Flashcards in Psychiatry Deck (235)
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. Pavlov's classical experiments with dogs- ringing the bell provoked salivation.
Learning in which a particular action is elicited because it produces a punishment or reward. Usually deals with voluntary responses.
A type of operant conditioning. A desired reward produces action (mouse presses button to get food).
A type of operant conditioning. A target behavior (response) is followed by removal of averse stimulus (mouse presses button to turn off continuous loud noise).
A type of operant conditioning. repeated application of aversive stimulus extinguishes unwanted behavior.
A type of operant conditioning. Discontinuation of reinforcement (positive or negative) eventually eliminates behavior. It can occur in operant or classical conditioning.
Patient projects feelings about formative or other important person onto physician (eg psychiatrist is seen as parent).
Doctor projects feeling about formative or other important persons onto patient (eg patient reminds physician of younger sibling).
Unconscious mental processes used to resolve conflict and prevent undesirable feelings (eg. anxiety and depression).
Expressing unacceptable feelings and thoughts through actions. For example, tantrums.
Avoiding the awareness of some painful reality. For example, a common reaction in newly diagnosed AIDS and cancer patients.
Transferring avoided ideas and feelings to a neutral person or object (vs projection). For example, a mother yells at her child, because her husband yelled at her.
Temporary, drastic change in personality, memory, consciousness, or motor behavior to avoid emotional stress. For example, extreme forms can result in dissociative identity disorder (multiple personality disorder).
Partially remaining at a more childish level of development (vs regression). For example, adults fixating on video games.
Modeling behavior after another person who is more powerful (though not necessarily admired). For example, abused child identifies with an abuser.
Isolation of affect
Separating feeling from ideas and events. For example, describing murder in graphic detail with no emotional response.
Expressing negativity and performing below what is expected as an indirect show of opposition. For example, disgruntled employee is repeatedly late to work.
Attributing an unacceptable internal impulse to an external source (vs displacement). For example, a man who wants another woman thinks her wife is cheating on him.
Proclaiming logical reasons for actions actually performed for other reasons, usually to avoid self-blame. For example, after getting fired, claiming that the job was not important anyway.
Replacing a warded off idea or feeling by an (unconsciously derived) emphasis on its opposite (sublimation). For example, a patient with libidinous thoughts enters a monastery.
Turning back the maturational clock and going back to earlier modes of dealing with the world (vs fixation)
Involuntarily withholding and idea or feeling from conscious awareness. For example, a 20 year old does not remember going to counseling during his parents' divorce 10 years earlier.
Believing that people are either all good or all bad at different times due to intolerance of ambiguity. It is commonly seen in borderline personality disorder. For example, a patient says that all the nurses are cold and insensitive but that the doctors are warm and friendly.
A mature defense. Alleviating negative feelings via unsolicited generosity. For example, mafia boss makes large donation to charity.
A mature defense. Appreciating the amusing nature of an anxiety-provoking or adverse situation. For example, nervous medical student jokes about the boards.
A mature defense. 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). For example, teenager's aggression toward his father is redirected to perform well in sports.
Intentionally withholding an idea or feeling from conscious awareness (vs repression); temporary. For example, choosing to not worry about the big game until its time to play.
Altruism, humor, sublimation, and suppression. Mature adults wear a SASH.
Infant deprivation effect
Long term deprivation of affection in infants results in crying or Wah, Wah, Wah, Wah: Weak: decreased muscle tone, weight loss, and physical illness. Wordless: poor language skills and anaclitic depression. Wanting: poor socialization skills. Wary: lack of basic trust. Anaclitic depression or hospitalism is depression in an infant attributable to continued separation from a caregiver resulting in withdrawn and unresponsive infants. Deprivation greater than 6 months can lead to irreversible changes or even death
Physical child abuse
Physical child abuse can present with: Healed fractures on x-ray, Cigarette burns, Subdural hematomas, Multiple bruises, Retinal hemorrhage or detachment, Spiral fractures, Skin lesions (most common sign of child abuse), Avoidance of eye contact during examination. Active physical abuse is usually inflicted by the mother (or primary care-giver if not the mother). Physical child abuse typically occurs in children less than 3 years old. Any signs of child abuse must be reported to authorities.
Sexual child abuse
Sexual child abuse may present as: Oral trauma, Genital trauma, Anal trauma, Sexually transmitted diseases, Urinary tract infections. The abuser is usually male and is known to the victim. Peak incidence is between 9-12 years of age.
Failure to provide a child with adequate food, shelter, supervision, education, and/or affection. It is the most common form of child maltreatment. Evidence includes poor hygiene, malnutrition, withdrawal, impaired social/emotional development, failure to thrive. As with child abuse, child neglect must be reported to local child protective services.
Attention Deficit Hyperactivity Disorder (ADHD)
Attention Deficit Hyperactivity Disorder (ADHD) is characterized by: Inattention: problems with listening, concentrating, paying attention to details, organizing tasks, easily distracted, or often forgetful. Hyperactivity and Impulsivity: blurting out answers, interrupting, fidgeting, and talking excessively. The onset of ADHD is before age 12. The patient's behavior is inconsistent with their age or development. Children with ADHD often have normal intelligence. ADHD is associated with decreased frontal lobe volume. Two thirds of children with ADHD also have conduct disorder or oppositional defiant disorder. The treatment of ADHD includes: CNS stimulants (methylphenidate, dextroamphetamine) +/- cognitive behavioral therapy. Non-stimulants such as norepinephrine reuptake inhibitors (atomoxetine)
Tourette’s Disorder is characterized by both motor and vocal tics lasting for more than 1 year. Tourette's disorder must be diagnosed prior to age 18, and usually presents around 7-8 years of age. The incidence is three times greater in boys. Vocal tics may appear years after motor tics and can include: Coprolalia is the repetition of curse words (not necessarily made by another person) and tends to be uncommon. Echolalia is the repetition of words made by another person. There is a genetic relationship of Tourette's Disorder to attention deficit hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD). First line treatments for Tourette's disorder includes psychoeducation and behavioral therapy. Treatment for the intractable tics of Tourette's disorder includes: Low-dose, high-potency antipsychotics (e.g. fluphenazine, pimozide, haloperidol); Tetrabenazine (VMAT inhibitor); Clonidine (α2 agonist)
Conduct Disorder is characterized by a pattern of behavior that involves violation of basic rights of others. Behaviors may include: Aggression towards people or animals; Destruction of property; Deceitfulness. There is an increased incidence of ADHD, learning disorders, substance abuse, and criminal behavior in children with conduct disorder. After age 18, conduct disorder is considered antisocial personality disorder.
Oppositional defiant disorder
Oppositional defiant disorder is characterized by at least 6 months of disobedient and defiant behavior toward authority figures. Children with oppositional defiant disorder do not violate social norms with violence or crime, which differentiates this disorder from conduct disorder. At least 4 of the following are present in oppositional defiant disorder: Frequent loss of temper, Arguments with adults, Defying rules set by adults, Deliberately annoying people, Being easily annoyed, Anger and resentment, Spitefulness, Blaming others for mistakes.
Separation anxiety disorder
Separation anxiety disorder is characterized by excessive anxiety concerning separation from home or from those to whom the individual is attached. When forced to separate, children with separation anxiety disorder worry about losing their parents forever and try to avoid separation by feigning physical complaints. It commonly occurs at 7-8 years of age after a stressful life event such as the birth of a new sibling, moving out of a house, or starting a new school. Treatment of separation anxiety disorder includes: SSRIs, Behavioral therapy, Play therapy, Family therapy
Pervasive developmental disorders
Characterized by difficulties with language and failure to acquire or early loss of social skills. Includes autism spectrum disorder and Rett syndrome
Autism spectrum disorder (ASD)
Autism spectrum disorder (ASD) is characterized by: Impaired social interaction (reduced empathy, reduced interest in socialization), Impaired communication (inability to understand social cues and nonverbal messages), Repetitive/stereotyped patterns of behavior (fixated interests, inflexibility to change), According to DMS-V, ASD symptoms must be present by "early development" (previous DSM-IV timeframe was age 3). Individuals with autism spectrum disorder may have increased serotonin levels. Neuroanatomical findings in autism spectrum disorder include increased cortical thickness and increased total brain volume.
Rett syndrome is an X-linked disorder marked by regression in physical and psychomotor development after around 6 months of normal development. This is an important distinguishing factor when compared to autism spectrum disorder. Rett syndrome is predominantly seen in girls, since affected males die in utero. The classic description of Rett syndrome is stereotyped hand-wringing movements. Associated with the de novo mutations of the MECP2 gene on the X chromosome.
Changes of neurotransmitters with Alzheimer disease
ACh decreases, glutamate increases
Changes of neurotransmitters with anxiety
Norepinephrine increases, GABA decreases, 5-HT decreases.
Changes of neurotransmitters with depression
Norepinephrine decreases, 5-HT decreases.
Changes of neurotransmitters with Huntington disease
GABA decreases, ACh decreases, dopamine increases
Changes of neurotransmitters with Parkinson disease
Dopamine decreases, ACh increases
Changes of neurotransmitters with Schizophrenia
Orientation refers to the ability of a patient to know who she or he is, what date and time it is, and what his or her present location and circumstance are (Oriented x 3 = person, place, time). Order of loss of orientation is as follows: 1st time → 2nd place → 3rd person. Several common causes of loss of orientation include (among others): Alcohol intoxication, Drug overdose, Electrolyte imbalance, Trauma, Hypoglycemia, Infection
Retrograde Amnesia is defined as the inability to remember things that occurred before a CNS insult resulting in an inability to recall previously formed memories.
Anterograde Amnesia is defined as the inability to remember things that occurred after a CNS insult resulting in difficulty forming new memories
Dissociative Amnesia is defined as the inability to remember significant personal information, usually a result of severe trauma or stress. Dissociative fugue is characterized by reversible amnesia for personal identity, including memories, and personality; it is associated with unplanned travel or wandering. After recovery from fugue, previous memories usually return intact; however, during the fugue episode, there is complete amnesia.
Korsakoff’s Amnesia is a form of anterograde amnesia (and if severe, retrograde amnesia as well) that is caused by thiamine deficiency. In Korsakoff's amnesia, chronic insult leads to bilateral destruction of the mammillary bodies. Korsakoff's amnesia is classically seen in alcoholics and associated with confabulations.
Delirium is a disorder of impaired cognitive functioning with a hallmark of waxing and waning level of consciousness (DeliRIUM = changes in sensoRIUM). Delirium often is characterized by visual hallucinations, which are rare in dementia. Delirium usually has an abnormal EEG, which distinguishes it from dementia. Delirium is the most common psychiatric condition in patients treated in medical hospital units. Causes of delirium (AEIOU TIPS): Alcohol; Electrolytes; Iatrogenic (anticholinergics, anticonvulsants, antihypertensives, anti-Parkinson drugs, antibiotics, benzodiazepines, disulfiram, H2 receptor blockers, hypoglycemics, insulin, narcotics, NSAIDs, steroids); Oxygen hypoxia (bleeding, pulmonary disease, carbon monoxide poisoning); Uremia and hepatic encephalopathy; Trauma; Infection (especially urinary tract infection); Poisons; Seizures (post-ictal). The 1st line treatment of delirium is antipsychotics. The underlying cause must be treated as well after acute stabilization. (The only type of delirium treated by benzodiazepines is delirium tremens)
Dementia is a disorder of impaired memory and gradual decrease in cognitive functions. The hallmark characteristic is cognitive deficit with normal consciousness. (DeMEntia = MEmory loss). Dementia usually has an insidious onset, while delirium has an acute onset. Delirium is typically reversible, while dementia is most often not. The most common type of dementia is Alzheimer disease. It is a clinical diagnosis that can only be truly confirmed after death by autopsy. Vascular dementia is characterized by focal neurological deficits. Pick disease is characterized by pronounced personality changes and inappropriate behavior. Lewy body dementia is characterized by Lewy bodies in the cortex (as opposed to being confined to the substantia nigra in Parkinson's). Consider Lewy body dementia when the patient experiences visual hallucinations and Parkinsonism (resting tremor, bradykinesia, etc.). Normal pressure hydrocephalus is a potentially reversible cause of dementia. Suspect it when a patient also has ataxia and incontinence. Treatment of dementia involves ruling out reversible causes like normal pressure hydrocephalus and pseudodementia. Cholinergic agonists such as donepezil, galantamine, and rivastigmine may be used to slow cognitive decline, but ultimately cannot reverse or stop the disease.
A distorted perception of reality characterized by delusions, hallucinations, and/or disorganized thinking. Psychosis can occur in patients with medical illness, psychiatric illness, or both.
Hallucination is defined as a perception in the absence of an external stimulus.
Unique, false beliefs about oneself or others that persist despite the facts (eg thinking aliens are communicating with you)
Words and ideas are strung together based on sounds, puns, or loose associations.
Visual hallucinations are common in delirium (medical illnesses).
Auditory hallucinations may be present in psychiatric illnesses: Schizophrenia, Cocaine intoxication, Alcohol withdrawal, Sleep deprivation
Olfactory hallucinations often occur as an aura of psychomotor epilepsy or as a result of a brain tumor.
Tactile hallucinations (e.g. formication - the sensation of ants crawling on one's skin) can occur in patients experiencing severe alcohol withdrawal (delirium tremens) as well as in cocaine and amphetamine users.
HypnaGOgic hallucinations occur just as an individual GOes to sleep.
HypnoPOMPic hallucinations occur just as an individual wakes up (POMPous upon wakening).
Schizophrenia is a mental disorder characterized by psychotic episodes and decline in functioning that can be diagnosed after 6 months of schizophrenic symptoms. Schizophrenia is characterized by both “positive” and “negative” symptoms. Schizophrenia is associated with decreased dendritic branching. Lifetime prevalence of schizophrenia is 1.5% with equal rates in males and females and whites and blacks. Schizophrenia presents earlier in men (late teens to early 20s) as compared to women. Those born during the winter have a higher incidence of schizophrenia. Frequent cannabis use is associated with schizophrenia in teens. Patients with schizophrenia have a high risk of suicide.
Negative symptoms of schizophrenia
Negative symptoms of schizophrenia are “subtracted” from a normal person’s behavior. They include: Flattening of affect, Thought blocking (sudden halt in train of thought), Deficiencies in speech content, Cognitive disturbances, Poor grooming, Lack of motivation, Social withdrawal. Negative symptoms of schizophrenia are associated with decreased dopaminergic activity in the mesocortical pathway.
Positive symptoms of schizophrenia
Positive symptoms of schizophrenia include Delusions, Hallucinations, Disorganized speech (e.g., loose associations), Disorganized or catatonic behavior (immobility and unresponsive to environment. They are associated with increased dopaminergic activity in the mesolimbic pathway.
Diagnosis of schizophrenia
Diagnosis of schizophrenia requires at least two of the following: Delusions, Hallucinations, Disorganized speech (e.g., loose associations), Disorganized or catatonic behavior (immobility and unresponsive to environment), Presence of negative symptoms.
Treatment of schizophrenia
The mainstay treatment of schizophrenia centers around typical and atypical antipsychotics . Atypical antipsychotics are better suited to treat the negative symptoms of schizophrenia.
Brief psychotic disorder
Brief psychotic disorder is an unprecedented episode of psychosis lasting more than a day but
Schizophreniform disorder is an episode of psychosis lasting less than 6 months but greater than 1 month.
Schizoaffective disorder is a disorder characterized by psychosis associated with a mood disorder, such as mania or depression. Schizoaffective disorder is distinguished from major depressive disorder (MDD) with psychosis in the following way: Schizoaffective is psychosis with intermittent mood disorders. Psychosis in the absence of a mood disorder rules out MDD. MDD with psychosis is a constant mood disorder with intermittent psychosis.
Delusional disorder can appear similar to schizophrenic delusions. It is characterized by a fixed, non-bizarre delusional system and few if any other thought disorders. An important difference for diagnosis is that individuals with delusional disorder have relatively normal social and occupational functioning.
Dissociative identity disorder
Dissociative identity disorder (multiple personality disorder) is defined by 2 or more distinct personalities within a single patient. The classic description is a patient who receives photos of his/herself doing things the patient doesn't remember, with people the patient doesn't know. Most patients have experienced prior trauma, especially child abuse.
Depersonalization disorder is characterized by feelings of detachment from oneself or one’s environment. Transient depersonalization may occur during periods of severe stress, but this disorder is defined by persistent depersonalization that causes social/occupational distress.
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. Types includes major depressive disorder, bipolar disorder, dysthymic disorder, and cyclothymic disorder. Episodic superimposed psychotic features (delusions or hallucinations) may be present.
A manic episode
A manic episode is a distinct period of abnormally and persistently elevated, expansive, or irritable mood lasting at least one week (or any duration requiring hospitalization). During the mood disturbance, three or more of the following are present. Use the DIG FAST mnemonic: Distractibility, Irresponsible and erratic behavior, Grandiosity (inflated self-esteem), Flight of ideas (racing thoughts), Activity is increased and goal directed, Sleep (decreased need), Talkativeness or pressured speech.
A hypomanic episode
A hypomanic episode is similar to manic episode except the mood disturbance must last at least four days and is not severe enough to cause marked impairment in social and/or occupational functioning or to necessitate hospitalization; there are no psychotic features.
Bipolar Disorder involves a spectrum of manic and depressive symptoms. In bipolar disorder, cycles between depressive episodes and manic episodes last between 6-9 months and become shorter as the illness progresses. If untreated, a manic episode lasts approximately 3 months. Patients with bipolar disorder have a high risk of suicide.
Bipolar Disorder I
Bipolar Disorder I requires at least one episode of mania with or without a hypomanic or depressive episode. Many patients with Bipolar I have also experienced a major depressive episode, but this is not required for diagnosis.
Bipolar Disorder II
Bipolar Disorder II requires episodes of both hypomania and a major depressive episode.
Cyclothymic disorder is a mild form of bipolar disorder with dysthymia and hypomania lasting at least 2 years.
Treatment of bipolar disorder
First line medications for maintenance therapy of bipolar disorder include: Lithium, Valproic acid, Carbamazepine, Atypical antipsychotics (e.g., risperidone). Acute mania is treated with atypical antipsychotics (olanzapine, quetiapine, ziprasidone). In a misdiagnosed individual with bipolar disorder, antidepressants may trigger a manic episode.
Major Depressive Disorder (MDD)
Major Depressive Disorder (MDD) is marked by episodes of depressed mood associated with loss of interest in daily activities. MDD is characterized by at least 5 of the following for 2 weeks with either depressed mood or anhedonia (SIG E CAPS): Sleep disturbance, Interest loss (anhedonia), Guilt or feelings of worthlessness, Energy loss, Concentration or Cognitive deficits, Appetite loss, Psychomotor retardation or agitation, Suicidal ideations. Lifetime prevalence of major depressive episode is 5-12% for males and 10-25% for females. Recurrent major depressive disorder requires 2 or more depressive episodes with a symptom-free interval of 2 months. If major depressive disorder is untreated, it can last 6-12 months; with treatment, an episode resolves in approximately 3 months. First line treatment for depression is selective serotonin reuptake inhibitors (SSRIs) because they have limited side effects.
Persistent depressive disorder
Persistent depressive disorder is depression lasting at least 2 years.
Sleep changes that occur in MDD
There are several sleep changes that occur in MDD, including: Decreased REM sleep latency, Increased total REM sleep, Decreased slow wave sleep, Early morning awakenings
Atypical Depression is a separate form of depression, which is characterized by: Mood reactivity, Hypersomnia, Weight gain, Leaden paralysis (arms and legs feel heavy), Rejection sensitivity. Atypical depression is treated with SSRIs, Cognitive Behavioral Therapy (CBT) and MAO Inhibitors.
Electroconvulsive Therapy (ECT)
Electroconvulsive Therapy (ECT) is an electrically induced painless seizure under anesthesia. It is used to treat Mania, Catatonia (motor immobility), Major depressive disorder refractory to pharmacotherapy, Acute suicidality. ECT is usually administered in 8 treatments over a 2-3 week period, but major improvements are seen after the 1st treatment. ECT is safe to use in patients who may not tolerate the side effects of antidepressant medications, including the elderly and pregnant women. Major adverse effects of ECT include: Disorientation, Anterograde amnesia, Retrograde amnesia
Postpartum mood disturbances
Postpartum mood disturbances are depressive-like symptoms that occur within 4 weeks of delivery of an infant. The three types of postpartum mood disturbances include: Postpartum "blues", Postpartum depression, Postpartum psychosis
Postpartum "blues" are characterized by: Depressed affect, Tearfulness, Fatigue, Mild anxiety. The incidence rate of postpartum "blues" is 50-85%. The symptoms of postpartum blues usually appear 2-3 days after delivery and resolve within 10 days. The treatment of postpartum blues is supportive and follow-up is necessary.
Postpartum depression is characterized by: Depressed affect, Moderate-to-severe anxiety, Poor concentration, Hopelessness, Fatigue, Anhedonia. The incidence rate of postpartum depression is 10-15%. Postpartum depression starts within 4 weeks after delivery and lasts 2 weeks to a year or more. Treatment of postpartum depression includes antidepressants (SSRIs or TCAs) and psychotherapy.
Postpartum psychosis is characterized by: Delusions, Hallucinations, Confusion, Homicidal or suicidal ideations/attempts. The incidence rate of postpartum psychosis is 0.1-0.2%. Postpartum psychosis may last from days to 4-6 weeks. Treatment of postpartum psychosis includes: Antipsychotics, Antidepressants, Inpatient hospitalization
To be considered pathologic grief must meet one or more of the following criteria: Lasts >6 months, Includes psychotic symptoms (e.g. delusions), Meets major depressive criteria (such as weight loss, passive death wish, etc.). Other signs of pathologic grief include: Feelings of worthlessness, Suicidal ideation, Severe symptoms over 2 months
Risk factors for suicide
Risk factors for suicide completion can be remembered with the mnemonic: “SAD PERSONS”: Sex (male), Age (elderly over 65 and teenagers 15-24), Depression, Previous attempt, Ethanol or drug use, Rational thinking lost, Sickness (medical illness or 3 or more prescription medications), Organized plan/Ownership of firearm, No spouse (divorced, widowed, or single, especially if childless), Social support lacking. Men successfully commit suicide three times more often than women, although women attempt suicide four times more often than men.
An anxiety disorder is defined as excessive fear or worry, with physical manifestations of anxiety, which occur secondary to a source which is insufficient to account for the severity of the symptoms. In an anxiety disorder, the symptoms interrupt daily functioning. Anxiety disorders are more common in women. There are several types of anxiety disorders which include: Generalized Anxiety Disorder (GAD), Adjustment Disorder, Phobias, Panic Disorder, PTSD. Treatment inlcudes CBT, SSRIs, SNRIs.
Generalized anxiety disorder
Generalized anxiety disorder is persistent anxiety lasting 6 months or more in which the symptoms are not related to a specific person or situation (i.e., free-floating anxiety). Symptoms of generalized anxiety disorder include: Sleep disturbance, Fatigue, Difficulty concentrating, GI disturbance. First-line treatments for generalized anxiety disorder include: Cognitive behavioral therapy, SSRIs, SNRIs. Second-line treatments for generalized anxiety disorder include: Buspirone, TCAs, Benzodiazepines
Panic disorder is characterized by recurrent panic attacks that are followed by 1 month or more of at least one of the following: Continual concern about having another attack; Worrying about the consequences of the panic attacks; Maladaptive behavioral change in response to the attacks (e.g. behaviors designed to avoid having future panic attacks, such as uncomfortable situations). The symptoms of a panic attack have an abrupt onset, with symptoms peaking within 10 minutes. In a panic attack, each attack has no clear circumscribed stimulus (phobia related to a item) with a phobic-level reaction, whereas in phobias, there is a clear stimulus for the reaction. Symptoms of a panic attack include: Great apprehension and fear; Palpitations, trembling, sweating; Abdominal pain; Parasthesias; Fear of dying; "Going crazy" or loss of control; Hyperventilation, "air hunger"; Sense of unreality. Panic disorder can ultimately lead to agoraphobia. Treatment options for panic disorder include: Cognitive Behavioral Therapy (CBT), SSRIs, SNRIs, Benzodiazepines.
A specific phobia is an excessive fear that is unreasonable and interferes with normal routine. The phobia is stimulated by the presence or anticipation of a specific object or situation, thereby causing the affected person to avoid that specific object or situation. The affected person recognizes that the fear is excessive (i.e. insight), yet the exposure provokes an anxiety response. Specific phobia is the first and second most common mental health problem in men and women, respectively. Behavioral treatment for specific phobia is systematic desensitization.
Agoraphobia is defined as the fear of being in a public place or situation from which escape may be difficult.
Social anxiety disorder
Social anxiety disorder is diagnosed when a person has an excessive fear of embarrassment in social situations (e.g. public speaking, using public restrooms). Social anxiety disorder is treated with SSRIs or CBT.
Obsessive-compulsive disorder (OCD)
Obsessive-compulsive disorder (OCD) is characterized by anxiety provoking ideas, images, or impulses (obsessions) and urges to do something that will lessen that anxiety (compulsions). Obsession is an insuppressible, recurrent and persistent thoughts that cause marked anxiety, in which the patient realizes the thoughts are products of his or her own mind. Compulsions are repetitive behaviors in response to the obsession, aimed at reducing distress. OCD is ego-dystonic, where the person has recognized that the obsessions or compulsions are excessive or unreasonable. In contrast to the ego-dystonic nature of OCD, Obsessive Compulsive Personality Disorder is ego-syntonic, where the patient does not recognize that their behavior is excessive or unreasonable. The rate of OCD is higher in patients with first-degree relatives who have Tourette’s disorder. Treatment of OCD includes: Behavioral therapy (exposure and response prevention therapy), SSRIs (fluoxetine or fluvoxamine), TCAs (clomipramine)
Body dysmorphic disorder
Body dysmorphic disorder is characterized by normal-appearing patients who believe they are physically abnormal. Onset of body dysmorphic disorder is usually in the late teens.
Adjustment disorder is emotional symptoms, causing social, school, or work impairment, that occurs within 3 months of a stressful life event (i.e.: divorce, moving, serious illness). Adjustment disorder usually lasts less than 6 months. If the stressor is chronic, adjustment disorder may last more than 6 months. Treatment for adjustment disorder involves SSRIs and Cognitive Behavioral Therapy (CBT).
Post-Traumatic Stress Disorder (PTSD)
Post-Traumatic Stress Disorder (PTSD) is characterized by: Emotional symptoms (fear, helplessness, horror), Intrusive memories of the event (nightmares, flashbacks), Guilt, Dissociative symptoms (depersonalization, derealization),which occurs after a physiologic or psychological traumatic event. The presence of PTSD leads to avoidance of stimuli associated with the trauma and persistently increased arousal. PTSD symptoms last greater than one month and cause distress or social/occupational impairment. Treatment for PTSD includes psychotherapy and antidepressants (SSRIs).
Acute stress disorder
Acute stress disorder is characterized by the same symptoms as PTSD. However, it lasts from 2 days to 4 weeks, which differentiates it from PTSD.
Malingering is the conscious simulation of physical illness for financial or other obvious external gain (avoiding work, obtaining drugs). In malingering, complaints cease after gain (as opposed to factitious disorder). Patients who malinger do so for secondary gain.
Factitious disorders are conditions where the patient consciously simulates physical or psychiatric illness. People with factitious disorders seek attention for primary gain.
Factitious disorder imposed on self
In Factitious disorder imposed on self (formerly Munchausen syndrome), patients present with physical signs and symptoms that are vague in nature and have a history of multiple hospital admissions and excessive willingness to receive invasive procedures.
Factitious Disorder imposed on others (formerly Munchausen syndrome by proxy) presents with simulation of illness in another person, typically in a child by a parent. The motivation is to assume a sick role by proxy (they fulfill their need for attention and support by feigning symptoms in others). Factitious Disorder imposed on others is a form of child abuse and must be reported to a child protection agency.
Somatic symptom and related disorders are disorders
Somatic symptom and related disorders are disorders in which patients have physical complaints secondary to unconscious drives that cause emotional distress. The complaints occur in the absence of an identifiable physical cause. For example, a patient with a Somatic symptom or related disorder may present with ongoing abdominal pain that has been refractory to numerous medical treatments, causing significant distress to the patient. In somatic symptoms and related disorders, the patient does not knowingly or purposefully produce their symptoms. These disorders are common in women.
Somatic symptom disorder
Somatic symptom disorder is defined as having somatic symptoms (such as pain, GI complaints, sexual complaints, etc.), with or without co-occurring illness, that are either distressing to the patient or disrupt functioning in the patient.
Conversion disorder is characterized by the sudden loss of sensory or motor function, sometimes following an acute stressor. Conversion disorder is more common in adolescents and young adult women.
Illness anxiety disorder
Illness anxiety disorder (aka hypochondriasis) is an exaggerated concern with having a serious illness, without actually having symptoms. Patients with illness anxiety disorder are excessively preoccupied with having a serious illness, even in the face of medical evidence to the contrary. Pseudocyesis, or “false pregnancy,” is based on the patient’s belief that they are pregnant when in reality they are not.
A personality trait is defined as an enduring pattern of perceiving, relating to, and thinking about the environment and oneself that is exhibited in a wide range of important social and personal contexts.
A personality disorder is an inflexible and maladaptive pattern of behavior, causing impairment in social or occupational functioning or subjective distress. The person with a personality disorder is usually not aware of their problem. A personality disorder usually presents by early adulthood. The following personality disorders are more commonly seen in men: Schizoid personality disorder, Paranoid personality disorder, Antisocial personality disorder, Obsessive-compulsive personality disorder. The following personality disorders are more commonly seen in women: Histrionic personality disorder, Borderline personality disorder, Avoidant personality disorder, Dependent personality disorder.
Cluster A Personality Disorders
Cluster A Personality Disorders are a group of disorders with hallmarks of eccentric or odd behavior with inability to develop social relationships (they are “Weird” or Accusatory, Aloof, and Awkward). Cluster A personality disorders have a genetic association with schizophrenia.
Paranoid personality disorder
Cluster A personality disorder. Paranoid personality disorder is characterized by: Suspiciousness, Distrustful of others, Attributes responsibility for problems to others, Projection is the main defense mechanism.
Schizoid personality disorder
Cluster A personality disorder. Schizoid personality disorder is characterized by: Lifelong pattern of voluntary social withdrawal, Limited emotional expression, Unlike avoidant personality disorder, schizoid is content with social isolation, schizoiD=Distant
Cluster A personality disorder. Schizotypal personality disorder is characterized by: Peculiar appearance, Odd thought patterns, Magical thinking, Interpersonal awkwardness. schizoTypal=magical Thinking.
Cluster B personality disorders
Cluster B Personality Disorders are characterized by emotional, dramatic or erratic behavior (they are “Wild” or Bad to the Bone). Cluster B personality disorders have a genetic association with mood disorders and substance use disorder.
Histrionic personality disorder
A cluster B personality disorder. Histrionic personality disorder is characterized by the following behaviors: Dramatic, Extroverted, Emotional, Sexually provocative and attention seeking behavior, Overly concerned with appearance, Inability to maintain intimate relationships
Narcissistic personality disorder
A cluster B personality disorder. Narcissistic personality disorder is characterized by: Grandiosity, Envy, Sense of entitlement, Lack of empathy, Reacts to criticism with rage, Demands "top" physician, best health care
Antisocial personality disorder
A cluster B personality disorder. Antisocial personality disorder is characterized by: Inability to conform to social norms, Criminality, Disregard for and violation of rights of others. It is diagnosed as conduct disorder if the patient is less than 18 years old.
Borderline personality disorder
A cluster B personality disorder. Borderline personality disorder is characterized by: Unstable mood, behavior and interpersonal relationships; Suicide attempts; Boredom, emptiness, and loneliness; Impulsiveness. Splitting is the major defense mechanism used.
Cluster C Personality Disorders
Cluster C Personality Disorders are hallmarked by characteristics of fearful or anxious behavior (they are “Worried” or Cowardly, Compulsive, and Clingy). Cluster C personality disorders share a genetic association with anxiety disorders.
Avoidant personality disorder
Avoidant personality disorder is characterized by: Shy, sensitive to rejection; Socially withdrawn; Feelings of inadequacy, inferiority complex; Desires relationship with others (vs. schizoid personality disorder).
Obsessive-compulsive personality disorder
Obsessive-compulsive personality disorder is characterized by: Orderly, stubborn; Perfectionist; Misnomer because there are no obsessions nor compulsions; Preoccupation with control; Ego-syntonic (patient does not believe they have a problem), unlike OCD patients that are ego-dystonic (patient realizes their behaviors are not acceptable)
Dependent personality disorder
Dependent personality disorder is characterized by: Lack of self-confidence, Submissive, Clingy, Lets others assume responsibility.
Keeping "schizo-" straight
From least to most: schizoid, schizotypal (schizoid plus odd thinking), schizophrenic (greater odd thinking), schizoaffective (schizophrenic psychotic symptoms plus bipolar or depressive mood disorder). Schizophrenia time course: under a month there are brief psychotic disorder, usually stress related. From 1-6 months schizophreniform disorder. Over 6 months is schizophrenia.
Anorexia nervosa is an eating disorder characterized by the following: BMI under 18.5, Restriction of energy intake, Significantly low body weight, Intense fear of gaining weight or persistent behavior that interferes with weight gain, Distorted view of one's own weight, shape, or body image, Excessive exercising, May or may not be associated with purging. Anorexia nervosa is associated with several complications, including: Osteoporosis and metatarsal stress fractures, Amenorrhea, Anemia, Electrolyte disturbances (e.g. hypokalemia, hyponatremia), Lanugo (fine body hair). Anorexia nervosa is seen predominantly in females. Anorexia nervosa commonly coexists with depression. Initial treatment for severe anorexia nervosa initially involves hospitalization to restore a good nutritional status. Other treatment options for anorexia include antidepressants (e.g. mirtazapine due to weight gain side effects) and family therapy.
Bulimia nervosa is an eating disorder characterized by binge eating, with or without purging, often followed by abuse of laxatives, diuretics, or enemas. Body weight in bulimia nervosa is usually normal or slightly overweight. Bulimia nervosa may have several complications including: Esophageal tears (Mallory-Weiss syndrome) and rupture (Boerhaave syndrome); Dental caries; Inflammation of parotid glands; Electrolyte disturbances (e.g. hypokalemia, hypochloremia); Menstrual irregularities; Metabolic alkalosis; Dorsal hand calluses from inducing vomiting (Russell’s sign). Bulimia nervosa is most often seen in adolescent females. Treatment of bulimia nervosa may include the following: CBT, Dietician to provide nutritional education, Family therapy, Antidepressants (e.g. TCAs, SSRIs, MAOIs). When selecting an antidepressant for patients with bulimia nervosa, clinicians should avoid bupropion, as it is contraindicated due to a higher risk of seizures in people with bulimia nervosa.
Gender dysphoria is defined by strong cross-gender identification. It is not considered a sexual disorder. Transsexualism is defined as someone who desires to live as the opposite sex. Transvestism is defined as someone who wears clothes of the opposite sex. It is not considered gender dysphoria.
Transsexualism is defined as someone who desires to live as the opposite sex.
Transvestism is defined as someone who wears clothes of the opposite sex. It is not considered gender dysphoria.
Sexual dysfunction refers to any problem that prevents an individual from experiencing satisfaction from sexual activity. The two broad categories of sexual dysfunction are physical and psychological. Physical causes of sexual dysfunction include: Diabetes/vascular disease, Neurologic disorders, Endocrine dysfunction, Alcoholism/drug abuse. Psychological causes of sexual dysfunction include: Stress and anxiety (including performance anxiety), Depression, History of sexual trauma
Sleep terror disorder
Sleep terror disorder is characterized by periods of terror and screaming at night with the patient having no memory of the dream itself. Contrast with nightmares, in which the patient remembers the dream. Sleep terror disorder is most commonly seen in children. Although the cause is unknown, common triggers include: Fever, Lack of sleep, Emotional stress. The night terrors in sleep terror disorder occur during stage N3 of non-REM sleep (slow-wave sleep).
Narcolepsy is characterized by daytime somnolence and "sleep attacks" where patients suddenly fall asleep. True REM sleep occurs during these attacks. Narcolepsy can result from loss of neuropeptides orexin-A and orexin-B (aka hypocretin-1 and hypocretin-2) produced in the lateral hypothalamus. These peptides normally promote wakefulness. Cataplexy is a medical condition in which a patient loses all muscle tone after a strong emotional stimulus. Cataplexy is associated with narcolepsy. Narcolepsy is associated with hypnagogic (just before sleeping) and hypnopompic (occur during awakening) hallucinations. Mnemonic: HypnaGOgic is just before you GO to sleep. HypnoPOmpic is POst sleep. Patients with narcolepsy are treated with stimulants such as modafinil or amphetamines during the day to decrease sleepiness. At night, patients with narcolepsy can take sodium oxybate (GHB) to promote sleep and improve daytime somnolence.
Substance use disorder
Substance use disorder is a problematic pattern of substance abuse causing impairment in daily life activities or causing distress to the patient. In substance use disorder, the patient must have at least 2 of the following symptoms in a 12 month period: Taking the substance in larger amounts or for a longer period of time than the patient intends; Wanting to cut down or stop using the substance but not succeeding; Spending a lot of time getting, using, or recovering from use of the substance; Cravings and urges to use the substance; Not managing to do what is expected at work, home, or school because of substance use. Continuing to use the substance, even when it causes problems in relationships; Giving up important social, occupational, or recreational activities because of substance use, Using substances repeatedly, even when it puts the patient in danger, Continuing to use, even when the patient knows they have a physical or psychological problem that could have been caused or made worse by the substance, Needing more of the substance to get the effect the patient wants (tolerance); Development of withdrawal symptoms, which can be relieved by taking more of the substance
Stages of change model
The "stages of change model" for behavioral change is a popular model for how health behavior change (including recovery from substance use) takes place. It consists of five stages, the first being Pre-contemplation: not yet acknowledging that there is a problem. The second stage is Contemplation: acknowledging the problem, but not yet ready or willing to change it. The third stage is Preparation: preparing to change the behavior. The fourth stage is Action: changing the behavior. The fifth stage is Maintenance: maintaining the behavior change. In addition to the five stages, patients may also experience termination (patients have no temptation and are sure they will not return to the behavior) or relapse (return from action or maintenance stages to an earlier stage).
Alcohol is a depressant that acts as a positive allosteric modulator of the GABA receptor in the CNS. The signs of alcohol intoxication can be remembered with the mneumonic, ABCDES: Ataxia, Blackouts, Coma, Disinhibition, Emotional lability, Slurred speech. Serum gamma glutamyltransferase (GGT) is a sensitive indicator of alcohol use.
Symptoms of alcohol withdrawal include: Tremors, Tachycardia, Hypertension, Malaise, Nausea, Seizures, Delirium tremens (DTs), Agitation, Hallucinations. Alcohol withdrawal is treated with benzodiazepines.
Symptoms of opioid Intoxication include: CNS depression, Respiratory depression, Euphoria, Miosis, Nausea, Vomiting, Constipation, Seizures
Symptoms of opioid withdrawal include: Insomnia, yawning; Anorexia; Piloerection ("cold turkey"), sweating; Dilated pupils; "Flu-like" symptoms: fever, rhinorrhea, nausea, stomach cramps, diarrhea. Treatment of acute benzodiapepine intoxication consists of maintaining the airway first and then administer flumazenil (but care must be taken to avoid precipitating a life-threatening withdrawal reaction!).
Barbiturate intoxication is manifested by respiratory depression with a low safety margin.
Symptoms of barbiturate withdrawal include: Anxiety, Delirium, Seizures, Life-threatening cardiovascular collapse
Signs and symptoms of benzodiazepine intoxication include: Amnesia, Ataxia, Somnolence, Respiratory depression
Signs and symptoms of benzodiazepine withdrawal include: Rebound anxiety; Seizures; Tremor; Insomnia. Treatment of acute benzodiapepine intoxication consists of maintaining the airway first and then administer flumazenil (but care must be taken to avoid precipitating a life-threatening withdrawal reaction).
Amphetamine or cocaine intoxication
Amphetamines and cocaine are stimulants. Amphetamines increase release of catecholamines at the synapse. Cocaine blocks reuptake of norepinephrine and dopamine in the CNS. Signs of amphetamine or cocaine intoxication include: Pupillary dilatation, hypertension, tachycardia, cardiac arrhythmias; Psychomotor agitation, impaired judgment; Euphoria, prolonged wakefulness and attention; Delusions and paranoia; Hallucinations; Fever. Treatment of cocaine intoxication is with benzodiazepines and alpha-blockers.
Amphetamine or cocaine Amphetamine or cocaine
Signs of amphetamine and cocaine withdrawal include: Depression; Lethargy; Hypersomnolence; Headache; Stomach cramps, hunger; Severe craving
Caffeine is a stimulant and acts primarily as an adenosine receptor antagonist. Caffeine intoxication results in: Restlessness; Insomnia; Increased diuresis; Muscle twitching; Cardiac arrhythmias.
Caffeine withdrawal is manifested by: Headache; Lethargy; Depression; Weight gain
Nicotine is a stimulant and acts as a nicotinic acetylcholine receptor agonist. Nicotine intoxication results in the following: Restlessness; Insomnia; Anxiety; Arrhythmias.
Signs and symptoms of nicotine withdrawal include: Irritability; Headache; Anxiety; Weight gain; Bradycardia; Craving. Smoking cessation can be achieved with bupropion, an antidepressant, and varenicline, a partial nicotinic agonist.
Phencyclidine (PCP) is a hallucinogen that acts primarily as an NMDA receptor antagonist. Signs/symptoms of PCP intoxication include: Belligerence; Impulsiveness; Homicidal tendencies; Vertical and horizontal nystagmus; Fever; Psychomotor agitation, psychosis, delirium; Seizures. Treatment of PCP intoxication is with benzodiazepines and antipsychotics.
Signs of PCP withdrawal include: Depression, Anxiety, Irritability, Restlessness, Decreased reflexes, Confusion
Lysergic acid diethylamide (LSD) is a hallucinogen that acts as a serotonin (5-HT2) receptor partial agonist. Signs of symptoms of LSD intoxication include: Visual and auditory perceptual distortion, Marked anxiety, Delusions and paranoia, Flashbacks.
Marijuana is a commonly used drug that acts as a cannabinoid receptor agonist. Marijuana intoxication can be manifested by the following signs and symptoms: Euphoria; Anxiety, paranoid delusions; Perception of slowed time; Impaired judgment; Social withdrawal; Increased appetite, dry mouth; Hallucinations; Conjunctival injection
Signs and symptoms of marijuana withdrawal include: Decreased appetite; Insomnia; Irritability; Depression; Nausea. Marijuana can be detected in a person's urine after discontinuation for up to 7-10 days in a casual user and 1+ months in a chronic user. The prescription form of marijuana, dronabinol, can be used as an antiemetic and appetite stimulant.
Heroin is an opioid that acts similarly to other opioids as a mu opioid receptor agonist. Examination of a heroin abuser may show track marks indicating multiple needle sticks in veins. However, heroin can also be sniffed or smoked by users. Heroin users are at risk for: Hepatitis B and C, HIV/AIDS; Abscesses, hemorrhoids; Right-sided endocarditis; Adult respiratory distress syndrome; Death from respiratory or cardiac arrest or from pulmonary edema; Focal segmental glomerulosclerosis.
Naloxone is an opioid receptor antagonist used for cases of acute opioid overdose.
Buprenorphine is a partial agonist of the opioid receptor and is used for long term maintenance after heroin detoxification. It is active orally. It is often given with naloxone (opioid receptor antagonist) because naloxone is not active when taken orally. Therefore, if the combination is injected intravenously by IV drug abusers, only the naloxone is active, thus causing withdrawal symptoms. If the combination is taken orally as prescribed, then the user gets the benefit of buprenorphine maintenance and not any withdrawal symptoms from the naloxone.
Methadone is a long acting oral opiate is used for heroin detoxification or long term maintenance.
Naltrexone is a long acting opioid antagonist used for opioid relapse prevention.
Alcoholism is characterized by a physiologic tolerance and dependence with symptoms of withdrawal including: Tremor, Tachycardia, Hypertension, Malaise, Nausea, Seizure, Delirium tremens. Medications that are used in the treatment of alcoholism include: Disulfiram (Inhibits aldehyde dehydrogenase, thus increasing acetalydehyde, causing hangover-like symptoms); Naltrexone (opioid receptor antagonist); Acamprosate (GABA receptor modulator)/ Alcoholics Anonymous (AA) or other peer support groups (12-step programs) are considered the main supportive therapy for alcoholism. Alcoholism is four times more prevalent in children of alcoholics than in children of non-alcoholics, even if the children are raised by adoptive parents. End-organ complications of alcoholism include (among others): Hepatitis, Cirrhosis, Hepatic encephalopathy, Pancreatitis, Esophageal varices, Hyperestrinism (secondary to decreased p450 function of eliminating estrogen), Coagulopathy, Dilated cardiomyopathy, Peripheral neuropathy (direct effect of alcohol; separate from neuropathies from B vitamin deficiencies). Physical exam findings of alcoholism include: Jaundice, Scleral icterus, Spider angiomatas, Palmar erythema, Dupuytren's contractures, Testicular atrophy, Ascites
Biochemical effects of ethanol
The biochemical effects of ethanol ingestion include the following: Increased NADH/NAD ratio, Increased conversion of pyruvate to lactate, Inhibition of gluconeogenesis, Inhibition of fatty acid oxidation, Increased activity of glycerophosphate dehydrogenase, leading to elevated glycerophosphate, Increased lipogenesis, leading to fatty liver
Delirium tremens is a life threatening alcohol withdrawal syndrome. Delirium tremens peaks 2-5 days after the last drink, often as an inpatient where the patient is not able to consume alcohol. The following symptoms of delirium tremens occur in order of appearance: Autonomic system hyperactivity (tachycardia, tremors, anxiety, seizures); Psychotic symptoms such as hallucinations (occurring early in delirium tremens) and delusions; Confusion; The treatment for delirium tremens is benzodiazepines.
Wernicke-Korsakoff syndrome is common in malnourished alcoholics and is caused by vitamin B1 (thiamine) deficiency. Wernicke-Korsakoff syndrome presents with a triad of confusion, ophthalmoplegia, and ataxia (Wernicke’s encephalopathy). Korsakoff’s Psychosis is a progression from Wernicke’s encephalopathy which consists of memory loss, confabulation, and personality changes, all of which are irreversible. Wernicke-Korsakoff syndrome is associated with periventricular hemorrhage/necrosis, especially in the mammillary bodies. Treatment includes intravenous vitamin B1 (thiamine).
Mallory-Weiss syndrome is caused by excessive vomiting causing longitudinal lacerations at the gastroesophageal junction. It presents with hematemesis, abdominal pain, and melena. Mallory-Weiss syndrome is associated with pain in contrast to bleeding esophageal varices, which are not painful.
Medication for ADHD
Stimulants (eg methylphenidate)
Medication for bipolar disorder
lithium valporic acid, atypical antipsychotics.
Medication for alcohol withdrawal
Long acting benxodiazepines (eg cholordiazepoxide, lorazepam, diazepam)
Medication for bulimia
Medication for depression
Medication for general anxiety disorder
Medication for OCD
Medication for panic disorder
SSRI, venlafaxine, benzodiazepines
Medication for PTSD
Medication for schizophrenia
Medication for social phobias
SSRIs, beta blockers
Medication for Tourette sundrome
Antipsychotics (eg fluphenazine, pimozide), tetrabenazine, clonidine.
Methlyphenidate, dextroamphetamine, methamphetamine. They increase catecholamines in the synaptic cleft, especially norepinephrine and dopamine. They are used to treat ADHD, narcolepsy, appetite control.
Traditional antipsychotics or neuroleptics are a class of psychiatric medications used to treat psychotic disorders and psychotic symptoms by blocking dopamine D2 receptors, resulting in increased concentration of cAMP in the CNS. Typical antipsychotics are primarily used to treat: Schizophrenia (primarily positive symptoms), Psychosis, Acute mania, Tourette’s disorder. Typical antipsychotics can cause QT prolongation by antagonizing myocardial K+ efflux channels.
Low potency typical antipsychotics
Low potency typical antipsychotics have a lower affinity for dopamine receptors. Low potency antipsychotics include chlorpromazine and thioridazine. Low potency antipsychotics are distinguished from high potency antipsychotics by having less extra-pyramidal symptoms and more non-neurologic symptoms, including: Anticholinergic, Antihistaminic, Antiadrenergic. Toxicities of the low potency antipsychotics include: Chlorpromazine: Corneal deposits and blue-gray skin discoloration; Thioridazine: Retinopathy (similar to retinitis pigmentosa) and cardiotoxicity
High potency typical antipsychotics
High potency typical antipsychotics have a higher affinity for the dopamine receptor. The three most important high potency antipsychotics are (An angel with a halo will tri to fly): Haloperidol, Fluphenazine, Trifluoperazine. High potency antipsychotics have a high incidence of EPS (extrapyramidal symptoms) but minimal anticholinergic and antiadrenergic effects. Toxic side effects of typical antipsychotics include: Endocrine side effects (dopamine blockade causes hyperprolactinemia which in turn causes galactorrhea, amenorrhea, osteoporosis, gynecomastia, decreased libido); Antihistaminic (sedation and weight gain); Antiadrenergic (orthostatic hypotension); Anticholinergic (dry mouth, tachycardia, confusion, constipation, and urinary retention); Motor symptoms (extrapyramidal symptoms and neuroleptic malignant syndrome)
extrapyramidal symptoms (EPS) from antipsychotic toxicity
The four extrapyramidal symptoms (EPS) from antipsychotic toxicity are: Acute dystonia, Akathisia, Bradykinesia, Tardive dyskinesia. The onset of EPS in antipsychotic toxicity occurs by the rule of 4's: 4 hours: acute dystonia; 4 days: akathisia; 4 weeks: bradykinesia; 4 months: tardive dyskinesia
An EPS that can present after four days of typical antipsychotic use. Akathisia: subjective anxiety and restlessness, and objective fidgetiness. Akathisia is treated with propranolol, benzodiazepines, and benztropine.
An EPS that can present after four weeks of typical antipsychotic use. Bradykinesia: Parkinsonian symptoms (masklike face, cogwheel rigidity, pill-rolling tremor.
An EPS that can present after four months of typical antipsychotic use. Tardive dyskinesia: choreoathetoid (writhing) involuntary movements of mouth and tongue. Tardive dyskinesia is likely due to compensatory hypersensitivity and upregulation of dopamine receptors following long-term administration of neuroleptic drugs. Treatment involves discontinuation of current medication, and switch to an atypical antipsychotic if they are currently taking a typical antipsychotic. Typical antipsychotics are highly lipid soluble and thus are very slowly removed from the body.
An EPS that can present after four hours of typical antipsychotic use. Acute dystonia: sustained painful contraction of neck, tongue and oculogyric crisis. Acute dystonia and akinesia are treated with antihistamines (diphenhydramine) or anticholinergics (benztropine or trihexyphenidyl).
Neuroleptic Malignant Syndrome
Neuroleptic Malignant Syndrome is a major toxicity of typical antipsychotics resulting in: Rigidity, Myoglobinuria, Autonomic instability, Hyperpyrexia. For a mnemonic, think FEVER: Fever, Encephalopathy, Vital signs unstable, Elevated enzymes (CPK), Rigidity. The following agents can be used to treat neuroleptic malignant syndrome: Dantrolene, Bromocriptine, Amantadine
Atypical antipsychotics are a class of psychogenic medications which can be remembered by the mnemonic, "It's Atypical for OLd CLOsets to QUietly RISPER from A to Z." OLanzapine, CLOzapine, QUetiapine, RISPERidone, Aripiprazole, Ziprasidone. Atypical antipsychotics exert their effects by blocking the following receptors: 5-HT2, Dopamine (D2), α1 adrenergic, H1. Atypical antipsychotics are associated with less extrapyramidal and anticholinergic side effects than typical antipsychotics. Atypical antipsychotics are used to treat "MOST BAD" conditions: Mania, OCD, Schizophrenia (positive and negative symptoms), Tourette’s disorder, Bipolar disorder, Anxiety Disorder, Depression.
Toxicity of clozapine
It is an atypical antipsychotic. Due to risk of agranulocytosis and seizures, clozapine is reserved for severe schizophrenic symptoms refractory to traditional therapy. Clozapine requires weekly monitoring of WBC counts since it is associated with a 1% incidence of agranulocytosis Mnemonic: Must watch CLOZapine CLOZely! It is also associated with hyperlipidemia, glucose intolerance, and weight gain.
Toxicity of Olanzapine
Olanzapine is an atypical antipsychotic associated with hyperlipidemia, glucose intolerance, and weight gain.
Toxicity of Quetiapine
Quetiapine is an atypical antipsychotic associated with cataracts; therefore, periodic slit lamp examination recommended.
Toxicity of Risperidone
Risperidone is an atypical antipsychotic associated with elevated prolactin, causing gynecomastia, galactorrhea, and amenorrhea.
Toxicity of Ziprasidone
Ziprasidone is an atypical antipsychotic that prolongs QT interval (all atypical antipsychotics have the potential to increase QT interval, however ziprasidone is most likely to have this specific side effect).
An atypical antipsychotic
Lithium is used for maintenance of bipolar disorder (mood stabilizer), acute manic events, and SIADH (due to side effect profile of nephrogenic diabetes insipidus). The putative mechanism of lithium is inhibition of the enzyme inositol monophosphatase, thus decreasing the cellular concentration of the second messenger, inositol triphosphate (IP3), resulting in mood stabilization. Lithium also acts by inhibiting glycogen synthase kinase-3 (GSK-3).
Side effects of lithium
Side effects of lithium include: Ataxia, Tremors, Edema, Weight gain, Benign leukocytosis, Heart block, Nephrogenic diabetes insipidus, Hypothyroidism (requires monitoring of kidney function (GFR) and thyroid function (TSH levels)), Teratogenesis. Lithium use during pregnancy increases the risk of Ebstein’s cardiac anomaly in the fetus (the opening of the tricuspid valve is displaced towards the apex of the right ventricle of the heart, thus decreasing the size of the right ventricle). Requires a close monitoring of serum levels due to narrow therapeutic range and toxic levels can cause altered mental status, convulsions, and death. Lithium toxicity is increased by: Thiazide diuretics (diuretics lower water and sodium levels, causing increased lithium reabsorption in the proximal tubules), NSAIDs, ACE inhibitors, Dehydration, Salt deprivation, Impaired renal function
Buspirone acts as a partial 5-HT1A (serotonin) receptor agonist. Buspirone is used as an alternative to benzodiazepines and venlafaxine for treating generalized anxiety disorder. Mnemonic: I’m always anxious if the BUS will be ON time, so I take BUSpirONe. The efficacy of buspirone is comparable to benzodiazepines but has a slower onset of action of 1-2 weeks for the effect. Several advantages of buspirone compared to benzodiazepines include: Absence of sedation, Absence of addiction, Absence of tolerance, Does not potentiate CNS depression of alcohol (useful in alcoholics)
Selective Serotonin Re-uptake Inhibitors (SSRIs)
Selective Serotonin Re-uptake Inhibitors (SSRIs) are a class of antidepressants which include the following drugs: Fluoxetine, Sertraline, Paroxetine, Citalopram, Escitalopram, Fluvoxamine. SSRIs exert their effects by inhibiting reuptake of serotonin.
Selective Serotonin Re-uptake Inhibitor (SSRI)
Selective Serotonin Re-uptake Inhibitor (SSRI)
Selective Serotonin Re-uptake Inhibitor (SSRI)
Selective Serotonin Re-uptake Inhibitor (SSRI)
Selective Serotonin Re-uptake Inhibitor (SSRI)
Selective Serotonin Re-uptake Inhibitor (SSRI)
Clinical use of SSRIs
SSRIs are used to treat many illnesses, including: Major depressive disorder, Generalized anxiety disorder, Obsessive compulsive disorder, Bulimia nervosa, Anorexia nervosa, Social phobias, Panic disorder, Pain associated with diabetic neuropathy, Premenstrual dysphoric disorder, PTSD. Normally, SSRIs take 4-8 weeks to have an effect.
Adverse effects of SSRIs
Adverse effects of SSRIs include: Sexual dysfunction (loss of libido, delayed ejaculation, and anorgasmia), Nausea, Anxiety, Insomnia, Tremors, Anorexia and weight loss (note: some SSRIs can also cause weight gain), SIADH, Serotonin syndrome
It can occur with any drug that increases 5-HT (eg MAO inhibitors, SNRIs, TCAs) causing hyperthermia, confusion, myoclonus, cardiovascular instability, flushing, diarrhea, seizures. Treatment includes cyproheptadine (5-HT2 receptor antagonist).
Venlafaxine and duloxetine. They inhibit 5-HT and norepinephrine reuptake. They are used to treat depression. Venlafexine is also used to treat generalized anxiety disorder, panic disorder, and PTSD. Duloxetine is also indicated for diabetic peripheral neuropathy.
Side effects of SNRIs
Increases BP, also stimulant effects, sedation, and nausea.
Tricyclic antidepressants (TCAs)
Tricyclic antidepressants (TCAs) are a class of antidepressant drugs and include: Amitriptyline, Nortriptyline, Imipramine, Desipramine, Clomipramine, Doxepin, Amoxapine. They block reuptake of norepinephrine and 5-HT.
Clinical use of TCA
they are used to treat major depression, OCD (clomipramine), peripheral neuropathy, chronic pain, migraine prophylaxis.
Side effects of TCAs
Mild, more common side effects of TCAs include: Antihistaminic (sedation and weight gain), Antiadrenergic (orthostatic hypotension and arrhythmias - QT prolongation), Anticholinergic (dry mouth, tachycardia, confusion, constipation, and urinary retention). Serious adverse effects of TCAs include: 3 C's – Convulsions, Coma, Cardiotoxicity; Respiratory depression; Hyperpyrexia; Confusion and hallucinations. TCAs are lethal in overdose, thus one must assess suicide risk before prescribing TCAs. Treatment for TCA overdose includes the administration of IV sodium bicarbonate.
Monoamine oxidase (MAO) inhibitors
Tranylcypromine, Phenelzine, Isocarboxazid, Selegiline (selective MAO-B inhibitor) MAO Takes Pride In Shanghai.
MAO inhibitor mechanism of action
Nonselective MAO inhibition causes an increase in levels of amine neurotransmitters (norepinephrine, 5-HT, dopamine)
Clinical use of MAO inhibitor
Atypical depression and anxiety.
Toxicity of MAO inhibitors
Hypertensive crisis (most notably with ingestion of tyramine, which is found in many foods such as wine and cheese); CNS stimulation. It is contraindicated with SSRIs, TCAs, St John's wort, meperidine, dextromethorphan (to prevent serotonin syndrome).
It is an atypical antidepressant that is also used in smoking cessation. It increases norepinephrine and dopamine via unknown mechanism. Toxicity includes stimulant effects (tachycardia, insomnia), headache, seizures in anorexic/bulimic patients. No sexual side effects.
alpha 2 antagonist (increase release of norepinephrine and 5-HT) and potent 5-HT2 and 5-HT3 receptor antagonist. Toxicities include sedation (which may be desirable in depressed patients with insomnia), increased appetite, weight gain (which may be desirable in elderly or anorexic patients), dry mouth.