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					DISORDER           CRITERIA            SUBTYPES             PREVALENCE   MALE:    ONSET       ETIOLOGY          CLINICAL           DIFFERENTIAL      DRUG              THERAPY           OUTCOME
                                                                         FEMALE                                 SI/SX                                MANAGEMENT
                                                                                   PSYCHOTIC DISORDERS
SCHIZOPHRENIA      Psychosis and       1.Paranoid (affect   1%                    Early     Dopamine            Prodrome:                            Better at                           1/3 attempt
                   social/             not flat)                                  20s       hypothesis:         poor social                          treating                            and 10%
                   occupational        2.Catatonic                                (men),    hyperactivity in    skills, social                       negative                            complete
                   dysfunction         3.Disorganized                             late 20s  brain               w/d, unusual                         symptoms                            suicide
                   persisting at       4.Undifferentiated                         (women)   dopaminergic        thinking
                   least 6 months      (most common)                                        pathways                                                 Antipsychotics/
                                       5.Residual                                           (neuroleptics       Neg sxs:                             neuroleptics
                                                                                            block DA            affective                            (haldol)
                                                                                            receptors,          flattening,
                                                                                            cocaine/            alogia,
                                                                                            amphetamines        asociality
                                                                                            stimulate DA
                                                                                            receptors and       Pos sxs:
                                                                                            induce              hallucinations,
                                                                                            psychosis)          delusions,
                                                                                                                bizarre
                                                                                                                behavior
SCHIZOPHRENIFORM   Schizophrenia                                                                                “Full-blown”                                                             Self-limited
DISORDER           failing to last 6                                                                            episode of
                   months and that                                                                              schizophrenia,
                   does not involve                                                                             but duration of
                   social w/d (lasts                                                                            illness
                   1-6 months)                                                                                  (prodrome,
                                                                                                                active, residual
                                                                                                                phases) last 1-6
                                                                                                                months only
SCHIZOAFFECTIVE    Psychotic           1. Depressive        0.5-0.8%              Late                                             Distinguish b/w   Antipsychotic +
DISORDER           episodes                                                       teens,                                           neg sxs of        mood stabilizer
                   resemble            2. Bipolar                                 early 20s                                        schizophrenia     (Li, valproic
                   schizophrenia                                                                                                   from anhedonia    acid)
                   but w/                                                                                                          and lack of
                   prominent                                                                                                       energy in
                   mood                                                                                                            depressive
                   disturbances;                                                                                                   schizoaffective
                   psychotic sxs                                                                                                   pts
                   must persist (at
                   least 2 weeks)
                   for some time in
                   absence of
                   mood syndrome
BRIEF PSYCHOTIC    Psychotic sxs       1. With marked                                                           Can be                                                 Hospitalization   Self-limited
DISORDER           lasting from 1-     stressors                                                                preceded by a                                          may be
                   30 days             2. W/o marked                                                            stressor or be                                         necessary to
                                       stressors                                                                postpartum;                                            protect the
                                       3. Postpartum                                                            may occur w/o                                          patient
                                                                                                                an antecedent
DELUSIONAL         Non-bizarre         Erotomanic           <0.05%       Women>   Mid to      Psychosocial      Nonbizarre                           Antipsychotics    Psychotherapy     Chronic,
DISORDER           delusions           Grandiose                         men      late life   stressors (e.g.   delusions about                      (often            is primary tx,    unremitting
                   lasting at least    Jealous                                                following         things that                          ineffective)      taking care to
                   1 month; other      Persecutory                                            migration),       could happen in                                        neither support
                   than the            Somatic                                                premorbid         real life                                              nor refute the
                   delusion, the       Mixed                                                  paranoid                                                                 delusion, but
                   patient’s social    Unspecified                                            character                                                                maintain an
                   adjustment                                                                                                                                          alliance w/
                   remains normal                                                                                                                                      patient
DISORDER     CRITERIA                              SUBTYPES             PREVALENCE   MALE:    ONSET        ETIOLOGY                 CLINICAL        DRUG                THERAPY             OUTCOME
                                                                                     FEMALE                                         SI/SX           MANAGEMENT
                                                                                        MOOD DISORDERS
UNIPOLAR
MAJOR        At least 1 major depressive           Melancholic          5-20%        1:2     Incidence     Classic                  Usual           Antidepressants     ECT for severe      Often
DEPRESSIVE   episode, w/ 5 or more of the          depression:                               peaks b/w     psychoanalytic           duration of     are chosen          or refractory       recurrent
DISORDER     following, for at least 2 weeks:      severe form a/w                           ages 20-40    theory                   untreated       according to side   cases or when
             depressed mood most of the day,       guilt, remorse,                           and           Cognitive behavioral     episode is 6-   effect profiles:    meds are            15%
             nearly every day; insomnia or         loss of pleasure,                         decreases     model                    12 months       TCAs, SSRIs,        contraindicated     suicide rate
             hypersomnia; anhedonia;               and extreme                               over age 65   Learned helplessness                     MAO-Is, atypical
             feelings of worthlessness or          vegetative                                              model                                    antidepressants
             inappropriate guilt; low energy       symptoms                                                Neurotransmitter
             nearly every day; decreased                                                                   deficiency of NE, 5-                     Also: lithium,
             concentration or increased            Postpartum:                                             HT                                       thyroid hormone,
             indecisiveness; increased or          occurs w/in 4 wks                                       Neuroendocrine link                      psychostimulants
             decreased appetite or wt gain or      of delivery                                             (HPA axis                                for adjunctive tx
             loss; psychomotor agitation or                                                                abnormality)
             retardation; suicidality (ideation,   Seasonal                                                Sleep disturbances
             plan, attempt)                        depression                                              (deep sleep [delta
                                                                                                           sleep, stages 3 and 4]
             One sx must be depressed mood         Atypical:                                               is decreased,
             or loss of interest or pleasure       hypersomnia,                                            increased REM sleep
             (anhedonia), and the sxs must         increased appetite                                      and decreased REM
             cause distress or impairment          and wt gain,                                            latency)
                                                   mood reactivity,
                                                   rejection
                                                   sensitivity,
                                                   anergia, leaden
                                                   paralysis
DYSTHYMIC    Mild, chronic form of major                                6%                                                          If major        Same as above       Psychotherapy       Can be
DISORDER     depression lasting at least 2                                                                                          depressive                          may play a larger   chronic and
             years                                                                                                                  episodes co-                        role c/w major      difficult to
                                                                                                                                    occur                              depressive d/o      treat
                                                                                                                                    double
                                                                                                                                    depression
BIPOLAR
BIPOLAR I    Most severe of the bipolar            Rapid-cycling:       0.4-1.6%             Early 20s                                                                                      10-15%
             disorders, diagnosed after at least   frequent cycles,                                                                                                                         suicide rate
             1 manic episode (lasts at least 1     at least 4 mood
             week, and 3-4 of following are        disturbances per
             present during elevated mood          year
             period):
             Highly inflated or grandiose self-
             esteem, decreased need for sleep,
             pressured speech, racing
             thoughts or flight of ideas, easy
             distractability, increased goal-
             directed activity, hedonism
BIPOLAR II   Same as bipolar I, but mania is                            0.5%                                                                                                                10-15%
             absent and hypomania (milder                                                                                                                                                   suicide rate
             form of elevated mood) is the
             essential diagnostic finding                                                                                                                                                   Recurrent
             (mood oscillates b/w hypomania
             and depression)
CYCLOTHYMIC    Recurrent, chronic, mild form of   0.4-1%   Chronic
DISORDER       bipolar d/o in which mood                   and
               typically oscillates b/w                    recurrent
               hypomania and dysthymia
ETIOLOGIC
SUBSTANCE-
INDUCED MOOD
DISORDER
MOOD           Endocrine disorders such as
DISORDER DUE   thyroid and adrenal dysfunction
TO GENERAL     are common etiologies
MEDICAL
CONDITION
DISORDER           CRITERIA                  SUBTYPES      PREVALENCE    MALE:    ONSET      ETIOLOGY                     CLINICAL SI/SX          DRUG              THERAPY             OUTCOME
                                                                         FEMALE                                                                   MANAGEMENT
ANXIETY DISORDERS: Most Prevalent Group of Psychiatric Disorders
PANIC           Recurrent unexpected    With            2-3%             Women>   20s        CO2 hypersensitivity,        Panic attacks come on   TCAs, MAOIs,      CBT (relaxation
DISORDER        panic attacks           agoraphobia                      men                 abnormal lactate             suddenly, peak w/in     SSRIs, high-      exercises and
                                                                                             metabolism, locus            minutes, last 5-30      potency           desensitization)
                   One of following for      Without                                         coeruleus abnormality,       minutes                 benzodiazepines
                   at least 1 month:         agoraphobia                                     elevated CNS                 Pt must have 4/13
                   persistent concern                                                        catecholamines, GABA         typical sxs of panic
                   about having                                                              receptor abnormality (pts
                   additional attacks,                                                       respond to benzos, panic
                   worry about                                                               can be induced in pts w/
                   implications of                                                           anxiety disorders with
                   attacks (going crazy,                                                     GABA antagonists)
                   losing control),
                   significant change in
                   behavior related to
                   the attacks
AGORAPHOBIA        Fear of places in                       2-6%          Women>                                                                                     Exposure therapy:
                   which escape might                                    men                                                                                        incrementally
                   be difficult or that                                                                                                                             confront feared
                   might be                                                                                                                                         stimulus
                   embarrassing
                   Can be a
                   complication of panic
                   disorder, but most
                   often occurs alone
SOCIAL PHOBIA      Fear of exposure to       Generalized   3-5%                   Before                                  Hypersensitivity to     MAOIs, SSRIs,     CBT
                   scrutiny by others; for                                        age 25                                  rejection is often      beta-blockers,    incorporating
                   those under 18, sxs       Limited                                                                      antecedent              benzodiazepines   exposure therapy
                   must persist for at                                                                                                                              techniques of
                   least 6 months                                                                                                                                   systematic
                                                                                                                                                                    desensitization
                                                                                                                                                                    and flooding
SPECIFIC           Intense fear of a                       Most common                                                                            No role           Exposure therapy    Specific
PHOBIA             certain object, place,                  psychiatric                                                                                              in form of          childhood
                   activity, or situation;                 disorder                                                                                                 systematic          phobias tend to
                   avoidance of or                                                                                                                                  desensitization     remit w/ age
                   distress over the                                                                                                                                and flooding        spontaneously
                   feared situation must
                   impair everyday                                                                                                                                                      If persist into
                   activities or                                                                                                                                                        adulthood, often
                   relationships; for                                                                                                                                                   become chronic,
                   those under 18, sxs                                                                                                                                                  but rarely cause
                   must persist for at                                                                                                                                                  disability
                   least 6 months
OCD                                                        2-3%                   Late       Behavioral models: O                                 Clomipramine      Response
                                                                                  teens,     and C are produced and                               (TCA), SSRIs      prevention
                                                                                  early      sustained via classic and
                                                                                  20s, 1/3   operant conditioning                                                   Systematic
                                                                                  before                                                                            desensitization
                                                                                  age 15     OCD most frequently                                                    and flooding
                                                                                             seen after brain injury or
                                                                                             dz

                                                                                             Serotonin is a mediator
                                                                                             of OC thinking
GAD            Pervasive anxiety and     5%             Early                                                            Benzodiazepines,   Relaxation
               worry (apprehensive                      20s                                                              buspirone, beta-   techniques
               expectation) about a                                                                                      blockers
               number of events
               occurring most days
               for at least 6 months,
               difficulty controlling
               the worry, and at least
               3 of the following:
               Restlessness, easy
               fatiguability,
               difficulty in
               concentrating or mind
               going blank,
               irritability, muscle
               tension, sleep
               disturbance
ACUTE STRESS
DISORDER
PTSD           Persistant                0.5% (men)     Any        Central etiologic factor is   Re-experience of        TCAs, MAOIs        Psychotherapy
               reexperience of a         1.2% (women)   age,       the trauma (combat, rape,     trauma via repetitive   most common,
               trauma, efforts to                       hours to   physical assault,             intrusive images or     esp. w/ comorbid
               avoid recollecting the                   years      accident) in which actual     dreams or via           depression
               trauma, and                              after      or potential death,           recurrent illusions,
               hyperarousal                             initial    serious injury, or threat     hallucinations, or
                                                        trauma     to physical integrity was     flashbacks
                                                                   experienced or witnessed      Adaptive attempts to
                                                                                                 avoid recollections
                                                                                                 include psychological
                                                                                                 mechanisms
                                                                                                 (dissociation,
                                                                                                 numbing) or actual
                                                                                                 avoidance of
                                                                                                 circumstances that
                                                                                                 will evoke recall
                                                                                                 Feel detached from
                                                                                                 others, autonomic
                                                                                                 hyperarousal
SUBSTANCE-
INDUCED
ANXIETY
DISORDER
ANXIETY
DISORDER DUE
TO A GENERAL
MEDICAL
CONDITION
DISORDER       CRITERIA                   PREVALENCE          ETIOLOGY             CLINICAL SI/SX                                            DRUG MANAGEMENT            THERAPY                      OUTCOME
PERSONALITY DISORDERS
CLUSTER A: ODD AND ECCENTRIC
PARANOID       Distrustful,               0.5-2.5%            Small increase in    See world as malevolent, not forthcoming about            Widely used, but no        Resistant to treatment b/c
               suspicious, anticipate                         prevalence in        themselves, require emotional distance                    specific medicine for      personality has
               harm or betrayal or                            relatives of                                                                   any specific disorder;     temperamental
               deceit                                         schizophrenics                                                                 meds are targeted at the   components and is
SCHIZOID       Emotionally detached,      7.5%                Increased            Loners, aloof, detached, profound difficulty              various associated sxs     developed over a lifetime
               prefer to be left alone                        prevalence in        experiencing and expressing emotion, do not seek                                     of interacting with the
                                                              relatives of         relationships                                                                        environment
                                                              schizophrenics or
                                                              schizotypal PD;      Not commonly seen in clinical practice                                               Psychotherapy
                                                              Unloving or
                                                              neglectful parents                                                                                        Cognitive, behavioral, and
SCHIZOTYPAL      Odd thoughts, affects,   3%                                       Similar to schizophrenia but less severe and w/o                                     family therapy               10% suicide
                 perceptions, beliefs                                              sustained psychotic symptoms                                                                                      rate
                                                                                   Pts have few relationships, many are distrustful and                                 Dialectical behavioral
                                                                                   paranoid leading to constricted social world                                         therapy specifically for
CLUSTER B: DRAMATIC AND EMOTIONAL                                                                                                                                       borderline PD
ANTISOCIAL    Disregard rules/laws 1% of women                                     Exploitative, lie, endanger others, impulsive,                                                                    ½ have been
              of society, rarely   3% of men                                       aggressive                                                                                                        arrested; ½ of
              experience remorse                                                                                                                                                                     prison
              for actions                                                          Alcoholism often associated                                                                                       population

                                                                                                                                                                                                     5% suicide
                                                                                                                                                                                                     rate
BORDERLINE       Instability in           1-2%                Females often have   Relationships infused w/ anger, fear of abandonment,                                                              10% suicide
                 relationships, self-                         been sexually or     shifting idealization and devaluation; self image is                                                              rate
                 image, affect, impulse                       physically abused    fragmented and unstable w/ consequent unpredictable
                 control                                                           changes in relationships, values, goals; affectively
                                                                                   unstable and reactive; impulsiveness unsafe
                                                                                   behavior (promiscuity, drug use) and suicidal or
                                                                                   parasuicidal behavior
                                                                                   Principle intrapsychic defenses are primitive: gross
                                                                                   denial, distortion, projection, splitting
HISTRIONIC       Excessive superficial    2-3%                                     Dramatic clothing, exaggerated emotional response,
                 emotionality,                                                     inappropriate flirtation/seductiveness; difficulty w/
                 powerful need for                                                 intimacy, believing their relationships to be more
                 attention                                                         intimate than they actually are
NARCISSISTIC     Arrogant and entitled    1%                                       Paradoxical combination of self-centeredness and
                 but suffer from very                                              worthlessness; demand attention and admiration;
                 low self-esteem                                                   concern and empathy for others is absent; intense envy
                                                                                   of those they regard as more desirable, worthy, or able
CLUSTER C: ANXIOUS AND FEARFUL
AVOIDANT       Desire relationships       0.5-1%                                   Painfully sensitive to criticism; fear rejection and
               but avoid them                                                      humiliation consequent social inhibition
               because of the anxiety
               produced by their
               sense of inadequacy
DEPENDENT      Needy, rely on others      15-20%                                   Yearn to be cared for; live in great and continual fear
               for emotional support                                               of separation from someone they depend on, hence
               and decision making                                                 clinging and submissive behavior
OBSESSIVE-     Perfectionists, require    1%                                       Cold and rigid in relationships, make frequent moral
COMPULSIVE     order and control          Men diagnosed                            judgments; devotion to work often replaces intimacy;
                                          twice as often as                        serious and plodding; even recreation becomes a sober
                                          women                                    task
DRUG         TYPES               EPIDEMIOLOGY             CLINICAL                   SXS OF INTOXICATION         MINOR WITHDRAWAL             MORE SEVERE W/D                  MANAGEMENT
ALCOHOL                          2/3 of Americans         Denial                                                 “The shakes” : onset 12-     Alcoholic seizures: onset 7-     Dependent pts: folate 1 mg/day,
                                 drink occasionally       Early physical findings:                               18 hrs, peak 24-48 hrs       36 hrs, peak 24-48 hrs; 1-6      thiamine 100 mg/day
                                                          acne rosacea, palmar                                                                generalized seizures is
                                 12% are heavy            erythma, painless                                      Untreated, uncomplicated     common but rarely lead to        Minor w/d: chlordiazepoxide
                                 drinkers (almost every   hepatomegaly (from                                     alcohol withdrawal takes     status epilepticus; precede      (Librium), oxazepam (Serax)
                                 day, drunk several       fatty infiltration)                                    5-7 days and consists of     delirium tremens in 30% of
                                 times per month)         Later findings                                         tremors, N/V, tachycardia,   cases                            Major w/d: tx seizures w/ IV
                                                          (advanced): cirrhosis,                                 HTN                                                           benzos, maybe prophylactic
                                 Lifetime prevalence      jaundice, ascites,                                                                  Alcoholic hallucinosis: onset    phenytoin
                                 of alcohol               testicular atrophy,                                                                 w/in 48 hrs; vivid, unpleasant
                                 dependence=14%;          gynecomastia,                                                                       auditory hallucinations in       Alcoholic hallucinosis:
                                 male:female=4:1          Dupuytren’s contracture                                                             presence of clear sensorium      neuroleptic (Haldol 2-5 mg bid)
                                                          Wernicke-Korsakoff
                                                          syndrome (d/t thiamine                                                              Delirium tremens (5% of          Delirium tremens: IV benzos,
                                                          deficiency):                                                                        hospitalized pts w/ alcohol      supportive care
                                                              Wernicke                                                                        dependence): onset 2-3 days;
                                                          encephalopathy: triad                                                               life-threatening; delirium       Rehab: Disulfiram (Antabuse)
                                                          of nystagmus, ataxia,                                                               (perceptual disturbances,        inhibits 2nd enzyme in alcohol
                                                          mental confusion (sxs                                                               confusion or disorientation,     met pathway (aldehyde
                                                          remit w/ thiamine                                                                   agitation), autonomic            dehydrogenase), and
                                                          injection (100 mg IM)                                                               hyperarousal, mild fever;        acetaldehyde accumulates;
                                                              Korsakoff’s                                                                     lasts 3 days                     Naltrexone (opioid antagonist)
                                                          psychosis: anterograde                                                                                               reduces reinforcing high of
                                                          amnesia, confabulation                                                                                               alcohol; ½ of rehab pts relapse in
                                                          (irreversible in 2/3)                                                                                                first 6 months
SEDATIVE/    BDZs                15% of pop is            Sedative-hypnotics are     Similar to EtOH             Similar to EtOH              Similar to EtOH                  Pentobarbital challenge test (for
HYPNOTIC/    Barbiturates        prescribed a benzo       cross-tolerant w/                                                                                                    pts who have been abusing
ANXIOLYTIC                       each year                alcohol; barbiturates                                  Restlessness,                Coarse tremors, weakness,        alcohol + BDZs or barbs); allows
                                                          much more likely to                                    apprehension, anxiety        n/v, sweating, hyperreflexia,    for quantification of tolerance to
                                                          cause clin. sig.                                                                    orthostatic hypotension,         do controlled taper,  problems
                                                          respiratory comp                                                                    seizures                         of w/d
OPIOIDS      Morphine, heroin,   Relatively uncommon      Initial rush, then sense   Signs occur immediately     Begin 10 hrs after last      N/V, muscle aches, seizures      Gradual w/d using methadone 5-
             codeine,            Lifetime prevalence is   of well-being              after addict shoots up:     dose; can be                 (meperidine), abdominal          20 mg (weak agonist at mu opiate
             meperidine,         0.9%, app. 500,000                                  papillary constriction,     uncomfortable, but rarely    cramps, hot/cold flashes,        receptor has longer ½ life [15 hrs]
             hydromorphone       opiate addicts in U.S.                              respiratory depression,     medically complicated        severe anxiety                   than heroin or morphine), then
                                                                                     slurred speech,                                                                           methadone maintenance 60-100
                                                                                     hypotension, bradycardia,   Dysphoric mood, anxiety,                                      mg qd
                                                                                     hypothermia, n/v,           restlessness; lacrimation
                                                                                     constipation                or rhinorrhea, papillary                                      W/d from short-acting opiates
                                                                                                                 dilatation, piloerection,                                     lasts 7-10 days, and from longer-
                                                                                                                 sweating, HTN,                                                acting meperidine 2-3 weeks
                                                                                                                 tachycardia, fever,
                                                                                                                 diarrhea, insomnia,                                           Clonidine (centrally acting alpha
                                                                                                                 yawning                                                       2 agonist) treats ANS sxs of w/d
                                                                                                                                                                               w/o curbing the drug craving
CNS             Cocaine            Cocaine has very rapid onset and     Maladaptive behavior changes (euphoria, hypervigilance), tachy or bradycardia, papillary    2-4 days peak                  W/d is self-limited
STIMULANTS      Amphetamines       short ½ life and requires frequent   dilatation, hyper or hypotension, perspiration or chills, n/v, wt loss, psychomotor         Fatigue, depression,           and usually does not
                                   dosing to remain high                agitation or retardation, muscle weakness, respiratory depression, chest pain, cardiac      nightmares, headache,          require inpatient
                                                                        dysrhythmias, confusion, seizzures, dyskinesia, or coma                                     profuse sweating, muscle       detox
                                   Amphetamines have longer ½                                                                                                       cramps, hunger
                                   life and require fewer doses         Tactile hallucinations (“coke bugs”) in cocaine

                                                                        Agitation, impaired judgement, transient psychosis (paranoia, visual hallucinations) for
                                                                        both



EATING       SUBTYPES                CRITERIA                                   EPIDEMIOLOGY           ETIOLOGY                     CLINICAL                        MANAGEMENT            MEDICAL COMPLICATIONS
DISORDER
ANOREXIA     Restricting type        Refusal to keep body wt at greater than    Point prevalence:      High fear of losing          Long-term mortality             Supervised meals,     Vomiting: hypokalemic,
NERVOSA      (food restriction +     85% of ideal body wt, intense fear of      0.5%-1% in women       control, difficulty with     secondary to suicide or         wt and electrolyte    hypochloremic metabolic
             exercise)               wt gain, preoccupation w/ body size                               self-esteem, display “all-   medical complications is        monitoring, SSRIs     alkalosis (w/ cardiac
                                     and shape, disproportionate influence      Over 90% of pts        or-none” thinking,           >10%                            for comorbid          arrhythmias), esophageal
             Binge eating/           of body weight on personal worth,          are women              maybe past                                                   depression            rupture, parotiditis,
             purging type (food      denial of medical risks of low weight ;                           physical/sexual abuse,                                                             cardiomyopathy from ipecac
             restriction +           do not have a loss of appetite, but        Average onset: age     societal opinions of                                                               toxicity
             exercise may be         refuse to eat out of fear of gaining wt;   17                     beauty
             present, but binge      amenorrhea in post-menarchal girls                                                                                                                   Laxatives: metabolic acidosis,
             eating and then                                                                                                                                                              dehydration, constipation (d/t
             purging are also                                                                                                                                                             laxative dependence)
             present
BULIMIA      Nonpurging Type         Eating disorder characterized by binge     Point prevalence:                                   Binges can be precipitated      Medical               Starvation: leukoprenia,
NERVOSA                              eating with maintenance of body            1-3% of women                                       by stress or altered mood       complications of      anemia, increased
             Purging Type            weight; overconcern w/ body image,                                                             states, but once begun, feels   starvation are not    ventricular/brain ratio,
                                     preoccupied with becoming fat              Male:female=1:10                                    out of control; purging may     present               hypotension, bradycardia,
                                                                                                                                    follow (gag reflex or ipecac,                         hypercholesterolemia,
                                                                                More common                                         laxatives, diuretic abuse,      SSRIs more            hypothermia, edema, dry skin,
                                                                                among whites                                        enemas; bulimics often          effective than in     lanugo hair
                                                                                                                                    exercise and restrict food      anorexia (including
                                                                                                                                    intake                          in pts w/o comorbid
                                                                                                                                                                    depression)
                                                                               DISORDERS OF CHILDHOOD AND ADOLESCENCE
Things to keep in mind:
         Children express emotion in a more concrete manner (ask “Do you feel like crying” instead of “Are you sad”)
         Kids much more likely than adults to have comorbid mental disorders, making diagnosis more complicated
         Psychological testing instruments
                o    Stanford-Binet Intelligence Scale: IQ test used in young children
                o    Wechsler Intelligence Scale for Children-Revised (WISC-R): most widely used in school-age children, yields a verbal score, performance score, and full-scale IQ score

DISORDER            CRITERIA                               SUBTYPES         EPIDEMIOLOGY           ETIOLOGY                     CLINICAL                       DIFFERENTIAL         MANAGEMENT
MENTAL              Subnormal intelligence, as             Mild (50-70;     1-2% of pop            Trisomy 21: most             Most have physical                                  “Educable”: can learn to read, write,
RETARDATION         measured by IQ, combined w/            85% of MR                               common cause                 malformations                                       and perform simple arithmetic, and
                    deficits in adaptive functioning; IQ   pop)             2:1 male:fem                                                                                            most will be able to live w/ their
                    is defined as the mental age (as                                               Fragile X: most common                                                           parents; long-term goal=function in
                    assessed via WISC-R) divided by                                                heritable cause                                                                  community and hold some kind of job
                    chronological age and multiplied       Moderate (35-                                                                                                            “Trainable”: can learn to talk,
                    by 100; IQ<70 required for             50; 10% of                                                                                                               recognize his/her name and a few
                    diagnosis; onset of symptoms must      MR pop)                                                                                                                  simple words, and perform ADLs w/o
                    be prior to age 18                                                                                                                                              assistance; long-term goal=live and
                                                                                                                                                                                    function in a supervised group home
                                                           Severe (20-                                                                                                              Require institutional care
                                                           35; 3-4% of
                                                           MR pop)
                                                           Profound
                                                           (<20; 1-2% of
                                                           MR pop)
LD                  Performance in a specific area of      Reading d/o      4% of school-age       Focal cerebral injury or     2-4 times more common in       Physical or social   Remedial education
                    learning is substantially below                         kids                   neurodevelopmental           boys than in girls             factors must be
                    expectation of child’s chronologic     Mathematics      1% of school-age       defect                                                      ruled out            Learning strategies
                    age, measured intelligence, and        d/o              kids                                                Do not obtain achievement
                    age-appropriate education              Disorder of                             Tend to be familial          test scores consistent w/
                                                           written                                                              their overall IQs
                                                           expression
AUTISTIC            Most common pervasive                                   Rare; 2-5/10,000       Familial, with incomplete    Impairment in social                                Chronic lifelong disorder w/ severe
DISORDER            developmental disorder of                               live births            penetrance                   interaction (failure to                             morbidity
                    childhood onset                                                                                             develop social smile, facial
                                                                            Male:female is 3-      High rate exists with        expressions, eye-to-eye                             Behavioral management techniques:
                    Triad: impaired social interactions,                    4:1                    tuberous sclerosis           gaze)                                               to reduce rigid and stereotyped
                    ability to communicate, and                                                                                                                                     behaviors and improve social
                    restricted repertoire of activities                                            A/w fragile X syndrome       Impaired communication                              functioning
                    and interest                                                                                                (delay or lack of language
                                                                                                                                development, use repetitive                         Comorbid seizures: anticonvulsants
                                                                                                                                or idiosyncratic language,
                                                                                                                                or abnormal in pitch,                               Aggressive or self-harming behavior:
                                                                                                                                intonation, rate, rhythm, or                        neuroleptics, mood stabilizers, anti-
                                                                                                                                stress)                                             depressants

                                                                                                                                Restrictive, repetitive, or
                                                                                                                                stereotyped patterns of
                                                                                                                                behavior, interests, or
                                                                                                                                activities; persistent
                                                                                                                                preoccupation w/ parts of
                                                                                                                                objects

                                                                                                                                25% have comorbid
                                                                                                                                seizures; 75% of MR
                                                                                                                                (moderate type)
ADHD           Onset of inattentive or hyperactive   3-5% of school age   Perinatal injury,                                                          Psychostimulants
               sxs before age 7, and sxs must be     kids                 malnutrition, substance                                                    (methylphenidate=Ritalin is 1st line,
               present in 1 or more settings                              exposure                                                                   then D-amphetamine) used in smallest
                                                     Male:female is 4:1                                                                              effective dose b/c can have long-term
                                                                          Many have abnormal                                                         physical side effects (wt loss,
                                                                          sleep architecture                                                         inhibited body growth
                                                                          (increased delta latency,
                                                                          decreased REM latency)                                                     Behavioral management: positive
                                                                                                                                                     reinforcement, firm limit setting,
                                                                                                                                                     reduced stimulation (short, focused
                                                                                                                                                     tasks, one playmate at a time)
CONDUCT        Basic rights of others and age-       Most common                                                                                     Med used only to treat comorbid
DISORDER       appropriate social norms are          diagnosis in                                                                                    ADHD or mood disorder, but not for
               violated; childhood equivalent of     outpatient child                                                                                CD itself
               antisocial personality disorder       psych clinics
                                                                                                                                                     25-40% go on to have antisocial
                                                                                                                                                     personality disorder as an adult
OPPOSITIONAL   Annoying, difficult, or disruptive                                                                                                    Limit setting, consistency, behavioral
DEFIANT        behavior with a frequency                                                                                                             techniques
DISORDER       significantly exceeding that of
               other children his or her mental
               age; meant to describe kids who do
               not meet criteria for full-blown CD
TOURETTE’S     Multiple involuntary motor and        0.4% prevalence      Highly familial             Tic=sudden, rapid,          Wilson’s Disease   Low doses of high-potency
DISORDER       vocal tics                                                                             recurrent, nonrhythmic,                        neuroleptics
                                                     3:1 male:female      Frequently co-occurs w/     stereotyped motor           Huntington’s
                                                                          obsessive-compulsive        movement or vocalizaion     Disease            Supportive psychotherapy aimed at
                                                                          disorder                                                                   minimizing negative social
                                                                                                      Onset before age 18                            consequences

                                                                                                      Motor tics antedate vocal
                                                                                                      tics; barks or grunts
                                                                                                      antedate verbal shouts
DISORDER    CRITERIA                      PREVALENCE        ETIOLOGY                       CLINICAL SI/SX       DIFFERENTIAL                       DRUG MANAGEMENT           THERAPY      OUTCOME
                                                                                          COGNITIVE DISORDERS
DELIRIUM    Reversible state of global    10-15% of         Substance related: alcohol or  Key Features:                                           1. Oral, IM, or IV        1. Keep      1 year mortality
            cortical dysfunction w/       general medical   BDZ w/d, BDZ and anti-ACh      1. Disturbance of                                       haloperidol: treats       safe from    is 40-50%
            alterations in 1) attention   pts over age 65   drug toxicity                  consciousness                                           agitation                 harm
            and 2) cognition and                            General medical: metabolic     (attention, level of
            produced by a definable       Often seen        abnormalities (hyponatremia,   arousal)                                                2. Low dose BDZ           2. Tx
            precipitant                   postsurgically    hypoxia, hypercapnia,          2. Altered                                                                        underlying
                                          and in ICUs       hypoglycemia), infectious      cognition (memory,                                                                illness
                                                            illnesses (UTIs, pneumonia,    orientation,
                                                            meningitis)                    language,                                                                         3. Remove
                                                            Predisposers: old age,         perception)                                                                       offending
                                                            fractures, preexisting         3. Develops over                                                                  drug
                                                            dementia                       hrs to days
                                                                                           4. Presence of
                                                                                           medical or
                                                                                           substance-related
                                                                                           precipitant

                                                                                          Lab tests target ID
                                                                                          cause
DEMENTIA    Memory impairment in          2-4% over age     BRAIN NEURONAL LOSS                                 Pseudodementia (a/w depression):   1. Tacrine (AChE                       Alzheimer’s
            presence of other             65                1. Alzheimer’s: most                                mood sxs prominent;                inhibitor): some                       dementia: death
            cognitive defects (one or                       common cause, >50% of                               characteristically give “I don’t   efficacy in tx memory                  8-10 years after
            more of: aphasia, apraxia,    20% over age 85   cases); cortical atrophy                            know” answers to MSE queries but   loss in AD type                        onset
            agnosia, disturbance in                         2. Vascular: 2nd most                               answer correctly in pressed;       dementia
            executive functioning)                          common                                              memory is intact w/ rehearsal
                                                            3. HIV                                                                                 2. Low-dose, high-
                                                            4. Head trauma                                                                         potency neuroleptics:
                                                            5. Parkinson’s                                                                         tx agitation, paranoia,
                                                            6. Huntington’s: caudate                                                               hallucinations
                                                            atrophy
                                                            7. Pick’s: frontal and                                                                 3. Low dose BDZ,
                                                            temporal atrophy                                                                       trazadone: anxiety,
                                                            8. CJD: spongioform                                                                    agitation, insomnia
                                                            enceph.
AMNESTIC    Isolated disturbances of                        Substance-related: alcohol    Damage of:
DISORDERS   memory w/o impairment                           abuse most common            mammilary bodies,
            of other cognitive fxns;                        Korsakoff’s psychosis         fornix,
            there must be an                                (alcohol-induced persistent   hippocampus
            identifiable cause for the                      amnestic disorder)
            amnestic disorder                               General medical: head         Inability to recall
                                                            trauma, hypoxia, herpes       previously learned
                                                            simplex encephalitis,         info or to retain
                                                            posterior cerebral artery     new info
                                                            infarction
CHARACTERISTIC                                 DELIRIUM                                                                              DEMENTIA
                                                                                                 DELIRIUM V. DEMENTIA
Onset                                          Hours to days                                                                         Weeks to years
Course/duration                                Fluctuates w/in a day; may last hrs to weeks                                          Stable w/in a day; may be permanent, reversible, or progressive over wks to yrs
Attention                                      Impaired                                                                              May be impaired
Cognition                                      Impaired memory, orientation, language                                                Impaired memory, orientation, language, executive function
Perception                                     Hallucinations, illusions, misinterpretations                                         Hallucinations, delusions
Sleep/wake                                     Disturbed, may have complete day/night reversal                                       Disturbed, may have no pattern
Mood/emotion                                   Labile affect                                                                         Labile affect; mood disturbances
Sundowning                                     Frequent                                                                              Frequent
Identified precipitant                         Present                                                                               Not required

DISORDER           SUBTYPE             CRITERIA                         EPIDEMIOLOGY               ETIOLOGY                       CLINICAL SI/SX                    THERAPY                      OUTCOME
                                                                                            MISCELLANEOUS DISORDERS
DISSOCIATIVE       Dissociative        Temporary inability to recall                                                              Localized: information is
DISORDERS          amnesia             important personal                                                                         lost for a specific time period
                                       information; more serious                                                                  (traumatic event)
                                       than simple forgetfulness                                                                  Selective: some info during a
                                                                                                                                  given time period is retained,
                                                                                                                                  other is lost
                                                                                                                                  Generalized: personal info is
                                                                                                                                  lost for entire life span
                                                                                                                                  Continuous: inability to
                                                                                                                                  recall info from a single pt in
                                                                                                                                  time to present
                                                                                                                                  Systematized: particular
                                                                                                                                  categories of info are lost to
                                                                                                                                  retrieval
                   Dissociative        Amnesia for one’s identity                                     Typically precipitated by   Pt does not appear mentally                                    Eventually remits w/o
                   fugue               coupled w/ sudden                                              severe trauma or stressor   ill                                                            treatment
                                       unexplained travel away
                                       from home
                   Dissociative        Presence of 2 or more            Female>male                   Childhood history of        Average # alters=7; may be        2 camps:                     Chronic
                   identity disorder   separate personalities                                         severe physical or sexual   unaware of each other’s           1. Ignoring different
                   (formerly known     (alters) that recurrently take                                 abuse                       existence and thus may be         alters will cause them to
                   as “multiple        control of a person’s                                                                      quite confused as to how they     recede
                   personality         behavior                                                       Satanic or cult abuse       arrived at certain places; or     2. Long-term
                   disorder”)                                                                                                     may be aware                      psychotherapy exploring
                                                                                                                                  (coconsciousness); pt “loses      the alters and integrating
                                                                                                                                  time”                             them into a whole person
                                                                                                                                  Highly suggestible, easily        (preferred)
                                                                                                                                  hypnotized
                   Depersonalization   Pervasive sense of being                                                                   Sense of detachment
                   disorder            detached from or being                                                                     Feel mechanical or
                                       outside of one’s body                                                                      automated
                                                                                                                                  Absence of affect or
                                                                                                                                  sensation
                                                                                                                                  Easily hypnotized; prone to
                                                                                                                                  dissociate
SOMATOFORM        Somatization        Chronic multiple medical        Female>male                      Early psychoanalytic:          Have multiple MDs
DISORDERS         disorder            complaints not d/t a medical                                     repressed instincts            Make frequent office/hospital
                                      illness (some sxs must have                                                                     visits
Presence of                           begun before 30 and                                              Modern: means of               May seek disability
physical si/sx                        persisted):                                                      nonverbal communication
w/o medical                           1. Pain in 4 sites or
cause not                             involving 4 body fxns
willfully                             2. Other than pain: 2 GI sxs,
produced by the                       1 sexual sx, +
patient                               1 pseudoneurologic sx
                  Undifferentiated    Less severe form of above, briefer course
                  somatoform d/o
                  Conversion d/o      Complaints involving sensory (e.g. numbness) and voluntary motor (e.g. paralysis) fxn not d/t neurologic dysfunction
                  Pain d/o
                  Hypochondriasis     Preoccupation w/ having serious dz based on misinterpretation of bodily fxn and sensation
                  Body dysmorphic     Excessive concern w/ perceived defect in appearance
                  d/o
FACTITIOUS                            Individual willfully produces si/sx of a medical or psychiatric illness to assume the sick role (secondary gain); differentiate from conversion d/o (no willful) and malingering (lying
D/ O                                  about si/sx to obtain primary gain)
ADJUSTMENT                            Occur w/in 3 months of identified stressor and usually resolves w/in 6 months, unless stressor becomes chronic
D/O
                                                                                      SEXUAL AND GENDER IDENTITY DISORDERS
SEXUAL            Sexual desire       Hypoactive sexual desire d/o: sexual fantasy/desire for sex very low or absent
DYSFUNCTIONS      disorders           Sexual aversion d/o: aversion to genital sexual contact w/ another person
                  Sexual arousal      Female: inadequate vaginal lubrication and engorgement of external genitalia
Alterations in    d/o                 Male: inability to attain or maintain an erection
sexual response   Orgasmic d/o        Female/male: orgasm absent or delayed; sexual excitement phase normal
cycle or with                         Premature ejaculation: orgasm and ejaculation occur early and w/ minimal stimulation
pain a/w sexual   Sexual pain d/o     Dyspareunia: genital pain in a/w sexual intercourse
activity                              Vaginismus: involuntary contraction of external vaginal musculature as a result of attempted penetration
PARAPHILIAS       Exhibitionism       Sexual excitement derived from exposing one’s genitals to a stranger
                  Fetishism           Nonliving objects are focus of intense sexual arousal in fantasy or behavior
Culturally        Frotteurism         Sexual excitement derived by rubbing one’s genitals against or by sexually touching a nonconsenting stranger
unusual sexual    Pedophilia          Sexual excitement derived from fantasy or behavior involving sex w/ prepubescent children
activity that     Masochism           Sexual excitement derived from fantasy or behavior involving being the recipient of humiliation, bondage, or pain
causes distress   Sadism              Sexual excitement derived from fantasy or behavior involving inflicting suffering/humiliation on another
or impairment     Transvestic         Sexual excitement (in heterosexual males) is derived from fantasy or behavior involving wearing women’s clothing
in social or      fetishism
occupational      Voyeurism           Sexual excitement is derived from fantasy or behavior involving the observation of unsuspecting individuals undressing, naked, or having sex
functioning
GENDER                                Pervasive cross-gender identification and discomfort with one’s assigned sex
IDENTITY
DISORDER
                                                                                                SLEEP DISORDERS: PRIMARY
                                                                                  Occur as direct result of disturbances in sleep-wake cycle
DYSSOMNIAS        Primary insomnia    Difficulty falling or staying asleep, or sleeping but feeling as if one has not rested during sleep
                  Primary             Excess sleepiness, either sleeping too long at one setting or persistent daytime sleepiness not relieved by napping
                  hypersomnia
                  Narcolepsy          Sleep attacks during day coupled w/ REM sleep intrusions or cataplexy; daytime naps relieve sleepiness
                  Breathing-related   Abnormal breathing during sleep leads to sleep disruption and daytimes sleepiness
                  sleeping d/o
                  Circadian rhythm    Mismatch b/w a person’s intrinsic circadian rhythm and external sleep-wake demands
                  sleep d/o
PARASOMNIAS       Nightmare d/o       Repeated episodes of scary dreams that wake a person from sleep, usually during REM sleep
                  Sleep terror d/o    Repeated episodes of apparent terror during sleep; pts may sit up, scream, or cry out and appear extremely frightened; do not usually awaken during attack; occurs during delta sleep
                  Sleepwalking d/o    Recurrent sleepwalking, often coupled w/ other complex motor activity
SEXUAL RESPONSE CYCLE            Desire             Initial stage of sexual response; consists of sexual fantasies and urge to have sex
                                 Excitement         Physiological arousal and feeling of sexual pleasure
                                 Orgasm             Peaking sexual pleasure
                                 Resolution         Physiologic relaxation a/w sense of well-being; in males, there is usually a refractory period for further excitement and orgasm


SLEEP STAGES
NREM                             Stage 0            Awake
                                 Stage 1            Very light sleep, transition from wakefulness to sleep, drowsy
                                 Stage 2            Medium depth of sleep, occupies ½ of night in adults; transition b/w REM and delta sleep
Delta (slow wave sleep)          Stage 3            Moderate amt of delta wave activity; deeper sleep than stage 2
                                 Stage 4            Increased delta wave activity over stage 3; very deep sleep
REM                                                 Dream sleep; EEG is active, mimicking waking stage; depth of sleep is greater than stage 2 but probably less than delta

                EPIDEMIOLOGY                                      RISK FACTORS                                                                  CLINICAL
                                                                                           SPECIAL CLINICAL SITUATIONS
SUICIDE         In. U.S.:                                         1. Mental illness (esp. mood disorder, chronic alcoholism): depression,       Details of suicide attempt are critical to understanding the risk of a
                                                                  schizophrenia, alcoholism, personality disorders)                             future suicide (high risk if pt fully plans the attempt, use violent means,
                8th leading cause of death                        2. 1st degree relatives of people who have committed suicide                  and isolate themselves so as not to be found alive)
                                                                  3. Gay/lesbian youth=2-3x rate of attempts vs. heterosexual peers
                75/day and 25,000/yr                              4. Increasing age (men peak after age 45; women peak after 55)
                                                                  5. Elderly account for 25% of suicides, yet only 10% of population
                                                                  6. Single people
                                                                  7. Higher social classes
                                                                  8. White
                                                                  9. Certain professional groups (MDs, dentists, musicians, law
                                                                  enforcement)
                                                                  10. Low levels of 5-HIAA in CSF
                                                                  11. Hopelessness
SPOUSAL         2-12 million U.S. households                      1. Alcohol or drug abuse (>50% of abusers, many of the abused)                Reluctant to report abuse b/c:
ABUSE           1/3 of women have been beaten by husband at       2. Living in violent home where battering was witnessed or experienced        1. Fear retaliation
                least once during marriage                        (abusers and abused)                                                          2. Believe they are deserving
                Most battered women are eventually murdered by    3. Pregnant women are at elevated risk (directed toward abdomen)              3. Do not believe that help will be effective
                their spouses or boyfriends                                                                                                     4. Are intimidated, maligned, coerced, and isolated by the abuser
                                                                                                                                                5. Financial concerns
                                                                                                                                                6. Welfare of children
                                                                                                                                                7. Fear of being alone
                                                                                                                                                8. Threat of further battering

                                                                                                                                                The MSE should take into account the appropriateness of patient’s and
                                                                                                                                                partner’s reactions to an “accident”
ELDER           10% of those older than 65                                                                                                      Victims usually live w/ their assailants, who are often their children
ABUSE
                                                                                                                                                Forms of mistreatment: physical abuse, neglect, withholding of food,
                                                                                                                                                clothing, sexual molestation, emotional abuse
                                                                                                    ANTI-PSYCHOTICS

                            Therapeutic Dosage           Potency     Sedative     Hypotensive    Anti-              EPS         Other Adverse Rxns                         Notes
                            Range (mg)                                                           cholinergic
                                                                                                      Antipsychotics
Typical antipsychotics, or “Neuroleptics” (DA antagonists): Equally effective, differ in side effect profiles and potency
Thioridazine (Mellaril)    150-800                  100        High          High                High               Low         Pigmentary retinopathy at high doses       Fatal cardiac events (now approved only for
                                                                                                                                                                           refractory schizophrenia)
Chlorpromazine            200-800                   100        High         High             Med                     Low
(Thorazine)
Perphenazine              8-32                      10         Low          Low              Low                     Med
(Trilafon)
Trifluoperazine           5-20                      5          Med          Low              Low                     High
(Stelazine)
Thiothixene (Navane)      5-30                      5          Low          Low              Low                     High
Haloperidol (Haldol)      5-30                      2          Low          Low              Low                     High                                                  Available in depot IM preps (every 2-4 wks)
Fluphenazine              2-60                      2          Med          Low              Low                     High                                                  Available in depot IM preps (every 2-4 wks)
(Prolixin)
Atypical antipsychotics (DA/5HT antagonists): Less EPS; more effective for negative sxs of psychosis
Clozapine (Clozaril)      150-600                   100        High         High             High                    Very       Agranulocytosis (get weekly blood          More effective than typical antipsychotics in tx of
                                                                                                                     low        count w/ differential)                     refractory psychotic disorders
                                                                                                                                                                           Potent D4-R blocker
Quetiapine (Seroquel)       150-600                      150         High         Med             Med                Low        May increase risk of cataracts
Olanzepine (Zyprexa)        10-20                        12          Med          Low             Med                Low
Risperidone                 1-6                          1           Low          Med             Low                Low                                                   Potent D2-R blocker
(Risperdal)

Indications
           Positive psychotic symptoms (hallucinations, bizarre behavior, delusions) regardless of diagnostic category
                  o     Psychotic d/o: schizophrenia, schizophreniform, schizoaffective, delusional, brief psychotic
                  o     Mood d/o: depression w/ psychotic sxs, mania w/ psychosis, treatment-resistant mania, substance-induced mood disorder w/ psychosis)
                  o     Personality d/o: for transient psychotic sxs
                  o     Other d/o: organic brain syndromes, dementia, Tourette’s syndrome
           Less effective (w/ exception of clozapine and other atypical antipsychotics) against negative sxs of psychosis (akinesia, affective blunting, social w/d, amotivation)
MOA
Dopamine hypothesis: dopaminergic hyperactivitypsychosis
Note: antipsychotics have an initial sedative effect (esp. low potency drugs) and take several days to weeks to reach peak antipsychotic effect)
           Typical antipsychotics (DA antagonists)
                  o     DA-containing axons arising from a) VTA (ventral tegmental area) and b) substantia nigra project to
                                  Basal ganglia blockade of DA here produces extrapyramidal side effects (Parkinsonian)
                                  Frontal cortex blockade of DA here reduces psychotic sxs
                                  Limbic areas blockade of DA here reduces psychotic sxs
           Atypical antipsychotics (DA/5HT antagonists)
                  o     5HT-containing axons arise from raphe nuclei and project to same 3 regions listed above
                  o     5HT blockade conveys some protection against EPS
                  o     Nuances
                                  Risperidone: similar to neuroleptics b/c very potent D2-R blocker
                                  Clozapine: much less D2 affinity, potent blocker of D4-R (which may account for the drug’s broader therapeutic qualities)
Choosing a Medication Depends on 1) prior pt or family member response 2) side-effect profile 3) available form
Side Effects
           Anticholinergic: esp. low-potency antipsychotics; sxs include dry mouth, blurry vision, urinary retention, constipation; anticholinergic delirium; anti-ACh properties counter the EPS
           Reduced seizure threshold: low-potency typicals + clozapine; tx seizures resulting from antipsychotic tx by a) changing meds b) lowering dose c) adding antiseizure med
           Hypotension: orthostatic; esp. with low-potency agents and risperidone; d/t alpha-2 blockade
           Agranulocytosis: clozapine
           Cardiac: low-potency antipsychotics and risperidone may cause QT prolongation (and risk of torsades de pointes)
           Movement d/o: dystonia, EPS, akithisia, NMS, tardive dyskinesia
           Other: skin/ocular pigmentation, photosensitivity
                                                                                               ANTI-DEPRESSANTS

DRUG/TREATMENT                 MOA                  INDICATIONS                                        SIDE EFFECTS                                                                                  SPECIAL S.E.
SSRIS
Fluoxetine (Prozac)            Block 5HT                                                               Nausea, HA, NM restlessness, insomnia or sedation, delayed orgasm or anorgasmia
Sertraline (Zoloft)            reuptake (presyn)
Paroxetine (Paxil)                                                                                     SSRI + MAOI: fatal serotonin syndrome
Fluvoxamine (Luvox)
Citalopram (Celexa)
TCAS
Nortriptyline (Pamelor)        Block 5HT/NE                                                            Orthostatic hypotension: most common serious side effect, esp worrisome in elderly who
Imipramine (Tofranil)          reuptake (presyn)                                                       are prone to more falls
Desipramine(Norpramin)                                                                                 Anticholinergic effects
Clomipramine (Anafranil)                                                                               Cardiac toxicity (major complications are rare in pts w/ normal hearts): quinidine-like
                                                                                                       effects; avoid in pts w/ cardiac conduction dz (e.g. heart block)
                                                                                                       Sexual dysfunction
MAOIS
Tranylcypromine (Parnate)      Block MAO                                                               Tyramine crises, or hypertensive crises which can lead to MI or stroke (after ingestion of    Insomnia,
                               (catabolic presyn                                                       sympathomimetic amines, in cheese, wine, beer): amines fail to be detoxified b/c of           agitation
Phenylzine (Nardil)            enzyme)                                                                 inhibition of GI MAO system; tx tyramine crisis w/ IV phentolamine (alpha blocker) or         Daytime
                                                                                                       continuous nitroprusside infusion                                                             somnolescence
                                                                                                       Dose-related orthostatic hypotension
OTHERS
Buproprion (Wellbutrin)        Blocks DA/NE         Major depression                                   Higher than average risk for seizures compared w/ other antidepressants
                               reuptake             ADHD
Buproprion SR (Wellbutrin                           Smoking cessation
SR, Zyban)
Nefazodone (Serzone)           5HT modulating                                                          Similar to trazaodone, but less sedating
Venlafaxine (Effexor)
Mirtazapine (Remeron)          5HT/NE                                                                  Sedation
                               modulating
Trazodone (Desyrel)            5HT modulating       Adjunct to SSRI for sleep                          Sedation
                                                    Antidepressant only at high doses                  Priapism
SPECIAL TREATMENTS
Phototherapy                                        Seasonal affective d/o, delayed sleep phase        Can induce mania in susceptible individuals
                                                    syndrome, jet lag (2500-10000 lux; early morning
                                                    tx best)
ECT                                                 Oldest/most effective tx for major depression      Short-term memory loss and confusion
                                                    (refractory); some efficacy in refractory mania,
                                                    psychoses w/ prominent mood components or
                                                    catatonia

INDICATION            DRUG                                      DESCRIPTION                        SPECIAL CONSIDERATIONS           TX REGIMEN                                        OUTCOME
Major Depressive      SSRIs, buproprion (Wellbutrin),           Very low sedative, anti-           Pts w/ cardiac conduction dz,    1st episode: duration 6 months                    50% recovery w/ single adequate
                      venlafaxine (Effexor): 1st line           cholinergic, and orthostatic       constipation, glaucoma, BPH                                                        trial (at least 6 wks w/in
                                                                effects c/w TCAs/MAOIs                                              Recurrent/chronic depression: longer, perhaps     therapeutic range)
                                                                                                                                    lifelong maintenance                              Common reasons for failure:
                                                                                                                                                                                      inadequate trial length,
                                                                                                                                    Refractory depression: increase dose, add         noncompliance
                                                                                                                                    lithium or T3 (Cytomel), switch
                                                                                                                                    antidepressants, add 2nd antidepressant
                      TCAs: can be 1st line in younger,                                            Use in younger, healthier
                      healthier people (much cheaper than                                          people (cheaper)
                      SSRIs, buproprion, venlafaxine)
                        MAOIs                                        B/c of dietary restrictions and       Pts in whom SSRIs, TCAs
                                                                     risk of postural hypotension,         have failed
                                                                     used selectively                      Pts w/ concomitant seizure
                                                                                                           d/o
                                                                                                           Atypical depression, social
                                                                                                           phobia
Atypical                MAOIs, SSRIs
Depression, Social
Phobia
OCD                     SSRIs (high dose)                            Obsessions more responsive than
                        Serotonin-selective tricyclic                compulsions
                        clomipramine                                 OCD responds slower than
                                                                     depression (12 weeks)
Neuropathic Pain        TCAs
Enuresis                Impipramine

Other indications:      Mood disorders: bipolar d/o (depressed phase), depression w/ psychotic sxs, dysthymia, anxiety d/os, panic d/o
                        Others: bulimia, ADHD, cataplexy d/t narcolepsy, school phobia/separation anxiety d/o, pseudobulbar affect (pathologic laughing/weeping)

General MOA:            Major interaction is with monoamine NT system (DA, 5-HT, NE)
                                  DA: neurons originate from ventral brainstem
                                  5-HT: raphe nuclei
                                  NE: locus coeruleus


                                                                                                       MOOD STABILIZERS

DRUG                 INDICATIONS                              MOA                                                THERAPEUTIC MONITORING                   SE @ THERAPEUTIC LEVELS          SE @ TOXIC LEVELS
Lithium              Regular cycling bipolar d/o in pts       NE/5HT alteration of fxn: alters 2                 Renal fxn (check creatinine): drug is    Tremor, polyuria, GI distress,   Ataxia, coarse tremor, confusion,
                     w/ normal renal function (1st line)      intracellular 2nd messenger systems (AC/cAMP       renally excreted, and can reach toxic    minor memory loss, acne          coma, sinus arrest, death
                     Augments antidepressants in              and G-ptn coupled phosphoinositide)                levels in pts w/ altered renal fxn       exacerbation, wt gain
                     unipolar depression                      GABA metabolism interference                                                                                                 Narrow therapeutic window:
                     LESS effective in rapid cycling          Can directly alter ion channel fxn (as an ion      Thyroid fxn (TSH)                                                         watch for toxicity at prescribed
                     bipolar d/o                              itself)                                                                                                                      doses, esp if there is an abrupt
                                                                                                                                                                                           change in renal fxn
Valproate            Acute mania                              GABA: augments fxn, increases synthesis,           Liver fxn test (AST/ALT): check          Sedation, mild tremor, mild      Idiosyncratic: fatal
                     Prophylaxis against mania in bipolar     decreases breakdown, enhances post-synaptic        baseline, and frequently w/in 1st 6 mo   ataxia, GI distress              hepatotoxicity, fulminant
                     Rapid-cycling variant bipolar            efficacy                                           when idiosyncratic fatal                 Thrombocytopenia, impaired       pancreatitis, agranulocytosis
                     Mixed variant bipolar                                                                       hepatotoxicity most likely to occur      platelet fxn
                     Impulse dyscontrol
Carbamazepine        Mania (2nd line after Li, Valproate):    Bipolar illness: unknown                           Bone marrow depression                   Nausea, rash, mild leukopenia    Autonomic instability, AV block,
                     acute mania, prophylaxis of mania,       Seizure control: blocks Na+ channels in                                                                                      respiratory depression, coma
                     rapid-cycling and mixed mania            neurons that have just produced an AP,                                                                                       Idiosyncratic: agranulocytosis,
                     (more effective than Li)                 blocking neuron from repetitive firing;                                                                                      pancytopenia, aplastic anemia
                     Impulse dyscontrol                       decreases amt of NT release at presynaptic
                                                              terminals
Lamotrigine          Approved by FDA as anticonvulsant        Inhibits voltage-sensitive Na+ channels            Develop of serous allergic reactions     Ataxia, blurred vision,          Severe, potentially life-threatening
                                                              (stabilizes neuron membranes, modulates            related to rapid dose escalation or      diplopia, dizziness, N/V         rashes, that can escalate to
                                                              presynaptic excitatory NT release)                 drug interactions (esp. valproate and                                     Stevens-Johnson Syndrome
                                                                                                                 lamotrigine)
Gabapentin           Appears to lack sufficient efficacy as   Structurally related to GABA, but ha no
                     monotherapy for bipolar d/o episode      binding affinity to GABA receptor
                     prophylaxis
                     Used as adjunct to Li or valproate
                                                                                                          ANXIOLYTICS


DRUG CLASS          INDICATIONS                                     MOA                                                                                                     SIDE EFFECTS
BDZs                Anxiety                                         GABA-A receptor agonist (receptor regulates Cl- ion channel): GABA is inhibitory NT and its             Primary: sleepiness, groggy feeling
                                                                    receptor has multiple binding sites for GABA, BDZs, and barbiturates; BDZ MOA in treating               May produce disinhibition in some pts (and thus
                    Miscellaneous: akithisia induced by             psychiatric illness is augmenting GABA fxn in limbic system                                             worsen agitation)
                    neuroleptics, agitation from psychosis,                                                                                                                 Minimally depressive to respiratory system in
                    catatonia, EtOH w/d                             Effects are virtually instantaneous                                                                     healthy pts but can lead to fatal CO2 retention in pts
                                                                                                                                                                            with COPD
                                                                                                                                                                            In healthy pts, death after OD on BDZs along is rare,
                                                                                                                                                                            but does occur when BDZs are taken w/ EtOH or
                                                                                                                                                                            other CNS depressants
Buspirone           Generalized Anxiety Disorder                    5HT-1alpha receptor agonist                                                                             DOES NOT cause sedation, significant w/d
(Buspar)            Favored as tx for pts w/ history of substance   Some D2 antagonist effects                                                                              syndrome, or dependence
                    or BDZ abuse (not addictive)
                    NOT a sedative, and not useful in treating      Effects are not rapid (takes several weeks of sustained dosing)                                         Major side effects: dizziness, nervousness, nausea
                    insomnia
                    In general, lacks reliability of BDZs in
                    relieving anxiety, but is effective in some
                    people

                                                                                             Benzodiazepines: Choice of Medication

POTENCY                  RATE OF          ROUTE OF METABOLISM                                ELIMINATION ½ LIFE                                                                            ACTIVE METABOLITES
                         ONSET
Clonazepam               Fast:            Lorazepam                                          Long: toxicity can occur w/ repetitive dosing, but less likelihood of interdose symptom       LOT + clonazepam do not have active
Alprazolam               Diazepam         Oxazepam                                           rebound (clonazepam now favored over alprazolam in tx of panic b/c its longer elim ½          metabolites
Lorazepam                Flurazepam       Temazepam                                          life provides better interdose control of panic symptoms
Triazolam                Triazolam

High-potency;            Slow:            LOT do not require liver oxidation, but are        Shorter: useful for insomnia b/c less likely to produce residual daytime sedation or          All the rest do have active
used in panic d/o        Oxazepam         instead conjugated                                 grogginess                                                                                    metabolites, and thus have longer
                                          All the rest that do require oxidation are more                                                                                                  elimination half-lives
                                          likely to accumulate to toxic levels in pts w/
                                          impaired liver fxn


                                                                            BDZ                  TRADE NAME        COMMON USE IN PSYCHIATRY
                                                                            Alprazolam           Xanax             Panic, anxiety
                                                                            Chlordiazepoxide     Librium           EtOH Detox
                                                                            Clonazepam           Klonopin          Panic, anxiety
                                                                            Diazepam             Valium            Anxiety, insomnia, status epilepticus
                                                                            Flurazepam           Dalmane           Insomnia
                                                                            Lorazepam            Ativan            Anxiety, catatonia
                                                                            Oxazepam             Serax             EtOH Detox
                                                                            Temazepam            Restoril          Insomnia
                                                                            Triazolam            Halcion           Insomnia
                                                                                     MISCELLANEOUS MEDICATIONS

                            INDICATIONS                               MOA                                                                   SIDE EFFECTS
PSYCHOSTIMULANTS
Dextroamphetamine           ADHD                                      Facilitate endogenous NT release                                      Tolerance induction, psychological dependence abuse
(Dexedrine)                 Narcolepsy                                                                                                      Sympathomimetic: tachycardia, insomnia, anxiety, HTN, diaphoresis,
Methylphenidate (Ritalin)   Some forms of depression                                                                                        wt loss (bad in kids, can be good in adults)
Pemoline (Cylert)
ANTICHOLINERGICS
Benztropine                 Prophylaxis for neuroleptic-induced       CNS muscarinic antagonists                                            Peripheral: blurry vision, constipation, urinary retention
Trihexyphenidyl             movement disorders                                                                                              Central: sedation, delirium (anticholinergic toxicity is a major cause of
Diphenhydramine             Acute neuroleptic-induced dystonia                                                                              delirium, esp in pts w/ dementia and HIV encephalopathy)
                            Akathisia (try after beta blockers,
                            lorazepam)
                            Produce nonspecific sedation
                            (diphenhydramine)
BETA BLOCKERS
                            Anxiety                                   Central: diminish arousal                                             Bradycardia, hypotension, asthma exacerbation, masked hypoglycemia
                            Impulsivity                               Peripheral: reduce tachycardia, tremor, sweating, hyperventilation    in diabetics
                            Akathisia                                                                                                       Depression-like syndromes characterized by fatigue, depressed mood
                            Lithium-induced tremor
DISULFIRAM                  Prevention of EtOH ingestion              Blocks oxidation of acetaldehydebuildup of acetaldehyde toxic,      (In absence of alcohol ingestion): hepatitis, optic neuritis, impotence
(ANTABUSE)                                                            unpleasant rxn
                                                                      Use should be restricted to highly motivated pts who understand the
                                                                      consequences of drinking EtOH while taking disulfiram

CLONIDINE                   Antihypertensive (medicine)               CNS alpha2 adrenoreceptor agonist (presynaptic autoreceptor that      Sedation, dizziness, hypotension
                            Decrease ANS sxs a/w opiate w/d           inhibits release of CNS NE)
                            Tourette’s syndrome
                            Impulsiveness, behavioral dyscontrol
COGNITIVE ENHANCERS
Donepezil (Aricept)         Enhance cognition in mild-moderate        Reversible inhibitors of AChEase; raise synaptic [ACh] in remaining   GI upset, bradycardia, increased gastric acid secretion, urinary retention
Tacrine (Cognex)            dementia of Alzheimer’s type              cholinergic neurons
                                                                      Initially reduce cognitive impairment, but effect wanes with the      Increased serum transaminases (Tacrine)
                                                                      progressive loss of cholinergic neurons
THYROID HORMONE
T4                          Augment effects of antidepressants in     Altered HPA axis functioning occurs in depressed individuals; this    At low doses: minimal
                            refractory depression                     hormone can correct it                                                If dose overreplacement: hyperthyroidism
                            Adjuncts in tx of rapid-cycling bipolar
                            (T4 + Lithium)
                                                                                    MAJOR ADVERSE DRUG REACTIONS

DISORDER                 DEFINITION                                                                  RISK FACTORS                                       ONSET                    TREATMENT
NEUROLEPTIC-INDUCED MOVEMENT DISORDERS
Dystonia                 Muscle spasms commonly involving musculature of head and neck,              High-potency antipsychotics                        First few days of        IM/IV benztropine or
                         sometimes extremities                                                       Young men                                          therapy                  diphenhydramine
                         Sxs range from mild subjective sensation of increased muscle tension to                                                                                 Severe laryngospasm may require
                         life-threatening syndrome of severe muscle tetany and laryngeal                                                                                         intubation
                         dystonia (laryngospasm) w/ airway compromise
                         Spasms may lead to abnormal posturing of head/neck with jaw muscle
                         spasm
                         Spasm of tongue macroglossia and dysarthria
                         Pharyngeal dystonia may produce impaired swallowing and drooling
Akithisia                Subjective sensation of inner restlessness, strong desire to move one’s     Recent increase/onset of medication dosing (can    First month of therapy   Beta blockers (propranolol)
                         body, may appear anxious or agitated, may pace or move about, unable        also be caused by SSRIs)                                                    BDZs (lorazepam)
                         to sit still                                                                                                                                            Maybe anticholinergics
                         Can produce severe dysphoria and anxiety, may drive pts to become                                                                                       Reduce antipsychotic dose (if
                         assaultive or attempt suicide                                                                                                                           possible)
EPS (Neuroleptic-        Rigidity: “lead pipe” in which rigidity present continuously throughout     High-potency antipsychotics (½ of pts receiving    First few wks of         Anticholinergic
Induced Parkinsonianism) passive ROM of an extremity, or “cogwheel” in which rigidity has a          long-term neuroleptic therapy)                     therapy                  Lower antipsychotic dosage or
                         catch-and-release character                                                 Elderly                                                                     change to lower-potency drug
                         Akinesia, bradykinesia: decreased spontaneous movement, maybe               Prior episode of EPS
                         accompanied w/ drooling
                         Tremor: 3-6 Hz tremor of head and face muscles or limbs
NMS                      Idiosyncratic, potentially life-threatening                                 High-dose antipsychotics                           Usually w/in first few   Discontinue antipsychotic med
                         Sxs may develop gradually over period of hrs-days and can often             Rapid dose escalation                              wks                      Supportive sx management
                         overlap w/ sxs of general medical or psychiatric illness                    IM injection of antipsychotics                     Can occur at any pt in   Dantrolene (muscle relaxant): tx
                         Autonomic: tachycardia and other cardiac arrhthmias, labile BP (HTN         Agitation, dehydration                             antipsychotic therapy    rigidity and myonecrosis
                         and hypotension), diaphoresis, fever progressing to hyperthermia            Prior episode of NMS                                                        Bromocriptine (DA agonist):
                         Motor: rigidity/dystonia, akinesia, mutism, dysphagia                                                                                                   reverses DA-blocking effects of
                         Behavioral: agitation, incontinence, delirium, seizures, coma                                                                                           antipsychotics
                         Laboratory: increased creatinine kinase (secondary to myonecrosis                                                                                       May require intensive care (cardiac
                         from sustained muscular rigidity), abnormal liver fxn tests, increased                                                                                  monitoring and intubation)
                         WBC count
Tardive Dyskinesia       Constant, involuntary, stereotyped choreoathetoid movements most            Elderly                                            Usually after years of   Lower dosage of antipsychotic
                         frequently confined to head and neck musculature                            Long-term antipsychotic tx                         tx                       Change antipsychotic
                         Reversible in some cases, but tends to be permanent                         Female                                                                      Change to clozaril
                                                                                                     African-American
                                                                                                     Mood Disorders
SEROTONIN SYNDROME
SS                          Can be life-threatening and end in coma and death                        Combining MAOIs with other serotonin-altering                               Largely supportive, may require
                            Autonomic: tachycardia, HTN, diaphoresis, fever progressing to           drugs                                                                       ICU w/ cardiac monitoring and
                            hyperthermia                                                             A similar syndrome occurs when MAOIs used w/                                intubation
                            Motor: shivering, myoclonus, tremor, hyperreflexia, oculomotor           meperidine or dextromethorophan, and perhaps                                Offending meds should be d/c
                            abnormalities                                                            other opiates
                            Behavioral: restlessness, agitation, delirium, coma

NMS v. Serotonin Syndrome
        NMS: muscular rigidity and increased creatine kinase are prominent findings
        SS: develops in response to use of multiple medications that affect serotonin function (especially MAOIs) whereas NMS develops in response to antipsychotic meds
                                                                            PSYCHOLOGICAL THEORIES

THEORY                         DESCRIPTION                                                   MISCELLANEOUS COMPONENTS OF THEORY
PSYCHOANALYTIC/PSYCHODYNAMIC   Unconscious motivations and early developmental influences are essential to understanding behavior. 3 20 th century schools of psychodynamic psychology are:
THEORY (FREUD)
Drive Psychology               Infants have sexual and other drives, and advance               Developmental Stages:
                               sequentially through psychosexual developmental stages          Oral
                                                                                               Anal
                                                                                               Phallic
                                                                                               Latency
                                                                                               Genital
Ego Psychology                 Id, ego, superego; major fxn of ego is reduction of anxiety;    Ego Defense Mechanisms:
                               ego defenses are psychic mechanisms that protect ego from       Feelings or ideas that are distressing to the ego are…
                               anxiety                                                         Denial: blocked by refusing to recognize evidence for their existence
                                                                                               Projection: attributed to others
                                                                                               Regression: reduced by behavioral return to an earlier development phase
                                                                                               Repression: relegated to the unconscious
                                                                                               Reaction formation: converted into their opposites
                                                                                               Displacement: redirected to a substitute that evokes a less intense emotional response
                                                                                               Rationalization: dealt with by creating an acceptable alternative explanation
                                                                                               Suppression: not dealt with, but remain components of conscious awareness
                                                                                               Sublimation: converted to those that are more acceptable
Object Relations Theory        Objects refer to important people in one’s life
OTHER THEORIES
Erikson’s Life Cycle Theory    Psychosocial events drive change, leading to a                  Life Cycle Stages:
                               developmental crisis                                            Trust v. mistrust (birth to 18 mo)
                               Each stage presents core conflicts produced by the              Autonomy v. shame (18 mo to 3 yrs)
                               interaction of developmental possibility with the external      Initiative v. guilt (3-5 yrs)
                               world                                                           Industry v. inferiority (5-13 yrs)
                               Individual progress and associated ego development occur        Identity v. role confusion (13-21 yrs)
                               with successful resolution of the developmental crisis          Intimacy v. isolation (21-40 yrs)
                               inherent in each stage                                          Generativity v. stagnation (40-60 yrs)
                                                                                               Ego integrity v. despair (60 yrs to death)
Cognitive Theory               Subjective experience of oneself, others, and the world         Cognitive Distortion is a principle type of irrational belief. Types:
                               Irrational beliefs about oneself, the world, and one’s future   Arbitrary Inference: drawing a specific conclusion w/o sufficient evidence
                               can lead to psychopathology                                     Dichotomous thinking: tendency to categorize experience as “all or none”
                                                                                               Overgeneralization: forming and applying a general conclusion based on an isolated event
                                                                                               Magnification/minimization: over- or under-valuing the significance of a particular event
Behavioral Theory              Behaviors are fashioned through various forms of learning,      Modeling: form of learning based on observing others and imitating their actions and responses
                               including modeling, classical conditioning, and operant         Classical Conditioning: form of learning in which a neutral stimulus is repetitively paired with a natural
                               conditioning                                                    stimulus, with the result that the previously neutral stimulus alone becomes capable of eliciting the same
                                                                                               response as the natural stimulus
                                                                                               Operant Conditioning: form of learning in which environmental events (contingencies) influence the
                                                                                               acquisition of new behaviors or the extinction of existing behaviors
                                                                                                     LEGAL ISSUES

MALPRACTICE                                                                   INFORMED CONSENT                 INVOLUNTARY COMMITMENT              TARASOFF: DUTY TO WARN /PROTECT              M’NAGHTEN RULE:
                                                                                                                                                                                                INSANITY DEFENSE
Requires presence of 4 elements:                                              3 components:                    Judicially supported actions that   Tarasoff I (1976, California): therapists    A person is not held
      1. Negligence                                                                 1. Information             require persons to be               have duty to warn the potential victims      responsible for a criminal
      2. Duty                                                                       2. Voluntary consent       hospitalized or treated against     of their pts                                 act IF at the time the act was
      3. Direct Causation                                                           3. Competence              their will                          Tarasoff II: therapists have duty to take    performed, he/she suffered
      4. Damages                                                              Exceptions: true emergencies,    Criteria: evidence that pt is       reasonable steps to protect potential        from mental illness or MR
Negligence of duty that directly causes damages                               in which treatments necessary    danger to self or others or         victims of their pts (i.e. take reasonable   AND did not understand the
Claims in psychiatry typically involve suicides of pts in tx, misdiagnosis,   to stabilize a pt can be given   unable to care for himself;         action to protect a 3rd party if pt has      nature of the act OR realize
med complications, false imprisonment (involuntary hospitalization or         w/o informed consent             diagnosis of mental d/o often       specifically identified the 3rd part and a   that it was wrong
seclusion), and sexual relations w/ pts                                                                        must also be present (mental d/o    risk of serious harm seems imminent
                                                                                                               + danger)

				
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