Psychiatry

Developmental Stages

Anal phase in psychoanalytic point of view, an obsessive-compulsive disorder is traceable in this

developmental stage
Phallic Oedipal complex (separation-individuation), ambivalence (object relations), initiative or guilt
(psychosocial crises)
Ericksons Conception of 8 Stages of Ego Development
Stage 1: Trust vs Mistrust (birth to 18 mo)
Stage 2: Autonomy vs Shame & Doubt (18 mo to 3 yr)
Stage 3: Initiative vs Guilt (3 to 5 yr)
Stage 4: Industry vs Inferiority (5 to 13 yr)
Stage 5: Identity vs Role Confusion (13 to 21 yr)
Stage 6: Intimacy vs Isolation (21 to 40 yr)
Stage 7: Generativity vs Stagnation (40 to 60 yr)
Stage 8: Integrity vs Despair (60 yr to death)

Id, Ego, Superego

Id reservoir of unorganized instinctual drives, operating under domination of primary process, it lacks the
Capacity to delay or modify the instinctual drives with which an infant is born
Ego spans all topographical dimensions of conscious, preconscious & unconscious; defense mechanism
resides in the unconscious domain of ego; executive organ of psyche
Ego psychological seat of anxiety
Repository of drives & instincts not a function of the ego
Superego 3rd component of tripartite structural model; establishes & maintains moral conscience on the basis
of complex system of ideals & values internalized from parents
Superego heir to the Oedipus complex
Superego its presence is observed from the moment of birth (even before birth)
Ego ideal component of superego, an agency that prescribes what a person should do according to
internalized standards & values
Repression the force that keeps materials within unconscious

General Principles

Regular scheduled lists w/ a single identified physician treatment of patient w/ somatization disorder
Biological cause of conversion disorder defects in the processing of endogenous somatic signals & integrating
Sensory motor signals
Stevens-Johnson Syndrome associated w/ Carbamazepine
Bupropion given to patient who does not want the sexual side effect of antidepressant
Basal ganglia basic neuroanatomical structure involved in mood disorder
Pneumonia Axis III
Social familys role in behavior
Waxy flexibility not a Schneiderian symptom
Ambivalence not considered a negative symptom
Koro cultural belief where a person believes that retraction of the penis is a sign of impending death
 Amygdala fear
Mediobasal hypothalamus location for the cell bodies of the principal histaminergic neurons in the brain
Chlopromazine a tranquilizer
Schizophrenia a disease believed that the mesocortical system of dopaminergic neurons is hyperactive
Retrograde amnesia commonly precipitated by a blow on the head

History

Chief complaint recorded as verbatim (in patients own words)

HPI provides a comprehensive & chronological picture of events leading up to current moment in pxs life,
the most helpful in making a diagnosis
Past Illnesses transition between the story of present illness & the pxs personal hx
Family History alcohol, substance abuse or antisocial behavior; personalities & intelligence
Personal History anamnesis
Dreams royal road to the unconscious

MSE

MSE describes the sum total of the examiners observations & impressions of the psychiatric patient at the
time of interview
Dysprosody unusual rhythms
Mood pervasive & sustained emotion that colors the persons perception of the world
Affect present emotional responsiveness, inferred from the patients facial expression
Schizophrenic inappropriate affect
Hypnagogic hallucinations occurring as a person falls asleep
Hypnopompic hallucinations occurring as a person awakens
Depersonalization & derealization extreme feelings of detachment from self or environment
Formication feeling of bugs crawling on or under the skin, seen in cocainism
Thought process the way in which person puts together ideas & associations, the form in which a person
thinks
Flight of ideas rapid thinking carried to extreme
Flight of ideas a succession of multiple associations so that thoughts seem to move abruptly from idea to
idea; often expressed through rapid, pressured speech
Loose associations ideas expressed seemed unrelated & idiosyncratically connected
Blocking interruption of the train of thought before an idea has been completed; the patient may indicate an
inability to recall what what was being said or intended to be said
Circumstantiality loss of capacity for goal-directed thinking; in the process of explaining an idea, the patient
brings in many irrelevant details & parathentical comments but eventually does get back to the
original point
Circumstantiality overinclusion of trivial or irrelevant details that impede the sense of getting to the point
Tangentiality patient loses the thread of conversation, pursues divergent thoughts stimulated by various
external or internal irrelevant stimuli, never returns to the original point
Word salad incoherent or incomprehensible connections of thoughts
Clang associations association by rhyming or assonance
Clang associations thoughts are associated by the sound of words rather than by their meaning
Derailment synonymous w/ loose associations; breakdown in both the logical connection between ideas and
 the overall sense of goal-directedness; the words make sentences, but the sentences do not make sense
Punning association by double meaning
Neologisms new words created by the patient by combining or condensing other words; use of conventional
words in idiosyncratic ways
Perseveration repetition of out of context of words, phrases or ideas
Thought content refers to what a person is actually thinking about: ideas, beliefs, preoccupations, obsessions
Thought content obsession, compulsion, phobias, plans, intentions, recurrent ideas about suicide or homicide
hypochondrial symptoms & specific antisocial urges
Delusions fixed, false beliefs out of keeping w/ the patients cultural background
Ideas of reference persons belief that the television or radio is speaking to or about him or her
Ideas of influence beliefs about another person or force controlling some aspect of ones behavior
Confabulation unconsciously making up false answers when memory is impaired
Serial 7s test for concentration
Attention assessed by calculations or by asking the patient to spell the word world backward
Insight patients degree of awareness & understanding about being ill
Intellectual insight
True emotional insight
Remote memory childhood data, important events known to have occurred when the patient was younger
or free of illness, personal matters, neutral material
Recent past - the past few months
Recent memory the past few days, what the patient did yesterday, the day before, what the patient had for
breakfast, lunch, dinner
Immediate retention and recall ability to repeat 3 words immediately and 3-5 min. later; digit span measures

PE & Diagnostic Tests

Hoover test can rule out conversion disorder in a patient presented w/ paralysis; pressure noted on
examiners hand under paralyzed leg when attempting straight leg raise
Liver function test regularly monitored in patient taking valproic acid
MMSE

Defense Mechanism

Projection defense mechanism usually used in persecutory type of delusion

Intelectualization

Delirium & Dementia

Advanced age one of the independent risk factors for delirium

Lasts for months to years not a characteristic of delirium
Alzheimers dementia most common type of dementia
Onset can be dated w/ precision not a characteristic of dementia
Disorganized thoughts can be seen in both dementia & delirium

Personality disorder

Grandiosity outstanding feature of narcissistic in their behavior

Narcissistic sense of entitlement
 Repression & dissociation defense mechanism typical of histrionic personality disorder
Avoidant has inferiority complex
Cluster A Personality - schizotypal, schizoid, and paranoid; odd, aloof features
Cluster B Personality - narcissistic, borderline, antisocial & histrionic; dramatic, impulsive & erratic features
Cluster C Personality - obsessive-compulsive, dependent & avoidant; anxious & fearful features
Obsessive-compulsive orderly, neat & perfectionist, preoccupied w/ details
Magical thinking not a feature of borderline personality (suicidal thinking, feelings of emptiness, identity
disturbance)
Schizotypal premorbid for schizophrenia
Schizotypal ideas of reference, superstitious & having 6th sense
Projection defense mechanism for paranoid personality disorder
Respect the need for space advice that can be given in dealing w/ schizoid personality
Being constantly late typical of passive-aggressive disorder
Stubbornness not expected in a histrionic person (seductiveness, theatricality, suggestibility)
Antisocial adolescent w/ conduct disorder is prone to develop this kind of disorder
Locus ceruleus biological seat of anxiety
Fear response to a stimulus that is external, known, non-conflicting in origin
Anxiety response to a threat that is unknown, internal, vague & conflictual in origin
Anxiety neurosis was changed to panic disorder in DSM-IV TR criteria
Alexithymia inability to identify or verbalize emotional state
Psychotherapy effective because it leads to neuronal & structural changes in the brain according to Kandel
Use of exploratory psychotherapy may be harmful in patients w/ PTSD (Posttraumatic Stress Disorder)
SSRI drug of choice for long term treatment of panic disorder
Splitting not a defense mechanism in anxiety disorder ( repression, displacement, avoidance)
Obsession refers to recurrent & intrusive thoughts, feelings, ideas & sensations
Panic disorder discrete period of intense fear w/ autonomic symptoms
Panic disorder excessive worry or dread about a number of events or activity associated w/ motor tension
Though of contamination followed by frequent washing most common symptom pattern of OCD
Ego-dystonic not a characteristic of personality disorder
Paranoid fearful & anxious
Paranoia personality disorder which are more common in males than females
Anti-social highly represented in prison population

Mood Disorders

Unipolar mania or pure mania for pxs who are bipolar, but who do not have depressive episodes
Manic episode distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting
at least 1 week or any duration if hospitalization is necessary
Cyclothymia represent less form of bipolar disorder
Cyclothymic disorder at least 2 years of frequently occurring hypomanic symptoms that cannot fit the dx of
manic episode & of depressive symptoms that cannot fit the dx of major depressive episode
Dysthymia represent less form of major depression
Dysthymic disorder at least 2 years of depressed mood that is not sufficiently severe to fit the dx of
major depressive episode
NE & Serotonin 2 NTs most implicated in the pathophysiology of mood disorders
Hypomania

Hypomania episode of manic symptoms that does not meet the full text revision of DSM-IV-TR criteria
for manic episode
Hypomanic episode distinct period of persistently elevated, expansive or irritable mood lasting throughout
at least 4 days that is clearly different from the usual nondepressed mood

Bipolar Disorder

Bipolar disorder both manic & depressive episodes or pxs w/ manic episodes alone
Bipolar I disorder equal prevalence among men & women; onset earlier than MDD
Bipolar I disorder more common in divorced and single persons than among married

Major Depressive Disorder

Major depressive disorder or unipolar depression afflicted w/ only major depressive episodes
Major depressive disorder has the highest lifetime prevalence of any psychiatric disorder (almost 17 %)
Major depressive disorder
- occurs w/o history of manic, mixed or hypomanic episode
- 5 or more of the following symptoms present during the same 2 week period
- at least 1 of the symptoms: depressed mood or loss of interest or pleasure
- major depressive episode must last at least 2 weeks
- twofold greater prevalence in women than in men
- depression more common in rural than in urban areas

Anorexia nervosa

Nonpurging type of bulimia nervosa more likely to be obese

Least likely in patient w/ anorexia nervosa they have no or little interest in food

Amnesia

Dissociative amnesia patients are aware of memory loss

Dissociative fugue travel away from home is unexpected & unplanned; have amnesia in their past life;
Leads a life of reclusion & peacefulness
Behavior is non-purposeful & patient is confused not true of dissociative fugue

Psychosis

Psychosis there is impairment of the psychosocial functioning

Dependency marks the relationship between patients w/ psychotic disorder

Schizophrenia

Schizophrenia more common in lower socio-economic status

Running commentations a special symptom of schizophrenia
Flat affect characteristic of disorganized type of schizophrenia
Non-bizarre delusions finding which would make you reconsider your diagnosis of schizophrenia
 Patient w/ schizophrenia in the long term, they remain significantly impaired throughout their lifetime
Downward Drift Hypothesis affected persons move into, or fail to rise out of, a low socioeconomic group
because of this illness
Social Causation Hypothesis stresses experienced by members of low socioeconomic groups contribute
to the development of schizophrenia

Schizophrenia

- peak age of onset: 10 to 25 (men); 25 to 35 (women)

- women: bimodal age distribution
- men more likely to be impaired by negative symptoms
- late-onset schizophrenia: after age 45

Bipolar Disorder

Schizophrenia a differential diagnosis to Bipolar I disorder

Psychopharmacology best treatment of choice for Bipolar I disorder
Late age of onset good prognostic indicator for patients w/ Bipolar I disorder

Bipolar I Disorder
- a syndrome in which complete set of mania symptoms occurs during the course of the disorder
- the episodes of manic-like symptoms do not quite meet the diagnostic criteria for a full manic syndrome

Bipolar II Disorder
- clinical features of those of major depressive disorder combined with those of a hypomanic episode
- associated w/ more marital disruption
- onset at an earlier age than Bipolar I Disorder
- at greater risk of attempting and completing suicide than patients w/ Bipolar I Disorder and MDD
Depression, Grief, Major Depressive Disorder

NE, serotonin & dopamine NT involved in the pathophysiology of depression

GABA not involved in the pathophysiology of depression
Major depressive disorder more common in high socioeconomic status
4 number of categories needed in the DSM-IV TR to diagnose severe depression disorder
Indication of pathologic grief hearing the fleeting, transient voice of the deceased person
ECT recommended in a severely depressed, highly suicidal patient
SSRI drug of choice for depression

Phobia

Social phobia fear of an individual that he will act in a way that is humiliating or embarrassing when exposed
to unfamiliar people
Agoraphobia associated w/ panic disorder; refers to a fear of or anxiety regarding places from which
escape might be difficult
Agoraphobia fear of being alone in open spaces or not being able to obtain help
Animals the most common feared object or situation

Substance Abuse
 Acute effects of methamphetamine - arousal, sexual behavior, concentration
appetite not an acute effect of methamphetamine

Suicide

Safety highest priority when we do emergency psychiatric interview

Passive suicide ideation when a person wishes to die but has no plans to cause his death
Golden Gate Bridge prime suicide site in the world
Previous suicide attempt best indicator that the patient is at increased risk of suicide
Postpartum psychosis not a protective factor in suicide
Prevention best treatment for suicide
Listen when the patient talks how to handle violent patients
Indication for hospitalization absence of social support, history of impulsive behavior, suicidal plan of action
Altruistic suicide due to excessive integration in a group
Altruistic suicide suicide bomber
Hanging most common cause of suicide globally
Sigmund Freud - believed that suicide represents aggression turned against an itrojected ambivalently cathected
love object
At least 4 persons, 1 each extremity true in restraining the patient

Sexuality

Gender psychological & socio-cultural meaning added to biological symptoms

Orgasm peak of sexual pleasure & release of tension
Resolution subjective sense of well-being & a state of relaxation
Antipsychotics cause of retrograde ejaculation
Voyeurism recurrent preoccupation w/ fantasies & acts that involve observing people who are naked
Frotteurism man rubbing his penis against the buttocks of a fully clothed woman to achieve orgasm
Premature ejaculation a man ejaculates before or immediately after entering the vagina
Erectile dysfunction complete or partial failure to maintain an erection during a sexual act
Masochism preoccupation w/ sexual urge or fantasy involving being beaten, humiliated, bound or made
to suffer
Female orgasmic disorder inability to achieve orgasm in females
Hypoactive sexual desire characterized by deficiency or absence of sexual fantasy or desire for sexual activity

Drugs

Norepinephrine NT postulated to be depleted in patient w/ depression & responsible for symptoms of lost
of interest & energy
Serotonin depletion of metabolite of this NT is noted among suicidal patients
Sertraline has inhibitory action on serotonin uptake; serotonin reuptake inhibitors
Desipramine blocks the reuptake of both serotonin & norepinephrine (TCA)
Dopamine primarily degraded by MAO B
MAO A metabolizes epinephrine, NE, serotonin, dopamine & tyramine
MAO B metabolizes dopamine & tyramine
Serotonin syndrome interaction of MAOI & SSRI
Bupropion drug of choice for patient undergoing rehabilitation for nicotine addiction
 Lithium primarily metabolized in the kidney
Chloride conductance effect of benzodiazepine on GABA receptor
Zolpidem short-acting benzodiazepines
Clonazepam not a short-acting benzodiazepine
Lorazepam & midazolam good absorption thru IM (parenteral)
Diazepam benzodiazepine w/ the longest half-life
Less daytime sedation not a disadvantage of short-acting benzodiazepine
Chlorpromazine should be given in a patient having slurred speech, loose association, flight of ideas, auditory
hallucinations & delusions

Medications

Alprazolam
- Altrox, Xanor
- Benzodiazepine
- GABA A receptor
Amisulpride
- Solian
- SDAs
Biperiden
- Aketon, Akineton, Akidin
- Anticholinergic
Carbamazepine
- Tegretol, Equetro, Carbatrol
- Mood Stabilizer
- blocks sodium channels & adenosine receptors
Chlorpromazine
- Thorazine, Laractyl, Psynor
- Dopamine Receptor Antagonist
Clonazepam
- Clonotril, Rivotril, Klonopin
- Benzodiazepine
- GABA A receptor
Clozapine
- Leponex, Ziproc, Clozaril
- Serotonin-Dopamine Antagonists
Diazepam
- Valium
- Benzodiazepine
- GABA A receptor
Diphenhydramine
- Alerace, Benadryl, Benaxil, Dramelin
- Antihistamine (H1 receptor)
Divalproex sodium
- Aricept
- increases level of GABA in brain
 Escitalopram
- Lexapro
- Serotonin Reupatake Inhibitor
Fluoxetine
- Prozac
- Selective serotonin reuptake inhibitors (SSRIs)
Flupentixol
- Fluanxol
- antagonizes D1 & D2 receptors
Haloperidol
- Haldol, Seredol, Serenace, Zuredel, Loridol
- Dopamine receptor antagonist
Lamotrigine
- Lamictal, Lamitor
- Mood stabilizer
Levomepromazine
- Nozinan
- Dopamine Receptor Antagonist
Lithium
- Eskalith, Lithobid, Lithonate, Quilonium
- Mood stabilizer
- Blocks sodium channels
Lorazepam
- Ativan
Olanzapine
- Zyprexa
- Serotonin-Dopamine Antagonists
Oxcarbazepine
- Trileptal
- limits influx of sodium ions across cell membrane
Quetiapine
- Seroquel
- Serotonin-Dopamine Antagonists
Reserpine
- Serpasil
- Antihypertensive drug
Risperidone
- Aspidon, Rispedin, Risperdal, Rispond
- Serotonin-Dopamine Antagonists
Sertindole
- Serdolect
Sertraline
- Serenata, Zolodin, Zoloft, Zotral
- Serotonin Reuptake Inhibitor
Trimipramine
- Surmontil
 - NE & 5-HT Reuptake Inhibitors
Ziprasidone
- Zeldox, Geodon
- Serotonin-Dopamine Antagonists

Schizophrenia, Paranoid Type

- Chlorpromazine 200 mg/tab, 1 tab at h.s.
- Biperiden, 2 mg/tab, tab at h.s.

Bipolar I Disorder
- Chlorpromazine 200 mg/tab, 1 tab at h.s.
- Biperiden 2mg/tab, tab at 8 am
- Lithium Carbonate 450 mg/tab, 1 tab at 8am

MDD
- fluoxetine 20 mg/cap, 1 cap OD

Alcohol Dependence
- Oxcarbazepine 300mg/tab, 1 tab at h.s.
- Vit. B Complex 1 tab OD

18 mos to 2yrs stranger anxiety

Postgratification - ego