Psychiatry COMAT Prep – Flashcards
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Cotard Syndrome vs. Capgras Syndrome
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Cotard: Nihilistic delusion content Capgras: Belief that people have been replaced by imposters
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Simple Schizophrenia
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Consisting of entirely negative symptoms w/no positive symptoms
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Zoloft
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Generic: Sertraline MOA: SSRI, DA reuptake (-) also Use: Depression TOX: early/temporary diarrhea, dyspepsia, LOW risk for drug interaxns
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Paxil, Paxil CR
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Generic: Paroxetine, Paroxetine, CR MOA: SSRI Use: TOX: Anti-Cholinergic/Histamine SE profile, sedation, et. gain, dry mouth, HIGH drug interaxns, UNSAFE in Pregnancy (Class D)
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Prozac
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Generic: Fluoxetine MOA: SSRI, LONG t1/2 Use: Depression, esp intermittently compliant TOX: INCREASED drug interaxns
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Luvox
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Generic: Fluvoxamine MOA: SSRI Use: Depression TOX: RARELY used 2nd to SE profile
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Celexa
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Generic: Citalopram MOA: SSRI Use: Depression TOX: LOW risk for Drug interaxns
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Lexapro
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Generic: Escitalopram MOA: SSRI Use: Depression TOX: LOW risk for Drug interaxns
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Effexor XR
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Generic: Venlafaxine XR MOA: SNRI, Dual 5-HT/NE receptor activity Use: Depression, adjunct for chronic pain TOX: CI in difficult to Tx HTN, DECREASE dose with RI
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Pristiq
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Generic: Desvenlafaxine MOA: SNRI, Dual 5-HT/NE receptor activity Use: Depression TOX: CI in difficult to Tx HTN, DECREASE dose with RI
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Cymbalta
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Generic: Duloxetine MOA: SNRI Use: Fibromyalgia and Diabetic peripheral neuropathic pain TOX: Drug Interaxns
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Bupropion SR
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Generic: Wellbutrin SR MOA: Dual action on DA/NE receptors Use: Depression TOX: Avoid in seizure, anxiety, and eating disorders
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Bupropion XL
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Generic: Wellbutrin XL MOA: Dual action on DA/NE receptors Use: Depression TOX: May worsen anxiety assoc. w/depression Less used 2nd to SE profile, Avoid in seizure, anxiety, and eating disorders
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Remeron
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Generic: Mirtazapine MOA: INCREASE central 5-HT and NE activity (alpha-2-R inhibition ?) Use: Depression w/Insomnia or desired wt. gain TOX: Sedation/Sleepiness at low doses, appetite stim.
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Discontinuation Syndrome
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Due to Serotonin withdrawal. -Acute HA, Dizziness, Nausea, Insomnia, Anxiety, Tingling around ears, suicidal ideation. -Least likely to cause Fluoxetine (Prozac) -MCC by Paroxetine (Paxil)
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CYP450 Inhibitors
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Paroxetine, Duloxetine, Fluvoxamine, & Fluoxetine -Can dangerously INCREASE TCA tox, also BB tox -Citalopram (Celexa) & Escitalopram (Lexapro) least likely to cause CYP450 inh.
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Tx of Depression (Goals, Duration)
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Goal: Symptom remission & Normal Fxning Duration: at least 6-12mo of close F/U; 1-2wks after initiation need to curb high rate of discont. and monitor for suicidality. -Once in remission, pts. should cont. AD for additional 12mos (~1/3 its remission) -Lifetime use of ADs is usually rec. for 2 or more relapses of depression
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Electro-convulsive Therapy (ECT)
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Usually reserved for pts. w/medication refractory/unresponsive depression or when urgent Tx is critical (e.g. psychotic depression) MOA: inc. cortical GABA, inc. 5-HT fxn & altering fxnal brain activation SE: Retrograde Amnesia; Relative CI unstable cardiac and CVD
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Cognitive Behavioral Therapy (CBT) & Interpersonal Psychotherapy (IPT)
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CBT: 3 R's (Pt: Recognize, Reconstruct, Repeat; Physician: Read, Refer, Review)
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When to refer to Psychiatrist as PCP?
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-Uncertain Dx or Uncomfortable w/Tx -Suboptimal response - Repeated Adverse SE -Atypical S&S -Psychotic or Manic S&S -Comorbid Anxiety D/O URGENT (SI/SP, HI/HP, Grave Disability, Worsening Baseline, Need EtOH/Narc Detox, ECT)
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Mood Stabilizers & Antipsychotic Meds w/FDA Ind. for Bipolar D/O: Acute Mania or Mixed
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LiCO3, Carbamazepine (Tegretol), Divalproex Sodium (Depakote), Risperidone (Risperdal), Olanzapine (Zyprexa), Quetiapine (Seroquel), Ziprasidone (Geodon), Aripiprazole (Abilify)
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Mood Stabilizers & Antipsychotic Meds w/FDA Ind for Bipolar D/O: Bipolar Depression
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Quetiapine (Seroquel), Olanzapine/Fluoxetine (Symbyax) Also: LiCO3, Lamotrigine (Lamictal)
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Mood Stabilizers & Antipsychotic Meds w/FDA Ind for Bipolar D/O: Bipolar Maintenance
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Lamotrigine (Lamictal), Olanzapine (Zyprexa), Quetiapine (Seroquel) Also: LiCO3, Carbamazepine (Tegretol), Divalproex Sodium (Depakote)
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Lithium
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MOA: Mood stabilizing effects unknown (does modify Na+ ion channels, NT synth/turnover, 2nd messenger systems (IP pathway) Use: Bipolar D/O, Neutropenia, Thyrotoxic crisis, Migrain/Cluster HA, Last choice SIADH TOX: N&V, Tremor, Fatigue, Polydypsia, Polyuria (Nephro DI). Wt. Gain, Hypothyroidism, Leukocytosis (PMN), ECG T wave ∆'s, Preg Cat.D
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Depakote
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Generic: Divalproex Sodium MOA: Inh vgNa+ channels, INC GABA in CNS, Inh TType Ca2+ channels Use: Absence Seizures, Complex Partial, & Myoclonic Seizures, BP D/O assoc. w mania/mixed and BP D/O maintenance TOX: CNS (tremor, sedation), Inc LFTs, Folate antag (Neural tube defects= Preg Cat.D), Thrombocytopeni, Wt. Gain
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Tegretol
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Generic: Carbamazepine MOA: active met=oxcarbazepine; Ing vgNa+ channels Use: Partial Seizures, TN, Neuropathic pain, BP D/O TOX: Aplastic Anemia, SJS, Dizziness, Somnolence, SIADH, Preg Cat.D
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Trileptal
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Generic: Oxcarbazepine MOA: active met of Carbamazepine; ink. vgNa+ channels Use: Partial Seizures, TN, Neuropathic pain, BP D/O TOX: SJS, Preg Cat.C, Hyponatremia (SIADH?), Fatigue, Ataxia
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Lamictal
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Generic: Lamotrigine MOA: stabilizes vgNa+ channels Use: Tonic-Clonic Seizures, BP D/O maintenance TOX: Rash, SJS, hepatitis, Anemia, Leukopenia, Preg Cat.C
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Risperdal
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Generic: Risperidone MOA: SGA (INC 5-HT2a & D2 Receptors Antag.) Use: Antipsychotic, BP D/O acute mania/mixed TOX: EPS, Hyperprolactinemia
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Zyprexa
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Generic: Olanzapine MOA: Antipsychotic (DA-R blockade) Use: Antipsychotic, BP D/O maintenance/Acute Mania TOX: Metabolic Syndrome, Wt. Gain
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Seroquel
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Generic: Quetiapine MOA: Antipsychotic (DA-R blockade) Use: Antipsychotic, BP D/O maintenance/Acute Mania TOX: Metabolic Syndrome, Wt. Gain (<Olanzapine)
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Geodon
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Generic: Ziprasidone MOA: Antipsychotic (DA-R blockade) Use: Antipsychotic, BP D/O acute mania TOX: QTc prolongation
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Abilify
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Generic: Aripiprazole MOA: partial DA agonist Use: Schizophrenia, Mania, BP D/O, Depression (adjunctive) TOX: Less SE profile
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Invega
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Generic: Paliperidone MOA: 1º active met of Risperidone Use: Antipsychotic, BP D/O acute mania/mixed TOX: EPS, Hyperprolactinemia
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Common causes of insomnia in the elderly
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1. Environmental problems 2. Drugs/alcohol/caffeine 3. Sleep apnea 4. Parasomnias: restless leg syndrome/periodic leg movements/REM sleep behavior disorder 5. Disturbances in the sleep-wake cycle 6. Psychiatric disorders, primarily depression and anxiety 7. Symptomatic cardiorespiratory disease (asthma/chronic obstructive pulmonary disease/congestive heart failure) 8. Pain or pruritus 9. Gastroesophageal reflux disease (GERD) 10. Hyperthyroidism
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Serotonin Syndrome
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Lethargy, Reslessness, Rhabdomyolysis, Hypertonicity, Renal Failure, Possible Death Tx: BZDs, Cyproheptidine (5-HT2A Antag), Nitroprusside/Esmolol for HTN, NMSK blockade w/Veruconium
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Dementia
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-Impairment of 2 or more cognitive domains (Agnosia, Apraxia, Aphasia, Amnesia) -Progression of deficit -Fxnal Impairment (ADLs)
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Mild Cognitive Impairment (CGI)
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-Deficits in 1 or more cognitive domain -INTACT ADLs -Score >or=1.5 std dev below avg level of age peers on std memory test
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Vascular Dementia
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-Neuro Deficits -Stepwise Progression -Longstanding PMH of HTN (usually)
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Frontal-Subcortical Dementia
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-Movement Disorders -Mood Disturbance -Psychomotor and Cognitive Slowing (Apathy) e.g. Huntington's, Parkinson's, Progressive Supranuclear Palsy, Multi System Atrophy, HIV Dementia, Subcortical CVAs
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Dementia w/Lewy Bodies
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-Fluctuating Mental Status -Parkinsonism -Visual Hallucinations -Poor Response to Antipsychotics
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Alzheimer Disease
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-Memory loss (word finding difficulties, anterograde amnesia) -Language impairment -Visuospatial skills impairment (clock drawing test)
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Frontotemporal Dementia (Pick Dz)
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-Disinhibition (personality ∆) -Early loss of social awareness -Hyperorality -Early loss of insight -Stereotyped & Perserative behavior (wandering, mannerisms)
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3 MCC of Dementia
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AD (35%) VaD or Mixed AD-VaD (20%) LBD (15-20%)
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"At-Risk Drinking" according to the NIAAA
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Men: more than 14 drinks/wk or 4 drinks/occasion Women (Both sexes > 65yo): more than 7 drinks/wk or 3 drinks/occasion (Drinks= 1.5oz liq., 12oz beer, 5oz table wine)
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Alcohol Abuse (DSM IV)
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the recurring use of EtOH despite inability to fulfill social role obligations & despite hazardous, legal, and interpersonal problems -present >1yr in order to Dx EtOH abuse; EtOH dependence must 1st be R/O
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Alcohol Dependence (DSM IV)
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Alcohol Abuse + physical, psychological, and social consequences of excessive use: 1.) Tolerance 2.) Withdrawal 3.) Unsuccessful attempts to stop/reduce 4.) Excessive time spent in EtOH related activities 5.) Impairment in social/interpersonal fxning 6.) cont. use despite physical/psychological consequences -3 Criteria for >1yr
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Delirium Tremens vs. EtOH Hallucinations
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DT: Acute, altered LOC after 24-48hrs of abstinence; ANS instability (Tremor, HTN, Diaphoresis, Tachy, Fever); Tx: Fluid/E- replace, High Dose BZPs IV, close monitoring EtOH/H: visual hallucinations/tactile (formication), clear LOC after 12-24hrs of abstinence, resolving 24-48hrs
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CAGE Questionnaire
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Felt need to Cut down on EtOH use? Annoyed by people asking about/criticizing your EtOH use? Guilty about EtOH use? Eye-opener first thing in the morning to avoid hangover feelings?
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4 Common Medical Conditions Associated w/EtOH use
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GERD Peripheral Neuropathy HTN Pancreatitis
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Refeeding Syndrome
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What: Potentially fatal condition resulting from severe electrolyte and fluid shifts in malnourished pts. Mechanism: In starvation, phosphorous stores are depleted & as carb intake increases, 1º metabolism switches from fat to glucose and demand for phosphate increases (glycolysis)=> hypophosphatemia (cardiac failure, rhabdo, seizure, coma, or resp. failure) Mgmt: Obtain LABS q2-3 days first 10 days, then q/wk
