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354 Cards in this Set
- Front
- Back
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Pregnant woman tries to kill self 34th wk pregnancy, treatment?
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ECT (safe for mother and fetus)
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Paradoxical reaction
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Paradoxical agitation and confusion (instead of relaxation) with benzodiazepines, seen in elderly patients and pts with organic CNS disease
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Type II Schizophrenia
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Negative type, with flattened affect, poverty of speech/speech content, thought blocking, poor grooming, lack of motivation, anhedonia, social withdrawal, cognitive/attentional deficits
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Thought Broadcasting
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Typically seen w/ schizophrenia, a sense that others can read a patient's thoughts or vice versa
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What med can produce confusion, disinhibition, amnestic problems (like blackouts)?
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Alprazolam (short acting BZD) has this risk in the elderly
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Antisocial personality disorder
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Pervasive disregard/violation of rights of others after age 15; At least 3 of following: failure to conform to social norms (repeated arrests), deceitfulness, irritability/aggressiveness, disregard for safety of others, irresponsibility, lack of remorse
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Borderline Personality Disorder
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Pervasive pattern of instability in interpersonal relationships, self-image, and affect; Five of the follwing: impulsivity, efforts to avoid real/imagined abandonment, unstable relationships, affective instability, feelings of emptiness, difficulty controlling anger, identity disturbance
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Delusion vs Grandiose delusion:
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delusion is fixed false belief, grandiose attributes special powers to patient; by definition delusions can't be corrected with logic
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Idea of reference:
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belief that object in your life (TV, radio) has particular personal significance; also belief that others are focusing on you in some positive or negative way
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Dissociative Fugue:
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person travels far from their home and forgets important aspects of their former life
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Who can have high serum amylase?
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Bulimics
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Schizophrenia vs schizophreniform disorder:
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Schizophreniform is under 6 mos and w/o social withdrawal, full-on schizophrenia is at least 2 psychic symptoms (hallucinations, delusions, thought disorder, disorganized behavior, neg symptoms) at least 1 month w/ i<span style="font-weight:600;">mpaired social/occupational fxn</span> over 6 mos; if under 1 mo, it's called Brief Psychotic Disorder
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Stepwise progressive dementia oftwn w/ neuropsych symptoms cause:
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multiple cerebral infarcts often cause this
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Catatonia:
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voluntary assumption of inappropriate/bizzare postures for long periods of time, often an early sign of schizophrenia; negativism is tendency to resist being moved out of this posturing; can give benzo (esp lorazepam)
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Synesthesia:
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one sensory stimulus perceived as belonging to a different sensory modality
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Dysthymic disorder:
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depressed mood for most of the day, for more days than not, for 2 years or more
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Echopraxia:
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mimicking examiner's posture and body movements, as seen in chronic schizophrenia
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Axis IV:
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stressors in the patient's life (social, legal, financial, homelessness, divorce)
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Axis I:
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all primary psychiatric disorders (including substance abuse / developmental disorder) other than MR or personality disorders
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Axis II:
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MR or personality disorders
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Axis III:
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All known general medical conditions
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Axis V:
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global assessment of functioning on a scale of 1 to 100 (vs highest GAF in past year)
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Latency:
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Freudian stage ages 5-12 where sexual drive is latent while peer relations and school achievement become more important, play by rules, tendency towards organization/orderliness
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Testing intellectual ability ages 2-18 vs 16-75
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2-18 is Stanford-Binet test (think John-Benet Ramsey), while 16-75 is WAIS (Wechsler Adult Intelligence Scale) which has verbal and visual-spatial components
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MMPI
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Munnesota Multiphasic Personality Inventory, and objective personality test with standardized Q-A format used to identify pathologies and behavioral patterns
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Projective Personality Assessment Tests
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Thematic Apperception Test (TAT) test taker creates stories based on pictures to learn their intent; Rorschach test is ink blots, which ID thought disorders + defense mechanisms
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Positive vs Negative symptoms in schizophrenia
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Positive: hallucinations, delusions, bizzare behavior, thought disorder; Negative: blunted affect, anhedonia, apathy, inattentiveness (negatives thought to be at core of Schizophrenia)
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3 Phases of Schizophrenia
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Prodromal (decline in function, social withdrawal, irritability, newfound interest in religion/the occult); Psychotic (perceptual disturbances, delusions, disordered thought); Residual (flat affect, social withdrawal, odd thinking/behavior; basically. negative symptoms between episodes of psychosis); Pt must have symptoms >6 mos to make diagnosis of schizophrenia
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5 Subtypes of Schizophrenia
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<span style="font-weight:600;">Paranoid </span>(freq. auditory hallucinations, delusions; highest functioning, oldest onset, affect NOT flat); <span style="font-weight:600;">Disorganized </span>(disorganized speech/behavior, flat/inappropriate affect; poor functioning, early onset); <span style="font-weight:600;">Catatonic </span>(motor immobility, extreme negativism, echolalia/echopraxia; rare); <span style="font-weight:600;">Undifferentiated </span>(characteristic of many or no subtypes); <span style="font-weight:600;">Residual </span>(prominent neg. symptoms, with minimal positive ones)
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Psych exam in schizophrenia
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DIsheveled, flattened affect, paranoid delusions/auditory hallucinations/ideas of reference, disorganized thought process, CONCRETE thinking on proverbs etc, intact memory/orientation, lack of insight into disease)
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Epidemiology of schizophrenia
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Men present around 20, women around 30; More babies born in winter + early spring hve it; Strong genetic predisposition (50% monozygotic twins); More in low SES
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Pathophys of Schizophrenia
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Thought to be increased dopaminergic activity (so need dopamine blocker antipsychotics); Prefrontal cortical responsible for neg. symptoms, Mesolimbic responsible for + symptoms
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CT scans in schizophrenia
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Enlarged ventricles, diffuse cortical atrophy (dementia praecox)
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Pharmacologic treatment of positive vs negative symptoms of schizophrenia
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Positive treated better by typical neuroleptics (antipsychotics, D2 block) including chlorpromazine, thioridazine, trifluoperazine, and haloperidols (EPS, Neuro malignant syndrometardive dyskinesia symptoms) ; Negative treated (as well as pos) w/ atypicals like Risperidone, Clozapine/Olanzapine, Quetiapine, Aripiprazole, Ziprosidone (less EPS); Take meds at least 4 wks before determining efficacy
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What are extrapyramidal symptoms, what causes them, and how to treat?
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Occur w/ high-potency neuroleptics (haloperidol, trifluoperazine), see dystonia (spasms) of neck/face/tongue, parkinsonism, and akathisia; Treat w/ antiparkinsonian agents (benztropine, amantadine, etc.) and BZDs; also see tardive dyskinesia and NMS w/ these meds (use atypcals if it happens)
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What drugs cause anticholinergic symptoms?
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Low-potency typical antipsychotics like chlopromazine and thioridazine; See dry mouth, constipation, blurred vision; Treat symptomatically
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Schizophrenia vs Delusional Disorder
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Schizophrenia has bizzare (aliens) or nonbizzare (illness) delusion, daily functioning significantly impaired, and 2 of the following (delusions, hallucinations, disorganized speech or behavior, negative symptoms); Delusional disorder has ONLY nonbizzare delusions at least 1mo, daily functioning not significantly imparied, and doesn't have 2 symptoms (long-term and unremitting)
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Schizotypal vs Schizoid
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Both personality disorders; Schizoid is withdrawm w/ lack of enjoyment from social interactions, emotionally restricted; Schizotypal is paranoid w/ magical/odd beliefs, eccentric, lack of friends, social anxiety: criteris for true psychosis not met
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Symptoms of major depression:
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SIG E CAPS: Sleep (insomnia or hypersomnia), interest, guilt/worhtlessness, low energy, concentration, appetite (up or down), psychomotor activity (agitation or retardation), suicidal ideation; Must have 2 of these for at least 2 wks (and has to have either depressed mood or anhedonia as one of these)
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Manic Episode criteria
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Psych emergency, severely impaired judgment, pt. dangerous to self and others; 1+ wks of abnormally and persistently elevated, expansive, or irritable mood and including 3+ (distractability, increased self esteem/grandiosity, increased goal-directed activity, decreased need for sleep, flight of ideas / racing thoughts, more talkative or pressured speech, excessive involvement in pleasurable activities w/ negative consequences) DIG FAST
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Manic Episode symptoms
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DIG FAST (Distractability, insomnia, grandiosity, flight of ideas, activity/agitation, speech (pressured), thoughlessness)
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Mania vs Hypomania
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Mania lasts 7+ days, severe impairment in social/opccupational fxn, may need hopitalization and have psychotic features; Hypomania lasts 4+ days, no marked impairment in social/occupational fxn, doesn't have psychotic features or require hospitaliation
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Sleep problems with major depressive disorder
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Multiple awakenings, initial/terminal insomnia (hard to fall asleep, early awakening), hypersomnia, REM shifted to earlier in night, stages 3/4 decreased
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SSRI side effects
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Headache, GI disturbances, sexual dysfxn, rebound anxiety
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TCA side effects
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Most lethal in OD, sedation, weight gain, orthostatic hypotension, anticholinergic effects (confusion, blurred vision, constipation, dry mouth, light-headedness, difficulty starting and continuing to urinate, loss of bladder control); Prolonged QTc
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MAOi side effects
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Risk of hypertensive crisis + stroke/MI when used w/ sympathomimetics or tyrosine-rich foods (wine, beer, aged cheese, smoked meats); Risk of serotonin syndrome w/ SSRIs; most common side effect is orthostatic hypotension
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Serotonin Syndrome
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SSRIs used w/ MAOis, OD on serotonin and get autonomic instability, hyperthermia, shivering, GI issues, seizures (may bring coma or death); wait at least 2 wks before switching from SSRI to MAOi
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What to do if need to lower suicide risk greatly in depression or can't take antidepressants (elderly, pregnant)?
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Electroconvulsive therapy: premedicate w/ atropine, general anesthesia + muscle relaxant, induction of seizure (<1 min); 8 treatments over 2-3 wks; Retrograde amnesia is worst side effect, goes away 6 mos
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Rapid cycling bipolar disorder
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Defined by 4+ mood episodes in 1 year (major depressive, manic, mixed); Treat w/ lithium but also anticonvulsants (carbamazepine, <span style="font-weight:600;">valproic acid</span>), which are especially useful for rapid cycling bipolar disorder
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Side effects of lithium
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Weight gain, tremor, GI problems, fatigue, arrhythmias, seizures, goiter, coma, polyuria/polydypsia, alopecia, metallic taste, leukocytosis (benign)
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Bipolar I vs Bipolar II
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BP I is manic depression (involves mania and major depression, though major depression not needed for diagnosis), BP II is recurrent major depressive episodes w/ hypomania [no social/occupational probs] - FULL MANIA means BIPOLAR I, not 2! Treat both w/ lithium, anticonvulsants (carbamazepine, valproic acid esp for fast cycling), olanzapine, ECT, psychotherapy
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Dysthymic Disorder Criteria
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3Ds: 2 years of depression, never asymptomatic >2 mos, 2 listed criteria (CHASES low Concentration, Hopelessness, low/high Appetite, inSomnia, low Energy, low Self-esteem)
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Alternating periods of hypomania with mild to moderate depression
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Cyclothymic disorder, with 2+ yrs of hypomanic symptoms w/ periods of depressionm never > 2 mos symptom-free; treat like bipolar (Lithium, anticonvulsants carbamazepine/valproic acid, olanzapine, psychotherapy, ECT
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Panic disorder
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Spontaneous recurrent panic atacks w/ no obvious precipitant, with persistent concern about having them; always specify with or without agoraphobia; associated w/ major depression, substance abuse, OCD, other phobias; treat w/ SSRI
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Treating panic disorder
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BZDs can be used acutely, but they should be tapered (dependence can opccur) and replaced with SSRIs (paroxetine/sertraline), which are mainstay maintenance drugs for 8-12 mos; Can also use imipramine or other antidepressants; do NOT use high doses initally as activation side effects can mimic panic
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Agoraphobia
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Fear of open spaces, especially those from which it's hard to escape in panic attack (bridge, public transport, crowds); Treat with SSRIs, which will treat underlying panic disorder
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Treating specific phobias
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Systemic desensitization, as pharmacological treatment has not been found effective (can use BZDs or beta blockers during therapy); need to have 6+ mos if under 18, and has to impair functioning to be phobia
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Treating social phobia
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Parexetine (Paxil) and SSRI is FDA approved
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Obession vs Compulsion
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Obsession = recurrent/intrusive thought/feeling/idea; Compulsion = conscious repetitive behavior linked to obsession that relieves anxiety caused by obesession; OCD people have insight (know it's happening and hate it)
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OCD vs Obsessive-Compulsive Personality Disorder
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OCD people have insight into (are bothered by) intrusive thoughts and behaviors that ease anxiety w/ these thoughts; OC-personality disorder = person is unaware/happy and makes lists and is very organize, overconscientious and inflexible
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Treating OCD
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SSRIs in higher-than-normal doses, or TCAs like clomipramine; it's caused by serotonin deficit so SSRIs are first-line
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Treating PTSD
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TCAs (imipramine, doxepin), SSRIs, MAOi, anticonvulsants for flashbacks/nightmares; Try to avoid addictive substances like BZD due to high rate of substance abuse in this pop
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Acute stress disorder
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Major traumatic event followed by anxiety symptoms within 1 month, lasting a maximum of 1 month; Symptoms similar to PTSD (same treatment with TCAs, SSRIs, MAOi, anticonvulsants for flashbacks)
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General anxiety disorder
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Persistent, excessive anxiety > 6 mos; No specific person, event, activity triggers, must be present most days per week; Treat w/ buspirone, BZD, SSRIs, venlafaxine
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Psychological symptoms after stressful but not life-threatening event (divorce, death of loved one, job loss)
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Adjustment disorder; must be within 3 mos of event and end within 6 mos of stressor termination; treat w/ supportive and group therapy, maybe symptomatic pharamcotherapy (insomnia, anxiety)
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Personality Disorder Clusters
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A: Mad, B: Bad, C: Sad; Think you get mad at someone, you do something bad, and then you're sad
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Class A personality disorders
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Schizoid, schizotypal, paranoid (MAD); These pts are perceived as being eccentric and "weird"
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Examples of Axis II disorders:
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MR and personality disorders (OCD, paranoid or schizoid personality disorder, histrionic personality disorder, anxious/avoidant personality disorder, dependent personality disorder)
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Schiophrenia + loss of night vision:
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thioridazine in high doses irreversibly pigments retina (night vision and ultimatel blindness)
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Treating priapism (and psych med cause):
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Trazodone can cause it, tx is epinephrine injection into corpus
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Phenelzine drug class:
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MAOi, so make sure you don't have wine/cheese/beer etc.
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Eating disorders mean which psych drug is contraindicated?
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Bupropion due to decreased seizure threshold (can be used for smoking cessation)
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Symptoms of diabetes insipidus (polyuria/polydypsia) can occur w/ meds for which disease?
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Lithium use with Bipolar disease
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Elective hysterectomy, day 3 has AH, VH, tremors, agitation. What to do?
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Give BZDs because it seems like BZD or alcohol withdrawal
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TCAs and cardiac symptoms?
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Prolongs QTc, can lead to fatal arrhythmias
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Treating bipolar patient with seizures and coma?
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Dialysis needed for lithium toxicity when it's severe/life threatening
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NMS Symptoms:
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movement disorder (rigidity, dystonia, agitation) + autonomic instability (fever, sweating, tachycardia, HTN) with high WBC and CK levels; if it happens, extreme cooling, dantrolene/bromocriptine
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Who shouldn't use lithium?
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Cleared through kidneys, so those w/ renal problems (and elderly)<br />
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Paranoid personality disorder
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Suspicion w/o evidence others are exploiting/cheating, consistently doubt trustworthiness of acquaintances, reluctance to confide in others, interprenting benign remarks as threatening/demeaning, persistent grudges, recurrent suspicions regarding cheating; psychotherapy is treatment of choice
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Quiet/unsociable w/ constricted affect no desire for close relationships and prefer to be alone
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Schizoid personality disorder, little interest in sex, pleasure, confidants, indifferent to praise/criticism, emotional detachment; Treat w/ psychotherapy (esp. group)
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Schizoid vs Schizotypical personality disorder
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Schizoid is an android (detached), while schizotypical bit the bible (pervasive eccentric behavior/thinks there are aliens/likes cults, etc.); both treated w/ psychotherapy
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Cluster B Axis II disorders
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B is bad, so borderline, histrionic,antisocial, borderline and narcissistic personality disorders (emotional, impulsive, dramatic)
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Charming person who is impulsive, deceitful, violates law often
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Antisocial personality disorder; Associated w/ cpmduct disorder before age of 18 often /w hx of being abused of hurting animals or starting fires
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Cluster C Axis II disorders
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Avoidant, dependent, and obsessive-compulsive personality disorders; Pts are anxious and fearful
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Avoidant personality disorder
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Pervasive pattern of social inhibition (shyness) & intense fear of rejection (avoid situations); are easily injured but desire companionship
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Dependent personality disorder
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Poor self-confidence, fear of separationl Excessive need to be taken care of and for others to make decisions for them; helpless when left alone; submissive and clingy; onset must be before early adulthood
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Obsessive-Compulsive Personality Disorder
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Pervasive professionalism, inflexibility, orderliness; O preoccupied w/ details that often unable to complete tasks on time; Stiff, serious, constricted affect
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Substance abuse vs dependence
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Abuse is impairment/distress >1 yr w failure to fulfill obligations, use in dangerous situations, legal problems, or continued use despite social/interpersonal problems; Dependence is at least 3 in 12 month period: tolerance, withdrawal, using more than intended, can't cut down, lots of time spent doing or obtaining (at expense of other things), continued use despite physical/psych problems; Basically, dependence is I want to stop but cannot. Diagnosis of dependence supercedes diagnosis of abuse
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Treating cocaine dependence
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(remember cocaine activates fight-or-flight, withdrawal is opposite so constricted pupils); Use psychotherapy/group therapy, TCAs, and dopamine agonists (bromocriptine, amantadine) for dependence
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Rotatory nystagmus
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Pathognomonic for PCP intoxication; also see recklessness, impulsiveness, impaired judgment, ataxia, HTN, tachycardia, rigidity, high pain tolerance; OD = seizure/coma
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Treating PCP OD
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Monitor BP/temp/lytes (get tachy and HTN), acidify urine w/ ammonium chlorise/ascorbic acid, BZDs or dopa agonists for agitation/anxiety, diazepam for spasms/seizures, haloperidol for severe agitation/psychosis
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BZD vs barbiturate mechanism of action
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Both potentiate GABA; BZD increase frequency of opening, while barbiturates increase duration of Ca++ channel opening; At high doses, barbiturates act as direct GABA agonists so less safe than BZD
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Common date rape drug
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GHB (gamma-hydroxybutyrate), dose-specific CNS depressant
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Treating BZD overdose
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Flumazenil should be used w/ caution, as it may precipitate seizures; ABC, activated charcoal to decrease intestinal absorption
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Treating barbiturate overdose
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ABC, activated charcoal to decrease intestinal absorption, alkalinize urine w/ sodium bicarb to promote renal excretion
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Treating sedative-hypnotic withdrawal (BZD, barbiturates)
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Life-threatening if abrupt stop after chronic use; get hyperactivity (tachy, sweating), anxiety, tremor, n/v, delirium, hallucinations, seizures. Administer long-acting BZD (chlorodiazepoxide or diazepam) and taper dose; Can use tegretol or valproic acid for seizure control
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What is an ingredient in cough syrup?
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Dextromethorphan, which is an opioid (like heroin, codeine, morphine, methodone)
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Opiate intoxication symptoms + treatment
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Drowsiness, n/v, constricted pupils, seizure, respiratory depression, constipation; ABCs and naloxone/naltrexone can improve respiratory depression (but may cause severe withdrawal if dependent - use methadone for dependence)
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Classic triad of opioid OD
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Rebels Admire Morphine (Respiraotry depression, AMS, miosis/constriction)
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Meperidine
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Demerol, an opioid, is the one exception that increases pupil size vs others
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Piloerection, rhinorrhea, dysphoria, insomnia, weakenss, sweating, yawning
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Think opiate withdrawal (use clonidine/buprenorphine for moderate symptoms, methadone for severe for 7d); Withdrawal from opiates is NOT life threatening
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Nicotine's effects on newborn if mother smokes
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Low bbirth weight an persistent pulmonary HTN
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Dementia vs Delerium
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Dementia is memory impairment (without alterations in consciousness), while delirium is impairment of sensorium (waxing/waning)
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Pharmacologic treatment of delirium
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Antipsychotics (quetiapine/seroquel, haloperidol PO/IM since IV needs cardiac monitoring - can cause torsades)
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What should you check for in an eldely pt. with memory problems?
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Major depression is a common cause of memory loss and problems w/ cognitive functioning (this is called pseudodementia)
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Derpessed vs demented patients when asked question they don't know?
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Depressed say "I don't know" and will ofen give correct answer when pressed, whereas demented patients will confabulate and make something up; dementia onset is more insidious (vs acuter in depression) and sundowning (increased confusion) is common in dementia but not depression
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Timeframe for normal grief vs abnormal grief (major depression)
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Normal grief resolves w/in 1 yr w/ worst symptoms w/in 2 mos, while abnormal persists after 1 yr w/ worst symptoms over 2 mos and has SI, no attempt to resume normal activities
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REM sleep in elderly
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Same total amount of time, but more frequent and shorter in duration each time; also less stage 3/4 sleep (Deep) and more 1/2 (more awakenings)
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PT. unable to recall their name but can remember obscure details
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Dissociative amnesia (significant distress or impairment in daily functioning, not explained by another condition or substance use); also the inability to recall traumatic events like rape - hypnosis, lorazepam, or sodium amobarbital can be used to help get the memories out in therapy
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Who gets multiple personality disorder (dissociative identity disorder)?
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Women, as 90% of pts are female
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Primary vs secondary gain in somatoform disorders
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Primary gain is expression of unacceptable feelings as physical symptoms in order to avoid facing them; Secondary gain is for attention, decreased responsiblity, legal reasons, money, etc.
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Somatization disorder
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Physical symptoms w/o organic cause; must have 4+ pain symptoms, 2+ GI symptoms, 1+ sexual symptom, 1+ neuro symptom, ONSET BEFORE 30; think doctor shopping and sickness all their lives; Use CBT to treat
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La belle indifference
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Pt. is surprisingly calm and unconcerned when describing devastating symptoms in conversion disorder
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How long must fear be present in hypochondriasis? How's it different from somatization disorder?
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6+ mos; Somatization patients are concerned about symptoms (always sickly, doctor shop), while hypochondriacs worry about their disease (they have one disease)
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Malingering vs factitious disorder
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Malingering is for secondary gain, while factitious disorder (and Munchhanusen) are for primary gain (no monetary or other incentives, instead is expression of unacceptable feelings as physical symptoms in order to avoid facing them)
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Intermittent explolsive disorder
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Failure to resist impulses to assualt or destroy property (out of proportion to triggering events); SSRIs, anticonvulsants, lithium, propranolol may help; individual psychothrapy is ineffective but group/family therapy may work
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Who tends to have kleptomania?
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1/4 of pts w/ bulimia have comorbid kleptomania (pleasure/relief w/ stealing things not needed for personal/monetary reasons); need psychotherapy and behavioral therapy, as well as SSRIs
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Tricohtillomania
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Recurrent pullg out hair resulting in vivible hair loss (scalp, brows, lashes, facial/pubic har), tension release + pleasure/relief afterward; Use SSRIs, antipsychotics, lithium, hypnosis, relaxation techniques
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EEG in dementia vs delirium
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Dementia has normal EEG, while delirium has either fast waves or geenralized slowing
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Potential medical treatments for Alzheimer's
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NMDA receptor antagonists (memantine), Cholinesterase inhibitors may slow progression (donepezil, rivastigmine, tacrine)
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Vascular dementia vs Alzheimer's
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In vascular dementia, there are infarcts so also see focal neuro defects (hyperreflexia, paresthesias); Onset more abrupt in vascular, and greater preservation of personality in Vascular
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Pick's disease vs alzheimer's onset
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Pick has behavioral and personality changes more prominent early in the disease
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Definition of MR
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Significantly subaverage intellectual functioning (IQ 70 or below_ and deficits in adaptive skills appropriate for age group, onset must be before 18
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What to do in child if considering diagnosis of learning disorder?
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Always rule out hearing or visual deficit
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Conduct disorder
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Pattern of violating rules/rights of others, at least 3 in past year: aggression toward people/animals, deceitfulness, property destruction, serious violation of rules
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Oppositional defient disorder
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6 mos+ of negativitic, hostile, defiant behavior, especially towards adults over children (lost temper, arguments w/ adults, defying adults' rules, deliberately annoying people, easily annoed, anger/resentment, spiteful, blaming others for mistakes/misbehavior)
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ADHD types
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Innatentive (problems listening, concentrating, organizing, easily distracted, forgetful) vs Hyperactivity-Impulsivity (blurting out, interrupting, fidgeting, leaving seat, talking excessively); Can have a mix, must be before age 7 and behavior inconsistent w/ age and development
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Treating ADHD
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Ritalin (methylphenidate) is first line, other amphetamines; SSRIs/TCAs are adjunctive therapies, as is individual and group psychotherapy
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Autism
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Impaired nonverbal behavior (facial expression, gesture), failure to develop peer relationships and reciprocity, lack of varied/spontaneous play, lack of or delayed speech, repetitive use of language, inflexible rituals, preoccupation with parts of objects etc.; Can try tx w/ remedial education & behavioral therapy, neuroleptics, SSRIs for repeptitive behaviors
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Asperger's vs Autism
|
Asperger's children have normal language/cognitive development, while Autistic children have trouble with language; Both have trouble having peer relationships and making friends, and have stereotyped, repetitive behaviors
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|
Rett's Disorder
|
Normal development in F until 5-48 mos, when start lacking purposeful hand mvmt (get stereotyped hand mvmt eventually like hand wringing/washing), early loss of social interaction, gait/trunk problems, severely impaired language, seizures, cyanotic spells (small head circumf); Genetic on X chromosome (methyl-CpG)
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Childhood disintegrative disorder
|
Normal development until 2, then have problems w/ social interaction, use of language, and restrictive/repeptitive behaviors/interests (lose social skills, language, bowel/bladder control, play, motor skills) before 10, more boys than girls
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Tic disorder vs Tourette's
|
Tic is involuntary mvmt or vocalization, and Tourette's is most severe tic disorder (onset before 18); Tics must occur many times daily almost every day for > 1 yr (no tic-free period 3 mos+) for Tourette's; BOTH motor AND vocal tics must be present for diagnosis of Tourette's
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Coprolalia
|
Repeptitive speaking of obscene words (rare in children), as seen in Tourette's
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Treating Tourette's
|
Clonidne is first line; Impaired regulation of dopamine in caudate, so used to use haloperidol or pimozide (dopa receptor antagonists); Supportive psychotherapy as well
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|
Enuresis and types
|
Involuntary bedwetting after age 5, at least 2x weekly for 3 mos; Primary is never got it, secondary is had then lost (ages 5-8), diurnal involves daytime episodes, and nocturnal includes nighttime episodes
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What to check for if thinking enuresis? How to treat?
|
Rule out seizure, diabeter, urethritis; Treat w/ behavior mods (buzzer that goes off w/ wetness) and diuretics (DDAVP) or TCAs (imipramine)
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|
Encopresis
|
Bowel incontinence, which should be there by age 4; Rule out hypothyroidism, anal fissure, IBD, dietary factors; Treat w/ psychotherapy and stool softeners if from constipation
|
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|
Two main types of anorexia
|
Restrictive (eat little, vigorously exercise, withdrawn with OCD-type traits) and Binge eating/purging (Binging/purging/excessive exercise, use of laxatives/diuretics, = depression, substance abuse)
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Anorexia vs bulimia
|
Anorexia has low body weight, bulimia doesn't necessarily
|
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|
Melanosis coli
|
Darkened area of colon 2ary to laxative abuse, as seen in anorexia
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Binge Eating
|
Defined by excessive food intake w/in 2hr period accompanied by sense of lack of control
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Cholesterol in anorexia
|
High!
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|
Bulimia subtypes
|
Purging type: involves vomiting, laxatives, or diuretics; Nonpurging type involves excessive exercise or fasting
|
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|
Primary Hypersomnia
|
1+ mo excessive daytime sleepiness or excessive sleep not attributable to other causes; usually begins in adolescence, amphetamines are first-line
|
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|
Narcolepsy
|
Repeated, sudden sleep attacks in daytime 3 mos+, assoc. w/ cataplexy, short REM latency, sleep paralysis upon waking, and hallucinations (hypnagogic = as going to sleep, hypnopompic = as waking)
|
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|
Excess daytime sleepiness vs fatigue
|
EDS is falling asleep when don't want to (near-misses driving, etc.) as seen with OSA, while fatigue is being too tired to complete activities
|
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|
Nightmare disorder vs night terror disorder?
|
Nightmare is during REM sleep and awaken and remember episode (can use SSRIs to reduce REM); Night terror disorder has apparent fearfulness during stage 3 or 4 sleep (nREM) where they may screem and have intense anxiety but aren't awake and don't remember
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|
Neurotransmitter that enhances vs inhibits libido?
|
Dopamine enhances libido, while serotonin decreases it
|
|
|
Treating sexual desire disorder
|
Testosterone if low levels
|
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|
Freud's Topographic Theory
|
Unconscious (repressed thoughts out of awareness, primary processes), Preconscious (memories easy to bring into awareness), and Conscious (current thoughs, secondary process thinking
|
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|
Primary vs secondary process thinking
|
Primary is primitive, pleasure seeking urges w/ no regard to logic or time, prominent in children/psychotics, associated w/ unconscious in topographic theory); Secondary is logical, mature, and can delay gratification (conscious in Freud's topographic theory)
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Freud's Structural Theory
|
Id (present at birth, unconscious, instinctual sexual/aggressive urges + primary process thinking), Ego (present at birth, mediates id/environment interaction, uses defense mechanisms and reality testing to control ugres and create satisfying interpersonal relationsips), Superego (present after age 6, moral conscience)
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Mature Defense Mechanisms
|
Altruism (vicariously feel good), Humor, Sublimation (channeling to good things), Suppression (purposefully ignore impulse/emotion to accomplish a task)
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NEurotic Defenses
|
Controlling, Displacement (shifting anger to other things/objects), Intellectualization, Isolation of affect (blunting self to decrease emotion/anxiety), Rationalization (justifying things), Reaction formation (doing the opposite of urge), Repression (preventing thought from consciousness vs suppression is a conscious act)
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Immature defense mechanisms
|
Acting out (giving in to impulse to avoid anxiety of suppressing it), Denial (not accepting reality), Regression (performing behaviors from earlier stage of development), Projection (attributing bad thoughts to others)
|
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|
Classical vs operant conditioning
|
Classical is stimulus eventually evoking a conditioned response (Pavlov), operant is learned behaviors via positive or negative reinforcement
|
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|
Systemic desensitization vs flooding/implosion
|
Systemic desensitization is higher and higher amounts of stimulus not causing anxiety, while flooding is giving a huge stimulus and not allowing withdrawal until calmness comes (implosion is imagining flying vs real thing in flooding); both are behavioral therapies
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Token economy
|
Rewards given after specific behaviors to positively reinforce them (often used to encourage showering, shaving etc. in MR/disorganized individuals)
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|
Biofeedback
|
GIve physiological data like HR and BP to allow pt. to learn to control physiological states (for migraine, HTN, chronic pain, asthma, incontinence)
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|
Cognitive Therapy
|
Attempts to correct faulty assumptions (if I do this badly I am stupid and will never be a scientist) , replacing negative thoughts with positive ones (used a lot for depressive and anxiety disorders like panic)
|
|
|
Triangles in family therapy
|
Two family members are turned against the patient (needs to be corrected)
|
|
|
Antidepressants (TCAs, MAOis, SSRIs) and effect on mood, abuse potential
|
NO abuse potential, do not elevate mood (only fix depression)
|
|
|
In what 5 situations can confidentiality be broken?
|
Sharing info w/ other staff treating patient, subpoena (legal), suspect child abuse, immediate danger to others (Tarasoff Duty), pt. is suicidal (may need to admit pt. with or without consent, and share info w/ staff)
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|
Involuntary admission / Civil Commitment
|
2 staff physicians think danger to self/others or unable to care for self; Can be hospitalized against will, after set number of days independent board must rule whether needs continued hospitalization; Pts given holding papers and can contest admission in court at any time
|
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|
Parens patriae
|
Doctrine that allows civil commitment for citizens unable to care for selves
|
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|
Criteria for malpractice
|
There is established standard of care (duty), that physician breached (dereliction), and this led directly to injury or damage to plaintiff; Compensatory damages are for reimbursing patient for medical expenses, loss of salary, etc.; Punitive damages are just to punish doc for negligence
|
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|
Elements of Informed Consent
|
NARCC: Name/purpose of treatment, Alternatives, Risks/benefits, Consequences of refusing, Capacity (pt. must have)
|
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|
Which situations do not require informed consent?
|
Lifesaving medical emergency, suicide/homicide prevention (hospitalization), minors don't need consent from parents for: OB care, STD care, substance abuse care (keep all info confidential from parents in these cases)
|
|
|
Emancipated Minors
|
Competent to give consent w/o input from parents; Self-supporting, in military, married, have children
|
|
|
Competence vs Capacity
|
Competence is legal term (only judge can rule) vs capacity is clinical term assessed by physicians
|
|
|
Decisional capacity depends on what?
|
Task-specific and can fluctuate over time, so pts may have capacity to make one decision while lacking capacity to make another (must assess on treatment-specific basis)
|
|
|
Criteria for Capacity:
|
Can communicate choice/preference, Understands and can explain (purpose, risks/benefits, alternatives), Appreciates situation/consequences, Can logically and aratioanlly manipulate situation/conclusions
|
|
|
Competence to stand trial: what are criteria?
|
Must understand charges against them, have ability to work w/ attorney, understand possible consequences, and be able to testify
|
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|
Criteria for pleeading insanity
|
Must have mental illness, not understand right from wrong, and not understand consequences of actions at time act was committed
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|
What do TCAs do?
|
Inhibit reuptake of serotonin and norepinephrine; rarely used first-line due to higher incidence of side-effects, require greater dose monitoring, and are <span style="font-weight:600;">lethal in overdose</span>!
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|
|
Hallmark of TCA toxicity + treating OD
|
Widened QRS (>100 msec), used as threshold to treatment; Mainstay of treatment for TCA OD is IV sodium bicarbonate
|
|
|
TCA side-effects + major complications
|
Anti-HAM: anti-histaminic (sedation), anti-adrenergic (orthostatic hypotension, tachycardia, arrhythmias), anti-muscarinic (dry mouth, constipation, urinary retention, blurry vision, tachycardia), weight gain, lethal in OD (assess suicide risk!); Major complications are 3Cs: convulsions, coma, cardiotoxicity (watch w/ preexisting conduction abnormailities)
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|
|
What do MAOIs do?
|
Prevent inactivation of biogenic amines (norepi, serotonin, dopa, tyramine); very effective for refractory depression and refractive panic disorder
|
|
|
Phenelzine
|
MAOI
|
|
|
Common side effects for MAOIs
|
Orthostatic hypotension, drowsiness, weight gain, dry mouth (all so far like TCAs), sexual dysfxn, sleep dysfxn
|
|
|
Hypertensive Crisis
|
Risk when MAOIs sre taken with tyramine-rich foods (wine, cheese, chicken liver, fava beans, cured meats) or sympathomimetics
|
|
|
SSRI side-effects
|
far fewer than TCAs or MAOi, but can have sexual dysfxn, GI disturbance, insomnia, headache, anorexia/wt loss, serptpnin syndrome with MAOIs
|
|
|
Bupropion
|
NDRI (norepi/dopa reuptake inhibitor) commonly used for smoking cessation + seasonal affective disorder, adult ADHD; Lack of sexual side effects vs SSRIs, side effects similar to SSRIs (sweating, risk of seizure + psychosis at high doeses), bad for pts with high anxiety and those on MAOis, and <span style="font-weight:600;">decrease seizure threshold</span>
|
|
|
Trazodone
|
SARI (Serotonin antagonist and reuptake inhibitor) good for refractory major depression, anxiety (due to sedative side effects); Side effects like mausea, dizziness, orthostatic hypotension, cardiac arrythmias, <span style="font-weight:600;">sedation, priapism</span>; tRAZodone with RAISE the bone (priapism)
|
|
|
Mirtazapine
|
NASA (Norepi and serotonin antagonists) useful for treatment of major depression, especially in those who need to gain weight or in elderly; Sedation, <span style="font-weight:600;">weight gain</span>, tremor, agranulocytosis; Maximal sedative effect at low doses (higher doses have increased norepi uptake)
|
|
|
Typical vs atypical antipsychotics - receptors
|
Typical block dopamine receptors (D2), while atypicals block both dopa and serotonin, so they have fewer side effects
|
|
|
Low potency antipsychotics
|
Chlorpromazine and thioridazine, which have lower affinity for dopa receptors and thus higher dose required; higher incidence of anticholinergic/antihistaminic side effects [dry mouth, constipation, urinary retention, blurry vision] than high-potency, but fewer extrapyramidal effects and NMS (also may lower seizure threshold)
|
|
|
Which antipsychotics are available in long-acting (depot) forms?
|
Haloperidol and fluphenazine
|
|
|
High potency typical antipsychotics
|
Greater affinity for dopa receptors (need less) but more EPS w/ fewer anticholinergic/antihistaminic effects; Haloperidol, fluphenazine, trifluoperazine, perphenazine, pimozide
|
|
|
What does dopa normally do in brain?
|
Inhibits prolactin and ACh secretion
|
|
|
EPS of typical antpsychotics
|
Antidopaminergic, so see parkinsonism, akathisisa, dystonia (sustained contraction, hyerprolactinemia (decreased libido,galactorrhea/gynecomastia); Treat w/ antiparkinsonian, anticholinergic, antihistaminic meds (Amantadine, benadryl, benztropine)
|
|
|
Side effects of typical antipsychotics
|
EPS (parkinsonism, akathisia, dystonia), anti-HAM (histamine [sedation], muscarinic [dry mouth, tachy, urainry retention/constipation, blurry vision], adrenergic [orthostatic hypotension, sexual probs, cardiac probs]); Weight gain, liver enzymes/jaundice, ophtho probs, derm problems, seizures, tardive dyskinesia, NMS
|
|
|
Irreversible retinal pigmentation with which antipsychotic?
|
Thioridazine
|
|
|
Deposits in lens and cornea w/ which typical antipsychotic?
|
Chlorpromazine
|
|
|
Blue-gray skin discoloration with which typical antipsychotic?
|
Chlorpromazine, which also puts deposits in lens + cornea
|
|
|
NEuroleptic MAlignant Syndrome
|
FALTER (fever, autonomic instability, leukocytosis, tremor, elevated CPK, rigidity); STOP current meds, hydrate, cool, give dantrolene/bromocriptine/amantadine; Can restart neuroleptic at later time (this is NOT an allergic rxn)
|
|
|
What side effects don't atypical antipsychotics have?
|
Rarely cause EPS (parkinsonism, etc.), tardive dyskinesia, or NMS; More effective in treating negative symptoms of schizophrenia, too (First line for treatment of schizophrenia)
|
|
|
Treating mania
|
Quetiapine, Ziprasidone both FDA-approved
|
|
|
What must you do w/ clozapine?
|
Weekly blood draws for WBC counts because can cause agranulocytosis; atypical antipsychotic that can be used for tardive dyskinesia
|
|
|
Olanzapine side effects
|
Hyperlipidemia, weight gain, glucose intolerance, and liver toxicity(need to monitor LFTs) [Atypical antipsychotic]
|
|
|
Quetiapine - what tests do you need?
|
Show to cause cataracts in beagles so need slit lamp exams q6mos [Atypical antipsychotic]
|
|
|
Atypical antipsychotics
|
Clozapine, Risperidone, Quetiapine, Olanzapine, Ziprasidone; Block both dopa and serotonin receptors, rarely cause EPS side effects, NMS, and tardive dyskinesia (unlike typicals) but cause weight gain and diabetes
|
|
|
Mood stabilizers
|
Antimanics (used for manic episodes), can also be used to potentiate antidepressants/antipsychotics, treat impulsivity/aggression. Include lithium and two anticonvulsants, carbamazepine, and valproic acid
|
|
|
Therapeutic range for Lithium an what needs to be monitored
|
0.7-1.2, toxic above 1.5, lethal above 2; Can see AMS, cparse tremor, convulsion, death; Need to monitor Li levels, TSH levels (can cause hypothyroidism), and GFR periodically (can cause nephrogenic DI)
|
|
|
Lithium's side effects
|
Hypothyroidism/thyroid enlargement, nephrogenic DI (it's a salt so renally cleared), fine tremor, ataxia, metallic taste, polyuria, edema, weight gain, GI problems, benign leukocytosis
|
|
|
Carbamazepine uses
|
Especially for mixed episodes and rapid cycling bipolar disorder; Also used for trigeminal neuralgia (onset 5-7d); side effects incude hyponatremia, aplastic anemia, leukopenia, <span style="font-weight:600;">agranulocytosis</span>, NTD in pregnancy
|
|
|
Carbamazepine side effects
|
[Mixed/rapid-cycling bipolar] hyponatremia, aplastic anemia, leukopenia, agranulocytosis, NTD in pregnancy; also see skin rash, drowsiness, ataxia, slurred speech; get <span style="font-weight:600;">CBC and LFTs and monitor regularly</span> (as with valproic acid)
|
|
|
Factors that affect Lithium levels (what drugs not to take)?
|
NSAIDS decrease, dehydration/salt deprivation/impaired renal fxn all increase, diuretics, aspirin
|
|
|
Valproic acid use and side effects
|
increases GABA to treat mixed and rapid cycling bipolar dz; Hepatotoxicity, thrombocytopenia, NTDs in pregnancy; also has sedation, wt gain, alopecia, hemorrhagic pancreatitis; <span style="font-weight:600;">Monitor LFTs (liver failure) and CBC</span> (as with carbamazepine)
|
|
|
Long-acting benzos vs short-acting (names)
|
Chlordiazepoxide, diazepam, flurazepam are long [Had the flu, drank clorox, died]; Oxazepam and triazolam are short [3 oxen]; all others intermediate (10-20h)
|
|
|
Zolpidem
|
Short-term insomnia treatment that acts like BZD but isn't; no anticonvulsant or muscle relaxant effects, no withdrawal/tolerance/dependence, minimal rebound insomnia
|
|
|
Buspirone
|
Alternative to BZD or venlafaxine for general anxiety disorder that hits serotonin; slower onset than bzd (1-2 wks), does not potentiate CNS depression of alcohol (useful in alcoholics but not for BZD/alcohol withdrawal), low potential for abuse/addiction
|
|
|
Propranolol uses
|
Beta blocker that can be used for autonomic effects of panic attacks (ultimately need SSRI) or performance anxiety (palpitations, sweating, tachycardia); Can also be used to treat akathisia (side effect of typical antipsychotics)
|
|
|
What causes dystonia, how to treat?
|
High-potency traditional antipsychotics cause, reversible (occurs w/in days), can be life threatening if dystonia of diaphragm; Give anticholinergics like benztropine and trihexyphenidyl, or benadryl
|
|
|
What causes tardive dyskinesia, how to treat?
|
Occurs after years of typical antipsychotic use, can be irreversible (should monitor for it q6mos because of this); need to stop meds if this occurs, give clozapine
|
|
|
Fever, tachycardia, HTN, tremor, lead pipe rigidity, elevated CPK
|
Neuroleptic Malignant Syndrome, med emergency w/ 20 percent mortality rate
|
|
|
Two main diagnostic criteria for schizophrenia
|
Delusions and auditory hallucinations; ask whether there are 2+ people talking, if voices comment on patient, or the delusions are bizzare because this makes diagnosis easier; also, look for social and/or occupational dysfxn
|
|
|
Major issue in treatment w/ atypical antipsychotics
|
Metabolic syndrome (obesity, glucose intolerance/DM, HTN, dyslipidemia)
|
|
|
Hyperprolactinemia cause and effects
|
Typical antipsychotics cause impotence, amenorrhea, or gynecomastia
|
|
|
Treating dystonic and Parkinsonian symptoms of typical antipsychotics
|
Can reduce dose or use anticholinergic drug like benztropine/benadryl
|
|
|
Treating akathisia symptoms of typical antipsychotics
|
Taper dose as much as possible, then propranolol (or Benzo)
|
|
|
Schizoaffective Disorder
|
criteria for manic or major depressive episode, and must have had delusions/hallucinations for 2+ wks in absence of mood disorder symptoms (to differentiate from mood disorder w/ psychotic features)
|
|
|
Treating Narcolepsy:
|
since it's a disorder of REM at inappropriate times, use antidepressants, which decrease amt of REM sleep
|
|
|
Which meds act through GABA receptors?
|
BZDs, barbiturates, and anticonvulsants (this explains cross-tolerance)
|
|
|
Where do BZDs act?
|
GABA receptors
|
|
|
Where do barbiturates act?
|
GABA receptors
|
|
|
Where do many anticonvulsants act?
|
GABA receptors
|
|
|
What neurotransmitter is likely responsible for schizophrenia?
|
Dopamine is hyperactive in schizophrenia (antipsychotic block dopa receptors)
|
|
|
Decreased REM latency can be seen with what?
|
Major depression; also see early morning awakening
|
|
|
Kid took some pills, now neck twisted to one side, eyes rolled upward, tongue out?
|
Dystonic reaction to high-potency neuroleptic like Haldol; give diphenhydramine or another anticholinergic to treat
|
|
|
Severe forgetfulness in an alcoholic psych pt?
|
Think thiamine deficiency and Korsakoff syndrome (anterograde amnesia, can't form new memories)
|
|
|
Treating neuroleptic malignant syndrome:
|
Dantrolene or Bromocriptine, though amantadine is sometimes used
|
|
|
Perphenazine side effects:
|
As with other typical antipsychotics, Tardive Dyskinesia (choreoathetoid movements); will increase as dose is lowered (withdrawal dyskinesia) and get a bit better within 18 mos but never fully go away
|
|
|
Labs to get when using clozapine:
|
WBC and differential due to risk of agranulocytosis; atypical antipsychotic that can be used for tardive dyskinesia
|
|
|
Treating akathesia:
|
Taper dose of typical antipsychotic, then propranolol if not (or benzo)
|
|
|
Necessary conditions for major depressive disorder:
|
Either depresed mood or anhedonia
|
|
|
Likelihood to have more depression if had one major depressive occurence:
|
50-85% will have one further episode within 2-3 days
|
|
|
Most useful test for monitoring depressive symptoms and memory during the course of ECT?
|
Beck Depression Inventory (objective measure) for depression, Brown-Peterson task for memory
|
|
|
Test a schizophrenic wouldn't do well on
|
Wisconsin Card Sorting Test (WCST), since it tests executive fxn (frontal lobe) because you need to decide the new rule set for inclusion of cards
|
|
|
Cluster A Axis II disorders
|
Schizoid, schizotypal, paranoid personality disorders (odd and eccentric)
|
|
|
Cortisol in PTSD vs MDD
|
Cortisol is high in MDD but low in PTSD
|
|
|
Hallucinations vs delusion
|
Hallucinations tend not to go away when you pay more attention to them, while delusions go away (like PTSD)
|
|
|
Assessing hemispheric dominance
|
Wada test (sodium amytal into L carotid and assessing effects on speech)
|
|
|
Most common way adolescents commit suicide
|
More attempt with drug OD, but more succeed with firearms
|
|
|
Treating bulimia
|
Best tx is cognitive behavioral therapy (CBT) - also treats panic disorder well; can use SSRIs
|
|
|
Rumination Disorder
|
Repeated regurgitation and rechewing of food, as seen with infants in unstable environments with a variety of caretakers
|
|
|
Children vs adolescents and DD
|
Children tend to have more psychomotor agitation and anxiety/irritability thanadolescents, who are more sad/depressed (hypersomnia, hopelessness, weight change, drug abuse)
|
|
|
Common adverse effect of DDAVP (as when given for enuresis)
|
Headache
|
|
|
Fluoxetine Side Effects
|
Major ones of SSRI are GI upset, insomnia, agitation, headache; NOT sedation, weight gain
|
|
|
Most common initial symptoms in Tourette's
|
Eye rolling and blinking (eye tics)
|
|
|
Tourette's criteria
|
Multiple motor tics and vocal tics must be present during illness (not necessarily concurrently), onset before 18, neay every day for at last 1 year witho 3mo+ symptom-free period
|
|
|
What's a boy with enuresis likely to have?
|
Nothing! Most boys with enuresis are normal (no increased prevalence with MR, autism, etc.)
|
|
|
Yellowed skin in a thin woman
|
Think overeating carrots in attempt to satisfy appetite with low-calorie food
|
|
|
Which children don't have stranger anxiety?
|
Autistic children
|
|
|
At what age can children understand the irreversibility of death?
|
Around 7 or 8 (6-10)
|
|
|
Frequent adverse effect of clonidine (used for Tourette's)?
|
Sedation (subsides with continued treatment)
|
|
|
Possible complication of using methylphenidate in children?
|
Can unmask tics (but won't make them worse and thus can be used in ADHD when children have tics)
|
|
|
What infection as a child predisposes to OCD?
|
Group A Strep! Also predisposes to Tourette's; Tourette's and OCD frequently co-occur
|
|
|
Young boy with rectal bleeding and anemia
|
Think stereotypic movement disorder, in which there is self-inflicted bodily harm due to repetitive behavior
|
|
|
IQs that are mild, moderate, severe, and profoundly MR
|
Mild is 70-55, Moderate is 54-40, Severe is 39-25, and Profound is below 25 [So 70 down by 15 for mild, moderate, severe, profound]
|
|
|
Cotard Syndrome
|
Nihlistic delusion content (world doesn't exist)
|
|
|
Capgras Syndrome
|
Belief that people are replaced by replicas
|
|
|
Etiology of postpartum psychosis characterized by depression, mood lability, delusions, hallucinations
|
Most cases result from bipolar disorder
|
|
|
Common component of schizophrenia prodrome
|
Progressive social withdrawal, increasing negative symptoms in absence of positive ones
|
|
|
Downward drift hypothesis
|
Chronic mental illnesses have tendency to push sufferers down SES
|
|
|
What to make sure of before giving antidepressants?
|
R/o bipolar d/o because you can induce manic symptoms
|
|
|
Most common sleep disturbance in MDD
|
Early morning awakening; Combined psychotherapy and pharmacotherapy is best
|
|
|
Cycling between hypomania and dysthymia
|
Cyclothymia
|
|
|
Psych sx w/ strong abdominal pain
|
Check urinary porphobilinogen (porphyria possible)
|
|
|
What hallucinations are seen in schizophrenia-spectrum illness?
|
Mainly auditory, rarely visual; Nonauditory hallucinations tend to imply delirium
|
|
|
Nonauditory hallucinations
|
Nonauditory hallucinations tend to imply delirium auditory are seen w/ schizophernia-spectrum illnesses
|
|
|
Mobius Syndrome
|
Congenital absence of facial nerves + nucle w/ resulting b/l facial paralysis
|
|
|
Brain structure damaged w/ Kluver-Bucy Syndrome
|
Amygdala (see anterograde amnesia as well)
|
|
|
83 percent body weight, missed 3 periods, binges then exercises a lot
|
Anorexia automatically if miss 3+ periods, not bulimia; Below 85 pct body weight implies anorexia
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Labs in anorexia
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Hypercholesterolemia, high BUN (due to starvation), high GH
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HPA in MDD
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Dexamethasone suppression test positive in 50 percent (thus normal HPA); Patients w/ psychotic depression even less likely to respond to dexamethasone
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Next step after diagnosing woman w/ postpartum psychosis?
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Admit her for safety of baby
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Alcoholic lab value
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GGT increased
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Schizophrenia with echolalia (repeating others' words inappropriately), echopraxia (repeating others' gestures inappropriately), weird motor behaviors like dacial expressions
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Catatonic Subtype
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Pupils in cocaine, heroin, PCP
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Cocaine dilates, heroin constricts, PCP causes nystagmus like alcohol
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Factitious Disorder
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Put thermometer into hot water and manufacture other symptoms to gain gratification from assuming the sick role
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Infarcts of L frontal hemosphere (L MCA) vs R frontal hemisphere (R MCA)
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L give you depression, while R give you euphoria; Diffuse b/l frontal injury may give OCD
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Ages 30-50, cause of impotence
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90 percent of etiologies are psychological
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Prosody
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melody/rhythm/intonation of speech that carries its emotional quality
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Localized Amnesia vs continuous amnesia:
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memory loss surrounding discrete period of time (typically after traumatic event) vs memory loss of everything after a trauma except immediate past (continuous)
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Retrograde amnesia:
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Amnesia for event before a traumatic event
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Risk of schizophrenia if one vs 2 parents have it?
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12 percent if one, 40 if two, 40-50 if monozygotic twin has it
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REM sleep in depression:
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decreased REM latency, more REM in beginning of sleep, decreased deep (stage 3/4) sleep
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Thinking nothing exists and one is dead (disintegrated body with rancid odor):
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Cotard syndrome
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Anterograde vs Retrograde Amnesia:
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Retrograde is loss of remote or previously formed memories, while anterograde is loss of immediate or short-term memory
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Flight of ideas vs loosenig of associatons
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Can follow connections in flight of ideas, while in lossening of associations you have no clue how one got to the other
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Palinopsia
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Persistence of visual image after stimulus has been removed
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Which parts of brain have increased activity in OCD?
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Caudate nucleus, frontal lobes, and cingulum
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Circumlocution
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Substitution of description for word that can't be recalled or spoken
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Prosopagnosia
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Can't recognize faces despite perception of all components
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NEurovegetative signs
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Physiologic aspects of depression like changes in sleep, bowel habits, and weight
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Portions of brain decreased in schizophrenia
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Hipoccampus, parahippocampus, amygdala
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Brain area active in anxiety
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Locus ceruleus, which is center for most norepi-containing neurons in brain
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Where in brain is dopamine made?
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Substantia nigra
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Predictive factor most associated w/ suicide risk
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Age over 45 is top, then things like ETOH dependence, rage/violence, prior attempts, M gender, schizophrenia puts at high risk for suicide
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Most common disease in psych hospitalizations
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Schizophrenia
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What drug often causes psychotic or depressive symptoms?
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Slucocorticoids like prednisone are a common iatrogenic cause of reversible depression or psychosis
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One of the most dangerous withdrawals is from ths drug:
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Alprazolam (short-acting benzos in general are horrible)
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Glossolalia
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Ability to speak a new language suddenly
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Seorotonin Syndrome Effects
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Tachycardia, flushing, fever, HTN, myoclonic jerking, ocular oscillations
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MDD with weight gain, hypersomnia, SI and thinking about death
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MDD with atypical symptoms is best treated with MAOis but side effect profile is huge so use SSRIs
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How long does MDD need on meds?
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About 50 percent need 6 weeks for it to work (considered an adequate trial); Combined psychotherapy and pharmacotherapy is best
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Molecular effects of SSRIs
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Downregulate postsynaptic 5HT2 binding sites
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Most common serious complication of NMS
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Rhabdomyolysis (though renal failure, MI, DIC, PE can occur as well)
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Most potent antianxiety med
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Clonazepam, long half-life
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Lab studies needed with Lithium
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BUN/Cr due to kidney excreting 95 pct unchanged, Thyroid studies needed since lithium inhibits synthesis/release of thyroid hormone, may cause benign WBC elevation
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What OTC med shouldn't be used w/ Lithium?
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NSAIDS (use Aspirin instead) since in some people they increase lithium levels
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Most common side effects of methylphenidate
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Difficulty falling asleep and decreased appetite
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Differentiating schizophrenia from schizoaffective disorder
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Schizophrenia does not have prominent mood symptoms, while schizoaffective have persistence of 2+ wks psychotic symptoms without mood symptoms (as opposed to mood d/o w/ psychotic features)
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Brief Psychotic Disorder
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Psychotic symptoms up to 1 mo, followed by return to premorbid fxn; can be due to stress or postpartum but also w/o antecedent; Postpartum psychosis starts 1-2wks from delivery and can last 2-3 mos (no 1 mo limit)
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Schizophreniform disorder
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resembles schizophrenia but resolves completely in less than 6 months (schizophrenia or bipolar disorder most often result)
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Mood Disorder from a General Medical Condition example
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Endocrine disorders like thyroid and adrenal dysfxn are common etiologies
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Acute vs Chronic PTSD
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Acute is under 3 mos, chronic over 6 mos of symptoms; Delayed-onset PTSD means symptoms appear 6 mos+ after stressor
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PTSD Pieces
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Over 1 mo symptoms w/ significant impairment in fxn: Traumatic event, re-experiencing (with hyperarousal), and avoidance/numbing
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Thoughts in OCD vs Schizophrenia
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OCd has obsessions that are unwanted/obtrusive, while schizophrenics are ok with their delusions and don't notice them
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Correlations w/ antisocial personality disorder in men vs women
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Correlated w/ substance abuse in men, somatization disorder in women
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When is dialectical behavioral therapy (DBT) used?
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Developed specifically for borderline personality disorder, validated empirically
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Tolerance and withdrawal: abuse or dependence?
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Dependence once you have withdrawal and tolerance
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Rosacea and palmar erythema
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Consider alcohol abuse/dependence
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Drugs for alcohol cessation
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Disulfram (dangerous), Naltrexone (takes away high), and Acamprosate (similar to naltrexone)
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Barbiturates
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Pentobarbital/Phenobarbital used more for seizure and anesthesia now, VERY bad withdrawal, act by increasing duration of GABA channel opening
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Opiates
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Morphine, Heroin, Codeine, Meperidine; See pupillary constriction (psychomotor slowing, drowsiness, inactivity), resp depression, slurred speech, hypotension; N/V and constipation common; see <span style="font-weight:600;">lacrimation, yawning</span>, pupillary dilation, piloerection, sweating, fever, hot/cold flashes, diarrhea in withdrawal
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Buprenorphine
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Opiate withdrawal helper (like methodone but can be done outpt)
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Treating cocaine-related depression
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Bupropion (NDRI) or desipramine are good
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Who is at risk for HIV, endocarditis, pneumonia, hepatitis, cellulitis
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Opiate addicts (Morphine, Heroin, Codeine, Meperidine)
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What to check for with bulimia/anorexia?
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Heart, as can have cardiomyopathy from ipecac toxicity and cardiac conduction problems with hypokalemia from the vomiting; Also, with 75 pct or under wt, refeeding syndrome (delerium, seizure, rhabdomyolysis) occur due to hypophosphatemia (sudden carb load depletes phosphate stores)
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ADHD criteria
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Onset before age 7, in 2+ settings (otherwise may just be environmental or psychodynamic cause)
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Genetic basis for Rett's?
|
X chromosome, Methyl-CpG binding protein
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Which neurotransmitted is implicated in delirium?
|
Decreased CNS ACh is thought to cause delirium
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Somatization Disorder treatment
|
CBT, antidepressants, single-physician structured treatment (these people go to multiple docs)
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Two meds that have been shown to decrease suicide risk
|
Lithium in bipolar disorder, and clozapine in schizophrenia; however, abrupt lithium discontinuation increases suicide risk greatly for at least 1 year
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Bereavment length, treatment
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Normal bereavment lasts up to 2 mos, treat depression with antidepressants
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Who shouldn't get TCAs?
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People with cardiac conduction problems as TCAs can worsen them
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Treating hypertensive crisis
|
Caused by MAOi + tyramine-rich food; give phentolamine (a-blocker) to take down BP, can give continuous nitroprusside infusion
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Treating neuroleptic-induced Parkinsonism or dystonia
|
Anticholinergics like benztropine and trihexyphenidyl, or benadryl
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Treating opaite withdrawal
|
Clonidine, which is also used for Tourette's
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Used in alcohol dependence
|
Naltrexone
|
|
|
Memantine
|
NMDA receptorantagonist used for Alzheimers (along with anticholenesterases like rivastigmine, donepezil, and tacrine)
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|
|
NMS vs serotonin syndrome timing
|
NMS can be more gradual while serotonin syndrome tends to be rapid onset (and have more prominent GI symptoms like nausea/diarrhea, shivering, hyperreflexia)
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|
|
Oculogyric Crisis
|
Acute dystonia of ocular muscles induced by antipsychotic meds like haloperidol; Use anticholinergic meds (benztropine, benadryl)
|
|
|
EKG changes in bulimia
|
Flattened T waves w/ development of U waves (hypokalemia)
|
|
|
Best treatment for alcohol dependence after successful detox with benzos?
|
AA, CBT, and naltrexone are a good combination
|
|
|
Anticholinergic delirium vs NMS or Serotonin Syndrome
|
Anticholinergic delerium has hot/dry skin, while NMS/serotonin have diaphoresis
|
|
|
Drug for depression with history of ADHD
|
Bupropion, since it is an NDRI and norepi may help ADHD
|
|
|
Leading cause of OD-related deaths in psych population
|
Nortriptyline (QT interval prolongation causes cardiac arrhythmia and death)
|
|
|
What makes bipolar disease have atypical features?
|
Mood reactivity and significant weight gain, hypersomnia, leaden paralysis during mood episode
|
|
|
Neurotransmitter associated w/ anxiety
|
GABA
|
|
|
Benzos metabolized by conjugation and with no long-acting metabolites
|
Oxazepam, lorazepam, temazepam
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