PSYCHIATRY LECTURIO
18
PSYCHIATRIC ASSESSMENT ..................................................... 2
Psychiatric History .................................................................... 2
APPROACH TO THE CLINICAL INTERVIEW .................... 2
HISTORY TAKING ................................................................. 2
Mental Status Exam ................................................................. 3
Types of Psychotherapy .......................................................... 4
PERSONALITY DISORDERS ......................................................... 6
Behavioral Theories and Sigmund Freud ............................. 6
Defense Mechanisms .............................................................. 7
Mature Defenses .................................................................. 7
Neurotic Defenses ................................................................ 7
Immature Defense Mechanisms ....................................... 7
Other Defenses (Neurotic or Immature) .......................... 7
Personality Disorders ............................................................... 7
Personality ............................................................................. 7
Personality Disorders .......................................................... 7
CLUSTER A ............................................................................ 8
CLUSTER B ............................................................................ 9
CLUSTER C DISORDERS ...................................................11
OCPD ....................................................................................12
MAJOR PSYCHIATRIC DISORDERS .........................................12
Psychosis, Delusions, and Hallucinations (Psychotic
Disorders) .................................................................................12
Psychosis .............................................................................12
Thought Disorders .............................................................13
DDx for Delusional College Student ................................13
Schizophrenia ..........................................................................14
Epidemiology .......................................................................14
Pathogenesis ......................................................................14
Psychiatric Indications ......................................................14
Schizophrenia Assessment ..............................................14
Schizophrenia Treatment .................................................15
Antipsychotics .........................................................................16
Low Potency Traditional Antipsychotics .......................16
High Potency Traditional Antipsychotics .......................16
Neuroleptic Malignant Syndrome ...................................17
Atypical Antipsychotics .....................................................17
Depression (A mood disorder) .............................................
Pathogenesis ...................................................................... 18
Assessment ........................................................................ 19
Types of Depression .......................................................... 19
Depression Treatment ...................................................... 20
Antidepressants ................................................................. 20
Bipolar Disorder....................................................................... 22
Cause and Assessment .................................................... 22
Diagnosis ............................................................................. 23
Treatment ............................................................................ 23
Mood Stabilizers ................................................................. 24
Panic Disorders ....................................................................... 25
Diagnosis ............................................................................. 25
Treatment ............................................................................ 26
Obsessive-Compulsive Disorders ........................................ 26
Assessment ........................................................................ 27
Treatment ............................................................................ 27
Phobias ..................................................................................... 27
Assessment ........................................................................ 28
Treatment ............................................................................ 28
Post-traumatic Stress Disorders ......................................... 28
Assessment ........................................................................ 29
Diagnosis (Meet all of the criteria) .................................. 29
Treatment ............................................................................ 29
Anxiolytics ................................................................................ 30
Control Disorders ........................................................................ 30
Substance Disorders .............................................................. 30
Assessment ........................................................................ 30
Alcohol and Delirium .......................................................... 31
Other substance abuse disorders ................................... 32
Medical Substance Related Disorders ........................... 33
Impulse Control Disorders .................................................... 34
Intermittent Explosive Disorder ....................................... 34
Gambling Disorder ............................................................. 35
Kleptomania ........................................................................ 36
Pyromania ........................................................................... 36
Trichotillomania .................................................................. 36
Eating Disorders ...................................................................... 37
Age-Related Disorders ................................................................ 37
 Cognitive Disorders ................................................................37 3. Creates a picture of the patient
Mini Mental Status Exam and Other Assessments .....37 Formulation
Dementia ..............................................................................37 • ICD-10 vs DSM-5
Dementia ..............................................................................38 • Biopsychosocial Approach
o Illness, treatment, future trajectory
Dissociative and Somatoform Disorders ................................39
o Biological, Psychological, and Social Factors
Forensic Psychiatry .....................................................................39 that may interfere with achieving the best of
mental health
HISTORY TAKING
PSYCHIATRIC ASSESSMENT It is crucial to provide a therapeutic alliance. Be relaxed,
supportive, nonjudgmental, and comfortable. The patient needs
Psychiatric History to feel safe and have trust.
APPROACH TO THE CLINICAL INTERVIEW
• Presenting Complaint
Therapeutic Alliance
• HPI (Information about the current episode)
1. Introduce yourself o Why does the patient come to the doctor?
2. Create a comfortable environment o Can the patient describe the current episode?
3. Invite the patient to share a narrative and ask your o What were the events up to the present moment?
questions as they arise. Be non-judgmental. o How work and relationships have been affected?
4. Follow the patient’s lead! o What is the patients support system?
5. Respect the patients wish to avoid certain subjects on o How is the relationship between physical and
6. Staff safety is important and should be pre-planned psychological symptoms? (Biopsychosocial
before entering the room with a patient approach)
o Just as important as patient safety ▪ Are there vegetative symptoms? (Sleep,
o Exits are easily accessible Appetite, Concentration)
▪ Psychotic symptoms (voices, seeing things,
History
touch with reality)
1. Begin with open-ended questions and then narrow down ▪ Baseline functioning
questions based on chief complaint ▪ Patient’s Developmental History (something that
2. Explore present illness; symptoms, precipitants, social happened earlier in life)
setting, supports, current and past treatment and ▪ Life values and/or goals
complications ▪ Evidence for secondary gain (if there is
3. Collect thorough information something that they gain from having an illness
a. Past psychiatric history e. g. evading homelessness, criminal records)
b. Medical/Surgical History o Remember: OPEN-ENDED QUESTIONS
c. Substance history • PPH
d. Family History o What is the patient’s understanding of their
e. Medications diagnosis? What have you been told?
f. Allergies o What is the number of psychiatric admissions (when,
g. Safety including present and past suicidal/homicidal why, duration, locations, outcomes)?
ideation ▪ What was helpful? What was harmful?
h. Social History o Are there current or previous providers
i. Developmental History (psychiatrists/therapists) and what is the patient’s
reliance/partnership status with them?
Mental Status Exam (critical part) o History of self-harm, suicide attempts, or violence?
A tool to be able to relay information to other partners in What concerns do they have? Intent to carry through
treatment; descriptions for someone who has never met the with plans?
patient o Current/previous medication trials – doses, duration
of treatment, responses good or bad?
1. Observations o History of electroconvulsive therapy?
2. Questions about thoughts, beliefs, perceptions, and o What types of outpatient services are
cognition recommended?
 o What treatments did the patient prefer and why? Mental Status Exam
o How was the patients’ attendance/compliance and
This can change at every hour or every day. It only tells us about
adherence to treatment? What promoted
the MSE at that exact moment. They may have completely
compliance or hindered it?
different presentations every day. It’s analogous to the physical
• SDH
o History of Substance Abuse exam in internal medicine. Never forget to assess for safety,
▪ Alcohol/illicits/tobacco/caffeine screening – including suicidal and homicidal thoughts, intent, plans, and
frequence of intake, amount, preferred history of such thoughts, etc.
substance
It should be recorded at every patient encounter
▪ Prescription/over the counter/herbal medicines
▪ Intoxications, blackouts, withdrawals • Appearance and Behavior
▪ Problematic drinking o TIP: What do you notice about them?
▪ Rehabs or sobriety programs
o Physical Appearance (clothing, hygiene, posture,
o Social history (Chance to be curious about their grroming)
patient) o Behavior (mannerisms, tics, eye contact e. g.
▪ Where was the patient born and raised? psychomotor retardation)
▪ Who was in the nuclear family? What were they o Attitude (Cooperative, hostile, guarded, seductive,
like? What was their childhood like? apathetic)
▪ How is the relationship to early caregivers? o NOTE: Comments should be detailed enough that any
▪ Developmental history into kindergarten, grade treatment team member can identify the patient
school, high school, etc.
• Speech
▪ Highest level of education?
o Rate: Slow, average, rapid, or pressured
▪ Employment background?
(uninterruptible pressured speech seen in manic
▪ Extension
patient)
• Marital Status/Children
o Volume: Soft, Average, loud
• Hobbies o Articulation: Well-articulated, lisp, stutter, mumbling
• Ownership of guns/weapons o Tone: Angry vs. pleading, etc.
• Religious beliefs • Mood/Affect
• Forensic/legal history o Mood: Emotion that the patient tells you he is feeling;
• Physical/sexual/emotional abuse can also be conveyed nonverbally
• NOTE: When asking about sensitive material o Affect: Assessment of how the patient’s mood
(domestic violence, history of appears to the examiner, including the amount and
physical/emotional/sexual abuse, sexual range of emotional expression
activities/safety), be direct! Don’t hesitate! o Quality of Affect: depth and range of feelings shown.
Be open! ▪ Flat (none)
• PMSH ▪ Blunted (shallow)
o Medical problems ▪ Constricted (limited)
o Previous surgeries ▪ Full (average)
o Head injuries/concussion ▪ Intense (more than normal)
o Seizures o Motility: Describes how quickly a person appears to
o Traumatic Brain Injuries shift emotional states. Parameters include sluggish,
o HIV/AIDS supple, labile
• Medications/Allergies o Appropriateness to Conversation: Describes whether
• Family History the affect is congruent with the subject of
conversation → Appropriate or Not Appropriate
Many disorders are genetic
• Thought Process
o Psychiatric illnesses o Listening skills are important here
o Suicide attempts/Suicides o Describes how he/she uses language and puts ideas
o Violence together
o Members having treatment o Logical, meaningful, goal-directed thoughts?
▪ Therapy, Types or medications
▪ Responses to treatment
▪ Electroconvulsive therapy (ECT)
 o Does not comment on what the patient thinks, but
rather it only describes how the patient expresses
his/her thoughts
o Disorder examples
▪ Loosening of associations: no logical connection
from one thought to another
▪ Flight of ideas: A fast stream of very tangential
thoughts
▪ Neologisms: Made up words
▪ Clang associations: Word connections are due
to phonetics rather than actual meaning
(rhyming, alliteration without making any sense)
▪ Thought blocking: Abrupt cessation of
communication before the idea is finished
▪ Tangentiality: Point of conversation never
reached due to lack of goal-directed
associations between ideas
▪ Circumstantiality: Point of conversation is
reached after a very long road
• Thought Content
o Describes the type of ideas expressed by the patient
o Poverty of thought versus overabundance: Too few
versus too many expressed ideas
o Delusions: Fixed, false beliefs not shared by the
person’s cultured and cannot be changed by
reasoning
o Suicidal and homicidal thoughts: Ask if the patient
feels like harming him/herself
o Identify the plan: How well it is formulated and also
the intent
o Phobias: Persistent, irrational fears
o Obsession: Repetitive intrusive thoughts
o Compulsion: Repetitive behaviors
• Perceptions
o Hallucinations: Sensory experiences not based in
reality (visual, auditory, tactile, gustatory, olfactory)
o Illusions: Inaccurate perception of existing sensory
stimuli
o Type of hallucination is very important and whether it is
first or third person. Content of hallucinations? Are they
telling the patient to harm themselves or others?
▪ Doctor, I’m hearing things → Who, do you
recognize? How many are they. Describe. What
are they saying? → Command auditory
hallucination vs. Running commentary vs.
Persecutory
• Cognition
o Consciousness: Level of awareness → alert, drowsy,
lethargic, stuporous, coma
o Orientation: Person, Place, Time
o Calculations: Ability to add/subtract (test of
executive functioning) → Serial 7s
o Memory: Immediate (recall words immediately after
saying them, then after 5 minutes) → Three word
o Recent memory: Past few days
o Recent past: Last few months
o Remote memory: events from childhood
o Fund of knowledge: Level of knowledge in the
context of the patient’s culture and education
o Attention and Concentration: Ability to subtract serial
7s or spell “world” backwards, Months of the year,
Days of the Year backwards
o Reading and Writing: Write simple sentences. Or
write a sentence then follow a command.
o Abstract Concepts: Ability to explain similarities
between objects and understand the meaning of
simple proverbs
o Mini mental Status Exam: Brief test to assess gross
cognitive functioning → every encounter
• Insight/Judgement
o Insight: Patient’s level of awareness and
understanding of his or her problem.
▪ Problems include: complete denial of illness,
blame
▪ Affect understanding or problem and therefore
adherence
o Judgement: ability to understand the outcome of his
or her own actions and use this awareness in
decision making
Types of Psychotherapy
Psychotherapy is an interpersonal treatment often referred to as
talk therapy rooted in psychological principles
• Psychodynamic/Psychoanalysis
o Therapy that reveals unconscious aspects of a patient’s
life through → transference, countertransference,
resistance, free associations, dreams → repressed
experiences and feelings
o Dream interpretation – represent conflict between
urges and fears; interpretation of dreams →
therapeutic goals
o Countertransference – therapist’s redirections of
unconscious feelings about important figures in
his/her life onto the patients → potential to interfere
with objectivity unless the therapist is aware of
countertransference
o Free association – undirected expression of
conscious thoughts and feelings as a means of
gaining access to unconscious processes
o Transference – unconscious transference of
feelings and desires about important people in the
patient’s life and projecting it onto the therapists
o Therapeutic Alliance
 o Resistance – forces within the patient, conscious
and unconscious, which oppose the purpose of the
patient’s evaluation and the goals of treatment →
talk with the patient to reduce it
o Insight oriented for young adults with a history of
stability in relationships and daily living who are
intelligent and not psychotic
o Lying down on the couch to encourage free association
o Types
▪ Classical Psychotherapy (Freud) – unresolved
conflicts lead to psychopathology including
depression and anxiety
▪ Ego psychology (Anna Freud) – considers how
an individual interacts with external world as well
as responds to internal forces; defense
mechanisms are taken into consideration and is
rooted in Freud’s id-ego-superego model of the
mind
▪ Object relations (Melanie Klein and Donald
Winnicott) – process of developing a psyche in
relation to others in the environment during
childhood → first one is usually the mother;
Winnicott is known for his concept of the
transitional object and the good-enough mother
▪ Self-Psychology (Heinz Kohut) – goal is to
understand the patient from inside their
subjective experience via vicarious introspection
drawing on empathy, mirroring, and idealizing
• Interpersonal
o Addresses relationships in the here and now
o Manual driven therapy
o Four problem areas
▪ Grief over loss
▪ Interpersonal Disputes
▪ Role Transitions
▪ Interpersonal skill deficits
• Cognitive Behavioral Therapy
o Therapy that seeks to correct faulty assumptions and
negative feelings that exacerbate psychopathology
o Manual driven therapy described by Aaron Beck
o Fundamentals
▪ Education
▪ Relaxation
▪ Coping Skills Training
▪ Stress Management
▪ Assertiveness Training
o Best patient
▪ Highly motivated
▪ Requires self-observations
▪ Problem-solvers
• Behavioral Therapy
o Goal is to reduce symptoms via relaxation,
reinforcement, and graduated exposure to distressing
stimuli
o Treats psychiatric disorders by helping patients change
behaviors with healthy alternatives
o Learning Therapy – behaviors are learned by
conditioning and unlearned by deconditioning e. g.
Pavlov’s Dog vs. Operant conditioning (Skinner’s
Box)
o Deconditioning
▪ e. g. patient is afraid of dog → show her pictures
of dogs, or a stuffed animal with dogs, then meet
a dog and pet it (systematic desensitization)
(relaxation techniques + increasing anxiety
provoking stimulus) → Made to imagine going to
a dog park (implosion) → GO to a dog park
(flooding)
▪ Aversion Therapy - Alcoholic patient when given
Antebuse
▪ Token Economy – rewards are given after
specific behaviors to reinforce them
▪ Biofeedback – physiological data are given
patients as they try to mentally control
physiological states
• Motivational Interviewing
o Approach to helping patients change maladaptive
behaviors via recognition of problematic behaviors and
matching strategies to the patient stage of readiness to
change
o Includes expressing empathy, meeting the patient
where they are, creating an idea of the change they seek
o Pre-contemplative → Contemplative → Motivated →
Relapse → Pre-contemplative → Motivated (the
desired state)
o Best patients: highly motivated, requires self-
observations, problem solvers, actually want to
make a change
o Key elements: Expressing empathy, identifying
discrepancies between problematic behaviors and
personal values, Expecting the patient to resist
change and accepting it, Enhancing self-efficacy
• Dialectical Behavioral Therapy → For Borderline
Personality Disorder
o Special treatment for borderline personality disorder →
reduces self-injurious events and hospitalizations
o Primary Focuses
▪ Mindfulness
▪ Interpersonal effectiveness
▪ Emotional Regulation
▪ Distress Tolerance
• Supportive Psychotherapy
 o Brief, with an active focus on helping the patient deal
with a life crisis
o Therapist offers advice, sympathy, and support while
reinforcing the patient’s strengths
• Group Therapy
o Therapeutic approach that incorporates discussions,
peer support
o Like Alcoholics Anonymous
o Especially useful in substance abuse, adjustment
disorders, personality disorders, grief and
bereavement, MDD, anxiety
o Advantages over Individual Therapy: immediate
feedback from their peers fostering a non-
judgmental approach; gain insight into their own
conditions by listening to others; therapist observes
interactions, transferences for intervention
• Family or Marital Therapy
o Allows entire family to better understand how
psychopathology can affect the entire unit and be
aware when new tensions and conflicts may arise
and how to resolve them effectively
o Goals
▪ To reduce conflict
▪ Help members understand each other’s needs
(mutual accommodation)
▪ Help unit cope internally with disruptive forces
o Therapist will be attuned to boundaries between
family members (too rigid or too permeable);
therapist can point this out; triangles happen when
two families form an alliance against the third
o Marital therapy: Conflicts of sexual problems and
communication problems; party to safely express
their needs and desires and identifying obstacles;
conjoint and may have separate therapists who
collaborate with each other
PERSONALITY DISORDERS
Behavioral Theories and Sigmund Freud
• Sigmund Freud – behaviors result from unconscious
mental processes, including defense mechanisms and
conflicts between one’s ego, id, superego, and external
reality
o Austrian-born neurologist and founder of
psychoanalysis (topographic and structural
theories of the mind)
• Melanie Klein
o Austrian-British psychoanalyst → child
psychology and psychoanalysis
o Leader in object relations theory
o People developed a psyche in relation to others
in the environment during childhood
▪ Psyche = totality of the conscious and
unconscious mind
o First object is usually the internalized image of
the primary caregiver
• Heinz Kohut
o Austrian-american who practiced
psychoanalysis and developed self-psychology
▪ Three-part self
▪ Can only develop when the needs of
one’s self-states, including one’s sense
of worth and wellbeing are met in
relationships with others
• Margaret Mahler
o Hungarian Physician who later gained interest in
psychiatry
o A psychoanalyst who developed the separation-
individuation theory of child development (self of
children)
• Freud’s Theories of the Mind
o Thoughts that are out of ones awareness are
repressed thoughts (unconscious)
▪ Primary process thinking = primitive
pleasure-seeking (no regard to logic or
time); more prominent in children and
psychotics
▪ Id = unconscious state; includes sexual
and aggressive urges
o Preconscious includes memories or thoughts
that are just below the surface but can be
brought into awareness (similar to superego,
▪ Superego – moral conscience
o Conscious – one’s current thoughts that are in
complete awareness
▪ Ego = mediator between id and external
environment; develop gratifying
interpersonal relationships and relies on
defenses to control urges and to
achieve this
o Problems with reality testing occur in psychotic
individuals
• Defense Mechanisms
o Used by the ego to protect oneself and relieve
anxiety by keeping conflicts out of awareness
 o Unconscious = processes that are normal and
healthy when used in moderation
o Different groups
▪ Mature
▪ Neurotic
▪ Immature
Defense Mechanisms
Mature Defenses
Helps us to get by in day-to-day life.
• Altruism
o Performing acts that benefit others in order
to vicariously experience pleasure yourself
• Humor
o Expressing feelings through comedy
without causing discomfort to oneself or
others
• Sublimation
o Satisfying ones wishes or impulses in an
acceptable manner (channeling rather than
preventing)
• Suppression
o Purposely ignoring an unacceptable impulse
or emotion to diminish discomfort in
accomplishing a task
Neurotic Defenses
Can get in our way, can cause a lot of tension
• Controlling
o Regulating situations and events of external
environment in order to relieve one’s own
anxiety
• Displacement
o Shifting of emotions from an undesirable
situation to one that is personally tolerable
• Intellectualization
o Avoiding negative feelings by excessive use
of intellectual functions and by focusing on
irrelevant details in order to explain a point
• Isolation of affect
o Unconsciously limiting the experience of
feelings or emotions associated with a
stressful life event in order to avoid anxiety
• Rationalization
o Creating explanations of an event in order to
justify outcomes to make it justified to self
• Reaction Formation
o Doing the opposite of an unacceptable
impulse
• Repression
o Preventing a thought or feeling from
entering one’s consciousness
o Unconscious process, compared to
suppression
Immature Defense Mechanisms
• Acting Out
o Giving in to an impulse, even if socially
inappropriate in order to avoid the anxiety of
suppressing that impulse
• Denial
o Not accepting reality that is too painful
• Regression – performing behaviors from an earlier
stage of development in order to avoid tension
associated with current phase of development
• Projection – Attributing objectionable thoughts or
emotions onto others
Other Defenses (Neurotic or Immature)
• Splitting – Labelling people as all good or all bad (no
shades in the middle)
o Often seen in borderline personality disorder
• Undoing – attempting to reverse a situation by
adopting a completely new behavior
• Fantasy – Autistic retreat involving the creation of
imaginary lives to avoid conflict and obtain
gratification
• Dissociation – A temporary and drastic replacement
of an unpleasant mood state (or current personal
identity) with a more pleasant mood state (or
alteration in one’s sense of personal identity)
• Passive Aggressive – Aggression towards others is
expressed through passivity, masochism, and anger
towards oneself
Personality Disorders
Personality
• Enduring patterns of perceiving, relating to, and
thinking about the environment and oneself that are
exhibited across numerous social and personal
contexts
• It’s a set of stable, predictable emotional and
behavioral traits
Personality Disorders
• Disorders are egosyntonic (don’t disrupt the
individual who experiences them)
o A set of behaviors, values, feelings, needs,
goals, and ideal self-image which are in
perfect harmony
o Ingrained, and one has little insight into there
being a problem
o Far out of balance for others
• Approach to Management of Personality Disorders
o Aligning with the patient
 o Check countertransference
o Establish goals of treatment
o Psychotherapy usually most helpful
o Consider medication for target symptoms
• Psychodynamic Psychotherapy → helps patient
identify maladaptive parts of the personality →
transformation of a patient’s point of view of self’s
egosyntonic state which is actually an ego-dystonic
state
• Pharmacotherapy – used to treat biological
dimensions of personality that may respond to
medication (aggression, impulsivity, anxiety,
depression, and psychosis)
• Founders
o Sigmund Freud = personality traits are a
product of fixation at a particular stage at
psychosexual development
o Wilheim Reich – personality arose from
patterns of defense mechanisms
(unconscious mental processes that the ego
uses to resolve conflict and reduce anxiety)
• DSM-5 includes 10 personality disorders grouped
into three clusters based upon descriptive
similarities
o Cluster A (MAD) = Familial association with
psychotic disorders
▪ Schizoid
▪ Schizotypal
▪ Paranoid
o Cluster B (BAD) = familial association with
mood disorders
▪ Histrionic
▪ Borderline
▪ Narcissistic
▪ Antisocial
o Cluster C (SAD) = association with anxiety
disorders
▪ Avoidant
▪ Dependent
▪ OCD
• Overall personality disorder diagnosis and
assessment
o An enduring pattern of inner experience and
behavior that deviates markedly from the
expectations of the individual’s culture (Two
or more of the ff.)
▪ Cognition (ways of perceiving
andinterpreting self, other people,
events)
▪ Affectivity (range, intensity, lability,
appropriateness of emotional
response)
▪ Interpersonal functioning
▪ Impulse control
o The enduring pattern is inflexible and
pervasive
o Enduring pattern leads to clinically
significant distress or impairment in
functioning
o The pattern is stable and of long duration
(early adolescence or adulthood)
o Not better explained as a manifestation or
consequence of another mental disorder
o Not attributable to the physiological effects
of a substance (drug of abuse, a medication)
or another medical condition (head trauma)
CLUSTER A
• Commonly seen in encountered in a variety of clinical
settings
o 6% international prevalence
o Young adults, Poorly Educated, Unemployed
• Biological and Genetic Factors can be used, but the
best explanation is the Psychoanalytic Theory
• Preferred Defense Mechanisms
o Projection
o Denial
o Rationalization
Schizoid Personality
• Often confused with avoidant personality disorder.
Schizoid individuals do not want friends, but the
avoidant personality wants friends but is too shy
• Assessment
o Detachment from social relationships and a
restricted range of expression of emotions
in interpersonal settings (4 of the following):
▪ Neither desire nor enjoy close
relationships (including family)
▪ Prefer solitary activities
▪ Little sexual interest
▪ Takes pleasure in a few, if any,
activities
▪ Lacks close friends or confidants
other than 1st degree relatives
▪ Indifferent to the praise or criticism
of others
▪ Emotional coldness, detachment, or
flattened affectivity
• More common in males than females; higher
incidence in people with solitary jobs
• Psychotherapy is very helpful (capacity for
introspection)
• 1:1 therapy is important; it will take time to get this
patient willing to participate in group therapy
Schizotypal Personality o A pervasive distrust and suspiciousness of
• Assessment others such that their motives are
o Acute discomfort with and reduced capacity interpreted as malevolent (4 or more)
for close relationships as well as cognitive or ▪ Suspects, without sufficient basis,
perceptual distortions and eccentricities of that others are exploiting, harming,
behavior (5 or more of the following) or deceiving him or her
▪ Ideas of reference (excluding ▪ Doubts the loyalty or
delusions of reference) trustworthiness of friends and
▪ Odd beliefs or magical thinking that associates
influences behavior ▪ Fear confiding in others
▪ Unusual perceptual experiences, ▪ Misinterprets remarks or events as
including body illusions demeaning or threatening
▪ Odd thinking and speech (vague, ▪ Persistently bears grudges
circumstantial, metaphorical, (unforgiving of insults, injuries,
overelaborate, stereotyped) slights)
▪ Suspiciousness or paranoid ▪ Perceives attacks on his/her
ideation character or reputation as
▪ Inappropriate or constricted affect intentional and is quick to react
▪ Lack of close friends or confidants angrily or to counterattack
other than first-degree relatives) ▪ Recurrent suspicions without
▪ Behavior or appearance that is odd, justification of sexual partners,
eccentric, or peculiar married
▪ Excessive social anxiety associated o Does not occur exclusively during the course
with paranoid fears rather than of schizophrenia, bipolar disorder, or
negative judgements about depressive disorder with psychotic features,
themselves or another psychotic disorder and is not
o Does not occur during the course of attributable to the physiological effects of
schizophrenia, bipolar disorder, depressive meds
disorder with psychotic features, another • Prognosis: good support and ego strength
psychotic disorder, or ASD o Poor prognosis: individuals with poor insight
▪ “Premorbid” if happened before or a comorbid disorder
another disorder • Treatment
• Associated with superstitiousness, belief in o Psychotherapy: supportive, consistent,
clairvoyance, 6th sense, telepathy straightforward
• Teens or children may have bizarre fantasies or o 1:1 therapy best
preoccupations o Medications: (cautiously) low dose
• DDx: Schizophrenia antipsychotics and short-term
o Schizotypal has good reality testing, not benzodiazepines might help with paranoid
psychotic (odd and eccentric, but not ideation in severe anxiety, hostility,
psychotic) decompensation
• Facts CLUSTER B
o Affects 3%
Histrionic Personality
o Prognosis is guarded, since it can connect
• Assessment
with other people o Pervasive pattern of excessive emotionality
o 10% suicide rate and attention seeking, beginning by early
• Psychotherapy adulthood and present in a variety of
o Emphasis on the therapeutic alliance, contexts (5 or more)
support, and social skills training ▪ Uncomfortable when he/she is not
• Pharmacotherapy on low dose antipsychotics may the center of attention
be helpful ▪ Sexually seductive or provocative
Paranoid Personality behavior
• Assessment
 ▪ Rapidly shifting and shallow
expression of emotions
▪ Use physical appearance to draw
attention to self
▪ Imppresionistic speech
▪ Self-dramatization, theatricality,
exaggerated expression of emotion
▪ Suggestible (i. e. easily influenced)
▪ Considers relationships to be more
intimate than they really are
• Some other facts
o Women > men
o Variable Course
o Some experience attenuation of symptoms
with age
o Others have some co-morbid mood shifts
and dissociation to stressful states
• Treatment
o Psychodynamic psychotherapy (emotional
clarification, practical problem solving,
adherence to structure and detail to counter
their diffuse cognitive style)
o Medications: low dose benzodiazepine
(transient emotional states), low dose
antipsychotics for dissociation
Borderline Personality Disorder
• Assessment
o Pervasive pattern of instability of
interpersonal relationships, self-image, and
affects, and marked impulsivity, beginning
by early adulthood and present in a variety of
contexts (5 or more of the ff.)
▪ Frantic efforts to avoid real or
imagined abandonment
▪ Unstable and intense interpersonal
relationships (alternating between
extremes of idealization and
devaluation)
▪ Identity disturbance: marked
persistently unstable self-image or
sense of self
▪ Impulsivity in at least two areas that
are potentially self-damaging
▪ Recurrent suicidal behavior,
gestures, or threats, or self-
mutilating behavior
▪ Affective instability due to a marked
reactivity of chronic feelings of
emptiness
▪ Inappropriate, intense anger or
difficulty controlling anger
▪ Transient stress-related paranoid
ideation or severe dissociative
symptoms
o Enduring pattern that is inflexible and
pervasive across a broad range of personal
and social situations
o Enduring pattern leads to clinically
significant distress or impairment in
functioning
o Pattern is stable and of long duration, onset
can be traced back to at least adolescence
or early adulthood
o Enduring pattern not better explained as a
manifestation or consequence of another
disorder
o Enduring pattern is not attributable to the
physiological effects of a substance (drug of
abuse, medication) or another medical
condition (head trauma)
• Patients have a tendency to act out impulsively in
any of the following dangerous areas:
o Spending
o Sex
o Substance Abuse
o Reckless Driving
o Binge eating
• Differential Diagnosis
o Personality Disorders
o Bipolar Disorders
o Psychotic Disorders
• Epidemiology
o 2x women > men
o Increased risk for co-morbid disorders like
mood disorders, eating disorders,
substance abuse, etc.
o 10% will commit suicide before 30
• Treatment
o Dialectical behavioral therapy (how to take in
other points of views without being
unstable)
o Individual therapy (increasing coping skills,
distress tolerance, mindfulness affects
regulation and crisis management)
o Many clinicians experience counter-
transference
o Medications: Target symptoms like
impulsivity, emotional lability, psychosis, etc.
(antipsychotics or antidepressants)
▪ Shown to be more useful here than
in any other personality disorder
Narcissistic Personality
• Diagnosis
 o Pervasive pattern of grandiosity, need for
admiration, lack of empathy, beginning by
early adulthood and present in a variety of
contexts (5 or more)
▪ Grandiose self-importance
▪ Preoccupied with fantasies of
unlimited success, power, brilliance,
beauty, or ideal love
▪ Believes that he or she is special
▪ Requires excessive admiration
▪ Has a sense of entitlement.
▪ Is interpersonally exploitative (using
others to serve their own needs)
▪ Lacks empathy
▪ Often envious of others, believes
others are envious of them
▪ Arrogant, haughty behavior or
attitudes
• Exaggerates achievements and talents and expects
to be recognizes as superior without commensurate
achievements
• They often have unreasonable expectations of
especially favorable treatment or automatic
compliance with his or her expectations
• Course is chronic
• Biggest blow is aging
• Tend to hinge their self-esteem on things like youth
and beauty, career, and health, and are prone to
having a mid-life crisis
Antisocial Personality Disorder
• Diagnosis
o A pervasive pattern of disregard for and
violation of the rights of others, occurring
since age 15 years (3 or more)
▪ Failure to conform to social norms
with respect to lawful behaviors
▪ Deceitfulness – repeated lying, use
of aliases, or conning others for
personal profit or pleasure
▪ Impulsivity or failure to plan ahead
▪ Irritability and aggressiveness
▪ Reckless disregard for the safety of
self and others
▪ Consistent irresponsibility (failure to
sustain consistent work behavior or
honor financial obligations)
▪ Lack of remorse
o Individual must be at least 18 years old
o Conduct disorder before the age of 15
o Occurrence of antisocial behavior is not
exclusively during the course of
schizophrenia or bipolar disorder
• Most resistant in treatment
• Epidemiology
o More common in men than women
o Occurs five times more commonly in first
degree relatives of males with the disorder
o Course is variable (some people improve,
others end up in prison)
• Treatment
o Very difficult: hold people legally responsible
for their actions
o Medications: NO role in treatment unless
there are concerns for violence and
impulsivity
CLUSTER C DISORDERS
Avoidant Personality
• Diagnosis
o A pervasive pattern of social inhibition,
feelings of inadequacy, and hypersensitivity
to negative evaluation, beginning by early
adulthood and present in a variety of
contexts (4 or more)
▪ Avoids occupational activities that
involve significant interpersonal
contact because of fears of
criticism, disapproval, or rejection
▪ Needs a guarantee of being liked
before getting involved with others
▪ Shows resistant within intimate
relationships because of the fear of
being shamed or ridiculed
▪ Preoccupied with being criticized or
rejected in social situations
▪ Inhibited in new interpersonal
situations because of feelings of
inadequacy
▪ Views self as socially inept,
personally unappealing, or inferior
to others
▪ Is unusually reluctant to take
personal risks or to engage in any
new activities because they may
prove embarrassing
• DDx: Social phobia
• Equally among men and women
• Able to function in relationships, provided they feel
safe and accepted
• Treatment:
o Creating a safe environment
o Anxiolytics can be helpful along with SSRIs
Dependent Personality
• Diagnosis
o A pervasive and excessive need to be taken
care of that leads to submissive and clinging
 behavior and fears of separation, beginning
by early adulthood and persisting in a variety
of contexts (5 or more)
▪ Difficulty making everyday
decisions without an excessive
amount of advice and reassurance
from others
▪ Needs others to assume
responsibility for most major areas
of his/her life
▪ Has difficulty expression
disagreement with others because
of fear of loss of support or
approval (do not include realistic
fears of retribution)
▪ Difficulty initiating projects or doing
things on his or her own (lack of
self-confidence in judgement or
abilities rather than a lack of
motivation or energy)
▪ Goes to excessive lengths to obtain
nurturance and support from
others, to the point of volunteering
to do things that are unpleasant
▪ Feels uncomfortable or helpless
when alone because of exaggerated
fears of being unable to care for
himself/herself
▪ Urgently seeks another relationship
as a source of care and support
when a close relationship ends
▪ Unrealistically preoccupied with
fears of being left to take care of
themselves
• Females> males
• Childhood separation anxiety or chronic illness →
predisposition
• Comorbidities
o Dysthymia
o Major depression
o Alcohol abuse
• Treatment
o Individual psychotherapy and group therapy
o Medication: SSRIs intermittently effective
OCPD
• Diagnosis
o Pervasive pattern of preoccupation with
orderliness, perfectionism, and mental and
interpersonal control, at the expense of
flexibility, openness, and efficiency,
beginning by early adulthood and present in
a variety of contexts (4 or more)
▪ Preoccupied with details, rules, lists,
order, organizations, or schedules
to the extent that the point of the
activity is lost
▪ Shows perfectionism that interferes
with task completion (unable to
complete a project because of
his/her own strict standards)
▪ Excessively devoted to work and
productivity to the exclusion of
leisure activities and friendships
▪ Overconscientious, scrupulous,
inflexible about matters of morality,
ethics and values
▪ Unable to discard worn-out or
worthless objects even when they
have no sentimental value
▪ Reluctant to delegate tasks or work
with others unless they submit to
his exact way of doing things
▪ Miserly spending style toward both
self and others; money is hoarded
for future catastrophies
▪ Rigidity and stubbornness
• Epidemiology
o More common in males, concordance in
identical twins
o Tends to run in families
• Comorbidities
o Depression, Somatoform disorders, Alcohol
Abuse
• Treatment
o Hopeful, individuals have good insight into
the impact of their behavior
o Psychodynamic or group therapy
o Cognitive behavioral therapy
▪ Impulse control
▪ Frustration tolerance
▪ Impaired cognition strategies
MAJOR PSYCHIATRIC DISORDERS
Psychosis, Delusions, and Hallucinations
(Psychotic Disorders)
Psychosis
Defined as a break from reality, involving delusions, perceptual
disturbances, or disoriented thinking
Delusions
• Delusions: fixed, false beliefs, rational arguments
that cannot be accounted for by the cultural
background of the individual
 o Paranoid Thinking: irrational belief that one
is being followed, tracked, or targeted (FBI)
▪ “the FBI are tracking me”
o Ideas of reference: belief that some event is
uniquely related to the individual
▪ “The news is broadcasting me”
o Thought broadcasting: Ones thoughts can
be heard audibly by others
▪ “I can hear everything you say”
o Delusion of grandeur: One has special
powers beyond those of a normal person
▪ “I am the smartest person alive”
o Delusions of guilt: false belief that one is
guilty or responsible for something
▪ “I am solely responsible for my
aunt’s failing health”
o Persecutory delusions: belief one is being
followed/harassed by gangs
▪ “My class is ganging up on me”
o Erotomanic delusions: belief that a famous
movie star is in love with them
▪ “I am convinced that she loves me”
o Somatic delusions: Belief that the body is
somehow diseased
▪ “My scalp itches and therefore there
is lice”
Hallucinations
• Hallucinations: Perceived senses not existing in
reality (different from an illusion which is a
misinterpretation of an existing stimulus)
• Types
o Auditory hallucinations (hearing voices):
most common in schizophrenic patients
▪ Command voice
▪ Running commentary: very
distressing
▪ One/several voices talking at the
same time
o Visual hallucinations (hearing things): often
seen in Lewy Body dementia and drug
intoxication
o Olfactory hallucinations (smelling things):
often indicative of an aura with epilepsy
o Tactile hallucinations (feeling things):
secondary to drug abuse or alcohol
withdrawal
Thought Disorders
• Disordered Thought Content: Patient’s beliefs, idea,
and interpretations of his or her surroundings
• Alogia/poverty of content (very little information
conveyed by speech)
• Perseveration: repeating words or ideas persistently,
even after interview topic has changed
• Disordered Thought Process: Manner in which the
patient links ideas and words together
• Thought blocking: Suddenly losing train of thought
exhibited by interruption in speech
• Loosening of association: Speech content notable
for ideas presented in sequence that are not closely
related
• Tangentiality: Answers to interview questions
diverging increasingly from topic being asked about
(circumstantiality if content eventually returns to
original topic)
• Clanging or Clang association: Using words in a
sentence that are linked by rhyming or phonetic
similarities
• Word Salad: real words are linked together
incoherently, uielding nonsensical content
DDx for Delusional College Student
• General medical conditions (always consider this in
psychiatric disorders) – easy to treat, reversible
o Delirium: frequent cause of delirium
including fluid or electrolyte abnormalities
▪ Substance intoxication,
Hypoglycemia, Hypercapnea,
Hypoxia, Infections or medications
o Endocrine: thyroid, parathyroid, adrenal
o Hepatic: encephalopathies
o Infectious disease: syphilis, herpes simplex,
lyme disease, prions, HIV
o Inflammatory: SLE, ANRE,
Leukodystrophies, MS
o Metabolic disorders: Acute intermmitent
porphyria, Wilson’s
o Neurodegenerative: dementia with lewy
bodies, huntington’s, parkinson’s,
alzheimer’s
o Neurological: space-occupying lesions,
seizure, head trauma
o Vitamin deficiency: B12
o REMEMBER: VINDICATE
▪ Vascular
▪ Inflammatory/Infectious
▪ Neoplastic
▪ Degenerative/Deficiency/Drugs
▪ Idiopathic/Intoxication/Iatrogenic
▪ Congenital
▪ Autoimmune/Allergic/Anatomic
▪ Traumatic
▪ Endocrine/Environmental
▪ Metabolic
• Substance abuse – can be quickly treated
 • Brief psychotic disorder
• Schizophreniphorm disorder
• Schizoaffective disorder
• Schizophrenia
• Schiztoypal
• Mood disorder
• Schizoid personality
Schizophrenia
A psychiatric disorder characterized by a constellation of
abnormalities in thinking, emotion, and behavior
Epidemiology
• Affects 1% of people over their lifeting
• Men and women are equally affected (men at 20,
women at 30)
• It rarely presents before age 15 or after 45
• Winter birth is associated with higher rates of
schizophrenia: environmental stressors, nutrition,
infection?
Pathogenesis
• Dopamine pathways
o Mesolimbic pathway (positive symptoms)
▪ Plays a key and complex role in
motivation, emotions, reward, and
positive symptoms
schizophrenia
o Mesocortical (negative symptoms)
▪ Relevant for cognitive and executive
function (dorsolateral prefrontal
cortex)
▪ Emotions affect (ventromedial
prefrontal cortex)
▪ Hypofunctioning → negative
symptoms
o Nigrostriatal (extrapyramidal symptoms and
tardive dyskinesia)
▪ Contains about 80% of the
dopamine (dysregulated
psychosis)
▪ Pathway involved in motor planning,
dopaminergic neurons stimulate
purposeful movements
o Tuberoinfundibular (hyperprolactinemia)
▪ Dopaminergic projections in the
tuberoinfundibular pathway
influence prolactin release
▪ Released into portal circulation
connecting the median eminence
with the anterior pituitary gland
▪ Role of dopamine release in the
tuberoinfundibular pathway is to
tonically inhibit prolactin release
• Other causes
o Downward Drift Hypothesis: individuals who
are affected tend to follow a downward
trajectory (low education, low employment,
drifting downward in the social stratosphere
o Other neurotransmitters (serotonin,
norepinephrine, histamine, GABA)
o Glutamate neurotransmitter in research?
▪ NMDA glutamate receptor is
blocked by PCP (angel dust) →
produces similar symptoms to
schizophrenia
Psychiatric Indications
• Neuroimaging studies indicated for:
o First episode psychosis
o Confusion
o Dementia of unknown cause
o Prolonged catatonia
o Movement disorder of unknown etiology
o Personality changes after age 55
• Most consistent functional neuroimaging study
finding
of o Hypofrontality
Schizophrenia Assessment
• Three Phases of Schizophrenia
o Prodromal phase: decline in functioning that
precedes the first psychotic episode
(socially withdrawn, irritable)
o Psychotic: perceptual disturbances,
delusions, and disordered thought process
and content
o Residual: Between psychosis: flat affect,
social withdrawal, odd behaviors
• Strongest predictor of treatment: duration of
presenting symptoms before treatment
in
• Subtype of schizophrenia is associated with better
short and long-term outcomes: Paranoid subtype
• Different Symptoms of Psychosis
o Positive symptoms (more active)
▪ Disorganized thought
▪ Bizarre behavior
▪ Delusions
▪ Hallucinations
o Negative symptoms (more withdrawn)
▪ Blunted or flat affect
▪ Inattentiveness
▪ Apathy
▪ Anhedonia
• Schneider First-Rank Symptoms of Psychosis
 o Hallucinations developmental disorder, the additional
o Delusions diagnosis of schizophrenia is made only if
o Thought insertion prominent delusions or hallucinations are
o Thought Withdrawal also present for at least a month (or less if
o Thought Broadcasting treated)
• History ▪ Symptoms only persist for less than
o Kurt Schneider was a German psychiatrist → a month
writing on the diagnosis and understanding of • Schizophreniform: disruption to occupational
schizophrenia functioning is under 6 months
o Eugen Bieuler: 5 As of Schizophrenia: Schizophrenia Treatment
anhedonia, affect (flat), alogia (poverty of • Prognostic Factors
thought), avolition(apathy), attention (poor) o Onset: Adult onset is better
o Emil Kraeplin coined the term Dementia o Social Support: Good
Praecox o Positive symptoms are better than negative
• Head CT Scan: Ventricle enlargement and cortical symptoms
atrophy o Family history
• Suicide Risk Assessment is very important for o Mood symptoms have a better prognosis
suicide: 10% of patients will actually commit suicide o Gradual onset: bad prognosis
o Risk Factors o Females > Males
▪ Male gender o Few relapses vs. Many relapses (latter is
▪ <30 Age bad)
▪ College education o Good premorbid functioning
▪ Paranoid subtype • Tendency for violence?
▪ Comorbid substance o More likely victims of violence than
▪ Depressive perpetrators
▪ Unemployment • Cognitive problems: deficits of processing of
▪ Frequent exacerbation complex information, maintaining a steady focus of
▪ Prior suicide attempts attention, working memory, distinguishing between
▪ Living alone relevant and irrelevant stimuli, abstract thinking
▪ Recent hospital discharge • Social Skills: Difficult in generalizing information
• Core of Schizophrenia: considered the core, most learned to real-life settings
difficult to treat • Best Approach: Be direct and straightforward, take
• Assessment and Diagnosis an active and assertive approach
o Patient needs to have 2 or more of the • Group Therapy: not well tolerated by psychotic
following symptoms, present for a individuals due to overstimulation: only high
significant amount of time over a one-month functioning and stable persons can tolerate this
period • Behavioral Therapy
▪ Delusions o Developing social skills, self-sufficiency,
▪ Hallucinations ability to act appropriately in public
▪ Disorganized Speech o Aimed to help improve patients function well
▪ Grossly Disorganized behavior in society
▪ Negative Symptoms • Culture Specific Psychosis
o Disorder affects domains of life including o Koro: Belief that penis is shrinking and will
social and occupational functioning cause death
(continuous signs persist for at least 6 o Amok: Malaysia, SEA, sudden unprovoked
months) outbursts of violence often followed by
o Schizoaffective disorder and mood disorder suicide
with psychotic features have been ruled out o Brain fag: Headache, fatigue, visual
o Not due to substances or a general medical disturbances in male students
condition • Other syndromes
o If the patient has a history of autistic o Capgras: delusions that imposters have
disorder or another pervasive replaced familiar people
 o Fregoli’s syndrome: persecutor is taking on
a variety of faces like an actor
o Lycanthropy: Delusions of being a werewolf
o Heutoscopy: fale belief that one has a
double
o Cotard syndrome: Delusional belief that the
individual has lost everything, including body
organs
o Folie a deux: a shared psychotic disorder
Antipsychotics
Medications that are categorized as typical and atypical, which
work by blocking dopamine receptors and thereby reducing
psychotic symptoms
• Used to treat psychotic disorders and psychotic
symptoms associated with other psychiatric and
medical illnesses
• Typical: Chlorpromazine, thioridazine, fluphenazine,
haloperidol
o D2 antagonists (high potency)
o Better at treating positive symptoms than
negative
o Can cause extrapyramidal side effects
o Two types
▪ High potency expels are haloperidol,
trifluoperazine, fluphenazine
▪ Low potency are thioridazine and
chlorpromazine
• Atypical: Risperidone, clozapine, quetiapine,
aripiprazole, ziprasidone
o Antagonize D2 receptors (low potency) and
serotonin receptors
o Better at treating negative symptoms
o Can cause anticholinergic and metabolic
side effects
o Antagonize 5HT2, alpha, histamine, and
dopamine receptors
• Target of antipsychotic are: Dopaminergic neurons
• Specific pathways
o Nigrostriatal (extrapyramidal, motor)
o Mesolimbic (mood and reward)
o Tuberoinfundibular (prolactin)
• Neuroleptics are highly fat soluble and therefore
there are a lot of options or IM medications
• Use of Medications
o Psychosis
o Schizophrenia
o Mania
o Tourette’s Syndrome
Low Potency Traditional Antipsychotics
• Lower affinity for dopamine receptors and therefore
a higher dose is required
• Potency refers to the action on dopamine receptors,
not the level of efficacy
• Chlorpromazine (Thorazine) and Thioridazine
(Mellaril)
• Higher incidence of anticholinergic and
antihistaminic side effects than high potency
traditional antipsychotics
• Lower incidence of extrapyramidal side effects and
neuroleptic malignant syndrome
• Both traditional and atypical neuroleptics have
similar efficacies in treating the presence of positive
psychotic symptoms, such as hallucinations and
delusions
• Atypical antipychotics are better for negative
symptoms
High Potency Traditional Antipsychotics
• Have a greater affinity for dopamine receptors, and
therefore a relatively low dose is needed to achieve
effect
• Haloperidol (Haldol), Fluphenazine (Prolixin),
Trifluperazine (Stelazine) and Perphenazine
(Trilafon)
• Higher incidence of EPS and neuroleptic malignant
syndrome than low-potency traditional
antipsychotics
• Lower incidence of anticholinergic and antihistamine
side effects
Extrapyramidal Side Effects of High Potency D2 blockers
• Dopamine blockade typically through the
nigrostriatal pathway
• Acute Dystonia (3 hours) as oculogyric crisis or
torticollis → Bradykinesia (3 days to 3 weeks) or
Pseudo-parkinsonism as masked facies, cogwheel
rigidity, bradykinesia or slowed movement, turning
on block, tremor → Akathisia (3 months) or internal
sense of restlessness (pacing, tapping their foot) →
Tardive Dyskinesia (3 years to decades) usually
elderly Caucasian women, as abnormal movements
of somebody’s face (sticking tongue out repeatedly,
smacking their lips together, etc.); most cases are
non-reversible
Traditional Antipsychotic Side Effects
• Antidopaminergic
o Extrapyramidal side effects (dystonia,
akathisia, parkinsonism),
hyperprolactinemia, neuroleptic malignant
syndrome
• Anti-HAM
 o Antihistaminic o Unstable vitals
▪ Sedated o Increased CK, K+ and WBCs
o Anti-alpha adrenergic • Treatment
▪ Orthostatic hypotension, Cardiac o Anticholinergic medications
abnormalities, Sexual dysfunction o Beta blockers
o Antimuscarinic o Benzodiazepines
▪ Dry mouth, Tachycardia, Urinary o Stop high potency D2 blockers
Retention, Blurry vision, o Dantrolene
Constipation o Cooling
o Weight Gain o IV fluids
o Elevated Liver Enzymes o Stop antipsychotics
o Ophthalmologic o Switch to atypicals
o Dermatologic • NMS Is not an allergy (a patient can restart a
o Seizures neuroleptic later)
• Tardive Dyskinesia
o Choreoathetoid (writhing movements) Atypical Antipsychotics
movements of mouth and tongue (older • Mechanism of Action
women, often permanent) o Block both dopamine and serotonin
o Very serious side effect → permanent receptors, and are associated with fewer
disfiguration side effects than traditional antipsychotics;
o Give a drug holiday or switch to an atypical they rarely cause EPS, tardive dyskinesia, or
antipsychotic NMS
• Acute Dystonia o Increased effectiveness in treating negative
• Bradykinesia symptoms with fewer side effects → first
• Akathisia line in treatment of schizophrenia
• Neuroleptic Malignant Syndrome o High affinity for receptors other than
dopamine
Neuroleptic Malignant Syndrome • Types
A life-threatening reaction to antipsychotic drugs characterized o Clozapine
by fever, altered mental status, muscle rigidity, and autonomic o Risperidone
dysfunction o Quetiapine
o Olanzapine
• Most common in males, particularly young African o Ziprasidone
males early in treatment • Side Effects: Antihistaminic, Antimuscarinic
• Rare! But a true medical emergency, 20% can die o Clozapine (one of the oldest atypical)
• Assessment ▪ Not used quite as frequently
o Often preceded by a catatonic state because of its side effects that
o Fever require monitoring
o Autonomic Instability (Tachycardia, blood ▪ Great for treatment-resistant
pressure changes, diaphoresis) ▪ 1% incidence of agranulocytosis
o Leukocytosis and 2-5% incidence of seizures with
o Tremor clozapine
o Elevated creatinine phosphokinase ▪ Weight gain medication
o Rigidity ▪ Increased seizures, Sialorrhea
• Signs (atropine drops on their tongue at
o Muscle spasms night), Orthostatic hypotension,
o Trouble swallowing Myocarditis
o Symptoms of Parkinson’s disease o Olanzapine: significant weight gain,
o Sustained feeling of motion hyperlipidemia, glucose intolerance, liver
o Uncontrollable repetitive, stereotypical, toxicities → diabetes
writhing movements usually of the tongue o Risperidone
o High fever ▪ High potency
o Muscle rigidity ▪ Usually first line
 ▪ Comes in an injectable form
▪ Hyperprolactinemia, Weight Gain
o Ziprasidone
▪ Short acting injectable options are
available
▪ Minimal to no weight gain
▪ Increased QTc → check ECG
o Quetiapine
▪ Not only indicated for psychotic, but
can also be used for mood stabilizer
and antidepressant
o Lurasidone
o Aripiprazole (D2 partial agonist →
augmentation of major depression therapy)
o Metabolic Syndrome (elevated fasting
glucose, hypertension, abdominal obesity,
elevated triglycerides, decreased high-
density lipoproteins) → Clozapine and
Olanzapine
▪ Get on a weight-reduction program,
dietary changes, reduce dose of
medication or switch to another
agent
• Medications as IM
o Antipsychotics (IM and long-acting forms):
fluphenazine decorate, haloperidol
decanoate, Risperdal consta
o Newer agents: Paliperidone (Invega
Sustenna)
o Aripiprazole (abilify Maintena)
▪ Monthly or Bimonthly
o Emergency as Short-acting IM forms
▪ Fluphenazine, Haloperidol,
Chlorpromazine, Aripiprazole,
Ziprasidone, Olanzapine
• Clozapine
o Since it can cause agranulocytosis →
monitoring
o Discontinue if: WBC drops to 2000, or
3000/mm3 or ANC is < 1500.mm3
o Patients should be monitored daily if this
happens and closely watch for infection
o Recommendations for monitoring blood
counts
▪ Baseline and weekly for 6 months
then 2x a month for 6 months and
then monthly
▪ WBC >3500, ANC > 1500 then
treatment can continue
• Still consider nonpharmacologic therapy though
o Behavioral Therapy Treatment: social skills,
self-sufficiency, public
o Cognitive problems: memory, deficits of
complex information, abstract thinking,
getting pertinent information
o Social Skill Training → difficult
Depression (A mood disorder)
An episode of dysphoria associated with a low mode and a
disinterest in activities
• Epidemiology
o Lifetime prevalence is 15%
o Onset at any age: young adults and elderly
o 18-29-year-old individuals is3x higher than
other groups
o Females 1.5-3x higher
o None across ethnic groups, but some
minorities are more likely to be inaccurately
diagnosed
o 2/3 of all depressed patients will
contemplate suicide, 10-15% commit
suicide
o Only half every receive treatment
• Anger turned inward: Sigmund Freud in classic 1917
paper mourning and melancholia where he
described depression as introjected rage over object
loss
• Cause of Depression
o Unknown, but biological, genetic,
environmental, and psychosocial factors
play a role
Pathogenesis
• Pathogenesis: Serotonin, Catecholamines
o What is decreased? Drugs that increase
availability of serotonin, norepinephrine, and
dopamine alleviate symptoms of depression
o Antidepressants increase the amount of
norepinephrine and serotonin in the brain by
increasing concentration in the synapse and
by downregulating postsynaptic receptors
o CSF: Serotonin in CSF in decreased
• Pathogenesis: Neuroendocrine Abnormalities
o High cortisol: hyperactivity of the HPA axis
▪ Hippocampus is sensitive to the
neurotoxic properties of cortisol,
elevated during times of stress:
volume is correlated with
depressive episodes
o Thyroid disorders are associated
• Psychosocial Factors
o Family: loss of parent before age 11 is
associated with depression
o Stable Family and social Functioning: Good
prognostic Factors
 • Genetics
First degree relatives are 2-3x more likely
Assessment
• Patient must meet 5 of these criteria
o Depressed mood
o Sleep Disturbances – required (oversleeping
or undersleeping or early morning
awakening))
o Anhedonia (loss of pleasure) - required
o Appetite/Weight Changes
o Psychomotor agitation or retardation
(fidgety, or retarded)
o Loss of energy
o Feeling worthless or excessively guilty
o Trouble concentrating
o Recurrent thoughts of suicide (ask them if
they have any plan to harm themselves)
o SIGECAPS (Sleep, Interest, Guilt, Energy
changes, Concentration, Appetite,
Psychomotor Activity, Suicidal ideation)
• Note: symptoms have to cause marked impairment
in social or occupational functioning
• Symptoms are not due to a medical illness or
substances
o CVD (heart disease, stroke, jypertension)
o Endocrine (Cushing’s Syndrome, Addison’s
disease, hypoglycemia, etc)
o Neurological (seizures, Parkinson’s)
o Viruses (HIV/AIDS, mononucleosis)
o Cancer (lymphoma, pancreatic CA, head and
neck CA)
o Collagen Vascular Diseases (SLE)
o Pain (chronic)
o Substances: Alcohol, Anti-hypertensives,
Barbiturates, Corticosteroids, Levodopa,
Sedative-hypnotics, Anticonvulsants,
Antipsychotics, Diuretics, Sulfonamides,
Withdrawal
o Do a thorough history and a physical exam
Types of Depression
Anxious Distress
• Two or more of the following:
o Tension
o Restlessness
o Impaired concentration due to worry
o Fear that something awful might happen
o Fear of losing control
Atypical Features
• 3 or more of the following:
o Reactive to pleasurable stimuli (feels better
in response to positive events)
o Increased appetite or weight gain
o Hypersomnia (sleep at least 10 hours a day,
or at least 2 hours more than usual)
o Heavy or leaden feelings in limbs
o Longstanding pattern of interpersonal
rejection sensitivity (feeling deep anxiety,
humiliation, or anger at the slightest rebuff
from others)
Catatonia
Prominent psychomotor disturbances (increased or decreased
activity) which occur most during the episode
• Treat by antidepressants, sometimes antipsychotics
concurrently
Psychotic
• Psychotic features include delusions (false, fixed
beliefs) and hallucinations (false sensory
perceptions) which can occur at any time during a
depressive episode
Dysthymia
• Dysthymia Diagnosis (Persistent depressive
Disorder)
• 3 or more
o Depressed mood most of the day, more
days than not
o Decreased or increased appetite
o Insomnia or hypersomnia
o Low energy or fatigue
o Impaired concentration or decision making
o Hopelessness
Seasonal Pattern
• A regular temporal relationship between the onset of
major depressive episodes and a particular time of
year, for the past two years. Remission also occurs
at a specific time of the year
• Classic Triad: Irritability, Carbohydrates,
Hypersomnia
Melancholic
• Four or more of the following:
o Loss of pleasure in most activities
o Unreactive to usually pleasurable stimuli
(does not feel better in response to positive
events)
o Depressed mood marked by profound
despondency, despair, or gloominess
o Early morning awakening (2 hours before
usual)
o Psychomotor retardation
o Anorexia
 o Excessive guilt Best Treatment for Depression
• Hospitalization: indicated if patient is at risk of
Mixed
hurting themselves, others, or they cannot meet their
• 3 or more of the following basic needs
o Loss of pleasure in most activities o Involuntary admission
o Inflated self-esteem or grandiosity ▪ Permitted when an individual poses
o More talkative or pressured speech a serious risk of harm to self or
o Flight of ideas others
o Increased energy or goal-directed activity ▪ Goal: acute safety, observation, and
o Decreased need for sleep rapid treatment and effective
o Excessive involvement in pleasurable discharge planning
activities that have a high potential for o Voluntary Admission
painful consequences
• Pharmacotherapy: Antidepressants, stimulants,
Peripartum antipsychotics, mood stabilizers, anxiolytics
• Refers to onset of mood episodes during pregnancy o Antidepressants
or within four weeks of childhood ▪ SSRIs
• Postpartum onset: symptoms appear within 4 weeks ▪ Tricyclics
• 10-15% of postpartum depression ▪ Monoamine oxidase inhibitors
• Differentiated from baby blues (50% of postpartum o Adjunctive meds
women ▪ Stimulants
▪ Especially in elderly and terminally ill
Normal Grief and Bereavement can look like depression, but o Antipsychotics
is normal for two months. Beyond 2 months, it’s depression. ▪ Psychotic features, catatonia
o Other
Depression Treatment ▪ Thyroid treatment
Suicide Risk Assessment Screening o Equally effective but differ in side effects. They
• It is extremely important to screen for suicide risk at take about 4-8 weeks to work.
every encounter with a patient ▪ Serotonin Syndrome: marked by
• Risk Assessment autonomic instability, hyperthermia,
o Chronic: Age, Previous Suicide Attempts, seizures (SSRI + MAO inhibitor or
Ownership of Guns and Weapons, Race, multiple SSRIs) → coma and death
Family History of Suicide Attempts • Psychotherapy:
o Modifiable: mental illness, physical illness, o Behavioral, cognitive, supportive,
substance abuse, connection to treatment, psychotherapy, family therapy
support network o Useful along with medication management
o Protective: Finances, Education, Religion, • ECT
Family/Friends, Employment, Pets o Used in treatment resistant cases
• What percentage of people with major depression o Safe and can be used alone or along with
will go on to a second episode? pharmacotherapy: approximately 8-10
o 50% will experience a second treatments are useful
o 70% of those with two episodes will o Side effect: retrograde amnesia
experience a third
o 90% Three or more episodes → will Antidepressants
experience another General Principles
• Children: headline depression: often manifests as • SSRIs most often used, followed by atypical
irritability instead of a low mood • Treatment choice should be based on:
• Elderly: Major depression is a common mental o Symptoms
disorder; twice as likely to commit suicide as the o Risk of suicide
general population o Previous response to medications (by
o 15% of nursing home residents patient or family)
o Symptoms: look like memory and cognitive o Side effects
problems (mimicking dementia) = pseudo o Comorbid conditions
dementia • Indications other than Depression
 o OCD, Anxiety, Panic, Eating disorder,
Dysthymia, Social Phobia, PTSD, IBS,
Enuresis, neuropathic pain, migraine,
smoking cessation, autism, premenstrual
dysphoric disorder, depressive phase of
mania, insomnia
• Serotonin Syndrome: group of symptoms that may
occur form any SSRIs or combination of MAOs with
SSRIs or SNRIs
o Symptoms: autonomic dysfunction High
body temperature, agitation, increased
reflexes and tremors, sweating, dilated
pupils, diarrhea
• SS Assessment
o Lethargy
o Restlessness
o Confusion
o Flushing
o Diaphoresis
o Tremor and Myoclonus
o → Progresses to hyperthermia,
hypertonicity, rhabdomyolysis, renal failure,
convulsions, coma and death
• Complications when transitioning form SSRI to MAO
o Always wait at least 2 weeks before
switching from SSRI to MAOi to avoid
serotonin syndrome (5 weeks if switching
from fluoxetine to a MAOi)
• Treating Major Depression
o 70% will respond to antidepressant
medication
Tricyclic Antidepressants
• Imipramine, Amitriptyline, Doxepin, Clomipramine,
Nortriptyline, Desipramine
• Mechanism of Action: blocks reuptake of
noradrenaline and serotonin, increasing their
amounts in the synapse
• Use: Major Depression, Enuresis, OCD, Fibromyalgia
• Side Effects: Anticholinergic (Tachycardia, Urinary
Retention)
o Antihistamine, Antiadrenergic,
Antimuscarinic properties → lack specificity
o Anti-alpha adrenergic (Sedation)
o Lower seizure threshold
o Sedation, Orthostatic hypotension,
Constipation, Dry Mouth, Weight Gain,
Blurred Vision, Lethality
• Toxicity Side effects (Fatal): 3 Cs (don’t use on
elderly or with suicidal ideation)
o Convulsions
o Coma
o Cardiotoxicity (arrhythmia)
• Rarely first line agents: cardiotoxicity
• Start on low doses to allow acclimation to the
common early anticholinergic side effects
Monoamine Oxidase Inhibitors
• Phenelzine, Tranylcypromine, Isocarboxazid,
Selegeline
• Mechanism of Action: Decreased MAO activity →
decrease amine degradation and increase levels of
amine neurotransmitters
o Prevent inactivation of biogenic amines
(including tyramine) → overload of tyramine
• Use: Atypical depression, Treatment-resistant
depression, Anxiety, Hypochondriasis
• Side effects: hypertensive crisis (deadly when food is
tyramine rich like wine and cheese), CNS Stimulation,
drowsiness, weight gain, dry mouth, sexual and sleep
dysfunction
o Serotonin syndrome → treat with
cyproheptadine and discontinue
medications
• Not first line for safety and tolerability
SSRIs
• Drug examples: Citalopram, Escitalopram,
Fluoxetine, Fluvoxamine, Paroxetine, Sertraline
• MOA: Decreases serotonin reuptake pump in
presynaptic neurons thereby increasing synaptic
serotonin
• Similar efficacy and side effects despite structural
differences
o Advantages: low incidence of side effects,
no food restrictions, much safer in overdose
• Use: Depression, OCD, PTSD, Panic, Generalized
Anxiety, Bulimia, Binge Eating, Social Phobia,
Premenstrual Dysphoria
• Toxic/Side effects: mild, Weight Gain, QTC
Prolongation, GI distress, sexual dysfunction (treat
with buproprion or mirtazapine), serotonin syndrome
• Most common used
SNRIs
and • Drug examples: Venlafaxine, Duloxetine
• MOA: Serotonin, noradrenaline, and dopamine
increase
• Use: Depression, Fibromyalgia, Generalized Anxiety,
Diabetic peripheral neuropathy
• Toxicity/Side effects: hypertension, sedation, nausea
o Sexual dysfunction, GI disturbance,
Insomnia, headache, Anorexia, Weight Loss,
Serotonin Syndrome
• Withdrawal: after 1-3 missed doses (flulike
symptoms and electric-like shocks or zaps)
 • Venlafaxine: used in treating refractory depression o Medical causes of Mania
(low reaction potential) ▪ Neurologic Disorder (temporal lobe
seizures, MS, viral encephalitis,
Atypical Antidepressants tumors)
• Buproprion (NDRI): increased noradrenaline and ▪ Metabolic (hypothyroidism,
dopamine → stimulant Cushing’s)
o Used to aid In smoking cessation; treatment ▪ Neoplasms, HIV
of SAD and ADHD ▪ Systemic disorders (B12 deficiency,
o Significant advantage is lack of sexual side uremia, carcinoid syndrome)
effects o Medications: corticosteroids,
o Dopaminergic effect in higher doses can sympathomimetics, bronchodilators,
exacerbate psychosis (lowers seizure levodopa, antidepressants, dopamine
threshold) agonists
• Mirtazapine: Alpha-2 antagonist that can cause
weight-gain and sedation
o Useful in treatment of refractory depression
o So stressed that they’re not eating, sleeping,
etc. in elderly
• Trazadone: inhibits serotonin reuptake and causes
sedation
o Prapism (trazobone) = prolonged and
painful erection
• SARIs: treatment of refractory major depression,
major depression with anxiety, insomnia

Bipolar Disorder Cause and Assessment

A mood disorder that is characterized by episodes of mania,
hypomania, and major depression.
• Types of Bipolar Disorder
o Bipolar 1: At least one manic episode
accompanied by depressed or hypomanic
periods
o Bipolar 2: At least one hypomanic episode, at
least one major depressive episodes, no
manic episodes
o Mixed episodes: both depressive and manic
episodes at the same time
o Rapid cycling: alternating periods of
hypomania and periods with mild to
moderate depressive symptoms over the
course of two years
• Epidemiology
o 1-3% lifetime prevalence
o Mean age of onset
▪ Bipolar I: 18; Bipolar 2: 20
o MF 1:1
o Often presents in primary care settings
o History of one manic episode: 90% will have
another manic episode if not getting
treatment (during times of sleep disruption)
• Tends to be underdiagnosed and is often
misdiagnosed
• Differential Diagnosis
• Exact cause is unknown: biologic, psychologic, and
social factors
o Genetics: Family, twin, and adoption →
involved genetics in pathogenesis
▪ Candidate genes: genetic
susceptibility is the interaction of
many genes
o Psychosocial Factors
▪ Advancing paternal age, stressful
life events, childhood maltreatment,
abuse
▪ Sleep deprivation, experimentation
of illicit drugs
o Neurobiology: Brain structure and function
are altered in bipolar disorder
▪ Neuroimaging: Early developmental
processes (pruning) that modulate
emotional behavior are disrupted
▪ Inflammation: immune system
dysregulation (correlation with
mood disorder
• Assessment
o Evaluation
▪ Thorough History: Major
depression, Mania, Hypomania,
Suicidal thoughts, Risk factors,
family history, psychotic symptoms,
 co-morbid psychiatric or general
medical disorders
▪ Family History of bipolar,
medications
o Exam (rule out general medical problems)
▪ Mental Status Exam
▪ Full Head to Toe Exam
o Lab Tests
▪ TSH, CBC, BMP, LFT, Drug screen,
Pregnancy
• A manic episode
o Medical emergency: judgement is severely
impaired → places them at high risk
• Special considerations: collateral information from
patients family members: talk with former treatment
providers, primary care doctors, therapists. Etc
Diagnosis
• Diagnostic Criteria (3/4 if irritable)
o A distinct period of abnormally and
persistently elevated, expansive, or irritable
mood and abnormally and persistently
increased activity or energy, lasting at least
one week and present most of the day,
nearly every day
o Grandiosity (inflated self-esteem)
o Decreased need for sleep (with increased
energy)
o Pressured speech
o Flight of ideas
o Distractibility (attention too easily drawn to
unimportant or irrelevant external stimuli)
o Increased goal-directed activities (socially,
work or school, sexually) or psychomotor
agitation (purposeless non-goal-directed
activity
o Impulsivity (unrestrained buying sprees,
stuff that are out of character)
• Bipolar mania caused marked impairment in social
and occupational functioning and is not due to
another substance or general medical condition
• DIGFAST (Distractibility, Insomnia, Grandiosity,
Flight of Ideas, Activity/Agitation, Speech,
Thoughtlessness)
• Manic Episode: emergency because of impaired
judgement
o Period of elation and uncharacteristic
behaviors
• Cyclothymic Disorder
o A distinct period of abnormally and
persistently elevated, expansive, or irritable
mood and abnormally and persistently
increased activity or energy → lasting at
least 4 consecutive days, most of the day
nearly every day
o Numerous periods of hypomania and
depression
• Hypomania: not severe enough to cause marked
impairment in social or occupational functioning to
necessitate hospitalization
o Mania involves their lives
• Bipolar Major Depression
o Assessment (5 or more)
▪ Depressed mood nearly every day
▪ Anhedonia
▪ Appetite weight changes
▪ Sleep disturbances
▪ Psychomotor agitation or
retardation
▪ Loss of energy
▪ Excess guilt
▪ Trouble concentrating
▪ Recurrent Thoughts of Suicide
o Marked impairment in social and
occupational functioning not due to medical
illness or substance
• Major depression can be present in bipolar I or II
(after resolution of manic episode)
• Rapid Cycling
o Four or more mood episodes during a 12-
month period
o Defined by the occurrence of 4 or more
mood episodes in a year
• Seasonal Patterns
• Substances/Medications: PCPs, Cocaine,
Stimulants, Corticosteroids, SSRIs
Treatment
• Goal of treatment is remission: resolution of the
mood symptoms or improvement → only one or two
symptoms of mild intensity persist
• Psychotic features? Resolution! Before targeting the
other features. Treat psychosis first.
• Some patients don’t achieve remission → look for a
response to treatment: stabilization of the patient’s
safety and substantial improvement in the number,
intensity, and frequency of mood and psychotic
symptoms
• Setting and Monitoring
o Inpatient vs. Outpatient: depends on severity
of symptoms, comorbid psychopathology,
psychosocial functioning, support
o Inpatient: managing safety and monitoring
for suicidal ideation
 o Partial Hospitalization: ill patients or those
with suicidal thoughts but feeling safe and
without intent/plan to self-harm
o Outpatient: less acute, feel safe, adhering to
treatment plan
Mood stabilizers
• Lithium (Gold Standard)
o Kept within narrow therapeutic range
▪ Increased by NSAIDs, Tetracyclines,
Metronidazole, ACEi, Diuretics,
Theophylline, Osmotic diuretics,
Acetozolamide
o Toxicity: coarse tremor, ataxia, slurred
speech, dizziness, weakness, nystagmus
with GI upset → stupor/coma or delirium,
seizures, blurred vision, arrhythmia
▪ Mild toxicity: managing electrolyte
disturbances by IV hydration
(hemodialysis if level is above
3mmol/L)
▪ Teratogenic: Ebstein’s anomaly
o Side effect: weight gain, tremor, GI upset,
fatigue, arrhythmia, seizures, goiter,
increased thirst, polyuria, metallic taste,
alopecia; kidney disruption, benign
leukocytosis, hypothyroidism, nephrogenic
diabetes insipidus
▪ Regularly monitor blood levels of
lithium, kidney function, thyroid
• Anticonvulsants
o Valproic Acid, Carbamazepine, Lamotrigine
o Valproic Acid and Carbamazepine → Spina
Bifida
• Benzodiazepines (short-acting) thus can be helpful in
acute mania
• Electroconvulsive therapy: very controlled seizure
o Also good for bipolar disorder not
responding to treatment
Antipsychotics
• Typical neuroleptics
o Chlorpromazine, thioridazine, fluphenazine,
haloperidol
o D2 antagonists (high potency)
o For positive symptoms
o EPS
• Atypical neuroleptics
o Risperidone, clozapine, quetiapine,
aripiprazole, ziprasidone
o Antagonize D2 receptors (low potency) and
serotonin receptors
o Better at treating negative
o Anticholinergic and metabolic side effects
Mood Stabilizers
• Goal of Treatment: remission vs. stabilization
• Known as antimanic medications: used to treat
acute mania and manic episodes
• Indications
o Treatment for bipolar disorder
o Potentiation of antidepressants in patients
with major depression refractory to
monotherapy
o Potentiation of antipsychotics in patients
with schizophrenia
o Enhancement of abstinence in treatment of
alcoholism
o Treatment of aggression and impulsivity
(dementia, intoxication, mental retardation,
personality disorders, general medical
conditions)
• Types:
o Lithium
o Carbamazepine
o Valproic Acid
o Lamotrigine
Lithium
• Drug of choice in the treatment of Acute Mania and
as prophylaxis for manic and depressive disorders
• Gold standard for Mania
• MOA
o Alters neuronal sodium transport
o Secreted by the kidney; Onset of action is 5-
7 days
o Blood levels correlate with clinical efficacy
• Narrow therapeutic range: 0.7-1.2
o Toxic > 1.5
o Lethal > 2
• Mild toxicity: manage electrolyte disturbances by IV
hydration
o If above 3mmol/L, do hemodialysis
Carbamazepine
• Anticonvulsant that is especially useful in mixed
episodes and rapid cycling bipolar disorder; also
trigeminal neuralgia
• Teratogenicity: Spina Bifida
• Mechanism of Action: Blocks sodium channels and
inhibits action potentials
o Onset is 5-7 days
• Side Effects: Skin Rash, Drowsiness, Ataxia, Slurred
Speech, Leukopenia, Hyponatremia, Aplastic
Anemia, Agranulocytosis, Elevates liver enzymes
Valproic Acid
• Treats mixed manic episodes and rapid-cycling
bipolar disorder
 • MOA is unknown, but has been shown to increase • Neurobiology: many intricate neuronal pathways and
GABA various areas are different
• Side Effects: Weight Gain, Alopecia, Hemorrhagic o Amygdala and Hypothalamus are the
Pancreatitis, Hepatotoxicity, Thrombocytopenia, potential sites of neural triggers for panic
Teratogenicity: Spina Bifida attacks
o Inherit specific areas that are hyperexcitable
Lamotrigine o Exposure to stressors
• Indicated specifically for Bipolar Depression o Areas: Amygdala, Prefrontal, Temporal,
• Side Effect: Stevens Johnson’s Syndrome Anterior Cingulate Insula, Hippocampus,
Hypothalamus → complex human panic
Panic Disorders response
e. g. 32/F complains of fear going to the grocery store: o Alterations in GABA-benzodiazepine
dyspnea, chest pain, numbness, tingling → Delivery Service receptor and serotonin → increased fear
• Panic Attack vs. Panic Disorder generalization
o Panic Attack: discrete period of heightened • Spontaneous Episodes of Fear
anxiety that affects much of the population o Abruptly, for one minute to an hour
o Panic Disorder:: experience with panic o Agoraphobia (avoidance of situation where
attacks + persistent fear of having additional help or easy escape may not be readily
attacks (acute state that lingers chronically) available)
• Epidemiology of Panic Disorder o Somatic features: faster breathing,
o Lifetime prevalence: 2-5% heartbeat, sweating
o Women twice more likely than men Diagnosis
o Teens to early 30s
• An abrupt surge of intense fear or intense discomfort
o More common in people with family history
that reaches a peak within minutes, and during which
or other mental disorders
time at least 4/12 symptoms occur:
• Comorbidities highly associated with panic o Palpitations
o PTSD: A response to a catastrophic life o Shortness of breath
experience in which the patient o Sweating
reexperiences the trauma (flashbacks), o Feeilngs of Choke
avoids reminders of the event, and o Trembling/Shaking
experiences emotional numbing or o Chest Pain
hyperarousal o Fear of going crazy
o Generalized anxiety: persistent excessive o Nausea
anxiety and hyperarousal about general daily o Feeling dizzy (Lightheaded)
events. Tends to last more than 6 months, o Chills/Heat
does not generally interfere with ADLS o Derealization
• How does it develop: underlying predisposition + o Paresthesias
stress or life event • Recurrent unexpected panic attack
• Vulnerability: Genetics, Childhood adversity, • At least one attack is followed by one or more of
Personality Traits (at least 1) both:
o If a first degree relative is affected o Persistent fear or worry about additional
▪ 4x more likely panic attacks
o Anxious temperaments o Maladaptive changes to behavior in
o Neuroticism: poor stress resilience response to panic
symptoms and catastrophic cognitions
• Rule out other medical conditions (hyperthyroidism,
regarding bodily sensations
cardiovascular, substance use)
o Childhood Adversity
• Differential Diagnosis
▪ Physical or Sexual Abuse
o Somatic Symptoms Disorder
▪ Smoking
o Anxiety Disorder
▪ Asthma
o Specific Phobia
• How can a neurotic personality lead to panic:
o Substance Abuse
Misinterpretation of a fast heartbeat → panic
 o General Medical Conditions: Angina, • Duration of treatment: Vary, but usually continue
arrhythmias, COPD, temporal lobe epilepsy, whatever is working for about a year at least until
embolus, asthma, hyperthyroidism, symptoms are controlled
pheochromocytoma, medication side • Side Effects: dizziness, headache, sedation, fatigue,
effects (aminophylline, theophylline) tremor, blurred vision, sweating, sexual dysfunction

Treatment Cognitive Behavioral Therapy

SSRIs • Panic disorder: acquired fear of bodily sensations,
• Paroxetine, Fluoxetine, Sertraline, Citalopram, particularly sensations associated with autonomic
Escitalopram arousal → in patients with certain psychological and
• Efficacious compared to placebo biological predispositions
• Low doses (to avoid overstimulation)’ • Combination with pharmacotherapy →
• Low range for 2-4 weeks then increase if no clinical advantageous
improvement • Symptoms: Panic attacks, anxiety about panic
• Side effects: headache, irritability, GI distress, sexual attacks, avoidance
dysfunction, insomnia • Key treatment, extremely useful
• Drugs may treat the symptoms, CBT goes to the root
SNRIs cause
• Increase serotonin and noradrenaline • Works best in highly-motivated patients
• Venlafaxine, Duloxetine • Techniques
• Reduce three core components of panic disorder o Education, Muscle relaxation, self-
(attack frequency, anticipatory anxiety, phobic monitoring, cognitive restructuring,
avoidance) breathing retraining, exposure
• Side effects: nausea, dry mouth, constipation, o Relapse prevention is important: view any
anorexia, sweating, somnolence, sexual dysfunction, recurrence as a lapse rather than a failure →
hypertension reapply coping skills
Benzodiazepines
Obsessive-Compulsive Disorders
• Work quickly, but be cautious
Jane, a 30/F who fears contracting a disease. Cleans hands
• Examples: alprazolam, lorazepam, clonazepam
until chafing and bleeding from excessive rubbing and
• Reduces three core components
scrubbing. Intrusive thoughts → light switches
• Only alprazolam and clonazepam are approved
• Side effects: addiction, withdrawal, sedation, fatigue, • Obsessions: recurrent intrusive thoughts or images
psychomotor impairment, reduced memory and that cause anxiety or distress
concentration • Compulsions: repetitive mental or behavioral acts
• Drowsiness is a core side effect: don’t operate the patient feels driven to perform to neutralize
machinery or vehicles excessive thoughts
• Epidemiology
TCAs
o 2-3%
• Imipramine, Clomipramine, Amitriptyline
o Females > Males
• First two are superior to placebo
o Males > Females in OCD (onset before age
• Before initiating treatment: screen for cardiac 10)
conduction system delay, PE, lab tests, patients over o Main age of onset: Mid-20s
40 (ECG), suicidality o 25% of cases occur before 14 years old
• Side effects: anticholinergic effects, sweating, sleep o Strong link between suicidal thoughts and
disturbance, orthostatic hypotension, fatigue and behaviors and OCD
weakness, weight gain, blood pressure increase, o Strong link between mental illness within
sexual dysfunction close relatives
MAOIs • Comorbidity disorders: 29% have tic disorder
• Phenelzine, Tranylcypromine, Selegiline • DDx
• Strict dietary restrictions: low tyramine diet or else → o Personality disorders: OCP
HPN crisis (cheese, red wine, cured meats) o Anxiety disorders: Panic, Social anxiety,
Generalized anxiety, Specific Phobia
o Schizophrenia
 o Mood disorders: Depression, Bipolar • Associated with a reduced quality of life and high
o Somatoform disorder: Body dysmorphic levels of social and occupational impairment
o Eating disorders • Questions you should ask?
o Impulsivity: Tic disorder, Tourette’s, o How much time is spent obsessing or
Trichotillomania, Excoriations engaging in a compulsive act?
• Different factors o How much has independence been stifled?
o Genetic: familial and sporadic types; twins (jobs, home, errands, etc.)
o Environmental: Group A Streptococcus, o Places, people, or situations that are avoided
Premenstrual and Postpartum periods, o How has the family been impacted (rules,
Trauma (stress), neurologic lesions (stroke, who can and cannot go home, etc.)?
TBI) o Timely HW or occupational work getting
o Neurobiological: cortico-striato-thalamo- done
cortical circuits have abnormalities. PET and o How often does one see the physician?
fMRI have found abnormalilties. • Rate OCD: YBOCS (Yale-Brown OC Scale)
• Obsessions are not voluntary and pleasurable o Consists of a checklists of obsessions and
o Urges to harm self or others is extremely compulsions and a scale that assesses
important to illicit in history → take further severity
actions o Get a baseline, then repeat a YBOCS to track
• Obsession Types changes
o Images of violent scenes, Urges,
Types of OCD
Contamination Fears
• With Good or Fair Insight
• Compulsion Types
o Mental Acts, repeating words or numbers, • With Poor Insight
Repetitive behaviors, Counting, repetitive • With Absent Insight or Delusional Beliefs
washing, checking • Insight refers to patient awareness that something is
wrong/abnormal → willingness to adhere to treatment
Assessment plan
• Obsessions
o Intrusive/Repetitive Treatment
o Thoughts or Images • Pharmacologic
o Dysfunctional beliefs o SSRIs
▪ Inflated responsibility, o TCAs
overestimates threat • Behavioral and Talk Therapy
▪ Perfectionism, intolerance of o Exposure and response prevention to the
uncertainty ritual-eliciting stimulus and prevention of the
▪ Overvaluing importance of thoughts relieving compulsion
o Avoid people, places, things o Relaxation techniques are employed to help
• Compulsions: not connected in a realistic way to patients manage the anxiety that occurs
feared event; clearly excessive when the compulsion is prevented
o Repetitive behaviors (washing, switching,
checking) or mental acts Phobias
o Individual feels driven to perform a Sam is a 28-year-old sales representative who has been terrified
compulsive act in response to obsession or of animals since she was a child. Terrified of flying after an
according to rules that must be applied emergency landing. She does not like to eat in front of others.
rigidly Avoids large audience public speaking.
o Aim is to reduce the distress triggered by
obsessions or to prevent a feared event • Phobia: An irrational fear that leads to the avoidance
o Avoid people, places, or things that trigger of feared object or situation
compulsions • Specific Phobias: fear of objects or things
o If it is embarrassing → may not volunteer • Social Phobias: fear of embarrassing oneself in
information → therapeutic alliance is public
important o Examples: public speaking, eating in public,
using a public restroom
 • Epidemiology
o Most common mental disorder, 5-10% of US
Population
o Specific Phobias > Social Phobias
o Age of Onset: 5-35, but average is mid-teens
▪ Depend of type of phobia e. g.
injection, animal phobias are in
childhood, natural environment is in
adolescence or adulthood
o Females > Males
• Different Factors that lead to Phobias
o Genetic: Aggregate in families. First degree
relatives of individuals of specific phobias
have a 31% risk → inherited exaggerated
vasovagal response
o Behavioral: Traumatic events
o Neurobiological: hyperactivation of
amygdala and insula (structures involved in
negative emotional repsonses)
o Personality:
▪ Disgust sensitivity: tendency to
experience disgust in response to
certain stimuli
▪ Anxiety sensitivity: dispositional
variable reflecting beliefs that the
physical sensations of anxiety are
harmful
o Cognitive: Attentional biases to threat-
related information: perceptual and
cognitive distortions consistent with other
phobias
o Social/Environmental: Stress at time of
event, context, previous and subsequent
exposure, level of support
o Evolutionary: fear of scorpions, snakes, or
heights, or biologically predetermined
Assessment
• Specifiers
o Animals: spiders, insects, dogs
o Natural environment: Heights, storms, water
o Blood injection: needles, invasive medical
procedures
o Situational: airplanes, elevators, enclosed
spaces
o Others: choking, vomiting, loud noises,
costumed characters
• Comorbidities
o Agoraphobia, OCD, PTSD, Separation
Anxiety
▪ Agoraphobia: anxiety in situations
where person perceives
environment is unsafe, with no easy
way to get out
▪ OCD: recurrent intrusive thoughts
relieved by standardized behaviors
▪ SAD: fearful and nervous when
away from home or separated from
a loved one
▪ PTSD: response of reexperience to
trauma
o Eating disorder (fear of eating in public →
maladaptive eating behaviors)
• Requires all of the criteria
o Marked fear of anxiety about a specific
object or situation (children → crying,
tantrums, freezing, clinging)
o Phobic object or situation provokes
immediate fear or anxiety
o Phobic object or situation is actively avoided
or endured with intense fear and anxiety
o Fear of anxiety is out of proportion to the
actual danger posed by the specific object or
situation and to the sociocultural context
o Fear, anxiety, or avoidance is persistent (> 6
months)
o Fear, anxiety, or avoidance causes clinically
significant distress or impairment in
functioning
o Medical and psychiatric conditions have
been ruled out
• Sociocultural Context of an indivudal
Treatment
• Specific Phobias
o Excellent with exposure-based treatment
o Pharmacology is not useful
o Systemic desensitization and supportive
therapy is useful → gradual exposure to
feared objects or situations while teaching
relaxation and breathing
• Social Phobias
o Paroxetine
o Beta Blockers can control symptoms of
performance anxiety
o CBT
Post-traumatic Stress Disorders
Jim, a 54/M combat veteran. Most of his time at home, avoids
gatherings with more than a few people. Immediately went home
after the party of his niece because of a popped balloon. Vivid
nightmares.
• Definition: a severe and chronic disabling disorder
which develops in some persons following exposure
to a traumatic event involving actual or threatened
injury to themselves or others
 o Symptoms lead to considerable social,
occupational, and interpersonal dysfunction
• Risk Factors
o Sexual Violence: rape, childhood sexual
abuse, intimate partner violence
o Interpersonal network traumatic
experiences (unexpected death of a loved
one, life-threatening illness of a child,
traumatic event of a loved one)
o Interpersonal violence (childhood physical
abuse, witnessing home violence, threats)
o Exposure to organized violence (refugee,
kidnapped, civilian war zone)
o Participation in organized violence
(exposure, death/serious injury, dead
bodies)
o Others (car accidents, chemicals)
• Epidemiology
o 7-12% in adult population
Assessment
• Tell me about your experience in combat
o What was your experience of danger during
your time serving in war (potential triggers
revisited to help change emotional response
to memories)
o How did you initially respond to recognition
that you were in grave danger?
o What emotions were associated with your
experience?
• How do you find yourself re-experiencing the event?
o Be curious about dreams, flashbacks,
intrusive recollections
o What people, places, and events are being
avoided?
▪ Isolation, avoidance of social and
occupational functions
▪ Secondary conditions (depression,
loneliness)
o How do you respond in situations when you
feel triggered (limited range of affect,
feelings of detachment/estrangement)?
o How often do you feel hyperarousal
(sleeping difficulties, outbursts of anger,
startle response)?
• Persistent Exaggerated Negative Beliefs
• In Children
o Repetitive play that may express themes or
aspects of the traumatic event
o Child may have frightening dreams without
recognizable content
Diagnosis (Meet all of the criteria)
• Persistence of symptoms for at least 4 weeks, but most
patients consult after many months
• Exposure to actual or threatened death, serious
injury, or sexual violence
• Intrusive symptoms related to the trauma
• Persistent avoidance of stimuli associated with the
traumatic event
• Negative alterations in cognitions and mood
associated with the traumatic event
• Marked alteration in arousal and reactivity
associated with the traumatic event
• Duration of disturbance (BCDE) is more than a
month
• Disturbance causes clinically significant distress
that affects social functioning
• Rule out other medical, substance, or psychiatric
conditions
Subtypes
• With dissociative symptoms (depersonalization,
derealization)
o Depersonalization: persistent or recurrent
experiences of feeling detached from, as if
one were an outside observer of one’s
mental processes or body
o Derealization: persistent or recurrent
experiences of unreality of surroundings
• With delayed expression (full diagnostic criteria are
not met until 6 months)
Treatment
Early treatment may prevent chronicity
Drug Therapies have generally been most effective in decreasing
hyperarousal and mood
• First Line: SSRI
o Start low
o Prevents reuptake of serotonin in
presynaptic neurons
o Side effects: black box warning, GI upset,
sexual dysfunction, night sweats, mood
swings
▪ Black box warning: associated with
increased risk of suicidal thinking,
feeling, and behavior in young
people
• Second line: TCAs and MAOIs or second-generation
antipsychotics
• Therapy
o Cognitive behavioral therapy
o Relaxation, support groups, family therapy
• Alpha-adrenergic receptor blockers (prazosin)
 o Reduce nightmares and improve sleep in o No anticonvulsant or muscle relaxant, or
patients with PTSD (1mg at bedtime and withdrawal
increase until 3-15 mg) o Bind to benzodiazepine site on GABA
• Hypotensive patients or those probe to orthostatic Receptor
hypotension should be treated cautiously o Little or no tolerance dependence
• Benzodiazepines: anxiety and arousal, but beware of o Side effects: sleep walking, night terrors,
addiction memory loss
• Exposure therapy that rely on extinction learning o Not a BDZ, but same effect
• Given the high prevalence of comorbid substance
Buspirone
abuse in patients with PTSD, avoid using
• Alternative to BDZ or venlafaxine to treat GAD
benzodiazepines
• 1-2 weeks to take effect
o Benzodiazepines may also cause
• Anxiolytic action at the 5HT-1A receptor (partial
drowsiness and partial sedation
agonist)
Acute Stress Disorder vs PTSD • Does not potentiate CNS depression, low potential
• Anxiety symptoms from a traumatic event for only a for abuse
short duration (within 1 month of trauma and lasts
Propranolol
for a maximum of 1 month)
• Autonomic effects of panic attacks, performance
• Symptoms are similar to those for PTSD
anxiety, palpitations, sweating, tachycardia
Anxiolytics • Treat akathisia
• Causes depression
• Mechanism of Action: Depressing the CNS for
sedative effect Antipsychotics
• Used in low dose to treat anxiety
Antidepressants (First Line)
• SNRIs and SSRIs are non-addictive
• 4-6 weeks before it takes effects Control Disorders
Benzodiazepines Substance Disorders
• Most commonly prescribed in the US The essential feature is a cluster of cognitive, behavioral, and
• Indications: Anxiety disorders, Muscle spasm, physiological symptoms indicating that the individual continues
Seizures, sleep disorders, alcohol withdrawal, using the substance despite significant substance-related
anesthesia induction problems.
o Alcohol withdrawal: alcohol depresses the
CNS, and thus withdrawal may light up the • 20% in the US, men > women
brain and even cause seizures • Most abused substances:
• Short term use only: highly addictive substances o Caffeine
• Not first line anxiolytics anymore o Alcohol
• Advantages: safety at high doses (as opposed to o Nicotine
barbiturates) • Depression is very common in persons with
• Potentiates GABA Receptors substance abuse
• Long-acting: Diazepam (rapid onset, used in o Most important vitamin you can give to a
treatment of anxiety and seizure control) and person with alcohol dependence: Thiamine
Chlordiazepoxide (used in alcohol detox, presurgery (protects against developing Wernicke’s or
anxiety) Korsakoff’s syndrome)
• Immediate-acting: Lorazepam (treatment of panic • Four Syndromes associated with Alcohol Withdrawal
attacks, alcohol withdrawal), Alprazolam (panic o Minor Withdrawal
attacks), and Temazepam o Withdrawal Seizures
• Side Effects: Drowsiness, impairment of intellectual o Alcoholic Hallucinosis
functioning, reduced motor coordination o Delirium tremens
• Toxicity: respiratory depression in overdose
Assessment
especially when combined with alcohol
• Substance Abuse
• Zolpidem: a short-term treatment of insomnia
especially if it’s because of anxiety
 o Failure to fulfill obligations at work, school, Alcohol Intoxication
or home • Factors that affect absorption and elimination rates:
o Use in dangerous situations Age, Sex, Weight, Speed of Consumption
o Recurrent substance-related legal problems o Presence of food in the stomach
o Continued use despite social or o State of nutrition
interpersonal problems due to substance o Chronic alcoholism
abuse o Cirrhosis
• Substance Dependence • Blood Levels of Alcohol and Behavioral Effects
o Tolerance – need for markedly increased o 0.05% of Alcohol: Thought and Judgement
amounts of a substance to achieve Influenced
intoxication or desired effects and or o 0.1% Clumsiness, Legal Intoxication
diminished effect with the continued use of o 0.2% Depression of Motor Area
the same amount of the substance o 0.3% Confusion and Stuporous
o Withdrawal – A condition whereby a o 0.4-0.5% Coma and Death
characteristic syndrome for a particular • Legal limit = 80-100 mg/dL
substance occurs after diminished use • Differential Diagnosis: Hypoglycemia, Hypoxia,
o Using substance more than originally Mixed alcohol drug overdose, Poisoning, Psychosis,
intended Psychomotor seizure, Hepatic Encephalopathy
o Persistent desire to cut down or • Diagnostic Evaluation
unsuccessful attempts to reduce intake o Serum Ethanol Level
o Significant time spent seeking out o CT of the head: rule out subdural hematoma
substance or other brain injury
o Decreased social or occupational activities
because of use Treatment
o Continued use despite physical or • Assessment
physiological problems o Acute Intoxication
▪ ABCs
Alcohol and Delirium ▪ Finger stick blood glucose
• Alcohol MOA: Activates GABA and serotonin, inhibits ▪ Thiamine, Naloxone (protection in
Glutamate case there is a mixed alcohol-drug
o GABA receptors are inhibitory → alcohol overdose)
causes sedation o Alcohol Dependence
• Metabolism: Alcohol is metabolized via alcohol ▪ AA (highest likelihood of success),
dehydrogenase → Acetyl aldehyde which is SMART
metabolized by aldehyde dehydrogenase → Acetic ▪ Disulfiram (Antabuse) – aversive
Acid therapy (inhibits aldehyde
• People of Asian Descent: less aldehyde dehydrogenase → unpleasant
dehydrogenase, thus become intoxicated easier → effects); side effects include
flushing and nausea metallic taste, NV
• Screening tests ▪ Naltrexone – reduces the pleasure
o MAST (Michigan Alcoholism Screening test) of drinking as an opioid antagonist
o ADI (Adolescent Drinking Inventory) (mu opioid receptors) available as
o AUDIT (Alcohol Use Disorder Identification injection and a pill; side effects:
Test) nausea, vomiting, decreased
o CAGE appetite
▪ Have you ever wanted to cut down ▪ Psychotherapy
on drinking?
Alcohol Withdrawal
▪ Do you feel annoyed when people
• Alcohol Withdrawal: CNS excitation following the
criticize your drinking?
termination of the depressant effects of long-term
▪ Have you ever felt guilty about
ethanol consumption
drinking?
o HPI: Irritability, Insomnia, Fever,
▪ Have you ever taken a drink as an
Disorientation, Seizures, Hallucinations
eye-opener?
 • Delirium Tremens: most serious form of EtOH o Insomnia
withdrawal o Nausea
o Begins at 72 hours of cessation of drinking o Decreased appetite
o Visual and tactile hallucinations • Motivational Syndrome
o Gross tremor o Associated with cannabis use and is
o Autonomic instability characterized by an unwillingness to persist
o Fluctuating levels of psychomotor activity in tasks that require prolonged attention
o Assessment:
Caffeine
▪ Vital Signs
▪ ABCs • Intoxication Assessment
▪ Head CT for Trauma o Anxiety
▪ Hepatic Failure (ascites, jaundice, o Insomnia
caput medusae, coagulopathy) o Twitching
▪ CIWA (Clinical Institute Withdrawal o Rambling speech
Assessment from Alcohol) → o Flushed face
monitoring for signs that move o Diuresis
toward DTs → preemptive o Gastrointestinal disturbance
treatment with benzodiazepines o Restlessness
o Differential Diagnosis: alcohol-induced • Caffeine Consumption over 1 gram
hypoglycemia, psychosis, encephalitis, o Tinnitus
thyrotoxicosis, anticholinergic poisoning, o Severe agitation
withdrawal from sedative-hypnotic drugs. o Cardiac arrhythmia
o Treatment: tapering doses of • Extreme cases: seizures and respiratory failure
benzodiazepines, thiamine, folate, • Caffeine withdrawal (usually begins 12-24 hours
multivitamin, magnesium sulfate for post after last use, peaks in 24-48 hours, and will resolve
withdrawal seizures in approximately 1 week)
o Headache
Wernicke’s Encephalopathy and Korsakoff’s Syndrome o Nausea and vomiting
• What you want to protect against in Alcohol o Drowsiness
Withdrawal from Chronic Use o Anxiety
• Wernicke’s Encephalopathy o Depression
o Ocular abnormalities
o Confusion Nicotine
o Ataxia • Addiction is very prominent in other mental disorders
• Korsakoff’s Syndrome like anxiety, depression, schizophrenia
o Anterograde amnesia • Lifetime prevalence is 20%
o Impaired recent memory • 2 of the most common causes of death
o Confabulation o Cardiovascular disease: stroke and heart
attack
Other substance abuse disorders o Lung disease: COPD, Cancer, Pneumonia
Marijuana • Derived from the tobacco plant → stimulates
• Main active component is THC nicotinic receptors in autonomic ganglia of the
(tetrahydrocannabinol) sympathetic and parasympathetic nervous systems
• Assessment consists of urine drug screenings for → highly addictive via dopaminergic system
about 4 weeks • Nicotine intoxication: restlessness, insomnia,
• Marijuana Intoxication Assessment: anxiety, GI upset, cravings, dysphoria, anxiety,
o Euphoria increased appetite, irritability, insomnia
o Impaired coordination • Health and Cognitive Problems
o Mild tachycardia o Children at home of smoking parents: otitis
o Conjunctival Injection media, pneumonia, asthma, SIDS, low birth
o Dry Mouth weight, low performance on standardized
o Increased appetite tests, poorer athletic performance
• Marijuana Withdrawal Assessment • Treatment
o Irritability o Behavioral counseling
 o Replacement (gum or patch) • Intoxication Symptoms: recklessness,
o Medications: clonidine, bupropion, impulsiveness, impaired judgements, assaultive
varenicline behavior, rotatory nystagmus, ataxia, hypertension,
tachycardia, muscle rigidity, high pain threshold
Cocaine
• How many days for urine drug screen: 1 week
• Blocks dopamine uptake from the synaptic cleft
• Because of muscle rigidity: CPK and AST are also
causing a stimulant effect
elevated
• Plays a role in the reward center of the brain
• Treatment: manage ABCs, stabilize vital signs and
• Intoxication symptoms: euphoria, changes in blood
electrolytes, acidify urine, benzodiazepines or
pressure and heart rate, nausea, dilated pupils,
neuroleptics to help with agitation and hallucinatory
weight loss, psychomotor symptoms, chills,
effects
respiration problems, sweating, seizures, arrhythmia,
hallucinations Opiates
o Test heart EKG for arrhythmia, EEG, • Heroine, Codeine, Dextromethorphan, Morphine,
psychiatric symptoms Methadone, Meperidine
• Vasoconstrictive effect of cocaine → myocardial • There is a current opioid epidemic resulting for a
infarction or cerebrovascular accident push for doctors to prescribe less and focus on other
• Urine drug screen stays positive for 3 days methods to alleviate pain
• Street names: snow, coke, girl, lady • MOA: Stimulate opiate receptors (mu, kappa, delta)
• Most common causes of death: MI, cerebral → sedation, analgesia, and dependence
vascular accident, Muller’s maneuver • Drowsiness, Nausea, Vomiting, Constipation, Slurred
(pneumothorax caused by exhaling against a closed Speech, Constricted pupils, Seizures, Respiratory
glottis) Depression
• Treatment for cocaine dependence: psychotherapy, • Treatment
group therapy is the long term treatment o Intoxication: ABCs (especially for respiratory
o ER intoxication: benzodiazepines to calm depression)
them down, symptomatic support (EKG, o Overdose: IV naloxone or naltrexone, then
vital signs), haloperidol for hallucinations ventilate or intubate
o Withdrawal: Crash (hypersomnolence). Let o Dependence: medications (methadone,
them sleep suboxone), psychotherapy, Narcotics
anonymous
Medical Substance Related Disorders • Withdrawal Symptoms: dysphoria, insomnia,
Amphetamines lacrimation, rhinorrhea, yawning, weakness,
• Dexedrine, Ritaline sweating, piloerection, nausea and vomiting, fever,
• Release dopamine from nerve endings → dilated pupils, muscle aches
stimulating effect o Not life threatening
• Designer amphetamines (MDMA, ecstasy) → release • Four types of opiate receptors
dopamine and serotonin from nerve endings and o Mu
have both stimulant and hallucinogenic properties o Kappa
• Clinical Use: ADHD, Narcolepsy, Depression o Lambda
• Amphetamine Intoxication Symptoms: Euphoria, o Delta
Changes in blood pressure and heart rate, Nausea, • Skin poppers: circular depressed scars sometimes
Dilated Pupils, Weight loss, Psychomotor changes, complicated by underlying chronic abscesses
chills, respiration problems, sweating, seizures, located on the back of the thighs who use injectable
hallucinations opioids (injection site)
• Urine drug screen: 1-2 days o Deadly due to the abscesses → physical
• Withdrawal symptoms: crash (irritability and exam from head to toe
somnolence) • Pinpoint Pupils: causes pinpoint pupils
PCP (Phencyclidine) Inhalant Abuse
• A hallucinogen that antagonizes NMDA glutamate • Teenager in the room with an odd odor off his breath
receptors and activates dopaminergic neurons → consider inhalant abuse, look for a rash near his
• PCP and ketamine were both developed as nose and mouth
anesthetics
 • Common problems: brain atrophy caused by heavy
metals like copper and zinc, encephalopathy,
seizures, epilepsy, decreased IQ, ataxia, myoclonus,
chorea, optic neuropathy, motor and sensory
neuropathy, death by respiratory depression,
arrhythmia, aspiration, hepatic and renal failure,
rhabdomyolysis
• Treatment: supportive measures and maintain ABCs
Impulse Control Disorders
• Impulse is characterized by an inability to resist
behaviors that may bring harm to oneself or to others
(no intent to harm)
• Anxiety or tension is often experienced prior to the
impulse and relief or satisfaction after completion of
the act
• Types
o Intermittent explosive disorder
o Kleptomania
o Pyromania
o Pathologic gambling
o Trichotillomania
• Features common to all:
o Failure to resist an impulse o perform a self-
destructive act
o Escalating tension prior to committing the
act, and during commission of the act, the
person feels pleasure or release
• Most associated Brain Region and Hormone
o Most associated with the limbic system
o Most associated hormone with aggressive
behavior: testosterone
o CSF levels decreased in impulse control
disorders: 5-hydroxyindoleacetic acid (5-
HIAA), a metabolite of serotonin
Intermittent Explosive Disorder
• Problems controlling emotions and behaviors,
resulting in behaviors that violate social norms and
the rights of others:
o Verbal or physical aggression
o Aggression unplanned, out of proportion to
the provocation and causes distress or
psychosocial impairment in patients
• Different from antisocial personality disorder
because there is an expression of remorse for events
• Epidemiology
o More common in men than women, in late
teens
o Genetic, perinatal, environmental,
neurobiological factors
o History of child abuse, head trauma, or
seizure disorders
o Progress in severity until middle age
• Comorbidities
o Unipolar MDD
o Alcohol abuse
o Drug abuse
o Social phobia
o Specific phobia
o GAD
o PTSD
o Oppositional defiant disorder
o Conduct disorder
o ADHD
• Pathogenesis for IED is multifold
o Genetics: not yet identified, but runs in
families
o Neurobiology: impulsive, aggressive
behavior has been conceptualized as an
imbalance between excessive, aggressive
drives originating in limbic brain structures
such as the amygdala, and insufficient
control of these impulses by cortical
structures such as the orbital frontal cortex
and the anterior cingulate cortex
▪ Low levels of serotonin are
associated with impulse and
aggression
o Psychosocial factors: disruptive family
environment, multiple traumas → all are
involved
• Assessment: Ask these questions
o What thoughts or feelings immediately
precede the outburst? (Marked by rage,
irritability, increased energy, racing
thoughts, poor communication, inefficient
information processing, somatic symptoms
→ paresthesias, tremors, palpitations, chest
tightness)
o Explore the magnitude of the provocation –
how minor?
o Physical violence – ranges from low
intensity (shove or slap) to high intensity (e.
g. fistfights or using a weapon against
someone)
o Verbal outbursts (arguments to physical
assault others) – did the event occur during
temper tantrums or heated arguments
marked by shouting and loss of control
o Destruction of property – breaking objects
or injuring an animal
o How long did it last? Explosive outbursts
typically last less than 30 minutes and
immediately afterwards, patients may feel a
sense of relief
 o What was the feeling after the event?
Fatigue, dysphoria, regret, or
embarrassment
o Self-harm: superficial cutting with razor
blades or burning with cigarettes without
suicide content
o Suicide attempts: among patients with IED,
history of attempted suicide is reported by 8-
25%
o Non-suicidal injury: greater in patients with
comorbid personality disorders
• Signs that someone has an IED
o He fails to resist aggressive impulses
o Level of aggression is out of proportion with
triggering events
• General Principles
o Goal of Treatment: Remission
▪ Defined as resolution of symptoms
or improvement to the point that
only one or two symptoms of mild
intensity persist
o For patients who do not achieve remission:
Response
▪ Stabilizing the safety of the patient
and others, as well as substantial
improvement in number, intensity,
and frequency of symptoms
▪ IED should be advised to avoid
intoxication with alcohol and other
substances
• Treatment
o CBT: manual based treatment that follows a
patient for 12 weeks
▪ Challenge automatic thoughts and
behaviors through modification of
thoughts to be in proportion to the
reality of the situation
▪ Effectiveness: active participation
by the patient including dedication
to homework assignments
o Medication
▪ SSRIs like fluoxetine, paroxetine,
seraline, and citalopram
▪ Anticonvulsants like oxcarbazepine
▪ Others: mood stabilizers and
anticonvulsants (lamotrigine,
valproate, topiramate, lithium)
o Abstinence
• Monitoring outcome
o Daily-monthly: assessment of treatment
outcome in patients with IED from daily to
monthly, depending on severity of persistent
symptoms; hospitalized patients are
monitored daily
o Weekly: outpatients are commonly seen in
this way until they have responded for two to
four weeks
o 2-4 weeks: Patient can be seen every two to
four weeks until they remit. If they remit:
more frequent
Gambling Disorder
• Gambling: Placing something of value at risk with the
hope of gaining something of greater value. Less
than 10% of adult gamblers develop a gambling
problem
• Epidemiology
o Continued growth in the gambling industry
→ prevalence of gambling problem
o Men>Women
o Increased incidence of mood, anxiety, OC
disorders in people with gambling problems
• Predisposing Factors
o Loss of parent during childhood
o Inappropriate parental discipline in
childhood
o ADHD
o Lack of family emphasis on budgeting and
saving money
• Assessment
o Frequently preoccupied with gambling (e. g.
preoccupied with reliving past gambling
experiences, handicapping or planning the
next venture, or thinking of ways to get
money with which to gamble) – 4 or more of
the following
▪ Needs to gamble with increasing
amounts of money in order to
achieve desired excitement
▪ Made unsuccessful efforts to limit,
cut back, or stop gambling
▪ Restless or irritable when
attempting to cut down or stop
gambling
▪ Often gambles as a way of escaping
from problems or relieving
dysphoric moods (helplessness,
guilt, anxiety, or depression)
▪ After gambling and losing money,
often gambles another day to get
even
▪ Lies to family, therapist, or others
▪ Jeopardized or lost a significant
relationship, job, career, or
educational opportunity because of
gambling
 ▪ Relies on others to provide money • Treating Kleptomania
to relieve a financial situation o Insight-oriented psychotherapy: useful for
o Gambling behavior is not better explained by patients with guilt and depression
manic episode associated with their impulse control
• Treatment o Behavior therapy (systematic
o Gamblers Anonymous (12 step program) desensitization and aversion conditioning)
▪ Group therapy, psychodynamic o SSRIs for comorbid depression: fluoxetine,
therapy, CBT or supportive therapy sertraline, paroxetine
o SSRIs o Naltrexone: blockage of opioid receptors
o Treat co-morbid mood disorders, anxiety, thereby reducing pleasure once obtained
substance disorders from impulsive acts
• Gambling and Alcoholism
o Men with pathologic gambling have higher Pyromania
rates of alcoholism than the general • Epidemiology
population o More common in men and mentally retarded
o Women with the diagnosis are more likely to individuals
be married to men with an alcohol disorder o Better prognosis if diagnosis is in children
• Phases of Pathological Gambling • Assessment
o Winning o More than one episode of intentional fire
o Progressive losses setting
o Desperation o Tension present before the act and pleasure
• Defenses most prominent or relief experienced after
o Denial o Fascination with or attraction to fire and its
o Rationalization uses and consequences
o Pleasure, gratification, or relief when setting
Kleptomania fires or when witnessing participation in the
• Epidemiology aftermath
o Women > Men o Purpose of fire setting is not for monetary
o 5% of shoplifters gain, expression of anger, making a political
o Symptoms occur during times of stress statement, and is not due to a hallucination
o Increased incidence of comorbid mood or delusion
disorders, eating disorders, OCD o Fire setting is not better explained by
• Etiology: biologic factors and childhood family conduct disorder, a manic episode, or
dysfunction antisocial personality disorder
o Course is usually chronic • Treating pyromania
• Assessment o Behavior therapy
o Failure to resist urges to steal objects not o Supervision
needed for personal or monetary reasons o SSRIs, Mood Stabilizers
o Increasing sense of tension immediately
before committing the theft
Trichotillomania
o Pleasure, gratification, or relief at the time of • Epidemiology
committing the theft o 1-3% more often in men than women
o Stealing is not committed to express anger o Childhood or adolescence
or vengeance and is not in response to a o Associated with a stressful event
delusion or hallucination • Assessment
o Stealing is not better explained by a conduct o Recurrent pulling out of one’s hair resulting
disorder, a manic episode, or antisocial in visible hair loss
personality o Repeated attempts to stop pulling hair
• Bulimia Nervosa and Kleptomania o Hair pulling causes clinically significant
o 25% of patients with BN have K distress
o Hair pulling is not due to another medical
• Kleptomania is different from shoplifting: shoplifters
condition (important to rule out
do it for the monetary gain, kleptomaniacs do it for
dermatologic problems)
the thrill
 o Hair pulling is not due to another mental domains, including memory, language,
disorder attention, visuospatial, executive functions
• Pharmacology Treatment • The “Mini-Cog” test
o SSRIs o Consists of
o Antipsychotics ▪ Clock Drawing test: considered
o Lithium normal if all numbers are present in
• Non-pharmacologic Treatment the correct sequence and the hands
o Hypnosis display the correct time n a readable
o Relaxation way
o Behavior therapy (substituting for another ▪ Uncued recall of three unrelated
behavior) words
• Hair pulling: often entirely unconscious in patients o Scoring based on a simple decision tree with
with trichotillomania the following three rules
▪ If recalling none of he words →
Eating Disorders demented
▪ Indeterminate → CDT → if
abnormal, demented
o Advantages: high sensitivity for predicting
Age-Related Disorders dementia, short testing time; not limited by
Cognitive Disorders the subject’s education or language
Cognitive disorders result primarily from primary or secondary
Dementia
abnormalities of the CNS system and affects memory,
• Impairment of memory and other cognitive functions
orientation, attention, and judgement.
without an alteration in the level of consciousness
Mini Mental Status Exam and Other Assessments • Most forms are progressive and irreversible, but
• It’s a quick screening tool that tells you if you need to some are treatable
dig a little bit deeper • Epidemiology
o Incidence increases with age
• <26 = dysfunction
o 20% over 80 will have some form of
• Orientation
dementia
o What is the date, month, year? (5 pts)
• Symptoms
o Where are we? (City, State, Hospital) (5pts)
o Delusions and Hallucinations occur in about
• Registration
30% of patients with dementia
o Name three objects and repeat them (3 pts)
o Affective symptoms (depression and
• Attention and calculation
anxiety) are seen in 40-50% of patients
o Serial 7s, spell “world” backwards (5pts)
o Personality changes
• Recall
• Most common causes
o Name three objects above 5 minutes later (3
o Alzheimer’s Disease (50%)
pts)
o Vascular dementia (10-20%)
• Language
▪ Vascular disease is a stepwise
o Name a pen and a clock (2 pts)
decline in progression, whereas
o Say “no ifs, ands, or buts” (1 pt)
non-vascular disease is a steep
o Follow a 3-step command (3 pts)
decline.
• Executive Function o Major depression: pseudodementia
o Close your eyes (1 pt) ▪ Rule this out!
o Write a sentence (1 pt)
• Differential Diagnosis
o Copy a design (1 pt)
o Organic: rule out general medical conditions
• Montreal Cognitive Assessment (MOCA) ▪ Structural: hydrocephalus, normal
o A brief screening test to detect cognitive forgetfulness, subdural hematoma,
impairment in older adults Huntington’s disease, MS, Down’s,
o 30-point test that takes 10 minutes Head trauma, Brain Tumor,
o Tests things more sensitive for the detection Parkinson’s
of mild cognitive impairment, and includes
items that sample a wider range of cognitive
 ▪ Metabolic: Malnutrition (B12, o Cause: prominent neuronal loss of
thiamine, folate), Wilson’s, Hypoxia, substantia nigra → dopamine depletion
Lead Toxicity, Hypothyroidism o Assessment: bradykinesia, cogwheel
▪ Infectious: Encephalitis, Meningitis, rigidity, pill rolling tremor, masked facies,
CJD, Neurosyphilis, HIV Dementia, shuffling gait, dysarthria
Lyme disease o Treatment: levodopa, carbidopa,
o Drugs amantadine, anticholinergics, dopamine
▪ Alcohol agonists, MAOIs
▪ Phenothiazines • Creutzfeldt-Jakob Disease
▪ Anticholinergics o Cause: Prion disease
▪ Sedatives o Assessment: Rapidly progressive to
o Psychiatric dementia within 6-12 months, associated
▪ Pseudodementia with myoclonus
▪ Delirium o Treatment: none; death within a year
▪ Schizophrenia • Normal pressure hydrocephalus
▪ Malingering o Cause: enlarged ventricles with increased
CSF pressure
Causes of Dementia
o Assessment: Wet, Wacky, Wobbly
• Alzheimer’s Disease
(incontinence, dementia, gait disturbance)
o Cause: Low level of
o Treatment: relieve pressure with a shunt
acetylcholine/norepinephrine (autopsy)
o Assessment: Post-mortem as enlarged Dementia
ventricles and senile plaques, neurofibrillary Acute disorder of cognition, with waxing and waning of one’s
tangles, tau proteins sensorium.
o Treatment: Physical and emotional support,
Donepezil • Features are waxing and waning levels of
• Vascular Dementia consciousness, rapid onset, and moments of lucidity
o Cause: microvascular disease of the brain punctuated by hallucinations
with small infarcts • Difference between dementia and delirium
o Assessment: MRI o Dementia is slow and progressive
o Treatment: No cure; physical and emotional o Delirium is potentially reversible with
support, proper nutrition, exercise, treatment
supervision • Types
• Pick’s Disease o Quiet: patient may seem depressed or
o Cause: Atrophy of frontotemporal lobes exhibit symptoms similar to failure to thrive:
o Look for personality changes early in course an MMSE must be done to distinguish
of disease; Pick bodies found postmortem- depression and other disorders
intraneuronal-inclusion bodies o Agitated: most commonly seen; obvious
o Treatment: Supportive; Cholinesterase pulling out lines; hallucinations
inhibitors, low dose benzodiazepines, • Causes
antipsychotics o CNS injury or disease
• Huntington’s Disease o Systemic and non-systemic illness
o Cause: Autosomal Dominant genetic o Drug abuse/withdrawal
disorder o Hypoxia or fever
o Assessment: o Sensory deprivation
▪ Onset 30-50 years old o Medications (anticholinergics, steroids,
▪ Bizarre choreiform movements antipsychotics, antihypertensives, insulin,
▪ Depression and psychosis common etc.)
▪ Diagnose with genetic testing and o Post-op
MRI (caudate atrophy) o Electrolyte imbalances
o Treatment: Supportive; early mortality; • Differential Diagnosis
genetic testing for family o Dementia
• Parkinson’s Disease o Fluent aphasia (Wernicke’s)
o Acute amnestic syndrome
 o Psychosis • 70-year-old with aphasia, apraxia, and agnosia: Pick’s
o Depression Disease
o Malingering • Bizarre moving man dancing as he flails his arms
o Brain Injury (trauma, bleed, structural and legs, hallucinations and depression:
abnormality) Huntington’s Disease
o Post-operative • 58/F from knee replacement agitated: delirium
o Intoxication and substance withdrawal
• Treatment
o Rule out life-threatening causes
Dissociative and Somatoform Disorders
o Treat reversible causes: hypothyroidism,
electrolyte imbalances, UTI Forensic Psychiatry
o Antipsychotics are first line – Quetiapine or
Haloperidol; if IV, make sure patient is on
telemetry for cardiac monitoring
o Avoid benzodiazepines → paradoxical
disinhibition, respiratory depression,
increased risk for falls
o 1:1 Nursing for Safety
o Frequently reorient the patient: introduce
yourself, tell the patient what time it is,
explain why you’re there
o Avoid napping
o Keep lights on, shades open during the day
o Always write “hold for sedation” in orders

Difference between delirium and dementia

• Delirium
o Clouding of consciousness
o Acute onset
o Lasts 3 days to 2 weeks
o Orientation impaired
o Immediate/recent memory impaired
o Visual hallucinations more common
o Symptoms fluctuate, often worse at night
o Reversible: search for underlying cause
o Awareness reduced
o EEG Changes (fast waves or generalized
slowing)
• Dementia
o Loss of memory/intellectual ability
o Insidious onset
o Lasts months to years
o Orientation often impaired
o Recent and remote memory impaired
o Symptoms stable throughout the day
o 15% reversible
o Awareness clear
o No EEG Changes
• Old man with urinary incontinence: wide gait, acting
funny: Normal pressure hydrocephalus
• Stepwise loss of function with high cholesterol and
history of CVD, depressed and irritable, hyperreflexic
and infarcts on MRI: Vascular dementia