Psychiatry M3

Primary adrenal insufficiency MNEMONIC Etiology (Acute, Chronic) Pathogenesis Presentation Labs Old diagnostic test New diagnostic test Treatment

"Primary Pigments Skin" Etiology: Acute 1˚ Adrenal Insufficiency: #1 etiology: Abrupt withdrawal of glucocorticoids 2. N. meningitidis --> Waterhouse-Friederichsen syndrome --> DIC 3. Adrenal hemorrhage or infarction 4. Illness/injury/sx in patient with chronic AI 5. Pituitary apoplexy (bleeding) Chronic 1˚ Adrenal Insufficiency: AKA Addison disease #1 etiology: Autoimmune (ex: anti-21-hydroxylase antibodies) destruction of adrenal glands 2. TB 3. Metastatic carcinoma (ex: lungs) Pathogenesis: 1. Hypotension: Loss of glucocorticoid AND mineralocorticoid production (aldosterone) causes vasodilation and salt wasting 2. Hyperpigmentation: Increased ACTH metabolism (2˚ to low miceralo- and corticosteroids) into Melanocyte Stimulating Hormone (MSH) Presentation: 0. Hyper-pigmentation Mineralocorticoid deficiency: 1. Hypotension + shock (adrenal crisis) 2. Weight loss 3. Hyponatremia: Sugar/salt craving 4. Hyperkalemia Glucocorticoid deficiency: 5. Psychiatric manifestations (irritability, depressed mood) 6. Fatigue 7. Anorexia 8. GI upset Androgen deficiency: 9. Loss of libido 10. Women only: suppression of secondary sex characteristics (reduced pubic hair) Labs: 1. INCREASED ACTH 2. Hyperkalemia (2˚ to hypoaldosteronism) 3. Metabolic acidosis Old Diagnostic Test: Metyrapone stimulation test: a. Metyrapone inhibits 11-B-hydroxylase, resulting in decreased cortisol synthesis b. Normal: Decreased cortisol, increased ACTHc. 1˚ adrenal insufficiency: decreased cortisol, decreased ACTH New diagnostic test Cosyntropin (synthetic ACTH) stimulation --> low cortisol production = positive diagnosis of PAI Treatment: 1. Glucocorticoid replacement (hydrocortisone, prednisone) 2. Mineralocorticoid replacement (fludrocortisone)

MDMA intoxication adverse effects

1. Amphetamine toxicity: HTN, tachycardia, hyperthermia 2. Serotonin toxicity: serotonin syndrome (autonomic dysregulation, high fever, altered mental status, neuromuscular rigidity, seizures) 3. Hyponatremia (drug-induced SIADH plus excessive water intake to reduce hyperthermia)

Atypical subtype of MDD

1. Depressed mood 2. Social isolation (loss of interest) 3. Fatigue 4. Leaden paralysis 5. Hypersomnia 6. Weight gain 7. MOOD REACTIVITY (positive responsiveness to pleasant events or to being talked to pleasantly) 8. Hypersensitivity to rejection

Symptoms of nicotine withdrawal

1. Dysphoria 2. Irritability 3. Anxiety 4. Increased appetite

High risk for opioid overdose (risk factors)

1. Escalating or high-dose opioid therapy (provide patients on chronic opioids with naloxone and educate them/family on OD precautions) 2. Concurrent benzodiazepine use 3. History of substance use disorder or overdose 4. Close contacts (eg, children) who may accidentally ingest the drug

Adverse effects of growth hormone

1. Hyperglycemia 2. Sodium retention 3. HTN 4. Swollen hands 5. Joint and muscle pain

Symptoms of stimulant withdrawal

1. Increased appetite 2. Hypersomnia 3. Intense psychomotor retardation 4. Severe depression (crash)

Symptoms of cannabis withdrawal

1. Irritability 2. Anxiety 3. Insomnia 4. Depressed mood 5. Decreased appetite

Involuntary drug screens

1. Patients who lack decision-makings 2. Pts requireing Emergent care In adolescents, first explore patient concerns and consult about limitations of screening (false-positive, erosion of trust)

Options to manage antipsychotic-induced parkinsonism:

1. Reduce the dose of antipsychotic 2. Switch to antipsychotic with less potential to cause EPC if feasible 3. Add an anticholinergic antiparkinsonian medication (Benztropine or diphenhydramine [antimuscarinic] vs amantadine [partial dopamine agonist]) when antipsychotic is working well and there is concern for destabilizing the patient w/ dosage reduction

Indications for considering inpatient care (emergency assessment / possible hospitalization) in depressed child patient

1. Suicidal ideation 2. Poor psychosocial support 3. Lack of psychiatric follow-up (as an outpatient)

Symptoms of benzodiazepine withdrawal

1. Tremors 2. Anxiety 3. Perceptual disturbances 4. Psychosis 5. Insomnia Exam: 1. Seizures 2. Tachycardia 3. Palpitations

Homicide risk factors

1. Young male 2. Unemployed 3. Impoverished 4. access to firearms (#1) 5. substance abuse 6. antisocial personality disorder 7. Hx of violence or criminality 8. Childhood abuse 9term-167. Impulsivity

Progressive multifocal leukoencephalopathy

1Reactivation of the JC virus, presents with: 1. Motor deficits and other neurologic signs 2. Demyelination on neuroimaging

First line treatments of alcohol use disorder

1st Naltrexone - blocks µ-opioid receptors - decreases alcohol craving - reduces heavy drinking days - increases days of abstinence Contraindications: - patients taking opioids - acute hepatitis or liver failure 2nd Acamprosate - glutamate modulator - maintain abstenance - good for patients with liver disease or opioid use (since naltrexone is an opioid that's contraindicated in liver failure patients) Contraindications: - renal impairment 3rd Disulfram - aldehyde dehydrogenase inhibitor - use ONLY in abstinent patients, monitor closely - causes unpleasant physiologic reaction (tachycardia, flushing, headache, nausea, vomiting) with alcohol

How do you treat a patient with antidepressant-induced mania?

1st d/c antidepressant 2nd if mania persists, add mood stabilizer (lithium, valproate) or antipsychotic (quetiapine)

Low levels of what metabolite is associated with suicidal behavior

5-hydroxyindolecacetic acid (5-HIAA), the primary metabolite of serotonin

REM sleep behavior disorder Description Characteristic polysomnographic findings Increased risk for

A neurological disorder in which the person does not become paralyzed during REM sleep and thus acts out dreams (MIKE O'NEILL SINGING, KICKING, WALKING IN HIS SLEEP) Patient can be awakened and are alert and oriented, can recall dreams but not their actions/movements Characteristic polysomnographic findings Loss of normal REM sleep atonia Increased risk for: Parkinson Dementia with Lewy bodies Subtle signs of neurodegeneration: 1. Slowed gait 2. Anosmia 3. Constipation Tx: 1. Melatonin

X-linked adrenoleukodystrophy

ABCD1, Xq28 Peroxisomes cannot oxidize long-chain FA Long-chain FA accumulate in blood, cause damage to white matter of brain range from childhood cerebral (disabled by 2 years), adrenomyeloneuropathy (late 20's paraparesis), adrenocortical insufficiency (seen mostly in carrier females) Presents: 1. academic difficulties and behavioral abnormalities in early childhood and adolescence 2. Weakness 3. Ataxia 4. Paralysis

Extrapyramidal effects of antipsychotics Acute dystonia Akathesia Parkinsonism Tardive dyskinesia Pathophys: Timing: Symptoms: Treatment:

Acute dystonia Pathophys: - acute blockage of nigrostriatal pathway Timing: - Tmax effect (oral: minutes, IM seconds, IV: immediate) Symptoms: - sudden, sustained contraction of the neck, mouth, tongue and/or eye muscles - oculogyric crisis - forced upward gaze deviation - torticollis - blepharospasm - trismus Treatment: anti-muscarinic agents - benztropine / trihexyphenidyl - diphenhydramine Akathesia Pathophys: - Brain tries to respond to blockade of dopamine receptors by up-regulating other monoamine circuitry. I.E. adrenergic up-regulation (informs treatment) Timing: days to weeks Symptoms: - internal sense of restlessness, inability to sit still Treatment: - propranolol (the only oral beta-blocker that crosses the blood-brain barrier) - if propranolol is contraindicated (asthmatics or COPD/lung illness patients), use benzodiazepines (lorazepam) - benztropine (anti-muscarinic) Parkinsonism Pathophys: - CHRONIC blockade of nigrostriatal pathway Timing: weeks to months Symptoms: - gradual-onset tremor, rigidity, & bradykinesia (eg, slow finger tapping) - cogwheel rigidity (rigidity w/ tremor), shuffling gait (drags feet and doesn't move arms), masklike facies (expressionless face) Treatment: - anti-muscarinic agents: benztropine (on psych units) or diphenhydramine (elsewhere) - amantadine (partial dopamine agonist) Tardive dyskinesia Pathophys: - Brain tries to respond to blockade of dopamine receptors by upregulating other dopaminergic circuitry to fight D2 blockade: a. makes more receptors b. makes receptors more sensitive c. brain makes more dopamine So you have more dopamine that occasionally hits an supersensitive receptor Timing: months - years Symptoms: - Lip smacking, oral tics, choreoathetoid movements: writing, repetitive, nonrhythmic movements seen in multiple parts of the body Treatment: 1st Reduce D2 antagonism to give break time to readjust (works for some) 2nd reversible VMAT2 inhibitors (inhibit dopamine reuptake) - Valbenazine - Deutetrabenazine - tetrabenazine 3rd switch antipsychotic medication (quetiapine or clozapine)

Fomepazole

Alcohol dehydrogenase inhibitor used as an antidote to treat methanol or ethylene glycol poisoning

Standard drug screen Amphetamine, cocaine, cannabis opioid, PCP Drug Duration of positive test (short term use) Duration of positive test (long term use) False positives

Amphetamine positive test (short term use): ≤2 days positive test (long term use): ≤4 days False positives: 1. Atenolol, propranolol 2. Bupropion 3. Nasal decongestants Cocaine positive test (short term use): ≤2 days positive test (long term use): ≤7 days False positives: NONE Cannabis positive test (short term use): ≤3 days positive test (long term use): 1-2 months days False positives: 1. Hemp-containing foods Opioids: heroin and codeine NOTE: semisynthetic (hydrocodone, hydromorphone, oxycodone) or synthetic (fentanyl, meperidine, methadone, tramadol) opiods NOT detected on standard urine drug screens positive test (short term use): ≤3 days positive test (long term use): ≤3 days False positives: 1. Poppy seeds Phencyclidine (PCP) positive test (short term use): ≤7 days positive test (long term use): ≤7 days False positives: 1. Dextromethorphan 2. Diphenhydramine, doxylamine 3. Ketamine 4. Tramadol (opiod agonist) 5. Venlafaxine

Kid with a cold comes in with cold symptoms (fever, runny nose, cough) is given antihistamines (diphenhydramine, doxylamine) and alpha-adrenergic agents (phenylephrine, pseudophedrine) and dextromethorphan and starts acting weird

Antihistamines decrease nasal discharge Alpha-adrenergics construct blood vessels, decreasing nasal congestion Dextromethorphan is cough suppressant Taking too much can cause hallucinations

Medications with anticholinergic properties

Antihistamines: 1. Diphenhydramine 2. Cyproheptadine 3. Doxylamine Psychotropics 1st gen: haloperidol, chlorpromazine 2nd gen: clozapine TCAs: amitryptaline, clomipramine, doxepin Antiparkinson: 1. Benztropine 2. Trihexyphenidyl Antimuscarinics: 1. Ipratropium 2. Oxybutynin, darifenacin (Overactive bladder) 3. Dicyclomine, hyoscyamine (antispasmotics) 4. Scopolamine (antiemetic) Mydriatics: 1. Atropine 2. Cyclopentolate Plant based: 1. Muscarinic mushrooms 2. Jimson weed 3. Nightshade species

Assessment and management of suicidality Assessment (SADPERSONS) Management

Assessment: SAD PERSONS Sex (M>F) Age Depression Previous attempts #1 EtOH use Rational though loss (psychosis) Social support Organized plan No spouse or significant other Sickness or injury/pain Management: High imminent risk (ideation, intent, and plan) 1. Ensure safety: hospitalize immediately (involuntarily if necessary) 2. Remove personal belongings & objects in room that may present self-harm risk 3. Constant observation and security may be required (possibly against will) High nonimminent risk (ideation, intent, but no plan to act in near future) 1. Ensure close follow-up 2. Treat modifyable risk factors (underlying depression, psychosis, substance abuse, pain) 3. Recruit family or friends to support patient 4. Reduce access to potential means (secure firearms, medications)

Intention tremor Associated with Presents

Associated with cerebellar disorders (stroke or alcohol) Presents: 1. No tremor at rest 2. Tremor with movement that WORSENS as you get CLOSER to the target (unlike essential tremor, which stays the same throughout action) Tx: nothing

When to administer activated charcoal

Awake patient within a few hours of toxin ingestion Contraindication: altered mental status (aspiration risk)

Standard labs to order for acute psychosis...

BMP CBC Utox Syphilis HIV B12 TSH ANA

Why is metoprolol contraindicated in patients with cocaine use?

Beta blockers used during cocaine intoxication can lead to unopposed alpha1-adrenergic activation, which can lead to marked hypertension and further increase the risk for coronary vasospasm

Boarderline Personality Disorder (BPD) Brief description DSM Treatment

Brief description: chaotic relationships abandonment fears unstable mood impulsivity inner emptiness self-harm Epi: history of childhood abuse and insecure attachment to caregiver is common Diagnostic criteria: Pervasive patterns of marked impulsivity, with unstable relationships, self-image & affects, plus ≥5 of the following: 1. Frantic efforts to avoid abandonment 2. Unstable and intense interpersonal relationships 3. Markedly & persistently unstable self-image 4. Impulsivity in ≥2 areas that are potentially self-damaging 5. Recurrent suicidal behaviors or threats of self-mutilation (eg. cutting) 6. Affective instability (marked mood reactivity) 7. Chronic feelings of emptiness 8. Inappropriate & intense anger (often in response to feelings of abandonment) 9. Transient stress-related paranoia (eg delusional jealousy) or dissociation Treatment: 1st: Psychotherapy (best evidence for dialectical behavior therapy) 2nd adjunctive pharmacotherapy to target mood instability and transient psychosis (2nd-gen antipsychotics, mood stabilizers) 3rd antidepressants of comorbid mood or anxiety disorder NOTE: Postulated to be due to deficient seratonin

Histrionic personality disorder Brief description DSM-5 Tx vs narcissistic personality disorder

Brief: Superficial, theatrical, attention-seeking Pattern of excessive emotionality and attention seeking, with 5 of the following: 1. Uncomfortable when not center of attention 2. Inappropriately seductive or provocative 3. Rapidly shifting but shallow expression of emotion 4. Uses physical appearance to draw attention 5. Speech that's impressionistic and lacking detail 6. Theatrical and exaggerated expression of emotion 7. Easily influenced by others or situation 8. Perceives relationships are more intimate than they are Tx: Psychotherapy Pharmacotheraapy for associated depressive or anxious symptoms vs narcissistic personality disorder NPDs don't exhibit dramatic emotional displays NPDs lack empathy and engauge in interpersonal exploitation

Assessment of decision-making capacity

CUAR Criteria == Patients can: Communicate choice Understand info Appreciate consequences Rationalize decision

Serotonin Syndrome Causes Course Overlapping features (w neuroleptic malignant syndrome) & distinct features Management

Causative agent 1. Serotonergic agent (SSRI/SNRI, TCA, tramadol), especially in combination with each other 2. Serotonergic with MOI or linezolid 3. Switching from serotonertic to MOI before a 2 week washout period 4. Serotonergic agent then added detromethorphan (activates sigma opioid receptors to inhibit cough, but also has serotonergic activity at 5-HTA2 receptors) 5. Serotonergic medication overdose 6. Serotonergic drugs of abuse (MDMA) Course: 1. Rapid onset/offset (<24 hours) (vs NMS slow onset) 2. Often associated with dose increase or additional serotonergic agent Overlapping features with NMS: 1. Autonomic dysregulation (diaphoresis, HTN, tachcardia) 2. Altered mental status (anxiety, agitation, delirium) 3. Hyperthermia Distinct features: 1. Neuromuscular hyperactivity (tremor, myoclonus, hyperreflexia) 2. Clonus 3. Nausea / vomiting Management: 1st D/C serotonergic meds 2nd Supportive care: a. cooling, not antipyretics b/c hyperthermia is due to muscle contraction) b. sedation with benzos (lorazepam) to improve agitation and decrease muscle contraction and decrease HTN and HR c. manage severe hypertension with short-acting antihypertensives (esmolol) 3rd: If supportive measures fail --> Serotonin antagonist (cyproheptadine - antagonises 5-HT1a and 5-HT2a receptors) 4. Immediate sedation, paralysis, and tracheal intubation if temp >106

Neuroleptic malignant syndrome Causative agents Pathophysiology Signs/symptoms Treatment

Causative agents: dopamine antagonism - ANY antipsychotic medication - antiemetic medications (promethazine) - withdrawal of Parkinson's medications Pathophysiology - central dopaminergic receptor blockaid (hyperthermia, dysautonomia) - disruption of nigrostriatial dopamine pathways (rigidity) Signs/symptoms - fever - altered mental status - generalized muscle rigidity (distinguishing feature from Seratoning Syndrome) - autonomic instability (abnormal vital signs [tachypnea, HTN, tachycardia, dysrhythmia], diaphoresis) - elevated CK +/- renal failure (rigidity can lead to muscle breakdown) - myoglobinuria - leukocytosis with left shift Treatment: - stop antipsychotics or restart dopamine agents - supportive (hydration, cooling, electrolyte replete) ICU - benzodiazepines - Bromocriptine or amantadine (dopamine receptor agonist) or Dantroline (direct, rapid muscle relaxant) if refractory

Antidepressant discontinuation syndrome (ADS)

Cause: Stoping serotinergic antidepressants (especially those with shorter elimination half-lifes (paroxetine, venlafaxine), higher dose, and longer duration of tx Possible that long term use decreases decreases transporters (which usually decrease seratonin levels in synaptic cleft), causing less 5-HT reuptake. So discontinuation leads to hyperserotonergic manifestations. Effects on other NTs (like NE) may explain other ADS ssx like rhinorrhea Symptoms: 1. Flu-like symptoms - fatigue, myalgia, chills, headache, rhinorrhea 2. Neurosensory disturbances - parasthesa, "electric shock" sensations, vivid dreams 3. Psychological symptoms - dysphoria, anxiety, irritability Tx: RESTART serotonergic antidepressants

Locked-in syndrome Pathophysiology Presentation

Caused by pontine stroke Presents: 1. Paralysis 2. Mutism 3. Preservation of cognitive abilities

Disruptive Mood Dysregulation Disorder (DMDD)

Childhood condition (diagnosis <18 yo) characterized by repeated temper tantrums

Cyclothymic disorder

Chronic mood disorder lasting ≥2 years of: - fluctuating mood disturbances: mild hypomanic and depressive symptoms that don't meet criteria for hypomanic or major depressive episode

Advanced sleep-wake phase disorder

Circadian rhythm sleep-wake disorder Clinical: advanced sleep time 1. Inability to stay awake in the evening (after 7PM) 2. Early morning insomnia

Delayed sleep-wake phase disorder

Circadian rhythm sleep-wake disorder "Delays sleep" "night owls" Clinical: 1. sleep-onset insomnia 2. excessive morning sleepiness 3. normal sleep duration and quality when self-directed

Allopecia areata Features Treatment

Circular and smooth patches of complete hair loss Tx: 1. Intradermal corticosteroid injections

HSV encephalitis

Classically affects temporal lobe Presents: Rapidly worsening mental status 1. Develops in under 1 week 2. Accompanied by fever, headache 3. Seizures 4. Focal neurologic deficits

Anorexia nervosa Clinical features Labs Treatment When to hospitalize?

Clinical features 1. BMI <18.5 2. Intense fear of weight gain 3. Distorted view of body weight & shape 4. Possibly throw up food (no binge-ing) - parotid gland hypertrophy - pharyngeal erythema - dental carries - scars or calluses on hand - electrolyte abnormalities 5. Dermatologic complications: - dry, scaly skin - hair loss - lanugo (fine, downy hair) 6. Hypotention 7. Hypothermia 8. Bradycardia 9. Cardiac atrophy, arrhythmias 10. Amenorrhea 11. Osteoporosis Labs: 1. Low T3 and/or T4 Treatment 1. CBT 2. Nutritional rehab 3. Olanzapine (atypical antipsychotic) if no response to above When to hospitalize? 1. Unstable vital signs (hypotension, bradycardia, hypothermia) 2. Electrolyte derangements 3. Severely low body weight

Bulimia nervosa Clinical features Treatment

Clinical features 1. Recurrent episodes of binge eating 2. PLUS inappropriate compensatory behavior (vomiting, running) to prevent weight gain 3. Excess worrying about body shape/weight Treatment: 1. CBT 2. Nutritional rehab 3. SSRI (fluoxetine)

Tourette syndrome Clinical features At risk of developing which comorbidities? Treatment

Clinical features: 1. Both multiple motor tics & ≥1 vocal tics for >1 year - Motor: facial grimacing, blinking, head/neck jerking, shoulder shrugging, tongue protrusion, sniffing - vocal: grunting, snorting, throat clearing, barking, yelling, coprolalia (obscenities) 2. Onset age <18 (commonly 6-15) NOTE: Different than persistent motor or vocal tic disorder (which presents with EITHER motor or vocal tics) At risk of developing which comorbidities? MC are 1. OCD - typically develops 3-6 year after tics 2. ADHD Others are anxiety, depression, autism spectrum disorders, learning disorders, and disruptive impulse-control, and conduct disorders Treatment: 1. Psychoeducation (habit reversal training) 2. Behavioral interventions - habit reversal therapy 3. Medications (only if tics are impairing): 1st: guanfacine: alpha-2 agonist (first line) clonadine: alpha-2 agonist (more sedative) Antidopaminergic agents: 1. Tetrabenazine (VMAT2 inhibitors) 2. Second-generation antipsychotics (risperidone) >> first-generation (pimozide) antipsychotics

Premature ejaculation

Clinical features: 1. Decreased ejaculatory latency (<1 minute) 2. Uncontrolled orgasm 3. Distress to patient and/or partner Treatment: 1. SSRIs 2. Topical anesthetics (lidocaine) 3. Psychotherapy, joint/couples therapy

Autism spectrum disorder Clinical features Neuroimaging Assessment and management principles

Clinical features: 1. Deficits in social communication and interactions with onset in early development - sharing of emotions or interests - nonverbal communication - developing and understanding relationships - absence of joint attention (i.e. doesn't respond to pointing) 2. Restricted, repetitive patterns of behavior - repetitive movements or speech - intense fixated interests - insistence on sameness/routines - adverse responses to sensory input 3. May occur with or without language & intellectual impairment Neuroimaging: Accelerated head growth during infancy Increased total brain volume Assessment and management: 1. Early diagnosis and intervention 2. Comprehensive, multimodal treatment (speech, behavioral therapy, educational services) 3. Adjunctive pharmacotherapy for psychiatric comorbidities

Pyromania Clinical features Differential diagnosis

Clinical features: 1. Deliberate fire setting ≥2 times 2. Fascination with fire 3. Tension/arousal prior to act; pleasure/relief when setting/witnessing fires 4. No external motivation (financial gain, political statement, recognition) Differential diagnosis: 1. Conduct disorder, antisocial personality disorder (>18) 2. Mania, psychosis 3. Impaired judgement (neurocognitive disorder, substancce intoxication)

Adjustment disorder (with depressed mood) Clinical features DDx Management

Clinical features: 1. Onset within 3 months of identifiable stressor 2. Marked distress &/or functional impairment 3. Does not meet criteria for another DSM-5 dx (possibly present with some somatic symptoms) DDx: 1. Normal stress response not excessive, no impairment 2. Acute stress disorder traumatic event, intrusive re-experiencing 3. Major depressive disorder ≥2 weeks, 5/9 symptoms: depressed + SIGECAPS Management: 1st psychotherapy 2nd: adjunctive pharmacology to relieve symptoms (sleep aid, anxiolytic like zolpidem (GABA agonist)

Gender dysphoria Clinical features Initial management

Clinical features: 1. Persistent (≥6 month) incongruence between assigned and felt gender 2. Desires to be another gender 3. Dislikes on anatomy, desires sexual traits of another gender 4. Believes feelings/reaction are of another gender 5. Feels significant distress/impairment Initial management 1. Assessment of safety 2. Support; psychotherapy (individual, family) 3. Referral to specialist services (medical and mental health multidisciplinary)

Panic disorder Clinical features Treatment

Clinical features: 1. Recurrent & unexpected panic attacks with ≥4 of the following: - chest pain, palpitations, SOB, choking - trembling, sweating, nausea, chills - dizziness, paresthesia - derealization, depersonalization - fear of losing control or dying 2. Worry about additional attacks --> avoidance behavior Tx: 1st line/maintenance: SSRI / SNRI and/or CBT Acute panic attack: benzodiazepines NOTE: Lactate infusion can provoke panic attacks, and has been used in research to identify those with panic disorder

Restless leg syndrome Clinical features Associated secondary causes Diagnostic workup Treatment

Clinical features: Uncomfortable urge to move legs with: 1. Dysesthesia - unpleasant (crawling/itching) sensations in the legs 2. Onset with inactivity or at night 3. Urge to move legs partially relieved with movement (walking, stretching) Associated secondary causes: 1. Iron deficiency anemia 2. Uremia (ESRD, CKD) 3. DM 4. Multiple sclerosis 5. Parkinson disease 6. Pregnancy 7. Drugs: a. antidepressants b. metoclopramide Diagnostic work-up: 1st: obtain serum iron levels Treatment: 1. Supplement iron when serum ferritin <75µg/L Mild/intermittent symptoms 1. Supportive (leg massage, heating pads, exercise) 2. Avoid aggravating factors (sleep deprivation, meds) Persistent/moderate to severe symptoms: 1. Dopamine agonists (ropinrole, pramipexole) 2. alpha-2-delta calcium channel ligands (gabapentin)

Persistent depressive disorder (dysthymia) Clinical features Specifiers

Clinical features: Think low-grade depression that lasts for years 1. Chronic depressed mood for ≥2 years 2. ≥2 of the following: a. appetite disturbance b. sleep disturbance c. low energy d. low self-esteem e. poor concentration f. hopelessness Specifiers: 1. Pure dysthymic syndrome: criteria for major depressive episode never met 2. With intermittent major depressive episodes 3. With persistent major depressive episodes: criteria for major depressive episode met throughout previous 2 years Tx: Antidepressants +/- psychotherapy

Reactive attachment disorder Clinical features Associated features DDx Management

Clinical features: in children 1. Insufficient care (neglect, abuse, inconsistent caregiving [frequent moves in foster homes, prolonged institutionalization]) 2. Does not seek or respond to comfort 3. Poor social responsiveness, limited positive affect 4. Unexplained irritability/fear/sadness, even during safe encounters 5. Lack of positive emotions Associated features: 1. Toiletting & sleep difficulties 2. Anxiety, aggression (throws shit), hyperactivity, impulsivity, hoarding DDx: 1. Adjustment disorder, PTSD 2. Global developmental delay, intellectual disability 3. Autism 4. Anxiety (social anxiety, selective mutism) 5. Depressive disorders Management: 1. Early intervention promoting a. safe, stable, enriching environment b. consistent, responsive caregiving 2. Psych services (parenting skills, individual/family counseling)

PTSD Clinical features Treatment

Clinical features: ≥1 month 1. Exposure to trauma (personal or to others) 2. Nightmares, flashbacks, intrusive memories 3. Avoidance of reminders of trauma 4. Dissociation (staring into space) 5. Emotional detachment, negative mood, decreased interest in activities 6. Sleep disturbance, hypervigilance, irritability Treatment: 1st: Trauma-focused cognitive-behavioral therapy 2nd: antidepressants (SSRIs, SNRIs) 3rd: prazosin for nightmares

Systemic lupus erythematosus Clinical symptoms Laboratory findings

Clinical symptoms: 1. Constitutional: fever, fatigue, weight loss 2. Symmetric, migratory arthritis 3. Skin: butterfly (malar) rash & photosensitivity 4. Serositis: pleurisy (inflammation of the pleura), pericarditis, & peritonitis 5. Thromboembolic events (due to vasculitis and antiphospholipid antibodies 6. Neurologic: cognitive dysfunction & seizures, peripheral neuropathy, stroke, chorea, and can cause acute onset psychosis (also depression, mania, and anxiety) Lab findings: 1. Hemolytic anemia, thrombocytopenia, and leukopenia 2. Hypocomplementemia (C3 & C4) 3. Antibodies - antinuclear antibodies (sensitive) - anti-dsDNA & anti-Smith (specific) 4. Renal involvement: proteinuria & elevated creatinine

Which second generation antipsychotic has the highest risk of metabolic syndrome

Clozapine Olanzapine

DSM-5 Personality Disorders List Cluster A (ODD/Eccentric) Cluster B (Dramatic/erratic) Cluster C (Anxious/fearful)

Cluster A (ODD/Eccentric) 1. Schizoid 2. Schizotypal 3. Paranoid Cluster B (Dramatic/erratic) 1. Antisocial 2. Boarderline 3. Histrionic 4. Narcissistic Cluster C (Anxious/fearful) 1. Avoidant 2. Dependent 3. Obsessive-compulsive

Therapy --> indications --> features Cognitive behavioral therapy Interpersonal psychotherapy Supportive psychotherapy Psychodynamic psychotherapy Motivational interviewing Dialectical behavioral therapy Biofeedback

Cognitive behavioral therapy: Indications: - Depression - GAD - PTSD - Panic disorder - OCD - Eating disorders - Negative thought patterns Features: - Challenges maladaptive cognitions - Targets avoidance with behavioral techniques (relaxation, exposure, behavior modifications) Interpersonal psychotherapy: Indications: - Depression Features: - Links symptoms to current relationship conflicts and interpersonal skill deficits Supportive psychotherapy: Indications: - lower functioning; psychotic disorders - patients in crisis Features: - Maintains hope; provides encouragements - Reinforces coping skills, adaptive defences Psychodynamic psychotherapy: Indications: - High functioning - Personality disorders Features: - Builds insight into unconscious conflicts & past relationship - Use transference - Breaks down maladaptive defenses Motivational interviewing: Indications: - Substance use disorders Features: - Nonjudgemental; acknowledges ambivalence & resistance - Enhances intrinsic motivation to change Dialectical behavioral therapy: Indications: - Boarderline personality disorder Features: - Emotional regulation; distress tolerance, mindfulness, interpersonal effictiveness Biofeedback: Indications: - prominent physical symptoms; pain disorders Features: - Improves control over physiological reactions to emotional stressors

Hypothyroidism symtoms / PE

Cold intolerance (↓ heat production) Weight gain ↓ appetite Hypoactivityl Lethargy Fatigue Weakness Hyperactivity Constipation ↓ reflexes Bradycardia Dry, cool skin Coarse, brittle hair Diastolic hypertension (Na/H2O retention) Myxedema (facial/periorbital)a

Normal creative behaviors in children Imaginary friends Pretend play Storytelling with fanciful details

Common ages 3-6 Healthy, normal Aids creativity and navigating social relationships

Nigrostriatial system

Connect substantia nigra to caudate and putamen to regulate coordination of voluntary movements. In this pathway, dopamine acts as the 'gas' because it inhibits ACh release that would otherwise inhibit movement; degeneration thus leads to Parkinsonism

Generalized slowing with periodic sharp wave complexes on EEG is characteristic of...

Creutzfeldt-Jacob disease

What does finding 14-3-3 protein in CSF diagnose?

Creutzfeldt-Jakob disease Prion disease (rapid)

Antidote for serotonin syndrome

Cyproheptadine (serotonin receptor antagonist)

Narcissistic personality disorder DSM-5 Tx

DSM-5 Criteria: Pattern of grandiosity, need for admiration, lack of empathy beginning by early adulthood and present in a variety of contexts, with five or more of the following: 1. Exaggerated sense of self-importance 2. Preoccupation with fantasies of unlimited money, success, brilliance, etc. 3. Believes that he or she is 'special' or unique and can associate with only other high-status individuals 4. Requires excessive admiration 5. Sense of entitlement 6. Takes advantage of others for self gain 7. Lacks empathy (vs histrionic) 8. Envious of others or believes others are envious of him or her 9. Arrogant or haughty Tx: Psychotherapy Antidepressant for comorbid mood disorder (patients are depressed when they don't get the attention)

Bipolar I DSM-5 criteria Treatment of: a. Acute bipolar depression: b. Acute manie

DSM-5 criteria Manic episode PLUS /MINUS Major Depressive Episode (possible euthymia, MDE, hypomania, but not required) (possible psychotic features: delusions + hallucinations) Treatment: a. Acute bipolar depression: - lamotrigine (BEST), valproic acid, carbamazepine (anticonvulsant) - second-generation antipsychotics (quetiapine, lurasidone) - Lithium (decreases suicide risk) - valproate - combination olanzapine/ fluoxetine have also shown efficacy NOTE: AVOID antidepressant monotherapy due to risk of precipitating mania. If needed, use antidepressant therapy (SSRI, SNRI, MOI, TCAs) with mood stabilizers (lithium, valproate, 2nd gen antipsychotics) b. Acute mania: antipsychotic (consider IM such as olanzapine) c. SEVERE acute mania (psychotic features, aggressive behavior, risk of harm to self or others): antipsychotic + mood stabilizer d. Pregnant mania OR refractory or life-threatening mania/depression: electroconvulsive therapy

Schizoaffective disorder DSM-5 Treatment DDx

DSM-5 criteria: 1. Meet criteria for either major depressive or manic episode CONCURRENT with symptoms of schizophrenia (MDD or mania + schizo psychosis) 2. Lifetime history of delusions or hallucinations for ≥2 weeks in the absence of major depressive or manic episode (delusion/hallucinations ≥2 weeks WITHOUT mood) 3. Persistent mood symptoms (depression or manic episodes throughout life) Treatment: 1. Hospitalization and supportive psychotherapy 2. Medical therapy: a.) antipsychotics (2nd gen target both psychotic and mood symptoms) b.) Mood stabilizers c.) antidepressants d.) ECT DDx: 1. Major depressive or bipolar disorder with psychotic features: symptoms occur exclusively during mood episodes 2. Schizophrenia: mood symptoms may be present, but for relatively brief periods

Narcolepsy DSM-5 diagnostic criteria Associated features Treatment

DSM-5 criteria: 1. Recurrent lapses into sleep or naps (≥3 times / week for 3 months) 2. ≥1 of the following: - Cataplexy: brief loss of muscle tone precipitated by strong emotion (laughter, excitement) - Low CSF levels of hypocretin-1 - Shortened REM sleep latency Associated features: 1. Hypnagogic or hypnopompic hallucinations 2. Sleep paralysis Treatment: 1. Modafinil: nonamphetamine medication that promotes wakefulness

Obsessive-Compulsive Disorder (OCD) DSM-5 criteria Neuroimaging Treatment

DSM-5 criteria: Experiencing obsession and/or compulsions that are time-consuming (>1 hour/day) or cause significant distress/dysfunction: 1. Obsessions: recurrent, intrusive, anxiety-provoking thoughts, images, urges that pts attempts to suppress, ignore, or neutralize by some other thought or action (i.e. performing a compulsion) 2. Compulsion: repetative behaviors or mental acts the patient feels driven to perform in response to an obsession or a rule aimed at stress reduction or disaster prevention Neuroimaging: Structural abnormalities in the orbitofrontal cortex and basal ganglia Associated with: SI 50%, attempts in 25% Comorbidities: Anxiety (>75%), depressive or bipolar (>60%), OCPD (32%), tic disorder (30%) Treatment: 1. CBT focusing on exposure and response prevention: prolnged, graded exposure to ritual-eliciting stimulus and prevenion of the relieving compulsion 2. Medications: 1st line: SSRIs (fluoxetine, sertraline typically at higher doses) Others: Clomipramine (the most serotonin selective TCA) Can augment with 2nd gen antipsychotics Last resort: Psychosurgery (cingulotomy) or ECT (especially w comorbid depression)

Major Depressive Disorder DSM-5 Characteristic polysomnographic findings Treatment: Presentation of MDD with psychotic features Treatment

DSM-5: ≥2 weeks ≥5 of 9 symptoms: Depressed mood & SIGECAPS Sleep changes Interest (loss of) Guilt Energy Concentration Appetite Psychomotor agitation/retardation Suicidal ideation Significant functional impairment No lifetime history of mania Characteristic polysomnographic findings: 1. Decreased REM sleep latency (time from sleep onset until start of REM sleep) 2. Decreased slow-wave sleep (i.e. DEEP sleep) 3. Increased REM sleep duration and density 4. Disruptions in sleep continuity Neuroimaging: 1. Decreased hippocampal and frontal lobe volumes Labs: 1. Increased cortisol levels (hyperactivity of the hypothalamic-pituitary-adrenal axis) Treatment: 1. FILL IN (antidepressants) With psychotic features: Often mood-congruent delusions, often depressive (deserving punishment, worthlessness, body is rotting). Can be mood-incongruent Treatment: 1. Antidepressant + antipsychotic or ECT, especially in emergent conditions (pregnancy, refusal to eat or drink, imminent suicide risk)

Avoidant personality disorder DSM-5 DDx

DSM-5: Social inhibition, fear of rejection --> avoid social interaction, avoid situations where rejection is possible. Desire companionship, but shy and easily injured with at least four: 1. Avoids occupation that involves interpersonal contact due to fear of criticism and rejection 2. Unwilling to interact unless certain of being liked 3. Cautious of interpersonal relationships 4. Preoccupied with being criticized or rejected in social situations 5. Inhibited in new social situations because they feel inadequate 6. Believes they are socially inept/inferior 7. Reluctant to engage in new activities DDx 1. Schizoid patients don't care for companionship vs avoidant personality disorder people desire companionship 2. Social anxiety disorder is fear of embarrassment vs avoidant personality disorder is fear of rejection & sense of inadequacy Tx: Psychotherapy, with assertiveness and social skills training Group training SSRIs if comorbid social anxiety disorder or major depression

Hartnip disease Defect Presentation Treatment

Defect:Defective intestinal absorption of tryptophan --> decreased nicotinic acid, serotonin, melatonin, and niacin (B3) Presentation: 1. Niacin deficiency (pallagra) - Dementia (ATAXIA) - Diarrhea - Dematitis 2. Aminoaciduria (neutral acids in pee -- alanine, serine, thronine, valine, leucine, isleucine, phenylalanine, tyrosine, tryptophan, histidine) Treatment: Nicotinic acid or nicotinamide

ADHD Define Types DSM-5 criteria

Define: Persistent inattention, hyperactivity, and impusivity inconsistent with pts developmental stage Types: 1. Inattentive 2. Hyperactive/impulsive 3. Combined DSM-5 criteria: 1. Must be >6 months 2. Must be present in 2+ settings (home, school, work) 3. Onset prior to age 12, but can be dx retrospectively 4. Interfere or reduce quality of social/academic/occupational functioning 5. No other mental disorder Inattentive type: at least SIX inattentive symptoms 1. Little attention to detail, careless mistakes 2. Difficulty sustaining attention 3. Doesn't appear to listen 4. Struggles to follow through on instruction 5. Avoids/dislikes tasks requiring a lot of thinking 6. Loses things 7. Is easily distracted 8. Is forgetful in daily activities Hyperactive/impulsivity symptoms: 1. Fidgets with hands/feets + squirms in chair 2. Difficulty remaining seated 3. Runs or climbs excessively in childhood; extreme restlessness in adults 4. Difficulty in engaging in activities quietly 5. "Driven by a motor," internal sensation in adults - talks excessively - blurts out answers before questions complete - difficulty waiting or taking turns - interrupts or intrudes others NOTE: kids demonstrate poor frustration tolerance and impulsive behavior (throw toys) that cause conflicts Treatment: multimodal (first tx symptoms) Pharmacologic: 1st line: stimulants - methylphenidate, dextroamphetamine, mixed amphetamine salts 2nd line: nonstimulants (if substance abuse or preferred) - atomoxetine (norepi reuptake inhibitor) 3rd: alpha-2 agonists (clonadine, guanfacine) (if adverse effects or lack of response) Nonpharmacologic: 1. Behavior mod / social skills training 2. Educational interventions (classrom mods) 3. Parent psychoeduation (parent-child behavioral therapy, AKA parent management training), especially in children <6 - parents taught to consistently implement effective behavioral strategies (rewards, set limits, use time-outs, structure day)

Conduct disorder Define DSM-5 Criteria Comorbidities? Associated with...

Define: children's disorder Disruptive behavior which violates the rights of other humans and animals through physical and sexual violence. May lack remorse for crimes or lack empathy for victims. DSM-5 Criteria 1. Aggression to people and animals: bully/threat/intimidates others initiates fights; uses weapon; physically cruel forced sexual activity 2. Destruction of property Includes fire setting + other means 3. Deceitfulness or theft Breaks into homes/buildings/car Lied to obtain goods/favors Stolen 4. Serious rule violations: Stays out past curfew (under 13 y.o.) Runs away from home ≥2x Leaves school (before 13 y.o.) Comorbidities? High likelihood of having ADHD and ODD Associated with... antisocial disorder Treatment: multimodal 1. Behavior modification, family, and community involvement 2. PMT helps parents set limits and enforce consistent rules 3. Medications to target comorbid symptoms and aggression EX: SSRIs, guanfacine, propranolol, mood stabilizers, antipsychotics

Oppositional defiant disorder Define DSM-5 Criteria At risk of developing which comorbidities?

Define: children's disorder Maladaptive pattern of irritability/anger, defiance, or vindictiveness that causes dysfunction or distress in the patient or those affected (interpersonal issues involving at least one non-sibling) DSM-5 Criteria: At least FOUR symptoms for ≥6 months 1. Anger/irritable mood 2. Argumentative/defiant (break rules, argues w/ authority, annoys and blames others 3. Vindictive (spiteful 2x in last month) 4. Disturbance is associated w/ distress in the individual or others, or it impacts negatively on functioning 5. Behaviors do not occur exclusively during another mental disorder * NO phsyical aggression of vilation of other's basic rights (unlike conduct disorder) * At risk of developing which comorbidities? Substance use ADHD [Often precedes conduct disorder, but most do not develop CD] Treatment: 1. Behavior modification, conflict management training, and improving problem-solving skills 2. Parent Management Training (PMT) can help with setting limits and enforcing consistent rules 3. Medications to treat comorbidities like ADHD

Physician impairment Definition Recognition Management

Definition: - Impaired ability to practice medicine competently and safely due to psychiatric/medical illness, alcohol, or drug dependency Recognition: - Lateness, unexplained absences, inaccessibility - Unusual rounding times - Inappropriate orders, prescription errors, incorrect charting - Increased irritability, anger, conflicts w staff and colleagues - Substance misuse/abuse (excessive drinking at hospital functions, slurred speech, smell alcohol, poor hygiene, needle marks) - Increase in patient complaints - Deterioration in clinical performance Management: - Report to Physician Health Program

Selective mutism

Developmental disorder characterized by a consistent failure to speak in specific social situations (typically at school) despite speaking in other situations

Neurosyphilis dementia

Develops 10-25 years after infection: 1. General paresis 2. Dementia 3. Tabes dorsales (loss of sense of position -- slow degeneration of the nerve cells and nerve fibers that carry sensory information to the brain)

Social anxiety disorder (social phobia) Diagnosis Treatment

Diagnosis: 1. Marked anxiety about ≥1 social situations for ≥6 months 2. Fear of scrutiny by others, humiliation, and embarrassment 3. Social situations avoided or endured with intense distress 4. Marked impairment (social, academic, occupational) 5. Subtype specifier: performance only Treatment: 1. SSRI / SNRI 2. CBT 3. Beta blocker or benzodiazepine for performance-only subtype

Telogen effuluvium

Diffuse thinning of the hair (not patchy) Results from premature shedding and is often triggered by stress (major illness or sx, malnutrition, emotional trauma)

Avoidant/restrictive food intake disorder

Dislike of eating due to the sensory experience of eating or fear of the consequences of eating (such as fear of vomitting or choking) Associated with significantly poor growth or weight loss

Transient global amnesia

Disorder of anterograde amnesia and disorientation that lasts <1 day, is reversible, and is not associated with significant comorbidity

Disruptive mood dysregulation disorder

Disproportionatly verbal or physical outburts Persistently irritable or angry mood accompanied Onset before age 10, not diagnosed after 18

Synthetic cathinones AKA Bath Salts! YIPEE! Drug Type Presentation DDx and how to distinguish

Drug type: Amphetamine analog Presentation: 1. Severe agitation 2. Combativeness 3. Psychosis 4. Delirium 5. Myoclonus 6. Seizure DDx: Looks like PCP intoxication but: - PCP lasts hours (salts last days) - PCP has nystagmus - PCP shows up on drug screen, bath salts do not

Gambling disorder Dx criteria

Dx criteria: Persistent maladaptive gambling resulting in impairment or distress with ≥4 characteristics related to problematic gambling: 1. Preocupation w/ gambling 2. Frequent gambling to recover past losses 3. Damages relationships / jeopardizes employment 4. Reliance on others to make up losses 5. Gambling when distressed, depresssed, or anxious 6. Increased gambling to achieve desired excitement 7. Irritability/distresss when trying to cut back 8. Repeated and unsuccessful attempts to cut back on and conceal the extent of behaviors Tx: CBT & self-help programs (gamblers anonymous)

Delusional disorder

Dx requires: 1. Delusions lasting ≥1 month in the absence of other psychotic or mood symptoms 2. No other psychotic symptoms 3. Behavior not obviously odd/bizzare; ability to function apart from delusion's impact 4. Subtypes: erotomanic, grandiose, jealous, persecutory & somatic Treatment: 1. Antipsychotics 2. CBT

Fetal alcohol syndrome Dysmorphic features Comorbid conditions

Dysmorphic features: 1. Smooth/narrow philtrum (spot above upper lip) 2. Thin vermillion border (thin upper lips) 3. Small palpebral fissures (eye diameter) 4. Microcephaly 5. Midface hypoplasia 6. Bilateral palmar creases Comorbid conditions 1. Seizures 2. Growth restriction 3. Behavioral difficulties (distractibility, emotional reactivity) 4. Neurologic deficits: abnormal reflexes, tone, coordination (clumsiness) 5. Decreased executive functioning, impulse control, emotional regulation 6. Features of ADHD

STOP-Bang survey for Obstructive Sleep Apnea RFs Scoring Complications of OSA Tx

Each RF is 1 point: Snoring Tiredness in the daytime Observed apneas (choking/gasping) Pressure (HTN) BMI >35 Age >50 Neck size: >17 men, <16 women Gender M>F Low risk: 0-2 points Intermediate risk: 2-4 points High risk: 5+ points Complications of OSA: 1. Depressive symptoms: fatigue, sleep disturbance w multiple awakenings, impaired concentration, irritability, and low mood 2. Cardiac events Tx: Positive airway pressure / oral appliances

Early side effects of SSRIs Longer-term side effects of SSRIs

Early: - headache - nausea - insomnia/sedation - anxiety - dizziness Long-term: - sexual dysfunction - weight gain

Subclinical hypothyroidism labs

Elevated TSH, normal T4

Signs of surreptitious use of sulfonylurea

Elevated insulin and C-peptide. C-peptide is cosecreted with endogenous insulin but not present in injectable insulin. sulfonylurea use induces endogenous insulin secretion and thus also C-peptide secretion.

Elimination disorders Enuresis Features Treatment Encopresis Features Treatment

Enuresis: recurrent urination into clothes or bedwetting a. 2x/week for ≥3 consecutive months OR results in distress/impairment b. ≥5 y.o. c. can be nocturnal, diurnal, or both d. no substance (diuretic) or medical condition (UTI, neurogenic bladder, DM) Treatment: 1. limit fluid and caffeine 2. "bladder training" or urine alarm 3. pharmacology for refractory cases: 1st line: desmopressin 2nd line: imipramine at low doses Encopresis: recurrent defecation into inappropriate places (clothes, flood) a. ≥1x/month for ≥3 months b. ≥4 years old c. no substance (laxatives) or other conditions (hypothyroidism, anal fissure, spina bifida) except via a constipation-related mechanism Treatment: Without constipation: "bowel retraining" Due to constipation: bowel cleaning followed by stool softeners, high-fiber diet, toileting routine w/ behavioral program

Rett syndrome Epi Key features Addl features Diagnosis/etiology

Epi: 1. Rare neuodevelopment disorder, F>M 2. Onset 6-18 months 3. X-linked Key features: Normal development followed by: 1. Loss of speech 2. Loss of purposeful hand use (can't feed), stereotypical movements (hair pulling) 3,. Gait abnormalities (lurching gait) Addl features: 1. Head growth deceleration 2. Seizures 3. Breathing abnormalities (hyper/hypoventilation) 4. Sleep disturbances 5. Autistic features Diagnosis: DNA analysis for MECP2 gene mutations

Postpartum psychosis Epi Features Tx

Epi: First 2 weeks after delivery Increased risk in bipolar patients Features: 1. Depressed and/or manic moods 2. Severe insomnia 3. Agitation 4. Disorganized behavior 5. Delusions 6. Hallucinations Content frequently related to the infant Tx: medical emergency (risk of suicide + harming baby) 1. Hospitalize patient

Dhat syndrome Epi Symptoms

Epi: South Asian cultural-bound syndrome Symptoms: 1. Pt attributes a range of psychological and somatic complaints to the loss of semen via various methods (loss in urine, excess masturbation) Tx: Patient-centered approach: patient educations physician on beliefs about their illness: open-ended questions "What do you think is causing these symptoms?"

Separation anxiety disorder Epi Clinical features Treatment

Epi: Separation anxiety is normal up to age 2 - Stranger anxiety begins around 6 months and peaks around 9 months - Separation anxiety emerges by 1 year and peaks around 18 months Clinical features: Excessive and developmentally inappropriate fear/anxiety regarding separation from attachment figures with at least 3 of the following: - Separation leads to extreme distress - Excessive worry about loss of or harm to attachment figs - Excessive worry about experiencing an event that leads to separation from attachment figures - Reluctance to leave home, attend school, or work - Reulctance to be alone - Reluctance to sleep alone or away from home - Complaints of physical symptoms when separated from attachment figs - Nightmare of separation, refusal to sleep w/o proximity to attachment figs - Significant social, academic, or occupational dysfunction - Lasts ≥4 weeks in children and ≥6 weeks in adults Tx: Psychotherapy: CBT, family therapy Medications: SSRIs

Psychogenic nonepileptic seizures Clinical features Comorbidities Diagnosis Treatment

Epileptic seizures not associated with increased synchronous neuronal activity. W>M Clinical features: 1. Witnessed events during wakefulness 2. Long, fluctuating course 3. Asynchronous thrashing - eye closure or fluttering during spell - side-to-side head shaking - asynchronous limb movement - lack of postictal period (AA after 1st episode; second episode resolves within 1 minute) 4. Pelvic thrusting; rapid head turning 5. No loss of consciousness or postictal period Comorbidities 1. Psychiatric conditions (depression, anxiety) 2. Physicalsexual abuse 3. Epilepsy Diagnosis: video electroencephalogram Tx: CBT

Interemittent explosive disorder

Episodes of OOP verbally assaultive or destructive behavior that are not premeditated and typically result in feelings of remorse, dysphoria, embarassement Tx: CBT and SSRI

Parkinson's disease Etiology Symptoms Dx Treatment of idiopathic parkinson Treatment of drug-induced Parkinson's Drugs that cause psychosis in parkinson's patients? What meds to use in treatment of psychosis in Parkinson patient?

Etiology: #1: MTPT metabolite binds to melanin in dopaminergic neurons of substantia negra #2: D2 receptor blockers a. Antipsychotics (1st gen > 2nd gen) b. Antiemetics / GI motility agents (prochlorperazine, metoclopramide [Dopamine receptor antagonists]) Symptoms: 1. Cogwheel rigidity 2. Bradykinesia 3. 4 - 6 Hz resting tremor (rest and postural) Additional suggestive findings: 4. Masked facies 5. +/- psychosis, depression, sleep disturbances, dementia 6. Unilateral onset 7. Visual disturbances (blurred vision, impaired upward gaze) 8. MSK (micrographia, dystonia, myoclonus) 9. Shuffling gait, postural instability 10. Autonomic dysfunction 11. Possibly develop Parkinson disease dementia (RF age, duration, severity of ssx) Treatment: Levadopa + carbadopa -- carbadopa = DOPA deCARBoxylase inhibitor: Prevents peripheral degradation of levodopa into dopamine. Carbadopa reduces peripheral conversion of levodopa, allowing more to be available for effecrting the brain. Reduces peripheral effects (tacharrythmias, postural hypotension, hot flashes), but worsens levadopa side effects because more dopamine becomes available (Anxiety, Agitation, Insomnia, Confusion, Delusions, Hallucinations) Adjunct treatment (with levodopa): Dopamine agonists: - Pramipexole (nonergot - as in not derived from fungi) - Ropinrole (nonergot - as in not derived from fungi) also treat restless leg + Bromocriptine (ergot) Amantadine: promotes synthesis, release, and reuptake of dopamine AE: acute toxic psychosis, ataxia COMT inhibitors used to prolong the effects of levodopa by blocking it's degradation in peripheral tissues - Entacapone (peripheral) - Tolcapone (central + peripheral) MAO-B inhibitors (for mild PD symptoms) - selegeline - rasagalin Treatment if psychotic symptoms like visual hallucinations and paranoid delusions develop (associated with dopamine agonists [pramipexole, ropinrole] as well as dopamine precursers [levodopa]): 1. Reduction of antiparkinson medications 2. Medication substitution 3. &/or addition of low-potency antipsychotic medication with minimal dopamine-2 receptor antagonism (quetiapine, clozapine, pimavanserin) when #1 and #2 fail

Anticholinergic toxicity

Etiology: 1. Overdose or combination of anticholinergic agents 2. Competitive inhibition of muscarinic ACh receptors in CNS, cilary body, heart, smooth muscle, secretory glands Clinical features: 1. Agitation, delirium, hallucinations, seizures 2. Mydriasis, blurry vision 3. Tachycardia 4. Urinary retention, decreased bowel sounds 5. Dry & flushed skin, dry mucous membranes 6. Hyperthermia 7. QRS or QTc prolongation Dx: Clinical Tx: 1. Supportive 2. Activated charcoal (awake pts <2 hrs after ingestion) 3. Benzos for agitation & seizures 4. Physostigmene for severe central and peripheral ssx 5. Echocardiogram

Catatonia Etiology Clinical features Management

Etiology: Catatonia is a syndrome of marked psychomotor disturbance that occurrs in severely ill patients with mood disorders + psychotic features, physchotic disorders, autism spectrum disorder, and medical conditions (infectious, metabolism, neurologic, rheumatologic) Clinical features: 1. Immobility or excessive purposeless activity 2. Mutism, stupor (decreased alertness/response to stimuli) 3. Negativism (resistance to instructions & movement) 4. Posturing (assuming positions against gravity) 5. Waxy flexibility (initial resistance, then maintenance of new posture) 6. Echolalia, echopraxia (mimicking speech "date, date, date" and movements) Tx: 1. Benzodiazepines (lorazepam) Lorazepam challenge: IV loraz 1-2mg results in partial temporary relief within 5-10 minutes. Catatonia responds to loraz within a week 2. Electroconvulsive therapy: refractory to loraz

Adverse psychiatric effects possible from glucocorticoids

Euphoria, irritability, restlessness, anxiety, sleep disturbance Severe effects (high doses or prolongued use): Depression, hypomania, mania, psychosis, confusion

Sexual assault Evaluation Medical consequences Management Increases lifetime risk of...

Eval: 1. Physical and forensic examination (hair, semen) 2. Psychologic assessment Consequences: 1. Mental health (PTSD) 2. Unintended pregnancy 3. STIs Management: 1. Postexposure prophylaxis 2. Emergency contraception 3. Psychosocial counseling Increases lifetime risk of... Psych issues: Major depression Suicidal ideation and suicide attempts PTSD Medical issues: Pelvic pain Fibromyalgia Functional GI disorders Cervical cancer (possibly linked to avoidance of pelvic exams)

Hoarding disorder Features

Features 1. Accumulation of large number of possessions that may clutter living areas 2. Distress when attempting to discard possessions 3. Possible social isolation due to embarrassment Tx: CBT targeted to hoarding behaviors

Normal pressure hydrocephalus Features Dx Tx

Features 1. Gait instability (wide based) "magnetic gait" w/ frequent falls 2 Cognitive dysfunction 3. Urinary urgency/incontinence 4. Depressed (flat) affect from frontal lobe compression 5. UMN signs in lower extremities Dx: 1. Lumbar tap (Miller Fisher test) causes marked improvement in gait 2. Enlarged ventricles out of proportion to the underlying brain atrophy on MRI 3. ventriculomegaly with normal opening pressure on lumbar punture Tx: - ventriculoperitoneal shunting

Cerebellar tremor

Features: 1. Low frequency, high amplitude 2. Increase as an action approaches a target 3. Accompanied by other cerebellar signs (ataxia, nystagmus, dysmetria, impaired rapidly alternating movements)

Dissociative identity disorder Features Treatment

Features: 1. Marked discontinuity in identity & loss of personal agency with fragmentation into ≥2 distinct personality states - personality states are often connected to traumatic experience (teriffied crying child vs angry, persecutory figure) - pts often have chronic auditory hallucinations that have been present since childhood and are perceived inside the patients head (versus psychotic disorders, where voices seem to come from the outside) 2. Associated with severe trauma/abuse Treatment: Trauma-focused psychotherapy

Body dysmorphic disorder Clinical features Management

Features: 1. Preoccupation with ≥1 perceived physical defects (skin, hair, nose) 2. Defects not observable or appear slight to others 3. Compulsions: Repetitive behavior or mental acts 4. Significant distress or impairment 5. Variable insight (good, poor, absent, delusional beliefs) Management: 1. Antidepressants (SSRIs) - high dose 2. &/or CBT

Binge-eating disorder Clinical features Treatment

Features: 1. Recurrent episodes of binge eating 2. No inappropriate compensatory behaviors (like vomitting) 3. Lack of control during eating Tx: 1. CBT 2. Behavioral weight loss therapy 3. SSRI 4. Lisdexamfetamine (stimulant) 5. topiramate (antiepileptic)

Trichotillomania Features Exam Tx

Features: 1. Recurrent hair pulling resulting in hair loss (scalp, eyebrows, eyelids) 2. Repeated attempts to decrease/stop hair pulling 3. Not due to med/derm condition (alopecia areata) 4. Not due to mental disorder (body dysmorphic disorder) Exam: 1. Irregular patches or hair loss 2. Hair shafts of variable lengths 3. Noninflammatory, nonscarring Tx: CBT (Habit reversal)

Generalized anxiety disorder Features Associated with... Treatment

Features: 1. excessive, uncontrollable worry ≥6 months PLUS 2. ≥3 of the following (≥1 in children): a. restlessness b. fatigue c. difficulty concentrating d. irritability e. muscle tension (shoulder/neck/back/head aches) f. sleep disturbance 3. Chronic, fluctuating course; academic/occupation dysfunction Associated with: 1. physical symptoms related to tension (headaches, neck pain, stomachaches) 2. Comorbid depression, substance use 3. Increased risk of high health care utilization 4. CV events Treatment: 1. CBT Meds: 1st line: SSRI or SNRI 3. Buspirone or benzos (high abuse risk)

Manic episode Features Hypomanic episode

Features: ≥1 week of elevated or irritable mood & increased energy/activity with ≥3 of the following (4 if mood is irritable only): DIGFAST Distractability Impulsivity/indiscretion, risky behavior Grandiosity Flight of ideas/racing thoughts Activity increase/agitation Sleepless Talkativeness/pressured speech Severity: 1. Impaired psychosocial function 2. Possibly psychotic features (hallucinations, delusions) 3. May require hospitalizations Hypomanic episode ≥4 days of manic episode but: 1. No marked impairment in social or occupational functioning 2. Does not require hospitalization 3. No psychotic features

Language disorder

Features: begins in early deelopment 1. Difficulty understanding and/or producing language in multiple settings 2. Limited vocabulary, inaccurate sentence structure, difficulty using language to explain concepts or tell story 3. Often causes frustration (tempers) or aggression (hitting/grabbing)

Factitious disorder Illness anxiety disorder (hypochontriasis) Somatic symptom disorder Conversion disorder

Fictitious: Assumes sick role Falsify or even induces symptoms Exascerbate pre-existing illnesses Absence of external reward (unlike malingering) Illness anxiety disorder (hypochondriasis) FEW/NO SYMPTOMS - but fears having serious illness Somatic: ≥1 unexplained symptoms excessive thoughts, anxiety, behaviors in response to symptoms often consult multiple providers and undergo extensive diagnostic testing with negative results Conversion disorder (functional neurologic symptom disorder) Neurologic symptom incompatible with any known anatomy or physiology; acute onset with stress (got in fight with wife, now arm won't work)

Metachromatic leukodystrophy: Findings Deficient enzyme Accumulated substrate Inheritance Diagnosis

Findings: Central and peripheral demyelination with ataxia Dementia Deficient enzyme: Arylsulfatase A Accumulated substrate: Cerebroside sulfate Inheritance: AR Diagnosis: Prominent vacuoles in cytoplasm after staining with toludine blue

Treatments for nicotine cessation

First line treatmentsL 1. Varenicline = alpha-4 beta-2 nicotinic acetylcholine receptor partial agonist - diminishes nicotine cravings - increased risk of CV events in patients with preexisting CV disease 2. Buproprion = DA and NE reuptake inhibitor - contraindicated in patients with seizures and bullemic patients 3. Nicotine replacement therapy with transdermal patch and gum or lozenge

Delirium

Fluctuating disturbance in attention and arousal (from shouting to drowsy in minutes) that may be associated with: - psychotic symptoms (esp visual hallucinations) - sleep changes - behavioral changes

anti-NMDA receptor encephalitis Epidemiology Associations Dx

Form of autoimmune encaphalitis Epidemiology: Median age of onset is 21, W>M Associated with: Associated with ovarian teratomas (>50%) Presentation: Rapidly progressive 1. Behavior changes (anxiety, psychosis, insomnia) 2. Memory dysfunction 3. Abnormal movements / dystonia (dyskinesia, chorea, facial twitching) 4. Rigidity & hypereflexia 5. Hallucinations / response to internal stimuli 6. Autonomic instability (hyperthermia, hypertension, tachycardia) Diagnosis: CSF with antibodies to the GluN1 subunits of the NMDA receptor Tx: 1. Tumor resection and immunosuppresion

anti-Hu encephalitis

Form of autoimmune encaphalitis Paraneoplastic syndrome most commonly associated with small cell lung cancer (MC in smokers) Presents: 1. Rapid-onset dementia 2. Personality and behavior changes 3. Seizures 4. Hallucinations 5. Bainstem symptoms (dizziness, nausea)

Postural tachycardia syndrome

Generally affects young women and typically causes tachycardia without hypotension on standing

Acute intermittent porphyria Genetics/Path Exascerbating factors Manifestations Labs/Dx

Genetics/Path: AD with low penetrance Reduced activity of porphobilinogen deaminase Exacerbating factors: induce ATTACKS 1. Medication (cytochrome P-450 inducers, carbamazepine, phenytoin, rifampin, progesterone) 2. Physiologic stress (fasting, sx, illness) 3. Alcohol, tobacco Manifestations: typically in 20-30yo 1. Abdominal pain: neuropathic -- diffuse & not tender to palpation 2. Peripheral neuropathy in the proximal upper extremities (tingling in fingertips) 3. Autonomic dysfunction (tachy, diaphoresis, HTN) 4. Neuropsychiatric (hallucinations/delusions, anxiety, psychosis, insomnia, restlessness, mood fluctiations) 5. Red-tinged urine that oxidizes with light/air exposure Labs/Diagnosis: 1. Elevated serum and urinary prophobilinogen PBG and aminolevulinic acid +/- hyponatremia (due to SIAHD) and elevated transaminases

DiGeorge Syndrome Genetics Pathophysiology Presentation

Genetics: Microdeletion of 22q11.2 Pathophys: Defective neural crest migration into the 3rd and 4th pharyngeal pouch Presentation: CATCH-22 Cleft lip/palate Abnormal facies frontal bossing, hypertelorism Tyhmic hypoplasia/aplasia T-cell deficiency Cardiac abnormalities tetralogy of Fallot truncus arteriosus interrupted aortic arch Hypoparathyroidism --> hypocalcemia Microdeletion of 22q11.2

Velocardiofacial syndrome Genetics Presentation Diagnostic gold standard

Genetics: Microdeletion of 22q11.2 Presentation: Facial deformities: 1. Cleft palate 2. Elongated face 3. retrognathia 4. prominent nose 5. hypernasal speech Cardiac abnormalities: 1. tetralogy of fallot 2. truncus arteriosus 3. interrupted aortic arch Diagnosis: Fluorescence in situ hybridization of the genes of interest. Lack of a fluorescent signal is indicative of a microdeletion

Hospice care

Goal shifts from extending life toward maximizing comfort (promoting wellbeing, decreasing pain)

Traction alopecia

Hair loss (typically in frontal and temporal scale) through repetitive and excessive pulling or stretching of the hair, normally due to hairstyles (ex: braiding)

Dependent personality disorder DSM-5

Have poor self-confidence, feel helpless when alone, and fear separation with excessive need to be taken care of and allow others to make decisions, with five: 1. Difficulty making everyday decisions without reassurance from others 2. Needs others to assume responsibilities for most areas of their life 3. Difficulty expressing disagreement for fear of loss of approval 4. Difficulty initiating projects because of lack of self- confidence 5. Goes to excessive lengths ot obtain support from others 6. Feels helpless when alone 7. Urgently seeks another relationship when one ends 8. Preoccupied with fears of being left to take care of self DDx: Boarderline and histrionic personality disorders: DPD maintain long-lasting relationships Boarderline and histrionic don't maintain relationship Tx: Psychotherapy, CBT, assertiveness, social skills training Pharmacology for symptoms of anxiety or repression

Classic presentation of aseptic meningitis

Headache Fever Photophobia

Dementia with Lewy bodies Histology Dx criteria Supportive additional features Treatment:

Histology: Intracytoplasmic eosinophilic inclusion bodies of alpha-synuclein (Lewy bodies) in the brain parenchyma Dementia with two of the three following: 1. Cognitive fluctuations (fluctuating memory loss) 2. Visual hallucinations 3. Parkinsonism - increased muscle tone - coarse resting tremor 4. Rapid eye movement sleep behavior disorder Supportive additional features: 1. Frequent falling 2. Deficits in executive and visuospatial function: trouble driving, get lost, poor job performance 3. Delusions 4. Depression 5. Sensitivity to antipsychotics (dopamine antagonists), which can lead to worsening of Parkinsonian symptoms, confusion, autonomic dysfunction 6. Autonomic dysfunction (orthostatic hypotension, HR variability) Treatment: 1. Parkinsonism: carbidopa-levodopa 2. Cognitive impairment: cholinesterase inhibitors rivastigmine 3. REM sleep behavior disorder: melatonin 4. Visual hallucinations/delusions: risperidone (antipsychotics) CAVEAT: sensitivity to antipsychotics can cause worsening of Parkinson symptoms, confusion, autonomic dysfunction (orthostatic hypertension)

Specific phobia Pathophysiology History and clinical features Treatment

History and clinical features: 10% of population Common types: flying, heights, animals, injections, blood, water, driving 1. Marked anxiety (possibly panic attacks) about a specific object or situation (phobic stimulus) for >6 months 2. Avoidance behavior 3. Usually develops in childhood, often after traumatic event Tx: 1st CBT w/ exposure therapy 2nd: short acting benzos (limited role, may help acutely if therapist unavailable or insufficient time)

Prior to initiating antidepressants for a major depressive episode, all patients should be screened for...

History of hypomania/mania to rule out bipolar disorder

Atrophy of caudate and putamen is associated with...

Huntington Disease

Hyperprolactinemia symptoms SGA with high frequency of prolactinemia SGA with low frequency prolactinemia

Hyperprolactinemia symptoms: 1. Impotence 2. Ammenorrhia & infertility 3. Gynecomastia 4. Decreased libido Risperidone & paliperidone (a metabolite of risperidone) Aripiprazole (partial dopamine agonist as well as D2 receptor antagonist) and quetiapine (low-potency D2R antagonist)

How to treat acutely agitated patient (say in the ER)

IM Benzos (lorazepam) - rapid action and/or First or second-gen antipsychotic and/or combo

Home geriatric assessment

Identifies and coordinates planning for older adults with significant medical, psychosocial, and functional disabilities (ex: hip fracture)

Primary CNS lymphoma

In HIV-injected patients, strongly associated with Epstein-Barr virus, and presents as: 1. Focal neurologic findings with lesions evident on neuroimaging

Electroconvulsive therapy for depression Indications Safety

Indications: 1. Treatment resistance 2. Psychotic features 3. Emergency conditions - pregnancy - refusal to eat or drink - imminent risk for suicide Safety: 1. No absolute contraindication 2. Increased risk in patients with: - CV disease, recurrent MI - Space-occupying brain lesions - Recent stroke or unstable aneurysms

Tinea capitis

Infection of the scalp, typically in children Scaly, erythematous patches and alopecia with black dots representing broken hairs within follicles

Huntington's Disease Inheritance Pathophysiology Clinically Imaging Management Prognosis

Inheritance: AD CAG trinucleotide expansion on chromasome 4 Pathophys: 1. CAG trinucleotide repeat expansion results in formation of abnormal huntington protein that is particularly toxic to the caudate nucleus and the putamen (neostriatum), which is rich in GABA-producing neurons that are preferentially destroyed. Mutant huntington protein results in a gain-of-function that leads to pathological interaction with other proteins: a. Histone deacetylation - silencing genes necessary for neuron survival 2. Increased dopamine 3. Tinucleotide expansion causes anticipation effect in which consecutive generations develop symptoms progressively earlier TLDR: Decreased GABA + ACh, Increased DA Clinically: 1. Motor: a. chorea: facial grimacing, ataxia, dystonia, tongue protrusion, writing movements of the extremities can be mistaken for restlessness early in disease can be assimilated into purposeful movements (smoothing one's hair) b. delayed saccades c. hyperreflexia 2. Psychiatric: depression, irritability, psychosis, obsessive-compulsive symptoms 3. Cognitive: executive dysfunction Imaging: MRI shows atrophy of caudate and putamen and general cerebral atrophy Treatment: RECALL: Huntington = too much DA and low GABA and ACh. To treat movements: 1. Reserpine (VMAT inhibitor) - decreases dopamine packaging and release 2. Tetrabenazine (VMAT inhibitor) 3. Haloperidol (D2 receptor antagonist) For behavior: atypical antipsychotics For sleep disturbances: benzos

Malignant catatonia

Insiduous onset with a prodrom of motor agitation

Kleptomania vs Shoplifters

Kleptomania - Impulse control disorder anxiety/tension --> urge to steal --> theft --> relief typically followed by guild and shame, so individuals may return stolen items - typical onset in adolescence - impulses to steal objects of low monetary value Treatment: CBT . Shoplifters: - steal for personal gain - premeditated acts

Solution to medication nonadherance in schizophrenic patients

Long-acting injectable (LAI) (depot) antipsychotics available in all 1st and 2nd gen antipsychotics

Obsessive-compulsive personality disorder

Long-standing, pervasive need for control and order (preoccupation with orderliness, details, scheduling, and rigid rules) at the expense of efficiency and flexibility Require chronicity over time and are not diagnosed during childhood

Treatment of alcohol withdrawal

Lorazepam especially in patients with liver disease, where the preferred benzodiazepines are those that lack active metabolites and undergo phase I cyP450 reaction (lorazepam, oxazepam, temazepam)

Essential tremor

M>F 40-60 years old Familial Clinical: 1. Tremor that worsens with voluntary movement and stress, often of the hands and typically bilateral 2. No tremor at rest 3. Improves with alcohol Tx: propranolol (nonselective beta blockers) primidone Deep brain stimulation if refractory

Functional tremor

MC functional disorder, characterized by involuntary movements that are not consistent with a neurologic cause and that improve with distraction Characteristics: 1. Abrupt onset and static course that results in functional disability OOP to tremor magnitude 2. Increased severity with attention and decreased severity with distraction 3. Inconsistencies (can write name but not draw circles) 4. Fingers often spared 5. Changeable features (i.e. shifting tremor frequency, location)

Androgenic alopecia (in males/females) Features Tx

Male or female balding In females: - progressive hair thinning at the vertex and frontal hairline Treatment: Topical minoxidil

Naltrexone Mechanism Indications

Mech Opioid antagonist Indications: 1. Opioid maintenance therapy (suppresses cravings in patient that has stopped taking opioids for 1-2 weeks) 2. Alcohol dependence

Secondary causes of acute-onset psychosis in children and adolescents Medical disorders CNS injury/dysfunction Metabolic/electrolyte disturbances Systemic disorders Illicit substances Medication side effects Intoxication Withdrawal

Medical disorders CNS injury/dysfunction - trauma - space-occupying lesions - infection - stroke - epilepsy - cerebral hypoxia Metabolic/electrolyte disturbances - Urea cycle disorders - Acute intermittent porphyria - Wilson disease - Renal/liver failure - Hypoglycemia - Sodium/calcium/magnesium disturbances Systemic disorders - Systemic lupus erythematosus - Thyroiditis Illicit substances - Hallucinogens (PCP, LSD, ketamine) - Marijuana - Sympathomimetics (cocaine, amphetamines) - Alcohol withdrawal - Bath salts Medication side effects Intoxication - anticholinergics (diphenhydramine, scopolamine) - serotonin syndrome - amoxicillin/erythromycin/clarithryomycin - anticonvulsants - corticosteroids - isoniazid Withdrawal - baclofen - benzodiazepines

Antipsychotic medication effects (dopamine antagonism) in dopamine pathways Pathway --> Effect Mesolimbic Nigrostriatal Tubuloinfundibular

Mesolimbic --> antipsychotic efficacy Nigrostriatal --> extrapyramidal symptoms (acute dystonia, akathisia, parkinsonism Tubuloinfundibular --> hyperprolactinemia (impotence, ammenorrhia, gynecomastia, decreased libido) -Dopaminergic pathway that projects from the hypothalamus to the pituitary gland. Neurons in the tubuloinfundibular pathway secrete dopamine, which inhibits prolactin release from the anterior pituitary gland. Antipsychotics block this dopaminergic inhibition, resulting in increased prolactin secretion.

First-line treatment for opioid-dependent pregnant patients

Methadone: long-acting opioid agonist prevents withdrawal, decreases cravings, reduces euphoric effects of subsequent opioid use,. Can be used safely throughout pregnancy PLUS multidisciplinary program (prenatal care, social work, counseling)

Key defense mechanisms: NEUROTIC: Controlling Displacement Intellectualization Isolation of affect Rationalization Reaction formation Repression IMMATURE: Acting out Denial Regression Passive aggression Projection OTHER: Splitting Undoing MATURE: Altruism Humor Sublimation Suppression

NEUROTIC: Controlling: Regulating situations and events of external environment to relieve anxiety Displacement: Transferring feelings to less threatening object/person EX: Student angry at mother so yells at teacher Intellectualization: Focusing on nonemotional aspects to avoid distressing feelings Isolation of affect: Unconsciously limiting the experience of feelings or emotions associated with a stressful life event in order to avoid anxiety EX: woman describes death of husband w/o emotion Rationalization: Justifying behavior to avoid difficult truths Reaction formation: Transforming unacceptable feelings/impulses into the opposite Ex: daughter resentful of dad for abandonment but praises him in old age Repression: Preventing a thought or feeling from entering consciousness Repression is unconscious, suppression is conscious IMMATURE: Acting out: Expressing unacceptable feelings through actions Denial: Behaving as if an aspect of reality does not exist Regression: Reverting to earlier developmental stage Passive aggression: Avoiding conflict by expressing hostility covertly Projection: Attributing one's feelings to others ex: cheating spouse who suspects cheating partner OTHER: Splitting: Experiencing a person/situation as absolute (ALL positive or ALL negative) Undoing: Attempting to reverse a situation by adopting a new behavior EX: Man who had brief fantasy of killing wife by sabotaging her car takes the car for a complete checkup MATURE: Altruism: Performing acts that benefit others in order to vicariously experience pleasure EX: Donating money to ovarian cancer awareness after friend dies of it Humor: Expressing (usually) unpleasant or uncomfortable feelings without causing discomfort to self or others Sublimation: Channeling impulses into socially acceptable behaviors Suppression: Putting unwanted feelings aside to cope w/ reality

Evaluation of patient with SSRI overdose

NOTE: patients are typically asymptomatic or have mild CNS depression, so if patient is symptomatic, 1st: Evaluate for co-ingestion (especially acetaminophen and salicyclates, or ethanol/benzos when pt has decreased level of consciousness and RR) 2nd: lab evaluations - ECG (citalopram and escitalopram can prolong the QT interval) - glucose level (as in any patient with overdose or altered mental status) - serum bicarbonate level (for possible metabolic acidosis)

Adverse effects of anabolic (androgenic) steroid use Steroid names AEs

Names: 1. Testosterone 2. Trenbolone 3. Boldenone 4. Stanozolol 5. Nandrolone AEs: 1. Aggression 2. Male pattern baldness (premature) 3. Gynecomastia (excess testosterone--> estradiol) Treated by users of anabolic steroids by tamoxifen 4. Small testis, decreased sperm count 5. Hepatic dysfunction 6. Erythrocytosis (due to androgen-stimulated erythropoiesis) 7. HDL levels decrease 8. Acne 9. Aggression + mood disturbances, often complicated by concurrent alcohol use

Nightmare disorder vs Sleep terror disorder

Nightmare disorder: wake up from nightmare Dx: Recurrent episodes of complete awakening from sleep with recall of disturbing nightmares, ability to be comforted NOTE: Nightmares occur during REM sleep, more frequently in the second half of the night vs Sleep terror disorder: freak out but don't recall dream Dx: Non-REM arousal disorder characterized by incomplete awakenings, unresponsiveness to comfort, and NO RECALL of dream content Treatment: Reassurance Low dose benzo at bed time if episodes are frequent, persistent, and distressing

Sleep patterns consistent with normal aging

Nighttime sleep onset latency Decreased REM latency Decreased slow-wave sleep Decreased total sleep time Sleepy earlier in evening Nocturnal awakenings Reduced sleep during early-morning hours Daytime napping

Cognitive impairment in elderly patieents Normal aging Mild neurocognitive disorder (mild cognitive impairment) Major neurocognitive disorder (dementia) Major depression

Normal aging - lower energy level, changes in sleep pattern (lighter sleep and phase advance) - slight decrease in fluid intelligence (ability to process new information quickly), - possibly word-finding difficulty (expressive aphasia) or mild memory loss, but can provide details about forgetfulness - normal functioning in all ADLs Mild neurocognitive disorder (mild cognitive impairment) - MoCA score <26/30 - mild but noticible decline in ≥1 cognitive domains (complex attention, executive function, learning and memory, language) - normal functioning in all ADLs with compensation (take more effort, time, or compensatory strategies) Major neurocognitive disorder (dementia) - significant decline in ≥1 cognitive domains - Irreversible global cognitive impairment - Marked functional impairment - Chronic & progressive, months to years Major depression: depression + cognitive impairment - reversible mild-moderate cognitive impairment ("pseudodementia") - features of depression (mood, interest, energy) - episodic, weeks to months When old people get major depression, sometimes they also get dementia

HIV-associated dementia

Occurs almost exclusively in untreated HIV-infected patients (CD4 <200) Subcortical demendia characterized by: 1. Apathy 2. Early impairments in attention 3. Subcortical motor symptoms

Overlapping features of hyperthyroidism and anxiety disorders Distinguishing features of hyperthyroidism

Overlapping: 1. Anxiety 2. Insomnia 3. Sweating 4. Palpitations Distinguishing: 1. Unintentional weight loss 2. New onset afib 3. HTN 4. Lid lag

Parkinson disease dementia vs Dementia with Lewy bodies Tx

PDD: When parkinsonism precedes cognitive impairment and other ssx of Lewy body dementia - executive and visuospatial dysfunction (impaired attention and planning, inability to recognize familiar people, getting lost in familiar locations) with only mild memory impairment at first - higher rate of visual hallucinations, delusions, and sleep disorders Tx: 1. Cholinesterase inhibitors (donepazil, rivastigmine, galantamine) to improve cognitive impairment 2. Dose reduction of antiparkinsonian agents 3. Addition of low-potentcy antipsychotics (pimavanserin, quetiapine)

Neurotransmitter disregulation in psych disorders Parkinson's Alzheimer's MDD Bipolar Huntington's

Parkinson's = low DA in substantia negra Alzheimer's = decreased ACh MDD = low serotonin Bipolar = Mania = high DA Huntingtons = high DA, low GABA + ACh

Antidepressants with short half lives Antidepressants with long half lives

Paroxetine, venlafaxine Fluoxetine

Vascular dementia Pathophysiology Clinical manifestation Imaging Treatment

Path: AKA multi-infarct dementia (MID) Large areas of encephalomalacia due to ischemic stroke/infarct from: - large-vessel atherosclerosis - small-vessel arteriolosclerosis - cerebral amyloid angiopathy Clinically: - Early, prominent executive dysfunction Subtypes: 1. Multi-infarct: often with stepwise decline due to multiple small strokes 2. Strategic infect: Focal neurologic deficits due to one large stroke 3. Subcortical vascular encephalopathy: associated with subcortical signs (urinary incontinence, gait disturbances) Imaging: Evidence of cerebrovascular disease on imaging: 1. Cortical infarcts 2. Deep white matter changes (hyperintensities) 3. Subcortical lacunar infarcts Treatment: 1. Risk factor modification (HTN, DM) 2. +/- antiplatelet therapy 3. Cholinesterase inhibitor

Causes of QT interval prolongation Pathogen Electrolytes Medications Inherited

Pathogen QT-prolongation / torsade de pointes is the ECG manifestation of delayed ventricular repolarization, which occurs due to impaired function of voltage-gated POTASSIUM channels Electrolytes 1. Hypocalcemia 2. Hypokalemia 3. Hypomagnesemia Medications 1. Antibiotics - macrolides, fluoroquinolones 2. Psychotropics - antipsychotics, TCAs, SSRIs 3. Opioids - methadone, oxycodone 4. Antiemetics - ondansetron, granisetron 5. Antiarrhythmics - quinidine, procainamide, flecainide, amiodarone, sotalol Inherited 1. Jervell & Lange-Nielsen syndrome (AR) 2. Romano-Ward syndrome

Fragile X Syndrome

Pathogenesis: 1. Trinucleotide (CGG) repeat expansion of gene FMR1 2. Gene methylation silences FMR protein 3. X-linked dominant inheritance Neuropsychiatric features: 1. Developmental delay (delayed motor and speech) 2. Intellectual disability 3. ADHD 4. Autism spectrum disorder (poor eye contact, stereotypical hand movements, social deficits) 5. Aggression +/- self-injurious behavior (eg hand biting) 6. Anxiety Examination findings: 1. Long face with prominent forehead and chin 2. Large protruding ears, deep-set eyes 3. Macroorchidism (age >8) 4. Macrocephaly 5. Joint hypermobility (fingers and wrists) Diagnosis FMR1 DNA analysis (PCR or Southern Blot)

Wilson Disease Pathogenesis Clinical findings

Pathogenesis: IN TEENAGERS 1. Autosomal recessive mutation of ATP7B leads to defects in hepatic copper transport causing copper accumulation throughout the body. Initial copper buildup occurs within the liver, leading to hepatocellular apoptosis and release of free copper in the bloodstream. Extrahepatic copper is then deposited in various tissues, including the CNS, kidney, and cornea. The basal ganglia (putamen and globus pallidus) is the primary site of deposition in the CNS and accounts for the movement abnormalities seen in the disease. Because basal ganglia, frontal cortex, and limbic system communicate, copper build up also affects mood and cognition Presentation: Neuro/psychiatric symptoms precede hepatic symptoms, in ADOLESCENTS: 1. Neurologic - motor synsfunctions: parkinsonism, gait disturbances, dysarthrria, dystonia 2. Psychiatric - depression, personality changes, psychosis 3. Hepatic - acute liver failure, chronic hepatitis, cirrhosis (jaundice, RUQ pain) 4. Kayser-Fleischer rings Dx: 1. Kayser-Fleischer rings 2. Decreased ceruloplasmin & increased urinary copper excretion 3. Increased copper content on liver biopsy Tx: 1. Chelators (D-penicillamine, trientine) 2. Zinc (interferes with copper absorption)

Carcinoid tumor

Pathophys: Neuroendocrine tumor of small bowel (MC rectum and stomach), often produce 5-HT ectopically. Tumors lead to carcinoid syndrome if they metastasize to liver Symptoms of carcinoid syndrome: high seratonin 1. Cutaneous flushing 2. Recurrent diarrhea (increase bowel mortility) 3. Abdominal cramps 4. Asthma-like wheezing 5. Skin: erythema, pellagra skin lesions 6. possible Carcinoid heart disease affecting tricuspid valve Dx: 1. Urinary excretion of 5-HIAA (metabolite) Treatment: 1. Octreotide: somatostatin analogue 2. Resection

Schizophrenia Pathophysiology Diagnostic criteria Neuroimaging Treatment

Pathophysiology: - excessive pruning of glutamatergic synapses in the cerebral cortex during development Diagnosis: 1. ≥2 of the following (at least 1 from 1-3) a. Delisions b. Hallucinations c. Disorganized speech d. Disorganized or catatonic behavior e. Negative symptoms (flat affect, apathy) 2. Continuous impairment ≥6 months 3. Significant functional decline NOTE: Patients commonly experience deficits in cognitive domains (attention, working memory, verbal learning and memory, executive function) Neuroimaging: 1. Loss of cortical tissue volume with ventricular enlargement, MC lateral ventricular enlargement 2. Decreased volume of the hippocampus and amygdala Treatment: 1. Antipsychotic medications Treat with medication and routine follow-up indefinitely, even after 1st psychotic break 2. Adjunctive psychosocial interventions (eg. social skills training, cognitive-behavioral therapy, family intervention) reduce risk of re-hospitalization

Hyperventilation syndrome

Pathophysiology: 1. Increased alveolar minute ventilation (tidal volume x RR) causes decreases is PaCO2 via: a. tachypnea (increase RR) b. increased tidal volume Presentation: 1. Diagnosis of exclusion characterized by intermittent episodes of hyperventilation without any obvious cardiac of pulmonary etiology 2. Neurologic symptoms - paresthesias - headache - lightheadedness - carpopedal spasms vs Panic attacks: acute onset of intense fear + 4 of 13 symptoms (palpitations, chest pain, nausea, sweating, etc) Treatment: 1st: Reassurance and breathing retraining (abdominal, diaphragmatic breathing) 2nd: small dose of short-acting benzodiazepine (lorazepam)

Creutzfeldt-Jakob disease Pathophysiology Clinical features Findings Management and prognosis

Pathophysiology: Abnormal prion isoform leads to prion misfolding within neurons Clinical features: 1. Rapidly progressive dementia 2. Myoclonus (provoked by startle) 3. Cerebellar signs (ataxia, falls, dysdiadochokinesia) 4. Upper motor neuron signs (hyperreflexia) 5. Extrapyramidal signs (hypokinesia) 6. Mood disturbances 7. Hypersomnia 8. Visual cortex dysfunction (homonymous hemianopsia) Findings: MRI: widespread atrophy (cerebrum, cerebellum) cortical enhancement (i.e. cortical ribboning, see picture) enhancement of putamen & caudate head (i.e. hockey stick sign) CSF: normal routine analysis (WBC, gluc, protein) positive 14-3-3 protein titers, elevated tau protein positive real-time quaking-induced conversion (RT-QuIC) test EEG: sharp, triphasic, synchronous discharges generalized slowing with periodic sharp wave complexes on EEG Neuropath: spongiform degeneration without inflammation Management and prognosis: 1. Symptomatic treatment, conseling, social services referral 2. NO effective disease-modifying therapy (fatal in <12 months)

Alzheimer's disease (AD) Pathophysiology Risk factors Presentation Tx

Pathophysiology: Degeneration of neurons in the locus coeruleus causes decreased acetylecholine. Also: - extracellular amyloid plaques - intraneuronal neurofibrillary tangles - hippocampal and temporal lobe atrophy - hydrocephalus ex vacuo - MRI showing generalized nonspecific cerebral atrophy Risk factors 1. CV risk factors: hypertension, diabetes, obesity/physical inactivity 2. Engaging in cognitively stimulating activities and maintaining social relationships reduce risk Presentation 1. Early:: insidious, short-term memory loss 2. Middle: paranoia, delusions (more common in women), language deficits and spatial disorientation 3. Late: personality changes, visual hallucinations can appear Tx: 1. Donepezil, rivastigmine, galantamine: acetylcholinesterase inhibitors used to slow cognitive decline 2. memantine: NMDA antagonist

Akinetic mutism Pathophysiology Presentation

Pathophysiology: lesions in the frontal cortex Presents similarly to catatonia but NO echophenomena (echolalia, echopraxia -- repetition of speech or movement)

Home hospice care Patient selection Location of services Typical services

Patient selection - Life expectance <6 months - Agreement to forgo curative & life-sustaining treatment - Family/private caregiver available for daily needs - Current symptoms can be managed with home care Location of services - Patient home - Assisted living facility - Nursing home Typical services 1. Home visits by experienced personnel (nurse) 2. Palliative medications (analgesics, antiemetics) 3. Durable medical equipment (hospital bed) 4. Physical therapy (and other therapies)

Evidence of alcohol use disorder Presentation

Patients usually seek primary care due to sleep disturbances and/or anxiety symptoms from mild withdrawal - Aspartate aminotransferase/alanine aminotransferase ratio ≥2:1 - Macrocytosis - alcohol tolerance (decreasing sedative effects of alcohol over time - impaired function (work tardiness)

Oppositional defiant disorder Features Increases risk for Treatment

Pattern of irritability, defiant behavior, and vindictiveness toward authority figures for ≥6 months: 1. Argues with adults, defies authority figures, refuses to follow rules 2. Deliberately annoys others 3. Blames others for own mistakes or misbehavior 4. Easily annoyed, angry, resentful, or vindictive 5. Not due to another mental disorder Increases risk for: 1. Development of conduct disorder, adult antisocial behavior, impaired impulse control, substance abuse, anxiety, depression Treatment: 1. Parent management training (rewards and nonpunitive consequences rather than punishments, setting limits calmly, and having structured daily schedules) 2. Psychotherapy (anger management, social skills) 3. No pharmacology

Social (pragmatic) communication disorder

Persistent difficulty in the social use of verbal and nonverbal communications (eye contact, body language), with impairment in multiple settings

Depersonalization/derealization disorder

Persistent or recurrent experiences of 1 or both: 1. Depersonalization = feelings of detachment from, or being outside observer of, one's self 2. Derealization = experiencing surroundings as surreal

Paranoid personality disorder

Pervascive pattern of suspicion and mistrust of others

High-dose glucocorticoids can cause psychosis, often during the first week but can be at any time (can also cause manic or depressive symptoms)

Possible consideration for patients with allergic (asthma), inflammatory, or autoimmune conditions (MS)

Postpartum blues Postpartum depression Postpartum psychosis Prevalence Onset Symptoms Management

Postpartum blues Prevalence: 40-80% Onset: 2-3 days (resolves within 14 days Symptoms: Mild depression, tearfulness, irritability Management: Reassurance and monitoring Postpartum depression Prevalence: 8-15% Onset: typically within 4-6 weeks, but can present up to 1 year Symptoms: ≥2 weeks of moderate to severe depression, sleep or appetite disturbance, low energy, psychomotor changes, guild concentration difficulty, suicidal ideation Management: Antidepressants, psychotherapy Postpartum psychosis Prevalence: 0.1-0.2%, increased in pts w other psychiatric disorders (MC bipolar disorder) Onset: Days to weeks Symptoms: Delusions (evil baby, not my baby), hallucinations (commands to kill baby), thought disorganization, bizarre behavior Management: Medical emergency Hospitalize patient 51-50 (risk of infanticide) Antipsychotics, antidepressants, mood stabilizers to address underlying mood disorder

Premenstrual syndrome Premenstrual dysphoric disorder Initial workup

Premenstrual syndrome : - Begin 1 week prior to menses, resolve few days after - Bloating, fatigue, headaches, breast tenderness - Irritability, anxiety, mood swings, difficulty concentration, decreased libido, irritability Premenstrual dysphoric disorder: severe PMS - irritability, hopelessness, depressed mood, self-critical thoughts, anger, and psychosocial impairment Initial workup: details menstrual history (diary) Treatment: Exercise and stress reduction 1st SSRIs Oral BC can reduce symptoms GnRH agonists can be used

General reasons to 5150 a patient

Presence of mental illness with danger to self or others and/or grave disability (inability to care for self) due to mental illness

Symptoms of opioid withdrawal Treatment

Present within 6-12 hours, peak within 36-72 hours 1. GI distress: abdominal pain, loose stools, hyperactive bowel sounds 2. lacrimation 3. rhinorrhea 4. myalgias 5. mydriasis 6. piloerection 7. N/V 8. Yawning 9. Tachycardia/HTN Treatment: Supportive care + medications 1st Alpha-2 adrenergic agonists (clonadine, guanfacine) - especially useful in decreasing autonomic symptoms (diaphoresis, nausea, anxiety, tachycardia, HTN) 2nd methadone 3rd buprenorphine

Resting tremor Presentation

Presentation: 1. occurs when limbs are relaxed 2. best observed when distracting the patient 3. improves when the patient moves limbs 4. can be described as "pill rolling," important of Parkinson's disease

Physiological tremor Presentation Aggravating factors Tx Enhanced physiological tremor Aggravating factors (meds, physioligic conditions, medical condition)

Presentation: High frequency, low amplitude tremor Aggravating factors: 1. Affects all people but may become visible with a. caffeine b. beta-agonists c. hypoglycemia d. anxiety e. excitement f. alcohol g. opioid withdrawal h. thyrotoxicosis Treatment dependent on etiology e.g., decrease caffeine intake Enhanced physiologic tremor: due to increased adrenergic activity: Meds: (dose-response, temporal association, bilateral) 1. Beta-adrenergic agonists 2. SSRIs 3. TCAs 4. Nicotine 5. Caffeine 6. Corticosteroids 7. Lithium Physiologic: 1. Stress 2. Anxiety Med conditions: 1. Hypoglycemia 2. Alchohol/opioid withdrawal 3. Thyrotoxicosis 4. Liver disease

Multiple sclerosis Common presenting symptoms Risk factors Diagnosis

Presenting ssx: age 15-50, demyelinating disease Relapsing-remitting course of CNS disfunction, episodes commonly after stressful life events: 1. Sensory disturbances, motor weakness, bowel/bladder dysfunction 2. Ocular manifestations: optic neuritis (painful eye movements), internuclear ophthalmoplegia (impaired adduction on lateral gaze) 3. Lhermitte sign: electrical sensation in limbs or back 4. Uhthoff phenomenon: symptoms worsen with increased body temperature 5. Possible cognitive impairment (impaired attention, short-term memory, speed of info processing, executive fxn) RFs: 1. White female, HLA-DRB1 2. Environmental: location (USA/Europe), cold climate 3. Low vitamin D 4. Smoking 5. increased risk in early postpartum period Dx: 1. Episodic/progressive symptoms disseminated over time/space 2. hyperintense lesions on T2-weighted MRI 3. Oligoclonal IgG bands on CSF analysis Tx: FILL IN High-dose glucocorticoids can cause psychosis Sequellae: Depression in 2/3 of patients with MS

Down syndrome Increased risk for developing what diseases?

Presents with: Eyes: 1. Epicanthal folds 2. Upslanting palpebral fissures 3. Brushfield spots (white dots) on the iris Ears: 4. Hearing loss Face: 5. Small low-set ears 6. Flat facial profile 7. Short neck with excess skin 8. Furrowed tongue Feet: 9. Sandal-toe deformity Hands: 10. Hypoplastic incurved 5th finger 11. Single transverse palmer crease Heart: 12. Endocardial cushion defects (ostium primum atrial septal defects, regurgitant atrioventricular [tricuspid and mitral] valves) Increased risk for Obesity (cormbidity) Alzheimers ALL (we ALL fall DOWN) Acute megakaryoblastic leukemia - before 5y.o. GI diseases: Celiac disease Duodenal atresia Hirschsprung disease

Major depressive disorder with seasonal pattern AKA Seasonal affective disorder

Presents: 1. MC fall-winter onset and spring summer remission 2. Atypical features of depression: increased sleep, increased appetite, carb craving, and weight gain Treatment: 1. Antidepressants (SSRI/SNRI) + Bright light therapy

Marchiafava-Bignami disease

Presents: neurodegenerative disease in patients with chronic alcohol use disorder and attendant malnutrition 1. Dementia 2. Motor dysfunction 3. Dysarthria

Opioid prescribing best practices Prior to initiation During therapy

Prior to initiation 1. Screen for RFs for misuse 2. Perform urine drug screening 3. Query PDMP (perscription drug monitoring program) database 4. Sign controlled substance agreement (1 prescriber, 1 pharmacy) During therapy 1. Follow up every 1-3 months 2. Query PMDP database before each refill 3. Perform random urine drug screenings

Dialectical behavioral therapy (DBT)

Promising treatment for borderline personality disorder that integrates techniques of: emotion regulation mindfulness distress tolerance (tipp skill), and interpersonal effectiveness to target unstable moods, impulsivity, and suicidality.

Persistent complex bereavement disorder Features versus MDD

Proposed disorder that involves: 1. Persistent sorrow, yearning, or preoccupation continuing >12 months after the death of a loved one 2. Maladaptive, ruminative thoughts and dysfunctional behaviors (eg, AVOIDANCE) vs MDD (many overlapping features) Sadness centers around loss of loved one SI centered on not wanting to live without the deceased rather than generalized suicidality

Aggressive patient RFs Signs Management

RFs 1. Hx of violent behavior/antisocial personality disorder 2. Psychiatric illness (psychosis, delirium, suicidal/homicidal ideation) 3. Substance use; acute indoxication; withdrawal 4. Prolonged wait times Warning signs: 1. Angry, irritable demeanor 2. Loud, aggressive speech, cursing, verbal threats 3. Tense posture, clenched fists, pacine 4. Desk or wall pounding, throwing objects Management: 1. Maintain a distance of 2 arm lengths 2. Avoid direct eye contact 3. Interview with door open, clinician closer to exit 4. Verbal deescalation - calm voice - provide basic needs (food, drink, blanket) - listen and clarify - set clear expectations that violence is unacceptable; reinforced pt will not be harmed - offer choices (oral vs intramuscular medications) 5. Chemical (IM antipsychotic) & physical restraint when verbal deescalation fails and violence is imminent

Specific learning disorder RFs Key features and types Evaluation and management

RFs 1. Prematurity 2. Prenatal alcohol exposure 3. Poverty/understimulating environment 4. Psych conditions (ADHD, depression) 5. Chronic medical/neurologic conditions (DM, seizures) 6. Chromosomal disorders (Downs, fragile X, turner) 7. FHx Key features and types: Academic skill/achievement below individuals intellectual potential 1. Reading 2. Writing 3. Math Eval/Mngment: 1. Educational testing (requires the use of standardized testing) 2. Hearing/vision assessment 3. Rule out psychiatric/medical disorders 4. Quakity instruction/academic support/accomodations

Progressive supranuclear palsy (PSP)

Rare degenerative disease presenting with: 1. Dementia 2. Postural instability 3. Vertical supranuclear palsy 4. Parkinsonism

Bipolar II AKA

Recurrent major depressive episodes with hypomania

Shift work disorder

Recurrent pattern of sleep interruption due to shift work (eg. patient with normal circadian rhythm who is required to work night shift) Clinical: 1. Difficulty initiating and maintaining sleep 2. Daytime sleepiness

Elder abuse Risk factors Manifestations of abuse: Physical / sexual abuse Psychological & verbal abuse Neglect Financial exploitation

Risk factors 1. Female 2. Dementia, chronic mental illness 3. Functional impairments 4. Social isolation 5. Shared living environment 6. Poor socioeconomic status/financial stress Manifestations of abuse: Physical / sexual abuse - atypical abrasians, lacerations, contusions, fractures - pain not consistent with reported etiology - anogenital injuries - newly acquired STI Psychological & verbal abuse - change in behavior/personality - depression/anxiety Neglect - inadequate nutrition or hydration - pressure injuries - deterioration in comorbid conditions Financial exploitation - failure to adhere to medication regimen - multiple missed appts - unpaid expenses or rent payments

Somatic symptom disorder Risk factors Key features Management

Risk factors 1. Female 2. Lower education level 3. Chronic childhood illness or family history of chronic illness 4. Childhood abuse/neglect 5. Sexual trauma Key features 1. ≥1 somatic symptom(s) causing distress/functional impairment 2. Vague history of present illness 3. Health concerns not alleviated despite consultation w/ multiple providers 4. Exaggerated pain on exam, extensive thoughts, anxiety, or behaviors (time & energy) related to symptoms Management: 1. Legitimize symptoms, focus on stress reduction/coping strategies, deliver negative test results as good news that illness has been ruled out and then discuss psych factors, coping style, and dx 2. Schedule regular visits (not symptom driven) with same provider) 3. Limit unnecessary workup/referrals 4. Tx resistent: Antidepressants / CBT

Acute stress disorder Features Management

SHORT PTSD: Lasting from 3 days to 1 month following a life-threatening traumatic event, patient presents with: 1. Re-experiencing events (intrusive memories, flashbacks) 2. Avoidance 3. Negative mood 4. Dissociation 5. Hyperarousal Management 1. Trauma-focused, brief CBT: explain physical and emotional responses to trauma to normalize stress response while advising the symptoms can persist to cause distress and impairment 2. Consider medication for insomnia, intense anxiety 3. Monitor for PTSD (symptom duration >1 month)

Conversion disorder Symptoms Tx Risk for...

SSx: often precipitated by stress, W>M, any age usually adolescents 1. ≥1 neurological symptoms that are inconsistent with neurological disease, like: a. weakness b. abnormal movements c. mutism d. blindness e. paralysis f. paresthesias (sensory complaints) g. nonepileptic seizures h. globus sensation - sensation of lump in throat 2. Patients often calm and unconcerned when describing symptoms Tx: often spontaneous recoverring, 40-66% recurr 1. Education about illness 2. CBT +/- PT Risk for: Neurological, depressive, or anxiety disorder

Post-partum blues

Self-limited condition of mild depressive symptoms, tearfulness, and irritability. No psychosis Peaks at day 5 postpartum and resolves by 14 days

Which benzos produce earlier and more severe symptoms of withdrawal

Short half-life benzos (alprazolam, lorazepam, midazolam, triazolam, clonazepam, oxazepam)

Indications for hospitalization in patient with anorexia nervosa

Signs of dehydration Unstable vital signs Cardiac dysrhythmias Electrolyte disturbances Organ involvement due to malnutrition Very low weight

Persistent (Chronic) Motor or Vocal Tic Disorder

Single or multiple motor or vocal tics have been present during the illness, but not both motor and vocal Present >1 year

Childhood-onset fluency disorder

Speech difficulty that may include repeated syllabus (stuttering), pauses or substituting words that are easier to pronounce

Students studying for final exams are at increased risk of abusing what drugs? What to treat them with for acute episode

Stimulants! Benzos: Lorazepam

Disinhibited social engagement disorder

Symptoms: in children who were subject to insufficient care (neglect, abuse, inconsistent caregiving [frequent moves in foster homes, prolonged institutionalization]): 1. A pattern of abnormally extroverted behavior toward unfamiliar adults

Schizotypal personality disorder Three words DSM criteria Distinguishing features vs schizophrenia, vs schizoid Treatment:

Three words Unusual thoughts, perceptions, and behavior DSM criteria Eccentric behavior, cognitive or perceptual distortions, and discomfort with close relations, with 5 or more of: 1. Ideas of reference (false beliefs that random or irrelevant occurrences in the world directly relates to a person) 2. Odd beliefs or magical thinking, inconsistent with cultural norms 3. Unusual perceptual experiences (such as bodily illusions) 4. Suspiciousness 5. Inappropriate or restricted affect 6. Odd/eccentric appearance or behavior 7. Few close friends or confidants 8. Odd thinking or speech (vague, strereotyped, etc) 9. Excessive social anxiety Magical thinking can include: 1. Clairvoyance/telepathy 2. Bizzare fantasies or preoccupations 3. Belief in superstitions Odd behaviors may include: 1. Cults, strange religious practices Distinguishing features vs schizophrenia: not frankly psychotic and no fixed delusions vs schizoid No eccentric behavior in schizoid Treatment: Psychotherapy for social skills development Short, low-dose antipsychotics (for transient psychosis) to help decrease social anxiety and suspicion in interpersonal relationships

Schizoid personality disorder Three words DSM criteria Distinguishing features vs schizophrenia, vs schizotypal vs avoidant personality disorder, vs social anxiety disorder Treatment:

Three words: 1. Prefers to be a loner 2. Detached 3. Unemotional (often with flat affect) DSM criteria: Voluntary social withdrawal and restricted range of emotional expression, with 4 or more of the following: 1. Neither enjoying nor desiring close relationships (including family) 2. Generally choosing solitary activities 3. Little (if any) interest in sexual activity 4. Taking pleasure in few activities (if any) 5. Few (if any) close friends or confidants 6. Indifference to praise or criticism 7. Emotional coldness, detachment, or flattened affect vs schizophrenia Schiziod has NO hallucinations or delusions vs schizotypal Schizoid has no magical thinking or eccentric behavior vs avoidant personality disorder and social anxiety disorder: both desire relationships whereas schizoid doesn't Treatment: Lack of insight limits individual psychotherapy, group therapy may be threatening May benefit from day programs or drop-in centers Antidepressants if comorbid major depression

Paranoid personality disorder Three words DSM criteria

Three words: Suspicious, distrustful, hypervigilant General distrust of others, along with at least 4 of the following: 1. Suspicion (without evidence) that others are exploiting or deceiving him or her 2. Preoccupation with doubts of loyalty or trustworthiness of friends or acquaintances 3. Reluctance to confide in others 4. Interpretation that benign remarks are threatening or demeaning 5. Persistence of grudges 6. Perception of attacks on his or her character that is not apparent to others; quick to counterattack 7. Suspicions regarding fidelity of spouse or partner

Antisocial personality disorder Three words DSM criteria Tx

Three words: disregarding & violating rights of others without remorse, often skilled at reading social cues and can appear charming, but are impulsive and deceitful DSM: Pattern of disregard and violation of the rights of others since age 15, and patient must be older than 18 [otherwise child disorder is more consistent with conduct disorder] with three or more of the following: 1. Failure to confirm to social norms by committing unlawful acts 2. Deceitfulness/repeated lying/manipulation others for personal gain 3. Impulsivity/failure to plan ahead 4. Irritability and aggressiveness/repeated fights or assaults 5. Recklessness and disregard for safety of self and others 6. Irresponsibility/ failure to sustain work or honor financial obligations 7. Lack of remorse/takes no responsibility NOTE: 1. Associated w substance use / increased instance of use, trauma, suicide, homicide 2. Associated with decreased serotonin signaling (secondary to genetic polymorphisms) Tx: Psychotherapy ineffective Pharmacotherapy for anxiety/depression with caution (addiction risk)

Inhalants Types Effects Signs of abuse

Types: Glue Toluene Nitrous oxide (whip-its) Amyl nitrite (poppers) Spray paints Effects: immediate effects, last 15-45 mins - transient euphoria Signs of abuse: - loss of consciousness - "glue sniffer's rash" on mouth of nostrils due to chemical exposure - liver function tests elevated - chronic use of whip-its causes B12 deficiency and polyneuropathy - weight loss and anorexia - neurologic: tremor, disorientation, headaches, slurred speech, cerebellar dysfunction, and peripheral neuropathy (decreased reflexes) - GI: stomach cramps, nausea - CV: arrhythmia - Resp: wheezing/couching - Psychiatric: irritability, mood swings, aggression, grandiosity, hallucinations

Dissociative amnesia

Typically develops in the setting of trauma: 1. Dissociative disorder characterized by the sudden and extensive inability to recall important personal information, particularly details related to the traumatic event

Common causes of erectile dysfunction

Vascular - cardio RFs (smoking, HTN, DM) - abnormal vascular exam (bruits, decreased pulses) Neurologic - comorbidity (DM, MS, spinal injury/surgery) - gradual onset, loss of bulbocavernosus reflex Psychogenic: interpersonal conflict, performance anxiety, or underlying emotional disorder - sudden onset -situational (ED with partner, normal during masturbation) - normal nonsexual nocturnal erections Endocrine - additional symptoms due to underlying disorder - abnormal hormone levels (TSH, prolactin) Medications - onset related to starting medication - antihypertensives, SSRIs, anti-androgenic medications Hypogonadism - gradual onset - decreased libido, gynecomastia, testicular atrophy - low serum testosterone

Wernicke Encephalopathy Wernicke-Korsakoff syndrome (aka Korsakoff psychosis)

Wernicke encephalopathy: Pathophysiology: An acute disorder of thiamine deficiency that Neuropathologic findings: 1. Mamillary body atrophy 2. Dorsomedial thalamic neuron loss Presents with the classic triad: 1. Encephalopathy 2. Ataxia 3. Oculomotor dysfunction (ophthalmoplegia/nystagmus) Can progress to... NOTE: KS can develop without recognized acute episode of WE. Wernicke-Korsakoff syndrome (aka Korsakoff psychosis) Pathophysiology: Lesions in the anterior and medial thalami as well as the corpus callosum. Results from thiamine deficiency Presents: IRREVERSIBLE 1. Retrograde (past) and anterograde (new memories) amnesia with intact long-term memory 2. Confabulation (make up stories to fill in details) 3. Apathy 4. Lack of insight 5. HISTORY OF ALCOHOL USE

When do patients with MDD stop antidepressant treatment? When do patients with MDD receive maintenance antidepressant treatment? What is maintenance therapy? When do patients with MDD receive indefinite antidepressant treatment?

When do patients with MDD stop antidepressant treatment? Taper meds beginning 6 months after remission When do patients with MDD receive maintenance antidepressant treatment? What is maintenance therapy? Maintenance therapy: 1-3 years of SSRI if: a.) ≥2 episodes b.) early age of onset ≤18 c.) persistent residual depressive symptoms d. comorbid psych disorders When do patients with MDD receive indefinite antidepressant treatment? a. highly recurrent MDD (≥3 lifetime episodes) b. chronic episodes (≥2 years) c. severe episode (suicide attempts)

Absence seizure Presents Treatment

Young children Staring into space with possible motor automatisms (lip smacking, blinking) Treatment Ethosuximide

Diffuse 3-hZ spike and wave pattern on EEG is characteristic of...

childhood absense seizures

Second generation antipsychotics

clozapine aripiprazole quetiapine risperidone olanzapine ziprasadone ALSO: lurasidone amisulpride paliperidone

Speech sound disorder

difficulty producing or using sounds at an age-appropriate level

Frontotemporal dementia SSx: Imaging Prognosis: Variants

early-onset dementia starting w/ personality change Symptoms: (50-60 yo), AD 1. Early personality changes (socially offensive, social withdrawal) 2. Apathy 3. Disinhibition 4. Compulsive behavior (same meal every day) 5. Hyperorality (increased cigarette consumption) 6. Executive dysfunction (difficulty with tasks that require planning), mild memory impairment that worsens with dx progression Imaging: Frontotemporal atrophy on neuroimaging Prognosis: FTD progresses more rapidly than other dementing syndromes (like alzheimers) Ave survival 5-10 years Varients: BEHAVIORAL-variant FDT associated with accumulation of tau protein inclusions known as pick bodies in the hippocampi, temporal lobes, and frontal lobes Tx: SSRIs (sertraline, escialopram) or trazadone demonstrated efficacy in management of neuropsychiatric symptoms

Buzzword physical exam finding of cocaine use disorder

erythema of the nasal mucosa

Low concentreation of hypocretin (orexin) in the CSF is found in...

narcolepsy

Hydrocephalus ex vacuo on CT is seen in...

neurodegenerative conditions like Alzheimers

zolpidem Mechanism Indications Adverse effects

nonbenzo GABA agonist Muscle relaxant Insomnia

Which second generation antipsychotic has the lowest risk of metabolic syndrome

ziprasadone lurasidone aripiprazole