Emergency Medicine EOR: Psychiatry and Behavioral Medicine (Smarty PANCE)

What is the first-line pharmacologic treatment for generalized anxiety disorder (GAD)?

SSRIs (sertraline, escitalopram) or SNRIs (venlafaxine, duloxetine) are first-line; buspirone is an alternative; benzodiazepines are for short-term/acute use only

What are the DSM-5 diagnostic criteria duration requirements for GAD?

Excessive anxiety and worry occurring more days than not for at least 6 months, with ≥3 symptoms (WORST mnemonic: Worry, Restlessness, fatigued, Sleep disturbance, Tension in muscles)

What distinguishes GAD from normal anxiety on exam?

GAD: excessive, uncontrollable worry about multiple domains, causing functional impairment, lasting ≥6 months, with ≥3 somatic symptoms

What is the mechanism of buspirone and its clinical advantage in GAD?

Partial 5-HT1A agonist; non-addictive, no withdrawal, no sedation — ideal for patients with substance use history; takes 2–4 weeks to work

What phobia type is most commonly tested and how is it treated?

Specific phobia (situational, animal, blood-injection-injury); first-line treatment is exposure therapy (systematic desensitization); beta-blockers for performance anxiety

What is the classic presentation of social anxiety disorder vs. GAD?

Social anxiety: fear limited to social/performance situations, fear of embarrassment/scrutiny; GAD: worry spans multiple life domains (work, health, family)

What emergency medication is used for acute severe anxiety or agitation in the ED?

Benzodiazepines (lorazepam IV/IM) first-line; haloperidol or droperidol for agitation with psychosis; avoid benzodiazepines if respiratory compromise

What are the DSM-5 criteria for a manic episode (duration and symptoms)?

≥7 days (or any duration if hospitalized), with elevated/expansive/irritable mood + ≥3 DIGFAST symptoms: Distractibility, Impulsivity/Indiscretion, Grandiosity, Flight of ideas, Activity increase, Sleep decrease, Talkativeness

What distinguishes Bipolar I from Bipolar II?

Bipolar I: ≥1 full manic episode (may or may not have depression); Bipolar II: hypomanic episodes (≥4 days, less severe) + major depressive episodes — NO full mania

What is the first-line mood stabilizer for Bipolar I and its toxicity profile?

Lithium (therapeutic level 0.6–1.2 mEq/L); toxicity signs: LITH — Lethargy/tremor, Increased DTRs, Tremor coarse, Hyperreflexia/nausea/vomiting; requires monitoring of renal function and thyroid

What anticonvulsants are used as mood stabilizers in bipolar disorder?

Valproate (valproic acid) — preferred in rapid cycling and mixed states; lamotrigine — preferred for bipolar depression; carbamazepine — alternative

What antidepressant class is contraindicated in bipolar disorder without a mood stabilizer?

Antidepressants (especially TCAs) can precipitate mania or rapid cycling; always cover with a mood stabilizer first

What is cyclothymic disorder?

Chronic mood instability with hypomanic AND depressive symptoms (not meeting full criteria for either) for ≥2 years (1 year in children); never symptom-free for >2 months

What is the most important pharmacologic caveat in treating bipolar depression?

Quetiapine, lurasidone, and olanzapine-fluoxetine combination are FDA-approved for bipolar depression; avoid antidepressant monotherapy

What are the DSM-5 criteria for a major depressive episode (SIG E CAPS)?

≥5 symptoms for ≥2 weeks including depressed mood or anhedonia: Sleep changes, Interest loss (anhedonia), Guilt/worthlessness, Energy loss, Concentration difficulty, Appetite/weight changes, Psychomotor changes, Suicidal ideation

What is the first-line pharmacologic treatment for MDD?

SSRIs (sertraline, escitalopram, fluoxetine) — first-line due to efficacy and tolerability; adequate trial = 4–8 weeks at therapeutic dose

What is the gold standard treatment for severe or refractory depression and psychotic depression?

Electroconvulsive therapy (ECT) — most effective for severe MDD, psychotic depression, MDD in pregnancy, or when rapid response is needed

What is persistent depressive disorder (dysthymia) and how does it differ from MDD?

Depressed mood most of the day, more days than not, for ≥2 years (1 year children) with ≥2 symptoms; less severe but more chronic than MDD

What antidepressant is preferred post-MI and in cardiac patients?

Sertraline — most evidence for safety in cardiac patients; avoid TCAs (QTc prolongation, anticholinergic effects)

What is the black box warning for SSRIs and who is most at risk?

Increased risk of suicidal ideation in children, adolescents, and young adults (≤24 years); monitor closely in first 4 weeks of therapy

What are the four A's of Alzheimer's disease presentation?

Amnesia (short-term memory loss first), Aphasia (language), Apraxia (learned motor tasks), Agnosia (object recognition) — cortical dementia

How do you differentiate delirium from dementia in the ED?

Delirium: ACUTE onset, fluctuating, impaired attention, reversible; Dementia: insidious onset, stable throughout day, attention preserved early, irreversible

What is the most common reversible cause of dementia?

Normal pressure hydrocephalus (NPH) — classic triad: Wet (urinary incontinence), Wacky (dementia), Wobbly (gait disturbance); treat with ventriculoperitoneal shunt

What are the reversible causes of dementia (DEMENTIAS mnemonic)?

Drugs, Emotional (depression/pseudodementia), Metabolic (thyroid, B12, electrolytes), Eyes/Ears, Normal pressure hydrocephalus, Tumors, Infections, Atherosclerosis/vascular, Structural

What medications are approved for Alzheimer's dementia?

Mild-moderate: donepezil, rivastigmine, galantamine (AChE inhibitors); Moderate-severe: memantine (NMDA antagonist) ± AChE inhibitor

What is Lewy body dementia and its key distinguishing features?

Dementia + visual hallucinations + Parkinsonism + REM sleep behavior disorder; fluctuating cognition; AVOID antipsychotics (severe neuroleptic sensitivity)

What is frontotemporal dementia and how does it present differently from Alzheimer's?

Early personality/behavioral changes and language impairment; memory preserved early; younger onset (50s–60s); Pick bodies on pathology

What is the DSM-5 definition of a panic attack?

Abrupt surge of intense fear/discomfort peaking within minutes with ≥4 symptoms: palpitations, sweating, trembling, SOB, choking, chest pain, nausea, dizziness, chills, paresthesias, derealization, fear of dying/losing control

What distinguishes panic disorder from a single panic attack?

Panic disorder: recurrent UNEXPECTED panic attacks + ≥1 month of persistent concern about future attacks OR maladaptive behavioral changes (avoidance)

What is the first-line treatment for panic disorder?

SSRIs or SNRIs (long-term); CBT with interoceptive exposure; benzodiazepines for acute/short-term relief only

What medication should be avoided long-term in panic disorder despite acute efficacy?

Benzodiazepines — risk of dependence, tolerance, rebound anxiety; use only as bridge while waiting for SSRI effect

What cardiac and medical conditions must be ruled out before diagnosing panic disorder?

MI (troponin, ECG), PE (D-dimer, CT-PA), hyperthyroidism (TSH), hypoglycemia, pheochromocytoma (metanephrines), arrhythmia (Holter)

What is the DSM-5 criteria for PTSD (duration and symptom clusters)?

≥1 month after traumatic exposure with symptoms in 4 clusters: Intrusion, Avoidance, Negative cognitions/mood, Hyperarousal (mnemonic: I ANH — Intrusion, Avoidance, Negative alterations, Hyperarousal)

What are the first-line pharmacologic treatments for PTSD?

SSRIs: sertraline and paroxetine (only FDA-approved agents); SNRIs: venlafaxine (second-line); prazosin for trauma-related nightmares

What is the first-line psychotherapy for PTSD?

Trauma-focused CBT (TF-CBT) and Prolonged Exposure (PE) therapy — most evidence-based; EMDR (Eye Movement Desensitization and Reprocessing) is also effective

What is acute stress disorder vs. PTSD?

Acute stress disorder: 3 days–1 month after trauma; PTSD: symptoms persist >1 month; both require traumatic event exposure

What symptom cluster differentiates PTSD from adjustment disorder?

PTSD requires specific symptom clusters (intrusion, avoidance, hyperarousal, negative cognitions) after trauma; adjustment disorder is emotional/behavioral response to identifiable stressor, less specific

What are the DSM-5 criteria for schizophrenia?

≥2 of 5 symptoms (at least 1 must be positive): Delusions, Hallucinations, Disorganized speech, Disorganized behavior, Negative symptoms; continuous illness ≥6 months; significant functional decline

What is the most common type of hallucination in schizophrenia?

Auditory hallucinations (most common) — typically voices commenting on behavior or command hallucinations; visual hallucinations should raise suspicion for organic/medical cause

What distinguishes positive from negative symptoms of schizophrenia?

Positive (added): hallucinations, delusions, disorganized speech/behavior; Negative (lost): Affective flattening, Alogia, Avolition, Anhedonia, Attention deficit (5 A's)

What is the first-line treatment for acute psychosis/schizophrenia?

Second-generation (atypical) antipsychotics — risperidone, olanzapine, quetiapine, aripiprazole; clozapine for treatment-resistant schizophrenia (requires ANC monitoring for agranulocytosis)

What is the best antipsychotic for treatment-resistant schizophrenia and its major risk?

Clozapine — most effective for treatment-resistant cases; major risk: agranulocytosis (monitor ANC weekly x6 months, then biweekly); also risk of seizures and myocarditis

What differentiates brief psychotic disorder, schizophreniform, and schizophrenia by duration?

Brief psychotic disorder: < 1 month; Schizophreniform: 1–6 months; Schizophrenia: ≥6 months with functional decline

What is schizoaffective disorder?

Schizophrenia symptoms + concurrent major mood episode (depressive or manic), with ≥2 weeks of psychosis WITHOUT mood symptoms at some point

What antipsychotic side effect is life-threatening and how is it treated?

Neuroleptic Malignant Syndrome (NMS): fever, rigidity, autonomic instability, altered consciousness; tx: stop antipsychotic, dantrolene, bromocriptine, ICU supportive care

What are the Intimate Partner Violence (IPV) screening tools used in clinical practice?

HITS (Hurt, Insult, Threaten, Scream) — validated brief screening tool for IPV; SAFE questions also used; screen all patients privately

What are mandatory reporting requirements for domestic violence in most states?

Mandatory reporting varies by state; most require reporting if injuries from weapons or crime; providers must know local law; always document injuries with body diagram

What are common ED presentations that should raise suspicion for IPV?

Injuries inconsistent with history, delayed presentation, multiple injuries in various stages of healing, central body injuries, partner who insists on being present, frequent ED visits

What safety planning elements should be addressed for IPV victims in the ED?

Safety plan: code word with trusted person, safe exit plan, important documents (ID, medications), emergency contacts, shelter resources (National DV Hotline: [phone]-SAFE)

What are common barriers to leaving an abusive relationship?

Fear of escalation, financial dependence, children, immigration status, cultural/religious factors, emotional attachment, lack of support — avoid victim-blaming; provide resources without pressure

What are the DSM-5 criteria for alcohol use disorder severity?

≥2 of 11 criteria in 12 months: CAGE-type behaviors + tolerance + withdrawal + craving; Mild: 2–3, Moderate: 4–5, Severe: ≥6

What is the timeline and treatment for alcohol withdrawal?

6–12h: tremor/anxiety/tachycardia; 12–24h: hallucinations; 24–48h: seizures (PEAK risk); 48–72h: delirium tremens (DTs); tx: benzodiazepines (CIWA protocol), thiamine BEFORE glucose

What is Wernicke's encephalopathy and how is it treated?

Thiamine (B1) deficiency triad: Confusion, Ataxia, Ophthalmoplegia (CAO); give IV thiamine 100–500mg BEFORE dextrose to prevent precipitation; untreated → Korsakoff psychosis

What are the first-line medications for alcohol use disorder (maintenance)?

Naltrexone (μ-opioid antagonist, reduces craving/relapse), acamprosate (reduces GABA/glutamate imbalance, reduces cravings), disulfiram (aversion therapy — avoid in low motivation)

What is the toxidrome of opioid overdose and its treatment?

Triad: miosis, respiratory depression, decreased consciousness; tx: naloxone (0.4–2mg IV/IM/IN, repeat q2–3min); short-acting — monitor for re-narcotization; may need infusion

What is the treatment for opioid use disorder (OUD)?

Medication-assisted treatment (MAT): buprenorphine/naloxone (Suboxone) — first-line outpatient; methadone — supervised opioid agonist; naltrexone (Vivitrol) — after detox

What are the stimulant toxidrome findings for cocaine and amphetamines?

Sympathomimetic: hypertension, tachycardia, hyperthermia, mydriasis, agitation, diaphoresis; cocaine also causes coronary vasospasm (avoid beta-blockers — unopposed alpha); tx: benzodiazepines

What is the treatment for benzodiazepine withdrawal and why is it dangerous?

Benzo withdrawal can be LETHAL (like alcohol) — seizures, delirium; tx: long-acting benzodiazepine taper (diazepam/chlordiazepoxide); never abruptly stop in dependent patients

What are the Columbia Suicide Severity Rating Scale (C-SSRS) categories assessed in the ED?

Ideation (passive wish to die → active ideation with plan/intent) and Behavior (preparatory acts, aborted/interrupted/actual attempts); guides disposition

What are the highest risk factors for completed suicide (SAD PERSONS)?

Sex (male), Age (< 19 or >45), Depression, Previous attempt (strongest predictor), EtOH/substance use, Rational thinking loss, Social support lacking, Organized plan, No spouse, Sickness

What is the single strongest predictor of future suicide attempt?

Prior suicide attempt — most powerful risk factor for completed suicide

What psychiatric conditions carry highest suicide risk?

Bipolar disorder (highest among all psychiatric disorders), MDD, schizophrenia, borderline personality disorder, substance use disorders

What are indications for involuntary psychiatric hold (5150 in California / equivalent)?

Danger to self, danger to others, or gravely disabled (unable to provide food/shelter/clothing due to mental illness); must be evaluated by qualified clinician

What is the pharmacologic treatment for acute suicidal ideation with agitation in the ED?

Benzodiazepines (lorazepam) ± antipsychotics (haloperidol, olanzapine); treat underlying condition; clozapine and lithium have evidence for anti-suicidal effects long-term

What protective factors reduce suicide risk?

Reasons for living, children in the home, religious/moral objections, social support, pregnancy, future orientation, engaged in treatment — assess alongside risk factors