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Axis 1

Mood Disorders
1. Depressive 1 month
2. Bipolar 1 week mania (I); 4 days hypomania sand no impairment (II); rapid
cycling (>4 episodes in 12 mos)
a. depression usually precedes mania
b. Lithium/Valproate; Carb and Oxcarb 2nd line; Lamotrigine or add SSRI if
Bipol w/ depression; Add antipsychotic if psychotic symptoms
(Risperidone, Olanzapine)
c. Cognitive therapy, family therapy
d. Med Mim: steroids, levodopa, stimulants, schizophrenia, schizoaffective
3. Secondary Depressive
4. General Medical conditions
a. CNS, Endocrine, Uremia, Connective Tissue, Vitamins, HIV
5. Drugs
a. Antihypertensives/arrhythmics, Steroids, Sedatives, analgesics,
antineoplastics, antimicrobials, neurologic (PD, Antieplieptics)

Pharmacology
Anxiety
General Anxiety Disorder:
1. Buspirone
a. Decreases seizure threshold!
Specific Phobias:
1. CBT
2. Beta-blockers and/or SSRIs
PTSDL
1. Eye movement desensitization and reprocessing

Atypical Antipsychotics dopamine receptor antagonist


-

EPS rigidity, bradykinesia, tremor, akathisia (restlessness), masked facies,


micrographia
o Treated with Anticholinergics like Benztropine
o Akathisia treated with Propranolol
Risperdone:
o Most likely atypical to cause EPS

mild sedation, hypotension, prolactin elevation, and weight gain

Dantrolene muscle relaxant for NMS [2/2 antipsychotic use]

Substance Abuse Disorders


Abuse impairment or distress for > 1 year of:
-

failure to fulfill obligations; dangerous use; substance-related legal problems;


substance-related social problems

Dependence impairment or distress manifested by 3+ within 1 year:


-

Tolerance; Withdrawal; Greater-than-intended use; inability to cut down; time


impaired from getting/using/recovering; use despite substance-related
physical/psychological problem
Epidem: Men;
MC Substances: Caffeine (MC use), alcohol (MC abuse), nicotine

Tolerance need for increased amounts of substance for desired effect or


diminished effect is using the same amount of substance
1. Alcohol sedating - activates GABA, 5HT; inhibits glutamate
a. Metabolism:

1. Heroin
o Onset: 24 hours; Not life-threatening
o Intox: pinpoint pupils, CNS depression, constipation, drowsiness
o Withdrawal: Dilated pupils, irritability, autonomic instability, abdominal
cramps, muscle spasms, joint pain, N/V
o Symptoms are severe and out of proportion to physical findings
2. Cocaine / Amphetamines nasal turbinate erythema, suppressed appetite;
nosebleeds, septal perforation
o Intox: formication (bugs crawling all over); anxiety, aggression, psychosis,
delirium; autonomic cardiac changes (either way), sweating, pupillary
dilation, n/v, insomnia, hypervigiliance, weight loss, euphoria
o Overdose: arrhythmia, MI, stroke, seizure
o Onset:
o Rebound suppression of cocaines stimulant effect
o Withdrawal: dysphoric, Irritable, drowsy, fatigued, hypersomnic, Hungry,
psychomotor agitation / retardation
(but SSRIs not indicated, even though appears like atypical
depression)
3. Alcohol
o Intoxication: Ataxia, nystagmus, aggression, impaired judgment

Onset: 12-48 hours


6 hours: Sweating, hyperreflexia, tremors
12-48 hours: Seizures
12-24 hours: Hallucinations w/ normal vital signs and intact sensation
48-96 hours: Delirium Tremens altered sensation, hallucinations,
autonomic instability
o Associated medical complications: Wernicke-Korsakoff (anterograde)f,
cerebellar degeneration, hepatic encephalopathy, pancreatitis,
malabsorption, pancreatitis, peripheral neuropathy, anemia, increased
trauma, fetal alcohol syndrome
Nicotine
o Onset:
o Irritability, anxiety, depression, insomnia, restlessness, poor
concentration, increased appetite, weight gain, bradycardia
MJ injected conjunctivae, increased appetite
PCP
o Intox: Agitation, impulsivity, physical aggression, lability, impaired
judgment, psychosis, paranoia, hallucinations; nystagmus, dysarthria,
ataxia, tachycardia, hypertension, muscle rigidity, seizures, hyperacusis
Hostility + Cerebellar
o Psych Emergency b/c of Psychosis & propensity for violence
o Tx: hospitalization for 72 hrs, Acidification of urine (cranberry juice) to
promote excretion
LSD
o Intox: hallucination, intensified perceptions, depersonalization, illusions;
tachycardia, palpitations, pupillary dilation , sweating, poor coordination
o
o
o
o
o

4.

5.
6.

7.

Mood and Psychosis


Paranoid schizophrenia hallucinations and paranoid delusions for > 6 months
-

Hallucinations (AH), delusions


PE: Loosening of associations; flat affect
Imaging: Enlarged ventricles, prominent sulci, decreased cerebral /
hippocampal / temporal mass

Depression
Episode of depression
-

Medication: Antidepressant for 6 months post a positive response to the


medication

MDD 5 or more depressive symptoms [SIGECAPS] for the majority of everyday for
2 weeks
-

Sleep
Interests loss
Guilt
Energy (low)
Concentration (impaired)
Appetite (up or down)
Psychomotor retardation / agitation
Suicidal Thoughts

In cancer patients:
o 1. Assure appropriate pain control
o 2. Treatment w/ SSRI and psychotherapy
w/ psychotic features
o ssri + antipsychotic
o ECT esp in older patients, or patients immediately suicidal, catatonic,
refusing food

Dysthymia Depressed mood for most days for at least 2 years w/ 2 or more of:
-

Poor appetite / overeating


Insomnia / Hypersomnia
Low energy / fatigue
Low self-esteem
Poor concentration / difficulty making decisions
Feelings of hopelessness

Manic episode
-

1 week of disturbed behavior that include at least 3 DIGFAST symptoms

Tx: mood stabilizer; if severe psychosis/agitation/mania, antipsychotic for


acute effects

Avoidant
-

Persistent feelings of inadequacy ego dystonic


Avoiding activities for fear of being viewed negatively
Afraid to have intimate relationships

Schizoid
-

Persistent pattern of detachment form social relationships and restricted


range of emotions
Solitary lives with no interest in socialization ego syntonic
Have little support beyond family members
Can have successful work histories if isolative occupation (vs schizotypal,
schizophrenia)
Rare fam hx of schizophrenia (vs schizotypal, schizophrenia)

Schizotypal
-

Magical thinking, peculiarities in appearance, behavior


Dont have close friends
Suspicious and can be delusional about it (vs paranoid personality disorder,
which presents w/ non-delusional suspiciousness)
Can be suspicious, paranoid, and transiently psychotic under stress
Comorbid w/ Depression, Fragile X
Fam Hx of schizophrenia

Selective mutism - at least 1 month of anxiety/avoidance of speaking in some


situations but not others; interference with educational or expected achievement
Stranger anxiety normal until age 3
Body Dysmorphic disorder excessive preoccupation with an imagined bodily defect
that causes functional impairment
Hypochondriasis misinterpretation of bodily symptoms that produce intense
anxiety about developing a fatal disease
Somatization multiple medical complaints that include:
-

4
2
1
1

pain
GI
sexual
pseudoneurological

Delusional disorder non-bizarre delusions for at least 1 month w/ no life


impairment

Factitious disorder intentional production of false physical or psychological


signs/symptoms in order to assume the sick role without receiving any secondary
gain (malingering)
Malingering intentional production of false physical/psychological symptoms for
the purpose of secondary gain [financial, work avoidance, prescriptions] marked
disparity between stated disability and objective findings
Obsessive-compulsive personality disorder need for order, perfection, and
methodical execution that begins before adulthood. Anxiety, indecisiveness,
perseveration. Ego-syntonic
Aspergers impairments in reciprocal social interactions and restricted
interests/repetitive behavior. Absence of language delay, unlike autism
Obsessive-compulsive disorder obsessions that cause anxiety compulsive
behaviors to decrease the anxiety. Ego-dystonic
-

SSRIs + Exposure therapy (to the feared object/situation/obsession)


Relationship w/ tic/tourrettes

Defense Mechanisms
Displacement inequitable transferrance of negative emotions onto an alternative
target [Immature]
Acting out expression of unconscious impulse through a physical action
[Immature]
Rationalization creating an alternative rational logical reason for an event instead
of the real reason [neurotic]
Dissociation blocking off disturbing thoughts or feelings in order to avoid
emotional upset [neurotic]
Conversion

Illness Phase
Acute Phase
-

Response 50% recovery to baseline


Remission No longer meets minimum requirements for episode; no or
minimal symptoms, with return to baseline functioning;

Continuation Phase
-

Sustained remission
Relapse re-emergence of the acute symptoms

Maintenance Phase
-

Recovery episode is over; decide whether to discontinue treatment or


transition to prophylactic treatment
Recurrence subsequent acute event

Derealization disorder experiencing familiar people and surroundings as if they


were unreal

MAOI + tyramine hypertensive crisis


MAOI + SSRI Serotonin syndrome

Typical SEs
-

LPs eye problems


o Thioridazine retinal deposits
o Chlorpromazine photosensitivity + Jaundice + corneal deposits

Atypical Antipsychotic SEs


Risk of metabolic syndrome dysregulated glucose metab diabetes, HLD
HAM side effects
All metabolized through liver
Clozapine agranulocytosis; seizures; worse HAM; (myocarditis)
-

For treatment resistant psychosis dirtier drug, less specific, most efficacious
of atypicals more anticholinergic side effects
o At least two failed atypicals and one failed typical

Risperidone highest EPS of atypicals


Paliparidome active metabolite of Risperidone
Olanzapine most weight gain, most sedating; bad HAM
Ziprasidone prolongs QTc the most highest arrhythmia, WPW

Weight neutral

Ariprapazole partial agonist; Insomnia, akathisia


-

weight neutral

Quitiepine highest risk for orthostatic hypotension; weight gain; cataracts require
eye exam every 7 months; sedating but less then ziprasidone; bad HAM
Antipsychotic SE tx treat with Antihistamines (diphenhydramine) or
anticholinergics (Benztropine, trihexylphenidyl)
-

Acute dystonia first hours to days young men


Akathisia days as above + beta-blockers
Parkinsonism months older women
Tardive dyskinesia months to years d/c antipsychotic and switch to new
one

NMS
rigidity, mutism, obtundation, agitation, high fever (up to 107 F), very high levels of creatine phosphokinase (more
than 10 times the normal range), sweating, and myoglobinuria. Treat first by discontinuing the antipsychotic; then give
supportive care for fever and potential renal shutdown due to myoglobinuria (primarily IV fluids). Lastly, consider
dantrolene (just as in malignant hyperthermia, which is thought to be a similar condition).

eScitalopram is S enantiomer
Mirtazapine weight gain, sedation

Child Abuse is suspected


1.
2.
3.
4.
5.

Perform Physical
Additional studies if necessary radiographical, laboratory (coag panel)
Report to Child Protective Services
Admit to hospital if necessary
Consult w/ psychiatrist, evaluate family dynamics

Liver
Depakote
Kidney
Lithium nephrogenic diabetes insipidus
Lorazapem

Benzos - LOT safe in liver failure

Methylphenidate depressed appetite weight loss growth retardation; n/abd


pain; nervousness; insomnia; tachycardia

Personality Disorders:
-

A: Schizoid, Schizotypal, Paranoid


B: Histrionic, Borderline, Narcissistic, Antisocial
C: OCPD, Avoidant, Dependent

Dependent personality disorder insight-oriented therapy, behavioral therapy


-

Defense mechanism idealization; reaction formation (acts diametrically


opposed to their feelings); somatization

Conduct 3 sxs in 12 months and 1 in 6 months


-

Tx: Multisystemic treatment approach (parents, teachers)


Comorbid w/ ADHD --- treat w/ stimulants
antisocial, alcohol abuse

Normal Bereavement one year (sxs peak w/in 2 months


Anxiety/Panic types
Specific phobia of public speaking / performance anxiety Beta-blocker [situational, which is why you dont prescribe something daily like an SSRI; benzos
are bad bc can be sedating, which is bad for public speaking, along with their other
SEs]
-

CBT: relaxation training followed by progressive sensitization

Specific phobias CBT (ssri, beta-blockers 2nd line) MC mental disorder in US


exposure/densisitzation therapy
Social Phobia SSRI + assertiveness training
Panic Disorder benzos for acute attack, SSRIs chronically [anxiety, impending
doom, chest pain, palpitations, nausea, extremity numbness, etc] (SSRI/TCA/MAOI +
CBT)
-

Unexpected, unprovoked panic attacks


Medical mimickers:

o
o
o
often

Intox w/ stimulants, hallucinogens; Withdrawal from sedatives


Hyperthyroidism, hypercorticolism, pheo, angina, asthma/pe, CNS dz
anticholinergics, theophylline, thyroid replacement
comorbid with MDD

Generalized Anxiety Disorder - SSRI / SNRI 1st line (Benzos as bridge); 2nd line
Buspirone (but not efficacious after benzos are used) + CBT
-

cognitive + somatic symptoms 6 months


Med Mims: Graves, PE, Hyperhtyroid, Sjogren, Seizures

Paranoid Personality Disorder - long pattern of suspiciousness and distrust, but no


delusions
Adjustment Disorder starts within 3 months, ends within 6 months and causes
impairment treat w/ psychodynamic psychotherapy or brief psychotherapy
Psychotic Speech
Circumstantiality (long-winded but return to original point) | Tangentiality | Loose
Associations Flight of Ideas

Schizoid vs Avoidant
-

schizoid prefers to be alone; avoidants wants relationships but have fear of


rejection

Autism vs Aspbergers
-

(DSM IV) Autism is distinguished by language delays; both share restricted


social interaction and limited interests/repetitiveness

OCD vs OCPD
-

OCD is ego-dystonic and have these preoccupations/obsessions that are


relieved by their compulsions (although OCD can occur with either just
obsessions or just compulsions); OCPD is egodystonic and represents a
meticulousness 2/2 an overwhelming need for perfection

Anticholinergic Poisoning vs. Amphetamine/Cocaine intoxication


-

Anticholinergic poisoning has dry skin/mucus membranes + urinary retention,


ileus + motor symptoms (mycolonic jerks/tremors)
Both share mydriasis, hypertension, tachycardia, irritation, delirium

Most important prognostic factor in suicide?


-

Previous SI attempt

MI prognostic factor in schizophrenia?


-

Low level of Premorbid functioning


Fam hx of mood disorders is actually a good prognostic factor in schizo,
whereas fam hx of schizo is a poor prognostic factor
Prognosis: MDD w/ psychotic features > Schizoaffective > Schizophrenia w/
mood syxs

Schizo and Seasons


-

Most schizos are born in the winter!

Medical Mimickers ofSchizo:


-

Electrolyte disturbances: severe hypothyroidism, hypercalcemia


Meds: Steroids, anti-cholinergics
Dz: Delirium, Dementia

Schizoaffective vs Bipolar

Bipolar: Psychosis must occur during episodes of mania (mania without


psychosis)
Schizoaffective: psychosis without mood symptoms at least 2 weeks of
stable mood - + 1 mood episode
o SSRI + atypical [CMAP protocol]; 2nd line switch to different class of
antidepressant or try lithium/buspirone
o If responds to meds: d/c atypical after 3 months and d/c antidepressant
after 6-9 months
Depression w/ psychotic features depression is present without psychosis
(no mania) hallucinations/delusions are mood congruent

Delirium vs Dementia
-

Delirium: Short onset, fluctuating course, reduced alertness, reversible


prognosis, generalized EEG slowing
o Ach mediated
o Med mimics: anticholinergics, antihypertensives, anticonvulsants,
antiparkinsonians, steroids
Dementia: long onset, stable course, stable alertness, irreverisble

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