CLERKSHIP STUDY GUIDE

Psychiatry

Prepared by Mark Tuttle

 Table of Contents
Topic Page
Psychiatric Disorders: Axis I
o Psychotic Disorders 1
o Anxiety & Adjustment Disorders 3
o Mood Disorders 5
o Disruptive Behavior 8
o Adjustment Disorders in Children 9
o Eating Disorders 10
o Somatoform and Factitious Disorders 12
o Substance Related Disorders 14
o Pervasive Developmental Disorders 16
o Delirium and Dementia 17
o Sexual Disorders 19
o Dissociative Disorders 21
o Impulse Control Disorders 22
o Chronic Pain 23
Psychiatric Disorders: Axis II
o Mental Retardation & Tourettes 24
o Personality Disorders 25
Psychopharmacology
o Antipsychotics & Anxiolytics 27
o Antidepressants & Mood Stabilizers 28
PSYCHIATRY CLERKSHIP STUDY GUIDE 2009, 2011 Mark Tuttle 1
PSYCHOTIC DISORDERS (AXIS I). Psychosis: break from reality with delusions, perceptual disturbances, and/or disordered thinking
Disorder Epidemiology Timeline Symptoms Treatment
Schizophrenia 1-1.5% lifetime prev Signs persist for 6+ months Symptoms must last for 6+ months Antipsychotics: 70% improve
Males=Females Age of onset below 45 2+ in 1 month Typical antipsychotic meds
Men: worse prognosis : 15-25, : 25-35 Delusions: Paranoia, idea of reference, grandiosity o Block dopamine receptor (D2)
Often born during 55% good outcomes Hallucinations: auditory (common), visual, tactile o Effective treat positive symptoms
winter months (viral?) 45% severe deterioration Disorganized speech: content and thought process o Prominent side effects
Lower SES: drift 1. Prodrome (years b4) Grossly disorganized/catatonic behavior Atypical antipsychotic meds
30-50% alcohol abuse 2. Psychosis Negative symptoms: o 1st line treatment
Genetic: 50% MZ twin, 3. Residual: negative
affect, anhedonia, apathy, apologia, attention o Block DA + 5-HT receptors
10% in 1 relatives symptoms between 1+ Social/occupational dysfunction o More treat negative symptoms
50% attempt suicide Ex. Work, interpersonal, self care Other drugs: Anticonvulsants,
15% complete suicide benzodiazepines, anti depressants
Etiology Neurotransmitters: Dopamine (limbic system): positive symptoms. Serotonin (prefrontal cortex): negative symptoms. NE: activity (anhedonia)
Brain imaging: Ventricular enlargement, cortical atrophy, hypoactivity of frontal lobes upon PET
Presentation: Appearance: bizarre posture/behavior. Mood: depressed (25%), Judgment: usually deficient (violence: 12%). Orientation: oriented but attention.
Neurological deficits: short-term memory deficit, unstable smooth pursuit, sensory gating ( tolerance to novel stimuli)
1. Perceptual disturbances: hallucinations (cenesthetic), usually auditory but can be visual, tactile (common in EtOH), olfactory (common in seizures)
2. Disordered thinking: inferred from speech
a. Process (Form): circumstantial (circuitous), loose associations (disconnected ideas), tangentiality (never reach point), pressured
(uninterruptable), perseverating, clang (related sounds make sentence), blocking (stop in middle of sentence), echolalia, neologisms, paraphasias.
b. Content: delusions, insertion (others are placing thoughts in head), broadcasting (others can hear thoughts)
3. Delusions: Paranoid, Idea of reference (things are related to pt), Idea of influence, Grandeur, Guilt (I caused the holocaust)
Subtypes Disorganized Prominent disorganized speech, inappropriate affect, NOT catatonic. Early onset
Paranoid preoccupation with particular delusion NONE OF: disorganized speech, catatonic, inappropriate affect. Later onset
Catatonic Motor immobility: catalepsy (immobile position), excessive motoric activity. Echolalia, echopraxia (mimic behavior) RAREST
Undifferentiated
Residual Absence of positive symptoms for some time, but still have negative symptoms
Brief psychotic Secondary to medical 1+ day but <1 month with 1+ of: Hospital, meds, psychotherapy
disorder condition if: prominent return to function Delusions, hallucinations, disorganized speech Good prognosis: 50-80% have no
delusions Disorganized speech further psychiatric problems
Delusional 0.03% 1+ months of non-bizarre Function is not impaired (vs. schizophrenia) Low dose antipsychotic
disorder More women delusions Erotomatic: delusions someone is in love
50% recover long term Jealous: unfaithful partner
30% have no change Mean age: 40 Somatic: defect
Schizo- 1/3 recover, Lasts 1-6 months, but Exclusion rules met for schizophrenia not other 3-6 months antipsychotics
phreniform 2/3: go to schizophrenia return to function criteria Supportive psychotherapy
Schizo- Less than 1% 2 weeks of delusions/ No mood symptoms in absence of psychotic sx Concurrent antipsychotics and
affective More women hallucinations in absence of MDD, manic, or mixed episode WITH symptoms of antidepressants
disorder Not clear link to mood symptoms schizophrenia
Schizophrenia Better prognosis than schizophrenia
PSYCHIATRY CLERKSHIP STUDY GUIDE 2009, 2011 Mark Tuttle 2
Movement Hemiballismus is an uncontrolled swinging of an extremity. It is usually sudden, and once initiated it cannot be controlled.
definitions Choreiform movements are involuntary, irregular, and jerky but lack the ballistic-like nature of hemiballismus.
Athetoid movements, or athetosis, are slow, snake-like movements of the fingers and hands.
Myoclonus is a sudden muscle spasm, and myotonia is prolonged muscle contraction.
Common Cotard syndrome: Nihilistic, I am dead. There is no world.
delusions Capgras syndrome: family members are replaced by imposters
Fregoli syndrome: shapeshifter is taking form of different people.
Xacodemomania: patient is inhabited by an evil spirit
Folie a deux: shared delusion
Cultural Koro is a traumatic fear that the penis is shrinking into the body cavity. Amok is a violent fit followed byamnesia.
psychosis Pseudocyesis is the physiologic signs and symptoms of pregnancy developing inthe absence of pregnancy.
Couvade syndrome occurs when the husband of a pregnant woman goes into a sort of labor.
Illusions Micropsia and macropsia are misperceptions of visual stimuli. Objects appear smaller (micropsia) or larger (macropsia) than they are in reality.
Palinopsia is the persistence of the visual image after the stimulus has been removed.
PSYCHIATRY CLERKSHIP STUDY GUIDE 2009, 2011 Mark Tuttle 3
ANXIETY & ADJUSTMENT DISORDERS (AXIS I): NE, 5-HT, GABA
Disorder Epidemiology Timeline Symptoms Treatment
Posttraumatic Begins anytime - Re-experiencing sx: flashbacks, nightmares 1. Psychotherapy: relaxation, EMDR
Stress Disorder Lasts > 1 month o Called abreaction if while in therapy 2. SSRIs or TCAs
(PTSD) - Avoidance of stimuli associated with trauma 3. Clonidine: arousal & reexperiencing
- Numbing of responsiveness (affect, detachment) 4. Anticonvulsants for nightmares
- Increased arousal or flashbacks (Valproic acid)
Adjustment Females 2:1 - Begins < 3 months after - Distress in response to identifiable stressor 1. Supportive psychotherapy
Disorder Most frequently stressor o Not life threatening (vs. PTSD). a. Most effective
adolescents - Ends < 6 months after - In excess of what is expected or impairs function 2. Group therapy
stressor. - Not bereavement 3. Pharmacotherapy for
(Is GAD if does not end) - Subtypes associated symptoms
- Or chronic (> 6 mo) if o Depressed mood (insomnia, anxiety, depression)
stressor recurs/persists o Anxiety
o Disturbance of conduct
Generalized Females 2:1 Lasts 6+ months - Excessive worry about daily events & activities - Acute episode: benzodiazepines
Anxiety Disorder 45% lifetime prevalence Chronic and lifelong - Associated symptoms (3+) - Combination of psychotherapy
(GAD) 50-90% have MDD, symptoms in 50% o Restlessness, fatigue, irritability and pharamacotherapy
phobia, panic 50% completely recover o Impaired concentration o Buspirone, benzodiazepines
o Muscle tension, sleep disturbance (taper immediately), SSRI
o Venlafaxine (EffexorTM)
Panic disorder 2-5% prevalence Multiple/day 1/year - Spontaneous recurrent panic attacks with no - Rule out organic cause (MI)
4-8x if 1 relatives Avg: 2/week obvious precipitant: ~ 25 min - Acute: benzodiazepines
40-80% comorbid MDD 10-20% persistent - Panic attack followed by 1+ month of: 1. Maintenance: SSRIs 8-12 mo.
20-40% substance 50% mild o Fear of panic attack, worry, change behavior a. Paroxetine (PaxilTM)
30-40% cured b. Sertraline (ProzacTM)
2. CBT, Relaxation, biofeedback
Specific phobia Phobias are the most 6+ months if < 18 - Anxiety brought on by specific situation 1. Behavioral: Sys. Desensitization
common mental o Reproducible a. Relaxation: Counter conditioning
disorders o Versus panic disorder fear of panic attack b.Reciporical inhibition
(followed by substance- - Patient knows fear is excessive c. Not pharmacotherapy
induced, MDE, OCD) 2. Psychotherapy
Social phobia - Anxiety brought on by fear of embarrassment 1. Pharmacotherapy
o Ex. public speaking, public performance a. SSRI: paroxetine (PaxilTM)
o Versus agoraphobia: fear of having panic b. -blocker for perc. Anxiety
attack in public space and unable to get help 2. CBT: correct automatic thoughts
Obsessive 3% lifetime prevalence - Obsessions relieved by compulsions 1. CBT: exposure and response
Compulsive 4th most common o 75% have obsession AND compulsion but can prevention
Disorder (OCD) mental disorder just be intrusive thoughts (ex. sex/violence) 2. SSRI (high dose)
- Ego dystonic (have insight) (vs. OCPD) 3. TCA: clomipramine (AnafranilTM)
- Common: contamination, doubt, symmetry
PSYCHIATRY CLERKSHIP STUDY GUIDE 2009, 2011 Mark Tuttle 4
Acute Stress Disorder PTSD Adjustment Disorder Generalized Anxiety Disorder Bereavement: Must be loss of a
Length Begins within 1 month Begins anytime Begins within 3 months. 6+ months loved one
Lasts less than 1 month Lasts over 1 month Lasts less than 6 months. Grief: Can be anything (divorce)
Stressor Identifiable stressor: Death/rape/grave danger Identifiable stressor: Not identifiable stressors: Pathological if > 1 yr or overtly
Re-experiencing, avoidance, arousal Not life threatening. vague, diffuse, multiple psychotic (other than seeing dead
Dissociation, derealization, depersonalization (generalized) relative or wanting to join them)
PSYCHIATRY CLERKSHIP STUDY GUIDE 2009, 2011 Mark Tuttle 5
MOOD DISORDERS (AXIS I)
Disorder Epidemiology Timeline Symptoms Treatment
Major depressive cortisol 2+ weeks - Depressed mood or anhedonia plus (5+ total):
episode (MDE) o 50% impaired o SIG E CAPS: sleep changes, loss of interest, guilt or
suppression w/dex worthlessness, concentration problems, appetite
catecholamines changes, psychomotor slowing, suicidal ideation
immune function - Can have psychotic features but must not be predominant
Euthyroid - Must cause social/occupational impairment
o 30% impaired TSH - Sleep:
suppression w/TRH o sleep latency
o AM awakening (melancholic), hypersomnia (atypical)
o REM redistributed to first half of night
Manic episode 93% recur 1+ week - Elevated mood or irritability plus (3+ total):
Untreated: resolve in 3 o DIG FAST: distractibility, indiscretion, grandiosity, flight
months frequency with of ideas, activity, sleep deficit, talkativeness
progression of disease (pressured speech)
- 75% have psychotic features
Mixed episode 1+ week of both - Need to fulfill criteria for both ME and MDE
Hypomanic 4+ days - Need 3+ manic symptoms
episode - No psychotic symptoms, no impairment of function
Major depressive Average onset: 40 years - Subtypes 1. SSRIs, TCAs: 70% improve
disorder (MDD) 50% recur in 2 years o Melancholic (40-60% of pts hospitalized for depression) Minimum 16 weeks
Untreated: resolve in 6-
Early morning awakening, anhedonia, anorexia 70% effective vs 30% placebo
12 months o Atypical (most common subtype) 2. MAOIs if refractory
2/3 suicidal ideation
Hypersomnia, reactive mood, hyperphagia Stimulants in terminally ill
15% complete suicide o Catatonic patients
MZ twins: 90% o Psychotic ECT indications
- SAD if depression only occurs in winter months o 2-3 failed medical trials
o Severe suicidality
o Catatonia, malnutrition
Bipolar I Stronger genetic link 7+ days (manic) - Only need 1 manic episode (dont need MDE) 1. Mood stabilizers: 50% improve
Bipolar II (25% in 1 relatives)than 2+ weeks (MDE) - 1 hypomanic episode AND 1 MDE a. Lithium
unipolar depresison b. Vaproate, carbamazepine
Cyclothymia 2+ years - Mild depression + hypomania for 2 years. No normal 2 mo. c. Olanzapine (ZyprexaTM)
<1% prevalence - Often coexist with borderline PD 2. Supportive psychotherapy
3. Electroconvulsive therapy
a. effective than in MDD
Dysthymia 20% get MDE 2+ years - Mild depression for 2 years with no 2 months euthymic 1. CBT + psychotherapy are
6% prevalence 20% get bipolar Onset <25 in 50% - Double depression: dysthymia + MDE most effective
25% lifelong symptoms - Never have psychotic features 2. Antidepressants (need 2)
PSYCHIATRY CLERKSHIP STUDY GUIDE 2009, 2011 Mark Tuttle 6
MOOD DISORDERS IN PREGNANCY (AXIS I)
Disorder Epidemiology Timeline Symptoms Treatment
Postpartum 50% of pregnancies < 2 weeks Heightened emotional reactivity Rest and social support contribute
blues/pinks o Predisposed to o 2-14 days postpartum o Can be mild depression or mild elation
depression
Postpartum 15% of pregnancies <4 weeks after delivery Same criteria as for major depressive episode SSRIs, but caution for breast-feeding
depression CBT
Postpartum 2% of pregnancies Usually within 2 weeks of Can have bipolar type manic symptoms Hospitalization
psychosis 30-50% risk in delivery and/or psychotic delusions Antipsychotics
subsequent
pregnancies

Rapid cycling: 4+ mood episodes in a year

Suicide
Risk factors for attempted suicide: 1) age 45+, 2) alcohol dependence, 3) rage/violence, 4) prior suicidal behavior, 5) male gender
Risk factors for completed suicide: white race, male gender, age > 45, single/divorced, Protestant/Jewish
Children: more likely to ingest substances
Adolescents: more likely to use firearms
PSYCHIATRY CLERKSHIP STUDY GUIDE 2009, 2011 Mark Tuttle 7

Major depressive disorder o Fragmented sleep

o Initial insomnia o Frightening dreams, + sleep latency
o Reduced slow-wave sleep Psychotic disorders
o Increased REM length o Sleep deprivation increases positive symptoms of psychosis
o Vs. primary insomnia o Dream content less bizarre in psychotics

Early-morning awakenings: depression o Decreased sleep efficiency

Rapid onset of REP depression Panic disorder

Symptoms: 1+ month insomnia, 2 weeks for depression o Sleep panic attacks, difficulty falling asleep, + body mvmt

Other criteria for MDD Generalized Anxiety Disorder
Bipolar disorder manic phase o Decreased sleep efficiency, total sleep time
o Decreased need for sleep o Increased sleep latency
Seasonal affective disorder o Sleep problems may predate GA
o Decreased slow wave sleep Chronic Pain
o Directly related to amount of sunlight o Less restorative, less deep sleep, more fragmented
o Treat with light therapy o Increased pain sensitivity, increased spontaneous pain
PTSD
o Difficulty remaining asleep
PSYCHIATRY CLERKSHIP STUDY GUIDE 2009, 2011 Mark Tuttle 8
DISRUPTIVE BEHAVIOR (AXIS I)
Disorder Epidemiology Timeline Symptoms Treatment
ADHD 5-7% school age Some symptoms were present Inattention (6+ for 6+ months) 1. CNS stimulants
children before age 7. Onset may be age 3 o Attention to detail fail (Ritalin, Adderall, pemoline)
Boys 3-5x but not detected until school age. o Difficulty sustaining attention Adjunctive: SSRI
2/3 comorbid with Must occur in two settings o Does not follow through 2. Psychotherapy
conduct disorder/ODD (ex. Home AND school) o Organization fail 3. Parental counseling
25% risk of developing Inconsistent with age/development o Avoids tasks that require sustained effort 4. Group Therapy
antisocial PD o Loses things, easily distracted
Genetics most likely Preschool: temper tantrum o Doesnt listen
a primary role Elementary: Difficult peers/ OR Hyperactivity/impulsivity (6+)
Psychosocial not noncompliance o Hyperactivity: often fidgets
primary. Adolescents: Internal sense of
Often leaves seat, runs or climbs
Maybe toxins: lead, restlessness rather than motor
Difficulty playing or leisuring
food additives, but Adults: chronic disorganization
Often on the go
no empirical support o 20% have symptoms
Often talks excessively
Dysregulation of NE continuing in adulthood o Impulsivity
Can have abnormal
Often blurts out answers
EEG
Often has difficulty awaiting turn

Often interrupts
Oppositional - 50% comorbid with 6+ months 4+ for 6+ months 1. Psychotherapy behavioral
Defiant ADHD o Loses temper (angry/resentful) 2. Parenting skills training
Disorder - 25% remit o Argues with adults
spontaneously o Defies adults
- May progress to o Deliberately annoys people
conduct disorder o Blames others for misbehavior
o Easily annoyed
o Spiteful
No violation of basic rights (vs. conduct dis.)
Conduct 40% develop antisocial 12+ months 3+ for 12+ months 3. Multimodal
Disorder PD Child-onset: before 10 years old o Aggression to people/animals a. Firm rules, consistent
Adolescent-onset 10+ years old o Destruction of property (ex. Fire) b. Psychotherapy behavior
o Deceitfulness or theft 4. Antipsychotics & lithium for
o Serious violations of rules aggression
Causes significant impairment 5. SSRI for impulsivity/aggression
All disruptive - Constitutional-temperamental factors childs behavior is not socially rewarding to parent, leads to less positive interactions  vicious circle
disorders - Subpar Parenting skills leads to bad parent/child interactions  vicious circle
- ODD/CD children can result from violent disciplinary techniques, less monitoring of behavior, reinforce bad behavior
- of variability explained by genes
Treatment: Parent training is best. Multimodal treatments: use school, family, community resources to clearly state/enforce behav. Expectations.
Individual therapy has limited potential, doesnt address entirety of biopsychosocial model. Medication may be used to treat aggression
PSYCHIATRY CLERKSHIP STUDY GUIDE 2009, 2011 Mark Tuttle 9
Adjustment Disorders in Children (Consequences of Developmental Trauma)
Disorder Epidemiology Timeline Symptoms Treatment
Reactive Usually before 5 years Type I (Inhibited): Do not respond in developmentally appropriate fashion to social interactions
Attachment old o Hypervigilant or ambivalent/contradictory
Disorder of Type II (Disinhibited): Varied/indiscriminant attachments
Infancy/ Early Pathogenic care (1+)
Childhood o Persistent disregard for childs basic emotional needs
o Disregard of physical needs
o Repeated changes of primary caregiver
Often malnourished
Weak crying response, no reciprocal smile response
Tactile defensiveness
Cruel to animals/siblings or other children
Abuse (phys/sex): 72% show L hemisphere frontal/temporal EEG abnormalities
Neglect: sensory deprivation leads to brain abnormalities
PTSD in 1+ month duration of disturbance Arousal symptoms (2+):
Children Occurs months/years after event o Difficulty falling/staying asleep
Re-experience symptoms, fears related to trauma event o Irritability or outburst of anger
Bedwetting, separation anxiety, less interpersonally o Hypervigilence
sensitive, less social o Exaggerated startle response
More likely to be aggressive Psychobiological
Avoidance symptoms (3+): o Increased muscle tone, startle response
o Efforts to avoid thoughts, feelings related to event o Sleep disturbance
o Inability to recall an important aspect o Increased catecholamine activity
o Markedly diminished interest o Limbic system abnormalities (113%)
o Feeling detachment/estrangement o Deregulation of hypothalamic-pituitary-adrenal axis (HPA) leads to prolonged fight-
o Restricted range of affect or-flight responses
o Sense of foreshortened future Loss of self-regulation, cant inhibit fight-or-flight
Acute Stress 10% lifetime Lasts 2 days 4 weeks max Exposed to traumatic event Overcome denial / avoidance, teach
Disorder in prevalence Must occur within 4 weeks of At least one re-experiencing event coping skills
Children (80% of child burn trauma 3+ of these during or afer event: Pharma: SSRI, anticonvulsant, ACT
victims get PTSD) o Sense of numbing, detachment, absence of PSA
Note: children perceive emotion Problem-focused coping
trauma differently and o Derealization o Attempt to control stressor
can be more o Depersonalization o Can be most effective unless
susceptible o Dissociative amnesia stressor is uncontrollable
o Reduced awareness Emotion-focused coping
o Attempting to reduce their own
arousal and distress, stress
PSYCHIATRY CLERKSHIP STUDY GUIDE 2009, 2011 Mark Tuttle 10
EATING DISORDERS (AXIS I)
Disorder Epidemiology Timeline Symptoms Treatment
Anorexia 1% of adolescent females Peak: 12-13, 17-18 years Body weight below 85% (vs. bulimia) Psychotherapy
Nervosa 95% female old Intense fear of gaining weight o CBT, psychodynamic
Developed countries, wealthy, Disturbed perceptions of weight/image SSRI adjunct: helps gain weight
non black 30-50% recover within a Amenorrhea for 3+ months (vs. bulimia) o For comorbid depression
MZ twins=50% few years Associated signs: o Paroxetine (PaxilTM)
Theories: Better prognosis if o Russells sign: scaring on dorsum of hand o Mirtazepine(RemeronTM)
Hypothalamic: lack of leptin younger onset, restricter o Salivary gland hypertrophy Hospitalize if:
Low t3 (thyroid) o Hypothermia o Weight below 80% (BMI <18.5)
Low CCK 5-10% die after 10 yrs o Lanugo hair o Bradycardia or other arrhythmia
Psychological: feminine ideal 20% die after 20 years o Cerebral atrophy o Altered mental status
Types: Metabolic disturbances: o Suicidal ideation
o Binge/purge o Hypochloremic hypokalemic met. acidosis o Severe metabolic disturbance
o Restricting
Inverted or flat T waves on EKG o Hypothermia
of deaths are heart-related
o Hypercholesterolemia
o Hormones

Euthyroid, cortisol, GH
o BUN (protein catabolism)
o Osteoporosis (75%)
Bulimia 3% of young women Binge 2+ times/week for Recurrent episodes of binge eating Psychotherapy, CBT, group
Nervosa 40% college females symptoms 3+ months o Followed by compensatory behavior o Usually non-responsive
95% female Normal weight or overweight (vs. anorexia) SSRIs, TCAs: reduce by 50%
50% anorexic get bulimia 1/3 improve Normal hormone levels (vs. anorexia) Hospitalize if:
Better prognosis than anorexia 1/3 stay the same Perception of self-worth is excessively o Suicidal
1/3 of patients are DM 1 1/3 get worse influenced by body weight o Severe metabolic disturbance
Types: Ego-dystonic (vs. anorexia)
o Purge: vomiting, laxatives, Associated signs:
diuretics o Russells sign: scaring on dorsum of hand
o Nonpurge: excessive o Salivary gland hypertrophy
exercise or fast o See: anorexia
Eating Binge 2+ days/week for Recurrent episodes of binge eating Psychotherapy
disorder, NOS 6+ months o Binge not followed by compensatory Cognitive behavioral therapy (CBT)
(Binge-eating behavior (vs. anorexia & bulimia) Pharmacotherapy
Disorder) Eat rapidly, a lot, alone o Stimulants: amphetamine
Feel uncomfortably full ( appetite)
Feel depressed, guilty or disgusted after binge o Orlistat (XenicalTM): inhibits
pancreatic libase - steatorrhea
o Sibutramine (MeridiaTM):
inhibits reuptake of NE, 5HT, DA
PSYCHIATRY CLERKSHIP STUDY GUIDE 2009, 2011 Mark Tuttle 11
Disorder Epidemiology Timeline Symptoms Treatment
Feeding 1+ months Persistent failure to eat with decreased
Disorder of Onset before 6 years old weight
Infancy Not due to lack of available food
Pica 10-30% children 1-6 years 1+ months Eating of non-nutritive substances Psychosocial/family guidance
10% over 10 Onset between 1-2 years. inappropriate to childs developmental level Environmental
of institutionalized mentally Usually remits by Complications: Poisoning, anemia, intestinal Behavioral
retarded children adolescence obstruction, parasites
Male=Female DDx includes Fe/Zinc deficiency,
Might be nutritional insufficiency Schizophrenia, Autism, Dwarfism, Klein-Levin
(ex. Fe) or prenatal neglect syndrome (sleep for weeks wake up
ravenously hungry)
Rumination Rare-Most common in 3mo-1yr + 1+ months Repeated regurgitation Operant procedures
Disorder MR children/adults Infants: weight loss, failure to thrive o time out
6% Adults: usually normal weight o Electric shock
Male=Female Can be: pleasure, tension-relieving, learned o Pepper sauce, lemon juice
(Adult = more common in males) attention-getting squirt on tongue
May be genetic DDx: gastroesophegeal reflux, Pyloric stenosis o Overcorrection wash lips, use
(projectile vomiting) soap, use lotion
Side effects: esophagitis, recurrent dental o Satiation, bring in food often
problems, excessive salivation, anemia, social
ostracism
Adults: no pain/nausea, no anatomical basis,
occurs in nervous people
PSYCHIATRY CLERKSHIP STUDY GUIDE 2009, 2011 Mark Tuttle 12
SOMATIFORM AND FACTICIOUS DISORDERS (AXIS I)
Primary gain: Serve to keep internal conflicts out of consciousness. Expression Secondary gain: Able to get out of obligation and stressful situation with manifested
of unacceptable feelings as physical sx in order to avoid dealing. The act itself symptoms. The consequences of the manifested symptoms are rewarding to the
helps relieve stressor internal motivation. Not conscious of gain. patient external motivation. Not conscious of gain
Disorder Epidemiology Timeline Symptoms Treatment
Somatization 0.1-0.5% *Must be < 30* Multiple somatic symptoms which cannot be Medical management
Disorder 80-95% Female explained medically o Avoid tests and procedures
Lower SES Chronic begins in o Patient unintentionally manifests symptoms o Reduce unnecessary drugs
adolescence, stress Involve multiple organ systems, must have: o Avoid giving sick leave
Genetic abnormal precipitate symptoms o 4 pain symptoms o Single physician for care
cortical function? o 2 GI symptoms o Regularly scheduled PCP visits
Comorbid: o 1 sexual symptom Second-line therapy
Substance abuse, o 1 pseudoneurological symptom o Relaxation
GAD, phobias, Seeks medical care often o Hypnosis
depression o Psychotherapy
Conversion 1-25% admitted to Resolve in 1 month DSM IV-TR Criteria Medical workup to rule out
disorder general medical setting o 1+ pseudoneurological symptom medical cause (35% medical cause)
Underlying medical o Associated with psychological trigger Symptoms resolve after hypnosis or
problem in 15-35% o Not due to general medical cause amobarbital
2-5x females o Causes distress or impairment in functioning Psychotherapy (insight oriented)
Young, less educated o Problem is not limited to pain or sexual dysfunction
5-15% of inpatients La belle indifference unaware/careless of symptoms
getting psych consult Common sx: shifting paralysis, seizures, mutism
Factitious 3-9% of hospital admits History of abuse Intentionally manifest physical or psychological Avoid unnecessary procedures
Disorder More Males symptoms in order to assume sick role
More common in o Want to be a patient (primary gain)
healthcare workers o Symptoms worsen during observation
(ex. insulin) No external incentives. (Not secondary gain)
Higher intelligence Munchausesns Syndrome: Mostly physical symptoms
Often depressed, Munchausesn by proxy: create illness in another in
hallucinations order to get sympathy. (Factitious NOS)
Malingering Usually Men Production of false psych/physical symptoms with Treat coexisting problems
(most common) EXTERNAL incentive (like avoiding military, jail)
Associated with antisocial PD too
Referred by an attorney
Hypochondriasis 4-6% 6+ months No symptoms of disease Group psychotherapy
Male=Female Starts 20-30 yrs 30-50% Misinterpret normal body functioning as sign of disease Reassurance
have improvement or fear disease Frequent regularly scheduled
Fears persist despite medical workup physicals to 1 PCP
PSYCHIATRY CLERKSHIP STUDY GUIDE 2009, 2011 Mark Tuttle 13
Disorder Epidemiology Timeline Symptoms Treatment
Pain disorder 2x females Acute: > 6 months Pain which is not fully accounted for by a medical or Rule out:
75 million have chronic Chronic: < 6 months neurological condition o Medical cause
pain o Can coexist with medical cause but degree of o Hypochondriasis
25-50% have impairment not explained by medical cause o Malingering
depression comorbid 1+ anatomic site Analgesics not helpful
Causes distress or impairment in functioning SSRIs
Related to psychological factors Nerve stimulation
Biofeedback
Psychotherapy
Body 2% of those requesting Gradual onset Belief that body is misshapen or defective in some way Treat coexisting anxiety, depression
Dysmorphic plastic surg imagined or exaggerated Serotonin, antidepressants
Disorder Male=Female Request surgery to correct perceived defect
50% depressed Shy, self absorbed, self-centered
75% psychotic
33% housebound

Somatiform: patients believe they are ill

Factitious: patients pretend they are ill
Malingering: patients pretend they are ill with external incentives
PSYCHIATRY CLERKSHIP STUDY GUIDE 2009, 2011 Mark Tuttle 14
SUBSTANCE-RELATED DISORDERS (AXIS I)
Disorder Epidemiology Timeline Symptoms
Substance 16.8% 12+ months 1+ within a 12 month period
Abuse alcohol: 13.8% o Failure to fulfill major role obligations o Use despite legal problems
o Use when it is physically hazardous (ex. Driving) o Persistent use despite problems caused
Substance 12+ months 3+ within a 12 month period
Dependence o Tolerance & cross tolerance (other drug) Great deal of time is spent trying to obtain
o Withdrawal Use despite physical/psychological problem
o Desire to cut down
o social, occupational activities as a result
o Using more than originally intended
Drug Detection Intoxication Withdrawal Treatment
EtOH Breathalyzer or BAC Disinhibition 6-24 H: insomnia, anxiety, irritability, DT: benzodiazepines
Ataxia tachycardia, hyperreflexia, delirium, o Long acting if good liver function
Hazardous drinking: Sedation HTN, seizures, hallucinosis: Thiamine (IM), folate
Men 5+ drinks/day, Respiratory depression hallucinations while alert and oriented Mg2+ for seizures
women 4+ drinks/day Delirium tremens: <72 H (20% mortality) Dependence: Naltrexone
o Visual/tactile hallucinations craving, AA
Cocaine and Urine
for 3 days Euphoria, hallucinations Dysphoria, depression Intoxication:
amphetamines Dilated pupils Irritability, fatigue 1. Benzodiazepines, TCAs
heart & respiratory rate, HTN Withdrawal
appetite 1. Psychotherapy, group therapy
Seizures 2. TCAs
3. Dopamine agonist
PCP NMDA Urine
for ~ 1 week Aggression, pain tolerance No withdrawal syndrome but 1. Acidify urine (ammonium)
antagonist CPK, AST Nystagmus (rotary), ataxia flashbacks common 2. Benzodiazepine, DA agonist
Muscle rigidity 3. Haloperidol if psychosis
a. But worsens hyperthermia
Sedative Urine
for 1 week Drowsiness More common with short acting drugs Intoxication: ABCs, charcoal
hypnotics Slurred speech Autonomic hyperreactivity, N/V/D 1. Barbiturates: alkalinize urine
Nystagmus, ataxia Tremor, insomnia 2. Benzodiazepiens: Flumenazil
Respiratory depression Delirium, hallucinations Withdrawal: Long-acting benzo
Coma Seizures Tegretol/valproate
Opioids Urine
for 12-36 hrs Drowsiness Not life threatening. Dysphoria, dreams Overdose: Naloxone
Constricted pupil (miosis) Lacrimation, rhinorrhea, N/V/D Withdrawal: Clonidine/buprenorphone
Seizures/respiratory depression Piloerection, generalized myalgias Dependence: Methadone and
Serotonin syndrome with MAOIs Dilated pupils (mydriasis), yawning psychotherapy
Inhalants Serum
for 4-10 hrs Ataxia 1. ABCs, supportive treatment
Hallucinogens LSD: Lysogenic acid Dilated pupils No withdrawal syndrome 1. talk down patient
Psilocybin, diethylamide Last 8-12 hours 2. Benzodiazepines
LSD Stimulant-like effects 3. Antipsychotics
PSYCHIATRY CLERKSHIP STUDY GUIDE 2009, 2011 Mark Tuttle 15
Drug Detection Intoxication Withdrawal Treatment
Caffeine 75% symptomatic in 12-48 hours
Headache (50%)
Depressed mood, irritability
Cramps, nausea
Nicotine Exuberant
Muscle twitching, cramps
Palpitations
Coma, respiratory failure at high
dose
PSYCHIATRY CLERKSHIP STUDY GUIDE 2009, 2011 Mark Tuttle 16
PERVASIVE DEVELOPMENTAL DISORDERS (AXIS I)
Disorder Epidemiology Timeline Symptoms
Pervasive 1/150 births Almost always have 6+ total symptoms
Developmental 70% have comorbid MR symptoms before 3 years Social Interaction Impairment (2+) Social Communication Problem (1+)
Disorder 75% moderate severity old o Impairment of nonverbal behavior Delay or lack of spoken language
Autistic Disorder (ex. Poor eye contact) o Stereotyped use of language
NOT due to psychological o Failure to develop peer relationships o Lack of varied or spontaneous play
trauma, bad parenting, o Lack of spontaneous seeking to share Restrictive Behavior/Interests (1+)
physical abuse, separation enjoyment o Intense preoccupation with object
anxiety o Inflexible adherence to rules
o Repetitive motor movements
Pervasive More common in males Preschool motor delays Same criteria for autism except: No delay in speech, cognitive development
Developmental More common in families School social No clinically significant adaptive impairment
Disorder where Aspergers is Adults- modulation of
Aspergers Disorder common behavior
Pervasive ONLY in Females Prenatal/Perinatal: head circumference growth velocity during 5-48 months
Developmental MECP2 gene on X Normal Loss of previously acquired hand skills
Disorder chromosome Normal first 5 months Early loss of social interaction, usually followed by subsequent improvement
Retts Disorder 5-38 months: deceleration Severely impaired language and psychomotor development
Lifelong impairment Trunk/gait problem
Seizures
Cyanotic spells
Pervasive Males 4:1 Normal first 2 years Loss of previously acquired skills in at At least two of the following:
Developmental Onset before age 10 least two areas: o Impaired social interaction
Disorder o 1. Language o Impaired use of language
Childhood o 2. Social skills o Restricted, repetitive, and
Disintegrative
Bowel or bladder control stereotyped behaviors and interests
Disorder
Play

Motor skills
Pervasive Severe, pervasive impairment in development of reciprocal social interaction and verbal/nonverbal communication.
Developmental Not otherwise specified by a personality disorder or schizophrenia.
Disorder NOS Sometimes called atypical autism
Assessment of Medical: RULE OUT AN ORGANIC CAUSE (EX. VISION PROBLEM) Physical
developmental o Maternal age & health during pregnancy, alcohol use, smoking o Somatic growth-height, weight
disorders o Gestation age at birth, perinatal complications, NICU o Head circumference
o Presence of infection, materal diabetes, jaundice, birth defects o Vision
o Neurological, cardiac problems, parents IQ Lab testing
Lab testing o Chromosomal analyses, molecular-genetic
o Chromosomal analyses, molecular-genetic, toxicity, LEAD o Toxicity: lead levels
Psychological evaluation Speech & language evaluation
o Developmental/intelligence, behavioral observation scales
PSYCHIATRY CLERKSHIP STUDY GUIDE 2009, 2011 Mark Tuttle 17
DELIRIUM AND DEMENTIA (AXIS I)
Disorder Epidemiology Timeline Symptoms Treatment
Delirium 2x Males Less than 1 Impaired consciousness 1. Quetiapine (SeroquelTM)
secondary to______ 10-25% medical month o Confusion, disorientation, distractibility, decreased or haloperidol
30% ICU Develops in attention, short term memory deficits 2. Avoid benzodiazepines,
40% hip fract. short period Change in cognition or perception especially in elderly since they
40% ventilators hours to days Acute onset (vs. schizophrenia), fluctuates (vs. dementia) can have a paradoxical
Risk: age (65+), alcohol, Evidence of underlying cause is available worsening effect
hiv, cancer, heart surg,
malnutr. Prodromal phase not usually diagnosed
Delirium Dementia o Sleep disturbances, anxiety, irritability
Onset Acute Insidious Hyperactivity, hypoactivity, hallucinations, fearfulness,
Duration Transient Months-years apathy, agitation, dysphasia
Alertness Impaired Normal WHIMP Wernickes encephalopathy, Hypoxemia,
Attention Impaired Normal Intracranial bleeding, Meningitis, Poisons
Sleep Awake @ night Awake @ night
(sundowning)
Dementia 15% of 65+ Slow onset Multiple cognitive deficits and personality changes
5% severe Presenile <65 Impair social/occupational functioning.
20% over 80 Senile >65 Short and long term memory problems
$148B
Dementia 60-70% of dementia Early: <65 Memory impairment and 1+ of 1. AChE inhibitors (rivastigmine)
Alzheimers type 2-4% 65+ Late: >65 o Aphasia: impairment of language 2. NMDA antagonist (memantine)
50% nursing home Usually 8 years o Apraxia: inability to perform learned movements 3. PRN benzodiazepines,
patients until death o Agnosia: inability to correctly interpret sensory info quetiapine(SeroquelTM)
Genetics ApoE4/E2 o executive function: ex. Managing finances
Age is biggest risk factor Causes social or occupational impairment (vs. MCI)
Not exclusively during delirium
Dementia More Males Variable Same symptoms as Alzheimers plus focal neurologic Same as AD (AChE inhibit etc), treat
Vascular type 15-30% of all dementias More abrupt, findings CVD, control BP
Risk factors: earlier than CT/MRI multiple lesions of cortex/subcortical DDx: Alzheimers, TIAs if brief
hypertension, atrial Alzheimers, structures symptoms and RECOVER
fibrillation, CHD more stepwise
PSYCHIATRY CLERKSHIP STUDY GUIDE 2009, 2011 Mark Tuttle 18
Disorder Epidemiology Timeline Symptoms Treatment
Dementia More Males 50-60 years old Primary cortical dementia
Frontotemporal 5% of all irreversible Atrophy of frontotemporal regions, neuronal loss
type (Picks Disease) dimentia Impulsivity, irritability
Hard to distinguish from Alzheimers
Dementia 1/1million 40s-60s Definite: biopsy showing spongiform change NO TREATMENT
CJ mad cow disease Death within 6 Probable: Rapid onset of dementia, burst EEG, and 2+:
months- 2 o Myoclonus
years o Cortical blindness
o Ataxia, extrapyramidal symptoms
o Muscle atrophy
o Mutism
Prodrome: lethargy, fatigue, depression
Dementia 20-30% have dementia Slow movements, slow thinking L-Dopa, deep brain stimulation
Parkinsons type 30-40% have cog impair Cardinal signs: bradykinesia, tremor, rigid, posture
Secondary subcortical dementia
Degeneration of dopamine-releasing neurons in basal
ganglia substantia nigra pars compacta
Normal Pressure Wet, Wacky, Wobbly - Shunting of cereb. Aqueduct
hydrocephalus Urinary incontinence, Dimentia, Ataxia
Defective CSF drainage/reabsorption
Amnestic Disorder Causes: seizure, head Transient: Inability to learn new information OR inability to recall
trauma, tumor, CV <1month old information
disease, MS Persistent: 1+ Due to medical condition (Axis III)
Can be Immediate memory is INTACT
gradual/ Poor insight: confabulation make up answers
sudden Lack of initiative, blunted affect
Causes: trauma, tumor, cv disease, alcohol use,
Benzodiapines (during surg), OTC drugs
Amnesia Minutes to Inability to learn new information AND inability to Prognosis: Almost always recover
Transient Global hours recall recent information
Amnesia Causes: transient vascular insufficiency, tumors,
benzodiapines, migraines, embolism, arrhythmias
Personal ID not lost
Amnesia - Alcohol induced Can last 3 Comorbid Wernickes Encephalopathy confusion, Thiamine helps: 25% recover totally,
Korsakoffs months after ataxia, ophthalmoplegia 25% never recover
Syndrome treatment Confabulation, apathy, passivity
PSYCHIATRY CLERKSHIP STUDY GUIDE 2009, 2011 Mark Tuttle 19
SEXUAL DISORDERS (AXIS I)
Disorder Epidemiology Symptoms Treatment
Sexual Dysfunction A disturbance in sexual response cycle or pain with intercourse The marital unit is the patient
Causes marked distress or interpersonal difficulty Dual sex therapy: meet with male
Not caused by substance abuse or medical condition and female counselors
Examples of problems: performance anxiety, spectatoring, Behavior therapy
inadequate communication, distraction Hypnosis, psychotherapy
Physiological stages of sex P-LI-SS-IT Model
o Desire o Permission: empathy
o Excitement o Limited Information: educate
o Plateau o Specific Suggestions
o Orgasm
Improve communication
o Resolution o Intensive Therapy (specialist)

Trauma, serious issues
Desire Phase Disorders
Hypoactive sexual desire Persistent or recurrent deficiencies in or absence of sexual Testosterone (if low levels)
disorder fantasies and desire for sexual activity
Sexual aversion disorder Mostly in women as a Persistent or recurrent extreme aversion to, and avoidance of all
result of past sexual genital sexual contact
trauma
Excitement Phase Disorders
Dyspareunia 11% Male or Female Pain with before/during/after sexual intercourse without findings Gradual desensitization
1. Muscle relaxation
2. Erotic massage
Vaginismus 5% Female only Involuntary spasm of outer 1/3 of vagina that interferes with sex Vaginal dilation with fingers or
Higher SES o Also occurs with tampon insertion device. Kegal exercises
Strict religious upbringing
Female Sexual Arousal Inability to attain/maintain until completion of sexual activity Masturbation
Disorder Swelling response of female (60%) SS: lubricant, vaginal dilator
Lysis of clitoral adhesions
Male Erectile Disorder Primary: never had an erection Yohimbine
Secondary: have had erections in past Sildenavil (Viagra)
Most commonly psychological not biological cause. IV alprostadil
Vacuum pump, ring, surgery
Orgasm Phase Disorders
Premature ejaculation 35% of male sex disorders Ejaculation with minimal stimulation Gradual progression to vaginal
squeeze technique
SSRI side effect helps
Female/Male Orgasmic 30% of women Delay or absence of orgasm LI: explain conditioned response
Disorder SS: SSRIs, stop-start exercise
IT: learn to self-stimulate
PSYCHIATRY CLERKSHIP STUDY GUIDE 2009, 2011 Mark Tuttle 20
Disorder Epidemiology Timeline Symptoms Treatment
Gender Identity Disorders
Gender Identity Disorder Increased incidence of Gender identity is Strong, persistent cross gender identification Treatment is a long process
(transsexuality) comorbid depression, usually developed by Discomfort with ones own sex which causes Psychosocial therapy: sex
anxiety disorder, age 3 distress or impairment reassignment therapy, behavioral
suicide Children: cross dressing, strong preference of therapy, hormones
other sex playmates Live as other sex for 12 months
Adults: stated desires, passing as other sex, Sex reassignment surgery with
conviction of being other sex, request for long term psychotherapy
surgery/hormones Rarely become comfortable with
own biology
Compulsive Sexual Behaviors Least restrictive therapy first
Nonparaphilic compulsive Normal activities taken to extremes Psychotherapy (insight oriented)
Paraphilic disorder 6+ months Unusual sexual activities or fantasies Cognitive behavioral therapy
Poor prognosis: Impairs functioning in 1+ areas o Aversive conditioning to disrupt
Early age of onset Causes impairment in daily functioning the learned abnormal behavior
Comorbid Types: o Covert sensitization: pair images
substance abuse o Exhibitionism: exposure to strangers of negative consequences with
High frequency o Fetishism: inanimate objects sexually arousing fantasies
Law enforcement o Necrophilia: dead people o Victim empathy
Good prognosis o Telephone scatologia: calling strangers o 12-step programs
Self-referral o Frotterism (non-consenting) Pharmacological therapy
Sense of guilt o Masochism (own suffering) o Antiandrogens in hypersexual
History of normal o Sadism (other suffering) paraphilia in men
activity o Transvestic
o Voyeurism
Paraphilic Disorder: Often sexually abused 6+ months Fantasies of prepubescent under 13 years
Pedophilia For diagnosis: act on impulses and/or are
distressed by fantasies
o Distress not necessary
Hypersexual disorders
Hypersexual Disorder 6+ months Recurrent, intense, fantasies/urges
Not paraphilia
Compulsive: self-stimulation, multiple
partners, telephone/internet
Comorbidites: substance abuse, mood
disorders, anxiety disorders, impulse control
Contrast with OCD: OCD compulsion is
unwanted, but hypersexual are wanted
PSYCHIATRY CLERKSHIP STUDY GUIDE 2009, 2011 Mark Tuttle 21
DISSOCIATIVE DISORDERS (AXIS I): Loss of memory, identity, or sense of self. NOT due to medical or substance (this would be amnestic disorder)
Disorder Epidemiology Timeline Symptoms Treatment
Dissociative > Amnesia is the only dissociative symptom present 1. Retrieve memory to
Amnesia Young > old Not troubled by memory loss prevent recurrence
Common in child Causes marked impairment or distress a. Hypnosis
abuse Usually triggered by a traumatic/stressful event b. Amobarbital
Dissociative Fugue Alcohol/depression Hours-years Sudden travel from home with inability to remember parts of past or c. Ativan
identity 2. Psychotherapy
Often assume new identity
Unaware of amnesia
Causes marked impairment or distress
Dissociative Rare. 90% 2+ distinct personalities which alternate control of person
Identity Disorder 1/3 attempt suicide Each are mostly unaware of each other
Depersonalization 2: 1 Must be Recurrent feelings of detachment from self, environment, social status 1. Antianxiety PRN
Disorder Age 15-30 recurrent. o Reality testing intact during episode 2. Antidepressant PRN
Single episode o Feel like an outside observer
is normal Aware of symptoms, feel like they are going crazy
stress reaction Causes marked impairment or distress
Ganser Syndrome Vorbeireden: approximate answers to questions (ex. 2+2=5)
prison psychosis Somatic symptoms
Reaction to extreme stress
Mimic behavior of mental illness: echolalia, echopraxia
PSYCHIATRY CLERKSHIP STUDY GUIDE 2009, 2011 Mark Tuttle 22
IMPULSE CONTROL (AXIS I): Inability to resist behavior that may be harmful to self/others. Anxiety relieved by impulse. May be remorseful or not.
Disorder Epidemiology Timeline Symptoms Treatment
Intermittent << Episodes remit quickly Impulses of assault or property destriction 1. SSRI, anticonvulsant, lithium,
Explosive Disorder 5-HT Out or proportion to trigger propanolol
Usually feel remorseful afterward 2. Group Therapy
Psychotherapy not helpful
Kleptomania > May occur during stress Stealing not for personal or monetary gain 1. Insight-oriented psychotherapy
of bulimics Chronic course Pleasure derived from act of stealing 2. Behavior therapy
a. Systematic desensitization
b. Aversive therapy
3. SSRIs
Pyromania < Prognosis better in children >1 intentional fire setting 1. Behavioral therapy
Common in MR Tension before fire, relived afterward 2. SSRI
Fascination with fire
Not for monetary gain or expression of anger
Pathological 5+ symptoms of gambling addiction (do laterTM) 1. Gamblers anonymous
gambling 2. Insight-oriented psychotherapy

Trichotillomania > Often after stressful event Recurrent pulling out of hair resulting in visible 1. SSRI, antipsychotic
1-3% (25%) hair loss 2. Hypnosis
Comorbid with o Can be eyebrows, pubic hair 3. Behavioral therapy
OCD/OCPD Tension before, relieved by action
Causes marked distress or impairment
PSYCHIATRY CLERKSHIP STUDY GUIDE 2009, 2011 Mark Tuttle 23
CHRONIC PAIN  PAIN IS SUBJECTIVE
Disorder Epidemiology Timeline Symptoms Treatment
Chronic Pain Unrelated to 3+ months Pain without apparent biological cause
intensity or physical
Chronic Pain severity of original 6+ months Pain without apparent biological cause, which is MALADAPTIVE Prevention
Syndrome injury (distinguish from chronic pain) Return to active ASAP
Excessive use of medications, restriction of daily activities Take active role in own pain
Psych variables Might be pain doesnt worsen, but individual fails to adapt/cope management
(depression, anxiety) Factors: depression, kinesiophobia, inactivity Psychological testing
most accurate Biological factors Beck depression inventory
predictors, not o Physiologic dysfunction tissue dmg MMPI
severity of injury etc. o Genetics may be neurotransmitter o 1: Most pathological (CPS)
o Gender o 2: V profile (CP but not mal)
o Pain experience based on prior pain o 3: Chronic medical (not psyc)
Psychological factors most predictive o 4: Normal
o Meaning of pain Behavior- CBT
o Perception of control Transition out of sick role
o Coping style Reduce maladaptive behavior
o Secondary gains Modify beliefs, attitudes
o Pain-inactivity, pain-depression cycles Non-drug strategies
Risk factors Exercise, physical methods
o Depression, low activity, excessive pain behavior, maladaptive CBT
congnitions, fear/avoidance Chiropractic, acupuncture
o Somatization, PTSD, Age, job dissatisfaction, substance Homeopathic, relaxation,
hypnosis
Ex. Thermal biofeedback for
migraine
o Resulted in greater reduction
in headache than progressive
muscle relaxation or EMG
biofeedback
PSYCHIATRY CLERKSHIP STUDY GUIDE 2009, 2011 Mark Tuttle 24
MENTAL RETARDATION (AXIS II)
Disorder Epidemiology Timeline Symptoms
Developmental Before age 22 Functional limitations in 3+ areas
Disability Service needs are life long o Self care, Learning, Mobility
o Receptive/expressive language
o Self-direction, Independent living
o Economic self sufficiency
Mental Retardation 1-3% of population Onset before 18 Sub average IQ: >70
Concurrent deficits in 2+ areas: See list for developmental disability
Subtype: Organic 1.4x Males No discernable pathologic basis
(Idiopathic) higher in non-white Comorbid: epilepsy, cerebral palsy, autism, fetal alcohol, downs
Subtype: PREnatal 7-15% of MR, 30-40% unknown Fragile-X: 30-50%, Down syndrome, TORCHES infections
(Genetic) Chromosomal: 30% severe, 4-8% mild Prader-willi: 50-70% of paternal deletion
Subtype:PERInatal 1.6-1.9x with mom smoker 5% show signs at birth. 80-
or postnatal Fetal alcohol, anoxia, lead, mercury 90% serious problems by 2
Learning Disorder Reading disorder (3%): 3x < expected achievement for R/u organic cause (ex. vision)
Math disorder (5%): more age, education, intelligence
Written expression (3-10%) Not organic cause
Expressive Selective mutism: wont speak in certain situations only but has
Language Disorder normal language development
TOURETTES AND OTHER DISORDERS
Disorder Epidemiology Timeline Diagnosis Treatment
Tourettes Disorder Occurs in 0.05% of children 12+ months Motor and vocal tics (Need both) Pimozide/Haloperidol
Males 3:1 Onset between ages 7 and 8 Tics occur many times a day, almost Clonidine
Co-morbidity with OCD and ADHD 1. Eye: blinking/rolling every day for > 1 year Atypical antypsychotic
MZ twin concordance: 50% 2. Facial: licking o No tic-free period > 3 months Pimozide/Haloperidol
Etiology: DA dysregulation in caudate 3. Vocal: throat clearing Onset prior to age 18 Supportive psychoT
4. Whole body: pelvic Distress or impairment in Stimulants make tics
5. Self-abusive social/occupational functioning worse
Enuresis Normally continent before 4 3+ months Involuntary voiding after age 5 Rule out medical cause
7% of 5-year olds Occurs twice per week for 3 months (DM, seizures, urethritis)
Primary never previously continent Causes marked impariment 1. Behavioral (classical)
Secondary after previously continent 2. Pharmacotherapy
a. DDVP (ADH)
i. H2O intoxication
b. TCAs (imipramine)
Encopresis Normally continent before 4 3+ months Must be 4+ years old Rule out medical cause
1% of 5-year olds Involuntary or intentional passage of (anal fissure, IBD)
feces in inappropriate places Psychotherapy
Occurs once/month for 3+ months Stool softeners
PSYCHIATRY CLERKSHIP STUDY GUIDE 2009, 2011 Mark Tuttle 25
PERSONALITY DISORDERS (AXIS II)
Deeply ingrained, inflexible patterns of relating to others that are maladaptive and cause significant impairment in social or occupational functioning.
Ego-syntonic: Lack insight about their problems
DSM IV-TR Criteria
o Pattern of behavior/inner experience which deviates from culture, manifested by 2+:

Cognition

Affect

Personal relations

Impulse control
o Pattern is pervasive and inflexible, stable, onset no later than early adulthood, leads to distress in functioning, not result of another illness
Affect 1% of the population
Not otherwise specified: Passive-aggressive, sadistic (hurt others), sadomasochistic (hurt self and others)
Disorder Epidemiology Timeline Symptoms Treatment
PERSONALITY DISORDERS - CLUSTER A (MAD)
Schizoid PD 7.5% Dont really Prefer to be alone 1. Psychotherapy
(least severe) Men marry No desire for close relationships - Group therapy good - can
Women may Little interest in sex (with another person) provide only social contact
Can be comorbid passively Take pleasure in few activities 2. Pharmacotherapy PRN
with depression agree to Indifferent to criticism - Antidepressant if MDD
marry Emotional coldness, detachment, flat affect - Antipsychotics (short course)
No association with Choose solitary activities
schizophrenia Gravitate to solitary jobs
No loss of reality (no ideas of reference)
Schizotypal PD 3% May remain Magical thinking (not cultural) (clairvoyance, telepathy) 1. Psychotherapy
(middle Men, more common stable o Think their thoughts can have special powers on others. 2. Pharmacotherapy PRN
severity) familially Odd, eccentric appearance/behavior - Antidepressant if MDD
30-50% have MDD Odd habits, thinking, or superstition - Antipsychotics (low dose)
10% commit suicide Suspicious of others
Inappropriate/restricted affect
Excessive social anxiety
Unusual perceptive experiences
Ideas of reference
Paranoid PD 0.5%-2.5% Hostile, angry 1. Psychotherapy
(most severe) Males, minorities, Preoccupied with trustworthiness/loyalty of others 2. Pharmacotherapy PRN
immigrants, Reluctance to confide in anyone - Anti-anxiety
relatives of Interpretation of remarks as being threatening - Antipsychotics (short course)
schizophrenics Recurrent suspicions of infidelity of spouse
75% comorbid with Ideas of reference, not delusion (vs. Schizophrenia, paranoid type)
other PD
PSYCHIATRY CLERKSHIP STUDY GUIDE 2009, 2011 Mark Tuttle 26
Disorder Epidemiology Timeline Symptoms Treatment
PERSONALITY DISORDERS - CLUSTER B (BAD)
Histrionic PD 2-3% Show less Theatrical expression of emotion: temper tantrums 1. Psychotherapy
Female symptoms as Uncomfortable when not center of attention 2. Pharmacotherapy PRN
Comorbid with they age Inappropriately provocative. Use physical appearance to gain attention - Antidepressant
somatization and Speech is impressionistic, lacks details
depression Easily influenced by others
Superficial Constant need for praise
relationships Use regression as a defense mechanism
Narcissistic PD <1% Aging handled Lack of empathy. Sense of superiority. 1. Psychotherapy
50-75% MEN poorly Takes advantage of others for self-gain (vs. antisocial for subjugation) - Dont prick the bubble
Preoccupied with fantasies of unlimited wealth, power, success 2. Pharmacotherapy PRN
Envious of others. Believes others are envious of them.
Believes they are special and can only associate with high-status ppl
Antisocial PD 3% men, 1% women MUST begin in NO REMORSE for harmful actions. 1. Psychotherapy
50-75% prisoners adolescence Wont conform to society: violates laws 2. Pharmacotherapy PRN
r/o secondary Childhood conduct (15) and must Impulsivity, recklessness, irresponsibility - Treat anxiety and
to substance disorder. Hx of be 18 at dx Irritability, aggression depression but caution
abuse abuse, harming May or Manipulative con men. Intelligent. Charming when first encountered due to addictive
animals, fires with age High risk for suicide, depression personality.
Borderline PD 2-3% Get worse Unstable interpersonal relationships, self image, mood 1. Psychotherapy
2:1 Female with age Desperately avoid real or perceived abandonment - Cognitive behavioral
Women: 3-10x likely burnout. If Impulsive: sex, substance, spending - Substance abuse
to be victim of incest they can Recurrent suicidal thoughts and self-mutilation 2. Pharmacotherapy PRN
10% suicide. survive 20s, Problems controlling anger - Antidepressants (SSRI)
prognosis is Feel alone in the world - Antipsychotics
decent Splitting defense mechanism, see as all good or all bad
PERSONALITY DISORDERS - CLUSTER C (SAD)
Dependent 2.5% Want others to make decisions, feel helpless when alone,Im weak 1. Psychotherapy: independence
Women>men Difficulty initiating projects on their own 2. Pharmacotherapy
80% comorbid PD Urgently seek new partner if one is lost - Antidepressant
Avoidant 1% Can function WANT FRIENDSHIPS, just hard to form (vs. schizotypal/ schizoid) 1. Psychotherapy
Common in timid well Fear of rejection (vs. fear of embarrassment in agoraphobia) - Encourage interaction
infants Unable to interact unless assured that person will like them 2. Pharmacotherapy
Genetic predisposition Prone to depression
Obsessive- 2x men Course not Preoccupation with details such that main point of activity is lost 1. Psychotherapy: Group
Compulsive predictable Perfectionism detrimental to completing task 2. Pharmacotherapy
Personality EGO-SYNTONIC Will not delegate tasks. Miserly. Rigid, serioius, formal - Antidepressants
Disorder (vs. OCD) Workaholic: motivated by activity itself (vs. narcissitic by success) - Anxiolytics
Hoard meaningless objects.
 Antipsychotics
D2+4 antag: Tx positive sx
o Delusions
o Hallucinations
o Disorganized thought
5-HT antag: Tx negative sx
o Affect
o Anhedonia
o Apathy
o Alogia: speech
o Attention
Class
Typical
(1st Generation)
D2, D4 Antagonists
More anti-emetic , anti-
hiccup, anti-itch effects
from D2 block
Roughly equivalent
efficacies
Atypical
(2nd Generation)
5-HT2A Antagonists
First-line for schizophrenia
Principles of therapy: try 1 medication for 4 weeks. If it fails, switch to a different medication in the same class.
Anxiolytics
Buspirone (BuSpar) - 5-HT1A agonist
Benzodiazepines - GABA agonists
Takes 1-2 weeks for peak therapeutic effect; only days for adverse effects. NOT drugs of abuse.
- Antipychosis: mesolimbic + mesocortical pathways - Anti-HAM effects
- EPS (Extra-pyrimidal): Nigrostriatal pathway (pseudoparkinsonism) o H1 R antagonist
o Tx:Amantadine (SymmetrelTM), diphenhydramine (BenadrylTM), benztropine (CogentinTM)
Sedation
- Neuroleptic malignant syndrome (rare, anticholinergics ineffective): 20% mortality
Antiemetic
o Fever, autonomic labiality, leukocytosis, tremor, rigidity, CPK , rhabdomyolysis (26%) o 1 R antagonist
o Tx: 1) d/c drug, 2) supportive: cooling blanket, IVF, bromocriptine or dantrolene
Hypotension
- Tardive dyskinesia (10-30% of chronic users) (worsened by anticholinergics)
Sexual dysfunction

Repetitive involuntary movement (lip smacking). Worse with longer-term antipsychotic Tx o AntiMuscarinic effects

Hypersensitive D2 Rs; Tx with Clozapine
Typical atropine-like effects
- Hyperprolactinemia: Tubuloinfundibular (Less GnRH): libido, galactorrhea, amenorrhea - Weight gain
- Acute effects due to dopamine antagonism - Liver enzyme elevation
- Chronic effects due to D2 autoreceptors decreasing dopamine release - Seizures
- Used in the treatment of: schizophrenia, bipolar (manic phase), delusional disorder.
Class Side effects Drug Other Effects
- Stronger EPS side effects (vs. atypical) - Chlorpromazine(ThorazineTM) - Less EPS (vs. high potency)
Low potency
o Acute dystonia: torticollis, oculogyric crises TM
- Thioridazine (Mellaril ) - Strong Anti-HAM

Tx: anticolinergics: benztropine (CogentinTM) - Need eye exam:
o Akathisia (restlessness): o Chlorpromazine: Retinal deposits

Tx: -blockers, benzodiazepines o Thiordiazine: Corneal deposits
o Parkinsonism TM
- Haloperidol (Haldol ) - Strong EPS (vs. low potency)

Tx: anticholinergics (CogentinTM),
High potency
TM
- Fluphenazine (Prolixin ) - Less anti-HAM (vs. low potency)
Trihexyphenidyl (ArtaneTM), - Thiothixine (Navane TM
) - Pimozide: prolonged QT syndrome
Amantadine (SymmetrelTM) (releases DA), - Trifluoperazine (SterazineTM) - Haldol also tx Tourettes & Huntington
o Perioral tremor - Perphenazine (Trilaon )TM

Tx: anticolinergics: benztropine (CogentinTM) - Pimozide (OrapTM)
- Anti-HAM: H1, 1, Muscarinic antagonism - Clozapine (ClozarilTM) (strongest D4) - Clozapine: only one with no EPS
- Advantages versus typical antipsychotics - Risperidol (RisperdalTM) o Agranulocytosis (1%)
o EPS, TD - Olanzepine (ZyprexaTM) o Seizures (2-5%)
o Do not prolactin levels - Quetiapine (SeroquelTM) - Risperdol: most EPS, hyperP
o Increased efficacy, especially negative symptoms - Ziprazidone (GeodonTM) - Olanzepine: No hyperP
- Disadvantages versus typical antipsychotics o No weight gain (vs. all others) - Quetiapine: cataracts
o efficacious on positive symptoms - Zotepine (NipoleptTM) not USA o Can treat mania
o weight gain, type II DM, metabolic syndrome - Aripiprazole (AbilifyTM) o Helps insomnia causes sedation
o More cardiotoxic (QT prolongation) - Amisulpride (SolianTM) - Ziprasidone: QT prolongation
- Aripiprazole
o weight gain
o hyperprolactinemia
- Used in GAD, augment treatment in MDD, OCD - Sedation, dizziness, GI disturbance
- -
Antidepressants Takes 2-3 weeks for peak therapeutic effect; only days for adverse effects. NOT drugs of abuse. Most effective for MDD.
Mechanism Drug Pharmacokinetics Adverse Effects
Tricyclic - Imipramine (TofranilTM) (NE, 5-HT) - Need to establish homeostasis: takes a - 3Cs: convulsions, coma, cardiac arrhythmias
NE+5HT Reuptake o Also treats nocturnal enuresis few weeks for effect o Wide QRS, prolonged PR, prolonged QTc
Indications - Amitriptylene (ElavilTM) (NE>5-HT) - Delay due to downregulation of - Anti-HAM
- Depression o Less 1 block postsynaptic ARs and presynaptic 2Rs o Anti-H1: Sedation
TM
- Chronic pain - Nortriptyline (Pamelor ) (NE) o Anti-1: Hypotension (orthostasis)
- Desipramine (NorprminTM) (NE) o Anti-Muscarinic: dry mouth, blurred vision,
- Doxepin (SinequanTM) constipation, urinary retention, delirium
TM
- Clomipramine (Anafranil ): OCD - Weight gain
- Maprotiline (LudiomilTM) (NE)
Serotonin-selective - Fluoxetine (ProzacTM) : preg. safe! - Delay of effect due to downregulation of - Nausea/Vomiting/Diarrhea (most common)
Reuptake Inhibitors (SSRIs) o Treats comorbid hypersomnia 5-HT2A receptors - Agitation, akathisia, insomnia (worsened)
And 5-HT2A R antag o Only one indicated in children - Discontinuation syndrome - Sexual: libido, anorgasmia (), impotence ()
TM
Indications - Sertraline (Zoloft ) o Flu-like sx, vomiting, lethargy - Safe in overdose: minimal cardiotoxicity
- MDD, PTSD - Paroxetine (PaxilTM) o Especially with paroxetine (short t) - Serotonin Syndrome (w/ MAOIs, Li+, Carbemaz.)
TM
- OCD, Bulemia - Escitalopram (Lexapro ) o Altered mental status, diaphoresis, seizures
TM
- Panic disorder - Fluvoxamine (Luvox ): OCD too o Autonomic: orthostasis, hyperthermia, diarrhea
- PMS - Citalopram(CelexaTM) o Myoclonus, hypertension
o Most specific for 5-HT reuptake - Avoid in pregnancy
Serotonin and NE - Duloxetine (CymbaltaTM) Noradrenergic and specific serotonergic - Mirtazapine (RemeronTM): 1, 2, 5-HT2+3 antag.
reuptake inhibitors o Also diabetic neuropathy antidepressant (NaSSA) (no reuptake) o 2 block potentiates 5-HT1: appetite, weight
ATYPICALS

(SNRIs) - Venlafaxine (EffexorTM) o Also treats comorbid insomnia

Indications
- MDD
- Panic/Agoraphobia
- GAD
MAO Inhibitors
Indications (2nd line)
- MDD (atypical), SAD
- Social phobia
- Panic disorder
Mood Stabilizers
Acute episodes ? and
prophylaxis
Other indications
- Adjunct for MDD,
schizophrenia
- Alcoholism
- Aggression/impulsivity
o Also treats GAD
TM
- Desvenlafaxine (Pristiq )
- Amoxapine (DefanylTM)
o Also an antipsychotic  TD
- Phenelzine (NardilTM)
- Selegiline (ZelaparTM) (MAO-B)
- Tranylcypromine (ParnateTM)
- Isocarboxazid (MarplanTM)
MAO-A: 5-HT, NE, DA metabolism
MAO-B: DA metabolism
TM
- Lithium (Lithobid ) (NE, 5-HT)
TM
- Valproic acid (Depakote )
TM
- Carbamazepine (Tegretol )
- Lamotrigine (LamictalTM)
Serotonin antagonist and reuptake
inhibitors (SARIs)
Norepinephrine-dopamine reuptake
inhibitors (NDRI) Tx: MDD > 8hrs old, SAD
- Inhibit MAO irreversibly
o Long-acting (must regenerate MAO)
o Need 10 day washout period before
starting an SSRI, TCA
- Inhibition of CYP450 causes interactions
- Long-term Tx for manic episodes
- Lithium
o Narrow therapeutic range: 0.7-1.2 mEq
o Avoid in renal failure patients
o Blocks IP3 cycle in NE/5-HT effects
- Trazodone (DesyrelTM): 1 & 5-HT1A,1C,2 antagonist
o Short t. Priapism, orthostasis. Tx:insomnia
- Bupropion (WellbutrinTM, ZybanTM)
o seizure risk, no sexual side effects/wt gain
- Not first-line because of interactions:
o TCAs & SSRIs
o Tyramine-rich foods (cheeses, wine, beer)
o Sympathomimetics, Levodopa  HTN crisis
o Buspirone  hypertension
o Meperidine
- Lithium : Anything Na+  Li+ excretion ( Li)
o Dose-related: GI distress, tremor, and headache
o Idiosyncratic: Arrhythmias: flat/inverted T-wave
(usually benign), goiter, hypoT, leukocytosis,
diabetes insipidus (nephrogenic), alopecia
o Teratogenic: Ebstein anomaly (7.7%: 20x risk)
o NSAIDs (not aspirin) availability
- Valproic acid: fat, shaky, bald, yellow
o Wt gain, tremor, alopecia, jaundice, pancreatitis
o Teratogenic: neural tube defects