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Psych Rotation


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What are the major risk factors to inpatient suicide?
Severe anxiety and panic, global insomnia, severe anhedonia, and alcohol abuse
Though Broadcasting
Belief that thoughts are broadcast from one's head to the world so that others can hear them. Delusion or hallucination.
Hallucination, subject hears his own thoughts from the outside, not just within his head.
Thought Insertion
Thoughts are inserted into one's mind that are not their own. NOT FROM THE DEVIL OR GOD.
Thought Withdrawal
Thoughts have been removed from one's head. Diminished number of thoughts remain. Rare.
Delusions of being controlled
Feelings, impulses, thoughts or actions are not one's own. Imposed by an external force. Doesn't include the mere conviction that he is acting as an agent of god. Curse, victim of fate, not assertive, or someone is attmpeting to control.
Bizarre delustions
Delusions in the absence of the manic or depressive syndrome suggest Schizophrenia.
Flight of Ideas
Accelerated speech w/ abrupt changes from topic to topic usually based on understandable associations, distracting stimuli or play on words. When severe the associations may be so difficult to understand that loosening of associations or incoherence may also be present.
Non-affective Hallucinations of Any type
Hallucinations in any modality in which the content has no apparent relationship to either depression or elation. Do not rate as present if limited to voices saying only one or two words such as his name.
Impaired understanding of speech due to psychopathology
Lack of logical or meaningful connections between words, phrases, or sentences; excessive use of incomplete sentences which is not seen as part of psychomotor retardation; excessive irrelevancies.
Loosening of associations
no logical connection from one thought to another
made-up words
What is the in the HPI of a psych complaint?
why did the patient come to the doctor?
Description of current episode
Events leading up to current moment
How work and relationshipst are affected.
Patients support system
Relationship between physical and psychological symptoms
Vegetative symptoms
Psychotic symptoms

Past episodes

- functioning when well
- developmental Hx
- Life values, goals
- Evidence of secondary gain.
What are vegetative symptoms?
insomnia, loss of appetite, problems with concentrating.
What are the components of the mental status exam?
Thought Process
Suicidal/Homicidal ideation.
What should you look for when evaluating appearance for the Mental Status Exam?
Physical- clothing, hygiene, posture, grooming
Behavior- mannerisms, tics, eye contact
Attitude- cooperative, hostile, guarded, seductive, apathetic.
What should you look for when evaluating speech for the Mental Status Exam?
Rate- slow, average, rapid, or pressured
Volume- soft, average, or loud
articulation- well articulated vs. lisp, stutter, mumbling
Tone- angry vs. pleading
What should you look for when evaluating mood for the Mental Status Exam?
mood is a quote from the patient
What should you look for when evaluating affect for the Mental Status Exam?
range of emotional expression
quality- depth and range: flat (none), blunted (shallow), constricted (limited), full (average), intense (more than normal)
Motility- describes how quickly a person appears to shift emotional states- sluggish, supple, labile
Appropriateness- congruent
What are the side effects of lithium?
metallic taste
weight gain
GI probs
benign leukocytosis
thyroid enlargement
nephrogenic DI
toxic levels= altered mental status, coarse tremors, convulsions, and death. Monitor blood levels, TSH, and GFR.
What should you look for when evaluating thought process for the Mental Status Exam?
Loosening of associations- no logical connectoin from one thought to another
Flight of ideas- a fast stream of very tangential thoughts
Neologisms- made-up words
Clang associations- word connects from phonetics
Thought Blocking- Abrupt cessation of communication before the idea is finished
Tangentiality- point of conversations never reached due to lack of goal-directed associations between ideas
Word salad
incoherent collection of words
clang associations
connections due to phonetics
thought blocking
abrupt cessation of communication
point of conversation never reached due to lack of goal directed associations between ideas
point of conversation is reached after circuitous path
Poverty of thought vs overabundance
too few vs. too many ideas expressed
fixed, false beliefs that are not shared by the person's culture and cannot be changed by reasoning.
Suicidal and homicidal thoughts
feels like harming oneself or others.
wha tare some delusions?
psych disorder with abnormal thinking, emotion and behavior.
what are the positive symps of schizo?
hallucinations, delusions, bizarre behavior, or thought disorder
what are the negative symps of schizo?
blunted affect, anhedonia, apathy, and inattentiveness.
What are the three phases of schizo?
prodromal- decline in functioning that precedes the first psychotic episode. The patient may become socially withdrawn and irritable. He or she may have physical complaints and/or newfound interest in religion or the occult
Psychotic- perceptual disturbances, delusions, and disordered though process/contenet
Residual- occurs between episodes of psychosis. Makred by flat affect, social withdrawal, and odd thinking or behavior Pts continue to have hallucinations
What are the DSM-IV criteria for Schizo?
2 or more for 1 month:
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
5. Negative symptoms

Must cause significant social or occupational functional deterioration.
Duration of illness for at least 6 months- including prodromal or residual perios in which above criteria may not be met
Symptoms not due to medical neurological or substance-induced disorder
What is paranoid schizo?
Highest functioning type
- older
- preoccupatioon with one or more delusions or frequent auditory hallucinations
- no predominance of disorganized speech, disorganized or catatonic behavior, or inappropriate affect
What is disorganized schizo?
poor functioning type, early onset
- disorganized speech
- disorganized behavior
- flat or inappropriate affect
What is catatonic schizo?
must have 2 of the following:
- motor immobility
- excessive purposeless motor activity
- extreme negativism or mutism
- peculiar voluntary movements or posturing
- echolalia or echo praxia
What is undifferentiated schizo?
characteristic of more than one subtype or none of the subtypes.
What is residual schizo?
prominent negative symptoms with minimal positive symptoms
What are findings on psychiatric of schizophrenics?
Flattened affect
Disorganized thought process
Intact memory and orientation
Auditory Hallucinations
Paranoid delusions
Ideas of reference (made by televisions or newspaper)
Concrete understanding of similarities/proverbs
Lack of insight
What is the epi of schizo?
1% of people
Men- 20, more severe, more negative symps
Women- 30 better functioning
rare before 15 and after 45
50% monozygotes
40% w/ both parents
12% if 1 1st degree relative
Substance abuse. Postpsychotic depression in 50%

Winter and early spring.
What is downard drift in schizo?
many of those with low SES are schizo.
although they may be because they can't function in society.
What is the dopamine hypothesis in schizo?
Prefrontal cortical- negative symps.
Mesolimbic- positive symps
Where does neuroleptic therapy cause problems?
Tuberoinfundibular- hyperprolactinemia
Nigrostriatal- extrapyramidal symps.
Other than dopamine, what neurotransmitters are involved in Schizo?
Serotonin- risperidone and clozapine antagonize serotonin
Norepi- long term use of antipsychotic decreases noradrenergic neurons
Decreased GABA- in hippocampus which activates dopa.
What in schizo indicates a good outcome?
Late onset
Good social support
Positive symptoms
Mood symptoms
Acute onset
Few relapses
Good premorbid functioning
What in schizo can lead to a bad outcome?
Early onset
Poor social support
Negative symps
Gradual onset
Poor premorbid functioning
What is the Rx for schizo?
typical and atypical neuroleptics
Behavior therapy
family and group therapy
What are the typical neuroleptics?
Chlorpromazine, thioridazine, trifluoperazine, haloperidol. Dopa antags. Treat + symps.
What are the atypical neuroleptics?

antagonize serotonin. Treate neg symps. 4 wks
What si the DSM for Bipolar I?
1 manic or mixed episode.
What is the epi of bipolar I?
lifetime prevalence of 1%
No ethnic differences
Onset before 30
biologic, environment, psychosocial, genetic
1st degree relatives are 8-18x more likely to develop the illness. Concordance rates for MZ twins are approximately 75% and rates for dizygotic twins are 5-25%.
What is the course of Bipolar I?
untreted manic episosed last 3 months. Chronic course with relapses.

Flight of ideas
Speech- pressured
What is DSM for manic episodes?
Inflated self-esteem or grandiosity
goal directed activity
decreased need for sleep
flight of ideas or racing thoughts
more talkative or pressured speech
excessive involvement in pleasurable activites that havea high risk of negative consequences.
What are the SEs of TCAs?
Antihistamine- Sedation
Antiadrenergic- Orthostatic hypotension, tachy, arrhythmias
Antimuscarinic- dry mouth, constipation, urinary retention, blurred vision, tachy
Weight gain
Lethal in OD
MAJOR: 3Cs: Convulsions, coma, cardiotoxicity
What are the TCAs?
Don't Call Dad I Am Too Nuts
What is special about Nortriptyline?
least likely to cause orthostatic hypotension
What is special about Desipramine?
least sedation, least anticholinergic SEs
What is special about Clomipramine?
most serotonin specific, useful for OCD
What are the SSRIs?
For Sadness, Put Flowers Close Enough
What is special about fluoxetine?
longest half life with active metbolites. No tapering.
Okay to miss a dose
What is special about sertraline?
highest risk for GI issues
What is special about Paroxetine?
Serotonin specific, activating (stimulant)
What is special about fluvoxamine?
only for OCD
What is special about citalopram?
Celexa, used in europe prior to FDA approval
What is speical about Escitalopram?
Similar to citalopram, fewer side effects, more expensive
What are the SEs of SSRIs?
sexual dysfunction
GI disturbance
Anorexia, weight loss
Serotonin syndrome.
What are the MAOIs?
Phenelzine (nardil)
Tranylcypromine (Parnate)
Isocarboxazid (Marplan)
Wha are the common side effects of MAOIs
Orthostatic hypotension, drowsiness, weight gain, sexual dysfunction, dry mouth, sleep dysfunction.
What is serotonin syndrome?
SSRIs and MAOIs are takent together--> lethargy, restlessness, confusion, flushing, diaphoresis, tremor, and myoclonic jerks. May progress to hyperthermia, hypertonicity, rhabdomyolysis, renal failure, convulsions, coma, and death.
2 wks needed to switch.
What is hypertensive crisis with MAOIs?
MAOI and tyramine foods or sympathomimetics cause a buildup of stored catecholamines.
What type of drug is it?
When is it effective?
What are some SEs?
What is a contraindication?
Treates refractory depression and CAP.
Low drug interaction potentional
SEs- Similar to SSRIs,a nd can increase BP, should not be used in untreated or labile BP. Withrdawal occurs after 1-3 doses missed.- flulike symps, and electric shocks
What type of drug is it?
When is it effective?
What are some SEs?
What is a contraindication?
Smoking, SAD, ADHD.
No sexual SEs. High doses can bring out psychosis.
Nefazodone and Trazodone:
What type of drug is it?
When is it effective?
What are some SEs?
What is a contraindication?
Refractory major depression, major depression w/ anxiety and insomnia.
SEs- nausea, dizziness, orthostatic hyppotension, cardiac arrhythmias, sedation, and priapism- trazodone
What type of drug is it?
When is it effective?
What are some SEs?
What is a contraindication?
Treats refractory major depression, espcially in those who need to gain weight.
SEs- sedation, weight gain, dizziness, somnolence, tremor, and agranulocytosis. Maximal sedative effect at doses of 15mgs or less. High doses, more ne uptake and less sedations.
What antidepressant is good for chronic pain?

diabetic neuropathy, fibromyalgia, migraine HAs. Lower than depression.
Nortrip, amytriptyline
What antidepressant is good for Bulimia?
SSRIs in high doeses. MAOI, TCA are somewhat helpfulbut MAOIs may be bad for diet.
What antidepressant is good for OCD?
SSRIs, and clomipramine.
Obsessions respond better than compulsions. Trichotillomania and body dysmorphic disorder may also respond.
What antidepressant is good for Panic Disorder?
What antidepressant is good for PTSD?
Which TCAs are 3ry?
What TCAs are 2ry?
What TCA has 4 benzene rings?
What drug should be used for old cachetic people?
What is an issue with Venlafaxine?
hard to stop treatment.
What drug has the lowest "switch" rate?
What are teh low potency antipsychotics?
lower affinity for dopa receptors and higher dose is needed.
higher incidence of anticholinergic and antihistaminic side effects. lower extrapyramidal dise effects and lower neuroleptic malignant syndrome
What are the high potency antipsychotics?
Higher inscidence of extra-pyramidal SEs adn neuro malig syndrome.
What typical antipsychotics are available in long-acting forms?
haloperidol and fluphenazine.
What are the Anti-dopa SEs of typical antipsychotics?
- parkinsonism- masklike face, cogwheel, pill rolling
- Akathisisa- subjective anxiety and restlessness, objective fidgeting
- dystonia- sustained contraction of muscles of neck, tongue, eyes

HyperPRL- leading to decreased libido, galactorrhea, gynecomastia, impotence, amenorrhea, osteoporosis

Rx- decrease dose. administer antipark, antichol, antihistamine.
What are the anti-HAM effects of antipsychotics?
decreased sedation
orthostatic hypotension, cardiac abnlties, and sex dysfunction
antimuscarinic- dry mouth, tachycardia, urinary retention, blurry vision, constipation.
What are the SEs of antipsychotics?
3.Weight Gain
4.increased liver, jaundice
5.ophthalmologic problems- pigmentation w/ Mellaril
6.Dermatologic problems, including rashes and photosensitivity
7. Seizures.
8. tardive dyskinesia
9. nueoleptic malignant syndrome
What is tardive dyskinesia?
choreoathetoid movments of mouth and tongue that occures in pts who have used neuroleptics for moer than 6 months. most common in older women. 50% remit.
Rx- discontinue antipsychotic
What is neuroleptic malignant syndrome?
F- fever
A- Autonomic instability
L- Leukocytosis
T- Tremor
E- Elevated CPK
R- Rigidity

rare, males early in Rx. 20% mortality rate if untreated. preceded by catatonic state.
What is the Rx for neuroleptic malignant syndrome?
involves discontinuation of current meds and administration of supportive medical care (hydration, cooling)
Na dantrolene, bromocriptine, and amantadine are useful but have side effects. not an allergic reaction. Pt not prevented from restarting a neuroleptic.
what are the atypicial antipsychotics?

Fewer side effects, treats neg symps.
What are the SEs of the atypical antipsychotics?
clozapine- agranulocytosis
olanzapine- hyperlipidemia, glucose intolerance, weight gain, liver toxicity, monitor LFTs
Quetiapine- less weight gain, can cause cataracts.
what is the major SE of clozapine that we worry about?
What are the SEs of quetiapine?
Quetiapine- less weight gain, can cause cataracts.
What are the SEs of olanzapine?
olanzapine- hyperlipidemia, glucose intolerance, weight gain, liver toxicity, monitor LFTs
onset of action?
good blood levels?
for mood stabalization; manic episodes, depression.
5-7 days to act
therapeutic range- .7-1.2
toxic >1.5
lethal >2.0
anticonvulsante treating mixed episodes. rapid-cycling bipolar disorder.
- trigeminal neuralgia. blocks Na channels and inhibs action potential. action is 5-7 days.
what are the SEs of Carbamazepine?
skin rash
slurred speech
aplastic anemia
and agranulocytosis.
elevates liver enzymes and has teratogenic effects.
check a CBC and LFTs.
What affects Li levels?
NSAIDS decrease

Dehydration, salt deprivation, impaired renal function increase

aspirin and diuretics?
valproic acid
anticonvulsant that treats mixed manic epsodes and rapid cycling bipolar disorder. Mech of action is unknown, but has been shown to increase levels of GABA in the central nervous system
What are the SEs of Valproic Acid?
sedation, weight gain, alopecia, hemorrhagic pancreatitis, hepatotoxicity, and thrombocytopenia.
When are anxiolytics used?
muscle spasm
sleep disorder
alcohol withdrawal
What aer the long acting benzos?
chlordiazepoxide- alcohol detox, presurgery anxiety
diazepam- rapid onset, Rx of anxiety and seizure control
flurazepam- rapid onset, Rx of insomnia.
what are teh intermediate acting benzos?
Alprazolam- panic attacks
clonazepam- Rx of panic attacks, anxiety
lorazepam- Rx of panic attacks, adn alcohol w/drawal
ternazepam- Rx of insomnia
What are teh short acting benzos
Triazolam- rapid onset, insomnia.
what are the SEs of benzos
drowsiness, impairment of intellectual functioning, reduced motor coordination.
Tox- resp depression in OD, esp when combined w/ alcohol.
Zolpidem/ Zaleplon
short term insomnia Rx
selectively bind to benzo binding site
no anticonvulsant or muscle relaxant properties
no withdrawal effects
minimal rebound insomnia
little or no tolerance/dependence occurs w/ prolonged use.
Sonata- newer, has shoerter half-life.
not a benzo
alternative to Benzo or venlafaxine for anxiety
slower onset of action. 1-2 wks for effect
Anxiolytic action is at 5HT-1A receptor
does not potentiate the CNS depression of alcohol
low potential for abuse/addiction
treats autonomic effects of panick attacks or performance anxiety- palpitations, sweating, and tachy. treats akathisia.
What drugs cause psychosis
Caused by sympathomimetics, analgesic, antibiotics, anticholinergics, anticonvulsants, antihistamines, corticosteroids, and antiparkinsonian agents.
what meds cause agitation?
antipsychotics, antidepressants, antiarrhythmics, antineoplastics, corticos, cardiac glycosides, NSAIDs, Anti asthmatics, antibiotics, antiHTNs, antiparkinsonian agents, thyroid hornmones
What drugs cause depression
antiHTNs, antiparkinsonians, corticos
ca channel blockers, NSAIDs, antibiotics, and peptic ulcer drugs.
What drugs cause anxiety
Sympathomimetics, antiasthmatics, antiparkinsonian, hypoglycemics, NSAIDs and thyroid hormones
What drugs cause sedation/poor concentration?
antianxietys, antichols, antibiontics, antihistamines.
what is psychosis?
a break from reality involving delusions, perceptual disturbances , or disordered thnking. Schizo and substance induced psychosis are common
What is disordered thought?
disorders of process or content
- content- delusions, ideas of reference, and loss of ego
- process- linking of words.
Paranoid delusion
irrational belief that one is being persecuted
Ideas of reference
some event is uniquely related through the individual
auditory- schizos
visual- drugs
olfactory- epilepsy
tactile- drugs or alcohol
What is an illusion?
minterpretation of an existing stimulis
What is the DDx of psychosis?
2ry to general medical condition
substance induced
brief psychotic disorder
schizophreniform disorder
schizoaffective disorder
delusional disorder
what are the medical causes of psychosis?
CNS- CVD, MS, neoplasm, Parkinsons, huntingtons, temporal lobe, encephalitis, prions
Endocrine- addisons/cushings, hyper/hypothyroid, hyper/hypocalcemia, hypopituitary
Nutritional- B12, folate, niacin
Other- SLE, temporal arteritis, prophyria

DSM IV- prominent hallucinations or delusions. Symps do not occur only during delirium, evidence supports medical cause.
What are the substances that induce psychosis?
antidepressants, antiparkinsonians, antiHTNs, anti histamines, anticonvulsants, digitalis, beta blockers, anti TB, corticos, hallucinogens, amphetamines, opiates, bromide, heavy metal toxicity, and alcohol

DSM-VI- hallucinations, delusions
Symps not during delirium
Evidence to support meds or substance related cauase from lab data, Hx, or physical
Disturbance is not better accounted for by a psychotic disorder that is not substance induced.
what si the DSM IV for schizoaffective?
meet criteria for either MDD, manic episode, or mixed.
have had delusions or hallucinations for 2 wks in the absence of mood disorder.
mood symptoms are present during substantial part of psychotic illness.
What is the DSM IV for brief psychotic disorder
Pts w/ psychotic symps for 1 day to 1 month.
50 - 80% recover
20-50%-> schizo
What is the DSM IV for delusional disorder?
nonbizarre, fixed delusions for at least 1 month.
not schizo
functioning in live not impaired.
What are the types of delusions?
erotomanic type- delusion revolves around love
grandiose- inflated self-worth
somatic- physical
persecutory- delusions of being persecuted
jealous- unfathfulness
mixed- more than 1
What is delusional disorder
occursin older pts after 40. Immigrants and the hearing impaired.
What is the DSM IV for shared psychotic disorder?
same delusional symps as someone he or she is in a close relationship with.

40% improve from removeal of the other person.
What are the culturally specific psychosis with:
asia- koro- penis is shrinking, will disappear and cause death

Malaysia- Amok- outbursts of violence of which one does not remember--> suicide

Africa- Brain fag- headache, fatigue, and visual disturbances in males.
What is schizotypal personality disorder?
paranoid, odd or magical beliefs, eccentric, no friends, social anxiety.
What is schizoid personality disorder?
withdrawn, lack of enjoyment from social interactions, emotionally restricted.
What are mood episodes vs. mood disorders?
mood episodes are distinct periods of time in whihc some abnl mood is pressent. Mood disorders are defined by their patterns of mood episodes.
What are the types of mood episodes?
Major depressive episode
manic episode
mixed episode
hypomanic episode
What are teh main mod disorders?
Major depressive disorder
Bipolar I
Bipolar II
What is the DSM IV for a Major depressive Episode?
5 of the following for 2 wks:
Depressed mood
change in appetite or body weight
feelings of worthlessness or excessive guilt
insomnia or hypersomnia
diminished concentration
Psychomotor agitation or retardation
Fatigue or loss of energy
Recurrent thoughts of death or suicide

NOT due to substance use or medical conditions and must cause social or occupational impairment
What is the relationship between MDD and suicide?
MDD has a 15% risk in committing suicide
What is the DSM IV for Manic Episode?
period of abnlly and persistently elevated, expansive or irritable mood lasting at least 1 wk and including at least 3 of the following:
Inflated self-esteem or grandiosity
Increase in goal-directed activity
decreased need for sleep
flight of ideas/racing thoughts
more talkative or pressured speech
Excessive involvement in pleasurable activities that have a high risk of negative consequences
What is a mixed episode?
meets criteria for both manic and major depressive episodes. present every day for 1 wk. psyhchiatric emer
What are the criteria for hypomanic episode?
elevated, expansive, or irritable mood that includes at least 3 of the symps listed for manic episode.
What are the differences between manic episode and hypomanic?
mania- 7 days; severe impairment; may necessitate hospitalization to prevent harm to self or others; psychotic features

Hypomania- 4 days, no impairment in social functioning, no hospitalization, no psychotic features.
What are medical causes of depressive episode?
Cerebrovasc disease
Cushings, addisons, hypoglycemia, hyper/hypoTH, hyper/hypocalcemia
Viral illnesses
Cancer- lymphoma and pancreatic
Collagen vasc disease- SLE
What are medical causes of Mania?
Metabolic- HyperTH
Neuro- temporal lobe seizures, MS
What meds/substances induce depression?
W/drawal from psychostimulants- cocaine, amphetamines
What meds/Substance induce mania?
What is the DSM IV for MDD?
At least one major depressive episode
No Hx of manic or hypomanic episode.

SAD- only during the winter
What is the epi of MDD?
Lifetime- 15%
Onset at any age, average age is 40
2x as prevealent in women than men
No ethnic or socioeconomic differences
Prevalence in elderly from 25-50%.
What are teh sleep problems associated with MDD?
Multiple awakenings
Initial and terminal insomnia
REM early in night. decreased 3 and 4
What are teh abnlties of serotonin in depression?
decreased brain and CSF levels of serotonin and 5-HIAA found in depressed pts.
Abnl regulation of beta-adrenergic receptors found as well.
Drugs increase availabiility of serotonin, NE, and dopa alleviate symps of depression.
what neuroendocrine abnlties can cause depression?
High cortisol- hyperactivity of the hypothalamic-pituitary-adrenal axis shown by failure to suppress cortisol levels in dexamethasone suppresion test
Abnl thyroid axis- associated with depressive symps and 1/3rd of pts w/ MDD who have otherwise normal thyroid hormone levels show blunted response of TSH to infusion of TRH.

Not specific to major depression.
GABA also plays a role
How do psychosocial events play a role in depression?
loss of a parent before age 11. Stable family and social functioning have been shown to be good prognostic indicators in the course of major depression.
What role does genetics play in depression?
1st degree relatives are 2 or 3x more likely to have MDD. Concordance rate for MZ twins is about 50% and 10-25% for dizigotic
What is the course and prognosis for MDD?
if left untreated, they are self-limiting. last 6-13 months. occur more frequently as disorder progresses. risk of subsequent episode is 50% w/in 1st 2 yrs. 15% commit suicide

Antidepressants medications significantly reduce the length and severity of symptoms. may be used prophylactically between episodes. 75% treated successfully
What is the Rx for MDD?
hospitalization if at rist for suicide, homicide, or unable to care for self

SSRI- safe and better tolerated; SEs mild, include headache, GI, Sex, and rebound anxiety
TCA- most lethal in OD; SEs- sedation, weight gain, ortho hypotension, and anti-chol. aggravate prolonged QTC
MAOI- useful for Rx of refractory depression; risk of HTN crisis when used w/ wympathomimetics or ingestion of tyramine-rich foods.

stimulants; action is rapid, dependence limits use.
antipsychotics- useful in pts w/ psychotic features.
Thyroid, Li, or tryptophan for notn responders

Psychotherapy- behavioral, cognitive, supportive, dynamic psychotherapy and family therapy.
ECT and MDD?
indicated if pt is unresponsive to pharmacotherapy, if pt cannot tolerate pharmacotherapy, if pt cannot tolerate pharmacotherapy, or if rapid reduction of symptoms is desired.
safe, used in conjunction with pharm.
premedication w/ atropine, genearl anesthesia, generalized seizure si induced.
Approximately 8 treatments are administered over a 2-3 wk period.
Significant improvement after after 1st Rx.
retrograde amnesia is a common side effect. disappears w/in 6 mths.
What is melancholic depression?
40-60% of pts w/ major dpression. Anhedonia, early morning awakenings, psychomotor disturbance, excessive guilt, and anorexia. May diagnose MDD w/ melancholic
What is atypical depresion?
hypersomnia, hyperphagia, reactive mood, leaden paralysis, and hyprsensitivity to rejection
What is catatonic depression?
catalepsy, purposeless motor activity, extreme negativism, bizarre postures, echolalia.
What is psychotic depression?
10-25% of hospitalized depressions. Delusions or hallucinations.
what is the epi of bipolar?
no ethnic differences
onset before 30
What is the etiology of bipolar?
biological, environmental , psychosocial and genetics are important
1st degree relatives are 8-18x more likely to have the illness
MZs are 75%, and dizogotes are 5-25%
What is the course and prognosis of bipolar
untreated manics episodes last 3 monnths. course is chronic w/ relapses.
only 50-60 improve
what is the Rx for bipolar?
Lithium- mood stabalizer
anticonvulsants- mood for rapid changing bipolar disorder and mixed episodes
Olanzapine- typical antipsychotic

- supportive, family, group

- works well in treatment of manic episodes
- requires more treatments than for depression.
What is rapid cycling?
4 or more mood episodes in a year.
how do you Rx catatonic depression?
antidepressant and antipsychotics concurrently
what is the epi of bipolar II?
.5% prevalence
more common in women
before age 30
no ethnic differences
What is the DSM IV for dysthymic disorder?
chronic mild depression, 2 yrs (kids 1 yr)
2 of the following:
- poor concentration
- feelings of hopelessness
- poor appetite or overeating
- insomnia or hypersomnia
- low energy or fatigue
- low self-esteem
in 2yr period
- not been w/o symps for > 2 months
- no major depressive episode
What is double depression?
MDD and Dysthymic disorder
What is the EPI of dysthymia?
6% prevalence
2-3x more common in women
onset before age 25 in 50%
What is teh course and prognosis of dysthymic disorder?
20% of pts develop major depression. 20% will develop bipolar disorder and >25% have lifelone symps
what is the Rx for dysthymic?
cognitive therapy, insight-oriented psychotherapy
What is anxiety?
subjective experience of ear and its physical manifestations: plapitations, perspiration, dizziness, mydriasis, gastrointestinal disturbances, and urinary urgency and frequency
What are medical causes of anxiety?
B12 deficiency
Neurological disorders
Coronary disease
What are meds/substances that can cause anxiety?
Alcohol adn sedative w/drawal
other illicits w/drawal
Mercury or Arsenic toxicity
Organophosphate or benzene toxicity
What is a panic attack?
discrete period of heightened anxiety that occurs in pts w/ a panic disorder. May occur in other mental disorders. PTSD.
Peak in several minutes and subside w/in 25 minutes. Rarely > 1hr. attacks are unexpected or provoked by specific triggers. May be described as a sudden rush of fear.
What is teh DSM IV of a panic attack?
4 of the following:
choking sensation
chest pain
Fear of losing control or going crazy
Fear of dying
Numbness or tingling
Chills or hot flushes.
What is the DSM IV of Panic Disorder?
panic attacks w/ fear of future attacks
1. spontaneous recurrent attacks w/ no obvious precipitant
2. at least one attack followed by 1 month of :
- persistent concern of additional attacks
- worry about implications of attack
- significant change in behavior related to the attacks
What are the two types of panic disorder?
With and without agoraphobia.
What can induce a panic attack?
hyperventilation or inhalation of CO2. Caffeine and nicotine
What is the epi of panic disorder?
2-5% prevalence
2-3x more common in females
strong genetic component
onset from late teens to early thirties.
What conditions are associated w/ panic disorder?
major dpression (40-80%)
substance use (20-40%)
social and specific phobias
Obsessive-compulsive disorder
what is the prognosis of panic disorder?
10-20% of pts have significant symptoms that interfere w/ daily functioning
50% continue to have mild, infrequent symps
30-40% are free of symptoms after treatment
What is the meds for acute initial Rx of anxiety?
Benzos- tapered dose w/ SSRIs institutued

Beta blockers are not as good.
What can be used for maintenance therapy of panic sidorder?
SSRIs, Paroxetine and sertraline. Rx for 8 to 12 months.
What are non-pharm treatments for panic disorder?
Relaxation training, biofeedback, cognitive therapy
isight-oriented therapy
family therapy.
What is agoraphobia?
fear of being alone in public places. Develops 2ry to panic attack from apprehension over subsequent attacks where escape can be difficult
What is the DSM IV of agoraphobia?
-anxiety about being in places or situations where you can not escape.
-situations are avoided, endured with distress, or faced only w/ presence of a companion
- not explained by other disorder
What are typical fears in agoraphobia?
no being outside alone. being on a bridge or ina croud. riding in a car, bus, or train
What is the DSM IV for specific phobias?
persistent excessive fear brought on by a specific situation or object.
Exposiour brings anxiety
Situation is avoided when possible or tolerated w/ intense anxiety
pt recognizes fear is excessive
situation is avoided when possible or tolerated w/ anxity
if < 18, must last > 6 months.
What are common specific phobias?
blood or needles
illness or injury

speaking in public
eating in public
using restrooms
What is the epi of phobia?
most common mental disorder.
5-10% of population
onset as early as 5yo.
as old as 35

What is the etiology of phobia?
Genetics- fear of blood runs in families.
Behavioral- association w/ traumatic phobia.
Neurochemical- overproduction of neurotransmitters.
What is the treatment for specific phobia?
systemic desensitization. Supportive psychotherapy.
benzos or beta blockers.
Systemic- graduallly expose patient to feared object or situation while relaxing
How do you treat social phobia?
what is an obsession?
recurrent and intrusive thought, feeling or idea
what is a compulsion
concious repetative beehavior linked to an obsession, relieves anxiety.
What is OCD?
axis I disorder- obsessions increase anxiety. Compulsions relieved them. Pts are aware of the problems and realized that their thoughts and behaviors are irrational. Symptoms couse significant distress in their lives. pts. wish to get rid of them.
What is the DSM IV of OCD?
1. either obsessions or compulsions
- recurrent and persistent thoughts
- attempts to suprress
- knows they are a product of their own mind.

- no link between behavior and stress reduction.
2. person is aware that these things are unreasonable and excessive
3. the obsessions cause distress, interfere w/ daily functioning
what are the common patterns of an ocd pt?
obsessions about contamination w/ excessive washing or compulsive avoidance of the contaminant

doubt- forgot to turn off stove, lock the door. checking.

symmetry- eating, showering

intrusive thoughts- sexual, violent
what is the epi of OCD?
onset in adulthood, men=women
MDD, eating disorders, other anxiety disorders, OC personality disorder
higher in those with relatives w/ tourettes
what percent of OCD pts have both obsessions and compulsions?
what are the 4 most common mental disorders?
substance induced
major depression
what is the etiology of OCD
abnl reg of serotonin
psychosocial- onset triggered by stressful life event
what is the prognosis of OCD?
30% improve w/ treatment
40-50% improve moderately
20-40% remain impared.
what is the Rx for OCD?
SSRIs; higher than normal doses
Behavioral- as effective as pharm. outcomes best when both are used. Exposure and response prevention.
Relaxation techniques.

Last resort- ECT, cingulotomy
what is the DSM IV of PTSD?
experience of trauma; event was potentially harmful or fatal. inital reaction was intesne fear or horror
- persistence reexperiencing
- avoidance of stimuli
- numbin gof responsiveness
- persistent symptoms of increased arousal. (difficulty sleeping, outbursts of anger, exaggerated startel, difficulty concentrating)
1 month
How do you Rx PTSD?
TCA- imipramine, doxepin

relaxation training
support groups, family therapy
Whas is the DSM IV for acute stress disoder?
reserved for pts who experience a major traumatic event but have anxiety symptoms for only a short duration. must occur w/in a month, and last only 1 month.
What are the differences between PTSD and ASD?
PTSD- event occured in the past; last >1 month

ASD- event occured < 1 month ago, symps last < 1month
What is Generalized Anxiety Disorder?
persistent excessive anxiety and hyperarousal for 6 months. worry about day to day
What is the DSM IV of GAD?
excessive anxiety and worry for 6 months.
- difficult to control worry
3 of the following
- restlessness
- fatigue
- difficulty concentrating
- irritable
- muscle tension
- sleep disturbance
What is the epi of anxiety?
prevalence: 45%
GAD is very common in the general population
Women 2:1 Men
onset before 20
what is the clinical presentation of GAD?
most do not seek psychiatric help. Most go to specialist due to somatic complaints.
what are the comorbidities for GAD?
90% have phobia, panic disorder, or MDD
What is teh prognosis of GAD?
lifelong fluctuating symps in 50%
what is the Rx for GAD?
- buspirone, benzos (tapered quickly), ssris, venlafaxine

- behavioral therapy
- psychotherapy
what is the DSM IV for adjustment disorder?
1. development of emotional or behavioral symps w/in 3 months after a stressful life event
- sever distress in excess of what would be expected after such an event
- significant impairment

2. symps are not bereavement
3. symps resovle w/in 6 months

(not DSM but symps begin w/in 3 months, event is not life theratening)
what are the subtypes of adjustment disorder?
depressed, anxiety, conduct disturbance (aggression)
what is the epi of adjustment disorders?
2:1 W:M
What triggers adjustment disorder?
psychosocial factors
what is the Rx for adjustment disorder?
supportive psychotherapy
pharm (insomnia, anxiety, depression)
what is the DSM definition of a personality disorder?
1. pattern of behavior/inner experience that deviates from the persons culture in 2 or more of the following ways:
- cognition, affect, personal relations, impulse control
2. pervasive and inflexible in broad range of situations
- stable and has onset no later than adolescence or early adulthood
- leads to significant distress in functioning
- not accounted for by other illness

(each is 1 percent of the population)

Personal Relations
Impulse Control
What are the personality clusters?
schizoid, schizotypal, paranoid
- Eccentric, peculiar, withdrawn
- family association of psychotic disorders
Borderline, antisocial, histrionic, narcissistic
- emotional, dramatic, inconsistent; family has mood disorders
OCD, avoidant, dependant
-pts are anxious or fearful; family Hx of anxiety
what is teh definition of cognitive disorders?
affect memory, orientation, attention, and judgement
1ry or 2ry abnlties of CNS
- Dementia
- Delirium
- Amnestic disorders
waht is the definition of dementia?
impairment of memory and other cognitive function sw/out alteration in the level of consciousness. Most are progressive and irreversible. Dementia is a major couse of disability in the elderly. It affects memory, cognition, language skills, behavior, and personality.
what is the epi of dementia?
incidence increases w/ age
20% > 80 have dementia
associatiosn: delusions and hallucinations occur in 30% of demented pts. Affective symptoms, depression and anxiety are in 40-50%. Personality changes are also common.
What are the most common causes of dementia?
major depression
What is the DDx of dementia?
what are organic causes of dementia?
structural: benign forgetfulness, parkinsons, huntingtons, downs, head trauma, tumor, NPH, MS, Hematoma

Metabolic: thyroid, hypoxia, malnutrition (B12, folate, thiamine), Wilson's disease, lead

Infections: Lyme, HIV, CJd, Neurosyphilis, meningitis, encephalitis

Drugs: alcohol, phenothiazines, anticholinergics, sedatives.
what is the DSM IV of delirium?
Quit: may seem depressed, or exibit symps similar to failure to thrive; Agitated: pulling out lines, may hallucinate

waxing/waning of consciousness. can be caused by virtually aany medical disorder. High mortality rate.
Rx for delirium?
rule out life-threatening causes
Rx reversible causes, hypothyroid, electrolyte imbalance, urinary tract infections
Antipsychotics are #1- quetiapine; haloperidol
1:1 nursing
ferquently reorient pt
avoid napping
keep lights on, shades open
hold for sedation.
What are teh hallmarks of alzheimers?
gradual progressive decline of cognitive functions, especially memory and language. Personality change and mood swings.
inability to copy a picture
inability to interpret sensations
what is the DSM IV for Alzheimers?
Memory and 1 of the following:
- aphasia
- apraxia
- agnosia
- diminished executive functioning- problems w/ planning, organizing, and abstracting.
Personality mood changes
What is the neurophys of alzheimers?
decreased ACh (locus ceruleus of brainstem) and NE (los of cholinergic neurons in basal nucleus of meynert
Pathology of alzheimers
Gross- diffuse atrophy w/ enlarged ventricles ans flattened sulci

micro- sinle plaques, amyloid, tau
What is the Rx for alzheimers?
no cure or truly effective treatment
physical and emotioanl support
proper nutrition, exercise, and supervision
NMDA receptor and antagonist: mematine
Cholinesterase inhibitors to slow progression:
- tacrine
- donepezil
- rivastigmine
Rx of symps
- benzos for anxiety
- antipsychotics for agitation
- antidepressants for depresion
What are the clinical manifestations of vascular dimentia?
memory impairment and Aphasia, apraxia, agnosia or diminshed executive funtctioning.
what are differences between vascular and alzheimers?
vasc- focal neuro symps
onset more abrupt than alzheimers
greater preservation of personality
reduce risk by modifying risk factors

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