Internal Medicine: Behavioral Health

Advanced Directives

Legal documents completed while the patient has capacity, which is made up of the living will and healthcare power of attorney

-Living will → written statement of treatment preferences

-POA → naming specific person to make healthcare decisions if they are not able to

Generalized Anxiety Disorder

Persistent and excessive worry pertaining to multiple events or domains that continues for 6 months or more

-Presentation: must have 3+ of the following symptoms of restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbance. Worry is difficult to control and out of proportion to actual circumstances

-Dx: clinical by DSM criteria, GAD-7

-Tx: SSRI + CBT

Buspirone

What is an effective adjunct treatment for generalized anxiety disorder that takes 2-4 weeks and is appropriate for patients with a history of substance use?

SSRI

What is the medication of choice for GAD?

Panic Disorder

Recurrent, unexpected panic attacks with at least one month or more of worry or avoidant behavior following at least one attack. The symptoms develop abruptly and peak within 10 minutes

-Presentation: panic attacks with 4+ of the symptoms of palpitations, sweating, trembling, shortness of breath, chest pain, nausea, dizziness, derealization, fear of losing control, fear of dying, paresthesias, chills/hot flashes, anticipatory anxiety, agoraphobia

-Dx: DSM-5 criteria and rule out medical causes

-Tx: SSRI + CBT, benzos for acute attacks

Specific Phobia

Intense, irrational fear of a specific object or situation

-Dx: DSM-V criteria is diagnostic

-Tx: exposure therapy is first line

Social Phobia

Marked fear of social or performance situations where the person fears scrutiny or humiliation, which typically begins in childhood or adolescence

-Dx: DSM-V criteria

-Tx: SSRI + CBT, beta blockers for performance anxiety

Agoraphobia

Fear and avoidance of situations where escape might be difficult or help unavailable during a panic attack, typically involving crowds, open spaces, public transportation, or being outside the home alone

-Dx: clinical with DSM-V criteria

-Tx: SSRI + CBT

Bipolar 1 Disorder

A manic episode with or without major depressive episodes, where the mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or social activities

-Presentation: distractibility, impulsivity / indiscretion, grandiosity, flight of ideas, activity increase, sleep decreased, talkativeness

-Dx: > 1 manic episode lasting > 7 days or requiring hospitalization

-Tx: lithium, valproate, olanzapine / aripiprazole, or carbamazepine

>1.5

A lithium level of what can cause toxicity, which presents as a coarse tremor, ataxia, confusion, and seizures?

Antidepressants

What class of medications should be avoided in patients with bipolar disorder, due to the risk of causing mania?

Bipolar II Disorder

Disorder classified by the presence of hypomania and depression

-Dx: > 1 hypomanic episode + > 1 major depressive episode and NO MANIC EPISODES

-Tx: lithium, add quetiapine for depressive episodes

Cyclothymic Disorder

Chronic, fluctuating mood disturbance with numerous periods of hypomanic symptoms and depressive symptoms that never meet full criteria for a hypomanic, manic, or depressive episode. This lasts > 2 years

-Dx: clinical per DSM-5

-Tx: mood stabilizers (lithium / valproate), psychotherapy, avoid antidepressant monotherapy

Child Abuse

Deliberate action harmful to a child’s physical, emotional, or sexual well-being where the injury is not adequately explained by or is inconsistent with the history given

-Red Flag Presentations: posterior rib fractures, metaphyseal corner fractures, spiral fracture in a non-ambulatory patient, multiple fractures of different ages, retinal hemorrhages, immersion burns, cigarette burns

-Dx: history and physical, skeletal survey for children up to age 2, head CT, CBC/coagulation studies, SANE exam

-Tx: immediate medical care, mandatory reporting, STI management

Shaken Baby Syndrome

Retinal hemorrhages + subdural hematoma + encephalopathy in an infant

Neglect

Child is unattended or allowed to engage in potentially harmful behaviors, which may manifest as failure to thrive, poor hygiene, or lack of medical care

Elder Abuse

Physical or psychological mistreatment, financial exploitation, or neglect of elderly individuals that is most commonly perpetrated by a caregiver or family member

-Presentation: similar to child abuse

-RF: caregiver stress, substance use, hx of abuse, social isolation, shared living arrangements, financial dependence

-Dx: interview with the elder alone

-Tx: immediate medical care, mandatory reporting to APS

Delirium

Acute, fluctuating disturbance of attention and awareness caused by an underlying medical condition that is reversible

-Presentation: acute onset of inattention, fluctuating symptoms, and disturbed cognition (disorientation, memory deficit, perceptual disturbances)

-RF: older age, baseline dementia, multiple comorbidities, polypharmacy, ICU. Commonly precipitated by infection, drugs, metabolic derangements, alcohol withdrawal, pain

-Dx: CAM, identify underlying cause

-Tx: address underlying cause, non-pharmacologic interventions first, low dose antipsychotics

Benzodiazepines

What class of anti-anxiety medication should be avoided in a patient with delirium, due to their ability to worsen delirium?

Major Depressive Disorder

Presence of 5+ symptoms for > 2 weeks nearly every day and at least one of the symptoms is depressed mood or anhedonia

-Presentation: sleep disturbances, interest loss, guilt, energy loss or fatigue, concentration difficulties, appetite changes, psychomotor agitation, suicidal thoughts or behaviors

-Dx: > 5 symptoms for > 2 weeks

-Tx: SSRI with an increase in dosage q3-4 weeks until symptoms are in remission, see within 1-2 weeks of starting medication, ECT if refractory

Dysthymia

Chronic depressed mood for > 2 years, where the individual has never been without the symptoms for more than 2 months at a time

-Presentation: poor appetite, overeating, insomnia, low energy, low self esteem, poor concentration, feelings of hopelessness. No hx of mania or hypomania

-Dx: depressed mood for > 2 years with > 2 symptoms

-Tx: SSRI, therapy, exercise

Anorexia Nervosa

Eating disorder characterized by self-imposed energy restriction leading to significantly low body weight, intense fear of weight gain, and distorted body image

-Presentation: significantly low body weight, intense fear of gaining weight, distorted body image, amenorrhea, bradycardia, hypotension, hypothermia, lanugo, osteoporosis/osteopenia

-Associated with bradycardia, prolonged QT, dysrhythmias, hypokalemia, hyponatremia

-Dx: clinical, supported with labs

-Tx: nutritional rehabilitation + therapy

Hypophosphatemia

What metabolic disturbance is associated with refeeding syndrome in patients with anorexia nervosa?

Bulimia Nervosa

Eating disorder characterized by recurrent binge eating followed by compensatory behaviors, with patients typically maintaining a normal body weight

-Presentation: Russell sign, parotid gland enlargement, dental erosions, normal body weight, hypokalemia, hypochloremia, metabolic alkalosis, petechial hemorrhages

-Dx: clinical diagnosis

-Tx: restore nutritional state, fluoxetine, CBT

Bupropion

What medication should be avoided in patients with bulimia due to the lower seizure threshold?

Binge Eating Disorder

Most common eating disorder, characterized by recurrent binge eating without compensatory behaviors

-Presentation: eating rapidly until uncomfortably full, eating large amounts when not hungry, eating alone out of embarrassment, feeling guilty afterwards, obesity/overweight

-Dx: clinical diagnosis

-Tx: CBT + Vyvanse + SSRI

Acetaminophen, NSAIDs

According to the WHO analgesic ladder, what is the treatment of choice for mild pain?

Weak opioids

According to the WHO analgesic ladder, what is the treatment of choice for moderate pain?

Morphine, Oxycodone, Hydromorphone

According to the WHO analgesic ladder, what three pain medications are the treatment of choice for severe pain?

Gabapentin

What is the first-line treatment for neuropathic pain?

Opioids

What class of analgesics should be used in cancer pain, acute severe pain, and palliative care?

Schizophrenia

Chronic psychotic disorder characterized by positive symptoms (delusions, hallucinations, disorganized speech) and negative symptoms (blunted affect, alogia, avolition) for > 6 months with significant functional impairment

-Associated Risks: tardive dyskinesia, neuroleptic malignant syndrome, metabolic syndrome, and significantly elevated suicide risk

-Dx: DSM-V criteria of > 2 symptoms for > 6 months, rule out substance induced psychosis

-Tx: atypical antipsychotics, clozapine if treatment resistant

Atypical Antipsychotics

What drug class is the treatment of choice for schizophrenia?

Clozapine

What medication is reserved for treatment-resistant schizophrenia and uniquely reduces suicidality, requiring ANC monitoring?

Agranulocytosis

What is the most serious side effect of clozapine?

Brief Psychotic Disorder

>1 psychotic symptom lasting > 1 day but < 1 month, with full return to baseline

-Often follows a marked stressor

-Dx: clinical

-Tx: short course of antipsychotic + support

Schizophreniform Disorder

Schizophrenia symptoms lasting 1-6 months

-Dx: clinical

Schizoaffective Disorder

A major mood episode concurrent with schizophrenia, plus > 2 weeks of psychosis without prominent mood symptoms

-Dx: clinical

-Tx: antipsychotic + mood stabilizer or antidepressant

Delusional Disorder

>1 delusion for > 1 month with otherwise normal functioning and no other psychotic symptoms

-Dx: clinical

-Tx: antipsychotic trial + psychotherapy

Insomnia

Persistent difficulty with sleep initiation, maintenance, or early morning awakening, resulting in daytime impairment at least 3 nights per week for > 3 months

-Presentation: difficulty falling asleep, frequent nighttime awakenings, early waking, and non-restorative sleep, often leading to fatigue, poor concentration, irritability ,and mood disturbances

-RF: stress, anxiety, depression, chronic pain, medical conditions, and use of stimulants or certain medications

-Dx: clinical

-Tx: CBT + sleep hygiene + doxepin + z-drugs

Narcolepsy

Chronic sleep disorder of CNS hypocretin (orexin) deficiency in the lateral hypothalamus characterized by uncontrollable episodes of sleep during the day and premature entry into REM sleep

-Presentation: excessive daytime sleepiness, cataplexy, sleep paralysis, hypnagogic hallucinations

-Dx: PSG + MSLT

-Tx: scheduled naps, Modafinil for daytime sleepiness, sodium oxybate for cataplexy

Parasomnias

Dissociated sleep states consisting of partial arousals during the transition between wakefulness, NREM sleep, and REM sleep

-Dx: clinical, PSG to confirm RBD

-Tx: sleep hygiene, safety measures, clonazepam or melatonin

NREM

First third of the sleep period, where the patient is unresponsive and amnestic

Somnambulism

Repeated episodes of rising from bed and walking about during NREM sleep

-Presentation: blank, staring face and is relatively unresponsive to others. Can only be awakened with great difficulty

-Do not forcibly awaken, redirect gently

Night Terrors

Abrupt arousal from sleep with a panicky scream, intense fear, and autonomic arousal

-Presentation: tachycardia, diaphoresis, mydriasis, rapid breathing, unresponsive to comforting and amnestic to the episode

REM

Later portions of the sleep period, where patient recalls vivid and frightening dreams

RBD

Repeated episodes of vocalization and complex motor behaviors during REM sleep, where the patient “acts out” dreams

-Dx: PSG shows increased muscle tone during REM sleep, associated with Parkinson disease / Lewy body dementia / multiple system atrophy

-Tx: safety modifications, clonazepam or melatonin, neurology referral

Alcohol Use Disorder

Problematic pattern of alcohol use leading to clinically significant impairment or distress

-Screening: AUDIT-C, CAGE questionnaire

-Recommended Limits: < 4 drinks / day in males or < 14 week, women < 3 drinks / day or < 7 / week

6-24

During which hours of alcohol withdrawal would the following symptoms be present?

-Tremor, anxiety, diaphoresis, tachycardia, hypertension, nausea/vomiting

12-24

During which hours of alcohol withdrawal would the following symptoms be present?

-Alcoholic hallucinosis with intact orientation and normal vitals

12-48

During which hours of alcohol withdrawal would the following symptoms be present?

-Withdrawal seizures

48-96

During which hours of alcohol withdrawal would the following symptoms be present?

-Delirium tremens

CIWA

What scale is used to assess the severity of alcohol withdrawal?

Wernicke’s Encephalopathy

Thiamine (b1) deficiency → confusion, ataxia, ophthalmoplegia

Korsakoff Syndrome

Thiamine deficiency causing anterograde amnesia with confabulation → irreversible if untreated

Naltrexone

What medication can be used to reduce alcohol cravings?

-Opioid antagonist

Acamprosate

What medication helps reduce anxiety and restlessness of early sobriety from alcohol?

-Dose-reduce in renal impairment

Disulfiram

What medication inhibits acetaldehyde dehydrogenase, leading to aversive conditioning in alcohol use disorder?

Opioids

What class of drug is likely causing this intoxication?

-Miosis, respiratory depression, CNS depression, euphoria, constipation, nausea, track marks

Naloxone

What medication is a competitive opioid receptor antagonist, therefore used as the reversal agent in opioid intoxication?

Benzodiazepines

What class of medication is being described?

-MOA: GABAa, increases frequency of Cl channel opening

-Intoxication: respiratory depression, hypotension, amnesia, ataxia, stupor/somnolence, coma, death

-Withdrawal: rebound anxiety, seizures, tremor, death

-Tx of intoxication: Flumazenil

-Tx of withdrawal: long acting taper

Beta blockers

What class of medication should be avoided in cocaine intoxication?

CT

What should be done annually for lung cancer screening in adults aged 50-80 years with a > 20 pack-year smoking history who currently smoke or quit within the past 15 years?

Varenicline

Partial nicotine receptor agonist that mediates partial reward while blocking nicotine’s full effect

-Highest cessation success rate of all pharmacotherapy

Adjustment Disorder

Disproportionate emotional or behavioral responses to an identifiable stressor that begin within 3 months of the stressor and resolve within 6 months after the stressor has ended

-Stressors: divorce, job loss, illness, financial difficulties, relocation, new school or job, bereavement

-Dx: requires symptoms within 3 months of a stressor, symptoms are out of proportion to the stressor, symptoms do not persist beyond 6 months, and does not meet the criteria for another mental disorder

-Tx: therapy + short term SSRI

Grief

Feelings of sadness, anger, guilt, and yearning, accompanied by sleep disturbances, loss of appetite, and difficulty concentrating. The emotions fluctuate and come in waves

-Typically response in 6-12 months

Prolonged Grief Disorder

Persistent, intense grief symptoms lasting > 12 months in adults that cause significant functional impairment

-Features include persistent preoccupation with the deceased, difficulty accepting the loss, bitterness or anger, and avoidance of reminders of the loss

-Dx: DSM-V criteria

-Tx: therapy, SSRIs can be added on

PTSD

Development of four symptom clusters following exposure to actual or threatened death, serious injury, or sexual violence, with symptoms persisting for more than 1 month

-Symptoms: recurrent distressing memories, flashbacks, dissociative reactions, nightmares, avoidance, persistent negative beliefs about self or world, anhedonia, blame of self or others, hypervigilance, sleep disturbance

-Dx: clinical per DSM-5 criteria, symptoms must persist more than 1 month

-Tx: SSRI, trauma focused CBT, prazosin for nightmares

Acute Stress Disorder

Development of severe anxiety, dissociation, and other symptoms occurring within 3 days to 1 month after exposure to an extreme traumatic stressor

-Presentation: intrusion, negative mood, dissociation, avoidance, and arousal symptoms. Big risk factor for PTSD

-Dx: >9 symptoms from 5 categories beginning after trauma and lasting 3 days to 1 month

-Tx: trauma focused CBT, SSRI could be added on