03-03-2008, 08:27 PM
psychiatry cram facts
PSYCHIATRY
510. If you see a question about the best next test and one of the answers is “mini-mental exam,†pick that one.
511. Autism “ starts by 3yo. Impaired social interactions (unaware of surroundings), impaired verbal/nonverbal communication (if verbal is okay, dx is Asperger’s syndrome), and restrictive activities and interest (head banging, strange movements). Linked to congenital rubella. Tx c 1st structured classroom training, behavioral modifications, family support, 2nd halorperidol, risperidone, SSRI’s. If child has normal development and then deteriorates into this condition or worse, that is Rett’s syndrome.
512. Learning disorder “ impairment in reading (80%), math, language, written expression with no mental retardation or lifestyle anomalies. Tx c educational intervention.
513. ADHD “ dx <7yo. Boy is hyperactive, impulsive and has a short memory span, but is not cruel. Tx: 1st individual/family therapy and behavioral modifications, 2nd methylphenidate (Ritalin) or dextroamphetamine, both of which may cause insomnia, abdm pain, HA, anorexia, exacerbations of tics, weight loss or growth suppression. Tx c 1st atimoxitine (but must be given everyday, so if mom says kid only has s/s Monday thru Friday, then you cannot give this, give tx #2), 2nd Methylphenidate or amphetamine.
514. Conduct Disorder “ violates society norms, pediatric form of antisocial disorder. Look for fire setting (if only this, dx is pyromania), cruelty to animals, lying, stealing, fighting. Must have this disorder in order to make diagnosis of antisocial d/o as adult. Tx: 1st evaluate suicide/violence potential, 2nd containment by parents, schools, legal system or hospital, 3rd tx aggression c SSRI or haloperidol, 4th individual/group/ family therapy.
515. Oppositional Defiant Disorder “ negative, hostile and defiant behavior towards authority figure. Note the different between this and conduct d/o is that here, the kid is just bad to adults behaves with peers and is not a cruel, lying criminal. Tx c individual/family therapy
516. Separation anxiety Disorder “ look for a kid who refuses to go to school or sleep alone or away from home by claiming sickness, stomachache, HA or temper tantrums. Must be >6months old (might ask about 8mo baby who cries when he sees grandma for 1st time = separation anxiety, but if kid was under 6mo, its normal) School refusal is a psychiatric emergency and needs prompt evaluation and treatment involving parents, school and peers.
517. Tourette’s Disorder “ (only 10-30% curse), look for males c motor tics (blinking, grunting, throat clearing, grimacing, barking, shrugging) that are exacerbated by stress and remit c activity or sleep. Linked to ADHD and OCD. Tx: 1st Haloperidol (improves 80% but watch for EPS, mental dulling and tardive dyskinesia). 2nd Pimozide or Clonidine
518. Encopresis “ >4yo c passage of feces into inappropriate places (clothing, floor). r/o Hirschsprungs disease. Tx c behavioral techniques, individual therapy.
519. Enuresis - >5yo c inappropriate voiding of urine. Tx: 1st behavioral techniques (bell, buzzer, bed time fluid restriction), 2nd Imipramine (last resort).
520. Dementia vs Delerium: Delerium (rapid onset, fluctuating consciousness, often reversible, perceptual disturbances, incoherent speech). Dementia (insidious onset, clear consciousness (until late in course), irreversible).
521. Alzheimer’s vs Vascular (Multi-Infarct) Dementia: Alzheimers dementia (women, older, chrom 21, linear/progressive, no focal defecits (key), supportive tx). Vascular dementia (men, younger than alzheimers, HTN, stepwise/patchy pattern, (+) focal deficits (key), tx underlying condition).
522. Alcohol “ intoxication includes slurred speech, ataxia, disinhibition, impaired judgement, coma and blackouts. Withdrawal includes tremor, agitation, irritability, n/v, fever, seizures, delirium tremens (onset of delirium, vivid auditory/tactile/visual hallucinations, paranoid delusions 2-3 days post cessation of long-term heavy use). Tx intoxication supportively. Tx withdrawal c vital sign/electrolytes/Mg/thiamine/vit B12/folate/glucose monitoring. 2nd Hydration c thiamine before glucose (prevent Wernicke), 3rd benzodiazepine (chlordiazepoxide). Tx dependence c confrontation of denial and rehab (AA). Specific managements: Alcohol hallucinations (chlordiazepoxide, IVF, haloperidol), Wernicke’s encephalopathy (sudden ataxia, confusion, nystagmus, lateral rectus palsy from thiamine deficiency. Tx c thiamine) Korsakoff’s syndrome (severe anterograde/retrograde amnesia, confabulations and polyneuritis from thiamine defiency).
523. Opioids “ intoxication includes euphoria, analgesia, hypoactivity, anorexia, drowsiness, n/v, constipation, pin-point pupils, hypotension and bradycardia. Overdose includes CNS/respiratory depression, pinpoint pupils, pulm edema, seizure, coma and death. Withdrawal includes (not deadly) rhinorrhea, yawning, diarrhea, sweating, dilated pupils, tachycardia and HTN. Tx overdose c naloxone. Tx dependence c abstinence through methadoes titration.
524. Stimulants “ amphetamines/cocaine, rapid dependence of tolerance, IVDA risks, paranoid psychosis. Intoxication includes euphoria, alertness, increased energy, anxiety, talkativeness, mydriasis, tactile hallucinations (crawling bugs), HTN and tachycardia. Withdrawal includes (non-deadly) fatigue, hypersomnia, anxiety, dysphoria, suicidal ideation, craving. Tx intoxication symptomatically (antiarrhythmic, benzo for agitation, haloperidol). Tx withdrawal supportively (observe for suicidality). Tx dependence c rehab.
525. Sedatives “ benzo/barbs “ intoxication causes slurred speech, drowsiness, impaired attention, disinhibition. (Flumetrazepam is the date-rape drug). Overdose c barbs for suicide, (not so much benzo b/c of high therapeutic index, unless taken with another drug or alcohol). Both cause resp depression, coma, death. Withdrawal causes anxiety and insomnia. Severe withdrawal is a medical emergency (n/v, autonomic hyperactivity, photophobia, tremor, hyperthermia, delerium, seizures, death) most severe c short-acting drugs. Overdose benzo c flumazenil (does not reverse resp depression), barbs c charcoal, gastric lavage. Tx barbiturate withdrawal c pentobarbital challenge test to get daily dose, and taper off. Tx benzo withdrawal c long-acting benzo (diazepam, clonazepam) and gradually withdraw.
526. Nicotine “ acetylcholine (nicotinic) agonist. Withdrawal causes irritability, wt gain, and difficulty c concentration. Tx: 1st obtain specific date to stop, 2nd educate/counsel.
527. PCP “ paranoia, assaultiveness, impulsiveness, vertical and/or horizontal nystagmus (dead give-away), diaphoresis, resp depression, seizures, normal size pupils. Tx symptomatically
528. Hallucinogens “ LSD, Ecstacy “ sympathomimetic effects (mydriasis, tachycardia, sweating, diarrhea, urination), panic reactions, illusions, paranoia. Later on, pt may not be using drug anymore and reexperience intoxication (flashback).
529. Cannabinoids “ Marijuana/THC “ intoxication has euphoria, bad judgement, slowed reactions, dry mouth, conjunctival injection (dead give-away). Chronic use causes amotivational syndrome and memory impairment.
530. Hallucination is a disturbed sensory perception (visual, tactile, auditory). Delusion is a fixed, false belief (even if people prove to you otherwise). Psychosis is inability to judge boundary between real and unreal.
531. Schizophrenia “ presence of >2 s/s of the following for >6months: delusions, hallucinations (generally auditory, link visual c alcohol withdrawal), disorganized speech/behavior, negative s/s (flat affect, no speech, no motivation, anhedonia). Better prognosis (NBME 3 question) if acute, late onset, good social/occupation hx, positive s/s, medication compliance, married, female gender. Symptoms due to altered dopamine activity (newer antipsychotics affect serotonin also). Negative s/s have enlargement of cerebral ventricles and hypoactive frontal lobe. Tx: 1st assess if pt needs hospitalization (protect self/others), 2nd Antipsychotics (Risperidone), 3rd Psychosocial tx. [Timeline: <1month = brieft psychotic d/o, 1-6months = schizophreniform, >6mo = schizophrenia]
532. Delusional (Paranoid) Disorder “ persistent, nonbizarre, well-systematized delusion. Erotomanic (on is loved by a famous other, NBME 3 TQ), grandiose (one possesses great talent), jealous (conviction that lover is unfaithful), persecutory (one is conspired against, MC), somatic (one has a physical abnormality like odor). Tx: 1st hospitalization for inability to control suicidal/homicidal impulses or danger a/w delusions, 2nd psychotherapy, 3rd antipsychotics/antidepressants.
533. Schizophreniform “ schizophrenia <6months. Good prognosis c acute onset, confusion, disorientation, full affect, tx c antipsychotics for at least 6 months.
534. Brief Psychotic Disorder “ sudden onset of psychotic s/s c emotional turmoil and confusion, often following obvious stressor, duration <1month. Suicide risk, thus tx 1st hospitilization as needed, 2nd antipsychotics/antianxiety agent, 3rd psychotherapy
535. Schizoaffective “ schizophrenia c depression or mania for at least 2 weeks.
536. Shared Psychotic disorder “ submissive, dependent isolated relationship with person c established delusion. Suicide/homicide pacts. Tx: 1st separate the 2 people, 2nd antipsychotics.
537. Mania “ >1wk of elevated, expansive, irritable mood c grandiosity, no sleep, talkativeness, impulsitivity (shopping sprees, gambling, promiscuity) , racing thoughts, distractibility, agitation. Hypomania is less severe and lasts >4days.
538. Major depression disorder (MDD)“ 2 of SIGECAPS in >2wks“ sleep changes (delayed sleep onset, decreased REM. Note the difference: Anxiety has increased REM latency, depression and narcolepsy have decreased REM latency), interest loss, guilt, energy loss, concentration decreased, appetite (up or down), psychomotor (retardation or agitation), suicidality. Decreased serotonergic activity a/w violence and suicide. Tx: Hospitalize if suicide risk, 2nd Antidepressant (SSRI 1st) for 6-12 months (not that it takes 4-6wks to start effects), 3rd ECT (rapid response in pregnancy, elderly, medically ill), 4th psychotherapy, 5th antipscyhotic + antidepressant for psychotic pts, 5th Phototherapy if depression is seasonal, 6th treat comorbid psychopathology (anxiety, substance abuse, personality d/o, ADHD).
539. Depression vs Bereavement “ Depression (mood pervasive/unremitting, constant low self-esteem/worthlessness, suicidal, sustained psychotic s/s, no improvement c treatment, social withdrawal). Bereavement (mood fluctuates, self-reproach regarding deceased, not suicidal, transient visual/auditory hallucinations or deceased, s/s improve c time and usually gone by 6 months, often welcomes social support). It is normal to have an illusion or hallucination about the deceased, but a normal grieving person knows that it is an illusion or hallucination, while an MDD pt thinks its real. Other clues to MDD that are not normal are feeling of worthlessness, suicidality and psychomotor retardation.
540. Bipolar Disorders: Type I is full-blown mania c MDD. Type II is hypomania c MDD. Tx: 1st assess risk of suicide, assaultiveness, dangerous poor judgement. 2nd For acute mania give mood stabilizer (lithium). For depression “ modd stabilizer c or w/o antidepressant if necessary.
541. Cyclothymia “ numerous hypomanic episodes c depressive episodes for >2yrs. (Cyclo is a psycho, while dysthymia is just depression for >2yrs).
542. Panic Disorder “ minutes to hours of unexpected, sudden intense anxiety, dyspnea, parasthesia, CP, fear of dying. A/w agoraphobia (fear of places where escape is difficult such as bridges, public transportation, large crowds, traveling). Tx: 1st If acute, emergent case, give reassurance and benzo (alprazolam, clonazepam). 2nd R/o MI, PE, CVA, hypoglycemia, 3rd Antidepressants (SSRI is tx of choice for long-term management), 4th Cognitive-behavioral therapy (CBT) for agoraphobia.
543. Obsessive-Compulsive Disorder “ recurrent intrusive images, impulses, thoughts (obsessions) and ritualistic behaviors (compulsions) that produce anxiety and affect way of life. A/w Tourette syndrome. Abnormality is serotonin system. Tx c SSRIs (fluvoxamine), but if you only see TCA’s pick clomipramine.
544. Specific Phobia “ irrational, excessive fear and avoidance of a specific object or situation. Tx: Systemic desensitization.
545. Social Phobia “ fear of embarrassment, scrutiny of others (public speaking, eating in public, public bathrooms). Tx: 1st CBT, 2nd BB (propranolol) for stage fright, 3rd Antidepressants (not TCAs) and high-potency benzodiazepines.
546. Posttraumatic Stress Disorder “ >1 month, must have 3: reexperiencing (flashbacks), emotional numbing (avoidance), autonomic arousal (insomnia, irritability). Tx: 1st hospitalize for acute suicide, violence risk. 2nd CBT, 3rd Antidepressants.
547. Acute Stress Disorder - <1month of the same 3 symptoms. Tx c psychotherapy.
548. Generalized Anxiety Disorder “ unrealistic, persistent anxiety for >6months. Muscle tension, restlessness, poor concentration, fatiguability, irritability, loss of sleep. Tx: 1st psychotherapy, 2nd Antidepressants (Buspirone).
549. Somatorofrm Disorders “ unlike factitious disorder and malingering, the symptoms are not intentionally produced but are strongly linked to psychological factors. Examples include somatization disorder (multiple somatic complaints, tx c regularly scheduled visits c PMD), conversion disorder (neurologic s/s), pain disorder (pain in absence of adequate physical findings, tx c psychotherapy), hypochondriasis (fear of specific disease, tx c regular medical visits), and body dysmorphic disorder (preoccupation c defect in appearance, tx c psychotherapy and SSRI’s after you assess suicide risk).
550. Factitious disorder “ “Munchausen syndrome.†Intentional production of s/s for unconscious psychological reasons (need to assume sick role) usually in someone in medical occuption or c history of illness. If s/s produced by parent, this is Munchausen’s by proxy. Tx c psychiatric consult, confrontation may be helful.
551. Malingering “ intentional production of symptoms for a recognized gain (money, drugs, avoid work/military/prison).
552. Dissociative Identity disorder “ multiple personalities, which take over life and pt may or may not be aware of each other. Tx c intensive psychotherapy.
553. Amnestic Disorder “ 2 types: psychogenic fugue (sudden, unexpected travel c amnesia of old identity and assumption of new identity that lasts hours to months, pt is unaware of loss) and psychogenic amnesia (sudden inability to recall important personal information of a traumatic or stressful event, but aware of loss). Recovery usually returns spontaneously. If not, try hynosis, amobarbital or psychotherapy.
554. Depersonalization disorder “ recurrent feeling of detachment from one’s body or self (feel like you’re in an outside world).
555. Anorexia Nervosa “ must have 3: amenorrhea, minimal normal body weight, fear of gaining weight. Tx: 1st hospitalize for dehydration, starvation, hypotension, electrolyte, hypothermia, suicide risk. 2nd treatment contract for wt gain, 3rd CBT.
556. Bulimia Nervosa “ binge eating, normal weight, overconcerned c wt/diet/exercise, self-induced vomiting, laxatives/diuretics, a/w kleptomania. Tx: 1st hospitalize for ECG (hypokalemia-induced arrhythmia is MCCOD), electrolytes, amylase, LFTs, esophageal/gastric rupture, suicide risk. 2nd psychotherapy, nutritional counseling, SSRI for binging (do not give buproprion for risk of seizures).
557. Old, classic USMLE TQ: Mom finds her son having sex c another boy, is this normal or homosexuality? Normal (unless they say he enjoys it). Another TQ is a man, who knows he is a man and likes women, dresses up like a woman and acts like a woman, what is his sexual orientation? Heterosexual (b/c he likes women).
558. Projection “ attributing your own wishes to someone else. A/w paranoid personality d/o (p for p “ paranoia c projection)
559. Denial “ if they deny having a disease, next step is do nothing! (because it usually does not interfere c treatment, but if it does, next step is confront the pt).
560. Splitting “ all is good or bad. a/w borderline d/o. If they only say all is good, its idealization. If they only say all is bad, its devaluation. Splitting must have both.
561. Regression “ look for h/o bedwetting in a kid >5yo (<5yo is normal).
562. Reaction formation vs Undoing “ rxn formation is a thought, undoing is an action. Both are classically a/w obsessive compulsive d/o, where rxn formation is the obsession, and undoing is the compulstion.
563. Reaction formation vs sublimation “ sublimation does something good for mankind.
564. Primary insomnia “ disturbance in initiating, maintaining or feeling rested after sleep. Tx: 1st hygeine treatment: regularize sleep hours, use of bed only for sex/sleep, if not asleep in 30 minutes then leave bed and return only when drowsy, no napping, regular exercise but not immediately prior to bedtime, reduce/eliminate alcohol/caffeine/smoking, relaxation exercise. 2nd sedative-hypnotics (benzo, zolpidem) for short-term relief
565. Narcolepsy “ daytime drowsiness, irresistible sleep attacks c hypnagogic/hympopompic hallucinations, sleep paralysis, cataplexy (loss of muscle control c strong emotions). Tx c short daytime naps, 2nd stimulants for sleep attacks and TCAs for cataplexy.
566. Sleep apnea “ obstructive type d/t occlusion of upper airway during sleep in an obese pt. Central type is d/t reduced nocturnal resp drive). Dx c polysomnography. Tx:1st wt reduction, 2nd CPAP for obstructive type, Acetazolamide or protriptyline for central type.
567. Restless Legs Synd “ agonizing, deep creeping sensations in leg/arm muscles relieved by moving or massage. Pt has trouble falling asleep at night because of it. Tx c benzodiazepam.
568. Intermittent Explosive “ discreet episodes of loss control of aggressive impulses, but otherwise not aggressive. Tx c benzo (causes disinhibition) and CBT.
569. Kleptomania “ failure to resist stealing unnecessary and unneeded things. a/w Bulimia.
570. Pyromania “ deliberate fire setting and fascination c fire, usually in kids. Make sure the guy is not getting paid to do it and that it is completely for self-satisfaction.
571. Trichotillomania “ recurrent pulling out of one’s own hair. Tx c psychotherapy, SSRI.
572. Adjustment Disorder “excessive emotional/behavioral responses that occur within 3 months of a stressor that is within range of normal experience (unlike PTSD), such as school problems, marital discord, job loss or illness. Does not persist after 6 months of stressor. Lacks sufficient evidence to make for other diagnosis (MDD). Tx:1st evaluate suicide risk. 2nd psychotx, antianxiety, antidepressants, 3rd stress reduction.
573. Personality Disorders - Cluster A (Weird: Paranoid, Schizoid (pt wants to be alone), Schizotypal (peculiar ideations/appearance/behavior magical thinking)), Cluster B (Wild: Antisocial (exploitative, destructive, impulsive behavior c no remorse. Childhood h/o conduct d/o essential for dx. Tx c SSRI), Borderline (instability of self-image, identity, relationships and mood. Does crazy things and still feels empty inside. h/o child abuse. Tx c pschotx (long-term), SSRI for mood stability and impulsitivity, haloperidol for psychosis. Avoid benzo), Histrionic (attention seeking, hits on the doctor, needs praise and reassurance), Narcissistic (grandiose, mad if humiliated, lack of empathy). Cluster C (Worried: Obsessive-compulsive (tx c fluvoxamine), Dependent, Avoidant (does not want to be alone (unlike schizoid), but fears rejection)
574. Antipsychotics (Neuroleptics): Low-doses (thioridazine, chlorpromazein), high-doses/long-acting (haloperidol, fluphenazine. Highest risk of EPS, NMS), atypical (clozapine, risperidone, olanzapine, quetiapine, ziprasidone). Typicals block dopamine (D2) receptors, thus used for positive symptoms only and have many side-effects, while Atypicals block serotonin (5-HT), D2 and D4, thus can be used for positive and negative symptoms and have fever side-effects. Adverse-effects: Hours-Days: Dystonia (spasms), Torticollis and oculogyric crisis (eyes stay looking up). Tx c benztropine, diphenhydramine or trihexylphenidate. Weeks: Akathisia (restlessness). Tx c lowering drug-dose, benzo, BB, or switch to atypical (best). Months: Tardive dyskinesia (lip-smacking). Tx c switching to atypical. Neuroleptic malignant syndrome: MC c high-potency drugs, increased risk if used c lithium, fever, rigidity, autonomic instability, very high CPK levels, high K+, tx c IV dantrolene or bromocriptine. Clozapine causes agranulocytosis (must do weekly CBC if taking), thioridazine causes retinal pigment deposits, chlorpromazine causes jaundice and photosensitivity.
575. Newer Atypicals Adverse Effects: Risperidone (less sedative, but increases prolactin, incrase risk of movement d/o), Olanzepine (love to ask about. weight gain (MC), risk of DM), Ziprasidone (prolonged QT), Quetiapine (risk of movement d/o)
576. Antidepressants: block NE, 5-HT, Dopamine. MAOIs (bad b/c of Tyramine food reaction (cheese, red wine, chocolates, sausages). Must stop MAOI at least 2 weeks before starting TCAs or SSRI. Tx of choice for atypical depression (increased sleep/weight/appetite or Leaden paralysis)). TCAs (best ones are nortryptilline and desipramine, worst is amitriptylline. Causes hypotension, anti-cholinergic s/s, conduction defect (MCCOD, MC is sinus tachy, but USMLE loves widened QRS, tx c bicarb), sexual problems, changes in wt, sedation). SSRI (1st choice for MDD (fluoxetine, sertraline, peroxitine, citalopram, escitalopram), Anxiety (fluoxetine, sertraline, peroxitine) and OCD (fluvoxamine only). Causes headache (MC), GI upset, sedation, agitation, sexual dysfunction (worst s/s), weight gain). Others include Venlafaxine (MDD, anxiety), Duloxetine (MDD, pain d/o), Bupropion (MDD, smoking cessation), Mirtazipine (weight good (good for anorexia), sedation), Trazodone (priapism). In a nutshell, always answer SSRI unless: 1- pt c MDD and neuroleptic (spinal) pain, give duloxetine; 2 “ pt c MDD and has sexual changes/weight gain, give bupropion (not buspirone for GAD).
577. Mood stabilizers “ Depressed pt (lithium or lamotrigine) or Mixed/Manic (Lithium, valproic acid, antipsychotics). Either way, lithium is 1st line. It causes tremors, GI upset, hypothyroidism, nephrotoxic, teratogenic, acne, wt gain, leukocytosis, ataxia, and seizures. Must get weekly blood levels and must get TSH, BUN/Cr, hCG before starting it. If renal disease, pick valproic acid, if very acute mania pick haloperidol, otherwise always go with lithium first. Never discontinue lithium abruptly and levels >3.0 is a medical emergency that needs IV saline or hemodialysis.
578. Electroconvulsive therapy “ increases serotonin for conditions like MDD, mania and schizophrenia. No absolute contraindications. Only relative CI is high intracranial pressure (brain tumors). Who gets it? Suicidal pt (tx of choice), those who don’t respond to meds, pregnancy, h/o benefit c ECT, medication complications. MC adverse effect is memory loss.
579. Benzodiazepines “ all work on CP450 exams OTL (Oxazepam, Temazepam, Lorazepam), so remember OTL for Outside The Liver.
580. Suicide “ if pt mentions it, next step is to ask more questions (attempt, ideations), then admit. Risks: h/o attempt (best indicator of eventual success), hopelessness, psychiatric/physical illness, drug abuse, elderly, social isolation (living alone is worse than single, they are not the same thing!), low job satisfaction. MC method in males are guns, females are guns. MC attempt in males are guns, females are pills.
PSYCHIATRY
510. If you see a question about the best next test and one of the answers is “mini-mental exam,†pick that one.
511. Autism “ starts by 3yo. Impaired social interactions (unaware of surroundings), impaired verbal/nonverbal communication (if verbal is okay, dx is Asperger’s syndrome), and restrictive activities and interest (head banging, strange movements). Linked to congenital rubella. Tx c 1st structured classroom training, behavioral modifications, family support, 2nd halorperidol, risperidone, SSRI’s. If child has normal development and then deteriorates into this condition or worse, that is Rett’s syndrome.
512. Learning disorder “ impairment in reading (80%), math, language, written expression with no mental retardation or lifestyle anomalies. Tx c educational intervention.
513. ADHD “ dx <7yo. Boy is hyperactive, impulsive and has a short memory span, but is not cruel. Tx: 1st individual/family therapy and behavioral modifications, 2nd methylphenidate (Ritalin) or dextroamphetamine, both of which may cause insomnia, abdm pain, HA, anorexia, exacerbations of tics, weight loss or growth suppression. Tx c 1st atimoxitine (but must be given everyday, so if mom says kid only has s/s Monday thru Friday, then you cannot give this, give tx #2), 2nd Methylphenidate or amphetamine.
514. Conduct Disorder “ violates society norms, pediatric form of antisocial disorder. Look for fire setting (if only this, dx is pyromania), cruelty to animals, lying, stealing, fighting. Must have this disorder in order to make diagnosis of antisocial d/o as adult. Tx: 1st evaluate suicide/violence potential, 2nd containment by parents, schools, legal system or hospital, 3rd tx aggression c SSRI or haloperidol, 4th individual/group/ family therapy.
515. Oppositional Defiant Disorder “ negative, hostile and defiant behavior towards authority figure. Note the different between this and conduct d/o is that here, the kid is just bad to adults behaves with peers and is not a cruel, lying criminal. Tx c individual/family therapy
516. Separation anxiety Disorder “ look for a kid who refuses to go to school or sleep alone or away from home by claiming sickness, stomachache, HA or temper tantrums. Must be >6months old (might ask about 8mo baby who cries when he sees grandma for 1st time = separation anxiety, but if kid was under 6mo, its normal) School refusal is a psychiatric emergency and needs prompt evaluation and treatment involving parents, school and peers.
517. Tourette’s Disorder “ (only 10-30% curse), look for males c motor tics (blinking, grunting, throat clearing, grimacing, barking, shrugging) that are exacerbated by stress and remit c activity or sleep. Linked to ADHD and OCD. Tx: 1st Haloperidol (improves 80% but watch for EPS, mental dulling and tardive dyskinesia). 2nd Pimozide or Clonidine
518. Encopresis “ >4yo c passage of feces into inappropriate places (clothing, floor). r/o Hirschsprungs disease. Tx c behavioral techniques, individual therapy.
519. Enuresis - >5yo c inappropriate voiding of urine. Tx: 1st behavioral techniques (bell, buzzer, bed time fluid restriction), 2nd Imipramine (last resort).
520. Dementia vs Delerium: Delerium (rapid onset, fluctuating consciousness, often reversible, perceptual disturbances, incoherent speech). Dementia (insidious onset, clear consciousness (until late in course), irreversible).
521. Alzheimer’s vs Vascular (Multi-Infarct) Dementia: Alzheimers dementia (women, older, chrom 21, linear/progressive, no focal defecits (key), supportive tx). Vascular dementia (men, younger than alzheimers, HTN, stepwise/patchy pattern, (+) focal deficits (key), tx underlying condition).
522. Alcohol “ intoxication includes slurred speech, ataxia, disinhibition, impaired judgement, coma and blackouts. Withdrawal includes tremor, agitation, irritability, n/v, fever, seizures, delirium tremens (onset of delirium, vivid auditory/tactile/visual hallucinations, paranoid delusions 2-3 days post cessation of long-term heavy use). Tx intoxication supportively. Tx withdrawal c vital sign/electrolytes/Mg/thiamine/vit B12/folate/glucose monitoring. 2nd Hydration c thiamine before glucose (prevent Wernicke), 3rd benzodiazepine (chlordiazepoxide). Tx dependence c confrontation of denial and rehab (AA). Specific managements: Alcohol hallucinations (chlordiazepoxide, IVF, haloperidol), Wernicke’s encephalopathy (sudden ataxia, confusion, nystagmus, lateral rectus palsy from thiamine deficiency. Tx c thiamine) Korsakoff’s syndrome (severe anterograde/retrograde amnesia, confabulations and polyneuritis from thiamine defiency).
523. Opioids “ intoxication includes euphoria, analgesia, hypoactivity, anorexia, drowsiness, n/v, constipation, pin-point pupils, hypotension and bradycardia. Overdose includes CNS/respiratory depression, pinpoint pupils, pulm edema, seizure, coma and death. Withdrawal includes (not deadly) rhinorrhea, yawning, diarrhea, sweating, dilated pupils, tachycardia and HTN. Tx overdose c naloxone. Tx dependence c abstinence through methadoes titration.
524. Stimulants “ amphetamines/cocaine, rapid dependence of tolerance, IVDA risks, paranoid psychosis. Intoxication includes euphoria, alertness, increased energy, anxiety, talkativeness, mydriasis, tactile hallucinations (crawling bugs), HTN and tachycardia. Withdrawal includes (non-deadly) fatigue, hypersomnia, anxiety, dysphoria, suicidal ideation, craving. Tx intoxication symptomatically (antiarrhythmic, benzo for agitation, haloperidol). Tx withdrawal supportively (observe for suicidality). Tx dependence c rehab.
525. Sedatives “ benzo/barbs “ intoxication causes slurred speech, drowsiness, impaired attention, disinhibition. (Flumetrazepam is the date-rape drug). Overdose c barbs for suicide, (not so much benzo b/c of high therapeutic index, unless taken with another drug or alcohol). Both cause resp depression, coma, death. Withdrawal causes anxiety and insomnia. Severe withdrawal is a medical emergency (n/v, autonomic hyperactivity, photophobia, tremor, hyperthermia, delerium, seizures, death) most severe c short-acting drugs. Overdose benzo c flumazenil (does not reverse resp depression), barbs c charcoal, gastric lavage. Tx barbiturate withdrawal c pentobarbital challenge test to get daily dose, and taper off. Tx benzo withdrawal c long-acting benzo (diazepam, clonazepam) and gradually withdraw.
526. Nicotine “ acetylcholine (nicotinic) agonist. Withdrawal causes irritability, wt gain, and difficulty c concentration. Tx: 1st obtain specific date to stop, 2nd educate/counsel.
527. PCP “ paranoia, assaultiveness, impulsiveness, vertical and/or horizontal nystagmus (dead give-away), diaphoresis, resp depression, seizures, normal size pupils. Tx symptomatically
528. Hallucinogens “ LSD, Ecstacy “ sympathomimetic effects (mydriasis, tachycardia, sweating, diarrhea, urination), panic reactions, illusions, paranoia. Later on, pt may not be using drug anymore and reexperience intoxication (flashback).
529. Cannabinoids “ Marijuana/THC “ intoxication has euphoria, bad judgement, slowed reactions, dry mouth, conjunctival injection (dead give-away). Chronic use causes amotivational syndrome and memory impairment.
530. Hallucination is a disturbed sensory perception (visual, tactile, auditory). Delusion is a fixed, false belief (even if people prove to you otherwise). Psychosis is inability to judge boundary between real and unreal.
531. Schizophrenia “ presence of >2 s/s of the following for >6months: delusions, hallucinations (generally auditory, link visual c alcohol withdrawal), disorganized speech/behavior, negative s/s (flat affect, no speech, no motivation, anhedonia). Better prognosis (NBME 3 question) if acute, late onset, good social/occupation hx, positive s/s, medication compliance, married, female gender. Symptoms due to altered dopamine activity (newer antipsychotics affect serotonin also). Negative s/s have enlargement of cerebral ventricles and hypoactive frontal lobe. Tx: 1st assess if pt needs hospitalization (protect self/others), 2nd Antipsychotics (Risperidone), 3rd Psychosocial tx. [Timeline: <1month = brieft psychotic d/o, 1-6months = schizophreniform, >6mo = schizophrenia]
532. Delusional (Paranoid) Disorder “ persistent, nonbizarre, well-systematized delusion. Erotomanic (on is loved by a famous other, NBME 3 TQ), grandiose (one possesses great talent), jealous (conviction that lover is unfaithful), persecutory (one is conspired against, MC), somatic (one has a physical abnormality like odor). Tx: 1st hospitalization for inability to control suicidal/homicidal impulses or danger a/w delusions, 2nd psychotherapy, 3rd antipsychotics/antidepressants.
533. Schizophreniform “ schizophrenia <6months. Good prognosis c acute onset, confusion, disorientation, full affect, tx c antipsychotics for at least 6 months.
534. Brief Psychotic Disorder “ sudden onset of psychotic s/s c emotional turmoil and confusion, often following obvious stressor, duration <1month. Suicide risk, thus tx 1st hospitilization as needed, 2nd antipsychotics/antianxiety agent, 3rd psychotherapy
535. Schizoaffective “ schizophrenia c depression or mania for at least 2 weeks.
536. Shared Psychotic disorder “ submissive, dependent isolated relationship with person c established delusion. Suicide/homicide pacts. Tx: 1st separate the 2 people, 2nd antipsychotics.
537. Mania “ >1wk of elevated, expansive, irritable mood c grandiosity, no sleep, talkativeness, impulsitivity (shopping sprees, gambling, promiscuity) , racing thoughts, distractibility, agitation. Hypomania is less severe and lasts >4days.
538. Major depression disorder (MDD)“ 2 of SIGECAPS in >2wks“ sleep changes (delayed sleep onset, decreased REM. Note the difference: Anxiety has increased REM latency, depression and narcolepsy have decreased REM latency), interest loss, guilt, energy loss, concentration decreased, appetite (up or down), psychomotor (retardation or agitation), suicidality. Decreased serotonergic activity a/w violence and suicide. Tx: Hospitalize if suicide risk, 2nd Antidepressant (SSRI 1st) for 6-12 months (not that it takes 4-6wks to start effects), 3rd ECT (rapid response in pregnancy, elderly, medically ill), 4th psychotherapy, 5th antipscyhotic + antidepressant for psychotic pts, 5th Phototherapy if depression is seasonal, 6th treat comorbid psychopathology (anxiety, substance abuse, personality d/o, ADHD).
539. Depression vs Bereavement “ Depression (mood pervasive/unremitting, constant low self-esteem/worthlessness, suicidal, sustained psychotic s/s, no improvement c treatment, social withdrawal). Bereavement (mood fluctuates, self-reproach regarding deceased, not suicidal, transient visual/auditory hallucinations or deceased, s/s improve c time and usually gone by 6 months, often welcomes social support). It is normal to have an illusion or hallucination about the deceased, but a normal grieving person knows that it is an illusion or hallucination, while an MDD pt thinks its real. Other clues to MDD that are not normal are feeling of worthlessness, suicidality and psychomotor retardation.
540. Bipolar Disorders: Type I is full-blown mania c MDD. Type II is hypomania c MDD. Tx: 1st assess risk of suicide, assaultiveness, dangerous poor judgement. 2nd For acute mania give mood stabilizer (lithium). For depression “ modd stabilizer c or w/o antidepressant if necessary.
541. Cyclothymia “ numerous hypomanic episodes c depressive episodes for >2yrs. (Cyclo is a psycho, while dysthymia is just depression for >2yrs).
542. Panic Disorder “ minutes to hours of unexpected, sudden intense anxiety, dyspnea, parasthesia, CP, fear of dying. A/w agoraphobia (fear of places where escape is difficult such as bridges, public transportation, large crowds, traveling). Tx: 1st If acute, emergent case, give reassurance and benzo (alprazolam, clonazepam). 2nd R/o MI, PE, CVA, hypoglycemia, 3rd Antidepressants (SSRI is tx of choice for long-term management), 4th Cognitive-behavioral therapy (CBT) for agoraphobia.
543. Obsessive-Compulsive Disorder “ recurrent intrusive images, impulses, thoughts (obsessions) and ritualistic behaviors (compulsions) that produce anxiety and affect way of life. A/w Tourette syndrome. Abnormality is serotonin system. Tx c SSRIs (fluvoxamine), but if you only see TCA’s pick clomipramine.
544. Specific Phobia “ irrational, excessive fear and avoidance of a specific object or situation. Tx: Systemic desensitization.
545. Social Phobia “ fear of embarrassment, scrutiny of others (public speaking, eating in public, public bathrooms). Tx: 1st CBT, 2nd BB (propranolol) for stage fright, 3rd Antidepressants (not TCAs) and high-potency benzodiazepines.
546. Posttraumatic Stress Disorder “ >1 month, must have 3: reexperiencing (flashbacks), emotional numbing (avoidance), autonomic arousal (insomnia, irritability). Tx: 1st hospitalize for acute suicide, violence risk. 2nd CBT, 3rd Antidepressants.
547. Acute Stress Disorder - <1month of the same 3 symptoms. Tx c psychotherapy.
548. Generalized Anxiety Disorder “ unrealistic, persistent anxiety for >6months. Muscle tension, restlessness, poor concentration, fatiguability, irritability, loss of sleep. Tx: 1st psychotherapy, 2nd Antidepressants (Buspirone).
549. Somatorofrm Disorders “ unlike factitious disorder and malingering, the symptoms are not intentionally produced but are strongly linked to psychological factors. Examples include somatization disorder (multiple somatic complaints, tx c regularly scheduled visits c PMD), conversion disorder (neurologic s/s), pain disorder (pain in absence of adequate physical findings, tx c psychotherapy), hypochondriasis (fear of specific disease, tx c regular medical visits), and body dysmorphic disorder (preoccupation c defect in appearance, tx c psychotherapy and SSRI’s after you assess suicide risk).
550. Factitious disorder “ “Munchausen syndrome.†Intentional production of s/s for unconscious psychological reasons (need to assume sick role) usually in someone in medical occuption or c history of illness. If s/s produced by parent, this is Munchausen’s by proxy. Tx c psychiatric consult, confrontation may be helful.
551. Malingering “ intentional production of symptoms for a recognized gain (money, drugs, avoid work/military/prison).
552. Dissociative Identity disorder “ multiple personalities, which take over life and pt may or may not be aware of each other. Tx c intensive psychotherapy.
553. Amnestic Disorder “ 2 types: psychogenic fugue (sudden, unexpected travel c amnesia of old identity and assumption of new identity that lasts hours to months, pt is unaware of loss) and psychogenic amnesia (sudden inability to recall important personal information of a traumatic or stressful event, but aware of loss). Recovery usually returns spontaneously. If not, try hynosis, amobarbital or psychotherapy.
554. Depersonalization disorder “ recurrent feeling of detachment from one’s body or self (feel like you’re in an outside world).
555. Anorexia Nervosa “ must have 3: amenorrhea, minimal normal body weight, fear of gaining weight. Tx: 1st hospitalize for dehydration, starvation, hypotension, electrolyte, hypothermia, suicide risk. 2nd treatment contract for wt gain, 3rd CBT.
556. Bulimia Nervosa “ binge eating, normal weight, overconcerned c wt/diet/exercise, self-induced vomiting, laxatives/diuretics, a/w kleptomania. Tx: 1st hospitalize for ECG (hypokalemia-induced arrhythmia is MCCOD), electrolytes, amylase, LFTs, esophageal/gastric rupture, suicide risk. 2nd psychotherapy, nutritional counseling, SSRI for binging (do not give buproprion for risk of seizures).
557. Old, classic USMLE TQ: Mom finds her son having sex c another boy, is this normal or homosexuality? Normal (unless they say he enjoys it). Another TQ is a man, who knows he is a man and likes women, dresses up like a woman and acts like a woman, what is his sexual orientation? Heterosexual (b/c he likes women).
558. Projection “ attributing your own wishes to someone else. A/w paranoid personality d/o (p for p “ paranoia c projection)
559. Denial “ if they deny having a disease, next step is do nothing! (because it usually does not interfere c treatment, but if it does, next step is confront the pt).
560. Splitting “ all is good or bad. a/w borderline d/o. If they only say all is good, its idealization. If they only say all is bad, its devaluation. Splitting must have both.
561. Regression “ look for h/o bedwetting in a kid >5yo (<5yo is normal).
562. Reaction formation vs Undoing “ rxn formation is a thought, undoing is an action. Both are classically a/w obsessive compulsive d/o, where rxn formation is the obsession, and undoing is the compulstion.
563. Reaction formation vs sublimation “ sublimation does something good for mankind.
564. Primary insomnia “ disturbance in initiating, maintaining or feeling rested after sleep. Tx: 1st hygeine treatment: regularize sleep hours, use of bed only for sex/sleep, if not asleep in 30 minutes then leave bed and return only when drowsy, no napping, regular exercise but not immediately prior to bedtime, reduce/eliminate alcohol/caffeine/smoking, relaxation exercise. 2nd sedative-hypnotics (benzo, zolpidem) for short-term relief
565. Narcolepsy “ daytime drowsiness, irresistible sleep attacks c hypnagogic/hympopompic hallucinations, sleep paralysis, cataplexy (loss of muscle control c strong emotions). Tx c short daytime naps, 2nd stimulants for sleep attacks and TCAs for cataplexy.
566. Sleep apnea “ obstructive type d/t occlusion of upper airway during sleep in an obese pt. Central type is d/t reduced nocturnal resp drive). Dx c polysomnography. Tx:1st wt reduction, 2nd CPAP for obstructive type, Acetazolamide or protriptyline for central type.
567. Restless Legs Synd “ agonizing, deep creeping sensations in leg/arm muscles relieved by moving or massage. Pt has trouble falling asleep at night because of it. Tx c benzodiazepam.
568. Intermittent Explosive “ discreet episodes of loss control of aggressive impulses, but otherwise not aggressive. Tx c benzo (causes disinhibition) and CBT.
569. Kleptomania “ failure to resist stealing unnecessary and unneeded things. a/w Bulimia.
570. Pyromania “ deliberate fire setting and fascination c fire, usually in kids. Make sure the guy is not getting paid to do it and that it is completely for self-satisfaction.
571. Trichotillomania “ recurrent pulling out of one’s own hair. Tx c psychotherapy, SSRI.
572. Adjustment Disorder “excessive emotional/behavioral responses that occur within 3 months of a stressor that is within range of normal experience (unlike PTSD), such as school problems, marital discord, job loss or illness. Does not persist after 6 months of stressor. Lacks sufficient evidence to make for other diagnosis (MDD). Tx:1st evaluate suicide risk. 2nd psychotx, antianxiety, antidepressants, 3rd stress reduction.
573. Personality Disorders - Cluster A (Weird: Paranoid, Schizoid (pt wants to be alone), Schizotypal (peculiar ideations/appearance/behavior magical thinking)), Cluster B (Wild: Antisocial (exploitative, destructive, impulsive behavior c no remorse. Childhood h/o conduct d/o essential for dx. Tx c SSRI), Borderline (instability of self-image, identity, relationships and mood. Does crazy things and still feels empty inside. h/o child abuse. Tx c pschotx (long-term), SSRI for mood stability and impulsitivity, haloperidol for psychosis. Avoid benzo), Histrionic (attention seeking, hits on the doctor, needs praise and reassurance), Narcissistic (grandiose, mad if humiliated, lack of empathy). Cluster C (Worried: Obsessive-compulsive (tx c fluvoxamine), Dependent, Avoidant (does not want to be alone (unlike schizoid), but fears rejection)
574. Antipsychotics (Neuroleptics): Low-doses (thioridazine, chlorpromazein), high-doses/long-acting (haloperidol, fluphenazine. Highest risk of EPS, NMS), atypical (clozapine, risperidone, olanzapine, quetiapine, ziprasidone). Typicals block dopamine (D2) receptors, thus used for positive symptoms only and have many side-effects, while Atypicals block serotonin (5-HT), D2 and D4, thus can be used for positive and negative symptoms and have fever side-effects. Adverse-effects: Hours-Days: Dystonia (spasms), Torticollis and oculogyric crisis (eyes stay looking up). Tx c benztropine, diphenhydramine or trihexylphenidate. Weeks: Akathisia (restlessness). Tx c lowering drug-dose, benzo, BB, or switch to atypical (best). Months: Tardive dyskinesia (lip-smacking). Tx c switching to atypical. Neuroleptic malignant syndrome: MC c high-potency drugs, increased risk if used c lithium, fever, rigidity, autonomic instability, very high CPK levels, high K+, tx c IV dantrolene or bromocriptine. Clozapine causes agranulocytosis (must do weekly CBC if taking), thioridazine causes retinal pigment deposits, chlorpromazine causes jaundice and photosensitivity.
575. Newer Atypicals Adverse Effects: Risperidone (less sedative, but increases prolactin, incrase risk of movement d/o), Olanzepine (love to ask about. weight gain (MC), risk of DM), Ziprasidone (prolonged QT), Quetiapine (risk of movement d/o)
576. Antidepressants: block NE, 5-HT, Dopamine. MAOIs (bad b/c of Tyramine food reaction (cheese, red wine, chocolates, sausages). Must stop MAOI at least 2 weeks before starting TCAs or SSRI. Tx of choice for atypical depression (increased sleep/weight/appetite or Leaden paralysis)). TCAs (best ones are nortryptilline and desipramine, worst is amitriptylline. Causes hypotension, anti-cholinergic s/s, conduction defect (MCCOD, MC is sinus tachy, but USMLE loves widened QRS, tx c bicarb), sexual problems, changes in wt, sedation). SSRI (1st choice for MDD (fluoxetine, sertraline, peroxitine, citalopram, escitalopram), Anxiety (fluoxetine, sertraline, peroxitine) and OCD (fluvoxamine only). Causes headache (MC), GI upset, sedation, agitation, sexual dysfunction (worst s/s), weight gain). Others include Venlafaxine (MDD, anxiety), Duloxetine (MDD, pain d/o), Bupropion (MDD, smoking cessation), Mirtazipine (weight good (good for anorexia), sedation), Trazodone (priapism). In a nutshell, always answer SSRI unless: 1- pt c MDD and neuroleptic (spinal) pain, give duloxetine; 2 “ pt c MDD and has sexual changes/weight gain, give bupropion (not buspirone for GAD).
577. Mood stabilizers “ Depressed pt (lithium or lamotrigine) or Mixed/Manic (Lithium, valproic acid, antipsychotics). Either way, lithium is 1st line. It causes tremors, GI upset, hypothyroidism, nephrotoxic, teratogenic, acne, wt gain, leukocytosis, ataxia, and seizures. Must get weekly blood levels and must get TSH, BUN/Cr, hCG before starting it. If renal disease, pick valproic acid, if very acute mania pick haloperidol, otherwise always go with lithium first. Never discontinue lithium abruptly and levels >3.0 is a medical emergency that needs IV saline or hemodialysis.
578. Electroconvulsive therapy “ increases serotonin for conditions like MDD, mania and schizophrenia. No absolute contraindications. Only relative CI is high intracranial pressure (brain tumors). Who gets it? Suicidal pt (tx of choice), those who don’t respond to meds, pregnancy, h/o benefit c ECT, medication complications. MC adverse effect is memory loss.
579. Benzodiazepines “ all work on CP450 exams OTL (Oxazepam, Temazepam, Lorazepam), so remember OTL for Outside The Liver.
580. Suicide “ if pt mentions it, next step is to ask more questions (attempt, ideations), then admit. Risks: h/o attempt (best indicator of eventual success), hopelessness, psychiatric/physical illness, drug abuse, elderly, social isolation (living alone is worse than single, they are not the same thing!), low job satisfaction. MC method in males are guns, females are guns. MC attempt in males are guns, females are pills.