Sbm Unit 8 - Psychiatry, Eye

Front 1

What are the 5 axes in psychiatric diagnosis?

Back 1

Axis I: the clinical psychiatric disorder (includes substance abuse and childhood disorders)
Axis II: Personality disorder, retardation
Axis III: All other medical illnesses
Axis IV: Psychosocial and environmental stressors
Axis V: Global Assessment of Function (number from 0 – 100 reflecting a person’s general level of function)

Front 2

What are the 3 Ds that define mental illness?

Back 2

3 Ds: dysfunction, distress, disability
“A clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g. a painful symptom) or disability (i.e. impairment in one or more important areas of functioning) or with a significant increased risk of suffering death, pain, disability, or an important loss of freedom.”

Front 3

What is Schneiderian hallucination?

Back 3

Schneiderian hallucination is an overheard (mumbling) conversation (muffled voices). If you ask the pt what they heard, they would say they couldn’t make it out, although they may be able to describe other attributes of the conversation.

Front 4

What is the role of dopamine in the pathogenesis of schizophrenia?

Back 4

• Excess dopamine in the mesolimbic dopamine tract may be responsible for the positive symptoms of schizophrenia.
• Decreased dopamine in the mesocortical tract may be responsible for the negative and cognitive symptoms.

Front 5

What are the positive symptoms of schizophrenia?

Back 5

• Hallucinations:
o Auditory, visual, tactile
o gustatory, or olfactory
• Delusions:
o Fixed, false beliefs
o (bizarre versus non-bizarre)
• Disorganization of thoughts
o and behavior

Front 6

What are the negative symptoms of schizophrenia?

Back 6

• Affective flattening
o Intonation of voice
o Facial expression
o gestures
• Alogia (poverty of speech)
• Anhedonia (inability to enjoy things)
• Avolition (inability to act)
• Social withdrawal
* Apathy
* Poor hygiene

Front 7

What forms of cognitive impairment would you expect to see in a patient with schizophrenia?

Back 7

• Attention
• Memory (working)
• Visuospatial perception
• Executive function (cognitive control)

Front 8

What are the subtypes of schizophrenia?

Back 8

• Paranoid (primarily delusions and/or auditory hallucinations)
• Disorganized (disorganized thoughts and/or behavior)
• Residual (negative symptoms or attenuated positive symptoms)
• Undifferentiated (variable)
• Catatonic (mutism and/or negativism)

Front 9

What is the most important prognostic feature in schizophrenia?

Back 9

Most important prognostic feature is gender. Being male is associated with a poor prognosis.

Front 10

Blockage of dopamine in which pathway can produce the negative symptoms of schizophrenia?

Back 10

Mesocortical

Front 11

How does efficacy and potency vary from anti-psychotic to anti-psychotic?

Back 11

• All antipsychotics have same/similar efficacy (different potency) for positive symptoms in schizophrenia, except clozapine (which has a greater efficacy)
• Potency is related to affinity for the dopamine receptor (i.e., greater potency = greater affinity for D2 receptors)

Front 12

How does one treat Neuroleptic Malignant Syndrome?

Back 12

Treatment is supportive (can use dopamine agonists like bromocriptine and muscle relaxants like dantroline)

Front 13

Blocking dopamine in which brain pathway causes extrapyramidal side effects (EPS)?

Back 13

Nigrostriatal dopamine pathway

Front 14

Blocking dopamine in which brain pathway causes a decrease in hallucinations and delusions?

Back 14

Mesolimbic dopamine pathway

Front 15

Blocking dopamine in which brain pathway causes a worsening of “secondary” negative symptoms?

Back 15

Mesocortical dopamine pathway

Front 16

Blocking dopamine in which brain pathway causes increased prolactin secretion?

Back 16

Tuberoinfundibular dopamine pathway

Front 17

What are key differences between typical and atypical antipsychotics?

Back 17

• Atypical:
o Less movement-related disorders
o Blocks both serotonin and dopamine (more serotonin than dopamine)

Front 18

Blockade of which neurotransmitter causes hypotension (including orthostatic hypotension), dizziness, and sedation?

Back 18

Alpha-1 adrenergic blockade

Front 19

Blockade of which neurotransmitter causes sedation and weight gain?

Back 19

H1 histaminic blockade

Front 20

Blockade of which neurotransmitter causes memory and cognitive deficits, xerostomia, constipation, tachycardia, blurred vision, urinary retention, and hyperthermia?

Back 20

Anticholinergic (muscarinic) blockade

Front 21

How would you treat tardive dyskinesia, the long term (often permanent) neurological impairment that is characterized by involuntary dyskinetic movements?

Back 21

Treat Tardive Dyskinesia with anticholinergics (benztropine, diphenhydramine)

Front 22

What are the adverse drug reactions related to dopamine blockade?

Back 22

• Tardive dyskinesia
• Dystonic reactions
• Drug-induced parkinsonism
• Akathesia
• Hyperprolactinemia

Front 23

What are all the first generation antipsychotics that Cronenwett mentioned in his syllabus?

Back 23

1. Haloperidol
2. Fluphenazine
3. Perphenazine
4. Thiothixine
5. Chlorpromazine
6. Thioridazine

Front 24

Which second-generation antipsychotic has the greatest efficacy, and what is an serious adverse effect that it can cause?

Back 24

Clozapine can cause agranulocytosis (1-2% incidence)—can be fatal. Clozapine should be discontinued if WBC drops below 3,000/mcL or 50% of the patient’s normal level.
Not associated with Tardive Dyskinesia, and in some cases can actually improve TD

Front 25

Which second generation antipsychotics have reported new onset DM2?

Back 25

• Olanzapine (Zyprexa)
• Quetiapine (Seroquel)

Front 26

Which second generation antipsychotic has a black box warning that it can increase the QT interval (thus, some recommend having baseline EKG before administration)?

Back 26

Ziprasidone

Front 27

Which antipsychotics cause the least disturbances in metabolic profiles?

Back 27

• Aripiprazole
• Ziprasidone

Front 28

What is the difference between efficacy and potency?

Back 28

• Efficacy is the ability to achieve a desired clinical effect.
• Potency is a measure of how much medication is needed to achieve the desired efficacy, and it is related to the affinity of a drug for its targeted receptor.

Front 29

What is an example of negative reinforcement?

Back 29

If a person experiences anxiety in a situation and leaving the situation decreases anxiety, the avoidance behavior will be increased.

Front 30

What is an example of positive reinforcement?

Back 30

• An example of positive reinforcement could be the increased attention one might receive from a spouse or a friend when exhibiting fearful behavior.
• Positive reinforcement increases the frequency of a behavior by pairing it with a positive stimulus.

Front 31

What symptoms are associated with a panic attack?

Back 31

• Discrete period of discomfort in which symptoms peak within 10 minutes.
• Must have four of the following:
– heart palpitations (69%*)
– Sweating or trembling (89%)
– Numbness (65%)
– sensation of shortness of breath (80%)
– chest pain (69%)
– sensation of choking (54%)
– Dizziness (82%)
– abdominal distress (NA)
– derealization or depersonalization (80)
– fear of dying or losing control (81%)

Front 32

What drug(s) has/have proven effectiveness in preventing suicide?

Back 32

• Lithium
o Lithium has anti-aggressive and anti-impulsive effects
• Clozapine

Front 33

What symptoms are associated with alcohol withdrawal?

Back 33

• Two or more of the following, developing in hours to days:
– Autonomic hyperactivity (sweating,HR, BP)
– Increased hand tremor
– Insomnia
– Nausea or vomiting
– Transient tactile, visual, auditory hallucinations or illusions
– Agitation, anxiety
– Grand mal seizures

Front 34

What IQ qualifies for intellectual disability?

Back 34

<70 (at least 2 standard deviations below the mean)

Front 35

What severity of intellectual disability (ID) makes up the bulk of that population?

Back 35

“Mild” ID makes up 75% of ID population

Front 36

What disease causes the most common inherited form of severe intellectual disability (ID)?

Back 36

Fragile X Syndrome

Front 37

What neurotransmitters are involved in currently available antidepressants?

Back 37

All currently approved antidepressants increase either:
• Serotonergic
• Noradrenergic
• Dopaminergic
Drive

Front 38

What is cyclothymia?

Back 38

• Recurrent milder depressive symptoms and hypomanias
• Analogous to dysthymia but with periods of hypomania
• Does not have fully syndromal major depressive episode during first 2 years

Front 39

T/F: response to medication is diagnostic of ADHD.

Back 39

F: response to medicine is NOT diagnostic of ADHD

Front 40

What are the subtypes of ADHD?

Back 40

• Inattentive Type
• Hyperactive/Impulsive Type
• Combined Type
• ADHD Not Otherwise Specified (NOS)

Front 41

What drugs are used to treat ADHD?

Back 41

• Methylphenidate (Ritalin)
• Amphetamines

Front 42

When does regression occur in autistic children?

Back 42

One-third of autistic patients present with regression at 15-18 months after relatively normal development.

Front 43

Which antidepressant has a 2-3 fold increased risk of teratogenicity compared to other antidepressants?

Back 43

Paroxetine has a 2-3 fold increased risk of teratogenicity, specifically a ventral septal defect.

Front 44

What is the serotonin syndrome?

Back 44

The serotonin syndrome is a serious and potentially fatal syndrome of serotonin overstimulation characterized by:
1) Diarrhea
2) Restlessness
3) Extreme agitation, hyperreflexia, autonomic instability
4) Myoclonus, seizures, hyperthermia, shivering and rigidity
5) Delirium, coma, confusion, cardiovascular collapse
It can occur if SSRIs are co-administered with monoamine oxidase inhibitors

Front 45

In what antidepressant medication is it important to follow patients’ blood pressures?

Back 45

• SNRIs (Venlafaxine, Desvenlafaxine, Duuloxetine)
• A potential side effect is increased diastolic blood pressure

Front 46

What is the mechanism of action of bupropion?

Back 46

• Bupropion offers weak norepinephrine and dopamine reuptake inhibition, but its hydroxylated active metabolite is responsible for most of the therapeutic effect.
• Ultimately, the medication increases dopamine and NE turnover in the CNS.
• It is considered an activating antidepressant that also has use for ADHD

Front 47

Which antidepressants have no sexual side effects?

Back 47

• Bupropion
• Mirtazapine (antagonist at presynaptic inhibitory alpha2 autoreceptors

Front 48

What is the mechanism of action of trazodone?

Back 48

• Trazodone inhibits serotonin reuptake and blocks 5HT2 serotonin and alpha1 adrenergic receptors
• It’s not particularly effective as an antidepressant but is used as a sleep aid due to its sedating properties

Front 49

What is the mechanism of action of aripiprazole in anti-depressant action?

Back 49

• Although aripiprazole (abilify) is an antipsychotic, it’s used as an add-on to SSRIs in treatment-resistant patienst with mood or anxiety disorders.
• It partially agonizes (modulates) dopamine D2 receptors and serotonin 5HT1A receptors
• Antagonizes 5-HT2A receptors

Front 50

Which class of antidepressants are notorious for their narrow therapeutic window and ease of overdose?

Back 50

Tricyclic antidepressants:
• Tertiary
o Amitriptyline
o Clomipramine
o Imipramine
• Secondary
o Desipramine
o Nortriptyline
MOA: block reuptake of serotonin and NE and to a lesser extent, dopamine.
They also block muscarinic cholinergic receptors, H1 histamine receptors, and alpha 1 adrenergic receptors, accounting for their side effects.
Note: these drugs can slow cardiac conduction and stop your heart in an overdose

Front 51

What drugs are the monoamine oxidase inhibitors, and what food compound should be avoided when taking these drugs?

Back 51

• The monoamine oxidase inhibitors are phenelzine and tranylcypromine.
• MOA = inhibits monoamine oxidase, which catabolizes intracellular monoamines (e.g., dopamine, NE, serotonin, tyramine)
• One should avoid foods with tyramine, as this can lead to excessive accumulation of NE.

Front 52

What antidepressant should be avoided for people with anxiety?

Back 52

• Bupropion has activating effects and shouldn’t be used in people with anxiety.
• It can also cause grand mal seizures.

Front 53

What mood stabilizer can cause hypothyroidism?

Back 53

Lithium causes hypothyroidism in 5-10% of patients, which can be treated with supplemental thyroid hormone.

Front 54

How long does it take for lithium to work as a mood stabilizer, and in what percentage of patients is it effective?

Back 54

• Lithium can take 1-3 weeks, and thus it’s not used for treating acute mania
• It’s effective in about 50% of patients.

Front 55

What side effects can valproic acid cause, and what tests should be ordered for patients put on valproic acid?

Back 55

Side effects:
• Weight gain
• Hepatotoxicity (not very common)
• Pancreatitis (rare)
• GI (abdominal pain, nausea, diarrhea, vomiting)
• Sedation, tremor, ataxia, alopecia
• Thrombocytopenia (rarely)
Due to these side effects, LFTs and CBCs are checked regularly

Front 56

Which mood stabilizing drug can lead to the development of a rash that can progress to Steven-Johnson syndrome (a life-threatening condition in which cell death causes the epidermis to separate from the dermis)?

Back 56

Lamotrigine causes rash in about 10% of patients. 1-10% of those who develop rash can then get Steven Johnson syndrome and toxic epidermal necrolysis. Occurs more commonly in children.

Front 57

What possible danger could occur from the combined use of valproic acid and lamotrigine?

Back 57

Valproic acid inhibits lamotrigine metabolism, so when they’re used together, lamotrigine is given at a lower dose and titrated up more slowly.

Front 58

What drug interactions should you be careful about with the use of carbamazepine?

Back 58

Carbamazepine induces heaptic P450 enzymes, so it can decrease other medications, for example:
• Oral contraceptives
• Warfarin
• Other anticonvulsants

Front 59

Which mood stabilizers should be avoided in pregnancy?

Back 59

Carbamazepine and valproic acid both increase the risk of neural tube defects and other birth defects and thus should be avoided in pregnancy.
Furthermore, lithium increases the risk for Ebstein’s anomaly (characterized by a dysplastic tricuspid valve) as a birth defect.

Front 60

What are adverse effects that lithium can have on the following: kidney, nervous system, heart?

Back 60

• Kidney: polyuria and polydipsia, which can progress to nephrogenic diabetes insipidus. Chornic lithium use can also lead to interstitial nephritis and impaired glomerular function.
• Nervous system: sedation and impaired cognition, tremor (can be treated with beta-blockers), ataxia and dysarthria
• Heart: cardiac conduction problems (e.g., sinus bradycardia, SA node blockade), AV blockade and ventricular irritability

Front 61

What are important side effects of carbamazepine?

Back 61

• Weight gain
• Sedation
• Ataxia
• Rash
• Agranulocytosis and aplastic anemia (rare but very serious)
• Hepatitis
• Hyponatremia/SIADH
• Hypersensitivity rash
LFTs, CBCs and basic chemistries are checked regularly

Front 62

What is an ideal therapeutic range for Li use?

Back 62

0.6-1.2 mEq/L (1.0 is ideal)

Front 63

How would you characterize someone with schizotypal personality disorder?

Back 63

• M [2] Magical thinking or odd beliefs
• E [31 Experiences unusual perceptions
• P [5] Paranoid ideation
• E [71 Eccentric behavior or appearance
• C [6] Constricted (or inappropriate) affect
• U [4] Unusual (odd) thinking and speech
• L [8] Lacks close friends
• I [1] Ideas of reference
• A [9] Anxiety in social situations
• R Rule out psychotic disorders and pervasive develop-mental disorder

Front 64

What would you call antisocial personality disorder if it is in someone who’s 14 years old?

Back 64

Conduct disorder (before the age of 15)

Front 65

How would you characterize borderline disorder?

Back 65

• A [1]Abandonment
• M [6] Mood instability (marked reactivity of mood)
• S [5] Suicidal (or self-mutilating) behavior
• U [2] Unstable and intense relationships
• I [4] Impulsivity (in two potentially self-damaging areas)
• C [81 Control of anger
• I [3] Identity disturbance
• D [9] Dissociative (or paranoid) symptoms that are transient and stress related
• E [7] Emptiness (chronic feelings of)

Front 66

How would you characterize avoidant personality disorder?

Back 66

• C [2] Certainty (of being liked required before willing to get involved with others)
• R [4] Rejection (or criticism) preoccupies ones' thoughts in social situations
• I [3] Intimate relationships (restraint in intimate relation-ships due to fear of being shamed)
• N [5] New interpersonal relationships (is inhibited in)
• G [1] Gets around occupational activity (involving significant interpersonal contact)
• E [7] Embarrassment (potential) prevents new activity or taking personal risks
• S [6] Self viewed (as unappealing, inept, or inferior)

Front 67

What is the difference between a factitious illness and malingering?

Back 67

• Patients with factitious disorders create the presence of a medical condition, either by some active means like ingesting a toxic agent or falsifying lab studies or by deliberately withholding care from an existing illness to worsen it (e.g., not taking insulin for Type I DM). The motivation is unconscious or unknown.
• Malingering is similar to factitious illness in that the patient is aware that they’re making it up, but malingering patients do it for an instrumental end of which they are aware (e.g., avoiding incarceration).

Front 68

Deficits in what side of the brain can produce attention-deficits?

Back 68

Right sided lesions tend to affect attention most profoundly (it’s the dominant center for attention)

Front 69

What are the components of the CAM test for delirium?

Back 69

1. Acute onset and fluctuating course
o Is there evidence of an acute change in mental status from the patients baseline? Did the (abnormal) behavior fluctuate during the day, that is, tend to come and go, or increase and decrease in severity?
 Test: observation
2. Inattention
o Did the patient have difficulty focusing attention, for example, being easily distractible, or having difficulty keeping track of what was said
 Test: continuous performance test
3. Disorganized thinking
o Was the patient’s thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?
 Test: Yes/No questions
4. Rating of consciousness
• Alert (normal)
• Vigilant (hyperalert)
• Lethargic (drowsy, easily arousable)
• Stuporous (difficult to arouse)
• Coma (unarousable)

Front 70

What motives for drinking are most associated with increased risk for alcohol dependence/abuse?

Back 70

Coping motives (forget problems, cheer up)
Enhancement motives (get high, fun)

Front 71

How does the metabolism of the long-acting benzodiazepines (e.g., diazepam, flurazepam) differ from that of the short-acting agents (e.g., lorazepam, oxazepam, temazepam -- LOT)?

Back 71

The short acting, LOT, agents do not have active metabolites, whereas the long-acting agents do.
Ultimately, all of the drugs are subjected to glucuronide conjugation (a Phase II reaction) and then excreted in the urine.

Front 72

In what kinds of patients can benzodiazepines be patient (i.e., what underlying medical morbidities)?

Back 72

COPD
Obstructive Sleep Apnea

Front 73

What clinical efficacy do the ZAZOLES have? Remeber that the ZAZOLES are: Zaleplon (Sonata), Zolpidem (Ambien), Eszopiclone (Lunesta)?

Back 73

The ZAZOLES reduce th number of awakenings and can restore sleep architecture to normal. They bind to the benzodiazepine binding site on the GABA-A receptor but are not benzodiazepines structurally.

Front 74

What is the first line drug for treating ethanol withdrawal?

Back 74

Benzodiazepines

Front 75

What areas of the brain are typically affected in delirium, and what neurotransmitter is often decreased?

Back 75

Right-sided and bilateral lesions are typical for delirium, and the neurotransmitter that's decreased is Acetylcholine.

Front 76

What is the most common change in the EEG in a confusional state?

Back 76

Slowing

Front 77

What are the 4 basic questions to keep in mind when diagnosing a delirium?

Back 77

1. Acute onset and fluctuating course.
2. Inattention
3. Disorganized thinking
4. Altered level of consciousness (either lethargic or hypervigilant)

Front 78

What are the 2 pathological hallmarks of Alzheimer's disease?

Back 78

1. Beta-amyloid plaques (consisting of beta-amyloid protein, degenerated synapses, axons, and dendrites)
2. Neurofibrillary tangles (consisting predominantly of a hyperphosphorylated form of the tau protein, which is a microtubule associated protein)

Front 79

What are the core features of Lewy Body Dementia (LBD)?

Back 79

1. Fluctuaqtions in attention and alertness
2. Motor changes of Parkinsonism
3. Recurrent visual hallucinations

Front 80

What are some diagnostic criteria for ADHD?

Back 80

1. Symptoms causing impairment present before age 7 (DSM 5 - before age 12)
2. Impairment present in 2 or more settings
3. Clinically significant impairment in at least one domain of functioning:
a. Social
b. Academic
c. Occupational

Front 81

What areas are impaired in autism disorder?

Back 81

Social relatedness/interaction
Communication
Restricted/Repetitive behavior, interests, activities

Front 82

What changes in the eye allow distance vision versus near vision?

Back 82

The ciliary muscle relaxes for distance vision so that the lens remains flat, whereas the ciliary muscle contracts to round up the lens for near vision.

Front 83

What's the weakest point of the eye?

Back 83

Lamina cribrosa

Front 84

What is uveitis?

Back 84

Uveitis is inflammation of the iris, ciliary body, or choroid.

Front 85

What's the difference between dry and wet age-related macular degeneration?

Back 85

Dry AMD is non-exudative macular degeneration
Wet AMD is exudative macular degeneration

Front 86

How do you define temperament, character, and psyche?

Back 86

Temperament: innate biases in the modulation of behavioral responses to external stimuli; seen early in life
50% of variance is genetic
Character: self-concept and interpersonal relatedness
Psyche: consciousness, self-awareness, and spirit