Dr.

Alis Uworld Notes For Step 2 CK

Psych

Psych Timelines
Manic Episode - 1 week
Hypomanic - 4 consecutive days
Cyclothymia - Dysthymia + Hypomania for 2 years
Persistant Depressive Disorder - 2 years
Major Depressive Disorder - 6-12 months with each episode >2 weeks
Postpartum Blues - start 2-3 days, resolve 10 days
Postpartum Depression - starts within 4 weeks & lasts 2 weeks to a year or
more
Postpartum Psychosis - days - 4-6 weeks
Brief Psychotic Disorder < 1 Month
Schizophreniform Disorder 1-6 Months
Schizophrenia - > 6 Months
Bipolar I Manic Episode
Bipolar II Hypomania + Major Depression
Delusional Disorder - >1 month
Selective Mutism - >1 month
Tourette Syndrome - Motor or Vocal tics >1 year
Pathologic grief - >1 year
Normal Grief - < 6 Months

Persistent Complex Bereavement Disorder = >12 months

Adjustment Disorder - < 6 Months i.e, 2 months of depression + 4 months of
distress.
Generalised anxiety disorder - > 6 months
Acute stress disorder - <1 Month
PTSD - >1 month
Imaginary Friends 2 6 Years
BMI = Weight in Kgs/ Height in meters squared. 100 Cm = 1 Meter
Defense Mechanisms

Passive-aggressive behavior is an immature defense mechanism in which

an individual expresses his aggression toward another person with repeated,
passive failures to meet the other person's needs.
Fantasy is an immature defense mechanism that substitutes a less
disturbing view of the world in place of reality as a means of resolving
conflict. In this case, the mother interprets the appearance of an angel in her

dream as meaning her son will live a long time, but the reality is that the son
is going to die soon. Fantasy offers escape from anxiety about her son's
illness.
Intellectualization is the transformation of an unpleasant event into a
purely intellectual problem with no emotional component

Drug Side Effects

Bupropion is an antidepressant that produces its effects primarily through
the inhibition of the re-uptake of norepinephrine, dopamine, and serotonin. It
is particularly noted for improving the impaired concentration and diminished
energy that many depressed patients experience. It does not cause the

sexual dysfunction commonly associated with most antidepressant

medications, making it a good choice for young patients or those who are
particularly concerned about sexual side effects.
An important side effect of bupropion is decreased seizure threshold,
which is usually seen at higher doses. This medication should therefore be
avoided in patients with seizure disorders or conditions that predispose to
seizures ( eg. concurrent alcohol or benzodiazepine use, eating
disorders). Individuals with anorexia nervosa or bulimia nervosa
frequently develop electrolyte abnormalities that can precipitate seizures.
Therefore, a history of anorexia nervosa/bulimia is a contraindication to
bupropion usage.
Drug Induced Psychosis - Cocaine and amphetamine intoxication present
in a similar manner, but psychosis is more commonly associated with
amphetamine use. Common symptoms of stimulant intoxication include
dilated pupils, hypertension and tachycardia.
Basically if you think the Dx is Psychosis but the question mentions
DILATED Pupils, is a DRUG INDUCED Psychosis, especially
Amphetamines.
Tardive Dyskinesia (TD), defined as a hyperkinetic movement disorder
that is a side effect of medications (usually dopamine receptor blocking
drugs, antipsychotics, and metoclopramide). Patients typically present within
1-6 months after starting the medication with symptoms as shown
below. Tremor is rarely seen in these patients, and the diagnosis of TD is
clinically made.

Antipsychotics are classified as typical and atypical. Extrapyramidal

symptoms (EPS) frequently occur as side effects of typical antipsychotics
but can occasionally occur with atypical antipsychotics. Risperidone is the
most likely atypical antipsychotic to cause EPS. Clozapine is the least
likely atypical antipsychotic to cause EPS but is considered to be a
medication of last resort because it can cause agranulocytosis. The patient's
TD is best managed by replacing risperidone with clozapine. A complete
blood count should be done before starting clozapine and throughout
treatment to monitor for possible agranulocytosis.
Akathisia is a subjective feeling of restlessness that compels patients to not
sit still and constantly move around (e.g., repeated leg crossing, weight
shifting, and stepping in place). It can occur at any time during treatment
with antipsychotics, and beta-blockers provide some relief.
Dystonia can occur between 4 hours and 4 days after receiving an
antipsychotic medication. It is characterized by muscle spasms or stiffness,
tongue protrusion or twisting, opisthotonus, and oculogyric crisis.
Antihistamines (e.g., diphenhydramine) or anticholinergics (e.g.,
benztropine) provide relief.
Antipsychotics cause hyperprolactinemia by blocking dopamine
activity along the tuberoinfundibular pathway.
Olanzapine is an atypical antipsychotic medication often used to treat
schizophrenia, bipolar disorder, or agitation. Although all atypical
antipsychotics have a lower risk of extrapyramidal side effects, they are all

associated with an increased risk of weight gain, hyperglycemia,

dyslipidemia, and hypertension. ClOzapine and Olanzapine appear to pose
the greatest risk of weight gain. Due to these potential side effects, the
American Psychiatric Association recommends baseline assessment of
weight, fasting plasma glucose, blood pressure, and fasting lipid
profile before starting atypical antipsychotics. In addition, these
parameters should be reassessed after 12 weeks of treatment in all patients
taking these medications.
Phenelzine is a monoamine oxidase inhibitor (MAOI). The MAOi are an older
class of antidepressant drugs mostly used in the treatment of refractory
depression. MAO Is are typically not used as first-line therapy in part because
of the dietary restrictions associated with their use. If a patient taking an
MAO I consumes foods high in tyramine, including aged meats and cheeses,
hypertensive crisis can result.
Abrupt cessation of alprazolam, a short-acting benzodiazepine, is
associated with significant withdrawal symptoms such as generalized
seizures and confusion.

ECT Side Effects - Indications for using electroconvulsive therapy (ECT)

include severe depression, depression in pregnancy, refractory
depression, refractory mania, neuroleptic malignant syndrome, and
catatonic schizophrenia. One of the most common side effects of ECT is
amnesia, which can either be anterograde or retrograde. Anterograde
amnesia tends to resolve rapidly, while retrograde amnesia may persist for a
longer period. Other adverse effects occasionally observed include prolonged
seizures, delirium, headache, nausea, or skin burns.
Methylphenidate is a mild CNS stimulant commonly used to treat attention
deficit hyperactivity disorder (ADHD), which is a childhood condition
characterized by hyperactivity, short attention span, and easy distractibility.
Common side effects from the use of methylphenidate include nervousness,
loss of appetite, nausea, abdominal pain, insomnia, and tachycardia.
Prolonged therapy has been shown to cause mild growth retardation
or weight loss. Methylphenidate should not be used in children younger
than 6 years old because safety and efficacy in this age group have not been
evaluated.

Depression Management - When treating a single episode of major

depression, the antidepressant should be continued for a period of six
months following the patient's response. If multiple episodes of depression
have occurred, maintenance therapy will likely need to be continued for a
longer period.

Pain disorder is characterized by the presence of pain in one or more

anatomical sites. Symptoms are psychologically influenced but not
intentionally produced and cause severe functional impairment.
Genito-pelvic pain/penetration disorder should be considered in female
patients expressing pain with intercourse or attempted penetration.

Somatization Disorder management - Patients with somatization disorder

benefit from regularly scheduled appointments intended to reduce the
underlying psychological distress.
Telling the patient that there is nothing wrong with her will offend her and
undermine future doctor-patient communication.
Acting in a paternalistic and dismissive manner will likely alienate this patient
It is important to listen well and be tactful when discussing patient concerns,
especially when sensitive psychological issues may be involved.
Additional medical workup will not be helpful because this patient has
already undergone extensive evaluation of her symptoms. Instead the
emphasis should be on scheduling regular appointments with the intention of
addressing the psychological distress associated with the symptoms.

Immediately telling the patient that she has somatization disorder is not
recommended as it would likely alienate her at this early stage. The patient
is convinced that she's seriously ill, and she considers all of her previous
doctors incompetent because they were unable to provide a diagnosis.
Therefore, the best approach would be to schedule regular appointments for
her, After several visits have strengthened the therapeutic bond, the patient
should be made aware that there are psychological factors involved that
might warrant a psychiatric consult.
Factitious disorder can have psychological signs/symptoms, physical
signs/symptoms, or both. When a patient displays symptoms of factitious
disorder that are predominantly physical in nature, it is called
Munchausen's syndrome. This is a condition in which patients present to a
healthcare setting with signs and symptoms that they have deliberately
and consciously produced for no obvious reason other than to gain
admission to a hospital and adopt the sick role. They are very knowledgeable
about which diagnoses/symptoms warrant an admission. Patients with this
condition often resort to extreme and dangerous measures, such as
surreptitious use of insulin. They have also been known to contaminate their
urine with various substances (e.g. blood, feces) and take anticoagulants to
produce laboratory results that may make the doctor think they have a
bleeding disorder. They may endure numerous surgeries resulting in scarring
and adhesions. Patients with this condition are usually very demanding and
typically become highly upset when confronted. They will often leave
against medical advice and go to a different hospital where the cycle
continues.
Malingering - As defined in DSM-IV-TR, malingering is the intentional
production of false or grossly exaggerated physical or psychological
symptoms, motivated by external incentives or secondary gain (e.g.
avoiding military duty or work, obtaining financial compensation or shelter,
evading arrest and obtaining drugs).

Schizophrenia - The symptoms of schizophrenia can be classified as either

positive or negative. The positive symptoms include hallucinations,
delusions, disorganized speech, and disorganized behavior. Negative
symptoms include the "five A's": affective flattening (diminished
emotional responsiveness); alogia (poverty of speech); apathy (i.e ..
impaired grooming and hygiene. unwillingness to perform activities);
asociality (i.e .. few recreational interests. social detachment, impaired
relationships); and attention (inattentiveness and impaired concentration
when interviewed).

Patients demonstrating more negative symptoms tend to have a poorer

prognosis, as negative symptoms are primarily responsible for the low
functionality and debilitation seen in schizophrenic patients.
Positive symptoms respond well to typical antipsychotics.
Negative symptoms respond well to atypical antipsychotics (e.g ..
risperidone, clozapine, olanzapine. etc.).
Schizophrenia is divided into four subtypes based on the predominant
symptoms that the patient presents with during the active phase of the
illness: paranoid, disorganized, catatonic and undifferentiated.
Paranoid schizophrenia presents with preoccupation with delusions or
auditory hallucinations without prominent disorganized speech or
inappropriate affect. These patients are usually less severely disabled and
are more responsive to pharmacotherapy.
Disorganized type schizophrenia is characterized by disorganized
behavior, disorganized speech, and flat or inappropriate affect.
Catatonic symptoms are not present. Rambling speech, inappropriate
behavior like masturbation in public & laughing at strange times) are
characteristic.
Catatonic schizophrenia is characterized by a predominance of physical
symptoms, including immobility or excessive motor activity and the
assumption of bizarre postures. Patients may be unresponsive to the
environment and demonstrate extreme negativism or mutism.
Residual schizophrenia occurs in patients with previous diagnoses of
schizophrenia who no longer have prominent psychotic symptoms. The
persistent symptoms may include eccentric behavior, emotional blunting,
illogical thinking or social withdrawal.
Although the primary treatment of schizophrenia is pharmacologic, an
integration of pharmacotherapy with psychosocial treatment modalities will
achieve the best outcome in these patients. Family therapy is one of the
most important psychosocial interventions in schizophrenia. Many studies
indicate that schizophrenic patients adjust better and have a
decreased risk of re-hospitalization if the home atmosphere is
stable and family stressors and conflicts are kept to a minimum. A
supportive and non-demanding environment will contribute greatly to the
patient's ability to adapt. Later, the patient can be encouraged to participate
in a social skills training program.
Schizophrenic patients have increased ventricular size as shown on CT
scan of the brain.

Antipsychotics are divided into typical and atypical agents; both types are
equally effective in treating patients with schizophrenia.
Typical agents work by blocking dopamine D2 receptors and include
drugs such as haloperidol, thioridazine, fluphenazine, and chlorpromazine.
Extrapyramidal system (EPS) side effects are common and are the less
preferred drugs.
Atypical antipsychotics function by blocking dopamine and 5-HT2
receptors. These medications have fewer EPS side effects but tend to have
more metabolic side effects, including diabetes mellitus, lipid abnormalities
and weight gain. Examples include olanzapine, quetiapine, and risperidone.
Atypical antipsychotics ( eg, quetiapine) other than clozapine are
considered first-line treatment for psychosis secondary to
schizophrenia or bipolar disorder. This is due to the lower risk of
extrapyramidal side effects in comparison to typical antipsychotics.
Currently recommended first-line atypical antipsychotics include oral
aripiprazole, asenapine, iloperidone, olanzapine, paliperidone, quetiapine,
risperidone, and ziprasidone. These are equally efficacious, but olanzapine
seems to be the best tolerated by patients, and risperidone is available in
generic form. Clozapine is reserved!!!
Patients who live by themselves, have poor social support systems,
are elderly, or have developed side effects with the use of neuroleptics are
more likely to be noncompliant with their medications. This leads to
symptom exacerbation, relapse, and recurrent hospitalization. Therefore, it is
recommended that schizophrenic patients with a history of noncompliance
be given long-acting injectable antipsychotics in depot form or
deconate form, as shown below.

Clozapine is the atypical antipsychotic with the greatest efficacy; however,

it can cause agranulocytosis, seizures, and mvocarditis. Its indications
include patients with the following
Failure to respond to treatment with appropriate courses of
standard schizophrenia medications
Intolerable side effects from alternate treatments
Serious risk of recurrent suicidal behavior in schizophrenia or
schizoaffective disorder
Contraindications to clozapine:
Myeloproliferative disorders
Uncontrolled epilepsy
History of clozapine-induced agranulocytosis or severe
granulocytopenia
Severe central nervous system depression
Clozapine is used to treat schizophrenia in patients who fail to
respond to or cannot tolerate alternate antipsychotic medications.
The extrapyramidal side effects of antipsychotics can be treated with
anticholinergic medications like benztropine.
Schizoaffective disorder is defined as the presence of symptoms of
schizophrenia along with mood symptoms (major depression. bipolar
disorder. or a mixed episode). To make the diagnosis, there should be at least
two weeks when psychotic symptoms are present without any mood
symptoms.
Disorganized thought and speech are common in schizophrenic individuals.
Those with circumstantial (from circumsfare, Latin for "to stand around")
thought processes provide unnecessarily detailed answers that deviate
from the topic of conversation but remain vaguely related. Eventually,
there is a return to the original subject
The term "flight of ideas" refers to loosely associated thoughts that
rapidly move from topic to topic.
Tangentiality refers to a thought process in which there is an abrupt,
permanent deviation from the current subject. This new thought
process is minimally relevant at best and never returns to the original
subject
Loose associations are best described as the lack of a logical
connection between the thoughts or ideas of an individual. It tends to

be a more severe form of tangentiality in which one statement follows

another but there is no clear association between the sentences.
Perseveration is the repetition of words or ideas during a conversation.

Tourette syndrome is characterized by multiple motor and one or more

vocal tics. The tics occur frequently throughout the day, often in bouts. The
motor tics include barking, grunting, grimacing, eye blinking, and
shoulder shrugging. The vocal tics may be obscene (coprolalia). The
episodes are exacerbated by stress and usually subside during sleep.
Frequent comorbid conditions in this patient population include attention
deficit hyperactivity disorder (60 percent) and obsessive-compulsive
disorder (27 percent). Obsessive-compulsive disorder (OCD) develops within
3-6 years after the tics first appeared. It may peak in late adolescence or in
early adulthood at a time when the tics are waning. Less common comorbid
conditions include anxiety, depression, and impulse control disorders
Individuals with severe, uncontrolled symptoms are best treated with the
traditional antipsychotics such as haloperidol or pimozide.
Major Depression - For a diagnosis of major depression, a patient must
have symptoms for the majority of the day, nearly every day, for a period
exceeding 2 weeks. One of the associated symptoms must be depressed
mood or loss of interest in activities that were previously enjoyable
(anhedonia). All of the symptoms aside from depressed mood can be
remembered with the mnemonic SIGECAPS: Sleep (insomnia or
hypersomnia), loss of Interest, Guilt, low Energy, impaired Concentration,
change in Appetite, Psychomotor retardation or agitation, and Suicidal
thoughts. Four symptoms of the mnemonic, in addition to depressed mood or
loss of interest, must be present for a diagnosis of major depression.
A diagnosis of adjustment disorder with depressive features would also be
a consideration. However, for an adjustment disorder, the symptoms must
occur within 3 months of an identifiable stressor; the symptoms in this
patient began after this timeframe. The initial step in the treatment of
depressive symptoms in cancer patients is assurance of appropriate pain
control. A combination of psychotherapy and selective serotonin
reuptake inhibitor (SSRI) medications should be tried. There should be a
low threshold for starting antidepressants in cancer patients given the generally
low risk of side effects and the large potential benefit

Support groups help cancer survivors and their families cope with
survivorship and the morbidity and potential mortality associated with
cancer. These can be used as an adjunct to antidepressant treatment. Similar
to support groups, individual supportive psychotherapy could be beneficial as
well. However support groups are not likely to shorten the duration of
depressive episodes, whereas successful antidepressant therapy can.

The strongest indicator that a future suicide attempt is likely is a history

of previous suicide attempt(s) (Table). Both risk and protective factors for
suicide should be considered in patient assessment and development of a
treatment plan. Other factors to consider include compliance with treatment,
history of violence, and alliance with the treatment team.

Statistics have repeatedly demonstrated that elderly persons, especially

elderly white men, are at increased risk of suicide. More recently, individuals
age 35-64 have also been shown to be at increased risk. The suicide rate for
adolescents and young adults (age 15-24) also remains high, with
impulsivity, hopelessness, substance use, and suicide contagion contributing
largely to the rate. Thus, patient age is considered to be a less attributable
risk factor than a history of previous suicide attempts.
All depressed patients should be screened for suicidal ideation.
Actively suicidal patients will often need to be hospitalized for stabilization
and to maintain their safety.

Patients who are an acute threat to themselves should be hospitalized

(involuntarily. if necessary) for treatment and stabilization. This principle also
applies to minors, even without parental or guardian consent.
Patients with depression and comorbid medical conditions, including
terminal illnesses, can benefit from treatment with antidepressant
medications to improve their quality of life.
It is considered normal for patients with advanced cancer to have feelings of
sadness. However, differentiating bereavement from major depression is
important as patients with major depression will often have decreased
quality of life.
Antidepressants can largely be classified as the following:
Selective serotonin reuptake inhibitors (SSRis)

Citalopram ( Celexa)
Fluoxetine (Prozac)
Paroxetine (Paxil)
Sertraline (Zoloft)

Serotonin norepinephrine reuptake inhibitors (SNRis)

Duloxetine (Cymba Ita)
Venlafaxine (Effexor. Effexor XR)
Desvenlafaxine (Pristiq)
Tricyclic and heterocyclic antidepressants (TCAs)

Amitriptyline (Eiavil)
Clomipramine (Anafranil)
Doxepin (Sinequan)
Nortriptyline (Pamelor)

Monoamine oxidase inhibitors (MAOis)

Phenelzine (Nardil)
Tranylcypromine (Parnate)
Other or atypical antidepressants
Bupropion (Wellbutrin)
Mirtazapine (Remeron)
Trazodone (Desyrel)

Sertraline is an SSRI that works by blocking the reuptake of serotonin at the

presynaptic nerve terminal, thereby increasing the concentration of available
serotonin in the brain. Important side effects of SSRis include anorexia and
sexual dysfunction ( eg. decreased libido, delayed/retrograde ejaculation,
erectile dysfunction). SSRI medications are generally considered the first-line
treatment for patients with moderate-to-severe depression. If there is no
improvement and/or side effects, Treatment guidelines recommend
switching to a different medication in same class. If there is no
improvement and/or side effects after 2 trials, switching to a different class
of antidepressants is indicated.
When choosing between medications for depression, consider treatment
guidelines as well as the safety and side effect profiles. Also, consider a
medication that may be effective for more than one condition. Bupropion is
an example of a medication with two uses, as it is an antidepressant and a
smoking cessation aid.
Mirtazapine is an effective antidepressant for the treatment of depression;
however, weight gain can be a fairly common side effect with its use.
Dysthymia - A mood disorder characterized by the diagnostic criteria
defined in the table below. Patients with dysthymia will often say that they
have felt depressed their entire life, although the symptoms of
dysthymia are less severe than those seen in major depressive disorder.

SSRis such as fluoxetine are the first-line treatment for depression and
may take 4-6 weeks before a beneficial effect is noticed. Therefore, as long
as the patient is tolerating the medication without significant side effects, he
should be advised to continue fluoxetine for at least another 2 weeks
(when he comes after only 2 weeks of usage) before a change is considered.
Primary insomnia is characterized by the isolated symptom of having
difficulty in falling or staying asleep. Given
Panic Disorder Panic disorder occurs most commonly in women between
20-40 years old. The condition is characterized by sudden-onset of
episodes in which the patient experiences extreme anxiety, a sense of
"impending doom," and somatic complaints such as chest pain,
palpitations, nausea, shortness of breath, numbness in extremities, and
diaphoresis. The diagnosis is typically made based on the clinical
presentation, but drug screening and an EKG should be performed to rule out
more serious conditions.
Acute treatment of panic disorder includes the administration of
benzodiazepines (e.g. alprazolam) for rapid relief of symptoms. A
selective serotonin reuptake inhibitor (SSRI) should also be started for longterm symptom relief, but this won't take effect for a few weeks. Once
symptoms are controlled, the benzodiazepines should be tapered off due to
risks of dependence. Cognitive/behavioral therapy may also be of benefit.

Problems commonly associated with panic disorder include depression,

bipolar disorder, agoraphobia, and substance abuse. Observational studies
have shown that 1/3 to 1/2 of patients meet DSM-IV criteria for major
depression at initial presentation and >60% have had 1 or more lifetime
episodes of major depression. Approximately 40% of patients meet the
criteria for agoraphobia.
Pyromania is characterized by intentional and repeated firesetting with no
obvious motive. Conduct disorder can also have a history of fire setting, but
other features (e.g .. lying. theft. and cruelty to others) are also present.

Bipolar Disorder Patients grandiose delusions, racing thoughts,

distractibility, increased energy, and irritability are highly suggestive of a
manic episode. The history of depression and now manic symptoms, with
apparent good functioning between episodes, support a diagnosis of bipolar
disorder.
The key difference between DSM-IV-TR and DSM-5 is that patients with
bipolar I disorder are, now, by definition, not required to have had a
depressive episode.
For the general population, the lifetime risk of developing bipolar disorder is
1%. However, an individual with a first-degree relative (eg, parent, sibling,
or dizygotic twin) who suffers from bipolar disorder has a 5-10% risk of
developing the condition in his lifetime.

Bipolar II disorder is characterized by episodes of major depression and

hypomania (manic-like symptoms that are milder, do not require
hospitalization, and do not cause psychosis). The diagnosis of bipolar I
disorder is differentiated from bipolar II disorder by whether there have been
any previous episodes of mania.
First-line pharmacologic treatment for bipolar disorder includes the following:
1. Atypical antipsychotics ( eg, risperidone, aripiprazole, olanzapine)
2. Lithium
3. Valproic acid
Monotherapy with atypical antipsychotics is preferred for mild to moderately
ill patients. Monotherapy with lithium or valproic acid can be used as
alternate therapy. For more severe episodes, combination therapy with
lithium or valproate plus atypical antipsychotics is usually preferred over
monotherapy. Combination therapy (compared to lithium or valproate
monotherapy) has a more rapid onset of action.
In patients with severe acute mania, psychosis, or extreme agitation,
an antipsychotic is often required. In this case, haloperidol should be
given immediately because of its acute onset of action in order to
decrease this patient's increasing agitation.

The long-term treatment of choice for bipolar disorder is either lithium

carbonate or valproic acid. The therapeutic effects of lithium carbonate are
attributed to its ability to inhibit inositol-1-phosphatase in neurons. Because
the margin of safety for lithium is very low, frequent monitoring is required to
avoid toxicity. The potential adverse effects associated with lithium usage
include gastrointestinal distress (e.g. nausea, vomiting, diarrhea, or
abdominal pain), nephrotoxicity (resulting in polyuria and polydipsia,
ultimately leading to nephrogenic diabetes insipidus), hypothyroidism,
leukocytosis, tremors, acne, psoriasis flares, hair loss, and edema. Lithium is
also a teratogen that is associated with Ebstein's anomaly (a cardiac
defect). In a young woman, it is therefore important to evaluate thyroid
function, renal function, and human chorionic gonadotropin levels
before prescribing lithium.
Lithium is a first-line medication for bipolar disorder. However, it is
contraindicated in renal diseases.
If the patient is on lithium for sometime & still experiences a manic episode,
it is important to first obtain a urine toxicology screen to ensure he has
not recently taken cocaine or amphetamine, as usage of either stimulant can
result in a manic presentation. In the presence of a negative toxicology
screen, lithium levels should be evaluated to determine if
noncompliance or insufficient drug levels could be responsible for
this man's manic episode.
Patient with Hx of Manic episodes presents with mania despite on
medication, the possible explanations are
1. He is taking Stimulants like Cocaine or Amphetamines (Do
urine tox)
2. He is non compliant with his meds (Do blood lithium levels)
The mood stabilizers such as lithium and valproate are the mainstays of
treatment for bipolar disorder. For a bipolar patient on lithium, maintenance
therapy should be continued for at least one year following an acute
episode. If there are no relapses and the patient has attained good
symptomatic control, then the lithium can be gradually tapered off and
ultimately discontinued. Because abrupt cessation of lithium increases
the risk of suicide and relapse, tapering the medication is always
recommended.

Specific Phobias Treatment - The first-line treatment for specific

phobia is cognitive behavioral therapy (CBT). CBT has been shown to be
effective even with a relatively short number of sessions (ie .1-5). Medication
is considered second-line treatment for specific phobias. If medication is
needed, beta blockers and selective serotonin reuptake inhibitors are
the best initial pharmacologic choices.

Generalized Anxiety Disorder - According to the DSM-IV, GAD is

characterized by excessive anxiety and concern regarding multiple events
or activities for a minimum of 6 months. Three or more of the following
symptoms must also be present sleep impairment, easy fatigability,
restlessness, muscle tension, poor concentration, and irritability. First-line
medications for GAD are selective-serotonin reuptake inhibitors (SSRis),
such as citalopram, or serotonin-norepinephrine reuptake inhibitors (SNRis).
These medications are highly effective in combination with cognitivebehavioral psychotherapy.
Treatment of Anxiety Disorders

Social Phobia - These patients have extreme fear and avoidance of settings
that require socialization. Patients stricken with this condition tend to view
themselves as inferior and will blame themselves for any failures or negative
outcomes in social situations. Functional impairment is common.
An effective treatment regimen for social phobia is the combination of
assertiveness training and an SSRI such as paroxetine. Assertiveness
training is a subset of cognitive-behavioral psychotherapy that involves
social skills training and the exploration and elimination of fearful thoughts
that arise because of faulty cognitive processing. SSRis are also of help and

are considered first-line drugs in the management of social phobia.

Therefore, a combination of these two therapies would be most effective for
this patient.
Specific Phobia of Public Speaking - Beta-blockers such as propranolol
are excellent medications for prophylaxis against anxiety for this patient
population when public speaking is unavoidable. They can be used on an as
needed basis to help control much of the trembling, tachycardia, and other
sympathetic symptoms associated with anxiety. Specific phobias can also
benefit from behavioral therapy such as flooding, biofeedback, relaxation
therapy, and exposure desensitization.
Selective serotonin reuptake inhibitors (SSRIs) are used in the treatment of a
variety of anxiety disorders. Since the patient's anxiety is only situational,
it would be inappropriate to prescribe a daily medication.
Hypochondriasis - a condition characterized by the misinterpretation of
bodily symptoms and a persistent fear of fatal illness despite negative
medical workups. Hypochondriacal symptoms become more prominent
during periods of psychological stress. Therefore, it is always helpful to
inquire about current emotional stressors with these patients. This
discussion should be followed up with brief psychotherapy, which often
resolves the symptoms.

Adjustment disorder requires the development of emotional or behavioral

symptoms in response to an identifiable stressor within 3 months of the
onset of the stressor. These symptoms cause impairment in the patient's life,
but do not meet criteria for other psychiatric illnesses. Even moving away
from home & living alone for the first time can cause symptoms of
tension and insomnia leading to Adjustment Disorder.
The treatment of choice for adjustment disorder is cognitive or
psychodynamic psychotherapy.
Grief is the specific emotional response to a loss and includes pain, distress,
and physical and
emotional suffering. Bereavement is a person's response to the loss of a
close relationship and is many times interchangeably used with grief. A
normal grief reaction typically subsides by 6 months after the initial
loss, and the bereaved individual usually starts moving on with their usual
daily activities. Although the symptoms can recur for up to 1 year and on

particular days, such as anniversaries, the patient generally has overall

improvement.
Abnormal bereavement/complicated grief reactions are characterized by
difficulty moving on with life, bitterness, empty feelings, trouble
accepting death, and social withdrawal. This can many times overlap
with the symptoms of major depression, listed below using the
"SIGECAPS" mnemonic. These symptoms can present in a 2-week period with
depressed mood.
In other words, its okay to have symptoms of depression for the 1st 2 months
after the loss of a loved one.
Bereaved patients who have at least 2 weeks of symptoms of
depression 6-8 weeks after a major loss should be considered for
treatment with both psychotherapy and a trial of antidepressants. This
patient satisfies the criteria for major depression because he has
experienced depressed mood, insomnia, guilt, energy deficit, decreased
appetite, and suicidality. If the patient is not acutely suicidal, they can be
started on first-line treatment for major depression with a selective serotonin
reuptake inhibitor (SSRI), such as sertraline, and continue psychotherapy.

Obsessive-Compulsive Personality Disorder - Those with this condition

develop a need for order and perfection and carry out activities in an
extremely methodical way beginning before adulthood. They frequently do
not complete tasks in a timely manner due to being extremely rigid,
meticulous, and focused on the need for perfection. These patients often
have anxiety, indecisiveness, and perseveration on assignments. These
patients do well in school because they have little to do in school. However,
when they enter college, they have a lot of work & Study & assignments to
do and this is when they frequently end up finishing their work after the
allotted time. They have limited insight and are ego-syntonic.
Obsessive-Compulsive Anxiety Disorder - According to the DSM-IV, OCD
is characterized by the presence of persistent, intrusive thoughts that
lead to the performance of compulsive acts in order to allay inherent
anxieties. Individuals suffering from this disorder often perform multiple
time-wasting rituals and recognize the absurdity of their behavior but feel
unable to stop. They suffer from significant functional impairment. They are
ego-dystonic.
This disorder results from altered levels of serotonin, a neurotransmitter
that regulates mood, aggression, and impulsivity. The treatment of choice for

OCD is a selective serotonin reuptake inhibitor (SSRI), such as paroxetine

& TCAs like Clomipramine.
Alzheimers Dementia - Although the etiology of Alzheimer's dementia is
not well understood, histopathologic examination of brain tissue in affected
patients clearly indicates a selective loss of cholinergic neurons. The first-line
treatments for cognitive symptoms of Alzheimer's dementia are
cholinesterase inhibitors. The cholinesterase inhibitors donepezil
(Aricept), galantamine (Razadyne), galantamine ER (Razadyne ER), and
rivastigmine (Exelon) have been shown to be effective in patients with
mild-to-moderate dementia. Cholinesterase inhibitors may improve quality of
life and cognitive functions, including memory, language, thought, and
reasoning. Donepezil is approved for all stages of Alzheimer's dementia.
Memantine, an N-methyl-D-aspartate receptor antagonist, is approved for
moderate-to-severe dementia.

Dissociative Disorders
Dissociative Fugue - The dissociative disorders are characterized by
forgetfulness and dissociation. Dissociative fugue is the only condition
within this group that is associated with travel.
Dissociative amnesia is characterized by the presence of one or more
episodes of inability to recall important personal information. The memory
disturbance is usually related to a traumatic or stressful event and is too
extensive to be considered ordinary forgetfulness.
Depersonalization disorder is characterized by persistent or recurrent
feelings of detachment from one's own physical or mental processes in the
context of an intact sense of reality. These patients tend to feel they are
observing their body and thoughts from afar, as if they are living in a dream.
This condition usually results in significant occupational or functional
impairment.
Derealization disorder describes the state of experiencing familiar persons
and surroundings as if they were strange or unreal.
Dissociative identity disorder, formerly known as multiple personality
disorder, is characterized by the presence of two or more distinct identities
that alternatively assume control of the person's behavior. Amnesia
regarding important personal information about some of the identities is
observed.

Physical/Sexual Abuse - Always have a high index of suspicion for

physical/sexual abuse in children (especially females) with sudden
behavioral problems, families with unstable economic backgrounds, or
parents with a history of drug/alcohol abuse.

Anorexia nervosa is most common in adolescent girls from affluent

families. The DSM-IV criteria for the diagnosis of anorexia nervosa include:
1) Body weight at least 15% below normal weight accompanied by a
refusal to maintain body weight at normal levels (Still want to lose
weight);
2) Amenorrhea for three months;
3) Distortion of body image in which the individual views herself as
obese when she is in fact thin; and
4) Fear of gaining weight or becoming fat despite being underweight.
To continue to lose weight, individuals suffering from anorexia nervosa will
either:
1) Fast and/or exercise excessively (the restricting subtype), or
2) Binge eat followed by laxative usage or induced vomiting (the binge and
purging subtype).
Hospitalization is highly recommended for patients with anorexia
nervosa when there is evidence of dehydration, starvation, electrolyte
disturbances (i.e. hyponatremia, hypokalemia, or hypophosphatemia),
cardiac arrhythmias, physiologic instability, or severe malnutrition (i.e.
weight< 75% of average body weight for age, sex, and height). The goals of
hospitalization include weight gain as well as prevention and management of
the medical complications caused by anorexia nervosa.
Although patients with anorexia may have thyroid dysfunction, meaning
they will feel cold & have dry skin & bradycardia, low BP & low pulse. The
primary illness needs to be managed first.
On physical examination, the most striking finding is emaciation. Some
individuals develop lanugo (a fine downy body hair) on the back and
abdomen. Other common findings include bradycardia, hypotension,
hypothermia, hair loss, and dry skin. Those who induce vomiting may
have "puffy cheeks" from parotid gland hypertrophy, dental caries,

halitosis, and scars or calluses on the hand from contact with the teeth
("Russell's sign) Electrolyte derangements can result from vomiting.

Although a woman with eating disorder has corrected her eating disorder,
she remains at increased risk for developing pregnancy complications
associated with the chronic deprivation of essential nutrition. Patients with a
current or previous diagnosis of anorexia nervosa are at higher risk for giving
birth to infants that are premature, small for gestational age (secondary
to intrauterine growth retardation) or both. Other potential complications
include miscarriage, hyperemesis gravidarum, cesarean delivery, and
postpartum DEPRESSION (Not psychosis). Children born to anorexic
mothers often suffer from poor growth and intellectual impairment.
Remember the other common findings seen in anorexic patients (important
for USMLE):
1. Osteoporosis
2. Elevated cholesterol and carotene levels
3. Cardiac arrhythmias (prolonged QT interval)
4. Euthyroid sick syndrome
5. Hypothalamic-pituitary axis dysfunction resulting in anovulation,
amenorrhea and estrogen deficiency
6. Hyponatremia secondary to excess water drinking is often the only
electrolyte abnormality, but the presence of other electrolyte
abnormalities indicates purging behavior.

Conversion disorder requires the following diagnostic criteria:

Common triggers include relationship conflicts or other stressors with an

intense emotional component. But the symptoms are not feigned or
purposefully produced. Patients with conversion disorder can be hysterical or
strangely indifferent (i.e .. "Ia belle indifference") to their symptoms.
Definitive diagnosis of conversion disorder requires an extensive workup to
rule out possible underlying medical causes. Treatment options include
hypnosis and relaxation techniques in the acute setting, while
psychotherapy offers the best long-term results.
Delusional disorder is characterized by non-bizarre (i.e., can occur in real
life) false beliefs in an otherwise high-functioning individual. Common types
of delusions include: erotomanic (false belief that a person of higher social
status is in love with them, such as a movie star); persecutory (false belief
that someone is out to harm them or someone close to them); jealous (false
belief that their spouse is cheating when the evidence shows that they have
remained faithful).
Delusional disorder involves one or more non-bizarre delusions in an
otherwise high-functioning individual meaning, they have a normal
functioning lifebut they have this one delusion.
Grandiose Delusion - A delusion is a fixed, false belief not consistent with
cultural norms. Individuals with grandiose delusions typically believe they
have special powers, extraordinary accomplishments or a special relationship
with God. Grandiosity is defined as a grossly inflated sense of selfimportance.
Vs

Magical thinking is the belief that one's thoughts can control events in
a manner not explained by natural cause and effect. It also includes the
attribution of casual incidents to supernatural forces.
Folie a deux In this disorder, a delusion or set of delusions is shared
simultaneously by individuals who share a close relationship. Usually, the
dominant individual in the pair becomes delusional and transfers the
delusion onto the second person. Treatment includes separating the pair to
break the chain of reinforcing each other's beliefs. The individual who first
had the delusion, always requires psychiatric treatment (sometimes in an
inpatient setting), whereas the other individual only requires treatment in
some cases. It is important to assess both individuals separately to
determine the degree of impairment in each.
Selective Mutism These individuals demonstrates poor communication
and reduced verbal expression in a specific social setting (school) but
behaves normally at home because she feels comfortable and relaxed
there. This supports the diagnosis of selective mutism, a condition in which
people have a fear of situations in which they are expected to talk ( eg.
school or a formal social gathering). They may "freeze up" and become
expressionless. To establish the diagnosis, symptoms must be present for
at least one month. Cause significant functional impairment, and not be
caused by another communication or learning disorder.

Child Abuse - The table below summarizes the history, physical

examination findings, and caregiver behaviors that increase the likelihood
that abuse is the cause of an injury.

The first step is to perform a more complete and thorough

examination with the clothes completely removed because sometimes
the initial cursory examination can miss some of the findings noted in the
above table. Injuries that are suggestive of a cigarette burn (e.g .. circular
punched-out lesions) or immersion in scalding hot water (e.g .. clear line of
demarcation with no splash marks) are very concerning for child abuse. If
there are physical examination findings suggestive of current or past
abuse/injury, appropriate laboratory (e.g .. liver function tests to evaluate for
abdominal injury) and radiologic (e.g .. skeletal survey x-rays to document
fracture) studies should be done. Once this investigation is complete, a
physician can determine if there are data to suggest abuse and consult Child
Protective Services (CPS), perform an evaluation of family dynamics, or
admit the patient to the hospital for further care if necessary.
When child abuse is suspected, the following steps should be performed:
1.
2.
3.
4.
5.

Complete physical examination

Radiographic skeletal survey (if necessary)
Coagulation profile (if multiple bruises are present)
Report to Child Protective Services
Admittance to the hospital (if necessary)
6. Consultation with a psychiatrist and evaluation of family dynamics
Domestic Abuse - Physicians should be alert to clues suggestive of physical
abuse as patients will rarely report such abuse on their own. Multiple
ecchymoses, fractures, or repeated visits to the physician with different
injuries are all signs of possible physical abuse. The initial statement in such
cases should be made delicately. Open-ended questions and general

statements of observation often provide the best introduction to such a

discussion. Therefore, encouraging the patient to say a little more about the
bruises is a good start as it encourages an open dialogue. The fact that the
patient cried at mention of the bruises suggests that she indeed has
something to say. She should also be reminded that this conversation is
confidential.
Physical abuse should be suspected in a woman with multiple bruises and
frequent injuries. In these cases, the following steps should be carried out
1.
2.
3.
4.
5.
6.
7.

Confront the patient gently, in a nonjudgmental way.

Assure the patient of confidentiality and any limitations.
Emphasize that the abuse is not acceptable.
Suggest informing the police.
Ensure safety of the patient and any children.
Ask the patient if she has an escape plan.
Suggest talking to a support group or agency dealing with these issues.
8. Assure the patient of continuing support.
Pathologic gambling is more common in males and defined as a persistent
and maladaptive gambling behavior that usually results in a preoccupation
with gambling and arranging for the means to indulge in it. These patients
might gamble increasing amounts of money to achieve the desired
excitement and can resort to illegal behavior to finance their activities.
Attempts to reduce gambling behavior are typically unsuccessful and result
in jeopardized relationships and financial instability. When confronted about
the issue, pathologic gamblers are usually dishonest and evasive. The
gambling can also be used as a means of escaping from problems or
relieving unhappiness.
Bereavement is a normal reaction to the loss of a loved one. Normal
bereavement rarely lasts longer than a few months and is distinguished from
PCBD by duration and degree of impairment.
However, Persistent Complex Bereavement Disorder can occur in
patients experiencing significant impairment and other symptoms more
than 12 months following the loss.

Imaginary Friends - Parents often become concerned and puzzled when

their children acquire imaginary friends, but this phenomenon is generally
considered an indication that the child has found creative ways to deal with
being alone. Children between the ages of two and six years are most likely
to develop imaginary friends, typically in response to times of change or
stress. Most children abandon this behavior within the first few years of
elementary school.
Autism - Autism presents early in childhood, becoming evident before
three years of age. The autistic child fails to develop normal interactions
with others and has impaired verbal and non-verbal communication. These
children often indulge in repetitive, stereotyped behavior and may
babble and use strange words. They avoid eye contact and have restricted
interests.

Vs
Hearing impairment in children can mimic the communication and social
abnormalities evident in autism spectrum disorder. However, patients with
hearing impairment are unlikely to demonstrate the abnormal motor and
sensory responses
Vs
Attention deficit hyperactivity disorder in DSM-5 presents before age 12
and is characterized by inattention, impulsiveness, overactivity,
forgetfulness, poor organization, and short attention span.

Trichotillomania - By definition. trichotillomania is an impulse-control

disorder. According to the DSM-IV diagnostic criteria. The patient must have
the following characteristics:
1. 1 . Repeated episodes of pulling out one's hair resulting in hair loss
that is noticeable
2. Experiencing anxiety right before the act of pulling out the hair or
when trying to resist the temptation
3. A sense of relief after the hair has been pulled out
4. This behavior causes impairment or distress

5. Features inconsistent with any other medical or dermatological

condition causing hair loss
These individuals most commonly pull out hair from the scalp. However,
other areas can also be affected (e.g .. eyebrows, eyelashes, facial hair,
armpits and even pubic hair). The act is usually triggered by a stressful event
and is often associated with other disorders (e.g .. obsessive compulsive
disorder (OCD), anxiety disorders, Tourette's, eating disorders. etc.)
Sleep Disorders
Sleep hygiene Inadequate sleep hygiene is a sleep disorder due to
performance of daily living activities that are inconsistent with the
maintenance of good-quality sleep and full daytime alertness. Poor sleep
hygiene can be associated with insomnia. Examples of poor sleep hygiene
practices include poor sleep scheduling with variable wake and sleep times
and frequent daytime napping; routine use of caffeine. alcohol. or nicotine
especially in the period preceding sleep; engaging in mentally or physically
stimulating activities too close to bedtime; and frequent use of the bed for
activities other than sleep. It is typically seen in people who have a very
hectic job & have lot more activities. They have a delayed sleeping phase
due to anxiety of work.

Delayed sleep phase syndrome is a circadian rhythm disorder

characterized by inability to fall asleep at "normal" bedtimes such as 10 PMmidnight. These patients often cannot fall asleep until 4-5 AM, but their sleep
is normal if they are allowed to sleep until late morning. They present with
complaints of insomnia and excessive daytime sleepiness. An accurate
history and/or a sleep diary are essential in making the diagnosis.
Advanced sleep phase disorder is also a circadian rhythm disorder and is
characterized by an inability to stay awake in the evening (usually after 7
PM), making social functioning difficult. These patients frequently complain
of early-morning insomnia because of their early bedtime.

Age Related Changes - Sleep patterns tend to change in older individuals.

As people age, they typically sleep less at night and nap during the day.
The period of deep sleep (Stage 4 sleep) becomes shorter and eventually
disappears. Older people also awaken more during all stages of sleep.
These changes are normal and usually do not indicate a sleep disorder.

Age Dependent Changes - changes that are inevitable with age.

Auditory - Presbycusis: sensorineural hearing loss, particularly at high
frequency, Otosclerosis: fusion of ear ossicles producing conductive hearing
loss
Body composition - Total body fat increases while total body water and
lean body mass decrease: watersoluble medications (e.g., cimetidine,
digoxin, ethanol) have decreased volume of distribution causing higher levels
in the plasma. Fat-soluble drugs (e.g., chlordiazepoxide) have a larger
volume of distribution causing a decreased plasma concentration; excretion
from the body is at a slower rate, which increases half-life and extends
pharmacologic effects.
Cardiovascular - Blunted maximal cardiovascular responses to exercise
Central nervous - Cerebral atrophy with mild forgetfulness, Impaired
sleep patterns such as insomnia, early wakening, Decreased
dopaminergic synthesis: parkinsonian-like gait
Decrease in cerebral blood flow and increase in blood-brain barrier
permeability: increases sensitivity to medications that affect CNS
Female reproductive- Breast and vulvar atrophy, Decreased estrogen and
progesterone: FSH and LH, respectively
Gastrointestinal- Decreased gastric acidity: predisposes to Helicobacter
pylori infection
Decreased colonic motility: constipation predisposing to diverticulosis
General Increased body fat- decreased number insulin receptors (glucose
intolerance)
Hepatobiliary Liver mass decreases 25%35% with increasing age: liver
blood flow decreases
35%45%; hence, medications have a longer duration of effect Immune
Decreased skin response to antigens (called anergy)
Male reproductive - Prostate hyperplasia: predisposes to urinary
retention, Prostate cancer: most common cancer in men
Musculoskeletal - Osteoarthritis in weight-bearing joints: wearing down
of articular cartilage in the femoral head
Renal - Kidney loses 20%-25% of renal mass as people age from 30 to 80
years, Decreased GFR (10% per decade from the age of 30 years):
increased risk of drug, toxicity from slow clearance of drugs

Respiratory - Mild obstructive pattern in pulmonary function tests: e.g.,

TLC, vital capacity, Mild hypoxemia and increased A-a gradient
Skin - Decreased skin elasticity due to increased crossbridge formation
between collagen fibers
Senile purpura over the dorsum of the hands and lower legs
Visual Cataracts - visual impairment, increased risk for falls, Presbyopia:
inability to focus on near objects
Age Related Changes - changes that have a greater incidence with age
but are not inevitable with age.
Cardiovascular Atherosclerosis: increased risk for coronary artery disease,
heart failure, peripheral vascular disease, strokes, Aortic stenosis: most
common valvular abnormality in the elderly, Systolic hypertension: due to
loss of aortic elasticity, Giant cell arteritis: large vessel vasculitis involving
aortic arch vessels
Central nervous Alzheimer disease: most common cause of dementia in
people >65 years
Parkinson disease, Subdural hematomas: due to falls.
Endocrine Type 2 diabetes mellitus
Female reproductive Increased incidence of cancers of the breast,
endometrium, ovary
Gastrointestinal Increased incidence of colorectal cancer
Immune MGUS: most common cause of monoclonal gammopathy
Musculoskeletal Osteoporosis: vertebral column in females and femoral
head in males Polymyalgia rheumatica: muscle and joint pain associated with
an increased
erythrocyte sedimentation rate
Renal/lower urinary tract Renovascular hypertension secondary to
atherosclerosis
Urinary incontinence
Respiratory Pneumonia: usually Streptococcus pneumonia
Primary lung cancer: particularly in smokers

Skin UVB-induced cancers: e.g., basal cell carcinoma (most common),

Actinic (solar) keratosis: precursor for squamous cell carcinoma, Pressure
sores: pressure on capillaries is the most important risk factor
Visual Macular degeneration: most common cause of blindness in the
elderly