Psych

classic conditioning

Pavlov's dog. A neutral stimulus (bell ringing) becomes a conditioned stimulus when presented with a biologically potent unconditioned stimulus (the dog food)

personality disorders and treatment

Pervasive and inflexible behavior that is outside the norm of one's culture, starting in adolescence or early adulthood, is stable over time, and causes distress or impairment. TX:therapy is 1st line for all. Little research has been done for medications, but in general uptodate says that mood stabilizers and antipychotics are preferred over SSRIs for treating symptoms such as affective dysregulation or impulsivity.

medical/lab tests for AMS/psychosis

-urine drug screen -chem panel (electrolytes or fluid disturbance. -CBC for infection -hepatic panel including ammonia -TSH -serum treponemal test (such as FTA-ABS) for syphilis -urinalysis for UTI -vitamin B12 and folate levels -HIV test

bulimia nervosa. Associated lab values of hypokalemia, hypochloremia, metabolic alkalosis, high amylase.

1. binge eating; eating more than normal in a short period of time. 2. A sense of lack of control over binge eating. 3. compensating behavior, such as fasting, vomiting, laxatives, etc. 4. occur at least once a week for three months. 5. self evaluation is unduly influenced by body shape and weight. 6. Dose not exclusively occur during episodes of anorexia. T: FLT is psychotherapy or therapy plus pharmacotherapy (SSRIs). 2nd line drugs include antiepileptic drugs (like topiramate) or ADHD meds (like lisdexamfetamine).

dissociative amnesia. Dissociative fugue is travel or wandering while forgetting identify, personality, memories, etc.

1. inability to recall autobiographical information this is usually of a traumatic or stressful nature that is inconsistent with normal forgetting. This can be for specific events or for general identity and life history. 2. cause clinically significant distress in social or occupational functioning. 3. not due to a substance or medical condition. 4. not better explained by dissociative identify disorder, PTSD, or other. Dissociative Fugue is a specifier. Retrogradoe amnesia is characteristic, not anterograde. Amnesia is either of specific event or events, or is general and includes identity and life history.

anorexia nervosa. Severity is based on BMI. Normal BMI is 18.5 - 25. Mild is >17, moderate is 16-16.9, sever is 15-15.9, extreme is <15.

1. low food intake that leads to significantly low weight (less than 18.5 BMI). 2. fear of gaining weight 3. altered perception of of one's weight. Tx: psychotherapy. psychotropics (like SSRIs) have not shows any benefit, antipsychotics occasionally given to help weight gain. Refeeding syndrome is associate with hypophosphatemia. Reasons to hospitalize for anorexia include: <75% body weight, BP <80 systolic, arrhythmia, hypothermia.

mild neurocognitive disorder (aka mild neurocognitive impairment), major neurocognitive disorder (dementia). DSM specifies them by cause (e.g., mild neurocognitive disorder due to alzheimers or major vascular neurocognitive disorder). DSM specified causes include alzheimers, frontotemporal, lewy body, vascular, TBI, substance induced, HIV infection, prion disease, parkinson's, huntington's, due to another medical condition, due to multiple etiologies, and unspecified.

1. modest cognitive decline in one or more cognitive domains (complex attention, executive function, learning, memory, language, perceptual-motor, or social cognition) based on either concern of the individual, an informant, or the clinician, or based on neuropsychological testing or clinical assessment. 2. The cognitive deficits do not interfere with capacity for independence in everyday activities such as paying bills or managing medications; but greater effort or compensations may be required. 3. not due to delirium. 4. not better explained by another mental disorder. Dementia is called major neurocognitive disorder in DSM V and has the same criteria as mild except that criteria 2 says that the deficits do interfere with independence in everyday activities; so at least some assistance is required with things like paying bills or managing medications. The AAN says initial workup for dementia should include CT or MRI, but other sources say its not necessary unless there are acute neurocognitive changes or focal neurological deficits.

conversion disorder (aka functional neurologic symptom disorder)

1. one or more symptoms of altered voluntary motor or sensory function. 2. incompatability between symptoms and neurological/medical state. 3. not better explained by another medical or mental disorder. 4. causes distress, psychosocial impairment, or warrants medical attention. tx: education is FLT, SLT is physical therapy m

Disruptive Mood Dysregulation Disorder (DMDD). Classified under depressive disorders in DSM-V. This diagnosis was added to DSM-V because doctors kept diagnosis kids with severe irritability with bipolar disorder.

1. severe recurrent temper outbursts manifested verbally and/or behaviorally that are out of proportion in intensity to situation or provocation. 2. temper outbursts are inconsistent with developmental level. 3. temper outbursts occur three or more times per week on average. 4. the mood between temper outbursts is persistently irritable or angry most of the day, almost every day, and is observed by others (parents, teachers, peers). 5. criteria 1-4 present for 12 or more months. throughout that time there has not been a period lasting 3 consecutive months without all the symptoms of criteria 1-4. 6. Criteria 1 and 4 are present in at least two of three settings (like home, at school, or with peers) and are severe in at least one of these. 7. diagnosis should be made between ages 6 and 18. 8. Age of onset should be before 10 yo. 9. There has never been a distinct period longer than one day where the full symptom criteria for manic or hypomanic episode has been met. 10. behavior do not occur exclusively during MDD episode and are not better explained by another mental disorder such as autism, PTSD, etc. 11. not due to a substance. Note (from DSM): this diagnosis cannot coexist with ODD, intermittent explosive disorder, or bipolar. It can coexist with others such as MDD, ADHD, conduct disorder, and substance use disorders. tx: nothing on uptodate. Kaplan says there are few studies, but says that if it resembles unipolar depression (often comorbid with ADHD according to kaplan) then treat with SSRI and stimulants. But if symptoms resembles bipolar disorder than atypical antipsychotics and mood stabilizers are recommended.

dissociative identity disorder (DID)

1. two or more distinct personality states. There is marked discontinuity between the states. May be observed by others or the individual. 2. Recurrent gaps in recall of events, personal information, or traumatic events that are inconsistent with ordinary forgetting. 3. Causes clinically significant distress. 4. Not a normal part of a broadly accepted cultural or religious experience. 5. Not due to substance or medical condition. tx: with CBT which tries to help the patient acquire coping strategies then "switching" to other personalities when under stress. DID is often the results of traumatic experience.

dihydroergotamine (not an ergot type drug, which are dopamine agonists)

5-HT agonist used to treat migraine (like triptans).

alcohol withdrawal symptoms

6-8 hrs: tremor/autonomic symptoms 8-12 hrs: hallucination 12-24: seizures 72- 1 week: DT (delirium tremens, aka withdrawal delirium) alcohol hallucinosis: unlike DT cognition is not altered and vital signs normal. DT: fluctuation of attention and cognition, may include hallucination, and can include agitation and extreme autonomic hyperactivity: fever, tachycardia, HTN, drenching sweats. Severe alcohol withdrawal syndrome: seizures + DT.

avoidant/restrictive food intake disorder

A an eating or feeding disturbance due to lack of interest in food or not liking food. Includes at least one of the following: 1 significant weight loss, 2 nutritional deficiency, 3 dependence on enteral feeding or oral nutritional supplements, 4 marked interference with psychosocial functional. B not due to lack of food or cultural practice. C not due to anorexia or bulimia and there is no disturbance in how the patient views their weight or body shape. D not due to medical condition or other mental disorder.

catatonia

A behavioral syndrome marked by the inability to move normally. It is usually found in those with a psychiatric illness so it is usually diagnosed as a specifier, can also be due to medical illness. Bush-francis rating scale is often used to quantify severity of symptoms. D: 3 or more of following: stupor, catalepsy (muscular rigidity, fixed posture), waxy flexibility, mutism, negativism, posturing, mannerism, stereotypy, agitation, grimacing, echolalia, echopraxia. Treatment with 1 or 2mg lorazepam (ativan) IV, also helps with diagnosis. If there is no change than 2nd dose can be given; change usually occurs within 5-10 minutes. There are three subtypes (not listed in DSM). retarded: muted, inhibited movement, staring. excited: excited and purposeless motor activity, impulsivity. malignant: fever, autonomic instability, rigidity, and life threatening. May include leukocytosis, elevated CK. Signs are similar to NMS. Progresses rapidly over a few days.

Persistent Depressive Disorder (dysthymia). a consolidation of DSM IV chronic MDD and dysthymic disorder)

A depressed most of the day for most days, indicated by self or others, for at least two years. In children it only needs to be a year and mood can be irritable. B presence, while depressed, of two or more of the following: 1 appetite changes, 2 sleep changes, 3 low energy or fatigue, 4 low self esteem, 5 poor concentration or difficulty making decisions, 6 feeling of hopelessness. C during the two year period (one for children/adolescents) the individuals hasn't been without the symptoms of criteria A and B for more than 2 months at a time. D criteria for MDD may be continuously present for two years. E no manic or hypomanic episodes and criteria not met for cyclothymic disorder. F not better explained by schizophrenia spectrum disorders. G not due to substance H cause clinically significant distress

cyclothymic disorder

A for at least two years (one in children/adolescents) there have been numerous periods with hypomanic symptoms that don't meet criteria for a hypomanic episode and numerous periods with depressive symptoms that don't meet criteria for major depressive episode. B During the two year period the hypomanic and depressive episodes have been present for at least half the time and the individual has not been without the symptoms for more than two months as a time. C criteria for major depressive, manic, or hypomanic episodes have never been present. D symptoms in criterion A are not better explained by a schizophrenia spectrum disorder. E not due to a substance F Cause clinically significant distress or impairment

gender dysphoria in children

A marked incongruence between one's experienced/expressed gender and assigned gender, lasting 6 months and including criteria 1 and 5 others: 1 desire to be the other gender, 2 cross dressing, 3 cross gender roll play, 4 prefers toys or activities of other gender, 5 seeks playmates of other gender, 6 avoidance of assigned gender toys and activities, 7 dislike of one's sexual anatomy, 8 desire for the primary B clinically significant distress

gender dysphoria in adolescents and adults

A marked incongruence between one's experienced/expressed gender and assigned gender, lasting 6 months and including two of the following: 1 incongruence between expressed gender and primary/secondary characteristics, 2 desire to be rid of or prevent development of primary or secondary sex characteristics, 3 desire primary/secondary sex characteristics of other gender, 4 desire to be the other gender, 5 desire to be treated as the other gender, 6 a strong conviction that one has the feelings and reactions of other gender. B clinically significant distress

encopresis. One of two disorders in DSM in the category of elimination disorders, the other being enuresis.

A passage of feces in inapproprate places (clothing, floor, etc), whether intentional or involuntary. B at least once a month for 3 months. C at least 4 yo (or equivalent) D not due to a substance (like laxatives).

histrionic personality disorder

A pervasive pattern of excessive emotionality and attention-seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. is uncomfortable in situations in which he or she is not the center of attention 2. interaction with others is often characterized by inappropriate sexually seductive or provocative behavior 3. displays rapidly shifting and shallow expression of emotions 4. consistently uses physical appearance to draw attention to self 5. has a style of speech that is excessively impressionistic and lacking in detail 6. shows self-dramatization, theatricality, and exaggerated expression of emotion 7. is suggestible, i.e., easily influenced by others or circumstances 8. considers relationships to be more intimate than they actually are

genito-pelvic pain/penetration disorder(aka vaginismus)

A. Difficulty with one or more of: 1 vaginal penetration, 2 vaginal or pelvic pain during intercourse, 3 fear, anxiety, or anticipation of pelvic or vulvovaginal pain due to vaginal penetration, 4 tensing or tightening or the pelvic floor muscles during attempted penetration. B. have occurred for at least 6 months C. Causes clinically significant distress D. not better explained by nonsexual mental disorder, relationship stress, other substances, etc.

conduct disorder

A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, must have 3 of the following 15 criteria of any category in the last 12 months and at least one criterion in the last 6 months. Aggression to people and animals: 1 often bullies, threatens, or intimidates others. 2. Often initiates physical fights. 3. Has used a weapon that can cause serious damage (e.g., a brick, bat, knife, etc). 4. has been physically cruel to people. 5. has been physically cruel to animals. 6. has stolen while confronting a victim (e.g., purse snatching, mugging, extortion, armed robbery) 7. has forced someone into sexual activity. Destruction of property: 8. has deliberately engaged in fire setting with the intention of causing serious damage. 9. has deliberately destroyed other's property (other than fire setting). Deceitfullness or theft: 10 has broken into someone else's house, building, car. 11. often lies to obtain goods or favors to avoid confrontation (i.e., "cons" others). 12. has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery) Serious violations of rules: 13. often stays out at night despite parental prohibitions, beginning before age 13 14. has run away from home overnight at least twice while living in parental or parental surrogate home; or once without returning for a lengthy period. 15. is often truant from school, beginning before age 13. B The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning. C. If the individual is age 18 or older, criteria are not met for antisocial personality disorder.

Enuresis. Primary enuresis is when bladder control was never learned, secondary is lack of bladder control after having it at one point.

A voiding of urine into bed or clothes, intentional or involuntary. B at least twice a week for 3 months and cause clinically significant distress. C at least 5 yo (or equivalent developmental age) D not due to a substance (like diuretic) tx: for kids first try motivation therapy, then try enuresis alarms or desmopressin (retains water).

circadian rhythm sleep-wake disorder. Specifiers include delayed sleep phase type, advanced sleep phase type, shift work type, non 24 hour sleep-wake type, irregular sleep-wake type.

A, persistent pattern of sleep disruption that is primarily due to alteration of the circadian system or misalignment between endogenous circadian rhyth and the sleep-wake cycle required by an individual (such as social or professional schedule). B the sleep disruption leads to excessive sleepiness or insomnia or both. C, causes clinically significant distress or impairment in social, occupational, or other areas of functioning. tx: delayed sleep phase type: melatonin and morning light therapy. Advanced type; evening light therapy. non 24 hours type: melatonin at night and morning light therapy. shift work: sleep hygiene like maintaining sleep schedule, light blocking shades, etc. Melatonin or hypnotic like zolpidem can be used.

central sleep apnea

A, polysomnography of five or more central apneas per hour of sleep. B, not better explained by another sleep disorder

sleep-related hypoventilation

A, polysomnography shows decreased respiration with levelated CO2 levels (or persistently low O2 saturation unassociated with apneic/hypopneic events). B, not better explained by another sleep disorder.

pedophilic disorder

A. 6 months of sexually arousing fantasies, sexual urges, or behaviors involving sexual activity with a child (generally 13 or younger). B. the individual has acted on these sexual urges or the urges or fantasies caused marked distress. C. individual is at least 16 yo and at least 5 years older than the child. Note: does not include an individual in late adolescence with a 12 or 13 yo.

Oppositional Defiant Disorder (ODD).

A. A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by 4 of the following criteria from any category and exhibited during interaction with at least one individual who is not a sibling. Angry/irritable mood: 1 often loses temper, 2 is often touchy or easily annoyed, 3 is often angry and resentful. Argumentative/defiant behavior: 4 often argues with authority figures, or for children/adolescents, with adults. 5 often actively defies or refuses to comply with requests from authority figures or with rules. 6 often deliberately annoys others. 7 often blames other for their mistakes or misbehaviors. Vindictivenes: 8 has been spiteful or vindictive at least twice within the past 6 months. Note: Frequency is used to distinguish between behavior WNL. Children less than 5yo should have almost daily behavior of criteria 1-7 for six months. Ages 5 and older should be at least once per week for 6 months. Other factors to consider if behavior is WNL is the patient's developmental level, gender, and culture. B. The disturbance is associated with distress in the patient's social context (family, peer group, work), or impacts negatively on social, educational, occupational, or other areas. C. Do not occur exclusively during psychosis, substance use, MDD, or bipolar. The criteria are not met for DMDD. Does not include illegal activity like conduct disorder. tx: no article exists on uptodate. Kaplan recommends "family intervention using both direct training of the parents in child management skills". The American Psychiatric Publishing textbook says CBT.

antisocial personality disorder

A. A pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years, as indicated by three or more of the following. 1 failure to conform to social norms with respect to lawful behaviors, as indicate by repeatedly performing acts that are grounds for arrest 2. deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure. 3. impulsivity or failure to plan ahead. 4. irritability and aggressiveness, as indicated by repeated physical fights or assaults 5. reckless disregard for safety of self or others 6. consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations. 7. lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another. B. the individual is at least 18 years old. C. There is evidence of conduct disorder with onset before age 15 yo. D. the occurrence of antisocial behavior is not exclusively during the course of schizophrenia or bipolar disorder.

schizoaffective disorder. Symptoms only need to be present for a month for diagnosis.

A. An uninterrupted period of illness during which there is a major mood episode (major depressive or manic) concurrent with Criterion A of schizophrenia. Note: The major depressive episode must include Criterion A1 : Depressed mood. B. Delusions or hallucinations for two or more weeks in the absence of a major mood episode (depressive or manic). C. symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of the illness. D. Disturbance is not attributable to the effects of a substance.

gambling disorder. classified in DSM under substance related and addictive disorder

A. Persistent gambling causing distress over 12 months of at least four of the following: 1 needs to gamble with increased amounts of money to achieve desired excitement, 2 restless or irritable when trying to cut down or stop gambling, 3 repeated failed attempts to control or stop gambling, 4 preoccupied (persistent thoughts) of gambling, 5 gambles when distressed, 6 after losing money often returns another day to get even, 7 lies to conceal extent of gambling, 8 jeopardized or lost relationship, 9 relies on others to provide money due to financial desperation due to gambling. B. not better explained by a manic episode. tx: CBT, treat comorbid diagnoses. SSRIs and naltrexone have shown mixed results.

female orgasmic disorder

A. Presence of either of the following during approximately 75%-100% of sexual activity. 1, delay in, infrequency of, or absence of orgasm. 2, Reduced intensity of orgasm. B. Occurs over 6 months C. cause distress D. not better explained by something else

delirium

A. a disturbance in attention and awareness (reduced orientation). B. the disturbance develops over a short period of time (usually hours to days), and fluctuates in severity over the course of a day. C. An additional disturbance in cognition (e.g., memory deficit, disorientation, language, visiospatial ability, orientation). D. disturbances in criteria A and C are not better explained by preexisting, or evolving neurocognitive disorder and not due to severe decrease in arousal like a coma. E. evidence from history, physical exam, or lab findings that suggest that the disturbance is due to another medical condition, substance intoxication or withdrawal, exposure to toxin, or multiple etiologies.

Psychological Factors Affecting Other Medical Conditions (under somatic symptoms and related disorders section in DSM)

A. a medical symptom or condition (other than a mental disorder) is present. B. Psychological or behavioral factors adversely affect the medical condition in one of the following ways: 1 exacerbate or delay recovery of condition, 2 interfere with the treatment of the medical condition (e.g., poor adherence), 3 cause additional health risks, 4 the factors influence the underlying pathophysiology, precipitating or exacerbating symptoms or necessitating medical attention. C. not better explained by another medical disorder. Basically its a diagnosis of the patient causing their own medical condition or making it worse.

disinhibited social engagement disorder

A. a pattern of behavior in which a child interacts with unfamiliar adults and exhibits two of the following: 1 reduced or absent reticence in interacting with unfamiliar adults, 2 overly familiar verbal or physical behavior (that is not consistent for culture and age), 3 not checking back with adult caregiver after venturing away, 4 willingness to go off with an unfamiliar adult with minimal or no hesitation. B. the behaviors in criterion A are not limited to impulsivity (like in ADHD) but include socially disinhibited behavior. C. the child has experience a pattern of extremes of insufficient care as evidenced by at least one of the following: 1 lack of emotional comfort, stimulation, and affection by caregiving adult, 2 repeated change of primary caregivers that limits opportunities to form stable attachments, 3 rearing in unusual settings that limit opportunities to form relationship with caregivers (like instituations with high child-caregiver ratios). D. The care in criterion C is presumed responsible for behavior in criterion A. E. child has developmental age of at least 9 monts.

Intellectual disability (Intellectual Developmental Disorder). Will supposedly be called Intellectual Developmental Disorder in ICD-11 according to DSM-V desk reference. A federal law called Rosa's Law replaces the term mental retardation with Intellectual disability

A. deficits in intellectual functions ... confirmed by both clinical assessment and individualized, standardized intelligence testing. B. Deficits in adaptive functioning that result in failure to meet developmental and social responsability. Limited functioning in one or more activities of daily life such as communication, social participation, independent living, across multiple environments such as home, school, work, and community. C. Onset of intellectual and adaptive deficits during the developmental period. Specifies are mild, moderate, severe, and profound.

Autism Spectrum Disorder

A. deficits in social communication or interaction manifested by: 1.deficits in social-emotional reciprocity, 2 nonverbal communication, 3 developing and maintaining relationships. B. Restricted, repetitive patterns of behavior, interests, or activities manifested by two of following: 1 repetitive motor movements, 2 adherence to routines or ritualized patterns of verbal or nonverbal behavior, 3 highly restricted or fixated interests, 4 hyper or hyporeactivity to sensury input C. symptoms must be present in early developmental period D. symptoms cause clinically significant impairment in social, occupational, or other areas of functioning E. disturbances are not better explained by intellectual disability or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level.

insomnia

A. difficulty starting sleep, maintaining sleep, or waking up too early. For kids this includes requiring a parent to soothe them to sleep. B. causes significant distress or impairment in social, occupational, etc. C. occurs at leasat 3 nights per week D. present at least 3 months E. sleep difficulties occur despite adequate opportunity and circumstance. F. not better explained by and does not occur exclusively during the course of another sleep-wake disorder (e.g. narcolepsy, breathe related sleeping disorder, circadian rhythm disorder, parasonia). G. no due to a medication or drug H. not explained by coexisting mental disorders or medical conditions tx: symptoms lasting <1 month are usually from psychological or physiological stress, treat with education and reassurance; but if severe then use a benzo or similar. Long term insomnia: 1st line is CBT-I (CBT-insomnia), but if patient in severe distress then CBT-I with a medication is acceptable according to uptodate. Medications include benzos, zolpidem, sedating antidepressants, many others. Most effective part of CBI-I is sleep restriction, meaning not going to bed until your sleepy, which is supposedly more effective than sleep hygiene.

clonidine (kapvay is ER, catapres is IR),

A2 agonist drugs whose ER formulations are indicated for ADHD and whose IR forms treat HTN. D: 0.1mg - 0.4mg/day, often in divided doses which is at night and in morning. If doses are not equal then give bigger dose at night. Start with .05mg qhs if child weighs <45kg and .1mg qhs if >45kg. SE: drowsiness, headache, fatigue

PTSD (PostTraumatic Stress Disorder)

A. exposure to actual or threatened death, injury,or sexual violence; or learning that the traumatic event happened to family member or close friend. B. distressing memories, dreams, dissociative reactions (flashbacks), psychological stress when exposed to triggers, or physiologic reactions when exposed to triggers. C. avoidance of triggers or memories. D. negative alterations in cognition or mood E. alterations in arousal and reactivity due to the event (angry outbursts, hypervigilance, trouble concentrating, sleep problems, etc) when exposed to triggers. F. lasts more than 1 month (less would be acute stress disorder) tx: trauma focused CBT and/or SSRI. Prazosin helps with nightmares. atypical antipsychotics sometimes used as monotherapy or adjunct. Trauma focused CBT involves repeated imaginal exposure to trauma memories and in vivo exposures to decrease cue reactivity.

acute stress disorder

A. exposure to actual or threatened death, serious injury, or sexual violation. (Same as criteria A of PTSD) B. Presence of 9 or more symptoms of the five categories of intrustion, negative mood, dissociation, avoidance of stimuli, and arousal. (similar to criteria B, C, D, and E of PTSD). C. symptoms of criteria B occur 3 days to a month after trauma. D. cause clinically significant distress or impairment.... E. not attributable to a substance, another medical condition (e.g. mild traumatic brain injury), and not better explained by brief psychotic disorder. tx: trauma focused CBT. Intense anxiety, agitation, or sleep disturbance can be given a short term benzo according to uptodate. Psychological debriefing (aka critical incident stress debriefing) should be avoided because it does not prevent PTSD and might worsen symptoms.

kleptomania

A. failure to resist impulse to steal stuff that aren't needed. B. increasing sense of tension before stealing. C. pleasure, gratification, or relief while stealing. D. the stealing isn't due to anger in response to a delusion or hallucination. E. not better explained by conduct disorder, manic episode, or antisocial personality disorer. tx:

factitious disorder imposed on self (aka munchausen syndrome), factitious disorder imposed on another

A. falsification of physical or psychological symptoms, or induction of injury or disease. B. The individual presents himself as ill or injured. C the deceptive behavior is evident despite absence of obvious external reward. D The behavior is not better explained by another disorder such as delusional disorder. Factitious disorder imposed on another is the same but its when someone presents someone else as ill. tx: present diagnosis of factitious disorder compassionately, knowing that the patient likely won't agree.

Premenstrual dysphoric disorder (PMDD)

A. in the majority of menstrual cycles at least five symptoms present in the final week before menses, start to improve within a few days after onset of menses (menses is days 1-7 of menstrual cycle), and become minimal or absent in the week postmenses. B. One or more of following symptoms: 1 affective lability, 2 irritability or anger, 3 depressed mood, 4 anxiety or tension. C. one or more of following for a total of 5 symptoms with criterion B: 1 decreased interest in usual activities, 2 subjective difficulty concentrating, 3 lethargy/lack of energy, 4 appetite changes, 5 hypersomnia or insomnia, 6 sense of being overwhelmed or out of control, 7 physical symptoms like breast tenderness or swelling, joint pain, "bloating", or weight gain. D. cause clinically significant distress E. not an exacerbation of another disorder like MDD, panic disorder, persistant depressive disorder, or personality disorder, but it can coexist with any of these. F. Criterion A must be confirmed by prespective daily ratings during at least two symptomatic cycles. G. Not due to substance/medication, or another medical condition.

selective mutism (under anxiety disorders in DSM)

A. inability to speak in social situations where is it expected despite speaking in other situations. B. interferes with educational, occupational, or social areas. C. lasts at least one month. D. not due to proficiency of spoken language. E. not better explained by other communication disorder (like child onset fluency disorder), or during the course of autism, schizophrenia, or other psychotic disorder.

reactive attachment disorder

A. inhibited and emotionally withdrawn behavior towards adult caregivers, manifested by both rarely seeking comfort when distressed and rarely responding to comfort when distressed. B. social and emotional disturbance charactered by two of the following: 1 minimal social and emotional response to others, 2 limited positive affect, 3 episodes of unexplained irritability, sadness, or fearfulness towards adult caregivers C. the child has experienced a pattern of extremes of insufficient care as evidenced by one of the following: 1 persistent emotional neglect by caregivers, 2 repeated change of primary caregivers that limits opportunities to form attachments, 3 rearing in unusual settings that limit opportunities to form relationship with caregivers (like instituations with high child-caregiver ratios). D. the care in criterion C is presumed responsible for behavior in criterion A. E criteria not met for autism spectrum disorder. F disturbance is evident before age 5. G the child has developmental age of at least 9 months

tourette syndrome. A tic is not defined in DSM but truelearn describes it a something that an be delayed with effort but is eventually irresistable.

A. multiple motor and at least one vocal tic present at some point, not necessarily concurrently. B present for one year tho tics may wax and wane in frequency. C onset is before age 18. D not attributable to a substance or another medical condition. one year history of multiple motor tics and at least one phonic tic that occur multiple times a day, almost every day. tx: for mild/nondisabling tics try education and counseling. For more severe symptoms use tetrabenazine. SLT options are botulinum injections, antipsychotics. The only approved medications are antipsychotics (haloperidol, pimozide, aripiprazole). Treatment with stimulants in children with ADHD and tics has been shown to reduce tics (not stimulants alone are not used as treatment).

delusional disorder

A. one month history of a delusion. B. Criterion A from schizophrenia is not met. C. functionality not markedly impaired. D. Do not occur only in manic or MDD episodes. E. Not due to another substance or medical condition. tx: FLT is antipsychotics, uptodate suggests aripiprazole or ziprasidone due to minimal SE. If the patient can't tolerate then try CBT.

Pica. Specific lab findings or evidence of malnutrition is not required for diagnosis.

A: Eating nonnutritive or nonfood over one month. B: inappropriate for age. C: not part of culture, etc. D: If in the context of another mental disorder (autism, IDD, etc) it is severe enough to warrant clinical attention.

derealization/depersonalization disorder diagnostic criteria

A. one or both of the following. A: depersonalization: unreality, detachment, or being an outside observer to one's thoughts, feelings, sensations. B. derealization: experiences of unreality or etachment with respect to one's surrounding; such as individuals or objects are experienced as unreal, dreamlike, foggy, lifeless, or visually distorted. B. during the depersonalization or derealization experiences, reality testing remains intact. C. cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. Not attributable to substance or medical condition (seizure). E. Not better explained by another mental disorder.

body dysmorphic disorder. This can coexist with an eating disorder like anorexia but is rare; its different because anorexia is concerned with body weight/fat and body dysmorphic disorder is about a specific body defect like the face.

A. preoccupied with appearance B. at one point has had repetitive behaviors: mirror checking, skin picking, seeking reassurance C. causes significant distress.... D. not better explained with concerns of body fat or weight in a person that meets criteria for another eating disorder (like anorexia, but both can coexist).. tx: SSRI and/or CBT that is tailored to this disorder

Intermittent Explosive Disorder (IED)

A. recurrent behavioral outbursts representing a failure to control aggressive impulses as manifested by 1 or 2: 1, verbal or physical aggression towards property, animals, or individuals occurring on average twice weekly for 3 months. The aggression does not damage property or cause physical injury to animals or people. 2, Three behavioral outbursts involving damage to destruction of property and/or physical assault involving physical injury against animals or other individuals within a 12 month period. B. Magnitude of aggressiveness during outburst is grossly out of proportion to the provocation or to any psychosocial factors. C. Outbursts are not premeditated (thus they are impulsive and/or anger-based) and are not committed to achieve some tangible objective (money, power, intimidation). D. Outbursts cause either marked distress in the individual or impairment in occupational or interpersonal functions or are associated with financial or legal consequences. E. Age is at least 6 yo or equivalent developmental level. F. Outbursts are not better explained by another mental disorder (e.g. MDD, Bipolar, DMDD, psychosis, borderline), or medical condition (e.g. alzheimers), or a drug/substance. Note: this diagnosis can be made in addition to ADHD, conduct disorder, ODD, or autism when recurrent impulsive aggressive outbursts are in excess of those seen in those disorders and warrant clinical attention. Tx: SSRI plus CBT recommended by uptodate.

substance use disorder (correct coding is by naming the substance, followed by use disorder). Specifiers or severity are mild for 2-3 symptoms, moderate for 4-5, severe for 6 or more. In early remission if no use in 3-12 months, sustained remission if no use in 12+ months.

A. substance use leading to clinically significant impairment or distress, manifested by at least two of the following over a 12 month period. 1 larger amounts consumed or taken longer than intended, 2 desire or unsuccessful efforts to control use, 3 a lot of time is spent using, trying to obtain, or recovering from use, 4 cravings to use, 5 substance use results in failure at work, school, or home, 6 continued use despite problems caused or exacerbated by substance use, 7 important social, occupational, or recreational activities are given up due to use, 8 substance use in situations where it is physically hazardous, 9 continued use despite physical or psychological problem caused or exacerbated by substance, 10 tolerance, which is manifested by needed higher amount of substance or diminished effect from same amount of substance. 11 (only with downer drugs like alcohol and opioids, not meth, pcp, etc) withdrawal, as manifested by criteria A and B of particular substance withdrawal (unique to each substance), or manifested by substance use to relieve or avoid withdrawal symptoms.

Major or mild neurocognitive disorder due to traumatic brain injury (TBI)

A. the criteria are met for major or mild neurocognitive disorder. B evidence of TBI due to one or more of following: 1 loss of consciousness, 2 postraumatic amnesia, 3 disorientation and confusion, 4 neurological signs like imaging showing injury, new or worsening seizures, visual field deficits, anosmia, hemiparesis. C the neurocognitive disorder presents immediately after TBI or

adjustment disorder. If symptoms last longer than 6 months after stressor stops then specifier "adjustment-like disorders with prolonged duration of more than 6 months without prolongation of stressor" applies.

A. the development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor. B. symptoms or behavior are clinically significant , as evidenced by one or both of the following: 1 marked distress that is out of proportion to the stressor. 2 significant impairment in social, occupational, or other important area of functioning. C. the stress-related disturbance does not meet criteria for another mental disorder (like acute stress disorder) and is not merely an exacerbation of a pre-existing mental disorder. D. the symptoms do not represent normal bereavement. E. once the stressor or its consequences have terminated, the symptoms do not persist for more than an additional 6 months . tx: CBT according to kaplan

schizophrenia criteria. Schizophreniform criteria is similar but is for 1-6 months and doesn't require functional impairment. On MRI there is less brain volume and hippocampal atrophy.

A. two or more of the following for a significant portion of at least one month. At least one must be one of the first three: 1, delusions, 2, hallucinations, 3, disorganized speech, 4, grossly disorganized or catatonic behavior, 5 negative symptoms (emotionless or avolition). B. Marked disturbance in level of functioning of work, interpersonal relations, or self care. C. Signs of the disturbance last at least 6 months, at least one month qualifies for criteria A. D

prazosin (Minipress)

A1 antagonist that crosses BBB. A1 antagonism usually decreases peripheral arterial tone, thus decreasing resistance and lowing BP. I: HTN. OL for nightmares. Sometimes takes weeks to begin working (uptodate). D: for nightmares start 1mg qhs, then increase 1-2mg every 2-3 days or weekly. Uptodate and medscape say max dose of 15mg/day. The VA has an official recommended target dose of 6-10mg. HTN max dose is 40mg in divided doses.

guanfacine (Intuniv is ER, tenex is IR)

A2 agonist drugs whose ER formulations are indicated for ADHD and whose IR forms treat HTN D: 2-7mg/day depending on weight of the child. Dosed once a day. SE: drowsiness, headache, fatigue

obsessive-compulsive personality disorder (OCPD)

A: a pervasive pattent of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning in early adulthood and present in a variety of contexts, indicated by four or more of the following: 1 preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost. 2 shows perfectionism that interferes with task completion 3 is excessively devoted to work and productivity to the exclusion of leisure activities and friendships ( not accounted for by obvious economic necessity). 4 is overconsciountious, scupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification). 5 in unable to discard worn-out or worthless objects even when they have no sentimental value. 6. is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things. 7 adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes. 8. shows rigidity and stubbornness.

manic epidose, hypomanic episode

A: a week of elevated, expansive, or irritable mood that is present most of the day and nearly every day. B:during the period of mood disturbance there must be three or more of the following (four if the mood is only irritable): 1 grandiosity, 2 decreased sleep, 3 talkative or pressured speech, 4 flight of ideas, 5 distractability, 6 increase in goal directed activity or agitation, 7 indiscretion (activities with high potential for negative consequences like buying things, sexual indiscretion, etc). C: mood disturbance causes marked impairment. D: not due to a substance. A hypomanic episode is only 4 days of mood disturbance. Hypomanic symptoms of criteria B is the same as manic episode. There is a change in functioning but not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. Psychotic features are manic by definition.

restless leg syndrome

A: an urge to move the legs due to uncomfortable or unpleasant sensations characterized by: 1 the urge to move legs begins or worsens during periods of rest or inactivity, 2 the urge to move is partially or totally relieved by movement, 3the urge to move the legs is worse in the evening or night than during the day, or only at evening/night. B: occur at least 3x per week for 3 months C: cause significant distress or impairment is social, occupational, educational, academic, behavioral, or other areas of functioning. D: not attributed to another mental disorder or behavioral disorder (habitual foot tapping). E: not due to drugs of abuse or medication akathisia. D: clinical. check iron levels. tx: First check iron levels, because it can be caused by deficiency. Then try behavioral modifications (exercise, heat massage, etc). Lastly, treat with either dopamine agonists or gabapentin or pregabalin.

generalized anxiety disorder. Anxiety disorder are most common mental health condition, then depressive disorders, then substance abuse. mneumonic is ICREST Irritability Concentration difficulty Restlessness Energy decreased (easily fatigued) Sleep problems Tension in muscles

A: excessive anxiety and worry most days for 6 months about a number of events or activities. B: difficult to control the worry C: three or more of the following: 1 restlessness or on edge, 2 easily fatigued, 3 difficulty concentrating, 4 irritability, 5 muscle tension, 6 sleep disturbance. D: the anxiety, worry, or physical symptoms cause clinically significant distress or impairment. E: not attributable to drugs or medication or due to another medical condition (like thyroid). F: not better attributable to another mental disorder. tx: treat with pills (SSRI), CBT, or both. If SSRI has only a partial response then augment with buspirone.

Major Depressive Disorder (MDD). Criteria A-C represent criteria for a major depressive episode (MDE). Leading cause of disabilty among mental illness.

A: five or more of the following symptoms during a 2 week period, and one of the symptoms must be either (1) depressed or (2) loss of interest or pleasure (can also be irritability in children or adolescents). 1 depressed mood, 2 diminished interest or pleasure, 3 appetite or weight changes, 4 sleep changes, 5 psychomotor agitation or retardation, 6 fatigue or loss of energy, 7 feelings of guilt or worthlessness, 8 diminished ability to think or concentrate, 9 recurrent thoughts of death or suicidality. B: cause significant distress or impairment C: not due to physiological effects of substance or another medical condition. D: not better explained by schizoaffective, schizophrenia, etc. E: no manic or hypomanic episode

agoraphobia

A: marked fear or anxiety about two or more of: 1 public transportation, 2 open spaces, 3 enclosed spaces, 4 standing in line or in a crowd, 5 being outside of the home alone. B: the individual fears or avoids these situations C: these agoraphobic situations almost always provoke fear or anxiety. D: avoidance of these situations, require the presence of a companion, or are endured with intense fear or anxiety. E: fear or anxiety is out of proportion to actual danger or sociocultural context. F: fear, anxiety, or avoidance lasts for 6 months or more. G: cause clinically significant distress or impairment H: if another medical condition (inflammatory bowel disease, parkinson's) is present, the fear, anxiety, or avoidance is excessive. I: not better explained by another mental disorder. tx:

narcolepsy (some say type l is with cataplexy and type ll is without cataplexy but with low hypocretin levels and low sleep latency, but DSM doesn't categorize them that way. cataplexy is caused by low hypocretin.

A: must include 3 months of daily irrepressible sleepiness. B: must include one of the following; 1 cataplexy, 2 low CSF concentration of hypocretin-1 (orexin A, low levels cause sleepiness) deficiency, 3 polysomnography showing REM sleep latency < 15 minutes, or polysomnography with a mean sleep latency period of <8 minutes and at least two SOREMPS (sleep onset REM sleep periods) on a sleep study. Other symptoms include hypnogogic (GOing to sleep) and hypnopompic (wakening) hallucinations and paralysis. TX: is symptomatic: modafinil or stimulants to treat daytime sleepiness. SSRIs, TCAs, or sodium oxybate for cataplexy (also improves nighttime sleep quality and improves daytime sleepiness).

obstructive sleep apnea

A: one of the following: 1 polysomnography of at least five obstructive apneas or hypopneas per hour of sleep and either of the following: a, nocturnal breathing disturbances such as snoring, snorting, gasping, or breathing during sleep. b, daytime sleepiness, fatigue despite adequate opportunity to sleep. 2 polysomnography of 15 or more obstructive apneas or hypopneas per hour of sleep regardless of accompanying symptoms.

somatic symptom disorder

A: one or more somatic symptoms that are distressing or cause disruption of daily life. B: excessive thoughts, feelings or behavior characterized by at least one of the following; 1 disproportionate thoughts of symptoms, 2 persistent high levels of anxiety about symptoms, 3 excessive time and energy devoted to symptoms. C: symptoms occur continuously for 6 months even if the same symptom does not persist for that long. tx: form therapeutic alliance, patient education, regular PCP visits. SLT for peeps with symptoms of anxiety or depression can be treated with antidepressants.

hypersomnolence disorder

A: self reported sleepiness despite 7 hours of sleep with one of the following: 1 falling asleep multiple times during the day, 2 sleep periods of 9 hours or more that are unrestorative (unrefreshing), 3 difficulty being fully awake after abrupt wakening. B: hypersomnolence occurs 3 times per week for 3 months. C: causes significant distress or impairment in social, occupational, etc D Not better explained by another sleep disorder E not due to a substance (medication or drug) F not explained by other medical or mental disorders.

psychotropics while breast feeding (according to me)

All drugs given to the mother can be found in the breast milk. Fluoxetine, paroxetine, sertaline, and TCAs are considered to be of low risk; little is passed into the breast milk and complications are rare. Benzos: respiratory distress, sedation, poor feeding have been reported but incidence is low. Mood stabilizers: lithium (cyanosis, hypotonia, hypothermia), carbamazapine (hepatotoxicity later in life) and VPA (hepatotoxicity later in life) should be avoided. Lamotrigine might be ok but why risk it. The american academy of pediatrics lists both VPA and carbamazapine as OK to use during breastfeeding. Antipsychotics: data is very limited so they should be avoided. Chlorpromazine has been linked to sedation and developmental delay, though that hasn't been reported in higher potency antipsychotics.

mirtazapine (remeron), considered a tetracyclic. A2 antagonist, increasing release of NE and serotonin, antihistamine, also some some antagonism at 5-HT2a 5-HT2c, 5-HT3, and histamine)

Approved for MDD only. Often added to SNRIs when SNRI isn't sufficient. D: 15-45mg per day. HL (half life) 20-40 hrs. SE: sedating at low doses, stimulating at high doses. Increased appetite and weight gain, probably from antihistamine activity. Can cause agranulocytosis. If taken with tramadol it increases risk of seizures (tramadol does that with many psychotropics). Alcohol can increase sedation, cognition, and motor effects.

Four principles of Ethics

Autonomy: patients make their own decisions. Beneficence: Acting in the best interest of the patient or of society. Non-maleficence: not doing anything that may harm the patient or society. From Hippocrate's primum non nocere "First do no harm". Justice: emphasizing fairness across society and treating all individuals equally.

axis system (discontinued after DSM- IV)

Axis I: clinical disorders. axis II: personality disorders and mental retardation. axis III: general medical conditions. axis IV: psychosocial factors.

ziprasidone (geodon). Inhibits D2 and 5-HT2a and partial agonist at 5-HT1a like all atypicals. Partial agonist at 5-HT2c (like aripiprazole) which is why theres no weight gain.

Bioavailability doubles when taken with food. I: schizophrenia, delaying relapse is schizophrenia, acute agitation in schizphrenia, bipolar. D: half life is 6.6 hours so doses must be divided; 40-200mg/day in schizophrenia, start with 20mg BID, usual doseage is 40-80mg BID. 80-160mg/day bipolar. IM form is twice as potent, so usual IM dose for agitation is 10 - 20mg. SE: CI in peeps with QTc elongation (QTc over 500ms according to uptodate, 550 according to maya from Mass general psych program). Almost no weight gain or cardiometabolic SE. Supposedly activating at very low doses, but sedating at moderate to high doses.

Bipolar disorder (BD), rapid cycling is a specifier for someone who has at least 4 manic, hypomanic, or major depressive episodes in 12 months. Mixed features is with 3 non-overlapping depressive symptoms during a manic episode.

Bipolar I disorder is a diagnosis of a manic episode (see above) with or without a depressive episode. Depressive episode criteria for BP are the same as for MDD. acute tx: mild to moderate symptoms treat with lithium, anticonvulsants (valproate, carbamazepine, not lamotrigine), or antipsychotics (risperidone, haloperidol, olanzapine etc). severe symptoms are characterized by suicidal or homicidal ideations, aggressive behavior, or psychotic features. Use lithium plus an antipsychotic or valproate plus an antipsychotic. maintenance tx: FLT is lithium or valproate or whatever worked for acute events. SLT is quetiapine or lamotrigine.

tricyclic (TCA) antidepressants. Nortriptyline (pamelor), amitriptyline (elavil), doxepin (silenor). Amoxapine has some dopamine blocking, similar to an antipsychotic, and is technically a tetracylic. Prite says that Nortriptyline has a "curvilinear therapeutic window" probably means a narrow therapeutic index.

Block reuptake of NE and serotonin. Nortriptyline is the active metabolite of amitriptyline; nortriptyline is just as sedating at a low dose as a high dose. Amitriptyline and doxepin (FDA indication for insomnia) are the most sedating. MOA is inhibiting reuptake of serotonin and NE (like SNRIs). SE: anticholinergic (dry mouth, blurred vision, constipation, urinary retention), A1 antagonism (orthostatic hypotension), H1 antagonism (sedation). Overdose causes three Cs: coma, convulsions, cardiotoxicity (arrhythmia due to widened QRS). Peeps with history of heart disease of patients over 40 are recommended (by uptodate) to have a baseline ECG, the APA says peeps with cardiac risk factors of over 50 need ECG. Prite says that bethanechol (mimics acetylcholine) is used to treat urinary retention caused by TCAs.

differentiating NMS from serotonin syndrome. treating serotonin syndrome

Both serotonin syndrome and NMS can cause unstable vitals and altered mental status. Serotonin syndrome evolves rapidly after administration of serotonergic drugs, where NMS evolves over hours or days. Serotonin syndrome also causes hyperreflexia, clonus (rhythmic muscular contractions), GI symptoms.

when are LP (lumbar puncture) contraindicated, or when should imaging be done first

CI to LP: thrombocytopenia, cerebral mass, recent head trauma, papilledema. It is ok to do LP if meningitis is suspected as long as the other CI are not suspected.

pregnancy risk categories according to FDA (food and drug administration)

Category A: controlled human studies show no risk. B: either animal studies showed no risk and there are no human studies, or animal studies showed risk but human studies did not. C: animal studies show risk, no studies in humans, benefits may outweigh risks. D: human studies show risk, benefits may still outweigh risks. X: use contraindicated due to human studies showing risk outweighs benefits.

Stevens-Johnson Syndrome (SJS)

Causes fever, flu like symptoms, skin and mucocutaneous lesions, sore throat. tx: suspected cases should be admitted to the hospital. Treated like burn victims; skin coverage, fluids as needed, supportive management.

noninvasive neuromodulation therapies (usually for depression)

Convulsive therapies: ECT, MST (magnetic seizure therapy), FEAS (focul electrically administered seizure therapy). TMS T-PEMF (transcranial low voltage pulsed electromagnetic fields) Trigeminal nerve stimulation Low field magnetic stimulation Cranial electrical stimulation TENS/TNS (transcutaneous electrical nerve stimulation): used for pain, pads are placed on skin.

Aripiprazole (Abilify)

D2 partial agonist (like cariprazine). Partial agonist at 5-HT2c (like ziprasidone) I: schizophrenia, bipolar, irritability in autism, adjunct for MDD, tourette syndrome. D: 15-30mg/day for schizophrenia and bipolar, 5-20 for tourette's, 5-15 for autism, 2-15 for augmenting SSRI/SNRI in MDD. SE: Theoretically should have less EPS and hyperprolactinemia due to D2 partial agonist. Minimal metabolic effects/weight gain.

panic disorder

D: A: at least 4 of 13 panic attack criteria. B: after a panic attack there has been at least one month of either 1; persistent concern about another panic attack, or 2, maladaptive behavioral changes to avoid a panic attack. C: not due to a substance. D: not better explained by another disorder tx: choose between medication or CBT. CBT and EX/RP are equally effective according to truelearn. If medication try an SSRI. If CBT doesn't work then try an SSRI. If SSRI doesn't work try another SSRI or SNRI. If that doesn't work then use benzo for peeps without SUD (substance use disorder) history. Benzo dosing can be schedued rather than PRN to lower frequency of attacks; often clonazepam is preferred due to longer half life.

Lithium, competes with Na at proximal tubule.

D: Starting dose is usually 300mg two or three times daily, the total daily dose is increased 300-600mg every one to five days based on response, tolerability, and BMI. Dividing the dose is to eliminate side effects. The goal is to reach a therapeutic serum level which usually occurs with a dose of 900-1800 per day. Half life of lithium is 24 hours, so it takes 5 days to reach steady state after dose is changed. Target trough serum levels is .8 - 1.2 mEq/L. One random website says it takes 7-10 days to treat acute mania, and that atypical antipsychotics take 6-10 days. PRITE says it takes 1-3 weeks for onset of antimanic effect. SE: hypothyroidism (by inhibiting thyroid hormone secretion), polyuria (ADH antagonist), tremor, leukoytosis, cognitive slowing, dermatological problems like acne, hyperparathyroidism, hypernatremia. Can cause low T waves on ECG due to hypokalemia. Teratogen (causes ebstein's anomaly). Hypothyroidism caused by inhibiting thyroid hormone synthesis and release. May lower blood glucose, stimulate appetite, and cause weight gain. Signs of OD include gi upset, QTc elongation, AMS, irregular tremors. Dialyze if lithium level is 4-5 or with AMS.

SSRI SE and indications

D: trial should be 4-6 weeks before increasing or discontinueing. SE: sexual SE, drowsiness, insomnia, dry mouth, headache, hyponatremia. It used to be thought that SSRIs can cause bleeding due to 5-HT activity of platelets, but that has been debunked. BBW (black box warning) for increased suicidality in ages 0-24.

malingering (on abbreviated DSM V page 373), V code is V65.2 and Z code is Z76.5

DSM V says that the essential feature is the intentional production of false or grossly exaggerated symptoms for external gain, such as avoiding work, monetary compensations, obtaining drugs, etc. Differs from factitious disorder which has an incentive to assume the sick role and the attention it may bring. DSM V says to strongly suspect malingering if any of the following things are present: 1, medicolegal context of presentation, such as if the patient is referred by an attorney or the patient self refers during litigation, 2 marked discrepancy between individuals claimed stress or disability and objective findings, 3 lack of cooperation during the diagnostic evaluation and in complying with treatment, 4 presence of antisocial behavior.

separation anxiety disorder

DSM-V diagnosis no longer requires onset before age 18.

emotional support animal

Defined by the Fair Housing Act for use in public housing and the Air Carrier Access act for use in air travel. Airline companies can required documentation including a letter from a licensed mental health professional stating that they are treating the individual, that the individual has a DSM diagnosis (doesn't need to say which diagnosis) and that the animal is necessary.

sexual dysfunction section of DSM

Delayed Ejaculation, erectile disorder, female orgasmic disorder, female sexual interest/arousal disorder, genito-pelvic pain/penetration disorder, male hypoactive sexual desire disorder, premature (early) ejaculation, substance/medication-induced sexual dysfunction disorder, other specifed sexual dysfunction, unspecified sexual dysfunction

duloxetine (cymbalta)

Dr Fig says serotonin and NE effect are about equal, even at low doses (unlike venlafaxine). I: chronic musculoskeletal pain, diabetic peripheral neuropathy, fibromyalgia, GAD, MDD. D: dose range is 30-60mg once daily for most indications. MDD dose can be given twice daily (dose is split). Doses up to 120mg/day can be given but studies haven't shown any improved symptoms above 60mg/day. SE: nausea, insomnia, somnolence, headaches, sexual dysfunction, CI in angle closure glaucoma.

Exposure and response prevention (ERP, similar to habituation in Prite), flooding, implosion

ERP is a type of therapy where peeps are exposed to progressively stronger fear-inducing stimuli in vivo. It is FLT for treating OCD and specific phobia. Flooding: exposure but you start with most severe fear-inducing thing. Implosion: imagining fearful things.

determining seizure via EEG during ECT

Even though EEG activity should show stages of a seizure that causes specific waveform characteristics, in practice these are hard to pick out. Identifying a seizure on the EEG is by identifying 1, evolution of the dominant frequency of the EEG, and 2, the addition of spikes compared to the prestimulus EEG. 1. The frequency should slow within the first 10 seconds of the seizure, with sustained lower frequency activity thereafter. Lack of slowing could be due to a stimulus that is barely suprathreshold. 2. If the stimulus is barely suprathreshold and slowing does not occur, seizure activity can be indicated by spikes in the EEG activity compared to prestimulus EEG. If the prestimulus EEG activity has a high amplitude then these spikes may be difficult to see. Seizures of this type usually have absent motor activity.

CBT (cognitive behavioral therapy)

Helps patient identify automatic thoughts or bad thought patterns/cognitive errors (cognitive therapy) and then helps correct the unwanted behavior (behavioral therapy) that results for the bad thought patterns. Cognitive triad: 1, negative self perception. 2, patient sees world as negative place. 3 patient expects negative things. 3 components of CBT: didactics (educating patient on mental disorder). Cognitive techniques. Behavioral techniques.

Hospice vs palliative care

Hospice is for people with 6 months or less to live. Palliative care has no time requirement.

desvenlafaxine (pristiq)

I (indications): approved for MDD only. Compared to venlafaxine it has greater NET reuptake inhibition than SERT. Less need for dose titration and more consistent NET inhibition compared to venlafaxine. D: usually 50-100mg once a day, though up to 400mg can be given.

buspirone/buspar (partial agonist at 5-HT1a receptor)

I (indications): generalized anxiety, unipolar depression OL (off label). D (dose): range is 10-60mg/day split between two or three doses. Usually start at 10mg/day. Dose is split due to short half life (2-3 hours). Usually the max dose is requiered for effectiveness. SE: dizziness, GI upset

buprenorphine prescribing

I think Dr. Reddy's clinic gives prescribes enough for one week and requires weekly follow up for a month, then requires follow up every two weeks.

prescribing valproic acid (depakote, VPA). MOA is inactivates sodium channels and increases GABA levels by inhibiting GABA transaminases.

I: Bipolar, focal (partial) onset and generalized onset seizures, migraine prophylaxis. D: therapeutic dose for mania starts at 750 mg/day divided into 2-4 doses. ER formulation starts at 25mg/kg. Usual effective dose is 1.5 - 2.5g/day. Max recommended dose is 60mg/kg/day (3600 for a 60kg person). Dose likely must be increased when switching from IR to ER formulations. Trough concentrations (taken just before the next dose) should be done 2-4 days after initiation or adjustment of dose. Therapeutic serum concentrations are 50-125 mcg/ml. 1/2 life is 9-19 hours. Dosing is 3-4 times daily for IR, 2-3 for DR (delayed release) version, and once a day for ER. SE: decreases glucuronidation/metabolism of valproic acid. Hepatotoxic, headache, alopecia, weight gain, HSR (hypersensitivity reaction, not SJS) causing rash and thrombocytopenia. Teratogen (inhibits folate absorption causing neural tube defects like spina bifida). Has 4 black box warnings: hepatotoxicity, patients with mitochondrial disease (have increased risk of liver failure), fetal risk, and pancreatitis. Hyperammonemia and encephalopthy can occur with labs showing normal LFTs.

pregabalin (lyrica). It either acts similar to gabapentin or inhibits calcium channels, or both.

I: Fibromyalgia, partial (focal) seizures), postherpetic neuralgia, peripheral neuropathy due to diabetes, neuropathic pain associated with spinal cord injury. OL for chronic cough, anxiety, other peripheral neuropathy, restless leg syndrome. D: IR and ER available. For IR start at 75mg/day, increase by 75/day, with max dose 450 or 600/day, with dosing BID or TID. ER doseage is similar, but pills are 82.5mg, 165, and 330, with max dose 660mg/day.

bupropion/wellbutrin (increases NE and dopamine by inhibiting reuptake which is similar to amphetamines, stimulant effect)

I: MDD, usually used as adjunct, seasonal affective disorder, smoking cessation. OL: ADHD CI: anorexia and bulimia D: range is 200-450mg/day split between 2-4 doses. Start at 100mg BID. Max single dose is 150mg. Sustained release and extended release forms also available. SE: stimulant affects: tachycardia, insomnia, weight loss, minimal sexual dysfunction (less than SSRI). CI in anorexia/bulimia because of seizure risk cuz bulimics can have electrolyte abnormalities from vomiting. Also CI due to lowering seizure threshold: peeps discontinueing alcohol or sedatives (benzos, barbs, or antiepileptic), head trauma, use of MAO in last 14 days. Incidence of seizure is .05% in doseage 300 or less and .1% in doses 400 or greater

carbamazepine (tegretol). Acts by inactivating Na channels to prevent depolarization.

I: SLT for acute mania after lithium and VPA. Epilepsy and trigeminal neuralgia (aka tic doloureous). D: start with 200mg BID with increase of 200mg every 2-3 days until reaching 1,200mg/day in TID doses. Blood tests are not done because they are unreliable because active metabolite is often undetected. Better absorbed with food. SE: BBW for 1, SJS and 2, aplastic anemia and agranulocytosis. Nausea, sedation, vertigo, diplopia, aplastic anemia, agranulocytosis, hepatitis, SJS. Can cause craniofacial abnormalities in fetus. induces CYP3A4, so any medication taken with it that is metabolized by CYP3A4 will need an increase in dose. Since carbamazapine is also metabolized by CYP3A4 (autoinduction), which decreases half-life to 12 hours and is the reason for TID dosing. Baseline and periodic labs include CBC and others. Must discontinue use if WBC is <3,000 (due to agranulocytosis, aka granulocytopenia, aka neutropenia, aka low neutrophil count). Regular blood draws two weeks and four weeks after starting treatment, then every 6 months. serum levels normalize after 3-5 weeks after initiation.

venlafaxine (effexor)

I: approved for MDD, GAD, SAD, panic disorder. SERT reuptake inhibition is stronger than NET (same as most SNRIs). It is metabolized in the body to desvenlafaxine. Dr Fig says at low doses its main action is SERT with little NET (unlike duloxetine) but at higher doses the NET effect is stronger. When given with mirtazapine it is referred to as "california rocket fuel". D: for MDD 75-225mg once daily for ER or divided into 2-3 doses up to 375mg/day for IR (immediate release). For GAD 150-225mg. SE: Stimulating. Dose dependent increase in BP. sexual dysfunction. SIADH. withdrawal symptoms significant but decreased with XR capsule. Use of cimetidine reduces clearance and raises drug levels.

pimavanserin (Nuplazid)

I: approved in 2016 for psychosis in parkinson's patients, it reduces hallucinations without worsening movement disorders. Not approved for schizophrenia (no D2 antagonism). Acts by antagonist activity at 5-HT2a, does not affect dopamine receptors.

Haloperidol (Haldol), an inverse antagonist (binds similar to an agonist but has the opposite effect, thus an antagonist) at D2

I: behavioral disorders in kids, hyperactivity accompanying conduct disorder in kids, psychotic disorders, schizophrenia, tourette syndrome D: for schizophrenia dose is 1-40mg/day in 2-3 doses. IM decanoate depot injection available and is 10-20 times previous daily dose. 1/2 life 12-36 hours for PO, 3 weeks for depot. SE: supposedly IV form has significant QTc prolongation, but when studied (https://www.ncbi.nlm.nih.gov/pubmed/11386487) there is only modest QTc elongation which did not leave to tachyarrhythmia.

oxcarbazepine (trileptal)

I: epilepsy. OL for neuropathic pain. D: start with 300mg nightly, then increase to total of 1,200mg/day in BID dosing. Unlike carbamazapine, taking medication with food does not increase bioavailability. SE: hyponatremia

lamotrigine (lamictal), acts by blocking Na channels and other stuff.

I: maintenance of bipolar (not for acute mania or bipolar depression), epilepsy. D: start with 25mg daily for weeks 1 and 2, 50mg daily for weeks 3 and 4, 100mg for week 5, then up to 200mg on week 6. Manufacturer recommended max dose is 200mg but some use up to 400mg. SE: BBW for SJS. Benign skin rash is 5-10%, serious rash (like SJS) is .1%, but more common in kids. . Other SE are minimal, but include SJS, especially if taken with VPA. VPA decreases glucuronidation/metabolism of lamotrigine so dose should be halfed if VPA is taken concurrently. Highly affected by carbamazepine (and other CYP inducers) and dose should be almost doubled. Oral contraceptives containing estrogen cause decreases levels for some reason.

melatonin

I: not FDA approved for any use because it is considered a dietary supplement, which aren't regulated. D: 3-5mg qhs

gabapentin (neurontin), a GABA analog, but doesn't work as a GABA analog, it just potentiates GABA

I: post-herpetic neuralgia and partial seizures. It is used OL for a ton of things and the company was sued for advertising it for OL things. D: max dose for partial seizures is 3600mg/day in three doses. For anxiety start with 100mg or 300mg once a day. SE: dizziness, drowsiness, peripheral edema.

Thioridazine (Mellaril)

I: schizophrenia when other antipsychotics have failed. D: 200-800mg/day in divided doses SE: severe cardiac arrythmias due to QTc elongation; the brand drug was withdrawn from the market, but generic still available.

Olanzapine (Zyprexa)

I: schizophrenia, bipolar. Adjunct with fluoxetine for treatment-resistant depression or bipolar depression. D: 10-20mg/day. Depot injection form available. Dissolvable form is called zyprexa zydis and can be put dissolved in a drink. SE: one of the worst antipsychotic for metabolic SE. If giving benzos IM also then wait at least 1 hour after olanzapine IM is given or else respiratory collapse can occur; but they can be given concurrently if either or both is PO.

levetiracetam (Keppra)

I: various seizures. D: 500mg BID initially, up to 3000/day in combined doses. ER version available. SE: SJS syndrome

intelligence tests

IQ (intelligence quotient): the ratio of mental/chronological age, thus an IQ of 100 means your mental age matches your chronological age. Wechsler ADult Intelligence Scales(WAIS): the most widely used intelligence test.

further ketamine dosing

IV infusion dosing of .5 -1.0 mg/kg is effective. redemption psych starts at .5mg/kg.

sertraline (zoloft)

In addition to SSRI activity it inhibits DAT (Dopamine transporter) and binds to σ1 (sigma-1 receptor). Sigma-1 decreases DA activity. Increased dopamine antagonist effect is preferred for peeps with MDD with psychotic features due to dopamine inhibition. It has a mild activating activity which can be beneficial but required slower titration when treating panic disorder to not cause increased anxiety. D: 25-200mg, half life is 22-36 hours. Abrupt cessation can cause discontinuation symptoms, which is more prevalent in this drug due to its relatively short half life.

specifiers for depressive disorder. Naming order is as follows; list diagnosis (major depressive disorder), then single or recurrent episode, then severity/psychotic/remission specifiers, then as many of the rest of the specifiers that apply. Each of the following severity/course specifiers have two ICD-10 codes (one for single and one for recurrent episode): mild, moderate, severe, with psychotic features, in partial remission, in full remission, unspecified.

In partial remission if there are some symptoms from prior depressive episode but criteria are not current met; or if there is a period lasting less than 2 months without significant symptoms. In full remission: no symptoms in two months. With peripartum onset: occurs during or 4 weeks after pregnant. with seasonal pattern (seasonal affective disorder is old term). mixed features: some symptoms of mania. Atypical features: hypersomnia, increase in appetite/weight gain, leaden paralysis. anxious distress melancholic features catatonia mood congruent psychotic features: psychosis involving negative ideas mood incongruent psychotic features: psychosis involving positive things/ideas. In partial remission if there are some symptoms from prior depressive episode but criteria are not current met; or if there is a period lasting less than 2 months without significant symptoms. In full remission: no symptoms in two months.

Disruptive, Impulse-Control, and conduct disorders

Include ODD, IED, Conduct disorder, Pyromania, Kleptomania, other specified, and other unspecified.

child and adolescent psychological assessment

Intelligence: WISC-lll (wechsler intelligence scale for children-lll. Achievement: Woodcock-Johnson psychoeducational battery-Revised (W-J). Wide Range Achievement test-3 (WRAT-3). Adaptive behavior: Vineland Adaptive Behavioral Scales.

communication disorders (under the category of neurodevelopmental disorders in DSM V)

Language disorder: difficulty in acquisition and use of language as evident by reduced vocab, limited sentence structure, and impairments in discourse. Speech sound disorder: difficulty with speech sound production that interferes with verbal communication. Childhood-onset fluency disorder (stuttering): stuttering. social (pragmatic) communication disorder: difficulty adapting to conversation, such as the difference in formal and nonformal speech, verbal and nonverbal communication.

mood stabilizers during pregnancy

Lithium and AEDs such as VPA, and carbamazapine have noted SE, so atypical antipsychotics are often preferred. Lamotrigine is generally considere the safest mood stabilizer; one study showed increased cleft palate at an overall rate of 0.9%, but other studies did not shown an increase of risk. Odds of cardiovascular malformations such as ebstein's anomaly due to lithium exposure are estimated (according to womensmentalhealth.org) to be between .05 and .1%.

borderline personality disorder (BPD)

Main characteristics of BPD are affective instability and impulsivity. Dx: five or more of the following. 1. frantic efforts to avoid real or imagined abandonment. 2. unstable interpersonal relationships characterized by alternating between extremes of idealization and devaluation. 3. identity disturbance: unstable self-image 4. impulsivity in at least two area that are potentially self damaging like spending, sex, substance abuse, reckless driving, binge eating, etc. 5. recurrent suicidal behavior, gestures, or threats, or self mutilating behavior 6. affective instability due to marked reactivity of mood; such as intense episodic dysphoria, irritability or anxiety lasting usually a few hours up and rarely more than a few days. 7. chronic feelings of emptiness. 8. inappropriate intense anger or difficulty controlling anger. 9. transient, stress-related paranoid ideations or severe dissociative symptoms. tx: dialectic behavioral therapy or another therapy. Pharmacotherapy is only indicated for peeps with; 1. severe cognitive perceptual experiences such as paranoia, dissociation, hallucinations, etc. Can be given antipsychotics. 2. severe impulsivity or behavioral dyscontrol like anger, self harm, recklessness. Can be given mood stabilizer. 3. severe affective dysregulation such as dysphoria, anger, mood lability. Can be given mood stabilizer. Prognosis: most don't meet criteria for BPD after 4-6 years but 5-10% never achieve remission. Those that do achieve remission often have characteristics of the disorder even if they don't meet diagnostic criteria. STEPPS (systems training for emotional predictability and problems solving) is a relatively short outpatient therapy program that can help BPD; according to Decker.

objective tests

Millon clinical multiaxial inventory: per PRITE "the most helpful in confirming a personality disorder". MMPI (minnesota multiphasic personality inventory). Structured clinical diagnostic assessments also fit into this category

Anti-NMDA receptor encephalitis

Most patients have prodromal headache, fever, or viral like process that is followed in a few days by progression of symptoms such as psychiatric symptoms (agitation, anxiety, bizarre behavior, hallucinations, etc), insomnia, memory deficits, seizures, decreased consciousness or stupor, dyskinesia, autonomic instability. Psych symptoms often wax and wane. dx: anti-nmda Ig found in CSF. Brain MRI and EEG usually normal. CT abdomen/pelvis for ovarian teratoma which is present 50% of the time in female at least 18 yo. tx: immunosuppression with IV steroids and either IVIG or plasma exchange. Tumor resection if teratoma present.

methylphenidate (ritalin, concerta, cotempla (chewable tablet), many more), dexmethylphenidate (focalin, an isomer of methylphenidate)

NE and DA reuptake inhibitor, minimal effect on 5-HT (unlike amphetamine). Greatest effect is on DA (like amphetamine). I: ADD and narcolepsy. methylphenidate OL for depression in elderly or terminally ill. D: adult dosing with IR tablet same for kids 6 and over: start at 5mg BID after breakfast and lunch. Increase by 5 - 10mg/day at weekly intervals. Max dose 60mg/day in 2 or 3 doses. SE: insomnia, headache, irritability, decreased appetite, tachycardia, other stimulant effects

Atomoxetine (Strattera)

NE reuptake inhibitor for ADHD. Non stimulant I: ADHD D: start at 40mg/day then increase after 3 or more days to 80mg. Max dose 100mg. Dose may be divided. SE: Dry mouth, insomnia, drowsiness, decreased appetite. Black box warning for increasing SI in children.

NMDA (N-methyl D-aspartate), NMDA receptor

NMDA is one of many things that can activate NMDA receptor. NMDA receptors are glutamate receptors and ionotropic receptors. When glutamate binds to the receptor it causes influx of calcium. Overactivation of NMDA receptors can cause seizures and excitotoxic cell death by large influx of calcium. Glutamate (an excitatory neurotransmitter) activates NMDA receptors. Antagonists include ketamine, dextromethorphan, and memantine.s

SE typical of all antipsychotics

Nigrostriatal pathway D2 receptor blockade cuases EPS symptoms. Tuberoinfundibular D2 blockade increases prolactin and causes galactorrhea, amenorrhea, infertility, sexual dysfunction. Anticholinergic muscarinic blockade: dry mouth, urinary retention, blurred vision, etc. alpha adrenergic blockade: orthostatic hypotension. histamine blockade: weight gain and sedation. Can also cause NMS, seizures, agranulocytosis (misnomer), leukopenia.

citalopram (celexa)

Only approved for MDD. racemic mixture. The R enantiomer has antihistamine properties. ECG advised in patients with heart conditions. D: 20-40mg/day, max dose was previously 60mg/day but it was lowered due to QTc elongation. Max dose is 20mg in patient over 60 yo due to QTc. SE: normal SSRI SE: sexual dysfunction, GI upset, insomnia, sedation. Uptodate says to stop if ECG is >500. This drug was shown in one study to help negative symptoms of schizophrenia ("citalopram in first episode schizophrenia: the DECIFER trial") even though it did not help subsyndromal depressive symptoms.

global developmental delay

Only for individuals under the age of 5 when the clinical severity level cannot be reliably assessed during early childhool. This category is diagnosed when an individual fails to meet expected developmental milestones in several areas but the child is too young for standardized testing (a requirement for intellectual disability). This category requires reassessment after a period of time.

continuation and maintenance after initial ECT

Options are psychotropics, continueing ECT, psychotherapy with psychotropics or ECT, or psychotropics with ECT (for peeps who failed monotherapy). There is no strict guidelines for frequency of treatments during continuation (which comes after ECT course) or maintenance, but usually ECT is done once a week for 4 weeks and then the less and less frequently until it is once a month (this frequency varies widely). Maintence ECT may be as long as every 3 months.

MMSE part

Orientation: what is the year and day? Registration: name three objects and have the patient repeat them. Attention and calculation: Seriel 7s, or spell "world" backwards". Recall: name three objects mentioned earlier. Language: name a pencil and watch, copy a design.

primary, secondary, tertiary prevention (now called universal, selected, and indicated).

Primary prevention: to prevent occurrence of a condition, such as vaccinating people. Secondary prevention: to detect and treat early disease, like a screening test like mammography. Tertiary prevention: stops things from getting worse in established disease.

lab monitoring for lithium

Prior to starting lithium carlat report says do TSH, BUN/cr, pregnancy test, ECG if elderly or cardiac disease. other sources say to also do a urinalysis, CBC, electrolytes, calcium, , and EKG for peeps 40 yo or with risk factors for CAD (such as DM, HTN, smoking, dyslipidemia). Lithium levels should be checked 5- days after started/changing dose (this is when steady state is reached), then every 6-12 months after that; every 3 months if there are significant medical comorbidities. If considering a dosing change then levels must be drawn 2 weeks prior to changing dose. Serum trough (taken right before next dose is due) lab level should not exceed 1.2 (therapeutic range usually between 0.8 and 1.2) and severe toxicity occurs at 2.5.

due to another medical condition diagnoses

Psychotic disorder due to another medical condition. Bipolar and related disorder due to.... Depressive disorder due to: DSM says that it is "direct pathophysiological consequence of another medical condition" and not "adjustment disorder, with depressed mood, in which the stressor is a serious medical condition". Personality change due to....: causes include TBI, AIDS, neurosyphilis, etc.

REMSBD (REM sleep behavior disorder), NREMSAD (non REM sleep arousal disorders), nightmare disorder

REMSBD occurs during REM sleep and involves vocalization and/or complex motor behaviors. The person can easily be woken up and is immediately awake and alert. There is no atonia (inability to move) which usually occurs during normal REM sleep. Peeps with REMSBP are more likely to be diagnosed with parkinsons. NREMSAD can be either sleepwalking or sleep terrors (aka night terror) and occur during slow wave sleep (stages 3 and 4). In both the person is very difficult to wake up, and doesn't remember what happened. In sleep terrors a person might scream and appear to have woken up but is really confused and Nightmare disorder is well-remembered nightmares that are vivid and occur during REM sleep. No abnormal movements, and when awakened the person quickly becomes oriented and alert. Both REMSBD and NREMSAD are treated with behavior modifications such as creating a safe sleep environment. Clonazepam can be given if necessary, it decreases both violent dreams and injurious behavior.

dopamine antagonists (lots of questions about them on PRITE)

Reserpine, benazine drugs (like tetrabenazine), both inhibit dopamine by inhibiting dopamine packaging and release by inhibiting VMAT.

ECT SE

Retrograde amnesia is common after ECT but most cases resolve with time, few have permanent loss. Anterograde amnesia is usually limited the the time shortly after treatment, but some have permanent loss. Cognitive impairment is less common; sometimes there is cognitive improvement. Medical SE are the same as any other procedure involving general anesthesia and are usually cardiopulmonary related. Aspiration pneumonia, bruises or bone fractures from convulsing, nausea, vomiting.

M'Naghten Rule

Rule to determine NGRI (not guilty by reason of insanity), which is based on if the patient understands the consequences of what he is doing.

milnacipran (savella)

SNRI. in the US it is only approved for fibromyalgia, not depression. More potent NET than SERT inhibition.

fluvoxamine (luvox)

SSRI approved for OCD and maybe social anxiety disorder. May be an agonist at σ1 (sigma-1 receptors) which affects dopamine levels and may explain its anxiolytic properties as well as its effectiveness in psychotic and delusional depression. D: 100-300mg/day for OCD and anxiety, 100-200mg/day for depression. Short half life (9-28 hours) means that the immediate release pills need to be taken twice a day, ER (extended release) tablets are available for once a day dose. SE: sexual dysfunction, GI upset, insomnia, sedation, can rarely cause seizure. LeastCYP2D6 inhibiting among SSRIs.

vortioxetine (Trintellix)

SSRI but also has increases release of everything ( SER, NE, DA, glutamate, ACH, and histamine) and reduces release of GABA. I: MDD D: start with 10 and increase to 20 after a week.

vilazodone (viibryd)

SSRI that has 5-HT1a partial agonist, called a SPARI (serotonin partial agonist reuptake inhibitor). Has less sexual dysfunction and weight gain SE compared to other SSRIs which may be due to partial agonist activity. half life is 25 hours. Approved for MDD only. Used for anxiety disorders plus depression. D: 20-40mg/day, take with food. SE: same as other SSRIs: GI upset,

important trials

STAR D: compared antidepressants and investigated whether adding CBT or adding/switching to another antidepressant is preferred if first/second/or third intervention doesn't work. CATIE: compared newer antipsychotics olanzapine, quetiapine, risperidone, and ziprasidone with the older antipsychotic perphenazine and found that they are all similar but people stayed on olanzapine longer and was slightly more effective (but no significant difference) than the rest but had greater metabolic SE. Olanzapine had most weight gain by far, then quetiapine, then risperdone.

extinction

fading of a non-reinforced conditioned response over time. Seen in both operant and classical conditioning.

syphilis and neurosyphilis testing

Screening is only for patient with symptoms or patient consider high risk for acquiring. testing is with serum VDRL or RPR and can be confirmed with FTA-abs (fluorescent treponemal antibody absorption). CSF analysis with VDRL and other tests often part of workup. Its possible VDRL and RPR can be negative with someone with advanced neurosyphilis, but that person would have very obvious clinical symptoms. Neurosyphilis is considered uncommon since advent of antibiotics.

Freud Psychosexual development stages. Sexual energy moves from one body part to another.

Sexual energy moves from one body part to another in each state. Oral; birth - 1 year, anal: 1 - 3 years, disruption in this development is anal retentive or anal expulsive. Phallic: 3 - 6 years, disruption in develoment can cause oedipus complex. latency; 6 - puberty, sexual unfulfilment if fixation occurs in this stage. genital; puberty - death, sexual interests mature.

Sigecaps digfast

Sleep, interest, guilt, energy, concentration, appetite, psychomotor retardation/agitation, suicide. 5 are required for MDE Distractibility, indiscretion (risky behavior/activities), grandiosity, flight of ideas, activities (increased goal activity), sleep (decreased need), talkativeness (pressured speech). 3 required for manic episode (or 4 if mood is only irritable and not elevated or expansive).

weird supplements

St John's wort (hypericum perforatum): inducer of CYP, can act as an SSRI and cause serotonin syndrome. Ginkgo Biloba: antiplatelet effect, increased blood flow, supposedly helps with memory/dementia. Ginseng: interacts with psychotropics, used for sexual dysfunction.

clozapine (clozaril)

Strong antagonist at 5-HT2a and D4, not as strong antagonism at D2, some antimuscarinic activity. Higher doses often required in chronic smoking. I: refractory schizophrenia (schizos who failed other antipsychotics will respond to clozapine 50-60% of the time), and suicidal behavior in schizophrenia or schizoaffective D: target trough level is 350ng/ml. Start with 25mg at night and increase 25-50mg/day every 48-72hrs until taking 200mg at night, dose may be increased to 600-900mg/day. prescriptions and WBC draws are given weekly for 6 months, then every two weeks for next 6 months, then monthly. After discontinuation check WBC weekly for 4 weeks. Due to possible myocarditis, all patients also get initial ECG and weekly lab tests for the first four weeks to test troponins, eosinophils, and CRP or erythrocyte sedimentation rate. SE: neutropenia (aka agranulocytosis), sialorrhea (drooling), benign fever, myocarditis (within first 6 weeks of treatment), seizures, typical antipsychotic SE. Antimuscarinic activity also causes constipation, dry mouth, etc. Less likely to cause EPS symptoms due to weaker D2 antagonism.t

tetrabenazine (xenazine), deutetrabenazine (Austedo), valbenazine (Ingrezza)

Tetrabenazine and deutetrabenazine approved for chorea (abnormal involuntary muscle movement) of huntingtons. Deutetrabenazine and valbenazine are approved for TD (the only approved drugs). Acts by inhibiting the VMAT-2 (vesicular monoamine transporter type ), which decreases the uptake of monoamines (dopamine, serotonin, norepinephrine, and histamine) into synaptic vesicles (which normally transport neurotransmitters into synaptic cleft) and depletes the amount of monoamine available in the presynaptic neuron. SE: sedation, insomnia, depression, GI upset, upper respiratory infection.

depersonalization/derealization disorder

Though to be a response to trauma. Risk factors: acute and chronic trauma or severe stress, other mental health conditions especially anxiety or depression, and substance use. tx: CBT is the FLT. for peeps with comorbid depression or anxiety, also treat with meds for those disorders.

thought process, thought content

Thought process: the quantity, tempo, form (logical coherence) which is represented in the patient's speech. Abnormal thought processes are called formal thought disorders and include derailment, tangential thinking, circumstantial thinking, thought blocking, loosening of associations, etc. Thought content: include delusions, phobias, paranoia, obsessions, overvalued ideas, etc.

acetylcysteine

Used to treat trichotillomania, excoriation, and other similar disorder. It is a building block of an amino acid which is the building block of a neurotransmitter. It is thought to modulate the neurotransmitter glutamate. Also the antidote to acetaminophen overdose.

electroconvulsive therapy (ECT), frequency and course

Usually used for severe depression or catatonia; rarely for bipolar or schizophrenia. Effective 53% of the time for treatment refractory MDD. There are no absolute CI to ECT, always risk-benefit analysis. No required labs (Tomek says do cbc, cmp, and EKG). EKG should be done for peeps with cardiac conditions. Hold lithium during ECT, which can cause prolonged seizures and prolonged confusional state. Pregnant women should have fetal heart rate monitoring. ECT is done on average 3 times per week, a typical course is 6-12 treatments but can be 3-20; treatment is stopped after the patient is believed to have a maximum clinical response. If there is not much improvement after 6 treatments then modifications such as unilateral to bilateral electrode placement, increasing stimulus intensity, or potentiating the seizure pharmacologically should be done; if the patient still hasn't responded after 3-4 more treatments or the response has plateaued, stop doing ECT.

invasive neuromodulation therapies (usually for depression)

VNS (vagal nerve stimulation): small device is placed under clavicle and connect to vagal nerve close to the carotid sheath. DBS (deep brain stimualtion: an electrode is placed deep in the brain. Direct cortical stimulation: electrodes placed on the surface of the brain. Ablative neurosurgery

Wisconsin Card Sorting Test (WCST), Trail making test

WCST: Assesses executive functioning. The most useful test to evaluate concept formation with "set shifting", which is abstract reasoning in problem solving. It is useful when diagnosing acquired brain injury, neurodegenerative disease (like dementia), or mental illness. The trail making test connects letters and numbers together, and is used to evaluate concentration and executive functioning.

wernicke vs korsakoff

Wernicke: ophthalmoplegia, ataxia, confusion, foot drop, and more. All are reversible if treated. Korsakoff: confabulation, amnesia, and apathy.

nonbenzodiazepine hypnotics

Zaleplon, Zolpidem (ambien), EsZopiclone (ZZZ)(order of duration is <4 hrs, 6 hrs, >6 hrs respectively). Act via the BZ1 GABA receptor (subunit of GABAa receptor). SE: BBW for "complex sleep behaviors" including sleep-walking, sleep-driving, etc. Discontinue if this happens.

trazodone (desyrel)

a SARI (serotonin antagonist and reuptake inhibitor) that also blocks 5-HT2a, A1 and H1. Does not cause sexual dysfunction. D: 150-400mg in divided doses for IR in MDD. SE: Sedating, higher doses can cause hangover effect.

sagittal sinus thrombosis (aka cerebral venous sinus thrombosis)

a blood clot in the dural venous sinus that causes headache (often in occipital area), papilledema, CSF shows increased opening pressure and RBC. Can be visible on CT but not always.

interpersonal psychotherapy

a brief, highly structured, and time limited therapy that is used for 12-16 weeks. It focuses on improving patient's relationships/interpersonal problems. Uses attachment theory to understand basis of difficult relationships. Developed by Klerman and utilized by Harry Stack Sullivan.

selective abstraction (aka cognitive distortion)

a cognitive bias or cognitive distortion where a person where a person takes a detail out of context while everything else is ignored, such as a student who failed one test believing that they are going to fail out of college and never get a job.

carbohydrate deficient transferrin, gamma-glutamyl transferase (GGT)

a lab value that is most useful lab value to determine amount of drinking over the past 7-10 days. GGT: a lab value that can detect alcohol abuse for up to 8 weeks after alcohol cessation.

caprylidena (brand name axona)

a medical food (not evaluated by the FDA) and requires a prescription. Used to treat alzheimers. There is no evidence that is works.

sodium oxybate, aka gamma hydroxybutyrate (GHB), (brand name is xyrem).

a metabolie of GABA that interacts with the GABAb receptor. Causes drowsiness which is meant to improve quality of nighttime sleep and hopefully decrease daytime somnolence cause by narcolepsy. Helps with cataplexy I: cataplexy and daytime sleepiness of narcolepsy; more usefu for cataplexy. D: range is 4.5g-9g per night divided in two doses. Typically a first dose is given at night and then another dose 4 hours later. Initial starting dose 2.25 g. Dose form is an oral solution

dialectic behavioral therapy (DBT)

a modified form of CBT developed for borderline personality disorder, it identifies maladaptive behavioral patterns or feelings and tries to help form new ways of coping. It combines normal CBT with buddhist ideas such as distress tolerance, acceptance, mindfulness.

vagal nerve stimulation (VNS)

a pulse generator about the size of a matchbox attached to the vagal nerve (usually the left) in the chest wall. Controlled by a handheld transmitter that controls the current, pulse width, and frequency. approved in 2005 by FDA for treatment of severe, recurrent, unipolar and bipolar depression, and epilepsy.

CAGE (Cut, Annoyed, Guilty, Eye) questionnaire

a questionnaire to screen for alcohol use disorder. The four questions: have you felt the need to Cut down on your drinking, have you felt Annoyed when people criticize your drinking, have you felt Guilty about drinking, have you needed a drink in the morning (Eye opener) to steady nerves. If peeps answer yes to two questions it warrants further investigation.

Pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS)

a theory that some children with rapid onset OCD is due to group A beta-hemolytic streptococcal infections like strep throat.

mentalization based treatment

a type of psychotherapy designed for BPD. Mentalization is understanding how we interpret the actions of ourselves and others and how that impacts our emotional state. It does not include developing copings skills or behavioral skills, its just analyzing emotions

attention-deficity/hyperactivity disorder (ADHD). MC childhood psychiatric disorder.

a. a persistent pattern of inattention and/or hyperactivity-impulsivity with functioning or development, as characterized by 1 and/or 2. 1 Inattention: 6 or more of the following symptoms (if child/adolescent) for at least 6 months that is inconsistent with developmental level and that negatively impacts social, academic/occupational activities (ages 17 and up require only 5 symptoms): lacks close attention, difficult sustaining attention, does not seem to listen, does not follow instructions, difficulty organizing tasks, avoids tasks that require sustained mental effort, often loses things, easily distracted, often forgetful. 2 Hyperactivity and impulsivity: 6 or more symptoms....(same as inattention): fidgety, cant stay seated, often runs about or climbs when innappropriate, unable to play quietly, often "on the go", often talks excessively, often blurts out an answer before question is completed, has difficulty waiting for his/her turn, often interrupts or intrudes on others. B several symptoms were present prior to age 12. C symptoms present in two or more settings D symptoms interfere with social, academic, or occupational functioning. E symptoms do not occur excusively during the course of schizophrenia or another disorder and are not better explained by another mental disorder.

3 methods of switching antipsychotics, all three have a use

abrupt discontinuation: stop previous antipsychotic and start new at full dose. A useful strategy when previous caused severe SE. cross tapering: preferred in most situations. overlap and discontinuation: start new while continueing full dose of previous. Useful for peeps recently stabilized or high risk for relapse.

LSD (Lysergic Acid Diethylamide, acid)

acts mostly via via agonist at 5-HT but also at dopamine. Causes perceptual distortion (visual and auditory, heightened senses), depersonalization, anxiety, paranoia, psychosis, flashbacks. Similar to MDMA (ecstasy)

suicide probability

adolescents/young adults and older/elderly most likely, with older males the most likely. Most common cause of completing suicide is firearms.

cardiovascular effects of ECT

after the initial charge is given there is a 15-20 parasympathetic discharge that can arrhythmias including bradycardia with or without hypotension, atrial arrhythmias, atrial and ventricular contractions, AV block, and asystole. The clonic phase (rhythmic muscle contractions) of the seizure causes a catecholamine surge causing tachycardia and HTN.

childhood milestones (some according to prite)

age when children use sentences of two or more words: 24 months. 18 months a child uses word combinations. At 12 months a child can walk without help, can say mom and dad and two other words. At 9 months a child can stand with support. At 3 years a child can pedal a tricycle.

neuropsychiatric symptoms of lupus

almost anything: cognitive dysfunction, delirium, psychosis, seizures, headache, peripheral neuropathies.

Types of EEG waves

alpha: 8-13 Hz, usually located in posterior region of head. Occurs when patients are relaxed with eyes closed; reduced when people open eyes or drift to sleep.. beta: >13 Hz, usually located anteriorly. Normal wakefullness; ccurs when people open their eyes or concentrate. theta (4-7 Hz) and delta (<4 Hz), occur everywhere in brain (generalized), and occur normally in children and in adults during sleep. The usual background activity of an adult consists mostly of alpha and beta activity.

Projective tests,

ambiguous stimuli that the patient responds to and the response is interpreted, as opposed to objective tests which gives a numerical score like the MOCA. Rorschach test: ink blots, the most widely used projective test. Thematic apperception test (TAT): shows pictures and askes you to describe them. Sentence completion test (SCT): "sometimes I wish ..." word-association technique: Draw-a-person test:

differentiating different types of amnesia

amnesia due to PTSD: usually causes amnesia of the event that caused the PTSD. due to traumatic brain injury: anterograde amnesia of stuff that occurs about an hour after the TBI, autobiographical info (name, etc) is not forgotten. dissociative amnesia: retrograde amnesia, often includes autobiographical info. transient global amnesia: usually affects older peeps and causes 24 hours of anterograde and maybe retrograde amnesia (but they can still remember autobiographical info). anticholinergic (medication induced): typically anterograde.

panic attack (not a diagnosis, it is a specifier that can be added to another diagnosis such as MDD, PTSD, substance use disorder, or a medical condition like cardiac, respiratory etc.)

an abrupt sense of fear or discomfort that peaks in around 5 minutes and during which four or more of the following occur: 1. palpitations, accelerated HR 2. sweating 3. trembling or shaking 4. sensation of shortness of breath or smothering. 5. feeling of choking 6. chest pain or discomfort 7. nausea or abdominal distress 8. dizzy, unsteady, lightheaded, or faint 9. chills or heat sensation 10. paresthesias (numbness or tingling) 11. derealization or depersonalization 12. fear of losing control or "going crazy" 13. fear of dying

MDD with psychotic features

an episode of MDD plus delusions or hallucinations. tx: acute: ECT or antidepressant plus an antipsychotic. ECT is used for severe psychosis or suicidality, most cases are treated with pharmacotherapy. Sertraline and olanzapine is suggested by uptodate. Maintenance: same as used for acute tx. Because MDD with psychosis is highly recurrent, antipsychotic is continued for at least 4 months and the antidepressant for 2 years.

deep brain stimulation (DBS)

an investigational treatment involving electrodes planted in the brain via burr holes, then connected via wires to a pulse generator implanted in the chest. It is implanted in internal capsule (according to PRITE). It treats motor symptoms (aka primary symptoms) of parkinson's, but doesn't improve psychosis or dementia.

pseudobulbar affect (PBA)

failure of voluntary control of emotion, causing crying/laughing at inappropriate times. Often due to bilateral lesions of descending corticobulbar tract.

naltrexone (Revia, Vivitrol is IM injection or suspension)

antagonist of mu-opioid receptors. I: alcohol dependence, opioid dependence. D: can be taken daily as PO or suspension or given q4 weeks with injection. IM injection is 380mg. Daily dose is 50mg/day on monday and wednesday and 150mg on friday according to Dr Fig. Must be given at least a week after stopping opioids to prevent causing withdrawal. SE: N/V, dizziness, dysphora, anxiety, eosinophilic pneumonia, hepatocellular injury, injection site reactions.

medications during ECT

anticholinergic are given to reduce secretions and prevent bradycardia and are given 2-3 minutes before anesthetic: glycopyrrolate (robinul) .2 - .4mg IV 2-3 minutes before anesthetic. Atropine can also be given but some think it makes postictal delirium worse because it crosses BBB. Anesthetics: methohexital (brevital) is a preferred because although it is a barbiturate it lowers seizure threshold (or at least it doesn't raise it), .75-1mg/kg is given. Etomidate (.2-.6mg/kg) or ketamine can also be given Muscle relaxants are given after anesthetics so people dont feel paralyzed: succinylcholine (.5-1.25mg/kg) or rocuronium (.6-1.3mg/kg) and non depolarizing muscle relaxants can be given. Succinylcholine is effective 1-3 minutes after being given and is effective for 3-5 minutes. Non depolarizers last longer. 5mg of rocuronium can be given prior to succinylcholine to prevent the intense fasciculations of succinylcholine.

benztropine/benzatropine (cogentin), a m1 antagonist

anticholinergic drug used for acute dystonia. I: drug induced EPS symptoms, adjunct therapy for parkinsonism (like trihexyphenidyl). Does not help with tardive dyskinesia. D: dose range is 1-6mg/day. dose is usually 1-2 mg once a day. Dose can be BID. Usually only given for 1-2 weeks. Dr Elliott does 2mg daily. Usually effective in 1-2 days. SE: typical anticholinergic activity: constipation, nausea, tachycardia, blurry vision, other CNS symptoms.

trihexyphenidyl (artane)

anticholinergic drug used for acute dystonia. Muscarinic receptor antagonists. I: drug induced EPS symptoms, adjunct therapy for parkinsonism (like benztropine), same indications as benzatropine D: dose range is 5-15mg/day in 3-4 doses. Usually start with 1mg/day

treatment for antisocial personality disorder and conduct disorder.

antisocial: CBT. Medication is only for patients with severe aggressive behavior. FLT is atypical antipsychotic, SLT is an SSRI, then a mood stabilizer. Conduct disorder treatment is probably the same, uptodate doesn't have an article but it mentions efficacy of mood stabilizers in conduct disorder in the article for treatment of antisocial PD.

neurobiological explanation for personality disorders (according to decker)

antisocial: due to poor functioning of prefrontal cortex, which usually helps with executive function and decision making; so a decreased functioning of this area causes poor impulse control. borderline: trauma can cause epigenetic change that reduces oxytocin gene transcription and thus reduces oxytocin levels. avoidant: hyperarousable limbic system (especially amygdala) that doesn't respond well to stimuli. Also have higher cortisol levels (stress hormones). schizotypal: too much dopamine, but not enought to cause schizophrenia

most common psychiatric disorder in US (according to board vitals)

anxiety disorder

pseudocyesis. found in DSM V under Other Specified Somatic Symptom and Related Disorders

appearance of pregnancy but not pregnant; can include enlarged abdomen, breast enlargement, labor pains at expected date of delivery, and possible lab abnormalities.

nefazodone

atypical antidepressant that acts as antagonist at 5-HT2 receptor. SE: orthostatic hypotension, hepatotoxic (can be extreme), inhibits CYP 450.

Brexpiprazole (Rexulti)

atypical antipsychotic and adjunct for depression. D2 partial agonist (like aripiprazole). I: schizophrenia and adjunct for MDD. D: 1-4mg for schizophrenia dose is 1-4mg, 1mg is started for 5 days then 2mg. for MDD dose is .5-3mg, start with 1mg for 5 days and then increase to 2mg daily.

asenapine (saphris)

atypical antipsychotic that has a higher afinity for D3 and D4 receptors than D2 receptors (like clozapine). Less anticholinergic activity. I: schizophrenia, acute mania as monotherapy or adjunct to lithium or valproate. D: must be taken sublingually due to poor bioavailability on first pass metabolism. Half life 13-39 hours. 10-20mg/day in two doses for schizophrenia and bipolar.

cariprazine (vraylar)

atypical antipsychotic that is a partial agonist at D2 (like aripiprazole), D3, and 5-HT1a, and antagonist at 5-HT2a. I: schizophrenia, acute bipolar mania or mixed episodes, and bipolar depression. D: start 1.5mg, next day increase to 3mg. Normal dose range 3-6mg. Very long half life according to drug rep.

iloperidone (Fanapt)

atypical antipsychotic that is unique in MOA; mixed D2 and 5-HT2a antagonism, less effect on histamine and muscarinic receptors. I: schizophrenia SE: QTc prolongation like ziprasidone. Must be titrated slowly to prevent orthostatic hypotension

5-HT2a, 5-HT1a, D2, 5-HT2c

atypical antipsychotics block 5-HT2a receptors and are partial agonists at 5-HT1a. All also block D2 and D3 receptors (except aripiprazole and cariprazine which are partial agonists). Strong antagonists of 2c (clozapine, olanzapine) causes weight gain, which is why partial agonist at 2c (aripiprazole, ziprasidone) does not cause weight gain.

antipsychotics in pregnancy (according to me after look up womensmentalhealth.org and uptodate)

avoid giving them because of potential for adverse effects, but likelihod of adverse outcomes is low. atypical antipsychotics haven't shown any negative outcomes but there is limited data. High potency first gen are preferred to low potency first gen. The FDA now lists on its label for all antipsychotic drugs the warning for withdrawal symptoms and abnormal muscle movements (EPS) in newborns.

SSRIs during pregnancy

basically it is advised to keep giving SSRIs during pregnancy because there is no conclusive evidence that it causes any negative outcomes (malformations, pulmonary hypertension, cardiac defects). One study claimed that paroxetine caused heart defects, but follow up studies did not. Some evidence suggests that there is poor perinatal outcomes such as neonatal withdrawal syndrome (tremor, restlessness); but these usually resolve in 1-4 days without any intervention. Discontinueing SSRIs prior to delivery has shown been shown to change neonatal outcomes.

clozapine neutropenia monitoring

before starting, baseline ANC must be 1500 for general population (GP) or 1000 for BEN (benign ethnic neutropenia). If ANC between 1000 and 1500 (mild neutropenia) for GP don't stop treatment but repeat labs three time weekly. For ANC <1000 (moderate neutropenia) stop treatment and do daily lab draws until ANC >1000. Once ANC >1000 resume treatment and then labs three times weekly until >1500. For BEN with ANC between 500 and 1000, repeat labs but don't stop treatment, but stop if <500.

anticholinergic drugs. (blocks either nicotinic or muscarinic receptors. nicotinic receptors are on the postsynaptic cell body (aka ganglia) of sympathetic and PS circuits, on the adrenal medulla for sympathetic stimulation, and on striated muscle of the somatic nervous system. Muscarinic receptors are on the effector organs/tissues that receive parasympathetic stimulation.)

blocks acetylcholine in the CNS and PNS, which can be either muscarinic or nicotinic receptors. Atropine and antipsychotics are antimuscarinic anticholinergics. Antinicotinics include neuromuscular blockers like rocuronium. The effect of anticholinergic drugs usually refers to effects caused by antimuscarinic inhibition of parasympathetic activity caused by (hot as a hare, dry as a bone (dry skin and mucous membranes), red as a beet (vasodilation), blind as a bat (mydriasis, aka pupil dilation), mad as a hatter (psychogenic effects can include agitation, delirium, hallucinations)

topiramate (topamax)

blocks voltage dependent sodium channels and enhances gaba, weakly inhibits carbonic anhydrase. I: seizures and migraines D: SE: dizziness, fatigue, paresthesia, weight loss (very popular for this reason), gi upset, acute closed angle glaucoma.

MMSE (mini mental status exam) and MOCA (montreal cognitive assessment)

both are used to measure cognitive impairment, especially when diagnosing dementia. A 24 or over for MMSE and 26 or over for MOCA are considered normal. MMSE is copyrighted so often MOCA is preferred.

cholinesterase inhibitors donepezil (aricept), galantamine, rivastigmine. NMDA antagonist memantine (namenda). Donepezil may selectively inhibit AChe in the CNS, little in the periphery.

both cholinesterase inhibitors and memantine are consider mild cognitive enhancers in peeps with dementia. They do not delay or slow disease course. cholinesterase inhibitors usually given earlier in disease course. SE of both: GI upset.

chlordiazepoxide (librium), diazepam (valium)

both have half lifes around 30 hours but have an active metabolite that lasts for almost 100 hours. Diazepam has rapid onset of action. D: chlordiazepoxide 5-25mg, 10 mg is comparable to 1mg alprazolam. Diazepam is 2-10mg, 5mg is comparable to 1mg alprazolam. Diazepam has IV form that is twice as potent (so use half dose of oral equivalent).

propofol (diprivan), dexmedetomidine (precedex)

both sedatives. propofol acts on GABA like a benzo. dexmedetomidine is an A2 agonist like clonidine.

botulin toxin, botulism (appears many times on the PRITE evidently)

botulin toxin inhibits acetylcholine release from presynaptic terminals, thus inhibiting both nicotinic and muscarinic receptors.. Botulism presents with autonomic symptoms (from muscarinic inhibition) of blurred vision, unreactive pupils, diplopia, dry mouth, nausea, vomiting. Causes weakness of bulbar muscles (CN , 10, 11, 12), causing hoarse voice, neck weakness, dysarthria.f

Heinz Kohut

came up with "self psychology" and mirroring.

steroid (systemic glucocorticoid) psychosis

can cause almost any psychiatric symptom, including delirium, mania, depression, psychosis, etc. Symptoms are more likely with increased doseage and length of treatment (Dr. Elliott says dosages of prednisone 60mg and above are much more likely). Severe psychiatric symptoms usually occur a few days of high dose glucocorticoids.

paraphilic disorders. Include voyeuristic disorder, exhibitionistic disorder, Frotteuristic disorder (rubbing against or fondling nonconsenting person), sexual masochism disorder, sexual sadism disorder, pedophilic disorder, fetishistic disorder, transvestic disorder, other specified and other unspecified paraphilic disorders.

cause sexual arousal over 6 months. Usually must involve a nonconsenting person or cause clinically significant distress or impairment. If diagnosis requires a person to have distress or impairment then the diagnoses cannot be made unless the patient admits the symptons, unlike diagnoses that require nonconsenting people like exhibitionistic disorder where the nonconsenting person is evidence for diagnosis.

thyrotoxicosis, hyperthyroidism, thyroid storm

causes accelerated HR, can cause anxiety, agitation, depression, psychosis. Initial symptomatic treatment is with beta blocker to control HR. I'm guessing antipsychotics if needed?

cannabis/marijuana

causes dopamine release in mesolimbic pathway

difference between childhood schizophrenia according to prite

child onset is slower onset and is more likely to be chronic.

sigmund freud

classical or structural theory, founder of psychoanalysis.

vitamin B12 (cobalamin) or folate deficiency symptoms

classically cause gait abnormalities, paresthesia or numbness. Does not cause confusion (unlike wernicke). This is thought to be due to the role of folate/B12 in myelin, and a lack causes degeneration of the dorsal and lateral columns of the spinal cord. B12 deficiency will cause high methylmalonic acid because B12 is a necessary coenzyme for metabolism of methylmalonic acid. Can be caused by nitrous oxide (N2O) abuse.

risperidone (risperdal)

considered by dr fig to be a bridge between typical and atypical antipsychotics. I: schizophrenia, bipolar, irritability associated with autism. OL for bipolar depression, behavioral disturbances in dementia, children, and adolescents, disorders associated with impulse control. D: .5-2mg/day for children and elderly, 2-8mg/day for acute psychosis and bipolar. Depot form available and is 12.5-50mg/two weeks. SE: highest likelihood of hyperprolactinemia (along with paliperidone) among both typical and atypical antipsychotics.

sleep cycle changes in MDD

decreased REM latency (shorter time to get to REM sleep, REM maybe starts 45 minutes after falling asleep compared to normally taking 90), increased REM sleep, decreased stage IV sleep.

acute intermittent porphyria

defective enzyme causing buildup of porphobilinogen, causes; painful abdomen, port wine colored urine, polyneuropathy, psychogenic disturbances, possible seizures. Precipitated by drugs, alcohol, starvation. Psychogenic features include anxiety, agitation, hallucinations, delirium, depression, AMS.

service animal

defined by the american with disability act of 1990. Animals do not require any training from a licensed group or authority, they do not require documentation or a vest that identifies them as a service animal. Employees are only allowed to ask if the dog is a service animal and what the dog has been trained to perform. The animal must be trained to perform a specific function to treat a disability, not just be of general comfort, as opposed to emotional support animals. However its possible that an animal could be considered a service animal for someone with anxiety or mental disorder if they have been trained to perform a specific job to help with the anxiety/mental disorder.

world health organizsation #1 cause of loss of years of healthy life as measured by disability adjusted life years for people ages 15-40? What condition causes greatest economic burden of chronic disability among mental health disorders?

depression. The leading cause for all ages is heart disease and depression is number two. According to Prite, the greatest economic burden of chronic disability among mental health disorders is schizophrenia. Board exam book says anxiety is the most prevalent mental health condition in the US and is more common than depression. Prite says that depression is most common comorbid mental health diagnosis for most mental health conditions.

Progressive Supranuclear Palsy

deterioration of certain areas of the brain that cause loss of balance/falls, muscular rigidity/bradykinesa, and saccadic movements (quick movements by both eyes) impaired, especially in vertical gaze, pseudobulbar palsy (inability to control facial movements), often dementia is present. No known cause.

dextromethorphan/quinidine (nuedexta)

dextromethorphan is an NMDA antagonist, opioid receptor agonist, and others. Quinidine is an antiarrhythmic which is part of the combo because it inhibits CYP2D6 which breaks down dextromethorphan, thus inhibiting degradation. I: PBA, OL for diabetic peripheral neuropathy, unstable mood and affect in PTSD and mild TBI. D: 20mg/10mg BID SE: dizziness, NV, cough, euphoria. Rare but dangerous SE are thrombocytopenia, hepatotoxicity, QTc prolongation. Do not give with MAOs, which can cause serotonin syndrome due to CYP2D6 inhibition.

Confusion assessment method (prite says it is the easiest to use for initial assessment of delirium in the geriatic population)

diagnosis of delirium requires criteria 1 and 2, plus 3 or 4. 1. acute onset and fluctuating course. 2. inattention 3. disorganized thinking 4. altered level of consciousness.

capacity and competency

different but overlapping. Capacity is a person's ability to make a medical decision. Competency is a legal judgement, often guided by an assessment of capacity, that determines one's legal right to make a decision.

Juvenile myoclonic epilepsy

disorder between ages 12-18 that causes generalized seizures and sudden jerks of entire body, can also cause tonic-clonic seizures and absence seizures. EEG often shows 4-6 Hx irregular polyspike/wave bursts. Treat with valproic acid.

ropinirole (truelearn has so many questions on it)

dopamine agonist at D2 and D3 receptors. I: parkinson's and restless leg syndrome. SE: sedation, hallucinations, GI upset, headache, dyskinesia, edema., orthostatic hypotension.

benzodiazepine equivalent dose chart

downloaded but not uploaded here

Interferon

drug treatment for hepatitis C that can cause depression (on the Prite).

when to give QTc prolongation drugs

drugs such as ziprasidone that are known to have QTc prolongation can be given unless QTc over 500ms according to uptodate, 550 according to maya from Mass general psych program. Maya also says that more caution should be had in patient with bradycardia than normal rate or tachycardia because supposedly bradycardia is more likely to convert to convert to torsades de pointes (aka polymorphic ventricular tachycardia) than tachycardia, but this is all according to maya. Darron said cardiologist said to not give if QTc >500.

hypothyroid, myxedema psychosis

dx: high TSH (most labs have upper limit between 4 and 5) and low T4. tx: levothyroxine (t4) until TSH is normalized. Myxedema psychosis is a rare form of untreated hypothyroidism that can progress to dementia, delirium, hallucinations, psychosis, coma.

lewy body dementia (dementia, visual hallucinations, parkinson's symptoms)

dx: mainly clinical, but imaging such as MRI can be helpful. tx: behavioral therapies mainly. an AChe inhibitor like donepezil can be given for dementia. Antipsychotics and levodopa are only given for disabling psychotic symptoms or disabling parkinson's symptoms.

anna freud

ego psychology: the important of ego in development

erik erikson theory of development, the age ranges differ based on source, these age ranges are from prite ninja, wikipedia has different ones but also gives time periods generic names (in parenthesis).

eight stages that involve two competing forces, if the individual reconciles these two forces then a specific attribute is developed. trust vs mistrust (infancy) 0 - 18 months: hope autonomy vs shame; (toddler)18 months - 3 years: will initiative vs guilt: (early childhood) 3 - 5 years: purpose industry vs inferiority (middle childhood) 5 - 13 years: competence identity vs role confusion: (adolescence) 13 - 21 years: fidelity intimacy vs isolation: (early adulthood) 21 - 40 years: love generativity vs stagnation: (middle adulthood) 40 - 60 years: care integrity vs despair: (late adulthood) 60 - death: wisdom

capacity

evaluates 1. understanding, 2, expressing a choice, 3, appreciation, 4, reasoning. understanding: understanding the treatment is being offered (drug, surgery, etc). expressing: able to express their decision appreciation: understanding how the treatment applies to the patient. reasoning: weighs the treatment vs not having the treatment.

Ganser syndrome. previously classified as a factitious disorder that was listed in DSM IV under dissociative disorder NOS. Not found in DSM V

factitious disorder characterized by vague answers, pseudo hallucinations, amnesia, decreased consciousness. Also referred to as prison psychosis.

specific phobia

fear or anxiety about something like flying, or a type of animal, etc. Most phobias cause arousal response, but blood, injection, or injury phobias cause vasovagal response with decreased HT and BP. tx: CBT with in vivo exposure is FLT. If CBT isn't possible, benzos can be given.

social anxiety disorder (social phobia)

fear, anxiety and avoidance of social situations, usually for >6 months. A specifier is permormance only, where the fear is specific for speaking or performing. tx: monotherapy with pills (SSRIs) or CBT is just as effective as both according to uptodate.

treating akathisia from EPS

first option is trying to lower dose. FLT is beta blockers like propranolol, 2nd best is benzos.

CYP2D6 and SSRIs

fluoxetine is a potent inhibitor, sertraline inhibits somewhat, fluvoxamine has least inhibition of 2D6 among SSRIs, escitalopram has little inhibition of 2D6 and other CYP enzymes.

treatment of MDD success rates

for treatment resistant depression ECT works 53% and TMS 32%. SSRIs are about 40% effective as initial treatment.

clearance for surgery

for young healthy peeps almost nothing needs to be done. In general, testing such as ECG, blood tests, etc, are discouraged due to false positives and research showing no improved outcomes. Unless there is a preexisting condition like hx of MI or COPD, nothing is done. Any tests that are done are tests that should be done whether or not the person will have surgery, and not due to investigation of surgical risk. For cardiac concerns, RCRI (revised cardiac risk assessment) should be done and peeps with high risk should have further evaluation. Even an ECG is not indicated unless the patient has a hx of cardiac problems and even then the ECG is mainly done to provide a baseline in the event of perioperative abnormal findings.. Pulmonary workup only necessary for stuff like COPD or sleep apnea. Blood counts and electrolytes are not generally taken.

when to switch to a different antidepressant

full effect of SSRIs take 8-12 weeks. If no improvement in symptoms by week 4 then switch.

gender identity age (according to prite). definitions of terms

gender identity is recognized at age 3. gender identity: one's view of their own gender. gender expression: one's behavior or appearance that they choose to associate with a gender (usually the same as gender identity). sexual orientation: who a person is attracted to (heterosexual, etc).

catatonia treatment

give 1 or 2mg lorazepam (ativan) IV, which also helps with diagnosis. If there i no change than 2nd dose can be given; change usually occurs within 5-10 minutes. Symptomatic treatment is also given (for HTN, hyperthermia, etc). For malignant subtype benzos plus ECT is FLT. For other subtypes start with lorazepam 1-2mg TID and the dose is increased by 3mg/day every one or two days. Dose range per day is 6-21mg, but can be as high as 30mg. Duration of treatment for full remission of symptoms is 4-10 days, and then the effective dose is continued for 3-6 months to maintain recovery and then slowly tapered. ECT is second line. Antipsychotics are CI during treatment.

when to give SSRI/SNRI (whether it makes you sleepy or interferes with sleep)

give in the morning: fluoxetine, venlafaxine night: paroxetine, duloxetine, citalopram, escitalopram doesn't matter: sertraline

Quetiapine (Seroquel)

has an active metabolite norquetiapine. Has greater affect on D1 and D4 receptors and less on D2 receptors. I: schizophrenia, bipolar mania, bipolar depression, ER form can be used as adjunct for depression. OL: often used for psychosis in parkinson's due to minimal EPS symptoms. D: short half life of 6-7 hours means that IR form must be dosed BID for psychosis, but usually daily for everything else. XR form available. For bipolar depression start at 50mg/day and increase 50-100 per day, therapeutic dose usually 300mg/day but can go up to 600mg/day. 400-800mg/day for schizophrenia and bipolar mania. SE: sedative effect is significant and can be utilized. Minimal QTc elongation. CATIE study showed less weight gain than. Long term use of low doses will not cause EPS according to attendee.

coliseum alcohol withdrawal protocol

heavy phenobarbital protocol: 120mg initially, 30mg BID and 60 qhs for 3-5 days. 60mg phenobarbital and 50mg chlordiazepoxide are PRNs. Light phenobarbarbital: Half of heavy. 60 inital, 15mg BID, 30mg qhs. heavy chlordiazepoxide: 6 days taper, day 1 is 50mg QID (x 4 doses), day 2 is 50mg TID, day 3 is 25mg QID, day 4 is 25mg TID, day 5 is 25mg BID, day 6 is 25mg qhs. light chlordiazepoxide: days 1 and 2 25mg QID, days 3, 4 are 25mg TID, day 5 25mg BID, day 6 25mg qhs.

fluphenazine (prolixin)

high potency antipsychotic, I: psychotic disorders D: PO is 1-20mg/day, IM is 1/3 to 1/2 the PO dose. Decanoate is ER IM injection, 12.5 - 100mg/two weeks. half life of PO is 16 hours, of IM is 7 hours. SE: Same as all antipsychotics but less risk of sedation and orthostatic hypotension, but increased EPS compared to low potency antipsychotics. Stop treatment if ANC (absolute neutrophil count) <1,000.

Thiothixene (Navane)

high potency antipsychotic. I: schizophrenia D: range is 15-60mg/day, usually start with 5-10mg dose. SE: high risk of EKG changes

metabolic risk for atypical antipsychotics. SE for atypical. All atypicals are antagonist at 5-HT2a and partial agonist at 5-HT1a

high risk: clozapine, olanzapine medium: risperidone, paliperidone, quetiapine, iloperidone. low: ziprasidone, aripiprazole, lurasidone, asenapine, brexpiprazole

specific EEG wave types

hypsarrhythmia: chaotic and unorganized pattern seen in infantile spasms. PLEDs (periodic lateralizing epileptiform discharges): seen in HSV encephalitis and seizures (hence the name). triphasic sharp waves: hepatic or metabolic encephalopathy, or creutzfeldt-Jakob disease. burst-suppression: seen in anoxic brain injury. Creutzfeldt-Jakob disease also has periodic sharp waves (similar to triphasic sharp waves).

brexanolone (Zulresso)

identical to endogenous allopregnanolone, which is derived from progesterone and acts of GABA. Work over the course of the 60 hours (2.5 day) infusion. I: Post partum depression (first drug approved specifically for this). SE: sleepiness, dry mouth, loss of consciousness

other conditions that may be a focus of clinical attention

last section of DSM V. Many of the codes in this section are V codes and Z codes, including malingering. V codes are ICD-9 codes and Z codes are ICD 10 codes.

periodic limb movement disorder

legs move randomly during sleep, the patient are unaware.

seizure management

if an initial seizure is not provoked (from toxic or metabolic conditions) then uptodate says that starting antiseizure medication doesn't help much. Uptodate says that it reduces the risk of another seizure within two years but does not change the course of the condition after year two. For acute management, if someone is having seizure for longer than two minutes then it should be treated.

when to try another antipsychotic in new onset schizophrenia, other interventions.

if there is no noticeable change or minimal change in symptoms after two weeks than try a different antipsychotic. If there is some change after two week than there is likely to be further improvement after two more weeks. article https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6180374/ In the studies of this meta-analysis the titration to a target dose was 3 days (pretty fast). PRITE says that "cognitive remediation" has the most evidence for treatment of schizophrenia during recovery or chronic phase of schizophrenia.

neurotransmitters and aggressive/violent behavior

in aggressive/violent behavior a correlation has been seen with low serotonin levels and increased dopamine levels.

DSM note on distinguishing grief (bereavement) from MDD. Normal grief can last 6-12 months.

in grief the predominant feelings are emptiness and loss but may have positive emotions and humor, in MDD they are depressed mood and inability to anticipate happiness or pleasure. Dysphoria in grief likely decreases over time and occurs in waves due to reminders of decease. In grief the person focuses on the deceased, in MDD the focus is on self, often of worthlessness. Thoughts of death during grief are focused on joining the deceased, in MDD thoughts of death are due to own worthlessness.

Depressive disorders in DSM

include DMDD, MDD, persistent depressive disorder, prementstrual dysphoric disorder, Substance/medication induced depressive disorder, Depressive disorder due to another medical condition, other specified and unspecified depressive disorder.

obsessive-compulsive and related disorders

include OCD, body dysmorphic disorder, hoarding disorder, trichotillomania, excoriation disorder, substance/medication-induced obsessive compulsive and related disorder, etc

feeding and eating disorders

include pica, rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, binge-eating disorder, other specified (including purging disorder and night eating syndrome) and unspecified.

Cognitive testing

includes testing of executive functioning, visuomotor coordination, receptive and expressive language.

Unspecified Intellectual Disability (Intellectual Developmental Disorder)

individuals over 5 years old that can't be adequately diagnosed with standardized testing because of blindness, prelingual deafness, locomotor disability, or presence of severe problem behaviors or co-occurring mental disorder. This category "should only be used in exceptional circumstances and requires reassessment after a period of time".

CYP 450 3A4

inducers are barbiturate, AED (antiepileptic drugs except VPA and lamotrigine), smoking, rifampin and St John's wort. Inhibitors are everything else that affects CYP 450 3A4, including VPA, grapefruit juice, cimetidine. Among SSRIs citalopram and especially escitalopram have least CYP interaction. Estrogen is a substrate.

phencyclidine (PCP, angel dust)

inhibits NMDA receptor. Synthetic substance. A dissociative agent (causes "out of body" experience). Symptoms are violence/belligerance, nystagmus, ataxia, seizures. Chronic use can cause memory loss and depression. NMDA receptor activation is excitatory, and overactivation can cause seizures (even tho inhibition can also cause seizures).

ketamine, esketamine (Spravato)

inhibits NMDA which causes release of glutamate. Also a dopamine agonist. I: esketamine for adjunct treatment with SSRI of treatment resistant depression. D: for IV, .5mg/kg over 40 minute infusion. Esketamine is IN (intra nasal) and induction phase is 56mg twice a week for 4 weeks, then maintenance phase for 4 weeks with dosing once a week of 56mg or 84mg, then dosing once a week or every two weeks. SE: drowsy, dizzy, blurred vision, headache.

disulfiram (antabuse)

inhibits enzyme acetaldehyde dehydrogenase, which converts acetaldehyde to acetyl coenzyme A. This buildup of acetaldehyde causes awful symptoms of flushing, headache, nausea, etc. I: maintenance of alcohol abstinence. D: 250-500mg/day SE: the above mentioned symptoms if alcohol is used. Also can cause metallic taste, dermatitis, sedation, hepatotoxicity, MI, CHF. Not recommended for peeps >60 or those with pulmonary disease, renal failure, DM, peripheral neuropathy, seizures, cirrhosis, or portal hypertension.

MAO (monoamine oxidase) inhibitors. Inhibits breakdown of NE, serotonin, dopamine, epinephrine, tyramine (tyrosine is precursor to dopamine, NE, epinephrine. Tryptophan is precursor to serotoin).

inhibits monoamine oxidase which usually breaks down NE, serotonine, and dopamine, thus increasing levels of those. Tranylcypromine, Phenelzine, and Isocarboxazid are non selective, meaning they inhibit MAO-A and MAO-B. Selegiline and Rasagiline selectively inhibits MAO-B only. I: depression. Selegiline also indicated for adjunct with carbidopa/levodopa for Parkinson's. D: 14 day washout period (14 days between doses) if switching from an SSRI to MAOI, and 10-14 if switching from MAOI to SSRI (5 weeks for fluoxetine). Transdermal selegiline prevents tyramine buildup. SE: hypotension, insomnia (stimulant effect), weight gain, edema, sexual dysfunction. Hypertensive crisis can occur if consuming foods with tyramine (alcohol, aged cheeses and fish). Some say only red wine is harmful, not all alcohols. Treat with alpha blockers first (like pheochromocytoma or cocaine OD) CI: Sooo many: SSRIs, TCAs, antihistamines, stimulants, sympathomimetics, buspirone, opioids (especially meperidine), levodopa. A patch is available to avoid dietary restrictions.

cocaine

inhibits reuptake of serotonin, NE, and dopamine. Can cause pupillary dilation along with other stimulants.

Donald Winnicott

invented the term "good enough mother (or parent)", which means that a parents gives the child a background to grow without smothering them. This allows them to fail (disillusionment) but strengthens long term ability.

female sexual interest/arousal disorder

lack of interest in sex, lack of sexual thoughts, reduced initiation in sexual activity, and reduced sexual excitement during sex. Flibanserin is indicated.

transcranial magnetic stimulation (TMS)

less effective than ECT for treatment of depression. Targets left dorsolateral prefrontal cortex. Sometimes preferred over ECT because it does not require anesthesia and may have less cognitive SE. Treatment course is usually 5 days a week for 4-6 weeks. Individual sessions last 30 minutes. There are multiple types of TMS, but only repetitive TMS is FDA approved for treatment resistant depression. I: treatment resistant unipolar depression. Absolute CI: psychosis, active SI, epilepsy, any metal within 30cm of TMS site (aneurysm clips. cochlear implants, bullet fragments, etc), many others. SE: site pain, headache, anxiety, seizure (.1%), tongue injury. Induced seizures are very rare. There is some concern about inducing manic episodes.

long term memory: explicit (declarative) and implicit

long term memory is made up of explicit and implicit memory. explicit (declarative): consists of episodic (specific events) memory and semantic (recall of facts) memory. implicit (non-declarative): procedural memory such as muscle memory like riding a bike.

chlorpromazine (thorazine)

low potency antipsychotic I: schizophrenia, manic episodes of bipolar, nausea and vomiting, restless and apprehension prior to surgery, acute intermittent porphyria, adjunct of tetanus treatment, hiccups, combativeness or explosive hyperactivity in children 1-12 yo. D: 200-800mg/day. Half life is 30 hours so dosing is daily. SE: EPS symptoms (acute dystonia, TD, parkinsonism, akathisia), galactorrhea, dizziness, sedation, dry mouth, constipation, weight gain, NMS.

antipsychotic classes

low potency first generations: chlorpromazine, prochlorperazine, thioridazine. medium potency: perphenazine high potency first gen: haloperidol, fluphenazine, pimozide, thiothixene. 2nd gen (atypicals): aripiprazole, asenapine, cariprazine, clozapine, iloperidone, lurasidone, olanzipine, quetiapine, paliperidone, risperidone, ziprasidone

drugs not used or not available in US

loxapine: typical antipsychotic, supposedly available in pill form, aerosol powder inhalation form available. Reboxetine: NE reuptake inhibitor not available in US.

laxatives

magnesium citrate: tablets are 100mg. 200mg -300mg (2-3 tablets) PO in single dose or divided. Or take 2-4 tablets QHS

AIMS (abnormal involuntary movement scale)

measures abnormal movements. The APA recommends doing it once every 6 months for typicals and 12 months in atypicals, or 3 and 6 months for individuals of increased risk.

perphenazine (trilafon)

medium potency antipsychotic I: schizophrenia, treatment of severe nausea/vomiting. D: 4 to 8mg PO TID initially for moderately disturbed outpatients; reduce as soon as possible to minimum effectie dosage. For hospitalized psychotic patients, 8 to 16mg PO initially 2-4 times daily. Lower doses recommended for geriatric patients. After the dose is stabilized it may be given as a single nighttime dose or in 2 divided doses (1/3 in the morning, 2/3 at bedtime) to improve compliance.

more terms

mens rea: evil intent actus reus: voluntary act

Neuroleptic malignant syndrome (NMS)

mental status change, fever, rigidity (but not myoclonus), unstable vitals, diaphoresis, and dysautonomia. Associated with use of antipsychotics (neuroleptics). D: labs and brain imaging done to rule out other diagnoses. Imaging usually normal. Labs usually show elevated creatine kinase level (from rigidity) and leukocytosis, but those aren't used for diagnosis. T: treatment is mainly supportive, most cases resolve after stopping antipsychotics. Stop antipsychotic medicine and give IV fluids first. Dantrolene, bromocriptine (dopamine agonist), amantadine and lorazapam can be given but should be case by case basis because use is controversial. If hyperthermic, use ice packs, evaporative cooling, and cool IV fluids.

dopamine projections (pathways of dopamine)

mesolimbic: excess DA responsible for positive symptoms of schizophrenia. mesocortical: D2 block worsens negative sympoms of schizophrenia nigrostriatal: lack of DA causes parkinsonian symptoms (rigidity, bradykinesia, tremor), excess causes chorea, dyskinesia. tuberoinfundibular: DA in this pathway normally inhibits prolactin release, so a lack of DA causes excess prolactin.

opioid induced constipation

methylnaltrexone (relistor): peripheral opioid antagonist. subcutaneous form is best according to one article https://www.ncbi.nlm.nih.gov/books/NBK493184/ 450mg PO qd. naloxegol (Movantik): peripheral opioid receptor antagonist. lubiprostone (Amitiza): type 2 chloride channel activator that increases fluid secretion in GI tract.

seizure augmentation

missed or inadequate seizures at maximum stimulus intensity requires lowering the seizure threshold or improving the duration of seizures. Switch to methohexital or ketamine, decrease anesthetic dose, caffeine (and other adenosine receptor antagonists), hyperventilate. Caffeine and hyperventilation increase seizure duration but not threshold.

sublocade (buprenorphine)

monthly injectable buprenorphine. A patient is first given a 7 day course of oral buprenorphine to evaluate tolerability. The 300mg injections are given for the first two months, then 100mg monthly. Dose may be increased to 300mg monthly if desired. up to a two week delay in dosing shouldn't greatly affect treatment; the next dose is no less than 26 days later despite how delayed the former dose. If an injection needs to be given to cover two months then 300mg can be given, then 100mg monthly can be resumed later.

paroxetine (paxil)

more sedating than other SSRI's, also preferred for anxiety. It has weak NET (norepinephrine transporter, a reuptake transporter) inhibitory affect, also has muscarinic anticholinergic activity. Due to small sedation affect it can be more calming, especially early in treatment, and is preferred by some for treating anxiety. Also inhibits nitric oxide synthetase which can cause sexual dysfunction in men. Notorious for causing withdrawal symptoms such as akathisia, GI symptoms, dizziness, and tingling. D: 20-50mg, half life is 21 hours. SE: shorter half life than most SSRIs (maybe fluvoxamine is shorter) and most likely to have withdrawal syndrome.

fluoxetine (prozac)

more stimulating compared to other SSRIs, causing an energizing and fatigue-reducing affect. Indicated with olanzapine for bipolar depression and treatment resisent MDD. D: 10-80mg, half life is 2-3 days. In addition to SSRI activity it blocks 5-HT2c activity which disinhibits release of NE and DA.

M'Naghten rule

the rule that in order to be not guilty for a crime due to mental illness a person must not have understanding of what they are doing while they are committing the crime.

night eating syndrome, SRED (sleep related eating disorder)

night eating syndrome is a specifier of other specified feeding or eating disorder in DMS-V; and is eating at night with memory and recall of the event. SRED is not in DSM but is ICSD (international classification of sleep disorder); peeps have no recollection of eating and may only see evidence in the kitchen in the morning. Often attributed to zolpidem The difference between these is that in SRED the patient has no memory of eating, which makes sense because SRED is a sleep disorder.

Vitamin D and depression

no evidence for its use in depression. uptodate says nothing about testing for it for evaluation of depression, but does say that in trials where peeps with depression were given vitamin D supplements it didn't help.

sleep aids

nonbenzodiazepine hypnotics: act on the GABA receptor (like benzos) such as zolpidem (ambien), zaleplon (sonata), zopiclone (imovane), eszopiclone (lunesta). RaMELteon (rozerem): agonist at melatonin receptors. SuvOREXant (belsomra): antagonist at orexin receptors. Orexin maintains wakefullness. Lemborexant (dayvigo): similar to suvorexant, antagonist at orexin receptors. daridorexant (quviviq): antagonist at orexin receptor. dose is 25-50mg.

Mahler's milestones of development

normal autism: birth - 2 months. symbiosis: 2 - 5 months the child thinks that he and the mother are one. differentiation: 5 - 10 months, begins to distinguish self from mother. practicing: 10 - 18 months, child begins to move independently and explore. rapprochement: 18 - 24 months, the child can stray from mom but comes back for reassurance. object constancy: 2 - 5 years, the child understands the permanence of other people, even when they are not present.

anosognosia

not being aware of one's disability. Such as a person who becomes blind but has confabulations because they aren't aware of their own blindness.

melanie klein

object relations theory: the childhood development of a psyche in relation to others in a childhood development.

structured clinical diagnostic assessments

objective tests that give a numerical score to show the severity of an illness. including: Beck Depression inventory (best to screen for depression), Hamilton Rating scale for Depression (Ham-D), Yale-Brown Obsessive-compulsive scale.

obsessive-compulsive disorder (OCD). Obsessions are defined by 1 and 2. 1 recurrent and persistent thoughts, urges, or images that are intrusive and unwanted and cause most individuals marked anxiety and or distress. 2 the individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., performing a compulsion). Compulsions are 1 repetitive behaviors (e.g, hand washing), or mental acts (praying) that the individual driven to perform in response to an obsession, and 2 the behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded situation; however these behaviors or mental acts are clearly excessive

obsessions or compulsions that are time consuming and cause clinically significant distress or impairment. Supposedly associated with group A streptococcal infections. PRITE says it is associated with hyperactivity in circuit involving orbitofrontal cortex, basal ganglia, and thalamus. A: Presence of obsessions, compulsions (actions, behaviors or rituals), or both. B: the obsessions or compulsions are time-consuming (e.g., take more than an hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. C: the obsessive-compulsions are not due to substance or medical condition. D: not better explained by another mental disorder (e.g., excessive worries, as in generalized anxiety disorder, ritualized eating as in eating disorders, etc) tx: CBT/exposure therapy and/or pharmacotherapy (such as SSRI or clomipramine). After an SSRI then try clomipramine or venlafaxine. Antipsychotics that have shown success include risperidone and ziprasidone. Ivania likes lamotrigine. Cingulotomy is also an option.

tardive dyskinesia (TD)

occur usually after 6 months of antipsychotic treatment or metoclopramide. Causing repetitive involuntary movements such as lip smacking, tongue movement, grimacing, choreiform movement or extremities. If symptoms are mild then treatment may not be necessary. Stopping the causative drug is preferred but not always possible (psychosis needs treatment). Switching to atypical antipsychotic can be done; clozapine is ideal but requires blood testing, quetiapine is an option. Peeps with TD and anxiety can be given benzos. Persistant TD can be given valbenazine, tetrabenazine, or deutetrabenazine. A last option for severe/disabling TD is starting a first or second generation antipsychotic.

escitalopram (lexapro)

only the S enantiomer of citalopram. causes less QTc elongation. Aproved for MDD and GAD. Has pure SERT (serotonin transporter) inhibition. Well tolerated because it has little CYP450, 2D6, or 3A4 interference. ECG advised in patients with heart conditions. D: Maintenance dose range is 10-20mg/day (because it is the active half of citalopram). Dose of 30mg often used for depression, doses up to 60mg have been used for OCD and body dysmorphic disorder. Slightly activating. SE: sexual dysfunction (but less than other SSRIs), GI upset, insomnia (activation), sedation, QTc elongation.

operant conditioning, positive/negative reinforcement, positive/negative punishment.

operant conditioning is when a behavior is encourages via positive or negative reinforcement, or discouraged via positive or negative punishment. positive reinforcement: reward a rat with food to push a lever. negative reinforcement: removal of a negative stimulus, like turning off a loud annoying sound if the rat pushes the lever. positive punishment: pain from a spanking (added stimulus), which decreases the behavior. negative punishment: taking away a child's toy (removal of stimulus) if they do a certain behavior, which decreases the behavior.

buprenorphine (subutex was brand name but was discontinued once generic came out, generic still available), buprenorphine/naloxone (suboxone, suboxone SL tablet discontinued but SL strip still available, zubsolv is SL tablet). Dosing instruction found at suboxonerems.com.

opioid partial agonist. Labelled for opioid use disorder and chronic pain (same as methadone). D: day 1 of induction start with 2-4mg and increase by 2-4mg every two hours with a max of 8mg. day 2 may increase up to 16mg. Maintenance dose may be up to 24mg according to website, but medscape says 32mg, uptodate says doses greater than 24 have been used but are not clinically effective. 2nd chance treatment dose one week f/u initially for maybe 6 months (not sure) and then two week appointments afterwards.

choosing SSRIs and SNRIs for GAD (generalized anxiety disorder)

they are all the same, with response rates 60-70% versus 40% for placebo

flibanserin

partial agonist at 5-HT1a, less antagonist activity at 5-HT2a, with other lesser activity at other serotonin and dopamine receptors. Only drug indicated for hypoactive sexual desire disorder which in DSM V is now female sexual interest/arousal disorder.

EEG findings in seizures and other conditions

partial complex: spikes and polyspikes and waves, usually over both temporal region. absence: bursts of 3 hz spike and wave complexes. tonic-clonic: spikes, polyspikes, and occasional slow waves. delirium: generalized slow wave activity of theta and delta waves.

illness anxiety disorder (previously hypochondriasis)

persistent worrying of at least six months of one's health with only mild or no symptoms. A: preoccupation with having or acquiring a serious illness. B: mild or no somatic complaints. C: high level of anxiety around health. D: excessive health-related behaviors such as repeated checking or maladaptive avoidance. E: present for 6 months. F: not better explained by another disorder. tx: goal is to treat coping with health fears rather than eliminating them. FLT is scheduling regular visits, patient reassurance. SLT is psychotherapy, especially CBT. 3rd line is antidepressants.

arizona PMP/PDMP

prescribers who prescribe an opioid or a benzodiazepine must get a report from from the PMP monitoring website on starting the medication and at least quarterly while the medication is being prescribed.

serum prolactin levels in seizures

prolactin levels increase for about 10-20 minutes following a seizure

purging disorder

purging behavior such as induced vomiting, laxatives, etc, to change weight or shape. Binge eating is not present (which would make it bulimia). vomiting can cause hypokalemia.

trauma and stress related disorders

reactive attachment disorder, disinhibited engagement disorder, PTSD, acute stress disorder, adjustment disorder, other specified and other unspecified

jean baker miller

relational theory: the idea that deep understanding of other people in relationships leads to better relationship; supposedly this theory is aligned with social justice movement.

abreaction

reliving an experience to purge it of it's emotional excess. Similar to catharsis.

Pharmacokinetics (distribution and metabolism of drugs) in geriatrics. Pharmacodynamics is physiological effects of drugs on the body.

renal function decreases in elderly (probably most significant factor in ageing). hepatic function also decreases. Body fat percentage increases in elderly causing longer elimination half life of lipophilic drugs. Absorption remains the most stable with age.

Freud's id, ego, super-ego

represented by the iceberg model by freud. Id: a person's basic instinctual drive ego: helps redirect the id's drive into a longer lasting and practical direction. super-ego: conforms behavior to fit social and legal expectations.

transverse myelitis

resembles guillain-barre. Postviral or post vaccine autoimmune reaction affecting spinal cord and causing both UMN and LMN effects. Causing motor and sensory deficits, can affects bowel/bladder incontinence. MRI often showes lesions. Often occurs before multiple sclerosis. Guillain-barre only causes LMN effects and doesn't affect bowel/bladder.

hepatic encephalopathy

reversible neuropsychiatric abnormalities in patients with liver dysfunction and/or portosystemic shunting. Occurs in 30-45% of peeps with cirrhosis. Symptoms range from subtle deficits in attention, memory, and reaction time to mood changes, confusion, coma. Neuromuscular manifestations include bradykinesia, rigidity, myoclonus, asterixis. Can less commonly causes focal neurological deficits like hemiplegia. Dx: maybe diagnosis of exclusion. ammonia levels aren't helpful, this can be diagnosed with out without elevated ammonia levels. Diagnostic workup includes evaluation for precipitating factors such as hepatotoxins like medication or alcohol, GI bleeds, or infections. tx: treating precipitating factors. Lower ammonia with lactulose (acidifies the urine and causes excretion of NH4+), lactitol, rifaximin (kills intestinal bacteria).

scheduled drugs

schedule I: drugs of abuse with no medical purpose, not prescribed. Heroin, LSD. schedule II: High potential for abuse; opioids, amphetamines. Prescription must be original or faxed. No refills allowed, but three prescriptions at once may be given to allow a 90 day supply. III: may be communicated orally, original, or faxed. Includes Ketamine. anabolic steroids, buprenorphine. IV: Control methods same as III; includes benzodiazepines, benzo-like hypnotics like zolpidem, tramadol. V: Same control methods as III and IV; includes pregabalin.

schema

schema: a pattern of thought or behavior.

Mental disorder most likely to be inherited

schizophrenia (according to Focus book)

attachment theory, developed by John Bowlby

secure attachment: a child will explore freely when the mother is present. a child is somewhat upset when a mother leaves and calm when she returns. insecure attachment: a child will cry when mom leaves and continue to be upset when mom comes back.

determining inadequate seizures

seizure length should be 20 seconds of motor activity and 25 seconds on EEG. First assess if there was a motor seizure (by looking at the leg with the blood pressure cuff on it) because if there is a motor seizure then EEG will def show seizure activity; but sometimes stimulus barely above threshold will show EEG seizure but no motor seizure which indicates an inadequate seizure. If there is no seizure at all then wait 20 seconds before giving another stimulus. If there is a seizure but it is inadequate, wait 60 seconds before giving another.

treatment for prolonged seizures

seizures should be 20 - 120 seconds. 3 minutes is a prolonged seizure (even if its only evident on EEG). For this give midazolam 1-2mg IV or another benzo, then wait for 2 minutes while monitoring EEG; if it hasn't stopped then give another benzo dose and wait for two minutes. If they're still seizing then give phosphenytoin or propofol or something else and consult neurology. While waiting for the seizure to end continue to ventilate, monitor vital signs, give additional NM blocker as needed. ECT can be resumed for further treatments even if this happens.

Viloxazine (Qelbree)

selective NE reuptake inhibitor for ADHD. D: 200-600mg qd for an adult. ages <12 start at 100mg qd. SE: GI, tremor

Piaget's stages of cognitive development

sensorimotor: 0 - 2 years, object permanence is developed. preoperational: 2 - 7 years, thinking and imagination develops. concrete operational: 7 - 11 years, concepts attached to concrete situations, conservation is learned (liquid in beaker example). formal operational: 11 and older, theoretical, hypothetical thinking develops.

memory

short term memory is recall within previous 30 seconds. working memory is dorsolateral prefrontal cortex and is memory temporarily held and man for 18-30 seconds to help with processing. Hippocampus converts immediate memory to stored memory. Temporal lobe is stored memory. The limbic system (including hippocampus) and mammillary bodies contain explicit memory, basal ganglia and cortex are implicit memory. remote memory: long term memory of days to years old.

provisional tic disorder, persistent (chronic) motor or vocal tic disorder. stereotypic movement disorder

similar criteria as tourette's disorder; single or multiple motor or vocal tics but not both (which would be tourette's). Provisional tic disorder is for symptoms lasting >1 year, persistent tic disorder is for a year or more. Stereotypic movement disorder is repetitive purposeless motor movement that can be voluntarily suppressed like hand shaking or body rocking, as opposed to a motor tic which is appears suddenly and then goes away.

binswanger disease (subcortical leukoencephalopthy)

small vessel vascular dementia causing white matter atrophy. Can be caused by many things, such as chronic hypertension or old age. causes loss of memory, cognitive deficits, and mood changes. White matter changes should be visible with imaging such as cerebral atrophy.

benzos in pregnancy

some studies show (some studies do not) an increased risk of cleft lip in women who take benzos during pregnancy, but the likelihood of a baby born with a cleft palate to a mother taking benzos is still <1%.

amphetamine (adderall, mydayis), lisdexamfetamine (vyvanse) is a prodrog that is metabolized into dextroamphetamine in the body. Methamphetamine (desoxyn). Phentermine (adipex). MDMA/ecstasy/molly is a "designer amphetamine" which acts mainly via DA and 5-HT effect.

strongest effect is by causing presynaptic release of DA (dopamine), NE, and 5-HT. also prevents reuptake of NE and DA. Greatest effect is on DA. Lisdexamfetamine is a prodrug that is inactive until ingested, thus can't be used for abuse by snorting or injecting it. I: amphetamine: ADHD and narcolepsy. lisdexamfetamine: ADHD and binge eating disorder. Phentermine and other similar sympathomimetic drugs for short term treatment of obesity. methamphetamine: ADHD D: range is usually 5-40mg in divided doses for IR, but can give 60mg/day. SE: HTN, insomnia, decreased appetite, headache

the only benzo that isn't metabolized by the liver

temazepam. It can be given to peeps with liver dysfunction. Acually all benzos are metabolized by liver but some don't have active metabolites after hepatic conjugation, so the half life is minimally effected in liver failure patients; these are LOT: Lorazepam, Oxazepam, Temazepam.

physiologic changes during sleep and with age. EEG changes in sleep cycles. In 2008 the american academy of sleep medicine says that stage 4 is not a separate stage.

temperature decreases, but increases slightly during REM sleep. Other REM changes include increased HR, eye movements, BP, respiratory rate, and cerebral blood flow. Older people have increased fragmentation of sleep, spend less time in REM and slow wave sleep (stages 3 and 4) and more time in stages 1 and 2. During stages 3 and 4 (aka slow wave sleep) the frequency is low and has delta waves compared to theta waves in stage 1. According to kaufman clinical neurology 4ed stages 3 and 4 provide physical restfullness. The frequency is faster during REM and much faster while awake. REM has relatively low voltage and fast EEG activity similar to wakefullness. Stage 2 sleep is characterized by K complexes and sleep spindles. Benzos decrease REM sleep. Depression decreases REM latency and increases REM sleep.

neuropsychological test

testing for a specific brain function such as memory, language, IQ, executive function, attention, visuospatial function. The testing can be one of many specific tests such as digit span or boston naming test.

biofeedback

testing the autonomic nervous system using things like HR, EEG, EMG to measure autonomic activity to find where it is elevated. Useful for treatment of panic attacks when it it coupled with relaxation techniques.

competency to stand trial

the American academy of psychiatry and law recommends a standard set of specific questions that should be answered by the patient which should be the primary basis for assessing competency, and that the clinical interview and medical records should be secondary.

paliperidone (invega)

the active metabolite of risperidone, which is normally metabolized in the liver, thus paliperidone may be a better choice for peeps with liver problems. But since it is excreted largely unchanged in the urine it depends on renal excretion, thus requires dose reduction in peeps with renal disease. I: schizophrenia, schizoaffective D: usually 6mg/day, but range is 3-12mg. Sustenna is monthly injection and 39-234mg. Trinza is 237-819mg/3 months. SE: slightly more QTc elongation than other antipsychotics. Along with risperidone it has highest likelihood of hyperprolactinemia among typicals and atypicals.

levomilnacipran (fetzima)

the levorotary enantiomer of milnacipran. approved for MDD, not fibromyalgia. Do not use if patient has angle closure glaucoma.

lurasidone (latuda)

the only atypical antipsychotic that is not effective in treating acute mania. I: schizophrenia, bipolar depression as a monotherapy or adjunct to lithium or VPA. Dr Mikita says it doesn't work that well for schizophrenia. D: 40-160mg/day for schizophrenia, 20-120mg/day for bipolar depression. half life 18-31 hours. Must be taken with 500 calories of food to maximize bioavailability (like ziprasidone). Drug rep says no weight gain, QTc elongation, or any other SE.

is someone wants to sign out AMA from the behavioral health unit

the patient fills out a 1010 form requesting discharge. The attending physician is notified and has 72 hours (not including Sundays or holidays) to allow the person to sign out AMA, do a normal discharge, or pursue an involuntary admission. All this information is on the application for voluntary admission.

supportive psychotherapy

the role of the therapist is to act as an emotional support for patients in a time of need

how long drugs are detectable

time are variable according to source. Alcohol in urine not detectable after 4-12

why VPA and lithium are taken multiple times per day. Difference in use between them

to minimize SE, specifically GI upset. According to practice question the half life of lithium and VPA are long enough for once a day doseage (not true for VPA) but both are given BID or TID to lessen SE. Supposedly lithium is better for at treating depression and suicidality of bipolar while valproic acid is better for severe bipolar and for rapid cycling.

carl jung

transpersonal psychology: similar to freud's psychoanalysis but includes lifelong development of self extends beyond (thus trans) sense of self or identity.

treating acute dystonia, tardive dystonia. Laryngospasm can be manifestation of acute dystonia and is managed the same way.

treat with 1mg or 2mg of benztropine given PO, IV, or IM, for mild or severe symptoms. Diphenhydramine 50mg can also be given for mild to moderate sypmtoms. Tardive dystonia can also be treated with botulinum toxin injection in addition to the above treatment.

psychodynamic psychotherapy (aka psychoanalytic psychotherapy)

tries to identify unconscious paradigms (develops insight) related to current cognitive or behavioral patterns.

trichotillomania

tx: CBT (like habit reversal therapy). Clomipramine may help a little.Studies show SSRIs aren't much better than placebo. Rosh review says acetylcysteine.

hoarding disorder

tx: CBT is FLT. Often there are comorbid anxiety or mood disorders, which should be evaluated and treated if necessary. SSRIs can be given but effectiveness hasn't been proven.

excoriation (skin picking) disorder

tx: psychiatric referral is recommended but patients often decline. SSRI. N-acetylcysteine (a building block of an amino acid which is the building block of a neurotransmitter) has shown benefit whether used alone or with SSRI. If lesions are pruritic then topical steroids can be used.

unilateral vs bilateral electrode placement for ECT

unilateral causes less cognitive side effects, bilateral is more effective. Unilateral is started for peeps that are more likely to have cognitive effects, like the elderly, peeps that had bad cognitive SE in previous treatments, and peeps that are worried about SE. Everyone else should have bilateral. Unilateral placement is on the right side because most people are left brain dominant (right handed). If only one sided EEG electrodes are placed (usually they are bilateral) then they should be placed on the opposite side as the stimilus so that it verifies that the seizure was generalized.

serotonin syndrome

unstable vitals, AMS (altered mental status), hyperreflexia and clonus. Labs show hypocalcium and hypomagnesemia. Evolves over hours or days. Can be caused by antibiotic linezolid, which inhibits serotonin breakdown. tx: first with benzos and supportive management (of HTN, hyperthermia, etc), in more severe cases cyproheptadine (5-HT antagonist) an be given.

fibromyalgia. Not found in DSM V, was in previous editions but replaced with somatic symptom disorder.

uptodate diagnosis is the following, number of pain sites is no longer used. A. History: 1 widespread (multisite) pain, 2 present for 3 months, 3 fatigue and sleep disturbances, 4 other symptoms like cognitive disturbance, headache, bowel irritability. B. Physical examination: 1, widespread (multisite) tenderness, 2 absence of join swelling and inflammation. C. Lab testing, 1 absence of acute phase reactants (ESR, CRP), 2 normal CBC, 3 in some cases, muscle enzymes and thyroid testing. tx: initial treatment is patient education and exercise program, and can include meds. Indicated drugs are duloxetine, milnacipran, pregabalin. Other drugs commonly used are TCAs, SSRIs, SNRIs.

acamprosate (campral)

used to eliminate alcohol cravings in people to maintain alcohol abstinence. Increases GABA, decreases glutamate activity, which is similar to what alcohol does. Chronic alcohol users are thought to have decreased GABA and increased glutamate activity due to chronic alcohol use, so acamprosate is kind of like a alcohol substitute. I: maintenance of alcohol abstinence D: tablet is 333mg. Peeps <60kg are given 666mg BID, peeps >60kg are given 666mg TID. SE: diarrhea, nausea, anxiety, depression, potential suicidal ideations.

varenicline (chantix)

used to help quit smoking. partial agonist at the alpha 4 beta 2 nicotinic acetylcholine receptor (nACh) subtype that causes release of dopamine from the nucleus accumbens and helps reduce cravings and withdrawal from smoking cessation. Supposedly more effective than nicotine or bupropion. I: smoking cessation D: usual dose is 1mg BID. SE: Nausea, vomiting, constipation, insomnia, headache, abnormal dreams, rarely causes agitation, suicidal behavior, seizures.

Limbic encephalitis

usually paraneoplastic syndrome that can be due to a tumor in the lungs (has anti-HU antibodies), testis (anti-Ma2), or ovaries (anti-NMDAR)

REM (rapid eye movement) characteristics

usually takes 90 minutes after starting sleep to start REM cycle. During REM heart rate, BP, and RR increase (or variable vital signs?). Dreaming occurs. Skeletal muscles are paralyzed. REM stages last about 15 minutes earlier on in night and last increasingly longer (up to 40 minutes) later on in night. EEG shows alpha waves and saw tooth pattern.

MOCA parts

visuospatial and executive function: trail making test and clock draw test. language: naming three animals, and repeating. memory: repeating five objects. Delayed recall is by mentioning the five objects later. attention: repeat list of digits, tapping test, serial 7s. abstraction: "similarities between apple and banana". orientation: knowing date, month, year, day, etc.

wernicke-korsakoff encephalopathy. severe and chronic B1 deficiency is beriberi

vitamin B1 (thiamine) deficiency causing classic triad of confusion, ataxia, and ophthalmoplegia (weakened extraocular muscles, aka ophthalmoparesis). also causes paresthesias. thiamine deficiency affects the mammillary bodies. Diagnosis is clinical and is made with two of four possible criteria; the three mentioned symptoms or serum thiamine deficiency. When in doubt give thiamine because it side affects are very rare. Unlike b12 deficiency, it does not cause dorsal column spinal cord lesions that result in paresthesia.

modafinil (provigil), armodafinil (nuvigil)

weak dopamine reuptake inhibitor. Helps people stay awake. indicated for narcolepsy, obstructive sleep apnea, and shift work sleep disorder. Does not help cataplexy (loss of muscle tone with eyes spared and maintenance of consciousness, usually triggered by emotions like laughing, crying, or terror) which is common in narcolepsy (sodium oxybate treats cataplexy but is less affective for daytime sleepiness). I: both have same indications: narcolepsy, obstructive sleep apnea, shift work sleep disorder. SE: headache, HTN, tachycardia, decreased appetite, insomnia, somnolence (doesn't make sense).

subclinical hypothyroidism (according to uptodate)

when TSH levels are high but T4 levels are normal. If the TSH is above 10 then treat. If TSH is 7-10 for peeps over 65 yo then treat only if symptomatic (because TSH tends to get higher with advanced age). If TSH 7-10 for peeps <65 yo then treat. If TSH is high but less than 7 then treat peeps <65 yo if symptomatic; peeps >65 don't need treatment.

ideas of reference, delusions of reference

when people take innocuous events or coincidences and believe they have strong personal implications, such as believing what is said on TV applies specifically to them. Ideas vs delusions of reference: with ideas a person may believe or have a feeling about something but are not 100% convinces, but a delusion of reference is a stronger conviction.