Emma Holliday - Psychiatry

Schizophrenia:

Time duration and Brain histological findings

Chronic mental disorder with periods of psychosis, disturbed behavior and thought,

and decline in functioning that lasts > 6 months.

Associated with increase dopaminergic

activity, decrease dendritic branching.

Schizophrenia:

Symptoms needed for diagnosis

2 or more of the following

(first 4 in this list are "positive symptoms"):

~Delusions

~Hallucinations—often auditory

~Disorganized speech (loose associations)

~Disorganized or catatonic behavior

"Negative symptoms"—flat affect, social withdrawal, lack of motivation, lack of speech or thought

Most common type of schizophrenia

Paranoid type

Most treatable type of schizophrenia

Paranoid type

Prevalence in society of schizophrenia

1%

Schizophrenia:

~Risk of MZ twin

~Risk of sibling

twin = 50%

sibling = 10%

Positive symptoms for schizophrenia

Increased dopamine in the mesolimbic tract

Negative symptoms for schizophrenia

Decreased dopamine in the mesocortical tract

Dopamine systems of the brain

which one controls the: EPS

which one regulates prolactin

Diagnosis: Delusions hallucination and flattened affect for 3 weeks

Brief psychotic disorder ( > 1 WEEK AND <1 MONTH)

Diagnosis: Delusions hallucination and flattened affect for > 1 month and < 6 month

Schizopreniform disorder

Typical antipsychotics help what kinds of symptoms in schizophrenia

Positive symptoms, but no effect on the progression

Difference between schizoaffective disorder and depression with psychotic features?

What was present first without the other, i.e. schizoaffective thave had psychosis without any depressive symptoms

Diagnosis: MDD for 3 years and reports hearing voices telling him he is worthless and to kill himself

MDD with Psychotic Features; delusions are typically mood congruent

Treatment for MDD with Psychotic Features?

Atypical antipsychotic + SSRI or ECT (especially in pregnant patients)

Diagnosis: Persecutory delusions for past 3 years (diagnosed with schizophrenia), 6 months ago he started having sadness, guilt, insomnia, ↓ concentration, SI

Schizoaffective Disorder; delusions/hallucinations for > 2 weeks in absence of mood symptoms

Treatment for Schizoaffective Disorder?

Atypical antipsychotics

+ SSRI if depression

+ Li if manic

A man is convinced Miley Cyrus is in love with him, but is otherwise functional

Delusional Disorder, erotomanic type. Non-bizzare

Treatment for Delusional Disorder?

Therapeutic relationship + meds

Treatment: Acute agitation OR psychosis

IM haloperidol

--Quick onset of action

--D2 dopamine angtagonist

Haloperidol: Effects on nigrostriatal pathway and tubularinfundibulum?

Nigrostrial = causes EPS

Tubularinfundubulum = Hyperprolactinemia

Low potency antipsychotics:

Chlorpromazine and Thioridazine

--Less EPS, more anti-Ach

--Non-neurologic side effects (anticholinergic, antihistamine, and α1-blockade effects).

Side effects of Chlorpromazine?

Corneal deposits

Side effects of Thioridazine?

Retinal deposits

Side effects of haloperidol?

--NMS

--Tardive dyskinesia

Symptoms of Neuroleptic malignant syndrome (NMS)?

Rigidity, myoglobinuria, autonomic instability,

hyperpyrexia

Treatment for NMS?

Dantrolene, D2 agonists (e.g., bromocriptine)

Stop offending med, cooling blankets, and Dantroline Na or Bromocriptine

Neuroleptic syndrome:

FEVER

Fever

Encephalopathy

Vitals unstable

Enzymes elevated

Rigidity of muscles

High potency Antipsychotics:

Trifluoperazine, Fluphenazine, Haloperidol

—neurologic side effects (EPS symptoms)

Treatment of psychotic patient with a history of medication non-adherence?

Give injection/decanoate - Fluphenazine or Haldol every 2-4 weeks

Side effect: Purple grey metallic rash over sun-exposed areas and jaundice?

Chlorpromazine

Side effect: Prolonged QTc and pigmentary retinopathy?

Thioridazine --> can lead to torsades

Diagnosis: Medicated, psychotic patient wakes up with eyes "stuck" looking up or head "stuck" turned to the side

Acute Dystonia

<12 hours of beginning medication

Treatment for Acute Dystonia?

Benztropine or diphenhydramine

Diagnosis: Medicated, psychotic patient reports feeling like they "always have to move"

Akathesia

30 - 90 days of beginning medication

Treatment for Akathesia?

Propranolol (1st line) or benzodiapene

Diagnosis: Coarse resting tremor, masked facies, unsteady gait, bradykinesia

Parkinsonism

>6 months of beginning medication

Treatment of Parkinsonism side effects?

Treatment: Benztropine, diphenhydramine, amantidine or bromocriptine

NOT L-dopa!

Diagnosis: After 10 years on fluphenazine, tongue movements and grimacing

Tardive Dyskinesia

> Many years after starting antipsychotic

Treatment of Tardive Dyskinesia?

Stop antipsychotic and switching to and atypical or clozapine

Diagnosis: Within hours of a haloperidol injections, ↑CPK, T = 103F, rigidity, autonomic instability, and delirium

Neuroleptic Malignant Syndrome

Other causes: metoclopramide, compazine and droperidol

Antipsychotic medication: Weight neutral but prolongs the QTc?

Ziprazodone

Antipsychotic medication: Weight neutral but increases akathesia?

Aripiprazole

Antipsychotic medication: Atypical agent with highest risk for EPS and ↑prolactin?

Risperidone, also in depo form

Antipsychotic medication: Most associated with weight gain, BUT most common side effect is sedation?

Olazepine

Antipsychotic medication: Causes orthostasis and cataracts?

Quetiapine

--Alpha blocking properties

Antipsychotic medication: Good for treatment-refractory schizophrenia?

Clozapine

Most common side effects of Clozapine?

Sedation, weight gain, ↑blood sugar and lipids

Most dangerous side effects of Clozapine?

Agranulocytosis

Decreased seizure threshold

What do you monitor with Clozapine?

CBC --> ANC every week for 6 months and every 2 weeks for next 6 months

Stop Clozapine if WBCs < 3000 or ANC < 1500

What the most important and first question to ask the depressed patient?

Suicidal ideation, most likely to kill the patient

Risk factors for suicidal ideation?

#1 - Prior attempt

>45 years old, white male, serious illness, detailed plan, no support, use of ETOH and drugs

Polysomnogram for a depressed person?

Early REM latency and more frequent REM

Increased hormone in depressed patient?

Coritsol

Dexamethsone supression test would be abnormal

Medications that might cause depression?

IFN, beta-blockers, α-methyldopa, L-dopa, OCPs, ETOH, cocaine/amphetamine withdrawal, opiates

Medical diseases that might cause depression?

HIV, Lyme, Hypothyroidism, Porphyria, Uremia, Cushings Dz, Liver disease, Huntington's, MS, Lupus, L-MCA stroke

First line drug for treatment of depression?

SSRIs = Fluoxetine, paroxetine, sertraline, citalopram

Other conditions treated with SSRIs?

OCD, bulemia, anxiety, or premature ejaculation

Side effects of SSRIs

GI distress, sexual dysfunction (anorgasmia and decreased libido)

Fewer than TCAs

SSRI toxicity

Serotonin syndrome with any drug that increases 5-HT

(e.g., MAO inhibitors, SNRIs, TCAs

Symptoms of Serotonin syndrome?

Hyperthermia, confusion, myoclonus,

cardiovascular collapse, flushing, diarrhea,

seizures

Treatment of Serotonin syndrome?

Cyproheptadine (5-HT2 receptor antagonist)

SSRI with most drug-drug interactions?

Paroxetine

SSRI that can be discontinued without a taper?

Fluoxetine

SSRI with fewest drug-drug interactions?

Citalopram

Suddenly stopping SSRI and experiences HA, N/V/D dizziness and fatigue

5-HT discontinuation syndrome; more common with sertraline and fluvoxam

Diagnosis: Myoclonic jerks, tachycardia, hypertension, hyperreflexia, n/v/d

5-HT syndrome, particularly if the patient is taking both SSRI + MAOI

Patient experiences loss of erection/ejaculation on SSRI?

Switch to buproprione (dopamine and norepinephrine antagonist)

Contraindications of buproprione?

Due to increased rick of seizures:

Alcoholics

Epileptics

Bulimics

Drug: Erections lasting longer then 3 hours?

Trazodone

Drug: Anti-depressant for old, skinny, sad ladies?

Mirtazepine - Sedating, increases appetite

Drug: Anti-depressent NOT for hypertensives?

Venalfaxine

Drug: Anti-depressent NOT for patients taking St John's Wart?

Venalfaxine

Diagnosis: Pounding head, flushing, nausea, myoclonus after eating cheese, drinking red wine, taking decongestant or merperidine?

Hypertensive crisis with MAOI

Treatment for Hypertensive crisis with MAOI?

5mg IV phentolamine

Pediatric patient ingested unidentified pills. He now has dry mouth, tachycardia, vomiting, urinary retention, and seizures. EKG demonstrates widened QRS and prolonged QT intervals. What medication did the child ingest?

Tricyclic antidepressants

Most common cause of death in a kid who ingested TCAs?

Arrhythmia --> torsades, v-fib, and death

What is the treatment for tricyclic antidepressant overdose?

Sodium bicarbonate

--Helps metabolic acidosis

--Cardio protective

Patient who is eating and sleeping more, gaining weight, and has leaden paralysis in the morning.

Atypical depression

--Hypersensitive to rejection, affecting social functioning

Treatment for Atypical depression

MAOI

Diagnosis: One month following the death of her child, a mother feels guilty, can't sleep, concentrate, eat, or enjoy her interests?

Uncomplicated Bereavement

--No suicidal ideation (other than thoughts of wanting to be with loved one)

--No psychosis (other than hearing/seeing loved one)

Treatment for Uncomplicated Bereavement?

Rarely; treat with antidepressants for symptoms

Diagnosis: Four months following the death of her chihuahua, a woman still feels guilty, can't sleep, concentrate, eat, or enjoy her interests?

Adjustment Disorder

Symptoms present within 3 months of stressor and are out of proportion to inciting event

--Can't persist longer than 6 months

What is Adjustment disorder?

Emotional symptoms (i.e. anxiety, depression) causing impairment following an identifiable psychosocial stressor (e.g., divorce, illness) and lasting < 6 months

(> 6 months in presence of chronic stressor)

Treatment for adjustment disorder?

Psychotherapy

Prevalence of Bipolar disorder in the population?

1%

Prevalence of Bipolar disorder in MZ twin?

90%

Diagnosis: 75 year old man with first manic phase of lifetime?

Medical cause

--Right frontal hemisphere stoke

What is Generalized anxiety disorder?

Pattern of uncontrollable anxiety for at least 6 months that is unrelated to a specific person, situation, or event. --Associated with sleep disturbance, fatigue, GI disturbance, and difficulty concentrating

Treatment for GAD?

SSRIs, SNRIs, buspirone, cognitive behavioral therapy

How many symptoms and for how long do you need to have in order to diagnose schizophrenia?

Bizarre delusions or hearing voices = 1 month

Otherwise = 2 or more symptoms for 6 months

Incidence of mania in the population?

1%

Risk for diagnosis of mania in a MZ twin?

80-90%

Diagnosis: Symptoms of manic depression in 75 year old patient for the 1st time in that patient's lifetime?

Medical cause

--Right frontal hemisphere stroke

What medication need to be avoided in a patient with manic depression

SSRI and TCA can trigger mania

Medications to start in a manic depressive patient? For maintenance?

Haloperidol or clonazepam for acute agitation/delusion (if you cant interview them)

Maintenance: Lithium or valproic acid or carbamazepine

Diagnosis: Manic patient takes Advil and develops n/v/d, coarse tremor, ataxia, confusion, and slurred speech?

LIthium toxicity

Precipatated by NSAIDs

Preferred pain medications for patients on Li: aspirin or sulindac

EKG findings in Lithium toxicity?

--T wave flattening or inversion

--U inversions

Treatment For Lithium toxicity?

Depends on serum Li levels:

<4: Fluid resuscitiation

>4: Emergent dialysis

Side effects of Lithium?

Weight gain, acne, GI irritation, and cramps