Depression

Tx: SSRIs preferred

Most important RF for suicide: Previous attempt

Sleep: shortened REM latency and increased REM

—-> REM not restorative (Stages 3/4 are) —->> depressed ppl tired!

Atypical lab test: Cortisol

——> dexamathesone doesn’t suppress

Medications that cause depression:

Beta blockers, IFN Gamma, alpha methyl dopa; levodopa

Diseases that cause depression:

HIV, Seroconversion disorder, Lyme, thyroid, porphoryria, Uremia, Liver disease etc

Left MCA stroke

MDD

>2wks

SIGECAPS:

Sleep Disturbance

Loss of Interest

Guilt/Worthlessness

Low Energy

Impair. Concentration

Altered Appetite

Psychomotor retardation/Agitation

Suicidal thoughts

First line antidepressants: SSRIs, SSRIs, Buproprion, Mirtazapine

SSRIs:

Tx for Premature Ejaculation; OCD; Bulimia; Anxiety; PTSD

Most drug drug interactions: Paroxetine (cyt p450)

Paroxetine may be unsafe in pregnancy (cardiac malformations) but SSRIs safe otherwise

Dont need to taper fluoxetine when stopping as short half life ——-> no discontinuation
syndrome

Citalopram has fewest drug drug interactions: But avoid if recent MI

——-> d/t dose dependent QT Prolongation

——->> sertraline safer: v low risk of adverse reactions, esp cardiac

Sertraline most likely to cause Serotonin discontinuation syndrome

——> flu like sx, GI distress, dysphoria, fatigue

Sexual dysfunction —->>> switch to bupropion (DA/NE Reuptake I): no sex on the bus!

———>> also useful in smoking cessation

—->>> cannot use if seizure risk: alcoholic, epileptic, eating disorders

Avoid venlafaxine in very hypertensive patient

——>>> St. John’s wort and SNRI can also cause hypertensive crisis

MAOI hypertensive crisis d/t NE ——> Tx with alpha blocker (PHENTOLAMINE)

—> seen if taking merperidine (opioid) or decongestant

TCA OD:
Widened QRS (>0.10) and prolonged QT (>0.4) -> Torsades
—> QRS duration best predictor of complications (arrhythmia/seizure)

Tx: Sodium Bicarbonate

Atypical depression

Sleep more, eat more, leaden paralysis in morning

Hypersensitive to rejection

Tx: MAOI

Cyclothymic Disorder
>2yrs of fluctuating hypomanic and depressive sx

—->> that does not meet criteria for hypomanic/major depressive episodes

Adjustment Disorder

Sx start within 3 months of stressor and last < 6 months

Sx out of proportion to stressor

Tx: psychotherapy

Bipolar

Mania Sx similar seen in frontal hemisphere stroke/R MCA stroke (elderly pt first time)

SSRIs and TCAs can trigger mania

Tx: Haloperidol or clonazepam for acute agitation/delusions

Acute depression: Quetiapine/Lurasidone

Maintenance: Lithium, valproate acid or carbamazepine

——>> Drugs to be avoided: Antidepressant monotherapy (Bupropion, SSRI, Mirtazapine)

—->> induce mania (antidepressants can be used in comb with anti manic drug)

Bipolar I

Manic Episodes: delusions associated with elevated mood, increased energy and
hyperactivity, pressured speech (not disorganised cf schizo or flat, monotone effect)
Marked impairment; may have psychotic features (makes episode manic by definition)

1 wk unless hospitalised

Depressive episodes common but not necessary for dx

Bipolar II

Hypomanic episodes: elevated mood, increased energy and productivity, decreased need for
sleep etc)

—>> 4 or more consecutive days; change in function from baseline but no marked impairment

1 or more major depressive episode (2 or more wks)

Catatonia most often develops in context of mood disorder but also seen in psychotic
disorders, autism and others

LITHIUM

Main side effects:

Weight gain, acne, GI irritation, cramps; hyperPTH (DI)

Suppresses Inosital Triphosphate

Therapeutic level: 0.6-1.2

Monitoring: Li level every 4-8 wks, TFTs every 6 months

CI for use: Severe renal dz, MI, diuretics or digoxin, Myasthenia Gravis, Pregnancy/
Breastfeeding

Pregnancy: Epstein’s Anomaly: Malformed TV atrialises RV if taken during first trimester

—>> use Clonazepam instead

Lithium Toxicity

Precipitated by NSAIDs (use aspirin instead)

Coarse tremor, n/v/d, confusion, slurred speech, ATAXIA

T wave fluttering or inversion + U waves

Tx: Fluid resuscitation

Emergent dialysis if >4 or kidney disease; or >2.5 with prominent signs of toxicity

Valproate acid

Hepatitis, n/v/d, skin rash, teratogen NTD (increased AFP)

THERAPEUTIC LEVEL: 6-12

Lamotragine: SJS

Carbamazepine: RASH, SJS, agranulocytosis, teratogen NTD (increased AFP), drug drug
interaction

THERAPEUTIC LEVEL: 60-120

Move decimal place: 0.6 —>>6 —>>60

Panic disorder

Tx: BZDs short term (to bridge) but SSRIs DOC

NB BZDs suppress respiratory drive so avoid in pts with COPD/restrictive lung disease

Acute BZD withdrawal reaction

——> Similar to DTs: High temp, convulsions, confusion and HTN (autonomic instability),
seizures,

hallucinations etc

Tx: diazepam + haloperidol (if psychotic)

Specific Phobia

Tx: CBT with desensitisation (ERP)

BZDs for situational use

Social Phobia

Fear of being laughed at

Performance only subtype

Non performance subtype: Daily/manifest in multiple situations (personal, work etc)

Tx: SSRI/SNRI

Beta blockers to stop hyperarousal in performance only social phobia and BZDs, both
situationally

Avoidant PD

Tx: CBT

Selective mutism

Anxiety disorder

> 1 month of not speaking in situations in which its expected (school) despite talking at home etc

—-> can impair academic and social development

Frequently comorbid w social anxiety disorder

Tx: CBT with graded exposure to social situations; Family therapy and SSRIs

GAD
> 6 months
Somatic sx: Fatigue and physical sx related to muscle tension: headaches, neck/shoulder/back
pain

GI sx, sweating, trembling

TX: SSRIs/SNRIs; CBT or combo

Buspirone (5HT1a partial agonist); BZDs to bridge as takes >3wks to take effect

—-> Buspirone primarily used to tx anxiety disorders

OCD

Comorbidities: Tourette’s

Tx: SSRIs first one; clomipramine gold standard

PTSD

Sx must last >1 month

Delayed onset PTSD can present 6 months after stressor

DISSOCIATION

Tx: SSRIs with CBT

Prazosin for nightmares

Acute stress Reaction

Sx start within 4 wks

Same sx but present < 1 month

Somatic sx disorder

1 or more somatic sx which is distressing to pt or leads to disruption of life

Pt experiences excessive thoughts, feelings and behaviour in relation to sx/health

——->>> thoughts about severity of sx disproportionate and persistent

Somatic sx must be present for >6 months although sx may not always be continually present

Tx: Single physician/care worker

Schedule monthly visits and psychotherapy

Avoid unnecessary dx tests

Comorbid: Depression; anxiety; Personality disorder

Conversion disorder

Altered sensory/or voluntary motor function eg pseudoseizure

——> ANY part of CNS over which voluntary control is exercised

—-> real seizure Prolactin levels are high (not in pseudo)

Not intentional

Clinical findings not consistent with recognised neurological or medical conditions

Pts sx better explained by another condition/disorder

Sx causes little distress

Tx: Develop therapeutic alliance (first line)

CBT

Munchausen Syndrome

Primary gain

Inducing Sx:

Eg: Melanosis coli

——->> Laxative abuse

Munchhausen by proxy
Inducing sx eg giving child insulin——>> seizure

Form of child abuse —> 10% die before reaching adulthood

——> Notify Child protective surfaces

Malingering
Secondary gain

Associated with antisocial PD

V Code: circumstances other than dz/injury result in medical visit

——->>> Bereavement also V Code

Eating disorders:

Russel Sign: Calluses on knuckles d/t self induced vomiting

Anorexia

Vital signs: All decreased

CBC: Leukopoenia

Chemistry: High HCO3, Low Cl and K; high carotene (yellow skin); high LFTS and amylase

——->> liver stressed trying to produce glycogen

TFTs are normal

Fasting Lipid Profile: high Cholesterol

Hormones: High Cortisol, low LH/FSH, low oestrogen

Most common cause of death: Heart disease then suicide

Tx: Inpatient to maximise nutrition (nutritional rehab); needs intensive counselling (CBT)

SSRIs ineffective

Refeeding syndrome: low PO4, low Mg, low Ca and fluid retention ——>> arrhythmias

Olanzapine if no response to CBT and nutritional rehabilitation

Bulimia

SSRIs (Prozac); CBT; nutritional rehabilitation

Binge eating disorder

Min 1 per wk for 3 months (bulimia also)

Tx: CBT; behavioural weight loss therapy; SSRIs; Lisdexamfetamine

Body Dysmorphic Disorder

Tx: SSRIs; CBT

Sleep: BATS Drink Blood

Awake: Low amplitude and high frequency EEG

Beta waves
Alpha waves: eyes closed

Stage 1: Theta waves

Stage 2: Sleep spindles (inc f) and K complexes (inc amplitude)

Longest stage

Stage 3/4: Delta waves (slow f and high amplitude)

—->> slow wave sleep:

—->> sleep walking, talking, night terrors and bed wetting

—->> Night terrors: NREM Sleep Arousal Disorders: Don’t remember dreams!
——-> common in ages 2-12 and resolve spontaneously in 1-2 yrs (dx clinical)

REM: Sawtooth Beta waves; resembles awake (paradoxical sleep)

Dreaming; memory processing

Skeletal muscle paralysed except for extra ocular muscles: Rapid Eye Movement

—> loss of tone

Nightmare Disorder: Remember Dream!!

REM Sleep behaviour disorder (RBD): Complex motor behaviours eg dream enactment

—-> M > 50

Associated w alpha synuclein neurodegenerative disorders: RBD considered prodrome

—->> 90% w idiopathic RBD develop Parkinson Disease or related

NE, Serotonin and Histamine suppress REM sleep —> SLEEP more restful

GABA Agonists (alcohol, BZDs and barbiturates) reduce REM and delta (deep) sleep

Elderly: More rapid cycling with decreased REM latency (resembles depression)

Normal sleep amount overall but decreased REM sleep (cf depression); more naps

Insomnia

Impairment of function for > 1month

Rule out medical cause

Best initial test: Polysomnography

Tx: Educate about sleep hygiene then try zolpidem short term only

Melatonin; trazadone

Restless leg Syndrome

Rule out medical causes: Fe Def anaemia; CKD; Neuropathy

Tx: Ropinirole or Pramipexole

Obstructive Sleep Apnea

Tx: Weight Loss

CPAP to reduce pulm HTN

Narcolepsy

Cataplexy after emotion (tx w TCAs)

Hallucination upon waking/going to sleep

Short paralysis with awakening

Sleep attacks alone dont qualify dx

Sleep episodes start off with REM sleep but reduced REM latency

Loss of orexin (hypocretin) neuropeptides

Evaluation: Polysomnography

Tx: Scheduled naps (refreshing) and Modafinil (first line)

Alcohol use disorder

Tx: first line: Acamprosate (Glutamate modulator) or Naltrexone (hepatotoxic)

Dilsufiram second line

Mild withdrawal: 6-24hrs post drink

Alcoholic hallucinosis

Onset since last drink: 12-48hrs

Stable vitals

Seizure:

Onset since last drink: 12-48hrs

DTs: 48-96hrs post drink

PMS

Tx: SSRIs

Neuroleptic Malignant Syndrome

High fever, hypertension, tachycardia, “lead pipe” rigidity, elevated CPK;K+ , leukocytosis,
metabolic acidosis

Tx: discontinue offending agent, IV Fluids, cooling

Dantrolene (muscle relaxant); Bromocriptine if refractory

SEROTONIN syndrome: NM hyperactivity eg

Myoclonic jerks, hyperreflexia, n/v/diarrhoea, tachycardia, HTN (AN dysregulation)

==> bilateral Babinski; ocular clonus (slow continuous horizontal eye movements)

Serotonin discontinuation syndrome

——> flu like sx, GI distress, dysphoria, fatigue

Schizophrenia:

Any Sx for 6 months

Negative sx tend to predate

Paranoid type most common and has best px

Neurobiology:

Positive Sx: Excess Dopamine in mesolimbic tract binding D2 R

Negative Sx: Decreased Dopamine in Prefrontal cortex/meso-cortical tract

——>>>> typical antipsychotics worsen negative sx

Affective flattening; avolition (lack of motivation, loss of drive), Alogia; anhedonia; attention
deficits; social withdrawal, diminished capacity to feel close to others

Family Therapy and psycho education reduce risk of rehospitalisation

Delusions may mimic Bipolar but speech is monotone and disorganised (not pressured and hard
to

interrupt); mood is flat/inappropriate/avoids eye contact (not irritable/elated)

4 DA Tracts: Nigrostriatal and tubuloinfundibular affected by antipsychotics

——->> side effects!

Good Px: Predominantly positive psychotic sx

Catatonia
Waxing flexibility
Hyperreflexia
Tx: BZDs; ECT

Brief Psychotic Disorder

> 1wk < 1 month

Tx: typical antipsychotic for Positive sx

—->> does not alter risk of disease progressing

Schizophreniform

> 1 month < 6 months

Tx: typical antipsychotic for Positive sx

—->> does not alter risk of disease progressing

Schizoaffective Disorder

Psychosis and mood disorder

Delusions/hallucinations > 2wks in absence of mood sx

Can have concurrent psychosis and mood issues but much have at least 1 episode >2wks of
pure

psychosis

Tx: Atypical antipsychotics + SSRI (depression)/Lithium (mania)

MDD with psychotic Features

Delusions are typically mood congruent (coincide)

Tx: Atypical antipsychotics + SSRI (depression)/Lithium (mania)

ECT(esp if pregnant)

Psychosis+Mania is Psychosis+Mood sx!

Delusional disorder

Functional despite delusion

Non bizarre (believable)

> 1 month in absence of other psychotic/mood sx

Tx: Atypical antipsychotic and CBT

Postpartum psychosis

Within 2 wks postpartum

Mood sx, agitation, severe insomnia

Acute onset delusions, hallucinations and disorganised behaviour

Often seen in pts w hx of bipolar

High risk for recurrent episodes in future pregnancies

Tx: hospitalisation

Acute agitation/psychosis: IM Haloperidol

—>> D2R antagonist non selectively

Psychosis has normal EEG

—-> Diffuse background slowing —-> Delirium

MDD with psychotic sx

Tx: ECT

—->> esp good in those who refuse to eat/drink/ are actively suicidal

Antipsychotics:

2 classes: Typical or atypical

Typical:

——>> stronger D2 receptor antagonism

———>>↑ [cAMP]

Atypical:

——>>> weaker D2 receptor antagonism and stronger 5-HT2, α, and H1 antagonism

—>>>> orthostatic hypotension; sexual dysfunctions; sedation; dry mouth, constipation,

vision
issues

Specific pathways affected include:

Nigrostriatal (extrapyramidal motor)

Mesolimbic (mood and reward): Positive sx —->> psychosis

Mesocortical (negative sx)

Tuberoinfundibular (prolactin release)

Low Potency: Chlorpromazine and Thioridazine (typical)

—->> less EPS but more anticholinergic

High potency: haloperidol and Fluphenazine. (Typical)

—->> more EPS

——> Fluphenazine been implicated in hypothermia

Hx of medication non adherence: Decanoate forms every 2-4 wks

Chlorpromazine

Purple gray metallic rash over sun exposed ares and jaundice; corneal deposits

Thioridazine

Prolonged QTc and pigmentary retinopathy

Acute dystonia

Early onset 4-12hrs

Sustained or slowed abnormal positions of the limb, trunk, or face:

—->> torticollis; blepharospasm; spasmodic dysphonia

Spasm of face, neck, tongue, extraocular muscles

Dysfunction in basal ganglia

Tx: Benztropine or Diphenhydramine

Parkinsonism

> 6 months

Tx: anticholinergics: Benztropine, diphenhydramine, trihexyphenidyl

—->>> not L DOPA!!! —-> worsens psychosis

Akathesia

4 days - 4 months

Urge to move, restlessness

Tx: Beta blockers (first line) and BZDs

Tardive dyskinesia. Anticholinergics worsen!!!

Late onset/irreversible

Involuntary repetitive movements of facial, neck, tongue and neck muscles

Stereotypical writhing movements

Stop high potency typical antipsychotic and switch to atypical antipsychotic/clozapine

VMAT2 Inhibitor (Valbenazine) can help

Atypicals: Can treat positive and negative sx!

Can produce false positive for TCAs on urine toxicology

———> esp quetiapine

Risperidone: Highest risk for EPS and prolactinaemia

Ziprazodine: Prolongs QTc but no weight gain

Aripiprazole
D2 Partial Agonist

Weight neutral but worsens akathesia

Olazapine

Weight gain but most significant side effect is sedation

Lurasidine
Minimal weight gain; used in bipolar depression

QUIETIAPINE

Blocks alpha R—> ORTHOSTATIC HYPOTENSION

Cataracts

Clozapine

Least likely to cause NMS

Sedation, weight gain, increased blood sugars and lipids, myocarditis, constipation

Agranulocytosis, decreased seizure threshold

Monitor: CBC

BZDs cause paradoxical agitation in elderly

Acute intermittent Porphyria

AD; Age of Onset 20s/30s

Abdo pain and Fam Hx

Periph neuropathy

Common precipitates: Fasting (carb restriction induces enzymes); carbamazepine/phenytoin/

rifampin;

Tobacco and Alcohol

Neuropsychiatric sx:

Abdo pain is neuropathic so tenderness to palpation often absent

Vomiting, constipation, sensory and motor neuropathies and tachycardia

Psychiatric sx nonspecific but can inc psychotic sx

Acute sx may last days to weeks

Dx: Elevated urine porphobilinogen during an attack

Phenytoin /Toxicity

In CYP450 Inhibitor use

Cerebellar dysfunction: horizontal nystagmus; ataxia; dysmetria;

N/V, hyperreflexia and slurred speech

Altered mental state, paradoxical seizures

Hypotension and bradyarrhythmia with rapid IV infusion

Management: Supportive with gastric decontamination; poss hemodialysis

Side Effects:

Impaired folate absorption in jejenum: Deficiency in folate (gingival hyperplasia); disrupts bone
and mineral metabolism (reduced bone density);

Extra Pyramidal Sx

More common with first gen antipsychotics

Risperidone most likely second gen

Ziprasidone one has lowest metabolic risk

Clozapine, although virtually no EPS, only used if failed at 2 other antipsychotics d/t risk of

agranulocytosis

Also d/t antiemetics: Prochloperazine, promethazine, metoclopromide

Acute dystonia reaction

Sustained sudden contraction of neck, mouth, tongue and eye muscles

Oculogyric crisis: Forced upward gaze deviation

Torticollis, blepharospasm, Tri’s is

Tx: Reduce dose or switch to antipsychotic with less EPS if poss

Or....—>> Add IV anticholinergic (Benztropine; trihecyphenidyl) with antihistamine

Akathisia

Subjective restlessness, inability to sit still

Tx: Reduce dose or switch to antipsychotic with less EPS if poss

Or.... —>> Add Propanolol, BZD, Benztropine

Parkinsonism

Tx: Reduce dose or switch to antipsychotic with less EPS if poss

Or...—>> Add Benztropine or Amantadine

Tardive Dyskinesia

Gradual onset after prolonged therapy (>6months)

Dyskinesia of mouth, face, trunk and extremities

Tx: Stop offending agent

Switch to second line: Quetiapine/clozapine if continued antipsychotic needed

Valbenazine or Deutetrabenazine (rev I of VMAT2)

D/t Dopamine R SUPERSENSITIVITY and D2 upregulation

TCAs and MAOIs not firstline in tx of depression d/t side effect profile

NMS:
Fever (>40C)

Confusion

Generalised muscle rigidity

Autonomic Instability: Abnorm vitals; sweating

SS

NM Hyperactivity: Tremor, hyperreflexia, myoclonus

Ecstasy, bath salts (amphetamine analogs) and cocaine can precipitate this

BZD abrupt discontinuation: Seizure risk

Withdrawal of BZDs with short half lives: eg alprazolam (ATOM)

Seizures; tremors, anxiety, perceptual disturbance and psychosis

Corticosteroids can cause Medication induced Mood Disorder:

Hypomania, psychosis, mania

Circadian Rhythm Sleep Disorder

Cannot sleep and wake at time needed for normal work and social needs

Can sleep at other times

Normal sleep, energy and functioning when they can set their own sleep cycle

Complex partial seizures most commonly arise in temporal lobe:

Confirmed by smelling burnt rubber and hearing hissing noise

Spikes on EEG localise seizure activity

Burst suppression pattern: Inactivated brain ie COMA

Hypsarrhythmia: infantile spasms

Diffuse 3 Hz spike and slow wave activity: absence

Triphasic wave: Toxic Metabolic Encephalopathy

Neurotransmitters decreased in depression:

Serotonin, dopamine and norepinephrine

Decreased conc of 5 hydroxyindoleacetic acid in CSF

Delayed Phase Sleep Disorder

Delayed REM sleep on nighttime polysomnography

GAD:

Increased sensitivity to lactate infusion

Cocaine Intoxication: BZD

Enuresis norm until age 5

Encoparesis (fecal) norm until age 4

Mydriasis: dilated

BZD suitable in cirrhosis d/t decreased first pass metabolism:

Oxazepam, Lorazepam and Temazapam

Adjustment Disorder

Onset within 3 months of non-life threatening stressor

Usually resolves within 6 months

Poor performance eg fail a test

Tx: CBT

Conversion Disorder

La belle indifference: pt aware but indifferent to sx

Loss of sensory or motor function following acute stressor

Psychogenic Nonepileptic Seizure

Type of conversion disorder

—-> clinical findings inconsistent with seizures/other known neuro conditions

Forceful eye closure; side-to-side head or body movements; ‘shaking all over’

Rapid alerting and reorienting post ‘seizure’; memory recall of event

Events typically occur infront of witnesses

Pts may model behaviour after friend/relative with epilepsy

Norm cortical activity

—->> Video EEG god standard DX as shows absence of epileptiform activity

Many pts have comorbid psych disorders and/or hx of trauma

Opiate OD

Low BP, Low HR, low resp (RR under 8 intubate!)

Prolonged QTc (Methadone esp)

Tx: IM Naloxone

——->> Mydraisis 2/2 to hypoxia d/t resp depression

Opiate Withdrawal: JUICY (Wet)

Joint and muscle pain, photophobia, goosebumps, diarrhoea, tachy, HTN, sweat

Runny noise, mydriasis, GI Cramps, anxiety/depression

Tx: Symtomatic: Clonidine for autonomic sx; loperamide for diarrhoea etc

LT Dependence tx: Methadone, buprenorphine (mixed agonist and antag) or Naltrexone

—-> must be in withdrawal to start buprenorphine/naltrexone as precipitates?

Meperidine okay if pregnant, rest not (fetal addict)

—-> serotonin Syndrome risk

Side effects:

Increases ADH and prolactin secretion

Decrease LH secretion

Tolerance: miosis and constipation are not affected by tolerance

NMDA receptor antagonists (e.g., ketamine) and delta-receptor antagonists have been reported
to prevent opioid tolerance

Amphetamine intoxication:

Paranoia, tachycardia, hyperreflexia, rapid speech, agitation, HTN, Seizure

Best first test: ECG then urine tox screen

Tx seizure with lorazepam

Tx HTN with CCBs as BBs CI

Cocaine/Amphetamine Withdrawal

Suicidal, Hypersomnia, depression and anergia

Hallucinogen intoxication: PCP/LSD

Perceptual distortion eg visual, anxiety, paranoia, negative urine toxicology (LSD not in standard
test)

PCP: Horizontal nystagmus, mydriasis, ataxia and acute psychosis

—>> BZDs; haloperidol

NB. Dextramethorphan can cause false positive for PCP!

—-> Also: diphenhydramine, ketamine, tramadol, venlafaxine and doxylamine

Methamphetamine Use Disorder

Paranoid delusions, tactile hallucinations (bugs crawling); aggression, severe insomnia

Poor dentition (meth mouth); bruxism (teeth grinding)

Excoriation d/t chronic skin picking

Cannabinol Intoxication
Conjunctival injection; dry mouth; impaired time perception/slow reflexes;

Euphoria or dysphoria/panic; tachycardia

Delusional disorder

>1 month with otherwise norm functioning

Childhood Development

Formal Operational (Deductive reasoning and hypothetical thinking): 11 years

Concrete Operational (Death is permanent): 6-11 yrs

Fragile X

Seizures, tremors, ataxia, ADHD like behaviour

MV Prolapse, dilation of aorta

Most common cause of inherited Mental retardation

AXIS 2: Mental Retardation and personality disorders

Mental Retardation:

Average IQ is 100

Mild: 55-70

Moderate: 40-55

Severe: 25-40

Profound: <25

Hurler syndrome

Coarse facies, short stature, cloudy cornea

AR

Neurofibramatosis

Cafe au lait, seizure, large head

AD

Maple syrup Urine Disease: branched chain AA

Vomiting, seizures, lethargy, coma

Acidosis with stress/illness

Causes neurological damage

Urine smells of syrup

Rett Syndrome

Mainly in F as mutation usually paternal origin:

—> X linked dominant deletion of MECP2

Normal development for 6-8 months then regression

Stereotypical hand movements: Clapping; hand to mouth licking; handwringing

Loss of speech and use of hands, gait abnormalities

Head growth deceleration; seizures; autistic features; sleep issues

Childhood Disintegrative disorder

Normal development until age 2 then major loss of verbal, social skills with autistic like behaviour

ADHD

RF: low birth weight, tobacco/EtOH in pregnancy, fam hx

Comorbidity: Oppositional defiant/conduct disorder

Tx: Methylphenidate (DA RI); Amphetamine (DA/NE RI); Atomoxetine (NERI);

——->> Atomoxetine only non stimulant

Alpha 2 agonists and antidepressants

Conduct disorder

Sx for 6 months

Reduced Serotonin issue aggression; reduced cortisol

Tx: Psychotherapy

Oppositional defiant disorder

Does not inc theft —->> CD

Sx for 12 months

Tourette’s

Comorbid: OCD

Tx: First line is clonadine (less side effects) but most effective is haloperidol/pimozide (DA R
Antags)

Reactive Attachment Disorder

Not formed relationships

Inhibited and hypervigilant

Problems in early infancy where needs not consistently met

Rumination Disorder

PICA common ——-> Check lead levels in case they has inadvertently ingested

Baby recently been regurgitating and rechewing food

——>> previously been eating normally

Elimination Disorders

Tx: Behavioural modification with reward system

Defence Mechanisms

Immature:

Acting out

Denial

Displacement: taking feelings out on another

Intellectualisation: Focus on non emotional aspects of eg cancer

Passive Aggression

Projection: Attributing ones own feelings to another

Rationalisation

Reaction formation: Transforming unacceptable feelings/impulses into opposite

Regression

Splitting

Mature:

Sublimation: Channelling impulses

Suppression

Humour

Altruism

Persistent Complex Bereavement Disorder/prolonged grief

>12 months after loss

Tx: Psychotherapy

Pancreatic Cancer

Depression and associated anxiety may be prodromal

—->> feel low for no reason

Premonitory sensation (something bad is going to happen)

MOA Unclear:

Increase inflamm cytokines or paraneoplastic syn or alt in pancreatic function

New onset DM may precede dx in 25%

—>> cancer induced beta cell dysfunction/secretion of adrenomedullin (insulin regulating

peptide)

Thin, older patient with smoking hx and marked weight loss

Dx: CT Abdo

Gender Dysphoria

Does not always persist if present in early childhood

Adolescents more likely to be enduring

Management:

Assess safety

Support: psychotherapy (family, individual)

Referral to specialist services (multidisciplinary)

Obstructive Sleep Apnea

Depressive Sx: Fatigue, sleep disturbance with multiple awakenings, impaired conc

Irritability, low mood

Disruptive Mood Dysregulation Disorder

Created d/t concerns of over diagnosis of bipolar

Onset before age of 10

Dx must be made before age of 18

Irritability between anger episodes

Tx: Methylphenidate? Tx

Intermittent Explosive Disorder

Decreased serotonin —> acts on prefrontal cortex to suppress aggression

Episodes last <30 min and often followed by remorse, dysphoria and embarrassment

Chronic

High rates of psych comorbidities

Tx: CBT and SSRI

Cluster A: Weird

Paranoid PD: Low dose antipsychotic can help paranoia (pseudo psychotic sx)

Schizoid PD: Resembles negative sx of schizophrenia.

Preference of solitary pursuits, affectively flat

Restricted emotional expressively and social detachment: aloof and difficult to

engage.

Indifferent to others

Schizotypal PD:

Peculiar behaviour, odd thoughts, odd speech, unusual perceptive experiences and magical
beliefs.

Suspiciousness and paranoid ideation, lack of eye contact

Social dysfunction, social anxiety, lack of motivation.

Occupational underachievers.

Closest relation to schizophrenia

Cluster B: Wild

Antisocial PD

Recurrent antisocial, delinquent and criminal behaviour that begins in childhood or early
adolescence

Negative job performance and marital instability

Disregard for the rights and feelings of others

Easily bored and impulsive —->> substance abuse

Borderline PD
Most common defence mechanism is Splitting

Histrionic PD

Centre of attention.

Emotionally labile, need for approval (avoids rejection)

Concerned with physical appearance and attractiveness, seductive and provocative.

Dramatic and relationships tend to be superficial

Look for substance abuse or eating disorder (bulimia)

Repressed anger

Narcissistic PD

Grandiosity, lack of empathy

Lack of consideration for others, show contempt and disdain

Hypersensitive to evaluation by others, react v badly to criticism

Exaggerate achievements, egotistic, manipulative

Entitled, envious of others

Little insight

Hypomania
Tx: Individual therapy not group

Cluster C: Worried

Avoidant PD

Avoidance is created by anxiety. Feelings of inadequacy

Low self esteem and sensitive to rejection

Perceive innocuous comments of criticism due to excessive concern with evaluation

Tx: Social Phobia like sx with beta blocker/ SSRI

Dependent PD

Submissiveness

Low self esteem, fear of abandonment

Repressed expression of anger or displeasure

Comorbid depression and anxiety treatable

Obsessive Compulsive PD

Rigidity and affective constriction

Inflexibility, obstinacy, penchant for orderliness

Perfectionism

Formal, stilted style of relating

Emotionally muted

View themselves as superior, not distressed by the disorder cf OCD.

—>> egocentonic cf egodystonic (OCD)