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Psychiatry

Q: What type of therapy is used for schizophrenia?

Behavioral therapy or family and group therapy

Q: What is the ophthalmologic side effect of thioridazine?

Irreversible retinal pigmentation with high doses

112 important questions on Psychiatry

First generation antipsychotics

Low-potency: More anticholinergic and antihistamine side effects, QT prolongation, agranulocytosis, higher risk of seizure, chlorpromazine (bluish skin), thioridazine (retinitis pigmentosa)
Midpotency: Trifluoperazine, loxapine (seizure), thithixene, perphenazine
High-potency: Greater risk of extrapyramidal sxs, haloperidol, fluphenazine, pimozide (cardiac)
D2 antagonists
Effective against positive symptoms
Side effects: extrapyramidal sxs, neuroleptic malignant syndrome, tardive dyskinesia

Tyramine reaction/hypertensive crisis

Due to ingesting tyramine containing foods while on MAOI
Sxs: Hypertension, headache, neck stiffness, sweating, nausea, vomiting, visual problems, stroke, death
Tx: Phentolamine

Negative symptoms of schizophrenia

Anhedonia: Inability to feel pleasure
Flat affect
Alogia: Poverty of speech
Avolition
Poor attention

Dopamine pathways causing side effects of neuroleptics

Tuberoinfundibular: Causes hyperprolactinemia-->gynecomastia, galactorrhea, and menstrual irregularities
Nigrostriatal: Extrapyramidal side effects, such as tremor, slurred speech, akathisia, and dystonia

Neurotransmitter abnormalities in schizophrenia

Elevated dopamine, serotonin, and norepinephrine
Decreased GABA and glutamate/NMDA receptors

Factors associated with a good schizophrenia prognosis

Later onset, good social support, positive symptoms, mood symptoms, acute onset, female sex, few relapses, good premorbid functioning

Second generation antipsychotics

Risperidone (has injectable form), clozapine (more effective, agranulocytosis, seizures, more anticholinergic, only antipsychotic that decreases the risk of suicide), quetiapine (sedating, orthostatic hypotension), olanzapine (weight gain), aripiprazole (partial D2 agonist, akathisia), ziprasidone, paliperidone (has injectable form), asenapine, iloperidone
Serotonin and dopamine antagonists
Lower incidence of extrapyramidal side effects, but higher risk for metabolic syndrome
May take 4 weeks to see effects

Major side effect of clozapine

Agranulocytosis, requires weekly blood draw for the first 6 months, discontinue if absolute neutrophil count <1500

What type of therapy is used for schizophrenia?

Behavioral therapy or family and group therapy

What is the ophthalmologic side effect of thioridazine?

Irreversible retinal pigmentation with high doses

What is the ophthalmologic side effect of chlorpromazine?

Deposits in the lens and cornea

Which non-psychiatric meds can exacerbate psychosis?

Beta blockers and digoxin

What fraction of patients with schizophreniform disorder progress to schizoaffective disorder or schizophrenia?

2/3

Treatment of schizoaffective disorder

Hospitalization
Psychotherapy
Antipsychotic and mood stabilizer

Treatment of brief psychotic disorder

Hospitalization
Psychotherapy
Antipsychotic and/or benzodiazepine

Can a person with borderline personality disorder have a brief psychotic disorder?

No, transient, stress-related psychotic episodes are considered part of the BPD

Delusional disorder criteria

Nonbizarre, fixed delusion for 1 month that does not significantly impair function

Types of delusions in delusional disorder

Erotomanic
Grandiose
Somatic
Persecutory
Jealous
Mixed

Treatment of delusional disorder

Very difficult to treat
Psychotherapy
Antipsychotics are not usually effective, but still must start

Treatment of shared psychotic disorder

Separate patient from the person who is the source of the shared delusions
Psychotherapy
Start antipsychotic if sxs do not improve 1-2 weeks after separation

What percentage of manic patients have psychotic symptoms?

75%

What is a mixed episode?

Criteria for manic episode and major depressive episode are both met and symptoms are present for at least 1 week.
Irritability is the typical mood state.
Tends not to respond as well to lithium, but anticonvulsants are often helpful.

How does hypomania differ from mania?

Lasts at least 4 days (instead of 7)
No marked impairment in social or occupational functioning
No hospitalization or psychotic features

Medical causes of manic episode

Wilson's disease
Temporal lobe epilepsy
Hyperthyroidism
Neoplasm
HIV

What is the most common sleep disturbance in MDD?

Initial and terminal insomnia

What is used to measure the severity of depression?

Hamilton Rating Score

What percentage of patients with MDD commit suicide?

15% (highest rate of any disorder)

What are the types of MDD?

-Melacholic: Anhedonia, early morning awakening, psychomotor disturbance, excessive guilt, anorexia
-Atypical: Hypersomnia, hyperphagia, reactive mood, leaden paralysis, hypersensitivity to interpersonal rejection
-Catatonic: Catalepsy, purposeless motor activity, extreme negativism or mutism, bizarre postures, echolalia (has a great response to ECT)
-Psychotic: Delusions, hallucinations

Side effects of lithium

Weight gain, tremor, GI, fatigue, arrhythmias, seizures, goiter, leukocytosis, coma, polyuria, polydipsia, alopecia, metallic taste

Which disorder has the highest genetic link?

Bipolar I

What is the best treatment for manic in a pregnant woman?

ECT--can be used safely throughout pregnancy

Treatment of postpartum mania

Lithium + antidepressant for prophylaxis (cannot breastfeed)

Criteria for dysthymic disorder diagnosis

-Depressed mood for the majority of 2 years
-At least 2 of the following symptoms (CHASES): Poor concentration, hopelessness, poor appetite, insomnia or hypersomnia, low energy, low self-esteem
-Not without symptoms for more than 2 months at a time
-No major depressive episode

Prognosis of dysthymic disorder

20% develop MDD
20% develop bipolar
>25% have lifelong sxs

Treatment of cyclothymic disorder

Same as bipolar tx

Treatment of adjustment disorder

Supportive psychotherapy

What are medical causes of anxiety disorders?

Hyperthyroidism
B12 deficiency
Hypoxia
Neurologic disorders
CV disease
Anemia
Pheochromocytoma
Hypoglycemia

Which medical conditions are associated with panic attacks?

Mitral valve prolapse
Asthma
Pulmonary embolus
Angina
Anaphylaxis

What can induce a panic attack?

Caffeine, nicotine, or hyperventilation

Treatment of panic disorder

High dose of paroxetine or sertraline. Start at low dose and slowly titrate up, because anxiety may be worsened at first.
Other options: Clomipramine, imipramine, benzodiazepines, relaxtion training, biofeedback, cognitive therapy, insight-oriented psychotherapy
Treat for at least 8 months to prevent relapse

What is associated with agoraphobia?

Panic disorder, treating panic disorder often resolves agoraphobia

What is associated with phobias?

Substance disorders and MDD

What is the difference between shyness and social phobia/social anxiety disorder?

Social phobia causes a complete avoidance of scrutiny and exaggerated fears in day-to-day life that cause significant distress and/or disability

OCD is more common in people who have relatives with what disorder?

Tourette syndrome

How long do sxs have to be present to diagnose GAD?

6 months, must have 3/6 symptoms

Average onset of GAD

Before age 20

What is axis IV?

Psychosocial stressors

Personality disorder criteria

Abnormal behavior manifested in 2/4 of the following: Cognition, affect, personal relations, impulse control
Pattern is pervasive and inflexible
Onset no later than young adulthood
Causes impairment in daily functioning

What should be corrected to prevent seizures in alcohol withdrawal?

Hypomagnesemia

How do you treat seizures in alcohol withdrawal?

Benzodiazepine (no long-term treatment with an anticonvulsant)

Medications for alcohol dependence

-Disulfiram: Blocks aldehyde dehydrogenase, contraindicated in CV disease, pregnancy, and psychosis, monitor liver function
-Naltrexone: Opioid receptor blocker that decreases cravings
-Acamprosate: GABA agonist, prevents relapse in pts who have stopped drinking, contraindicated in severe renal disease
-Topiramate: GABA agonist, decreases cravings

What is the neurotransmitter abnormality in cocaine use?

Increased dopamine due to decreased reuptake

What are he neurotransmitter abnormalities in alcohol use?

Activation of GABA and serotonin
Inhibition of glutamate and voltage-gated Ca channels

Management of cocaine intoxication

Reassurance, benzodiazepines, antipsychotics

The heavy use of which drug may mimic schizophrenia?

Amphetamines

Symptoms of amphetamine abuse

Dilated pupils, increased libido, perspiration, respiratory depression, and chest pain

What are signs of chronic amphetamine use?

Acne and accelerated tooth decay ("meth mouth")

How do amphetamines affect neurotransmitters?

Block reuptake and facilitate release of dopamine and norepinephrine

What are substituted/designer amphetamines?

MDMA/ecstasy or MDEA/eve
Facilitate release of DA, NE, and 5-HT
Have both stimulant and hallucinogenic properties

What effect does PCP have on neurotransmitters?

Antagonizes NMDA glutamate receptors and activates dopamine receptors

PCP intoxication symptoms

rage (increases violence), erythema, dilated pupils, tactile and visual hallucinations, delusions, amnesia, nystagmus (only cause of rotary nystagmus), skin dryness, synesthesia, high tolerance to pain

Treatment of PCP intoxication

Benzodiazepines or antipsychotics

What effect do barbiturates have on neurotransmitters?

Potentiate the effects of GABA by increasing the duration of chloride channel opening

What is gamma-hydroxybutyrate (GHB)?

A sedative-hypnotic that produces memory loss, respiratory distress, and coma and is commonly used as a date rape drug

Withdrawal from which drug has the highest mortality rate?

Barbiturates

Treatment of BDZ overdose

Flumazenil, a short-acting BDZ antagonist
Activated charcoal or gastric lavage if drug was ingested within last 4-6 hours

Treatment of barbiturate overdose

Alkalinize urine with sodium bicarbonate to promote renal excretion
Activated charcoal or gastric lavage if drug was ingested within last 4-6 hours

Opioid intoxication presentation

Constricted pupils, nausea, vomiting, sedation, decreased pain perception, GI motility, respiratory depression. Meperidine (demerol) dilates pupils and can cause serotonin syndrome when taken with MAOI.

Treatment of opioid overdose

Naloxone or naltrexone (opioid antagonists)

Opioid withdrawal symptoms

Insomnia, lacrimation, rhinorrhea, yawning, sweating, piloerection, nausea/vomiting, fever, dilated pupils, hypertension, tachycardia
Not life-threatening

Treatment of opioid withdrawal

Clonidine for autonomic sxs
NSAIDs
Dicyclomine (anticholinergic) for abdominal cramps
Buprenorphine or methadone for detox
COWS: Scale to monitor severity of withdrawal

Treatment of opioid dependence

Methadone: Opioid receptor agonist, gold standard for pregnant women, can cause QT prolongation, so do EKG in patients with cardiac disease
Buprenorphine: Partial opioid receptor agonist, safer than methadone
Suboxone=buprenorphine + naloxone
Naltrexone: Opioid antagonist, good choice for highly motivated pts (health care professionals)

What do cannabinoid receptors inhibit?

Adenylate cyclase

What is the pill form of THC?

Dronabinol

Symptoms of inhalant intoxication

Psychosis, nausea/vomiting, nystagmus, tremor, hyporeflexia, ataxia, slurred speech, hypoxia, stupor
Overdose may cause respiratory depression or cardiac arrhythmia
Long-term use may cause permanent CNS, PNS, liver, kidney, heart, and muscle damage

How does caffeine affect neurotransmitters?

It is an adenosine antagonist that causes an increase in cAMP
Increases dopamine

Treatment of nicotine dependence

Varenicline: Alpha4beta2 nicotinic cholinergic receptor partial agonist that prevents withdrawal sxs
Bupropion: Partial agonist at nicotinic cholinergic recepors and inhibitor of DA reuptake that helps reduce withdrawal sxs
Nicotine replacement therapy
Behavioral counseling should be a part of every treatment

What presents with dementia, gait apraxia, urinary incontinence, and dilated cerebral ventricles?

Normal pressure hydrocephalus

What presents with dementia, diminished position and vibration sensation, and argyll robertson pupils?

Neurosyphilis
Argyll robertson pupils=accommodation response present, but response to light is absent

What is the neurotransmitter abnormality in Alzheimer's?

Decreased acetylcholine due to a loss of noradrenergic neurons in the basal ceruleus and decreased choline acetyltransferase (required for acetylcholine synthesis)

How is Alzheimer's diagnosed?

It is a clinical diagnosis
Neuropsychological testing can be useful, but a definitive diagnosis can only be made postmortem

What are the genes involved in Alzheimer's?

Presenelin I, presenelin II, amyloid precursor protein, apolipoprotein e4

Which type of stroke can produce symptoms of schizophrenia, bipolar disorder, and depression?

Frontal lobe stroke

What are lateralizing signs?

Spasticity, hemiparesis, ataxia, pseudobulbar palsy (emotional lability, abnormal speech cadence, dysphagia, and abnormal reflexes)
Seen in vascular dementia

Treatment of vascular dementia

Chlinesterase inhibitors

Etiology of lewy body dementia

Lewy bodies and lewy neurites (aggregates of alpha-synuclein) in the basal ganglia

Clinical manifestations of lewy body dementia

waxing and waning of cognition
visual hallucinations
paranoid delusions
parkinsonism (onset of dementia within 12 months of Parkinson sxs)
sensitivity to neuroleptics
REM sleep behavior disorder

Treatment of lewy body dementia

Cholinesterase inhibitors help improve visual hallucinations
Dopamine agonists improve cognition
Atypical neuroleptics help delusions and agitation
Clonazepam treats REM sleep behavior disorder

Which gene is associated with Pick disease/frontotemporal dementia?

Mutation in progranulin or MAPT gene

Clinical manifestations of frontotemporal dementia

Change in personality and social conduct
Disinhibited
Echolalia
Overeating and oral exploration of inanimate objects
Lack emotional warmth, empathy, or sympathy
Poor insight
Cognitive deficits in attention, abstraction, planning, and problem solving, but preservation of memory, language, and spatial functions

Treatment of frontotemporal dementia

Anticholinergic medications and antidepressants can improve behavior

Brain abnormality in Parkinson disease

Neuronal loss in substantia nigra, which provides DA to basal ganglia
Senile plaques and neurofibrillary tangles (like Alzheimer's)

How do people get Creutzfeldt-Jakob disease?

Affects older adults and is inherited, sporadic, or acquired (eg. through corneal transplant)

How is Creutzfeldt-Jakob disease diagnosed?

EEG shows generalized sharp waves
2 of the following: Myoclonus, cortical blindness, ataxia, muscle atrophy, mutism (doesn't speak)

HAM side effects

AntiHistamine: Sedation, weight gain
AntiAdrenergic: Hypotension
AntiMuscarinic: Dry mouth, blurred vision, urinary retention
Found in TCAs and low-potency antipsychotics

Which psych meds can cause hyperprolactinemia?

High-potency traditional antipsychotics and risperidone

Antidepressant withdrawal symptoms

Dizziness, headache, nausea, insomnia, malaise

Treatment of TCA overdose

IV sodium bicarbonate

What needs to be monitored when on lithium?

Lithium level, creatinine, and thyroid function

Which antipsychotics are approved for the treatment of mania?

quetiapine, olanzapine, aripiprazole, risperidone, and ziprasidone

What are the neuroimaging findings in autism, OCD, panic disorder, PTSD, and schizophrenia?

Autism: Increased total brain volume
OCD: Abnormalities in orbitofrontal cortex and striatum
Panic disorder: Decreased volume of amygdala
PTSD: Decreased volume of hippocampus
Schizophrenia: Enlargement of cerebral ventricles

Treatment of illness anxiety disorder

Discuss current emotional stressors
Psychotherapy

Treatment of acute mania

Antipsychotics have a more rapid onset of action: Risperidone, olanzapine, quetiapine, aripiprazole, and haloperidol
Lithium (avoid in renal disease)
Valproate (avoid in liver disease)
Carbamazepine (increases metabolism of other drugs)
Benzodiazepines can treat insomnia and agitation

Survivors of sexual assault are at risk for which psychiatric illnesses?

PTSD, depression, and suicidality

Which BZDs can be used in patients with liver disease?

lorazepam, oxazepam, and temazepam, because they are not metabolized by the liver

Medications that may cause sxs of depression

Antihypertensives, antiparkinsonian agents, corticosteroids, calcium channel blockers, NSAIDs, antibiotics, peptic ulcer drugs

What psych sxs can procainamide and quinidine cause?

confusion and delirium

What psych symptom can isoniazid cause?

Psychosis

What is deep brain stimulation used for?

chronic pain, Parkinson disease, tremor, dystonia, and affective disorders

Who qualify as emancipated minors?

Minors that are self-supporting, in the military, married, or have children

What is parens patriae?

The legal principle that protects citizens who cannot care for themselves

What makes a defendant competent to stand trial?

Understand the charges, be familiar with courtroom personnel, have the ability to work with an attorney and participate in the trial, and understand possible consequences

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STEP 2

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