EOR: BH treatments

acute mania in bipolar disorder

lithium + AP (preferably 2nd gen)

bipolar disorder

mood stabilizers → lithium, valproate, lamotrigine, carbamazepine, oxcarbamazepine

bipolar depression (bipolar II)

lamotrigine

rapid-cycling/mixed episodes bipolar disorder

carbamazepine & oxcarbamazepine

major depressive disorder (MDD)

psychotherapy (CBT) plus:

1st line → SSRI

2nd line → SNRI

3rd line → TCA/MOAI

refractory → ECT

MDD pts < 18 y/o

CBT +/- pharm

persistent depressive disorder (dysthymia)

psychotherapy + pharm

therapy → interpersonal, cognitive, insight-oriented

pharm → SSRI, SNRI, TCA, MAOI

disruptive mood dysregulation disorder

1st line → psychotherapy (parent management training)

adjunctive pharm (sxs control) → stimulants, SSRIs, mood stabilizers, 2nd gen APs

premenstrual dysphoric disorder

life mods → reduce stress, exercise, limit caffeine/alc/cigs/salt

OTC → NSAIDs, vit B6 & E

1st line pharm → SSRIs

adjunctive → OCPs (drospirone-containing), spironolactone

postpartum depression

SSRI → paroxetine or sertraline

**least SSRIs secreted into breast milk

generalized anxiety disorder

CBT + SSRI/SNRI

acute tx → benzos (until SSRI kicks in)

avoid/decrease caffeine

panic disorder

CBT + pharm

1st line pharm → SSRI (sertraline, citalopram, escitalopram)

2nd line → SNRI (venlafaxine)

3rd line/refractory → TCA (clomipramine, imipramine)

acute tx → benzos

specific phobia

CBT → exposure & desensitization therapy

agoraphobia

CBT + SSRI

social anxiety disorder

1st line → CBT

pharm → SSRI/SNRI

performance only → propranolol

selective mutism

CBT + SSRI

separation anxiety disorder

psychotherapy (CBT, family) + SSRI

PTSD

1st line → SSRI (sertraline & paroxetine) or SNRI (venlafaxine)

nightmares → prazosin

psychotherapy → trauma-focused, exposure, cognitive processing, EMDR

acute stress disorder

counseling & psychotherapy

if sxs persist > 1 month → tx as PTSD

adjustment disorder

supportive psychotherapy, group therapy

pharm → only if needed to target sxs (insomnia, anxiety, depression)

alcohol intoxication

"banana bag" → thiamine, folate, mag sulfate, multivitamins

alcohol withdrawal

long-acting benzos → diazepam, clonazepam

alcohol addiction

1st line → naltrexone (decreases cravings & euphoria)

disulfiram

cannabis withdrawal

mild → supportive therapy, relaxation techniques

mod-sev (impacting life) → dranabinol, ADs, mood stabilizers

hallucinogen intoxication (PCP, LSD)

APs (haloperidol) + benzos

inhalant intoxication

APs (haloperidol) if severe agitation

opioid intoxication

naloxone (Narcan)

opioid withdrawal

acute → clonidine

chronic → methadone, naltrexone, buprenorphine/naloxone (Suboxone)

benzo/sedative/anxiolytic withdrawal

long acting benzos → clonazepam

benzo overdose

flumazenil → only if life threatening

stimulant intoxication

benzos

AVOID BBs & DHP CCBs "-dipines" → coronary spasm

stimulant withdrawal

sxs → benzos, ADs, psychotherapy

stimulant addiction

long acting amphetamine

modafinil

disulfiram

bupropion

tobacco withdrawal/addiction

counseling, support therapy, CBT

varenicline (Chantix)

bupropion (Wellbutrin)

nicotine replacement therapy → patches, gun

TCA toxicity/overdose

sodium bicarb

delusional disorder

2nd gen APs

somatic type → ADs

persecutory type → CBT

schizoaffective

2nd gen APs +/- SSRI (depression) or mood stabilizer (bipolar)

schizophreniform

2nd gen APs

schizophrenia

2nd gen APs

acute psychosis in schizophrenia spectrum

risperidone or aripirazole

catatonia → benzos

acute dystonia

benztroprine or benadryl

Parkinsonism (EPS)

amantadine or anticholinergic (Benadryl)

akathisia (EPS)

BB, benzo or anticholinergic

tardive dyskinesia

valbenazine (Ingrezza)

neuroleptic malignant syndrome

dantroline, bromocriptine

lower BP → clonidine, nirtoprusside

positive sxs of schizophrenia

1st gen APs

negative sxs of schizophrenia

2nd gen APs

dementia

cholinesterase inhibitors → donepezil, rivastigmine, galantamine

memantine

AVOID paroxetine → anticholinergic

conduct disorder

multimodal:

- behavior modification

- family involvement

- parent management training

- pharm → SSRIs, propranolol, APs

oppositional defiant disorder

behavior modification

conflict management training

parent management training

pharm (comorbid ADHD) → stimulants

ADHD

preschool → psychotherapy

1st line → stimulants

2nd line → atomoxetine

adjunct → a2 agonists (clonidine, guanfacine)

non-pharm → behavior modification, social-skills training, educational interventions, parental education

tic disorder

1st line → behavioral intervention (habit reversal training)

pharm (if needed) → guanfacine/clonidine; APs

nocturnal enuresis

1st line → desmopressin

2nd line → TCA

elimination disorders

parent management treatment

psychoeducation

OCD

CBT + pharm

CBT → exposure & response prevention

pharm → SSRIs, SNRIs, TCA (clomipramine)

**SSRIs need to be started at high doses

last resort → cingulotomy (psychosurgery), ECT

body dysmporhic disorder

SSRIs +/- CBT

trichotillomania

specialized CBT → habit reversal training

SSRIs, 2nd gen APs, lithium

excoriation disorder

habit reversal training

SSRIs

autism spectrum

comprehensive approach:

- early intervention

- behavior analysis

- APs → risperidone or aripiprazole

- stimulants (if comorbid ADHD)

first line tx for all personality disorders unless otherwise specified

CBT

what to avoid in paranoid personality disorder

group therapy

antisocial personality disorder (pharm)

1st line → 2nd gen APs (risperidone, quetiapine)

2nd line → fluoxetine or sertraline

borderline personality disorder

1st line = dialectical behavioral therapy

pharm as adjunct for comorbid dxs

narcissistic personality disorder

CBT → transference focused

pharm for comorbids → lithium (mood swings) or ADs (depression)

avoidant personality disorder (pharm)

SSRIs → anxiety or depression

BBs → nervous system hyperactivity

dependent personality disorder

CBT → cognitive-behavioral assertiveness, social skills training

adjunct pharm for comorbids → SSRIs (anxiety/depression)

OCPD

CBT if the most effecting psychotherapy

pharm (not very effective) → comorbid anxiety/depression

somatic sx disorder

regularly scheduled PCP (ONE PROVIDER ONLY)

address psych issues slowly

psychotherapy → group, hypnosis, biofeedback behavioral

support from fam/friends

illness anxiety disorder

regularly scheduled PCP visits (one provider only)

psychotherapy → CBT

pharm for comorbid anxiety → SSRIs

functional neurologic symptom disorder (conversion disorder)

CBT

pt education about 1st line tx for illness of presenting sxs

factitious disorder

imposed on self → psychotherapy

imposed on other → abuse & report to CPS/DCF

what is contraindicated in all feeding/eating disorders?

bupropion → seizure risk

anorexia nervosa

1st line → weight restoration

- nutritional rehab vs hospitalization

psychotherapy → CBT, family therapy (Maudsley approach)

adjunct pharm for comorbids → SSRIs, APs (olanzapine), pre-meal xanax

bulimia nervosa

fluoxetine + therapy

therapy → CBT (most effective), interpersonal, group, family

nutritional counseling & education

**fluoxetine is started at high dose

refeeding syndrome

reduce nutritional support, aggressive correction of hypophosphatemia, hypokalemia & hypomagnesemia

binge eating disorder

psychotherapy (CBT or interpersonal) + strict diet & exercise plan from dietician

pharm → SSRIs, lisdexamfetamine (Vyvanse)

ARFID

multidisciplinary:

- CBT-AR (special type of CBT)

- dietitians, GIs, mental health, OTs, SLPs

- pharm (not first line/off-label) → cyproheptadine, mirtazepine, lorazepam, olanzapine

rumination disorder

habit-reversal behavioral therapy

PPIs for esophagus damage

pica

if iron deficiency anemia → chelation

multivitamin supplement

tx of behavioral problems

paraphilia disorders (general)

psychotherapy → CBT, group therapy, insight-oriented therapy, 12 step programs

pharm → SSRI, long-acting GnRH, or anti-androgens

**pharm is used to decrease sex drive/fantasies

voyeuristic disorder

- psychoanalytic, group therapy, shock aversion

- pornography

- APs & ADs

- tx methods for OCD (SSRIs)

pedophilic disorder

SSRIs (fluoxetine & sertraline) → reduce urge

leuprolide (GnRH) or medroxyprogesterone acetate (depo vera) → reduces frequency

sexual masochism disorder

psychotherapy → individual CBT and insight-focused therapy

pharm → SSRIs

severe cases → short term anti androgen injections (depo shot or GnRH) to reduce libido & frequency of risky sex

female sexual interest/arousal disorder

non-pharm (1st line):

- consistent date nights

- bringing novelty to sexual repertoire → new positions/locations, toys

- lubricants/moisturizers

- sex or couples therapy

pharm (if refractory):

- flibanserin → premenopausal women; increases DA & 5HT

- topical estrogen → postmenopausal women w dryness/atrophy

erectile disorder

PDE-5 inihibtors

alprostadil injection

vacuum-assisted devices or prostheses

premature ejaculation disorder

SSRIs (paroxetine) & TCA (clomipramine) → prolong time to orgasm (remember they have ADRs of sex dysfunction so this helps to prolong time)

squeeze or stop-start technique → increases threshold of excitability

male hypoactive sexual desire disorder

testosterone replacement therapy

female orgasmic disorder

directed masturbation

Genito-pelvic pain/penetration disorder

gradual desensitization & cognitive-behavioral pain management

serotonin syndrome

1st line → benzos

2nd line → cyproheptadine (antihistamine that is a serotonin antagonist)

pregnancy treatments

bipolar → lamotrigine

ECT is safe but only use if refractory

SSRIs → sertraline & paroxetine are best

insomnia

1st line → CBT

pharm → Z-hypnotics, ORAs, MRAs

- benzos (last resort pharm option)

off-label → ADs (TCAs, trazodone, mirtazapine)

Z-hypotics (non-benzos)

sleep onset & maintenance insomnia

*zaleplon has shortest t1/2 → not the best for maintenance

orexin receptor antagonists (suvorexant & lemborexant)

sleep onset & maintenance insomnia

contraindication to orexin receptor antagonists

narcolepsy

melatonin receptor agonist (ramelteon)

sleep onset insomnia ONLY (no effect on maintenance)

**best for pts w COPD & sleep apnea

hypersomnolence disorder

modafinil/armodafinil

stimulants → methylphenidate, amphetamines

sodium oxybate

pitolisant

narcolepsy

modafinil, armodafinil, pitolisant, solriamfetol

narcolepsy with cataplexy

sodium oxybate

shift-work disorder

modafinil or stimulants