Psychiatric interview

● Mental status exam is the physical exam of psych

○ Objective
○ Can do it on anyone, even if they are comatose
○ General appearance and behavior
■ Grooming, posture, movements,
○ Speech
■ Mechanical production, rate, flow, latency, coherence
○ Affect
■ What is their face doing- flat, blunted,
○ Mood
■ On average for the past two weeks, euthymic,
○ Perception
■ Hallucinations vs perception
○ Thought content
■ Delusions- cannot convince them otherwise, obsession, idea of reference- believe
something neutral in the environment has specific meaning to you
○ Thought process
■ Goal directed, circumstantial, tangential, loosening of associations, word salad
○ Safety
■ Suicidal, homicidal, self-injurous ideas, impulses and plans
○ Cognition
■ Level of consciousness
■ Orientation
■ Attention and concentration
■ Memory
■ Calculation
■ Abstraction
○ Judgement
○ Insight
● Make sure to ask if ok with relatives present
● ED- safe to discharge or not?
●
Note
● Onset, treatments tried. Safety assessment. Try to write a story so it makes sense.
● Psychiatric disease- previous episodes of this problem, suicide attempts, non suicidal injuries,
inpatient/outpatient treatment, medications, psychotherapy. Don’t just go off other people’s
diagnosis.
Data Collection
● Childhood- abuse. Adolescence- school. Midlife- work, income, marriage, relationship, sexual
activity, military or legal involvement
● This is fun to type without looking at my computer screen, I didn’t realize I could do this til now
which means I have no life whatsoever Quality blah blah blah
 ● Can you work and maintain a relationship.
● Screen for substance use, how much, how often and for how long. Any consequences related to
the use. Tolerance or withdrawal symptoms, history of substance treatment. Ask about marijuana
separately

Psychiatric Emergencies
● Suicide- super common
● Prairie vole is the mating for life vole
○ Has more oxytocin than the mountain voles
● Mountain vole- fucks anything with a pulse
○ Women- never go for mountain voles
● By age 24
○ Frontal cortex is complete in myelination
■ Breaks for doing stupid things
○ This is why suicide decreases after 24, why insurance
● Nonhispanic old white men - greatest suicide risk
● Protestant- most likely to kill themselves
Tarasoff
● Part 1-duty to warn
● Part 2- duty to protect
Restraining
● Haloperidol+ anticholinergic- lead to a relative excess of dopamine- so add the anti-cholinergic to
balance AcH and dopamine
● Second generation- also lowers Ach themselves, so don’t need to add an anticholinergic
Drugs
● Flumazenil can cause seizures in benzo dependent patients- only give it to kids cuz they for sure
aren’t dependent- anti GABA
● Lithium
○ Hemodialysis
○ Tremor, nausea, vomiting
● All overdose patients get charcoal
○ They might be lying/not know what they took
● Dystonia
○ Anticholinergic- give IV, IM hurts
● Akathisia
○ Treat with beta blocker
○ Cannot sit still
○ Anticholinergics do not help
● NMS
○ Fever, fever, elevated white count, vital signs instability, elevated CPK, rigidity
○ Parkinson’s medication withdrawal
● Serotonin syndrome
 ○ Fentanyl, ondansetron are the most common
○ Ondansetron binds to 5Ht3 receptors, which causes the unbound serotonin to go
elsewhere

Child Psych
● Attachment
○ Different types of attachment
● Development
○ At 3- start to realize your gender
■ Transgender can be seen then as well

●
● Piaget
○ Object permanence- peekaboo
○ Matchbox experiment- show kids have theory of mind or not- can lie
● ADHD
○ Less dopamine in the frontal cortex
○ Stimulant are better than combo of stimulant+therapy
● Autism
○ Advanced paternal age
○ Fragile x syndrome, tuberous sclerosis
○ Don’t get social cues
○ ABA- social interaction therapy
● Rett
○ Deceleration of head growth between 5-48 months
● Depression
○ Same rate in kids
 ○ Child can just be 1 year for dysthymia
● Bipolar

Sleep
● Hypersomnia- at least 1 month. Excessive daytime sleepiness and somnolence
● Obstructive sleep apnea
○ 30%
○ Polysomnography
● Sleep apnea
○ Signs and symptoms- can cause HTN- watch out if you are treating their hypertension,
snoring
○ Predictors- BMI, neck circumference
○ Do sleep diary to make sure that
○ Sleep studies- is there sleep study or no. determine the pressure the patient needs to
overcome the obstruction
○ CPAP is the treatment of choice.
○ Uvulopalatoplasty
● Primary insomnia
○ CBT and nonbenzo intially are good, but CBT gets better over time
○ So go with CBT
○ zolpidem/eszopliclone
○ Trazadone protects the break.
○ Ramelteon- melatonin agonsist
○ Benzos promote stage II sleep, decrease N3,N4, REM
● Dissociation
○ Dissociative experience scale
■ 28 item self report
■ Structured clinical interview for dissociative disorders
○ Younger individuals more likely to do it
○ Repression- unconscious blocking of disturbing impulses
○ Dissociative fugue- could potentially even get new identity in new location
○ 1000 mile stare- in war people, they dissociate and look calm when there is chaos around
them
● Dissociative identity disorder
○ Could be related to borderline disorder
○ Will have 2 personalities
○ ⅓-½ will have inner voices, schizo was external
○ Extended psychotherapy is treatment of choice
○ Use meds for comorbid
○ Dialectical- also used for borderline
■ Mindfulness- for here and now
■ Cognitive- to deal with stress
● Depersonalization
 ○ Feel detached
○ 50% of people will feel like that
○ Feel like they are watching movie
○ Refractory to intervention

Alcohol and Drugs

● Alcohol
○ Promotes GABA- Cl channel enters
○ Dependence
■ CAGE
○ Ask why if they say they don’t drink
○ Physical appearance- spider telangactasia, palmar erythema,
○ BAC- if high and patient is still coherent, then they def an alcoholic
○ CIWA- clinical institute withdrawal assessment
■ Don’t just look at autonomic instability for withdrawal, they may
○ Serotonin syndrome- also tachy restless- check for myoclonus
● If withdrawal
○ Give them long acting benzos
○ Precedex- clonidine on steroids
○ Can give ethanol IV as last resort- NEVER oral
■ Can use in the burn units
● Opioids
○ Trackmarks anywhere, cardiac murmur, signs/symptoms of hepatic injury, HIV,
malnutrition, tolerance
○ Withdrawal- lacrimation (use causes lack of secretion), diarrhea, piloerection, GI cramps,
○ Methadone- long acting mu receptor agonist- must be dispensed at methadone clinic
■ Can be used for pain as outpatient
■ Can go as high as 40 mg, have to allow time to go back down
○ Buprenorphine
■ Partial mu receptor agonist
■ Have sublingual forms
■ Suboxone
● Buprenorphine + nalaxone= nalaxone is full antagonist,
○ Add the naloxone to prevent abuse- if you make the pill into a
liquid and shoot it, the naloxone takes effect and the patient goes
into withdrawal and they feel like crap- never again
■ al -anon- family members of addicts go there
■ False positives- dextromorphan, me
■ Requiem for a dream
● Marijuana
○ Weak endocannabinoid receptor
○ Paranoia, conjuctival injection, munchies,
 ● Cocaine
○ Peru
○ Vasoconstrictor- nasal septal perforation
○ Freebaseing cocaine
■ Crack is neutral, you can freebase it better and get a better high
○ CIA for crack in south/central LA
○ Grandiosity, psychotic, mydriasis ,
● Methamphetamine
○ Meth mouth
■ Dry mouth, bruxism, and the other crap left over from production melts the
enamel
● MDMA
○ Molly
○ Bruxisms, heightened sensory stimulation, keep touching everyone,
● Legal Highs
○ Synthetic cannabinoids
● Bath Salts
○ Cathanone

Somatoform Disorders
● The real house- george
● Munchausen
○ 18th century nobleman known for his tall tales
● Illness anxiety
○ Happens EQUALLY in men and women
● Conversion disorder- CBT is great

PTSD/Anxiety
● PTSD- hippocampus affected in adults, reduced medial and posterior corpus callosum in kids
● Specifiers- depersonalization/derealization. Delayed expression- if not within 6 months of trigger
● Anxiety related- lack of trust- no one knows what they are going through
● If psychotic- not really as much PTSD as much as psychosis
● CBT is the main thing- can use SSRI if needed, alpha 2 agonists in kids
● Anxiety- most common disorder, 20% of people will have in life
● Separation anxiety- after 6 years old
● GAD- at least one somatic complaint
● Specific phobia- 6 months
● Panic attack- unpredicted. REALLY bad feeling. Anxiety attacks are triggered by real life events
○ Can be built up
○ Those kids who saw the adults crumble have more anxiety and have a fundamental
distrust in the world
○ Buddhism-
 ● Agoraphobia
○ 2+ places
● Anxiety
○ Check for hyperthyroidism-
● Defense mechanisms reduce the trigger of reality. Want to alter our perception of reality.
Repression is a high percentage of our defenses, erhave one hungred thoguhts for each one
thought that we actually have. Denial,
● Failure of defense mechanisms is what allows for anxiety
● Serotonin is important in anxiety.

Delirium
● Disturbance of attention in the sine quan non
● Ask the days of the week backwards
● Increased dopamine and decreased ACh from oxidative stress
○ Dopamine gets packaged into vesicles before needed
○ Dopamine neurons die and the packages release
■ Schizo symptoms
○ Ach issues- not prepackaged so if the symptoms
● EEG slower than 8 Hz-
● Extra loops on clock- lack of inhibition from frontal cortex
● Haldol- sigma 1 antagonism- reduce limit neuronal death
● GIVE HALDOL WHEN GETTING A STROKE
○ Prevents ischemia
● QTc prolongation
○ QT/square root of RR. Or cube root of RR
○ 2 gram of Mg
○ Estrogen messes with QT
● Don’t give Parkinson’s patient Haldol
○ Give seroquil/clozaril/clozapine
● Akathisia- beta blockers
● Dementia with lewy body
○ Can also be waxing and waning like delirium- watch out cuz if you give them haldol thats
bad

Depression
● Adjustment disorder- start within 3 months, end 6 months
● Anxiety can be comorbid with depression, SSRI’s used to be for anxiety, maybe SSRI are
beneficial because they are helpful with treating the anxiety
● Risk of sudden death after MI is 5 times higher if you have depression
● Beta blocker/propranolol can cause depression
○ So can reserpine
● opioids/barbiturates
● dopamine/serotonin/NE are involved
○ safe/unsafe- serotonin
● Ventricular enlargement, reduced hippocampus
○ Depression causes brain damage
● Cognitive theory- distortions of self, environment, and the future
● Learned helplessness- keep failing and you just expect failure
● MDD recovery- 12 weeks if treated, 6-13 months if untreated
● Half of patents who have first episode