Psychiatry & Behavioral Health PAEA EOR
Terms in this set (150)
Bipolar 1 Disorder Definition
≥ 1 manic episode and occasional MAJOR DEPRESSIVE episodes
Bipolar 1 Disorder strongest risk factor
Abnormal & persistently elevated, expansive or irritable mood (at least 1 week, or less if hospitalization required), marked impairment of social/occupational function
Thinking (racing, disorganized)
Behavior (Bipolar 1 Disorderhyper, pressured speech, risk taking...)
Bipolar 2 Disorder
Hypomania + Major depressive episode*
Bipolar 1 Disorder Management
Mood stabilizers (2nd or 1st gen antipsychotics, may add SSRI for depressive sx)
Period of eleood stabilizers (2nd or 1st gen antipsychotics, may add SSRI for depressive sx)vated, expansive or irritable mood (at least 4 days that is clearly different from normal depressed mood), does not cause marked impairment (no psychotic features)
Thinking: racing, disorganized...
Behavior: hyper, pressured speech, excessive involvement in pleasurable activities
Bipolar 2 Disorder Management
1. Mania: Lithium, valproate, 2nd gen antipsychotics
2. Depression: (same as mania)
3. Mixed: atypical antipsychotics, valproate
Major Depressive Disorder
Less severe version of bipolar, often longer lasting
Mania: never, but periods of elevation.
Depression: symptoms but no full episode within 1st 2 years
Hypomania: may have sx, but do not meet full criteria
Major Depressive Disorder Definition
Depressed mood + anhedonia w/ ≥5 assoc sx almost everyday for most of the day x2 weeks*
Absence of mania or hypomania
Major Depressive Disorder Sx
Fatigue, sleep changes, guilt/worthlessness, recurring thoughts of death/suicide...
Constipation, headache, skin changes, chest/abd pain...
Major Depressive Disorder Risk factor
Major Depressive Disorder Pathopysiology
Alteration in neurotransmitters
Major Depressive Disorder Management
1. Psychotherapy: 1st line in mild to moderate depression
2. Medications: SSRIs first line medical tx*
3. Cognitive behavioral therapy
Severity of mood does not meet criteria for major depression. (chronically depressed >2y in adults, >1y in children).
Persistent Depressive Disorder
Includes chronic major depressive disorder & dysthymic disorder.
Generalized Anxiety Disorder
Excessive anxiety or worry a majority of days in a 6 month period associated w/ ≥3: fatigue, restlessness, difficulty concentrating, muscle tension, sleep disturbance, irritability, shakiness, headaches.
Generalized Anxiety Disorder Management
1. Antidepressants: SSRIs (paroxetine & escitalopram)
2. Buspirone (Buspar): does not cause sedation
3. Benzodiazepines (short term only), beta blockers
Diffuse, unpleasant, vague sense of apprehension, often accompanied by autonomic symptoms (ex sweating, palpitations, etc)
Sense of danger becomes prominent
Episode of intense fear or discomfort, with ≥4 of the following sx developing abruptly, reaching a peak in 10 minutes:
palpitations, trembling, choking feeling, parathesia, sweating, shortness of breath, chest pain, chills of hot flashes, dizziness, fear of dying/losing control/being detached, nausea/abdominal distress
Panic Disorder Criteria
Symptoms not due to substance, medical condition or other mental disorder
Recurrent, unexpected panic attacks (at least 2), not related to a trigger. Famial trait.
Panic attacked followed by concern about more attacks, worry about the implication of the attacks, significant change in behavior realted to the attacks.
Included with panic disorder
Anxiety about being in a certain place or situation (fear of crowds, wide open spaces, avoidance of these situations)
Panic Disorder Management
1. SSRIs 1st line long-term tx* (paroxetine, sertraline, fluoxetine)
2. Benzodiazepines: for acute attacks
3. Cognitive behavioral therapy (CBT)
Post-traumatic Stress Disorder (PTSD)
1. exposed to a traumatic event & actual or threatened death or serious injury/violation to self or others AND
2. the response may involve helplessness, dissociative sx, avoidance of associated stimuli, emotional numbing, increased autonomic arousal
PTSD MC group
Young adults (combat exp, urban violence, rape, assualt, other traumatic event (ex. adult survivors of sexual abuse)
Trauma is re-experienced: >1 month as recollections (dreams, acting/feeling if event were recurring) AND avoidance of related stimuli
1. Anti-depressants: SSRIs 1st line tx* (paroxetine, sertraline, fluoxetine)
2. Cognitive behavioral therapy
Social Anxiety Disorder (Social Phobia)
Marked or persistent fear of social or performance situations in which the person is exposed to scrutiny of others (fear of embarrassment). Expected panic attacks.
Social Anxiety Disorder (Social Phobia) Management
1. Antidepressants: SSRIs
Acute Stress Disorder
Similar to PTSD but sx <1 month. Anxiety as a result of an extraordinary life stress event
Acute Stress Disorder Management
Counseling/psychotherapy. If persistent, tx as PTSD
Refusal to maintain a minimally normal body weight
1. self induced starvation
2. relentless desire for thinness (morbid fear of fatness)
3. medical signs/symptoms stemming from starvation. Depression in 60%
Anorexia Nervosa MC group
Anorexia Nervosa Clinical Manifestations
1. BMI <17%*
2. misuse of weight loss medications (laxatives, enema, diuretics...)
Anorexia Nervosa Diagnosis
1. Vital signs: emaciated, hypotension, bradycardia, skin/hair changes (lanugo), dry skin, salivary gland hypertrophy, amenorrhea
2. Labs: CBC: leukocytosis, leukopenia, anemia; hypokalemia, ↑BUN (dehydration), hypothyroidism, arrhythmias
Anorexia Nervosa Management
1. Hospitalization for <75% expected body weight to stabilize medically
2. Psychotherapy: cognitive behavioral therapy
3. Pharmacotherapy: if depression SSRI, atypical anti-pshychotics (help w/ weight gain as well)
-Similar to anorexia but engage in compensatory purging behaviors at least once a week
-Major difference is patients w/ bulimia are normal weight or even overweight
Bulimia Nervosa Clinical Manifestations
1. Binge-eating: recurrent episodes characterized by eating c/n 2 hour period more than people would in a similar period c lack of control during at eating episode
2. Purging: Compensatory purging behaviors: misuse of weight loss medications: laxatives, enema, diuretics, excessive exercise, self-induced vomiting, drinks excess water, fasting
Bulimia Nervosa Diagnosis
1. Teeth pitting or enamel erosion (from vomiting), may have callus on finger used to induce vomiting
2. Labs: hypokalemia, hypomagnesemia
Bulimia Nervosa Management
1. Psychotherapy: cognitive behavioral therapy
2. Pharmacotherapy: Fluoxetine has been shown to reduce binge-purge cycle (but may have cardiovascular side effects especially if electrolyte abnormalities are present.
Antisocial Personality Disorder
Behaviors deviating sharply from the norms, values & laws of society (harmful or hostile to society). VIOLATES THE RIGHTS OF OTHERS. MUST BE 18y TO DX.
Antisocial Personality Disorder Clinical Manifestations
1. Inability to conform to social norms w/ disregard & violation of the rights of others. Drunk driving common.
Antisocial Personality Disorder Management
1. Psychotherapy: establishing limits
2. Pharmacologic: not helpful. Conduct disorders in children may lead to antisocial in adulthood*
Borderline Personality Disorder
Unstable, unpredictable mood affect, unstable self image & relationships. MOOD SWINGS, moments of intense anger. MC in women.
Borderline Personality Disorder Clinical Manifestations
1. Extreme pattern of instability in relationships but cannot tolerate "being alone"
2. "Black and white thinking"
3. Self-harm: suicide threats, self-mutilation. Substance abuse, reckless driving, binge eating, self-damaging behaviors.
Borderline Personality Disorder Management
1. Psychotherapy: including group therapy tx of choice!
2. Pharmacologic: ± short term low doses antipsychotics, antidepressants or benzodiazepines
Histrionic Personality Disorder
Overly EMOTIONAL, DRAMATIC, SEDUCTIVE. ATTENTION SEEKING*
Histrionic Personality Disorder Clinical Manifestations
1. Self-absorbed, "temper tantrums", need to be center of attention, inapropriate, seductive, shallow or exaggerated emotions.
Histrionic Personality Disorder Management
Psychotherapy: including group therapy tx of choice
Narcicisstic Personality Disorder
Grandiose often excessive sense of self-importance* but needs praise and admiration
Narcicisstic Personality Disorder Clinical Manifestations
Consider themselves special, entitled, require extra special attention BUT have a fragile self esteem. Lacks empathy. Difficulty w/ aging process, jealous or believes others are envious of them.
Narcicisstic Personality Disorder Management
Psychotherapy: including group therapy tx of choice!
Avoidant Personality Disorder
Desires relationships but avoids them "inferiority complex"* (intense feelings of inadequacy, very sensitive to criticism, timid, shy, lacks confidence)
Avoidant Personality Disorder Management
1. Psychotherapy: establishing limits
2. Pharmacologic: ± beta blockers for anxiety or SSRIs for depression
Dependent Personality Disorder
Dependent submissive behavior
Dependent Personality Disorder Clinical Manifestations
Constantly need to be reassured, relies on others, will not initate things, intense discomfort when alone, may volunteer for unpleasant tasks.
Obsessive-Compulsive Personality Disorder
Perfectionists whoe require a great deal of order & control. ORDER and PERFECTION paramount*. Preoccupied w/ minute details.
Obsessive-Compulsive Personality Disorder Management
1. Psychotherapy: only personality disorder where patients frequently seek help.
2. Pharmacologic: ± Beta blockers for anxiety or SSRIs for depression
obsessive-compulsive disorder (OCD)
Obsessions, compulsions, or both (75%), men present age 20, men=women, but men present earlier
Obsessive-Compulsive Disorder clinical manifestations
4 major patterns: contamination, doubt, symmetry / precision, and intrusive thoughts without compulsion
Obsessive-Compulsive Disorder Management
1. Antidepressants: SSRI's (may also try TCAs)
2. Cognitive Behavioral therapy
recurrent / persistent thoughts; thoughts are NOT excessive worries about real life problems. Patients often try to suppress thoughts .
Repetative behaviors the person is driven to perform.
Anemotional reaction to an identified stressor (ex. Job loss, physical illness) or an event that causes a DIPRAPORTIONATE response than would normally be expected c/n 3 MONTHS of stressor
-sx usually remiss by 6mo
Schizoid personality disorder
Long pattern of voluntary social withdrawal, anhedonic introversion (constricted affect)
-usually early childhood onset
-MC in Males
-Hermit-like behavior (reclusive)
Schizoid personality disorder clinical manifestations
1. inability to form relationships, lifelong pattern of social withdrawal. Prefer to be alone (take no enjoyment in close relationships, sex)*
2.Anhedonic: appears indifferent to others, lack of response to praise or criticism or feelings expressed by others
3. Appear eccentric, isolated, or lonely, "cold" flattened affect
Schizoid personality disorder treatment
2. Pharmacologic: low dose antipsychotics, antideppressants, or psychostimulants
Schizotypal personality disorder
Odd eccentric behavior and peculiar thought patterns suggestive of schizophrenia but WITHOUT psychosis (delusions)
-"Strange, Eccentric" behavior
Schizotypal personality disorder clinical manifestations
1. Odd in behavior or appearance, innapropriate affect, "Magical thinking" (believes in clairvoyance, telepathy, supersitions, etc),
2. Pervasive discomfort with close relationships, may talk to self in public
Schizotypal personality disorder management
1. Psychotherapy: group therapy tx of choice
2. Pharmacologic: low dose antipsychotics, antideppressants, or psychostimulants
Paranoid personality disorder
Distrust and suspiciousness. Begins in ealy adulthood, MC in males
Paranoid personality disorder clinical manifestations
1. Distrust and suspiciousness: systemized delusions of persecutions or grandeur without hallucinations
-Preoccupation with doubt regarding the loyalty of others.
Paranoid personality disorder treatment
1. Psychotherapy: group therapy tx of choice
2. Pharmacologic: short-term - low dose antipsychotics, if severe haldol
Body dysmorphic disorder
excessive preoccupation that a body part (or slight anomaly) is deforemed, this often causes them to feel ashamed
Disorder that meets criteria for schizophrenia but has had sx for less than 6mo duration.
Schizophrenia + mood disorder
paranoid disorders, delusions about things that could happen in real life (being followed, poisoned)
>6 mo duration of illness with 1 month of acute sx along with functional decline and greater than or equal to two of the following:
3. disorganized speech
4. disorganized/catatonic sx
5. Negative sx - paranoid, disorganized (behavior, speech, affect), catatonic (silent, does not respond to stimuli), residual (socially withdrawn)
Pathophysiology of schizophrenia
-Positive sx: Hallucinations, delusions, disorganized speech and thinking, movement disorders
these are caused by excess dopamine receptors in the mesolimbic pathway
-Negative sx: flat affect - caused by dopamine dysfunction in the mesocortical pathway
-1% of population. !0% incidence if 1st degree relative is schizophrenic
Management of schizophrenia
1. Antipsychotics: Dopamine receptor antagonists
-2nd gen: 1st line tx!* - Clozapine, risperidone, olanzapine
-1st gen: chlorpromazine or haloperidol (increased extrapyrimidal sx)
chronic condition in which patient HAS physical sx involving one or more part of the body, but NO physical cause found.
-pts have multiple physical complaints with preoccupation with medical or surgical therapy
Neurologic loss of sensory or motor function suggestive of a physical disorder but caused by psychological factors. Sx are not intentionally produced or feigned
Illness anxiety disorder
Preoccupation with the fear or belief one has a serious, undiagnosed disease (despite reassurance)
- age 20-30y, tend to "doctor shop"
-managed with group therapy
Spectrum of development disorders with probable etiology linked to a combination of prenatal virual exposure, immune system abnormality, and genetics
-Impairment in several areas of development:
Clinical manifestation of autism
-social interaction difficulties: significant emotional discomfort or detachment (ex avoiding eye contact, no response to cuddling)
-Communication difficulties: either inability to communicate or has the ability but chooses not to in social settings
2. Other signs
-persistent failure to develop social relationships
-failure to shw preference to parents over other adults
-unusual sensitivity to visual, auditory, or olfactory stimuli
-unusual attachments to ordinary objects
Management of autism
Referral for neuropsychological testing, behavioral modification strategies, medications
Oppositional defiant disorder
Persistent pattern of negative, hostile, and defiant behavior towards adults. BLAMES OTHERS.
3 components: 1. angry/irritable mood, 2. argumentative/defiant behaviors and 3. vindictiveness
Oppositional Defiant Disorder management
Attention-deficit hyperactivity disorder (ADHD)
Short attention span, easy distractability (sometimes with hyper focus), hyperactivity, impulsivity
-duration more than 6 mo (onset before age 7)
-no association with psychosis,
-Sx must occur in more than one setting (ex school, home)
Management of ADHD
1. Behavor modification
2. Stimulant drugs: sympathomimetic
-Methylphenidate (ritalin), D-amphetamine (adderall), atomexetine (strattera), Vyvanse
patterns of behavior in which the rights of others or basic social rules are violated
- lack of remorse/ guilt, defies authority.
-Sets fires, steals, is cruel to animals / people.
-poor prognosis... 40% develop antisocial personality disorder. MC in boys
avoid in patients with long QT syndrome
Buproprion (Wellbutrin, Zyban)
phenelzine, tranylcypromine, isocarboxazid, selegiline
typical antipsychotic "1st gen"
Typical Antipsychotic; Antiemetic
typical antipsychotics, antiemetic
MOA of Risperidone [Risperdal]
Partial dopamine D2 receptor and serotonin 5-HT1a receptor antagonist, Serotonin 5-HT2 receptor antagonist
Indications for Risperidone or Ziprasidone
Psychotic disorders (schizophrenia, bipolar)
Risperdal used for Tourette's
S/E for Risperidone or Ziprasidone
EPS, INCREASED PROLACTIN*, sedation, weight gain, hypotension
Aripriprazole (Abilify) Class, MOA, and IND
"3rd gen" atypical antipsychotic
MOA: exact unkown, but blocks D2 receptors, 5-HT1 and 5HT2 receptors
Indicated in psychotic disorders
Lithium MOA and side effects
MOA: increases Ne and 5HT receptor sensitivity
S/E: Hypothyroidism, sodium depletion, increased urination and thirst, diabetes insipidus, sz, arrhythmias, hyperparathyroidism
Monitor: Narrow therapeutic index
Anticovulsants may help suppress impulsive and aggressive behavior
1st line therapy for depression*, anxiety disorder. Preferred over other classes for children. Low toxicity in case of overdose.
SSRI side effects
GI upset, sexual dysfunction, nervousness, headaches, dry mouth
Toxic level of Serotonin, caused by any drugs that increase 5-HT (e.g., MAO inhibitors, SNRIs, TCAs) -Sx: hyperthermia, acute AMS, tremor, sinus tachycardia, flushing, diarrhea, seizures, abdominal cramps, mydriasis.
-Treatment: cyproheptadine (5-HT2 receptor antagonist).
May be used as a first line agent particularly in patients with significant fatigue or pain syndromes in association with depression.
-Used as 2nd line agents in patients with no response to SSRIs
SNRI side effects
B - Body weight increase;
A - Anorexia;
D - Dizziness;
S - Suicidal thoughts;
N - Nausea, Vomiting;
R - Reproductive/Sexual dysfunction
I - Insomnia;
also monitor for LIVER toxicity
MAOI use (serotonin syndrome), renal/hepatic impairment, seizures, and avoid abrupt discontinuation. Use with caution in HTN
Will cause Serotonin syndrome if used in conjunction with St. John's wort.
Block reuptake of NE and serotonin
TCAs side effects
anticholingeric - dry mouth, blurred vision, constipation, memory problems
antihistaminergic - sedation and wt gain
Prolonged QT intervals
Overdose will cause sinus tachycardia with Wide complex tachycardia
MDD, Bipolar depression, dysthymia, panic d/o, generalized social phobia, GAD, OCD (clomipramine), pain.
-Generally used less often due to side effect profile and toxicity of overdose.
Mirtazapine (Remeron) MOA
enhance NE and 5HT activity
Mirtazapine (Remeron) side effects
Less nausea and sexual AE
Weight gain, dizziness, dry mouth
Do not use with an MAOI!
Bupropion (Wellbutrin) MOA
Blocks norepinephrine and dopamine reuptake
Bupropion (Wellbutrin) Indications
Depression; smoking cessation
-Has less sexual dysfunction and GI distress compared to SSRIs
Bupropion (Wellbutrin) side effects
Seizures* (lowers threshold), agitation, anxiety, restlessness, weight loss
Bupoprion (Wellbutrin) contraindications
Seizure disorders*, avoid abrupt withdrawal, bulemia, anorexia, etoh detox
extrapyramidal symptoms caused by antipsychotic medications
Rigidity, bradykinesia, tremor, akisthesia (restlessness). High incidence seen in typical antipsychotics.*
3 common EPS syndromes:
1. Dystonic reactions (dystonia) (reversible)
2. Tardive Dyskinesia
Side effects of typical antipsychotics
Higher risk of extrapyramidal symptoms (EPS)
Dystonia: prolonged muscle contractions
Akathisia: can't stop moving
Tardive dyskinesia (potentially permanent): can't control any of your muscles
Neuroleptic Malignant Syndrome: state of autonomic dysfunction. A lot of histamine blockade, alpha adrenergic and muscarinic blockade
Weight gain, QT prolongation, cardiac arrhythmias, sedation
Contraindication for Haldol
Parkinsons disease, anticoagulant use
Management of dyskinesia
IV Diphenhydramine, or add anticholinergic agents (ex benxotropine)
repetitive, involuntary movements of the jaw, tongue, face, and mouth and body tremors resulting from the extended use of traditional antipsychotic drugs
Neuroleptic Malignant Syndrome (NMS)
Life threatening disorder due to D2 inhibition in basal ganglia:
-Mental status changes, Extreme muscle rigidity, tremor, autonomic instability (tachycardia, tachypnea, hyperthermia/fever*, incontinence, profuse diaphoreses, BP changes). Leukocytosis
-MC within 90 dyas of intitiaion/dose increase
-MC in young adults
Neuroleptic Malignant Syndrome Treatment
-Stop offending agent!
-Tx hyperthermia with cooling blankets and dantrolene.
atypical antipsychotics indications
1st line for psychotic disorders. (clozapine is useful in patients who are resistant to other psych medications.
atypical antipsychotics side effects
Less EPS compared to first generation (esp less with clozapine and quetiapine)
-Clozapine causes agranulocytosis
-Marked DM and weight gain with Olanzapine