COMAT Psychiatry

Schizoid Personality Disorder

*"Schizoid Android"* - Social withdrawal - Limited emotional expression (*constricted* affect) - *Does not desire relationships with others* (vs. Avoidant)

Schizotypal Personality Disorder

*"Schizotypal bit the bible"* - Pervasive eccentric behavior (e.g. joins cults) & thought patterns (e.g. superstitions) - Magical thinking

Drug Abuse vs. Dependence

*Abuse* = pattern of substance use that causes impairment for at least *1 year* --> life problems *Dependence* = drug use --> tolerance + withdrawal

DSM-IV Axes

*Axis I* = All mental illness EXCEPT personality disorders & mental retardation *Axis II* = Personality disorders & Mental retardation *Axis III* = General medical conditions *Axis IV* = Psychosocial & Environmental problems *Axis V* = Global Assessment of Functioning (GAF) score

Mechanism of Actions of Sedative-Hypnotics - Benzodiazepines - Barbiturates

*Benzos* = increase frequency of Cl- channel opening --> potential GABA effects *Barbs* = increase duration of Cl- channel opening --> potential GABA effects

Bizarre vs. Nonbizarre delusions

*Bizarre* = can't occur in real life (e.g. aliens) *Nonbizarre* = may occur in real life, but is not true (e.g. having a disease)

Pseudodementia - Characteristics

*Characteristics* - Presence of cognitive deficits in patients *with major depression* - Demented symptoms are *secondary* to underlying depression *See page 83 of Psych FA for Dementia vs. Pseudodementia*

Disorders of thought *Content* vs. *Process*

*Content* = reflects patient's beliefs & interpretation of his surroundings *Process* = how patient links words/thoughts together

Dementia - Definition - Most common causes - Onset & Progression Timeline

*Definition* Impaired memory & cognitive function *without loss of consciousness* *Common Causes* = Alzheimers + Vascular Dementia + Major Depression - *Insidious* onset --> lasts for *months/years*

Delusional disorder - Dx Criteria - Treatment

*Dx Criteria* - *NONBIZARRE* delusions for at least *1 month* - Does not meet criteria for schizophrenia - Life functioning not significantly impaired *Treatment* - Psychotherapy - Anti-psychotics may not be effective, but should be tried

Cyclothymic Disorder - Dx Criteria

*Dx Criteria* - Alternating periods of *hypomania* and mild-moderate *depressive* symptoms for at least *2 years* - No hx of major depressive or manic episodes

Agoraphobia - Dx Criteria - Association with panic disorder

*Dx Criteria* - Anxiety about being in a place/situation where escape would be difficult - Places/situations are avoided *Association with panic disorder* - Have panic attack in supermarket --> anxiety about having future panic attacks in supermarket --> avoid supermarket --> progresses to avoiding public areas in general

Major Depressive Disorder - Dx Criteria - Associated Sleep Changes - NT changes - Endocrine changes

*Dx Criteria* - At least 1 major depressive episode - No history of manic/hypomanic episode *Sleep changes* - Multiple awakenings - Initial & terminal insomnia - Hypersomnia - REM sleep shifted earlier + stages 3 & 4 decreased *NT changes* - Decreased Dopamine, 5-HT, & NE *Endocrine changes* - Increased cortisol - Decreased TSH release in response to TRH

Mixed Episode - Dx Criteria

*Dx Criteria* - Criteria met for both Manic & Depressive episodes - Lasts for at least *1 week* - *Psych emergency*

Schizoaffective Disorder - Dx Criteria + Duration - Prognosis - Treatment

*Dx Criteria* - Meet criteria for *Major depressive* and/or *Manic* episode *during schizophrenic episodes* - Have delusions/hallucinations for *2 weeks* without mood disorder symptoms --> *rules out mood disorder with psychotic features* *Prognosis* - Better than Schizophrenia - Worse than Mood disorders *Treatment* - Antipsychotics - Mood stabilizers, Antidepressants, or ECT

Specific phobia - Dx Criteria

*Dx Criteria* - Persistent excessive fear --> exposure causes anxiety - Pt is aware the fear is excessive - If under *18 y.o.*, duration must be at least *6 months*

Brief Psychotic Disorder - Dx Criteria - Treatment

*Dx Criteria* - Schizophrenic symptoms for *1 day - 1 month* *Treatment* - Antipsychotics - Psychotherapy - Benzos for agitation

Acute Stress Disorder - Dx Criteria

*Dx Criteria* - same as PTSD, but symptoms must occur within *1 month* of trauma and last no more than *1 month*

Personality disorder - Dx Criteria - Clusters & familial association to what disorder?

*Dx Criteria* = Behavior pattern that deviates from the norm and is manifested in 2+ of *CAPRI* - *C*ognition - *A*ffect - *P*ersonal *R*elations - *I*mpulse control *Clusters* - Cluster A = MAD = Paranoid, Schizoid, Schizotypal - Cluster B = BAD = Antisocial, Borderline, Histrionic, Narcissistic - Cluster C = SAD = Avoidant, Dependent, Obsessive-compulsive - Personality Disorder Not Otherwise Specified (NOS) = Passive-aggressive personality disorder

Alzheimer's Disease - Dx Criteria - NT changes & locations - Pathophysiology - Treatment

*Dx Criteria* = Memory impairment with at least 1 of... - Apraxia - Aphasia - Agnosia - Decreased executive functioning - Personality & mood changes may occur *NT changes & locations* - Decreased ACh = locus ceruleus of brainstem - Decreased NE = basal nucleus of Meynert (midbrain) - Increased glutamate *Pathophysiology* = Senile plaques (amyloid) + Tau protein tangles *Treatment* - Anticholinergics (e.g. donepezil, rivastigmine) = slow progression - Memantine = NMDA receptor antagonist - Symptomatic treatment

Hypomanic Episode - Dx Criteria

*Dx Criteria* = at least *3* of DIGFAST (same as manic) but for at least *4 days* ("4 letters in *hypo*") - No impairment of life functioning - No need for hospitalization - No psychotic features

Manic Episode - Dx Criteria

*Dx Criteria* = at least *3* of DIGFAST for at least *1 week* - *D*istractability - *I*nsomnia/*I*rritability - *G*randiosity - *F*light of ideas - *A*gitation/*A*ctivity (increased) - *S*peech (pressured) - *T*houghlessness - Causes severe impairment in life functioning - *Psychiatric emergency* = requires hospitalization to prevent harm to self/others - May have psychotic features

Major Depressive Episode - Dx Criteria

*Dx Criteria* = at least *5* of SIGECAPS for at least *2 weeks* - *S*leep decrease - *I*nterest decrease (anhedonia) - *G*uilt - *E*nergy decrease - *C*oncentration decrease - *A*ppetite decrease - *P*sychomotor retardation - *S*uicidal ideation

Histrionic Personality Disorder - Dx Criteria/Characteristics

*Dx Criteria/Characteristics* - Attention-seeking - Excessive emotionally - Dramatic, flamboyant, extroverted - Sexually inappropriate/provocative - *Unable to form long-lasting, meaningful relationships*

Borderline Personality Disorder - Dx Criteria/Characteristics - Common Defense Mechanism

*Dx Criteria/Characteristics* = IMPULSIVE - *I*mpulsive - *M*oody - *P*aranoid - *U*nstable - *L*abile, intense relationships - *S*uicidal - *I*nappropriate anger - *V*ulerable to abandonment - *E*mptiness *Common Defense Mechanism* = Splitting

Schizophreniform Disorder - Dx criteria - Prognosis - Treatment

*Dx criteria* - Schizophrenic symptoms that have lasted *between 1-6 months* *Prognosis* = 1/3 recover + 2/3 progress to schizophrenia or schizoaffective disorder *Treatment* = antipsychotics

Inhalants - Effect - Intoxication symptoms - How does OD cause death? - Long term use effects - Treatment

*Effect* = CNS Depressant *Intoxication Symptoms* - Impaired judgement + Belligerence + Impulsivity - Perceptual disturbance + Nystagmus - Tremor + Muscle weakness *OD* --> Arrhythmias or Respiratory depression --> Death *Long Term Use* --> damage to CNS, PNS, Liver, Kidneys, and Muscles *Treatment* = Monitor + Symptomatic treatment

Cocaine Intoxication - Effects - How does overdose cause death? - Diagnosis - Intoxication Treatment - Dependence Treatment

*Effects* = sympathetic effects - Euphoria + Increased BP + Increased HR + Dilated pupils + nausea + sweating - *OD* causes death commonly via MI, cardiac arrhythmia, stroke, seizure, or respiratory depression *Diagnosis* = Urine drug screen (positive for 3 days) *Intoxication treatment* - Benzodiazepine = mild/moderate agitation - Haloperidol = severe agitation - Sympathomimetic support *Dependence treatment* - Psychotherapy - Tricyclic Antidepressants - Dopamine agonists

Mood Episodes vs. Mood Disorder

*Episode* = period of abnormal mood *Disorder* = pattern of relapses with relatively normal functioning between episodes

Types of delusions (6)

*Erotomanic* = delusion revolves around love *Grandiose* = inflated self-worth *Somatic* = physical delusion *Persecutory* = delusion that people are blaming you for something *Jealous* = delusions of unfaithfulness

Amphetamines - Examples - Mechanism of action

*Examples* = Meth + MDMA (ecstasy) + Ritalin *Mechanism of Action* = - Releases Dopamine --> stimulant effects - Releases Serotonin --> hallucinations (*MDMA only*)

Side effects of Antipsychotic medications (4)

*Extrapyramidal symptoms* - Dystonia (spasm) of face/neck/tongue - Parkinsonism - Restlessness *Anticholinergic symptoms* "Hot as a Hare, Dry as a Bone, Red as a Beet, Blind as a Bat, Mad as a Hatter" *Tardive dyskinesia* = darting/writing movements of face/neck/tongue *Neuroleptic Malignant Syndrome* = Confusion + High fever + High BP + Tachycardia + "Lead pipe" rigidity + Sweating + Increased creatinine phosphokinase (CPK) - Potentially *life threatening*

NT abnormalities & Effects on sleep - Increased Dopamine & Norepinephrine - Increased Acetylcholine - Increased Serotonin

*Increased Dopamine & Norepinephrine* --> decreased total sleep time *Increased Acetylcholine* --> Increase sleep time & proportion of REM sleep *Increased Serotonin* --> Increased sleep time & proportion of delta wave sleep

Culture-Specific Psychoses - Koro - Amok - Brain fag

*Koro* = Asia - Penis shrinking --> disappears --> death *Amok* = Malaysia, SE Asia - Sudden, unprovoked bouts of violence - Often commits suicide afterwards *Brain Fag* = Africa - Headache + Fatigue + Visual disturbances in *male* students

Caffeine - Mechanism of Action

*Mechanism of Action* - Adenosine antagonist --> increased cAMP - Stimulates dopaminergic system

Vascular Dementia - Mechanism - Dx Criteria - Differences from Alzheimer's - Treatment

*Mechanism* = microvascular disease --> diffuse small infarcts --> dementia *Dx Criteria* = same as Alzheimer's *Differences from Alzheimer's* - More acute onset - Less behavioral changes - More focal neurological symptoms *Treatment* = Symptomatic

Other types/features of Depressive Disorders - Melancholic - Atypical - Catatonic - Psychotic

*Melancholic* - Anhedonia + Early morning awakenings + Psychomotor disturbance + Excessive guilt + Anorexia *Atypical* - Leaden paralysis + Hypersomnia + Hyperphagia + Reactive mood + Hypersensitivity to rejection *Catatonic* - Immobility + Purposeless movement + Bizarre postures + Mutism/Echolalia *Psychotic* = presence of hallucinations/delusions

Panic Disorder - NT changes - Dx Criteria - Diagnosis types

*NT Changes* - Increased NE - Decreased GABA & 5-HT *Dx Criteria* - At least 1 panic attack + - At least *1 month* of anxiety about future attacks - Change in behavior related to attacks (e.g. avoid situations that may provoke panic) *Diagnosis types* - Always specify panic disorder *with agoraphobia* or *without agoraphobia*

Obsessive-Compulsive Disorder - What is an obsession? - What is a compulsion? - Dx Criteria - Neurochemical association

*Obsession* = recurrent thought, feeling, or idea *Compulsion* = conscious, repetitive behavior done to relieve anxiety caused by an obsession *Dx Criteria* - Presence of an obsession *and/or* compulsion - Obsession/compulsion causes distress + decreased fxn - Pt is aware of obsession/compulsion *Neurochemical association* = abnormal regulation of *serotonin*

Electroconvulsive therapy - Procedure - Common side effect

*Procedure* - Premedication with *atropine* --> general anesthesia + muscle relaxant - Pass electricity across brain --> generalized seizure *Common side effect* = retrograde amnesia

Alcohol - What receptors does it affect? and how? - Metabolism - Screening for abuse

*Receptors* - Stimulates GABA and 5-HT receptors - Inhibits Glutamate receptors *Metabolism* - Alcohol dehydrogenase = alcohol --> acetylaldehyde - Aldehyde dehydrogenase = acetylaldeyde --> acetic acid *Screening for abuse* = CAGE questions - Have you felt the need to *C*ut down on drinking? - Have you felt *A*nnoyed by criticism of your drinking? - Have you ever felt *G*uilty about drinking? - Have you ever taken a drink as an *E*ye opening?

Alcohol intoxication - Sensitive marker - Treatment

*Sensitive marker* = GGT = γ-glutamyltransferase *Treatment* = Thiamine + Folate + Naloxone

Somatization Disorder - Characteristics - Dx Criteria - Course

*Soma*tization = *So Ma*ny complaints - Multiple vague complaints involving multiple organ systems - Long history of doctor visits *Dx criteria* = 2+ GI symptoms + 1+ reproductive symptom + 1+ neurological symptom + 4+ pain symptoms *Course* = chronic + debilitating - Can get better --> worse after stress

Amphetamine Withdrawal - Symptoms & Treatment

*Symptoms & Treatment* = same as cocaine

Psychosis - Symptoms - Medical causes

*Symptoms* - Abnormal perception of reality - Hallucinations + Delusions + Disorganized thinking *Medical Causes* - CNS disease - Endocrinopathies - Nutritional/Vitamin deficiencies

Caffeine Intoxication - Symptoms - How does OD cause death? - Treatment

*Symptoms* - Anxiety + Insomnia + Twitching + Restlessness - GI disturbance - Rambling speech - *Severe* --> Tinnitis + Agitation + Cardiac arrhythmias *OD* --> Respiratory failure + Seizure --> Death *Treatment* =

Sedative-Hypnotic Withdrawal - Symptoms - Treatment

*Symptoms* - Autonomic hyperactivity + Delirium + Hallucinations + Anxiety + Tremors + Seizures *Treatment* - *Long Acting Benzo Taper* = e.g. chlorodizepoxide or diazepam - *Seizure Prevention* = Valproic acid or Tegretol

Cocaine Withdrawal - Symptoms - Treatment

*Symptoms* - Constricted pupils - Psychomotor agitation/retardation - Malaise/Fatigue *Treatment* - Supportive = sleep it off

Opiate Intoxication - Symptoms - Intoxication Treatment - OD Treatment - Dependence Treatment

*Symptoms* - Drowsiness + Nausea/Vomiting + Constipation + Respiratory depression + Constricted pupils *Intoxication Treatment* = monitor & support breathing *OD Treatment* = Naloxone or Naltrexone - may induce withdrawal in dependent patients *Dependence Treatment* = Methadone taper

Opiate Withdrawal - Symptoms - Treatment (moderate & severe)

*Symptoms* - Dysphorea + Lacrimation + Weakness - Rhinorrhea + Sweating - Nausea/Vomiting - Dilated pupils - Piloerection *Treatment* - Moderate --> Clonidine +/- Buprenorphine - Severe --> Methadone taper

Nicotine Withdrawal - Symptoms - Treatment

*Symptoms* - Dysphoria + Craving + Anxiety + Irritability + Insomnia *Treatment* = Smoking cessation with... - Behavioral counseling - Nicotine replacement therapy - *Zyban* = antidepressant to reduce cravings - Clonidine

Caffeine Withdrawal - Symptoms - Treatment

*Symptoms* - Headache - Nausea/Vomiting - Drowsiness *Treatment* - Taper caffeine consumption - Analgesics for headache - Benzos for anxiety control (rare)

Nicotine Intoxication - Symptoms - Treatment

*Symptoms* - Insomnia + Anxiety + Restlessness - Increased GI motility - Increased focus & mood *Treatment* = Smoking cessation

Dysthymic Disorder *Symptoms* *Dx Criteria*

*Symptoms* = CHASES - Poor *C*oncentration - *H*opelessness - Poor *A*ppetite - in*S*omnia or hyper*S*omnia - Low *E*nergy - Low *S*elf-esteem *Dx Criteria* - Chronic mild depression for at least *2 years* - At least *2* of the symptoms (CHASES) - No major depressive, manic, or hypomanic episodes "Dysthymic Disorder (DD) = *2* D's = 2 years + at least 2 symptoms"

PCP Intoxication - Symptoms - OD effects - Diagnosis - Treatment

*Symptoms* = Hallucinations + Violence + Impaired judgement + *Rotatory nystagmus* + High pain tolerance *OD* --> seizures & coma *Diagnosis* = urine drug screen --> CPK & AST elevated *Treatment* - Monitor & support - Acidify urine = NH4Cl & Ascorbic acid - Benzodiazepine & Dopamine antagonists = reduce anxiety & agitation - Diazepam = for muscle rigidity - Haloperidol = for severe agitation + psychosis

Panic attack - Symptoms

*Symptoms* = PANICS - *P*alpitations/*P*araesthesias - *A*bdominal distress - *N*ausea/*N*umbness - *I*ntense fear of impending doom/death - *C*hills/*C*hest pain/*C*hoking - *S*haking/*S*weating/*S*hortness of breath

Delirium - Symptoms - Types - Onset & Progression Timeline - Differential - Treatment

*Symptoms* = Waxing & Waning consciousness *Types* - *Quiet* = may seem depressed - *Agitated* = may hallucinate - *Acute* onset --> lasts for *days/weeks* *Differential* = AEIOU TIPS - *A*lcohol - *E*lectrolytes - *I*atrogenic - *O*xygen (hypoxia) - *U*remia/hepatic encephalopathy - *T*rauma - *I*nfection - *P*oisons - *S*eizures *Treatment* = treat underlying cause & symptoms - *Avoid benzos* = often exacerbate delirium

Alcohol withdrawal - Symptoms - Delirium tremens - Treatment

*Symptoms* = anxiety + irritation + tremors + diaphoresis + insomnia + seizures *Delirium tremens* = most serious form of ETOH withrdrawal - Delirium + Visual/Tactile hallucinations + Tremor *Treatment* = Benzo taper (chlorbiazepoxide, lorazepam) - Thiamine + Folate + Multivitamin - MgSO4 for seizures

Sedative-Hypnotic Intoxication - Symptoms - Treatment

*Symptoms* = drunk *Treatment* - Monitoring - Activated Charcoal - *Benzos* = Flumazenil - *Barbs* = Sodium Bicarb --> alkalinizes urine

Amphetamine Intoxication - Symptoms - Diagnosis - Treatment

*Symptoms* = same as cocaine *Diagnosis* = Urine screen (positive for 1-2 days) *Treatment* = same as cocaine

Attention Deficit Hyperactivity Disorder - 3 Types - Treatment

*Types* 1) Predominantly inattentive 2) Predominantly hyperactive-impulsive 3) Mixed *Treatment* - CNS Stimulants = *Ritalin* (1st line) + Dextroamphetamine + Pemoline - SSRI/TCA antidepressant = adjuvant therapy - Psychotherapy

*Hallucination Types* - What are they commonly associated with? - Visual - Auditory - Olfactory - Gustatory - Tactile - Hypnagogic - Hypnapompic

*Visual* = medical illness > psychiatric illness - Most common in *drug intoxication* *Auditory* = psychiatric illness > medical illness - Most common in *schizophrenics* - *Olfactory* = aura of seizure - *Gustatory* = rare; seizures - *Tactile* = Alcohol & Cocaine abuse/withdrawal - *Hypnagogic* = occurs when *going* to sleep; Narcolepsy - *Hypnapompic* = occurs when *waking* from sleep; Narcolepsy

- Which dopamine pathways are responsible for positive/negative symptoms of Schizophrenia?

- *Prefrontal cortical* pathway = NEGATIVE symptoms - *Mesolimbic* pathway = POSITIVE symptoms

Childhood Disintegrative Disorder - Gender more commonly affected - Timeline/Progression

- Affects boys more than girls - Normal development --> onset at 2-10 y.o. --> loss of language, social, & motor skills

Alcohol Dependence - Treatment

- Alcoholics Anonymous - Psychotherapy - Disulfiram (Antabuse) = inhibits aldehyde dehydrogenase --> retching when drinking - Naltrexone = decreases cravings

Binge Eating Disorder - Characteristics - Difference from anorexia & bulimics - Treatment

- Binge eat --> Guilt + Emotional distress + Obesity - Don't try to control their weight like anorexics & bulimics *Treatment* = therapy + diet + exercise - Pharmacotherapy used to promote weight loss

Bulimia Nervosa - Characteristics - Types - Difference from anorexia - Treatment

- Binge eating + Behaviors of weight control *Types* - *Purging* = vomiting/laxatives/diuretics - *Non-purging* = excessive exercise or fasting *Bulimia vs. Anorexia* - Bulimics usually are *normal or over-weight* - Bulimia is more *ego-dystonic* = more likely to ask for help --> better prognosis *Treatment* = therapy - SSRIs are first line, then TCAs

Cocaine - Mechanism of action

- Blocks Dopamine reuptake --> affects reward system - Blocks Norepinephrine reuptake --> indirect sympathomimetic

When is *urinary continence* & *bowel control* established? - What words (2) mean loss of urinary and bowel control respectively?

- Both established before *age 4* - *Enuresis* = loss of urinary continence - *Encopresis* = loss of bowel control

Antisocial personality disorder - Age requirement

- Disregard for & violation of rights of others - Fails to conform to social norms --> breaks laws - Patient must be *≥18 y.o.* - *Conduct disorder* if *< 18 y.o.*

Dopamine & Serotonin effects on Libido

- Dopamine enhances libido - Serotonin inhibits libido

Gross brain changes of Schizophrenia

- Enlarged ventricles - Diffuse cortical atrophy

Narcissistic Personality Disorder

- Excessive sense of self-importance - Sense of superiority - Need for admiration - Lack of empathy

Intermittent Explosive Disorder - Characteristics - NT changes - Treatment

- Failure to resist impulsive urges --> anxiety - Fulfillment of urges --> relief +/- remorse - Impulses associated with *low serotonin* *Treatment* = SSRIs

Bereavement

- Grief reaction from losing loved ones or friends - Need to distinguish from signs of *major depression*

- Neurotransmitter changes in Schizophrenia

- Increased *Dopamine* + *Serotonin* + *Norepinephrine* - Decreased *GABA*

Sleep changes in Elderly - Treatment

- Increased *number* of REM episodes + Decreased *duration* of REM = *still same amount of total REM sleep* - Increased *stage 1 & 2* + Decreased *stage 3, & 4* (deep) sleep - Increased awakenings *Treatment* = try non-pharm methods first before sedative-hypnotics

Rett's disorder - Gender affected - Timeline - Cause

- Occurs in *girls* - Normal psychomotor development up to ~4 years old --> regress & die *Cause* = MECP2 gene mutation on X chromosome

Conversion Disorder - Characteristics - Course

- Patient *converts* psychological problems to neurological problem --> spontaneously *converts* back to normal - Always preceded/exacerbated by psychological stressor - Often resolve within *1 month*

Obsessive-Compulsive Personality Disorder

- Pattern of perfectionism, inflexibility, & orderliness - Preoccupied with details --> can't finish simple tasks - Successful professionally, but poor interpersonal skills

Avoidant Personality Disorder

- Pattern of social rejection (shy) - Intense fear of rejection - Feelings of inadequacy - *Desires companionship*

Schizophrenia - Definition - Etiology - Men vs. Women - Downward Drift - Dx Criteria - Phases - Treatment (& what is best for negative symptoms?)

- Periods of Psychosis + Disturbed behavior/thought + Decline in functioning for *>6 months* - *Etiology* = Genetic + Environmental + Assoc. w/ frequent cannabis use - More severe in men --> more *negative symptoms* + greater decline in function *Downward Drift* = patients with schizophrenia have decreased functioning --> drop down to lower socioeconomic groups - Reason why many homeless people are schizophrenic *Dx Criteria* = 2+ of the following: - *Positive symptoms* = Hallucinations + *Bizarre* delusions + Disordered speech + Disorganized/catatonic behavior - *Negative symptoms* = Flat affect + Lack of motivation (anhedonia) + Social withdrawal + Lack of speech/thought *Phases* 1) *Prodromal* = decrease in functioning 2) *Psychosis* 3) *Residual* = negative symptoms between psychotic episodes TREATMENT *Atypical antipsychotics* = 1st line --> best for *negative* symptoms - Lower incidence of *extrapyramidal* side effects - *Clozipine* = best atypical *Typical antipsycotics* = best for *positive* symptoms

Factitious disorders - Characteristics - Münchhausen syndrome - Münchhausen syndrome by proxy

- Person produces symptoms in order to assume to the role of a patient (*primary gain*) - *No external incentives* *Münchhausen syndrome* = factitious disorder with mostly physical complaints *Münchhausen syndrome by Proxy* = intentionally produce symptoms in someone else who is under one's care

Autism - Symptoms

- Poor communication & social skills - Restricted interests - Ritualized/repetitive behavior "*PRR* like an autistic cat..."

Dependent Personality Disorder

- Poor self-confidence - Fear of separation --> feels helpless when alone - *Submissive & Clingy*

Hypochondriasis - Characteristics - Management

- Prolonged concern over health or possible illness for *> 6 months* - Misinterpretation of normal bodily symptoms as disease *Management* = no cure - Schedule frequent visits to *ONE* primary care doctor

Post-Traumatic Stress Disorder - Duration - Dx Criteria - Treatment

- Response to catastrphic/life-threatening experiences - Reliving traumatic events --> impairs social functioning - Lasts for *> 1 month* *Dx Criteria* - Witness/experience traumatic event - Persistently relives event - Avoids stimuli associated to trauma - Emotional numbing or Hyperarousal *Treatment* = CBT + SSRI + Venlafaxine

Passive-Aggressive Personality Disorder

- Stubborn, inefficient procrastinators - Alternate between compliance and defiance - Make excuses & lack assertiveness - Manipulate others to do their work

Difference between Tourette's disorder vs. Motor/Vocal tic disorder - NT changes in tic disorders - Treatment

- Tourette's requires *both motor & vocal* tics for diagnosis - Disregulation of *dopamine* in *caudate nucleus* --> tic disorders *Treatment* = Dopamine receptor antagonists (e.g. Haloperidol or pimozide)

Phencyclidine (PCP) - aka? - What is similar to PCP? - Mechanism of action

- aka *Angel dust* - *Ketamine* is similar to PCP *Mechanism of Action* - Antagonizes NDMA glutamate receptors - Activates Dopaminergic neurons

Social anxiety disorder - aka? - Dx Criteria

- aka *Social Phobia* *Dx Criteria* = same as specific phobia, but caused by public situations

Opiates - Examples - Mechanism of Action

- e.g. Morphine, Heroin, Codeine, Destromethorphan (cough syrup), Methadone *Mechanism* - Activates opiate receptors (mu, kappa, delta) --> analgesia, sedation, & dependence - Affects dopaminergic system --> addiciton

Subtypes of Schizophrenia - Defining characteristics

1) *Paranoid type* = highest functioning - Preoccupation with 1+ delusions - No disorganized speech/behavior or inappropriate affect 2) *Disorganized type* = lowest functioning - Disorganized speech/behavior - Inappropriate affect 3) *Catatonic type* = rare - Motor immobility - Excessive purposeless movement - *Echolalia* or *Echopraxia* = copy speech/behaviors 4) *Undifferentiated type* = characteristics of 1+ subtype 5) *Residual type* = mostly negative symptoms

Blood Alcohol Level (BAL) & Effects

25-50 = fine motor skills impaired 50-100 = judgement & coordination impaired 100-150 = Ataxic gait + Poor balance 150-250 = can't sit upright (PTFO) 300 = coma in novice drinker 400 = respiratory depression

Rapid Cycling - Definition

4+ mood episodes in 1 year

Parasomnia

Abnormality in behavior & physiology during sleep

Dyssomnia

Abnormality in the amount, quality, or timing of sleep

Generalized Anxiety Disorder - Duration - Dx criteria

Anxiety for *> 6 months* due to an *unidentifiable* stresssor *Dx Criteria* = at least 3 of... - Difficulty concentrating - Irritability - Restlessness - Fatigue - Muscle tension - Sleep disturbance

Adjustment Disorder - Dx Criteria

Anxiety/Depression occuring within *3 months* after an *identifiable* stressor & lasting *< 6 months*

Asperger's Disorder - Difference from Autism

Basically autism, but *normal language & cognitive development*

Nicotine - Mechanism of Action

Binds nicotinic receptors on automatic ganglia --> stimulates sympathetic & parasympathetic nervous systems

Serotonin Syndrome

Confusion + Hyperthermia + Hyper/hypotension + Muscular rigidity

Stages of Dying (5)

Denial Anger Bargaining Depression Acceptance

Primary gain

Expression of unacceptable feelings as physical symptoms to avoid facing them

Delusions - Definition - Paranoid delusion - Ideas of reference - Thought broadcasting - Delusions of grandeur - Delusion of guilt

Fixed, false beliefs that cannot be changed by rational argument + *not accounted for by culture background* - *Paranoia delusion* = belief that one is being persecuted - *Ideas of reference* = belief that an event is uniquely related to the patient - *Thought broadcasting* = belief that one's thoughts can be heard by others - *Delusions of grandeur* = belief that one has special powers - *Delusion of guilt* = belief that one is guilty/responsible for something

Oppositional Defiant Disorder

Like conduct disorder but *without violation of basic rights of others*

Loss of ego boundaries

Loss of awareness of where one's mind/body ends and those of others begin

What is *Double Depression*?

MDD with dysthymic disorder during residual periods

Malingering

Making up symptoms for personal gain (*secondary gain*)

Amnestic Disorders - Definition

Memory impairment *without other cognitive problems or altered consciousness*

Illusion

Misinterpretation of an existing sensory stimulus

Paranoid personality disorder vs. Paranoid schizophrenia

Paranoid personality disorder *does not have the fixed delusions/psychosis* that Paranoid schizophrenia does

Shared Psychotic Disorder

Patient develops psychotic symptoms/delusions similar to someone he/she is close to

Anorexia Nervosa - Characteristics - Types - Difference between Anorexia & Major Depression - Treatment

Preoccupation with weight & staying thin *Types* - *Restrictive* = doesn't eat + lots of exercise - *Binge eating/purging* = may use laxatives & diuretics *Anorexia vs. Major Depression* - Anorexia = good appetite + preoccupied with food - Major depression = poor appetite + no interest in food *Treatment* = therapy - Antidepressants that cause weight gain may be useful (e.g. mirtazapine & paroxetine)

Pain Disorder

Prolonged severe discomfort that often co-exists with a medical condition *but is not caused by it*

Mini Mental Status Exam - What does it test? (6) - Scoring (Perfect & Dysfunction)

Tests *Orientation* + *Registration* + *Attention* + *Calculation* + *Recall* + *Language* *Scoring* - Perfect = 30 - Dysfunction = <25

Secondary gain

Use of symptoms to benefit the patient

Conduct Disorder

Violation of basic rights of others or of social norms/rules

Bipolar I Disorder - Dx Criteria

aka *Manic Depression* *Dx Criteria* - At least *1* manic episode - Euthymic, Major depressive, Dysthymic or Hypomanic episodes between manic episodes *not required for dx*

Bipolar II Disorder - Dx Criteria

aka *Recrurent Major Depressive Episodes with Hypomania* *Dx Criteria* - Hx of 1+ major depressive episodes + at least 1 *hypomanic* episode

PCP Withdrawal

none