0
Q
When dealing with difficult pts, the physician must maintain professional conduct and responsibilities while addressing their medical and psychological needs.
A
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1
Q
Adjustment disorder
A
Characterized by the development of emotional or behavioral symptoms in response to an identifiable stressor that occurs within 3 months of the stressor; it usually causes a significant impairment in the patients life and disruption of daily activities.
2
Q
mania
A
- commonly gamble and spend large sums of money
- decreased need for sleep
- increased goal-oriented activity
- flight of ideas
- grandiosity
- talkativeness
3
Q
Obsessive-Compulsive behavior
A
- recurrent obsessive thoughts that cause marked distress and anxiety
- to relieve anxiety, repetitive and compulsive behaviors are performed
- in adult pts, they typically recognize the absurdity of the behavior but feel helpless to control it
4
Q
Antisocial personality disorder
A
- pattern of repetitive and persistent behavior in which the basic rules of society and rights of others are violated
- must be aged >18 years to be diagnosed (conduct disorder in childhood)
5
Q
Adjustment disorder
A
- emotional or behavioral symptoms in response to an identifiable stressor
- marked distress is present in excess of what would be expected by exposure to the stressor
6
Q
emotions common in the grieving process
A
-anger, grief, shock, and denial
7
Q
pathologic gambling
A
- chronic hx of gambling and an inability to stop
- significant financial losses and damaged relationships are common consequences
8
Q
are extrapyramidal side effects more common w/ first or second generation anti-psychotics?
A
first generation
9
Q
common side effect of paliperidone and risperidone
A
-amenorrhea resulting from prolactin elevation
10
Q
side effects of clozapine
A
-leukopenia and agranulocytosis
11
Q
lithium can cause what side effect?
A
-nephrogenic diabetes insipidus
12
Q
which second generation antipsychotics cause the greatest weight gain?
A
Olanzapine and Clozapine
13
Q
Olanzapine
A
- second generation (atypical) antipsychotic
- serotonin-dopamin antagonist (also has affinity for histamine, alpha1 adrenergic, and muscarinic receptors)
- common side effects are sedation and weight gain
- may cause other metabolic side effects
14
Q
HIPAA
A
- protects health info by requiring VERBAL OR WRITTEN authorization for release of info
- hospitals and physicians frequently have additional policies requiring written forms for release of info and procedures to verify the identity of phone callers
- its important that health care providers be familiar w/ these rules and disclose ONLY THE MINIMUM NECESSARY INFO.
15
Q
Adolescents presenting with behavioral changes should be evaluated for the use of illegal and illicit substances. In additions to substance use, other considerations include what?
A
- partner violence
- date rape
- physical or sexual abuse
- pregnancy
16
Q
Psychological defense mechanisms
A
- unconscious means of responding and adapting to different situations while preserving one’s self-image
- serve to decrease anxiety associated w/ shame and vulnerability, ensure safety in the face of abandonment and other disappointments, and insulate a person from external dangers
- classified as IMMATURE or MATURE
17
Q
Dissociation
A
- immature defense mechanism that involves disruptions in memory, identity, consciousness, or perception to retain the illusion of psychological control in the face of loss of control/helplessness
- may involve the alteration of memory of events
- i.e. a patient who was rescued from a burning building and now has no memory of it, instead describing a missing block of time
18
Q
Distortion
A
- immature defense mechanism involving an altered perception of disturbing aspects of external reality to make them more acceptable
- an example is an IV drug abuser who contract HCV and attributes it to inadequate control of the disease in the community
19
Q
Projection
A
- immature defense mechanism that involves attributing unacceptable internal thoughts or emotions to others
- an example is a husband w/ thoughts of infidelity who accuses his wife of being unfaithful
20
Q
Regression
A
- immature defense mechanism involving a return to more immature levels of functioning to avoid the stress and conflict associated w/ one’s current developmental level
- i.e. a child who was previously toilet-trained but began to wet the bed after the birth of a sibling
- an adult example is a man in his 30’s who moves back home w/ his parents in response to pressure to propose to his girlfriend
21
Q
Repression
A
- immature defense mechanism that involves blocking upsetting ideas or impulses from entering consciousness
- involves blocking INNER states, in contrast to denial, which involves blocking acceptances of EXTERNAL sensory data
- i.e. a person who repressed memories of abuse by a parent when young and always “forgets” to call this parent on birthdays w/o understanding why
22
Q
Displacement
A
-immature defense mechanisms in which unacceptable feeling about an object or person are displaced onto another “safer” object or person
23
Q
Mature defense mechanisms
A
- Altruism: avoiding negative feelings by helping others
- Humor: using humor to avoid uncomfortable feelings
- Sublimation: channeling impulses into socially acceptable behaviors
- Suppression: putting unwanted feelings aside to cope w/ reality
- “Mature people were a SASH when dealing w/ their problems”
24
Immature defense mechanisms (primitive and neurotic)
-Acting out, denial, displacement, dissociation, distortion, fantasy, intellectualization, isolation of affect, passive aggression, projection, rationalization, reaction formation, regression, repression, somatization, splitting
25
acting out
- immature
| - easing unacceptable feelings by behaving badly
26
denial
- immature
| - behaving as if an aspect of reality doesn't exist
27
Displacement
- immature
| - transferring feelings to a more acceptable object
28
Dissociation
- immature
| - disrupting memory, identity and consciousness to cope w/ an event
29
Distortion
- immature
| - altering perception of upsetting reality to be more acceptable
30
Fantasy
- immature
| - substituting imaginary scenarios
31
Intellectualization
- immature
| - using intellect to avoid uncomfortable feelings
32
Isolation of affect
- immature
| - separating a thought from its emotional components
33
Passive aggression
- immature
| - avoiding conflict by expressing hostility covertly
34
Projection
- immature
| - attributing one's own feelings to others
35
Rationalization
- immature
| - justifying behavior to avoid difficult truths
36
Reaction formation
- immature
| - responding in a manner opposite to one's actual feelings
37
Regression
- immature
| - reverting to earlier in developmental stage
38
Repression
- immature
| - blocking upsetting feelings from entering consciousness
39
Somatization
- immature
| - transforming emotional conflicts into physical symptoms
40
Splitting
- immature
| - seeing others as all bad or all good
41
altruism
- mature
| - avoiding negative feelings by helping others
42
humor
- mature
| - using humor to avoid uncomfortable feelings
43
sublimation
- mature
| - channeling impulses into socially acceptable behaviors
44
suppression
- mature
| - putting unwanted feelings aside to cope with reality
45
psychosis
-presence of one or more of the following: delusions, hallucinations, and disorganized speech or behavior
46
Clozapine
- second generation antipsychotic that is considered the gold standard for TREATMENT-RESISTANT SCHIZOPHRENIA
- due to the risk of AGRANULOCYTOSIS, its reserved for pts who have failed to respond to at least 2 trials of antipsychotics
47
when are injectable, long-acting antipsychotics indicated?
-when there are concerns regarding compliance after discharge
48
is lorazepam short or long acting?
short
49
Treatment for psychosis
- second generation antipsychotics (risperidone, olanzapine, quetiapine, aripiprazole, ziprasidone, paliperidone) are first-line
- first generation (haloperidol) may be used but are not preferred due to higher risk of EPS/tardive dyskinesia
- benzodiazepines may be added to treat associated agitation
- chronic noncompliance: consider long-acting injectable
- treatment resistant (2 failed trials): consider clozapine
50
Pts w/ depression or underlying psychiatric issues frequently come to their primary care physicians w/ physical complaints.
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51
Malingering
- characterized by grossly exaggerated physical or psychological complaints, often accompanied by the intentional production of false physical symptoms
- always associated w/ secondary gain (financial, leave from work, narcotics), whereas the motivating factor in factitious disorder is to assume the sick role
52
Factitious disorder
- intentional production of false physical or psychological signs or symptoms in order to assume the sick role
- unlike pts w/ malingering, those w/ factitious disorder receive no secondary gain
53
Hypochondriasis
- fear of disease and preoccupation w/ the body that manifests itself through multiple somatic complaints
- the concerns persist in spite of appropriate medical evaluations, cause marked impairment, and last for at least 6 months
54
Conversion disorder
- characterized by the development of unexplained serious neurological symptoms preceded by an obvious emotional trigger (a tragic event or argument)
- the symptoms are not artificially produced, are unexplained by any medical condition, and can be severe enough to cause social and functional impairment
55
Cauda equine syndrome
-characterized by low back pain, sciatica, saddle sensory disturbances, bladder and bowel dysfunction, and motor and sensory loss of the lower extremities
56
Dependent personality disorder
- tend to be unable to make decisions w/o help and crave protection and guidance from others
- they are devastated by separation and loss and will go to great lengths to stay in a dependent relationship
57
Loss of a loved one can trigger the onset of a major depressive episode. Bereaved pts who experience depressive symptoms for at least 2 weeks after a major loss should be considered for tx w/ both psychotherapy and a trial of antidepressants.
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58
A pregnant woman who has capacity to make decisions has the right to refuse treatment, even if it places her unborn child at risk. Her autonomy supersedes the rights of the unborn child. A judicial intervention should only be considered as a last resort in exceptional circumstances, such as when the refused tx poses insignificant risk to the mother, involves minimal invasions of her bodily integrity, and would prevent substantial and irrevocable harm to the fetus.
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59
how is amphetamine intoxication differed from anticholinergic poisoning?
-anticholinergic poisoning will have DRY skin and mucous membranes, motor symptoms (ie myoclonic jerks, tremors), and other classic anticholinergic manifestations such as ileus and urinary retention.
60
Brief psychotic disorder
- requires presence of one or more of the following: hallucinations, delusions, disorganized speech, and grossly disorganized behavior.
- symptoms must be present for at least a day but less than a month, w/ eventual complete resolution
61
Opioid withdrawal symptoms
- muscle spasms, joint pain, nausea and vomiting, diarrhea, abdominal cramps, rhinorrhea, lacrimation, and sweating
- patient may demonstrate irritability, hypertension, and mydriasis
62
manic episode
- abnormally expansive or irritable mood and increased goal-directed activity or energy for at least a week
- also distractibility, decreased sleep, and pressured speech
63
Pheochromocytoma symptoms
-elevated BP, headaches, sweating, palpitations, anxiety, nausea, weight loss
64
Schizophrenia
- hallucinations, delusions, disorganized speech, grossly disorganized or catatonic behavior, or negative symptoms (flat affect, social withdrawal, poverty of speech)
- these symptoms must be present for at least 6 months ( <6 months is schizophreniform)
65
amphetamine intoxication
- agitation, irritability, paranoia, or delirium
- chest pain or palpitations, tachycardia, hypertension, diaphoresis, and mydriasis
- cardiac arrhythmias, seizures, hyperthermia, and intracerebral hemorrhage
66
Confidentiality
-physicians are prohibited from disclosing info about the patient's diagnosis or tx to anyone not directly involved in, or necessary to, the patient's management
67
what is the greatest risk factor for future suicide attempt?
-past history of suicide attempt(s)
68
Difference between competence and capacity?
- Competency is a legal definition decided by the courts
- Capacity is used in medical situations to determine if someone has the ability to give informed consent to receive or refuse therapy
69
what is "presumed" consent?
- in emergency situations, the physician can assume that the patient would give consent and should proceed with intervention therapy
- situations include unconsciousness or incapacitated or when no surrogate decision maker is available
70
Patients w/ psychiatric diagnoses can give informed consent as long as their judgement and decision-making abilities are determined to be intact.
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71
Paranoid personality disorder
- distrust and fear
- individuals frequently have unfounded suspicions and misinterpret the motives of others
- they may find it difficult to confide in or forgive people
72
Obsessive-compulsive personality disorder
- preoccupation w/ orderliness or precision
- typically stubborn and inflexible, these pts may have obsessive thoughts that cause anxiety until a specific action is taken (ie the arranging of figurines on a shelf in a certain pattern)
73
Delusional disoder
-requires the presence of non-bizarre delusions (involving situations that are logical possibilities) for at least one month
74
Antisocial personality disorder
- an ADULT condition characterized by disregard for and violation of the rights of others
- individuals frequently engage in illegal activities and have a hx of conduct disorder during adolescence
75
Acute stress disorder
- symptoms identical to those observed w/ PTSD (ie flashbacks and nightmares about a traumatic event, hypervigilance, social detachment, poor sleep).
- the symptoms must develop WITHIN 4 WEEKS of the traumatic event and last no longer than an additional 4 weeks
76
Adjustment disorder
- development of behavioral or emotional symptoms in response to a psychosocial stressor (ie divorce, physical illness) that arose within the past 3 months.
- the symptoms cause marked distress in excess of that expected from exposure to the stressor
- functional impairment is present
77
Narcissistic personality disorder
-exaggerated sense of self-importance, feelings of entitlement, egocentrism, and a lack of empathy for others
78
Benztropine
-anticholinergic medication that can be used to treat antipsychotic-induced extrapyramidal symptoms, but it is NOT used in the management of NMS
79
Naloxone
-used to treat opioid overdose
80
Physostigmine
-used to reverse toxic CNS effects caused by anticholinergic drugs
81
Propranolol
-sometimes used to treat the antipsychotic side effect akathisia
82
Neuroleptic malignant syndrome (NMS)
- an unusual but potentially lethal side effect from the use of antipsychotics (neuroleptics).
- it is treated primarily w/ DANTROLENE SODIUM and supportive care (aggressive cooling, antipyretics, fluid and electrolyte repletion, and alkaline diuresis in the case of rhabdomyolysis)
- amantadine and/or the dopamine agonist bromocriptine can also be used
- may occur at any time during the treatment w/ dopamine ANTAGONISTS
- symptoms include hyperthermia, autonomic instability, muscular rigidity, and altered sensorium, and rhabdomyolysis
83
Avoidant personality disorder
-pts desire social interaction but shy away due to feelings of inadequacy or fear of criticism, failure, or rejection
84
diagnosis of major depression
-requires 5 of 9 of the following symptoms for 2 wks or longer: depressed mood, Sleep disorder, Interest deficit (anhedonia), Guilt (worthlessness, regret), Energy deficit, Concentration deficit, Appetite disorder, Psychomotor retardation or agitation, and Suicidality (SIGECAPS)
85
Social anxiety disorder
-involves excessive fears of embarrassment and humiliation in social situations
86
Persistent depressive disorder (dysthymia)
- refers to a depressed mood lasting most days for at least 2 years
- symptoms of a major depressive episode may occur concurrently or intermittently in persistent depressive disorder
87
Pramipexole
- dopamine agonist
| - used to treat symptoms of Parkinson disease and restless legs syndrome
88
Narcolepsy
- excessive daytime sleepiness and episodes of cataplexy
- tx includes maintaining proper sleep schedules and avoiding alcohol and drugs that cause drowsiness
- when meds are needed, stimulants such as modafinil are the preferred drugs to reduce daytime somnolence
89
Borderline personality disorder
- often show a pattern of instability in relationships and can be impulsive and/or reckless
- they also have identity disturbance, recurrent suicidal or self-mutilating behavior, and feelings of emptiness
90
Conduct disorder
- children and adolescent w/ conduct disorder often become adults w/ antisocial personality disorder
- the diagnosis requires at least 3 symptoms from the following: aggression towards people or animals, destruction of property, deceitfulness or theft, or a serious violation of rules
- however, if someone qualifies for the diagnosis of antisocial personality disorder, they no longer have conduct disorder
91
histrionic personality disorder
-demonstrate excessively labile emotions and attention-seeking behavior
92
narcissistic personality disorder
- often have an exaggerated sense of self importance, demonstrate arrogant behavior, and lack empathy for others
- however, they usually do not break the law and are not violent towards others
93
Antisocial personality disorder
- diagnosed in pts aged 18 yrs or older who engage in illegal activities and disregard the rights of others
- these individuals often display evidence of conduct disorder as minors
94
Schizotypal personality disorder
- odd and eccentric behavior, magical thinking, and a reduced capacity for close relationships
- may have bizarre fantasies and believe in telepathy, clairvoyance, or the concept of a sixth sense
- they often have paranoid ideation and unusual perceptual experiences
- while individuals w/ SCHIZOID personality disorder also lack close friends and have a restricted range of emotional expression, they do NOT have eccentric behavior or odd thinking
- those w/ avoidant personality disorder want friends but fear ridicule
95
Avoidant personality disorder
- hypersensitivity to criticism, social inhibition, and feelings of inadequacy
- these individuals want friendships, but they avoid them because they fear ridicule
- they also perceive themselves as inferior and are reluctant to engage in new activities or to take risks for fear of being embarrassed
96
Dependent personality disorder
- have an excessive need to be cared for and tend to be clingy and submissive w/ loved ones
- they are usually indecisive and avoid taking the initiative because of feelings of inadequacy
- they have difficulty expressing disagreement w/ others for fear of losing support, and they dread being left alone to fend for themselves
97
Schizoid personality disorder
- social detachment and an inability to express emotion
- they do NOT enjoy close relationships and prefer to be aloof and isolated
- they rarely indulge in any pleasurable activities and appear indifferent to praise or criticism
98
Pts have the right to refuse tx except when doing so poses a serious threat to public health. In these cases, the physician is justified in restricting individual liberties until the public's health is no longer at risk.
.
99
mechanism of action of antipsychotic meds
- primarily consists of dopamine-D2 receptor blockade
| - the added serotonin receptor binding of atypical antipsychotics reduces the likelihood of extrapyramidal side effects
100
Risperidone
- binds w/ a very high affinity to serotonin receptors, which results in an improvement in the negative symptoms of schizophrenia, a reduction in the incidence of EPS side effects, and concomitant tx of depression
- however, risperidone primarily affects psychosis be blocking dopamine D2 receptors
101
Psychosis is associated w/ increased dopaminergic activity, and is therefore best tx w/ drugs that primarily block the dopamine D2 receptors
.
102
Amantadine
- dopamine AGONIST used in the tx of Parkinson's disease
- it has been shown to delay the onset and minimize the severity of dementia in pts w/ Parkinson's disease
- however, the utility in Alzheimer's pts is quite limited
103
Tx for Alzheimer's disease
- Reversible acetylcholinesterase inhibitors such as donepezil (aricept), rivastigmine (exelon), and galantamine (razadyne) are of benefit in slowing the cognitive decline associated w/ Alzheimer's
- Donepezil is approved for all stages of Alzheimer's dementia
- Memantine, an N-methyl-D-aspartate receptor antagonist, is approved for moderate-to-severe dementia
104
If parents refuse to consent to tx of their child for a non-emergency but fatal medical condition, the physician should seek a court order mandating treatment. If a delay in obtaining consent would be imminently life-threatening, the physician is legally authorized to provide emergency tx for the child, regardless of the parent's wishes.
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105
CBT
- focuses on reducing automatic negative thoughts and avoidance behaviors that cause distress
- its effective as monotherapy or in combo w/ meds for a wide range of psychiatric disorders
- addresses distortions such as OVERGENERALIZING of negative events, CATASTROPHIZING, minimizing positive events, and maximizing negative events
106
melancholic depression
- subtype of major depression
- characterized by anhedonia, absent mood reactivity, depressed mood (typically worse in the morning), insomnia or early morning awakening, loss of appetite w/ weight loss, excessive guilt, and psychomotor agitation or retardation
- more common in older adults
107
atypical depression
-hypersomnia, increased appetite, rejection sensitivity, and leaden paralysis (heavy feelings in limbs)
108
The diagnosis of major depressive disorder requires at least 5 of 9 depressive symptoms for at least 2 weeks, w/ at least 1 being depressed mood or loss of interest/pleasure. Symptoms must cause significant functional impairment.
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109
Pts have the right to know their diagnoses. If family members request that the diagnosis not be revealed to the patient, the underlying reasons should be explored before deciding how to proceed.
.
110
social anxiety disorder (social phobia)
-anxiety restricted to social and performance situations, FEAR OF SCRUTINY and embarrassment
111
Panic disorder
-recurrent, UNEXPECTED panic attacks
112
Specific phobia
-excessive anxiety about a SPECIFIC OBJECT or situation (phobic stimulus)
113
GAD
-CHRONIC MULTIPLE WORRIES, anxiety, tension
114
Social anxiety disorder
- characterized by fear of one or more social situations and anxiety about acting in a way that will be humiliating or embarrassing.
- it should be differentiated from other DSM-5 anxiety disorders such as panic disorder (unexpected panic attacks) and specific phobias (specific phobic stimulus)
115
Panic disorder comorbidities and tx
- frequently associated w/ other psychiatric illnesses, including agoraphobia, major depression, bipolar disorder, and substance abuse
- its also linked to higher rate of suicide attempts or suicidal ideations
- tx in the immediate period is benzo's; over the long term its SSRI/SNRI and/or CBT
116
Advanced sleep phase disorder
- circadian rhythm disorder characterized by inability to stay awake in the evening (usually after 7pm), making social functioning difficult
- these pts frequently complain of early-morning insomnia due to their early bedtime
117
Delayed sleep phase syndrome
- circadian rhythm disorder characterized by inability to fall asleep at "normal" bedtimes such as 10pm-midnight
- often cannot fall asleep until 4-5am, but their sleep is normal if they are allowed to sleep until late morning
118
Restless leg syndrome
- intense and unpleasant creeping sensation in the lower extremities that is relieved by moving the legs
- symptoms occur most often w/ the onset of sleep
119
Poor sleep hygiene
- can be associated w/ insomnia
- ie. poor sleep scheduling w/ variable wake and sleep times and frequent daytime napping; routine use of caffeine, alcohol, and nicotine especially in the period preceding sleep; engaging in mentally or physically stimulating activities too close to bedtime; and frequent use of the bed for activities other than sleep
120
alcohol withdrawal
- develop signs and symptoms between 12 and 48 hours after the last drink
- during the acute stage: sweating, hyperreflexia, tremors, and seizures
- this is followed by ACUTE HALLUCINOSIS (auditory/visual) in the absence of autonomic symptoms
- final stage is DELIRIUM TREMENS, which usually occurs 2-4 days after the last drink
- pts suffering from DT present w/ altered sensorium, hallucinations, and autonomic instability (tachycardia, fever, sweating). Death can result if not properly treated
121
heroin withdrawal
- pupillary dilatation, rhinorrhea, muscle and joint aches, abdominal cramping, nausea, and diarrhea
- the symptoms are severe and out of proportion to physical findings
- NOT life threatening
122
Brief psychotic disorder
- positive psychotic symptoms for >1 day and <1 month
| - sudden onset and full return to premorbid level of functioning
123
Schizophreniform disorder
- differentiated from schizophrenia by the duration of symptoms
- lasts for > 1 month but < 6 months
- diagnosis of schizophrenia requires symptoms to be present for at least 6 months
- same symptoms of schizophrenia, but functional decline not required
124
Schizophrenia
- at least 6 months (includes at least 1 month of active symptoms, can include prodromal and residual periods)
- requires functional decline
125
Schizoaffective disorder
-concurrent mood episode, active phase symptoms of schizophrenia and at least 2 week lifetime hx of delusions or hallucinations in the absence of prominent mood symptoms
126
Delusional disorder
-one or more delusions for > 1 month, no other psychotic symptoms, normal functioning apart from direct impact of delusions
127
Schizotypal personality disorder
-pervasive pattern of social deficits, cognitive or perceptual distortions, and eccentric behavior (no clear delusions or hallucinations) that are below the threshold for diagnosis of a psychotic disorder
128
Dissociative fugue
- latin for flight
- sudden and unexpected travel, inability to remember past, confusion about personal identity
- pts may assume new identities altogether
- type of dissociative disorder, and is the only one in this group that is associated w/ travel
129
Dissociative identity disorder
- aka multiple personality disorder
- presence of 2 or more distinct identities that alternatively assume control of the person's behavior
- amnesia regarding important personal info about some of the identities is observed
130
Dissociative amnesia
- presence of one or more episodes of inability to recall important personal info
- the memory disturbance is usually related to a traumatic or stressful event and is too extensive to be considered ordinary forgetfulness
131
Depersonalization disorder
- persistent or recurrent feelings of detachment from one's own physical or mental processes in the context of an intact sense of reality
- tend to feel they are observing their body and thoughts from afar, as if they are living in a dream
- usually results in significant occupational or functional impairment
132
Derealization disorder
-describes the state of experiencing familiar persons and surroundings as if they were strange or unreal
133
Hospice
- palliative, interdisciplinary model of care for pts w/ a prognosis of < 6 months
- the focus is on symptom control; quality of life; and psychosocial, spiritual, and bereavement care
134
altered neurotransmitter in OCD and tx?
- altered levels of serotonin play an important role
- tx is SSRIs
- approved meds: Clomipramine (TCA, to be used after a failed SSRI trial due to side effects), Fluvoxamine, Fluoxetine, Paroxetine, Sertraline.
135
are pts w/ OCD aware that their behavior is irrational?
Yes
136
what is the greatest risk in completing homicide? other risk factors?
- Access to firearms is most important risk factor
- others include:hx of violence, substance abuse, high levels of impulsivety, hx of childhood abuse, antisocial personality disorder, impoverished, unemployed, young male
137
tx protocol for depressed pts
- fist line is SSRI, if that fails, then use another med in the same class (SSRI)
- if there is no improvement and/or side effects after 2 trials, switching to a different class of antidepressants is indicated
138
Trazodone
- has antidepressant properties and sedation as a side effect
- used primarily for the tx of insomnia related to depression
- Priapism is another potential side effect
139
Rationalization
-involves offering a rational, logical reason for an upsetting event or behavior rather than the true reason in order to prevent anxiety and protect self-esteem
140
Body dysmorphic disorder
- involves the preoccupation w/ a perceived defect in appearance that is not observable or appears slight to others
- individuals may perform repetitive behaviors (excessive mirror checking, grooming) or mental acts (comparing)
141
Patients w/ OCD typically engage in multiple compulsive activities
.
142
Trichotillomania
- recurrent hair pulling resulting in hair loss, distress, and functional impairment
- repeated attempts to decrease/stop hair pulling
- should be differentiated from medical/dermatological disorders and other OCD related disorders
- tx is habit reversal training (CBT)
143
Chlorpromazine
-low potency, first-generation antipsychotic
144
Risperidone long-acting injectable
- used in pts who have shown a good response to oral risperidone
- can be administered every 2-4 weeks and is a useful strategy in pts who are chronically noncompliant
145
Ziprasidone
-second-generation antipsychotic used in schizophrenia
146
Clozapine
- uniquely effective antipsychotic medication
- its reserved for patient w/ treatment-resistant schizophrenia or those at high risk for suicidality
- with the exception of clozapine, there is no evidence that one antipsychotic is more effective than another
- side effects: AGRANULOCYTOSIS, seizures, myocarditis, metabolic syndrome
147
Anorexia nervosa
- BMI <18.5 (KEY POINT)
- intense fear of weight gain
- distorted views of body weight and shape
- Tx: CBT, nutritional rehab, OLANZAPINE if no response to above
148
Bulimia nervosa
- Recurrent episodes of binge eating
- Binge eating followed by COMPENSATORY BEHAVIOR to prevent weight gain
- excess worrying about body shape and weight
- maintains NORMAL BODY WEIGHT (BMI 18.5-30)
- Tx: CBT, nutritional rehab, SSRI
149
Binge-eating disorder
- recurrent episodes of binge-eating
- NO COMPENSATORY BEHAVIORS
- lack of control during eating
- Tx: CBT, behavioral weight loss therapy, SSRI
150
Key difference between binge-eating disorder and bulimia nervosa
-lack of compensatory purging behaviors in binge-eating disorder
151
2 types of anorexia nervosa
- restricting subtype (fasting and/or hyper-exercising)
| - binge-eating/purging subtype (binge-eating or purging w/ laxatives or vomiting)
152
what is the key difference between binging/purging suptype of anorexia nervosa and bulimia nervosa?
-Pts w/ anorexia nervosa maintain a LOW BODY WEIGHT (s in bulimia (except welbutrin))
153
Somatic symptom disorder
-one or more somatic symptoms that cause distress or significant impairment in daily life, w/ disproportionate and excessive anxiety and energy devoted to these physical symptoms
154
Pts w/ anorexia nervosa and bulimia nervosa have distorted body image and can engage in purging behaviors. The main difference between the diagnoses is that pts w/ anorexia maintain a body weight below a minimal level for age, sex, and developmental trajectory
.
155
maintenance therapy for bipolar disorder
- atypical antipsychotics are preferred for mild to moderately ill pts
- monotherapy w/ lithium or valproic acid can be used as alternate therapy
- for more severe episodes, combination therapy w/ lithium or valproate plus atypical antipsychotics is usually preferred over monotherapy
156
acute dystonic reaction
- sudden onset, sustained contraction of the neck, mouth, tongue, eye muscles
- greater risk w/ high or rapid dose escalation
- tx: anticholinergic (benztropine), antihistamine (diphenhydramine)
157
Akathisia
- subjective restlessness, inability to sit still
| - tx: beta blocker (propranolol)
158
Drug-induced parkinsonism
- gradual onset
- tremor, rigidity, bradykinesia, masked facies
- tx: anticholinergic or amantadine (dopamine agonist)
159
Antipsychotic class and EPS risk
- risk is related to degree of D2 blockade
- high potency typical antipsychotics (haloperidol) > low potency typical antipsychotics (chlorpromazine)
- typical antipsychotics > atypical antipsychotics
160
amantadine
-dopamine agonist used in the treatment of drug-induced parkinsonism
161
Dantrolene
-muscle relaxant that has been used in severe cases of neuroleptic malignant syndrome, a rare but life-threatening condition characterized by high fever, muscle rigidity, and rhabdomyolysis
162
Levodopa
- tx for Parkinson's disease
- when parkinsonism develops as a side effect of antipsychotic use, the preferred tx is an anticholinergic agent such as benztropine or amantadine
163
Patient confidentiality should NOT be maintained if it endangers the health and welfare of others. In cases of HIV, public health laws require reporting of the patient's positive test results to the local health department. The health department usually contacts the patient's contacts.
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164
Schizoid personality disorder
- persistent pattern of detachment from social relationships and restricted range of emotions
- these pts lead solitary lives, have no interest in socialization, and have little support beyond family members
165
Neuroimaging findings in psychiatric disorders
- Autism: Increased total brain volume
- OCD: abnormalities in orbitofrontal cortex and striatum
- Panic disorder: decreased volume of amygdala
- PTSD: decreased hippocampal volume
- Schizophrenia: enlargement of cerebral ventricles
166
what is the most consistently replicated neuroimaging finding in schizophrenia?
-Enlargement of the lateral cerebral ventricles
167
Generalized social anxiety disorder
- anxiety and fear of scrutiny in social situations, resulting in avoidance, distress, and social-occupational dysfunction
- tx: SSRI or SNRI, CBT
168
circumstances in which minors do not require consent?
- emergency care
- STIs
- Substance abuse (most states)
- Prenatal care (most states)
- Emancipated minor (homeless, parent, married, military, financially independent, high school graduate)
169
Pts w/ a hx of alcohol use who develop tremulousness, unstable vital signs, and/or seizures shortly after hospital admission should be assessed for alcohol withdrawal. LORAZEPAM, an intermediate-duration benzo available in IV form, is preferred in the inpatient setting, particularly in pts w/ comorbid liver disease.
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170
Kleptomania
- rare impulse control disorder w/ typical onset in adolescence
- repetitive failure to resist impulses to steal
- stolen objects have little value
- increasing tension prior to theft; pleasure or relief when committing theft
- stolen objects given away, discarded, or returned; guilt and remorse are common
- tx: CBT is tx of choice
171
Ddx for Kleptomania?
- Shoplifting: theft for personal gain
- Antisocial personality disorder: general pattern of antisocial behavior
- Bipolar disorder, manic episode: impulsivity, impaired judgment
- Psychotic disorders: stealing in response to delusions, hallucinations
172
Lithium exposure in the first trimester of pregnancy increases the risk of what?
- cardiac malformations including septal defects and possibly Ebstein's anomaly
- in the second and third trimesters, goiter and transient neonatal neuromuscular dysfunction are of concern
173
Conversion disorder
- aka "functional neurologic symptom disorder"
- involves unexplained serious neurologic symptoms, usually preceded by an emotional trigger (ie tragic event, argument)
- the symptoms are NOT produced intentionally, are unexplained by medical evaluation, and are inconsistent w/ known neurophysiology
- symptoms are severe enough to cause social and functional impairment, although pts may appear indifferent to them ("la belle indifference")
174
somatic symptom disorder
- involves one or more somatic complaints (including pain) that are distressing or result in significant disruption of daily life, w/ excessive thoughts, feelings, or behaviors related to these symptoms and lasting > 6 months
- pts may have concurrent medical illness, or the symptoms may represent normal bodily function
175
factitious disorder
-intentional falsification or induction of symptoms w/ the goal of assuming the sick role
176
illness anxiety disorder
-fear of a serious illness despite having few or no symptoms and consistently negative evaluations
177
body dysmorphic disorder
- preoccupation w/ >/= 1 perceived physical defects
- defects are not observable or appear slight to others
- repetitive behavior or mental acts performed in response to the preoccupation
- significant distress or impairment
- specify insight (good, poor, absent/delusional beliefs)
178
Body dysmorphic disorder is defined as an excessive preoccupation w/ a slight or imagined bodily defect. It is best treated w/ medication or psychotherapy (not surgery) and requires a measured, sensitive, and empathic approach that takes into account the patient's level of insight.
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179
Cyclothymic disorder
-chronic mood disturbance involving fluctuating periods of hypomania and mild depression that do not meet the full criteria for hypomanic of major depressive episodes
180
The diagnosis of schizoaffective disorder requires assessing the longitudinal course of illness and determining if there is a period of at least 2 weeks of psychotic symptoms in the absence of mood symptoms. Schizoaffective disorder is distinguished from schizophrenia by the presence of mood symptoms for the majority of the illness.
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181
Hoarding disorder
- difficulty discarding possessions regardless of their actual value
- the difficulty is due to a perceived need to save items or to distress related to discarding them
- accumulation of items congests and/or clutters living areas and compromises daily life
- distress or functional impairment, including safety issues occus
- the situation is not attributable to another condition
182
Hoarding disorder tx
-SSRIs and CBT
183
Tourette syndrome
- pts have a significantly increased risk of developing ADHD or OCD
- multiple motor and one or more vocal tics that present before the age of 18
- the tics occur many times a day (frequently in bouts) nearly every day or at regular intervals for at least one year
- motor tics frequently include grimacing, eye blinking, nose twitching, head jerking, and shoulder shrugging
- vocal tics include barking, grunting, squeaking, coughing, and throat clearing
- exacerbated by stress and tend to subside during sleep
184
Asperger's disorder
- impairments in reciprocal social interactions and restricted interests
- often desire relationships but lack awareness of social conventions, including the use of nonverbal communication
- the absence of language delays distinguish Asperger's disorder from autism
185
obsessive-compulsive personality disorder
-characterized by impairment resulting from perfectionism and intense concerns about time and the need to complete tasks meticulously
186
Risk of developing bipolar disorder
- for the general population, lifetime risk is 1%
- an individual w/ a first degree relative (parent, sibling, dizygotic twin) who suffers from bipolar disorder has a 5-10% risk
- if both parents have bipolar disorder, the risk is 60%
- if a monozygotic twin has bipolar disorder, the risk is 70%
187
mesolimbic pathway
- dopamine pathway that extends from the ventral tegmental area to the limbic system
- decreased dopamine activity in the mesolimbic pathway accounts for the therapeutic effects of antipsychotics
188
nigrostriatal pathway
- dopamine pathway
- extends from the substantia nigra to the basal ganglia and is involved in the coordination of movement
- decreased dopamine activity in the nigrostriatal pathway causes the EPS side effects associated w/ antipsychotic use, as well as signs and symptoms of Parkinson disease
189
antipsychotics cause hyperprolactinemia by blocking dopamine activity in the tuberoinfundibular pathway. Clinical effects of hyperprolactinemia include amenorrhea, galactorrhea, gynecomastia, and sexual dysfunction.
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190
4 dopaminergic pathways in the brain
- mesocortical
- mesolimbic
- nigrostriatal
- tuberoinfundibular
191
drug to treat anorexia nervosa?
Olanzapine
192
when do pts w/ anorexia nervosa require hospitalization?
- when they have unstable vital signs, severe bradycardia or cardiac dysrhythmias, and electrolyte derangements
- goals of tx include nutritional rehab and weight gain
- pts should be monitored closely for refeeding syndrome (electrolyte depletion, arrhythmias, and heart failure, which can result from fluid and electrolyte shifts)
193
borderline personality disorder
- pattern of instability in relationships and marked impulsivity
- "splitting"
- impulsive and reckless and may demonstrate suicidal or self-mutilating behavior
- feelings of anger and chronic emptiness are common
194
Schizoid personality disorder
- socially detached and aloof but do not have bizarre cognition
- restricted range of expressed emotion
- do not enjoy close relationships w/ others and prefer to be isolated
- indifferent to praise or criticism
195
which is the most likely atypical antipsychotic to cause EPS?
Risperidone
196
which is the least likely atypical antipsychotic to cause EPS?
Clozapine
197
Akathisia
- subjective feeling of restlessness that compels pts to not sit still and constantly move around (repeated leg crossing, weight shifting, and stepping in place)
- it can occur at any time during tx w/ antipsychotics
- beta blockers provide some relief
198
Dystonia
- can occur between 4 hours and 4 days after receiving an antipsychotic med
- muscle spasms or stiffness, tongue protrusion or twisting, opishotonus, and oculogyric crisis
- antihistamines (ie. diphenhydramine) or anticholinergics (ie. benztropine) provide relief
199
Parkinsonism
- can develop between 4 days and 4 months after receiving an antipsychotic med
- presents w/ cogwheel rigidity, masked facies, bradykinesis, pill-rolling finger tremors, and shuffling gait
- tx is w/ anticholinergics (ie. benztropine)
200
brief psychotic disorder
-positive psychotic symptoms lasting at least 1 day but less than 1 month
201
delusional disorder
-involves one or more delusions and the absence of other psychotic symptoms in an otherwise high-functioning individual
202
methylphenidate
- CNS stimulant that is frequently used to treat ADHD
| - common side effects: nervousness, decreased appetite, weight loss, insomnia, and abdominal pain
203
Imaginary friends are a normal component of development for many young children, and are usually outgrown by the early elementary school years.
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204
oppositional defiant disorder
- children may blame others for their mistakes or misdeeds
| - also tend to have a pattern of angry, argumentative, and negative behavior towards their parents and teachers
205
Major Depressive Episode
- at least 5 of the following (including either depressed mood or anhedonia) are present nearly every day for at least 2 consecutive weeks: Depressed mood, Sleep disorder, loss of Interest, Guilt, loss of Energy, poor Concentration, decreased Appetite, Psychomotor retardation or agitation, or Suicidality.
- SIGECAPS
- critical to assess whether they are actively suicidal and if so, do they have a specific plan
206
Survivors of sexual assault are at high risk for developing what?
-PTSD, depression, and suicidality
207
Midazolam
-benzo used most often to induce conscious sedation during medical procedures
208
acute tx of panic attacks
- Benzo's
| - in panic DISORDER, a SSRI/SNRI and/or CBT should be used for long-term symptom relief
209
Patients taking MAOIs like phenelzine should avoid what?
-foods high in tyramine, as the combo can result in HYPERTENSIVE CRISIS
210
If no significant harm is likely to result from withholding therapy, parental wishes regarding the medical care of a child should be honored and the discussion documented in the chart.
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211
Pts who are an acute threat to themselves should be hospitalized (involuntarily, if necessary) for treatment and stabilization. This principle also applies to minors, even without parental or guardian consent.
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212
Pts have a right to confidentiality unless their condition poses an imminent danger to other individuals or society. However, pts should be strongly encouraged to discuss their health and medical conditions w/ loved ones.
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213
most common side effects of ECT
-amnesia, both retrograde and anterograde
214
first-line treatments for OCD?
-SSRI (fluoxetine, fluvoxamine, paroxetine, sertraline) or clomipramine (a TCA)
215
Classification of psychiatric illnesses by phase is necessary to determine the appropriate pharmacotherapy. Treatment RESPONSE occurs when a patient demonstrates significant improvement (with or without a remission), generally defined as a 50% reduction in the baseline level of severity
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216
Minimizing conflict and stress in the home decreases the risk of relapse in pts w/ schizophrenia. Family psychosocial interventions are indicated for pts w/ a recent psychotic episode who have significant ongoing contact w/ family members.
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217
Physicians are ethically obligated to protect patient confidentiality. With few exceptions, physicians cant disclose info to family members if the patient objects. What are the exception to breaching confidentiality?
-prevent a serious and imminent threat to the health and safety of the patient or others
218
Unlike pts w/ anorexia nervosa, pts w/ bulimia nervosa maintain a normal body weight and are not amenorrheic
.
219
diagnosis of major depression
-4 SIGECAPS plus a depressed mood or anhedonia for at least 2 weeks
220
absolute contraindications to the use of bupropion?
- hx of seizure disorder
- individuals w/ anorexia nervosa or bulimia nervosa frequently develop electrolyte abnormalities that can precipitate seizures. therefore, a hx of anorexia nervosa/bulimia is also a contraindication to bupropion usage
221
diagnosis of hypomanic and manic episodes
- requires elevated/irritable mood and increased energy plus 3 of the following (or 4 if mood is irritable):
- Distractibility
- Impulsivity
- Grandiosity
- Flight of ideas/racing thoughts
- Activity (increased goal-directed/psychomotor agitation)
- Sleep
- Talkativeness/pressured speech
- "DIGFAST"
222
cyclothymic disorder
-at least 2 years of fluctuating, mild hypomanic and depressive symptoms that do not meet criteria for hypomanic episodes or major depressive episodes
223
Bipolar type 1
- manic episodes
| - depressive episodes common, but not required for diagnosis
224
Bipolar type 2
- hypomanic episodes
| - 1 or more depressive episodes required
225
Disruptive mood dysregulation disorder
-childhood disorder characterized by chronic irritability, manifested as temperamental outbursts and persistent angry/irritable mood (DSM-V added DMDD to differentiate children w/ chronic, persistent irritability from those presenting w/ classic episodic bipolar disorder)
226
Bipolar 1 vs. Bipolar 2?
- Bipolar 1 includes manic episode(s) w/ or without a hx of major depressive episodes
- Bipolar 2 is distinguished from bipolar 1 by hypomanic episodes (less severe, less functional impairment, no psychotic symptoms) and hx of one or more depressive episodes
227
how often to get CBC while on Clozapine?
-weekly during the first 6 months of treatment
228
routine testing for lithium?
kidney and thyroid function
229
routine testing for ziprasidone?
-ECG to monitor for QT PROLONGATION
230
Side effect of Risperidone?
- Hyperprolactinemia (galactorrhea, menstrual disturbances, sexual dysfunction, gynecomastia)
- also can occur w/ the first generation antipsychotics
231
Second generation antipsychotics cause metabolic side effects (weight gain, hyperglycemia, dyslipidemia) to varying degrees. Routine monitoring for the development of side effects is recommended. Olanzapine and Clozapine are associated w/ the greatest risk.
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232
Pts who have experienced 2 episodes of acute mania should be considered for long-term (years), if not lifetime, maintenance treatment w/ lithium, especially if the episode were severe or there is a family hx. Pts w/ a hx of 3 or more relapses are recommended to have lifetime maintenance therapy.
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233
If a pts health care proxy disagrees w/ a living will and demands care that contradicts the pts written wishes, the best initial step is to discuss the matter w/ the proxy and other family members. If a discussion fails to resolve the situation, the hospital's ethics committee should be consulted.
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234
2 basic components to an advance directive?
- a living will
- a durable power of attorney for health care (health care proxy)
-surrogate decision makers should make decisions different from the living will only if they have good reason to believe that pts would have changed their minds when confronted w/ the current clinical situation
235
what is the most likely atypical antipsychotic to cause EPS, especially at higher doses?
Risperidone
236
EPS symptoms
- rigidity
- bradykinesia
- tremor
- akathisia
237
Dantrolene
-muscle relaxant sometimes used in cases of neuroleptic malignant syndrome, which can be caused by typical antipsychotics
238
Propranolol
-sometimes used to treat antipsychotic-induced akathisia
239
The EPS side effects of antipsychotics can be treated with what?
anticholinergic medications like benztropine
240
Flight of ideas
-loosely associated thoughts that rapidly move from topic to topic
241
Tangentiality
- refers to a thought process in which there is an abrupt, permanent deviation from the current subject
- this new thought process is minimally relevant at best and never returns to the original subject
242
Loose associations
- lack of a logical connection between the thoughts or ideas of an individual
- tends to be more severe form of tangentiality in which one statement follows another but there is no clear association between the sentences
243
Perseveration
-repetition of words or ideas during a conversation
244
Circumstantiality
- provide unecessarily detailed answers that deviate from the topic of conversation but remain vaguely related
- eventually, there IS A RETURN TO THE ORIGINAL SUBJECT (in contrast to tangential though process which drifts away without ever returning to the subject)
245
Acutely psychotic patients should be assessed for suicidal/homicidal ideation, command hallucinations to hurt self or others, and ability to care for self. Indications for involuntary psychiatric hospitalization include being a danger to self or others and/or grave disability.
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246
Pregnant women w/ a current or previous diagnosis of anorexia nervosa are at risk for numerous complications. What are they?
- miscarriage, intrauterine growth retardation, hyperemesis gravidarum, premature birth, cesarean delivery, and postpartum depression
- osteoporosis is also a common finding in anorexic patients, whether pregnant or not
247
Common findings seen in anorexic patients
- OSTEOPOROSIS
- elevated cholesterol and carotene levels
- cardiac arrhythmias (prolonged QT interval)
- Euthyroid sick syndrome
- HPA dysfunction resulting in anovulation, amenorrhea, and estrogen deficiency
- Hyponatremia secondary to excess water drinking is often the only electrolyte abnormality, but the presence of other electrolyte abnormalities indicates purging behavior
248
Clomipramine
-tricyclic antidepressant used as a second-line treatment of OCD
249
Buspirone
-used to treat generalized anxiety disorder, but not social anxiety disorder
250
Phenelzine
- MAOI that is also effective in generalized social anxiety disorder
- however, not considered first-line tx due to dietary restrictions and risk of hypertensive crisis
251
Performance-related anxiety
- classified as a social anxiety disorder, performance-only type
- tx includes as-needed beta blockers or benzo's in pts w/o substance abuse hx
- CBT is an effective non-pharmacological approach
252
Somatic symptom disorder
- one or more persistent physical symptoms w/ disproportionate and excessive anxiety, concern, and energy devoted to these symptoms
- while the underlying symptoms (ie pain, heartburn, fatigue) are physiologic, they are generally minor and do not indicate a serious disease, though they generate significant worry (by contrast in conversion disorder, the symptoms are by definition non-physiologic)
253
Conversion disorder
- sudden onset of neurological symptoms and clinical findings that are incompatible w/ recognized neurological conditions
- often precipitated by stress, and pts can present as hysterical or strangely indifferent ("la belle indifference") to their symptoms
254
tx for conversion disorder
- education and self-help techniques (first-line)
- CBT (second-line)
- Physical therapy for motor symptoms
255
Eye movement desensitization and reprocessing treatment
- complex method of psychotherapy that integrates therapy w/ eye movements
- helpful for pts w/ PTSD
256
Specific phobia
- fear of a specific object or situation
| - Behavioral therapy using exposure techniques is the preferred treatment
257
In an emergency, family members or friends of a Jehovah's Witness who suggest that a patient would not accept blood transfusion should be asked to provide documentary evidence, such as an advance directive. Without this documentation, or when uncertainty remains, it is advisable not to withhold blood in life-threatening situations.
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258
Neuroleptic malignant syndrome
- associated w/ meds that block dopamine transmission (antipsychotics)
- fever, rigidity, mental status changes, and autonomic instability
- more commonly associated w/ use of high potency, typical antipsychotics like haloperidol
- tx: discontinue all antipsychotics, aggressive monitoring in the ICU, control of hyperthermia, and maintenance of electrolyte balance
- DANTROLENE is a skeletal muscle relaxant that may be used
- Serotonin syndrome can appear similar to NMS with high fevers and rigidity. However, it often begins w/ diarrhea, restlessness, and autonomic instability
259
established psychosocial interventions for schizophrenia
-family therapy and social-skills training
260
Long-acting injectable antipsychotics
- first-generation (haloperidol, fluphenazine)
| - second generation (risperidone, paliperidone, olanzapine, aripiprazole)
261
Clozapine
- second generation antipsychotic used in treatment-refractory schizophrenia
- associated w/ risk of agranulocytosis
262
Tourette disorder
- best treated w/ antipsychotic medications and habit reversal training
- Haloperidol and pimozide are FDA approved, but second-generation antipsychotics such as risperidone are well studied and are increasingly preferred due to their favorable side effect profile
263
Help-rejecting patients who are hopeless about treatment can lead the physician to become frustrated and desire to refer the patient to another provider. Clear expression of empathy and a collaborative approach w/ limited goals is the most effective approach
.
264
Adjustment disorder
- emotional or behavioral symptoms that develop within 3 months of exposure to an identifiable stressor and that rarely last more than 6 months after the stressor ends
- pts experience marked distress in excess of what would be expected from exposure to the stressor
- tx: psychodynamic psychotherapy or cognitive psychotherapy
265
First-line pharmacologic treatment for bipolar disorder
1. Atypical antipsychotics (ie risperidone, aripiprazole, olanzapine)
2. Lithium
3. Valproic acid
Monotherapy w/ atypical antipsychotics is preferred for mild to moderately ill pts. Monotherapy w/ lithium or valproic acid can be used as alternate therapy. For more severe episodes, combo therapy w/ lithium or valproate PLUS atypical antipsychotics is usually preferred over monotherapy.
266
Lithium should not be administered to patients w/ renal dysfunction. Valproic acid, with or without an antipsychotic, is suitable alternate therapy for the initial tx of bipolar disorder, manic or mixed-phase.
.
267
Avoidant personality disorder
-shyness, feelings of inferiority, and a desire to make friends that is overridden by an intense fear of embarrassment or rejection
268
Borderline personality disorder
- pattern of instability of relationships and marked impulsivity
- "splitting"
- tend to be impulsive and reckless
- may demonstrate suicidal or self-mutilating behavior
- feelings of anger and chronic emptiness are common
269
Conduct disorder
- psychiatric condition of childhood and adolescene characterized by a repetitive and persistent pattern of violating major societal rules or the rights of others
- diagnosis requires at least 3 of 15 behaviors that fall into 4 categories: aggression toward people and animals, deceitfulness or theft, destruction of property, and serious violation of rules.
270
Oppositional defiant disorder
-pattern of angry/irritable mood and argumentative/defiant behavior toward authority figures
271
Pyromania
- characterized by intentional and repeated fire setting w/ no obvious motive
- individuals w/ conduct disorder can also have a hx of fire setting, but other features (ie lying, theft, cruelty to others) are also present
272
Genito-pelvic pain/penetration disorder
- ongoing difficulties w/ at least 1 of the following:
- vaginal penetration during intercourse
- vaginal or pelvic pain during intercourse or attempted penetration
- tenseness of pelvic floor muscles during attempted vaginal penetration
- at least 6 months in duration
- significant distress
- not accounted for by other medical, mental, substance use, or relationship issues
273
Brief psychotic disorder vs schizophreniform vs schizophrenia
- brief psychotic disorder lasts < 1 month
- schizophreniform lasts between 1-6 months
- schizophrenia is at least 6 months
274
acute stress disorder
- event occurred < 1 month ago
| - symptoms last < 1 month
275
Unlike Conduct Disorder, Oppositional Defiant Disorder does NOT involve physical aggression or violation of the basic rights of others.
.
276
non-stimulant used to treat ADHD?
Atomoxetine
277
SSRI with longest half life
fluoxetine
278
SSRI with shortest half life
paroxetine
279
SSRI with fewest drug-drug interaction
citalopram
280
SSRI with highest risk of GI side effects?
sertraline
281
Fluvoxamine
SSRI used only for tx of OCD
282
SSRI most highly protein bound, thus having many drug interactions?
Paroxetine
283
SSRIs should not be used for at least how long after stopping an MAOI?
2 weeks for most (must wait 5-6 weeks for Fluoxetine due to long half life)
284
SNRI used commonly in depression and neuropathic pain?
Duloxetine
285
Depression in elderly
- use mirtazapine (a2 adrenergic antagonist antidepresssent)
- helps with sleep and weight gain
286
dopamine pathways associated with the side effects of antipsychotics
- positive symptoms (mesolimbic pathway)
- negative symptoms (mesocortical pathway)
- EPS symptoms (nigrostriatal pathway)
- hyperprolactinemia (tuberoinfundibular pathway)
287
atypical antipsychotics less associated with weight gain
ziprasidone and aripiprazole
288
common side effects of quetiapine
sedation and orthostatic hypotension
289
SSRI safe in pregnancy and approved for use in children?
fluoxetine
290
SSRI used for OCD?
FLUVOXAMINE (not fluoxatine)
291
SNRI often used for depression, neuropathic pain, fibromyalgia?
Duloxetine
292
Nefazodone
black box warning for rare but serious liver failure
| -(similar to the drug trazodone in mechanism of action)
293
Mirtazapine
- a2 adrenergic antagonist
- used in refractory major depression
- sedation and weight gain
294
Amytriptiline
-useful in chronic pain, migraines, and insomnia
295
Imipramine
-useful in enuresis and panic disorder
296
Clomipramine
TCA useful in OCD
297
doxepin
TCA useful in chronic pain
298
Nortriptyline
- least likely TCA to cause orthostatic hypotension
| - useful in treating chronic pain
299
desipramine
- TCA
- more activating; less sedating
- least anticholinergic
300
tx for serotonin syndrome
- discontinue meds
- calcium channel blocker
- possibly chlorpromazine or phentolamine
301
Antipsychotics lower the seizure threshold. Low potency antipsychotics are more likely to cause seizures than high potency antipsychotics.
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302
atypical antipsychotics less associated with weight gain?
aripiprazole and ziprasidone
USMLE Step 2
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