Psychiatry, Usmle Endpoint by DR Ahmed Shebl

USMLE ENDPOINT PSYCHIATRY
CLASSICAL CONDITIONING:
 Learning in which a natural response (salivation) is elicited by a conditioned, or learned,
stimulus (bell) that previously was presented in conjunction with an unconditioned stimulus
(food).
 Usually deals with involuntary responses.
 Examples:
 Pavlov’s classical experiments with dogs— ringing the bell provoked salivation.
 White coat hypertension.
OPERANT CONDITIONING
 Learning in which a particular action is elicited because it produces a punishment or reward.
 Usually deals with voluntary responses.
 Reinforcement Target behavior (response) is followed by desired reward (positive
reinforcement) or removal of aversive stimulus (negative reinforcement).
 Extinction Discontinuation of reinforcement (positive or negative) eventually eliminates
behavior. Can occur in operant or classical
conditioning.
 Punishment Repeated application of aversive
stimulus (positive punishment) or removal of
desired reward (negative punishment) to
extinguish unwanted behavior (Skinner’s
operant conditioning quadrant).
TRANSFERENCE AND COUNTERTRANSFERENCE

 Transference:
 Patient projects feelings about formative or other important persons onto physician
(eg, psychiatrist is seen as parent).
 Emotions often originate from feelings toward early significant figures, particularly
parents.
 Countertransference: Doctor projects feelings about formative or other important persons
onto patient (eg, patient reminds physician of younger sibling).
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EGO DEFENSES
 Mental processes (unconscious or conscious) used to resolve conflict and prevent undesirable
feelings (eg, anxiety, depression).
IMMATURE DEFENSES:
 Acting out:
 Expressing unacceptable feelings and thoughts through actions.
 Example: Tantrums, patient reacting by tearing up her discharge paperwork or
throwing her food tray at the resident.
 Denial:
 Avoiding the awareness of some painful reality.
 A patient with cancer plans a full-time work schedule despite being warned of
significant
fatigue during chemotherapy.
 Displacement:
 Redirection of emotions or impulses to a neutral person or object (vs projection).
 A teacher is yelled at by the principal. Instead of confronting the principal directly,
the teacher goes home and criticizes her husband’s dinner selection.
 Dissociation:
 Temporary, drastic change in personality, memory, consciousness, or motor behavior
to avoid emotional stress.
 Patient has incomplete or no memory of traumatic event.
 A victim of sexual abuse suddenly appears numb and detached when she is exposed to
her abuser.
 Fixation:
 Partially remaining at a more childish level of development (vs regression).
 A surgeon throws a tantrum in the operating room because the last case ran very late.
 Idealization:
 Expressing extremely positive thoughts of self and others while ignoring negative
thoughts.
 A patient boasts about his physician and his accomplishments while ignoring any
flaws.
 Identification:
 Largely unconscious assumption of the characteristics, qualities, or traits of another
person or group.
 A resident starts putting his stethoscope in his pocket like his favorite attending,
instead of wearing it around his neck like before.
 Intellectualization:
 Using facts and logic to emotionally distance oneself from a stressful situation.
 In a therapy session, patient diagnosed with cancer focuses only on rates of survival.
 Isolation (of affect):
 Separating feelings from ideas and events.
 Describing murder in graphic detail with no emotional response.
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 Passive aggression:
 Expression of angry feelings in a non- confrontational manner; showing indirect
opposition.
 Disgruntled employee is repeatedly late to work, but won’t admit it is a way to get
back at the
manager.
 Projection:
 Attributing an unacceptable internal impulse to an external source (vs displacement).
 A man who wants to cheat on his wife accuses his wife of being unfaithful.
 Rationalization:
 Proclaiming logical reasons for actions actually performed for other reasons, usually
to avoid self-blame.
 After getting fired, claiming that the job was not important anyway.
 Reaction formation:
 Replacing a warded-off idea or feeling by an (unconsciously derived) emphasis on its
opposite (vs sublimation).
 A patient with libidinous thoughts enters a monastery.
 Regression:
 Involuntarily turning back the maturational clock and going back to earlier modes of
dealing with the world (vs fxation).
 Seen in children under stress such as illness, punishment, or birth of a new sibling (eg,
bedwetting in a previously toilet-trained child when hospitalized).
 Patient sulked and refused to speak rather than maturely discussing his feelings with
the psychiatrist.
 Repression:
 Involuntarily withholding an idea or feeling from conscious awareness (vs
suppression).
 A 20-year-old does not remember going to counseling during his parents’ divorce 10
years earlier.
 Splitting:
 Believing that people are either all good or all bad at different times due to
intolerance of ambiguity.
 "all or nothing thinking,"
 Commonly seen in borderline personality disorder.
 A patient says that all the nurses are cold and insensitive but that the doctors are warm
and friendly.
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MATURE DEFENSES
 Sublimation:
 Replacing an unacceptable wish with a course of action that is similar to the wish but
does not conflict with one’s value system (vs reaction formation).
 Teenager’s aggression toward his father is redirected to perform well in sports.
 Altruism:
 Alleviating negative feelings via unsolicited generosity.
 Mafia boss makes large donation to charity.
 Suppression:
 Intentionally withholding an idea or feeling from conscious awareness (vs
repression); temporary.
 Choosing to not worry about the big game until it is time to play.
 Humor:
 Appreciating the amusing nature of an anxiety provoking or adverse situation.
 Nervous medical student jokes about the boards.
Mature adults wear a SASH.
PSYCHIATRY PATHOLOGY
INFANT DEPRIVATION EFFECTS
 Long-term deprivation of affection results in:
 Failure to thrive.
 Poor language/socialization skills.
 Lack of basic trust.
 Reactive attachment disorder (child doesn't establish healthy attachments with
parents or caregivers & infant withdrawn/unresponsive to comfort).
 Deprivation for > 6 months can lead to irreversible changes.
 Severe deprivation can result in infant death.
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CHILD ABUSE
Physical abuse:
 EVIDENCE:
 Fractures (eg, ribs, long bone spiral, multiple in different stages of healing), bruises
(eg, trunk, ear, neck; in pattern of implement), burns (eg, cigarette, buttocks/thighs),
subdural hematomas, retinal hemorrhages.
 During exam, children often avoid eye contact.
 ABUSER:
 Usually biological mother.
 EPIDEMIOLOGY:
 40% of deaths related to child abuse or neglect
 Occur in children < 1 year old.
Sexual abuse
 EVIDENCE:
 Genital, anal, or oral trauma; STIs; UTIs.
 ABUSER:
 Known to victim, usually male.
 EPIDEMIOLOGY:
 Peak incidence 9–12 years old.
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CHILD NEGLECT
 Failure to provide a child with adequate food, shelter, supervision, education, and/or
affection.
 Most common form of child maltreatment.
 Evidence:
 Poor hygiene, malnutrition, withdrawal, impaired social/emotional development,
failure to thrive.
 As with child abuse, suspected child neglect must be reported to local child protective
services.
VULNERABLE CHILD SYNDROME

 Parents perceive the child as especially susceptible to illness or injury.
 Usually follows a serious illness or life-threatening event.
 Can result in missed school or overuse of medical services.
CHILDHOOD AND EARLY-ONSET DISORDERS

Attention-deficit hyperactivity disorder (ADHD)
 Diagnosis:
 Inattentive &/or hyperactive/ impulsive symptoms for ≥ 6 months:
 Inattentive symptoms: Difficulty focusing, distractible, does not listen or
follow instructions, disorganized, forgetful, loses /misplaces objects.
 Hyperactive/impulsive symptoms: Fidgety, unable to sit still, "driven by a
motor." hyper talkative, interrupts, blurts out answers.
 Onset before age 12.
 Symptoms occur in at least 2 settings (home, school places of worship, etc.) & cause
functional impairment.
 Subtypes: Predominantly inattentive, predominantly hyperactive/ impulsive,
combined type.
 Normal intelligence, but commonly coexists with difficulties in school.
 Continues into adulthood in as many as 50% of individuals.
 Pathophysiology of ADHD:
 ↓ levels of norepinephrine and dopamine in the prefrontal cortex.
 Stimulant drugs, including methylphenidate and amphetamines, are first-line drug
treatments for school-age children with ADHD. They work by increasing release of
norepinephrine and dopamine from vesicular storage sites and blocking
norepinephrine and dopamine reuptake at synapses in the prefrontal cortex.
 Treatment:
 Psychostimulants (methylphenidate and amphetamines) are first- line treatment for
ADHD in school-age children and are generally safe and well tolerated.
 The most common adverse effects include ↓ appetite, weight loss, and
insomnia.
 Other psychostimulant adverse effects that are less common include tics and
increases in heart rate and blood pressure.
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During treatment, patients are typically seen monthly to monitor weight,
height, heart rate, and blood pressure.
 +/– cognitive behavioral therapy (CBT).
 Alternatives include atomoxetine, guanfacine, and clonidine.
Learning disorder
 Difficulties with learning key academic skills (reading, writing, or mathematics).
 Problems manifest at school age when these skills are being acquired and performance is
well below average for age.
 Many children display symptoms of anxiety, inattention, or hyperactivity when under stress
to perform in an area of weakness.
 If a learning disorder is confirmed, focusing on writing skills will help lower the boy's
distress, stop the teasing, and prevent further absences.
Autism spectrum disorder

 Characterized by:
 Poor social interactions, social communication deficits:
 Social emotional reciprocity.
 Nonverbal communicative behaviors.
 Difficulty in developing, maintaining & understanding relationships.
 Repetitive/ritualized behaviors:
 Insistence on sameness or inflexible adherence to routines.
 Restricted interests.
 Hyper- or hypo-reactivity to sensory input (eg, extreme responses to sounds or
textures, indifference to pain).
 Must present in early childhood (by the age of 3).
 May be accompanied by intellectual disability; rarely accompanied by unusual abilities
(savants).
 More common in boys.
 Associated with ↑ head/brain size.
Rett syndrome
 X-linked dominant disorder seen almost exclusively in girls (affected males die in utero or
shortly after birth).
 Majority of cases are caused by de novo mutation of MECP2.
 Symptoms usually become apparent around ages 1–4,
 It is characterized by normal development until age 5-18 months followed by a loss of motor
and language skills and the development of stereotypic hand movements.
 Deceleration of head growth is a classic feature of Rett syndrome and can be an early sign.
 No longer a solitary diagnosis within DSM-5.
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Conduct disorder
 Pattern of violating major societal norms & rights of others for ≥ 1 year.
 eg, aggression to people and animals, destruction of property, theft, set fires.
 After age 18, often reclassified as antisocial personality disorder.
 Treatment for both: psychotherapy such as CBT.
Oppositional defiant disorder

 Enduring pattern of hostile, defiant behavior toward authority figures in the absence of
serious violations of social norms.
 Argues with adults, defies authority figures, and refuses to follow rules.
 Deliberately annoys others.
 Blames others for own mistakes or misbehavior.
 Easily annoyed angered, resentful, or vindictive.
 Not due to another mental disorder.
 Does not exhibit physical aggression or cruelty toward people or animals,
destruction of property or the typical pattern of stealing or deceit seen in conduct
disorder.
 Treatment: psychotherapy such as CBT.
Separation anxiety disorder

 Overwhelming fear of separation from home or attachment figure.
 Can be normal behavior up to age 3–4.
 May lead to factitious physical complaints to avoid school. Kleptomania is characterized by inability to
resist the impulse to steal objects that are of
(Vs. learning disorder in which the child avoid school due to low monetary value or not needed for
his low performance) personal use. Overwhelming feelings of
 Treatment: CBT, play therapy, family therapy. tension or anxiety precede impulses and are
relieved with the act of theft.
Pyromania is characterized by intentional

and repeated fire setting with no obvious
Tourette syndrome: motive; it does not involve other behaviors
seen in conduct disorder (eg, lying, theft,
 Onset before age 18. cruelty to others).
 Characterized by sudden, rapid, recurrent, nonrhythmic,

stereotyped motor and vocal tics that persist for > 1 year.
 Coprolalia (involuntary obscene speech) found in only 10–20% of patients.
 Associated with OCD and ADHD.
 Treatment:
 Psychoeducation, behavioral therapy.
 For intractable and distressing tics,
 High-potency antipsychotics (eg, haloperidol, fluphenazine, pimozide),
 tetrabenazine,
 α2-agonists (eg, guanfacine, clonidine), or
 Atypical antipsychotics may be used.
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Disruptive mood dysregulation disorder

 Onset before age 10.
 Severe and recurrent temper outbursts out of proportion to situation.
 Child is constantly angry and irritable between outbursts.
 Treatment: psychostimulants, antipsychotics, CBT.
ORIENTATION
 Patient’s ability to know who he or she is, where he or she is, and the date and time.
 Common causes of loss of orientation: alcohol, drugs, fluid/electrolyte imbalance, head
trauma, hypoglycemia, infection, nutritional deficiencies.
 Order of loss: time  place  person.
AMNESIAS
 Retrograde amnesia:
 Inability to remember things that occurred before a CNS insult.
 Anterograde amnesia:
 Inability to remember things that occurred after a CNS insult (↓ acquisition of new
memory).
 Korsakof syndrome:
 Amnesia (anterograde > retrograde) caused by vitamin B1 deficiency and associated
destruction of mammillary bodies.
 Seen in alcoholics as a late neuropsychiatric manifestation of Wernicke
encephalopathy.
 Confabulations are characteristic.
 Dissociative amnesia:
 Inability to recall important personal information, usually subsequent to severe
trauma or stress.
 May be accompanied by dissociative fugue (abrupt travel or wandering during a
period of dissociative amnesia, associated with traumatic circumstances).
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DISSOCIATIVE DISORDERS
Dissociative identity disorder
 Formerly known as multiple personality disorder.
 Presence of 2 or more distinct identities or personality states.
 More common in women.
 Associated with severe trauma/abuse.
Depersonalization/ derealization disorder

 Persistent feelings of detachment or estrangement from one’s own body, thoughts,
perceptions, and actions (depersonalization)  observing their body and thoughts
from afar, as if they are living in a dream.
 Derealization disorder  state of experiencing familiar persons and surroundings as
if they were strange or unreal.
 Sense of being an outside observer of the self.
Dissociative fugue
 Fugue (from the Latin word fugere, meaning "flight").
 Evidence in support of this diagnosis includes:
 Sudden and unexpected travel,
 Inability to remember the past, and confusion about personal identity.
 At times, patients with this condition will assume new identities altogether.
 Example: A 42-year-old Caucasian man is brought to the emergency department by
police officers after he was found wandering aimlessly at the Washington Dulles
International Airport. The man appears to be confused about his identity and his
whereabouts. Extensive inquiry fails to reveal any helpful information, as the patient
does not remember his name, his family members, his profession, where he lives,
or how he came to be at the airport. A search of his personal belongings reveals an
airline ticket from Las Vegas to Washington, D.C.
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DELIRIUM
 ―Waxing and waning‖ level of consciousness with acute onset; rapid ↓ in attention span and
level of arousal.
 Characterized by disorganized thinking, hallucinations (often visual), illusions,
misperceptions, disturbance in sleep-wake cycle, cognitive dysfunction.
 Usually 2° to other illness (eg, CNS disease, infection, trauma, substance abuse/withdrawal,
metabolic/electrolyte disturbances, hemorrhage, urinary/fecal retention).
 May be caused by medications (eg, anticholinergic), especially in the elderly.
 Reversible.
 Most common presentation of altered mental status in inpatient setting, especially in the
intensive care unit and with prolonged hospital stays.
 Commonly, diffuse slowing EEG.
 Treatment:
 Identify and treat the cause.
 Antipsychotics may be used acutely as needed.
Delirium = changes in sensorium.
DEMENTIA
 ↓in intellectual function without affecting level of consciousness.
 ―Dementia‖ is characterized by memory loss.
 Usually irreversible.
 Characterized by memory deficits, apraxia, aphasia, agnosia, loss of abstract thought,
behavioral/personality changes, impaired judgment.
 A patient with dementia can develop delirium (eg, patient with Alzheimer disease who
develops pneumonia is at ↑ risk for delirium).
 Causes:
 Irreversible causes: Alzheimer disease, Lewy body dementia, Huntington disease,
Pick disease, cerebral infarct, Wilson disease, Creutzfeldt-Jakob disease, chronic
substance abuse (due to neurotoxicity of drugs), HIV.
 Reversible causes: hypothyroidism, depression, vitamin deficiency (B1, B3, B12),
normalpressure hydrocephalus, neurosyphilis.
 ↑ Incidence with age.
 EEG usually normal.
 UW: In elderly patients, depression and hypothyroidism may present like dementia
(pseudodementia). Screen for depression, exclude neurosyphilis with RPR if high clinical
suspicion, and measure TSH, B12 levels.
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PSYCHOSIS
 Distorted perception of reality characterized by delusions, hallucinations, and/or
disorganized thought/speech.
 Can occur in patients with medical illness, psychiatric illness, or both.
Delusions
 Unique, false, fixed, idiosyncratic beliefs that persist despite the facts and are not typical of a
patient’s culture or religion (eg, thinking aliens are communicating with you).
 Types include:
 Erotomanic ( believing that someone is in love with them),
 Grandiose (believing they have great talent, insights, or achievements).
 Jealous (believing their partner is unfaithful).
 Persecutory (believing they are being cheated spied on, poisoned, or harassed).
 Somatic (believing bodily functions and sensations are abnormal).
Disorganized thought
 Speech may be incoherent (―word salad‖), tangential, or derailed (―loose associations‖).
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Hallucinations
 Perceptions in the absence of external stimuli (eg, seeing a light that is not actually present).
 Contrast with illusions  misperceptions of real external stimuli.
 Types include:
 Visual—more commonly a feature of medical illness (eg, drug intoxication) than
psychiatric illness.
 Auditory—more commonly a feature of psychiatric illness (eg, schizophrenia) than
medical illness.
 Olfactory—often occur as an aura of temporal lobe epilepsy (eg, burning rubber)
and in brain tumors.
 Gustatory—rare, but seen in epilepsy.
 Tactile—common in alcohol withdrawal and stimulant use (eg, cocaine,
amphetamines), delusional parasitosis, ―cocaine crawlies.‖
 Hypnagogic—occurs while going to sleep. Sometimes seen in narcolepsy.
 Hypnopompic—occurs while waking from sleep (―pompous upon awakening‖).
Sometimes seen in narcolepsy.
SCHIZOPHRENIA
 Chronic mental disorder with periods of psychosis, disturbed behavior and thought, and
decline in functioning lasting > 6 months.
 Diagnosis requires at least 2 of the following, and at least 1 of these should include 1–3
(first 4 are ―positive symptoms‖):
 1. Delusions
 2. Hallucinations—often auditory
 3. Disorganized speech:
 Circumstantiality: giving detailed answer irrelevant to the question THEN
return back to
main topic.
 Tangential thought: drift away from object WITHOUT returning back to it.
 4. Disorganized or catatonic behavior
 5. Negative symptoms (affective flattening, avolition, anhedonia, asociality, alogia
―poverty of speech‖)
 Positive symptoms (delusions, hallucinations, disorganized speech, and catatonic behavior)
are associated with ↑ dopaminergic activity. The negative symptoms are associated with
the muscarinic receptors.
 Associated with ↑ dopaminergic activity, ↓ dendritic branching.
 Frequent cannabis use is associated with psychosis/schizophrenia in teens.
 Lifetime prevalence—1.5% (males =females, African Americans =Caucasians).
 Presents earlier in men (late teens to early 20s vs late 20s to early 30s in women).
 Patients are at ↑ risk for suicide.
 Ventriculomegaly on brain imaging.
 Treatment:
 Atypical antipsychotics (eg, risperidone) are first line.
 Negative symptoms often persist after treatment, despite resolution of positive
symptoms.
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 Clozapine  treatment resistant schizophrenia & Schizophrenia associated with
suicidality.
Brief psychotic disorder

 Lasting < 1 month, full return to function.
 Usually stress related.
Schizophreniform disorder
 Lasting 1–6 months.
 Same symptoms as schizophrenia.
Schizoaffective disorder
 Meets criteria for schizophrenia in addition to major mood disorder (major depressive or
bipolar).
 To differentiate from a major mood disorder with psychotic features, patient must have > 2
weeks of hallucinations or delusions without major mood episode.
UW: Substance-induced psychotic disorder

 Psychosis (paranoid ideation) + physical signs (tachycardia, hypertension, hyperthermia,
diaphoresis, and mydriasis).
 Stimulant intoxication (amphetamine or cocaine).
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DELUSIONAL DISORDER
 Diagnosis:
 ≥1 delusions for at least 1 month.
 Other psychotic symptoms absent.
 Behavior not obviously bizarre or odd; ability to function apart from delusion.
 Behavior not due to substances or another medical condition.
 Can be shared by individuals in close relationships (folie à deux).
 Differential diagnosis:
 Schizophrenia & schizophreniform disorder:
 Other psychotic symptoms (eg, hallucinations, disorganization, negative
symptoms) present with greater functional impairment.
 Paranoid or schizotypal personality disorder:
 Pervasive pattern of suspiciousness or odd beliefs (no dear delusions)
MOOD DISORDERS
 Characterized by an abnormal range of moods or internal emotional states and loss of control
over them. Severity of moods causes distress and impairment in social and occupational
functioning.
 Includes major depressive disorder, bipolar disorder, dysthymic disorder, and cyclothymic
disorder.
 Episodic superimposed psychotic features (delusions or hallucinations) may be present.
Manic episode
 ≥1 week (unless hospitalized) of persistently elevated or irritable mood & increased
energy/activity.
 Diagnosis requires hospitalization or at least 3 of the following (manics DIG FAST):
 Distractibility
 Irresponsibility—seeks pleasure without regard to consequences (hedonistic)
 Grandiosity—inflated self-esteem
 Flight of ideas—racing thoughts
 ↑ in goal-directed Activity/psychomotor
 Agitation
 ↓ need for Sleep
 Talkativeness or pressured speech
 Manic episodes can occur with or without psychotic features (eg. delusions,
hallucinations).
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Hypomanic episode
 Like a manic episode except mood disturbance is not severe enough to cause marked
impairment in social and/or occupational functioning or to necessitate hospitalization.
 Exhibit a noticeable change in behavior but are often very productive despite requiring less
sleep.
 In contrast to manic patients, those who are hypomanic are often able to work and are rarely
hospitalized.
 No psychotic features.
 Lasts at least 4 consecutive days.
BIPOLAR DISORDER (MANIC DEPRESSION)

 Bipolar I  defined by presence of at least 1 manic episode +/− a hypomanic or depressive
episode.
 Bipolar II  defined by presence of a hypomanic and a major depressive episodes.
 Patient’s mood and functioning usually return to normal between episodes.
 High suicide risk.
 Strong genetic component:
 For the general population, the lifetime risk of developing bipolar disorder is 1%.
 However, an individual with a first-degree relative (eg, parent, sibling, or dizygotic
twin) who suffers from bipolar disorder has a 5-10% risk of developing the condition
in his lifetime.
 A child whose parents both suffer from bipolar disorder has a 60% risk of
developing the condition.
 A monozygotic twin of an individual who suffers from bipolar disorder has a 70%
risk of developing the condition.
 Treatment:
 Mood stabilizers (eg, lithium, valproic acid, carbamazepine, lamotrigine),
 Atypical antipsychotics.
 UW: Antidepressant monotherapy should be avoided in bipolar maintenance
treatment due to the risk of mood destabilization.
Cyclothymic disorder
 Milder form of bipolar disorder lasting at least 2 years, fluctuating between mild depressive
and hypomanic symptoms.
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MAJOR DEPRESSIVE DISORDER (UNIPOLAR)

 Episodes characterized by at least 5 of the 9 diagnostic symptoms lasting ≥ 2 weeks
(symptoms must include patient reported depressed mood or anhedonia).
 Diagnostic symptoms:
 SIG E CAPS:
 Depressed mood
 Sleep disturbance
 Loss of Interest (anhedonia)
 Guilt or feelings of worthlessness
 Energy loss and fatigue
 Concentration problems
 Appetite/weight changes
 Psychomotor retardation or agitation
 Suicidal ideations
 Patients with depression typically have the following changes in their sleep stages:
 ↓ slow-wave sleep
 ↓ REM latency
 ↑ REM early in sleep cycle
 ↑ total REM sleep
 Repeated nighttime awakenings
 Early-morning awakening (terminal insomnia)
 No history of mania or hypomania.
 Not due to substances or another medical condition.
 UW: All patients with major depression should be screened for a past history of manic
episodes to differentiate major depressive disorder (unipolar depression) from bipolar
disorder.
 Antidepressant monotherapy should be avoided due to the risk of inducing mania.
 Treatment:
 CBT and SSRIs are first line.
 SNRIs, mirtazapine, bupropion can also be considered.
 Antidepressants are indicated if bipolar disorder is ruled out.
 Electroconvulsive therapy (ECT) in select patients.
Major depressive disorder with psychotic features

 Severe subtype of unipolar major depression.
 Characterized by symptoms meeting the criteria for a major depressive episode and the
presence of delusions and/or hallucinations.
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Both mood and psychotic

symptoms
major depressive
Schizoaffective
disorder with
disorder
psychotic features
presence of delusions
psychotic symptoms
and/or hallucinations
present exclusively
for ≥2 weeks in the
during his depressive
absence of a major
episode
mood episode
Persistent depressive disorder (dysthymia)

 Depression, often milder, lasting at least 2 years.
Depression with atypical features

 Characterized by:
 Mood reactivity (being able to experience improved mood in response to positive
events, albeit briefly),
 ―reversed‖ vegetative symptoms (hypersomnia, hyperphagia),
 Leaden paralysis (heavy feeling in arms and legs),
 Long-standing interpersonal rejection sensitivity.
 Most common subtype of depression.
 Treatment:
 CBT and SSRIs are first line.
 MAO inhibitors are effective but not first line because of their risk profile.
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 UW: Differential diagnosis of depressed mood:
SEASONAL AFFECTIVE DISORDER

 The diagnosis is seasonal affective disorder when the case describes depressive symptoms in
the winter months (shorter daylight hours) and absence of depressive symptoms during
summer months (longer daylight hours).
 Treatment is phototherapy or sleep deprivation.
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POSTPARTUM MOOD DISTURBANCES

 Onset within 4 weeks of delivery.
Maternal (postpartum) ―blues‖

 50–85% incidence rate.
 Characterized by depressed affect, tearfulness, and fatigue.
 Starting 2–3 days after delivery, usually resolves within 10 days. Self-limiting condition.
 Treatment: supportive. Follow up to assess for possible postpartum depression.
Postpartum depression
 10–15% incidence rate.
 Characterized by depressed affect, anxiety, and poor concentration for ≥ 2 weeks.
 Treatment: CBT and SSRIs are first line.
Postpartum psychosis
 0.1–0.2% incidence rate.
 Characterized by mood-congruent delusions, hallucinations, and thoughts of harming the
baby or self.
 Risk factors include history of bipolar or psychotic disorder, first pregnancy, family history,
recent discontinuation of psychotropic medication.
 Treatment: hospitalization and initiation of atypical antipsychotic; if insufficient, ECT
may be used.
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GRIEF
 The five stages of grief :
 Patients may experience stages of grief in a different order or only some of the stages.
 Other normal grief symptoms include: shock, guilt, sadness, anxiety, yearning, and
somatic symptoms.
 Simple hallucinations of the deceased person are common (eg, hearing the deceased
speaking).
 Duration varies widely; usually < 6 months.
 UW: In normal grief, pervasive anhedonia, worthlessness and suicidality are not present.
 UW: The best approach to a patient in denial is to first determine whether the denial is
interfering with medical care (eg, patient refusing a curative treatment) or significant
relationships.
 If interfering  the patient should be confronted "I am concerned that you are in
denial about your prognosis."
 Not interfering  encourage him to focus on short-term plans to maximize his
participation in areas that give meaning to his life (i.e. spending quality time with his
children).
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Pathologic grief
 Persistent and causes functional impairment. Can meet criteria for major depressive
episode.
ELECTROCONVULSIVE THERAPY
 Indications:
 Treatment-refractory depression,
 depression with psychotic symptoms,
 Acutely suicidality.
 Patients who are not eating or drinking.
 Produces grand mal seizure in an anesthetized patient.
 Adverse effects:
 Disorientation, temporary headache, and
 Partial anterograde/retrograde amnesia usually resolving in 6 months.
 Safe in pregnancy.
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RISK FACTORS FOR SUICIDE COMPLETION

 Sex (male)
 Age  The highest-risk age group for suicide is age 45-64: the second highest risk group is
age >85.
 Depression
 Previous attempt (highest risk factor) UW
 Ethanol or drug use
 Rational thinking loss (psychosis)
 Sickness (medical illness)
 Organized plan
 No spouse or other social support
 Stated future intent
 SAD PERSONS are more likely to complete suicide.
 Most common method in US is firearms; access to guns ↑ risk of suicide completion.
 Women try more often; men complete more often.
 UW: Among Americans age <40, it is the second leading cause of death behind motor
vehicle accidents, with the majority of these deaths occurring by firearm.
 UW: Evaluation of a patient's access to guns is a key part of suicide risk assessment.
 UW: Protective factors:
 Social support family connectedness
 Pregnancy
 Parenthood
 Religion & participation in religious activities
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ANXIETY DISORDERS
 Inappropriate experience of fear/worry and its physical manifestations (anxiety)
incongruent with the magnitude of the perceived stressor.
 Symptoms interfere with daily functioning and are not attributable to another mental
disorder, medical condition, or substance abuse.
 Includes panic disorder, phobias, generalized anxiety disorder, and selective mutism.
 Treatment: CBT, SSRIs, SNRIs.
PANIC DISORDER
 Defined by recurrent, unexpected attacks of intense fear that something bad will happen.
 Thinking of (danger or threat) leads to physiological symptoms (palpitations …)
 Diagnosis:
 Symptoms: (PANICS)  at least 4/13  Palpitations, Paresthesias,
dePersonalization or derealization, Abdominal distress or Nausea, Intense fear of
dying, Intense fear of losing control or ―going crazy,‖ lIght-headedness, Chest pain,
Chills, Choking, Sweating, Shaking, Shortness of breath.
 UW: should be considered in young, healthy adults who come to the
emergency department with unexplained chest pain.
 Symptoms are the systemic manifestations of fear.
 Attacks are spontaneous with no obvious trigger (eg. when an individual is relaxing
or emerging from sleep [ie. nocturnal panic attack]).
 requires attack followed by 1 month (or more) of 1 (or more) of the following:
 Persistent concern of additional attacks.
 Worrying about consequences of attack.
 Behavioral change related to attacks.
 Arrhythmias, hyperthyroidism, hyperparathyroidism, pheochromocytoma, chronic
obstructive pulmonary disease, pulmonary embolus, vestibular dysfunction, and
seizure disorders.
 Substance- induced causes of panic attacks include intoxication with central
nervous system stimulants (eg, amphetamines, cocaine, and caffeine) and alcohol or
sedative hypnotic withdrawal.
 Strong genetic component.
 Comorbidities commonly associated with panic disorder:
 Major depression (60%), bipolar disorder, agoraphobia (40%) (fear of public
places), and substance abuse.
 Higher risk of suicide attempts and suicidal ideations.
 Treatment:
 Immediate  Benzodiazepines (lorazepam).
 Long term  SSRI/SNRI &/or cognitive behavioral therapy and venlafaxine are
first line.
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SPECIFIC PHOBIA
 Extreme, unreasonable, irrational fear of something.
 History & clinical features:
 Marked anxiety about a specific object or situation (the phobic stimulus) for >6
months.
 Types: Flying, heights, animals, infections, blood.
 Avoidance behavior (bridges, elevators, refusing work requiring travel).
 Common. 10% of population.
 Usually develops in childhood, can develop after traumatic event.
 Treatment:
 Behavioral therapy (exposure, systematic desensitization) is treatment of choice.
 Short-acting benzodiazepines may help acutely but have a limited role (therapist
unavailable, insufficient time).
Social anxiety disorder (Social phobia)

 Diagnosis
 Exaggerated fear of embarrassment in social situations (eg, public speaking, using
public restrooms).
 Marked anxiety about ≥1 social situations for ≥6 months.
 Fear of scrutiny by others, humiliation, embarrassment.
 Social situations avoided or endured with intense distress.
 Marked impairment (social, academic, occupational).
 Subtype specifier: only Performance anxiety disorder: Public speaking or
presentations.
 Treatment:
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Agoraphobia
 Irrational fear/anxiety while facing or anticipating ≥ 2 specific situations (eg, open/ closed
spaces, lines, crowds, public transport).
 If severe, patients may refuse to leave their homes.
 Associated with panic disorder.
 Treatment: CBT, SSRIs.
GENERALIZED ANXIETY DISORDER (GAD)

 Diagnosis:
 Excessive, uncontrollable worry about multiple issues > 6 months.
 Multiple worries about everyday issues (eg, work, health, finances, safety of family
members, minor matters) that cause significant distress and functional impairment.
 Unrelated to a specific person, situation, or event.
 ≥3 of the following symptoms:
 Restlessness / feeling on edge.
 Fatigue.
 Difficulty concentrating.
 Irritability.
 Muscle tension.
 Sleep disturbance.
 Treatment:
 CBT, SSRIs, SNRIs are first line.
 Buspirone, TCAs, benzodiazepines are second line.
 UW: However, SSRIs must be administered for approximately 4 weeks before any
noticeable therapeutic effect occurs, and their initial activating effects can lead to
increased agitation and anxiety during this period. Thus, a temporary course of
benzodiazepines is sometimes used during SSRI initiation if there is a significant
increase in anxiety- related symptoms.
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ADJUSTMENT DISORDER
 This is a normal psychological reaction (anxiety, depression, irritability) that occurs soon
after profound changes in a person’s life, such as divorce, migration, or birth of a
handicapped child.
 Symptoms are usually experienced within 3 months of the stressful event and are not severe
enough to be classified in another category. Do not treat adjustment disorder patients
Adjustment disorder is not a true anxiety disorder. with medications; instead provide
counseling to help with the patient adjust to
 You experience more stress than would normally the life stressor.
be expected in response to a stressful or
unexpected event, and the stress causes significant
problems in your relationships, at work or at school.
 Work problems, going away to school, an illness, death of a close family member or any
number of life changes can cause stress. Most of the time, people adjust to such changes
within a few months. But if you have an adjustment disorder, you continue to have emotional
or behavioral reactions that can contribute to feeling anxious or depressed.
 Emotional symptoms (anxiety, depression) that occur within 3 months of an identifiable
psychosocial stressor (eg, divorce, illness) lasting < 6 months once the stressor has ended.
 Doesn’t meet the criteria of other psychiatric illness. (E.g: if the patient's symptoms meet
the full criteria for a major depressive episode, the diagnosis of an adjustment disorder is not
applicable.)
 If stressor lasts > 6 months and causes continual impairment, it is GAD.
 Treatment: CBT, SSRIs.
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OBSESSIVE-COMPULSIVE DISORDER
 Clinical features:
 Obsessions:
 Recurrent, intrusive, anxiety-provoking thoughts, urges, or images.
 Compulsions:
 Response to obsessions with repeated behaviors or mental acts.
 Behaviors not connected realistically with preventing feared event.
 Time-consuming (>1 hr/day) or causing significant distress or impairment.
 Ego-dystonic: behavior inconsistent with one’s own beliefs and attitudes (vs obsessive-
compulsive personality disorder).
 Associated with Tourette syndrome.
 Pathophysiology:
 ↓ Serotonin neurotransmitter; so SSRIs are the first line of treatment.
 Treatment:
 CBT, SSRIs, and clomipramine are first line.
Body dysmorphic disorder

 Preoccupation with minor or imagined defect in appearance  significant emotional distress
or impaired functioning; patients often repeatedly seek cosmetic treatment.
 Treatment: CBT.
POST-TRAUMATIC STRESS DISORDER (PTSD)

 Clinical features:
 Exposure to life threatening trauma.
 Nightmares, flashbacks, intrusive memories.
 Avoidance of reminders, amnesia for event.
 Emotional detachment, negative mood, decreased interest in activities.
 Sleep disturbance, hypervigilance, irritability.
 Duration ≥1 month with significant distress or impaired social-occupational
functioning.
 Treatment:
 CBT, SSRIs, and venlafaxine are first line.
 Prazosin can reduce nightmares.
Acute stress disorder

 Exposure to a traumatic event followed by development of characteristic symptoms (re-
experiencing, avoidance, arousal).
 Lasts between 3 days and 1 month.
 Treatment: CBT; pharmacotherapy is usually not indicated.
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DIAGNOSTIC CRITERIA BY SYMPTOM DURATION
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PERSONALITY
Personality trait
 An enduring, repetitive pattern of perceiving, relating to, and thinking about the environment
and oneself.
Personality disorder
 Inflexible, maladaptive, and rigidly pervasive pattern of behavior causing subjective distress
and/or impaired functioning.
 Person is usually not aware of problem.
 Usually presents by early adulthood.
 Three clusters, A, B, and C; remember as Weird, Wild, and Worried based on symptoms.
Cluster A personality disorders

 Odd or eccentric; inability to develop meaningful social relationships.
 No psychosis.
 Genetic association with schizophrenia.
 ―Weird.‖
 Cluster A: Accusatory, Aloof, Awkward.
Paranoid
 Pervasive distrust (Accusatory) and suspiciousness of others and a profoundly cynical view
of the world.
 Believes being exploited & deceived by others.
 Interprets benign comments & events as threats; reacts angrily.
 Bears grudges.
 Questions loyalty of partner without justification.
 Delusional disorder (delusions only)
 Schizophrenia (delusions, hallucinations, disorganization, negative symptoms)
 Schizotypal personality disorder (odd. Eccentric behavior & thinking, unusual
perceptual experiences)
Schizoid
 Voluntary social withdrawal (Aloof), limited emotional expression, content with social
isolation (vs avoidant).
 Emotionally detached, do not desire social acceptance and prefer to be alone.
Schizotypal
 Eccentric appearance, odd beliefs or magical thinking, interpersonal Awkwardness.
 Rarely sustain close interpersonal relationships due to excessive social anxiety that does not
diminish with familiarity.
 Schizotypal = magical thinking.
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Cluster B personality disorders

 Dramatic, emotional, or erratic.
 Genetic association with mood disorders and substance abuse.
 ―Wild.‖
 Cluster B: Bad, Borderline, flamBoyant, must be the Best.
Antisocial (Bad)
 Disregard for and violation of rights of others with lack of remorse, criminality, impulsivity;
males > females; must be ≥ 18 years old and have history of conduct disorder before age 15.
 Conduct disorder if < 18 years old.
 Antisocial = sociopath.
Borderline
 Diagnostic criteria:
 Pervasive pattern of unstable relationships, self -image & affects & marked
impulsivity; with ≥5 of the following features:
 Frantic efforts to avoid abandonment.
 Unstable & intense interpersonal relationships.
 Markedly & persistently unstable self-image.
 Impulsivity in ≥2 areas that are potentially self-damaging (eg, substance use
unsafe sex).
 Recurrent suicidal behaviors or threats of self-mutilation (eg. Cutting,
burning) during an interpersonal crisis.
 Affective instability (marked mood reactivity).
 Chronic feelings of emptiness.
 Inappropriate & intense anger.
 Transient, stress-related paranoia or dissociation.
 Females > males.
 Splitting is a major defense mechanism.
 Treatment: dialectical behavior therapy.
Histrionic (flamboyant)
 Excessive emotionality and excitability, attention seeking, sexually provocative, overly
concerned with appearance.
 UW: Both borderline and histrionic personality disorders are characterized by attention-
seeking behavior, but excessive anger and self-destructive behavior are more characteristic
of borderline personality disorder.
Narcissistic
 Grandiosity, sense of entitlement; lacks empathy and requires excessive admiration; often
demands the ―best‖ and reacts to criticism with rage.
 Must be the Best.
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Cluster C personality disorders ―Worried‖

 Anxious or fearful.
 Genetic association with anxiety disorders.
 Cluster C: Cowardly, obsessive-Compulsive, Clingy.
Avoidant (Cowardly)
 Hypersensitive to rejection, socially inhibited, timid, feelings of inadequacy.
 Desires relationships but fear rejection (vs schizoid).
 Very limited social relationships due to fears of being judged, embarrassed, or rejected.
 Occupational dysfunction due to difficulties interacting with coworkers or turning down
promotions due to fear of criticism is common.
Obsessive-Compulsive
 Preoccupation with order, perfectionism, and control.
 Ego-syntonic: behavior consistent with one’s own beliefs and attitudes (vs OCD).
Dependent ―Clingy‖
 Submissive and Clingy, excessive need to be taken care of, low self-confidence.
 Patients often get stuck in abusive relationships.
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MALINGERING
 Patient consciously fakes, profoundly exaggerates, or claims to have a disorder in order to
attain a specific 2° (external) gain (eg, avoiding work, obtaining compensation).
 Poor compliance with treatment or follow-up of diagnostic tests.
 Complaints cease after gain (vs factitious disorder).
 Eg, a patient feigning hemiparesis to receive disability benefits.
FACTITIOUS DISORDERS
 Patient consciously creates physical and/or psychological symptoms in order to assume ―sick
role‖ and to get medical attention and sympathy (1° [internal] gain).
 Absence of obvious rewards.
 These patients are aware of their symptoms and conceal their attempts to simulate or cause
them, but they lack conscious awareness of why they do it.
 When confronted with the possibility of feigning or producing symptoms, they typically
respond with denial and may reject medical and psychiatric care.
Factitious disorder imposed on self ―Munchausen syndrome‖

 Chronic factitious disorder with predominantly physical signs and symptoms.
 Characterized by a history of multiple hospital admissions and willingness to undergo
invasive procedures.
 More common in women and healthcare workers.
 Behaviors may include deceptive reporting of symptoms, manipulating laboratory samples,
ingesting a substance (eg. insulin), altering medical records, or inducing illness (eg injecting
fecal matter to produce an abscess).
Factitious disorder imposed on another ―Munchausen syndrome by proxy‖

 Illness in a child or elderly patient is caused or fabricated by the caregiver.
 Motivation is to assume a sick role by proxy.
 Form of child/elder abuse.
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SOMATIC SYMPTOM AND RELATED DISORDERS

 Category of disorders characterized by physical symptoms causing significant distress and
impairment.
 Both illness production and motivation are unconscious drives.
 Symptoms not intentionally produced or feigned.
 More common in women.
Somatic symptom disorder

 Variety of bodily complaints (eg, pain, fatigue) lasting for months to years.
 Associated with excessive, persistent thoughts and anxiety about symptoms.
 May co-occur with medical illness.
Conversion disorder (functional neurologic symptom disorder)

 Loss of sensory or motor function (eg, paralysis, blindness, mutism), often following an
acute stressor.
 The neurological symptoms are incompatible with any recognized neurological condition
and cannot be explained by another medical or mental disorder.
 Symptoms must be neurological and include weakness, paralysis, gait disturbance, blindness,
diplopia, aphonia anesthesia, and seizures (also called psychogenic or non-epileptic seizures)
 Patient is aware of but sometimes indifferent toward symptoms (―la belle indifférence‖).
 More common in females, adolescents, and young adults.
Illness anxiety disorder (hypochondriasis)
 Excessive preoccupation with acquiring or having a serious illness, often despite medical
evaluation and reassurance; minimal somatic symptoms.
 Excessive fears of having a serious physical disease.
 The fear is usually due to misinterpretation of bodily symptoms or normal functions (eg. a
woman with gas pain becoming preoccupied with having colon cancer).
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NB: both somatic symptom disorder and illness anxiety disorder (hypochondriasis)
have a prolonged fear and concern about getting or having a disease but in
hypochondriasis with minimal or no actual physical symptoms.
EATING DISORDERS
 Most common in young females.
Anorexia nervosa
 Excessive dieting, exercise, or binge eating/purging with BMI < 18.5 kg/m2;
 Intense fear of gaining weight.
 Distortion or overvaluation of body image.
 Associated with ↓ bone density, severe weight loss, metatarsal stress fractures, amenorrhea
(due to loss of pulsatile GnRH secretion), lanugo hair, anemia, electrolyte disturbances.
 Commonly coexists with depression.
 Treatment: Psychotherapy and nutritional rehabilitation are first line; pharmacotherapy
includes SSRIs.
Refeeding syndrome
(↑ Insulin  hypophosphatemia (insulin shifts it intracellular)  cardiac complications) can
occur in significantly malnourished patients.
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Bulimia nervosa
 Binge eating with recurrent inappropriate compensatory behaviors (eg, self-induced
vomiting, using laxatives or diuretics, fasting, excessive exercise) occurring weekly for at
least 3 months and overvaluation of body image.
 In contrast to individuals with anorexia nervosa, those with bulimia nervosa are normal
weight to overweight.
 Self-induced vomiting will lead to:
 Parotitis and increased salivary amylase.
 Enamel erosion.
 Electrolyte disturbances (eg, hypokalemia, hypochloremia, metabolic alkalosis)
 Dorsal hand calluses (Russell sign).
 Treatment:
 Selective serotonin reuptake inhibitor (fluoxetine)
 Nutritional rehabilitation
 Cognitive- behavioral therapy
Binge eating disorder

 Regular episodes of excessive repeated episodes of binge eating, without the compensatory
behaviors seen in bulimia.
 ↑ Risk of diabetes.
 Treatment: psychotherapy such as CBT is first-line; SSRIs, lisdexamfetamine.
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Pica
 Compulsive consumption of a nonfood and/or non-staple food source for 21 month.
 It is most commonly seen in pregnant women and schoolchildren.
 The ingested substance is not a culturally accepted food source, and the consumption is not
appropriate to the person's developmental level.
 Although the cause of pica is unclear it is often (but not always) associated with nutritional
deficiencies, including iron and zinc deficiencies and anemia of any etiology.
 There are 3 main types of substances consumed:
 earth/soil –rich substances,
 raw starch such as flour or cornstarch, and
 ice
 Pica can occur at any stage of pregnancy. It is important to assess the patient throughout the
pregnancy for pica and screen for nutritional deficiencies as necessary
 Ice is the most commonly ingested substance, and more than a third of women ingest more
than one substance.
GENDER DYSPHORIA
 Patients with gender dysphoria disorder experience significant distress in response to the
sex and gender they were assigned at birth.
 These patients have a strong desire to be acknowledged and treated as the other gender or to
alter their current sex characteristics surgically
 Transsexualism—desire to live as the opposite sex, often through surgery or hormone
treatment.
 Transvestism—paraphilia, not gender dysphoria. Wearing clothes (eg, vest) of the opposite
sex (cross-dressing).
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SEXUAL DYSFUNCTION
 Includes sexual desire disorders (hypoactive sexual desire or sexual aversion), sexual
arousal disorders (erectile dysfunction), orgasmic disorders (anorgasmia, premature
ejaculation), sexual pain disorders (dyspareunia, vaginismus).
 Differential diagnosis includes:
 Drug side effects (eg, antihypertensives, antipsychotics, SSRIs, ethanol)
 Medical disorders (eg, depression, diabetes, STIs)
 Psychological (eg, performance anxiety)
SLEEP TERROR DISORDER

 Inconsolable periods of terror with screaming in the middle of the night;
 Occurs during.
 Most common in children.
 Occurs during non-REM sleep (slow-wave/ deep (stage N3) sleep) (no memory of the
arousal episode) as opposed to nightmares that occur during REM sleep (memory of a scary
dream).
 Cause unknown, but triggers include emotional stress, fever, or lack of sleep.
 Usually self-limited.
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NARCOLEPSY
 Disordered regulation of sleep-wake cycles.
 1° characteristic is excessive daytime sleepiness (sleep attacks + feeling refreshed after
awaken).
 UW: Recurrent lapses into sleep or napping multiple times within the same day;
occurring at least 3 times weekly for 3 months.
 UW: Diagnosis: At least 1 of the following:
 Cataplexy, defined as either
 Conscious, brief episodes of sudden bilateral muscle tone loss precipitated
by emotions such as laughter or joking.
 Spontaneous, abnormal facial movements without emotional triggers.
 Hypocretin-1 deficiency by cerebrospinal fluid analysis.
 These neuropeptides function to promote wakefulness and inhibit REM sleep-
related phenomena.
 Produced in the lateral hypothalamus.
 Rapid eye movement sleep latency ≤15 minutes.
 Also associated with:
 Hypnagogic (just before sleep) or hypnopompic (just before awakening)
hallucinations.
 Nocturnal and narcoleptic sleep episodes that start with REM sleep (sleep paralysis).
 Inability to move on awakening (sleep paralysis) is highly suggestive of narcolepsy.
 Cataplexy (loss of all muscle tone following strong emotional stimulus, such as
laughter) in some patients.
 Strong genetic component.
 Treatment:
 Daytime stimulants (eg, amphetamines, modafinil) and
 Nighttime sodium oxybate (GHB).
HYPERSOMNOLENCE DISORDER
 Excessive and impairing daytime sleepiness cannot be explained by another sleep disorder.
 Not occurring in attacks but it is persistent.
 Unlike patients with narcolepsy, they typically do not feel refreshed after naps.
OBSTRUCTIVE SLEEP APNEA

 The most common cause of excessive daytime sleepiness.
 Characterized by loud snoring, gasping, and apneas during sleep.
 It is due to upper airway obstruction.
 Not associated with cataplexy, sleep-related hallucinations, or sleep paralysis.
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INSOMNIA
Sleep changes in elderly:

1) Sleep less at night and nap during the day.
2) The period of deep sleep (Stage 4 sleep) becomes shorter and eventually disappears.
3) Awaken more during all stages of sleep.
Considered a normal part of aging.
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SUBSTANCE USE DISORDER

 Maladaptive pattern of substance use defined as 2 or more of the following signs in 1 year
related specifically to substance use:
1. Tolerance: need more to achieve same effect.
2. Withdrawal: manifesting as characteristic signs and symptoms.
3. Substance taken in larger amounts, or over longer time, than desired.
4. Persistent desire or unsuccessful attempts to cut down.
5. Significant energy spent obtaining, using, or recovering from substance.
6. Important social, occupational, or recreational activities reduced.
7. Continued use despite knowing substance causes physical and/or psychological
problems.
8. Craving.
9. Recurrent use in physically dangerous situations.
10. Failure to fulfill major obligations at work, school, or home.
11. Social or interpersonal conflicts.
STAGES OF CHANGE IN OVERCOMING SUBSTANCE ADDICTION

1. Precontemplation:
 Not yet acknowledging that there is a problem.
 Example: alcoholic patient believes that his increased drinking is not a problem and
blames it on work stress.
2. Contemplation
 Acknowledging that there is a problem, but not yet ready or willing to make a change.
 Example: patient thinks about quitting drinking but takes no steps to do so.
3. Preparation/determination:
 Getting ready to change behaviors.
 Example: alcoholic patient preparing to call the treatment center and get help.
4. Action/willpower:
 Changing behaviors.
 Example: alcoholic patient enters treatment and reduces his drinking patient enters
treatment and reduces his drinking.
5. Maintenance—maintaining the behavioral changes (eg, maintaining abstinence).
6. Relapse—returning to old behaviors and abandoning new changes. Does not always happen.
Precontemplation Contemplation Preparation Action Maintenance
• Not thinking • Acknowledging • Getting ready to • Putting the plan • Maintaining the
about behavior that there is a change behaviors. into action new behaviour
modification problem. • Planning
• Not yet • Thinking about behaviour
acknowledging behaviour
that there is a modification.
problem.
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PSYCHOACTIVE DRUG INTOXICATION AND WITHDRAWAL

Drug Common intoxication symptoms Common withdrawal
category symptoms
Depressants Mood elevation, ↓ anxiety, sedation, behavioral Anxiety, tremor, seizures,
disinhibition, respiratory depression. insomnia.
Stimulants Mood elevation, psychomotor agitation, insomnia, Post-use ―crash,‖ including
cardiac arrhythmias, tachycardia, anxiety. depression, lethargy, ↑
appetite, sleep disturbance,
vivid nightmares.
Hallucinogens
1-Depressants
Alcohol
 Mechanism of action and related toxicity & alcoholism:
 It potentiates the effects of GABA (primary inhibitory neurotransmitter in the CNS) at
GABA-A receptors, leading to sedation.
 Chronic ethanol use causes:
 Downregulation of GABA receptors.
 Alcohol also weakly inhibits excitatory NMDA receptors in the brain, and
chronic exposure leads to upregulation of these receptors.
 These adaptive changes result in tolerance (the need to increase the dose to
achieve the desirable effect) and symptoms of withdrawal on abrupt alcohol
cessation.
 Specific intoxication symptoms:
 Emotional liability, slurred speech, ataxia, coma, blackouts.
 Serum γ-glutamyltransferase (GGT)—sensitive indicator of alcohol uses.
 AST value is twice ALT value.
 Specific withdrawal symptoms:
Page 43 of 63
 UW: Tremor, or tremulousness or the ―shakes, ―is the most common initial finding.
 UW: Delirium tremens is the most severe manifestation of alcohol withdrawal and
typically begins 48-96 hours after the last drink.
 UW: Alcoholic hallucinosis:
 Visual hallucinations can develop within 12- 24 hours after the last drink.
 Typically resolve within 24-48 hours.
 Treatment of withdrawal symptoms: benzodiazepines.
Opioids
 Euphoria, respiratory and CNS depression, ↓ gag reflex, pupillary constriction
(pinpoint pupils), seizures (overdose).
 Most common cause of drug overdose death.
 Treatment: naloxone.
 Sweating, dilated pupils, piloerection (―cold turkey‖), fever, rhinorrhea, yawning,
nausea, stomach cramps, diarrhea (―flu-like‖ symptoms).
 Treatment: long-term support, methadone (oral), buprenorphine.
 UW: Treatment of opioids addiction:
 Includes the use of alternative opioid agonists with less euphoric effect and
less potential for acute withdrawal and craving, thereby allowing patients to
function more productively on a daily basis.
 In the United States, the most commonly used agonists are methadone and
buprenorphine.
 Why methadone?
 Full mu-opioid receptor agonist  ↓ chronic pain, ↓ withdrawal
symptoms.
 Long half-life  suppresses cravings and withdrawal symptoms for
≥24 hours.
 Good bioavailability and can be given in once daily oral dosing.
 High affinity for the opioid receptor, which blocks the euphoric effects
of other opioids and also accounts for its potent analgesic effects.
 UW: In the United States, the majority of overdose deaths are caused by prescription
drugs, particularly opioid analgesics.
Barbiturates
 Low safety margin.
 Marked respiratory depression.
 Treatment: symptom management (eg, assist respiration, ↑ BP).
 Delirium, life-threatening cardiovascular collapse.
Page 44 of 63
Benzodiazepines
 Greater safety margin.
 Ataxia, minor respiratory depression.
 Treatment: flumazenil (benzodiazepine
receptor antagonist, but rarely used as it can
precipitate seizures).
 Sleep disturbance, depression, rebound
anxiety, seizure.
2- Stimulants
Amphetamines
 Euphoria, grandiosity, pupillary dilation, prolonged wakefulness and attention,
hypertension, tachycardia, anorexia, paranoia, fever.
 Severe: cardiac arrest, seizures.
 Treatment: benzodiazepines for agitation and seizures.
Cocaine
 Impaired judgment, pupillary dilation, hallucinations (including tactile), paranoid
ideations, angina, sudden cardiac death.
 Formication (also known as "cocaine bugs"}, in which the individual is convinced
there are bugs crawling all over him.
 Nosebleeds and septal perforation can occur in patients who snort cocaine.
 Treatment: α-blockers, benzodiazepines. β-blockers not recommended.
 acute depression accompanied by fatigue,
 Vivid dreams, hypersomnia, and hyperphagia.
Caffeine
 Restlessness, ↑ diuresis, muscle twitching.
 Headache, difficulty concentrating, flu-like symptoms.
Nicotine
 Restlessness.
 Irritability, anxiety, restlessness, difficulty concentrating.
 Treatment: nicotine patch, gum, or lozenges; bupropion/varenicline.
Page 45 of 63
3- Hallucinogens
Phencyclidine (PCP)
 Mechanism of action:
 N-methyl-D- aspartate (NMDA) receptor antagonist; it can work secondarily to
inhibit the reuptake of norepinephrine, dopamine and serotonin.
 Violence, impulsivity, psychomotor agitation, nystagmus, tachycardia,
hypertension, analgesia, psychosis, delirium, seizures.
 Moderate amounts of PCP cause dissociative symptoms including detachment and
withdrawal.
 Trauma is most common complication.
 Treatment: benzodiazepines, rapid-acting antipsychotic.
Lysergic acid diethylamide (LSD)

 Perceptual distortion (visual, auditory), visual hallucinations, depersonalization,
anxiety, paranoia, psychosis, possible flashbacks.
Marijuana (cannabinoid)
 Tetrahydrocannabinol (THC) stimulates cannabinoid receptors (CB1 and CB2
receptors) to produce effects on mood, perception, and cognition.
 Euphoria with inappropriate laughter, anxiety, paranoid delusions, perception of
slowed time, impaired judgment, social withdrawal, ↑ appetite, dry mouth,
conjunctival injection, hallucinations.
 Smoking is the preferred route of delivery.
 UW: The most characteristic physiological signs of marijuana intoxication are:
conjunctival injection (red eyes), tachycardia, increased appetite, and dry mouth.
 Marijuana is metabolized in the liver, distributed and stored in lipophilic tissues, and slowly
released. It remains in the body for a long time; depending on the amount and frequency of
use. it can be detected in the urine up to 30 days after daily use has ceased
 Pharmaceutical form is dronabinol: used as antiemetic (chemotherapy) and appetite
stimulant (in AIDS).
 Irritability, anxiety, depression, insomnia, restlessness, ↓ appetite.
Page 46 of 63
MDMA (ecstasy)
 Hallucinogenic stimulant: euphoria, disinhibition, hyperactivity, distorted sensory
and time perception, teeth clenching.
 Life-threatening effects include hypertension, tachycardia, hyperthermia,
hyponatremia, serotonin syndrome.
 Depression, fatigue, changes in appetite, difficulty concentrating, and anxiety.
HEROIN DETOXIFICATION MEDICATIONS

 Users at ↑ risk for hepatitis, HIV, abscesses, bacteremia, and right-heart endocarditis.
 Methadone:
 Long-acting oral opiate used for heroin detoxification or long-term maintenance
therapy.
 Buprenorphine + naloxone:
 Sublingually.
 Buprenorphine (partial agonist) is absorbed and used for maintenance therapy.
 Naloxone (antagonist, not orally bioavailable) is added to lower IV abuse potential.
 Naltrexone
 Long-acting opioid antagonist used for relapse prevention once detoxified.
Page 47 of 63
ALCOHOLISM
 Physiologic tolerance and dependence on alcohol with symptoms of withdrawal when intake
is interrupted.
 Diagnosis:
 The most accurate diagnosis is made with the CAGE questionnaire. Laboratory tests
are never included in the diagnosis of alcohol abuse.
CAGE: An answer of yes to any 2 of the following questions is suggestive of alcohol
abuse:
 Have you ever felt that you should Cut down your drinking?
 Have you ever felt Annoyed by others who have criticized your drinking?
 Have you ever felt Guilty about your drinking?
 Have you ever had an Eye-opener to steady your nerves or alleviate a
hangover?
 Complications: alcoholic cirrhosis, hepatitis, pancreatitis, peripheral neuropathy, testicular
atrophy.
 Treatment:
 Disulfiram (to condition the patient to abstain from alcohol use).
 Acamprosate. ―partial co-agonist‖ at the NMDA receptor‖
 Naltrexone.
 Supportive care: support groups such as Alcoholics Anonymous are helpful in
sustaining abstinence and supporting patient and family.
Wernicke-Korsakoff syndrome
 Caused by vitamin B1 deficiency.
 Triad of confusion, ophthalmoplegia, ataxia (Wernicke encephalopathy).
 May progress to irreversible memory loss, confabulation, and personality change
(Korsakoff syndrome).
 Symptoms may be precipitated by giving dextrose before administering vitamin B1 to a
patient with thiamine deficiency.
 Associated with periventricular hemorrhage/ necrosis of mammillary bodies.
 Treatment: IV vitamin B1.
Delirium tremens
 Life-threatening alcohol withdrawal syndrome that peaks 2–4 days after last drink.
 Characterized by
 Autonomic hyperactivity (eg, tachycardia, hypertension, tremors, anxiety, seizures).
 Electrolyte disturbances, respiratory alkalosis.
 Classically occurs in hospital setting (eg, 2–4 days postsurgery) in alcoholics not
able to drink as inpatients.
 Treatment: benzodiazepines (eg, chlordiazepoxide, lorazepam, diazepam).
Page 48 of 63
Page 49 of 63
PHARMACOLOGY
Preferred medications for selected psychiatric conditions:
CENTRAL NERVOUS SYSTEM STIMULANTS:

(Methylphenidate, dextroamphetamine, methamphetamine.)
 MECHANISM: ↑ catecholamines in the synaptic cleft, especially norepinephrine and
dopamine.
 CLINICAL USE: ADHD, narcolepsy, appetite control.
 ADVERSE EFFECTS: Nervousness, agitation, anxiety, insomnia, anorexia, tachycardia,
hypertension.
Page 50 of 63
 The mesolimbic pathway

 Extends from the ventral tegmental area to the limbic system.
 Increased dopamine activity in the mesolimbic pathway accounts for the euphoria
accompanying drug use as well as the delusions and hallucinations experienced by
patients with schizophrenia
 Decreased dopamine activity in the mesolimbic pathway accounts for the therapeutic
effects of antipsychotics.
 The nigrostriatal pathway
 Extends from the substantia nigra to the basal ganglia
 Involved in the coordination of movement.
 Increased dopamine activity in the nigrostriatal pathway is thought to be involved in
movement disorders such as chorea and tics.
 The tuberoinfundibular pathway
 Projects from the hypothalamus to the pituitary gland.
 Inhibits prolactin release from the anterior pituitary gland.
Page 51 of 63
TYPICAL ANTIPSYCHOTICS:
Haloperidol, pimozide, trifluoperazine, fluphenazine, thioridazine, chlorpromazine.
 MECHANISM Block dopamine D2 receptor (↑ cAMP).
 CLINICAL USE Schizophrenia (1° positive symptoms), psychosis, bipolar disorder,
delirium, Tourette syndrome, Huntington disease, OCD.
POTENCY:
High potency:
 Trifluoperazine, Fluphenazine, Haloperidol (Try to Fly High)
 Neurologic side effects (eg, extrapyramidal symptoms [EPS]).
Low potency:
 Chlorpromazine, Thioridazine (Cheating Thieves are low)
 Anticholinergic, antihistamine, α1-blockade effects.
ADVERSE EFFECTS of typical antipsychotics:
 Lipid soluble  stored in body fat  slow to be removed from body.
 Endocrine: dopamine receptor antagonism  hyperprolactinemia  galactorrhea,
oligomenorrhea, gynecomastia.
 Metabolic: dyslipidemia, weight gain, hyperglycemia.
 Antimuscarinic: dry mouth, constipation.
 Antihistamine: sedation.
 α1-blockade: orthostatic hypotension.
 Cardiac: QT prolongation.
 Ophthalmologic:
 Chlorpromazine—Corneal deposits;
 Thioridazine—reTinal deposits.
Page 52 of 63
EPS (Extrapyramidal symptoms)—ADAPT:
 Pathophysiology: (↓D2 & ↑M1)
 In the striatum, the inhibitory effects of dopaminergic neurons (D2) are normally
balanced by the excitatory actions of muscarinic cholinergic neurons (M1).
 Strong dopaminergic blockade causes an excess of cholinergic activity, resulting in
extrapyramidal side effects.
 Symptoms:
 Hours to days: Acute Dystonia:
 Sudden involuntary contraction of a major muscle group, muscle spasm,
stiffness.
 Oculogyric crisis: a forced, sustained elevation of the eyes in an upward
position.
 Opisthotonus: arching of the back and head thrown backward.
 Rarely, laryngospasm.
 Days to months: Akathisia (feeling of restlessness and inability to sit still.),
Parkinsonism (bradykinesia).
 Months to years: Tardive dyskinesia (orofacial chorea).
 Repetitive, rhythmic, involuntary movements of the tongue, lips, face, trunk,
and extremities.
 Orofacial dyskinesias (eg, facial grimacing, tongue movements, lip smacking
and puckering) are most common, but choreoathetoid movements of the trunk
and limbs can also occur.
 Treatment:
 Benztropine (acute dystonia, tardive dyskinesia).
 Benzodiazepines, β-blockers (akathisia).
Page 53 of 63
Neuroleptic malignant syndrome (NMS)

 Symptoms: Malignant FEVER:
 Myoglobinuria, Fever, Encephalopathy, unstable Vitals, ↑ Enzymes, muscle Rigidity.
 Treatment:
 Dantrolene.
 D2 agonist (eg, bromocriptine).
ATYPICAL ANTIPSYCHOTICS
(SECOND GENERATION ANTIPSYCHOTICS)
 Drugs include:
 Aripiprazole,
 asenapine, clozapine, olanzapine, quetiapine,
 iloperidone, paliperidone, risperidone,
 Lurasidone, ziprasidone.
 MECHANISM:
 Most are D2 antagonists;
 Aripiprazole is D2 partial agonist  does not cause galactorrhea as does risperidone.
 Risperidone binds with a very high affinity to serotonin receptors, which results in
an improvement in the negative symptoms of schizophrenia, a reduction in the
incidence of extrapyramidal side effects, and concomitant treatment of depression.
 CLINICAL USE:
 Schizophrenia—both positive and negative symptoms.
 Also used for bipolar disorder,
 OCD, anxiety disorder, depression, mania, Tourette syndrome.
 Use clozapine for
 Treatment-resistant schizophrenia or schizoaffective disorder.
 Suicidality in schizophrenia.
Page 54 of 63
 ADVERSE EFFECTS:
 All—prolonged QT interval, fewer EPS and anticholinergic side effects than typical
antipsychotics.
 ―-pines‖—metabolic syndrome (weight gain, diabetes, hyperlipidemia).
Olanzapine  Obesity.
 Clozapine—agranulocytosis (monitor WBCs frequently) and seizures (dose related).
―Must watch bone marrow clozely with clozapine.‖
 Risperidone—hyperprolactinemia (amenorrhea, galactorrhea, gynecomastia).
 Quetiapine is the most sedating of all the atypical antipsychotics.
Page 55 of 63
LITHIUM:
 MECHANISM:
 The therapeutic effects of lithium are attributed to its ability to inhibit inositol-1-
phosphatase in neurons.
 CLINICAL USE: Mood stabilizer for bipolar disorder; blocks relapse and acute manic
events.
 Tremor.
 hypothyroidism, polyuria (causes nephrogenic
diabetes insipidus)  Periodic monitoring of
TSH & renal function (BUN & Cr)
 Teratogenesis  causes Ebstein anomaly in newborn if taken by pregnant mother.
 Narrow therapeutic window requires close monitoring of serum levels.
 Almost exclusively excreted by kidneys; most is reabsorbed at PCT with Na+.
 Thiazides (and other nephrotoxic agents) are implicated in lithium toxicity.
 UW: When hypothyroidism develops, it can be treated with T4 and does not
necessarily require lithium discontinuation.
Page 56 of 63
BUSPIRONE
 MECHANISM:
 Stimulates 5-HT1A receptors.
 Nonbenzodiazepine anxiolytic.
 CLINICAL USE:
 Generalized anxiety disorder. ―I’m always anxious if the bus will be on time, so I
take buspirone.
 2 advantages:
 Does not cause sedation, addiction, or tolerance.
 Does not interact with alcohol (vs barbiturates, benzodiazepines).
 2 disadvantages:
 Takes 1–2 weeks to take effect.
 Not effective in treating panic disorder.
ANTIDEPRESSANTS
Page 57 of 63
Selective serotonin reuptake inhibitors
 Fluoxetine, fluvoxamine, paroxetine, sertraline, escitalopram, citalopram.
 MECHANISM:
 Inhibit 5-HT reuptake.
 It normally takes 4–8 weeks for antidepressants to have an effect.
 CLINICAL USE: Depression, generalized anxiety disorder, panic disorder, OCD, bulimia,
social anxiety disorder, PTSD, premature ejaculation, premenstrual dysphoric disorder.
 ADVERSE EFFECTS: Fewer than TCAs. GI distress, SIADH, sexual dysfunction
(anorgasmia, ↓ libido).
Serotonin-norepinephrine reuptake inhibitors

 Venlafaxine, desvenlafaxine, duloxetine, levomilnacipran, milnacipran.
 MECHANISM: Inhibit 5-HT and norepinephrine reuptake.
 CLINICAL USE:
 Depression, general anxiety disorder, diabetic neuropathy.
 Venlafaxine is also indicated for social anxiety disorder, panic disorder, PTSD,
OCD.
 Duloxetine is also indicated for fibromyalgia.
 ADVERSE EFFECTS ↑BP most common; also stimulant effects, sedation, nausea.
Serotonin syndrome
 Can occur with any drug that ↑ 5-HT (eg, MAOIs, SSRIs, SNRIs, TCAs, tramadol,
ondansetron, triptans, linezolid, MDMA, dextromethorphan).
 Characterized by 3 A’s:
 neuromuscular hyperActivity (clonus, hyperreflexia, hypertonia, tremor, seizure),
 Autonomic stimulation (hyperthermia, diaphoresis, diarrhea), and
 Agitation.
 Treatment: cyproheptadine (5-HT2 receptor antagonist).
Page 58 of 63
Tricyclic antidepressants
 Amitriptyline, nortriptyline, imipramine, desipramine, clomipramine, doxepin, amoxapine.
 MECHANISM: Inhibit NE and 5-HT reuptake.
 CLINICAL USE:
 Major depression, OCD (clomipramine), peripheral neuropathy, chronic pain,
migraine prophylaxis.
 Nocturnal enuresis (imipramine, although adverse effects may limit use).
 Sedation,
 α1-blocking effects including postural hypotension, and
 Atropine-like (anticholinergic) side effects (tachycardia, urinary retention, dry
mouth).
 3° TCAs (amitriptyline) have more anticholinergic effects than 2° TCAs
(nortriptyline).
 Can prolong QT interval.
 Tri-C’s: Convulsions, Coma, Cardiotoxicity (arrhythmia due to Na+ channel
inhibition);
 Also respiratory depression, hyperpyrexia.
 Confusion and hallucinations in elderly due to anticholinergic side effects
(nortriptyline better tolerated in the elderly).
 Treatment of toxicity:
 NaHCO3 to prevent arrhythmia (cardio protective) by alkalinization of blood, which
uncouples TCA from myocardial sodium channels and increases extracellular
sodium concentration, thereby improving the gradient across the channel.
EKG is the single most important test to guide therapy and prognosis in TCA
overdose. Watch out for prolonged QRS, QT, and PR intervals. Most serious
complication is ventricular tachycardia and fibrillation
Page 59 of 63
Monoamine oxidase inhibitors (MAOIs)
 Tranylcypromine, Phenelzine, Isocarboxazid, Selegiline (selective MAO-B inhibitor).
(MAO Takes Pride In Shanghai).
 MECHANISM: Nonselective MAO inhibition ↑ levels of amine neurotransmitters
(norepinephrine, 5-HT, and dopamine).
 CLINICAL USE: Atypical depression, anxiety. Parkinson disease (selegiline).
 CNS stimulation;
 Hypertensive crisis, most notably with ingestion of tyramine, which is found in
many foods such as aged cheese and wine. Tyramine displaces other
neurotransmitters (eg, NE) into the synaptic cleft  ↑ sympathetic stimulation.
 Contraindicated with SSRIs, TCAs, St. John’s wort, meperidine, dextromethorphan
(to prevent serotonin syndrome). Wait 2 weeks after stopping MAO inhibitors before
starting serotonergic drugs or stopping dietary restrictions.
Page 60 of 63
Atypical antidepressants
 Bupropion:
 Inhibits reuptake of NE and dopamine.
 Also used for smoking cessation.
 Toxicity:
 Stimulant effects (tachycardia, insomnia), headache.
 ↓ Seizure threshold, therefore be avoided in patients with seizure disorders or
conditions that predispose to seizures (eg, concurrent alcohol or benzodiazepine
use, eating disorders).
 Seizures in anorexic/bulimic patients. Individuals with anorexia
 May help alleviate sexual dysfunction. nervosa or bulimia nervosa
frequently develop electrolyte
 Mirtazapine: abnormalities that can precipitate
 Mechanism: seizures. Therefore, a history of
 α2-antagonist (↑ release of NE and 5-HT), anorexia nervosa/bulimia is a
 potent 5-HT2and 5-HT3 receptor antagonist contraindication to bupropion
and usage.
 H1 antagonist.
 Toxicity: sedation (which may be desirable in
depressed patients with insomnia), ↑ appetite, weight gain (which may be desirable in
elderly or anorexic patients), dry mouth.
 Trazodone:
 Sedating antidepressant.
 Mechanism:
 Serotonin modulator (antagonizes postsynaptic serotonin receptors and inhibits
serotonin reuptake).
 α1-adrenergic, and H1 receptors blocking activity.
 Used primarily for insomnia, as high doses are needed for antidepressant effects.
 Toxicity: sedation, nausea, priapism (persistent erection of the
Conditions that
penis for >4 hours and not associated with sexual excitement), predispose to priapism
postural hypotension.  sickle cell disease,
multiple myeloma.
 Called traZZZobone due to sedative and male-specific side
effects.
 Varenicline:
 Nicotinic ACh receptor partial agonist.
 Used for smoking cessation.
 Toxicity: sleep disturbance, may depress mood.
Page 61 of 63
 Vilazodone:
 Mechanism:
 Inhibits 5-HT reuptake;
 5-HT1A receptor partial agonist.
 Clinical use:
 major depressive disorder and
 Generalized anxiety disorder (off-label).
 Toxicity:
 Headache, diarrhea, nausea, ↑ weight, anticholinergic effects.
 May cause serotonin syndrome if taken with other serotonergic agents.
 Vortioxetine:
 Mechanism:
 Inhibits 5-HT reuptake;
 5-HT1Areceptor agonist and
 5-HT3 receptor antagonist.
 Clinical use:
 Major depressive disorder.
 Toxicity:
 Nausea, sexual dysfunction, sleep disturbances (abnormal dreams),
anticholinergic effects.
 May cause serotonin syndrome if taken with other serotonergic agents.
Page 62 of 63
Delirium tremens Neuroleptic malignant Serotonin syndrome

syndrome
Alcohol withdrawal; Side effect of antipsychotics drug that ↑ 5-HT

2–4 days after last
drink
Autonomic  Malignant FEVER:  by 3 A’s:

hyperactivity.  Myoglobinuria,  neuromuscular
Fever, hyperActivity (clonus,
Confusion.
Encephalopath hyperreflexia,
Electrolyte y, unstable hypertonia, tremor,
disturbances, Vitals, ↑ seizure),
respiratory alkalosis. Enzymes,  Autonomic stimulation
muscle (hyperthermia,
Classically occurs in
Rigidity. diaphoresis, diarrhea),
hospital setting (eg,
 Agitation.
2–4 days postsurgery)
in alcoholics not able
to drink as inpatients.
benzodiazepines Dantrolene cyproheptadine
Page 63 of 63

Psychiatry, Usmle Endpoint by DR Ahmed Shebl

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Psychiatry, Usmle Endpoint by DR Ahmed Shebl

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USMLE ENDPOINT PSYCHIATRY

TRANSFERENCE AND COUNTERTRANSFERENCE

VULNERABLE CHILD SYNDROME

CHILDHOOD AND EARLY-ONSET DISORDERS

Autism spectrum disorder

Oppositional defiant disorder

Separation anxiety disorder

Pyromania is characterized by intentional

 Characterized by sudden, rapid, recurrent, nonrhythmic,

Disruptive mood dysregulation disorder

Depersonalization/ derealization disorder

Brief psychotic disorder

UW: Substance-induced psychotic disorder

BIPOLAR DISORDER (MANIC DEPRESSION)

MAJOR DEPRESSIVE DISORDER (UNIPOLAR)

Major depressive disorder with psychotic features

Both mood and psychotic

Persistent depressive disorder (dysthymia)

Depression with atypical features

 UW: Differential diagnosis of depressed mood:

SEASONAL AFFECTIVE DISORDER

POSTPARTUM MOOD DISTURBANCES

Maternal (postpartum) ―blues‖

RISK FACTORS FOR SUICIDE COMPLETION

Social anxiety disorder (Social phobia)

GENERALIZED ANXIETY DISORDER (GAD)

Body dysmorphic disorder

POST-TRAUMATIC STRESS DISORDER (PTSD)

Acute stress disorder

DIAGNOSTIC CRITERIA BY SYMPTOM DURATION

Cluster A personality disorders

Cluster B personality disorders

Cluster C personality disorders ―Worried‖

Factitious disorder imposed on self ―Munchausen syndrome‖

Factitious disorder imposed on another ―Munchausen syndrome by proxy‖

SOMATIC SYMPTOM AND RELATED DISORDERS

Somatic symptom disorder

Conversion disorder (functional neurologic symptom disorder)

Illness anxiety disorder (hypochondriasis)

Binge eating disorder

SLEEP TERROR DISORDER

OBSTRUCTIVE SLEEP APNEA

Sleep changes in elderly:

SUBSTANCE USE DISORDER

STAGES OF CHANGE IN OVERCOMING SUBSTANCE ADDICTION

Precontemplation Contemplation Preparation Action Maintenance

PSYCHOACTIVE DRUG INTOXICATION AND WITHDRAWAL

Lysergic acid diethylamide (LSD)

HEROIN DETOXIFICATION MEDICATIONS

CENTRAL NERVOUS SYSTEM STIMULANTS:

 The mesolimbic pathway

Neuroleptic malignant syndrome (NMS)

Serotonin-norepinephrine reuptake inhibitors

Delirium tremens Neuroleptic malignant Serotonin syndrome

Alcohol withdrawal; Side effect of antipsychotics drug that ↑ 5-HT

Autonomic  Malignant FEVER:  by 3 A’s:

benzodiazepines Dantrolene cyproheptadine