1
Q
mature defenses
A
mature adults wear a SASH sublimation - social unacceptable impulses are unconsciously transformed into social acceptable ones altruism suppression humor
2
Q
infant deprivation effects
A
…
reactive attachment disorder - infant withdrawn/unresponsive to comfort
deprivation for 6+ mo –> irreversible changes
3
Q
child abuse
A
child avoid eye contact during exam
usu biological mother
40% of deaths occur in kids < 1 yo
4
Q
ADHD
A
treat with stimulant = methylphenidate +/- CBT
alternatives - atomoxetine (NE reuptake inhibitor), guanfacine (a2 receptor antagonist, so it can also treat HTN), clonidine (a2 agonist)
5
Q
Rett syndrome
A
XD, seen in girls (affected males die utero)
de novo mutation in MECP2 (important for normal function of nerve cells)
around age 1-4 - regression, loss of verbal abilities, ID, ataxia, stereotyped hand-wringing
6
Q
Tourettes
A
tics persist for > 1 yr
associated with OCD and ADHD
use typical antipsychotics for intractable, distressing tics - fluphenazine & pimozide antipsychotics, tetrabenazine (anti-chorea drug)
7
Q
disruptive mood dyregulation disorder
A
~temper problems seen in kids younger than 10 yo
treat with psychostimulant, antipsychotic, CBT
8
Q
orientation
A
order of loss: time –> place –> person
9
Q
Korsakoff syndrome
A
anterograde > retrograde amnesia
anterograde - means decreased ability to form new memories
10
Q
dissociative amnesia
A
dissociative amnesia - usu subsequent to trauma or stress
dissociative fugue - abrupt travel or wandering…
11
Q
delusional disorder
A
fixed, persistent false belief system lasting 1+ mo
-erotomaniac, grandiose, persecutory, jealous, somatic (believing bodily functions and sensations are abnormal)
psychotic features absent
12
Q
manic episode
A
lasting at least 1 week - elevated/irritable mood with increased energy/activity
ddx requires hospitalization of 3/DIG FAST Distractibility Irresponsibility Grandiosity - inflated self-esteem Flight of ideas - racing thoughts Activity/psychomotor agitation Sleep - decreased Talkativeness/pressured speech
pts with 1(+) lifetime manic episode are ddx with BPD1
13
Q
hypomanic episode
A
no psychotic features
lasts at least 4 consecutive days
14
Q
postpartum psychosis
A
treat with hospitalization and atypical antipyschotic
ECT is a second line
15
Q
grief
A
denial anger bargaining depression acceptance pathological grief (6+ mo) is persistent and causes functional impairment --- major depressive episode
16
Q
ECT
A
grand mal seizure in anesthetized pt
adverse effects - …partial anterograde/retrograde amnesia resolving in 6 months
safe in pregnancy
17
Q
panic disorder
A
treatment: CBT, SSRIs, venlafaxine
18
Q
OCD
A
CBT, SSRIs, and clomipramine (=TCAD)
19
Q
PTSD
A
treatment: CBT, SSRIs, venlafaxine (same as for panic disorder)
prazosin can reduce nightmares
v.s. acute stress disorder - similar, lasts 3d-1 mo
20
Q
conversion disorder
A
aka functional neurologic symptom disorder - under the somatic symptom/related disorders
loss of sensory or motor function, following acute stressor
- internal inconsistency of symptoms
pt is aware of but sometimes indifferent toward symptoms
21
Q
anorexia
A
…
refeeding syndrome - increased insulin –> hypophosphatemia –> cardiac complications
-refeeding involves giving glucose –> increases insulin –> insulin shifts K and P into the intracellular space
buproprion contraindicated
22
Q
sexual dysfunction
A
drug side effects - antihypertensives, antipsychotics/SSRIs, ethanol
23
Q
sleep terror
A
occurs during slow-wave/deep (stage N3 sleep)
occurs during non-REM sleep - so no memory of arousal episode
24
Q
narcolepsy
A
caused by decreased hypocretin (orexin - regulates arousal, wakefulness, and appetite) production in lateral hypothalamus
- associated with hypnagogic or hypnopompic (just before awakening) hallucinations
- nocturnal and narcoleptic sleep episodes that start with REM sleep = sleep paralysis
- cataplexy - loss of muscle tone following ex laughter
strong genetic component
treatment: daytime stimulants (amphetamines, modafinil - weak dopamine reuptake inhibitor) and nighttime sodium oxybate (GHB)
25
stages of change
1. ) precontemplation
2. ) contemplation - acknowledging there is a problem but not yet ready/willing to make a change
3. ) preparation/determination
4. ) action/willpower
5. ) maintenance
6. ) relapse
26
alcohol withdrawal
alcohol binds to GABAa receptors - chronic alcoholics have decreased GABA sensitivity
- alcohol withdrawal decreases inhibitory tone
6-48hrs - withdrawal seizures
12-48hrs - alcoholic hallucinosis, visual, delirium
48-96hrs - delirium tremens, classically occurs post-surgery
-delirium tremens - autonomic hyperactivity, electrolyte disturbances, respiratory alkalosis, fever
alcoholism - ...peripheral neuropathy, testicular atrophy
- treat with... benzos, acamprosate (helps with withdrawal), naltrexone
- benzos - chlordiazepoxide, lorazepam, diazepam
27
opioids
use - pinpoint pupils
OD - seizures
withdrawal - muscarinic stimulation
- develop tolerance to everything but constipation and miosis
long term use
- increased turnover of receptor downregulation and decoupling
- upregulation of NMDA receptors
- -> tolerance and opioid-induced hyperalgesia (due to increased pain sensitivity)
- partial agonists such as buprenorphine can precipitate withdrawal - because it binds strongly (can prevent the binding of other opioid agonists) but has low activity
28
barbiturates
low safety margin! - dont mess with Barb
treat OD with symptom management
withdrawal - delirium, life threatening CV collapse
29
benzos
greater safety margin
treat OD with flumazenil - but flumazenil can cause seizures
withdrawal - anxiety, perceptual disturbances, psychosis, etc.
30
stimulants
amphetamines, cocaine, caffeine, nicotine
| withdrawal - includes sleep disturbance, vivid nightmares
31
amphetamines
use - ...pupillary dilation
OD - cardiac arrest, seizures
treat with benzos
32
cocaine
inhibits NE uptake by pre-synaptic neurons --> NE binds to a1 receptors on vascular smooth muscle --> vasospasm
use - pupillary dilation, hallucinations (tactile),
treat with a-blockers, benzos, DONT give b-blockers
- b-blockers are withheld from cocaine users with heart disease
- why? - b-blockers can exacerbate vasospasm, unopposed a effect and b2 receptors blocked --> vasodilation inhibited
33
hallucinogens
PCP, LSD, marijuana, MDMA (ecstacy)
34
PCP
violence --> trauma is the most common complication
nystagmus
treat with benzos
35
LSD
perceptual distortion, psychosis
36
droNABINOl
uses - antiemetic, appetite stimulant (AIDS)
37
MDMA
...teeth clenching
| life-threatening effects - HTN..., hyperthermia, hyponatremia, serotonin syndrome
38
buprenorphine
NOT buproprion
buprenorphine (partial mu opioid receptor antagonist) + naloxone - sublinguinal
-naloxone = antagonist, not orally available, added to reduce abuse potential
39
BPD
Li, valproate, carbamazepine, lamotrigine, atypical antipsychotics
40
CNS stimulants
increased catecholamines in synaptic cleft - esp NE and dopamine
caffeine - adenosine receptor antagonist (prevents drowsiness)
41
serotonin syndrome
obvious: SSRIs, SNRIs, TCADs, MAOIs, ondansetron, triptans
others: tramadol, linezolid, MDMA, dextromethorphan
Autonomic stimulation - hyperthermia, diaphoresis, diarrhea
Activity - NM hyperactivity
Agitation
treat with cyproheptadine - 5HT2 receptor antagonist
42
bupropion
atypical antidepressant
inhibits NE and D reuptake
seizures in anorexic/bulimic pts
may help alleviate sexual dysfunction
43
mirtazapine
atypical antidepressant
a2-ANTAgonist (increased release NE and 5HT)
potent 5HT2 and 5HT3 receptor antagonist
H1 antagonist
tox - sedation (may be desirable in pts with insomnia), increased appetite, weight gain (helpful in elderly or anorexics), dry mouth
44
trazodone
atypical antidepressant, aka traZZZoBONE (tox is priapism - prolonged erection)
blocks 5HT2, a1, H1 receptors
weakly inhibits 5HT reuptake
insomnia --> high doses - antidepressant
45
vareniciline
NAch receptor partial agonist
smoking cessation
tox - sleep disturbance, may depress mood
46
vilazodone
inhibits 5HT reuptake, 5HT1A receptor partial agonist
used for major depressive disorder and GAD (off-label)
tox - headache, diarrhea, nausea, increased weight, anticholinergic effects
may causes serotonin syndrome if taken with other serotonergic agents
47
vortioxetine
inhibits 5-HT reuptake, 5HT1a receptor agonist and 5HT3 receptor antagonist
major depressive disorder
tox - nausea, sexual dysfunction, sleep disturbances (abnormal dreams), anticholinergic effects
may cause serotonin syndrome
48
atypical antidepressants
buproprion - NE/D reuptake inhibitor
varenicline - NACh partial agonist
-smoking cessation, buproprion is contraindicated in anorexics/bulimics
traZZZobone - blocks 5HT, H1, a receptors
mirtazabine - blocks 5HT, H1, a receptors
-sedation, depression
vilazodone, vortioxetine - major depressive disorder
- inhibits 5HT reuptake
- 5HT1 partial agonist
49
MAOIs
MAO Takes Pride In Shanghai - tranylcypromine, phenelzine, isocarboxazid, selegiline
-MAO located in axon
uses - atypical depression, anxiety, Parkison's (selegiline)
ADRS: CNS stimulation, hypertensive crisis
- contraindicated with SSRIs, TCAs, St. Johns wort, meperidine, dextromethorphan
- wait 2 weeks after stopping MAOIs before starting serotonergic drugs
pt has to have intact memory, cognition - there are a lot of foods you have to avoid when you are taking MAOIS
50
TCADs
amitriptyline, nortriptlyine, imipramine, desipramine, clomipramine, doxepin, amoxapine
-inhibits NE and 5HT reuptake
uses - major depression, OCD (clomipramine), peripheral neuropathy, chronic pain, migraine prophylaxis, nocturnal enuresis (imipramine, ADRs may limit use)
ADRs - sedation, a1-blocking effects (postural HTN), atropine-like (anticholinergic) effects (3rd gen like amitriptyline have greater anticholinergic effects than second gen like nortrip)
-prolonged QT interval!!
Tri-Cs: convulsions, coma, cardiotox (arrhythmia due to Na+ channel inhibition), respiratory depression, hyperpyrexia
- NaHCO3 to prevent arrhythmia
- confusion and hallucinations in elderly - due to anticholinergic effects, use nortrip in elderly
51
SSRIs
-tines, -prams, sertraline (aka zoloft)
uses - depression, GAD, panic disorder, OCD, bulimia, social anxiety disorder, PTSD, premature ejaculation, premenstrual dysphoric disorder
-takes 4-8 weeks to have an effect
ADRs - fewer than TCAs, GI distress, SIADH, sexual dysfunction
52
SNRIs
venlafaxine, -praN
uses - depression, GAD, diabetic neuropathy
-venlafaxine - social anxiety disorder, panic disorder, PTSD, OCD
-duloxetine - fibromyalgia
ADRs - increased BP
53
Li
something about inhibition of phosphoinositol cascade
mood stabilizer for BPD, blocks relapse and acute manic events
ADRs - LiTHIUM, low thyroid, heart (Ebstein anomaly - tricuspid valve is displaced towards apex), DI, unwanted movements (tremor)
54
buspirone
stimulates 5HT1A receptors
GAD - no sedation, addiction, or tolerance
-1-2 weeks to take effect
-doesnt interact with alcohol (v.s. barbiturates, benzos)
55
NE reuptake inhibitors
TCADs SNRIs
56
5HT reuptake inhibitors
TCADs, SSRIs, SNRIs, trazadone
57
typical antipsychotics
haloperidol, pimozide, -azines (ex fluphenazine)
block D2 receptor - increase cAMP
schizophrenia (primary positive symptoms), psychosis, bipolar disorder, delirium, Tourette syndrome, Huntington's dz, OCD
high potency - time to fly high, Trifluoperazine, Fluphenazine, Haloperidol - neuro side effects (anticholinergic, anti-histamine), extrapyramidal symptoms
low potency - cheating thieves are low, Chlorpromazine, Thioridazine - anticholinergic, antihistamine, a1-blockade effects
- chlorpromazine lowers seizure threshold
ADRs - lipid soluble, takes a long time to be eliminated
- endocrine - hyperprolactinemia
- metabolic - dyslipidemia, weight gain, hyperglycemia
- antimuscarinic
- anithistamine - sedation
- a1-blockade - orthostatic hypotension
- cardiac - QT prolongation
- ophthalmologic - chlorpromazine (corneal deposits), thioridazine (reTinal deposits)
extrapyramidal symptoms - ADAPT
- hours-days - Acute Dystonia (muscle spasm/stiffness, oculogyric crisis - looks like you keep trying to roll your eyes back)
- esp occurs with rapid dose escalation of first gen (like haloperidol)
- d-mo - Akathisia (restlesness**, dont increase dose, decrease dose if possible), Parkinsonism (bradykinesia)
- mo-yr - Tardive dyskinesia (orofacial chorea, can be irr)
- treat with benzotropine (anticholinergic, used to treat parkisonism), benzos, b-blockers (akathisia)
neuroleptic malignant syndrome
58
neuroleptic malignant syndrome
Malignant FEVER
myoglobinuria, fever, encephalopathy, unstable vitals, increased enzymes, muscle rigidity
treat with dantrolene (muscle relaxant) or D2 agonist (bromocriptine)
59
atypical antipsychotics
-apine, -peridone, aripiprazole (aka abilify)
most are D2 antagonists, varied effects on other receptors
uses - schizophrenia (positive and negative symptoms), BPD, anxiety, depression, mania, Tourettes
-clozapine!! - for treatment resistance schizophrenia
ADRs - prolonged QT, fewer EPS and anticholinergic side effects than typical antipsychotics
- apines- metabolic syndrome
- clozapine - agranulocytosis (monitor WBCs) and seizures (dose related)
- risperidone - hyperprolactinemia
- ziprasidone - long QT
strangely enough prolactin levels are not regularly monitored
60
delirium
waxing and waning level of consciousness
- rapid decrease in attention span and level of arousal
- disorganized thinking, hallucinations (visual), illusions, misperceptions, disturbance in sleep-wake cycle, cognitive dysfunction
most common presentation of altered MSE in inpt setting
-commonly, diffuse slowing EEG
may be caused by anticholingerics - esp in the elderly
reversible
61
Dementia
decrease in intellectual fx - NO effects on level of consciousness
irreversible causes - Alzheimers, Lewy body dementia, Hungtingtons, Pick disease, cerebral infarct, Wilson disease, CJD, chronic substance abuse (due to neurotox of drugs), HIV
reversible causes - hypothyroid, depression, B1/B3/B12 deficiency, normal pressure hydrocephalus, neurosyphilis
increased incidence with age - EEG usually normal
62
psychosis
distorted perception of reality - delusions, hallucinations, and/or disorganized thought/speech
63
disorganized thought
word salad, tangential, or derailed (loose associations)
64
hallucinations
olfactory - often occur as an aura of temporal love epilepsy (burning rubber) and brain tumors
gustatory - rare, but seen in epilepsy
tactile - alcohol withdrawal and stimulant use
65
cluster A
weird = accusatory, aloof, awkward
-no psychosis
paranoid
schizoid = aloof
schizotypal - odd beliefs or magical thinking, interpersonal awkwardness (think Quentin)
66
cluster B
wild - bad, borderline, flamBoyant, must be Best
antisocial - conduct disorder if < 18
borderline - ... unstable, impulsive, self-mutilation, sucidality, sense of emptiness, treatment is dialectical behavior therapy
unstable relationships, self-image and affects, impulsive
-*depression, suicidal, impulsive in the setting of feeling rejected*
-mood shifts that occur in response to interpersonal stressors
histrionic
narcissistic
67
cluster C
worried = cowardly, OC, clingy
avoidant - desires relationships with others (v.s. schizoid), timid
OC
dependent - pts often get stuck in abusive relationships
68
schizophrenia
6+ months - psychosis, declining function
ddx 2/5 + 1/first three, first 4 are positive symptoms (positive symptoms are feelings/behaviors that are not normally present)
1) delusions
2) hallucinations
3) disorganized speech
4) disorganized or catatonic behavior
5) negative symptoms - affective flattening, avolition, anhedonia, asociality, alogia
- frequent cannabis use is associated with psychosis/schizophrenia in teens
- presents earlier in men (teens -20s), later in women (20s-30s)
- pts are at increased risk for suicide
ventriculomegaly on brain imaging
Atypical antipsychotics are first-line (ex risperidone) -negative symptoms often persist after treatment
69
brief psychotic disorder
less than 1 mo, usu stress related
would not see mood symptoms (like mania)
70
schizophreniform
1-6 mo
71
schizoaffective disorder
meets criteria for schizophrenia + major mood disorder (major depressive disorder or BPD)
pt must have major mood disorder with >2 weeks of hallucinations or delusions with major mood episode (v.s. major mood disorder with psychotic features)
72
BPD
BPD1 - manic episode +/- hypomanic or depressive episode
-depressive episodes are not required for ddx
BPD2 - hypomania + depressive episode
-pts mood and functioning can return to normal between episodes
treat with mood stabilizers - Li, valproic acid, carbamezepine, lamotrigine, atypical antipsychotics
73
cyclothymic disorder
mild BPD = mild depressive symptoms + hypomania
| 2(+) years
74
major depressive disorder
5/9 SIGECAPS + 2 - last 2(+) weeks
treat with CBT and SSRIs, ECT in select pts
**note - adjustment disorder is NOT ddx if pt meets criteria for major depressive disorder (adjustment disorder is ddx of exclusion - lasts for less than 6 mo)
persistent depressive disorder - milder depression - 2(+) yrs
sleep changes
- decreased slow-wave sleep
- decreased REM latency
- increased REM in early sleep cycle
- increased total REM sleep
- repeated nighttime awakenings
- early-morning awakening (terminal insomnia)
75
depression with atypical features
mood reactivity - can experience improved mood in response to positive events
hypersomnia, hyperphagia, long-standing interpersonal rejection sensitivity, *leaden paralysis
most common subtype of depression
treat with CBT and SSRIs, MAO are effective but not first line due to their high risk profile
76
derealization
experiencing ones surroundings as unreal
reality testing is intact during depersonalization/derealization - person feels detached from body but knows this is not true
77
medical conditions with anxiety symptoms
hypoglycemia
other more obvious ones - hyperthyroidism, pheo, hypercortisolism, arrhythmias
withdrawal from sedative-hypnotics, stimulant intoxication
78
stimulant withdrawal
increased appetite, hypersomnia, intense psychomotor retardation, severe depression (crash)
cocaine withdrawal - vivid dreams, minor PHYSICAL symptoms (v.s. depressant withdrawal)
79
nicotine withdrawal
increased appetite
80
2 antidepressants that dont cause sexual side effects
bupropion
| mirtazapine
81
psychotic spectrum
brief psychotic disorder (less than 1 mo) - schizophreniform disorder (like schizophrenia but shorter) - schizophrenia
schizoaffective disorder
delusional disorder - 1 month or more of delusions, no other psychotic symptoms
82
neonatal opioid withdrawal
irritability, tremors, sweating, yawning, feeding difficulties
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