Complete Psych Objectives

Describe the features, evaluation and management of *Oppositional Defiant Disorder*

*Diagnostic Criteria* (your kid is being a dick when you tell them to do their chores) ○A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting *at least 6 months and at least 4 symptoms* of the following with at least one individual who is not a sibling: ○ Often loses temper, often touchy or easily annoyed, angry and resentful, argues with authority figures/adults, actively defies or refuses rules from authority figures, deliberately annoys others, blames others for mistakes or misbehaviors, spiteful/vindictive *Treatment* ○ Therapy ○ No Medications! ○ Involve family and treat comorbid conditions

o Discuss the clinical features and diagnostic criteria for the various Cluster A - *Paranoid* personality disorder -

*Paranoid:* a pervasive distrust and suspiciousness of others *Need 4 or more* of the following to make Dx: - Suspects others are exploiting or harming him - Preoccupied with unjustified doubts about loyalty - Reluctant to confide in others because of unwarranted fear that the information will be used against him - Reads hidden threatening meanings into benign things - Persistently bears grudges - Perceives attacks on his or her character or reputation that are not apparent to others and quick to react - Recurrent suspicions regarding fidelity of partner

o Compare and contrast cluster A, B and C personality disorders

*WEIRD (A) , WILD (B), WORRIED (C)* CLUSTER A - odd, eccentric behavior ("Weird") - Paranoid - Schizoid - Schizotypal CLUSTER B - dramatic, erratic, impulsive ("Wild") - Antisocial - Narcissistic - Borderline - Histrionic CLUSTER C - anxious, fearful ("Worried") - Obsessive-Compulsive PD - Dependent - Avoidant Diganosis is difficult because it is very *common* for patients to have *overlap of symptoms* of disorders in one or multiple clusters.

Discuss *attention deficit disorder (ADD) and attention deficit hyperactivity disorder (ADHD)* in terms of signs, diagnosis and management.

**THIS CAN BE EITHER WITH HYPERACTIVITY OR WITHOUT IT** ○ Thus ADD vs. ADHD *Diagnostic Criteria* ○ At least 6 symptoms of inattention (making careless mistakes, forgetting things, difficulty organizing etc) *AND/OR* ○ At least 6 symptoms of hyperactivity/impulsivity (talking excessively, blurting out answers before question has been completed, difficulty awaiting turn, unable to stay in assigned seat) ○ Symptoms onset *before age 12* ○ The symptoms occur in *at least 2 settings for 6 months* ○ Symptoms interfere with social, academic, or occupational functioning ○ R/O other psychiatric disorders. *Treatment* ○ School accommodations ○ Organizational skills training ○Medication: - Stimulants (Schedule 2) ex. SNRIs - *Methylphenidate* class safer than Amphetamine class in terms of CV side effects ex. Ritalin, Concerta, Focalin (Methylphenidate) ex. adderall, dexedrine (*Amphetamine*) - Non-Stimulants ex. Strattera (atomoxetine) and alpha agonists (Intuniv and Kapvay)

Compare and contrast *Anorexia Nervosa and Bulimia Nervosa*

*Anorexia* ○ *Low* body weight ○ Purging *may* be present ○ High risk for depression and anxiety ○ Family tends to be perfectionist ○Lower risk for substance disorders than Bulimia *Bulimia* ○*Normal to high* body weight ○Purging is *always* present ○ High risk for depression and anxiety ○ Family tends to be chaotic and conflictual ○ Higher risk for substance disorders than Anorexia

o Discuss the clinical features and diagnostic criteria for the various Cluster B - *Antisocial* personality disorders -

*Antisocial:* pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years May improve as impulsivity diminishes w/ age Decreased emotional arousal leads to decreased empathy and increased thrill seeking ---> Higher prevalence in the incarcerated population *Need 3 or more* for Dx: - Failure to conform to social norms with respect to lawful behaviors - Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit - Impulsivity or failure to plan ahead - Irritability and aggressiveness → but often very charming to suck people in - Reckless disregard for safety of self or others - Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations - Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another - The individual is at least age 18 years. - There is evidence of Conduct Disorder with onset before age 15 years.

o Discuss the clinical features and diagnostic criteria for the various Cluster C - *Avoidant* personality disorders -

*Avoidant:* Pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation - More than just "shyness" - Comorbid: Anxiety D/O, Substance D/O - Overlap with Social Phobia, Schizoid PD - Well-suited to therapy *Needs 4* or more for Dx: - Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection - Unwilling to get involved with people unless certain of being liked - Shows restraint within intimate relationships because of the fear of being shamed or ridiculed → want the relationships but they get very anxious about them (different than schizoid type who don't want the relationships) - Preoccupied with being criticized or rejected in social situations - Inhibited in new interpersonal situations because of feelings of inadequacy - Views self as socially inept, personally unappealing, or inferior to others - Unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing

Treatment regimens for adjustment disorder

*Behavioral approach*: first-line: psychotherapy second line: CBT (cognitive Behavioral Therapy) /interpersonal /supportive psychotherapy *Pharm approach*: First line- antidepressant (ie sertraline or another SSRI); Second line: zolpidem or anxiolytics if pt has no hx of alcohol abuse

o Discuss the clinical features and diagnostic criteria for the various Cluster B - *Borderline* personality disorder -

*Borderline Personality Disorder*: A pervasive pattern of *instability* of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts. - suicidal behavior (depression/substance abuse increases risk of suicide) - Comorbid disorders = Everything - " The Great Imitator" (The Syphillis of personality disorders - *CONSISTENTLY INCONSISTENT* *Need 5* the following for Dx (AEIOU): - *A*ffective Instability (due to mood reactivity) - *A*nger - *A*bandonment avoidance ("if you leave me, i'll kill myself") - *E*mptiness - *I*mpulsivity in at least 2 areas that are potentially self-damaging (Examples: spending, sex, substance abuse, reckless driving, binge eating) - *I*dentity disturbance (unstable self-image) - *I*nterpersonal instability (alternating between extremes of idealization and devaluation) - Psych*O*tic breaks - S*U*icidal gestures Treatment: - Therapy: *Dialectical Behavioral Therapy (DBT)*, Cognitive therapy, - Meds: SSRIs, Mood stabilizers, Anti-anxiety meds, antipsychotics Hospitalization if dangerous to themselves or others.

OCC Synthetic Drugs

*Classes - LSD, psilocybin, mescaline/peyote, MDMA, GHB, Ketamine, PCP* ● Intoxication - pupillary dilation, tachycardia, sweating, palpitation, blurred vision, tremors, incoordination → symptoms often don't separate out which drug they are using but should clue you that they are using drugs in this category ○ *LSD* lasts 6-12 hours, adverse effects mostly psychological and can be dangerous; colorless and tasteless; has long effects so this is not a drug that is usually taken daily by patients ■ treat intoxication w/ "talking down" ○ *Psilocybin *- mushrooms, serotonin agonist properties, clinical effect similar to LSD ○ *MDMA (ecstasy)* - club drug/aphrodisiac; acts as stimulant AND hallucinogen; effects last 2-8 hours: euphoria, energy, empathy, heightened sensations, anorexia ■ toxicity: malignant hyperthermia/dehydration, hyponatremia ■ physical effects: tremors, cramps, nausea, blurred vision, increased HR and BP, sweating ■ This drug is often combined with other dangerous drugs like cocaine, ketamine, ephedrine etc which can be very dangerous and have long lasting effects ○ *Phencyclidine *- "angel dust" can be swallowed, smoked, snorted, or injected - "Clickums" is a common mode of use (mixed with weed in a rolling paper and then dipped in formaldehyde and smoked like a joint) ■ effects unpredictable, risk of accidental injury or death (ex: patients trying to fly because they think they can then they break their leg), can induce psych state almost indistinguishable from schizophrenia, can be stored in body and re-excreted later ■ toxicity: nystagmus, HTN, tachycardia, ataxia, dysarthria, muscle rigidity, seizures, coma ○ *Spice/K2 *- psychoactive herbal product containing synthetic cannabinoids; mimics the effects of weed; tests negative for pot ■ side effects: loss of control, loss of pain response, increased agitation, seizures, vomiting, uncontrolled/spastic body movements, elevated BP, HR, palpitations, hallucinations/paranoia ■ Recently have started testing athletes for this ○ *Bath salts *- newest fad, inhaled, injected, snorted, or injected IV ■ dangerous synthetic stimulant! act in brain like stimulant - agitation, paranoia, chest pain, hallucinations, suicidality, delirium ● HTN, elevated HR, extreme sweating, high body temp, stroke, death ■ thought to worsen previously stable psychotic disorders, trigger chronic/long-term psychotic disorders ○ *Flakka* - surging in FL, similar to bath salts ■ Foul smelling crystal that can be eaten, snorted, injected or vaporized ■ Causes excited delirium with hyperstimulation, paranoia, hallucinations and self injury ■ Raises body temperature and can lead to kidney damage or failure ○ *Kratom* - tropical tree with psychoactive leaves that are chewed ■ used to uplift mood, for cough, diarrhea, muscle aches and pain

Outline the clinical features, diagnosis and management of *mood disorders in children* including depressive disorder and early onset bipolar disorder. *Early Onset Bipolar Disorder*

*Clinical Manifestation* ○ Bipolar Disorders (Type 1, Type 2, Unspecified, Rapid Cycling) ○ Highly comorbid with ADHD and Disruptive Behavior Disorders (ODD or Conduct Disorder) *Diagnostic Criteria* ○ Distinct period of persistently elevated, expansive, or irritable mood and persistently increased goal-directed activity or energy, lasting at least 1 week. ○ During this period 3+ for the following symptoms must be present: - Inflated self-esteem/grandiosity, decreased need for sleep, more talkative, racing thoughts/flights of ideas, distractibility, increase in goal directed activity/psychomotor agitation, activities that have high risk for painful consequences - Mnemonic: *DIGFAST* (Distractibility, Indiscretion, grandiosity, flight of ideas, goal directed activities, sleep deficit, talkativeness) *Treatment* ○ Mood Stabilizer - Lithium - Depakote/Valproic Acid (Not Approved For Children) ○ Anti-psychotics - Risperdal/Risperidone - Abilify/Aripiprazole - Seroquel XR/Quetiapine - Zyprexa/Olanzapine

Define and discuss *eating disorders* including: anorexia nervosa, bulimia nervosa and obesity. *Obesity*

*Clinical Manifestation* ○ Overweight Patient ○ Increased risk of DM, Stroke, and Cardiac Disease *Diagnosis* ○ BMI > 30 Adults ○ BMI over 95th Percentile for children and adolescents *Management* ○ Healthy diet, physical activity ○ Calories consumed should be equal or less than calories burned (to lose weight) ○ There are no *FDA* approved medications for children - Topomax (off label) bc it has anorexia as side effect ○ Adult medications (in combo with healthy diet and physical activity) - Stimulants - Orlistat (GI lipase inhibitor) - Qysmia (Combo of phentermine and topamax)

Define and discuss *Enuresis* in terms of diagnosis and management.

*Clinical Manifestation* ○ Repeated voiding of urine into bed or clothes in child *5+ years old* ○ Voluntary or involuntary; occurs at least *twice a week x 3 months or causes significant distress or dysfunction* ○ Not attributable to substance use or another medical condition ○ Prevalence = 5-10% among 5 year-olds; more common in males ○ Diurnal enuresis commonly occurs in those who also have nocturnal enuresis *Management* ○ Behavioral treatments (*bed alarm system*) have longer-lasting results than medications ○ Star Chart! - Goal/Reward System ○ Scheduled voiding ○ Decrease fluid intake before bedtime ○ Medications: - *DDAVP* (desmopressin) - Reduces urine volume

Define and discuss *Encopresis* in terms of diagnosis and management.

*Clinical Manifestation* ○ Voiding of feces into bed or (other than toilet) at least *once a month x 3 months* *DSM Diagnostic Criteria:* ○ Repeated passage of feces into inappropriate places whether involuntary or intentional ○ At least one such event a month for at least 3 months ○ Age *at least 4 years old* (or developmentally equivalent) ○ Behavior not due exclusively to direct physiological effects of a substance or medical condition *Management* ○ *Schedule toilet times*, treat comorbid constipation ○ Sit child briefly on toilet at same time twice per day. ○ Star Charts!! ○ Treat psych issues ○Medication: Laxatives, Stool softeners, Fiber, Imipramine.

Outline the clinical features, diagnosis and management of *mood disorders in children* including depressive disorder and early onset bipolar disorder. *Depressive Disorder*

*Clinical Manifestation* ○D-SIGECAPS ○Depressed mood or anhydonea plus four of the following symptoms during the same *2 week* period and represent a change from previous functioning: - Depressed mood (can be irritable mood), markedly diminished interest and pleasure in activities, significant weight loss/gain or change in appetite, insomnia/hypersomnia, psychomotor agitation or retardation, fatigue, feelings of worthlessness or guilt, diminished ability to think or concentrate, recurrent thoughts of death or suicidal ideations. *Treatment* ○ Combination of Medicine and Psychotheraby (Best Option) - If mild sx, try therapy alone first ○ Medication - Antidepressants - Prozac/Fluoxetine (ages 7+) - Lexapro/Escitalopram (ages 12+) ○ Psychotherapy - CBT (Cognitive Behavioral Therapy) - IPT (Interpersonal Psychotherapy)

o Define and discuss delusions, delirium, and hallucinations

*Delusion*- fixed, false beliefs. The key here is that they are *fixed* and you cannot talk someone out of this belief. (Ex: "Aliens put a device in my brain." you show the head CT with nothing in it "Your technology can't pick it up.") *Delerium*- associated w/ fluctuating sensorium, sudden onset, *brief fluctuating course*, and rapid improvement w/ treatment of underlying disorder, may have visual and tactile hallucinations *Hallucinations*- *False sensory perception* occurring in the absence of any relevant external stimulus. Can be any sense

o Discuss the clinical features and diagnostic criteria for the various Cluster C - *Dependent* personality disorders -

*Dependent:* Pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation: *Need 5* of the following for Dx: OBEDIENT mnemonic - *O*bsessive about approval (e.g. volunteering to do things that are unpleasant) - *B*ound by other's decisions - *E*nterprises (projects) are rarely initiated d/t lack of self-confidence (NOT due to lack of motivation) - *D*ifficult to make decisions - *I*nvalid feelings while alone - *E*ngrossed w/ fears of self-reliance (Fear they can't care for themselves) - *N*eeds to be in a relationship (Urgently seeks another when one ends) - *T*entative about decisions

Describe the features, evaluation and management of *Conduct Disorder*

*Diagnostic Criteria* (your kid is a gigantic bag of dicks all the time) ○ Repetitive and persistent pattern of behavior which violates the rights of others or violates social norms and rules. ○ This will cause impairment in social, academic, and/or occupational function. ○ The presence of *3+ in the past 12 months* of the following: - *Aggression to people or animals*: Bullies, threatens, intimidates, initiates fights, use of weapons, cruelty, steals with confrontation, forced sexual activity. - *Destruction of property*: Setting fires with the intend to cause damage, destroying others property/belongings. - *Deceitfulness or Theft*: broken into someones house/car, lies to obtain goods/avoid obligations, steals without confrontation. - *Serious violation of rules*: stays out at night despite parental objection before age 13, ran away from home at least twice or once without returning for a lengthy period, truant from school before age 13. *Treatment* ○ Therapy ○ Involve the family and treat any comorbid conditions

o Describe screening methods for identifying substance abuse

*Drug Testing* -Know what the test you order does and does not look for. • *Urine* - noninvasive but non quantitative and easy to rig • *Hair/nails* - detects remote use but may miss recent use, typically 3 months can detect • *Blood* - quantitative and tamper proof but invasive • *Others* - saliva, sweat, breath UF Health has the 5 panel mostly: • *5 Panel* - cannabinoids, cocaine, amphetamines, opiates, pcp • *10 Panel* - above + meth, benzo, propoxyphene, barbs, methadone • *12 Panel* - above + MDMA, expanded opioids (oxy, hydrocodone) *History* • *Present problem* - Blackouts, withdrawal sx, doctor shopping, running out early, age at first use • *Social* - DUI, substance-related arrests, IVDA, blacking out, passing out • *Psych* - Prior substance treatment: detox/rehab/outpatient • *PMHx*- liver (hepatitis/cirrhosis), lung (COPD/cancer), GI (ulcers/bleeds) • *Family hx* - substance use disorders

Compare and contrast major depression and dysthymia

*Dysthymia is mild and constant, MD is not constant but more severe* 1) *Major Depression:* Sx are marked, and present for most of the time for *2+ weeks* with at least *5* of these symptoms (*must contain depressed mood or Anhedonia( an inability to enjoy usual activities)*) - DSIGECAPS D - DEPRESSED mood or anhedonia *+ 4 of* S - SLEEP I - INTEREST or pleasure (anhedonia ) G- GUILT or worthlessness E - ENERGY or fatigue C - CONCENTRATION or indecisiveness A - APPETITE P - PSYCHOMOTOR (slowing of physichal or emotional reactions) S - SUICIDE ideation or attempt (⅔ contemplate suicide, 10-15% commit suicide) 2) *Dysthymia* (persistant depressive disorder) This is a *Constant, mild depression* Sx: low self-esteem/confidence, feelings of hopelessness, generalized anhedonia, social withdrawal, chronic fatigue, feelings of guilt, irritability, excessive anger, decreased activity, difficulty thinking/concentrating Dx: depressive symptoms present *most of the day and more days than not* for at least 2 years (1 year in kids) *no major depressive episodes* during this time

o Be familiar with the clinical presentation of overdose and withdrawal with the following, also include medical uses. • Marijuana

*Examples*: Pineapple Express *Sx of Intoxication*: - Effects are subjective and varies between users. (route of admission JACKKNIFE, setting, expectation) -Initial period of feeling "high" with sense of well-being and happiness. Followed by drowsiness or sedation. -Perception of time is altered, hearing and vision distorted. Increased appetite. -Pupil dilation, and possibly tachycardia *Sx of Withdrawal*: -Cannabinoids very slowly eliminated from the body, and no specific sx of withdrawal recognized in DSM - IV. -Only with very heavy use someone may have: insomnia, irritability, dysphoria, anorexia, hand tremor, and nausea. *Sx of Overdose*: -*Not overdoses per say, but at high dosages:* acute panic reactions, paranoia, hallucinations, illusions, thought disorganization, and agitation -*Extremely high dosages:* acute toxic psychosis, depersonalization, and loss of insight. *No death ever recorded. Like ever.* *Treatment/Detox*: Believed to be *more psychological addiction than physiological*. (Lab rats don't self admin this one). ...Lot of what the angry presenter man said is more the old-school logic. Long term effects not really understood, lots of research needed. *Timeline*: Impairment persists 4-8 hours after user first feels high begin.

Describe the indicators of a *potentially suicidal child/adolescent* and appropriate management for that patient.

*Facts* ○ Boys > Girls - Deaths ○ Girls > Boys - Attempts ○ Third leading cause of death Age 15-24 *Indicators* ○ Hx of suicide attempts, Suicidal ideation, Family hx, Hx of depression or mental illness, Alcohol/drug abuse, Stressful life event or loss, Easy access to lethal methods, Exposure to the suicidal behaviors of others, Incarceration, Parasuicide (self injury that is low lethality) *Treatment* ○ Baker Act (hospitalize) - Treat underlying psych disorder and comorbidities ○ Coping Measures ○ CBT ○ SSRI (fluoxetine) *Controversial* ○ "No harm contact" refrain from self-harm - Remove access to weapons, medications, etc.

(OCC) SSRI

*First line* depression/dysthimia Tx due to low side effect profile and OD potential compared to MAOI and TCAs Also used in panic disorder, OCD, Social anxiety disorder, generalized anxiety disorder, and PTSD. Paxil is the most anticholinergic, and causes the majority of the anticholinergic side effects All cause weight gain, but paxil is again the worst Can cause nausea, tension HA, Anxiety, insomnia, daytime drowsiness, sexual disfunction (buspirone levitra, cialis, viagra all help with this last side effect) (top 3 are usually first choice-lowest side effects) Sertraline-Zoloft Escitalopram-Lexapro Citalopram-Celexa Fluvoxamine-Luvox Fluoxetine-prozac Paroxitine-Paxil All have about the same efficacy with *depression*, They all have slightly different side effects, and each has slightly different indications for other disorders. You switch them based on side effects per each pt. ecxept only fluvoxamine works for OCD, and only FLuoxetine is used in both adults and children.

o Discuss the clinical features and diagnostic criteria for the various Cluster B - *Histrionic* personality disorder - AKA Michael Scott or Corrine from the Bachelor

*Histrionic:* A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of context *Need 5* of these for Dx: - Uncomfortable when not center of attention (Ex: Zoolander) - Inappropriate sexually seductive or provocative behavior - Displays rapidly shifting and shallow expression of emotions - Uses physical appearance to draw attention to self - Has a style of speech that is excessively impressionistic and lacking in detail - Self-dramatization, theatricality, and exaggerated expression of emotion - Easily influenced by others or circumstances - Considers relationships to be more intimate than they actually are

o Identify common defense mechanisms employed by patients with personality disorders in the *Immature Defenses Category*

*Immature Defenses* - Acting out: Expressing an unconscious wish or impulse through action to avoid being conscious of an accompanying affect. - Blocking: Temporarily or transiently inhibiting thinking. - Hypochondriasis: Exaggerating or overemphasizing an illness for the purpose of evasion and regression. - Introjection: Internalizing the qualities of an object or person (a child adopting views held by his/her parent, this is the opposite of projection) - Passive aggression: aggression towards others is expressed indirectly - Regression: Attempting to return to an earlier libidinal phase of functioning to avoid the tension and conflict evoked at the present level of development (potty trained child wetting the bed when parents argue.) - Schizoid Fantasy: Indulging in autistic retreat in order to resolve conflict and to obtain gratification. - Somatization: Converting psychic derivatives into bodily symptoms and tending to react with somatic manifestations, rather than psychic manifestations.

Compare and contrast mania and hypomania

*Manic Episode* (this includes some form impairment) A period of abnormally and persistently elevated, expansive, or irritable mood AND persistently increased goal-directed activity or energy Lasts *at least 1 week* (or any duration if hospitalized) but can last up to 3 months if untreated Must include at least 3 of the following: *DIGFAST* *Distractibility*; *Indiscretion*/involvement in pleasurable activities; *Grandiosity* or inflated self-esteem; *Flight* of ideas (FOI) or subjective racing thoughts; *Activity* increase or psychomotor agitation; *Sleep* deficit;* *Talkativeness* or pressured speech (also apparently they get really irritated if they are kept from doing something they have their mind set on) Medical causes of manic symptoms: metabolic (hyperthy), neuro (temporal lobe seizures, MS), SLE, any cause of delirium, *syphilis*, HIV, head trauma Medications that cause mania: alcohol, cocaine, amphetamines, caffeine, antidepressants, corticosteroids, dopamine, levodopa, bronchodilators *Hypomanic* Episode (no impairment) Must last *at least 4 days* and At least 3 of the Sx of manic (or irritability +3 others) but there is *no impairment of function, no hospitalization, no psychotic symptoms* Many people with Bipolar disorder funtion at this level and get tons of stuff done.

o Identify common defense mechanisms employed by patients with personality disorders in the *Mature Defenses Category*

*Mature Defenses* - Altruism: deriving personal satisfaction from helping others - Anticipation: planning for future stress with preparation -Asceticism: severe self-discipline and avoidance of all forms of indulgence - Humor: disarming the negativeness of the situation by bringing humor to situation - Sublimation: Achieving impulse gratification and the retention of goals but altering a socially objectionable aim or object to a socially acceptable one. (Ex: a person who gets angry all the time becoming a soldier, or expressing themselves through music) - Suppression: Consciously or semiconsciously postponing attention to a conscious impulse or conflict. Discomfort is acknowledged but minimized.

Causes of Depression

*Medical causes* Neuro (stroke, MS, cancer), Endocrine (DM, Cushing's, Addison, hypothyroid (less often hyper)), Infection and Inflammation (mono, AIDS, SLE, TB), Cancer (especially pancreatic), Trauma, Vitamin deficiency (folate, B12) *Medications/substances* antiHTN meds (beta blockers), *Alcohol*, barbiturates, sedatives, corticosteroids, analgesics, anti-inflam, immunosuppressive agents, antibacterials, anticonvulsants, antineoplastics, withdrawal from stimulants And just *life in general*... but there is a difference between bereavement and MDD When symptoms persist > 2 months, functional impairment, preoccupation with worthlessness, suicidal ideation or behavior, psychotic symptoms it's no longer berevement

o Identify common defense mechanisms employed by patients with personality disorders in the *Narcissistic Defenses Category*

*Narcissistic Defenses* - Denial: refusal to accept external reality bc it's too threatening - Distortion: reshaping external reality to suit inner needs - Projection: Perceiving and reacting to unacceptable inner impulses and though they were outside the self.

o Discuss the clinical features and diagnostic criteria for the various Cluster B - *Narcissisitic* personality disorders -

*Narcissistic:* a pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy Some clues: - Many are successful - Sensitive to criticism, blames others - May not be evident until middle age due to sense of loss or personal limitations ("Narcissistic injury") - Comorbid: Depression, Bipolar, Substance abuse *Need 5 or more* of these: - Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior) - Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love - Believes that he or she is "special" and unique and can only be understood by, or should associate with, other special or high-status people (or institutions) - Requires excessive admiration - Has a sense of entitlement - Is interpersonally exploitative, i.e., takes advantage of others - Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others - Is often envious of others or believes that others are envious of him or her - Shows arrogant, haughty behaviors or attitudes

o Identify common defense mechanisms employed by patients with personality disorders in the *Neurotic Defenses Category*

*Neurotic Defenses* - Controlling: Attempting to manage or regulate their environment to minimize anxiety/stress - Displacement: shifting aggressive impulses onto a less threatening target (Example: getting yelled at at work but cant yell at boss so comes home and yells at kids) - Externalization: Tending to perceive in the external world one's own personality (what you hate about other people is what you really what you hate about yourself, projection is a specific form of this) -Inhibition: Consciously limiting some ego functions to evade anxiety. - Intellectualization: focusing on the intellectual rather than anxiety producing emotional aspects of the situation - Isolation: Splitting or separating an idea from the affect that accompanies it but is repressed. - Rationalization: convincing oneself that they did no wrong - Dissociation: Temporarily but drastically modifying a person's character or one's sense of personal identity to avoid emotional distress. - Reaction Formation: Transforming an unacceptable impulse into its opposite. - Repression: unconsciously putting unacceptable thoughts or memories out of mind - Sexualization: Deeming sexual significance to an object or function that it did not previously have in order to ward off anxieties associated with prohibited impulses.

o Discuss the clinical features and diagnostic criteria for the various Cluster C - *Obsessive Complusive PERSONALITY disorder* -

*Obsessive Compulsive PERSONALITY disorder:* a pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency (different from OCD discussed earlier) - The "I should" thinkers *Need 4* of the following for Dx: - Preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost - Shows perfectionism that interferes with task completion - Excessively devoted to work and productivity to the exclusion of leisure activities - Overconscientious, scrupulous, and inflexible about matters of morality - Unable to discard worn-out or worthless objects even when they have no sentimental value - Reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things (Difficulty working in groups) - Miserly spending style toward both self and others; money is to be hoarded - Shows rigidity and stubbornness

(OCC) Psychotherapy

the use of *psychological* methods, particularly when based on regular personal interaction, to help a person change and overcome problems Sit in this chair and tell me about your childhood

Outline treatment regimens for depression, Major depression Disorder (*Non pharmacological*)

*Psychotherapy treatment* supportive, interpersonal, CBT, dialectical behavioral therapy, psychoanalysis, family therapy *ECT* Electroconvulsive Therapy → inducing a seizure in a controlled environment ■ 80-90% success rate ■ very effective for depression, *no absolute contraindications*, requires anesthesia, unknown mechanism of action, can be used in pregnancy, requires multiple treatments (6-12 ballpark) ■ indications: failure of several medications, severe depression w/ psychotic features, high risk of suicide, medical emergency d/t severe wt loss, previous good response to ECT because it works faster than meds ■ Conditions that *require consultation* prior to ECT: HTN, cardiac arrhythmias, cardiac pacemaker, MI, intracardiac thrombi, anticoagulant therapy, pregnancy, dementia, aneurysms, brain tumors, epilepsy, respiratory disorders, orthopedic problems, history or family hx of issues with anesthesia *Other treatments* Phototherapy (lightboxes), acupuncture, thiamine, B12, folate, herbs, endocrine therapies

(not an objective) Types of delusions

*Referential*- Believing that random or coincidental events have deep personal significance. "they're talking about me on the news" *Grandiose*- grossly exaggerated beliefs of power, wealth, or significance *Religious*- any delusion involving religious themes or subject matter that is not within the expected beliefs for an individual's background/culture *Persecutory*- pt believes that they are being persecuted, spied on, poisoned, etc *Somatic*- About their body. They believe a body part is infested, emits a foul odor, isn't functioning, is misshapen *Jealousy*- Lover or spouse is unfaithful *Erotomanic*- you believe someone else is in love with you Delusions are deemed "with *Bizarre* content" if clearly implausible. Ex: That's bullshit Gary, you clearly don't have robot testicles

Outline treatment regimens for depression, Major depression Disorder *(Medications)*

*SSRI* are the *1st line* - (fluoxetine, sertraline, paroxetine, citalopram, escitalopram) First line because they are safe, effective, hard to OD on, less drug interactions Primary side effects: GI upset (Seratonin receptors in the gut), headache, sexual side effects, agitation, sedation (only fluoxetine and escitalopram for kids, never give paxil (paroxetine) to kids, causes suicide) *Tricyclic Antidepressants*: elavil, tofranil, norpramin, sinequan These all are lethal in overdose (so be careful giving to depressed pt's); primary side effects: anticholinergic, weight gain, sedation, cardiac arrhythmias *Other antidepressants* venlafaxine - SNRI - can cause HTN mirtazapine - can cause increased appetite and weight gain (increases seratonin, NE) bupropion - significant risk of seizure above 450 mg/day, avoid in people w/ hx of seizures or eating disorders MAOIs - risk of acute hypertensive crisis and acute toxicity through interfering with metabolism of other drugs, also delirium is a risk Avoid Benzodiazepines (valium, ativan, xanax) → potential for abuse, tolerance

o Discuss the clinical features and diagnostic criteria for the various Cluster A - *Schizoid* personality disorders -

*Schizoid:* pervasive pattern of social withdrawal and a restricted range of expression of emotions *Need 4 or more* of these for Dx: - Neither desires nor enjoys close relationships - Almost always chooses solitary activities - Little interest in sexual experiences w/another person - Takes pleasure in few, if any, activities - Lacks close friends other than first-degree relatives - Appears indifferent to the praise or criticism of others - Emotional coldness, detachment, or flattened affect

o Discuss the clinical features and diagnostic criteria for the various Cluster A - *Schizotypal* personality disorders -

*Schizotypal:* pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior: *Need 5* of these for diagnosis: - Ideas of reference (excluding delusions of reference) ---> Ex: believe in step on a crack and break your mother's back - Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or "sixth sense"; in children and adolescents, bizarre fantasies or preoccupations) - Unusual perceptual experiences, including bodily illusions - Odd thinking and speech (e.g., vague, circumstantial, metaphorical, over-elaborate, or stereotyped) - Suspiciousness or paranoid ideation - Inappropriate or constricted affect - Behavior or appearance that is odd, eccentric, or peculiar (ex: willy wonka) - Lack of close friends or confidants other than first-degree relatives - Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self Treatment: - Psychotherapy - Low dose antipsychotics (New research, NOT FIRST LINE)

o Describe the diagnostic utility of DSM as it relates to psychiatric disorders. The *DSM-5* is the official classification system of mental disorders in the US. (22 major categories, >150 discrete illnesses) Arranged by symptom clusters, follows lifespan (early life -> end of life)

*Standardizes*: -Classification of diagnoses -Distinguishes one psych diagnosis from another -Communication among healthcare professionals, researchers and 3rd party payers. *Guides Treatment* but doesn't discuss treatment. *Descriptive*: describes the manifestations of clinical features of mental disorders *Diagnostic Criteria*: lists features that must be present for a diagnosis to be made; increases reliability *Systematic*: describes specific demographics (including cultural features), prevalence, incidence, risk, course, complications, predisposing factors, familial pattern, differential diagnosis

o Outline the clinical signs and symptoms of substance dependence and substance abuse

*Substance Abuse* 1. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by *one or more of the following within a 12mo period ->* - Recurrent substance use resulting in failure to fulfills roles at work/home - Recurrent substance use in situations in which it is physically hazardous - Recurrent substance related legal problems - Continued substance use despite social/personal problems 2. Symptoms have never met the criteria for substance dependence *Specifically for Alcohol Abuse:* *Men* o No more than 14 drinks/wk o No more than 4 drinks/day *Women* o No more than 7 drinks/wk o No more than 3 drinks/day *Substance Dependence* "You used it, abused it, and now you depend on it" 1.A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by *3 or more of the following, occurring at any time in the same 12-month period ->* - Tolerance - Withdrawal - Substance is often taken in larger amounts over longer period - Persistent desire or unsuccessful efforts to cut down - A lot of time spent to get or use the substance, or recover from it - Substance use is continued despite knowledge of having a persistent or recurrent problem

o Be familiar with the clinical presentation of overdose and withdrawal with the following: • Opiods

*What are they?*: - Action is *analgesia*, sedating at high doses, and - *Addiction can be severe and leads to poor behavior to support habit. (dat criminal life)* *Examples*: ○ Endogenous - enkephalins, endorphins ○ Opium alkaloids - morphine, codeine ○ Semi-synthetic - heroin, hydrocodone, oxycodone, (all of these derived from morphine) ○ Synthetic - fentanyl, methadone *Sx of Intoxication*: euphoria or dysphoria, feelings of warmth, facial flushing, itchy face, dry mouth, and pupil constriction *Sx of Withdrawal*: hyperalgesia, photophobia, goose flesh, diarrhea, tachycardia, increased blood pressure, gastrointestinal cramps, joint and muscle aches, and anxiety and depressed mood - *Causes intense craving for the drug 2/2 reduction dopamine release* - *No delirium, not life threatening* *Sx of Overdose*: Shallow breathing, bradycardia, cold/clammy, apnea, hypotention, miosis, circulatory collapse, areflexia, respiratory arrest, death *Treatment/Detox*: FOR OVERDOSE: *Naloxone* - and repeat, watch for rebound sedation when naloxone wears off ■ half-life = 1 hour; puts them into instant withdrawal FOR ADDICTION: *Agonist Therapy*: *Methadone* pure agonist- gold standard - half life is 24-36 hours; abusable, can produce respiratory depression *Buprenorphine:* partial agonist, long half-life, less abuse potential, safer in OD, high affinity will block heroin kick - Sublingual *Timeline*: Depends on opioid T1/2, but generally: Onset: 6-12h Peak: 24-72hr Length: up to 2w Post-acute w/d: up to a year

o Be familiar with the clinical presentation of overdose and withdrawal with the following: • Sedative hypnotics

*What are they?*: - Drugs that *depress or slow down body's function*. "The pill form of alcohol" - "Hypnotic" because you forget things after you take one, dangerous for elderly. *Examples*: 2 Main classes: *Benzodiazepines* : commonly prescribed and abused (short T ½ - alprazolam medium T ½ - lorazepam long T ½ - diazepam) *Barbiturates*: not as common Other: Ambien *Sx of Intoxication*: Mild impairment of motor skills, slow reaction time, sedation, decreased motor coordination, impaired judgement, diminished memory and cognitive skills, sleep *Sx of Withdrawal*: • *More dangerous than the other classes, including alcohol.* • Tolerance develops quickly. • Determined by dose and T1/2 o autonomic hyperactivity, hand tremor, insomnia, N/V, hallucinations, psychomotor agitation, anxiety, grand mal seizures, delirium (this is what can kill you), death • Can be prolonged for months *Sx of Overdose*: •Dizziness, confusion, drowsiness, blurred vision, unresponsiveness, anxiety, agitation •*Death 2/2 benzos unlikely unless paired with EtOH* -Treatment of benzo overdose is *Flumazenil* *Treatment/Detox*: ○ Severe w/d predictors: long-term use, high dosage, short-acting drug, hx of DTs, hx w/d seizures, known CVD, severe psych comorbidity ○ 2 basic strategies: taper a cross-tolerant ideally benzo (explained in OCC), long-acting drug; treat symptoms with unrelated drugs ○ With delerium, use benzo taper *Timeline*: -Withdrawal starts after ~12 hours and is worse with shorter T1/2 - Withdrawal could be several days delayed with long T1/2

o Be familiar with the clinical presentation of overdose and withdrawal, treatment, with the following: • Alcohol

*What are they?*: - Unclear still if there is a connection b/t genetic disposition to drinking and simultaneously, substance abuse. *Sx of Intoxication*: Mild impairment of motor skills, slow reaction time, sedation, decreased motor coordination, impaired judgement, diminished memory and cognitive skills, sleep *Sx of Withdrawal*: Hand tremor, anxiety/panic, sweating, psychomotor agitation, insomnia, irritability, restlessness, tachycardia, hyperthermia, headache, nausea/vomiting, auditory/visual/tactile hallucinations, grand mal seizures, *delirium tremens* *Sx of Overdose*: Loss of consciousness, vomiting, coma, respiratory failure, death *Clinical Presentation*: - Lifetime abuse: 10% women, 20% men Breath odor, elevated BP Frequent injuries - Women more susceptible to alcoholic liver disease, heart muscle and brain damage *Chronic Use:* cirrhosis, pancreatitis, epilepsy, polyneuropathy, alcoholic dementia, heart disease, cancer, CNS damage *Cirrhosis ->* ascites, jaundice, spider angioma, muscle wasting, esophageal varices *FREQUENT injuries* *Labs* ○ Elevated AST and ALT in combo with medical conditions like hepatosplenomegaly, ascites, etc ○ ETG/ETS urine drug screen = can detect ETOH use up to 5 days later ○ PEth blood spot = can detect heavy alcohol use for the past 2-3 weeks ○ Blood Alcohol Level = fraction of 1% of blood content: ■ 0.30 = start to lose consciousness and vomit ■ 0.60 = most die *Treatment/Detox*: *For Detox:* -*Benzos:* long acting diazepam, lorazepam w/ liver disease. - Trx duration varies with severity. - Better to over treat (sedatino) than under treat (seizures, delirium tremens -> death) - Thiamine (B1) for Wernicke's encephalopathy (low Vit B1 2/2 malnutrition) - For delerium, use benzo taper *For Anti-abuse:* *Disulfiram* - makes them feel really sick whenever they drink a little alcohol *Naltrexone* - prevents relapse, reduces cravings because of high reduction *Timeline*: Onset: 6-8h Peak: 24 hr Length: up to 7d Tonic Clonic seizures @ 12-48 hours after last drink. Delerium @ 48-72hrs Sx of acute alcohol withdrawal abate by 3-5 days after last drink.

o Be familiar with the clinical presentation of overdose and withdrawal with the following: • Stimulants

*What are they?*: •Blockade of reuptake of *NE and Dopamine* (so you have more in the synapse) •Produces feelings of well-being, confidence, euphoria ■ this group of medications is* commonly sold on the illegal market* or malingered by pts •*VERY addicting*. Lab rats will pick this over food until they die. •Cocaine esp. had a tremendous reinforcing effect (person remembers how good it felt and is super driven to feel it again) *Examples*: Cocaine (D2) (Schedule II) Amphetamine (NE) (Schedule II) *Sx of Intoxication*: *Dopamine reuptake blockade:* self-stimulation, anorexia, stereotyped movements (aimless and repetitive), hyperactivity, and sexual excitement. *NE reuptake blockade:* tachycardia, hypertension, vasoconstriction, mydriasis, diaphoresis, and tremor *Sx of Withdrawal*: Dysphoria "crash", hypersomnolence, anergia, vivid/unpleasant dreams *Sx of Overdose*: *General:* Rambling speech, tachy, brady, pupil dialation, hypo/hypertension, chills/sweat *Cocaine:* MI, CVA, seizures, renal failure, heart problems, death *Meth:* MI, HTN, CVA, seizures, twitchy, coma, death *Treatment/Detox*: *On PE:* "meth mouth" no saliva + teeth grinding (Bruxism), deviated septum with cocaine *Imaging*: Chronic cocaine leads to deterioration of utilization of glucose by brain which can show on PET scan. - Supportive care, rest, eat sleep in safe environment *Trx sx* Anxiety: Lorazepam/diazepam Depression: SSRI Cocaine psychosis is self limited Meth psychosis may be longer and need meds *Timeline*: Typical cycle is several binges "crash" 9hrs-4days (Meth effects are longer than Cocaine) withdrawal from 1-10wks During Withdrawal craving and relapse is common.

Eating Disorder Labs/Treatment Review

*What would you order for a patient with an eating disorder being admitted to the hospital? Expected Findings:* (OCC) ○ *EKG* (bradycardia, QTc prolongation) ○ *CBC* (leukopenia, anemia) ○ *CMP* (elevated BUN/creatinine d/t dehydration, metabolic alkalosis from self-induced vomiting (threw up your HCL) which causes elevated serum bicarbonate, hyponatremia, hypochloremia, hypokalemia. mild metabolic acidosis from laxative abuse (pooped out your bicarb); elevated liver enzymes ○ *Lipid Panel* - hypercholesterolemia (body trying to hold onto energy source), LFTs elevated ○ *LOW*: magnesium, phosphate, zinc, T3, testosterone in males, estrogen in females ○ *High*: amylase *Treatment Review* ○ Family therapy has most evidence for treatment ○ Treat comorbidities (depression, anxiety, OCD) ○ Prozac for Bulimia, no meds approved for Anorexia ○ Monitor for *Re-feeding syndrome* w/ Anorexia - Usually within 3-5 days, sudden increase in feeding causes insulin secretion, and increased glycogen and protein synthesis - This requires phos, mag, and K which may already be depleted → complicates electrolyte abnormalities - Cardiac workload increased → risk for fatal arrhythmia!! - *Treatment*: reduced caloric intake, correct Mg, Phos, K, vitamins, thiamine

o Compare and contrast Post *Traumatic Stress Disorder (PTSD) and Generalized Anxiety Disorder (GAD)*

this is repetitive, see individual cards -basically, history is what will clue you in.. -PTSD has flashbacks about significant trauma they either witnessed directly or indirectly -GAD worries about day-to-day events (work, family health/finances, school)

o Outline the risk factors, clinical features and appropriate management for *Agoraphobia*

*You're worried you'll have a panic attack in public, so you don't go out* the *avoidance of settings* where previous panic attacks have occurred or places where escape may be difficult -*RARELY occurs without a history of panic attacks* -late adolescence & adulthood -*end-result= homebound* dx: -anxiety about being in places or situations where escape may be difficult or embarrassing or in which help may not be available in the event of having an unexpected or situationally predisposed panic attack or panic-like symptoms. -fear or anxiety about *2 or more* of following situations: *public transportation (planes, ships, buses), being in open spaces (parking lots, marketplaces, bridges), enclosed places (shops, movie theatre), standing in line or being in a crowd, being outside of home alone* -the situations are avoided or endured w/ marked distress or w/ anxiety about having a panic attack or panic-like sxs or require the presence of friend -no other psych disorder or explanation See House MD Season 5 Episode 7: "The Itch" about agoraphobic patient (performed surgery in agoraphobic patients house) tx: CBT

What is a Personality Disorder? (Not an objective, just background info)

- "An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the culture of the individual who exhibits it". Can impact: - Cognition/Perception - Affectivity/Mood regulation - Impulse control - Interpersonal/Social Interactions The Disorder causes: - Inflexible, maladaptive, or dysfunctional across broad range of situations - Personal distress *OR* adverse impact on the social environment Traits usually evident by young adulthood or adolescence, sometimes early childhood

NOT an objective... Interesting things from text/ OCC

-*Reconnaissance* -*Stereotypies* are organized, repetitive movements or speech or perseverative postures. They are usually associated with schizophrenia, particularly the catatonic type. A striking variant of postural stereotypy is *waxy flexibility*, in which the patient will remain indefinitely in a position into which the interviewer places him or her (e.g., standing on one leg). -*Lability* is rapid changes in mood(e.g., excited anticipation, affection, irritation). -*Histrionic affect*, the blatant but rather shallow expression of emotion often observed in those who exaggerate their feelings in order to avoid being ignored -*Morbid euphoria*, a sense of well-being expressed in inexorable good spirits -*Apathy* , a pervasive lack of interest and drive (also known as *anergia*) -*Anhedonia*, a subjective sense that nothing is pleasurable -*Torpor* denotes a lowering of consciousness short of stupor. -*Dissociative fugue state*: Subtle restriction of consciousness often occurs during acute anxiety and results in vagueness or amnesia for traumaticexperiences. -*Confabulation* is a false memory that the patient believes is true. -*Perseveration*: refers to a tendency to persist with a point or theme, even after it has been dealt with exhaustively or the listener has tried to change the subject. Interesting tidbits: -Depression typically has a *diurnal variation*: Dysphoria, hopelessness, and agitation are worse in the morning, and the patient brightens up by evening. -Anxiety and fear are biologically advantageous because they signal the need for constructive responses. -Orientation is usually lost in the following order: time, place, and person. -"Anybody can help somebody, but nobody can help everybody."

o Discuss the risk factors, clinical features and management of *Panic Disorder*

-*onset typically in 20s* -*highest genetic association out of all the anxiety disorders* (50% have family hx of panic disorder) Sx: -*recurring, spontaneous, unexpected* panic attacks with rapid onset & short duration (<1 hour, most are <30 mins) -usually *wax & wane* (worse in stressful situations) -see below to dx panic attack Dx of Panic Disorder: *NEED BOTH 1 AND 2* 1. RECURRENT, *UNEXPECTED* panic attacks 2. *At least 1 of the panic attacks have been followed by at least 1 month of at least 1 of the following*: -persistent concern about having subsequent attacks -worry about the implications/consequences of the attack (i.e. having MI) -significant change in behavior related to attacks 3. presence or absence of agoraphobia 4. panic attacks are not due to substance or medical condition 5. panic attacks are not accounted for by another psych disorder (in dsm 5 if you do have another disorder that is causing a panic attack you would add "with panic attacks to the other Dx. Ex- bipolar with panic attacks.) Dx of Panic Attack: -discrete period of intense fear or discomfort in which *at least 4* of the following *sxs developed abruptly and reached a PEAK WITHIN 10 MINUTES*: -palpitations, pounding heart, accelerated HR -sweating -trembling/shaking -feeling SOB or smothered/ tachypnic (rapid irregular breathing) -feeling like you're choking -CP or chest discomfort -Nausea or abdominal distress -dizziness, unsteady, lightheaded, or faint-feeling -derealiztion or depersonalization -fear of losing control or going crazy -fear of dying -paresthesias (numbness or tingling) -chills or hot flashes) ^^clue: panic attacks often feel like an MI so the patient commonly presents to the ER dx: clinical -"panicogens" such as IV Sodium Lactate or inhalation of 5-35% CO2 can induce panic attacks in patients w/ panic disorder but will not induce attack in healthy person tx: -*mild --> psychotherapy (behavioral or CBT)* -*mod/severe & to prevent attacks --> SSRI or SNRI * -*acute attack tx --> Benzodiazepine (lorazepam or alprazolam)*

o Identify various factors that may influence a psychiatric evaluation.

-Difficult patients, inability to collect collateral data or records, low rapport -Memory, comprehension, language

o Describe the components of the history and physical that are related to the psychiatric patient, including ROS, family and social history.

-Introduce yourself, put patient and supporters at ease (and spend some time alone w. pt) -Establish rapport, listen actively, be empathetic, check identifiers of patients (form hypothesis throughout initial interview) *History* Obtain corroborative info from collateral sources when possible (get records). *Chief Complaint and HPI* -**Onset, precipitating factors**, observe for things they don't/can't tell you. -CC may not be ultimate focus of treatment -Start with open-ended questions, and end with problem-focused questions -Get answer to *WHY NOW?* -Identify recent stressors (Axis IV), differentiate acute from chronic conditions -Cover mood (depression, bipolar), anxiety (OCD, PTSD, Panic), psychotic (Schizophrenia), substance abuse (alcoholism) -Understand *insight, judgement, and motivation for treatment* *Psychiatric Eval- The BIG 4*: Increase the risk of self harm or harm to others -Suicidal ideation -Homicidal ideation -Psychosis (auditory hallucinations, self-injurious behavior, inability to care for self, reckless/impulsive) -Substance use disorders *Past Psych* current or prior dx -Including alcohol and substance use hx -Meds, psychotherapy (what works best, side effects) -Psychiatric hospitalizations (baker acts?) -Acts of violence or suicide attempts? (How, when, where, why, how many?) -Past violence is best indicator of future violence *Past medical/surgical* -Medical conditions that could affect their psychiatric condition: thyroid disorders, endocrine disorders, seizure/neurological disorders, head trauma, CNS infection -Disorder/meds (herbal and OTC) that may influence treatment, allergies vs side effects -Reproductive hx (pregnant? contraception use?) *Family psych and medical history* -Blood relatives having nervous breakdowns, mental problems, emotional problems, suicide attempts or substance abuse (1-2 generations back- genogram) -Meds of family often work similarly for pt. *Developmental history* -Birth, milestones, delays -Home life: parents and siblings -School performance: special education, conduct, highest grade level achieved -Peer relationships, dating -Trauma, abuse *Social history* -Job, education (interruption- setback/crisis?), military (stability/salary) -Relationship -Religion/spiritual (current and past) -Living situation (support network) -Legal hx (*Domestic violence*) -Abuse hx: physical, emotional, sexual (It's anti-therapeutic to have pt. dig deep first visit, but also need to have idea of potential abuse) *Substance Use History* -All recreational, street, herbal, OTC, supplements (including caffeine and ephedra), tobacco use (past and present). -Amounts, frequency, most recent use -Any legal consequences -*CAGE* Screening (2+ is indicator for alcohol abuse): Felt need to *cut* down drinking? *Annoyed* by criticism? Felt bad/*guilty*? Drink to get rid of hangover (*eye opener*)? *MSE* -Appearance: body habitus, nourishment, age, hygiene, dress, grooming -Behavior/speech: attitude, cooperativeness, *eye contact*, rate, quality of speech -Mood(inner-state)/affect(feeling): internal emotional tone ("happy", "fine", "sad") and external expression of mood (expansive, flat, dysphoric) -Thought process: Normal is linear, logical, and goal-directed. Abnormal is changing, loose associations, tangential, and derailment. -Thought content: normal, suicidal/homicidal, general themes, obsessions/compulsions -Perceptions: delusions, hallucinations, illusions -Insight: their appreciation/understanding of current illness/situation -Judgement: ability to make sound decisions (best assessed w. recent hx) -Cognitive/Memory Testing: MMSE (Folstein), IQ *Physical Exam* -General appearance: sign of endocrine disorders -Vital signs, CV, neuro (look for focal deficits) *Laboratory Testing* -No tests for psych conditions, unless they are due to general med condition. -Screening labs, drug screens, plasma levels of prescribed drugs, B12, folate -Screening tests: EKG, CXR -Imaging: CT/MRI to rule out mass/structural abnormality and EEG for seizures

o Outline the psychiatric examination.

-Psychiatric history -Mental Status Exam (MSE): systematic observations and assessments, guided by hypothetico-deductive approach. -Physical Exam (varies per provider) -Laboratory testing/EEG/Imaging -The four stages of the interview—inception, reconnaissance, detailed inquiry, and termination- are adapted to different topics.

(Not an objective) general treatment approach to Psychosis

1. Evaluate for delirium and general medical conditions first 2. Psychotic disorder?—consult psychiatry 3. Start antipsychotic—start low and go slow, especially in elderly 4. Be aware of medication interactions (present in a lot of antipsychotics) 5. Never hesitate to refer to psychiatry

o Discuss the clinical features and management of *Obsessive Compulsive Disorder (OCD)*

-obsessions and/or compulsions -*obsessions*: unwanted, recurrent intrusive/inappropriate cognitive experiences usually associated w/ feelings of dread or a disturbing sense that something isn't right. the person recognizes that these are inappropriate and tries to ignore or suppress them; cause distress or anxiety -*compulsions*: repetitive overt behaviors or covert mental acts (i.e. hand washing, praying) the person feels driven to perform to reduce the intensity of the aversive obsessions; they are WILLED responses directed at reducing the aversive circumstances associated w/ the obsessive thoughts -most commonly first seen in *childhood/early adulthood* -60% have multiple obsessions or compulsions -obsessions & compulsions can change over time -*commonly associated w/ tourettes syndrome & ADHD* -most recognize that their behaviors are unrealistic or excessive (not kids) -*50% will develop a major depressive episode in their lifetime* -50% have associated personality disorder dx: -either obsessions and/or compulsions that are not connected in a realistic way; compulsions do not do what they were intended to do -*obsessions/ compulsions take > 1 hr/ day* - the thoughts/impulses/images are NOT excessive worries about real-life problems -the person attempts to ignore or suppress the thoughts with some other thought or action -the person recognizes that its a product of their own mind *Yale-Brown Obsessive Compulsive Scale (YBOCS)* evaluates severity of symptoms based on time spent, interference, distress, resistance, & degree of control; scale from 0-40 <16: mild- supportive tx/stress reduction 16-23: mod: 24-31: severe >31: extreme OCC: -CT & MRI have shown decreased gray matter volume in the head of the caudate nucleus -PET: have found increased resting metabolic activity around prefrontal cortex and basal ganglia tx: -goal of tx= to lessen the time-commitment (OCD is life-long) -CBT- exposure & response prevention -1st line medical therapy= High Dose SSRIs (Fluvoxamine) -deep brain stimulation (DBS)= last resort

(OCC) Outline treatment regimens for depression, Major depression Disorder *(Antidepressant Discontinuation Syndrome)*

Abrupt d/c of antidepressant may lead to dizziness, insomnia, nervousness, nausea, agitation, "zaps"-feels like a random brain shock Sx are due to serotonin withdrawal This is especially seen w/ *short half-life agents*, paroxetine (paxil) and venlafaxine (effexor) are notorious ■ not seen with fluoxetine (prozac) (very long half-life) this is good for patients who are *non-compliant* or *children* because it won't matter as much if they miss a dose every once in awhile

(not an objective) Delusional disorder (DSM-5)

1) Don't meet criteria for schizophrenia (if they do have hallucinations, they are not prominent, and they fit with the theme of their delusion. Ex: delusions of parasitosis may have hallucinations of parasites.) 2) Non-bizarre delusions for at least 1 month → usually one very focused delusion (ex: my boss is tapping my phone) 3) Apart from delusions and their impact , functioning is not markedly impaired and behavior is not obviously odd or bizarre 4) If Manic or depressive episodes are present, they are briefer than the delusions 5) Not attributed to another disorder, condition, drug, or medication (OCC) ○ social and marital functioning more likely to be impaired than occupational ○ Men more likely to have paranoid delusions and jealous type ○ Women more likely to have erotomanic type - usually socially isolated, unattractive women - choose people opposite them as love objects ● Mean age of onset is 40 but can happen anytime ● Can be difficult to treat with medications ○ 50% recover at follow up, 20% w/ decreased symptoms, 30% no change

Define and discuss *eating disorders* including: anorexia nervosa, bulimia nervosa and obesity. *Bulimia Nervosa*

1-1.5% among young females (10x more common in Females than Males) There is an increased risk of alcohol and drug abuse *Clinical Manifestation* ○ Dental erosion of enamel from repeated vomiting (HCl) ○ Russell's sign - abrasions on hands from teeth from self induced vomiting ○ Bilateral parotid enlargement *DSM Criteria* ○ Recurrent episodes of binge eating (eating, in a discrete period of time an amount of food that is definitely larger than what most would eat) and a sense of lack of control over eating during the episode ○ Recurrent inappropriate compensatory behaviors in order to prevent weight gain ○ Binging and purging occur *3+ times per month* ○ Self-evaluation unduly influenced by body shape and weight ○ Rule out anorexia! *Management* ○ Prozac only approved medication ○ SSRIs and anti-psychotics often used ○If admitting to the hospital: - Order: meal plan, eye contact during meals, lock out of bathroom for 30 minutes after meal, consider eye contact when using the bathroom, calorie count, ensure, orthostatic vital signs, daily blind weights in hospital gown - Bulimia tends to have slightly higher recovery rates than Anorexia

Psychiatric Disorders (aside from depression) with depressive Sx

Adjustment disorder Anxiety disorders Bereavement Bipolar, Cyclothymia Dysthymia, Delirium, Dementia Psychotic disorders Substance induced

You down with OCC? Yeah you know me.

Alcohol OCC: Two Types of alcoholism: *Type 1* is onset after 25 *Type 2* is onset before 25 - In general, patients with type 2 alcoholism are characterized by thrill seeking, impulsiveness, and aggressiveness, whereas those with type 1 alcoholism have a greater tendency to become anxious and depressed as a result of their drinking. Also, environment plays a heavy role in development of Type 1 alcoholism, but plays only a small role in developing Type 2. -Even though women start drinking later than men, they tend to develop, at about the same age as men, more serious physical complications. These observations suggest greater intrinsic toxicity of ethanol to the liver, brain, and possibly other organ systems of women compared to men. -If you abuse a substance you are 2.7x more likely to have a mental illness FUN Drug Facts: -Patient's who stop chronic BZ use may have rebound anxiety and withdrawal sx -Xanax : careful with elderly, forget they took it and take too many, then can't wake them up -Of all the BZ: Xanax can have the worst rebound/withdrawal sx, use clonipine to taper them off -Ambien : can make you sleep walk, get up and make food -Heroin: has a very fast tolerace development -Fancy term for tolerance is Neuroadaptation *Cross Tolerance:* Cross tolerance means that one drug will alleviate the withdrawal effects of another. It also means that tolerance of one drug will result in tolerance of another similarly-acting drug. Benzodiazepines are often used for this reason to detoxify alcohol-dependent patients There is cross tolerance between alcohol, the benzodiazepines, the barbiturates, the nonbenzodiazepine drugs, and corticosteroids.

4 main classes of antidepressants (OCC)

Antidepressents either *block norepinephrine (NE) or Seritonin (5HT) reuptake,* or *block their breakdown*. The plan is to *increase synaptic concentrations*, a theory is that levels of *seretonin and NE* are depleted in depression. When you block seritonin people become "less depressed", but it's absence won't make you euphoric (except in kids) Tricyclic antidepressants (TCA) Monoamine Oxidase Inhibitors (MAOI) Selective Seratonin Reuptake inhibitors (SSRI) Serotonin noepinephrine reuptake inhibitors (SNRI)

DSM 5 Anxiety Disorder Categories (not a specific objective)

Anxiety Disorders Obsessive Compulsive Disorder Related Disorders Trauma and Stress Related Disorders

General Intro to Anxiety Disorders (not a specific objective)

Anxiety is a normal reaction to a stressor. It becomes pathologic when the normal psychological adaptive process is so overwhelmed that daily functioning is impaired. Normal fears: emotional response is APPROPRIATE to an actual danger vs. Anxiety Disorders can occur either without obvious external threat OR when the response to an actual threat is excessive. etiology: -15% of population is affected w/ an anxiety disorder -all of the anxiety disorders: *Females > Males* -often associated with other psych disorders Theories: -Lots -Becks Cognitive Triad (see next card) -Biological theory: GABA receptor, benzodiazepine receptor, chloride channel receptor, and serotonin receptor are implicated dx: -no lab findings or psychological testing are useful to dx anxiety disorder alone -focal neuroimaging studies may show neurophysiological abnormalities involving limbing, paralimbic, & sensory associated regions tx: cognitive behavioral therapy (CBT) +/- meds --> CBT attempts to discover & correct distortive thinking

Describe a defense mechanism. Identify the *categories of common defense mechanisms* employed by patients with personality disorders

Automatic psychological processes that protect the individual against anxiety and from the awareness of internal or external dangers or stressors. - *Individuals are often unaware* of their use of these mechanisms. *4 Categories* - Mature Defenses - Narcissistic Defenses - Immature Defenses - Neurotic Defenses Examples of specific mechanisms in each category or listed in the next few cards. Good chart @: http://www.mis.rzeszow.pl/media/DefensesChart.pdf

Outline the diagnostic criteria for Bipolar disorders

Average age onset before 30 (usually teens/20s), range 5-50 y/o, accounts for ¼ of all mood disorders Only requires 1 manic episode for diagnosis, a depressive episode is not required for DSM-5 (OCC) ○ high rates of divorce, often have occupational history of numerous jobs, excellent academic achievement, chaotic life histories, 60% develop substance abuse at some point, 50% w/ anxiety disorders, may have more ADHD

o Discuss the diagnosis and treatment of substance abuse

Best way to dx = *Early Identification* *oScreening* - @ clinics, ER, Hospital, schools, community based programs - Identify "at risk" individuals, identify "risky" behaviors - Identify symptoms of intoxication or withdrawal *Multistage Treatment:* 1. Detoxification 2. Rehabilitation 3. Relapse Prevention 4. Maintenance (Abstinence from all substances of abuse) 3 Aspects of Treatment: ■ *Biological:* Detox -> acute withdrawal -> chronic withdrawal ○ it takes months-years for body and brain to heal ■ *Psychological:* Motivational interviewing, brief intervention (helpful for abuse, not dependence), cognitive behavioral therapy, monitoring programs ■ *Social:* self, family, work, school issues need to be addressed/managed *Long-term residential treatment (~3mos) have the best outcomes* Consider if: - Medical/psych comorbidity - Unstable home - Failed outpatient Long Term Includes: - Individual therapy - Group Therapy - Family Therapy - Education -Relapse prevention - 12 Step Introduction* (super effective, help from people with mutual addiction helps everyone)

(OCC) Depression presentation in children, the elderly

Children- antisocial or hyperactive Elderly- memory impairment, back pain (somatic presentation)

(OCC) CBT

Cognitive based therapy Most widely used evidence based practice for treating mental disorders CBT focuses on the development of personal coping strategies that target solving current problems and changing unhelpful patterns in cognitions (thoughts, , and attitudes), behaviors, and emotional regulation. I it was originally designed to treat depression, and is now used for a number of mental health condition Ex) In a pt that is having panic attacks, and thinks they will have an MI every time their hear beats, their CBT would be to avoid physical exertion and to leave situations where they started to feel anxious

(OCC) DBT

Dialectical behavior therapy (DBT) is a therapy designed to help people suffering from mood disorders as well as those who need to change patterns of behavior that are not helpful, such as self-harm, suicidal ideation, and substance abuse. helping people increase their emotional and cognitive regulation by learning about the triggers that lead to reactive states and helping to assess which coping skills to apply in the sequence of events, thoughts, feelings, and behaviors to help avoid undesired reactions Dialectic refers to the two things you're telling them "1) You're doing the best you can, 2) You need to change" Works really well on *borderline disorder*

Compare and contrast *Bipolar I* and Bipolar II disorders

Fluctuating Episodes of Severe mania and depression (Difference from Bipolar II is this one *Has manic episodes*) *Manic phase*: Only requires *one* manic or mixed episode; Episodes begin quickly, rapid progression through the stages → a depressive episode immediately precedes or follows a manic episode *Depressive phase* → minimum of 2 weeks, DSIGECAPS (OCC) ○ Used to be called "Manic Depression" ○ "Mood swings" are *NOT* enough to qualify for the diagnosis of bipolar disorder ○ One episode of mania, most pervasive symptoms is depression, lifetime prevalence 1-4%, First manic episode 20's-30's ○ strong genetic component - one parent w/ bipolar I → 25% child has mood d/o, both parents with bipolar I → 50-75% child has mood d/o ○ starts w/ *depression* in 75% females, 67% males ○ untreated manias last on average *3 months*; 10-15% commit suicide ○ Often comorbid w/ Substance Abuse

(Not an objective) Work up for Psychosis

Full set of labs: CBC, BMP, liver enzymes, B12 and folate, TSH and free T4 Urine tox screen and blood alcohol level Consider ANA (antinuclear antibody) test pt has other symptoms of autoimmune disorder Consider neuro consult to r/o seizure disorder Head CT - always want to scan the brain for new onset psychoses

(Repeat from earlier section) CAGE score

Have you ever felt you should *C*ut down on your drinking? Have people *A*nnoyed you by criticizing your drinking? Have you ever felt bad or *G*uilty about your drinking? Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (*E*ye opener)? A score of 2 or more is clinically significant as an indicator of alcohol abuse

Define and discuss *eating disorders* including: anorexia nervosa, bulimia nervosa and obesity. *Anorexia Nervosa*

Highest mortality of any psych disorder (usually due to medical complications or suicide) .4-.5% in young women (higher in teenage girls) Average age of onset is 15 years old and up to 90% are Female *Two Types:* ○ *Restricting Type*: No binging/purging in last 3 months. Weight loss is primarily due to dietary restriction or excess exercise. ○ *Binge/Purge Type*: Binging/Purging in last 3 months. (Higher alcohol/drug use than Restricting Type) - Russell's sign (abrasions on hands from teeth from self induced vomiting) - Tooth enamel eroded from constant purging and exposure to HCl - Low body weight (as compared to symptoms of Bulimia) *Clinical Manifestation* ○ Significantly low body weight - Adult BMI < 17 - Children/Adolescents BMI less than 5th Percentile ○ Brittle nails, skin changes, increased hair growth, visible ribs, bony prominences *DSM Criteria* ○ Restriction of energy intake relative to requirements, leading to a significantly low body weight ○ Intense fear of gaining weight/becoming fat or persistent behavior that interferes w/ wt gain ○ Disturbance in the way in which one͛s body wt or shape is experienced, undue influence of body wt. or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight gain *Management* ○ No Medications Approved ○ Consult a Nutritionist! (Possible complications with feeding somebody who does not eat) ○ If admitting to the hospital: - Dexa scan (osteoporosis) - Order: meal plan, eye contact during meals, lock out of bathroom for 30 minutes after meal, consider eye contact when using the bathroom, calorie count, ensure, orthostatic vital signs, daily blind weights in hospital gown ○ Monitor for re-feeding syndrome!

OCC Anticholinergic Overdose visual

I saw this asked a lot as a typical "Pimping question" in the ED. Culprit was usually Benadryl. Mad as a Hatter Dry as a Bone Hot as Hades/Hare Blind as a Bat Red as a Beet

Outline treatment regimens for the bipolar disorders

If you had to pick one it would be Lithium ○ Mania ■*Acute*: *lithium*, valproate, carbamazepine(anticonvulsant), 2nd gen antipsychotics ■ *Maintenance* : *Lamotrigine* ■ Electroconvulsive therapy ○ Depression ■ 1st line:* lithium*, lamotrigine, quetiapine, olanzapine/fluoxetine combo ■ VPA + Lithium ■ Antidepressants? DO NOT USE ALONE. ■ ECT, CBT ○ Mood Stabilizers ■ *Lithium - gold standard for bipolar treatment* (OCC) *Extra crap about lithium*: blood levels monitored, renal excretion, dehydration, NSAIDs, or sodium restriction increases retention of lithium, thought to work through a second messenger system Side effects: cognitive, tremor, GI, thyroid, weight gain, skin, renal, toxicity, diabetes insipidus *Acute lithium toxicity* - medical emergency! nausea/vomiting, diarrhea, coarse tremor, confusion, delirium, hallucinations, seizures, stupr ○ death can result. Treatment: *remove lithium ASAP*, induce vomiting in alert patients, gastric lavage in comatose

(OCC) Tricyclics

Imipramine (tofranil) was the first. Amitryptyline, doxepine, and desipramine all came after but have not been proven to be more effective These have dangerous side effects(Hypotension, anticholinergic, and cardiac arrythmias (prolonged pr interval), chance,and more medication interactions, so they are not first line, but they can still have use in clinical applications. For major depression disorder 25-50mg/hs and increased by 25 mg every 3-4 days until theraputic dosage (150-250 mg/hs)

(OCC) spectrum of depression and why it's so important to treat

It is better to think of depression as a spectrum from mild (judgement, intellect not impaired) to severe (extreme hopelessness, helplessness, psychotic thinking) It is important to treat depression because up to 15% with severe depression, but 80-90% would respond to treatment of some kind

(OCC) Mild depression Sx

Judgement, intellect, and orientation are nor impaired. self depricative thoughts, guilt still exist vegetative state (fatigue, weight gain, crying spells, anhedonia) common (weight loss more common in severe) Sexual interest is impaired. Tx is same as MDD Dx is actually "unsepcified depressive disorder" in DSM-5.

Outline treatment regimens for depression, Major depression Disorder (*Tx duration*)

Totally depends on the Pt 6-8 weeks trial on adequate dosing Advise pt not to stop the meds on their own, PT may need to be on the medication for 4-6 months, maybe longer. Taper the pt off slowly if they want to stop Once therapeutic effect is achieved, antidepressant meds should be continued through period of high risk for relapse *(6 months)* some pts should be placed on *long-term tx* based on history (frequency of depressive episodes, age of patient, multiple factors) in which case slow tapering of the med can be considered after *5 yrs* if pt is asymptomatic. Some pts prefer lifetime tx.

Medical Marijuana

Medical Marijuana in 28+ states Still counts as *Schedule I drug "High potential for abuse with no medicinal value"* *Medicinal values:* Epilepsy, reduce seizures MS and park dz, muscle relaxant Chemo, help N/V sx AIDS, help anorexia Helps Chronic pain Helps IBS/Crohn for anti-inflammatory and antispasmodic qualities RA, anti-inflam Migraines Glaucoma Tourette's, OCD, slows tics Psych, helps w/ anxiety, depression, PTSD, etc... *Cannabidiol* is the anti-seizure element, but it doesn't get you very high.

Compare and contrast Bipolar I and *Bipolar II* disorder

Minimum for Dx: *1 hypopmanic episode + 1 major depressive episode, and NO MANIC EPISODEs* Hypomania does not present with psychotic symptoms, so hypomanic pts do not perceive themselves as ill → likely to minimize their symptoms and resist treatment 0.5% lifetime prevalence

(OCC) MAOI

Monoamine Oxidase Inhibitors Phenylzine ( nardil) isocarboxazide (Marplan) Tranylcypromine (parnate) Effective antidepressents, but used with caution because In addition to NE and 5HT buildup, it build up levels of *tyrosine* (found in beer,beens, yeast,cheese) which can cause hypertensive crisis if too much is ingested

Not an objective. *Major changes from DSM-IV-TR to DSM-5*

No longer using multi-axial dx (can write dx list as a narrative now), removal of "Not otherwise specified" (NOS) diagnoses. -Still has Unspecified disorders... but should really only use this in ER with incomplete histories

(OCC)

Only Connor cares If you see a flashcard with this on it, it is probably not going to be on the test, and it won't make it to the condensed version of the quizlet. If you don't plan on going into psych then don't waste your time on it.

o Define and discuss the risk factors, clinical features and management of *Post Traumatic Stress Disorder (PTSD)*

predicated on the occurrence of *at least 1 discrete traumatic external event* -the person experienced, witnesses, or was confronted w/ an event(s) that involved actual or threatened death or serious injury or a threat to physical integrity to self or others AND their response involved fear, helplessness, or horror -*commonly associated with major depressive disorder, suicide attempts, & alcohol abuse* Risk factors: -female -history of prior trauma (i.e. childhood sexual abuse, war veterans, first responders) -previous mental illness (i.e. personality disorder) -family history of anxiety disorders -NEM (negative emotionality): disposition characterized by anxiety, emotional lability, poor interpersonal interactions, & overall negative mood symptoms usually begin *within 3 months* after incident -->*1st month after incident= acute stress disorder* this resolves within 4 weeks of symptom onset or continues onto PTSD --->*if symptoms persist after 1st month= PTSD* Sx's: -*reexperiencing* (undesireable flashbacks, nightmares, intrusive memories); pt acknowledges that although these illusions felt real, they are not truly reoccurring versus patients w/ psychotic delusions & hallucinations are unaware of reality -*avoidance* (emotional numbing, avoiding potential reminders) -*hyperarousal* (difficulty sleeping, easily startled, hyper alert to danger, irritable, etc.) -amnesia: inability to recall certain trauma-related memories (due to selective attention/ dissociation) -insomnia: difficulty falling/staying asleep dx: -*at least 1 intrusion symptom beginning after the traumatic event occurred* (distressing memories, dreams, flashbacks, distress) see next card -clinical (there are MANY self-reporting questionnaires) -may have increased HR reactivity to trauma-related stimuli -may show increased latency in naming trauma or emotion words -may have cognitive impairment (lower IQ, deficits in working memory & concentration) -may see increased activity of right hemisphere amygdaloid complex during rehearsal of trauma tx: -CBT (exposure therapy and cognitive therapy): reexposing to sensory stimuli associated w/ the event; changing perspectives; diaries/scripts about the trauma -SSRIs: good for all 3 main sxs (reexperiencing, avoidance, & hyperarousal); 1st line according to uptodate +/- antipsychotic -TCAs -Monoamine Oxidase Inhibitors (good for sleep disturbance)

OCC Synthetic Marijuana overdose visual

Saw this a lot in the ED, seems to be popular in FL.

(OCC) SNRI

Seritonin Norepinephrin reuptake inhibitor (initially a SSRI, but NE as well at high doses) Venlafaxine (effexor)-another good first line Depression Tx. Has less sex and weight gain side effects, but more anxiety, insomnia, and nausea

(Not an objective) What are psychotic disorders (DSM 5)

Super basic definition is *loss of contact with reality* In DSM 5 it is an abnormality of one or more of the following five domains: 1)Delusions 2)Hallucinations 3)Disorganized thinking (speech) 4)Grossly disorganized or abnormal motor behavior (including catatonia) 5)negative Sx (OCC after this) Includes: Schizotypal Deslusional disorder Brief psychotic disorder Schizophreniform Schizophrenia Schizoaffective Substance/medicine induced Psychotic disorder Psychotic disorder due to another medical condition Catatonias

Adjustment disorder

The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring *within 3 months* of the onset of the stressors. (stressor is something that is part of life like family problems, wedding, or a job loss) 1) marked distress that is *in excess of what would be expected* from exposure to stressor 2)*significant impairment* in social or occupational (academic) functioning 3)The symptoms do not represent bereavement 4) Once the stressor has terminated, the symptoms do *not persist for more than 6 months*

o Discuss treatment options for personality disorders

Treatment = *Psychotherapy* Medication may help with specific symptoms of depression, anxiety, and psychosis OCC: Personality disorders are difficult to treat partly because they often do not cause personal distress. Because the personality disorders are experienced as a fundamental part of the individual, they may have limited insight into the nature of his or her problems. (They are *ego-syntic* disorders) Therefore, people with personality disorders are *likely to present for treatment only during times of crisis* or with the resurgence of major psychiatric symptoms such as depression or anxiety, or *when others* such as family or coworkers *are disturbed by their behavior.* Patients with personality disorders tend to be challenging to their therapists. They are often angry, manipulative, demanding, or defensive. However, improvement in personality disorders often occurs over time.

(OCC) Adjustment Disorder subtypes

With depressed mood With anxiety With Disturbances in conduct

Major depression *Disorder*

at least one major depressive episode; no history of mania or hypomania

o Given a clinical scenario select the best management for *Specific Phobias*

further classified into specific phobia & social phobia -onset typically childhood/early adulthood *specific phobia:* intense/irrational fear or aversion to a *particular object or non-social situation* -examples: animals (insects/spiders), natural environment (storms), blood/ injection/injury, situations (heights, elevators, closed spaces, airplanes) OCC: animal and natural environment types: childhood onset blood/injection/injury type: highly familial; associated w/ vasovagal response situational type: bimodal age of onset- childhood & 20s *social phobia aka social anxiety disorder:* extreme anxiety response in situations where they may be observed by others; fear they will act in an embarrassing or humiliating manner in performance situations -examples: public speaking, using public bathrooms -often associated w/ shyness, avoidant personality, & panic disorder dx specific phobia: 1. marked and persistent *excessive fear cued by anticipation of specific object or situation* 2. exposure to the phobic stimulus almost invariably provokes an *immediate anxiety response* which may take the form of a situationally bound/predisposed anxiety attack (in kids this may be crying/tantrum) 3. the person recognizes that the fear is excessive (may be absent in kids) 4. the object or situation is avoided or endured w/ intense anxiety 5. avoidance or distress in the feared situation interferes w/ life or causes distress 6.duration is *at least 6 mos.* 7. no better explanation or psych disorder that better accounts dx of social phobia: 1. marked & persistent fear of 1 or more social or performance situations where exposed to unfamiliar people or to possible scrutiny AND 2 through 7 above **impt: these phobias can include panic attacks, but these are NOT panic disorders because the attacks are restricted to a PARTICULAR object or situation. versus in panic disorder, the attacks are unexpected** tx: -*1st line= CBT psychotherapy* involving relaxation training while repetitively visualizing the phobic stimulus resulting in desensitization -*benzodiazepines: acutely* (i.e. before a flight) -*SSRIs or Beta-blockers: may benefit social phobia*

o Define and discuss the risk factors, clinical features and management of *Generalized Anxiety Disorder (GAD)* (not a specific objective)

it's a syndrome of persistent worry coupled with symptoms of hyper-arousal. -onset: early adulthood -*high rate of comorbid Major Depressive Disorder* and other psych disorders sx's: -think of this as *your average PA student*, aka me, who chronically worries about school :) -often wax & wane -often do not realize they have a psychiatric disorder dx: -excessive anxiety & worry (apprehensive expectation) occurring more days than not for *at least 6 months* about various events or activities such as *day-to-day tasks* (i.e. work or school performance) -difficulty in controlling the worry -anxiety/worry is associated with *at least 3* of the following: -restlessness or feeling "on edge" -easily fatigued -difficult concentrating or mind going blank -irritability -muscle tension -sleep disturbance **children need only 1 ^^ -*the focus of the anxiety/worry is about day-to-day tasks such as work, family health, finances, children*. (it is NOT worry about having a panic attack, being contaminated as in OCD, gaining weight as in anorexia) -the anxiety, worry, or physical symptoms cause distress/impairment in functioning -not due to medical condition or substance effects tx: -SSRIs or tricyclic antidepressants -benzodiazepines: only used as *adjunctive therapy* in severely acute conditions. NOT used by themselves or chronically. -Beta Blockers and Clonidine -psychotherapy (CBT): helps elucidate the relationship between distorted thinking and specific situations -psychotherapy (behavioral): teaches deep muscle relaxation while patient imagines anxiety-inducing stimuli -meds + CBT = best tx option

Outline treatment regimens and complications of dysthymia

similar to MDD (therapy +/- antidepressants) Behavioral: interpersonal psychotherapy, cognitive behavior therapy Pharm: SSRI's first line; TCAs and MAOIs secondary methods complications: condition that occurs most frequently with dysthymic d/o is *major depressive disorder*. Also substance dependence or chronic psychosocial stressors can coexist.

Diagnosis of *PTSD* (criteria will give you anxiety in itself)

this is so long it needs its own card :/ dx: 1. exposure to a traumatic event in which *both* of the following were present: -experienced, witnessed, or was confronted w/ an event(s) involving actual or threatened death or serious injury or a threat to physical integrity of self or others -the response involved intense fear, helplessness, or horror (in kids, response may be disorganized or agitated behavior) 2. the traumatic event is persistently re-experienced in *at least 1* way "intrusion sx's": -recurrent & intrusive distressing recollections of the event (images, thoughts, etc) -recurrent distressing dreams of the event -acting or feeling as if the event were reoccurring (either reliving the event, illusions, hallucinations, flashbacks) -intense psychological distress or reactivity at exposure to internal or external cues that symbolize/resemble an aspect of the event 3. persistent avoidance of stimuli associated w/ the trauma & numbing of general responsiveness as indicated by *at least 2 of following*: -efforts to avoid thoughts/feelings/conversations assoc. w/ event -efforts to avoid activities, places, people that arouse recollections of the event -inability to recall an impt. aspect of the trauma -markedly diminished interest or participation in significant activities -feeling of detachment/estrangment from others -restricted range of affect -sense of foreshortened future (i.e. doesn't expect to have career/marriage/children/nml life span) 4. Persistent symptoms of increased arousal indicated by *at least 2* of following: -difficulty falling or staying asleep -irritability/anger outbursts -difficult concentrating -hypervigilance -exaggerated startle response 5. duration of the disturbance *sxs > 1 mo* 6. disturbance causes significant distress/impairment in functioning

(OCC) Premenstrual Dysphoric Disorder

● In majority of menstrual cycles, with at least 5 symptoms present in week before menses, starts to improve within few days of menses onset, and become minimal/absent in week post-menses → KEY: fluctuates on a monthly basis ● one or more: affective lability, irritability, depressed mood, anxiety ● One or more: decreased interests, concentration, lethargy, appetite, sleep, overwhelmed, physical symptoms