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1

[Psychotic Disorders]
1. Delusions and types
2. Illusions vs hallucinations and types

1. Delusions - fixed, false beliefs against cultural norms and despite evidence to the contrary
- persecutory - most common
- ideas of reference - external stimuli perceived as personal (Eg actor on TV winking at you)
- delusions of control -- thought broadcasting, thought insertion
- delusions of grandeur - special powers
- delusions of guilt
- somatic delusions - disease or illness

2. Illusions vs hallucinations
A. Illusions - misinterpretation of existing stimulus
B. Hallucinations- sensory perception without existing stimulus
- auditory - schizo
- visual - delirium, drugs, alcohol withdrawal
- olfactory - epilepsy
- tactile - drug use, alcohol withdrawal

2

[Psychotic Disorders]
Schizophrenia
1. Types of symptoms
2. Criteria for diagnosis

Schizophrenia
1. Types of symptoms
A. Positive
- delusions
- hallucinations
- disorganized speech e.g. looseness of association, clanging, flight of idea, neologisms
- disorganized behavior e.g. catatonia

B. Negative *most impairment to QOL, most difficult to treat
- apathy / avolition
- anhedonia
- affect (flat)
- alogia
- attention - decreased

C. Cognitive - decreased executive function and working memory
- decreased size of hippocampus and amygdala

2. Criteria for diagnosis - 2+ symptoms (1 must be either delusions, hallucinations, or disorganized speech) for >1 months
- total duration >6 months
- course includes prodromal (decreased functioning), psychotic, and residual (more neg sx)

3

[Psychotic Disorders]
Schizophrenia
3. Pathophysiology via tracts (mesolimbic, mesocotical, nigrostriatal, tubuloinfundibular) and neurotransmitters
4. CT scans

Schizophrenia
3. Pathophysiology
- ↑ dopamine in mesolimbic tract --> psychotic sx
- ↓ dopamine in mesocortical tract (frontal cortex) --> negative sx, poor cognition
- nigrostriatal tract - blocked by antipsychotics --> EPS
- tubuloinfundibular tract - blocked by antipsychotics esp typicals and risperidone --> hyperprolactinemia --> gynecomastia, galactorrhea, sexual dysfunction, menstrual irregularities

- also ↑ serotonin (atypicals also antagonize 5HT)
- ↑ norepi (long-term antipsychotic use decreases norepi levels)
- ↓ GABA (which has regulatory effect on dopamine) in hippocampus
- ↓ glutamate - fewer NMDA receptors *why ketamine (NMDA antagonist) causes psych sx

4. CT shows enlarged ventricles, cortical atrophy, and decreased brain volume

4

[Psychotic Disorders]
Schizophrenia
5. Compare contrast with schizophreniform disorder, brief psychotic disorder

Schizophreniform - symptoms between 1 and 6 months
- 1/3 recover, 2/3 progress to schizophrenia or schizoaffective
tx - 6 months course of antipsychotics, supportive psychotherapy

Brief psychotic disorder - symptoms between 1 day and 1 month, eventual full return to level of functioning
- positive symptoms only (delusions, hallucinations, disorganized speech/ behavior)
- tx - antipsychotics, benzos, supportive psychotherapy

*borderline personality may have transient, stress-related psychotic symptoms but this is not brief psychotic disorder, it's attributed to their underlying personality disorder

5

[Psychotic Disorders]
Delusional disorder
1. Criteria
2. Types
3. Treatment

Delusional disorder - more common after age 40
1. Criteria - 1+ delusions for >1 month
- does not meet criteria for schizophrenia
- no bizarre behavior, functioning not impaired
- usually non-bizarre delusions

2. Types
- erotomanic
- grandiose
- somatic
- persecutory *most common
- jealous
- mixed
- unspecified

3. Treatment - difficult to treat given lack of insight and impairment
- antipsychotics
- supportive therapy but NO groups

6

[Psychotic Disorders]
Culture-specific psychoses
1. Koro
2. Amok
3. Brain fag

1. Koro - anxiety that penis will recede into body, leading to death -- in southeast asia (singapore)

2. Amok - sudden, unprovoked outbursts violence followed by suicide - in malaysia

3. Brain fag - headache, eye pain, fatigue, cognitive difficulties in male students - in Africa

7

[Psychotic Disorders]
Differentiate mood disorder with psychotic features from schizoaffective disorder

Schizoaffective - meet criteria for either major depressive or manic episode during which psychotic symptoms are also present
- but also - delusions or hallucinations for 2 weeks in absence of mood disorder symptoms
- mood sx present for majority of psychotic illness

Mood disorder with psychotic features -- better prognosis, hallucinations and/or delusions present ONLY during depressive or manic episodes
- usually mood congruent e.g. depression --> paranoia, mania --> grandiosity, invincibility
- treat MDD w psychosis --> antidepressant and antipsychotic or ECT
*remember that bipolar I may have psychotic features that occur during depressive OR manic episodes

8

[Mood Disorders]
1. Depressive episode criteria
2. Manic criteria
3. Hypomanic criteria
4. Mixed features

1. Depressive episode criteria - 5 symptoms for 2+ weeks
- depressed / sad mood + 4 SIGECAPS
- anhedonia (loss of interest) + 4 add'l SIGECAPS
SIGECAPS: sleep, interest, guilt/worthlessness, energy/fatigue, concentration, appetite, psychomotor activity (restlessness or slowness), SI

2. Manic criteria - at least 3 symptoms for 1+ week or until hospitalized
- abnormally elevated or irritable mood (if irritable, need 4 symptoms)
DIGFAST - distractibility, insomnia/impulsive behavior, grandiosity, flight of ideas/racing thoughts, activity/agitation, speech (pressured), thoughtlessness
*50% have psychotic features

3. Hypomanic criteria - no marked impairment in functioning *only psych disorder where this is true*
- no psychotic features
- at least 3 symptoms for 4+ days (4 sx if mood is irritable)

4. Mixed features - meet criteria for manic or hypomanic episode and 3+ symptoms of major depressive episode are present for 1+ week
- predominant mood state is irritability
* poorer response to lithium --> give valproic acid

9

[Mood Disorders]
Medical and substance/medication causes of
1. Depressive episode

1. Depressive episode
A. Medical -
- cardiovascular (stroke, MI)
- endocrinopathies (DM, Cushing, Addison, hypoglycemia, thyroid, calcium)
- other - Parkinsons, mono, Carcinoid, SLE
- cancer (lymphoma, pancreatic)

B. Medications
- alcohol
- barbiturates and other sedative hypnotics
- corticosteroids + levodopa (can also cause mania)
- antipsychotics
- anticonvulsants
- beta blockers
- diuretics
- sulfonamides
- withdrawal from stimulants (cocaine, amphetamines)

10

[Mood Disorders]
Medical and substance/medication causes of
2. Manic episode

2. Manic episode
A. Medical
- metabolic (hyperthyroid)
- neuro (MS, temporal lobe seizures)
- HIV

B. Medications --> bipolar
- antidepressants
- sympathomimetics
- dopamine
- corticosteroids (can also cause depression)
- levodopa (can also cause depression)
- bronchodilators
- cocaine
- amphetamines

11

[Mood Disorders]
Major depressive disorder (MDD)
1. Criteria
2. Sleep problems
3. Etiology
4. Treatment

Major depressive disorder
1. Criteria - at least one major depressive episode, no hx of mania/hypomania

2. Sleep problems
- multiple awakenings
- initial and terminal insomnia (hard to fall asleep, early morning awakening) *most common problems*
- decreased REM sleep latency, earlier cycles and longer duration
- decreased slow wave (3 and 4) sleep

3. Etiology - neurotransmitters (Decreased serotonin, 5HIAA - main 5HT metabolite- in CSF)
- HPA axis hyperactivity --> increased cortisol
- abnormal thyroid axis
- multiple adverse childhood events eg loss of parent
- genetics

4. Treatment - CBT and SSRI, try for 6- 8 weeks before another SNRI/SSRI, then another MOA (bupropion, mirtazapine)
- continuation phase tx - continue antidepressants for addl 6 months with single episode, unipolar major depression
- maintenance tx - 1-3 years for history of recurrent MDD, -
chronic (>2 years), family hx, or severe episodes
maintenance tx indefinitely - history of highly recurrent or very severe chronic MDD episodes
- hospitalization if risk for SI/HI, can't take care of themself

12

[Mood Disorders]
Describe ECT
1. Indications
2. Contraindications
3. Procedure
4. Side effects

Electroconvulsive therapy

1. Indications
- MDD - treatment resistant or w psychotic features
- acute mania
- pregnant
- emergency conditions (not eating/drinking, catatonic, actively suicidal)

2. Contraindications - none!
- relative c/i: recent MI or stroke, space-occupying brain lesion, unstably aneurysm

3. Procedure
- atropine, then general anesthesia with methohexital, then muscle relaxant succinylcholine
- induce generalized tonic clonic seizure for 30-60 sec
- 12 treatments over 3 week period or so
- d/c after symptomatic improvement, but can have monthly maintenance ECT

4. Side effects
- retrograde and anterograde amnesia, resolves within 6 months
- also headache, nausea, muscle soreness

*1st line tx for MDD w psychotic features = ECT or antipsychotic + antidepressant

13

[Mood Disorders]
Major depressive disorder
Specifiers -
1. Atypical
2. Melancholic
3. Mixed
4. Catatonia
5. Psychotic
6. Anxious distress
7. Postpartum
8. Seasonal

1. Atypical - hypersomnia, hyperphagia, reactive mood (mood brightens in response to positive events), leaden paralysis, hypersensitivity to interpersonal rejection

2. Melancholic - anhedonia, depression worse in AM, anorexia, excessive guilt

3. Mixed - manic/hypomanic symptoms present during major depressive episode

4. Catatonia - catalepsy (immobility), mutism, bizarre postures, echolalia; give ECT or benzos (lorazepam challenge test --> temporary relief w/in 10 min)

5. Psychotic - delusions/hallucinations

6. Anxious distress - restless, fearful, feeling of loss of control

7. Postpartum - during or within 4 weeks of pregnancy (as opposed to postpartum blues - which resolves w/in 2 weeks)
*give sertraline bc lowest transfer rate to infant

8. Seasonal - irritability, carb craving, and hypersomnia

14

[Mood Disorders]
Bipolar I
1. Criteria
2. Etiology
3. Treatment

Bipolar 1
1. Criteria - manic episode is only requirement (3+ DIGFAST symptoms for at least one week)
- do not need major depressive episode
- can have psychotic features (delusions/hallucinations)

2. Etiology - M=F, onset before 30
- highest genetic link of all major psychiatric disorders
- high suicide risk
- 90% have repeat episode w/in 5 years

3. Treatment - untreated --> lasts months
- pharmacotherapy -
* mood stabilizer (e.g. lithium)
*anticonvulsants (Carbamazepine, valproic acid)
*atypical antipsychotics (for acute mania; use for 6 weeks until Lithium kicks in)
*do NOT give antidepressants, may precipitate mania

- bipolar depression -- quetiapine, lurasidone, lamotrigine
- psychotherapy
- ECT for acute mania

15

[Mood Disorders]
Bipolar II
1. Criteria
2. Etiology
3. Treatment

Bipolar II
1. Criteria - 1+ major depressive episodes and at least one hypomanic episode
*if there is any full manic episode --> automatically bipolar I disorder

2. Etiology - same etiology as bipolar I
- better prognosis than bipolar I

3. Treatment - same as bipolar I
- bipolar depression -- quetiapine, lurasidone, lamotrigine

16

[Mood Disorder]
Criteria for:
1. Dysthymia
2. Cyclothymic disorder

1. Dysthymia
- at least 2 years of depressed mood (1 year in children)
- at least 2 of the following: poor concentration, hopelessness, poor or too much appetite, insomnia/hypersomnia, fatigue, low self-esteem
- never asymptomatic for >2 months
- many also meet criteria for MDD but can not have had manic/hypomanic episode (bipolar/cyclothymic respectively)

2. Cyclothymic disorder
- at least two years of alternating hypomanic symptoms (but not full hypomanic episode) and depressive symptoms (but not full MDE)
- never asymptomatic for >2 months
- no MDE, hypomanic, or manic episode
*may coexist with borderline personality disorder
*1/3 develop bipolar disorder

17

[Mood Disorder]
Criteria for:
3. Premenstrual dysphoric disorder
4. Disruptive mood regulation disorder (DMDD)

3. Premenstrual dysphoric disorder
- 5+ symptoms in the final week before menses and absent by the week postmenses:
* 1+ is affective lability, irritability, depressed mood, anxiety
* 1+ is anhedonia, anergia, appetite changes, hypersomnia/insomnia, overwhelmed, physical (breast tenderness, joint pain, bloating, weight gain)
- symptoms cause distress/impairment
- treatment: keep menstrual diary, exercise, stress reduction, SSRI (eg fluoxetine)

4. Disruptive mood regulation disorder (DMDD) - severe, persistent irritability in childhood and adolescence
- symptoms before age 10, can be diagnosed from ages 6-18
- 2+ settings (home school peers)
- at least 3 verbal and/or physical outbursts per week
- mood bw outbursts is angry/irritable
- symptoms for at least 1 year, no more than 3 months without symptoms
*cannot coexist with oppositional defiant disorder, intermittent explosive disorder, or bipolar disorder

18

Treatment for EPS:
1. Acute dystonia
2. Akathisia
3. Parkinsonism
4. Tardive dyskinesia

EPS - eps with typical antipsychotics (bc of decreased dopamine in nigrostriatal tract)

1. Acute dystonia (muscle spasms/stiffness, torticollis, oculogyric crisis, grimacing) - hours to days --> treat with anticholinergics (e.g. benztropine, diphenhydramine)

2. Akathisia (subjective feeling of restlessness) - days to weeks --> Treat with propranolol, benzos (lorazepam), or benztropine and lower antipsychotic dosage (since it is dose-dependent)

3. Parkinsonism (masklike face, bradykinesia, pill-rolling tremor, cog-wheel rigidity)- days to weeks --> treat with benztropine, amantadine

4. Tardive dyskinesia - (months to years of prolonged therapy, can also appear following dose discontinuation or reduction)
- due to D2 receptor upregulation and supersensitivity following chronic blockade
- irreversible, no definitive treatment, but switch to clozapine may help (least likely to cause EPS), along with Vitamin E or botox

*NMS can occur at any time, usually early on in treatment

19

[Anxiety Disorders]
1. Define pathologic anxiety, signs/sx
2. Substance / medication causes
3. Medical causes
4. Treatment

1. Pathologic anxiety - excessive, irrational, out of proportion to trigger or without trigger
- SOB, chest pain, palpitations, HTN, vertigo, tremors, n/v, stomach pain, diarrhea/constipation

2. Substance / medication causes
A. Withdrawal - sedative-hypnotics (benzos, barbs)
B. Intoxication - marijuana, hallucinogens (PCP, LSD, MDMA), caffeine, opioids
C. Withdrawal and intoxication - stimulants (cocaine), tobacco

3. Medical causes -
- neurologic (brain tumors, MS, HD, epilepsy, migraines)
- endocrine (carcinoid, pheo, hypoglycemia, hyperthyroid)
- metabolic (B12 deficiency, porphyria)
- respiratory (COPD, asthma, PE, pnuemonia)
- cardiovascular (CHF, arrhythmia, MI)

4. Treatment
- first-line - SSRIs, SNRIs
- also benzos, diphenydramine, hydroxyzine - for prn use
*benzos may worsen depression in comorbid MDD
- buspirone (5HT1 partial agonist) - for augmentation
- beta blockers - to control autonomic sx for panic attacks, performance anxiety

20

[Anxiety Disorders]
Criteria and treatment for:
1. Panic disorder
2. Generalized anxiety disorder

1. Panic disorder
A. Criteria - 1+ spontaneous, recurrent panic attacks without trigger followed by 1+ month of continuous worry about experiencing subsequent attacks and/or change in behavior (avoidance)
- panic attack: Da PANICS (dizziness, disconnectedness, derealization/depersonalization, palpitations/paresthesias, abdominal distress, numbness, intense fear of dying, chills/chest pain, sweating/SOB)
- comorbid with MDD and other anxiety disorders esp agoraphobia
- decreased volume of amygdalaa
B. Treatment - SSRIs and CBT
- TCAs are second line
- benzos (lorazepam ie Ativan) for prn or as bridge until long-term meds are effective
- give propranolol for treating autonomic effects of panic attacks (also performance anxiety or akathisia)
- screen for suicide risk
*increased sensitivity to lactate infusion (Causes panic sx)

2. Generalized anxiety disorder
A. Criteria - excessive anxiety/worry about various events for at least 6 months with 3+ symptoms: WARTS (wound-up, worn-out, absent-minded, restless, tense, sleepless)
- comorbid with anxiety/depressive disorders
- begins ~30 years old
B. Treatment - CBT, SSRI/SNRI, short-term benzos, augment with buspirone, exercise

21

[Anxiety Disorders]
Criteria and treatment for:
3. Agoraphobia
4. Phobias / social anxiety disorder

3. Agoraphobia
A. Criteria - intense fear/anxiety about 2+ situations due to fear of difficulty escaping e.g. bridges, crowds, buses/trains, open areas for >6 months
- fear/anxiety out of proportion to potential danger posed
- significant impairment
- frequently following traumatic event, 50% have panic attack prior to onset
B. Treatment - CBT and SSRIs

4. Phobias / social anxiety disorder
A. Criteria - >6 months irrational fear that leads to avoidance of trigger or endurance of anxiety
- specific phobia: environmental, animal, situational, blood/injection
- social anxiety phobia - fear of scrutiny by others or of negative evaluation e.g. public speaking
*most common psych disorder in women, 2nd MC in men (substance is 1st)
B. Treatment - behavioral therapy (systematic desensitization) is first line
- for social anxiety disorder, can give SSRIs (fluoxetine)
- beta blockers (propranolol) for performance anxiety subtype of social anxiety disorder

22

[Anxiety Disorders]
Criteria and treatment for:
5. Selective mutism
6. Separation anxiety disorder

5. Selective mutism
A. Criteria - failure to speak in specific situations, despite speech ability in other situations, for at least 1 month (extending beyond 1st month of school)
- starts in childhood, suffering from anxiety
B. Treatment - CBT, family therapy, SSRIs for comorbid social anxiety disorder

6. Separation anxiety disorder
A. Criteria - >1 month in children, >6 months in adults developmentally inappropriate fear/anxiety re separation from attachment figures with at least 3:
- worry about loss of figures
- reluctance to leave home, be alone, sleep alone
- physical symptoms when separated
- nightmares
*normal devlpt: stranger anxiety (~6-9 mos), separation anxiety (12-18 mos)
B. Treatment - CBT, family therapy, SSRIs

23

Triad of uncontrollable urges seen in children or adolescents

OCD, ADHD, tic disorder

24

[Anxiety Disorders]
Criteria and treatment for:
1. OCD

1. OCD
A. Criteria - obsessions and/or compulsions that are time-consuming (>1 hour/day) or cause significant distress

- obsessions - intrusive, anxiety-provoking thoughts or urges that the patient attempts to suppress, ignore, or neutralize by performing a compulsion e.g. contamination, harm/doubt, symmetry, intrusive taboo thoughts (sexual, violent)
- compulsions - repetitive behaviors or mental acts that the patient feels driven to perform e.g. cleaning, checking, ordering/counting

B. Course - mean age of onset 20 years old
- genetic component
- suicidal ideation in 50%
- structural abnormalities and increased activity of orbitofrontal cortex and caudate nucleus (dorsal striatum of the basal ganglia)

C. Treatment - combo of psychopharm + CBT
- psychopharm - SSRIs at higher doses for longer period (8-12 weeks)
- can also use clomipramine, augment with atypicals
- use cingulotomy for treatment resistant
- CBT - exposure and response prevention

25

[Anxiety Disorders]
Criteria and treatment for:
2. Body dysmorphic disorder
3. Hoarding disorder

2. Body dysmorphic disorder
A. Criteria - preoccupation with perceived defects in physical appearance not observable by others that they try to cover up with makeup, derm procedures, plastic surgery
- repetitive behaviors (grooming, skin picking) or mental acts (comparing appearance) performed in response
- significant distress or impairment
- increased prevalence with childhood abuse and neglect
B. Treatment - SSRIs or CBT to reduces OCD symptoms

3. Hoarding disorder
A. Criteria - persistent difficulty and distress discarding possessions, regardless of value
- impairment in social, occupational other areas of functioning
- begins in early teens but more prevalent in older pts, 3/4 have comorbid MDD or anxiety
B. Treatment - specialized CBT, don't need SSRI unless they also have OCD symptoms

26

[Anxiety Disorders]
Criteria and treatment for:
4. Trichotillomania
5. Excoriation disorder

4. Trichotillomania
A. Criteria - recurrent pulling of ones hair, repeated attempts to stop
- associated with stressful event, onset at puberty
B. Treatment - SSRIs, atypicals, N-acetylcysteine, lithium
- CBT (habit reversal training)

5. Excoriation disorder
A. Criteria - recurrent skin picking resulting in lesions, repeated attempts to stop
- mostly women
B. Treatment - habit reversal training, SSRIs

27

[Anxiety Disorders]
Criteria and treatment for
6. Acute stress disorder, PTSD

6. Acute stress disorder, PTSD
A. Criteria
- recurrent intrusions of reexperiencing event via nightmares, memories, dissociation (e.g. flashbacks)
- active avoidance of triggering
- 2+ of the following negative mood: dissociative amnesia (e.g. forgetting info about own life), negative feelings (fear, anger), self-blame, anhedonia, detachment
- 2+ of increased arousal: hypervigilance, startle, impaired concentration, insomnia

Acute stress disorder - trauma occurred <1 month ago, symptoms last <1 month
PTSD - trauma occurred any time in the past, symptoms last >1 month
- decreased volume of hippocampus

B. Treatment - SSRIs or SNRIs are first line along with trauma-focused CBT (exposure)
- prazosin for nightmares and paranoia
- augment with atypicals
*avoid benzos bc high rate of comorbid substance use disorder

28

[Anxiety Disorders]
Criteria and treatment for
7. Adjustment disorder

7. Adjustment disorder

A. Criteria - development of marked distress in excess of what would be expected within 3 months of identifiable stressful life event (not life-threatening --> PTSD)
- resolve within 6 months after stressor has terminated
- subtypes - depressed mood, anxiety, disturbance of conduct (eg aggression), mixed
- does not meet criteria for MDD or another disorder

B. Treatment - supportive psychotherapy *most effective*
- group therapy, pharmacotherapy
*may be chronic if stressor is chronic or recurrent

29

[Personality Disorders]
1. Criteria
2. Clusters
3. Treatment

Personality disorders
1. Criteria - pervasive, inflexible, maladaptive behavior/inner experience that deviates from culture and manifests in 2+ ways:
*cognition e.g. orphan annie
*affectivity e.g. john mcenroe
*interpersonal functioning e.g. elizabeth taylor
* impulse control e.g. lindsay lohan
- stable, onset during adolescence / early adulthood --> diagnose after age 18
- ego-syntonic (pts lack insight)

2. Clusters
Cluster A - Weird
- schizotypal, schizoid, paranoid
Clubster B - Wild
- borderline, antisocial, histrionic, narcissistic
Cluster C - Worried
- avoidant, dependent, OCPD

3. Treatment - psychotherapy e.g. CBT except borderline --> DBT

30

[Personality Disorders]
Cluster A
1. Paranoid

Cluster A
1. Paranoid - pervasive distrust and suspiciousness of others and blame problems on others with 4+ of following:
- suspicion others are cheating them
- preoccupation with loyalty
- reluctance to confide in others
- holds grudges
- perception of attacks on character
- think spouse is cheating on them (pathologically jealous)

defense mechanism --> projection
*can have transient psychosis under stressful situations
*avoid group psychotherapy