CMN 568 - Unit 5

Significant interactions of MAOIs with other drugs

*INCREASE EFFECT OF*: Antihistamines Dextromethorphan Insulin Psuedoephedrine Succinylcholine Sulfonylureas (↓ blood sugar) SSRIs/SNRIs/triptans (serotonin syndrome) McPhee p 1092

Significant interactions of TCAs and non-MAOIs with other drugs

*↑ BLOOD LEVELS* + Cimetidine (↑ level of antidepressant) + Disulfuram (↑ level of antidepressant) + Haloperidol (↑ level of antidepressant) + Lithium (fluoxetine ↑ lithium levels) + Phenytoin MISC + ↓ absorption of antacids + ↑ effect of anticoagulants + ↑ effect of insulin (decreases blood sugar) + ↑ hypotension with propranolol + ↑ sedation with sedatives McPhee p 1092

Lab tests for children to rule out medical problems with sx that can mimic depression

+ *CBC* - Check for anemia/infection + *Serum electrolytes* - ↑ Na+, ↓ Na+, ↑ Ca+ and ↑ Ph+ can exacerbate or worsen sx of depression - ↑ glucose or ↓ glucose can cause fatigue and alter normal energy and sleep patterns + *Thyroid function tests* - ↑ TSH is related to chronic sx of depression. A hyperthyroid state may be r/t anxiety. + *Toxicology and blood ETOH level* - Serum tox screens and blood ETOH levels can be used to determin if substance abuse if an underlying cause for depressive sx "Mgmt of childhood depression" article

Desvenlafaxine

+ *Generic name* + *Class* + *Indications for use* + *Contraindications* + *Common side effects* + *Dosage*

Carbamazepine

+ *Generic name* - Carbamazepine + *Class* - Antiseizure + *Indications for use* -- Tx of trigeminal neuralgia -- Tx of bipolar in pts who cannot take lithium (doesn't work or ↑ side effects) + *Contraindications* CONTRAINDICATED in pts using MAOIs, bone marrow depression, sensitivity to TCAs CAUTION in CNS depressant use, ETOH use, elderly, asian, hepatic/renal impairment, CV disease, arrhythmia risk (MONITOR WITH serial blood counts and LFTs) + *Common side effects* -- Nystragmus, dysarthria, diplopia, ataxia, drasiness, nausea, hepatoxicity, hyponatremia + *Interactions* -- Will ↑ carbamazepine levels! -- NSAIDs (except aspirin), erythromycin, isoniazid, some CCBs (verapamil and diltiazem, but not nifedipine), fluoxetine, cimetidine (Tagamet). + *Dosage* -- Trigeminal neuralgia: 400 - 1600 mg (immediate or extended release) divided in 2 daily doses -- Bipolar: Start at 400-600 PO daily and increase to 800 - 1600 PO daily. McPhee p 990, 1096

Clomipramine

+ *Generic name* - Clomipramine + *Class* - Tricyclic antidepressants (TCAs) + *Indications for use* - OCD in adults + *Contraindications* CONTRAINDICATED IN acute MI recovery CAUTION IN elderly, < 25 years, GI/GU obstruction, urinary retention, seizure disorder, thyrpid disease, DM, asthma, hepatic/renal impairment, bipolar disorder, ETOH abuse, suicide risk. + *Common side effects* - Xerostomia, drowsiness, tremor, dizziness, HA, consiptaion, fatigue, n/v, etc. + *Dosage* -- OCD: 150-250 mg PO qhs (Start at 25 mg po QD and increase gradually over weeks) NOTE for OCD: Check plasma levels 2-3 weeks after a dose of 50 mg/day is reached to keep plasma levels ↓ 500 ng/mL to avoid toxicity

Fluoxetine

+ *Generic name* - Fluoxetine + *Class* -- SSRI + *Indications for use* -- OCD in adults -- Depression + *Contraindications* CAUTION IN ETOH use, concurrent CNS depressant use, elderly, pts < 25 years, pregnancy 3rd trimester, hepatic impairment, QT issues, bradycardia, DM + *Common side effects* -- Insomnia, nausea, HA, diarrhea, libido ↓, dirrhea, anorexia, somnolence, anxiety, can ↑ serum concentrations of some meds. + *Dosage* -- OCD: Up to 60-80 mg day (start at 20 qd and increase after several weeks. taper to d/c) -- Depression: Starting dose of 10 mg/day for 1 week, before increasing to avg daily dose of 20 mg/day. McPhee xxx, 1089

Lithium

+ *Generic name* - Lithium + *Class* - Antipsychotic + *Indications for use* -- Tx of mania, bipolar disease + *Contraindications* -- CAUTION - Breastfeeding, elderly, renal issues, thyroid disease, ETOH use + *Common side effects* -- EARLY: Mild GI sx, fine tremors, slight weakness and sedation. Moderate polyuria and polydipsia. Thyroid and kidney issues sometimes (check function at 4 -6 month intervals) -- LONG TERM: Cogwheel rigidity and sometimes EPS. + *Interactions* -- ↑ lithium levels! AVOID thiazide diuretics (loop ok), ACEI, fluoxetine, ibuprofen, K-sparing diuretics + *Dosage* -- Bipolar/Manic disorder: start at 300 mg po bid or tid, measure trough after 5 days, 12 hours after last dose. Peak serum levels in 1 - 3 hours. McPhee p 1094-5

Lorazepam

+ *Generic name* - Lorazepam (valium) + *Class* - Benzodiazepine + *Indications for use* -- INSOMNIA + *Contraindications* + *Common side effects* + *Dosage* -- INSOMNIA: 0.5 mg PO nightly

TRIGEMINAL NEURALGIA: Phenytoin

+ *Generic name* - phenytoin + *Class* -- Antiseizure + *Indications for use* - Tx of trigeminal neuralgia + *Contraindications* CONTRAINDICATED in sinus bradycardia, SA block, AV block CAUTION in CV disease, hypotension, ETOH use, elderly, renal/hepatic impairment, DM, thyroid disease, depression + *Common side effects* - Nystagmus, ataxia, sedatino, confusion, blood dyscrasias, SLE, peripheral neuropathy + *Dosage* -- PO, 200 - 400 mg daily McPHee p 990

Amitryptaline

+ *Generic name* -- Amitriptyline + *Class* -- Tricyclic antidepressant + *Indications for use* -- Prophylaxis of migraine + *Contraindications* -- CONTRAINDICATED in recovery from acute MI -- CAUTION in pts < 25 years old, elderly, hepatic impairment, QT issues, torsades, bradycardia, urinary retention, asthma, DM, thyroid disorder, bipolar disorder, schizophrenia, Parkinsons + *Common side effects* -- Sedation, dry mouth, constipation, weight gain, blurred vision, edema, hypotension, urinary retention + *Dosage* -- PO, 10 - 150 mg at bedtime McPhee p 988

Candesartan (not FDA approved for migraine)

+ *Generic name* -- Candesartan + *Class* -- Angiotensin receptor blocker + *Indications for use* - Prophylaxis of migraine + *Contraindications* -- CONTRAINDICATED in pregnancy, pts < 1 year old -- CAUTION in renal or hepatic impairment, hyponatremia + *Common side effects* -- Dizziness, cough, diarrhea, fatigue + *Dosage* -- PO, 8 - 32 mg once daily McPhee p 988

MIGRAINE: Cafergot

+ *Generic name* -- Ergotamine tartrate (1 mg) + caffeine (100 mg) + *Class* -- Ergotamines + *Indications for use* -- Onset of migraine headache + *Contraindications* -- Avoid during pregnancy, in pts with CV risk factors, and pts taking potent CYP3a4 inhibitors + *Common side effects* + *Dosage* -- 1-2 tablets at onset of migraine or warning symptoms, followed by 1 tablet q 30 minutes if needed, up to 6 tablets per attack. NO MORE THAN 10 days per month! McPhee p 987

Guanfacine

+ *Generic name* -- Guanfacine + *Class* -- Cardiovascular, alpha-2 adrenergic receptor agonist + *Indications for use* -- Prophylaxis of migraine + *Contraindications* -- CAUTION in elderly, hepatic/renal impairment, CV disease or hx, CAD, recent MI + *Common side effects* -- Dry mouth, somnolence, dizziness, constipation, erectile dysfunction + *Dosage* -- PO, 1 mg once daily McPhee p 988

MIGRAINE or CLUSTER HA: Sumatriptan

+ *Generic name* -- Sumpatriptan + *Class* -- Triptan + *Indications for use* -- Used to abort migraine attacks or as treatment for cluster HA + *Contraindications* --AVOID in pregnancy, pts with hemiplegic or basilar migraine, pts with risk factors for stroke (e.g. uncontrolled HTN, prior stroke or TIA, DM, hypercholesterrolemia, obesity) -- CAUTION in pts with controlled HTN -- CONTRAINDICATED in pts with coronary or peripheral vascular disease + *Common side effects* -- Nausea and vomiting + *Dosage for migraine* -- SQ, 4-6 mg once, repeat after 2 hours if needed; max dose 12 mg/24 hours --Nasal and PO avajilable, but less effective r/t slower absorption *Dosage for cluster HA* --SQ 6mg or IN 20 mg/spray McPhee p 987

MIGRAINE or CLUSTER HA or TRIGEMINAL NEURALGIA: Topiramate

+ *Generic name* -- Topiramate + *Class* -- Anticonvulsant + *Indications for use* -- Prophylaxis for migraine and cluster HA + *Contraindications* --CAUTION if use of CNS depressant, use of ETOH, depression, suicidal ideation, hepatic impairment + *Common side effects* -- Somnolence, nausea, dyspepsia, irreiability, dizziness, ataxia, nystagmuse, diplopia, glaucoma, renal calculi, weight loss, hypohidrosis, hyperthermia + *Dosage for MIGRAINE* -- PO, 100 mg divided twice daily *Dosage for CLUSTER HA* -- PO, 100-400 mg daily *Dosage for TRIGEMINAL NEURALGIA* -- PO, 50 mg BID McPhee p 988

Valproic acid (not FDA approved for migraine)

+ *Generic name* -- Valproic acid + *Class* -- Anticonvulsant + *Indications for use* -- Prophylaxis for migraine -- Tx of mania + *Contraindications* -- CONTRAINDICATED in hepatic disease or impairment, pregnancy -- CAUTION in peds, elderly, renal impairment, head injury, hx of hepatic disease + *Common side effects* -- N/V, diarrhea, drowsiness, alopecia, weight gain, hepatotoxicity, thrombocytopenia, tremor, pancreatitis. Blood/liver/glucose tests at 2, 4, 12 weeks initially. + *Interactions* -- Aspirin will ↑ valproate levels -- Carbamezepine or phenytoin will ↓ valproate levels -- Valproate will ↑ warfarin levels! + *Dosage* -- PO, 500 - 1000 mg divided twice daily McPhee p 988, 1094

MIGRAINE or CLUSTER HA: Zolmitriptan

+ *Generic name* -- Zolmitriptan + *Class* -- Triptan + *Indications for use* -- Used to abort migraine attacks AND for immediate tx of migraine; also for tx of cluster HA + *Contraindications* --AVOID in pregnancy, pts with hemiplegic or basilar migraine, pts with risk factors for stroke (e.g. uncontrolled HTN, prior stroke or TIA, DM, hypercholesterrolemia, obesity) -- CAUTION in pts with controlled HTN -- CONTRAINDICATED in pts with coronary or peripheral vascular disease + *Common side effects* -- Nausea and vomiting + *Dosage for MIGRAINE* -- PO, 5 mg initially and relief usually occurs within 1 hour. May repeat ONCE after 2 hours. *Dosage for CLUSTER HA* -- IN, 5 or 10 mg/spray McPhee p 987

Propranolol (and other ß-adrenergic antagonists)

+ *Generic name* -- propranolol + *Class* -- Beta blocker + *Indications for use* - Prophylaxis of migraine + *Contraindications* -- CONTRAINDICATIONS -- Bradycardia or heart block w/o pacemaker, bronchial asthma -- CAUTION in elderly, 2nd/3rd trimester of pregnancy, rena/hepatic impairment, PVD, DM, thyroid disorder + *Common side effects* -- Fatigue, dizziness, hypotension, bradycardia, depression, insomnia, n/v, constipation + *Dosage* -- PO, 80 - 240 mg, divided 2 to 4 times daily McPhee p 988

Venlafaxine

+ *Generic name* -- venlafaxine (Effexor) + *Class* -- Serotonin-norepinephine reuptake inhibitors (SNRI) + *Indications for use* -- Prophylaxis of migraine -- Depression + *Contraindications* -- CAUTION in concurrent CNS depressant use, ETOH use, pts < 25 years, elderly, pregnancy 3rd trimester, renal/hepatic impairment, bleeding risk, HTN, hyperthyroid, recent MI + *Common side effects* - HA, nausea, somnolence, dry mouth, dizziness, diaphoresis, sexual dysfunction, anxiety, weight loss, tinnitus, insomnia, nervousness, HTN (monitor BP) + *Dosage* -- MIGRAINE -- PO, 37.5 - 150 mg extended release once daily -- DEPRESSION -- More effective with doses > 200 mg/day PO. + *Notes* -- Few drug-drug interactions. -- No significant anticholinergic side effects -- ↑ risk of lethal arrhythmias compared to SSRIs but ↓ risk than TCAs. McPhee p 988, 1090

MIGRAINE AND CLUSTER HA: Verapamil (and other calcium channel antagonists)

+ *Generic name* -- verapamil + *Class* -- Calcium channel blocker + *Indications for use* -- Prophylaxis of migraine and cluster HA + *Contraindications* -- CONTRAINDICATED in pts with severe LV dysfunction, AV block, atrial fib/flutter, severe hypotension -- CAUTION in CHF, bradycardia, hepatic/renal impairment, GERD, changes in smoking habit, elderly + *Common side effects* -- HA, hypotension, flushing edema, constipation. (Monitor PR interval with ECG) + *Dosage in MIGRAINE* -- PO, 120 - 240 mg, divided 3 times daily *Dosage in CLUSTER HA* -- PO, start at 240 mg daily, increase by 80 mg q2 weeks to 960 mg daily McPhee p 988

Differential dx for depression in children

+ *NEURO* -- Trauma, MS, epilepsy, sleep disturbances and sleep apnea + *PSYCH* -- SAD, bereavement, bipolar disorder, GAD, somatization disorder, delirium, PTSD + *Endo/Metabolic* -- SLE, juvenile RA, Cushing's, DM, hypothyroidism, hyperthyroidism + *Drugs/Drug withdrawal* -- Effects of anticonvulsants, beta blockers, steroids contraceptives, chemo, NSAIDs and stimulants + *Infectious* -- Mono, TB, HIV/AIDS and hepatitis + *Hem/Onc* -- Anemia, leukemia, Hodgkin's, non-Hodgkin's, malignant tumors + *Nutritional* -- Vitamin deficiencies (e.g. B12, C, folate, niacin, thiamine) "Mgmt of childhood depression" article

Prophylaxis of cluster headaches

+ *PO meds* -- Lithium carbonate (start at 300 mg daily, titrate up to total daily dose of 900-1200 mg as tolerated) -- Verapamil (start at 240 mg daily, increase by 80 mg q2weeks to 960 mg daily -- MONITOR WITH ECG for changes in PR interval) -- Topirimate (100-400 mg daily) McPhee p 989

Treatment of insomnia

+ *Psychological* -- Start here for primary insomnia -- Good sleep hygiene + *Medical: Short 2 week course* -- BENZOS: Lorazepam (0.5 mg) or temazepam 7.5 - 15 mg) -- NON-BENZOS: Zolpidem (5 mg ♀, 5-10 mg ♂), zaleplon (5-10 mg). McPhee p 1099

When should autism screening be performed

+ 18 months + 24 - 30 months, to catch children whose autism was not detected at the earlier screening Hay p 89

Crying patterns in US middle-class infants

+ 2 hours per day at 2 weeks of age + 3 hours per day by 6 weeks of age + 1 hour per day by 3 months of age Hay p 82

An adjustment disorder occurs within ________________________ (time period) of an identifiable stressor.

+ 3 months

Definition of at-risk drinking

+ 4 drinks/day or 14 drinks/week for MEN + 3 drinks/day or 7 drinks/week for WOMEN McPhee p 1103

New headache in a patient > ________________ years or with ___________________ (condition) should warrant IMMEDIATE neuroimaging.

+ > 50years + HIV infection McPhee p 39

IMMEDIATE TREATMENT: Infections

+ Abscess + Encephalitis + Meningitis Mc Phee p 39

Pt with HA and *hypertension, "cotton wool spots", flame hemorrhages and disk swelling* suggests....

+ Acute severe hypertensive retinopathy McPhee p 40

Commonly used antidepressants: TCAs and similar (from $ to $$$, sedation from 1 - 4)

+ Amitriptyline (Elavil): 150-250 mg qd (max 300 mg qd) S4 + Doxepin (Sinequan): 150-200 mg qd (max 300 mg qd) S4 + Imipramine: 150-200 mg qd (max 300 mg qd) S3 + Amoxapine: 150-200 mg qd (max 400 mg qd) S2 + Nortriptyline: 100-150 mg qd (max 150 qd) S2 + Maprotiline: 100-200 mg qd (max 300 qd) S4 + Desipramine: 100-250 mg qd (max 300 qd) S1 + Trimipramine: 75-200 mg qd (max 200 qd) S4 + Protriptyline: 15-40 mg qd (max 60 qd) S1 + Clomipramine: 100 mg qd (max 250 qd) S3 NOTES: Effective in panic disorder, pain syndromes and anxiety states. Also OCD, enuresis, psychotic depression and craving reduction in cocaine withdrawal. Full trial is daily for 6 weeks. ↑ anticholinergic effects McPhee Table 25-7

Components of chronic pain syndrome

+ Anatomic changes + Chronic anxiety and depression + Anger + Changed lifestyle McPhee p 1069

Meds for PREVENTION of migraine

+ Antiepileptic -- Topamax -- Valproic acid + CV meds -- Beta blockers like propranolol, timolol -- CCBs like verapamil + TCAs like amitriptyline All taken DAILY BBB

Medications for PREVENTION of migraine?

+ Antiepileptic: --Topiramate (Topamax) --Valproic acid (Depokene) - may be good for pts with fairly frequent migraines +Cardiovascular: --Beta blockers: Propranolol, Timolol --Calcium channel blockers: Verapamil +Antidepressant: tricyclics: amitriptyline (Elavil) NOTE: Medications are taken daily to prevent migraines BBB

Differential diagnoses for adjustment disorder

+ Anxiety disorders + Mood disorders + bereavement + Other stress disorders (e.g. PTSD) + Personality disorders exacerbated by stress + Somatic disorders with psychic overlay NOTE: Adjustment disorders are *wholly situational* and usually resolve when the stressor resolves or the individual effectively adapts to the situation. McPhee p 1059

ESSENTIALS OF DIAGNOSIS: Adjustment disorders

+ Anxiety or depression in reaction to an identifable stress, though out of proportion to the severity of the stressor + Symptoms not as serious as a major depressive episode or as chronic as a generalized anxiety disorder. McPhee p 1059

Interviewing pt about non-adherence to depression medication regimen

+ Ask pt what they are taking and when + 50% of pts fail to take meds as prescribed due to lack of understanding of instructions or unnatural fears of side effects/drug dependence + Ask about troubling and intolerable side effects, including sexual dysfuntion, nausea, akathisia, etc. Johns Hopkins PPT

Behavioral approaches to chronic pain

+ Assign patient self-help tasks graded up to maximal activty as a means of positive reinforement. + Avoid positive reinforcers for pain such as marked sympathy and attention to pain. + Emphasize a positive response to productive activities which remove the focus from the pain. + Hypnosis tends to be more effective in patients with a high level of denial who are more responsive to suggestion. McPhee p 1070

Diagnostic criteria for GAD

+ At least ONE of these symptoms: - Fatigue - Restlessness or poor concentration - Irritability - Feeling on edge - Sleep disturbance + Symptoms must cause significant distress or disturbance of function AND be present for ≥ 6 (SIX) months Hay p 194

Age of normal colic presentation

+ Begins in first few weeks of life, and peaks at age 2 - 3 months. + In about 30-40% of cases, colic continues into the 4th and 5th months Hay p 82

ESSENTIALS OF DX + TYPICAL FEATURES: Tantrums and breath-holding spells

+ Behavioral responses to stress, frstration and loss of control + Tantrum - Child may throw him or herself on the grown, kick, scream or strike out at others + Breath-holding spell - Child engages in a prolonged expiration that is reflexive and may become pale or cyanotic + R/o underlying organic disease in children with breath-holding spells (e.g. CNS abnormalities, Rett syndrome, seizures, etc.) Hay p 88

Other types of medications often used to treat peripheral symptoms of PTSD

+ Beta blockers - Helps with anxiety (e.g. propranolol) + Noradrenergic agents - Help with hyperarousal (e.g. clonadine) + α-adrenergic blockers - Decrease nightmares (e.g. prazosin) + Antiseizure medications - Mitigate impulsivity and difficulty with anger management (e.g. carbamazepine) + Benzodiazepines - Reduce anxiety and panic attacks but CAUTION WITH DEPENDENCE (e.g. clonazepam) NOTE: 2nd generation antipsychotics have not proven useful. McPhee p 1061

Bipolar 1 vs Bipolar 2

+ Bipolar 1 - Individual has manic episodes + Bipolar 2 - Individuals who experience hypomanic episodes without frank mania McPhee p 1084

Symptoms of basilar artery migraine

+ Blindness/visual disturbances throughout both visual fields + Dysarthria + Dysequilibrium + Tinnitus + Perioral/distal paresthesias + transient loss/impairment of consciousness or confusional state. McPhee 987

ESSENTIALS OF DIAGNOSIS: Trigeminal neuralgia

+ Brief episodes of stabbing ffacial pain + Pain in territory of 2nd and 3rd division of trigeminal nerve + Pain exacerbated by touch :McPHee p 990

Mainstay of therapy for social anxiety disorder

+ CBT with a goal to modify behavior and diminish anxiety + SSRIs have been approved for children with social anxiety disorder Hay p 194

Treatment of OCD in kids

+ CBT-specific for OCD + SSRIs -- specifically fluvoxamine and sertraline -- have FDA approval for treatment of pediatric OCD NOTE: Combination of CBT *plus* medicatio is the most effective tx for patients who do not respond to either treatmetn alone. Hay p 195

What kind of imaging should be done when subarachnoid hemorrhage is suspected?

+ CT scan (preferably with CT angiography) IMMEDIATELY. -- If CT is normal, CSF must be examined for presence of blood or xanthochromia before discounting possibility of subarachnoid hemorrhage. (< 2000 RBC is unlikely due to subarachnoid hemorrhage). McPhee p 1008

Meds for symptomatic relief of migraine

+ Cafergot: 1/100 mg (ergot/caff), start with 1-2 tabs, repeat q 30 min to max dose of 6 mg per 24 hours + Triptans -- CONTRAINDICATED in CV disease -- CAUTION in pregnancy, hemiplegic or basilar migraines, hx of stroke or TIA, hx of DM, hyperlipidemia or obesity May be combined with naproxen BBB

Treatment for agoraphobia

+ Challenging because often pt won't leave home + CBT with exposure is 1st line tx + Addition of SSRI for pts who do not respond to treatment or who are severely impacted Hay p 193

Characteristics of night terrors

+ Child sits up in bed, screaming, thrashing + Rapid breathing, tachycardia and sweating + Child is often incoherent and unresponsive to comforting + May last up to 30 minutes after which child goes back to sleep and has *no memory of it the next day*. Hay p 86

ESSENTIALS OF DIAGNOSIS: Chronic pain disorders

+ Chronic complaints of pain + Symptoms frequently exceed signs + Minimal relief with standard tx + History of having seen many clinicians + Frequent use of several nonspecific medications NOTE: Counterproductive to speculate whether or not pain is real. IT IS REAL TO PATIENT. McPhee p 1069

Dysthymia

+ Chronic depressive disturbance. + DIAGNOSIS: Sadness, loss of interest and withdrawal from activites *over a period of ≥ 2 years with a relatively persistent course*. + Milder symptoms but longer lasting than a major depressive episode McPhee p 1084

Commonly used antidepressants: SSRIs (from $ to $$$, sedation from 1 - 4)

+ Citalopram (Celexa): 20 mg qd (max 40 mg qd) S0 + Escitalopram (Lexapro): 10 mg qd (max 20 mg qd) S0 + Paroxetine (Paxil): 20-30 mg qd (max 50 mg qd) S1 + Sertraline (Zoloft): 50-100 mg qd (max 200 mg qd) S0 + Fluvoxamine (Luvox): 100-300 mg qd (max 300 qd) S1 + Fluoxetine (Proxac): 5-40 mg qd (max 80 mg qd) S0 McPhee Table 25-7

Atypical facial pain - Patient profile and treatment

+ Common in middle-aged women, many of them depressed + Trials of simple analgesics and TCAs, carbamazepine, phenytoin; although response is often disappointing. McPhee p 991

Conversion disorder

+ Conversion of psychic conflict into physical symptoms commonly co-occurs wtih panic disorder or depression. (e.g. paralysis for panic disorder) McPhee p 1067

Behavioral states in children

+ Crying state + Quiet alert state + Active alert state + Transitional state + Deep sleep state -- These states are 1) maintained until NECESSARY to shift to another, 2) STABLE over several minutes, 3) SAME STIMULUS elicts a STATE-SPECIFIC response different from other states -- Behavior is more easily influenced during TRANSITIONAL state Hay p 82

Causes of insomnia

+ Depression + Manic disorders + Abuse of ETOH (can be cause of or secondary to a sleep disturbance) + Heavy smoking (> pack/day) + Other medical conditions (e.g. delirum, pain, respiratory distress, uremia, asthma, thyroid disorders, nocturia r/t BPD) McPhee p 1099

In 75% of cases of PTSD, it occurs with comorbid existence of WHAT OTHER disorders?

+ Depression + Panic disorder NOTE: There is considerable overlap in symptoms between the three. McPhee p 1061

CLINICAL FINDINGS: Adjustment disorder with depressed mood

+ Depression occuring in reaction to some identifiable stressor or adverse life situation. + Anger is often associated with the loss, and this in term often produces a feeling of guilt + Occurs within 3 months of the stressor and causes significant impairment in social or occupational functioning + The presence of a stressor is NOT the determining diagnostic! It is the resultant syndromal complex. McPhee p 1084

ESSENTIALS OF DX + TYPICAL FEATURES: Sleep disorders in children < 12 years

+ Difficulty *initiating* or *maintaining* sleep that is viewed as problem by child or caregiver + May be characterized by its severity, chronicity, frequency AND associated impairment in daytime function in child or family + May be due to primary sleep disorder OR occur in association with other sleep, medical or psychiatric disorders Hay p 85

ESSENTIALS OF DX + TYPICAL FEATURES: Sleep disorders in adolescents

+ Difficulty initiating or maintaining sleep, or early morning awakening or nonrestorative sleep or a combination of these problems Hay p 85

Commonly used antidepressants: SNRIs (from $ to $$$, sedation from 1 - 4)

+ Duloxetine (Cymbalta): 40 mg qd (max 60 mg qd) S0 + Desvenlafaxine (Pristiq): 50 mg qd (max 100 mg qd) S1 + Milnaciprin: 100 mg qd (max 200 mg qd) S1 + Levomilnaciprin: 40 mg qd (max 120 mg qd) S1 + Venlafaxine XR (Effexor): 150-225 mg qd (max 225 qd) S1 McPhee Table 25-7

ANY abnormality on neuro exam (esp mental status) of pt with HA warrants....

+ EMERGENT neuroimaging McPhee p 40

Components of treatment for NE

+ Education and not shaming child + Waking child at night so that he can go urinate -- Requires CONSISTENCY from parents -- Bedwetting alarms are useful -- Therapy needs to continue for 3 months and be used EVERY NIGHT -- Most common cause of tx faiure is that the child doesn't awaken OR that the parents do not wake the child. Hay p 81

Symtoms of cluster headaches

+ Episodes of severe, unilateral periorbital pain occurring daily for several weeks + Frequently accompanied by one or more of following: Ipsilateral nasal congestion, rhinorrhea, lacrimation, redness of eye, Horner syndrome (ptosis, pupillary meiosis, facial anhidrosis/hypohydrosis) + Restlessness/agitation during attacks + Often occur at night, waking patient + Last between 15 minutes to 3 hours + Remission can last for weeks or months, but will recur. + Bouts may last for 4 - 8 weeks and recur several times a year. + Triggers can be ETOH, stress, glare, ingestion of specific foods McPhee p 989

ESSENTIALS OF DX + TYPICAL FEATURES: Social anxiety disorder

+ Excessive worrying in social settings + Inability to perform in front of others as expected for age + Avoidance of events or settings that are social in nature or involve large groups Hay p 194

For a diagnosis of agoraphobia, pt must:

+ Experience 2 or more specific fears related to: -- Open spaces -- Public transportaiton -- Standing in line -- Crowds -- Enclosed space -- Being outside home alone -- Similar fears + Fears must last for over 6 months and lead to impairment Hay p 193

ESSENTIALS OF DIAGNOSIS: PTSD

+ Exposure to traumatic or life-threatening event + Flashacks, intrusive images and nightmares in which pt re-experiences event + Avoidance symptoms (e.g. social, numbing) and avoidance of triggers + Increased vigilance, such as startle response and difficulty falling asleep + Symptoms impair functioning McPhee p 1060

4 D Model for managing Treatment Resistant Depression

+ FIRST D - Diagnosis -- Is this major depression? -- Has bipolar disorder been r/o? -- Has a medical cause been r/o? -- Has psychosis been r/o? -- Has substance/ETOH use been r/o? + SECOND D - Right DRUG -- Was appropriate drug (or combination of drugs) selected for pts individual needs? -- Were comorbidities considered when selecting drug? -- Were adverse events optimally managed? + THIRD D - Right DOSE -- Was pt given right dose of med? -- Was pt's age, weight, sex and ethnic background considered in dose determination? -- Was patient compliant with med? + FOURTH D - DURATION -- Did pt take medication for a MINIMUM of 6 - 8 weeks? -- Did patient skip doses or reduce dose on their own? Johns Hopkins PPT

ESSENTIALS OF DIAGNOSIS + TYPICAL FEATURES: Anxiety Disorder in children

+ Fear or anxiety that is excessive or persists beyond developmetnally appropriate period + Fear or anxiety is accompanied by behevioral disturbances or physical manifestations + Symptoms cause functional impairment or significant distress Hay p 187

Medication approved for tx of OCD in children and adolescents?

+ Fluoxetine (Prozac) + Sertraline (Zoloft) + Fluvoxetine (Luvox) FDA

What types of headaches should be referred?

+ Frequent migraines not responsive to std tx + Migraines with atypical features + Chronic daily ha r/t medication overuse McPhee p 41

Nightmares - Definition and when they start

+ Frightening dreams that occur during REM sleep typically followed by awakening, usually occuring latter part of night + Peaks between 3 and 5 years + Child who awakens is usually alert, can describe images, recall dream and talk abou tit during the day. + Child seeks and will respond to positive pareent reassurance. + Can be associated with stress, trauma, anxiety, sleep deprivation which can cause a rebound in REM sleep, or medication that increase REM sleep Hay p 86

Conditions which must be ruled out before a diagnosis of colic is made

+ Gastroesophageal reflux + Cow's milk allergy + Undetected corneal abrasion + UTI + Unrecognized traumatic injuries (incl. child abuse) Hay p 82

Pt with HA and *diminished visual acuity* suggests....

+ Glaucoma + Temporal arteritis + Optic neuritis McPhee p 40

Components of good sleep hygiene

+ Go to bed only when sleepy + Use bedroom for sleep and sex + Get up if not asleep in 20 minutes + Get up at same time every day + No caffeine/nicotine in pm + Daily exercise + Avoid ETOH + Limit fluids in PM + Use relaxation techniques + Bedtime ritual and routine for going to sleep McPHee p 1099

Grades of withdrawal from opioids

+ Grade 0 - Craving/anxiety + Grade 1 - Yawning, lacrimation, rhinorrhea, perspiration + Grade 2 - Above + mydriasis, pilerection, anorexia, tremors, hot/cold flashes with generalized aching + Grades 3/4 - ↑ intensity of above + ↑ temp, BP, pulse, RR/D If very severed, vomiting, diarrhea, weight loss, hemoconcentration and spontaneous orgasm Treatment for withdrawal starts at Grade 2 McPHee p 1109

Signs/symptoms of pseudotumor cerebri

+ HA + Diplopia and other visual disturbances due to papilledema and abducens nerve dysfunction + Some pts have pulse-synchronous tinnitus NOTE: Exam reveals papilledema and some enlargement of blind spots, but patients otherwise look well. McPhee p 1018

Acute HA - RED FLAGS in children

+ HA in pt < 5 yrs + New or worsening HA in previously healthy child + Worst HA of life + FUO + HA = BE CONCERNED! + Night-time HA that wakes child + Posterior HA at back of skull + HA with vomiting, esp w/o nausea + ↑ HA with straining or postural chgs + Neuro deficits + Neurocutaneous stigmata (cafe au lait spots or hypopigmentation) + Recent head trauma BBB

ESSENTIALS OF DIAGNOSIS: Pseudotumor cerebri

+ HA, worse on straining + Viscual obscurations or diplopia may occur + Examination reveals papilledema + Abducens palsy is commonly present (6th nerve palsy causes eye to turn out) McPhee p 1018

Model programs for treating depression in older adults

+ Healthy IDEAS (Identifyin Depression, Empowering Activities for Seniors): In-home treatment + IMPACT (Improving Mood - Promoting Access to Collaborative Treatment): Clinic-based depression program + PEARLS (Program to Encourage Active, Rewarding Lifestyles for Seniors): Home-based care for minor depression and dysthymia. CDC Healthy Aging Article

Other than cluster headaches, name other trigeminal autonomic cephalgias?

+ Hemicrania continua + Paroxysmal hemicranias + Short-lasting neuralgiform headache attacks with conjunctival injection and tearing McPhee p 989

Major depression with atypical features

+ Hypersomnia, overeatingm lethargy and mood reactivity in which the mood brightens in response to positive envets or news. TREATMENT/MEDICATION + Buproprion or an SSRI + MAOIs may be more effective than TCAs, and an MAOI can be used if more benign antidepressant strategies prove unsuccessful. McPhee p 1084, 1089

Medical illnesses that can lead to symptoms suggestive of anxiety

+ Hyperthyroid + Hypoglycemia + Hypoxia + Pheochromocytoma Hay p 187

Name for idiopathic pseudotumor cerebri and patients most often affected?

+ Idiopathic intracranial HTN + Most commonly affects overweight women aged 20 -44 McPhee p 1018

ESSENTIALS OF DIAGNOSIS + TYPICAL FEATURES: Feeding disorders

+ Inadequate or disordered intake of food due to any of the following conditions -- Poor oral/motor coordination -- Fatigue resulting from a chronic disease -- Lack of appetite -- Behavioral issues related to parent-child interaction -- Pain associated with feeding Hay p 83

Defintion of a specific phobia

+ Intense fear of a particular thing, experience or situation + Lasts for at least 6 months. + Cause of great distress nearly every time the individual is exposed to or anticipates the stimulus Hay p 189

IMMEDIATE TREATMENT: Vascular events

+ Intracranial hemorrhage + Thrombosis + Cavernous sinus thrombosis + Vasculitis + Malignant hypertension + Arterial dissection + Aneurysm McPhee p 39

In approximately HALF of pts with chronic dialy HA, _____________ is responsible.

+ Medication overuse NOTE: Initiating migraine preventive tx EARLY permits withdrawal of analgesics and eventual relief of HA McPhee 990

Treatment of psuedotumor cerebri

+ Medications to reduce production of CSF to ↓ ICP. Some examples -- Acetazolamide (250-500 mg PO TID, increasing slowly to maintenance dose of up to 4000 mg daily divided 2 to 4 times per day) -- Topiramate (also causes weight loss) -- Furosemide (can be used as adjunct tx) + Sometimes CSF is drawn off to ↓ ICP. Shunts are sometimes inserted. McPhee p 1018

Primary headache syndromes?

+ Migraine + Tension-type headache + Cluster headache McPhee p 986

When is preventive tx of migraines indicated?

+ Migraines occur > 2-3 times per month, OR + Significant disability is associated with attacks McPhee p 987

Commonly used antidepressants: Atypicals and other (from $ to $$$, sedation from 1 - 4)

+ Mirtazipine (Remeron): 15-45 mg qd (max 45 mg qd) S4 + Trazodone: 100-300 mg qd (max 400 mg qd) S4 + Buproprion SR: 300 mg qd (max 400 mg qd) S0 + Vilazodone: 10-40 mg qd (max 40 mg qd) S1 + Buproprion XL: 300 mg qd (max 450 mg qd) S0 + Nefazodone: 150-600 mg qd (max 600 qd) S3 + Vortioxetine: 10 mg qd (max 20 qd) S0 McPhee Table 25-7

Potential causes of treatment-resistant depression

+ Misdiagnosis + Inadequate tx, undertreatment or starting tx too late + Failure to achieve initial remission + Nonadherence + Failure to address concurrent disorders -- Occult substance abuse -- Occult general medical conditions -- Concurrent Axis I or II disorders Johns Hopkins PPT

ESSENTIALS OF DIAGNOSIS: Possible symptoms in mania

+ Mood ranging from euphoria to irritability + Sleep disruption + Hyperactivity + Racing thoughts + Grandiosity or extreme overconfidence + Variable psychotic symptoms. McPhee p 1083

ESSENTIALS OF DIAGNOSIS: Most depressions

+ Mood varies from mild sadness to intesnse despondency and feelings of guilt, worthlessness and hopelessness + Difficulty in thinking, including inability to concentrate, ruminations and lack of decisiveness. + Loss of interest, with diminished involvement in work and recreation + Somatic compaints such as disrupeted, lessend or excessive sleep; loss of energy; change in appetite; decreased sex drive McPhee p 1083

Differential dx for trigeminal neuralgia

+ Multiple sclerosis -- Suspect when < 40 years of age + Other neoplasm when symptoms are BILATERAL McPhee p 990

ESSENTIALS OF DX + TYPICAL FEATURES: Generalized anxiety disorder

+ Multiple, intense, disproportionate or irratinoal worries, often about future events + Worry is accmpanied by other symptoms + Worry is difficult to control Hay p 193

Criteria for dx of separation anxiety disorder

+ Must be distinguished from normal development + Must occur for more than 4 weeks for children + Must lead to impairment or significant distress Hay p 189

What kind of early treatment of diagnosed migraine or migraine-like headache can abort or provide significant relief of symptoms?

+ NSAIDs (e.g. ketorolac) + Triptans McPhee p 41

Acute HA - RED FLAGS in adults

+ New onset HA in pt > 50 yrs + Thunderclap HA + HA + fever + Hx head trauma + Vision changes + Hx of/current HTN + Immunosupprssion + Positive neuro exam (e.g. dilated eyes, slowed responses, etc.) + Changes in personality BBB

Features of HA due to intracranial mass lesions

+ New or worsening HA in middle or later life (should prompt for brain imaging) + Pain may be worse upon lyind down, awaken pt at night or peak in morning after overnight recumbency. + Sx suggestive of infection or malignancy include: fever, night sweats and weightloss; immunocompromise; hx or malignancy McPHee p 989

What is a post-traumatic HA?

+ Occurs after a closed head injury. + Usually appears within a day or so following injury, may worsen over ensuing weeks, and gradually subsides + HA which START 1-2 weeks after injury are probably not directly attributable to injury McPhee p 989

Characteristics of sleepwalking and age when it starts

+ Occurs during slow wave/deep sleep + Common between 4 - 8 years of age Parents should take steps to ensure that child doesn't injure himself walking around at night -- maybe a bell on the door to alert parents if child gets up. Hay p 86

Psychotic major depression

+ Occurs in 14% of all patients with major depression and in 25% of patients hospitalized with depression + Psychotic symptoms (e.g. delusions, paranoia) are more common in depresssed persons who are > 50 years old. + Somatic delusions revolve around feelings of impending annhilation or somatic concerrns (e.g body is rotting away with cancer). + Hallucinations are uncommon TREATMENT + Combination of antipsychotic (such as olanzapine) and an antidepressant (such as an SSRI) at their usual doses. + Mifepristone may have specific and early activity against psychotic depression. + ECT is generally regarded as the single most effective tx for psychotic depression McPhee p 1084, 1088

Postherpetic neuralgia - Patient profile, symptoms and treatment

+ Occurs in 15% of pts with hx of shingles (usually when rash is severe and when 1st division of trigeminal nerve is affected) + WITHIN 72 hours of rash onset, reduce post-herpetic neuralgia by ALMOST HALF with: -- Acyclovir (800 mg 5 times daily) -- Valacyclovir (1000 mg TID) + Topical application of capsacian cream and topical lidocaine may be helpful. McPHee p 991

What patients are most at risk for subarachnoid hemorrhage?

+ Older age + Female + Non-white + Hypertensive + Smoker + ↑ ETOH consumption + Previous symptoms + Posterior circulation aneurysms + Larger aneurysms McPhee p 1008

What age of child suffers most from social anxiety disorder?

+ Older children and adolescents Hay p 194

Differential dx for separation anxiety disorder

+ Other anxiety disorders + Mood disorders + Oppositional defiant disorder + Conduct disorder + Psychotic disorder + Personality disorders -- *School refusal* is a common behavioral manifestation of separation anxiety disorder. Hay p 189

Differential dx for agoraphobia

+ Other anxiety disorders + PTSD + Depression + Medical conditions (eg inflammatory bowel disease) Hay p 193

Treatment of cluster headache attack?

+ PO meds are generally ineffective + SOMETIME effective: -- SQ or INTRANASAL sumatriptan -- 100% O2 via non-rebreather mask -- INTRANASAL zolmatriptan -- Dihydroergotamine (IM/IV) or viscous lidocaine (intranasal) McPhee p 989

Symptoms of tension type headache

+ Pericranial tenderness + Poor concentration + Daily headaches which are "vise-like" but not pulsatile + Exacerbated by emotional stress, fatigue, noise or glare. + Usually generalize, but may be more intense about neck or back of head and associated with focal neuro symptoms. NOTE: Triptans are NOT indicated for this type of HA. McPhee p 988

Differential diagnoses with depression

+ Personal life adjustment problems + Medication side effects + Schizophrenia, partial complex seizures, organic brain syndromes, panic disorders and anxiety disorders. + Thyroid dysfunction and other endocrine disorders + Malignancies + Strokes McPhee p 1085

Commonly used antidepressants: MAOIs (from $ to $$$, no sedation!)

+ Phenelzine (Nardil): 45-60 mg qd (max 90 mg qd) + Tranylcypromine: 20-30 mg qd (max 50 qd) + Selegiline: 6 mg patch qd (max 12 qd) NOTES: THIRD line medications for depression after failure of SSRI, SSNI, TCA and atypicals because of dietary and other restrictions (no cheese, no wine, no aged meats, soy sauce; and no meds with phylephrine, detromethorphan and pseudoeephedrine) McPhee Table 25-7

Worsening behavior of a child with autism may be indicative of what?

+ Possible medical issues (e.g. dental abscess or esophagitis) Hay p 95

What medications can be given as "transitional therapy" for 2 weeks or so until prophylactic medications for cluster HA become effective?

+ Prednisone -- 60 mg daily for 5 days, followed by gradual withdrawal over 7 - 10 days. + Ergotamine tartrate -- 0.5 - 1 mg nightly via rectal suppository, 2 mg daily PO, or 0.25 mg TID SQ five days per week. McPhee p 989

ESSENTIALS OF DIAGNOSIS: OCD and related disorders

+ Preoccupations and rituals (repetitive psych9ologically triggere behaviors) that are distressing to the individual + Symptoms are excessive or persi+ stent beyond potentially developmentally normal periods McPhee p 1066

ESSENTIALS OF DX + TYPICAL FEATURES: Separation anxiety

+ Presistent excessive worr yabout losing or being separate from attachmet figures, due to harm,illness or death befallign either the attachment figure of the patient + Reulctance or refusal to leave th attachment figure or sleep away from the attachment figure + Fear of being home alone without the attachment figure + Physical complaints when separation occurs or is anticipated. Hay p 189

Somatic symptom disorder

+ Previously known as hypochondriasis + Characterized by one or more somatic symptoms associated with significant distress or disability. + HIgh level of anxiety about health + Usually chronic + Major depression is an important consideration in differential diagnosis + Usually occurs before age 30, and is 10 times more common in women. McPhee p 1067-8

Useful screening instruments for PTSD

+ Primary Care PTSD Screen + PTSD Checklist McPhee p 1060

ESSENTIALS OF DIAGNOSIS: Some severe depressions

+ Psychomotor retardation or agitation + Deulsions of a somatic or persecutory nature. + Withdrawal from activties + Physical symptoms of major severity, e.g. anorexia, insomnia, reduced sexual drive weight loss and various somatic complaints + Suicidal ideation McPhee p 1083

Types/duration of psychotherapy as tx for PTSD

+ Psychotherapy should begin as soon as possible after the event and should be brief (8 - 11 sessions) as soon as individual feels safe. + Types of psychotherapy which have proven useful: -- Cognitive processing therapy -- Prolonged exposure therapy -- Eye-movement desensitization reprocessing McPhee p 1061

When to refer/admit pts with suspected pseudotumor cerebri

+ REFER all patients + ADMIT pts with worsening vision requiring shunt placement or optic nerve sheath fenestration. McPhee p 1018

Management of night terrors

+ Reassurance of parents + Measures to avoid stress, irregual sleep schedule or sleep deprivation (which prolongs deep sleep when night terror occur). Hay p 86

ESSENTIALS OF DX + TYPICAL FEATURES: Obsessive compulsive disorder

+ Recurrent obsessive thoughts, impules or images that are experienced as instrusive at times + Repetitive compulsive behaviors or mental acts are performed to prevent or reduce distress stemming from obsessive thoughts + Obsessions and compulsions cause marked distress, are time-consuming and interfere with normal activities Hay p 195

Encopresis

+ Repeated passage of stool into clothes or bed by a child who is chornologically or developmentally older than 4 years. + Occurs each month for at least 3 months and is not attributable to meds or medical condition (except for constipation) Hay p 81

What is "kindling"

+ Repeated stimulation of brain that makes it more susceptible to focal bgrain activtiy with minimal stimulation. + Stimulants and depressants lead to kindling McPhee p 1102

Symptoms of seratonin syndrome

+ Rigidity + Hyperthermia + Autonomic instability + Myoclonus + Confusion + Delirium + Coma McPhee p 1089

Medical management of chronic pain

+ SNRIs (e.g. venlafaxine, milnacipran and duloxetine) and TCAs (e.g. nortriptyline) in doses up to those used in depression may be helpful, particularly in neuropathic pain syndromes. + Fibromyalgia -- Both duloxetine and milnacipram are approved for tx. + Duloxetine is approved in chronic pain conditions. + SNRIs are safer in overdose than TCAs. + Gabapentin and pregabalin anticonvulsants have been shown to be useful in somatic symptom disorders and fibromyalgia. McPhee p 1070

Pharmaceutical interventions for anxiety in pediatric patients

+ SSRIs and alpha agonists have shown some benefit, but are not FDA approved for < 8 years old + Benzos are not recommended for peds because the developing brain is at increased risk for dependency and iatrogenic substance abuse. Hay p 188

What is a primary cough HA?

+ Severe head pain produced by coughing, lasting for a few minutes or less + CT and MRI scans should be done in all cases to check for lesions or tumors, and should be repeated annually for several years. + Symptoms may clear after lumbar puncture McPhee p 989

Typical presentation of colic

+ Severe, paroxysmal crying that occurs mainly in late afternoon. + Knees are drawn up and fists clenched, flatus expelled, facies has pained appearance, soothing is difficult + Crying occurs for more than 3 hours a day, for more than 3 days per week, for more than 3 weeks ("rule of threes") + INFANT IS HEALTHY AND WELL FED Hay p 82

Medications that can cause anxiety in pediatric patients

+ Steroids (e.g. taken for asthma, allergies) + ACE inhibitors + Anticholinergics + Dopamine agonists + Beta-adrenergic agonists (e.g. asthma) + SSRIs (e.g.depression) + Thyroid medications + Procaine derivatives Hay p 187

Clinical findings in trigeminal neuralgia

+ Sudden lancinating facial pain + Commonly located near one side of mouth + Pain shoots toward ear, eye or nostril on same side McPhee p 990

Factitious disorders

+ Symptoms are produced CONSCIOUSLY + Self-induced or described symptoms or false physical or lab findings for purpose of deceiving clinicians or other health care personnel. Also known as "Munchausen's" -- Examples: Self-mutilation, fever, hemorrhage, hypoglycemia, seizures, etc. + Disorders can be imposed on another person (previously known as "Munchausen's by proxy") for perceived psychological benefit of the first person. + "Doctor shopping" is common in these pts McPhee p 1068

Glossopharyngeal neuralgia - Symptoms and tx

+ Symptoms: Trigeminal neuralgia-like pain occurs in throat, near tonsillar fossa and sometimes deep in ear and at back of tongue + Pain may be precipiated by yawning, swallowing, chewing, talking and is cometimes accompanied by syncope + No underlying structural issue, often. MS is sometimes responsible + Oxcarbasepine and carbamazepine are tx of choice McPHee p 991

Other causes of facial pain

+ TMJ dysfunction -- Tenderness of mastication muscles and pain begins with chewing + Giant cell arteritis -- pain develops progressively with mastication + Sinusitis and ear infections -- Pt has hx of respiratory infection, fever and sometimes nasal/aural discharge + Glacuoma - Pain in periorbital region + Cardiac issues - Jaw pain may be related to MI or angina pectoris, especially when precipitated by exertaion and when radiating. McPhee p 991

Dosage of triptans in tx of migraine

+ Take at onset of HA + Most can be repeated q2h for a total of 2 doses in 24 hours. BBB

ESSENTIALS OF DIAGNOSIS: Anxiety disorders

+ Three primary types: Generalized anxiety disorder, panic disorders, phobic disorders + Persistent excessive anxiety or chronic fear and associated behavioral disturbances + Somatic symptoms referable to the autonomic nervous system or to a specific organ system (e.g. dyspneal, palpitations, paresthesias) + Not limited to an adjustment disorder + Not a result of physical disorders, other psychiatric conditions (e.g. schizophrenia) or drug abuse + Anxiety disorders may be long standing and difficult to treat. McPhee p 1062

S/S of subarachnoid hemorrhage

+ Thunderclap headache of severity never before experienced + Followed by N/v and a loss or impairment of consciousness that can either be transient or progress toward coma and death + If consciousness is regained, pt is often confused and irritable and may show other signs of altered mental status. + Neuro exam reveals nuchal rigity and other signs of meningeal irritation McPhee p 1007-8

When to refer pt with sx of HA?

+ Thunderclap onset + Increasing HA unresponsive to simple measures + Hx of trauma, HTN, fever, visual changes + Presence of neuro signs or scalp tenderness McPhee p 990

Constipation

+ Two or more of the following events for 2 months: -- Fewer than 3 BMs/week -- More than one episode of encopresis/week -- Impaction of rectum with stool -- Stool so large that it obstructs toilet -- Retentive posturing and fecal withholding -- Pain with defecation Hay p 81

Signs of aneurysm prior to rupture

+ Usually asymptomatic unless they compress adjacent structures. + Some pts have headaches with nausea and neck stiffness a few hours or days before massive hemorrhage occurs. (r/t "warning leaks") McPhee p 1008

Symptoms of migrainous headaches

+ Usually lateral, can be generalized + Usually throbbing, can be dull + Can be associated with anorexia, n/v, photophobia, phonophobia, osmophobia, cognitive impairment, blurring of vision + Build up gradually and last ≥ 7 hours + Visual disturbances may precede or accompany HA + Triggered by emotional/physical stress, lack of/excess sleep, missed meals, specific foods, ETOH, bright lights, loud noise, menstruation, use of oral contraceptives McPhee 986-7

Common imaging results for pseudotumor cerebri?

+ Usually no evidence of a space-occupying lesion is seen + CT/MRI reveal normal or small ventricles + Sometimes stenosis of one or more of the venous sinuses will be observed McPhee p 1018

Causes of headache that require IMMEDIATE TREATMENT

+ Vascular events + Infections + Intracranial masses + Preeclampsia + Carbon monoxide poisioning McPhee p 39

Pt with HA and *ophthalmoplegia or visual field defects* suggests....

+ Venous sinus thrombosis + Tumor + Aneurysm McPhee p 40

Components of visual exam for pt presenting with HA?

+ Visual acuity (Snellen) + Ocular gaze (Motor test - 9 positions) + Visual fields (Cover test - central/periph vision) + Pupillary defects (Size, dilation) + Optic disks + Retinal vein pulsations McPhee p 40

Critical components of physical exam for complaint of HA?

+ Vital signs + Complete neuro exam + Vision testing (with funduscopic exam) McPhee p 40

When relief of symptoms is obtained, under what circumstances should the full dose of an antidepressant be continued indefinitely?

+ When pt has 1st episode before 20 or after 50 yrs + When pt is > 40 years with 2 episodes + When pt has ≥ 1 episode after 50 yrs + When pt has ≥ 3 episodes at any age. McPhee p 1092

When do night terrors typically occur?

+ Within 2 hours after falling asleep, during deepest stage of NREM sleep. + Often associated with sleepwalking Hay p 86

Types of pts most commonly affected by trigeminal neuralgia

+ Women more often than men + Middle/later life McPhee p 989

Uses of lithium

+ Works best in patients with Bipolar 1 disorder + Works bets in patients with low frequency of episodes. + Sometimes useful in prophylaxis of recurrent unipolar depressions. + Can be used alone long-term for dx of bipolar disease in MOST patients. McPhee p 1094

Chronic pain patients have a marked ____________ in pain threshhold.

+ decrease McPhee p 1069

Ottawa criteria for evaluation of pts presenting with acute non-traumatic headache for signs of subarachnoid hemorrhage

+ ≥ 40 years of age + Neck pain/stiffness + Witnessed loss of consciousness + Onset during exertion + Thunderclap headache + Limited neck flexion on examination McPhee p 41

Treatment for OCD in adults

+BEHAVIORAL/PSYCHOLOGICAL ++ Behavior modificatyion with systematic desensitization which involves gradually exposing patient to his fears to help manage anxiety. --- Do research to help educate patient and family and help with desensitization ++ "Thought-stopping" + PHARMACOLOGY ++SSRIs and TCAs are recommended, but may take up to 12 weeks to take effect. -- Clomipramine (TCA) - Primary med. Same dose as with depression. OR can be used as low dose adjunct to SSRI, but caution with seratonin syndrome. -- Fluoxetine (SSRI) - Primary med. higher dose than with depression ++ Antipsychotics and topiramate may be used as adjuncts to SSRIs in treatment-resistant cases. + OTHER ++ Work with employer to facilitate leave for recovery McPhee p 1066-7

Enuresis

+Repeated urination into the clothes during the day and bed at night by a child who is chornologically and developmentally > 5 years of age + Pattern must occr at least twice a week for 3 months. Hay p 79

Stages of NREM sleep

1 - Light sleep, reduced body movements, slow rolling of eyes 2 - Slowing of eye movements, respirations and heart rate and relaxation of muscles. **Most mature individuals spend most of their time in this stage.** 3 and 4 - Deepest NREM stages, during which breathing is slow and shallow and heart rate is slow. Also known as delta or slow-wave sleep. Hay p 85

Obsessions and compulsions of OCD consume more than _________ (time) per day

1 hour Hay p 195

Four groups of antidepressants

1) "Newer" antidepressants - SNRIs, SSRIs, buproprion, vilazodone, vortioxetine, and mirtazapine 2) TCAs and classically similar 3) MAOIs 4) Stimulants, ECT and repetitive transcranial magneyic stimulation. McPhee p 1086

Treatments for adjustment disorder

1) Behavioral (e.g stress reduction techniques to mitigate symptoms when recognized to keep them from blowing up, keeping log of stress precipitators, relaxation, mindfulness, exercise 2) *Social* (clarifying problem in the patient's psychosocial context to allow pt to view it in proper fram and facilitate decision making to mitigate stressor) 3) *Psychological* (Supportive psychotherapy -- usually not long term -- to help pt develop coping mechanisms. Cognitive/behavioral therapy has also shown useful.) 4) *Medical* (Sedatives for SHORT TIME to provide relief from acute anxiety sx. Also, short-term SSRIs targeting dysphoria and anxiety might be helpful.) McPhee p 1060

Treatment for panic attack in children

1) CBT which focuses on the cognitions r/t attack AND the physiologic distressing sx. 2) Pts who do not respond to tx alone may benefit from addition of an SSRI Hay p 192

In colic, the behavioral states of importance with respect to making behavior changes are....

1) Crying state 2) Transitional state Hay p 82

Components of the neurodevelopmental examination of pediatric patient

1) Defining child's level of developmental abilities in a variety of domains, including: -- language -- motor -- visual-spatial -- attention -- social abilities 2) Determine etiology of any developmental delays 3) Planning a treatment program Hay p 90

What are some predictors of persistent social anxiety disorder over time?

1) Early age of onset 2) More severe avoidance 3) Presence of panic symptoms Hay p 194

Recommendations to parents for management of colic

1) Educate them on normal crying patterns for age, and that crying will increase in month 2 and decrease some by month 3/4. 2) Reassure parents that child is not sick. Explain conditions that have been ruled out. The condition is usually self-limited. Keep diary of patterns. Ease anxiety. 3) Teach to understand infant's cues. Help to devise interventions to calm parent and infant. Quiet environment without excessive handling. -- If onset of crying can be anticipated, swinging/rocking, drives in car or walks in stroller can be helpful. -- If gastric distention appears to be contributing to problem, change feeding habits to not rush infant, allow ample opportunity to burp, feed more frequently. 4) Do not use meds with risk of adverse reactions and overdose. If GERD is making child uncomfortable, a trial of ranitidine or another PPI can be tried. 5) For colic refractory to behavioral changes, try eliminating cow's milk from infant's or mother's diet. Maybe whey formulas. (Conflicting evidence regarding usefulness of probiotics) 6) No conclusive evidence for complementary and alternative interventions for tx of colic. Hay p 83

Main classes of prescription medications used for migraine therapy

1) Ergotamines 2) Triptans McPhee p 987

Depression may be the final expression of 3 things:

1) Genetic factors (e.g. neurotransmitter dysfunction 2) Developmental problems (personality problems, childhood events) 3) Psychosocial stresses (divorce, unemployment) McPhee p 1083

Early developmental stages and associated feeding behavior

1) Homeostasis (0 - 2 months) Parent allows infant to determine timing, amount, pacing and preference of food intake 2) Attachment (2 - 6 months) Allow infant to control feeding so that parent can engage infant in a positive manner 3) Individuation (6 months - 3 years) Conflict may arise if parent seeks to dominate child by intrusive and controlling feeding behavior at the same time the child is striving to achieve autonomy. Hay p 84

Education of adolescent patient and family on a dx of depression

1) It's an illness, not a weakness. Very common. Genetic + environment 2) Functional impairment in various domains can be manifestations of illness 3) Can be recurrent. Recovery may take awhile 4) Stay with tx plan long term is KEY 5) Parent/child stress may be part of problem 6) Ask adolescent about future goals (if none, be wary of suicidal ideation) ACPM

Prevention of medication overuse headaches

1) Limit simple analgesics to ≤ 15 days per month 2) Limit combination analgesics to ≤ 10 days per month McPhee p 987

3 types of childhood depressions

1) Major depressive disorder --Sad or depressed mood ≥ 2 weeks. Described as "irritability" and may have somatic manifestations in younger kids. Adolescents engage in risky behavior and may become withdrawn or aggressive. 2) Dysthymia or dysthymic disorder -- Chronic depression that does not meet full MDD criteria and is present on MOST days for ≥ 1 year. Sx are less life-threatening but do interfere with function 3) Bipolar affective disorder -- Sx of MDD but have manic episodes that alternate with depression. NOTE: Sx are sometimes mistaken for ADHD and medical tx for that disorder can intensify mania! "Mgmt of childhood depression" article

Suggestions for parents to manage tantrums

1) Minimize need to say "no" by childproofing environment 2) Use distraction when furstration ↑; direct child to other activities and reward response 3) Present options to allow child to achieve mastery and autonomy 4) Fight only the battles that need to be won 5) Do not abandon child when tantrum occurs. Stay nearby without intruding. Threats serve no purpose 6) Do not use negative terms when tantrum is occurring. Point out that child is out of control and give praise when control is regained 7) Never let child hurt himself 8) Do not hold a grudge afterwards, but do not grant demands that led to tantrum 9) Maintain environment that provides positive reinforcement for desire behavior 10) Some tantrums are so severe that referral might be needed. Can reflect poor parenting, problems with parent/child interaction, or overpermissiveness. Hay p 88

Subcategories of "major depressive disorder"

1) Psychotic major depression 2) Major depression with atypical features 3) Melancholic major depression 4) Major depression with seasonal onset (SAD) 5) Major depression with peripartum onset McPhee p 1084

Symptomatic therapy for migraines

1) Rest in darkened room + analgesic (aspirin, acetaminophen, ibuprofen, naproxen) taken right away 2) Prescription therapy

Causes of pseudotumor cerebri

1) Thrombosis of transverse venous sinus as a complication of otitis media or chronic mastoiditis 2) Sagittal sinus thrombosis 3) Chronic pulmonary disease 4) Lupus 5) Uremia 6) Endocrine disturbances such as hypoparathyroidism, hypthyroidism or Addison disease 7) Vitamin A toxicity 8) Use of tetracycline or oral contraceptives 9) Occasionally withdrawal of long term corticosteroids McPhee p 1018

Males have an earlier age of onset of OCD, usually occuring before ____ years of age

10 (TEN) Hay p 195

School aged children typically sleep _________ hours per night without a nap

10 - 11 hours Hay p 85

Fetal alcohol syndrome includes one or more of the following developmental defects in the offspring of alcoholic women: 1) normal birth weight 2) low birth weight 3) mental retardation with an average IQ in the 60s 4) esophageal varices 5) a variety of birth defects with a large percentage of facial and cardiac abnormalities

2, 3, 5 FB

Early antimicrobial treatment in the __________________ time frame may decrease the risk for renal damage from a UTI

24- to 48-hour UTI Medscape article

In patients < ______________ years, there is an association between antidepressant use and increased suicidality.

25 (TWENTY FIVE)

Most children stop napping between ___ and ___ years of age.

3 and 5 Hay p 85

Highest prevalence of encopresis is between __________ and ________ years of age

5 and 6 Hay p 81

Most infants beyond __________ (age) can go through the night without being fed.

6 months Hay p 86

Age by which daytime continence is achieved

70% by 3 years of age 90% by 6 years of age Hay p 81

Ages of developmental screenings

9, 18 and 24 or 30 months. Hay p 89

More than _____________% of cases of encopresis result from constipation

90%

Scalp and temporal artery tenderness should be performed on pts with HA who are > ______________ years.

> 60 McPhee p 40

A first-line prophylactic treatment option for the prevention of tension-type headache is: A. nortriptyline. B. verapamil. C. carbamazepine. D. valproate.

A NPCE

The mechanism of action of triptans is as a(n): A. selective serotonin receptor agonist. B. dopamine antagonist. C. vasoconstrictor. D. inhibitor of leukotriene synthesis.

A NPCE

Which of the following statements about ergotamines is false? A. are effective for tension-type headaches B. act as 5-HT1A and 5-HT1D receptor agonists C. have potential vasoconstrictor effect D. should be avoided in the presence of coronary artery disease

A NPCE

Prophylactic treatment for migraine headaches includes the use of: A. amitriptyline. B. ergot derivative. C. naproxen sodium. D. clonidine.

A NPCE book

Cornerstone to a unified approach to chronic pain syndromes is __________________________________.

A comprehensive behavioral program. McPhee p 1069

What are the Kleinmann questions?

A set of questions used to elicit the patient's thoughts about the cause of their depression: 1) What do you think caused your problem? 2) Why do you think it started when it did? 3) What do you think your sickness does to you? 4) How severe is illness? Short or long course? 5) What kind of tx should you receive? 6) What are the most important results for you? 7) What are the chief problems your illness has caused in YOU? 8) What do you fear most about your sickness? Medscape article

Diagnosis of UTI is made upon the basis of these three factors (choose 3): a) presence of pyuria b) b/l flank pain c) frank hematuria d) 50,000 colonies per mL or more of a single uropathogenic organism e) urine specimen must be appropriately collected

A, D, E Medscape UTI article

What is the most common neurodevelopmental disorder in children?

ADHD Hay p 89

What types of headaches may respond well to high-flow O2 therapy?

ALL types McPhee p 41

Tx of acute pyelonephritis in peds?

Acute Pyelonephritis is treated for 10 days with a cephalosporin BBB

Common age of onset of migraines?

Adolescence or early adult life McPhee p 986

Panic disorder is more likely to present WHEN?

After the onset of PUBERTY Hay p 192

Evidence of "joint attention" should be present by what age, and if it is not, may be a sign of an ASD if other, earlier sx are present?

Age 16 - 18 months + "Joint attention" occurs when two people attend to the same thing at the same time. Child should be able to point to object by this age Hay p 94

Age during which breath-holding spells commonly occur

Age 6 months to 6 years Hay p 88

USPSTF recommends screening for adolescents WHEN?

Ages 12-18 AND when adequate systems are in place to ensure accurate dx, psychotherapy and follow up! ACPM article

When does Bright Futures (AAP) suggest beginning screening for depression?

At the 11 year old visit ACPM

A 48-year-old woman presents with a monthly 4-day premenstrual migraine headache, poorly responsive to triptans and analgesics, and accompanied by vasomotor symptoms (hot flashes). The clinician considers prescribing all of the following except: A. continuous monophasic oral contraceptive. B. phasic combined oral contraceptive with a 7-day-per-month withdrawal period. C. low-dose estrogen patch use during the premenstrual week. D. triptan prophylaxis.

B NPCE

The use of neuroleptics such as prochlorperazine (Compazine) and promethazine (Phenergan) in migraine therapy should be limited to less than three times per week because of their: A. addictive potential. B. extrapyramidal movement risk. C. ability to cause rebound headache. D. sedative effect.

B NPCE

Which of the following oral agents has the most rapid analgesic onset? A. naproxen (Naprosyn) B. liquid ibuprofen (Motrin, Advil) C. diclofenac (Voltaren) D. enteric-coated naproxen (Naproxen EC)

B NPCE

Wernicke encephalopathy consists of a triad of sx including which 3 of the following: a) akinesia b) ataxia c) confusion d) confabulation e) retrograde amnesia f) ophthalmoplegia (6th nerve palsy)

B, C, F FB

Colic is a _________________ that involves interaction between infant and caregiver.

BEHAVIORAL PHENOMENON. + Inconsiderate caregiver response to crying infant (i.e. infant is "spoiled", or caregiver is hurried) can result in infant being unable to organize or self-soothe. + Caregivers who understand temperament of colicky infant and work to decipher the rhythm cues, can anticipate crying and intervene before the behavior becomes "organized" in crying state and is more difficult to extinguish. Hay p 83

Screening tools for childhood depression

Beck Depression Inventory + Adolescents < 10 minutes Childhood Depression Inventory + 7 - 18 years < 20 minutes Children's Depression Rating Scale + 6 - 12 years + 45-70 minutes Hopelessness Scale for Children + Children/adolescents + < 15 minutes Center for Epidemiological Studies Depression Scale for Children + Children/adolescents + < 10 minutes "Mgmt of childhood depression" article

Relationship of creativity and mood disorders

Best work is done BETWEEN episodes of mania and depression. McPhee p 1084

Ages in childhood during which sleep-disordered breathing peaks?

Between ages 2 - 6 Hay p 87

During what ages are temper tantrums common in children?

Between ages of 12 months and 4 years, occurring about once a week in 50 - 80% of children in this age group. Hay p 88

Distinction between cluster headaches and other trigeminal autonomic cephalgias?

Both have UNILATERAL periorbial pain associated with ipsilateral autonomic symptoms. Cluster headaches have DIFFERENT attack duration, frequency and HIGH responsiveness to indomethacin McPhee p 989

A 47-year-old woman experiences occasional migraine with aura and reports partial relief with zolmitriptan. You decide to add which of the following to augment the pain control by the triptan? A. lamotrigine B. gabapentin C. naproxen sodium D. magnesium

C NPCE

You are examining a 65-year-old man who has a history of acute coronary syndrome and migraine. Which of the following agents represents the best choice of acute headache (abortive) therapy for this patient? A. verapamil B. ergotamine C. timolol D. sumatriptan

C NPCE book

Mainstay of treatment for specific phobia

CBT aimed at reducing anxiety or fear of the phobic stimulus Hay p 191

First line treatment for GAD

CBT with possible addition of SSRI if response is insufficient Hay p 194

Tool for assessing ETOH withdrawal symptom severity?

CIWA-Ar: Max score = 67 points + Minimal withdrawal sx -- < 8 pts -- PO benzo with taper over 3 days -- Assess sedation and sx q 6 hours + Mild withdrawal sx -- 8 to 15 pts -- PO/IV benzo hourly for 2 hours, then q 4 hours -- Assess sedation and sx q 4 hours + Moderate withdrawal sx -- 16 to 20 pts -- PO/IV benzo hourly for 2 hours, then q 2 hours -- Assess sedation and sx 30 minutes after each PO dose and 15 minutes after each IV dose. + Severe withdrawal sx -- 21 pts McPHee p 1106

Cyclothymic disorders

Chronic mood distrubances with episodes of subsyndromal depression and hypomania. Symptoms must have at least a *2 year* duration and are milder than those that occur in depressive or manic episodes. + If symptoms escalate into a full blown manic or depressive episode, reclassification as bipolar 1 or 2 would be warranted McPhee p 1085

Primary treatment for anxiety disorder in children

Cognitive behavioral therapy (CBT) Hay p 188

Primary treatment for separation anxiety disorder

Cognitive behavioral therapy (CBT) tailored to child's developmental level. Hay p 189

What do younger children with GAD usually worry about?

Competence or performance Hay p 193

What is selective mutism disorder

Consistent failure to speak in social settings (such as school) where this is expected, despite speaking on other settings. Usually present in younger children, < 5 years.

Most common early characteristics of an ASD in a pediatric patient, recognizable in the first 12-18 months of life.

Consistent failure to: + orient to one's name + regard people directly + use gestures + develop speech Hay p 94

Evidence supports the use of all of the following vitamins and supplements for migraine prevention except: A. butterbur. B. riboflavin. C. feverfew. D. ginkgo biloba.

D NPCE book

With migraine, which of the following statements is true? A. Migraine with aura is the most common form. B. Most migraineurs are in ongoing healthcare for the condition. C. The condition is equally common in men and women. D. The pain is typically described as pulsating.

D NPCE book

Nocturnal enuresis (NE)

Diagnosis requires that a child must never have been dry atnight for over 6 months with no daytime accidents. Hay p 80

Symptoms of withdrawal from antidepressants

Diziness, paresthesias, dysphoric mood, agitation and a flu-like state have been reported for the SSRIs and SNRIs, but may also occur with TCAs and MAOIs. Discontinue over a period of WEEKS or MONTHS to reduce risk of withdrawal phenomena McPhee p 1090

Deepest NREM sleep occurs when?

During the first 1-3 hours after going to sleep Hay p 85

Major depression with seasonal onset

Dysfunction of circadian rhythms that occur ore commonly in the fall and winer months and is believed to be due to ↓ exposure to full-specturm lights. + Common symptoms include carbohydrate craving, lethargy, hyperphagia and hypersomnia. TREATMENT/MEDICATION + Buproprion or an SSRI + MAOIs may be more effective than TCAs, and an MAOI can be used if more benign antidepressant strategies prove unsuccessful McPhee p 1084, 1089

Which triptan is good for pts with prolonged attacks or attacks provoked by menstrual periods?

Eletriptan + *Contraindications* --AVOID in pregnancy, pts with hemiplegic or basilar migraine, pts with risk factors for stroke (e.g. uncontrolled HTN, prior stroke or TIA, DM, hypercholesterrolemia, obesity) -- CAUTION in pts with controlled HTN -- CONTRAINDICATED in pts with coronary or peripheral vascular disease + *Common side effects* -- Nausea and vomiting + *Dosage* -- PO, 20-40 mg at onset, may repeat ONCE after 2 hours (MAXIMUM DOSE = 80 mg/24 hours) McPhee p 987

Episodic migraine vs. chronic migraine

Episodic is < 15 days/month Chronic is > 15 days/month BBB

Bipolar disorder

Episodic mood shifts into mania, major depression, hypomania, and mixed mood states.

Notes on SSRIs

Examples: Fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), citalopram (Celexa) and escitalopram (Lexapro) ADVANTAGES: + Generally well tolerated + Starting dose is often therapeutic + Lower lethality in overdose DOSING + Most given in AM to not interfere with sleep --- EXCEPTION: Paroxetine and fluvoxamine have sedation and are given at bedtime. + Given ONCE daily + Usually some delay in response -- EXCEPTION: Fluoxetine requires 2-6 weeks for depression 4 - 8 weeks for panic disorder, 6 - 12 weeks for OCD. + Most have short half-life and lesser effect on hepatic enzymes, and less effect on metabolism of other meds, and more rapid clearing if side effects occur. INDICATIONS + Depression, panic disorder, bulimia, GAD, OCD and PTSD SIDE/ADVERSE EFFECTS + HA, nervousness, tinnitus, nausea, insomnia + Akathisia is common + Abnormal bleeding can occur r/t affected platelet seratonin levels -- NOTE: Sertraline and escitalopram are safest to use with warfarin. + Sexual side effects very common + High doses or combinations with MAOIs can cause *seratonin syndrome* + Safer to use than TXAs in patients with cardiac disease. Sertraline is ok for pts with AMI or unstable angina. McPhee p 1089

True/False: Migraine pain is commonly unilateral in children?

FALSE

True/false: Depression is a normal response to loss

FALSE. Sadness and grief are normal, but depression is not. Grief is usually accompanied by intact self-esteem, whereas depression is marked by a sense of guilt and worthlessness. McPhee p 1083

Clinical Findings and treatment: Generalized Anxiety Disorder

FINDINGS + Anxiety symptoms of apprehension, worry, irritability, difficulty in concentrating, insomnia or somatic complaines are present *more days than not for at least 6 months* + Focus of anxiety can be a number of everyday activities TREATMENT + Antidepressants (includings SSRI, SNRI) are 1st line medications, but may take awhile to start working. --Venlafaxine and duloxetine (SNRIs) are approved for tx of GAD. Start low and titrate upward -- Escitalopram and paroxetine (SSRIs) are also approved for GAD. -- TCAs and MAOIs are 2nd or 3rd line tx. + Benzodiazepines can provide immediate symptom relief but can lead to dependence. --Diazepam and clorazepate are most rapidly absorbed PO. --Lorazepam is better for use in elderly and pts with liver dysfunction. -- Avoid long acting benzos (e.g. flurazepam and diazepam) in older adults r/t long half-lives. OTHER TREATMENT + Cognitive behavioral tx appears to work. McPhee p 1063-4

Clinical Findings and treatment: Phobic Disorder

FINDINGS: + Fear of a specific object or situation + Rule out all underlying medication disorders TREATMENT: + SSRIs (e.g. paroxetine, sertraline and fluoxamine) are used. + Certain phobias may respond to moderate doses of beta blockers. + Behavioral therapies such as systematic desensitaivation have been successful. McPhee p 1063-4

Clinical Findings and treatment: Panic Disorder

FINDINGS: + Recurrent, unpredicable episodes of intense surges of anxiety accompanie by marked physiologic manifestations. + Key to diagnosis is psychic pain individual expresses. + Onset usually < 25 years, female to male ratio is 2:1 + Consider MI, phyochromocytoma, hyperthyroid and drug reactions in differential dx TREATMENT - MEDICATION + Antidepressants are 1st line treatment --- Fluoxetine, paroxetine and sertraline (SSRIs) are approved for panic disorder --- Venlafaxine (SNRI) is approved for panic disorder + Benzos are best used early in tx, because dependence is possible. --- Taper meds like clonazepam and alprazolam after antidepressant starts working. --- Paradoxical reactions to short-acting benzos have been reported. --- Reversal agent is flumazenil. OTHER TREATMENT + Cognitive behavioral tx appears to work. + Peer support groups. NOTE: In acute panic attacks, SSRIs are initial medication of choice. Benzos can manage symptoms as antidepressant is titrated upward. Beta blockers have also been successful in resistant cases. McPhee p 1063-4

Common denominator in feeding disorders?

FOOD REFUSAL Hay p 83

Depression medication -- If no background information is available, what two medications are good STARTING places?

FULL TRIALS can be started with either: + Sertraline (Zoloft) - 25 mg PO, increase gradually to 200 mg + Venlafaxine (Effexor) - 37.5 mg/day PO and titrated graually to maximum dose of 225 mg/day. +++Monitor for worsening mood or suicidal ideatio ecry 1-2 weeks until week 6. McPhee p 1086

What do older youth with GAD usually worry about?

Family finances or being on time Hay p 193

Medication approved for treatment of depression in children and adolescents?

Fluoxetine (Prozac) FDA

Sudden onset of OCD should alert pediatricians to what?

Group A strep infections, as pediatric autoimmune disorders associated with these infections have been implicated in development of OCD in some children Hay p 195

Attitude of clinician to patient with chronic pain

Honesty, interest and hopefulness -- not for a cure but for control of pain and improved function. McPhee p 1070

Pt with HA and *ipsilateral ptosis and miosis* suggests....

Horner syndrome AND/OR carotid artery dissection McPhee p 40

Depression can be secondary to what illnesses and medications?

ILLNESSES + Chronic illnesses like RA, MS, stroke and chronic heart disease + Common in cancer, and especially high in pancreatic cancer. + ETOH dependency frequently coiexists with serious depression. MEDICATIONS + Reserpine + Corticosteroids and oral contraceptives are associated with depression and hypomania + Anti-HTN meds likemthyldopa, guanethidine and clonidine have been associated with development of depressive episodes, as have dititalis and antiparkinsonism medications. + Interferon is strongly associatd with depressed mood and fatigue as a side effect McPhee p 1085

Confirming dx of PTSD lies in the ability to do WHAT?

Identify the hx of exposure to actual or perceived life-threatening event, serious injury or sexual violence McPhee p 1060

What is the STAR*D trial and what does it suggest with regard to medication for depression?

If response to 1st medication is inadequate, best alternatives are: 1) Switch to a second agent from the same or different class of antidepressant 2) Try augmenting the 1st agent with buproprion (150-450 mg/day), lithium (300-900 mg/day PO), thyroid medication (liothyronine 25-50 mcg/day PO) or a 2nd generation antipsychotic (aripiprazole 5-15 mg/day or olanzapine 5 - 15 mg/day). <---- This approach is often taken when there has been at least a PARTIAL response to the initial drug. McPhee p 1088

When is agoraphobia most likely to occur in children?

In later adolescence Hay p 193

Melacholic major depression

Lack of mood reactivity seen in atypical depression, presence of a prominent anhedonia and more severe vegetative symptoms (e.g. insomnia, anorexia with weight loss and constipation). TREATMENT/MEDICATION + May respond to ECT, TCAs and SNRIs, *which are prefereable to SSRIs* (although SSRIs can be effective in many cases of melancholic depression) McPhee p 1084, 1089

Autism severity score per DSM-5

Level I - Requiring support Level II - Requiring substantial support Level III - Requiring very substantial support Hay p 94

Acute manic or hypomanic symptoms will respond to ____________ after several days of treatment, but it is increasingly common to use ___________ as 1st line agents because they do not require serum monitoring!

Lithiuim or valproic acid, 2nd generation antipsychotics NOTE: 2nd gen antipsychotics (eg. risperadone, olanzapine, aripiprazole) seem to be more rapidly effective. Gradually reduce dosage when lithium or valproic acid is started. McPHee p 1093

Lab findings in pseudotumor cerebri

Lumbar puncture can confirm presence of intracranial HTN but CSF is normal McPhee p 1018

Screening tool for pediatric patients and their parents

M-CHAT Hay p 95

Treatment of somatic symptom disorders

MEDICAL + Pt's distress is REAL + Just because no organic basis can be found, does not mean that it is necessarily a mental disease. -- Find connection with events in a patient's life. Ask them to keep a diary. --Regular, frequent, short appts. -- ONE CLINICIAN should be primary. PSYCHOLOGICAL + Pragmatic current changes, rather than exploration of earlier events which patient may not relate to current distress. + Group therapy sometimes helpful + Hypnosis used early can help + Early psych consultation for factitious disorders is indicated. -- Joint consult with primary clinician and psychiatrics -- Double bind ("either its something i can fix with this tx, or it's a factitious disorder for which you will need psych treatment") BEHAVIORAL + Biofeedback -- e.g. using electronic stethoscopie to amplify ↑ peristalsis so pt can recognize and learn to identify and change sounds. SOCIAL + Family members should come for appts with pt. + Ongoing communication with employer may be important. NOTE: Prognosis better if primary clinician can intervene early before situation deteriorates. McPhee p 1068-9

Minimum recommended trial period for initial medication treatment

MINIMUM of 6 - 12 weeks. Johns Hopkins PPT

Headache patients with hx of hypertension (esp uncontrolled htn) should be examined for other features of WHAT?

Malignant hypertension McPhee p 39

SUICIDE: Differences between men and women

Men > 50 years old are more likely to COMPLETE a suicide, bc of tendency to use violent means Women make MORE ATTEMPTS but are less likely to complete. McPhee p 1085

Kernig and Brudzinski signs are indicative of what?

Meningeal irritation McPhee p 40

Adolescents need _______ hours per night but often only get ____.

NEED 9 - 9.5 hours GET 7 - 7.25 hours + This is complicated by the 1 - 3 hours sleep phase delay due to physiologic changes in hormonal regulation of adolescent circadian rhythms. Hay p 85

What medications are recommended for management of sleep disorders in children?

NONE Hay p 88

Cause of spontaneous subarachnoid hemorrhage

Non-traumatic, frequently results from rupture of arterial sacular ("berry") aneurysm, or from an AVM. McPhee p 1007

A patient is at HIGH RISK if he thinks about suicide > _____________ hours per day

ONE McPhee 1086

What medications are approved for maintenance of bipolar disorder, to prevent subsequent cycles of mania and depression?

Olanzapine quetiapine ziprasidone aripiprazole long acting injectable risperidone McPHee p 1094

Duration and withdrawal of prophylactic migraine medications

Once a drug is found to help, it should be continued for several months. If patient remains headache-free, the dose should be TAPERED AND EVENTUALLY WITHDRAWN. McPhee p 988

In the case of chronic pain, the clinician must shift from the idea of biomedical care to ________________________.

Ongoing care of the patient. McPhee p 1069

Horner Syndrome mnemonic

P - Ptosis A - Anhydrosis M - Miosis

PTSD is more common when associated with WHAT TYPE of injury?

PHYSICAL, rather than psychological. McPhee p 1060

Episodic headache associated with triad of hypertension, heart palpitations and sweats is suggestive of __________________.

Pheochromocytoma McPhee p 39

Headache associated with pregnancy?

Preeclampsia McPhee p 39

To meet criteria for a panic attack, what must occur

Pt must experience fear or or related to future attacks that leads to maladaptive behavior Must ≥ 4 (FOUR) of the following symptoms + Palpitatations + Sweating + Shortness of breath + Choking + Chest pain or tightness + GI distress + Dizziness or associated feelings + Chills or heat + Numbness or tingling Hay p 192

Definition of "rapid cycling" bipolar disorder

Pts with four or more discrete episodes of a moood disturbance in 1 year.

When does GAD usually present?

RARELY does it present before adolescence Hay p 193

What drugs are 1st line tx for depression in children and adolescents?

SSRIs + Fluoxetine (START @ 10 mg/day, MAX 60 mg/day) + Fluvoxamine (START @ 25 mg/day, MAX 200 mg/day) + Sertraline (START @ 25 mg/day, MAX 200 mg/day) + Escitalopram (START @ 5 mg/day, MAX 20 mg/day) + Citalopram (START @ 5 mg/day, MAX 60 mg/day) --- All may cause nausea, diarrhea and sleep disturbances. "Mgmt of childhood depression" article

What kind of medications are useful in ameliorating depresssion, panic attacks, sleep disruption and startle responses in PTSD pts?

SSRIs + They are the only class of meds approved for tx of PTSD + Examples: Sertraline (Zoloft), paroxetine (Paxil) McPhee p 1061

How is agoraphobia in children most likely to present?

School refusal Hay p 192

UTI in sexually mature adolescents can be treated with?

Sexual mature adolescents can be treated with a fluoroquinolone for 3 days BBB

Secondary causes of headache?

Some examples: + Intracranial lesions + Head injury + Cervical spondylosis + Dental/ocular disease + TMJ dysfunction + Sinusitis + Hypertension + Depression McPhee p 986

Diminution of headache in response to typical migraine therapies (e.g. seratonin receptor antagonists or ketorolac) does not rule out _________________ as underlying cause?

Subarachnoid hemorrhage or meningitis Mcphee p 39

"Thunderclap headache" is the classic presentation of what condition?

Subarachnoid hemorrhage! Should precipitate IMMEDIATE workup! McPhee p 39

What should be considered in adolescents who experience a sudden onset of anxiety?

Substance-induced anxiety Hay p 194

Best prognostic indicator for children exposed to trauma?

Supportive relationship with a caregiving adult Hay p 196

Diagnostic criteria for selective mutism disorder

Symptoms must: + Interfere with function at school, work or social communication + Must last longer than 1 month, not including 1st month of school + Cannot be due to autism, a communication disorder or psychotic disorders Hay p 189

Symptoms for diagnosis or ruling out migraine in the absence of "classic" presentation (e.g. scintillating scotomoa, unilateral ha, photophobia and n/v)?

Symtoms: Nausea, photophobia, phonophobia and exacerbation with physical activtiy THREE OR MORE = MIGRAINE < THREE = r/o MIGRAINE McPhee p 39

Which two classes of antidepressants should NEVER be prescribed to children in primary care?

TCAs and MAOIs "Mgmt of childhood depression" article

True/False: Children with anxiety disorders often have other psychiatric disorder as well

TRUE + Important to carefully screen children with anxiety disorder to ensure that another disorder isnot missed. Hay p 187

ESSENTIALS OF DX + TYPICAL FEATURES: Autism spectrum disorders

TWO core deficits + Persistent deficits in social communication and social interation across multiple contexts + Restricted, repetitive patterns of behavior, interests or activities Hay p 93

______________________________ is the style with which a child interacts with his environment.

Temperment + NOTE: Clinicians have an opportunity talk with parents about the difference between a child's temperament being simply a *developmental variation" versus being "bad" or having a "behavior disorder". Hay p 79

Most common type of primary headache disorder?

Tension-type headache McPhee p 988

Primary cause of Wernicke-Korsakoff syndrome is?

Thiamine deficiency. Most common in pts with alcoholism McPhee p 1035

What is a "washout time"?

Time between switching from one group of antidepressants to another durig which the previous med clears the system. ++ 2-3 weeks between stopping MAOI and starting TCA ++ at LEAST 2 weeks between stopping SSRI and starting MAOI (**ALLOW 4-5 weeks for fluoxetine!**) No washout time is needed for switching WITHIN groups. McPHee p 1091

Most common cause of subarachnoid hemorrage

Trauma. Prognosis depends on severity of head injury McPhee p 1007

Tx for uncomplicated cystitis in children?

Uncomplicated cystitis can be treated with amoxicillin or Bactrim for 7-10 days BBB

________________ is a 1st line tx for mania because it has a broader safety index than lithium.

Valproic acid INTERACTIONS: McPHee p 1094

What is a sleep onset association disorder?

When a child wakes during the night, he will require the same interventions (parental, routine, etc.) needed to get to sleep initially. Hay p 86

What is "emergence" with regard to childhood depression?

When a pt makes a suicide plan prior to starting on medication but does not have the energy to carry it out until AFTER the medication regimen starts. "Mgmt of childhood depression" article

How are youth with panic disorder most likely to present to pediatrician?

With physical symptoms, such as a fear that there's something wrong with their heart. Hay p 192

At what age does night waking often start?

at 9 months, as separation anxiety is beginning + At this time, parents should receive guidance to know to reassure theri child without making the interaction prolonged or pleasurable. Hay p 86

Headaches that worsen with standing and improve with lying down are suggestive of _________ caused by ________. a. increased intracranial hypertension, hydrocephalus b. low pressure headaches, tear in dura from an LP, trauma, or surgery c. CNS infection, bacterial infection.

b FB

Pt with HA and *papilledema or absent retinal venous pulsations* suggests....

↑ ICP + Follow with neuroimaging prior to performing lumbar puncture McPhee p 40

Why should opioids be avoided in tx of migraines

↑ rates of rebound HA and tendency to develop medication overuse HA McPhee p 987

Criteria for adult-diagnosed ADHD

≥ 5 inattention symptoms or ≥ 5 hyperactivity/impulsivity symptoms are required McPhee p 1097