PSYCH
Cluster A Personality Disorders
"WEIRD" Paranoid Schizoid Schizotypical
Cluster B Personality Disorders
"WILD" Borderline Histrionic Narcissistic Antisocial
3 out of 4: 1. Aggression Toward Others. 2. Destruction of Property. 3. Rule-Breaking. 4. Deceitfulness or Theft.
Conduct vs. Antisocial Personality
Inhibit reuptake of NE and Serotonin, approved for depression and neuropathic pain
Duloxetine
EEG often shows generalized slowing of activity, fast-wave activity, or focal abnormalities. Correction of physiologic problems is essential
Dx and Tx of Delerium
WHICH ANTIPSYCH DRUG CAN CAUSE S.E. = ORTHOSTATIC HYPOTENSION
RISPERIDONE = OTHER THAN BLOCKING D2 ALSO BLOCK ALPHA 1 RECEPTOR Because of the alpha1- blocking activity, it may cause orthostatic hypotension
MOST COMMON METHOD USED BY KIDS TO COMIT SUCIDE ======== KID=ENURESIS= PEEING AT NIGHT GIVEN DDAVP= DESMOPRESSIN S.E. OF DDAVP??
SUSBTANCE INGESTION =========== DDAVP ==AKA===ADH S.E. = HEADACHE + NAUSEA
1 DAY AFTER HIS SURGERY PT STARTS GETTING = SEIZURES VITAL = FEVER HTN HIGH HR SWEATING
SUSPECT SEIZURE DUE TO ALCOHOL WITHDRAWL = REM- CAN OCCUR UPTO 2 DAYS POST LAST DRINK ((VS DTs= CAN OCCUR UPTO 4 DAYS POST LAST DRINK) ============ TX OF ALCOHOL WITHDRAWL = BZs = LORAZEPAM CHLORDIAZEPOXIDE
diagnose?? tx?? PT SAYS SX A = HER BOSS IS HAVING HER FOLLOWED WORRIED HER FOOD IS BEING POISONED SHE ALSO SX B= ADMITS TO SUCIDAL THOUGHTS LOST WEIGHT CANT SLEEP LOSS CONCENTRATION
SX A=== PSYCHOTIC SX (((not just delusional--do these count as psychosis??) sx B=== MDD HER DIAGNOSIS = MDD WITH PSYCHOTIC FEATURES = TX - SSRI + ANTIPSYCHOTIC= 2ND GEN= ATYPICAL = (B) fluoxetine and risperidone ============== REM= CLOZAPINE= 2ND GEN ANTI PSYCH DRUG = ONLY GIVEN TO SCHIZOPHRENIC PTS WHO HAVE ALREADY FAILE DON 2 OTHER ANTIPSYCH DRUGS
AFTER BEING GIVEN A DRUG PT HAS FOLL SX = FEVER DIAPHORETIC HIGH BP HIGH HR -- UNIQUE = ARMS FEEL STIFF/ DIFF. TO BEND WHAT DRUG IS THIS?
SX OF NMS = LOOK FOR FEVER WITH MUSCLE RIGIDITY DRUG CAN CAUSE NMS= = TYPICAL PSYCHOTIC == HALOPERIDOL TX= DANTROLENE =
PT IN PSYCH WARD NURSE FIND HIM LAYING IN BED===STIFF CONFUSED/SWEATING TEMP=103 BP= 164/98 HR= 122/MIN``
SX OF NMS = SE OF ANTIPSYCH DRUGS TX= DANTROLONE NMS HALLMARK = FEVER WITH AUTONOMIC INSTABILITY + MUSCLE RIGIDITY!!!!!!!!!
Mood stabilizers such as Lithium, Carbamazepine, and Valproic Acid
Treatment of Cyclothymic Disorder
1. Jealous. 2. Persecutory. 3. Erotomanic. 4. Grandiose. 5. Somatic.
Types of Delusional Disorder
Mania Includes Elevated or Irritable Mood with 3 of the Following:
1. Distractibility. 2. Irresponsible or Impulsive Behavior. 3. Grandiosity. 4. Flight of Ideas or Racing Thoughts. 5. Activity. 6. Sleep Disturbance. 7. Talkativeness.
illness anxiety disorder
excessive health anxiety without somatic symps
social anxiety disorder
fear of scrutiny/ embarassment
Metabolic acidosis
Laxative abuse
Acute Phase of Treatment: Remission vs. Response
Baseline vs. Better Than Baseline
Headache, palpitations, hallucinations, paranoia, violence, increased heart rate and blood pressure
Bath salts
Lurasidone (Latuda) Use
Depressive Episode of Bipolar Disorder (Alone or With Lithium or Valproate)
PCP features
- aggression, agitation - impulsion - acute [sychotic (paranoid, hallucinations) - nystagmus
Features of the external world are taken and made part of the self "the resident dresses like the physician whom he admires"
Introjection
WHAT IS TX OF HTN CRISIS FROM MAOI DRUGS
PHENTOLAMINE = BLOCK A1 RECEPTOR LOWER BP == BETTER CHOICE THAN B-BLOCER OR CA CHANNEL BLOCKERf
"HYPER"- THYROIDISM CAN CAUSE WHAT KIND OF PSYCH SX
"HOT FLASHES"--not a psych sx, but more common in these patients symptoms consistent with a variety of psychiatric disorders, including depression, anxiety, psychosis, mania, and, at an extreme, delirium
Sx of Narcolepsy: (1) Sleep attacks (2) Sudden loss of muscle tone which may have been precipitated by a loud noise or intense emotion. If short episode, pt remains awake (3) Hallucination that occur as the pt is going to sleep and is waking up from sleep respectively (4) Most often occurs during awakening, when the patient is awake but unable to move
(2) Cataplexy (3) Hypnagogic and hypnopompic hallucinations (4) Sleep paralysis
PERSONALITY TYPE DIFFERENCE BETWEEN KID WITH ADHD VS MANIs ======================================================== WHAT TO DO IF SCHOOL THAT A ADHD KID ATTENDS SAYS THEY CAN NO LONGER KEEP HIM AS A STUDENT?
ADHD KID= LOW SELF ESTEEM VS MANIA== HIGH SELF ESTEEM= EVEN GRANDIOSE DELUSIONS === FOUND IN BOTH = Distractibility, impulsivity, motoric overactivity, and pressured speech may be seen in children with both disorde ============================================================= IF ADHD KID CANT ATTEND REGULAR SCHOOL = SEND HIM TO: THERAPEUTIC DAY SCHOOL - GET SCHOOLING + THERAPY TO HELP COPE NOTE= HOMESCHOOLING= BAD IDEA AS THIS OPTION DOESNT PROVIDE WITH TEACHERS WITH SPECIAL SKILLS TO DEAL WITH ADHD KIDS
Splitting; Suicide or Self-Mutilation
Borderline
WHAT IS LONG TERM TX FOR ALCOHOL ADDICTION AAA VS DISULFIRAM
AAA= MAIN /BEST CHOICE >>>>> DISULFIRAM
EXTRA-PYRAMIDAL S.E. WITH "TYPICAL" ANTIPSYCH DRUGS DESCRIBE THE FOLL: ACUTE DYSTONIA VS AKATHISIA VS TARDIVE DYSKINESIA
ACUTE DYSTONIA = Mneonic- DYS-TONIA--TONE THAT IS "STUCK" IN "SPASM" SUSTAINED CONTACTION (ONE SIDED) = MUSCLE SPASM/STIFFNESS OF NECK---> TORTICOLLUS EYE MUSCLES---> Oculogyric crisis= CANT STOP LOOKING UP Trismus is a spasm of the jaw muscles. ========= AKATHISIA.... a kuthi who cant sit still = INABILITY TO SIT STILL RESTLESSNESS = TX== B BLOCKER =========== TARDIVE DYSKINESIA===TX= BENZTROPINE = Mnemonic- pt "tardy" in class for sticking tongue out DYS-KIN-ESIA OF MOUTH FACE EXTREMITIES = TONGUE PROTRUSION LIP SMACKING CHEWING MOVEMENTS = tongue and lip movements, as well as choreoathetoid movement of the trunk or limbs =============================== == PARKINSONISM=ALSO A EXTRAPYRAMIDAL S.E.== TX= BENZTROPINE = RIGIDITY BRADY-KINESIA
WHAT ARE TX FOR ACUTE DYSTONIA AKATHISIA TARDIVE DYSKINESIA
ACUTE DYSTONIA TX = ANTICHOLINERGIC DRUGS = BENZTROPINE=anti-cholin-ergic OR DIPHENHYDRAMINE=anti-histamine ================ AKATHISIA TX = BZ= LORAZEPAM OR B-BLOCKER =============== TARDIVE DYSKINESIA = ANTICHOLINERGIC DRUGS = BENZTROPINE= OR DIPHENHYDRAMINE=anti-histamine
PT HAS NECK STUCK ON THE RIGHT SIDE= ==TORTICOLLIS SUSTAINED ELEV OF EYES IN UPWARD DIRECTION = OCULO-GYRIC CRISIS
ACUTE DYSTONIC S.E. TX= BENZTROPINE OR DIPHENHYDRAMINE
LAST WK PT WAS ROBBED= AT GUN POINT LAST WEEK NOW SHE HAS ANXIETY NIGHTMARES AVOIDING PLACE WHERE SHE WAS ROBBED DIAGNOSE?
ACUTE STRESS DISORDER < 1 MONTH= PT EXP. ALMOST DEATH= HELD AT GUN POINT = MAJOR STRESSOR + HAVING NIGHTMARES/FLASHBACKS = SO CAN NOT BE ADJUSTMENT DISORDER
Increased during sleep; linked to REM sleep
ACh
Tx of Narcolepsy
Amphetamines (methylphenidate)
DIFFERENTIATE ACUTE STRESS DISORDER VS PTSD
BOTH OCCUR POST ACTUAL/THREATENED DEATH OR SERIOUS INJURY (((SO NOT SOMETHING RELATIVELY MINOR LIKE MOVING TO COLLEGE/CHANGE OF JOB ETC))) ================ ACUTE STRESS DISORDER = <1 month WITHIN 1 MONTH OF ABOVE MENTIONED STRESSOR VS PTSD= > 1 MONTH POST STRESSOR =============
Increase toward end of sleep; linked to arousal and wakefulness
Dopamine
FLUOXETINE DRUG TREATS WHICH EATING DISORDER
BULIMIA NERVOSA BUT MAIN TX OF CHOICE= THERAPY!
Characterized by an unstable affect, mood swings, marked impulsivity, unstable relationships, recurrent suicidal behaviours, chronic feelings of emptiness or boredom, identity disturbance, and inappropriate anger. If stressed, may become psychotic.
Borderline PD
CT: Lateral and third ventricular enlargements, reduction in cortical volume MRI: Increased cerebral ventricles PET: Hypoactivity of the frontal lobes and hyperactivity of the basal ganglia
Brain imaging in Schizophrenia
Hallucinations Delusions Disorganized speech Grossly disorganized or catatonic behaviour Sx more than one day but less than 30 days
Brief Psychotic Disorder
f jitteriness, diuresis, irritability, insomnia, psychomotor agitation, and nausea ============================= graduate student woke up late and skipped breakfast. She now has a massive headache and is irritable when she walks into her first morning class. She feels like falling asleep and as if she "has the flu" by the end of the morning
CAFFEINE OVERDOSE = JITTERY, PEEING A LOT, INSOMNIA ================ CAFFEINE WITHDRAWL = SIMILAR TO WHAT HAPPENS TO ME WHEN I DONT DRINK COFFEE= HEADACHE/IRRITABLE
WHAT IS IT CALLED WHEN A SCHIZO PT THINKS PEOPLE HAVE BEEN REPLACED BY THEIR IDENTAL IMPOSTERS == example: patient now claims that his mother and father have been recently replaced by "cyborg alien robots" that look identical to his parents
CAP-GRAS SYNDROME (((imposter wearing a cap to hide true identity)
SIDE EFFECT APLASTIC ANEMIA AND SIADH WHICH DRUG? ========= WHAT LAB SHOULD BE CLOSELY MONITORED IN PT WITH NMS
CARBAMAZAPINE === PT WITH NMS== RIGID MUSCLES = CLOSELY MONITOR CPK = IF HIGH: The offending antipsychotic should be discontinued, the patient should be hydrated and cooled, and dantrolene (IV) and/or bromocriptine (orally) may be given
OTHER THAN CLOZAPINE WHICH OTHER DRUG S.E =ALSO AGRANULOCYTOSIS= LOW WBC ======================= WHICH IS THE ONLY ANTIPSYCH DRUG THAT DOES NOT INCREASE= PROLACTIN = DOES NOT CAUSE ALL SXX ASS. WITH PROLACTINOMA = GALACTORHEA NO PERIODS ETC
CARBAMEZIPINE ======================= CLOZAPINE = ONLY ANTIPSYCH DRUG THAT DOES NOT INCREASE= PROLACTIN = DOES NOT CAUSE ALL SXX ASS. WITH PROLACTINOMA = GALACTORHEA NO PERIODS ETC
WHAT IS DISRUPTIVE MOOD DYSREGULATION DISORDER ============ WHAT IS SCHIZOAFFECTIVE DISORDER
CHILDHOOD DISORDER PERSISTENT/ CHRONIC ((not episodic!) IRRITABILITY/ ANGRY MOOD = TEMPERMENTAL OUTBURST ==================== SCHIZO AFFECTIVE DISORDER = EITH MANIA OR MAJOR DEPRESSION WITH SX OF SCHRIZOPHRENIA
WHAT ARE THESE SIGNS CHOVSTEIK VS COURVOSEIR
CHOVSTEIK = HYPOCALCEMIA = TAP ON CHEEK==>CONTRACTION ========VS=========== COURVOSEIR SIGN = PALPABLE GALLBLADDER = SUSPECT IN PANCREATIC CANCER
what is CAUSE OF THIS PUPIL DILATION TACHYCARDIA SWEATING/ DIAPHORESIS
COCAINE OVERDOSE ======VS======== HEROIN OVERDOSE--OPOID = PUPIL CONSTRICTION RESP DEPRESSION ===VS=== LSD OVERDOSE = LSD will often cause prominent VISUAL hallucinations during intoxication
TX OF BINGE EATING DISORDER
COGNITIVE BEHAV THERAPY +/- SSRI POSSIBLE = TOPIRAMATE
Age appropriate behaviour, response to environmental problems, ID, ASD, and mood disorders
DDx of ADHD
BOY HAS A "MASS ON TESTICLE" WHEN DOC ASK WHY HE DIDNT GET IT CHECKOUT OUT EARLIER, HE SAYS "I AM SURE ITS NOTHING"
DENIAL
MDD WHAT ARE SOME SLEEP ISSUES THESE PEOPLE HAVE === WHAT NEUROTRANSMITTER CHANGE FOUND IN PEOPLE WITH MDD ((WHICH ONES ARE HIGH VS WHICH ONES ARE DECREASE))
EARLY MORNING AWAKENING= MOST COMMON OTHERS = "DECREASE" IN REM STAGE --LATENCY ========================== MDD PEOPLE HAVE = INCREASE: CORTISOL LEVELS DECREASE: CATECHOLAMINES + SEX HORMONES
MAN WITH DOWN SYNDROME WHAT WILL CAUSE HIM TO HAVE MEMORY LOSS ============== man WITH HTN WHAT WILL CAUSE HIM TO HAVE MEMORY LOSS ====================== MAN WITH MYO-CLONIC JERK MOVEMENTS OF LIMB WHAT WILL CAUSE HIM TO HAVE MEMORY LOSS
EARLY ONSET ALZEIHMER- common in downs pt Neurofibrillary tangles, neuritic plaques, and loss of acetylcholine neurons in the nucleus basalis of Meynert—pathological changes characteristic of Alzheimer disease ========= HTN/CARDIAC PROBLEMS ==>> MULTI INFARCT DEMENTIA Unlike Alzheimer disease, multi-infarct dementia is characterized by sudden onset and a stepwise progression ============ MYOCOLONIC JERKS ===> CJD = a very rapid cognitive deterioration , myoclonic jerks, , and ataxia DEATH IN ABOUT A YR Creutzfeldt-Jakob caused by a transmissible infectious agent, the prion. Most cases are iatrogenic, : following transplant of infected corneas or use of contaminated neurosurgical instruments
OVERDOSE OF WHAT? UNIQUE = HYPO=N=ATREMIA HIGH BP HIGH HR SEROTONIN SYNDROME==HIGH FEVER, ALTER MENTAL STATUS INCREASE SEXUAL DESIRE INCREASE SOCIABILITY
ECSTACY=MDMA = VERY COMMON AT LARGE PARTIES/RAVES/COLLEGES == OTHER S.E. WITH ECSTASY OVERDOSE = BRUXISM== TEETH GRINDING initial phase of disorientation, followed by a "rush" that includes increased blood pressure and pulse rate as well as sweating bruxism (grinding of the teeth), shortness of breath, cardiac arrhythmia, and death
Topic-to-Topic
Flight of Ideas
HUSBAND BRINGS IN HIS WIFE TO DOC SAYS SHE WAS FEELING DEPRESSED 2 MONTHS AGO AND WAS GIVEN A DRUG , WHICH FIXED HER SADNESS NOW SHE HAS FOLLOWING SX: GRANDIOSE DELUSIONS = "GOD IS TALKING THROUGH ME" + EXCESSIVE SPENDING = CREDIT CARD DEBT/ GAMBLING + PRESSURED/ RAPID SPEED OF TALKING DIAGNOSE
HER CURRENT SX = MANIA SINCE SHE HAS PMH FOR MDD AND NOW HAS MANIA = BIPOLAR 1 ((REM- BIPOLAR 2=== HYPO-MANIA)) ((BIPOLAR 1= ALTHOUGH DIAG CAN BE MADE WITH MANIA ALONE, MOST PTS TEND TO ALSO HAVE MDD LIKE SX))) ========= CAUSE OF HER MANIA = ANTIDEPRESSANT SHE WAS GIVEN 2 MONTHS AGO
what causes this: sx of "flu" = LACRIMATION RHINORHEA--runny nose MUSCLE SPASM JOINT PAIN SWEATING
HEROIN = opiate WITHDRAWL
pt has DIAHREA + DILATED PUPILS WHAT OTHER SX WILL THIS PT HAVE? DIAGNOSE? =============== PT HAS = RESPIRATORY DEPRESSION + CONSTRICTED PUILS = OVERDOSE OF WHAT?
HEROIN= OPIATE= WITHDRAW DIAHREA = KINDA LIKE A "FLU" SX WILL ALSO HAVE=== RUNNY NOSE, VOMITTING == NOTE- THIS CAN NOT BE HEROIN/ OPIATE OVERDOSE BECAUSE OF DILATED PUPILS == TX OF OPIATE= HEROIN = ADDICTION==OVERDOSE ACUTE= NALOXONE LONG TERM= METHADONE =================================== RESPIRATORY DEPRESSION + CONSTRICTED PUILS = OVERDOSE OF = OPIATES REM- OPIATE OVERDOSE CAUSE DROP IN RESPIRATIONS DROP IN BP
MA/CA x 100
IQ
0.1% Blood EtOH level
Motor actions become clumsy
Decreased during sleep; linked to REM sleep
NE
Tx of opiate intoxication
Naloxone
List of TCAs
Nortryptyline Amitriptyline Imipramine Desipramine Clomipramine
Relapse vs. Recurrence
Relapse from Remission vs. Recurrence from Complete Recovery
WHICH MDD DRUG IS GOOD FOR PT WHO= DOES NOT WANT TO GAIN WEIGHT
SSRI
Name the Personality Disorder: Detached "loners" who also have cognitive or perceptual distortions (maginal thinking)
Schizotypical
A sense of unfamiliar things being familiar
deja vu
WHAT IS COMMONLY FOUND IN FAMILIES OF KIDS WITH CONDUCT DISORDER = FOUND SHOPLIFITING AS ADULTS, THIS TURNS INTO?
(A) absence of a biological father AS ADULTS ==?>> ANTISOCIAL PERSONALITY DISORDER
SNRI and Dopamine Re-Uptake Inhibitor; No Sexual Dysfunction; Lowers Seizure Threshold (Compare to Clozapine) at High Doses
(Wellbutrin) Bupropion; Avoid in Patients with Electrolyte Abnormalities like Eating Disorders
Separation of an idea from the affect that accompanies it. " As she arrived at the station to identify the body, she appeared to show no emotion"
Isolation
drugs given for ALZIEHERM'S
) Donepezil, rivastigmine, galantamine as a first-choice therapy, donepezil should be chosen ================== anticholinesterase inhibitor, such as galantamine. === Memantine, an N-methyl D-aspartate (NMDA) receptor antagonist, is a newer medication that may be added
SNRI (Venlafaxine) 1. Side efects
- Diastolic HTN - Sexual dysfunction insomnia, nervousness, sedation, nausea
War Veteran Tells Gruesome Stories Without Showing Signs of Sadness
Isolation of Affect
Bupropion (Welbutrin) - Contraindication
- Seizure disorder b/c it lowers the seizure threshold
Tricyclic Antidepressants
- Side effects 3 C's Convulsion Coma Cardiac Arrhythmias
meth intoxication
- agitation (imma blow up) - paranoia (i dont like the way youre looking at me) - sweating - irritability (damn, woman) - mydriasis - CP, palpitaitons, tachy, HTN, - cardiac arrythmia, seizures, hyperthermia, intracerebral hemorrhaege
inhalent abuse
- brief euphoria, then LOC - males 14-17 - many household chemicals , life threatening - inc LFTs see rash around mouth (glue sniffers rash)
what sTAGE OF SLEEP DO THE FOLL. OCCUR NIGHT-TERROR NIGHT-MARE SLEEP WALKING
NIGHTMARE = REM ======= BOTH NIGHT TERROR AND SLEEP WALKING =during DEEP SLEEP = STAGE 3-4
if on Li, tests to order?? Li is for acute mania and bipolar do
- can cause DM insipidus, thyroid dysfunction and hyperparathyroidism as chronic ACUTE: think of Dylan Banks. upset stomach, polyuria, polydipsia, tremors, weakness - order TFT, BUN/ Cr, UA, Calcium CI: CKD, Heart dz, hyponatremia/ diuretic use monitor q 6-12 mo or whenever there is a dose change or added med that interacts with Li (5-75 d after)
NMS VS SEROTONIN SYNDROME HALLMARK SX THAT DIFFER BETWEEN THE TWO
NMS = STICK MUSCLES/ HYPERTONIC MUSCLES VS SEROTONIN SYNDROME = MYOCLONIC JERKS =========
narcolepsy
- daytime sleepiness - cataplexy (loss of mm tone triggered by strong emotions) tx: modafinil or amphetamine stimulants or sodium oxybate - maintain proper sleep schedule. - avoid alchy/ drugs
risperdol SE mOA
- dope and serotonin blocker - causes hyperprolactinemia (galactorrhea and ammenorrhea) - u get fat
bupropion
- for MDD and smoking cessation CI: seizure d/o and eating d/o (causes lyte abnormalities and predisposes to seizures)
social anxiety disorder (social phobia) tx split into generalized socail anx and performance anx disorder
- marked anxiety more than 1 situation more than 6 months - fear of scrutiny by others, humiliation and ambarassment tx for performance related: benzo or BB30-60 mins before presenting or cbt
Which of the following factors most increases this patient's risk of committing suicide? (A) cutting behavior (B) diagnosis of depression (C) gender (D) relative who committed suicide (E) substance use
(B) diagnosis of depression BUT LARGEST RISK FACTOR = A history of a prior suicide attempt is the largest risk factor for suicide for both males and females in all age groups; ======= ALL RISK FACTORS FOR SUCIDE= ) Risk factors for completed suicide include (1) age > 45, (2) male gender, (3) separated/ divorced > married, (4) white race > black race ==================== Male gender, a prior suicide attempt, history of psychiatric illness, ===DEPRESSION family history, and substance abuse
best strategy in making the transition from the SSRI to the MAOI
(E) Taper the SSRI and 5 weeks after the last dose begin increasing the MAOI.
schizotypal person d/o
- odd behavior - magical thinking - bizarre fantasies (telepathy, clairvoyance, 6th sense)
Schizophreniform Disorder
- same as schizophrenia, but duration of < 6 months
alcohol withdrawal syndrome
- withdrawal within 12-24 hrs. can see SEIZURES here! GI upset, palps, tremor, anx, insomnia - DTs happen within 2-4 days. see fever, confusion, agitation, tachy, HTN, sweating
===========online MEDED
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KID WITH BIPOLAR, MANI Which of the following medications would be the most appropriate treatment? (A) bupropion (Wellbutrin) (B) duloxetine (Cymbalta) (C) methylphenidate (Ritalin) (D) mixed amphetamine salts (Adderall) (E) valproic acid (Depakote)
(E) valproic acid (Depakote) BIPOLAR MANIA TX = ANTIPSYCH DRUG + MOOD STABILIZER ======= BOTH DULOXETINE, BUPROPRIONE = ANTIDEPRESSANTS = WILL MAKE MANI SX ==WORSE!!!!!!!!!! === methylphenidate =STIMULANT-ADHD TX
FOR THE PAST 2 MONTHS PT SAYS "MAFIA AFTER ME" "FOOD BEING POISONED" AND HE IS ALSO HEARING VOICES OF MEN TALKING TO HIM DIAGNOSE
"MAFIA AFTER ME" "FOOD BEING POISONED" = DELUSIONS==J-PEG HEARING VOICES= HALLUCINATIONS ===== < 6 MONTHS = SCHIZO-PHRENIFORM == THIS IS NOT DELUSIONAL DISORDER BECAUSE OF HALLUCINATIONS
Cluster C Personality Disorders
"WORRIED AND WIMPY" Obsessive Compulsive Avoidant Dependent
tx for ADJUSTMENT DISORDER
# 1= NOT SSRI!!!! === #1 - PSYCHO-THERAPY =LEARN COPING SKILLS TO DEAL WITH STRESSOR SSRI= CAN BE ADDED WITH PSYCHOTHERAPY TX = BUT NOT ONLY OR MAIN TX OF CHOICE
TX FOR GREIF/ BREAVEMENT
# 1= PSYCHO-THERAPY = SUPPORTIVE THERAPY >>> CBT ==== IF PT IS STILL FEELING SAD THEN PSYCHOTHERAPY + SSRI
ocd TX ======= PT ON A ANTIDEPRESSANT SIDEEFFECT = FELL OFF FROM CHAIR AFTER STANDING UP =========== MANIA =pressured/fast speech, spending too much, grandiose delusions staying up all night FIRST LINE TX? =================== mom who DIDNT STOP TAKING LITHIUM DURING PREG WHAT TEST TO DO ON BABY
#1 = SSRI #2 - TCA= CLOMI-PRAM-INE LANGE ============ TCA= IMI-PRAM=INE = S.E.= ORTHOSTATIC HYPOTENSION ========== FIRST LINE TX OF MANIA = MOOD STABILIZER= all are tetragenic!! == LITHIUM, VALPORIC ACID >>> CARBAMEZIPINE WITH OR EVEN WITHOUT 2ND GEN ANTIPSYCH DRUG ========== LITHIUM= TETRAGENIC===>> EBSTEIN ANOMALY ORDER = ECHO FOR BABY
AFTER CONSERVATIVE MANAGEMENT HAS FAILED TO TX ENURESIS = WHAT ARE DRUGS TO TX IT
#1 DRUG = DESMOPRESSIN=DDAVP = BETTER THAN TCA DUE TO LESS S.E. #2 DRUG = IMIPRAMINE= TCA
TX FOR PTSD WHAT IS #1
#1- PSCYHO-THERAPY- talk about stressor to help with sx #2- SSRI SSRIs can be used to augment therapy and improve outcomes, especially treating the depressive symptoms of PTSD, but are NOT front line therapy
WHAT ARE DIFFERENT TYPES OF DELUSIONS = DELUSIONAL DISORDER
( J-PEG) PERSECUTORY TYPE = PT BEIEVES HE IS BEING: POISONED SPIED ON ==================== ERO-TOMANIC' = PT BELIEVES THAT SOMEONE OF HIGHER STATUS IS IN LOVE WITH THE PT ========================= GRANDIOSE DELUSION == GREAT TALENT/INSIGHT/ACHIEVEMENT ====================== JEALOUS DELUSION = PT BELIEF HE/SHE HAS UNFAITHFUL PARTNER ============= SOMATIC DELUSION = FALSE PERSISTANT BELIEF ABOUT BODILY FUNCTIONS
OCD DRUG OF CHOICE FOR TX
(((lange says #1= clonidine===check)))) SSRI = PAROXETINE = 1ST LINE DOC ========= 2ND LINE DOC FOR OCD = TCA = CLOMIPRAMINE
WHATS BIPOLAR 1 VS BIPOLAR 2 VS SCHITZOAFFECTIVE vs major depression with psychotic features.
((BIPOLAR IS A MOOD NOT A PSYCHOTIC DISORDER)) BIPOLAR 1 = ONLY NEED "MANIA" ((((vs. hypo-mania in bipolar 2) (((In bipolar I disorder, the mania is more severe causing notable occupational dysfunction, psychotic symptoms, or hospitalization.))) BUT!!!!!!!111 MOST PTS WITH BIPOLAR 1 =have MANIA + DEPRESSION LIKE SX ((((vs.... MDD in bipolar 2))) ===============VS================= BIPOLAR 2 = HYPO-MANIA (((symptoms of mania not severe enough to cause occupational dysfunction or psychiatric hospitalization)))) + MAJOR DEPRESSION DISORDER =MDD ========== SCHITZOAFFECTIVE = SCHIZOPHRENIA==PSYCHOTIC SX that occur when she is not having mania/ or depression + MOOD DISORDER==MANIA OR DEPRESSION ============= major depression with psychotic features. = psychotic SX= HALLUCINATIONS= THAT ONLY OCCUR WHEN PT IS ALSO HAVING DEPRESSION SX = If thehallucinations and delusions only occurred in the context of her depressive episodes
Severe anxiety symptoms following a threatening event that caused feelings of fear, helplessness, or horror. (1) lasts < 1 month (2) lasts > 1 month
(1) Acute stress disorder (2) Post traumatic stress disorder
(1) Benzos (2) Azapirones (3) SSRIs (4) B blocker (5) Sedative antihistamine
(1) Aprazolam, chlordiazepoxide, diazepam (2) Buspirone, etc (3) Citalopram, Escitalopram, fluoxetine (4) Propanolol (5) Hydroxyzine
Anxiolytic Medications
(1) Benzos (2) Azapirones (3) SSRIs (4) B blocker (5) Sedative antihistamine
Onset of mood and/or psychotic sx occurs during pregnancy or in the 4 weeks following delivery, sx of depression, mania along with delusions, hallucinations and thoughts of harm; may have thoughts of harming the baby. Treated with antipsychotic medication, lithium, and possible antidepressants
(1) Bipolar disorder with peripartum onset (2) Brief psychotic disorder with peripartum onset
Lithium Teratogenicity
(1) Early: Ebstein Anomaly. (2) Late: Diabetes Insipidus and Polyhydramnios.
Affirmative answers to any 2 of the following questions are suggestive of alcohol abuse: CAGE
(1) Have you ever felt that you should cut down your drinking? (2) Have you ever felt annoyed by others who have criticized your drinking? (3) Have you ever felt guilty about your drinking? (4) Have you ever had a morning drink (eye-opener) to steady your nerves or alleviate a hangover
Fine Downy Body Hair on Trunk and Scars or Calluses on Hand; BMI Under 18.5
(1) Lanugo and Russell Sign of Anorexia Nervosa (Adaptation to Hypothermia). (2) Other Signs: Hair Loss, Bradycardia, Hypotension (Hypovolemia), Dry Skin, Parotid Hypertrophy, Dental Caries, Halitosis
Thorough substance abuse hx
(1) Substance(s) (2) Dosage(s) (3) Effects (4) Duration and social context of use (5) Prior experiences with substance detoxification, rehabilitation, and relapse prevention
LABS IM--NEURO-MEDED NOTES REVEIW PHARM DRUGS ========= REVIEW KIDS ==DEVELOP. MILESTONES AGE OK TO PEE IN BED ETC ((PRETEST==Nocturnal enuresis is not diagnosed before age 5)) SEP. ANXIETY --WHAT AGE, ETC ==== REVIEW KIDS== GENETIC DISORDERS= WILLIAM ETC
.. NO HALLUCINATIONS -AUDITORY OR VISUAL --IN : GAD ADJUSTMENT DISORDER MDD ((if mdd + halluc. = schizo affective
PSYCH
...
Time Requirement for Delusional Disorder
1 Month; Non-Bizarre Delusions
PTSD 1. Diagnosis 2. Treatment
1 Symptoms lasting > 1 month: - reexperiencing of event (nightmares, flashbacks) - avoidance of trauma related stimuli - hyerarousal (hypervigilence, irritability, difficulty falling or staying asleep) 2. SSRI
DEFENSE MECHANISM? 1--A 52-year-old man is hospitalized after a severe myocardial infarction. On the second day in the hospital, when his physician comes by on rounds, the patient insists on jumping out of bed and doing several pushups to show the physician that "they can't keep a good man down—there is nothing wrong with me!" 293. A man who, as a child, was beaten by his parents for every small infraction nonetheless idealizes them and describes them as "good parents who did not spoil their children." He is baffled and angry when he is ordered to start parenting classes after the school nurse reports that his children consistently come to school with bruises
1-- DENIAL = MAN HAS A FREAKIN MI --> NEXT DAY HE IS SAYING "they can't keep a good man down—there is nothing wrong with me!" 293 = IDENTIFICATION WITH AGGRESSOR = MAN BEATEN BY PARENTS BUT THINKS PARENTS WERE GOOD TO HIM
DEFENSE MECHANISM? 1---a woman who has just been told she has a diagnosis of cancer goes home that evening and tells her husband that everything is fine. When confronted by this error, she seems genuinely surprised to hear the cancer diagnosis 2- , a person who is very angry at his wife brings home flowers for her 3- a person who wishes to be admired by everyone channels this behavior into doing charity work 4- (A person who has gotten into a disagreement with his best friend spends hours objectively analyzing the conversation to understand what happened.
1--- REPRESSION = Repression is the expelling or withholding of an idea or feeling from consciousness 2- REACTION FORMATION = REACT OPP. TO HOW U REALLY FEEL = HUSBAND REALLY FEELS ANGRY, BUT REACT BY BRINGING HER FLOWERS 3- SUBLIMATION = NEGATIVE FEELING- WANT TO BE ADMIRED ACHIEVED BY TURNING IT INTO SOMETHING POSITIVE--CHARITY 4- INTELLECTUALIZATION = EXCESSIVELY FOCUSING ON SOMETHING
Management of SSRI Inefficacy
1. After 6 Weeks, Increase Dose. 2. Switch to Different SSRI. 3. Try Different Class.
Psychiatric Side Effects of Steroids
1. Agitation. 2. Psychosis. 3. Suicide.
Schizophrenia 1. Diagnosis 2. Treatment
1. At least 2 of the following sx with duration of > 6 months: - DELUSIONS (fixed, false beliefs) - HALLUCINATIONs - DISORGANIZED SPEECH - DISORGANIZED OR CATATONIC BEHAVIOR - NEGATIVE SYMPTOMS (flat affect, apathy, lack of socializing) 2. Anti-psychotic (2nd generation) - *RISPERIDONE*; Olazapine; Quetiapine, Siproasidone
SSRI (fluoxetine, sertraline, paroxetime, citalporam) - Drug interactions - side effects
1. Can increase warfarin levels b/c of P450 interactions 2. SEXUAL DYSFUNCTION, nausea, diarrhea, anorexia, HA, Anxiety, tremor, sleep disurbance
2 Requirements for Involuntary Hospitalization
1. Danger to Self or Others. 2. Inability to Care for Self.
Generalized Anxiety Disorder 1. Presentation 2. Diagnosis 3. Treatment
1. Excessive and pervasive worry about a lot of things, causes significant impairment and distress 2. Anxiety/Worry on most days x 6 months or more - 3 or more somatic sx: restlessness, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbances 3. *SNRI (Venlafaxine)* SSRI Benzodiazepines (acute relief but dependance occurs) Buspirone
Factitious Disorder vs Malingering Disorder
1. Facticious D/o: sx are intentionally faked for 2ndary gain (assuming a sick role). More common in Men and in Health Care Workers 2. Malingering D/o: sx are intentionally faked for external gain (money, food, shelter)
Rett's Disorder 1. MC seein in what gender? 2. Presentation 3. Pts are at increase risk of what?
1. Girls 2. Normal development until 5 months of age, followed by: - Microcephaly (deceleration of head circumfirence) - Wringing of hands - loss of social engagement - poor gait and truncal movements - severely impaired language development - seevre psychomotor retardation 3. Seizures
Generalized Anxiety Disorder Requires Majority of the Following:
1. Impaired Sleep. 2. Poor Concentration. 3. Tiredness. 4. Irritability. 5. Muscle Tension. 6. Restlessness.
Treatment for Bipolar Depression Tx if 1st line tx fails?
1. Lithium * Tx with anti-depressants is NOT recommended* 2. Lamotrigine
SAD PERSONS
1. Male. 2. Age Under 20 or Over 50. 3. Depression. 4. Previous Attempt. 5. Ethanol or Drugs. 6. Rational Thought Loss (Psychosis). 7. Social Support Issues. 8. Organized Plan. 9. No Spouse or Significant Other. 10. Sickness or Injury.
3 Mono-Amine Oxidase Inhibitors
1. Selegiline. 2. Phenelzine (Nardil). 3. Tranylcypromine (Parnate).
Substance Abuse vs Substance Dependence
1. Substance Abuse: failure to meet oblications, substance use during hasardous activity, substance-related legal problems, continued use despite social problems 2. Substance Dependence: tolerance, withdrawal, increase use with desire to decrease use, spending a significant amoutn of time obtaining the sustance
Bipolar Disorder Risk: First-Degree Relative vs. Both Parents vs. Monozygotic Twin
10% vs. 60% vs. 70%
WHICH DRUG CAUSING THESE: 112. An 18-year-old high school student with conjunctival redness, increased appetite, dry mouth, tachycardia, and a sensation of slowed time. 113. A 31-year-old man with miosis, bradycardia, hypotension, hypothermia, and constipation. 114. An assaultive 26-year-old man with vertical nystagmus, echolalia, paranoid ideation, and hallucinations. 115. A 16-year-old girl with abdominal cramps, confusion, palpitations, and muscle twitching. 116. A 21-year-old man with tachycardia, dilated pupils, hallucinations, and complaints of chest pain
112- CANABIS= CONJUCTIVAL REDNESS 113= OPIATE OVERDOSE= MIOSIS, RESP DEPRESSION 114 = PCP= NYSTAGMUS, 115= NICOTINE OVERDOSE!!!!!!!!!!!!11 = MUSCLE TWITCHING 116= COCAINE OVERDOSE= DILATED PUPIL/CHEST PAIN
113. A 23-year-old man is brought to the emergency department by the police. He shows agitation, vertical nystagmus, and analgesia . 114. A 62-year-old homeless man admitted to a psychiatric unit begins having elevated vital signs, visual hallucinations, diaphoresis, tremor, and seizures. 115. A 43-year-old woman presents to the psychiatric emergency department complaining of depression and suicidality. She is observed to be fatigued, irritable, and with a dysphoric affect. 116. A 30-year-old musician presents in the outpatient clinic. He complains of fever and chills, runny nose, nausea, body aches, diarrhea, and abdominal cramps for the last 24 hours.
113= NYSTAGMUS =PCP OVERDOSE 114 = ADMITTED IN HOSPITAL THEN elevated vital signs, visual hallucinations, diaphoresis, tremor, and seizures. = ALCOHOL WITHDRAWL 115 = COCAINE WITHDRAWL 116 = FLU LIKE SX= RUNNY NOSE/ NAUSEA = OPIATE= HEROIN= WITHDRAWL
Match the following EEG wave forms with their characteristic properties. a. Alpha b. Beta c. Delta d. Theta 169. Dominant brain wave frequency (8 to 13 Hz) of the normal, eyes-closed, awake EEG. 170. Frequency is faster than 13 Hz; not uncommon in normal adult waking EEGs, particularly over the frontal-central regions. 171. Prominently featured in deeper stages of sleep. Frequency of less than 3.5 Hz. 172. Waves with a frequency of 4.0 to 7.5 Hz. Prominent feature of the drowsy and sleep tracing.
169- ALPHA = normal, eyes-closed, awake EEG. = . It emerges with closing of the eyes and with relaxation, = and attenuates with eye opening or mental exertion ========= 170= BETA = normal adult waking EEGs, particularly over the frontal-central regions. ======== DELTA = DEEPER SLEEP STAGES =========== THETA = DROWSY/ SLEEP TRACY
TX FOR CONVERSION DISORDER?
1ST LINE = EDUCATION = SELF HELP TECHNIQUES ===== 2ND LINE = COGNITIVE BEHAVIOR THERAPY
TX OF BODY DYSMORPHIC DISORDER
1ST== PSYCHO-THERAPY 2ND= SSRI
269. A 21-year-old man is brought to the psychiatrist by his parents. They state that for the previous year, he has been withdrawn, apathetic, and somewhat suspicious of his friends. For the past week, he has isolated himself in his room because he states that there are voices telling him that his friends are going to hurt him. 270. A 36-year-old woman presents to the physician with hallucinations of feeling that her skin is burning. Her speech is somewhat disorganized and difficult to follow. Her husband states that this behavior has been occurring for the past week, ever since she was told of a car crash that killed her daughter. 271. A 39-year-old man is referred to a psychiatrist by his employment assistance program, after he began having trouble on his job. The patient states that his stress level is very high ever since he was promoted to his new job as manager of his computer department. He states that before the promotion, he was quite happy off in his cubicle interacting with no one but the computer all day long. He had that job for over 15 years, and did it well. 273. A 26-year-old woman presents to the emergency room accompanied by her fiancée. He notes that she has been acting increasingly strangely over the past 3 weeks. She states that the TV is beaming messages directly into her brain, and that she can't understand why he can't hear the messages too. Her hygiene has also gotten poorer, and she has not taken a shower in the past week because the water might "turn into acid."
269 = AUDITORY HALLUC, SUSPICIOUS OF FRIENDS= DELUSIONS = SCHIZOPHRENIA ========== 270 DAUGHTER DIED OVER 2 WEEK, HALLUCINATIONS = BREIF PSYCHOTIC DISORDER === 271 HAPPY NOT INTERACTING WITH OTHERS = SCHIZOID ========= 273 < 6 MONTHS THINKS TV IS SENDING HER MESSAGES = SCHIZOPHRENIFORM
WHAT KIND OF DEFENSE MECHANISM? 288. A patient starts complaining of chest pain and coughing whenever her therapist confronts her. She insists, however, that she is not at all distressed or angry. 289--A 34-year-old man is deeply envious of his younger but much more successful brother. Although it is difficult for him to admit, he believes the younger brother was their parents' favorite as well. He tells his friends that his younger brother is envious of his good looks and successes with women, even though there is some evidence that this is not so
288 SOMATIZATION = WHEN PT COMES UP WITH PHYSICAL SX--chest pain, coughing AS A DEFENSE MECH. = ANOTHER EXAMPLE = person who is extremely anxious about her relationship with her husband begins having ABDOMINAL PAIN when in his presence ============================== 289-- PROJECTION MAN "ACCUSES" HIS YOUNGER BRO OF BEING ENVIOUS OF HIM WHEN IN FACT THIS MAN IS ENVIOUS OF HIS BRO
Treatment of Acute Agitation and Acute Grandiosity During Manic Episode
2nd-Generation Anti-Psychotics: Risperidone or Olanzapine
Number of Manic Episodes Requiring Lifetime Therapy (Lithium or Valproate with 2nd-Generation Antipsychotic)
3 (At Least 1 Year after 1st Episode)
a. Tolerance b. Potentiation c. Withdrawal d. Dependence e. Addiction f. Substance abuse 426. A 22-year-old man continues to use alcohol on a once-weekly basis, despite the fact that every time he uses it he does something embarrassing, which he regrets. This has led him to lose some of his friends because they do not want to be around him when such behavior occurs. 427. A 36-year-old cocaine user notices that the longer he uses the drug, the more of it he requires to achieve the same effect. 428. A 22-year-old woman passes out in a bar after one drink of wine. She normally can drink two glasses before she feels any effects from the alcohol. Her psychiatrist has recently started her on a new medication for her nerves.
426= SUBSTANCE ABUSE = y. Substance abuse describes a maladaptive behavioral pattern characterized by recurrent use in spite of academic, social, or work problems 427= TOLERANCE 428= POTENTIATION = . An example of the use of potentiation for clinical benefit is the coadministration of a benzodiazepine and an antipsychotic to an agitated psychotic patient. Both medications can be administered at lower doses when used together than either could if used alone
Time Requirement for Specific Phobia (10% of Population)
6 Months
Treatment of 1 Episode of Major Depression
6 Months of Effective SSRI; Do Not Taper for Nausea
SEE PHONE PIC WHICH DRUG OVERDOSE IN THESE PTS? PT A= PCP VS PT B= LSD VS PT C= THC
======================================= TX OF PCP AND LSD AND THC OVERDOSE = SUPPORTIVE CARE ======== PCP OVERDOSE = NYSTAGMUS ======================== LSD OVERDOSE = VISUAL HALLUCINATIONS ================ THC OVERDOSE = CONJUCTIVAL INJECTION
=====LANGE========================
===LANGE===================
duration to QUALIFY AS BREIF PSYCHOTIC DISORDER
> 1 DAY BUT < 1 MONTH (((VS.SCHIZOPHRENI-FORM = > 1 MONTH AND < 6 MONTH ===== SUDDEN ONSET === FULL RETURN TO NORMAL FUNCTION NOTE = NORMAL VITALS!
WHATS KEY TERM FOR EACH A = words or phrases strung together because of the sounds they make, not because of the meaning they convey. =========== B = patient will repeat what is said by someone else, regardless of the context, and often in a repetitive manner. F =================================== C = PATIENT believes that HER HUSBAND is really an impostor who looks exactly like her husband. ====================== D = PATIENT BELIEVES THAT HE IS DEAD OR HIS ORGANS ARE DEAD/DYING ============================ E = BELIEF THAT PENIS= SHRINKING INSIDE BODY
A = CLANG ASSOCIATION===clang sounds like a sound words make togehter ======= B = ECHO-LALIA=== echo/repetition OF WORDS VS ECHO-PRAXIA = REPETITION OF ACTIONS =EXAMPLE PATIENT mimics the examiner's body posture and movements===== ==================== C= CAPGRAS SYNDROME= IMPOSTER (wearing a cap) ============ D= COTARD SYNDROME== death/organs dying buried in a coffin called cotard ========== E= KORO= japanese belief that penis is shrinking
WHAT ARE THE 2 DRUGS THAT CAUSE SEIZURES UPON DRUG WITHDRAWL
ALCOHOL AND BENZODIAZIPINES!!!!!!!!!!!!!!!! = XANAX= ALPRAZOLAM ============= NOTE= BUPROPRION = CAUSES SEIZURES IN BULIMICS BUT THIS OCCURS WITH BUPROPRION USE NOT WITHDRAWL AND Q WILL SAY SOMETHING ABOUT PT HAVING BULIMIA
ACID-BASE CHANGES IN KID WITH BULIMIA WHAT IS A DANGEROUS S.E OF THIS =============== WHAT IS MOST EFFECTIVE KIND OF THERAPY FOR BULIMIC PTS
A hypokalemic- hypochloremic ((LOSE HCL))) = alkalosis (due to vomiting) is a possible serious finding ===> DANGEROURS S.E that can contribute to a cardiac arrhythmia. ======================================================== (A) cognitive-behavioral therapy = BEST FOR BULIMICS
Oppositional Defiant Disorder
A negative, hostile, and defiant attitude towards authority figures for >6 months
MOM COMPLAINS THAT SON IS unable to sit still, constantly fidgets, and is unable to complete class work because he is so easily distracted s extremely difficult because of her son's disorganization and forgetfulness. DIAGNOSE?? TX??
ADHD TX==STIMULANT===EX- METHYLPHENIDATE = WATCH OUT FOR S.E. = TICS LIKE== repetitive grimacing and blinking movements =========== MOST COMMON S.E. OF STIMULANTS = insomnia, decreased appetite,== weight loss, dysphoria, and irritability. ((SOMETIMES/LESS COMMONLY = STIMULAT S.E.== TICS))
HOW DOES HYPER-ACTIVITY IN BIPOLAR, MANIA VS ADHD DIFFER
ADHD = KID WILL NOT HAVE grandiosity and delusional thinking. VS BIPOLAR, MANIA =can have HYPERACTIVITY---talk fast / sleep less + psychotic sx = grandiosity and delusional thinking. =========== EXAMPLE = KID WITH BIPOLAR, MANIA SX: DELUSIONAL THINKING =KID THINKS doesn't need a doctor because he has powers to heal himself of all sickness. + GRANDIOSE DELUSIONS = KID THINKS "I AM THE GREATEST" + MANIA SX = He speaks rapidly and has not slept more than 6 hours
14 YEAR OLD GIRL IS BROUGHT IN BY MOM MOM COMPLAINS SHE HAS POOR GRADES DESPITE DOING WELL IN SCHOOL PREVIOUSLY TEACHER SAYS = "MIND SEEMS ELSEWHERE" GIRL IS MOODY/EASILY FRUSTRATED == GIRL HAS MANY FRIENDS NO SX OF DEPRESSION= SLEEPS WELL ======== DIAGNOSE? TX?
ADHD =look for PT WHO IS EASILY= DISTRACTABLE DOES NOT LISTEN/FOLLOW INSTRUCITONS DISORGANIZATION ================ TX= STIMULANT = METHYLPHENIDATE AMPHETAMINE
PT JUST MOVED TO COLLEGE NOW PARANOID SOMEONE MIGHT BREAK IN HAVING TROUBLE SLEEPING AT NIGHT
ADJUSTMENT DISORDER NORMAL FOR PT TO HAVE DELUSIONS= BELIEFS THAT CAN POSSIBLY BE TRUE = J-PEG BUT NOT NORMAL FOR PT TO HAVE PSYCHOSIS= HALLUCINATIONS!!!!! ========= THIS IS NOT ACUTE STRESS DISORDER = MINI PTSD == < 1 MONTH SO ALSO HAPPENS AFTER A MAJOR STRESSOR THAT INVOLVES DEATH/NEAR DEATH
CRITERIA THAT SEPERATES ADJUSTMENT DISORDER VS MDD
ADJUSTMENT DISORDER = SX OF DEPRESSION MUST NEVER LLAST LONGER THAN > 6 MONTHS FOLLOWING A STRESSOR =========== TRICKY = BOTH MDD + ADJUSTMENT DISORDER CAN OCCUR WITHIN 3 MONTHS POST A STRESSOR
AFTER BREAKING UP WITH HER BF PT FEELS SAD, ANXIOUS, STAYS INDOORS
ADJUSTMENT DISORDER---this can have both anxiety and depression like sx! =============== MDD VS ADJUSTMENT DISORDER = SX MUST NEVER PERSIST > 6 MONTHS IN ADJUSTMENT DISORDER, IF THEY DO THEN ITS MDD ============= this is not acute stress disorder, = because this require the patient is exposed to a traumatic even and BREAKING UP/ MOVING TO COLLEGE = NOT AS TRAUMATIC STRESSORS
PT'S WIFE RECENTLY DIED HE IS SAYING HE "WANTS TO KILL HIMSELF" WHAT SHOULD DOC TO
ADMIT PT TO PSYCH CENTER = EVEN IF HAVE TO DO THIS INVOLUNTARILY = THIS IS ESP DONE FOR PTS WITH CLEAR PLAN OF HOW THEY WANT TO COMMIT SUCIDE OR HX OF PREVIOUS ATTEMPTS OF SUCIDE
BY WHAT AGE A KID'S FAILURE TO SAY 200 WORDS =CONSIDERED SPEECH DELAY
AGE 3 2 YR OLD=SPEAKS 200 WORDS SO IF BY AGE 3, KID STILL CANT SAY 200 WORDS =CONSIDER IT A SPEECH DELAY
WHICH AGE DO KIDS NORMALLY UNDERSTAND DEATH ============= KID DOES NOT SPEAK AT SCHOOL BUT MOM SAYS SHE HAS NOT NOTICED MUCH CHANGE IN HIS LANGUAGE AT HOME ================== WHAT IS factitious disorder by proxy?
AGE 7-8 ============ SINCE KID ONLY DOESNT SPEAK AT SCHOOL = SELECTIVE MUTISM ================ factitious disorder by proxY = MOM WANTS SYMPATHY GIVEN TO PARENT OF A SICK CHILD SO MOM INTENTIALLY PRODUCES SX IN KID
PT ON ARIPRAZOLE= 2ND GEN ANTI PSYCH DRUG NOW HE FEELS RESTLESS DIAGNOSE? TX?
AKATHISIA= RESTLESSNESS TX= NOT BENZOTROPINE!!!----restless kuthi has special tx INSTEAD TX= PROPANOLOL==IST LINE 2ND LINE==BENZODIAZIPINES == If pt has CI to B BLOCKER ========== anticholinergic agents = such as benztropine are used to treat extrapyramidal symptoms such as dystonia or parkinsonism.
Tongue Protrusion and Twisting, Lip Smacking, Pouting, Puckering, Chewing Movements, Piano Movements, Foot Tapping, Toe Extension, Torticollis, Shoulder Shrugging, Rocking or Swaying, Grunting Noises
Tardive Dyskinesia
. A 17-year-old high school student attends a college fraternity party hosted by his elder brother. After several hours, he feels more courageous and approaches ladies he would normally be too shy to engage, his words are slightly slurred, and he has difficulties moving in a straight line. He is slightly flushed and notes mild memory problems for events earlier in the night. =========================== On the third postoperative day your 63-year-old patient becomes agitated, demands you remove the snakes from his room, and asks why it's so loud at night (it's daytime). He is tachycardic, hypertensive, and tremulous
ALCOHOL INTOXICATION==OVERDOSE = SHY GUY TALKIN TO GIRLS/ SLURRED WORDS/ AMNESIA worsening motor performance, incoordination and judgment errors, mood lability, nystagmus, slurred speech, potential blackouts, altered vital signs, and possibly death. ============================== ALCOHOL WITDRAWL = MOST COMMON IN POST-OP PTS/ HOSPITALIZED FOR SOMETHING---SO HAVENT GOTTEN A CHANCE TO DRINK ALCOHOL WITHIN 6 HOURS = SWEATING/PALPITATIONS ================= 12-48 HRS= UPTO 2 DAYS = SEIZURES ================= UPTO 2 DAYS = ALCOHOLIC HALLUCINATIONS = AUDITORY/VISUAL HALLUC = UNLIKE DTs, VITALS ARE NORMAL DURING THIS ================== 2-4 DAYS = DTs = FEVER!! HTN HIGH HR SWEATING
man is admitted to the emergency room after he was witnessed having a seizure Vital signs include: blood pressure 165/105 mm Hg, pulse 120 beats/minute
ALCOHOL WITDRAWL ((NOTE- NO info on pupil size so rule out heroin/opiate, cocaine) Symptoms of this delirium include: autonomic hyperactivity==HIGH BP, HIGH HR hallucinations TX= BENZODIAZIPINE
PT CAME TO ED WITH SOB CHEST XRAY=CONFIRM= PNEUMNIA HE IS ADMITTED AND TX WITH ANTIBIOTICS NOW HE HAS FOLL. SX: SAYS THINGS ARE "CRAWLING ON HIM" profusely diaphoretic, agitated, with tachycardia to 142, hypertensive at 162/98, and is tremulous
ALCOHOL WITHDRAWL = HIGHLY SUSPECT THIS IN PT'S WHO HAVE BEEN ADMITTED TO HOSPITAL FOR ANYTHING BECAUSE THIS MEANS PT HAVEN'T HAD ANYTHING TO DRINK FOR >1 DAY TX= BZ= NEED TO GIVE SOMETHING THAT ACTS FAST = LORAZEPAM ((CHLORDIAZEPOXIDE= BAD CHOICE BECAUSE THIS IS LONG ACTING SO NOT GOOD FOR ACUTE TX OF ALCOHOL WITHDRAWL)) ========= DONT CONFUSE SAYS THINGS ARE "CRAWLING ON HIM" = AS COCAINE INTOXICATION! BECAUSE ALCOHOL WITHDRAWL ALSO HAS = HALLUCINATIONS
DEFINE ALEXIA VS AGNOSIA VS ANOMIA VS APRAXIA ======== FOR OCD WHAT IS A NON-DRUG TX
ALEXIA= CAN'T READ AGNOSIA==CAN'T "RECOGNIZE" OBJECTS=DEPSITE ALL SENSES BEING INTACT ANOMIA==CAN'T NAME OBJECTS APRAXIA==MOTOR DEFICIT= inability to perform learned motor skills despite normal strength and coordination. ======= OCD = Cognitive behavioral therapy for OCD is the nonpharmacologic therapeutic treatment of choice SUSPECT OCD IN THIS KID = An 8-year-old boy with erythematous, chapped hands, and an otherwise normal physical and laboratory examination. = CHAPPED HANDS AND NOTHING ELSE ABNORMAL =DUE TO EXCESSIVE WASHING
PT STOP TAKING HER DRUGS FOR MANIA BEFORE GETTING PREGNANT BUT DURING PREG, ALL HER MANIA SX =RETURNED WHAT DOES DOC DO
ALL 3 MANIA MOOD STABILIZER= TETRAGENIC = LITHIUM, VALPORIC ACID, CARBAMEZIPINE SO STUCK WITH TX THIS PREG PT WITH MANIA = ECT electroconvulsive therapy (ECT) = ECT has been used in pregnancy for more than 50 years and its safety and efficacy is well documented
NAME THE ONLY 4 "MATURE" DEFENSE MECHANISM
ALTRUISM= HELP OTHERS IN ORDER TO AVOID NEGATIVE FEELINGS HUMOR SUBLIMATION= CHANGE IMPUSLES INTO SOCIALLY ACCEPTABLE BEHAVIOR = EX AGGRESSIVE TEENAGE BECOMES A WRESTLER = For example, a man with strong homicidal impulses writes extremely graphic but successful horror novels SUPPRESSION= PUTTINNG UNWANTED FEELINGS ASIDE TO COPE WITH REALITY
TX OF DRUG INDUCED PARKINSONISM = PARKINSON SX AS S.E. OF ANTIPSYCHOTIC DRUGS = RIGITIY BRADY-KINESIA
AMANTADINE OR BENZTROPINE
DOC FOR MIGRAINES/HEADACHES + MDD
AMITRIPTYLINE = TCA
WHICH ANTIDEPRESSANT CAN TX DIABETIC NEUROPATHY AND PREVENT MIGRAINES
AMITRIPTYLINE=== TCA
most IMP SIDE EFFECT OF ECT HOW MANY SESSIONS OF ECT DO PTS WITH MDD USUALLY NEED
AMNESIA =BOTH RETROGRADE + ANTEROGRADE NEED 6-12 SESSION OF ECT
PT BELIEVES "college administration was sending a "hit squad" to kill him also notes that he can see "visions" of men dressed in black URINE TOX. POSITIVE FOR WHAT
AMPHETMINE OVERDOSE = PARANOIA Amphetamine intoxication can result in a psychosis very closely resembling acute paranoid schizophrenia, with symptoms including paranoid delusions!!! and visual hallucinations
TX FOR ANOREXIA VS BULIMIA
ANOREXIA = 1ST LINE = CONGIT. BEHAV THERAPY POSSIBLE FORCE FEEDING LAST RESORT = OLANZAPINE TO GAIN WEIGHT ================ BULIMIA TX = 1ST CHOICE = COGNITIVE BEHAV THERAPY WITH== +/- SSRI= FLUOXETIINE ======================= NOTE = NO SSRI FOR TX OF ANOREXIA!
ALL ANOREXIA VITALS/LABS WHAT COMPLICATION= JUSTIFIES HOSPITALIZATION
ANOREXIA PT WITH CARDIAC ARRYTHMIA===> IMMED HOSPITALIZE ==== VITALS LOW HR LOW BP LOW WBC=LEUKO=PENIA LOW TEMP= HYPOTHERMIA BODY- LAGUNO /THIN HAIR ALSO= SECONDARY AMENORHEA UNLIKE BULIMIA, LOW WEIGHT ALSO HYPO-KALEMIA, HYPO-PHOSPHATEMIA DEATH FROM- CARDIAC PROBLEMS
BULIMIA VS ANOREXIA TX WHICH ONE USE== SSRI WHICH IS DOC FOR ANOREXIA = BULIMIA WHAT IS A WEIRD CHOICE OF DRUG TO TX THESE PTS
ANOREXIA= OTHER THAN THERAPY = NOT SSRI ! = OLANZAPINE= TO GAIN WEIGHT ======VS=========== BULIMMIA = THERAPY + SSRI ====== WEIRD DRUG TO TX BULIMIA = TOPIMARATE== ANTI-SEIZURE DRUG
Family counseling and special education Major rule-outs are ID, hearing impairments, environmental deprivation, selective mutism and Rett syndrome
Tx and DDx of Autism Spectrum Disorders
Forced naps at regular time of day, psycho-stimulants are preferred. If cataplexy is present antidepressants such as TCAs are preferred. Gamma-hydroxybutyrate is also used to improve quality of nighttime sleep.
Tx of Narcolepsy
delIRIUM INDUCED HALLUCINATIONS/DELUSIONS IS THE TX BZ OR ANTIPSYCHOTIC
ANTIPSYCHOTIC= HALOPERIDOL PRETEST--NEED TO CHECK IF LANGE/PRETEST CORRECT Haloperidol is a commonly used drug to treat the psychotic symptoms that may be apparent in delirious patients
19 YEAR OLD ADMITS TO DOING DRUGS DRINKING ALCOHOL NOT BEING SAFE DURING SEX
ANTISOCIAL PERSONALITY DISORDER HE IS BREAKING LEGAL RULES = DOING DRUGS, DRINKING ALCOHOL
Dopamine precursors (Levodopa, carbidopa) Dopamine agonists (bromocriptine) Anticholinergic medications (Benzotropine, trihexphinidyl) Amantadine and selegiline
Tx of Parkinson disease
Onset of mood sx occurs during pregnancy or in the 4 weeks following delivery, depressed mood, weight changes, sleep disturbances, and excessive anxiety, may have negative feelings towards child and treated with antidepressants
Depressive disorder with postpartum onset
Usually depends on an individual's emotional strength and coping skills. Extremely common; all age groups Complaints of overwhelming anxiety, depression, or emotional turmoil associated with specific stressors Social and occupational performance deteriorate, erratic or withdrawn behaviour
Adjustment disorder
Depressed mood Anxiety Mixed anxiety and depressed mood Disturbance of conduct Mixed disturbance of emotions and conduct
Types of adjustment disorders
Perception of the environment is often distorted or strange during episodes of depersonalization, accompanied by a feeling of being detached from physical surroundings.
Derealization
RUMINATION DISORDER?
COMMON IN INFANT/ YOUNG CHILDER PTS "REGURGITATE" CHEWED FOOD ---> SX SIMILAR TO GERD = INDIGESTION RECURRENT STOMACH ACHE HENCE VERY IMP TO RULE OUT THAT PT DOESNT ACTUALLY HAVE GERD PYLORIC STENOSIS OTHER ESOPHAGEAL CONDNS, ETC --------- PHYSICAL EXAM HALLMARK = BAD BREATH CHAPPED LIPS TOOTH DECAY
Haloperidol, Fluphenazine, chlorpromazine
Typical antipsychotics
Treatment for Highly-Resistant (2 Anti-Psychotics) or Suicidal Schizophrenia
Clozapine; Monitor White Count and Absolute Neutrophil Count (Also Causes Seizures, Myocarditis, or Metabolic Syndrome)
WHAT KIND OF MEMORY LOSS IS THIS PT CANT REMEMBER = RECENT RECALL =============== WHAT IS Dissociative amnesia
ANTEROGRADE AMNESIA = the loss of immediate or short-term memory; = patients are unable to form new memories. =============VS---------------- RETROGRADE AMNESIA = is the loss of remote or previously formed memories. ==========VS=============== Dissociative amnesia is the loss of memory for a period of time without the loss of ability to form new memories. It is usually associated with emotional trauma == LIKE I CANT REMEMBER MUCH WHEN OUR HOUSE ROOM GOT ON FIRE
OVERDOSE OF WHAT? URINARY RETENTION DRY SKIN/MUCUs MEMBRANES
ANTI=CHOLINERGIC POISONING LOOK FOR MUSCLE/ MOTOR SX = TREMORS MYOCLONIC JERKS
TX OF PARKINSONISM DUE TO EXTRAPYRAMIDAL SE FROM ANTIPSYCH DRUGS
ANTICHOLINERGIC = BENZTROPINE ====================== SX- COGWHEEL RIGIDITY MASKED FACIES BRADY=KINESIS PILL ROLLING TREMOR
PTS WHO ARE GIVEN BENZTROPINE CAN HAVE WHAT KIND OF S.E. ========= WHAT DRUG CAN BE GIVEN TO REPLACE= BENZTROPINE FOR PT'S HAVING A LOT OF THESE S.E.s
ANTICHOLINERGIC S.E. = BLOCK PARAYSYMP= INCREASE SYMPH SX = tachycardia, dilated pupils, and flushed skin URINARY RETENTION ======== IF PT IS EXP BENZTROPINE S.E = SWITCH TO AMANTADINE
MIRTAZAPINE USE? MOA? S.E.
ANTIDEPRESSANT MOA = BLOCKS ALPHA 2 RECEPTOR BLCOKS HISTAMINE RECEPTOR BLOCKS SEROTONIN RECEPTOR S.E. = WEIGHT GAIN= INCREASE APETITE H1 BLOCK===> SEDATION
PT TAKING ANTYPSYCH DRUGS NOW HAS DECREASE LIBIDO BREAST ENLARGEMENT W. GAIN WHICH PATHWAY AFFECTED?
ANTIPSYCH DRUGS = BLOCK DOPAMINE = INCREASE PROLACTIN = AMENORHEA GYNECOMASTIA SEXUAL DYSFUNCTION ========= TUBERO-INFUNDIBULAR PATHWAY
Treatment of choice for rapid-cycling bipolar disorder, or when lithium is ineffective, impractical, or CI May cause sedation, cognitive impairment, tremor, GI distress, hepatotoxic
Divalproex
WHAT PART OF BRAIN IS MOST ACTIVE IN FOLLOWING STATES ANXIETY VS FEAR ANGER MEMORY FORMATION
ANXIETY = The locus ceruleus is the "alarm" center of the brain and is hyperactive in anxiety states. It is the location of most of the norepinephrine-containing neurons in the brain. ===========VS================ FEAR ANGER MEMORY FORMATION The amygdala and hippocampus, both part of the limbic system, are involved in fear/anger responses and memory formation, respectively. ==================================== The basal ganglia coordinate motor activity,
PT WITH GENERALIZED ANXIETY DISORDER WORRY ABOUT WHAT KIND OF THINGS
ANXIETY MUST PERSIST > 6 MONTHS WORRY ABOUT MULTIPLE ASPECTS OF LIFE = FINANCES WORK FAMILY ETC
PRETEST TX OF = CATAPLEXY -] r tendency to collapse on the floor whenever she feels strong emotion
ANY MDD DRUG Many antidepressants, including SSRIs, TCAs, and MAOIs, can be useful in the treatment of cataplexy
PT A = A 7-year-old boy who performs well in school, but seems to talk as if reciting a monologue rather than interacting in conversation and generally avoids other children. ============== PT B = A 6-year-old boy, who is having difficulty in school, avoids interactions with his classmates and others. He is noted making repetitive rocking movements.
ASPERGERS---think of heather from ANTM UNLIKE AUTISTIC KIDS, THESE KIDS language is normal (even though sounds like reciting monologue in this kid) however his use of expressive language appropriately in social situations is severely impaired. ======================== PT B = AUTISTIC = display stereotyped and repetitive movements plus they UNLIKE ASPERGER KIDS, also have impaired expressive language ========= BOTH AUTISTIC AND ASPERGER KIDS HAVE = IMPAIRED SOCIAL SKILLS
mom brings 4 YEAR OLD SON FOR EVAL THIS SON GRABS DOCS KEYS AND he takes the key and locks and unlocks your door = repeatedly. Despite attempts to redirect and distract him, he remains = preoccupied with this task. DIAGNOSE? CRITERIA?
AUTISM = REQ FOR DIAGNOSIS: LANGUAGE DELAY/IMPAIRMENT another example = He spends hours lining up his toy cars or spinning their wheels = preoccupied with this task
PT TURNED DOWN A PROMOTION WHICH WOULD REQUIRE HER TO WORK WITH A TEAM SHE WORRIES THAT THE TEAM WILL THINK SHE IS INADEQUATE
AVOIDANT PEROSNALITY
MOM BRINGS HER DAUGHTER WITH CONCERN THAT SHE HAS NO FRIENDS STAYS IN HER ROOM DAUGHTER SAYS "NO ONE WANTS TO BE FRIENDS WITH SOMEONE UGLY/STUPID LIKE ME"
AVOIDANT PERSONALITY DISORDER = PT WANTS TO MAKE FRIENDS BUT UNABLE TO DUE TO FEELING INFERIOR OR INTENSE FEAR OF BEING REJECTED/EMBARASSED =========VS==== SCHIZOID PERSONALITY DISORDER = PT DOESNT HAVE FRIENDS BECAUSE PT HAS NO DESIRE OF MAKING FRIENDS = HAPPY LONERS
PT ADMIRES HER COWORKERS FOR AFAR DAILY BUT NEVER GOES AND TALKS TO THEM DUE TO HALLMARK = FEAR OF REJECTION WORRY ABOUT HOW OTHERS WILL PERCIEVE HER
AVOIDANT PERSONALITY DISORDER = SHY PEOPLE LOW SELF ESTEEM WANT FRIENDS UNLIKE SCHIZOID===DONT CARE ABOUT HAVING FRIENDS
Effect of Risperidone on Negative Symptoms (Flat Affect)
Activation of Serotonin Receptors
Spasms of various muscle groups, can be dramatic and frightening to pt. Can tx with anticholinergics such as benzotropine, diphenhyramine, or trihexphenyldine
Acute dystonia
Depression or Anxiety Within 3 Months of Stressor (Must Return to Normal by 6 Months After Stressor)
Adjustment Disorder; Treat with Psychodynamic or Cognitive Psychotherapy
Maladaptive reactions to an identifiable psychosocial stressor
Adjustment disorder
Imaging Change: Obsessive-Compulsive Disorder
Frontal Cortex Abnormalities
Fear or avoidance of places from which escape would be difficult in the event of panic symptoms
Agoraphobia
Motor restlessness, often mistaken for anxiety and agitation. Tx by lowering the dose, adding benzos or beta blockers
Akathisia
Ataxia, Impaired Judgment; No Hallucinations
Alcohol
Talkativeness, sullenness, gregariousness, moodiness, etc.
Alcohol
(1) Sweating and Tremors (Seizures Possible) After 6 Hours; (2) Audio-Visual Hallucinations During 1st Day; (3) Both (Delirium Tremens) After 2 Days; Altered Sensorium and Autonomic Instability
Alcohol or Benzodiazepine Withdrawal
1. Diuretics. 2. Non-Steroidals Except Aspirin. 3. SSRIs. 4. ACE Inhibitors or ARBs. 5. Anti-Epileptics.
Alter Lithium Dose
Long-acting cholinesterase inhibitors such as donepezil, rivastigmine, galantamine and memantine
Alzheimer Tx
Occupy more than 50% of nursing home beds, increased in females, family history, head trauma and Down syndrome. Cortical atrophy, flattened sulci, and enlarged ventricles
Alzheimer disease
Senile plaques (amyloid deposits), neurofibrillary tangles, neuronal loss, synaptic loss, and granulovacuolar degeneration of neurons. Associated with chromosome #21 Decreased ACh and NE Gradual; average duration from onset to death is ~8 years. Focal neurologic sx are rare Sundowning
Alzheimer disease
d pilot is brought in for evaluation because he has not slept for days, and now he is anxious, tachycardic, tremulous, and unable to give coherent history . His pupils are dilated and his blood pressure is high, despite normal values 2 weeks ago on a flight physical
Amphetamine intoxication==STIMULANT STIMULANT---> HAVENT SLEPT IN DAYS, VITALS SHOWING INCREASE SYMPATHETICS = tachycardia pupillary dilation, insomnia, blood pressure changes, sweating or chills, nausea or vomiting both behavioral and physiological changes. Patients may experience euphoria , interpersonal sensitivity, anxiety, tension, or anger, impaired judgment, =========================================== Amphetamine withdrawal = y fatigue, vivid dreams, sleep disturbances, increased appetite, and psychomotor retardation or agitation.
Euphoria, hypervigilance, autonomic hyperactivity, weight loss, papillary dilatation, perceptual disturbances
Amphetamines, cocaine
Anxiety, tremulousness, headache, increased appetite, depression, risk of suicide
Amphetamines, cocaine withdrawel
Imaging Changes: Panic Disorder
Amygdala Atrophy
Irritability, aggression, mood changes, psychosis, heart problems, liver problems, etc
Anabolic steroids
Depression, risk of suicide
Anabolic steroids withdrawel
CaGEd SPAS (2 Weeks)
Anhedonia or Depression; Plus 4 of the Following: 1. Concentration. 2. Guilt (Worthlessness). 3. Energy. 4. Sleep. 5. Psycho-motor Retardation. 6. Appetite. 7. Suicidal Ideation.
Average age is 17 years, very late onset has a poorer prognosis Restricted food intake and maintaining diets of low-calorie foods. Weight loss may also be achieved through purging and exercise. Emaciation, hypotension, bradycardia, lanugo, and peripheral edema
Anorexia Nervosa
Failure to maintain a normal body weight, fear and preoccupation with gaining weight and unrealistic self-evaluation as overweight. Subtyper are restricting and binge-eating/purging
Anorexia Nervosa
Re-feeding Syndrome (Hypophosphatemia) vs. Responsive to SSRI
Anorexia vs. Bulimia
Difference Between Toxicity from Amphetamines and Anti-Cholinergics
Anti-Cholinergics Cause Dryness and Clonus (Both = Mydriasis, Delirium, Hyperthermia, Tachycardia, HTN)
Mechanism of Weight Gain and Sedation from Olanzapine
Anti-H1 (Histamine)
Adult; Difficulty Maintaining Employment
Antisocial
Name the Personality Disorder: Violoate rights of others, social nroms, laws. Impulsive, Lack Remorse. Long criminal record
Antisocial
Characterized by continuous antisocial or criminal acts, inability to conform to social rules, impulsivity, disregard for the rights of others, aggressiveness, lack of remorse, and deceitfulness
Antisocial PD
List of Benzos
Aprazolam (Xanax) - short acting most adictive Clonazepam Diazepam (Valium) - long acting Lorazepam (Ativan) - does not require liver metabolism
Partial D2 Agonist
Aripiprazole (Abilify)
Family conflict and school failure, low self-esteem and mood lability, early onset of substance abuse, ADHD and learning disorders and conduct disorder may follow
Associate problems and outcome of Oppositional Defiant disorder
diagnose? tx? PT HAS MULTIPLE SUCIDE ATTEMPTS + MANY DIFF. RELATIONSHIPS WITH MEN =============== ALTHOUGH SSRI = SAFE PREGNANCY WHAT CAN BABY END UP WITH IF MOM HAD BEEN ON SSRI
BORDERLINE PERSONALITY DISORDER TX = #1== DBT +/- SSRI= FLUOXETINE =========== SSRI USE IN PREG MOM ===> BABY WITH==PULMONARY HTN (E) persistent pulmonary hypertension of the newborn
Inattention, hyperactivity, and impulsivity that interfere with social or academic function. Sx occur before 12 yo and sx are present in multiple settings
Attention Deficit Hyperactivity Disorder
Hypersomnia and Increased Appetite; Leaden Paralysis
Atypical Depression; Treat with Mono-amine Oxidase Inhibitor
Risperidone, olanzapine
Atypical antipsychotics
Work mostly on dopamine and serotonin receptors, treat positive and negative symptoms (flat affect, poor grooming, social withdrawel, anhedonia) and have fewer side effects; always used as first line agents
Atypical antipsychotics
Name the Personality Disorder: Socially inhibited, Rejection sensitive. Fear of being disliked or ridiculed
Avoidant
Have social inhibition, feelings of inadequacy, and hypersensitivity to criticism. They shy away from work or social relationships because of fears of rejection that are based on feelings of inadequacy. They feel lonely and substandard and are preoccupied with rejection.
Avoidant PD
DIAG? PT = RECURRENT SUCIDAL/SELF HARM BEHAVIOR FEEL EMPTY PATTERN OF INSTABILITY OF RELAITONSHIPS
BORDERLINE PERSONALITY DISORDER = OFTEN SHOW "SPLITTING" = EITHER SOMETHING IS VERY GOOD OR VERY BAD
TX FOR PT WHO IS AFRAID OF = SPEAKING IN FRONT OF A CROWD VS AFRAID OF= SNAKES/ FLIGHTS/ SPECIFIC THINGS
B-BLOCKER = TX FOR PT WHO IS AFRAID OF = SPEAKING IN FRONT OF A CROWD VS DESENSITIZATION, FLOODING TECHNIQUE = TX FOR PHOBIA OF SPECIFIC THING= SNAKES/ FLIGHT/ETC
PT WITH SX OF DEPRESSION SUBSTANCE ABUSE SHE DENIES= SUICIDE THOUGHTS Which of the following would be the most appropriate plan for treatment? (A) Admit her to the hospital given her history and potential risk. (B) Ask your psychiatric colleague to see her within the next few days. (C) Prescribe antidepressant medications and schedule a follow-up appointment in 1 month. (D) Refer her to a social worker. (E) Tell the mother you'll follow up with her at your next routine visit. ================= FIRST LINE TX OF MDD?
B= ANSWER EVEN THOUGH SHE DENIES SUCIDE THOUGHTS, HER HX OF MDD + SUBSTANCE ABUSE = SHE NEEDS TO BE SEEN BY A PSYCHIATRIST ASAP ======= IF PSYCHIATRIST GIVES HER ANTI-DEPRESSANTS = SHE WILL NEED A F/U < 1 WK ========== DOESNT NEED TO FORCIBLY HOSPITALIZE since she does not appear at imminent risk of self-harm =========== SSRI===SERTRALINE==1ST LINE TX OF MDD
social anxiety d/o tx
BB like propanolol ! or benzo
SX OF AMPHETAMINE OVERDOSE/INTOXICATION
BEHAVIOR CHANGES = PT USED TO BE POLITE, BUT NOW "IRRITABLE" PARANOID WITH SX OF INCREASE IN SYMPATHETIC SINCE THIS IS AMPHETAMINE OVERDOSE = DILATED PUPILS HTN HIGH HR =
TX OF CATANOIC STATE (See above)
BENZODIAZEPINE==== LORAZEPAM OR ECT EVEN IN A PT WITH MDD, CATATONIC SUBTYPE = GIVE BZs INSTEAD OF SSRI
CLOMIPRAMINE IS
BEST STUDIED MED FOR OCD == THIS IS A TCA LANGE === The best-studied medication to treat OCD is clomipramine, a TCA. SSRIs are also very effective in treating symptoms of OCD, but usually at doses higher than those used to treat depression
difference between BIPOLAR 1 VS BIPOLAR 2 VS CYCLO-THYMIC DISORDER
BIPOLAR 1 = DOES NOT NEED MAJOR DEPRESSION = JUST MANIA ALONE ENOUGH FOR DIAGNOSIS = COMMONLY PTS TEND TO HAVE BOTH MANIA + MAJOR DEPRESSION (but this is not req) ============== BIPOLAR 2 = MAJOR DEPRESSION + HYPO=MANIA =============== CYCLO-THYMIC DISORDER = 2 YEARS OF = MILD MANIA= HYPO MANIA AND MILD DEPRESSION
pt says she is feeling sad/ cant sleep/ lost weight after losing her job Additionally, she describes a period about a year ago in which she stayed up for several days in a row planning a big party for her husband's birthday; at that time, others commented that she was talking quickly and acting "like the energizer bunny."
BIPOLAR 2 = NOW HAD== MDD PREVIOUSLY HAS SX OF = HYPO-MANIA =============== TX OF DEPRESSION IN BIPOLAR = LAMOTRIGINE ========== TX OF HER CURRENT DEPRESSION= THAT IS NOT JUST MDD BUT DEPRESSION THAT IS PART OF BIPOLAR = NOT SSRI!===DANGEROUS TO HER HER A ANTIDEPRESSANT SINCE THESE COULD EXACERBATE HER MANI ((Monotherapy with antidepressants = (eg, bupropion, fluoxetine, venlafaxine) is not recommended due to the risk of inducing mania)) =
POST PARTUM PSYCHOSIS MANIFEST AS WHAT PSYCH DISORDER, ================================ PT WITH PSYCHOTIC SX= HEARING VOICES AND URINE TOXICOLOGY = POSITIVE DIAGNOSE? ========================= HOW LONG IS CRITERIA FOR DIAG TO BE BREIF PSYCHOTIC DISORDER
BIPOLAR DISORDER === LOOK FOR A NEW MOM WITH HALLUCINATIONS/ DELUSIONS THOUGHTS OF HURTING BABY =================== EVEN IF OBVIOUS SCHIZOPHRENIC SX, IF URINE TOXICOLOGY= POSITIVE FOR DRUG THEN PSYCHOTIC SX DUE TO substance-induced psychotic disorder IMPORTANT==THIS IS WHY IT IS VERY IMPORTANT TO ORDER URINE TOXICOLOGY FOR EVERY PT WHO COMES IN WITH ABSOLUTELY ANY PSYCHOTIC SX, MOOD SX =========== BREIF PSYCHOTIC DISORDER = > 1 DAY AND < 1 MONTH VS. Schizophreniform disorder refers to symptoms lasting more than 1 month but less than 6 = in the absence of concurrent mood disorder, substance use, or a general medical condition
15 YR OLD PT COMES IN WITH SX OF PARANOIA = THINKS GOVMT IS SPYING ON HIM WHAT CONDITION DOES HE POSSIBLY HAVE/? (A) anorexia nervosa (B) bipolar disorder, manic (C) borderline personality disorder (D) generalized anxiety disorder (E) major depressive disorder
BIPOLAR DISORDER, MANIA = OFTEN PRESENT WITH PSYCHOTIC SX LIKE hallucinations, delusions, and disorganized thinking. ((REM- BIPOLAR MANIA TX = ANTI-PSYCH DRUG + MOOD STABILIZER) ============ NEVER HAVE ANY PSYCHOTIC SX = ANOREXIA + GAD ================== BORDERLINE=DONT HAVE PSYCHOTIC SX INSTEAD HAVE depression, suicidal thinking, and substance abuse. ============= MDD==CAN SOMETIMES HAVE PSYCHOTIC SX LIKE PARANOIA BUT NOT AS COMMONLY AS BIPOLAR= = major depressive disorder with psychotic features
KID HAS PSYCHOTIC SX== DELUSIONAL BELIEFS= CAN TALK TO GOD + MANIA SX==TALKS TOO FAST DIAG? WHAT ILLICIT DRUG CAN CAUSE BOTH MANIA + PSYCHOTIC SX
BIPOLAR, MANIA (see above) MANIA + PSYCHOSIS OCCUR AS A RESULT OF USE OF = COCAINE = STIMULANT THAT CAN PRODUCE BOTH MANIA + PSYCHOTIC SX ============= IN COMPARISON: Alcohol, cannabis, heroin, and PCP ingestion can induce a psychotic state including hallucinations and paranoia, but it would not classically be accompanied by manic symptoms.
woman with bipolar disorder develops a high fever with chills , bleeding gums, extreme fatigue, and pallor WHICH DRUG IS SHE ON?
BLEEDING GUMS/ PALLOR= ANEMIA/ FATIGUE = SX OF APLASTIC ANEMIA = S.E. OF CARBAMEZIPINE
WHICH ANOREXIC PT NEED TO BE HOSPITALIZED
BMI < 17, ==MOST IMP metabolic derangements, are classic board ways of determining "severe" disease.
2 Differences Between Anorexia Nervosa and Bulimia
BMI Under 18.5; Amenorrhea
FEMALE PT ADMITTED FOR ATTEMPTING SUCIDE SEVERAL PREVIOUS ATTEMPTS AT SUCIDE TROUBLE WITH HUSBAND BEEN DIVORCE BEFORE
BORDERLINE PERSONALITY SX OF SPLITTING = "ALL RESIDENTS ARE BAD VS ALL ATTENDINGS ARE GOOD"
PT HAS RAPID MOOD SWINGS + rage attacks," where she will break items, scream, or scratch herself superficially on her arms + 30 SEXUAL PARTNERS + become deeply depressed for hours to days, usually in response to separation from a loved one WHAT KIND OF PERSONALITY DISORDER? WHAT KIND OF DEFENSE MECHANISM?
BORDERLINE PERSONALITY DISORDER==ali's mom they used = SPLITTING=DEFENSE MECH. ALSO HAVE: recurrent self-mutilation or suicidality
DIFF BETWEEN CONDUCT VS ANTI=SOCIAL PERSONALITY DISORDER
BOTH = /ILLEGAL ACTIVITIES= THEFT, DRUG USE HARM OTHERS = ASSAULT HURT ANIMALS ======== CONDUCT <18 YEAR OLD VS ANTI SOCIAL PERSONALITY = >18
SX OF "OVERDOSE" WITH COCAINE METH-AMPHETAMINE
BOTH ARE STIMULANTS COCAINE OVERDOSE = CHEST PAIN SEIZURES MYDRIASIS ----------------------- COCAINE OVERDOSE= PT MAY HAVE TRACK MARKS ON ARMS ================ METH-AMPHETAMINE OVERDOSE = VIOLENT SWEATING HIGH HR HIGH BP
WHAT DIFFERENTIATES ASPERGERS VS AUTISM
BOTH HAVE = LIMITED INTEREST IMPAIRED SOCIAL INTERACTIONS =========== ASPERGERS = NORMAL LANGUAGE VS AUTISM = LANGUAGE DEFICIT
DIFFERENCE BETWEEN OVERDOSE OF BENZODIAZIPINES VS OPIATE
BOTH HAVE = LOW RESPIRATION POSSIBLE SEDATION OPIATE OVERDOSE = MIOSIS -= TX-- NALOXONE ((methadone long term)) VS BZ OVERDOSE = MYDIRASIS= PUPIL DILATION = TX= FLUMAZENIL
DIFFERENCE BETWEEN CONDUCT DISORDER VS OPPOSITIONAL DEFIANT DISORDER
BOTH PT MUST BE < 18 YR OLD CONDUCT DISORDER = BREAK "LAW"= STEAL/ VANDALIZE VS OPPOSITIONAL DEFIANT DISORDER = NO BREAKING "LAW"= dont listen to authority etc
DIFFERENCE BETWEEN ACUTE STRESS DISORDER VS ACUTE/ BREIF PSYCHOTIC DISORDER
BOTH REQ SX TO PRESENT < 1 MONTH/ 4WEEKS ACUTE STRESS DISORDER = MINI PTSD == < 1 MONTH SO ALSO HAPPENS AFTER A MAJOR STRESSOR THAT INVOLVES DEATH/NEAR DEATH = NO HALLUCINATIONS ((expect flash backs/ nightmares)) === ACUTE PSYCHOTIC DISORDER = MINI SCHIZOPHRENIA === < 1MONTH - HAPPENS AFTER A STRESSOR BUT UNLIKE ACUTE STRESS DISORDER, PT WILL HAVE HALLUCINATIONS
WHAT TO GIVE FOR "PROPHYLAXIS" OF ALCOHOL WITHDRAWL VS "TX" OF ALCOHOL WITHDRAWL
BOTH- BZ but IT COMES DOWN TO HALF LIFE OF BZ === CHLOR-DIAZ-E-POXIDE = LONG ACTING BZ = "PROPHYLAXIS" OF ALCOHOL WITHDRAWL ================ LORAZEPAM = SHORT ACTING BZ = "TX" OF ALCOHOL WITHDRAWL
PT'S MOM DIED 13 MONTHS AGO NOW SHE HAS : she feels alone and empty without her. While she still works, ==NO LOSS OF FUNCTION she has difficulty interacting with family and friends since the death. She is disinterested in activities and keeps mostly to herself DENIES= SUCIDAL IDEATIONS
BREAVEMENT LIKE SX BUT > YEAR = NEW DSM 5 DIAGNOSIS = Persistent Complex Bereavement Disorder (PCBD
PT'S WIFE DIED 3 MONTHS AGO NOW HE SAYS HE IS TALKING TO HER CAN SEE HER BUT ALSO SAYS "she is waiting for me to join her, don't you see? I need to go join her." DIAGNOSE
BREAVEMENT SX BUT ALSO SIGNS OF SUICIDE =regardless of how long its been since death MDD ========= ALTHOUGH SX ARE < 1 MONTH/ 4 WEEKS = THIS CAN NOT BE ACUTE/BREIF PSYCHOTIC DISORDER = MINI SCHIZOPHRENIA BECAUSE THIS PT IS HALLUCINATING ABOUT HIS WIFE WHO HAS RECENTLY DIED ((vs..hallucinating about something random like in schizo)) =============================== THIS CAN NOT BE ACUTE STRESS DISORDER!! = MINI PTSD = LOOK FOR < 1MONTH WITH FLASHBACKS, ETC
BREAVEMENT/GREIF HAS WHAT SX THAT MAJOR DEPRESSION DOES NOT ==============
BREIVEMENT = LESS COMMON TO HAVE SUCIDAL IDEATIONS ========================== SX "NOT" IN BREAVMENT = If he had suicidal ideation, severe loss of functioning, significant distressing auditory hallucinations or other symptoms of psychosis, = a diagnosis of major depression with or without psychotic features would be more appropriate OVER BREAVMENT =========== GREIF/BREAVEMENT = PT HAS "WAVES" OF FEELINGS OF SADNESS ((not sad all the time))
PT TAKING SSRI FOR MDD BUT COMPLAINS ITS CAUSING TO MANY SEXUAL S.E. WHICH IS THE ONLY ANTI-DEPRESSANT = WITHOUT ANY SEXUAL S.E. ======================= DIAGNOSE THIS PT SHE NEVER SLEEPS SHE NEVER SHUTS UP The patient insists this is because she has discovered an important mathematical proof that she must finish writing
BUPROPRIAN= TX MDD WITHOUT SEXUAL SE ============ THIS PT HAS MANIA TX=== LITHIUM OR VALPROIC ACID >> CARBAMEZIPINE
WHICH DRUG TX DEPRESSION + HELP SMOKIGN CESSATION =========== ANTIDEPRESSANT THAT CAUSES WEIGHT GAIN ============ MODAFINIAL USE?
BUPROPRION ((vs. buspirone= for GAD))) = ANTIDEPRESSION AND QUIT SMOKING ========= CAUSES W. GAIN = MIRTAZAPINE ALSO= OLANZAPINE, CLOZAPINE ============================== MODAFINIL = STIMULANT = MAIN DOC FOR NARCOLEPSY
BUPROPRION VS BUSPIRONE
BUPROPRION= SMOKER + DEPRESSION SEE ABOVE BUSPIRONE = TX= LONG TERM MAINTENANCE OF GENERALIZED ANXIETY DISORDER
HOW IS DOPAMINE ACTIVITY MEASURED IN BRAIN =========== WHICH SLEEP STAGE IS THIS PT IN . After he has been asleep for 90 minutes, his EEG shows low-voltage, random fast activity with sawtooth waves. When awakened during this period, the patient reports that he was dreaming
BY CHECKING AMT OF Homovanillic acid = the primary metabolite of dopamine ======== REM (((MDD== DECREASE REM LATENCY))) Dreaming is the main characteristic of REM sleep. The EEG shows random, fast, and sawtoothed A lack of muscle tone during REM sleep prevents the individual from acting out his or her dreams. REM sleep is also characterized by increased heart rate and blood pressure and penile or clitoral nocturnal===erections.
TWO CLASS OF DRUGS THAT CAUSES DELIRIUM LIKE SX- AMNESIA /CONFUSIONS/DISORIENTATION ETC SPECIFICALLY IN ELDERLY ================= . A 41-year-old woman with chronic schizophrenia has been tried on several first- and secondgeneration antipsychotics at therapeutic doses, but she remains psychotic, with auditory hallucinations telling her to kill herself
BZs AND H1 ANTAG= FIRST GEN = DIPHENHYDRAMINE ========= CLOZAPINE = FOR TX RESISTANT SCHRIZOPHENIA
WHAT IS A WARNING DOC SHOULD GIVE SPECIFICALLY TO ELDERLY PTS BEFORE GIVING BENZODIAZEPINES
BZs S.E. IN ELEDERLY = CONFUSION DISORIENTATION===>> EVEN POSSIBLE BLACK OUT AMNESIA ======= TX BZ OVERDOSE=== FLUMAZENIL ============= REMEMBER===MAJOR WARNING = BENZODIAZEPINE= = HIGHLY ADDICTING
1st-Line Therapy for Specific Phobia
Behavioral Therapy: Gradual Desensitization (Not Medications)
Suppress stage 4 and, when used chronically, increase sleep latency
Benzodiazepine
Avoid abrupt changes in dosage Use lower dosages in the elderly Do not mix with alcohol or other sedative-hypnotic medication Consider dependency potential May cause confusion, problems with memory and falls Abrupt DC may cause seizures
Benzodiazepine Clinical guidelines
Inappropriate sexual or aggressive behaviour, impairment in memory or concentration
Benzodiazepines
Autonomic hyperactivity, tremors, insomnia, seizures, anxiety
Benzodiazepines withdrawel
Integrates Mind and Body (Pulse, Temperature, or Blood Pressure) to Lower Stress and Improve Awareness of Reactions
Biofeedback
Typically experiences symptoms of elevated mood, for at least 1 week that cause significant distress or impairment in his/her level of functioning. Average age of onset is 18 years and more prevalent among high socioeconomic status. Considered to be the illness with the greatest genetic linkage.
Bipolar I Disorder
Lithium
Bipolar and schizoaffective disorders
Belief that some body part is abnormal, defective, or misshapen. Women more than men typically age 15-20 and unlikely to be married
Body Dysmorphic disorder
Name the Personality Disorder: Unstable mood/relationships Feelings of emptiness Impulsive Splitting; Manipulative
Borderline
2 of the Following: Delusions, Hallucinations, Disorganized Speech, Disorganized Behavior, Negative Symptoms (Flat Affect and Alogia)
Brief Psychotic Episode vs. Schizophreniform vs. Schizophrenia
Frequent binge-eating and purging behaviour, associated with borderline personality disorder in about 50% of pts.
Bulimia nervosa and Binge eating disorder
Seizures can be caused, so avoid in patients with eating disorders, alcohol withdrawal seizures or seizure disorders
Bupropion (Wellbutrin)
Treatment of Generalized Anxiety Disorder; Stimulates 5-HT(1A) Receptors
Buspirone; Ineffective for Acute Anxiety (Takes 2 Weeks); No Interaction with Alcohol
WITH DRAWL OF WHAT? INCREASE HUNGER IRRITABLE DROWSY FATIGUE!
COCAINE WITHDRAWL = WITHDRAWL SX ARE OPPOSITE OF NORMAL STIMULANT SX OF COCAINE = FATIGUE/IRRITABLE ETC
what DRUG'S SUBSTANCE ABUSE COMMONLY CAUSES CHEST PAIN WHAT IS TX FOR THIS PT WHO HAS HTN + COCAINE OVERDOSE
COCAINE===> CHEST PAIN =========== COCAINE INDUCED HTN = TX== PHENTOLAMINE THEN Once alpha-blockade is complete, beta blockade can safely be performed.
TX FOR HOARDING DISORDER
COGNITIVE BEHAVORIAL THERAPY = MAIN DOC COMBINE WITH = SSRI
Work mostly on dopamine receptors, treat the positive symptoms (hallucinations and delusions) and have many side effects
Typical antipsychotics
WHAT KIND OF DRUG IS CHLORPROMAZINE =========== S.E. OF WHICH DRUGS = ORTHOSTATIC HYPOTENSION
CHLORPROMAZINE = TYPICAL/ 1ST GEN ANTIPSYCH DRUG ========= ORTHOSTATIC HYPOTENSION = DIZZY UPON STANDING S.E. OF = TCAs CHLORPROMAZINE CLOZAPINE
WHAT IS CIRCADIAN RHYTHM SLEEP DISORDER vs PRIMARY HYPER-SOMNIA VS Nightmare disorder
CIRCADIAN RHYTM SLEEP DISORDER = HALLMARK=== day time sleepiness due to SLEEP SCHEDULE CHANGES FROM PT'S NORMAL SLEEP ROUTINE/SCHEDULE JET LAG NIGHT SHIFT WORK (for a pt who always had day shifts) EXAMPLE = NIGHT nurse works different shifts almost every week. She is constantly sleepy and fatigued. However, even when she has days off, she has great difficulty falling asleep at night and remaining asleep for more than 2 to 3 hours at a time ==========VS================ Primary hypersomnia = is excessive daytime drowsiness EVEN EXCESSIVE SLEEPING AT NIGHT = EXAMPLE = man has felt consistently sleepy during the day for as long as he can remember. Although he sleeps from 9 to 11 hours every night, he wakes up unrefreshed and needs to take a nap at least once a day in order to function. According to his wife and bed partner, he does not snore and he does not kick her while sleeping. Aside from the difficulties caused by his chronic sleepiness, his history is unremarkable. ==============VS============ Nightmare disorder = WHEN THERE IS NO PTSD OR ACUTE STRESS DISORDER AND PT IS STILL HAVING repeated nightmares causing significant distress
DOC FOR PT WITH HALLUCINATIONS + TRUE= PARKINSONS
CLOZAPINE ) Clozapine is the preferred treatment for psychotic symptoms in patients with Parkinson diseas
WHICH ANYTIPSYCH DRUGS S.E= WEIGHT GAIN!!! DYSLIPIDEMIA ==>> HIGH RISK OF DM
CLOZAPINE AND OLANZAPINE ======= HENCE WITH BOTH THESE DRUGS, CHECK PTS FASTING PLASMA GLUCOSE LIPID PANEL
OTHER THAN AGRANULOCYTOSIS WHAT IS ANOTHER COMMON S.E ASS. WITH CLOZAPINE
CLOZAPINE ASSOCIATED SEIZURES ============ REM- WITH CLOZAPINE, REGULARLY CHECK PT'S (B) complete blood count with differential TO CHECK FOR CLOZAPINE INDUCED a decrease in the number of WBCs, with a specific decrease in the number of neutrophil granulocytes
WHICH DRUG 'S OVERDOSE SX CAN RESEMBLE SX OF BIPOLAR 1= MANIA
COCAINE increase in energy , euphoria, DELUSIONS OF grandiosity, pressured speech SLEEP VERY LITTLE SPENDS $ FRIVOROUSLY
seizures, chest pain, hyperpyrexia, and death. Susceptible users may also experience paranoia, ranging from mild hypervigilance to frank paranoia and persecution ===================================== male admitted for depression and suicidal ideation is irritable, asks for extra food, and spends most of the first day sleeping. The chest pain he had on admission has subsided and he has no ECG changes.
COCAINE OVERDOSE = Cocaine intoxication (I) is similar to amphetamine intoxication COCAINE OVERDOSE = CHEST PAIN SEIZURES MYDRIASIS===PUPIL DILATION ========================= COCAINE WITHDRAWL = hypersomnia,--- SLEEP A LOT increased appetite, and fatigue ((CHEST PAIN ON ADMISSION COULD BE FROM INITAL COCAINE= OVERDOSE SX))
OVER DOSE OF WHAT? PT CAN GET ARRYTHMIAS MI SEIZURES STROKES
COCAINE OVERDOSE = PUPIL DILATION ================ HEROIN/OPIATE OVERDOSE = PINPOINT OVERDOSE CNS DEPRESSION CONSTIPATION
OVERDOSE OF WHAT WILL CAUSE PT TO HAVE PARANOIA EX== PT s she is afraid to leave the house unless she checks that the door is locked at least 5 times
COCAINE OVERDOSE == CAUSE= PARANOID DELUSIONS
PT HAS SUDDEN WEAKNESS IN LE BILATERALLY HER HUSBAND RECENTLY CHEATED ON HER DIAG?
CONVERSION DISORDER POST A STRESSOR = SX LIKE---can be motor or sensory loss UNEXPLAINED/SUDDEN WEAKNESS PARALYSIS NUMBNESS PARESTHESIAS SEIZURE BLINDNESS ====== OFTEN ALSO EXP "LA BELLE INDIFFERENCE" = PT FEEL STRANGELY INDIFFERENT ABOUT SX
what is IT CALLED WHEN A SCHIZOPHRENIC PT THINKS HE HAS "LOST HIS ORGANS- heart/ intestine" "LOST HIS BLOOD" EVEN "LOST WORLD"
COTARD SYNDROME
for past 2 YEARS PT MOODS EXCHANGES FROM little energy and has trouble concentrating TO feeling very good, with lots of energy and no need for sleep
CYCLOTHYMIC DYSTHYMIA = little energy and has trouble concentrating + HYPO-MANIA = feeling very good, with lots of energy and no need for sleep FOR ATLEAST LAST 2 YEARS
WHATS CYCLOTHIMIC DISORDER VS DYSTHYMIC DISORDER ========================================================= WHAT IS TX OF CYCLOTHYMIC DISORDER
CYCLOTHYMIC DISORDER = HYPO--MANIA + SUB-CLINICAL DEPRESSION VS DYSTHYMIA = > 2 YEARS=== ONLY MILD DEPRESSION ========================================================= TX OF CYCLOTHYMIC DISORDER = SAME AS TX FOR BIPOLAR DISORDER---LANGE
TX OF SEROTONIN SYNDROME
CYPRO-HEPTADINE COMBANK
Impaired motor coordination, slowed sense of time, social withdrawal, conjunctival injection, increased appetite, dry mouth, tachycardia
Cannabis
Second-line tx for bipolar disorder when lithium and divalproex is ineffective or CI Rare but serious hematologic and hepatic SE and may cause agranulocytosis
Carbamazepine
Treatment of Bipolar Disorder and Seizure Disorder; Risk of Aplastic Anemia and SIADH
Carbamazepine (Tegretol); Change if Absolute Neutrophil Count Drops Below 1000
Repeated voiding or urine into the patient's clothes or bed in a child of at least 5 years of age
Childhood Enuresis
Indication for Long-Acting Risperidone Injections (Or: Haloperidol, Fluphenazine, Paliperidone, Olanzapine, Aripiprazole)
Chronic Non-Compliance; Responsive to Oral Anti-Psychotics (Must Bridge with Oral Version)
although she is able to recognize objects, she fails to provide an accurate name for many of them. EX--- When the patient is shown a pen, she responds, "that thing that you write with," ========== WHAT IS CLANG ASSOCIATION
Circumlocution = is the substitution of a word or description for a word that cannot be recalled or spoken ERR...WHAT I DO A LOT ============== VS Clang association is the use of words based on sound and not with reference to the meaning, commonly seen in mania.
Super Detailed Answers Deviating Vaguely from Questions with Eventual Return to Original Subject
Circumstantial Speech (Schizophrenia)
2 Tri-Cyclic Anti-Depressants In Addition to Amitriptyline (Elavil) and Nortriptyline (Pamolor)
Clomipramine (Anafranil) and Doxepin (Sinequan)
Agranulocytosis
Clozapine
Gold standard for the tx of schizophrenia but not used as first line because may cause agranulocytosis so monitoring WBCs is essential
Clozapine
Anxiety, Agitation, Psychosis, Delirium; Sweating, Dilated Pupils, Nausea, or Inability to Sleep; Formication
Cocaine; Overdose Results in Arrhythmias, Infarctions, Seizures, or Stroke
Treatment of Panic Attacks
Cognitive Behavior Therapy (helps pt learn a new way to cope) SSRI's +/- Benzodiazepines
Identifies and Challenges Bad Thoughts with 12 Sessions and Home Diaries (Overgeneralization of Negative Events or Catastrophizing)
Cognitive Behavioral Therapy (Anxiety, Mood, Personality, Somatic Symptom Disorders, and Eating Disorders)
0.4-0.5% Blood EtOH level
Coma At higher levels, death may occur due to respiratory depression
Court-Determined vs. Caretaker-Determined Ability to Give Informed Consent for Therapy
Competency vs. Capacity
Persistent violations over at least 6 months in 4 areas: aggression property destruction deceitfulness or theft rules
Conduct disorder
0.3% Blood EtOH level
Confused or stuporous
Emotional Trigger, Serious Unexplained Neurological Symptom (Possible Indifference)
Conversion Disorder
Individual experiences one or more neurologic sx that cannot be explained by any medical or neurologic disorder seen more frequently in young women.
Conversion disorder
A chronic disorder characterized by many periods of depressed mood and many periods of hypomanic mood for at least two years. Many pts have interpersonal and marital difficulties with a FHx of bipolar disorder.
Cyclothymic Disorder
Tx of Ecstasy intoxication
Cyproheptadine, benzodiazepines, dantrolene
DIFF BETWEEN SCHIZOPHRENIA VS SCHIZOPHRENIFORM VS DELUSIONAL DISORDER
DELUSIONAL DISORDER = > 1 MONTH = SX= DELUSIONS= NON-BIZZARE BELIEFS= J-PEG = NO OTHER PSYCHOTIC SX + VERY IMPT = PT'S FUNCTIONALITY IS OTHERWISE NORMAL = WORK A JOB. / HAVE FRIENDS ETC ================== SCHIZOPHRENIA VS SCHIZO=PHRENI=FORM = BOTH HAVE SAME SX = DELUSIONS OR HALLUCINATIONS FLAT AFFECT= SHOW LIL EMOTION, NO EYE CONTACT A-SOCIAL ========= SCHIZO-PHRENIFORM = > 1 MONTH = > 4 WEEKS ((remember if <1 month can be breif psychotic disorder))) but < 6 month vs SCHIZOPHRENIA = > 6 MONTS
MS, myasthenia gravis, SLE, AIDS, thyroid disorders, and chronic systemic infection
DDx of Somatic Symptom Disorder
PT IS IN HOSP POST OP DAY 4 AFTER APPENDECTOMY HE HAS THESE SX: HALLUCINATIONS AND acutely diaphoretic, tachycardic, hypertensive, tremulous, and agitated DIAGNOSE? TX?
DELIRIUM DELIRIUM + autonomic instability = Alcohol withdrawl induced delerium tremors MOST LIKELY DELIRIUM TREMORS DUE TO ALCOHOL WITHDRAWL = VITALS ABNORMALITIES + ACUTE MENTAL CHANGES + HALLUCINATIONS = The likelihood for onset is highest in the third to fifth day after the last drink. ========== CAN NOT BE BREIF PSYCHOTIC DISORDER B/C FOR THIS SX MUST BE PRESENT > 1 DAY AND < 1 MONTH ============= TX = BZs= OXAZEPAM, LORAZEPAM >>>> DIAZEPAM
POST OP PATIENT IS NOW = PUNCHING STAFF YELLING CURSING DIAGNOSE? TX?
DELIRIUM TX===> NOT BZs! tx of DELIRIUM INDUCED SX CAUSING AN ACUTE ATTACK = ANTIPSYCH DRUG = HALOPERIDOL
DEFINE DELIRIUM
DELIRIUM = DELIRIUM- ACUTE ONSET= LOOK FOR SOMEONE WHO HAS BEEN HOSPITALIZED/ GETTING TX/ REALLY SICK usually oCCURS DUE TO A UNDERLYING MEDICAL CONDITION OR A DRUG PT IS TAKING===THEN THIS DELIRIUM IS CALLED SUBSTANCE INDUCED PSYCHOSIS ============= REM= ALCOHOL WITHDRAWL = ALSO CAUSE A FORM OF DELIRIUM= DELIRIUM TREMONS = LOOK FOR HOSPIT. PT WHO HAS HALLUCINATIONS + AUTONOMIC INSTABILITY- HTN/ DIAPHORESIS/ HIGH HR =========== COMMON TO HAVE HALLUCINATIONS ======================== TX=== RESOLVE THE UNDERLYING MEDICAL CAUSE CAUSING THE DELIRUM
7O YEAR OLD MALE PT HAS BEEN TALKING TO PEOPLE WHO ARE NOT THERE = AUDITORY HALLUCINATIONS he is also FORGETTING TO TURN OFF STOVE DIAGNOSE
DELIRUM ALTERED CONCIOUSNESS= AUDITORY HALLUCINATIONS IMPAIRED COGNITION = FORGETTING TO TURN OFF STOVE ========= LOOK FOR ANY MEDS THIS PT IS TAKING THAT COULD BE CAUSING DELIRIUM AS S.E AND ANY OTHER MEDICAL CAUSES
DIAGNOSE PT has refused to go out of the house, believing that the neighbors are trying to harm her This evidence includes the neighbors' leaving their garbage cans out on the street to try to trip her " She denies hearing the neighbors or anyone else talk to her, but is sure that they are out to "cause her death and mayhem." ================= PT SAYS "MOVIE STAR IS IN LOVE WITH ME" She states that the movie star invited her into his home because the two are secretly married " The movie star denies the two have ever met, but notes that the woman has sent him hundreds of letters over the past 2 years
DELUSIONAL DISORDER ONLY HAVING DELUSIONS = J-PEG= FALSE BELIEF THAT COULD POSSIBLY BE TRUE = NEIGHBOR TRYIN TO KILL HER --- NOT SCHIZO BECAUSE NO PSYCHOTIC SX LIKE HALLUCINATIONS AND NO BIZZARE BEHAVIOR-llike walking around naked etc =============== ALSO DELUSIONAL DISORDER J-PEG
PT BELIEVES SHE CAN SMELL A REALLY BAD BODY ODOR ON HERSELF EVERYONE AROUND HER TELLS HER , SHE DOESNT SMELL BUT SHE STILL INSIST THAT SHE HAS A BAD ODOR SHE TAKES MULTIPLE SHOWERS BUT STILL SAYS SHE CAN SMELL HER SELF ===IMP! = OTHER THAN SX ABOVE, SHE IS FULLY FUNCTIONAL = HAS A JOB/ TALKS TO FRIENDS ETC
DELUSIONAL DISORDER PT IS FULLY FUNCTIONAL OTHERWISE These patients otherwise have an organized thought process and function well in other aspects of their life. BUT HAS A NON-BIZZARE BELIEF J-PEG =============== Paranoid personality disorder could be diagnosed if the paranoia were a longstanding problem that affected multiple aspects of the patient's life
HUSBAND THINKS HIS WIFE IS TRYING TO POSION HIM HE THINKS= WIFE IS JEALOUS OF HIM
DELUSIONAL DISORDER = JEALOUSY AND PARANOIA PART OF J-PEG = BELIEFS THAT COULD POSSIBLE BE TRUE PT MUST BE FULLY FUNCTIONAL OTHERWISE THERE MUST BE NO HALLUCINATIONS BIZZARE BEHAVIOR = SCHIZOPHRENIA
pt believes she IS BEING POISONED OTHERWISE FULLY FUNCTIONAL = MSE IS NORMAL
DELUSIONAL DISORDER = DELUSION MUST PERSIST FOR ATLEAST 1 MONTH = OTHER THAN DELUSION, NO OTHER PSYCHOTIC SX (hallucinations etc) FULLY FUNCTIONAL OTHERWISE ================================== THIS IS NOT PARANOID PERSONALITY DISORDER = NO PERSISTENT DELUSION = NO CLEAR/SPECIFIC/PERSISTENT DELUSION INSTEAD PATTERN OF SUSPICIOUSNESS OR ODD BELIEFS = NOT ABLE TO FUNCTION AS WELL AS SOMEONE WITH DELUSIONAL DISORDER =========== THINK OF DELUSIONAL DISORDER AS THE "MILDER" LESS SEVERE ONE IN COMPARISON TO PARANOID PERSONALITY DISORDER P
AFTER STARTING A NEW MED PT IS " SEEING EVIL KIDS" DIAG?
DELUSIONS OR HALLUCINATIONS AFTER STARTING NEW MED = MEDICATION INDUCED PSYCHOTIC DISORDER ((NOT DELIRIUM!) ========== MEDS MOST LIKELY TO CAUSE THIS = STEROIDS =its even called GLUCOCORTICOIDS INDUCED PSYCHOSIS
DIFFERENCE BETWEEN DENIAL VS REPRESSION
DENIAL = BLOCKING SOMETHING ABOUT "EXTERNAL" REALITY OF PT LIFE = PT REFUSE TO ACKNOWELEDGE THAT SHE HAS A POTENTIALLY CANCEROUS BREAST MASS DESPITE THE MASS LOOKING LIKE OBVIOUS CANCEROUS = HERE THE "EXTERNAL" REALITY IS BREAST MASS =========VS============= REPRESSION = BLOCKING "INTERNAL" ASPECT OF PT REALITY = BLOCKING A "MEMORY" OR A "FEELING" = PT CAN'T REMEMBER THE MEMORY OF GETTING TX FOR CANCER IN PAST
WHAT ARE DIFFERENT STAGES OF ACCEPTING DEATH
DENIAL-- pt inisit on getting 2nd opinion ANGER BARGAINING--pt tries to "offer" things in exchange DEPRESSION ACCEPTANCE
WOMEN COMES IN WITH BRUISES ALL OVER HER BODY WHEN DOC QUESTIONS HER AND SAYS SHE GOT THEM FOR BEING "TOO STUPID" WHAT KIND OF PERSONALITY DISORDER?
DEPENDENT PERSONALITY DISORDER = THESE PTS ARE AT HIGH RISK OF BEING ABUSED BY PARTNERS BECAUSE THEY HAVE FEAR OF BEING LEFT ALONE VERY NEEDY
wife DOESNT LEAVE HER HUSBAND BECAUSE SHE IS AFRAID OF BEING ALONE DIAGNOSE
DEPENDENT PERSONALITY DISORDER = CLINGY SUBMISSIVE WANT PROTECTION/CARE BY OTHERS
PATIENT WHO HAVE BEEN ON LITHIUM FOR 2 EPISODES OF MANIA IN PAST NOW COMES IN SAYING = LITHIUM TX HER MANIA AND HER SX HAVE RESOLVED ======= WHAT SHOULD DOC DO IN REGARDS TO HER TX WITH LITHIUM
DESPITE SX OF MANIA / BIPOLAR GOING INTO REMISSION = LITHIUM THERAPY SHOULD "NOT "BE DISCONTINUED DUE TO HIGH RISK OF RELAPSE OF MANIA/BIPOLAR IN PTS WHO STOP TAKING LITHIUM WHEN THEY THINK THEIR SX HAVE RESOLVED ========================= ANYONE WITH > 2 EPISODES OF MANIA =need to be on LIFE TIME MAINTENANCE OF LITHIUM = TO PREVENT A POSSIBLE RELAPSE
WHICH LABS SHOULD BE TAKEN "BEFORE" PT IS GIVEN LITHIUM ===========
DIABETIS INSIPIDUS = POLYURIA POLYDIPSIA ===== HYPER=PTH ==? HYPER CALCEMIA ========== HYPO=THYROIDISM
DISCUSS ADHD SX? DIAG REQ WHAT REQ? TX?
DIAG REQ = ONSET OF SX < 12 YEAR OF AGE AND SX IN > 2 SETTINGS= HOME/SCHOOL For a diagnosis of ADHD, symptoms MUST =be present for at least 6 months = in at least two settings ================== SX= ATTENTION DEFICIT = DISTRACTIBLE FORGETFUL DISORGANIZED DOESNT LISTEN/FOLLOW INSTRUCITONS HYPERACTIVE = FIDGETY DOESNT SIT STILL HYPER TALKATIVE =================== TX- STIMULANT = METHYLPHENIDATE AMPHETAMINE ==== S.E. OF STIMULANT = DECREASE IN APETITIE
pt has SUDDEN ONSET==KEY CHEST PAIN SOB "SENSE OF IMPENDING DOOM" WHAT TEST DOES DOC NEED TO ORDER-- TO WORKUP HER CHEST PAIN COMPLAINT? DIAGNOSIS? TX?
DIAGNOSIS= PANIC ATTACK =mnemonic for Sx PANICS (Palpitations, Abdominal Pain, Nausea, Impending doom, Chest Pain, and shortness of breath) =========== TEST TO ORDER= WORK UP OF CHEST PAIN = AS LONG AS PT IS YOUNG/HEALTHY/NO RISK FACTORS/NO OTHER SX like JVD/edema etc = ONLY NEED TO ORDER EKG + TROPONINS --- NO NEED TO ORDER = STRESS TEST!! --- ======================== TX OF ACUTE ONSET PANIC ATTACK = BENZODIAZEPINE NOT SSRI!! = SSRIs play little role in panic attacks because panic attacks come out of nowhere and are difficult to predict ============= NOTE = IF THIS PT HAD SAME SX-CHEST PAIN/SOB BUT WAS ALSO + FOR RISK FACTORS= HTN/ DM/FAT = GIVE NITROGLYCERIN= AND SEE IF CHEST PAIN RESOLVES
PT WITH PMH= HEROIN ABUSE HAS BEEN NOT USING HEROIN FOR PAST 10 YRS COMES IN = WANTS SOMETHING TO HELP HIM FALL ASLEEP
DIPHENHYDRAMINE= H1 ANTAG= SEDATING NOT A GOOD IDEA TO GIVE ZOLPIDEM FOR SLEEP =TO SOMEONE WITH PMH OR CURRENT USE OF SUBSTANCE ABUSE DUE TO ZOLPIDEM= BZs== ADDICTIVE POTENTIAL
PT WITH PMH= MDD BEING TX WITH== PAROXETINE NOW HE STARTS HAVE SX OF MANIA WHAT IS A VERY IMP THING DOC SHOULD DO BEFORE TX HIS NEW MANIA SX
DISCONTINUE ANY ANTIDEPRESSANTS HE IS ON!!! = THESE ANTIDEPRESSANT COULD HAVE VERY LIKELY INDUCED/MADE HIS MANIA SX== WORSE FOR MANIA ===GIVE HIM MOOD STABILIZER = VALPORIC ACID ================ IMPORTANT = While SSRIs are used in bipolar patients with depressive episodes, their use is not recommended as monotherapy due to this potential to induce mania.
DEFENSE MECHANISM? PT WHO WAS RESCUED FROM BURNING BUILDING = NOW DENIES ANY MEMORY OF THIS EVENT ============= PT B = The patient is irritated at his therapist for pushing him on several issues in the last session. The patient does not show up or call for his next session
DISSOCIATION = COMPLETELY BLOCKING OFF/ FORGETTING DISTURBING THOUGHTS === PT B = ACTING OUT
PT LOSES ALL MEMORY OF A DOCTOR'S APPOINTMENT WHEN SHE WAS TOLD SHE HAS CANCER DESPITE PT'S FAMILY REMINDING HER OF THIS DOC APPT =
DISSOCIATION = DEFENSE MECH. USED SPECIFICALLY TO "COPE WITH AN EVENT" WHERE PT FEELS HELPLESS ================================= PT USE THIS WHEN PT IS IN A SITUATION WHERE THEY FEEL THEY HAVE NO CONTROL OVER A SITUATION = FEELING HELPLESS =========================== HERE TO COPE WITH HAVING BREAST CANCER, A PT LOSES MEMORY OF BEING TOLD SHE HAS CANCER ====================
PT BROUGHT TO ED BY POLICE SHE SAYS SHE CAN NOT REMEMBER PAST 12 HRS HER FACE IS BLOODIED/ BODY INJURED PE SHOWS SHE HAS BEEN SEXUALLY EXPLOITED
DISSOCIATIVE AMNESIA = FORGETTING/AMNESIA AFTER A STRESSOR= THIS PT HAD PROB BEEN RAPED
PT WITH DEPRESSION TAKING SERTRALINE SAYS MOST OF HIS DEPRESSION SX ARE RESOLVING BUT HE IS STILL HAVING TROUBLE WITH COPING WITH STRESSES IN HIS LIFE HOW SHOULD DOC CHANGE HIS TX PLAN?
HE IS ALREADY ON SSRI= WORKING WELL HE NEEDS HELP WITH DEALING WITH STRESS =SO ADD PSYCHOTHERAPY TO HIS TX PLAN
DISCUSS DISSOCIATIVE IDENTITY DISORDER VS DISSOCIATIVE FUGUE VS DISSOCIATIVE AMNESIA VS DE-PERSONALIZATION
DISSOCIATIVE IDENTITY DISORDER == MULTIPLE PERSONALITY DISORDER = What you look for in the vignette are "blackouts" (periods of amnesia where the primary personality is unaware she has been overtaken by the subordinate personalities and she has no recollection of the time with the alternates) or behavioral changes noticed by others (particularly sex and drugs). = IN RESPONSE TO SOME SORT OF TRAUMA IN PAST The treatment is intense psychotherapy ========== DISSOCIATIVE FUGUE = INVOLVES TRAVEL = LOOK FOR AMNESIA + TRAVEL ============= DISSOCIATIVE AMNESIA- me forgetting about HOUSE fire = stressful event--> pt forgets about this event ========== DE-PERSONALIZATION = PT THINGS HER BODY/ORGANS ARE NOT HER OWN
DEFENSE MECH? 292. A 28-year-old woman is in psychotherapy for a long-standing depressed mood and poor self-esteem. One day during the session, the therapist yawns because she is very tired, though she is interested in what the patient has to say. The patient immediately bursts into tears, saying that the therapist must be bored and uninterested in her and must have been so for quite some time
DISTORTION IDK HOW In distortion, external reality is grossly rearranged to conform to internal needs. (For example, a patient states that her husband smiles broadly whenever she tells him of her obsessions, when in reality he is grimacing.)
DISULFIRAM? VS FLUMAZENIL? VS PRAMIPEXOLE
DISULFIRAM = NOT USED TO TX ACUTE ALCOHOL WITHDRAWL SX INSTEAD USE IS FOR LONG TERM ALCOHOL ABSTINENCE MOA OF DISULFIRAM = INHIBIT ALDEHYDE DEHYDROGENASE = INCREASE ACETALDEHYDE =which CAUSES PT TO FEEL ILL AFTER INGESTING ALCOHOL = Disulfiram inhibits aldehyde dehydrogenase, resulting in an accumulation of acetaldehyde. Acetaldehyde causes facial flushing, tachycardia, hypotension, nausea and vomiting, and physical discomfort ================================ FLUMAZENIL = TX OVERDOSE FROM A BZs (TRICKY= IF RESP DEPRESSION + MIOSIS= OPIATE OVERDOSE==GIVE NALOXONE) =================================== PRAMIPEXOLE = DOPAMINE "AGONIST" = TX PARKINSON ALSO TX = RESTLESS LEG SYNDROME
WHAT DISEASES DOES A PT NEED TO HAVE FOR DOC TO BE ABLE TO = ADMIT PT WITHOUT CONSENT = TX PT AGAINST PT'S WISHES
DOC IS ABLE TO TAKE AWAY PT'S RIGHT TO CONSENT AND TX/ ADMIT INVOLUNTARILY IF HAS FOLLOWING CONTAGIOUS CONDITIONS = TB MENINGOCOCAL MENINGITIS =Gonorhea==> petechia==> pain with flexing neck ===== other times DOC IS ABLE TO TAKE AWAY PT'S RIGHT TO CONSENT AND TX/ ADMIT INVOLUNTARILY = IF PT IS HARM TO HIMSELF = SUCIDAL/ ACUTELY PSYCHOTIC IF PT IS HARM TO OTHERS = HUMICIDAL IDEATIONS
MAN SAD BECAUSE HE RECENTLY BROKE UP WITH HIS GF HE TELLS DOC THAT HE PLANS ON KILLING HIS GF WHAT SHOULD DOC DO
DOC NEEDS TO INFORM BOTH POLICE + EX GF ABOUT HIS PLANS
15 YR OLD PT COMES IN WITH SX OF PARANOIA = THINKS GOVMT IS SPYING ON HIM WHAT IS THE FIRST DIAG TEST DOC SHOULD ORDER
DOC SHOULD 1ST ORDER = URINE TOXICOLOGY TEST - WANT TO RULE OUT SUBSTANCE ABUSE IS NOT CAUSE OF HIS PARANOIA===ESP IN A TEENAGE PT
PT WITH ANY CURRENT OR PMH OF ABUSE OF ANY DRUG WHICH SLEEP AID DRUG = SHOULD NOT BE GIVEN TO THIS PT DUE TO THESE DRUG'S HIGH ADDICTION POSSIBILITY
DONT GIVE ANY BZs ZOLPIDEM , ZELEPLON ========== SAFE TO GIVE = RAMELTON= LIKE MELOTONIN==>S,E= HEADACHE = DIPHENHYDRAMINE = TRAZODONE
PT WITH BIPOLAR MANIC EPISODE ALREADY ON RISPERIDONE HIS BUN= 28 WHAT OTHER DRUG TO GIVE HIM?
DONT GIVE LITHIUM DUE TO RENAL ISSUES ((rem lithium can cause DIAB. INSIPIDUS)) GIVE = VALPROIC ACID
schizo PT ON RISPERIDONE BUT HE IS STILL HAVING ALL THE SAME SX WITH NO IMPROVEMENT HOW SHOULD DOC CHANGE HIS MEDS? =========
DONT JUMP TO CHANGING TO ANOTHER MED INSTEAD INCCREASE DOSE OF= RISPERIDONE . The escalation of therapy should be =the minimum dose with a dose increase daily until symptoms are controlled or the dose maxed. Once the dose is maximized, then the patient can be changed to another medication;
PARENTS BRING IN THEIR KID FOR OBVIOUS SX OF ADHD = FIDGETY. / DISTRACTED = AT HOME NEXT BEST STEP?
DONT JUMP TO TX FOR ADHD = MUST HAVE ADHD SX IN 2 SEP. ENVIORMENT = SO BEFORE TX/CONFIRMING ADHD DIAG = CHECK TO SEE IF KID HAS ADHD SX IN SCHOOL === LATER TX= STIMULANT= METHYLPHENIDATE
PT WITH NO OTHER PROBLEMS BUT TROUBLE SLEEPING AT NIGHT ((NO OSA/NARCOLEPSY/ ETC)) FIRST LINE TX?
DONT JUMP TO TX INSOMNIA WITH DRUGS FIRST LINE = CHANGE SLEEP "ROUTINE" = Things to look for are: bed for sleep and sex only, sleep schedule, avoid stimulants close to bed time, go to sleep only when tired , leave bed if not falling asleep, do something relaxing prior to sleep time.==DON'T DO SCHOOL WORK IF CANT FALL ASLEEP ==== 2ND STEP IF SLEEP HYGEINE CHANGES - DIDN'T HELP = ZOLPIDEM BUT IF INSOMNIA + MDD= TRAZODONE
tx OF BREAVEMENT= AKA= NORMAL GREIF
DONT JUST GIVE REASSURANCE AND TELL PT TO WAIT FOR SX TO GO AWAY = Reassurance is not the right answer either. He is grieving and should be allowed to do so. But with a grief counselor, he can be more functional sooner INSTEAD TELL PT TO GET = PSYCHOTHERAPY==WITH A GREIF COUNSELOR == NOTE= FOR tx OF BREAVEMENT= AKA= NORMAL GREIF = NO NEED TO JUMP TO SSRI = ALWAYS FIRST START WITH THERAPY! --- IF PT HAS MDD =AKA BREAVEMENT SX + SUICIDE IDEATIONS = SSRI OR IF PT HAD BREAVEMENT SX FOR > 1 YEAR = SSRI =============== SUMMARY = The answer on the Shelf is only to give SSR I if it is "not grief" = (suicidal ideations, , lasting more than a year).
DRUG A = SIDE EFFECT OF WHICH DRUG GIVEN FOR MOOD DISORDER DRY MOUTH TROUBLE URINATING AND DIZZINESS =========================================== ============ DRUG B = SIDE EFFECT POLYURIA POLYDIPSIA ================= DRUG C - SIDE EFFECT = gastrointestinal upset, sexual dysfunction, and activation/agitation
DRUG A = S.E. OF TCAs== IMIPRAMINE = ANTI CHOLINERGIC = DRY MOUTH, URINARY RETENTION DIZZINESS IS DUE TO HYPOTENSION = due to TCA S.E.--> block ALPHA 1 RECEPTORS ================== DRUG B = LITHIUM---> DIAB INSIPIDUS---> POLYURIA/DIPSIA ========== DRUG C = SSRI
WHICH ANTIPSYCH DRUG CONTRAINDICATED IN DIABETIC PT ========= WHICH ANTIPSYCH DRUG CAUSES QT PROLONGATION
DRUGS THAT CAUSE WEIGHT GAIN = OLANZAPINE CLOZAPINE = CONTRAINDICATED IN DIABETIC PT ============== CAUSE QT PROLONGATION = ZIPRASIDONE= 2ND GEN ANTIPSYCH DRUG
17 YR OLD PT PARENTS SAY HE WAS PREVIOUSLY POLITE BUT FOR PAST FEW WEEKS= IRRITABLE/RUDE PT STOLE MONEY FROM PARENTS PT STATES "HE IS ON A SECRET MISSION THAT HE WAS SENT TO BY SOME KING" == PUPILS= DILATED SWEATING PROGUSELY ========= AFTER STAY AT ED = CONDITION IMPROVES
DUE TO DILATED PUPIL/ SWEATING/TACHYCARDIA = NOT due to a PSYCHOTIC DISORDER ==== THIS IS = AMPHETAMINE INTOXICATION = IRRITABLE PARANOIA!!!! DELIRIUM + ABNORMAL VITALS = ((all happen with amphetamine induced increase symp)) PUPIL DILATED HIGH BP SWEATING HIGH HR
WHICH DRUG TX DEPRESSION AND NEUROPATHIC PAIN==COMMON IN DIABETICS AND = "PINS AND NEEDLE" PAIN FIBROMYALGIA ==================== WHICH DRUG TX BIPOLAR, MANIA AND TRIGEMINAL NEURALGIA = PAIN IN FACE
DULOXETINE= SNRI ALSO TCA= g amitriptyline and nortriptyline BUT WHEN HAVE TO CHOOSE ONE CLASS OF DRUG FOR ANTIDEPRESSION + PAIN RELIEF = SNRI > TCA- has higher S,E, ===================== CARBAMEZIPINE = anticonvulsant that is used to treat both bipolar mania and trigeminal neuralgia
30 YEAR OLD PT SAYS FEEL SAD= ENTIRE LIFE SLEEPS > 12 HRS A NIGHT OVER EATS HAS FRIENDS= ENJOYS PLAYING VIDEO GAMES
DYSTHMIA = PERSISTANT= > 2 YEARS OF MILD DEPRESSION
Treatment of Neuroleptic Malignant Syndrome
Dantrolene
Prominent disturbances in alertness, as well as confusion and a short, fluctuating course. It is caused by acute metabolic problems or substance intoxication. Common in systemic infections, metabolic disorders, hepatic/renal diseases, seizures, head trauma. Also associated with high, sustained, or rapidly decreasing levels of many drugs, especially in elderly and severely ill
Delerium
Nonbizarre delusions for at least one month No impairments in level of functioning The pts are usually reliable unless it is in relationship to their delusions Types include erotomanic, jealous, grandiose, somatic, mixed and unspecified
Delusional disorder
Name the Personality Disorder: Submissive, Clingy, need to be taken care of. Difficulty making decisions.
Dependent
Submissive and clinging behaviour related to a need to be taken care of: Consumed with the need to be taken care of, clingy behaviour and worry unrealistically about abandonment. Associated features are self-doubt, excessive humility, poor independent functioning, mood disorders, anxiety disorders, adjustment disorder.
Dependent PD
Indecisive, Difficulty Expressing Disagreement
Dependent; Treat Co-morbid Depression or Anxiety
Out of body experience
Depersonalization
Persistent or recurrent feeling of being detaches from one's mental processes or body, accompanied by intact sense of reality. Risk from psychologic stress
Depersonalization and Derealization disorder
An emotion or drive is shifted to another that resembles the original in some aspect "I had to get rid of the dog since my husband kicked it every time we had an argument"
Displacement
Disruption of Memory, Identity, or Consciousness to Cope with Event; Forgetting You Were Fired and Continuing to Report to Work
Dissociation
Sudden Travel, Inability to Remember Past, Confusion About Personal Identity
Dissociative Fugue
Multiple, distinct personalities that recurrently control the individuals behaviour, accompanied by failure to recall important personal information
Dissociative Identity disorder
Multiple Personality Disorder
Dissociative Personality Disorder (With Mild Dissociative Amnesia)
Episodes of being unable to recall important and often emotionally charged memories. May involve purposeful travel or bewildered wandering
Dissociative amnesia and Dissociative amnesia with fugue
Altered Perception of Disturbing Aspects of Reality to Make It More Acceptable; Heroin Abuser Blames Hepatitis C on Inadequate Control in Community
Distortion (Immature)
Impairment in the ability to think abstractly and plan such activities as organizing, shopping, and maintaining a home
Disturbances in executive function
Behavioral Deterrent in High-Functioning Alcoholics
Disulfiram; Inhibits Acetaldehyde Dehydrogenase
WHICH DRUG SE IS HAIR LOSS
Divalproex sodiumis
SE of Lithium
Dose-related tremor, GI distress and headache Acne Weight gain ECG changes Hypothyroidism 5% Leukocytosis Polyuria (DI is common) Teratogenicity (Ebstein's anomaly) Nephrotoxic
FOR A MARRIED PT WHO CAN LEGALLY MAKE MEDICAL DECISION WHEN PT CAN NOT
IN ORDER = Designated power of attorney with documentation to prove it Spouse Oldest child Other children in order of age Parent!!! GrandparenT
1. Refractory Depression or Mania. 2. Pregnant Depression. 3. Neuroleptic Malignant Syndrome. 4. Catatonic Schizophrenia.
ECT; Risk of Short-Term Anterograde or Chronic Retrograde Amnesia (Also Status Epilepticus, Delirium, Headache, Nausea, or Burns)
BEFORE STARTING ANY TCA DRUG WHAT LAB TEST SHOULD BE ORDER
EKG TCA= HIGH CARDIAC TOXICITY = . The side effect of all TCAs are the "3 Cs" (Convulsions,==SEIZURE Cardiac QT prolongation==MOST COMMON , and Coma) ALSO ANTICHOLINERGIC S.E.
ENURESIS AFTER WHAT AGE CAN IT BE DIAGNOSED? BEFORE JUMPING TO DRUGS TO TX, WHAT MUST BE DONE FIRST?
ENURESIS = NORMAL UPTO AGE 5 >5 YR OLD ENURESIS= NOT NORMAL= CAN DIAGNOSE ================= BEFORE GIVING ANY DRUGS, LIFESTYLE MODIFICATIONS ASK IF KID HAS "eVER BEEN DRY" PARENTS SHOULD have rewarded good behavior (and not punished bad behavior) and used alarms. AVOID late night and caffeinated beverages. =============== RULE OUT AN ORGANIC CAUSES OF ENURESIS BEFORE GIVING DRUGS = DO UA, URINE CULTURE === MAKE SURE ENURESIS IS NOT JUST REGRESSION = ASK ABOUT LIFE STRESSORS
PT ON MDD DRUGS= PAROXETINE FOR EXAMPLE COMES BACK = ALL MDD SX ARE RESOLVED WHAT CHANGES SHOULD DOC MAKE TO HIS SSRI FOR MDD
EVEN IF EVERY SINGLE MDD SX HAS RESOLVED = PT MUST KEEP TAKING SSRI FOR 6 MONTHS! even with significant improvement, the patient should be treated for 6 months. SIX MONTHS. That is the magic number == THEN AT > 6MONTHS IF STILL NO MDD SX DOC CAN TAPER MDD DRUG/ SSRI UNTIL DISCONTINUE USE ------ SUMMARY = SSRI/ANTIDEP. TAKE 6 "WEEKS" TO SHOW ANY EFFECT== WAIT PERIOD BEFORE TRYING ANOTHER DRUG IF SSRI/ANTI RESOLVE ALL SX= PT MUST STILL KEEP TAKING DRUG FOR 6 "MONTHS" =WAIT PERIOD BEFORE DISCONTINUING TX WITH THIS DRUG
PT STATES HE IS HEARING VOICES ALSO FEELS SAD/ LOST WEIGHT/ FEELS GUILT GIVEN = RISPERIDONE, FLUOXETINE ===>> HE DOESNT FEEL SAD ANYMORE = MOOD HAS IMPROVED BUT FOR PAST 1 MONTH SHE IS STILL EXP. AUDITORY HALLUCINATION OR OTHER PSYCHOTIC SX = THINKS HER BOSS IS NOT WHO HE SAYS HE IS, ETC
EVEN THOUGH HER MAJOR DEPRESSED SX HAVE IMPROVED THIS IS STILL SCHIZO=AFFECTIVE DISORDER
PT TAKING SERTRALINE FOR MAJOR DEPRESSION ON F/U VISIT =HE SAYS ALL SX OF DEPRESSION = IMPROVING WHAT SHOULD DOC DO IN TERMS OF DEPRESSION MANAGEMENT IN THIS PT
EVEN THOUGH HIS SX ARE IMPROVING WITH SERTALINE = CONTINUE ANTIDEPRESSANT FOR 6 MONTHS
WHAT DRUG SHOULD BE GIVEN TO PT TO CALM HIM DOWN WHO IS IN ED WITH PCP INTOXICATION== NYSTAGMUS + AGRESSION TOWARDS NURSES THREATNING + HE IS TALKING TO HIMSLEF
EVEN THOUGH ITS OBVIOUS THAT HIS VIOLENCE IS DUE TO PCP OVERDOSE = NOT BZ!!! GIVE HALOPERIDOL = USE WHENEVER NEED TO CALM DOWN A PT WHO IS AGITATE/VIOLENT + PSYCHOTIC==TALKING TO HIMSLEF
PT TOOK A SSRI FOR MDD COMES BACK 2 MONTHS LATER= ALL MDD SX GONE HOW LONG SHOULD SHE KEEP TAKING SSRI ? =========== PT WITH ALCOHOL WITHDRAWL WHICH BZ SHOULD BE GIVEN IF HE ALSO HAS LIVER PROBLEMS = history of cirrhosis, hepatitis C
EVEN THOUGH MDD SX= RESOLVE TO PREVENT RELAPSE KEEP TAKING SSRI= ALMOST A YR = 8-10 MONTHS ================= BZ= NOT METABOLIZED BY LIVER = LOT = LORAZEPAM OXAZEPAM T...PAM
DIAG THIS PT 21 YR OLD OVER LAST MONTH = THINKS FBI IS TRYING TO CATCH HIM/ SEND HIM MESSAGES LOCKS HIMSELF IN ROOM SO FBI DONT GET TO HIM WILL ONLY EAT FOOD THATS BEEN MADE IN FRONT OF HIM HAS BEEN ADMITTED IN PSYCH CENTER 2X IN PAST AT AGE 17 FOR SIMILAR SX ALREADY TAKING = RISPERIDONE OLANZAPINE HALOPERIDOL ARIPRAZOLE ============== DIAG THIS PT? WHAT DRUG CAN BE GIVEN TO HIM?
EXACERBATION OF SCHRIZOPHRENIA ======================= TX OF SCHRIZOPHRENIA = START WITH ANTIPSYCH MED -->SWITCH TO ANOTHER IF 1ST DOESNT WORK ============== TX OF SCHRIZOPHRENIA THAT IS TX= RESISTANT = CLOZAPINE
MAN IS ARRESTED FOR EXPOSING GENITALS TO STRANGERS HE SAYS THIS PROVIDES HIM W/ SEXUAL RELIEF ==== DIAG? TX?
EXHIBITIONISM = STRONG URGE TO EXPOSE GENITALS FOR SEXUAL AROUSAL ============================ TX= MEDROXY-PROGESTERONE ACETATE
Euphoria, mild psychedelia, hyponatremia, seizures, death, rhabdomyolysis, increased heart rate, blood pressure and temperature.
Ecstacy
Imaging Changes: Autism
Enlarged Brain
Suppresses REM
EtOH and Barbituates
Tremors, hallucinations, seizures, delirium tremens
EtOH withdrawel
Men have an earlier onset, usually age 15-25, many theories indicate high levels of dopamine and abnormalities in seretonin Monozygotic twin --> 47% First-degree relative --> 12% Two schizophrenic parents --> 40%
Etiology and Prevalence of Schizophrenia
Recurrent urge to expose oneself to others
Exhibitionism
Illusion vs. Hallucination
External Stimulus vs. Only Internal Stimulus
FACTITIOUS DISORDER VS MALINGERING ======= FACTITIOUS = UNCONCIOUS--desire to be in sick role MALINGERING==concious desire ==========================
FACTITIOUS = PT INTENTIONALLY COMES UP WITH FAKE SX =INORDER TO TAKE ON "SICK PERSON" ROLE = FOR ATTENTION ((COMPARE TO --FACTITIOUS BY PROXY))) ============ MALINGERING = PT COMES UP WITH FAKE SX = FOR SECONDARY GAIN = AVOIDING JAIL GETTING DISABILITY CHECK GETTING NARCOTICS ======================= FACTITIOUS = Conscious, intentional production of symptoms with primary gain MALINGERING = b. Conscious, intentional production of symptoms with secondary gain
PT COMES INTO ED WITH VERY LOW B. GLUCOSE ADMITTED IN ICU LATER NURSE FINDS A INSULIN SYRINGE NEAR PT
FACTITIOUS DISORDER = PT JUST WANTED ATTENTION THAT SOMEONE IN SICK ROLE GETS
WHAT IS AGORA=PHOBIA
FEAR OF ANY PLACE where escape may be difficult if having a panic attack (such as in agoraphobia) FEAR OF "MARKET PLACE" = FEAR OF BEING IN PLACES WITH CROWDS WIDE OPEN SPACES UNFAMILIAR SURROUNDINGS
GENERAL ANXIETY TX
FIRST LINE = COGNITIVE THERAPY +/- SSRI, OR SNRI ========== 2ND LINE TX = BUSPIRONE!!!!!!!!!!!!!!!!!!!1 ((bus full of people w/ anxiety)) OR BZs===2ND LINE DUE TO RISK OF DEPENDENCE
IN A KID WITH MDD WHICH IS BEST SSRI ============= BEFORE DIAG SOMEONE WITH MDD WHAT MEDICAL CONDITION SHOULD DOC RULE OUT FIRST
FLUOXETINE== LONG HALF LIFE = LESS LIKELY TO CAUSE WITHDRAWL SX IF DISCONTINUED ========= RULE OUT HYPOTHYROIDISM==MOST COMMON TO ALSO HAVE MDD SX VIT B12 DEF.
WHAT IS FOLEI A DEUX ======== WHAT IS FREGOLI DELUSION
FOLEI A DEUX = 2 ---deux---PEOPLE WITH SIMILAR/SAME DELUSION = when a similar delusion is aroused in one person by the close influence of another; ================================== FREGOLI DELUSION = AKA the delusion of doubles = PERSON BELIEVES THAT 2 DIFFERENT PEOPLE ARE INFACT 1 PERSON= THE SAME PERSON who changes appearance or is in disguise.
substance abuse versus substance dependence
FOR BOTH = Neither using a substance alone nor the frequency used are considered criteria for abuse or dependence; ========= SUBSTANCE ABUSE = Substance abuse relates to troublesome behaviors and consequences associated with the use, ==including a failure to meet work or school expectations (such as failing grades), putting oneself at risk (such as driving while using) or legal problems ========= SUBSTANCE DEPENDENCE = reflects the person's physical and/or psychological dependency on the substance. This includes assessing tolerance, withdrawal, heavier use than intended, and displaying an ongoing desire or unsuccessful attempts to cut back on substance use. = ======================================== EXAMPLES OF SUBS. DEPENDECE = The patient's inability to quit drinking regardless of a desire to quit or knowledge of its negative aspects best differentiates dependence from abuse AND MARIJUANA USE ---ALONE
FIRST LINE TX OF ANOREXIA
FOR PT WHO IS NOT "SEVERELY" ANOREXIC AKA ALL ANOREXIC SX= AMENORHEA,ETC BUT BMI >18 = PSYCHO-THERAPY= 1ST HOSPITALIZATION IS NOT 1ST LINE TX BECAUSE NOT EVERY ANOREXIC PT NEEDS TO BE HOSPITALIZED VERY SEVERE CASES=ONLY== BMI <18 = HOSPITALIZATION WITH FORCE FEEDING
PT COMES IN SAYING HE IS HEARING VOICING TELL HIM TO "DO BAD THINGS" HE DENIES SUCIDAL OR HUMICIDAL IDEATIONS WHAT SHOULD DOC DO?
FORCIBLY HOSPITALIZE PT "DO BAD THINGS"= =qualifies as "COMMAND" AUDITORY HALLUCINATION = WHICH COULD POSE DANGER TO BOTH PT AND OTHERS ((despite pt denying it))
what kind of hallucination found in COCAINE USERS = BUG CRAWLING ALL OVER
FORMICATION = A TYPE OF TACTILE HALLUCINATION = Formication is the sensation that bugs are crawling on one's skin, often in drug intoxication or withdrawal. =======VS=========== Gustatory hallucinations are taste without stimulus =========VS========= NARCOLEPSY HAS = Hypnagogic and hypnopompic hallucinations = from wakefulness to sleep and sleep to wakefulness, respectively
WHAT IS IT CALLED WHEN A MAN RUBS HIS GENITALIA AGAINST CLOTHED WOMEN, WHO IS NOT AWARE / NOT CONSENTING TO THIS ACT
FROUTTEURISM
The conscious production of signs and sx of both medical and mental disorder. Main objective is to assume the sick role and eventually hospitalization (1) Imposed on self (2) Imposed on others Seen more commonly in women and in hospital and health care workers
Factitious Disorder
WHAT IS RESPONSIBE FOR EUPHORIA/HIGH EXP. WITH DRUG USE + DELUSIONS/HALLUCINATIONS EXP. BY SCHRIZOPHRENICS
INCREASE DOPAMINE ACTIVITY IN MESOLIMBIC PATHWAY ==================== VS INCREASE DOPAMINE IN NIGRO=STRIATAL PATHWAY = TICS CHOREA = HYPER=MOVEMENT DISORDERS
Panic Disorder vs. Social Anxiety
Fear of Attacks vs. Fear of Scrutiny
Involves the use of nonliving objects usually associated with the human body
Fetishism
Tx of Benzodiazepine intoxication
Flumazenil
List of SSRIs
Fluoxetine Paroxetine Sertraline Fluvoxamine Citalopram Escitalopram
KID MILESTONES
Focus on following the rules. = (D) school age (7-12 years) ====================== Establishing self as autonomous, separate from caregiver, by practicing leaving and returning to the caregiver. = (B) toddler (18-36 months) ====================== Establishing trust in the world through responsiveness and empathy of a caregive = (A) infant (0-18 months) ========== . Preoccupation with superheroes who represent idealized caregivers as a result of conflicted feelings toward caregivers. = (C) preschool age (3-6 years) =============== . The development of the ability to apply reasoning = (D) school age (7-12 years) = ALSO AGE WHEN UNDERSTAND DEATH ======================================== 92. The development of the ability to think about and manipulate ideas abstractly. = (E) adolescence (13-17 years) =====================
Tx of Alcohol intoxication
Fomeprizole or mechanical ventilation
WHAT IS SEEN ON HEAD CT FOR DEMENTIA VS PICK'S DISEASE
Fronto==parietal atrophy = is seen in Alzheimer dementia. = HEAD CT -->> diffuse cortical atrophy and normal ventricles. presenilin 1 gene, located on chromosome 14, is involved Acetylcholine is most commonly associated with dementia of the Alzheimer type, as well as with other dementias VS Fronto--temporal atrophy is found in = Pick disease
Recurrent urge or behaviour involving touching or rubbing against a non-consenting partner
Frotterurism
Difference Between Bipolar 1 and 2
Function-Impairing Mania With or Without Depression vs. Hypomania with Function-Impairing Depression
HOW DOES GAD DIFFER FROM OTHER ANXIETY DISORDER
GAD SX = PT WORRIES ABOUT "MULTIPLE" ASPECTS OF HER LIFE = EX== SCHOOL, FAMILY, KIDS, JOB ETC
The child's breath smells of garlic,---UNIQUE and he has bloody diarrhea , vomiting, and muscle twitching
GARLIC BREATH ==> ARSENIC POISONING
DIFFERENCE BETWEEN GENERALIZED ((SOCIAL)) ANXIETY VS PERFORMANCE ONLY SOCIAL ANXIETY HOW DO TX DIFFER?
GENERALIZED ANXIETY = ANXIETY WITH MORE THAN JUST IN SITUATION WHERE PT IS SPEAKING IN FRONT OF GROUP = ANXIETY AT PARTIES ANXIETY AT HAVING INTERACTION WITH OTHER PEOPLE = SEE ABOVE FOR MOVE TX== SSRI/SNRI, COGNITIVE THERAPY ================================= PERFORMANCE ONLY SOCIAL ANXIETY = ANXIETY WITH PUBLIC SPEAKER/ PRESENTATIONS = ANXIETY EXP . BY PERFORMERS TX==== B-BLOCKER=PROPANOLOL OR BZs= CLONAZEPAM = TAKE 30 MIN BEFORE ANXIETY PROVOKING SITUATION
BUSPIRONE TX WHAT? ====================================== WHAT IS TX OF SOCIAL ANXIETY DISORDER = CANT TALK ON STAGE/IN FRONT OF CROWD = FEAR OF "SCRUTINY"/EMBARASSMENT BY OTHERS
GENERALIZED ANXIETY DISORDER bus full of people with anxiety =============== TX OF SOCIAL ANXIETY DISORDER THAT HAS TO DO WITH PERFORMANCE IN FRONT OF A GROUP/ PUBLIC SPEAKING = B-BLOCKER = PROPANOLOL
PT WITH BULIMIA ALREADY IN THERAPY ALREADY TAKING == SSRI STILL NOT BETTER
GIVE HER TOPIRAMATE Topiramate is an anticonvulsant used in the treatment of bulimia
PT ON CHEMO/ANY CANCER TX FEELS SAD FEELS WEAK/DRAINED DOESNT WANNA LEAVE HOME
GIVE HER SSRI SSRI GOOD TO GIVE TO PTS FIGHTING DANGEROUS CONDITIONS THAT CAN MAKE PT FEELING DEPRESSED ============== THRESHOLD OF PRESCRIBING SSRI = DOES NOT NEED TO MEET 3 CRITERIA OF SIGECAPS = THRESHOLD LOWER IN PT FIGHTING SOMETHING BIG LIKE CANCER
JUMP TO GIVING SSRI OR CHECKING TSH IN PT WHO HAS SX OF MDD AFTER HER SON DIED
GIVE SSRI NOTE = HYPO-not hyper-THYROIDISM = MOST COMMONLY RESEMBLES MDD = SO IF PT IS "LOSING WEIGHT" THEN ITS NOT LIKELY TO BE THYROID ISSUES CAUSING MDD LIKE SX
METHADONE?
GIVEN TO TX ADDICTION TO OPIATES===HEROIN = USED FOR ADDICITON "MAINTENANCE/ LONG TERM" THERAPY ======= EVEN SAFE TO GIVE TO PREGNANT PT WHO HAS BEEN USING HEROIN FOR PAST 8 MONTHS === Methadone maintenance is the most appropriate pharmacological therapy for treatment of heroin addiction, even in pregnancy.
PT BELIEVES HE HAS SPECIAL RELATIONSHIP WITH GOD ==================== WHEN ANSWERING A Q, PT MAKES UP HIS OWN WORDS
GRANDIOSE =DELUSION--common in mania ((((can be seen i people with BIPOLAR, MANIA))) DELUSIONS SUCH AS PERSON HAVING = SPECIAL POWERS==power to heal etc SPECIAL RELATIONSHIP WITH GOD =============== NEO-LO-GISM = fabricated word made up by the patient, which is usually a combination of existing words.
WHAT IS TERM FOR THIS THOUGHT PROCESS?? PT SAYING she was sent by the holy order of Jesuits to strike out fornication. She alone possesses the power to fend off the evil they bring, for she has been ordained by God to strike out the evil
GRANDIOSE DELUSIONS = CAN OCCUR ALONE BUT ALSO COMMON IN ==MANIA =====VS============== MAGICAL THINKING = PT THINKS SHE CAN CHANGE SOMETHING JUST BY THINKING ABOUT IT = PT THINKS SHE THOUGHT ABOUT CAR CRASHING SO THATS WHY IT CRASHED ===VS IDEAS OF REFRENCE = REGULAR OBJECTS HAVE SPECIAL CONNECTION TO PT = MAGAZINE/ TV IS COMMUNICATING TO PT
May be predisposed by death, loss of a loved one, poor parenting, exposure to gambling behaviour, and/or divorce. May engage in antisocial behaviour to obtain money for gambling, appear overconfident, suicide attempts
Gambling disorder
Persistant and recurrent gambling behaviour that includes a preoccupation with gambling, a need to gamble with more money, attempts to stop gambling and/or to win back losses, illegal acts to finance the gambling, or loss of relationships due to gambling
Gambling disorder
Persistent discomfort and sense of inappropriateness regarding the pts assigned sex Children will have preference for friends of the opposite sex Preoccupied with wearing opposite genders clothes Refuse to urinate sitting down, if a girl, or standing up if a boy Believe they were born with the wrong body
Gender Dysphoria
WHICH ANTIPSYCH DRUG IS BEST FOR PT WITH SCHIZOPHRENIA WHO IS TERRIBLE AT REMEMBERING/ OR TOO PSYCHOTIC TO BE RESPONSIBLE ENOUGH TO TAKE HER OWN MEDS
HALOPERIDOL DEPOT Depot forms are given monthly or q2 weeks (depending on the injection and the patient) and ensure compliance. The medication stays in their system the entire time and gives a long-term effect. ============= NOTE = DO NOT GIVE THIS PT CLOZAPINE===S.E.= agranulocytosis + SEIZURES = ONLY GIVEN WHEN MULTIPLE ANTIPSYCH PTS HAVE NOT RESOLVE SCHIZO SX IN A PT WHO IS ACTUALLY COMPLIANT/GOOD AT TAKING HER OWN MEDS
Excessive, poorly controlled anxiety that continues for more than 6 months. Both psychologic and physiologic symptoms are present and somatic symptoms such as irritability, decreased sleep, and poor concentration.
Generalized anxiety disorder
WHEN PT IS ASKED A QUESTION SHE GIVE VERY LONG EXPLANATIONS + UNNECESSARY DETAILS BEFORE SHE FINALLY ANSWERS QUESTIONS
HALLMARK = SHE ENDS UP FINALLY ANSWERING THE QUESTION = CIRCUMSTANTIALITY ------------ R/U= LOOSE ASSOCIATION- PERSON NEVER ENDS UP ANSWERING ORIGINAL Q
PT DOESNT TALK HALLMARK = She actively resists any attempt to be moved VERY SOCIALLY WITHDRAWN
HALLMARK ===> CATATONIC TYPE OF SCHIZOPHRENIA
FEMALE KEEPS PUSHING HER WEDDING DATE FORWEARD FOR PAST 8 YRS HER FIANCE SAYS SHE GETS ANGRY WHEN ASKY FOR REASON HALLMARK = FEMALE REFUSES TO SHARE ANY PERSONAL INFORMATION WITH ANYONE EVEN HER FAMILY AND EVEN FIANCE
HALLMARK INDICATES SHE MISTRUSTS PRETTY MUCH EVERY ONE IN HER LIFE PARANOID PERSONALITY DISORDER THESE PTS SUSPECT OTHERS ARE TRYING TO DECIEVE HER
PT WHO DRINKS 8 BEERS A DAY IS ADMITTING TO HOSPITAL AFTER A MVA ON DAY 2 OF HOSP = SAYS HE IS HEARING PEOPLE TALK = HALLUCINATIONS ON DAY 5 OF HOSP = HIS CONDITION RETURNS TO BASELINE/NO MORE HALLUCINATIONS
HALLUCINATIONS + NORMAL VITALS IN PT WHO DRINKS ALOT = ALCOHOLIC HALLUCINOSIS
SUMMARIZE IF HAVING HALLUCINATIONS VS DELUSIONS IS PART OF MANIA VS SCHIZOPHRENIA
HALLUCINATIONS---auditory/visual (pt talking to himself/ seeing or hearing someone not there) = NOT NORMAL IN MANIA!!!!!!!!!!!!!!!!!!!!!!!!!!!!1 = THIS IS SEEN IN SCHIZOPHRENIA! BUT GRANDIOSE DELUSIONS OR OTHER J=PEG DELUSIONS = NORMAL IN MANIA
PT IS agitated and restless and convinced that she can fly. She also notes that she is having visual, auditory, and tactile hallucinations. On examination, she is noted to have tachycardia, tremors, hypertension, and mydriasis
HALLUCINATIONS==HALLMARK + PUPIL DILATION = LSD
FOR PAST 3 WEEKS PT WHO JUST MOVED TO COLLEGE PT IS SAYING= HEARING VOICES + DOESN'T EAT/ DOESNT BATHE/ DOSENT GO TO CLASS
HE IS HAVING AUDITORY HALLUCINATIONS + DISORGANIZED BEHAVIOR === SINCE SX ARE "NOT" >1 MONTH = CAN NOT BE SCHIZOPHRENIFORM schizophreniform disorder would be diagnosed if these symptoms persisted for greater than 1 month but fewer than 6 months. === THIS IS = BREIF PSYCHOTIC DISORDER > 1 DAY AND < 1 MONTH
DIAGNOSE TX? 3 MONTHS AFTER HER BF BROKE UP WITH HER PT SAYS LESS SLEEP/ENERGY/ APETITE FEELS REALLY SAD ALSO!!! SHE SAYS THERE IS A VOICE TELLING HER THAT SHE SHOULD KILL HERSELF
HEARING VOICES= AUDITORY HALLUCINATION = NOT PART OF ADJUSTMENT DISORDER! SHE HAS SX OF DEPRESSION + PSYCHOTIC SYNDROME = TX: SSRI + 2ND GEN ANTIPSYCHOTIC
PT SAYS HEARING VOICES ALSO OVER PAST MONTH = Her sleep is poor and her energy is low. She also describes a 10 lb weight loss =========== WHICH DRUG SHOULD NEVER BE GIVEN TO PT WITH CARDIAC ISSUES
HEARING VOICES= SCHIZOPHRENIC + POOR SLEEP/APETITE/ENERGY= MOOD SX = SCHIZO= AFFECTIVE DISORDER == TX= SSRI + ANTI PSYCH= 2ND GEN/ ATYPICAL = ziprasidone (Geodon) and sertraline (Zoloft) ================= TCA===>> CARDIAC ARRYTHMIAS
RISPERIDONE SIDEEFFECT
HIGH PROLACTIN LEVELS = AMERNORHEA GALACTORHEA ===== RISPERIDONE= 2ND GEN ANTIPSYCH=check
PT FLIRTS WITH OTHER MEN IN FRONT OF HER HUSBAND IN HOPES THAT THIS WILL MAKE HER HUSBAND FEEL JEALOUS
HISTORONIC PERSONALITY = HIGHLY SUPERFICIAL + SEXUAL
PT HAS HAD =a dramatic change from her premorbid personality. She also presents with HALLMARK =irregular, purposeless, and asymmetrical movements of her face, limbs, and trunk,
HUNTINGTON DISEASE = choreic movements of the face, limbs, and trunk;===MOVEMENT DISORDER progressive dementia; and psychiatric symptoms=== NOT IN ALZEIHEMER Personality changes and mood disturbances, = including depression and mania, === MRI = MRI shows atrophy of the caudal nucleus and the putamen.
ANOREXIA WHAT LAB VALUE===ELEVATED?
HYPER-CHOLESTROL!==VERY WEIRD OTHER LABS = MILD , NORMOCYTIC ANEMIA ========== LOW WBC- LEUKO-PENIA ==== If vomiting is induced, hypokalemia, hypochloremia, and metabolic alkalosis may be seen ======= WEIRDLY ENOUGH
pt TAKING A MAOI EATS FOOD HIGH IN = TYRAMINE = MEATS / CHEESES/ RED WINE WHAT CAN BE CONSEQ OF THIS
HYPERTENSIVE CRISIS HENCE VERY IMP TO CLOSELY MONITOR THESE PT'S BP REGULARLY
DIFF IN HYPOMANIA VS MANIA
HYPO=MANIA = NO PSYCHOTIC FEATURES = HAS LESS FUNCTIONAL IMPAIRMENT THAN FULL BLOWN MANIA ===== REMEMBER HYPO=MANIA WITH MAJOR DEPRESSION = BIPOLAR 2
Ideas of reference, perceptual disturbances, impaired judgement, dissociative sx, pupillary dilatation, tremors, incoordination
Hallucinogens
Schizoid vs. Avoidant
Hermit vs. Actively Afraid of Criticism of Adequacy
Imaging Changes: PTSD
Hippocampus Atrophy
Name the Personality Disorder: Excessively emotional and attention seeking. Sexually provocative
Histrionic
Sexually-Provocative
Histrionic
Usually characterized by colourful, exaggerated behaviour and excitable, shallow expression of emotions; uses physical appearance to draw attention to self; sexually seductive - must be center of attention
Histrionic PD
Appetite in Cocaine, Amphetamine, or Nicotine Withdrawal
Hungry
Loss of GABA-ergic neurons of the basal ganglia, manifested by choreoathetosis, neurocognitive disorder, and psychosis Defect in an autosomal dominant gene located on chromosome #4 trinuceotide expansion CAG Atrophy of the caudate nucleus, with resultant ventricular enlargement Onset ~ age 40 and suicidal behaviour is fairly common
Huntington disease
what causes this : HALLMARK = RASH AROUND MOUTH = PERI-ORAL SKIN CHANGES PT WAS FOUND = DROWSY DIZZY/HEADACHE
INHALANT ABUSE-overdose THAT PERIORAL SKIN CHANGES = "GLUE SNIFFER'S" RASH SUSPECT IN BOYS AGE 14-17
PT BELIEVES TV IS SPEAKING DIRECTLY TO HIM OR A MAGAZINE ARTICLE HAS A SPECIAL MESSAGE FOR HIM
IDEAS OF REFERENCE = EVERYDAY OBJECTS HAVE SPECIAL "MESSAGES" OR CONNECTIONS TO THE PATIENT
MAN WHO IS FAN OF A SINGER= HIS IDOL HE DRESSES LIKE HIS IDOL BOUGHT SAME GUITAR AS HIS IDAL
IDENTIFICATION==defense mechanism in which the person incorporates the characteristics and qualities of another person or object into his or her own ego system
LANGE when are THE 3 MOOD STABILIZERS = LITHIUM, VALPORIC ACID, CARBAMEZIPINE NOT GOOD DOC FOR PT HAVING MANIA EPISODE
IF PT HAVING ACUTE MANIA EPISODE =is also THREATNING/ VIOLENT/ VERY AGITATED = NEED DRUG THAT WORK WAY FASTER THAN THE 3 MOOD STABILIZERS ((these agents take days to work)) = USE ANTIPSYCHOTIC DRUG= EX HALOPERIDOL = WORK WAY FASTER THAN 3 MOOD STABILIZER HENCE BETTER TX OPTION FOR PT WHO IS VIOLENT= NEEDS TO BE CALMED ASAP === NOTE= WILL STILL USE THE 3 MOOD STABILIZERS EVENTUALLY SINCE THIS PT HAS MANIA BUT WHEN NEED TO ACUTELY USE SOMETHING TO CALM A VIOLENT MANIC ASAP = MOOD STABILIZERS TO SLOW === Antipsychotics are indicated for acute treatment of agitation and violence sometimes seen in manic patients. Haloperidol works relatively quickly
pt in ICU MISTAKES IV POLE=AS FAMILY MEMBER
ILLUSION example = MAN MISTAKES CURTAIN DRAPE AS A MAN ================= Palinopsia is the persistence of a visual image after the stimulus has been removed.
DRUG THAT CAN TX BOTH ENURESIS + ADHD
IMIPRAMINE= TCA Imipramine is effective in the treatment of nocturnal enuresis, through a still unknown mechanism treatment of children and adults with ADHD, although it is not as effective as the stimulants.
GAD IMMEDIATE RELIEF?
IMMEDIATE RELEIF FOR GAD= NOR SSRI---for long term GAD Tc BENZODIAZEPINES All benzodiazepines are effective ============ Buspirone is effective for reducing symptoms of GAD but requires several weeks for significant improvement
OPIOD OVERDOSE WHICH ANTIDOTE FOR IMMEDIATE RELIEF VS FOR OPIOD==DETOXIFICATION= LONG TERM TX
IMMEDIATE TX= NALOXONE BUT!! FOR OPIOD DETOXIFICATION= LONG TERM TX FOR OPIOD OVERUSE PTOBLEM = BUPRE-NOR-PHINE =buprenorphine
TX OF PANIC DISORDER ACUTE VS LONG TERM
IMMEDIATE/ ACUTE ATTACK = BZs==LORAZE=PAM LONG TERM TX = SSRI, + , CONGITIVE BEHAV THERAPY===CBT
PT HAVING ALCOHOL WITHDRAWL SX = HALLUCINATIONS, ABNORMAL VITALS, = His temperature is 102.1°F, pulse is 130 beats/min, and blood pressure is 220/120 mm Hg UNIQUE = HE ALSO HAS LIVER ISSUES (high LFTs) which BZ ARE MOST APPROPRIATE FOR HIM
IN A PT WITH LIVER ISSUES, MUST ONLY GIVE HIM THOSE BZs THAT ARE NOT METABOLIZED BY LIVER = LOT drugs: (Lorazepam, Oxazepam, Temazepam) = give via IV ROUTE ============ choice of BZs IN A PT WITH ALCOHOL WITHDRAWL SX AND WITHOUT LIVER ISSUES = chlordiazepoxide and diazepam = BOTH GET METABOLIZED BY LIVER ((hence not appropriate in pt wiht high LFTs)) ============ remember = Disulfiram is used to treat alcohol dependence, not acute alcohol withdrawal.
PT WITH MDD AND NOW HE HAS SX OF MANIA = BUYING SHIT TON OF THINGS + TALKING TOO FAST + MAKES A THREAT THAT HE WILL "KILL HIS WIFE" WHAT SHOULD DOC DO?
IN ADDITION TO INFORMING WIFE,, IMPORTANT TO KEEP THIS GUY AWAY FROM OTHERS WHOM HE CAN HARM, SO DOC SHOULD GET A POLICE OFFICER TO HELP DOC TRANSFER PT TO ED/ PSYCH CENTER? = (B) Escort the patient (with police assistance as needed) to the nearest emergency room. ================= NOTE THIS PT'S MANIA SX + THREATS TO KILL WIFE== PSYCHOTIC SX =b/c MANIA==CAN HAVE PSYCHOTIC SX AS WELL (check)
DIFFERENCE BETWEEN LOOSE ASSOCIATION VS FLIGHT OF IDEAS
IN BOTH= PERSON NEVER ENDS UP ANSWERING ORIGINAL Q FOR DIFFERENCE = LOOK FOR IF THERES A CONNECTION BETWEEN SENTENCES ============ LOOSE ASSOCIATION = NO CLEAR CONNECTION BETWEEN SENTENCES VS FLIGHT OF IDEAS = constant shifting from one idea to another, though the ideas are often connected. = PERSON ALSO TALKS VERY FAST In flight of ideas, there are rapid and frequent changes in ideas or topics, =but the connections may still be recognizable. In loosening of associations, the logical connections between ideas are completely lost;
Beginning to Believe Another's Negative Perspective About You; Battered Woman Believes Husband Right When He Says She Is Worthless
Introjection
CHILD SHOWING SX OF REGRESSION = STARTED PEEING IN BED AFTER HER PARENTS TOLD HER THEY ARE DIVORCING CHILD IS ALSO SHOWING OTHER BEHAV CHANGES LIKE STAYING QUITE OTHERWISE, CHILD HAS NO SX DOC'S NEXT BEST STEP
INQUIRE ABOUT SEXUAL OR PHYSICAL ABUSE IN CHILD = DO THIS IN ANY KID WHO SHOWS:- >>REGRESSION (even if obvious why- parents divorcing) >>BEHAV CHANGES >>CHANGE IN ACADEMIC/SCHOLASTIC PERFORMANCE >>PHYSICAL INJURIES TO CHILD ============ AMITRIPTYLINE = USED IN TX OF ENURESIS IN KIDS WHO ARENT SHOWING ANY WARNING SIGNS MENTIONED ABOVE
PT TOLD SHE HAS CANCER PT DECIDES TO EXHAUSTIVELY RESEARCH DETAILS ABOUT CANCER AND IGNORES NORMAL ANXIETY OF A CANCER DIAGNOSIS
INTELLECTUALIZATION = NEUROTICALLY FOCUSSING ON INTELLECTUAL/ACADEMIC ASPECT OF PROBLEM INSTEAD OF DEALING WITH HOW THE PROBLEM MAKES PT FEEL
IS THIS INTELLECTUALIZATION OR RATIONALIZATION man accidentally crashes his car into another vehicle. LATER, he explains in meticulous detail to anyone listening all of the steps leading up to his accident
INTELLECTUALIZATION = WHEN DO "EXCESSIVE" AMT OF SOMETHING AFTER SOMETHING BAD HAPPENS = "EXCESSIVE READING ABOUT CANCER" "EXCESSIVELY" TALKING ABOUT ACCIDENT'S DETAILS excessive use of intellectual processes to avoid affective expression or experience In this case, the man avoids his guilty feelings through the meticulous explanation, over and over, of the events leading up to his car accident
pt just GOT TOLD HE HAS CANCER HE TELLS HIS FAMILY THIS NEWS AND SPEAKS WITHOUT ANY EMOTION
ISOLATION OF EFFECT
6 Months, Fear of Serious Illness Despite Negative Evaluations
Illness Anxiety Disorder (Hypochondriasis)
A disorder characterized by the patients belief that he/she has some specific disease. Despite constant reassurance, the patient's belief remains the same. Sx must occur for >6months generally between age 20-30
Illness Anxiety disorder
Increasing Tension Prior to Act; Pleasure or Relief During (Not For Personal Gain); Guilt or Remorse After
Impulse Control Disorder (Kleptomania); Treat with CBT
Pts are unable to resist a negative impulse. Before the act they have increased anxiety and after the act they feel a reduction in anxiety. Regulated by the serotonergic system
Impulse control disorders
Neurotransmitter Affected by Valproic Acid
Increases GABA
SUMMARY OF RISK FACTORS THAT INCREASE VS DECREASE SUCIDE RISK
Increases Likelihood of Suicide attempt = Psychiatric illness (PTSD, MDE)!!!! Homeless Previous attempt==HIGHEST RISK FACTOR Lack of social support (family, religion, support group) Elderly White Male Unemployed Physical illness ======================= Decreases likelihood of suicide attempt = Social support Plans for the future Parenthood Religion and participation in religious activities
Belligerence, apathy, assaultiveness, impaired judgement, blurred vision, stupor or coma
Inhalants
Discrete episodes of failure to resist aggressive impulses that result in serious assaultive acts or destruction or property. The degree of the aggressive act is typically out of proportion to the stressor
Intermittent Explosive Disorder
Short-Term Psycho-Therapy for Current Relationship Conflicts (Including Grief or Role Transitions)
Interpersonal
PT BELIEVES THAT well-known pop music star is in love with her and that they have had an ongoing affair DIAGNOSE
J-PEG = DELUSIONAL DISORDER = ======= NOTE = VERY IMP THAAT FOR A PT TO BE DIAG WITH DELUSIONAL DISORDER = PT MUST ONLY HAVE 1 THING WRONG= believes in a delusional belif that is non=bizarre and EVERYTHING ELSE ABOUT PT SHOULD BE NORMAL = NORMAL FUNCITONALITY NO PSYCHOSIS= HALLUCINATIONS ETC NO MOOD SX= MANIA OR DEPRESSION
A sense of familiar things being strange
Jamais vu
for past 3 MONTHS 15 YR OLD'S TEACHER SAYS HE HAS BEEN DRAWING THREATNING PICTURES WHEN ASKED, KID SAYS ALIENS ARE TELLING HIM TO DRAW THESE PICS =============== roomMATES SAY FOR PAST 1 MONTH, PT IS HAVING CONVOS WITH PEOPLE NOT THERE WALKING AROUND NAKED THINKS FBI= FOLLOWING HER
KID IS EX= AUDITORY HALLUCINATIONS SINCE SX <6 MONTHS = SCHIZOPHRENIFORM =============================== SCHIZOPHRENIFORM HAVING CONVOS WITH PEOPLE NOT THERE = AUDITORY HALLUCINATIONS FBI FOLLOWING HER= DELUSIONS WALK AROUND NAKED== DISORGANIZED BEHAVIOR
LABS TO ORDER WITH LITHIUM
KIDNEY FUNCTION-- CREATININE AND THYROID-- TSH Lithium causes hypothyroidism, nephrogenic diabetes insipidus, and Ebstein's anomaly in utero.
WHAT IS A MDD SX THAT MAY DIFFER IN KIDS VS. ADULTS WITH MDD ==================== WHEN A KID PT TALKS frequently makes errors with verb tense SPEECH IS EASY TO UNDERSTAND/CLEAR BUT t he uses simple sentences with a limited vocabulary
KIDS= IRRITABLE MOOD VS ADULT= FEEL SAD ALSO KIDS MORE LIKELY THAN ADOLESCENTS TO HAVE = PSYCHO-MOTOR AGITATION =============== KID HAS = EXPRESSIVE LANGUAGE DISORDER = SX: markedly limited vocabulary, making errors in tense, and having difficulty recalling words or producing sentences with developmentally appropriate length or complexity.
DIFFERENCE BETWEEN KLEPTOMANIA VS PETTY THEFT
KLEPTOMANIA = STEAL SAME OBJECT- MULTIPLE TIMES VS PETTY THEFT = STEAL DIFFERENT OBJECTS OF LITTLE VALUE
PT HAS HX OF STEALING THINGS SAYS SHE FEELS REALLY IMPUSLIVE BEFORE STEALING FEELS RELIEF AFTERWARD BUT ALSO = FEEL GUILT/REMORSE FOR STEALING
KLEPTOMANIA= form of impulse control disorder TX= COGNITIVE BEHAVIORAL THERAPY ((DO NOT RESPOND WELL TO MEDS)
PT had temporal lobes b/l removed now she has HYPERSEXUALITY---walks around naked + MEMORY DEFICITS =AMNESIA + EATS EVERYTHING ---EVEN NON-EDIBLE ITEMS
KLUVER BUCY SYNDROME = lack of fear response, + anterograde amnesia, + hyperphagia, and hypersexuality =============== OCCURS DUE TO DAMAGE TO TEMPORAL LOBE'S AMYGDALA Damage to the amygdala might render patients unable to recognize fear or anger in others ==========VS============ Möbius syndrome is a congenital absence of the facial nerves and nuclei with resulting bilateral facial paralysis.
WHICH CONDITIONS OCCUR DUE TO LESION IN MAMILLARY BODIES? SX?
KORSKOFF SYNDROME CAUSE= THIAMINE DEFICIENCY SX=
Management of Li toxicity
Keep plasma levels <1.5 mEq/L Dehydration and hyponatremia predispose to lithium toxicity by increasing serum Li levels Tremor may respond to decrease dose Li levels may increase with ACE-I, NSAIDs, loop and thiazide diuretics KEEP HYDRATED
Recurrent failure to resist impulses to steal objects that the patient does not need. Increased anxiety prior to the act, followed by release of anxiety after the act; the act of stealing is the goal
Kleptomania
Chronic Irreversible Confusion, psychosis, anterograde and retrograde amnesia Tx: Thiamine
Korsakoff
LITHIUM ALL CONTRAINDICATIONS? WHAT LABS SHOULD BE STARTED "BEFORE" STARTING LITHIUM
LABS TO ORDER =BEFORE LITHIUM USE (E) serumcreatinine , BUN and electrolytes, thyroid studies ============================ CONTRAINDICATIONS TO LITHIUM = KIDNEY DISEASE PREGNANCY HEART DISEASE HYPO-N-ATREMIA ================== BEFORE START USING LITHIUM, OTHER THESE LABS: THYROID FUNCTION TEST BUN/CREATINE EKG== ONLY DO THESE IN PTS WITH RISK FOR MI = DIABETES HTN SMOKING
LANGE TX FOR DEPRESSIVE SX SEEN IN BIPOLAR ================= HOW CAN LITHIUM AFFECT WBC
LAMOTRIGINE AND LITHIUM ((CHECK IF THIS IS FOR BOTH BIPOLAR 1 AND 2 SINCE BIPOLAR 1 CAN HAVE SOME DEPRESSION SX TOO)) ====== LITHIUM = can cause mild INCREASE= WBC
WHICH ANTI-SEIZURE DRUG USED TO TREST DEPRESSIVE ((NOT MANIC!))) EPISODE SEEN IN BIPOLAR DISORDER SIDE EFFECT?
LAMOTRIGINE S.E. = RASH==SJS
BIPOLAR PT IS ON WHAT DRUG CAUSING THESE S.E: DIAHREA nausea and vomiting, ataxia, and tremor
LITHIUM A therapeutic lithium level is 0.8 to 1.2. AT HIGHTER LEVELS, LITHIUM S.E. INCLUDE tremor, nausea, diarrhea, and ataxia; RENAL FAILURE===> DIAB INSIPIDUS, INTERSTITIAL NEPHRITIS HYPO-THYROIDISM SEIZURES===>> COMAN
WHICH DRUG CAN CAUSE TREMOR = WORSE WITH ACTIVITY
LITHIUM INDUCED TREMOR
OTHER THAN BZs TO TX ACUTE SX OF PANIC ATTACK, WHAT DRUG CLASS = TX PANIC DISORDER= LONGTERM ======= WHAT IS MOA OF BUPROPRION VS BUSPIRON
LONG TERM TX OF PANIC ATTACKS = SSRI= FLUOXETINE EXAMPLE ======== BUPOROPRION= ANTI-DEPRESSION., ANTI SMOKING = BLOCK DOPAMINE VS BUSPIRONE== ANTI= ANXIETY = BLOCK SEROTONIN
WHAT IS DIFF BETWEEN BULIMIA VS BINGE EATING DISORDER
LOOK FOR COMPENSATORY BEHAVIOR LIKE VOMITTING POST BINGING TO PREVENT WEIGHT GAIN BULIMIA = HAS COMPENSATORY BEHAVIOR = VOMIT POST BINGE EAT V VS BINGE EATING NERVOSA = NO COMPENSTORY VOMITTING OR ANY OTHER ACTIONS AFTER BINGE EATING TO KEEP WEIGHT DOWN = NO VOMITING NO FASTING NO EXCESSIVE EXERCISE
what neurotransmitter is likely LOW in pts WHO COMMIT SUCIDE WHO HAVE === HIGH VIOLENCE/ AGRESSION ================ WHAT IS CALLED WHEN PT THINKS TV IS DIRECTLY TALKING TO HIM
LOW SEROTONIN WHICH IS WHY SSRI WORK SO WELL ============== IDEA OF REFERENCE = The patient interprets an event as relating to him, even though it clearly does not.
OUT OF ALL ANTIPSYCH 2ND GEN DRUGS WHICH HAS LOWEST RISK OF WEIGHT GAIN/ HYPERCHOLESTROL/ D.M HIGHEST RISK?
LOWEST RISK OF W. GAIN = ARI-PRAZOLE AND ZIPRASIDONE ============== Most of the second-generation antipsychotics cause weight gain =, including clozapine, olanzapine, quetiapine, and risperidone. However, both ziprasidone and aripiprazole are weight neutral.
Hallucinations, Enhanced Sensations; Sweating, Fast Heart Rate, Dilated Pupils, Palpitations, Tremors, and Poor Coordination
LSD
Treatment of Depressive Episode for Bipolar 2 Patient; Watch for Rash
Lamictal (Lamotrigine)
Approved for bipolar depression and may cause Steven Johnson syndrome
Lamotrigine
Treatment of Epilepsy and Bipolar Disorder; Risk of Stevens-Johnson Syndrome
Lamotrigine (Lamictal)
Imaging Changes: Schizophrenia
Lateral Ventricle Enlargement
Hallucinations, parkinsonian features, and extrapyramidal signs. Antipsychotic medication may worsen behaviour. Pts typically have fluctuating cognition, as well as REM sleep behaviour disorder <1yr onset
Lewy Body dementia
Treatment for Acute Mania
Lithium
Treatment of Moderate or Severe Bipolar Disorder
Lithium or Lamictal (Lamotrigine) or Valproate with Atypical Anti-Psychotic
Monitored with Kidney (BUN, Creatinine, Calcium, and Urinalysis) and Thyroid Function Tests
Lithium: Nephrogenic Diabetes Insipidus, Chronic Interstitial Nephritis, or Low Thyroid Function
1. Acute Use Resulting in Tremor, Ataxia, or Weakness. 2. Chronic Use Resulting in Hyper-Parathyroidism (Or Nephrogenic Diabetes Insipidus or Thyroid Changes).
Lithium; Weight Gain, Acne, GI Irritation, and Cramps Are Most Common; Also Contra-Indicated in Cardiovascular Disease (Risk Factors = ECG)
Panic Disorder: Immediate vs. Chronic Treatment (After UDS, ECG, and Cardiac Enzymes Checked)
Lorazepam (Benzodiazepine Taper) vs. SSRI and/or CBT
DELIRIUM VS DEMENTIA
MAIN DIFFERENCE = DELIRIUM===acute onset==OCCURS PT WHO HAS BEEN HOSPITALIZED/ STARTED A NEW DRUG- most commonly, steroids Vs DEMENTIA=== chronic onset==occurs over time = Not in a pt hospitalized ================== ONLY IN DELIRIM = fluctuation in the level of consciousness (ie, from alertness to somnolence) with deficits in attention = are the hallmarks for delirium. ============ Attention is usually intact in dementia. Further, the acute onset of symptoms is more suggestive of delirium.==SINCE ITS USUALLY DUE TO A UNDERLYING MEDICAL CONDN
tx OF ACUTE MANIA? SX= TALKING REALLY FAST DECREASE NEED FOR SPEEED AGITATED ETC
MAIN DOC = MOOD Stabilizer (valproic/ lithium/ carbamezipine) MAYBE ADD = 2ND GEN ANTIPSYCH DRUG ==================== ACUTE MANIA ALONE = BIPOLAR 1 DISORDER===DOUBLE CHECK START TX WITH = 2ND GEN / ATYPICAL ANTIPSYCHOTIC = RISPERIDONE OLANZAPINE QUETIAPINE ETC SEVERE MANIA = ATYPICAL ANTIPSYCHOTIC + EITHER LITHIUM ((AVOID IF RENAL ISSUES) OR VALPROIC ACID ((AVOID IF LIVER ISSUES)) OR CARBAMAZAPINE
pt comes in saying he has been feEling DEPPRESSED ENERGY AND MOTIVATION=LOW POOR APETITE SLEEPS 12 HRS==WEIRD FOR DIAG ALSO: LOSING $ DUE TO INDISCRIMINATE PURCHASES
MAKING FRIVULOUS PURCHASE = HYPO-MANIA + OTHER SX=== MDD = BIPOLAR 2 == NOT THIS IS NOT BIPOLAR 1 BECAUSE HE IS NOT HAVING SEVERE/ FULL BLOWN MANIA
pt COMES IN WITH BACK PAIN WORKS AS A CHEF REFUSES PHYSICAL EXAM BEGS DOC TO WRITE A DOCTOR NOTE SAYING SHE CAN ONLY WORK CERTAIN JOBS
MALINGERING = SUSPECT WHENEVER A PT IS RELUCTANT TO BE EXAMINED/TREATED ===== REMEMBER EVEN A DRUG ADDICT FAKING SX TO GET NARCOTICS = MALINGERING
DIAGNOSE? PT DESTROYS HIS HOME BECAUSE HE IS SAYING HE IS " LOOKING FOR EVIDENCE" THAT SOMEONE STOLE A "CLASSIC BOOK I WROTE" CLAIMS HIS GF IS TRYING TO POISON HIM + ALSO SAYS = HAVENT SLEPT IN A WEEK HAS A PMH OF = "ACTING CRAZY"
MANIA= BIPOLAR 1 = HAVENT SLEPT, " ACTING CRAZY" + DELUSIONS= THINKS SOMEONE STOLE HIS SHIT, SOMEONE IS TRYING TO POSION HIM + GRANDIOSE DELUSIONS= HE WROTE A CLASSIC BOOK ALSO CAN HAVE = PRESSURED SPEECH = AKA SUPER FAST SPEECH
WIFE BRING HER HUSBAND DUE TO CHANGE IN HIS PERSONALITY HE STAYS UP ALL NIGHT GAMBLING AWAY ALL THEIR MONEY TALKS FAST DIFFICULTY FOCUSING WHAT DRUGS SHOULD HE BE GIVEN?
MANIC EPISODE GIVE ANTIPSYCH=ATYPICAL + MOOD STABILIZER = LITHIUM, VALPORIC ACID LAMOTRIGINE CARBAMEZIPINE
TX OF ATYPICAL ANTIDEPRESSION PT SAD/GUILTY/ CANT CONCENTRATE BUT ALSO WEIGHT GAIN SLEEPING A LOT
MAOI= tx of atypical depression---LANGE Phenelzine , tranylcypromine, and isocarboxazid = are irreversible blockers of MAO-A (monoamine oxidase-A) and MAO-B activity; = selegiline ==================== s. Although atypical features = respond best to MAOIs such as phenelzine, these medications are rarely used because of the potential risk of a fatal hypertensive crisis when eating certain tyramine-containing foods
PREGNANT PT WITH DEPRESSION SX DIAGNOSE
MDD Pre-partum blues and pre-partum depression are = not things
PT SAYS SHE HAS ALL SX OF MDD SHE SAYS SHE ALSO EXPERIENCES f an elevated and expansive mood, a decreased need for sleep, and an increase in activities, BUT SHE ALSO SAYS SHE FUNCTIONS= ADEQUATELY ========= DOES DYSTHMIA HAVE MANIA/ HYPOMANIA SX?
MDD + HYPOMANIA = SOME MANIA SX + NORMAL FUNCTIONALITY = BIPOLAR 2 ======= DYSTHMIA = NO MANIA/ HYPOMANIA SX AT ALL = ONLY MILD DEPRESSION= PAST 2 YRS
PREGNANT PT COMES TO YOU WITH SX OF DEPRESSION SHE ALSO HAS = SUICIDE IDEATIONS TX?
MDD + PREGNANT PT = JUMP TO TX WITH = ECT!!!!!!!!!!!!!====safe for mom and baby ========= DON'T WASTE TIME WITH SSRI = BECAUSE SSRI= TAKE WEEKS= 4-6 WKS TO HAVE AN EFFECT WHICH CAN BE DANGEROUSLY LONG TIME TO WAIT IN A PREG. PT WITH MDD
WHEN IS TX FOR MAJOR DEPRESSION = ELECTRO-CONVULSIVE THERAPY INDICATED
MDD PT WHO IS HIGHLY SUCIDAL MEDED= PREG PT WHO IS MDD AND SUCIDAL =============== NOTE= PT WITH MAJOR DEPRESSION AND PSYCHOSIS- AKA SCHIZOAFFECTIVE =should be given ANTIDEPRESSANT DRUG ==MAIN + ANTIPSYCHOTIC DRUG ====================== ECT INDICATIONS: WHEN PT WITH MAJOR DEPRESSION EVENTUALLY ALSO STARTS GETTING PSYCHOSIS= HALLUCINATION ========= WHEN PT WITH DEPRESSION HAS HIGH RISK OF SUCIDE ========== UNIQUE = WHEN GERIATRIC PT WITH DEPRESSION = REFUSE TO EAT OR DRINK ANYTHING === WHEN MAJOR DEPRESSION HAS BEEN TX RESISTANT
PT WITH MDD ALREADY TAKING = FLUOXETINE = BUT NOT WORKING NEXT BEST STEP
MDD TX = 1ST SSRI DOESNT WORD ==>> TRY== 2ND SSRI = (C) Switch to citalopram. IF 2ND SSRI FAILS TOO ===> TRY SNRI ====== TCA AND MAOI- VERY LAST RESORT FOR MDD TX =========
WHAT WOULD COLONSCOPY SHOW FOR A PT WHO HAS BEEN CHRONICALLY USING LAXATIVE ===================================== RUSSEL SIGN WHAT IS IT? WHICH PTS ARE LIKELY TO HAVE IT?/
MELANOSIS COLI= BLACK SPOTS ON COLON MUCOSA ================================================== RUSSEL SIGN = CALLUSES ON HAND FROM FORCE PURGING = SUSPECT IN BULIMICS
lange FIRST LINE TX FOR ACUTE MANIA=== BIPOLAR 1
MOOD STABILIZER = 1ST LINE ARE LITHIUM OR VALPORIC ACID 2ND LINE== CARBAMEZIPINE ========== NOTE ALTHOUGH ANTIPSYCH DRUG== ARIPRAZOLE ALSO USED TO TX BIPOLAR, FOR PT HAVING MANIA MOOD STABILIZERS > ANTIPSYCH DRUGS DUE TO HIGHER S.E. ASSOCIATED W/ ANTIPSYCH DRUGS
OTHER THAN ATYPICAL ANTIPSYCH DRUGS WHAT OTHER DRUGS TO TX ACUTE MANIA ======== WHAT DRUGS NEVER EVER GIVEN TO PATIENT WITH MANIA
MOOD STABILIZERS = LITHIUM VALPROIC ACID CARBAMAZIPINE ===== NOTE CAN ALSO GIVE FOR MANI BENZODIAZEPINES = TX AGITATION INSOMNIA ========================== NEVER EVER GIVE ANTIDEPRESSANTS TO PT WITH MANIA AS THESE WORSEN MANIC EPISODES
MOST COMMON S.E. OF SSRI===FLUOXETINE
MOST ARE GI = NAUSEA DIAHREA OTHERS = HEADAHCE INSOMNIA ((rem- ssri so increase serotonin in cleft)) === NOT A S.E.- WEIGHT GAIN!
WHAT IS REQ FOR DIAGNOSIS OF TOURETTE === NOTE = IF KID HAS BOTH TOURETTE + ADHD = STILL OK TO GIVE STIMULANT TO TX ADHD (wont make tics much worse)
MULTIPLE MOTOR TICKS + ATLEAST 1 = VOCAL TICK for diag to be made = ONSET MUST BE BEFORE AGE 18 ==== AVERAGE AGE OF ONSET= AGE 7 ======== LOOK OUT FOR OCD IN THIS KID TOO ======== THERE SHOULD BE ..NO... tic-free period longer than 3 consecutive months.
1) Sx wax and wane, shame and guilt are less often, threaten suicide less often, usually return to baseline level of functioning within 2 months.
Main difference between depression and grief/bereavement
Shortened REM latency, increased REM time, suppression of delta, multiple awakenings, and early morning awakening
Major Depression Sleep
At least a 2 week course of symptoms that is a change from the patient's previous level of functioning. Must have a depressed mood or anhedonia.
Major Depressive Disorder
A disorder characterized by depressive symptoms found during winter months and absent during summer months. Believed to be caused by abnormal melatonin metabolism (decreased MSH)
Major Depressive Disorder with Seasonal Pattern
ECT
Major depressive episodes that have no responded to antidepressant medication or mood stabilizers High risk of immediate suicide Contraindications with medications Responded well to ECT in the past
Conscious production of signs and symptoms for an obvious gain (money, avoidance of work, free bed and board) It is not a mental disorder. Seen more frequently in men, especially in prisons, factories, the military.
Malingering
Increased Appetite, Impaired Time Perception, Red Eyes, Dry Mouth (Gynecomastia with Chronic Use)
Marijuana; Extended Psychomotor Impairment Increases Risk of Accidents
Recurrent urge or behaviour involving the act of humiliation
Masochism
Hypertensive crisis MAO
May occur with tyramine rich foods or if certain other medications are ingested, including nasal decongestants, anti-asthmatic mediations, and amphetamines. Avoid red wine, ages cheese and chocolate
Hypothyroidism, Parkinson's disease, dementia, medications such as antihypertensives, pseudodementia, tumors, CVA
Medical DDx for Major Depressive Disorder
WHAT IS MEIGE SYNDROME ================ WHAT IS SYNDHAM CHOREA ======== S.E. OF WHICH DRUG = PT IS EXTREMELY THIRSTY AND URINATING A LOT
Meige syndrome is an oral facial dystonia involving blinking and chin thrusting, sometimes lip pursing or tongue movements, and ======= SYNDHAM CHOREA = associated with rheumatic fever =============== POLYURIA, POLYDIPSIA = DIAB INSIPIDUS = S.E. OF LITHIUM
Treatment of Illness-Associated Depression in Patients with Short Life Expectancy (Rapid Onset) or ADHD
Methylphenidate (Ritalin) or Modafinil (Provigil)
Anti-Depressant for PTSD, Hot Flashes, or Insomnia; Weight Gain
Mirtazapine (Remeron)
Treatment of Narcolepsy (Daytime Sleepiness and Cataplexy); Improves Motivation and Energy
Modafinil (Provigil)
Malingering vs. Factitious
Money-Seeking (Secondary Gain) vs. Fragile (Attention-Seeking)
Characterized by slight (mild) or prominent (severe) memory disturbances coupled with other cognitive disturbances that are present even in the absence of delirium. Key sx: Increasing disorientation, anxiety, depression, emotional lability, personality disturbances, hallucinations and delusions
Neurocognitive Disorders
Normal Sleep Disturbance of Aging
More Naps; Less Stage 4 Sleep; More Frequent Awakenings
Psycho-Therapy That Addresses Ambivalence to Change in Drug Abuser
Motivational Interviewing
0.2% Blood EtOH level
Motor area of brain is depressed Emotional behaviour is affected
Risk factors are Male, advanced age, HTN Examination may reveal carotid bruits, fundoscopic abnormalities and enlarged cardiac chambers. MRI may reveal hyperintensities and focal atrophy suggestive of old infarctions
Multi-infarct neurocognitive disorder
May be stepwise or gradual, depending on underlying pathology Focal neurologic sx (pseudobulbar palsy, dysarthria, and dysphagia are most common) Abnormal reflexes and gait disturbance are often present
Muti-infarct neurocognitive disorder
PT HAS HAD 3 SYNCOPE EPISODES AT WORK WHEN SHE HEARS A LOUD BANG = SHE IS UNABLE TO MOVE==UNIQUE DIAGNOSE? TX?
NARCOLEPSY 3 "SYNCOPE" EPISODES ARE ACTUALLY HER FALLING ASLEEP CATAPLEXY = CAN'T MOVE UPON FEELING A STRONG EMOTION =========== TX OF NARCOLEPSY = OTHER THAN AMPHETAMINES = SCHEDULE NAPS
pt says when he wakes up he feels momentarily "PARALYZED" ALSO= NEEDS SEVERAL NAPS IN DAY TIME ANOTHER EXAMPLE = PT KEEPS FALLING ASLEEP IN DAYTIME = SAYS WHEN HE WAKES UP, "CAN'T MOVE"
NARCOLEPSY "PARALYZED" UPON A EMOTION== CATAPLEXY = EXMAPLE: A young man drops to the floor whenever he is having a good laugh hypnagogic or hypnopompic hallucinations =(vivid hallucinations upon falling asleep or waking up), cataplexy (a sudden dramatic loss of muscle tone, usually following an intense emotional reaction), and sleep paralysis = (a loss of voluntary muscle tone at the beginning or end of sleep, as seen in this case).
NARCOLEPSY OTHER THAN DAY TIME SLEEPINESS WHAT OTHER SX? =========== TX OF NARCOLEPSY? WHAT IS MAIN DOC?
NARCOLEPSY = DAY TIME SLEEPY (like in OSA) + CATAPLEXY = SUDDEN LOSS OF MUSCLE TONE which gets triggered by STRONG/INTENSE EMOTIONS = PT FEELS "FROZEN" /UNABLE TO MOVE + hypnopompic or hypnagogic hallucinations, + or sleep paralysis = (an inability to perform voluntary movements either at sleep onset or awakening that can be terrifying) ==================================== NARCOLEPSY TX = #1 DOC = MODAFINIL= STIMULANT LANGE---METHYL-PHENIDATE LAST RESORT DOC = AMPHETAMINES = DEXTRO-AMPHETAMINE METH-AMPHETAMINE
which drug S.E. DRUG A =JAUNDICE!! ABD PAIN ======== HIGH BP ========== WHICH DRUG S.E. WEIGHT GAIN COLD INTOLERANCE DIAHREA
NEFA-ZO-DONE---> LIVER FAILURE ===> JAUNDICE NO LONGER PRESCRIBED =========== VENLAFAXINE--> HIGH BP ============= SE.= SX OF HYPO-THYROIDISM = SIDE EFFECT OF===LITHIUM
PT HAS ONE PUPIL= THAT ACOMMODATES BUT DOES NOT REACT TOW?
NEURO-SYPHILLUS OTHER SX = a loss of vibratory and proprioceptive Argyll-Robertson pupil = (a pupil that accommodates but does not react to light) --- Testing for neurosyphilis should include a blood test for VDRL and fluorescent treponemal antibody absorption test (FTA-ABS).
side EFFECTS OF TCAs ======================= WHAT IS NARCOTICS ANYONYMOUS
NEVER GIVE TO PT WITH CARDIO ISSUES!! CARDIAC = prolong QT INTERVAL ANTI-CHOLINERGIC- URINE RETENTION ETC ==================================================== NARCOTICS ANYONYMOUS = GROUP TO HELP OVERCOME ANY DRUG aDDICTION = COCAINE HEROIN MARIJUANA PRESCRIPTION DRUGS
MOM SAYS KID WAKES UP IN MIDDLE OF NIGHT WHEN HE SCREAMS + INCONSOLABLE BUT HE EVENTUALLY FALLS BACK TO SLEEP IS THIS NIGHTMARE VS NIGHT-TERROR
NIGHT TERROR= AKA= SLEEP TERROR === TO COMPARE NIGHT MARE VS NIGHT-TERROR - LOOK AT HOW KID REACTS WHEN HE WAKES UP AT NIGHT === WAKE UP W/ PANIC SX===NIGHT TERROR = and is associated with unresponsiveness to comfort or attempts to awaken them. VS WAKE UP AND QUICLY BECOMES ORIENTED = NIGHT-MARE
NAME DRUGS THAT ACT AS ANTIDOTES FOR NMS SYNDROME SEROTONIN SYNDROME EXTRAPYRAMIDAL S.E.
NMS ((stiff muscles))ANTIDOTE = DANTROLENE VS SEROTONIN SYNDROME ANTIDOTE ((mycolonic jerks)) = CYPROHEPTIDATE ================= ANTIPSYCH DRUGS -->CAUSE= EXTRAPYRAMIDAL S.E. = ANTIDOTE - ANY ANTICHOLINERGIC DRUG = DIPHENHYDRAMINE OR BENZTROPINE --> FOR PARKINSON LIKE sx, ---->ACUTE DYSTONIA PROPNOLOL--> FOR AKANITHISIA
WHAT CAN NMS LEAD TO
NMS= RIGID/ STIFF MUSCLES FEVER AUTONOMIC INSTABILITY COMPLICATIONS = MUSCLE BREAKDOWN= RHABDOMYOLYSIS= HIGH CPK ===>> KIDNEY FAILURE
DIAGNOSE? WHATS IT MOST DANGEROUS COMPLICATION PT TAKING HALOPERIDOL= 1ST GEN/ TYPICAL ANTI PSYCH NOW HE HAS STIFF EXTREMITIES (((VS. MYCOLONIC JERKS IN SEROTONIN SYNDROME)) he is diaphoretic with a temperature of 105.8°F==IN SEROTONIN SYNDROME ALSO, has a heart rate of 130 beats/min and a respiratory rate of 20 breaths/min =============================================== WHAT DRUG CAUSES THIS S.E. = RETINAL PIGMENTATION
NMS= VERY COMMON WITH ANTIPSYCH DRUGS, ESPECIALLY 1ST GEN = STIFF EXTREMITIES + FEVER (((VS. MYCOLONIC JERKS IN SEROTONIN SYNDROME)) ======= NMS MOST SERIOUS S.E. = RHABDOMYLOYSIS ============= RETINAL PIGMENTATION===> possible blindness S.E. OF = THIORIDAZINE
ARE THERE ANY MEDS TO TX BODY DYSMORPHIC DISORDER WHAT IS TX?
NO DRUGS EXIST TO TX BODY DYSMORPHIC DISORDER TX== THERAPY
MOM BRINGS IN KID PT MOM SAYS THEY WERE LATE TO APP BECAUSE KID REFUSED TO GET IN CAR KID ALSO ARGUES WITH MOM ABOUT BUYING TOYS he does not have a history of aggression toward peers or property and has not had any legal problems
NO LEGAL PROBLEMS NO AGREESION TOWARDS PEERS/PROPERTY = R/U CONDUCT DISORDER ======== KID HAS HX OF NOT LISTENING TO MOM'S ORDERS = OPPOSITIONAL DEFIANT DISORDER = Children with ODD are often angry, argumentative, and easily annoyed by others
FAMILY FORCIBLY BRING ALCOHOLIC PT TO ED SO HE CAN GET ADMITTED HE DOES NOT HAVE ANY CURRENT SX WHAT SHOULD BE GIVEN TO HIM IN ED
NO SX= NO NEED TO GIVE HIM BZs FOR ALCOHOL WITHDRAWL SINCE WE KNOW HE IS AN ALCOHOLIC =start with giving him THIAMINE>> BEFORE giving him GLUCOSE If a thiamine-deficient patient is given food (glucose), he or she can develop Wernicke encephalopathy (a delirium ---------------- THEN AFTER HE IS ADMITTED, SINCE HE WONT BE GETTING ANY ALCOHOL IN HOSPITAL EXPECT HIM TO HAVE SX OF ALCOHOL WITHDRAWL =for this give him LORAZEPAM= BZ
DOES SCHIZOPHRENIA ONLY HAVE HALLUCINATIONS
NO! HALLUCINATIONS =VISUAL- seeing shit not there =AUDITORY= hearing voices not there DELUSIONS== J-PEG ==someone is following pt/poisoning pt, etc DISORGANIZED BEHAVIOR
IS USE OF IBUPROFEN SAFE WITH USE OF = LITHIUM ========= NO MATTER WHAT KIND OF PSYCHOTIC SX A PT MAY BE HAVING WHAT IS 1ST TEST= DOC SHOULD ORDER
NO! IBUPROFEN= CAUSE INCREASE IN LEVELS OF LITHIUM INSTEAD SWITCH IBUPROFEN===>> ASPIRIN== SAFER NSAID ============ PT COMES IN WITH "ANY" PSYCH SX = ORDER TOXICOLOGY REPORT = WANNA R/U SX ARE NOT DUE TO SUBS. ABUSE THIS IS ESPECIALLY TRUE FOR WHEN PT= YOUNG ADOLESCENT
PT ON MAOI FOR MDD GETS PREGNANT SHOULD SHE STAY ON MAOI ============ Which of the following over-the-counter medications is contraindicated with MAOI treatment? a. Pseudoephedrine b. Acetaminophen c. Diphenhydramine d. Ibuprofen e. Guaifenesin
NO! MAOI= CONTRAIND IN PREG==> CAN RAISE BP SWTICH TO SSRI ========== a. Pseudoephedrine = sympathomimetic agents such as pseudoephedrine can cause severe hypertensive crises SO BAD IDEA TO GIVE 2 DRUGS TOGETHER THAT CAN BOTH CAUSE HYPERTENSIVE CRISIS
17 YEAR OLD BOY WHO HAS DEPRESSION TELLS YOU HE PLANNS TO USE A ROPE TO HANG HIMSLEF SHOULD DOC PROTECT HIS CONFENDITIALITY
NO! SINCE HE HAS A CONCRETE PLAN ON HOW TO COMMIT SUCIDE = DENY CONFENDITIALITY TELL PARENTS MOST IMPORTANTLY = FORCIBLY HOSPITALIZE PT IMMEDIATELY
IS IT SAFE FOR PT TO ABRUPTLY STOP TAKING SSRI? WHAT ARE CONSEQ
NO! STOPPING SSRI IN A MDD PT =CAUSE SSRI WITHDRAWL SX = SEROTONIN DISCONTINUATION SX FLU LIKE SX = HEADACHE MUSCLE ACHE NAUSEA ===========
DOES ADJUSTMENT DISORDER EVER HAVE PSYCHOTIC SX = HALLUCINATIONS DELUSIONS
NO! ((double check but pretty sure)) usualy cause mood sx= depression like, anxiety etc
SCHIZOAFFECTIVE DISORDER IS THIS ONLY THE CASE WHEN PT HAS SCHIZOPHRENIA + MDD?
NO!! EVEN WITH SCHIZOPHRENIA + MANIA = SCHIZOAFFECTIVE! ==================
WHAT KIND OF PUPIL CHANGES OCCUR WITH ALCOHOL OVERDOSE
NONE! BOTH ALCOHOL AND PCP = NYSTAGMUS
5 YEAR OLD GIRL IS HEARD TALKING TO "SANDY"--- IMAGINERY FRIEND OTHERWISE, SHE HAS REACHED ALL MILESTONES, DOING WELL IN SCHOOL, NO OTHER SX/PROBLEMS
NORMAL BEHAVIOR! FOR A 5 YR OLD TO BE TALKIN TO IMAGIN. FRIEND = NOT AUDITORY HALLUCINATIONS SEEN IN SCHIZOPHRENIA!! Sandy does not represent an auditory hallucination (schizophrenia - I say this purposefully for the test - NEVER has an onset so young), but rather a healthy imagination in a growing child
SUMMARIZE WHAT IS NORMAL TO HAVE IN BREAVEMENT ====== NOT NORMAL TO HAVE SUCIDAL THOUGHTS marked functional impairment.
NORMAL FOR UPTO = 2 MONTHS POST DEATH ==but need to check this --may be diff. now (1) guilt about things other than actions taken or not taken by the survivor at the time of the loved one's death, (2) thoughts of death other than the survivor feeling he/she would be better off dead without the loved one, (3) a morbid preoccupation with worthlessness , (4) marked psychomotor retardation, (5) marked and prolonged functional impairment, and (6) hallucinations other than the survivor believing he/she can hear the voice or see the loved one.
IN A KID WHAT AGE THE FOLL. OCCUR STRANGER ANXIETY VS SEPERATION ANXIETY ======================= KID WITH SCHIZOPHRENIA WHAT KIND OF FAMILY IS THIS KID LIKELY TO HAVE? WHAT MEANS== POOR OUTCOME==FOR SCHIZOPHRENIA IN A KID
NORMAL TO HAVE STRANGER ANXIETY IN = ALMOST A YR OLD== 7-8 MONTH OLD CHILD = EX---9-month-old girl = Previously very friendly with everyone, BUT NOW- she now bursts into tears when she is approached by an unfamiliar adult. VS SEPERATION ANXIETY = IN A SCHOOL AGE KID =============== SCHIZOPRENIA IN A KID = MOST LIKELY TO HAVE A PARENT WITH PSYCHOTIC---CAN BE ANY!!---DISORDER ASWELL ===================== POOR OUTCOME FOR SCHIZO PTS = AGE OF ONSET OF SCHIZO SX BEFORE AGE < 10 YR ==== GOOD OUTCOME FOR SCHIZOPHRENIC PT = Good premorbid functioning= CAN HOLD A JOB ETC later age at presentation, female gender, acute and rapid onset of symptoms (as opposed to insidious onset), and the presence of mood symptoms
pt believes her THOUGHTS RESPONSIBLE FOR HER FRIEND'S MISCARRIAGE
NOT IDEAS OF REFRENCE! = other individuals (eg, government, entertainers, the media) are referring to== "REFRENCING" or talking about the person Experiencing the delusion. ====================================== THIS IS MAGICAL THINKING = e belief that one's thoughts can control outside events. = another example of MAGICAL THINKING = PATIENT IS convinced that she has caused a recent earthquake because she was bored and wishing for something exciting to occur
MOM TELLS DOC SHE DOESNT WANT HER KID TO BE TAKING ANY STIMULANTS FOR TX OF HIS ADHD WHAT CAN DOC GIVE HIM
NOT ADERALL= THIS IS A STIMULANT == GIVE Atomoxetine =is a nonstimulant, norepinephrine reuptake inhibitor ========= SUSPECT ADHD IN THIS KID = boy who frequently blurts out comments in class =without waiting his turn to be called on.
7 MONTHS AFTER BREAKING UP WITH BF/ MOVING TO COLLEGE PT IS EXP DECREASE SLEEP LOST WEIGHT LOST INTERESTIN ACTIVITIES DIAGNOSE?
NOT ADJUSTMENT DISORDER B/C ITS SX SHOUD NEVER PERSIST FOR > 6 MONTHS SO NOW THIS PT HAS = MDD
1 MONTH AGO PT'S GF BROKE UP WITH HIM NOW HE HAS FOLL SX: MAXED OUT CREDIT CARD==BUYING SHIT TON = excessive spending HE IS SAYING HE HAS RIGHTS THAT ARE "GIVEN TO ME BY GOD" = grandiose delusions + PRESSURED SPEECH===Another way of saying fast speed DIAGNOSE?
NOT ADJUSTMENT DISORDER!!! = never has such obvious sx of MANIA ================ THESE SX ARE PRETTY SEVERE =AKA OBVIOUS FOR overt MANIA = pressured speech, grandiose delusions, and history of excessive spending DIAG= BIPOLAR 1= MANIA ((bipolar 1 usually has MANIA + some sx of depression)) ((rem bipolar 2= hypomania + MDD)) --> this pt def. has mania not hypomania
1 YEAR AFTER HER HUSBAND DIED PT HAS== AMNESIA SHE ALSO HAS LOSS OF FUNCTION = DOESNT KEEP HER HOUSE CLEAN ANYMORE DOESNT ENGAGE IN SOCIAL LIFE
NOT ALZIHEMER= THIS IS MORE CHRONIC!! ============ THIS IS PSEUDO=DEMENTIA = ALZIEHERM LIKE SX IN A PT WHO IS DEPRESSED==since her husband died a year ago == Pseudodementia is actually depression masking itself as dementia. She has a reason to be depressed (loss of her husband) and is exhibiting signs of dementia (forgetfulness, neglect ============ tx OF PSEUDO=DEMENTIA = ANTI-DEPRESSANTS
TX FOR "B"ORDERLINE PERSONALITY COMBANK ALSO IN LANGE
NOT CBT!!!!!!!! D"B"T = DIALETICAL BEHAVIORAL THERAPY
13 YEAR OLD PT TALKS BACK TO TEACHER AND PARENTS DOESNT DO HOMEWORK DOESNT OBEY HIS CURFEW DOES NOT FOLLOW CLASSROOM RULES
NOT CONDUCT DISORDER! SINCE HE IS NOT BREAKING ANY LEGAL RULES = OPPOSITIONAL DEFIANT DISORDER
PT DIAG WITH CANCER HE SPENDS HOURS READING ABOUT CANCER/TX/DIAG FAMILY SAYS THAT PT IS ODDLY DETACHED/ UN-CONCERNED ABOUT HIS PROGNOSIS
NOT ISOLATION OF AFFECT! (due to pt obsessively focusing on intellectual aspect of cancer))) INSTEAD THIS IS = INTELLECTUALIZATION = to AVOID ANXIETY ABOUT SOMETHING , PT DECIDES TO FOCUS ON TECHNICAL/INTELLECTUAL ASPECT OF THE SITUATION ((like in this example, pt is spending all his time reading up on cancer instead of really thinking about how it makes him feel)))
PT SAYS 3 WEEK AGO SHE SAW A KID DIE IN A CAR ACCIDENT SINCE THEN, SHE HAS BEEN REALLY AGITATED ANXIOUS SAD DIAGNOSE?
NOT JUST ADJUSTMENT DISORDER! SEEING SOMEONE DIE= MAJOR STRESSOR! SINCE <1 MONTH = ACUTE STRESS DISORDER = IF SX LAST >1 MONTH==>> PTSD
student comes to the physician with the complaint of shortness of breath during anxiety-provoking situations, such as examinations . She also notes perioral tingling, carpopedal spasms, and feelings of derealization at the same time. All of the symptoms pass after the anxiety over the situation has faded. The episodes have never occurred "out of the blue."
NOT PANIC ATTACK =since sx never occurred "out of the blue." = s. Panic disorder is characterized by recurring, spontaneous===NOT DURING JUST ANXIETY PROVOKING SITUATIONS , and unexpected anxiety attacks ============= this pt is suffering from JUST HYPERVENTILATION = Hyperventilation causes hypocapnia and respiratory alkalosis, ==> decreased cerebral blood flow and = Dizziness, derealization, and light-headedness ==>a decrease in ionized serum calcium. = SX SIMILAR TO HYPO-CALCEMIA carpopedal spasm, , PERIORAL TINGLING TX FOR HYPERVENTILATION = BREATHE INTO PAPER BAG
TX OF DELUSIONAL DISORDER?
NOT SSRI! 2ND GEN ANTIPSYCH DRUG= OLANZAPINE, ETC ERR. BUT MEDED SAYS THERAPY ((own tip -delusions are like mild hallucinations/ crazy beliefs so not tx with ssri= not depressed or anxiety)))
TX OF SOMEONE WITH SCHIZOTYPAL PERSONALITY DISORDER ========== BEST BZs FOR ALCOHOL WITHDRAWL
NOT THERAPY! = THESE PEOPLE ARE WAY TOO BIZARE IN HEAD TO BENEFIT FROM THERAPY TX=ANTIPSYCH DRUG ====== ALCOHOL WITHDRAWL =- LORAZEPAM (B) elevated or depressed liver enzymes = EXPECT IN ALCOHOL WITHDRAWL STATES IN A PT
WHAT IS DIAG? WHAT IS ANOTHER SX? WHAT WILL HEAD CT SHOW? 72 YR OLD MAN WITH UNSTABILITY ON FEET= GAIT=== UNIQUE + CONFUSION OVER TIME
NPH= NORMAL PRESSURE HYDROCEPHALUS = LOOK FOR TRIAD = GAIT CONFUSION INCONTINENCE===ANOTHER SX = CANT PEE CAND STAND CANT UNDERSTAND ===== HEAD CT FOR NPH = (B) dilated lateral ventricles
A state of sleep characterized by slowing of the EEG, high muscle tone, absence of eye movements, and thoughtlike mental activity. In this stage the brain is inactive while the body is active
NREM
PT COMPLAINS TO DOC ABOUT DOC'S NURSE PT SAYS PREVIOUSLY SHE HAD A VERBAL ARGUMENT ABOUT INSURANCE WITH THIS NURSE EVER SINCE THEN , WHENEVER PT CALLS TO MAKE APT WITH DOC, NURSE ALWAYS SAYS "I AM SORRY, THERE ARE OTHER PTS WAITING RIGHT NOW" NURSE IS SHOWING WHAT KIND OF DEFENSE MECHANISM?
NURSE IS SHOWING = PASSIVE AGGRESSIVE BEHAVIOR = NURSE IS SHOWING HER AGRESSION TOWARDS THIS PT VIA PASSIVE METHOD = POLITIELY/PASSIVELY SAYING TOO MANY PTS ARE WAITING
Name the Personality Disorder: Grandoise, Need amiration, Sense of entitlement. Lack of empathy
Narcissistic
Sense of self importance, grandiosity, and preoccupation with fantasies of success. Believes they are special, requires excessive admiration, reacts with rage when criticized, lacks empathy.
Narcissistic PD
Daytime sleepiness and abnormalities of REM sleep for a period of greater than 3 months. REM sleep occurs in less than 10 minutes. Patients feel refreshed upon awakening.
Narcolepsy
Directly and progressively destroys brain parenchyma 30% of individuals with AIDS beginning with subtle personality changes Diffuse and rapid multifocal destruction of brain structures occurs and delirium is often present Gait disturbances, hypertonia and hyperreflexia, pathologic reflexes (frontal release signs) and oculomotor deficits, Apathy, emotional liability or behavioural disinhibition
Neurocognitive disorder due to HIV
Prominent memory impairement in the absence of disturbances in level of alertness or the other cognitive problems that are present with delirium or neurocognitive disorder
Neurocognitive disorder due to substance/medication or another medical condition
Fever, Encephalopathy, Unstable Vitals, Lead-Pipe Rigidity (Myoglobinuria)
Neuroleptic Malignant Syndrome; Central Dopamine Inhibition by Haloperidol or Metoclopromide
Muscular rigidity, hyperthermia, autonomic instability, and delirium. CPK will be elevated. Usually associated with high dosages of high-potency antipsychotic medication. Tx with dantrolene or bromocriptine
Neuroleptic malignant syndrome
Occurs in Stages 3 and 4 Awakened by scream or intense anxiety No memory of the event the following day Seen more frequently in children MOre common in boys
Night terror
Occurs in REM Memory of event upon awakening, increases during times of stress
Nightmares (dream anxiety disorder)
Bereavement vs. Depression
No Guilt, Suicidal Ideation, or Functional Impairment; Yearning to Join Them and Hallucinations of Them Are Normal
Contrast Asperger to Autism
No Language Delays
SUMMARIZE DURATION CRITERIA FOR BREAVEMENT Persistent Complex Bereavement Disorder (PCBD = SEE MORE ON THIS BELOW =NEW IN DSM 5 DEPRESSION
Normal Bereavement == now <12 months= A WHOLE YEAR!! + , no loss of function REM- NORMAL TO HAVE HALLUCINATION IN BREAVEMENT AS LONG PT IS HALLUCINATING ABOUT THE DEAD PERSON SPECIFICALLY --------------------- Depression onset at whatever time, SIG E CAPS or suicidality. ================= . PCBD =BREAVEMENT THAT EXTENDS TO MORE THAN A YEAR = > 12 months,
1) Fear of strangers in unfamiliar contexts that is present from age 6 months to approximately 2 years 2) Fear of separation from the caregiver that is present from approximately 1-3 years of age
Normal childhood anxiety: (1) Stranger anxiety (2) Separation anxiety
Enlarged ventricles Normal pressure Neurocognitive disorder, urinary incontinence, and gait apraxia Tx includes shunt placements
Normal pressure hydrocephalus
DIAG? PT OBSESSED WITH PERFECTIONISM + HAVING EVERYTHING A CERTAIN WAY WHEN PLAYING GAMES, MUST FOLLOW RULES "PRECISELY" = FEEL THERE IS ONLY ONE WAY TO DO THINGS CORRECTLY =HENCE VERY STUBBORN TROUBLE WITH RELATIONSHIPS BECAUSE "NEED FOR PERFECTION"
OBSESSIVE COMPULSIVE "PERSONALITY" DISORDER = OBSESSED WITH HAVING THINGS A CERTAIN WAY/ PERFECT/ORDERLY ================= DIFF BETWEEN THIS AND OCD = OCD PTS ===>RECOGNIZE THEIR BEHAVIOR IS UNREASONABLE VS OCD "PERSONALITY" = DO NOT SEE A PROBLEM WITH THEIR BEHAVIOR
MAN CONSTANTLY BLAMES HIS COWORKERS OF TAKING "SHORTCUTS" HIS COWORKERS FIND HIM TO BE VERY DIFFICULT TO WORK WITH
OBSESSIVE COMPULSIVE PERSONALITY DISORDER
PT WHO WAS VALEDICTORIAN IN HIGH SCHOOL IN COLLEGE, UNABE TO FINISH HIS ASSIGNMENTS because HE SPENDS A LOT OF TIME = ENSURING HE KNOWS ALL CONTENT IN BOOKS UNIQUE = HE HAS VER "METICULOUS" WAY OF COMPLETING ASSIGNEMENTS
OBSESSIVE COMPULSIVE PERSONALITY DISORDER = DOESNT COMPLETE TASK ON TIE DUE TO BEING METICULOUS VERY RIGID WITH WAY THINGS ARE DONE
PT EXCESSIVELY WORRIES ABOUT DOOR BEING LOCKED AFTER COMPLETING HOMEWORK, SHE SPENDS A LOT OF TIME CHECKING HER WORK REPEATEDLY SHE KNOWS THIS BEHAVIOR DOESNT MAKE SENSE BUT CANT HELP HERSELF DIAG? TX?
OCD = RECURRENT UNWANTED THOUGHTS = WORRY EXCESSIVELY ABOUT DOOR BEING LOCKED OR REPETITIVE BEHAVIOR = KEEPS ON CHECKING HER WORK =================== OCD TX = (((lange says #1= clonidine===check)))) SSRI--->IF FAILS 2ND SSRI -->IF FAILS= ANOTHER CLASS OF DRUGS =============== IF 2 SSRI DONT WORK ONLY TCA THAT CAN TX OCD = CLOMIPRAMINE
WOMEN COMES IN SAYING SHE HAS HALLMARK = RECURRENT THOUGHTS OF STABBING HER 7 MONTH OLD BABY BUT SHE SAYS SHE DOESN'T WANT TO DO THIS SO SHE HAS REMOVED ALL KNIVES FROM HER HOME DIAGNOSIS? TX???
OCD! = RECURRENT THOUGHTS THAT ARE DISTURBING TO PT OF HARMING HER BABY NOTICE UNLIKE IN POSTPARTUM PSYCHOSIS, THIS MOM IS TRYING TO DISTRACT HERSELF FROM THESE THOUGHTS ((hiding the knives) TX==LANG===SSRI = FLUVO-OX-AMINE<===========didnt learn that name === this pt does not have SCHIZOPHRENIA because unlike schizo pts, this pt has very good insight of these recurrent thoughts and what she needs to do to avoid them ((schizo pts are not as smart))
PT IS TAKING LAMOTRIGINE BUT ITS NOT WORKING WHAT IS ANOTHER DRUG THAT COULD BE RESPONSIBLE FOR THIS
OCP = REDUCE EFFICACY OF LAMOTRIGINE ((LAMOTRIGINE ALSO REDUCES OCP EFFICACY))
PT COMES INTO ER MIOSIS RESP RATE= 6 HR= 50
OPIATE OVERDOSE = IMMEDIATELY GIVE NALOXONE --------------------------- SEE BELOW FOR WHY THIS IS NOT BZ OVERDOSE
A 23-year-old man is found unresponsive with slowed breathing. ========================== s complains of yawning, diarrhea , abdominal cramps, and nausea. Her pupils are dilated and she has notable piloerection
OPIATE OVERDOSE=HEROIN, ETC = RESP. DEPRESSION----> UN-RESPONSIVENESS ((rem- this was also in benzodiazipine overdose) PUPIL CONSTRICTION (((vs cocaine overdose- pupil dilation)) ================== opiate WITHDRAWL = nausea, vomiting, muscle aches, lacrimation, rhinorrhea, piloerection, sweating, diarrhea, yawning, fever, and insomnia.
SX OF HEROIN "OVERDOSE" ============= WHAT KIND OF DRUG IS FENTANYL
OPIOID PUPIL CONSTRICTION=MIOSIS (((remember- heroin overdose= mydriasis))) RESP DEPRESSION DEPRESSED MENTAL STATUS CONSTIPATION ================================= fenTANYL -= OPIOD
OVER DOSE OF WHAT? LOW BP LOW HR ATAXIA SEDATION ================== S.E OF WHICH DRUG = GINGIVAL HYPERPLASIA
OVERDOSE OF BARBITUATES OR BENZODIAZEPINES ============ PHENYTOIN--->GINGIVAL HYPERPLASIA
PT TAKEN TO ER WITH: PUPILS CONSTRICTED BRADY CARDIA HE IS---UNRESPONSIVE OVERDOSE OF WHAT? IMMEDIATE TX?
OVERDOSE==HEROIN IMMEDIATE TX===NALOXONE ===== REM-METHADONE==NOT FOR IMMEDIATE TX INSTEAD ITS FOR LONG TERM TX OF OPOID ADDICTION ===== HEROIN==OPOID ==OVERDOSE RESP DEPRESSION ===>>> decreased level of consciousness, and pinpoint pupils =========VS================== COCAINE OVERDOSE = PUPIL DILATION AGITATION
WHICH DRUG S.E. = HYPO-N-ATREMIA = RELATED SX- CONFUSION, ETC ====== WHICH KIND OF DRUG IS Divalproex sodiumis
OX-CARBEZI=PINE ==find out what kind of drug S.E==> HYPONATREMIA ---------------- Divalproex sodiumis a mood stabilizer and is used for bipolar disorder. USED- VERY RARELY
OXYCODONE WHAT KIND OF DRUG? ============ WHICH DRUG OVERDOSE CAUSE = LOW SODIUM
OXYCODONE = OPIATE= LIKE HEROIN = OVERDOSE==> respiratory depression, pinpoint pupils (miosis) =========== LOW SODIUM = MDMA= ECSTASY
Name the Personality Disorder: Preoccupied with perfectionism, order, control. Inflexible morals, values
Obsessive-Compulsive
Recurrent obsessions or compulsions that are recognized by the individual as unreasonable. Obsessions are anxiety-provoking, intrusive thoughts, commonly concerning contamination, doubt, guilt, aggression, and sex. Compulsions are peculiar behaviours that reduce anxiety.
Obsessive-Compulsive Disorder (OCD)
Overly Meticulous, Not Timely
Obsessive-Compulsive Personality Disorder; 1st-Line SSRI vs. Gold Standard Clomipramine
MAIN SX THAT DIFFERENTIATE OVERDOSE WITH PCP VS LSD
PCP= VIOLENT AGRESSION + NYSTAGMUS NOTE- NO TX FOR THIS/ NO ANTIDOTE ======== LSD OVERDOSE = VISUAL HALLUCINATIONS ========== LDS OVERDOSE ALSO HAS = PUPIL DILATION TREMORS SWEATING = BUT THESE PRESENT WITH COCAINE ALSO
Increased risk of weight gain, metabolic syndromes, diabetes, etc
Olanzapine
Weight Gain, Abnormal Lipid Profile; High Sugar
Olanzapine or Clozapine; Monthly BMI, Annual Blood Tests
Rhinorrhea and Lacrimation, Spasms and Joint Pain, Nausea, Sweating; Yawns
Opiate Withdrawal; Also Diarrhea and Dilated Pupils
Fever, chills, lacrimation, runny nose, abdominal cramps, muscle spasms, insomnia, yawning
Opiate withdrawel
What kind of drug is MEPERIDINE ============= WHICH DRUG S.E = RENAL STONES WHAT IS IT USED TO TX? ======== which drug s.E = PANCREATITIS
Opiate= MEPERIDONE ======== TOPIRAMATE= anticonvulsant ===> RENAL STONES= S.E. ===> USE= BULIMIA ( REM- ALSO SSRI ======= VALPROIC ACID S,E, = PANCREATITIS
Apathy, dysphoria, papillary constriction, drowsiness, slurred speech, impairment in memory, coma or death
Opiates
Pinpoint Pupils, Drowsiness, Constipation
Opiates
Acute Dystonia (High-Potency Typical Anti-Psychotics): Back vs. Sustained Elevation of Eyes
Opisthotonus vs. Oculogyric Crisis
Irritability Toward Authority Figures; Child
Oppositional Defiant Disorder
Persistent pattern lasting at least 6 months of negativistic, hostile, and defiant behaviours toward adults, including arguments, temper outbursts, vindictiveness, and deliberate annoyance
Oppositional Defiant Disorder
De-Realization vs. De-Personalization
Others and Environment (Strange and Unreal) vs. Self
PT COME SIN SAYS SHE IS AGITATED SWEATING PROFUSELY PALPITATIONS CHEST TIGHTNESS SAYS= SIMILAR SX IN PAST THAT LASTED 20 MINS AND RESOLVED ON OWN EKG== ONLY SHOWS SINUS TACHYCARDIA URINE DRUG SCREEN= NEGATIVE ====== DIAG? TX?
PANIC ATTACK = NOTE SX SIMILAR TO POSSIBLE HEART CONDITION-hence this should be ruled out with ekg cardiac enzymes SINCE SHE IS ACUTELY HAVING A PANIC ATTACK =GIVE HER BZ= LORAZEPAM ============= WHENEVER PT COMES IN FOR PANIC ATTACKS = Regardless of the clinical setting or psychiatric history== FIRST THING TO DO = RULE OUT CARDIAC/ LUNG CAUSES FOR PANIC ATTACK SX
PANIC ATTACK== MAIN TX? ======================== which DRUG CAUSED THIS PT'S S.E. A 14-year-old boy being treated pharmacologically for Tourette disorder is additionally started on citalopram and has an increase of 11 msec in his QTc values on ECG.
PANIC ATTACK---> SERTRALINE =================== PIMOZIDE= FIRST GEN ANTIPSYCH DRUG WHENEVER THIS IS GIVEN WITH CITALOPRAM = EXPECT EKG== PROLONG QT INTERVAL
patient DESCRIBES episodes of shaking, gasping for air, and feeling like she is going to die. UNIQUE =The feelings intensify for a few minutes and resolve spontaneously DIAGNOSE? ========== PT HAS CHRONICALLY "CHAPPED HANDS" SUSPECT WHAT
PANIC DISORDER TX OF PANIC ATTACKS = CHECK!--IF THERAPY FIRST? SSRI- SERTRALINE-WORK ============ CHRONICALLY "CHAPPED HANDS" = FROM WASHING TOO OFTEN ===>> OCD TX OCD= CBT
DIFF BETWEEN ANXIETY SEEN WITH PANIC ATTACKS/DISORDER VS SOCIAL ANXIETY DISORDER
PANIC DISORDER = "UNEXPECTED" ATTACKS OF ANXIETY VS SOCIAL ANXIETY DISORDER = ANXIETY TRIGGERED BY SPECIFIC STRESSORS = PERFORMANCE SITUATION = ANXIETY MAINLY BECAUSE PT IS WORRIED ABOUT BEING JUDGED BY OTHERS
PT HAS RECURRING EPISODES THAT LAST 5 MINS SUDDEN ONSET PALPITATIONS SWEATING TREMORS TURNS PALE OVERCOME WITH FEAR AFTER EACH EPISDOE, FEELS EMBARRASED TX?
PANIC DISORDER = ATLEAST 1 ATTACK FOR >1 MONTH FEEL "UTTER DOOM" "ALMOST DYING" ======= TX FOR ACUTE EPISODES = BZ===SPECIFICALLY=== Alprazolam ===ASSOCIATED WITH==== = DEPRESSION BIPOLAR AGORAPHOBIA= FEAR OF PUBLIC PLACES SUBS ABUSE
DIAGNOSE THIS PT? WHAT DEFENSE MECH. WILL HE USE? PT CAUGHT BY POLICE FOR STEALING OTHER PEOPLE'S IDENTITIES PT SAYS HE DID THIS BECAUSE "PEOPLE ARE AFTER ME" "THEY WANT TO CATCH ME
PARANOID PERSONALITY DISORDER DEFENSE MECHANISM = PROJECTION = "ACCUSE" ANOTHER PERSON OF SOMETHING YOU YOURSELF ARE ACTUALLY GUILTY OF ==========VS=========== SPLITTING =USED BY BORDERLINE PERSONALITY DISORDER =look for SUCIDE ATTEMPTS= ATTENTION SEEKING FAILED RELATIONSHIPS
WHICH SSRI MOST LIKELY TO CAUSE SSRI WITHDRAWL SX? ================ WHICH ONES = LEAST LIKELY TO CAUSE WITDRAWL SX
PAROXETINE= SHORT HALF LIFE = SIG. WITHDRAWL SX==SEE ABOVE==IF ABRUPTLY STOPPED ==================== FLUOXETINE == LONG HALF LIFE = LESS LIKELY TO CAUSE WITHDRAWL SX IF DISCONTINUED
Nystagmus and Aggression; Severe Agitation; High Pressure and Fast Heart Rate, Ataxia, Difficulty Speaking, Rigid Muscles, Seizures, or Coma
PCP
A veterinarian technician is brought to the emergency department after attacking what he thought was a cougar (it was a housecat). I n the emergency room he is febrile, appears panicked, has nystagmus, and demonstrates unexpected strength and rage.
PCP OVERDOSE = AGRESSION/ FIGHTING NYSTAGMUS The presence of nystagmus helps to distinguish PCP intoxication from other forms of psychosis.
IS THIS PMDD OR PMS week before her period, she often experiences marked anger and irritability and argues more with her boyfriend. diminished energy and concentration, and is sleeping more than is usual for her. These symptoms, in addition to breast tenderness and headaches, always remit in the week after her menses is finished.
PMDD (D) premenstrual dysphoric disorder (PMDD)
elderly PT HOSPITALIZED SHE HAS SX OF CYSTITIS HER OTHER SX: She reports that the president is Lyndon B. Johnson. She is easily distracted and cannot recall any of three items after a few minutes. She is irritable DIAGNOSE?
POST MEDICAL CONDITION (Cystitis) -->ALTERED MENTAL STATUS = DELIRUM
diagnose? tx?? 3 WEEKS AFTER GIVING BIRTH PT COMPLAINS OF SX OF DEPRESSION ALSO SAYS EVEN WHEN BABY IS NOT CRYING = SHE HEARS BABY'S CRYING VOICE SHE DOESNT WANT TO HURT HER BABY
POSTPARTUM DEPRESSION BUT WITH PSYCHOSIS- due to hearing baby's crying voices = tx == DUE TO PSYCHOSIS= JUST THERAPY NOT ENOUGH! SSRI + ANTIPSYCH DRUG = ) fluoxetine (Prozac) and haloperidol (Haldol)
TX AND DURATION OF POSTPARTUM= BLUES VS POST PARTUM = DEPRESSION
POSTPARTUM= BLUE = 2 WKS POST DELIVERY = , where mom wants to take care of baby, there is no depression==MUST NOT HAVE SIGE CAPS , but just a little dysthymia = TX==REASSURANCE== SX SHOUD RESOLVE ON THEIR OWN IN 2 WKS POST DELIEVERY = err. another question says answer is 2 Cognitive behavioral therapy would be used to treat post-partum blues, ========== POSTPARTUM = DEPRESSION = 4 WKS/1 MONTH POST DELIVERY = LOOK FOR SX IN SIGE CAPS = PT MUST DENY HALLUCINATIONS, FEARING BABY, ANY PSYCHOTIC SX = TX==SSRI== WILL NOT GO AWAY ON ITS OWN!!
PT ON RISPERIDONE FOR AUDITORY HALLUCINATIONS NOW SHE HAS " FLAT AFFECT WALKING SLOW WRITING IS VERY SMALL [---------- DIAG? TX?
PRAKINSONIAN =EXTRAPYRAMIDAL S.E. OF RISPERIDONE TX===BENZTROPINE ======== NOTE NOT GOOD IDEA TO SWITCH RISPERIDONE TO HALOPERIDOL AS THIS CARRIES A HIGHER RISK IN CAUSING PARKINSONIAN S.E.
PT WITH SCHIZOPHRENIA PREVIOUSLY HAD GOOD RESPONSE TO ANTI PSYCH MEDS BUT HE IS VERY NON COMPLIANT HENCE HIS SX KEEP COMING BACK
PRESCRIBE A LONG ACTIVE INJECTABLE ANTIPSYCH DRUG = BETTER THAN ORAL ANTIPSYCH DRUG IN PT WHO IS NON COMPLIANT
Treatment of Alcohol or Benzodiazepine Withdrawal (Contra-indicated in Patients with Lung Disease)
PRN Long-Acting Benzodiazepine (-aze- Last for Days); Adjunct Phenobarbital
DESCRIBE DEMENTIA DUE TO LEWY BODY DISEASE VS VASCULAR DEMENTIA VS PSEUDO=DEMENTIA
PSUEDO=DEMENTIA = PT ACTUALLY HAS DEPRESSION BUT ALSO HAS DEMENTIA LIKE==MEMORY DIFF. ------------------------------------------------------------------ DEMENTIA DUE TO LEWY BODY DISEASE = MEMORY LOSS + HALLUCINATIONS + PARKINSONIAN LIKE SX + EXTRAPYRAMIDAL SX ================================= VASCULAR DEMENTIA-- DUE TO LACUNAR INFACTS = MEMORY LOSS IN SOMEONE WITH: HTN CARDIOVASCULAR DISEASE = MRI OF BRAIN WILL show: Periventricular white-matter changes
SSRI " NOT" USED IN TX FOR
PSYCHOTIC DISORDERS = SCHIZOPHRENIA DELUSIONAL DISORDER ((( j- peg menomnic))) BIPOLAR OR ANYOTHER PSYCHOTIC DISORDER==where pt exp hallucinations etc
PT A =man presents with extreme rigidity, altered mental status, temperature of 104°F, and a highly elevated CPK --- PT B = n presents to the emergency room with a temperature of 105°F, tachycardia, arrhythmia, vomiting, diarrhea, and dehydration --- PT C = y she complained of blurry vision, dry mouth, and constipation
PT A = NMS ===== PT B = THYROID STORM === PT C = ANTI-CHOLINERGIC TOXICITY
WHICH DRUG CAUSED THESE PT'S S.E.s PT A = woman being treated for bipolar I disorder develops acute pain in her abdomen and is diagnosed with pancreatitis ========= PT B = The WBC count of a 27-year-old man being treated for treatment refractory schizophrenia drops to 3000/mL. ======== PT C = woman being treated for bipolar disorder finds herself urinating very frequently ======================= PT D = after starting on a new antipsychotic, a 32-year-old patient's total cholesterol increases from200 to 250 mg/dL.
PT A = BIPOLAR DRUG===> S.E. PANCREATITIS = VALPORIC ACID ================== PT B = CLOZAPINE Although carbamazepine and clozapine can BOTH cause agranulocytosis, clozapine is more likely to be used (and is FDA approved) for treatment of refractory schizophrenia. =========== PT C = BIPOLAR DRUG===> POLYURIA== DIAB INSIPIDUS = LITHIUM ========= PT D = clozapine SCHIZOPHRENIA= ANTIPSYCH DRUG THAT CAUSES HIGH CHOLESTROL==> W. GAIN===> DIABETES = CLOZAPINE ((ALSOE OLANZAPINE)))
WHAT KIND OF DEFENSE MECHANISM? PT A = IV DRUG USER SAYS HE GOT HEP C BECAUSE OF INADEQUATE CONTROL OF HEP C IN HIS CITY ============= PT B = WOMEN ANGRY WITH HUSBAND AND THROWS AWAY HIS VIDEO GAMES AS RETALIATION
PT A = DISTORTION = TO MAKE SOMETHING NEGATIVE (LIKE HEP C) MORE ACCEPTABLE, PT "DISTORTS" HIS PERCEPTION = Distortion is the reshaping of external reality to suit one's inner needs ================== PT B = DISPLACEMENT = WOMEN DISPLACES HIS ANGER WITH HUSBAND ONTO HIS VIDEO GAMES
KEY TERMS FOR FOLLOWING: PT A =PT'S ANSWERS ARE IRRELEVANT TO Q ASKED BECAUSE SHE DRIFTS AWAY FROM TOPIC BEING DISCUSSED BUT EVENTUALLY SHE RETURNS TO TALKING ABOUT ORIGINAL SUBJECT VS PT B = PT'S ANSWER SHOW SHE KEEP DRIFTING AWAY FROM SUBJECT BEING DISCUSSED AND SHE "NEVER" RETURN TO GIVEN SUBJECT
PT A = EVENTUALLY RETURNS TO SUBJECT = CIRCUMSTAN-TIALITY (stands out in circumference but soon jumps back in to center of circle) =vs============ PT B = TANGENTIALITY = NEVER RETURNS TO MAIN TOPIC = y. For example, Question: "How are you feeling?" Answer: "This sofa is feeling particularly soft today." NOTE = "LOOSE ASSOCIATIONS" = SEVERE FORM OF TANGENTIALITY
WITHDRAWL OF WHAT DRUG? PT A = DILATED PUPILS + RHINORHEA=CLEAR NASAL DISCARGE + MUSCLE PAIN + ABD CRAMPING ================ PT B = INCREASE APETITE ==> WEIGHT GAIN + LOW HR + IRRITABLE/DEPRESSED/ INSOMNIA
PT A = HEROIN WITHDRAWL ============ PT B = NICOTINE WITHDRAWL = W.GAIN/ INCREASE APETITE (REMEMBER= NICOTINE/CIGS USED TO LOSE WEIGHT)
WHAT IS IT CALLED WHEN PT FEELS HE HIMSELF IS NOT REAL= HE FEELS STRANGE/ UNREAL AKA PT DOESNT RECOGNIZE HIS OWN SENSE OF EXISTENCE VS PT FEELS HIS SURROUNDINGS ARE NOT REAL/ STRANGE
PT FEELS HE HIMSELF IS NOT REAL= HE FEELS STRANGE/ UNREAL AKA PT DOESNT RECOGNIZE HIS OWN SENSE OF EXISTENCE = DE=PERSONALIZATION ========VS================ PT FEELS HIS SURROUNDINGS ARE NOT REAL/ STRANGE = DE=REALIZATION = she feels as if she is disconnected from the world, as though it were artificial or distant
DEFENSE MECHANISM? PT A = AFTer slipping in front of your boss on a frozen puddle, you exclaim that "in a former life I was actually an elite figure skater!" =========== PT B = Your 69-year-old patient states he just has a bad cold after being diagnosed with metastatic lung cancer, and states all he needs is some hot tea and rest. === PT C = You argue with the boss at work, and when you come home you harshly groom your cat so that she actually wriggles away out of your arms === PT D = After not matching into your chosen specialty, you say that it was full of boring nerds anyway and that you really have way too much personality to be part of them.
PT A = HUMOR ==== PT B= DENIAL GOT TOLD HE HAS CANCER BUT HE SAYS HE REALLY JUST HAS A BAD COLD ==== PT C = DISPLACEMENT = ANGRY AT BOSS BUT TAKE OUT THIS ANGER ON POOR CAT ====== PT D = "MAKING EXCUSES" = INSTEAD OF ACCEPTING OWN FAULT FOR SOMETHING NOT GOING HOW YOU WANTED TO GO, YOU "RATIONALIZE" BY COMING UP WITH A LAME EXCUSE FOR WHY THINGS DIDNT GO YOUR WAY = rationalization (H) is the process of "making excuses" or cognitively reframing a situation to make it less anxiety or distress provoking; reaction formation
WHAT KIND OF DEFENSE MECHANISM: PT A = WOMEN WHO BELIEVES HER BF IS RIGHT WHEN HE TELLS HER THAT SHE IS WORTHLESS ========= PT B = WOMAN RECENTLY FOUND OUT HER FATHER HAS CANCER, SHE DECIDES TO FOCUS ON HER KIDS INSTEAD OF THINKING ABOUT HER DAD'S HEALTH
PT A = INTROJECTION = WHEN A PERSON ASSIMILATES ANOTHER PERSON'S ATTITUDE INTO ONE'S OWN PERSPECTIVE ========== PT B = SUPPRESSION = MATURE DEFENSE MECH. = INTENTIONALLY POSTPONING ANXIETY PROVOKING THOUGHTS BY SUBSITIUTING OTHER THOUGHTS
KEY TERMS FOR FOLLOWING: PT A = SENTENCES HAVE NO CLEAR CONNECTION VS PT B = REPETITIN OF WORDS OR REPETITION OF SAME IDEAS DURING A CONVO
PT A = LOOSE ASSOCIATIONS VS PT B = PERSERVATION = example While the patient is being interviewed, he answers every question with the same three words
WHAT KIND OF MEMORY LOSS: MOM BRINGS SON, SAYING HE STAYS IN HIS ROOM, AND DOESNT ENJOY HIS HOBBIES ANYMORE + MEMORY LOSS
PT A = MDD + MEMORY LOSS = PSEUDO-DEMENTIA = MEMORY LOSS IS REALLY JUST TO GET PAST MDD Pseudodementia is reversible once the depression is treated.
what kind of memory loss in pts below: PT A = PT IS SEEING A PERSON WHO IS NOT THERE + MEMORY LOSS ============ PT B = PT HAS CURSING ALOT WHEN HE USED TO BE VERY POLITE BEFORE + MEMORY LOSS =================== PT C = PT KEEPS FALLING ASLEEP-->WAKING UP - CYCLE ALSO HAS FEVER-high WITH MEMORY LOSS
PT A = MEMORY LOSS + VISUAL HALLUCINATIONS = LEWY BODY DEMENTIA CAN ALSO HAVE =Motor disturbances similar to that of Parkinson ============================ PT B = CHANGE IN PERSONALITY + MEMORY LOSS = PICKS DISEASE atrophy of the frontal and temporal lobes ========================== HIGH FEVER===> PSYCH SX= IN/OUT OF CONSIOUSNESS = DELIRIUM look for one or more underlying causes, such as electrolyte abnormalities, infections, and side effects of medications.
DEFENSE MECHANISM? PT A = WOMEN HATES IMMIGRANTS FOR TAKING AMERICAN JOBS = SHE ALSO HELPS IMMIGRANTS GET JOBS I NAMERICA ============= PT B = PT CHANNELS HIS ANGER INTO PLAYING TENNIS
PT A = REACTION FORMAITON (((react in opp way to how u feel))) = WHEN A PERSON ACTS OPPOSITE TO HOW HE REALLY FEELS (USUALLY THESE FEELING ARE NEGATIVE) = ANOTHER EXAMPLE: woman lives with her mother, whom she intensely dislikes. She feels embarrassed by this, and compensates by hovering over her mother, attending to her every need. =================== PT B = SUBLIMATION = MATURE DEFENSE MECH. = DIVERT UNACCEPTABLE DRIVES INTO SOMETHING MORE ACCEPTABLE
WHAT KIND OF DEFENSE MECHANISM? PT A = married male is just told by his wife that she has been having an affair. He immediately hugs her and tells her he loves her ============ PT B = Your borderline patient misses seven appointments in a row resulting in your terminating her treatment contract ========== PT C = After repeatedly failing to bring your portion of the group project to class, you accuse the group leader of forgetting to e-mail you a reminder.
PT A = REACTION FORMATION = REACT OPPOSITE TO HOW U FEEL = HUG A CHEATING WIFE EVEN THOUGH WANNA KILL HER =========== PT B = projective identification (F) can be thought of as a self-fulfilling prophecy, wherein the patient's unacceptable feelings are projected to another, but the other (eg, therapist) acts in such a way that they become true— for instance, a patient views the world as full of unloving people (she hates herself), then acts to push her therapist to the breaking point where he terminates her care, therefore c onfirming her belief that the world is full of unloving people. ==================== PT C = PROJECTION = INVOLVES ONE PERSON "ACCUSING" ANOTHER = ONE PERSON IS REALLY WRONG, BUT "ACCUSES" ANOTHER PERSON ; in projection (E) one's OWN unacceptable ideas or thoughts are seen as coming from another (for instance, a cheating husband accuses his wife of being unfaithful)
WHAT KIND OF DEFENSE MECH. ? PT A = ADULT MAN DECIDES TO MOVE BACK HOME WITH PARENTS IN RESPONSE TO PRESSURE TO PROPOSE TO HIS GF VS PT B = GIRL GETS YELLED AT BY BOSS. GIRL DOESNT SAY ANYTHING TO BOSS BUT LATER GETS IN ARGUMENT / YELLING/ AT BOSS'S SECRETARY
PT A = REGRESSION = RETURN TO IMMATURE LEVEL TO AVOID STRESS/CONFLICT - ANOTHER EXAMPLE- 5 YR OLD STARTS PEEING IN BED AFTER BIRTH OF SIBLING OR MOVING TO NEW CITY ================= PT B = DISPLACEMENT
WHICH DRUG CAUSED THESE PT'S S.E.s pt A = woman being treated for schizophrenia develops diabetes. ============ PT B = girl being treated for major depressive disorder' reports suicidal ideation
PT A = SCHIZOPHRENIA= ANTIPSYCH DRUG THAT CAUSES HIGH CHOLESTROL==> W. GAIN===> DIABETES = CLOZAPINE ((ALSOE OLANZAPINE))) ========= PT B = paroxetine some of the SSRIs, including paroxetine, may increase the risk of suicidal thoughts in children
WHAT RECEPTOR IS BEING BLOCKED THAT WOULD CAUSE A DRUG TO CAUSE FOLL. SIDE EFFECTS? PT A = DIZZINESS UPON STANDING =========== PT B= CONSTIPATION ========= PT C = experiences a milky discharge fromhis breasts. ========== PT D = RESOLUTION OF PSYCHOTIC SX LIKE HALLUCINATIONS
PT A= ORTHOSTATIC HYPOTENSION = S.E. OF BLOCKING DRUGS THAT BLOCK ALPHA 1 RECEPTOR ((CLONIDINE, CHECK MORE?) Blockade at the alpha-1 receptor ( B ) is responsible for the dizziness, sedation, and orthostatic hypotension = TCA!! ================ PT B= CONSTIPATION = S.E. OF DRUGS THAT ARE ANTI-CHOLINERGIC= BLOCKING ACH PARASYMP ACTION = BLOCK MUSCARINIC RECEPTORS = THESE DRUGS ARE: ANTIHISTAMINES TCAs CHECK FOR MORE ======== PT C = BLOCK DOPAMINE RECEPTORS= D "2" RECEPTOR = blockade in the tubero-infundibular pathway is responsible for the prolactinemia seen with antipsychotics === PT D =also BLOCK DOPAMINE D2 RECEPTOR in the mesolimbic and mesocortical areas of the brain are responsible for reducing the positive psychotic symptoms in schizophrenia
WHAT DEFENSE MECHANISM WOMEN HAS BEEN HAVING ANGER PROBLEMS HER ENTIRE LIFE , she tells the psychiatrist that she is very afraid of him because he is "so angry all the time." She behaves as if this is true and that the psychiatrist will explode with rage at any minute
PT IS ACCUSING PSYCHIATRIST OF BEING ANGRY AT ALL TIMES = "ACCUSATION" = PROJECTION Projection is recognized when a person perceives and reacts to an unacceptable inner impulse as if the impulse were coming from the external environment. In this case, the patient, likely with a huge amount of internal anger that she finds dangerous and unacceptable, projects this anger onto the therapist and reacts as if the therapist is angry at her
PT WITH (true) PARKINSON''S IS TAKING MEDS FOR IT NOW COMPLAINs = VISUAL HALLUCINATIONS
PT IS NOT GOING PSYCHOTIC! Hallucinations are the = most common side effect of anti-Parkinson medication SO DOC NEEDS TO JUST LOWER DOSE OF L-DOPA
WHAT IS A WEIRD= NOT AGRAUNLOCYTOSIS S.E. OF CLOZAPINE
PT STARTS DROOLING= PRODUCING SHIT TON OF SALIVA TX/ ANTIDOTE FOR THIS S.E. = ANTI-CHOLINERGIC = propylthiouracil
OTHER THAN HX OF EPILEPSY/SEIZURES WHAT IS ANOTHER CONTRAINDICATION FOR BUPROPRIAN
PT WITH PMH OF ANOREXIA OR BULIMIA THIS IS BECAUSE BOTH THESE CONDNS CAN CAUSE ELECTROLYTE ABNORMALITIES = INCREASE SEIZURE RISK
risk factors of sexual assault
PTSD depression suicidality
DIFF BETWEEN PYROMANIA VS ARSON
PYROMANIA = SET THINGS ON FIRE BUT NOT DONE FOR== INCENTIVE/FINANCIAL GAIN VS ARSON = SET THINGS ON FIRE FOR $$ OR SECONDARY GAIN/ REVENGE = EXAMPLE GUY SETS HIS PARENTS HOUSE ON FIRE AFTER THEY TELL HIM HE IS BEING SEND TO MILITARY SCHOOL ===> IN THIS CASE, CAUSING FIRE WAS FOR PURPOSE OF REVENGE ON PARENTS
Recurrent, unexpected panic attacks are present: intense anxiety that often include marked physical sx, such as tachycardia, hyperventilation, dizziness and sweating. Followed by 1 month of fear of having no attacks.
Panic Disorder
Name the Personality Disorder: Distrusful, suspicious; interpret others' motives as malevolent
Paranoid
Distrust and suspicious: Individuals are suspicious of the motivations and actions of others and are often secretive and isolated. Emotionally cold and odd
Paranoid PD
Sexual activity is ritualistic, fantasy is typically fixed and shows very little variation, intense urge to carry out the fantasy
Paraphilic disorder
Loss of dopaminergic neurons in the substantia nigra, clinical onset usually age 50-65 Motor sx include resting tremor, rigidity, bradykinesia, and gait disturbances Neurocognitive disorder occurs in 40% of cases Environmental toxins, infection, genetic predisposition, and aging
Parkinson disease
Treatment: Generalized Anxiety vs. Social Anxiety
Paroxetine vs. Prophylactic Benzodiazepine (Unless Academic Setting or History of Drug Abuse) or Propranolol
Difference Between Disruptive Mood Dysregulation Disorder and Bipolar Disorder
Pediatric and Chronic (Irritability)
Recurrent urges or arousal toward prepubescent children. Most common paraphilia
Pedophilia
Involuntary constriction of the outer one-third of the vagina that interferes with the sexual act
Penetration disorder
Repetition of Words or Ideas
Perseveration
A chronic disorder characterized by a depressed mood that lasts most of the time during the day and is present on most days for at least 2 years. Pts typically have other psychiatric disorders, such as anxiety, substance abuse, and/or borderline personality disorders
Persistent Depressive Disorder (Dysthymia)
Spongiform encephalopathy is caused by a slow virus (prion) Neurocognitive disorder, myoclonus, and EEG abnormalities Sx progress over months from vague malaise and personality changes to neurocognitive disorder and death. Visual and gait disturbances, choreoathetosis or other abnormal movements, and myoclonus
Prion disease
SSRIs and Prazosin has been used to reduce nightmares
Pharmacologic Tx of PTSD
Belligerence, assaultiveness, psychomotor agitation, nystagmus, hypertension, seizures, coma, hyperacusis
Phencyclidine
MAOIs
Phenelzine Tranylcypromine Isocarboxazid Selegiline (selective MAOI-B) tx Parkinson's
Chapped hands when hand-washing compulsions is present Behavioural psychotherapies, guided imagery, exposure to paradoxical content and even SSRIs
Physical Examination and Management of OCD
Somatic Symptom Disorder vs. Conversion Disorder vs. Illness Anxiety Disorder
Physiologic (Pain or Fatigue) vs. Non-Physiologic (Neurologic) vs. None
Atrophy in the frontal and temporal lobes Intraneuronal argentophilic inclusions and swollen neurons in affected areas of the brain May see features of Kluver-Bucy syndrome (hypersexuality, hyperphagia, passivity)
Pick disease (Frontotemporal neurocognitive disorder) Pick bodies Pick neurons
Onset of mood sx within 2 weeks after delivery Sadness, mood lability, tearfulness, no negative feeling towards child, treated with support.
Postpartum blues or Baby blues
Dopamine Agonist (Risk of Pathologic Gambling); Treatment of Parkinson Disease or RLS
Pramipexole
5:1 male to female ratio Onset: before 3 years of age ID is present in 75% of patients Higher incidence of abnormal EEGs, seizures and abnormal brain morphology Predictors of a poor outcome are associated ID and failure to develop useful speech Seizures may develop in 25% of adults Self-injuries caused by head banging or biting sometimes present
Presenting sx of Autism Spectrum Disorders
Abnormal or persistently elevated mood lasting at least 1 week Increased self-esteem or grandiosity Distractibility Excessive involvement in activities More talkative than usual Psychomotor agitation Flight of ideas Increased sexual activities Increase in goal-directed activity
Presenting sx of Bipolar I Disorder
Depressed mood most of the day Anhedonia during most of the day Significant weight loss Insomnia Psychomotor agitation or retardation (stooped posture, slowing of movements, slowed speech) Fatigue or loss of energy nearly every day Feelings of worthlessness or guilt Diminished ability to concentrate Recurrent thoughts about death
Presenting sx of Major Depressive Disorder: *Psychotic features = worse prognosis *Atypical features = Increased weight, appetite and sleep
About 50% of cases resolve within three months and usually begin immediately after trauma but can occur after months or years. Reexperiencing of traumatic events Avoidance of stimuli associated with the trauma or numbing of general responsiveness Increased arousal: anxiety, sleep disturbances, hypervigilence
Presenting symptoms of ASD/PTSD
5% of school-age children and 2.5% of adults with a 2:1 male to female ratio. Family hx of mood and anxiety disorders, substance-related disorders, and antiscocial personality disorders
Prevalence and FHx of ADHD
4% of school-age children seen more in males with FHx of antisocial personality disorder, ADHD, mood disorders and substance-related disorders
Prevalence and FHx of Conduct disorder
3-5% of children aged 10 more common in boys and may occur only at night, only during daytime or both. Must assess for UTI or abnormalities
Prevalence and PE of Childhood Enuresis
3/1000 and more common in males, onset of 7 years with motor tics and 11 years with vocal tics which both wax and wane over time. Lifelong with remissions and exacerbations
Prevalence and onset of Tourette Disorder
Metabolic alkalosis, hypochloremia, and hypokalemia
Purging emesis
Attributing your own wishes, thoughts or feelings, onto someone else. "Im sure my wife is cheating on me"
Projection
Cheating Husband Accuses Wife of Being Unfaithful
Projection
Typically seen in an elderly pt who has a depressive disorder but appears to have sx of neurocognitive disorder; should improve after being treated with antidepressants Can usually date the onset of their sx Answers: "I don't know" to questions instead of confabulating
Pseudodementia
Differential for Sad Mood, Diminished Energy, Slow Movement, Poor Concentration, and Poor Appetite
Psychiatric (Major Depression) or Endocrine Hypo-Thyroidism
Ongoing Psycho-Therapy for Exploration of Past Relationship Conflicts by Examination of Transference
Psychodynamic
Pts will score lower on all IQ tests Neuropsychologic tests are consistent with bilateral frontal and temporal lobe dysfunction --> deficits in attention, retention time, and problem-solving abilities
Psychologic tests in Schizophrenia
Difference Between Mania and Hypomania, In Addition to Differences in Severity and Duration
Psychosis; Avoid SSRIs and TCAs in Manic Patients
Deliberate fire-setting on more than one occasion. There is anxiety before the act and a release of anxiety after the act, sometimes followed by fascination and gratification. Must rule out arson. Seen more in men who are mildly retarded, many have hx of truancy and cruelty to animals. May become sexually aroused by the fire.
Pyromania
Lowest risk of movement disorders
Quetiapine
The patient feels disconnected from reality and frightened. On physical examination, he is noted to have a rash around his mouth.
RASH AROUND MOUTH ==> INHALANT ABUSE
PT GOT FIRED BY BOSS HE SAYS THIS WAS "BLESSING IN DISGUISE" AND REFUSES TO ACKNOWLEDGE HIS OWN FAULTS THAT LED TO HIM BEING FIRED
RATIONALIZATION = INSTEAD OF ACCEPTING PERSONAL RESPONSIBILITY FOR A SITUATION, PT COMES UP WITH AN EXPLANATION THAT IS SELF=SATISFYING
PT DIAG WITH CANCER HE IS FEARFUL OF DEATH BUT ACTS= OPTIMISTIC ABOUT HIS PROGNOSIS
REACTION FORMATION = REACT OPPOSITE TO HOW U REALLY FEEL INTERNALLY
TX OF HYPOCHONDRIACS ======= pt CAN'T FEEL HER RIGHT ARM/LEG HER HUSBAND DIED EARLIER TODAY
REASSURANCE Management of hypochondriasis revolves around minimizing testing, minimizing specialists, and maintaining a strong physician-patient relationship ============== CONVERSION DISORDER = If you see a "neurologic deficit" and "psychological stressor" in the same the vignette, it is conversion disorder.
WHAT IS TX FOR NIGHT TERROR===STAGE 3/4 = WAKE UP SCREAMING BUT DOESNT REMEMBER ANYTHING IN MORNING
REASSURANCE Zolpidem and other sleep aids are used for adults primarily. They should be AVOIDED in children
Easiest to arouse, lengthens in time as night progresses, increased during the second half of the night
REM
Aroused EEG patterns, sexual arousal, saccadic eye movements, generalized muscle atony (except middle-ear and eye muscles), and dreams. Brain is active and body is inactive.
REM (bursts of sawtooth) 25%
The period lasting from the moment you fall asleep to the first REM period. Lasts approximately 90min in most individuals. However several disorders will shorten this such as depression and narcolepsy
REM Latency
WHAT ARE THE 3 DOPAMINE PATHWAYS AND ASSOCIATED EFFECTS
REM-SINCE ANTIPSYCH DRUGS BLOCK DOPAMINE, THEY ALL ACT ON THESE PATHWAYS 1. MESOLIMBIC = ANTI=PSYCHOTIC EFFICACY ================= 2. NIGRO-STRIATAL = EXTRA-PYRAMIDAL SIDE EFFECTS ASSOCIATED WITH ANTIPSYCH DRUGS = DYSTONIA AKATHISIA PARKINSONISM =============== 3. TUBER-O-INFUNDIBULAR = HYPER-PROLACTIN-EMIA
PT HAS ALL OBVIOUS SX OF MANIA = pressured speech, ===TALKING SUPER FAST insomnia, ==HAVENT SLEPT IN DAYS grandiose delusions. ==SHE THINKS SHE CAN SAVE HER SCHOOL FROM THEFT -- NOW SHE IS ER, WHERE SHE IS AGITATED PACING AROUND ROOM YELLING AT SECURITY MAKING HER HOSPITAL BED OVER AND OVER AGAIN WHAT DRUG TO GIVE HER
REMEMBER- TALKING TO HIMSELF= COUNTS AS HALLUCINATIONS ========= TRICKY! NOT A MOOD STABILIZER! = TAKE WEEKS TO HAVE EFFECT This woman is bouncing off the walls in the ED and does not have a week to wait. She needs something RIGHT NOW ======== HER AGITATED CONDITION IN ER SHOWS THAT SHE NEEDS TO BE CALMED DOWN ASAP = NEEDS A DRUG THAT WILL HAVE ITS EFFECT ON HER MANIA SX ASAP = HALOPERIDOL -- CAN ALSO GIVE HER BZ= TO CALM HER DOWN = BUT BEST IS HALOPERIDOL IF HER MANIA INCLUDES SX OF PSYCHOSIS
PT IS NOT ABLE TO SIT STILL REPEATED LEG CROSSING CONSTANTLY MOVES AROUND = "I feel like I have to move." ==== woman presents to the emergency room because she is unable to move her head, which remains tilted off to one side.
RESTLESS PT = AKATHISIA===TX= B BLOCKER === TORTICOLLUS = ACUTE DYSTONIC=== TX BENZTROPINE ALSO: f feeling "stiffness and twisting" of her neck and jaw
MOM BRINGS IN HER DAUGHTER ==2 YR OLD W/ COMPLAINTS THAT SHE HAS ONLY SPOKEN FEW WORDS DOESNT INTERACT WITH SIBLINGS HALLMARK== REPETITIVE HAND MOVEMENTS UNIQUE== HER RATE OF HEAD CIRCUMFERENCE GROWTH HAS DECREASED OVER TIME
RETT SYNDROME = is deceleration of head growth, loss of hand skills = stereotyped hand movements = such as hand wringing, loss of social interaction (which may improve later), ================VS=========== ASPERGERS= NORMAL LANGUAGE DEVELOPMENT
WHICH 2ND GEN ANTIPSYCH DRUG HAS HIGHEST RISK OF CAUSING EXTRAPYRAMIDAL S.E. ========= DOPAMINE RECEPTORS HAVE TO BE BLOCKED IN WHICH PATHWAY TO CASUES S.E. OF = PROLACTINOMA
RISPERIDONE = SIDE EFFECTS: BLOCK PROLACTIN-->GALACTORHEA, AMENORHEA , ETC ORTHOSTATIC HYPOTENSION!!! WEIGHT GAIN- SOMEWHAT =================== LITHIUM S.E. == MILD INCREASE IN WBC =============== PROLACTINOMA S.E. SX WHEN D2 BLOCKED IN TUBERO-INFUNDIBULAR PATHWAY
WHICH DRUG IS TX FOR THIS PT? PT A = A 34-year-old man with schizoaffective disorder has been noncompliant with medications in the past. You want to be able to give hima depot injection of an antipsychotic. ================================== PT B = PTSD GUY ASK DOC TO GIVE HIM SOMETHING TO HELP HIM SLEEP
RISPERIDONE= 2ND GEN ANTIPSYCH ] ============= PT B = TRAZODONE
An unacceptable impulse is transformed into its opposite; results in the formation of character traits. "Listen to him tell his family he was not afraid, when I saw him crying"
Reaction formation
An idea or feeling is withheld from consciousness; unconscious forgetting vs. conscious forgetting (only conscious defence mechanism) 1) "I do not remember having had a dog" 2) "I would rather talk about my operation until after the party"
Repression vs. Suppression
(1) Young Male. (2) Jobless. (3) Poor. (4) Drug Abuse. (5) Anti-Social Personality. (6) History of Childhood Abuse. (7) Impulsivity.
Risk Factors for Completed Homicide. Access to Guns = Biggest Risk Factor.
Excessively close-knit families, excessive expectation of children, and innate temperamental anxiety
Risk factors of Childhood Anxiety
Current psychologic stress, family hx and UTIs
Risk factors of Childhood Enuresis
Mean age of onset is about age 40, seen more commonly in women and most are married and employed.
Risk factors of Delusional disorder
Seen more frequently in women due to several factors such as hormonal differences, great stress, or simply a bias in the diagnosis
Risk factors of Major Depressive Disorder
Separations during childhood and interpersonal loss in adulthood. Lactate CO2, yohimbine, caffeine, and other substances can precipitate sx
Risk factors of Panic disorder
Psychological stress, more common in women and younger adults. Amnesia that me general or selective for certain events The amnesia may suddenly or gradually remit, particularly when the traumatic circumstance resolves, or may become chronic
Risk factors, Sx, and course of Dissociative amnesia
Childhood sexual abuse, more common in women Chaotic interpersonal relationships, impulsivity and self-destructive behaviour, suicide attempts, substance abuse. Pts may also have Borderline personality disorder
Risk factors, etiology and associated problems of dissociative identity disorder
Cause is CNS damage due to known or unknown factors. General medical conditions associated are encephalitis, maternal rubella, PKU, tuberous sclerosis, fragile X and perinatal anoxia
Risk factors/Etiology of Autism Spectrum Disorders
Autosomal dominant transmission may occur in some cases, associated with ADHD (50%) and OCD (40%). Abnormalities in the dopaminergic and adrenergic system have been implicated
Risk factors/Etiology of Tourette Disorder
Suicidal Ideation: Plan vs. No Plan
Risk-Free Inpatient Room vs. Outpatient Therapy
Increased risk of movement disorders and elevation of prolacting
Risperidone
PT ON ANTIPSYCH DRUGS FOR SCHIZOPHRENIA NOW SHE "KEEPS LOOKING UP" = CANNOT MOVE HER EYES IN ANY OTHER DIRECITON DIAGNOSE? TX?
S.E. OF ANTIPSYCH DRUG= ESP TYPICAL LIKE HALOPERIDOL "EYES STUCK UP" = OCULAR-GYRISIS CRIS =PART OF ACUTE DYSTONIA = ANOTHER EXAMPLE: a sustained contraction of this neck and right shoulder. ======== TX OF ACUTE DYSTONIA = ANTICHOLINERGIC DOES NOT JUST HAVE TO BE BENZTROPINE!!!!!!!!!!!!!! CAN ALSO BE OTHER DRUGS THAT ARE ANTICHOLIN = DIPHENHYDRAMINE!
PT HAS SX OF SBO = N/VOMITTING, NO GAS/BM CONFIRMED BY= ABD XRAY BUT SHE ALSO HAS UNEVEN HAIR LENTGH/PIECES
SBO DUE TO TRICHTOLOMANIA = CALLED: TRICHO-BEZEOR = bezoar (literally a hair ball) ===VS========= ALOPECIA= HAIR WILL BE MISSING IN PATCHES VS BEING DIFFERENT LENTGHS
PT HAS PMH= DEPRESSION SHE ALSO HAS COMMAND HALLUCINATIONS = that are often present even when her MOOD symptoms are in remission =============== PT TRIED TO COMMIT SUCIDE/LOW ENERGY ETC AND SHE SAYS = "DEVIL IS TRYING TO KILL ME
SCHITZO=AFFECTIVE DISORDER ==== ALSO SCHIZOAFFECTIVE MDD SX WITH COMMIT SUCIDE DESIRE + "DEVIL IS TRYING TO KILL ME = PSYCHOSIS = THIS CAN NOT BE A DELUSION BECAUSE THIS IS NOT A BELIEF THAT CAN POSSIBLY BE TRUE
DIAGNOSE PT HAS = AUDITORY HALLUCINATIONS--talking to himself, talking to someone named "jerry" + BIZARRE BEHAVIOR--doesn't shower/ keeps staring at ceiling HE ALSO HAS = PRESSURED SPEECH GRANDIOSE DELUSIONS + HE IS PICKING UP WAY TOO MANY PROJECTS
SCHIZO =AFFECTIVE sx of SCHIZOPHRENIA = AUDITORY HALLUCINATIONS--talking to himself, talking to someone named "jerry" + BIZARRE BEHAVIOR--doesn't shower/ keeps staring at ceiling + sx of MANIA = PRESSURED SPEECH GRANDIOSE DELUSIONS + HE IS PICKING UP WAY TOO MANY PROJECTS
PT HAS PMH OF DEPRESSION BUT FOR PAST 6 MONTHS = ONLY SX OF HALLUCINATIONS DIAG?
SCHIZO=AFFECTIVE EVEN IF CURRENTLY HE DOESNT HAVE MOOD SX, HIS PMH= QUALIFIES ============== IN FACT TRUE DEFINITION OF SCHIZOAFFECTIVE = DELUSIONS/HALLUCINATION FOR >2 WEEKS "IN ABSCENCE" OF MOOD DISORDER-depression or mania AND PMH OF MAJOR DEPRESSION OR MANIC EPISODE
SCHIZOAFFECTIVE VS SCHIZO=TYPAL PERSONALITY DISORDER
SCHIZO=TYPAL = LADY GAGA = NO HALLUCINATION OR DELUSIONS =but ECCENTRIC BEHAVIOR ======== SCHIZO=AFFECTIVE = SCHIZOPHRENIA + MOOD DISORDER = MANIA OR DEPRESSION
for past 10 YRS PT= LAUGHS FOR NO REASON KEEPS MUTTERING SOFTLY TO HERSELF NEEDS HELP= GETTING DRESSING
SCHIZOPHRENIA == PT= LAUGHS FOR NO REASON + KEEPS MUTTERING SOFTLY TO HERSELF = PSYCHOTIC SX/ BIZZARE CANT DRESS HERSELF= NON FUNCTIONAL-
pt says she BELIEVES IN WITCH-CRAFT SHE HAS SUPERNATURAL POWERS SHE IS OTHERWISE NORMAL= EARNS GOOD GRADES
SCHIZOTYPAL PERSONALITY DISORDER = BELIEF IN MAGICAL THINKING BELIEVE IN = GHOST HOLY SPIRITS = KID WHO ADMITS TO FEELING PRESENCE OF GHOST IN HIS HOME
PT WITH DEPRESSION TAKING VENLAFAXINE ALREADY TRIED OTHER ANTI DEPRESSANTS==SSRI STILL NO RELIEF SHE ALSO IS A LONG TIME SMOKER== UNIQUE
SMOKER + DEPRESSION = BUPROPRION = SIDE EFFECT": SEIZURES NEVER GIVE THIS DRUG TO PTS WITH ANOREXIA/ BULIMIA
WHAT DOES BRAIN MRI OF FOLLOWING CONDITIONS SHOW SCHRIZOPHRENIA PANIC DISORDER PTSD AUTISM OCD
SCHRIZOPHRENIA = >6 MONTHS AUDITORY HALLUCIN. + PARANOID DELUSIONS =MRI SHOWS ENLARGED CEREBRAL VENTRICLES ((esp LATERAL VENTRICLES) ====================== AUTISM MRI = INCREASED TOTAL BRAIN VOLUME ======================== OCD MRI = STRUCTURAL ABNORMALITIES IN ORBITO=FRONTAL CORTEX ============================= PANIC DISORDER MRI = LOW VOLUME OF AMYGDALA ============ PTSD MRI = LOW VOLUME OF HIPPOCAMPUS ================
WHAT KIND OF DRUG IS SELEGILINE
SELECTIVE MAOI
8 YR OLD BOY HATES GOING TO SCHOOL + STILL SLEEPS IN PARENTS BED ======= HOW DOES THIS COMPARE TO (B) reactive attachment disorder of early childhood
SEPERATION ANXIETY DISORDER EXPECT THIS KIDS PARENTS TO HAVE = ANXIETY DISORDER Other risk factors for developing a childhood anxiety disorder include parents who have an overly controlling and rejecting style, an insecure attachment with ones primary caregiver, =======VS============== (B) reactive attachment disorder of early childhood = MORE COMMON IN KIDS < 5 YR + the boy would need to have suffered markedly disturbed social relatedness,
PT WHO HAD BEEN TAKING = MAOI NOW, AFTER TAKING VENLAFAXINE===EFFEXOR PT HAS: tachycardic and diaphoretic and develops myoclonic jerks. DIAGNOSE?? TX??
SEROTININ SYNDROME ======= Cyproheptadine ==ANTIDOTE =is a 5-HT2a antagonist that is sometimes used in the treatment of the most severe cases of serotonin syndrome ======== SX OF SEROTONIN SYNDROME MYOCLONIC JERK!! Symptoms include tachycardia, fever, hypertension, ocular oscillations, and ==== Severe serotonin syndrome may result in serious hyperthermia==SUPER HIGH FEVER , coma, autonomic instability, convulsions, and death;
WHAT PART OF BRAIN FOLLOWING NTs ReSIDE in:- SEROTONIN VS NE, EPINEPHRINE VS DOPAMINE ================== WHICH NT s has been shown to stimulate the appetite? associated with the mediation of the perception of pain?
SEROTONIN==RAPHE NUCLEUS NE AND EPIN (((INCREASE VIA ACTION OF MAOI)))) ==>> LOCUS CERULUS DOPAMINE== >> SUBSTANTIA NIGRA ACH==>> ========== PERCEPTION OF PAIN = SUBSTANCE P STIMULATE APETITE= = NEUROPEPTIDE Y
DIAGNOSE? TX??? FOR PAST 1 MONTH PT HAS BEEN HAVING ALL SX OF MDD BUT ALSO SHE REFUSES TO EAT ANYTHING = THINKS SHE WILL "GET INFECTED" AND HER "INTESTINES DONE WORK"
SHE HAS SX OF MDD + DELUSIONS== thinks food will get her sick, her bodily function can't handle food = MDD WITH PSYCHOTIC FEATURES = TX: SSRI + ANTIPSYCH = (E) sertraline and risperidone
PT GIVEN FLUOXETINE FOR MDD TX NOW SHE = RESOLUTION OF ALL SX OF MDD BUT NOW SHE IS = NOT SLEEPING FOR DAYS TAKING ON WAY TOO MANY PTS
SHE IS NOW EXP SX OF = MANIA GIVING HER SSRI WAS A MISTAKE BECAUSE SHE ACTUALLY HAS BIPOLAR DISORDER NOT MDD ANTIDEPRESSANTS= MAKE MANIA= WORSE
DIAGNOSIS OF MAJOR DEPRESSION
SIGE CAPS = MUST HAVE 5/9 OF THESE AND LAST > 6MONTHS...check this = S--SLEEP LESS I--NTEREST DEFICIT= ANHEDONIA G= GUILT / FEEL WORTHLESS E=ENERGY LOW C-ONCENTRAITON DEFICIT APPETITE= LOW PSYCHOMOTOR DEFICIT SUCIDAL IDEATIONS
DIFFERENTIATE SX OF NMS VS SEROTONIN SYNDROME
SIMILAR IN BOTH = FEVER WITH MUSCLE RIGIDITY??? really SEROTONIN SYNDROME =begins with DIAHREA RESTLESSNESS AUTONOMIC INSTABILITY
PT NEARLY DIED IN A CAR ACCIDENT 3 WEEKS AGO SINCE THEN SHE HAS BEEN HAVING NIGHTMARES DIAGNOSE ============= WHAT IS TRANSFERENCE VS COUNTER-TRANSFERENCE
SINCE < 1 MONTH = NOT PTSD!! THIS IS ACUTE STRESS DISORDER =============================================== TRANSFERENCE = PT LIKING THE DOC COUNTER-TRANSFERENCE = DOC LIKING HIS PT
PREGNANT PT SAYS OVER LAST 3 MONTHS HER HUSBAND HAS BEEN SAYING SHE IS PREGNANT "WITH A ALIEN"
SINCE < 6 MONTHS = SCHITZOPHRENIFORM
2 WEEKS AGO PT'S SON DIED NOW SHE IS she will not eat because she believes he has been poisoning her food The patient believes that the nurses in the emergency room are going to cause her harm as wel
SINCE <1 MONTH BREIF PSYCHOTIC DISORDER
22 YR OLD MAN PHYSICALLY ABUSIVE TOWARDS HIS WIFE BEEN ARRESTED FEW TIMES FOR DRUG POSSESSION
SINCE >18 = ANTI SOCIAL PERSONALITY DISORDER
DOC CAN TELL PT IS FAKING SX IN DISABILITY CLINIC
SINCE FAKING SX IN DISABILITIY CLINIC = PT WANTS DIABILITY CHECK = MALINGERING == FACTITIOUS= FAKING SX= FOR "SICK PERSONS" ROLE= ATTENTION
PT COMES IN WITH COMPLAINT OF FEELING WORTHLESS SX STARTED 2 MONTHS AGO WHEN HIS GF CHEATED ON HIM EVER SINCE THEN, HE HAS LOST INTEREST IN HOBBIES NOT SLEEPING WELL =========== DIAG? TX?
SINCE HIS SX STARTED AFTER AN OBVIOUS STRESSOR--gf cheating = THIS IS ADJUSTMENT DISORDER ====== ALTHOUGH HE HAS OBVIOUS SX FOR IT, THIS IS NOT DEPRESSION BECAUSE DEPRESSION LIKE SX STARTED POST IDENTIFIABLE STRESSOR=gf cheating on him (((ADJUSTMENT DISORDER TEND TO HAVE DEPRESSION SX))))
cops FOUND A GUY NEAR A DRUG TRAFICIKING AREA IN ED HE IS He responds only to painful stimuli, wakes up briefly and yells, then goes back to sleep WHAT SHOULD ED DOC GIVE HIM?
SINCE NOT SURE WHAT EXACT DRUG HE TOOK GIVE HIM A COCKTAIL OF DEXTROSE==FIX HYPOGLYCEMIA NALOXONE==FIX OPIOD OVERDOSE THIAMINE== FIX E-OH OVERDOSE == NO NEED FOR FLUMAZENIL IN THIS COCKTAIL
PT AVOIDS GETTING CHECKED BY A DOC WHEN SHE FINDS A BREAST MASS WHEN ASKED WHY SHE DIDN'T COME SEE A DOC SOONER WHEN SHE LOCATED A HUGE MASS SHE SAYS "I WAS WAITING FOR MY KIDS TO GRADUATE. I DIDNT WANT TO HAVE DOC APPTS TAKING UP MY TIME" SHE ADMITS = BEING FEARFUL OF TX OF BREAST CANCER DEFENCSE MECHANISM?
SINCE SHE ADMITS THAT SHE WAS FEARFUL OF TX = SHE IS NOT IN DENIAL ======================== THIS IS = RATIONALIZATION = JUSTIFYING BEHAVIOR TO AVOID DIFFICULT TRUTH/SITUATION TO PREVENT ANXIETY ABOUT SOMETHING DIFFICULT, PT COMES UP WITH A "LOGICAL" REASON" INORDER TO AVOID DEALING WITH THE DIFFICULT SITUAITON =============== THIS PT AFRAID OF CANCER TX== DIFFICULT SITUATION SO SHE AVOIDS THIS BY USING CHILDERN'S GRADUATION= "LOGICAL REASON/EXCUSE" TO AVOID GOING TO DOC TO GET EVALUATION FOR HER BREAST MASS SO SHE WONT HAVE TO DEAL WITH CANCER TX
7-year-old girl is brought to the physician because her parents note that she gets up at night and, still asleep , walks around the house for a few minutes before returning to bed. When she is forced to awaken during one of these episodes, she is confused and disoriented
SLEEP WALKING NO TX a. Tell the parents to maintain a safe environment and monitor the patient's symptoms.
WHAT ARE SOME SNRIs TCAs MAOIs ================== S.E OF ANTIDEPRESSANTS = ANOREXIA + SEXUAL DYSFUNCTION = LOW LIPIDO DELAY EJACULATION ERECTILE ISSUES
SNRIs = DULOXETINE==CYMBALTA VENLAFAXINE==EFFEXOR ================= TCAs = AMITRIPTYLINE CLOMI-PRAM-INE DOXEPIN NORTRIPTYLINE =============== MAOI = PENELZINE TRANYL=CY=PROMINE
SOMATIC SYMPTOM DISORDER WHATS THE DURATION?
SOMATIC SYMPTOM DISORDER = SX FOR > 6 MONTHS = BUT ALL LABS ETC= NORMAL ===VS=== HYPOCHONDRIAC = NO ACTUAL SX BUT JUST WORRY OF GETTING THESE SX
woman comes to her primary care doctor with multiple symptoms which are present across several organ systems. She has seen five doctors in the past 3 months, and has had six surgeries since the age of 18
SOMATIZATION ) Somatization disorder is characterized by a poly--symptomatic presentation, ANOTHER EX = student has suffered from chronic headaches , fatigue, shortness of breath, dizziness, ringing ears, and constipation. He is incensed when his primary physician recommends a psychiatric evaluation because no organic cause for his symptoms could be found.
diagnose For the last 6 months she has complained of multiple achy joints and headache. Her right elbow, left shoulder, thigh on the left side, and her head hurts. sexual complaints numbess in arms but all test are negative
SOMATIZATION SYNDROME
ESCITALOPRAM WHAT KIND OF DRUG ============ PT HAS CHEST PAIN + SAYS HE "FEELS LIKE HE IS GOING TO DIE"
SSRI = CHOOSE SSRI > THERAPY ONLY FOR MDD GAD ======= PANIC DISORDER MAIN ACUTE== BZ ONLY FOR LONG TERM== SSRI
summary of NAME OF DRUGS FOR MDD
SSRI (always the right answer) - Citalopram - Escitalopram - Fluoxetine - Paroxetine - Sertraline SNRI (always the right answer) - Duloxetine - Venlafaxine - Desvenlafaxine TCA (never the right answer unless it is about neuropathic pain) - Amitriptyline - Doxepin - Nortriptyline MAO-I (never the right answer unless the vignette is about hypertensive crisis while eating cheese) - Phenelzine - Tranylcypromine Others (never the right answer except when treating the specific condition and not depression) - Trazodone = Sleep + MDD - Bupropion = Smoking Cessation + MDD - Mirtazapine = Sleep and Appetite stimulant/W. GAIN
Treatment of Obsessive-Compulsive Dosirder
SSRI + Behavior therapy (exposure and response prevention)
PT HAS BOTH MDD AND OCD DOC?
SSRI > CLOMIPRAMINE SSRI WILL TAKE CARE OF BOTH MDD AND OCD Fluvoxamine is an SSRI particularly indicated for both depression and OCD
Treatment of Hoarding (Inherited Inability to Discard Presenting in Young Adulthood or After Traumatic Event)
SSRI and CBT
OCD tx
SSRI or clomipramine if initial trial failed, try another SSRI
PT ON DRUGS TO TX MDD NOW HE IS EXP: UNIQUE= jerking of her muscles OTHER SX = and vivid visual hallucinations of colorful flowers JERD
SSRI---> MYOCLONIC "JERKING" = SEROTONIN SYNDROME ===== REM- NEVER GIVE BOTH SSRI + MAOI = HIGH CHANCES OD SEROTONIN SYNDROME
PROTOCOL FOR HOW/WHAT TO PRESCRIBE FOR MDD TX
START - SSRI WAIT FOR 6 WEEKS= TO SEE IF IT WORKED IF DIDN'T WORK ---> SNRI ========= REST, TCA, TRAZODONE/BUPROPRION/MIRTAZAPINE = ONLY USED WHEN PT NEEDS TX FOR MDD + SOMETHING ELSE THAT MDD DRUG CAN ALSO TX = EX - Trazodone = Sleep + MDD - Bupropion = Smoking Cessation + MDD - Mirtazapine = Sleep and Appetite stimulant/W. GAIN TCA (never the right answer unless it is about neuropathic pain) -
PRETEST PT COMES IN WITH OBVIOUS MDD WHICH SHOULD DOC OFFER FIRST = THERAPY OR ANTIDEPRESSANT
START OFF WITH = ANTIDEPRESSANT-- SSRI
PT HAS MAJOR DEPRESSIVE DISORDER DISCUSS WHAT DRUGS TO GIVE HIM? WHAT IF THIS DRUG FAILS?
START WITH SSRI = ESCITALOPRAM SERTRALINE==ZOLOFT CITALOPRAM===CELEXA PAROXTINE===PAXIL FLUOXETINE==== PROZAC ============== IF 1ST SSRI DOESNT WORK = SWITCH TO ANOTHER SSRI ============= IF 2 SSRIs DO NO WORK = SWITCH TO ANOTHER CLASS OF ANTIDEPRESSANTS
PT IN HOSP GETTING TX FOR MUTLIPLE SCLEROSIS NOW SHE HAS FOLLOWING SX SAYS "NINJAS TRYING TO STEAL HER SOAL" SHE HAS DELUSIONS= GOVMT TRYING TO SPY ON HER
STEROIDS USED TO TX MS ARE CAUSING HER SX SUBSTANCE INDUCED PSYCHOSIS High-dose steroids can cause mood disturbance in many patients,
METHYL-PHENIDATE KIND OF DRUG? USED TO TX? MOST COMMON S.E
STIMULANT TX== ADHD S.E. Difficulty falling asleep and decreased appetite = are the two most common side effects of methylphenidate
A 69-year-old woman slips on the ice and =hits her head on the pavement. During the following 3 weeks, she develops a persistent headache, is increasingly distractible and forgetful, and becomes fearful and disoriented at night diagnose?
SUB (not epi!!))-DURAL HEMATOMA Chronic subdural hematoma =causes a reversible form of dementia. It frequently follows head trauma (60% of the cases), with tearing of the bridging veins in the subdural space
DEFENSE MECH? YOU WANT TO PUSH PEOPLE AROUND SO YOU BECOME A COP
SUBLIMATION = Sublimation is when you do something you shouldn't, but find a socially acceptable way to still do it.
TX OF ACUTE/ URGENT TX / PT MUST BE GIVEN SOMETHING ASAP OF MANIA pt who is hallucinating VS MANIA pt who is hallucinating= NO NEED FOR "URGENT " TX ================= rem- MANIA + HALLUCINATIONS/PSYCHOSIS = SCHIZOAFFECTIVE
SUMMARY = NORMALLY MANIA= SHOULD NOT HAVE HALLUCINATIONS ((ONLY DELUSIONS) SO IF A MANIC PERSON IS HALLUCINATING + IN ER= AGITATED/ /DOC NEEDS TO GIVE PT SOMETHING ASAP TO CALM DOWN INSTEAD OF GIVING SOMETHING LIKE MOOD STABILIZERS OR SSRI THAT TAKE WEEKS TO HAVE AN EFFECT = GIVE HALOPERIDOL ======= ACUTE/ URGENT TX / PT MUST BE GIVEN SOMETHING ASAP to "calm" down OF MANIA = HALOPERIDOL==choose this if pt also has psychotic sx OR BZ---choose this if mania without psychosis vs NON-URGENT TX OF MANIA = MOOD STABILIZER= LITHIUM, VALPROATE, CARBAMAZEPINE
pt has= FEAR OF FLYING / FEAR OF SPIDERS WHAT SHOULD DOC RECOMMEND FOR TX?
SYSTEMIC DESENSITIZATION== LONG TERM TX BUT IF SHE NEEDS SOMETHING RIGHT BEFORE GETTING ON AIRPLANE = TO CALM HER NERVES = BZ= LORAZEPAM
Recurrent urge or behaviour involving acts in which physical or psychological suffering of a victim is exciting to the pt
Sadism
Uninterrupted period of sx meeting criteria for major depressive episode, manic episode, or mixed episode. Sx of schizophrenia present and delusions or hallucinations for at least 2 weeks in the absence of mood sx
Schizoaffective disorder
Name the Personality Disorder: Isolated, Detached "loners. Restricted emotional Expressions
Schizoid
Detachment and restricted emotionally: Individuals are emotionally distant, they are disinterested in others and indifferent to praise or criticism. Associated features include social drifting and dysphoria
Schizoid PD
Thought disorder that impairs judgement, behaviour, and ability to interpret reality. Sx must be present for at least 6 months to be able to make a diagnosis. Consider urine drug screening to r/o substance-induced as well as rapid HIV antibody to r/o CNS lymphoma
Schizophrenia
Hallucinations Delusions Disorganized speech Grossly disorganized or catatonic behaviour Negative symptoms Social and/or occupational dysfunction Sx are present more than 1 month but less than 6 months Most pts return to their baseline levels of functioning
Schizophreniform disorder
Discomfort with social relationships; thought distortion; eccentricity: Socially isolated and uncomfortable with others. They have peculiar patterns of thinking, including ideas of reference and persecution, odd preoccupations and odd speech and affect
Schizotypal PD
S/E of antipsychotics
Sedation Hypotension (alpha-adrenergic blockade) Anticholinergic sx (dry mouth, blurry vision, urinary hesitancy, constipation, bradycardia, confusion and delirium) Endocrine effects (gynecomastia, gallactorrhea, and amenhorrhea) Dermal and Ocular Syndromes (photosensitivity, abnormal pigmentation, cataracts)
Increase during sleep; initiates sleep
Serotonin
Clonus, Muscle Tone, Hyperactive Bowels
Serotonin Syndrome (Distinguish from Amphetamine Toxicity); Treat with Cyproheptadine
Psychic derivatives are converted into bodily symptoms "Just thinking of the exam gives me butterflies in my stomach"
Somatization
man complains to his therapist that his new partner enjoys sexual activity only when inflicting pain on him. This disturbs and frustrates the patient
Sexual sadism and sexual masochism are, respectively, the derivation of sexual pleasure from causing or receiving mental/physical abuse. ============================ Exhibitionism is exposure of the genitalia in public to an unwilling participant, and usually occurs in men. Frotteurism, the rubbing of genitals against another to achieve arousal and orgasm, is also usually seen in men and performed in crowded places. Transvestic fetishismis arousal by cross-dressing
Emergency room tx of psychotic symptoms
Short acting intramuscular agent such as haloperidol, fluphenazine, olanzapine or ziprasidone
Tx of Amphetamine/Cocaine intoxication
Short-term use of antipsychotics, benzodiazepines, vitamin C to promote excretion in urine, anti-hypertensives
SE of SSRIs
Significant incidence of agitation, nausea, vomiting, HA, diarrhea, and sexual dysfunction
SE TCAs
Significant sedation, orthostatic hypotension, and anticholinergic effects. (most dangerous antidepressants to OD on)
Normochromic, normocytic anemia, elevated liver enzymes, abnormal electrolytes, low estrogens and testosterone levels, sinus bradycardia, reduced brain mass, and abnormal EEG
Signs of malnutrition
The time needed before you actually fall asleep. Typically < 15min in most individuals
Sleep Latency
Cessation of airflow at the nose or mouth during sleep. These apneic episodes usually last longer than 10 seconds each. Characterized by a loud snore followed by a heavy purse. Considered pathological if the pt has more than 5 episodes an hour or more than 30 episodes during the night
Sleep apnea
Total sleep time decreases, REM % decreases, stages 3 and 4 vanish
Sleep characteristics with age
Occurs in all stages Common in children and usually involves a few words
Sleeptalking
Occurs in Stages 3 and 4 Sequence of behaviours without full consciousness May perform perservative behaviours, usually terminates in awakening followed by confusion
Sleepwalking
Fear of humiliation or embarrassment in either general or specific social situations (ie. public speaking)
Social anxiety disorder
Many physical sx affecting many organ sx Excessive thoughts, feelings, or behaviours related to the somatic sx Long, complicated medical histories Interpersonal and psychologic problems are usually present Seek out tx and have significant impairment in their level of functioning
Somatic Symptom Disorder
4 Pain, 1 GI, 1 Sexual, 1 Pseudoneurological (Tingling or Numbness); Before Age 30
Somatic Symptom Disorder; Frequent Visits with 1 Doctor (Avoid Unnecessary Tests)
ALCOHOLIC PT HAS FOLL. SX confused and agitated. HALLMARK = He cannot move his eyes upward or to the right, and he is ataxic
WERNICKE ENCEPHALOPATHY (think COAT: Confusion, Ophthalmoplegia,==EYE SX Ataxia, and Thiamine to treat)
BOTH GAD AND MDD TX = WHAT IS FIRST LINE = SSRI OR THERAPY =========== MDD PT = MAKES A THREAT TO HIS GF WHO SHOULD U CONTACT
Ssri and mood stab= take weeks to have effect=== so GOOD choice for MDD/GAD where person doesn't have a specific/ one stressor that can be discussed in therapy SSRI > therapy = FIRST LINE FOR BOTH- GAD, MDD = ALSO TX FOR POST-PARTUM DEPRESSION = PT MUST DENY HALLUCINATIONS, FEARING BABY, ANY PSYCHOTIC SX ========= CONTACT BOTH!! GF + POLICE
Longest of all the sleep stages
Stage 2
Also called slow wave or delta sleep, hardest to arouse and tends to vanish in the elderly
Stages 3 and 4
Stage 1: Disappearance of alpha wave and appearance of theta wave Stage 2: k complexes and sleep spindles (45%) Stage 3: Appearance of delta wave Stage 4: Continuation of delta wave
Stages of NREM
IF PT TAKING CLOZAPINE DOES END UP HAVING LOW WBC= AGRANULOCYTOSIS WHAT SHOULD DOC DO?
Start twice per week CBCs with differential counts. STILL==Continue the clozapine
Cause of Acute Relapse in Schizophrenia
Stress (Family Judgment or School or Work)
Impulse gratification has been achieved, but the aim or object has been changed from unacceptable to acceptable; allows instincts to be channeled. Most mature of the defenses. "Jack the Ripper becomes a surgeon"
Sublimation
Negative behaviour, cognitive, and/or physiologic sx due to use of a substance, yet continues despite these adverse consequences. Presence of a constellation of sx that suggest compulsive substance use, monopolization of time by substance-related activities, social and occupational consequences, and physiologic changes including tolerance and withdrawel
Substance use disorder
Short attention span, constant fidgeting, inability to sit through cartoons or meals, inability to wait in lines, failure to stay quiet or sit still in class, disobedience, shunning by peers, fighting, poor academic performance, carelessness, and poor relationship with siblings.
Symptoms of ADHD
Stomachaches and malaise, unrealistic fears (monsters) and nightmares, phobias such as school phobia and fear of animals or the dark, difficulty sleeping, and self-mutilation such as scratching, nail-biting, and hair-pulling
Symptoms of Childhood Anxiety
TX OF HYPOCHONDRIAC PT
TALK TO PT ABOUT POSSIBLE STRESSORS IN PT'S LIFE THEN REFER PT TO = PSYCHO-THERAPY PRETEST = c. Have the patient see a primary care physician at regular intervals. = The patient should be referred to a primary care doctor who will see her regularly but not perform any invasive procedures unless there is a clear indication to do so ========= THIS IS BECAUSE HYPOCHONDRIAC SX TEND TO START DURING PERIODS OF STRESS
Ongoing Psycho-Therapy for Building Adaptive Defense Mechanisms (Coping)
Supportive
Intentionally Postponing Anxiety-Provoking Thoughts by Substitution of Other Thoughts
Suppression
Occurs in >40% of elderly, hospitalized patients. Key sx include: Agitation/stupor Fear Emotional lability Hallucinations Delusions Disturbed psychomotor activity PE: Incoordination Tremor Asterixis Nystagmus Incontinence
Sx and PE of Delerium
Preoccupations with diseases Preoccupation persists despite constant reassurance by physicians Belief is no delusional Duration at least 6 months Tx is psychotherapy and frequently scheduled visits
Sx and tx of Illness Anxiety disorder
Acute Stress Disorder
Sx are the same as PTSD but last < 1 month and occur within one month of trauma
Most common concerns involve facial flaws Constant mirror-checking Attempt to hide the alleged deformity Housebound Avoids social situations Causes impairment in their level of funcitoning
Sx of Body Dysmorphic disorder
Onset late childhood or early adolescence with sx of bullying, fighting, cruelty to people or animals and rape, vandalism, fire setting, theft, robbery, running away, school truency
Sx of Conduct disorder
One or two neurologic sx affecting voluntary or sensory function Psychologic factors associated with the onset or exacerbation of the symptoms Mutism, blindness, and paralysis are the most common symptoms Abnormal movements, gait disturbance, weakness, paralysis, ticks, jerks, etc Secondary gain: benefits from being sick La belle indifference: pt seems unconcerned about impairment
Sx of Conversion disorder (must have psychologic factors)
Typically demand tx when in the hospital If tests return negative, they tend to accuse doctors and threaten litigation Become angry when confronted
Sx of Factitious Disorder
Tend to complain a lot and exaggerate its effect on their functioning and lives Preoccupied more with rewards than with alleviation of sx
Sx of Malingering
Hallucinations (mostly auditory) Delusions (mostly bizarre) Disorganized speech or behaviour Catatonic behaviour Negative sx Usually experience social and or occupational dysfunction May find saccadic eye movements and hypervigilance
Sx of Schizophrenia
Obese, middle-aged males Sometimes associated with depression, mood changes, and daytime sleepiness Complain of dry mouth in the morning Headaches in the morning Being tired during the day May develop arrythmias, hypoxemia, pulmonary hypertension, and sudden death
Sx of Sleep apnea
HOW CAN SERTONIN SYNDROME BE PREVENTED SEROTONIN SYNDROME TO PREVENT SEROTONIN SYNDROME = IF PT IS ALREADY TAKING A MAOI, DO NOT GIVE OTHER DRUG CLASSES THAT ALSO BLOCK REUPTAKE OF SEROTONIN: SNRI= VENLAFAXINE, DULOXETINE SSRI TCA BU-S-PIRONE =========== PROTOCOL = ne must wait at least 14 days after discontinuing an MAOI before starting a serotonergic agent.
Symptoms include tachycardia, fever, hypertension, ocular oscillations, and myoclonic jerks. Severe serotonin syndrome may result in serious hyperthermia==SUPER HIGH FEVER , coma, autonomic instability, convulsions, and death; ======== TO PREVENT SEROTONIN SYNDROME = IF PT IS ALREADY TAKING A MAOI, DO NOT GIVE OTHER DRUG CLASSES THAT ALSO BLOCK REUPTAKE OF SEROTONIN: SNRI= VENLAFAXINE, DULOXETINE SSRI TCA BU-S-PIRONE =========== PROTOCOL = ne must wait at least 14 days after discontinuing an MAOI before starting a serotonergic agent.
PT WAS MOLESTED 2 WEEKS AGO NOW SHE IS TALKING TO HERSELF stayinG ISOLATED FROM FRIENDS When examined, the patient is expressionless and mimics everything the examiner says, except to pause to talk to herself.
TALKING TO HERSLEF= HALLUCINATIONS = CAN NOT BE ACUTE STRESS DISORDER THIS IS ACUTE PSYCHOTIC DISORDER ((IF THESE SX PERSISTED > 1 MONTH BUT < 6 MONTHS= SCHIZOPHRENIFORM IF > 6 MONTHS== SCHIZOPHRENIA)
LIP SMACKING TONGUE PROTRUSION IN PT TAKING ANTIPSYCH DRUGS WHAT IS THIS CALLED? TX?
TARDIVE DYSKINESIA = facial grimacing,== LIP SMACKING, TONGUE PROTRUSION and choreoathetoid-like movements of the limbs and trunk. = irregular movements of his arms
PT MOM COMPLAIN HE REPEATEDLY PROTRUDES TONGUE SMACKS HIS LIPS ============= PT B = pt complains of spasms of the jaw!!!!!!!!!! , abnormal positioning of the head, or difficulty swallowing laryngospasm, opisthotonos===stiffness of the neck and back muscles Oculogyric crisis is spasm of the extraocular muscles, often resulting in the patient looking up and unable to look down
TARDIVE DYSTONIA = SX TONGUE PROTRUSION LIP SMACKING CHEWING MOVEMENTS ======================= PT B = ACUTE DYSTONIA
PT WITH ABNORMAL EKG WHICH ANTIDEPRESSANT DRUG CLASS ALWAYS CONTRAINDICATED IN THIS PT ======= PT WAS RECENTLY = RAPED NOW FEELING VERY ANXIOUS/ SAD DIAGNOSE? TX? ====== WHAT DRUG CAN BE USED TO GET RID OF NIGHTMARES = IN PTSD PT
TCA==> CARDIAC TOXICITY ====== PTSD TX= SSRI== FLUOXETINE ======= TO HELP RELIEVE NIGHTMARES IN PTSD = PRAZO-SIN= an alpha-1-adrenergic receptor blocker, traditionally used to treat hypertension and benign prostatic hypertrophy, which has demonstrated efficacy in treating nightmares and other symptoms in patients with PTSD. ((NOT A GOOD IDEA TO TX NIGHT MARES WITH A SEDATIVE LIKE BZs DUE TO ADDICTION RISK)
PT GIVING ANTIDEPRESSANT COMES BACK 2 WKS LATER COMPLAINING THAT ITS NOT WORKING ============================================ ANOTHER NAME FOR MULTIPLE PERSONALITY DISORDER
TELL PT THAT MOST ANTIDEPRESSANTS TAKE 4-6 WEEKS TO WORK ============================================= DISSOCIATIVE IDENTITY DISORDER
DIAGNOSE PT BELIEIVES IN TELEPATHY CONCEPT OF 6TH SENSE BELIEVE IN WITCHES
THESE ARE ALL BIZARE FANTASIES = LADY GAGA = SCHIZO TYPAL
PT HAS BEEN "TALKING WITH ALIENS" FOR PAST 2 MONTHS HE IS WITHDRAWN SCHOOL GRADES DECLINGING NO EYE CONTACT LIMITED SPEEC
THESE ARE ALL SX OF SCHRIZOPHRENIA BUT!!! SINCE ITS BEEN < 6 MONTHS =qualify as SCHIZO=PHRENI=FORM
WHICH SLEEP STAGE HAS THESE THETA WAVES K-COMPLEXES, SPINDLE WAVES LOSS OF TONE AND RAPID EYE MOVEMENTS DELTA WAVES
THETA WAVES=== STAGE 1 K-COMPLEXES, SPINDLE WAVES====STAGE 2 LOSS OF TONE AND RAPID EYE MOVEMENTS = REM DELTA WAVE= STAGE 3, STAGE 4 -- mnemonic, but I learned "TKD, like a TKO" and got a question on my exam regarding this very subject. T theta, K K-complexes, D Delta.
2 MONTHS SINCE HIS WIFE DIED, GUY HAS THESE SX POOR SLEEP HEARS VOICE OF HIS DEAD WIFE SOMETIMES =AUDITORY HALLUCINATIONS LOW APETITE FEELS GUILTY THAT SHE DIED BEFORE HIM BUT!! HE IS STILL BATHING , COOKING
THIS IS BREAVEMENT NOT MDD WITH PSYCHOSIS == HE IS STILL BATHING/COOK = he is still able to function and is taking care of his basic needs. ====== LANGE = EVEN BREAVEMENT CAN HAVE HALLUCINATIONS-AUDITORY OR VISUAL = BUT THESE USUALLY INVOLVE THE PERSON WHO DIED ==== Also, many individuals experience survivor's guilt as part of their grieving ================================================== NOT MDD WITH PSYCHOSIS BECAUSE NO SUCIDE THOUGHTS STILL ABLE TO FUNCTION ON OWN NOT HALLUCINATING ANYTHING THAT DOESNT INCLUDE THE DECEASED
DIAGNOSE THIS PT ANXIETY BEFORE STAFF MEETINGS = WORRY THAT HE WILL EMBARASS HIMSELF IN FRONT OF COWORKERS COMPLAINS THAT HE FINDS IT DIFFICULT TO RELAX AT PARTIES REFUSED JOBS THAT REQUIRE HIM TO INTERACT WITH OTHER PEOPLE
THIS IS NOT PERFORMANCE ONLY ANXIETY AS HE IS ANXIOUS EVEN WHEN HE IS NOT SPEAKING IN FORNT OF A GORUP EX- HE IS ANXIOUS EVEN AT SMALL PARTIES HE IS ANXIOUS TO HAVE TO INTERACT WITH OTHER PEOPLE AS CUSTOMERS HE IS ANXIOUS AT PARTIER -->NOTE- PT IS NOT GOING TO BE "PERFORMING" HERE, =INSTEAD ======================== HE IS ANXIOUS IN ANY SITUATION WHERE HE HAS TO BE AROUND OTHER PEOPLE = GENERALIZED ANXIETY DISORDER = ANXIETY IN >1 SOCIAL SITUATIONS TX = SSRI/ SNRI COGNITIVE THERAPY
WHAT KIND OF DEFENSE MECH: MURDERER IS IN JAIL HE FEELS GUILTY FOR HIS CRIMES SO HE JOINS TH JAIL'S CHURCH AND Regretting his mistakes, he takes the cloth and joins the local church. He volunteers there, lives on the grounds, acting as the groundskeeper, and attends church nightly.
THIS IS NOT ALTRUISM!!! = IN ALTRUISM, YOU DONT DO A GOOD DEED BECAUSE U FEEL GUILTY / U FEEL REGRET FOR MISTAKES IN THE PAST =========== THIS IS REACTION FORMATION = YOU want to do (or have done!!!) something that you don't like or society doesn't like, so you go in a drastically different direction. ===== Religion is usually part of the vignette.
WHAT IS FIRST TEST DOC SHOULD ORDER? DIAGNOSE? PT LOCKS HIMSELF IN ROOM STARES AT ONE PLACE AND MUMBLES TO HIMSELF HASN'T TAKEN A SHOWER
THIS PT HAS = BIZZARE BEHAVIOR = LIKELY SCHIZOPHRENIA (if > 6 months) likely SCHIZOPHRENIA (if sx > 1 month, < 6 month likely BRIEF PSYCHOTIC DISORDER (if sx >1 day, < 1 month == BUT NO MATTER WHAT PSYCHOTIC PT MAY HAVE = FIRST TEST TO "ALWAYS" ORDER = URINE TOXICOLOGY SCREEN = always wanna r/o psychotic sx due to drugs vs actual disease like schio
POLICE BRINGS IN A PT WHO IS SMELLY, DISHEVELD she STARES IN 1 DIRECTION WHEN ASKED ANY QUESTION, REPLIES WITH "JINGLE JINGLE DOC" == DIAG PT? TX?
THIS PT IS EXPERIENCING PSYCHOSIS ((can be from any psychotic condition-schitzo/ bipolar/ETC) ======== TX = 2ND GEN ANTIPSYCHOTICS = ATYPICAL ============= REM- SSRI ARE NOT FOR CONDITIONS THAT CAUSE PSYCHOSIS! ================ ONLY GIVE CLOZAPINE IF 2 ANTIPSYCH DRUGS DIDNT WORK
PT JUST MOVED TO COLLEGE TO LIVE ON OWN FOR PAST 1 MONTH SHE IS: GETTING ANXIOUS THAT SOMEONE MIGHT BREAK IN/ HARM HER FEELS TENSE, INSOMNIA--->TIRED ===============
THIS STRESSOR IS NOT AS LARGE TO QUALIFY UNDER ACUTE STRESS DISORDER SHE HAS = ADJUSTMENT DISORDER WITH ANXIETY = SX OCCUR WITHIN 3 MONTHS OF STRESSOR ============================ MDD VS ADJUSTMENT DISORDER = SX MUST NEVER PERSIST > 6 MONTHS IN ADJUSTMENT DISORDER, IF THEY DO THEN ITS MDD ==================== NOTE DIFFERENCE BETWEEN ADJUSTMENT DISORDER WITH ANXIETY= WITHIN 3 MONTHS = RELATIVELY MINOR STRESSOR VS ACUTE STRESS DISORDER = WITHIN 1 MONTH = MAJOR STRESSOR=DEATH OR SERIOUS INJURY VS GENERALIZED ANXIETY DISORDER = 6 MONTHS
HALOPERIDOL== WHAT IS IT FREQ USED FOR =============== CLONIDINE= TX WHAT PSYCH CONDITION
TO "CALM DOWN" A PT WHO IS AGITATED/ ACTING CRAZY DUE TO DELIRIUM Haloperidol is the drug of choice for managing the agitated or confused patient with delirium. =========== CLONIDINE= A2 AGONIST = TX==TOURETTE S.E.== ORTHOSTATIN HYPOTENSION MOST COMMON S.E. = SEDATION
DOC FOR CATATONIC SCHIZOPHRENIA TO TX CATATONIC SX , SPECIFICALLY
TO TX CATATONIC SX==pt doesn't move in pt with SCHIZOPHRENIA = BZ= LORAZEPAM
TEACHER COMPLAINS without warning, the boy will make a disruptive sound or shout out in class. They describe himas polite and neat but restless and jumpy. DIAGNOSE? TX?
TOURETTE --- TX = 1ST LINE== CLONIDINE===A2 AGONIST ((PRETEST = HALOPERIDOL AND A2 AGONIST) ==== CLONIDIE SIDE EFFECTS = HYPOTENSION EVEN----SEDATION!!!!!!!!!!!!!1 ======= 2ND LINE----??? CHECK Recently, the newer atypical (or second-generation) antipsychotics = risperidone and olanzapine have also been used to treat the disorder. ================== VERY COMMON TO HAVE TOURETTE + OCD =TOGETHER ============
DIAGNOSE? TX? PT repeatedly blink his eyes and frown = while clearing his throat. OTHER SX = he often sticks out his tongue and smells his shirt while speaking with classmates
TOURETTE TX= #1 = HALOPERIDOL Clonidine, an alpha-2-agonist, is preferable in the treatment of mild Tourette's
DIAGNOSE? TX? PT IS MAKING strange grunting sounds and moves his head funny. These episodes are associated with grunting, blinking, and grimacing.
TOURETTE TX= DOPAMINE ANTAGONIST = ANTIPSYCH DRUG!! = RISPERIDONE ===================== vs OCD TX = SSRI= CITALOPRAM
WHICH DRUG TX INSOMNIA = PT ONLY SLEEPS FEW HOURS EVERY NIGHT AND MDD =============== WHAT ARE LITHIUM'S EKG CHANGES ===== WHICH DRUG CAN INCREASE BLOOD LITHIUM LEVELS
TRAZODONE ===>> PRIAPISM ========= LITHIUM EKG CHANGES = (E) T-wave depression ====== THIAZIDE DRUG = INCREASE B. LITHIUM LEVEL ((get rid of excess fluid, concentrating lithium levels?) ========== Other medications that can increase lithium levels are the diuretics ethacrynic acid, spironolactone, and triamterene;
CHILD WITH LEUKEMIA + MDD WHEN SHOULD MDD BE TX? ====================== WHAT KIND OF DEFENSE MECHANISM: KID GOT DIAG WITH LUPUS KID TELLS HIS FRIEND TO "PLAY DOCTOR"
TX MDD WITH LEUKEMIA emotional state is related to immune response SO TX MDD CAN HELP HIM RECOVER FROM LEUKEMIA/ ANY MEDICAL ILLNESS TOO ============= IDENTIFICATION = process of adopting other people's characteristics. = may occur as an attempt to imitate the doctor because she admires her, or it may represent an effort to cope with anxiety about the doctor because she fears her
PT IS AFRAID OF FLYING IN PLANES TX?
TX FOR SPECIFIC PHOBIA # 1 TX = BEHAVIOR THERAPY = EXPOSURE SYSTEMATIC DESENSITIATION ====== #2 TX = BENZODIAZEPINE = HELP ACUTELY= PT SHOULD TAKE THIS RIGHT BEFORE ENTERING PLANE
DRUG OF CHOICE IF #1 DRUG FOR PTSD= NOT WORKING
TX FOR PTSD==SINCE SHIT TON OF ANXIETY = SSRI ====== IF SSRI= NOT WORKING THEN PARAZO-SIN Prazosin, an alpha-1 adrenergic receptor blocker has demonstrated significant efficacy in treating all three clusters of PTSD symptoms
DANTROLENE? ================ OTHER THAN DANTROLENE, WHAT OTHER DRUG CAN BE USED TO TX THIS CONDITION ========= PHYSOSTIGMINE?
TX NMS==S.E OF ANTIPSYCH DRUGS = FEVER MUSCLE RIGIDITY!!!!!!!!! HIGH CPK==RHABDOMYOLYSIS== HIGH CPK =========================== NMS IF DANTROLENE NOT AVAILAIBLE CAN USE=== BROMOCIPTINE= DOPAMINE AGONIST ================== PHYSOSTIGMINE = REVERSES EFFECTS OF ANTICHOLINERGIC DRUGS
same pt as above SHE THEN TRIES TO GET OUT OF BED SHOUTS AT NURSES VERY AGITATED WHAT DRUG CAN BE GIVEN TO TX THIS
TX OF CALMing AN AGITATED PT WITH DELIRIUM = HALOPERIDOL<--------WEIRD!! ((not any sedatives like BZ or 1st gen antihistamine!!!)) BUT LONG TERM THERAPY OF TX ALTER MENTAL STATUS ===AKA===DELIRIUM SX = TX THE UNDERLYING MEDICAL CONDITION CAUSING DELIRUM = IF UTI IS CAUSING DELIRIUM THEN LONG TERM TX OF THIS DELIRUM - GIVE PT ANTIBIOTICS TO TX THE UTI
PT GIVEN PHENELZINE NOW HE HAS: HALLUCINATIONS TX?
TX OF MAOI INDUCED DELIRIUM = BZs = LORAZEPAM = THIS WILL WORK FOR ANY OTHER S.E. OF MAOI ALSO ===> RHABDOMYOLYSIS, AUTONOMIC INSTABILITY ETC =============================== MAOI== CAN BE GIVEN TO TX DEPRESSION BUT DUE TO HIGH S.E.= SHOULD ONLY BE GIVEN AFTER SSRI/SNRI/OTHERS HAVE ALREADY BEEN TRIED ((kinda last resort for MDD)) Phenelzine , tranylcypromine, and isocarboxazid = are irreversible blockers of MAO-A (monoamine oxidase-A) and MAO-B activity; = selegiline =========== REMEMBER- PT SHOULDN'T TAKE WITH CHEESE/ MEAT ===>>> HTN CRISIS ================= CONTRAINDICATIONS WITH MAOI = stimulants, decongestants, amine precursors such as L-dopa and L-tryptophan, and the antihypertensives: methyldopa, guanethidine, and reserpine.
WHAT IS AN ADVANTAGE THAT 1ST GEN= TYPICAL ANTIPSYCH DRUGS HAVE OVER 2ND GEN= ATYPICAL ANTIPSYCH DRUGS
TYPICAL ANTISPYCH DRUGS HAVE LESS ANTICHOLINERGIC S.E THAN ATYPICAL ANTIPSYCH DRUG == SO TYPICAL ANTIPSYCH DRUG WOULD BE BETTER IN PT WHO HAVE LOW BP EXAMPLE = TYPICAL ANTIPSYH DRUG > ATYPICAL FOR THIS PT: = man with a long history of recurrent psychotic depression is hospitalized during a relapse. He has prostatic hypertrophy, coronary heart disease, and recurrent orthostatic hypotension.
Tx of hallucinogen intoxication
Talking down, antipsychotics, benzodiazepines
Abrupt Permanent Deviation from Questions with No Return
Tangential Speech
Choreoathetosis and other involuntary movements most often first occurring in the tongue or fingers and later involve the trunk. Seen more frequently in elderly females.
Tardive dyskinesia
WHAT STRESSORS ARE TOO BIG/SIGNIFICANT TO NOT COUNT AS ADJUSTMENT DISORDER ===================== PT WHO ALMOST DIED FROM MI IN HOSPITAL COMES BACK HOME WHERE SHE SAYS SHE HAS INTENSE FEAR OF HOSPITALS = THESE FEARS FOR PAST WEEK
The event must involve death, threatened death, or serious injury = THESE STRESSORS ARE BIG ENOUGH TO CAUSE ACUTE STRESS DISORDER OR PTSD =============== ACUTE STRESS DISORDER = ALMOST DIED IN HOSPITAL SINCE ITS BEEN < 1 MONTH= NOT PTSD!
IQ FOR NORMAL VS VARIOUS SEVERITY OF RETARDATION
The range of IQ for average (normal) intelligence is = 90 to 110. -- IQ for mild mental retardation is = 55 to 70. --- IQ for moderate mental retardation is = 40 to 54. --- IQ for severe mental retardation = is 25 to 39.
Cardiac conduction abnormalities
Thioridazine
Childhood onset of multiple motor and vocal tics
Tourette Disorder
Treatment of Depression with Insomnia
Trazodone
Management of Folie a Deux (Shared Delusions)
Treat Primary Patient; Interview Dependent Patient Separately (Shared Psychosis Requires Separate Mental Health Units)
Stimulants: Methylphenidate and dextroamphetamine Non-stimulants: Atomoxetine (less s/e therefore chosen about first line stimulants)
Treatment of ADHD
Toilet training, avoiding large amounts of fluid before bed and decreasing emotional stressors. A bell-pad apparatus is the best treatment. Imipramine and desmopressin (DDAVP) for short-term
Treatment of Childhood Enuresis
SSRIs, venlafaxine, buspirone, and benzodiazepines
Treatment of Generalized anxiety disorder
Must first secure the safety of the patient, SSRIS, SNRIS, TCAS, MAOIs. ECT may be indicated if patient is suicidal or intolerant to medications
Treatment of Major Depressive Disorder
Parents should be advised to spend time interacting with a child, and to reward desired behaviour
Treatment of Oppositional Defiant disorder
Eye Movement Desensitization and Reprocessing
Treatment of PTSD
They may benefit from psychotherapy and if medications are indicated use of SSRIs, TCAs, or MAOs are preferred.
Treatment of Persistent Depressive Disorder (Dysthymia)
Hospitalization for safety of the pt and antipsychotic medications. If no response, consider using clozapine after other medications have failed.
Treatment of Schizophrenia
Must have a single identified physician as a primary caregiver with regularly scheduled brief monthly visits to increase pts awareness that sx are psychological nature.
Treatment of Somatic Symptom Disorder
Antipsychotic drugs, including pimozide, haloperidol, olanzapine and reiperidone
Treatment of Tourette disorder
2nd-Line for OCD
Tri-Cyclic Clomipramine (1st-Line = SSRI)
Pulling one's own hair, resulting in hair loss. There is anxiety before the act and a release of anxiety after the act. Hair loss is significant over all areas of the body May eat hair, resulting in bezoars, obstruction and malnutrition. Head banging, nail-biting, and gnawing may be present.
Trichotillomania
Increases total sleep time
Tryptophan
Time Requirement for Bulimia
Twice Weekly for 3 Months; Purging Preceded by Disgust and Guilt
COMMON SX / VITALS OF PTS WITH ANOREXIA
UNDERWEIGHT= BMI <18 = WIEGHT IS BELOW 85% (((but sx like hypo-thyroidism: HYPOTHERMIA BRADYCARDIA HYPO-TENSION LANUGA==THIN BODY HAIR DRY SKIN DUE TO MALNUTRITION = CARDIAC AND ENDOCRINE DISTURBANCES AMENORHEA
DISCUSS CLOZAPINE GIVEN FOR? S.E?
UNIQUE ANTIPSYCHOTIC DRUG IN THE SENSE THAT WHILE OTHER ANTIPSYCH DRUGS ARE ALL AROUND SIMILAR EFFICACY CLOZAPINE=UNIQUE =SUPERIOR EFFICACY = BUT ONLY GIVE AS LAST RESORT DUE TO S.E. = only give this after 2 OTHER ANTI=PSYCH DRUGS DIDNT HELP THE PT =============== CLOZAPINE INDICATIONS = TX RESISTANT SCHIZOPHRENIA (((2 other atypical antipsych drugs didn't work on the pt))) AND SCHIZOPHRENIA ASSOCIATED WITH PERSISTANT SUCIDE THOUGHTS =================== S.E.S = AGRANULOCYTOSIS = KEEP AN EYE ON WBC AND NEUTROPHILS SIEZURES MYOICARDITIS
36 YEAR OLD PATIENT UNIQUE SX = FAMILY SAYS HE HAS BEEN MOVING VERY SLOWLY ON P.E.= PSYCHO-MOTOR RETARDATION OTHER SX = LOST INTEREST IN FISHING STAYS IN APT ALL THE TIME DECREASE APETITE + GUILT = FELT LIKE A BURDEN ON FAMILY
UNIQUE SX AND P.E. FINDING = CATATONIC STATE/SUBTYPE HIS OTHER SX===> MDD = so he has: MDD, CATATONIC SUBTYPE ==============VS============= Malignant catatonia = pronounced vital sign abnormalities, + possibly with marked rigidity and + elevations in CPK.
WHAT IS childhood disintegrative disorder???
UPTO 2 YEARS =KID HAD NORMAL DEVELOPMENT BUT AFTER 2 YEARS = marked regression in multiple areas of functioning ((disintegrate in functioning after > 2 yr)
Time Requirement for Acute Stress Disorder
Under 1 Month, Within 1 Month of Event
Eligibility for Hospice Care
Under 6 Months
Acting out the reverse of an acceptable behaviour; consists of an act. "I need to wash my hands whenever I have these thoughts"
Undoing
WHICH DRUG FOR BIPOLAR CAN CAUSE NEURAL TUBE DEFECTS
VALPROIC ACID
WHICH ANTI-ANXIETY DRUG SHOULD NOT BE GIVEN TO PT WITH HTN ====================== PT HAS GAD WHICH ANTI ANXIETY MEDICINE IS THE ONLY MED SAFE TO BE GIVEN WITH WARFARIN
VENLAFAXINE = S.E.= INCREASE BP ========= WARFARIN= DANGEROUS TO BE TAKEN WITH MOST ANTI ANXIETY DRUGS BEST DRUG TO TX GAD/ANXIETY IN A PT ALSO TAKING WARFARIN = CLONA-ZE-PAM== BZ
ALL SIDE EFFECTS OF SSRIs
VERY COMMON = INSOMNIA----this is counterintuitive since SSRI given for depression and one of MDD sx= insomnia SEXUAL DYSFUNCTION =decreased libido, erectile dysfunction, anorgasmia OTHERS GI SX diarrhea, constipation, nausea,
Inhibit reuptake of NE and Serotonin used for depression and anxiety may cause hypertension, blurry vision, diaphoresis, etc
Venlafaxine
Usually grunts; coprolalia (cursing) in 10% of pts
Vocal tics
Recurrent urges or behaviours involving the act of observing an unsuspecting person who is engaging in sexual activity, disrobing, etc. Earliest paraphilia to develop
Voyeurism (peeping-tom)
e college student is evaluated by his college student health center after being arrested for masturbating outside of a sorority window late at night. He admits to having watched a particular female student inside the building over a period of several months
Voyeurismis deriving sexual pleasure from JUST watching another person or persons involved in the act of undressing or other sexually oriented activity. === Voyeurism involves secretly watching someone engaged in disrobing, nudity, or sexual behavior. =======VS============= Fetishism is sexual urges or fantasies involving an inanimate object. Pedophilia involves sexual fantasies and behaviors concerning children.
WERNICKE VS KORSKOFF? =============== MNEMONIC FOR WERNICKE AND KORSKOFF
WERNICKE -->IF NOT TX--->LEAD TO = KORSKOFF ======== Wernicke encephalopathy = (think COAT: Confusion, Ophthalmoplegia, Ataxia, and Thiamine to treat) Korsakoff syndrome = (think RACK: Retrograde and Anterograde amnesia, Confabulation, Korsakoff syndrome)
PT IN ED WITH FOLLOWING SX HALLMARK = HORIZONTAL NYSTAGMUS + 6TH NERVE PALSY PT IS ALSO==VERY CONFUSED, DISORIENTED
WERNICKE ENCEPHALOPATHY =SEE HALLMARK SX CAUSE = THIAMINE DEFICIENCY== B1 ((even if pt's alcohol levels were negative, pt can STILL have this due to non alcohol induced thiamine deficiency))
PT WITH ALCOHOL DEPENDCE HAS IMPAIRED ==RECENT RECALL WHAT CONDITION IS HE SUFFERING FROM
WERNIKE KORSKOFF= IN ALCOHOLICS = ANTEROGRADE AMNESIA + CONFABULATION = pt tries to pretend they dont actually have memory loss instead fabrication of fictitious responses in compensation of a memory loss + eye sx--nystagmus===check!!
PT HAS MDD + ONGOING SUCIDE THOUGHTS= CLEAR PLAN TX?
WHEN MDD ALSO HAS SUCIDE THOUGHTS = THERAPY ALONE==NOT ENOUGH === WHEN MDD PT HAS HIGH CHANCES OF KILLING HIMSELF = JUMP TO ECT
DISCUSS SX OF ALCOHOL WITHDRAWL
WITHIN 6 HOURS = SWEATING/PALPITATIONS ================= 12-48 HRS= UPTO 2 DAYS = SEIZURES ================= UPTO 2 DAYS = ALCOHOLIC HALLUCINATIONS = AUDITORY/VISUAL HALLUC = UNLIKE DTs, VITALS ARE NORMAL DURING THIS ================== 2-4 DAYS = DTs = FEVER!! HTN HIGH HR SWEATING
Acute Reversible Ataxia, nystagmus, and opthalmoplegia Tx: Thiamine
Wernicke
Ceruloplasmin deficiency Hepatolenticular degeneration Kayser-Fleischer rings in the eye Asterixis
Wilson disease
"ABRUPT DISCONTINUATION" OF WHICH DRUG WILL CAUSE = SEIZURE
XANAX = ALPRAZOLAM = SHORT ACTING BZs ============ NOTE= BUPROPION ALSO CAUSES SEIZURE- BUT THIS IS FROM ITS OVERDOSE NOT DISCONTINUATION ======= ABRUPT DISCONTINUATION CAN LEAD TO = SEIZURES REBOUND== after not taking drug, pt feels return/ rebound of Sx again= feel anxious again
CAN A SKINNY PT WHO IS CONCERNED WITH WEIGHT GAIN BUT ALSO VOMITING ACTUALLY HAVE ANOREXIA? =============== REMEBER VOMITTING CAUSES = LOSE HCL ==>> METABOLIC ALKALOSIS HYPO-K-ALEMIA
YES! THIS IS A SUBTYPE OF ANOREXIA = BINGE EATING/ PURGING/VOMITTING SUBTYPE = ANOREXIC PT WITH SIMILAR SX TO BULIMIA DUE TO VOMITTING LIKE PAROTID ENLARGEMENT DENTAL EROSION HAND VALLUSES ELECTROLYTE CHANGES DUE TO VOMITTING ============VS======== DIFFERENTIATE THIS FROM BULIMIA BECAUSE ANOREXIA PT= UNDERWEIGHT = BMI < 18.5 VS BULIMIA PT = NORMAL/OVER-WEIGHT = BMI 18.5- 30
pt's WIFE DIED 1 MONTH AGO HE IS NOW AUDITORY HALLUCINATIONS =HEARING HIS WIFE'S VOICE IS THIS STILL CONSIDERED BREAVEMENT? TX OF BREAVEMENT?
YES!= STILL BREAVEMENT AS LONG AS HALLUCINATIONS INVOLVE THE DEAD PERSON=== OK TO HAVE THESE DURING BREAVEMENT PERIOD === BREAVEMENT TX = INITALLY=== NO DRUGS== SX SHOULD RESOLVE SPONTANEOUSLY AFTER CERTAIN PERIOD OF TIME IF SX PERSIST=== SSRI
PT HAS COMPLAIN OF INSOMNIA NO OTHER MDD/ ANXIETY/ DEPRESSION SX TX OF INSOMNIA? =========== TX OF PT WHO HAS ANXIETY PERFORMIN ON STAGE ============ S.E OF WHICH DRUG = (K) pigmented retinopathy
ZALEPLON > ZOLPIDEM NO =========== B-BLOCKER= PROPANOLOL ========= THIORIDAZINE ===> RETINAL CHANGES ===>MAY LEAD TO BLINDNESS
SIDE EFFECT OF WHICH PSYCH DRUG = PROLONGED QT =============== WHAT ARE S.E OF LITHIUM
ZIPRASIDONE CHECK REGULAR EKG FOR PT ON THIS DRUG =============== PT ON LITHIUM , REGULARLY CHECK = Patients on lithium, at minimum, should be monitored for the following: plasma lithium level , thyroid function tests, creatinine, and urinalysis ----- KIDNEY===CREATINENE LEVEL AND THYROID TEST S.E = HYPO=THYROIDISM DIABETES INSIPIDUS INTERSTITIAL NEPHRITIS
WHAT DRUG TO GIVE TO PT WHO HAS INSOMNIA DUE TO GENERALIZED ANXIETY DISORDER
ZOLPIDEM == BZs TX INSOMNIA == DOES not tx general ANXIETY
PT TRAVELS OFTEN complaining of significant insomnia and daytime fatigue after arriving in Germany WHAT DRUG WILL HELP HER
Zolpidem= extremely useful for the short-term treatment of insomnia WILL HELP HER SLEEP ON FLIGHTS/ FIX HER INSOMNIA == NO NEED TO GIVE HER ANY ANTIDEPRESSANTS OR ANTIANXIETY DRUGS THAT ARE ALSO SEDATIVE LIKE TRAZODONE SINCE SHE DOESN'T HAVE DEPRESSION/ANXIETY
Conduct Disorder
aggressive Violate the rights of others (bullies, tortures animals, destroys property) Precursor to antisocial personality disorder
mature def mechs:
altruism: avoid neg feelings by helping others humor: using humor to avoid uncomfortable feelings sublimation: channel impulses into socially acceptable behaviors suppression: putting unwanted feelings aside to cope with reaity
tx for acute mania
antipsychotics, or li or , valproate, carbamazepine for mild - mod mania - can try antipsychotic alone or combine with mood stabilzer for severe mania w agitation
PROFESSOR SPEAKS WITH FLAT TONE, NO MELODIC TONE WHAT KIND OF SPEECH?
aprosody = Prosody describes the melody, rhythm, or intonation of speech that carries =its emotional quality. The lack of this type of emotional variation is called aprosodic speech. ================ Dysarthria = is poor articulation, often due to a neurologic injury such as a stroke. ================= Scanning speech is = irregular pauses between syllables, which also breaks the fluidity but does not cause the repeating of sounds or syllables. ======================== Stuttering is the disturbance of the fluidity of speech as in repeating sounds or syllables or using broken words.
NMS symps THIS IS FROM TAKING ANTIPSYCHOTICS
autonomic instability: - diaphoresis - fever - tachypnea - tachy - HTN - Dysrrythmia confusion / delirium muscle rigidity Labs: high CK leukocytosis
reaction formation
blaming immigrants for taking jobs. but helps the same group of ppl w finding jobs/
NMS
caused by antipsychotics/ neuroleptics. dopamine antagonists (haldol) syms: - hyperthermia - muscle rigidity - autonomic instability - altered sensorium - high CPK --> rhabdo --> acute renal failure tx: dantrolene (muscle relaxant) , amantadine dope agonist (bromocriptine) - supportive care: cooling, antipyretic, fluids and lytes
IS THIS AUTISM OR childhood disintegrative disorder? The girl's mother states that her daughter seemed normal for at least the first 2 to 3 years of her life. She was walking and beginning to speak in sentences. . The mother has been noticing that over the past 2 months her daughter has lost these previously acquired abilities. She will no longer play with anyone else and has stopped speaking entirely. She has lost all bowel control, when previously she had not needed a diaper for at least a year
childhood disintegrative disorder
GAD
chronic multiple worries, anxiety, tension
schizoaffective disorder
concurrent mood episode, active phase symptoms of schizo + at least 2 week lifetime hx of delusions or hallucinations in the absence of prominent mood symptoms
what is term for common TIC IN TOURETTE WHERE PT MAKES = OBSCENE GESTURES =============== term for SUSTAINED BLINKING
copropraxia COPRO=PRAXIA = show the mid finger/ obscene gesture to copro=ate ============= BLEPHAR-O-SPAM = Ocular/ blinking
HOW DO BZ CHANGE SLEEP CYCLE ========== WHICH DRUG S.E = VIVID DREAMS
decrease sleep latency (time to fall asleep) but also shorten REM sleep (restfulness and dreams) = BZ AFFECT ON SLEEP CYCLE ================= BZ SIDE EFFECT = VIVID DREAMS
other immature defense mechs:
denial: acting as if an aspect of reality does not exist dissociation: disrupting memory, identity, and consciousness to cope with an event. fantasy: substituing imaginary scenarios isolation of affect: separating a thought from its emotional components passive aggression: projection: attributing one's own feelings to others splitting reaction formation regression: reverting to earlier dev stage repression: blocking blocking upsetting feelings from entering consciousness
panic d/o is linked w/ :
depression agoraphobia bipolar d/o substance abuse
SUMMARIZE DIAGNOSIS CRITERIA FOR ADHD
diagnostic criteria for ADHA is: Time > 6 months Age < 7 years at onset !!!!!!!!!!!!!!!!1 Settings > 2 Attention Deficit: decreased attention, inability to finish tasks, easily distracted Hyperactivity: Interruptions, fidgets, cannot wait turn
OTHER THAN MYOCLONIC JERKS WHAT OTHER SX IN SEROTONIN SYNDROM
diarrhea;===NEVER IN = NMS restlessness; extreme agitation, MYOCLONIC JERKS==hyperreflexia, and autonomic instability
adjustment disorder
emotional or behavioral symps taht develop within 3 months of exposure to a stressor, and that rarely lasts longer than 6 months after stressor ends
illness anx do
excessive fear of having severe illness despite no syms and consistentlt negative evaluaitons somatic sym do: have one or more syms
specific phobia
excessive worry about specific object or stimulation
factitious disorder
falsifying info to assume the sick role (losers)
ECT
for severe depression refractory to antidepressants - for geri pts unable to eat/ drink - active psychosis - preg females
hoarding disorder
give SSRI plus CBT
acute mania / bipolar
give lifetime lithium to pt if he has 2 or more acute mania episodes
adjustment do
happens within 3 months of start of stressor
involuntary commitment
if there is grave disability (cant take care of oneself, danger to self/ others, has a mental illness)
splitting
immature. all good or all bad. ex: borderline pt thinks therapist is wonderful but previous doc was horrible
displacement
immature: transferring feelings to a more acceptable object
OCD PTS HAVE INCREASE BRAIN ACTIVITY WHERE ============ IQ OD 55- ??
increased activity (metabolism) in the caudate nucleus, frontal lobes, and cingulum. T =========== IQ OF 55= MILD RETARDATION
A 32-year-old single, male with injected conjunctiva can't concentrate at work, laughs readily at his coworkers' doodles, feels "relaxed," and speaks slowly while seemingly focused on the air in front of him. ============= student smells "funny," is stumbling, feels dizzy and nauseated, yet remains smiling and says she feels "such a rush." By the middle of her next class she has a headache but otherwise feels like she did this morning
injected conjuctiva===> cannabis overdose ===== (L) inhalant intoxication = e rapid onset of effects, dizziness, nausea, then slowing, ataxia, slurred speech, and disorientation Intoxication usually improves within an hour of abstinence because the substances are usually volatile hydrocarbons.
schizoid personality disorder
lack close friends restricted range of emotional expression like to be aloof/ isolated
competency
legal def determineed by the courts
sublimation
mature. channel unacceptable instinctual drive into somethingi positive. - dude w explosive temper channels it into doing athletic sports
suppression
mature. suppressing inner thought by focusing on other things. mom focuses on kids' hw instead of her dad's cancer dx
LIST THE ONLY 3 ANTIDEPRESSANT DRUGS THAT DO NOT CAUSE SEXUAL S.E.
mirtazapine, bupropion == rem- SSRI AND MAY OTHER ANTIDEPRPRESANTS - S,E = SEXUAL SIDE EFFECTS= decreased libido, erectile dysfunction, anorgasmia
binge eating d/o
no compensatory changes in behavior after binging!! - recurrent episodesof binge eating - lack of control during eating
tardive dyskinesia
no effeective treatment :/ gradual onset 1-6 months after therapy
PT HAS FEAR OF BEING TRAP IN ELEVATOR SO SHE ALWAYS TAKES STAIRS ======== PT FEAR OF PUBLING SPEAKING TX?
not agoraphobia!! SPECIFIC PHOBIA TX==SYSTEMIC DESENSITIZATION ================ TX= PROPANOLOL For control of performance anxiety, either β-adrenergic receptor antagonists (commonly atenolol or propranolo
SX OF SEROTONIN SYNDROME ==== CAUSED BY SSRI, SNRI
note unlike with NMS, NO MUSCLE RIGIDITY IN SEROTONIN SYNDROME =============================== VERY HIGH FEVER----ALSO in NMS/ ALTER MENTAL STATUS AUTONOMIC DYSREGULATION POSSIBLE = SEIZURE
pt has symptoms of "the flu." Her pupils are now slightly dilated, and she is yawning. ================ WHICH CLASS OF MEDS SHOULD NEVER BE "SUDDENLY DISCONTINUED"
opiate WITDRAWL =========== THESE DRUGS SHOULD NEVER UNDERGO "SUDDEN DISCONTINUATION" = ALCOHOL BENZODIAZIPINES BARBITUATES = NOTICE!!== ALL ARE SEDATIVESS!!!! can cause significant withdrawal symptoms, including seizures
body dysmorphic do tx
psychotherapy or meds
5 YEAR OLD GIRL indiscriminately social with adults and unusually "clingy." inappropriately aggressive with OTHER KIDS
reactive attachment disorder of early childhood = display markedly disturbed and inappropriate social relatedness EXPECT THIS KID'S PARENT TO HAVE SHOWN NEGLECT/ SUBSTANCE ABUSE
bulimia
recurrent episodes of binge eating - binge eating followed by compensatory beh. to prevent wt gain - maintains nl wt gain
panic disorder
recurrent, unexpected panic attacks
anticholinergic SE (benztropine, trihexiphenidyl) - used for parkinson and med induced EPS
red as a beet: flushing dry as bone: dry mouth, anhidrosis hot as a hare: hyperthermia mad as a hatter: delirium/ confusion blind as a bat: mydriasis/ vision changes full as a flask: urinary retention
akathesia
restlessness, cant freaking sit still tx: benzo
HOSPIT. PT becomes very agitated in the emergency room, screaming that the nurses were there to kill her and that she had to escape. She tried to strike one of the nurses before being restrained WHAT DRUGS WILL CALM THIS PT
screaming that the nurses were there to kill her = PSYCHOSIS= DELUSIONS strike one of the nurses before being restrained = VERY AGITATED/ VIOLET TO CALM PT HAVING DELUSIONS + VIOLENT/AGITATED = HALOPERIDOL + BZ= LORAZEPAM
cocaine
seizures mydriasis tachy/ HTN CP
pt says she is feeling sad/ cant sleep/ lost weight after losing her job Additionally, she describes a period about a year ago in which she stayed up for several days in a row planning a big party for her husband's birthday; at that time, others commented that she was talking quickly and acting "like the energizer bunny."
she currENTLY HAS== MDD YEAR AGO= HAD SX OF HYPO-MANIA (NOT FULL BLOWN MANIA!))
DIAGNOSE? TX? boy is brought to the physician by his parents because he experiences episodes of waking in the middle of the night and screaming. , they find him in his bed, thrashing wildly, his eyes wide open. He pushes them away when they try to comfort him. After 2 minutes, the boy suddenly falls asleep, and the next day he has no memory of the episode
sleep terror disorder, =a dyssomnia characterized by sudden partial arousal accompanied by piercing screams, motor agitation, disorientation, and autonomic arousal PT do not have any memory of the episodes the next day == TX== GIVE THE KID VERY SMALL DOSE OF DIAZEPAM= VALIUM = AT BEDTIME = i guess this knocks kid out so dont want up with these night terror like episodes
D2 antagonist SE (antipsychotics)
these cause hyperprolactinemia (amennorhea, galactorrhea, gynecomastia, sexual dysfxn) - block dopamine activity in the tubuloinfundibular pathway
serotonin syndrome
this is from combo of serotonergic meds or the interaction of serotonergic meds w MAOis - see N/M irritability, NOT RIGIDITY - see more GI issues (vomiting)
capacity
to determine if pt has is capable to give informed consent to get or refuse therapy. psych pt can give IC as long as their jdgment and decision making abilities are determined to be intact
MOST CONVINCING REASON FOR ORDERING ECT FOR PT WITH MDD?? WHAT SHOULD ALWAYS BE CHEFCKED BEFORE JUMPING TO ECT? ===================================== ========= WHAT IS A CONTAINDICAITON FOR ECT THERAPY
treatment-resistant depression =ESPECIALLY with recurrent suicidal ideation =========================== IMPORTANT! = BUT BEFORE JUMPING TO ECT FOR MDD, MAKE SURE PT HAS ALREADY TRIED ANTI=DEPRESSION DRUGS + CHECK TO MAKE SURE PT DOESNT HAVE HYPOTHYROIDISM ---> CAN CAUSE MDD LIKE SX ============================================================ CONTRAINDICATIONS FOR ECT = ANYTHING IN BRAIN THAT CAN INCREASE ICP = BRAIN MASS ---- "NOT" CONTRAINDICATIONS FOR ECT = PREGNANCY PACE MAKER CAD/ MI IN THE PAST TRAUMATIC BRAIN INJURY
WHAT IS Dementia pugilistica = (punch---drunk syndrome)
type of dementia seen = following repeated head trauma over years (as in boxers) and is characterized by emotional lability, dysarthria, and impulsivity. L
man develops acute urinary retention and blurred vision after taking an antidepressant which MDD DRUG CAUSE THIS?
urinary retention and blurred vision = ANTICHOLINERGIC S.E MDD DRUG CAUSING THIS = TCA
Ecstasy / (MDMA)
used in raves - HTN, tachy - hyperthermia - serotonin syndrome - hyponatremia
avoidant personality d/o
want friends but fear rejection / ridicule
writhing movements of his wrists and fingers IN PT TAKIN ANTIPSYCH DRUG ========== LARYNGEAL SPASM
writhing movements of his wrists and fingers = TARDIVE DYSKINESIA BASAL GANGLIA= IMPAIRMENT= CAUSES THIS ============= LARYNGEAL SPASM = ACUTE DYSTONIA