Master the board step 3

Psychiatry
Treatment
1. If the case describes bizarre or paranoid symptoms, hospitalize the patient.
2. Give benzodiazepines for agitation and start antipsychotics.
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Antipsychotic medications are given for 6 months and are the most effective
therapy to prevent further episodes.
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Long-term antipsychotics are only given when there is a history of repeat
episodes.
3. Initiate long-term psychotherapy.
Antipsychotics
Antipsychotics have an immediate quieting effect in acute psychotic attacks
of any cause (e.g., schizophrenia, depression with psychotic features, mania in
bipolar disorder). They also delay relapses.
There are 2 other indications for antipsychotics:
1. For sedation when benzodiazepines are contraindicated or as an adjunct
during anesthesia
2. For movement disorders: Huntington’s disease and Tourette syndrome
(to suppress tics and vocalization)
Basic Science Correlate
Huntington’s disease is a trinucleotide repeat disorder = CAG repeat =
Glutamine.
Antipsychotics are chosen based on side effect profile, not efficacy:
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Low-potency antipsychotics have the highest risk of causing orthostatic
hypotension (alpha blockade), acute urinary retention, dry mouth, blurry
vision, and delirium (anticholinergic effect). Change to an atypical antipsychotic
if these symptoms are present.
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Thioridazine is associated with prolonged QT and arrhythmias. Always
get an EKG if the case describes chest pain, shortness of breath, or palpitations
in a patient taking thioridazine. Thioridazine is also associated with
abnormal retinal pigmentation after many years of use. Routine eye exam
is needed for chronic therapy.
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Impotence and inhibition of ejaculation (α-blocker effect) are common
reasons for noncompliance in males.
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Weight gain (due to hyperprolactinemia) is a common reason for noncompliance
in females. Also ask about galactorrhea and amenorrhea.
Clozapine is associated
with agranulocytosis
(1 percent). Always check
CBC with differential both
before initiating therapy
and weekly after starting
therapy.
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