Psychiatry

Psychiatry

260
Psychiatry
Anxiety
General overview
Patient ■ Anxiety -> Worry - Fear - Hypervigilance a
■ Physical presentation -> Palpitation - Perspiration - Dyspnea - Chest pain
■ Sex : Female > Male
■ Age : 20s
■ +/- MDD
■ +/- Alcohol self medication
Generalized anxiety disorder (GAD)
C/P ■ Chronic insidious low level persistent anxiety
■ About most things
■ In most days
■ ≥ 6 months duration
■ ≥ 3 somatic complaints -> Fatigue - Change in sleep - change in weight - Irritability
- Change in concentration - Muscle tension - Restlessness
■ Not better explained by another medical condition, mental disorder, or substance
Dx Clinical
Tx ■ Psychotherapy -> better than medications
■ Medications
● Chronic -> 1st line (SSRIs) - 2nd line (Buspirone “May used if patient has erectile
dysfunction”)
● Acute (Panic attacks) -> Benzodiazepines b
Panic disorder c
C/P ■ Acute , Overt , Catastrophic anxiety attacks
■ Come out of the blue
■ Not provoked
■ Might experience agoraphobia along with panic disorder d
■ C/P -> ≥ 4 of the following -> Mnemonic (STUDENTS PANIC)
S Shortness of breath P Palpitation
T Trembling A Abdominal pain
U Unsteadiness N Nausea
D Depersonalization I Intense fear of death
E Excessive heart rate (Tachycardia) C Chest pain
N Numbness
T Tingling
S Sweating
Dx ■ ECG - Troponins -> to rule out Acute coronary syndrome
■ TSH -> to rule out hyperthyroidism
■ History of asthma or wheezing on examination -> To rule out asthma
Tx ■ Medications -> Better than psychotherapy
● Acute -> Benzodiazepines
● Chronic -> SSRIs -> to reduce the frequency of panic attacks
■ Psychotherapy -> CBT

MDD -> Major depressive disorder SSRI -> Selective serotonin reuptake inhibitor CBT -> Cognitive behavioral therapy
TCA -> Tricyclic antidepressant

a Hypervigilance is a state of heightened alertness accompanied by behavior that aims to prevent danger
b It’s better not to prescribe Benzdiazepines for patient with GAD -> as they may become dependent on them
c Increased sensitivity to lactate infusion is associated with panic attacks -> Amygadala in brain responds to low pH
and helps control our response to fea
d ■ Agoraphobia -> anxiety in situations where the person perceives their environment to be unsafe with no easy
way to escape.These situations can include open spaces, public transit, shopping centers, or simply being
outside their home
■ Patients with panic attacks may have agoraphobia -> Due to fear of occurrence of panic attack in public places
■ Tx -> SSRI -> If not adequately controlled , CBT would be treatment of choice (not adjusting her medication)

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Psychiatry
Phobia
C/P Fear that’s exaggerated and / or irrational against specific thing or situation
Specific phobia -> Heights - Situations - Spiders - Clowns - Snakes -> ≥ 6 months
Social phobia (Social anxiety disorder) ->
■ Marked anxiety about ≥ 1 social situation for ≥ 6 months
■ Fear of scrutiny by others
■ Social situations avoided
■ Marked impairment
Tx Specific phobia Psychotherapy ->CBT ->
■ Two types ->
1. Flooding -> Works less well but more quickly
2. Desensitization -> More long lasting but it takes longer
■ Steps ->
1. Calm the patient with benzodiazepines
2. Then introduce the stimulus
3. In flooding method -> Overload the patients with the
stimulus of the thing that they fear
4. In desensitization method -> Slowly increasing amount of
stimulus
Social phobia ■ Beta blocker (Not used in asthma , bradycardia) or
benzdiazepines-> For performance-only subtype -> Tremors
and cracked voice
■ CBT
■ SSRI/SNRI

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Psychiatry
Impulse disorder
General overview
Patho Stressor External impulse that anxiety
Action The action reduces Anxiety -> Relief
Response What happens after the action -> Variable
Tx Most of the time neither medications nor psychotherapy work
Intermittent explosive disorder (IED)
Patho ■ Stressor -> Could be anything -> Usually violation of personal space or emotional
attacks
■ Action -> Violence that is disproportionate to the stressor
C/P ■ Male > Female
■ ↓ with age
■ Mild -> No harm (To a person or to a living creature) -> 2 outbursts / week for 3
months
■ Severe -> there’s harm -> 3 times over the course of 12 months
Dx Clinical
Tx Do you need to incarcerate? -> it’s going to be up to law enforcement not the doctor
■ Mild -> No need to incarcerate
■ Severe -> Yes
Kleptomania
Patho ■ Stressor -> the sight of the object
■ Action -> Stealing
C/P ■ Female > Male
■ Stealing things with little or no value (Something that the patient can afford)
■ Response -> Guilt or Remorse -> so the patient gifts the stolen object , hide it or
return it back a
Dx Rule out Theft ->
■ Kleptomania patient generally steals impulsively without plans and without help
and feels guilty about it
■ Someone who stole because he wanted the thing -> plans the theft and has help ->
and then will use the stolen item
Tx Do you need to incarcerate ? ->
■ Generally -> No need to incarcerate -> as the thing the patient steals is of little
value -> and the patient can be coached with therapy to give it back but it’s difficult
to coach the patient to prevent other subsequent thefts
Pyromania
Patho ■ Stressor -> Anxiety or desire to increase sexual arousal (Just because the patient
liked it)
■ Action -> Lighting fire to increase sexual arousal
C/P ■ Male > Female
■ ≥2 occasions of setting fires
Dx Rule out other things ->
■ Arson -> Setting fire deliberately to kill somebody
■ Intermittent explosive disorder -> May set fire as a disproportionate reaction to
the stressor
■ Malingering -> Setting fire to collect insurance
■ Pyromania -> Setting fire because they like it
Tx Do you need to incarcerate ? ->
■ This depends on how much damage they do -> They usually end up getting
incarcerated for damage

a If the patient returns it for whatever reason the anxiety doesn’t return

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Psychiatry

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Psychiatry
OCD and related disorders
OCD
Patho ■ Obsessions -> Internal,intrusive,unwanted thoughts or preoccupations that
anxiety
■ Compulsions -> Behavior or ritual (Done many times not for safety but to relieve the
anxiety) -> if the patient ignores the compulsion , the anxiety remains
C/P Obsession Compulsion
Safety Checking -> Lock - Window - Door
Contamination Washing or cleaning
Symmetry Putting things into order
■ There should be impairment of function to diagnose OCD
Dx Clinical
Tx Psychotherapy ->
■ Almost always the best response and better than medications
■ Desensitization therapy ->
1. First , control the anxiety with medications
2. Then , expose to the stimulus
■ Or Redirect the compulsion to something else like snapping fingers
Medications ->
■ Chronic -> SSRIs - Clomipramine (only TCA that can be used to treat OCD)
■ Acute (Panic attacks) -> Benzodiazepines
Related disorders
Disorder Obsession Compulsion Effect on the patient
Hoarding a Not wanting to through things Keep these things Unsafe environment
away (Usually trash)
Body dysmorphic Preoccupation with some part Check appearance Not as bad as in muscle
disorder of the body (Skin - Hair - Nose - - Unnecessary dysphoria disorder
Breast) surgeries
Muscle dysphoria Wanting to Muscle size not Excessive exercise ■ Rhabdomyolysis
disorder related to competitive athletes and use anabolic ■ ARF
or wanting to have a good look steroids ■ Roid rage b
■ Copper disorder
■ Testicular atrophy
Trichotellomania Anything Pullout hair at Alopecia -> Hair in
different site each varying length -> Rule
time c out fungal infection

a Distress at the thought of getting rid of the items. Excessive accumulation of items, regardless of actual value
b Uncontrollable anger or violent behavior resulting from the usage of anabolic steroids
c The patient may eat the hair after pulling it out -> forming a Bezoar (Solid mass of indigestible material that
accumulates in your digestive tract, sometimes causing a blockage)

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265
Psychiatry
Stress disorders
General
Stressor Disorder a
Life threatening stressor PTSD - ASD
Child neglect / Abuse RAD - DSED
Non life threatening stressor Adjustment disorder
PTSD
Patho ■ Stressor b -> Actual death - Threatened death - Combat - Survivors of severe events
(Rape - being kidnapped) - Abuse / Neglect
■ Exposure -> the stressor could be Experienced (Happens to self) , Witnessed
(happens to others), learned (heard about) or Repeated aftermath
C/P ■ Intrusion -> Memories , Flashbacks , nightmares related to the event
■ Mood change -> Depressed mood
■ Dissociation -> Depersonalization
■ Avoidance -> Not going to the place where it happened - Not talking about the
event
■ Arousal -> Hypervigilance -> Irritability - Always looking over shoulder - Always
aware of surrounding - Never being able to calm down
■ Numbing of responsiveness through anhedonia, amnesia, restricted affect and/or
detachment
Dx Clinical -> according the duration of symptoms ->
■ 3 days - 1 month -> ASD
■ >1 month -> PTSD
Tx c Psychotherapy -> the best
■ Group therapy -> the patient talks to people who experience a similar event
Medication ->
■ Chronic ->
● 1st line -> SSRIs - SNRIs - Prazosin (To improve sleep)
● 2nd line -> Anxiolytics, β-blockers and α2-agonists
■ Acute (Panic attacks) -> Benzodiazepines
F/U Mood disorder - Substance abuse
RAD / DSED
Patho Stressor -> Abuse / Neglect that happens in infancy
C/P ■ Age < 5 years old
■ RAD -> the kid pairs too little
■ DSED -> the kid pairs too much
Dx ■ Clinical
■ Rule out autism
Tx Targeted at caregiver -> Teach them how to parent better
F/U Mood disorder - Substance abuse - Anxiety - Learning disability
Adjustment disorder
Patho Stressor -> Non life threatening
C/P ■ Mood change that didn’t meet the criteria for another disorder
■ Marked distress - Functional impairment
Dx ■ Onset within < 3 month of the non life threatening stressor
■ Duration < 6 month
■ Exclude suicidal or homicidal ideations
Tx ■ 1st line -> Psychodynamic psychotherapy or Brief cognitive psychotherapy
■ May give medications to prevent progression to something else
■ Benzodiazepines (zolpidem) for anxiety and insomnia

PTSD -> Post traumatic stress disorder ASD -> Acute stress disorder RAD -> Reactive attachment disorder
DSED -> Disinhibited social engagement disorder SSRI -> Selective serotonin reuptake inhibitor
SNRI -> Serotonin Norepinephrine reuptake inhibitor

a That occurs when the person doesn’t keep up with stressor

b ■ The closer you are to experiencing the stressor -> the less severe the stressor need to be to induce PTSD
■ The further removed you are from the stressor -> the more severe the stressor has to be to induce PTSD
c Engage and treat earlier so the symptoms don’t persist

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Psychiatry
SPIKES protocol
Definition Evidence-based protocol used for delivering serious news
Includes ■ Create appropriate Setting
■ Address patient’s Perception
■ Seek patients Invitation
■ Give Knowledge to the patient about diagnosis and prognosis
■ Address the patient’s Emotions
■ Provide Strategy and Summary

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Psychiatry
Mood disorders
MDD
C/P ■ Depressed mood or Anhedonia (Loss of interest)
■ +Duration ≥2 weeks
■ +≥5 SIGE CAPS ->
S Sleep a C Concentration
I Interest A Appetite a
G Guilt P Psychomotor retardation
E Energy S Suicide b
■ Social/occupational distress or impairment
■ Not better explained by another medical condition, mental disorder, or substance
■ No history of manic or hypomanic episodes
Dx ■ Clinically as above
■ Assess for suicidal ideation
■ Rule out bipolar -> by asking about history of manic or hypomanic episodes
Tx c Suicide assessment (Ideation, intent, and plan)
MDD + Suicidal ideation + suicidal plan -> Hospitalized
MDD + Suicidal ideation but no plan (Or no means to carry out that plan Or the plan
makes no sense) ->
■ Contract for safety (the patient signs a piece of paper that says they won’t kill
them selves and if they think about it they call the doctor instead
■ Recruit family and friends to support patient
■ Reduce access to potential means
■ Treat depression
MDD with no suicidal ideation ->
■ Medications (1st line) -> SSRI - SNRI - MAOI (2nd line) - Psychostimulants (i.e.
methylphenidate -> For terminally ill patients)
● the dose to the maximum tolerable dose
● Then continue for 1-2 months
● Then decide if the patient needs another drug or the patient is doing okay
● Recurrent, chronic, or severe episodes -> Require treatment for 1 - 3 years or
indefinitely
● Single episode of MDD -> continue antidepressants for 6 months
■ Psychotherapy -> good
■ Combination of medications and psychotherapy -> very effective
■ ECT -> the most effective treatment ->
Indications ■ Severe cases that are refractory
■ Catatonia
■ Psychosis
■ Emergency (Refusal to eat - Imminent suicide risk)
■ Pregnancy (With medications ineffective or undesirable)
Method Electrodes placed over non dominant hemisphere to induce tonic-clinic
seizures under sedation
Side effects ■ Temporary headache
■ Disorientation
■ Amnesia (Anterograde and retrograde)
■ Has a stigma against it
■ High risk of side effects in (Severe cardiovascular disease - Recent
myocardial infarction - Space occupying brain lesion - Recent stroke -
Unstable aneurysm)

MDD -> Major depressive disorder SSRI -> Selective serotonin reuptake inhibitor
SNRI -> Serotonin Norepinephrine reuptake inhibitor ED -> Emergency department ECT -> Electroconvulsive therapy
a ■ in typical depression but in atypical depression
■ Early morning awakenings -> Due to increased cortisol
b Risk factors for suicide completion -> "SAD PERSONS" -> Sex (male) - Age (teenage or elderly) - Depression -
Previous attempt (highest risk factor) - Ethanol or drug use - Rational thinking impaired (psychosis) - Sickness
(medical illness) - Organized plan - No spouse or other social support - Stated future intent
c Young adults (18-24) has an especially high risk of suicide immediately following the initiation of pharmacotherapy
for Major Depressive Disorder
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Psychiatry

Bipolar disorder type I

Patho Risk ->
■ General population -> 2%
■ 1st degree relative is affected -> 10%
■ Monozygotic twin has bipolar -> The other has up to a 70% lifetime risk of
developing the disorder
C/P ■ Mania predominant (≥ 1 manic episode +/- a hypomanic or depressive episode that
may be separated by any length of time)
■ Manic episode -> Diagnosis requires hospitalization or Marked functional
impairment + ≥ 3 of the following symptoms for ≥1 week -> DIG FASTER
D Distractability F Flight of ideas
I Impulsivity A Agitation / Activities
G Grandiosity S Sleep
T Talkative
■ Rapid cycling bipolar I (Poor prognosis - 20% of bipolar I patients)-> at least 4
mood episodes in 12 months
Dx ■ Clinically as above
■ Rule out stimulants -> Cocaine - Amphetamines
■ Rule out bipolar II and cyclothymia
Tx a ■ Agitated patient who is super manic in ED -> Antipsychotics and hospitalize (As
50% are psychotic; prone to extremely dangerous behavior )
■ Chronic -> Mood stabilizer (Lithium - Valproate - Lamotrigine - Carbamazepine) b
■ Anti psychotic -> Quetiapine c
■ Rapid cycling -> Valproate
Bipolar disorder type II
C/P ■ Hypomania + Major depressive episode
■ Hypomania -> Similar to manic episode but not necessitate hospitalization and
doesn’t impair function -> Lasting ≥ 4 days
■ No history of manic or mixed episodes
■ Not better explained by another medical condition, mental disorder, or substance
■ Social/occupational distress or impairment
Dx ■ Clinical
■ Rule out catatonia and psychosis -> because if one of them is present -> it’s Bipolar
type I
Cyclothymia
C/P ■ Milder form of bipolar just not as same as bad -> Fluctuating between Mild
depressive and hypomanic symptoms
■ Duration ≥ 2 years ,with symptoms present at least half of the time ,with any
remission lasting ≤2 months
Dx Clinical

SSRI -> Selective serotonin reuptake inhibitor MDD -> Major depressive disorder ECT -> Electroconvulsive therapy

a Do not begin antidepressants before mood stabilizers in depressive phase -> As it may precipitate mania
b ■ Lithium -> 1st line -> The most effective but has narrow therapeutic index and many adverse effects
■ Valproate -> 1st line -> used when lithium can’t be used for whatever reason
■ Lamotrigine -> 2nd line
■ Carbamazepine-> 3rd line
c ■ Is the backup antipsychotic
■ Can be used in all phases whether depressed or manic
■ Added to the Lithium or valproate if bipolar disorder that is not adequately controlled with monotherapy

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Psychiatry
Dysthymia (Persistent depressive disorder)
C/P ■ ≥2 depressive symptoms lasting ≥ 2 years , with no more than 2 months without
depressive symptoms
■ The patient is going to be a little slow , a little down that looks like hypothyroidism
Dx ■ Clinical
■ Rule out hypothyroid -> TSH
Tx SSRI
MDD with psychotic features
C/P ■ MDD + Psychotic features (Delusions - Hallucinations)
■ Psychotic features occur in the context of MDD , unlike Schizoaffective disorder
Tx ■ Antidepressant with atypical antipsychotic
■ ECT
MDD with seasonal pattern
C/P ■ Lasting≥2years with≥2major episodes associated with seasonal pattern (Usually
winter)
■ Absence of non seasonal depressive episodes
■ Atypical symptoms (Hypersomnia - Hyperphagia - Leaden paralysis) -> Common
Tx ■ Antidepressants
■ Bright-light therapy -> Administered with a 10,000-lux light box shortly after
awakening
Mood problems related to death and dying
Grief a PCBD MDD
Onset Any time -> But usually close to > 6 months after Any time
the time of the stressor the stressor
Duration <12 months after the stressor ≥12 months Should be suspected if grief is
prolonged for > 12 months
Focus b On the deceased On the patient himself
Depressed ■ Waxes and wanes ■ Persistent , pervasive
mood ■ They can imagine a time in ■ Can’t imagine a time in the future when they
the future when they can be can be happy
happy
Behaviors All the following are normal in In relation to hallucinations that may occur in
grief provided that there’s MDD with psychotic features -> Lack insight ->
insight that the deceased is ■ Auditory -> Talking with the deceased
gone -> ■ Visual -> Can see the deceased
■ Talking to the deceased
■ Visiting the graveside
■ Seeing them in the crowd
Why Thinking of suicide is normal in grief -> as long as Thinking suicide would free
suicide? the reason is to be with the deceased -> Don’t need them from misery
to be hospitalized
Tx ■ Don’t need to medicate SSRI - SNRI
■ May need counselling

PCBD -> Persistent complicated bereavement disorder SSRI -> Selective serotonin reuptake inhibitor
MDD -> Major depressive disorder SNRI -> Serotonin Norepinephrine reuptake inhibitor

a Kubler-Ross model of grief -> Denial - Anger - Bargaining - Depression - Acceptance (May occur in any order)
b Focus of symptoms (Dysphoria - Anhedonia - Guilt) is either on the deceased or on self

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Psychiatry
Mood problems related to delivery
Blues Postpartum depression Postpartum psychosis
Risk First baby First baby ■ First pregnancy
factors ■ History of bipolar or
psychotic disorder
■ Family history
■ Recent discontinuation of
psychotropic medication
Mom Mom cares Mom doesn’t care about ■ Mom fears the baby
cares for the baby -> Neglect ■ May kill the baby
the baby ?
Onset Within 2 -3 days after Within 4 weeks after Within days to weeks after
delivery delivery delivery
Duration Resolves within 2 Ongoing unless you treat Ongoing unless you treat
without weeks
Tx
Symptoms Depressed mood -> it’s Major depressive episode Psychosis predominates -> it’s
effectively adjustment (SIGECAPS) effectively brief psychotic
disorder disorder
Tx Reassurance + CBT and/or SSRI ■ Hospitalization
Monitoring ■ Antipsychotic

CBT -> Cognitive behavioral therapy SSRI -> Selective serotonin reuptake inhibitor

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Psychiatry
‫ﻏ‬﫿Psychotic disorders
Schizophrenia
Patho ■ Thought disorder
■ Genetic component -> Very high risk in identical twin of a patient
■ Positive symptoms (Delusion - Hallucination - Disorganized speech or behavior)
-> Due to excess dopamine -> Mesolimbic pathway
■ Negative symptoms (Flat affect - Poverty of speech or of movement - Anhedonia
- Cognitive delay)-> Due to excess serotonin -> Mesocortical pathway
■ Rural areas have a tighter family unit and more support -> Thus lower incidence
than urban
■ Higher incidence in babies born in winter/early spring
■ Obstetric complications (hypoxia, hemorrhage, infection, preterm labor) -> have
been identified as an environmental risk factor for the later development of
schizophrenia
C/P ■ Age -> Presents earlier in men (Late teens to early 20s vs late 20s to early 30s in
women )
■ After a major stressor (Adulthood)
■ ≥2 of the following (including at least one of the 1st 3) for ≥ 6 months a ->
1. Delusions -> False fixed beliefs incongruent with patient culture -> E.g. persecution
- Grandiosity
2. Hallucinations -> Auditory
3. Disorganized speech
4. Disorganized behavior
5. Negative symptoms -> Flat affect - Poverty of speech or of movement - Anhedonia
- Cognitive delay
■ Significant impairment in social or occupational functioning
■ Not better explained by another mental disorder, medical condition, or substance
■ If there is a history of autism spectrum disorder, diagnosis of schizophrenia is made
only if prominent delusions or hallucinations
■ Psychotic break -> Break of medication -> More cognitive impairment than they
had before
Dx ■ Clinical
■ Rule out drugs
■ Determine duration of symptoms and whether or not there are mood problems
■ If neuroimaging done (For another reason) -> Ventriculomegaly (particularly of the
lateral cerebral ventricles) and cortical atrophy
Tx ■ Antipsychotic -> Lifelong
■ Medication non-adherence -> Long-acting depot antipsychotics
■ Resistant -> Clozapine
■ Family therapy (Minimizing conflict and stress in the home) -> Risk of relapse
Brief psychotic disorder
C/P ■ ≥1 +ve symptom lasting > 1 day but < 1 month
■ Usually stress related
Tx Antipsychotic -> For a month

a Positive symptoms Negative symptoms

Delusions - Hallucinations - Disorganized speech - Flat affect - Poverty of speech or of movement -
Disorganized behavior Anhedonia - Cognitive delay
Driven by mesolimbic pathway (D2C receptor -> Acted 5-HT-1 receptor -> Acted upon by serotonin
upon by dopamine)

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Psychiatry
Schizophreniform
C/P ≥2 symptoms lasting 1-6 months
Tx Antipsychotic -> For 3-6 months
Schizoaffective
C/P ■ Presence of a major depressive, manic, or mixed episode concurrent with symptoms
of schizophrenia
■ Lifetime history of delusions or hallucinations for > 2 weeks in the absence of
prominent mood symptoms
■ Mood symptoms are present for the majority of the illness
■ Not due to substances or another medical condition
Tx Treat the mood first
Mood disorder with psychotic features
C/P Mood changes predominate but there are some psychotic features
Tx Treat the mood first
Delusional disorder
C/P ■ Non bizarre delusion (≥ 1 delusion for ≥1 month) that doesn’t impair function
■ No other psychotic features
■ Ability to function
■ Subtypes -> Erotomanic - Grandiose - Jealous - Persecution - Somatic
Tx ■ Antipsychotics -> 1st line (Gain a therapeutic alliance as patients are often
suspicious of the clinician's motives)
■ CBT ->Gentle confrontation
Glucocorticoid-induced psychosis
Patho High dose glucocorticoids
C/P Hypomania - Confusion - Hallucinations
DDx Medication-induced delirium -> Patient would not be alert and cognitively intact
Folie a deux
C/P Delusions can be shared by individuals in close relationships
Dx Assess both individuals separately to determine degree of delusions in each

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Psychiatry
Eating disorders
Compensatory methods used in eating disorder
Restriction Reduced caloric intake (Diet - Fasting) - ↑Caloric expenditure (Excess exercise)
Purge Emesis ->
■ Affects Teeth (Dental erosion) - Back of the hand (Dorsal hand scar -> Russel
sign) - Parotid (Swelling->elevated serum amylase)
■ Low K and Low Mg
■ Metabolic alkalosis
Laxative abuse ->
■ Metabolic acidosis
■ Diarrhea
Trends
Sex Female
Age 10s to 20s
Restriction More in anorexia
Purge More in Bulimia
Death Either due to complications of the disease or suicide
Anorexia nervosa Bulimia nervosa
Body weight Underweight Normal or slightly overweight
Self-image ↓↓↓ -> Unrealistic image of self -> afraid of
getting overweight
What induces ■ Fearing of weight gain ■ Binge (Uncontrolled eating)
anxiety? ■ No insight -> despite being told that she’s -> at least weekly over the
normal wight , she still has impaired last 3 months
self-image ■ There’s insight -> feel bad
about it
Compensatory Restriction Purge
method
C/P Resembling hypothyroid but thin -> Lanugo Signs of the purge-> As above
hair - Amenorrhea a - Cold intolerance -
Emaciated
When is ■ BMI <15 Rarely
hospitalization ■ <70 % of expected body weight
required? ■ Electrolyte disorder
■ Leukopenia
■ Organ compromise
■ Bradycardia - Hypotension
Tx ■ Hospital -> Force feeds b - IV fluids - ■ SSRI - SNRI
Electrolyte correction ■ CBT
■ CBT ■ Never use Bupropion -> as
■ Outpatient -> Antipsychotic (Olanzapine it risk of seizure in
-> after CBT and nutritional rehabilitation bulimic patients
fails)
■ If MDD or OCD are associated -> then
the 1st line will be SSRI or SNRI
Follow-Up MDD - OCD

CBT -> Cognitive behavioral therapy MDD -> Major depressive disorder OCD -> Obsessive compulsive disorder
SSRI ->Selective serotonin reuptake inhibitor SNRI -> Serotonin Norepinephrine reuptake inhibitor

a Due to decreased adipose tissue -> Decreased leptin -> Decreased Pulsatile GnRH
b Refeeding syndrome -> Sudden increased caloric intake in severely malnourished patients -> insulin ->
Hypophosphatemia - Hypokalemia - Hypomagnesemia - Hypernatremia -> Cardiac complications - Rhabdomyolysis -
Seizures

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Psychiatry
Binge eating disorder
C/P ■ Recurring episodes of binge eating without purging at least weekly over the
last 3 months
■ Obese
■ ↑ Diabetes risk
Tx ■ Psychotherapy -> 1st line
■ SSRI
■ Lisdexamfetamine
Cancer-related Anorexia/Cachexia syndrome
C/P ■ Weight loss
■ Poor appetite
■ /Normal adipose tissue
■ Muscle wasting
■ Fatigue
Tx Progesterone analogs (preferred) or corticosteroids
HIV Cachexia
Tx Megestrol acetate (Synthetic cannibinoids)

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Psychiatry
Personality Disorders
■ Personality disorder -> Rigid permanent and maladaptive traits that define the way a person
behaves -> Impeded early in adulthood -> and are completely egosyntonic a -> interferes with
functionality
■ Personality trait -> Not interfere with functionality
Personality Description How to handle
Paranoid ■ Distrustful (interprets other as malicious) Clear , honest and non
■ May use projection as a defense mechanism threatening
Schizoid Loners (Have no relationships and are happy not You won’t see them
A (weird)

having any)
Schizotypal ■ Magical thinking Clear , honest and non
■ Eccentric (Bizarre) thoughts , behaviors and threatening
dress
■ Borders on psychosis
■ But fully functional
Borderline Pervasive pattern of unstable Dialectic Behavioral
relationships ,self-image and affects + Marked therapy
impulsivity + ≥ 5 of the following ->
■ Fantastic effort to avoid abandonment
■ Unstable interpersonal relationships
■ Impulsivity ≥ 2 areas that are potentially
self-damaging
■ Markedly and persistently unstable self-image
■ Suicidal gestures -> which may be successful
■ Emotional emptiness
■ Affective instability
■ Inappropriate or intense anger
■ Transient stress-related paranoia or dissociation
Use splitting as a defense mechanism
B (Wild)

Histrionic ■ Theatrical Set rules and insist they

■ Attention seeking are followed
■ Hypersexual
■ Exaggerated but superfluous emotions
Narcissistic ■ Inflated sense of worth or talent Set rules and insist they
■ Eccentric dress to draw attention are followed
■ Self centered unlike histrionic
■ Fragile ego
■ Often found in men
Anti-social ■ No regard for others ■ Set rules and insist
■ Impulsive they are followed
■ Lack remorse ■ Jail -> if damage
■ Age > 18 years (if <18 years -> Conduct disorder) properties or hurt
others
■ Tx of comorbid
conditions
Avoidant ■ Fear rejection and criticism ■ Avoid power struggles
■ Want relationships but don’t pursue them ■ Make patients choose
■ Pass on promotions
Dependent ■ Unable to assume personality ■ Give clear advice
■ Submissive and clingy ■ Patient may try to
C (Whimpy)

■ Fear being alone deliberately destroy

■ Have long-lasting relationships vs Borderline their own treatment ->
and histrionic to come and see the
doctor more often as
they become
dependent on him
Obsessive Order , control and seeking perfection at the
compulsive expense of efficacy

a Egosyntonic -> they don’t see that there’s a problem and thus they don’t want to change

276
Psychiatry
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277
Psychiatry
Dissociative Disorders
Dissociation
Definition Separation of mental functions that are normally connected (Thoughts - Memory -
Identity)
Cause Usually after severe prolonged stressor
Dx Rule out Malingering and substance abuse
Tx Psychotherapy
F/U Non severe stressor -> the patient is likely to recover thought , memory and identity
The More severe the stressor -> the less likely to recover
Dissociative identity disorder “DID”
C/P ■ ≥ 2 distinct identity or personality states
■ The primary self (the person)
1. Doesn’t know about the other identity -> Memory gaps (Blackouts)
2. History of severe trauma (Sexual abuse - Borderline personality - Depression -
Substance abuse - Somatoform conditions)
3. Might have other dissociative symptoms
■ What other people experience ->
1. Paradoxical behaviors by the patient a
2. Appearance change b
Dissociative amnesia
C/P ■ Dissociative amnesia with fugue -> Amnesia + Abrupt travel associated with
traumatic circumstances
■ Dissociative amnesia without fugue -> Amnesia without travel
■ Amnesia -> of any of the following
1. The stressor or the event
2. Every day occurrences
3. Routines
4. Entire autobiography c
Depersonalization / Derealization
C/P ■ Depersonalization -> sense of detachment from the body -> De-Ja-vu is an example
■ Derealization -> sense of detachment from the environment -> Experiencing things
as if they are in a dream
■ Intact reality testing -> Unlike psychosis
■ History of non severe trauma or stressor
■ Age -> usually adolescent

a Major changes in the patients lifestyle and attitude

b As facial muscles shift as new identity takes over -> the person physically looks different
c know how to talk and how to do math -> but don’t know who they are

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Psychiatry
Catatonia
Catatonia
Patho No longer a disease but it’s a modifier of another illness ->
■ Psychiatric -> Mood disorders more than schizophrenia
■ Medical disease -> Autoimmune - Paraneoplastic - Nutritional
C/P ≥3 of the following symptoms ->
Retarded catatonia Excited catatonia
Stupor Stereotypy -> Repeated purposeless
movements over and over again
Catalepsy -> Muscular rigidity and fixity Agitation and grimace
of posture regardless of external stimuli,
as well as decreased sensitivity to pain
Waxy flexibility -> response to stimuli Echolalia -> the patient copies what you
and a tendency to remain in an immobile say
posture -> Allows the patient to be put in
whatever position you want
Negativism -> Tendency to resist Echopraxia -> the patient copies what you
direction from others, and the refusal to do
comply with requests
Mutism -> Not speak
Dx ■ Clinical
■ Therapeutic diagnosis (Lorazepam challenge test) -> IV lorazepam 1-2 mg
resulting in partial, temporary relief within 5-10 minutes confirms the diagnosis
Tx ■ 1st line -> Lorazepam
■ 2nd line -> Electroconvulsive therapy
F/U ■ Malnutrition -> Track their albumin -> may need to give enteral or parenteral
nutrition while they come out of catatonia
■ DVT risk -> LMWH - Pneumatic compression devices
■ Rhabdomyolysis -> Check CK
Disorder Precipitant Symptoms Tx
Malignant ■ There’s a psychiatric disease ■ Rigidity a -> in all of these Stop the
catatonia ■ No Precipitant medication disorders except offending
Neuroleptic ■ There’s a psychiatric disease serotonin syndrome agent
malignant ■ There’s a Precipitant drug-> which has hypertonicity/
syndrome Antipsychotic hyperreflexia instead of
Serotonin ■ There’s a psychiatric disease rigidity
syndrome ■ There’s a Precipitant drug-> ■ Dysfunctional autonomic
SSRI nervous system -> HR -
Malignant ■ No psychiatric disease BP - Temperature Dantrolene
hyperthermia ■ There’s a Precipitant drug->
Halothane anaesthesia b

LMWH -> Low molecular wight heparin CK -> Creatine kinase HR -> Heart rate BP -> Blood pressure
SSRI -> Selective serotonin reuptake inhibitor

a ■ Lead pipe rigidity -> All the muscles are contracted at once
■ Muscle breakdown -> Elevated CK
■ Very strong resistance to movement
b Ask for family history of reaction to anaesthesia

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279
Psychiatry
Pediatric neurodevelopment
Intellectual disability disorder (IDD)
Patho ■ ↓ Cognitive skills -> loss of the ability to do complex thought processes and
higher order functions
■ ↓ Adaptive functions -> They need help from family or support staff
Patient When it will be seen ->
■ Genetic screening -> Done only if the patient is willing to terminate pregnancy if
the screening is positive
■ As a part of a syndrome -> Down - Fragile X - Cri du chat
■ Acquired forms -> Lead poisoning - Maternal alcohol abuse during pregnancy -
Hypothyroidism
Dx Clinical ->
■ How severe is the disorder proportionate to the loss of the adaptive function a
■ IQ test -> useful but not diagnostic -> Not the right answer
IQ score Grade Functions
>70 Can progress to any grade ■ Can live on their own
■ Can work independently
■ Can take care of their ADLs (activities of daily living)
50-70 Progresses to about the 6 ■ Lose the ability to live independently
th

grade level ■ Can work independently -> Remedial tasks

■ Can take care of their ADLs (activities of daily living)
35-49 Progresses to about the 3rd ■ Lose the ability to live independently
grade level ■ Lose the ability to work independently
■ Can take care of their ADLs (activities of daily living) ->
but need constant reminders
20-34 Progresses to about the level Need help with every thing -> Living - ADLs
of a 3 year old normal child
<20 Infant level Requires total care
Tx ■ Special education classes
■ Training social skills
Autism spectrum disorder (ASD)
Patho Social communications
C/P Impaired social communication -> Evidenced by ->
■ Impaired Social reciprocity ( Back-and-forth flow of social interaction)
■ Impaired Social relationships -> Look for eye contact and social smile
■ Impaired Nonverbal communication -> Can’t understand gesturing but can
understand words just fine
■ Impaired Joint attending -> Has no interest in sharing experiences
Restricted / Repetitive behavior ->
■ Stereotypy (Persistent repetition of an act for no obvious purpose)
■ Sameness (Need objects to be in a very rigid pattern -> any small deviations cause
great distress)
■ Restricted interests (Fixated on one thing)
■ Change in sensory perception
Rarely accompanied by unusual abilities (Savants)
Not better explained by intellectual disability or another condition
Severity Age of onset Presentation
Mild 4-6 years Regression to a lesser level of cognition and behavior
Moderate 2-4 years Plateau (Which means they grow normally then all of a sudden not continue
but not reach the same development level as in mild disease)
Severe 0-2 years Never progress at all -> No social interaction - No social smile - No eye contact
Dx ■ Clinical
■ Rule out other causes of learning disability
Tx Multimodal treatment (Special education classes - Training social interaction)

IDD -> intellectual disability disorder

a It’s not about do the patient has the disorder or not , It’s about how much care the patient needs

280
Psychiatry
Attention deficit hyperactivity disorder (ADHD)
Patho Unknown
C/P ■ Inattention -> Talks really fast - Easily distracted - Fails to complete tasks
■ Impulsivity -> Blurts out answers - Interrupts people - Fidgets a lot - Can’t wait in
line
Dx Clinical ->
■ Symptoms should be noticed in ≥ 2 settings (Home and school for example)
■ Onset at age 7-12 years
■ Duration of symptoms ≥ 6 month
■ Symptoms must be frequent -> Impairing function
■ Continues into adulthood in 50% of cases
Tx ■ 1st line -> Stimulants (Methylphenidate) -> Not used before 6 years of age (Use
behavioral therapy instead)
■ 2nd line -> Atomoxetine (Inhibits 5HT and NA reuptake - No potential for addiction
and favorable side-effect profile)
■ Special educations
■ Train parents
DD Absence seizure -> Treat with ethosuxamide or valproate
Tourette syndrome
Patho Association with OCD , ADHD
C/P ■ Sudden, Rapid , Recurrent , Nonrhythmic , Stereotyped tics
■ Tics could be -> Physical (Movement) or vocal (Grunts or coughs ,not words, never
swears)
Dx Clinical ->
■ Multiple motor & ≥ 1 vocal tic
■ Age of onset < 18 years
■ Duration of tic > 1 year
Tx Drugs ->
■ α2-Agonist (Clonidine - Guanfacine) -> 1st line
■ D2-Antagonist (Antipsychotic) -> For intractable
CBT -> better
Rett syndrome
Patho ■ De novo mutations in MECP2
■ X-Linked dominant
C/P ■ Mostly females
■ Normal development till 7-24 months of age then regression (characteristic hand
wringing, ataxia/chorea, intellectual and verbal disability)
Learning disorders

CBT -> Cognitive behavioral therapy IDD -> intellectual disability disorder ASD -> autism spectrum disorder
ADHD -> Attention deficit hyperactivity disorder

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281
Psychiatry
Pediatric behavior
Enuresis
Patho Repeated urination on bed or clothes -> > 2 times per week for 3 months in a
patient that’s > 5 years old
Causes ->
■ Voluntary -> Someone acting out
■ Anatomic defect
■ Medications
■ Disease states
■ Regression -> happens in kids with new sibling , new place or child abuse
Approach

Encopresis
Patho ■ Same thing as enuresis but stool instead of urine
■ Stool could be coming from a fistula
C/P ■ > 4 years old

STI -> Sexually transmitted infection

a Training ->
■ Nocturnal assistance
■ +ve reinforcement
■ Don’t use -ve reinforcement
■ Water restriction
■ Void before going to sleep
■ Alarm blankets
DDAVP -> keeps the child dry but not help with training
b If present -> it’s sexual abuse
c New sibling , new place or child abuse

282
Psychiatry
Conduct disorder Oppositional defiant disorder
Patho Similar to antisocial personality disorder ■ Incongruent parenting
but age < 18 years ■ Associated with ADHD
C/P ■ Bullying -> Hurt animals - Torture ■ No bullying
others - Cruel to others ■ Lie - Cheat - Steal
■ Destruction -> Setting fires - Lie - cheat ■ Defiant to authorities
■ Violation of rules -> Truancy - Running
away from home ate least twice - Fight
authorities
Dx Clinical Clinical
Tx Juvenile detention -> Reintegrating them ■ Parent management training
into society before getting full blown ■ Psychotherapy -> Anger
antisocial personality disorder management , Social skill training
Disruptive mood dysregulation disorder
C/P ■ Onset -> Before age 10 years
■ Severe and recurrent temper outbursts out of proportion to a situation
F/U May develop MDD or anxiety disorders in adulthood
Separation anxiety disorder
C/P Persistent anxiety with separation and excessive worry about losing major attachment
figures for at least 4 weeks

ADHD -> Attention deficit and hyperkinetic disorder

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Psychiatry
Addiction
Substance use ■ Any consumption of alcohol or drugs -> may not lead to abuse or
dependency in some people
■ Effect of the drug -> Feel euphoric then return to normal baseline
Substance abuse ■ When someone continues to use drugs or alcohol even when it causes
problems
■ Effect of the drug -> Feel euphoric then dysphoric (hangover) then
return to baseline
Substance addiction ■ Unable to stop drinking or using drugs, and have physical withdrawal
symptoms when you try to quit
■ Effect of the drugs -> Feel euphoric then dysphoric (hangover) then
return to a lower baseline each time till becoming totally dependent
on the drug to feel like normal people do
Substance abuse disorder

Diagnosis
Clinical
Determine severity -> determined by number of points in the check list (see above)
■ Mild -> 2-3
■ Moderate (aka substance abuse) -> 4-5
■ Severe (aka substance dependence) -> ≥6
Screen ->
■ CAGE -> Trying to Cut down - Anger when some one talks to the patient about the substance -
Guilty about using the drug - using the drug as an Eye opener
■ CRAFFT (More specific for adolescents) -> Using the substance while driving a Car - Using the
substance to Relax - Using the substance Alone - Trouble with Friendships - Forget stuff they
have done while using drugs - Trouble with law , parents , teachers ...
Stage What happens in it
Pre-contemplative Denial of the problem
Contemplative Acceptance of having the problem but unwilling to change
Preparation Took the first steps -> Ready and thinking about the things they want to do
Action Actual behavioral change -> e.g. smoking less cigarettes - alcohol cessation
- using a medication to help quit
Maintenance Sustain behavioral changes
Relapse Abandoning changes and returning to the old behaviors

284
Psychiatry
Tx
■ Group therapy -> where the patients meet with others with the same problem where they
relate and talk about it
■ +/- pharmacological components
■ Psychotherapy -> FRAMES ->
1. Patients should give Feed backs on the decisions they have made or actions they have
done
2. Ensuring that the patients accept Responsibility for their actions for staying clean or for
relapsing
3. Offer Advice
4. Offer a Menu of options
5. Empathy
6. Self efficacy -> showing the person that by being clean , they are doing better
■ Relapse treatment
Alcohol abuse
Patho ■ Most commonly abused substance
■ Male : female > 3:1
■ Certain races are more susceptible to developing alcohol abuse -> Native
american - Alaskan natives
■ Tends to cluster in families -> Genetic component of predilection to abuse
C/P Intoxication -> Altered mental status - Disinhibition - Slurred speech - Cerebellar
dysfunction a - Nausea vomiting (Happens when blood alcohol level is about 0.2 in
most people) - Coma - Death
Chronic alcohol use ->
■ Brain ->
● Wernicke’s encephalopathy -> CAN (Confusion - Ataxia - Nystagmus) ->
Reversible by giving IV thiamine and folate then glucose (No lab or imaging
needed)
● Korsakoff’s encephalopathy -> Irreversible loss of brain volume -> Amnesia -
Confabulation
■ Liver -> Cirrhosis
■ GIT -> GI bleeds and gastritis
Coma -> the person is found down with cause unknown (Could be alcohol or opiate
intoxication) -> So give coma Cocktail (Thiamine then D50 - Naloxone)
Dx ■ Breathalyzer
■ Blood alcohol content -> the legal point in US is 0.08 (reached by 2-3 alcoholic
drinks)b
Tx ■ Acute intoxication -> Reassurance - IV fluids in time
■ Coma -> Thiamine then D50
■ Chronic alcohol abuse -> Alcoholics anonymous - Drugs (Naltrexone -
Acamprosate - Disulfiram (Used when other are ineffective or contraindicated))

BZD -> Benzodiazepine IV -> Intravenous PO -> Per os

a Alcohol cerebellar degeneration

Patho >10 year of heavy alcohol use -> Degeneration of purkinje cells (Vermis)
C/P ■ Develop over weeks to months
■ Wide-based gait
■ Leg incoordination
■ Intact cognition
Dx Clinical ->
■ Impaired tandem walking / heel-knee-shin
■ Preserved finger-nose testing
CT/MRI -> Cerebellar atrophy
Tx ■ Alcohol cessation
■ Nutritional supplement
■ Ambulatory assistance devices (e.g. walker)
b The liver can process only 0.03 / hour -> This fact can be used to determine how drunk a person was when an event
happened

285
Psychiatry
Alcohol withdrawal = BZD withdrawal
Patho ■ Alcohol -> GABA -> activity of the brain
■ Chronic alcohol use -> there will be Down regulation of GABA receptors to
maintain the normal activity
■ Abrupt alcohol withdrawal after chronic use -> Excess brain activity
C/P Symptoms/signs Onset since last
drink (In hours)
Mild withdrawal ■ Anxiety - Insomnia - Tremor - 6-24
Diaphoresis - Palpitation -
Gastrointestinal upset
■ Intact orientation
Seizures Single or multiple generalized tonic-clonic 12-48
Hallucinosis ■ Visual , Auditory , or tactile 12-48
■ Intact orientation
■ Stable vital signs
Delirium tremens ■ Confusion - Agitation - Fever - 48-96
Tachycardia - Hypertension -
Diaphoresis - Hallucination
■ Altered mental status
Dx Clinical
Tx ■ Long acting BZD -> Chlordiazepoxide - Diazepam than tapering gradually
■ Rapid acting BZD as they need -> Alprazolam - Lorazepam either IV or PO
■ If liver disease (High LFT)-> Use lorazepam (Avoid diazepam and
chlordiazepoxide)
Inhalant abuse (e.g. glue, toluene)
C/P ■ Unconsciousness followed by drowsiness and headache
■ Mild rash around the patient's mouth (Glue sniffer's rash)

286
Psychiatry
Drug Toxicity Withdrawal
Opioid Patho -> Starting with pills and ending up with heroin a Yawning -
C/P -> Euphoria - Coma - Constricted pupil b - Respiratory Lacrimation -
rate - Constipation Sweating - Pain -
Dx -> Opioid in urine (UTOX) - Naloxone challenge test c - ECG Itching
(For prolonged QT) - ABG (For Resp. acidosis)
Tx ->
■ Acute intoxication -> Naloxone -> Prevents the effect of
any opiate for about 12 hours so if you are controlling
pain , be careful how much you give - Also if given rapidly ,
may induce severe nausea and vomiting
■ Chronic abuse -> Naltrexone - Methadone - Suboxone ->
the craving without getting the patient high
BZD Patho -> BZDs are safe -> so a large dose of BZD or Same as alcohol
combination with alcohol is required to cause intoxication
C/P -> Delirium in elderly - Respiratory rate - Coma -
Amnesia - Paradoxical agitation (Benzodiazepine use in the
elderly - Typically within an hour after use)
Tx ->
■ Flumazenil (it lowers the seizure threshold -> so used only
when sure that there’s BZD overdose)
■ BZD taper
Cocaine C/P -> Psychomotor agitation - HTN - Tachycardia - Psychosis - Depression -
Dilated pupils - Angina - HTN crisis Cocaine bugs
Tx -> α then β blockade - Benzdiazepines
Amphetamine C/P -> Psychosis - Dilated pupils - Overheating (Fever - Crash - Depression
Tachycardia) - Water intoxication d - Lasts > 20 hours
Tx -> Supportive
PCP C/P -> Severe random
■ Aggressive psychosis violence
■ Vertical (Only one that does so) + Horizontal nystagmus
■ Impossible strength
■ Blunted senses
■ Lasts < 8 hours
Tx ->
■ 1st line -> Benzodiazepines
■ 2nd line -> Haloperidol (Haldol) to subdue them
■ Urine acidification -> to excretion
Ecstasy ■ Life-threatening effects-> Hyperthermia - Hypernatremia
e
(MDMA) - Hypertension - Tachycardia - Serotonin syndrome

BZD -> Benzodiazepine

a ■ Risk of prescription opioid misuse may be reduced by -> Regular patient follow-up - Random urine drug screen
- Reviewing the state's prescription drug-monitoring program data
■ Risk factors for misuse include -> Age < 45 - Psychiatric disorder - History of substance abuse or legal history
b The patient develops tolerance to euphoria but not to pupillary constriction
c This test is performed to assess physical dependence. As an intramuscular injection or IV, 0.2-0.8 mg of naloxone is
administered. A positive test is indicative of physical dependence and consists of typical withdrawal symptoms and
signs
d They constantly drink water due to over heating -> Leading to water intoxication
e Dry mouth -> thirst -> increase water intake without electrolyte depletion -> hyponatremia -> seizures and
life-threatening cerebral and pulmonary edema

287
Psychiatry
Drug Toxicity Withdrawal
LSD C/P -> Hallucinations - Flashbacks - senses Flashbacks
Tx -> Supportive
Marijuana C/P -> Tired - Slowed reflexes - Conjunctivitis - Munchies -
Paranoia
Tx -> Supportive
Barbiturates Low safety margin - Respiratory depression - Coma Rapid as they
Redistribute into
fat
Nicotine None - Jittery - Stimulated - Ventricular tachycardia C/P -> Craving
Tx -> Nicotine
patch - Nicotine
gum - Bupropion
(Wellbutrin)

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288
Psychiatry
Sleep
Stages
Stage EEG changes Characters
I Theta waves - Absent alpha waves Easily aroused
II K complexes - Sleep spindles
III Delta waves Difficult to arouse - the most restful sleep
REM Beta waves Awake brain - Atonia - REM - Erections
Definitions
Sleep ■ Period from putting the head down to entering stage I
latency ■ ↑ -> in insomnia
■ ↓ -> in Narcolepsy - Sleep deprivation
REM ■ Period from entering stage I to getting to REM
latency ■ Normally -> about 40 minutes
■ ↓ -> in Narcolepsy - Sleep deprivation (OSA - Alcohol abuse) - Depression - Normal
aging
REM ■ ↑ -> in Depression , Sleep deprivation (Rebound -> The amount of REM you get
Duration
Significantly when body is deprived from REM sleep)
■ ↓ -> in normal aging
Neurotransmitters
Serotonin Serotonin -> sleep
Acetylcholine Acetylcholine -> Dreaming making it more vivid
Norepinephrine Norepinephrine -> Arousal
Dopamine Dopamine -> Arousal
GABA ■ GABA -> sleep latency - NREM stage III and REM
■ GABA is increased by -> Alcohol - BZD
Nightmares Sleep terrors
Patho Dreams going bad -> occur in REM ■ Occur in NREM stage III
■ Cause unknown, but triggers include
emotional stress, fever, or lack of sleep
C/P ■ Atonia -> Not act out the ■ Tone present -> act out their dreams - Sleep
dream walking - Sleep talking
■ Awake from the dream ■ Appear awaken to others (But they aren’t)
■ Remember the dream ■ Not remember
■ Any age ■ Age -> Children
Dx Clinical Clinical
Tx ■ No treatment required ■ Reassurance of the parents ->
■ Reduce stressors ● That it’s a normal thing
■ Patients may self medicate ● Not to use BZD or Alcohol to treat it
with alcohol
Obstructive sleep apnea (OSA)
Patho Excess tissue (Fat) - Large tongue - Short neck -> airway obstruction
C/P ■ Daytime sleepiness - Obese - Snoring - Non restorative sleep - Morning headaches
- Affective symptoms
■ Complications -> Systemic hypertension - Pulmonary hypertension and right
heart failure
Dx Polysomnography -> Looking for either of the following
■ ≥ 15 apnea spells/hour
■ Or combination of ≥5 apnea spells + snoring
Tx ■ CPAP or PEEP -> to keep the airway open
■ Lose weight

REM -> Rapid eye movement OSA -> Obstructive sleep apnea BZD -> Benzodiazepine
CPAP -> Continuous positive airway pressure PEEP -> Positive end-expiratory pressure

289
Psychiatry
Central sleep apnea (CSA)
Patho ■ Lost respiratory drive -> So the patient forgets to breath -> CO2 accumulation
■ Causes ->
● Idiopathic -> Most common
● Over oxygenation in COPD patients
● Opiates
● Stroke
Dx Polysomnography
Tx BiPAP
Narcolepsy
Patho ■ Due to ↓ orexin (hypocretin) production in lateral hypothalamus and
dysregulated sleep-wake cycles
C/P Recurrent lapses into sleep or naps ≥3 times / week for 3 months
≥ 1 of the following ->
■ ↓ sleep latency - ↓ REM latency
■ Cataplexy -> Loss of tone following strong emotional stimulus such as laughter ->
may even wake up paralyzed
■ Low cerebrospinal fluid level of hypocretin-1
Associated with -> Hypnagogic or hypnopompic hallucinations - Sleep paralysis (starts
with REM sleep)
Dx ■ Polysomnography -> Baseline
■ Multiple Sleep Latency Test (MSLT)
■ Hypocretin levels -> Not used anymore -> as they vary way too much
Tx ■ Lifestyle -> Ensure regular sleep periods - Avoid medications that disturb
sleep-wake rhythm (alcohol, antipsychotics, opiates)
■ Stimulants -> Modafenil (1st line for daytime somnolence) - methylphenidate (2nd
line)
■ Sodium oxybate (Nighttime) ->
● Specifically for reducing cataplexy, but can also decrease daytime somnolence
● Never taken with alcohol or other CNS depressants— may cause
life-threatening respiratory depression
■ SNRIs/SSRIs (venlafaxine, atomexetine, and fluoxetine) -> for cataplexy, sleep
paralysis, and sleep hallucinations
REM sleep behavior disorder
Patho Risk factors -> Narcolepsy - Psychiatric medications - Neurodegenerative disorders
C/P ■ Acting out dreams
■ Easily arousable and confused for only a few moments after awakening
■ Describes a recurrent dream where he feels trapped
■ Often occurs with other subtle prodromal symptoms (e.g. constipation, subtle
changes in gait) -> In case of neurodegeneration
Dx Clinical
Tx ■ Remove dangerous objects from bedroom
■ Discontinue causative medications if applicable
■ Benzdiazepines
■ Melatonin analogs
Advanced sleep phase disorder
Patho Circadian rhythm sleep-wake disorder in which the sleep-wake cycle begins and ends
earlier than normal
C/P Individuals go to bed early and wake up early in the morning, irrespective of when
they go to bed
Dx Clinical
Tx Phototherapy in the evening
Delayed sleep phase disorder
Patho Circadian rhythm sleep-wake disorder characterized by recurrent delay in sleep onset
and waking times
C/P Go to sleep late and wake late (“night owl”)
CPAP -> Continuous positive airway pressure PEEP -> Positive end expiratory pressure
BiPAP -> Bilevel Positive Airway Pressure SSRI -> Selective serotonin reuptake inhibitor
SNRI -> Serotonin Norepinephrine reuptake inhibitor

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Psychiatry
Insomnia
C/P ■ Trouble falling asleep or awakening
■ 3 times /week for 3 months
Approach

a Tell them to stay awake till the time they are supposed to sleep in the area they travelled to whether it’s day or
night
b ■ Used in areas where circadian rhythm is off like in Alaska where days might be really long or really short ->
■ Lights on -> when awake
■ Light off -> when going to sleep
c Zolpidem -> is the last resort -> it may cause problems with sleep walking or talking
d ■ To do -> Bed is for sex and sleep - Lights off
■ To avoid -> Stimulants - Exercise before sleep - Alcohol (Don’t get restful sleep)

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Psychiatry
Homicide
Homicide
Risk factors Young male - Unemployed - Impoverished - Access to firearms - Substance abuse -
Antisocial personality - History of violence or criminality - History of childhood
abuse - impulsivity

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Psychiatry
Gender dysphoria
Definitions
Assignment Given at birth by an adult based on unambiguous external genitalia (Male or
female) -> Phenotype
Identity Internal belief -> what the patients think they are
Transgender When identity is incongruent with assignment
Transsexual Someone who made the switch from one gender to the other (Change in body -
Change in social status)
Transvestism Deriving pleasure from Cross dressing but not transgendered
Gender dysphoria
C/P ■ Identity is incongruent with assignment + Distress (Impairment emotionally ,
financially , professionally)
■ Desire to be or be treated like the other sex
■ Rid of secondary sexual characteristics
■ Believe they are the other sex
■ In kids -> Rejection of same sex rules or acceptance of opposite sex rules
■ Duration > 6 months
Dx Clinical
Tx Psychotherapy

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Psychiatry
Somatoform disorders
Somatoform disorder
C/P ■ Real (Not fabricated) symptom with No organic cause
■ Gone to multiple physicians
■ Had many tests
■ May have undergone many procedures or surgeries to find out the cause
■ Anxiety disorder or depression
■ Impairment of function
Dx ■ Rule out organic disease -> History - Physical examination - Investigations
■ Rule out factitious disorder
■ Rule out malingering
Tx Regularly schedule visits and promote stress reduction
There should be only one health care provider to ->
■ Set boundaries -> Set the number of visits , specialist accessed , tests
■ To avoid ignoring the new complaints which could be real like MI
Don’t hospitalize the patient
If no response -> CBT and a trial of antidepressant medications (SSRI's) are warranted
Disorder Symptom Preoccupation Motivation
IAD (aka No symptoms Acquiring an illness despite repeated Unwanted
hypochondriasis) reassurance
SSD ≥ 1 Somatic ■ Somatic complaint
symptom -> Pain - ■ May be related to a medical
Fatigue disease but disproportionate to it
■ Duration ≥ 6 months
CD a Neurologic ■ None -> La belle indifference (This
complaint that’s is not required to diagnose)
proportionate to ■ But won’t hurt themselves b
the stressor
Factitious Any Primary gain -> Achieve attention-role Done
Malingering Any ■ Secondary gain -> Money - intentionally to
insurance - freedom deceive
■ Characterized by poor compliance
with treatment or follow-up of
diagnostic tests

IAD -> illness anxiety disorder SSD -> somatic symptom disorder CD -> Conversion disorder
Ms -> multiple sclerosis

a ■ Need to rule out Stroke and MS

■ The cool thing about CD is that if you treat it as a stroke -> they recover fully as it’s a psychiatric condition
■ Tx -> 1st line (Education and self-help techniques) - 2nd line (CBT) - Physical therapy of for motor symptoms
b ■ The person who is blind (As neurologic symptom of CD) wont walk into a door
■ The person who is paralyzed won’t fall down the stairs

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294
Psychiatry
Pharmacotherapy
Antidepressant
Mechanism ↑↑ Serotonin - Norepinephrine -> Plasticity a -> Improved mood
Choose the Trial and error ->
drug ■ Pick one drug (SSRI or SNRI) -> try it out , see how it goes -> if the side effects are
bad and the patient can’t tolerate it try another one
■ Single dose Tried for ≥ 6 weeks to see whether it’s effective or not (the person
feels better or not)
■ Once you find an effective dose you need to treat depression for ≥ 6 months
■ You need ≥ 6 weeks to washout b
■ The goal is to reach the maximum dose which is limited based on the side effect
profile
■ Combination with psychotherapy is most effective
Drugs Selective serotonin reuptake inhibitor (SSRI)
Examples Escitalopram , Fluoxetine , Paroxetine , Sertraline
Side effect ■ Sexual dysfunction -> libido - Prolonged ejaculation (So can be
used to treat premature ejaculation)
■ Serotonin syndrome
Serotonin Norepinephrine reuptake inhibitor (SNRI)
Examples Desvenlafaxine , Duloxetine
Side effect ■ Better and cleaner than SSRI - they just cost more money
■ Venlafaxine -> Increases diastolic blood pressure -> typically avoided
in hypertensive patients
Atypicals
Bupropion ■ Help people quit smoking -> so can be used in patients with a little
bit of depression and is trying to quit smoking
■ No weight gain
■ Can’t be used in bulimia -> as it seizure threshold (Bulimic patients
are already liable to developing seizures)
Serotonin modulators
Examples Mirtazapine - Trazodone
Side effect These drugs are usually used for their side effects not for their primary
antidepressant effect
■ Mirtazapine -> Appetite stimulant (so can be used in patients with
depression who are underweight) - Sedation
■ Trazodone -> Sedation (so can be used as a sleep aid) - Priapism
(Medical emergency)
TCA -> Bad drug
Examples -tryptiline - Imipramine - Doxepin
Uses Depression - Neuropathic pain - Enuresis
Side effect ■ Acetylcholine like effect (Urine retention) -> So can be used to
treat enuresis especially in kids
■ Convulsion - Cardiotoxicity (Prolonged PR/QRS/QT) - Arrhythmia c -
Coma
MAO inhibitors -> Bad drug
Examples Selegiline - Phenelzine
Side effect ■ May cause hypertensive emergency -> Especially with Tyramine-rich
food (old wine and cheese)
■ Antidepressants should be discontinued at least 2 weeks (Fluoxetine
5 weeks) before initiating MAO

SSRI -> Selective serotonin reuptake inhibitor SNRI -> Serotonin Norepinephrine reuptake inhibitor

a Plasticity -> the ability for nerve cells to change through new experiences -> thought to be due to neural
connections over time
b Washout -> Means the period you have to wait after stopping one medication to start another one
c ■ QRS widening > 100 msec or ventricular arrhythmia -> Manage toxicity with NaHCO3 -> Increases plasma pH ->
favors inactive form of TCA & Decreases drug avidity for sodium channels
■ Seizures -> Benzodiazepines
■ 1st 2 hours after ingestion of toxic dose -> Activated carbon as soon as the airway is secured

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Psychiatry
Continue antidepressants
Antidepressant discontinuation syndrome
Patho ■ Sudden discontinuation after use > 6 weeks
■ More common with antidepressants with a shorter half-life (e.g. paroxetine,
venlafaxine)
C/P Flu-like symptoms - Headache - Nausea - Insomnia - Myalgias
Mood stabilizers
Choose the ■ Acute mania -> Mood stabilizer (Lithium or valproate) + Antipsychotic
drug ■ Chronic mania -> Maintenance (With the drugs used in acute mania)
■ Quetiapine -> Can be used in any phase of bipolar disorder
Drugs Lithium
Use 1 line in bipolar disorder (Very potent - Very effective) -> Used
st

to ->
■ Prevent relapse
■ Treat acute mania
Side effect ■ Teratogen (Ebstein anomaly) - Very narrow therapeutic
index - Nephrotoxic - Nephrogenic DI - Tremor - Ataxia -
Thyroid problems - Hyperparathyroidism
■ Lithium toxicity a-> If given with Thiazide diuretics, NSAIDs,
ACE inhibitors, tetracyclines, and metronidazole
Contraindication ■ Renal disease -> So get renal function tests
■ Cardiac disease -> So get ECG
■ Hyponatremia or diuretic use
Precautions Renal function tests - Thyroid function tests - ECG - Serum
Calcium - hCG
Valproic acid
Use 1 line in bipolar disorder -> used if you can’t use lithium for
st

whatever reason
Side effect Teratogen (Spina bifida) - Pancreatitis - Agranulocytosis -
Thrombocytopenia
Contraindication Liver disease
Quetiapine
Use The backup antipsychotic -> Can be used in any phase of bipolar
disorder
Side effect Weight gain - QT prolongation (Get ECG before starting) -
Somnolence
Lamotrigine
Use 2nd line in bipolar disorder
Side effect ■ Considered very clean
■ Mild rash
■ Stevens-Johnson syndrome -> So stop at first sign of rash
Carbamazepine
Use 3 line in bipolar disorder - Trigeminal neuralgia - Absence
rd

seizures in kids
Side effect Aplastic anemia - Agranulocytosis
Anti-anxiety
Acute anxiety Benzodiazepines -> used in attacks only as it causes dependence and its
withdrawal is similar to alcohol withdrawal because both bind to GABA receptor
■ Dependence -> occurs more with rapid acting BZD like Alprazolam and
Lorazepam
■ Withdrawal -> occurs with long acting BZD like Diazepam and
chlordiazepoxide
Chronic anxiety SSRI or SNRI + Psychotherapy
Specific phobia Public speaking -> Non selective beta blocker (Propranolol - Nadolol - Atenolol)

DI -> Diabetes insipidus SSRI -> Selective serotonin reuptake inhibitor SNRI -> Serotonin Norepinephrine reuptake inhibitor

a Indications for dialysis in lithium toxicity -> Level >4.0 / Altered mental status / Life-threatening arrhythmias.

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Psychiatry
Antipsychotic
Typical (1st generation)
Examples ■ High potency drugs -> Haloperidol - Fluphenazine
■ Low potency drugs -> Thioridazone - Chlorpromazine
Mechanism ■ Mesolimbic D2 C receptor blocker -> Positive symptoms
Side effects ■ Extrapyramidal side effects ->
Cause -> Due to blocking of D2 receptors in nigrostriatal pathway
↑ Potency -> Extrapyramidal side effects
■ Gynaecomastia in men and Galactorrhea/Amenorrhea in women ->
Cause -> Due to blocking of D2 receptors in the tubuloinfundibular tract
which leads to prolactin
■ Anticholinergic side effects -> Blurry vision - Dryness of body secretions -
urine retention - Tachycardia
■ Antihistamine -> sedation
■ α 1 blocking action -> Orthostatic hypotension
■ QT prolongation on ECG
■ Metabolic -> Weight gain - Hyperglycemia
■ Chlorpromazine -> Corneal deposits - Purple grey metallic rash over
sun-exposed areas
■ Thioridazone -> Retinal deposits
■ Neuroleptic malignant syndrome (NMS)
■ Fluphenazine -> Hypothermia (By disrupting thermoregulation and the body's
shivering mechanism)
Atypical (2nd generation)
Examples Quetiapine - Olanzapine - Resperidone - Aripiprazole - Ziprazidone - Clozapine a
Mechanism ■ Mesolimbic D2 C receptor blocker -> Positive symptoms
■ 5-HT1 receptor blocker -> Negative symptoms
■ Aripiprazole -> has serotonergic effect and is D2 partial agonist
Side effects ■ Less extrapyramidal side effects than typical antipsychotics -> as atypicals
are more selective on mesolimbic D2 C receptors + inhibition of 5HT-2A (also
5HT-2C)
Weight EPS QT Other
gain/Metabolic prolongation
syndrome
Aripiprazole Low Low Low
Olanzapine Very high Low Low F/U -> Fasting
glucose and lipids
Risperidone High High High
Ziprasidone Lowest Low High
Clozapine Very high Low Low Agranulocytosis -
Seizure - Salivation -
Sedation
Quetiapine High Low Low Somnolence -> so can
be used to treat
insomnia - Also can
be used as an
antipsychotic mood
stabilizer in
treatment of bipolar
disorder

EPS -> Extrapyramidal symptoms

a Clozapine ->
■ By far the best drug for schizophrenia
■ Used when all other medication fail -> As it causes agranulocytosis
■ Need to be followed up by CBC to check ANC (absolute neutrophil count) -> Blood draw schedule: weekly x 6
mo, every 2 weeks x 6 mo, monthly thereafter while on medication

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Psychiatry
Choosing the medication
■ Patients who know they have schizophrenia and want to take medications -> Atypical
antipsychotic -> Quetiapine - Resperidone - Clozapine
■ Combative patient -> Intramuscular -> Haloperidol or Olanzapine
■ Dysphagia -> Oral dissolving tablets -> Olanzapine - Resperidone
■ Non compliant patient -> Depot forms -> Olanzapine - Resperidone
■ Every other medications fail -> Clozapine
EPS Develops after Notes
Acute Hours to days Any contraction of major muscle group ->
dystonia ■ Oculogyric crisis -> Eyes get locked in one position
■ Torticollis -> Spasm of sternocleidomastoid
■ Hand wringing -> Repeated clasping or squeezing of the
hands
Tx -> Anticholinergics (Benztropine - diphenhydramine)
Akasthesia Days to months Restlessness with urge to move
Tx ->
■ dose of antipsychotic
■ Beta blocker
■ Anticholinergics (Benztropine - Diphenhydramine)
Dyskinesia Days to months Parkinsonism
Tx -> Anticholinergics (Benztropine - Amantadine)
Tardive Months to years Patho -> Chronic blockade of dopamine receptors produces D2
dyskinesia receptor upregulation and supersensitivity
Chronic and lifelong ->
■ Grimacing
■ Sticking out of the tongue
■ Moving the bottom of jaw
Tx ->
■ Screen people on antipsychotic every 6 months -> and stop
the medication if they develop tardive dyskinesia symptoms
■ Valbenazine
■ Deutetrabenazine
Serotonin syndrome Neuroleptic malignant syndrome
Cause Any drug that ↑ serotonin -> Antipsychotic + Genetic
■ Psychiatric drugs -> MAO inhibitors, SSRIs, predisposition
SNRIs, TCA, vilazodone, vortioxetine
■ Nonpsychiatric drugs -> tramadol,
ondansetron, triptans, linezolid, MDMA,
dextromethorphan, meperidine, St. John's
wort
C/P 3 A s -> Malignant FEVER -> Myoglobinuria -
■ Activity -> Clonus - Hyperreflexia - Fever - Encephalopathy - Vitals
hypertonia - Seizure unstable, Enzymes (CK) - Muscle
■ Autonomic instability -> Hyperthermia - Rigidity (Lead-pipe)
Diaphoresis - Diarrhea
■ Altered mental status
Tx ■ Cyproheptadine -> 5-HT2 receptor blocker ■ Discontinue causative drug
■ Supportive -> Hydration - Cooling
■ Refractory -> Dantrolene -
bromocriptine

EPS -> Extrapyramidal symptom CK -> Creatine kinase

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Psychiatry

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299
Psychiatry
Psychotherapy
Duration Typical patient
Cognitive behavioral therapy Time-Limited Maladaptive thoughts , Avoidance behavior , Ability
to participate in homework
Interpersonal psychotherapy Time-Limited Depressed with relationship conflicts
Supportive psychotherapy Ongoing Lower functioning , In crisis , Psychotic
Psychodynamic psychotherapy Ongoing Higher functioning , Persistent pattern of
dysfunction
Motivational interviewing Variable Substance use disorder
Dialectical behavioral therapy Variable Borderline personality disorder
Biofeedback Variable Prominent physical symptoms, Pain disorders

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