"Amphetamine intoxication presents with 1) prominent psychiatric symptoms such as

agitation, irritability, "

"Lithium toxicity = LMNOP - Heart Movement (tremor) Nephrotoxicity(nephrogenic

diabetes insipidus, interstital nephritis), hypOthyroidism(hyperparathyroidism),
Pregnacy (Ebstein Anomaly) and Heart (can cause arrhythmias so contraindicated in
patients with cardiac disease) "
"The baseline labs you should get before prescribing Lithium are: 1)KIDNEY LABS:
BUN, Cr, Ca2+, urinalysis 2) Thyroid function tests 3) ECG "
Lithium is used both as maintenance therapy for Bipolar disorder AND to treat ACUTE
mania.
"Drug levels of Lithium should be checked every 6-12 months and after 5-7 days when
a DOSE CHANGE occurs or patient takes a drug that interacts with Lithium ie
diuretics, ACE, NSAIDS"
Atypical antipsychotics can predipose patients to lipid or glucose abnormalities ie
OBESITY

"When answering any ethical question, in order for the answer to be correct it MUST
ACKNOWLEDGE the patient's emotions W/O saying anything OFFENSIVE or JUDGEMENTAL"
"Alcohol intoxication causes NAAJing. Nystagmus, Ataxia, Aggression, Impaired
judgement. "
"Marijuana (Cannabis) intoxication presents with 1) conjunctival injection
(bloodshot eyes), 2) dry mouth 3) tachycardia 4) Increased appetite 5) paranoia or
anxiety (socialwithdrawn) 6) psychomotor impairment with slow reaction time "
Your PEERs smoke weed. Paranoia/anxiety Euphoria/Relaxation Eating Red eyes
Slow reflexes/reactime time
"PCP (Phenycyclidine) presents with 1) Violent behavior 2) Dissociation 3)
Hallucinations 4) Amnesia, 5) Nystagmus (horizontal or vertical) 6) Ataxia " "While
on PCP, you are so High (Hallucinations) you can lift a VAN (Violent behavior
Amnesia Aggression Acute psychosis Nystagmus) "
"LSD presents 1) Visual hallucinations 2) Euphoria 3) Dysphoria/panic 4)
Tachycardia/HTN and subjective perceptual intensificaiton(colors are richer, tastes
are heightened sensation is enhanced), depersonalization" LSD makes you VED
flashbacks --> Visual hallucinations Euphoria Dysphoria/panic
Cocaine presents with 1) Mydriasis 2) Agitation/psychosis 3) Tachycardia/HTN 4)
Euphoria 5) Seizures. You can become both MANIC and PSYCHOTIC on coccaine. "You
smoke Cocacine with your MATES - Chest pain, Mydriasis Agitation/Psychosis
Tachycardia/HTN Euphoria Seizures"
Methamphetamine presents with 1) Violent behavior 2) Psychosis 3) Diaphoresis 4)
Euphoria 5) Choreiform movements 6) Tachycardia/HTN 7) Tooth Decay MATES +
Tooth decay + Skin picking/marks
"Heroin presents with 1) Euphoria 2) Depressed mental status (drowsiness) 3)
Miosis, 4) Respiratory depression 5) Constipation " Opioids present with ARMED
Chinese man - Analgesia Respiratory depression Miosis Euphoria Drowsiness
Constipation
"Opioid withdrawal causes lacrimation, pupillary dilation, yawning, diaphoresis
(cold turkey), and GI probs: diarrhea, n/v"
"Ectasy (MDMA) intoxication presents with euphoria, sociability, empathy, and
sexual dessire + hyponatremia from drinking more water and sweating. "
"Whenever there is a suspicioin that a Schizophrenic patient or any other patient
is going to harm themselves or others you HAVE TO ADMIT them, involuntarily if
necessary! Any other answer choice as offering them antipsychotics med on an
outpatient service or ""asking the patient to go to the ED"" is wrong and
irresponsible. This person is psychotic and cannot be trusted to do anything. "
"Acute psychotic patients should be assessed for suicidal/homicidal ideation,
command hallucinations to hurt themselvese or others, and the ability to care for
themselves. "
"The definition of normal aging is a SLIGHT decrease in fluid intelligence eg the
ability to process new information quickly, and changes such as occasional
forgetfullness, word-finding difficulty, and changes in sleep pattern (sleep
earlier wake up earlier) BUT they are NORMAL functoning in all activities of
daily living. Dementia or Major Neurocognitive disorder is 1) Significant decline
in 1 or more cognitive areas 2) Irreversible global impairment 3) MARKED FUNCTIONAL
impairment 4) Chronic and progressive over months to years. Major depression is
defined as reversible mild-moderate cognitive impairment, features of depression
(mood, interest, energy), and episodic over weeks to months. "

"Sleep terrors are a type of parasomia where 1) a child has disturbances in sleep
during NON-REM sleep (Stages 3-4) and wakes up and YELLS, SCREAMS, GETS OUT of bed
2) EVEN AFTER WAKING UP, they remain INCONSOLABLE/UNRESPONSIVE and CANNOT be fully
awakened 3) OFTEN have no MEMORY of the incident. Sleep terrors usually occur in
children age 2-12 and resolve spontaneously as the child ages. "

" Catatonic: psychomotor retardation, posturing, resisting movements "

You treat Catatonia with 1) Lorazepam or ECT as first-line.This guy is Catatonic:
let him a BE -> Benzodiazepine or ECT
"to have a diagnosis of normal aging in a patient they have to still be able to
function INDEPENDENTLY. Might get a little slow, and memory worses but they can
still live alone. "
Binswanger disease is a subcortical arteriosclerotic encephalopathy characterized
by multiple small infarcts I nthe white matter that spares the cortical regions.
"Being dependent on a substance is defined as the ""inbility to quit drinking
regardless of a desire to quit or knowledge of the negative aspects of drinking.
Substance dependence is NOT defined by how much of the substance the patient
consumes and the patient does not need to have physiologic dependence "
Histrionic center around superifical seductiveness and theatricality.
"For Boderline personality watch for ""perceived abandomenet ie resident leaving oh
he's horrible"
"Treat Borderline personliaty with individual psychotherapy, specifically
Dialectical Behavioral therapy (DBT) which focuses on mindfulness and distress
tolerance. (CBT focuses on dysfunctional thoughts and their behavioral and
emotional manifestations. "
"With medication refractory depression of depression with psychotic features, ECT
is a good option. One of the most common side effects of ECT is amnesia. "
"For catatonic condtions, 2-4 ECT treatments are effective. For Major depression,
6-12 treatments of ECT are effective. For mania or psychosis can use 20 or more ECT
treatments. "
"Impulse control disorder, not otherwise specified, is appropriate for patients
with the acting of impulses that are not as ego-dystonic (disturbing) as in this
case, and that do not have an obsessional, non-enacted (thinking) component"
"In cases of delirium with very severe agitation, phenobarbital may be used."
"Sexual masochism is where patients are aroused by psychologically or physically
punishing acts by another person (or fantasies of punishment). Sexual sadism, the
patient is aroused by giving such punishment (or fantasies of giving it) to others.
Fetishism is sexual arousal connected to nonliving objects. Frotteruism- the
patient is sexually aroused by touching or rubbing against a nonconsenting person.
" "Masochist - tries to be a ""man"" and takes the pain. The Sadist is ""sick
and likes to make people sad"" so he dishes out the pain. "
"Narcolepsy is a disorder of REM sleep in which there is not enough hypocretin
(orexin). It results in excessive daytime sleepiness, cataplexy: sudden loss of
motor tone with strong emotions, hypnopompic or hypnogogic hallucinations, and
sleep paralysis. Circadian rhythm sleep disorder is a disorder caused by changing
such sleep schedules such as during jet-lag or night shift work. Dyssomia is a
sleep disturbance of unknown cause related to environmental disturbances that
results in prolonged sleep deprivation eg RESTLESS LEG syndrome. Nightmare
disoder is when a patient does not have a mental illness(NO PTSD) but continues to
experience repeated nightmares that cause distress. Primary hypersomnia is
excessive daytime drowsiness or hours that are not accounted for during the night.
"
"PMDD causes extreme mood shifts that can disrupt your work and damage your
relationships. In PMDD, however, at least one of these emotional and behavioral
symptoms stands out: Sadness or hopelessness, Anxiety or tension, Extreme
moodiness, Marked irritability or anger"
Acetylcystien is used for acetaminophen overdose. Deferoxamine is used in iron
overodse.
EMDR (Eye movement densensitization and reprocessing) is a specific therapy that
has been developed for PTSD. Insight-oriented therapy is a long-term dynamic
therapy. Interpersonal therapy addresses relationships as a contributor of
depression and is used to treat individuals with major depression

"Factitious disorder is sometimes referred to as Munchausen syndrome is when a a

patient who is feigning or producing symptoms of an illness to gain gratification
by assuming the sick role. In Munchausen by proxy is when caretakers intentionally
cause illness in their charges, such as children. Conversion disorder is when
patients present with neurologic symptoms that are not physiologic.
Hypochondriasis is when a patient beleives that he or she has some particular
medical diagnosis even though they have been told/received reassurance that they do
not. The worry about having the diagnosis causes distress. In Malingering, a
patient fakes having an illness or condition in order for a secondary gain (ie free
housing, missing work, disability benefits etc - they gave benefits that are
EXTERNAL not INTERNAL like in Munchausen. Somatization is when a patient has a
cluster of subjective symptoms over time affecting multiple organ sysytems or
anatomic parts that do not correlate to any specific diagnosis. "
Patients with factitious disorder have an unconscious desire to assume the sick
role. Their symptom production is fully conscious.
"Adjustment disorders can present following an identifiable stressor and may
manifest with mild mood,
anxiety, or behavioral disturbances, but not overt mania"
"Left MCA strokes cause depression while Right ACA strokes cause euphoria , mania,
or apathy. "
High dose steroids can induce mood disturbances and psychosis in patients. Watch
out for the MS patient who develops acute psyhcosis with treatment. MS does NOT
cause psychosis.
"For males 30-50, 90% of cases of impotence is caused by psychological reasons. At
age 50+ meds, diabetes, HTN, and alcoholism play a more important role in causing
impotence. "
"Signs of Schizophrenia include soft neurologic signs such as short-term memory
deficits, unstable smooth-pursuit eye movements, and decreased ability to habituate
to repeated sensory stimuli (sensory gating abnormalities). In addition, patients
with schizophrenia have difficulty in conceptualizing complex visual compositions.
"

"An idea of reference is when the patient interprets an event as relating to him,
even though it clearly does not. A hallucination is a perception in the absence of
a clearly defined stimulus, whereas an illusion is a misinterpretation of an
evident stimulus (for instance, IV tubing appearing like snakes). Thought
broadcasting is a delusional belief that one?s thoughts can be heard or somehow
known by others without direct communication. Thought insertion is another delusion
where the patient believes thoughts from some external entity are placed in his
mind."
"Localized amnesia refers to memory loss surrounding a discrete period of time,
typically occurring after a traumatic event; in this case, the patient?s amnesia
results from learning of her husband?s death. Rarely, a patient may forget his or
her entire preceding life (generalized amnesia) or forget all events following a
trauma, except for the immediate past (continuous amnesia). Retrograde amnesia is
any amnesia for events that come before a traumatic event. Selective amnesia
involves the inability to recall certain aspects of an event, though other memories
of the event may be intact."
"Derealization is the sense that one?s surroundings are strange or unreal, and
depersonalization is the feeling that one?s identity is lost or the feeling of
being unreal or strange. Dereism is simply mental activity not in accordance with
reality. Hypermnesia is an abnormal recall of details." Derealization - your
surroudings seem strange. Depersonalizaiton your internal mind seems strange.
Prosopagnosia is the inability to remember faces despite being able to recognize
that they are faces.
"Confabulation is the fluent fabrication of fictitious responses in compensation of
a memory disturbance, classically seen in dementias or Korsakoff syndrome. Clang
associations are the use of words based on sound and not with reference to the
meaning; this may be seen in manic or psychotic states. Flight of ideas is another
form of thought process in manic patients, where thoughts and speech shift rapidly
from one idea to another, although the relationship between the themes can
sometimes be followed. Hypermnesia is the ability to recall detailed material that
is not usually available to recall. Logorrhea is uncontrollable or excessive
talking sometimes seen in manic episodes." "Clang associations - CLANGING
words that sound CORRECT Logorhea = long speech, excessive talking. Hypermensia-
if amensia is to forget, then hypermensia is to remember excessively. "
"Formication is a particular type of tactile hallucination in which one has the
sensation of bugs crawling on or under the skin. It can be seen in cocaine/meth
intoxication and in alcohol
withdrawal. Gustatory hallucinations are taste without stimulus. Hypnagogic and
hypnopompic hallucinations are not tactile hallucinations but hallucinations
experienced in the transition state
from wakefulness to sleep and sleep to wakefulness, respectively. Synesthesia is a
secondary sensation of an actual perception (eg, the sensation of a color
associated with a taste); it is usually secondary to neurologic disease or
hallucinogen use, most notably LSD." "Formication - imaging worms and bugs
""forming"" and crawling under your skin. "
"Aphasia is the inability to communicate by speech or language. Dysarthria is poor
articulation, often due to a neurologic injury such as a stroke. Scanning speech is
irregular pauses between syllables, which also breaks the fluidity but does not
cause the repeating of sounds or syllables. Stuttering is the disturbance of the
fluidity of speech as in repeating sounds or syllables or using broken words."
"Circumstantial speech is the overuse of detailed information providing extraneous
detail in a digressive manner in order to convey an idea. Derailment refers to the
abrupt interruption of an idea and then, after a period of time (a few seconds),
beginning a new topic. This is usually without the patient?s being aware of the
switch in material. In flight of ideas, there are rapid and frequent changes in
ideas or topics, but the connections may still be recognizable. In loosening of
associations, the logical connections between ideas are completely lost; although
proper grammar and words may be used, the speech is not logical or goal directed.
Tangential speech quickly moves off topic but can be followed, although the patient
never arrives at the point that is trying to be made. "
"An illusion is a misperception of an actual stimulus, and a hallucination is the
perception in the absence of a stimulus. Macropsia and micropsia are the
misperceptions of objects being larger or smaller than they actually are.
Palinopsia is the persistence of a visual image after the stimulus has been
removed."
"In regards to delusional phenomenon in schizo patients: Capgras syndrome is when a
person believes that people they know have been replaced by doubles ""copy"".
Cotard syndrome is when Folie a deux is when the patient has a delusion about
someone who they are very close to (foile a 2, u need a second person). Fregoli
syndrome is the belief that familiar people are now acting strange or mean ""ie
being frugal"". "
"Patients with obscessive compulsive disorder have increased activity (metabolism)
in the caudate nucleus, frontal lobes, and cingulum."
"Circumlocution is the substitution of a word or description for a word that cannot
be recalled or spoken. Apraxia is the inability to perform previously learned motor
skills. Clang association is the use of words based on sound and not with reference
to the meaning, commonly seen in mania. Confabulation is the fluent fabrication of
fictitious responses in compensation of a memory disturbance, such as dementia. A
neologism is a novel word used by patients, often in psychotic disorders (eg,
schizophrenia)." Circumlocution is when you circumvent your inability to name a
word by stating what it does.
"Anomia is an inability to name objects, not solely due to an aphasia.
Paralinguistic components of speech refer to nonverbal communications such as
facial expression and body movements." prosopagnosia - when you used to be a pro
at soap opera with beautiful faces but now you can't recognize faces.
"With SSRI treatment, Sleep, energy, and appetite changes are the first to respond,
followed later by libido, hopelessness/helplessness, and suicidal ideation."
"Exhibitionism is exposure of the genitalia in public to an unwilling participant,
and usually occurs in men. Frotteurism, the rubbing of
genitals against another to achieve arousal and orgasm, is also usually seen in men
and performed in crowded places. Transvestic fetishism is arousal by cross-
dressing"
"Koro, taijin-kyofusho, and zar are all examples of culture-bound delusions. Koro
is the worry that the penis is shrinking into the abdomen and is found in South and
East Asia. Taijinkyofusho is the belief that one?s body is offensive to others, and
zar is the delusional belief of possession by a spirit" "Koro - the story of a
mana whose penis shrunk into his abdomen. Taijin-Kyofusho - my taijustu body is
offensive to others ""kyo-fusho"" Zar = spirit"
Voyeurism is deriving sexual pleasure from watching another person or persons
involved in the act of undressing or other sexually oriented activity.
Exhibitionism is another paraphilia involving exposing one?s genitalia to an
unsuspecting audience Transvestic fetishism involves being dressed in clothing of
the opposite sex for sexual excitement. It is often present in heterosexual men and
differs from transsexualism in that the person is usually comfortable and content
with his gender identity. voyeruism = sexual pleasure from secretly watching
someone.
Loss of ego boundaries is commonly manifested as inappropriate conversational
distance.
Uninterrutible speech = PRESSURED SPEECH. Hyperverbal speech is at a rapid pace
but is interruptible.
"Acting out represents the enactment of a behavior originating from a conflict; the
behavior relieves the sense that the conflict exists at all. In order to have
acting out there needs to be a CONCRETE CONFLICT. Externalization represents the
tendency to project one?s own internal characteristics onto
others = Projection. "
Clinicians must wait at least 14 days after discontinuing an MAOI before starting a
serotonergic agent due to risk of serotonin syndrome.
"Average IQ is 100, and a standard deviation of 15 is utilized; therefore, most of
the population falls within 2 standard deviations. As such, the lower end of ?
normal? IQ is 70. IQs of 50 to 69 are classified as mild MR; between 35 and 49 as
moderate MR; between 20 and 34 as severe MR; and less than 20 as profound MR"

"Panic disorder is defined as 1) 1 or more episodes of a panic attack where the

patient has chest pain, palpitations, shortness of breath, trembling, sweating,
nausea, dizziness, paraesthesias, derealization, depersonalization, fear of losing
control, dying etc and 2) Worry and AVOIDANCE behavior about additional attacks
that last at least 1 MONTH. The immediate treatment for panic disorder is
BENZODIAZEPINES (Lorazepam) and Long-term treatment is SSRI/SNRI and CBT. "
If someone is actuely symptomatic and functionally impaired from a panic
attack give them a benzo.
Busiprone is an anxiolytic that is used to treat GAD only. It cannot treat acute
anxiety or panic disorder.

"Cocaine withdrawal present with depression, fatigue, hypersomnia, hyperphagia,

impaired concentration, and intense cravings. " "Cocaine withdrawal is the opposite
of intoxication. If taking cocaine makes you ""supreme"", you have lots of energy,
you can stay up without sleeping, and have super concentration then withdrawal
would cause depression, fatigue, hypersomnia, hyperphagia, and impaired
concentration. "
"Alcohol withdrawal presents with CNS hyperactivity including: anxiety, insomnia,
tremulousness, tacycardia, HTN. "
"Opiate withdrawal presents with dysphoria, myalgias, yawning, abdominal cramping,
mydriasis, lacrimation, increased bowel sounds, and piloerection. "
"Always try to rule-out substance induced mood disorders. Remember for MDD u need 2
blue weeks, for mania you need 1 fun week and for Cyclothymia or Dysthymia you need
2 years. "

"Clozapine is a 2nd gen antipsychotic used to treat treatment-resistant

schizophrenia and schizoaffective disorder ie treat patients who have failed 2 or
more antipsychotic trials. It is associated with the risk of agranulocytosis aka
(leukopenia) so ""Watch CLozapine CLosely""" """Watch Clozapine Closely"""
"Serum CK is elevated in patients with NMS - suspect this after a patient treated
with antipsychotics develops severe, generalized muscle rigidity. "
Creatinine and thyroid function tests are performed every 3-6 months in patients
taking Lithium.

"In a patient who presents with depression and SI lasting SEVERAL DAYS, a history
of being moody and failed relationships, prior suicide attempts, and failure to
improve with SSRIs or SNRIs think BORDERLINE PERSONALITY DISORDER. "
"Borderline personality disorder is defined as 1) PERVASIVE pattern of unstable
relationships 2) mood lability and anger, 3) self image problems, fear of
abandoment 4) impulsivity, 5) recurrent suicidal behavior or threats of self-
mutilation. 1st-line treatment is PSYCHOTHERAPY ie Dialectical Behavior Therapy
(DBT). Adjunctive therapy includes 2nd gen antipsychotics to treat psychosis or
mood stabilizers, and antidepressants if they have a comorbid mood or anxiety
disorder. "
"Dependent personality disorder also fears abandonement but lack impulsivity,
uncontrolled anger etc because they are cowards. They react fo fears of rejection
with increasing submissiveness rather than emptiness and rage. "
" Histrionic can also present with intense emotion, attention-seeking, and
manipulative behavior similar to borderline but they would not have recurrent
suicidal behavior and chronic emptiness. "
If a patient presents and they CLEARLY satisfy the SIGECAPS and 2 blue weeks
criteria for Depression then your next step is to PRESCRIBE an SSRI +/- CBT.
ALWAYS. Untreated depression in medically ill patients causes reduced quality of
life and can negatively impct treatment adherence and medical management.

A guy presenting with symptoms of mania (DIG FAST) that interefers with his work or
life (social) has full blown MANIA. If he has symptoms of MANIA but it has not
significantly affected his work or life then he has hypomania. 1 episode of mania
that lasts 1 week is enough for Bipolar 1.
Cyclothymia is defined as at least 2 years of FLUCTUATING 1) mild hypomanic
symptoms and 2) mild depressive symptoms ie symptoms that don't meet all the
SIGECAPS criteria.
Criteria for MANIA are Distractibility Irresponsibility/Impulsivity Grandiosity
Flight of ideas Agitation/Activity Sleep (decreased since you are digging fast)
Talkativeness --> 3-4 of these symptoms diagnoses MANIA.
Stimulants and cocaine can induce mania. Marijuana cannot.

"An adequate trial of an antidepressant is 1) adequate dose and 2) duration for 6

weeks or more. If a patient fails one antidepressant, then you can switch to
another antidepressant (another SSRI or SNRI) or augment the agent with agents:
Bupropion, Lithium etc or CBT. If the patient has failed MULTIPLE (2 or more)
trials or has PERSISTENT SUICIDALITY or malnutrition/dehydration(really can't take
care of themselves) then you consider ECT. "
"If someone presents with atypical depression (sleeping more, eating more,
weakness:legs and arms feel heavy) and you want to switch them to a MAO from
Fluoxetine you have to wait 5 weeks for a washout period. For all other
antidepressants you have to wait 2 weeks. This reduces risk of serotonin syndrome.
"
A patient presenting with NEUROLOGIC symptoms after an acute stressor in life has
CONVERSION DISORDER.

"Acute psychosis is treated with firstline 1) 2nd gen antipsychotics: Risperione,

Quetiapine, Olanzapine, Aripiprazole, and Ziprasidone 2nd line with Haloperidol
(1st gen antipsychotics) +/- Benzodiazpines if the patient is also agitated. "
2nd gen antipsychotics are preferred over 1st gen due to decreased risk of
extrapyramidal side effects and tardive dyskinesia.
"If a patient with schizophrenia or mood disorder, shows a pattern of medication
nonadherence then you can consider switching to a long-acting injectable
antipsychotic. But remember that the patient must try the PO version of the
medication before the DEPOT version. " PO before the DEPOT
"Clozapine is a 2nd gen antipsychotic that is the GOLD-STANDARD for treating
""treatment-resistant"" schizophrenia ie a schizo patient who has failed to respond
to at least 2 trials of antipsychotics. "

Signs of acute intoxication from inhalant use are 1) brief transiet euphoria 2)
loss of consciouness 3) peri-oral ski n changes aka glue sniffers rash around the
mouth or nostrils due to exposure to chemicals. Inhalants are highly lipid soluble
and porduce immediate effects in the brain that last 15-45 minutes. they act as
central nervous system depressants and can cause death. Boys 14-17 are at
highest risk for inhalant use because it may go unnoticed as common household
products are used and there are no drug paraphernalia.
"Cocacine is a CNS stimulant that causes increased arousal, psychomotor agitation,
and increased heart rate and blood pressure. "
Heroin can cause loss of consciousness but would be + on a utox and would cause
pupillary constriction.

"To diagnose cyclothymia, you need a patient who barely/doesn't satisfy depression
symptoms and satifies HYPOMANIC symptoms(ie manic but does not interfere with
life) who fluctuates between these for at least 2 YEARS. "
To diagnose cyclothymia in children then only need flucating symptoms for 1 year.
Medical condtions such as hypothyroidism can also cause fluctuating mood symptoms
but one would see signs of PHYSICAL EXAM or ABNORMAL Labs.

"Cocacine-use presents with symptoms of CNS stimulation (MATES), irritability,

weight loss 2/2 to decreased appetite, and erythema of turbinates and nasal septum
or perforation of the nasal septum. "
Anorexia nervosa is associated with intense fear of gaining weight and distorted
body image despite a low body weight.
Diangosis of bulmia nervosa requries evidence of binge eating and compensatory
behaviors.

"Tardive dyskinesia - involuntary movement disorder with orofacial (rhythmic

movements of the face, lips, and tongue, trunk and extremities and choreoathetoid
movements that occurs in patients who take antipsychotics chronically or for a
prolonged time. It is common for TD to worsen or first appear after an antpsychotic
is stopped or dose reduced due to D2 receptor upregulation or supersensitivity from
chronic blockade of the D2 receptors. "
Caudate nucleus atrophy and CAG repeats are seen in Huntington Disease
Lithium toxicity can cause tremor and ataxia.

"Dysthymia or persistent depressive disorder is defined as a CHRONIC (at least 2

years) low grade depression that satisfies at least 2 or more of SIGECAPS symptoms
and lasts for 2 years in adults (1 year in kids). If the person has never had a
major depressive episode then they are defined as ""pure dysthymic syndrome"". "
Avoidant and dependent personality disoder involve feelings of low self esteem and
LIFELONG patterns of either avoidant:fear of rejection and worry about fear of
rejection and
Benzos and antihistamines such as Diphenylhydramine should NOT be used in the
elderly due to the risk of cogntive impairment and delirium.
Ramelteon is a melatonin agonist used to for sleep-oonset insomnia and is SAFE in
the elderly. It is different than Remeron (Mirtzapine)

Somatic symptom disorder is when a patient OVERLY concered about and seeks
treatment for physical complaints that have otherwise been cleared medically.
"Acute intermittent porphyria is a hereditary condition that can cause 1)
Intermittent neuropsychiatric symptoms such as NEUROPATHIES, anxiety, MOOD CHANGES
and PSYCHOSIS,2) GI Complaints: nausea, abd pain, constipation, and
tachycardia.KEY POINT here is that the symptoms should be INTERMITTENT ie
episodic and can last days to weeks.Urinary porphobilinogen is elevated."
Brief psychotic disorder is when a person has psychosis that lasts 1 day to 1
monthand is UNEXPLAINED by any other condition. (DOES).
"Wilson disease is a disorder of copper transport. Copper accumulates and causes
hepatic, psychiatric, and neurologic dysfunction.Classic associated findings
are 1) Kayser-Fleischer rings (copper deposits in cornea) dysarthria, dystonia,
tremor, and parkinsonism AND 2) Depression is the most COMMON psychiatric
manifestation."

REM sleep behavior disorder is characterized by complex motor behaviors that occur
during REM sleep.Hallmark features are 1) They end to occur LATER at night (when
REM sleep normally occurs) 2) Patients can be awakened and may have transient
confusion BUT BECOME FULLY ALERT. This is in opposition to Sleep terrors and
Sleep walking where the patient may not be easily arousable AND DOES NOT become
ALERT immediately.
It is usually occurs in OLDER ADULT men and if recurrent can be a sign of
neurodegeneration in patients with Parkinson's disease or Dementia with Lewy
bodies.

Nightmare disorder is when you have VIVID recall of a disturbing dream content;
there is no associated motor activity or sleep-related injury.
Nocturnal seizures are seizures that occur at night ie repetitive and stereotypical
movements including tonic or dystonic movements. Occur at any time of the night and
usually occur in YOUNGER patients.
Restless leg syndrome is an overwhelming urge to move the legs that builds up and
is associated with sleep disturbance and involuntary jerking movements of legs
during sleep.

"Schizoaffective disorder = MOOD symptoms (Mania or Depression) with psychosis AND

then 2 or more weeks of delusions, disorganized thoughts and behaviors (psychosis)
outside of having a mood disorder. "
"Alcoholic ""hallucinosis"" is a type of alcohol withdrawal that develops 12-24
hours after last drink and resolves within 24-48 hours."
Schizophrenia = 6 months Schizophreniform = 1 month - 6 month Acute psychotic
disorder = 1 day - 1 month.

Narcolepsy is characterized by: 1) Excessive daytime sleepiness 2) Cataplexy:

sudden loss of muscle tone with strong emotions 3) Sleep paralysis 4)Hypnagogic or
Hypnopompic hallucinations. You treat with Modafinil as 1st line; other
amphetamines or stimulants as 2nd line. Cataplexy symptoms are treated with Sodium
Oxybate and Antidepressants.
"OSA - report daytime fatigue, snoring, pauses during sleep, and other symptoms of
obesity metabolic syndrome but DO NOT have cataplexy, sleep paralysis, or
hallucinations. Treat with CPAP."
Melatonin can be used to treat circadian rhythm sleep disorders such as jetlag.
Pramipexole is a dopamine agonist used to Parkinson Disease and Restless Leg
Syndrome.

Older adults that are depressed present with more SOMATIC complaints that
subjective changes in mood and interest.
Normal age-related sleep changes are 1) decreased total sleep time 2) increased
nighttime awakenings and 3) Go to sleep earlier and wake up Earlier. If a patient
complains about this you
Insomnia disorder is when a patient has PERSISTENT difficulty initiating or
maintaining sleep resulting in distress or impairment and is NOT explained by a
mood disorder.
"Benzos, Antihistamines such as diphenhydramineshould NOT be used in the elderly
due to risk of delirium and cognitive impairment. "

stopping benzos abrupty can cause SEIZURES due to rebound. Xanax or Alprazolam a
short acting benzo is a common cause of this.
"Withdrawal symptoms of benzos include seizures, tremors, anxiety, perceptual
disturbances, and psychosis. "
Lamotrigine is an anticonvulsant used to treat bipolar disorder and rapidly
stopping it could causes seizures in a PATIENT with an underlying seizure disorder.

"Delirium Tremens from alcohol withdrawal occurs 2 days after the last drink and
can present with Confusion, Agitation, Fever, tachycardia, diaphoresis, and
hallucinations. It is treated with benzos (Lorazepam). Don't forget to also give IV
fluids and thiamine. " "DTS Are HELL. Delirium Tremens Sympathethic Activation
(Tachy, HTN, Fever) + normal withdrawal symptoms: confusion, agitation etc.
Deliriums and your vitals TREMBLE up. "
Chlordiazepoxie is a long acting benzodiazepine. It is metabolized by liver so
contraindicated in patients with liver disease.
DiSULFiRAM is used as a behavioral deterrent in HIGH-functioning alcoholic patients
who desire long-term abstinence. IT IS NOT good in patients who are undergoing
acute withdrawal.

"Antisocial Personality Disorder is diagnosed by 1) Violates rights of others,

social norms, laws 2) Violent/aggressive: Impulsive, irritable, (fights and
assault), 3) Manipulative: lies, deceitful 4) No Remorse 5) Have to be 18 or older
6) History of Conduct disorder before age 15. If a person satisfies more than one
of categories think ASPD. "
Borderline personality disorder can exhibit manipulative and impulsive behavior but
they DO NOT COMMIT CRIMES. They are more EMOTIONAL and will injury themselves
before hurting someone else.
Intermittent explosive disorder involves ISOLATED episodes of assaultive or
destructive behavior but there is no history of childhood conduct disorder or
other features of ASPD. Think of someone who was ASPD once. There is no history or
pattern.
Narcisstic personality is defined as EXAGGERATED SENSE of SELF-IMPORTANCE and No
EMPATHY. They do not commit crimes
Paranoid personality disorder is defined as a person motivated by DISTRUST and
SUSPICIOUSNESS of others rather than a desire for personal gain or to exploit
others.
Delusional disorder is defined as having 1 or more delusions for 1 or more months.
The key feature here is that the delusions are potentially possible AND DO NOT
impair the person's social or work life and that their BEHAVIOR otherwise is
normal. You treat with 1) Antipsychotics 2) CBT.
"In Schizophrenia, the delusions and other symptoms: psychosis, disordered though
etc do IMPAIR the patient's ability to function. "
Personality disorders are defined by LONG-STANIND pattern of interpersonal
problems. They DO NOT have delusions or other psychotic symptoms.
Primary amenorrhea is only concerning if it has not occurred by age 15.
"Woman comes in with an extreme vegan diet but her BMI is normal and expresses that
she is vegan because she cares about animals, then this is NORMAL - reassure. "
An adolescent who 1) significantly low weight for age 2) history of inappropriate
dietary restriction 3) distorted body image and/or phyiscal findings of an eating
disorder - you need to work them up fro an eating disorder.
"Vomiting from bulimia can cause 1) Hypokalemia, 2) Hypochloremia, and 3)
hyperamylasemia. "
Eating disorders are treated with CBT as 1st line therapy. SSRI such as
fluoxetine can be used to treat Bulimia

"For treating schizophrenia, in addition to giving the proper medicaiton:

Psychosocial interventions including Family counseling and psychoeducation can be
helpful because they minimize confilict and stress in the home. Eg educate
patients parents about the symptoms of schizophrenia including social isolation.
patients who have critical, hostile, or over-involved parents are at higher risk of
relapse. "
"After an acute psychotic episode, patients should take things slow and ease back
into their routines. "

"NMS is caused dysregulation of dopamine due to D2 receptor antagonism. Hallmark

features are 1) Fever, 2) Encephalopathy (AMS) 3) Vitals unstable from autonomic
instability (tachycardia, labile BP, tachypnea, diaphoresis) 4) Elevated enzymes
(CK, Leukocytosis) 5) Rigidity (lead-pipe muscle rigidity). It can be caused by
1) Antipsychotics, 2) Antiemetics (promethazine, metoclopramide), 3) Withrawal
from Antiparkinson drugs 4) Infection and Surgery. It is treated with
Dantroline, Bromocriptine, and Amantadine + supportive care, stop the
neuroleptics. "
SSRI and SNRI and Benzos DO NOT cause NMS.
"When delivering bad-news, choose a FACE-to-FACE visit. It is important to assess
patient's undersanding of the condition and how much the patient wants to know. "

Avoidant/restrictive food intake disorder involves lack of interest and avoidance

of eating based on sensory characteristics of food and usually starts in INFANCY or
early Childhood.
"Suspect cocaine abuse in a patient with weight loss, behavioral changes, an
erythema of the turbinates and nasal septum. "

The Mesocortical pathway is responsible for the negative symptoms of Schizophrenia

the Mesolimbic pathway is responsible for the psychotic symptoms of schizo HENCE it
is the target of antipsychotic drugs. "Also, responsible for euphoria with
drugs. "
"The Nigrostriatal pathway is responsible for extrapyramidal symptoms: acute
dystonia, akathisia, and parkinsonism. "
"The tuberoinfundibular pathway is responsible for hyperprolactinemia, amenorrhea,
galactorrhea, gynecomastia, and sexual dysfunction. " You block the dopamine
neurons that tonically inhibit Prolactin secretion.

"In order for a patient to be diagnosed with ADJUSTMENT DISORDER the following
have to be satisfied 1) Identifiable stressor 2) Development of symptoms within 3
months of the start of the stressor 3) the patient has to be MARKEDLY distressed
AND have SIGNIFICANT FUNCTIONAL IMPAIRMENT - ie issues with social and/or work
life. 4) NOT MEET criteria for depression, mania, or schizophrenia. "
If a patient presents similar to adjustment disorder but is not significantly
imparied then they have a NORMAL STRESS RESPONSE.
Acute Stress Disorder = 3 days - 1 month PTSD = > 1 month

GAD requires 1) excessive worry about MULTIPLE (2 or more) issues and 2) Lasts 6
months or more.

Insomnia disorder if diagnosed by insomnia for 3 or more nights a week and a

duration of 3 or more months.

Body dysmoprhic disorder is defined as 1) Preoccupaton with 1 or more perceived

physical defects 2) the defects are not observable or appear slight to others 3)
repetive behavior or mental acts performed in response to the preoccpuation
( worry) 4) significant distress or impariment from worry. It can present similar
to OCD but the main difference is the patient is focused on a body part.
Treatment is CBT + SSRIs.

Folie a deux - is when a delusion is shared by 2 inviduals with a close relationsip

eg Mother and daughter share same delusion. Treatment is SEPARATE the pair to
break the chain of reinforcing each other's beliefs. The dominant person in the
delusion may still require full treatment.
tarasoff decision - clinicians have a duty to warn or protect an individual who is
being threatened by a patient. You either 1) inform patient 2) inform police.
Either way this patient expressed intent to harm so they will be admitted.
Never try to reassure a psychotic patient.

"Conduct disorder is defined as a pervasive pattern of 1) violating rights of

others or major social norms for 1 year or more 2) Aggression towards people and
animals (fights in school or torturing animals) 3) Destruction of property,
Stealing, etting fires, deceitfulness, 4) Violates rules - truancy (missing school)
and running away. 5) Be under age 18. "
"ADHD is defined as inattentiveness, impulsivity, and hyperactivity BEFORE age 12.
They are not violent, violate others rights, steal or demonstrate destructive
behavior. "
"Kleptomania is defined as individuals with an irresistible urge to steal objects
that are of low value or not actually needed. ""Stealing for the thrill of
stealing"" "
Oppositional defiance disorder is when a kid defies authority figures but again is
not violent and does not commit crimes.
Personality disorders do not HAVE psychosis.
Schizotypal personality is defined as magical thinking (odd thinking) and eccentric
behavior but they are not delusional.
Acute mania is treated with 1) 2nd gen antipsychotics such as Risperidone 2) 1st
gen atypicals 3) Mood stabilizers such as Lithium or Valproic acid. If someone is
acutely manic with agitation you have to GIVE an antipsychotic and can then add a
mood stabilizer for (long-term treatment/stabilization).
SSRIs can trigger manic episodes in Bipolar disorders and can actually worsen
Mania.
Lamotrigine is GREAT for treating Depressive episodes of Bipolar disorder. The big
risk is stevens-johnson syndrome.

"Somatic Symptom Disorder is defined as 1) 1 or more somatic symptom(s) that cause

distress or functional impairment to the patient 2) excessive thoughts, worries, or
behaviors related to the somatic symptom ie persistent thoughts that the illiness
is serous, anxiety about the symptoms, excessive time and energy thinking about
symptoms and 3) duration of 6 or more months. Treatment is 1) regularly scheduled
visits with same provided 2) Limit uncessary workup and referrals 3) Legitimize
symptoms but make functional improvments the goal 4 )stress reduction and coping
strategies 5) mental health referral. "
"with a somatic symptom disorder patient try to focus on discussing the role of
psychosocial stressors on the symptoms, stress reduction, and healthy behaviors. "

"ADHD is defined as 1) Inattentiveness: difficulty focusing, distractible, does not

listen or follow instructions, disorganized 2) impulsivity, 3) hyperactivity:
fidgety, unable to sit still, driven by a motor, hyper-talkative, interrupts,
blurts out answers 4) in MORE THAN ONE SETTING (eg school and home) for 6 months
and be 12 years or younger. Treatment is 1st line) Stimulants(adderall,
methylphenidate) 2nd line: Nonstimulants: atomexitine (norepinephrine reuptake),
alpha 2 agonists, 3rd line: behavioral therapy. "
SSRIS and other antidepressants can't treat ADHD.

"In serotonin syndrome you see Hyper-reflexia: myoclonus, tremor) and in NMS you
see lead-pipe rigidity. "
"When a patient is on a MAO-I, you have to wait 2 weeks before starting another
serotonergic agent. If it's fluoxetine you have to wait 5 weeks. "
"Benzodiazepines can cause paradoxical agitation which presents with CONFUSION
(ams), Agitation, disinhition, and aggression in the elderly and increase the risk
of falls. "

"Conversion disorder aka functional neurological symptom disorder is when a

patient suddenly develop a ""neurologic symptom"" in response to an emotional,
life, or psycological stressors. The patients aren't pretending and truly feel
like they have the symptoms. Common presentations are 1) unexplained weakness (leg
weakness or paralysis but reflexes are intact) 2) non-epileptic seizures, 3)
ataxia, aphonia, numbness, and parathesias. The patients can be worried about their
symptoms or indifferent. First-line treatment is 1) EDUCATION, Encouragemen, and
support for patients and family members about the disorder. 2nd line treatment is
CBT. 3rd line is physical therapy for motor symptoms. "