PANCE-Psychiatry – Flashcards
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ADHD
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Onset before 7. Emotional lability, motor impairment. Normal intelligence. Low frontal lobe volume. Tx: methylphedinate, amphetamines, atomoxetine (SNRI)
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Conduct disorder
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UNDER 18. Violent, aggressive, violates social norms. Over 18 = antisocial personality disorder.
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Oppositional defiant disorder
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Hostile, defiant, without serious aggression/violence. Defiance of AUTHORITY figures like teachers/parents but doesnt violate rights of others or society morals
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Tourette's syndrome
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Onset before 18. Motor and vocal tics for more than a year. Coprolalia in 20% (involuntary swearing) --> Assoc with OCD. Tx: haloperidol
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Autism Dx. & Tx.
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Male. Language & social impairment. Objects > people, repetitive behavior. Si/sx before age 3* Usually brought in ~18mo = no words, no social smile, no separation anxiety Dx -EEG & Psych evaluation Tx -Risperdal (mood) -SSRI (agitation)
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Asperger's
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No lang. or cognitive impairment. Repetitive behavior, all-absorbing interests. SOCIAL deficit but normal language
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Delirium
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Acute onset change in consciousness. Usually secondary to other illness. Less attention, arousal. Disorganized thinking, visual hallucinations. Sleep disturbance. ABNL EEG (vs. dementia has NL EEG)
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Hallucination
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Visual: medical illness Auditory: psych illness Olfactory: epileptic aura, brain tumor Tactile: EtOH withdrawal, cocain (formication) Hypnagogic: going to sleep Hypnopompic: waking from sleep Illusion = abnormal interpretation of EXTERNAL stimuli vs. hallucination = no external stimuli
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Schizophrenia
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Delusions, hallucinations, disorganized speech, disorganized/catatonic behavior, negative sx. Lasts >6 mo. negative sx = loss of funx, anhedonia, flat affect Brief psychosis: <1mo Schizophreniform: 1-6mo Schizoaffective: psychosis + mood disorder poor prognosis: younger insidious onset, fam hx, neg ssx better prognosis: older acute onset, mood d/o
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Manic episode
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More than 1wk of distractability, irresponsibility, grandiosity, flight of ideas, increased activity/agitation, LESS SLEEP, pressured speech. Hypomania: no impairment in functioning, no psychosis
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Bipolar disorder
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Bipolar 1: mania + depression Bipolar 2: hypomania + depression Cyclothymic: dysthymia, hypomania >2years Tx: lithium, valproic acid, carbamazepine. Atypical antipsychotics.
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Major depression
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Episodes 6-12 mo, with depressed mood, anhedonia. May include change in sleep, energy, concentration, appetite/weight, psychomotor retardation, guilt/worthlessness. Atypical depression: too much sleep, eating, mood reactivity.
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Panic disorder
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Peaks ~10min. Palpitations, c/p, SOB, sweating. Paresthesia, abd pain, disconnectedness. Fear of death/another attack. Heritable. Tx: CBT, SSRI, TCA, benzodiazepines. acute panic attack = BENZO - alprozalam chronic panic d/o treatment = SSRI - sertraline
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PTSD
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More than 1 month of nightmares/flashbacks, avoidance of associated stimuli, increased arousal. Acute stress disorder: 2d-1mo
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Generalized anxiety
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At least 6mo, unrelated to anything specific. Sleep disturbance, fatigue, GI upset, difficulty concentrating. Tx = SSRI Buspirone
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Cluster A PD WEIRD
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Eccentric. Assoc with schizophrenia. Paranoid: distrust, projection. Schizoid: voluntary withdrawal. Schizotypal: eccentric, odd beliefs.
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Cluster B PD WILD
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Erratic. Assoc with mood disorders, substance abuse. Antisocial: criminal behavior. Male. Borderline: impulsive, splitting. Female. Histrionic: dramatic, provocative, appearance-oriented Narcissistic: grandiose, lacks empathy, angry to criticism
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Cluster C PD WIMPY
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Anxious. Assoc with anxiety disorders. Avoidant: hypersensitive, desires relationships. Obsessive-compulsive: perfectionism, control. Dependent: need to be taken care of.
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Serum indicator of alcohol use
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y-glutamyltransferase (GCT) also ethyl glucuronide (EtG) = used to monitor abstinence
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Heroin addiction
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Risk of hepatitis, abscess, hemorrhoids, HIV, R-sided endocarditis. Methadone: long-acting oral, used for detox/maintenance. Suboxone (naloxone+buprenorphine): long-acting oral with fewer withdrawal sx; naloxone causes withdrawal sx only if injected.
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Wernicke-Korsakoff syndrome
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Thiamine (B1) deficiency in EtOH. Periventricular hemorrhage, mamillary body necrosis. Wernicke encephalopathy: confusion, ataxia, ophthalmoplegia. Korsakoff psychosis: anterograde amnesia, confabulation, personality change.
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Delirium tremens
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EtOH withdrawal, peaks 2-5d. Life-threatening ANS hyperactivity (tachycardia, tremor, anxiety, seizure), THEN psychosis (hallucination, delusion), THEN confusion. Tx: benzos.
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Haloperidol Stelazine (TrifluoperAZINE) Prolixin (FluphenAZINE) --> -AZINE = PhenothiAZINE class
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High-potency antipsychotics. Block D2 receptors Used in schizophrenia (+sx), psychosis, mania, Tourette's. Tox: extra-pyramidal effects (dystonia->akinesia->akathisia->dyskinesia). DA antagonism->high PROLACTIN NMS - FVR, muscle rigidity, incr CPK
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ThioridAZINE ChlorpromAZINE --> Also, belong to the PhenothiAZINE class*
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Low-potency antipsychotics. Block D2 receptors Used in schizophrenia (+sx), psychosis, mania, Tourette's. Tox: anti-cholinergic (constipation, dry mouth), antihistamine (sedation), a-blockade (hypotension). DA antagonism->high Prolactin NMS
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Neuroleptic malignant syndrome (NMS)
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SE of anti-psychotics Fever, rigidity, mylglobinuria, ANS instability (vitals). - rigid muscles / LEAD PIPE RIGIDITY - can progress to rhabdo - malignant hyperthermia - elevated CPK (vs. serotonin syndrome) Tx: 1. dantrolene = skel muscle relaxant, used to tx. malignant hyperthermia 2. bromocriptine (D2 agonist) = will raise dopamine 3. cooling blankets
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Tardive dyskinesia
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Oral-facial movements from long-term antipsychotics. *Irreversible.*
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Olanzapine (Zyprexa) Clozapine Quetiapine (Seroquel) Risperidone (Risperdal) Aripiprazole (Abilify) Ziprasidone (Geodon) (these are the brand names in brackets)
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Atypical antipsychotics. Treat + and - ssx of schizo Tox: fewer extrapyramidal, anticholinergic efx. Clozapine: wt gain, agranulocytosis (weekly CBC), seizure. Ziprasidone: long QT Atypical much higher METABOLIC syndrome - do not use in obese or diabetic pts. Olanzapine / Quetiapine = highest wt gain / metabolic SE
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Buspirone (Buspar)
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5-HT1a agonist. Used in generalized anxiety. NO sedation, tolerance, addiction. No interaction with EtOH.
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Amitriptyline Nortriptyline Imipramine Desipramine Clomipramine Doxepin Amoxapine
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TCA. Block NE, 5-HT reuptake. Used in depression, fibromyalgia. Imipramine: eneuresis Clomipramine: OCD Tox: sedation, a-blockade, ANTICHOLINERGIC (tachycardia, urinary retention--esp amitriptyline). Risk of convulsion, coma, arrhythmia, resp depression, fever. Anticholinergic efx can cause confusion/hallucinations in elderly Do not use TCA in elderly TCA OD/poisoning is treated with sodium bicarb
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Fluoxetine (Prozac) Paroxetine (Paxil) Sertraline (Zoloft) Citalopram (Celexa)
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SSRI. Block 5-HT reuptake. Used in depression, OCD, PTSD, bulimia, phobia. Take 1-2mo to work. Tox: GI upset, anorgasmia. Serotonin syndrome: hyperthermia, flushing, seizure, diarrhea, CV collapse. -->Tx: cyproheptadine (5-HT2 antagonist).
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Venlafaxine (Effexor) Duloxetine (Cymbalta)
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SNRI. Block NE, 5-HT reuptake. Used in depression. Venlafaxine: generalized anxiety. Duloxetine: greater NE effect, used in DM neuropathy. Tox: HTN, stimulant effects, sedation, nausea.
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Tranylcypromine Phenelzine (Nardil) Isocarboxazid Selegiline (MAO-B selective)
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MAO inhibitors. Inc. NE, DA, 5-HT. Used in atypical depression, anxiety, hypochondria. Tox: HTN with tyramine (wine, cheese), B-agonists. CNS stimulation. NO with SSRI, meperidine--serotonin syndrome.
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Bupropion (wellbutrin) MOA Indications Tox. AE's
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Inc. NE, DA. Used in depression, smoking cessation. Tox: tachycardia, insomnia, h/a, seizure lowers seizure threshold; activating = restlessness, insomnia, anxiety
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Mirtazapine (remeron) Indications Tox. AE's
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Used in depression w insomnia. Tox: sedation, appetite, wt gain, dry mouth. wt. gain (so good for elderly) & sleepiness
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Maprotiline
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NE reuptake inhibitor. Used in depression. Tox: sedation, orthostatic hypotension.
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Trazodone
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5-HT reuptake inhibitor. Used in insomnia--need high doses for antidepressant effects. Tox: priapism*, postural hypotension, nausea, sedation.
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Most activating SSRI
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Fluoxetine (Prozac) -dose in AM
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benzodiazepines: MOA
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bind to BZD receptor, facilitate GABA
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DOC for chronic, persistent anxiety (GAD)
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Buspirone (Buspar) -not a benzo -not for acute anxiety
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clozapine ADR that must be monitored
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agranulocytosis -Absolute neutrophil count <500/mm3
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Lithium
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MOOD STABILIZER - BIPOLAR Renal clearance - OD danger if dehydrated SE: GI upset, fine tremor OD: N/V, course tremor, ataxia Cardiac: can cause 1st degree block renal: diabetes insipidus MUST monitor levels = narrow therapeutic dose acute mania: 0.8-1.5 mEq/L maintenance: 0.6-1.2 mEq/L
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Lithium: what will increase serum levels?
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"STAND (up)" -Sodium restricted diet -Thiazide diuretics -ACE-Is/ARBs -NSAIDs -Dehydration
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Valproic acid (depakote)
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Mood stabilizer Indications: bipolar, rapid cycling mania, schizoaffective SE: Wt. gain, sedations, thrombocytopenia
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serotonin syndrome
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Serotonin overdose = triad COGNITIVE - HA, AMS AUTONOMIC - shivering, sweating, hypothermic, diaphoresis SOMATIC - myoclonus, hyperreflexia, tremor exam must assess DTR** RF: SSRI and MAOi used w/in 2 weeks of each other TX: cooling, cyproheptadine
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Axis I
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mental disorders (except personality d/o and mental retardation)
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Axis II
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personality d/o and mental retardation
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Axis III
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non-psych medical conditions
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Axis IV
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psychosocial and environmental conditions
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Axis V
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Global Assessment of Functioning (GAF)
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Anorexia: Dx
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-loss of 15% body wt. -distorted body image/fear of weight gain -malnutrition -increased BUN/Crt -decreased FSH/LH*
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Schizophrenia: 1. positive symptoms VS. 2. negative symptoms
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1. -hallucinations (often auditory) -delusions -thought d/o VS. 2. -flat affect, monotone -decreased sociability/withdrawn - poor speech
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Delusional disorder
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-NONbizarre delusions for @ least 1 month -often partner infidelity or in love/related to famous person -TOC: antipsychotics
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Adjustment disorder
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-depression directly related to stressor -onset with 2 months -lasts < 6 months
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Dysthymic disorder
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>2 years of chronic depressive symptoms -no psychotic symptoms
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SIGECAPS for depression screening
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Sleep d/o Interest (loss) Guilt Energy (loss) Concentration deficit Appetite d/o (up or down) Psychomotor retardation Suicidal thoughts
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Bipolar: Tx
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-Mood stabilizers:Lithium, VPA/topamax, lamotrigine/carbamazepine -Antipsychotics (depressive sx): seroquel/risperidone, olanzapine (Zyprexa)
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panic attack: Tx
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acute= benzo sustained= SSRI
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SSRIs approved in peds
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-fluoxetine (Prozac) -sertraline (Zoloft)
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clozapine ADR
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agranulocytosis (bone marrow doesn't make enough WBCs)
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somatization disorder
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-multiple physical complaints (4 pain symptoms, 2 GI, 1 sexual, 1 pseudoendocrine) -onset <30 yo -not feigned or intentionally produced!
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conversion disorder
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-expression of emotional conflict through physical symptoms -motorneuro: ie. I can't move my right arm -not feigned or intentionally produced -not limited to pan or sexual dysfunction
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PTSD: 1. types based on timing 2. 3 clinical features 3. Dx. (other than clinically) 4. Tx.
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1. Acute= 3 months Delayed onset= >6 months after event 2. -numbness -avoidance -hyperarousal 3. *MRI will show hippocampal atrophy 4. FDA-approved SSRIs = sertraline (Zoloft) & paroxetine (paxil)
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cyclothymia
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mild depression and hypomania x >2 years
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Major Depressive Disorder (MDD)
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5/9 criteria present daily for >2 weeks -one symptoms must be either depressed mood or loss of interest/pleasure - Plus SIGECAPS
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mania symptoms last...
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> 1 week hypomania <1wk and does not interfere with functioning
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panic attacks: cue or no cue?
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NO cues! Come out of no where -if they are cued/triggered by something think phobia, PTSD, situational, etc.
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panic attacks: peak within...
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10 minutes
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obsessions
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recurrent, intrusive thoughts/images
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compulsions
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unnecessary or bizarre rituals which pts are driven to perform repeatedly
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Wellbutrin: MOA
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NE/DA reuptake inhibitor -so no direct 5-HT effect
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SSRI that's particularly bad to D/C abruptly...
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Paroxetine (Paxil)
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SNRI approved for major depression
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desvenlafaxine (Pristiq)
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hydroxyzine (Atarax)
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antihistamine -symptomatic relief of anxiety or tension -causes sedation
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Benzos: How to D/C long-term benzo use?
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taper 10-25% every 1-2 weeks
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Benzos: SA vs IA vs LA
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-Short acting: alprozalam, oxazepam, triazolam Intermediate: lorazepam (ativan) -Long acting: diazepam, clonazepam, flurazepam, chlordiazepoxide benzo antidote: FLUMAZENIL (benzo receptor antagonist)
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Benzos: ok to use in hepatic dysfunction
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LOT with a different T (not triazolam) -lorazepam, oxazepam, temazepam
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Benzos: ok to use in alcohol withdrawal
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long acting -diazepam, clonazepam, flurazepam, chlordiazepoxide -or benzos used in hepatic dysfunction
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Benzos: best for IM administration?
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lorazepam (Ativan)
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Benzos: slowest onset, least potential for abuse
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oxazepam (3-6 hours)
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DA pathways: 5HT blockade does what to dopamine?
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increases DA release
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DA pathways: nigrostriatal
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-normal DA role: control motor movements -D2 blockade: extrapyramidal symptoms (EPS) -5HT blockade: increases DA release, lessens EPS
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DA pathways: mesolimbic
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-DA overactivity: positive symptoms (hallucinations) -D2 blockade: improves positive symptoms
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DA pathways: Mesocortical
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-DA deficits: negative symptoms -D2 blockade: worsens negative and cognitive symptoms -5HT blockade: increases DA release, lessens negative symptoms
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DA pathways: tuberoinfundibular
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-regulation of prolactin release -D2 blockade: increase in prolactin -5HT blockade: increases DA release, less risk of hyperprolactinemia
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1st Gen (Typical) antipsychotics: MOA
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-block D2 receptors in mesolimbic, nigrostriatal and tuberoinfundibular dopamine tracks
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DA pathways: name 2 low and 3 high potency
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-low: chlorpromazine and thioridazine -high: haloperidol, thiothixene, fluphenazine
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1st Gen (Typical) antipsychotics: LA drug given IM for rapid tranquilization
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haloperidol (Haldol)
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1st Gen (Typical) antipsychotics: which one assoc with QT prolongation?
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thioridazine
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2nd Gen (atypical) antipsychotics: MOA
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-block D2 and 5HT receptors -alleviate positive AND negative symptoms, cognitive dysfunction
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2nd Gen (atypical) antipsychotics: common drugs
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-clozapine (Clozaril) -risperidone (Risperdal) -Olanzapine (Zyprexa) -Quetiapine (Seroquel) -Ziprasidone (Geodon) -Aripiprazole (Abilify)
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2nd Gen (atypical) antipsychotics: worst drug in all adverse effect categories
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clozapine (Clozaril)!!!!! -causes the worst of all effects: agranulocytosis, antiCh, orthostasis, sedation, seizures, weight gain, impaired BG, lipid abnormalities
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antipsychotics: class worst for hyperprolactinemia
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-1st Gen (typical) antipsychotics -d/t DA blockade increases prolactin levels -2nd Gen drugs also have 5HT blockade which increases DA release--> less risk of hyperprolactinemia
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Lithium: preg category
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D -avoid esp in 1st trimester -increases fetal risk of CV malformations
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Lithium: labs
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-BUN/Crt (renally eliminated) -CBC with diff (leukocytosis) -serum Na (hponatremia) -TSH: (hypothyroidism)
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Lithium: toxicity
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> 1.5mEq/L: coarse hand tremor, V/D, CNS (confusion, ataxia, slurred speech, lethargy) > 2mEq/L: profound CNS depression, arrhythmias, seizures, coma
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Lamotrigine (Lamictal):
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maintenance Tx of Bipolar I Not for treatment of acute mania 10% get rash - can progress to Stevens-Johnson syndrome ANY RASH ON LAMICTAL = d/c drug
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Serotonin Syndrome: mnemonic
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SADHHATT -Shivering -Anxiety -Diaphoresis -Hyperthermia -Hyperreflexia -Agitation -Tremor -Tachycardia
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Topiramate (Topamax): used for...
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acute bipolar mania
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anti epileptics used for bipolar d/o
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-Lamotrigine (Lamictal) -Topiramate (Topamax) -Oxarbazepine (Trileptal)
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SSRIs: Best choice for a pt on warfarin?
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Citalopram (Celexa) -least DDIs
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anitdepressants: MC sexual SEs
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-anorgasmia and delayed ejaculation (so used to Tx premature ejaculation)
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Benzos: antidote
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flumazenil
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bulimia definition
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binge eating 2x/week x 3 months bulimics are normal body wt. lack impulse control. Will BINGE vs. ano = strict control of food, severely underwt. Both ano and bulimics have vomiting patterns
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Schizoid PD
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"-oid" as in avOID -DISTANT: Detached, Indifferent, Sexual disinterest, Tasks performed alone, Absence of close friends, Neither desires/enjoys relations, Takes pleasure in few activities
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Schizotypal PD
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"-typ" as in not your TYPical dude (weird) -ME PECULIAR: Magical thinking, Experiences unusual perceptions, Paranoid ideation, Eccentric behavior, Constructed affect, Unusual thinking, Lacks close friends, Ideas of reference, Anxiety in social, Rule out psychosis
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Schizophreniform
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"-form" as in FORMing schizophrenia if it continues > 6 months -must have auditory hallucinations
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Antisocial PD
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Cluster B- CORRUPT -Conformity lacking -Obligations ignored -Reckless disregard for self/others -Remorse lacking -Underhanded -Planning insufficient (Impulsive) -Temper
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Histrionic PD
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Cluster B- PRAISE ME -Provocative -Relationships -Attention (center of) -Influenced easily -Style impressionistic -Emotions shifting -Made up (appearance) -Emotions exaggerated
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Narcissistic PD
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Cluster B- SPEEECIAL -Special -Preoccupied with fantasies -Envious -Entitlement -Excessive admiration required -Conceited -Interpersonal exploitation -Arrogant -Lacks empathy
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Borderline PD
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Cluster B- I DESPAIRR -Identity problem -Disordered affect -Empty feeling -Suicidal behavior -Paranoia or dissociative -Abandonment terror -Impulsivity -Rages/Rapid shifts -Relationship instability Tx: DIALECTICAL behavior tx (DBT) and MEDS - DBT combines cognitive-behavior techniques with mindful awareness
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Avoidant PD
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Cluster B- CRINGES -Certainty needed -Rejection preoccupied -Intimate relations avoided -New relations avoided -Gets out of activities -Embarrassment -Self view as unappealing
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Dependent PD
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Cluster B- RELIANCE -Reassurance required -Expressing disagreement difficult -Life responsibilities by others -Initiating no projects -Alone w/ discomfort -Nurturance desired -Companionship sought -Exaggerated fears of caring for self
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Obsessive-compulsive PD
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Cluster B- LAW FIRMS -Lose point of activity -Ability to complete tasks affected by perfectionism -Worthless objects kept -Friendships excluded -Inflexible -Reluctant to delegate -Miserly -Stubborn
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Wernicke's encephalopathy
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-classic triad: nystagmus, ataxia, and confusion in a patient who drinks alcohol daily -d/t deficiency in Vitamin B 12 -Tx= thiamine replacement
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tardive dyskinesias
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-movements of the tongue, face, fingers, and toes are common. -"lip smacking" -think about clozapine as a likely culprit
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akathisia
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-pacing, can't sit still, inner restlessness -the most common extrapyramidal symptom of the neuroleptic medications
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45yo F c/o depressed mood, lack of pleasure, sleep problems, decreased wt, problems with concentration. States ssx started 4 wks ago when she was fired. What is the most indicated treatment
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1. Alprozalam 2. Paroxetine 3. Bupropion 4. Venlafexine 5. Trazadone 6. ECt 2 - Paroxetine bc SSRIs are 1st line for major depression. SSRIs have the least side effects
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alcohol dependence
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increase in GABA receptors = relaxation / sedation when on EtOH 1. Wernickes = encephalopahy, ocular, gait ataxia - eye pain, stumbling when sober - THIAMINE 2. Korsakoffs = chronic amnesia but preserved social behavior. Pt is UNAWARE of the memory issues = confabulation 3. DTs = acute delusional state 3-5 days into withdrawal. hallucinations, delusions, confusion, ATN hyper-activity, seizures - LORAZEPAM (ativan)
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Which complication can be found in anorexia but not bulimia
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wt <85% salivary gland HYPERTROPHY
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pt looses thread of conversation and discusses irrelevant topics. pt never gets back to the main point
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TANGENTIALITY = person starts train of thought but never gets to the point vs. circumstantiality - will eventually get to the point but gives a lot of irrelevant details (circumstances) loose associations = totally unrelated word subjects - 'yellow pizza walked in rain' neologisms = invents new words
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speech in autism
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ECHOLALIA and use of stereotyped phrases not clanging
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most freq SE of MAOi
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orthostatic HYPOTENSION also QUETAPINE causes postural hypotension much more than other atypicals
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defense mechanisms
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Denial = denies reality from an external source. EG: failed exam but forgets that it ever happened Displacement = taking out frustrations/impulses on less threatening objects = Displaced aggression at spouse vs. boss Repression = information is not in our consciousness but influences our behavior. EG: someone abused as a child, doesnt recall abuse but it influences relationship formation. Regression = revert to child like behavior (common in histrionics)
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anti-depressant with the LONGEST half-life
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FLUOXETINE (4-14d) = will not cause discontinuation syndrome fluoxetine also has highest INSOMNIA probability of the SSRIs
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anti-psychotic cause QT delay not to be used in cardiac pts
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ZIPRASIDONE get EKG to follow
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Verenicline (Chantix)
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partial nicotine receptor agonist - stimulates receptors more weakly than nicotine - reduces cravings by partial receptor stim - reduces effects of nicotine by blocking receptors better rates of quitting than with nicotine replacement or bupropion
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most activating SSRI
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fluoxetine (Prozac) -dose in AM
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Zoloft affected by food how?
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food increases bioavailability~ 40%
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ADRs of Wellbutrin
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-lowers seizure threshold -activiating: restlessness, insomnia, anxiety
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Mirtazapine (remeron) ADRs
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-weight gain (so good for elderly)
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benzodiazepines: MOA
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bind to BZD receptor, facilitate GABA
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DOC for chronic, persistent anxiety
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Buspirone (Buspar) -not a benzo -not for acute anxiety
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clozapine ADR that must be monitored
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agranulocytosis -Absolute neutrophil count <500/mm3
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Lithium: things that increase levels
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"STAND (up)" -Sodium restricted diet -Thiazide diuretics -ACE-Is/ARBs -NSAIDs -Dehydration
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Lithium: therapeutic range
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acute mania: 0.8-1.5 mEq/L maintenance: 0.6-1.2 mEq/L
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VPA/Depakote levels
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50-125 mcg/mL for antimanic
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signs of serotonin syndrome
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-shivering -anxiety -diaphoresis -hyperthermia
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serotonin withdrawal symptom
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-electric shock sensation in periphery
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Axis I
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mental disorders (except personality d/o and mental retardation)
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Axis II
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personality d/o and mental retardation
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Axis III
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non-psych medical conditions
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Axis IV
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psychosocial and environmental conditions
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Axis V
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Global Assessment of Functioning (GAF)
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Personality disorders: Type A
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"wierd and wacky" -Paranoid -Schizoid -Schizotypal
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Personality disorders: Type B
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"Wild", "Drama queens, erratic" -borderline -antisocial -histrionic -narcissistic
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Personality disorders: Type C
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"whiny", "anxious and fearful" -avoidant -dependent -obsessive compulsive
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Autism: Dx
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-EEG -Psych evaluation
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Autism: Tx
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-Risperdal (mood) -SSRI (agitation)
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anorexia: Dx
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-loss of 15% body weight -distorted body image/fear of weight gain -malnutrition -increased BUN/Crt -decreased FSH/LH
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ADHD: s/sx begin...
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before age 5yo
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psychosis definition
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general term describing an inconsistent and variable thought process -includes hallucinations, delusions, lack of insight
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Schizophrenia: positive symptoms
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-hallucinations (often auditory) -delusions -thought d/o
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Schizophrenia: negative symptoms
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-flat affect, monotone -decreased sociability/withdrawn -poor speech
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Schizophrenia: Tx
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-dopamine antagonist -haloperidol -resperidone
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delusional disorder
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-nonbizarre delusions -often partner infidelity or in love/related to famous person -TOC: antipsychotics
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Adjustment disorder
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-depression directly related to stressor -onset with 2 months -lasts < 6 months
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Dysthymic disorder
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>2 years of chronic depressive symptoms -no psychotic symptoms
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SIGECAPS
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Sleep d/o Interest (loss) Guilt Energy (loss) Concentration deficit Appetite d/o (up or down) Psychomotor retardation Suicidal thoughts
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super suicidal...
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Bipolar! Way more than MDD
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Bipolar: Tx
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-Mood stabilizers:Lithium, VPA/topamax, lamotrigine/carbamazepine -Antipsychotics (depressive sx): seroquel/risperidone, olanzapine (Zyprexa)
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panic attack: 20% assoc with...
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alcoholism
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panic attack: Tx
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acute= benzo sustained= SSRI
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SSRIs approved in peds
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-fluoxetine (Prozac) -sertraline (Zoloft)
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clozapine ADR
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agranulocytosis (bone marrow doesn't make enough WBCs)
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somatization disorder
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-multiple physical complaints (4 pain symptoms, 2 GI, 1 sexual, 1 pseudoendocrine) -onset <30 yo -not feigned or intentionally produced!
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conversion disorder
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-expression of emotional conflict through physical symptoms -motorneuro: ie. I can't move my right arm -not feigned or intentionally produced -not limited to pan or sexual dysfunction
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PTSD: types based on timing
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Acute= 3 months Delayed onset= >6 months after event
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PTSD: 3 clinical features
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-numbness -avoidance -hyperarousal
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PTSD: what does the MRI show?
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hippocampal atrophy
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PTSD: FDA-approved SSRIs
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-sertraline (Zoloft) -paroxetine (Paxil)
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cyclothymia
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mild depression and hypomania x >2 years
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Major Depressive Disorder (MDD)
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5/9 criteria present daily for >2 weeks -one symptoms must be either depressed mood or loss of interest/pleasure - Plus SIGECAPS
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mania symptoms last...
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> 1 week
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Bipolar: I vs II
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I= mania II= hypomania + major depressive episodes
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cyclothymic vs bipolar II
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-cyclothymic= depression and hypomania x >2 -years -Bipolar II= MAJOR depression + hypomania
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panic attacks: cue or no cue?
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NO cues! Come out of no where -if they are cued/triggered by something think phobia, PTSD, situational, etc.
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panic attacks: peak within...
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10 minutes
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obsessions
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recurrent, intrusive thoughts/images
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compulsions
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unnecessary or bizarre rituals which pts are driven to perform repeatedly
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Wellbutrin: MOA
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NE/DA reuptake inhibitor -so no direct 5-HT effect
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SSRI that's particularly bad to D/C abruptly...
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Paroxetine (Paxil)
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SNRI approved for major depression
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desvenlafaxine (Pristiq)
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hydroxyzine (Atarax)
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antihistamine -symptomatic relief of anxiety or tension -causes sedation
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Benzos: How to D/C long-term benzo use?
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taper 10-25% every 1-2 weeks
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Benzos: SA vs IA vs LA
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-EATLOT= SA + intermedA -Intermediates: estazolam, alprazolam, temazepam, lorazepam -Short acting: oxazepam, triazolam -Long acting: diazepam, clonazepam, flurazepam, chlordiazepoxide
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Benzos: ok to use in hepatic dysfunction
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LOT with a different T (not triazolam) -lorazepam, oxazepam, temazepam
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Benzos: ok to use in alcohol withdrawal
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long acting -diazepam, clonazepam, flurazepam, chlordiazepoxide -or benzos used in hepatic dysfunction
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Benzos: best for IM administration?
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lorazepam (Ativan)
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Benzos: slowest onset, least potential for abuse
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oxazepam (3-6 hours)
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DA pathways: 5HT blockade does what to dopamine?
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increases DA release
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DA pathways: nigrostriatal
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-normal DA role: control motor movements -D2 blockade: extrapyramidal symptoms (EPS) -5HT blockade: increases DA release, lessens EPS
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DA pathways: mesolimbic
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-DA overactivity: positive symptoms (hallucinations) -D2 blockade: improves positive symptoms
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DA pathways: Mesocortical
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-DA deficits: negative symptoms -D2 blockade: worsens negative and cognitive symptoms -5HT blockade: increases DA release, lessens negative symptoms
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DA pathways: tuberoinfundibular
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-regulation of prolactin release -D2 blockade: increase in prolactin -5HT blockade: increases DA release, less risk of hyperprolactinemia
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1st Gen (Typical) antipsychotics: MOA
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-block D2 receptors in mesolimbic, nigrostriatal and tuberoinfundibular dopamine tracks
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DA pathways: name 2 low and 3 high potency
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-low: chlorpromazine and thioridazine -high: haloperidol, thiothixene, fluphenazine
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1st Gen (Typical) antipsychotics: LA drug given IM for rapid tranquilization
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haloperidol (Haldol)
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1st Gen (Typical) antipsychotics: which one assoc with QT prolongation?
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thioridazine
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2nd Gen (atypical) antipsychotics: MOA
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-block D2 and 5HT receptors (except Abilify) -alleviate positive AND negative symptoms, cognitive dysfunction
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2nd Gen (atypical) antipsychotics: common drugs
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-clozapine (Clozaril) -risperidone (Risperdal) -Olanzapine (Zyprexa) -Quetiapine (Seroquel) -Ziprasidone (Geodon) -Aripiprazole (Abilify)
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2nd Gen (atypical) antipsychotics: worst drug in all adverse effect categories
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clozapine (Clozaril)!!!!! -causes the worst of all effects: agranulocytosis, antiCh, orthostasis, sedation, seizures, weight gain, impaired BG, lipid abnormalities
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antipsychotics: class worst for hyperprolactinemia
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-1st Gen (typical) antipsychotics -d/t DA blockade increases prolactin levels -2nd Gen drugs also have 5HT blockade which increases DA release--> less risk of hyperprolactinemia
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Lithium: preg category
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D -avoid esp in 1st trimester -increases fetal risk of CV malformations
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Lithium: MOA general idea
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mood stabilizer -antagonize adrenergic and DA activities while enhancing serotonergic activity
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Lithium: labs
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-BUN/Crt (renally eliminated) -CBC with diff (leukocytosis) -serum Na (hponatremia) -TSH: (hypothyroidism)
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Lithium: toxicity
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> 1.5mEq/L: coarse hand tremor, V/D, CNS (confusion, ataxia, slurred speech, lethargy) > 2mEq/L: profound CNS depression, arrhythmias, seizures, coma
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VPA: how can it be used for bipolar d/o?
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-FDA approved for acute Tx of bipolar, but also used for maintenance -antimaniac levels= 50-125mcg/ml
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Lamotrigine (Lamictal): used for...
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maintenance Tx of Bipolar I
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Serotonin Syndrome: mnemonic
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SADHHATT -Shivering -Anxiety -Diaphoresis -Hyperthermia -Hyperreflexia -Agitation -Tremor -Tachycardia
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Topiramate (Topamax): used for...
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acute bipolar mania
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anti epileptics used for bipolar d/o
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-Lamotrigine (Lamictal) -Topiramate (Topamax) -Oxarbazepine (Trileptal)
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SSRIs: Best choice for a pt on warfarin?
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Citalopram (Celexa) -least DDIs
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antidepressants: MC ADR
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GI upset
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anitdepressants: MC sexual SEs
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-anorgasmia and delayed ejaculation (so used to Tx premature ejaculation)
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Benzos: antidote
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flumazenil
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bulimia definition
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binge eating 2x/week x 3 months
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Schizoid PD
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"-oid" as in avOID -DISTANT: Detached, Indifferent, Sexual disinterest, Tasks performed alone, Absence of close friends, Neither desires/enjoys relations, Takes pleasure in few activities
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Schizotypal PD
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"-typ" as in not your TYPical dude (weird) -ME PECULIAR: Magical thinking, Experiences unusual perceptions, Paranoid ideation, Eccentric behavior, Constructed affect, Unusual thinking, Lacks close friends, Ideas of reference, Anxiety in social, Rule out psychosis
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Schizophreniform
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"-form" as in FORMing schizophrenia if it continues > 6 months -must have auditory hallucinations
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Antisocial PD
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Cluster B- CORRUPT -Conformity lacking -Obligations ignored -Reckless disregard for self/others -Remorse lacking -Underhanded -Planning insufficient (Impulsive) -Temper
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Histrionic PD
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Cluster B- PRAISE ME -Provocative -Relationships -Attention (center of) -Influenced easily -Style impressionistic -Emotions shifting -Made up (appearance) -Emotions exaggerated
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Narcissistic PD
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Cluster B- SPEEECIAL -Special -Preoccupied with fantasies -Envious -Entitlement -Excessive admiration required -Conceited -Interpersonal exploitation -Arrogant -Lacks empathy
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Borderline PD
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Cluster B- I DESPAIRR -Identity problem -Disordered affect -Empty feeling -Suicidal behavior -Paranoia or dissociative -Abandonment terror -Impulsivity -Rages/Rapid shifts -Relationship instability
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Avoidant PD
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Cluster B- CRINGES -Certainty needed -Rejection preoccupied -Intimate relations avoided -New relations avoided -Gets out of activities -Embarrassment -Self view as unappealing
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Dependent PD
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Cluster B- RELIANCE -Reassurance required -Expressing disagreement difficult -Life responsibilities by others -Initiating no projects -Alone w/ discomfort -Nurturance desired -Companionship sought -Exaggerated fears of caring for self
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Obsessive-compulsive PD
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Cluster B- LAW FIRMS -Lose point of activity -Ability to complete tasks affected by perfectionism -Worthless objects kept -Friendships excluded -Inflexible -Reluctant to delegate -Miserly -Stubborn
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Wernicke's encephalopathy
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-classic triad: nystagmus, ataxia, and confusion in a patient who drinks alcohol daily -d/t deficiency in Vitamin B 1 -Tx= thiamine replacement
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tardive dyskinesias
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-movements of the tongue, face, fingers, and toes are common. -"lip smacking" -think about clozapine as a likely culprit
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akathisia
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-pacing, can't sit still -the most common extrapyramidal symptom of the neuroleptic medications
