Psychiatry Short review

1. Psychotic disorder

Psychosis
• Delusion: False, fixed, culturally inappropriate belief that cannot be altered by rational arguments
• Hallucination: Perception without external stimuli
» Auditory: Schizophrenia or other psychotic d/o
» Visual: Organic brain disease, Dementia Drug & Alcohol intoxication & withdrawal
» Olfactory hallucination: Temporal lobe epilepsy
• Disordered thinking

Differential diagnosis
• Brief psychotic d/o (< 1 month)
• Schizophreniform d/o (1 – 6 months)
• Schizophrenia (> 6 months)
• Schizoaffective d/o
• Delusional d/o
• Mood disorder (MDD or Bipolar) with psychosis
• Substance induced pscyhosis
• Delirium, Dementia
• Psychosis due to general medicalc condition

Phase of schizophrenia
• Prodrome –  Function, Social withdrawal, Irritable, Depressed
• Psycosis – Hallucinaion, Dellusion, Disorganize speech & behavior
• Residual (episode between pscyhotic exacerbations) – Negative symptoms, social withdrawal

Positive vs Negative symtoms

Positive symptoms Negative symptoms

• Delusion • Apathy
• Hallucination • Anhedonia
• Disorganized speech •  Attention
• Disorganized behavior

Schizophrenia
• Prevalence: 1%
• Men present earlier
• Strong genetic predisposition
• A/w  Dopamine, Serotonin, Norepinephrine

Schizoaffective d/o
• Meet criteria for MDD or Manic or Mixed episode + Schizophrennia
• Mood symptoms (MDD, Manic) only substantial portion of psychotic illness
• Must have dellusion or hallucination for at least 2 week without mood symptoms
Delusional d/o
• Non-bizarre, fixed delusion for at least 1 month
• Delusion: Erotomanic, somatic, persecutory, grandiose
• Not meet criteria for schizophrenia
• MC age > 40 y/o
• Anti psychotic – less effective

Anti-psychotic drug

Typical
• Dopamine D2 blocker
• Treat positive symptoms > negative symptoms
• S/E:  risk of EPS than Atypical agents
• Low potency agents = Need larger dose, less
risk EPS
• High pontency agents = Need small dose, More
risk of EPS
Side effect
• Extrapyramidal symptoms (EPS) – Dystonia,
Parkinsonism, Akathisia
• Anticholinergic symptoms – Dry mouth,
Constipation, Blurring vision
• Tardive dyskinesia – Darting movement of face,
tongue, MC woman, can be permanent
Atypical
• Dopamine D2 & Serotonin blocker
• Treat positive + negative symptoms
• Treat negative symptoms, better than typical
agents
Side effect
• Risperidone – Hyperprolactinemia
• Olanzapine – Hyperlipidemia, Weight gain,
Glucose intolerance, Hepatotoxicity
• Clozapine – Agranulocytosis, Seizure
• Ziprasidone – Prolong QTc, Need to take with
food

Neuroleptic malignant syndrome

• Symptoms:
FALTER
F – Fever – High
A – Altered Mental status
L – Leukocytosis
T – Tachycardia
E – Elevated CPK
R – Rigidity (‘Lead pipe’)
• Can cause death
• Treatment: Supportive
• Not allergic reaction, can restart with same medication

2. Mood disorder

Common mood d/o

• Major depressive d/o
• Bipolar d/o
• Dysthymic d/o
• Cyclothymic d/o
 Major depressive episode
• 5 symptoms, include low mood (depressed) or loss of interest for at least 2 weeks
MI SEG CAPS
M –  Mood
I –  Interest
S – Sleep disturbances
E –  Energy
G – Guilty
C –  Concentration
A –  Appetite
P – Psychomotor agitation or retardation
S – Suicide thought

About MDD
• At least 1 major depressive episode
• No mania or hypomania
• Lifetime prevalence: 15%

Types of anti-depressant

SSRI • Mechanism: Inhibit Serotonin pump reuptake   Serotonin in synaptic cleft

• Advantage: Fairly safe in overdose, no food restriction
• Common s/e: Diarrhea, Insomnia, Sexual dysfunction
• SSRI withdrawal ( Serotonin): Irritable, dizzy, nausea #need to tapered dose before stop
• Serotonin syndrome ( Serotonin): Fever,  HR, Myoclonus
• Treat: Depression, Anxiety disorder
• Fluoxetine: Longest half-life, no withdrawal
• Sertraline: Useful for elderly, least weight gain
• Paroxetine: Most activating, given in morning, Highest anticholinergic effect
• Fluvoxamine: Very short half-life, risk of SSRI withdrawal if sudden stop, approved for OCD
only
• Citalopram: Commonly used because minimal drug to drug interaction
Atypical • Venlafaxine (SNRI) – can  BP, Withdrawal phenomenon: Electric shock
agents • Bupropion (NDRI) – Minimal sexual s/e,  risk of seizure,
• Mirtazapine (Norepinephrine & Serotonin blocker): Often used in elderly, S/E: Sedation,
weight gain
TCA • Mechanism: Inhibit reuptake of NE & Serotonin   NE & Serotonin in synaptic cleft
• S/E: Lethal in overdose (d/t prolong QRS complex), Seizure, Coma, Cardiotoxicity, Orthostatic
hypotension,  HR, Anti cholinergic effect (dry mouth, constipation, urinary retention),
Sedation
MAO • MOA: Irreversibly inhibit MAO  Prevent inactivation of NE, Serotonin, Dopamine, Tyramine
inhibitor   NE, Serotonin, Dopamine, Tyramine
• Common S/E: Orthostatic hypotension, Drowsiness, Weight gain, Sexual dysfunction
• Tyramine: Agent that release NE
 Side effect of Anti-depressant

Serotonin • P/w: Lethargy, restlessness, confusion, flushing, excess sweating, tremor,

syndrome myoclonus
• Can progress to hyperthermia, rhabdomyolysis, kidney injury, coma
• Usually occur when combine SSRI + MAO inhibitor
Hypertensive • Can occur if Tyramine rich foods is ingested when using MAO inhibitor
crisis

Manic episode
• Abnormally & Persistently elevated, expansive or irritable mood for at least 1 week
• Need at least 3 of following
DIG FAST
D – Distractibility
I – Irritability
G – Grandiosity
F – Flight of ideas
A –  Goal driven activity
S –  Need of sleep
T – Thoughtlessness, Talkative

Mania vs Hypomania

Mania Hypomania
Duration At least 7 days At least 4 days
Impairment Severe None
Hospitalization √ X
Psychotic features √ X

Mania due to General medical condition Substance induced mania

• Hyperthyroidism • Corticosteroids
• Multiple sclerosis • Stimulant
• Tumor • Dopamine agonist
• HIV • Bronchodilator
• Stroke • Antidepressant
• Temporal lobe epilepsy

Mood stabilizer

Lithium • MOA: Unknown

• Narrow therapeutic index (0.5 – 1.0), so must monitor possible complication to thyroid
& kidney (TSH & Creatinine)
• Careful when also using another medication diuretic, ACE inhibitor, NSAIDs – could 
drug excretion
• S/E: Hypothyroidism, Nephrogenic diabetic insipidus, tremor, polyuria, weight gain
Carbamazepine • Anti-convulsant
• S/E:  WCC,  Na+, Aplastic anemia, Agranulocytosis, Transaminitis
• Must monitor FBC, LFT
Valproic acid • Anti-convulsant
(Epilim) • S/E: Alopecia, weight gain, hepatotoxicity, thrombocytopenia, neural tube defect (baby)
• If patient want to pregnant, need prophylaxis folic acid, to avoid neural tube defect in
baby
Lamotrigine • Anti-convulsant
• S/E: Steven Johnson syndrome
• Used for Bipolar disorder with depressive episode
• Very slow acting

3. Anxiety disorder

Generalized anxiety d/o

• Persistent, excessive anxiety & hyperarousal for at least 6 months
• Hyperarousal symptoms: Irritability, Impulsiveness,  Concentration, Anger & aggression, Nightmare,
Constant feeling of danger
• Treatment: Behavioral therapy + SSRI (Antidepressant)

OCD
• Obsession
» Recurrent & intrusive thought, that cause marked anxiety
» Failed attempt to suppress thought
» Realize that the thought is product of his mind
• Compulsion
» Repetitive behavior in respond to his obsession
» This is to reduce distress caused by obsession
• Common pattern: Contamination, symmetry, doubt, subsequent checking
• Treatment: SSRI (1st line) + Behavioral therapy (Exposure & response prevention; Relaxation
technique)

Panic d/o
• Panic attack (PA): Brief sudden rush of fear & anxiety (usually < 30 minutes)
• PANICS
P – Palpitation
A – Abdominal distress
N – Numbness, Nausea
I – Intense fear of death
C – Choking, Chills, Chest pain
S – Shortness of breath, Sweating
• Criteria:
» Spontaneous recurrent panic attack, without triggering factor
» PA cause worry about additional attack or avoidance (behavioral changes)
• Differential diagnosis
» Drugs: Stimulants, caffeine, nicotine, hallucinogen, alcohol, opiate, benzodiazepine withdrawal
 » Psychiatric illness: Depression, other anxiety d/o
» Medical illness
• Treatment
» Short term: Benzodiazepine (Alprazolam known as Xanax)
» Long term: SSRI, Relaxation training, Cognitive therapy

Agoraphobia
• Definition: Fear of open space (Agora: Public space, Phobia: Fear)
• Usually cause panic disorder (Panic d/o with Agoraphobia)
• Panic d/o + Agoraphobia: Treat panic d/o, resolve agoraphobia
• Panic d/o without agoraphobia: Difficult treatment

PTSD & Acute stress d/o

PTSD Acute stress d/o

Differences • Event occur anytime in the past • Event occur < 1 month ago
• Symptoms duration > 1 month • Symptoms duration < 1 month
Similarity • Witness traumatic event
• Persistent re-experiencing event – nightmare, flashback
• Avoidance of stimuli
• Hyperarousal
Treatment • Psychotherapy: Relaxation technique
• Medication: SSRI (1st line), Alpha blocker (Prazosin)

Phobia
• Most common psychiatric d/o
• Ego-dystonic – Patient known that the fear is exaggerated
• Specific phobia – exaggerated fear of specific object or situation, treat with systemic desensitization
• Social phobia – exaggerated fear of social situation, in which humiliation can occur, treat with SSRI +
Cognitive therapy

Substance induced anxiety d/o

• Stimulant – caffeine, amphetamine
• Depressant – alcohol, antidepressant
• Others: Carbon monoxide inhalation

General medical condition induced anxiety

• Endocrine: Hyperthyroidism, Hypoglycemia, Pheochromocytoma
• Neurological d/o: Seizure d/o, Brain tumor, Multiple sclerosis
• CVS ds
• Pulmonary ds – Hypoxia (anxiety provoking)

Treatment – Anxiety d/o

• Short term – Benzodiazepine
• Long term – SSRI
4. Personality d/o
• Define as Inflexible pattern of interaction, which impair social function
• Patient has No insight into problematic interaction style
• Onset: 15 – 25 y/o

Cluster A: ‘Weird’
• Eccentric, withdrawn, border on psychosis

Schizoid Schizotypal Paranoid

• Quiet, reclusive • ‘Magical thinking’ • Pervasive suspiciousness
• Don’t want close relationship • Bizarre fantasies

Cluster B: ‘Wild’
• Emotional, dramatic, often with mood d/o

Anti-social Borderline
• Don’t care safety of other • Desperate attempt to avoid abandonment
• Manipulate other for personal gain • Unstable & intense relationship
• Usually break the law • Recurrent suicidal thought
• May border on psychosis
• Histrionic: Attention seeker, flamboyant,
extroverted, sexually inappropriate
• Narcissistic: Over self-importance, want
admiration from others, manipulate other for
personal gain

Cluster C: ‘Worried’
• Anxious, fearful, shy
• Avoidant: Avoid interpersonal contact because of fear of rejection, but want a companion
• Dependent: Low confident, Excessive need cared from others
• Obsessive-Compulsive: Obsess with orderliness, perfectionism, control

Treatment Personality d/o

• Commonly co-exist with mood & anxiety d/o, so must treat same as mood & anxiety d/o
• For personality d/o, Psychotherapy is the mainstay of treatment

5. Substance use d/o

Abuse Dependence
Pattern of substance use cause functional impairment for at least 1 year
Need 1 of following: Need 3 of following:
• Fail to finish task at work, school, home • Fail to finish task at work, school, home
• Use in dangerous situation • Tolerance
• Recurrent criminal history d/t substance use • Withdrawal
• Continue usage despite of social problem due • Actual use exceeds extended use
to use • Continued use despite medical or psychological
problem due to use
 • Persistent desire or unsuccessful efforts to cut
#Patient cannot meet criteria for dependence as down on use
such supersedes a diagnosis of abuse • Significant time spent using, getting, recovering
from substance

Alcohol intoxication – management

• Ensure ABC – Airway Breathing Circulation
• Monitor electrolytes
• Blood glucose level
• Test: Breath analyzer or blood alcohol level

Alcohol withdrawal (Life threatening)

Mild Moderate Severe

• Irritability • Disorientation • Autonomic instability
• Insomnia • Fever • Seizure
• Mild tremor • Delirium tremens (altered
consciousness)

Delirium tremens
• Onset: After 2 days of alcohol cessation
• Untreated cause high mortality rate
• Key features: Delirium (altered, waning sensorium)
• A/w Hallucination (Visual, Tactile), Psychomotor changes, Autonomic instability

Treatment alcohol withdrawal

• Acute alcohol withdrawal, reverse with thiamine, before giving glucose
• Vital signs monitoring
• Benzodiazepine
• Seizure precaution

Korsakoff’s syndrome
• Chronic & irreversible
• Impaired recent memory
• Anterograde amnesia

Opiates
• MOA: Stimulate opiate receptor  Analgesia, sedation, dependence
• Example: Heroine, Codeine, Morphine, Methadone, Meperidine

Opiate Intoxication Withdrawal

 Feature Drowsy, Altered mental status,
Respiratory depression, Constipation,
Constricted pupil, coma
Treatment • ABC
• Naloxone (Opiate blocker)
Craving, Anxiety, Rhinorrhea, Diaphoresis,
Abdominal discomfort, Mydriasis, Myalgia,
Irritability
• Clonidine ( Catecholamine)
• Methadone ( Withdrawal effect by give
minimal effect of opioid)

Sedative-Hypnotics
• Benzodiazepine:  frequency of Cl- channel opening   GABA
• Barbiturates:  duration of Cl- channel opening   GABA
• Intoxication: Drowsy, altered mental status, ataxia (uncoordinated movement), respiratory depression,
nystagmus, coma
• Treatment: Withdrawal – Maintain ABC, Benzodiazepine blocker

6. Cognitive disorder
• Problem with memory, orientation, attention, judgement
• Major category
» Dementia
» Delirium
» Amnestic d/o

Dementia Delirium
Impaired • Memory • Sensory
Onset • Gradual • Acute
Course of symptoms • Stable • Fluctuating
Reversibility X √

Dementia
• Define as Memory impairment, without changes in consciousness
• May have behavioral disturbance ± psychosis
• Must rule out pseudodementia in depression
• Must rule out reversible cause of dementia
» Vit B12, Folate deficiency
» Hyper or hypothyroidism
» Electrolyte imbalance

Alzheimer’s disease
• Most common type of dementia (50%)
• Course: Progressive & linear
• Commonly a/w Personality + Mood changes
• Pathology: Tau protein, Amyloid protein
• Diagnosis: Memory problem + 1 of following
» Aphasia (language difficulty)
» Apraxia: Practiced activity difficulty
 » Agnosia: Recognition difficulty
• Treatment
» Memantine (NMDA blocker), Rivastigmine (Cholinesterase blocker) – Treat Alzheimer
» Anti-depressant – Treat depression
» Anti-psychotic (low dose) – Treat behavioral disturbance

Vascular dementia
• Cognitive deficit due to brain infarct
• Clinical criteria same as Alzheimer disease
• Commonly have neurological deficit
• Control vascular risk factor

Delirium
• Fluctuating clinical course
• Psychomotor agitation or retardation
• Commonly have hallucination
• Causes: Drug induced, liver, renal, endocrinal dysfunction, electrolyte abnormality, infection
• 1st thing to do is to identify the cause of delirium
• After identify the causes, treat the causes & delirium
• Treat delirium by giving Low dose antipsychotic to treat agitation

Amnestic disorder
• Memory impairment without cognitive problem a/w dementia
• No altered consciousness
• Always caused by medical condition: Seizure, hypoxia, head trauma, substance abuse

7. Other disorder

Mental retardation
• Significant deficit in intellectual function + age appropriate adaptive skills
• Onset: Childhood < 18 y/o
• Causes: Most common is no clear cause
» Genetic syndrome: Down syndrome, Fragile X syndrome
» Prenatal & perinatal exposure

Pervasive developmental d/o

• Deficit in social skills, language, behavior
• Onset: Early childhood
• Autism – Difficulty in social interaction, communication impairment, Repetitive & stereotyped
behavior
• Asperger d/o – Same as autism, but higher functioning because normal cognitive & language skills

Disruptive behavioral d/o

• Conduct d/o – Pattern of behavior that violates rights of others & defies social norms. Aggressive
toward people, animal, property. Precursor to antisocial personality disorder
• Oppositional defiant d/o (ODD) – Hostile & defiant behavior, Don’t violate the right of others (different
from conduct d/o)

ADHD
• Onset: < 7 y/o
• Behavior inconsistent with age & development
• Symptoms: Inattentiveness, hyperactivity or both for > 6 months
• Treatment: CNS stimulant (Methylphenidate, dextroamphetamine)

Eating disorder
• Anorexia nervosa – Body weight > 15% below normal, Amenorrhea, Obsess with body image
• Bulimia nervosa – Recurrent binge eating & attempts to compensate (vomit, laxative, diuretic, excess
exercise). Obsess with body image
• Treatment: Behavioral therapy, Individual psychotherapy