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Psychiatry: High-Yield Facts in
Psychiatry: High-Yield Facts in
Psychiatry: High-Yield Facts in
PSYCHIATRY
Childhood and Adolescent Disorders
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422
432
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434
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Personality Disorders
436
To URETTE SYNd Ro ME
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438
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Psychotic Disorders
Sc HIZo PHRENIA
Anxiety Disorders
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425
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PANIc d ISo Rd ER
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427
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Ad JUSTMENT d ISo Rd ER
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Neurocognitive Disorders
Mood Disorders
Eating Disorders
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440
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BULIMIA NERVo SA
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Miscellaneous Disorders
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SUIc Id ALITY
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430
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d ELIRIUM
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HIGH-YIELD FACTS IN
PSYCHIATRY
KEYFACT
Children must exhibit ADHD symptoms
in two or more settings (eg, home and
school).
A persistent pattern of excessive inattention (mostly girls) and/or hyperactivity/impulsivity (mostly boys); typically presents between ages 3 and 13. Often
shows a familial pattern.
His To r y /Pe
Diagnosis requires ve or more symptoms from each category listed below for
6 or more months in at least two settings, leading to signi cant social and
academic impairment. Symptoms must be present in patients before age 12.
Inattention: Exhibits a poor attention span in schoolwork/play; displays
poor attention to detail or careless mistakes; has dif culty following
instructions or nishing tasks; is forgetful and easily distracted.
Hyperactivity/impulsivity: Fidgets; leaves seat in classroom; runs around
inappropriately; cannot play quietly; talks excessively; does not wait for
his or her turn; interrupts others.
Tr ea Tmen T
Initial treatment may be nonpharmacologic (eg, behavior modi cation).
Sugar and food additives are not considered etiologic factors.
Pharmacologic treatment includes the following:
Psychostimulants: Methylphenidate (Ritalin), dextroamphetamine
(Dexedrine), mixed salts of dextroamphetamine and amphetamine
(Adderall). Adverse effects include insomnia, irritability, appetite, tic
exacerbation, and growth velocity (normalizes when medication is
stopped).
Nonstimulants (eg, SSRIs, nortriptyline, bupropion) and 2-agonists
(eg, clonidine), and atomoxetine (Strattera).
AUTISM SPECTRUM DISORDER
His To r y /Pe
Characterized by abnormal or impaired social interaction and communication together with restricted activities and interests, evident before age 3.
Patients fail to develop normal social behaviors (eg, social smile, eye contact) and lack interest in relationships.
Development of spoken language is delayed or absent.
Children show stereotyped speech and behavior (eg, hand apping) and
restricted interests (eg, preoccupation with parts of objects).
Tr ea Tmen T
Intensive special education, behavioral management, and symptomtargeted medications (eg, neuroleptics for aggression; SSRIs for stereotyped behavior).
Family support and counseling are crucial.
PSYCHIATRY
HIGH-YIELD FACTS IN
423
KEYFACT
Conduct disorder is seen in Children.
Antisocial personality disorder is seen
in Adults.
Tr ea Tmen T
Individual and family therapy.
INTELLECTUAL DEVELOPMENTAL DISORDER
Associated with male gender, chromosomal abnormalities, congenital infections, teratogens (including alcohol/illicit substances), and inborn errors of
metabolism.
His To r y /Pe
Patients have impaired intellectual functioning (IQ < 70) with de cits in
adaptive functioning (eg, hygiene, social skills); onset is before age 18.
Levels of severity are mild (IQ 5070; 85% of cases), moderate (IQ
3549), severe (IQ 2034), and profound (IQ < 20).
KEYFACT
Fetal alcohol syndrome is the most
common avoidable cause o intellectual
disability.
Tr ea Tmen T
1 prevention consists of educating the general public about possible
causes of intellectual disability and providing optimal prenatal screening
to mothers.
Treatment measures include family counseling and support; speech and
language therapy; occupational/physical therapy; behavioral intervention;
educational assistance; and social skills training.
TOURETTE SYNDROME
KEYFACT
Coprolalia = repetition o obscene
words.
424
HIGH-YIELD FACTS IN
PSYCHIATRY
Psychotic Disorders
SCHIZOPHRENIA
KEYFACT
Psychosis (hallucinations and/
or delusions without insight)
schizophrenia. Di erential diagnosis
must also include medical diseases,
other psychiatric illnesses, and
substance-induced psychosis.
KEYFACT
Terms used to describe components o
psychosis:
Delusion: A xed alse idiosyncratic
belie .
Hallucination: Perception without
an existing external stimulus.
Illusion: Misperception o an actual
external stimulus.
Characterized by psychotic symptoms (hallucinations, bizarre delusions), disorganization (thought disorder, behavioral disturbances), and negative symptoms (poverty of affect, thought, and social interaction).
Epidemiology: Prevalence is approximately 1%; men and women are
affected equally. Peak onset is earlier in men (ages 1825) than in
women (ages 2535). Schizophrenia in rst-degree relatives also risk.
Up to 50% of patients attempt suicide, and 10% of those affected successfully commit suicide.
Etiology: Etiologic theories focus on neurotransmitter abnormalities such
as dopamine dysregulation (frontal hypoactivity and limbic hyperactivity)
and brain abnormalities on CT and MRI (enlarged ventricles and cortical volume).
His To r y /Pe
Two or more of the following are present continuously for 6 or more
months with social or occupational dysfunction:
Positive symptoms: Hallucinations (most often auditory), delusions,
disorganized speech, bizarre behavior, and thought disorder.
Negative symptoms: Flat affect, emotional reactivity, poverty of
speech, lack of purposeful actions, and anhedonia.
See Table 2.14-1 for the differential diagnosis of psychosis.
TA B L E 2 . 1 4 - 1 .
d iSo r d er
Psychotic disorders
d u r at io n /c h a r a c t er iSt ic S
Brief psychotic disorder: > 1 day and < 1 month.
Schizophreniform disorder: > 1 month and < 6 months.
Note: Both have same presentation as schizophrenia, but are usually
preceded by stressors, have no prior episodes, are less likely to
have negative symptoms, and have better lifetime prognosis.
Schizophrenia: > 6 months.
Schizoaf ective disorder: Schizophrenia + major a ective disorder
(major depressive disorder or bipolar a ective disorder).
Personality disorders
Delusional disorder
PSYCHIATRY
Tr ea Tmen T
Antipsychotics (see Table 2.14-2); long-term follow-up.
Supportive psychotherapy, training in social skills, vocational rehabilitation, and illness education may help.
Negative symptoms may be more dif cult to treat than positive symptoms;
atypical antipsychotics are drug of choice.
Anxiety Disorders
HIGH-YIELD FACTS IN
425
MNEMONIC
Evolution of EPS
4 and A
4 hours: Acute dystonia.
4 days: Akinesia.
4 weeks: Akathisia.
4 months: Tardive dyskinesia (often
permanent).
Antipsychotic Medications
d r u g c l a SS
Typical
e x a Mpl eS
High potency.
Haloperidol, fluphenazin .
antipsychotics
in d ic at io n S
Psychotic disorders, acute
Sid e e FFec t S
EPS (see Table 2.14-3)
Tourette syndrome.
constipation).
QTc prolongation and torsades,
especially IV haloperidol.
Neuroleptic malignant
syndrome (see Table 2.14-3).
Thioridazine, chlorpromazine.
Atypical
antipsychotics
mellitus, somnolence,
quetiapine, olanzapine,
ziprasidone, aripiprazole,
e ects.
prolongation.
clozapine.
agranulocytosis, requiring
426
HIGH-YIELD FACTS IN
TA B L E 2 . 1 4 - 3 .
Su bt ype
Acute dystonia
PSYCHIATRY
d eSc r ipt io n
Prolonged, painful tonic muscle contraction or
t iMe
o F o n Set
Hours
t r eat Men t
Anticholinergics (benztropine or diphenhydramine)
are acute therapy; some patients on antipsychotics
who are prone to dystonic reactions may need regular
prophylactic dosing (eg, benztropine).
Dyskinesia
Days
cogwheel rigidity).
Akathisia
Weeks
Tardive
Months
dyskinesia
Neuroleptic
malignant
Anytime
syndrome
His To r y /Pe
Presents with anxiety on most days (6 or more months) and with three or
more somatic symptoms (restlessness, fatigue, dif culty concentrating, irritability, muscle tension, disturbed sleep).
KEYFACT
Buspirone is another drug, in addition
to SSRIs, that should not be used in
conjunction with MAOIs.
Tr ea Tmen T
Short-term therapy:
Benzodiazepines may be used for immediate symptom relief.
Taper benzodiazepines as soon as long-term treatment is established
(eg, with SSRIs) in view of the high risk of tolerance and dependence.
Do not stop benzodiazepines cold turkey, as patients may develop
potentially lethal withdrawal symptoms similar to those of alcohol withdrawal.
Long-term therapy:
Lifestyle changes.
Psychotherapy.
Medications (see Table 2.14-4): SSRIs ( rst-line treatment), venlafaxine, buspirone. Patient education is essential.
PANIC DISORDER
PSYCHIATRY
TA B L E 2 . 1 4 - 4 .
HIGH-YIELD FACTS IN
427
Anxiolytic Medications
d r u g c l a SS
SSRIs (flu xetine, sertraline,
in d ic at io n S
GAD, OCD, panic disorder.
Sid e e FFec t S
Nausea, GI upset,
paroxetine, citalopram,
somnolence, sexual
escitalopram)
dysfunction, agitation.
Buspirone
tolerance, dependence, or
withdrawal.
-blockers
Bradycardia, hypotension.
dependence; disinhibition
in young or old patients;
confusion.
His To r y /Pe
Panic attacks are de ned as discrete periods of intense fear or discomfort in which at least four of the following symptoms develop abruptly and
peak within 10 minutes: tachypnea, chest pain, palpitations, diaphoresis,
nausea, trembling, dizziness, fear of dying or going crazy, depersonalization, or hot ashes.
Perioral and/or acral paresthesias, when present, are fairly speci c to panic
attacks, which produce hyperventilation and low O 2 saturation.
Patients present with 1 or more months of concern about having additional attacks or signi cant behavior change as a result of the attackseg,
avoiding situations that may precipitate attacks.
Determine whether a patient has panic disorder with or without agoraphobia so that agoraphobia can also be addressed in the treatment plan.
KEYFACT
Walks like a chicken, talks like a chicken
its a bear. Di erential diagnosis or
panic disorders:
Medical conditions: Angina,
MI, arrhythmias, hyperthyroidism,
pheochromocytoma.
Psychiatric conditions:
Substance-induced anxiety, GAD,
PTSD.
Tr ea Tmen T
Short-term therapy: Benzodiazepines (eg, clonazepam) may be used
for immediate relief, but long-term use should be avoided in light of the
potential for addiction and tolerance (see Table 2.14-4). Taper benzodiazepines as soon as long-term treatment is initiated (eg, SSRIs).
Long-term therapy:
CBT.
Medications: SSRIs ( rst-line therapy), TCAs.
PHOBIAS (SOCIAL AND SPECIFIC)
Distinguished as follows:
Social phobia: Characterized by marked fear provoked by social or performance situations in which embarrassment may occur. It may be speci c (eg, public speaking, urinating in public) or general (eg, social interaction) and often begins in adolescence.
428
HIGH-YIELD FACTS IN
PSYCHIATRY
KEYFACT
Agoraphobia is de ned as ear o
being alone in public places. Literally
translated, it means ear o the
marketplace.
His To r y /Pe
Presents with excessive or unreasonable fear and/or avoidance of an object or
situation that is persistent and leads to signi cant distress or impairment in
function. Patients recognize that their fear is excessive.
Tr ea Tmen T
Speci c phobias: CBT involving desensitization through incremental
exposure to the feared object or situation along with relaxation techniques.
Other options include supportive, family, and insight-oriented psychotherapy.
Social phobias: CBT, SSRIs, low-dose benzodiazepines, or -blockers (for
performance anxiety) may be used (see Table 2.14-4).
Obsessive-Compulsive Disorder
and Related Disorders
OBSESSIVE-COMPULSIVE DISORDER
KEYFACT
Many OCD patients initially present to a
nonpsychiatristeg, they may consult
a dermatologist with a skin complaint
2 to overwashing hands.
Characterized by obsessions and/or compulsions that lead to signi cant distress and dysfunction in social or personal areas. Typically presents in late
adolescence or early adulthood; prevalence is equal in male and female
patients. Often chronic and dif cult to treat.
His To r y /Pe
Obsessions: Persistent, unwanted, and intrusive ideas, thoughts,
impulses, or images that lead to marked anxiety or distress (eg, fear of
contamination, fear of harm to oneself or to loved ones).
Compulsions: Repeated mental acts or behaviors that neutralize anxiety from obsessions (eg, handwashing, elaborate rituals for ordinary tasks,
counting, excessive checking).
Patients recognize these behaviors as excessive and irrational products
of their own minds (vs obsessive-compulsive personality disorder, or
OCPD; see Table 2.14-5).
Patients wish they could get rid of the obsessions and/or compulsions.
TA B L E 2 . 1 4 - 5 .
OCD vs OCPD
o cd
o c pd
compulsions.
infl xible.
(ego dystonic).
PSYCHIATRY
HIGH-YIELD FACTS IN
429
Tr ea Tmen T
Pharmacotherapy (SSRIs are rst-line pharmacologic treatment).
CBT using exposure and desensitization relaxation techniques.
Patient education is imperative.
BODY DYSMORPHIC DISORDER
Clinically signi cant stress or impairment in day-to-day social/work interactions as a result of direct exposure to an extreme, life-threatening traumatic
event (eg, assault, combat, injury, rape, accident, violent crime), witnessing a
traumatic event, indirect exposure through learning of a life-threatening event
involving a close family member or friend, or reexposure to trauma-related
events through occupation.
KEYFACT
Top causes o PTSD in male patients
are (1) sexual assault and (2) combat.
Top causes o PTSD in emale patients
are (1) childhood abuse and (2) sexual
assault.
His To r y /Pe
Characterized by the following four symptom clusters:
Intrusion: Reexperiencing of the event through nightmares, ashbacks, intrusive memories.
Avoidance of stimuli associated with the trauma.
Negative alterations in mood and cognitions: Numbed responsiveness (eg, detachment, anhedonia), guilt, self-blame.
Changes in arousal and reactivity: arousal (eg, hypervigilance, exaggerated startle), sleep disturbances, aggression/irritability, and poor
concentration that leads to signi cant distress or impairment in functioning.
Symptoms must persist for > 1 month; the same symptoms present for 3
days to 1 month characterize acute stress disorder.
t r ea Tmen T
Short-term therapy: To target anxiety; includes -blockers and 2-agonists
(eg, clonidine).
Long-term therapy:
Medications: SSRIs are rst line; buspirone, TCAs, and MAOIs may
be helpful. Benzodiazepines are also used but should be avoided in
light of their addictive potential, as there is a high incidence of substance abuse among patients with PTSD.
Psychotherapy and support groups are useful.
KEYFACT
In patients with a history o substance
abuse, benzodiazepines should be
avoided in view o their high addictive
potential.
430
HIGH-YIELD FACTS IN
PSYCHIATRY
ADJUSTMENT DISORDER
Clinically signi cant distress following a profound life change (eg, divorce,
unemployment, nancial issues, romantic breakup), not severe enough to
meet criteria for another mental disorder.
His To r y /Pe
Occurs within 3 months after onset of the stressor, can place person at
higher risk for suicidality. Symptoms can be further characterized by anxiety, depressed mood, or issues in conduct. Usually resolves with 6 months of
onset.
Tr ea Tmen T
No pharmacologic treatment! Treat adjustment disorder with supportive
counseling.
Neurocognitive Disorders
Affect memory, orientation, judgment, and attention.
DEMENTIA (AKA MAJOR NEUROCOGNITIVE DISORDER)
MNEMONIC
Ca uses of dementia
DEMENTIASS
Degenerative diseases (Parkinson,
Huntington)
Endocrine (thyroid, parathyroid, pituitary,
adrenal)
Metabolic (alcohol, electrolytes, vitamin
B12 deficien y, glucose, hepatic, renal,
Wilson disease)
Exogenous (heavy metals, carbon
monoxide, drugs)
Neoplasia
Trauma (subdural hematoma)
Infection (meningitis, encephalitis,
endocarditis, syphilis, HIV, prion
diseases, Lyme disease)
A ective disorders (pseudodementia)
Stroke/Structure (vascular dementia,
ischemia, vasculitis, normal-pressure
hydrocephalus)
A decline in cognitive functioning with global de cits. Level of consciousness is stable (vs delirium). Prevalence is highest among those > 85 years of
age. The course is persistent and progressive. The most common causes are
Alzheimer disease (65%) and vascular dementia (20%). Other causes are
outlined in the mnemonic DEMENTIASS.
His To r y /Pe
Diagnostic criteria include memory impairment and one or more of the following:
The four As of dementia (the progression of cognitive impairment follows this order): Amnesia (partial or total memory loss), Aphasia (language
impairment), Apraxia (inability to perform motor activities), Agnosia
(inability to recognize previously known objects/places/people).
Impaired executive function (problems with planning, organizing, and
abstracting) in the presence of a clear sensorium.
Personality, mood, and behavior changes are common (eg, wandering and
aggression).
Dia g n o s is
A careful history and physical is critical. Serial mini-mental state exams
should be performed.
Rule out treatable causes of dementia; obtain CBC, RPR, CMP, TFTs,
HIV, B12/folate, ESR, UA, and a head CT or MRI.
Table 2.14-6 outlines key characteristics distinguishing dementia from
delirium.
Tr ea Tmen T
Provide environmental cues and a rigid structure for the patients daily
life.
PSYCHIATRY
TA B L E 2 . 1 4 - 6 .
Delirium vs Dementia
Va r ia bl e
Level of
HIGH-YIELD FACTS IN
d el ir iu M
d eMen t ia
Usually alert.
Onset
Acute.
Gradual.
Course
Progressive deterioration.
attention
sundowning.
Consciousness
Clouded.
Intact.
Hallucinations
Prognosis
Reversible.
Treatment
Low-dose antipsychotics;
Environmental changes.
MNEMONIC
Ma jor ca uses of delirium
I WATCH DEATH
Infection
Withdrawal
Acute metabolic/substance Abuse
Trauma
CNS pathology
Hypoxia
Deficiencie
Endocrine
Acute vascular/MI
Toxins/drugs
Heavy metals
431
432
HIGH-YIELD FACTS IN
KEYFACT
It is common or delirium to be
superimposed on dementia.
KEYFACT
MDEs can be present in major
depressive disorder or in bipolar
disorder types I and II.
PSYCHIATRY
Dia g n o s is
Check vital signs, utilize pulse oximetry, and provide glucose; perform
physical and neurologic examinations.
Note recent medications (narcotics, anticholinergics, steroids, or benzodiazepines), substance use, prior episodes, medical problems, signs of
organ failure (kidney, liver), and infection (occult UTI is common in the
elderly; check UA).
Order lab and radiologic studies to identify a possible underlying cause.
Tr ea Tmen T
Treat underlying causes (delirium is often reversible).
Normalize uids and electrolytes.
Optimize the sensory environment, and provide necessary visual and
hearing aids.
Use low-dose antipsychotics (eg, haloperidol) for agitation and psychotic
symptoms.
Conservative use of physical restraints may be necessary to prevent harm
to the patient or others.
Mood Disorders
Also known as affective disorders.
MAJOR DEPRESSIVE DISORDER
MNEMONIC
Symptoms of a depressive
episode
SIG E CAPS
Sleep (hypersomnia or insomnia)
Interest (loss of interest or pleasure in
activities)
Guilt (feelings of worthlessness or
inappropriate guilt)
Energy () or fatigue
Concentration ( )
Appetite ( or ) or weight ( or )
Psychomotor agitation or retardation
Suicidal ideation
MNEMONIC
TCA toxicity
Tri-Cs
Convulsions
Coma
Cardiac arrhythmias
PSYCHIATRY
TA B L E 2 . 1 4 - 7 .
HIGH-YIELD FACTS IN
433
d iSo r d er
medical condition
Substance-induced
mood disorder
Adjustment disorder
Normal bereavement
Dysthymia
KEYFACT
Discontinue SSRIs at least 2 weeks
be ore starting an MAOI. Wait 5 weeks i
the patient was on uoxetine.
Su bt ype
Postpartum blues
Postpartum psychosis
t iMe o F o n Set
SyMpt o MS
Within 2 weeks of
delivery.
23 weeks postdelivery.
Postpartum
13 months
depression
postdelivery.
434
HIGH-YIELD FACTS IN
TA B L E 2 . 1 4 - 9 .
d r u g c l a SS
SSRIs
PSYCHIATRY
e x a Mpl eS
Fluoxetine, sertraline,
in d ic at io n S
Depression, anxiety.
paroxetine, citalopram,
Sid e e FFec t S
Sexual side e ects, GI distress, agitation, insomnia, tremor, diarrhea.
Serotonin syndrome (fever, myoclonus, mental status changes,
flu oxamine.
cardiovascular collapse) can occur if SSRIs are used with MAOIs, illicit
drugs, or herbal medications.
Paroxetine can cause pulmonary hypertension in the fetus. Avoid in
pregnancy.
Atypicals
Bupropion, mirtazapine,
Depression, anxiety.
trazodone.
SNRIs
Venlafaxine, duloxetine.
Depression, anxiety,
chronic pain.
TCAs
Nortriptyline,
Depression, anxiety
desipramine,
amitriptyline, imipramine.
migraine headaches,
enuresis (imipramine).
MAOIs
Phenelzine,
Depression, especially
tranylcypromine,
atypical.
available).
KEYFACT
SIG E CAPS = MDD. DIG FAST = BPD.
Bipolar I: Involves at least one manic or mixed episode (usually requiring hospitalization).
Bipolar II: Involves at least one MDE and one hypomanic episode (less
intense than mania). Patients do not meet the criteria for full manic or
mixed episodes. Characterized predominantly by depression with occasional hypomanic episodes.
Rapid cycling: Involves four or more episodes (MDE, manic, mixed, or
hypomanic) in 1 year.
Cyclothymic: Chronic and less severe, with alternating periods of hypomania and moderate depression for > 2 years.
PSYCHIATRY
His To r y /Pe
The mnemonic DIG FAST outlines the clinical presentation of mania.
Patients may report excessive engagement in pleasurable activities (eg,
excessive spending or sexual activity), reckless behaviors, and/or psychotic
features.
Antidepressant use without a mood stabilizer may trigger manic episodes.
Dia g n o s is
A manic episode is 1 week or more of persistently elevated, expansive,
or irritable mood plus three DIG FAST symptoms. Psychotic symptoms
are common in mania.
Symptoms are not due to a substance or medical condition and lead to signi cant impairment socially, occupationally, or familially.
Hypomania is similar but does not involve marked functional impairment
or psychotic symptoms and does not require hospitalization.
HIGH-YIELD FACTS IN
435
MNEMONIC
Symptoms of ma nia
DIG FAST
Distractibility
Insomnia ( need for sleep)
Grandiosity ( self-esteem)/more Goal
directed
Flight of ideas (or racing thoughts)
Activities/psychomotor Agitation
Sexual indiscretions/other pleasurable
activities
Talkativeness/pressured speech
Tr ea Tmen T
Bipolar mania: Mania is considered a psychiatric emergency because of
the impaired judgment and great risk of harm to self and others.
Acute therapy: Antipsychotics, lithium, valproate.
Maintenance therapy: Mood stabilizers (see Table 2.14-10).
Use benzodiazepines for refractory agitation.
Bipolar depression: Mood stabilizers with or without antidepressants.
Start mood stabilizers rst (see Table 2.14-10) to avoid inducing mania.
ECT may be used to treat refractory cases.
TA B L E 2 . 1 4 - 1 0 .
Mood Stabilizers
d r u g c l a SS
Lithium
in d ic at io n S
First-line mood stabilizer. Used for acute mania (in
Sid e e FFec t S
Thirst, polyuria, diabetes insipidus, tremor, weight
Carbamazepine
Valproic acid
BPD; anticonvulsant.
Lamotrigine
436
HIGH-YIELD FACTS IN
PSYCHIATRY
MNEMONIC
Cha ra cteristics of persona lity
disorders
MEDIC
Maladaptive
Enduring
Deviate from cultural norms
Infl xible
Cause impairment in social or occupational
functioning
TA B L E 2 . 1 4 - 1 1 .
Personality Disorders
Personality can be de ned as an individuals set of emotional and behavioral traits, which are generally stable and predictable. Personality disorders
are de ned when ones traits become chronically rigid and maladaptive, and
affect most aspects of ones life (see the mnemonic MEDIC). Onset occurs
by early adulthood. Speci c disorders are outlined in Table 2.14-11.
d iSo r d er
c h a r a c t er iSt ic S
c l in ic a l pr eSen t at io n
c l u St er a : Weir d
Paranoid
malevolent.
Schizoid
expression.
Schizotypal
c l u St er b: Wil d
Borderline
new clinician as better than all the others. She reveals that she
harm.
mechanism.
Histrionic
provocative; theatrical.
PSYCHIATRY
TA B L E 2 . 1 4 - 1 1 .
HIGH-YIELD FACTS IN
437
d iSo r d er
c h a r a c t er iSt ic S
c l in ic a l pr eSen t at io n
c l u St er b: Wil d
Narcissistic
Lack empathy.
Antisocial
disorder.
c l u St er c : Wo r r ied
Obsessivecompulsive
and
WiMpy
Avoidant
social interactions.
Dependent
that her parents just kicked her out of their house and she is
struggling to survive on her own. She says she is too weak to
even make choices at the grocery, as her mother would always
care for her and now these decisions are overwhelming. She
has been sitting outside of their house daily, hoping they will
let her live there again.
Dia g n o s is
Ask about attitudes, mood variability, activities, and reaction to stress.
Patients have chronic problems dealing with responsibilities, roles, and
stressors. They may also deny their behavior, have dif culty changing their
behavior patterns, and frequently refuse psychiatric care.
Tr ea Tmen T
Psychotherapy is the mainstay of therapy.
Pharmacotherapy is reserved for cases with comorbid mood, anxiety, or
psychotic signs/symptoms.
438
HIGH-YIELD FACTS IN
PSYCHIATRY
Occurs more often in men (4:1) and in those 2134 years of age, although the
incidence in women is rising. Also associated with a family history.
His To r y /Pe
See Table 2.14-12 for the symptoms of intoxication and withdrawal. Look for
palmar erythema or telangiectasias as well as for other signs and symptoms of
end-organ complications.
Dia g n o s is
Screen with the CAGE questionnaire. Monitor vital signs for evidence of
withdrawal. Labs may reveal LFTs, LDH, and mean corpuscular volume.
PSYCHIATRY
TA B L E 2 . 1 4 - 1 2 .
439
d rug
Alcohol
HIGH-YIELD FACTS IN
in t o x ic at io n
Wit h d r aWa l
threatening in overdose).
diarrhea, yawning.
Opioid withdrawal is not life-threatening, hurts all over,
and does not cause seizures.
such as methadone.
Amphetamines
disturbance, nightmares.
nightmares.
hydrochloride
(PCP)
None.
None.
440
HIGH-YIELD FACTS IN
TA B L E 2 . 1 4 - 1 2 .
PSYCHIATRY
d rug
in t o x ic at io n
Barbiturates
Wit h d r aWa l
Anxiety, seizures, delirium, life-threatening cardiovascular
collapse.
Benzodiazepines
craving.
agitation.
Nicotine
MNEMONIC
CAGE questionna ire:
1. Have you ever felt the need to Cut
down on your drinking?
2. Have you ever felt Annoyed by
criticism of your drinking?
3. Have you ever felt Guilty about
drinking?
4. Have you ever had to take a morning
Eye opener?
More than one yesanswer makes
alcoholism likely.
Tr ea Tmen T
Rule out medical complications; correct electrolyte abnormalities.
Start a benzodiazepine taper for withdrawal symptoms. Add haloperidol
for hallucinations and psychotic symptoms.
Give multivitamins and folic acid; administer thiamine before glucose
(which depletes thiamine) to prevent Wernicke encephalopathy.
Give anticonvulsants to patients with a seizure history.
Group therapy, disul ram, or naltrexone can aid patients with dependence.
Long-term rehabilitative therapy (eg, Alcoholic Anonymous).
Co mPl iCa Tio n s
GI bleeding from gastritis, ulcers, varices, or Mallory-Weiss tears.
Pancreatitis, liver disease, DTs, alcoholic hallucinosis, peripheral neuropathy, Wernicke encephalopathy, Korsakoff psychosis, fetal alcohol syndrome, cardiomyopathy, anemia, aspiration pneumonia, risk of sustaining trauma (eg, subdural hematoma).
Eating Disorders
ANOREXIA NERVOSA
Risk factors include female gender, low self-esteem, and high socioeconomic
status. Also associated with OCD, MDD, anxiety, and careers/hobbies such as
modeling, gymnastics, ballet, and running.
His To r y /Pe
Patients restrict (eg, severely restricting caloric intake by fasting or by
excessively exercising) or binge and purge (through vomiting, laxatives,
and diuretics).
Signs and symptoms include cachexia, a body mass index (BMI) < 18,
lanugo, dry skin, bradycardia, lethargy, hypotension, cold intolerance, and
hypothermia (as low as 35C [95F]).
See Table 2.14-13.
PSYCHIATRY
TA B L E 2 . 1 4 - 1 3 .
HIGH-YIELD FACTS IN
441
Anorexia vs Bulimia
Va r ia bl e
a n o r ex ia n er Vo Sa
Presentation
b u l iMia n er Vo Sa
as fat).
Weight
are overweight.
Attitude toward
illness
treatment.
Treatment
Psychotherapy
antidepressants.
necessary.
Psychotherapy.
Treat comorbidities.
Dia g n o s is
Measure height and weight; check BMI; check CBC, electrolytes, endocrine
levels, and ECG. Perform a psychiatric evaluation to screen patients for
comorbid conditions.
Tr ea Tmen T
See Table 2.14-13.
KEYFACT
There are two types o anorexia
nervosa:
Restricting type
Binging/purge-eating type
c o n St it u t io n a l
c a r d ia c
gi
gu
o t h er
Amenorrhea
Dermatologic: Lanugo
Nephrolithiasis
Hematologic:
Cachexia
Arrhythmias
Hypothermia
Sudden death
Fatigue
Hypotension
Abdominal pain
Electrolyte abnormalities
Bradycardia
Delayed gastric
(hypokalemia, pH
abnormalities)
Prolonged QT interval
decay
emptying
Leukopenia
Neurologic: Seizures
Musculoskeletal:
Osteoporosis, stress
fractures
442
HIGH-YIELD FACTS IN
PSYCHIATRY
BULIMIA NERVOSA
KEYFACT
Bulimic patients tend to be more
disturbed by their behavior than
anorexics and are more easily engaged
in therapy. Anorexic patients deny
health risks associated with their
behavior, making them resistant to
treatment.
KEYFACT
Bupropion should be avoided in the
treatment o patients with eating
disorders, as it is associated with a
seizure threshold.
More common among women; associated with low self-esteem, mood disorders, and OCD.
His To r y /Pe
See Table 2.14-13.
Signs include dental enamel erosion, enlarged parotid glands, and scars
on the dorsal hand surfaces (if there is a history of repeated induced vomiting).
Tr ea Tmen T
See Table 2.14-13.
Co mPl iCa Tio n s
See Table 2.14-14.
Miscellaneous Disorders
SEXUAL DISORDERS
PSYCHIATRY
TA B L E 2 . 1 4 - 1 5 .
HIGH-YIELD FACTS IN
443
d iSo r d er
c l in ic a l Ma n iFeSt at io n S
Exhibitionistic
Pedophilic
Voyeuristic
Fetishistic
Transvestic
Frotteuristic
Sexual sadism
Sexual masochism
options include sex-reassignment surgery or hormonal treatment (eg, estrogen for men, testosterone for women). Supportive psychotherapy is helpful.
Sexual Dysfunction
Up to one-third of all American adults suffer from some type of sleep disorder
during their lives. The term dyssomnia describes any condition that leads to
a disturbance in the normal rhythm or pattern of sleep. Insomnia is the most
common example. Risk factors include female gender, the presence of mental and medical disorders, substance abuse, and advanced age.
1 Insomnia
KEYFACT
Recommended sleep hygiene
measures: Stimulus control therapy
to reestablish a circadian (24-hour)
sleep/wake cycle.
Establishment o a regular sleep
schedule
Limiting o ca eine intake
Avoidance o daytime naps
Warm baths in the evening
Use o the bedroom or sleep and
sexual activity only
Exercising early in the day
Relaxation techniques
Avoidance o large meals near
bedtime
444
HIGH-YIELD FACTS IN
PSYCHIATRY
PSYCHIATRY
HIGH-YIELD FACTS IN
445
KEYFACT
Factitious disorders and malingering
are distinct rom somato orm disorders
in that they involve conscious and
intentional processes.
Patients often present with excessive thoughts, anxiety, and behaviors driven
by presence of somatic symptoms that is distressing and negatively affects
daily life. This may occur with or without any medical illness present. High
health care utilization is often present.
Tr ea Tmen T
Regularly scheduled appointments with one clinician as 1 caregiver.
Avoid unnecessary diagnostics.
Psychotherapy.
Conversion Disorder
KEYFACT
In malingering, patients intentionally
simulate illness or personal gain.
446
HIGH-YIELD FACTS IN
PSYCHIATRY
Tr ea Tmen T
Psychotherapy.
Minimal diagnostics and treatment to avoid reinforcement of behaviors.
KEYFACT
Sexual abusers are usually male and
are o ten known to the victim (and are
o ten amily members).
MNEMONIC
Risk fa ctors for suicide
SAD PERSONS
Sex (male)
Age (older)
Depression
Previous attempt
Ethanol/substance abuse
Rational thought
Sickness (chronic illness)
Organized plan/access to weapons
No spouse
Social support lacking
KEYFACT
Suicide is the third leading cause o
death (a ter homicide and accidents)
among 15- to 24-year-olds in the
United States.
KEYFACT
Emergent inpatient hospitalization
is required or patients with suicidal
intentions.
Accounts for 30,000 deaths per year in the United States; the eighth overall cause of death in the United States. One suicide occurs every 1720
minutes.
Risk factors include male gender, age > 45 years, psychiatric disorders
(major depression, presence of psychotic symptoms), a history of an admission to a psychiatric institution, a previous suicide attempt, a history of
violent behavior, ethanol or substance abuse, recent severe stressors, and a
family suicide history (see the mnemonic SAD PERSONS).
Women are more likely to attempt suicide, whereas men are more likely
to succeed by virtue of their use of more lethal methods.
Dx:
Perform a comprehensive psychiatric evaluation.
Ask about family history, previous attempts, ambivalence toward death,
and hopelessness.
Ask directly about suicidal ideation, intent, and plan, and look for
available means.
Tx: A patient who endorses suicidality requires emergent inpatient hospitalization even against his/her will. Suicide risk may after antidepressant
therapy is initiated because a patients energy to act on suicidal thoughts
can return before the depressed mood lifts.