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117 Cards in this Set
- Front
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Biomedical clinical care model
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• Biomedical Model: (done very quickly and mainly what we will do)
o biological aspects of CC o Psychological experiences are 2⁰ (this is misconception) |
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Biophsychosocial clinical care model
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• **Biopsychosocial Model – influence predisposition, onset, course, & outcome of most illness: (need to eval all 3 for effective tx). If you give them the opportunity to talk- this is what establishes the Dr:Pt relationship that we want.
o biological: anatomical, structural & molecular substrates of dz & effects on biological fnxing o psychological: psychodynamic factors, motivation & personality on experience/react’n to illness o social: cultural, environ, familial influences on illness |
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Evidence based clinical care model
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• **Evidence Based Model (EBM): - conscious, explicit & judicious use of best evidence in making decisions about pts tx. This is the basis of medicine today that saves money based on systems put in place by advisors/govt. Do what majority % of pts respond to.
o Formulate ?’s to be asked o Search literature & online database o validity/relavence o integrate data w/ clinical aspects of pt’s illness |
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paternalistic/autocratic model
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• Paternalistic/Autocratic Model “Old Style”
o pod makes all decisions – pts has no say; pod provides info the pt needs to know o works best in pts who: emergency; overwhelmed w/ illness; crisis & feel reassured by strong authority figure |
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Shared decision making model
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• Shared Decision – Making model “Internet educated patient”
o Interactive – TEAM WORK (pt-pod-family) o pt provides experience of illness (foot pain/arthritis), specific concerns of illness and knowledge/priorities of tx o pod provides info on illness, tx options, possible tx outcomes o together arrive at consensus for tx; interact’n warm/empathetic; most pts satisfied w/ this style= better compliance |
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Consumer based model
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• Consumer based Model – common for elective procedures
o options provided by pod – provide the rational for tx recommendations o decisions made by patient o interact’n cordial and business like |
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Government/mangaged care model
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• Government/Managed Care “Obama Care” what is coming up.
o Pt referred to pod Pt evaluated, diagnosed Tx based on what is outlined on a List created by government boards. |
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Friendship Model
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• Friendship Model “Trap”
o pod uses pt to satify own needs &/or vice versa – can be emotional or physical – transference/contertrasference issues o This is a violat’n of Medical Code of Ethics for pod to have sexual relationship w/ pt. Even accusations that lead to Board Review puts you on a list where your name will never be removed. |
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3 elements of Pod-Pt relationship
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Effective listening, Empathy, Interest
• Effective listening – undivided attention. This is the HARD part! o Impediments: anxiety, professional insecurity, fatigue, impatience, inattentiveness, restlessness, day dreaming • Empathy – ability to experience transiently the feelings of another person/subjective feelings; communicating your understanding w/ what pts has said to you – if they feel you understand they will be more open; actively participate; comply w/ tx o Reflect’n- you seem _____ o Legitimization- I can understand _______ o Support- You are doing very well dealing with ______ o Partnership- Let’s work together to resolve your pain o Respect- You are demonstrating courage by facing up to the Dx. • Intrinsic interest more important – than position, appearance, reputation, clinical experience, training, technical o Pt will work with the Dr sooooo much more if they feel the Dr cares. |
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Three elements of compliance
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Resistance, Transference, Countertransference
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Resistance
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• Resistance – late to appts; avoids looking at pod; sits stiff or constantly moving; someone else made them come in
o express hopelessness- can’t be helped; attempt to have pod talk about themselves (made example in class); short answers |
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Transference
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• Transference – unconsciously applying feelings, attitudes, expectations from a person in the past to person in present
o (+) or (-) don’t take anything personal (You remind THEM of someone else) |
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o Susan is a 39 year-old woman who related to her Podiatrist that when she was a child her mother use to severely restricted her food intake because she felt her daughter was fat. Susan is currently 25 lbs overweight and has recently developed high blood pressure and pain in both feet. When her Podiatrist advises her to lose weight, she becomes angry with her and refuses to follow her advice.
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Transference
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Mental Status 5 axises
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1-Clinical disorders of importance
2-Personality Disorders/retardations 3- medical/physical disorders 4-Psychosocial and environmental factors 5-Global assesment of function |
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Axis 1
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- clinical disorders/conditions of clinical importance/attention
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Axis 2
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Axis II
- personality disorders/mental retardation |
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Axis 3
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Axis III
- any medical/physical disorder + mental disorder (pneumonia, bunions, fractures) |
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Axis 4
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- psychosocial + environmental factors (support/ social/ educat’n/ occupat’n/ housing/ economics/ access to health care/ probat’n (legal system)
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Axis 5
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- Global Assessment of Functioning (social/ occupational/ psychological)
- higher # = better px. based on 0-100 pts= pay. 100 = less pay. |
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A 45 year A 45 year-old man comes to your office with a old man comes to your office with a chief complaint of chief complaint of severe pain in both feet severe pain in both feet which has been present for the past 3 months. has been present for the past 3 months. Six months ago he was laid off laid off from his job. Four from his job. Four months ago his months ago his wife left him wife left him for another man another man. He has become depresse epressed, has difficulty s leeping, has a 12 lb weight loss, is tearful and is having thoughts of ending his pain by shooting himself thoughts thoughts of ending his pain by shooting shooting himself himself. He is also being treated for an He is also being treated for an upper respiratory upper respiratory infection infection. He has lost his medical insurance coverage coverage due to his job loss.
What axis has medical conditions? |
Axis III
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Thought process: Tangential
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o Tangential – doesn’t directly answer ? (how have you been sleeping? A: I usually sleep in the bed, but now I’m on the sofa) The answer is Sort of there, but sort of not.
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Thought process: Circumstatnial
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loss of capacity to reach goal
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Thought process: Perservation
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Keeps responding to previous stimuli after new ? has been asked
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Thought process: Blocking
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Blocking- Interruption in train of thought. Starts then stops talking
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Thought process: Word Salad
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incoherent/incomprehensible use of words or phrases
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Thought process: Clang associations
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rhyming, but no meaning (schools in pools with spools of thread til your dead fred)
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Thought process: neologisms
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new words creatd by pt through combo of other words
frustrated + flustered= Flustrated |
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Thought process: deliusions
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o Delusions – fixed, false; can’t be corrected by reasoning “Don’t say: That doesn’t make any sense”
Paranoid (belief they’re being harassed); talking about me, looking at me, making fun of me Grandeur: exaggerated Nihilistic – false feeling that self & others or world is nonexistent or coming to end ideas of reference – belief the radio or tv is speaking to or about him/her *- ideas on influence – belief that another person/force is controlling some aspect of their behavior |
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Thought Process: Obsessions
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o Obsessions – pathological persistent thought that cannot be eliminated from consciousness
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Thought process: Ideas of reference
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ideas of reference – belief the radio or tv is speaking to or about him/her
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Thought process: Ideas of influence
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ideas on influence – belief that another person/force is controlling some aspect of their behavior
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Thought process: Compulsions
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o Compulsions – pathological need to act in response to an obsession (thought) in order to prevent something in the future
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Hallucinations
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• Hallucinations – Sensory, doesn’t mean you are psychotic: auditory, visual, hearing, tactile, gustatory (taste), somatic (body),
Hypnogogic (while falling asleep) – or – Hypnopompic (while awakening) -- these are normal (hear talking) o Illusions – misperception/misinterpretation of real external stimuli (books looks like cigarettes) o Depersonalizat’n – person’s subjective sense of being unreal, strange or unfamiliar o Formicat’n – feeling of bugs crawling under skin (cocaine m/c) |
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Somnolence
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abnormal drowsiness- huge SE of drugs
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Levels of memory
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o remote mem – childhood
o recent remote mem – past several months o recent mem – breakfast, name of interviewer o immediate retention/recall – repeat 6 digits forward and backward |
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Judgement/insight/reliability
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• judgement – does pt understand outcome of behavior (would they shout fire in a theatre or tell security they smell smoke)
• insight – degree of understanding/awareness of their illness/ appreciation of need for tx • reliability – ability to report problems accurately; estimate truthfulness or veracity – confirming truth – is this pain real? |
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7 habits of Highly Effective Psychopharm
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1. Begin with the end in mind
2. Synergize 3. Sharpen the saw 4. Put things first 5. Think win/Win 6. Become proactive 7. Understand and be understood |
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7 Sins of Psychopharm
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1. 3 D’s: Diagnosis, Dose, Duration
2. Polypharmacy 3. Not understanding the physiological background or context of the patient 4. May not provide better living 5. Lack of communication with other physicians 6. Lack of interhealth communication 7. Not keeping up with field |
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ADHD children/Adults Inattention
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ADHD children/Adults Hyperactivity
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ADHD Children/Adults Impulsivity
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• A 10 year old boy has trouble sitting in A 10 year old boy has trouble sitting in class, constantly fidgets, and is easily distracted. He is unable to complete classroom assignments and loses his pencils. His mother reports that these problems began around his 7th birthday. What is the probable Dx?
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ADHD
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ADHD dx
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• Criteria: onset before 7yo, impairment in 2 settings (home/school/playground); sxs >6 mo;
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Rx for ADHD
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o Ritalin- (old drug) Methylphenidate
o Vivance- (newest in group) Methylphenidate o Adderall- Methylphenidate o Straterra (non-stimulant) |
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Delerium characteristics
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- impairment of consciousness
- change in cognition - Rapid Onset with short duration (<week usually) - reduced awareness – orientation lost - fluctuating clinical presentation - Rapid improvement when cause tx - hospitalized/surgery/burns |
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Delirium Risks
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- >65, preexisting dementia/brain dz/
- 3+ meds, indwelling catheter= immobilization; “you prescribe a med and the pt already has a couple they could have an interaction.” - sleep deprived; drug/ETOH abuse |
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Deliruium Etiology
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Post surg
Immobilization |
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Delirium Signs
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Disturbed sleep “sleep switch”; orientation to time lost; ramblings, can’t comprehend speech; impaired memory; perception off;
impaired problem solving; mood flips |
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Deliriuim Tx
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Tx: underlying cause
Review meds and labs *fluid/electrolyte balance “sundowning” - ↑sxs in evening. Things to tune them into the “Here and Now” help orient the patient. |
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Remember for Delerium
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“Some items will show up more than once as an answer on the exam. An example is Delirium b/c I feel it is underdiagnosed.”
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Dementia Characteristics
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- deteriorating memory W/O loss of consciousness.
- progressive/gradual - reversible (15%) dependent on pathology/timing (infxns, DM, Nutritional (thiamine def)) |
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What are the 4 A's of Dimentia?
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The 4 A’s = Amnesia, Aphasia, Apraxia, Agnosia
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Dementia Risks
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- female, 1st degree relative, head injury; Down’s synd, - 60s/70s/ 80s
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Dementia Signs
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difficulty:
Recalling recent events; making judgments; managing routine chores; fatigue, failing @ tasks; needs constant supervision, orientation lost; Terminal: forget how to swallow |
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Dementia Dx
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memory impairment
- disturbance in executive fnxing with deteriorat’n in both social & occupation’l fnx - death 3-15 yrs after sxs start **Vascular Dementia – 2nd m/c cause (correlate w/ pneumonia) “My mother died of vascular Dimentia” - Lewy Bodies dementia – Parkinsonian coexisting w/ cognitive decline - head trauma – Dementia pugilistica - Substance induced (ETOH, drugs) “young person comes in with problems of memory/language” |
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Dementia Rx
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Aricept- Tx for alzheimers/dementia
Memantine- moderate to severe Alz- tries to help decrease amyloid plaques |
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The patient is a 64 year old married man who was seen 2 days after quadruple coronary bypass surgery. had done well until this evening when he became disoriented and agitated. He called for the nurse 3 times and then forgot why he called her. When interviewed by the PD student, he gave a coherent, logical history. He was alert and cooperative. Thirty minutes later he could not give appropriate answers to questions but talked about to questions but talked about 3 men in his room who had come through who had come through his window. He wondered how they could do this since he was on the floor of the hospital (accurate). He said they talked about him and then left, but h e could not recall how they left. He said h e was at home where he has lived in for the past 20 years. He thought the surgeon who had operated on him was his family pyhsician. His mental status varied from normal to abnormal, fluctuating every 30 to 60 minutes.
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Delirium
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2. A 47 year old man is hospitalized with traumatic brain injury and a right leg and ankle fracture he suffered in an automobile accident while driving in an intoxicated state. He is increasingly anxious, belligerent, disoriented, and incoherent during the first 36 hours of hospitalization. He has a long history of heavy alcohol use.
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Delirium
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Personality Disorders
Axis? Clusters & Contents |
Axis II
A-Eccentric/odd B- Dramatic/Emotional C- Anxious/Fearful |
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Cluster A contents
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Paranoid Personality
Shchizoid personality Schyzotypal Personality |
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Paranoid Personality
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1. Paranoid Personality
• distrustful, misperceive act’ns of others: exploitive, deceptive, harmful • bears grudges; socially isolated • questions fidelity of spouse • suspicious that someone makes fun of them; litigious (brings charges against someone/gets law involved) |
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Schizoid Personality Disorder
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• Inability to form social relationships
• NO close friends, solitary activities • indifferent to praise OR criticism • cold/detached, NO interested in sex • absence of sense of self • **preoccupied w/ angry violent fantasies – could blow @ any time |
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Schizotypal Personality Disorder
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. Schizotypal Personality Disorder
• No close relationships outside fam • social anxiety • suspicious/paranoid • odd beliefs/magical thinking • bizarre; peculiar appearance- • Not violent or anything- just weird and in their own world. |
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Borderline Personality Disorder
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. Borderline Personality Disorder
• instability: affect, impulse control, interpersonal relationships, identity • demanding – never satisfied • engages in: suicidal gestures, mutilate themselves; sexual promiscuity; substance abuse o we must ask: where are you, what’s your #; is anyone w/ you? • Under stress: o paranoid ideation; brief psychotic epidsodes; dissociative sxs o Fear of abandonment so try not to let you get close o *Splitting – play 1 person against the other (so and so is better dr than you) |
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Antisocial Personality Disorder
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2. Antisocial Personality Disorder
• Disregard for social normal; • Violat’n of rights of others • Irresponsible (physically violent) • Deceitful – lie/con/manipulate • lack remorse/shame guilt • impulsive – need immediate gratificat’n • disregard for safety of others “rules don’t apply to them” • often in jail! |
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narcissistic Personality Disorder
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• Grandiose sense of self importance
o actually childish, dependent & inferior on inside • excessive admirat’n- The world revolves around them • fears depending on others • lack empathy for others (nothing good enough) |
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Avoidant personality Disorder
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• inadequate/inferious feeling/timid
• hypersensitive to real or imagined reject’n • thinks they’re the cause of their own difficulties • few interpersonal relationships • longs for attachment w/ others |
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Dependent Personality Disorder
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• Needy, clinging, submissive
• searches for support/reassurance • unable to make decisions on own/feels helpless • difficulty taking initiative/pessimistic about future |
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Obsessive Compulsive Personality Disorder
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•NOT OCD
Orderly, perfectionist • rigid attempts to control others & themselves • absence of flexibility & openness • entangled in: details, rules, lists, order, organizat’n, schedules • may like to collect things & can’t throw anything away • reluctant to delegate tasks to others • work/productivity more important than relationships • rigid/stubborn/Miserly- stingy • excessively conscientious & rigid regarding morals & ethical matters • W/O Obsessive Compuslive Tendencies (other than lists) |
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Treatment for Personality disorders
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1- personality structure (1. Need motivation to change, 2. patient capacity for insight, 3. Pt capacity to engage in relationship.) Cluster B&C benefit from this
2- supportive psychotherapy 3-Directive Based tx |
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Schizophenia- general def and dx
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Schizophrenia – apathy, avolition (lack of desire, drive, or motivation), affective blunting... have alterat’ns in thoughts, perceptions, mood & behavior... may display delusions/hallucinat’ns/misinterpretat’ns of reality
• DSM-IV Criteria = 2+ sxs >1 mo continuous signs of illness for > 6 mo |
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Schizophrenia + Sx
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- Hallucinat’ns (m/c auditory or visual)
- Delusions - Disorganized behavior - Thought disorder: loos ass/ tangentiality/ incoherent thoughts/ neologisms/ thought blocking/ thought insertion/ thought broad casting/ ideas of reference - Tx: Clozaril “I don’t think I’ll ask you this” |
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Schizophrenia - Sx
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- alogia (poverty of speech or thought content)
- Anhedonia (loss of pleasure) - Flat affect - Avolition – loss of moto - Attention deficits |
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Paranoid schizophrenia
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Preoccupat’n w/ one or more delusions or frequent auditory hallucinat’ns
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Disorganized Schizophrenia
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Prominent disorganized speech, behavior, and flat or inappropriate affect
“hypophrenia” (sadness w/o cause) |
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Catatonic Schizophrenia
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2+: motor immobility; excessive motor activity; extreme negativism or mutism; peculiar voluntary mvmts (bizarre posture); Echolalia/echopraxia
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Undifferentiated schizophrenia
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Criteria for schizo, but cannot be characterized as paranoid, disorganized or catatonic
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Residual Schizophrenia
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Presence of (-) sxs w/ 2+ attenuated (+) sxs
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An 18 year old male has an 18 month history of gradual social withdrawal and diminished emotional responsiveness. In the past 8 months, he states that he is sure his food is being contaminated with bacteria. He has lost 10 pounds in the past 7 months and is not caring for this biologic needs. He has insomnia and early morning awakening. Before he eats he chants certain phrases. There is no history of drug use and his general medical state is within normal limits.
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paranoid type schizophrenia
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Schizophreniform disorder
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Schizophreniform Disorder – criteria for schizo BUT durat’n of illness is between 1-6 months
• 2 + sxs for one mo (either (-) or (+) • social and occupational fnxing impaired |
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A 27 year old female college graduate is brought to her doctor by her mother. She is described as being odd since losing her job 5 months ago. The patient complains of voices in her ears and a thought that her body is a receiving antenna for a foreign spy operation. She has become increasingly withdrawn and isolated. She is alert and oriented but suspicious and guarded on
examination Her affect is flat and her speech reveals looseness of examination. Her affect is flat, and her speech reveals looseness of associations. A medical workup is negative. The most likely diagnosis is: |
Schizophreniform disorder
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Brief Psychotic disorder
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hallucinat’ns, delusions, disorganized speech or behavior – 1 day – 1 month
• emotional turmoil/confusion often present; mood and affect may be labile; onset = sudden; attention deficits common; risk of suicide |
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• A 20 year old man with no previous psychiatric history is noted by his college roommate to be acting bizarrely for the past month and a half, talking to people who are not there, walking around the room naked, and accusing his roommate of calling the FBI to have him monitored. The patient’s vital signs, medical evaluation and neurological evaluation are WNL. The most appropriate medication to initiate treatment would be
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Treat Psychosis with Haldol- it will help immediately and work against the Sx and the Disease
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Delusional Disorder
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*nonbizarre delusions have lasted for >1mo; disorder by the absence of (+) or (-) sxs of schizo;
• appear normal cept when describing delusion “a specific thing they get caught up in.” Hallucinations NOT prominent • cognition and sensorium intact; insight to illness poor – could cause sig impairment in social and occupational fnxing • The only type of Tx is to chip away at the delusion to introduce some doubt into their mind |
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big guy in my office that couldn’t understand that our program couldn’t treat him and he became very defiant. Another Pt had a girlfriend that broke up with him and about a month later she was raped. He has become convinced that he could have helped her and prevented it and helped her by pushing her to get treatment
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Delusional Disorders
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Delusion types
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Persecutory
Somatic Erotomanic Grandiose Jealous Mixed |
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Persecutory Delsusion
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delusions that indiv is being harassed
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Somatic Type Delusion
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delusions of physical deficit or medical condition
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Erotomanic Type Delusion
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another person is in love w/ them
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Grandiose type Delusion
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delusions of exaggerated power, wealth, knowledge, identity or relationship to famous person or religious figure
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Jealous Type delusion
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delusion that partner is unfaithful
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Tx for Delusional Disorders
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Neuroleptics: Chlorpromazine, Haldol (EPS is a problem) Newer: Abilify (helpful and add on for antidepresent), Seroquel
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Neuroleptic SE
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Dystonia
parkinsonian Syndrome Akathisia Tardive Dyskinesia neuroleptic malignant Syndrome |
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Acute Dystonia
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• Acute dystonia (sustained contract’n of neck mm (torticollis), eyes (oculogyric crisis), tongue, & jaw – 3-5 days after initial tx;
o laryngeal spasms – obstruct’n of airway o A 26 year old man is admitted to the psychiatric ward with severe agitated psychosis with auditory hallucinations telling him to kill himself. He is him to kill himself. He is given Haloperidol 15 IM. Twelve hours later, he develops torticollis. What is the best treatment for this occurrence? Benztropine |
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Parkinsonian Syndrome
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• Parkinsonian Syndrome – cogwheel rigidity (pulling arm against R); mask like face; bradykinesia; shuffling gait
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Akathisia
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• Akathisia – inner restlessness – cannot sit still/pacing “ants in the pants” 1-stop med, 2- counter the ants in pants
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tardive Dyskinesia
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• Tardive Dyskinesia – invol mvmts involving tongue/mouth/fingers/toes/etc – chewing mvmts/smacking lips/blinking/spastic facial distortions
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Neruoleptic Malignant Syndrome
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• Neuroleptic Malignant Syndrome – fatal – severe mm rigidity; fever; altered mental status; automonic instability – elevated WBC/CPK waaaay up/LFTs
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Bipolar: Scenarios that increase suspicion for bipolar illness
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o 1- antidepressant failures: 3 or more
o 2- Antianxiety failures o 3- Antidepressant activation causes a manic switch o 4- Behavior disruptions o 5- screening methods basis of suspicion |
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Manic episode definition
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o Elevated or irritable mood lasting at least 1wk with 3 or more of the following Sx
Grandiosity (can conquer the world), Pressured Speech (talk a mile a minute), No need for sleep, racing thoughts- flight of ideas, easily distracted, Psychomotor agitation, Buying sprees o Marked impairment of social, occupational, or relationships with others |
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HypoManic episode definition
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o Elevated or irritable mood lasting 4 days with 3 of the same sx.
o Episodes NOT causing social problems and change in mood isn’t normal for person |
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Mixed Episode Definition
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o Combo of Manic and Major Depressive nearly Every Day for at least 1 Week
o Marked impairment in social and occupational functioning (may need to hospitalize b/c of potential for harming) o Mixed = recurrence= Suicide rate of 10-15 up to 20% |
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Bipolar 1
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• Dx: SINGLE manic/hypomaic episode, Depressed episode, or Mixed episode
• Mental Status Exam o Appearance, Behavior, language, Emotions, Thought, memory Colorful clothes, Appears Schizo- Disheveled, disorganized, etc; excited, restless Interactions are Dramatic, Inappropriate (dirty), with frequent violations of personal space Easily Distracted Loud, pressured speech, Alliteration, Neologism (flusterated) Euphoria, irritable, depressed, anxious w/ liability of Affect People who threaten the government are more likely to have a bipolar disorder than any other psychiatric disorder. No memory issues |
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Rapid Cycling Definition
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• Rapid Cycling: Cycle of manic to depressive >4x/year and symptom free at least 2 months b/t episodes. Poor Px.
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• A 24 year old graduate student is taken to the ER by campus security after he demanded to have a meeting with the college President 6AM. In the ER he became irritable and hostile and resisted attemp py ts to restrain him. The physical was WNL. The student was talking rapidly with pressured speech and his words were running together. He reported that he had not slept in 3 days and yesterday he went to the Apple store and bought 2-Imacs, 3-Ipads and 2-Iphones using his Visa card. His dress was very colorful wearing bright green pants and a purple shirt with colorful wearing bright green pants and a purple shirt with pictures of red birds. He did acknowledge that he stopped taking his medications 2 weeks ago because he felt he didn’t need them any more.
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Bipolar 1
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• A 25 year old graduate student is brought to the emergency room by the police after he attempted to enter the White House to “have a meeting with the President”. When the police stopped him he became irritable, angry hostile threatening shout angry, hostile, threatening, shouting obscenities and belligerent ing obscenities and belligerent. In the ER, physical examination and lab tests were normal. There was no evidence of substance abuse. The patient spoke rapidly with pressured speech. The patient’s roommate reported that he had been acting strangely for the past several weeks and was questioning everything anybody said to him.
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Bipolar 1
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Bipolar 2
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• Dx: One or more Major Depressive Episode AND Hypomanic Episode (Doesn’t go quite as high, but goes very low- depression predominates)
o No manic or mixed • Rapid Cycling (same) |
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• A 28 year-old graduate student is brought for psychiatric evaluation. Her roommate has noticed that she has been staying up all night working on many research projects, with the stereo playing loudly. The patient has a history of being treated for major depressive episodes, but had tapered off her antidepressant medication (Prozac). Her roommate noticed that about a week ago the patient became markedly hyperactive in her graduate school research, working all night, stating that she is the smartest student in her program. She acknowledged that she has had these mood swings in the past. The hyperactive Period does not last long and then she swings back into a depressive state. Further evaluation revealed that when she was in the depressed state she met the criteria for major depression. Despite this, the patient had not acted bizarrely (no relationship/sexual issues) and was meeting all her research deadlines.
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bipolar 2 (major depressive + Hypomanic)
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• A 36 year old woman complains of increasing fatigue, insomnia, with early morning awakening, 8 lb. weight loss in the past three months, difficulty concentrating and focusing, and having difficulty making decisions. She further states that at other times she is full of energy, enthusiastic, will work 12 - 15 hours a day and go out dancing in the evening. These up feelings are very brief and only lead to her becoming depressed again. Her husband tells you they have been married 12 years and she has been like this even before they were married. He states he can no longer tolerate these ups and downs and is planning to divorce her
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bipolar 2 (major depressive + Hypomanic)
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Cyclothymic
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• Dx: Numerous periods of depression (not major) and hypomania occurring for at least 2 years with sx breaks no greater than 2 mos duration.
o Sx cause significant distress in social, occupational, relationship functioning o Sx are similar to bipolar 1 but of less magnitude • Coexisting substance abuse and/or borderline personality disorder |
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• 29 year-old advertising executive is being evaluated for mood swings. The patient does not feel he has a problem, but is aware that he has “good days” and “bad days”. He has experienced episodes of feeling “down” for 3 to 4 weeks at time since age 20. During these episodes, he is unmotivated, has hypersomnia, and often does not carry out his responsibilities. The patient also has periods of feeling “great”with a markedly decreased need for sleep and is far more productive at work. He reports that his best creations come when he feels this way. He does get into trouble at work because he flirts with coworkers to the point of having sexual encounters. Currently, he feels pretty normal. There is no medical or psychiatric history and he does not use illicit drugs. However, he drinks often during the good days while at the numerous social functions and he feels it helps him sleep better. There is a family history of bipolar illness
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Cyclothymic
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• A 32 year old accountant made an appointment at the request of his wife because of mood swings. The patient cknowledged that he has good days and bad days. He has experienced episodes of feeling down for 2-3 weeks at a time over the past 3-4 years. During these episodes, he becomes indecisive, sleeps excessively, and neglects his biologic needs. When he feels really good he reports he stays up most of the night and is more productive at work. He says his best creative ideas for work projects occur during these good days, but he also gets into trouble because he becomes promiscuous during these days. He drinks alcohol to excess during the good days. He takes no medication and there is no significant psychiatric or medical history The most likely diagnosis is: medical history.
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Cyclothymic
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Bipolar Rx
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• Lithium- response rate of 80%, onset 6-8 wks, helps with mania, does not help with rapid cycling.
o Drug “slows things down”, prevents suicide/impulse behavior o SE: Edema, Wt gain, Diabetes Insipidus due to decreased GFR • Depakote- First line drug o SE: Wt gain, hair loss, tremor Black box: Hemmoragic pancreatitis and polycystic ovaries • Lamitrogene- anticonvulsant o Helps with SE, don’t need to check blood levels. |
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Drugs for ADD
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Drugs for ADD
• Methylphenidate (Ritalin) • Atomoxetine (Strattera) • Dextroamphetamine (Adderall) • Lisdexemftamine (Vynase) |
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Drugs for Cognition (Dimentia)
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Drugs for Cognition
• Donepezil (Aricept) • Mementadine (Nemenda) |
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Drugs for Psychosis
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Atypicals- Add ons for Psychosis.
• Quetiapine (Seroquel) • Aripiprazole (Abilify) Drugs for Psychosis: norleptics • Chrorpromazine (Thorazine) • Haloperdol (haldol) |
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Drugs for Bipolar Disorder
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• Lithium
• Divalproex (Depakote) • Lamotrigine (Lamictal) |
