PA Psychiatry EOR

SIGECAPS of Depression

Sleep disturbances

Interests are ↓

Guilt

Energy is ↓

Concentration is ↓

Appetite is ↓

Psychomotor Agitation

Suicidal thoughts

Major depressive disorder

Depressed Mood or Anhedonia

Dx: 5 or more of the SIGECAPS Sxs for > 2 wks effecting normal function

Tx:

SSRI or SNRI > TCA/MAOi > ECT

S/Es of SSRIs

Sexual Dysfunction

Wt gain

Anxiety

Nausea

SHIVERS of Serotonin Syndrome

Shivering

Hyperreflexia

Increased temp (fever)

Vitals, unstable

Encephalopathy

Restless

Sweating

Tx: Cyproheptadine

1st line Tx of depression in children

Fluoxetine (Prozac)

- Longest Half-life of all SSRIs

- Caution ↑ SI in the 1st 2 weeks of use

SSRI known to cause QT interval prolongation

Citalopram (Celexa)

Screening tool or questionnaire used in clinic for:

Bipolar Disorder

Major Depression Disorder

BPD: The Mood Disorder Questionaire

MDD: Beck Depression Inventory

Atypical Antidepressant which inhibits DA reuptake, has less sexual and wt-related side effects, but decreases seizure threshold

Bupropion

smoking cessation

SNRI Trade Names

Effexor

Pristiq

Cymbalta

Fetzima

SNRI Drug Names

Venlafaxine

Desvenlafaxine

Duloxetine

Levomilnacipran

TCA antidepressants

special characteristics

Desipramine - selective NET inhibitor

Imipramine - tx of enuresis

Amitriptyline- tx of neuromuscular pain

Nortriptyline

QT Interval prolongation = arrythmias

MAO Inhibitors used as antidepressants

Take Pride in Shanghai

Tranylcypromine

Phenelzine

Selegiline

Antidepressant which inhibits MAO b mechanisms and can ↑ dopamine concentrations

Selegiline

- Can be added in Tx of Parkinson's

Suicide Risk Assessment

SAD PERSONS

0-4 Low

5-6 Moderate

7-10 High

Sex (males)

Age (biphasic)

Depression

Previous attempts

Excessive substance abuse

Rational thinking, loss

Social support lacking

Organized plan

No spouse

Sick (chronic)

DIG FAST of Bipolar

Distractibility

Irresponsibility

Grandiosity

Flight of ideas

Agitation

Sleep disturbances

Talkative

Bipolar II

Dx:

MDD + Hypomania (DIG ST) < 1wk

Function in not fully compromised

Tx: Risperdal

Bipolar I Disorder

Dx:

MDD > 2wks + Mania (DIG FAST) > 1wk

Inhibits function of daily living

Tx:

Acute Manic Episode: Antipsychotic + Mood Stabilizer

Chronic Cycle Episodes: Mood Stabilizer

Mood Stabilizers to Tx Bipolar Disorder (4)

Lithium

Valproic Acid (Depakote)

Carbamazepine (Tegretol)

Lamotrigine (Lamictal)

Side Effects of Lithium

LMNOP

Lithium Side Effects

Movements (tremors)

Nephrotoxicity

hypOthyroid

Pregnancy problems (Ebstein's Anomoly)

Mood Stabilizer used to Tx Bipolar I Disorder w/ predominant depressed state and may cause an itchy rash or SJS

Lamotrigine (Lamictal)

Tx of Bipolar I Disorder by ↑ GABA and ↓ Na+

C/I in pregnancy = ↓ Folate

Hepatic Necrosis

C/I with ASA or Warfarin = ↓ protein binding availability

Valproic Acid (Depakote)

Mood Stabilizer & Anticonvulsant especially helpful to Tx the cycling of Bipolar Disorder but may cause.......

Carbamazepine (Tegretol)

Agranulocytosis

Anticonvulsant, not FDA approved for the use as a mood stabilizer, causes wt loss, ↓ cognition, word searching, ↑ risk of kidney stones and metabolic acidosis

Topiramate (Topamax)

Causes rapid cycling in Bipolar Disorder pts

The use of antidepressants is C/I in Bipolar Disorder

- leads to mania

Persistent depressive disorder (Dysthymic disorder)

Dx: (MDD Lite)

<5 SIGECAPS criteria for >2 yrs

Still able to function

Tx: Psychotherapy > SSRIs

Failed medication criteria when using antidepressants to Tx MDD?

Noticeable change of Depressive Sx's in 2-6 weeks of Rx initiation

Cyclothymic disorder

Dx: (Bipolar II Lite)

Hypomania + Dysthymia >2 yrs

Sx free for <2 mo

Still able to function

Tx: Psychotherapy/CBT/Family Therapy

Premenstrual dysphoric disorder

PMS on an anger pill - affecting function

Major depressive disorder with peripartum onset

Dx:

>2wks of SIGECAPS

Within 4 weeks of childbirth

Tx: Rest & Support

Paroxetine

Sertraline - if breast feeding

Schizophrenia

Dx:

Auditory hallucinations

Delusions (fixed, false beliefs)

Sx's continue for at lease 6mo

Tx: Olanzapine

- S/E: ↑ wt gain unrelated to caloric intake

Prodromal Sx's of Schizophrenia

Social Isolation

New interest in religion/philosophy

Restlessness

Difficulty concentrating

Positive Sx's of Schizophrenia

Delusions

Hallucinations

Strange behaviors

Incoherent thought process

Grossly disorganized

Catatonic behavior

Negative Sx's of Schizophrenia

Flat affect

Decreased fluency

Decreased productivity of thought & speech

Social withdrawal

Decrease in goal-directed behavior

Rx for acute, agitated psychosis in schizophrenic pts

S/E's seen w/ chronic use

Typical 1st Generation Antipsychotics

-Haldol

-Chlorpromazine (corneal deposits)

-Thioridazine (retinal deposits)

S/E: ↑ risk of extrapyramidal symptoms or Neuroleptic Malignant Syndrome

Extrapyramidal Symptoms (EPS) seen w/ typical antipsychotics high affinity for D2 receptors

Dystonia "muscle" - hours

Akathisia "rustle" - days

Akinesia "hustle" - weeks

- Tardive Dyskinesia (haldol)

Neuroleptic Malignant Syndrome (NMS) seen w/ typical antipsychotic use

FEVER

Fever

Elevated enzymes (CPK)

Vitals are unstable (BP)

Encephalopathy

Ridgity (psudoparkinsonism)

Tx: Dantrolene + ice baths

Atypical antipsychotic known to ↓ rate of suicide in psychotic patients but can cause agranulocytosis

Clozapine (Clozaril) - 2nd Line Tx of schizophrenia due to S/E's

Absolute C/I to use: Hx of agranulocytosis or myocarditis

Erroneous beliefs

Grandeur thinking

Disorganized speech

Loose associations

Tangential responses

Delusions

Sx's of delusions w/o hallucinations = Delusional Disorder

Onset of schizophrenia based on gender

Men: 10-25 y/o

Women: 25-35 y/o

The earlier the onset = the worse the disease

Same sx's as Schizophrenia, but lasting only 1-6 months

Schizophreniform

Schizoaffective disorder

Schizophrenia + Major Depressive episode

(Hallucinations & Delusions persist even when not depressed)

Brief psychotic disorder

Sudden onset of psychotic symptoms

May include delusions, hallucinations, disorganized speech or behavior, or catatonic behavior

Sx's last >1 day, but <1mo

Alcohol-related CAGE Questions

1. Ever wanted to Cut down?

2. Ever get Annoyed when ppl criticize your drinking?

3. Ever feel Guilty about drinking?

4. Ever need an Eye-opener?

Stages of Alcohol-related disorder: Withdrawal

Stage 1 (up to 8hrs)

Anxiety, Insomnia, Nausea, Abd. pain

Stage 2 (1-3 days)

↑ BP, ↑ body temp w/ cold & hot sweats

Stage 3 (days - weeks)

Hallucinations, fever, seizure, agitation, DT's

Tx: Benzo's to prevent seizure

Tx of Stimulant-related disorders (Amphetamine-related disorders)

Cocaine

Amphetamines

Cathinones (bath salts)

Tx:

Mild - individual or group therapy > IOT > CBT

Moderate: intensive outpatient therapy 8-12 wks

Resistant: IOT + CBT + Desipramine

Pharmacotherapy for Opioid-related disorders

Tx Strategy:

Opioid agonist (Methadone/Buprenorphine) > Opioid antagonist (Naloxone)

Opioid withdrawal

Flu-like illness

Abdominal cramps

Diarrhea

Mydriasis

Pilo-erection

Yawning

Tx: Clonidine, Antiemetics

Panic disorder Sx's

Palpitations, pounding heart, tachycardia

Sweating, trembling, shaking, SOB or feeling of choking

Fear of dying, numbness, tingling, chills, or hot flashes

Acute Panic Attack (<1hr) Tx

vs

Panic Disorder (recurrent) Tx

Acute = Alprazolam (Xanax) or Clonazepam (Klonopin)

1st Line to prevent: SSRIs (Paroxetine, sertraline, fluoxetine) or Buspirone

8-12 months to avoid relapse

+ cognitive, insight-oriented, relaxations, or behavioral therapy

Anxiety towards places, situations in which escape may be difficult or embarrassing

Agoraphobia

Obsessive-compulsive personality

Perfectionist, Egocentric, Indecisive

Rigid thought patterns & need for control

Unable to finish tasks due to perfectionism

Tx: Psychotherapy > SSRIs

Obsessive-compulsive disorder

Presence of Obsessions (thoughts), Compulsions (behaviors), or Both

> 1 hr/day or cause impairment in daily functioning

Recurrent and persistent thoughts, urges, or images that are intrusive and unwanted which cause anxiety or distress

Obsessions

Post-traumatic stress disorder

Dx: 3 or more

Inability to recall an important aspect of the event

Avoidance of activities, places or people which trigger a memory

Attempts to avoid thinking or talking about the event

Feelings of detachment from others

Markedly decreased interest or anhedonia

Restricted range of affect

Increased state of arousal (insomnia, aggitation, can't concentrate, hypervigilant, ↑ startle response)

1st Line: SSRIs (sertraline, paroxetine)

- EMDR

2nd Line: TCAs (imipramine, desipramine, amitriptyline)

Buspirone, MAOIs, and anticonvulsants, such as carbamazepine and valproate

Crisis counseling (Support groups, family therapy, and cognitive or behavioral therapies) are recommended

Tx of PTSD

Generalized anxiety disorder

Genetic vulnerability

PTSD

Inability to cope

Excessive, uncontrollable worry > 6mo

Mediated by NE & Serotonin

3 or more to Dx GAD

Restlessness or hypervigilance

Easy fatigability

Irritability

Sleep disturbance

Muscle tension

Difficulty concentrating

Tx of GAD

Acute attacks of anxiety: Longer-acting Benzo - Lorazepam (Ativan)

1st Line to prevent: SSRIs (Paroxetine, Citalopram) + behavioral therapy

Benzodiazepines

Short TOM Medium CAAT Long DivorCe

Short

Triazolam (Halcyon)

Oxazepam (Serax)

Midazolam (Versed)

Medium

Clonazepam (Klonopin)

Alprazolam (Xanax)

Lorazepam (Ativan)

Temazepam (Resoril)

Long

Diazepam (Valium)

Chlordiazepoxide (Librium)

↑ frequency of Cl- channel opening = ↑ GABA

Impaired cognition

Motor incoordination

Dizziness

Drowsiness

Benzodiazepine Overdose

Tx: Flumazenil

Specific Phobia - 5 types

Animal or Insect

Natural phenomena (storm, flood, lightening)

Blood (injection or injury)

Situational (heights, bridges, flying, driving, small spaces)

Other

Tx: CBT

Conduct Disorder (Adolescents)

3 or more in the past 6 mo

< 18 y/o

Aggression to people and animals

Destruction of property

Deceit or Theft

Serious violations of rules

Tx: Psychotherapy (social competence, family, medications, academic engagement, skills building, and school interventions)

Oppositional Defiant Disorder

Dx: at least 6mo of 4 or more:

Loses temper

Argues w/ adults

Defies or refuses to comply w/ request or rules

Deliberately annoys people

Blames others for own mistakes

Angry, Resentful, Spiteful, or Vindictive

Social phobia

Embarrassment or humiliation in front of others

- Public Speaking (tx w/ propranolol)

- Public restrooms

- Eating in public

Tx: CBT

Paranoid Personality Disorder

Defensive

Oversensitive

Secretive

Suspicious

Hyper-alert

Limited emotional response

Tx: Psychotherapy > SSRIs if long-term

Fixed False Beliefs...

I.e.; Being followed or Poisoned

No hallucinations

Persecutory is MC

Delusions (bizarre vs. non-bizarre)

Schizoid Personality Disorder

Eccentric & reclusive

Quiet & unsociable

Constricted affect

Prefer to be alone

Tx: Group therapy + Psychotherapy > low-dose anti-psych or anti-dep

Schizotypal Personality Disorder

Detached from social relationships

Restricted expression of emotion

Magical or bizarre thinking

Odd speech or peculiar thought patterns -starts in early adulthood

Tx: Psychotherapy > low-dose risperdal or zyprexa > SSRIs/Benzo's

Examples of fixed false beliefs

Delusions:

Erroneous beliefs

Delusions of grandeur

Disorganized speech

Loose associations

Tangential response

Antisocial Personality Disorder (Adults)

Conduct Disorder Dx < 18 yrs old

Selfish, callous, promiscuous, impulsive

Breaking the law - legal problems

Drug & alcohol abuse

No employment or financial responsibility

Inability to learn from mistakes

Tx: No specific effective treatment

Borderline Personality Disorder

Mood swings & impulsive behavior

Unstable personal relationships

Poor impulse control - splitting

Always in Crisis Mode

Substance Abuse

Stress-induced paranoia/psychosis

Tx:

1st Line: Dialectical Behavioral Therapy

2nd Line: SSRIs (fluoxetine)

Narcissistic Personality Disorder

Exhibitionist

Grandiose

Preoccupied w/ power and lack empathy

Excessive demands for attention

Lying is an integral part of the behavior

Sense of entitlement

Tx:

1st Line: Long-term psychodynamic therapy

2nd Line: SSRIs

Histrionic Personality Disorder

Center of attention - egocentric

Temper tantrums -immature, emotionally labile

Inappropriately seductive or provocative

Dependent

Substance abuse

Tx:

1st Line: Psychotherapy

2nd Line: SSRIs

Avoidant Personality Disorder

Fear of rejection

Hypersensitive to rejection or failure

Low self-esteem

Poor social-skills

Tx:

1st line: Psychotherapy

2nd line: Paroxetine (Paxil)

3rd line: Clonazepam (Klonopin) or BB for performance anxiety

Dependent Personality Disorder

Inability to make independent decisions

Fear of losing support or approval if they disagree

Reliant of others to take care of them

Dislike being alone

Avoid responsibility

Tx: Psychotherapy (insight oriented) > Anti-psych/dep

Delirium Causes:

I WATCH DEATH

Acute onset of hallucinations & disorientation

Waxing/waning confusion

Infections

Withdrawal (EtOH, Benzo's)

Acute (dehydration/electolytes)

Toxins

CNS (stroke, bleed)

Hypoxia

Deficiencies (thiamine, B12)

Endocrine

Acute vascular shock (encephalopathy)

Trauma

Heavy metals

Progressive loss of short term memory

Neurofibrillary tangles & amyloid plaques

Alzheimer Dementia

Tx: Donepezil to slow progression

Associated w/ MDD

Memory problems but attention span and concentration are intact

Subjective hallucinations

Pseudodementia

Tx: SSRIs

Dissociative amnesia

Pt cannot recall autobiographical info (cognitive, emotional and motivational aspects of events)

Trauma or Stress related

Reporting laws for Child Abuse

Tarasoff vs. Regents

Physician's Duty to breach patient confidentiality for:

Bucket handle fracture

Posterior rib fracture

Fractures of different ages

Cutaneous bruises, bites, burns (cigarette)

Shaken baby syndrome (retinal hemorrhages)

Confidentiality

Physician must not discuss any information regarding a patient's care w/ anyone, even another physician who is not actively involved in that patient's care, including:

Name

Diagnosis

Treatment

Prognosis

Adjustment disorder w/ depressed mood

Behavioral response to stressful event

Develops < 3mo after onset of stressor

Reaction is excessive

Symptoms resolve by 6 mo

Pt does not meet criteria for MDD

Tx: Psychotherapy

Attention-deficit/hyperactivity disorder

Hyperactivity + Impulsivity + Inattention

> 1 setting (home & school) and affect function

Sx's present prior to 12 y/o

Sx's >6mo

Sx's are inappropriate for child's developmental stage

Tx: Rx, CBT, & environmental intervention

Repeated, Individually recognizable, intermittent movements

Briefly suppressible

Awareness to perform the movement/sound

TIC Disorder

Persistent motor and phonic tics = Tourette Syndrome

- childhood onset & typically resolve by 18y/o

Tx: Pimozide

Autism spectrum disorder (ASD)

Deficits in interpersonal relationships

Speech and language delay (No language delay in Asperger type)

Poor eye contact

Stereotypic behaviors of impaired social interaction and communication

Somatization disorder

Vague physical complaints w/ negative workup

Stress makes sx's worse (GI, neuro, OB-gyn) >1 organ system

Females >> Males

No external incentive

Tx: Reassurance + minimize providers > psychotherapy

Conversion disorder

Single Unexplained neuro complaint

- blindness

- paralysis

- deafness

- seizures

Body dysmorphic disorder

Preoccupied w/ image & physical flaw

MC: facial flaws

Risky procedures to correct perceived flaw

Malingering

Deliberate production of sx's for external gain:

ER setting: drugs, shelter, or to avoid legal situation

Office or clinic setting: financial compensation

Factitious disorder

aka (Munchausen Syndrome)

Deliberate harm of self to assume the "sick role"

Intentional medical or psychiatric Sx but

Preserved cognitive funciton

Seeking hospital admissions

Agitated w/ negative workup and AMA

Anorexia nervosa - Egosyntonic

Avoidance of food and meals

Low body weight - 15% below expected

Intense fear of wt gain

Distorted body perception

Excessive exercise regimen

Denial of illness

Amenorrhea

Tx: Psychotherapy + SSRIs > Li+

Diagnostic labs & imaging to evaluate pt w/ Anorexia nervosa

EKG: SVT or Long QT-Syndrome or Sinus Bradycardia

Labs: ↑ BUN Hypokalemia, Hypochloremia, Hyperaldosterone, ↑ GnRH

Acidosis w/ dehydration

Osteopenia seen in anorexic patients

Due to a decrease in estrogen

Bulimia nervosa - Egodystonic

Recurrent binge eating

Self-induced vomiting or laxative abuse = alkalosis

Dental enamel erosion

Salivary gland enlargement

Calluses over dorsal aspect of fingers (Russell's Sign)

Normal or above normal body wt

Tx:

1st line: CBT > SSRIs > TCAs

The female athlete triad

Low bone density

Menstrual dysfunction

Low energy availability

Obesity

BMI 20-25: Little to no risk

BMI 25-29.9 w/ no CAD risk factors: prevent wt gain

BMI 25-29.9 w/ CAD risk factors or BMI 30-34.9: diet & exercise

BMI 35-40+ High risk: lifestyle mod + pharmacotherapy > bariatric

Dissociative identity disorder

Dx: 2 or more distinct personality states and recurrent gaps in recall of personal information or events

Alterations in: affect, behavior, consciousness, perception, cognition, senory-motor funciton

Amnesia

Depersonalization

Derealization

Self-alteration

Trance state

Depersonalization

Feeling of detachment or estrangement from one's self

"out of body experience"

Derealization

Feeling the external world is strange or unreal

Self-alteration

Sense that one part of one's self is markedly different from another part of one's self

Dissociative amnesia with fugue

Sudden, unexpected travel or wandering in a dissociated state w/ autobiographical memory loss for the duration of the episode