Study Notes – Ψ James Lamberg 28Jul2010 Text: Kaplan & Sadock Ψ, Crash Course Ψ, First Aid for Ψ Clerkship ------------------------------------------------------------------------------------------------------------------------------------------Common

Problems in ψ Mood D/o: Depn, Anxiety, Bipolar D/o, Obsessive-Compulsive D/o, Suicide, Para-Suicide Childhood: ADHD, Eating D/o Elderly: Dementia, Delirium Psychoses: Schizophrenia Behavioral: EtOH, Illicit and Rx Drug Addiction, Tobacco Abuse, Weight Loss Counseling, Stress Mgmt, Dysfxnal Family Issues Women's: Postpartum Depn, PMDD D/o: Personality D/o, Somatoform D/o ------------------------------------------------------------------------------------------------------------------------------------------Survival Guides (Ψ & Behavioral Science) – Student Consult MSE is the std way of examining the ψ Pt (although clearly there might be reasons for carrying out a medical exam as well). Here is a list of everything that you should look for in the MSE. * Appearance and behavior: Restlessness, dress, are they tense, shy, over-familiar, aggressive? * Speech: Is there any pressure of speech, sudden changes in subject or expression, abnml form of speech or rate? * Mood: Depn, anxiety, “is life worth living?” * Thought content: What are the Pt’s preoccupations? Delusions. * Abnml experiences: Hallucinations, pseudo hallucinations, illusions, abnml body sensations. * Cognitive state: Orientation (time, place, person). Attention and concentration (serial sevens). Memory (Recent, repeat three objects; Distant, ask three objects at the end of exam). General knowledge. *Insight: What does the Pt think is wrong and what do they thing about their tx and the future? Do’s & Don’ts: Talk to Pts. Be sensible about your own safety (i.e. sit door side of Pt). Try to be exposed to the wide range of ψ problems, including outPts, inPts, high security and ER care. If you are unhappy being w/ a Pt, leave the room. Schizophrenia: Pos and neg sx. Negative sx are thought of as neglecting what a nml person would do, remembered as: alogia, anhedonia, asociality, affective blunting, concentration deficit. Pos sx are what a nml person would not do, such as delusions, hallucinations, bizarre/disorganized behavior. * Paranoid schizophrenia shows marked pos sx & can be quite afraid. * Disorganized schizophrenia shows disorganized speech, behavior & flat or inappropriate affect. * Catatonic has marked psychomotor disturbances present. * Undifferentiated is the most common & does not clearly meet criteria for paranoid, catatonic or disorganized. Mgmt: antipsychotic drugs, typically DA blockers, some atypical drugs also have serotonin blockade. Depn: an affective d/o (i.e. a d/o of mood). Mood & affect are actually different & can be thought of as mood being the emotional climate & affect as being the emotional weather. Sx (SIG E CAPS): sleep disturbances, loss of interest, guilt, loss of energy, loss of concentration, change in appetite, psychomotor retardation, suicidal ideations, & depressed mood. Sx must last at least 2 mo. Mgmt: cognitive behavioral therapy (CBT), interpersonal therapy, psychoanalytic therapy. Antidepressants can be used but have to be used at an adequate dose for an adequate length of time. Ψ Medications: Neuroleptics (antipsychotics): Used to tx schizophrenia. * Atypicals = clozapine, olanzapine, quetiapine, risperidone, ziprasidone. * Clozapine can cause agranulocytosis. * Typicals = chlorpromazine, thioridazine, haloperidol, loxapine, trifluoperazine. * Thioridazine prolongs QT interval * Typicals can cause extrapyramidal side effects (EPS), tardive dyskinesia (TD), & neuroleptic malignant syndrome (NMS). Antidepressants: Used to tx depressive d/o. * Can lead to mania if used in Pts w/ bipolar. * Selective serotonin reuptake inhibitors (SSRIs) = citalopram, fluoxetine, paroxetine, sertraline. * Common adverse effects: GI distress (abd pain, N/V/D) & impotence (reversible). * Tricyclic antidepressants (TCAs) = amitriptyline, clomipramine, imipramine, nortriptyline. * Monoamine oxidase inhibitors (MAOIs) = phenelzine, tranylcypromine.

* Others: Can cause serotonin syndrome if given w/SSRIs. If given w/ foods containing tyramine, MAOIs can lead to hypertensive crisis. Trazodone may cause priapism. Mirtazapine can cause agranulocytosis. Mood stabilizers: Used to tx bipolar. * Carbamazepine, lithium, olanzapine, valproic acid. * Carbamazepine can cause aplastic anemia, agranulocytosis, & neural tube defects. * Lithium can cause Ebstein’s anomaly if taken during pregnancy. * Valproic acid can lead to elevated liver enzymes, so you must get baseline LFTs before beginning tx. Anxiolytics: Used to tx anxiety d/o. * BZDs = alprazolam, chlordiazepoxide, clonazepam, diazepam, lorazepam. * Non-BZDs = buspirone. * Do not give buspirone Bulimic Pts. Some evidence that buspirone may ↑ impulsivity & aggressiveness in Pts w/BN Stimulants: Used to tx ADHD & narcolepsy. * Modafinil, Ritalin. Types of Psychotherapy: Who: What: Psychoanalysis Make major personality Δs by IDing & working thru unconscious conflicts via free assn & dream interpretation Supportive Eval Pt’s situation & help him make changes that will make it better Interpersonal Improve interpersonal skills Group Family Drug of Abuse EtOH Opioids Amphetamines Cocaine Phencyclidine (PCP) LSD Marijuana BZDs Alleviate sx of emotionally ill & Δ interpersonal relations Improve family fxn Intoxication Disinhibition, slurred speech, ataxia CNS Depn, N/V, constipation, miosis Psychomotor agitation, impaired judgment, mydriasis, HTN, euphoria, delusions, hallucinations Euphoria, psychomotor agitation, impaired judgment, mydriasis, hallucinations (including tactile) Aggressiveness, impulsiveness, nystagmus, psychosis, delirium Anxiety, Depn, VH, flashbacks, mydriasis Euphoria, hunger, paranoid delusions, impaired judgment, hallucinations, dry mouth Amnesia, ataxia, somnolence, respiratory Depn

Indication: - internal conflict - can get sx relief of a problem by understanding it - w/ coping problems - w/serious ψ illness, (bipolar or schizo) -OutPt, non-bipolar, non-psychotic depressive d/o -w/ personality d/o Dysfxnal families

NOT useful for… - Older - low IQ - antisocial PD - psychotic d/o

Pts w/ high suicide risk

Withdrawal Tremor, tachycardia, HTN, nausea, DTs Anxiety, insomnia, anorexia, mydriasis, diarrhea Depn, lethargy, HA, hunger, hypersomnolence Depn, hypersomnolence, fatigue Recurring intoxication sx, severe violence none None Rebound anxiety & insomnia, SZ, tremor

Defense mechanisms: Mechanisms used by people to cope w/ the struggles that they face in life. * Acting out: H&ling emotional conflict through actions instead of feelings *Affiliation: Dealing w/ emotional conflict by turning to others for support * Aim inhibition: Accepting partial fulfillment of desires. For ex, a student wants to be a physician, but finding it academically difficult, 'decides' that all he really wants is to be a physician’s assistant. * Altruism: H&ling emotional conflict by dedicating oneself to meeting the needs of others. For ex, a woman’s husb& dies, & she begins to spend all her time counseling others. * Avoidance: Refusal to encounter difficult situations

* Compensation: Overemphasizing one area in an attempt to compensate for failure in another. * Conversion: Emotional conflicts presenting as physical sx. Devaluation: Attributing exaggerated negative qualities to yourself or others. * Displacement: Shifting emotions from one object/idea to another. For ex, an employee is angry at his boss, but suppresses his feelings until he gets home, & beats his children for behavior that would nmlly be tolerated. * Fixation: Stopping personality development at a stage prior to maturity. * Projection: Attributing one’s thoughts or impulses to someone else. For ex, a woman who doesn’t like a coworker becomes convinced that the co-worker is the one who doesn’t like her. * Sublimation: Using an activity to replace an unacceptable wish. Stages of Dying: denial, anger, bargaining, Depn, acceptance. ------------------------------------------------------------------------------------------------------------------------------------------Acute Care For EtOH Intoxication (Yost, Postgrad Med 2002;112:6) Multiple factors, such as trauma & concomitant use of other drugs, can confuse the diagnostic pictures & affect the choice of tx. CDC & NCHS estimate 52% of U.S. drank EtOH in the past month, 16% are binge drinkers consuming 5+ drinks on the same occasion in the past month. An estimated 20-25% of ER Pts have been drinking. Legal intoxication level varies by state, but in general it is a blood EtOH content (BAC) of 80 to 100 mg/dL (0.08, 0.10). The average clearance rate in both adults & children is 18 to 20 mg/dL per hour. Elderly drinkers have a higher BAC than younger abusers of the same wt for any given amount of EtOH consumed. Ingestion of large volumes of high concentration EtOH (>40%, 80 proof) or concomitant consumption of fatty foods or drugs that impede GI motility can result in acute N/V or other signs of gastric inflammation. Acute EtOH consumption has been linked w/ tachyarrhythmias, particularly idiopathic atrial fibrillation. Ethanol inhibits gluconeogenesis, which can result in hypoglycemia. Ethylene glycol & other EtOH may contribute to an ↑ osmolar gap. Estimated BAC can be calculated by an increase of 22 mOsm/L for every 100 mg/dL rise in serum EtOH. Intoxication is a/w thrombocytopenia; habitual drinkers may show evidence of leukopenia. As many as 90% of alcoholics < 30 yrs use another drug in addition to EtOH. Mental status changes noticed to be markedly uncharacteristic of a Pt’s previous intoxication pattern are often a warning sign that more aggressive assessment is needed for head injuries, electrolyte abnmlities, adverse rxns to illicit or Rx drugs, or other causes of mental deterioration. Disulfiram (Antabuse) rxn includes flushing, N/V, vertigo, HA, abdominal pain, diaphoresis. Other drugs w/disulfiram-like rxn incl: metronidazole (Flagyl), cephalosporins, chlorpropamide (Diabinese), sulfonamides, & chloral hydrate (Aqua chloral Supprettes). EtOH clearance can be ↓ by verapamil & high-dose cimetidine (Tagamet) EtOH intoxication tx incl: IV hydration, sx nausea control, & electrolyte correction (e.g. hypomagnesemia). Glucose may be needed & thiamine supplementation may be needed for chronic drinkers. Pre-mixed IV solutions (e.g. rally pack, banana bag) include 1L D5 1/2NS, 2g Mg, 1mg folate, 100mg thiamine. EtOH may compound hypoTN in trauma & mask injuries 2/2 ↓ pain sensation. Each episode of acute intoxication in a pregnant Pt presents an opportunity for risk counseling. Fetal EtOH syndrome (FAS) incidence is ~ 10% for women who drink 6-7 drinks/day The rapid absorption of EtOH through intestinal mucosa gives gastric lavage limited value in Pts w/ delayed presentation of intoxication; it may be useful if done w/in min of ingestion. Extended liability may hold MDs responsible for premature D/C of intoxicated Pts who subsequently cause harm to themselves or others; physicians need to be prepared to contact local law enforcement if a Pt w/unresolved mental status changes insists on leaving the hospital or office & driving away. In previously un-tx Pts who presented w/ intoxication to urgent ambulatory settings, almost 50% of those referred for EtOH intervention kept their tx appointment. ------------------------------------------------------------------------------------------------------------------------------------------Article – Suicidal Ideation (Gliatto & Rai, Amer Fam Phys 1999; March 15) Many Pts who commit suicide saw their primary care physician w/in several months prior to death, & many of these physicians were unaware of the Pts’ intentions or that the Pt had previously attempted suicide. Epidemiologic factors for suicide: male (4:1), white, Native American, age > 65 yrs, widowed, divorced, living alone, presence of stressful life events, & access to firearms.

Ψ d/o a/w suicide: major Depn, substance abuse (particularly EtOH), schizophrenia, panic d/o, borderline personality d/o, & impulsive/antisocial behavior in children. Hx & sx for suicide: previous attempt, hopelessness, anhedonia, insomnia, severe anxiety, impaired concentration, psychomotor agitation, & panic attacks. The best predictor of completed suicide is hx of attempted suicide. Evaluating a Pt w/ suicidal ideation: ask about a hx of ψ illness & substance abuse, hx of SI & SA, use CAGE to screen for EtOH abuse, perform a MSE w/emphasis on mood, affect, & judgment. Suicide among medically ill Pts, incl. AIDS, rarely occurs in the presence of a comorbid ψ d/o, such as major Depn. Asking Pts about suicide will not give them the idea or the incentive to commit suicide. Most Pts who consider suicide are ambivalent about the act & will feel relieved that the clinician is interested & willing to talk w/ them about their ideas & plans. One approach is, “Sometimes when people feel sad or depressed or have problems in their lives, they think about suicide. Have you ever thought about suicide?” Delineate extent of suicidal ideation: When did you begin to have suicidal thoughts? How often do you think about suicide? What makes you feel better? Do you have a plan to end your life? What stops you from killing yourself? Ascertain plans for furtherance & lethality: Do you own a gun or have access to firearms? Do you have access to potentially harmful medications? Have you imagined your funeral & how people will react to your death? Have you “practiced” your suicide? Have you changed your will or life insurance policy or given away your possessions? The most common ψ dx a/w completed suicide are MDD & EtOH abuse.

Occasionally, Pts may not allow the clinician to contact their families. When someone’s life is in danger, confidentiality may be breached. Legal consultation may be advisable if there are any questions about infringing on a Pt’s autonomy. The grounds for involuntary commitment are: 1) imminent danger to self or others & 2) an inability to care for one’s self. Most states allow for 48 to 120 hours of involuntary hospitalization. OutPts: One technique that is frequently employed is to ask the Pt to sign or verbally agree to a “no-harm contract.” Such a contract is not legally binding; it serves mainly to solidify the therapeutic alliance. Antidepressants are more effective than placebo in decreasing suicidal ideation, & serotonin reuptake inhibitors (SSRIs) may act more rapidly in this regard. Tricyclic antidepressants should be avoided due to lethal potential. Safe agents are fluoxetine (Prozac), sertraline (Zoloft), fluvoxamine (Luvox), & venlafaxine (Effexor). Pts w/ a plan, access to a lethal means, recent social stressors, & evidence of a ψ d/o should be hospitalized. ------------------------------------------------------------------------------------------------------------------------------------------Article – Depn In Adolescents (Son & Kirchner, Amer Fam Phys 2000;62:2297-2308,2311-2) About 2% of prepubertal children & 5-8% of adolescents have Depn. A structured clinical interview & various rating scales, such as the Pediatric Sx Checklist, are helpful in determining Depn. Psychotherapy appears to be useful in most children & adolescents w/ mild to moderate Depn. A growing body of evidence has confirmed that children & adolescents not only experience a whole spectrum of mood d/o but also suffer from the significant morbidity & mortality a/w them. Major depressive d/o, tx w/ psychotherapy or medication (SSRI, TCA), involves 5 to 9 of these criteria:

depressed/irritable, recurrent thoughts of death, diminished interest/pleasure, weight loss/gain, psychomotor agitation/retardation, fatigue or energy loss, feelings of worthlessness, diminished concentration, insomnia. Bipolar d/o should be tx w/ psychotherapy & medication (lithium, anticonvulsants). Adolescents may exhibit more anhedonia, hypersomnia, weight change, & substance abuse than younger children. 90% of children w/ major depressive d/o reach remission by 18 months to two yrs after onset. About half of children diagnosed w/ dysthymic d/o are still struggling w/ their sx at 18-24 months. Because of its relatively good sensitivity & specificity & its ease of administration, the Pediatric Sx Checklist can be a valuable screening tool. Specificity is 68% in middle-class, 100% in lower socioeconomic status. Testing should include a CBC (to rule out anemia or infection), electrolytes, creatinine, BUN (to rule out electrolyte d/o or renal disease), LFT (to rule out hepatitis & drug effects), TFT (to rule out thyroid d/o), EEG (to assist in ruling out a SZ d/o), & an ECG as a baseline if TCA therapy is being considered. The high placebo response in children confounds many studies of the effectiveness of antidepressants in children. SSRIs dominate the pharmacotherapy of Depn by primary care clinicians because of their relative safety. As in geriatrics, the adage, “Start low & go slow,” is a useful guideline in determining dosage levels for antidepressant medication in children. ------------------------------------------------------------------------------------------------------------------------------------------Article – Generalized Anxiety D/o (Gliatto, Amer Fam Phys 2000;62:1591-600,1602) Pts w/ generalized anxiety d/o experience worry or anxiety & a number of physical & psychological sx. Tx consists of pharmacotherapy & various forms of psychotherapy. The BZDs are used for short-term tx, but because of the frequently chronic nature of generalized anxiety d/o, they may need to be continued for months to yrs. Buspirone & antidepressants are also used w/GAD. Pts must receive an appropriate pharmacologic trial w/ dosage titrated to optimal levels as judged by the control of sx & the tolerance of side effects. Ψ consultation should be considered for Pts who do not respond to a trial of pharmacotherapy. Generalized Anxiety D/o (GAD): Excessive anxiety & worry (apprehensive expectation), occurring more days than not for at least six months, about a number of events or activities (such as work or school performance). Characteristics of GAD: excessive physiologic arousal (muscle tension, irritability, fatigue, insomnia), distorted cognitive processes (poor concentration, unrealistic assessment of problems), poor coping strategies (avoidance, procrastination, poor problem-solving skills). If panic attacks are present, tx for panic d/o. If sx of major Depn are present, tx Depn. Generalized anxiety d/o is distinguished from other medical & ψ conditions & nml worrying principally by the long duration of the anxiety & the resultant impairment in daily fxning. Neurologic & endocrine diseases, such as hyperthyroidism & Cushing's disease, are the most frequently cited medical causes of anxiety. The clinician should inquire about herbal products, drugs of abuse, & vitamins. Pts w/ generalized anxiety d/o may respond to psychological or pharmacologic therapies or a combination of both approaches. BZDs are the most frequently used anxiolytics. BZDs from shortest half-life to longest: oxazepam (Serax, 9hr), alprazolam (Xanax, 14hr), lorazepam (Ativan, 14hr), chlordiazepoxide (Librium, 20hr), diazepam (Valium, 40hr), clonazepam (Klonopin, 50hr), clorazepate (Tranxene, 60hr). Benzos like oxazepam (Serax) are useful for elderly Pts or those w/ liver disease. Benzos like clonazepam (Klonopin) should be used in younger Pts w/o concomitant medical problems. Abused benzos are the ones most rapidly absorbed: diazepam, lorazepam (Ativan), & alprazolam (Xanax) Buspirone is commonly used as a tx modality, although BZDs are the most widely used for GAD. ------------------------------------------------------------------------------------------------------------------------------------------Kaplan Videos (2001) – Ψ w/ Alina Gonzalez Mayo, MD ------------------------------------------------------------------------------------------------------------------------------------------Mental Status Exam: Overview * Used to describe the observations & impressions of the Pt during the interview. Most useful tool in psych. * Don’t sit behind a desk when talking w/ a Pt; it creates a boundary & a power issue. Also, never stand & talk to the Pt while they are sitting down; it is an issue of power. Ideally, sit diagonally from the Pt. * The best way to get a Dx or confirm a Dx is the mental status exam. * General description, Appearance: grooming, poise, clothes (e.g. inappropriate attire), body type (e.g. disheveled). * If Pt has inappropriate attire for the weather (poor judgment), think about psychoses such as schizophrenia. * If Pt is wearing dirty clothes, hair not really combed, think about mood d/o/Depn.

“The FBI & CIA are after me because they know I’m selling nuclear secrets to the foreign government because I made a nuclear bomb at home. * An illusion is a sensory misperception in the presence of sensory stimuli. * General description. restlessness. which makes the problem worse. * Schizophrenics who hallucinate have auditory (2/3 of Pts) or visual (1/3 of Pts) hallucinations. when the Pt gives brief & empty replies to questions. loose associations. memory (recent. as well as catatonic schizophrenia. Form: the way in which a person thinks (flight of ideas. * Mood & Affect. * Akathisia is generalized restlessness.” * A non-bizarre delusion would be a Pt saying. write a sentence). for visual pick drugs. Ex would be schizophrenic Pt w/ akathisia getting more medication. Auditory hallucinations are seen in psychotic d/o. restlessness) seen in mania & anxiety. So initially they may think the yr is a decade behind or that it is summer when it is winter. & olfactory hallucinations seen w/ SZ d/o. If the Pt says they are Santa Clause. fluent).” * Sensorium & Cognition: Folstein Mini-Mental Status Exam (MMSE). * Parkinson disease gives “mask-like facies. remote). . illusions). never reaching the point. concentration & attention (serial 7’s from 100. spelling backwards). paranoia. but not person. frank. don’t tell them they aren’t because they may get agitated & even aggressive toward you. * Speech: the physical characteristic of speech (relevant. tangentiality). A real hallucination would be turning around in an empty room because you thought someone called your name. * Formication (insects or ants crawling on skin) seen in cocaine intoxication & EtOH withdrawal (DTs). eventually. “Doctor. β blockers & BZDs can also be used. for olfactory pick SZ d/o. * Temporal lobe SZ (complex partial) give foul-smelling hallucinations. score of 23-24 or lower is indicative of dementia. * Use the terms congruent & incongruent when describing mood & affect. & sometimes mood d/o. * A bizarre delusions means no one in their right mind would believe you. stooped posture) seen in Pts w/ Depn. they forget who they are. Behavior: quantitative & qualitative aspects such as tics. * Psychomotor retardation (e. name past presidents). Circumstantiality reaches the point. * Thought. * Pts w/ dementia tend to lose orientation to time. seen in psychosis. First documented case was Ansel Bourne. seductive.” Described as “ants in your pants. * Mood & Affect. * A hallucination is a false sensory perception w/o any sensory stimuli. * Changes in affect occur typically in psychotic d/o such as schizophrenia. angry). * Loose associations are a rapid shifting of topics w/o a connection. whose name was used for the movie Borne Identity. visuospatial capacity (copy a figure of interlocking pentagram).” Must be recognized as distinct from psychomotor agitation. tactile hallucinations seen w/ drugs. orientation (time. Tx of choice is lowering the dose of the drugs. visual hallucinations seen w/ drugs or organicity (tumor. person). think about mood d/o/mania & histrionic. this is incongruent. * Pts w/ manic or bipolar d/o will have pressured speech. etc. seen in the “thorazine shuffle. Content: what the person is actually thinking about (delusions. Such as dissociative amnesia or fugue. as well as schizophrenia. A common auditory hallucination/illusion seen in the general public is turning around on a busy street because you think someone called your name. & fund of information (calculating ability. then place. for tactile pick drugs or delirium tremens (DTs).g. * In Depn. Affect: Pt’s present emotional responsiveness (blunted. clouding of consciousness). Attitude: cooperative. * Thought.* If Pt is wearing bright ridiculous clothes & tons of jewelry. Testing alertness & level of consciousness (awake. labile).” a problem w/ affect. seen in mania. do not confront the Pt. going at “a thous& words a min. either bizarre (schizophrenia) or non-bizarre (delusional d/o). place. Important in detecting aphasias. * Psychomotor agitation (e. if auditory pick schizophrenia. trauma). capacity to read & write (read a sentence & do what it says. If a Pt has a delusion. * General description. * Mood & Affect. * Tangentiality is going off topic. * Dissociative d/o are good w/ time & place. Mood: emotions perceived by the Pt (depressed. * Flight of ideas is a rapid shifting of topics w/ connection (there is a trigger). * Perceptual disturbances: experiences in reference to self or the environment (hallucinations. If Pt says they are depressed but laughing. * For hallucinations. anxious. Ex. * MMSE top score is 30. flat. I think my wife is trying to poison me. coherent. they forget who their significant others are. then person.” * Alogia (poverty of speech) is seen in schizophrenia. abstract thinking (proverb interpretation). * Delusions are fixed false beliefs. suicidal ideas). gustatory hallucinations are rare. Appropriateness: in reference to the context of the subject. such as burning rubber. Next they will have trouble determining where they are located currently. Last. there is a ↓ speech w/ barely audible tone.g.

” Then ask where the Pt hears the voices. They might be told. Malingering Pts would then take this information & pretend to be in pain on palpation of the opposite knee. It typically affects the parietal lobe on the nondominant side. Once they take 7 from 100 & say 93.g. say to Pt that you have $5 & go to the store to get a loaf of bread. Poor judgment would be to throw the letter away. rock-paper-scissors). * Spinothalamic tract can be tested by temperature & sharp versus dull. “Yes. this is not a good question unless you know what the Pt actually had for breakfast. this is called constructional apraxia. * A review of systems (ROS) would involve mostly closed-ended questions. * Depressed Pts have trouble concentrating. & at times his mother’s voice as well. “Tell me about the voices.39. * Reassurance. * Leading questions should be avoided. rapid alternating movements. which can help differentiate malingering from true psychological pathology. “Oh yea. Poor impulse control would be a Pt who starts shouting obscenities during an interview or gets mad & punches another Pt. * Basal ganglia pathology can involve rigidity w/ limb movement & involuntary movements. they were prompted. allowing the Pt to speak in their own words & as much as possible. A good ex is homeless Pts who use hospitals for shelter. While in your office. Which of the following would be . she beings to cry. Antisocial w/ good judgment would be to open the letter & check for money then throw away the envelope. “You’re angry today. & Romberg test. The bread is $1.” However.* Most famous recent memory test is “what did you have for breakfast. * Impulse Control: estimated from hx or behavior during interview. ask “what is 7 from that?” instead of saying “what is 93 minus 7?” because they may have forgotten that they said 93. “Are you right or left handed? Right-handed people tend to hear voices more in their left ear. * Testing posterior columns can be done w/ a turning fork at the wrists & ankles. Remote memory can be tested by birth date or phone number. so they have trouble w/ serial 7’s or serial 3’s.” * A 30yo woman comes to see you after her Father’s death approximately 3 weeks ago. continue. How much money will the cashier give you back? * Executive fxning problems are seen w/ frontal lobe pathology (e. Since then she has complained of depressed mood & feelings of hopelessness. You could be sly & say things like. * Parietal lobe can be assessed by the ability to identify objects based on touch w/ their eyes closed (stereognosis). * For calculating ability. “Just go to the hospital & say you’re hearing voices. if malingering they will grab onto those bits of information that you know aren’t true. He reports hearing his father’s voice. it implies you are there for the Pt & listening to them. * Cerebellum can be assessed w/ tremor.” Silence is also a form of facilitation. think about the cognitive d/o such as dementia.” On admission. * Judgment & Insight: ability to act appropriately & self-reflect. Paranoid Pts might say they wouldn’t touch it due to anthrax. You can ask several of these questions & document the responses. * When memory is the problem. ------------------------------------------------------------------------------------------------------------------------------------------Mental Status Exam: Interviewing Techniques * Ask open-ended questions. then saying there is a nerve that connects the two knees so pressure on the opposite knee would activate the pain. The Pt appears distressed by the hallucinations & wants your help. Which of the following would be the most appropriate statement at this time? Answer is open-ended question. * Reliability: your impression on the Pt’s ability to assess their situation. * Posterior fossa lesions can be assessed by asking the Pt to roll their eyes upward (Parinaud sign). Another ex would be w/a Pt faking knee pain. “Can you tell me about the voices?” Avoid closed-ended questions that are very specific & would result in a yes or no answer. don’t say “Are the voices telling you to hurt yourself?” The Pt. “Are you hearing voices?” * Facilitation means helping the Pt continue by providing verbal & nonverbal cues. This is especially bad for malingering Pts. This is basically putting words into the Pt’s mouth. would you like to talk about it?” * Confrontation is a good technique for substance abusers. * A 20yo male presents to your office complaining of auditory hallucinations for approximately 7 months in duration. * Confrontation should be avoided as it makes the Pt angry. if truthful. will increase compliance. they sure are” but might not have been. “You seem upset. * If Pt cannot copy a complex figure. & left-handed people tend to hear voices more in their right ear. will probably say. what’s wrong w/ you?” * Facilitation should be used instead. * Frontal lobe can be assessed by repeatedly executing a motor sequence. Common question is to say to the Pt that you find an envelope on the street & the envelope is sealed & stamped. as they might not be accepting the fact. if malingering.

2yo). this Pt is in the hospital getting tx. Ego keeps everything in balance. * Superego: conscience. conversion. * All defense mechanisms are unconscious (except suppression). An ex is being angry at one person & taking it out on another person. ex is a woman who has never seen a live snake but dreams about snakes being all over her bed. * In cartoons w/devil & angel on shoulders. Regression would be bed-wetting & thumb sucking. * Denial: used to avoid becoming aware of some painful aspect of reality. “I didn’t have a heart attack” even in the face of an ECG w/ ST elevation. such as death or the ocean. like stealing & lying. It allows for doing certain things. Could be related to hx of sexual abuse. constantly buzzing the nurse & asking for blankets/food/juice. I didn’t pass the test because the professor wrote horrible questions. we leave it alone. * Introjection: features of the external world are made part of self. such as in severe trauma. Seen in paranoid personality d/o. Seen in somatoform d/o. * Repression: unconsciously forgetting. object relationships. w/o remorse. The more we learn about something. we have to find out why. Another ex is a resident who dresses like the attending. & feelings to someone else. If conscious. * Displacement: an emotion or drive is shifted to another that resembles the original in some aspect. discrete. answer is id. * Isolation: separation of an idea from the affect that accompanies it. they may accuse their spouse of cheating. or even find out the Pt’s view on death. relation to reality. the more our fear decreases. The Pt’s blame convinces them there is something physically wrong w/ them. * Intellectualization: excessive use of intellectual processes to avoid affective expression or experience.g. If it does interfere. Birth of a sibling or divorce is stressful for a 7yo child. Ex is a 5yo who watches Superman then goes & grabs their bed-sheet & pretends to fly. . & adaptive. but the Pt talks about it w/o any emotion (father does not cry). developed shortly after birth. thoughts. but medical hx shows tx for STDs at young ages (e. This shows caring & facilitation.the next step in the Mgmt of this Pt? Answer is offer tissue & remaining silent. ------------------------------------------------------------------------------------------------------------------------------------------Psychic Structures: Freud Structure Model of the Psyche * Id: drives (instincts) present at birth. answer is superego. * Projection: attributing your own wishes. interpreting w/ dream analysis. Usually in the case of very bad memories. A new widow may make dinner for their dead husb& at the nml time in which he’d come home from work. the important part is this is an unconscious act. The two drives are sex & aggression. not snakes. * Rationalization: when excuses are used to justify things that are unacceptable. ------------------------------------------------------------------------------------------------------------------------------------------Psychic Structures: Defense Mechanisms * The ego’s way of warding off anxiety. Seen in borderline personality d/o. They go to the bookstore & buy a ton of books on cancer & reading. confronting denial. judgment. but they don’t want to talk about it. The correct answer is to do nothing. * Ego: defense mechanisms.” This is mostly due to stress. If someone is cheating on their spouse. Pt would say they don’t remember being raped. * Somatization: psychic derivatives converted into bodily sx. Considered the least mature defense mechanism. What is the next step in the Mgmt of the Pt? Answer is not to refer to psych. If the denial does not interfere w/ tx. hypochondriasis. Ex is Pt told they have cancer. elevated cardiac enzymes. into the fetal position. * Splitting: external objects are divided into all good or all bad. * Antisocial personality d/o has a defective superego (superego lacunae). etc. body dysmorphic. The Pt’s defense mechanisms are there to help them. The wrong answer is almost always referring to ψ. Later they may say they were. * Suppression: conscious forgetting. If “conscious” or “morality”. they will come in & get massive work-ups w/ no findings. Usually adults will act like children. & an IV in their arm. “I can’t seem to remember his name. * Blocking: temporary block in thinking. the devil = id & angel = superego. * Elderly Pts may presents w/ somatic d/o when they actually have underlying Depn. It can also be relate to phobias. An ex would be a Pt being sure they were never abuse. it is called imitation. Adults may regress. Pt has just experienced something horrible (young daughter hit & killed by a car). Biggest fears are the unknown. dynamic & irreversible. * If “drive” or “instinct” is in the question. Temper tantrums are also regression. May be interpreted as a fear of penises. I need to have six drinks every night because work is so stressful. * Regression: returning to an earlier stage of development. formed during latency period. * If question says “object relationships” or “judgment” then pick ego.

These types of tests require a great deal of clinical training to administer. This test has a lie scale as well as a validity scale. * Major Depn is a mood d/o lasting more than two weeks & involving depressed mood or anhedonia. woman gets diagnosed as major Depn & man as adjustment d/o. Most common obsession is fear of contamination. Another ex would be someone who wants to set fires then becoming a special effects expert in Hollywood. original impulse might be the want to touch everything. SD = 15. how you perform on an exam. over 500 questions. Men have higher risk of suicide so the implication here is that men may not receive the tx they need for Depn. & DA (all ↓). * Other risk factors of major Depn include family hx & exposure to stressors (e. * Risk factors: women (possible hormonal bias. Pt tells story based on a picture. no relationships. * Have been studies where man & woman go to doctor saying same things. Ex would be someone who wants to start fires. * Adults: Wecheler Adult Intelligence Scale Revised (WAIS-R).g. age > 40. “She wants to be left alone. feelings of helplessness. death of spouse). or of superior intelligence. CA is age in yrs (chronological age). norepinephrine. but was caught multiple times doing just that. from an experiment w/ a fully electrified cage where the cat attempts to get out but finds all sides are electrified. * MA is mental age. * Another is the sentence completion test. ↓ concentration. it can tell if the person is “faking good” or “faking bad. Stanford Binet was the first test created & is good for children who are very young. ↓ energy. “walking home today I ____” * Last type of test is the drawing test. the cat gives up.* Rxn Formation: unacceptable impulse is transformed into its opposite. but instead becomes a firefighter. Undoing for OCD about contamination is h& washing. Since then. * MMPI is a test w/ a series of true & false questions. * Behaviorists mention “learned helplessness” in Depn. * A nurse. * Acting Out: emotional or behavioral outburst. Most of the drugs to tx Depn are a combination of serotonin & norepinephrine or purely serotonin. is MA/CA * 100. has been ignoring an elderly female Pt who has terminal cancer. not rationalization. Another would be someone who wants to kill babies. Pt says what they see. Ex would be a very overweight comic talking about being overweight & getting kicked out of buffet restaurants. the Pt reports a 30lb weight loss.” * Projective tests use ambiguous stimuli. * Personality tests are objective or projective. & ↓ sleep. Meaning if you realize there is no way out then you just give up. Ex is spilling salt on the table. WISC-R is good for children from age 6 & up (ages 6 to 18). Also known as the animal model of Depn. then becoming a pathologist or surgeon. & hopelessness. meaning no right or wrong answer. * Humor: permits the feelings & thoughts w/o discomfort. * Sublimation: considered the most mature of all defenses. then throwing it over your shoulder to undo the bad luck. such as a question. Someone who likes pornography would become a censor. Ex is someone who wants to stab & dismember people. stresses. ------------------------------------------------------------------------------------------------------------------------------------------Ψ Tests * Intelligence Quotient (IQ) measures academic performance. So. EtOH is involved in 50% of the cases of homicide (perpetrator or victim). * Undoing: acting out the reverse of an unacceptable behavior. This is doing exactly what you want to do (unacceptable) but in an acceptable way in society. * Major Depn is linked to serotonin. ------------------------------------------------------------------------------------------------------------------------------------------Mood D/o: Major Depn * 70yo female was recently admitted after her son informed the doctor that his mother had been doing very poorly since her husb&’s death many months ago. mentally retarded. . but instead becomes a pediatrician. A child having a temper tantrum (age appropriate). * Children: Wecheler Intelligence Scale for Children Revised (WISC-R) & Stanford Binet test. Used for people ages 17 & older. the nurse replied. which is good for assessing child abuse. * One common projective test is the Rorschach (inkblot) test. working in a hospice. Seen often in obsessive-compulsive d/o (OCD). or Dx bias). ↓ mood. Objective tests use simple stimuli. The most widely used objective test is the Minnesota Multiphasic Personality Inventory (MMPI). * Metabolite of serotonin is 5-HIAA.” Which of the following defense mechanisms best explains her response? Answer is projection. which would be ↓ in suicide & aggression (disinhibition). Another ex is Jimmy Swaggart who preached about sins of the flesh. divorce. * Another is the thematic apperception test (TAT). mean = 100. When asked why she has been ignoring the Pt.

such as the chess club. fatigue. substance d/o (e. & MAOIs (all neurotransmitters). * Bipolar affects men & women equally & it has a mean age of onset of about 30 yrs. Psychomotor retardation. right sided CVAs a/w apathy).” * Ideally for tx.g. * When asked what is the best tx for Depn. Depn can mimic hypothyroidism. feelings of worthlessness. ------------------------------------------------------------------------------------------------------------------------------------------Mood D/o: Bipolar D/o * A 19yo college student is taken to the school counselor after he fails several classes. It involves homework so the Pt must be willing to get the therapy. given to Pt the measure thyroid-stimulating hormone (TSH) expecting an increase in TSH. student government. w/ pacemaker insertion. * First “break” or manic episode often seen during college. * Dexamethasone suppression test. more toward African Americans. but might have some psychomotor agitation & pressured speech. * ECT does not have absolute contraindications. sports. concentration trouble (serial 7s. can’t sleep. beta blockers). . & grief. cerebrovascular accidents (in particular. other mood d/o. If the cortisol goes up. These Pts should get special observation. * Physical exam is usually w/in nml limits. & at least two fraternities. answer is ECT. * Lab tests are not very diagnostic. more toward women. ECT today is painless & the Pt’s do not remember the experience. * Many experts say that if a Pt is bipolar then it is assumed the Pt is using drugs. but has slept 10 hours a day. * Major Depn w/ psychotic features has worse prognosis than major Depn alone. drama club. it’s a fact of life. ECT will reduce suicide risk. Bad things happen to everyone.g. His speech is pressured & he has psychomotor agitation. schizophrenia) have a race bias. pseudo dementia. most sleep less. although medication is used as a first line. which is meant to change behavior patterns. feelings of guilt. His grades are poor & he seems undisturbed by this. & constantly thinks about death. * DDx includes hypothyroidism (order TSH). More prevalent among high socioeconomic status & those who did not finish college. Parkinson disease. most of which have conflicting times. thinks about killing herself. gained 30lbs. eats a ton. which is not routinely ordered). * Medication should be the one w/ the least amount of side effects. cocaine withdrawal). but used for Depn. It is a safe procedure & usually used for suicidal Pts. This does not put thoughts into the Pt’s head about suicide.g. * Mood d/o (e. This is typical of pts w/mania. which is SSRI. Answer is not medication. increases compliance. Considered to be the illness w/ the greatest genetic linkage. * Major Depn w/ atypical features would be Pt w/ depressed mood. * Individual psychotherapy is also indicated for Depn. * Tx involves talking about suicide. this is a pos test. If there is a blunted response. Medications include antidepressants such as SSRIs (serotonin). EtOH dependence. Ex is woman who has two months of feeling hopeless. meant to suppress cortisol. These are dexamethasone suppression test & thyrotropin releasing hormone. & substance-related d/o. * Electroconvulsive therapy (ECT) may be used as well. anhedonia. The Pt is enrolled in numerous classes. expecting a drop. has lost 30lbs…& has been hearing her dead sister’s voice telling her to join her. * Bipolar d/o is a mood d/o in which the Pt typically experiences manic sx for at least 1 week that cause significant distress or impairment in his/her level of fxning. He is also enrolled in numerous organizations. major Depn) has a gender bias. medication & therapy together are always better than either alone. serial 3s). dementia. * Thyrotropin releasing hormone. which can help the Pt deal w/ life stressors. typically losing weight. Everyone thinks about the scene from One Flew Over The Cuckoo’s Nest w/ Jack Nicholson being strapped to a table & held down by four men. Coexisting d/o may include anxiety. Relative contraindications are ↑ intracranial pressure. medications (e. * What is the next step in a depressed Pt? Answer is inquire about thoughts of suicide. tumors (CT scan. Cognitive therapy is used as well. TCAs (serotonin & norepinephrine). It is safe for Pts w/ previous MI. A common drug used is EtOH for selfmedication of manic episodes. & even Pts who are pregnant.* Depn sx are depressed mood & anhedonia most of the day. Public should be educated about the safety & efficacy of ECT. Weight changes occur as well. Give Pt dexamethasone & check the Pt’s cortisol the next day. Psychotic d/o (e. Ex would be changing the Pt’s thoughts from “I’m a bad person” to “I’m a good person that bad things sometimes happen to.g. Sleep disturbances occur. this is a pos test. loss of energy.

------------------------------------------------------------------------------------------------------------------------------------------Mood D/o: Questions * 50yo woman is taken to the hospital after neighbors find her w&ering the streets mumbling to herself & gesturing. & anhedonia. amphetamines. Her sx resolve in the spring & summer. a manic person would empty their bank account at the store. * Thought to be caused by a defect in the metabolism of melatonin (↓ MSH). * Cyclothymia is a chronic d/o characterized by many periods of depressed mood & many periods of hypomanic mood for at least 2 yrs. When questioned. . & psychotherapy as indicated. When approached. a hypomanic person would go to the department store for a dress & come back w/ 5. * Bipolar I is mania & major Depn. drugs. * Many cyclothymics have interpersonal & marital difficulties. She now has begun to hear her husb&’s voice telling her to “join” him. Mania would affect fxning. Family hx of bipolar d/o is seen. Ex. These sx have occurred for more than 2 yrs. or antipsychotics. Another ex: Pt from the northern climate who relocates to a warmer climate & no longer has Depn. * Dysthymia is a chronic d/o characterized by a depressed mood that occurs most of the time & lasts for at least 2 yrs. * DDx is major Depn. * DDx includes SZ. Chemical rxn occurs when light hits retina. ------------------------------------------------------------------------------------------------------------------------------------------Mood D/o: Seasonal Affective D/o * A young woman from Minnesota w/o depressed mood & sleep disturbances every winter. & antipsychotics (for mood stabilizer non-responders or in an emergency situation). & low self-esteem. * Dysthymic d/o more common in women. which resulted in her quitting her job & staying at home. carbamazepine). & medications (e. & difficulty in making decisions. she reports feeling depressed since her husb& died 5 months ago. younger than 64 yrs old. & personality d/o. Psychotherapy as indicated. & from low-income families. * Tx is phototherapy. unmarried. personality d/o. She reports a decrease in concentration & feelings of helplessness. During her feeling-great periods. w/ a reduction or termination of sx at that time. They often also have borderline personality d/o & are more often women. A hypomanic person would have ↑ sexual drive w/ their partner. & ↑ irritability. ------------------------------------------------------------------------------------------------------------------------------------------Mood D/o: Cyclothymia * Mrs. substance abuse. Bipolar II is hypomania & major Depn. * Tx usually does not include hospitalization. which affects his ability to complete his assignments at work. Also minor depressive d/o.* Tx includes assessing Pt safety to determine need for hospitalization. pharmacotherapy including mood stabilizers (lithium. If medications are indicated. EtOH & substance abuse are commonly seen when they are in the hypomanic phase. not refer to ψ. caffeine. BZDs. ------------------------------------------------------------------------------------------------------------------------------------------Mood D/o: Dysthymia * Mr. while a manic person would be stopping strangers on the street to ask for sex. she begins to cry & expresses thoughts about hurting herself. Tx for major Depn is to prevent suicide. pay attention to the duration of sx. Major Depn typically lasts 1 yr. Examination reveals scratch marks on both her forearms & questionable lacerations on her throat. fatigue. CNS infections. hopelessness. poor concentration. & other stimulants). not start medication. not ECT. * DDx includes schizophrenia. low energy. McDonald has experienced a 12-yr hx of periods of feeling great followed by periods of feeling lousy. Smith complains of poor appetite. tumors. Pts may benefit from long-term individual insight oriented psychotherapy to help them overcome their long-term sense of despair & resolve conflicts from childhood. TCAs. BZDs. It is considered a milder form of Bipolar II D/o. * If you would hospitalize the person. euphoric mood. * Difference between mania & hypomania is how the sx affect fxning. hyperthyroidism. &/or borderline personality. Typically have other ψ d/o such as anxiety. During her feeling-lousy periods. Which of the following would be the next step in the Mgmt of this Pt? Answer is to assess for thoughts about suicide. or MAOIs. * Tx is mood stabilizers. Dysthymia is a mild form of major Depn & lasts a long time. or sleep deprivation. SSRIs. Best option is SSRI due to side-effect profile. the answer is mania. she experiences ↑ sexual drive.g. some medications. * A d/o characterized by depressive sx found during winter months & absent during summer months. she experiences insomnia. valproic acid.

5) acceptance. Depn sx are unremitting. * If you have Depn sx for up to a yr after the death of a loved one. Typical ex would be a mother waking up her husb& & saying that the baby is trying to control her mind. * Sx must be present for a period of at least 6 months to be able to make a Dx. & intrusive. so no tx needed. is antidepressants & mood stabilizers. If the Pt had mania & Depn. * “Baby blues” (postpartum blues) occurs. * Tx for postpartum psychoses. * Women w/ postpartum blues tend to care a lot for their babies. then ended up in low SES) or social causation (more stress in low SES). which is thought to be an underlying bipolar d/o. the mother may have thoughts to hurt their children. Women age 25 to 35. the mothers may see the killing as an act of love for their child. Answer here is risperidone first. * Tx for postpartum Depn. . She believed most individuals experience stages that are common rxns to death. not shock & denial. & ability to interpret reality. we call it grief. ------------------------------------------------------------------------------------------------------------------------------------------Mood D/o: Death & Dying * Death & dying based on the stages ID by Elisabeth Kubler-Ross. due to hormones after pregnancy. * Families that are “High EE” (high expressed emotion) are very involved. If longer than one yr. got schizophrenia. or when washing the baby I felt two little horns growing. if Pt leaves the hospital then their relapse rate is very high. tx someone in one way & tx them a different way. a lot of Pts (up to 1/3) will never return to pre-morbid state. * Depn is also known as pathological grief. 4) Depn. use to have the term schizophrenogenic mother. so you tend to see postpartum psychoses from the first baby onward. Which of the following would you expect to see first? Answer is any of the above. risperidone. * First baby is considered the most traumatic. is antidepressants. * A common reason these mothers kill their children is because the mothers are miserable. * Postpartum Depn or psychoses typically occur one month after birth & the sx may continue. in theory. which do not have to occur in any specific order. * 1) shock & denial. believed the woman spoke in a mixed message. not fluoxetine or phenelzine. * If family is High EE. which of the following is most indicated as the initial tx? Here the Pt has Depn & psychoses. * Final step in tx is looking into the mother’s thoughts about the child to determine if the child is at risk. * ↑ number of schizophrenics born in the winter & early spring. in postpartum Depn & psychoses. tx like a baby but spoke to like an adult (double bind theory).* Assuming you decide to be tx. we tx the mania. so likely to return to hospital. but the psychosis is the worst so that is tx. ------------------------------------------------------------------------------------------------------------------------------------------Mood D/o: Grief & Postpartum Depn * Grief is also known as bereavement. olanzapine target both DA & serotonin. usually at age 15 to 25. 2) anger. so if they show up together as answer then don’t pick either. She believed dying Pts did not follow a regular series of responses that could be easily ID’d. Postpartum Depn tends to occur w/ the second baby. * Newer atypical antipsychotics clozapine.g. Grief sx tend to wax & wane. so if they are in the same answer choice then don’t pick either. which is thought to be an underlying Depn. * Many believe the family may be the cause of the Pt’s schizophrenia. * A 32yo female was recently diagnosed w/ breast cancer. e. it is Depn. * Pts w/ grief usually return to baseline period w/in two months. & thus they do not want their child to be miserable as well. ------------------------------------------------------------------------------------------------------------------------------------------Schizophrenia * Schizophrenia is a thought d/o that impairs judgment. critical. * These stages are not specific to death & dying. * Schizophrenia a/w high levels of DA & abnmlities in serotonin. Thus. Postpartum psychoses mothers are the most likely to kill their babies. 3) bargaining. they may occur after being fired or after a car accident. This double bind theory has fallen out. * There are five stages of death & dying. could be 1:1 or group therapy. However. either as a result of downward drift (were in high SES. * Schizophrenia is more prevalent in the low socioeconomic status (SES) groups. psychoses are worse for prognosis. Postpartum Depn or psychoses are usually related to an underlying d/o & the stress of childbirth precipitates the d/o. so some believe it may be viral in origin. not any other stage. or even antipsychotics. * Thought d/o affect everything in one’s life. not anger. * Tx for grief is supportive psychotherapy. * Tx for baby blues is self-limiting. behavior. * Onset is earlier for men. * The baby blues starts immediately after birth & does not last longer than two weeks. they don’t have to be in order.

higher order fxning. this is the answer for exams. anhedonia. * Psychoanalysis (intrusive therapy. reduction in cortical volume (a/w presence of negative sx. abstract thinking (concrete answers to a proverb). God). ↑ neurologic signs. also w/ one schizophrenic parent (12%) & two schizophrenic parents (40%). dead relative. * Personality d/o. residual. Also seen in REM sleep. * Tx involves determining if this Pt is safe. hallucinogens. * Hallucinations are likely & are usually auditory (2/3) or visual (1/3). “why don’t you kill yourself. look for lateral & third ventricular enlargement. * On CT scan (or MRI). paranoid type.g. When asked who “they” are. schizophreniform. he looks up at the sky & points to a faraway planet. * Frontal lobes deal w/ personality. look at duration of mood sx. neuroψ impairment. This is schizophrenia. Typicals only affect pos sx. yellow) in frontal lobe. & undifferentiated. maybe due to low intelligence at the preset or as a result of the disease. latest age of onset. * Schizotypal has illusions. the antipsychotics. Typically they hear bad voices. unknown why.g. * Pts may be hyper-vigilant. so you want to assure compliance. * Borderline personality d/o can have short-lived psychotic episodes w/ stress. thus give paranoia. * Delusions are mostly bizarre. * For personality test. The worse the ventricular enlargement. Pt told they are evil. Speech & behavior disorganized. odd beliefs. won’t ask about parents/dreams/etc.” * Comm& hallucinations are worrisome & most Pts will not listen to these voices telling them to kill themselves or others. the worse the prognosis. disorganized. May have saccadic eye movement. brief reactive psychosis. * Schizophrenics usually have social & occupational dysfxn. EtOH hallucinosis. such as a family member. epilepsy (temporal lobe). proved in concordance studies w/ monozygotic (47%) & dizygotic twins (12%). * Malingering & factitious d/o. & poor premorbid adjustment). * Sick Pts get least intrusive therapy (supportive psychotherapy) & well/healthy Pts get psychoanalysis. look at duration of sx as well as Pt’s level of fxning. * A 15yo boy while at a summer camp is taken to a nearby hospital after counselors notice a quick deterioration in his behavior. cognitive defects. CVAs. * Atypicals help w/ both pos & negative sx. His roommates noticed him talking to himself as well as exhibiting bizarre behavior such as grimacing & laughing inappropriately. 3-5 times per day for the rest of your life) is not used for schizophrenia. * Negative sx seen. constantly scanning the room. * Cocaine & amphetamine use DA tracts. * The lower number of side effects improves compliance. asks Pt how they’re doing. * Clozapine is used if the Pt does not respond to typicals or atypicals (tx resistant schizophrenia). these tend to be brief in schizophrenia. worthless. Bipolar 50% if both parents are bipolar. saying everything that’s on your mind. Catatonic behavior may be seen. want to give a projective test (e. terrible. * Schizophrenia types: paranoid. * IQ scores will be lower. lost job. better prognosis. barbiturate withdrawal. how to fill out an application) is the classic therapy used for schizophrenics. do a urine drug screen to rule out).. The difference is schizotypal is fxning. You see irregular or jerky movements w/ following objects. Atypicals are considered first line because they have the least side effects. & other psychotic d/o (schizoaffective. * Use medications that affect DA. steroids. Cocaine will stay in the body for about two days. In real life. assess whether the Pt is in control of the sx & whether there is an obvious gain. * DDx includes substance-induced (psychostimulants. where you sit w/ the therapist & basically free associate. no friends. This is schizophrenia. Mood d/o. Worse scenario is that the voice(s) is someone the Pt knows & looks up to. disorganized type.* Schizophrenia is genetic. hyper-vigilance. * Paranoid type is most common. * Positron emission tomography (PET scan) will show hypoactivity in the frontal lobes & hyperactivity of the basal ganglia relative to the cerebral cortex. . * Problems w/ frontal lobes & sometimes temporal lobes. delusional d/o). * Physical exam will likely be unremarkable. will they kill themselves or others. Most important is no areas of pickup (red. did they get a job. which is an abnmlity in smooth eye pursuit. flat affect. Themes are of gr&eur or persecution. * Medical causes include HIV. tumors. catatonic. magical thinking. * Supportive psychotherapy (least intrusive. or deity of some form (e. cost plays a large factor so typicals may be used instead. inkblot) to get bizarre answers. social withdrawal. * A 24yo man is brought to the ED by his parents after they found him covering the windows w/ aluminum foil because “they” were after his ideas. etc.

* Catatonic type has psychomotor disturbances. she replied. Erotomania is most dangerous if stalker. comes into room & swirls around then falls over. His thoughts are logical & coherent. or catatonic behavior. to themselves & to others. masturbating in public). no bizarre thoughts. & loose associations. persecutory. * Erotomania type is the one that makes the news. When she speaks. disorganized speech/behavior. mixed. There is extreme negativism. ranging from severe retardation to excitation. undifferentiated type. around age 40. Hallmark is negative sx only.” She states she heard a voice telling her she was irresistible. Jones is evaluated at a nearby clinic after she was noticed acting inappropriately at work. He appears to have poor grooming. a/w recent immigration & w/ low SES.” She also believed that others were talking about her & routinely asked them to stop. no thoughts of gr&eur. she replies. but he knows that the voices are coming from outside his head & are not heard by others. Tend to be younger than 25yo. he is not sure. married. * Tx involves determining if the Pt is safe. thus worst prognoses. hallucinations. peculiarities of voluntary movements. employed. * A 25yo female is found walking nude in the shopping mall. Staff questions him & notes that his thoughts are illogical. seen in older Pts. “I am making it easy for others to have sex w/ me since I know they all want me. an independently wealthy woman. ------------------------------------------------------------------------------------------------------------------------------------------Other Psychotic D/o * Mrs. I know you’ll be waiting for me when I get out. inappropriate affect. While in groups. or a girl named Billy Jean who thought Michael Jackson wrote that song for her. There is an absence of prominent delusions. she remains mute & does not respond to questions. emotional blunting. * Schizophreniform risk factors include affective sx. * Schizophreniform involves hallucinations (usually auditory). walking around naked. “I will not let you read my mind. * A 50yo homeless man is taken to the hospital after he was hit by a motor vehicle. According to her coworkers. catatonic type. negative sx. * Delusional d/o seen mostly in women. Suicide is a risk. disorganized speech. such as the guy who jumped over Madonna’s fence because he thought he was her boyfriend. marked regression to primitive disinhibited behavior (howling at moon. unspecific. * Delusional d/o types include erotomania. & commonly mutism. * Also called “burned out” schizophrenia. & most importantly is lasting less than 6 months (better prognosis). This is schizophrenia. gr&iose. * While working in a ψ unit. disorganized speech. This is schizophrenia. Will not have pos sx. poor contact w/reality. He also presents w/ loose associations & frequent derailment. or the woman who broke into Brad Pitt’s house & was found wearing her sneakers & sweatpants then at the trial when being taken away said “Don’t worry Brad. delusions. he believed his wife was trying to poison him & get his money. Pt meets schizophrenia criteria but does not meet criteria for a specific type. she began to act strangely 3 months ago. She began wearing a hard hat to work & when asked why. * Sx include mood d/o & schizophrenia. You learn she was hospitalized many yrs ago because she believed others were reading her mind & sending her messages. jealous. These Pts do not have impairment in level of fxning. * Mr. she stares at the wall & stays in a fixed position until the group ends. He denies any hallucinations. * Use antipsychotic medications for 3-6 months & individual psychotherapy. * A psychiatrist evaluates a 19yo male after the young man complains to his friends of hearing voices that ask him questions & talk to him. When asked what the voices talk to him about. This is delusional d/o. you notice a 43yo female who has been hospitalized for many yrs due to mental illness. Her mood is described as euphoric & her affect labile. . somatic. Answer is schizophreniform d/o (less than 6 months). she had to be escorted out of the room because she started to argue w/ others whom she believed were controlling her mind. which he believes are due to the poison in the food. His wife. While on the ward. Smith has been married for approximately 10 yrs & during most of those yrs. social & occupational dysfxn. This is schizophrenia. residual type. * Term “waxy flexibility” is for catatonic Pts who you can move into positions & they will stay that way.* Disorganized type will be “strange” in all aspects. meaning no psychomotor disturbances. Sometimes called a “wastebasket Dx. When asked why. does not underst& her husb&’s logic since she has more money than he does. * “Tasmanian devil” is similar to catatonic type. On several occasions. He frequently complains of stomach pains. she cannot focus on one topic at a time & frequently jumps from one topic to another.” * Most common type of delusional d/o is persecutory. Answer is schizoaffective d/o.” * Prognosis: major Depn > schizoaffective > schizophrenia * Tx for schizoaffective d/o involves antipsychotics (first) & antidepressants (second).

complicated medical hx. you observe her to be dressed bizarrely & laughing inappropriately. grossly disorganized behavior. * A 35yo female Chinese immigrant is brought in by neighbors after she was found w&ering in the streets yelling out someone’s name. or fluphenazine diaconate. * Somatization d/o affects women more than men. such as once a month. * Typically. This is brief psychotic d/o. * Commonly a/w major Depn. * Pt will have a long. While in the waiting room.* If medical. but the side effects are worse.S. Since then. jerks. not medications. 4 pain. & drug d/o. histrionic. she is unable to give a clear explanation but insists that what she is saying is true. won’t go out for fun because they are going to the hospital to get tests or procedures. could be weakness. She believes that the neighbors are putting poisons in her food & want to kill her. & 1 sexual. “regular office visits. Sx last 1 day but less than 30 days. not schizophrenia (more than 6 months). sees bad things & becomes blind). myasthenia gravis. don’t have many friends.” * Tx of choice is psychotherapy. * If her sx do not improve w/in the next week. * Somatization d/o is a Pt w/ multiple physical sx affecting multiple organs. Pseudo-SZ may be seen. antisocial d/o. . Pt has brief psychotic d/o. * Tx is to rule out medical problems or hospitalize if they are making threats. these are Pts who have experienced a stressor & will usually have sx involving either voluntary muscle or sensory control (hears bad news & becomes deft. conversion d/o. don’t give false hope. These are difficult to tx. While in the waiting room. 2 GI sx. SLE. call in sick. she appears to be responding to internal stimuli. inversely related to SES. She appears disheveled & grossly disorganized. * Brief psychotic d/o has hallucinations. * Primary gain: keeps internal conflicts outside Pt’s awareness. Again. She states that the voice in her head told her it is true & that you should stop asking questions. her behavior started 3 weeks ago after she was involved in a car accident. * Tx involves having a single identified physician as the primary caretaker (minimize referrals). Basically they will have everything on a review of systems w/o you prompting them. The answer in somatoform d/o is never telling the Pt “there is absolutely nothing wrong w/ you” because you are never absolutely sure. * Voluntary muscle d/o is usually paralysis. they will think you’re a bad doctor & go elsewhere. she has been following the neighbors for several days & harassing them at work. thyroid. disorganized speech. When asked why. ------------------------------------------------------------------------------------------------------------------------------------------Somatoform D/o * A group of d/o characterized by the presentation of physical sx w/ no medical explanation(s). * These Pts miss work. * DDx includes MS. * Tx also involves limiting visits. get fired. they will still not be injured due to their blindness. * Pharmacotherapy & individual psychotherapy to gently confront the Pt’s delusions. The sx are severe enough to interfere w/ the Pt’s ability to fxn in social or occupational activities. * Identification/modeling: Pt usually models their behavior on someone who is important to them. * Need 8 sx. Pts will get haloperidol because it works fast & comes in IM preparation. * A/w passive aggressive. not haloperidol. delusions. Will likely have interpersonal & psychological problems. tics. if the Pt is blind. * If you find nothing on the exam or w/ tests. female relatives tend to have histrionic personality d/o. * Brief psychotic < 1 month < schizophreniform < 6 months < schizophrenia * Tx for brief psychotic d/o is hospitalization & antipsychotics or BZDs for agitation. clozapine. personality d/o. Answer is schizophreniform d/o. * Secondary gain: benefits received from being sick. * A 23yo female was seen today after she complained that her neighbors were talking about her. * Conversion d/o is a d/o in which the individual experiences on or more neurologic sx that cannot be explained by any medical or neurologic d/o. * La belle (“the beautiful”) indifference: Pt seems unconcerned about impairment. * Ex: woman slapped by husb& & two hours later she cannot move her legs. 1 pseudo-neurological. witnessed the death of her 3yo son. lorazepam. male relatives tend to have antisocial personality d/o. usually begins by age 30. seen in lower SES. * Important note about conversion d/o. AIDS. which of the following is she at greatest risk of developing. You learn that she arrived in the U. In the hospital. several days ago & upon her arrival. Which of the following is most indicated in the Mgmt of this Pt? Answer is risperidone. According to the neighbors. condition in either limbic system or basal ganglia.

e. * Sx include preoccupation w/ diseases despite reassurance. * All tests return negative.” “cats have 5 legs”). there were numerous episodes recorded on the monitor. schizophrenia. Pts tend to accuse doctors & threaten litigation. So there is no conscious sx production or sx motivation. * Tx is individual psychotherapy. It used to be called Munchausen disease. * Pts w/ somatoform d/o do not know they are the cause of their problems. both sx production & motivation are conscious. I know I have a brain tumor. ------------------------------------------------------------------------------------------------------------------------------------------Factitious & Malingering D/o * Factitious d/o is a d/o characterized by the conscious production of signs & sx of both medical & mental d/o. * Hypochondriasis is a d/o characterized by the Pt’s belief that he/she has some specific disease. narcissistic personality d/o. * Tx is Mgmt & must be aware of countertransference. These Pts are not trying to lie to you. put foreign objects anywhere. schizophrenia. “Doctor. sx are unconscious. antisocial personality. OCD. Are preoccupied w/ pain. * Discussion of probably psychological origin of the pain w/ the Pt early in the tx. * Somatization Pt will bombard you w/ sx. nerve blocking. * Seen more frequently in women. 4th & 5th decades of life. As far as the Pt is concerned. * Body dysmorphic d/o is linked to serotonin. . * Pain in one or more anatomic sites (HA. * DDx includes other somatoform d/o. individual psychotherapy (best). * Become angry when confronted (i. However. * Hypochondriasis seen mostly between ages 20 & 30. basal ganglia disease. such as claiming whiplash in a minor crash to sue insurance company or get disability. backache) & is distressing to the Pt. * Sx motivation means the Pt knows what is driving the sx forward. shortly after her mother’s visit. “the sky is red. lasts at least six months. delusional d/o. * Gain might be money. histrionic personality d/o. it is not considered ethical. * DDx includes brain damage. TCAs. Hx reveals childhood abuse. * Body dysmorphic d/o is a Pt who believes some part of their body is misshapen. * Pain d/o is a d/o in which the presence of pain is the Pt’s main complaint. biofeedback. The mother was given an apnea monitor to take home & when she returned there were numerous episodes registering on the monitor. Another option is amobarbital (Amytal) interview. * Giving Pts placebos is not allowed. Some plastic surgeons will have a Pt fill out questionnaires. tumors. Many are depressed.” Even if CT is negative. & so on. optic neuritis. inject themselves w/ insulin. so tx is SSRIs & individual psychotherapy. malingering. * These Pts will do horrible things. hypochondriasis Pt will look at big picture. there were no episodes registering on the monitor. & Ganser syndrome (near miss answers. * These Pts will do things like sticking their finger to put blood in their urine. * Factitious d/o (Munchausen) by proxy are sometimes found out when hospitals have hidden cameras in the Pt’s room. Unconsciously. * In factitious d/o. sx production is conscious but sx motivation is unconscious. or pharmacotherapy (SSRIs. anorexia. don’t confront these Pts).meaning they won’t walk into walls or trip on things. they are convinced they are blind. * A 2yo girl is hospitalized after the mother complained she had multiple episodes of apnea in the middle of the night. antidepressants. * These Pts end up in plastic surgery many times. * Goal of Pts w/ factitious d/o is to be in the hospital & will do anything possible to be admitted. drug use. not delusional.” * DDx includes dementia. they’ll go elsewhere for the MRI/tests. since no matter what is done the Pt will come back thinking there is something wrong w/ them which leads to malpractice lawsuits. “Truth serum. they are not trying to deceive you. MAOIs). hypnosis. * Tend to have long hx of surgeries & medical admissions. swallow ground glass. give themselves infections. * Seen more commonly in men & tend to be hospital & health care workers. or defective. men & women equally affected. * May have a gridiron abdomen from the multiple surgeries. Well-known case of a mother injecting fecal matter into her child’s IV. they truly believe they are blind. * Sx are not faked. abnml. In the hospital. * Sx production means the Pt knows where the sx are coming from. Typically dem& tx in the hospital. schizophrenia. This is factitious d/o by proxy. * In malingering d/o. these are true sx. malingering. factitious. * Tx is psychotherapy. * Malingering is characterized by the conscious production of signs & sx for an obvious gain. I have blurry vision.

systemic desensitization. “I made a mistake. set off the alarm. mild retardation. & not confront the Pt. not a trial of lorazepam. hx may include SZ/head trauma. * Tx is insight-oriented psychotherapy. limbic system or testosterone abnmlities. ashtrays. She calls your service every night & dem&s you call her at home. Neighbors have observed him in the past starting fires in his own backyard. * Systematic desensitization is the therapy of choice for phobias. the act is out of proportion in regard to the stressor. * Pyromania is a d/o characterized by deliberate fire-setting on more than one occasion. & problems w/ marriage & law. & low levels of 5HIAA. pharmacotherapy. ------------------------------------------------------------------------------------------------------------------------------------------Impulse Control D/o * Impulse control d/o are a group of d/o in which Pts are unable to resist an impulse. going from least anxiety to most anxiety. * Risk factors are men in prison. tingling in her fingers. SSRIs. factory. an ego-syntonic d/o. * Pts may set a little fire. & requiring more than 100 stitches. This is kleptomania. Tend to show resentment toward authority figures/parents. She routinely goes to the Emergency Department when she knows you are in the hospital. * Important note. . * When Pt has the urge to steal something. hx of EtOH use. Answer is schedule regular office visits. EEG tends to be nml. “he took my potato chips. When asked why the man assaulted the other Pt he replied. big deal. * 25yo woman has a hx of over 20 arrests for stealing small items. large dose). * In this d/o. She schedules appointments to see you on a regular basis as well as irregularly. they can practice relaxation techniques. double vision. In pyromania. This is ego-syntonic (no remorse). then practices relaxation techniques to make it through each of the levels until all levels are mastered. & beta-blockers (for chronic violence. Pt claims chest pain. Main difference is how we feel about ourselves once we engage in the act. may be a/w mood d/o. thus these d/o may involve violence. not tell the Pt nothing is wrong w/ her. Pt gives a hierarchy of fear or anxiety. * The police recently arrested a 24yo ψ inPt after he beat up another Pt. & watching them burn. Her frequent complaints include HA. & eating d/o. weakness in her arms & legs. Up to 1/4 of Pts w/ bulimia nervosa have kleptomania. * Both impulses & compulsions are meant to reduce anxiety. brain disease. torching business for insurance claim).” Compulsions are ego-dystonic. All of her medical workup has been negative so far. * In arson. * Kleptomania is a d/o characterized by the recurrent failure to resist impulses to steal objects that the Pt does not need. * More common in women. DDx includes epilepsy (episodes of violence). tend to complain a lot. * Systematic desensitization involves replacing anxiety w/ relaxation. meaning you feel awful that you had to come back home to check if the stove was left on or awful that you have to wash your h&s w/ bleach. malingering. hearing voices. & watch the fire trucks come. * Psychotherapy should be done in a group setting. Allow the physician-Pt relationship to work. fire is set for monetary gain (e. & palpitations. napkin rings. * A 45yo female presents to your office & dem&s to be seen immediately. Impulses are related to serotonin. causing severe injury to the other Pt’s head & neck area. * Intermittent explosive d/o is characterized by discrete episodes of failure to resist aggressive impulses that result in serious assaultive acts or destruction of property. staring at them for hours. behavioral therapy. * Are preoccupied w/ the rewards instead of getting rid of the sx. * Neurological exam may show soft signs. antipsychotics. burning on urination.* Another gain is shelter & food (hospital). may have poor work hx. mental retardation. * Risk factors for pyromania are men > women. mania. She comes from a wealthy family & her parents do not underst& her behavior. * DDx for kleptomania includes antisocial personality d/o. OCD. shortness of breath. * Impulses are ego-syntonic. * Most express subjective sx. * A 19yo mentally retarded boy is arrested after he is found setting the neighbor’s garbage cans on fire. * Affects men > women. Which of the following would be the next step in the Mgmt of this Pt? Answer is somatization d/o. Key point is that the Pt does not need the objects. wanting to kill self. psychological test may be nml. & military settings. & more.g. tend to exaggerate the complaints. I’ll try again tomorrow. Many become sexually aroused by fire. * Tx includes anticonvulsants. At home she has numerous salt & pepper shakers. sx may be linked to stress. one must avoid confronting the Pt. may be genetically linked.” This is intermittent explosive d/o. schizophrenia. fire is set to relieve anxiety or get pleasure.

father of two. attempts to stop gambling &/or to win back losses. depressive d/o. Meaning. & maybe dermatologist consult & wig. probably both. Individuals are mistrustful & suspicious of the motivations & actions of others & are often secretive & isolated. fearful) * Personality d/o are ego-syntonic. * Personality d/o are the product of the interaction of inborn temperament w/ subsequent developmental environment. * Mary. * May have associated head banging. this Pt has bulimia nervosa. * Mike is a 40yo married man. & preexisting . Alopecia areata is loss of hair at same time. schizophrenia. Answer is kleptomania. A physical exam reveals an intestinal obstruction (bezoar). so clear & clean bald spot. EtOH dependence. * Tx is gamblers anonymous (GA) & pharmacotherapy. * Risk factors include innate temperamental difficulties. Which of the following impulse d/o is she at risk for developing? So. “I’ll bet you $10 Joe will say…” * More common in men. is rushed to the hospital after she complains of severe abdominal pain. who was fired from his job due to embezzlement (theft) of company funds. * Tx is behavioral modification techniques. * You must be 18 or older to be given the antisocial personality d/o. The obstruction is due to eating her hair (not all do this). OCD. may be linked to mood d/o/OCD/ADHD/agoraphobia. illegal acts to finance the gambling. tinea capitis. nail biting. * Trichotillomania is a d/o characterized by pulling one’s own hair. These Pts have been doing this their whole life & usually don’t think there is anything wrong. or loss of relationships due to gambling. thus do not want to have tx. These are pervasive & inflexible. obsessive-compulsive personality d/o. They are emotionally cold & odd. W/ trichotillomania there will be irregular bald spots (short broken hairs along w/ long hairs). He disappeared w/ the company payroll cash. dissociated sx. anything that is gratifying. preoccupation w/ rejection. * Tend not to give personality d/o Dx among adolescents. & is missing lots of hair from her scalp & eyebrows. Weird. adverse environmental events. emotional) * Cluster C: Anxiety. a need to gamble w/ more money. & factitious d/o. * Pharmacotherapy includes SSRI since this d/o is linked to serotonin. people do not want to get rid of it. Under 18. She has numerous calluses on both fingers. preoccupation w/ criticism or rigidity. His wife left him two months ago & he has not seen his wife or children since then. * This affects women more. * More women tend to have borderline & histrionic personality d/o. when found he did not have the money on him & admitted to losing it while gambling. Use of mood stabilizers & antidepressants is sometimes useful for Cluster B personality d/o. * Tx may involve putting Pt in prison (& hoping they don’t set the prison on fire). may be predisposed by death. * DDx includes brain dysfxn. * A 22yo woman was recently seen at her college graduation hoarding food in her purse & briefcase. * DDx includes alopecia areata. She appears thin. a/w OCD. * These Pts will appear overconfident (“I’ve got the sure win”) & may commit suicide after losing. This is trichotillomania. When asked why she replied. This is very similar to alcoholism. “Wild” (dramatic. “Weird” (odd) * Cluster B: mood lability. * Pathologic gambling is a d/o characterized by persistent & recurrent gambling behavior that includes a preoccupation w/ gambling. divorce. Intensive & long-term psychodynamic & cognitive therapies are tx of choice for most personality d/o. ------------------------------------------------------------------------------------------------------------------------------------------Personality D/o: Cluster A * Paranoid personality d/o involves distrust & suspiciousness. Worried: * Cluster A: peculiar thought processes.* This d/o is very difficult to tx. Wild. w/drawn. may be predisposed by poor parenting. ------------------------------------------------------------------------------------------------------------------------------------------Personality D/o * A personality d/o is a maladaptive pattern of behavior. it is unknown if this is genetic or environmental. There are three clusters. brief episodes of psychosis w/ persecutory delusions. pharmacotherapy. * Tx is psychotherapy. conduct d/o. & gnawing. mania. it is conduct d/o. “I might be hungry later. Associated features include social isolation. inappropriate affect. “Worried” (anxious. a 20yo woman.” She appeared to be of average height & weight but w/ poor dentition. * Most commonly affected area is scalp. antisocial personality d/o. * More males tend to have antisocial & narcissistic personality d/o. * Pt may attempt to make bets during simple conversation.

sexually seductive. Have short-lived psychotic episodes. conduct d/o). mood swings. & duration. ------------------------------------------------------------------------------------------------------------------------------------------Personality D/o: Cluster C * Avoidant personality d/o is characterized by lack of social inhibition. If you criticize someone & they freak out (sensitive).20 * Narcissistic personality d/o usually characterized by a sense of self-importance. superficial cutting). aggressiveness. Thus. Actors are prone to this personality d/o. Marilyn Monroe. including ideas of reference & persecution. * Borderline personality d/o Pt usually have a hx of child abuse. then is prone to Depn. Study Notes – Ψ James Lamberg 28Jul2010 DO NOT DISTRIBUTE . * Dependent personality d/o is characterized by submissive & clinging behavior related to a need to be taken care of. * Hallmark of this d/o is someone who is unable to conform themselves to the rules of society. odd preoccupations. If you criticize someone & they don’t care. Defense mechanism is projection. goes to restaurant alone. identity disturbance. * Borderline may use drugs. feelings of inadequacy. * Schizoid is basically a loner. & hypersensitivity to criticism. This person believes he/she is special. * Unlike schizoid personality d/o.g. Ex is doctor who introduces himself at a party as “Doctor Jones” when everyone is using first names. probably Dx is narcissistic. & inappropriate anger. uses physical appearance to draw attention to self. want to feel physical pain to know that I’m here. * Paranoid personality d/o may be seen in immigrants & deft Pts. impulsivity. Paranoid personality d/o fxn though the annoyance. shallow expressions of emotions. loses hair. goes to movies alone. & is interpersonally exploitative. They feel lonely & subst&ard. thought distortion. * Cluster C tends to have social phobias. * Schizoid is not afraid of being close. * Schizotypal. been like this all their life & can fxn. Individuals are emotionally distant.e. If stressed. they have peculiar patterns of thinking (“magical thinking”). reacts w/ rage when criticized. how they look. disregard for the rights of others. exaggerated behavior & excitable. * If you criticize someone & they get angry. may become psychotic. marked impulsivity. unstable relationships. is envious of others. eccentricity. They . They shy away from work or social relationships because of fears of rejection that are based on feelings of inadequacy. recurrent suicidal behaviors. Individuals are consumed w/ the need to be taken care of. 3 yrs ago). may say “I don’t feel like I’m alive” & thus may make suicidal gestures (e. Associated features include social drifting & dysphoria. * Narcissistic injury is when Pt starts to get older. * When differentiating paranoid personality d/o from schizophrenia. & preoccupation w/ fantasies of success. They are disinterested in others & indifferent to praise/criticism. (e. gets a little belly. look at level of fxning. They have clinging behavior & worry unrealistically about ab&onment. & illusions. ------------------------------------------------------------------------------------------------------------------------------------------Personality D/o: Cluster B * Histrionic personality d/o is usually characterized by colorful. requires excessive admiration. & are preoccupied w/ rejection. gambling). probably Dx is avoidant personality d/o. as are doctors & other respected professionals. They feel inadequate & helpless. however when they become stressed they will jump to the psychosis side & then back. lack of remorse. Schizophrenia will have a start point (e. lacks empathy. goes on vacation alone.g. & wears a giant caduceus chain around their neck outside their shirt to constantly advertise their status. & the individual is at least 18 yrs of age. These have occurred since the age of 15 (i. * Schizoid personality d/o involves detachment & emotionality. psychoses.g. probably Dx is schizoid. gr&iosity. & is uncomfortable in situations where he or she is not the center of attention. Personality d/o are long term. * Antisocial personality d/o usually characterized by continuous antisocial or criminal acts. gets “MD” or “DO” on their driver’s license. how they talk.sensory impairment. not afraid of rejection. not a job involving seeing customers. inability to conform to social rules. Schizophrenics basically don’t fxn. chronic feelings of emptiness or boredom. everything about them is bizarre. may have a job working at home or during night security. * Schizotypal personality d/o involves discomfort w/ social relationships. Main defense mechanism is splitting. Charo “cuchi-cuchi”) * Borderline personality d/o usually characterized by an unstable affect. & avoid disagreements w/ others. Individuals are socially isolated & uncomfortable w/ others. be very impulsive (alcoholism. & deceitfulness. hangs an extra stethoscope on their rearview mirror when driving. odd speech & affect. just happy being alone.

12% of total sleep time. (“s& man”). So there is more REM in the 2nd half of the night. Theta.” 25% of total sleep time. saccadic eye movements. OCD would be tx w/ pharmacotherapy. * NREM Stage 3: Delta wave. but will decline the promotion so they can be in a position where they are constantly told what to do. one could do a penile nocturnal tumescence test. * In REM. * NREM Stage 4: More delta wave. disappearance of alpha. * Associated features include self-doubt. * REM gets longer & longer as night progresses. poor independent fxning. It increases total sleep time. BATS Drink Blood: Beta. while the body is active. * REM has a “saw tooth wave. an absence of eye movements. they don’t leave when others would. * Norepinephrine decreases during sleep & is linked to REM sleep. Alpha. a separate d/o. expect tumescence during REM. the longest of all sleep stages. adolescent 8-10 hours/day. * DA agonists (e. * These Pts may get a promotion at work. so it may be called “delta sleep” or “slow wave sleep” or “deep sleep. Stages 3 & 4 tend to disappear in the elderly. there is a slowing of the EEG rhythms. perfectionism. They may be obsessed w/ work & productivity.” It will be the most difficult to wake someone who is in stages 3 & 4. * Acetylcholine increases during sleep & is linked to REM sleep.g. * Stages 3 & 4 has delta sleep. over conscientious. & are hesitant to delegate tasks to others. * Sleep latency is the time needed before you actually fall asleep. In OCD. basically everything decreases in the elderly. total sleep time decreases. mood d/o. & other personality d/o. Associated features include indecisiveness.g. This personality d/o should not be confused w/ OCD. you woke up from REM. thus not assuming a leadership role. * REM latency is the period lasting from the moment you fall asleep to the first REM period. * NREM Stage 2: Sleep spindles & K complexes. dreams. bromocriptine) will product arousal. Alpha is a “drowsy wave. The brain is inactive. They are often consumed by the details of everything & lose their sense of overall goals.usually focus dependency on a family member or spouse. * Mnemonic: at night. there is an aroused EEG pattern. * REM percentage decreases w/ age. However. * REM is the easiest to arouse. Beta. high muscle tone. * Dependent personality d/o a/w abusive relationships. * Mnemonic: S&. haloperidol) will . anally fixated) involves individuals who are preoccupied w/ orderliness.” 5% of total sleep time. If you wake up & remember a dream. & thought like mental activity. you were in stage 2. for neurotransmitters of sleep. generalized muscular atony (except middle-ear & eye muscles). & control. anxiety d/o. They are strict & perfectionistic. dysphoria (mood down). & desperately seek a substitute should this person become unavailable. anger. sexual arousal (erections). there is a relatively nml period then the problem. Stage 2 is the longest. ------------------------------------------------------------------------------------------------------------------------------------------Sleep Stages * Two major stages of sleep are rapid eye movement (REM) & non-rapid eye movement (NREM). you can differentiate by dreams. NREM decreases as well. adjustment d/o. * NREM Stage 1: Theta wave. & difficult interpersonal relationships. If you wake up & don’t remember a dream. infant may sleep 16 hours/day. Sleep spindles. Delta. a slow wave. 50% of this stage is delta. 13% of total sleep time. Typically less than 15 min in most individuals. * Other traits include being miserly & unable to give up possessions. DA antagonists (e. * In NREM. * NREM has 4 stages (stages 1-4). these d/o include Depn (about 60 min) & narcolepsy (about 10 min). * From infancy to old age. * To test for impotence. however it may be abnml in many d/o such as insomnia. & inflexible. It lasts about 90 min in most individuals. The first REM will be about 10-15 min & by the end of the night REM will last 20-45 min. * Serotonin increases during sleep & initiates sleep. * DA increases during sleep & is linked to arousal & wakefulness. social inhibition. several d/o will shorten REM latency. * Personality d/o are tx w/ psychotherapy. 45% of total sleep time. People w/ obsessive-compulsive personality d/o are able to fxn. * Obsessive-compulsive personality d/o (anal-retentive. Waking up in the morning occurs out of either REM or stage 2. excessive humility. & the brain is active w/ the body being inactive. * People w/ OCD do not fxn well. Turkey & milk have tryptophan. * Tryptophan is a precursor to serotonin.

* Hypnopompic speech refers to waking up & babbling nonsensically for a short period. * Cataplexy is the pathognomonic sign. * In a Pt w/ insomnia. & less than 8 hours of sleep. where the Pt is awake but unable to move. Thus. The most common sx is the “sleep attacks. * BZDs suppress stage 4 &. * In EtOH or barbiturate withdrawal. Meaning. This is why BZDs should not be given for more than 2 weeks. we would expect to see many REM periods. * Stages 3 & 4 decrease as the night progresses. more awakenings. it could say the man crashed his car after leaving a bar & the police noted EtOH on his breath. * Bottom of chart is deepest sleep. * Each of the shaded blocks are REM periods. If short episode. * Pts report falling asleep quickly at night. It may also include medications. we would expect to see a shift of the REM latency way to the left. His friends reported occasions when he fell asleep during dinner & during conversations w/ him. about 90 min. the Pt remains awake. hypnopompic occur on awakening. Cataplexy does not involve a loss of consciousness. * A common hypnopompic hallucination is dreaming that you fell off a building then waking up startled. we would see insomnia & thus ↑ sleep latency. consisting of a sudden loss of muscle tone. the Pt goes into REM w/in 10 min so the first REM cycle will be near the beginning. the change we would expect on the sleep architecture chart is an ↑ sleep latency.decrease arousal (produce sleep). * In EtOH or barbiturate intoxication. the Pt feels refreshed. * If you haven’t slept in a long time & are very tired. suppresses the delta wave (stages 3 & 4). there is more REM later in the night. * Tx involves forced naps at a regular time of day. psychostimulants are . The note about feeling refreshed is the clue that this is narcolepsy & not alcoholism. you might have a dream as soon as you fall asleep. * HypnaGOgic occur when the Pt GOes to sleep (most common). * Cataplexy is differentiated from syncope because syncope involves a loss of consciousness on top of the muscle tone loss. * In BZD withdrawal after chronic use. the very first part (the awake portion) will be ↑. which may have been precipitated by a loud noise or intense emotion. a disappearance of the delta portions of the graph. Pts feel refreshed upon awakening. * As shown. His friends report he has been fired from numerous jobs because of falling asleep on the job. * In a Pt w/ Depn. * Barbiturate (& EtOH) withdrawal causes REM rebound.” seen in 80% of Pts. * Sleep paralysis most often occurs during awakening. * Narcolepsy is a d/o characterized by excessive daytime sleepiness & abnmlities of REM sleep for a period of > 3 months. ------------------------------------------------------------------------------------------------------------------------------------------Sleep Architecture * Top of chart (shown) is awake or lightest sleep. REM sleep occurs in less than 10 min. when used chronically. we would expect to see few (if any) REM periods. he did not remember the cause of the accident & had just had his license suspended. ------------------------------------------------------------------------------------------------------------------------------------------Sleep D/o * A 35yo man was recently hospitalized for the 10th time after he crashed his car into a post. so if we are sleep deprived your brain will cause more of those stages. * EtOH (& barbiturate) intoxication suppresses REM. This is narcolepsy. causes multiple awakenings. In reality. * The question may not be as straightforward. * From awake to stage 1 is sleep latency about 15 min. REM & stage 4 are very important. * From stage 1 to first REM is REM latency. Your body is trying to make up for the lost REM time. delta. Chronic alcoholism will constantly suppress REM. these people may be on the drug chronically. * Major Depn shortens REM latency. For ex. Upon awakening. * Hypnagogic & hypnopompic hallucinations are a/w narcolepsy. * In a Pt w/ narcolepsy. When questioned. increases REM time. They will therefore have poor work hx & may have a revoked drivers license. the change we would expect on the sleep architecture chart is a ↓ REM latency. * These people can fall asleep at any time. & causes early morning awakening. stages 3 & 4. His license has been suspended. increase sleep latency.

such as the TCAs. middle-aged men. he reports feeling tired & waking up w/ a dry mouth & HA. * Tx for night terrors is rarely required. What you’ll find is most Pts are actually sleeping through the night. * Typically a/w some form of anxiety or anticipatory anxiety (e. get out of bed. These occur in stages 3 & 4. During the day he is tired & falls asleep during his classes. * TCAs are REM suppressants. mood changes. but not a tx. At night he lies awake & imagines himself doing poorly on the exam & failing medical school. OCD. they may just have sleep problems. & go back to bed w/ no memory of the event in the morning. TCAs are preferred. seen more frequently in women. nasal. So. For obstructive. * Most commonly prescribed medication for the elderly (since insomnia is most common) are BZDs. * Ex: an elderly Pt saying they have insomnia but when asked they say they wake up often in the middle of the night to urinate. * Tx for central sleep apnea is respiratory stimulants (medroxyprogesterone). Go to living room to read.” occurring during REM. This can be lethal. ------------------------------------------------------------------------------------------------------------------------------------------Parasomnias * Nightmare is a “bad dream. * If you wake up a sleep walker. bed/wake at same time). there may be more than 300 episodes in a night. sometimes a/w Depn. This is insomnia. * Most Pts w/ insomnia have the insomnia due to something else. such as rearrange living room or cook food. & daytime sleepiness. or tonsil obstruction. if you’re lying in bed & can’t fall asleep. or worry. BZDs could be used. They wake up in the middle of the night. * Predominant complaints in difficulty initiating or maintaining sleep. * Tell the Pt to put a journal next to their bed & write down every time they wake up during the night or early in the morning. & tx is rarely required. * Most people who complain about insomnia do not actually have insomnia. * Tx of sleep apnea is tx the underlying condition. * An overweight man reports having difficulties in his marriage because of his snoring at night. Spouses typically complain of partner’s snoring & of partner’s restlessness during the night.g. This is sleep apnea. or sleep w/ the air conditioner on. Depn). scream. They increase during times of stress & about 50% of population tends to have nightmares. you should really be looking at their prostate instead of giving BZDs. * Usually seen in obese. but once your brain knows the bed is for sleeping. * Obstructive sleep apnea is muscle atonia in the oropharynx. During the day.g. Tx the underlying d/o first. then wakes up in another location such as living room or someone else’s bed. Answer is not tell the Pt to work out at night. What should you tell this Pt? Answer is to adjust the schedule. Cataplexy is the beginning of REM. * Night terror is seen commonly in young boys. Considered pathological if Pt has 5 or more episodes an hour or more than 30 episodes during the night. & there is frequent yawning & tiredness during the day. Depn. before a big exam). * Tx is to consider good sleep hygiene techniques (e. * While studying for an important exam. * Sleep apnea is cessation of breathing for more than 10 seconds occurring at night. Pt goes to bed in own bed then gets up during stages 3 or 4 (unknowingly) & may do some activity. If you get drowsy in the living room. It will take some time for this to work. Myth is not to wake up sleep walker because . Don’t read in bed. involves saying a few words. * Tx could involve suppressing REM. a second yr medical student has been unable to sleep for the past several days. * Central sleep apnea is lack of respiratory effort. Cataplexy can be tx w/ antidepressants.preferred. such as anxiety. * Sensation of not falling asleep is the most common complaint in the elderly. We can have memory of our dreams. give BZDs. * Most Pts receive continuous pos airway pressure (CPAP) device. * 70yo Pt complains he sleeps 7pm to 3am every day. In severe cases. tongue. * Insomnia is a d/o characterized by difficulties in initiating or maintaining sleep. tell the Pt to drink less coffee. * Tx of choice for insomnia is stimulus control. so tell the Pt to go to bed later as 8 hours is nml. sometimes w/ eating d/o. * Other conditions include PTSD. & eating d/o.g. behavioral modification techniques such as stimulus control. weight reduction or surgery. you will fall asleep when you lie in bed. affects the Pt’s level of fxning. elderly should not be given BZDs because it increases confusion & disorientations. EtOH does too. However. * If due to a ψ d/o (e. they will be disoriented & confused. Mixed is central that prolongs as the airway collapses. * Sleep walking (somnambulism) occurs in stages 3 & 4 (NREM). go to bedroom. & medications such as BZDs (for a short period of time). * Sleep talking is seen in children.

mutual masturbation. No difference in the sexual practices from those exhibited by heterosexuals. or asexual (no sex). established by the age of 3. it doesn’t mean they are homosexual. * Sexual arousal d/o include female sexual arousal d/o & impotence.” * Gender role is based on the external behavioral patterns that reflect the person’s inner sense of gender identity. has three kids. 2-6% of females. * Recent studies indicate homosexuality may be due to genetic & biologic causes. prisoners will have sex w/ same-sex partners but are not homosexual (“down low”). Some men believe the vagina has teeth (vagina dentata). likely due to narcolepsy. & secondary sexual characteristics. bisexual (both sexes). Ex is man married for 10 yrs & has never had sex. * It is considered a variant of human sexuality. * Greater incidence among monozygotic versus dizygotic twins. Most homosexuals report feelings toward same sex individuals since adolescence. hormonal characteristics. & the elderly. * Equal incidence of mental illness & pedophilia when compared w/ heterosexuals. * These d/o are triggered by religion. Which of the following is the most likely Dx. * Exceptions (nml during adolescence) are visual comparisons of genitalia. such as external & internal genitalia. Sexual therapy should almost always be couples therapy. group exhibitionism. Freud believed it was an arrest of psychosexual development. etc. & is currently believed to have been determined by parents. * As puberty arrives. He has missed several days of work due to this problem. & kissing. * Masturbation is considered excessive only if it interferes w/ daily fxning.they become violent.6% of white males aged 20-35 were given a rating of 3 for this period of their lives. . * Homosexuality was removed from the DSM in 1980 as a mental illness. Commonly seen among adolescents. were given a rating of 5 & 1-3% of unmarried females aged 20-35 were rated as 6. a reason for sexual aversion. Will not initiate sex but may be willing when pressured by her spouse. meaning the child only thinks about kissing or sexual activities w/ members of the same sex. biological. some people can commit violent acts while sleep walking. * D/o of the desire stage are the hypoactive sexual desire d/o & the sexual aversion d/o. ------------------------------------------------------------------------------------------------------------------------------------------Human Sexuality * Sexual identity is based on the person’s sexual characteristics. arousal. “Gender has nothing to do w/ the package we came w/. These d/o can be psychological. h&holding. * Sexual aversion d/o is someone who is completely repulsed by sex. * Only way to tell if child will be homosexual is to get information about the child’s fantasy life. However. guilty feelings about sex. Also. & pain. aged 20-35. * 11. or both. not a pathologic d/o. upbringing. sexual interest peaks & masturbation increases. If someone had a thought or a homosexual experience. * Masturbation is a nml precursor or object-related sexual behavior. * What is the tx of choice for insomnia? Answer is behavioral techniques. * Hypoactive sexual desire d/o is someone who has sex once in a while but it is not something they want to do. This is untrue. such as BZDs. * Males learn to masturbate earlier than females & tend to do it more often. * An overweight male of average height presents to his doctor’s office complaining of feeling tired during the day. homosexual (same sex). All men & women masturbate. Answer is sleep apnea. Ex is a woman who is married for 10 yrs. * Which of the following is the most likely explanation for a young man suddenly falling down but not losing consciousness? Answer is cataplexy. * Kinsey Scale is a 0-6 scale w/ homosexuality on one (0) & heterosexuality on the other end (6). Adolescents will have sexual fantasies while masturbating. orgasm. * Tx is to suppress REM. * Tx is sexual therapy. such as stimulus control. * Gender identity is based on the person’s sense of maleness or femaleness. & include desire. has had sex 10 times. ------------------------------------------------------------------------------------------------------------------------------------------Sexual Dysfxn * Sexual dysfxn is a group of d/o related to a particular phase of the sexual response cycle. * Genital self-stimulation begins at the age of 15 to 19 months. It may be heterosexual (opposite sex). * Sexual orientation is based on the person’s choice of a love object. married couples. no sexual fantasies are present then. Male-male relationships may be less stable than female-female relationships. * 7% of single females aged 20-35 & 4% of previously married females aged 20-35 were given a rating of 3 for this period of their lives.

he would w&er the subway station & rub himself up against women as well as expose himself to women who were nearby. fantasizing. etc. thus you test for erections at night during REM. religion. “flasher”). If organic. or the postage stamp test. either as he enters the vagina or just before he enters the vagina. then stop. anxiety about sex. They usually focus on humiliation &/or suffering. because then it would be due to organic causes. * If pain during intercourse is due to medical reasons or lack of lubrication. * Want to know if this impotence is organic or psychological. What happens is that it will be longer & longer until ejaculation. as part of a prison sentence). Tx is teaching Pt how to achieve orgasm. the use of nonliving objects. not because they sought tx willingly. The most common cause is anxiety about the sexual experience. he stops. guilty feelings about sex. previous rape. * Exhibitionism is a recurrent urge to expose oneself to strangers (e. there will be no erections at night. it is not called dyspareunia. ------------------------------------------------------------------------------------------------------------------------------------------Paraphilias * Paraphilias are a group of d/o that are recurrent & sexually arousing. Dyspareunia is pain during intercourse. then start. * Impotence is now called erectile dysfxn (ED). & use of toys such as a vibrator. there may be multiple paraphilias so if the Pt reveals one then inquire about others. shoes). These are the SSRIs or clomipramine. * A good majority of the Pt who get tx for the paraphilias are forced into tx (e. then stop. * Paraphilias more commonly affect men. * Orgasmic d/o include the female orgasmic d/o & premature ejaculation. All of these activities produce great pleasure to the Pt. * If pharmacotherapy is used. * Tx of choice for vaginismus is use of dilators & couples therapy. . Typically occur for more than 6 months & are usually distressing & cause impairment in the Pt’s level of fxning (e. panties. This is common among paraphilias. pick one w/ delayed ejaculation. when one foregoes all other sexual acts & the only thing that works for arousal is one of these paraphilias (humiliation. * Pain d/o include dyspareunia & vaginismus. Impotence is inability in attaining or maintaining an adequate erection until completion of the sexual act. Causes include guilty feelings about sex. * A 20yo man was caught outside his neighbor’s window looking in as she disrobed. * The stop-&-go technique is when the man is thrusting & when he is about to ejaculate. previous abuse. * Postage stamp test is get a roll of stamps & adhere to penis. Then you start again. non-consenting partners) then there is a problem. * It is a fetish only if the object must be present for the person to become aroused or achieve orgasm. * Premature ejaculation is male ejaculation before he wishes to do so. * Causes of dyspareunia include upbringing. cynics will say that women have “a way out” such as working at a strip club. Before his arrest. quitting work). etc. Then the partner stimulates & the man squeezes. Female orgasmic d/o is a woman who cannot achieve orgasm. * Tx is retraining the Pt via the stop-&-go technique &/or the squeeze technique. high SES women. including anatomy. not ψ. * As mentioned.g. However. man opening trench coat. * Tx involves individual psychotherapy to help the Pt underst& the reason why the paraphilia developed. * A/w men who are less experienced sexually & w/ men who have had the bulk of their sexual experiences w/ a prostitute or in non-romantic/hurried settings such as the back of a car. & involve non-consenting partners. peak between ages 15 & 25.g. which tests for nocturnal erections via a gauge connected to the penis that measures stretch. & there are intense urges to carry out the fantasy. & the frequency tends to decrease w/ age. there tends to be other paraphilias. * Sexual activity is usually ritualistic. * Exhibitionists tend to be men. if roll has been broken then one can assume there was an erection during the night. The Pt also becomes aware of daily activities & how they are related to paraphilic behavior.* Female sexual arousal d/o is women who have problems getting adequate lubrication. * Vaginismus is involuntary constriction of the outer third of the vagina. & so on. the fantasy is typically fixed & shows little variation.g. non-living objects. * The squeeze technique is where the partner stimulates the man & when the man is about to ejaculate he squeezes the gl&s of the penis. Most have a paraphilia before age 18. * Fetishism involves the use of non-living objects usually a/w the human body (e. * Testing is nocturnal penile tumescence test.g. * It is important to note that engaging in these activities along w/ nml sexual practices is not considered a major ψ problem. which eventually interferes w/ the act of sex.

This is gender identity d/o. take testosterone to deepen the voice. & may have surgeries to remove the penis & create a vagina. * The precise mechanism is unknown. Typically it is a nml looking guy who wears women’s panties under their clothes or goes home & puts on teddy lingerie. * Periodic impotence in a middle-aged man is most commonly caused by EtOH. prison sentence). a 5yo boy.* Frotteurism is a recurrent urge or behavior involving touching or rubbing against a non-consenting partner. & believe they were born w/ the wrong body. These Pts are convinced they are trapped in the opposite sex’s body. the most common paraphilia. * Transvestic fetishism is recurrent urges or behaviors involving cross-dressing. not cirrhosis. * Tx also involves extensive behavioral therapy. where the Pt is made to masturbate so much that they lose the desire to masturbate afterwards. When an adult has sex w/ a girl under the age of 13. such as aversive conditioning for pedophilia. was found in his mother’s bedroom wearing her clothes. * Some newer antipsychotic medications also block some serotonin receptors (5HT3). & many believe there are biological reasons such as hormones. “Peeping Tom. * They are preoccupied w/ wearing the opposite gender’s closes. etc. Ex is the person who likes to tie up their sexual partner. He prefers wearing dresses & hates being a boy.e. puts penis in a plastic bag. tuxedo. This is typically a man w/ gender identity as a man. * Medications used are anti-&rogens. which includes both prepubescent children & adolescent minors younger than the local age of consent. usually found in heterosexual men. not myocardial infarction. cause is unknown. The electric shock is not used these days. D4) receptors in the brain. not pleasurable. * What is the tx of choice for premature ejaculation? Answer is squeeze technique. * Typical transvestite is not the performer seen in movies or at clubs. * Voyeurism is recurrent urges or behaviors involving the act of observing an unsuspecting person who is engaging in a sexual activity. however antipsychotic medication (APM) blocks several populations of DA (D2. Cynics say women have an out because society does not see it abnml for them to wear a tie. * Pedophile is typically a male & there is typically an age limit. ------------------------------------------------------------------------------------------------------------------------------------------Psychopharmacology: Antipsychotic Medication * Antipsychotic medication is used to tx manifestations of psychosis & other ψ d/o. This is the earliest paraphilia to develop. Women may bind their breasts. He’s been observed going to the bathroom to urinate while sitting on the toilet while playing w/ dolls instead of his trucks & guns. disrobing. then goes to work. not EtOH. * Another tx is masturbatory satiation. These reduce the urge/desire to have sex. given in shots.” * Masochism is recurrent urges or behaviors involving the act of humiliation. Ex is the person who likes to be bound. or stop-&-go. have mastectomies. using pedophilia as someone accused of sexual abuse of a minor. * Aversive conditioning would involve the pedophile seeing slides of naked children then receiving an electric shock. * Sadism is recurrent urges or behaviors involving acts in which physical or psychological suffering of a victim is exciting to the Pt. * Ex is guy on way to work & takes the subway. likes to be gagged. but likes dressing as a woman. a property that may be . usually chooses a female sexual partner. The law enforcement definition differs. * Routinely request medications or surgery to change their physical appearance. * Billy. * Which of the following is the most common cause of erectile dysfxn due to a medical condition? Answer is diabetes. * Most common psychological cause of impotence is fear of failure. it is called statutory rape (i. refuse to urinate sitting down (if girl) or st&ing up (if boy). then rubs on unknowing women on the subway & achieves orgasm w/in seconds. Men may have electrolysis to remove body hair & take estrogens to change the voice. * Part of the tx involves going to work as the opposite sex before sexual reassignment is performed. repeats. * Paraphilias are tx w/ behavioral modification techniques & medications. * Seen more frequently in men than women. but the idea is the paraphilia becomes painful. suit. ------------------------------------------------------------------------------------------------------------------------------------------Gender Identity D/o * D/o characterized by a persistent discomfort & sense of inappropriateness regarding the Pt’s assigned sex. Children prefer to have friend of the opposite sex. Ex is a 16yo boy w/ a girl that is younger than 13yo. using the toilet. the pedophile must be at least 16yo & 5 yrs older than the prepubescent child. * Pedophilia is recurrent urges or arousal toward prepubescent children. likes to be told to bark like a dog during sex.

can be dramatic & frightening to the Pt. * Acute dystonia presents w/ spasms of various muscle groups. * Pure D2 antagonists are the typical antipsychotics. pigmentation. useful for the tx of agitation & psychosis during mood episodes. * Blocking mesolimbic tract reduces psychoses. * Parkinsonism tends to be seen as slow volitional movement. * Since these block muscarinic receptors. Pt cannot sit still. Include low-potency (chlorpromazine) & high-potency (haloperidol) older medication. galactorrhea. * Risperidone has D2 blockade so it can cause movement side effects (extrapyramidal sx). * Akathisia is generalized restlessness. * APM used for other psychotic d/o. Acetylcholine shoots up & the Pt may be torticollis. seen w/in hours to days of tx. blurred vision. cataracts). This causes rigidity & stiffness. IM). * Tx for these dystonic rxns is anticholinergic medications (benztropine. acetylcholine is found at neuromuscular junction. * Typically. * Lorazepam (BZDs) is a common drug used in the Emergency Department for psychosis. & blurred vision. D2. * Parkinsonism more commonly seen in elderly. & nigrostriatal tract. acetylcholine is high. pick the medication w/ the least side effects for the elderly population. effective in tx psychoses & cognitive d/o due to general medical conditions & substance. Young men may be at higher risk.g. & pill-rolling tremor. amenorrhea).a/w ↑ efficacy. * Blocking of the alpha-receptors leads to hypotension. causing extrapyramidal sx (tremors. They may get oculogyric crisis. acetylcholine is low. * Adverse effects include sedation (histamine blockade). * Blocking of the histamine receptors leads to sedation & weight gain. or amenorrhea. D4. thus no gynecomastia. This is important for Pts who may have laryngeal spasm. * Blocking nigrostriatal tract increases movement d/o. have less movement side effects. & alpha-adrenergic receptors. * Multi-receptor antagonists are clozapine (D4. & anticholinergic sx (dry mouth. brief psychotic d/o. festinating gait. confusion). So. delusional d/o. * APM used for mood d/o. Can be a major contributing factor to noncompliance. * Clozapine blocks the mesolimbic tract selectively. Parkinsonian side effects.” “Thorazine shuffle. * The multi-receptor drugs. hypotension (alpha blockade w/ low potency APMs). schizophreniform d/o. bradycardia. 5HT2) & olanzapine or quetiapine (D2. urinary hesitancy. * Most commonly used tx are benztropine (Cogentin) & diphenhydramine (Benadryl) because they are available in injectable concentration (e. you get anticholinergic sx such as urinary retention. * Antipsychotic most likely to cause retinitis pigmentosa is thioridazine. diphenhydramine. dermal & ocular syndromes (photosensitivity. histaminic. constipation. * DA tracts are tuberoinfundibular tract. or amantadine). * Psychomotor agitation is an indication for high potency antipsychotics (haloperidol). * Acute dystonia is the first thing that can occur. * D2-5HT2 antagonists include risperidone. cardiac conduction abnmlities (especially thioridazine). Key signs include ↓ facial expression (mask-like facies). “Ants in pants. but should be avoided in the elderly as it can add to the Pt’s confusion. * When DA is high. * APM are the tx of choice for schizophrenia presenting w/ acute psychotic episodes & for prophylaxis against further episodes. 5HT2). * Thus. * Antipsychotics also variably blocks central & peripheral cholinergic. dry mouth. * In Parkinson’s. causing gynecomastia. & agranulocytosis specifically w/ clozapine (1% of Pts). . ↑ muscle tone. haloperidol is used over the other antipsychotics in an emergency situation because it comes in an injectable form. It will also not cause tremors or Parkinsonian side effects seen w/ nigrostriatal tract. akathisia). galactorrhea. Tx of choice is to lower dose or stop medication if needed. mesolimbic tract.” * Akathisia mistaken for anxiety or agitation. it’s the only one that you can give as an IM shot in the butt & calm them down. w/ an antipsychotic DA is dropped. * Other effects include endocrine (gynecomastia. galactorrhea. & resting tremor. where the Pt’s eyes roll up & cannot be brought down (10% of Pts). When DA is low. & other more rare psychotic d/o. amenorrhea. another reason to be careful in the elderly. DDx includes catatonic rigidity or apathy & withdrawal. which work on D4. * Blocking tuberoinfundibular tract increases prolactin. cogwheel rigidity. Pt has low DA thus high acetylcholine. Thus. trihexyphenidyl.

The Pt can stop the movements for a short time. * If a Pt presents w/ schizophrenia. It has minimal sedation & a small incidence of movement d/o in doses below 6mg. * For chlorpromazine. * Tardive dyskinesia is a chronic d/o & tends to be irreversible. then every two weeks. * Quetiapine was originally shown to be a/w cataracts. * Drooling (can be significant). potentially life threatening. ICU). Serious adverse effects include SZ (5% or Pts) & agranulocytosis (1% of Pts). & have few remaining indications. * Tardive dyskinesia (TD) is characterized by choreoathetosis & other involuntary movements. haloperidol lasts 4 weeks. * NMS is not a contraindication for restarting the drug at a lower dose. * CPK elevated into 1. typical low-potency is chlorpromazine. * Clozapine is the most effective antipsychotic for schizophrenia. or other confounding factors. thus can cause tremors & akathisia. Don’t worry about cost. * Tx of TD is to stop antipsychotic & switch to newer one. * Make sure you give a test dose to these Pts prior to giving the depot injection. atypical antipsychotics. * Older high-potency D2 medications have depot (deaconate) route for haloperidol & fluphenazine. stop antipsychotic & give either dantrolene or bromocriptine. Some new research is hinting that clozapine can reverse TD. Blood sugars will drop down after drugs are stopped.g. & psychotic d/o. e. or antihistamines.g. & remain useful for acute agitation (especially via IM route). you get little EPS but more anticholinergic. This is st&ard for the U. * This is seen on typical APM such as haloperidol. avoid in Pts w/ cardiac problems. abnml arm movements. * Seen when Pt is on medications for a long time. getting the new pills when their WBC results comes back. * So for ex. fluphenazine. * Risperidone works on D2 receptor. * Olanzapine & clozapine have been known to cause diabetes. olanzapine). Movements tend to disappear w/ sleep. have a low frequency of acute movement syndromes. .. But less if dose below 6mg. in some countries they check monthly & other countries they never check. Etiology may be a form of “chemical denervation hypersensitivity.* Extrapyramidal sx (EPS) can be tx w/ anticholinergic medications. * Fluphenazine lasts 2 weeks. Movements often occur first in the tongue or fingers & later involve the trunk. which are the most prone to getting cataracts. the guidelines say start atypical medications (e. Just pay attention to the guidelines. * Risperidone is a first choice medication for the tx of schizophrenia. The mechanism is unknown but may be due to significant weight gain. CPK is usually diagnostic. & ziprasidone are first choice medications for schizophrenia. There is no incidence of movement d/o but significant sedation & weight gain.” which is caused by chronic DA blockade in the basal ganglia. & characterized by muscle rigidity. higher frequency of acute movement syndromes. ------------------------------------------------------------------------------------------------------------------------------------------Psychopharmacology: Antidepressant Medication * Antidepressant medications (ADs) are used to tx mood. chlorpromazine. thioridazine. * Tx of choice is transfer Pt to medicine (e. less anticholinergic effects. Amantadine may exacerbate. adjustment. Thus. * Ziprasidone can cause prolongation of the QTc interval. & weight gain also are common. sedation. * Potency of APM is directly related to extrapyramidal sx & inversely related to anticholinergic effects. less hypotension. anticholinergic effect. but most will switch to another drug. * Olanzapine. meaning 3 to 6 months.g. hyperthermia. * Akathisia can be tx w/ propranolol. * Neuroleptic malignant syndrome (NMS) is fairly rare. You see tongue protrusion. cause more hypotension. especially when sedation is not tolerable. Tx for schizophrenia in non-complaint Pts. * Pt needs weekly WBCs for first 6 months. So. but significant adverse effects make it a second line medication. cause more anticholinergic effects. * Older low-potency D2 medications (chlorpromazine) are highly sedating. give haloperidol because it has less anticholinergic affects. Risk after 6 months. Pts here have to be in a national registry & are given medication week by week. * High-potency typical drug is haloperidol. quetiapine. BZDs. Elderly & female Pts are at higher risk. * There is no incidence of movement d/o w/ clozapine. autonomic instability. & delirium. lip smacking. no cataract link. * For 85yo agitated Pt. haloperidol will have more EPS but less anticholinergic. HMOs. however the research was flawed because the doses were very high & given to beagle dogs. * Older high-potency D2 medications (haloperidol) are less sedating.S. * NMS is usually a/ doses of high-potency antipsychotic medications.000s.

* SSRIs are first line due to side effect profile. * SSRI w/ slightly less sexual dysfxn is citalopram (Celexa). & must be matched to Pt preference & ability to tolerate. clinicians should generally prescribe in small quantities & only after determining the absence of suicidal intent. less severe w/ others. * Sedation lest severe w/ desipramine (Norpramine). d/o of impulse control. fluvoxamine (Luvox). & TCAs all tx Depn w/ the same efficacy. * Likely most common reason for stopping SSRI is anorgasmia. & anticholinergic effects. * The most common cause of drug failure is the physician not giving the medication an adequate trial. or if Pt cannot tolerate current AD. * If Pt comes in on week 2 & says they don’t feel any better. Answer is to switch to another AD. histamine. * MAOIs work by inhibiting enzymes (monoamine oxidase) that metabolize neurotransmitters. dry mouth. * The mechanism is currently believed to be an effect of the monoamine neurotransmission in the CNS through reuptake inhibition & modulation of receptor fxn. * Newer ADs should be considered first because of better safety profile. if Pt coming in on TCA overdose must be connected to a cardiac monitor (or serial ECGs). . MAOIs. maprotiline (Ludiomil) & bupropion (Wellbutrin). * Research was flawed w/ bupropion as it was tested in high doses on women w/ eating d/o. * SSRIs block the reuptake of serotonin neurotransmitter. & anxiety d/o such as panic d/o. bipolar d/o). & benign prostatic hypertrophy. urinary retention. AD meds work on same neurotransmitters. * When used to tx individuals w/ depressive sx. * Tx for TCA overdose is bicarbonate given in amps until QTc is no longer significantly prolonged. who are more likely to have SZ. given at night (qHS). * Sexual dysfxn including anorgasmia & ↓ libido w/ SSRIs.* Also used to tx various anxiety d/o. * TCAs also down-regulate beta-adrenergic receptors. * Thus. * Individual antidepressants differ greatly in their side-effect profiles. sertraline (Zoloft). & citalopram. answer is tell Pt to wait. protriptyline (Vivactil). none w/ most SSRIs (except paroxetine/Paxil) & trazodone. * Amitriptyline (TCA) is especially useful for chronic pain. generalized anxiety d/o. * Sedation most severe w/ doxepin (Sinequan). & acetylcholine (muscarinic) especially seen in TCAs. * Overall efficacy for tx of major depressive d/o is around 70%. * Safest TCAs (used most frequently) are nortriptyline & desipramine. So. chronic pain. bulimia nervosa. enuresis. uncommon w/ SSRIs. * So w/ TCAs. hypotension. an ECG must be done prior to starting TCAs. depressive episodes in other mood d/o (e. * If Pt is started on fluoxetine & has unwanted side effects. * Tx response may be augmented w/ lithium or thyroxine. So in reality. * Worst TCA because of most side effects is amitriptyline. delayed ejaculation. * TCAs tend to prolong the QTc interval. * 90% of Pts w/ Depn also have anxiety. amitriptyline (Elavil). * If no response to tx after 4 to 6 weeks. ↓ libido. paroxetine (Paxil). not because they work better. it increases endogenous opiates (pain threshold). * AD medications can cause sedation. * SSRIs include fluoxetine (Prozac). * Tx should continue for 6 months to 1 yr after favorable response. glaucoma. weight gain. serotonin. Don’t give to 80yo Pt w/ mild dementia. & trazodone (Desyrel). * TCAs are extremely dangerous when an overdose is ingested (QTc prolongation). priapism w/ trazodone (Desyrel). & SSRIs. * SZ more common w/ TCAs. * Blockade of alpha-adrenergic. SSRIs shouldn’t because they only work on serotonin. * Doxepin & trazodone used often at night to help w/ sleep. Bupropion also has low incidence. * Hypotension more severe w/ TCAs (amitriptyline worse. * All AD medications can lower the SZ threshold. expect sedation. so trials of several antidepressants may be necessary before an effective one is found. * Only switch medications if you’ve maximized the dose & maximized the time (or side effects). Older antidepressants are extremely dangerous when an overdose is ingested. * Anticholinergic effects most severe w/ amitriptyline & doxepin. risk of SZ is not that much higher compared w/ the other ADs. * Difficult to predict which Pt will respond to which antidepressant. hypotension. nortriptyline best). * SSRIs. switch to another. Clinicians should generally prescribe in small quantities & only after determining the absence of suicidal intent. OCD. & DA. social phobia. * TCAs block the reuptake of norepinephrine. * ADs used to tx Depn. blurry vision.g.

* When imipramine breaks down. cardiac effects. DA linked to smoking cessation because DA is linked to reward center in brain. wine) because it will produce a hypertensive rxn. which increases in severity over the course of ECT. such as nasal decongestants. basically an offshoot of the TCAs. * Used particularly in major depressive episodes w/ high risk for immediate suicide. the severity of adverse effects. gets HA. Possibly more rapid onset of antidepressant effects than w/ SSRIs. anxiety) doesn’t mean it won’t tx that. If Pt gets sedation. Crumbly. clomipramine used for OCD (works most on serotonin) & amitriptyline used to tx chronic pain. * Similar to naltrexone. It is used for Pts who have not responded to antidepressant medications or mood stabilizers. * ECT can cause transient memory disturbances. * Nefazodone (Serzone) has sedation similar to trazodone but less sexual dysfxn than SSRIs or trazodone. but white wines are not. which blocks pleasure centers in brain for EtOH. * Hypertensive crisis may also occur w/ combination of other medications. * Bupropion is also known as Zyban for smoking cessation. then goes to hospital. or aged cheeses are rich in tyramine. It works on the same neurotransmitters. & sexual dysfxn. & amphetamines. nausea. but more likely to cause SZ. imipramine often used for panic d/o. Red wine is rich in tyramine. * Venlafaxine (Effexor) has a profile similar to SSRIs. amitriptyline. often used to tx depressed Pts who have severe insomnia. panic d/o. * TCAs (especially tertiary) tend to cause significant sedation. like cottage cheese or Velveeta. The serum drug level has to fall w/in the therapeutic window in order for it to be effective & not toxic. Answer is hypertensive crisis w/ MAO-I. or hypotensive effect. liver toxicity (w/ hydrazine MAOIs). * Mirtazapine (Remeron) has a profile roughly similar to tertiary TCAs but a lot of sedation. have them take it during the day. clomipramine. smelly.* SSRIs have reduced number of serious side effects & simple dosing schedules (once a day). * Also used in major depressive episodes in Pts w/ contraindications to using antidepressant medications. * Tertiary TCAs are imipramine. * Adverse effects include sedation. & bulimia nervosa.g. * Hydrazines are more sedating. which Pts do not like. diarrhea. Arrives w/ BP of 220 systolic. * Trazodone is a heterocyclic antidepressant. & protriptyline. they are the most dangerous antidepressants in overdose. * ECT raises intracranial pressure. Used commonly in the elderly. Other tyramine-rich foods include chocolate. sausage.” * Significant incidence of agitation. used in alcoholics. so high ICP is a contraindication. * “Just because a drug doesn’t have FDA approval for a specific indication (e. it converts to desipramine. * Amitriptyline breaks down to nortriptyline. or sexual dysfxn. appetite loss. vomiting. & anticholinergic effects. anti-asthmatic medications. & pickled products. & sexual dysfxn. nortriptyline. nosebleed. * Active metabolites (desipramine & nortriptyline) are “cleaner” meaning fewer side effects. have them take it at night. * If Pt gets agitation. weight gain. So when you smoke you don’t get the pleasure from the smoking. & then . * Tertiary amine TCAs used for mood d/o. * TCAs earliest antidepressants to be widely used. & the specificity of inhibition (MAO-A or MAO-B). Processed cheese is fine. * Problem w/ MAOIs is Pt cannot eat foods w/ tyramine (cheese. has minimal hypotension. * Trazodone (Desyrel) has marked sedation. anticholinergic effects. orthostatic hypotension. * MAOIs work by inhibiting MAO-A &/or MAO-B in the CNS & have antidepressant efficacy. * Few cardiac side effects. & trimipramine. ------------------------------------------------------------------------------------------------------------------------------------------Electroconvulsive Therapy (ECT) * Considered the best tx for Depn. HA. doxepin. * MAOIs differ by the type of inhibition (reversible or irreversible). * Levels need to be checked for most of the TCAs. minimal anticholinergic effects. orthostatic hypotension. * Bupropion (Wellbutrin) is activating. nuts. * Case ex is Pt at wine & cheese party. * Secondary amine TCAs are desipramine. * Specific efficacy in OCD.

6 to 1. * Lithium has a narrow margin of safety. * If lithium level gets very high. impulse control d/o. * Most common lithium side effects are tremors (e. order LFT before starting Pt). gabapentin (Neurontin). Friday) then tapered down to twice a week. impractical. * Topiramate helps the Pt reduce weight. so a TSH must be done prior to starting lithium. * Dehydration & hyponatremia predispose to lithium toxicity by increasing serum lithium levels. they should stop lithium per medical doctor. & possible teratogenicity (spina bifida). head CT to rule out tumor/trauma/space-occupying lesions. ------------------------------------------------------------------------------------------------------------------------------------------Psychopharmacology: Anxiolytic Medication . * Hypothyroidism if > 1. bipolar d/o. unlike all the other mood stabilizers. * Lithium used for bipolar d/o. gabapentin. SZ. * Other lithium overdose effects include ataxia. * Therefore. * Typical ECT course is between 10 & 15 tx. aggression. * Divided doses or slow release preparations minimize dose-related effects by decreasing peak plasma levels. * Complications of associated anesthesia & induced paralysis can occur. * Efficacy for prophylaxis is unclear. full series of neurological tests/questions. divalproex (valproic acid). gabapentin. poor kidney fxn. In the past. * Divalproex time course of tx response is similar to lithium. > 2. diarrhea). or when lithium is ineffective. & topiramate are second-line or can be used in addition to first-line for bipolar. hepatotoxicity (e. If Pt becomes pregnant. violence. * Lithium can cause HAs. * Rare but serious hematologic & hepatic side effects & significant sedation make carbamazepine less useful. * Carbamazepine is second-line choice for tx of bipolar d/o when lithium & divalproex are ineffective or contraindicated. worsen acne.g. Therapeutic is 0.5mEq/L plasma level. & carbamazepine. divalproex. * In reality. * Lamotrigine. * ECG conduction changes are usually benign. * Lithium can cause leukocytosis. ------------------------------------------------------------------------------------------------------------------------------------------Psychopharmacology: Mood-Stabilizing Medication * Mood stabilizing medications include lithium. polydipsia. Tx starts approximately 3x/week (e. Wednesday. * Transiently ↑ intracranial pressure. An ECG must be done before lithium tx is started. or contraindicated (e. leading to fetal cardiac malformations (Ebstein anomaly affecting tricuspid valve). * Divalproex is the tx of choice for rapid-cycling bipolar d/o (cycle w/in days). * Pre-assessment for ECT involves being admitted. thyroid disease). tremor.g. topiramate. assess kidney fxn. schizoaffective d/o. * ECT involves electrodes connected to head & an induced SZ. nephrogenic diabetes insipidus. The Pt does not have a physical SZ. Monday. ECG/EKG. * Divalproex is becoming increasingly popular in emergency settings. & then maintenance ECT. else you create more side effects. & weight gain. * Mood stabilizers take anywhere from 10-14 days to reach effective level. There are a lot of side effects. * Tremors may occur at therapeutic levels & may respond to ↓ dosage. * Carbamazepine can cause agranulocytosis. However. tx of choice is dialysis. h& shaking) & GI problems (e. cognitive impairment. carbamazepine. * Divalproex is considered second line for the exam. * Most commonly used mood-stabilizers are lithium.5mEq/L plasma levels. the more ECT the more memory loss.g. * Lithium is teratogenic. Thus. sometimes complete bone scan to rule out unhealed fractures. GI distress. * Lithium causes hypothyroidism. Lithium is considered first line for the exam. must do a pregnancy test on any young female before starting lithium & also advise Pt to avoid pregnancy. & mood d/o. then once a week. * Side effects include sedation.3 approximately. Newer research has found that a SZ is not absolutely necessary.gradually resolves over several weeks. * Other mood stabilizers include lamotrigine (Lamictal). * Some studies say to keep levels close to 1mEq/L & not go higher. a physical SZ was thought to be necessary. so be careful if mixing w/ clozapine. lamotrigine. & topiramate (Topamax). it is not needed for ECT to be effective. polyuria. regular blood-work. agitation.g. which is a number agreed upon by anesthesiologist & psychiatrist. check pregnancy test before starting. interferes w/ Pt compliance. * Commonly used as anticonvulsants.g. lithium has a rough side effect profile so divalproex may be used more than lithium for first line. so caution w/ space-occupying lesions. & coma.

Answer is lithium. * Adjustment d/o w/ anxious mood. Use lower dosages for elderly. * Pt w/ bipolar d/o (nml or liver d/o). * Ex: Pt attempted suicide while she was alone. then leave dinner to go to the bathroom. She says. she more than likely will call the ambulance herself. * Mnemonic is OTL: oxazepam. open the bottle. No sedation or cognitive impairment. have tolerance & withdrawal issues. alprazolam. clomipramine). temazepam. & left a will. can cause death. * Pt presents w/ acute mania (emergency). “Yes. thyroid fxn. * Suicide assessment includes ideation (have you thought about suicide?). but I would never do that to my family. & take it all in front of my husb&. & are possibly teratogenic. then come back to dinner. so good anxiety medication for substance abuser. * Asking a Pt about suicide will not put that idea in their head & increase suicide risk. Everyone thinks about suicide at some point. intent (are you serious about suicide?). * Do not mix benzos w/ EtOH or other sedative-hypnotic medications. “I wasn’t really serious. The attempt occurred at a time when no one was there to rescue her. * What three tests should be ordered before starting lithium? Pregnancy.” This is most likely a Pt that is not really suicidal. * Pt presents w/ mania. What is the tx? Fluoxetine (SSRI) not nortriptyline (TCA). kidney fxn. If her husb& does not stop her. * Social phobia. disinhibition. * Chlordiazepoxide given over 3-5 days. Not addicting. She left things in place in case she actually did die. If not a choice. the more isolate the plan the more serious the intent. * Generalized anxiety d/o. They bind to specific CNS receptors that modulate GABA transmission. social phobia (SSRIs). * OCD. * Some places use oxazepam (Serax) for EtOH withdrawal because it does not go through CP450 system. * A suicide plan would include giving away possessions. SSRIs & clomipramine decrease obsessional thinking. writing a note. specifically lithium. * No withdrawal syndrome. * Pt may say. She is hoping that her husb& will stop her. * Pt w/ bipolar d/o w/ kidney d/o. SSRIs). or going to isolated place. * Lag time of about 1 week before clinical response. tapered every day. Answer is any BZD. * However. * Another case: Pt says. * Benzo used most frequently for the prevention of EtOH withdrawal? Answer is chlordiazepoxide (Librium). I think about suicide. pick valproic acid. & generalized anxiety d/o (venlafaxine. it means nothing. Their plan was well thought out. lorazepam do not go through CP450 system. SSRIs. * No additive effect w/ sedative hypnotics. Answer is mood stabilizer. * Antidepressants are used for panic d/o (SSRIs. It is effective in the tx of GAD & social phobia. venlafaxine. * Pt presents to the ED w/ hx of EtOH abuse & is agitated. & clonazepam decrease frequency & intensity of panic attacks. Answer is BZD or antipsychotic. * Usually. you have to admit them. Admit this Pt.” This Pt does not need admission into a hospital for ψ examination. * Consider dependency potential w/ BZDs. left a note. ------------------------------------------------------------------------------------------------------------------------------------------Ψ Interventions: Suicide * Suicide is very common in adults (7th or 8th cause of death) & adolescents (2nd or 3rd cause of death). imipramine). BZDs are used w/ brief psychotherapy.” Do not believe this Pt. but specifically alprazolam (Xanax). other SSRIs. * Benzos cause sedation. * Panic d/o. Answer is divalproex. not lithium. * There has never been a proven BZD death from overdose alone. * Buspirone (Buspar) is used for generalized anxiety d/o (GAD) & social phobia. “I’m going to have dinner w/ my husb&. which gives a safe detoxification. if the test says the Pt thinks about suicide & nothing else is given. They open sodium-chloride channels & allow GABA transmission. * Pt has panic d/o. Likely should be admitted anyway. may be abused. I wish I were dead. * Buspirone is thought to work on serotonin. * BZDs should not be abruptly changed in dosage. I didn’t want to die. buying a gun. * Pt has Depn. HA may occur. * Tx for Depn should be nortriptyline instead of amitriptyline due to safety profile. & buspirone decrease overall anxiety. SSRIs & buspirone decrease fear a/w social situations. raising GABA levels. but can cause death from respiratory compromise when mixed w/ EtOH. OCD (SSRIs. & plan (do you have any plan?). impaired cognition. get a bottle of Tylenol.* BZDs are first choice for acute anxiety. . Answer is lorazepam (Ativan) because it does not go through CP450 system & it is available in an IM injection.

One theory is that the car is a means of committing suicide. * Suicide presentation includes recent suicide attempt. Unemployed kill themselves more (they’ve lost it all). & use antipsychotic medications &/or BZDs to control agitation. an attempt to frighten or manipulate. * When men use guns. they should be admitted. However. most lethal is firearms for women. but still > all others. such as during the Great Depn. They go seeking help. White people kill themselves more than African Americans. boy decided not to. social isolation. being picked on. warn others. girl committed suicide. * Most Pts who commit suicide have gone to the doctor w/in the past 6 months prior.” They should not be immediately released from the hospital. * Get information from third parties. ------------------------------------------------------------------------------------------------------------------------------------------Ψ Interventions: Combative Behavior * If the Pt is combative. the more likely they are to be admitted. * Ex is Charter Hospitals that used inappropriate methods for h&ling agitated Pts. use appropriate equipment & trained personnel. * Set clear limits. such as a boyfriend. * Risk factors include previous suicide attempts. * Number one cause of death for adolescents is motor vehicle accidents. Boy & girl in Massachusetts. low job satisfaction. Even if the Pt says he wrote the will to protect his family & bought the gun for hunting because he loves to hunt. * Emergency assessment involves detaining the Pt until the evaluation is complete.g. The wrists & ankles are restrained to sides. He recently wrote a will & bought a gun. * Myth: Pts who talk about suicide won’t actually hurt themselves. * An elderly white male may be brought in by his family for Depn. he is going to need to be admitted. 5-point restraints add on a strap . but are much more successful. a bad grade. perceived hopelessness (demoralization). * Most of Pts who try to kill themselves will try again w/in 3 months of the first attempt. Poor economic times cause ↑ suicide rates. & ends up killing themselves. Don’t identify w/ the Pt (“I’d kill myself too if that were me”). male gender. anger at a specific person. * Ex is 15yo in Tampa who took flying lesions & slammed a Cessna into a Bank of America. cancer. * The Pt presents to the doctor because they know something is wrong. * High socioeconomic status is another risk factor (more to lose). as the stock markets plummet the investor will grab a gun & go hunt down their stockbroker. * Men most commonly use guns. This has happened numerous times in numerous cities. family hx. leading to the death of several Pts. & demonstration of possible suicidal behavior. * Determine stressors (lessen stress if possible). * Some hospitals use 4-point restraint. or in mouth. Suicide rates for elderly have dropped over last century. their Depn sinks in. determine the reason for combativeness: general anger. * These days. The doctor sends them home. gets behind the wheel. they don’t get better. The more risk factors the Pt has. or poison for attempts. overdose. admission of suicidal thoughts upon questioning. the doctor does not recognize the Depn. * Men are more likely to be successful in their suicide attempts because of where they are shooting themselves. & dialysis. * Women attempt suicide more often than men. Elderly white males. They tend to commit less suicide. * Chronic illnesses include HIV. there has been a change in suicides w/ stock markets. complains of suicidal thoughts. they don’t mess around. When women use guns. * Take all suicide threats seriously. They put it against their temple. * Emergency tx decisions about suicidal behavior are based on clinical presentation & presence of risk factors. presence of ψ illness or drug abuse. Determine psychopathology. throat facing up. Common location is gun against middle of chest. search for concealed weapons. & then they kill themselves. “I can’t believe I’m alive. which increases suicide success.* If Pt wakes up from suicide attempt & says. * Delay physical examination of combative Pts. * Elderly is the number one risk factor for suicide. (copycat suicide) * Ask about suicide pacts. elderly. * Men are more likely to use lethal means. * If Pt has suicidal ideation & plan. Women most commonly use pills. A note was found in his pocket that said how he adored Osama Bin Laden & his 9/11 terrorist attack. The teen drinks. they avoid blowing up their face. Question about suicide (e. However. friends committing suicide). * Adolescents will kill themselves over very silly things. & chronic physical illness.

discussion among designated tx personnel. * You cannot tell anyone about substance about (e. or yell at them. even for lifesaving tx. If you suddenly get into a Pt’s face & talk to them. clothing. ------------------------------------------------------------------------------------------------------------------------------------------Confidentiality * Confidentiality is implicit in clinician-Pt relationship. * Medication. The male student saw a therapist at the university & said he was going to kill the girl (Tarasoff). benefits. * Straightjacket is rarely used & likely to be ab&oned in all states. * Emergency medical tx may be administered if the Pt is unconscious or severely cognitively impaired. or shelter. sexual abuse. & therapeutic privilege (information would be harmful to Pt). these are the things that you must do for someone to take away your basic rights & lock you up on a psych ward. * Waiver by Pt could be. * Make sure you are between the door & the Pt. informed consent must almost always be obtained. This allows for some arm movement but prevents the Pt from punching others. * In medical cases. * HIV status can be broken in the state of New York. judicial subpoena. not commonly used. * Some hospitals use a belt restraint. this may help them calm down & trust you. drugs) cannot give consent. the answer is do not notify others. The therapist becomes . seclusion. * Pt must be informed when confidentiality is breached. * Can ethically be breached in certain circumstance. * Pts under the influence (EtOH intoxication. except if you are going to kill yourself. or physical restraint should be used for ψ emergencies or by judicial order.” * Appropriate breaches include essential information during an emergency. * You should tell the Pt. homicidal. It is my duty to report those & do something about it. partners). * For the purpose of the exam. a waiver by the Pt (if Pt is competent to do so). * Grave disability is an inability to provide for food. Pt requests. parents. Usually suicide.g. Everyone can be notified including partner. For the test. kill someone else. or are being abused. More than 30 states in the country are looking to do this. they will become more agitated. voluntariness (non-coerced). * Pts are very creative & will hide interesting weapons in even more interesting places. alternatives). ------------------------------------------------------------------------------------------------------------------------------------------Involuntary Tx * Ψ hospitalization for suicidal. This does not apply to all states. * If you take away a Pt’s right of freedom. Based on the American Ψ Association (APA). or gravely disabled. * Offer food or water or juice or soda to the Pts. you will be told they don’t know that person or they aren’t there even if they are there.” * Therapeutic privilege could be an unconscious Pt who needs non-emergency surgery. homicide.across the chest to prevent the Pt from sitting up. * Special protection exists for HIV status & substance abuse hx. tell the Pt everything even if it means the Pt would go kill them self. * A “calming blanket” is a tough canvas-like material used to wrap-up agitated Pts. * Calming an agitated Pt should always be started w/ verbal de-escalation. you have to provide tx. * Pts who are extremely schizophrenic but not suicidal/homicidal have the right to be free. * Tarasoff was a case in California where two students were in a relationship & stopped seeing each other. * Non-emergency medical tx requires a judicial order. We could deprive the Pt of their rights & perform the surgery. child abuse. must wait for drug to wear off. If you call a substance abuse clinic & ask for a specific person. * Therapeutic privilege also includes telling Pt information that would be catastrophic to the Pt. * Exceptions include emergencies (min to hours). you do what you think is best. you have to go to court (have a hearing) & have tx ordered else the Pt must be discharged. which h&cuffs their wrists to their waist. ------------------------------------------------------------------------------------------------------------------------------------------Informed Consent * Informed consent has three components: information (risks. you can give medication/seclusion/restraint because it is imminent danger to the Pt or others. & competency (underst&ing & judgment). If the Pt refuses tx. “Look doc. & state medical reporting such as abuse & duty to warn & protect (Tarasoff). “Everything you tell me will be confidential. * If the Pt is going to hurt someone or themselves. Meaning.

* Most psych Emergency Departments have locked doors. then lets him go eventually. perceptual-cognitive. What do I do w/ my life? * Stage 7. Intimacy of sexual relations. His theory consisted on how children & adolescents think & acquire knowledge. the Pt runs out of your office. which are the turning points of the stages. His stages are determined by crises. They say they went to Wal-Mart & bought a shotgun & tomorrow at 5pm I’m going to st& behind the bushes & blow his head off. They can be cooperative or stubborn. industry versus inferiority (6 to 11 yrs). They gain a sense of their separateness from others. * If this happens in a hospital. the girl is dead. Able to work & acquire adult skills. development of altruism & creativity. exploration. three things must happen. * Erikson’s stages are based on social development. Group identity. sensorimotor stage (birth to 2 yrs). This is learned trust. there were two rulings. writes a memo. the child does not cry. * Piaget believed that children develop through cognitive stages. autonomy versus shame & doubt (1 to 3 yrs). * 1. * Stage 6. preoperational stage (2 to 7 yrs). You detain the individual. toupee. Sexual curiosity is present. Identity crisis occurs at the end of this stage. Children learn they are able to master & complete a task. * Stage 2. basic trust versus mistrust (birth to 1 yr). Object permanence is achieved. & all deep associations are present. & you notify the victim (warn). * If the Pt comes in w/ a serious intent to kill someone. * Stage 4. What do you do? Answer for the first step is to notify the police. sibling rivalry. in the U. sound. This is where peer pressure comes into play. * Stage 3. intimacy versus isolation (21 to 40 yrs). * Erik Erikson believed that human personality was determined by childhood & adult experiences. ------------------------------------------------------------------------------------------------------------------------------------------Childhood Development * Milestones include gross motor. tells the therapist to go to the campus police & get the memo to be destroyed because it is confidential. Children w/ autism never bonded w/ parents.” It is there sense of control. integrity versus despair (over 65 yrs). which Piaget called normative. This is the stage where the mom can leave the room & the child will not cry because the child has internalized the structure of the mother (permanence). Despair if you are unhappy w/ how your life turned out. They felt there is a duty to warn & a duty to protect. you are said to have a fixation.S. Children are learning to master their senses (sight. initiative versus guilt (3 to 5 yrs). Two months later. Midlife crises can occur here (e. The campus police gets the memo. * Babies learn that if they cry for any reason (hunger. * Age 6 children go to school. The therapist boss comes in. Ability to care & share w/ others w/o fear or losing self. Child uses symbols & language more extensively. smell). you have to warn any victims.concerned. detains the Pt. liposuction). meaning you have to be buzzed in & buzzed out. Not a lot happens here. * Stage 1. Freud’s stages are based on sexual development. This is a clue for autism. The family sues the California Board of Regents. Children have a sense of mastery over themselves & their drives. Meaning. & social. Having & raising children as well as other interests outside the home. identity versus role diffusion/confusion (11 yrs through adolescence). “Where am I? Am I where I wanted to be?” * Stage 8. friendships. emotional. generativity versus stagnation (40 to 65 yrs. A sense of satisfaction w/ one’s life. Piaget’s stages are based on cognitive development. Questioning self. “middle adulthood”). gets mad. Children are . if parent is not attentive. Deal w/ morality & ethics. wet diaper) parents will come & take care of everything. Allows for an acceptance of one’s place in the life cycle.g. Sexual experimentation occurs here. Child enters program of learning. * The word they learn to master is “no. * If the Pt comes into your office & says they hate their neighbor & can’t st& them. communicative. & manipulation of the environment. preoccupation w/ appearances. * Stage 5. Intelligence was an extension of biological adaptation & had a logical structure. the infant will learn to mistrust. in general. an arrested stage of development. If childless. You also have to protect the victim. you notify the police (protect). the answer for the first step is to detain the Pt because they are right there. Infants develop feelings of trust that their wants will be satisfied. * Stage 1. calls campus police to have the male student detained. * Stage 2. If parents don’t show up when the baby cries. Infants begin to learn through sensory observation & gain control of their motor fxns through activity. they learn mistrust. fine motor.5yo in room & mother leaves room. His theory of human development covers infancy to old age. Then. Initiates both motor & intellectual activity. There is no separation anxiety. convertible. As a result of that. * If you do not complete a stage.

death is irreversible at age 10 (or even 9). anal stage (1 to 3 yrs). According to Freud. gr&pa is dead & in heaven like you told me. Since then. * Stage 3. Being stuck in this stage would include nail biters. traffic accident). “Yes. oral stage (birth to 18 months). An adult would say they are both pieces of furniture. reason deductively. Ex is from the movie Rainman when the character expected to have 8 fish sticks. Could expect a child to say. Sx must develop w/in 3 months. use animalistic thinking. got fired). The mouth is the main site of gratification & is manifested by chewing. The anus & surrounding areas is the main site of gratification. A 6yo would say a chair & podium are both made out of wood. * Presenting sx include complaints of overwhelming anxiety. the child blames them self. pen gnawing. Increase in genital masturbation w/ fantasies involving the opposite-sex parent. Can become chronic if stressor continues & new ways of coping w/ the stressor are not developed. This is an important stage. then another character cut them in half making 8 & that was a solution. Depn. Capacity for true intimacy. fired. * Side note: Critics will go on to point out that Freud did cocaine & may have had a relationship w/ his daughter.egocentric. * Cause can be environmental stressors having an effect on fxning (e. * Associated problems include social & occupational performance deterioration. Lack the law of conservation. These children will underst& that two 8oz containers hold the same amount of fluid even though one is thin & tall while the other is wide & short. This is the stage where children can underst& abstract thoughts. ------------------------------------------------------------------------------------------------------------------------------------------Adjustment D/o * Maladaptive rxns to an identifiable psychosocial stressor. & sucking. Children feel the sun goes up because they made it. Death is reversible. Sublimation of sexual energy into energetic learning & play activities. Have the law of conservation. * Sigmund Freud believed that children were influenced by sexual drives. stressor occurs (e. Primarily involved in bowel fxns & bladder control. * Anxiolytics or antidepressant medications are used to ameliorate sx. But when is he taking me to the park like he promised?” Children here do not underst& things can change shape & be the same. they can see things in other’s perspective. What is peace? What is justice? What is liberty? * If you ask a 6yo how are an apple & an orange alike. women marry someone like their father. * Stage 5. the first of which were non-sexual. Men make up for this later by marrying someone just like their mother. Brief psychotherapy is used to improve coping skills. she has complained of ↓ sleep & . * Onset occurs w/in 3 months of the initial presence of the stressor. Punishment at this age should be a time-out because that is what a child underst&s. Prevalence is extremely common. or emotional turmoil associated w/ specific stressors. formal operations stage (11 yrs to end of adolescence). phallic stage (3 to 5 yrs). * Risk that a stressor will cause an adjustment d/o depends on an individual’s emotional strength & coping skills. Formation of the superego. Once sx develop. * Course lasts 6 months or less once the stressor is resolved. Ability to think abstractly.g. * Stage 2. * Stage 1. may become “anally fixated” (obsessive compulsive personality d/o). This theory has been disproved. therefore. A 13yo would likely say they are both fruit. Sexual interests during this period are believed to be quiescent. If harsh toilet training. latency stage (5 to 11-13 yrs). they cannot last more than 6 months. biting. resolution of the Oedipal complex. * Stage 4. Penis envy & fear of castration are evident during this stage. If that doesn’t work she expects to get a baby from the father.g. * The psychotherapy used for adjustment d/o is supportive psychotherapy. If someone is getting a divorce. * Stage 4. There has to be a stressor. & have a sense of immanent justice. The genital area is the main site of gratification. She expects to get it from her father. * A 22yo female was fired two months ago from her job. He noted that infants were capable of sexual activity from birth. * Stage 3. this is the stage where girls want a penis. concrete operations stage (7 to 11 yrs). * So. * Tx is to remove or ameliorate the stressor. Egocentricity is replaced by operational thought. erratic or withdrawal behavior.” “Electra complex” where girl is in love w/ father. you cannot reason deductively w/ a 2yo. fight. genital stage (11-13 to adulthood). they will likely say they are both round. drinkers. smokers. Characterized by hypothetical thinking & deductive reasoning. but only had 4. “Oedipal complex. seen in all age groups. & define concepts.

as measured by a variety of IQ tests. sensory impairment. * Associated genetic & chromosomal abnmlities include inborn errors of metabolism (e. live in residential community settings. poor prenatal care. ------------------------------------------------------------------------------------------------------------------------------------------Childhood D/o: Learning D/o * Characterized by learning achievement in specific areas that is substantially below expectations. Mental retardation may be written as MR. Types are reading d/o (most common). not bipolar I (no mania. cytomegalovirus. * The onset is before 18 yrs of age. * A/w intrauterine infections (e. rubella. glycogen storage diseases) & chromosomal abnmlities (e. Section 8 housing). One week later. * Tx of associated general medical conditions may improve overall level of cognitive & adaptive fxn. cri du chat syndrome. physical trauma. . For the next several weeks. postnatal exposure to heavy metals. * Amniocentesis may reveal chromosomal abnmlities a/w mental retardation in high-risk pregnancies (mother > 35 yrs of age). sensory abilities. * Prevalence is 1% of population & occurs at a 1. anxiety d/o NOS. ------------------------------------------------------------------------------------------------------------------------------------------Childhood D/o: Mental Retardation * This goes on axis II in ψ. * There must be significant sub average intellectual fxn (IQ less than 70). & attention deficit hyperactivity d/o (ADHD). go to school nmlly. * Tx includes primary prevention. * Some general medicine conditions & substance-induced conditions a/w learning d/o.g. genetic counseling. * Some cases are due to the effects of coexisting general medical conditions such as cerebral palsy on CNS fxn. * DDx includes learning & communication d/o. & 25-pound weight loss. feelings of guilt. major Depn. ↓ sleep. helplessness. fragile X syndrome). major Depn). but then when they hit grade school (4th grade onward) you start to notice problems in social adaptive fxning. * Lead poisoning case may be described as a child living in an old run-down building (e.weight gain. substance-related d/o. * Moderate retardation (IQ 35-50). social. * Do Pts w/ mild MR have the ability to underst& tx you will be giving in the hospital setting & be able to consent? Answer is yet. This is adjustment d/o. D/O is used to denote d/o. adjustment d/o. attain academic skills to a second grade level. postnatal causes (e. & may have associated conduct d/o. major Depn). Is this adjustment d/o? Yes. * Proposed higher risk of Depn. the woman quits her job w/o giving notice & begins drinking heavily. & other environments. Down syndrome. so they meet milestones nmlly. anhedonia. Severe MR can do basic things but cannot live alone. little or no speech.g. * NOS means not otherwise specified. work. attain academic skills to approximately the sixth-grade level. * A 65yo male retired 3 months ago & for the last 5 weeks has complained of depressed mood. No. & autism. may be able to manage activities of daily living. toxin exposure. the woman telephones friends & tearfully expresses suicidal rumination. & safe environments. aminoacidurias. * Most w/ MR have a mild version. & educational experience.g.5:1 male-to-female ratio. * Physical examination shows evidence of underlying d/o or injury. * A 28yo woman w/o previous behavioral problems becomes angry & bitter after he husb& of 5 yrs leaves her to live w/ his female business partner. Down syndrome Pts are at high risk for early development of Alzheimer disease. other viruses). good prenatal care. giving the Pt’s age. hopelessness. often live independently in the community or w/ minimal supervision. * Severe (IQ 20-35) & profound retardation (IQ less than 20). may have problems w/ impulse control & self-esteem. intelligence. * Many cases have no obvious etiology.g. work in sheltered workshops. No. She also makes several threatening calls to her husb&’s new girlfriend. * Mild retardation (IQ 50-70). mathematics d/o. requires highly supervised are settings. & d/o of written expression. lipidoses. * This must be accompanied by concurrent impairment in adapting to dem&s in school. not bipolar II (no hypomania. * A 40yo female has complained of ↑ anxiety for the last 2 months. including lead poisoning & fetal EtOH syndrome. very limited abilities to manage self-care.g. basically a catch-all phrase. not borderline (don’t all of a sudden get a personality d/o). social deprivation). infections. & have significant problems conforming to social norms.

physician’s office). * ADHD is characterized by inattention. imaginative activities. * IQ testing & academic achievement tests are the major diagnostic tools. * SZ develop by adulthood in 25% of autistic individuals. cases of taking own eyes out. * School failure & behavioral disturbances may occur. * Approximately 30% of individuals w/ autistic d/o become semi-independent in adulthood but almost all have severe residual disabilities. * There is no obvious etiology in many cases. 5:1 male-to-female ratio. * Case of families who sued the APA & pharmaceutical company making the ADHD drug saying the Dx was made up & a conspiracy to sell medication. SZ. Sites of CNS damage specifically associated w/ autistic d/o are unknown. * Subtypes are based on the predominance of sx or inattention or of hyperactivity & impulsivity. * Tx includes family counseling. * Some cases involve a parent who is looking for an answer why their child is a menace. They will see multiple physicians. * Communication sx include absent or bizarre use of speech. . & ADHD may be present. * General medical conditions a/w autistic d/o include encephalitis. * The cause is CNS damage due to known or unknown factors. * Physical findings include higher incidence of abnml EEGs. communication. maternal rubella (common cause). environmental deprivation. & abnml brain morphology. The courts found the allegation to be completely bogus. stick w/ this physician. * DDx is to rule out environmental deprivation. watching cartoons for 5 hours. * Perceptual-motor problems may be present. it does not occur in multiple settings. * Poor self-esteem & social immaturity may be present. * Special education to ensure general learning & maximize skills in the deficient areas is the mainstay of tx. * Speech is one way to differentiate mental retardation (nml speech) from autism (abnml speech). * Sx are present in multiple settings (e. * Behavioral sx include odd preoccupation w/ repetitive activities & bizarre mannerisms. fragile X syndrome.g. & newer antipsychotic medications to control episodes of severe agitation or self-destructive behavior. * DDx includes ruling out mental retardation. do not care about their parents. * More than 75% of autistic children have mental retardation (IQ < 70) & 50% have IQ < 50. home. being told the child is nml. Onset is usually during elementary school. hearing or vision impairment. tuberous sclerosis. * When child w/ autism gets upset or hurt they will employ “self-soothing mechanisms” such as rocking back & forth or banging their head against the wall. work. ------------------------------------------------------------------------------------------------------------------------------------------Childhood D/o: Autistic D/o * Qualitative impairments in social interaction. Onset is before 3 yrs of age. Is this ADHD? No. phenylketonuria (PKU). hearing impairment. & mental retardation. * Prevalence is 0. Counseling of Pts & families to improve self-esteem. ------------------------------------------------------------------------------------------------------------------------------------------Childhood D/o: Attention Deficit Hyperactivity D/o (ADHD) * Many experts believe ADHD is very over-diagnosed today. * Conduct d/o. * Self-injuries caused by head banging or biting are sometimes present on exam.* Prevalence is about 5% of school-age children. & perinatal anoxia. & interest. * Predictors of a poor outcome are a/ retardation & failure to develop useful speech. oppositional defiant d/o. * Social sx include lack of peer relationships & a failure to use non-verbal social cues. * Autistic children never bond w/ their parents. but hyperactive & has attention problems at school plus poor grades.04% in general population. school. * Communication is the most important factor affected by autism. So there is usually no separation anxiety w/ autism. special education. hyperactivity. * Eye contact is one way to differentiate deftness (makes eye contact) from autism (little or no eye contact). * Deficits sometimes persist into adulthood & interfere w/ occupational fxn. & follow the medication & tx plan prescribed. & selective mutism. The sx last for at least 6 months & onset occurs before 7 yrs of age. * Ex: child is nml at home. & are not interested in their parents. & family fxning helps. & impulsivity that interferes w/ social or academic fxn. social behavior. until one physician gives the ADHD Dx. Then they will not seek other opinions.

& joining a gang may require doing something illegal. the sx gradually remit. * They should generally be given only on school days. * Sx include short attention span. constant fidgeting. response to environmental problems. * Other medications include various antidepressants & clonidine. v&alism. * Dextroamphetamine is given to children about the age of 3. This is conduct d/o. This is antisocial personality d/o. Family education is important. rape. Psychological. * Family hx of ADHD. * Pharmacotherapy of choice is stimulant medications. etc. ------------------------------------------------------------------------------------------------------------------------------------------Childhood D/o: Conduct D/o * Persistent violations in four areas: aggression. conduct d/o. * DDx is rule-out age appropriate behavior. & the whole cycle repeats itself. disobedience. cruelty to people or animals. carelessness. * Latest theory is that ADHD is due to low levels of DA. * Often outcomes include antisocial personality d/o. Now this adult starts drinking. mood & anxiety d/o. ADHD. conduct d/o. drug abuse. * Family hx can include antisocial personality d/o. So they become adolescents who are not better. ADHD persists into adulthood in approximately 30% of affected individuals. provided by structures sports programs & other programs (e. & sx usually persist throughout childhood. Medications are aimed at increasing DA. Structures living settings that place value on group identification & cooperation are useful. so you may do a family hx & learn about drugs. * Prevalence is 5% of school-age children. ADHD. * In most individuals. & impulsivity. & antisocial personality d/o. * Physical exam may find perceptual-motor problems & incoordination. mental retardation. Occurs at a 9:1 male-to-female ratio. especially methylphenidate (Ritalin) & other amphetamines like dextroamphetamine (Dexedrine) & pemoline (Cylert). the problem is they cannot focus. uses drugs. cutting class. One way kids can fit in is by joining a gang. & mood d/o. * Children w/ ADHD many times do not get better. learning d/o. The point is this could happen. inattention. & not automatically restarted following the Pt’s summer vacation. & substance-related d/o.* No specific etiologies have been identified. setting fires. fire setting.g. running away. robbery. property destruction. & antisocial personality. Big Brothers). Other CNS pathology & disadvantaged family & school situations are sometimes present. * Complications include substance-related d/o & school failures. usually morning or during day (not after 2pm). autistic d/o. . Occurs at a 9:1 male-to-female ratio. sometimes. * Conners Rating Scale (Revised) is used by teachers to help determine if a child has ADHD. inability to sit through cartoons or meals. who killed animals then eventually people. & rules. * Tx is healthy group identity & role models. * Drug holiday is when the child only takes the medication during the school yr & stops during the summer. shunning by peers. mood d/o. * They are usually effective in decreasing hyperactivity. theft. Another ex is Jeffrey Dahmer. * Common associated problems include low self-esteem. &/or school truancy. motor skills d/o. poor academic performance. inability to wait in lines. somatoform d/o. ADHD. * Tx focuses on psychopharmacology. Stressful family & school environments have also been implicated. failure to stay quiet or sit still in class. Children could have ADHD. depressive d/o. & educational interventions. mood lability. fighting. * Children w/ ADHD do not have learning problems. Ex is stealing other kid’s lunch money. * Genetic influences play a role by affecting temperament. conduct d/o. * Key sx include bullying. & physical trauma as a result of impulsivity. & poor relationships w/ siblings. substance related d/o. fighting. deceitfulness or theft. Truant officers ensure these kids go to school. * Onset usually first recognized when a child enters school. * Specialized educational techniques. social. Say that adolescent becomes 18yo & is not better. & oppositional defiant d/o. * Methylphenidate is given to children above the age of 6. communication d/o. & substance related d/o. * Onset is most often during late childhood or early adolescence. * DDx has major rule-outs of environmental problems. school failure. * Prevalence is 10% of school-age children. & has children. * IQ tests & various structured sx-rating scales for use by teachers & parents are often used.

& defiant behavior toward adults. The boy doesn’t we the bed at the sleep over because he doesn’t sleep the entire night. * Risk factors include excessively close-knit families (overbearing parents). & urinary tract infections. * Tx is appropriate toilet training & avoiding large amounts of fluids before bed. * High reactivity & ↑ motor behavior are innate features of temperament that may predispose to this d/o. ------------------------------------------------------------------------------------------------------------------------------------------Childhood D/o: Childhood Enuresis * The d/o is characterized by repeated voiding of urine into the Pt’s clothes or bed in a child at least 5 yrs of age. decreasing emotional stressors & rewarding the child w/ praise for a dry bed or clothes. & to be consistent in statements & deeds. gets DPT shot at 6 months. * Associated problems include family conflict & school failure. excessive expectations of children. There may be special parenting classes available. Then. Often causes emotional turmoil in the child or parents. only during daytime. Make sure to rule out medical conditions. It is diagnosed only if the behavior is not due to a medical condition. sore throat. * Social phobia in children is characterized by excess timidity & fear of stranger. School phobia is common. low self-esteem & mood lability. * Oppositional defiant d/o children do not break the basic rules of society. but baby starts crying. * Common case is a boy who wets the bed at home & gets invited to a sleep over. to reward desired behaviors & not to simply punish undesired behaviors. ------------------------------------------------------------------------------------------------------------------------------------------Childhood D/o: Childhood Anxiety * Stranger anxiety (nml) is the fear of strangers in unfamiliar context that is present from 8 months to approximately 2 yrs of age. head hurts.Punishment & incarceration are not often effective. Onset is later in females. Basically we cross our fingers & hope something works. * Bell-pad apparatus is a pad that lays on top of the bed. * Separation anxiety (nml) is fear of separation from the caregiver that is present from approximately 1 to 3 yrs of age. early onset of substance abuse. & competence. but they feel just fine on Saturday morning. * Pharmacotherapy includes desmopressin (DDAVP) & imipramine for short-term tx. Inconsistent or poor parenting may also contribute. The hope is that they learn to not break the law. Outcome often results in conduct d/o. ------------------------------------------------------------------------------------------------------------------------------------------Childhood D/o: Oppositional Defiant D/o * Persistent pattern of negativistic. then cries. Ex is gr&ma spends first three months w/ child & the child doesn’t cry. Alternative caregivers may be indicated in some cases. ADHD. Occurs at a 1:1 male-to-female ratio. Bart has oppositional defiant. senses wetness. hostile. * Tx involves advising parents to spend time interacting w/ the child. * Family conflict often escalates after the onset of sx. * Phobias (nml) are irrational fears that often present from approximately 3 to 6 yrs of age. no crying. This goes away as child goes through object permanence stage. * Prevalence is 3% of children aged 10 & slightly more common in boys. then she comes back at 7 months & tries to kiss baby. * Generalized anxiety d/o in children is characterized by excessive or unrealistic anxiety about future events. * DDx includes conduct d/o. temper outbursts. * Age 5 is where you should have complete control of your sphincter. including arguments. no crying. * One popular therapy today is taking kids who are almost ready to go to jail & put them in boot camp. past behaviors. or both. children will have sx only M-F mornings. Nelson has conduct d/o. * Physical exam should focus on medical problems. * Childhood anxiety d/o involve anxiety that is inappropriate in terms of focus or intensity. such as urinary tract infection or diabetes. * Onset is usually in latency or early adolescence & may start gradually. & learning d/o. & innate temperamental anxiety. Another ex is baby going in to get DPT shot at 2 months. * Etiology includes current psychological stress. tummy aches. because if they fail boot camp they go to jail. & then rings a loud bell. * May occur only at night. the parents think the boy is being bad & intentionally wetting the bed only at home to make the parents miserable or punish them. . A bell-pad apparatus is sometimes used. & deliberate annoyance. * Prevalence is 10% of school-age children. family hx of enuresis. Ex is the TV show The Simpsons. vindictiveness. Conduct d/o involves breaking the law. gets DPT shot at 4 months.

quivering voice) & motor tension. we lost an engine & are out of fuel.” A nml response will be panic & screaming. timidity. Clonidine & clonazepam are sometimes useful (noradrenergic system). * Physical examination can include evidence of nail biting & scratching. * Some studies show blood pressure rises the moment Pts arrive at a physician’s office (white coat syndrome). difficulty sleeping. They also do masking techniques to hide the tics from others. * Physical exam may show autonomic arousal. & behavioral therapy. * Associated problems include ADHD & obsessive-compulsive d/o. * Tx of choice for phobias is behavior modification. * A 13yo boy is referred by his junior high school principal for evaluation of his short attention span & inability to sit quietly in class or on the school bus. nail-biting. * Prevalence is 5 per 10. Ex is fake coughing along w/ a vocal tic. * Kids w/ Tourette syndrome can suppress their sx for a short period of time. & excessive worries. singing. difficulty concentrating. originally paired w/ a feared situation. * Behavioral theory says anxiety is a conditioned response to environmental stimuli. h&s shake. fears. * Psychodynamic theory says anxiety occurs when instinctual drives are thwarted. & risperidone because they lower the level of DA. There are associations between ADHD (50%) & OCD (40%).g. Now every time you drive by an airport you get scared & panicked. exaggerated startle responses. * Complications include social avoidance. spinning. & hair-pulling. ------------------------------------------------------------------------------------------------------------------------------------------Childhood D/o: Tourette D/o * Childhood onset of multiple motor &/or vocal tics. Another ex is pretending to adjust your hair w/ your h& to cover up a neck-rolling motor tic. & self-mutilation such as scratching. 5HT. * Autosomal dominant transmission may occur in some cases. Key sx include prominent physical complaints such as stomachaches & malaise. * Ex for PTSD is you are sitting on a plane & the flight attendant says “everybody assume the crash position. then being afraid of all animals at age 16. * Course is lifelong w/ remissions & exacerbations. trunk. or may involve complex behaviors such as pacing. ------------------------------------------------------------------------------------------------------------------------------------------Anxiety D/o * Anxiety is a syndrome w/ psychological & physiologic components. & other general medical conditions. BZDs. * Motor tics may present as twitching of face. * Psychological components include worry that is difficult to control. motor restlessness. He has a quick temper at school & at home.* Prevalence is 5% of school-age children. & GABA (most implicated). * Tx is high potency antipsychotic drugs. * Tx includes antidepressants. * Presenting sx include excessive nervousness. & anxiety attacks. . haloperidol. monsters) & nightmares. or touching.000. cocaine. dry mouth. Abnmlities in the DA & adrenergic systems have been implicated. palpitations. * Biological theory says various neurotransmitters & various CNS structures are involved. * Physiologic components include autonomic hyperactivity (e. Ex is being bitten by a rabbit at age 4. coprolalia occurs in about 10% of cases. & his peers tease him about his temper. * Vocal tics are usually grunts. A more common ex is being in a car crash then being afraid of certain intersections or car situations. This occurs in phobias & in post-traumatic stress d/o (PTSD). hyper-vigilance. upset stomach. various phobias such as school phobia & fear of animals or the dark. It is twice as frequent in males. such as NE. may be screaming. * Clonidine is a presynaptic inhibitor of norepinephrine. irrational avoidance of objects or situations. * Vocal & motor tics wax & wane over time. unrealistic fears (e. sense of impending doom. & inhibited social development may occur. amphetamines). Brain areas involved include the locus ceruleus (NE) & raphe nucleus (5HT). * Stimulus generalization says that any stimulus that resembles the original will produce the same effect. the pilot & copilot have died. or extremities. clicking. low self-esteem. Average age of onset is 7 yrs. * Mental status exam may show hyper-arousal. present in about one-third of cases. * Diagnostic tests include general medical conditions (thyroid) & drug use (caffeine. including pimozide. What will most likely be associated? Answer is conduct disturbances. & sleep disturbances. The plane then crashes but you survive. & we are about to crash into a mountain.g. restlessness.

organizing. that is likely a phobia. epinephrine. * Obsessive-compulsive d/o (OCD) involves obsessions. * Psychotherapeutic interventions include relaxation training & systemic desensitization for agoraphobia. & reduce anxiety. generalized anxiety. substance-induced anxiety. Exs include people being afraid of speaking in public. time consuming. that’s not necessarily a phobia. guilt. counting. & MAOIs. exposure & response prevention (similar to flooding). Occurs at a 1:1 male-to-female ratio. * Pharmacologic interventions include SSRIs.g. & praying. * Agoraphobia is fear or avoidance of places from which escape would be difficult in the event of panic sx. flumazenil. * High incidence of social phobia in the avoidant personality d/o. * Systemic desensitization pairs anxiety w/ relaxation because it is not physiologically possible to have both anxiety & relaxation at the same time. or early adulthood. & occurs during childhood. These may be h& washing. which are anxiety provoking intrusive thought that tend to be repetitive. hyperventilation. doubt. & be a/w intercurrent sessions. aggression. checking (e. * Panic attacks include intense anxiety often marked w/ physical sx. * Phobic d/o are irrational fears & avoidances of objects & situations. imipramine. * Key sx include attacks that last a few min & Pts may complain of impending doom or fear of death. then pictures of spiders. Once that step is mastered. & genetic components. clonazepam. & substance abuse. It has to be irrational. These Pts may present to the Emergency Department thinking they have a heart attack. * Exposure & response prevention would be taking a person who has a fear of contamination & getting them really dirty & then not letting them wash. * Tx includes behavioral therapy such as relaxation training. CO2). dizziness. “panicogens” (lactate. Associated problems include agoraphobia. When confronted w/ the feared object. Most commonly seen in young women w/ genetic loading.* DDx includes adjustment d/o. then fake rubber spider. * Onset is during third decade of life (20 to 30 yrs). * Sx usually wax & wane. * Risk factors include separations during childhood. If you are swimming in the ocean & feel afraid of sharks. senseless. the anxiety decreases. * Onset is insidious. such as tachycardia. * Relaxation training is focused on breathing exercises & guided imagery (picturing self in relaxing setting). afraid of eating in restaurants or using public restrooms. These typically occur out of the blue & cause intense distress to the Pt. * Imipramine is common only because many studies on TCAs & anxiety involved that drug specifically. * OCD involves compulsions. * Pharmacotherapy includes SSRIs. the stove). & sex. * Tx in mainly cognitive-behavioral therapies. ex worst is real spider. But if you are sitting at work or in a classroom & get anxious about sharks. * Severity of sx may wax & wane. such as systemic desensitization & assertiveness training. * Pharmacology includes SSRIs & TCAs (clomipramine). general medical conditions. Depn & substance abuse are associated. * Etiology is thought to be abnmlities of serotonin metabolism. * Social phobia is fear of humiliation or embarrassment in either general or specific social situations. Occurs at a 1:2 male-to-female ratio. buspirone. Ex would be the Pt is brought into a room w/ the therapist & w/ 1000 spiders. guided imagery. * Specific phobia is fear or avoidance of objects or situations other than agoraphobia or social phobia.g. The Pt sees that the therapist is calm & they learn from that & hopefully calm down as well. Systemic desensitization is used more commonly than this. * Flooding is a technique that involves massive exposure (e. adolescence. anxiety d/o. Depn. * Prevalence is 2% of population. * Alprazolam (Xanax) is typically the drug of choice for urgently stopping a panic attack. After a while. alprazolam. * Beta-blockers mask the autonomic sx of anxiety (such as h&/voice quivering in performance anxiety). * Important differentiating point for phobias: most people are afraid of height or afraid of sharks. Then the therapist starts at the least anxious item on the list & works on relaxation techniques w/ that item being present. & sweating. & commonly concerning contamination. * Acute stress d/o (ASD) & post-traumatic stress d/o (PTSD) are characterized by severe anxiety . * OCD is usually chronic & sx worse w/ stress. * Panic d/o has recurrent unexpected panic attacks. which are peculiar behaviors that tend to be repetitive. Clomipramine is the most serotoninergic of the TCAs. & beta-blockers (especially for stage fright). * Prevalence is 2% of the population. the TV show Fear Factor). Pts typically experience anxiety. The Pt makes a list of what makes them the most anxious to the least anxious. they move on to the next item in the list.

“Why should I quit smoking? If I’m destined to get lung cancer. & substance specific syndromes. * Internal locus of control means you feel you control your own destiny. personality d/o. anxiety lasts less than 1 month (but > 2 days).sx & follow a threatening event that caused feelings of fear. * Physical exam may show impairment in CNS fxn (tremors. Premorbid factors include substance abuse. sensory impairment. doesn’t smoke. or who is driving home from the store & gets lots. * EEG. poorly controlled anxiety about life circumstances that continues for more than 6 months. * Generalized anxiety d/o (GAD) is excessive. For the next week. intrusive recollections). & disturbances in executive fxn (abstract thinking. although not diagnostic. helplessness. or keeping a home). somatic sx. poor coordination. external locus of control (fate or luck controls your destiny). Slowing really means nothing though. * Ex of executive fxn problems would be a Pt who can no longer balance their checkbook. but can occur after months or yrs. agnosia (failure to recognize or identify people or objects). reassurance. other antidepressants. more likely among young or elderly. stopping a medication). debilitation. focal deficits. * Tx is counseling (especially immediately after the event reduces incidence). etc. especially if due to medical reasons. but can tell you what it is if they feel it. * GAD is usually chronic & sx worsen w/ stress. * There is a genetic predisposition for anxiety trait. presence of specific general medical conditions. & pharmacotherapy (SSRIs. * Prevalence is 5% of the population. & amnesia. * A 31yo local politician has a sudden onset of extreme anxiety. & sustained or excessive exposure to a variety of substances. Onset is mainly during childhood. * Associated problems are Depn. which are caused by general medical conditions. especially if due to medical reasons. antidepressants. underlying general medical conditions. About 50% of cases resolve w/in 3 months. flashbacks. * Tx includes behavioral psychotherapy & pharmacotherapy. * Sx include memory impairment (especially recent memory). & diaphoresis immediately before his first scheduled appearance on national television. * Sx usually begin immediately after trauma. substances. * Dressing apraxia would be a Pt who takes a pair of pants & puts them on their head. I will.g. but can by visualization. & he cancels all of his scheduled public appearances. & just got lung cancer. * Tx PTSD right away improves the chances of recovering. * Tx is amelioration of underlying pathology (e. shopping. CNS pathology. & ↑ arousal (anxiety. Occurs at a 2:3 male-to-female ratio. * Sx include re-experiencing of the traumatic event (nightmares. or both. * Visual agnosia would be a Pt that cannot recognize a quarter. childhood trauma. Psychological & physiologic sx are present. or horror. will see slowing or focal activity. * Buspirone (Buspar) can be used because it is not addicting. * Behavioral therapy focuses on relaxation training & biofeedback. * Neuro-imaging testing can be done. making plans. & emotional support. etc. * Buspirone does not potentiate the effects of EtOH. * Pharmacotherapy includes venlafaxine (Effexor). BZDs). hyper-vigilance). * Risk factors are traumatic events. * In ASD. apraxia (failure of ability to execute complex motor behaviors). * Onset may occur at any age. dementia. sleep disturbances. * Neuro-ψ testing can be done.). avoidance of stimuli a/ trauma (phobic avoidance). * Risk factors are very young or advanced age. buspirone. Which of the following is the most likely Dx? Answer is social phobia. * In PTSD. ------------------------------------------------------------------------------------------------------------------------------------------Cognitive D/o * Cognitive d/o are characterized by the syndromes of delirium. Mgmt includes frequent orientation. These Pts may worry their entire lives. He is unable to go on the air. anxiety lasts longer than 1 month. versus waiting for several months.” These individuals are more prone to illness (physical & psychological). My parents have smoked for 50 yrs & don’t have cancer. & BZDs. aphasia (failure of language fxn). group psychotherapy w/ other survivors. * Ex for external locus of control would be a Pt that says. tremulousness. * Tactile agnosia would be a Pt who cannot recognize a quarter by touch. & substance abuse. he is paralyzed by fear each time he faces an audience. My next door neighbor is 27. .

* Studies show most people who have had a traumatic brain injury eventually develop some type of dementia. * Most common cause of delirium is drugs. caused by acute metabolic problems or substance intoxication. * DDx include delirium or age related cognitive decline. * The stability or deterioration of course depends on etiology. Delirium typically lasts from days to weeks. * Physical exam could show CNS pathology. emotional. Huntington disease. * MMSE is performed routinely in the elderly. reassurance. metabolic. intracranial processes (HIV). protective use of physical restraints. delusions. & basic laboratory examination to rule out the reversible causes (e. emotional lability. reassurance. head trauma. metabolic d/o (Wilson). radiation. hospitalized Pts. vascular dementia (multi-infarct dementia). Depn. & person. * Visual hallucinations are more likely in delirium than dementia. & toxins (EtOH. tx infection). flattened sulci. endocrinopathies (hypothyroidism). Creutzfeldt-Jakob disease. * Dementia is characterized by prominent memory disturbances coupled w/ other cognitive disturbances that are present even in the absence of delirium. all of these tests will come back negative. Pick disease. * Tumor/trauma. Caused by CNS damage & tends to have a chronic course. Infections like syphilis order an rapid plasma reagin (RPR). stop drug. Anyone who scores < 24/30 is indicative of dementia. * Specific dementias include Alzheimer dementia. anxiety. 85yo Pt starts having visual hallucinations for the first time. & enlarged ventricles. & more than 20% of those over 85yo. * Disorientation occurs in the order of time. * 90% of dementias are irreversible. neuro-imaging. incontinence. hallucinations (Pt may scream in the middle of the night or talk to family members who are not there).g. * Alzheimer dementia Pts occupy more than 50% of nursing home beds. Huntington). TSH. * Risk factors include medical conditions. * Neuro-imaging testing & neuro-ψ testing may be ordered as well. nutritional. or rapidly decreasing level of many drugs. * DDx includes dementia.* Delirium is characterized by prominent disturbances in alertness. confusion. * A/. * EEG typically finds slowing of waves or local abnmlities. neuroψ. Pick. * Ex. & a short & fluctuating course. B12. nystagmus. tumor/trauma. & HIV related dementia. such as systemic infections. place. * Elderly Pts have lower glomerular filtration rate (GFR). Physical exam would find features of alcoholism. order a head CT. * Nearly every time. so a “nml” dose will remain longer. general medical conditions. Folstein mini-mental status exam (MMSE). sustained. * Reversible dementias are (mnemonic is DEMENTIA) drugs. hepatic diseases. emotional support. * Presents w/ agitation or stupor. * Put Pt in familiar surroundings. metabolic d/o. general medical conditions. & head trauma. & high potency antipsychotic medications (less anticholinergic side effects). * EtOH dementia is the third most common cause. medications). asterixis (h& flapping). Prevalence is almost 50% post-hip surgery. * Risk factors include SZ d/o. personal disturbances. * Tx is focused on ameliorating the underlying condition (e. traumatic brain injuries. Parkinson disease. & substance specific syndromes. * Associated findings of dementia include abnmlities in neuro-imaging testing & neuroψ testing. *Neuroanatomical findings include cortical atrophy. calendar on wall). & substance specific sx. Think delirium & not schizophrenia. * Testing includes EEG. & Down syndrome. & if agitated give antipsychotics. * Key sx are increasing disorientation. tremor. especially in the elderly or debilitated. atherosclerosis. * Physical exam may show incoordination. * Prevalence is 5% of the population over 65 yrs of age. * It is found in 50-60% of Pts w/ dementia.g. folic acid). * Risk factors are female gender. Not much information here. * Some types of neurodegenerative dementias are inheritable. infections. &/or disturbed psychomotor activity. cerebrovascular disease (vascular dementia). nutritional deficiencies (thiamine). & delusions. endocrine. * Risk factors include neurodegenerative disease (Alzheimer. * Delirium occurs in 25% of elderly.g. substance intoxication or withdrawal. * Tx is amelioration of underlying pathology. psychotic d/o. pernicious anemia (vitamin B12). hallucinations. Most are dementia of the Alzheimer type. fear. SZ. & tumors. family hx. . * Tx includes frequent orientation (e. emotional lability.

correction of sources of emboli. & EEG abnmlities. such as smoking cessation. * Motor sx include resting tremor (e. myoclonus. a high rage threshold. etc. * Presents w/ dementia. * Sx progress over months from vague malaise & personality changes to dementia & death. & enlarged cardiac chambers. Second most common type of dementia. * Pick disease is another type of dementia. * Abnml reflexes & gait disturbances are often present. manifested by choreoathetosis. bradykinesia. * Dementia occurs in 40% of cases. hyper-sexuality. Ach is linked to memory. HTN. progressive. * Thrombolytic agents (TPAs) are given in hopes of decreasing cellular ischemia during the first hours of an acute ischemic stroke. & psychosis (e. suicidal behavior. * Creutzfeldt-Jakob disease is a rare spongiform encephalopathy caused by a slow virus (prion). neurofibrillary tangles. * Affects small & medium sized vessels. w/ resultant ventricular enlargement. progressive. * Deterioration is generally gradual. & gait disturbances. * Differentiate nml aging tremor (intention tremor) from Parkinson dementia tremor (resting tremor). * Tx is directed toward the underlying condition & lessening cell damage. * MRI may reveal hyper-intensities & focal atrophy suggestive of old infarctions. pill-rolling). such as hyperphagia. or dropping objects.g.g. * Caused by a defect in an autosomal dominant gene located on short arm of chromosome 4. * Vascular dementia found in 15-30% of Pts w/ dementia. carotid artery). * Deterioration may be stepwise or patchy. & myoclonus. * Risk factors include male gender. & passivity. Neuroanatomical findings include atrophy in the frontal & temporal lobes. * Huntington disease is a rare. & psychotic features are fairly common. * Clinical onset is usually between age 50 & 65. olanzapine. the “worst” dementia. Very rapid progression. neurodegenerative disease that involves loss of GABA-ergic neurons of the basal ganglia. visual hallucinations). * Difficult to distinguish from Alzheimer disease. neuronal loss. fundoscopic abnmlities. not at rest. * Tx includes long-acting cholinesterase inhibitors. severe mood instability. * Examination may reveal carotid bruits. Tissue plasminogen activator is known as tPA. * Atrophy of the caudate nucleus. Alzheimer dementia is usually linear or continuous decline. * Behavioral disorganization. * May see features of Kluver-Bucy syndrome. & dementia. & granulovascular degeneration of neurons. or other cardiovascular d/o. * Etiology is unknown. control of cholesterol. so takes a lot to get them upset. weakness. choreoathetosis & other abnml movements. depending on underlying pathology. Congo red stain is used for amyloid. hyperorality. * Choreoathetosis could be described as being clumsy. endarterectomy (e. * Findings include ↓ acetylcholine (Ach) & norepinephrine (NE). Most common in men w/ family hx of Pick disease. neurodegenerative disease involving loss of DA neurons in the substantia nigra. is common. * Triad for Huntington: dementia. & depressive sx are common. &/or focal deficits. * Control of certain risk factors is useful. * Risperidone. * Early sx include personality changes & subtle movement disturbances w/ progression to choreoathetosis & dementia. * In contrast. Use to be called multi-infarct dementia. * Parkinson disease is a common. look for atrophy of the frontal & temporal lobes. w/ average duration from onset to death being about 8 yrs. * Intention tremor is a tremor that occurs only when something is picked up &/or moved. * Clinical onset usually occurs at approximately 40 yrs of age. . may have lateralizing signs. synaptic loss. * Focal neurologic sx or deficits are rarely seen. * Passivity means lack of fear of predators. * Alzheimer disease is a/w chromosome 21 (Down syndrome association).* Histopathology findings include senile plaques (amyloid). * A prion is a protein w/ no RNA or DNA material. Histopathology findings include Pick bodies & Pick cells in affected areas of the brain. such as tacrine (Cognex) or donepezil (Aricept). focal neurologic sx are common. choreoathetosis. dysarthria. rigidity. * Findings include visual & gait disturbances. & anticoagulation therapy may be indicated.g. psychosis. carotid bruits. & quetiapine (atypical antipsychotics) can be used. * Cerebrovascular pathology. * Risperidone & other high potency antipsychotic medications may be helpful in low doses to decrease agitation. * In vascular dementia. clozapine is second line. * If vascular dementia.

Mood disturbances in individuals w/ HIV infection may mimic cognitive impairment. * HIV related dementia is caused by HIV directly & progressively destroying brain parenchyma. a sloppy signature would be indicative of nml aging. forgetting that you wanted to go to the kitchen. how you took care of his wife. it is splitting off of the brain from conscious awareness. A nml signature would be seen in Parkinson. SZ. * Destruction of DA neurons in the substantia nigra is a key pathogenic component. then getting up for water but ending up in the living room wondering why you are there. if an individual’s consciousness becomes too fragmented. etc. what a wonderful doctor you are. depending on etiology. hypertonia. & severe infestation of cockroaches. * Risk factors include bilateral damage to diencephalic & mediotemporal structures. * Presenting complaints & findings of dissociative d/o include amnesia. DA agonists. like in a dream. how you took care of his children. All you know if you got in the car & now you’re at work. open the fridge. & then just stare. * Tx of Parkinson disease involves use of DA precursors. will typically see evidence of EtOH abuse. L-DOPA is used because DA does not cross the blood brain barrier. as in Korsakoff encephalitis. & EtOH. Answer is dementia. cerebrovascular disease. * Testing includes EEG (typically slowing of waves). anticholinergic medications. stop lights. however. thiamine deficiency. * A 65yo woman is found by the police in a filthy apartment after they were called by neighbors complaining of an unpleasant odor. getting thirsty. * Presenting sx include memory loss that may be sudden or gradual. Emergency room assessment reveals a very frail & unkempt woman who is completely alert & attentive. She believes it is 10 yrs earlier than it actually is. & dysphoria. genetic predisposition. introducing yourself. The woman angrily refuses to leave w/ the police. hypoxia. like floating & seeing self below). * It becomes clinically apparent in at least 30% of individuals w/ AIDS. * Confabulation (false memory formation) often occurs. likely Alzheimer. then the Pt starts telling you a story about all of the wonderful things you’ve done for him in the past. who had dissociative personality d/o (formerly multiple personality d/o) as a result of severe sexual abuse by her mother. personality changes. * May be misdiagnosed as Depn in early stages due to complaints of apathy. * Diffuse & rapid multifocal destruction of brain structures occurs. neuro-imaging & -ψ testing (may be abnml). & odd inner experiences (e. including environmental toxins. it may pathologically interfere w/ the sense of self & ability to adapt. & oculomotor deficits. She is unable to give the current addresses or phone numbers of her children & cannot find her phone book or purse. * Recent memory is disproportionally affected. & perception.g. * Another ex is being in bed. * Motor findings include gait disturbances. Her brain created another personality to dissociate (protect) herself from realizing the horrible acts she was going through. pathologic reflexes. dementia. * Dissociative amnesia is significant episodes in which the individual is unable to recall important & often . social withdrawal. & may be caused by multiple factors. ------------------------------------------------------------------------------------------------------------------------------------------Amnestic D/o * Amnestic d/o are characterized by prominent memory impairment in the absence of disturbances in level of alertness or the other cognitive problems that are present w/ delirium or dementia. local infection. * DDx include delirium. & aging. beginning w/ subtle personality changes. May include 70-90% of Pts by the time they die. Pt won’t remember what they did yesterday or ate for breakfast. * Another ex is you are hungry for something in particular. & selegiline.* So. identity. ablative surgical procedures. ------------------------------------------------------------------------------------------------------------------------------------------Dissociative D/o * Dissociation is the fragmentation or separation of aspects of consciousness. & she seems confused about her current finances & social contacts. clogged sinks & toilets. erratic behavior. Police find spoiled food in the kitchen. & dissociative amnesia. stating that her neighbors have threatened her w/ attack & she fears that they will rob her apartment in her absence. infection. * Ex of confabulation would be meeting a Pt for the first time. * Sybil was a book that told the story of Mason. & delirium is often present. head trauma. * When doing physical exam. * So. * Ex of nml dissociation is getting in car to drive to work & not remembering seeing any traffic. Some degree of dissociation is always present. or l&scape on the way there. * EtOH is the most likely cause or amnestic d/o. including memory. amantadine. & hyperreflexia. * Dissociative amnesia is where a Pt exhibits a stressor & has a memory loss.

& dissociative d/o. accompanied by the inability to remember one’s past & by confusion about personal identity. Usually occult (may take many yrs). * Ex is personality A goes to a movie. * Sx include amnesia that may be general or selective for certain events. “I don’t remember my name”). more severe than dissociative amnesia (e. often following a stressful life event. are not aware of the memory loss. factitious d/o. Look for gaps in memory. * Co-morbid conditions are borderline personality d/o. * Associated problems include mood d/o. * Sx may fluctuate or be continuous.g. & relaxation techniques are helpful.2%. They are convinced that their new identity is their actual real identity & have no recollection of any previous identity. & they’re doing this just to bother me.g. or by the assumption of a new identity. typically. * DDx includes complex partial SZ. * Incidence is 0. & malingering. during war). Onset is usually sudden. Another ex is Jason Borne in the movie Borne Identity. * The presence of distinct personalities is often subtle. substance induced amnestic d/o. * Associated problems include chaotic interpersonal relationships. & personality d/o. They are coming into my house. & substance abuse. * DDx include amnestic d/o due to a general medical condition.” * Might say. “Someone is trying to make me go crazy. “I miss days in the week. unexpected travel. * Hypnosis (to retrieve memories). * Ex is a Pt who got in a car accident. * Pts w/ dissociative fugue. PTSD. . & eating d/o. & relaxation techniques are helpful. * Seen more commonly in women & younger adults. * Risk factors are psychological stressors.” * DDx include borderline personality d/o & other personality d/o. It would be pretty easy to move to New Jersey. changing my furniture. suggestion. sexual d/o. * The Pt should be removed from stressful situations when possible. * Psychotherapy should be directed at resolving underlying emotional stress. & is confused about why they are at a movie because they don’t remember buying a ticket. accompanied by failure to recall important personal information. * Depersonalization d/o are characterized by persistent or recurrent feelings of being detached from one’s mental processes or body. * Most episodes are isolated & last from hours to months. & substance-induced d/o. clinical presentation is several yrs later when disturbances in interpersonal fxning are present. E. * Tx of associated general medical conditions may improve overall level of cognitive & adaptive fxn. substance-related d/o. other dissociative d/o. * Associated problems are mood d/o. accompanied by intact sense of reality. suggestion. major depressive d/o & other mood d/o. * Hypnosis. In some cases. * Onset is usually detected retrospectively by the discovery of memory gaps of extremely variable duration. & malingering. it is discovered only during tx for associated sx.” *Amnesia may suddenly or gradually remit. starts a new life w/ a new name. * Tx includes diagnostic evaluation for general medical conditions or substances that may cause amnesia.emotionally charged memories. * Tx is psychotherapy to uncover psychologically traumatic memories & to resolve the associated emotional conflict. then claim you don’t know anyone when they find you. particularly when the traumatic circumstance resolves. then moves across the country. During the movie. distinct personalities (two or more) that recurrently control the individual’s behavior. * Resolution is usually rapid. This typically occurs as a result of psychological stress. * Childhood sexual abuse has been postulated as a risk factor. conversion d/o. suicide attempts. start a new identity. * Dissociative fugue is a sudden. personality B comes out. * Pts w/ dissociative amnesia are aware of the memory loss (e.g. * Seen more commonly in women. bipolar d/o w/ rapid cycling. impulsivity & self-destructive behavior. factitious d/o. * Ex for malingering is living in New York City & owing lots of people money. * Dissociative identity d/o (formally multiple personality d/o) is the presence of multiple. & has no memory of their previous identity or life. but amnesia may persist. Amobarbital (Amytal) interview may be used. “I don’t remember my name. * Tx is diagnostic evaluation for general medical conditions or substances that may cause amnesia. changing my clothes. Hypnosis or Amytal interview could be used as well. PTSD.

” (Pt believes they are not real) * Derealization means a perception of the environment is often distorted or strange during episodes of depersonalization. body dysmorphic d/o is when the Pt feels one part of their body is abnml. * Anorexia nervosa is characterized by failure to maintain a nml body weight. laxative abuse. * Average age of onset is 17 yrs. * Associated sx include excessive interest in food-relative activities (other than eating). the circumstances of his trip. * Episode of depersonalization are common. * Denial of emaciated conditions. or callused h&s/fingers from self-gagging to induce emesis. particularly conflicts w/ parents about independence. * About 70% of girls w/ anorexia nervosa also binge & purge. or any other information about his life. hypomagnesemia). reduced brain mass. He says that he found himself in Los Angeles. Jamais vu (a sense of familiar things being strange). * There may be a cultural risk factor due to emphasis on thinness. . but for different reasons. there is a significant weight loss. bradycardia. * There is a fear & preoccupation w/ gaining wait & unrealistic self-evaluation as being overweight. vomiting or taking laxatives. or enemas) & exercise. lanugo hair. ------------------------------------------------------------------------------------------------------------------------------------------Eating D/o * If a Pt binges & purges. do not automatically think anorexia nervosa. In bulimia.* Psychological stress it the major risk factor. & abnml EEG. accompanied by a feeling of being detached from physical surroundings. elevated liver enzymes. & diuretic abuse may be seen. & sexual conflicts. * These Pts may lose about 15-20% of what is considered ideal body weight. Answer is dissociative fugue. The man claims he cannot remember who he is. but that he cannot remember where he comes from. * Typical cause of death in these Pts is abnml electrolytes. * Volunteers bring a 19yo man to the emergency department from a homeless shelter. He has neither identification nor money. the weight will be around nml. self-induce vomiting. * W/ binge eating/purging. * Biologic factors are suggested by higher concordance for illness in monozygotic twins.g. Weight loss may also be achieved through purging (i. * Signs of malnutrition are normochromic normocytic anemia. scratched. * Tend to have amenorrhea for 3 cycles or more. They will be doing the same thing.5% & occurs at a 1:10 male-to-female ratio. diuretics. * Psychological risk factors include emotional conflicts concerning family control & sexuality. * Depersonalization described as “out-of-body experience. * Pts restrict food intake & maintain diets of low-calorie foods. * Amenorrhea may precede abnml eating behavior. but he has a bus ticket from New York. * Some individuals recover after a single episode & others develop a waxing & waning course. & purging. hypotension. * There is a body image disturbance present. Stressful events may precede the onset of the d/o. particularly hypokalemia. starvation. Significant amount of time spent examining & denigrating self for perceived signs of excess weight. (Pt believes the world is not real) * DDx includes substance-induced mental d/o w/ dissociative sx. * Onset is often a/w emotional stressors. & peripheral edema. sinus bradycardia. & other forms of perceptual distortion may occur. In contrast. If a Pt exercises & fasts. * Usually in adolescence or early adulthood. * Signs of purging include eroded dental enamel caused by emesis & scarred. * In anorexia. * General medical conditions caused by abnml diets. they feel overweight no matter what. abnml electrolytes (e. & depressive sx. déjà vu (a sense of unfamiliar things being familiar).e. * Great concern w/ appearance. do not automatically think bulimia nervosa. * Prevalence is 0. * Physical exam may show signs of malnutrition including emaciation. * Tx is psychotherapy. obsessive-compulsive sx. low estrogen & testosterone levels. Late onset anorexia nervosa has a poorer prognosis. * Subtypes are restricting (no binge-eating or purging) & binge-eating/purging (regularly engaged in binge eating/ purging).

Mallory-Weiss tears). saying you must gain a pound per week else you are fed via NG tube. She admits that she uses laxatives because she has been binge-eating frequently & is worried about gaining weight. ------------------------------------------------------------------------------------------------------------------------------------------Substance Dependence * Substance dependence is characterized by substance abuse that leads to loss of control or substance use & monopolization of time by substance use. cookies. . * Associated problems include depressive sx. & body dysmorphic d/o. substance abuse. helplessness. but they do it to go eat it secretly. * Comorbid d/o include borderline personality d/o. If a man is 6’ tall. not based on eating behaviors. & discussing drugs. * DDx includes bulimia nervosa. cakes. are usually employed. laxative induced diarrhea. add 5lbs. EtOH). * For men. major depressive d/o w/ atypical features. particularly SSRIs. “I work 9-5 during the week & don’t drink a drop. seen in about 50% of cases. * Course may be chronic or intermittent. The individual spends the majority of his time obtaining & using drugs. * Anorexic & bulimic Pts would rather eat alone so they can serve themselves the amount of food they want. or enemas. For every inch over 5’. schizophrenia. * Could sign a contract w/ the Pt. * Diagnostic tests may show evidence of laxative or diuretic abuse.” However. she believes that she is overweight. hypochloremic hypokalemia caused by emesis. * Onset is usually during late adolescence or early adulthood & often follows a period of dieting. * Rough estimate for ideal body weight: women who are 5’ tall should weigh 100lbs. Although the woman is very thin. Answer is anorexia nervosa. * Prevalence is 2% in young adult females. * Antidepressants may play a limited role in tx when comorbid Depn is present (cause weight gain). 5’ should weight 106lbs. OCD. they only drink to get drunk & every time they get drunk they get in trouble. They may serve themselves a larger portion when others are around to hide the problem. * Non-purging includes fasting or exercise. Co-occurring substance abuse is a/w a poorer prognosis.” * Substance abuse is an individual who uses drugs in a maladaptive way (e.* Signs of purging are metabolic alkalosis (loss of gastric acid).g. potato chips.g. * Typical foods during a binge are carbohydrate-rich (e. * Psychodynamic psychotherapies are useful for accompanying borderline personality traits. * May describe Pt as a gymnast. a ballerina. “Drugs become your life. Occurs at a 1:9 male-to-female ratio. & body image may predispose. * A 19yo woman is hospitalized for dehydration caused by severe. * Psychological conflict regarding guilt. Behavioral therapy should be initiated. & borderline personality d/o. or another “thin” body-type profession. pies. So if you’re 5’ 7”. & metabolic acidosis caused by laxative abuse. w/ rewards or punishment based on absolute weight. * Bulimic Pts also hide food around the house. * Bulimia a/w kleptomania. stealing things that they do not need. * Bulimia nervosa is characterized by frequent binge eating & purging & a self-image that is unduly influenced by weight. pastries). ideal body weight is 135lbs. recovering from drug use. general medical conditions that cause weight loss. For every inch over 5’. a supermodel. add 6lbs. * Physical exam may show evidence of purging (e. self-control. than that is abuse (e. * Biologic factors are suggested by frequent association w/ mood d/o. * Sx include recurrent episodes of binge eating & recurrent. She is depressed about the recent breakup of a romantic relationship. * Self-evaluation is unduly influenced by body shape & weight. * DDx includes anorexia nervosa. inappropriate compensatory behavior. She has never had a menses. * Anorexic may hide food around the house then throw it away when no one is around. Bulimia linked to low levels of serotonin. & impulsivity. * Tx is cognitive & behavioral therapy. They do this to make others think they are eating. gets self in trouble). * Initial tx should be correction of significant physiologic consequences of starvation w/ hospitalization if necessary.g. binge eating/purging. but no purging during bulimic episodes. * Family therapy designed to reduce conflicts about control by parents is often helpful. Ex is a Pt who only drinks on weekends saying. * Purging is self-induced vomiting or the use of laxatives.g. major depressive d/o. * Antidepressant medications. * 70% of cases have remitted after 10 yrs. diuretics. they should weight 178lbs.

* Look for evidence of self-inflicted injuries or accidents. * EtOH intoxication in most states is 100mg/dL of EtOH or 0. hepatitis C. * Intravenous drug abuse workups include HIV. economic disadvantage. bipolar d/o. & social isolation. especially for chronic users. benzos. * Have you ever felt that you should cut down on your drinking? Have you ever felt annoyed by others who have criticized your drinking? Have you ever felt guilty about your drinking? Have you ever had a morning drink (eye-opener) to steady your nerves or alleviate a hangover? * In addition to a general physical examination. how much do you use. Depn.* Substance dependence involves adverse medical.g. SGOT. Depn. * Experimentation w/ gateway drugs (e. E = Eye-opener. expect denial from abusers. & interactions w/ friends & acquaintances. substance intoxication. & tuberculosis. * Individuals who are innately more tolerant to EtOH may be more likely to develop EtOH abuse. childhood physical or sexual abuse. & consider behavioral approaches. * Laboratory toxicology includes breath (EtOH). * When assessing substance abuse. C = Cut down. cough. blood. such as aversive conditioning w/ disulfiram (inhibits aldehyde dehydrogenase). opiates/opioids. facial flushing. * Drug abuse affects 3 million people in the United States. when do you use it. & substance withdrawal. * Environmental risk factors include peer pressure. G = Guilty. what happens to you. so you cannot trust the Pt. staying up to 30 days. tobacco. poor nutrition.1% BAC. or emotional consequences from substance use. such as conduct d/o. Even if the person being tested has a shaved head (perhaps in preparation for the test). have you been in rehab programs. referral to group psychotherapy (alcoholics anonymous/AA) & family members to Al-Anon. the clinician should look for signs of poor hygiene. * Marijuana is likely the longest. have you been in tx centers. * Many experts believe naltrexone really doesn’t work. * Ψ disturbances can also lead to ↑ drug use. SGPT. This test is most useful for programs w/ a zero-tolerance policy. have you had withdrawal. * No one likes to admit they have a problem w/ drugs. * Poor parenting. & urine drug screens (w/ permission). * Twin studies show children of EtOH parents are 4 times more likely to develop alcoholism. * Cocaine is likely the shortest. &/or skin infections. * Hair testing is not routinely ordered. arms. Affirmative answer to any 2 of the questions (or to the last question alone) is suggestive of EtOH abuse.e.g. getting sick). & try to obtain additional hx from significant family members or friends. 80mg/dL. or emotional turmoil a/w specific stressors. barbiturates. * The self-medication hypothesis states individuals w/ certain psychological problems may abuse substances in an effort to alleviate sx. So if acetic acid is not produced then you have a buildup of acetaldehyde. & legs). & low self-esteem. a clinician should maintain an index of suspicious. ADHD. hair can also be taken from almost any other area of the body (e. * Substance abuse hx should include what drugs do you use. a high incidence of EtOH use during college does not necessarily imply future alcoholism. EtOH. * CAGE questionnaire for EtOH abuse. facial hair. hepatitis B. the enzymes that breaks down acetaldehyde into acetic acid. * Associated problems include social & occupational performance deterioration. including tolerance (more drug needed to produce the same effect) & withdrawal. college).g. & LDH. etc. * Sons of alcoholics are more likely to develop alcoholism than is the general population. but provides a longer window of detection. staying in the urine 2-3 days at most. Pt’s life basically spirals out of control. * Urine can test for TCAs. Some states down to 0. * EtOH abuse affects 14 million people in the United States (5% of population). & permissive attitudes toward drug use. & erratic or w/drawn behavior. school & occupational performance. & more. & physical signs of drug use including burns. which is toxic (e. needle marks. * Laboratory detection of EtOH abuse includes SGGT. * Tx for EtOH dependence includes using medications that reduce cravings (naltrexone). * Asians are less likely to develop EtOH abuse because they have reduced amounts of aldehyde dehydrogenase.08. social. then marijuana) may start as early as preadolescence. * The highest prevalence of substance abuse is between 18 & 22 yrs of age (i. the underarms. * Sx include overwhelming anxiety. A = Annoyed. * Clinical interview should include questions about family fxn. * Ask about “licking the needle” as this may predispose Pts to polymicrobial endocarditis & other infections as a result of mouth flora being injected into the bloodstream. . However.

enkephalins). * Heroin is by far the most commonly abused opioid. Methamphetamine (“crystal. especially those that require prolonged alertness (e. nicotine gum.g. Compulsive use of marijuana is a/w poor adaptation skills. Recommend cessation to Pts (e.* AA for Pts & Al-Anon for family members to learn how to stop enabling the user. * Marijuana (cannabis) is the most frequently used illicit drug. oxycodone). constipation. preventing respiratory Depn. & Non-STEMI (NSTEMI). & coma. Almost no one really wants to smoke. respiratory Depn. such as fading where you slowly reduce the reinforcer w/ the subject being aware. Psychosis. * Methadone & long-acting L-alpha-acetylmethadol (LAAM) are opioid agonists that decrease the chance of recurrence of severe heroine dependence. but being willing to quit is a different story. Exs include the patch. 1-800-QUIT-NOW). such as morphine & codeine. Naltrexone is given by mouth & has a long half-life. If you hide it in your spouse’s coffee. * Tx for opioid dependence includes using medications to reduce cravings (naltrexone). finding a new job. * Opioids/opiates cause pinpoint pupils (miosis). * Tx for nicotine dependence includes using medications that reduce cravings (bupropion). starting w/ 21mg. truck drivers) are at risk for amphetamine abuse. heroin. LAAM has a much longer half-life than methadone. drug-induced CNS damage.g. Significant withdrawal sx occur. assume opioids. . Depn. * Cocaine works on the DA system. This could involve finding new friends. & inhaler. * Suicidal ideation is an important withdrawal sx to watch for in cocaine abusers. * Amphetamines are rapidly increasing in popularity. * Naltrexone & naloxone blocks opioid receptors. it is essential to ask all Pts first if they are ready to quit smoking. Some occupational groups. occasional adjunctive pharmacology. & this may strongly contribute to compulsive use. ST elevation myocardial infarction (STEMI). population uses nicotine regularly. mouthwash.g. referral to group psychotherapy (smoking cessation groups). * Detoxification is substance-specific but generally involves calming support. This increases paranoia. or fully synthetic (e. referral to group psychotherapy (narcotics anonymous/NA). try to get everyone to do tx at the same time.” “ice”) is usually the amphetamine of choice & is often taken intranasal. hydrocodone. * If the Pt lives in a house w/ other smokers. * Use of crack cocaine has declined recently. Binge abuse is the usual pattern because tolerance develops quickly. & trauma from accident. & finally to 7mg. & violence are common findings in heavy users. then going to 14mg after several weeks. Anything w/ EtOH will cause a rxn (e. The Pt would then learn to avoid the restaurant or perfume. slurred speech. perfume. * Drug rehabilitation involves cessation of drug use & development of new coping skills that make relapse less likely.g. * Opioids are endogenous (e. * Complications include social deviancy. cologne). panic. etc. instead of ethanol EtOH. methadone. * Naltrexone is an opioid antagonist that blocks the pleasurable effects of opioids & EtOH. Beer & wine are the EtOH beverages of choice for most abusers.S. endorphins. both for rehabilitation & relapse prevention. Al-Teen also. & use of methadone to slowly taper the Pt off narcotics. semi-synthetic (e. * The patch is the most commonly used. & consider the use of behavioral approaches. tramadol) chemicals that bind to opioid receptors. & Dx & tx of medical complications have been the most effective tx available for many adult substance abusers.S. fentanyl. * EtOH is the most commonly abused substance in the U. * Disulfiram is an aldehyde dehydrogenase inhibitor that causes an unpleasant rxn when EtOH is ingested. * Acute coronary syndrome (ACS) may occur in cocaine users due to coronary vasospasm created by the drug. ACS covers unstable angina. * Disulfiram has to be purely volitional. so use increases DA levels.g. * Prevention programs teach adolescents how to resist social pressures to use drugs & to enhance other social & personal skills. * Since smoking is so difficult to quit. both for rehabilitation & relapse prevention. * A significant number of Pts remain on methadone tx for their entire lives. but always refer the Pt to group psychotherapy as well. Avoidance of opioid withdrawal often leads quickly to daily use & a need to obtain money for the habit. crème brûlée due to vanilla extract. * If Pt presents w/ pinpoint pupils & lower level of consciousness. * 25% of the U. * Opiates are natural alkaloids of the opium poppy.g. * Ex is the patch. * Self-help groups have been the most effective tx available for many adult substance abusers. Drug of choice is naloxone (Narcan). which blocks opioid receptors. they won’t learn. reassurance. Opioid abusers often isolate themselves from nonusers. hydromorphone. “Just say no” campaign commercials.

jumping off. dosage(s). & MDEA (“eve”). The man denies that he is addicted but is willing to enter tx in order to avoid more severe criminal penalties. * Hallucinogens cause “trips” w/ depersonalization & derealization. * Anabolic steroids are used by approximately 5% of adolescents. including 3. * If Pt has hx of EtOH abuse. * BZDs & other sedative-hypnotics are prescribed frequently. emotional reassurance & a structured/secured environment. plus prior experiences w/ substance detoxification. * Phencyclidine (PCP) use has declined. caused by the cessation of or reduction in heavy & prolonged substance use. * Designer drugs are transiently popular among small groups. This includes thiamine (prevents Wernicke encephalopathy). maladaptive behavioral change. * Tx involves removing sensory stimulation. glues. & solvents.g. Inhalants are often used by younger & poorer populations (e. They are commonly a/w other substance abuse. Some anabolic steroids may have psychoactive effects. Use of hallucinogens is usually intermittent. tremors or SZ in EtOH withdrawal). homicide.* Inhalants commonly abused include gasoline. * Medical hx includes complications of substance abuse (e. & psilocybin (mushrooms). usually days after a typical dose. * “Date-rape” drugs include flunitrazepam (Rohypnol). Ex would be a person getting up on a balcony. substance-specific syndrome caused by the recent ingestion of or exposure to a substance. * Family intoxication & withdrawal are disturbances that are a direct physiologic result of a substance.” N.g. It typically only occurs w/ heavy drinking for 3-5 yrs. Peak for DTs is 3-4 days. These effects usually are shorter than the original “trip. effects. * Hallucinogens include lysergic acid diethylamide (LSD. & BZDs for 3-5 days tapered slowly. ------------------------------------------------------------------------------------------------------------------------------------------- . Pts should be tapered off BZDs slowly to reduce SZ risk. st&ard procedure is to prevent delirium tremens (DTs). There is also an association w/ nystagmus of the eyes. multivitamins & folic acid.g. ask what substance(s) used. duration & social context of use. * Ψ hx includes other primary ψ Dx & past tx. Many of these drugs are methoxylated amphetamines. Tolerance & withdrawal are common. elevated liver enzymes in alcoholism). rehabilitation & relapse prevention. which is known as “XTC” or “ecstasy. both legal & illicit. “super human strength”) & psychosis are common w/ PCP intoxication. paint thinners. predominantly males. * Physical exam includes signs of substance abuse (e. * Substance intoxication is a reversible. Older persons may be at special risk because of problems w/ insomnia. w/ physiologic & cognitive concomitants. * Mental status exam includes signs of substance-induced d/o (e. quiet room.Ndimethyltryptamine (DMT).g. Gamma-hydroxybutyrate (GHB) produces a giddy intoxication lasting 4 hours. Most frequently used BZD is chlordiazepoxide (Librium) or oxazepam (Serax). * When getting a substance abuse hx. & flapping their arms to fly. Central America) because they are cheap & accessible. paranoia in cocaine intoxication).” * Hallucinogen persisting perception d/o (HPPD) is characterized by continual visual disturbances that are reminiscent of those generated when previously ingesting hallucinogens. * Hypnagogic regression (“flashback”) is when the individual experiences some subjective effects long after the drug has worn off.4-methylenedioxymethamphetamine (MDMA). * A 29yo man is brought in by judicial order for evaluation of his continued involvement w/ heroin use. Which of the following is essential to determine the presence of heroin dependence in this individual? Answer is he spends all his time trying to obtain heroin & can’t stop himself from using it. * Toxicology examination for types of substances & concentrations is helpful. * Substance withdrawal is a substance specific. Gasoline & toluene are a/w significant & possibly irreversible cognitive impairment in users. & pharmacologic intervention to ameliorate psychological or physical sx. such as putting the Pt in a dark. Ex is a young weight lifter is brought into the hospital w/ psychotic sx. Violence (e.g. * Tx is correction of physiologic complications resulting from substance abuse. can cause intoxication & withdrawal. mescaline (peyote). “acid”). which produce rapid onset of BZD-like intoxication including amnesia. Many recreational drugs. These work on serotonin (possible association w/ schizophrenia).

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