7/11/16 1 Psychiatry Internal Medicine Board Review July 2016 Lee Rawitscher, M.D. Clinical Professor of Psychiatry UCSF School of Medicine Disclosure I have nothing to disclose Objectives o Describe the most common psychiatric disorders. o Describe the most common psychiatric medications, their indications, and their side effects. o Describe risk factors for suicide. Case #1 o Mr. D. is a 68 y-o man here for an initial visit with you. He has a h/o DM, CAD, CRI, PUD and Hypercholesterolemia. He also has a long history of Major Depression and is treated with sertraline (Zoloft) 100mg daily. He feels that the Zoloft is helpful. He denies any current SI but has been suicidal in the past.
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PsychiatryInternal Medicine Board ReviewJuly 2016Lee Rawitscher, M.D.Clinical Professor of PsychiatryUCSF School of Medicine
DisclosureI have nothing to disclose
Objectiveso Describe the most common psychiatric
disorders.o Describe the most common psychiatric
medications, their indications, and their side effects.
o Describe risk factors for suicide.
Case #1o Mr. D. is a 68 y-o man here for an initial visit
with you. He has a h/o DM, CAD, CRI, PUD and Hypercholesterolemia. He also has a long history of Major Depression and is treated with sertraline (Zoloft) 100mg daily. He feels that the Zoloft is helpful. He denies any current SI but has been suicidal in the past.
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Zoloft would be most concerning with respect to which of the following?
1. DM2. CAD3. CRI4. PUD5. Hypercholesterolemia
Question #1
SSRIs & Bleedingo First case report 1990 (44 F, ↑BT 2nd fluoxetine)o First epidemiological study published in 1999o By 2010, 34 observational epidemiological studies.
Moderately increased risk of bleeding.o UGIB odds ratio pooled from 14 studies = 1.7
n SSRI: OR=1.8n NSAID: OR=3.3n Combined (SSRI + NSAID): OR=9.1n Offset by use of antacids
o Study of 520 surgery patients àdouble blood loss
Case #1 continuedo You treat Mr. D for an H. pylori infection.
His PUD resolves, and he continues his Zoloft. He does well for two months but is then hospitalized with a VRE infection and is started on Zyvox (linezolid). The following day, he experiences anxiety, restlessness, flushing and confusion. He also develops a HR of 120 and a BP of 210/110.
What is the likely explanation?1. Acute Dystonic Reaction2. Antidepressant Withdrawal3. Akesthesia4. Neuroleptic Malignant Syndrome5. Serotonin Syndrome
Question #2
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Serotonin Syndromeo Etiology
n Too much of one agentn Two or more agents
o Symptomsn anxiety, restlessness,
flushing, confusion, tremor, fever, ↕ vitals
o Treatmentn D/C agent, Hydration
Depressive Disorderso Major Depressive Disorder
n 2 weeks sadness or ↓interest (Δweight, Δsleep, ↓energy, Δagitation, guilt, ↓concentration, SI or death)
o Persistent Depressive Disorder (Dysthymia)n 2 years of chronic sadness (Δappetite, Δsleep, ↓energy, ↓self-esteem , ↓concentration, hopelessness). MDD okay.
o Premenstrual Dysphoric Disordern Week prior to menses: depression, irritability, anxiety
Case #2o A 37 y-o woman with bipolar disorder is
BIBA following a seizure. She is confused, tremulous and ataxic with increased muscle tone and ongoing N/V and diarrhea. Labs reveal a lithium level of 2.2 (0.6-1.2). She had been stable on the same dose of lithium for years, but recently she started some new medications.
Which medication is the culprit?1. Motrin2. Depakote3. Oral Contraceptives4. Claritin5. Vitamin C
Question #3
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Bipolar I & II (Mania vs. Hypomania)A) Euphoric (or Irritable)1. Grandiose2. ↓ Sleep3. Talkative4. Racing thoughts5. Distractibility6. ↑ Activity7. ↑ Pleasurable activities
M: 1 weekH: 4 daysM: Can be psychoticH: No psychosisM: Often hospitalizedH: No hospitalizationM: Major impairmentH: Mild impairment
Treatments for Bipolar Disordero lithium
n Nephrogenic DI, Hypothyroidism, preg-D
o divalproexn Thrombocytopenia, Liver toxicity, Pancreatitis, preg-D
o carbamazapinen Aplastic anemia, Liver toxicity, Auto-induction, preg-D
o lamotriginen Stevens-Johnson syndrome
o atypical antipsychotics
Case #3o Over the past few months, a 30 year-old man
has had several episodes (~20 minutes), during which he experienced chest pain, SOB, sweating, nausea, numbness and fear. He thought he was dying and went to the ED each time where a full medical work up was completely normal. He is quite worried this will happen again.
Which medication would you add?1. Zoloft (sertraline)2. Wellbutrin (bupropion)3. Seroquel (quetipine)4. BuSpar (buspirone)5. None of the above
Question #4
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Key Anxiety Disorderso Panic Disorder
n Intense fear with multiple somatic symptomso Specific Phobia
n Fear or anxiety about an object or situationo Social Anxiety Disorder (Social Phobia)
OCD and Related Disorderso Obsessive-Compulsive d/o
n Intrusive thoughts ↑distress – Behavior ↓distresso Body Dysmorphic d/o
n Preoccupation with perceived physical defect
o Hoarding d/on Distress associated with discarding items
o Trichotillomanian Pulling out ones own hair
o Excoriation d/on Picking at skin à lesions
Post Traumatic Stress Disordero Exposure to death, serious injury, or sexual violence
n Experiencing it yourselfn Witnessing another experiencing itn Learning this happened to close family or friendn Repeated exposure to aversive details
o Intrusive: memories, dreams, flashbacks, distress 2° to cueso Avoidance: memories or feelings, external reminderso Negative cognition/mood: memory, ↓pleasure, ↓activityo ↓Arousal: irritable, angry, reckless, hypervigilance, ↓sleep
SSRI’s & Other Considerations o Sexual Dysfunctiono Nausea (90% of
receptors in GI tract)o Platelet Dysfuntiono Hyponatremiao Insomniao Bruxismo Fairly safe in OD
Case #4o A 50 y-o man has a h/o recalcitrant
hypertension. He is on multiple antihypertensive medications and required hospitalization for a hypertensive crisis last year. Over the past few weeks you have been evaluating him for depression and have decided an antidepressant is indicated.
Which would you avoid?1. Effexor (velafaxine)2. Wellbutrin (bupropion)3. Prozac (fluoxetine)4. Remeron (mirtazapine)5. Serzone (nefazadone)
Question #6
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Serotonin Norepinephrine Reuptake Inhibitors
o Examplesn Effexor (venlafaxine), Cymbalta (duloxetine)
o Indicationsn MDD, GAD, Panic d/o, Fibromyalgia, Diabetic
Neuropathic Pain, Musculoskeletal Pain
o Side Effectsn ↑BP, Nausea, Sexual dysfunction, Insomnia,
Anticholinergics, ↓ Appetite
Other Common AntidepressantsName Indications Side Effects Specialmirtazapine (Remeron) MDD Sedation No sexual5HT blockade and Weight gain dysfunctionAlpha2-antagonism Orthostatis Good in HIV
Few interactionsnefazodone MDD Sedation Black box for5HT & NE blockade Dizziness hepatotoxicityAlpha1-antagonism low sexual
dysfunctionbupropion (Wellbutrin) MDD Insomnia No sexualDA & NE reuptake Smoking- Agitation dysfunctionBlockade cessation ↓ appetite Avoid in Sz &
Off-label ADHD Seizures Eating d/o
Case #5o A 55 y-o man with a long h/o migraines and
insomnia sustains a fall and injures his back. Over the following year, he develops neuropathic pain in his legs, and he becomes quite depressed. His screen for mania is negative. You decide to start him on Pamelor (nortiptyline )
Before starting, you would check?1. Liver Function2. Renal Function3. An EKG4. Cholesterol Level5. Fasting Blood Sugar
Pain, Insomniao Side Effects: Anticholinergics, Orthostasis,
Weight gain, Sexual dysfunction, Cardiac Conduction Delay
o Can check blood levels
Case # 6o A 30 y-o male post-doc believes his neighbor
has been spying on him and reading his mail for the past 4 months. “I think he’s also been taking pictures of me when I leave my apartment.” The patient denies depressed or elevated mood and denies hallucinations. No drug use. He reports making good progress on his thesis.
Which diagnosis is most likely?1. Brief Psychotic Disorder2. Schizoaffective Disorder3. Delusional Disorder4. Schizophrenia (paranoid)5. Schizophrenia (undifferentiated)
Question #8
Schizophreniao 6 months of social/occupational impairmento Two or more symptoms for a month:
o Brief Psychotic (< 1 m); Schizophreniform (< 6 m)
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Schizoaffective Disordero Criteria are met for schizophreniao Criteria are met for MDD or Bipolaro 2 weeks of psychosis without mood
symptomso Mood symptoms must be present for a
substantial portion of the overall illness
Case #6 Continuedo He is given Haldol 5mg qhs, and 2wks later
presents to the ED with moderately ↑ muscle tone and t=101.5 (otherwise normal vitals). He also seems mildly confused. Laboratory testing reveals a CK of 3500 with normal renal function. You make a tentative diagnosis of NMS and stop his Haldol. You also start IV hydration.
What other treatment is indicated?1. Dantrolene2. Bromocriptine3. Dantrolene + Bromocriptine4. Cogentin5. None of the above
Question #9
Traditional Antipsychotic Side Effectso EPS – parkinsonism, dystonias, akathisia,
tardive dyskinesian Often treated with anticholinergics
o Hyperprolactinemia – galactorrheao Neuroleptic Malignant Syndrome:
n Fever, AMS, ↕vitals, rigidity (↑CK)n Treat: d/c med, supportive care, bromocriptine
(D2 agonist), dantrolene (muscle relaxant), ECT
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Case #7o A 74 y-o man with dementia has had delusions for 2-months
that ghosts have been stealing his food. He does not see them but is certain they visit while he is asleep or away from home. He says this happens a couple times a week and thinks it is the ghosts of dead relatives.
o In general he is alert and calm but annoyed about the ghosts. He denies SI/HI/AH/VH.
o He is started on haloperidol 2mg po daily, but after 1-week of treatment, the delusions are unchanged. His MSE remains the same.
In addition to patient-education which of the following would you do next??
1. D/C haloperidol and monitor2. Continue haloperidol 2mg daily3. ↑ haloperidol to 5mg and add benztropine
(Cogentin) 0.5mg twice a day4. D/C haloperidol and start risperidone
(Risperdal) 1mg twice a day5. D/C haloperidol and start quetiapine
(Seroquel)50mg nightly and titrate up slowlyQuestion #10
Atypical Antipsychoticso DA, SE, Ach Receptorso Indications
n Schizophrenia, SAD, Bipolar, MDDo ↓ rates of EPS and NMSo Weight gain, ↑ lipids, DM,
Case #8o A 48 y-o man with a h/o IVDU is brought in
by his roommate who says, “He’s up in the middle of the night, mopes around all day and yells at me all the time.” On exam, the patient is irritable, labile and distractible. He shows psychomotor slowing, thinks he can read minds and scores a 24/30 on his MMSE. He denies any psychiatric history.
Which is most likely:1. Paraphrenia2. Depression 2º substance use3. Multi-infarct dementia4. Schizophrenia5. HIV-associated mania
Question #12
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Psychiatric Illness Secondary to a GMC Psychiatric Illness Secondary to a GMCo Endocrine
n Thyroidn Diabetesn Cushing’s Syndromen Addison’s Disease
o CNSn Tumors, Parkinson’s,
Seizures, Infectionso Autoimmune
o Vitamin Deficiencyn B12, Thiamine
o Metabolismn AIP, Wilson’s disease
o Toxins (CO, lead, mercury, aluminum)
o Medications (anticholingerics, steroids, Parkinson d/o)
Case # 9o A 25 year old man is preoccupied with
being criticized in social settings. He left his last job because he felt that others would likely disapprove of him. He tends to be very guarded with his girlfriend, because he thinks she will probably make fun of him.
Which diagnosis is most likely?1. Avoidant P.D.2. Schizoid P.D.3. Paranoid P.D.4. Dependent P.D.5. Interpersonal P.D.
Question #13
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Personality DisordersA. Pattern of inner experience
and behavior that deviates markedly from the cultural norm. (Two or more of the following)
1. Cognition (perception)2. Affectivity3. Interpersonal Functioning4. Impulse Control
Cluster A (“weird”)1. Paranoid – Distrust2. Schizoid – Detachment and ↓ emotional expression
3. Schizotypal - EccentricCluster C (“worried”)
1. Avoidant – Social inhibit., feelings of inadequacy
2. Obsessive-Compulsive –Perfection, order, control
3. Dependent - Clinging
Cluster B (“wild”)1. Antisocial – Disregard for
the rights of others2. Borderline – Unstable
(relationships, self-image, emotion), “splitting”
3. Histrionic – excessive emotionality and attention seeking. Flamboyant.
4. Narcissistic – Need for admiration, ↓empathy
Case #10o A 45 y-o man is admitted for severe alcohol
withdrawal. When he is able to converse, he endorses a long h/o alcohol and IV heroin use. He has tried multiple rehab programs over the years with variable success. In addition to counseling and rehab, which of the following medications would you consider?
DSM5 - Substance Use Disordern Cravingsn Use more than intendedn Attempts to cut downn Increase time to obtain, use, recovern Tolerance, Withdrawaln Physical or physiological problemsn Failure to fulfill obligations at school, work, or homen Social or interpersonal problemsn Use in physically hazardous situationsn * Severity: mild(2-3), Mod(4-5), Severe (>5)
Medications for Substance Use D/OMedication Targeted Substancevarencline Nicotinebupropion Nicotinenicotine replacement Nicotinedisulfiram Alcoholacamprosate Alcoholnaltrexone Opiods, Alcoholmethadone Opiodsbuprenorphine Opiods
Case #11o A 66 year-old, divorced, Caucasian man with
two sons presents with SI. Since his divorce three years ago, he has become more depressed and has been drinking more. He has a history of one prior suicide attempt at age 17 when his father died. He endorses vague AH telling him that he is a “bad father”. He denies HI or access to firearms.
Which is not a risk factor for suicide?1. Age > 652. Divorced3. Alcohol4. Children5. Hallucinations
Question #15
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Suicideo U.S. rate is 11 per 100,000o 11th leading cause of death (3rd for age 15-24)o Firearms > Suffocation > Overdoseo Men > Women (roughly 4 times)o White > Nonwhite (except Native American)o Older white > Younger whiteo Younger non-white > Older non-white
Suicide Risk Factorso Sexo Ageo Depressiono Previous attempto Ethanolo Rational thought losso Sicknesso Organized plano No spouseo Social support lacking
