Psychiatry Shelf Exam Quick Facts – Flashcards
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neurotransmitter changes in anxiety
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increased NE decreased GABA decreased serotonin (5-HT)
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neurotransmitter changes in depression
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decreased NE decreased serotonin (5-HT) decreased dopamine
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neurotransmitter changes in Alzheimer's disease
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decreased Ach
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neurotransmitter changes in Huntington's disease
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decreased GABA decreased Ach
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neurotransmitter changes in schizophrenia
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increased dopamine
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neurotransmitter changes in Parkinson's disease
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decreased dopamine increased Ach
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Korsakoff's amnesia
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classic anterograde amnesia (inability to remember things that occured after a CNS assault) caused by thiamine deficiency bilateral destruction of mammillary bodies may also lead to some retrograde amnesia a/w alcoholism a/w confabulations
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dissociative amnesia
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inability to remember important personal information, usually subsequent to severe trauma or stress
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delirium
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waxing and waning level of consciousness with acute onset rapid decrease in attention span and level of arousal acute mental status changes disorganized thinking hallucinations (often visual) illusions misperceptions disturbance in sleep-wake cycle cognitive dysfunction most common psychiatric illness on medical and surgical floors abnormal EEG
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dementia
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gradual decrease in cognition with no change in level of consciousness memory deficits* aphasia agnosia loss of abstract thought behavioral/personality changes impaired judgment patient is alert (unlike delirium) normal EEG
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depression in the elderly
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may present like dementia
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common causes of dementia
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Alzheimer's disease vascular thrombosis hemorrhage HIV Pick's disease (frontotemporal lobe dementia) substance abuse CJD
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olfactory hallucinations
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often a/w aura in psychomotor epilepsy
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tactile hallucinations
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alcohol withdrawal (formication) cocaine abusers ("cocaine bugs")
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hypnagogic hallucinations
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occurs while GOing to sleep
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hypnopompic hallucinations
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occurs while waking from sleep (POMPous on awakening)
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sleep patterns of depressed persons
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decreased slow wave sleep decreased REM latency increased REM early in sleep cycle increased total REM sleep repeated nighttime awakenings early-morning awakening* (important screening question)
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risk factors for suicide completion
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sex (male) age (teenager or elderly) depression previous attempt ethanol or drug use loss of rational thinking sickness (medical illness, 3+ prescription meds) organized plan no spouse (divorced, widowed, single, esp if no kids) social support lacking
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types of delusions
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--grandeur (beliefs that one has special powers) --paranoid --reference (belief that some event is uniquely related to patient, like radio/tv characters speaking to him/her) --thought broadcasting (belief that one's thoughts can be heard by others) --religious (conventional beliefs exaggerated)
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insight
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level of awareness and understanding of problem; problems with insight include complete denial of illness and blaming it on something else
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judgment
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ability to understand the outcome of actions and use this awareness in decision making
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what are the criteria of a serious suicide threat?
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-detailed plan -intent -means
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mental retardation IQ scores
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mild= 50-70 moderate= 35-50 severe= 25-25 profound= < 25
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differential diagnosis of psychosis
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--psychosis 2/2 GMC --substance induced psychotic d/o --delirium/dementia --bipolar d/o --MDD with psychotic features --brief psychotic d/o --schizophrenia --shizophreniform d/o --schizoaffective d/o --delusional d/o **always rule out medical, neurological, and substance-induced conditions**
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medical causes of psychosis
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1. CNS dz [stroke, MS, neoplasm, Parkinson's, Huntington's chorea, temporal lobe epilepsy, encephalitis, prion dz] 2. endocrinopathies [Addison's/Cushing's dz, hyper/hypothyroidism, hyper/hypocalcemia, hypopituitarism] 3. nutritional/vitamin deficiencies [B12, folate, niacin/B3] 4. other [connective tissue dz like SLE and temporal arteritis; porphyria]
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causes of medication/substance-induced psychosis
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antidepressants antiparkinsonian agents antihypertensives antihistamines anticonvulsants digitalis beta blockers antituberculosis agents corticosteroids hallucinogens amphetamines optates bromide heavy metal toxicity alcohol
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3 phases of schizophrenia
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1. prodromal = decline in functioning that precedes 1st psychotic episode; socially withdrawn and irritable; +/- physical complaints; +/- new interest in religion/occult 2. psychotic = perceptual disturbances, delusions, disordered thought process/content 3. residual = occurs between episodes of psychosis; flat affect, social withdrawal, odd thinking/behavior (negative symptoms); can continue to have hallucinations even with treatment
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negative symptoms of schizophrenia
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The FIVE A's of Schizophrenia: anhedonia affect (flat) alogia (poverty of speech) avolition (apathy) attention (poor)
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DSM-IV criteria for schizophrenia
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2+ for at least 1 month: delusions, hallucinations, disorganized speech, grossly disorganized/catatonic behavior, negative symptoms causes significant social and occupational functional deterioration duration of illness for at least 6 months (including prodromal or residual periods in which above criteria may not be met) symptoms not due to medical, neurological, or substance abuse
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5 subdivisions of schizophrenia
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1. paranoid (highest functioning type) 2. disorganized (speech, behavior, & flat/inapprop affect) 3. catatonic (motor immobility, excessive purposeless motor activity, extreme negativism/mutism, peculiar voluntary movements/posturing, echolalia/echopraxia) 4. undifferentiated (features of >1 subtypes) 5. residual (prominent neg sxs)
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dopamine pathways
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affected in schizophrenia: --prefrontal cortical = negative symptoms --mesolimbic = positive symptoms others: --tuberinfundibular = blocked by neuroleptics --> hyperprolactinemia --nigrostriatal = blocked by neuroleptics --> EPS
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typical antipsychotics
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D2 antagonists, good for + sxs, ADRS = EPS, NMS, tardive dyskinesia chlorpromazine (Thorazine) thioridazine (Mellaril, Novoridazine, Thioril) trifluoperazine (Stelazine) haloperidol (Haldol)
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atypical antipsychotics
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5-HT2 + D2 antagonists, good for - sxs, lower incidence of EPS risperidone (Risperdol) clozapine (Clozaril) olanzapine (Zyprexa) quetiapine (Seroquel) aripiprazole (Abilify) ziprasidone (Geodon)
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treating EPS 2/2 antipsychotics
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Antiparkinsonian agents: --benztropine/Cogentin (anticholinergic) --amantadine (increases release of DA, NE; also anticholinergic) BZDs
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what are the common EPSs a/w high potency antipsychotics?
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dystonia of face, neck, tongue Parkinsonism (resting tremor, rigidity, bradykinesia) akathisia
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treating tardive dyskinesia
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--discontinue agent and substitute atypical antipsychotic --use: BZD, BB, cholinomimetics for short term
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neuroleptic malignant syndrome
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confusion, high fever, elevated BP, tachycardia, "lead pipe" rigidity, sweating, greatly elevated CPK level caused by typical antipsychotics can be life threatening (20% mortality), and is NOT an allergic reaction most common in men who have recently begun med
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who commonly develops delusional d/o?
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older patients > 40y immigrants hearing impaired
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diagnosis of delusional d/o
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nonbizarre, fixed delusions for at least 1 month does not meet criteria for schizophrenia functioning in life NOT significantly impaired
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types of delusions in delusional d/o
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--erotomanic type = revolves around love --grandiose type = inflated self worth --somatic type = physical delusions --persecutory type --jealous type = delusions of unfaithfulness --mixed type = >1 of the above
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nonbizarre vs bizarre delusions
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nonbizarre: beliefs that might occur in real life but are not currently true (like having a dz, unfaithful spouse, etc) bizarre: beliefs that have no basiss in reality (ie: aliens living in the attic)
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Koro
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psychosis of asia patient believes his penis is shrinking and will disappear, causing death
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Amok
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in malaysia, SE asia sudden unprovoked outbursts of violence of which the person has no recollection
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brain ***
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in africa headache, fatigue, and visual disturbances in male students
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diagnosing a manic episode
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period of abnormally and persistently elevated, expansive, or irritable mood lasting at least 1 week, and including at least 3 of the following [4 if mood is irritable]: distractibility inflated self-esteem and grandiosity increased goal directed activity (socailly, at work, sexually) decreased need for sleep flight of ideas or racing thoughts pressured speech excessive involvement in enjoyable activities that have high risk of negative consequences (buying sprees, sex) DIG FAST (distractibility, insomnia, grandiosity, flight of ideas, activity/agitation, speech pressured, thoughtlessness) emergency
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manic episodes and psychosis
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75% manic patients have psychotic symptoms
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mixed episode
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criteria for both manic episode and major depressive episode met must be present daily for at least 1 week psychiatric emergency mood is typically irritable
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differences between manic and hypomanic episodes
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duration: mania (7+d), hypomania (4+d) social/occupational impairment: mania (severe), hypomania (none) hospitalization: mania (required), hypomania (not) psychotic features: mania (usually), hypomania (never)
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medical causes of manic episodes
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hyperthyroid neurological (temporal lobe seizures, MS) neoplasms HIV infection
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examples of TCAs
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amitriptyline (Elavil) imipramine (Tofranil) desipramine clomipramine (Anafranil) nortriptyline (Pamelor)
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TCA side effects
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anticholinergic: dry mouth, blurred vision, constipation, urinary retention, delirium, worsening glaucoma cardiac arrhythmias: widened QRS, prolonged PR and QTc orthostatic hypotension seizures
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cons of TCAs
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poor compliance due to side effects lethal in overdose have to titrate slowly must check EKG before starting, after a few days, at therap. dose
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examples of SSRIs
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fluoxetine (Prozac) sertraline (Zoloft) paroxetine (Paxil) fluvoxamine (Luvox)
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SSRI side effects
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agitation anxiety insomnia sexual dysfunction (most common cause of noncompliance) GI distress anorexia multiple drug interactions
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examples of MAOIs
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phenelzine (Nardil) tranylcypromine (Parnate)
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MAOI side effects
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hypertensive crisis (tyramine reaction): avoid aged cheeses, cured/pickled foods, yeast extracts, OTC sympathomimetics headache dizziness sleep abnormalities
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venlafaxine (Effexor/Pristiq) side effect
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hypertension
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bupropion (Wellbutrin) side effect
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lowers seizure threshold
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trazodone (Desyrel) side effect
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priapism
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cyclothymia
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periods of hypomania and depressive symptoms for at least 2 years; less severe depression and hypomania than is the case with bipolar disorder not a/w hallucinations or delusions
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lithium side effects
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fine tremor nausea acne weight gain benign leukocytosis arrythmias hypothyroidism nephrogenic DI CRF
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labs during lithium administration
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EKG BUN/Cr (maybe Cr clearance) TFTs
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when is valproic acid/divalproex better than lithium for mood stabilization?
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better in mixed mania, substance abusers outside of these cases, likely as effective as lithium
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target lithium level
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0.8-1.2 (acute mania) 0.6- 1.0 (maintenance)
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target valproic acid level
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75-125 (acute mania) 50-100 (maintenance)
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valproic acid (Depakote) side effects
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GI distress sedation hepatotoxicity (very rare) --> measure LFTs thrombocytopenia --> measure platelets
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carbamazepine (Tegretol) side effects
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not a first line mood stablilizer aplastic anemia (very rare) --> regular CBC every 3-6mos Stevens Johnson syndrome (common)
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differential of schizophrenia (organic)
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early Huntington's chorea early Wilson's disease complex partial seizures (ie: temporal lobe epilepsy) frontal or temporal lobe tumors early MS early SLE acute intermittent porphyria
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high potency typical antipsychotics
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haloperidol (Haldol) fluphenazine (Prolixin) thiothixene (Navane)
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medium potency typical antipsychotics
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trifluoperazine (Stelazine) perphenazine (Trilafon)
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low potency typical antipsychotics
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thioridazine (Mellaril) chlorpromazine (Thorazine)
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what types of EPS are caused by typical antipsychotics?
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acute dystonia: early sudden twisting of neck/rolling of eyes, mainly in young black men. Treat with benztropine (Cogentin), trihexyphenidyl (Artane), or diphenhydramine (Benadryl) akathasia: treat with beta blocker (propranolol), or benzodiazepine (Klonopin) Parkinsonism: tremor, rigidity, bradykinesia; treat with anticholinergics tardive dyskinesia: withdraw medication or change to clozapine
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common side effects of typical antipsychotics
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EPS NMS hyperprolactinemia anticholinergic effects sedation seizures EKG changes, arrhythmias
