Internal Medicine EOR: Psychiatric & Behavioral Health (2026) (Smarty PANCE)

What is Generalized Anxiety Disorder (GAD)?

A chronic condition of excessive, difficult-to-control worry about multiple domains occurring more days than not for at least 6 months.

What are the DSM-5 diagnostic criteria for GAD?

Excessive anxiety/worry ≥6 months plus ≥3 of 6 symptoms: restlessness, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbance (only 1 needed in children).

What is first-line pharmacotherapy for GAD?

SSRIs or SNRIs; buspirone is an adjunct/alternative; benzodiazepines only for short-term bridging due to dependence risk.

What is first-line psychotherapy for GAD?

Cognitive behavioral therapy (CBT), which is as effective as medication and preferred for durable benefit.

Why are benzodiazepines avoided as long-term GAD treatment?

Risk of tolerance, dependence, sedation, cognitive impairment, and withdrawal; they do not treat the underlying disorder.

What screening tool is commonly used for GAD?

The GAD-7 questionnaire (score ≥10 suggests clinically significant anxiety).

What is Panic Disorder?

A condition defined by recurrent unexpected panic attacks plus persistent worry about future attacks or maladaptive behavioral change.

What defines a panic attack?

An abrupt surge of intense fear peaking within minutes with ≥4 symptoms such as palpitations, sweating, trembling, dyspnea, chest pain, dizziness, derealization, or fear of dying.

How long must symptoms persist to diagnose panic disorder?

≥1 month of persistent concern about additional attacks or significant maladaptive behavior change following at least one attack.

What is first-line treatment for panic disorder?

SSRIs/SNRIs combined with CBT; benzodiazepines only short-term for acute distress.

What medical conditions should be excluded before diagnosing panic disorder?

Hyperthyroidism, arrhythmia, MI, pheochromocytoma, hypoglycemia, and substance intoxication/withdrawal.

What is the relationship between panic disorder and agoraphobia?

Agoraphobia (fear/avoidance of situations where escape is difficult) frequently co-occurs and may develop from anticipatory anxiety about attacks.

What are Phobic Disorders?

Disorders characterized by marked, persistent, irrational fear and avoidance of specific objects, situations, or social scrutiny.

How is specific phobia diagnosed?

Marked fear/anxiety about a specific object or situation, near-always provoked, actively avoided, out of proportion, lasting ≥6 months.

What is the treatment of choice for specific phobia?

Exposure therapy (systematic desensitization); medications are generally not first-line.

What characterizes social anxiety disorder (social phobia)?

Marked fear of social or performance situations with possible scrutiny, leading to avoidance, lasting ≥6 months.

What is first-line treatment for social anxiety disorder?

SSRIs/SNRIs and CBT; beta-blockers or benzodiazepines may help performance-only (situational) anxiety.

What is Major Depressive Disorder (MDD)?

A mood disorder defined by ≥2 weeks of depressed mood or anhedonia plus associated neurovegetative symptoms causing functional impairment.

What are the DSM-5 criteria for MDD (mnemonic SIGECAPS)?

≥5 symptoms over 2 weeks including depressed mood or anhedonia: Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor changes, Suicidality.

What is first-line pharmacotherapy for MDD?

SSRIs are first-line; SNRIs, bupropion, and mirtazapine are alternatives.

How long should antidepressants be continued after a first episode of MDD?

Continue 6-12 months after remission; longer or indefinite for recurrent episodes.

What is the most effective treatment for severe, refractory, or psychotic depression?

Electroconvulsive therapy (ECT).

What screening tool is used for depression?

The PHQ-9 (and PHQ-2 for initial screening).

What is serotonin syndrome and how does it present?

A potentially life-threatening reaction to serotonergic excess presenting with altered mental status, autonomic instability, hyperthermia, and neuromuscular hyperactivity (clonus, hyperreflexia).

What is Persistent Depressive Disorder (Dysthymia)?

A chronic depressed mood present most days for at least 2 years (1 year in children/adolescents) with milder symptoms than MDD.

What are the diagnostic criteria for persistent depressive disorder?

Depressed mood ≥2 years plus ≥2 of: appetite change, sleep change, low energy, low self-esteem, poor concentration, hopelessness, without symptom-free period >2 months.

What is "double depression"?

A major depressive episode superimposed on underlying persistent depressive disorder.

What is first-line treatment for persistent depressive disorder?

Combination of antidepressants (SSRIs) and psychotherapy (CBT).

How does persistent depressive disorder differ from MDD?

It is more chronic but less severe, with fewer required symptoms and a longer duration requirement (≥2 years).

What is Bipolar I Disorder?

A mood disorder defined by at least one manic episode, often alternating with depressive episodes.

What defines a manic episode?

≥1 week of elevated/irritable mood and increased energy plus ≥3 DIGFAST symptoms causing marked impairment, hospitalization, or psychotic features.

What does the DIGFAST mnemonic stand for in mania?

Distractibility, Indiscretion/impulsivity, Grandiosity, Flight of ideas, Activity increase, Sleep decrease, Talkativeness.

What is first-line treatment for acute mania?

Lithium, valproate, or second-generation antipsychotics; antidepressants are avoided as monotherapy.

What monitoring is required for lithium therapy?

Serum lithium levels, renal function, and thyroid function; narrow therapeutic index with toxicity risk.

What are early signs of lithium toxicity?

Tremor, nausea, diarrhea, ataxia, confusion, and at high levels seizures and arrhythmias.

Why must depression in bipolar disorder be treated cautiously?

Antidepressant monotherapy can precipitate a manic switch; mood stabilizers should be used.

What is Bipolar II Disorder?

A mood disorder with at least one hypomanic episode and at least one major depressive episode, but no full manic episode.

What defines a hypomanic episode?

≥4 days of elevated/irritable mood with ≥3 manic symptoms causing observable change in function but without marked impairment, psychosis, or hospitalization.

How does hypomania differ from mania?

Hypomania is shorter (≥4 days vs ≥1 week), less severe, lacks psychosis, and does not cause marked functional impairment or require hospitalization.

What is first-line treatment for bipolar II depression?

Mood stabilizers/quetiapine or lamotrigine; lamotrigine is particularly useful for bipolar depression maintenance.

Which mood episode predominates and causes most morbidity in bipolar II?

Depressive episodes, which are typically more frequent and disabling than hypomania.

What is Psychosis?

A state of impaired reality testing marked by delusions, hallucinations, disorganized thought, or disorganized behavior.

What are the positive symptoms of psychosis?

Hallucinations, delusions, disorganized speech, and disorganized/abnormal motor behavior.

What are common medical and substance causes of psychosis?

Stimulant intoxication, hallucinogens, delirium, dementia, CNS lesions, temporal lobe epilepsy, and severe metabolic derangements.

What is the general approach to acute psychosis?

Ensure safety, evaluate for medical/substance causes, and use antipsychotics; benzodiazepines may help acute agitation.

What distinguishes delirium from primary psychotic disorders?

Delirium has acute onset, fluctuating course, and altered consciousness/attention with an identifiable medical cause.

What is Schizophrenia?

A chronic psychotic disorder with ≥6 months of symptoms including ≥1 month of active-phase positive symptoms causing functional decline.

What are the DSM-5 criteria for schizophrenia?

≥2 of: delusions, hallucinations, disorganized speech, grossly disorganized/catatonic behavior, negative symptoms (≥1 must be a core positive symptom) for ≥1 month, with ≥6 months total disturbance.

What are negative symptoms of schizophrenia?

Flat affect, alogia, avolition, anhedonia, and social withdrawal.

How is schizophrenia distinguished from schizophreniform and brief psychotic disorder by duration?

Brief psychotic disorder

What is first-line pharmacotherapy for schizophrenia?

Second-generation (atypical) antipsychotics due to fewer extrapyramidal effects.

Which antipsychotic is used for treatment-resistant schizophrenia and what is its key risk?

Clozapine; requires ANC monitoring due to risk of agranulocytosis.

What is the peak age of onset for schizophrenia?

Late teens to mid-20s in men and late 20s in women.

What is Anorexia Nervosa?

An eating disorder marked by restriction of intake leading to significantly low body weight, intense fear of weight gain, and distorted body image.

What are the two subtypes of anorexia nervosa?

Restricting type and binge-eating/purging type.

What are key physical and lab findings in anorexia nervosa?

Bradycardia, hypotension, hypothermia, amenorrhea, lanugo, electrolyte abnormalities, osteopenia, and elevated cortisol.

What is the most serious complication of refeeding in anorexia?

Refeeding syndrome with hypophosphatemia, which can cause cardiac failure and arrhythmias.

What is the cornerstone of treatment for anorexia nervosa?

Nutritional rehabilitation and weight restoration plus psychotherapy; family-based therapy is first-line in adolescents.

What distinguishes anorexia from bulimia?

Anorexia involves significantly low body weight; bulimia patients are typically normal weight or overweight.

What is Bulimia Nervosa?

An eating disorder defined by recurrent binge eating followed by inappropriate compensatory behaviors, with self-evaluation overly influenced by body shape/weight.

What are the DSM-5 criteria for bulimia nervosa?

Recurrent binge eating and compensatory behaviors (vomiting, laxatives, fasting, exercise) ≥1/week for 3 months in patients not significantly underweight.

What physical exam findings suggest bulimia with purging?

Russell sign (knuckle calluses), dental erosion, parotid gland enlargement, and hypokalemic metabolic alkalosis.

What is first-line treatment for bulimia nervosa?

CBT plus an SSRI (fluoxetine is the only FDA-approved agent).

Which medication is contraindicated in bulimia nervosa?

Bupropion, due to increased seizure risk in purging patients.

What is Binge-Eating Disorder?

An eating disorder defined by recurrent episodes of binge eating without compensatory behaviors, associated with distress.

What are the DSM-5 criteria for binge-eating disorder?

Recurrent binges ≥1/week for 3 months with ≥3 of: eating rapidly, eating until uncomfortably full, eating when not hungry, eating alone, feeling disgusted/guilty afterward.

How does binge-eating disorder differ from bulimia?

Binge-eating disorder lacks the recurrent compensatory behaviors seen in bulimia.

What is first-line treatment for binge-eating disorder?

Psychotherapy (CBT); SSRIs and lisdexamfetamine (FDA-approved) can reduce binge frequency.

What is the most common eating disorder in the United States?

Binge-eating disorder.

What is Alcohol Use Disorder?

A problematic pattern of alcohol use causing clinically significant impairment or distress, diagnosed with ≥2 of 11 DSM-5 criteria in 12 months.

What screening tools are used for alcohol use disorder?

CAGE questionnaire and AUDIT.

What is the timeline and danger of alcohol withdrawal?

Tremors/anxiety 6-24h, seizures 12-48h, alcoholic hallucinosis 12-24h, and delirium tremens 48-96h (life-threatening).

What is first-line treatment for alcohol withdrawal?

Benzodiazepines, with supportive care and thiamine before glucose to prevent Wernicke encephalopathy.

What medications are used for maintenance of alcohol abstinence?

Naltrexone, acamprosate, and disulfiram.

What is the classic triad of Wernicke encephalopathy?

Confusion, ophthalmoplegia, and ataxia, due to thiamine deficiency.

What is Opioid Use Disorder?

A problematic pattern of opioid use leading to significant impairment or distress meeting ≥2 of 11 DSM-5 criteria.

How does opioid intoxication present?

Miosis (pinpoint pupils), respiratory depression, sedation, and decreased bowel sounds.

What is the treatment for acute opioid overdose?

Naloxone, an opioid antagonist, with airway/respiratory support.

What are signs of opioid withdrawal?

Mydriasis, yawning, lacrimation, rhinorrhea, diaphoresis, piloerection, myalgias, nausea/vomiting, and diarrhea (uncomfortable but not life-threatening).

What are maintenance treatments for opioid use disorder?

Methadone, buprenorphine (often with naloxone), and naltrexone.

What is Sedative-Hypnotic Use Disorder?

A problematic pattern of benzodiazepine or barbiturate use causing significant impairment or distress.

How does sedative-hypnotic intoxication present?

Slurred speech, ataxia, sedation, disinhibition, and respiratory depression, similar to alcohol intoxication.

Why is withdrawal from sedative-hypnotics dangerous?

Like alcohol, abrupt withdrawal can cause seizures and life-threatening autonomic instability/delirium.

What is the antidote for benzodiazepine overdose and its caution?

Flumazenil; use cautiously as it can precipitate seizures in dependent patients.

What is the management approach for sedative-hypnotic withdrawal?

Gradual tapering with a long-acting benzodiazepine and supportive care.

What is Stimulant Use Disorder?

A problematic pattern of cocaine or amphetamine use causing significant impairment or distress.

How does stimulant intoxication present?

Mydriasis, tachycardia, hypertension, hyperthermia, agitation, euphoria, and possible psychosis or seizures.

What are the major medical risks of acute stimulant intoxication?

Myocardial infarction, stroke, arrhythmias, and seizures.

What is the management of stimulant intoxication and agitation?

Supportive care with benzodiazepines for agitation; avoid beta-blocker monotherapy in cocaine toxicity due to unopposed alpha stimulation.

How does stimulant withdrawal present?

"Crash" with depression, fatigue, hypersomnia, increased appetite, and intense cravings (not life-threatening).

What is Tobacco Use Disorder?

A problematic pattern of tobacco/nicotine use causing significant impairment or distress with dependence.

What are the pharmacologic options for tobacco cessation?

Nicotine replacement therapy, varenicline, and bupropion.

Which agent is considered most effective for smoking cessation?

Varenicline, a partial nicotinic receptor agonist.

How does nicotine withdrawal present?

Irritability, anxiety, difficulty concentrating, increased appetite, restlessness, and depressed mood.

What behavioral framework guides smoking cessation counseling?

The 5 A's: Ask, Advise, Assess, Assist, Arrange.

What is Posttraumatic Stress Disorder (PTSD)?

A disorder developing after exposure to a traumatic event with symptoms lasting >1 month across four clusters.

What are the four symptom clusters of PTSD?

Intrusion (re-experiencing), avoidance, negative alterations in cognition/mood, and alterations in arousal/reactivity.

What duration distinguishes PTSD from acute stress disorder?

PTSD symptoms last >1 month; acute stress disorder lasts 3 days to 1 month.

What is first-line treatment for PTSD?

Trauma-focused psychotherapy (CBT, prolonged exposure, EMDR) and SSRIs/SNRIs.

Which medication can help PTSD-related nightmares?

Prazosin, an alpha-1 antagonist.