CATEGORY

A.) Mental d/s of infancy &

adolescents

DISORDER/DISEASE

PRIMARY TREATMENT (CATEGORY)

Peeing clothes or bed-wetting (intentional or not), day or night.

1. [course] Occurs 2/week
2. [duration] for 3 consecutive months OR marked social/academic dysfunction
(SAD)
3. [age of onset] 5 years old developmentally
Not due to a substance (e.g., diuretic) or another medical condition (e.g., urinary
tract infection, neurogenic bladder, diabetes)
Nocturnal: nighttime.
Diurnal: waking hours.
Both
1. inappropriate defecation
2. [course] episode 1/per month
3. [duration] for minimum 3 months
4. [age of onset] 4 years old developmentally
Not due to

CBT >& Rx
The majority of enuresis cases spontaneously remit (510% per year) by
adolescence.
1st- Psychoeducation is key for children and their primary caregivers. ParentManagement-Training (PMT).
i.e., Limit fluids, behavioral program with rewards or urine alarm or bell and
pad
2nd- Pharm: 1st-line is Desmopressin (DDAVP), Imipramine (TCA) at low doses for
refractory cases (2nd line).

Key to accurate diagnosis is AGE OF ONSET (DSM-5).

Enuresis

Encopresis

B.) Substance Use Disorder

(S.U.D)

DSM-5 CRITERIA & DIAGNOSTIC FEATURES

CBT, symptomatic relief

1st- Psychoeducation is key for children and their primary caregivers. ParentManagement-Training (PMT). bowel-retraining toileting routine behavioral
program
2nd- if due to constipation and release, initial Tx should include stool softeners,
diet high in fiber,

DSM5 Criteria gives the same diagnosis (SUD) regardless of the substance:- [(2/11 Signs) / for less than 12 months]
1.
Toleranceneed more to achieve same effect
2.
Withdrawal
3.
Using more
4.
Desire or unsuccessful cut downs
5.
Significant time spent obtaining, using, or recovering
6.
Reduced activities (social, occupational, or recreational )
7.
Continued despite physical &/or psychological problem/disease/disorder
8.
Craving
9.
Use in dangerous situations
10. Failed obligations at work, school, or home
11. interpersonal conflicts related to substance use
Alcohol Use Disorder
- MEN: 5+ drinks per day (BAC 0.08g/dL) or 15+ drinks per week, AUDITsc of 4 or more
- WOMEN: 4+ drinks per day (BAC 0.08g/dL) or 7+ drinks per week, AUDITsc of 3 or more
- Recent prolonged drinking: (AST:ALT ratio = 2:1), (increased GGT), (Increased MCV)
(+) DSM5 Criteria.
Alcohol Withdrawal
Cocaine Use Disorder

(+) DSM5 Criteria.

Intoxication/OD Tx: reassurance, agitation give BNZ (diazepam), cardiovascular give Nitroglycerin or if with chest pain Phentolamine (-a1), cooling for hyperthermia, and if
cocaine induced psychosis give haloperidol.
Tx for C.U.D: Contingency management and CBT, AA, NA, etc.
No Rx is FDA approved, but off-label use includes:
- Off-label Dopamine agonists: dextroamphetamine , methylphenidate, and amantadine in severe withdrawal (direct dopamine agnosit)
- Disulfiram: to prevent relapse. MoA is that it inhibits dopamine-beta hydroxylase and raises dopamine levels. Which are depleted in cocaine users. Good Tx for comorbid
alcohol use.
Withdrawal Tx: never give Rx (SSRI etc) for cocaine withdrawal depression, its short lived, whereas SSRIs take too long to have an effect. Amantadine for severe
withdrawal may be used.

Sedative-Hypnotics
Barbiturates Phenobarbital,
pentobarbital, thiopental,
secobarbital.

(+) DSM5 Criteria. Include BDZs and Barbiturates

Intoxication: Confusions, ataxia, nystagmus, *hypotension. Barbiturates higher risk of respiratory depression, delirium, death. Alcohol, benzodiazepines, and barbiturates
are associated with REM sleep and delta wave sleep.
Intoxication/OD Tx: Maintain airway, circulation, and monitor vitals.

Benzodiazepines Diazepam,
lorazepam, triazolam,
temazepam, oxazepam,
midazolam, chlordiazepoxide,
alprazolam.
Opioid Use Disorder

A. BDZ: Flumazenil for OD, but watch for seizures

B. Barbiturate OD: sodium bicarbonate to alkalinize urine (promote renal clearance)

Wernicke encephalopathy

Reversible condition caused by a lack of vitamin B1.

Common in 1. Alcoholism, 2. Malabsorption syndromes (or bariatric surgery),
Wernicke problems come in a CAN of beer: Confusion, Ataxia, Nystagmus.
***If you give an alcoholic food (glucose) prior to thiamine, you will induce Wernickes
Encephalopathy bc the body can not process the glucose without its coenzyme. Give
Thiamine before food/glucose
Anterograde amnesia and confabulation.

Korsakoff syndrome
C.) Schizophrenia & Psychotic
d/s

Psychotic d/s due to Another Medical

Condition

Substance/Medication Induced
Psychotic Disorder
Schizophrenia

Tardive dyskinesia (TD)

Withdrawal: abrupt abstinence after chronic use can be life threatening. Like etoh withdrawal. Tonic-Clonic Seizures and death

1. hallucinations OR delusions
2. symptoms not occurring exclusively during delirium
3. Case hx WITH any evidence suggestive of a medical etiology via *labs, H&P,
imaging.
Etiologies: CNS diseases (NDDs, MS, cancer, epilepsy, encephalitis, HIV),
endocrine disease, vitamin deficiency (B12, folate, niacin), rheumatologic,
porphyria.
1. hallucinations OR delusions
2. symptoms not occurring exclusively during delirium
3. Case hx/labs supporting a substance/rx etiology,
4. doesn't better fit with a psychotic d/s diagnosis
1. [presentation] Must have episode of min 2 symptoms that are present at least 1
month, 1 Sx must be (+) either delusions, hallucinations, or disorganized speech.
May also be Must be in combination with catatonic behavior, negative symptoms
[5 As of schizophrenias negative sx: anhedonia (inability to feel pleasure), affect
flat, alogia, avolition/apathy, attention poor]
2. Must cause SSOD (social, self, and/or occupational dysfunction.
3. Duration of minimum 6 months of Sx (including milder Sx prodromal or residual
stages).
4. Psychosis Sx not due to substances or medical etiology
Note: Intact orientation!
delayed onset, usually after prolonged use of dopamine receptor blocking agents,
mainly the antipsychotic drugs (also called neuroleptics) and the antiemetic drug
metoclopramide.
-High potency typical antipsychotics have higher EPS risk

Treat the underlying etiology first and formost. r/o medication induced psychosis
(from the history).

1. Workup: TSH, RPR, imaging, etc

-reexamining the need for continued treatment at least every six months.
-After remission of a first acute psychotic episode, the dose of antipsychotic
drug should at least be decreased, and probably best discontinued, within 6
to 12 months
-"Where possible, antipsychotic drugs should be tapered and discontinued as
soon as the diagnosis of TD is made, although control of the patient's psychosis
may ultimately be the most critical factor in the use of the offending drug.
-For patients who are developing signs of TD while receiving first generation
(conventional) antipsychotic drugs, but still require treatment for psychosis, it is
now considered prudent to switch to second generation (atypical)
antipsychotic drugs that may be associated with a lower risk
The Abnormal Involuntary Movement Scale (AIMS) can be used to quantifyand
monitor for tardive dyskinesia

EPS

Onset of Antipsychotic side effects

NMS: Any time (but usually early in treatment)
Acute dystonia: Hours to days
Parkinsonism/Akathisia: Days to weeks

TD: Months to years

The Abnormal Involuntary Movement
Scale (AIMS) can be used to quantify
and monitor for tardive dyskinesia
D.) Mood Disorders

E. Anxiety d/s

General:
- required: r/o medical or drug/medicine related Mood d/s (by either evidence in exam/labs or hx drug change or abuse)
- episodes versus diagnosis
- chronic, with normal periods between episodes
Substance/Medication Induced Mood d/s
Must be ruled out before making other primary psychiatric diagnoses. Look for recent drug change as the most prominent feature
i. Depressive type
in history, and note DS5 requires it be excluded as the diagnosis.
ii. Bipolar Manic type
i. (depressive) Etoh, Antihypertensive (propranolol), corticosteroids, levodopa, diuretics, antipsychotics, anticonvulsants,
stimulant withdrawal, sulfonamides, sedatives.
ii. (manic) Antidepressants, sympathomimetic, dopamine, corticosteroids, levodopa, cocaine, amphetamine, bronchodilators
Mood disorder due to medical condition
i. (depressive) cerebrovascular, endocrinopathies, cancer (lymphoma, pancreatic), viral mononucleosis, carcinoid syndrome,
i. Depressive type
autoimmune
ii. Bipolar Manic type
ii. (manic) hyperthyroidism, neurologic (temporal lobe seizures; multiple sclerosis; cancer, HIV, infx)

i. Identify
ii. Tx titrate or alter medication
OR Tx underlying illness
Identify
Tx underlying etiology

General:
- Most common psychopathology (lifetime prevalence of 30% in women; 19% in men).
- DCx1: r/o anxiety due to Substance/Medication (see above) or medical condition (see above)
- DCx2: requires (SOD) Social or Occupational Dysfunction or (SAD) Social Academic Dysfunction.
- attacks versus disorder
- Late onset anxiety, think medical condition or substance.
- Categories: A) Anxiety d/s B) Obsessive Compulsive related d/s C) Trauma & Stress related d/s D) Somatic/Conversion/Malingering
Substance/Medication Induced Mood d/s
See above in Mood category
Medications: etoh, sedatives, cannabis, hallucinogens, stimulants, caffeine, tobacco, opiods
Anxiety Sx due to medical condition
Conditions that cause anxiety:
Neurologic (epilepsy, tumors, migraines, MS, HD), endocrinopathies, metabolic d/s, porphyria, Vit B12 def, pulmonary d/s (asthma, COPD, PE, pneumonia,
pneumothorax), cardio d/s (CHF, angina, arrhythmia, MI)

Phobia
Social Anxiety Disorder
(Social Phobia)
(Performance Anxiety)

Adjustment d/s

OCD

Phobias are the most common psychiatric disorder in women and second most
common in men (substance-related is first)
Fear of scrutiny. Phobic stimulus is related to social scrutiny and
negative evaluation.
1. excessive fear, out of proportion to specific trigger/stimulus
2. Fear response with exposure
SAxD occurs equally in men and women.

CBT. Specific Phobia

Focus on onset within 3 months of an identifiable stressor. Duration shouldn't

be longer than 6 months, i.e., symptoms resolve within 6 months (you SHOULD
diagnose if the duration of Sx is less than 6months, unless specific stressors
remain chronic).

Tx
1st line: Supportive therapy, Group therapy as mono-therapy.

COMBINATION Tx
CBT + SSRI, SNRI (1st line)
-For Performance specific Social Anxiety, use Beta-Blockers (propranolol) as 1 st
line.
-BNZ as bridge

Supportive PsychoPharm for symptom alleviation if necessary.

COMBINATION TX
Utilize combination pharmacology and CBT:
- CBT focuses on exposure and response prevention: prolonged, graded
exposure to ritual-eliciting stimulus and prevention of the relieving
compulsion
First-line medication: SSRIs (e.g., sertraline, fluoxetine), typically at
higher doses
Can also use the most serotonin selective TCA, Clomipramine
Can augment with atypical antipsychotics
Last resort: In treatment-resistant, severely debilitating cases, can use

psychosurgery (cingulotomy) or electroconvulsive therapy (ECT)

(especially
if comorbid depression is present).
1st line: CBT (exposure response prevetion) & SSRI at high dose, or
Clomipramine TCA (highly serotonin selective TCA).
2nd line for refractory OCD or OCD+Depression is surgery (cingulotomy) or ECT
CBT >> SSRIs wt c/m OCD but

Hoarding
Trichotillomia

F.

Somatic Symptom Disorder

Conversion Disorder

G. (other disorders)

Combination Therapy [CBT>Rx]

CBT
-SSRIs
-AAntupsychotics (olanzapine)
-N-acetylcysteine
1. one or more symptoms causing distress over a long period
2. compensatory behaviors (multiple labs, hospitalizations, etc) or
2. concern is expressed, chronic thoughts/feelings =
3. [duration] minimum 6 months. Usually chronic course
1. ABRUPT onset of (neurological) symptoms! Motor or sensory
2. unconcerned with symptoms
3. may have underlying disease process, but neuro-symptom not compatible
with diagnosis and overblown.

Regularly scheduled apts with PCP

1. low body weight (BMI<18.5)

2. Fear of gaining weight or persistent behaviors to avoid weight gain
3. Disturbed body image (denial, misinterpretation)
1. Recurrent binge eating and compensatory behaviors (laxatives, vomiting,
exercise).
2. [duration] min 1binge-compensate/week for 3 mo.
When malnurished patients are refed too quickly:
- decreased phosphorous [<3mg/dl], ,magnesium [<1.5mEq/L], and calcium
[<8.4mg/dl].
-fluid retention
1. Recurrent Binge Eating without compensatory (wt out reduction) behaviors
but with guilty Sx
2. [duration] once a week for three months

1st-Line: CBT, family therapy, supervised weight-gain programs. NO

PSYCHOPHARM has been deemed effective. But, if comorbid disorder exitsts,
then treating it as well is fine.
1st-Line: CBT + SSRI (fluoxetine)
CBT+interpersonal, group, and family
-avoid buproprion (seizures)
Replace electrolytes and slow feeding

CBT wt physical therapy to aid recovery.

-Eating Disorders
Anorexia nervosa
Bulimia nervosa
-Refeeding Syndrome

Binge Eating Disorder

1st-Line: CBT/Interpersonal-psychotherapy and Strict Diet and Exercise program

2nd-Line: maybe use (stimulant, phentermine or amphetamine as appetite
suppresant) or (antiepileptics, topiramate/zonisimide associated weight loss).

-Dissociative Disorders
Dissociative Amnesia
Depersonalization/Derealization Disorder
Dissociative Identity Disorder
(Multiple Personality Disorder)
Other Specified Dissociative Disorder

-Impulse Control Disorders

Intermittent Explosive Disorder

Verbal and/or physical aggression with:

Either
A) without physical damage to person or property: 2per week, for 3 months
B) with physical damage to person or property, episodes (3/year)
1. out of proportion to the trigger
2. Not premeditated, due to medical/drug, or better explained by other

Combination:
CBT + Group/Family Therapy + SSRIS/anticonvulsants/lithium

Kleptomania

Pyromania

H. Disease of Nervous System

and Special Senses

diagnosis.
+ Diagnosis Confirmed by low serotonin 5-HIAA in CSF.
+ Have a history child abuse, head trauma, seizures.
1. Stealing of objects with no monetary value
2. Tension before, & pleasure relief DURING theft, with GUILT after
-3:1 Women > Men
-Comorbid with Bulimia (hence similar Tx)
1. Min (2+) fires started
2. Tension before & pleasure relief after
-Chronic, waxing frequency
-Men >women

Combination: CBT (Systematic Desensitization or Aversive Conditioning) + SSRIs.

-2nd line naltrexone
CBT, SSRI, Mood Rx, Antipsychotics, etc.

Seizures
Headaches
Neurodegenerative disorders
Acute Intermittent Porphyria

Barbiturates (i.e., phenobarbital, pentobarbital, thiopental, secobarbital: which

facilitate GABA action by increasing duration of Cl channel opening, thus
decreasing neuron firing) contraindicated in porphyria for p450.
1. Bed alarms CBT
2. DDAVP &/or
3. Imipramine [TCA, 5HT&NE -reuptake]
1. Stop antipsychotic!!!!
2. Cooling and IV fluids, alkaline for renal failure rhabdo
3. Dantrolene: Muscle relaxant for the muscle rigidity
4. Bromocriptine: Dopamine agonists to revers D2antagonism
No Rx, just supportive therapy.s

Enuresis
NMS

SS
Delirium

Problem of ATTENTION whereas dementias are a problem of memory.

Catatonia specifier

Seen in schizophrenia, MDD, and Bipolar disorder