What's the firstline Tx for depression?

What's the firstline Tx for depression with comorbid neurologic pain?

What's the firstline Tx for atypical depression?

depression - SSRIs

depression + neurologic pain - SNRIs

  -SNRIs are second line for depression in pts who fail SSRI therapy

atypical depression - MAO-Is

Stop MAO-I at least 2 weeks before giving SSRI so that resynthesis of MAO can occur

  -this is b/c MAO-Is are irreversible inhibitors of MAO

  -if SSRI was fluoxetine, wait at least 5-6 weeks because it has the longest halflife

1) MAO-Is

2) St. Johns Wort and Kava Kava

3) Tryptophan

4) Cocaine and amphetamines

5) Lithium

At least 4 of SIGECAPS, including either depressed mood or anhedonia lasting > 2 weeks:

Sleep disturbances 

Interest loss

Guilt

Energy reduction (fatigue)

Concentration impairment

Apetite changes

Pyschomotor retardation

Suicidial ideation

Depressed mood + 2 or more of the following Sx for > 2 years w/o major depressive epsidode or mania:

-hopelessness

-change in sleep pattern

-change in apetite

-fatigue

-inability to concentrate

-low self esteem

Note: dysthymia can have the CASE (conc, apetite, sleep, energy) of SIGECAPS. Also, pt must NOT be w/o the above Sx for > 2 months at a time

Rule of 2Ds is helpful: 2 yrs depression, 2 listed criteria, never > 2 months asymptomatic

-Dysthymia is mild but more chronic than MDD

-Pts with dysthymia may not have the psychomotor retardation and suicidal ideation that a MDD pts does

What are the 4 main medical categories of causes of psychosis?

Give examples of each.

1.  CNS disease: stroke, MS, tumor, Alzhiemers, PD, Huntingtons, tertiary syphilis, temporal epilepsy, encephalitis, prions, neurosarcoid, AIDS

2. Endocrineopathies: Addisons/Cushings, hyper/hypothyroidism, hyper/hypocalcemia, hypopituitarism

3. Nutritional/Vitamin deficiency: B₁₂, folate, niacin

4. Other: connective tissue disease, SLE, temporal arteritis, porphyria

1. Corticosteroids

2. Anti-parkinson drugs (by elevating DA levels)

3. Anti-convulsants

4. Anti-histamines

5. Anti-cholinergics

6. Anti-hypertensives (including beta-blockers)

7. Digitalis

8. Methylphenidate

9. Fluoroquinolones

10. Benzos and Barbs

Pt must have 2 or more of the following 8 for at least 2 month:

-Positive symptoms

   1. Delusions

   2. Hallucinations (75% of pts have this)

   3. Disorganized speech (loose associations)

   4. Disorganized or catatonic behavior

-Negative symptoms

   1. Flat affect

   2. Social withdrawal

   3. Lack of motivation

   4. Lack of speech or thought (alogia)

Note: Only one of the above Sx are required if the delusions are bizarre or hallucinations consist of voices keeping up or a running commentary on the pt's behavior or thoughts, or 2 or more voices conversing with each other

What is typicall considered when a pt fails both typical and atypical antipsychotics?

FA for Psyche, pg 24

Anhedonia

Affect (flat)

Alogia (poverty of speech)

Avolition (apathy)

Attention (poor)

-OCPD is egosyntonic (pt thinks they're ok), whereas OCD is egodystonic (pt has insite into their disorder

-OCPD pts are more preoccupied by details, order, unflexibale beliefes. They are perfectionists. OCD pts have an obsession causing anxiety, resulting in compulsive behaviors to decrease the anxiety

What is the progression of extrapyramidal symptoms (EPS)?

What's the management for each?

4 hours - acute dystonia (mm spasm, stiffness, oculogyric crisis)

  -Tx: benztropine

4 days - akinesia (Parkinsonian Sx)

  -Tx: benztropine

4 weeks - akathesia (restlessness)

  -Tx: propranolol

4 months - tardive dyskinesia (bitting, chewing, tongue protrusion)

  -Tx: Stop the medication!

 Note: Acute dystonia and akinesia are result of decreased DA in nigrostriatal pathway. Akathesia and tardive dyskinesia result from adaptation of post-synaptic cell to decreased DA by increasing DA sensitivity.

What's the risk of a pt having schitzophrenia if their identical twin has it?

Is there a higher risk of a pt being schitzophrenic if their biological parent had it but the child is adoped by nml parents?

50%

Yes! Adopted children of schizophrenics are at increased risk of schizophrenia

What are ideas of reference?

Who is it often seen in?

-The belief that everyday occurrences have a special impaction for them. Examples include believing that the TV or radio are talking to you or that an article in the paper contains a special message for you.

-Often see in schizophrenia

While they are both characterized by high fever and rigidity. Seratonin syndrome is also characterized by diarrhea, flushing, restlessness, myoclonus, and hyperreflexia

Recall: TCA overdose also causes myoclonus, hyperreflexia, agitation, and coma!!!

How do you differentiate bereavement from complicated bereavement following loss of a loved one?

How do you differentiate bereavement from a MDE?

-Bereavement is grief after loss and is characterized by sadness, difficulty concentrating,  decreased apetite, insomnia, thoughts/dreams of person. Can last up to 6 months (though rarely last more than 2 months), and are self-limiting.

-Complicated bereavement is characterized by detachement from incident, bitterness towards deceased, inability to accept life w/o deceased, frequent agitation/distrust for others, lasting > 6 months

If Sx of MDE begin w/in 2 months of loss and don't persist beyond 2 months, they're considered result of bereavement unless a/w marked impairment of any of the following:

  1) Thoughts of death other than feeling that they would be better off dead or should have died w/ deceased person

  2) Expressing guilt other than about actions taken or not taken by survivor at time of death

  3) A morbid preoccupation w/ worthlessness

  4) Marked psychomotor retardation

  5) Hallucinations other than hearing voice or seeing image of deceased individual

Intoxication: euphoria, anxiety, paranoid delusions, perception of slowed time, impaired judgement, social withdrawal, increased apetite, dry mouth, conjunctival injection, hallucinations

Withdrawal: depression, irritability, insomnia, nausea, anorexia

Describe the effects of LSD intoxication.

What is is MOA?

Marked anxiety or depression, delusions, visual hallucinations, flashbacks (can occur weeks-years later), pupillary dilation

Lysergic acid diethylamide is a seratonin agonist

Describe how phencyclidine (PCP) intoxication and withdrawal presents.

How do you treat intoxication?

Intox: belligerence, impulsivemens, fever, ataxia, psychomotor agitation, vertical + horizonatal nystagmus, tachycardia, homicidality, psychosis, delerium

   -Treat intox with benzos or haloperidol (if psychotic)

Withdrawal: depression, anxiety, irritability, restlessness, anergia, disturbance of thought and sleep

Malingering pts have grossly exaggerated physical or psychological complaints in order for secondary gain (get out of work, narcotics, etc)

Facticious pts intentionally produce false physical or psychological signs/sx to assume the sick role (no secondary gain)

Perform a more detailed physical exam to identify other possible findings of abuse, these include:

  -multiple fractures

  -injuries in different stages of healing

  -cigarette burn

  -poorly kept child

  -bruising on neck, abd, or unusual sites

  -injury to genitalia, hands, back, or buttocks

1. Radiographic skeletal survey

2. Coag profile

3. Report to child protective services

4. Admittance to hospital (if necessary)

1) Euphoria accompanying drug use

2) Delusions and hallucinations experienced by pts with schizophrenia

Recall, the mesolimbic pathway extends from the ventral tegmental area to the limbic system

What specific sleep abnormalities are seen in MDD?

-early morning and multiple awakenings

-difficulty falling asleep

-REM sleep shifted to earlier in night

-Stage 3-4 sleep decreases

Combined antidepressant and antipsychotic

Also, combination of medication and psychotherapy offer the best Tx outcome

Retrograde and anterograde amnesia

  -usually disappears w/in 6 months

  -other common transient SEs include HA, n/v, muscle soreness

-Discontinue any use of DA-blocking agents, even if pt is psychotic, impulsive, or aggressive (recommendations from UpToDate)

-Lorazepam (1-2 mg) reduces the "top down" inhibition on the motor system

-IV fluids as needed to prevent rhabdomyolysis

-If all else fails -> ECT

1) Dementia -> can cause decreased frontal lobe inhibition, so pts act inappropriately

2) Catatonia -> decreases "top down" inhibition of motor system

1. Denial

2. Anger

3. Bargining

4. Depression

5. Acceptance

Define rapid cycling Bipolar disorder?

Tx?

What is the most effective treatment for bipolar in general?

Rapid cycling is defined as 4 or more episodes (depression, mania, mixed) in 1 year of

Tx: valproate and carbamazepine

  -unlike Li however, they are a/w increased risk of suicide

  -anticonvulsants are also better than lithium for mixed (mania/depression) episodes

-Most effective Tx for bipolar in general is ECT

How many times more likely is a pt to hve Bipolar disorder if their first degree relative has it?

What's the monozygotic and dizygotic twin concordance rate?

-Pts are 8-18 times as likely to develop bipolar disorder if they have a 1st degree relative with it

-Monozygotic concordance - 40-70%

-Dizygotic concordance - 5-25%

Note: Bipolar I has the highest genetic link of all major psychiatric disorders

What has a worse prognosis, MDD or bipolar?

Rank the following from best to worst prognosis:

-brief psychotic d/o

-schizoaffective d/o

-mood d/o

-schizophrenia

-schizophreniform

-Bipolar

    -Suicide rate in bipolar is 15%!

Mood d/o > brief psychotic d/o > schizoaffective d/o > schizophreniform > schizophrenia

How long does it take for lithium to take effect?

What is the therapeutic range for lithium?

5-7 days

  -blood levels correlate with clinical efficacy and should be checked after 5 days, and then every 2-3 days until therapeutic

  -therapeutic range for lithium is 0.6 - 1.2 (toxic is >1.5 and lethal is >2.0)

ECT

  -its a great alternative to antipsychotics and can be used w/ relative safety in all trimesters

How do you differentiate bereavement from adjustment disorder?

befeavement rarely lasts > 2 months after major loss, and is characterized by crying spells, problems sleeping or concentrating, dreams of lost loved one

adjustment disorder occurs < 3 months after stressful life event, and ends w/in 6 months of cessation of stressor; characterized by severe distress in excess of what would be expected, and impaired function

What is the classic triad of seasonal affective disorder (SAD)?

What's the diagnostic criteria for SAD?

irritability, carbohydrate craving, hypersomnia

diagnostic criteria for SAD:

  -at least 2 consecutive years of two major major depressive episodes during the same season (usually winter)

-Numerous periods of hypomanic Sx and periods w/ depressive Sx for at least 2 years

-Person must never have been Sx free for > 2 mo during the 2 yrs

-No Hx of MD episode or manic episode

Mercury

Arsenic

Organophosphate

Benzene

Pt must have at least 4 of PANICS

palpitations

abd distress

numbness/nausea

intense fear of death

choking/chills/chest pain

sweating/shaking/shortness of breath

Pt must have at least one of the panic attacks (4 of PANICS, see FA p 49) must be followed by at least 1 month of the following:

-persistent concern of having addn'l attacks

-worry about its implications

-changes in behavior related to attacks

Always be sure to specify whether panic disorder is w/ or w/o agoraphobia

Start them at a low dose and increase slowly b/c some SSRIs can have SE that may initially worsen anxiety

Recall, like in OCD and ADHD, it takes a higher dose of SSRIs to be effective in panic disorder.

Describe dissociative fugue and what's it associated with?

Give the classic example

Dissociative Fugue: abrupt change in geographic location with inability to recall past, confusion about personal idenity, or assumption of new identity. It's a/w traumatic circumstances (natural disasters, wartime, trauma).

Example: person wakes up in a different city and recalls a vague memory of watching a movie aof someone (himself) taking a bus trip. They are detached from the actual experience.

DID (aka multiple personality disorder): presence of 2 or more distinct identities or personality states that alternatively assume control over persons behavior. Amnesia regarding important personal info about some of the identities can occur.

It is more common in women.

Dissociative amnesia: presence of one or more episodes of an inability to recall important personal info (often large periods of time), but can still retain new memories

  -This is related to a stressful event

  -Pts are often unable to recall common personal info but able to remember obscure details, which is opposite to the type of memory loss usually found in dementia

Describe depersonalization dissorder?

Depersonalization disorder: persistent or recurrent feelings of detachement or estrangement from one's own body, social situation, or the environment.

Think of fight club.

Define the following terms:

-circumstantiality

-tangentiality

-loose associations

-flight of ideas

-circumstantiality: pt provides unnecessarily detailed answers that deviate from topic of conversation but remain vaguely related to original subject. Eventually, pt returns to original subject

-tangentiality: thought process in which there's an abrupt, perminent deviation from the subject. This new thought is vaguely relevant to the original subject and never returns to original subject

-loose assoications: lack of longical connection btwn thoughts or ideas. It tends to be more severe form of tangentiality in which one statement follows another w/o clear association btwn sentences

-flight of ideas: loose associations that rapidly move from topic to topic

What is the mneumonic for suicide risk factors?

Which is the strongest predictor of commiting suicide?

SAD PERSONS

Sex (M>F)

Age (>45)

Depression

Previous attempts (strongest predictor)

EtOH

Rational thought loss (psychosis)

Social support

Organized plan

No spouse (married<single<divorced<widowed)

Sickness

What 2 anatomic abnormalities are seen on CT of the brain of pts with schizophrenia?

What 3 other things can be seen anatomically (but not necissarily on CT?

CT: Enlarged ventricles and prominent sulci

Other: decreased cerebral mass, hippocampal mass, temporal mass

A 13 y/o girl grunts and clears her throat several times in an hour, and her conversation is often interrupted by random shouting. She also performs idiosincratic, complex motor activities such as turning her head to the right while she shuts her eyes. She can prevent these movements for brief periods of time, with effort.

Dx?

NSIM?

Dx: Tourette's syndrome

Tx: Typical neuroleptics (haloperidol, pimozide) or alpha-2 agonists (clonidine, guanfacine)

Reaction formation: pt's anxiety is addressed by substituting unacceptable feelings with behavior that is the exact opposite of those feelings.

Example: A woman, angry about immigrants competing with her for jobs, goes and substitutes that anger with the action of offering vocational advice to that same group of immigrants.

Dissociation is temporary, drastic change in personality, memory, conciousness, or motor behavior to avoid emotional stress.

Ex: Engineer blocking out the fact that he was fired, with this wife discoving the truth only when a concerned friend calls to give her condolences.

Suppression: mature defense mechanism where pt intentionally withholds/postpones anxiety provoking thoughts by substituting other thoughts.

Example: woman focuses on her kid's homework question instead of thinking of her father's cancer Dx

Sublimination: mature defense mechanism where pt replaces an unacceptable wish with a course of action similar to that wish but does not conflict with one's value system

Example: man with explosive temper channels his anger into athletic persuits

Binding of the drug to seratonin receptors

  -this can also lead to decreased EPS and concomitant treatement of depression

Qid 2499

1. Persistent excessive fear brought by specific situation or object

2. Exposure to situation brings immediate anxiety

3. Pt recognizes fear is excessive

4. Situation is avoided when possible

5. Pt is < 18 y/o, duration must be at least 6 mo

Specific phobias are comorbid with what?

What's the lifetime prevelance and suicide rates for:

-MDD

-Bipolar disorder

-Schizophrenia

-MDD: LP 16.2%, suicide rate: 15%

-Bipolar: LP 1%, suicide rate: 15-20%

-Schizophrenia: LP: 1%, suicide rate 10%

ADHD (60%) and OCD (30%)

Oppositional defiant, conduct disorder, and antisocial personality disorder are also linkd to Tourettes but the association is much less than for ADHD and OCD

TCAs with greater norepinephrine reuptake blocking activity are more efficacious for neuropathic pain

  -ex: imipramine, amitryptaline, nortryptaline

TCAs with greater seratonin reuptake blocking activity are more efficacious for anxiety and OCD

  -ex: clomipramine (most seratonin specific)

1. Pt has experienced/witnessed a traumatic event that was potentially harmful/fatal (war, rape, natural disaster)

2. Pt has re-experiencing of event (dreams, flashbacks, intense psychological distress from cues related to event)

3. Avoidance of stimuli a/w trauma (avoiding locations that will remind pt of event)

4. Numbing of responsiveness (ltd affect, detachement/estrangement from others)

5. Sx of hyperarousal (decreased sleep, oubursts of anger, hypervigilance, poor concentration)

6. Sx last for > 1 month

A 27 y/o male with Hx of major depressive disorder is brought in by his wife because of a 4 month history of repetitive hand washing. She says he constantly to washes his hands after touching anything. The pt reports feeling anxious if handwashing is not performed. Was on sertraline for MDD, but stopped 3 years ago b/c he hasn't had any episodes. Vitals and PE are wnl. You restart pt on sertraline at the same dose. One month later he returns b/c the Sx have not abated.

NSIM?

Administer a higher dose of SSRI

  -Treatment of OCD requires higher doses of SSRIs than for MDD

Management: SSRIs, TCAs (imipramine, doxepine)

Remember, benzodiazepines should be avoided in the treatment of PTSD b/c these pts have a high rate of substance abuse

Before starting the drugs, and 12 weeks after starting them you need to check:

-weight

-fasting glucose

-fasting lipid profile

-BP

Of the atypicals, which one decreases the risk of depression and suicide?

Which increases prolactin the most?

Which has the greatest sedating effect?

-Clozapine decreases risk of depression and suicide

-Rispiridone increases prolactin the most

-Quitiepine has greatest sedating effect and alpha-1 blockade (thus you need to titirate it up slower to avoid severe othostatic hypotension)

Describe the defense mechanism displacement.

Displacement: immature defense mechanism where individual displaces negative feelings a/w an unacceptable object or situation onto a "safer" object or situation.

Ex: A resident gets chewed out by an attending. Frusterated, the resident then yells at the med student ("safer" object) when they asked a question.

Rationalization: neurotic defense mechanism is the offering of rational, logical reason for an upsetting event rather than the real reason

Ex: Engineer stating that being fired was a "blessing in disguise," as he can now spend more time with his family.

Acting out: immature defense mechanism is the expression of an unconcious impulse through physical action.

Ex: Engineer screaming and kicking the floor when he was fired.

What is the firstline treatment for enuresis?

Name 2 alternative treatments.

-Classic conditioning with a bell (or buzzer) and a pad--this is generally the most effective treatment

-Alternative treatments include: antidiuretics (DDAVP), and imipramine

Conversion: where emotional conflicts are transformed into physical (often neurological) sx.

Ex: Engineer being struck mute after learning that he was fired.

1. One or more neurologic or general systemic sx

2. Precipitated by psycholigcal stressor

3. Sx not intentionally produced

4. Medical investigation can't explain sx

5. Sx not explained by another mental disorder

6. Sx impair social, occupational, or daily function

1. Onset before age 30

2. At least 4 pain sx (pain has 4 letters)

3. At least 2 Gi sx (GI has 2 letters)

4. At least 1 sexual/reproductive sx

5. At least 1 pseudoneurological sx (not ltd to pain)

6. Cannot be explained by general medical condition or susbtance abuse

7. Sx are not intentionally produced

Note: Sx do not have to appear at the same time!

Facticious disorder pts conciously create physical and/or psychological sx in order to assume "sick role" and to get medical attention (primary gain).

Munchausen syndrome is chronic facticious disoerder with predominantly physical signs and sx. Characterized by a hx of multiple hospitalizations and willingness to receive invastive procedures.

Define body dysmorphic disorder.

Management?

Preoccupation with minor or imagined defect in appearance, leading to significant emotional distress or impairment of function. Pts often repeatedly seek cosmetic surgery.

Management: SSRIs (effective in up to 50% of cases)

depression (60%), agoraphobia (40%), generalized anxiety disorder, subtance abuse

Yes!

  -pts should be on lithium for at least 1 year after first episode. If they're asymptomatic for 1 year, they can be tapered off

  -pts with three ore more relapses require lithium for life

-prematurity

-small for gestational age

-miscarraige

mothers are at risk for:

-hyperemisis gravidorum

-C-section

-postpartum depression

What 4 things do personality disorders effect in a person?

What is the lifetime prevelance of personality disorder?

cogntion, affect, personal relationships, impulse control (thinks CAPRI)

lifetime prevelance is 6%

For the 3 clusters of personality disorders, what familial associated psychiatric condition are they associated with?

Cluster A (eccentric/withdrawn): familial a/w psychotic disorders

Cluster B (emotional/dramatic): familial a/w mood disorders

Cluster C (anxious/fearful): familal a/w anxiety disorders

-Dialectical behavior therapy (DBT) - combines CBT (for emotional regulation) with distress tolerance, acceptance, and mindful awareness largely derived from Budist meditative practice

-Behavioral therapy

Pharmacotherapy is most useful in what personality disorder?

An unacceptable internal impulse is attributed to an external source. It can be linked to paranoia and auditory hallucinations.

Ex. A man, who is angry at his wife for something she said to him, comes home from work where he is greeted by his wife. He responds by saying, "Oh honey, you're mad at me. Whatever it is, I'm sorry." He projected his anger onto her.

Differentiate denial from repression from suppression.

Qid 3799

-Denial: Pt subconciously avoids awareness of painful reality

-Repression: Pt was once aware of painful reality but then subconciously represses it, and can only be recalled by using certain cues

-Supression: Pt conciously preplaces the thought of a painful reality with something else that is important (an upcoming exam)

Regression

  -they often revert to childlike behavior

  -regression is often seen in pts with Dependent personality disorder as well

-To dx dependent personality disorder, the features must manifest in early adulthood

-Also these pts cannot express disagreement, which is necessarily seen in pts who are medically ill

Systemic desensitization therapy is most effective (pharmacotherapy is not)

  -If necessary, a short course of benzodiazepines or beta blockers may be used to help control autonomic symptoms

Recall, the best pharmacotherapy for performance anxiety are beta-blockers

Best management is combination of psychotherapy (specifically a type of cognative behavioral therapy called Assertiveness training) and SSRIs (drug of choice for social phobia)

Supportive psychotherapy and psychodynamic pscyhotherapy are not as effective in these pts

Isolation is the separation of thought from its emotional components, thereby making it tolerable. It is a mature defense mechanism.

Ex: Bank teller remains calm and collected while foiling a robbery attempt.

Resistance is an intense opposition to bring unpleasant thoughts to concious awareness.

Ex: A woman who unconciously realizes her husband is a criminal but resists concious assembly of the available evidence.

75 y/o male with no PMHx presents with WL and fatigue. He notes having has blood in his stool lately. Further evaluation reveals the presence of colon cancer. After reviewing the treatment options and prognosis, the pt refuses all treatment and says "I want to die peacefully at home." What's the NSIM?

A) Respect his decision

B) Ask why he is reluctant to therapy

B) Ask why he is reluctant to therapy

  -Pt's reasoning should first be thoroughly explored and discussed

  -Often, pts are simply affraid of enduring pain or unfamiliar procedures. Sometimes it's more philisophical, like "I to control my own destiny"

  -If pt refuses medical treatment despite clarification and reassurance from physician, then their decision should be respected

All atypical antipsychotics of some mood stabilizing properties, but which two is best and is sometimes used for bipolar disorder?

Qid 2495

What is the treatment course for a pt who experiences their first major depressive episode?

What about for pts who have had muliple MDE?

First episode: continue antidepressant for 6 months (recall, Bipolars need lithium for 1 year after 1st episode)

Multiple episodes: maintenance therapy should be continued for longer

1) substance abuse

2) partner abuse, physical/sexual abuse at home

3) date rape or rape in general

4) pregnancy

Name as many of the potential side effects of lithium as you can.

What must you evaluate in any pt before starting lithium?

Side Effects:

-GI disturbance (n/v/d, abd pain)

-nephrotoxicity, including nephrogenic DI

-hypothyroidism

-leukocytosis 2/2 demargination (rarely > 20K)

-tremors

-acne

-psoriasis flares

-alopecia

-edema

-teratogenicity (Ebstein's anomaly)

Must Check: ECG Thyroid function, Renal function, CBC, and hCG

Fantasy: immature defense mechanism that substitutes a less disturbing view of the world in place of reality as means of resolving conflict.

Ex: Mother interprets the appearance of an angel in her dreams as a meaning that her son, who is terminally ill, will love a long time.

Do HIPAA regulations extend to employers?

What about pt's health insurance company?

HIPAA applied to both

  -the exception is if the pt's condition poses a risk to his/her co-workers and pt refuses to divulge information to those at work who are in jeapordy

How is naltrexone efficacious for alcohol abuse?

How does it work?

How many drinks/day or per week puts a pt at risk for EtOH withdrawal?

-Naltrexone works by decreasing the reinforcing effect of alcohol resulting in decreased desire/craving for alcohol.

    -Naltrexone is the only drug proven to increase abstenance from alcohol

-Greater than 4 drinks/day or 14/week for men, and greater than 3/day or 7/week for women

Name 6 reasons why you would need to admit a pt to the psychiatric ward.

-homicidal ideation

-suicidal ideation

-grave disability

-gross disorganization

-agitated or threatened behavior

-severe sx of substance intoxication or withdrawal

-nervousness

-loss of appetite

-nausea

-abdominal pain

-insomnia

-tachycardia

-mild growth retardation or weight loss (with prolonged use)

In altruism, individuals dedicate themselves to helping others in order to deal with an emotional conflict, or internal/external stressor. Unlike in reaction formation, pts do not overcompensate with the opposite reaction of how they actually feel.

In reaction formation, pts do opposite of what they really feel or desire to bury an inappropriate feeling/conflict. The purpose of their actions are not for the benefit of others. Ex: Woman, who is disturbed about attraction for her husband's friend, treats the friend rudely to hider her feelings.

What are the symptoms of mania?

What is the diagnostic criteria for manic episode?

Distractability

Insomnia/Impulsivity

Grandiosity

Flight of Ideas

Actvity/Agitation

Speech (pressured)

Thoughtlessness

-Pt must have period of abnormally elevated, expansive, or irritable mood for at least 1 week AND at least 3 of the above symptoms

What are 4 first-line agents used in the longterm management of bipolar disorder?

What are 2 second-line agents?

Qid 2495

Firstline: lithium, lamotrigine, olanzapine, quetiapine

Secondline: valoproate, aripipriozole

How long do first-line antidepressants like SSRIs take to treat major depressive disorder?

What do you do if there's no effect by this time?

Qid 2494

-4-6 weeks

-If no effect by then, then increase the dose of the SSRI

  -If this doesn't work, then try a different SSRI

What is the time course for Tourettes?

Sx of Tourettes syndrome are best treated with what?

Qid 3375

Pretest #180

-Tics occur many times/day, almost every day for > 1 yr, with no tic-free period > 3 months, and onset prior to age 18

-Tx of choice is psychopharmacology if Tics cause impairment:

  -If Tics cause moderate impairment, atypical neuroleptics (risperidone) can be used and alpha-2 agonists (clonidine, guanfecine) [also an adjuvant Tx for ADHD!]

  -If Tics cause severe impairment, typical neuroleptics are used (pimozide, haloperidol)

SSRIs are useful in treating the comorbid behavioral disorders like ADHD (present in 60%) and OCD (present in 30%)

Name ways that LSD and PCP intoxication are similar.

Name ways they are different.

Qid 3191

Similar: tachycardia, HTN, palpitations

Different:

  -LSD: visual hallucinations and intensified perceptions are hallmarks

  -PCP: agitation and aggression occur more often in theses pts

-Excessive anxiety or worry about daily events and activities (this difficult to control) for at least 6 months

-Must be a/w at least 3 of the following: restlessness, fatigue, difficulty concentrating, mm tension, sleep disturbance

What are the diagnostic criteria for bulemia nervosa (including freq and time course)?

What are the main distinguishing factors of bulemia from anorexia?

Criteria:

  -Recurrent episodes of binge eating at least twice/week for 3 months

  -Recurrent, inapprorpriate attempts to compensate for overeating and prevent weight gain (laxative abuse, vomiting, diuretics, or excessive exercise)

  -Perception of self-worth is excessively influenced by body weight and shape

Unlike pts with anorexia nervosa, pts with bulemia maintain nml bodyweight and are not amenorrheic

It's a circadian rhythm disorder characterized by an inability to stay awake in the evening (usually 7 pm), making social functioning difficult. They frequently complain of early-morning insomnia 2/2 early bedtime.

-Agranulocytosis

-Lowers the seizure threshold (bupropion does this too!)

-myocarditis

It can also cause hypersalivation

-highly sedating

-severe orthostatic hypotension (thus, must titrate up slowly)

-cataracts

What is an easy way to distinguish conversion disorder from somaticization disorder?

Qid 7728

Other than Ebstein's anomaly, what congential anomalies can lithium cause  if taken during pregnancy?

What is:

-positive reinforcement

-negative reinforcement

-punishment

-positive reinforcement: giving reward for desired behavior

-negative reinforcement: encouraging desired behavior by removing an aversive stimulus

-punishment: aversive response to an undesired behavior

What opiates commonly come up negative on a general drug screen?

Can you order separate panel for them?

Methadone and oxycodone commonly don't come up on general screen

Yes, a separate panel is used

Seratonin syndrome

Note: this can also occur if you mix meperidine with MAO-Is b/c the metabolite of meperidine is an SSRI

Does PCP have stimulant or depressant effects?

How is PCP related to Ketamine?

Phencyclidine (PCP) is an NMDA antagonist and activates the DA receptors

  -it can have stimulant or depressant effects depending on dose taken

Ketamine is similar to PCP, but is less potent. Ketamine is sometimes used as a "date rape" drug, as it is colorless and odorless

What is the mechanism of action of benzodiazepines?

Barbiturates?

Benzos: increase the frequency of chloride channel opening

Barbs: increase the duration of chloride channel opening

Barbiturates

In general, withdrawal from drugs that are sedating is life threatening, while withdrawal from stimulants is not

What can you do in the event of barbiturate overdose?

Benzodiazepine overdose?

Barb: alkalinization of urine with sodium bicarb to promote renal excretion

Benzo: flumazenil (watch out for withdrawal seizures!)

Define substance abuse.

Deine substance dependence.

Abuse: substance use -> impairment or distress for at least 12 months with 1 or more of:

  -failure to fulfill obligations at work, school, home

  -use in dangerous situations (driving)

  -recurrent substance-related legal problems

  -cont'd use despite social or interpersonal problems

Dependence: subtance use -> impairment/distress for at least 12 months with 3 or more of:

  -tolerance

  -withdrawal

  -using substance more than originally intended

  -persistent desire to cut down

  -significant time getting, using, or recovering from substance

  -functional impairment

What can be used or severe symptoms of opioid withdrawal?

Psyche FA pg 85

-Methadone (long acting opioid agonist) - significantly reduces morbidity and mortality in opiod dependent pts. Gold standard for pregnant women

-Buprenorphine (partial opiod agonist) - sublingual preparation is safer as its effects reach a plateau and make overdose unlikely

Note: Though opioid withdrawal can be very uncomfortable, it is NOT life threatening

What is the time point for Dxing adjustment disorder?

What is the management of adjustment disorder?

Time point for adjustment disorder:

  -occurs >3 months after stressor begins

  -resolves w/in 6 months of cessation of stressor

  -causes impairment of function

Tx: Supportive psychotherapy

  -these focus on developing coping mechanisms and improving individual's response to and attitudes about stressful situations

Note: Adjustment disorder is usually the Dx if a pt has a maladaptive response to a stressor that does not fit criteria for MDD (4/9 SIGECAPS), PTSD (life-threatening event, reexperiencing event), or bereavement (no impairment of function)

72 y/o female with breast cancer is brought in by her daughter b/c of increased irritablility and low mood. Pt has less than 1 year to live. The daughter says she "seems to have given up." She has decreased sleep, concentration, and apetite, daytime fatigue, and does not attend weekend brunch with friends like she used to.

NSIM?

Perscribe an SSRI for management of major depressive episode

  -pts with comorbid medical cond'ns, including terminal illness, can benefit from Tx with antidepressant meds to improve quality of life

  -for pts with shorter life expectancy, psychostimulants (methylphenidate, modafinil) may be more appropriate b/c SSRIs take longer to reach full therapeutic effect

What is the management of neuroleptic malignant syndrome (NMS)?

Qid 2501

-Prompt discontinuation of any antipsychotics

-Dantroline (direct mm relaxant)

-Amantadine and/or bromocriptine (DA agonists)

Name 4 indications for Electroconvulsive Therapy.

What is the MC side effect of ECT?

Indications:

-treatment resistant depression

-treatment resistant mania

-depression in pregnancy

-NMS/catatonia

MC Side Effect:

-Amnesia (anterograde resolves rapidly, retrograde persists for longer)

A 26 y/o female comes in with vaginal discharge for 1 week. She is married, but notes having had unprotected sex 2 weeks ago with another man. Further work-up reveals a diagnosis of both chlamydia and HIV. After deliving the news she is shocked, and pleads with you not to tell her husband.

NSIM?

Encourage the pt to tell her husband, but tell her that you are required to inform the local health department of her diagnosis

  -the health department will then inform her partners (including her husband) that they are at risk of getting HIV without giving any identifying information about the partner who placed them at risk

  -physicians have a certain time frame (usually 48 hrs) to notify the health department of such matters

What alcohol withdrawal syndromes do you see in alcoholics who've had their last drink in:

-6 hrs

-12-24 hrs

-12-48 hrs

-48-96 hrs

6 hrs - mild withdrawal (can -> DT): anxiety, tremors, sweating, palpitations

12-24 hrs - alcoholic hallucinosis (auditory, visual, tactile hallucinations with normal vitals and intact sensorium

12-48 hrs - withdrawal seizures (can -> DT)

48-96 hrs - DTs (fever, HTN, tachycardia, diaphoresis, hallucinations, disorientation)

The physician should seek a court order to proceed with the necessary intervention

  -a court order mandates treatment

A mother and daughter present to the ED with shared delusions requiring hospital admission.

NSIM?

What is residual schizophrenia?

How do pts present?

-Residual schizophrenia occurs in pts with previous Dx of schizophrenia who no longer have prominent psychotic symptoms, but lingering negative symptoms

-Persistent Sx may include eccentric behavior, emotional blunting, illogical thinking, or social withdrawal

What is used for symptomatic treatment of delerium, particularly if they are agitated?

What drug must be avoided?

-Haloperidol can be used for agitation

-Drugs to avoid are benzodiazepines because they can exacerbate or precipitate delerium

  -The exception to this is when pt's delerium is 2/2 alcohol or benzo withdrawal

1. Disturbance of conciousness (i.e. reduced clarity of awareness of environment with reduced ability to focus, sustain, or shift attention)

2. Change in cognition (memory deficit, disorientation, language, disturbance) or dev't of perceptual disturbance that's not better accounted for by preexisting dementia

3. Disturbance develops over a short period of time (hours-days)

1. Development of multiple congitive deficits manifest by both:

   -memory impairment (impaired ability to learn new info or recall previously learned info)

   -one or more of the following: aphagia, apraxia, agnosia, disturbance in executive functioning (i.e. planning, organizing sequence, abstracting)

2. Cause significant impairment in social or occupational functioning

3. Deficits don't occur exclusively during the course of a delerium

It's the dominant explanation for Alzheimer's dementia

  -excess A-beta peptides either by overproduction (amyloid precursor protein [APP] gene, presenelin I or II) or underexcretion (sporadic cases result from failure of metabolism and degredation)

What are the gross and microscopic findings of a brain with Alzheimer's dementia?

What microscopic finding correlates with disease severity?

Gross: diffuse atrophy with enlarged ventricles and flattened sulci

Microscopic: Senile plaques and neurofibrillary tangles

  -neuritic plaques (not tangles) correlate with severity of dementia

Lewey Body Dementia: onset of dementia within 12 months of PD

Parkinson's Disease Dementia: onset of dementia is over 12 months after PD symptoms have begun

In pts with Lewey Body Dementia, what drug helps improve visual hallucinations?

What drug(s) help with cognition?

What drug(s) help with apathy and psychomotor slowing?

Cholinesterase inhibitors improve visual hallucinations

Psychostimulants, levodopa/carbidopa, and DA antagonists may improve cognition, apathy, and psychomotor slowing

What 2 things is HIV associated dementia caused by?

A change in what lab value regarding the pt's HIV correlates with improvment of AIDS dementia?

It's caused by infections due to neutropenia as well as direct effects of the virus on cells

  -recall HIV infects the microglia of the brain

Decrease in viral load is a/w improvement of AIDS dementia

What movement disorder is commonly a/w Creutzfeld-Jakob Disease?

What EEG finding is common in these pts?

What Sx do you need to Dx?

-Myoclonus (sudden mm spasm)

-EEG may show generlised sharp waves

-Pts must have 2 more of the following for Dx:

  -myoclonus

  -cortical blindness

  -ataxia, pyramidal signs, EPS

  -mm atrophy

  -mutism

Define pseudodementia.

How do you manage it?

-Pseudodementia - presence of apparent cognative deficits (often resembling dementia) in pts with major depression. The cognative deficits are the result of MDD

-Management: Supportive psychotherapy and low dose SSRI

1) Denial

2) Anger

3) Bargining

4) Depression

5) Acceptance

Think "DABDA"

Adding EtOH use to the following may result in what?

-H₂ blockers

-ASA or NSAIDs

-Acetaminophen, INH, Phenylbutizone

-Reserpine, Nitroglycerine, Hydralazine

-H₂ blockers - increased blood alcohol level

-ASA or NSAIDs - increased bleeding time + irritation of gastric lining

-Acetaminophen, INH, Phenylbutizone - increased hepatotoxicity

-Reserpine, Nitroglycerine, Hydralazine - increased risk of hypotension

1. Music, exercise, pet therapy

2. Strict daily schedule to minimize change in routine

3. Continual reorientation of pt

4. Reduce stimuli (quiet living environment)

5. Surround pt with familiar objects (family photos, a favorite quilt)

In general, you want to increase pt's familiarity with their environment.

Hallucinations are common findings in pts with dementia (up to 33%). When do you suspect hallucinations are 2/2 Lewey Body Dementia?

Countertransference - redirection of a psychotherapist's/therapist's feelings or emotional entanglement toward a client

  -Ex: Therapist begins to feel like he/she must overprotect their pt and treat them gingerly b/c pt was treating them as if they were unreliable.

Transference - redirection of feelings/desires (esp. subconcious ones from childhood) toward a new object. In a psychotherapy setting, it refers to rederection of a pt's feelings for a significant person (father, mother) to the therapist.

  -Ex: Pt, whose parents neglected him growing up, treats therapist as incompetent and uncaring.

Describe magical thinking.

Describe nhihilism.

Magical thinking:

1. belief in clairvoyance (ability to gain information about something through extrasensory means) or telepathy

2. bizarre fantasies or preoccupations

3. belief in superstitions

Nihilism is the belief that oneself, others, or the world are either nonexistent or are coming to an end.

Define the following subtypes of schizophrenia:

-paranoid

-disorganized

-catatonic

-undifferentiated

-residual

-paranoid: often higher functioning, older age onset; must have the following:

   -one or more delusions or freq. AH

   -no predominance of disorganized speech, behavior, catanonia, or inapporpriate affect

-disorganized: poor functioning, early onset; must have the following:

   -disorganized speech and behavior

   -flat or inappropriate affect

-catatonic: must have 2 of the follwoing:

   -motor immobility

   -purposeless mov't

   -extreme negativism or mutism

   -peculiar volunatry mov'ts or posturing

-undifferentiated: characteristic of >1 subtype

-residual: prominent negative Sx (flat affect, social withdrawal) w/ only minimal evidence of positive Sx (AH/VH or delusions)

Beyond what age is enuresis abnormal?

What is the first, second, and third-line therapy?

Enuresis is abnormal beyond age 5

Steps in managment:

1. Behavioral therapy including enuresis alarms and positive reinforcement

2. Desmopressin

3. Imipramine

Describe the EEG findings in the following conditions:

-Caffeine withdrawal

-Nicotine withdrawal

-Barbiturate withdrawal

-Caffeine withdrawal: increased theta activity

-Nicotine withdrawal: decreased alpha activity

-Barbiturate withdrawal: generalized paroxysmal activity and spike discharges

-At least 6 Sx of inattentiveness, hyperactivity, or both that:

  -have persisted for at least 6 months

  -are present at a degree that is maladaptive

  -onset is at age 6 or less

Mneumonic: kids ADHD are devilish (666) -> 6 Sx, 6 months, age 6 or less

What is reactive attachement disorder?

What usually causes it?

Reactive attachement disorder is a severe disturbance of a child's ability to relate to others, manifested by a variety of behavioral and interpersonal problems

  -It is caused by severely dysfunctional early relationship between the principle caregiver and the child. When caregivers consistently disregard the child's physical or emotional needs, the child fails to develop a secure and stable attachement with them

What is night terror?

What is the pharmacologic management?

Night terror is a dyssomnia characterized by sudden partial arousal accompanied by piercing screams, motor agitation, disorientation, and autonomic arousal. 

  -occurs during transition to REM sleep

  -there is no memory of the episode

Tx: rarely requires pharmacotherapy, but if needed, use diazepam

What are the IQ ranges for the following Types of Mental Retardation:

-Profound

-Severe

-Moderate

-Mild

-Profound: IQ<25

-Severe: IQ 25-40

-Moderate: IQ 40-55

-Mild: IQ 55-70

-Mental retardation, hyperphagia, obesity, hypogonadism, hypotonia, osteoporosis in childhood, short stature 3/3 partial GH deficiency

Caused by deletion of normally active Paternal allele on chromosome 15

Mental retardation, seizures, ataxia, inappropriate laughter ("happy puppet")

Caused by deletion of normally active Maternal allele on chromosome 15

Describe the findings in William's syndrome.

What's it caused by?

"Elfin" facies, mental retardation, hypercalcemia (increased sensitivity to VitD), well-developed verbal skills, extreme friendliness with strangers, cardiovascular problems

Caused by a microdeletion of the long arm of chromosome 7 (includes elastin gene)

What is the risk of getting the following if a 1st degree relative has it:

-schizophrenia

-bipolar disorder

-MDD

-schizophrenia: 12% risk (12x greater)

   -50% monozygotic twin concordance

-bipolar disorder: 8-18% risk (8-18x greater)

   -40-70% monozygotic twin concordance

-MDD: 2-3x greater risk (prevelance in general population is 16%)

  -50-70% monozygotic twin concordance

At least 6 Sx must be present by age 3, with at least two from 1, and one from 2 and 3:

1. Problems with social interaction: impaired nonverbal behaviors, lack of peer relationships, lack of interest in sharing enjoyment with others, lack of social/emotional reciprocity

2. Imairments in communication: delayed speech, inability to hold conversations, repetitive or stereotyped use of language, lack of make believe and immediate play

3. Repetitive and stereotyped behavior: narrowed interest, inflexible adherence to rituals, repetitive motor mannerisms (hand flapping), preoccupation with parts of objects

What are the 2 most important predictors of adult outcome in autistic children?

What 3 disorders is autism associated with?

-2 important predictors: level of intellectual functioning, and communicative competence

-3 associated disorders: fragile X, tuberous sclerosis, and seizures

How many and what kinds of Tics need to be present to diagnose Tourettes?

What's the time course?

What is the proposed neurologic mechanism for Tourettes?

-Pt needs multiple motor and 1 or more vocal tics (can be present at different times) most of the time for > 1 year (and not Tic free for >3 mo)

-Impaired regulation of DA in the caudate nucleus

What is the time course for Retts disorder?

What physical findings are a/w it?

What gene is it associated with?

Retts is characterized by nml physical and psychomotor dev't during first 5 months after birth, followed by decreasing rate of head growth and loss of previously learned purposeful hand skills between 5-30 months

These kids then develop sterotyped hand mov'ts (hand wringing/washing), impaired language, psychomotor retardation, and problems with gait or trunk mov'ts

It's a/w MECP2 gene mutation on X chromosome

What is the time course for childhood disintegrative disorder?

How do these pts present?

-Pts have nml dev't in first 2 yrs of life, including communication, social relationships, play, and adaptive behavior

-Pts then have loss of previosly acquired skills before age 10 (typically between 3-4 y/o) in at least 2 of the following areas: language, social skills or adaptive behavior, bowel/bladder control, play, motor skills

  and at least 2 of the following: impaired communication, restricted, repetetive, stereotyped behaviors and interests

-Excessice fear for >/= 4 weeks of leaving one's parents or other major attachement figure

-Kid may refuse or complain of physical Sx to avoid going to school/sleeping alone/etc.

-axiety disorders

-depressive disorders

-dissociative disorders

-self destructive behaviors

-substance abuse disorders

-PTSD

Describe the type of memory loss in dissociative amnesia.

What typically triggers DA?

Dissociative amnesia is a sudden retrograde autobiographical memory loss ranging from hrs to yrs.

  -Typically occurs following a traumatic experience (sexual abuse)

  -This type of memory loss is opposite the type of memory loss in dementia and transient global amnesia

Unlike pts with dissociative amnesia, pts with dissociative fugue are (aware/unaware) they forgot anything.

They are unaware they forgot anything

  -pts show characterisitcally low anxiety despite their confusion; their affect is similar to la belle indifference

-persistent recurrent experiences of being detached from one's body or mental process

-reality testing remains intact

-social/occupational impairment, can't be accounted for by another mental/physical disorder

Define the following terms:

  -ataque de nervios

  -amok

  -Ganser syndrome

-ataque de nervios: culturally bound trance disorder common in Puerto Rico that consists of convulsive mov'ts, fainting, crying, and visual problem

-amok: culture-bound synd of Malaysian origin that refers to violent/furious outbursts of homicidal intent. Defined by: homicidal outbursts, and amnesia

-Ganser syndrome: giving approximate answers to simple questions such as how many legs do you have?

What 2 things can benzodiazepines do in elderly population?

-delerium

-paradoxical excitement

  -recall, the GABAergic effects of benzos causes a release of inhibition, and in pts with subclinical dementia this can result in paradoxical excitation

With bizarre behavior w/o clasical Gran Mal shaking movements. Instead it's characterized by:

  -hyposexuality

  -emotional intensity

  -perseverative approach to interactions

What is hypochondriasis and what is the time course?

How do you manage hypochondriasis?

-Preoccupation with fear of having or contracting a serious disease based on misinterpreting bodily Sx and must be present for 6 months

-By having the pt f/u with PCP regularly (but do not perform invasive procedures unless clear indication)

  -Pts don't think they have a psychiatric problem, so referring to psychiatry won't help!!!

How do partial complex seizures usually manifest?

It usually manifests by staring, accompanied by:

  -hallucinations (typically olfactory)

  -automatisms (buttoning and unbuttoning, masticatory movements, speech automisms)

  -perceptual alterations (objects changing shape or size)

  -complex verbalizations

  -autonomic symptoms

Recall, partial complex seizures result when seizure occurs in a larger part of brain and results in alterations or loss of conciousness

-somaticization disorder pts typically express lots of concern over their cond'n and chronically perseverate over this

-conversion disorder pts often have an abrupt onset of their "disability" (blindness, etc) and the pt usually appears apathetic.

Antidepressants + psychotherapy (CBT, interpersonal psychotherapy, group therapy, and/or family therapy)

  -SSRIs are drug of choice (fluoxetine is the only FDA-approved medication for bulemia)

What is pain disorder and how do you manage it?

What is the time course for acute and chronic?

What is the management?

-Pain disorder is pain at one or more anatomic sites that is not intenionally produced and not caused by a medical illness (but is often comorbid with it), and causes significant distress.

-Acute is < 6 months, chronic is > 6 months

Tx: SSRIs, biofeedback, hyponosis, psychotherapy

Seratonin

Recall that SSRIs are one of the main drugs (aside from anticonvulsants, lithium, and propranolol) in the treatment of intermittent explosive disorder

Gamblers anonymous (a 12-step program)

  -After 3 months of abstinence, insight oriented psychotherapy may be attempted

Prolactin!

  -Prolactin levels rise sharply following a GMS and lasts for about 20 mins

  -Since nonepileptic seizures do not cause prolactin levels to change, this test may be useful in ruling out epileptic seizures

What are the 4 diagnostic criteria for anorexia nervosa?

Tx?

1) Refusal to maintain minimally nml body weight for one's age and height (<85% of ideal BW or BMI <17.5)

2) Intense fear of gaining weight or becoming fat

3) Distrubed body image, undue influence of weight or shape on self evaluation, or denial of seriousness of current low BW

4) Amenorrhea in postmenarchal females (i.e. absence of at least 3 consecutive menstrual cycles)

Tx:

  -food is best medicine--weight gain programs are available

  -behavioral and family therapy is often helpful as well

  -if body weight is <80% of ideal -> inpatient management!

Describe the what lab findings are seen in anorexia nervosa:

-clinical chemstry

-blood pH

-EKG findings

-cholesterol level

-LFTs

-CBC findings

-cortisol level

-GH level

-gonadotropin level

-sex hormone levels

-thyroid hormone

-clinical chemstry: hyponatremia, hypochloremia hypokalemia (all 3 if vomiting), high BUN

-blood pH: metabolc alkylsosis (if vomiting)

-EKG findings: prolonged QT_c

-cholesterol level: hypercholeterolemia

-LFTs: transaminitis

-CBC findings: leukopenia, normocytic anemia

-cortisol level: hypercortisolism

-GH level: elevated GH

-gonadotropin level: low gonadotropin level

-sex hormone levels: low sex hormone level

-thyroid hormone: hypothyroidism

-If their body weight is more than 20% less than ideal body weight

-Serious medical or psychiatric complication

Anorexia: pts have a good appetite but starve themselves due to distorted body image. They're often preoccupied by food, preparing it for others, etc, but do not eat it themselves

MDD: pts have poor appetite and no interest in food -> WL

What electrolyte abnormalities are seen in refeeding syndrome?

What is the pathophysiology behind the main electrolyte disturbance?

-hypophosphatemia (main one), hypokalemia, hypomagnesemia, vitamins (thiamine), trace metals, volume overload (and edema)

-pathophys: stores of phosphate are depleted during episodes of starvation. Then, with nutritional replenishment, glucose -> release of insulin -> cellular uptake of phosphate (and potassium and magnesium). Insulin -> cells to produce depleted molecules that require phosphate (ATP and 2,3-BPG)

  -Low ATP and 2,3-BPG can result in tissue hypoxia -> cardiac dysfunction and respiratory failure

What's the time course for insomnia?

What is the management (3 modalities) for insomnia?

-time course for insomnia is 1 month

Tx:

  -improve sleep hygiene

  -cognative behavioral therapy (first-line therapy for chronic insomnia!)

  -pharmocotherapy (benzos, non-benzos, antidepressants [trazadone, amitriptyline])

Describe the defense mechanism undoing.

Give an example.

Undoing is when a pt attempts to reverse a situation by adopting a new behavior

Ex: Man who has a brief fantasy of killing his wife by sabotaging her car takes the car in for a complete check up

3 months

  -Pt must have irresistable attacks of refreshing sleep that occur daily for at least 3 months + REM dysregulation Sx (cataplexy, sleep attacks, sleep paralysis, hypnogogic/pompic hallucinations)

When do hypongogic hallucinations occur?

When do hypopompic hallucinations occur?

gogic - occur when transitioning from sleep

pompic - occur when transitioning to sleep

For sleepiness: modafinil or methylphenidate

For REM-sleep suppression (i.e. suppressing cataplexy):

  -First Aid says GHB is firstline

  -UptoDate says SSRIs are firstline, and GHB is secondline

In idiopathic hypersomnia, pts do not have REM-onset episodes (cataplexy, sleep paralysis, etc), which is required for Dx of narcolepsy

Recall, idiopathic hypersomnia is characterized by excessive daytime sleepiness, prolonged nocturnal sleep, and frequent irresistible urges to nap.

Recurrent hypersomnia with episodes of:

  -daytime sleepiness

  -hyperphagia

  -hypersexuality

  -aggression

Think of a sleepy, fat, hypersexual, aggressive man. Also, think of Kluver Bucy

-sleep deprivation (including OSA)

-stress

-hyperthyroidism

-seizures

-migraines

-meds (sedatives, Li, anticholinergics)

-Mg deficiency

What is the first-line and second-line management for:

-sleep terror (aka night terror)

-nightmare disorder

-sleep (night) terror: reassurance, however, if refractory -> short acting benzos and improvement of sleep hygiene is recommended

-nightmare disorder: imagery rehersal therapy (IRT) - involves use of mental imagery to modify outcome of recurrent nightmare, writing outcome down, mentally repeating it in rexlaxed state

  -has been very successful in Tx of nightmares in PTSD pts

  -if refractory -> consider antidepressants

What is REM sleep behavior disorder?

How is it treated?

Common RFs?

 -Characterized by complex motor mov'ts a/w dream mentation (dream enactment)

   -sleep talking, yelling, limb jerking, walking/running, punching, etc.

-Tx: Clonazepam is efficacious in 90% of pts (other usefull agents include imipramine, carbamazepine, pramipexole, and levodopa)

-RFs: Use of SSRIs, TCAs, MAO-Is, old age, narcolepsy, brainstem lesions, dementia (esp LBD)

1. Desire: interest in sexual activity, often reflected by sexual fantasies

2. Excitement: begins w/ fantasy of physical contact. Men -> erection. Women -> vaginal lubrication and clitoral erection. Both -> increased BP and HR, nipple erection

3. Plateau: men -> increased size of testicles, tightened scrotum, secretion of seminal fluid. women: contraction of outer 1/3 of vagina and enlargement of upper 1/3

4. Orgasm: ejaculation (women also have uterine contraction)

5. Resolution: mm relax and CV state returns to baseline. Men have refractory period but women don't

What 3 main medication classes result in sexual dysfunction?

How do estrogen, testosterone, and progesterone effect sexual function?

How does DA and 5HT effect sexual function?

1. antihypertensives

2. anticholinergics

3. antidepressants (esp. SSRIs and antipsychotics)

-Estrogen promotes vaginal lubrication and thickening

-Testosterone and DA promotes libido in both sexes

-Progesterone inhibits libido in both sexes by blocking androgen-R; found in OCPs, HRT, Tx for prostate cancer

-5HT inhibits libido

Define the following:

-sadism

-fetishism

-masochism

-sadism: sexual excitement from hurting/humiliating another

-fetishism: sexual preference for inanimate objects (shoes, pantyhose)

  -transvestic fetishism: when men (usually heterosexual) wear women's clothing

-masochism: sexual excitement from being humiliated or beaten

-otherwise known as transsexuality, these pts have subjective feeling that they're born the wrong sex

Tx:

  -kids - therapy, family involvement

  -adults - sex reassignment by hormonal/surgical techniques

Id: unconcious, invovles instictual sexual/aggressive urges and primary process thinking

Ego: mediator btwn id and external environment and seeks to develop satisfying interpersonal relationships; uses defense mechanisms to control instictual urges and distinguishes fantasy from reality using reality testing. Problems with reality testing occur in psychotic individuals

Superego: moral conscience

1. Controlling: regulating situations to relieve anxiety

2. Displacement

3. Intellectualization

4. Isolation of Affect

5. Rationalization

6. Reaction formation: doing opposite of an unacceptable impulse

7. Repression

1. Acting out

2. Denial

3. Regression

4. Projection: attributing objectionable thoughts or emotions to others

What is the focus of behavioral therapy?

What is it based on?

Behavioral therapy seeks to treat psychatric disorders by helping pts change behaviors that contribute to their Sx. Can be used to extinguish maladaptive behaviors (phobia, avoidance, sex dysfunction, compulsions) by replacing them with healthy alternatives

Its based on learning theory - behaviors are learned by conditioning and unlearned by deconditionaing

CBT combines ideas from cognative therapy (IDing maladaptive thoughts and replacing them with positive ones) with behavioral therapy (extinguishing maladaptive behaviors by replacing them with healthy ones)

  -basicaly, it focuses on pt's current Sx and problems by examining connection between thoughts and behaviors

  -useful in treating depression, anxiety, substance abuse

What is classical conditioning?

What is operant conditioning?

Classical: stimulus can eventually evoke conditioned response (ex: Pavlov's dog would salivate when hearing bell b/c it learned that bells are followed by food)

Operant: behaviors can be learned when followed by positive ofr negarive reinforcement

Briefly describe the following deconditioning techniques:

-desensitization

-flooding/implosion

-aversion

-token economy

-biofeedback

-desensitization: pt performs relaxation technique while exposed to stimulus, and gradually learns to associate stimulus with state of relaxation.

-flooding/implosion: pt is confronted with real (flooding) or imagined (implosion) stimulus and not allowed to withdraw until pt is calm.

-aversion: negative simulus (shock) is paired with specific behavior to cause avoidance of behavior (ex: Alcoholic taking disulfiram)

-token economy: reward given after specific behavior to positively reinforce them

-biofeedback: physiologic data (HR, BP) given to pts as they try to mentally control physiolocal states.

What is the aim of cognative therapy?

What is it helpful in treating?

Congative therapy seeks to correct faulty assumptions and negative feelsings that exacerbate psyciatric symptoms. Pt is taught to ID maladaptive thoughts and replace them with positive ones.

-Most commonly used to treat depressive and anxiety disorders, as well as paranoid PD, OCPD, somatiform disorders, and eating disorders

What is the aim of dialectical behavioral therapy?

What is it most useful in treating?

DBT is a form of CBT that has proven effective in redcuing the urge to engage in self-harm behavior and has led to fewer hospitalizations.

  -DBT has demonstrated effectiveness in work with borderline personality disorder pts

What is group therapy?

What is it most useful in treating?

Group therapy is when 3 or more pts with similar problem meet together to discuss a shared problem/feeling, and provide support for each other

  -therapist might not be present (ex: AA)

  -useful in treating substance abuse, adjustment disorder, and personality disorders

What must you monitor in any patient taking valproate?

Name 7 important SE.

-Monitor LFTs and CBC

-Side Effects include:

  -weight gain

  -sedation

  -alopecia

  -pancreatitis

  -hepatotoxicity or benign aminotrasferase elevation

  -thrombocytopenia

  -teratogenicity (NTD)

Name the most common side effects of the following SSRIs:

-fluoxetine (3)

-sertraline (1)

-paroxetine (2)

-citalopram

-fluoxetine: sleep changes and anxiety, can elevate levels of neuroleptics, safest in pregnancy

-sertraline: highest risk for GI disturbances

-paroxetine: more anticholinergic effects, shortest half-life -> withdrawal phenomenon

-citalopram: possibly fewer sexual SE

Increased suicidal thinking and behavior, especially in children and adolescents.

  -This may be related to fact that in pts on pharmocotherapy for MDD, the first thing to return is motivation and activity. This coupled with SI can lead to suicidal action

SSRIs inihibit cytochrome P450

  -thus they can elevate warfarin levels

Name some common conditions the following SNRIs can be used to treat:

-venlafaxine (3)

-duloxetine (2)

Name 2 conditions bupropion helps treat.

-venlafaxine: depression, generalized anxiety disorder, and ADHD

-duloxetine: depression, neuropathic pain (fibromyalgia, DM) due to high NE activity

Bupropion helps treat depression and ADHD

What 2 conditions does trazadone treat?

What 2 SE must you look out for?

-Refractory major depression (including MD w/ anxiety)

-insomnia

SE: sedation, priapism

Recall: nefazadone can cause serious liver failure!

Name 2 things other than depression each of the TCAs are used to treat

-clomipramine

-doxepine

-nortriptyline (1)

-clomipramine: OCD and anxiety (most 5HT spec)

-doxepine: chronic pain, sleep aid at low doses

-nortriptyline: chronic pain

Name important side effects of the following atypical antipsychotics:

-rispiridone

-olanzapine

-quetiapine

-ziprazidone

-aripiprazol

-clozapine

-rispiridone: EPS (most similar to "typicals"), hyperprolactinemia

-olanzapine: most weight gain and cardiometabolic effects

-quetiapine: very sedating, severe orthostasis (have to titrate slowly b/c of this)

-ziprazidone: least sedating, least likely for weight gain

-aripiprazol: also less potential for sedation and weight gain, can be more activating (akathesia)

-clozapine: agranulocytosis, myocarditis, seizure, hypersalivation

Note: ALL atypicals increases mortality in elderly

-Decreases risk of suicide (Li is only mood stabilizer to do this)

-Only antipsychotic show to be more efficacious

-Least likely to cause Tardive Dyskinesia

What are 3 SE of chlorpromazine?

It be used for what 2 other things besides psychosis?

Side Effects:

-orthostasis

-blue skin color (link w/ amioderone)

-eye effects: photosensitivity and corneal deposits

Can be used for:

-n/v

-intractible hiccups

Cardiotoxicity

  -including heart block, V-tach, and other cardiac effects

The mesolimbic pathway is implicated in the positive symptoms of schizophrenia. What are the main components of the mesolimbic pathway?

-potentiation of antidepressants in pts with MDD refractory to monotherapy

-potentiation of antipsychotics in pts with refractory schizophrenia

-enhancement of abstinence in Tx of alcoholism

-ancillary Tx of aggression and impulsivity

What must be obtained before initiating carbamazepine?

Name some of the main SE.

-CBC and LFTs must be obtained before initiating treatment and monitored regularly

-Side Effects:

  -confusion, stupor, ataxia (these are MC)

  -Steven-Johnson Syndrome

  -Leukopenia, thyrombocytopenia, aplastic anemia, agranulocytosis

  -SIADH -> hyponatremia

  -hepatitis

  -teraogenic (neural tube defects)

What can topiramate be used for?

Name 3 side effects.

-can be used for: impulse control disorder and anxiety

-3 side effects include:

  -weight loss

  -hyperchloremic, non-AG metabolic acidosis and kidney stones

  -cognative slowing (most limiting SE)

Lorazepam

Oxazepam

Temazepam

(LOT)

-elevated serotonin (some atypicals like rispiridone and clozapine antagonize 5HT-R)

-elevated norepinephrine

-decreased GABA

-decreased glutamate receptors

antidepressants and lithium

  -there is a relative contraindication to breastfeed, however, if pts are on this regimen

-Mania last at least 7 days, hypomania is at least 4

-Mania impairs function, hypomania does not

-Mania necessitates hospitalization, hypomania does not

-Mania may have psychotic features, hypomania does not

Both can exhibit fear and avoidance of social situations. The difference is:

-Avoidant PD: sx are an integral part of pts personality and have been evident since before adulthood. They have a fear of rejection

-Social phobia: pts have fear of embarrasment in a particular setting (speaking in public, urinating in public)

What are the goals of the following psychotherapies:

-supportive

-dialectical behavioral

-cognative

-supportive: strengthen current defense mechanisms. Through supportive care, pt learns to cope w/ different problems using already established abilities. Is ideal for pts in a crisis

-dialectical behavioral: personality change

-cognative: correct faulty ideas

PTSD: event occured at any time in past, and Sx occur for > 1 month

ASD: event occured < 1 month ago, and last for <1 month

What is the best treatment for generalized anxiety disorder (GAD)?

FA for psych, pg 56

CAPRI

Cognition

Affect

Personal Relations

Impulse control

1. belief in clairvoyance (ability to gain information about something through extrasensory means) or telepathy

2. bizarre fantasies or preoccupations

3. belief in superstitions

Pt must have non-bizarre fixed delusions for at least 1 month

  -function is not impaired

-alpha-2 agonists (clonidine, guanfacine)

-atomoxetine (norepi reuptake inhibitor [NRI])

-bupriopion

Note: use of stimulants for ADHD when there is a comorbid tic disorder is controversial because of possibility for exacerbation of tics

-linazolid

-insoniazid

-depression with:

  -anhedonia

  -early morning awakenings

  -psychomotor disturbances

  -excessive guilt

  -anorexia

1. Weightloss/anorexia (at high doses)

2. Decreased sleep (at low doses)

              -mneumonic: slow wave sleep

How do you prevent the growth delay associated with methylphenidate use for treatment of ADHD?

Allow pts to go on drug holidays

  -Ex: when pt is on summer vacation and no longer needs help focusing on school work

-presenelin I and II

-amyloid precursor protein (APP)

-apolipoprotein e4

1. mood disorders: incl depression

  -if depression came before dementia, think of pseudodementia

2. agression

3. psychosis

  -delusions occur in up to 70% of Alzheimers

  -hallucinations can be seen in up to 33% of dementia pts

What is the time course for selective mutism?

How about for separation anxiety disorder?

-Selective mutism:  refusal to speak in certain situations for at least 1 month

  -onset usually around 2-5 y/o

-Separation Anxiety Disorder: excessive fear for >/= 4 weeks of leaving parents or major caregiver

Grief persists for at least 6 months and includes at least 4 of the following:

1. difficulty moving on with life

2. numbness/detachement

3. bitterness

4. feeling that life is empty w/o deceased

5. trouble accepting loss

6. feeling that future holds no meaning

7. agitation

8. difficulty trusting others since loss

What is the management for somaticization disorder?

What is the managment for hypochondriasis?

A 34 y/o woman comes to you because she says hse frequnetly cannot account for hours or even days of her life. She occasionally doesn't remember how or when she arrived at specific locations. She finds clothes she does not like in her closet, and doesn't remember having bought them. Her friends say she sometimes acts in a childish, dependent way and other times uncharacteristically becomes aggressive. She has a history of being abused as a child by her parents and was forced to live in a foster home.

Dx?

Dissociative identity disorder

  -pts history of dramatic changes in mannerisms and affect is a clue to different personalities

  -pts may have hallucinations in any sensory modality

  -pts may have fluctuations in skills, well-learned abilities, and habits

What are the goals of the following psychotherapies?

-psychodynamic

-interpersonal

-behavioral

-psychodynamic (aka insight oriented): for pt to gain self-awareness of influences of the past on present behavior. Allows pt examine unresolved conflicts of the past and how they affect present coping behavior

-interpersonal: developing social skills to improve interpersonal relations

-behavioral: focuses on alleviating ppls maladaptive behavior w/o theorizing about their inner conflicts

behavioral therapy and/or SSRIs

Recall: Management for bullemia nervosa is CBT + SSRIs

-recurrent episodes of binge eating (excessive eating in 2 hr period)

-severe distress over binge eating

-at least 2 binges a week for 6 months

A 5 y/o boy is referred to you by his pediatrician for aggressive behavior. Pediatric neurology is nagative. Interview with parents and the pt reveals a restless boy who is able to engage in conversation. He tells you he gets angry and frustrated in school and things it's boring. His parents report he's neverb een the strongest student. He is currenlty repeating kindergarten b/c of poor performance. His mother tells you he still needs help picking out his clothes for school and getting dressed.
What is the most likely Dx?

What test might help reveal the Dx?

-Dx: Pt is likely metally retarded

  -his angry and aggressive outbursts may be centered around not understanding school work nor being able to socialize with peers

-A Wechsler Intelligence Scale for Children (WISC) may reveal the Dx

A 12 y/o boy is brought in by mom for evaluation of hyperactivity. He has difficulty sitting still and concentrating. On exam, pt is highly distractible and mom has a hard time getting him to sit down. When he does sit down, he swings his legs and has poor eye contact. He frequently clears his throat, sniffs, and blinks his eyes. Further evaluation reveals that he frequently has episodes where he counts numbers in his head and doesn't stop until he's done it eight times. He admits these habits are bothersome but cannot stop them because he gets very anxious.

Dx?

Tourette's

  -Diagnostic criteria:

      -Multiple motor tics

      -one or more vocal tics

      -present for >1 year, and no tic free period for >3 months

      -onset prior to 18 y/o

Recall, Tourette's is commonly comorbid with ADHD and OCD

Name drugs that treat OCD.

Name drugs that treat ADHD.

OCD:

  -fluvoxamine (SSRI) [high dose], clomipramine

ADHD

  -methylphenidate, clonidine/guanfacine, atomoxetine (NRI), bupropion

Name things other than depression each of the TCAs are used to treat:

-amitriptyline (3)

-imipramine (2)

-amitriptyline: chronic pain, migraines, insomnia

-imipramine: enuresis, panic disorder

1. STOP ALL IMPLICATED MEDS (answer according to FA for psych)

2. Supportive care aimed at normalization of vitals

3. Benzos for sedation

-Moderate autonomic instability -> aggressive treatment, including cyproheptadine

-Calcium channel blockers (nifedipine) can also be used (according to FA)

What patient population is NMS more likely to occur in?

How about Tardive dyskinesia?

NMS: young males  (occurs early in Tx with both atypcal and typical antipsychotics)

TD: older women as well as older black men