psychosis
= disorganized speech and behavior (catatonia), hallucinations, delusions, negative sxs (flat affect, asociality, incoherence)
- typical antipsychotics make negative sxs WORSE (no selectivity in D blockade)
brief psychotic disorder - 1d-1mo
- sudden onset of psychotic sxs
- rule out other causes
- - ex OTC cold meds contain antihistamines - these have anticholinergic properties –> confusion and hallucinations
- - a-adrenergic agents –> psychosis and agitation
- - dextromethorphan (vicks cough medicine) - NMDA antagonist –> sxs and hallucinations
- - cocaine
schizophreniform - 1mo-6mo
schizophrenia - 6mo+, 1 mo of active sxs, can include prodome, requires fx decline
- highly inheritable - 50% risk for MZ twins
- subset of pts have loss of cortical tissue with lateral ventricular enlargement
schizoaffective disorder
meds
- 2nd gen antipsychotic - risperidone (most likely to cause EPS among 2nd gen, most likely to cause galactorrhea…), aripiprazole (antagonist, partial agonist), quetiapine, olanzapine (side effects are weight gain and sedation), ziprasidone (less potential of weight gain)
- - less EPS, tardive dyskinesia - haloperidol and fluphenazine are high potency
- benzos for agitation
for chronic nonadherence - consider long-acting injectable
- IM q2-4wks
- haloperidol, fluphenazine, risperidone, paliperidone, olanzapine, aripiprazole
for treatment resistance or schizophrenia associated with suicidality (2 failed drug trials) - clozapine (risk of agranulocytosis, seizures, myocarditis, metabolic syndrome)
- associated with tachy, hypersalivation, and weight gain
- clozapine - only antipsychotic shown to decrease the risk of suicide
first generation antipsychotics
chlorpromazine, haloperidol
- chlorpromazine - low potency antipsychotic, associated with cholestatic jaundice, orthostatic hypotension, and blue-gray skin discoloration
EPS - decrease (dont d/c, this could result in psychotic decompensation) the antipsychotic and add other agents
1) acute dystonia, within hrs-days - benztropine (anti-cholinergic) or diphenhydramine
2) akathisia (restless, inability to sit still, dose dependent, distinguish this from worsening psychotic agitation, clue is akathisia following dose increase) - add propranolol or lorazepam
- aripiprazole - increases akathasia
3) Parkinsonism - add benzotropine or amantadine (dopaminergic, weak NDMA antagonist) (or trihexyphenidyl)
4) tardive dyskinesia - after 6+ mo of use, usu following dose reduction or d/c
- due to D2 upregulation and supersensitivity
- no definitive treatment, can switch to clozapine or quetiapine
side note - metoclopramide can also cause EPS
personality disorders
narcissistic - grandiose, lack of empathy
schizoid - detachment from social relationships, restricted range of emotions (flat affect)
antisocial - can also display feelings of narcissism
- treat with psychotherapy
- or treat co-morbid disorders - substance abuse, depression
borderline
often have hx of childhood abuse
extremes of idealization and devaluation (splitting)
unstable relationships, self-image and affects and marked impulsivity with
- suicidal behaviors, self-harm behaviors
- affective instability
- chronic feelings of emptiness
- inappropriate/intense anger
- transient stress-related paranoia or dissociation
treat - DBT
- DBT = CBT + mindfulness and distress tolerance - used for borderline personality
- adjunctive - 2nd gen antipsychotics and mood stabilizers
- antidepressants if comorbid mood/anxiety disorders
v.s. dependent personality disorder - where they react to rejection with submissiveness (rather than emptiness and rage)
depression
many pts will present with physical complaints - fatigue, insomnia, nonspecific aches/pains
MDD episode > 2 weeks
- can have qualifier - w/ psychotic features (note psychotic features will usually have depressive themes)
- note - employ low threshold for starting antidepressants in pts with cancer (and chronic illness?)
- anti-depressants take 4-6 weeks to work
- if pt has failed 2 trials for SSRIs - switch to med with diff MOA
- can add bupropion (NDRI, activating) if pt has partial response to SSRIs
- - can also consider adding a med with a diff MOA - 2nd-gen antipsychotic, Li, therapy - pts with a single episode of MDD who respond to acute treatment - continue antidepressant for 4-9 mo
- atypical lab test - cortisol is high, dexamethosone suppression test will show failure to suppress
post-stroke depression - underdiagnosed, if left untreated –> worse functional outcomes
- EARLY treatment with antidepressants and/or psychotherapy
dysthymia (persistent depressive disorder) > 2yrs (fairly continuously)
- poor app/overeating
- insomnia/hypersomnia
- low energy
- low self-esteem
- poor concentration
- feelings of hopelessness
- may have met criteria for major depressive episode at some point.. dysthmia with intermittent/persistent depressive episodes
adjustment disorder with depressed mood - onset wi 3 mo of stressor, resolve w/i 6 mo
- fx impairment
- ddx of exclusion
- treat with psychotherapy
normal stress response - NO impairment in functioning (note - this is a requirement for dx of all psych disorders)
pediatric depression - presents with irritability
- SSRIs - fluoxetine
bipolar
manic episode - 1 week
- psychotic features = manic episode
- impairment in social/occupational functioning
hypomanic >4 consecutive days
- no psychotic features
- no impairment in functioning
BPD 1 - manic episode
- lithium, valproate, carbamazepine, quetiapine, lurasidone, lamotrigine
- for pts with inadequate response to monotherapy and/or severe episodes - Li/valproate + second-gen antipsych (quetiapine)
- AVOID antidepressant monotherapy, and in general avoid antidepressants in maintenance therapy - precipitates mania
BPD2 - 1+ major depressive episodes required
cyclothymic disorder >2yrs of hypomanic and depressive sxs that dont meet criteria for hypomania or major depressive episodes
- *note - BPD is a highly recurrent illness** (meds may be needed indefinitely)
- also highly inheritable - twins have 90% risk
lithium
lithium - reduces suicidality, therapeutic serum range is 0.8-1.2
- get drug levels every 6-12 mo and 1 week after any dose/med changes
lithium - narrow therapeutic index, renally excreted
- avoid in pts with elevated cr (or CKD, hyponatremia, diuretic use) and heart disease (risk of dysrhythmias)
- avoid in preggos - Ebsteins, later stages (polyhydramnios, DI, floppy infant syndrome)
tox etiology - OD, volume depletion (decreases GFR), drug-drug interactions (with thiazides, nsaids, acei, tets, metronidazole)
- people at increased risk - elderly (low GFR), dehydrated
- note - normally thiazides are used in treatment of nephrogenic DI, but NOT in Li-induced nephrogenic DI (?)
acute tox - GI upset, polyuria, polydipsia, cognitive impairment
- late neuro sequelae (tremor, ataxia, weakness)
manage - hemodialysis with severe cases
lithium can adversely affect kidneys and thyroid
- long term therapy associated with nephrogenic DI and chronic tubulointerstitial nephropathy
- thyroid dysfunction, hyperparathryoidism
side note - meds that decrease Li levels are theophylline and K-sparing diuretics
alcohol withdrawal
remember - alcohol has 0 order kinetics
1) mild, agitation sxs - 6-24hrs
2) seizures - 12-48hrs
2) alcoholic hallucinosis - 12-48hrs, visual hallucinations predominant
3) DT - 48-96hrs, confusion, agitation, fever, tachy, HTN, diaphoresis, hallucinations
- dont give b-blocker - because it can mask sxs of DT
- fatal in 5% of cases
treat - lorazepam IV (intermediate duration benzo)
IV fluids, frequent monitoring of vital signs, thiamine, folate, nutritional support
for alcohol use disorder
- first line - naltrexone (mu opioid receptor antagonist) - decreases cravings, reduces heavy drinking days, increases days of abstinence
– can be started while pt is drinking
– contraindicated in pts taking opioids and those with acute hepatitis/liver failure
- first line - acamprosate - glutamate modulator, initiated after abstinence is achieved
- disulfiram - for pts who are abstinent and highly motivated
- topiramate has also been used
motivational interviewing
substance use disorders, other behaviors in pt who are not ready to change
acknowledge resistance to change, address discrepancies between behavior and long-term goals, enhance motivation to change, nonjudgmental
ask open-ended questions, give affirmations, reflect and summarize main points
five stages of change
- precontemplation –> contemplation –> preparation –> action –> maintenance, relapse
PTSD
1) educate about sxs, normalize stress response
acute stress disorder - 3d-1mo
- first line treatment -
trauma-focused CBT
PTSD > 1mo
- trauma-focused cognitive-behavioral psychotherapy
- first line - SSRIs (SNRIs)
- prazosin - a1 antagonist (side effects orthostasis and headaches)
PCP intoxication
psychosis + combative behavior, delirium, dissociated sxs, ataxia, nystagmus
high doses - severe HTN and life-threatening hyperthermia
use benzos to treat psychomotor agitation
note - ketamine can also cause nystagmus
- but also causes impaired consciousness and does not cause agitation
bupropion
NE-dopamine reuptake inhibitor
doesnt cause weight gain or sexual dysfunction
stimulating - anxiety and insomnia are side effects
seizures are a side effect
- contraindications - seizure disorders, bulimia, anorexia, and use of MAOIs in the past 2 weeks
- also - caution with abrupt withdrawal from sedative hypnotics (?)
anxiety
GAD > 6 mo
- excessive worry and restlessness/feeling on edge, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbance, distress
- pts frequently present with somatic sxs - muscular tension
- first line - cognitive behavioral therapy, SSRIs/SNRIs
- second line - benzos, buspirone (non-benzo anxiolytic)
social anxiety disorder - propranolol
panic disorder - immediate treatment with benzos
- long term - SSRIs/SNRIs and/or CBT
- add CBT if SSRIs alone are not effective - r/o - asthma, hyperthyroidism, pheochromocytoma, MI, arrhythmias, infections, cocaine, amphetamines
sick but not really
malingering
- feigned or grossly exaggerated sxs
- clues -… are vital signs consistent with being in pain
illness anxiety disorder > 6mo
factitious disorder
- confirm - ex get supervised rectal temperature
somatic sx disorder > 6 mo
- goal = fx improvement
- focus on stress reduction and improvement of coping strategies
separation anxiety
nl between 9-18 mo, can recur during times of transition
separation anxiety disorder - persistent anxiety, excessive worry about losing major attachment figures
- physical sxs - stomach aches, headaches
- repeated nightmares involving theme of separation, difficulty sleeping alone
- school refusal
SSRIs
increased risk of GI bleeds and bone fractures (but not contraindications)
hyponatremia
in the initial 2 weeks - antidepressants are activating –> increased risk of SI
- black box warning for people under 25
withdrawal sxs - dysphoria (note that depression does not recur immediately after antidepressant d/c), flu-like, neurosensory sxs (electric shock, vivid dreams, hyper-responsivity to light and noise)
- worse for paroxetine and venlafaxine - have shorter half-lives
- reinstitute and gradual taper
fluoxetine - longest half-life, 1 week 1/2 life, can even be dosed every other day
- can increase levels of antipsychotics
fluvoxamine
sertraline - GI upset!
citalopram
- fewest DDIs, dose-dep QT long
postpartum
blues (40-80%) - 2-3d after delivery, resolves within 2 weeks
- reassure
- watch for persistence beyond 2 weeks or SI
postpartum depression (8-15%) - onset in 4-6 weeks - antidepressants (SSRIs), psychotherapy
postpartum psychosis
- most commonly seen with BPD
- variable onset
- antipsychotics, antidepressants, mood stabilizers
- HOSPITALIZE
smoking cessation
NRT
varenicline (chantix) - diminishes cravings
- associated with mood changes and SI, and CV events in pts with pre-existing CVD
bupropion
OCD
anxiety plus disorders=
OCD - CBT (exposure and response prevention) and/or SSRI (first line)
- but clomipramine is gold std
- associated with structural abnormalities in orbitofrontal cortex and basal ganglia
hoarding disorder - treat with CBT
kleptomania
impulse control disorder - onset adolescence, stealing low value items
- treat with CBT
ddx - shoplifting (personal gain), antisocial personality disorder, BPD/manic episode (impaired judgement), psychotic disorders
body dysmorphic disorder - treat with SSRIs, CBT
psychodynamic psychotherapy
emphasizes role of unconscious mental processes in producing sxs –> goal of developing insight
sleep
age related changes
- decreased total sleep time, peak sleepiness earlier, nocturnal awakenings, reduced sleep during early morning hrs, napping
- when insomnia is impairing - sleep hygiene and CBT
- pharmacotherapy should be limited to short term
insomnia - 3 nights/week for 3 mo
narcolepsy - treat with stimulant, modafinil
- 3mo duration
- due to intrusions of REM sleep during sleep-wake transitions
- associated with low CSF levels of orexin/hypocretin
- ddx by polysomnography - to r/o other sleep disorders
restless leg - dopamine agonists (ropinirole, pramipexole), benzos (clonazepam)
valproate
therapeutic level - 6-12
side effects - GI sxs, hepatitis, pancreatitis, hepatic encephalopathy
ex - pt presents with malaise, N, and RUQ pain
defense mechanisms
immature: acting out denial displacement intellectualization passive aggression projection - attributing ones own feelings to others rationalization reaction formation - responding in a manner OPP to ones feelings regression splitting countertransferance - therapist directs emotions to pt (pt reminds therapist of his sibling)
mature: altruism, sublimation, suppression
NMS and serotonin syndrome
NMS
- delirium (1st), muscle rigidity, autonomic instability, leukocystosis, elevated CK (–> ARF)
- dantrolene or bromocriptine if refractory to supportive care (and stopping the offending agent)
- sxs typically begin w/i 2 weeks of initiation of precipitating agent (but can occur at anytime)
serotonin syndrome - serotonergic med and MAOIs
- can be precipitated by ecstasy (molly, MDMA) - causes increased synaptic NE, D, and S
- hyperrelfexia…
- GI sxs
- wait 2 weeks after stopping MAOI before starting serotonergic
- cyproheptadine - can be used in severe cases
