression in elderly
SSRIs
Tx for
Depression in elderly with insomnia and decreased appetite
Mirtazapine (Remeron)
Tx for
Depression in elderly on top of SSRI for psychomotor retardation
Methylphenidate
Criteria for grief to be pathological (4)
1) Weight loss
2) Hallucinations or delusions (not illusions)
3) Suicidal ideation
4) Sx for more than 1 year
Dx Criteria for
Mental Retardation
1) IQ less than 70
2) Onset before 18
Dx Criteria for
Learning Disorder
Lower than expected achievement in reading, math, or writing than would be expected given age, level of education, and level of intelligence.
Dx Criteria for
Conduct Disorder
Violation of the basic rights of others with 3:
1) Aggression towards people or animals
2) Destruction of property
3) Deceitfulness
4) Serious violation of rules or laws
Dx Criteria for
Oppositional Defiant Disorder
6 months of negativistic, hostile, defiant behavior with 4:
1) Frequent loss of temper
2) Arguments with adults
3) Deliberately annoying people
4) Easily annoyed
5) Anger and resentment
6) Blaming others for mistakes or misbehaviors
Difference between ODD and Conduct Disorder
ODD does not violate the basic rights of others and children frequently get along with peers but not with authority figures.
Dx Criteria for
ADHD (2)
1) 6 Sx of inattentiveness, hyperactivity, or both for at least 6 months
2) Onset before 7
Dx Criteria for
Autism
6 of:
1) Impairment in nonverbal behaviors (facial expressions etc)
2) Failure to develop peer relationships
3) Failure to seek enjoyment from others
4) Lack of social or emotional reciprocity
5) Lack of or delayed speech
6) Repetitive use of language
7) No imaginative play
8) Inflexible rituals
9)Repetitive movements
10) Preoccupation with parts of objects
Dx Criteria for
Asperger's Disorder
Autism without language delays
Dx
Diminished head circumference, stereotyped hand movements, cognitive development halted at 1 year, girl
Rett's syndrome
Dx Criteria for
Disintegrative Disorder
1) Normal development in first 2 years
2) Loss of acquired skills in at least two of: Language, social skills, bowel or bladder control, play, motor skills
3) At least 2: Impaired social interaction, impaired use of language, restricted, repetitive, and stereotyped behaviors and interests
Dx
Multiple daily motor and vocal tics with onset before 18.
Tourette's Disorder
Otherwise a motor or vocal tic in isolation
Dx
Bedwetting
Enuresis
Tx for
Enuresis
Antidiuretics or TCAs
Dx
Inappropriate bowel movements for 3 months at least once a month
Encopresis
Dx
Inability to recall important personal information usually involving a traumatic or stressful event, but can remember obscure details
Dissociative Amnesia
Dx
Sudden, unexpected travel away from home, accompanied by the inability to recall parts of one's past or identity, usually undertaking a new identity and having no insight.
Dissociative Fugue
Usually only lasts a few days, pt will not remember fugue episode
Dx Criteria for
Dissociative Identity Disorder (Multiple Personality Disorder)
1) Presence of two or more distinct identities which consistently overtake the person's behavior
2) Inability to recall personal information of one personality when the other is dominant
Dx
Persistent or recurrent feelings of detachments from one's self, environment, or social situation. Out of body experiences.
Depersonalization Disorder
Tx for
Depersonalization Disorder
SSRI
Difference between primary and secondary gain
Primary gain - Expression of unacceptable feelings as physical symptoms in order to avoid facing them.
Secondary gain - Use of symptoms to benefit the patient, money, meds, or worker comp, etc.
What is a somatoform disorder?
Patients with physical symptoms that have no organic cause. The patient's pain is real and is not faking (which would be malingering).
Dx
Multiple vague complaints involving many organ systems without an underlying organic cause and resistant to psychiatric referral.
Somatization disorder
Dx
Patient initiates or exacerbates a true neurological symptom bc of a psychological symptom. Examples include shifting paralysis, blindness, mutism, paresthesias, seizures. Usually spontaneously recover.
Conversion Disorder
Dx
Prolonged, exaggerated concern about health and potential illness.
Hypochondriasis
Pts with hypochondriasis worry about having disease, whereas pts with somatization disorder complain about the symptoms.
Dx
Preoccupied with body parts that they deem as ugly or unsightly but which are normal.
Body Dysmorphic Disorder
Tx for
Body Dysmorphic Disorder
SSRIs
Dx
Prolonged, severe discomfort, usually co-existent with a medial condition but not directly caused by it.
Pain Disorder
Dx
Intentional feigning or artificially causing of medical symptoms in order to assume role of sick patient
Factitious Disorder
(Munchhausen Syndrome)
Munchhausen can be by proxy if you force your kid to be sick role
Dx
Feigning of physical or psychological symptoms for personal gain.
Malingering

Different than Factitious in that factitious has no obvious external reward
Dx
Failure to resist aggressive impulses that result in assault or property destruction
Intermittent Explosive Disorder
Dx
Urge to steal when not needed for personal use.
Kleptomania
Dx
Intentional fire setting not for monetary gain, or expression of anger.
Pyromania
Dx
Recurrent pulling out of one's hair.
Trichotillomania
Dx Criteria for
Anorexia Nervosa (3)
1) Body weight less than 85% ideal
2) Intense fear of gaining weight or being fat
3) Disturbed body image
Indication for inpatient treatment of Anorexia (3)
1) Electrolyte disturbances
2) Less than 80% ideal body weight
3) Arrhythmias
Dx Criteria for
Bulimia Nervosa (3)
1) Recurrent episodes of binge eating
2) Compensating behavior
3) Binge and compensation happen sx per week for 3 months
Dx Criteria for
Binge Eating Disorder
1) Recurrent binge eating
2) Severe distress over binging
3) Binging 2x/week for 6 months
4) Fast, full, furtively, fallen (feeling disgusted)
Difference between Dyssomnias and Parasomnias
Dyssomnias - disturbances in amount, quality, or timing of sleep
Parasomnias - Abnormal events in behavior or physiology during sleep
Dx
Difficulty initiating or maintaining sleep resulting in daytime drowsiness or difficulty fulfilling tasks.
Primary Insomnia
Tx for
Primary Insomnia
Sleep hygiene
Meds: Benadryl, Zolpidem, Zaleplon, Trazodone
Dx
At least 1 month of excessive daytime sleepiness or excessive sleep.
Primary Hypersomnia
Dx
1) Cataplexy - collapse due to loss of muscle tone associated with emotion especially laughter (70% of pts)
2) Short REM latency
3) Brief paralysis upon awakening (50%)
4) Hypnagogic (falling asleep), or hyponopompic (waking up) hallucinations (30%)
Narcolepsy
Tx for
Narcolepsy (2)
Timed daily naps plus stimulants
SSRIs for cataplexy
Dx
HAs, depression, pulmonary HTN
Breathing Related Sleep Disorder
Dx
Disturbance due to circadian sleep wake cycles
Circadian Rhythm Sleep Disorder
Dx
Repeated awakenings from REM with recall of extremely frightening dreams that causes significant distress
Nightmare Disorder
Dx
Repeated episodes of fearfullness during early hours of sleep from which patient does not awaken.
Night Terror Disorder
Dx
Repeated episodes of ambulation or other activity while sleeping that are not remembered.
Somnambulism
Neurotransmitters in libido
Dopamine increases libido (antipsychotics are inhibitory)
Serotonin decreases libido (SSRIs are inhibitory)
Dx
Absence or deficiency of sexual desires or fantasies
Hypoactive sexual desire disorder
Dx
Avoidance of sexual contact with a sexual partner
Sexual aversion disorder
Dx
Inability to attain an erection
Male Erectile Disorder (primary if never in life; secondary if lost the ability)
Dx
Inability to maintain lubrication until completion of sex act (33% of women)
Female Sexual Arousal Disorder
Dx
Inability to achieve orgasm
Orgasmic disorder (30% of women)
Dx
Genital pain before, during, or after intercourse
Dyspareunia
Dx
Involuntary muscle contraction of the outer third of vagina upon insertion
Vaginismus
Dx
Sexual preference for inanimate objects
Fetishism
Dx
Sexual gratification from wearing opposite gender's clothing
Transvestic Fetishism
Dx
Sexual pleasure in rubbing genitals against unsuspecting people
Frotteurism
Dx
Sexual excitement from being humiliated or beaten
Masochism
Dx
Sexual excitement from hurting or humiliating others
Sadism
Dx
Sexual excitement form calling unsuspecting strangers and engaging in sexual conversations
Telephone scatalogia
Dx
Subjective feeling the patient was born the wrong sex.
Gender Identity Disorder (aka Transsexuality)
What are the Mature Defense
Mechanisms? (4)
HASS
Humor
Altruism
Sublimation
Suppression
What are the Neurotic Defense Mechanisms? (7)
CDI2R3
Controlling - regulating situations
Displacement - Shifting emotions from situation or person to another
Intellectualization -
Isolation of Affect - Unconsciously limiting the experience of feeling or emotions associated with a stressful life event
Rationalization - Conjuring explanations of an event in order to justify outcomes or behaviors
Reaction Formation - Doing the opposite of an unacceptable impulse
Repression - Preventing a thought or feeling from entering unconscious (repression in unconscious whereas suppression is conscious)
What are the Immature Defense Mechanisms? (4)
DRAP
Denial
Regression - to an earlier state of development
Acting Out - Giving in to impulse in order to avoid anxiety of suppressing it
Projection - Attributing one's own objectionable thoughts or emotions to others (Claiming other people have acted on your impulses)
Other defense mechanisms (2)
Splitting
Undoing - attempting to reverse situation by doing a new behavior
Elements of informed consent (4)
1) Name and purpose of treatment
2) Potential risks and benefits
3) Alternatives to the treatment
4) Consequences of refusing the treatment
Requirements to be not guilty by insanity (3)
1) Have a mental illness
2) Not understand right from wrong
3) Not understand consequences of action at time of act
4 D's of malpractice
Dereliction of a Duty that lead Directly to Damages

Compensatory damages are reimbursement for expenses, lost income, or for physical suffering.
Punitive damages are reimbursements to the patient to punish the doctor for gross negligence or carelessness.
Citalopram
-Brand name
-MOA
-s/e
-Indications
-Brand name: Celexa
-MOA: SSRI
-s/e:
5HT2A/C: Anxiety, insomnia, sexual dysfunction
5HT3/4: GI upset
-Indications: Depression and Anxiety
Escitalopram
-Brand name
-MOA
-s/e
-Indications
-Brand name: Lexapro
-MOA: SSRI
-s/e:
5HT2A/C: Anxiety, insomnia, sexual dysfunction
5HT3/4: GI upset
-Indications: Depression and Anxiety
Fluoxetine
-Brand name
-MOA
-s/e
-Indications
-Brand name: Prozac
-MOA: SSRI
-s/e:
5HT2A/C: Anxiety, insomnia, sexual dysfunction
5HT3/4: GI upset
-Indications: Depression and Anxiety
Fluvoxamine
-Brand name
-MOA
-s/e
-Indications
-Brand name: Luvox
-MOA: SSRI
-s/e:
5HT2A/C: Anxiety, insomnia, sexual dysfunction
5HT3/4: GI upset
-Indications: Depression and Anxiety
Paroxetine
-Brand name
-MOA
-s/e
-Indications
-Brand name: Paxil
-MOA: SSRI
-s/e:
5HT2A/C: Anxiety, insomnia, sexual dysfunction
5HT3/4: GI upset
-Indications: Depression and Anxiety
Sertraline
-Brand name
-MOA
-s/e
-Indications
-Brand name: Zoloft
-MOA: SSRI
-s/e:
5HT2A/C: Anxiety, insomnia, sexual dysfunction
5HT3/4: GI upset
-Indications: Depression and Anxiety
Desipramine
-Brand name
-MOA
-s/e
-Indications
-Brand name: Norpramin
-MOA: SNRI
-s/e:
Anti-H: Sedation, weight gain
Anti-A: Orthostatic hypotension, dizziness, falls
Anti-M: Drymouth, sedation, constipation, urinary retention, blurry vision
Anti-Na channel: Arrhythmia
-Indications: Mood, Anxiety, Alertness
Method of action of TCAs
Serotonin and Norepinephrine reuptake inhibitors
Nortryptiline
-Brand name
-MOA
-s/e
-Brand name: Pamelor
-MOA: SNRI
-s/e:
Anti-H: Sedation, weight gain
Anti-A: Orthostatic hypotension, dizziness, falls
Anti-M: Drymouth, sedation, constipation, urinary retention, blurry vision
Anti-Na channel: Arrhythmia (prolonged QT)
-Indications: Mood, Anxiety, Alertness
Amoxapine
-Brand name
-MOA
-s/e
-Brand name: Asendin
-MOA: SNRI
-s/e:
Anti-H: Sedation, weight gain
Anti-A: Orthostatic hypotension, dizziness, falls
Anti-M: Drymouth, sedation, constipation, urinary retention, blurry vision
Anti-Na channel: Arrhythmia
-Indications: Mood, Anxiety, Alertness
Atomoxetine
-Brand name:
-MOA:
-s/e:
-Indications:
-Brand name: Strattera
-MOA: Selective Norepinephrine reuptake inhibitor
-s/e: Urinary retention
-Indications: Add to SSRI for Norepi profile
Reboxetine
-MOA:
-s/e:
-Indications:
-MOA: Selective Norepinephrine reuptake inhibitor
-s/e: Urinary retention
-Indications: Add to SSRI for Norepi profile
Venlafaxine
-Brand name:
-MOA:
-s/e:
-Indications:
-Brand name: Effexor
-MOA: SNRI
Low dose - mostly serotonin
High dose - mostly NE
-s/e: HTN
-Indications: Mood, Anxiety, Alertness
Phenelzine
-Brand name:
-MOA:
-s/e:
-Indications:
-Brand name: Nardil
-MOA: MAOI - Serotonin, NE, and Dopamine reuptake inhibitor
-s/e: Tyramine restriction, weight gain, sedation
-Indications: Mood
Tranylcyrpromide
-Brand name:
-MOA:
-s/e:
-Indications:
-Brand name: Parnate
-MOA: MAOI - Serotonin, NE, and Dopamine reuptake inhibitor
-s/e: Tyramine restriction, weight gain, sedation
-Indications: Mood
Isocarboxazid
-Brand name:
-MOA:
-s/e:
-Indications:
-Brand name: Marplan
-MOA: MAOI - Serotonin, NE, and Dopamine reuptake inhibitor
-s/e: Tyramine restriction, weight gain, sedation
-Indications: Mood
Mirtazapine
-Brand name:
-MOA:
-s/e:
-Indications:
-Brand name: Remeron
-MOA: Alpha 2 agonist causing increased Serotonin and NE, also blocks 5HT2A/C, H5T3, and 5HT4
-s/e: Sedation, weight gain (blocking 5HT2 relieves insomnia but causes sedation)
-Indications: Depression especially with weight loss or insomnia
Nafazodone
-Brand name:
-MOA:
-s/e:
-Indications:
-MOA: 5HT2 antagonist (which indirectly agonizes 5HT1)
-s/e:
-Indications: Depression, no sexual side effects
Trazodone
-Brand name:
-MOA:
-s/e:
-Indications:
-MOA: 5HT2 antagonist (which indirectly agonizes 5HT1)
-s/e: Priapism, weight gain and sedation
-Indications: Sleep aid, no sexual side effects
Bupropion
-Brand name:
-MOA:
-s/e:
-Indications:
-Brand name: Wellbutrin
-MOA: DNRI, Dopamine and NE reuptake inhibitor
-s/e: Seizures in anorexics with IR formula
-Indications: Add to SSRI to relieve sexual dysfunction, depression, ADHD, Cigarette cessation
Buspirone
-Brand name:
-MOA:
-s/e:
-Indications:
-Brand name: Buspar
-MOA: 5HT1A partial agonist, also increases amount of serotonin in neurons by improving recycling
-s/e: none
-Indications: GAD
Duloxetine
-Brand name:
-MOA:
-s/e:
-Indications:
-Brand name: Cymbalta
-MOA: TCA - 5HT and NE reuptake inhibitor
-s/e: Sedation, weight gain
-Indications: Depression and neuropathic pain
Tx for
Delirium
Haloperidol
(High potency has no effect on CV or respiratory drive; do not use low potency bc anti-ACh worsens delirium, lowers seizure threshold, and causes hypotension)
Tx for
Tourette's
Haloperidol
Clozaril
Brand name:
MOA:
s/e:
Special considerations:
Brand name: Clozapine
MOA: D2, 5HT2A, HAM antagonist
s/e: Wt gain, sedation, constipation, decreased seizure threshold tachycardia, hypotension
Special considerations:
a. Can cause Agranulocytosis! so bi-weekly CBCs
b. Increased salivaiton
Olanzapine
Brand name:
MOA:
s/e:
Special considerations:
Brand name: Zyprexa
MOA: Blocks D2, 5HT2A, HAM
s/e: Wt gain, diabetes, sedation, dizziness
Special considerations: Lots of weight gain, otherwise a great drug
Ziprasidone
Brand name:
MOA:
s/e:
Special considerations:
Brand name: Geodon
MOA: Blocks D2, 5HT2A, HA
s/e: Sedation, prolonged QTc
Special considerations: Least likely to cause weight gain
Risperidone
Brand name:
MOA:
s/e:
Special considerations:
Brand name: Risperdal
MOA: Blocks D2 and 5HT2A (the latter mitigates the EPS sx)
s/e: Galactorrhea, sexual dysfunction, hypotension, tachycardia, sedation, wt gain, insomnia, decreased concentration
Special considerations: Least anti-M activity
Quetiapine
Brand name:
MOA:
s/e:
Special considerations:
Brand name: Seroquel
MOA: Lower affinity for blocking D2 and 5HT2A, blocks HA
s/e: Sedation, hypotension, insomnia, dry mouth
Special considerations: 1st line atypical bc no EPS without blood draws. Less weight gain, no prolactin elevation.
Psychological test for
Depression and/or Anxiety
Beck Depression Inventory
Psychological test for
short term memory (as for ECT s/e)
Brown-Peterson Task
Psychological test for
ADLs in moderate to severe dementia
Geriatric Rating Scale
Psychological test for
Dementia (2)
Mini Mental Status Exam (MMSE)
or
Montreal Cognitive Assessment (MOCA)
Psychological test for
Level of consciousness
Glasgow Coma Scale
Psychological test which
Asks patient's friends and relatives about their functional ability in their current environment
Blessed Rating Scale
Which psychiatric illness can look like dementia in elderly patients?
Depression
(Pseudodementia)
What does the Wisconsin Cart Sorting Test?
And what disease is it useful for?
-Executive functioning (frontal lobe)
-Schizophrenics perform worse than normal as do people with frontal lobe damage
Indications for Draw a Person Test?
Brain damage
What does Bender Gestalt test indicate?
Organic causes of brain disease
Rorschach, Thematic Apperception Test, Sentence Completion Test, and Draw a Person test are all testing what?
Personality
Projective tests are based on activity.
Rorschach and Word Association Test -
TAT -
Draw a Person -
Sentence Completion Test -
Rorschach and Word Association Test - Associations
TAT - Construction
Draw a Person - Expression
Sentence Completion Test - Completion
What does the Stroop Test
Concentration
(reading words in different colors)
What does the Fargo Map test?
Recent and remote spatial memory (basically a geography test)
What does the Rey-Osterrieth test show?
Redrawing figure with picture and from memory to assess visual spatial nonverbal memory.

-Right parietal lesion -->ignore left part of picture
-Right temporal lesion --> no problems copying, but cannot redraw from memory
What does the Boston Diagnostic Aphasia Examination show?
Evaluate aphasic disorders and speech problems (i.e. after stroke)
What does the serial 7s or world backward test?
Concentration
A defense mechanism that uses elaborate and reassuring explanations that avoid the actual underlying motives.
Rationalization
A defense mechanism that deals with stressors by breaking down the usual integration of memory, behavior, and perception.
Dissociation
A defense mechanism that utilizes reflecting on one's own thoughts and behaviors with appropriate responses.
Self-observation
Something should be familiar but appears novel and unfamiliar
Jamais vu
Feeling that you have heard this before
Deja Entendu
Feeling that you have seen this before
Deja vu
A defense mechanism that utilizes the formation of thoughts that are opposite to the anxiety provoking feelings
Reaction formation
A defense mechanism that transfers a feeling toward an object or person that is less threatening.
Displacement
The recurrence of Sx after abrupt cessation.
Rebound
The long term return of the original symptoms
Recurrence
Test used to quantitate the Rorschach
Exner Comprehensive System
What does the Random Letter test?
Concentration, cooperation, and hearing
Test to determine prior to ECT the hemisphere in which Language is
Wada Test
(Inject sodium amytal to anesthetize hemispheres one at a time and look for aphasia)
What is the rate of teenage suicide attempts and who are more likely to succeed?
9% of all have attempted.
Boys 5x more likely than girls to succeed.
Most frequent suicide attempt method, and most frequent method of success?
OD is most common, but firearms are far more likely to succeed so account for more total deaths
Strategies for questioning
Do not use "but"
Express concern
Use an open ended question
In what sleep stage does sleep terror and sleep walking happen?
3 and 4 (not REM)
First line Tx for
MDD in children and adolescents?
SSRI
1st line Tx for
Bulimia Nervosa
CBT
Dx
Markedly limited vocabulary, tense errors, undeveloped sentences, interferes with academic function
Expressive Language Disorder
Dx study for suspected
Expressive language disorder
IQ test (to rule out mental retardation)
Dx
Baby not gaining weight after period of nl development, drooling a lot, lots of caretakers
Rumination disorder
Baby regurgitates and then chews on food
Dx study for
Rumination disorder
Esophageal pH measurement (to rule out gastric reflux)
Dx
Child does not like school, sleeps in parents bed, repeated physical sx at school
Separation anxiety disorder
Dx
Emotional concerns manifest as physical symptoms
Somatization (defense mechanism)
Dx
Repeated speaking of obscene words
Coprolalia (as in severe Tourette's)
Dx
Eating of feces
Coprophagia
Dx
Defense mechanism in which an unacceptable impulse is transformed into its opposite
Reaction Formation
Most common cause of psychosis in children?
Substance induced
Most common psychiatric emergency in children and adolescents?
Suicide
What axis is stuff that has psychological and environmental problems that affect the diagnosis, treatment, or prognosis of Axis I?
Axis IV
II is personality and MR
III is medical
V is GAF
Common differences in MDD in children and adolescents?
Kids have PMA
Teens have hypersomnia, hopelessness, weight change, and drug abuse.
s/e of
Antidiuretic hormone
Headache and nausea
Laboratory abnormality in antidiuretic use for enuresis
Hyponatremia
Comorbidity rate of anxiety disorders and MDD in children
-with ADHD
50%
ADHD = 30%
Tx for
Lead toxicity -
Iron toxicity -
Acetaminophen toxicity -
Lead toxicity - CaEDTA
Iron toxicity - Deferoxamine
Acetaminophen toxicity - Acetylcysteine
Dx
Deceleration of head growth, loss of hand skills, stereotyped hand movements, poor gait, and severely impaired expressive and receptive language development with PMR
Rett syndrome
Common associations with CD.
ADHD and substance abuse
Explain adjustment disorder
Happens after an event within 3 months but lasts no more than 6, looks like depression.
Tx for
Tourette's
Clonidine is first line
Haldol has better evidence but is now second line
Interview strategy for 7 yo boy
Play interview
Psychiatric illness should be aggressively treated in children with medical illness as it improves medical outcomes.
!
First sx in
Tourette's
Blinking and eye rolling first
then grunting, grimacing, and licking
Dx criteria for Tourette's
Multiple motor tics and at least one vocal tic before 18 yo
Most common time period for MR to develop
Early embryonic development (s'somal abnls and prenatal damage)
Dx criteria for
Disruptive behavior disorder NOS
Meets some but not enough criteria for CD or ODD and causes impairment
Which drugs can predispose to tics
Stimulants
Most commonly associated with learning disorders?
ADHD
High school drop out rate for learning disabled?
40%
Tx for
Enuresis
Imipramine
Efficacy of stimulants for ADHD
70%
Milestones:
Copy circle -
Age and gender, ride tricycle -
Copy square and identify hands -
Copy circle - 2
Age and gender, ride tricycle - 3
Copy square and identify hands - 5
Dx
Impaired social interactions and attachments, restricted interests and behaviors, impaired communication
Autism
Best prognostic indicator for Autism
Converse meaningfully with others
Dx
Hypercholesterolemia, hypercarotenemia (yellowing of skin), no change in TSH
Anorexia Nervosa
Dx
Increased ventricular brain ratios, sinus brady
Anorexia Nervosa
Stranger anxiety is normal and abnormal when?
Normal in 8 month old
Absently abnormal in autistics
Most helpful distinction between mania and ADHD in children?
ADHD kids have low self esteem as opposed to grandiosity
Age at which death can be appreciated
6-10 yo
Defense mechanism in which a thought, impulse or effect is transiently inhibited causing tension or distress
Blocking
Main s/e of Clonidine
Sedation
Tx for
ADHD with tics
Stimulants anyway
Is punishment useful at age 4?
No, good modeling will build moral code but right and wrong are not understood well enough for punishment
Tx for
Panic Disorder
SSRI
Process of adopting other people's characteristics
Identification
A defense mechanism in which emotions are shifted from one idea or object to another that resembles the original but evokes less distress
Displacement
A defense mechanism in which a person's character or sense of identity is temporarily but drastically modified in order to avoid emotional distress
Dissociation
Most vulnerable month of pregnancy for mental illness
1st
Consistent failure to speak a specific social situation despite speaking in other situations
Selective mutism
Most common abuser of children
The mother
Must have this before 15 yo
CD for Antisocial dx (must be at least 18)
Lab changes in Anorexia nervosa
1) High cholesterol
2) High corticotropin releasing hormone
3) Hypogylcemia
4) Hypothyroidism
5) Leukopenia
Inability to perform learned motor skills
Apraxia
Inability to recognize objects
Agnosia
Inability to name objects even after recognizing them
Anomia
Inability to read
Alexia
Inability to express or comprehend language
Aphasia
Infection associated with OCD and Tourette's
Group A Strep
(Sreptococcus)
Dx
Toxocara and viscereal larva migrans
Pica
Lab abnormalities in bulimia
1) Low K
2) Low Na
3) Low Cl
4) Metabolic alkalosis
Dx
Rectal bleeding and anemia
Stereotypic Movement Disorder
Most likely to abuse substances
CD
Dx
Chapped, erythematous hands
OCD
(from hand washing)
Dx study for trouble reading
Vision test
Dx
Girl reached normal early milestones but now does not speak anywhere
Rett
Dx
Trouble in school, avoids classmates, odd movements with hands
Autism
MR cut offs
Mild - 70-55
Moderate - 54-40
Severe - 39-25
Profound - Less than 25
Nihilistic Delusional Content
Cotard Syndrome
Believe people are replaced by imposters
Capgras Syndrome
Most common cause of postpartum psychosis
Bipolar disorder
Dx
Rapid mood swings, efforts to avoid abandonment, chronic feelings of emptiness, intense anger outbursts, impulsivity, fluctuations between idealization and devaluation, and recurrent self mutilation or suicidality.
BPD
Dx
Non bizarre delusion, high level of social and occupational functioning
Delusional disorder
Tx
Severe depression, poor response to many medications, and poor compliance despite attempts
ECT
What not to prescribe for bipolar disorder
Antidepressants (can cause mania)
but you can prescribe if predominantly depressed and carefully
What sleep disturbance is most common with depression
Early morning awakening
Lab results in depression (3)
Increased cortisol
Decreased catecholamines
Decreased immune function
Tx for
Cyclothymia
Same as for bipolar disorder
Risk of mood disorder in first degree relatives of bipolar people
25% for mood disorder
What must always be ruled out in mania?
Cocaine or other drug intoxication
Dx
Psychotic or mood symptoms with abdominal pain
Porphyria
Dx
Inpt visual hallucinations
Delirium
Risk of mood disorder if first degree relative has bipolar
25% for mood disorder
What must you rule out in mania?
Cocaine or other drug intoxication
Dx
Psychotic or mood symptoms with abdominal pain
Porphyria
Dx
Inpt with visual hallucinations
Delirium
Dx
Docility, lack of fear response, anterograde amnesia, hyperhapgia, hypersexuality
Kluver-Bucy
Area of Kluver bucy; aggression, sexual behavior, and fear responses
Amygdala (need bilateral damage for kluver bucy)
Area involved with complex auditory information like language
Superior temporal gyri
Dx
Binging and purging with less than 85% ideal body weight
Anorexia nervosa binging purging type
Lab abnormalities in anorexia (5)
1) Elevated BUN (from increased catabolism)
2) Increased cortisol
3) TSH and TRH normal
4) Anemia
5) Elevated growth hormone
What percentage of MDD patients respond to a dexamethasone challenge?
50%
Thryoid abnormality in MDD
No increased in TSH from TRH challenge (TRH insensitive in 30% of people)
Methadone does not cause bone decay or decreased libido
Despite popular belief
Tx for
Postpartum psychosis
Inpt hospitalization
s/e
Dry mouth, dizziness, urinary hesitancy
TCAs
Imipramine
s/e
GI upset, sexual dysfunction, agitation
SSRIs
s/e
Hypotension, less likely anticholinergic
MAOIs
(Phenelzine)
s/e
Polyuria, polydipsia, tremor, mental confusion
Li
s/e
GI upset, sedation, tremor
VPA
Dx
Hypointensities in subcortical areas
Lacunar Strokes
Dx
Cerebellar atrophy
Congenital disorder or
Alcoholism
Lab results in alcoholism (3)
1) Increased GGT
2) Increased uric acid, 2:1 AST:ALT
3) Macrocytic anemia
ddx between PTSD, Acute stress disorder, and Adjustment disorder
PTSD and ASD are the same except if it lasts 4 weeks or less it's ASD.
Adjustment disorder can be either anxiety, conduct, or mood, and must happen within 3 months of an event, that MUST be NON-TRAUMATIC
Suicide rates in schizophrenics and general
Schizophrenics - 10%
General - less than 1%
Feelings and attitudes originating from the treater evoked by the patient
Countertransferance
Is ECT indicated for psychosis
yes
ECT sessions for
Catatonia -
MDD -
Mania -
Permanent memory impairment -
Catatonia - 2-4
MDD - 6-12
Mania or Psychosis - 20 or more
Permanent memory impairment - 20-40
Tx for
OCD
SSRIs
1st line
Placebo efficacy for MDD
30% of pts respond
Pharmacotherapy efficacy for MDD
65-75% of patients will improve with SSRIs or TCAs
Dx
Predominance of motor behaviors and nonverbal forms of communication such as facial experessions in schizophrenia
Schizophrenia Catatonic type
Dx
Sexual pleasure from experiencing pain, no sexual dysfunction or marked distress
No diagnosis
Only pathological if it causes distress or occupational/social dysfunction
Dx
Repeated nightmares that cause distress but doesn't fit PTSD
Nightmare disorder
Dx
Excessive drowsiness and many hours sleeping
Primary hypersomnia
The risk of completed suicide in MDD is
10-15%
Tx for
PTSD
SSRIs
Tx for
Panic Disorder
SSRI with CBT
Mean age of onset for bipolar disorder
30
Infarcts of the Left middle cerebral artery to the left frontal hemisphere cause what?
Depression
Diffuse damage to bilateral frontal hemispheres leads to what?
OCD
Infarcts to the Right frontal hemisphere lead to what?
Euphoria, inappropriate indifference, or mania
In men under 50 what percentage of impotence is psychological?
90%
Neurotransmitter correlation in suiciders, violence, agrees, and impulsivity
Decreased 5-HIAA (a serotonin metabolite)
Dx
Diffuse white matter plaques affecting frontal lobes
MS (w/ depression)
Dx
Ventricular enlargment and cerebral atrophy
Alzheimer's dementia
Worst prognostic indicator for schizophrenia
Predominantly negative symptoms
Risk of schizophrenia with 1 or 2 parents
1 parent = 12%
2 parents = 40%
Dx
Short term memory deficits, smooth pursuit eye movement problems, decreased sensory habituation
Schizophrenia
Tx for
Passive suicidal ideation with recent plan
Inpt hospitalization
Risk factors for completed suicide
1) White
2) male
3) older
4) single
5) Protestant or jewish
Believing an event relates to you when it does not
Ideas of reference
Belief that thoughts from an external entity are placed in your mind
Thought insertion
Belief that one's body parts are diseased (like rotting)
Somatic delusion
Belief that others know what you are thinking
Thought broadcasting
Forgetting of time around a specific event
Localized amnesia
Forgetting of some aspects of an event, while remembering others
Selective amnesia
Forgetting everything before a certain event
Retrograde amnesia
(Generalized if they've forgotten no parts, but everything from before)
Forgetting all events following a trauma except immediate past
Continuous amnesia
RFs for Schizophrenia
Parent -
Both parents -
Identical twin -
Fraternal twin -
Sibling -
Parent - 12%
Both parents - 40%
Identical twin - 50%
Fraternal twin - 12%
Thought processes:
Circumstantial - superfluous details but gets there
Tangential - relevant but doesn't get there
Flight of ideas - Extreme tangentiality that birdwalks quickly
Loosening of assocations - series of disconnected ideas
Word salad - Completely disorganized
Dx
Epileptic like activity but with purposeful movements
Pseudoseizure (as seen in stress, personality disorders, or conversion reactions)
REM changes in depression
1) decresed REM latency
2) REM redistributed to first half of night
Transient loss of motor tone associated with strong emotions
Cataplexy
State of immobility seen in catatonic patients
Catalepsy
The belief that you have an exact counterpart
Doppleganger
Belief that you are poisoned by a spirit
Cacodemonomania
Ascribing of personal meaning or messages that are not intended
Delusion of reference
Belief that nothing exists, including the patient's body to the point that they feel they are rotting away
Cotard syndrome
The belief that a single person is impersonating everyone
Fregoli syndrome
Dx
Formication
Cocaine intoxication or
EtOH withdrawal
Slowed or absent movement
Akinesia
Mental activity no in accordance with reality
Dereism
Abnormal recall of events
Hypermnesia
Loss of memory without loss of ability to make new memories, usually associated with trauma
Dissociative Amnesia
Inability to recognize something by touch
Astereognosis
Uncontrollable or excessive talking as seen in mania
Logorrhea
Fluent fabrication of fictitious responses in response to memory problems
Confabulation
irregular pauses between syllables
Scanning speech
Stopping speech abruptly then picking up with a new topic
Derailment
The persistence of an image after it has been removed
Palinopsia
Areas of brain implicated in OCD (3)
Caudate nucleus
Frontal lobes
Cingulum
Describing things but not naming them
Circumlocution
Physical manifestations of underlying unconscious motivations or drives
Conversion disorder
Areas of brain implicated in Schizophrenia
(2)
Hippocampus
Amygdala
Area of brain involved in anxiety
Locus Ceruleus
NE made here
Dx
Tachycardia, flushing, fever, hypertension, ocular osscilations, and myoclonic jerks.
Serotonin syndrome
How long to wait after TCA to start SSRI
14 days
Where is serotonin made in brain
" " Ne
" " Dopamine
Raphe nucleus
Locus ceruleus
Substantia nigra
Dx
Ataxia, eye paralysis, nystagmus, confusion, anterograde amnesia
Wernicke's encephalopathy
(Vit B1 (thiamine) deficiency)
Dx
Anterograde amnesia, retrograde amnesia, confabulation, apathy, lack of insight
Korsakoff's Psychosis
You can get Wernicke's encephalopathy and Korsakoff psychosis together
Usually the delirium of wernicke masks the korsakoff but with thiamine treatment it becomes more apparent
If the delusion is short
-if non bizarre
-if bizarre
-if non bizarre - Delusional disorder
-if bizarre - brief psychotic episode
Greatest predictor of suicide
Age over 45 and mood disorder
Gluccocorticoids can cause what
Reversible psychiatric symptoms of depression and psychosis
Difficulty with simple math
Dyscalculia
Ability to speak a new language
Glossolalia
Repetitive and meaningless talk
Verbigeration
Tx for
MAOI caused autonomic excitability
IV Lorazepam
Contraindicated fro MAOIs
Stimulants
Decongestants
L-dopa
Reserpine
Dx
Hypersomnia, weight gain, mood reactivity
Atypical depression
Tx for
Atypical Depression
MAOI
(Phenelzine or Tranylcypromide)
Minimum trial period for an anti-depressant
6 weeks
Tx for
Delirium with liver disease
Lorazepam or oxazepam
(not metabolized by liver)
What do low potency anti-psychotics do to seizure threshold?
Lower it
Tx for
DTs
IV benzos
Why do SSRIs take so long
Time to downregulate the 5-HT2 receptor
Most common sexual side effect of SSRIs in women
Anorgasmia
Tx for
Akisthesia (walking a lot)
1) Reduce neuroleptic agent
2) Propanolol
Tx for
Acute dystonia
Diphenhydramine
Most serious complication of NMS
Rhabdo
s/e of
Thioridazine (typical antipsychotic)
Retinal pigmentation
Dx
Retinal pigmentation
Thioridazine
Tx for
Panic disorder
SSRIs, TCAs, or MAOIs
Most potent benzo
Clonazepam
Preliminary tests to start Li
1) Electrolytes, BUN, and UA bc Li is renally excreted
2) Thyroid studies bc Li inhibits thyroid production and release
3) CBC is optional bc of benign elevation in WBCs
Avoid NSAIDs with Li, switch to what?
Aspirin
Which nt to block in Tourette's
Dopamine
hence use
Tx for
Tourette's
Haloperidol is more potent
but Clonidine is first line bc no EPS or other s/e
Indication for
Busprirone
GAD
Pharmacotheraphy for
BPD
1) Fluoxetine 1st line
2) Add Antipsychotics (haloperidol or clozapine) for impulsiveness
3) Add VPA for mood fluctuations
Pharmacotheraphy for
Bulimia
Fluoxetine
Pharmacotherapy for
Anorexia
None indicated, appetite increasers don't work
Dx
Dizziness, n/v, fatigue, lethargy, flu like symptoms
Most commonly caused by -
Tx -
SSRI discontinuation syndrome
Most commonly caused by - Paroxetine (short half life)
Tx - Add back paroxetine and taper
Pharmacotherapy for
MDD with Carbamazepine for epilepsy
Paroxetine
(others increase carb levels)
What EKG abnormality does Li cause?
1) Benign T wave flattening or inversion
2) Then basically every arrhythmia under the sun
Which drugs increase Li levels?
(5)
1) Thiazide diuretics
2) Spironolactone
3) NSAIDs except asa and sulindac
4) Metronidazole and Tetracycline
5) ACE-Is
Pharmacotheraphy for
OCD
Clomipramine
(TCA with potent serotonin activity)
SSRIs are second line
How does gedon (ziprasidone work)
D2 and 5HT2a receptor blockade
Atypical antipsychotic
Tx for
Antipsychotic resistant psychosis
Why?
Clozaril
Has more blockade activity at D4 than D2, as well as 5HT2a blockade
Blocking what causes orthostatic hypotension
and what drugs do it
Blocking alpha-1
TCAs block it
Mitzapine does not, it blocks alpha-2
Tx for
SSRI resistant depression
Venlafaxine (SNRIs)
Congenital defects with mood stabilizers
Li -
VPA -
Carbamazepine -
Li - Ebstein valve anomaly
VPA - Neural tube defects
Carbamazepine - Neural tube defects
Tx for
Agitation in delirious old people
Risperidone or other atypical anti psychotics
(Benzos can paradoxically disinhibit, and diphenhydramine can worsen delirium with anticholinergic effects)
Tx for
MDD with anorexia and insomnia
Mertazapine
Avoid TCAs with which CV abnormalities
Heart block, wide QRS, BBB
Tx for
Delirium in elderly
Haloperdiol (least risk of orthostasis)
Tx for
Antipsychotic resistant psychosis
Why?
Clozaril
Has more blockade activity at D4 than D2, as well as 5HT2a blockade
Antipsychotic with least orthostatic effects
Haloperidol
Blocking what causes orthostatic hypotension
and what drugs do it
Blocking alpha-1
TCAs block it
Mitzapine does not, it blocks alpha-2
Tx for
PTSD
SSRIs
Tx for
SSRI resistant depression
Venlafaxine (SNRIs)
Congenital defects with mood stabilizers
Li -
VPA -
Carbamazepine -
Li - Ebstein valve anomaly
VPA - Neural tube defects
Carbamazepine - Neural tube defects
Tx for
Agitation in delirious old people
Risperidone or other atypical anti psychotics
(Benzos can paradoxically disinhibit, and diphenhydramine can worsen delirium with anticholinergic effects)
Tx for
MDD with anorexia and insomnia
Mertazapine
Avoid TCAs with which CV abnormalities
Heart block, wide QRS, BBB
Tx for
Delirium in elderly
Haloperdiol (least risk of orthostasis)
Antipsychotic with least orthostatic effects
Haloperidol
Tx for
PTSD
SSRIs
Pharmacotherapy for
Re-experiencing and hyperarousal acutely
Clonidine
Pharmacotherapy for
Alzheimer's
Donepezil (aricept)
Tx for
Unknown drug overdose of downers
Fluids, naloxone, and thiamine
Not flumazenil (lowers seizure threshold)
What do you use to detox from heroin
For 1st time detoxers - Clonidine
For repeated relapsers - Methadone
Tx for
MDD and smoking cessation
Bupropion
Tx for
Bipolar disorder with neuropathic pain
Gabapentin
s/e of Risperidone
Blocks 5HT2a, D2, alpha 1 so causes
Weight gain, orthostasis
How is Clozaril different than all the other atypicals
While atypicals have less EPS s/e than typicals, only clozaril has none. All the others cause EPS at high doses
Where do hallucinations happen in brain?
EPS symptoms?
Prolactin problems?
Mesolimbic system for hallucinations
Nigrostriatal system for EPS
Tuberoinfundibular for prolactin
Pharmacotherapy option for
Impotence
Yohimbine
Alpha-2 Receptor drugs
Mirtazapine - Alpha-2 Antagonist
(indirect 5HT1 agonist and NE agonist)
Clonidine - Alpha-2 Agonist
Yohimbine - Alpha-2 Antagonist (also increased NE)
Clozapine =
Clonazepam =
Clozapine = Clozaril the antipsychotic
Clonazepam = Klonopin the benzo
Mood stabilizer therapy during pregnancy
ECT is 1st line but rarely taken
(usually they keep on Li despite cardiac teratogenicity)
Which mood stabilizer causes pancreatitis?
VPA
Which antipsychotic causes hyperglycemia?
Clozapine
Which antipsychotic interacts with citalopram?
Pimozide
1st line Depot injection antipsychotic
Risperidone (bc atypical), the only other depot being haldol
Tx for
Unknown drug overdose of downers
Fluids, naloxone, and thiamine
Not flumazenil (lowers seizure threshold)
What do you use to detox from heroin
For 1st time detoxers - Clonidine
For repeated relapsers - Methadone
Tx for
MDD and smoking cessation
Bupropion
Tx for
Bipolar disorder with neuropathic pain
Gabapentin
s/e of Risperidone
Blocks 5HT2a, D2, alpha 1 so causes
Weight gain, orthostasis
How is Clozaril different than all the other atypicals
While atypicals have less EPS s/e than typicals, only clozaril has none. All the others cause EPS at high doses
Pharmacotherapy for
Re-experiencing and hyperarousal acutely
Clonidine
Pharmacotherapy for
Alzheimer's
Donepezil (aricept)
Which drug causes nephrogenic diabetes insipidus?
Li (causes pissing)
Which antipsychotic has highest risk of metabolic syndrome?
Olanzapine
Minimum and recommended trial length for first antidepressant in life
6 month minimum with
10 month recommendation
Tx for
Sialorrhea from clozapine
Propylthiouracil
Tx for
Clozapine induced tachycardia
Propanolol (not labetalol which can exacerbate hypotension)
Contraindications for ECT (2)
1) Recent MI
2) Brain occupying lesion (brain stem herniation risk)
Only antipsychotic known to decrease suicidality in schizophrenia?
Clozapine
Aplastic anemia is a s/e of what?
Carbamazepine
HTN is a s/e of what?
Venlafaxine
Opisthotonos -
Pleurothotonos -
Torticollis -
Oculogyric crisis -
Laryngospasm -
Opisthotonos -
Pleurothotonos - Arching of back
Torticollis - SCM spasm pulling neck to one side
Oculogyric crisis - Spasm of extraocular muscle
Laryngospasm - Spasm of tongue or throat, can lead to respiratory distress
Antidepressant that works for diabetic neuropathy
Duloxetine (an SNRI)
Spasm of the eyelid
Blepharospasm
Rapid movement of the lips is an EPS s/e called?
Rabbit syndrome
Orthostatic hypotension is caused by blockade of what?
Alpha1
Dx
Yellow skin with chlorpromazine
Obstructive jaundice
Dx
Lack of ejaculation on antipsychotics
Retrograde ejaculation (not anorgasmia like with SSRIs)
When does alcohol withdrawal strike?
48-96 hours
Alcohol and benzos agonize which GABA receptor?
GABA-A
MAOIs increase NE, 5HT, and DA.
What is A and B
MAO-A = 5HT and NE
MAO-B = DA (antiparkinson)
What cardiac effect do TCAs have?
Torsades de pointes
Special TCA indications:
Pain syndromes -
OCD -
Enuresis -
Elderly Depression -
Pain syndromes - Amytriptyline
OCD - Clomipramine
Enuresis - Imipramine
Elderly Depression - Nortriptyline
Useful as adjunctive therapy for depression.
Buspirone (partial 5HT1 agonist)
Also Bupropion
Fatal s/e of
Nefazadone
Fatal hepatitis
Lithium
Range:
S/e:
Teratogenicity:
Range: 0.8-1.0
S/e: Neurotoxicity, hypothyroid, diabetes insipidus, leukocytosis, GI
Teratogenicity:Ebsteins anomaly
Carbamazepine (Tegretol)
Range:
S/e:
Teratogenicity:
Range: 8-12
S/e: Autoinducer at liver (VPA will decrease with acclimation in a few weeks), SJ rash, Aplastic anemia
Teratogenicity:Craniofacial defect
Valproate
Range:
S/e:
Teratogenicity:
Range: 80-120
S/e: Heptatitis, aplastic anemia, sedation, weight gain
Teratogenicity: Neural tube defect
Lamotrigine (Lamictal)
Range:
S/e:
Teratogenicity:
S/e: SJ RASH is big
Teratogenicity:
Tx for Opiate withdrawal
Methadone, suboxone, buphrenorphine, naltrexone/naloxone
Alcohol withdrawal therapy
Acamprosate (decrease glutamate response)
Naltrexone
Disulfiram
Dementia Tx meds
Donepezil (ACh-esterase inhibitor)
Memantine (NMDA receptor antagonist)
Specific to
Olanzapine
Worst metabolic side effects, sedating.
Must be combined with fluoxetine for mood stabilization.
Specific to
Risperidone
Most typical of the atypicals, available in dec shot
Specific to
Seroquel
Extremely sedating, causes orthostasis
Specific to
Ziprasidone
QT prolongation issue
Specific to
Aripiprazole
Partial DA agonist (even though anti-psychotic), weakest of all
Specific to
Clozapine
Aplastic anemia (agranulocytosis), seizures, cardiomyopathy, hypotension,
Only antipsychotic to decrease suicide with Li
Depression, agoraphobia, GAD, and substance abuse are associated with what?
Panic Disorder
Requirements for panic disorder
3 attacks in 3 weeks
No stimulus
Peak of sx within 10 minutes
Mgmt
Adolescent with change in behavior
Drug screen
Mgmt
Refractory mania on a mood stabilizer
Blood levels of mood stabilizer
Dx
Sudden onset neurological complains with obvious stressor
Conversion disorder
Dx
Impaired sleep, poor concentration, easy fatigability, irritability, muscle tension
GAD
1st line therapy for
Tourette's
Pimozide or
Haloperidol
Tx for
Anorexia nervosa
1) If under 75% body weight --> hospitalize
2) CBT is helpful
3) SSRIs for weight maintenance, depression, and binging/purging
Dx
Auditory, visual hallucinations, with normal vital signs and intact sensorium
Alcoholic hallucinosis
Cannot make acute psychotic episode dx if drugs or alcohol are likely contributors to symptoms
!
When to stop Li for young people with manic episodes?
1 manic episode - 1 year of Li then taper off
3 or more manic episodes - Lifelong Li
Risks of pregnancy with current or previous dx of anorexia (5)
1) Miscarriage
2) Intrauterine growth retardation
3) Premature birth
4) C section
5) Post partum depression
Common findings in Anorexia (6)
1) Osteoperosis
2) Elevated cholesterol and carotene levels
3) Prlonged QT
4) Euthyroid sick syndrome
5) Anovulation, amenhorrhea, and low estrogen
6) Hyponatremia from excess water drinking
Dx
Loss of normal skills after 2 years in language, social, sphincter control, or motor skills
Childhood disintegrative disorder
(looks like autism, except autistics have sx before age 3 always if observed properly)
Mgmt
Suicidal patient who doesn't want inpt, and neither do parents
Hospitalize anyway
1st line Tx for
Enuresis
Desmopressin
Difference between adjustment d/o and normal human life with mild depressive sx to a stressor
If affects level of functioning than adjustment disorder
Dx
Replacing a less disturbing view of the world in place of reality to ease distress
Fantasy (defense mechanism)
Tx for
Somatization disorder
Frequent regularly scheduled visits with their PCPs to reduce underlying psychological distress
Monitoring for all atypicals
Weight, glucose, and lipids
and BP
Defense mechanism in which a person assimilates another person's attitudes into one's own perspective
Introjection
Defense mechanism in which a person expresses his aggression toward another person with repeated failures to meet the other person's needs
Passive-aggressive
Difference between PCP and LSD intoxication
LSD has more visual hallucinations and intensified perceptions
While PCP has more aggression
Tx for
Bipolar w/ renal insufficiency
VPA or Carbamazepine
Associations with Tourette's (2)
ADHD and OCD
Attributing excessive negative qualities to another
Devaluation
Process by which repressed material particularly painful kinds are brought back to consciousness
Abreaction
Process of disclosing suppressed feelings, ideas, or events to other group members
Ventilation
similar to catharsis without the emotional overtones both before or after
Hypnosis should not be used in which disorders?
Psychosis
Systematic desensitization uses what?
Reciprocal inhibition
Dx
Abducent nerve palsy, nystagmus, ataxia, global confusion
Cause?
Wernicke's encephalopathy
caused by thiamine (B1 deficiency)
Dx study for suspected
Wernicke's encephalopathy
Head CT
Mgmt for
Command hallucinations
Inpt hospitalization
Fatal part of alcohol withdrawal
Seizures
Tx for
Agitation in delirious elderly patient
Low dose haldol
(Anticholinergics and lose potency typicals exacerbate delirium)
Benzos cause paradoxical inhibition
Dx
Complaints with at least one pain and one neurological
Somatization disorder
Tx for
MDD with delusions but not hallucinations
Still an antipsychotic and an antidepressant
Tx for
Adjustment disorder
Psychotherapy
Dx
Neurologic symptoms with no clear pathology
Conversion disorder
S/e of Pimozide
Monitoring test
Pronlonged QT
Get EKG
Dx
Sensory aurus and automatic behaviors
Complex partial seizure
Dx
HTN, diaphoresis, palpitations, anxiety fear
Pheochromocytoma
or
Panic Attack
Dx
Dementia, weakness, imbalance, congitive decline, social withdrawal
HIV associated dementia
Dx
Depressive, mild cognitive impairment especially with math,tremor, brisk reflexes
Hyperthyroid
Dx
Recent change in personality, angry, headaches, pains, fever
SLE associated lupus psychosis
Dx
Tachy, tremor, HTN, seizure
Hypoglycemia
Delirium work up
CBC
Chem 7
PRP
B12/Folate
TSH
Ca/Mg
UDS
LFTs
O2 sat
Dx
Nystagmus, HTN, tachy, pain tolerance, muscular rigidity
PCP
Dx
Dysphoria, SI, unpleasant dreams, hunger, fatigue
Cocaine withdrawal
Dx
Dysphoria, fever, nausea, vomiting, muschle aches,
Opiate withdrawal
Wernicke's encephalopathy signs (3)
ACE
Ataxia
Confusion
Eye movements
Lesions in Korsakoff are where
Mamillary bodies and Thalamus
The delusions that are mood congruent can sometimes be attributed to depression with psychosis
.