Psych/Geriatric Clinical Medicine Exam

Anorexia Nervosa

• DSM: restriction of energy intake related to requirements leading to significantly decreased body weight (BMI), intense fear of gaining weight/becoming fat, disturbance in the way one’s body weight is experienced and denial of seriousness of condition (Ego-systonic)

• Risks: adolescence to young adulthood, women/men, hobbies with strict control over body shape/size (dance, wrestling), after a life changing event, over consumed by behaviors to promote thinness

• S/S: emaciated (extremely low BMI), persistent hypothermia, hypotensive and bradycardia, chronic constipation, amenorrhea, lanugo hair, carotenemic skin, parotid gland enlargement/erosion of teeth, denial of condition

  • Labs: high cortisol, hypothyroid, hypokalemic, acidotic/alkalotic, high BUN and amylase

• Dx: collateral data from family/friends, hx

• Tx: medical intervention (fluid/electrolyte imbalance)

  • Behavioral therapies (inpatient)- focus on weight restoration→ CBT years after resolution

  • Meds: SSRIs + 2nd gen anti-psychotic (Olazapine: has weight gaining properties)

• Complications: electrolyte imbalance, remain obsessive about exercise, only 25% make a full recovery

Bulimia Nervosa

• DSM: recurrent episodes of binge eating characterized by eating a large amount of food really fast and having a lack of control during the binge with eating rapidly and feeling uncomfortably full, eating while not hungry, feeling embarrassed/disgusted and hiding it from family→ followed by compensatory behaviors/purging

• Risks: later in life, women/men, high risk in people with relatives that have experienced a purge/binge cycle, shame/disgust/guilt that perpetuates next cycle

  • Severity dependent on compensatory behavior and frequency (laxative, diuretic, enema, stimulant, fasting, exercise, vomit)

  • Bulimia without purging

    • Overuse of thyroid meds: overactive metabolism

    • Overuse of amphetamines (stimulant) meds: Adderall

    • Diabetics skip insulin: will burn fat (diabulimia)

• S/S: dental erosions/caries, Mallory-weiss tears from forced vomit, parotid gland enlargement, Russell’s sign (marks on hand from gagging), ego-dystonic (shame/guilt/awareness of self)

  • Labs: hypocalcemia, hypokalemic, metabolic alkalosis/acidosis, high LFTs and amylase

• Tx: Prozac and CBT

  • DO NOT USE WELLBUTRIN XL (high seizure risk d/t electrolyte imbalance)

Binge Eating disorder

• DSM: similar to bulimia nervosa w/o any compensatory mechanisms

• Risks: women, strongly associated with obesity

• S/S: report extreme weight gain, describe binging episodes

• Tx: CBT ± SSRI, behavioral weight loss therapy

Avoidant restrictive food intake disorder (ARFID)

• DSM: Eating/feeding disturbance so pervasive that the person is unable to meet appropriate nutritional needs→ significant weight loss, nutritional deficiencies, dependency on supplements, interference with social fxn that cannot be explained by lack of food, cultural/religious practices, not an issue about weight/size and cannot be caused by another medical/mental condition

• Risks: infancy/early childhood, body image distortion absent, do not fear weight gain

• S/S: “Hx of picky eating” that has now surpassed normal limits, only eat crackers/prepackaged/processed foods (same every time they are consumed), complain of textures

• Tx: Occupational therapy and pediatric dietician

  • SSRI if fear of choking, SLP for swallow eval

  • Can use Cyproheptadine as an appetite stimulant

PICA

• DSM: persistent eating of non-nutritive/non-food substance that is inappropriate for development and not apart of a cultural norm, can be in another mental/med disorder if it is significant enough to require clinical attention

• Risks: severe intellectual disability, pregnant women who are iron deficient

  • Clay (MC), paper, hair, dirt, bar of soap, chalk, rock, ice (pagophagia)

• S/S: loved ones concerned about consumption habits, abdominal pain (watch for SBO), usually a truthful response to “what did you eat today?”

• Tx: Behavior modification therapy

  • medically treat SBO if present

  • give iron if underlying anemia

Rumination Disorder

• DSM: consistently regurgitate food 1+ mo that is not attributed to GI/med conditions, is not associated with any other ED and if in any other medical condition must be significant enough to seek attention

• Risks: infants/young, developmental disability, absence of other GI findings, no force

• Tx: Behavior modification treatment and habit reversal technique (diaphragm training)

Obsessive Compulsive Disorder (OCD)- no longer GAD, independent anxiety disorder

• Patho: anxiety disorder identified by intrusive thoughts and obsessions alleviated by compulsions

  • Obsession (“the thought”): unwanted repetitive intrusive ideas or images

  • Compulsions (“the action”): performed in attempt to suppress/neutralize the obsession

  • Do not have to have both, >1 hr a day of either or both is a valid OCD diagnosis

• Risks: Genetic link with clusters in the family, serotonin dysfunction orbital cortex and caudate nuclei, complain of loneliness (time consuming and social isolation)

  • Specifiers of Dz

    • Good: curling iron is off and I took a pic before I left

    • Poor: need to leave work because I don’t trust the picture

• S/S: obsessions and compulsions present, compulsions present inconvenient→ incapacitating, resisting compulsions increases anxiety

• Dx: Yale Brown Obsessive Compulsive Scale (YBOCS): 16-40 is severe enough to treat

• Tx: Exposure and response prevention (ERP) and CBT

  • ± Pharmacotherapy

    • Best: SSRIs (Fluoxetine- Prozac, Fluoxamine- Luvox, Sertraline- Zoloft)

    • TCA: Clomipramine

    • NO BENZO

  • Differ OCD personality disorder (not problematic) from OCD (problematic)

Post Traumatic Stress Disorder (PTSD)

• DSM: exposure to traumatic stressors, re-experiencing symtoms, avoidance behaviors, cognitive distortions, increased arousal, duration, fxnl impairment, exclusion (not meds/substance/other illness)

  • can be delayed YEARS after precipitating events

• Risks: veterans (men), sexual assault victims (women), co-morbid psych disorders

• S/S: re-experieencing trauma through intrusive thoughts/nightmares, avoidance of stimuli associated with event, negative alterations in mood (emotionally numb), alterations in arousal (irritability/exaggerated startle response)

• Dx: depersonalization (out of body), derealization (surroundings don’t feel real)- may take 6+ months to appear

• Tx: Eye movement desensitization reprocessing (EMDR), CBT and family therapy

  • Meds: SSRI/SNRI effective (Paroxetine- Paxil, Fluoxetine- Prozac)

  • Benzo- short term relief for panic, Alpha-1-adernergic agonists (Prazosin)- nightmares

Acute stress disorder- “baby PTSD”

• DSM: disturbance lasts for a minimum of 2 days and maximum of 4 weeks after the traumatic event

  • similar to PTSD bit subsides within 1 month of trauma exposure

• Tx: CBT therapy (can prevent full blown PTSD), SSRI/SNRI

  • controversial B-blocker right after incident for hyper-activity

Adjustment Disorder- “Walking Wounded”

• DSM: Patients with severe emotional distress after a life-stressor that is upsetting but not life threatening, cannot be existing disorder, surpasses normal bereavement

  • within 3 months of incident but does not persist longer than 6 months (after 6 months is GAD or MDD)

• Risks: school problems, financial issues, marital issues/ divorce, moving, patients are usually young (lack coping skills)

• S/S: conduct issues, depressed mood, increase in anxiety, inciting event (my child has been acting out since we got a divorce), parents also have adjustment disorders, patients fail to meet criteria for MDD (6+ mo)

• Tx: Therapy, 6+ months look at alternative diagnosis (GAD/MDD) and think about anti-depressant therapy

Psychosis

Break with reality; poor reality testing

• Hallucinations, delusions, disorganized thinking, bizarre behavior, catatonia

  • Hallucinations: auditory, visual, sensory, command

  • Delusions: persecutory, grandiose, religious, erotomanic, somatic, ideas of reference, thought control

• Hx: get from patient and their family (if it allows), physical illness, acute/chronic illness, substance abuse history, family history

  • MSE: inappropriate appearance, strange/awkward movement, psychomotor agitation, poverty of speech and content, loose associations, neologisms, vocal inflection reduced/absent, mood can be depressed or elated, affect is flat/constant/labile, poverty and race of thought, hallucination/delusion, suicidal/homicidal ideation, abstract thinking, insight lacking, judgment impaired

• Dx: essential medical evaluation- PE/lytes, liver/renal fxn, tox screen, CBC, thyroid, B12/folate, FTA/RPR (neurosyphilis)

  • Refer to psych for evaluation of psychosis: neuropsychological testing, projective tests, personality inventory

Psychotic disorders

• Schizotypal personality disorder

• Delusional disorder: delusions 1+ mo

• Brief psychotic disorder (1 day- 1 month)

• Schizophrenia (6+ months)

• Schizophreniform disorder (1mo-6mo)

• Shizoaffective disorder (Mood and psychosis)

Delusional disorder

Presence of a well-systemized delusion in the absence of odd or bizarre behavior; no thought disorganization, blunted affect or catatonia; no functional deterioration (hallucinations may occur but are not prominent and are only in relation to the delusion)

• DSM: 1 or more delusions for 1 month and does not meet the criteria for schizophrenia, mania and depression

• Risks: middle/late life, family hx of other psychotic disorders

• S/S: fxn in society (may be socially withdrawn or have issues/outbursts)

• Tx: Typically resistant to therapy especially group therapy

  • 1st line: Atypical (2nd generation) antipsychotics

  • 2nd line: SSRIs

Brief psychotic disorder

Psychotic s/s 1 day-1 month (not caused by a substance or medical disorder)

• S/S: similar to schizophrenia- hallucinations, delusions, disorganized speech/behavior

• Tx: often inpatient, antipsychotics for agitation

Schizophrenia

• Psychotic symptoms 6+ months characterized by 2 types of symptoms: positive and negative

• Risks: Men 18-30 yo, women 20-40 yo

• DSM: 2 + s/s over significant amount of time in a month, social/occupational dysfunction and 6+ months of disturbance

  • Dimensions of schizophrenia: 0 (symptom not present)→ 4 (severe), psychosis rating

• S/S: occasional prodrome (schizoid traits, low educational achievement, social withdrawal, unusual behavior)

  • Active phase (>1 mo): delusion, hallucination, disorganized speech, catatonic/disorganized behavior, marked - s/s

  • Deterioration (> 6 mo): marked decline, social relationships, poor ADLs

  • Residual: acute phase s/s mild/absent, negative s/s predominant

• Tx: Antipsychotics, daily routine, community resources, family connections

  • Hospitalize if: illness is new, ECT, pt is a danger to self or others, cannot care for themselves, medication side effects

  • 10-15% of patients only respond to Clozapine (atypical antipsychotic)- refractory

Positive s/s schizophrenia

Active psychosis- hallucinations, delusions, thought disorganization, bizarre behavior, catatonia

Negative s/s of schizophrenia

Blunted affect, poverty of speech and thought, loss of interest/pleasure/motivation, psychomotor slowing, poor attention, diminished social relationships

Good prognosis for schizophrenia

Later onset, good social support, mainly positive symptoms (easier to treat), acute onset, female, few relapses

Schizophreniform disorder

Same criteria as schizophrenia, the difference is time, 1 month- 6 months

• 1/3 recover, 2/3 develop schizoaffective disorder or schizophrenia

Schizoaffective disorder

Differs from schizophrenia; MOOD and PSYCHOSIS must be present and be chronic and debilitating- mood syndrome (MDD/GAD) must be present for 50% or more of total duration of illness

• DSM: uninterrupted periods of illness where a major mood episode is concurrent with s/s of schizophrenia, delusions/hallucinations for 2+ weeks without a major mood episode, mood is present a majority of the total duration

  • Specifiers: bipolar type, depressive type, catatonia type

• Tx: Antipsychotics + mood stabilizers (long term)

Major depressive disorder with psychotic features

Major depressive episode complicated by psychotic s/s (high risk for suicide)

• S/S: delusions, hallucinations, thought disorganization, catatonia, voices telling patient to harm themselves and feel compelled to obey

• Tx: Hospital admission for suicidal patient

  • Meds: Atypical antipsychotic + SSRI (Haldol + Zoloft)

  • Electroconvulsive therapy: most effective tx for psychosis+depression (good for catatonia subtype)

Manic episode with psychotic features

Distinct periods of mood elevation and psychotic thinking, mood is euphoric→irritable, psychosis is usually consistent with mood elevation

• S/S: voices tell patient to do something like buy a castle in France, delusions of importance, sometimes mood incongruent, physical assaultiveness is common, irritability

• Tx: Antipsychotic, may need a mood stabilizer (after acute episode hold the antipsychotic and continue the mood stabilizer)

Oppositional Defiant Disorder (ODD)

Pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness for at least 6 months, disturbance in behavior is associated with distress in an individual or others as well as distress in other social/occupational/educational settings (behaviors are not during psychotic, substance abuse, depressive, or bipolar disorders)’

• Specify Severity: Mild= one setting, Moderate= two settings, Severe= 3+ settings

  • less than 5 yo= most days for 6+ months

  • more than 5 years old= at least once a week for 6+ months

• S/S: temper outburst, argue with parents and others, refuse to clean room, obey curfew, naughty

• Dx: annoying, difficult, disruptive behavior

• Tx: individual and family counseling, treat comorbid conditions, CBT, school based and parental management

Intermittent Explosive Disorder (IED)

Verbal aggression or behavioral outbursts representing a failure to control aggressive impulses and episodes out of proportion to the provocation to the psychosocial stressor

• DSM: recurrent behavioral outbursts representing a failure to control aggressive impulses (verbal aggression or aggression to property), reaction out of proportion to the stressor, not premeditated, causes distress/consequences, at least 6 years of age

  • Can be made in addition to ADHD, conduct disorder, ODD, ASD

• Risks: men with low frustration tolerance, comorbid mood and anxiety disorders

• Tx: none are FDA approved; SSRI or anti epileptic- mood stabilizer (carbamazepine), CBT, 2nd gen antipsychotic- Risperidone, beta-blocker

Conduct Disorder

Pattern of behavioral problems in child/adolescence and forerunner of antisocial personality disorder; 4 major domains- aggression to people/animals (deliberate violence/harm), destruction of property, deceitfulness of theft and serious violations of rules

• Childhood onset: begins before 10 yo, poorer prognosis

• Adolescent onset: begins after 10 yo, better prognosis

• DSM: Repetitive and persistent pattern of behavior in which basic rights of others or major age associated societal norms/rules are violated and at least 1 criteria/domain present in the past 6 months (4 domains)

  • Specify: child/adolescent/unspecified, limited prosocial emotion, mild/mod/severe

• Risks: history of being sexually abused, comorbid with ADHD/mood/anxiety disorders, learning disorders, genetics, psychosocial factors (divorce, delinquent peers)

• S/S: angry, sullen, resentful, poor school performance, truancy, callous behavior and lack of remorse, childhood equivalent to psychopathy, may have self doubt and worthlessness

• Tx: Individual and family therapy, parental management training, meds for comorbidity

Pyromania

Deliberate and purposeful setting of fire on more than one occasion, pt has tension then starts the fire and feels pleasure and gratification, fascination with fires; there are no secondary benefits to starting the fire (insurance money, protest)

• Risks: men/boys, late teens/early 20s, comorbid: mood disorders, substance use, impulsive behaviors

• Tx: treat comorbid disorders, family therapy, coping mechanisms

Kleptomania

Recurrent failure to resist impulses to steal objects not needed for personal use to monetary value, patient feels tension until they steal and then feel gratification and pleasure; it is not done d/t anger or vengeance and not in response to a delusion or a hallucination

• Risks: women, comorbid mood/anxiety disorders, adolescence or early adulthood

• Tx: SSRI and naltrexone (narcan- impulse control), treat comorbid conditions, CBT

Male hypoactive sexual desire disorder (HSDD)

• Persistent or recurrent deficient/absent fantasies or desire for sexual activity that causes marked distress or interpersonal difficulty not d/t a psychiatric disorder or substance abuse

  • Lifelong: usually due to a psychosocial factor→ chronic= poor prognosis

  • Situational: suggestive of interpersonal discord (relationship)→ resolve as conflict resolves

• Risks: general medical condition, substance disorder, psychiatric disorders, social anxiety, interpersonal conflict, negative attitude towards sexuality

• S/S: absence of desire of sexual activity, absent sexual thoughts/fantasies, marked distress

• Dx:

  • Medical workup: testosterone, FSH/LH/prolactin, thyroid panel, CBC/lytes/liver/renal

• Tx: Underlying hormonal imbalance, CBT/sex therapy, avoid distractions, develop fantasies

Erectile Disorder (medical or psychogenic)

Persistent or recurrent inability to attain or maintain until completion of sexual activity, inadequate erection that causes marked distress and embarrassment, self doubt and loss of confidence

• Risks: increased age, depression, smoking, diabetes, HTN, medication, medical complications, medications, hormones, vascular changes, expectations, interpersonal issues, psych issues

• Dx: Psychogenic vs. Organic- nocturnal tumescence testing (NPT): any blood flow to the area points to a psychogenic cause (blood is physiologically getting there)

  • Labs: serum free testosterone, serum prolactin, fasting glucose and lipids

• Tx: PDE-5-Inhibitor- Sildenafil (Viagra), Tadalafil (Cialis), Vardenafil (Levitra), Couples behavior therapy

Premature ejaculation

Persistent or recurrent ejaculation with minimal sexual stimulation before, on or shortly after penetration and before the person wishes it that causes marked distress (intravaginal ejaculation latency <1-2 mins)

• Risks: genetic set point, panic disorder/anxiety

• Tx: Paroxetine (Paxil)/Clomipramine (Anafranil), topical anesthetics, psychotherapeutic therapy

  • Paxil causes ED

Delayed ejaculation

Persistent or recurrent delay in or absence of orgasm following normal sexual excitement phase that causes marked distress

• Risks: psych factors (MDD), drug induced, general medical condition

• S/S: pt unable to ejaculate to that it takes a long amount of sexual stimulation to ejaculate

• Dx: Take a thorough medication and medical history

  • Neuro exam: pudental nerve conduction study

• Tx: switch medications if medication induced, behavioral therapy (partner related)

Female sexual interest/arousal disorder

Absence or reduced sexual interest, thoughts/fantasies, invitation of sex, persistent or recurrent inability to attain our maintain completion of sexual activity, inadequate lubrication swelling response that causes marked distress

• Risks: increases with age and after menopause, psych factors, radiation/chemo, lesions to the nervous system of the genetalia

• Dx: low or absent sexual desire, female sexual function index, evaluate the relationship

• Tx: Flibanserin (Addyi), Dopamine receptor agonists (apomorphine), psychotherapy, estrogen replacement (menopausal)

Female Orgasmic Disorder

Persistent or recurrent delay in (or absence of) orgasm following normal sexual excitement

• Risks: psychogenic (depression, anxiety), drug-induced (antidepressants), general medical condition

• S/S: complain of normal libido without capacity to reach orgasm

  • Global, lifelong= psych

  • Acquired and global= r/o med causes and substance use

  • Acquired and situational= relationship

• Tx: Sildenafil (PDE-5-I), Bupropion (Wellbutrin), self-stimulation

Genitopelvic Pain/Penetration Disorder

Recurrent or persistent genital pain associated with sexual intercourse that causes distress- not exclusively vaginismus or lack of lubrication

• Risks: greater in females than males

• S/S: painful coitus, superficial or deep pain during sexual activity other than chronic throbbing pain hours after the interaction

• Dx: Medical W/U- yeast cultures, STI, endometriosis eval

• Tx: Antidepressants (Duloxetine- Cymbalta), vaginal creams for atrophic vaginitis, CBT or pelvic floor training, lidocaine, corticosteroids

Vaginismus

Recurrent or persistent involuntary spasm of the outer third of the vagina that interferes with coitus→ often appears in women trying to engage in intercourse for the first time

• Risks: anxiety, previous painful sexual encounter or abuse, or fear

• S/S: inability to achieve vaginal penetration, spasms during exam

• Tx: Benzodiazepam (Clonazepam), behavioral relaxation training (pelvic floor relaxation)

Paraphilia

Voyeuristic, exhibitionistic, frotteuristic, sexual masochism, sexual sadism, pedophilic, fetishistic, transvestic

• Deviations from what are considered normal sexual interests and behaviors

• Recurrent intense sexually arousing fantasies, sexual desires/urges/behaviors involving nonhuman objects, suffering/humiliating someone, children or other non-consenting people

• Over a period of 6 or more months

Exhibitionism (paraphilia)

Exposure of ones genitals to unsuspecting strangers and have acted on it

• Tx: SSRI (Paxil), LHRH agonist, Buspar, psychotherapy

Fetishism (paraphilia)

Use of non-living objects (female underwear) or from non-genital body parts

Frotteurism (paraphilia)

Touching and rubbing against a non-consenting person

• Risks: peaks at 15-25 yo, ASD

• Tx: CBT, hormone therapy

Pedophillia (paraphilia)

Sexual activity with prepubescent child or children (age 13 or less), person is at least 16 years old and 5 years older than the children involved, can specify if interested in males and/or females

• Risks: starts in adolescence and fluctuates with stress

  • ADHD, dementia, mental retardation, hormonal/NT fluctuations, sexual abuse in childhood (none excuse the behavior)

• S/S: sexual arousal by children (fantasies, child porn, contacting children via the internet, sexual abuse towards children), usually have antisocial personal disorder

• Tx: done in a controlled setting (focused on reducing interest in children, establish adult sex interests, decrease fascination and beliefs)

  • Naltrexone (impulse control), antidepressants, MPA/LPA hormones

  • Psychotherapy: desensitization, cognitive restructuring, victim empathy training

Sexual Masochism (paraphilia)

Being humiliated, beaten, bound, or otherwise suffer with significant distress

• Mild= spanked, Severe= bound/beaten/whipped/cut, Hypoxyphillia= O2 deprivation

• Often with sadism, transvestic, fetishism

Sexual Sadism (paraphilia)

Psychological/physical suffering (including humiliation) of the victim is sexually exciting and acted with a non-consenting person (PERPETRATORS OF SEXUAL ASSAULT)

• Tx: specialized centers, SSRI, psychotherapy/CBT

Transvestic Fetishism (paraphilia)

Cross-dressing fulfilling fantasies

• Risks: heterosexual males, typically married, in their forties

• Tx: SSRI, Buspar, lithium, psychodynamic psychotherapy

Voyeurism (paraphilia)

Observing unsuspected person who is naked in process of deriving or engaging in sexual activity

• S/S: self gratification while watching, CAN ESCALATE TO SEXUAL ASSAULT

• Tx: SSRI, CBT/behavioral therapy

Gender dysphoria

Distess b/t expressed gender and identified gender, anxiety and depression and not feeling comfortable in one’s own body, usually a strong wish to change body medically or surgically to align closer to how pt identifies

• DSM: 2 + criteria in adults, much more in children

• Tx: Underlying psych conditions (GAD, MDD, substance use), gender clinic (specialists, therapists, possible hormone or surgical intervention)

  • Male → Female Transition

    • Feminizing hormones (estradiol patch/oral, anti-androgen)

    • Gender affirming surgery (neovagina), breast augementation, other sx alt

  • Female → Male Transition

    • Mastectomy, hysterectomy/oophorectomy (after a round of masc. hormones)- testosterone

    • Neophallus procedure

  • Children

    • Prepubescent: family and personal therapy, encourage patient to be themselves

    • Pubescent: Leuprolide (Gonadtropin-RH blocker): slows puberty and development of secondary sex characteristics

      • caution with the use in male→ female transition (makes the sx harder)

Generalized Anxiety Disorder (GAD)

• DSM: excessive anxiety and worry occurring more days than not for at least 6 months about a number of activities; 3 + restlessness/muscle tension/fatigue/sleep disturbance/ concentration problems/irritability, that causes distress/impairment that is not d/t substances

• Risks: 45% of general population, women 2x likely, starts near 20 yo, chronic

• S/S: “stomach ache during school”, chest pain, SOB, GI distress, N/V

• Tx: Therapy (CBT) and Medication (SSRI)

  • Other meds: buspirone, hydroxyzine, benzodiazepines

Panic Disorder

• DSM: panic episodes that are random and recurrent, at least one episode has been followed by at least 1 month of persistent concern; pts worry about implications of their panics, panic is not due to any substances or other psychiatric disorders

• Risks: Comorbid with anxiety, 15-35 yo

• S/S: chest pain and palpitations, sweating, trembling/shaking, SOB, choking, nausea, dizzy, derealization/depersonalization, fear of losing control, fear of dying, numbness/tingling, chills/hot flashes

• Tx: Therapy (CBT) and Medication (SSRI/SNRI)

  • ± benzodiazepines to bridge the SSRI and then discontinue it

  • ± beta blockers for S/S control, hydroxyzine, buspirone

Agoraphobia

• DSM: fear/anxiety of 2+: using public transportation, being in open spaces or enclosed spaces, standing in line, being outside of their home; they fear and avoid these situations, fear is out of proportion to the danger

  • Unmanaged panic disorder that prevents pt from leaving their homes

• Tx: Therapy (CBT) and Meds (SSRI/SNRI) ± benzodiazepines to bridge

  • likely to use ETOH and substances as a means of social lubrication

Social anxiety Disorder/Social phobia

• Patho: persistent and irrational fear of embarrassment or humiliation when in social situations; can be public speaking or more general; patients will avoid these situations

• DSM: Fear/anxiety of 1+ social situations in which they are exposed to possible scrutiny from others, fears that anxiety will be negatively evaluated by others and social situation provoke fear and anxiety for 6 + months, significant distress and impairment and the anxiety is out of proportion to the actual threat

• Tx: Therapy (CBT and exposure therapy) and Meds (SSRI and propranolol 1 hour prior to the precipitating event)

Specific Phobia

Irrational fears of objects, places, situations, or activities that are usually well circumscribed for at least 6 months and causes significant distress and impairment; persistent fear is excessive and unreasonable cued by the fear itself

• Tx: CBT (desensitization/exposure therapy) and SSRI/SNRIs

Major Depressive Disorder (MDD)

• DSM: must include at least one depressive episode characterized by a depressed mood for majority of the time or anhedonia, not caused by medical condition or ETOH use and causes the patient significant distress

• Risks: 2x more likely in women, high prevalence/mortality/morbidity, MCC comorbid condition in people that commit suicide

• S/S: change in appetite, worthlessness/hopelessness, change in sleep, lessened ability to concentrate, fatigue, inability to complete tasks, sadness, dread

• Dx: R/O hx of mania/hypomania (SSRI/SNRI induce manic episodes), PHQ9 assess

• Tx: Medication (4-6 weeks effective)- use SSRI 1st, can use SNRI, TCA/MAOi

  • ECT, inhaled esketamine (after 2-3 medication fails)

Disruptive Mood Disregulation Disorder (DMDD)

Persistent, severe temper outbursts (verbal or behavioral) inconsistent with development; severe mood dysregulation considered pediatric bipolar disorder

• DSM: severe, recurrent outbursts 3 or more times a week, between outbursts the mood is angry/irritable, 12 months or more of symptoms (no more than 3 months symptom free), should not diagnose before 6 or after 18 but must be present prior to 10 yo, present in 2 settings but severe in at least 1

• S/S: disruptions of daily life- strained relationships, social/isolation, academic disruption, extreme irritability

• Tx: CBT (possible DBT) and parent training, medications for irritability/aggresion

  • ADHD (stimulant), 2nd gen antipsychotics (irritability), SSRI (dep/anxiety)

Dysthymia

• DSM: depressed mood for most of the day for most days at least 2 years, not symptom free for any period greater than 2 months, no hypo/mania, functional deficits

  • persistent depressive disorder, chronic, does not wax and wane

• S/S: unwavering sadness for 2 years, miserable/unmotivated

  • 2+: appetite changes, sleep habit changes, low energy/self esteem, poor concentration, hopelessness

• Tx: CBT and Meds (SSRI, SNRI, TCA, MAOi)

Premenstrual Dysphoric Disorder

• DSM: Emotional/mood symptoms predominate with physical symptoms and cause clear functional impairment with work or personal relationships

• Dx: careful eval, daily record of severity of problems

• S/S: Predominate irritability/aggressiveness/depression/lethargy, cravings, bloating, breast pain, HA, swelling

• Tx: SSRI (fluoxetine, sertraline)

  • combined hormonal contraceptive (CHC)- drosperinone and ethyl estradiol pill (Yaz)

Mania/Manic Episode

• DSM: elevation or intense irritability with hyperactivity, over involvement in life activities, flight of ideas, easily distractible and little need for sleep

  • Initially over expansive/overenthusiastic→ depression, aggression, grandiosity

  • Abrupt and can last days→ months

• S/S: excessive spending, resignation from a job, hasty marriage, risky sex habits, exhibitionistic behavior, alienation of friends/family

  • Atypical: gross delusions, paranoid, auditory hallucinations related to grandiose hallucinations

• Dx: 4+ discrete episodes of a mood disturbance, can be bipolar 1 manifestation

• Tx: Possible need for hospitalization, mood stabilizers and antipsychotics for fast stabilization, CBT

Cyclothymic Disorder (cyclothymia)

Chronic mood disorder characterized by mild, frequent and persistent alternating periods of high-energy hypomania and low mood depression lasting at least 2 years (mild bipolar disorder)

• Risks: family hx of bipolar disorder, adolescence/early adulthood, chronic stress, hx of substance abuse

• S/S: hypomania (high energy, decreased need for sleep, racing thoughts, high creativity, high productivity, increased impulsivity), low mood, cycles frequently and unpredictably

• Dx: does not meet criteria for MDD or full manic episode

• Tx: CBT, mood stabilizer or an anti-depressant

Bipolar I Disorder

• DSM: presence or hx of a manic episode (not from schizophrenia or anything else) that causes impairment of functioning or significant distress→ often followed by several months of depression

• Risks: around 18 yo, strong genetic component, CACNA1C sodium channel regulator, cell damage in brain circuitry

• S/S: mania (>or equal to 1 week), often presents in the hospital (critical), restlessness/agitated, dangerously impulsive, decreased need for sleep, destructive behavior

• Tx: 1st line: Medicate- Mood stabilizers, therapy can be adjunct

  • Lithium most effective for mania and suicide prevention

Bipolar II Disorder

• DSM: presence or history of 1+ major depressive episode and 1+ hypomanic disorder (no full manic episode)

• Risks: older age than BP I (22-28 yo), genetic components

• S/S: often present depressed, often to not recognize hypomanic episode (lack of sleep and goal directed behavior)

• Tx: Medication (mood stabilizers): Lamotrigine is best for depressive disorders ± SSRI

MUST when it comes to assessing depression

ALWAYS assess for hx of hypo/mania

• SSRI/SNRI can induce mania episodes (risk with TCAs as well)

• oftentimes how bipolar disorder is found in patients

Mania vs. hypomania

• Hypomania: milder, shorter form (lasting at least 4 days) that usually does not impair daily life

• Mania: more severe, lasts at least 7 days (or requires hospitalization), and causes significant dysfunction or includes psychosis

Treatment combinations for BP I

• Lithium (euphoric/severe mania): add anti-psychotic for hallucination/delusion

• Lithium or Depakote (mild/mod/mixed mania)

• Lamotrigine (depressed mania): add SSRI for severe depression

Illness Anxiety disorder (hypochondriasis)

Chronic mental health condition marked by excessive, persistent worry about having or developing a serious undiagnosed medical illness

• S/S: excessive worry, misinterpretation (minor s/s→ major), frequently visiting doctor/hospital, constant checking for illness

• Tx: CBT, SSRI (anxiety)

Somatization

Conscious or unconscious physical manifestations of mood/anxiety/distress, patients usually go through extensive medical workup and have no diagnosis

• Risks: low socioeconomic females with stress intolerance, childhood sexual abuse survivors (GI distress, pelvic pain, urinary incontinence)

• S/S: generalized pain, GI (N/V/pain), CV (chest pain, dizzy, tachy), Neuro (faint/seizure), pelvic floor

  • Alexithymia: unable to define current psychiatric complaints so they are likely to physically manifest

Somatic Symptom Disorder (SSD)

• DSM: 6+ mo somatic complaints and excessive thoughts/feelings/behaviors associated; devote increased time to seeking answers

• Risks: females sexually abused, any age, established psych hx, hx of seeking a lot of medical help

• S/S: wax and wane with variable stress (unable to connect it), “nebulous” complaints- complaints to not align with one condition, physical ailments without concrete cause, messy medical history

• Tx: underlying anxiety and depression (SSRI), f/u with PCP to confirm

Factitious Disorders

• DSM: Intentional falsification of physical or psychological symptoms, present as ill/injured for an internal reward, NOT EXTERNAL

• Risks: women, medical personnel

• S/S: exaggerating/inducing symptoms, may exacerbate illness, tamper with equipment to destabilize and cause infection, forge records, ingest/inject meds (laxatives for GI distress and extra insulin for hypoglycemia), purposefully delay wound healing (picking/rubbing dirt), swallow blood (occult blood in stool-extensive work up)

• Tx: confront patient, they often leave AMA because they are unsatisfied, careful of pitting providers against one another

Munchausen’s by Proxy- Extreme Factitious Disorders

Extreme presentation of faking an illness for an internal reward (sometimes done by a family member)

• submit to sx, tx, procedures, life-altering medication for tx of a disease they don’t have (chemotherapy)

• Ex. Gypsy Rose Blanchard

Malingering

• DSM: intentional falsification of symptoms for an external reward

  • receiving care may help financially, getting disability, avoiding jail, obtaining medications (benzos, narcotics)

Conversion Disorder

• DSM: one or more symptoms of motor/sensory functional deficits, symptoms incompatible with neurological or other general medical conditions, not explained by another condition and causes marked distress

• Risks: stress/life altering events

• S/S: overwhelming and sometimes sudden onset of neuro s/s that ARE NOT organic

  • Weakeness, muscle tremors/spasm, seizures, speech abnormalities (mutism), swallowing difficulties, sensory deficits

• Dx: Work with neurology to confirm that s/s ARE NOT ORGANIC

• Tx: CBT, PT, OT

  • Tx underlying conditions with medications

Cluster A Personality Disorders

“Wacky”

• Paranoid

• Schizoid

• Schizotypal

Cluster B Personality Disorders

“Wild”

• Histrionic

• Narcissistic

• Antisocial

• Borderline

Cluster C Personality Disorders

“Worried”

• Avoidant

• Obsessive-compulsive

• Dependent

Personality Disorders

Long standing maladaptive patterns in relating to others that causes impairment and often lack insight regarding their own problematic behavior so they often do not reach out for help

• Dx: must have s/s in early adulthood, if earlier than 18 yo pts must have s/s for >1 yr

  • Pts cannot present with a frank psychosis

• Tx: ALWAYS THERAPY, can treat co-occuring depression/anxiety (meds cannot tx personality)

  • Avoid medications with addiction potentials (benzes, immediate release stimulants)

Paranoid PD

Cluster A PD

• DSM: Suspicion that others are deceiving them without evidence, reluctant to confide in others, preoccupied with loyalty, interpretation of otherwise benign remarks as threatening/damaging, hold grudges, suspicion of infidelity in relationships

  • Chronic pervasive mistrust of others, usually angry or hostile

  • NO DELUSIONS and pts ARE NOT SCHIZOPHRENIC

Schizoid PD

Cluster A PD

• DSM: Neither enjoy nor desire sexual or personal relationships, actively choose solitary lifestyle, few pleasurable activities, lack close friends, cold with flat affect

  • Longstanding voluntary social withdrawal, weird or “eccentric”

  • Pts are NOT mentally or developmentally delayed

Schizotypal PD

Cluster A PD

• DSM: Ideas of reference, odd beliefs/magical thinking, unusual perceptions, suspiciousness, odd appearance/dress, few close friends, odd thought, excessive social anxiety

  • Dress bizarre, have magical thoughts

  • PREMORBID TO SCHIZOPHRENIA

Histrionic PD

Cluster B PD

• DSM: uncomfortable when not the center of attention, inappropriately seductive, shallow personality, physical appearance used for attention, exaggerated and theatrical

  • Extroverted patients, overly emotional and sexually provocative

  • “Life of the Party”

Narcissistic PD

Cluster B PD

• DSM: exaggerated self-importance, occupied by money/status/intelligence, they are “special and different”, requires others admiration, takes advantage of others for self gain, lacks empathy, envious and arrogant

  • Grandiose, pompous, entitled, they are “above everyone else”, denial and displacement (they are never the problem)

Antisocial PD

Cluster B PD

• DSM: Blatant disregard to rights of others since 15 yo but must be >18 yo for dx; failure to conform to norms, repeated lying and deceit, impulsive/disregard for safety, failure to sustain promised obligations and lack of remorse

  • Often have childhood dx of conduct disorder

  • Charming, educated, calm unless provoked

Borderline PD

Cluster B PD

• DSM: Frantic efforts to avoid being alone, unstable but intense relationships, unstable self image, impulsive (spending/sexually), suicidal attempts, chronic emptiness, difficulty controlling anger

  • Unstable behavior/mood, chronic suicidality, complain of feeling alone, manipulative

  • denial, displacement, splitting

  • COMORBID WITH MDD AND EATING DISORDERS

Avoidant PD

Cluster C PD

• DSM: Avoids occupations and situations involving interpersonal contact and unwilling to interact unless certain to be liked, cautious of relationships, inhibited in social situations, perceives themselves as socially inept

  • social inhibition, hypersensitivity and feelings of inadequacy since early adulthood

  • shy, sensitive and socially withdrawn

  • intense fear of rejection, but pts do desire companionship

Obsessive-Compulsive PD

Cluster C PD

• DSM: Preoccupations with details/rules/lists/organization, perfectionist, excessive devotion to work, preoccupation with ethics and morality, will not delegate tasks, miserly spending, rigid/stubborn, unable to discard worthless objects

  • Chronic patterns of orderliness, control, and perfectionism since early childhood

  • fear of imperfection, stubborn, impulsive

  • No actual compulsions, no distress or impairment

Dependent PD

Cluster C PD

• DSM: Difficulty making their own decisions, need others to assume their responsibilities, difficulty expressing concern or disagreement, goes to excessive lengths to be liked and get approval from others, feels helpless when alone, urgently seeks another relationship when one ends, fears being alone

  • pattern of an excessive need to be taken care of while being chronically submissive

  • often fear rejection and have low self esteem, allow others to assume their responsibilities and makes their decisions

Body dysmorphia

OCD related disorder; appearance obsession, compulsive behavior, poor insight

• DSM: Preoccupations with 1 or more perceived defect, repetitive behaviors or mental acts, clinically significant distress/impairment, not better explained by eating disorders

• S/S: Mirror checking, skin picking, seeking reassurance, excessive grooming

• Tx: CBT, SSRIs (depression), avoid cosmetic procedures

Hoarding

OCD related disorders; can’t discard, cluttered home, poor insight, safety issues

• DSM: persistent difficulty discarding possessions, perceived need to save, distress discarding accumulation→ congested/cluttered living areas, significant distress/impairment

• Tx: CBT, SSRIs

Trichotillomania/skin picking

OCD related disorder; repetitive skin picking/hair pulling, relief afterward, patchy hair loss with broken hairs

• DSM: recurrent hair pulling→ hair loss, repeated attempts to stop, causes distress/impairment, not d/t other conditions

• S/S: patchy alopecia with varying hair lengths, may try to hide with hats

• Tx: CBT (habit reversal)

Anticholinergic Toxicity

Cholinergic blockade of muscarinic (primarily brain) or nicotinic receptors or both

• Risks: Causes: TCA’s, phenothiazines, antihistamines, antiparkinsonian drugs, Jimsonweed

• S/S: Mydriasis, HoTN, hypoactive or absent bowel sounds, tachycardia, flushed skin, disorientation, hyperthermia, urinary retention, agitation, hallucinations

  • “Hot as Hades, blind as a bat, dry as a bone, red as a beet, mad as a hatter”

• Dx: Primarily clinical

• Tx: Supportive, cardiac monitoring and IV access, gastric lavage and activated charcoal

  • Physostigmine= reversible cholinesterase inhibitor (controversial)

Barbiturates Toxicity

• Hepatically metabolized, depress nerve and muscle cell activity

  • Long acting (phenobarbital)

  • Intermediate acting (amobarbital)

  • Short acting (pentobarbital, secobarbital)

  • Ultra short acting (thiopental)

• S/S

  • Mild: resembles alcohol intoxication, drowsiness, disinhibition, ataxia

  • Severe: stupor, coma, complete neurological unresponsiveness, HoTN, hypoglycemia

• Dx: Serum levels, bedside glucose

• Tx: ABCs, cardiac monitoring, IV access, intubation, urinary alkalization

Barbiturate Abstinence syndrome

Occurs with abrupt withdrawal in chronic users (minor- first 24 hrs, life threatening- 2/8 days)

• Short acting agents are more severe withdrawal (Pentobarbital, secobarbital, thiopental)

• S/S: similar to alcohol withdrawal

• Tx: aggressive supportive care, IV benzos or barbiturates with tapering doses

Salicylates toxicity

Inhibits Krebs cycle enzymes; increased catabolism, elevated CO2, increased heat production, increased glycolysis, increased production of organic acids contributing to acidosis→ causes anion gap metabolic acidosis and res. alkalosis

• S/S: N/V, sweating, tinnitus, hyperventilation GI irritation

• Tx: ABCs, cardiac monitoring, IV access, monitor the pH and other lab levels including glucose and lytes

Digoxin toxicity

Inactivates the sodium-potassium pump which accumulates intracellular sodium that is exchanged for calcium. Increased calcium has positive ionotropic effect, increases vagal tone and decreased AV node conduction (bradydysrhythmias)

• S/S: cardiac dysrhythmias, N/V, mental status changes

• Tx: supportive care, cardiac monitoring, IV access, prevention of further absorption, tx of complications, Atropine for dysrhythmias

Insomnia (sleep-wake disorder)

Difficulty getting to sleep, staying asleep, intermittent wakefulness at night, early morning awakening or any combinations of these

• Risks: psychiatric disorders- depression, mania/manic episode, sleep related panic attacks, abuse of alcohol

• Tx: Teach patient good sleep hygiene, lorazepam/temazepam (benzos)

Hypersomnias (sleep-wake disorder)

Disorders of excessive sleepiness: obstructive sleep apnea, narcolepsy, Kleine-Levin syndrome, periodic limb movement disorder, shift work sleep disorder

• Tx: dextroamphetamine sulfate, Modafanil

Parasomnias (sleep-wake disorder)

Sleep terrors, nightmares, sleepwalking, enuresis

• Tx: benzodiazepines (diazepam)

Separation Anxiety Disorder

Dysregulation of fear circuits; anxiety disorder characterized by excessive fear/distress about being separated from people the individual is attaches to- developmentally inappropriate and out of proportion to the situation

• Risks: MC in children (>4 weeks), adolescence/adults (>6 months)

• S/S: functional impact- school refusal, social impairment, family disruption

• Tx: CBT, SSRI if refractory

Selective Mutism

Anxiety disorder where a person consistently fails to speak in specific social situations (like school) despite speaking normally in other settings (like home) that is not due to a language barrier or communication disorders

• Tx: CBT, if severe or not improving SSRI

Substance Use Disorder (SUD)

Inappropriate use of a substance that causes significant impairment/distress

• Patho: Reward pathway (mesocorticolimbic system), release of dopamine in these pathways motivates continued use

  • Tolerance: overtime euphoric feelings lessened → need more to achieve high

  • Withdrawal: cluster of s/s that follow cessation or reduction

• Risks: use in adolescence, heritable, family dysfunction, negative life events, low self esteem, poor social connection, increased rate of comorbidity with other psych conditions

• Tx: psychosocial and pharmacological tx (better if they seek help themselves)

DSM of SUD

2 present within 12 months

• Large amounts of substance or use longer than needed, persistent desire/unable to quit, spending increased time obtaining or using the substance, craving, failure to meet obligations, continuing to use the substance despite problems with use, giving up or reducing activities, recurrent use even if physically hazardous, tolerance to substance, experiencing withdrawal

  • Further determine severity

    • Mild- 2 to 3

    • Moderate- 4 to 5

    • Severe- 6 plus

Stages of change in SUD

1. Precontemplation: no plans to quit and doesn’t see a problem

2. Contemplation: recognizes the consequence, thinks about the possibility of quitting

3. Preparation: Pt has plans to stop

4. Action: Pt actively stops

5. Maintenance and Relapse Prevention: stopped for 6+ months and focus on relapse prevention

Alcohol Use Disorder

Pervasive alcohol use that affects daily fxn

• Patho: Alcohol potentiates GABA (inhibit) and inhibits Glutamate (excite) and slows brain activity resulting in common signs of alcohol intoxication

• Risks: Men>women, college students, Native American people, early/mid 20s, genetic/psychosocial, impulsive traits, trouble coping with stress, availability and cost of alcohol

• Dx

  • Screening: CAGE (Cut, annoyed, guilty, eye opener), AUDIT-C, SASQ

  • DSM + severity, remission (early/sustained), environment (controlled or uncontrolled)

Treatment of AUD

• Acute Detox: hospital admit, benzodiazepines (chlordiazepoxide (Librium), Clonazepam (Klonopin), Diazepam (Valium)), IV fluids, thiamine, electrolyte supplementation

  • CIWA: ± haloperidol (hallucinations), ± supporting meds

• Long Term: CBT, Alcoholic Anonymous, rehab

  • ± Disulfiram (Antabuse), Naltrexone (Vivitrol), Acamprosate