Psychiatry - First Aid Flashcards by Grazielle Verzosa

Psychology:

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

Classical Conditioning

How well did you know this?

Not at all

Perfectly

Psychology:

learning in which a particular action is elicited because it produces a punishment or reward
usually deals with voluntary responses

Operant Conditioning

How well did you know this?

Not at all

Perfectly

Operant Conditioning:

target behavior (response) is followed by desired reward (positive reinforcement) or removal of aversive stimulus (negative reinforcement)

Reinforcement

How well did you know this?

Not at all

Perfectly

Operant Conditioning:

discontinuation of reinforcement (positive or negative) eventually eliminates behavior
can occur in operant or classical conditioning

Extinction

How well did you know this?

Not at all

Perfectly

Operant Conditioning:

repeated application of aversive stimulus (positive punishment) or removal of desired reward (negative punishment) to extinguish unwanted behavior (Skinner’s operant conditioning quadrant)

Punishment

How well did you know this?

Not at all

Perfectly

Psychology:

patient projects feelings about formative or other important persons onto physician (eg. psychiatrist is seen as parent)

Transference

How well did you know this?

Not at all

Perfectly

Psychology:

doctor projects feelings about formative or other important persons onto patient (eg. patient reminds physician of younger sibling)

Countertransference

How well did you know this?

Not at all

Perfectly

Psychology:

mental processes (unconscious or conscious) used to resolve conflict and prevent undesirable feelings (eg. anxiety, depression)

Ego Defenses

How well did you know this?

Not at all

Perfectly

Ego Defenses:

Immature

Acting Out
Denial
Displacement
Dissociation
Fixation
Idealization
Identification
Intellectualization
Isolation of Affect
Passive Aggression
Projection
Rationalization
Reaction Formation
Regression
Repression
Splitting

How well did you know this?

Not at all

Perfectly

Immature Ego Defenses:

expressing unacceptable feelings and thoughts through actions
A young boy throws a temper tantrum when he does not get the toy he wants.

Acting Out

How well did you know this?

Not at all

Perfectly

Immature Ego Defenses:

avoiding the awareness of some painful reality
A patient with cancer plans a full-time work schedule despite being warned of significant fatigue during chemotherapy.

Denial

How well did you know this?

Not at all

Perfectly

Immature Ego Defenses:

redirection of emotions or impulses to a neutral person or object (vs. projection)
A teacher is yelled at by the principal. Instead of confronting the principal directly, the teacher goes home and criticizes her husband’s dinner selection.

Displacement

How well did you know this?

Not at all

Perfectly

Immature Ego Defenses:

temporary, drastic change in personality, memory, consciousness, or motor behavior to avoid emotional stress
patient has incomplete or no memory of traumatic event
A victim of sexual abuse suddenly appears numb and detached when she is exposed to her abuser.

Dissociation

How well did you know this?

Not at all

Perfectly

Immature Ego Defenses:

partially remaining at a more childish level of development (vs. regression)
A surgeon throws a tantrum in the operating room because the last case ran very late.

Fixation

How well did you know this?

Not at all

Perfectly

Immature Ego Defenses:

expressing extremely positive thoughts of self and others while ignoring negative thoughts
A patient boasts about his physician and his accomplishments while ignoring any flaws.

Idealization

How well did you know this?

Not at all

Perfectly

Immature Ego Defenses:

largely unconscious assumption of the characteristics, qualities, or traits of another person or group
A resident starts putting his stethoscope in his pocket like his favorite attending, instead of wearing it around his neck like before.

Identification

How well did you know this?

Not at all

Perfectly

Immature Ego Defenses:

using facts and logic to emotionally distance oneself from a stressful situation
In a therapy session, patient diagnosed with cancer focuses only on rates of survival.

Intellectualization

How well did you know this?

Not at all

Perfectly

Immature Ego Defenses:

separating feelings from ideas and events
Describing murder in graphic detail with no emotional response.

Isolation of Affect

How well did you know this?

Not at all

Perfectly

Immature Ego Defenses:

demonstrating hostile feelings in a nonconfrontational manner
showing indirect opposition
Disgruntled employee is repeatedly late to work, but won’t admit it is a way to get back at the manager.

Passive Aggression

How well did you know this?

Not at all

Perfectly

Immature Ego Defenses:

atributing an unacceptable internal impulse to an external source (vs. displacement)
A man who wants to cheat on his wife accuses his wife of being unfaithful.

Projection

How well did you know this?

Not at all

Perfectly

Immature Ego Defenses:

proclaiming logical reasons for actions actually performed for other reasons, usually to avoid self-blame
After getting fired, claiming that the job was not important anyway.

Rationalization

How well did you know this?

Not at all

Perfectly

Immature Ego Defenses:

replacing a warded-off idea or feeling with an (unconsciously derived) emphasis on its opposite (vs. sublimation)
A patient with lustful thoughts enters a monastery.

Reaction Formation

How well did you know this?

Not at all

Perfectly

Immature Ego Defenses:

involuntarily turning back the maturational clock and going back to earlier modes of dealing with the world (vs. fixation)
Seen in children under stress such as illness, punishment, or birth of a new sibling (eg. bedwetting in a previously toilet-trained child).

Regression

How well did you know this?

Not at all

Perfectly

Immature Ego Defenses:

involuntarily withholding an idea or feeling from conscious awareness (vs. suppression)
A 20-year-old does not remember going to counseling during his parents’ divorce 10 years earlier.

Repression

How well did you know this?

Not at all

Perfectly

Immature Ego Defenses: * believing that people are either all good or all bad at different times due to intolerance of ambiguity * commonly seen in borderline personality disorder * A patient says that all the nurses are cold and insensitive but that the doctors are warm and friendly.

Splitting

Ego Defenses: Mature

**Mature** adults wear a **SASH**. * **S**ublimation * **A**ltruism * **S**uppression * **H**umor

Mature Ego Defenses: * replacing an unacceptable wish with a course of action that is similar to the wish but socially acceptable (vs. reaction formation) * Teenager’s aggressive urges toward his parents’ high expectations are channeled into excelling in sports.

Sublimation

Mature Ego Defenses: * alleviating negative feelings via unsolicited generosity, which provides gratification (vs. reaction formation) * Mafia boss makes large donation to charity.

Altruism

Mature Ego Defenses: * intentionally withholding an idea or feeling from conscious awareness (vs. repression) * temporary * Choosing to not worry about the big game until it is time to play.

Suppression

Mature Ego Defenses: * appreciating the amusing nature of an anxietyprovoking or adverse situation * Nervous medical student jokes about the boards.

Humor

Infant Deprivation Effects

* Long-term deprivation of affection results in: * failure to thrive * poor language/socialization skills * lack of basic trust * reactive attachment disorder (infant withdrawn/unresponsive to comfort) * disinhibited social engagement (infant indiscriminately attaches to strangers) * Deprivation for \> 6 months can lead to irreversible changes. * Severe deprivation can result in infant death.

Child Abuse: Physical Abuse

* Fractures (eg. ribs, long bone spiral, multiple in different stages of healing), bruises (eg. trunk, ear, neck; in pattern of implement), burns (eg. cigarette, buttocks/thighs), subdural hematomas/retinal hemorrhages (“shaken baby syndrome”). * During exam, children often avoid eye contact. * Red flags include history inconsistent with degree or type of injury (eg. 2-month-old rolling out of bed or falling down stairs), delayed medical care, caregiver story changes with retelling. * Abuser is usually the biological mother. * 40% of deaths related to child abuse or neglect occur in children \< 1 year old.

Child Abuse: Sexual Abuse

* genital, anal, or oral trauma * STIs * UTIs * Abuser is known to victim and is usually male. * Peak incidence is 9–12 years old.

Psychopathology: * failure to provide a child with adequate food, shelter, supervision, education, and/or affection * mmost common form of child maltreatment * presents with poor hygiene, malnutrition, withdrawal, impaired social/emotional development, and failure to thrive * must be reported to local child protective services

Child Neglect

Psychopathology: * parents perceive the child as especially susceptible to illness or injury * usually follows a serious illness or life-threatening event * can result in missed school or overuse of medical services

Vulnerable Child Syndrome

Childhood and Early-Onset Disorders: * onset before age 12 * at least 6 months of limited attention span and/or poor impulse control * characterized by hyperactivity, impulsivity, and/or inattention in multiple settings (school, home, places of worship, etc) * normal intelligence, but commonly coexists with difficulties in school * often persists into adulthood * Treatment: * stimulants (eg. methylphenidate) +/– cognitive behavioral therapy (CBT) * alternatives include Atomoxetine, Guanfacine, and Clonidine

Attention-Deficit Hyperactivity Disorder

Childhood and Early-Onset Disorders: * characterized by poor social interactions, social communication deficits, repetitive/ritualized behaviors, restricted interests * must present in early childhood * may be accompanied by intellectual disability * rarely accompanied by unusual abilities (savants) * more common in boys * associated with ↑ head/brain size

Autism Spectrum Disorder

Childhood and Early-Onset Disorders: * repetitive and pervasive behavior violating the basic rights of others or societal norms (eg. aggression to people and animals, destruction of property, theft) * after age 18 * often reclassified as antisocial personality disorder * treated with psychotherapy such as CBT

Conduct Disorder

Childhood and Early-Onset Disorders: * onset before age 10 * severe and recurrent temper outbursts out of proportion to situation * child is constantly angry and irritable between outbursts * Treatment: * Stimulants * Antipsychotics * CBT

Disruptive Mood Dysregulation Disorder

Childhood and Early-Onset Disorders: * enduring pattern of hostile, defiant behavior toward authority figures in the absence of serious violations of social norms * Treatment: * psychotherapy such as CBT

Oppositional Defiant Disorder

Childhood and Early-Onset Disorders: * overwhelming fear of separation from home or attachment figure lasting ≥ 4 weeks * can be normal behavior up to age 3–4 * may lead to factitious physical complaints to avoid school * Treatment: * CBT * Play Therapy * Family Therapy

Separation Anxiety Disorder

Childhood and Early-Onset Disorders: * onset before age 18 * characterized by sudden, rapid, recurrent, nonrhythmic, stereotyped motor and vocal tics that persist for \> 1 year * coprolalia (involuntary obscene speech) found in only 40% of patients * associated with OCD and ADHD * Treatment: * Psychoeducation * Behavioral Therapy * for intractable and distressing tics, high-potency antipsychotics (eg. Haloperidol, Fluphenazine), Tetrabenazine, α2-Agonists (eg. Guanfacine, Clonidine), or atypical antipsychotics may be used

Tourette Syndrome

Orientation

* patient’s ability to know who he or she is, where he or she is, and the date and time * Common Causes of Loss of Orientation: * alcohol * drugs * fluid/electrolyte imbalance * head trauma * hypoglycemia * infection * nutritiona deficiencies * hypoxi * Order of Loss: time → place → person

Amnesias: inability to remember things that occurred before a CNS insult

Retrograde Amnesia

Amnesias: inability to remember things that occurred after a CNS insult (↓ acquisition of new memory)

Anterograde Amnesia

Amnesias: * amnesia (anterograde \> retrograde) caused by vitamin B1 deficiency and associated destruction of mammillary bodies * seen in alcoholics as a late neuropsychiatric manifestation of Wernicke encephalopathy * confabulations are characteristic

Korsakoff Syndrome

Dissociative Disorders: * persistent feelings of detachment or estrangement from one’s own body, thoughts, perceptions, and actions (depersonalization) or one’s environment (derealization) * intact reality testing (vs. psychosis)

Depersonalization/Derealization Disorder

Dissociative Disorders: inability to recall important personal information, usually subsequent to severe trauma or stress

Dissociative Amnesia

Dissociative Disorders: * formerly known as Multiple Personality Disorder * presence of 2 or more distinct identities or personality states * more common in women * associated with history of sexual abuse, PTSD, depression, substance abuse, borderline personality, somatoform conditions * may be accompanied by dissociative fugue (abrupt travel or wandering associated with traumatic circumstances)

Dissociative Identity Disorder

Psychopathology: * “waxing and waning” level of consciousness with acute onset * rapid ↓ in attention span and level of arousal * characterized by disorganized thinking, hallucinations (often visual), illusions, misperceptions, disturbance in sleepwake cycle, cognitive dysfunction, agitation. * usually 2° to other illness (eg. CNS disease, infection, trauma, substance abuse/withdrawal, metabolic/electrolyte disturbances, hemorrhage, urinary/fecal retention) * most common presentation of altered mental status in inpatient setting, especially in the intensive care unit and with prolonged hospital stays * EEG may show diffuse slowing * treatment is aimed at identifying and addressing underlying condition * use antipsychotics acutely as needed * avoid Benzodiazepines * may be caused by medications (eg. anticholinergics), especially in the elderly * reversible.

Delirium

Psychopathology: * distorted perception of reality characterized by delusions, hallucinations, and/or disorganized thought/speech * can occur in patients with medical illness, psychiatric illness, or both

Psychosis

Psychosis: * unique, false, fixed, idiosyncratic beliefs that persist despite the facts and are not typical of a patient’s culture or religion (eg. thinking aliens are communicating with you) * types include erotomanic, grandiose, jealous, persecutory, somatic, mixed, and unspecified

Delusions

Psychosis: speech may be incoherent (“word salad”), tangential, or derailed (“loose associations”)

Disorganized Thought

Psychosis: * perceptions in the absence of external stimuli (eg. seeing a light that is not actually present) * contrast with illusions, misperceptions of real external stimuli

Hallucinations

Types of Hallucinations

* Visual—more commonly a feature of medical illness (eg. drug intoxication) than psychiatric illness * Auditory—more commonly a feature of psychiatric illness (eg. schizophrenia) than medical illness * Olfactory—often occur as an aura of temporal lobe epilepsy (eg. burning rubber) and in brain tumors * Gustatory—rare, but seen in epilepsy * Tactile—common in alcohol withdrawal and stimulant use (eg. cocaine, amphetamines), delusional parasitosis, “cocaine crawlies” * Hypnagogic—occurs while going to sleep, sometimes seen in narcolepsy * Hypnopompic—occurs while waking from sleep (“pompous upon awakening”), sometimes seen in narcolepsy

Psychopathology: * chronic mental disorder with periods of psychosis, disturbed behavior and thought, and decline in functioning lasting ≥ 6 months (including prodrome and residual symptoms) * associated with ↑ dopaminergic activity, ↓ dendritic branching * frequent cannabis use is associated with psychosis in teens * Lifetime Prevalence * 1.5% males \> females * African Americans = Caucasians * presents earlier in men (late teens to early 20s vs. late 20s to early 30s in women) * patients at ↑ risk for suicide * ventriculomegaly on brain imaging * Diagnosis requires ≥ 2 of the following symptoms for ≥ 1 month, and at least 1 of these should include #1–3 (first 4 are “positive symptoms”): 1. Delusions 2. Hallucinations—often auditory 3. Disorganized Speech 4. Disorganized or Catatonic Behavior 5. Negative Symptoms (affective flattening, avolition, anhedonia, asociality, alogia) * Treatment: * Atypical Antipsychotics (eg. Risperidone) are first line * negative symptoms often persist after treatment, despite resolution of positive symptoms *

Schizophrenia

Schizophrenia: * ≥ 1 positive symptom(s) lasting \< 1 month * usually stress related

Brief Psychotic Disorder

Schizophrenia: * ≥ 2 symptoms * lasting 1–6 months

Schizophreniform Disorder

Schizophrenia: * meets criteria for Schizophrenia in addition to major mood disorder (major depressive or bipolar) * to differentiate from a major mood disorder with psychotic features, patient must have \> 2 weeks of psychotic symptoms without major mood episode

Schizoaffective Disorder

Psychopathology: * fixed, persistent, false belief system lasting \> 1 month * functioning otherwise not impaired (eg. a woman who genuinely believes she is married to a celebrity when, in fact, she is not) * can be shared by individuals in close relationships (folie à deux)

Delusional Disorder

Psychopathology: * characterized by an abnormal range of moods or internal emotional states and loss of control over them * severity of moods causes distress and impairment in social and occupational functioning * includes major depressive, bipolar, dysthymic, and cyclothymic disorders * episodic superimposed psychotic features (delusions, hallucinations, disorganized speech/behavior) may be present

Mood Disorder

Psychopathology: * distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently ↑ activity or energy lasting ≥ 1 week * often disturbing to patient and causes marked functional impairment and oftentimes hospitalization * Diagnosis requires hospitalization or at least 3 of the following: * Distractibility * Impulsivity/Indiscretion—seeks pleasure without regard to consequences (hedonistic) * Grandiosity—inflated self-esteem * Flight of Ideas—racing thoughts * ↑ Goal-Directed Activity/Psychomotor Agitation * ↓ Need for Sleep * Talkativeness or Pressured Speech

Manic Episode Manics **DIG FAST**: * **D**istractibility * **I**mpulsivity/**I**ndiscretion * **G**randiosity * **F**light of Ideas * ↑ Goal-Directed **A**ctivity/Psychomotor **A**gitation * ↓ Need for **S**leep * **T**alkativeness or Pressured Speech

Psychopathology: * similar to a manic episode except mood disturbance is not severe enough to cause marked impairment in social and/or occupational functioning or to necessitate hospitalization * no psychotic features * lasts ≥ 4 consecutive days

Hypomanic Episode

Bipolar Disorder (Manic Depression)

* _Bipolar I_—defined by presence of at least 1 manic episode +/− a hypomanic or depressive episode (may be separated by any length of time) * _Bipolar II_—defined by presence of a hypomanic and a depressive episode (no history of manic episodes) * Patient’s mood and functioning usually normalize between episodes. * Use of antidepressants can destabilize mood. * High suicide risk. * Treatment: * Mood Stabilizers (eg. Lithium, Valproic Acid, Carbamazepine, Lamotrigine) * Atypical Antipsychotics

Psychopathology: * milder form of bipolar disorder lasting ≥ 2 years * fluctuating between mild depressive and hypomanic symptoms

Cyclothymic Disorder

Psychopathology: * episodes characterized by at least 5 of the 9 diagnostic symptoms lasting ≥ 2 weeks (symptoms must include patient-reported depressed mood or anhedonia) * screen for history of manic episodes to rule out bipolar disorder * Diagnostic Symptoms: * Depressed Mood * Sleep Disturbance * Loss of Interest (Anhedonia) * Guilt or Feelings of Worthlessness * Energy Loss and Fatigue * Concentration Problems * Appetite/Weight Changes * Psychomotor Retardation or Agitation * Suicidal Ideations * Patients with depression typically have the following changes in their sleep stages: * ↓ slow-wave sleep * ↓ REM latency * ↑ REM early in sleep cycle * ↑ total REM sleep * repeated nighttime awakenings * early-morning awakening (terminal insomnia) * Treatment: * CBT and SSRIs are first line. * SNRIs, Mirtazapine, and Bupropion can also be considered. * Electroconvulsive Therapy (ECT) in treatment-resistant patients.

Major Depressive Disorder SIG E CAPS: * **S**leep Disturbance * Loss of **I**nterest (Anhedonia) * **G**uilt or Feelings of Worthlessness * **E**nergy Loss and Fatigue * **C**oncentration Problems * **A**ppetite/Weight Changes * **P**sychomotor Retardation or Agitation * **S**uicidal Ideations

Major Depressive Disorder: * often milder * ≥ 2 depressive symptoms lasting ≥ 2 years with no more than 2 months without depressive symptoms

Persistent Depressive Disorder (Dysthymia)

Major Depressive Disorder: * formerly known as Seasonal Affective Disorder * lasting ≥ 2 years with ≥ 2 major depressive episodes associated with seasonal pattern (usually winter) and absence of nonseasonal depressive episodes * atypical symptoms common (eg. hypersomnia, hyperphagia, leaden paralysis)

MDD with Seasonal Pattern

Psychopathology: * characterized by mood reactivity (able to experience improved mood in response to positive events, albeit briefly) * “reversed” vegetative symptoms (hypersomnia, hyperphagia), leaden paralysis (heavy feeling in arms and legs), long-standing interpersonal rejection sensitivity * most common subtype of depression * Treatment: * CBT and SSRIs are first line. * MAO inhibitors are effective but not first line because of their risk profile.

Depression with Atypical Features

Psychopathology: onset during pregnancy or within 4 weeks of delivery

Postpartum Mood Disturbances

Postpartum Mood Disturbances: * 50–85% incidence rate * characterized by depressed affect, tearfulness, and fatigue starting 2–3 days after delivery * usually resolves within 10 days * Treatment: supportive * follow up to assess for possible postpartum depression

Maternal (Postpartum) Blues

Postpartum Mood Disturbances: * 10–15% incidence rate * characterized by depressed affect, anxiety, and poor concentration for ≥ 2 weeks * Treatment: CBT and SSRIs are first line

Postpartum Depression

Postpartum Mood Disturbances: * 0.1–0.2% incidence rate * characterized by mood-congruent delusions, hallucinations, and thoughts of harming the baby or self * risk factors include history of bipolar or psychotic disorder, first pregnancy, family history, recent discontinuation of psychotropic medication * Treatment: * hospitalization and initiation of atypical antipsychotic * if insufficient, ECT may be used

Postpartum Psychosis

Grief

* The five stages of grief per the Kübler-Ross model are Denial, Anger, Bargaining, Depression, and Acceptance (may occur in any order). * Other normal grief symptoms include Shock, Guilt, Sadness, Anxiety, Yearning, and Somatic symptoms that usually occur in waves. * Simple hallucinations of the deceased person are common (eg. hearing the deceased speaking). * Any thoughts of dying are limited to joining the deceased (vs. pathological grief). * Duration varies widely; usually within 6–12 months. * Pathologic grief is persistent, causes functional impairment, and can meet criteria for major depressive episode.

Psychotherapy: * rapid-acting method to treat resistant or refractory depression, depression with psychotic symptoms, and acute suicidality * induces grand mal seizure while patient anesthetized * adverse effects include disorientation, temporary headache, partial anterograde/retrograde amnesia usually resolving in 6 months * no absolute contraindications * safe in pregnant and elderly individuals

Electroconvulsive Therapy

Suicide

* Most common method in US is firearms; access to guns ↑ risk of suicide completion. * Women try more often; men complete more often. * Family history of completed suicide is another well-known risk factor.

Risk Factors for Suicide Completion

**SAD PERSONS** are more likely to complete suicide. * **S**ex (male) * **A**ge (young adult or elderly) * **D**epression * **P**revious attempt (highest risk factor) * **E**thanol or drug use * **R**ational thinking loss (psychosis) * **S**ickness (medical illness) * **O**rganized plan * **N**o spouse or other social support * **S**tated future intent

Psychopathology: * inappropriate experience of fear/worry and its physical manifestations (anxiety) incongruent with the magnitude of the perceived stressor * symptoms interfere with daily functioning and are not attributable to another mental disorder, medical condition, or substance abuse * includes panic disorder, phobias, generalized anxiety disorder, and selective mutism * Treatment: * CBT * SSRIs * SNRIs

Anxiety Disorder

Psychopathology: * recurrent unexpected panic attacks not associated with a known trigger * periods of intense fear and discomfort peak in 10 minutes with at least 4 of the following: palpitations, paresthesias, depersonalization or derealization, abdominal distress or nausea, intense fear of dying, intense fear of losing control or “going crazy,” lIght-headedness, chest pain, chills, choking, sweating, shaking, shortness of breath * strong genetic component * ↑ risk of suicide * Diagnosis requires attack followed by ≥ 1 month of ≥ 1 of the following: * persistent concern of additional attacks * worrying about consequences of attack * behavioral change related to attacks * symptoms are the systemic manifestations of fear * Treatment: * CBT, SSRIs, and venlafaxine are first line. * Benzodiazepines occasionally used in acute setting.

Panic Disorder **PANICS**: * **P**alpitations * **P**aresthesias * de**P**ersonalization or derealization * **A**bdominal distress or **N**ausea * **I**ntense fear of dying * **I**ntense fear of losing control or “going crazy” * l**I**ght-headedness, * **C**hest pain * **C**hills * **C**hoking * **S**weating * **S**haking * **S**hortness of breath

Psychopathology: * severe, persistent (≥ 6 months) fear or anxiety due to presence or anticipation of a specific object or situation * person often recognizes fear is excessive * can be treated with systematic desensitization

Phobia

Phobia: * exaggerated fear of embarrassment in social situations (eg. public speaking, using public restrooms) * Treatment: * CBT * SSRIs * Venlafaxine * for performance type (eg. anxiety restricted to public speaking), use β-Blockers or Benzodiazepines as needed

Social Anxiety Disorder

Phobia: * irrational fear/anxiety while facing or anticipating ≥ 2 specific situations (eg. open/closed spaces, lines, crowds, public transport) * if severe, patients may refuse to leave their homes * associated with panic disorder * Treatment: * CBT * SSRIs

Agoraphobia

Psychopathology: * anxiety lasting \> 6 months unrelated to a specific person, situation, or event * associated with restlessness, irritability, sleep disturbance, fatigue, muscle tension, and difficulty concentrating * Treatment: * CBT, SSRIs, and SNRIs are first line. * Buspirone, TCAs, and Benzodiazepines are second line.

Generalized Anxiety Disorder

Psychopathology: * emotional symptoms (anxiety, depression) that occur within 3 months of an identifiable psychosocial stressor (eg. divorce, illness) lasting \< 6 months once the stressor has ended * if symptoms persist \> 6 months after stressor ends, it is GAD * symptoms do not meet criteria for MDD * Treatment: * CBT * SSRIs

Adjustment Disorder

Psychopathology: * recurring intrusive thoughts, feelings, or sensations (obsessions) that cause severe distress * relieved in part by the performance of repetitive actions (compulsions) * Ego-Dystonic: behavior inconsistent with one’s own beliefs and attitudes (vs. obsessive-compulsive personality disorder, Ego-Syntonic) * associated with Tourette syndrome * Treatment: * CBT, SSRIs, Venlafaxine, and Clomipramine are first line

Obsessive-Compulsive Disorder

Obsessive-Compulsive Disorder: * preoccupation with minor or imagined defect in appearance → significant emotional distress or impaired functioning * patients often repeatedly seek cosmetic treatment * Treatment: CBT

Body Dysmorphic Disorder

Psychopathology: * experiencing a potentially life-threatening situation (eg. serious injury, rape, witnessing death) → persistent hyperarousal, avoidance of associated stimuli, intrusive re-experiencing of the event (nightmares, flashbacks), changes in cognition or mood (fear, horror, distress) * disturbance lasts \> 1 month with significant distress or impaired socialoccupational functioning * Treatment: * CBT, SSRIs, and Venlafaxine are first line. * Prazosin can reduce nightmares.

Post-Traumatic Stress Disorder Having PTSD is **HARD**. * persistent **H**yperarousal * **A**voidance of associated stimuli * intrusive **R**e-experiencing of the event (nightmares, flashbacks) * changes in cognition or mood (fear, horror, **D**istress)

Psychopathology: * lasts between 3 days and 1 month * Treatment: * CBT * pharmacotherapy is usually not indicated

Acute Stress Disorder

Diagnostic Criteria by Symptom Duration

Personality: an enduring, repetitive pattern of perceiving, relating to, and thinking about the environment and oneself

Personality Trait

Personality: * inflexible, maladaptive, and rigidly pervasive pattern of behavior causing subjective distress and/or impaired functioning * person is usually not aware of problem (ego-syntonic) * usually presents by early adulthood

Personality Disorder Three Clusters: * A—Weird * B—Wild * C—Worried

Personality Disorders: * odd or eccentric * inability to develop meaningful social relationships * no psychosis * genetic association with schizophrenia * “weird”

Cluster A Personality Disorders Cluster **A**: **A**ccusatory, **A**loof, **A**wkward

Cluster A Personality Disorders: pervasive distrust (**A**ccusatory) and suspiciousness of others and a profoundly cynical view of the world

Paranoid

Cluster A Personality Disorders: * voluntary social withdrawal (**A**loof) * limited emotional expression * content with social isolation (vs. avoidant)

Schizoid

Cluster A Personality Disorders: * eccentric appearance * odd beliefs or magical thinking * interpersonal **A**wkwardness

Schizotypal

Personality Disorders: * dramatic, emotional, or erratic * genetic association with mood disorders and substance abuse * “wild”

Cluster B Personality Disorders Cluster **B**: **B**ad, **B**orderline, flam**B**oyant, must be the **B**est

Cluster B Personality Disorders: * disregard for and violation of rights of others with lack of remorse, criminality, and impulsivity * males \> females * must be ≥ 18 years old and have history of conduct disorder before age 15 * conduct disorder if \< 18 years old * "**B**ad"

Antisocial

Cluster B Personality Disorders: * unstable mood and interpersonal relationships, impulsivity, self-mutilation, suicidality, and sense of emptiness * females \> males * splitting is a major defense mechanism * Treatment: dialectical behavior therapy

**B**orderline

Cluster B Personality Disorders: * excessive emotionality and excitability, attention seeking, sexually provocative, and overly concerned with appearance * flam**B**oyant

Histrionic

Cluster B Personality Disorders: * grandiosity and sense of entitlement * lacks empathy and requires excessive admiration * often demands the “**B**est” and reacts to criticism with rage

Narcissistic

Personality Disorders: * anxious or fearful * genetic association with anxiety disorders * “worried”

Cluster C Personality Disorders Cluster **C**: **C**owardly, obsessive-**C**ompulsive, **C**lingy

Cluster C Personality Disorders: * hypersensitive to rejection, socially inhibited, timid, feelings of inadequacy, desires relationships with others (vs. schizoid) * **C**owardly

Avoidant

Cluster C Personality Disorders: * preoccupation with order, perfectionism, and control * Ego-Syntonic: behavior consistent with one’s own beliefs and attitudes (vs. OCD)

Obsessive-**C**ompulsive

Cluster C Personality Disorders: * excessive need for support * low self-confidence * patients often get stuck in abusive relationships * submissive and **C**lingy

Dependent

Psychopathology: * symptoms are intentional, motivation is intentional * patient consciously fakes, profoundly exaggerates, or claims to have a disorder in order to attain a specific 2° (external) gain (eg. avoiding work, obtaining compensation) * poor compliance with treatment or follow-up of diagnostic tests * complaints cease after gain (vs. factitious disorder)

Malingering

Psychopathology: * symptoms are intentional, motivation is unconscious * patient consciously creates physical and/or psychological symptoms in order to assume “sick role” and to get medical attention and sympathy (1° [internal] gain)

Factitious Disorders

Factitious Disorders: * also known as Munchausen syndrome * chronic factitious disorder with predominantly physical signs and symptoms * characterized by a history of multiple hospital admissions and willingness to undergo invasive procedures * more common in women and healthcare workers

Factitious Disorder Imposed on Self

Factitious Disorders: * also known as Munchausen syndrome by proxy * illness in a child or elderly patient is caused or fabricated by the caregiver * motivation is to assume a sick role by proxy * form of child/elder abuse

Factitious Disorder Imposed on Another

Psychopathology: * symptoms are unconscious, motivation is unconscious * category of disorders characterized by physical symptoms causing significant distress and impairment * symptoms not intentionally produced or feigned * more common in women

Somatic Symptom and Related Disorders

Somatic Symptom and Related Disorders: * variety of bodily complaints (eg. pain, fatigue) lasting for months to years * associated with excessive, persistent thoughts and anxiety about symptoms * may co-occur with medical illness * Treatment: * regular office visits with the same physician in combination with psychotherapy

Somatic Symptom Disorder

Somatic Symptom and Related Disorders: * also known as functional neurologic symptom disorder * loss of sensory or motor function (eg. paralysis, blindness, mutism), often following an acute stressor * patient may be aware of but indifferent toward symptoms (“la belle indifférence”) * more common in females, adolescents, and young adults

Conversion Disorder

Somatic Symptom and Related Disorders: * also known as hypochondriasis * excessive preoccupation with acquiring or having a serious illness, often despite medical evaluation and reassurance * minimal somatic symptoms

Illness Anxiety Disorder

Psychopathology: most common in young females

Eating Disorders

Eating Disorders: * intense fear of weight gain and distortion or overvaluation of body image leading to restriction of caloric intake and severe weight loss (BMI \< 18.5 kg/m²) * restricting and binge/purge subtypes * associated with ↓ bone density (often irreversible), amenorrhea (due to loss of pulsatile GnRH secretion), lanugo, anemia, and electrolyte disturbances * commonly coexists with depression * psychotherapy and nutritional rehabilitation are first line * pharmacotherapy includes SSRIs for comorbid anxiety and/or depression

Anorexia Nervosa

Eating Disorders: * ↑ insulin → hypophosphatemia, hypokalemia, hypomagnesemia → cardiac complications, rhabdomyolysis, seizures * can occur in significantly malnourished patients

Refeeding Syndrome

Eating Disorders: * binge eating with recurrent inappropriate compensatory behaviors (eg. self-induced vomiting, using laxatives or diuretics, fasting, excessive exercise) occurring weekly for at least 3 months and overvaluation of body image * body weight often maintained within normal range * associated with parotitis, enamel erosion, electrolyte disturbances (eg. hypokalemia, hypochloremia), metabolic alkalosis, dorsal hand calluses from induced vomiting (Russell sign) * Treatment: * psychotherapy * nutritional rehabilitation * antidepressants (eg. SSRIs) * Bupropion is contraindicated due to seizure risk

Bulimia Nervosa

Eating Disorders: * regular episodes of excessive, uncontrollable eating without inappropriate compensatory behaviors * ↑ risk of diabetes * Treatment: * psychotherapy such as CBT is first line * SSRIs * Lisdexamfetamine

Binge Eating Disorder

Psychopathology: persistent cross-gender identification that leads to persistent distress with sex assigned at birth

Gender Dysphoria

Gender Dysphoria: desire to live as the opposite sex, often through surgery or hormone treatment

Transsexualism

Gender Dysphoria: * paraphilia, not gender dysphoria * wearing clothes (eg. vest) of the opposite sex (cross-dressing)

Transvestism

Psychopathology: * Includes sexual desire disorders (hypoactive sexual desire or sexual aversion), sexual arousal disorders (erectile dysfunction), orgasmic disorders (anorgasmia, premature ejaculation), and sexual pain disorders (dyspareunia, vaginismus) * Differentials: * Drug Side Effects (eg. antihypertensives, antipsychotics, SSRIs, ethanol) * Medical Disorders (eg. depression, diabetes, STIs) * Psychological or Performance Anxiety (eg. nighttime erections [nocturnal tumescence])

Sexual Dysfunction

Psychopathology: * inconsolable periods of terror with screaming in the middle of the night * occurs during slow-wave/deep (stage N3) sleep * most common in children * occurs during non-REM sleep (no memory of the arousal episode) as opposed to nightmares that occur during REM sleep (remembering a scary dream) * cause unknown, but triggers include emotional stress, fever, or lack of sleep * usually self limited

Sleep Terror Disorder

Psychopathology: * urinary incontinence ≥ 2 times/week for ≥ 3 months in person \> 5 years old * First-Line Treatment: * behavioral modification (eg. scheduled voids) * positive reinforcement * For Refractory Cases: * bedwetting alarm * oral Desmopressin (ADH analog; preferred over imipramine due to more favorable side effect profile)

Enuresis

Psychopathology: * disordered regulation of sleep-wake cycles characterized by excessive daytime sleepiness (despite feeling rested upon waking) and “sleep attacks” (rapid-onset, overwhelming sleepiness) * caused by ↓ hypocretin (orexin) production in lateral hypothalamus * strong genetic component * Also associated with: * hypnagogic (just before going to sleep) or hypnopompic (just before awakening; “pompous upon awakening”) hallucinations * nocturnal and narcoleptic sleep episodes that start with REM sleep (sleep paralysis) * cataplexy (loss of all muscle tone following strong emotional stimulus, such as laughter) in some patients * Treatment: * good sleep hygiene (scheduled naps, regular sleep schedule) * daytime stimulants (eg. amphetamines, modafinil) and nighttime sodium oxybate (GHB)

Narcolepsy

Substance Use Disorder

Maladaptive pattern of substance use defined as 2 or more of the following signs in 1 year related specifically to substance use: * Tolerance—need more to achieve same effect * Withdrawal—manifesting as characteristic signs and symptoms * substance taken in larger amounts, or over longer time, than desired * persistent desire or unsuccessful attempts to cut down * significant energy spent obtaining, using, or recovering from substance * important social, occupational, or recreational activities reduced * continued use despite knowing substance causes physical and/or psychological problems * Craving * recurrent use in physically dangerous situations * failure to fulfill major obligations at work, school, or home * social or interpersonal conflicts

Stages of Change in Overcoming Substance Addiction

1. Precontemplation—not yet acknowledging that there is a problem 2. Contemplation—acknowledging that there is a problem, but not yet ready or willing to make a change 3. Preparation/Determination—getting ready to change behaviors 4. Action/Willpower—changing behaviors 5. Maintenance—maintaining the behavioral changes 6. Relapse—returning to old behaviors and abandoning new changes, does not always happen

Psychiatric Emergencies: * Cause: * any drug that ↑ 5-HT. * Psychiatric Drugs: * MAO inhibitors, SSRIs, SNRIs, TCAs, Vilazodone, Vortioxetine * Nonpsychiatric Drugs: * Tramadol, Ondansetron, Triptans, Linezolid, MDMA, Dextromethorphan, Meperidine, St. John’s Wort * **3 A**’s: * ↑ **A**ctivity (neuromuscular) * **A**utonomic stimulation * **A**gitation * symptoms of neuromuscular hyperactivity include clonus, hyperreflexia, hypertonia, tremor, and seizure * symptoms of autonomic stimulation include hyperthermia, diaphoresis, diarrhea * Treatment: * Cyproheptadine (5-HT2 receptor antagonist)

Serotonin Syndrome

Psychiatric Emergencies: * Cause: carcinoid tumor of GI tract or lung * diarrhea, flushing, wheezing, and right heart disease (if tumor is in the gut) * Treatement: Octreotide

Carcinoid Syndrome

Psychiatric Emergencies: * Cause: * eating tyramine-rich foods (eg. aged cheeses, cured meats, wine) while taking MAO inhibitor * tyramine displaces other neurotransmitters (eg. NE) in the synaptic cleft → ↑ sympathetic stimulation * Treatment: Phentolamine

Hypertensive Crisis

Psychiatric Emergencies: * Causes: * antipsychotics + genetic predisposition * myoglobinuria, fever, encephalopathy, vitals unstable, ↑ enzymes (eg. ↑ CK), rigidity of muscles (“lead pipe”) * Treatment: * Dantrolene * Dopamine Agonist (eg. Bromocriptine) * discontinue causative agent

Neuroleptic Malignant Syndrome **M**alignant **FEVER**: * **M**yoglobinuria * **F**ever * **E**ncephalopathy * **V**itals unstable * ↑ **E**nzymes (eg. ↑ CK) * **R**igidity of muscles (“lead pipe”)

Psychiatric Emergencies: * Cuase: * inhaled anesthetics, Succinylcholine + genetic predisposition * fever and severe muscle contractions * Treatment: Dantrolene

Malignant Hyperthermia

Psychiatric Emergencies: * Cause: * alcohol withdrawal * occurs 2–4 days after last drink * classically seen in hospital setting when inpatient cannot drink * altered mental status (eg. hallucinations), autonomic hyperactivity, anxiety, seizures, tremors, psychomotor agitation, insomnia, nausea * Treatement: * Benzodiazepines (eg. Chlordiazepoxide, Lorazepam, Diazepam)

Delirium Tremens

Psychiatric Emergencies: * Cause: * typical antipsychotics * anticonvulsants (eg. Carbamazepine) * Metoclopramide * sudden onset of muscle spasm, stiffness, oculogyric crisis that occurs within hours to days after medication use * can lead to laryngospasm requiring intubation * Treatment: * Benztropine * Diphenhydramine

Acute Dystonia

Psychiatric Emergencies: * Cause: * change in lithium dosage or health status (narrow therapeutic window) * concurrent use of Thiazides, ACE Inhibitors, NSAIDs, or other nephrotoxic agents * nausea, vomiting, slurred speech, hyperreflexia, seizures, ataxia, and nephrogenic diabetes insipidus * Treatment: * discontinue lithium * hydrate aggressively with isotonic sodium chloride * consider hemodialysis

Lithium Toxicity

Psychiatric Emergencies: * Cause: TCA overdose * respiratory depression, hyperpyrexia, prolonged QT interval * **Tri**-**C**’s: * **C**onvulsions * **C**oma * **C**ardiotoxicity (arrhythmia due to Na⁺ channel inhibition) * Treatment: * supportive treatment * monitor ECG * NaHCO₃ (prevents arrhythmia) * activated charcoal

Tricyclic Antidepressant Toxicity

Psychoactive Drug Intoxication and Withdrawal: * Intoxication: * nonspecific, mood elevation, ↓ anxiety, sedation, behavioral disinhibition, respiratory depression * Withdrawal: * nonspecific, anxiety, tremor, seizures, insomnia

Depressants

Psychoactive Drug Intoxication and Withdrawal: * Intoxication: * emotional lability, slurred speech, ataxia, coma, blackouts * serum γ-glutamyltransferase (GGT)—sensitive indicator of alcohol use * AST value is 2× ALT value * Withdrawal: * 3–36 hr: tremors, insomnia, GI upset, diaphoresis, mild agitation * 6–48 hr: withdrawal seizures * 12–48 hr: alcoholic hallucinosis (usually visual) * 48–96 hr: delirium tremens (DTs) * Treatment: Benzodiazepines

Alcohol To**AST 2 AL**cohol: **AST** value is **2**× **AL**T value

Psychoactive Drug Intoxication and Withdrawal: * Intoxication: * euphoria, respiratory and CNS depression, ↓ gag reflex, pupillary constriction (pinpoint pupils), seizures (overdose) * most common * cause of drug overdose death * Treatment: Naloxone * Withdrawal: * sweating, dilated pupils, piloerection (“cold turkey”), fever, rhinorrhea, lacrimation, yawning, nausea, stomach cramps, diarrhea (“flu-like” symptoms) * Treatment: * long-term support * Methadone * Buprenorphine

Opioids

Psychoactive Drug Intoxication and Withdrawal: * Intoxication: * low safety margin * marked respiratory depression * Treatment: * symptom management (eg. assist respiration, ↑ BP) * Withdrawal: * delirium * life-threatening cardiovascular collapse

Barbiturates

Psychoactive Drug Intoxication and Withdrawal: * Intoxication: * greater safety margin * ataxia * minor respiratory depression * Treatment: * Flumazenil (Benzodiazepine receptor antagonist, but rarely used as it can precipitate seizures) * Withdrawal: * sleep disturbance, depression, rebound anxiety, and seizure

Benzodiazepines

Psychoactive Drug Intoxication and Withdrawal: * Intoxication: * nonspecific, mood elevation, psychomotor agitation, insomnia, cardiac arrhythmias, tachycardia, and anxiety * Withdrawal: * nonspecific, post-use “crash,” including depression, lethargy, ↑ appetite, sleep disturbance, and vivid nightmares

Stimulants

Psychoactive Drug Intoxication: * euphoria, grandiosity, pupillary dilation, prolonged wakefulness and attention, hypertension, tachycardia, anorexia, paranoia, fever * skin excoriations with methamphetamine use * Severe: cardiac arrest, seizures * Treatment: * Benzodiazepines for agitation and seizures

Amphetamines

Psychoactive Drug Intoxication: * impaired judgment, pupillary dilation, hallucinations (including tactile), paranoid ideations, angina, and sudden cardiac death * chronic use may lead to perforated nasal septum due to vasoconstriction and resulting ischemic necrosis * Treatment: * α-Blockers * Benzodiazepines * β-Blockers not recommended

Cocaine

Psychoactive Drug Intoxication and Withdrawal: * Intoxication: * restlessness, ↑ diuresis, and muscle twitching * Withdrawal: * headache, difficulty concentrating, and flu-like symptoms

Caffeine

Psychoactive Drug Intoxication and Withdrawal: * Intoxication: * restlessness * Withdrawal: * irritability, anxiety, restlessness, and difficulty concentrating * Treatment: * nicotine patch, gum, or lozenges * Bupropion/Varenicline

Nicotine

Psychoactive Drug Intoxication: * hallucinogen * violence, impulsivity, psychomotor agitation, nystagmus, tachycardia, hypertension, analgesia, psychosis, delirium, and seizures * trauma is the most common complication

Phencyclidine (PCP)

Psychoactive Drug Intoxication: * hallucinogen * perceptual distortion (visual, auditory), depersonalization, anxiety, paranoia, psychosis, possible flashbacks

Lysergic Acid Diethylamide

Psychoactive Drug Intoxication and Withdrawal: * Intoxication: * euphoria, anxiety, paranoid delusions, perception of slowed time, impaired judgment, social withdrawal, ↑ appetite, dry mouth, conjunctival injection, and hallucinations * pharmaceutical form is Dronabinol: used as antiemetic (chemotherapy) and appetite stimulant (in AIDS) * Withdrawal: * irritability, anxiety, depression, insomnia, restlessness, and ↓ appetite

Marijuana (Cannabinoid)

Psychoactive Drug Intoxication and Withdrawal: * Intoxication: * hallucinogenic stimulant * euphoria, disinhibition, hyperactivity, distorted sensory and time perception, and teeth clenching * life-threatening effects include hypertension, tachycardia, hyperthermia, hyponatremia, and serotonin syndrome * Withdrawal: * depression, fatigue, change in appetite, difficulty concentrating, and anxiety

MDMA (Ecstasy)

Psychopathology: * physiologic tolerance and dependence on alcohol with symptoms of withdrawal when intake is interrupted * Complications: * alcoholic cirrhosis, hepatitis, pancreatitis, peripheral neuropathy, and testicular atrophy * Treatment: * Disulfiram (to condition the patient to abstain from alcohol use) * Acamprosate * Naltrexone (reduces cravings), * supportive care * Support groups such as Alcoholics Anonymous are helpful in sustaining abstinence and supporting patient and family.

Alcoholism

Psychopathology: * caused by vitamin B1 deficiency * triad of confusion, ophthalmoplegia, and ataxia (Wernicke encephalopathy) * may progress to irreversible memory loss, confabulation, and personality change (Korsakoff syndrome) * symptoms may be precipitated by giving dextrose before administering vitamin B1 to a patient with thiamine deficiency * associated with periventricular hemorrhage/necrosis of mammillary bodies * Treatment: IV Vitamin B1

Wernicke-Korsakoff Syndrome

Psychopharmacology: ADHD

Stimulants * Methylphenidate * Amphetamines

Psychopharmacology: Alcohol Withdrawal

Benzodiazepines * Chlordiazepoxide * Lorazepam * Diazepam

Psychopharmacology: Bipolar Disorder

* Lithium * Valproic Acid * Carbamazepine * Lamotrigine * Atypical Antipsychotics

Psychopharmacology: Bulimia Nervosa

SSRIs

Psychopharmacology: Depression

SSRIs

Psychopharmacology: Generalized Anxiety Disorder

* SSRIs * SNRIs

Psychopharmacology: Obsessive-Compulsive Disorder

* SSRIs * Venlafaxine * Clomipramine

Psychopharmacology: Panic Disorder

* SSRIs * Venlafaxine * Benzodiazepines

Psychopharmacology: PTSD

* SSRIs * Venlafaxine

Psychopharmacology: Schizophrenia

Atypical Antipsychotics

Psychopharmacology: Social Anxiety Disorder

* SSRIs * Venlafaxine * Performance Only: * β-Blockers * Benzodiazepines

Psychopharmacology: Tourette Syndrome

* Antipsychotics * Fluphenazine * Risperidone * Tetrabenazine

Central Nervous System Stimulants

* Methylphenidate * Dextroamphetamine * Methamphetamine

Psychopharmacology: * ↑ catecholamines in the synaptic cleft, especially norepinephrine and dopamine * used for ADHD and narcolepsy * causes nervousness, agitation, anxiety, insomnia, anorexia, tachycardia, hypertension, weight loss, and tics

Central Nervous System Stimulants

Typical Antipsychotics

* Haloperidol * Pimozide * Trifluoper**azine** * Fluphen**azine** * Thiorid**azine** * Chlorprom**azine**

Psychopharmacology: * block dopamine D2 receptor (↑ cAMP) * used for Schizophrenia (1° positive symptoms), psychosis, bipolar disorder, delirium, Tourette syndrome, Huntington disease, and OCD

Typical Antipsychotics

Typical Antipsychotics: High Potency

**Try** to **Fl**y **High**: * **Tri**fluoperazine * **Fl**uphenazine * **H**aloperidol \*more neurologic side effects (eg. extrapyramidal symptoms [EPS])

Typical Antipsychotics: Low Potency

**Ch**eating **Th**ieves are **low**: * **Ch**lorpromazine * **Th**ioridazine \*more anticholinergic, antihistamine, α1-blockade effects

Typical Antipsychotics: Adverse Effects

* lipid soluble → stored in body fat → slow to be removed from body * Endocrine: dopamine receptor antagonism → hyperprolactinemia → galactorrhea, oligomenorrhea, gynecomastia * Metabolic: dyslipidemia, weight gain, hyperglycemia * Antimuscarinic: dry mouth, constipation * Antihistamine: sedation * α1-Blockade: orthostatic hypotension * Cardiac: QT prolongation * Ophthalmologic: * **C**hlorpromazine—**C**orneal deposits * **T**hioridazine—re**T**inal deposits * Neuroleptic Malignant Syndrome

Extrapyramidal Symptoms

**ADAPT**: * Hours to Days: * **A**cute **D**ystonia (muscle spasm, stiffness, oculogyric crisis) * Treatment: * Benztropine * Diphenhydramine * Days to Months: * **A**kathisia (restlessness) * Treatment: * β-Blockers * Benztropine * Benzodiazepines * **P**arkinsonism (bradykinesia) * Treatment: * Benztropine * Amantadine * Months to Years: * **T**ardive Dyskinesia (orofacial chorea) * Treatment: * switch to atypical antipsychotic (eg. Clozapine) * Tetrabenazine * Reserpine

Atypical Antipsychotics

* Aripiprazole * Asen**apine** * Cloz**apine** * Olanz**apine** * Queti**apine** * Ilo**peridone** * Pali**peridone** * Ris**peridone** * Luras**idone** * Zipras**idone**

Psychopharmacology: * not completely understood * most are D2 antagonists (Aripiprazole is D2 partial agonist) * varied effects on 5-HT2, dopamine, and α- and H1-receptors * used for schizophrenia—both positive and negative symptoms * also used for bipolar disorder, OCD, anxiety disorder, depression, mania, and Tourette syndrome * Clozapine is used for treatment-resistant schizophrenia or schizoaffective disorder and for suicidality in schizophrenia

Atypical Antipsychotics

Atypical Antipsychotics: Adverse Effects

* All * prolonged QT interval * fewer EPS and anticholinergic side effects than typical antipsychotics * “-pines” * metabolic syndrome (weight gain, diabetes, hyperlipidemia) * Clozapine * agranulocytosis (monitor WBCs frequently) and seizures (dose related) * Risperidone * hyperprolactinemia (amenorrhea, galactorrhea, gynecomastia) * **O**lanzapine, Cl**O**zapine → **O**besity

Psychopharmacology: * MOA not established; possibly related to inhibition of phosphoinositol cascade * used as mood stabilizer for bipolar disorder * treats acute manic episodes and prevents relapse * causes tremor, hypothyroidism, polyuria (causes nephrogenic diabetes insipidus), and teratogenesis * causes Ebstein anomaly in newborn if taken by pregnant mother * narrow therapeutic window requires close monitoring of serum levels * almost exclusively excreted by kidneys * most is reabsorbed at PCT with Na⁺ * Thiazides (and other nephrotoxic agents) are implicated in toxicity

Lithium **L**i**THIUM**: * **L**ow **T**hyroid (hypothyroidism) * **H**eart (Ebstein anomaly) * **I**nsipidus (nephrogenic diabetes insipidus) * **U**nwanted **M**ovements (tremor)

Psychopharmacology: * stimulates 5-HT1A receptors * used for generalized anxiety disorder * does not cause sedation, addiction, or tolerance * takes 1–2 weeks to take effect * does not interact with alcohol (vs. Barbiturates and Benzodiazepines)

Buspirone

Antidepressants

Selective Serotonin Reuptake Inhibitors (SSRIs)

* Fluoxetine * Fluvoxamine * Paroxetine * Sertraline * Escitalopram * Citalopram

Psychopharmacology: * inhibit 5-HT reuptake * normally takes 4–8 weeks to have an effect * used for depression, generalized anxiety disorder, panic disorder, OCD, bulimia, social anxiety disorder, PTSD, premature ejaculation, and premenstrual dysphoric disorder * Adverse Effects * fewer than TCAs * GI distress * SIADH * sexual dysfunction (anorgasmia, ↓ libido)

Selective Serotonin Reuptake Inhibitors (SSRIs)

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

* Venlafaxine * Desvenlafaxine * Duloxetine * Levomilnacipran * Milnacipran

Psychopharmacology: * inhibit 5-HT and NE reuptake * used for depression, general anxiety disorder, and diabetic neuropathy * Venlafaxine is also indicated for social anxiety disorder, panic disorder, PTSD, and OCD * Duloxetine is also indicated for fibromyalgia * causes ↑ BP, stimulant effects, sedation, nausea

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

Tricyclic Antidepressants

* Amitriptyline * Nortriptyline * Imipramine * Desipramine * Clomipramine * Doxepin * Amoxapine

Psychopharmacology: * TCAs inhibit 5-HT and NE reuptake * used for major depression, OCD (Clomipramine), peripheral neuropathy, chronic pain, and migraine prophylaxis * nocturnal enuresis (Imipramine, although adverse effects may limit use) * causes sedation, α1-blocking effects including postural hypotension, and atropine-like (anticholinergic) side effects (tachycardia, urinary retention, dry mouth) * 3° _____ (Amitriptyline) have more anticholinergic effects than 2° _____ (Nortriptyline) * can prolong QT interval * **Tri**-**C**’s: * **C**onvulsions * **C**oma * **C**ardiotoxicity (arrhythmia due to Na⁺ channel inhibition) * also causes respiratory depression and hyperpyrexia * confusion and hallucinations in the elderly due to anticholinergic side effects (Nortriptyline better tolerated in the elderly) * Treatment: NaHCO₃ to prevent arrhythmia

Tricyclic Antidepressants

Monoamine Oxidase Inhibitors

**MAO** **T**akes **P**ride **I**n **S**hanghai. * **T**ranylcypromine * **P**henelzine * **I**socarboxazid * **S**elegiline (selective MAO-B inhibitor)

Psychopharmacology: * nonselective _____ inhibition ↑ levels of amine neurotransmitters (norepinephrine, 5-HT, dopamine) * used for atypical depression, anxiety, and Parkinson disease (selegiline) * causes CNS stimulation and hypertensive crisis, most notably with ingestion of tyramine * contraindicated with SSRIs, TCAs, St. John’s wort, Meperidine, and Dextromethorphan (to prevent serotonin syndrome) * wait 2 weeks after stopping _____ before starting serotonergic drugs or stopping dietary restrictions

Monoamine Oxidase Inhibitors

Atypical Antidepressants: * inhibits NE and Dopamine reuptake * also used for smoking cessation * Toxicity: * stimulant effects (tachycardia, insomnia) * headache * seizures in anorexic/bulimic patients * favorable sexual side effect profile

Bupropion

Atypical Antidepressants: * α2-antagonist (↑ release of NE and 5-HT), potent 5-HT2 and 5-HT3 receptor antagonist and H1 antagonist * Toxicity: * sedation (which may be desirable in depressed patients with insomnia) * ↑ appetite * weight gain (which may be desirable in elderly or anorexic patients) * dry mouth

Mirtazapine

Atypical Antidepressants: * primarily blocks 5-HT2, α1-adrenergic, and H1 receptors * also weakly inhibits 5-HT reuptake * used primarily for insomnia, as high doses are needed for antidepressant effects * Toxicity: * sedation * nausea * priapism * postural hypotension

Trazodone Tra**ZZZ**o**bone**: * sedative * priapism

Atypical Antidepressants: * nicotinic ACh receptor partial agonist * used for smoking cessation * Toxicity: * sleep disturbance * may depress mood

Varenicline Vare**nicline** helps **ni**cotine cravings de**cline**.

Atypical Antidepressants: * inhibits 5-HT reuptake * 5-HT1A receptor partial agonist * used for major depressive disorder * Toxicity: * headache * diarrhea * nausea * ↑ weight * anticholinergic effects * may cause serotonin syndrome if taken with other serotonergic agents

Vilazodone

Atypical Antidepressants: * inhibits 5-HT reuptake * 5-HT1A receptor agonist and 5-HT3 receptor antagonist * used for major depressive disorder * Toxicity: * nausea * sexual dysfunction * sleep disturbances (abnormal dreams) * anticholinergic effects * may cause serotonin syndrome if taken with other serotonergic agents

Vortioxetine

Intravenous drug users at ↑ risk for \_\_\_\_\_.

* hepatitis * HIV * abscesses * bacteremia * right-heart endocarditis

Opioid Withdrawal and Detoxification: long-acting oral opiate used for heroin detoxification or long-term maintenance therapy

Methadone

Opioid Withdrawal and Detoxification: * sublingual B\_\_\_\_\_ (partial agonist) is absorbed and used for maintenance therapy * N\_\_\_\_\_ (antagonist, not orally bioavailable) is added to lower IV abuse potential

Buprenorphine + Naloxone

Opioid Withdrawal and Detoxification: * long-acting opioid given IM or as nasal spray to treat acute overdose in unconscious individual * also used for relapse prevention once detoxified

Naltrexone Use Nal**trex**one for the long **trex** back to sobriety.

Psychiatry - First Aid Flashcards

(195 cards)