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EMMA Holliday - psychiatry
Terms in this set (249)
1. schizophrenia - over 6 mos
2. schizophreniform - 1-6 mos
3. brief psychotic disorder - less that 1 mo
4. schizoaffective - more than 2 wks (psychosis + mood episode; then psychosis may come w/out mood episode)
5. delusional - more than 1 mo
Schizophrenia - what is it?
time duration and
Brain chemicals & histology
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
Diagnosis requires 2 or more of the following
(first 4 in this list are "positive symptoms"):
Disorganized thought/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
Most treatable type of schizophrenia
Prevalence in society of schizophrenia
Risk of Twin for schizoprenia --
Risk of sibling --
Schizophrenia: how many positive symptoms do you need to have?
If bizarre delusions or hearing voices you only need 1
other wise you need 2 for greater then 6 months
chemistry for Positive symptoms for schizophrenia
too much dopamine in the mesolimbic tract
chemistry for Negative symptoms from where in the brain and why
not enough dopamine in the mesocortical tract
Dopamine systems of the brain
for +/- symptoms; EPS, prolactin
+ symptom: mesolimbic tract (midbrain & nucleus accumbens - reward/arosal, memory, behavior)
- symptom: mesocortical (cognition, socialization)
Major side effect
EPS - negostriatal modulation
prolactinemia - Tuberoinfundibular
Dx: A patient has delusions hallucination and flattened affect for 3 weeks
Brief psychotic disorder (MORE THEN A WEEK AND LESS THEN A MONTH)
Dx: A patient has delusions hallucination and flattened affect for > 1 mon and < 6 mons
Typical antipsychotics help what symptoms in schizophrenia
they help the positive symptoms but have no effect on the progression
difference between schizoaffective disorder and depression with psychotic features
What was present first without the other...
Major depressive disorder with psychotic features: delusion only appeared after he developed depressive symptoms.
Schizoaffective disorder: must have psychosis for at least 2 weeks without a mood disorder.
Dx: A patient has had MDD for 3 years and reports hearing voices telling him he is worthless and to kill himself; tx? (2)
MDD with Psychotic Features.
Delusions are typically mood congruent.
Tx w/ Atypical antipsychotic + SSRI or ECT (esp in preggos)
Dx: A patient has had persecutory delusions for the past 3 years ( has be diagnosised with schizoprenia before) . 6 months ago he started having sadness, guilt, insomnia, ↓concentration, SI; tx? (3)
Schizoaffective Disorder.(delusions/hallucinations for >2wks in absence of mood ss)
Tx w/ Atypical antipsychotics + SSRI if depression and + Li if manic
Tx: A man is convinced Miley Cyrus is in love with him but is otherwise functional; tx?
Tx w/ therapeutic relationship + meds
DOC for acute agitation or psychosis
Quick onset of action
Blocks ( antagonist) the d2 dopamine receptor
Low potency typical antipsychotics: (
hieves are low)
Chlorpromazine and Thioridazine. Less EPS more anti-Ach
side effects (anticholinergic, antihistamine, and α1-blockade effects).
Side effects of Chlorpromazine
Side effects of Thioridazine
Haldo affects on the nigrostriatal path and the tubularinfundibulum
Nigrostrial - causes EPS
Tubularinfundubulum - Hyperprolactinemia
High potency Antiphyscotics : (Try to Fly High)—
: Trifluoperazine, Fluphenazine,
—neurologic side effects (EPS symptoms).
Side effects of haloperidol (2 main categories)
4 hr: acute dystonia
4 ds: akathesia/Parkinsonian
4 wk: bradykinesia
4 mo: tardive dyskinesia.
Mneumonic for Neuroleptic syndrom
igidity of muscles
Neuroleptic malignant syndrome (NMS) tx: (2)
Treatment: dantrolene, D2
agonists (e.g., bromocriptine).
If patient w/ psychosis has a history of medication non-adherence, what rx to give
need to give an injection to ensure compliance- Fluphenazine or haldol aka decanoate forms every 2-4wks.
drug side effect: Purple grey metallic rash over sun-exposed areas and jaundice?
drug side effect: Prolonged
and pigmentary retinopathy?
- prolonged QTC- can lead to torsades
drug side effect: Pt wakes up with eyes "stuck" looking up or head "stuck" turned to the side; tx (2)?
Tx w/ benztropine or diphenhydramine
drug side effect: Pt reports feeling like they "always have to move"; tx (2)?
Akathesia. (30-90 days).
Tx w/ propranolol (1stline) or benzo
drug side effect: coarse resting tremor, masked facies, unsteady gait, bradykinesia; tx (4)? avoid (1)?
Tx w/ benztropine/diphenhydramine, amantadine (DA releasing agent) or bromocriptine.
After 10 years on fluphenazine, tongue movements and grimacing. tx (2)?
Tardive Dyskinesia. (>years)
Tx by stopping antipsychotic and switching to and atypical or clozapine.
W/in hours of a haloperidol injections, pt has ↑CPK, T = 103F, rigidity, autonomic instability, and delirium; other high yield drugs (3)?
Neuroleptic Malignant Syndrome.
1st-d/c the offending med.
2nd-cooling blankets and dantroline Na or bromocriptine (2ndline).
Remember that metoclopramide, compazine and droperidol can cause.
drug: Weight neutral but prolongs the QTc?
drug: Weight neutral but increases akathesia?
Atypical agent w/ highest risk for EPS and ↑prolactin
Risperidone. But comes in depo shot
drug: Most assoc w/ weight gain? (but #1 S/E is sedation.)
drug: causes orthostasis and cataracts?
Quetiapine (alpha blocking properties)
drug: Good for tx-refractory schizophrenia?
Most Common S/E- Clozapine (4)
Sedation, weight gain, ↑blood sugar and lipids
Most Danagerous S/E- Clozapine (2)
Agranulocytosis, decreased seizure threshold.
What do you monitor and for how long with clozapine; what is the criteria to d/c?
CBC --> ANC q week for 6mo and q2wks for next 6mo.
D/c if WBCs<3000 or ANC<1500
6 Mood disorders
1. manic - over 1 wk
2. hypomania - over 4 days super productive
6. grief - less than 6 mos
3 Bipolar disorders
Bipolar 1 - 1 manic episode over 1 wk
Bipolar 2 - hypomanic over 4 days (almost 1 wk)
Cyclothymic - hypomanic + mild depression over 2 yrs
5 depression d/o
1. major depressive d/o
2. persistent depressive d/o (dysthymia) - over 2 yrs; never symptom free for 2 mos
3. atypical depression
4. seasonal affective d/o
5. (uw) MDD w/ psychotic features
3 post partum depressive d/o
w/in 4 wks postpartum
Maternal blues - 1 wk
Postpartum depression - 3 wk
What the most important 1st question to ask the patient
Sucisidal ideation - because this is the most likely to kill the patient
MDD duration & mnemonic
6-12 mos; SIG-E-CAPS
depressed + anhedonia +
RF for Suicidal ideation (4)
#1 - prior attempt
> 45 white male with a serious illness a detailed plan, no support decreased support
use of ETOH and drugs
polysomnogram for a depressed person
Early REM latency and more frequent REM
Hormone that is high in a patient with depression
Coritsol, the dexamethsone supression test would be abnormal
Medications that might cause Depression in addition to EtOH & opiates (5)? what withdrawal (2)?
IFN (interferon), beta-blockers, α-methyldopa, L-dopa, OCPs,
cocaine /amph withdrawal.
Medical diseases that might cause depression? what stroke?
2 infection, 1 GI, 2 endocrine, 2 hemoc, 2 genetic, 1 autoimmune
Infection: HIV, Lyme
GI: Liver disease
Endodrine: Hypothyroidism, Cushings
Hemoc: Porphyria, Uremia
Inherited: Huntington's, MS
(middle cerebral artery)
What is the number 1 class of drugs used for the txt of depression (4 examples) and what other disease (4) can you treat with these drugs
SSRI-Fluoxetine/prozac, paroxetine/paxil, sertraline/zoloft, citalopram/celexa, escitalopram/lexapro
Also used in OCD, Bulimia, anxiety or premature ejaculation (Paxil)
major side effect for SSRI; 7 clinical presentation, what worsens it (3)? tx?
Serotonin syndrome w/ any drug that increases 5HT e.g. MAO inhibitors, SNRIs, TCAs
hyperthermia, confusion, myoclonus, SZ
CV collapse, flushing, diarrhea
Treatment: cyproheptadine (5-HT2
SSRI side effect other than serotonin syndrome (2)
Fewer than TCAs.
GI distress, sexual dysfunction (anorgasmia and decreased libido).
With SSRI has the most Drug drug interactions
What SSRI do you not need to taper when stoping
Which SSRi has the fewest Drug drug interactions
if a patient is taking an SSRI and stops it suddenly and experiences HA, N/V/D dizziness and fatigue; most common in what SSRI (2)?
5HT discontinuation syndrome: more common with sertraline and fluvoxamine
Myoclonic jerks, tachycardia, High BP, hyperreflexia, n/v/d
5HT syndrom - If SSRI + MAOi
needs a 2wk wash out period b/w MAOi b/f starting SSRi
IF you have a loss of erection/ ejaculation w/ SSRI
Switch to buproprione/Wellbutrin
(dopamine and norepinephrine inhibitor )
Contraindications of buproprione (3)
all because increased rick of seizures.
drug side effect: Erections lasting longer then 3 hours
Anti-depressant for old skinny sad ladies
MIRTAZEPINE - Sedating increases appetite
What Anti-depressents NOT for hypertensives OR those taking st johns wart; what class of drug is it? other example?
VENALFAXINE/Effexor; CYP inducer
SNRI - also duloxetine/Cymbalta
drug side effect: what class of drug causes Pounding HA, flushing, nausea, myoclonus after eating cheese, drinking red wine, taking decongestant or merperidine? tx?
Hypertensive crisis w/ MAOI.
Tx w/ 5mg IV phentolamine
(merperidine = demerol)
kid ate some unidentified pills out of grandma's purse. Grandma has HTN, HLP, fibromyalgia, insomnia and peptic ulcer disease. He now has dry mouth, tachycardia, vomiting, urinary retention, and seizures
EKG for TCA OD?
widened QRS + prolonged QT intervals
Most common cause of death in a kid who ingested Tricyclic antidepressants
Arrhythmia--> torsades, v-fib and death
What is the Treatment for tricyclic overdose (2)
sodium bicarbonate - helps metabolic acidosis and is cardio protective
but if early on give acitvated charcoal (w/in 1-2hr)
Dx: Patient who is eating more, gaining weight, sleeping more and has leaden paralysis in the morning; these pt are hypersensitive to? tx?
Atypical depression -
these peple are hypersenstivie to rejection and can affect social functing
treat with MAOi
After death of her child, a mother feels guilty cant sleep, concentrate, eat, or enjoy her interests; tx?
(other than thoughts of wanting to be w/ loved one; ok to want to die but not ok to want to kill herself).
No psychosis (other than hearing/seeing loved one)
*Rarely tx w/ antidepressants for sxs
(v-code on DSM5 i.e. not mental disorder)
after the death of her chihuahua, a woman still feels guilty, can't sleep, concentrate, eat, or enjoy her interests; tx? what is personality d/o is this tx also for?
of stressor out of proportion. Can't persist longer than 6mo.
Best treated w/ psychotherapy-( other one is avoidant personality disorder
Adjustment disorder; what is it? duration?
emotional symptoms (anxiety, depression) causing impairment following an identifiable psychosocial stressor (e.g., divorce, illness) and lasting < 6 months
(> 6 months in presence of chronic stressor).
Prevalence of Bipolar in the populaiton
Prevalence in the identical twin brother
75 y/o man with the first manic phase; NBS?
- look for medical cause right frontal hemisphere stoke. -
Generalized anxiety disorder; duration - what is it?
associated with what somatic symptoms (1) & other symptom (3)?
Pattern of uncontrollable anxiety
for at least 6 months
that is unrelated to a specific person, situation, or event.
Associated with GI issue, sleep disturbance, fatigue, and difficulty concentrating.
GAD- treatment (4)
buspirone (5-HT1a partial receptor blocker), cognitive behavioral therapy.
what is the incidence of manic in the population
Risk for diagnosis of manic in a twin
If these sxs of manic depression occurred in a 75 year old patient for the
; look at what area
Look for a medical cause
right frontal hemisphere stroke
Manic symptoms mnemonic
Irresponsible pleasure seeking
Flight of Ideas
What medication need to be avoided in a patient with ea manic depression (2)
SSRI and TCA can trigger mania
Medications to start in a manic depressive patient; (2 for acute phase w/ what symptoms? 3 for maintenance)
Acute agitation or delusion: Haloperidol or clonazepam/Klonapin for acute agitation
Maintenance: Lithium or valproic acid or carbamazepine
taking Advil develops n/v/d coarse tremor, ataxia, confusion, slurred speech; Dx? what is the precipitating factor? What is the alternatives?
Precipatated by NSAIDs
Better pain (safe) med are aspirin or sulindac
Lithium toxicity - EKG findings
flattening or inversion +
Treatment For lithium toxicity (2); what is the lithium vol cut off?
Fluid resuscitiation emergent dialysis
if levels > 4 kidney diz
if under 4 then then just fluids
Side effects for lithium (general, skin, GI)
Weight gain and acne, GI irritation and cramps
MOA of lithium
Suppresses inosital triphosphate
What is the therapeutic window for lithium; check it how often?
check q4-8 wks
What lab to follow in addition to Lithium level, CBC?
TFT s q6mo (thyroid function test - can cause hypothyroidism)
Cr (kidney function)
Lithium Contraindications to use (2)
Severe Reanl diseas ( because no clearence )
NOt for preggers or breastfeeding
why lithium not for preggos? what is the specific structure involved? what period is dangerous
Ebstein abnormality - tricuspid malfunction, atrialization right ventricle
if taken at 1st trimester
Preferred treatment for bipolar in preggos
Bipolar meds that causes elevated LFT and hepatitis; what general symptoms can it cause (2)
GI issue (n/v/d) & skin rash
Bipolar meds that cause steven johnsons syndrome (2)
Lamotrogene ( more classic ) can be cambazepeine
Bipolar meds cause agranulocytosis; NBS? what is the cut off?
Carbamazepine/Tegretol - check CBC regularly
if ANC < 2000 - watch closely every week; ANC <1000- D/c med
Bipolar meds increase AFP in a 20 wk preggos (2)? prophylaxis?
Could be valproate/depakote or carbamazepine/tegretol --> Neural tube defect
Any one of reproductive age should take 4 g of folate daily
most common complications of carbamazepine
therapeutic levels Valproate
therapeutic levels carbamazepine
( move the decimals over)
8 Anxiety d/o
1. Panic d/o - 10 mins & 1 mo
2. Adjustment d/o - less than 6 mo
3. General Anxiety d/o - more than 6 mo
4. Social Anxiety d/o
5. Specific phobia e.g. agoraphobia
6. Obsessive Compulsive d/o
7. PTSD - over 1 mo
8. Acute stress d/o - 3 ds-1 mo
28 y/o female is brought in by EMS complaining of sob, palpitations and chest pain. She smokes 1 PPD and her only medication is OCPs. She had one of these attacks previously while grocery shopping. She shares with you that she is so afraid of having another one she rarely leaves her house .
What is this ... whats the next step
panic disorder + agora-phobia
first medical work up--EKG ( check for heart disease), drugs screen, tsh/t4, cardiac enzymes
What is the drug regimen for panic disorder- short term (2), long term drug (1)? special consideration?
Alprazolam/xanax or clonazepam/klonipin low dose PRN short term
-- but SSRI are the preferred drug long term
SSRI needs 4 - 6 wks to work; use benzo bridge
Benzo should not be given to what panic d/o pt w/ what medical conditions (3)
restrictive lung disease
(suppress the respiratory drive)
Panic disorder on benzo and then stopped taking the benzo now comes in
sxs of a temp 101, convulsions, confusion and hypertension
Acute benzo withdrawal reaction
Similar to DT
tx w/ diazepam or chlordiazepoxide + haloperidol
pt presents with a deathly fear of flying that inhibits her from interveiwing at the program of her dreams
What is the diagnosis and what are the two best treatment? 1 meds?
Diagnosis : specific phobia
Best txt is CBT w/ flooding or exposure/extinction.
Medication is benzo for situational use.
Patient presents with a deathly fear of presenting a case at ground rounds because the surgeons will laugh at her
Best txt is propranolol to stop the hyperarousal and then situational benzo
Patient keeps to herself and doesnt talk to peers b/c she is afraid they will laugh at her, tx?
Avoidant personality disorder
Best txt is CBT
A patient is having a diffculty falling asleep b/c she keeps thining about failing biochem. IN class she cant concentrate b/c she worries her boyfriend will leave her
Symtpoms have lasted 6 months; diagnosis? tx?
Generalized anxiety Disorder.
Best txt is
5HT1a partial blocker
-But does not work fast therefore benzo bridge
18 you just started college his grades are declining because he spends 2-3 hours in the shower scrubbing because on days he doesnt he worries about contracting an illness
diagnosis - obsessive compulsive disorder
Comorbid condition with OCD (2)
High prevelance of vocal motor ticks &
5-7% of OCD pt have full blown tourettes
What is the treatment for Obessive compulsive disorder.
First line- SSRI
Gold standard - Clomipramine
25 y/o sexual assult survivor comes to you with a six week history of of recurrent night mares of when she was raped at knifepoint she now avoids situations where unknown men are present and she had to quite her job.
PTSD - reliving, hyperarousal and avoidance
Treatment for PTSD (2)
Treatment for the night mares specifically (1)
PTSD - SSRI- sertraline or paroxetine
Nightmares give the alpha blockers - prazosin
IF someone had hyperarousal, avoidance behaviours and re-living of an experiance present for
only 3 weeks
- in responce to a traumatic event like rape
Diagnosis - acute stress reaction
stop with in 1 month
If someone had hyperarousal, avoidance behaviours and re-living of an experiance present for only 3 weeks - in responce to a bad breakup
onset w/in 3 months and goes away by 6 months
Factitious d/o (7)
1. Somatoform d/o i.e. hypochondriac
2. Illness anxiety d/o
3. Conversion d/o
4. Pseudocyesis i.e. false pregnancy
6. Factitious d/o i.e. Munchausen
A women complains of pelvic pain during menses you review the chart adn it says that she has also sought help over the past 10 years for pain in her low back, neck arms and feets. tingling in the arms She also complains of constipation
comorbid condition (3)
Best txt ---
Diagnosis --- somatoform disorder; 6+ mo, 2+ organ; actually sick
comorbid condition --- depression, anxiety, personality disorder.
Best txt --- frequent follow with 1 physician; only do tests if needed
Somatization disorder - intentional/unintentional? onset age? what is the criteria?
hypochondriac; Not intentional
-- onset before age 30
4 pain symptoms
1 gi symptoms
1 pseudoneurological symptom
33 y/o is brought to the ER after having a seizure in the waiting room of her neurologist office.
Her worried husband describes the episode as lasting 20 min. consisting of shaking with her eyes closed? dx? what to look for? What tests should be order anyway (2)?
odd to have a SZ in the neurologist office, any postictal symtoms? (urination/defecation)
EEG, prolactin (will be sky high) - if normal, pseudo seizure
Conversion Disorder - intentional/unintentional? Criteria (3)?
Not intentional (can't be lying to get out of jail)
-Not limited to pain or sexual dysfunction
- view as a cry for help (have underlying issues)
- not always la belle indifference (textbook term, pt doesn't care, not always true)
A 54 y/o RN has a history of 2 mo of diarrhea and ab pain.
He has been to 4 other hospitals w/ the same complaints
-- Colonscopy reveals pigmentation in the wall of the colon
- melanosis coloni - from laxtives
- giving himself diarrhea - muchausen syndrome ( they make themselves sick )
more severe then simple factitious (these people complain of symptoms but don't do anything to create them) b/c they actually induce sxs and do it for primary gain
A concerned mother presents with 15 mon baby who is having recurrent seizures. She requests an MRI, sleep deprived EEG with intercranial leads; NBS?
munchausen syndrome by proxy
a form of child abuse (probably giving him insulin to cause SZ)
next step alert the child protective agency
45 y/o unemployed man is involved in a car accident. H3 sues the drive stating he has nerve damage to his legs that keeps him from walking; Video evidence shows him dancing at a club the night before. Dx? associated with what PD?
MALIGERING - V code
Associated w/ antisocial personality disorder, they do it for secondary gain
18 y/o presents with no menstrual cycle for 3 mo. A PREGNACY TEST is negative but her BMI is 17. her teeth are eroded and she has calluses on her knuckles ( russels sign); Dx?
What are the
vital signs (3):
Liver func: (2)
Fasting lipid profile:
ANOREXIA purging type - always have an endocrine abnormality (Amenorrheia, osteoporosis, etc.) , and low bmi -
VItal: Hypotension, braycardia and hypothermia
CBC: leukopenia - susceptible to infection
CMP: vomiting - high H3co, low Cl, low K
high LFTs and amylase
TFT: normal thyroid function test
Fasting lipid profile: elevated
Hormones* elevated cortisol, low estrogen - cause amenorrhhea, low LH/FSH - hypogonad/from top
high carotene( may cause yellowing of the skin)
Long term complications of anorexia (3)
osteoporosis - also lentigo- downy hair, possible parotitis
Most common cause of death anorexia (2)
heart disease (arrthymia), suicide #2
Treatment of anorexia (2)? what meds?
needs admission; intensive conseling, nutritions ( give tpn), SSRIs help bulemia & anorexia
Complications of TPN in anorexia (3)
Re-feeding syndrom = fluid retention leading to
low PO4, low Mg, low ca
Sleep EEG FOR AWAKE what are the characteristics
alpha (highest frequency, lowest amplitude)
Sleep EEG For stage 1
5% stage I
, 50% stage II, 20% stages III and IV
Sleep EEG for stage 2? what occurs in this stage?
Sleep spindle & K complex -
spindle - high frequency
complex - high amplitude
5% stage I,
50% stage II
, 20% stages III and IV
What happens in Stage 2 sleep
Deeper sleep; when bruxism occurs
Sleep EEG for stage 3 & 4
Delta (lowest frequency, highest amplitude)
Stage 3 = less then 50% delta waves; stage 4 = greater then 50% delta waves
5% stage I, 50% stage II,
20% stages III and IV
What happens in Stage 3/4 sleep
Deepest non-REM sleep (slow-wave sleep);
when sleepwalking, night terrors, and
What drugs decrease stage 3/4 sleep (3)
Alcohol also decrease stage 3 and 4 sleep
impramine used to decrease betwetting
EEG for REM sleep
What happens during REM sleep - brain, muscle, VS, 2 general, what function takes place?
Skeletal muscle paralysis
Increase brain O2 use, and
variable pulse and blood pressure;
dreaming and penile/clitoral swollen
Depression sleep eeg
Decrease REM latency and increase REM % (get to REM faster, REM is longer)
Sleep EEG in the elderly
Decrease latency of REM and increase cycling
(takes longer to get to REM, more cycles)
Trouble falling asleep or staying asleep causes impairment in fxn >1mo; what is it? Tx (1+3)
1st: sleep hygiene
Benzos: reduce sleep latency, increase slow wave sleep & REM
Non-benzo hypnotics (GABA receptor agonist: Zolpidem, zaleplon, escopiclone)
As falling asleep, feel creepy-crawlies on legs, better when they get up and move; 3 medical cause to r/o; Rx (2)?
Dysomnia NOS. - (Axis I diagnosis for Restless leg syndrome and periodic leg moment syndrome)
R/o: Fe-def anemia, chronic kidney dz, Neuropathy.
Tx w/ DA agonist - ropinirole (pathological gambling) or pramipexole
Daytime sleepiness and depression in a big fat guy with a big neck; how is it diagnosis?
Obstructive Sleep Apnea. Goes on axis III, "breathing related sleep d/o" goes on axis I. polysomnogram: more than 10 hypopneic/apneas per hour.
Irresistible attacks of refreshing (REM) sleep. Upon intense emotion, they lose muscle tone or have hallucinations as waking or falling asleep; tx? What condition is needed to dx the condition?
Narcolepsy. Tx w/ scheduled naps and Modafinil
Need 1 of 2 w/ sleep attack to diagnosis: cataxpecy or hynogognic/hypnopmonic hallucinations
Personality d/o (3 + 4 + 3)
1. Paranoid - projection
2. Schizoid - voluntary social withdrawal
1. Antisocial - b/f 15 yr
2. Obsessive Compulsive Personality d/o
30 y/o man and his wife present for couples counseling. He constantly accuses her of cheating. He's in a feud w/ the neighbor b/c he feels they are attacking his character when they say they like his flowerbeds. Dx? Tx?
Paranoid Personality Disorder: Low dose anti-psychotics can help paranoid behavior.
30 y/o man, never been married or have any close friends. Works as a night security guard and in his free time works on his model ships in his basement.
Schizoid Personality Disorder; distinguish from Avoidant b/c they DON't want relationships
(schizoid: don't want friends, just a little odd)
30 y/o man, never been married or have any close friends because "people make him uncomfortable". He is unemployed because he spends his time reading books on how to communicate with animals so he can "be at one with nature".
Schizotypal PD Distinguish from Schizoid by magical thinking/ interests.
Distinguish from Schizophrenia by lack of delus/hallu
25y/o man comes to court mandated counseling for beating his girlfriend. He was kicked out of high school for fighting & just got out jail for stealing a car. Dx? comorbid condiiton?
Antisocial Personality Disorder
2/3 have substance abuse (most common co-morbid codition).
His girlfriend has a hx of unstable relationships, has superficial cuts on both wrists, is impulsive in her spending and sexual practices. Dx?
Borderline Personality Disorder
Commonly defensive mechanism used splitting.
26 y/o MS2 is asked to seek counseling. Her classmates complain that she dresses too provocatively to class. She recently tried to seduce a professor. Dx? comorbid (2)?
Histrionic personality disorder
Substance abuse or eating d/o ( comorbid condition)
A 22 y/o MS1 doesn't feel like he needs to come to any classes or labs because he "already has the brilliance to be a doctor. Dx? Tx?
Narcissistic Personality Disorder
Can be confused w/ hypomania b/c of grandiosity.
Give individual therapy (need to buy into their narcissism; group therapy does not work)
30 y/o woman has no friends and avoids happy hours with her coworkers b/c she fears ridicule and rejection. She feels "no one would want to be friends with me". Dx? Tx (2)?
Avoidant Personality Disorder
Can tx social phobia sxs w/ b-blocker or SSRI
-- different from social phobia because it is more pervasive
(with social phobia, they can have 1 to 1 interaction but cannot talk in front of a crowd)
30 y/o woman has jumped from one relationship to another because she "doesn't do well alone". She calls her friends and family >20x a day to get their input on her daily decisions. Dx? Tx?
Dependent Personality Disorder
Look for co-morbid depression and anxiety. SSRI treats the comorbid condition but not the personality disorder
25 y/o MS4 spends more time color coding her notes and textbook highlighting than actually studying. She makes lists and study schedules 3 times per day. People don't like to work with her because she is so "anal"
Obsessive Compulsive PD.
Different from OCD b/c the actions are
"ego-syntonic"- these people arent bothered by there compulsions !!!
78 y/o lady is brought in from her nursing home for altered mental status. She sleeps more during the day and becomes agitated at night-reporting seeing green men in the corner. She also complains of pain upon urination. Dx, NBS/ basic lab (5), rare lab (2); Rx side effect (3)?
labs - UA and culture
basic: glc, na, blood culture,
rare: b12, RPR - Make sure to look at med list benadryl, opiates, benzos
What is the biggest risk factor for delrium
then underlying dementia is the 2nd biggest
3rd most causes of delirium
Acute substance withdrawal.
Look for it on the 2nd or 3rd post-op day in alcoholic
What are the EEG changes of the Delrium
Diffuse slowing of the background rhythm - Slow waves
psychosis has a normal EEG
Treatment of Delirium (3); what Rx for what condition?
Reduce excessive stimuli
calendar and clock to orient the patient
STOP unnecessary meds
Give haloperidol if agitated
4 types of Dementia + 3 differentials
2. Frontotemporal Pick's
3. Lewy Body
4. Vascular Dementia
1. Tertiary Syphilis
2. Creutzfeldt Jakob
3. Normal pressure hydrocephalus
A 78 y/o female presents with memory loss...Aphasia, apraxia, gets lost while driving; dx? what does MMSE show?
Alzheimer's Dementia. MC type (when in doubt, pick Alzheimer)
On MMSE, prompting does not ↑recall
MRI for Alzheimer dementia? brain histology (2)? what neurotransmitter, what location?
Diffuse brain atrophy
b-amyloid plaques or tau tangles
decrease basal nucleus of meynert
(B-amyloid - birefringent apple-green, tangles correlate with the degree of dementia)
What are the genes associated to alzheimers dementia. Early onset (3), late onset (1); what is protective (1)?
APP (Chr 21), presenilin-1 (Chr 14), presenilin-2 (Chr 1)
Late onset: ApoE4 (Chr 19)
ApoE2 (Chr 19) is protective.
1st group of meds for Alzheimer (3)
Rivastigmine, Donepezil, Galantamine (diarrhea)
2nd group of meds for Alzheimer
NMDA antagonist - want to decrease excitability
Draw backs of Alzheimer rx
none of these improve the memory only decrease rate of decline
A 78 y/o female presents with memory loss becomes more sexually explicit, apathy.
Frontotemporal Dementia. (Pick's Dz).
Pathology of frontotemporal pick diz; what histology finding? what part is spare?
intra neuronal silver staining inclusions
spares the parietal lobe
(inclusions = Pick body)
What is the treatment for frontotemporal aka pick diz.
Olanzepine for severe disinhibition.
(stop the behavioral problems)
A 78 y/o female presents with memory loss Fluctuation in consciousness,
and shuffling gait
Lewy body dementia
some delirium + some Parkinson
hard to tell apart from Parkinson; this will have fluctuation in consciousness & hallucination
Lewy body dementia pathology
Intra cytoplasmic Alpha-synuclein inclusions in neocortex (lewy body)
Lewy body dementia treatment? What do we avoid?
Don't give L-dopa
Don't give neuroleptics: haldo & benzos
(worsen delirium & paradoxical rxn)
A 78 y/o female presents with memory loss...
Sudden, step-wise decrease in memory/cognitions
What is it and what is the work up
- Work up is MRI and MRA
A 78 y/o female presents with memory loss Loss of vibration sense, labile affect. Pupil that accommodates but doesn't react.
What is it what is the test (3)
What is the treatment
spinal tap for spirochetes.- (if neurosyphilis it has to be IV PCN)
IV penicillin. If Pen-allergic, must desensitize.
A 78 y/o female presents with memory loss Myoclonus, startle response, seizures. Recently had a corneal transplant.
What is it?
What is the pathology ?
EEG findings ?
Pathology: Sponigorm encephalopathy
A 78 y/o female presents with memory loss Incontinence, gait disturbance/freq falls, and rapidly developing
Work up (2)
DX: Normal Pressure Hydrocephalus.
Work up: CT/MRI shows hydrocephalus, spinal tap shows nl opening pressure
Tx: Ventriculoperitoneal shunt improves cognitive fxn in 50-67% of pts
A 50 y/o known alcoholic presents to the ER with tonic clonic seizures. BP 180/110, HR 118, T 100.1.
How long since the last drink
12-24 hrs. (bimodal peak at 8 and 48hrs)
A 50 y/o known alcoholic presents to the ER with tonic clonic seizures. BP 180/110, HR 118, T 100.1.
How long till he develops confusion, fluctuations in consciousness and the feeling of ants crawling on him?
~48-72 hrs since last drink is when delirium tremens usually start.
A 50 y/o known alcoholic presents to the ER with tonic clonic seizures. BP 180/110, HR 118, T 100.1.
His blood alcohol level is 225 mg/mL. How long till its out of his system?
~9 hrs, Alcohol is metabolized by zero order kinetics (same amt/unit time = 25 mg/hr)
A 50 y/o known alcoholic presents to the ER with tonic clonic seizures. BP 180/110, HR 118, T 100.1.
If his medications included propranolol, lactulose, and allopurinol, what would be the best sign to monitor for his withdrawals?
Beta-blockers mask the signs
of autonomic hyperactivity, but you
can follow hyperreflexia
to dose the benzos during w/drawal.
Best intial treatment for our patient with alcohol withdrawl
Diazepam or chloridiazepoxide b/c they have 80 & 120 hr 1/2 lives respectively
WHAT if the alcoholic has child class C ( cirrohosis )
Lorazepam, oxazepam or tempazepam
(mnemonic: Out The Liver)
MOSt specific test for ETOH consumption in the past 10 days (1); 2 less specific
and AST more than twice ALT.
Our next patient comes in w/ confusion, ataxia, and you find opthalmopelgia: Dx?
Wernicke Encephalopathy. Caused by thiamine deficiency
Give thiamine 1st, then glucose containing fluids
Wernicke can progress to what and how can you tell (3 actions); MRI - what is damaged?
Can progress to Korsakoff's syndrome
(irreversible damage to mamillary bodies, etc)
-apathy, anter/retrograde amnesia and confabulation. Can see MB atrophy on MRI
A patient is brought into the ER in a non-responsive state. His BP is 100/60, HR is 50, RR is 6. He has multiple track marks on his arms.
•Best first step?
• Diagnosis ?
Diagnosis - heroin
Best intial step- intubate ( under 8 intubate always ABC)
Then give IV or IM naloxone(full mu-opiate antagonist)
A patient is brought into the ER in a non-responsive state. His BP is 100/60, HR is 50, RR is 6. He has multiple track marks on his arms.---> NOW
You realize his pupils are dilated. Does that change your dx?
No. The hypoxia 2/2 respiratory depression can cause hypoxia
•What sxs to you expect as he starts to withdraw? heorin
Juicey - goosebumps
Joint and muscle pain, photophobia, goosebumps, diarrhea, tachycardia, HTN, GI cramps, dilated pupils, anxiety/depression
Treatment for heroin for withdrawal symptoms (3 acute, 3 long term)
Clonidine for autonomic sxs,
ibuprofen for muscle cramps,
loperimide for diarrhea,
Methadone, buprenorphrine or Naltrexone can be used for long-term dependence.
Pt presents with horizontal nystagmus, dilated pupils, ataxia and acute psychosis; 1 tx?
Hallucinogen (PCP) intoxication. Can use haloperidol for acute psychosis
Pt presents s/p MVC with injected conjunctiva, sedation and is asking for Doritos.
Pt presents with Suicidal ideation, hypersomnia, depression and anergia
Pt presents with dilated pupils, seizure, tachycardia and HTN.
-Best 1st test
Cocaine/Amphetamine intoxication EKG 1st
then urine tox screen. Tx seizure w/ lorazepam
Tx of HTN and tachycardia in a patient with cocaine/amphetamine intoxication
Calcium channel blocker.
Beta-blockers are CONTRAINDICATED!
When is death considered permanent
6 years - 11 years - considered concrete operational
Childhood + Early Onset d/o
1. ADHD - b/f 12, 2 settings
2. Autism Spectrum - b/f 3
3. Rhett - 1-4 y/o
4. Conduct d/o
5. Oppositional Defiant d/o
6. Separation anxiety d/o - 7-9
7. Tourette - 1 yr; less than 18 y/o
8. Tic - less than 1 yr
9. Learning d/o - can read, do math, not write; can't learn key academic skills
IQ of 40-55
Iq of 55 -70
IQ of 25-40
IQ of < 25
What is the average and standard deviation for IQ
Average is 100 - std is 15
where does mental retardation go in DSM 4
(uw) regression, loss of development to verbal & intellect ability
An 11 year old boy is evaluated for developmental delay, poor school and social performance. Formal IQ testing reveal his IQ to be 50. He has a macrocephaly, long face and macroorchidism:
What is the most likely cause
What is the gentic cause
What are the co-morbid genetic conditions
X-linked dominal inheritance
CGG repeats w/ anticipation
Cx = Seizures, MVP, dilation of the aorta, tremors, ataxia, ADHD-like behavior.
MC cause of inherited MR.
A newborn baby has decreased tone, oblique palpebral fissures, a simian crease, big tongue, white spots on his iris
what are the whitespots called
Diagnosis: down syndrom
white spots: brushfeild spots
What can you tell his mother about his expected IQ? for down syndrome
He will likely have mild-moderate MR. Speech, gross and fine motor skill delay
Common medical complications down syndrom ?
- Endocrine :
-Heart?VSD, endocardial cushion defects
-GI? Hirschsprung's, intestinal atresia, imperforate anus, annular pancreas
-Msk? Atlanto-axial instability- careful for intubation
-Neuro? Incr risk of Alzheimer's by 30-35. (APP is on Chr21)
-Cancer?10x increased risk of ALL
Café-au-laitspots, seizures large head. Autosomal dominant
oarse facies, short stature, cloudy cornea. Autosomal recessive.
Broad, square face, short stature, self-injurious behavior. Deletion on Chr17
Hypotonia, hypogonadism, hyperphagia, skin picking, agression. Deletion on paternal Chr15.
Seizures, strabismus, sociable w/ episodic laughter. Deletion on maternal Chr15.
Elfin-appearance, friendly, increased empathy and verbal reasoning ability. Deletion on Chr7.
ADHD-like sxs, microcephaly, smooth philtrum. Most common cause of mental retardation.
Fetal Alcohol Syndrome
Seizures, chorioretinitis, hearing impairments, periventricular calcifications, petechiae@ birth, hepatitis.
Congenital CMV infection.
Seizures, hearing impairments, cloudy cornea/retinitis, heart defects, low birth weight.
Congenital Rubella Syndrome
Abnormal muscle tone, unsteady gait, seizures, mental retardation or learning disability.
Cerebral Palsy from birth asphyxia.
IUGR, hypertonia, distinctive facies, limb malformation, self-injurious behavior, hyperactive.
Cornelia de Lange
Coloboma, heart defects, choanalatresia, growth retardation, GU anomalies, ear deformity and deafness. Chr8.
Autism spectrum sxs, heart disease, palate defects, hypopasticthymus, hypoCa. Chr22 deletion.
Vomiting, seizures, lethargy, coma. Acidosis w/ stress, illness. Causes neurological damage.
Maple Syrup Urine Disease
Exclusively in girls, normal development for 6-8mo, then regression, handwringing, loss of speech and use of hands. X-linked dominant deletion of MECP2.
Normal development until age 2 then major loss of verbal, social skills w/ autistic like behavior.
Childhood Disintegrative Disorder
Lack of mother-child eye contact, language delay/repetitive language, peroccupation w/ "parts of toys" before age 3.
Problems with social skills (usually recognized in preschool) w/ preserved verbal ability.
A 7 year old boyis brought in by his parents. They report he must be told several times to complete his chores, they cannot get him to focus on completing his homework (he is easily distracted), and that he often loses his shoes, pencils, books, etc.
next best step
Normal age appropriate behavior !!!-- Diagnosis of ADHD- need misbehaviour in 2 settings
Next best step : How does he do at school
Risk facotris for ADHD
Family history 77% heritability, LBW tobacco ETOH exposure
Co morbid ocnditons with ADHD
ODD/CD in 30 - 50%
TREATMENT IN ADHD
Methylphenidate (blocks only Da) - Nausea, decrease appetite, increase HR Adn BP stunted growth
Amphetamine (blocks da and Ne)- same se
Atomoxetine NE reuptake inhibitor non stimulant -
A 14 year old boy is sent for court mandated counseling. He stole his neighbor's lawn mower and then set fire to his tool shed. He has a 5 year history of truancy from school and assaulted a 13 year old school mate.
Conduct Disorder. Need sxs for 6mo.Comorbid substance abuse. May progress to anti-social personality disorder
A 14 year old boy is brought in by his grandmother. For the past year, he has been getting in trouble at school for being argumentative and disrespectful to his teachers. He defies the rules she sets for the house and often deliberately annoys her.
Oppositional Defiant Disorder.
Need sxs for 12mo.
Stops just short of breaking the lay or physically harming others.
A 9 year old boy is sent to counseling at the recommendation of his teacher. She states that at least once a day he makes loud grunting noises and hand movements that are disruptive to the class.Diagnosis? brain issue?
For tics to qualify as Tourettes they must occur at
least once a day for 1 year w/o a tic-free period longer than 3mo
; caudate & frontal lobe atrophy
Comorbid conditions for tourettes ?
Look for the compulsions of OCD
Treatment for tourettes
first line vs. most effective
-First line: Clonidine 2/2 relatively benign S/E profile
- Most Effective?- Haloperidol or pimozide-DA-receptor antagonists
7 year old complains of frequent abdominal pain resulting in many missed school days. He never gets the pain on the weekends or in the summer.
Separation Anxiety Disorder
6 year old adopted child is brought in because she has not formed a relationship with her adoptive parents. She is inhibited and hyper vigilant.
Reactive Attachment Disorder
•An 18mo old baby has recently been regurgitating and re-chewing her food. She had previously been eating normally.
Check lead levels.
6y/o stools in her clothes once every 2 weeks.
Next best test?
Next best test is to check for fecal retention
treatment is behavioural modification that only rewards
6 y/o that unrinates in her clothes once a day
NExt best test? R/o UTI
Treatment: alarm and pad
Erikson 8 stages of development
TAG It RISE
birth - 1 y/o: trust vs mistrust
1 -3 y/o -: autonomy vs shame
3-5 y/o - initiative vs guilt
6-11 y/o - industry vs inferiority
11 - adolescence - identity vs role diffusion
21 - 40 - intimacy vs isolation
40 - 60 - generation vs stagnation
over 65 - integrity vs despair
Piaget 5 stages of development
birth - 1 y/o: Sensorimotor
control motor function; object permanence
1 -3 y/o; 3-5 y/o -: preoperational
6-11 y/o - concrete operational
Death is permenant
11 - adult - formal operational
think abstractly, deductive reasoning, hypothetical thinking
Fraud 5 stages
birth - 1 y/o - oral
1 -3 y/o - anal
3-5 y/o - phallic
6-11 y/o - latent
11 - adult - genital
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