Psych core rotation - week 3 & 4

Anticholinergic toxicity

"Hot as a hare, red as a beet, dry as a bone, mad as a hatter, blind as a bat, full as a flask." - hyperthermia - delirium - dilated pupils - dry mucous membrane - urinary retention - dec'd bowel sounds

16yo F brought to ED 30 min after suicide attempt w/acetaminophen. Tx?

- < 4 hrs after ingestion - use ACTIVATED CHARCOAL - > 4hrs after ingestion - use IV or oral N-acetylcysteine. IV used when pt have intractable vomiting, preg or hepatotoxicity w/ INR >2

What is the formula to calculate BMI? Calculate BMI for someone who is 157.5 cm tall and weighs 47.6kg?

- BMI = 19.2 kg/m^2 - <18.5 is concern for anorexia

Which personality disorder is more common in people with a hx of sexual abuse?

- BORDERLINE PERSONALITY DISORDER

11yo F w/angry outbursts that onset at 9yo when family moved. After that pt starting spending time w/older cousins who family considered a bad influence. Now she has been consistent irritable and has freq temper tantrums w/physical aggression and verbal rage. Dx?

- DISRUPTIVE MOOD DYSREGULATION DISORDER - severe, recurrent temper outburst that are inconsistent w/the situation and the child's level of devel - 3x/wk for 12mo - btw outbursts pt is consistently irritable - dx'd btw 6-18y Differentials: - Oppositional defiant disorder - defiant to authority figures - Conduct disorder - violates the basic rights of others or social norms. < 18 yo. ≥ 18y then becomes antisocial personality disorder - intermittent explosive disorder - 2-3 x /wk for 3 mo. norm mood btw outbursts

7 yo M brought in for temper tantrums that have inc'd in freq over past 2 yrs. Ofter result from frustration w/his video games or not getting a dessert he wants. Yells, cries, punched a wall. He says that "sometimes I just get angry". Denies depression, has full affect, pleasant to office staff, doing well in school. Dx?

- INTERMITTENT EXPLOSIVE DISORDER - 2-3 x /wk for 3 mo - norm mood btw outbursts Differentials: - Oppositional defiant disorder - defiant to authority figures - Conduct disorder - violates the basic rights of others or social norms. < 18 yo. ≥ 18y then becomes antisocial personality disorder - disruptive mood dysregulation disorder - irritable btw outbursts. 3x/wk for 12mo

What are the immediate and more long term treatments for severe depression with psychotic features?

- Immediate: ECT - Long term: Antidepressant + antipsychotic - antidepressant mono therapy would be inadequate

What is the difference btw alcohol use disorder and alcohol abuse disorder?

- In DSM-V alcohol abuse and alcohol dependence disorders have been combined into one disorder called alcohol use disorder. Thus there is no longer such a thing as alcohol abuse disorder

Dantrolene

- Muscle relaxant - blocks Ca2+ release from sarcoplasmic reticulum of skeletal muscle. - used for emergency treatment of malignant hyperthermia and neuroleptic malignant syndrome

Atomoxetine

- NOR reuptake inhibitor - tx for ADHD

Which drugs have a negative interaction with lithium?

- NSAIDS - ex: ibuprofen (not acetaminophen) - thiazide diuretics - ACEi - tetracyclines - metronidazole

5yo M who wets bed 2-3 times per mo. Next step?

- PARENTAL EDUCATION AND MOTIVATIONAL THERAPY - try this b4 enuresis alarm

What is the difference btw reaction formation and sublimation?

- RF - transforms unacceptable emotions, desires, impulses into their extreme opposites - S - channel unacceptable thoughts or impulses into socially acceptable behavior, which is similar to the thought/impulse and provides satisfaction

Which benzos are more likely to cause withdrawal sx?

- Short acting benzos like ALPRAZOLAM

Amytriptyline

- TCA - sedating

What is the difference btw dissociative amnesia and dissociative fugue?

- When a pt has dissociative amnesia that is associated w/traveling or wandering the term "dissociative fugue" is used as a specifier for dissociative amnesia Note: - remember that dissociative amnesia and gaps in memory can also be a sx of acute stress disorder, PTSD or dissociative identity disorder

Jimson weed intoxication

- aka Datura stramonium - anticholinergic atropine containing plant Sx: - hallucinations, delirium - hyperthermia - tachycardia - nonreactive mydriasis - dry, red skin Mnemonic: - mad as a hatter, hot as a hare, dry as a bone, blind as a bat, red as a beet

Persistent complex bereavement disorder

- aka complicated grief - persistent yearning for the deceased and prolonged emotional pain related to the loss - maladaptive ruminative thoughts - dysfunctional behaviors

Major depressive disorder with seasonal pattern. Tx?

- aka seasonal affective disorder Tx: - antidepressants and bright light therapy - lt therapy: administer 10,000 lux light box shortly after awakening. takes 1-4wks. continue to tx through fall and winter until spont remission in spring/summer. lt therapy alone can tx mild to mod SAD

Chronic fatigue syndrome

- aka systemic exertion intolerance disease - relatively sudden onset of overwhelming fatigue - often associated w/an infection like mono

dexmedetomidine

- alpha 2 agonist - used in ICU and for procedural sedation

Transient global amnesia

- anterograde amnesia for time and place - memory loss typically resolves w/in 24 hrs

benztropine

- anticholinergic - used to tx antipsychotic-induced EPS like acute dystonia and parkinsonism

Which neuropsychiatric diseases are the following neuroimaging findings associated with? - atrophy of the caudate - enlargement of the cerebral ventricles - structural abnormalities of the orbitofrontal cortex - decreased volume of hippocampus - increased total brain volume - structural abnormalities of the basal ganglia - decreased volume of the amygdala - accelerated head growth during infancy

- atrophy of the caudate: Huntington's - enlargement of the cerebral ventricles: schizophrenia - structural abnormalities of the orbitofrontal cortex: OCD - decreased volume of hippocampus: schizophrenia - increased total brain volume: autism - structural abnormalities of the basal ganglia: OCD - decreased volume of the amygdala: schizophrenia - accelerated head growth during infancy: autism

Delayed sleep phase disorder

- circadian rhythm sleep wake disorder w/delayed sleep phases - difficulty falling asleep. inability to fall asleep for ≥ 2 hrs - inability to waken at preferred time. awakening at a later than desired time

Hypokalemia in an otherwise healthy young adult is concerning for this disease? What other electrolyte disturbances might be found?

- covert BULIMIA NERVOSA - vomit --> loss H+ --> metabolic alkalosis --> renal losses of potassium --> hypokalemia

SSRI discontinuation syndrome

- d/t abrupt discontinuation of SSRIs Sx: - dizzy - fatigue - HA - nausea - anxiety - myalgia - paresthesia

Antidepressant discontinuation syndrome

- d/t abrupt discontinuation of venlafaxine or paroxetine Sx: - acute onset dysphoria, dizzy, GI distress, flu-like sx, myalgias

Define still birth

- death of a fetus after 20 wks gestation

Stranger anxiety

- fear of being around unknown people - can occur w/parents in the room - begins around 6-12 mo

Anticholinergic toxicity

- hyperthermia - anhidronic hyperthermia - delirium - mydriasis - urinary retention - constipation

Dantrolene

- indicated for neuroleptic malignant syndrome that does not respond to discontinuation of antipsychotics - treated the muscular rigidity aspect of NMS

What is the treatment for exhibitionistic disorder?

- intense arousal from exposing one's genitals to non consenting ppl for at least 6 mo Tx: - PSYCHOTHERAPY

15yo M brought in by parents bc has become more withdrawn over last 3mo. Spends time alone and turns down chances to hang w/friends. Moody, irritable, unmotivated, unconcerned that grades dropped. Onset after a girl rejected him and called him loser on social media. Says he doesnt think he will ever get over the girl and he feels pretty down. He says he would consider taking medication to help but please don't tell his parents bc he doesnt want to worry them. Next step?

- no matter how logical the other options sound, in any question where a patient is depressed and they want to know the next step, the answer is ALWAYS to INQUIRE IF THE PATIENT HAS ANY THOUGHTS OF KILLING HIMSELF Differentials: - do not say you will treat him w/o telling his parents bc confidentiality cannot be promised if there is a concern for his safety - parental consent is still required to prescribe mediation - you can't just go ahead and prescribe him meds or psychotherapy w/o completing a thorough assessment of his depression. you have to ask more questions like about suicide first - do not just offer reassurance bc he has had persistent depressive sxs for 3 mo

Malignant hyperthermia

- occurs in genetically susceptible patients who have preoperative exposure to volatile anesthetics or succinylcholine - hypercarbia - muscle rigidity - hyperthermia

Hypersomnolence disorder

- persistent daytime sleepiness not explained by another sleep disorder

What is the difference btw delusional disorder and psychosis?

- psychosis has symptoms of hallucinations, disorganized speech, disorganized behavior. This is absent in delusional disorder

Oppositional defiant disorder. Duration?

- recurrent pattern of angry/irritable mood, argumentative/defiant behavior, vindictiveness - lasts ≥ 6 mo

cyproheptadine

- serotonin antagonist - tx for serotonin syndrome

25yo F w/abd bloating, HA, fatigue, wt gain, mood swings, dec'd libido that lasts 1 wk then subsides but always seems to come back again. Also gets inc in appetite and craves sweet and salty foods. PMH of depression that responded to CBT and uncle w/bipolar. Next step? Tx?

- she has signs suggestive of PMS which must first be confirmed w/ a MENSTRUAL DIARY before starting tx Sx: - breast tenderness Tx: - mild PMS - exercise and stress reduction - moderate to severe PMS/PMDD- SSRIs

What is the difference btw kleptomania and shoplifting?

- shoplifting is for personal gain and usually is premeditated - kleptomaniacs steal things of little value and ofter discard them d/t feelings of guilt later. it is an impulse control disorder

How can you prevent benzodiazepine withdrawal in patients who want/need to discontinue their benzos? Which benzos are more likely to cause withdrawal sx upon discontinuation?

- shorter acting benzos like alprazolam and lorazepam produce earlier and more severe sxs - can manage withdrawal by tx'ing pt w/a longer t1/2 benzo like diazepam and gradually tapering it over a few months Duration of action of benzos based on half-life. Ranked in order from shortest to longest acting: (1. shortest - alprazolam - shortest acting according to UW only. Really it is intermediate acting) 2. short - t1/2 < 6hr - triazolam, oxazepam, midazolam 3. medium - t1/2 = 6-24hr - alprazolam, lorazepam, temazepam 4. long - t1/2 = diazepam, chlordiazepoxide, flurazepam

Which neurotransmitter receptors are affected and how in tardive dyskinesia?

- tardive dyskinesia is caused by long term use of dopamine blocking agents like antipsychotics - this upregulates dopamine receptors causing DOPAMINE RECEPTOR SUPERSENSITIVITY

What is the treatment for agoraphobia?

- the avoidance of ≥ 2 situations in which escape obtaining help may not be possible Tx: CBT and SSRIs

List the MAOis

- tranylcypromine - phenelzine - isocarboxazid - selegine MAO takes pride in Shanghai

Mirtazapine AE

- used to treat depression and insomnia - 1st line - causes wt gain, sedation, favorable sexual side effect profile

List the SNRIs

- venlafaxine - desvenlafaxine - duloxetine - levomilnacipran - milnacipran

valbenazine

- vesicular monoamine transporter 2 inhibitor - treats tardive dyskinesia

modafinil

- wakefulness promoting agent - treats narcolepsy and used as an adjunct in depression to improve motivation and energy

Amantadine. MOA?

- weak antagonist of NMDA glutamate receptor - dopaminergic - used to treat drug-induced parkinsonism

25yo graduate student w/recent PMH of bulimia who wants to quit smoking. 1st line tx?

1st line FDA approved rxs: - nicotine replacement therapy - varenicline - diminishes cravings. inc'd risk of CVS events in pts w/CVS disease - bupropion - NRDI that is contra'd in pts w/seizure risk or bulimia

Acamprosate

1st line rx for alcohol use disorder

73 yo M w/bipolar disorder brought to ED by daughter. She says he has been increasingly confused which is not typical. He has had bilateral hand tremors, difficulty walking straight, and has vomited over past few days. 2 wks ago saw a new PCP who added hydrochlorothiazide. He also sees a psychiatrist who prescribed mood stabilizers and antipsychotics. Temp = 99, BP = 130/80, PR = 65, RR = 16, O2 sat = 93%. PE shows disorientation and ataxia then he has a generalized seizure for 2-3 min. Which med most likely caused these sx? What medications interact w/this rx?

Dx: LITHIUM TOXICITY Other rxs that ppt toxicity: - thiazides - dec renal clearance of lithium - ACEi - NSAIDS - tetracyclines - metronidazole Physiological conditions that ppt toxicity: - pts who are dehydrated from any cause like vomiting, diarrhea, fever, diuresis - elderly patients bc they have a lower GFR and lower Vd (bc have higher fat content in bodies)

25yo F goes to ED for lower back pain and insists on immediate IV hydromorphone. Yells in pain on straight leg test but when does another test for pain in this area she doesnt endorse any pain. Medical workup, imaging, tox screen are negative. Dx?

Dx: MALINGERING - malingering is when a person intentionally falsely reports a sx for personal gain like money, time off work, narcotics Differential: - factitious disorder is when they are trying to assume the sick role

38 yo M w/2mo hx of depressed mood, low e, insomnia, impaired concentration and suicidal ideation. He is started on an antipsychotic which, over the next several months, is increased to the max dose. An antipsychotic is added to target persistent depressive sxs. At 6mo f/u he is improved but now shows new onset mild HTN. Which med is he on?

Dx: MDD Rx: - SNRI like VENLAFAXINE AE: - HTN, stimulant effects, sedation, nausea

4 yo M comes in for well child visit. Started preschool 3 wks ago, Mother is concerned abt his adjustment to school bc wants to stay home like baby sister, takes long time to get dressed in morning, gets upset when dropped off at school. On first day of school he stomped his feet and yelled "take me home" and wrapped his arms around her legs so she couldn't leave. Teacher reported that he settles down a few minutes after she leaves. He is shy but plays w/other kids. Dx?

Dx: NORMAL DEVELOPMENT - separation anxiety develops at 9-18mo but can recur during transitions that require separation like attending school - he is able to settle down quickly after being dropped off Differential - separation anxiety disorder - extreme and persistent anxiety, excessive worry abt loosing attachment figures, phys sxs (stomach aches, HA), nightmares abt separation, difficulty sleeping alone, school refusal

46 yo M w/HTN controlled w/rxs comes in for routine check up. BP = 115/80. You note pt's mood seems low and he admits to being stressed out for last 2 mo bc ppl quit at work 2 mo ago and he has to pick up the slack. Says he is irritable and tense at work and has neck and shoulder pain. Worries abt not being able to spend time w/wife. Occasional difficulty falling asleep after long day and feels tired during day. Doesn't enjoy job but has no choice but to stay. Continues to get work done and enjoys social activities like playing golf on weekends. Drinks 2-3 beers on weekends and occasional marijuana use. Dx?

Dx: NORMAL STRESS RESPONSE - pt continues to fxn well - not markedly distressed (like he didnt bring it up to you on his own, you had to ask) - social and occupational fxning is unaffected

44yo M found talking to self in park. Became agitated and combative and said he was "destined to lead" and to wait in the park for a "sign". Appears distractible, disorganized, unable to care for self. Admitted and started on haloperidol and valproate and improves for 1 wk. 10d after admission fails to come to breakfast and is found in bed confused, sweating and stiff. Temp = 102.6, BP = 164/98, PR = 122, RR = 28. All meds are halted. If he fails to improve what rx should he get (3)?

Dx: Neuroleptic malignant syndrome Rx: - dopaminergic agents - BROMOCRIPTINE or amantadine. reverse dopamine blockade - muscle relaxant - dantrolene

27yo M found naked at traffic circle cursing at passing cars and brought to ED. PMH of substance abuse and similar past admissions to hosp. PMH of epilepsy, DM2. During interview says "they are all out to get me and are coming through the walls!" Temp = 100.9, BP = 148/100, HR = 98, RR = 16. PE shows ataxia, nystagmus, muscle rigidity. Next step?

Dx: PCP intoxication Tx: - LORAZEPAM or other benzo to calm him down - best to use a parenteral benzo like lorazepam or diazepam bc these pts so agitated they can't take pills by mouth Differentials: - haloperidol is 2nd line in PCP resistant to benzos. contra'd in pt w/seizure disorder bc antipsychotics lower seizure threshold - propofol - use in severe PCP where its unresponsive to benzos and antipsychotics

35 yo M w/poor sleep and impaired concentration at work. Has had difficulty falling asleep and staying asleep since his last military tour of duty. Has nightmares, awakens in state of panic. Feels tired during day. Thinks he is going crazy bc sometimes sees images of explosions and hears his friend's voice calling him for help. Says he keeps checking the doors to see if anyone is breaking into the house. PMH of HTN, colon cancer, GAD. PE shows him to be visibly tense and restless and jumps when telephone rings. Rx?

Dx: PTSD Rx: - PAROXETINE or another SSRI or an SNRI and trauma focused CBT - prazosin (alpha adrenergic blocker) is added as an augmentation to dec nightmares

Kleptomania tx

CBT Meds: SSRIs, opioid antagonists, lithium, anti-convulsants

45yo F w/hx of sexual abuse. In therapy she presents one persona which is shy and diffident and another that is aggressive and angry. Which defense mechanism is she using?

Defense mechanism: - DISSOCIATION - this is dissociative personality disorder aka multiple personality disorder

45yo M goes to see PCP for annual check up. Yells at the receptionist that his time is being wasted bc appt is late and paces around waiting room. In exam room he doesnt make eye contact and returns doctor's greeting w/a grunt. He tells the doctor "ppl are so rude these days" and describes the receptionist and ppl in the waiting area. Which defense mechanism is he using?

Defense mechanism: - PROJECTION - the person has a trait that they are not consciously aware of, like being rude. Subconsciously they cannot tolerate the existence of this trait w/in themselves so they constantly see or project this trait onto others - the pt has a feeling that is wrong so accuse someone else of having that same feeling

The risk of which psychiatric condition and actions are increased in patients w/ a history of sexual assault?

Disorders: - ptsd - major depression Actions: - SUICIDAL IDEATION AND ATTEMPTS

Which benzos have the shortest duration and which have the longest? Which are better to use in patients who are going to discontinue their medication?

Duration of action of benzos based on half-life. Ranked in order from shortest to longest acting: (1. shortest - alprazolam - shortest acting according to UW but really is intermediate acting) 2. short - t1/2 < 6hr - triazolam, oxazepam, midazolam 3. medium - t1/2 = 6-24hr - alprazolam, lorazepam, temazepam 4. long - t1/2 = diazepam, chlordiazepoxide, flurazepam - use long acting to prevent withdrawal after discontinuation of meds - short acting are more likely to cause withdrawal sx

What is the duration for brief psychotic disorder?

≥ 1d but < 1 mo

27yo M w/anxiety and poor sleep that has been worsening over past year. Has really hard time on nights leading up to weekly staff meeting d/t worry he will say something stupid or embarrassing. Says its hard for him to relax at meetings despite being well prepared. Also worried abt having to attend family reunion next month. Recently turned down promotion that would have required him to work more w/clients. No depression, difficulty concentrating, appetite issues. Formerly used EtOH to calm nerves but now only drinks 1x/wk. PE shows tense appearance, poor eye contact, freq sighs. Asks for meds to help him relax? Dx? Duration?

Dx: Social anxiety disorder aka social phobia - self medicating w/EtOH is a common cx of SAD - turning down promotion = functional impairment Rx: SSRI like SERTRALINE or SNRI Differentials: - benzos and beta blockers are only used in the performance only subtype of SAD - doesnt need sleep aid like zolpidem bc sleep issue bc of his anxiety and will improve w/SSRI or SNRI REMEMBER: - SSRI and SNRI are the only 2 1st line antidepressants that can be used for SAD

27yo M who's wife says that he has been depressed, withdrawn, difficulty sleeping, poor appetite, no energy, anhedonic for 3 weeks. 6mo ago hospitalized bc aggressive towards wife after she confronted him abt staying up all night and gambling away their savings and investing their money in a start up internet company that went bankrupt. At that time he spoke rapidly and had a "brilliant" plan for world peace. He has a similar episode 2 y ago that responded well to pharmacotherapy but the pt stopped taking his rxs shortly after stabilization. What combo of meds is best for him?

Dx: bipolar disorder Rx: - here he is having a severe episode bc he has aggression. if he had psychosis, suicidal or required hospitalization then these are also requirements for combination therapy - you also give combination therapy if mono therapy didnt work or if there are frequent episodes - 1st line: LITHIUM or valproate combined with a 2nd generation antipsychotic like QUETIAPINE

What is the role of dopamine in each of the following pathways? - mesolimbic - nigrostriatal - tuberoinfundibular

Mesolimbic: - extends from ventral segmental area to limbic system - decreased DA --> therapeutic effects of antipsychotics - increased DA --> euphoria in drug use, delusions and hallucinations in schizophrenia Nigrostriatal: - extends from substantia nigra to basal ganglia - involved in mvmt coordination - decreased DA --> EPS of antipsychotics, sxs of Parkinson's - increased DA --> chorea, tics Tuberoinfundibular: - decreased DA --> prolactin not inhibited by DA --> inc'd prolactin --> amenorrhea, galactorrhea, gynecomastia, sexual dysfxn - increased DA --> prolactin inhibited

During which stage of sleep do night terrors occur?

N3

Reaction formation vs sublimation

Reaction formation: - transferring unacceptable feelings/impulses into the opposite Sublimation: - channeling impulses into socially acceptable behaviors

23 yo F w/milky discharge from both nipples, errant menstrual cycles for 3 mo, poor libido, mild breast tenderness. PMH of depression where she thought her neighbor was plotting to burn down her house last year that was tx'd w/meds. PMH of breast cancer, bipolar disorder, Grave's disease. Drinks alcohol and smokes cigs. Prolactin = 70 ng/mL (norm = 3-30), TSH = 3.0, neg preg test. Cause of her sx? MOA?

Rx: RISPERIDONE - some antipsychotics cause dopamine blockade - dopamin inbits prolactin --> pt has too much prolactin w/o dopamine - prolactin inhibits GnRN --> pt has too much prolactin --> not enough GnRN --> menstrual irregularity - affects tuberoinfundibular pathway Sx: - gynecomastia, galactorrhea, menstrual dysfxn, dec'd libido Differentials: - aripiprazole - acts as both an antagonist and partial D2 agonist --> less likely to cause hyperprolactinemia - hypothyroidism can cause prolactinemia but she would also have lethargy, dry skin, cold intolerance - Prolactinoma - cause prolactin levels > 200. Medication related prolactin causes levels of 25-100

What is the only antidepressant class that causes HTN?

SNRIs - venlafaxine - duloxetine - desvenlafaxine - levomilnacipran - milnacipran

What is the drug of choice in post-stroke depression?

SSRIs

What is the difference btw schizoid and schizotypal personality disorder?

Schizoid: - loner - detached - unemotional - preference for solitary activities - lack of desire for close relationships - have few friends by choice - flat affect - indifference to praise or criticism Schizotypal: - unusual thoughts, behaviors, perceptions

21 yo M comes to ED after breaking nose in fight. He also requires stitches for scalp and arm lacerations. Gf says they were having a beer and he became angry and paranoid over how someone was looking at her. Pt says "the other guy looks much worse than i do but he had it coming". He is unemployed and recently quit his job bc the boss was "against him for being late a few times". He says he can easily go to college or pick up another job if he wanted to. Since 7th grade he has hx of repeated suspensions for truancy and fighting. He blames his failure to be accepted to college on the teachers who reported this. Uses alcohol, weed, crack for fun and when he can get it. Dx?

Dx: - ANTISOCIAL PERSONALITY DISORDER (APD) Sx: - failure to accept responsibility for their actions: blames boss and teachers for his mistakes - no remorse like in IED Differentials: - conduct disorder is APD before the age of 15, as evidenced by his hx of truancy and fighting from 7th grade onward - intermittent explosive disorder - no conduct disorder before 15yo. IED has isolated incidents of assaultive or destructive behavior

16yo M expelled from school for 3rd time for fighting. Father says he's has behavior problems for as long as he can remember. Last yr spent several mo in juvenile detention facility after tried to burn down ex-gf's house. Fam had to give away cat bc found out he was torturing the cat. Dx? Tx?

Dx: - CONDUCT DISORDER Tx: - PSYCHOTHERAPY Differentials: - oppositional defiant disorder - generally begins in childhood or adolescence and involves disruptive, defiant behavior towards authority figures. The major difference between ODD and CD is the lack of violent and illegal behavior in ODD

15 yo F who's mother says she is moody. Was sent to principle's office for disobeying "stupid classroom rule." Then was suspended from school for talking back and cursing at principle. Blames poor grades on boring teachers . Stays out past curfew, room always messy, gets extremely annoyed when asked to do chores. Fam hx of bipolar disorder and depression. MSE shows irritable affect and loud speech. Dx?

Dx: - OPPOSITIONAL DEFIANT DISORDER Differentials: - Conduct disorder - more severe and aggressive behaviors like physical aggression or cruelty of animals, destruction of property, stealing, lying - normal adolescent behavior - apparently normal adolescents don't get school suspensions, academic dysfxn, chronic parent-child problems - Antisocial personality disorder - not dx'd in patients <18y

19yo M w/anxiety and fears that he is "loosing his mind." When he drives over a bump in road he is convinced he ran over small child and has to pull over and check under car and then retraces driving route looking for injured children. This makes him late for work every time. Once gets to work has intrusive thoughts abt stabbing coworkers. Fam hx of schizophrenia and panic disorder. Which NT is affected by the primary tx? What are the 2ndary txs? Dx?

Dx: - Obsessive compulsive disorder Rx: - 1st line - SSRIs which target SEROTONIN nt's - 2nd line - clomipramine

35 yo M comes in w/insomnia and feeling "worthless". Onset 2 mo ago when found out gf was cheating on him and he had to dump her. No longer socializes and instead stays home alone. Now has little interest in dating women even though he has met some good matches. Continues to go to gym to escape his feelings for former gf. Uses marijuana to help him sleep. Fam hx of depression in sister who was tx'd w/venlafaxine. Tx? Dx?

Dx: - adjustment disorder Tx: - PSYCHOTHERAPY = treatment of choice. focuses on developing coping mechanisms and improving attitude and response to stressful situations

57 yo F w/intermittent HA, shoulder and neck pain, fatigue, insomnia. Sx worsened over last 8mo bc started new job and put mother in nursing home. Lies awake at night worrying abt mother, her own health issues, finances of her 2 adult children. Tired during day and worries abt job performance. Drinks 1-2 glasses of wine to fall asleep. PE shows sweaty palms and diffuse abd tenderness. Labs norm. Tx?

Dx: - Generalized anxiety disorder - pts freq have somatic sx like fatigue and sx bc of musc tension like HA, neck and shoulder pain and back pain. commonly see trembling, sweating, GI sxs Tx: - CBT AND SSRIs OR SNRIs Note: - benzos are only used if SSRI/SNRIs don't work and would not be used in this pt who uses alcohol to self medicate

54 yo M w/chronic excessive fatigue during day, decreased concentration at work, depressed mood. Poor sleep and awakens multiple times per night. Wife and him have been arguing bc she is mad that he doesnt want to participate in activities anymore and he doesnt have any energy. She recently moved out of bedroom and sleeps in living room d/t his loud snoring. PMH of hypercholesterolemia tx'd w/statins and HTN tx'd w/hydrochlorothiazide. Drinks alcohol socially. Ht = 175 cm, wt = 118 kg, BP = 140/85, PR = 78. MSE shows mildly depressed mood, full range of affect, no suicidal ideation. Dx?

Dx: - MOOD DISORDER D/T ANOTHER MEDICAL CONDITION - even though he has 5 SIGECAPS apparently he as enough sxs of obstructive sleep apnea - OSA presents w/depressive sxs

25yo homeless man w/schizophrenia destroyed TV set at local store then became agitated and violent so brought to ED. His speech is hard to follow, distracted, listening to voices that only he can hear. Admitted and given haloperidol. Later that night has sustained contraction of neck on R side. Rx (2)? Dx?

Dx: Acute dystonia d/t haloperidol Sx: - muscle spasms or stiffness in head and neck - tongue protrusions or twisting - facial grimacing - torticollis - opisthotonos (back) - oculogyric crisis - forced sustained elevation of eyes in upward position Rx: - benztrophine - anticholinergic - DIPHENHYDRAMINE - anticholinergic antihistamine

55yo F w/ insomnia and fatigue that onset shortly after her divorce was finalized 1y ago. Has had difficulty falling asleep and drinks 2-3 glasses of wine before bed to fall asleep. Recently started to wake up around 3am each night and then its awake for several hrs worrying abt her future. She has no daytime anxiety. Has brief sadness and loneliness. Recently started showing up late for work and stopped attending weekly work out class. PMH of hypothyroidism tx'd w/levothyroxine and GERD tx'd w/ranitidine. Temp = 99, BP = 140/90, PR = 90, RR = 12. Labs: Hb = 11.4 Hct = 34% MCV = 106 BUN = 20 AST = 85 ALT = 42 TSH = 2.7 Dx?

Dx: Alcohol use disorder - women of all ages and men ≥ 65y who drink >7 drinks/wk or >3 in a day Clues: - this pt has ≥ 14 drinks/wk - AST:ALT ≥ 2:1 - macrocytosis - alcohol tolerance - needs to drink more to fall asleep - impaired functioning - late to work - alcohol helps pt fall asleep but then when it wears off she will wake up d/t CNS hyperarousal

35yo F w/depression tx'd for 2y w/paroxetine and CBT. Her main AE is anorgasmia which wasn't a problem until she started a new relationship and decided to stop her paroxetine. 3d later she comes to the office saying that she is much worse. Sounds worried and says that she thinks her depression is coming back. She says she has no energy and her muscles are weak and they hurt. She says she has been unable to sleep and has been restless. Tx? Which antidepressants are common for this to happen with? Why? What is a better alternative for her?

Dx: Antidepressant discontinuation syndrome Sx: - onset - 2-4d following discontinuation - more common w/SSRIs and SNRIs w/shorter t1/2 like paroxetine and venlafaxine, higher doses and longer duration - dysphoria - fatigue - insomnia - myalgias - dizziness - flu-like sx - GI sx - tremor - neurosensory disturbances like electric shock and rushing sensations in the head, paresthesias, hyper responsivity to light and noise, vivid dreams - pts perceive the onset of these sx as an emergence of the underlying disorder being treated!! However following abrupt discontinuation of an SSRI sxs do not return immediately Tx: - re-institute the same antidepressant and taper the dose gradually over 2-4 weeks or longer in severe cases - you can also substitute fluoxetine which is more easily tapered d/t its longer t1/2

22yo M admitted after suicide attempt. Cut his wrist after fight w/gf. Says he has always struggled w/depression and anger since he was a teen. PMH of suicide attempt from OD in teens. When depressed feels empty, hopeless and alone. Says moods are always up and down. Bouts of depression are too numerous to count. Trials of fluoxetine and sertraline were ineffective and sexual AEs. Tx/rx?

Dx: Borderline personality disorder Tx: - 1st line is psychotherapy and specifically DIALECTICAL BEHAVIOR THERAPY. Developed specifically for BPD to teach emotion regulation, mindfulness, distress tolerance to target unstable moods, impulsivity, suicidality - adjuncts include lithium, valproate, lamotrigine to target mood instability, aggression, impulsivity

17yo M who has been getting into trouble for yrs and does poorly in school. Pt says he can't pay attention in class bc teachers "boring". Mother says he never listens and last week caught him stealing $20 from neighbor. Said he thought it was ok to take the money bc they never paid him for mowing their lawn. Suspended from school several times for fighting, truancy, talking back to teachers. Argues with and lies to parents. Uses EtOH and marijuana occasionally. Dx?

Dx: CONDUCT DISORDER Differentials: - ADHD - Not violent or deceitful like in CD - oppositional defiant disorder - less severe that CD, its are not aggressive towards ppl and don't steal - once a pt turns 18 then this is reclassified as Antisocial personality disorder

28yo F w/unusual neurological finding that neuro team cannot explain w/imaging and medical workup. She says that she cannot walk w/o a walker bc of weakness in her L ankle. Onset 1wk ago following a serious fight w/her husband. She says it has prevented her from going to work bc she has to walk at work. PE shows weakness in plantar/dorsal extension/flexion in L ankle when attempting to walk. When sitting on edge of bed she is found to have 5/5 strength. Dx?

Dx: CONVERSION DISORDER - remember these are NEUROLOGICAL SXS Differential: - in factitious disorder the sx are physical or psychological or induction of injury or disease and there is identified deception with the intent of assuming the sick role.

37 yo F comes to office w/low energy and fatigue. Recently got promoted at work and was excited and motivated but now finds herself procrastinating and having problems concentrating. Fam hx of mother w/thyroiditis. HPI significant for many yrs of unpredictable mood swings w/low energy periods and periods where she feels energetic, confident, optimistic. These periods vary from days to weeks and have no clear relationship to situations in her life. PMH of cutting and bulimia in high school but stopped. MSE shows sad affect and lapses in concentration, although the patient brightens easily. Dx?

Dx: CYCLOTHYMIC DISORDER Differentials: - Borderline personality disorder - mood instability happens in response to interpersonal stressors. self harm is recurrent and in this pt it stopped after high school - bipolar II - if she had the SIGECAPS criteria then she needs to be evaluated for bipolar II w/hypomania and MDD

46 yo M w/suicidal ideation and hearing voices. Has become increasingly depressed for 1 mo and has not been able to work. He has been on risperidone, lithium, escitalopram but wife not sure if he is compliant. PMH of bipolar disorder since 18yo and hospitalizations for manic and depressive episodes. Also has allergies and hypercholesterolemia. He is hospitalized and during his interview he is mute and motionless. He resists all instructions to move. When his arm is lifted it remains in the same position even after it is let go. Next step?

Dx: Catatonia syndrome - Catatonia is a syndrome Causes of catatonia: - mood disorders w/psychotic features - psychotic disorders - autism spectrum disorder - medical conditions - infectious, metabolic, neurologic, rheumatologic Tx: - benzos - most commonly LORAZEPAM - ECT Notes: - Lorazepam challenge test - give IV lorazepam 1-2 mg and should show partial temporary relief w/in 5-10 min - can take a week to respond after administration of lorazepam - Antipsychotics can WORSEN catatonia. Defer tx w/risperodone of underlying bipolar disorder until catatonia resolves w/lorazepam

73 yo F brought to office by son d/t change in behavior and increasing forgetfulness. For last 2d has been irritable, unable to sleep, forgot to pick up mail and feed dogs. During interview pt responds to internal stimuli by shouting at the nurse to get out of her house and asking where did you thieves take my clothing. Several minutes later becomes drowsy. Over past yr has forgotten ppls names and had word finding difficulty but still lived alone and completed shopping, cooking, and handled finances. Temp = 101, BP = 140/90, HR = 118, RR = 18, Leukocytes = 15,500. U/A shows positive for leukocyte esterases, nitrates, WBC and RBC. Dx?

Dx: DELIRIUM - elderly person w/UTI & psychotic sx = DELIRIUM always Differentials: - Psychotic disorder d/t a medical condition is diagnosed only in the absence of delirium. There must be a causal link btw psychotic sxs and a medical condition. For ex, hallucinations d/t a B tumor

28yo F brought in by husband bc for 6 mo has refused to eat any food that is not prepackaged and is concerned about becoming ill. Thinks someone has poisoned her food bc has rash consistent w/eczema. Eats lunch alone at work. Mood is anxious and affect is tense. Tx? Dx? Duration?

Dx: Delusional disorder Sx: - ≥1 delusions for ≥1 mo - subtypes: erotomanic (belief that someone is in love with you), grandiose, jealous, persecutory (think someone is poisoning you, harassed, plotted against), somatic Tx: - antipsychotics - CBT

33yo married father of 2 has poor sleep and concentration that is affecting his work performance. Distracted @ work and not meeting deadlines. Has memory gaps that frustrate him bc friends recall things that he can't remember. For 2mo has had nightmares causing poor sleep. Wife says he is depressed and irritable and less interested in spending time w/the fam. PMH of ADHD as child. Social hx of veteran of 3 deployments where saw combat, drinks wine to fall asleep and beers on weekends. PE shows him to be restless, scans room, becomes visibly tense when a door slams nearby. Stares into space and doesnt respond to name for few moments. Dx?

Dx: PTSD!! - apparently even if there wasn't a specific trigger if they were in the military at all then they could have PTSD. esp if they had mult deployments, saw combat, or were there a long time - also apparently the amnesia can occur anytime and not just be loss of memory from the traumatic experience - pts can feel depersonalization/derealization disorder and dissociative amnesia but these are just considered part of the PTSD - remember MILITARY = PTSD

24 yo M brought to ED bc wife said he is threatening her. He has been increasingly irritable and abusive for last several months. Becomes angry for no reason and had fist fight at work. Say they have been unable to conceive for 2 yrs. He says there is nothing wrong. Healthy and exercises frequently. BP = 148/92, PR = 102. PE shows receding hairline and palpable tissue underneath nipples bilaterally. Which rx is the cause?

Dx: Pt is taking testosterone steroid supplements

68 yo M who's wife says he has been moving around in his sleep in the early morning hours for several months. He kicks in bed, pushes over the nightstand, and has pushed her while she was lying next to him. When she wakes him up he is confused before becoming fully awake. He does not snore and there are no pauses in breathing while sleeping. Patient says that he has been having a recurrent dream abt being lost in woods. Only other sx is constipation and well controlled HTN and slightly slowed gait. Dx? What can these sx be a sign of?

Dx: RAPID EYE MVMT SLEEP BEHAVIOR DISORDER - complex motor mvmts that occur during REM sleep - dream reenactment - occurs during latter part of night - pts can be awakened but are confused at first - more common in older men - if freq and recurrent it can be a prodromal sign of parkinson's disease or dementia w/lewy bodies. will occur w/other prodromal signs like subtle motor deficits like changes in gait, anosmia, constipation Differentials: - sleep terrors and sleep walking are examples of non-REM sleep arousal disorders. occurs in younger pts, during 1st 3rd of sleep, longer period of confusion after waking

27yo F brought to ED after being found running down busy highway screaming that she is blessed w/the power to save all souls. She believes she is Christ reincarnate and the long lost daughter of the president. She has been homeless and unemployed for a year. PE shows her to be disheveled w/poor hygiene. She smiles and laughs for no apparent reason. Speech is rambling and difficult to follow. When asked if she has psychiatric hx she says she was hospitalized last year and bad doctors tried to trick her into taking poison but she outsmarted them. Dx?

Dx: SCHIZOPHRENIA - even though they don't say that this has gone on for ≥ 6 mo bc she has shown signs of impaired functioning (homeless, hospitalized last year, 1 yr of unemployment) we can assume that she has been schizophrenic for at least 1 year. Impaired functioning is assumed to be d/t her mental state Differentials: - schizophreniform is the dx if the schizophrenic sx haven't gone the full 6 mo yet

38yo F brought to ED by sister after onset of acute anxiety, HA, N/V while eating dinner. PMH of allergies tx'd w/ diphenhydramine and MDD and panic attacks. She has had poor response to several antidepressants. Was tx'd w/escitalopram for 1 yr but stopped 1 wk ago so could switch to phenelzine yesterday. PE shows agitation, disorientation, diaphoretic, tremulous, dilated pupils, bilateral tremors, 3+ bilateral DTRs. Temp = 102, BP = 170/110, PR = 115, RR = 24. Dx? What drugs can cause this (6)?

Dx: SEROTONIN SYNDROME - for all SSRIs except for fluoxetine you have to stop them 2 weeks before starting MAOi to prevent serotonin syndrome - for fluoxetine, which has a long t1/2, you must stop it 5 wks before starting MAOi - note that linezolid w/serotonergic antidepressants can cause this - rxs that cause SS are serotonergic meds = SSRI, SNRI, MAOi, TCA, tramodol, MDMA

14yo F brought to ED after rambling on about "bats on the ceiling" and trying to run out of school. PMH of asthma tx'd w/albuterol and ADHD tx'd w/XR mixed amphetamine salts. Fam hx of Grave's disease and schizophrenia. Father says she has had odd behavior for a few days like poor sleep, anxious, staring at bedroom walls. Several weeks earlier she had HA, poor concentration, sore knees. Recently started staying home from school and missing play dates bc her joints have been hurting too much. U/A shows +2 protein and 5-10/hpf RBCs and pos for amphetamines. CBC shows platelets of 85000/mm^3. TSH and electrolytes are normal. Next step?

Dx: SLE - SLE can cause psychosis, depression, mania, anxiety - SLE neuropsychiatric sx = seizure, HA, peripheral neuropathy, stroke, chorea - she also presents w/arthralgia, thrombocytopenia, hematuria, proteinuria Next step: - OBTAIN ANTINUCLEAR ANTIBODIES - if ANA+ then get more specific abs like anti-dsDNA, anti-smith, anti-U1 ribonucleoprotein Differential: - thyroiditis can result in anxiety, insomnia, acute psychosis

32 yo M comes in for 1 mo f/u after discharge for schizoaffective disorder. 10lb wt gain d/t significant inc in appetite. He also has high blood glucose. Rx responsible (2)? What drug can he be switched to (3)?

Dx: Schizoaffective disorder Rx: - 2nd generation atypical antipsychotics: OLANZAPINE and clozapine have the greatest risk of wt gain and hyperglycemia Switch to: - Aripiprazole, lurasidone, ziprasidone Differentials: - Lithium, valproate, mirtazapine, paroxetine cause wt gain but not hyperglycemia

52yo M w/schizophrenia started on new antipsychotic for auditory hallucinations this month. Intensity of voices dec'd but became increasingly agitated. Dosage elevations do not appear to calm his agitation. He leaves his group home in the mornings and walks all day in the neighborhood and into other patient's rooms. Dx? Rx changes?

Dx: Schizophrenia Rx: - typical antipsychotics AE: - AKATHISIA - restlessness Tx: - LOWER HIS DOSE AND GIVE beta blocker like PROPRANOLOL - can also give benztropine (anti-cholinergic) Differentials: - benzos are not 1st line tx bc inc mortality in schizophrenics