Psych

Question 1

Breathholding spells

• ____ is more prevalent in children with BHS
• 2 types: 1) Cyanotic (commonly preceded by cries, lose consciousness, become cyanotic) 2) Pale//pallid form (vasovagal scope, turn pale)
• Tx: Reassurance. Prevent situations that induce attack and iron supplementation.

Answer 1

Breathholding spells

• Iron deficiency anemia is more prevalent in children with BHS
• 2 types: 1) Cyanotic (commonly preceded by cries, lose consciousness, become cyanotic) 2) Pale//pallid form (vasovagal scope, turn pale)
• Tx: Reassurance. Prevent situations that induce attack and iron supplementation.

Question 2

Thumb sucking

- __yo: refer for dental evaluation

Answer 2

Thumb sucking

• <4yo: reassure parents as most will self resolve with no consequences
• > 4yo: refer for dental evaluation

Question 3

Sleepwalking:

• ___ sleep.
• Tx: ___

Answer 3

Sleepwalking:

• Non-REM sleep.
• Tx: Gently lead back to bed. Preemptive awakening

Question 4

Sleep/Night Terrors:

• ___ stages, during ___ 3rd of night.
• Strong ___ predisposition.
• Pt does not remember the incidence later
• Tx: ____

Answer 4

Sleep/Night Terrors:

• Non-REM stages, during 1st 3rd of night.
• Strong genetic predisposition.
• Pt does not remember the incidence later
• Tx: Observe WITHOUT attempting to awaken. A preemptive awakening before usual time can break cycle

Question 5

Nightmares

• Peak age 3-5yo
• ___ 1/3 of night during REM, muscle tone is inhibited.
• Child remembers the dream
• Tx___

Answer 5

Nightmares

• Peak age 3-5yo
• Last 1/3 of night during REM, muscle tone is inhibited.
• Child remembers the dream
• Tx: Reassure child that dream is over. Good sleep hygiene.

Question 6

Narcolepsy

• ___ sleep disorder due to a deficiency in neuropeptide ___
• 4 clinical features for at least 3 mo: ____, _____, _____, _____
• Dx: Polysomnography followed by multiple sleep latency testing (MSLT)
• Tx: ____

Answer 6

Narcolepsy

• REM sleep disorder due to a deficiency in neuropeptide hypocretin-1
• 4 clinical features for at least 3 mo: Excessive daytime sleepiness (cardinal feature), cataplexy (sudden paralysis), hypnagogic hallucinations (hallucinations during sleep onset), sleep paralysis
• Dx: Polysomnography followed by multiple sleep latency testing (MSLT)
• Tx: Pharm: Stimulants/methylphenidate. Lifestyle modifications.

Question 7

Obstructive sleep apnea (OSA)

• If left untreated, long-term sequelae of frequent episodes of intermittent hypoxia and sleep arousals: HTN, pulmonary HTN, cardiovascular disease, arrhythmias, heart failure, metabolic disorders, obesity, neuropsychiatric and developmental issues.
• Dx: Polysomnography (PSG) to confirm significant obstruction
  
  • Mild OSA: AHI 1-4.9
  • Moderate OSA: AHI 5-9.9
  • Severe OSA: >__
• Tx: In those with adenotonsillar hypertrophy, ENT referral for tonsil and adenoidectomy (also known as adenotonsillectomy) is recommended as the 1st line tx.

Answer 7

Obstructive sleep apnea (OSA)

• If left untreated, long-term sequelae of frequent episodes of intermittent hypoxia and sleep arousals: HTN, pulmonary HTN, cardiovascular disease, arrhythmias, heart failure, metabolic disorders, obesity, neuropsychiatric and developmental issues.
• Dx: Polysomnography (PSG) to confirm significant obstruction
  
  • Mild OSA: AHI 1-4.9
  • Moderate OSA: AHI 5-9.9
  • Severe OSA: >10
• Tx: In those with adenotonsillar hypertrophy, ENT referral for tonsil and adenoidectomy (also known as adenotonsillectomy) is recommended as the 1st line tx.

Question 8

Restless Legs Syndrome

• Path: ______
• Supportive features of RLS
  
  • Sleep disturbance for age (eg sleep onset/maintenance insomnia)
  • A biologic parent or sibling with definite RLS
  • The child has documented PLMS index of >5/hour
• Tx and management
  
  • Measure serum ferritin, TIBC, serum iron.
  • Tx when the serum ferritin falls <50ng/mL. The goal of therapy is ferritin level of 80-100ng/mL
  • Use of cognitive and physical countermeasures for RLS symptoms - physical relaxation techniques, warm baths, and cognitive restructuring
  • Avoid activators of RLS-sleep deprivation and certain drugs and medications (caffeine, nicotine, SSRIs, TCAs, antiemetics, and antihistamines)

Answer 8

Restless Legs Syndrome

• Path: Iron deficiency
• Supportive features of RLS
  
  • Sleep disturbance for age (eg sleep onset/maintenance insomnia)
  • A biologic parent or sibling with definite RLS
  • The child has documented PLMS index of >5/hour
• Tx and management
  
  • Measure serum ferritin, TIBC, serum iron.
  • Tx when the serum ferritin falls <50ng/mL. The goal of therapy is ferritin level of 80-100ng/mL
  • Use of cognitive and physical countermeasures for RLS symptoms - physical relaxation techniques, warm baths, and cognitive restructuring
  • Avoid activators of RLS-sleep deprivation and certain drugs and medications (caffeine, nicotine, SSRIs, TCAs, antiemetics, and antihistamines)

Question 9

Anorexia Nervosa

• Euthyroid hyperthyroxinemia (euthyroid sick syndrome) is typically seen. Characterized by normal free thyroxine T4 and TSH and low serum total T4 and T3 concentrations - all in the absence of signs or symptoms of thyroid dysfunction.
• Dx: 1. Persistent restriction of energy, 2. Intense fear of gaining weight, 3. Severe body image distortion with denial of seriousness of illness
• Reasons for admission:
  
  • Marked cachexia: less than 75% ideal body weight or failure of outpatient tx with ongoing weight loss despite intensive management
  • Refusal to eat or uncontrolled binging and purging; dehydration
  • EKG rhythm disturbances other than sinus bradycardia
  • HR less than ___ in daytime, less than __ at night
  • Acute medical complications of malnutrition (eg cardiac failure, liver failure, pancreatitis, hypoglycemia)
  • Hypotension: less than __/___ mmHg
  • Orthostatic changes >20bpm increase in HR or a decrease in bp (>20 mmHg systolic or >10mmHg diastolic)
  • Syncope
  • Temp less than ____
  • Severe electrolyte disturbances
  • Seizures
  • Comorbidity that prevents adequate outpatient care
  • Suicidal ideation or other psychiatric emergency

Answer 9

Anorexia Nervosa

• Euthyroid hyperthyroxinemia (euthyroid sick syndrome) is typically seen. Characterized by normal free thyroxine T4 and TSH and low serum total T4 and T3 concentrations - all in the absence of signs or symptoms of thyroid dysfunction.
• Dx: 1. Persistent restriction of energy, 2. Intense fear of gaining weight, 3. Severe body image distortion with denial of seriousness of illness
• Reasons for admission:
  
  • Marked cachexia: <75% ideal body weight or failure of outpatient tx with ongoing weight loss despite intensive management
  • Refusal to eat or uncontrolled binging and purging; dehydration
  • EKG rhythm disturbances other than sinus bradycardia
  • HR <50 in daytime, <45 at night
  • Acute medical complications of malnutrition (eg cardiac failure, liver failure, pancreatitis, hypoglycemia)
  • Hypotension: <90/45 mmHg
  • Orthostatic changes >20bpm increase in HR or a decrease in bp (>20 mmHg systolic or >10mmHg diastolic)
  • Syncope
  • Temp <96 / 35.6
  • Severe electrolyte disturbances
  • Seizures
  • Comorbidity that prevents adequate outpatient care
  • Suicidal ideation or other psychiatric emergency

Question 10

Bulimia

• Dx:
  
  • 1) Recurrent episodes of binge eating characterized by:
    
    • Rapid intake of food in a short period of time
    • Sense of lack of control over eating during the episode
  • 2) Recurrent inappropriate compensatory mechanisms to prevent weight gain (purging) such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise
  • 3) The binge eating and inappropriate compensatory behaviors both occur, on average, at least 1x/week for 3 months
  • 4) Self-evaluation is unduly influenced by body shape and weight
  • 5) The binge eating does not occur exclusively during episodes of inappropriately compensatory behavior.
• Tx: ______ are more effective in BN than in AN. ____ approved.
• Admission reasons:
  
  • Syncope
  • K less than ___
  • Cl less than __
  • Esophageal tears
  • Cardiac arrhythmias, prolonged QTc
  • Hypothermia
  • Suicide risk
  • Intractable ____
  • Hematemesis
  • Failure to respond to outpatient management

Answer 10

Bulimia

• Dx:
  
  • 1) Recurrent episodes of binge eating characterized by:
    
    • Rapid intake of food in a short period of time
    • Sense of lack of control over eating during the episode
  • 2) Recurrent inappropriate compensatory mechanisms to prevent weight gain (purging) such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise
  • 3) The binge eating and inappropriate compensatory behaviors both occur, on average, at least 1x/week for 3 months
  • 4) Self-evaluation is unduly influenced by body shape and weight
  • 5) The binge eating does not occur exclusively during episodes of inappropriately compensatory behavior.
• Tx: SSRIs are more effective in BN than in AN. Fluoxetine approved.
• Admission reasons:
  
  • Syncope
  • K <3.2
  • Cl < 88
  • Esophageal tears
  • Cardiac arrhythmias, prolonged QTc
  • Hypothermia
  • Suicide risk
  • Intractable vomiting
  • Hematemesis
  • Failure to respond to outpatient management

Question 11

Refeeding syndrome

• Pt: ___, ____, ____
• Delirium, chest pain, heart failure

Answer 11

Refeeding syndrome

• Pt: Hypophosphatemia, hypokalemia, hypomagnesemia
• Delirium, chest pain, heart failure

Question 12

Tics

• ____ medications sometimes unmasks a tic disorder. Discontinuation only if tic is worse than ADHD.
• Tx: Supportive with education. Comprehensive behavioral intervention for tics.
  
  • 2 meds: ___ and ___. Many try ____

Answer 12

Tics

• Stimulant medications sometimes unmasks a tic disorder. Discontinuation of stimulant only if tic is worse than ADHD.
• Tx: Supportive with education. Comprehensive behavioral intervention for tics.
  
  • 2 meds: Haloperidol and pimozide. Many try alpha2-adrenergic agonist such as clonidine or guanfacine.

Question 13

Tourette syndrome

• ___
• Dx: Tics for at least 1 year with presence of both vocal and motor tics, no tic-free interval for >3mo, onset prior to 18yo, and no underlying medical cause
• Tx: Supportive with education. _____ is FDA approved for tx.

Answer 13

Tourette syndrome

• AD
• Dx: Tics for at least 1 year with presence of both vocal and motor tics, no tic-free interval for >3mo, onset prior to 18yo, and no underlying medical cause
• Tx: Supportive with education. Haloperidol is FDA approved for tx.

Question 14

Rett syndrome

• ____ mutation. Most patients are girls
• Pt:
  
  • Earliest sign is _____.
  • Psychomotor development is normal in first 6-18mo after birth, followed by _______ in language and motor skills (intellectual disability)
    
    • Autistic-like behaviors
  • Hand-wringing and repetitive, stereotypic hand movements

Answer 14

Rett syndrome

• XLD mutation. Most patients are girls
• Pt:
  
  • Earliest sign is a decline in head growth.
  • Psychomotor development is normal in first 6-18mo after birth, followed by developmental regression in language and motor skills (intellectual disability)
    
    • Autistic-like behaviors
  • Hand-wringing and repetitive, stereotypic hand movements

Question 15

Depression

• FDA has approved 2 SSRIs- ___ for children >8yo and adolescent depression, and ____ for adolescent depression
  
  • In 2004, the FDA issued a black box warning for the risk of increased suicidal ideation and behaviors (but not completed suicides).
• ____ is 1st line for tx both depression and tobacco cessation.
• Medication trial should last at least 6-12 weeks.
• Once an effective SSRI has been identified and symptoms have resolved, treatment with the SSRI should be continued for an additional 6-12 months.

Answer 15

Depression

• FDA has approved 2 SSRIs- fluoxetine for children >8yo and adolescent depression, and escitalopram for adolescent depression
  
  • In 2004, the FDA issued a black box warning for the risk of increased suicidal ideation and behaviors (but not completed suicides).
• Bupropion is 1st line for tx both depression and tobacco cessation.
• Medication trial should last at least 6-12 weeks.
• Once an effective SSRI has been identified and symptoms have resolved, treatment with the SSRI should be continued for an additional 6-12 months.

Question 16

ADHD

• Dx:
  
  • For >6 months
  • Setting at least 2 settings
  • Onset before age ___
• Tx:
  
  • AAP 2012 guidelines recommend that preschool-age children 4-5 yo who are diagnosed with ADHD are provided with parent- and teacher-administered behavior therapy as initial treatment.
    
    • Behavioral therapy is 1st line for preschool child __yo: Behavioral therapy AND medication is the preferred treatment
  • Stimulants
    
    • Stimulant medications used to tx ADHD sometimes unmasks (but does not cause) a tic disorder; discontinuation of stimulant is only recommended if tic becomes more of a problem than the ADHD. Tic disorder is not a contraindication to stimulant therapy for ADHD, as the effect of medication on tics is unpredictable.
    • Stimulant therapy does NOT appear to increase the risk of sudden, unexpected cardiac death or serious cardiac complications in pts without underlying cardiac disease. AAP does NOT recommend screening for cardiac abnormalities with an ECG, unless findings from the patient’s hx (including family hx) or physical exam are suggestive of heart disease.
  • Nonstimulant medications (atomoxetine, guanfacine, clonidine) are typically used when there is poor response or significant side effects with stimulant medication, concerns about substance/medication abuse, significant tics, or parental preference. Nonstimulant medications may take longer 4-6 weeks to demonstrate a max response than with stimulant meds.
    
    • Atomoxetine (Strattera) is a selective presynaptic norepinephrine reuptake inhibitor that can be useful in pts who do not respond to or are unable to tolerate stimulants.
    • Guanfacine (long-acting daily preparation, Intuniv) and clonidine (long-acting, daily preparation, Kapvay) are alpha2 agonists, also used as second line.
  • ___ and ___ can increase BP; ____ can decrease blood pressure.

Answer 16

ADHD

• Dx:
  
  • For >6 months
  • Setting at least 2 settings
  • Onset before age 12
• Tx:
  
  • AAP 2012 guidelines recommend that preschool-age children 4-5 yo who are diagnosed with ADHD are provided with parent- and teacher-administered behavior therapy as initial treatment.
    
    • Behavioral therapy is 1st line for preschool child <6yo.
  • School-age >6yo: Behavioral therapy AND medication is the preferred treatment
  • Stimulants
    
    • Increase in BP and HR
      
      • Stimulant medications and atomoxetine can increase BP; alpha-agonists (clonidine, guanfacine) can decrease blood pressure.
    • Stimulant medications used to tx ADHD sometimes unmasks (but does not cause) a tic disorder; discontinuation of stimulant is only recommended if tic becomes more of a problem than the ADHD. Tic disorder is not a contraindication to stimulant therapy for ADHD, as the effect of medication on tics is unpredictable.
    • Stimulant therapy does NOT appear to increase the risk of sudden, unexpected cardiac death or serious cardiac complications in pts without underlying cardiac disease. AAP does NOT recommend screening for cardiac abnormalities with an ECG, unless findings from the patient’s hx (including family hx) or physical exam are suggestive of heart disease.
  • Nonstimulant medications (atomoxetine, guanfacine, clonidine) are typically used when there is poor response or significant side effects with stimulant medication, concerns about substance/medication abuse, significant tics, or parental preference. Nonstimulant medications may take longer 4-6 weeks to demonstrate a max response than with stimulant meds.
    
    • Atomoxetine (Strattera) is a selective presynaptic norepinephrine reuptake inhibitor that can be useful in pts who do not respond to or are unable to tolerate stimulants.
    • Guanfacine (long-acting daily preparation, Intuniv) and clonidine (long-acting, daily preparation, Kapvay) are alpha2 agonists, also used as second line.
  • Stimulant medications and atomoxetine can increase BP; alpha-agonists (clonidine, guanfacine) can decrease blood pressure.

Question 17

Smoking cessation

• Nicotine replacement therapy is most frequently used approach.
  
  • Patch is long acting medication as “controller”
  • Nicotine gum is “rescue” medication
• Non-nicotine therapies
  
  • Bupropion (inhibits uptake of NE, serotonin, and dopamine)
    
    • Adverse effects: _____
      
      • Black block warning for ____
    • CIs:
      
      • should not be used in pts with ___
        
        • Also CI in patients with ____
  • Varenicline (Chantix) (partial nicotine acetylcholine receptor agonist)
    
    • FDA black-box warning regarding ____
    • Not adequately studied in adolescents; not recommended for adolescents. Shown to be effective in adults

Answer 17

Smoking cessation

• Nicotine replacement therapy is most frequently used approach.
  
  • Patch is long acting medication as “controller”
  • Nicotine gum is “rescue” medication
• Non-nicotine therapies
  
  • Bupropion (inhibits uptake of NE, serotonin, and dopamine)
    
    • Adverse effects:
      
      • Dry mouth, insomnia; both resolve with continued use
      • Black block warning for increased suicidality in adolescents with major depression
    • CIs:
      
      • Lower seizure threshold and should not be used in pts with hx or risk of seizures
      • Also CI in patients with anorexia or bulimia
  • Varenicline (Chantix) (partial nicotine acetylcholine receptor agonist)
    
    • FDA black-box warning regarding neuropsychiatric side effects including suicidality and vivid dreams
    • Not adequately studied in adolescents; not recommended for adolescents. Shown to be effective in adults

Question 18

Antipsychotics - block ___ receptors

• Typical - more likely to cause EPS
  
  • Haloperidol - high potency
  • Fluphenazine
  • Thioridazine - retinal deposits
  • Chlorpromazine - corneal deposits
• Atypicals - less likely to cause EPS
  
  • Risperidone - most likely to cause PES
  • Quetiapine - Cataracts
  • Olanzapine - Greatest weight gain
  • Aripiprazole
  • Ziprazadone - QT prolongation; only atypical with no weight gain
  • Clozapine: Gold standard for treatment-resistant schizophrenia
    
    • ____

Answer 18

Antipsychotics - block dopamine receptors

• Typical - more likely to cause EPS
  
  • Haloperidol - high potency
  • Fluphenazine
  • Thioridazine - retinal deposits
  • Chlorpromazine - corneal deposits
• Atypicals - less likely to cause EPS
  
  • Risperidone - most likely to cause PES
  • Quetiapine - Cataracts
  • Olanzapine - Greatest weight gain
  • Aripiprazole
  • Ziprazadone - QT prolongation; only atypical with no weight gain
  • Clozapine: Gold standard for treatment-resistant schizophrenia
    
    • Agranulocytosis

Question 19

Extrapyramidal side effects
- 4 hours: \_\_\_\_
    - Tx: \_\_\_
- 4 days: \_\_\_
    - Tx: \_\_\_
- 4 weeks: \_\_\_
    Tx: \_\_\_\_
- 4 months: \_\_\_\_\_

Answer 19

Extrapyramidal side effects

• 4 hours: acute dystonia
  
  • Involuntary spastic contractions - torticollis/hand wringing/ooculogyric-crisis
  • Anti-Ach Benztropine or diphenhydramine
• 4 days: dyskinesia
  
  • Parkinsonism
  • Anti-Ach Benztropine or diphenhydramine
• 4 weeks: akathisia
  
  • Restlessness
  • Tx: beta blocker (propranolol) or benzodiazepine (lorazepam)
• 4 months: tardive dyskinesia
  
  • Irrevesible sensitization. Facial tics, difficulty swallowing, stiff neck
  • No tx. Stop drug.

Question 20

MAO-I

• Tranylcypromine
• Phenelzine
• Isocarboxazid
• Selegiline
• HTN crisis

Answer 20

MAO-I

• Tranylcypromine
• Phenelzine
• Isocarboxazid
• Selegiline
• HTN crisis