Psychiatry Case Files

Case Files

Presentation: 42 y/o currently depressed does not like TCA b/c MDD
of anti-AcH ADE. 1. Diagnostic Criteria: >2 MD EPISODES č 5+ Depressed + SIGECAPS symptoms for at least 2 weeks
• Next Step: SSRI > SSNRI > Bupropion / Mirtazapine • SIGECAPS: ∆Sleep, ↓Interest, ↑Guilt, ↓Energy (MC), ↓Concentration, ∆Appetite, Psychomotor Agitation/Ret. Suicide
• ADE: GI Symptoms + Sexual Dysfunction (except Bupropion) • ∆Sleep: MC = Initial/Terminal Insomnia ~ hard to fall asleep + early morning wakenings

Definitions • Note: must cause social/occupational impairment, cannot be related to substances and no h/o manic/hypomanic episodes
1. Mood: description of internal emotional state • Recall: Rx for MDD worsen Bipolar Disorder!
2. Mood Episodes: distinct period of time č abnormal range of
moods (depression, mania, hypomania, mixed state) • Subtypes of Depression
3. Affective Disorders = Mood Disorders: patterns of mood • Melancholic: typical in hospitalized patient
episodes (MDD, Bipolar 1/2 +/- psychotic features) • Atypical: hypersomnia, hyperphagia, reactive mood and leaden paralysis
• Catatonic: catalepsy (immobility), bizarre postures, echolalia ~ ↑Response to ECT
Rx • Psychotic: +delusions + hallucinations
• SSRI: Fluoxetine, Paroxetine, Sertraline, Citalopram; ADE =
Case GI Disturbance + Sexual Dysfunction • Epidemiology: 40 y/o, women > men in reproductive years, no ethnic differences, ↑mortality if +co-morbid conditions
1 • SSNRI: Venlafaxine/Duloxetine ---> MDD + Anxiety Disorder • DDx: ↓Thyroid, MS, Anti-HTN Rx, Steroids, Substances (↑EtOH / Cocaine Withdrawal)
+/- Diabetic Neuropathy; ↑BP (Venlafaxine)
• Bupropion: xNE/xD Reuptake ---> MDD + Anxiety upon 2. Pathophysiology: ↓neuroTx in Brain
MDD and Smoking Cessation • NeuroTx: ↓5HT / ↓5-Hydroxyindolacetic Acid (5-HIAA) ----> Improvement č Rx that ↑5HT, NE, Dopamine
• Mirtazapine: xNE/x5HT (≠reuptake) ---> MXX + Anxiety • ∆Endocrine: ↑Cortisol + ∆TFT ---> ↑Depression
Disorder and ↑Sleep • Genetics: 1st ° relatives = 2-3x ↑Risk

Bereavement: simple grief usually 2° loss of person <6 months 3.Management

• Bereavement: illusions ≠hallucinations/suicide, <6 months • Assess Suicide: ↑Risk of any Disorder = ↑Age, Male, h/o Suicide Attempts, +FMHx and (current risk) plans to perform
+/- ∆cognition <1 year. Tx č Psychotherapy +/- BNZ for sleep • First Line Rx: SSRI, SSNRI, Bupropion and Mirtaazapine
• Complicated Grief: >6 months č worsening symptoms • Atypical Depression: MAO-I (Phenelzine) ---> ADE = Orthostatic Hypotension >>> HTN Crisis (Tyramine), 5HT Syndrome
• Bereavement-Associated Dep.: progression to SIGECAPS • Psychotherapy: +Rx >>> either treatment alone
• ECT: if unresponsive to Rx, intolerable of Rx (Pregnant) or rapid treatment needed (Suicide)
Seasonal Affective Disorder: 2+ years of 2x MDD in a season č • MoA: atropine + muscle relaxant ---> induce generalized seizure x6-8 episodes ---> ADE = antero/retrograde amnesia
triad of Irritability, Carb Craving and Hypersomnia • Prognosis: 50-80% recurrent episode experienced

Presentation: 21 y/o currently bizarre/dangerous has 1 yr h/o Schizophrenia

delusions/hallucinations of multiple voices. Socially isolated č 1. Diagnostic Criteria: 6 months disturbance č 2+ active phase symptoms present for 1 month
disturbances in grooming. Paranoid, loose thoughts. • Any +Symptoms: Delusions, Hallucinations, Disorganized Speech, Disorganized/Catatonic Behavior
• Dx: Schizophrenia, Paranoid Type • Any -Symptoms: 5 As of Schizophrenia ~ Anhedonia, Affect (Flat), Alogia, Avolition, Attention (Poor)
• R/O: Psychosis 2° Substance Abuse / GMC • Stipulations: only 1 needed if bizarre delusion, significant social dysfunction, total 6 months, R/O other Psych DZ/GMC
• Next Step: Hospitalize patient b/c danger to himself/others
2. Pathophysiology
Definitions • Epidemiology: males (↑-symptoms) ~ 20 y/o vs. females ~ 30 y/o; ↑genetic component, ↑concurrent EtOH/Cannabis use
1. Flat Affect: absence of expression of any mood • Downward Drift: ↓SE-status = ↑schizophrenia; hypothesize that 1st schizo ---> ↓social functioning ---> ↓SE-status Diagnostic Criteria
2. Ideas of Reference: ↑false beliefs of things referring to self • Prognosis: female, ↑age of onset and +Symptoms >>> male, ↓age of onset and -Symptoms
3. Loose Associations: thoughts are not connected to e/o • Pathophysiology: ∆Dopamine >>> ↑5HT, ↑NE, ↓GABA, ↓Glu (=↓NMDA ~ psychosis č Ketamine)
4. Tangentiality: thoughts connected, but not answering initial ? • Prefrontal Cortical Pathway: ↓Dopamine ---> -Symptoms
5. Echo-: -lalia (repeat phrases) vs. -praxia (repeat practices) • Mesolimbic: ↑Dopamine ---> +Symptoms
6. Neologism: word č meaning only to person using it ≠ • Note: Tubuloinfundibular pathway (x = ↑prolactin) + Nigrostriatal (x = ↑EPS ADE) affected č neuroleptics
orthodox meaning of word • Phases: Prodrome (↑ withdrawal, ↑interest religion) --> Psychosis (↑+Symp.) --> Residual (↑-Symp. btw Psychosis)
• Subtypes ~ eliminated in DSM-V
Case Timeline • Paranoid: ↑preoccupation č 1+ delusions/auditory hallucinations; often older č ↑level of functioning DDx
2 1. Schizophreniform Disorder: same criteria, 1-6 months • Disorganized: ↑disorganized speech/behavior č flat affect; often younger (think about your OGYN patient!)
• Mgmt: Hospital + Neuroleptics, 1/3 Recover, 2/3 Progress • Catatonic (2+): immobility (catalepsy), ↑purposeless mvmt, ↑negativism/mutism, peculiar mvmt, echolalia/echopraxia
• Undifferentiated: characteristic of multiple / none of the above subtypes
2. Brief Psychotic Disorder: same criteria, 1day - 1month • Residual: ↑-symptoms >>> rare +symptoms
• Mgmt: Hospital + Neurolpetics, 80% Recover, 20% Progress
3. Management
Lessons Learned from Questions • R/O: Psychosis 2° GMC (Delirium, Dementia, ↑Thyroid, ↑Ca) vs. Psychosis 2° Rx (Phencyclidine Intox, Anti-AcH)
1. Typical Neuroleptics: look for EPS, TD and NMS • R/O: Schizophrenia vs. Mood Disorders
2. DoC NMS: Bromocriptine + Dantrolene • Schizoaffective: psychotic symptoms always present +/- additional depressive/manic disorder
3. Neuroleptic ADE Buzz Words • Mood Disorder č Psychotic Features: psychotic symptoms present only during mood disorder
Enlarged Ventricles/Cortical
• ThioRidazine: Retinal Pigmentation • Hospitalize: active psychosis requires hospital admission b/c 50% schizophrenics attempt suicide Atrophy
• ChLorpromazine: Cornea + Lens Pigmentation • Imaging: note CT +/- show enlargement of ventricles + cortical atrophy
• Rx: Atypical Antipsychotics ~ Olanzapine, Clozapine, Quetiapine, Risperidone, Ariprazole, Ziprasidone =======================
• Extrapyramidal ADE: Typical > Atypical ---> ↑Dystonic/Parkinsonism (+Benztropine), Akathisia (+β-B), NMS Schizophrenia: lifelong psychosis
• ↑Negative Symptoms: Typical > Atypical Antipsychotics (Typical effective against +Symptoms, but ↑-Symptoms) Schizoaffective: “ + mood disorder
• Agranulocytosis: Clozapine ---> use after failed attempts č multiple other Rx Schizotypal: magical personality
• Metabolic Syndrome: all Atypicals ~ Olanzapine + Clozapine (↑Risk) >>> Aripiprazole + Ziprasidone (↓Risk) Schizoid: withdrawn personality

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Psychiatry Case Files

Case Files

Presentation: 36 y/o č symptoms of panic disorder and ↑concern Panic Attacks: discrete periods of ↑anxiety common in Panic Disorder > Other Anxiety Disorders (PTSD/Phobias)
between episodes of another attack also is taking Synthroid for 1. Criteria: 4+ of PANICS D Criteria
hypothyroidism. • PANICS: Palpitations, Abdominal Distress, Numbness, Intense Fear of Death, Choking, Sweating/Shaking/SOB
• Dx: Panic Disorder vs. Synthroid induced Anxiety Disorder • D: Depersonalization (disconnected from oneself) vs. Derealization (feeling the world/surroundings aren’t real)
• Next Step :Thyroid Profile • Presentation: peaks within 10 minutes and lasts <25 minutes; often hear “I think I’m going CRAZY!”

Anxiety: subjective fear č its physical symptoms 2. Associated Medical Conditions: MVP, Asthma, PE, Angina, Anaphylaxis
1. Nl vs. Abnl: normal in response to threat; abnormal if
excessive response to threat or interfering č daily life Panic Disorder: Spontaneous (No Obvious Precipitant) Recurrent Panic Attacks
Case
1. Criteria
3
2. Pathophysiology: ↑NE + ↓GABA / ↓5HT • 1 Month Duration s/p Panic Attack: Anticipatory Anxiety (for another), Consequences of Attack? ∆Behavior (Avoid Places)
• Tables: see tables for Symptoms + Causes • R/O: Medical (CHF, MI, CAD, ↑Thyroid, Pheochromocytoma, Carcinoid, COPD), Rx (Stimulants), Other Anxiety Disorder
• Unexpected: vs. PTSD / Phobia where a cue leads to the panic attack
3. Facts: ↑Risk č ↑Socioeconomic Groups • Fear of Additional Attack: not a specific situation vs. OCD / General Anxiety Disorder
• 33% +/- Agoraphobia: anxiety ---> fear of inability to escape / repeat attacks ---> fear of being alone in public places

2. Pathophysiology: as č most anxiety disorders ---> ↑NE č ↓GABA + ↓5HT

3. Management: BNZ Alprazolam (Immediate Management) ---> SSRI Paroxetine > Sertraline (Chronic) +/- Behavioral Tx

Presentation: 55 y/o č depressed mood, ↓energy, ↑wt. Never Mood Disorder 2° GMC
had symptoms before. ↑Thyroid gland, coarse/brittle hair. 1. Pathophysiology: depression or mania 2° objective Hx/PE/Labs c/w GMC ~ cannot be 2° to “stress” associated č GMC
• Dx: Mood disorder 2° GMC (Hypothyroidism) • Depression 2° GMC: SPECCC ~ Stroke, Parkinson’s, Endocrinopathies, Carcinoid Tumor, Cancer (Pancreatic), Collagen DZ
• Next Step :TFTs • Hypothyroidism: ↑weight and NO ∆appetite vs. depression where ↑/↓appetite ---> ↑/↓weight
Case • Mania 2° GMC: MAN ~ Metabolic (Hyperthyroidism), AIDS, Neurologic DZ (Temporal Lobe Epilepsy, MS)
4 Lessons Learned from Questions • Depression 2° Rx: ABCDEF ~ Anti-HTN/Psychotic/Convulsant, Barbs, Corticosteroids, Diuretics, EtOH, sulFonamide
1. S/p MI vs. S/p Stroke: both stroke and MI can cause • Mania 2° Rx: ABCDE ~ Antidepressants, Bronchodilators, Corticosteroids, Dopamine, Epinephrine (~sympathomimetic)
depression. Note, if either does not result in longterm
sequela, then the depression that follows is 1° depression. If 2. Management: Treat Underlying Conditions ---> Improvement
+longterm sequela, depression is 2° GMC. • Recurrent/Chronic/Untreatable GMC: 2° Dementia, CVA, Cancer ---> Antidepressants (SSRI/SSNRI/TCA) vs. Mood Rx

Presentation: 14 y/o č skipping school to work on a project, no Mania/Hypomania: Mania = Medical Emergency b/c ↓Judgement = ↑Risk to Self/Others
sleep, ↑energy, disordered thoughts, ↑talking, irritable, labile, 1. Manic Criteria: ↑elevated/irritable mood ≥1 week (or any duration if +hospitalization) of 3+ (4+ if irritable) of DIGFAST
Paranoid and grandiose. • DIGFAST: distracted, insomnia/impulsive, grandiose, flight of ideas, activity (goal-oriented)/agitation, speech, thoughtlessness
• Dx: Bipolar I Disorder č Single Manic Episode + Psychotic • Other Criteria: must cause social impairment
Features • +/-Psychosis: 75% manic patients experience psychotic symptoms
• Next Step: Mood Stabilizer + Atypical Antipsychotic
2. Hypomanic Criteria: same criteria for Manic Episode č important differences
Lessons Learned from Questions • Duration: manic episodes = 1 week vs. hypomanic episodes = 4 days
1. Rapid Cycling: 4+ mood EPISODES (MD, Manic, Mixed) in 1 • Severity: manic episodes = social impairment vs. hypomanic episodes = no ∆social/occupational functioning
year; Best Rx = Carbamazepine • Hospitalization: manic episodes = +/-hospitalization vs. hypomanic episodes = no hospitalization
• Psychotic Features: manic episodes = 75% have psychosis vs. hypomanic episodes = no psychosis
2. Bipolar Disorder vs. Mixed Episodes: mixed EPISODE
refers to criteria for both manic + MD EPISODES are met Bipolar Disorder
Case qDay for 1 week. ≠ Bipolar + MDD, b/c these are mood 1. Bipolar 1 ~ “Manic Depression”
5 DISORDERS. • Criteria: 1x Manic Episode (or mixed episode) ever (past or present) ; note depression is NOT REQUIRED for the diagnosis
• Epidemiology/Prognosis: ↑Risk č +FMHx, 90% have repeat episode in 5 years, overall worse than MDD, ↑Suicide Risk
3. Unique Features to Children • Etiology: bio-psycho-social implications; ↑genetic link of all psychiatric disorders
• Presentation: usually MD Episode ---> Manic Episode; • Treatment: Mood Stabilizers (Li, Carb, Valproate), Atypicals (mono/adjunctive), Psychotherapy, ECT (best for pregnant!)
psychosis is usually more prominent in youth (vs. adults) • Mood Stabilizers: Li = ↑prognosis + prophylaxis; Carbamazepine = best for Rapid Cycling
• DDx: ADHD +/- ODD / CD ~ Manic/Hypomanic episodes; key • Postpartum Mania: pt receives prophylaxis lithium and antidepressants in future pregnancies (but CI č breastfeeds)
difference is h/o behavior disorder, which would suggest • What about Antidepressants? NO NO NO = ↑risk for exacerbating mania
more ADHD/ODD/CD vs. bipolar disorder
• Treatment: Lithium is only FDA approved for youth bipolar 2. Bipolar 2 ~ “Major Depressive Episodes č Hypomania”
• Criteria: 1x MD episodes + at least 1x Hypomanic episode; if +h/o full manic episodes ---> Bipolar 1 (not Bipolar 2)
4. Lithium ADE • Epidemiology: MC than Bipolar 1
• Brain: tremor, ataxia, sedation Etiology/Treatment: same as Bipolar 1
Glands: edema, hypothyroid
•
•
• Kidney: Nephrogenic DI
• Teratogen 3. Management: Hospitalization (Mania = EMERGENCY) ---> Mood Rx/Atypical Rx +/- Psychotherapy +/- ECT, as above

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Psychiatry Case Files

Case Files

Presentation: 36 y/o č stress when transferred from reclusive job Schizoid Personality Disorder: Eccentric/Reclusive č Lifelong Pattern of Social Withdrawal
to social job. 1. Diagnostic Criteria: voluntary social withdrawal + restricted emotional range in early adulthood
• Dx: Schizoid Personality Disorder • Symptoms: ↓close relationships, ↓sexual interest, indifferent to praise/critics, flat affect, choses solitary activities
• Management: Psychotherapy • vs. Avoidant Personality Disorder: Schizoids prefer to be alone
• Relationship to Schizophrenia: NO ↑relationship (FMHx/Prognosis) to Schizophrenia (vs. Schizotypal Personality Disorder)
Background: Personality Disorder
Case 1. Criteria: ingrained/inflexible maladaptive patterns of relation 2. Management: Psychotherapy +/- Antipsychotic (if aggressive/psychotic) +/- Antidepressant (if depressed)
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to others that are ego-syntonic (↓insight), stable č onset no • R/O: Paranoid Schizophrenia (schizoids are š delusions) vs. Schizotypal (schizoids lack magical thinking / ∆perception)
later than adolescence. Managed č psychotherapy.

2. Clusters First Aid Classic Script: 45 y/o scientist works in lab most of the day š friends. Not been able to keep a job b/c failure to
• Associations A (Psychosis), B (Mood), C (Anxiety) collaborate č others. He expresses no desire to make friends and is content č his single life. He has no evidence of a thought
• Personality DO NOS: Passive-Aggressive, Depressive disorder.

Presentation: 75 y/o refusing to drink for 24 hours č 3 week h/o Recurrent Major Depression č Psychotic Features ~ Recall 1 of 4 Subtypes of MDD (as above)
signs of MD. PMHx of MDD š episodes of mania. 1. Diagnostic Criteria
• Dx: Recurrent MD č Psychotic Features • Recurrent MD: 2+ episodes of MD š h/o manic/hypomanic/mixed episodes (vs. bipolar disorder)
• Next Step: Hospital, IV Hydration, +/- ECT if ↑°severity • č Psychotic Features: hallucinations/delusions š schizoaffective disorder (psychotic for 2 weeks š depression)

Lessons Learned from Questions 2. Elderly Patients: common population where Recurrent MDD occurs; must R/O Dementia
Case
7
1. ECT Indications: psychotic features, suicidal ideation, • Normal Aging: ↓brain (↑ventricles), ↓muscle=↑fat, ↓vision/↓hearing, benign senescent forgetfulness (normal forgetfulness)
catatonic patient or ↓food/water ingestion = all situations • Depression: Unique Aspects in Elderly Population
where immediate intervention is needed! • Risk for Depression in Elderly: Post-MI, Post-Stroke, New Admit to Nursing Home
• Pseudodementia: MD+↓Cognition; vs. Dementia pts aware, say “I don’t know”>confabulating, improve cognition č Rx
• Dementia (AD): answers questions č effort, no insight into any disease, no cognitive improvement č Rx

3. Management: SSRI + Psychotherapy ---> ECT especially č ↑°severity of Depression (Elder Pt = ↑chance for DD-interaction!)

Presentation: 35 y/o č social phobia has to speak in front of a Phobia: Irrational Fear 2° Stimulus/Cue ---> Avoidance of Feared Object (Specific Phobia) or Social Situations (Social Phobia)
large public. 1. Diagnostic Criteria
• Dx: Social Phobia • Specific Phobia: persistent ↑fear from situation/object, exposure elicits anxiety, pt senses fear is excessive, trigger is avoided
• Next Step: SSRI / β blocker • Social Phobia: “ “ č ↑fear being from social setting such as public speaking, eating in public, public restrooms
Case
• Neuroimaging: ↑activity in amygdale + insula
8 Lessons Learned from Questions
1. Phobias: MC Mental Disease in USA (Specific > Social) 2. Management
• Specific Phobia: Systemic Desensitization
• Social Phobia: Behavioral > Paroxetine (FDA for Social Phobia) + β Blocker (Frequently for Performance Anxiety)

Presentation: 18 y/o brought to ED, belligerent, paranoid and PCP ~ Angel Dust
hostile. He has vertical nystagmus. 1. Pharmacology: NMDA-R Antagonist + DA-R Agonist
• Dx: PCP Intoxication • Form: smoked on a cigarette (“Wet”) or č Marijuana (“Joint”) ~ latter often +UDS in PCP intoxication
• Next Step: BNZ > Antipsychotic • Ketamine: “Special K” ~ similar to PCP č ↓potency; previously used in surgery, now used č date/rape (colorless/odorless)
Case Other Hallucinogens 2. Intoxication: Pathognomonic = Rotatory Nystagmus + Dysarthria + Violence + Tactile/Visual Hallucinations
9 1. Psilocybin (Shrooms), Mescaline (Peyote Cactus), LSD • RED DANES: Rage, Erythema (Red Skin), Dilated Pupils, Delusions, Amnesia, Nystagmus, Excitations, Skin Dry
2. Presents: ∆Perception ---> “Bad Trip” č anxiety/paranoid • Treatment: BNZ (anxiety/agitation, muscle spasm, seizures) + Haldol (Severe agitation/Psychosis)
3. Treatment: Reassurance +/- BNZ/Haldol for severe symptom • Location: dark/quiet room (↓stimulation); avoid restraints to prevent further muscle breakdown

3. Withdrawal: No Withdrawal Syndrome but +/- Flashbacks (Intoxication Syndrome) b/c PCP stored in Body Fat/Lipid

Presentation: 32 y/o depressed after break up č GF, but did so b/ Dependent Personality Disorder
c overly reliant on a mother who did not approve. Dependent on 1. Diagnostic Criteria: pattern of submissive and clinging behaviors 2° to constant need to be taken care of; ≥5 symptoms
few friends. • Symptoms: Obsessive about approval, Bound by others decisions, Enterprises, Difficulty č decisions, Invalid, Engrossed č
• Dx: Dependent Personality Disorder Fear, Needs relationships, Tentative about Everything (OBEDIENT)
• Next Step: Psychotherapy (Insight Oriented) • Defense Mechanism: Regression (adopt characteristics of younger age of maturity)
• Somatization: expression of psychologic difficulties as physical complaints
Case Definitions • Somatization = form of Regression b/c verbalizing emotions is considered to be a component of progression
10 1. Idealization: defense mechanism where exaggerative • Course: ↑risk for depression especially after loss of a relationship; problems č employment b/c cannot act independently
positive qualities attributed to others ~ “My husband is the
best thing that happened to me,” says woman abused by him. 2. Management
• R/O Avoidant Personality Disorder: DPD constantly seek relationships while APD want relationships, but fear rejection
2. Reaction Formation: defense mechanisms where opposite • Borderline/Histrionic PD: DPD depend on one relationship while BPD/HPD act dependent č multiple short relationships
feelings/actions replace unacceptable ones ~ Woman cooks • Tx: Psychotherapy (Insight Oriented/Group Therapy) +/- Rx for associated Anxiety or MDD
dinner for husband she knows had an affair.

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Psychiatry Case Files

Case Files

Presentation: 28 y/o č symptoms of chronic anxiety from Generalized Anxiety Disorder: Persistent Excess ↑Arousal/Anxiety about General Daily Activities +/- Somatic Complaints
worrying about many problems not related to one category. She 1. Diagnostic Criteria: at least 6 months č ↑anxiety/worry about daily events č 3/6 Symptoms
has physical/somatic symptoms as well. • Symptoms: Restlessness, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbance
• Dx: GAD • Hint from FA: GAD anxiety is free-floating as opposed to being fixed on specific person, event or activity
Case • Management: SSRI, SSNRI • Epidemiology: ↑risk of coexisting mental disorder, anxiety disorder or major depression
11 • R/O: Hyperthyroid, ↑Caffeine, CVD, PE, Seizures
Buspirone: agonist at 5HT1A receptors*** • Pulmonary Embolism: presents as ↑HR, ↓BP and ↑RR and “Feeling like I’m going to die!”

2. Management: Cognitive Behavioral Therapy + 4 Agents = SSRI, SSNRI, Buspirone and BNZ
• “Battling Stress Since Birth”: Buspirone, SSRI, SSNRI, BNZ

Presentation: 27 y/o č classic signs / symptoms of mania Bipolar Disorder - Manic (Adult) ~ Review Case 5 Above for Notes on Mania/Bipolar 1-2 Disorder
• Dx: Bipolar 1 Disorder, Manic 1. Bipolar 1 ~ “Manic Depression”
• Next Step: UDS + Blood EtOH Level • Criteria: 1x Manic Episode (or mixed episode) ever (past or present) ; note depression is NOT REQUIRED for the diagnosis
• Management: Mood Rx +/- Antipsychotic +/- Commitment • Epidemiology/Prognosis: ↑Risk č +FMHx, 90% have repeat episode in 5 years, overall worse than MDD, ↑Suicide Risk
Case • Etiology: bio-psycho-social implications; ↑genetic link of all psychiatric disorders
12
2. Treatment: Mood Stabilizers (Li,Valproate > Carb.), Atypicals (mono/adjunctive), Psychotherapy, ECT (best for pregnant!)
• Mood Stabilizers: Li = ↑prognosis + prophylaxis; Carbamazepine = best for Rapid Cycling
• Lamotrigene: ↑Efficacy if presenting during depressive phase of Bipolar Disorder
• What about Antidepressants? NO NO NO = ↑risk for exacerbating mania
• Involuntary Commitment: requires mental illness, possibility of harm to self/others or inability to care for oneself

Presentation: 13 y/o č excessive showering (5 hours) b/c always OCD: Recurrent Intrusive Idea ---> Conscious Repetitive Behavior Related to Obsession to Relieve Anxiety of Obsession
feeling dirty. 1. Diagnostic Criteria
• Dx: OCD • Obsessions: recurrent/persistent intrusions ---> ↑anxiety; person tries to suppress thoughts
• Management: Exposure-Response + SSRI • Compulsions: repetitive behaviors to ↓distress from obsessions
• Ego Dystonic: patient is aware that obsessions and compulsions are unreasonable/excessive (NOT required for peds!)
Common Obsessions ---> Compulsions • ∆Function of Daily Living: obsessions cause anxiety, are time consuming and interfere č daily functioning
1. Contamination: excessive washing of hands/clothes
2. Doubt: forgetting to turn off stove ---> checking all the time 2. Pathophysiology: abnormal ∆5HT
Case 3. Symmetry: or order ---> slow slow slow task performance ↑Risk: Genetics (1st °Relatives) and Medical Conditions (Head Injury, Basal Ganglia Disease, Postpartum)
•
13 4. Thoughts: usually š compulsion Associations: ↑risk of MDD and Tourette’s Syndrome / Chronic Motor Tic Disorder
•
5. Somatic: pt views parts of body as abnormal • R/O: PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder After Streptococcal Infection) ~ OCD

3. Management: best management is COMBINATION of PyschoRx + Behavioral Therapy (ERP)

• Rx: SSRI > Clomipramine (TCA Designed for OCD but ↑Coma, Convulsions and Cardiac Arrhythmias)
• SSRI in Peds: BBW for SUICIDE
• Behavioral: Exposure Resopnse Prevention (ERP) where the person must experience stimulus (obsession) š compulsion
• Last Resort: ECT / Cingulotomy

Presentation: 45 y/o č fatigue and heavy drinking; take more to EtOH (EtOH Withdrawal in Separate Case)
get him drunk thank before hand. 1. Intoxication
• Dx: Alcohol Dependence • Epidemiology: MC Co-Ingestant in Drug OD, ↑Risk of Spousal Abuse, MC Abused Substance in USA
• Complications: DTs, WK Syndrome, Cerebellar • Pathophysiology: EtOH activates GABA-R > 5HT-R (“hard to get up”) in CNS ---> CNS Depressant
Degeneration, FAS, Peripheral Neuropathy, Hepatic • Metabolism: EtOH --(EtOH Dehydrogenase)--> Acetaldehyde --(Aldehyde Dehydrogenase)--> Acetic Acid
Encephalopathy, Malabsorption/Pancreatitis, • Note: Alcoholics have ↑enzyme activity while genetics (Asians) have ↓aldehyde dehydrogenase activity
Cardiomyopathy, Trauma • Metabolic Acidosis: EtOH, Methanol and Ethylene Glycol ~ ↑AG Metabolic Acidosis
• Presentation: depends on BAL (mg/dL)
• <100 ---> ↓Fine Motor Control, ↓Judgement, ↓Coordination
• 200 ---> Lethargy, ↓Ability to Sit Up/Ataxic/↓Balance ↓Memory
• 300 ---> Coma in Novice Drinker
Case • 400 ---> Respiratory Depression, Death
14 • Tx: ABC ---> Thiamine > Glucose, +/- Naloxone (Co-Ingested Opioids) ---> +/- CT (Hematoma) ---> Monitor pH/Electrolytes
• GI intervention (Lavage, Emesis, Charcoal): not typically indicated unless ↑↑↑Amounts

2. Dependence: Screen č CAGE Questions ~ >2 “Yes” = +Screen ~ Most Sensitive Test for Dependance
• Consequence: xB1 ---> Wernicke’s (Ataxia, Opthalmoplegia, AMS) ---> Korsakoff (Confabulation, Chronic Amnesia)
• Markers: ↑AST/ALT Ratio č ↑GGT; BAL; ↑MCV (Macrocytosis)
• Management: Note Disulfiram has ↑efficacy only in those that are compliant!
• Disulfiram: xaldehyde dehydrogenase ---> ↑acetaldehyde ---> ↑flushing, GI (CI: pregnant, psychotic, cardiac DZ)
• Naltrexone: xOpioid-R ---> ↓desire/craving but ppt withdrawal in dependents; better for +FMHx alcoholism
• Acamprosate: ~GABA SAFE in Liver DZ; start post-detox for relapse prevention in patients who stopped drinking
• Topiramate: potentiates GABA / ↓Glut; ↓craving

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Psychiatry Case Files

Case Files

Presentation: 24 y/o immediately postpartum is R/O Schizotypal Personality Disorder ~ Developed to Describe Peculiar Relatives of Schizophrenic Patients
Schizophrenia. She has odd beliefs, thinking, ideas of reference. 1. Diagnostic Criteria: pattern of socially eccentric behavior, cognitive/perceptual distortions, discomfort č close relationships
She dresses peculiarly and has tangential thinking. • 5+ Symptoms: Ideas of Reference (≠Delusions), Magical Thinking, Perceptual Experience, Restricted Affect, Few Friends
• Dx: Schizotypal Personality Disorder (Cluster A) • “Magical Thinking”: Clairvoyance/Telepathy, Bizarre Fantasies, Superstition
• Management: Exposure-Response + SSRI • +/- Belief of Control On Events: “It snows every winter because I buy sidewalk salt every fall.”
Case • ↑Risk: Major Depressive Episode ~ 50% Schizotypal Patients Experience MDE
15 Definition • vs. Paranoid Schizophrenia: Schizotypals not psychotic (hallucinations, illusions, delusions); +/- bouts of acute psychosis
1. Idealization: defense mechanism where emotional response • Example: Schizotypals may dress in space suits b/c believe aliens are coming, but they don’t see/hear aliens
is to attribute exaggerate positive qualities to others
2. Management: Chronic Disorder +/- Develop Schizophrenia
• Psychotherapy: as č all personality disorders, psychotherapy is the mainstay of treatment
• Rx: ↓Dose Antipsychotic for transient psychosis and Antidepressant when MDE occurs

Presentation: 29 y/o arrested trying to rob grocery store. She Cocaine: xReuptake of Dopamine ---> ↑Stimulant Effect + Reward System
shows 30lb weight loss while using drugs, constricted pupils, 1. Intoxication ~ Gradually ↑Fight/Flight Response
hunger and depression. • General: Euphoria, Dilated Pupils, ↓Weight, ↑or↓ HR/BP
• Dx: Cocaine Dependence • Dangerous: Hallucinations (Tactile), Respiratory Depression, Arrhythmias, Seizures, Paranoia / Agitation / Anxiety
• Deadly: MI or Stroke 2° Severe Vasoconstrictive Effect
Case • Management: BNZ (Milder Anxiety/Agitation) ---> Haldol (Severe Agitation/Anxiety)
16
2. Dependence: recall dependence is ≥12 months č the presence of Tolerance (↑required) or Withdrawal (syndrome č ↓Rx)
• Treatment: NO FDA APPROVED TREATMENT ---> Psychotherapy is SOC

3. Withdrawal
• Opposite of Intoxication: Post-intoxication Depression, Constricted Pupils, Hunger, ∆ANS Symptoms
• Treatment: NOT life threatening ---> supportive

Presentation: 64 y/o č 3 day h/o surgery has visual Delirium ~ Look at 5 MC Clinical Scenarios on Psych Shelf
hallucinations, paranoia, disorientation. Next day improved č 1. Diagnostic Criteria: Acute Fluctuating ↓Consciousness + ∆Cognition / ∆ Perception
slight ↓orientation to time. • Causes: AEIOU TIPS ~ EtOH/Withdrawal, ∆Elec., Iatrogenic (Rx), ↓O2, Uremic/Hep., Trauma, Infec., Poison, Seizure/Stroke
• Dx: Delirium • Symptoms: xRecent Memory > Sundowning (worse @night), Visual Hallucinations and ↓Attention Span
• Next Step: ID Cause of Delirium • R/O Dementia: cannot make diagnosis of delirium if better explained by dementia (but can have both!)
• Onset: short č delirium (hours-days) vs. long č dementia (months-years)
Lessons Learned from Questions • Course: fluctuating č delirium vs. stable/progressive č dementia
Case 1. Cognitive Disorder: ∆memory/attention/language/judgement • Alertness: hypoactive/hyperactive/mixed č delirium vs. stable č dementia
17 form baseline = Delirium vs. Dementia • Consciousness: ↓ č delirium vs. no ∆ č dementia
• Prognosis: reversible č delirium vs. fixed č dementia
2. Most Sensitive Diagnostic Step in Delirium: EEG which will
show generalized slowing 2. Management
• Clinical Dx: ID ↓Attention č Serial Reversal Test (“Spell World Backwards”) ~ History is KEY ~ get info from caregivers
3. Largest Risk Factor for Delirium? Post-Cardiotomy • Evaluation: CT, CMP (R/o ↓glu, ∆electrolytes, hepatic/uremia), CBC (infections),TFT, ABG, UDS, Toxicology
• Treatment: directed towards symptoms (agitation/hallucinations) ---> Haloperidol
• BNZ? Avoid b/c +/- exacerbate delirium. Only use if delirium is 2° to EtOH Withdrawal

Presentation: 16 y/o č MDE č mood congruent auditory Major Depression č Psychotic Features
hallucinations. 1. Diagnostic Criteria: 5+ SIGECAPS in 2 week period č Mood Congruent Psychotic Features only during MDE
• Dx: MDD č Psychotic Features • Mood Congruent: content of delusions/hallucinations reflect the nature of illnesses ~ psychosis of guilt / punishment
Case • Next Step: SSRI + Atypical Antipsychotic • vs. Schizoaffective Disorder: psychosis persists for 2 weeks of euthymia in Schizoaffective Disorder
18
2. Management: SSRI + Atypical Antipsychotic + Supportive Psychotherapy
• Start Low and Slow: especially in pediatric populations as č this case b/c ↑risk č SSRI and suicidal thoughts
• +Response: taper antipsychotic ---> SSRI

5
Psychiatry Case Files

Case Files

Presentation: 15 y/o gets into fights, intimidates others, steals, Conduct Disorder
skips schools and breaks curfew š remorse. 1. Diagnostic Criteria: persistent behavior violating basic rights of others or social norms č 3/15 symptoms in last year
• Dx: Conduct Disorder • Symptom Category: Animal/People Aggression, Destruction of Property, Deceit/Theft, Serious Violation of Rules
• Next Step: Multisystemic Treatment (MST) +/- Rx for • ↑Risk: Punitive Parents, H/o Abuse, H/o of Parents č Antisocial / EtOH Abuse
Aggression • Epidemiology: ↑risk of Substance Abuse + Suicidal Attempts + ADHD; 40% develop Antisocial Personality Disorder

Lessons Learned from Questions 2. Management: Family/Community Involved ∆ (MST) + Rx for Aggression (Antipsychotic, Mood Stabilizers, SSRI)
Case 1. Antisocial Personality Disorder: pattern of behavior needs
19 to be there since 15 y/o but diagnosis not made until >18 y/o Oppositional Defiant Disorder (ODD)
1. Diagnostic Criteria: negative, hostile, defiant behavior for 6+ months č ≥4 symptoms as below
2. CD + Comorbid Psych Condition: treat comorbid condition • Symptoms: ↑Temper, ↑Arguments, ↑Blaming Others, Annoys Others / Easily Annoyed, Defying Rules
first!!! • Classic Script: no problems č peers + no compliance č parents/teachers = ODD
• vs. CD: no physical aggression and no violation of others’ rights
• Epidemiology: ↑Comorbid Substance Abuse, ADHD and Mood DZ

2. Management: Psychotherapy č Behavioral Management and Problem Solving Skills

Presentation: 36 y/o č preoccupation č rules, work, order. Misses Obsessive Compulsive Personality Disorder
deadlines and bad at making decisions timely. Ego-syntonic. 1. Diagnostic Criteria: preoccupation č control, order and perfection at expense of efficiency č ≥4 symptoms
• Dx: OCPD • Symptoms: rules/lists, perfectionism, ↑attention to work/morals/ethics, xdelegation, hoarding, stubborn
• Note: can have OC “Traits” if nl functioning = MED SCHOOL • Course: MC in males and oldest children č +/- development of other Psych Dz (OCD, Schizophrenia, MDD)

Definitions 2. Management
Case 1. Isolation of Affect: defense mechanism of separating • R/O OCD: OCPD has no recurrent obsessions or compulsions and OCPD is ego-syntonic
20 emotion/mood from details ~ Man recounts finding wife in • R/O Narcissistic: both involve assertiveness and achievement, but NPD appreciate status while OCPD appreciate work itself
bed č other man š any emotion • Tx: Psychotherapy

2. Undoing: defense mechanism of engaging in actual or Personality Disorder NOS: No Cluster ~ Passive Aggressive, Depressive, Sadomasochistic and Sadistic PDs
symbolic acts that oppose thoughts, feelings or actions 1. Passive Aggressive PD: stubborn + inefficient procrastinators alternating btw compliance/defiance č ↑excuses
2. Depressive PD: lifelong traits of pessimism, self-doubt, chronic unhappiness

Presentation: 34 y/o raped 1 year ago, since been depressed, PTSD

irritable, angry and disconnected. Difficulty sleeping/ 1. Diagnostic Criteria: 1 month of “R-A-P-E”
concentrating. Nightmares about rape, tries to block it from mind • Event: patient must have experienced or witnessed traumatic (life-threatening) event at any time in the past (vs. ASD)
and avoids the location where it happened. Wants rapist to die. • Avoidance: patient mentally tries to block the experience from mind and also physically avoids location/surroundings
• Dx: PTSD • Reexperience: patient experiences dreams, flashbacks, recollections
Case
• Involuntary Commitment? No, she has passive homicidal • Persistent ↑/↓Response: Hyperarousal (↓sleep, anger) or ↓Response (detachment, isolation)
ideation, but no active plans or intent.
21
2. Management
• Rx: P-T-S-M (Prazosin, TCA , SSRI, MAOI) + Anticonvulsants (Flashbacks/Nightmares)
• Other Tx: CBT, Eye Movement Desensitization and Reprocessing
• R/O: Other Anxiety Disorders, Borderline Personality Disorder (+Hx of Abuse), Dissociative Rxn (but ↑amnesia symptom)
• Screen Comorbid Conditions: ↑risk for substance abuse (∴avoid BNZ for treatment) + Major Depression
• ↑Risk Patients: ♀, ↓socioeconomic status / ↓education

Presentation:34 y/o č h/o MDD and 10 yr h/o depressed mood č Dysthymic Disorder ~ Chronic Diet Depression
↓concentration, hopeless feeling, ∆appetite. Denies suicide, 1. Diagnostic Criteria ~ 2s = 2 Years Duration, 2+ Symptoms and no symptom-free period >2 months
psychosis. • CHASES: ↓Concentration, Hopelessness, ∆Appetite, ∆Sleep, ↓Energy, ↓Self-Esteem
• Dx: Dysthymic Disorder • Note: cannot meet criteria for MDD in first 2 years, mania (=Bipolar Disorder) or hypomania (=Cyclothymic Disorder)
• Next Step: SSRI, SSNRI, Bupropion and Mirtazapine • vs. MDD: Dysthymic has earlier onset, ↓°severity and ↑duration
• R/O: Double Depression where patients č dysthymia develop episode of MDD
Case Lessons Learned from Questions
22 1. No/↓Response to SSRI: if there is no response, the next 2. Management: Cognitive + Psychotherapy (Most Effective) +/- Antidepressants (Concurrent č Psychotherapy)
step is to try another SSRI before switching the class. If there
is a partial response, the next step is to augment the dose. Cyclothymic Disorder ~ Hypomania + Diet Depression
1. Diagnostic Criteria: episodes of hypomania and dysthymia for ≥2 years š symptom-free >2 months
• Note: ↑association č Borderline Personality Disorder

2. Management: Mood Stabilizers as for Bipolar 2 Disorder (See Case)

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Psychiatry Case Files

Case Files

Presentation: 69 y/o č h/o ↑BP has problems č memory, Dementia

disorganized behavior, aphasia. 1. Diagnostic Criteria: multiple cognitive defects including ↓memory + 1 other cognition that ↓QoL
• Dx: Dementia • Associations: Mood Episodes, ∆Personality and Hallucinations/Delusions
• Next Step: R/O reversible causes of dementia • MC: AD > Vascular Dementia > DLBD

Definition of “Other Cognitive Impairment” 2. Management

1. Agnosia: xRecognition despite intact Sensation (↓higher • MMSE: ↑sensitivity for dementia and delirium ~ <26 = BAD
order processing of sensory input) • W/U: CBC, Electrolytes, TFT, VDRL/RPR, B12/Folate, CT/MRI
2. Apraxia: loss of learned/known abilities
3. Aphasia: disorder of Language Alzheimer’s Disease: MC in USA
1. Pathophysiology: ↓AcH 2° to loss of neurons in Basal Nucleus of Meynart + ↑Amyloid Production
Other Forms of Dementia • Genetics: APP, Presenelin I, Presenelin II = Overproducers of Amyloid
1. Huntington’s: AD ↑#CAG ~ atrophy of caudate ---> chorea + • ↑Risk: ApoE4, Down’s Syndrome
dementia č ↑risk of suicide • Pathology: Diffuse Atrophy, Senile Plaques + Neurofibrillary Tangles
• Neuritic Plaques: correlate č °severity of dementia (≠Neurofibrillary Tangles)
2. Parkinson’s: ↓DA in SN 2° idiopathic (MC), traumatic • Presentation: ↓Memory (∆HIppocampus) ---> ↓Visuospatial (∆Parietotemporal) ---> ↓Attn/Insight/∆Personality (∆Frontal)
(Muhammad Ali), Familial (MJ Fox)
2. Management: Clinical (Definitive = Autopsy) ---> AcH-ase Inhibitor (Donepezil, Galantamine, Rivastigmine) + Memantine
3. CJD: rapidly progressive dementia + myoclonus +
generalized sharp waves (Triphasic) on EEG Vascular Dementia: 2nd MC in USA
1. Pathophysiology: Microvascular Disease ---> ↑#Small Infarcts ---> Accumulate ---> Vascular Dementia
Case
23
4. NPH: Urinary Incontinence, Dementia, ∆Gait ~ REVERSIBLE • Presentation: Stepwise ↓Function ~ represents the microinfarcts “adding up”
cause of dementia 2° to ↓CSF absorption; once shunt
placed to ↓ICP ---> improved symptoms 2. Management: No Cure ---> Supportive + Anti-HTN +/- AcH-ase Inhibitors

Rx DLBD: 3rd MC in USA

1. Agitation/Aggression: treat č ↓dose of ↑potency steroids 1. Pathophysiology: ↑Lewy Bodies (aggregation of neurites composed of ɑ-synuclein) in Basal Ganglia
---> avoid low potency b/c of ↑Anti-AcH + Orthostatic Effects • Presentation: Dementia č ↑Visual Hallucinations + Sensitivity to Neuroleptics ---> Parkinsonism Follows
• Parkinson’s: dementia that begins >12 months after Parkinsonism
• REM Sleep Disorder: common feature, treat č Klonopin (Clonazepam)

2. Management: Levodopa/Carbidopa +/- Atypical Neuroleptics (if not too sensitive)

Pick’s Disease [FTD]

1. Pathophysiology: Tauopathy ---> atrophy of Frontal/Temporal Lobes ---> ∆Behavior, Personality, Poor Conduct, Etc.
• Genetics: familial cases associated č progranulin or MAPT gene
• vs. DLBD: no hallucinations, but rather ↑°severity ∆personality; no motor findings suggestive of Parkinsonism

2. Management: ↓AcH + Antidepressant

HIV Associated Dementia: MCC Dementia 2° Infectious Disease č ↑#s as Patients Live Longer
1. Pathophysiology: direct effects of virus on CNS + ↑2° infections from neutropenia ---> Rapid Dementia (DDx = CJD)
2. Management: HAART ---> ↓Viral Load ---> ↑Cognition

Presentation: 54 y/o complains of numerous vague symptoms Hypochondriasis

she fears and believes are caused by a serious life-threatening 1. Diagnostic Criteria: preoccupation č fear of serious disease 2° misinterpretation of bodily symptoms for ≥6 months
illness. • Note: ≠°intensity as delusional disorder and no regard for appearance as in BDD (see below)
• Dx: Hypochondriasis • Course: only Somatoform DO where men = women; disease waxes/wanes č exacerbations under stress
• Management: Regular visits č single PCP
2. Management: Regularly Scheduled Visits to Single PCP +/- SSRIs for comorbid Depression/Anxiety + CBT Psychotherapy
Case Lessons Learned from Questions • Goal: maintain contact č patient before relief from each reassurance fades to the point she is convinced again of a disease
24 1. vs. Delusional Disorder, Somatic Type: Hypochondriasis
has bodily complaints that ∆ over time and the pt is able to Body Dysmorphic Disorder
be reassured. However, delusions DO NOT ∆ and there is no 1. Diagnostic Criteria: preoccupation č imagined defect in appearance or slight actual physical anomaly
reassurance possible. • Hints: ↑dermatologic, plastic surgery procedures; ↑use of makeup
• Course: MC in unmarried females

2. Management: SSRI (Symptoms of Anxiety/Depression)

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Psychiatry Case Files

Case Files

Presentation: 32 y/o incarcerated man gets into fight č inmate. Antisocial Personality Disorder
Multiple incarcerations, inability to confirm to societal norms 1. Diagnostic Criteria: disregard for / violation of rights of others š remorse since age 15 but diagnosis only after age 18
which all began at age 13 y/o. No remorse. • 3+ Symptoms: Capraciousness, Oppressive, Non-Confrontational, Deceitful, Unlawful, Carefree, Temper (CONDUCT)
• Dx: Antisocial Personality Disorder • H/o: childhood activity c/w Conduct Disorder
• Risks: Childhood Abuse (physical/sexual), parents č EtOH Abuse or +FMHx Antisocial Personality Disorder
Case Definitions • Somatization: ↑risk as antisocial patients grow older
25 1. Acting Out: defense mechanism through actions rather than
reflections or feelings 2. Management
• R/O: Drug Abuse ~ tricky b/c Antisocial Personality Disorder has ↑abuse; determine which came first? Rx or Personality!
2. Projective Identification: defense mechanism where falsely • Monitor: ↑comorbid depression, substance abuse and death from suicide/homicide/trauma
attributing feelings to another person and thereby induce • Tx: Behavioral Therapy / Dialectical Behavioral Therapy (DBT ~ Borderline > Antisocial PDs)
those very actions in the other person. • Aggression: treat č SSRI +/- Mood Stabilizers +/- Antipsychotic

Presentation: 15 y/o girl č MD and suicide attempt. Treated, Schizoaffective Disorder: Psychotic Episodes č Episodic Mood Disorders
responds well but still is paranoid after mood stabilizes. 1. Diagnostic Criteria: criteria for MDD, manic or mixed episode are met WHILE criteria for schizophrenia are met
• Dx: Schizoaffective Disorder • IMPORTANT: 2 weeks of psychotic features (delusions + illusions) AND NO ∆mood (to R/O Mood Disorder č Psychosis)
• Management: Antipsychotic ---> SSRI • Subtypes: Depressive (Schizo č Superimposed MDD) vs. Bipolar (Schizo č Superimposed Mania)
Case
26 2. Management
• R/O: Mood Disorder č Psychotic Features vs. Drug-Induced (↑Cocaine = Psychosis + Mania; ↓Cocaine = Psychosis + MDD)
• Next Step: Antipsychotic ---> +/- SSRI (if Depressive type) or + Lithium, Carbamazepine, Valproate (if Manic type)
• Note: for manic subtype, always start both on Antipsychotic + Mood Stabilizer (vs. depressive subtype)
• Note: only add SSRI if antipsychotic alone does not alleviate both psychosis + MDD

Presentation: 24 y/o č olfactory hallucinations and staring off into Psychosis 2° GMC
space. 1. Psychosis: distorted perception of reality exemplified by delusions, hallucinations and disorganized thought
• Dx: Psychosis 2° GMC (Seizure) • Illusion: misperception of existing stimuli
• Next Step: B-E-M ~ Blood, EEG, MRI • Hallucinations: interpretation of a non-existing stimulus
• Auditory: MC č Schizophrenia
• Visual/Tactile/Gustatory: MC 2° GMC / ↑Cocaine / EtOH Withdrawal
• Olfactory: MC as aura č epilepsy

2. Criteria (3): Psychotic Features (Delusions/Hallucinations) + xDelirium + Evidence of GMC (Labs, Hx/PE); DDx = CONE
• CNS Disease: CVA, Tumor, Alzheimer’s, Encephalitis/Prion, AIDS/Lyme/3° Syphilis, Seizures
• Other: CT Disorders (SLE, Marfans, Temporal Arteritis)
• Nutritional: ↓Vitamin B12, Folate, Niacin
Case
• Endocrine: ∆Thyroid, Adrenals (Addison/Cushing), Pituitary and ↑/↓Ca
27
Psychosis 2° Substance Abuse: Psychotic Features + xDelirium + Evidence of Rx-Use + Not Accounted for by Psych DZ
1. Rx ~ AAA, B, C, D, E, F ~ Anti-AcH, Anti-H, Anti-PD, βBlock, Corticosteroids, Digitalis, methylphEnidate, Fluoroquinolone
2. Illegal ~ ABC, DEP ~ Alcohol, BNZ/Barb, Cocaine, LSD, Ecstasy, PCP

Delusions: fixed false beliefs not altered by rational arguments and not accounted for by cultural background of patient
1. Types: Bizarre (false belief that is impossible) vs. Non-Bizarre (false belief that is plausible)

2. Delusional Disorder: Non-Bizarre fixed delusions for 1mo, xSchizophrenia, no ↓Function

• Epidemiology:↑Rate in Age>40, Immigrants and Hearing Imparied
• vs. Schizophrenia: non-bizarre delusions, no ↓daily functioning, does not meet criteria
• Treatment: trial of anti-psychotic ---> Psychotherapy

Presentation: 7 y/o referred by teacher b/c ADHD symptoms ADHD ~ Inattention +/- ↑Activity/↑Impulsive č 3 Subtypes = Inattentive, Hyperactive/Impulsive, Mixed/Combined
(see “Diagnostic Criteria”). 1. Diagnostic Criteria: ≥6 Symptoms of Inattentiveness/Hyperactivity/Both for 6 months before 7 y/o
• Dx: ADHD • Inattentive: mistakes, ↓instructions, ↓organization, losing things, forgetful, easily distracted
• Management: “ASA” ~ Atomoxetine, Stimulants, ɑ-2 • Hyperactive/Impulsive: restless, difficulty č quiet (blurting answers), driven by a motor, hard to wait in line
Agonist • Multiple Settings: evaluate home, school, daycare

Case Lessons Learned from Questions 2. Pathophysiology ~ Multifactorial (Genetic, Environmental, Neuro-Chemical/-physiological, Toxin Exposure)
28 1. Lead Intoxication: lead to hyperactivity in children; get lead • Epidemiology: 60% č persistent symptoms (impulsive > hyperactive) into adulthood
level! • ↑Risk Comorbid Psych DZ: ODD, CD

2. ADE Stimulants: weight loss 2° ↓appetite + new/worsening 3. Management ~ Rx (ASA) + Group (Family, Teacher, Patient) Psychotherapy for Behavioral ∆
tics, insomnia. Benefit = rapid acting / effects gone by PM • ASA: CNS Stimulants are 1st Line ---> ɑ2 Agonist (Guanfacine, Clonidine) if ADE / Ineffective CNS Stimulants
• Atomoxetine: 1st line in patients č +FMHx Substance Abuse (not abusive), tics (vs. stimulants = worsen tics) or anxiety d/o
3. Atomoxetine: presynaptic NE inhibitor • +Comorbid Mood Disorder: treat mood disorder 1st

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Psychiatry Case Files

Case Files

Presentation: 19 y/o č normal BMI is binging and preoccupied č Bulimia Nervosa

compensatory activities to lose this weight. 1. Diagnostic Criteria: binging č actions to compensate for binging/prevent ↑weight ≤2x week for 3 months
• Dx: Bulimia Nervosa • “Binge Eating”: ↑intake in 2 hour period č sense of lack of control ~ most diagnostic feature of Bulimia Nervosa
• Next Step: Nutritional Rehab + SSRI + Therapy • Subtypes
• Purging: ↑vomiting, laxatives, enemas and/or diuretics to counter binge eating
Lessons Learned from Questions • Nonpurging: ↑exercise / fasting to counter binge eating
Case 1. Binge Eating Disorder: binge eating š compensatory • vs. Anorexia: normal BMI and ego-dystonic ~ troubled by actions
29 mechanisms or preoccupation/concern of gaining weight. • Course
Treat č behavioral therapy, stimulants (↓appetite) and • Medical: Sialadenosis (↑parotid/salivary gland), dental caries, Russell’s SIgn (callous on hand dorsum)
Orlistat (xPancreatic Lipase ---> ↓absorption) • Labs: ↓Cl/↓K + ↑pH (=vomit), ↑HCO3, ↑Na, ↑Amylase

2. Management: Nutrition + SSRI + Therapy (CBT)

• Fluoxetine: only FDA approved Rx for Bulimia
• Buproprion: ↓seizure threshold ---> NEVER give to a bulimic or anorexic patient

Presentation: 35 y/o č wife killed in tornado 1 week ago. Now Acute Stress Disorder
feels numb, has images of wife in rubble, anxious, ↓function. 1. Diagnostic Criteria: event occurs <1 month ago and symptoms last for <1 month (same diagnostic symptoms as PTSD)
• Dx: ASD • R-A-P-E: Reexperiences, Avoidance, Persistent ∆Response (Hyperarousal/Isolation) and Experiencing Threatening Event
• Next Step: Support +/- Hypnosis +/- PTSM • Dissociative Amnesia: MC č ASD (>PTSD) ~ memory loss of the event, especially if event = traumatic
• Note: if a person presents 2 weeks after seeing friend die, he does note qualify for PTSD b/c symptoms ≠ >1 month
Case
30
2. Pathophysiology: fear response activated via hypothalamic-pituitary-adrenal axis + ↑NE-Locus Ceruleus
• DDx: Head Trauma (esp. if s/p traumatic event), Substance (Cocaine), Other Anxiety / Dissociative Disorders

3. Management: Supportive +/- Hypnotic Therapy +/- P-T-S-M (as č PTSD) = Prazosin, TCA, SSRI, MAOI
• vs. PTSD: +/- use Hypnotics (ZOLPIDEM) + Anxiolytics or Propranolol for immediate symptoms

Presentation: 54 č abdominal pain, watery nose, lacrimation. He Opioids

has dilated pupils. Work up is normal. 1. Pharmacology: stimulate μ, κ and δ receptors involved in pain + sedation; also stimulate DA = Addictive/Rewarding
• Dx: Opioid Withdrawal • Ex: Heroin, Oxycodone, Codeine, Dextromethorphan (Cough Syrup), Morphine, Methadone, Meperidine (Demerol)
• Tx: Clonidine (mild) ---> methadone, buprenorphine and • MC Abused ~ Prescriptions = OxyContin (Oxycodone), Vicodin (Hydrocodone/Tylenol), Percocet (Oxy/Tylenol)
naltrexone for long term therapy
2. Intoxication: Classic Triad ~ AMS/Coma + Respiratory Depression + Pinpoint Pupils
Lessons Learned from Questions • Additional Symptoms: constipation, seizures, slurred speech
1. Muscle Pains: recall the “C” in ABCDEF for opioid withdrawal • Meperidine: unique b/c Demerol Dilates Pupils and also can cause 5HT Syndrome when used č MAOI
Case is cramps; best treatment for this is OTC Ibuprofen • Tx: ABC ---> Naloxone / Naltrexone (↓Respiratory Depression) but note this may ↑Withdrawal
31
2. Withdrawal Early in Methadone Tx: common in treating 3. Dependence: treat č Methadone, Buprenorphine, Naltrexone
heroine addiction; in this case, ↑methadone b/c š doing so • Methadone: long acting opioid agonist; Gold Std in pregnancy and ↓Morbidity in any opioid-dependent pt; ADE = ↑QTc
will force patient to go find more heroin • Buprenorphine: partial opioid agonist ∴no OD; commonly formulated č Naloxone to avoid abuse
• Naltrexone: competitive antagonist +/- ↑withdrawal č-in 1 week of heroin ∴ADE=Compliance and Good for Motivated Pts

4. Withdrawal = Anorexia/Anxiety, Bumps (Piloerection), Cramps (Muscle), Diaphoresis/Draining, Enlarged Pupils, Fever
• Mild: Clonidine for ANS signs/symptoms
• Moderate/Severe: detox č Methadone / Buprenorphine

Presentation: 42 y/o č unremitting back pain for 6 months after Pain Disorder
minor back trauma (no fractures, no back strain). H/o domestic 1. Diagnostic Criteria: pain at one or more anatomic sites of sufficient °severity to warrant clinical attention
violence. • ?GMC: GMC may be present but pain symptoms are excess of the disease pathology
Case • Dx: Pain Disorder • Course: often MC in blue-collar workers ---> chronic/disabling disease
32 • Next Step: SSRI, Biofeedback, Hypnosis, Psychotherapy
2. Management: SSRI, Biofeedback, Hypnosis and Psychotherapy
• Validate: doctor must validate pain and take opportunity to explain the many psychological contributors to pain
• ?Analgesic + Pain Rx: ineffective and not advised because patients become dependent!

Presentation: 42 y/o č depressed mood and trouble sleeping. GF Histrionic Personality Disorder: Attention Seeking + ↑Emotion (Dramatic, Extroverted) + Sexual + ↓Longterm Relationship
recently left him, he is obviously depressed about it but cannot 1. Diagnostic Criteria: pattern of ↑Attention Seeking + Emotion č ≥5 key features
describe her in any detail. He speaks overly dramatic. Dressed • Symptoms: Need Center of Attn, Seductive, Physical Appearance for Attn, Theatrical, Influenced, “intimate” Relations Only
in tropical shirt and leans to touch ♀ interviewer on shoulder. • Defense Mechanism: Regression (show child-like behavior) > Repression, Dissociation
Case • Dx: Histrionic Personality Disorder • Epidemiology: ♀ > ♂
33 2. Management
Definitions • R/O: Borderline PD ~ BPD experience ↑anxiety, psychosis, depression, suicide; HPD ~ ↑functionality
1. Repression: actively expel disturbances from awareness • Tx: Psychotherapy ~ c/w any personality disorder
2. Disassociation: emotion --> integrated functions breakdown • Limit Setting: setting ground rules as to what actions are or are not appropriate ~ needed for histrionic type patients

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Psychiatry Case Files

Case Files

Presentation: 17 y/o č 3-4 week somatic complaints, mood/ Adjustment Disorder ~ Maladaptive ∆Behavior 2° Nonthreatening Stressful Event
anxiety issues b/c of father’s army service commitment. Mild 1. Diagnostic Criteria: ∆behavior <3 months after stressful event producing disproportional distress or daily impairment
decline in functioning, but communicates feelings well to others. • Additionally: symptoms ≠ bereavement and resolve within 6 months after stressor is eliminated
• Dx: Adjustment Disorder č Mixed Anxiety/Depressed Mood • Subtypes: č Depressed Mood, č Anxiety, č Conduct Disturbance, č Mixed Depressed/Anxious, č Mixed Emotion/Conduct
Case
• Next Step: Supportive = Psychotherapy • Presentation: may begin č somatic complaints
34
Lessons Learned from Questions 2. Management: Supportive Psychotherapy (Most Effective) +/- Rx for Associated Symptoms
1. Clinically Significant Symptoms: distress in excess of what • R/O Bereavement: usually bereavement is prolonged rather than inappropriate response to life stressor
is expected to a stress that also has impact on functioning • R/O PTSD: usually PTSD has a stressor that is an actual threat of death/serious injury

Presentation: 41 y/o nurse presents č symptoms typical of Factitious Disorder

insulinoma. Labs show actual exogenous insulin use. 1. Diagnostic Criteria: intentional production of medical / psychiatric signs and symptoms to assume sick role (1° Gain)
• Dx: Factious Disorder • Medical: fever (via heating thermometer), abdominal pain, hematuria, seizures and skin lesions
• Next Step: Avoid Confrontation • Psych: hallucinations, depression, pseudologia fantastica (Compulsive Lying)
Case • Hints: occurs in health care workers (recognize how to feign symptoms well) and in persons of ↑intelligence
35 Definitions • Borderline Personality Disorder is a common comorbid psychiatric condition in patients č Factitious Disorder
1. 1° Gain: symptoms used to defend against internal conflicts • vs. Malingering: no 2° gain; patient’s single goal is to assume sick role
2. 2° Gain: symptoms used to provide external benefit • vs. Somatoform: patient consciously produces symptoms in Factitious Disorder

2. Management: collect information + form therapeutic alliance č patient + avoid confrontation b/c ↑risk of leaving AMA

Presentation: 2.5 y/o č new onset sleep problems associated č Parasomnias: Unusual Sleep Related Behaviors
screaming, SNS symptoms and no recollection next day. 1. Sleep Walking: simple/complex behavior in slow wave sleep ~ eyes open č glassy look, difficulty waking --> amnesia/anger
• Dx: Sleep Terrors • Etiology: OSA in Children, ↓sleep hygiene, ↑Thyroid, ↓Magnesium ~ usually NOT associated č psychiatric illness
• Next Step: Self limiting, +/- Clonazapam • Management: address underlying GMC + ↑sleep hygiene + Clonazepam (Short Acting BNZ) / Zolpidem / TCA

Normal Sleep Wake Cycle (See Stages in Case 37) 2. Sleep Terrors: sudden arousal (screaming) in slow wave sleep č ↑SNS Tone (↑HR, ↑RR, Sweat, dilated pupil) + Amnesia
1. Define: based on ∆physiology, brain waves, eyes, motor • Etiology: Fever (“Otitis Media”), Nocturnal Asthma, GERD, Stimulants, Other Sleep Disorders
Case • Management: ↑sleep hygiene + Treat Underlying Sleep Disorder + Clonazepam
36 2. NREM/REM: q90 min~NREM induces transition to deep REM
• NREM: progression = slowing waves + ↑arousal threshold 3. Nightmare Disorder: recurrent frightening dreams in REM sleep ---> awakening č vivid recall
• REM: EEG ~ aroused person; waking in REM = vivid recall • Etiology: 50% of PTSD patients experience Nightmare Disorders
• REM ∆: ↑BP, ↑HR, ↑RR • Management: Image Rehearsal Therapy (mental imagery modifying outcome of nightmare) +/- Antidepressants

3. Slow Wave = δ Waves = ↓f + ↑Voltage sleep 4. REM Sleep Disorder: loss of atonia during REM sleep ---> violent behavior ---> injury to self or partner
• Etiology: ↑Age, Antidepressant Use (TCA, SSRI, MAOI), Dementias
4. Nightmare vs. Night Terror: REM vs. δ Wave Sleep • Management: Clonazapam (Most Effective) + Ensure Safe Sleeping Environment

Presentation: 28 yr old woman č problems going to sleep and Dyssomnias: Insomnias (Difficult to Fall / Remain Sleep) vs. Hypersomnias (Excessive Daytime Sleepiness = Breathing Dz)
preoccupation č trying to go to sleep. xs 1. 1° Insomnia: difficulty initiating (Sleep-Onset Insomnia), maintaining (Sleep Insomnia) or nonrestorative sleep ≥1 month
• Dx: 1° Insomnia • Etiology: poor sleep hygiene, preoccupation č sleep, underlying mood > psychiatric disorder (MDD)
• Next Step: Examine sleep hygiene + Rx • Subtypes: Acute Insomnia (1-4 weeks ~ 2° stress, resolves) vs. Chronic Insomnia (≥1 month ~ ↑risk psych illness)
• Management: CBT + BNZ (MC Reason for Person to be on Long Term BNZ) + Improve Sleep Hygiene
Normal Sleep Wake Cycle • BNZ: ↓sleep latency + nocturnal wakes; ADE = tolerance, addiction, ↑daytime sleepiness, rebound insomnia, elderly
1. Define: based on ∆physiology, brain waves, eyes, motor • Non-BNZ (Zolpidem, Eszoplicone, Zaleplon): short term č ↓daytime sleepiness ADE but worse in elderly for falls
• Melatonin: Ramelteon ~ melatonin receptor agonist
2. NREM/REM: q90 min~NREM induces transition to deep REM • Antidepressant (“TAD More Sleep = Trazodone, Amitriptyline, Doxepin): Trazodone MC used sedating antidepressant
• NREM: progression = slowing waves + ↑arousal threshold
• REM: EEG ~ aroused person; waking in REM = vivid recall 2. OSA: repetitive collapse of upper airway ---> ↓Blood O2 Saturation
• REM ∆: ↑BP, ↑HR, ↑RR • Etiology: Obesity, ↑Neck Circumference ~ anything that narrows airway
• Features: Hypersomnia, Sleep Maintenance Insomnia, Nonrestorative Sleep, Morning HAs, Snoring
Case 3. Stages of Sleep ~ Bats Drink Blood • Management: PAP (CPAP, BiPAP), Weight Loss, Surgery
37 • Awake: β + ɑ
• Stage 1: Theta Waves (Drowsy) 3. Narcolepsy: Classic Tetrad ~ Sleep Attacks, REM Sleep Phenomenon, Hypn- Hallucinations, Cataplexy for 3 Months
• Stage 2: Sleep Spindles + K Complexes • REM Sleep Phenomenon: Sleep Paralysis, Vivid Sensation in REM (Seeing Colors, Hearing Noise as if Awake)
• Stage 3 + 4: δ Waves • Hallucinations: Hypnagogic (Going to Sleep) vs. Hypnopompic (Awaking from Sleep)
• Stage 5 (REM): β Waves • Management: ↑Sleep Hygiene + Stimulants (Modafenil) + Cateplexy Treatments (Na-Oxybate), TCAs/SSRI/SSNRI

4. Idiopathic Hypersomnia: hypersomnia, prolonged nocturnal sleep episodes and irresistible urges to nap
5. Kleine-Levin Syndrome: hypersomnia č hypersomnia, hyperphagia, hypersexuality and aggression

6. Circadian Rhythm Sleep Disorders: 2° intrinsic defects (suprachiasmatic nucleus) OR impaired stimuli (↓Light Stimuli)
• Delayed Sleep Phase Disorder: chronic delay in sleep onset č nl sleep duration 2° puberty, nicotine, ↓hygiene
• Advanced Sleep Phase Disorder: chronic early onset in sleep č nl sleep duration 2° ↑age
• Shift Work Disorder: misalignment of circadian rhythm 2° ∆work hours
• Jet Lag Disorder: sleep disorder 2° to travel across time zones

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Psychiatry Case Files

Case Files

Presentation: 28 y/o č HA qDay for past month; laying down + Somatization Disorder
Codeine/Tylenol +/- improves. Multiple GI complaints, chest and 1. Diagnostic Criteria: onset before 30 y/o č multiple complaints in multiple organ systems č specific criteria
back pain as well as numbness/tingling in arms. • Specific Criteria: 4 Pain + 2 GI + 1 Sexual/Reproductive + 1 Pseudoneurologic š GMC that causes significant impairment
• Dx: Somatization Disorder • Pseudoneurologic: pain or tingling in extremities
• Next Step: Regular visits č same PCP • Signs of Impairment: lost jobs b/c of many sick days + repeated surgeries č accidental associated consequences
• +GMC: 50% actually have a GMC; in these causes, the physical complaints are excess of what is expected
Case Definitions • Common Hints: wax/waning over time č h/o multiple medical procedures and frequent ∆providers
38 1. Somatoform DO: physical symptoms š organic cause where
patients are not consciously feigning symptoms 2. Management
• R/o Organic Causes: MS, MG, AIDS, CT Disorders (Vasculitis), Porphyria, Thyroid Disease
2. Somatoform vs. Malingering: while somatoform DOs might • R/o Other Psych Disorders: Depression (Mood THEN Somatic), Anxiety (few symptoms in 1 organ system)
occur for 1° / 2° gain, it is not considered malingering unless • R/o Other Somatoform Disorders: Hypochondriac (conviction of single illness), Conversion (neuro symptom), Pain (all pain)
consciously feigning symptoms • F/u: Regular visits č single PCP that limits medical work ups
• Psych Issues: address slowly over time; ↓response rate and quick ∆physician č abrupt addressing of psych condition

Presentation: 23 y/o s/p delivery č auditory hallucinations to kill Psychotic Disorder NOS ~ in this case Postpartum Problems
NB b/c delusion that NB is devil. Depressed mood, labile affect 1. Postpartum Problems
all suddenly appeared in 24 hours s/p delivery. No FMHx/PMHx/ • PP Blues: transient mood disorder, predominately happy that resolves <2 weeks
Rx. • PP Depression: same criteria as MDD; ↑Risk č +h/o MDD/PP Depression ~ 6 weeks PP
• Dx: Psychotic disorder NOS • PP Psychosis: medical emergency b/c ↑risk harm to baby; now thought to be 2° underlying bipolar disorder
• Next Step: Separate mom from baby ---> hospitalize mom +/-
anti-psychotic agents 2. Treatment: No Rx for PP Blues ---> SSRI for PP Depression ---> Mood Stabilizers for PP Psychosis (b/c 2° Bipolar DZ)
Case • Prophylaxis: if safe for pregnancy initiate SSRI (h/o PP Depression) or Lithium (h/o Mood Disorder)
39
Shared Psychotic Disorder [Folie à Deux]
1. Criteria: diagnosed when patient develops same delusional symptoms as someone he/she is close to = FAMILY
2. Management: Separate (20-40% Recover) ---> Antipsychotic Rx if 1-2 Weeks Later = No Improvement

Cultural-Specific Psychoses
1. Koro [Asia]: patient believes penis is shrinking and will lead to death
2. Amok [SE Asia]: sudden outburst of violence š recollection ---> eventual suicide
3. Brain Fag [Africa]: HA, fatigue and ∆vision in ♂ students

Presentation: 65 y/o č h/o GI discomfort, now on Tardive Dyskinesia

metoclopramide, has involuntary mouth/facial mvmt + arching of 1. Pathophysiology: occurs 2° central dopamine blocking Rx ---> ↓D receptors (odd/↓mvmt) ---> ↑D receptors (odd/↑mvmt)
back + neck. • Central Dopamine Block: metoclopromide (gParesis), neuroleptics (haloperidol + -azine), ↓č Atypical Antipsychotics
• Dx: Tardive Dyskinesia • Time: Dystonia (4 hr=oculogyric crisis) ---> Akathisia (4 days=restless) ---> Parkinsonism (4 weeks) ---> Tardive (4 month)
• Next Step: D/C Metoclopromide, start BNZ +/- Baclofen • TD Symptoms: involuntary movements + dystonia of back/neck ~ Retrocollis (vs. Idiopathic Dystonia ~ face/neck)
Case
40 2. Management
• Rx: BNZ, Baclofen, Vitamin E
• Further Block D-R?: giving further neuroleptic (D2 blocker) can ↓dykinesia, but overall worse longterm outcome
• If Need ↓D: switch to reserpine + tetrabenzine (VMAT inhibitors = deplete CNS dopamine ~ efficacy of D2 antagonist)
• ↑Risk Permanent Dyskinesia: ↑age, ♀, co-existing brain damage

Presentation: 45 y/o patient wants to leave AMA b/c he is not Narcissistic Personality Disorder
treated č respect he deserves. Wants food from outside 1. Diagnostic Criteria: Pattern of Grandiosity + Need for Admiration + Lack of Empathy č ≥5 Symptoms
cafeteria. Shows interest in interviewers new watch. • Symptoms: Self-importance (I’m Special), Fishing Compliments, Entitled, Lack Empathy, Envious, Arrogant, Exploit Pple
• Dx: Narcissistic Personality Disorder • Note: despite grandiosity, NPD often have fragile self-esteem
• Approach: Validate patient’s experience so he may agree to • “Narcissistic Injury”: personality may become apparent after acute life-threatening illness ~ MI, Stroke
Case stay in the hospital • Why? Such an acute event shows the patient that his body is not immortal
41
Definition 2. Management
1. Denial: emotional conflict ---> refusal to see reality • R/O: Antisocial PD ~ APD usually want material gains č no respect to others; NPD wants subjective recognition
2. Devaluation: emotion --> ↑bad qualities to self/others • Tx: Psychotherapy (c/w personality disorders) +/- Antidepressants / Mood Rx

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Psychiatry Case Files

Case Files

Presentation: 7 y/o č 1 yr h/o uncontrollable blinking and throat Tourette Disorder

clearing. 1. Tics: sudden, repetitive, nonrhythmic, stereotyped involuntary movements or vocalizations
• Dx: Tourette Disorder • Motor Tics: MC involve face/head ~ blinking
• Management: ɑ2 Agonist ---> Risperidone • Vocal Tics: Coprolalia (repetitive obscene outbursts ~ Uncommon in Peds) vs. Echolalia (exact repetition of words)

2. Tourette Diagnostic Criteria: multiple motor and vocal tics (both at some time during disease) č onset <18 y/o
• Tic Features: evolve over time č multiple tics a day almost every day for >1 year č no tic-free period >3 months
Case • Comorbid Psych DZ: ADHD + OCD
42
3. Pathophysiology
• Neurochemical Factors: ↓Dopamine Regulation in caudate Nucleus
• Post-Infectious: PANDAS ---> OCD > Tourette Disorder

3. Management: Psychotherapy + Rx (ɑ2 Agonist ---> Risperidone)

• +ADHD: stimulant use controversial b/c exacerbates tics
• +OCD: SSRI augmentation to antipsychotic (Risperidone) effective

Presentation: 12 y/o č OCD and motor tics č h/o strep infections Anxiety Disorder NOS / 2° GMC
• Dx: PANDAS 1. Diagnostic Criteria: Anxiety, Panic Attacks, Obsessions or Compulsions č evidence (Hx/PE/Labs) of underlying GMC
• Next Step: ASO / DNAse-B Titers • Additional Criteria: must cause impaired daily living, no concurrent delirium
• Management: SSRI/CBT + Risperidone
2. Pathophysiology
Case • Endocrine: Graves Disease, Sjogren, Pheocrhomocytoma, Insulin OD
43 • Neuro/Psych: PANDAS, MS, Parkinson Disease
• Other: Cardiomyopathy, COPD, Arrhythmias

3. Management
• PANDAS: ASO (3-6 weeks) and DNAse-B (6-8 weeks) ---> SSRI/CBT (OCD) + Risperidone (Motor Tics)
• Anxiety 2° GMC: Tx Cause +/- Additional Anxiety Therapy (“Battling Stress Since Birth” = BNZ, SSRI, SSNRI, Buspirone)

Presentation: 17 y/o is grossly underweight but she denies any Anorexia Nervosa
problems other than mild depression. She sees herself as 1. Diagnostic Criteria: refusal to maintain 85% ideal body weight or BMI <17.5 č fear of fat and amenorrhea (>3 missed)
overweight despite low BMI. • Subtypes
• Dx: Anorexia Nervosa • Restrictive: ↓intake š binge/purge activity; common č OC-traits
• Next Step: Advise hospitalization to restore nutrition, • Binge/Purge: binge-eating ---> vomiting, laxative/diuretics, ↑↑↑Exercise
correct electrolyte problems, solve dehydration. • vs. Bulimia: both have desire for thinness and both can have binge/purge; only anorexia has ↓BMI
• vs. MDD: both have ↓eating; MDD has no interest in food while anorexia is a preoccupation č food but ↓eating
Case Lessons Learned from Questions • Course: common in industrialized locations (↑food č ↑emphasis on thin) + sports (ballet, cheerleading)
44 1. Albumin Level: can be used on admission to determine • Medical: Amenorrhea, Cold Intolerance, Orthostasis, Arrhythmia, Lanugo Hair, Seizures, Osteoporosis
°starvation of patient • Labs: ↓Na, ↓Cl/↓K + ↑pH (=Vomit), QTc Prolongation, Anemia/Leukopenia, ↓Gonadotropins, ↓Glucose

2. Management: Outpatient Treatment unless >20% Underweight or Severe Medical (Dehydration) / Psych (Suicidal) Risk
• Hospitalization: Nutritional Replacement, Electrolyte Correction, Dehydration Correction
• Refeeding Syndrome: too quick malnourish correction ---> fluid retention, ↓PO4, Mg, Ca ---> arrhythmia, seizures
• Psychotherapy: behavioral + family therapy
• Rx: SSRI Ineffective (2° ↓dietary intake tryptophan = ↓5HT Available)

Presentation: 18 y/o has sudden hallucinations and asks to be Malingering

admitted to hospital. He is about to be deployed by navy. 1. Definition: conscious feigning of symptoms driven by external motivations in order to achieve personal (2°) gain
• Dx: Malingering • External Motivation: avoid police, receive room/board/monetary compensation, narcotics
• Next Step: Obtain collateral information and carefully • Hint: symptoms improved once certain non-medical gain is achieved; likewise no ∆mood č good prognosis from doctor
Case confront inconsistencies č presentation while validating his • ↑Insight: often patients will have no psych history and yet have remarkable insight into disease
45 feelings on his military duty
2. Management: Maintain Therapeutic Alliance +/- Collateral Information +/- Gentle Confrontation

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Psychiatry Case Files

Case Files

Presentation: 2 y/o č poor interaction č peers + family, delayed Autistic Disorder

language, repetitive movements and difficult accepting ∆. 1. Diagnostic Criteria: at least 6 symptoms (mainly from “Social Interaction” as below) by age 3 y/o:
• Dx: Autistic Disorder • Problems č Social Interaction: ↓social/emotional reciprocity, lack of peer interests, no non-verbal communication
• Management: Language Development most important • Problems č Communication: delayed speech, lack of make-believe/imitative play
prognostic factor*** • Repetitive/Stereotyped Behavior/Activity: hand flapping, inflexible adherence to rituals, reoccupation č objects

Definitions 2. Pathophysiology ~ Prenatal (Rx/Infections) + Genetic (Siblings = 22x ↑Risk) + Immunology/Biochemical Factors (↑5HT)
1. Pervasive Developmental Disorders: group of 5 disorders • ↑Prevalence: +/- 2° to ↑awareness / recognition of condition
č young age of onset affecting multiple areas of development • Association č MR: 70% meet the criteria for Mental Retardation (IQ <70)
~ social skills, language and behaviors
3. Management: 2 Most Important Prognostic Factors = Level of Intellect and Communication Competence
2. PDD List: Autistic, Asperger, Rett, Childhood Disintegrative • R/O: Hearing Test important to order before diagnosing Autism
Disorder and PDD NOS • Treatment: Remedial Education + Behavioral Therapy + Symptom-Needed Rx (Antipsychotics, Antidepressants, Etc)

Lessons Learned from Questions Asperger Disorder ~ High Functioning Autism

1. Recognizing Autism: symptoms often recognized when child 1. Diagnostic Criteria: Impairment of Social Interaction č Repetitive Behaviors and NORMAL Language + Cognition
Case is placed in environment č children of similar age; ∴ becomes
46 • Other Differences from Autism: no association č MR (Cognition); adequate self-help skills
more of a recognition issue č single children because no
siblings to compare to! 2. Management: Same as Autism Above
• Note: preservation of verbal skills allows ↑benefit from Remedial Education and Behavioral Therapy

Rett Disorder
1. Diagnostic Criteria: normal physical + psychomotor development from Birth - 5 months ---> ↓Head Growth / Regression
• “Regression”: ↓purposeful hand movements / ↑stereotyped hand movements, ↓language, ↓movement
• Associations: Cognitive Development NEVER progresses that of 1 y/o; ↑Risk of Seizures (Abnormal EEG)

2. Pathophysiology: ↑association č MECP2 Gene on X-Chromosome ~ mainly affects Girls (Lethal to Boys In Utero)

3. Management: Supportive

Childhood Disintegrative Disorder

1. Diagnostic Criteria: normal development from Birth - 2 years ---> Regression before 10 y/o
• vs. Rett Disorder: no ∆head size, no ∆hand movement, MC in boys > girls

Presentation: 21 y/o comes to counseling center b/c she had a Avoidant Personality Disorder: Intense Fear of Rejection ---> Avoid Social Situations BUT Desire Relationships
situation in class that made her feel more “socially retarded” and 1. Diagnostic Criteria: social inhibition + hypersensitivity + feelings of inadequacy č ≥3 symptoms
“rejected” than normal. • Symptoms: (AFRAID) ~ Avoids occupation č others, Fear, Reserved, Always thinking of rejection, Isolated, Distance themself
• Dx: Avoidant PD • Associated Anxiety: Social Phobia
• Management: Psychodynamic / CBT • Course: chronic č ↑risk of anxiety, MDD

Case Definitions 2. Management

47 1. Displacement: emotional conflict avoided by transferring to a • R/O Schizoid: APD desire relationships while schizoids do not
less dangerous person/situation • R/O Social Phobia: Social Phobia is a fear of embarrassment (particular setting) while APD is fear of rejection (general)
• Ego ____: recognize that social phobia, an anxiety disorder, will be ego-dystonic (vs. Avoidant Disorder)
2. Projection: attribute feelings about themselves to world/ • R/O Dependent Personality Disorder: both cling to relationships, but dependents are constantly seeking relationships
others • Tx: Psychotherapy (Assertiveness Training) + Propranolol (Anxiety Symptoms) +/- SSRI (MDD)

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Psychiatry Case Files

Case Files

Presentation: 10 y/o č ↑anxiety when separated from mother; all Separation Anxiety Disorder
started when she became very ill and required hospitalization. 1. Diagnostic Criteria: ↑fear ≥4 weeks of leaving major figures (parents) č somatic complaints upon separation
• Dx: Separation Anxiety Disorder • Associations: +/- preceded by stress (parent falling ill) / worry of losing parent forever + ↑risk of Panic Disorder / MDD
• Management: SSRI + Gradual Separation Therapy • Age: Uncommon <6 y/o because separation anxiety +/- normal between 7 months - 6 y/o
• vs. Stranger Anxiety: 8-12 months č baby distress when seeing new faces
Lessons Learned from Questions
1. CBT Reminder: focuses on connecting patient’s thoughts 2. Management: family therapy, CBT, gradual separation and +/- ↓dose antidepressant (SSRI) to manage initial anxiety
(cognitive) to the behaviors. Effective for SAD (Substance
Abuse, Anxiety, Depression). Other Childhood Disorders
1. Encopresis: involuntary/intentional passage of feces by age 4 y/o at least 1x/month for 3 consecutive months
2. SSRI in Kids: FDA has BBW for suicidal thoughts when • R/O: Endocrine (Hypothyroid), ↓GI Problems (Anal Fissure, IBD), Diet
children use ANY antidepressant • Etiology: ↓sphincter control vs. repetitive constipation č overflow incontinence
Case • Management: Bowel Catharsis ---> Stool Softener
48
2. Enuresis: involuntary urine voiding after 5 y/o at least 2x/week for 3 consecutive months (Continence nl before 4 y/o)
• R/O: UTI, Diabetes, Seizures
• Etiology: small bladder vs. ↓nocturnal ADH
• Management: Behavioral (Enuresis Alarm), Anti-Diuretic (DDAVP), Imipramine

3. Selective Mutism: refusal to speak in certain situations 1+ month despite ability to use/understand language
• Management: Psychotherapy, CBT +/- Anxiety Management (Rx)

4. Child Abuse ~ Neglect >>> Physical, Emotional and Sexual Abuse [MC Perpetrator in Sustained Abuse = PARENT]
• Abused Child: ↑Risk of Anxiety, MDD, Dissociative Disorder, Substance Abuse (EtOH), PTSD + becoming Abusive
• Signs of Sexual Abuse: ↑sexual knowledge/play inappropriate for age
• Management: legal requirement to report to DCS

Presentation: 45 y/o man has been working in a bar for 3 weeks Dissociative Disorders
š memory of life before. Located by wife, claiming he is a 1. Definition: loss of memory (amnesia), identity or sense of self (integration of thoughts, behaviors, perceptions, feelings)
different man by identity that lives č her many miles away. • Common Cause: +/- 2° trauma or abuse from childhood or severe cases as adults ---> copes by living in parallel life
• Dx: Dissociative Fugue • 4 Key Disorders: as below, if Dissociative NOS, consider:
• Management: Rapid Spontaneous Recovery is Common • Ataque De Nervios: culturally bound trance of Puerto Rico č convulsion, fainting, crying
• Ganser Syndrome: approximate answer-giving to simple questions (“How many legs do you have?”)
Lessons Learned from Questions
1. Abreaction: strong reaction when patient retrieves memories 2. Dissociative Amnesia [MC Dissociative Disorder]
• Diagnostic Criteria: 1+ episode of xRecall of Personal Information usually 2° traumatic/stressful event
2. Dissociative Amnesia vs. Fugue: other than information • Course: new memory formation retained; acute cases abruptly may resolve; chronic=↑risk comorbid depression and anxiety
about travel, patients č DA can eventually recognize amnestic • vs. Dementia: DA = loss of personal information while retaining memory of details; dementia is the exact opposite
period, but patients č fugue are not aware they have forgotten • Treatment: establish safety ---> psychotherapy +/- agents to ease interview (Hypnosis, Na-Amobarbital, Lorazepam)
anything; similarly, DA patients recall general information
and lose information only about identity 3. Dissociative Fugue [Think Fugitive Running Away and Forming New Identity]
Case
49 • Diagnostic Criteria: sudden unexpected travel away from home/work + inability to recall personal details/past
3. Dissociative DZ vs. Dementia/Delirium: latter have more • Identity: +/- simply confusion ---> assume new identity č unremarkably little anxiety regarding their confusion
purposeless or disorganized travels and do not assume • ↑Risk Patients: h/o EtOH Abuse, MD and Head Trauma
new identities; in fugue the travel and assumption of new • Course: duration = hours - days ---> patient assumes old identity š any recollection of fugue
identity are purposeful • Treatment: see Dissociative Amnesia above

4. Dissociative identify Disorder (Multiple Personality Disorder)

• Diagnostic Criteria: 2+ Distinct Identities that recurrently take control of behavior č inability to recall other identities info
• Epidemiology: Age of Onset = 6 y/o but Age of Diagnosis = 30 y/o. H/o Childhood Abuse is common
• Course: 90% Female and 33% attempt Suicide ~ overall WORST prognosis of all dissociative disorders
• Treatment: Psychotherapy +/- Hypnosis, Na-Amobarbital, Lorazepam for interviewing

5. Depersonalization Disorder
• Diagnostic Criteria: recurrent experiences of detachment from body or mental processes; reality testing remains intact
• Treatment: Psychotherapy

Presentation: 16 y/o č suicidal ideation 9 days after stopping Substance Induced Mood Disorder
cocaine. She has +SIGECAPS. 1. Diagnostic Criteria
• Dx: Substance Induced Mood Disorder • Mood Symptoms: signs/symptoms c/w SIGECAPS or DIGFAST
Case • Next Step: Psychotherapy for Substance Abuse Treatment • Substance Use: evidence from Hx/PE/Labs (UDS)
50 • What Substance? Anything under the sun EXCEPT FOR CANNABIS

2. Treatment: Psychotherapy >>> SSRI

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Psychiatry Case Files

Case Files

Presentation: 12 y/o č OCD and motor tics č h/o strep infections Neurosis
• Dx: No Diagnosis ~ Neurotic Patient 1. Pathophysiology: chronic nonpsychiatric condition caused by unconscious conflict(s) generating anxiety
• Management: Insight-oriented therapy • “Unconscious Conflict”: involve forbidden wishes/feelings usually involving individual’s roots/early development
• Symptoms: occur when defense mechanisms do not effectively allow patient to cope č the anxiety
Case Lessons Learned from Questions • Ego-Dystonic: required for diagnosing neurosis
51 1. Freud’s Neurotic Triad: trouble č working (procrastination),
loving (no longterm relationships) and insight (recognizes 2. Management: all geared towards ID Meaning of Unconscious Conflict
she is doing something) • R/O Other Psych: OCD (no severe compulsions) vs. GAD (Neurotics Focus on 1 Thing)
• Insight Oriented (Psychodynamic) Therapy: ↑emphasis of unconscious mental processes č ↑ability to interpret neurosis
• Psychoanalysis: “lying on couch” saying anything (free association) č ↑transference to therapist

Presentation: 12 hours after admission, 42 y/o gets shaky. 6 EtOH Withdrawal

hours later, she has GI symptoms, hallucinations and gets 1. Pathophysiology: chronic EtOH ---> CNS adjusts to depressed (not mood!) state ---> withdrawal ---> reactive hyperactivity
sweaty. 2. Presentation: first symptoms begin 6-24 hours after last drink and EtOH Withdrawal can last 2-7 days
• Dx: EtOH Withdrawal • Withdrawal Presentation
• Mild: irritable, insomnia, tremors
Case • Moderate: think ANS ~ diaphoresis, HTN/↑HR, Fever, AMS
52 • Severe: Tonic-Clonic Seizures, DTs, Hallucinations
• DTs: begins 48-72 hours after last drink; present as delirium, hallucinations, tremor, ANS instability ---> BNZ
• Management: monitor withdrawal č Clinical Institute Withdrawal Assessment (CIWA)
• Seizures: manage č BNZ (LOT = Liver Disease) ---> long term anticonvulsant therapy NOT indicated
• HypoMg: common and ↓seizure threshold ---> CORRECT
• Banana Bag: thiamine, folate and vitamins for nutirtional deficienies
• DTs: BNZ

Presentation: 26 y/o man has always felt that he was in the Gender Identity Disorder [Transsexuality]
wrong body; has adopted the gender of a woman. 1. Definition: subjective feeling they were born to the wrong sex (gender does not match the sex ~ “parts”)
• Dx: Gender Identify Disorder • Hints: dress like opposite sex, take sex hormones, undergo ∆sex procedures
• Pediatrics: usually occurs around age 3 when gender identity is established
Case Definitions
53 1. Anatomical Sex: sex based on appearance of genitals 2. Treatment: family therapy for younger patients +/- sex reassignment for older patients
2. Chromosomal Sex: sex based on karyotype • R/O Delusional Disorder: Gender ID recognize recognize gender ≠ anatomy; delusion = think they have opposite anatomy
3. Intersex: genitals don’t allow assignment • Live in Community of Desired Gender: recommend prior to hormones or surgery ~ associated č +Outcome
4. Gender Identity: pt’s perception of ♂/♀ regardless of sex • Other Tx: Estrogen to create breasts + ↑♀ body physique + Electrolysis to remove ♂ hair

Presentation: 47 y/o č multiple conflicts at work b/c suspicious of Paranoid Personality Disorder: Distrust + Interpret Motives as Malevolent + Blame Others + Jealous (“Cheating Spouse”)
colleagues. He finds hidden suspicious meaning in benign 1. Diagnostic Criteria: General Distrust of Others č at least 4 Symptoms
actions (checking pager). Paranoid. • Symptoms: suspicious š reason, preoccupied č doubts of loyalty, benign ---> malevolent, persistent grudges, quick to attack
• Dx: Paranoid Personality Disorder (Cluster A) • vs. Schizophrenia: no frank psychosis (hallucinations) + not °severity of delusions +/- acute bouts of psychosis
Case • Management: Working Alliance č Patient • vs Paranoid Delusions: Paranoid Ideation is more the worry of harm and patients don’t act on paranoia (vs. Delusions)
54
Lessons Learned from Questions 2. Management: Straightforward Discussions č Patient
1. Cluster A + Schizophrenia: schizoid is only Cluster A š • Psychotherapy: Mainstay of Treatment for All Personality Disorders
relationship to Schizophrenia • Working Alliance: therapeutic relationship between pt + physician allowing constructive interactions
• Reality Testing: “No my pager went off b/c my secretary outside this room needed to contact me regarding the office.”
2. Ideas of Reference: belief that others are talking about you • Rx: +/- Antipsychotic during bout of acute psychosis

Presentation: 42 y/o č seizure, nausea, diaphoresis and BNZ on Sedative-Hypnotics

urine. 1. Pharmacology: Rx include BNZ, Barbiturates, Zolpidem, ɣ-Hydroxybutyrate (GHB, date rape)
• Dx: BNZ Withdrawal • BNZ: potentiate GABA by ↑frequency of Cl- channel opening
• Barbiturates: potentiate GABA by ↑duration of Cl- channel opening; @↑Dose Barbs act as agonists at GABA-R = DEATH
Lessons Learned from Questions
1. Dependence: the more short acting the more likely to have 2. Intoxication: Think EtOH ~ Drowsiness, AMS, ↓BP, Slurred Speech, Ataxia/Nystagmus
symptoms of dependence (↓Duration = ↑Dependence) • Synergy: avoid combination of BNZ, Barbs, Opioids and EtOH
Case • Treatment: ABCs ---> Charcoal/Lavage if ingested in last 4-6 Hours ---> Reversal
55 2. Life Threatening Withdrawal: in general, withdrawal of • Barbs ---> Alkalize urine č NaHCO3 to ↑renal excretion
sedating drugs is life threatening while withdrawal of • BNZ ---> BNZ antagonist = Flumazenil
stimulants is not life threatening.
3. Withdrawal: note of all Substance Withdrawal, Barb Withdrawal = Most Life Threatening ~ mimics EtOH Withdrawal
• Tx: BNZ to prevent reactive seizures +/- Carbamazepine/Valproate taper (KEY DIFFERENCE from Mgmt EtOH Withdrawal)

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Psychiatry Case Files

Case Files

Presentation: 8 y/o “slow learner” and “falling behind” peers. H/o Mental Retardation
aggression in pre-school, now “grown out”. No current/past DZ. 1. Diagnostic Criteria: subaverage intellectual functioning (IQ ≤70) + ↓adaptive skills (BOTH required) <18 y/o
• Dx: Mild Mental Retardation • Types: Mild [85% of MR] (IQ 55-70) --> Moderate (40-55) --> Severe (IQ 25-40) --> Profound (IQ<25)
• Next Step: Intelligence Testing + Assess Adaptive Function • Mild: not detected until school ---> work/live č some social support [Only form that allows holding a job]
• Management: Complete Evaluation, R/O Other Psych, • Moderate: social isolation in school ---> needs ↑level of supervision
Coordinate Care • Severe: minimal speech ---> not-independent
• Profound: absent speech ---> Nursing for Life
Psych Evaluation of Child • Etiology: 50% Unknown + 50% Genetic, Prenatal, Perinatal, Postnatal
1. Historians: Child, Parents, Teachers, Pediatrician • Genetic: Down Syndrome, Fragile X, PKU, PWS/AS, William’s Syndrome, Tuberous Sclerosis
2. Gathering Info • Prenatal: TORCH
• Diagnostic Play: child reveals by play, draw, role-play • Perinatal: Anoxia, Prematurity, Birth Trauma, Meningitis, ↑Bilirubin
• Classroom Observation: great for determining function • Postnatal: Hypothyroid, Malnutrition, Toxin Exposure, Trauma, Psychosocial Causes
Case • Formal Neuropsych Testing: quant. strength/weakness
56 • Kaufman Assessment Battery for Children: intelligence 2-12 2. Management
• Wechsler Intelligence Scale for Children: IQ for 6-16 • Evaluation: +/-Karyotype to ensure syndrome-associated MR
• R/O Psych: 40% MR have a 2nd Psychiatric Disorder

Learning Disorder
1. Diagnostic Criteria: lower achievement in math, reading, writing for expected age, education level or intelligence level
• Additional Criteria: affect achievements of daily living, cannot be explained by sensory defects and often 2° ∆cognition
• Epidemiology: Reading > Writing > Math

2. Management
• R/O Sensory: always rule out sensory deficits before thinking learning disorder
• Remedial Education: tailor to child’s specific needs

Presentation: 24 y/o č new onset blindness š physiologic Conversion Disorder: Convert Psychiatric Illness ---> Neurologic Illness ---> Convert Spontaneously Back to Baseline
explanation. His mother died recently after he was unable to 1. Diagnostic Criteria: 1+ Neurologic Symptom (Sensory / Motor) ~ Paralysis, Blindness, Mutism, Globus Hystericus (Lump)
send her mother b/c he lost it in gambling. Not bothered by • “La Belle Indifference”: patients are often calm and apathetic regarding their focal neurologic deficit
Case blindness. • Course: ↑comorbid Schizophrenia, MD, Anxiety; note 25% will re-experience conversion disorder č additional stresses
57 • Dx: Conversion Disorder
• Management: Spontaneously resolve, but +/- Psychotherapy 2. Management: majority of patients spontaneously convert back to baseline
(Insight Oriented), Hypnosis, Behavioral Relaxation • R/o Organic Cause: note conversion-type presentation in elderly patient ---> think possibly real neurologic deficit
• Tx: Psychotherapy (Insight Oriented), Hypnosis and/or Behavioral Relaxation

Presentation: 32 y/o man insists wife wears high heeled shoes Paraphilia ~ MC = Pedophilia, Voyeurism, Exhibitionism
during all sexual play. 1. Definition: engagement in unusual sexual activities or preoccupation č unusual sexual urges/fantasies for ≥6
• Dx: Fetishism • Pedophilia: gratification from activities / fantasies č children <13 y/o in pts at least 16 y/o and 5 years older than child
• Frotteurism: gratification from touching/rubbing non-consenting person
Lessons Learned from Questions • Voyeurism: gratification from watching unsuspecting nude person (binoculars)
1. Compound Paraphilias: tend to occur in groups; if pt has a • Exhibitionism: gratification from exposing genitals to another person
paraphilia, ask about other possible paraphilias • Fetishism: gratification / sexual preference from inanimate objects (shoes, panty-hose)
• Transvestic Fetishism: gratification in heterosexual men from wearing women's clothing (especially underwear)
Case • Masochism: gratification from being humiliated or beaten
58 • Necrophilia: gratification from sexual acts č dead people
• Telephone Scatologia: gratification from calling unsuspecting women and engaging in sexual conversation č them

2. Management
• Prognostic Factors: Poor = ↓age of onset, substance use, arrests Good: self-treatment, guilt, otherwise nl sex behavior
• Insight Oriented Psychotherapy: patient gain insight into stimuli that make them act the way they do
• Behavior: Aversive Conditioning ~ couple impulse to unpleasant stimuli (electric shock)
• Rx: anti-Androgens to ↓desire ~ MDPA, Cyproterone, Leuprolide

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Case Files

Presentation: 26 y/o č h/o drug abuse has dilated pupils, ↑libido Amphetamine
and sweating from a dance party. 1. Pharmacology: block reuptake and facilitate “dumping” of DA + NE from nerve endings = STIMULANT
• Dx: Amphetamine Intoxication • Manufacturing: easily synthesized from OTC Pseudoephedrine
• “Club Drug” Amphetamines: think dance clubs/raves including MDMA (Ecstasy) and MDEA (Eve)
• vs. Amphetamines: ↑DA + NE + ↑5HT; ∴↑risk of 5HT Syndrome č SSRI
• Effects: ↑risk of hallucinations + ↑stimulant properties + additional feeling of ↑closeness to others
Case
59 2. Intoxication
• Presentation: ~ Cocaine = Dilated Pupils + ↑Libido (think Dance Clubs) + Perspiration (Dance) + Respiratory Depression
• Overdose: Hyperthermia + Dehydration + Rhabdomyolysis
• Treatment: Cool + Rehydrate + Monitor Electrolyte/Renal Status
• Heavy Use: Amphetamine Psychosis ~ resembles psychotic state as in schizophrenia
• Chronic Use Hints: Meth Mouth (Accelerated Tooth Decay) + Acne

3. Withdrawal: Prolonged Depression +/- Psychosis

Presentation: 23 y/o admitted to psych unit after superficial wrist Borderline Personality Disorder
cutting attempt. Admitted several times before this when she has 1. Diagnostic Criteria: pattern of impulsivity and unstable relationships, moods, images and behaviors č ≥5 symptoms
been “abandoned” by those around her. She is also center of • Symptoms: (IMPULSIVE) ~ Impulsive, Moody, Paranoid, Unstable Self Image, Labile/Love-Hate, Suicide, Inappropriate
disagreement btw resident and nursing staff. Anger/Aggression, Vulnerable to Abandonment, Emptiness
• Dx: BPD • Defense Mechanism: Splitting (view people / single person as all good or bad / black or white)
Case • Management: Dialectal Behavioral Therapy • H/o: ↑risk of childhood physical, emotional and sexual abuse than general population
60
Lessons Learned from Questions 2. Management
1. Idealization ---> Devaluation: classic in BPD where patients • R/O Schizophrenia: no frank psychosis (hallucinations/delusions) in BPD
build up hospital as safe haven and then quickly claim how • R/O Bipolar 2: Borderline patients have more moment-to-moment shifts in mood in response to specific triggers
awful it is • Tx: Psychotherapy (DBT) + Rx for Depression / Psychosis (Rx more effective for BPD than other Cluster Disorders)
• Dialectical Behavioral Therapy: ↓self-destructive behaviors/hospitalizations in BPD

Impulse Control Disorders Intermittent Explosive Disorder

1. Repetitive behaviors despite adverse consequences 1. Diagnostic Criteria: recurrent outbursts of aggression against others/property that quickly go away resulting in distress
2. Little control over negative behavior 2. Management: SSRI, Mood Stabilizers (Lithium) and Propranolol
3. Anxiety/craving prior to engaging in behavior
4. Relief/Satisfaction after completing behavior Kleptomania
1. Diagnostic Criteria: impulsive urge to steal objects NOT for personal gain č ↑guilt aftewards
I 2. Management: screen for Bulimia (↑association č Kleptomania) + Psychotherapy (insight oriented/CBT)
M
P Pathologic Gambling
U 1. Diagnostic Criteria: maladaptive gambling behavior č ↑$$ to achieve pleasure, hiding gambling, funding gambling illegally
L 2. Management: Gambler’s Anonymous = MOST EFFECTIVE
S
E Trichotillomania
1. Diagnostic Criteria: intentional pulling out of one’s scalp > eyelash/eyebrow/facial/pubic hair 2° to hair texture = Trigger
2. Management: SSRI, Mood Rx, Antipsychotic + Psychotherapy

Pyromania
1. Diagnostic Criteria: 1+ episode of deliberate fires č ↑interest/curiosity in fire
2. Management: Psychotherapy (Behavioral), SSRI and Supervision

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Case Files

Sexual Response Cycle Sexual Disorders

1. Desire: interest in sexual activity ~ fantasies / contact 1. DDx Sexual Dysfunction ~ note, generally, that DA ↑Libido and 5HT ↓Libido
2. Excitement: desire ---> somatic ∆ (erection, lubrication) • GMC: atherosclerosis (ED 2° Vascular Damage), DM, pelvic adhesions (dyspareunia ~ Endometriosis), Depression
3. Plateau: further physical ∆ ~ ↑testes size/ vaginal contraction • Rx: SSRI
4. Orgasm: ejaculation / uterine-vaginal contractions • Substances: EtOH (acute = ↓inhibition/↑sex; chronic = ↓desire), Cocaine/Amphetamine (↑ via DA reward), Narcotics (↓)
5. Resolution: refractory period (♂) vs. none (♀) • Endocrine/Reproductive: ↓E after menopause causes ∆vagina (≠∆desire); ↑P antagonizes E-effects ---> ↑P = ↓E = BAD
Sexual ∆ č ↑Age: no ∆desire but ↑required time for stimulation • Sexual Disorders: MC in Women (Sexual Desire Disorder, Orgasmic Disorder) vs. MC in Men (2° ED, Premature Ejaculation)
(♂ > ♀), ↓duration of orgasm, ↑refractory period
2. Disorders of Desire
• Hypoactive Sexual Desire Disorder: ↓sexual desire/fantasies
Sexual Disorder Tx • Sexual Aversion Disorder: avoidance of genital contact č sexual partner
1. Dual Sex Therapy: uses concept of marital unit rather than
individuals č couple + male/female therapists. 3. Disorders of Arousal/Excitement
SEX
• Male Erectile Disorder: inability to attain erection (“impotence”). 1° (Never) vs. 2° (Previously no ED)
2. Behavior Therapy: systemic desensitization / sexual • Psychological vs. Physical Etiology: if +Erection in AM, during masturbation or č others = Psych > Physical
exercises at home • Female Sexual Arousal Disorder: ↓ability to maintain lubrication until completion of sexual act

3. Rx 4. Disorders of Orgasm: +/- 1° (Never) vs. 2° (Acquired, Loss of Ability)

• ED: PDE-I (erection č stimulation) vs. Alprostadil (erection š • Female Orgasmic Disorder: inability to have orgasm after normal excitement phase (Tx: Masturbation / Vibrator)
stimulation) • Male Orgasmic Disorder: achieves orgasms č great difficulty if at all (Tx: Extravaginal Ejaculation --> Intravaginal Ejaculation)
• Premature Ejaculation: SSRI + TCA ADE delay orgasm • Premature Ejaculation: ejaculation earlier than desired (prior/upon entering vagina) (Tx: Squeeze/Stop-Start Technique)
• Hypoactive Sexual Desire: Testosterone + Estrogen
5. Sexual Pain Disorders
• Dyspareunia: genital pain before, during or after sexual intercourse (Tx: Desensitization)
• Vaginismus: involuntary muscle contraction of outer 1/3 vagina during insertion of penis, tampon or speculum (Tx: Dilation)
• Common: ↑socioeconomic status / ♀ of strict or religious upbringing

Forensic Psychiatry: where psych is applied to legal issues Decision Making

• Criminal: nature of someone being charged č crime 1. Informed Consent (4 Rs) ~ Reason for Treatment, Risks/Benefits, Reasonable Alternatives, Refused Consequences
• Civil: monitory / compensation given to wronged person • No Informed Consent ~ Emergency SOAP = Emergency Situations, STDs, Overdose, Addiction, Pregnancy

Standard of Care: skill level/knowledge of average psychiatrist 2. Decisional Capacity: note capacity is clinical determined by doctor while competency is legal determined by judge
F 1. Negligence: practicing below standard of care • Capacity: task specific (+/-fluctuate), requiring understanding, appreciation of decision impact, logic, communication
O 2. Malpractice: act of being negligent as a doctor = 4 Ds • Competence to Stand Trial: 6th + 15th Ammendments prevent trying someone if they are not legally competent
R
• 4 Ds: Deviation of Duty that was Direct cause of Damage
E
• Damages: compensatory or punitive 3. Guardians + Conservators: appointed by patient / judge to make decisions as patient would if they were competent
N
S Confidentiality: all information in doctor-patient relationship Admission
I confidential unless exempt: 1. Voluntary: patient requests/agrees to admission (≠request discharge later), assuming patient is competent
C
• Other Caretakers: sharing info č other caretakers 2. Involuntary: mental illness + harm to self/others + cannot care for self; operates under Police Power and Parens Patriae
• Tarasoff Duty: patient is suicidal or a harm to themselves
• Abuse: required to report all forms of abuse Disability: Mental Impairment (↓mental function) vs. Mental Disability (∆capacity for personal, social, occupational demand)
• Subpoenaed: all information must be provided
NGRI: Not Guilty by Reason of Insanity ~ conviction requires both evil deed and evil intent

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Case Files

Substance Abuse/Dependence Detection

1. Substance Abuse: pattern of use ≥12 months č impairment: 1. EtOH: stays in system for few hours ---> Blood/Urine >>> Breath
• Work, home school obligations 2. Cocaine: +UDS for 2-4 days
• Interpersonal/social consequences despite use 3. Amphetamines: +UDS for 1-3 Days
• Legal Problems 2° Substance 4. PCP: +UDS for 3-8 days often č ↑↑CPK / AST-ALT
• Dangerous Situations (Driving Car) 5. Opioids: +UDS for 2-3 days; note Methadone/Oxycodone are negative on general screen, can order separate panel
6. Marijuana: one time use = +UDS for 3 days; recurrent use = +UDS for 3 weeks (THC released from adipose)
2. Substance Dependence: pattern of use ≥12 months č 3: 7. Sedative/Hypnotics: Blood/Urine Levels depend on Rx
• Tolerance: ↑amount required / ↓effect č same amount • BNZ: Short-Active (Lorazepam) for 3 days ---> Long-Active (Diazepam) for 30 days
• Withdrawal: substance-specific č d/c heavily used substance • Barb: Short-Active (Pento-) for 1 day ---> Long-Active (Pheno-) for 3 weeks
• Desire: wants to ↓use
• Time: ↑time spent getting, using or recovering Marijuana: active part, Tetrahydrocannabinol = THC, inhibit adenylate cyclase ---> ↓N/V + ↑Appetite (Therapeutic Use)
1. Intoxication: Euphoria, ↓Motor Coordination/Perception, Conjunctival Injection, Dry Mouth, ↑Appetite
Note: substance dependence possible š physiologic • Cannabis-Induced Psychosis: +paranoia, hallucinations, delusions
dependence (withdrawal / tolerance) b/c only 3 symp needed! • Tx: Supportive
RX
Epidemiology: EtOH + Nicotine MC, Total Substance Abuse in 2. Withdrawal: Anxious/Irritable, Strange Dreams, ↓Appetite
USA ~ 17%
Inhalants: generally CNS Depressants used by Younger Age ~ Solvent, Glue, Paint Thinner, Fuel
Psychiatric Symptoms: Mood + Psychosis symptoms are 1. Intoxication: acute intoxication lasts minutes č stupor for hours ~ ∆Perception, Dizzy, HA/N/V, Euphoria
common in patients č Substance Abuse • OD: fatal 2° Respiratory Depression + Arrhythmia
1. Personality Disorders: don’t forget that many Cluster B • Tx: ABC ---> ID source b/c some (gasoline) need to be chelated
disorders especially have comorbid Substance Abuse
Caffeine
2. Psych Disorders: most commonly MDD + Anxiety Disorders 1. OD: note 2-3 cups (250 mg) normal ---> >1g = Tinnitus + Light Flashes + Arrhythmia ---> >10g = Death
have comorbid Substance Abuse 2. Withdrawal: non-specific resolving in ~1 week

Nicotine: Therapies
1. Varenicline (Chantix): ɑ4-β2 nAcH-R partial agonist ---> mimics effects
2. Bupropion: also partial agonist at above receptor + ↓DA reuptake

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Psychotherapy Antidepressants: all effective č different ADE / Safety ~ all should be given 1-2 months @ full dose before ∆
1. Freud’s Theories 1. SSRI: block pre-synaptic pumps that take up 5HT ---> ↑5HT in Synaptic Cleft
• Topographic Theory: Unconscious (1° Repressed Ideas) ---> Preconscious (retrievable) ---> Conscious • Why?: Best ADE/OD Profile that Resolve in Weeks, No Food Restrictions 2° to No Anti-HAM Effects
(Current Thought) • ADE: Withdrawal (Taper), Sexual (+Buproprion, +PDE-I or ∆), ↑Suicide (Teens), Gi Disturbance
• Structural Theory: ID (Unconscious 1° Ideas) ---> Ego (uses Defense Mech / Reality Testing) ---> SuperEgo • 5HT Syndrome: ↑#5HT Rx (SRRI + MAOI, Cough Syrup, Triptans) ---> sep Rx by 2 weeks + Cypro.
(Morals) • Rx: “Frequent Flashbacks Paralyze Senior Citizens”
• Fluoxetine: ↑T/12, safe in pregnancy/children, ↑ADE when combined č neuroleptics
2. Psychoanalysis: based on Freud’s theories that behaviors represent unconscious processes • Fluvoxamine: aproved only for OCD
• Approach: resolve unconscious conflicts insight-oriented integration of those feelings into pt’s awareness • Paroxetine: ↑Protein Bound (↑Rx Interactions) + ↑”Paralyzing” 2° Most anti-AcH effects + Withdrawal
• Technique: Free Association, Dream Interpretation, Therapeutic Alliance, Transference/ • Sertraline: ↑GI ADE
Countertransference • Citalopram: ↓Rx Interactions ∴ best to use on CL (Escitalopram similar č ↓ADE but ↑$$)
• Who?: Tx of Anxiety + Related Disorders (Cluster C, OCD, Sexual Disorders, Anorexia)
• Avoid: not for any patients č questionable grasp on reality ~ Psychotics, Cluster A / Cluster B Disease 2. Misc
• Related Therapies • Venlafaxine: SNRI used in GAD, ADHD and Depression; ADE = ↑BP + Similar to SSRI
• Psychoanalytically Oriented / Brief Dynamic: briefer and face-to-face (no couch) • Duloxetine: SNRI used in depression + neuropathic pain; ADE = ↑Dry Mouth, Constipation, Liver + “”
• Interpersonal Therapy: focus on development of social skills for improving disorder • Buproprion: NE + DA RI č ↓sexual ADE; ADE = ↓seizure threshold ~ CI č Anorexia + Seizures
• Supportive Psychotherapy: help patient feel safe during time of crisis • Trazadone: 5HTR-A/Ant for Refractory Depression, Insomnia; ADE = priapism, arrhythmia, sedation
• Mirtazapine: ɑ2 Ant for Refractory Depression, ↑Weight, Insomnia; ADE = ↑Weight, sedation
3. Defense Mechanisms: used by Ego to protect oneself by keeping conflicts out of awareness
• Mature: common in healthy, ↑functioning adults 3. Tricyclic Antidepressants ~ 3° + 2° Amines that ↑Amines in Synaptic Cleft known for Anti-AcH ADE!!!
• Altruism: acts that benefit others in order to vicariously experience pleasure • 3°: ↑xAcH (Sedation) ~ Amitriptyline, Imipramine (Enuresis/Panic), Clomipramine (OCD), Doxepin (Sleep)
• Humor: form of expression uncomfortable/unpleasant feelings š causing harm to self / others • 2°: ↓xAcH ~ Nortriptyline (↓Orthostatic Hypotension), Desipramine
• Sublimation: channeling (≠preventing) socially unacceptable impulses into acceptable acts • Tetracyclic: Amoxapine (metabolite of Loxapine ---> ↑EPS Antipsychotic ADE), Maprotiline (Seizure, Arr.)
• Suppression [CONSCIOUS]: ignoring unacceptable impulse/emotion to avoid discomfort • ADE: Anti-HAM (H=Coma, A=Cardiotoxic/Convulsions, M=xDUMBELLS), Anti-5HT (xSex) --> Give NaHCO3
• Neurotic
• Controlling: regulating situations / external events to relieve anxiety 4. MAOIs: xMAO-A (↑5HT, DA, Tyramine) + xMAO-B (↑NE/Epi, DA, Tyramine) ---> č Refractory Depression
• Displacement: emotion from undesirable situation redirected towards tolerable situation • Rx: Tranylcypromine, Isocarboxazid, Phenelzine and EMSAM Patch (Selegiline ~ don’t avoid foods)
• Intellectualization: avoid emotion by excess application of intellectual functions • ADE: 5HT Syndrome (SSRI+MAOI), HTN Crisis (MAOI+Cheese/Wine --> Phentolamine), Orthostasis (MC)
• Isolation of Affect: unconscious limiting of feelings/emotions associated č stressful life event
• Rationalization: creating explanations for event in order to make the event/outcome more acceptable Antipsychotics: both effective for positive symptoms, while atypical>typical for negative symptoms
• Reaction Formation: doing the opposite of an unacceptable impulse 1. Typical: xD2-R č similar efficacy, but different potency. Note ↓Potency = ↓EPS/↑xAcH=↑QTc (opp. true)
• Repression [UNCONSCIOUS]: preventing a thought or feeling from entering consciousness • ↓Potency: Chlorpromazine (blue discoloration/photosensitivity) and Thioridazine (retinitis pigmentosa)
• Immature • ↑Ptoency: Haldol (+Decanoate), Fluphenazine (+Decanoate), Pimozide ~ more injected in acute situations
• Acting Out: giving in to an impulse in order to avoid anxiety from suppressing the impulse • ADE: TD (Benztropine=xAcH, Benadryl=xM, Amantadine=↑D), ↑Prolactin, anti-HAM (xH=↑Weight)
• Denial: not accepting reality that is too painful
Tx
• Regression: performing behaviors form an earlier stage ofd development 2. Atypical: xDR-R + 5HT-2A-R also used in Acute Mania / Bipolar Disorder
• Projection: attributing emotions to others • Olanzapine: ↑weight gain
• Other • Clozapine: most effective and only ↓suicidal, but worst ADE -↑xAcH, AGRANULOCYTOSIS, myocarditis
• Splitting: labeling people / situations as all good or all bad • Quetiapine: “quiets” the patient ---> Sedation / Orthostasis are common ADE
• Undoing: attempting to reverse situation by adopting new behavior • Riseridone: long acting form available
• Aripirazole: PARTIAL D2 agonist ---> least likely to cause Metabolic Syndrome
4. Behavioral Therapy: help patients ∆behaviors based on learning theories (∆behavior by conditioning /
• Ziprasidone: worst for ↑QTc
deconditioning)
• ADE: Metabolic Syndrome (SHODDY), ↑Weight, ↑CVA (Elderly), QTc Prolongation
• Conditioning: Classical (Stimulus ---> Response) vs. Operant (+/- Reinforcement ---> Behavior)
• Positive Reinforcement: desired behavior ---> reward Mood Rx ~ Lithium: used for acute mania, prophylaxis for Bipolar + Schizoaffective Disorder
• Negative Reinforcement: lack of aversive stimulus ---> desired behavior (≠Punishment) 1. ADME: metabolized by kidney (↑blood level č sweating, dehydration, AKI vs. ↓blood level č NSAID)
• Behavioral Therapy Technique (Deconditioning) 2. ADE: AMS + tremor + ∆Thyroid + Nephrogenic DI + Teratogenic (Ebstein’s Anomaly)
• Systemic Desensitization: perform relaxation techniques during ↑dose of anxiety-producing stimulus
• Flooding/implosion: real (flooding) or imagined (implosion) stimulus --> not removed until patient calms Anticonvulsants: Carbamazepine (+Oxacarbazine č ↓ADE), Valproate, Others
down
1. Carbamazepine: xNa Channels ---> ↓AP; ADE: Agranulocytosis, Hepatitis, Teratogenic (NTDs), SJS, CYP-I
• Aversion Therapy: negative stimulus (electric shock) paired č specific behavior 2. Lamotrigine: ↑risk for SJS; Note: valproate = ↑Lamotrigine level but ↑Lamotrigine = ↓Valproate
• Token Economy: rewards given to reinforce positive behaviors 3. Others: Gabapentin (Tx Anxiety/Sleep), Pregabalin (Anxiety), Tiagabine (Anxiety), Topiramate (↓Weight)
• Biofeedback: physiologic data given to patients as they try and mentally control visceral symptoms
(migraines, etc)
Anxiolytics/Hypnotics: Anxiety, Sleep, Seizures, EtOH Withdrawal (Loraz-, Oxaz-,Temaz) and Anesthesia
5. Cognitive Therapy: patient taught to ID maladaptive thoughts ---> replace č good thougths 1. BNZs: potentiate GABA č ↑risk of dependence (↑amount required), abuse and lethality č EtOH (↓RR)
• Who?: Depression + Anxiety Disorders • Long Acting: Diazepam (Rapid: EtOH Detox / Seizures), Clonazepam (Sleep Disorders)
• Int Acting: Alprazolam (Shortest Onset = ↑ABUSE) + others
6. Cognitive Behavioral Therapy: examine connections between thoughts and behaviors ~ Depression, • Short: Triazolam (Insomnia) + Midazolam (Medical / Surgical Settings)
Anxiety, Substance • ADE: Drowsiness / ↓Motor Coordination (ELDERLY!), Anterograde Amnesia, Lethal Withdrawal (Seizures)
7. Dialectal Behavioral Therapy [Borderline PD]: incorporates cognitive + supportive techniques to ↓self-harm
behavior 2. Hypnotics (Non-BNZ): Zolpidem (BZ1-R-Ag,↓Term Insomnia, ↓Abuse), Ramelteon (MT1/MT2-Ag, xAbuse)
8. Group Therapy: 3+ Pts č Similar Disease ~ Substance Abuse, Adjustment and Personality Disorders 3. Anxiolytics (Non-BNZ): Buspirone (↓EtOH Effects, use in EtOHics), Barbiturates, Propranolol
9. Family Therapy: used because family = source of psych disorder or b/c psych disorder ---> family affected
10.Couples Therapy: see sexual disorders above Psychostimulants
1. Amphetamines (Dextroamphetamine): Schedule 2 (↑Abuse), monitor ↓Wt, Insomnia, BP
Other 2. Methylphenidate: as above (Schedule 2, similar ADE), monitor LFTs, CBC
1. ECT: anesthesia + succinylcholine ---> GTC Seizure. Tx ↑↑Depression, Psychotic Fx, Mania, Catatonia 3. Atomoxetine: pre-synaptic NE inhibitor ---> ↓appetite suppression
2. DBS: implant medical device ---> impulses to focal areas. Tx Pain, PD, Tremor, Dystonia
3. Repetitive Transcranial Magnetic Stimulation: non-invasive excitation of areas of brain Cognition Enhancers ~ ↑AcH / xAcH-ase (Donepezil, Galantamine, Rivastigmine) + Memantine (augment)
4. Light Therapy: seasonal affective disorder

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