PSYCHIATRY

1. Antipsychotics Antipsychotic agents (e.g. haloperidol) can cause QT-interval prolongation; therefore, an ECG
should be obtained prior to administering these agents to avoid causing a life-threatening arrhythmia (e.g. torsade de
pointes).
2. Adrenal Insufficiency In patients with depressed mood, an underlying medical condition should be considered
and may be suggested by findings that are unexplained by psychiatric illness alone. Primary adrenal insufficiency presents
with clinical manifestations of deficiency of mineralocorticoids (eg. dietary salt craving), glucocorticoids (e.g. fatigue,
depressed mood), and androgens (e.g. reduced secondary sexual characteristics in women).

3. Male Sexual Dysfunction Premature ejaculation is characterized by uncontrolled ejaculation and decreased
ejaculatory latency. Most patients respond to selective serotonin reuptake inhibitors, which prolong ejaculatory latency.
Patients may also benefit from local anesthetics and/or psychotherapy to address concurrent anxiety, mood disorders, and
relational issues.

4. Serotonin Syndrome Serotonin syndrome is characterized by the triad of mental status changes, autonomic
dysregulation, and neuromuscular hyperactivity. It may be an unintentional result of the combined use of serotonergic
agents (e.g. selective serotonin reuptake inhibitors and tramadol).

5. Multiple Sclerosis Multiple sclerosis (MS) is an immune-mediated inflammatory demyelinating disease that
typically presents in young women with episodes of CNS dysfunction. When MS is suspected, brain MRI showing
demyelinating plaques disseminated in time and space can help confirm the diagnosis.

6. Tremor Functional (psychogenic) tremors often present abruptly with significant disability. They often decrease
with distraction, have changeable or inconsistent features, and are not consistent with known tremor syndromes.

7. Conversion Disorder Psychogenic nonepileptic seizure (PNES) is a type of conversion disorder commonly
misdiagnosed as a seizure disorder. Features suggestive of PNES include forced eye closure, side-to-side head or body
movements, memory recall of the event, and lack of postictal confusion. The gold standard for diagnosis of PNES is
video-electroencephalogram of an event demonstrating lack of epileptiform activity.

8. Parkinson Disease Parkinson disease dementia (PDD) is characterized by executive and visuospatial
dysfunction with relatively mild memory impairment at first. PDD may be distinguished from dementia with Lewy bodies
by the timing of symptom onset: If parkinsonism predates cognitive impairment by > 1 year, PDD should be diagnosed.

9. Antipsychotics Antipsychotics cause hyperprolactinemia by blocking dopamine activity in the tuberoinfundibular

pathway. Clinical effects of hyperprolactinemia include amenorrhea, galactorrhea, gynecomastia, and sexual dysfunction.

10. Narcolepsy Narcolepsy is characterized by excessive daytime sleepiness, cataplexy, hypnagogic/hypnopompic

hallucinations, and sleep paralysis. Treatment includes sleep hygiene, scheduled naps, and avoidance of alcohol and drugs
that cause drowsiness. When medications are needed to decrease daytime somnolence, wakefulness-promoting agents such
as modafinil are preferred.

11. Benzodiazepines Benzodiazepines should be used with extreme caution in the elderly due to increased risk
of cognitive impairment, falls, and paradoxical agitation.

12. Seizures Absence seizures typically occur in children age 4-10 and are characterized by < 20-second
episodes of impaired concentration (e.g. pause, blank stare) with preserved postural tone. Automatisms (e.g. blinking, lip
smacking) are common, and ethosuximide is the first-line treatment.

13. Fragile X Syndrome Fragile X syndrome is seen in young children with developmental delay and dysmorphic
features (e.g. elongated face, deep-set eyes, large ears). Diagnosis is confirmed with polymerase chain reaction and
Southern blot analysis.
14. Depression Sleep disturbances are commonly seen in depression. New-onset insomnia in elderly patients who
have associated symptoms of depression should raise concern for major depressive disorder.

15. Dementia With Lewy Bodies Dementia with Lewy bodies is characterized by fluctuating cognitive impairment,
recurrent visual hallucinations, REM sleep behavior disorder, and parkinsonism. Severe sensitivity to antipsychotics
(dopamine antagonists) is a supportive clinical feature.

16. Serotonin Syndrome Serotonin syndrome is precipitated by medications that increase serotonergic activity in
the CNS, which results in altered mental status, autonomic instability, and neuromuscular excitability. Sustained muscle
contraction and autonomic dysfunction can lead to rhabdomyolysis, acute kidney injury, and disseminated intravascular
coagulation.
17. Selective Serotonin Reuptake Inhibitors Isolated overdose of selective serotonin reuptake inhibitors (SSRIs) is
usually well tolerated. When a patient with SSRI overdose has altered mental status and abnormal physical examination
findings, levels of common coingestants (e.g. salicylates, ethanol) should be obtained.

18. Depression All women should be assessed for depression at their postpartum follow-up visits. Treatment
options for postpartum depression include psychotherapy and/or pharmacotherapy. Selective serotonin reuptake inhibitors
are used as first-line therapy.

19. Child And Adolescent Mental Health Family therapy is a type of counseling that focuses on changing
dysfunctional patterns of interaction among family members to enhance family functioning. It has been shown to increase
positive outcomes in adolescent behavioral problems, substance use disorders, and depression.

20. Somatic Symptom Disorder A history of childhood sexual abuse and/or adult sexual trauma has been
consistently associated with the development of lifetime somatic symptom disorders (SSDs). Other significant risk factors
for SSD include female sex, low educational level, chronic illness as a child, or childhood exposure to a family member
with a chronic illness.

21. Somatic Symptom Disorder When medical workup fails to identify a medical etiology in a patient with
suspected somatic symptom disorder, the results should be communicated in a positive tone that reassures the patient that
there is no evidence of serious medical illness. The distressing and real nature of the symptoms should be acknowledged
first, followed by a discussion of the diagnosis of somatic symptom disorder and contributing psychologic factors.

22. Depression The serotonin-norepinephrine reuptake inhibitor venlafaxine is associated with dose-dependent
hypertension due to increased norepinephrine reuptake inhibition at higher dose ranges. Blood pressure should be assessed
before starting venlafaxine and regularly monitored throughout treatment.

23. Serotonin Syndrome Serotonin syndrome is characterized by the acute onset (within hours) of altered mental
status, neuromuscular excitability, and autonomic dysregulation. Symptoms typically resolve within 24 hours of stopping
all serotonergic medications.

24. Serotonin Syndrome Serotonin syndrome is characterized by mental status changes, autonomic dysregulation,
and neuromuscular excitability. Management includes discontinuation of serotonergic medications, hydration, cooling, and
blood pressure control. Benzodiazepines are used to decrease agitation and muscle contractions. Cyproheptadine is used to
decrease central serotonergic activity.

25. Conversion Disorder Psychogenic nonepileptic seizures present similarly epilepsy, with loss of consciousness
and shaking. Suggestive features include asynchronous limb movement, eye fluttering, and lack of a postictal period.
Diagnostic clarification with continuous video electroencephalogram to capture and characterize a spell should be pursued
prior to treatment initiation.

26. Factitious Disorder Factitious disorder is characterized by intentional falsification of illness in the absence of
external reward. Patients appear to be motivated by internal factors, such as psychosocial stressors or desire for validation.
Patients with factitious disorder may have hypoglycemia due to the surreptitious intake of sulfonylureas or insulin.
27. Post-Traumatic Stress Disorder Post-traumatic stress disorder may not develop immediately following a trauma
and is specified as ‘with delayed expression'. Trauma-focused cognitive-behavioral therapy and/or serotonergic
antidepressants are first-line treatments.

28. Post-Traumatic Stress Disorder Prazosin, an α1 adrenergic receptor antagonist, is effective for the treatment of
post-traumatic stress disorder-related nightmares. It is particularly helpful as an adjunct to selective serotonin reuptake
inhibitor or serotonin norepinephrine reuptake inhibitor treatment.

29. Post-Traumatic Stress Disorder Life-threatening medical events may be experienced as traumatic and result in
post-traumatic stress disorder. Trauma-focused cognitive-behavioral therapy is the preferred initial treatment.

30. Cocaine The initial management of stimulant intoxication involves controlling agitation and reducing
sympathetic hyperactivity with benzodiazepines, medications that enhance the inhibitory effect of GABA.

31. Impulse Control Disorders Ropinirole and other dopamine agonists can induce impulse control disorders that
may present with a manic-like syndrome. The treatment of choice in these situations is discontinuation of the offending
agents.
32. Tourette Syndrome Tourette syndrome is characterized by multiple motor tics and at least one vocal tic.
Treatment options include habit reversal training and pharmacotherapy with antipsychotics, dopamine depleters, or α-
adrenergic receptor agonists.

33. Mild Cognitive Impairment Hearing loss in the elderly is common and may present with social isolation and
cognitive decline. Careful history-taking and a whispered voice test should be conducted. Audiometric testing can help
confirm the diagnosis and direct management.

34. Driving Evaluating older drivers requires a careful evaluation of the patient’s functional capacity to drive and
balancing patient autonomy and confidentiality with public safety. In addition to the performance of a history and physical
examination, an on-road driving evaluation is recommended in complex cases.

35. Alzheimer Disease Patients with a family history of Alzheimer disease are at increased risk of developing the
disease but can mitigate risk by addressing modifiable risk factors. Aggressive treatment of cardiovascular risk factors
(e.g. hypertension, diabetes, obesity/physical inactivity), especially in mid-life, can help reduce risk.

36. Gender Dysphoria Exploring gender expression is a normal part of child and adolescent development.
Nonconformity with typical gender norms should be differentiated from an experienced gender identity that is incongruent
with assigned gender.

37. Stimulants Stimulant misuse should be considered in patients with psychomotor agitation and signs of
sympathetic hyperactivity. Benzodiazepines are the treatment of choice.

38. Body Dysmorphic Disorder Body dysmorphic disorder is characterized by preoccupation with slight to
nonexistent appearance flaws and related repetitive behaviors such as checking, comparing with others, and camouflaging
the perceived defect. Accurate diagnosis is critical to prevent patients from pursuing inappropriate cosmetic or surgical
treatments.
39. Inhalants Inhalant abuse typically begins in childhood or early adolescence. Perioral dermatitis involving
the nasolabial folds is characteristic. Presenting features include irritability, anorexia, abdominal cramps and neurological
dysfunction. Chronic use can result in long-term neurocognitive impairment.

40. Brief Psychotic Disorder Brief psychotic disorder is characterized by the acute onset of psychotic
symptoms (e.g. disorganized speech and behavior, delusions, hallucinations) lasting between 1 day and 1 month. It can be
triggered by a marked stressor such as the loss of a loved one.

41. Personality Disorders Dependent personality disorder is characterized by a need to be taken care of, leading to
submissive and clingy behavior with a fear of separation. Individuals often have symptoms of anxiety or depression in the
 context of a breakup or loss, with an urgent need to seek out another relationship.

42. Personality Disorders Schizotypal personality disorder is characterized by odd beliefs/magical thinking,
eccentric behavior, and a reduced capacity for intimacy. Paranoid ideation often results in social anxiety and avoidance.
Frank delusions and hallucinations are absent.

43. Bipolar Disorder Patients with bipolar II disorder experience at least 1 episode of hypomania and > 1 major
depressive episodes. First-line treatment of bipolar depressive episodes includes the antipsychotics lurasidone and
quetiapine.
44. Bulimia Nervosa Binge eating disorder is characterized by repeated episodes of excessive eating
accompanied by a loss of control and subsequent distress. The most effective treatment is psychotherapy. Medication
options include selective serotonin reuptake inhibitors (e.g. sertraline), lisdexamfetamine, and topiramate.

45. Normal Child Development Young children often prefer particular foods or food groups, which is consistent
with normal development. However, when picky eating is accompanied by behavioral rigidity, poor growth, weight loss,
or developmental delays, further evaluation is indicated.

46. Personality Disorders Histrionic personality disorder presents with attention seeking, inappropriately
provocative behavior, and dramatic emotions and actions. These behaviors must be present since early adulthood and
across multiple contexts.

47. Personality Disorders Paranoid personality disorder is characterized by a long-standing pattern of suspicion and
mistrust of others' intentions. In the physician-patient relationship, it may manifest as difficulty establishing rapport and
creating a therapeutic alliance.

48. Pancreatic Cancer Depression, weight loss, and new-onset diabetes mellitus may occur as early
manifestations of pancreatic cancer. CT of the abdomen is indicated as part of the initial diagnostic evaluation.

49. Parkinson Disease Psychosis may develop in Parkinson disease as a result of the underlying disease process,
treatment with anti-Parkinson medications (e.g. levodopa, pramipexole), or a combination of the two. In patients treated
with anti-Parkinson medications who develop psychotic symptoms, dose reduction should be considered.

50. Post-Traumatic Stress Disorder Trauma-focused cognitive-behavioral therapy is the first-line treatment of post-
traumatic stress disorder. It combines cognitive therapy and exposure techniques to help the patient process the trauma and
decrease avoidance behaviors.

51. Post-Traumatic Stress Disorder Early intervention for acute stress disorder is indicated to reduce the severity of
symptoms and prevent progression to post-traumatic stress disorder. Trauma-focused cognitive-behavioral therapy is
recommended as first-line treatment.

52. Generalized Anxiety Disorder Generalized anxiety disorder presents with excessive concern about a range of
issues, which can result in irritability, poor sleep, and trouble concentrating. Children with anxiety commonly experience
somatic symptoms.

53. Schizophrenia Early-onset schizophrenia (onset age < 18) is associated with a more severe and impairing course.
Youth commonly have a prodromal phase marked by social withdrawal and academic decline prior to the onset of active
psychotic symptoms. Hallucinations are common and need to be differentiated from imaginary friends.

54. Depression Neuropsychiatric manifestations of Cushing syndrome include depressed or labile mood, anxiety,
irritability, insomnia, memory deficits, and fatigue. Patients with these symptoms may be mistakenly diagnosed with
primary psychiatric disorders. Initial diagnostic tests include 24-hour urinary cortisol excretion, late-night salivary cortisol
assay, and overnight low-dose dexamethasone suppression test.

55. Clozapine The antipsychotic clozapine is associated with an increased risk of seizure.
56. Schizophrenia The diagnosis of schizophrenia requires > 2 of the following: delusions, hallucinations,
disorganized speech, disorganized behavior, and negative symptoms; at least 1 of the first 3 findings is required. Negative
symptoms are a core domain of schizophrenia and include apathy, avolition, lack of facial expression, alogia, social
withdrawal, and diminished interest in relationships. These symptoms may be mistaken for aspects of personality or
depressive disorders.

57. Personality Disorders Borderline personality disorder is characterized by mood instability, inappropriate anger,
impulsivity, and unstable relationships. Self-injury is common but not required for diagnosis. Patients may have transient
psychotic symptoms in times of stress.

58. Normal Child Development Having imaginary friends is developmentally appropriate in preschool and
school-aged children. It represents a form of creative play, aiding in the development of emotional and social competence,
as well as providing comfort in times of distress.

59. Tardive Dyskinesia Tardive dyskinesia is characterized by abnormal involuntary movements of the face, lips,
tongue, trunk, or extremities that develop as a result of prolonged exposure to antipsychotic medication. If feasible, the
causative medication should be tapered and discontinued.

60. Schizophrenia Antipsychotic medication should be maintained indefinitely in patients with schizophrenia,
including those with a first episode of psychosis.

61. Schizophrenia Family therapy is an effective adjunct to antipsychotic medication in patients with schizophrenia
and has been shown to reduce the risk of relapse. It focuses on educating the family about the symptoms, course, and
treatment of the disorder, and it helps to promote a supportive family environment.

62. Psychosis Delusional disorder is characterized by one or more delusions. Other prominent psychotic
symptoms are absent, and the individual is still able to function in areas unrelated to the delusion.

63. Psychosis Parkinson disease presents with bradykinesia, resting tremor, and rigidity. It may be complicated
by visual hallucinations, which can be treated with a low-potency, second-generation antipsychotic (e.g. quetiapine,
pimavanserin).
64. Substance-Induced Psychotic Disorder Glucocorticoid therapy may cause psychosis, anxiety, and mood
symptoms. Restlessness, sleep disturbances, and memory loss may also occur. Glucocorticoid dose reduction, or
discontinuation, is indicated whenever possible.

65. Alcohol Withdrawal Alcohol withdrawal should be considered in patients who are newly admitted to
supervised settings and develop tremor, agitation, and elevated pulse and blood pressure within 12-48 hours following
admission. Benzodiazepines are indicated for the treatment of alcohol withdrawal.

66. Lithium Lithium toxicity presents with neurologic (e.g. altered mental status, seizure, fasciculations, tremor) and
gastrointestinal (e.g. vomiting, diarrhea) signs. The treatment of choice is hemodialysis.

67. Lithium Certain medications (e.g. lithium) can enhance a physiologic tremor, which is typically a fine, symmetric
action tremor of the hands that increases with sympathetic activity.

68. Bipolar Disorder Bipolar II disorder is characterized by distinct episodes of major depression and
hypomania. In contrast, the labile mood states seen in borderline personality disorder tend to fluctuate more rapidly.

69. Substance Induced Mood Disorder Cocaine intoxication can produce manic symptoms, including elevated or
irritable mood, hyperactivity, agitation, and pressured speech. Signs of sympathetic stimulation (e.g. diaphoresis,
mydriasis, tachycardia, hypertension) can assist in differentiating cocaine intoxication from bipolar disorder and other
primary psychiatric disorders.

70. Substance Induced Mood Disorder Evaluation of new-onset mood symptoms requires that medical and
substance-induced causes be ruled out. The neuropsychiatric side effects of glucocorticoids include euphoria, depression,
 hypomania or mania, and psychosis.

71. Bipolar Disorder Mania in adolescence may be confused with normal adolescent moodiness, defiance,
overconfidence, and risk taking. However, an abrupt change from baseline, together with decreased need for sleep,
distractibility, excessive goal-directed activity, and grandiosity, should raise suspicion for a manic episode.

72. Bipolar Disorder Patients with a manic episode of bipolar I disorder may have an irritable rather than
euphoric mood, which can manifest as uncharacteristic angry outbursts and aggressive behavior.

73. Bipolar Disorder Core features of a manic episode include elevated or irritable mood, increased
energy/activity, and a decreased need for sleep. Manic patients may feel rested and energetic despite getting very little or
no sleep.
74. Depression Atypical features of major depressive disorder include hypersomnia, hyperphagia, heavy feelings
in limbs, hypersensitivity to rejection, and mood reactivity (ability to respond to positive events).

75. Depression Sleep disturbance is a core symptom of depression. Polysomnographic findings in major
depressive disorder include decreased REM latency and slow-wave sleep, as well as increased REM sleep duration and
REM sleep density.

76. Antidepressants Depression after myocardial infarction can increase the overall risk of cardiac mortality.
Psychotherapy and antidepressant treatment (especially in combination) are likely to be effective. The selective serotonin
reuptake inhibitor sertraline is considered a first-line treatment.

77. Depression Major depressive disorder is frequently recurrent. Long-term maintenance antidepressant therapy
is indicated for patients with > 2 major depressive episodes.

78. Depression Psychotherapy is the preferred treatment approach for patients with adjustment disorders.

79. Suicide 5-hydroxyindoleacetic acid (5-HIAA) is a metabolite of serotonin. Low cerebrospinal fluid 5-HIAA is
associated with suicidal behavior.

80. Obsessive Compulsive Disorder Treatment of obsessive-compulsive disorder consists of serotonergic

antidepressants and exposure and response prevention based cognitive-behavioral therapy. Selective serotonin reuptake
inhibitors are first-line medications.

81. Obsessive Compulsive Disorder Obsessive-compulsive disorder is characterized by intrusive, recurrent, and
persistent unwanted thoughts (obsessions) and repetitive behaviors or mental acts (compulsions) in response to the
obsessions. Patients typically have prominent anxiety symptoms that must be differentiated from those of primary anxiety
disorders.
82. Child And Adolescent Mental Health Post-traumatic stress disorder in children may present with distressing
dreams with vague content and re-enactment of traumatic themes in play, rather than clearly formulated memories. This is
often accompanied by emotional dysregulation and behavioral difficulties.

83. Psychosis Options for pharmacological management of an acutely agitated patient include the administration
of a benzodiazepine and/or an antipsychotic agent. The benzodiazepine lorazepam is often used due to its rapid onset of
action and intramuscular formulation.

84. Attention Deficit Hyperactivity Disorder In addition to inattention and hyperactivity, patients with attention deficit
hyperactivity disorder (ADHD) may display impulsive blurting out of thoughts and frequent interruption of others. ADHD
may be mistaken for willfully defiant behavior and causes difficulties in social relationships.

85. Language Disorder Language disorder becomes evident in the early developmental period when a child has
difficulty acquiring and/or using language appropriately. It can result in behavioral difficulties and negatively impact later
academic achievement.
86. Bipolar Disorder The second-generation antipsychotics quetiapine and lurasidone are first-line medications
for the treatment of acute bipolar depression. Antidepressant monotherapy should be avoided due to the risk of inducing
mania.
87. Bipolar Disorder Bipolar disorder is characterized by depressive and manic episodes. If psychotic
symptoms occur, they are only present in the context of a manic or major depressive episode.

88. Bipolar Disorder Patients with > 1 manic episode are diagnosed with bipolar I disorder. Depressive
episodes are not required for diagnosis but are common. Manic episodes may include psychotic symptoms, often with
grandiose themes.

89. Bipolar Disorder Bipolar disorder is a highly recurrent illness. Maintenance treatment is recommended to
decrease the risk of recurrent manic or depressive episodes. Lithium therapy should be maintained in patients whose
condition is stable and who are tolerating the medication.

90. Autism Spectrum Disorders High functioning autism in children may come to attention only when social
demands reveal their social-emotional deficits during school-age years. Features include social awkwardness, fixated
interests, and unusual responses to sensory experiences.

91. Child And Adolescent Mental Health Adolescent depression may be characterized by irritability; loss of
interest in previously enjoyed activities; fatigue; disturbances in sleep, concentration, and appetite; excessive guilt/feelings
of worthlessness; and suicidal ideation. The severity of symptoms and related impairment can help differentiate depression
from adjustment disorder and normal adolescent behavior.

92. Depression Diagnosing major depressive disorder in patients with cancer is difficult because somatic
symptoms of depression (e.g. fatigue, weight loss) may overlap with those of cancer and its treatment. If these symptoms
are associated with depressed mood or loss of interest, major depressive disorder should be considered.

93. Antidepressants An antidepressant trial is at least 4-6 weeks at a therapeutic dose. Physicians should continue
antidepressants for at least 4-6 weeks before considering the next step in treatment.

94. Depression Nonresponders to an adequate trial of a selective serotonin reuptake inhibitor (SSRI) should be
switched to another antidepressant. Bupropion, a norepinephrine dopamine reuptake inhibitor that does not cause sexual
side effects, is a preferred choice in patients with SSRI-related sexual dysfunction.

95. Depression Major depressive disorder with psychotic features is characterized by an episode of major
depression accompanied by delusions and/or hallucinations, often with depressive themes. Treatment involves combined
antidepressant and antipsychotic medication or electroconvulsive therapy.

96. Depression Postpartum depression should be differentiated from postpartum blues, a milder and self-limited
form of depression that peaks at 5 days and resolves within 2 weeks. Postpartum depression is diagnosed using the same
diagnostic criteria for a major depressive episode outside the postpartum period.

97. Adjustment Disorders Adjustment disorder involves symptoms occurring within 3 months of an identifiable
stressor that cause significant distress and/or impairment. It is not diagnosed if a patient meets diagnostic criteria for
another mental disorder.

98. Depression Electroconvulsive therapy is a safe and effective first-line treatment for major depressive disorder
with psychotic features. It is particularly appropriate for severely depressed patients who refuse to eat and drink or are
acutely suicidal.
99. Depression Major depressive disorder can be differentiated from adjustment disorders and normal grief
reactions by the persistence and severity of symptoms. Pervasive sadness and anhedonia that do not decrease in severity
over time should raise suspicion for major depression.

100. Depression Patients with depression should be carefully assessed for suicidal thoughts and behavior
to determine the appropriate treatment setting. Patients with active suicidal ideation and both a plan and access to means
 are at increased risk and should be hospitalized.

101. Autism Spectrum Disorders Autism spectrum disorder is characterized by deficits in social
interaction, restricted interests, repetitive behaviors, and abnormal sensory perception. Food selectivity is common.

102. Catatonia Catatonia is characterized by immobility, mutism, negativism, and echophenomena. It

most often presents in the context of bipolar disorder or major depressive disorder. Catatonia is treated with
benzodiazepines (e.g. lorazepam).

103. Prion Disease Creutzfeldt-Jakob disease presents with rapidly progressive dementia, myoclonus, mood
symptoms, and hypersomnia. This disease is associated with high levels of 14-3-3 protein in the cerebrospinal fluid. It is
untreatable and generally fatal within 1 year of diagnosis.

104. Dementia With Lewy Bodies Dementia with Lewy bodies is characterized by early visuospatial and
executive dysfunction and at least 2 of 4 additional core features: visual hallucinations, parkinsonism, fluctuating
cognition, and rapid eye movement sleep behavior disorder.

105. Opioids Unresponsiveness, reduced respirations, shallow breathing, and decreased bowel sounds are signs
of opioid intoxication. Miosis is usually present as well, but normal pupil size does not rule out opioid intoxication due to
possible coingestants. For emergency management, naloxone should be administered to reverse respiratory depression.

106. Tourette Syndrome Tourette syndrome is characterized by multiple motor tics and at least one vocal
tic, which may wax and wane in intensity. It commonly presents in children age 6-15 and may result in distraction and
teasing in the school setting.

107. Fetal Alcohol Syndrome Neurobehavioral manifestations of fetal alcohol syndrome include
intellectual disability, emotional dysregulation, inattention, and social skill deficits. Accompanying features include facial
dysmorphism (short palpebral fissures, thin upper lip, smooth philtrum) and growth retardation.

108. Anxiety Due To Another Medical Condition Hyperthyroidism and anxiety disorders have considerable
symptom overlap, including sleep disturbances, palpitations, and sweating. Measurement of thyroid functioning is the first
step in management of patients with new-onset anxiety and physical symptoms to prevent misdiagnosis and provide
appropriate treatment.

109. Selective Serotonin Reuptake Inhibitors Prior to prescribing selective serotonin reuptake inhibitors,
common early side effects (e.g. headache, nausea, insomnia/sedation, anxiety, dizziness) and late side effects (e.g. sexual
dysfunction, weight gain) should be discussed. Patients should be advised to avoid abrupt discontinuation and be informed
that response typically requires 4-6 weeks of continued use.

110. Gender Dysphoria Gender dysphoria is characterized by persistent distress due to the incongruence
between gender identity and assigned gender. It is often accompanied by discomfort with the development of unwanted
secondary sexual characteristics.

111. Depressive Disorder Due To Another Medical Condition Multiple sclerosis is frequently associated with
depression. Treatment, which includes psychotherapy and antidepressants, can alleviate suffering and improve quality of
life.
112. Body Dysmorphic Disorder Treatment of body dysmorphic disorder consists of selective serotonin
reuptake inhibitors and/or cognitive-behavioral therapy. Cosmetic treatments and surgery should be avoided.

113. Impulse Control Disorders Intermittent explosive disorder is characterized by recurrent episodes of
impulsive verbal or physical aggression. The aggressive behaviors are unplanned and out of proportion to the provocation.

114. Alcohol Use Disorder A combination of psychosocial interventions and pharmacotherapy is indicated
for patients with moderate to severe alcohol use disorder. Acamprosate and naltrexone are first-line medication options.
115. Wernicke-Korsakoff Syndrome Korsakoff syndrome is a potential complication of Wernicke
encephalopathy that is characterized by retrograde and anterograde amnesia with preserved long-term memory,
confabulation, lack of insight, and apathy. Korsakoff syndrome is caused by thiamine deficiency and develops more
frequently in alcohol use disorder than in other malnourished states.

116. Anxiety Due To Another Medical Condition Pheochromocytoma is an adrenal tumor that presents
with episodic headache, hypertension, tachycardia/palpitations, and diaphoresis and may be accompanied by anxiety and
panic attacks. Given the risks associated with a missed medical diagnosis, physicians must maintain a high index of
suspicion for underlying medical causes of psychiatric symptoms.

117. Alcohol Withdrawal In patients with liver disease, the benzodiazepines lorazepam, oxazepam, and
temazepam are preferred due to their shorter half-life and lack of active metabolites. Benzodiazepines with longer half-
lives and active metabolites, such as chlordiazepoxide and diazepam, place patients with hepatic dysfunction at risk for
toxic drug buildup.

118. Bipolar Disorder A mild rash may develop in up to 10% of those treated with lamotrigine, whereas
life-threatening Stevens-Johnson syndrome or toxic epidermal necrolysis may occur in 0.1%. Any occurrence of rash
during the treatment of lamotrigine requires immediate discontinuation of the drug.

119. Stimulants Caffeine is a stimulant that, when used in excessive amounts, can cause sympathetic
hyperactivity, leading to anxiety, jitteriness, insomnia, palpitations, and tremors. Energy drinks typically contain large
amounts of caffeine and should be considered as a cause of stimulant intoxication.

120. Depression First-line treatment options for major depressive disorder include antidepressants,
psychotherapy, or a combination of both. Among psychotherapies, cognitive-behavioral therapy and interpersonal
psychotherapy have the best evidence for efficacy.

121. Anorexia Nervosa Dermatological complications of anorexia nervosa (AN) include dry, scaly skin;
hair loss; and lanugo. First-line treatment for AN consists of nutritional rehabilitation and psychotherapy. Most medical
complications of AN (e.g. hair loss) improve with weight restoration.

122. Depression Major depressive disorder with psychotic features is a subtype of depression characterized
by severe depression and delusions and/or hallucinations. First-line treatment consists of an antidepressant plus an
antipsychotic or electroconvulsive therapy.

123. Selective Serotonin Reuptake Inhibitors Activating effects (e.g. anxiety, insomnia) are possible early
adverse effects of selective serotonin reuptake inhibitors but frequently improve with time. Patients with anxiety disorders
are more sensitive to activating adverse effects and may benefit from a temporary dose reduction or initiation at a lower-
than-normal dose.

124. Depression Persistent complex bereavement disorder is characterized by prolonged grief, difficulty
accepting the death, persistent yearning for the deceased, and maladaptive ruminative thoughts and behaviors.
Psychotherapy is the treatment of choice.

125. Premenstrual Syndrome Premenstrual dysphoric disorder is characterized by cyclical mood swings,
irritability, appetite changes, and physical discomfort that resolve after menses. It is not diagnosed when premenstrual
mood symptoms represent an exacerbation of an underlying disorder in which symptoms are not limited to the
premenstrual phase.

126. Antidepressants Venlafaxine is a serotonin-norepinephrine reuptake inhibitor that can cause dose-
dependent hypertension. Blood pressure should be monitored regularly, especially at higher doses.

127. Lithium Approximately 25% of patients treated with lithium will develop hypothyroidism, requiring that
all patients have regular TSH monitoring every 6-12 months. Lithium-induced hypothyroidism is generally treated with T4
 supplementation rather than discontinuation of lithium.

128. Dissociative Identity Disorder Dissociative identity disorder is characterized by switching among two or
more distinct personality states that take control of the patient's behavior and by an extensive inability to recall important
personal information. The disorder is associated with severe childhood trauma and treated with long-term psychotherapy.

129. Depression Major depressive disorder with seasonal pattern (seasonal affective disorder) is
characterized by seasonal onset and remission (most commonly fall-winter onset and spring-summer remission).
Treatment consists of bright light therapy alone or with an antidepressant.

130. Bipolar Disorder Bipolar II disorder is characterized by hypomanic and major depressive episodes
with no history of manic episodes. Hypomania is distinguished from mania by less severity, no psychotic features, and no
need for hospitalization. Functioning in hypomania is either improved or only mildly impaired.

131. Personality Disorders Borderline personality disorder is characterized by mood instability, recurrent
suicidal behavior, unstable relationships, inappropriate anger, impulsivity, and abandonment fears. Stress-related paranoia
and dissociation may be mistaken for primary psychosis. A history of childhood trauma is common.

132. Personality Disorders Dialectical behavioral therapy is the treatment of choice for borderline personality
disorder. Pharmacotherapy is used as an adjunct to psychotherapy or to treat comorbid disorders.

133. Generalized Anxiety Disorder Generalized anxiety disorder is characterized by multiple worries lasting
> 6 months with symptoms of restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep
disturbance.
134. Adjustment Disorders Adjustment disorder is characterized by the development of emotional or
behavioral symptoms in response to an identifiable stressor. The diagnosis is appropriate when the patient does not meet
the criteria for another mental disorder.

135. Depression Major depressive disorder is often a recurrent illness. Patients with > 3 lifetime depressive
episodes, severe episodes (e.g. suicide attempts), or episodes lasting > 2 years are candidates for lifelong antidepressant
treatment.
136. Antidepressants All patients who have a major depressive episode should be screened for a history of
hypomanic/manic episodes to rule out bipolar disorder. This is especially important prior to being prescribed
antidepressants due to the risk of antidepressant-induced mania.

137. Bipolar Disorder All antidepressants are associated with a risk of inducing mania in susceptible
patients. The first step in management is discontinuation of the offending medication.

138. Physician Patient Communication Dhat syndrome is a culture-bound syndrome of South Asia that
manifests with psychological and somatic symptoms that are attributed to loss of semen. When evaluating culture-bound
syndromes, it is important to take a patient-centered approach and allow the patient to explain the cultural explanations,
manifestations, and consequences of a given syndrome.

139. Psychosis Schizophrenia is characterized by delusions, hallucinations, disorganized speech and

behavior, and negative symptoms of > 6 months duration. The differential diagnosis includes mood disorders with
psychotic features, other primary psychotic disorders, and substance and medical causes of psychosis.

140. Psychosis Substance-induced psychosis should be considered in the differential diagnosis of all
patients who come to the emergency department with acute psychosis. Standard workup of new-onset psychosis includes
obtaining a urine toxicology screen.

141. Dementia With Levy Bodies Patients with dementia with Lewy bodies (DLB) are extremely sensitive
to antipsychotics, and use of this class of medication may be associated with worsening confusion, parkinsonism, and
autonomic dysfunction. If DLB-associated psychotic symptoms are functionally impairing, a trial of a low-potency
 second-generation antipsychotic (e.g. quetiapine) may be cautiously undertaken.

142. Frontotemporal Dementia Behavioral-variant frontotemporal dementia presents with behavioral

changes (e.g. disinhibition), compulsive behavior, hyperorality, apathy, and executive dysfunction. Unlike Alzheimer
disease, memory impairment is normally mild early in the disease.

143. Bulimia Nervosa Binge eating disorder is characterized by episodes of binge eating associated with
distress and a sense of loss of control. It is differentiated from bulimia nervosa by the absence of recurrent, unhealthy
compensatory behaviors (e.g. self-induced vomiting, fasting, excessive exercise).

144. Bulimia Nervosa Self-induced vomiting in bulimia nervosa results in dehydration and volume
depletion, resulting in secondary hyperaldosteronism and a hypokalemic, hypochloremic metabolic alkalosis. Symptoms
may occur as a result of volume contraction (e.g. dizziness, orthostasis) and electrolyte abnormalities (e.g. arrhythmias,
weakness, muscle cramps, constipation).

145. Panic Disorder Selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors
are first-line pharmacotherapy for panic disorder. Benzodiazepines are reserved for patients who require immediate relief
and should be avoided in those with substance abuse.

146. Brief Psychotic Disorder Brief psychotic disorder involves the presence of > 1 psychotic symptoms
lasting > 1 days and < 1 month, with full return to the previous level of functioning.

147. Prescription Drug Misuse Standard urine drug screens test for opioid use by measuring morphine, a
breakdown product of all natural, nonsynthetic opioids (e.g. heroin, codeine). Semi-synthetic (e.g. hydrocodone,
hydromorphone, oxycodone) and synthetic (e.g. fentanyl, meperidine, methadone, tramadol) opioids are not detected on
standard testing.

148. Attention Deficit Hyperactivity Disorder Stimulant medication is a first-line treatment for most adults with
ADHD. The nonstimulant atomoxetine, however, is preferred in patients with history of substance use disorder to avoid
the risks of drug misuse and addiction.

149. Prescription Drug Misuse The most frequently used standard urine drug screens (UDS) test for
amphetamine, cocaine, cannabis, opioids, and phencyclidine. Dextromethorphan may cause a false-positive phencyclidine
result. Most UDS detect natural opioids (e.g. morphine, heroin, codeine) but not semi-synthetic or synthetic opioids.

150. Prescription Drug Misuse Risk factors for prescription opioid misuse include age < 45, psychiatric
disorder, personal or family history of substance disorder, or a legal history. Review of the state's prescription drug-
monitoring program data, random urine drug screens, and regular follow-up are all associated with risk reduction for long-
term prescription opioid misuse.

151. Depression Pediatric depression can present with symptoms of irritability rather than depressed mood.
Treatment options include psychotherapy and/or pharmacotherapy. Fluoxetine is the drug of choice.

152. Child And Adolescent Mental Health Suicide-risk assessment in adolescents should include direct and
nonjudgmental questions to determine the nature and intensity of suicidal thoughts. Confidentiality should not be promised
because it cannot be maintained if the patient is at high risk for self-harm.

153. Bulimia Nervosa Fluoxetine is first-line pharmacotherapy for bulimia nervosa. Best results are
achieved as part of a multimodal therapy that includes cognitive-behavioral therapy and nutritional rehabilitation.

154. Alcohol Use Disorder Naltrexone is a first-line pharmacotherapy for alcohol use disorder that decreases
craving and heavy drinking. It can be initiated in opioid-free patients without significant liver disease who are still
drinking.
155. Depression Major depressive disorder with psychotic features is a severe subtype of unipolar major
depression. It is characterized by an episode of major depression accompanied by delusions and/or hallucinations,
 typically with depressive themes.

156. Substance-Induced Psychotic Disorder Over-the-counter cold and cough medications often contain
ingredients that can have unwanted side effects, including confusion and hallucinations. These medications should be used
cautiously in young children, with recommended doses not exceeded nor used in combination.

157. Separation Anxiety Disorder Transient distress on initial separation from major attachment figures is
age appropriate in children age 9-18 months and then again at times of transition, such as going to preschool. Children
with persistent anxiety and distress at separation, repeated somatic complaints, or school refusal warrant further
assessment.
158. Factitious Disorder Factitious disorder involves the intentional falsification of symptoms with the
goal of assuming the sick role. Clues to factitious disorder include inconsistencies in the patient's symptoms, physical
examination, and laboratory results.

159. Benzodiazepines Benzodiazepine overdose can result in altered mental status, ataxia, and slurred
speech. When vital sign derangements or respiratory depression are seen, co-ingestion with other sedative-
hypnotics/central nervous system depressants should be suspected.

160. Acute Intermittent Porphyria Acute intermittent porphyria should be suspected in patients with sudden-
onset abdominal pain, neuropsychiatric symptoms (e.g. neuropathies, anxiety, mood changes, psychosis), and a family
history of similar episodes. Elevated urine porphobilinogen during an attack is diagnostic.

161. Drug Induced Liver Injury The anticonvulsant mood stabilizer valproate can cause elevated
aminotransferases and in rare cases hepatic failure, most commonly in the first 6 months of treatment.

162. Benzodiazepines Abrupt discontinuation of a benzodiazepine can result in a potentially life-

threatening withdrawal syndrome, characterized by anxiety, insomnia, tremors, psychosis, and seizures. In patients with
anxiety disorders, mild withdrawal may be difficult to distinguish from re-emergence of the underlying disorder.

163. Alcohol Use Disorder Patients with unhealthy alcohol use are frequently seen in the primary care setting
for insomnia and/or anxiety. These patients should be carefully screened for alcohol use disorder. Findings of increased
liver enzymes and macrocytosis can also assist in screening.

164. Lithium Concurrent use of thiazide diuretics - as well as ACE inhibitors, tetracyclines, metronidazole, and
nonsteroidal anti-inflammatory drugs - and lithium can increase serum lithium levels and lead to symptoms of lithium
toxicity, including gastrointestinal symptoms, confusion, ataxia, tremor, and seizures.

165. Anorexia Nervosa Well-balanced vegetarian diets can meet the nutritional needs of adolescents.
However, patients with low BMI, evidence of excessively restrictive diets, or distorted body image should be evaluated for
eating disorders.

166. Suicide It is a physician's duty to use clinical judgment when assessing suicide risk. Even if a patient
denies a suicide attempt, when a likely attempt has been made and the risk of further self-harm remains high, the patient
must be hospitalized (involuntarily if necessary) to ensure safety.

167. Generalized Anxiety Disorder Generalized anxiety disorder is characterized by excessive and persistent
worry about multiple issues. Patients frequently come to their primary care provider with insomnia, fatigue, and physical
symptoms related to muscular tension.

168. Substance Induced Mood Disorder Although physical symptoms are typically minor, cocaine
withdrawal can cause acute depression with suicidal ideation. Other features include fatigue, hypersomnia, increased
dreaming, hyperphagia, impaired concentration, and intense drug craving.

169. Depressive Disorder Due To Another Medical Condition Diagnosis of primary mood disorders (e.g. major
depressive disorder) requires exclusion of medical and substance-induced causes. Untreated obstructive sleep apnea can
 present with symptoms that overlap with depression (e.g. low mood, fatigue, sleep disturbance, impaired concentration).

170. Cocaine Cocaine use disorder can present with anxiety, irritability, mood swings, grandiosity, and
psychotic symptoms such as paranoia and hallucinations. Physical signs of sympathetic nervous system activation can help
differentiate cocaine-induced symptoms from primary mood and psychotic disorders.

171. Bipolar Disorder Patients with bipolar disorder may exhibit distractibility and hyperactivity that are
difficult to distinguish from symptoms of attention deficit hyperactivity disorder. An episodic (not chronic) course and
prominent mood symptoms are more characteristic of bipolar disorder.

172. Learning Disorders Learning disorders present in school-age children as difficulties in acquiring and
using academic skills (reading, writing, and/or mathematics). Dyslexia is a common learning disorder characterized by an
inability to decode words, resulting in problems in reading fluency and spelling.

173. Lithium The addition of nonsteroidal anti-inflammatory drugs (or thiazide diuretics, ACE inhibitors,
tetracyclines, and metronidazole) to lithium can increase serum lithium levels and lead to symptoms of toxicity, including
gastrointestinal symptoms, confusion, ataxia, and tremor.

174. Depression Major depressive disorder is associated with hyperactivity of the hypothalamic-pituitary-
adrenal axis, resulting in increased cortisol levels.

175. Post-Traumatic Stress Disorder The initial approach to patients with acute stress disorder is to educate
them on the range of reactions to trauma. Trauma-focused cognitive-behavioral therapy can be beneficial for patients with
severe and persistent symptoms.

176. Gender Dysphoria Gender dysphoria is diagnosed when a persistent, intense desire to be another
gender is accompanied by distress or impairment. The initial approach involves providing nonjudgmental support,
assessing the patient's safety, and offering evaluation with a multidisciplinary team of specialists in order to tailor
treatment to the individual's medical and mental health needs.

177. REM Behavior Disorder Rapid eye movement (REM) sleep behavior disorder involves dream
enactment that occurs during REM sleep due to absence of muscle atonia. If awakened, patients become fully alert and
recall their dreams. In older patients, these behaviors may be a sign of neurodegeneration.

178. Attention Deficit Hyperactivity Disorder Behavioral therapy is the preferred initial treatment for
preschool-aged children with attention deficit hyperactivity disorder or problematic hyperactive behavior.

179. Suicide In the primary care setting, patients with depression often have somatic symptoms. Any patient
who reports feelings hopeless, even if the initial symptoms are somatic, should be screened for suicidal ideation.

180. Tardive Dyskinesia Tardive dyskinesia (TD) develops in the setting of prolonged exposure to
dopamine-blocking agents, which is thought to result in the upregulation and supersensitivity of dopamine receptors. TD is
characterized by abnormal involuntary movements of the mouth, tongue, trunk, and extremities and can first appear during
treatment or following antipsychotic dose reduction or discontinuation.

181. Antipsychotics Neuroleptic malignant syndrome (NMS) is characterized by severe muscular rigidity,
mental status changes, autonomic instability, and high fever. Serum creatine kinase and white blood cell count may also be
elevated. Dopamine antagonism, which occurs with the use of most antipsychotics, has been implicated as a primary cause
of NMS.
182. Aging Normal, age-related sleep changes include decreased total sleep time; increased nighttime
awakenings; sleepiness earlier in the evening with early morning awakening; and increased daytime somnolence
(napping).
183. Bipolar Disorder Cyclothymic disorder is a chronic mood disturbance characterized by > 2 years of
numerous periods of hypomanic and depressive symptoms that are subthreshold for diagnosing major depressive or
 hypomanic/manic episodes.

184. Depression Postpartum blues is a self-limited condition that presents with mild depressive symptoms
such as tearfulness, irritability, dysphoria, anxiety, insomnia, and impaired concentration. The condition begins several
days postpartum and typically resolves within 2 weeks. Women with more severe depressive symptoms lasting for > 2
weeks should be evaluated for postpartum depression.

185. Post-Traumatic Stress Disorder Trauma-focused cognitive-behavioral psychotherapy and selective

serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors are first-line treatments for post-traumatic
stress disorder.
186. Post-Traumatic Stress Disorder Acute stress disorder is a severe anxiety response characterized by re-
experiencing of trauma, dissociation, negative mood, avoidance, and hyperarousal lasting > 3 days and < 1 month after
exposure to a traumatic event.

187. Parkinson Disease Psychosis is common in Parkinson disease, occurring at a higher rate in those
treated with dopamine agonists than in those treated with carbidopa-levodopa. Psychotic symptoms can be treated with
antiparkinson medication dose reduction and/or the addition of a low-potency antipsychotic (e.g. quetiapine,
pimavanserin).
188. Specific Phobia Specific phobia is a common anxiety disorder characterized by a clinically significant fear
of a specific object or situation, leading to avoidance behavior. Exposure-based cognitive-behavioral therapy is the
treatment of choice.

189. Serotonin Syndrome Switching antidepressants to or from a monoamine oxidase inhibitor (MAOI)
must be done cautiously as drug-drug interactions can cause serotonin syndrome. Switching from most antidepressants to
an MAOI requires a 2-week washout.

190. Catatonia Catatonia is a syndrome seen in severe psychiatric and medical illness and is
characterized by immobility, mutism, and posturing. Lorazepam and electroconvulsive therapy are the treatments of
choice.
191. Substance Use Disorders Chronic methamphetamine use can cause psychotic symptoms, including
paranoid delusions and auditory, visual, and tactile hallucinations (e.g. bugs crawling under the skin). Other signs include
marked weight loss, severe tooth decay, and excoriations due to skin picking.

192. Narcolepsy Narcolepsy is characterized by excessive daytime sleepiness, cataplexy, and REM sleep-
related phenomena (e.g. hypnagogic/hypnopompic hallucinations, sleep paralysis).

193. Nightmare Disorder Nightmare disorder involves recurrent awakenings from REM sleep associated
with full alertness and dream recall. It should be differentiated from non-REM sleep terrors, which are characterized by
partial arousals, unresponsiveness, and lack of dream content.

194. Psychotic Disorder Due To Another Medical Condition The sudden onset of psychosis in a child or
adolescent is rare, and it is important to search for potentially reversible conditions such as medical disorders or substance
use. Common medical conditions to rule out include systemic lupus erythematosus, thyroiditis, metabolic or electrolyte
disorders, CNS infection, and epilepsy.

195. Physician Patient Communication Poststroke depression is common, underdiagnosed, and

associated with increased morbidity and mortality. Patients can benefit from early treatment with selective serotonin
reuptake inhibitor antidepressants.

196. Schizophrenia Compared with first-generation antipsychotics, second-generation antipsychotics cause

fewer extrapyramidal symptoms but are associated with metabolic effects to varying degrees. Clozapine and olanzapine
carry a high risk of metabolic side effects, whereas ziprasidone, aripiprazole, and lurasidone are associated with the lowest
risk.
197. Selective Serotonin Reuptake Inhibitors Abrupt discontinuation or rapid taper of short half-life
serotonergic antidepressants can result in antidepressant discontinuation syndrome. Treatment consists of restarting a
 serotonergic antidepressant.

198. Alzheimer Disease Because HIV infection is being successfully managed with antiretroviral therapy
and patients are living longer with lower morbidity, common forms of dementia such as Alzheimer disease have become
much more common than HIV-associated dementia in these patients. HIV-associated dementia is a severe form of
subcortical dementia found almost exclusively in untreated HIV-infected patients.

199. Separation Anxiety Disorder Separation anxiety disorder is most commonly seen in infants and
toddlers but can occur at any age and is often associated with transition or change. It is characterized by a marked fear of
separation from a loved one and may present as school or work absences.

200. Physician Patient Communication Effective brief interventions for alcohol abuse require an
understanding of the patient's level of awareness of the problem and readiness to change. When the patient does not
acknowledge the problem, the physician's role is to increase the patient's awareness that alcohol use may be interfering
with personal goals.

201. Depression Augmentation with bupropion is an option for treatment of patients with depression with
partial response to selective serotonin reuptake inhibitors (SSRIs). Bupropion has activating effects and a favorable side-
effect profile (no weight gain or sexual side effects), making it a good choice for patients who are on SSRI therapy but
have fatigue, weight gain, or a history of sexual side effects.

202. Opioids Opioid withdrawal is characterized by myalgias, gastrointestinal symptoms, piloerection,

pupillary dilation, irritability, yawning, and lacrimation. Temperature is usually normal and delirium is uncommon.

203. Oppositional Defiant Disorder Oppositional defiant disorder is characterized by a pervasive pattern of
argumentative and defiant behavior toward authority figures. It does not involve the more severe violations of basic rights
of others seen in conduct disorder.

204. Delirium Delirium-induced psychosis is differentiated from primary psychotic disorders by

fluctuating levels of consciousness, acute onset, and association with an underlying condition and/or offending
medications.
205. Antidepressants Serotonin and norepinephrine reuptake inhibitors (e.g. duloxetine) have analgesic
properties that can be helpful in treating patients with comorbid depression and chronic pain, including painful diabetic
neuropathy.
206. Schizophrenia Akathisia should be considered if a patient becomes agitated or restless when an
antipsychotic is changed or the dosage is increased. Treatment options include reducing the dose, changing to an
antipsychotic with less potential to cause extrapyramidal symptoms, and/or starting treatment with propranolol,
benztropine, or a benzodiazepine.

207. Neuroleptic Malignant Syndrome Neuroleptic malignant syndrome is a life-threatening condition

associated with the use of antipsychotics. It is characterized by delirium, high fever, autonomic instability, severe rigidity,
elevated creatine kinase, and leukocytosis.

208. Panic Disorder Patients with panic disorder may be misdiagnosed with a somatic symptom disorder due
to preoccupation with unexplained symptoms and a history of high health care use. The recurrent abrupt onset of
characteristic physical symptoms that resolve within minutes should raise clinical suspicion for panic disorder.

209. Attention Deficit Hyperactivity Disorder Stimulants are first-line treatment for attention deficit
hyperactivity disorder in school-aged children. They are highly effective and generally well tolerated.

210. Autism Spectrum Disorders Early intervention for autism spectrum disorder (ASD) in the preschool
and school-age years has been shown to significantly improve outcomes. If there is any concern about ASD, a thorough
screening and evaluation should be undertaken and individualized educational/behavioral services offered as soon as
possible.
211. Bipolar Disorder Second-generation antipsychotics (e.g. quetiapine, lurasidone) are effective in the
depressed phase of bipolar illness. Antidepressant monotherapy should be avoided in patients with bipolar I disorder.

212. Postpartum Psychosis Postpartum psychosis is a medical emergency characterized by delusions,

hallucinations, and disorganized thoughts or behavior often accompanied by mood symptoms. Due to the high risk for
suicide/infanticide, most patients require hospitalization to ensure safety.

213. Attention Deficit Hyperactivity Disorder Stimulant medications (methylphenidate, amphetamines) are a
first-line treatment for attention deficit hyperactivity disorder in school-aged children.

214. Substance Use Disorders MDMA (3,4-methylenedioxy-methamphetamine) is a synthetic

amphetamine with mild hallucinogenic properties. It can cause euphoria, increased sexual desire, and empathy.
Intoxication may lead to hypertension, tachycardia, hyperthermia, serotonin syndrome, and hyponatremia. Coma, seizures,
and death may occur.

215. Depression Electroconvulsive therapy is an evidence-based treatment for major depression that
carries a low risk for complications. It is a first-line treatment for major depression with psychotic features and appropriate
for severely depressed elderly patients who are not eating or drinking and require rapid intervention.

216. Post-Traumatic Stress Disorder Patients with post-traumatic stress disorder (PTSD) commonly have
symptoms of sleep disturbance, impaired concentration, and negative mood. A history of trauma, dissociative symptoms,
and increased startle response are clues for PTSD.

217. Substance Use Disorders Inhalant abuse usually occurs in boys age 14-17 and may involve
multiple common household chemicals. Users may display characteristic perioral skin changes ('glue sniffer's rash').
Inhalant intoxication is characterized by a rapid onset and relatively short duration.

218. Substance-Induced Psychotic Disorder Medication-induced psychotic disorder is characterized by the

acute onset of delusions and/or hallucinations that are temporally associated with the use of a new medication.
Glucocorticoids, particularly at high-dose (HD)s, are often implicated in new-onset psychotic symptoms in patients who
may have no current underlying psychiatric illness.

219. Antipsychotics Medications that block the dopamine (D2) receptor (e.g. antipsychotics, metoclopramide)
may cause extrapyramidal symptoms, including acute dystonia, parkinsonism, akathisia, and tardive dyskinesia. Drug-
induced parkinsonism typically presents with bradykinesia, rigidity, and tremor.

220. Suicide A teenager with active suicidal ideation must be hospitalized for safety and the parents must be
informed. Parental consent is ideal but not required for hospitalization.

221. Physician Patient Communication The loss of a fetus is a traumatic experience for parents that
requires a direct and empathic response from the physician that alleviates self-blame. The physician should be prepared to
stay in the room and tend to emotions that arise without prematurely providing reassurance or discussing medical
management.
222. Patient Confidentiality Physicians are ethically obligated to protect patient confidentiality. Unless a
patient is at active risk of harm to self or others, physicians cannot disclose information to family members without the
patient's consent.

223. Physician Patient Communication Help-rejecting patients who are hopeless about treatment can lead
the physician to become frustrated and confrontational and to desire to refer the patient to another provider. Clear
expression of empathy and a collaborative approach with limited goals are the most effective approaches.

224. Homicide And Other Violence Access to firearms is the greatest risk in completing homicide. Other
important risk factors include a history of violence, substance abuse, and high levels of impulsivity. Parents of adolescents
should be advised to limit access to firearms.
225. Depression Cognitive-behavioral therapy focuses on reducing automatic negative thoughts and
avoidance behaviors that cause distress. It is effective as monotherapy or in combination with medication for a wide range
of psychiatric disorders.

226. Sexual Abuse Patients who experience sexual assaults are at high risk for developing post-traumatic
stress disorder, depression, and suicidality.

227. Depression Patients with underlying mood disorders frequently come to the office with physical
rather than psychologic symptoms. Evaluation should include screening for depression by inquiring about mood and
ability to enjoy usual activities.

228. Social Anxiety Disorder Social anxiety disorder (SAD) is characterized by a fear of social situations and
anxiety about embarrassment. In the performance-only subtype, anxiety occurs only in performance-related situations.
SAD should be differentiated from panic disorder (unexpected panic attacks) and specific phobia (stimulus not related to
social anxiety).
229. Hoarding Disorder Hoarding disorder is characterized by difficulty discarding possessions regardless
of their actual value. It is best treated with cognitive-behavioral therapy.

230. Depression When major depression fails to respond to an initial selective serotonin reuptake inhibitor
(SSRI) trial, patients should be switched to another first-line antidepressant. Options include a different SSRI, a serotonin-
norepinephrine reuptake inhibitor, bupropion, mirtazapine, or serotonin modulators.

231. Schizophrenia Clozapine is the medication of choice for treatment-resistant schizophrenia and should be
considered in patients who have failed > 2 antipsychotic drug trials.

232. Factitious Disorder Patients with factitious disorder intentionally produce signs and symptoms for the
purpose of assuming the sick role. Factitious disorder should be differentiated from malingering, in which sickness is
feigned for an external incentive.

233. Depression Medically ill patients who develop comorbid depression can benefit from treatment with
antidepressant medications and psychotherapy to improve their quality of life.

234. Child And Adolescent Mental Health The slightly increased risk of antidepressant-related suicidal
thoughts and behaviors in some children and adolescents must be weighed against the efficacy of antidepressants and the
risk of completed suicide in depression. Patients should be carefully monitored for suicidality at the beginning of
antidepressant therapy.

235. Panic Disorder Panic disorder is characterized by recurrent, unexpected panic attacks and fears about
future attacks and/or maladaptive behavior related to the attacks. Some patients will develop agoraphobia, which is the
avoidance of > 2 situations in which escape or obtaining help may not be possible.

236. Bipolar Disorder Lithium, valproate, quetiapine, and lamotrigine are first-line maintenance
treatments for bipolar disorder.

237. Specific Phobia Specific phobia is characterized by marked fear of a specific object or situation.
Cognitive-behavioral therapy using exposure techniques is the preferred treatment.

238. Psychosis Delusional disorder involves one or more delusions and the absence of other prominent
psychotic symptoms. Apart from the impact of delusional beliefs, the individual is still able to function.

239. Physician Patient Communication Acutely psychotic patients with no insight are unable to
determine that their psychotic experiences are not real. To build rapport, it is important to acknowledge the patient's
experience and distress without endorsing specific delusions or hallucinations.
240. Schizophrenia Antipsychotic medications are the first-line treatment for psychosis. Long-acting
injectables should be considered for nonadherence after tolerability and dosage parameters are established on oral
medications. Clozapine should be considered for patients who have failed at least 2 antipsychotic trials.

241. Antipsychotics Neuroleptic malignant syndrome is a potentially life-threatening condition that can occur
after administration of antipsychotic medications. Symptoms include high fevers, lead-pipe rigidity, altered mental status,
and autonomic instability. Creatine kinase level and white blood cell count may be elevated.

242. Antipsychotics Antipsychotics may cause drug-induced parkinsonism, a type of extrapyramidal symptom
(EPS). Treatment options include antipsychotic dose reduction, treatment with benztropine or amantadine, or switching to
another antipsychotic with a lower potential to cause EPS, if feasible.

243. Antipsychotics Second-generation antipsychotics cause metabolic side effects (e.g. weight gain,
hyperglycemia, dyslipidemia) to varying degrees. Routine monitoring for the development of these side effects is
recommended in patients taking second-generation antipsychotics. Olanzapine and clozapine are associated with the
greatest risk.
244. Depression Bupropion is an antidepressant with mild stimulant properties that can be particularly
helpful for depressed patients with low energy, impaired concentration, hypersomnia, and weight gain. It can also be used
to aid smoking cessation.

245. Adjustment Disorders Patients with situationally triggered depressive symptoms should be assessed for
major depressive and adjustment disorders. Normal stress reactions are distinguished by lower severity and absence of
marked distress or significant functional impairment.

246. Depression Major depressive disorder can be diagnosed if depressive symptoms following the loss of
a loved one are sufficiently severe to meet diagnostic criteria. Compared to normal grief, major depression is associated
with more persistent and pervasive sadness, feelings of hopelessness and worthlessness, and suicidal ideation.

247. Monoamine Oxidase Inhibitors Patients taking monoamine oxidase inhibitors such as phenelzine should
avoid foods rich in tyramine as the interaction of such food-drug combinations can result in hypertensive crisis.

248. Physician Patient Communication Patients may be reluctant to discuss sensitive issues in the
presence of family members. All patients of all ages and functional levels should be given the opportunity to meet with
their physicians alone.

249. Suicide Patients who are an acute threat to themselves should be hospitalized (involuntarily, if necessary)
for treatment and stabilization. This principle also applies to minors, even without parental or guardian consent.

250. Parasomnias Sleep terrors are a common and usually benign parasomnia of childhood. They occur
during non-REM sleep and are characterized by fear, crying and/or screaming, and amnesia of the event. The diagnosis is
made clinically. Parents should be reassured that episodes are self-limited and typically resolve within 1-2 years.

251. Antipsychotics Antipsychotic medications exert their effects through dopamine antagonism. The blocking
of dopamine may result in hyperprolactinemia, which can lead to galactorrhea, amenorrhea, and infertility. The second-
generation antipsychotic risperidone is most likely to increase prolactin.

252. Dysthymia Persistent depressive disorder is characterized by chronic depressed mood and > 2 other
depressive symptoms lasting > 2 years. Treatment with antidepressants and/or psychotherapy can improve symptoms and
quality of life.
253. Personality Disorders Obsessive-compulsive personality disorder involves a pervasive pattern of
preoccupation with orderliness, rigid rules, perfectionism, and control. It is differentiated from obsessive-compulsive
disorder by the lack of clear obsessions and compulsions.

254. Alzheimer Disease Cognitive deficits that interfere with independence in everyday activities are a
key feature that distinguishes dementia (major neurocognitive disorder) from normal age-related changes. Patients with
 dementia have functional impairments that necessitate assistance.

255. Aging Normal age-related cognitive changes include occasional forgetfulness, word-finding difficulty,
and sleep pattern changes that do not impact activities of daily living.

256. Androgenic Steroids Anabolic-androgenic steroids are used to improve physique and athletic
performance but are associated with numerous adverse effects, including acne, baldness, gynecomastia, hepatic
dysfunction, altered lipid profiles, virilization, testicular failure, and possible mood and behavior changes.

257. Antipsychotics Neuroleptic malignant syndrome (NMS) typically presents with altered mental status,
fever, muscle rigidity, and autonomic instability. Stopping the causative medication is the most critical intervention.

258. Panic Disorder Panic disorder involves recurrent unexpected panic attacks, fears of future attacks, and
avoidance behavior. Diagnosis requires differentiation from other anxiety disorders that may include triggered panic
attacks and ruling out medical causes.

259. Cannabis Patients with cannabis intoxication typically present with conjunctival injection, dry
mouth, tachycardia, and increased appetite. Psychomotor impairment, anxiety, and paranoia may also occur, especially at
higher doses.
260. Delusional Disorder Delusional disorder is characterized by at least 1 persistent delusion and no other
prominent psychotic symptoms. Apart from the impact of the delusion or delusions, functioning is not markedly impaired.

261. Generalized Anxiety Disorder Serotonin reuptake inhibitors and serotonin-norepinephrine reuptake
inhibitors are first-line medications for treating generalized anxiety disorder that can also potentially treat comorbid major
depression. Benzodiazepines should be reserved for nondepressed patients without a history of substance abuse who fail to
respond to or cannot tolerate antidepressants.

262. Schizophrenia Antipsychotic medication nonadherence is a common cause of relapse and

rehospitalization in patients with schizophrenia. Long-acting injectable antipsychotics are useful for patients who have
responded to oral antipsychotics but relapse frequently due to medication nonadherence.

263. Obsessive Compulsive Disorder Serotonergic antidepressants (e.g. selective serotonin reuptake inhibitors)
are the first-line medication treatment for obsessive-compulsive disorder.

264. Schizoaffective Disorder Schizoaffective disorder is diagnosed when major depressive or manic
episodes co-occur with psychotic symptoms in a patient with a history of persistent psychosis for > 2 weeks in the absence
of mood symptoms.

265. Dysthymia Persistent depressive disorder (dysthymia) refers to a depressed mood lasting most days
for > 2 years. It includes patients with pure dysthymia and those with intermittent or persistent major depressive episodes.

266. Antipsychotics Weight gain, dyslipidemia, and hyperglycemia are common complications of treatment
with second-generation antipsychotics. Olanzapine and clozapine carry the greatest risk.

267. Depression Patients with cancer may have somatic symptoms that overlap those of depression (e.g.
sleep disturbance, appetite change, poor energy). However, if there are additional symptoms such as persistent sadness,
guilt, loss of interest, and suicidal thoughts, major depression should be considered, with a low threshold for beginning
treatment.
268. Bipolar Disorder Bipolar I disorder is a highly recurrent illness that requires long-term
maintenance pharmacotherapy to decrease the risk of recurrent mood episodes. Clinically effective medication should be
continued unless significant side effects or contraindications prohibit use.

269. Cocaine Cocaine abuse should be suspected in an individual with weight loss, behavioral changes,
and erythema of the nasal mucosa.
270. Generalized Anxiety Disorder Generalized anxiety disorder is characterized by excessive anxiety about
multiple issues, in conjunction with > 3 of the following symptoms for at least 6 months: Restlessness, fatigue, poor
concentration, irritability, muscle tension, and impaired sleep.

271. Schizophrenia Family psychosocial interventions are indicated for patients with a recent psychotic
episode who have significant ongoing contact with family members. Minimizing conflict and stress in the home decreases
the risk of relapse in patients with schizophrenia.

272. Depression Patients with a single episode of major depressive disorder should continue
antidepressants for an additional 6 months following acute response to reduce the risk of relapse. Patients with recurrent,
chronic, or severe episodes should be considered for maintenance treatment (1-3 years or indefinitely).

273. Social Anxiety Disorder Social anxiety disorder is characterized by anxiety and fear of scrutiny in social
situations, resulting in avoidance, distress, and social-occupational dysfunction. The preferred pharmacological treatment
is a selective serotonin reuptake inhibitor or serotonin-norepinephrine reuptake inhibitor. Cognitive-behavioral therapy can
also be used as a first-line nonpharmacological treatment.

274. Defense Mechanisms Displacement is an immature defense mechanism in which the individual
displaces negative feelings associated with a person or situation onto a 'safer', more acceptable object or situation.

275. Defense Mechanisms Reaction formation is a defense mechanism that involves transforming
unacceptable feelings and impulses into their extreme opposites.

276. Schizophrenia Indications for psychiatric hospitalization include being a danger to self or others and/or
grave disability. Hospitalization may be implemented on an involuntary basis if necessary.

277. Benzodiazepines Abrupt cessation of alprazolam, a short-acting benzodiazepine, is associated with

significant withdrawal symptoms, including a risk for generalized seizures and confusion.

278. Suicide Active suicidality is associated with intent and plan for self-harm. The first step in the care of
patients with active suicidality is to ensure their safety by admitting them to a psychiatric unit (involuntarily, if necessary).

279. Body Dysmorphic Disorder Body dysmorphic disorder (BDD) involves excessive preoccupation with
a slight or imagined bodily defect and is often accompanied by poor insight and a request for surgical procedures. The
initial approach should focus on the patient's suffering and impaired functioning without challenging the patient's beliefs.
Once rapport is established, the patient should be educated about BDD and treatment for it with cognitive-behavioral
therapy and/or antidepressants.

280. Somatic Symptom Disorder Patients with somatic symptom disorder benefit from regularly scheduled
appointments, which establish a strong physician-patient relationship and limit diagnostic testing and subspecialty
referrals.
281. Specific Phobia Specific phobia is characterized by an intense fear of an object or situation that is avoided
when possible and causes significant impairment. The treatment of choice is gradual exposure to the feared object or
situation.
282. Conversion Disorder Conversion disorder is characterized by the sudden onset of neurological
symptoms with clinical findings that are incompatible with recognized neurological conditions. Conversion disorder is
often precipitated by stress.

283. Antidepressants Bupropion is associated with an increased risk of seizures. It is contraindicated in patients
with seizure disorders, anorexia nervosa, or bulimia nervosa.

284. Informed Consent Patients with psychiatric diagnoses can give informed consent as long as they
have capacity, meaning that their judgment and decision-making abilities are determined to be intact at the time of
treatment.
285. Defense Mechanisms Intellectualization is the transformation of a distressing event into a situation
devoid of emotion to avoid confrontation of uncomfortable emotional components.

286. Treatment Adherence Physicians should explore nonadherence in an empathic and nonjudgmental
manner and try to understand behavior from the patient's perspective. This will help build rapport and facilitate
development of a united plan.

287. Impulse Control Disorders Gambling disorder is characterized by persistent and recurrent
maladaptive gambling behavior that results in impairment or distress. Significant financial losses and damaged
relationships are common consequences.

288. Impulse Control Disorders Kleptomania is an impulse control disorder characterized by an inability
to resist the impulse to steal objects of low monetary value or not needed for personal use.

289. Adjustment Disorders Adjustment disorder involves symptoms causing marked distress and impairment
that develop within 3 months in response to a stressor It is not diagnosed if symptoms meet the criteria for another specific
disorder (e.g. major depressive disorder). The treatment of choice is psychotherapy that focuses on improving coping skills
and promoting a return to functioning.

290. Schizophrenia Enlargement of the lateral cerebral ventricles is the most consistently replicated
neuroimaging finding in schizophrenia.

291. Schizoaffective Disorder The diagnosis of schizoaffective disorder requires assessing the
longitudinal course of the illness and determining if the patient has had at least 2 weeks of psychotic symptoms in the
absence of a mood episode. Schizoaffective disorder is distinguished from schizophrenia by the presence of mood
symptoms for a significant portion of the illness.

292. Dissociative Amnesia Dissociative amnesia involves isolated impairment in autobiographical memory.
If the amnesia is accompanied by travel or wandering, the specifier of 'with dissociative fugue' is given.

293. Phencyclidine Phencyclidine intoxication presents with severe agitation, delusions of enhanced strength,
psychosis, analgesia, multidirectional nystagmus, hypertension, tachycardia, and disorientation. Agitation and aggression
are managed with benzodiazepines.

294. Stimulants Amphetamine intoxication can present with psychiatric symptoms, including irritability,
agitation, and psychosis. Common physical signs include tachycardia, hypertension, hyperthermia, diaphoresis, and
mydriasis.
295. Opioids Heroin withdrawal should be suspected in patients with muscle and joint aches, nausea, diarrhea,
abdominal cramping, rhinorrhea, and pupillary dilation. These subjective symptoms are often severe but generally not life-
threatening.
296. Alcohol Withdrawal Patients with a history of alcohol use who develop tremulousness, unstable vital
signs, and/or seizures shortly after hospital admission should be assessed for alcohol withdrawal. Lorazepam, an
intermediate-duration benzodiazepine available in intravenous form, is preferred in the inpatient setting, particularly in
patients with comorbid liver disease.

297. Personality Disorders Avoidant personality disorder is characterized by a persistent pattern of social
avoidance, feelings of inadequacy, and hypersensitivity to rejection beginning in adolescence or early adulthood.

298. Personality Disorders Individuals with schizoid personality disorder are socially detached and prefer to
be alone. They can be differentiated from individuals with avoidant personality disorder, who desire relationships but
avoid them due to fears of rejection. They lack the eccentric cognitions and perceptual distortions characteristic of
schizotypal personality disorder.
299. Personality Disorders Dependent personality disorder is characterized by excessively dependent and
submissive behaviors, indecisiveness, and fear of being left to manage alone.

300. Personality Disorders Narcissistic personality disorder is characterized by an exaggerated sense of self-
importance, need for admiration, sense of entitlement, and lack of empathy.

301. Personality Disorders Schizotypal personality disorder is characterized by a long-standing pattern of

eccentric behaviors and social anxiety despite familiarity. Patients with this disorder typically exhibit magical thinking,
unusual thoughts, and perceptual disturbances that are subthreshold for a psychotic disorder.

302. Anorexia Nervosa Signs of self-induced vomiting include parotid gland hypertrophy, pharyngeal
erythema, dental caries, scars or calluses on the hand, and electrolyte abnormalities. The binge-purge type of anorexia
nervosa can be differentiated from bulimia nervosa by significantly low body weight.

303. Tricyclic Antidepressants Tricyclic antidepressant overdose is characterized by mental status

changes, seizures, cardiac conduction delay, and anticholinergic toxicity (e.g. dilated pupils, hyperthermia, flushed and dry
skin, intestinal ileus). QRS duration > 100 msec has been associated with an increased risk of arrhythmias and/or seizures
and is an indication for treatment with sodium bicarbonate.

304. Patient Autonomy Patients who have decision-making capacity have the right to refuse procedures
and treatment. The physician should address any modifiable obstacles to treatment. If the patient still refuses, services
should be offered if the patient reconsiders.

305. Phencyclidine Phencyclidine is a dissociative anesthetic that characteristically causes nystagmus. It can
also cause dissociative feelings, psychotic and violent behavior, severe hypertension, and hyperthermia.

306. Malingering Malingering is the intentional production or exaggeration of physical or psychological

symptoms for secondary gain. Malingering should be suspected when a patient is reluctant to be examined or treated and
there is a discrepancy between symptoms and objective findings.

307. Somatic Symptom Disorder Somatic symptom disorder involves excessive preoccupation and
overestimation of the seriousness of > 1 somatic complaints and is associated with high levels of medical care utilization.

308. Personality Disorders Borderline personality disorder is characterized by a persistent pattern of unstable
relationships, mood lability, impulsivity, and recurrent suicidal behavior. Treatment involves psychotherapy with a
behavioral focus (e.g. dialectical behavioral therapy).

309. Tardive Dyskinesia Tardive dyskinesia occurs after prolonged exposure to antipsychotic drugs and is
characterized by abnormal involuntary movements of the mouth, tongue, face, trunk, or extremities. When antipsychotic
dose reduction or discontinuation is not feasible, using valbenazine or deutetrabenazine or switching to clozapine should
be considered.
310. Suicide The greatest risk factor for suicide is a history of suicide attempt(s).

311. Bipolar Disorder Bipolar I disorder includes manic episode(s) with or without a history of major
depressive episodes. Bipolar II is distinguished from bipolar I by hypomanic episodes (less severe, less functional
impairment, no psychotic symptoms) and a history of > 1 depressive episodes.

312. Psychosis Schizophreniform disorder is differentiated from schizophrenia by the duration of

symptoms. In schizophreniform disorder, symptoms must last for > 1 month but < 6 months. The diagnosis of
schizophrenia requires symptoms to persist for > 6 months.

313. Antipsychotics Clozapine is indicated for the treatment of psychotic patients who do not respond to other
antipsychotics. Patients must undergo regular monitoring of absolute neutrophil counts due to the risk of neutropenia and
agranulocytosis.
314. Obsessive Compulsive Disorder First-line treatments for obsessive-compulsive disorder are exposure and
response prevention techniques based on cognitive-behavioral therapy and selective serotonin reuptake inhibitors.

315. Antipsychotics Acute dystonia is a type of extrapyramidal symptom associated with antipsychotic
treatment. It is most commonly seen with high-potency first-generation antipsychotics and is best treated with
anticholinergics (benztropine) or antihistamines (diphenhydramine).

316. Stimulants Methylphenidate is a central nervous system stimulant that is frequently used to treat
attention deficit hyperactivity disorder. Common side effects of stimulants include decreased appetite, weight loss, and
insomnia.
317. Depression Patients who do not respond to selective serotonin reuptake inhibitors may benefit from
switching to another first-line antidepressant medication. The norepinephrine and dopamine reuptake inhibitor bupropion
is an activating antidepressant with a favorable side effect profile (e.g. no weight gain or sexual side effects), making it a
good choice for patients with weight gain, hypersomnia, or sexual dysfunction.

318. Social Anxiety Disorder Performance anxiety is classified as performance-only social anxiety disorder in
DSM-5. Pharmacologic treatments include as-needed β blockers or benzodiazepines. Benzodiazepines should be avoided
in patients with a personal or family history of substance use disorder or when cognitive and sedative side effects could
impair performance.

319. Neuroleptic Malignant Syndrome Neuroleptic malignant syndrome is a rare but potentially life-
threatening emergency associated with the use of antipsychotics (neuroleptics). Patients who do not improve with
cessation of the antipsychotic and intensive supportive care can be treated with dopamine agonists and dantrolene.

320. Antipsychotics Second-generation antipsychotics (SGAs) are serotonin 2A and dopamine D2 antagonists.
The added serotonin receptor binding and lower dopamine binding affinity of SGAs reduce the likelihood of
extrapyramidal adverse effects.

321. Hyperprolactinemia Antipsychotic medications can cause hyperprolactinemia secondary to their

dopamine blockade effect. Risperidone has a high frequency of prolactin elevation. In comparison to antipsychotics,
prolactinomas are capable of producing very high levels of prolactin (> 200 ng/mL).

322. Panic Disorder Benzodiazepines provide rapid relief of anxiety and are indicated for the management of
acutely symptomatic and functionally impaired patients with panic disorder. Antidepressants and cognitive-behavioral
therapy are preferred for long-term treatment.

323. Bipolar Disorder Bipolar disorder is a highly recurrent illness that requires maintenance
pharmacotherapy. In patients with severe and frequent mood episodes, the combination of lithium or valproate and a
second-generation antipsychotic is used as first-line combination pharmacotherapy.

324. Depression Adequate duration of an antidepressant trial is generally considered to be 6 weeks.

Physicians should continue antidepressants at therapeutic dosages for at least 4-6 weeks before considering the next step in
treatment.
325. Conduct Disorder Conduct disorder is characterized by a repetitive pattern of violating basic social
norms and the rights of others. Common manifestations include truancy, lying for gain or to avoid repercussions, and
initiating physical fights with others.

326. Premenstrual Syndrome Premenstrual syndrome and premenstrual dysphoric disorder are characterized by
physical (e.g. fatigue, bloating, breast tenderness) and psychological (e.g. mood swings, irritability) symptoms that occur
in the week prior to menses and resolve during the follicular phase. Assessment should begin with a menstrual diary to
determine the relationship of symptoms to menstrual cycle phase.

327. Smoking Cessation Nicotine replacement therapy, varenicline, and bupropion are first-line treatments
for smoking cessation. They should be used in conjunction with counseling and supportive therapy.
328. Depression All depressed patients should be screened for suicidal ideation, intent, and plan. Actively
suicidal patients with intent and plan will often need to be hospitalized for stabilization and to maintain their safety.

329. Personality Disorders Antisocial personality disorder involves a pervasive pattern of violating the rights
of others and lack of remorse. Individuals must be > age 18 for diagnosis and have a history of conduct disorder symptoms
before age 15.
330. Bipolar Disorder Lithium and valproate are first-line options for bipolar disorder maintenance
treatment. Lithium is excreted unchanged by the kidneys and should generally be avoided in patients with renal
dysfunction due to the risk of systemic toxicity and long-term nephrotoxic effects.

331. Hypercalcemia Lithium is indicated both for the treatment of acute mania and for maintenance therapy in
bipolar disorder. Long-term side effects include hyperparathyroidism with hypercalcemia, nephrogenic diabetes insipidus,
chronic kidney disease, and thyroid dysfunction, as well as teratogenic effects.

332. Bipolar Disorder Management of patients who are agitated and have acute mania consists of
antipsychotic medication (administered intramuscularly if needed) to control behavioral disturbances. Patients
experiencing severe mania often require a combination of an antipsychotic and mood stabilizer to manage symptoms
effectively.
333. Bulimia Nervosa Bulimia nervosa involves recurrent binge eating and compensatory behaviors. In
contrast to patients with anorexia nervosa, those with bulimia nervosa are normal weight to overweight.

334. Anorexia Nervosa Indications for hospitalization in patients with anorexia nervosa include unstable
vital signs, cardiac dysrhythmias, electrolyte derangements, and severely low body weight.

335. Depression Bereaved patients who develop moderate to severe major depression should be considered
for treatment with both psychotherapy and antidepressants. Mirtazapine is a preferred choice for patients with marked
insomnia and weight loss due to its side effects of appetite stimulation and sedation.

336. Alcohol Withdrawal Alcoholic hallucinosis is an alcohol withdrawal syndrome that typically presents
after 12 hours of abstinence and resolves within 48 hours after the last drink. Unlike delirium tremens, it tends to present
in patients who are fully oriented and with relatively stable vital signs.

337. Informed Consent The informed consent process for procedures or treatment must be conducted for
all patients, including those admitted involuntarily for substance intoxication or mental illness. Consent for a
nonemergency surgical procedure or treatment must be voluntary.

338. Elder Abuse & Neglect Manifestations of physical abuse in the elderly may include unexplained pain,
injuries in multiple stages of healing, or injuries in unusual locations. Elderly individuals are also at risk for financial
exploitation, psychological abuse, sexual abuse, and neglect.

339. Assisted Suicide And Euthanasia The initial response to a request for physician-assisted suicide
should include exploring the patient's reasons for the request. Once the patient's concerns and fears are identified, the
provider can optimize palliative care interventions to address specific issues and improve quality of life.

340. Professional Conduct Decisions about whether to accept gifts from patients include the cost, type, and
timing of the gift and the motivation behind giving it. Gifts should not be accepted from patients experiencing a mood
episode potentially affecting their judgment.

341. Patient Confidentiality Under the Health Insurance Portability and Accountability Act, patients have the
legal right to obtain copies of their medical records within a specified timeframe.

342. Physician Patient Communication Delivering bad news is optimally done in a face-to face meeting
that allows the physician to better assess the patient's emotional reactions and provide empathy and necessary support.