Review Session 3 Annemarie Mikowski DO Assistant Clinical Instructor Chief Resident Psychiatry Case A 26 y/o F describes difficulty sleeping. She has been feeling steadily overwhelmed and anxious at her job where many of her coworkers have been laid off, feels fatigued and tense most of the day. She says she worries most over her daily tasks at work. She experiences frequent headaches for which she has seen her PMD, who has also been treating her with sertraline for depression over the last year. What do you know? What do you want to know?
GAD Excessive worry over everyday things Comorbidity with depression and substance abuse Worse during stress Fluctuating course > 6 months duration Insomnia, fatigue, somatic complaints, poor concentration The patient has been prescribed sertraline (Zoloft) by her PMD. She says she discontinued the medication 2 months prior but did not tell her PMD. What do you want to know? Does this change anything? SSRIs Side effects: sexual dysfunction GI upset Headache anxiety ( activation ) breast changes sweating The patient tells you she discontinued her medication after her boyfriend threw her pills in the trash, telling her she did not need them. She admits to having a decreased libido recently. What do you need to know? What treatment might you recommend?
Case 2 A 19 y/o F is brought to the ER for a stress fracture of the femur. She has been exercising for a total of 5 hours a day before and after her classes to become a nutritionist. Physical exam reveals her to be remarkably thin. Anorexia Nervosa Limit food intake because they are terrified of gaining weight. Very in control. Restricting- restrict food +/- excessive exercise Purging- restrict food AND binging +/- purging by vomiting, diuretics, laxatives Bulemia Nervosa Pattern of binge-eating most prevalent. 2 binges per week. Loss of control during binge Purging- vomiting, laxatives, enemas, etc. * Hypokalemic, hypochloremic alkalosis Nonpurging- can fast or exercise Eating Disorders Denial, denial, denial Abdominal pain/bloating Binge-eating disorder: can!t resist urges, often obese (BMI >40), shame Eating disorders have the highest mortality rate of any mental illness (CDC, NIMH) Treatment TEAM Therapy > medications
Case 3 A 53 y/o single M has been a night janitor for the last 30 years at a local high school. His primary enjoyment is creating a television show rating system based on the local channel guide. What cluster does he fall into? Case 4 A 21 y/o M college student is court-ordered for treatment after he impulsively stole his girlfriend!s car following an argument. He talks fast during the interview, jokes he has a tendency to be impulsive at times. He notes having had boughts of depression in his past, so bad he experienced suicidal ideation but did not act on this. Hypomanic Episode Abnormally and persistently elevated, expansive, or irritable mood for at least 4 days. DIGFAST symptoms (3 or more). Grandiosity must be nondelusional. NOT severe enough to cause social or occupational impairment. NOT severe enough for hospitalization. Bipolar I Bipolar Disorders Must have either a manic or mixed episode. Still see hypomanic episodes too. SEVERE IMPAIRMENT of function, often hospitalized. Bipolar II Recurrent MDD with hypomanic episodes. UNCHARACTERISTIC CHANGE in function, observable by others. No psychosis! No hospitalization!
The same patient is seen in CPEP 3 months later. He is yelling in a room alone about his girlfriend, but then is observed laughing and appearing to have a conversation a few minutes after. When interviewed, he claims to have girlfriends everywhere, stating, I!ve got girls in every state, New York, New Jersey, Virginia, for virgins. I could teach you something! Goodwill Hunting! Ha! how do you like them apples? Family notes patient has not slept much in the last week. Bipolar I Disorder Type I can exhibit psychotic features. What was more prevalent? Mood or Psychosis? } DIGFAST _ Distractibility _ Indiscretion _ Grandiosity _ Flight of ideas or SUBJECTIVE racing thoughts _ Activity _ Sleep _ Talkativeness Significant impairment in reality testing Hallucinations Delusions Thought disorganization Grossly disorganized behavior Schizoaffective Disorder Schizoaffective Disorder What is more prevalent? Mood or psychosis? Psychotic episode + Mood episode Schizophrenia Criteria A Delusions Hallucinations Disorganized speech Grossly disorganized or catatonic behavior Negative symptoms Mood Disorder Criteria Major Depressive Episode Manic Episode Mixed Episode At least 2 weeks of just psychotic episode alone (before or after). Or bizarre delusions, voice of running commentary, voices holding a conversation only Must be delusions or hallucinations for at least 2 weeks in the absence of mood symptoms.
Lithium Mood stabilizer- acute mania and maintenance, schizoaffective Excreted via the kidney MOA unknown 1-3 for antimanic effects (so use with benzo, antipsychotic, Depakote if needed) Decreases suicide risk Narrow therapeutic window, needs blood levels checked Lithium Dietary sodium decreases lithium Dehydration increases lithium Toxicity! stop Li! Rehydrate, may need dialysis GI upset, weight gain, sedation, tremor, polyuria, polydipsia Hypothyroidism! tx with levothyroxine (Synthroid) Teratogenic: Ebstein!s anomoly Valproate (Depakote, Depakene) Mood stabilizer- acute mania and maintenance, schizoaffective Anxiolytic and antiaggressive Preferred for acute mania in kids and elderly GI, increased LFTs, sedation, weight gain, hair loss, pancreatitis PCOS Neural tube defects (folate mvi) Carbamazepine (Tegretol) Anticonvulsant- FDA approval for acute mania, mixed Better tolerated, usually no weight gain Bid dosing GI and CNS side effects Agranulocytosis (depress bone marrow) Induces metabolism of itself/other drugs so tell this to patients on OCP or!
Other things to consider Atypical Antipsychotics Psychotherapy CCB (Verapamil) Antidepressants! Typical Antipsychotics Tx psychosis haloperidol* (Haldol), fluphenazine* (Prolixin), trifluoperazine (Stelazine), chlorpromazine (Thorazine) High affinity D2 receptor antagonism! greater EPS NMS = lead pipe rigidity, fever, autonomic instability, decreased consciousness, elevated CPK Lower the seizure threshold Atypical Antipsychotics Tx psychosis, some adjunctive indications Risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), ziprasidone (Geodon), aripiprazole (Abilify), clozapine (Clozaril) 5HT2 > D2 receptor blockade compared to typicals. Less EPS All have more weight gain and glucose abnormalities Atypical Antipsychotics risperidone* (Risperdal)- hyperprolactinemia olanzapine (Zyprexa)- weight gain quetiapine (Seroquel)- sedation, low EPS ziprasidone (Geodon)- orthostatic hypotention aripiprazole (Abilify)- partial agonist at D2, akathisia clozapine (Clozaril)- sedation, weight gain, no effect on prolactin, no EPS or TD BUT Agranulocytosis, needs registry
Know drug classes My Advice Differentiate disease by big picture (more mood symptoms? More psychotic symptoms?) If objectives are given in a lecture, be able to answer those objectives. And for Step 1 questions, questions, questions.