for the USMLE step to seek a exam this is specifically my you world notes that I am gonna be dictating this covers everything that I was able to gather from you world and it makes a pretty good review especially if you're out on the road or in a situation where you're not able to be reading something you still want to be studying this is a good tool for that so let's start her off so psychiatry we're gonna start off with the assessment of decision-making capacity so the assessment at the decision-making capacity it depends on the criteria and what the patient's task is so if the criteria means that that the person has to communicate a choice that means that the patient's able to clearly indicate a preferred treatment option that's the criteria for that decision-making capacity if the patient understands a condition and the treatment options that means that the patient understands the information provided if the patient acknowledges having a condition and likely consequences of treatment options including no treatment that means that he appreciates the consequences behind that decision and if a patient's able to weigh that risks and benefits and offers a reason for their decision that's a rationale given for the decision so all those are assessments of a good decision-making capacity next topic would be defense mechanisms so he defense mechanisms are divided into immature defense mechanisms versus mature the immature defense mechanisms include primitive and neurotic mechanisms and they're the majority of the ones so for example acting out means expressing unacceptable feelings through their action denial is behaving as if an aspect of reality doesn't exist displacement would be transferring someone's feelings to a more acceptable object as displacement intellectualization means using someone's intellect to avoid an uncomfortable feeling passive aggression means to avoid a conflict by expressing hostility covertly projection means that tributing one's own feelings unto other kind of like you're projecting your voice I always have a problem remembering this one but it's bright like projecting your voice in order for somebody to be heard this is projection you're projecting your own feelings unto others rationalization means justification of someone's behavior to avoid a difficult truth there's reaction for formation which means responding in a matter opposite to one's actual feelings regression would be reverting to an earlier developmental stage and then splitting would be seeing others as either all good or all bad so all of those are immature defense mechanisms the mature mechanisms there's only two there's sublimation and suppression so they both start with the letter S so sublimation means channeling someone's impulses into a socially acceptable behavior the classic example there is someone who likes to start fires and becomes a fire fighter that is a sublimation and then suppression would be putting unwanted feelings aside to cope with reality you can tell those two are going to be more mature ways of dealing with an issue in life versus all the other ones are kind of a childish very image well and a mature way of dealing with things so if he's just that's a good way of categorizing him altruism is a mature defense mechanism in which a person manages unpleasant emotions through services to others this service is going to provide gratification unlike in reaction formation in which a true sense of the internal pleasure is going to be lacking so the neural imaging in psychiatry disorders would be the following so in autism you'll have an increased volume total brain volume obsessive-compulsive disorder means that the abnormalities in the orbital cortex and the striatum so obsessive compulsive disorder the oh and obsessive is the oh and orbital cortex panic disorder is decreased volume of the amygdala so that a and panic you can remember it as the a and amygdala but it also affects that the left temporal lobe also post traumatic stress disorder means that you'll have a decreased volume in the hippocampal region and then gets afrien iya has enlargement of the cerebral ventricles in clinical patient and clinical practice there's structural neural imaging like CT s or MRIs and that's often done as part of a diagnostic workup for patients with new onset of psychosis --is to rule out any type of non psychiatric disorders so that's why you do a CT or MRI when you have a new diagnostic workup you want to see if there's increase in brain volume if there's any kind of abnormality and the cortex in the amygdala is and so on any type of cerebral ventricle enlargement so routine neuro imaging is not indicated in patients with unknown psyche out a psychotic disorder this is just done to evaluate first off to see if the diagnosis could be made through a CT but once it's not then you can just forget about doing any more neuroimaging functional neuroimaging techniques like a PET scan or a functional MRI and an MRI mr spectroscopy are important research tools in psychiatry and those are used to studying neural p'tee and brain pathways involved in psychiatric disorders however they're not routinely used in clinical practice and then we have selective mutism which is a condition in which children have a fear of a situation that call for them to speak like a school or social gathering as well as social phobia that's also called social anxiety disorder it's often a core morbid condition and children suffering from selective mutism with anxiety and avoidance commonly occurring the dsm-5 criteria for selective mutism is gonna be either consistent failure to speak in some specific situation like at home or at school but not others in which a person is expected to speak so these are all selective mutism is always a is always an alternative to some type of autism spectrum so be sure to differentiate these so the other one would be a duration of at least one month so mutism would be at least for one month there's interference with educational or other expected achievement or social communication it's not a tribunal attributable to lack of knowledge or comfort with a spoken language it's just them deciding to not speak other communication or optimism spectrum spectrum disorder or psychosis do not account for the presentation so that's what I was saying in these cases they only speak in specific situations either at home or at school but versus autism they just won't speak at all if that's what they don't if that's what they want to do so it's not it's not geared towards a specific situation or condition so continuing on with attention deficit hyperactivity disorder clinical features would be like inattentive or hyperactive-impulsive symptoms that last for more than a month more than six months so sorry inattentive symptoms would be difficulty focusing they're very distractible does not listen or follow instructions very disorganized forgetful and loses and miss places objects versus hyperactive-impulsive symptoms would be as if they would be fidgety or unable to sit still like if they were be like if they're driven by a motor is what it's what it's a an example would be hyper talkative interrupts blurts out answers symptoms would be severe if they present before age 12 and symptoms occur in at least two settings either at home or at school and cause functional impairment there are subtypes that are predominantly inattentive predominantly hyperactive or impulsive or combined inattentive impulsive and then the treatment for ADHD would be stimulants like methylphenidate or other amphetamines also non stimulants such as atomoxetine and alpha-2 adrenergic agonists as well as behavioral therapy adverse effects of methylphenidate would be like nervousness loss of appetite nausea abdominal pain insomnia and tachycardia the loss of appetite is the one that's most commonly associated in the nervousness and there's also a prolonged therapy has been shown to cause mild growth retardation with mild with weight loss methylphenidate should not be used in children younger than 6 years old because of safety and efficacy xand within this age group it just hasn't been evaluated so the dsm-5 criteria for ADHD would be more than six inattentive or more than six hyperactive or impulsive symptoms for more than six months there's several symptoms present before age 12 and symptoms do occur in at least two settings either at home school or in peer relations there can be functional impairment like social or academic impairment and there's predominant predominantly there's various subtypes so you have predominantly inattentive predominantly hyperactive-impulsive or combined inattentive impulsive type 4 inattention Cinch symptoms there is no attention to detail in patients with ADHD and they make careless mistakes it's there's difficulty focusing on things like games and tasks reading and lectures make it difficult they don't appear to listen when you speak to them they cannot follow instructions because of that and they get sidetracked easily they're unable to finish tasks they have also difficulty organizing tasks such as disorganized work poor time management and they avoid tasks you need to avoid tasks requiring sustained concentration for them they can easily lose or misplace objects requiring to perform tasks like books phones keys they can all misplace that they're easily distracted by extraneous stimuli and chores and appointments can then be forgetful to them they also have hyperactivity or impulsivity symptoms so characteristics would be they fidget a lot they have difficulty staying seated they run or climb inappropriately they cannot perform activities quietly they're physically active all the time as if they're driven by some kind of motor that constantly working they talk consistently and constantly and they blurt out answers and complete other people's sentences they also have difficulty awaiting someone's turn so like Anne they were in the line or something they have difficulty awaiting their turn and they're constantly interrupting and intruding when others are also busy or speaking so patients with ADHD are at higher risk of developing a conduct disorder in adolescence and one of the vignettes do describe a patient who has ADHD and they ask you what is the what are they more likely going to develop and it is conduct disorder when they reach adolescence now conduct disorder by the dsm-5 is categorized by a aggression towards other people and animals destruction of property serious violation of rules decide fulness or theft so aggression towards people and animals would be that they would initiate physical fights they're bullies they threaten intimidate other people they use weapons to cause serious harm to others it can also be physically cruel to people physically cruel to animals they can steal while confront confronting a victim and they can also force someone into a sexual activity just they can also be caught they can also cause destruction of property - such as setting fires so watch out with pyromania in these differentials also they can have intention they can intentionally destroy properties of others and they also have serious violation of rules so they'll run they'll be running away overnight at least twice or once without returning for a lengthy period being truant from school often starting before age 13 and they frequently are staying out at night despite prenup is despite parental prohibitions starting before age 13 so that won't they really won't listen to their even at an early age and just do whatever they want to do they frequently are lying to obtain goods for favors and they break into cars or buildings and steal items of non trivial value without confronting the victim so this is diagnosed at least when they have three behaviors and they have been present within the last year or within the past 12 months with at least one present in the past six months so they can also be at risk of developing antisocial personality disorder as adults and the diagnosis of antisocial is not given to patients less than 18 years of age before they're 18 years old anti antisocial personality disorders basically conduct disorder next is kleptomania clinical features would be rare impulsive control disorders of typical onset in adolescence the repetitive failures to resist impulsiveness to steal stealing objects have little value they just basically want to steal things for the for the purpose of just stealing they can also be a differential diagnosis would be shoplifting but in this case shoplifting would be theft for a personal gain and kleptomania there is no personal gain in anti person antisocial personality disorder it's a general pattern of antisocial behavior whereas in kleptomania and there could be a completely fine normal individual they just require themselves to steal for some reason bipolar disorder would be another differential manic with a manic episode such as a person who has impulsivity or an impaired judgment as well as other psychotic disorders like stealing in response to delusions or hallucinations like saying oh the devil made me steal this or break into this place to steal that with kleptomania there is no psychotic behavior or deceitfulness behind that so kleptomania can be treated with psychotherapy as well as medications psychotherapy is going to involve cognitive behavioral therapy orientation focusing on techniques to resist and manage urges and anxiety as well as medications that have been used in for this would include SSRIs opioid antagonists lithium and then ty convulsive pyromania is the next topic that dsm-5 describes this as a deliberate fire setting on more than one occasion with tension and arousal prior to the act there's fascination with fires and its consequences there's a pleasure behind setting fires and relief when setting or witnessing a fire there is no external gain there's no revenge or political motivation there's nothing of that sort it's just the primal urge I would say to just set a fire and it's not better explained by conduct disorder manic episode psychosis antisocial personality disorder impaired judgement none of that they just like setting fires ok tourettes disorder is the next topic the dsm-5 states that this is in both multiple motor and one or more vocal tics involved it's not necessarily concurrent but it does happen more than once a year the motor findings would be fit facial grimacing facial blinking head or neck jerking with shoulder shrugging there could be tongue protrusion and sniffing vocal tics would be like grunts or snorting throat clearing barking yelling or yelling obscenities also known as coprolalia the onset of this happens before age 18 and the treatments for Tourette's would be antipsychotics which is a very known question answer to a question alpha adrenergic agonists like clonidine and wolf Ineson and behavioral therapies that can have it reverse themselves so it's an in forms of training themselves to not do this or suppress these tics if the tics occur many times a day frequently in bouts nearly every day or at erect or at regular intervals the tics can wax and wane but they must persist for more than a year after the initial onset and they must occur before the age of 18 in order to be properly diagnosed there's an exacerbation and stress and fatigue and it's also relieved during sleep comorbid conditions there could be an association with ADHD and 60% of patients or an OCD with 27% of patients and it can develop within 3 to 6 years after the tics first appear it may peak and leak and in late adolescence or in early adulthood at a time when the tics are waning and less common core' morbid conditions include anxiety depression and impulse control disorders now their management would be pharmacotherapy if that's given it interferes with social academic or occupational functioning so it's based on older trials first generation antipsychotics like holo paradol can maza Dean these are the only fda-approved medications for Tourette's disorder however due to the side effects of first generation antipsychotics and prolongation of the QT C interval it's also that's associated with pema's I'd 2nd generation antipsychotics would then be generally preferred and among the second generations antipsychotics you have your risperidone which is going to be the best one because that's the one that's been mostly studied alright so next topic is autism spectrum disorders so some of the features of autism spectrum is multiple or persistent deficits in social communication and action and it's currently or by the history of involving either social emotional reciprocity nonverbal communicative de behaviors developing or maintaining and understanding relationships there's a restricted or repetitive pattern of behavior currently or by a history of either repetitive motor movements insistence on the sameness or inflexible adherence to routines fixated on interests of abnormal intensity or focus there's adverse responses to sensory input and the onset is in early developmental period and may occur with or without any kind of language or intellectual impairment now assessment and management of principles the early diagnosis is better for early intervention there can be a comprehensive assessment multimodal treatment such as speech treatment behavioral therapy and educational services provided as was adjunctive pharmacotherapy for psychiatric comorbidities the second-generation antipsychotics risperidone has been shown to improve the aggression seen in autism spectrum disorder patients but after other therapies are done it's not first-line the dsm-5 diagnosis of autism spectrum disorder encompasses high-functioning autism z' like previously known as Asperger syndrome or I believe it's it was just reintroduced recently the diagnosis of Asperger's so that would be a higher functioning autism spectrum disorder there's also childhood disintegrative disorder and any pervasive developmental disorder not otherwise specified diagnosis is going to be based on the history and behavioral observations that we just talked about and the physician should empathically listen to the parents concerns and a complete comprehensive evaluation should be done before making any type of Defense of diagnosis this evaluation is going to include structured assessments of social language and intellectual development in addition to hearing vision and genetic testing such as fragile X syndrome alright so sexual behavior in pre adolescence so what's normal what's abnormal so when a toddler what's normal is exploring their own or others genitals the movements of masturbatory movements undressing themselves or addressing others that's completely normal and a toddler in school-aged children there's increased interest for sexual words and play there's asking questions about sex and reproduction as well as masturbatory movements that can become more sophisticated now abnormal sexual behaviors and pre-adolescents would be repeated objects of insertions into the vagina or anus sex play involving the genital oral or anal region or contact any use of force threats or bribes and agent appropriate sexual knowledge that is all abnormal if you see that that is then going to be considered grounds for child abuse next would be psychotic disorders so the dsm-5 has certain criterias of the differential diagnosis of psychotic disorders there's several so brief psychotic disorders schizophrenic form it's good so Freni a-- schizoaffective and delusional disorders so brief psychotic disorders means that you will have psychotic symptoms that are more than a day but less than a month their sudden an onset and they have full return to function after the month is over so that's a brief psychotic disorder versus schizophrenia is at least six months and that includes at least one month of active symptoms and can include prodromal or residual pair and that requires functional decline so at least six months is schizophrenia versus psychotic disorders at last less than a month is brief psychotic disorders but what if you have a period that's between one month to six months that's called schizophrenia form disorders so if it lasts less than six months but more than a month you're in the schizophreniform category and those are the same symptoms of schizophrenia just with a shorter time period and because it's a shorter time period there is no functional decline required to make the diagnosis of schizophrenia also you have schizoaffective disorder which is basically schizophrenia with mood episodes which is an active phase of schizophrenia with at least two week life time histories of delusions or hallucinations in the absence of prominent mood symptoms so you'll have mood with schizophrenia it's the best way of describing it so you they'll present you with somebody who has signs and symptoms of maybe mania or major depressive disorder and then at the same time they'll have psychotic episodes like they'll see things or hear voices okay delusional disorder would be more than one delusion in more than one month with no other psychotic symptoms they're actually normal functioning apart from direct impact impaction of the delusions so a prior prior to the diagnosis it would be appropriate to rule out any type of substance induced psychosis or psychosis that's secondary to a general medication medical condition because in that case it would be kind of easy to misdiagnosed someone with a brief psychotic disorder or a schizophreniform disorder if in in fact they are just under the influence of some kind of substance induced psychosis so some of the symptoms of schizophrenia include the presence of either two or more of the following so they'll can have delusions hallucinations disorganized speech frequent derailment of ink or incoherence that can be grossly disorganized or catatonic behavior involved with negative symptoms affecting like a flat effect or some are a Society ality so somebody who doesn't want to be a part of society or a loggia no schizoaffective disorder is basically myth like we said it's major depressive disorder or a manic episode with skits with symptoms of schizophrenia so some type of mood disorder with schizophrenia there is a lifetime history of delusions or hallucinations for more than two weeks in the absence of major depressive or manic episodes the mood symptoms are present for the majority of the illness and it's not due to a substance or any other medical condition so again it's very important to distinguish substance abuse versus psych psychosis get so effective or other types of psychotic disorders the differential diagnosis for schizoaffective disorder would be like a major depressive disorder or bipolar disorder like we mentioned earlier with psychotic features and that can occur exclusively during those mood episodes as well as schizophrenia would be the mood symptoms present for relatively brief periods then you have your delusional disorder and clinical features of delusional disorder would be more than one delusion for more than one month other psychotic symptoms can be absent and not prominent there could be ability to function apart from a delusion and that's a behavior that's it's not obviously bizarre or odd subtypes of delusional disorders would be erato manic disorders grandiose disorders jealousy can be a delusional disorder as well as persecutory or and somatic symptoms can be delusional as well differential diagnosis is for delusional disorder could be schizophrenia other psychotic symptoms can present like hallucinations disorganized Asur ghen ization negative symptoms and they can have a greater functional impairment as well as another differential would be personality disorders like pervasive patterns of suspiciousness such as in patients that have paranoia or narcissism showing grandiosity or odd beliefs like skips a tipple patients but no clear delusions and the treatment for delusional disorder would be again antipsychotics or cognitive behavioral therapy or a combination of both is always a correct answer there's also a classification of psychotic disorders called shared psychotic disorders which is a very rare form of delusional disorder some delusions are present and individuals who share a close relationship so it's this is very strange if a person is completely normal yet they're very close let's say a husband or a wife or a sister or brother and they share the same relationship and one of them has psychotic disorders that disorder can actually spill on to the other person who was normally not supposed to have them but because of that close relationship they now have a form of delusion null psychotic disorder and that's called a shared psychotic disorder that's the same delusion as present in the individuals who share the close relationship like we mentioned it's usually the dominant individual and the pair that becomes delusional and transfers their delusions onto the second one the management in these cases is most our appropriate courses first of all is to separate them you basically break the chain of reinforcing each other's beliefs but usually they're the dominant one requires psychiatric treatments sometimes they'll require inpatient treatments whereas the other person will require treatment only in some cases like the first assess so first you want to assess the other one by separating the two and what are some of the indications for hospitalization would be the inability to function or obtain any type of outpatient treatment on their own or if they're being a threat to themselves or others and that just doesn't fall under this category that's basically a generalized rule for indications of hospitalization if you cannot function or obtain any type of treatment on your own as an outpatient or if you're seen as a threat to yourself as two or as two others that's an indication for a hospitalization if both patients require the inpatient treatment preferably you want to admit them in two different units remember separate the parents and if psychotic disorders are confirmed in an anti-psychotic Anna cognitive behavioral therapy in combination is recommended now the next topic is secondary causes of psychosis and children and adolescents so it could be either due to medical disorders like CNS injury or dysfunction trauma space-occupying lesion infection stroke epilepsy cerebral hypoxia could also be due to metabolic or electrolyte disturbances such as urea cycle disorders acute intermittent porphyria swil syns disease renal failure liver failure hypoglycemia or any kind of electrolyte disorders like sodium calcium or magnesium and then systemic disorders such as systemic lupus and thyroiditis as well also how those citizens like PCP LSD and ketamine marijuana sympathy um and medics such as cocaine or amphetamines and alcohol withdrawal and the new one is bath salts those are all illicit substance use causes of psychosis and children and adolescents and then finally medications that can cause this would be anakata intoxication with anticholinergics like diphenhydramine scopolamine serotonin syndrome amoxicillin erythromycin clarithromycin can cause it anticonvulsant steroids and inh and actually if you withdrawal from either baclofen or benzodiazepines it can cause a psychosis so how would you go ahead and manage them pharmacological management and treatment would be second generation antipsychotics are always good risperidone olanzapine quetiapine arab pepper is all supras adone and poly perdón also first generation antipsychotics can be used but they're obviously not preferred due to high risk of extrapyramidal side effects like tardive dyskinesia and benzodiazepines can be added to the treatment so that you can treat the any kind of agitation involved also special populations like chronic non-compliance populations you want to consider long-acting injectable in these patients as well as if they've had any type of treatment resistance such as they've tried two trials of medications and they didn't it failed you want to consider in those cases clozapine so clozapine has always been the answer to when haloperidol isn't isn't working or any type of first generation isn't working you want to do ace the second line it would be clozapine so although antipsychotic medications is primary is the primary treatment for schizophrenia integrating both psychosocial interventions into a broader treatment program can improve the outcomes family counseling and psycho in have proven to be high-yield interventions in schizophrenia for example educating the patient's father about symptoms of schizophrenia her social isolation and declining grades are not laziness can't help produce family stress but that's reduce not produce a family stress patients with schizophrenia who have critical hostile or over-involved family members such as higher risk relapse while if they're in the home atmosphere if they're stable and the family stressors are kept to a minimum you want to decrease the risk of real that decreases the risk of relapse so that is another test question where they ask what would you want to recommend to the family and it would be to stop arguing have a peaceful home environment keep family stress stress to a minimum antipsychotics such as long acting injectables you want to administer every two to four weeks both first generation and second generation antipsychotics can be long-acting so first generations are your haloperidol and your flu phenazine second generations we said earlier like risperidone and pellet perdón allows of pain and era pip result these are available along as is long-acting injectable and then suitable candidates would be unstable patients who let's say they'll at home have poor social support systems poor insight frequent medication non-compliance or or patients who have had a good response to oral medication alright so what are some of the anti-psychotic medication effects in the dopamine pathways and so we're gonna distinguish this into mesolimbic pathway the Niagra straddle pathway and the tubular and to burrow in from dibbler pathway so let's say for them as a limbic pathway antipsychotics have and a higher efficacy in the mesolimbic pathway whereas in the Niagra Nigro straddle pathway would be extrapyramidal symptoms like acute dystonia and Teesha and parkinsonism and then you have your two borough infundibular pathway which can cause hyperprolactinemia so mesolimbic would give you the efficacy of antipsychotics then micro straddle would be the extrapyramidal symptoms and the two burro infundibular will give you hyperprolactinemia so you can get things like a materia again akka mastiha dr. Arya decrease in libido resulting from an increase in prolactin that's more common with the high potency first generation antipsychotics like haloperidol and of phenazine and then second generation antipsychotics like palak para Doane which is a metabolite of risperidone and risperidone as well can cause those side effects prolactin Ouma's can cause a very high prolactin levels so you're looking at prolactin levels of more than 200 nanograms whereas medication related hyperprolactinemia is typically 25 to 100 nanograms with levels that seldom raise above 200 so some of these antihypertensives are associated with hyperprolactinemia and those include risperidone alpha methyl dopa and verapamil okay so moving on we have antipsychotic extrapyramidal effects so you have your extrapyramidal symptoms and their treatments so for acute dystonia this happens between four hours to four days these are sudden sustained contractions of the neck mouth tongue and eye muscles treatment would be Ben's atropine or diphenhydramine for acute dystonia akathisia can happen at any time akathisia is subjective restlessness or an inability to stand still or sit still and you treat akathisia with beta blockers like propranolol or benzodiazepines like lorazepam parkinsonism occurs four days to four months afterwards after an anti-psychotic is given and these usually have gradual onset of tremors rigidity and bradykinesia which is slow movement and some of these and the way you would treat that would be with a benzo with been stripping or amantadine and then you have tardive dyskinesia which occurs later on at 1 to 6 months of use and these are gradual this happens as a gradual onset after a prolonged therapy that usually lasts more than six months dyskinesia of the mouth dyskinesia of the face the trunk and the extremities and there's no definitive treatment unfortunately but clozapine can help with tardive dyskinesia so types of dyskinesia you have oral and facial dyskinesia limb neck and trunk and respiratory dyskinesia so the oral and facial are gonna be your tongue protrusions tongue twisting lip smacking lip and puckering retraction of the corners of the mouth and chewing movements if the limbs are affected you'll see limb twisting and spreading piano playing finger movements and foot tapping as well as dystonic extension of the toes neck and trunk you'll see torticollis shoulder struggling or muster I'm sorry shrugging the shoulders shrugging rocking and swaying rotary hip movements and for respiratory symptoms you'll see grunting noises so extrapyramidal side effects are more common again with first generation antipsychotics compared to the second-generation ones out of the second-generation antipsychotics risperidone is going to be the one that's most likely going to cause the extrapyramidal symptoms so remember that and that's going to be obviously at a higher dose and if the dose reduction is not even feasible with these patients then you would want to give medication associated with whatever it is that they're suffering from that we've listed moving on we have our next topic is neuroleptic malignant syndrome and this is a highly tested question so signs and symptoms would be sometimes they'll have severe feet fever so you're looking at over 40 degrees Celsius and that can develop within one to three days associated with delirium often as its first manifestation so high fever you can have mental status changes muscle rigidity autonomic instability tachyarrhythmias and dis arrhythmias labile blood pressure so rhabdomyolysis is followed by a mile globulin urea which can cause acute renal failure and that's a common complication and as well as leukocytosis also tachypneic and diaphoresis those are all signs of symptoms of neuroleptics malignant syndrome i remember them rhabdomyolysis that's a big one precipitating factors would be antipsychotics typical or atypical remember risperidone if it's the atypical one is the one that's gonna cause it and clozapine is gonna be your go-to drug for that for that treatment antiemetics like promethazine and metoclopramide but that's associated with meds that block dopamine transmission and that can occur at any time after treatment anti Parkinson drugs such as dopamine agonists and medication withdrawal can cause this and infections and surgeries and you would the way you would treat it is to first stop the neuroleptic or restart dopamine agents if they've done the withdrawal you want to restart them or if they're on a medication you want to stop the neuroleptic supportive care like hydration and cooling if they're having the fever so antipyretics alkaline the diarist diuresis and cases of rhabdomyolysis and also the big ones here are dantrolene and bromocriptine and amantadine so you can give either either one of those three dant redeem dantrolene bromocriptine or amantadine will treat neuroleptics malignant syndrome and you want to monitor these patients in the ICU so if they ask you typical a psychotic patient that's under medical management with an anti-psychotic and they present to you with a fever mental status changes rigidity and such and then you they ask you where would you want to monitor these patients in do you want to discharge them home after they're being treated and everything is fine it's the answer is no you want to take them into the ICU so what's the difference between neuroleptic malignant syndrome and serotonin syndrome is that in serotonin syndrome that begins with vomiting diarrhea restlessness and autonomic instability and that's characterized by neuromuscular irritability but not rigidity so they'll have tremors and hyperreflexia and myoclonus but they won't have muscle rigidity fever isn't really as high even though it may be present they'll give you a patient that's is is febrile so you'll see 101 maybe 102 as their fever but here with these patients they're suffering fevers more than 104 and also waiting two weeks between the discs it's the discontinuation of an MAOI like phenelzine and the start of a ceratin genic antidepressant like psych tala pram is deemed sufficient enough to avoid the risk of a developing serotonin syndrome so again neuroleptic malignant syndrome just remember it causes sweating to Kip Nia hypertension tachycardia you can have dis arrhythmia muscle rigidity is the big one fever and altered mental status so what are going on to the next topic what are some of the metabolic effects of second-generation antipsychotics so we know what first generations can do what is second generations do and one of them would be metabolic syndrome like weight gain this epidemia hyperglycemia including new onset of diabetes highest drug the highest risk drugs that can cause these metabolic effects would be clozapine and olanzapine remember Alonza pain causes weight gain the Oh remember the Oh think of a big oh as a big body and a person a big round belly or something it's olanzapine and that is associated with weight gain and monitoring guidelines would be a baseline and regular follow-ups such as body mass index cuz these drugs cause weight gain fasting glucose and lipids blood pressure and waist circumference and the BMI is measured monthly the rest is measured at baseline then three months and then annually the earlier and the more frequent the monitoring needed in those with diabetes or those who have gained more than 50 percent of their initial weight gain so you just want to closely monitor them if they are gaining weight Alonza pain is a serotonin and dopamine blocker but it also has affinity for the histamine receptors alpha one adrenergic receptors and muscular Inuk receptors allows apenas most common side effect is going to be weight gain and sedation like we said the weight gain is due to the antagonism of histamine 1 and serotonin receptors and the sedation is due to the blocking of the histamine receptors next is clozapine treatment guidelines so we said earlier that the indications for clozapine would be for a treatment resistant schizophrenia so if they're resistant at some type of treatment they're the go-to drug next in line would be clozapine and in schizophrenia associated with suicidality you also want to give clozapine so if they're suicidal clozapine is a good treatment and an indication to give adverse effects would be a granulocyte ptosis so you'll see a very low white blood cell count and all the granulocytes would be low seizures myocarditis metabolic syndrome as well as aliases and hypotension can all be adverse effects of clozapine so adverse effects so with the exception of clozapine no ins like psychotic is superior to another the least it's least likely cause of extrapyramidal side effects and it hasn't been shown to cause tardive dyskinesia so that's why it can be a treatment for tardive dyskinesia because it's maybe it's not necessarily treating the tardive dyskinesia but it can it just hasn't been shown to cause tardive dyskinesia okay also clozapine is associated with treatment resistance so any poor response are these two anti-psychotic trials will require regular monitoring of the white blood cell counts as well because of the agranulocytosis and absolute neutrophil counts to two risk of leukopenia and neutropenia as well as the agranulocytosis which we mentioned also weekly blood blood counts should be done within the first six months of treatment to look out for that so just remember that about clozapine what else oh just one of my professors said that clozapine sounds like a clown clozapine clown of pain or whatever and clowns are kind of weird and wacky so a closet pain can cause seizures so maybe because it causes seizures and makes you look kind of wacky when you're having a seizure that's a like a clown clozapine maybe that'll help you it did help me so why not wacky little things like that help sometimes next would be error pip resolve that's another second-generation antipsychotic is both antagonist and partial agonist of the dopamine d2 receptors and that's less likely to cause hyperprolactinemia so if you're asked most likely you'll be asked for era papers all the only question would be this patient has hyperprolactinemia as a side effect what medication would you like to switch them to and it would be err pippers all ziprasidone is associated with QT prolongation at higher doses so just remember that ziprasidone starts with the letter Z and the letters QT are all end of the alphabet letters so make that'll help as well so prolongation of the QT and ziprasidone all right moving on we have anxiety disorders so some of the differential diagnosis is of the dnc dsm-5 for anxiety disorders would be social anxiety disorders like social phobia and that would be an anxiety that's restricted to social and performance situations or fear of scrutiny and embarrassment so they'll give you a patient that only has anxiety when they're put in a specific situation so in that case that would be social anxiety disorder panic disorder would be if they have recurrent unexpected panic attacks versus specific phobia which is an excessive anxiety about one specific object or a situation so try to remember try to differentiate between specific phobia and social anxiety and a specific phobia it could be anything but it's a it's usually an object versus social anxiety disorder would be anxiety because of a fear of scrutiny or an embarrassment in a specific situation so I guess anxiety social anxiety would be according to the situation where a specific fody phobia would be according to a specific object or a situation but if in the exam they'll probably point you in the direction of a specific object all right and generalized anxiety disorder would be chronic multiple worrying anxiety and tension I know people that are constantly chronic worriers they're worried about this worried about that gives them anxiety and tension and if that's actually impeding on your daily life that would be given a category of generalized anxiety disorder so moving on we have we're gonna 12 into this a little bit more in detail so let's start off with social anxiety disorder or social phobias it's also known as the diagnosis is marked anxiety about more than one social situation for more than six months there you have your six month bracketing that these like these psychiatric conditions are based off of more than six months at about more than one social situation fear of scrutiny by others in humiliation and embarrassment social situations are then avoided or endured with very extreme intense de-stress and then marked impairment of social academic and occupational situations because you just don't want to deal with life at that point whatever it is that you're you have a phobia too as well as subtypes specifier so performance only such as if you are gonna go on stage or give a speech in front of hundreds of people that's some type of performance anxiety which is a specific social phobia or not specific phobia I'm sorry it would be a social anxiety disorder or social phobia okay a treatment would be in the in these situations an SSRI or SNRI as well as cognitive behavioral therapy again if you ever get the option of having both a treatment a medical treatment plus cognitive behavioral therapy always pick both beta-blockers or benzodiazepines are used for the performance subtype of this disorder so the beta blockers are preferred benzos because benzos can cause sedation or effects in cognition so you want to kind of avoid that because you don't want to actually make a fool out of yourself if you're sedated or or something on stage you just want to calm yourself down and it'll help you perform better on stage and avoid substance avoid benzos in substance abuse patients because benzos again are highly addictive cognitive behavioral therapy techniques include social skills training cognitive reframing of anxious thoughts and systemic de sensitization all right moving on we have panic disorders panic disorders are recurrent and unexpected attacks with more than four of the following so they can have chest pains palpitations shortness of breath trembling and sweating nausea dizziness paresthesias D realization or deep personalization fear of losing control or dying and worry about additional attacks and avoidance of behaviors so how do you treat panic disorder immediately you want to give benzodiazepine to just calm them down and then long term you calm them down how do you want to treat them long term is with an SSRI or SNRI or you can combined that with the cognitive behavioral therapy alright panic disorder the R is recurrent and unexpected panic attacks with more than four of the following so they can get palpitations and sweating trembling or shaking shortness of breath choking sensations that's a common one chest pain and discomfort so I can mimic an mi right nausea abdominal distress dizziness and lightheadedness chills or heat sensations paresthesias a derealization or depersonalization disorder fear of losing control or going crazy or the fear of dying these are all symptoms of panic disorders and this will happen very commonly at least one attack followed by one or both of the following for more than a month so they can have worry about additional panic attacks or Consequences and changes in behavior related to the attacks like avoidance the panic attacks are not attributable to other mental illnesses or substance abuse so how would you treat panic disorder you would treat it exactly the same as what we said earlier with benzodiazepine and long term with SSRIs and cognitive behavioral therapy you can also do a benzo like lorazepam well that's not all so you immediately you want to give benzodiazepines an example would be lorazepam and once the symptoms are controlled benzos should then be tapered off due to risk of dependent and then the diagnosis is mainly clinical but drug screening monitoring of vitals EKGs cardiac enzymes should all be performed to rule out any type of MI because again panic disorder does look like an mi core morbidities of panic disorder would be they could be associated with major depression studies have shown that about 60% of patients with panic disorder have at least one lifetime episode of major depression bipolar disorder is also a sort of ciated with panic disorder agoraphobia which is the fear of public places an approximately 40% of patients meet that criteria of agoraphobia and substance abuse and there's also a higher risk of suicide attempts and suicidal ideations now we can move on to specific phobia and that would be a marked anxiety about a specific object or a situation for more than six months again you have that six months time period common types of phobias would be phobias of flying phobias of heights animals injections or seeing blood those are all examples so avoidance behaviors like bridges and elevators refusing to work requiring travel like on an airplane or a boat or whatever their phobic to the object of their and they have phobia too and it's common around 10% of the population does have some type of specific phobia and usually it develops in childhood and can develop after a traumatic event so treatment for a specific phobia here you want to do behavioral therapy first such as exposure therapy like flooding I believe is the term right flooding a systemic desensitization as well and those are the treatment of choices short acting benzos can help acutely so if a therapist is unavailable there's just insufficient time benzodiazepines can be given if if there's something going on at this moment but since this is a specific phobia they're coming to you because they need help dealing with a folk with a phobia that just means that they need therapy at that time okay not not medical therapy okay or pharmacological therapy I'm sorry generalized anxiety disorder is the next one and this is excessive worrying or anxiety about multiple issues and that occurs more than six months they're difficult to control there's more than three of the following symptoms they can have restlessness or feeling on edge they can have fatigue difficulty concentrating irritability muscle tension and sleep disturbances as well as significant distress or impairment and it's not due to substances or any other type of mental disorder or medical condition and treatment for generalized anxiety disorder first line would be cognitive behavioral therapy with an SSRI or an SNRI and if those don't work second line would be to give them benzos or buspirone and be spur on is used in non depressed patients as well and in the absence of panic symptoms so it it if they have signs of panic symptoms you don't want to give them booster perón you actually want to give them a benzo to calm them down first and then again and then send them home on an SSRI or SNRI with cognitive behavioral therapy I think you're getting the point so benzodiazepines should not be used in patients with comorbid depression substance abuse because they're what they called Downers they should be used sparingly in elderlies due to slow metabolism and accumulation so remember that elderly patients have a slower rate of metabolism so any type of drug that you give them has to be titrated at a perfect amount because they have a very slow metabolism and can linger around their body causing toxic levels to accumulate so remember that about elderly patients and that slow metabolism and accumulation of the drug in elderly patients can cause confusion and an increased risk of Falls another adverse effect of benzodiazepine is paradoxical agitation now paradoxical agitation is gonna be characterized by increased agitation confusion and aggression as well as this inhibition and it's typically within an hour of administration although paradoxical reactions of benzodiazepines are relatively uncommon less than 1% they are important to recognize as increasing the doses of benzodiazepines will only worsen the patient's condition and discontinuing is going to be the most appropriate next step in the management if a patient starts developing paradoxical agitation okay the next topic is OCD or obsessive compulsive disorder and diagnostic criteria would be obsessions that are recurrent or intrusive obsessions anxiety provoking thoughts urges or images and there's attempts to suppress or neutralize them with other thoughts of actions like compulsions and it has no relation to other mental or substance use disorders so these are just straight obsessions compulsions are another diagnostic criteria which are responses to the obsessive thoughts and repeated behaviors or mental acts they have excessive behaviors that are intended to reduce the anxiety or to avoid any kind of outcome so their behaviors are not connected realistically with preventing anxiety or the feared event obsessions or compulsions they consume more than an hour's worth of your day and that causes significant distress and it interferes with a daily routine or social functioning whenever you see that phrase by the way as a general rule that it interferes with daily routine or social functioning that is a hint for a psychiatric condition if it doesn't have that it might just be counseling or whatnot but if you see that someone's daily routines or social functioning has been compromised then you're more look you're looking more into a psychiatric condition so be aware of that okay treatment options for OCD would be cognitive behavioral therapy exposure and response prevention and/or a high dose selective SSRI you can also give Kalama fene or an anti-psychotic for people who do not respond to that treatment that don't respond to SSRIs you can give them clear amine or antipsychotics and also deep brain stimulation for treatment of severe or refractory cases so I mean if nothing works the last case scenario would be to stimulate your brain that would be pretty much anybody's last resort is to actually get into the brain and do some kind of stimulation there all right next topic would be trichotillomania and that's basically hair pulling so dsm-5 criteria states that these are recurrent hair pulling causing hair loss with repeated attempts to decrease or stop the hair pulling they don't want to be doing this but they're just doing it causes significant distress in their lives again you have your that it affects their daily life that's an issue it's not due to a medical or dermatological conditions such as alopecia this is just them pulling out their hair and it's not due to any other mental disorders like body dysmorphic disorder so it's not it's not a symptom of something else this is it it's a it's a diagnosis in itself how you treated is with cognitive behavioral therapy to reverse their habits so it's like a training form of reversing that habit of hair pulling the dsm-5 classifies it as an OCD related disorder to reflect the increasing evidence of shared features that they have with OCD and because of their higher rates of core morbidity in patients with a personal or family history of OCD and commonly it affects areas such as the scalp the eyebrows and the eyelids more common in girls and women and they have something also called trick aphasia which means when they pull out their hair they'll eat it and subsequently they can actually form a trick Oh bezoar which remember was like a ball of hairs in the intestines or in the stomach that was from step one a bezoar so that can lead to abdominal pain and even bowel obstruction if it gets too bad next one would be hoarding syndrome and this is a new disorder in the dsm-5 it's distinct from OCD in that it is characterized by the accumulation of large numbers of questions that make clutter the living spaces to the point that they are the living spaces are not are not usable patients experience intense distress when they try to attempt to discard any of their possessions regarding to their actual value regarding of their actual value so it could be somebody collecting newspapers that have no significant value or no newspaper clippings I really have no significant value and yet it's so many of them that it's impeding their walkway to get into their bedroom and if you try to remove that they are extremely held on to this clippings in this example so they don't want you to get rid of it so that is a problem it can also become caitiff it's extreme it can cause associations with unsanitary conditions fire risks basically because of the blocked exits and then cognitive behavioral therapy would be the treatment specifically targeted to the hoarding behaviors that's the most effective treatment and their specific techniques to educate the patient as well as motivational interviewing skills skills training and organization and decision-making capacities also can cognitive reconstruction or restructuring of dysfunctional thoughts an actual gradual exposure to discarding possessions so you can say well we'll get rid of these little five clippings you don't really need that and so on and so forth until they're cured or at least they're stable all those SSRIs are often tried based on the efficacy in treating the OCD their efficacy in treating this disorder the hoarding behavior without obsessive-compulsive disorder is going to be limited so SSRIs can be considered as an adjunct to cognitive behavioral therapy and then it can be helpful in treating core morbid depressions and anxiety disorders but cognitive behavioral therapy in itself is basically first line also I'd like to add a side note that most of these disorders they require the patient to to basically tell you that there's a problem they have to admit there's a problem you can't just go out of your way because a family member brought them in and expect the patient to be compliant with any type of treatment that you give them because they're they think them themselves that this is perfectly fine behavior unless they come to you and say doc this is a problem then the treatment is always gonna be better versus if they don't then no amount of treatment is gonna help them because they're not gonna comply with anything you tell them to because in themselves they really think there's nothing wrong with them okay so just just a little adjuvant there so next disorder would be PTSD or post-traumatic stress disorder and the clinical features would be exposures to a life-threatening trauma as well as nightmares flashbacks intrusive memories there's avoidance of reminders amnesia of the event there's emotional detachment and a negative mood towards it with decrease interest in activities sleep disturbance hyper vigilance irritability and this is gonna be lasting more than one more than one month so again this is the that it affects their daily life treatment would be a trauma focused cognitive behavioral therapy like what is it that caused you to have the post traumatic stress disorder what traumatic experience were you exposed to and then the cognitive behavioral therapy will be geared towards that and you can also add an antidepressant to help out with the cognitive behavioral therapy such as SSRIs or SNR ice sexual assault patients and also military veterans are at increased risk of PTSD along with the risk of developing major depression and a contemplation of suicide attempts also there's an increased risk for medical problems including sexual transmitted diseases pelvic pains fibromyalgia functional gastric gastrointestinal disorders and cervical cancer those can all be linked to an avoidance of pelvic examinations some PTSD symptoms may appear immediately after a trauma however sometimes it's often delayed months or even years before you actually start seeing any kind of criteria for the diagnosis all right next topic is depression so we're gonna have differential diagnosis of depression specifically differentials of that depressed mood so you'll have your category of major depression adjustment disorder with a depressed mood and normal stress responses so that's category ISM so in major depressive disorder you're looking at something that's gonna be occurring more than two weeks there's gonna have more than five of the nine symptoms of ciggy caps there's gonna be a significant functional impairment there's no lifetime history of mania and there's it's not due to drugs or any kind of other medical conditions so it's just think about a significant functional impairment again with their daily lives with more than five of the symptoms of ciggy caps now the mnemonic ciggy caps you probably already know this but the S stands for sleep disturbance I stands for interest or loss of interest G is for excessive guilt use for energy so low energy that the seein caps is impaired concentration the a is appetite disturbance so they won't have an appetite or they will excessively or under appetite or low appetite of the P is for psychomotor agitation or retardation and the essence Iggy caps is suicidal ideation so if they have five of those nine symptoms and that is the criteria for major depressive disorder now adjustment disorder with depressed mood would be you can actually pinpoint the identifiable stressor the onset is going to be within three months of that stressor so it's more of an acute kind of thing it's mark there's mark distress in the patient there's significant functional impairment again with their daily lives but it doesn't meet any criteria for other dsm-5 disorders so here they have an identifiable stressor that happened within the last three months specifically these could be like an automobile accident or witnessing somebody being killed or or something very traumatic and it happened fairly recently within the last three months and that is significantly causing them to stress an impairment so that is adjustment disorder with a depressed mood and then you have your normal stress response and that is not excessive or out of proportion to severity of the stressor there's no significant functional impairment these people can actually go about doing their daily lives they may be thinking about the event or thinking about the stressor but they're still able to go to work they're still go to go to school study do their normal daily lives this is just a normal stress response okay so for adjustment disorder the symptoms rarely last more than six months after the stressor ends and the stressors can be either single or multiple stressors and it involves emotional or behavioral symptoms such as anxiety depression disturbance of conduct and you want to treat with psychotherapy that that's focused on developing coping mechanisms and improving individuals and responses to and an attitude about stressful situations so psychotherapy is going to be your treatment in adjustment disorder for major depression there's signs and symptoms of major depressions we already said a ciggy cab sleep lack of sleep increased or lack of theirs anhedonia decreased interest guilt so they have feelings of worthlessness or hopelessness their deficient and energy they've just they're not energetic they have a difficulty concentrating their appetite can either be increased or decreased they can have a psychomotor retardation or agitation and actually suicidal ideations so so some what are the differences between major depression and a grief reaction so a major depressive episode is basically five of the following nine symptoms so this the nine siggy caps I'm not gonna keep going over them but there's low solo mood or anhedonia must be present it has it can't occur in response to a variety of stressors including a loss of a loved one the duration here has to be at least more than two weeks and there can be social or occupational dysfunction and suicidality is really this is gonna be related to hopelessness they feel hopeless and worthless maybe the stock market crashed and they lost all their money and now they feel suicidal and they can't even function in life and right there and then that's the diagnosis for major depression a grief reaction or bereavement is going to be a normal reaction to the loss feelings of loss or emptiness the symptoms are going to resolve around they're not gonna they're gonna revolve around the deceased person functional decline is gonna be less severe the the grief is gonna occur in waves there's also going to be feelings of worthlessness self-loathing guilt but there's not really a feeling of suicidal tendency there that's that's not as common but they do feel extremely sad but it's more specific towards the deceased person that's what's why they're grieving thoughts of dying involved joining the deceased person oh they they had a strong connection to their loved one they just want to join the deceased there's also intensity is gonna the intensity is gonna decrease over time so the timeframe there would be weeks two months now there's also sub classifications of depression you have melancholic depression atypical depression and depression with psychotic features so a melancholic depression would be a subtype of major depression that's characterized by anhedonia absent mood reactivity a depressed mood and that's typically worse in the morning you have insomnia or early morning awakenings they get up early early in the morning with loss of appetite so they have weight loss they are typically they feel guilty excessively with psychomotor agitation or retardation and that subtype is and it's psychomotor changes are more common in older adults so that would be a melancholic depression older adults but if you see something that involves hypersomnia they constantly sleeping with an increase in appetite and they basically are not very sensitive to anything anymore and now they have physiological feelings of heaviness in their limbs that's an atypical depression and then versus major depression with psychotic features that is gonna be basically an elderly patient who has depression to the point of suicidal ideations so in those cases you want to treat with electro convulsive therapy the reason again is because remember we said earlier that in the elderly population their metabolic their metabolism is slowly reduced so they're going to have an increase of the concentration of whatever drug you give them in there system so it's gonna take them longer to eliminate psychotic antipsychotic drugs antidepressants any type of medication they're slower renal function they have a decline in renal function normally so you want to avoid any of these heavy heavy medications so just go straight into electrical fall severe apibe II cuz it is a rapid response it's a very quick procedure as very low side effects if not any and it's just preferred over the medical pharmacological therapy all right next topic would be dysthymia which is a persistent depressive disorder the dsm-5 categorizes as a chronic depressed mood that lasts more than two years when and one year in children or adolescents there is no symptom free period for at least two months so this is happening more than two months the presence of at least two of the following so they'll have poor appetite or overeating insomnia or hypersomnia low-energy or fatigue low self-esteem poor concentration or difficulty making decisions there could be feeling of hopelessness and with a peer dislike the Stimac syndrome it's a criteria for major depressive episodes that's never been met with intermittent major depressive episodes and they can also be with persistent major depressive episodes and that criteria is for major depressive episodes that's met previously for the previous two years okay so moving along we have antidepressants and there's several classifications of antidepressants first you have your SSRIs SNRIs your nd our eyes TCAs mao eyes and other medications so let's start off with SSRIs these are a selective serotonin reuptake inhibitor that's what it stands for you have your fluoxetine paroxetine sertraline citalopram escitalopram and fluvoxamine be careful with citalopram and escitalopram because that sounds like a benzo but it's actually an SSRI citalopram escitalopram SNR eyes would be your serotonin and norepinephrine reuptake inhibitors those are your venlafaxine dest venlafaxine and duloxetine you have your and DRI which is norepinephrine and dopamine reuptake inhibitors the end DRI the one that we should know is if you Pro prion and though that bupropion it helps with smoking association so that's a big one no weight gain so there's no weight gain involved no hypersomnia so that's good and no sexual dysfunction as well so that is those are really good benefits for the appropriate and they will be tested on they'll have which of the following helps with will help with this patient and they'll give you a patient who wants to stop smoking be appropriate they'll give you a patient who says that he really doesn't want to gain weight anymore so it's something appropriate contraindications however would be seizure disorders because they do cause seizures it's known to cause seizures so if they are suffering from seizure disorder that's contraindicated also patients who are bulimic because this medication does not cause weight gain and we want patients with bulimia nervosa anorexia nervosa to actually gain weight so that would be a contraindication and if they've had any type of maoi use within the past two weeks if they've been on like phenelzine or tripe trial super-mean within the past two weeks and you want to change them this would be a contraindication so you would not want to give be appropriate in those cases so caution needed when there is an abrupt withdrawal of sedative hypnotics and co-administration with other drugs that lower the seizure threshold because again this medication is known to cause seizures TCAs are your tricyclic antidepressants your amitriptyline nortriptyline you'll see later on that these tricyclic antidepressants and although they are classified as antidepressants are usually used as pain management so go figure but that's what it is and you have your mao eyes which are your monoamine oxidase inhibitors again your phenelzine trials if I mean and both TCAs and mio is our never first line because they have the greatest side-effect profile you want to give them five weeks after a washout period when you've taken fluoxetine and before starting at mio I basically to avoid serotonin syndrome other antidepressants would be mirtazapine trazodone and wart ty oxy teen alright so parents of adolescents patients should always be notified when the patient is at risk to themselves or to others or when starting a psychotropic medication if patient the patients are not suicidal and they simply just want to discuss his or her depression or obtain psychotherapy referrals and his request for confidentiality should be respected patients with a single episode of major depressive disorder who do respond to actual treatment should continue the anti-depressive medication for an additional four to nine months and that would be a continuation phase treatment there is a significantly increased risk of a depressive relapse in patients who suddenly discontinue their antidepressants earlier than four to nine months so if you have a patient who says thanks doc this has been working great and it's only been two months of treatment or three months what would be the next thing do you want to wean them off or what no you actually want to continue them on for at least nine months four to nine months the dose should be maintained at the level that was that achieved remission and it shouldn't be reduced the dose that gets the patient well keeps the patient well is what you should know so the maintenance phase treatment is going to be defined as continuing the antidepressant medication past the initial continuation phase treatment maintenance therapy is about 1 to 3 1 to 3 years that would be appropriate for patients with a history of multiple episodes like recurrent major depressive disorder and for chronic episodes that lasts more than like two years with a strong family history or if they've had severe episodes like that suicide is attempted that would be an indication patients with a history of highly recurrent lifetime episodes more than three lifetime episodes and very severe episodes chronic major depressive episodes those all should be continuing on with maintenance treatment indefinitely so in those patients no matter how much they want to ask you can we be weaned off because of their past history and risks you do you just want to continuing them you want to continue them on indefinitely when should you taper or discontinue when there's failure of initial SSRI treatment so you'd want to increase the dose to its maximum therapeutic dose then you'd want to do adequate duration of more than six weeks where you'll see minimal or no improvement then you want to switch to another first-line antidepressant with a different like let's say into Mayo I are in Smar SNRI and other options would include adding a second agent especially in those with that have some benefit but not complete improvement with either adding or switching that pharmacotherapy so it's all this is all tailored therapy in other words so you kind of want to see where the patients at have they been doing better with it or minimally better if not do you want to switch them to the same class of maybe a different class you want to add to a different class and maintain them on a current one because it's having a little bit of benefit here but not enough there so you want to add another medication everything is tailored in this case so patients undergoing chemotherapy also that have a low threshold of depression and starting SSRIs the first step in management would be pain control obviously because chronic pain can lead to depression mirtazapine side-effect that's weight gain and sedation and trazodone is very sedating and it's used in insomnia related to depression so if there's depression with insomnia trazadone would be a good treatment now coming back to the topic of electro convulsive therapy or a CT when would these be a good condition like we said in in well first of all in elderly patients with major depression or with unipolar and bipolar depression catatonic patients and patients that have bipolar mania so what are some of the specific indications if there's treatment resistance to other medications if it just didn't work or if they have psychotic features present or any type of emergency condition such as in pregnancy that's a good one refusal to eat or drink or imminent risk of suicide you want to treat them ASAP with a very quick treatment minimal side effect profile profile electroconvulsive therapy and then pharmacotherapy is contraindicated due to the core morbid medical illnesses and poor tolerability and also if they've had a history of response to electro convulsive therapy that would be in also a good indication to continue on doing that treatment because again that would be last resort anyway the safety is that there's no absolute contraindications to electric electro convulsive therapy there is an increased risk of severe cardiovascular disease or if patients have had severe recent MI or if they have a space occupying brain lesion or a recent stroke or they have some type of unstable aneurysm then that will make a contraindication so you want to perform it's performed under general anesthesia and it's one of the most common and one of the most common side effects of ECT would be amnesia it can't be a retrograde amnesia so like forgetting me recent memories that tends to last longer especially of events occurring during the ECT or it could be anterograde amnesia such as retaining new memories but that resolves rapidly there's an increased risk of fractures especially in osteoporotic patients but not as common as a boniva you want to do close monitoring of muscle relaxation with succinylcholine and that has decreased the incidence of bone fractures if they do have an increased risk of osteoporosis all right next topic would be postpartum blues depression and psychosis so postpartum blues the prevalence of that is 40 to 80 percent so this is fairly common the onset occurs within two to three days and it resolves within 10 days symptoms would be mild depression tearfulness irritability and basically you just want to reassure these patients and monitor them because it does go away in ten days and it's fairly common versus postpartum depression that is actually least common or less common only eight to 15% of the population has this usually happens within four weeks their symptoms are moderate to severe depression they'll have sleep or appetite disturbance low energy they can have psychomotor changes they can feel guilty lack of concentration or they can even go as far as to having suicidal ideation and treatment for postpartum depression would be antidepressants and psychotherapy and then finally you have your postpartum psychosis which thankfully it's the least prevalent at only 0.1 to 0.2% of the population this occurs it's onset is variable it can happen within days to weeks symptoms would be delusions or hallucinations fot dis organizations and bizarre behavior so all the symptoms of standard psychosis is just happening postpartum and their treatment would be antipsychotics and antidepressants and you don't want to leave the mother alone with the infant because there's a risk that the mother can kill the infant so if you see a vignette that says that she's doing something for Rita she's seeing things or voices are telling her to kill herself and the baby or something like that those are obviously red flags and that is not normal by any means so you want to admit the patient and don't leave the mother alone with the patient you don't want to discharge these patients and you want to treat them with antipsychotics and antidepressants immediately okay next would be bipolar disorder and that is bipolar disorder and it's related disorder so we can classify these first of all as either manic episodes or hypomanic episodes and then we'll go into bipolar one bipolar two and cyclothymic disorder so bipolar disorder that it's manic episodes or symptoms that are more severe it's usually one week long and less hospitalized they'll have marked impairment and social or occupational functioning or hospitalization necessary it may lead to psychotic features and that makes the episodic makes the episodes manic by definition so those psychotic features are basically a manic episode then you have your hypomanic episode which are less severe symptoms that occur more than four consecutive days long so a little bit less than a week there though it'll be unequivocal with observable changes in functioning from the patient's baseline so symptoms are not going to be severe enough to cause marked impairment or necessitate hospitalization with these patients and their key here is that there are no psychotic features so it'll be very very very less very low less severe symptoms of mania but with no psychotic features so then you have your bipolar one and bipolar one is basically defined as manic episodes they have depressive episodes that's pomander it's not required for the diagnosis the diagnosis of bipolar one are basically manic episodes versus bipolar two are hypomanic episodes there's episodes of mania but there's more than one major depressive episode required so they'll have mania and depression at some point in time that would be bipolar - just think of it as two episodes manic and depressive bipolar - bipolar one only manic they could have a depressive episodes but that's not common and it isn't required so bipolar one only manic bipolar two hypomanic episodes with at least one or more major depressive episodes and then finally you have your cyclothymic disorders which is at least two years of fluctuating in and out of mild hypomania and depressive symptoms that do not really meet criteria for hypomanic episodes or major depressive episodes it's just a waxing and waning kind of deal but it's lasting for more than two years and that would be cyclothymic disorder so let's break these down a little bit more in detail so acute mania its clinical features would be elevated arrabal and labile mood they'll have increased energy increased activity they'll have a decreased need for sleep they have pressured speech and racing thoughts and distractibility almost like like like ADHD but less severe or more severe sorry grandiosity risk of risky behavior they'll have pressured speech Martin pyramid and they could have psychotic symptoms as well and how would you manage acute mania first line would be yours antipsychotics it could be either first or second generation second generation again risperidone because of its more rapid onset of action and you always kind of want to give second generation antipsychotics before you give first generations kind of contra country intuitive there but second generations have less side effects profile like we already mentioned and out of all of them risperidone is the treatment of choice although it does have the highest side-effect profile of all the second-generation ones it is more rapid onset of action so you want to kind of give that first for acute mania you can also give lithium but you want to avoid in patients that do have renal disease because lithium does cause a renal failure without pro8 can also be used but you want to avoid valproate in patients with liver diseases carbamazepine lithium valproate they all require gradual titration over several days so yeah you don't want to give them for patients with liver disease because these are metabolized in the liver and not in the kidney also combinations in severe mania you can give antipsychotics with lithium or valproate and you can also give as an adjuvant benzodiazepines for patients that have insomnia or if they are agitated you can give the benzos so some of these manic episodes are classified as more than one week unless they're hospitalized so more than one week of persistently elevated or irritable moods and increase energy or activity and as well as more than three of the following symptoms so four of these if there's a mood or they're just irritable so more than a than three of the following so a decreased need for sleep symptoms of grandiosity pressured speech racing thoughts like flight of ideas distractibility hyperactive or psychomotor agitation and risky behaviors like spending a lot of money having lots and lots of investments and sexual indiscretions these are all symptoms of manic episodes and you only need more than a little three or more to make the diagnosis there's also a marked impairment of typically necessity that are typically necessitates hospitalization and psychotic features can also be present so there's a mnemonic called dig fast and that stands for a distractibility distractibility impulsivity or indiscretion the G is for grandiosity or the F is flight of ideas a is for increase in activity S is for sleep so there's a decrease in sleep and also talkativeness or T okay so moving on we have guidelines for lithium therapy so what are some of these indications for giving them lithium so mania due to a bipolar disorder that's an indication but contraindications remember chronic kidney disease you shouldn't give lithium also in patients with heart disease or if they have hyponatremia or diuretic use you should avoid lithium baseline studies before giving lithium would be to check their B when their creatinine calcium levels and your analysis because again these can cause renal failure the lithium can cause renal failure and thyroid function tests as well and you want to do an EKG in patients with coronary risk factors because heart disease is a contraindication adverse affects acutely you'll they'll have tremors a taxi and weakness polyuria polydipsia vomiting diarrhea they'll have weight gain cognitive impairment and then chronic adverse effects would be nephrogenic diabetes insipidus that can also cause chronic to below interstitial nephropathy that rarely progresses to end-stage renal disease but that's what it can cause and if Radek diabetes insipidus also thyroid dysfunction that's why you also want to check their thyroid function tests and hyperparathyroidism because it does cause an accumulation of calcium all right and pregnant women should either avoid lithium or adjust the dose during pregnancy because that can cause complications within the first trimester as most complications occur within the first trimester like Epstein's anomaly and in the later stages they can get polyhydramnios diabetes insipidus floppy infant syndrome which is a transient neonatal neuromuscular dysfunction as well as a goiter and the lithium has a narrow therapeutic index and can easily cause toxicity so those drug levels should be monitored every six to twelve months and five to seven days after any dose changes or after starting other medications that can interact with lithium so what are some of the common drug interact fm sorry what are the common drugs effecting lithium levels diuretics can do it can affect lithium levels NSAIDs except for aspirin SSRIs can affect lithium levels angiotensin converting enzyme inhibitors ACE inhibitors and ARBs angiotensin receptor blockers and anti-epileptics like carbamazepine and phenytoin because they can rev up the p450 system so that's that's a lithium can affect my anti the lithium can affect be affected by anti-epileptics so if a patient has an increase in creatinine level then you'd want to give them valproate remember you don't want to give them lithium so you Duvall Pro with periodic liver function tests because again valproate does this cause changes with within your liver enzymes and you want up so you want to monitor the liver function tests and platelet count needed due to a rare side effect profile of hepatic toxicity and thrombocytopenia because again your platelet and your coagulation factors are made in the liver management of acute bipolar depression commonly used medications would be your second-generation antipsychotics those would be quetiapine or Laura's adone and anticonvulsant like lamotrigine lithium valproate and the combination of ola subpoena fluoxetine also have been shown to have some efficacy and then anti-depressive monitor mono therapy you want to avoid that because there is a risk of precipitating mania so you just you don't want it in a patient with bipolar you don't want to give them just an antidepressant because you're just you're making the mania worse if necessary you can use in a combination with mood stabilizers like lithium or valproate second-generation antipsychotics those decrease the risks and decrease the risk to switch to mania so lamotrigine has the greatest efficacy for bipolar depressive episodes and can cause Sjogren's syndrome and one but in very low prevalence and only 0.1% of patients so that's a good medication the motor gene but it can cause it's even johnson syndrome not Sjogren's syndrome I'm sorry Steven Johnson syndrome maintenance therapy so for lifelong illnesses this is gonna require maintenance to decrease the risk of recurrence most require maintenance is for many years but lifetime lifetime maintenance is indicated for those with severe courses like highly recurrent episodes suicide attempts severe symptom impairments requiring hospitalizations and that can lead to let's say if the patient wants to stop the medication because of a strong therapeutic alliance there's a psychoeducation involved and adjunctive psychotherapy can also help the patient's accept the chronic nature of that illness and enhance their adherence so if the patient still insists on stopping the medication you want to slowly taper over weeks to months and frequently monitor them to identify any type of early signs and symptoms of recurrence so basically you just basically want to maintain them lifelong with these medications unless they really truly want to stop doing it slowly taper them off and then just observe them monitor them for any type of signs of recurrence maintenance treatment typically is going to involve continuation of the mood stabilizer and that's used to treat any kind of acute mood episodes and evidence-based options are gonna include lithium valproate quetiapine and lamotrigine patients with inadequate responses to these mono therapies or severe episodes like psychotic features or they get aggression or if they have a higher risk of suicide or frequent episodes with marked impairment of requirement requiring hospitalization that will often then require a combination therapy of lithium or valproate combined with any type of site the second-generation antipsychotics like quetiapine preferably over risperidone because of its higher side effect profile and that's recommended his first line to do a combination if the antidepressant is used in acute depression it should be tapered slowly and it should be discontinued in maintenance treatment now disruptive mood dysregulation disorder this is an individual with disruptive mood dysregulation and that can display with severity by the severity so severe pervasive irritability and poor frustration tolerance so they're very frustrated very irritable individuals and that results in frequent temper tantrums or temper outbursts that's called disruptive mood dysregulation disorder so somebody who's just think see is in a vignette somebody who has just it is always irritable always frustrated has temper tantrums attractive dysregulation mood disorder that's what that is okay now for sleep disorders you have poor sleep hygiene and that would be inadequate sleep hygiene that is the next topic so inadequate sleep hygiene is a sleep disorder due to performance of daily living activities that are inconsistent with a maintenance of a good quality sleep and full daytime alertness examples of poor sleep hygiene practices include poor sleeps scheduling with variable wake and sleep times and frequent daytime napping there's a routine use of caffeine alcohol or nicotine especially in the periods that precede the sleep so engaging in mentally or physical stimuli activities that are too close to bedtime all can give you a poor sleep hygiene as well as frequent use of the bed for activities other than sleep intent so all these are types of poor sleep hygiene okay so insomnia disorder would be insomnia for more than three nights a week or for more than three months that would give you an insomnia disorder narcolepsy is that patients are advised to maintain poor sleep habits minimize alcohol and avoid medications that can cause drowsiness and worsen the symptoms in addition a number of medications can be used to treat the symptoms of narcolepsy so some of these symptoms the ones used on you world would be modafinil and our modafinil those are the daffodils those are for narcolepsy these are Jurassic s-- excessive uncontrollable daytime sleepiness that's considered chemically to be a novel stimulant and it's preferred as the preferred treatment for not NorCal epsy because it's a very mild stimulant amphetamines simulants would be like your methylphenidate your dextromethorphan x' Dexter methamphetamine sorry sorry [Music] methamphetamines these have been traditionally used but an hour aren't currently considered first-line treatment anymore because of their high risk of abuse there's a potential tolerance with these medications and there's significant side of side effects with them so for instance if a patient can become tolerant to their dosages in time and by the time they reach maximum doses dosages then it could potentially not even be beneficial to them anymore but they're still hooked on it so that's why it's not first-line anymore so then you have sodium oxide bait and this reduces cataplexy due to the potential for abuse and illicit use both sodium oxide bait and amphetamines are regulated as controlled substances in the United States so so for narcolepsy just remember mow daffodils or armload daffodils are all the ones that say daffodil for a narcolepsy then you have something called advanced sleep phase syndrome and what this is is that it's a circadian rhythm disorder characterized by the inability to stay awake in the evening that's usually after 7:00 p.m. you can't stay awake it makes it make social functioning very difficult these patients frequently complain of early-morning insomnia due to their early bedtime the next one would be delayed sleep phase syndrome and this is another circadian rhythm disorder that's characterized by the inability to fall asleep at normal bedtimes normal bedtimes being 10:00 p.m. to midnight so remember in this exam it's everything's very generalized so this may not be a normal time for you but for the majority of the population normal bedtimes are 10 p.m. to midnight so this is a sleep onset insomnia and excessive morning sleep sleepiness of these patients cannot often cannot fall asleep until almost about 4 to 5 a.m. but their sleep is normal if they're allowed to sleep until late morning unfortunately society and their and the pressures in society make this kind of treatment impossible who's gonna explain to their boss say I can't come into work at 8 a.m. because I have delayed sleep phase syndrome so you're just gonna have to come in around noon yeah it's not gonna fly so sleep is normal when they are allowed to set their own schedules they describe themselves as night owls and the onset is usually in adolescence and they may respond to treatments such as light or behavioral therapy and an accurate history and sleep diary are essential for making the diagnosis so that's called delayed sleep phase syndrome easy enough because it's delayed now the other ones called shift work sleep disorder shift work sleep disorder involves a recurrent pattern of sleep interruptions due to due to a shift work causing it difficulty in initiating and maintaining sleep at daytime sleepiness this disorder is usually due to a work schedule that is incongruent with normal circadian clock so this could be a patient who was who has been working a normal shift from 9:00 to 5:00 and suddenly they've been asked to take the overnight shift so another working from 5:00 p.m. to 8:00 a.m. or something like that or that's actually kind of crazy maybe a p.m. to 8:00 a.m. or something like that where they're sleeping now during the day and having to work at night this can cause a transient inability to fall asleep at normal at their new normal times so this is called Metis Tuna their their work situation so it's their shift work sleep disorder well so these are pretty pretty easy to remember because of the the way they're described you have shift work sleep disorder delayed sleep phase syndrome disorder advance sleep phase syndrome disorder so delayed advanced shift work that's pretty easy to remember example would be like the next one age-related sleep changes these are sleep patterns that tend to change in older individuals or as the people age they typically sleep less at night and they nap during the day the periods of deep sleep which is stage 4 sleep becomes very short and eventually it disappears so older people often are more often awakened more during all stages of sleep these changes are normal and are usually not indication of a sleep disorder this is just very normal behavior the next one would be night terrors these occur in specifically a non REM sleep the child it's usually fine in children you'll have you get a child that cannot be fully awakened or I'm sorry the child cannot be fully awakened during the episode and it lasts for a few minutes but here's the the clue here is when they wake up they have no memory of the event that's a night terror means a child that's having it looks like he's having a nightmare but it's not a nightmare it's a night terror because when you ask him so what happened and they have no idea most common in children is 2 to 12 and it peaks at 5 to 7 years of age and it's usually resolves spontaneously as a child ages and this can be triggered by acute stress or sleep deprivation or illnesses or meds that affect the CNS then vs. nightmare disorder which this occurs during REM sleep so what we said earlier night terrors are non REM nightmare is during REM and it's usually in the middle of the night and early morning the child is fully asleep during a nightmare and doesn't scream or cry or become tachycardic such as in night terrors they do and they're fully alert when they wake up and but and when you ask them in so what happened I just had a nightmare that what they all tell you because they can recall the nightmare so in a nightmare the child can tell you what happened they can recall the nightmare and a night air they cannot in the nightmare the child is fully asleep wakes up when you shake them up to wake up they can wake up in a night terror a child cannot be fully awakened during an episode and and then they tear they do scream and cry and all that okay so next one next topics would be eating disorders so eating disorders can be classified as either as either anorexia nervosa bulimia nervosa or a binge eating disorder so in anorexia nervosa the BMI is going to be less than eighteen point five they're gonna have intense fear of gaining weight and they have a distorted views of their own body their their weight and shape and how do you treat anorexia with cognitive behavioral therapy you treat them with nutritional rehabilitation and often if they do not respond to cognitive behavioral therapy or nutritional rehabilitation then you start them on medications such as olanzapine remember olanzapine was the antipsychotic that causes weight gain because it's that shape the the first letter is an O so you want it causes weight gain there you go it's given to anorexia nervosa now for bulimia nervosa these are recurrent episodes of binge eating but a binge eating can be seen in all the eating disorders but they do have recurrent episodes of binge eating [Music] binge eating is then followed by a compensatory behavior to prevent weight gains so they'll try to vomit for instance but then again anorexia nervosa also vomits that doesn't tell you much either in bulimia nervosa they have excessive worrying about their own body weight and shape that doesn't tell me much either but here is the difference between bulimia and anorexia and bulimia their body weight is normal so their BMI is between eighteen point five to thirty versus anorexia nervosa their BMI is less than eighteen point five now the treatment for bulimia nervosa again is the same it's cognitive behavioral therapy and nutritional rehabilitation but since they do not need to gain weight since their body weight is normal you can give them an SSRI like fluoxetine and that often isn't given in combination with the cognitive behavioral therapy and the nutritional rehabilitation so in bulimia nervosa remember that their their treatment is going to be an SSRI not an anti-psychotic and that their body weight is gonna be normal versus and nrx the other body weight is gonna be a less than eighteen point five for BMI okay and then you have binge eating disorder and these would be recurrent episodes of binge eating with no compensatory behaviors and they have a lack of control during eating so in this case binge eating disorders they don't have a problem with their with their image per se they just have control AK of control of their meals they have to be eating eating eating constantly so again you want to start them off with cognitive behavioral therapy behavioral weight-loss therapy if they're well are probably going to be gaining weight and pharmacological treatments would be like topiramate and something called I'm gonna try to pronounce this list Dex some feta mean so let's dexon feta mean is I'm assuming I've never seen this one before it's I'm guessing it's an amphetamine and amphetamines are a stimulant that cause weight loss so that would be a pretty good treatment for binge eating disorder in these patients who doesn't say here but it's pretty obvious that they're gonna be having weight gain so to go into detail with these eating disorders in anorexia nervosa they could have binge eating or purging subtypes like we said earlier but the main difference here is in the weight they have a restrictive sub there's there could be a restrictive subtype meaning that they have fasting or hyper exercising they could be exercising a lot of times a day taking a lot of classes at the gym or something like that and then hospitalization and acute stabilization it's highly recommended due to dehydration and electrolyte disturbances such as hypokalemia or hypophosphatemia they can have bradycardia or severe weight loss remember that anybody that has a very very low BMI may require hospitalization and by a low BMI we're talking less than 18 point 18 less than 18 there's a new question somewhere in your world that I forgot I have to look it up but I it it tells you this patient it has basically anorexia nervosa and they're telling you that their their BMI is eighteen point five what would you do next but since they were normal they didn't have any symptoms of dehydration in this case what you do is you just send them home it's not to hospitalize them so also look for blood pressure readings if their blood pressure is less than 80 over 60 you don't want a hospitalized but if it's 90 over 70 you don't hospitalized so that can be tricky you want to also supervise their meals and some patients will require nasal gastric tube feedings during the onset of anabolism which is the it's the opposite of cata and catabolism which is the breakdown this is basically the gaining of weight patients will require close monitoring and refeeding syndrome refeeding syndrome is when you have is when you have electrolyte depletions and arrhythmias and heart failure and that's due to fluid and electrolyte shift imbalances so I mean think about it this patient hasn't been eating normally and suddenly you're introducing to them all these nutrients and electrolytes and those electrolytes that rush of potassium and calcium and sodium can cause arrhythmias and it can cause a leak to heart failure very quickly so that can result from those electrolyte light and balances there could be also vitamin deficiencies and that should be assessed and supplemented if there is any type of deficiency that you are identified you'd want to correct that all right next topics the next topic is bulimia nervosa these is another binge eating and inappropriate compensatory behaviors that occur once a week or three times a month or for three I'm sorry not three times a month but for three months in order for the diagnosis to be made so you have signs of sorry you have signs of bulimia which would be hypotension tachycardia dry skin menstrual abnormalities and electrolyte abnormalities as well connect hypokalemia hypochlorite metabolic alkalosis there could be erosions of dental enamel and parotid hypertrophy and patients who vomited Lee alright so the next topic is body dysmorphic disorder okay so I'm body dysmorphic disorder the clinical features are they have a preoccupation with more than one perceived physical defect the defects are not observable or appear slight to others they appear slightly different to other people there's a repetitive behavior or mental acts that are performed in response to the preoccupation and there can be significant distress or impairment there's a significant or a specific insight of either good poor or absent delusional beliefs and again body dysmorphic disorder can be found in both anorexia and bulimia and their management is with antidepressants so you give them SSRIs cognitive behavioral therapy also you always want to do CBT or cognitive behavioral therapy in conjunction with pharmacological treatments such as antidepressants alright so the next group of disorders that we're going to speak about is dissociative disorders so in dissociative disorders you have three types you have depersonalization or derealization disorder you have dissociative amnesia and you have a dissociative identity disorder so for depersonalization derealization disorder this means that the patient has persistent or recurrent episodes of either one or both of the following so they can have persistent and recurrent experiences of either deep personal is which is feelings of detachment from or being outside an observer of oneself so you're like detached from your your own body kind of view oh and then there's or they can have D realization which is experiencing surroundings as being unreal so they'll be in a room but they don't think that room is very is real or they can have both being a sense of detachment with experiencing as their surroundings being unreal so thats depersonalization derealization disorder but they have intact reality testing okay then you have something called dissociative amnesia this is the inability to recall important personal information usually of a traumatic or stressful nature it's not explained by any other disorder like substance use or post-traumatic stress disorder this is somebody who just forgot personal information that you should always remember like your address your telephone number versus the associative identity disorder means that this is marked discontinuity discontinuity in identity or the loss of personal agency with fragmentation into more than two distinct personality states it's associated with severe trauma or abuse this can be like your multiple personality disorder it's now called dissociative identity disorder alright then you have so for dissociative amnesia the specifier with its with dissociative fugue is used when amnesia is associated with seemingly purposeful travel or bewildered wandering okay so like they are in an airport and they don't know how they got there next one would be somatic and somatic symptom and related disorders so here you have somatic symptom disorder x' you have an illness anxiety disorders conversion disorder which is also known as functional neurological symptom disorder there's also a factitious disorder and malingering so for somatic symptom disorder this is basically excessive anxiety or a preoccupation with more than one unexplained symptom an illness anxiety disorder however you have fear of having a serious illness despite few or no symptoms of consistently negative evaluations okay so what's the what's the difference with these two and the somatic symptoms you have excessive anxiety with more than one unexplained symptom I'll have a I'll have gi pains but you do you do all testings for gi and there's nothing that'll explain your stomach pains versus illness anxiety disorder is a fear of having serious illnesses it's despite having either few or no symptoms at all and they're consistently negative evaluations so fearing fearing of having the consequence of an illness is called illness anxiety disorder versus the preoccupation of excessive anxiety due to a symptom is a specific thing that's a specific somatic symptom disorder it's a little confusing but I think we broke it down fairly easy then you have conversion disorder which is also known as functional neurological symptom disorder and that is basically neurological symptoms that are in kit incompatible with any known neurological disease and it's often acute onset associated with stress okay and then you have fictitious disorder and in fact Isha's disorder there's an intentional falsification or inducement of symptoms with a goal to assume the sick role so these patients they are going to make believe that they're sick just because they want to feel sick kind of like if you like it when they bring you ice cream in bed because you got sick so you lay the sick role so that you keep getting ice cream in bed kind of that's a simple way of seeing it but that's what it is you're falsifying your disorder in order to get a to get something out of it a reward alright so malingering is your next topic that is falsification or exaggeration of symptoms to obtain external as incentives or a secondary game so be careful here with factitious disorder versus malingering so in fact Isha's disorder you're just you're actually not doing it for the ice cream you're just doing it because you want to be sick you want to look like you're sick but for malingering you're doing it for the ice cream you're doing it because you want to not go into work that day and you call in sick so that's malingering alright next topic in more detail would be somatic symptom disorder we said the somatic symptom it's clinical features was more than one somatic symptom causing distress and functional impairment the thoughts are excess the thoughts are going to be excessive we're behaviors are going to be related to the somatic symptoms symptoms are going to be unwarranted persistent thoughts about seriousness of symptoms that don't really exist and they can have persistent anxiety about it about their health or other symptoms and they can have excessive times and energy devoted to those symptoms and that can lead and that can last more than six months back again to our rule of six months with psychiatry disorders so again these patients are worried about specific symptoms and how do you manage them is with regularly scheduled visits with the same provider so usually in the test question they'll ask you what would you do next and it would be to reschedule and reevaluate them and like a month or a week or two weeks you want to limit unnecessary types of work ups and specialist referrals you never want to refer anyone on the boards anyway so and you don't want to do a lot of working up on these people even though they may ask you to your response would be let's let's see what happens in two weeks you want to legitimize symptoms but make functional improvements to the goal and you want to focus on stress reducing and improving on coping on their coping strategies mental health referral is patient is if the patient will accept it all right next topic is going to be conversion disorder and this is a functional neurological symptom disorder common presenting symptoms would be weakness or paralysis not epileptic seizures and movement disorders that are also present with speech or visual impairment as well as swallowing difficulties and sensory disturbances as well as cognitive symptoms so what are some of the diagnostic criteria for conversion disorder you have symptoms of altered neurological function as well as voluntary motor or sensory function it's gonna be altered there's often a precipitated it's often precipitated by psychological stressors it's not fiend or intentionally produced as a fictitious disorder and mulignan malingering but findings are incompatible with a recognized neurological condition symptoms can cause a significant social or occupational impairment and there's treatment options which are usually stepwise so first you want to educate the patient with self-help techniques then second line would be cognitive behavioral therapy if education and self-help techniques don't work and finally physical therapy for motor symptoms and then patients can be hysterical or strangely indifferent to their symptoms differential diagnosis is require extensive workup to rule out other possible underlying medical causes there's also another condition called pseudo cc's and this is a fairly an uncommon condition and it's basically when a woman presents with many signs and symptoms of pregnancy she'll present with amenorrhea they'll have enlargements of her breast and the abdomen she'll even present with morning sickness weight gain sensations of fetal movement and reportedly she couldn't they've even reported positive urine pregnancy tests per the patient how Strange's us and then ultrasound however is going to reveal that there is a normal and de metrio stripe and that the pregnancy tests in the office will be negative so there your in pregnancy test will be positive at home but obviously the one done in the office will be negative so this is usually seen in women who have a very very strong desire to become pregnant it's also been suggested that the depression can cause by this need is behind the occurrence of some hormonal changes that can mimic those of pregnancy this is a form of conversion disorder it's management does require psychiatric evaluation and treatment so in these patients they present to you like if they're pregnant they might even have signs and symptoms of pregnancy but ultrasound however reveals otherwise and the office pregnancy test is negative all right then there's another condition called pathological gambling more common in males that's defined as a persistent and maladaptive gambling behavior that usually it's going to result in a preoccupation with gambling an arrangement for means to indulge in it so these patients might gamble increasing amounts of money to achieve the desired excitement and can result to a legal behavior to finance their activities attempts to reduce gambling behavior are typically unsuccessful and they result in a jeopardized relationship and financial instability when confronted about this issue pathological gamblers are usually very dishonest and evasive towards those questions so gambling can also be used as a mean of escaping from problems or relieving unhappiness so these are pretty straightforward not too difficult now we're going to go into the psychotherapy so there's different types of psychotherapy there's interpersonal psychotherapy supportive psychodynamic motivational cognitive behavioral therapy there's dialectical behavioral therapy be in biofeedback so let's go one by one so interpersonal psychotherapy is its duration is time limited typical patient will have relationship conflicts they'll have life role transitions as well as grief and their focus here is on the here and the now there's current relationships and conflicts with interpersonal psychotherapy the next one would be supportive psychotherapy it this would be something ongoing this is a lifetime of treatment a typical patient here has a lower functioning they're in crisis there they can be psychotic and they can be cognitively impaired some supportive psychotherapy focus is a therapist it is used as the guide it's to reinforce coping skills is to listen and foster understandings and build up an adaptive defense mechanism so that's the key here is to build up a defense mechanism for for these patients undergoing supportive psychotherapy versus psychodynamic psychotherapy this again is on an ongoing duration the typical patient is a higher functioning patient with persistent patterns of dysfunction and they're a little bit more neurotic patients so their focus the focus here is an unconscious conflict causing the symptoms there's an exploration of past relationships and conflicts it the utilized transference and the breakdown of defense mechanism so in this the difference between these two types of therapy supportive and psychodynamic remember that this would be psychodynamic would be in a more higher functioning individual we're in support of that psychotherapy there would be a lower functioning individual and psychodynamic psychotherapy has to do with past relationships and conflicts what has bothered you in the past you do have a problem with your mother did you have a problem with your father husband wife the things like that so motivational interviewing is the next one and this duration is variable because it's to deal with motivations it's it's basically the typical patient for motivational interviewing as a substance use disorder patient and he here is to address ambivalence it's to change it's a non-judgmental focus there's an enhancement of motivation to change and there's an acknowledgement of resistance here next one is cognitive behavioral therapy and this one's time limited its persistent the the typical patient is a persistent maladaptive thoughts a patient that comes in with persistent thoughts that are bad there's an avoidance behavior or the ability to participate in homework would be one of them the key focus here is to identify and challenge the maladaptive thoughts it's also to change their behaviors to change their emotions coming from those thoughts and to focus on behavioral techniques such as breathing exercises exposure goal-setting visualization eye on the prize kind of deal that's cognitive behavioral therapy and this is time limited this isn't something on going like psychodynamic or supportive then you have biofeedback which is also a variable duration and the typical patient here is a prominent physical relation with prominent physical responses that accompany psychiatric symptoms and here the goal of treatment is to improve awareness and control over psychological reactions it's also used to lower the stress levels and integrate mind and body techniques and that would be the role of biofeedback alright so moving along the next topic here is suicide there's a suicide risk and protective factors some of the risk factors for suicide would be a pre-existing psychiatric disorder feelings of hope this impulsivity previous suicide attempts or threats a divorce or a separated couple an elderly white man unemployed or unskilled patient physical illness family history of suicide family discord access to firearms is a big one and substance abuse and then protective factors would be a social support family connectedness you want to actually promote this pregnancy Parenthood religion and participation and religious activities these are all things that help support and prevent suicide so how would you assess suicide so suicide assessment is basically on evaluation of three things ideation intent and plan so for ideation it would be the wishing of to die not to wake up this would be a passive assessment thoughts of killing themselves I would be active and frequency duration intensity and controllability are also evaluated with ideation for evaluating intent the strength of the intent to attempt the suicide and the ability to control impulsivity and also to determine how close the patient has come to acting on a plan so if they've had any type of rehearsals or any type of failed attempts those are evaluations of a intent and then evaluation of plans would be specific details on how they're going to do it the method the time the place access to the means like weapons and pills here we have weapons again these are all high-yield keywords preparations like gathering pills changing one's will and you'd also want to evaluate the lethality of the method is a very lethal method that they're going to be choosing or the likelihood of rescue and then you always want to hospitalize these patients to maintain safety and that's indicated for patients with active suicidal ideation that includes a plan and an intent to act patients with suicidal ideations but not specific plans or intent need intensive outpatient treatment but not necessarily hospitalization if they're just sloppy about it but remember key thing here for the exam is suicide is a big topic and if you see any subtype of suicidal ideation and hospitalized as part of the option choices I would always put hospitalization so I would I have rarely have ever seen intensive outpatient treatment as an answer choice okay now you want to assess and manage this item suicidality so the assessment is the mnemonic called sad person's sad person stands for sex age depression previous attempts EtOH which means alcohol or other substance use also rational thought loss like psychosis a social support or a lack of social support an organized plan if there's no spouse or a significant other or a sickness or an injury these are all the mnemonics for sad persons and how would you manage this so for an hi imminent risk patient meaning a patient who has ideation or an intent and a plan you want to first ensure their safety hospitalized immediately you want to hospitalized and voluntarily if necessary like I said before you want to remove the personal belongings and objects in a room that can harm themselves so they have any kind of access to guns this doesn't mean putting locks on them or putting in a safe and it just remove them outside of any reach that they can be in so out of the house number one also constant observation and security can be need to be required to hold against their will how would you manage high non imminent risk of ideation or intent this would be if they have no plan to act in the future these are you want to just treat the modifiable risk factors like underlying depression or a psychosis or if they're under the influence of any kind of substance abuse you also want to go ahead and recruit family members or friends as a support for the patient and you also want to reduce access to potential means such as firearms and medication and there you have your firearms again I can't stress enough how important removing firearms and hospitalization for suicide is all right next topic would be firearm injury so for a firearm injury the risk factors would be a male adolescent there's behaviors of psychiatric problems an impulsive patient a violent patient or some patient with a history of criminal behavior and also low socioeconomic status how would you prevent a firearm injury easy you want to remove all the firearms from the house that's not rocket science there you want to store the firearms unloaded and you want to lock firearms and ammunition and separate containers but on the exam remove all firearms from the house is always the correct answer now so what are some of the homicide risk factors a young male an unemployed person if they have access to firearms substance abuse antisocial personality disorder or history of violence or criminality as well as history of child abuse and impulsivity okay so now we're going to go into the topic of personality disorders which is very fun and it could be a little bit confusing but we're gonna try to set this straight here oh here we go all right so some of the key features here on the dsm-5 for the personality disorders would be paranoid and this is a suspicious or distrustful person that's hyper vigilant so paranoid is a very hyper vigilant person versus a schizoid patient this prisoner presents as a loner someone who is detached and emotional schizotypal would be somebody has odd thoughts they're eccentric they have perceptions and behaviors that are odds that are odd there's a old mnemonic that says dressed like a pickle is someone who skits a tipple so dressed like a pic the pickle would be someone who's odd eccentric weird behaviors okay antisocial is any person who has total disregard and violations the rights of others you have borderline which is somebody who has chaotic relationships sensitivity to abandonment a labile mood impulsivity and inner emptiness with self-harm as part of their as part of their characteristics next one would be histrionic this is your typical dramatic person their superficial attention-seeking you'll probably have a very dramatic woman as part of your vignette somebody who's wearing very exotic clothing or something and they're very superficial always attending to themselves in the mirror or something this is your histrionic versus narcissistic which is somebody who has grandiosity about themselves with lack of empathy so don't get those two confused what you would think narcissistic is normally or what I would think is actually a histrionic person a narcissistic would be somebody who is completely into themselves in in in terms of grandiosity and lack of empathy is a big one you have a void n't person and avoidance is obviously one who avoids due to fear of criticism and rejection they might give you a situation where they had just they miss to mess you up they have a their job requires them to give a presentation or something and they're trying to avoid going there and you're thinking it's because of a situation and it's not the situation is that they really are avoiding the whole interaction just due to fear of criticism and rejection so keep an eye on those little details dependent is somebody who's very clingy they needs to be taken care of submissive they're just usually it's somebody who is an abusive in an abusive relationship and just can't leave the other person because they just need to be with them that's dependent and then you have obsessive compulsive behavior and this would be a perfectionist someone who's controlling or very rigid alright so moving on with anteye personality disorders or antisocial personality disorder sorry clinical features would be someone who have violates the rights of others social norms and laws they're impulsive they're irritable they're very aggressive they fight a lot they are accused of assault they're consistently and responsible they lie and they're very deceitful there's lack of any type of remorse they don't feel bad about anything they do and here the key thing is age is greater than 18 years of old so of age so this is an adult so in a versus in a minor less than 18 years of age it's not antisocial personality disorder it's it's a conduct disorder okay so management here how would you manage anti-personnel antisocial personality disorder is with psychotherapy you always want to try psychotherapy first for their ma if they're mild so you just want to monitor or manipulate them with some type of therapeutic techniques such as therapeutic relationships and you also want to treat any kind of comorbid psychiatric disorders that they might have such as substance abuse or depression if that's also found in them but I think that they might try to that's two conflicting and too many details for the exam so just just say there's somebody who just likes to hurt other people for no particular reason violate the laws and if there are there an adult that's antisocial personality disorder if they're a minor its conduct disorder so basically again it's failure to sustain consistent employment self appraisal and a very irresponsible work behavior I think he gets a picture next would be borderline personality disorder in borderline personality disorder the diagnostic criteria would require percent per vasive patterns of unstable relationships a self-image and effects of marked impulsivity with more more than five of the following features so they have frantic efforts to avoid abandonment there's unstable and intense interpersonal relationships markedly and persistently unstable self-image as well as impulsivity in more than two areas that are potentially self damaging there's recurrent suicidal behaviors or threats of self-mutilation like cutting and there's affective instability like a marked mood reactivity chronic feelings of emptiness and an appropriateness of an intense anger there's a transient stress-related paranoia or disassociation with borderline so how would you treat borderline personality disorders this would be a primary treatment is going to be psychotherapy and the types of psychotherapy or several types can be effective such as dialectical behavioral therapy that tends to be the best one there's a adjunctive pharmacotherapy also with psychotherapy to target mood instability and transient psychosis so in other words you want to combine primary or the you want to combine psychotherapy with second-generation antipsychotics and with mood stabilizers and then antidepressants if there's any type of comorbid mood or anxiety disorders now you have acute drug toxicities so these are some this is another highly tested topic is a pharmacal pharmacology in psychiatry so let's start with all the substance abuse drug toxicity so first of all we have PCP or phencyclidine it's a loose intogen that patients present with a violent behavior there's disassociation hallucinations amnesia there's vertical or horizontal nystagmus as well as ataxia and high doses can actually cause severe hypertension so you'll see very severe hypertension and these people seizures and life-threatening hyperthermia with benzos and that's used for severe psychomotor agitation so just a crazy person that comes in to the ER starts flipping over Gurney's and and just causing mild hysteria and there's just a bp's sky high and they're just very very violent you're thinking PCP and first of all you just want to give them a benzodiazepine to just calm their psychomotor agitation down next would be LSD this is another hallucinogen it's the it causes visual hallucinations euphoria dysphoria and panic attacks as well as tachycardia and hypertension but the visual hallucinations is gonna be the one for Alice do you think we all know that next one is cocaine that's a stimulant which causes euphoria agitation but the big one here would just be seizures and chest pain chest pain particularly as well as teki cardia hypertension and mydriasis now this can cause bradycardia or low blood pressure as well as anxiety and psychosis they can have sweating nausea and vomiting and an overdose can actually cause an MI and cardiac arrhythmias seizure or a stroke in these patients so if you're seeing a patient that has signs and symptoms of an MI but also has some type of euphoria or agitation involved and businessmen usually in their 20s or 30s I think a cocaine okay methamphetamines is a stimulant and this is associated with violent behaviors and psychosis there also have diaphoresis tachycardia hypertension and they also have core form movements of their hands and fingers as well as tooth decay the next one would be marijuana or tetra hydro cannabis or canta canta ball or cannabis and this is a psychoactive drug it's it's it causes an increase in appetite euphoria dysphoria with panik's impaired time perception a dry mouth and conjunctival injection that's pretty easy to figure out you'll see somebody in their teens come in and they come in with euphoria dry mouth it just look very low and their conjunctive they'll have a conjunctival injection and that's the key heroin is the last one and that's an opioid again causing euphoria but this time it causes heroines associated with a depressed mental status so associated with meiosis respiratory depression and constipation since it's an opiate it's gonna cause respiratory depression and constipation okay then you have inhalants so inhalant abuse is commonly abused some of the inhalants that are commonly abused would be glues nitrous oxide or whippets is what they call them amyl nitrate which are called poppers and spray paints there's a way of abuse such as sniffing you're huffing which is an inhaled form when they inhaled from us very from a very saturated cloth bagging over the mouth or nose very very weird but that's what it is signs of an acute intoxication you're gonna have brief transient euphoria loss of consciousness there's a very there's loss of consciousness that varies depending on a specific chemical and hild these are highly related soluble agents that produce immediate effects and since it's lipid soluble it lasts up to 45 minutes 15 to 45 minutes and it's rapidly eliminated from the body it's also not commonly included in toxicology screens so they might present you with a negative toxicology screen or you won't even do one because it's pretty obvious what they did they act as CNS depressants and cot and can cause death there's dermatitis associated with glue sniffers rash and let's do two a chemical exposure around the mouth and the nostrils their liver function tests can be elevated so look for that in the vignette as well as boys around the age of 14 to 17 those are the ones that are at the highest risk and they can go unnoticed as common Hospital products are used all right the next topic is and fetta mean intoxication and these are commonly exhibit these commonly an exhibit agitation irritability paranoia and delirium other side effects would be Chiapas other symptoms would be chest pains and palpitations as well as tachycardia hypertension diaphoresis and mydriasis other complications such as cardiac arrhythmias seizures hyperthermia and interest or ebrill hemorrhages are also found diagnosis is based on clinical is based clinically as well as laboratory tests and it's beyond the qualitative toxicology screen and these are of limited utility so one big one and a new one would be bath salt feta mean intoxication bath salts are and feta mean analog that can cause severe agitation and combativeness so they can present with hyperthermia as well as psychosis and the hyperthermia is due to the physical exertion but it's not as severe as other types of psychosis like PCP intoxication so this one is going to be kind of different from PCP and we'll see why so in bath salts these are synthetic cations which consists of a large family of amphetamine analogues so their mechanism of action is that they increase the release or they inhibit the reuptake of norepinephrine and dopamine as well as serotonin and they can cause myoclonus and rarely they can cause seizures but the most distinguishing feature of bath salts intoxication is going to be prolonged duration of effect these patients have delirium and psychosis that last days to weeks whereas the effects of intoxication with other in front of means like piece of peak PCP are very short duration so that's a good way of remembering the differences bath salts are gonna take longer PCP is gonna be short duration bath salts are usually sold as a white powder and small packages labeled as food as plant food as cleaners or other substances and may be ingested orally they could be inhaled or injected and it's not related to any products like epsom salts or other substances that are used in bathing routine toxicology screens do not test for bath salts unfortunately so here you're gonna have to just see the effects of the drug used okay the next drug would be MDMA ecstasy or something called Molly this is a three it's called three four methyl and deoxy methamphetamines or MDMA it's a synthetic and fed amine with a mild hallucinogenic property there's increased synaptic norepinephrine and dopamine as well as cert tonin concentrations it can lead to neurotoxicity with long-term use MDMA is austin you used by college students during raves and large dance parties to enhance euphoria and also to increase social ability to increase empathy and sexual desire but they don't have any type of combative behavior the intoxication here can lead to a form of hypertension tachycardia they can present with hyperthermia and serotonin syndrome which we can remember as an autonomic dysregulation causing high fever altered Mental Status a neuromuscular irritability and seizures and here they can cause hyponatremia and death there's a combination of MDMA with other certs and the genetic drugs such as serotonin genic antidepressants it can increase the risk of serotonin syndrome but it's not detected again by routine toxicology screens with these patients just remember somebody who went to a party and they're presenting with some signs of serotonin sand syndrome but they're also extremely hyperthermic and very thirsty very very thirsty so that is the behavioral pattern that you should look out for on the vignettes next topic is your marijuana intoxication it's pretty easy again cognitive effects that include slow reaction time and coordination there's impaired short-term memory poor concentration some some patients experience dysphoria they have anxiety paranoia they have perceptual disturbances like auditory original hallucinations can also occur but remember these patients aren't psychotic they're just under the influence of marijuana there's also a psycho motor impairment that lasts beyond the timeframe of euphoria and campers it persists for up to a day and that can result in a high risk of injury or death and motor vehicle accidents and chronic abuse is also associated with gynecomastia in men so that's a good way of stopping to use the drug withdrawal syndromes so we're gonna talk about now the withdrawal common withdrawal syndromes associated with substances so let's start off by alcohol withdrawal symptoms of alcohol would give you tremors agitation anxiety delirium or delirium tremens is what it's called as well as psychosis and their examination findings are seizures they can personally can present with seizures tachycardia and palpitations as well as benzodiazepines can also have seizures tachycardia and palpitations but here their symptoms are going to be actual perceptual disturbances and insomnia you can also add the tremors agitation and anxiety psychosis seen with alcohol withdrawal but the insomnia would also be part of a benzo and withdrawal for heroin withdrawal they present with nausea vomiting abdominal cramping with muscle aches they're also on exam you'll see dilated pupils so you'll see a mydriasis yawning pile of erection lacrimation there's hyperactive bowel sounds and that's pretty much it now with stimulants like cocaine and amphetamines their symptoms are increase in appetite hypersomnia intense psychomotor retardation and severe depressions like a symptom of crashing that's what their withdrawal symptoms would be there's no significant findings on exam it's just basically the symptoms as well as nicotine there's no significant findings but their withdrawal symptoms would be dysphoria and irritability state anxiety and increase in appetite because nicotine is an appetite suppressant alright so alcohol withdrawal syndrome so this can be so classified with mild withdrawal seizures alcoholic hallucinosis and other delivery tremens so basically a wacom mild withdrawal their symptoms would be just anxiety insomnia they can have tremors diaphoresis palpitations they can have intact orientation and usually that's basically within 6 to 24 hours since their last drink that's a mild withdrawal versus seizures seizures are basically going to occur within a timeframe of 12 to 48 hours of withdrawal seizures can be single they can be multiple and they're generalized tonic-clonic seizures versus alcoholic hallucinosis is when you actually see visual auditory or tactile hallucinations as well as and but they do have intact orientations and their vital signs are stable and again this happens between 12 to 48 hours but it usually develops with between 24 hours and resolves at 48 hours so at past two days there they're gonna be fine but the most complicated one would be delirium tremens which is a patient that presents with confusion agitation fever tachycardia hypertension diaphoresis and hallucinations and this is gonna happen 48 to 96 hours of withdrawal typically it Peaks during the second day following the cessation of alcohol in any hospitalized patients with a suspected suspected hype history of alcoholism there's gonna be precautions taken to prevent symptoms of withdrawal but due to the serious potential complications of alcohol withdrawal those patients should be placed on proactive treatment or protective treatment and be treated with benzodiazepines which are basically CNS depressants that will limit the effects of alcohol withdrawal there's clora dioxide POC side which is called Librium that's a benzodiazepine and that's the most common choice of treatment for alcohol withdrawal symptoms so if you see a patient that has type of alcohol withdrawal and they're just asking you what would you give them as a treatment oh is it's a benzodiazepine so what are some of the management of alcohol withdrawal seizures first you want to rule out other possible causes of seizures you just don't want to blame it on the alcohol you want to check for infections you want to check for hypoxia bleeding metabolic derangements persistent seizure disorders or pre-existing seizure disorders or any type of confirmed seizures that was happening beforehand then you want to treat with a benzo especially intermediate benzos such as IV lorazepam that's going to be the preferred in hospital setting to control the symptoms and prevent the progression to delirium tremens and it's also safe in possible liver disease so that's a big one alcoholics have to tend to have liver problems so um in this lorazepam would be safer in these patients because there's no active metabolites with lorazepam versus Clorox epoxide this is very long acting and it's not preferred in the hospital setting and the patients and patients with possible liver disease because of their metabolic side effects and their metabolites then you have adjunctive therapy that you give with the benzo like you're obviously going to go on IV fluids you're gonna frequently monitor their vitals you're gonna give them five meeting folate and nutritional support you can also give them phenobarbital which can be used as an adjunct to the benzo if they have any type of refractory alcohol withdrawal and withdrawal or two related seizures then we have heroin withdrawal now heroin withdrawal presents six to 12 hours and it Peaks 36 to 72 hours and it could continue on for several days it's very distressing but however it's not life-threatening this is a big one it's they present with restlessness elevated pulse and blood pressure all those usually not as elevated as alcohol withdrawal so it's actually it's interesting because it's actually more lethal to you can actually die from alcohol withdrawal but you cannot die from heroin withdrawal although heroin withdrawal would probably way more painful and obviously that's important to treat the pain but Harun Lu withdrawal is not life-threatening then there's neonatal abstinence syndrome which is neonates frequently exposed to heroin and methadone such as in from the mother methadone is given to heroin addicts and mothers to prevent uncontrollable withdrawal in infants and heroin does not cause this morphic feces but can cause intrauterine growth restriction so that's a very important one as well as microcephaly sudden infant death syndrome and neonatal abstinence syndrome signs of neonatal abstinence syndrome would be irritability a high-pitched cry poor sleeping tremors seizures sweating sneezing - kit Nia's poor feeding vomiting and diarrhea and they usually present within 48 hours after birth for heroin withdrawal and that happens between 48 to 72 hours for the methadone withdrawal it can't be a delayed up to it for weeks and treatment for neonatal abstinence syndrome includes symptomatic care to calm the infant down and help the infant go to sleep you want to such as swaddling and provide small frequent meals to the infant you want to keep the infant in a very low stimulated environment pharmacological treatment should be used only when supportive treatment does not control the infant's withdrawal symptoms remember always try first supportive treatment cheap is best on the boards and then you can move on to pharmacological treatments and morphine finally can be administered and systemically weaned off to help control the opiate withdrawal symptoms although also another type of withdrawal symptoms would be smoking cessation in addition to counseling several medications are going to be used to promote the short and long term of quitting to quit smoking bupropion is going to be the most commonly used it has modestly it's modestly effective it has an increasing quit rate so that's really good it's oh it's always going to be the answer if you have a patient who wants to stop smoking what kind of treatment you want to give them be pro prion is a good one TCAs are also moderately effective but they're not approved for this there's also variance cycling which is a partial agonist of the nicotinic acetylcholine receptor that's more effective than appropriate at increasing short and long term quitting and there's efficacy of all medications to enhance the nicotine replacement therapy and appropriate patients next some of the steroids like corticoids can induce manic or depressive psychotic episodes if a child or adolescence is going to present with recent changes in behavior emotions and a social circle then you want to suspect a substance abuse even if the patient denies it you want to perform urine toxicology screens but keep in mind that the patient may be using a substance that's not detected on urine or your routine toxicology screens so bath salts as we said k2 is another one salvia and household inhalants all those are not routinely detect they're not done when they don't they're not very detectable on toxicology screen so here you have to you have to actually go on see the symptoms of the patient in addition to substance use other considerations of adolescent patients presenting what behavioral changes are going to include the partners if they are violent date rapes it's like a physical physical or sexual abuse and finally pregnancy and that is you Inglés (generados automáticamente)