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Mood Disorders
Schizophrenia and Related
Meds
More Meds
Other
100
ECT therapy is the primary used 5-6 specific indication to treat depression. Name 3 indications.
What are MDD with high degree of impairment, psychotic/catatonic features, suicidal actions such as not eating, refractory to pharmacology and elderly/pregnant pt can be 1st line therapy especially if MDD is severe
100
Five pillars for schizophrenia diagnosis and how many does a pt need to exhibit to qualify?
What are A: To be diagnosed with schizophrenia, two diagnostic criteria have to be met over much of the time of a period of at least one month, with a significant impact on social or occupational functioning for at least six months. The person had to be suffering from… 1) Delusions (fixed, false usually bizarre beliefs that change be rationalized. Includes ideas of reference, thought broadcasting, delusions of grandeur 2) Hallucinations: usually auditory with running commentary 3) Disorganized speech: pronounced thought disorder included 4) Negative symptoms (anhedonia, Alogia: poverty of speech is a general lack of additional, unprompted content seen in normal speech Avolution- general lack of drive, or motivation to pursue meaningful goals) 5) Catatonic behavior
100
Pt comes in with TCA overdose. Best treatment to counteract the overdose and what is the mechanism?
Refractory hypotension is the most common cause of death from TCA overdose. Na+ HCO3- [1 mEq/kg bolus q3-5 min] will help stabilize the heart and arrhythmia
100
Atypical agent most associated with weight gain
What are Olanzapine or Zyprexa
100
A 37-year-old man comes to the hospital 3 months after being diagnosed with alcoholic cirrhosis. He has missed three appointments that he attributes to transportation problems. His driver’s license was suspended 3 months ago for driving under the influence of alcohol. He does not claim that is drinking is a problem but he has cut down the amount of drinks from 12 beers to 4 beers daily. He is disheveled and restless and claims that he has not slept well for the past 3 months. His pulse is 96, respirations are 16/min, and blood pressure is 170/90 mm Hg. Physical examination shows no other abnormalities except for peripheral edema of the lower extremities. On mental status examination, he describes his mood as fine, but he is irritable and has poor eye contact, especially when discussing his drinking. He speaks at a normal rate with normal response latency. His thought process is logical and coherent without evidence of psychosis. His serum albumin concentration is 3 g/dL, total serum bilirubin concentration is 2.6 g/dL and GGT activity is 158. Most appropriate next step in management.
What is to start benzo therapy Which benzo…LOTs Discuss the alcohol withdraw symptoms
200
These medications would cause the noted side effect: Bipolar + elevated LFTs and hepatitis? Bipolar + Steven’s Johnson Syndrome? Bipolar + agranulocytosis? (need 2/3)
What are valproate, lamotrigine and carbamazepine. Valproic Acid (Depakote®) = Divalproex is a more expensive less side effects * Increased GABA while decreasing conductance of Na+ and K+ * Monitor blood levels approx. ~100 * Need baseline CBC/BMP, LFTs and pregnancy test * Possibly hepatotoxic, more worrisome in the very young on dual anti-seizure medications. Teratogenic (neural tube defects) * Drug of choice for rapid cycling bipolar disorders, generalized tonic-clonic, myoclonic and absences seizures * May cause polycystic ovary disease in some young women, significant weight gain, hair loss thrombocytopenia (ITP) Lamotrigine (Lamictal®) * Inhibits flow Na+ and modulates glutamate and aspartate * Recently approved for bipolar disorder (mania and depression; not good for acute control) * Used for simple/complex partial seizures. Similar to Phenytoin except drug has no use for psych. Gingival hyperplasia nystagmus, dizziness, slurred speech, ataxia, mental confusion, and decreased coordination * Inhibits glutamate release which decreases CNS excitability. Decreases flow of Na+ = decreased excitation * Pregnancy category C: safe for seizure treatment in reproductive women * No blood levels necessary * Major side effect is severe rash (which may become SJS) * Recommend starting at a low dose and move up VERY slowly • Valproic acid inhibits lamotrigine metabolism, start 12.5 mg • Carbamazepine induces lamotrigine metabolism, start 50mg
200
A smelly 20 y/o college kid’s grades have been declining over the past 2 semesters as he keeps to himself, has flattened affect and no motivation. For the past 6wks, he has locked himself in his dorm room stating President Obama “put a hit on him”. He was told this by 2 voices having a discussion in his head. Change this vignette to diagnosis brief psychotic disorder, schizophreniform and schizoaffective disorder.
What is <1 month for brief psychotic disorder, 1-6 months for schizophreniform, and this is Schizoaffective. When psychotic symptoms occur during a mood episode of depression, mania, hypomania, or mixed episode, the DSM-5 indicates that the diagnosis must be either psychotic depression or psychotic bipolar disorder. When a psychotic condition lasts two-weeks continuously or longer without mood symptoms, is the diagnosis either schizophrenia or schizoaffective disorder. Occupational functioning is frequently impaired, but this is not a defining criterion (in contrast to schizophrenia).
200
Atypical agent with the highest risk of EPS and increased prolactin
What is Risperidone
200
This only medication which has been proven to decrease the risk of suicide has five black box warnings.
What is Clozapine (Clozaril) FIVE black box warnings: - Seizures, - Agranulocytosis, - Myocarditis, - Cardiovascular/cardiorespiratory collapse - increased mortality when treating elderly demented patients
200
You are an intern on the wards when a nurse calls about an 84-year-old man with dementia, Alzheimer type, is admitted to the hospital for treatment of pneumonia. At night, he becomes confused, yelling, "Where am I? How do I get room service in this place?" He then slaps one of the nurses and tries to kick the doctor. He behaves in a similar manner for the next 2 nights. Name 5 diagnostic tests you could order in this patient. Also, the most appropriate initial treatment to decrease this patient's agitation.
What is to request that the patient's family stay overnight, provide a 1-to-1 that constantly tried to calmly reorient the patient and possibly Place familiar objects and a night-light near the patient's bed. Work-up includes Complete blood cell count with differential - Helpful to diagnose infection and anemia Electrolytes - To diagnose low or high levels Glucose - To diagnose hypoglycemia, diabetic ketoacidosis, and hyperosmolar nonketotic states Renal and liver function tests - To diagnose liver and renal failure Thyroid function studies - To diagnose hypothyroidism Urine analysis - Used to diagnose urinary tract infection Urine and blood drug screen - Used to diagnose toxicological causes Thiamine and vitamin B-12 levels - Used to detect deficiency states of these vitamins Tests for bacteriological and viral etiologies - To diagnose infection Sedimentation rate Drug screen including alcohol level HIV tests
300
A patient is brought in by the police because he was attempting to solicit a prostitute. He has been sleeping little for the past 8 days, had sex with 15 different women, and talked in a pressured manner about maxing out his credit cards “starting a business that couldn’t fail.” Name the appropriate medication for acute management
What is an antipsychotic medication like haloperidol +/- benzodiazepine You start mood stabilizer medication three to four days later!
300
A 37 y/o male with no significant PMHx presents at his wife’s urging because he has been spying and setting up traps for the neighbors. He vehemently believes his neighbors are poisoning his family though he is lacking hard evidence at this time.
What is Delusional disorder…make sure to contrast this with the schizophrenia diagnosis where this patient is usually older, no PMHx, only ONE symptoms with any negative features and is able to function normally!!
300
Weight neutral atypical agent
What is Ziprasidone (Geodon) though aripiprazole or Abilify could also qualify
300
There are numerous medical/pharmacological causes of anxiety…name five.
What are Hyperthyroidism, hypoglycemia, hypoxia, pheochromocytoma, caffeine, amphetamines (including diet pills), alcohol w/draw, sympathomimetics and SSRI usage (usually the drug increases anxiety before alleviating so start small dose and gradual increase)
300
A 21 year old man comes to the physician because of a 3 week history of muscle aches and fatigue associated with exercise. He is worried that he might have multiple sclerosis. Two months ago, he was concerned that a mole on his right arm maybe cancerous. The physician reassured him that the mole was non malignant. One month ago, he had lateral chest pain while jogging. An ECG at that time showed no abnormalities. He appeared relieved once he heard the results. Today his temperature is 36.7 (98 F), pulse is 70/min, respirations are 20/min and blood pressure is 130/84 mm Hg. Physical examination shows no abnormalities. On mental status examination, he appears tense but makes full eye contact and is cooperative. He speaks clearly and at a normal rate and his thought process is goal directed. Most likely diagnosis.
What is Hypochondriasis Define the somatoform disorders
400
…after 5 days the patient is stabilized and the doctor wants to treat using the gold standard medication. You need this initial lab work.
What is baseline ECG, thyroid functions, CBC/BMP and pregnancy test for lithium. Lithium * Inhibit phosphoinositol 2nd messenger system * Monitor blood levels approx. ~1. Takes 5-7 days steady state * Still the "gold standard" for the treatment of Bipolar Disorder (about 70% effective), acute mania and schizoaffective disorder, cyclothymia and unipolar depression * Can cause a cardiac malformation (Ebstein's Anomaly) in babies. • Kidney: diabetes insipidus (polyuria/polydipsia, hypernatremia), or just plain kidney damage (always monitor BUN & Cr) • Thyroid: hypothyroidism (some cases of hyperthyroidism have been reported), and exophthalmos (always check TFT's) • Benign leukocytosis (13-14,000) without a left shift * Need baseline ECG, thyroid functions, CBC/BMP and pregnancy test * Li+ toxicity (> 1.5 and toxic >2): N/V/D, abd pain, drowsiness, flattened T waves. Fluids or dialysis (<4) treat overdose * NSAID are CI but aspirin/Tylenol are ok * Severe acne, especially in adolescents.
400
: A 19 y/o without any significant PMHx female recently starting her biology classes at the University of Florida when she started having consistent thoughts about killing her Organic chemistry teacher. The patient only has a peripheral relationship with him and no ill will. The patient finds counting helps alleviate the strong desire to hurt the professor but she has stopped attending classes because the thoughts are so intrusive.
What is Obsessive Compulsive secondary to the counting…kinda like hand washing.
400
The general category of Tri-Cyclic Anti-depressants (TCA's) and atypical antipsychotics have three major side effects in common.
What are HAM or Histamine Adrenergic and Muscarinic: * Anticholinergic Symptoms: blurry vision, constipation, urinary retention, dry mouth and weight gain * Antihistamine effects: sedation * Anti-adrenergic receptors: orthostatic hypotension, arrhythmias, widened QRS * Cardiac Effects: Cause of death in overdose. Cardiac conduction is blocked (widened QRS complex) and the heart stops. * Decreased Libido
400
Five classic, movement associated, side effects associated with antipsychotic medications. Name the five in the classic order they usually appear after starting the medication.
What are: Side effects for typical and atypical antipsychotics yet varying degrees: 1. Acute Dystonia (4hrs-4days): defined sustained muscle contractions causing trismus (jaw contraction #1 area affected) torticollis, tongue protrusion, oculogyric crisis (sustained/forceful upward gaze), torticollis, twisting/ repetitive movements or abnormal postures -Diphenhydramine or anticholinergic like benztropine or trihexyphenidyl will treat 2. Parkinson’s symptoms or akinesia (4days-4months): generalized motor restriction +/- tremor. Can’t treat with typical Parkinson's drug bc that would alter DA blockage = fucking up anti-psychotic nature drug. Treat with benztropine or trihexyphenidyl bc both anti cholinergic 3. Akathisia: inner restlessness that manifests itself with an inability to sit still or remain motionless. Similar to restless leg syndrome -Try Beta Blocker or benzo like lorazepam 4. Tardive Dyskinesia (1-6months): Tardive involuntary, repetitive body movements including Grimacing, Tongue movements, Lip smacking/puckering or excessive eye blinking. Secondary to upregulation of DA receptors -No treatment and usually permanent feature after years of treatment 5. Neuroleptic Malignant Syndrome: hyperthermia, muscle rigidity (lead pipe) with elevated Creatine Phosphokinase/leukocytosis, change in mental status, elevated temp and autonomic instability. • No change in eyes VS serotonin syndrome. • This mediated by blockage DA. Bromocriptine/amandine are DA agonist and can be given before dantrolene which is muscle relaxer. Malignant hyperthermia secondary to defective ryanodine receptor 6. Non EPS side effects (HAM): Low orthostatic hypotension (alpha adrenergic), weight gain (anticholinergic) and sedating effects (antihistamine). * Hyperprolactinemia: Galactorrhea, gynecomastia, amenorrhea and decreased libido secondary to loss of negative feedback on prolactin • More EPS less and anticholinergic and anti-histaminic than low potency agents • Treat positive symptoms of schizophrenia equally well nucleus accumbens, fornix, amygdala and hippocampus • Negative symptoms much harder to treat within mesocortical pathway
400
52yo woman with weird feeling in her calves when trying to go to bed that keeps her up at night for a couple of hours and is affecting her work/causing her stress. First line Tx.
What is Restless leg Evidence supports the use dopamine agonists including: pramipexole, ropinirole, rotigotine -Gabapentin, a non-dopaminergic treatment for moderate to severe primary RLS -Opioids are only indicated in severe cases that do not respond to other measures due to their high rate of side effects -Benzodiazepines, such as diazepam, which not only provide symptom relief but also often assist in staying asleep and reducing awakenings from the movements -Anticonvulsants, such as carbamazepine, help people who experience the RLS sensations as painful
500
55 y/o male with significant history of bipolar type I which has been treated successfully for years with a stable dose of lithium and arthritis managed with OTC medication. The pt presents with an acute onset n/v/d, coarse tremor, ataxia, confusion and slurred speech. The pt denies any medication changes. Name the pathophysiology behind symptoms.
What is lithium toxicity due to NSAID use. CI secondary to decreased prostaglandin within kidney possibly leading to toxic levels since Lithium is renally excreted. Aspirin/Tylenol are ok. Bonus question/tie breaker: what would you see on ECG with this patient? A: Flattening or inversion of the T wave.
500
A 57-year-old man with schizoaffective disorder, whose symptoms were in remission until 2 weeks ago, is brought to the emergency department by his girlfriend. He will not talk with you but the girlfriend tells you that he has a history of "overdoses", and she is afraid he has taken a lot of "his pills". He has been complaining of voices telling him he "should be dead". He has not left the house in a month and has spent several hours a day looking out the window for the "king and savior" to "come take him". His medications include haloperidol, valproic acid, and a small dose of amitriptyline for chronic pain related to nerve damage in his leg, which occurred in a motor vehicle accident 10 years ago. He has no other medical problems. A chart review reveals that he has no allergies and was diagnosed with schizoaffective disorder 30 years ago. His temperature is 37.0 C (98.6 F), blood pressure is 110/70 mm Hg, pulse is 70/min, and respirations are 26/min. He is a depressed appearing man with very poor eye contact. He smells of alcohol. He does not acknowledge you, but will answer some questions for his girlfriend. He does admit to feeling that "life is not worth living" and feeling "more religious than usual". He seems slightly drowsy and knows the date. His physical examination is normal. The most appropriate next step in management.
What is EKG. TCA OD. Antagonism of muscarinic acetylcholine receptors o Mydriasis (dilated pupils) "blind as a bat" o Dry skin "dry as a bone" o Red skin (flushed) "red as a beet" o Fever "hot as Hades" o Delirium and seizures "mad as a hatter" o Tachycardia o Urinary retention o Ileus • Block peripheral alpha receptors o Hypotension; vasodilated(a hallmark of TCA toxicity) • Blockade of sodium channels and GABA receptors o triad = conduction delays, dysrhythmias, and hypotension o Prolonged PR/QRS/QT possible SVTs o Wide-complex tachycardia: not ventricular tachycardia, but sinus tachycardia secondary wide QRS / aberrant conduction o Seizures • H1 antihistamine blocker o Sedation EKG will be the first step in diagnosis to rule out EKG changes and life threatening arrhythmias. The patient already has access to TCA's and is presenting with history of taking "lot of pills" with clear suicidal tendency. There is no need to wait for any specific signs and symptoms The qs stem tells us very clearly this man is "drowsy" and "doesnt" know u, which implies slight conscious change, which warrants people think anti-cholinergic effect exerting on brain...so immediately u shud be able to link to TCA. Haloperidol though has anti0cholinergic effect, the power is much lower than TCA.
500
Three of the five indications for using an SNRI medication.
What are social anxiety, GAD, MDD, panic disorder (venlafaxine), depression with neuropathic pain/fibromyalgia (duloxitine) Venlafaxine (Effexor-XR®) * Approved social anxiety disorder, GAD, MDD and panic disorder • Inhibits the uptake of both NE at higher does (150mg/day) and 5HT (immediately) * No clinically significant cytochrome P-450 inhibition * At higher doses may increase diastolic blood pressure of 10-12 points. • FDA recommends it not be used in patients under 18 years old Duloxetine (Cymbalta®) • Used for depression with neuropathic pain/fibromyalgia • Has effects on both serotonin and norepinephrine at starting doses • CYP 2D6 substrate and mild inhibitor • Approved for treatment of MDD
500
Antidepressants that prolong QT interval
What are TCAs