CM Psych Additional

PTSD most effective and FDA approved tx (short)

SSRI

26 year old woman is worried about a presentation, avoids giving them, feels like she might vomit if in public or being looked at by others. she gets sweaty and shakes, this lasts for 10-30 mins. dx

social anxiety disorder

embarassement* (whereas specific phobia is a harmless object and panic disorder is UNEXPECTED attacks)

down syndrome

horizontal palmar crease

almond shaped eyes

hypoplastic face

prominent epicanthic folds

low set ears

protruding tongue

disheveled appearance, no wish for social contact, no history of psychotic behaviors, no interests in anything. dx

schizoid PD

pt in ER is depressed after husband died, she believes she was responsible for the car accident (despite not beign there), she lost a lot of weight and wants to die at home. she attempted suicide. what do you do?

arrange with psych to have her placed in involuntary psych hold as “immediate danger to self” and aggressively treat her overdose under daughter’s direction as her legal power of attorney

30 year old in labor has a severe phobia of needles, she gets scared and has no healthcare peroxy. she is screaming and in physical distress. her husband tells the team to perform the c-section. what happens next

she does NOT have decision-making capacity, and her husband can be consulted to advise the team on how to proceed

22 year old x 7 days says blood “is magical” and is very elated in mood, agitation quickly, distracted. dx

bipolar I disorder, manic state with psychotic features

(schizotypal would not suddenly occur for 7 days, it’s a longitudinal thing)

before you start 2nd gen antipsychotics with psychosis, what labs to do?

1. EKG

2. blood glucose

3. lipids

features of dependence syndrome

1. compulsion to continue to use

2. preoccupation with drug

3. neglect of alternative pleasures

4. impaired control

5. increased tolerance

6. disregarding known harmful effects

pt has chest pain for an hour but no evidence. he now avoids going out in case it happens again. he feels nervous. tx

cognitive behavioral therapy and SSRI med

(somatic sx disorder, maybe panic disorder)

vomits fresh red blood, makes herself vomit, okay weight, uses laxatives, she wants to lose 10 more lbs to be happy. dx

bulimia

pt says he wish he were dead, has rope, bankrupted his family (he did not). he wants to go home. what do you do?

place him in psych hold as imminent danger to himself and involuntarily admit into locked unit for observation and tx

NO major concerns, struggles to make friends, doesn’t understand other’s motivations, doesn’t show interest in other people, likes comic books. he has done ok in school. dx?

autism

pt has significant abdominal pain and back, very foxused, no findings at all. if there is no physical cause, what is dx?

somatic symptom disorder

when asked a question he repeats the last syllable of the last word in the sentence several times and talks about “omnimicrotask”

neologism and preservation

neologism

made up words

tangentiality definition

person's speech continuously drifts from the original topic without ever returning to the main point

(asked a question → starts answering and then goes into a side tangent and NEVER returns to the original question)

circumstantiality definition

speaker wanders off with excessive, unnecessary details but eventually returns to the original point

perseveration definition

repeating a word, phrase, topic or doing a specific action over and over

what is most important about OCD diagnosis?

checking if pt recognizes that their thoughts are irrational and still can’t change them

self inflicted cut, self harm but does not want to hurt herself. what do you want to do?

talk to mom with patient’s permission and with her, attempt to contact the psych about the self-harm, offer pt to return to ED if she feels like harming herself again

expelled from school, substance abuse, assault. dx?

antisocial personality disorder

socially withdrawn, frightened, concerned neighbors talk about him and can hear him. he thinks there has to be hidden cameras. his mood is euthymic. no drugs. dx?

schizophreniform

schizophreniform vs. schizoaffective

phreniform: 1-6 mos, not rlly mood changes

affective: long-term, manic/depressive

lithium toxicity steps

admit ICU, start IV, hemodialysis, get frequent lithium levels, renal function tests, electrolytes, neuro checks

absolute CI for ECT

increased intracranial pressure

which prof should coordinate all of a pt’s care with deteriorating memory if they don’t have a family/trusted person?

primary care team (MD and PA)

what 2 sx is this: hearing voices in head but can’t see them, has heard radio broadcaster speak directly to him on air.

auditory hallucinations with delusions of reference

what is delusion of reference vs. thought insertion

delusion of reference: misinterpreting neutral external events as having highly personal meaning

thought insertion: belief that external forces are placing foreign thoughts directly into one's mind

psychosis tx if 2nd gen antipsychotic does not work repeatedly?

oral clozapine (another 2nd gen antipsy, later resort)

pt says when she skips a dose, she sweats, shakes and feels physically sick and she has needed larger doses of this drug to achieve anxiety relief

benzo (ativan)

pt wants to end life, the doctors are busy. what do you do?

ask ER MD to initiate emergency (CPEP) involuntary hold for 72 hour observation as soon as one doctor is available

dopaminergic pathway for hyperprolactinemia

tuberinfundibular

nigrostriatal pathway

voluntary motor (EPS)

mesolimbic pathway

reward processing (positive sx of psychosis)

mesocortical pathway

executive fx (negative/cog sx of schizophrenia)

IQ 45 =

mod intellectual ability

most appropriate tx if she feels down, loses weight, wakes a lot at night, worsening mood and anhedonia

begin SSRI

forgetful, confused, 23/30 on MMSE, has HTN but no other hx. she thougth she heard something at 4 am but nothing was there. what dementia?

alzheimers

sundowning (pt randomly “hears something” b/c they’re disoriented)

23/30 = early dementia

pt becomes more sad, has alzheimers, her current MMSE is 8/30. she wakes up early, all lab tests are normal. 1st line pharm tx

begin SSRI for depression and monitor status

what to check for lithium

BUN/CR

electrolytes

TFTs

lithium levels

TSH

pregnancy test

pt lost vision after watching her parent’s murder. all exams normal. dx

functional neuro symptom disorder (conversion disorder)

9 week hx low mood, wakes up early, doesn’t sleep, can’t concentrate, recurrent thoughts of death. dx

major depressive disorder

naked in public, said he was president of the bank, never had bipolar depression before. has depression. has bipolar disorder. taking lithium. what to add?

2nd gen/atypical antipsychotic

pt is in manic episode w/ psychotic features

severe manic episode w/ psychotic features first-line tx

mood stabilizer + 2nd gen (atypical) antipsychotic (risperidone)

what to do if alc withdrawal?

gradually reduce high-dose benzo over 5-7+ days with thiamine by injection

s/sx of wernicke’s encephalopathy

1. opthalmoplegia

2. nyastagmus

3. ataxia

4. confusion

has the thought to stop to get fast food, thinks the thought was “injected” into his mind and that this could be a trap

thought insertion

paranoid PD first-line tx

psychotherapy

igh fever, "lead-pipe" generalized muscle rigidity, altered mental status, and autonomic instability (tachycardia, sweating, labile blood pressure) AND starting a 1st gen antipsychotic (haloperidol) = ?

Neuroleptic Malignant Syndrome (NMS)

discontinue offending agent, supportive care (physical cooling and fluids)

enuresis tx option when non-pharm does not work, and what test do you do

imipramine

TCA (antichol)

you must do EKG before starting d/t risk of heart issues

Korsakoff's Syndrome cause and sx

cause: thiamine (vit b1) def from alcohol use

→ chronic amnesia (anterograde and retrograde) w/ confabulation (making up stories)

wernicke’s encephalopathy triad

confusion

opthalmoplegia

ataxia

schizophrenia first-line tx

2nd gen (atypical) antipsychotics

(risperidone, olanzepine, arpiprazole)

brief psychotic vs. schizophreniform vs. schizophrenia

brief psychotic: <1 month

phreniform: 1-6 month

schizophrenia: >6 mos

Dementia with Lewy Bodies (DLB)

1. fluctuating cognition

2. recurrent visual hallucinations

3. parkinson sx (rigidity, resting tremor, shuffling)

alzheimers 1st sign

anterograde amnesia (short-term memory loss)

antidote for TCA overdose

IV sodium bicarbonate

OCD first-line pharm + non-pharm

exposure and response prevention (CBT)

SSRI

what drug is CI in bulimia and anorexia?

wellbutrin

first-line tx for alcohol withdrawal (delirium tremens)

benzos (lorazepam, diazepam, etc)

MSE components

motor behavior

mood

affect

speech

perceptual disorders (impaired reality)

echolalia definition

repeating what is heard

blocking thought process

long pauses in talking

MMSE - judgement

understanding relationships and drawing conclusion

MMSE - insight

pt realizing there is a problem and needing tx

paranoid PD vs. delusional disorder (persecutory type)

P: NO specific delusional systems (ie refusing to eat food b/c they believe they’re being poisoned)

D: specific delusion thoughts, function is NOT impaired, behavior is not “disorganized”

drug causing nyastagmus + super human strength

dissociative psychedelics (phencyclidine / PCP)

difference in somatic sx vs. illness anxiety disorder

somatic sx disorder: pt is complaining of a sx

illness anxiety disorder: pt is worried about GETTING a disease

refeeding syndrome looks like?

surge in insulin secretion causing intracellular shift →

hypophosphatemia

hypokalemia

volume overload

which drug are you worriedfrom agranulocytosis?

clozapine (2nd gen antipsy)

watch NEUTROPHIL COUNT (ANC)

decreased hypocretin/orexin → ?

narcolepsy type 1

neuroleptic malignant syndrome + tx

rx d/t antipsychotics!

hyperthermia

“lead pipe” muscle rigidity

HTN/tachy

altered mental status

high CK

tx: dantrolene or bromocriptine

acute dystonic reaction + tx

localized, involuntary muscle contraction (ie torticollis)

NO fever, alt mental status

tx: benztropine or benadryl

antipsychotics are good for treating the _ sx of schizophrenia but NOT as good for the what

positive sx

negative sx

naltrexone

good for SUD

CI if liver disease

best FDA-approved med to reduce alc cravings + ok for liver dz

campral

panic disorder first-line tx

SSRI + CBT

what drug withdrawal → seizures?

benzos (alprazolam)

oppositional defiant disorder (ODD) vs. conduct disorder

ODD does not have violation of severe rights

BOTH have irritable mood, defiant behavior, >6 mos

social anxiety first-line tx

propranolol PRN

capgras, fregoli, and cotard delusion

capgras: familiar person replaced by imposter

fregoli: different people are the same person in disguise

cotard: self is rotting or dead

flight of ideas vs. word salad

flight of ideas you can see the shift to the topics (tx is to block the dopamine)

word salad is just a jumbled mess

pt comes in agitated, temp, dilated pupils, clonus, hyperreflexia, and started a new med recently. what is the cause?

SSRI and MAOI

(this is serotonin syndrome)

schizophreniform vs. delusional disorder

schizophreniform >1 month

delusional disorder >1 month and NO hallucinations, NO fx-al impairment, no change in speech, no flat affect, no self-neglect

doctrine of double effect

an action with a foreseeable bad effect (ie quickening death) is ok if the action if intended to achieve good (ie relieve pain)

most common SE of ECT

transient retrograde and anterograde amnesia (taht goes away on its own)

HA, nausea, muscle soreness

Reaction Formation

person transforms an unacceptable, distressing impulse or feeling (here: intense resentment and anger toward his newborn) into its exact opposite (overprotective affection)

Displacement

unacceptable feeling is redirected toward a different, safer target

sleep terrors

occur durning non-REM sleep, 1/3 of night

screaming, difficulty consoling

complete amnesia of event the next day

schizophrenia criteria*

2 or more sx:

1. delusions (ie “they’re watching my thoughts via wifi”)

2. disorganized speech (fragmented sentences)

3. negative sx (ie flat effect, social withdrawal)

disruptive mood dysregulation disorder vs. intermittent explosive disorder

DMDD: 3+ a week

IED is not as often

fragile X syndrome

long face, large ears, macroorchidism

autism-like traits

REM sleep behavior disorder

loss of normal muscle atonia → motor enactment of dreams