Diagnostic Methods

Diagnostic Test

Behavior
Healthcare
Problems
Managed in
Primary Care

Measures

Indications
Garden-variety mood
disorders
Substance Abuse
Problems

Categories of behavioral
problems that primary
care providers are able to
manage

Assessment of depressive
disorders

Anxiety
Disorders

Assessment of anxiety
disorders

GDS-S

Screening tool for

depression in older
adults
Screening tool for
depression

PHQ-9

Multipurpose instrument for

screening, diagnosing,
monitoring, and measuring
the severity of depression

DAS-10

Screening tool for

substance abuse

Alcohol
Smoking
Eating disorders

Somatizing patients

Some axis II patients

Coping issues

Living with chronic

illness
Dealing with family
stressors
Other health-realted
behaviors

Test Interpretation
Parameters

Other
Illness Not Managed by PCPs
Serious mental illness
Psychotic patients
Patients needing multiple MH
providers or MH team approach
Patients not likely to respond to
time-limited psychotherapy
Patients not responding to initial
medication trial
More serious psychiatric problems
than were initially apparent

PHQ-4

Patient Health
Questionnaire
MDI

MDI

Domestic abuse

Sexual trauma

Noncompliance with
medical regimens

Depressive
Disorders

Result

PHQ-8
Geriatric depression
scale
GAD-7

Scope
Number of Items
Minutes
Self
Scope
Number of Items
Minutes
Self
Scope
Number of Items
Minutes
Self
Scope
Number of Items
Minutes
Self

Symptom frequency
past 2 weeks
15
5
No
Symptom frequency
past 2 weeks
10
<2
Yes
Symptom frequency
past 2 weeks
9
<2
Yes
Symptom frequency
past 12 months
10
<2
Yes

> 5 - Suggestive and warrants followup comprehensive assessment

10 - Almost always indicative of
depression
20 - 24 - Mild
25 - 29 - Moderate
> 30 - Severe

5 - 9 - Mild (watchful waiting)

10 - 14 - Moderate
15 - 19 - Moderately severe
(active treatment)
20 - 27 - Severe

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Diagnostic Methods
Diagnostic Test

Measures

PHQ-2

Frequency of depressed
mood and anhedonia
over past 2 weeks

GAD-2

Generalized anxiety
disorder questionnaire

PHQ-4

4-item measure of
depression and anxiety

SCOFF

Screening for eating

disorders

DAST-1

Screening for substance

abuse

Indications
Scope
Number of Items
Minutes
Self
Scope
Number of Items
Minutes
Self
Scope
Number of Items
Minutes
Self
Scope
Number of Items
Minutes
Self
Scope
Number of Items
Minutes
Self

Result

Test Interpretation
Parameters

Other

Symptom frequency
past 2 weeks
2
2-Jan
Yes
Symptom frequency
past 2 weeks
2
1-2
Yes
Symptom frequency
past 2 weeks
4
2
Yes
Symptom frequency
past 3 months
5
2
Yes
Symptom frequency
past 12 months
1
<1
Yes

See PowerPoint slides for more information.

It was very hard to translate the lecture into this note format.

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Cause

Mental Disorder

Significant disturbance in cognition,

emotion, or behavior reflecting
underlying biological, psychological,
or developmental dysfunction

Signs and Symptoms

Most Common
Psychotropic
Medications
Axis I

Classification
of Mental
Disorders
(DSM-IV)

Method of categorizing
mental disorders

DSM-5
Classification of
Sleep Wake
Disorders

Types of sleep-wake
disorders

Axis II
Axis III
Axis IV

Anxiolytics (87%)
Antidepressants (79%)
Stimulants (66%)
Antipsychotics (51%)
Clinical Psychiatric
Disorders
Personality Disorders
and Mental Retardation
General Medical
Conditions

Test

Laboratory
Result

Treatment

Medications

Other
> 25% of the adult population meet
criteria for a mental disorder (based
on DSM criteria)

Psychosocial and
Environmental Problems

Global Assessment of
Functioning
Hypersomnolence
Insomnia disorder
disorder
Breathing-related sleep Circadian rhythm sleep
disorders
wake disorders
Non-REM sleep
arousal disorders
Nightmare disorder
Parasomnias
REM sleep
behavior disorder
Restless legs syndrome
1 of the Following
Axis V

Difficulty initiating sleep

Early wakening
Difficulty maintaining
sleep

Chronically nonrestorative sleep or

sleep that is poor in
quality

Above sleep difficulty occurs in spite of adequate

opportunity and circumstances for sleep

Insomnia
Disorder
Diagnostic
Criteria

DSM 5 criteria for

diagnosting insomnia
disorder criteria

Occurs 3 nights / week for 3 months

Daytime Impairments of Function
Deficits in memory,
Fatigue / malaise
Decreased motivation /
attention, or
energy / initiative
concentration
Social / work
Daytime sleepiness
dysfunction or poor
Proneness to errors /
school performance
accidents
Tension headaches / GI
Concerns or worry
symptoms in response
about sleep
to sleep loss
Narcolepsy
Sleep Disturbance Not
Obstructive sleep apnea
Due Sleep-Wake
Disorders
Circadian rhythm
disorders
Not adequately
Not attributable to the
explained by /
effects of substances or
co-existing mental or
medications
medical disorders
Acute / short-term insomnia lasting
< 3 months but meeting other criteria
Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Cause

Signs and Symptoms

Primary

Insomnia

Inability to sleep
Co-Morbid or
Secondary

Test

Laboratory
Result

Excessive daytime
sleepiness

Not attributable to
drugs, medical, or
psychiatric disorder
Pain, CHF, COPD,
neurodegenerative
disorders,
musculoskeletal
disorders
Depression, anxiety,
or mania

Narcolepsy

Circadian
Rhythm
Sleep-Wake
Disorders

Episodes of cataplexy
occurring few times /
month

CSF

Hypocretin

Nocturnal
REM sleep latency
Hypocretin deficiency
Sleep Poly 15 minutes
(not in the context of
somnography
acute brain injury,
One of the results in
inflammation, or injury)
Mean sleep
Laboratory section
latency 8
minutes
Multple Sleep
Sleep paralysis
Latency Test
Possible cataplexy
Hypnogogic and
2 Sleep-onset
associated with emotion
hypnopompic
REM periods
hallucinations
Biological clocks are set
Persistent or recurrent pattern of Delayed or Advanced ahead or behind what is
Sleep Phase Types
sleep disruption, primarily due to
normal

alteration of the circadian system

or misalignment between the
endogenous circadian rhythm and
the sleep-wake schedule dictated
by a person's physical
environment or social /
professional schedule

Temazepam
Triazolam
Zolpidem
Zaleplon
Eszopiclone
Ramelteon
Benadryl
Unisom
Barbituates

Other
Assessing Insomnia Patients
Sleep history
Medication history
Physical exam
Selective testing
Any PCP treatment / follow up

L-Tryptophan
Valerian

Self-reported EDS despite 7 hours of sleep

Recurrent lapses into
sleep within the
same day
EDS Occurs With at
Unrefreshing main sleep
Least One of
episode of 9 hours
Difficulty staying awake
after abrupt awakening
Accompanied by
3x / week for
significant distress or
3 months
functional impairment
Not attributable to
Not better explained by
substances, medications,
another sleep disorder
or other illness
1 of the Following

Recurrent periods of an
irrepressible need to
sleep that lapses into
sleep or napping occuring
within the same day

Medications

Go to bed only
when sleepy
Get up same time
every morning
"Sleep Hygiene" Use bed for sleep
Quiet, dark, and
cool environment
Resolve or
postpone worries
Cognitive-behavioral therapy
Benzodiazepine
Non-benzo hypnotics
Melatonin-receptor agonists
Antihistamines
Exercise

Decongestants, caffeine,
alcohol, or steroids

Hypersomnolence
Disorder

Treatment

Shift Work Type

Non-24 Hour Type

Jet Lag

Wakefulness promoters
Ritalin or Adderall
(to daytime sleepiness)

Armodafinil
Methylphenidate

0.74 new cases / 100k

25 - 50 cases / 100k
Peak age of onset is 14 years old, and
there is a second peak at age 40.

Antidepressants

NonPharmacological
Therapies

Maintain
7 - 8 hours of
sleep / night
Schedule naps
during day
Exercise

Melatonin

Can occur anytime when

work is scheduled during
regular sleep hours
Total blindness where
there is daily "drift"
Occurs when crossing
> 2 time zones

Modafinil

Adderall
Tricyclic
Antidepressants
SSRIs
SNRIs
Sleep disruption leads to excessive
sleepiness insomnia. The
disturbance causes significant
distress or impairment.

Wakefulness promoters

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Restless Legs
Syndrome

Periodic Limb
Movement
Disorder
Non-REM
Sleep Arousal
Disorders
Snoring
Major
Depressive
Episode

Cause

Irresistible urge to move

one's body to stop
uncomfortable or odd
sensations

Signs and Symptoms

Unpleasant /
Uncomfortable
Leg Sensations

Jittery
Creepy-crawly
Pins and needles

Occur / worsen at rest

Occur / worsen at night

and delay interrupt
sleep

Temporary total or
partial relief with
movement
Not associated with
another medical /
mental disorders

Possible arm
involvement

Clustered episodes every

Flexion of ankles, knees,
20 - 40 seconds of
and hips with toe
involuntary muscle
dorsiflexion
twitching / jerking
Nocturnal myoclonus
HTN
Associated
ESRD
Co-Morbidities
Alcohol abuse
Sleep apnea
Recurrent episodes of Usually during the first
incomplete awakening
of sleep episodes
Sleep terrors
Somnambulism
Episodes of incomplete
No dreaming
Amnesia during episodes
Not attributable to
awakening from sleep
Causes significant
effects of a substance or
distress or impairment in
medical / mental
functioning
disorder
Predisposing Factors
Resulting sound of the vibration of
Gender
Obesity
the respiratory structures due to
Sleep position
Narrow airway
obstructed air movement during
Alcohol
Sedatives
sleeping
Hypothyroidism
All symptoms must occur in the same 2 week
period, be present a minimum of most of the day
on most days, and result in clinically significant
impairment
Period characterized by
Anhedonia
Sleep
Feeling worthless
the symptoms of major
Guilt
Hopeless
depressive disorder
Energy
Concentration
Appetite
Suicidal ideation

Major depressive episode

that leads to depression
following the death of a
loved one

Laboratory
Result

Treatment

Medications
Pramipexole

Dopamine agonists

Ropinerole
Levodopa /
Carbidopa
Gabapentin

Levodopa / carbidopa
(not first line)
Gabapentin

Other
2 - 7.2% of population
>
Prevalence with age

Temazepam
Not attributable to
medication effects

Psychomotor retardation or agitation

BereavementRelated Major
Depression

Test

BZDRAs

Clonazepam
Zolpidem

Supplemental iron
(if serum ferritin < 50 g/L)

Zaleplon
Pramipexole
Ropinerole
Levodopa /
Carbidopa
Temazepam
Clonazepam
Zolpidem
Zaleplon

Dopamine agonists
Levodopa / carbidopa
(not first line)
BZDRAs

Weight loss
Avoid alcohol and sedatives

May be a sign of sleep apnea

Appliances to prevent back sleeping

Laser surgery
Cognitive biological therapy
Interpersonal therapy
Psychodynamic therapy
Electroconvulsive therapy
80 - 90%
Transcranial
remission rate
Magnetic
50 - 80%
Stimulation
relapse rate
Vagal nerve stimulation
Deep brain stimulation
Lightbox therapy

Other medical conditions,

medications, substance use, bipolar
disorder, or psychotic disorders need
to be R/O first.

Most likely in those with past personal and family

histories of major depressive episodes
Similar personality characteristics, comorbidity
patterns, and chronicity risks recurrence as nonbereavement-related major depressive episodes

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Premenstrual
Dysphoric
Disorder

Cause

Signs and Symptoms

Depressive disorder that

accompanies the
menstrual cycle

5 affective symptoms that emerge in the week

prior to menses which quickly dissipate with the
onset of menses
Documented
Present in all menstrual
prospectively for 2
cycles in the past year
menstrual cycles
5 symptoms in the
final week before onset
Criterion A
Near-absent in the week
post-menses
Lability
Criterion B
Irritability / anger /
( 1 symptoms)
conflicts
Anxiety / tension
Anhedonia
Impairment
Anergia
Criteron C
Significant appetite
( 1 symptoms to reach
change
a total of 5 with
Sleep disturbance
Criterion B)
Feeling overwhelmed or
out of control
Peripheral symptoms
Depression that persists for 2 years
( 1 year in children / adolescents)

Dysthymia

Persistent Depressive
Disorder

No episodes of major
depression during the
last 2 years

Symptoms have not

resolved for
2 months at a time
Appetitie
Insomnia / hypersomnia

Depressed with
2 Symptoms

Fatigue or energy
Self-esteem
Indecisiveness /
concentration
Hopelessness

History of a manic episode which is usually

accompanied by other types of mood episodes
1 manic episode

Bipolar
Disorder

Mental illness
characterized by
episodes of mania usually
alternating with episodes
of depression

Bipolar I Disorder

Insufficient or
unnecessary MDE
1 Hypomanic episode

Bipolar II Disorder
1 MDE

Cyclothymic Disorder

Test

Laboratory
Result

Treatment

Medications

Other

Daily

SSRIs

Luteal-phase

OCP for anovulation

Lifetime prevalence = 6%
Year prevalence = 0.5% with 1.5% for
MDD
Overlapping diagnosis of MDD is now
allowed.
Never been manic, hypomanic, or
cyclothymic
Dysthymia Specifiers
Early onset (< 21 years old)
Late onset ( 21 years old)
With pure dysthmic syndrome

Need to R/O schizophrenic disorders,

substance abuse (especially
stimulants), medication effects, or
medical conditions
Specifiers
Anxious distress
Mixed features
Rapid cycling (4 mood episodes in 12
months)
With melancholic features
With atypical features

2 years of subsyndromal
depression +
subsyndromal
hypomania

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Cause

Signs and Symptoms

3 of symptoms must be present or 4 of
symptoms if mood is only irritable

Manic Episode

Period of abnormality
and continual irritability,
expansive or elevated
mood which lasts
1 week

Grandiosity

Need for sleep

Excessive or pressured
speech

Racing thoughts
(subjective) or flight of
ideas (objective)

Distractibility

Goal-directed activity

Impulsivity or excessive involvement in pleasurable

or dangerous activities
Marked impairment of
functioning

Bipolar II
Disorder

Characterized by at least 1 episode of

hypomania and at least 1 episode of
major depression

Cyclothymic
Disorder

2 years of fluctuating
mood (1 year in children
in adolescents)

Suicide

Psychoactive
Substance

Killing oneself

Substances that affect

the mind

Not caused by other

factors or conditions

History of a major depressive episode and a

hypomanic episode but never has had a maniac
episode
Hypomanic symptoms
(but not episodes)
Symptoms the time
and no 2 months
symptom-free

Test

Laboratory
Result

Treatment

Medications

Other
If hospitalization is necessary, it is
automatically considered mania.
Hypomania
Less severity mania 4 days and
clearly different from the usual
nondepressed mood
No significant functional impairment
DIGFAST
Distractibility
Impulsivity
Grandiosity
Flight of ideas
Activity ()
Sleep ( need)
Talkativeness
Need to R/O schizophrenic disorders,
substance use, medication effects, or
medical conditions.

Dysthymic symptoms
(but no MDEs)
No manic /
hypomanic episodes
No depressive episodes

Important Risk Factors

(more likely to
Recent Suicide Attempt
complete)
White race
Access to Firearm
Native American
Presence of a
(more likely to
Suicide Note
attempt)
Medical Risk Factors
Seizure disorder
Multiple sclerosis
TBI
CVA
Illness with loss of
Dementia
mobility
Chronic pain
Cancer
Chronic Medical Issues
HIV
Caffeine
Nicotine
Alcohol
Cannabis
Cocaine
Amphetamine
Stimulants
MDMA
Cathinones
Heroin
Morphine
Opioids
Oxycodone
Hydrocodone
Benzos
Sedative-Hypnotics
Barbiturates
GHB
Hallucinogens
Tobacco
Solvents
Inhalants
Aerosol propellants

30 - 45% of suicide victims give no

warning.
Protective Factors
Pregnancy
Sense of coping skills and social
supports
Religiosity
Positive therapeutic relationship
Assessment of Suicide Risk
Suicidal ideation
Suicide plans
Purpose of suicide
Potential for homicide
Spectrum of Substance Use
Abstinence
Moderate use
"At-risk" or "hazardous" use
Mild use disorder
Moderate-severe use disorder
At-Risk Drinking
> 14 drinks / week and > 4 drinks /
occasion for
> 7 drinks / week and > 3 drinks /
occasion for or > 65 years old

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Substance
Intoxication

Cause

Signs and Symptoms

Reversible substancespecific syndrome due to

recent ingestion or
exposure to a substance

Maladaptive behavioral or psychological changes

developing during or shortly after use of the
substance

Alcohol
Intoxication

Excessive intake of
alcohol

Benzodiazepine
Intoxication

Ingestion of a large amount

of benzodiazepine

Opioid
Intoxication

Excessive intake of
opioids

Stimulant
Intoxication

Ingestion of a large
amount of stimulants

Cannabis
Intoxication

Smoked pot

Hallucinogen
Intoxication

Excessive intake of
hallucinogens

Not due to general medical condition or better

accounted for by another mental disorder

Test

Laboratory
Result

Treatment

Medications

Total abstinence from all substances

Assess withdrawal risk and psychiatric
/ medical co-morbity
Refer for eval / treatment in an
organized SUD treatment program
Discuss anti-relapse medications

Other
Schedule follow-ups to assess
adherence and support recovery

Inappropriate sexual or
Mood lability
aggressive behavior
Impaired judgement
1 of the Following
Slurred speech
Incoordination
Unsteady gait
Nystagmus
Impaired attention or
Stupor or coma
memory
Clinical features
identical to alcohol
intoxications

Respiratory depression
(when combined with
other CNS depressants)

Apathy
Dysphoria
Psychomotor agitation /
retardation
Impaired judgement
Drowsiness or coma
Pupillary Constriction
Slurred speech
with 1 of...
Impaired attention /
memory
2 Symptoms must be present
Tachy- / bradycardia
Dilated pupils
BP
Perspiration / chills
Nausea / vomiting
Weight loss
Psychomotor agitation /
Muscle weakness
retardation
Respiratory depression
Chest pain
Cardiac arrhythmias
Confusion
Seizures
Dyskinesias
Dystonias
Euphoria
Impaired coordination /
Anxiety
judgement
Sensation of slowed
time
Social withdrawl
2 Physical Symptoms
Munchies
Dry mouth
Conjunctival injection
Tachycardia
Transient psychosis (possible)
Anxiety
Depression
Ideas of reference
Paranoia
Fear of
Impaired judgement
"losing one's mind"
Intensification of
Depersonalization
perceptions
Derealization
Illusions
Hallcuinations
Synesthesias
Mydriasis
Tachycardia
HTN
Sweating
Palpitations
Blurred vision
Tremor
Incoordination
Initial Eupohria
Followed By

Associated Increased Risks

Falls and fractures in elderly
Motor vechile accidents
Cognitive impairment
Risk of lethal respiratory depression
Complications
Physical dependence
Gonadal suppression
Sedation / incoordination
Respiratory depression (can lead to
fatal overdose)

Adverse reactions are more common

with synthetics and unintentional
overdose with oral preparations.

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Alcohol
Withdrawl

Cause

Triggered by abrupt
cessation or reduction of
intake in dependent
individuals

Signs and Symptoms

Test

Laboratory
Result

Transient hallucinations

Psychomotor agitation

Generalized tonic-clonic seizures

Alcohol Withdrawl
Delirium

Delirium developing 24 - 48 hours

after cessation or reduciton of
alcohol intake

Benzodiazepine
Withdrawl

Physiological processes
that occur after
benzodiazepine
intoxication

Opioid
Withdrawl

Cessation or reduction of
opioid intake

Stimulant
Withdrawl

Physiological processes
that occur after stimulant
intoxication

Cannabis
Withdrawl

Cessation of excess
cannabis use

Alcohol

Vivid visual or tactile

hallucination

Treatment

Medications

Benzodiazepines
Thiamine (parenteral)
Vital sign monitoring
CIWA to track withdrawal symptoms
Reduce stimulation
Support / reassurance
Assess / treat medical illness
Inpatient or outpatient setting
Opportunity to engage in ongoing
treatment

Onset 12 - 24 hours after

Peak intensity at
last drink
24 - 48 hours
2 Symptoms
Sweating
Autonomic Hyperactivity
> 100 bpm
Hand tremor
Insomnia
Nausea / vomiting
Anxiety

Other
Medicated via the locus ceruleus

10 - 15% mortality

Severe autonomic
instability

Withdrawl seizure
4 - 7 day duration
(possibly)
2 Symptoms

Timing of onset depends on the

ingested drug's half-life.

Autonomic hyperactivity Transient hallucinations

Hand tremor
Insomnia
Nausea / vomiting
Psychomotor agitation
Anxiety
Grand mal seizures
3 Symptoms
Dysphoric mood
Nausea / vomiting
Muscle aches

Lacrimation / rhinorrhea

Diarrhea
Yawning
Fever
Insomnia
Pupillary dilatation
Piloerection
Dysphoric mood with 2 symptoms
Vivid, unpleasant
Fatigue
dreams
Insomnia / hypersomnia

Develops within hours to days of

cessation
Non-lethal apart from risk of selfharm

Appetitie

Psychomotor retardation / agitation

3 Developing symptoms within
1 week of cessation
Irritabilty / anger
Nervousness / anxiety

Suppresses glutamate
and norepinephrine and
enhances GABA
inhibition

Sleep difficulty

Appetite / weight loss

Restlessness

Depressed mood
Abdominal pain
Tremor
Physical Symptoms
Sweating
Fever / chills
Headache
Tremors
Excess Glutamate
Seizures
Tachycardia
Excess Norepinephrine
Hypertension
Sweating
Anxiety
Deficient GABA
Insomnia
Complications
Nervous
Cardiovascular
Gastrointestinal
Trauma
Reproductive
Pneumonia / TB

Replaced CAGE as
recommended
alcohol screen
Alcohol Use
As sensitive as
Disorders
CAGE for
Identification
detecting
Test
dependence
(AUDIT)
More sensitive for
detecting "at-risk"
drinking and
alcohol abuse

33% of suicides
50% of homicides
40% of MVA deaths
50% of domestic violence incidents
50% of trauma center cases
Positive AUDIT Scores
-4
60 years old - 8
> 60 years old - 4
AUDIT-C
AUDIT - consumption questions
Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Substance Use
Disorder

Cause

Problematic pattern of
substance use leading to
clinically significant
impairment or distress

Signs and Symptoms

Meets 2 of the 11 criteria within a
12-month period
Uses more than
Persistent desire /
intended
unsuccessful efforts to
Persistent desire /
cut down or control
unsuccessful efforts to
Craving for the
cut down or control
substance
Tolerance
Withdrawl
Excessive time devoted
Important relationships /
to obtaining, using, or
activities given up to use
recovering
Interpersonal problems Impaired role function
due to use
due to use
Continued use despite
Use that poses risk of
knowing it causes or
physical harm to self or
exacerbates physical or
other
psychological problems
Risk Factors
Genetics
Gender
Childhood abuse /
Impulsive temperament
neglect
Psychological trauma
Initiation at early age
Specific drug
Route of administration
characteristics
Availability / costs

Psychosis

Visual or Tactile

Suggest organic etiology

Associated with
temporal lobe pathology
Gustatory
Delusions
Paranoid
Grandiose
Religious
Nihilistic
Somatic
Behavior Abnormalities
Stereotypies
Catatonia
Affect Abnormalities
Blunted / flat
Bizarre
Incongruent with content
Disorganized, delusional,
Florid, Acute Psychosis
bizarre
Guarded, concealing
Covert Psychosis
paranoid delusions
Olfactory

Laboratory
Result

Treatment

Medications

Other
Severity
Mild - 2 - 3 positive criteria
Moderate - 4 - 5 positive criteria
Severe - 6 positive criteria
Remission
Early - No criteria met > 3 months
but < 12 months
Sustained - No cirteria met > 12
months
Exception - Craving may be present
in remission
For prescribed drugs such as opioids
or benzos, tolerance and withdrawl
do not count toward diagnosis.
Mechanisms of Genetic Risk
Drug reinforcement (euphoria)
Adverse effects
Adverse effect (protective
Deficit in innate reward pathways
Impulsivity, novelty-seeking
Abnormal stress response system
Mood dysregulation

Social and cultural milieu

Psychiatric disorders
Disorganized Thinking ("Thought Disorder")
Loosening of
Tangentiality
associations
Poverty of thought
Thought blocking
Abnormal Speech
Poverty of speech
Mutism
Echolalia
Neologisms
Clang associations
Verbigeration
Hallucinations
Common in
Auditory
schizophrenia

Severe breakdown of
mental functioning with
impaired contact with
reality

Test

Schneider's "First Rank Symptoms"

for Delusions
Thought insertion
Thought withdrawl
Thought broadcasting
Ability to read others' thoughts
Ideas of reference (ex: radio, TV)
Covert psychotics' delusions may
emerge with open-ended questioning
in a non-directive style.
Social Factors
"Downward drift" to lower
socioeconomic status
Family dysfunction in response to
illness
Problems with work or school
Disability income or financial

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Cause

SubstanceInduced
Psychosis

Psychosis due to
ingestion or excessive
consumption of a
substance

Psychosis Due to General

Medical Condition

Psychosis secondary to a
medical condition

Psychosis Due to
Primary Psychiatric
Disorders

Psychosis vs.
Delirium

Psychosis secondary to a
psychiatric disorder

Difference between
psychosis and delirium

Psychosis and
Psychosis in the setting of
Alzheimer's disease
Alzheimer's Disease

Brief Psychotic
Disorders

Psychosis that lasts at

least 1 day but less than
1 month

Schizophreniform
Disorder

Schizophrenic-like mental
disorder

Signs and Symptoms

Alcohol intoxication /
withdrawl
Synthetic cannabinoids
Hallucinogens
Steroids
Encephalitis
Brain tumor

Disorder characterized by
non-bizzare delusions

Laboratory
Result

Treatment

Medications

Other

First episode deserves a thorough

neurological work-up.

Hyper- / hypothyroidism Partial complex seizures

Mood disorders
Schizoaffective disorder
Delirium / dementia
Schizotypical personality
Brief psychotic disorder
disorder
Schizophreniform
Delusional disorder
disorder
PTSD
Disorientation and
Memory Impairment

Strongly suggests
delirium

Tactile and Visual

Hallucinations

Suggest psychosis

Paranoid delusions
(10 - 20%)
Hallucinations
(10 - 20%)

Misidentification
delusions (10 - 20%)

Followed by full return

to premorbid
functioning
More common in people with personality disorder
and limited coping abilities
Often in response to
severe stressor

Features identical to
schizophrenia

Non-Bizarre Delusions

Delusional
Disorder

Cocaine / amphetamine
intoxication
Benzodiazepine
withdrawal
Phencyclidine /
ketamine
Anticholinergics
CNS lupus
Porphyria

Test

Limited functional
impairment

Duration < 6 months

Functional deterioration
is not required
Jealous
Erotomanic
Somatic
Persecutory
Grandiose

Always assess congitive function

(orientation, memory, calculation,
speech) in evaluation of psychosis.
Delirium may involve all types of
psychotic features.

9% of initial psychotic episodes

recover fully
ultimately fulfill criteria for
schizophrenia
Must never have met criteria for
schizophrenia

Behavior is not obviously

odd or bizarre

Hallucinations directly related to the delusion

(possible)

Schizoaffective
Disorder

At the border between

mood disorder and
schizophrenia

Psychotic symptoms
occur during major
mood episodes

Persist during extended

periods outside the
mood episodes

Unclear if this is truly a distinct

disorder

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Cause

Signs and Symptoms

2 Symptoms During a
1-Month Period

Schizophrenia

Somatic
Symptom
Disorder

Chronic, often severely

disabling, lifelong
primary psychotic illness
possibly due to abnormal
neuronal organization in
the hippocampus

Excessive thoughts,
feelings, or behaviors
related to health
concerns or their
symptoms

Social / occupational
dysfunction

Delusions
Hallucinations
Disorganized speech
Grossly disorganized /
catatonic behavior
Negative symptoms

Hypochondriasis

Conversion
Disorder

Functional Neurological
Symptom Disorder

Treatment

Positive Symptoms
Hallucinations
Delusions
Disorganized speech /
Agitation
behaviors
Responsive to antipsychotic medications
Negative Symptoms
Avolition
Withdrawl / autism
Anhedonia
Blunted affect
Poverty of speech
May respond better to
Less responsive to
atypical antipsychotics
medication
Excessive worry about
the seriousness of
symptoms

Persistent anxiety about

health or symptoms

Medications

Comprehensive and biopsychosocial

therapy
Typically outpatient treatment
Safety
Goals

Stabilization

Not due to schizoaffective, mood, or substance

use disorder or another general medical condition

Recovery

Significant disruption of
daily life

Preoccupation with
having / acquiring
serious illness
Level of anxiety
about health
Illness preoccupation
6 months

Acute psychosis
Hospitalization
Criteria

Severe,
uncontrolled
substance use
May require
involuntary
commitment

Psychosocial rehabilitation

Regularly scheduled appointments

Pharmacologic
Treatment

SSRIs
SNRIs

Somatic symptoms are

not present or mild

CBT
Improve coping with symptoms
Schedule regular visits

Excessive health-related
behaviors or
maladaptive avoidence

1 Altered Motor / Sensory Function

Weakness
Paralysis
Deafness
Blindness
Pseudoseizures
Tics
Sensor disturbances
Aphonia
Symptom / deficit is not
better explained by
Clinical findings show
another medical /
incompatibility between
mental disorder
symptoms and
recognized neurological
Causes signifcant
/ medical condtions
distress or impairment

Other
Affects 1% of population
Reduces life expentancy by 20 - 30%
10 - 15% will commit suicide
Etiologies
Genetics
Pre- / perinatal insult
Birth in late winter / early spring
(possible viral illness?)
"Neurodevelopmental" model

Suicidality /
homicidality

TCAs
Excessive time and
energy devoted to
symptoms or health
concerns

Not better explained by other mental disorder

Altered voluntary motor

or sensory function in the
absence of clinical
findings

Laboratory
Result

6 month duration

Symptoms often persist into old age

Illness Anxiety
Disorder

Test

Avoid unnecessary diagnostic testing

Cognitive-behavioral therapy
(first line)
SSRIs (if patient unwilling to have
therapy)
Labeling and explaining the patient's
disorder (first line)

Cognitive-behavioral therapy
physical therapy
Antidepressants

Although any 1 somatic symptom

may not be continuously present, the
state of being symptomatic is
persistent (typically > 6 months).
Risk and Prognostic Factors
Negative affectivity
Comorbid anxiety / depression
Educational / SE status
, older age
History of sexual / physical abuse
Concurrent chronic medical illness
Biological vulnerabilty to pain
Sensitivity to bodily sensations
Distress emanates from patient fears
about what symptoms mean.
3 - 8% 6-month / 1 year prevalence
May be precipitated by major stress,
childhood abuse, or serious illness
May be a chronic and disabling
disorder

Specification
Symptom type
Acute (< 6 months) or persistent
Psychological stressor
Symptoms are not deliberately
produced.
5% of neurologist referrals
Occurs at all ages
Most common in adult

Hypnosis
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Clinical Medicine
Condition / Disease

Cause

Signs and Symptoms

Test

Laboratory
Result

Treatment

Medications

Falsification of physical or
Presents self or another Deceptive behavior is
psychological signs or symptoms, or to others as ill, impaired, evident in the absence
induction of injury or disease,
or injured
of external rewards
associated with identified deception
Not explained by another mental disorder

Factitious
Disorder

Muchausen Syndrome
Direct onto oneself

Medical Child Abuse or

Muchanausen Syndrome
By Proxy
Directed onto a child or another
person

Malingering

Production or
exaggeration of illness for
external gain

Methods of Deception
Injection of infectious
material
Tampering with IVs,
thermometers, or
specimens

Possible Goals

Altruism
Anticipation
Humor

Personality
Disorder

Use of medicines to
induce symptoms
Self-phlebotomy and
ingestion of blood

Patient is fully aware of motivation

Mature Defenses

Enduring pattern, that is

inflexible and pervasive,
of inner experience and
behavior that deviates
maredly from the
expectations of the
individual's culture

Confabulating history

To get drugs
Avoid work
Avoid military duty
For legal case

Sublimation

Suppression
Affiliation
Neurotic Defenses
Displacement
Externalization
Intellectualization
Dissociation

Repression
Reaction Formation

Appropriate, realistic
ways for dealing with
painful feelings
Meet the needs of
others
"Priming" oneself to
experience appropriate
emotions
Emphasize amusing
aspects of the situation
Channeling
maladapative feelings
into socially acceptable
behavior
Intentionally avoiding to
think about problems
Turning to other for help
and support
More frequently used
in PD
Transferring (-) feelings
between objects
Blaming other but
not onself
Rationalizing with wrong
explanations
Dealing with stress with
a breakdown of a mental
aspect
Expelling disturbing
thoughts, wishes, or
experiences
Substituting opposed
feelings

Other
Specify single episode or recurrent
episodes
Unconscious reward is attention
Onset often follow hospitalization
Factitious disorder imposed on
another is a crime and must be
reported.
Leads to iatrogenic injury and
accidental death
10% mortality from FD imposed on
another
Victims suffer long-term
psychological and developmental
problems

Make therapeutic decisions based on

objective evidence

Not a DSM diagnosis

Not likely to cause harm as in
factitious disease
Document presence or absence of
objective findings
Trait
Building blocks of personality
Personality
Overall pattern (sum total) of a
person's individual traits
Categorical Model (DSM-IV)
PDs are distinct entities from
normalcy
Dimensional Model (DSM-IV)
PD are overlapping entities that are
not distinct from normalcy
Immature Defenses
Denial
Autistic (schizoid) fantasy
Passive-aggressive behavior
Acting out
Splitting
Projection
Projective identification
Pattern of PD is manifested in two
or more areas of congition,
affectivity, interpersonal
functioning, and impulse control.

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Clusters of
Personality
Disorders

Paranoid

Schizoid

Schizotypal

Antisocial

Cause

Groups of different
personality types in PD

Pervasive distrust /
suspiciousness and
interprets other's
motives as malevolent

Pervasive pattern of
detachment from social
relationships and have
restricted ranges of
emotional expression

Acute discomfort in close

relationships with
cognitive distortions (but
not as severe as
hallucinations) and
eccentric behavior

Disregard for / violation

of the rights of others

Signs and Symptoms

Odd, eccentric
Cluster A
("weirdos")
Paranoid
Schizoid
Schizotypal
Dramatic, emotional,
Cluster B
erratic ("jerks")
Antisocial
Borderline
Histrionic
Narcissistic
Anxious, fearful
Cluster C
("losers")
Avoidant
Dependent
Obsessive-compulsive
"People are untrustworthy, and they try to take
advantage of me."
Appears guarded and
Answers questions
suspicious
reluctantly
4 of the Following Characteristics (SUSPECT)
Spousal infidelity
Perceives attacks
Unforgiving
Enemies
Suspects exploitation by
Confides never
others
Threats in benign
"I prefer to be alone, and my world is
completely empty."
Seems preoccupied in
Appears shy and aloof
his / her own world
4 of the Following Characteristics (DISTANT)
Absence of close friends
Detached affect
or confidants
Indifferent
Sexual experience is of Neither desires or enjoys
little interest
close relations
Tasks performed
Takes pleasure in few, if
solitarily
any, activities
"I'd like to have friends, but it's hard because
people find me pretty strange."
Describes strange ideas
Appears odd in any
that border on
number of ways
psychiotic
4 of the Following (ME PECULIAR)
Magical thinking or odd
Unusual thinking /
beliefs
speech
Experiences unusual
Lacks close friends
perceptions
Ideas of reference
Anxiety in social
Paranoid ideation
Eccentric behavior /
situations
appearance
Rule out psychotic or
pervasive developmental
Constricted affect
disorder
"I love taking advantage of other people, and I
never feel bad about it."
Appear cocky and
Protrays oneself as
arrogant
innocent and a victim
3 of the Following Since 15 YO (CORRUPT)
Conformity (lacking)
Remose lacking
Obligations ignored
Underhanded
Reckless disregard for
Planning insufficient
other's safety
Temper

Test

Laboratory
Result

Treatment

Medications

Other

Cluster A
Psychotherapy may work, but patients
often refuse treatment due to lack of
motivation or distrust in therapist's
intentions

Cluster A
Patients see little value in therapeutic
relationships

Writing assignments or exercises to

"break the ice" may help establish
therapeutic realtionship.
Cluster A

Patients typically do not present for

treatment voluntarily (possibly
brought in by families)

Patients are not interested in

establishing therapeutic relationship

Cluster B
Usually have an extensive legal
history
SSRIs or other medications (possibly
helpful for aggression and irritability)

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Borderline

Histrionic

Narcissistic

Avoidant

Cause

Instability in
interpersonal
relationships, self image,
and affects with marked
impulsivity

Excessive emotionality
and attention seeking

Grandiosity (in fantasy or

behavior), need for
admiration, and lack of
empathy

Social inhibition, feelings

of inadequacy, and
hypersensitivity to
negative evaluation

Signs and Symptoms

"I need people desperately, and when they reject
me, I fall apart completely. I hate them, and I get
suicidal."
Alternatively idealize
May be emotionally
and devalue the
labile
interviewer
5 of the Following (I DESPAIRR)
Identity disturbance
Abandoment fears
Disordered, unstable
Impulsivity in 2 areas
affect
that is potentially
self-damaging
Emptiness (chronic)
Rage (inappropriate)
Self-injurious or suicidal
Relationship instability
Paranoid ideation
"I'm quiet, emotional, and sexual charming person,
and I need to be the center of attention."
Rapidly and dramatically
Flamboyantly and
self-revealing to the
seductively groomed
point of
and dressed
inappropriateness
5 of the Following (PRAISE ME)
Provocative behavior
Influenced easily
Relationships more
Style of speech
intimate than they
Emotions
really are
Made up (appearance)
Attention
Emotions exaggerated
"I'm an extremely talented and special person,
better than most people, and yet I get angry and
depressed because people don't recognize how
great I am."
Appear haughty and
excessively critical of
your credentials or
experience

May begin interview

with angry complaints
about how unfairly other
have treated him / her

5 of the Following (SPEEECIAL)

Special
Entitlement
Preoccupied with
Conceited
fantasies
Interpersonal
exploitation
Envious
Excessive admiration
Arrogant
required
Lacks empathy
"I'm really afraid of what people will think of me,
so I avoid making new friends to
prevent rejection."
Appear shy and nervous Reluctant to open up at
but is eager to make
first but may become
contact
quiet self-revealing
4 of the Following (CRINGES)
Certainity of being liked
Gets around
before attempting
occupational activities
Embarrassment prevents
Rejection
Intimate relationships
new activities
avoided
Self viewed as
unappealing or inept
New ones avoided

Test

Laboratory
Result

Treatment

Long-Term
Psychotherapy

Medications

Dialectical
behavioral therapy

Other
Cluster B
10% die by suicide

Group therapy
Lability
Medications for
Certain Symptoms

Dysphoria
Paranoid thinking
Impulsivity
Cluster B
Psychopathology is less severe than
antisocial or borderline PDs and may
respond better to psychotherapy.

Psychotherapy focused on gaining

insight into their true feelings and
learning to achieve greater intimacy
with others.

Cluster B

Psychotherapy (alternating between

confrontation and support of fragile
self-esteem)

Cluster C

SSRIs or blockers (for anxiety)

Supportive psychotherapy then shift

to cognitive / behavioral interventions

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Dependent

ObsessiveCompulsive

Cause

Submissive and clinging

behavior related to an
excessive need to be
cared for by others

Preoccupation with
orderliness,
perfectionism, and
control, at the expense of
flexibility, openness, and
efficiency

Signs and Symptoms

"I'm pretty passive and dependent on others for
direction, and I go far out of my way not to
displease people who are important to me."
Seem to make extraordinary attempts to
immediately gain your affection
5 of the Following Starting By Early Childhood
(RELIANCE)
Reassurance required
Alone
for decisions
Nurturance
Expressing disagreement
Companionship shought
is difficult
urgently when close
Life responsibilities
relationships end
assumed by others
Initiating projects is
Exaggerated fears of
difficult
being left to care for self
"I'm a perfectionist. I keep lists. I drive myself
hard, and I'm very serious about life."
Tend to give an
Meticulously groomed excessive detailed and
and dressed
accurate account of
his / her symptoms
4 of the Following (LAW FIRM)
Inflexible, scrupulous,
Loses point of activity
Ability to complete tasks overly conscientious
is compromised
Reluctant to delegate
Worthless objects
Miserly spending style
Friendships excluded
due to preoccupation
Stubborn
Panic attacks

Poor sleep, fatigue, and

difficulty relaxing

Test

Laboratory
Result

Treatment

Medications

Avoid therapist becoming overly

protective of patient and patient
becoming overly dependent on
therapist

Cluster C

Psychotherapy centered around

helping them reconginve how they
"feel," not just intellectually by
emotionally, as well as to question
their need to be "in control."

Medications
Cognitive behavioral therapy (see
PowerPoint slides for more info)
Combination therapy

Generalized
Anxiety
Disorder

Distorted thinking, stress,

physical symptoms and
avoidance increase and
create significant
problems in daily life

Headache and pain in

Repeated visits to health
the neck, shoulder, and
professionals
back
Major depression
(30 - 50%)
Common Comorbidities

Panic disorder (25%)

Substance abuse

Phobia

Marked fear or anxiety

about specific object or
situation

Object / situation
actively avoided or
endured with intense
fear / anxiety

Object / situation
always provokes
immediate
fear / anxiety

Fear / anxiety /
avoidance persists
6 months

Fear / anxiety out of

proportion to actual
danger posed

Other
Cluster C

Feel the difference

between tension
and relaxation
Tense 7 seconds,
relax 15
Relaxation
Training

Specific muscle
groups to learn
the procedure
Group them as
skill increases
Use 10-second
relaxation cue

SSRIs

Anxiety
Emotional and/or physiological
resposnt to known and/or unknown
causes that may range from a normal
raction to extreme dysfunction
Fear and Anxiety Pathway
Amygdala - Directs central and
autonomic NS to trigger alarm and
stores memory of threat
Hypothalamus - Triggers pituitary
gland and NS
Pituitary - Secretes hormones to
influene thyroid and adrenal system
Hippocampus - Cements response to
threat into long-term memory
4.1 - 6.6% lifetime prevalence

Causes significant distress or impairment

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Social Anxiety
Disorder

Agoraphobia

Panic Disorder

ObsessiveCompulsive
Disorder

Cause

Marked fear or anxiety

about social situations,
exposed to scrutiny by
others, being observed,
or performing in front of
others

Fear of situations where

escape from bad things
is difficult

Discrete period of intense

fear or discomfort

Anxiety disorder
characterized by intrusive
thoughts that produce
uneasiness,
apprehension, fear, or
worry

Signs and Symptoms

Test

Laboratory
Result

Treatment

Persists 6 months

Other
> 10% lifetime prevalence
Majority of diagnoses aer made
during childhood or early
adolescence.
SAD is often seen in conjunction with
major depressive disorders, other
anxiety disorders, and substance use
disorders.
The "performance only" specifier is
given if anxiety is specific to speaking
or performing in public.

Social situations always

provoke anxiety
Fear actions will show
anxiety and be viewed
negatively

Medications

Social situations are

avoided or endured with
intense fear / anxiety
Causes significant
distress

Happens almost every

time an individual is
Avoidance of the event
exposed to the situation
or situation
or event
Fear / Anxiety About 2 of the Following
Being open spaces
Using public
transportation
Being in enclosed spaces
Standing in line or being
Being outside of the
in a crowd
home alone
4 of the Following Symptoms Developing
Abruptly and Reached a Peak Within 10 Minutes
Palpitations, pounding
Sweating
heart, or tachycardia
Trembling / shaking
Sensations of SOB or
Feeling of choking
smothering
Chest pain / discomfort
Feeling dizzy, unsteady,
Nausea / vomiting
Derealization /
lightheaded, or fainting
depersonalization
Fear of losing control or
going crazy
Fear of dying
Paresthesias
Chills / hot flushes
Recurrent and
Symptoms occurs
unexpected panic
1 month
Significant maladaptive change in behavior related
to the attacks
Obsessions are Defined By
Recurrent and persistent
Attempts to ignore or
unwanted or intrusive
neutralize thoughts or
throughts, urges which
urges with some other
causes marked anxiety
thought / action
or distress
Compulsions are Defined By
Behavior / mental acts
Repetitive behaviors or
simed at preventing /
mental acts feels driven
reducing anxiety or
to perform in response
distress not in a
to obession
realistic way
Obsessions or compulsions are time consuming (
1 hr / day) or cause clinically significant distress
Lifetime history of
Lifetime history of a
another anxiety disorder
mood disorder (63%)
(76%)
Obsessive-compulsive
History of a tic disorder
personality disorder
(29%)
(23 - 32%)

SSRI

Panic attacks are not a mental

disorder.
11.2% annual prevalence
Other Comorbities
Depression
Other anxiety disorders
Substance abuse

CBT

Lifestyle changes

1.2% year prevalence

2.3% lifetime prevalence
> in adulthood
> in childhood
Specifiers
Good / fair insight
Poor insight
Absent insight / delusional beliefs

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Cause

Signs and Symptoms

Test

Laboratory
Result

Treatment

Intrusion

Posttraumatic
Stress Disorder

Develops after a person

is exposed to one or
more traumatic events,
such as sexual assault,
serious injury, or the
threat of death

Criteria A
Criteria B
Exposure to actual or
Recurrent, involuntary,
threatened death,
and intrusive distressing
serious injury, or sexual
memories
violence
Recurrent dreams
Directly experienced,
related to trauma
witnessing, learning it
Dissociated reactions
happened to a loved
Marked reactions to
one, or being exposed to cues that resemble an
details of the event
aspect of the trauma
Avoidance (Criteria C)
Avoidance of distressing
memories, thoughts, or
feelings related to event

Avoidance external
reminders that may
arouse memories

Negative alteration in
cognitions and mood
associated with
traumatic event

Marked alterations in
arousal and reactivity
associated with
traumatic events

Medications

Cognitive
restructuring

Cognitive
Behavioral
Therapy

Restructures
catastrophic
thinking

Other
DREAMS Mnemonic
Detachment / dissociation
Reliving / re-experiencing the trauma
Event had emotional effects
Avoidance
Months in duration
Sympathetic hyperactivity or hyper-

Anxiety
management
strategies

Relaxation
Training

Slow breathing
Muscle relaxation

Behavioral exposure

Supportive therapy

Duration of disturbance > 1 month

Exposure to actual or threatened death, serious
injury, or sexual violence in 1 of the following:
(Criteria A)

Acute Stress
Disorder

Adjustment
Disorder

Alcohol
Metabolism

Psychological condition
arising in response to a
terrifying or traumatic
event

Individual is unable to
adjust to or cope with a
particular stressor

Directly experiencing the Witnessing the event as

trauma
it occurred to others
Experiencing repeated or
extreme exposure to
aversive details of
trauma
Presence of 9 of the following symptoms from
any of the 5 categories: (Criteria B)
Intrusion
Negative mood
Dissociation
Avoidance
Arousal
Development of symptoms to identifiable
stressor(s) occurring 3 months of stressor onset
Symptoms or behaviors clinically significant due to
1 of the following:
Marked distress that is
Significant impairment in
out of proportion to the
daily life
stressor
Learning events
occurred to close friend
/ family

Symptoms do not
represent normal
bereavement

Symptoms do not
persist 6 months once
stressor is removed

Ethanol distributes in water phase of both plasma

and erythrocytes

What happens to alcohol

once it is ingested

Specifiers
With depressed mood
With anxiety
With mixed anxiety and depressed
mood
With disturbance of conduct
With mixed disturbance of emotions
and conduct
Unspecified

Water content of RBCs < plasma, so alcohol

concentrations are > 12% than whole blood
Alcohol levels are usually measured on whole
blood specimens for uniformity

Partition Ratio
Breath
1
Urine
1.3
Blood
2100 (average)
Alcohol
Detects all
Dehydrogenas
alcohols
Gas Liquid
Differentiates
Chromatograp
alcohol types

US Legal Limits
0.08% ( 80 mg/dL) for public
0.01% for public transportation
workers

Alcohol Half Life

-15 - 18 mg / 100mL / hour
Detection window depend on peak
blood level generally 1.5 - 12 hours in
blood and an additional 1 - 2 hours in
urine.

0.04% for pilots

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Cause

Signs and Symptoms

Chronic
Alcohol Use

Effects of chronic alcohol

use on the laboratory
work

Lots and lots of alcohol over a long time

Laboratory
Result
Macrocytosis
CBC
Anemia
Thombocytopenia
Albumin
BMP
Protein
AST
HIGH
ALT
HIGH
GGT
HIGH
CDT
HIGH
Bilirubin
HIGH
Test

Treatment

Medications

Other

Acute treatment issue in Chronic treatment issue

ER / hospital setting
in outpatient setting

Drug Screening
/ Testing

Urine Drug
Testing

When it is a good time to

screen for drugs

Workplace
Military
Athletics
Criminal situations
Amphetamine / Metamphetamine
Half-Life
7 - 34 hours
Detection Period
2 - 3 days
Detection Threshold
1,000 ng / mL
Benzodiazepines
Half-Life
4 hours - 4 day
Detection Period
Up to 4 weeks
Detection Threshold
200 ng / mL
Cocaine
Half-Life
0.5 - 1.5 hours
Detection Period
2 - 4 hours
Detection Threshold
300 ng / mL
Opiates (Heroin)
Half-Life
1 - 1.5 hours
Detection Period
"Minutes"
Detection Threshold
300 ng / mL
THC
Half-Life
7 hours
Detection Period
Up to 1 month
Detection Threshold
50 ng / mL
Other Indications

Detection limits of drugs

in urine samples

Orthorexia
Nervous

Sub-group of athletes with eating

disorder symptoms
Individuals who take their concerns
about eating "healthy" foods to
dangerous and/or obsessive
extremes

Diabulimia

Manipulation of insulin by diabetics

for the purpose of losing weight

Drunkorexia

Self-imposed starvation or bingeing

and purging, combined with
alcohol use

Anorexia Athletica

Establishing cause of death

Specimen Types
Breath
Blood
Urine
Sweat
Gastric aspirate
Hair
Meconium / feces
Nails (toe / finger)

Group of unofficial terms

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Eating Disorder

Cause

Abnormal eating habits

that may involve either
insufficient or excessive
food intake to the
detriment of an
individual's physical and
mental health

Signs and Symptoms

Hiding food

Disappearance of food

Irregular eating patterns

Compulsive exercise

Instrinsic fear of food and

weight gain

Binge-Purge
Cycle

Continuous cycle seen in

eating disorders

Bulimia
Nervosa

Bingeing followed by
purging or non-purging
compensatory behavior

Intoxicated
Patient in
Clinic or ED

What to do when an
intoxicated patient tries
to drive home

Alcohol
Detoxification

Treating alcohol abuse

Laboratory
Result

Treatment

Medications

Intentional, individualized nutrition

progression
Medical acute
crisis
Inpatient

Sneaking away to
bathroom after meals

Yellowing teeth /
tooth decay

Weight fluctuations

Swollen parotids

Residential
Levels of Care

Partial
hospitalization
Intensive
outpatient
Outpatient

Scarring on knuckles

Anorexia
Nervosa

Test

Temperament
Harm-avoidant
Neurotic
Obsessional
Anxious
Reward dependent
Perfectionistic
Novelty seeking
Abysmal self-esteem

Strict dieting
Tension and cravings

Shame and digust

Binge eating

Purging to avoid weight loss

Temperament
Novelty seeking
Quick-tempered
Excitable
Exploratory
Not risk-averse
Impulsive
Easily form emotional
Easily bored
attachment
High reward-dependence
Clinician has responsibilty to attempt to prevent
impaired driving.
Seek patient's cooperation to call for ride or wait
for BAC before driving
Be aware of local policy
(notification of police about impaired driver)
Alcohol breathalyzer is a useful instrument to have
in clinic
Inpatient Treatment
Outpatient Treatment
History of seizures or No history of seizures or
delirium
delirium
Unstable medically
Stable medical / psych
SI, HI, or pschosis
Can return for daily visits
Unstable environment
No support or
Social support
transportation
Safe transportation
Ambulatory detox is safe and effective for patients
meeting above criteria with a much lower
expense.

Treat the delusional fear

Other
Body Mass Index Classifications
Severely underweight - < 16.0
Underweight - 16.0 - 18.5
Normal - 18.5 - 25
Overweight - 25 - 30
Obese Class I - 30 - 35
Obese Class II - 35 - 40
Obese Class III - > 40
Types
Anorexia nervosa
Bulimia nervosa
Binge eating disorder
Avoidant / restrictive food intake
disorder
Other specified feeding or eating
disorder
Unspecified feeding or eating
disorder

See Eating Disorders

Risk of relapse doubles if patient is
discharged < 90% expected weight for
height

Goals of Treatment
Safety
Alleviate distress
Engagement into ongoing recovery

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Cause

Signs and Symptoms

FRAMES for Brief Intervention
Feedback
Specific hazards of
On specific adverse
drinking given this
effects resulting from
patient's health
this patient's drinking
concerns / problems

Test

Laboratory
Result

Treatment

Medications

Other
First step in making referral for
treatment of moderate-severe
alcohol use disorder.
15 minute initial session
1 or more follow-up sessions

Not a general litany of risks and warnings.

Brief Alcohol
Intervention

Stand-alone intervention
for at-risk and problem
drinkers (mild alcohol use
disorder)

Responsibility
Acknowledge the
Change cannot be
patient's autonomy, that
imposed by other
only he / she can make
With autonomy goes
the decision and take
responsibilty for
action
outcomes
Advice
Always advise
Be clear and specific
Abstinence or adhering abstinence and formal
to specific drinking limit
treatment support
(mild)
program (mod-severe)
Menu of Options
Offer a relevant menu of
Be prepared to
options
negotiate if the patient
(ex: outpatient, meds,
is unwilling to accept
rehab, etc)
Express Empathy
"I understand this is a
"I can see that it's hard
difficult issue to discuss."
for you"
Support Self-Efficacy
Support the patient's
Point out the patient's
sense that he / she is
strengths and past
capable of making a
successes as evidence
change

Clinical Institute
Withdrawal Assessment
(CIWA-Ar)

Easily administered, standardized

rating scale for withdrawal
severity

10 items
Maximum score = 67
Goal 8
Psychosocial
MI and MET

Prevent
Relapse in
Substance Use
Disorder

12-step facilitation

Best ways to prevent

relapses in SUD

Contingency
management
Alcohol Dependence
Opioid Dependence
Tobacco Dependence

CB-RP
Behavior couples
therapy

Basing benzodiazepine dose on CIWA

score allows more precise dosing and
avoiding both under- and overmedication.
There are no effective meds for
stimulants or cannabis.

Housing / employment
assistance
Naltrexone
Acamprosate
Disulfiram
Buprenorphine
Methadone
Nicotine replacement
Bupropion
Varenicline

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

DisulfiramAlcohol
Reaction

Naltrexone

Cause

Drug used to support the

treatment of chronic
alcoholism by producing
an acute sensitivity to
alcohol

Opioid antagonist

Acamprosate

Enhances GABA
inhibitory activity

Methadone

Slow-onset, long-acting
opioid agonist

Buprenorphine

Partial opiod agonist

Signs and Symptoms

Nause / vomiting
Abdominal pain
Chest pain
Hypotension
Tachypnea
Headache
Fainting
Dizziness
Adverse Effects
Hepatotoxicity
Metallic / garlic taste
(monitor LFTs)
Psychosis
Sexual dysfunction
Neuritis / neuropathy
Febrile rash
Opioid dependence

Alcohol dependence

Reduces rewarding
effects of alcohol

Triggers withdrawal in
opioid-dependent
patients

D/C 72 hours before

elective procedure

Wait 7 days after last

opioid analgesic use to
resume naltrexone

Substance use disorder

Test

Laboratory
Result

Treatment

Medications

Patient and Family Education

Nature of reaction
Risk up to 14 days after last dose
Non-beverage alcohol exposure
Signs and symptoms of hepatitis
Wallet card med-alert bracelet
Signed consent

Other
Contraindications
CAD / CHF
Diabetes
Epilepsy
Cirrhosis
Renal impairment
Hypothyroidism
Cognitive impairment
Reduces likelihood of "slip" back into
full relapse
Anatgonizes opioid analgesia
Contraindications
Acute hepatitis
Hepatic failure
Pregnancy (category C)
Support respiration if high-dose
opioids are required to override
naltrexone's opioid antagonism
during emergency surgery or trauma
Not superior to placebo
Check BUN and creatinine before
treatment
Restricted to federally-licensed
opiate treatment program

Opioid use disorder

Low risk of respiratory depression

compared to methadone

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Pharmacology
Drug

Generic Examples /
Brand Name

Mechanism of Action

Indications

citalopram

Selective
Serotonin
Reuptake
Inhibitors

escitalopram

fluoxetine

fluvoxamine

Pharmacokinetics

Contraindications

Adverse Effects

Monitoring / Other

Sexual dysfunction
CNS stimulation
GI disturbances
Sedation (paroxetine)
Anticholinergic effects (paroxetine)
Pharmacodynamic-serotonin
syndrome

Pregnancy test need to be

performed when indicated.
Monitoring for suicidal ideation
or behaviors is required.
Fluoxetine, Fluvoxamine, and
Sertaline Drug Interactions
TCAs
Phenytoin
Warfarin
Fluoxetine, paroxetine, and
sertraline causes CYP2D6
inhibition and interacts with
those drugs.
Monotherapy for bipolar
disorder is inappropriate.

History of seizures
CNS lesions
Head trauma
Anorexia / bulimia nervosa

Seizures
Constipation
Dry mouth
Headache
Insomnia
Weight loss
Nightmares

Pregnancy test need to be

performed when indicated.
Monitoring for suicidal ideation
or behaviors is required.
Pharmacodynamic drug
interactions increase seizure
risk with TCAs and
pehnothiazines
Drug Reactions
TCAs
Haloperidol
Risperidone
Codeine
Propranolol
Propafenone

History of alcohol abuse

(use caution)
Uncontrolled HTN
(use caution)

Nausea
Dose-related BP increases
Hepatotoxicity (duloxetine)
Pharmodynamic-serotonin syndrome

Comorbid conditions
(use caution)

Sedation (trazodone)
Priapism (trazodone)
Orthostatic hypotension
(trazodone)
Hepatotoxicity (nefazodone)

Neutropenia (use caution)

Constipation
Dry mouth
Appetite
Weight gain
Sedation

Monitoring
Pregnancy
Suicidal ideations / behaviors
Blood pressure
Hepatic function (duloxetine)
Duloxetine causes and CYP2D6
inhibition and interacts with
those medications
Monitoring
EKG (baseline)
Serum creatinine
Liver-associated enzymes
(especially with nefazodone)
Trazodone Drug Interactions
Additive sedation
Additive hypotensive effects
Nefazodone Drug Interactions
TCAs
Alprazolam
Verapamil
Monitoring
Pregnancy
Weight
Liver-associated enzymes
Lipids
Drug Interactions
Additive sedation
PD-5-HT syndrome

D: QAM

Depression

Inhibits serotonin
(5-HT) reuptake
Panic disorders

paroxetine
sertraline

D: BID, TID, or daily

NorepinephrineDopamine
Reuptake
Inhibitor

SerotoninNorepinephrine
Reuptake
Inhibitor

Serotonin
Antagonist and
Reuptake
Inhibitor
Noradrenergic
and Specific
Serotonergic
Antidepressants

bupropion

Inhibits reputake of
norepinephrine (NE)
and dopamine (DA)

Depression

D: BID (venlafaxine), TID

(venlafaxine), or QAM

venlafaxine
desvenlafaxine

Inhibits reuptake of
serotonin and
norepinephrine

Depression

duloxetine
D: BID or daily
(trazodone XR)

nefazodone

trazodone

Inhibits reuptake of
serotonin and
serotonin
antagonists

Depression

trazodone XR
D: QPM

mitrazapine

Increases NE and serotonin

concentration by blocking
presynaptic receptors

Blocks histamine-1
receptors

Depression

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Pharmacology
Drug

SRI / 5-HT2A

Generic Examples /
Brand Name

vilazodone

Mechanism of Action

Inhibits reuptake of
5-HT by blocking
5-HT2A

Indications

Pharmacokinetics

Contraindications

D: Daily

Adverse Effects

Monitoring / Other

Bradycardia
Hypotension
GI disturbances

Monitoring
Blood pressure
Pulse
Pregnancy
Suicidal ideations
May also cause PD-5-HT
syndrome
Monitoring
Liver-associated enzymes
(baseline)
Suicidal ideations

Depression

5-HT1A agonist
D: Daily

Inhibits reuptake of 5-HT

SRI / 5-HT1A /
5-HT3 Antagonist

vortioxetine

Agonist activity at the

5-HT1A receptor

Depression

amoxapine

nortriptyline

phenelizine

selegeline

tranylcypromine

Inhibits reuptake of
5-HT and NE
Depression

Affects
-1 adrenergic,
histamine-1, and
muscarinic receptors

Breakdown of 5-HT,
epinephrine, and DA
(MAO-A)

Depression

Inhibits DA and
phenylethamine
(MAO-B)

Unknown
Lithobid

Valproic Acid

Mania

Pregnancy (category D)
Breast feeding

Thirst
Polyuria
Congitive complaints
Tremor
Weight gain
Sedation
Diarrhea / nausea
Hypothyroidism
See PowerPoint slides for adverse
effects due to lithium levels

Pregnancy (category D)
Breast feeding
(unknown effects)

Tremor
Sedation
Diarrhea
Nausea
Weight gain
Hair loss
Mild LFTs

Maintenance therapy

Eskalith

Epilim

Blockage of voltagedependent sodium

channels

Valparin

Increases brain levels of

GABA

Depakote

Phenelzine / Tranylcypromine
Edema
Insomnia
Orthostatic hypotension
Selegeline
Application-site reaactions
Diarrhea
Dry mouth
Weight gain

D: Daily (selegeline) or
BID (others)

Inhibits degradation
of 5-HT, NE, and DA

Bipolar disorder

Lithium

Blurred vision
Constipation
Dry mouth
Sedation
Urinary retention

D: BID or daily

clomipramine
doxepin

MAO
Inhibitors

Nausea
Hyponatremia (rarely)
PD-5-HT syndrome

5-HT3 receptor antagonist

amitriptyline

Tricyclic
Antidepressant

Hyponatremia
Severe liver disease

Drug Effects on Lithium Level

Thiazide Diuretics

Loop Diuretics

Potassium-Sparing

Diuretics
NSAIDs

ACE Inhibitors

CCBs

Bipolar disorder

Maintenance therapy

Usually dose at night due to

sedation
Monitoring
EKG (baseline and as indicated)
Pregnancy
Liver enzymes (baseline)
Blood levels (as indicated)
Drug Interactions
PD-additive sedation
PD-additive hypotension
PD-additive anticholinergic
effects
Monitoring
Pregnancy
Suicidal ideations
Blood pressure
Serum creatinine
Liver-associated enzymes
Drug Interactions
Tyramine-rich foods
(hypertensive crisis)
PD-5HT syndrome
2-week washout period from
most SSRIs before starting an
MAOI
5-week washout period from
fluoxetine before starting an
MAOI
Monitoring
Serum level Q 1 - 2 weeks (first
2 months)
Serum level Q 3 - 5 months
Thyroid function Q year
Renal function Q 6 - 12 months

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Pharmacology
Drug

Generic Examples /
Brand Name
Tegretol

Carbamazepine
Equetro

Lamotrigine

Antipsychotics

Atypical
Antipsychotics

Mechanism of Action

Stablizes inactivated
voltage-gated
sodium channels

Indications

Pharmacokinetics

Bipolar disorder

Mania

Mixed symptoms

Maintenance therapy

Bipolar disorder

Bipolar depression

Sodium channel
blockers

Decrease Lamotrigine
Level

haloperidol

D2 antagonist

Psychotic symptoms

Manic symptoms

fluphenazine

5-HT2C antagonist

Acute mania

In combination with
mood stabilizers

Maintenance therapy

Schizophrenia

Psychiatric emergency

Acute agitation
(haloperidol)

Bipolar disorder

Manic symptoms
(rapid reduction)

Acute and long-term

therapy

Mixed symptoms

Bipolar depression

Maintenance therapy

Schizophrenia
(first-line)

Psychiatric emergencies

1 antagonist

thioridazine

H1 antagonist

chlorpromazine

m1 antagonist

quetiapine

D2 antagonist

olanzapine + fluoxetine

5-HT1A agonist

aripiprazole

5-HT2A antagonist

asenapine
risperidone

5-HT2C antagonist
5-HT3 antagonist

clozapine

1 antagonist

olanzapine

H1 antagonist

ziprasidone

m1 antagonist

clonazepam

Benzodiazepines

lorazepam
chlordiazepoxide
diazepam
midazolam

Increases CNS
depression

Adverse Effects
Headache
Nystagmus
Ataxia
Sedation
Rash
Leukopenia
Mild LFTs
Stevens-Johnson syndrome
Sexual dysfunction
Dizziness
Double vision
Sedation

Pregnancy (category C)
Breast feeding

Drug Interactions
Carbamazepine
Phenobarbital
Primidone
Increase Lamotrigine
Valproate
Level
Sertraline ( 25%)

Lamictal

perphenazine

Contraindications
Pregnancy (category D)
Breast feeding

Insomnia in acute mania Agitation in acute mania

Psychiatric emergency

Generalized anxiety
disorder (acute relief)

Movement disorders
Anhedonia
Sedation
Moderate weight gain
Poikilothermy
Hyperprolactinemia
Postural hypotension
Sunburn
Prolonged QT interval
EPS
Hyperprolactinemia (risperidone)
Weight gain
Diabetes mellitus
Hypercholestolemia
Sedation
Moderate movement disorder
Hypotension
Seizures (clozapine)
Noctural salivation (clozapine)
Myocarditis (clozapine)
Lens opacities (clozapine)

A: Oral, IM, or IV
Onset: Within 30
minutes (IM or IV)

A: Oral, IM (lorazepam),
or IV
Onset: Within 30
minutes (IV)
Duration: 1 - 2 hours
(midazolam) and 8 hours
(lorazepam)

Sleep apnea (use caution)

COPD (use caution)
TBI (use caution)
MR (use caution)
Dementia (use caution)
Delirium (use caution)

Additive drug / alcohol effects

Monitoring / Other

Not an effective treatment for

acute mania
Avoid new foods, detergents,
or sun
Overdose can be fatal

See PowerPoint slides for

particular drug effect (ex: low
M1, H1 activity, etc.)

Not effective in long-term

prophylaxis

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Antidepressants
Class

Antipsychotic

Generic Name
citalopram
escitalopram
fluoxetine
paroxetine
sertraline

Brand Name
Celexa
Lexapro
Prozac
Paxil
Zoloft

NE-DA Reuptake
Blocker

bupropion

Wellbutrin

Serotonin-NE Reuptake
Inhibitor (SNRI)

venlafaxine
desvenlafaxine
duloxetine

Effexor
Pristiq
Cymbalta

mitrazapine

Remeron

Selective Serotonin
Reuptake Inhibitor
(SSRI)

SNRI / Presynaptic 2
Antagonist /
H-1 Antagonist
SSRI / 5-HT1A Receptor
Partial Agonist
SSRI / 5-HT1A Receptor
Agonist /
5-HT3 Receptor

vilazodone

Viibryd

vortioxetine

Brintellix

Tricyclic Antidepressant

nortriptyline

Pamelor

MAO Inhibitor

phenelzine
tranylcypromine

Nardil
Parnate

Class
Butyrophenone

Atypical Antipsychotic

Generic Name
halperidol
aripiprazole
clozapine
olanzapine
quetiapine
risperidone
ziprasidone

Brand Name
Haldol
Abilify
Clozaril
Zyprexa
Seroquel
Risperdal
Geodon

Anxiolytics
Class
5-HT Partial Agonist

Generic Name
buspirone

Brand Name
Buspar

Tricyclic Antidepressant

clomipramine

Anafranil