PSYCH UWORLD 3
explain antipsychotics and infertility
Antipsychotic medications exert their effects through dopamine antagonism. The blocking of dopamine may result in hyperprolactinemia, which can lead to galactorrhea, amenorrhea, and infertility. The second-generation antipsychotic risperidone is most likely to increase prolactin.
maintenance tx for depression - severe, chronic,recurrent
1-3 yrs Patients with a single episode of major depressive disorder should continue antidepressants for an additional 6 months following acute response to reduce the risk of relapse. Patients with recurrent, chronic, or severe episodes should be considered for maintenance treatment (1-3 years or indefinitely).
how long is an antidepressant trial/how long before try something else
4-6 weeks An antidepressant trial is at least 4-6 weeks at a therapeutic dose. Physicians should continue antidepressants for at least 4-6 weeks before considering the next step in treatment.
Acute intermittent porphyria sxs
5 Ps painful abdomen polyneuropathy port-wine colored urine psychiatric sxs precipitated by drugs, alcohol, starvation
maintenance tx for depression - 1 attack
6 months
ADJUSTMENT DISORDER
A 62-year-old woman comes to the office due to insomnia and depressed mood. She describes feeling angry and sad since her husband of 35 years unexpectedly announced that he wanted a divorce 2 months ago. She says, "I was devastated because I thought we had a pretty good marriage, better than most. My whole life has been turned upside down. I can't even think about going on dates at my age." The patient stays up well past her usual bedtime worrying about living alone and supporting herself financially. She recently started drinking wine before bedtime to help her fall asleep. Although she was regularly eating lunch with friends, she has canceled multiple times because she "can't bear to go through the whole story again and again." She has no suicidal ideation. The patient is tearful when discussing the divorce but brightens when asked about her grandchildren.
An 11-year-old girl is brought to the office by her mother after getting suspended from her new school for pushing a peer while waiting in line at the cafeteria. The patient has had a history of behavioral concerns since first grade and was suspended once before for talking back to her teacher. Her mother reports that the patient has always had a lot of energy and "needs to be active to stay out of trouble." The patient requires frequent prompting to complete homework assignments and forgets to do her chores. The mother states, "My daughter doesn't think before she speaks or acts, but this is the first really bad thing she has done this year. Her dog died last month, and she's been pretty upset. I have bipolar disorder, and I know what it's like to be down." Vital signs are within normal limits. Height and weight are consistently tracking at the 70th percentile. On examination, the patient is cooperative, mildly restless, and talkative. She says her mood is "fine" and that she "hates school because it's so boring." dx
ADHD
This patient's episodic agitation, insomnia, psychosis (eg, delusions about the CIA), change in behavior (eg, stealing money), and signs of sympathetic hyperactivity (eg, mydriasis, tachycardia, hypertension, diaphoresis) with subsequent return to baseline functioning following an observed period of abstinence are consistent with amphetamine intoxication. Potential serious complications of amphetamine intoxication include cardiac arrhythmias, seizures, hyperthermia, and intracerebral hemorrhage.
Amphetamine intoxication can present with psychiatric symptoms, including irritability, agitation, and psychosis. Common physical signs include tachycardia, hypertension, hyperthermia, diaphoresis, and mydriasis.
what type of dementia - MRI of the head shows generalized cerebral atrophy with no mass lesions or white matter changes.
Alzheimer's
Drug for ADHD if history fo addition and drug abuse
Atomexitine use that over methylphenidate
PTSD tx nonpharmacologic
CBT helps the patient emotionally process the trauma and recognize and correct maladaptive thought patterns while also targeting avoidance behaviors with exposure techniques (eg, in vivo or imaginal exposure).
Memantine use
Dementia
Core feature of delirium
Fluctuating cognitive impairment The core feature of delirium is fluctuating cognitive impairment, characterized by poor attention and disorientation; psychotic features may be present secondarily. This patient is alert and oriented, making delirium less likely.
treatment for acute stress disorder
Early intervention for acute stress disorder is indicated to reduce the severity of symptoms and prevent progression to posttraumatic stress disorder. Trauma-focused cognitive-behavioral therapy is recommended as first-line treatment.
Gambling disorder is characterized by persistent and recurrent maladaptive gambling behavior that results in impairment or distress. Significant financial losses and damaged relationships are common consequences.
Gambling disorder is defined as persistent and maladaptive gambling behavior that results in impairment or distress. It is considered a nonsubstance behavioral addiction, implying many shared features (eg, anticipatory craving, chronic relapsing course) with substance use disorders. Mood symptoms related to gambling behavior (ie, irritability, feeling "a little down") are common, as seen in this patient. The diagnosis requires ≥4 characteristics related to problematic gambling behavior. This patient exhibits the following 4: - preoccupation with gambling, - frequent return to gambling to attempt to recover past losses, - tendency to damage relationships or jeopardize employment, - reliance on others to make up for financial losses. Additional criteria listed in DSM-5 include: gambling when distressed, depressed, or anxious; increased gambling to achieve the desired excitement; irritability/distress when trying to cut back on gambling; and repeated, unsuccessful attempts to cut back on and conceal the extent of the behaviors.
Medication induced psychotic disorder - common drug that causes ut
Glucocorticoids Medication-induced psychotic disorder is characterized by the acute onset of delusions and/or hallucinations that are temporally associated with the use of a new medication. Glucocorticoids, particularly at high doses, are often implicated in new-onset psychotic symptoms in patients who may have no current underlying psychiatric illness.
how to handle suicidal patients if HIGH risk, imminent
High imminent risk (ideation, intent & plan) Ensure safety: hospitalize immediately (involuntarily if necessary) Remove personal belongings & objects in room that may present self-harm risk Constant observation & security may be required to hold against will
how to handle suicidal patients if LOW risk, nonimminent
High nonimminent risk (ideation, intent, but no plan to act in near future) Ensure close follow-up Treat modifiable risk factors (underlying depression, psychosis, substance abuse, pain) Recruit family or friends to support patient Reduce access to potential means (secure firearms, medications)
PHYSICAL sxs related to GAD
INSOMNIA FATIGUE MUSCULAR TENSTIO --> SORENESS, HEADACHES
benzos used for alcohol withdrawal if patient has liver disease, why?
LOT lorazepam oxazepam temazepam BC OF THEIR SHORT HALF LIFE, AND LACK OF ACTIVE METABOLITES
Alcohol use disorder definition numbers for men and women
Men: over 14 drinks a week or over 4 drinks a day women: over 7 drinks a week or over 3 drinks a day The National Institute on Alcohol Abuse and Alcoholism has found evidence of negative health effects for women of all ages and men age ≥65 who consume >7 drinks in a week or >3 in a day (for men age <65, the cutoffs are >14 drinks in a week or >4 drinks in a day). This patient's alcohol consumption pattern (≥14 drinks per week), abnormal liver enzymes (aspartate aminotransferase/alanine aminotransferase ratio ≥2:1), macrocytosis, alcohol tolerance (ie, decreasing sedative effects of alcohol over time), and impaired functioning (eg, work tardiness) are consistent with a diagnosis of alcohol use disorder. This diagnosis is also supported by her history of gastroesophageal reflux disease and hypertension as well as a tremor on examination.
Do safety contracts work for reducing risk of suicide?
Not really
First step in diagnosing new onset psychosis
Obtain UDS Substance-induced psychosis should be considered in the differential diagnosis of all patients who come to the emergency department with acute psychosis. Standard workup of new-onset psychosis includes obtaining a urine toxicology screen.
What causes false positive for amphetamines on UDS?
PBS pseudophedrine bupropion slegiline
A 48-year-old woman comes to the office with her sister for a preventive visit. Her sister says, "I got diagnosed with stage I breast cancer a year ago and want to make sure my sister is okay. It took a lot of convincing, but she finally agreed to come in for a checkup." The patient last saw a physician 10 years ago and says, "Doctors always try to find something wrong so that they can bill." She has no health issues and takes no medications. The patient does not use tobacco, alcohol, or illicit drugs. She lives alone and has never dated or married because she believes others may try to exploit her for the small inheritance she received from her parents. On physical examination, the patient appears older than her stated age; she is wearing baggy clothing, and her hair is unkempt. The patient agrees only to a breast examination and asks the physician, "Why would you need to examine anything else?" Throughout the examination, her gaze is fixated on the physician, and her affect is constricted.
Paranoid personality disorder
Paranoid personality disorder
Paranoid personality disorder is characterized by a long-standing pattern of suspicion and mistrust of others' intentions. In the physician-patient relationship, it may manifest as difficulty establishing rapport and creating a therapeutic alliance. Other characteristics include oversensitivity to perceived criticism, reluctance to confide in others, and a tendency toward aggression or defensiveness in response to perceived attacks.
Inhalant abuse signs
Rash involving the basil animal folds GI sxs like abdominal pain and cramping neuro sxs like tremors, decreased reflexes psych sxs like mood swings, irritability Cardio sxs like arrhythmia
Tardive dyskinesia tx
Remove offending agent Tardive dyskinesia is characterized by abnormal involuntary movements of the face, lips, tongue, trunk, or extremities that develop as a result of prolonged exposure to antipsychotic medication. If feasible, the causative medication should be tapered and discontinued.
risk factors for suicide mneumonic
Sex Age Depression Previous attempt EtOH (or other substance) use Rational thought loss (psychosis) Social support Organized plan No spouse or significant other Sickness or injury
A 31-year-old woman comes to the office due to chronic abdominal pain that is unrelated to meals and has persisted for the past 2 years. The patient reports no weight loss, nausea, vomiting, fever, or changes in bowel movements. She has consulted several physicians and undergone endoscopy, colonoscopy, and CT scan of the abdomen, as well as an exploratory laparoscopy, all without any significant findings. The patient was placed on sick leave because she has been unable to focus on anything other than her physical discomfort. She is anxious and frustrated that physicians have been unable to arrive at a diagnosis and fears that she will be unable to return to work. Other medical issues include obesity and tension headaches. Family history is significant for hypertension and diabetes in her father, who died of colon cancer at age 59. Physical examination shows diffuse abdominal tenderness on palpation and no other abnormalities. Which of the following is the most likely diagnosis?
Somatic symptom disorder
antipsychotic MOST likely to induce prolactin
risperidone
is HIV associated dementia found in patients doing antiretroviral therapy properly?
safe to say no
in controlled schizophrenia, what can cause increased risk of relapse?
stress
Inhalant abuse population
Usually children and adolescents Inhalants are easily accessible and found in everyday products (eg, glue, shoe polish, gasoline, spray paint). They readily cross the blood-brain barrier, resulting in euphoria and intoxication. Use typically begins in childhood or early adolescence via sniffing or inhaling (eg, placing a rag soaked with the substance on the mouth and/or nose). The characteristic perioral dermatitis (ie, "glue-sniffer's rash") is due to the drying effect of hydrocarbons. It extends around the mouth and/or nose, classically involving the nasolabial folds (a highly characteristic feature). Other clues of inhalant abuse include the odor of chemicals on the breath or clothes or finding rags, gauze, or chemical containers in the trash. Acute symptoms of inhalant use include neurologic (eg, tremor, disorientation, headaches, slurred speech, hallucinations), gastrointestinal (eg, stomach cramps, nausea), cardiovascular (eg, arrhythmia), and respiratory (eg, wheezing, coughing) effects. Psychiatric manifestations include irritability, mood swings, aggression, and grandiosity. Chronic use results in weight loss and anorexia, neurocognitive impairment, cerebellar dysfunction, and peripheral neuropathy (eg, decreased reflexes).
ALCOHOLIC HALLUCINOSIS TIMING
WITHDRAWAL PRESENTS AFTER 12 HOURS - RESOLVES WITHIN 48 HOURS AFTER LAST DRINK
what to do if taking risperidone, it is working, but having extrapyramidal side effects. Decreasing dose increases the sxs
add valbenazine or deutetrabenazine OR switch to clozapine Tardive dyskinesia occurs after prolonged exposure to antipsychotic drugs and is characterized by abnormal involuntary movements of the mouth, tongue, face, trunk, or extremities. When antipsychotic dose reduction or discontinuation is not feasible, using valbenazine or deutetrabenazine or switching to clozapine should be considered.
tx for dystonia
anticholinergics - even diphenydramine since it has anticholinergic properties
HIV associated dementia sxs
apathy, attention problems, motor problems HAD is predominantly a subcortical dementia characterized by apathy, early impairments in attention, and subcortical motor symptoms.
how to dx schizoaffective disorder
at least 2 weeks of psychosis without mood episodes
Akathisia txs
benzotropine benzos propranolol
A 27-year-old man comes to the office at his wife's insistence due to issues with concentration that are affecting his job performance. The patient works in information technology and has been easily distracted and unable to complete his assignments after returning from a business trip 4 weeks ago. The trip was stressful because it involved giving multiple presentations. Since his return, instead of working on current projects with assigned deadlines, he has spent hours developing new computer programs and is at risk of losing his job. He hardly sleeps at night and is increasingly anxious and irritable, behavior that is uncharacteristic. Last week, the patient became angry when his wife was skeptical of his idea to leave his job and start an internet company with no resources or investors. The patient has a history of attention-deficit hyperactivity disorder, for which he was treated with cognitive-behavioral therapy for 4 years beginning at age 8. He used cocaine in his early 20s but has not used illicit drugs in 3 years, apart from marijuana on occasion, which he says "helps me feel less anxious." Family history is significant for depression in his mother. On physical examination, the patient is cooperative but appears tense and anxious. He is talkative, easily distracted, and has difficulty sitting still; at one point he gets up to walk around the room. The patient has no psychotic symptoms or suicidal ideation. Urine drug screen is negative.
bipolar
What is the dx? A 46-year-old man is hospitalized due to suicidal ideation and hearing voices. The patient has become increasingly depressed over the past month and has been unable to work. Last week he told his wife that he was "tormented by voices" and that "death would be a relief." She brought him to the hospital after she found him staring at a blank screen on the television and not responding to her questions. The patient was prescribed risperidone, lithium, and escitalopram by his psychiatrist, but his wife is unsure if he takes them regularly. He has a history of bipolar disorder since age 18 with multiple hospitalizations for both manic and depressive episodes. His other medical problems are hypercholesterolemia and seasonal allergies. Temperature is 37 C (98.6 F), blood pressure is 125/80 mm Hg, pulse is 68/min, and respirations are 12/min. Routine laboratory results are within normal limits, lithium level is within therapeutic range, and a toxicology screen is negative. During the evaluation, the patient stares blankly and is mute and motionless. He resists all instructions to move. When the physician lifts the patient's arm, it remains in the exact same position after she lets go. Which of the following is the most appropriate next step in management?
catatonia
benzos that can be used for alcohol withdrawal in patient with no liver disease
chlordiazepoxide diazepam
sleep stage findings in depression
decreased REM latency decreased slow wave sleep increased REM duration
important thing to supplement pharmacotherapy with in schizophrenia patients
family therapy Explaining that the patient's lack of motivation, social withdrawal, and difficulty maintaining personal hygiene are negative symptoms rather than willful laziness can promote family support and help minimize critical comments that result in a stressful environment, which increases the patient's risk of relapse. Family therapy is an effective adjunct to antipsychotic medication in patients with schizophrenia and has been shown to reduce the risk of relapse. It focuses on educating the family about the symptoms, course, and treatment of the disorder, and it helps to promote a supportive family environment.
antihistamines can cause what sxs
hallucinations confusion
Postpartum psychosis next step
hospitalize pt
When to use antipsychotics for bipolar
in the DEPRESSED stage
CSF finding with suicidal behavior
low 5-hydroxyindolacetic acid 5-hydroxyindoleacetic acid (5-HIAA) is a metabolite of serotonin. Low cerebrospinal fluid 5-HIAA is associated with suicidal behavior.
dopamine agonists like ropinirole can induce what
mania like sxs
can you dx panic disorder after only one panic attack?
no An isolated panic attack can occur in many conditions, whereas a diagnosis of panic disorder requires recurrent unprovoked (ie, spontaneous) panic attacks followed by excessive concern or a change in behavior aimed at avoiding further attacks. This patient has had an isolated panic attack precipitated by fears of inadequacy after his separation.
A 33-year-old woman comes to the office due to weight gain and low self-confidence. She says, "I've always had trouble with my weight and mood swings. I've gained 11 pounds [5 kg] in the last 2 years and feel horrible about myself. I go through this cycle in which I feel good, stick to a diet, and exercise for a couple of weeks, but then my mood gets really down. I start eating junk food and feel bloated until I get my period." The patient is also upset about a recent fight with her best friend, saying "I blame myself because I am much more irritable before my period, and I lashed out at her for no reason. The following week I felt much better, but the damage was done." The patient has struggled with moodiness and being overweight for most of her adult life. She says, "I hate when I feel this way because, generally, I'm a pretty upbeat person." Physical examination and laboratory evaluation are unremarkable. BMI is 29 kg/m2. Which of the following is the most likely diagnosis?
premenstrual dysphoric disorder
Projection
psychoanalytic defense mechanism by which people disguise their own threatening impulses by attributing them to others