Psych

Dr. Ali’s Uworld Notes For Step 2 CK

Psych

Psych Timelines Manic Episode - 1 week Hypomanic - 4 consecutive days Cyclothymia - Dysthymia + Hypomania for 2 years Persistant Depressive Disorder - 2 years Major Depressive Disorder - 6-12 months with each episode >2 weeks Postpartum Blues - start 2-3 days, resolve 10 days Postpartum Depression - starts within 4 weeks & lasts 2 weeks to a year or more Postpartum Psychosis - days - 4-6 weeks Brief Psychotic Disorder < 1 Month Schizophreniform Disorder 1-6 Months Schizophrenia - > 6 Months Bipolar I – Manic Episode Bipolar II – Hypomania + Major Depression Delusional Disorder - >1 month Selective Mutism - >1 month Tourette Syndrome - Motor or Vocal tics >1 year Pathologic grief - >1 year Normal Grief - < 6 Months

Persistent Complex Bereavement Disorder = >12 months Adjustment Disorder - < 6 Months i.e, 2 months of depression + 4 months of distress. Generalised anxiety disorder - > 6 months Acute stress disorder - 1 month Imaginary Friends – 2 – 6 Years BMI = Weight in Kgs/ Height in meters squared. 100 Cm = 1 Meter Defense Mechanisms –

Passive-aggressive behavior is an immature defense mechanism in which an individual expresses his aggression toward another person with repeated, passive failures to meet the other person's needs. Fantasy is an immature defense mechanism that substitutes a less disturbing view of the world in place of reality as a means of resolving conflict. In this case, the mother interprets the appearance of an angel in her

dream as meaning her son will live a long time, but the reality is that the son is going to die soon. Fantasy offers escape from anxiety about her son's illness. Intellectualization is the transformation of an unpleasant event into a purely intellectual problem with no emotional component

Drug Side Effects – Bupropion is an antidepressant that produces its effects primarily through the inhibition of the re-uptake of norepinephrine, dopamine, and serotonin. It is particularly noted for improving the impaired concentration and diminished energy that many depressed patients experience. It does not cause the

sexual dysfunction commonly associated with most antidepressant medications, making it a good choice for young patients or those who are particularly concerned about sexual side effects. An important side effect of bupropion is decreased seizure threshold, which is usually seen at higher doses. This medication should therefore be avoided in patients with seizure disorders or conditions that predispose to seizures ( eg. concurrent alcohol or benzodiazepine use, eating disorders). Individuals with anorexia nervosa or bulimia nervosa frequently develop electrolyte abnormalities that can precipitate seizures. Therefore, a history of anorexia nervosa/bulimia is a contraindication to bupropion usage. Drug Induced Psychosis - Cocaine and amphetamine intoxication present in a similar manner, but psychosis is more commonly associated with amphetamine use. Common symptoms of stimulant intoxication include dilated pupils, hypertension and tachycardia. Basically if you think the Dx is Psychosis but the question mentions DILATED Pupils, is a DRUG INDUCED Psychosis, especially Amphetamines. Tardive Dyskinesia (TD), defined as a hyperkinetic movement disorder that is a side effect of medications (usually dopamine receptor –blocking drugs, antipsychotics, and metoclopramide). Patients typically present within 1-6 months after starting the medication with symptoms as shown below. Tremor is rarely seen in these patients, and the diagnosis of TD is clinically made.

Antipsychotics are classified as typical and atypical. Extrapyramidal symptoms (EPS) frequently occur as side effects of typical antipsychotics but can occasionally occur with atypical antipsychotics. Risperidone is the most likely atypical antipsychotic to cause EPS. Clozapine is the least likely atypical antipsychotic to cause EPS but is considered to be a medication of last resort because it can cause agranulocytosis. The patient's TD is best managed by replacing risperidone with clozapine. A complete blood count should be done before starting clozapine and throughout treatment to monitor for possible agranulocytosis. Akathisia is a subjective feeling of restlessness that compels patients to not sit still and constantly move around (e.g., repeated leg crossing, weight shifting, and stepping in place). It can occur at any time during treatment with antipsychotics, and beta-blockers provide some relief. Dystonia can occur between 4 hours and 4 days after receiving an antipsychotic medication. It is characterized by muscle spasms or stiffness, tongue protrusion or twisting, opisthotonus, and oculogyric crisis. Antihistamines (e.g., diphenhydramine) or anticholinergics (e.g., benztropine) provide relief. Antipsychotics cause hyperprolactinemia by blocking dopamine activity along the tuberoinfundibular pathway. Olanzapine is an atypical antipsychotic medication often used to treat schizophrenia, bipolar disorder, or agitation. Although all atypical antipsychotics have a lower risk of extrapyramidal side effects, they are all

associated with an increased risk of weight gain, hyperglycemia, dyslipidemia, and hypertension. ClOzapine and Olanzapine appear to pose the greatest risk of weight gain. Due to these potential side effects, the American Psychiatric Association recommends baseline assessment of weight, fasting plasma glucose, blood pressure, and fasting lipid profile before starting atypical antipsychotics. In addition, these parameters should be reassessed after 12 weeks of treatment in all patients taking these medications. Phenelzine is a monoamine oxidase inhibitor (MAOI). The MAOi are an older class of antidepressant drugs mostly used in the treatment of refractory depression. MAO Is are typically not used as first-line therapy in part because of the dietary restrictions associated with their use. If a patient taking an MAO I consumes foods high in tyramine, including aged meats and cheeses, hypertensive crisis can result. Abrupt cessation of alprazolam, a short-acting benzodiazepine, is associated with significant withdrawal symptoms such as generalized seizures and confusion.

ECT Side Effects - Indications for using electroconvulsive therapy (ECT) include severe depression, depression in pregnancy, refractory depression, refractory mania, neuroleptic malignant syndrome, and catatonic schizophrenia. One of the most common side effects of ECT is amnesia, which can either be anterograde or retrograde. Anterograde amnesia tends to resolve rapidly, while retrograde amnesia may persist for a longer period. Other adverse effects occasionally observed include prolonged seizures, delirium, headache, nausea, or skin burns. Methylphenidate is a mild CNS stimulant commonly used to treat attention deficit hyperactivity disorder (ADHD), which is a childhood condition characterized by hyperactivity, short attention span, and easy distractibility. Common side effects from the use of methylphenidate include nervousness, loss of appetite, nausea, abdominal pain, insomnia, and tachycardia. Prolonged therapy has been shown to cause mild growth retardation or weight loss. Methylphenidate should not be used in children younger than 6 years old because safety and efficacy in this age group have not been evaluated.

Depression Management - When treating a single episode of major depression, the antidepressant should be continued for a period of six months following the patient's response. If multiple episodes of depression have occurred, maintenance therapy will likely need to be continued for a longer period.

Pain disorder is characterized by the presence of pain in one or more anatomical sites. Symptoms are psychologically influenced but not intentionally produced and cause severe functional impairment. Genito-pelvic pain/penetration disorder should be considered in female patients expressing pain with intercourse or attempted penetration.

Somatization Disorder management - Patients with somatization disorder benefit from regularly scheduled appointments intended to reduce the underlying psychological distress. Telling the patient that there is nothing wrong with her will offend her and undermine future doctor-patient communication. Acting in a paternalistic and dismissive manner will likely alienate this patient It is important to listen well and be tactful when discussing patient concerns, especially when sensitive psychological issues may be involved. Additional medical workup will not be helpful because this patient has already undergone extensive evaluation of her symptoms. Instead the emphasis should be on scheduling regular appointments with the intention of addressing the psychological distress associated with the symptoms.

Immediately telling the patient that she has somatization disorder is not recommended as it would likely alienate her at this early stage. The patient is convinced that she's seriously ill, and she considers all of her previous doctors incompetent because they were unable to provide a diagnosis. Therefore, the best approach would be to schedule regular appointments for her, After several visits have strengthened the therapeutic bond, the patient should be made aware that there are psychological factors involved that might warrant a psychiatric consult. Factitious disorder can have psychological signs/symptoms, physical signs/symptoms, or both. When a patient displays symptoms of factitious disorder that are predominantly physical in nature, it is called Munchausen's syndrome. This is a condition in which patients present to a healthcare setting with signs and symptoms that they have deliberately and consciously produced for no obvious reason other than to gain admission to a hospital and adopt the sick role. They are very knowledgeable about which diagnoses/symptoms warrant an admission. Patients with this condition often resort to extreme and dangerous measures, such as surreptitious use of insulin. They have also been known to contaminate their urine with various substances (e.g. blood, feces) and take anticoagulants to produce laboratory results that may make the doctor think they have a bleeding disorder. They may endure numerous surgeries resulting in scarring and adhesions. Patients with this condition are usually very demanding and typically become highly upset when confronted. They will often leave against medical advice and go to a different hospital where the cycle continues. Malingering - As defined in DSM-IV-TR, malingering is the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives or secondary gain (e.g. avoiding military duty or work, obtaining financial compensation or shelter, evading arrest and obtaining drugs).

Schizophrenia - The symptoms of schizophrenia can be classified as either positive or negative. The positive symptoms include hallucinations, delusions, disorganized speech, and disorganized behavior. Negative symptoms include the "five A's": affective flattening (diminished emotional responsiveness); alogia (poverty of speech); apathy (i.e .. impaired grooming and hygiene. unwillingness to perform activities); asociality (i.e .. few recreational interests. social detachment, impaired relationships); and attention (inattentiveness and impaired concentration when interviewed).

Patients demonstrating more negative symptoms tend to have a poorer prognosis, as negative symptoms are primarily responsible for the low functionality and debilitation seen in schizophrenic patients. Positive symptoms respond well to typical antipsychotics. Negative symptoms respond well to atypical antipsychotics (e.g .. risperidone, clozapine, olanzapine. etc.). Schizophrenia is divided into four subtypes based on the predominant symptoms that the patient presents with during the active phase of the illness: paranoid, disorganized, catatonic and undifferentiated. Paranoid schizophrenia presents with preoccupation with delusions or auditory hallucinations without prominent disorganized speech or inappropriate affect. These patients are usually less severely disabled and are more responsive to pharmacotherapy. Disorganized type schizophrenia is characterized by disorganized behavior, disorganized speech, and flat or inappropriate affect. Catatonic symptoms are not present. Rambling speech, inappropriate behavior like masturbation in public & laughing at strange times) are characteristic. Catatonic schizophrenia is characterized by a predominance of physical symptoms, including immobility or excessive motor activity and the assumption of bizarre postures. Patients may be unresponsive to the environment and demonstrate extreme negativism or mutism. Residual schizophrenia occurs in patients with previous diagnoses of schizophrenia who no longer have prominent psychotic symptoms. The persistent symptoms may include eccentric behavior, emotional blunting, illogical thinking or social withdrawal. Although the primary treatment of schizophrenia is pharmacologic, an integration of pharmacotherapy with psychosocial treatment modalities will achieve the best outcome in these patients. Family therapy is one of the most important psychosocial interventions in schizophrenia. Many studies indicate that schizophrenic patients adjust better and have a decreased risk of re-hospitalization if the home atmosphere is stable and family stressors and conflicts are kept to a minimum. A supportive and non-demanding environment will contribute greatly to the patient's ability to adapt. Later, the patient can be encouraged to participate in a social skills training program. Schizophrenic patients have increased ventricular size as shown on CT scan of the brain.

Antipsychotics are divided into typical and atypical agents; both types are equally effective in treating patients with schizophrenia. Typical agents work by blocking dopamine D2 receptors and include drugs such as haloperidol, thioridazine, fluphenazine, and chlorpromazine. Extrapyramidal system (EPS) side effects are common and are the less preferred drugs. Atypical antipsychotics function by blocking dopamine and 5-HT2 receptors. These medications have fewer EPS side effects but tend to have more metabolic side effects, including diabetes mellitus, lipid abnormalities and weight gain. Examples include olanzapine, quetiapine, and risperidone. Atypical antipsychotics ( eg, quetiapine) other than clozapine are considered first-line treatment for psychosis secondary to schizophrenia or bipolar disorder. This is due to the lower risk of extrapyramidal side effects in comparison to typical antipsychotics. Currently recommended first-line atypical antipsychotics include oral aripiprazole, asenapine, iloperidone, olanzapine, paliperidone, quetiapine, risperidone, and ziprasidone. These are equally efficacious, but olanzapine seems to be the best tolerated by patients, and risperidone is available in generic form. Clozapine is reserved!!! Patients who live by themselves, have poor social support systems, are elderly, or have developed side effects with the use of neuroleptics are more likely to be noncompliant with their medications. This leads to symptom exacerbation, relapse, and recurrent hospitalization. Therefore, it is recommended that schizophrenic patients with a history of noncompliance be given long-acting injectable antipsychotics in depot form or deconate form, as shown below.

Clozapine is the atypical antipsychotic with the greatest efficacy; however, it can cause agranulocytosis, seizures, and mvocarditis. Its indications include patients with the following • Failure to respond to treatment with appropriate courses of standard schizophrenia medications • Intolerable side effects from alternate treatments • Serious risk of recurrent suicidal behavior in schizophrenia or schizoaffective disorder Contraindications to clozapine: • Myeloproliferative disorders • Uncontrolled epilepsy • History of clozapine-induced agranulocytosis or severe granulocytopenia • Severe central nervous system depression Clozapine is used to treat schizophrenia in patients who fail to respond to or cannot tolerate alternate antipsychotic medications. The extrapyramidal side effects of antipsychotics can be treated with anticholinergic medications like benztropine. Schizoaffective disorder is defined as the presence of symptoms of schizophrenia along with mood symptoms (major depression. bipolar disorder. or a mixed episode). To make the diagnosis, there should be at least two weeks when psychotic symptoms are present without any mood symptoms. Disorganized thought and speech are common in schizophrenic individuals. Those with circumstantial (from circumsfare, Latin for "to stand around") thought processes provide unnecessarily detailed answers that deviate from the topic of conversation but remain vaguely related. Eventually, there is a return to the original subject The term "flight of ideas" refers to loosely associated thoughts that rapidly move from topic to topic. Tangentiality refers to a thought process in which there is an abrupt, permanent deviation from the current subject. This new thought process is minimally relevant at best and never returns to the original subject Loose associations are best described as the lack of a logical connection between the thoughts or ideas of an individual. It tends to

be a more severe form of tangentiality in which one statement follows another but there is no clear association between the sentences. Perseveration is the repetition of words or ideas during a conversation.

Tourette syndrome is characterized by multiple motor and one or more vocal tics. The tics occur frequently throughout the day, often in bouts. The motor tics include barking, grunting, grimacing, eye blinking, and shoulder shrugging. The vocal tics may be obscene (coprolalia). The episodes are exacerbated by stress and usually subside during sleep. Frequent comorbid conditions in this patient population include attention deficit hyperactivity disorder (60 percent) and obsessive-compulsive disorder (27 percent). Obsessive-compulsive disorder (OCD) develops within 3-6 years after the tics first appeared. It may peak in late adolescence or in early adulthood at a time when the tics are waning. Less common comorbid conditions include anxiety, depression, and impulse control disorders Individuals with severe, uncontrolled symptoms are best treated with the traditional antipsychotics such as haloperidol or pimozide. Major Depression - For a diagnosis of major depression, a patient must have symptoms for the majority of the day, nearly every day, for a period exceeding 2 weeks. One of the associated symptoms must be depressed mood or loss of interest in activities that were previously enjoyable (anhedonia). All of the symptoms aside from depressed mood can be remembered with the mnemonic SIGECAPS: Sleep (insomnia or hypersomnia), loss of Interest, Guilt, low Energy, impaired Concentration, change in Appetite, Psychomotor retardation or agitation, and Suicidal thoughts. Four symptoms of the mnemonic, in addition to depressed mood or loss of interest, must be present for a diagnosis of major depression. A diagnosis of adjustment disorder with depressive features would also be a consideration. However, for an adjustment disorder, the symptoms must occur within 3 months of an identifiable stressor; the symptoms in this patient began after this timeframe. The initial step in the treatment of depressive symptoms in cancer patients is assurance of appropriate pain control. A combination of psychotherapy and selective serotonin reuptake inhibitor (SSRI) medications should be tried. There should be a low threshold for starting antidepressants in cancer patients given the generally low risk of side effects and the large potential benefit

Support groups help cancer survivors and their families cope with survivorship and the morbidity and potential mortality associated with cancer. These can be used as an adjunct to antidepressant treatment. Similar to support groups, individual supportive psychotherapy could be beneficial as well. However support groups are not likely to shorten the duration of depressive episodes, whereas successful antidepressant therapy can.

The strongest indicator that a future suicide attempt is likely is a history of previous suicide attempt(s) (Table). Both risk and protective factors for suicide should be considered in patient assessment and development of a treatment plan. Other factors to consider include compliance with treatment, history of violence, and alliance with the treatment team.

Statistics have repeatedly demonstrated that elderly persons, especially elderly white men, are at increased risk of suicide. More recently, individuals age 35-64 have also been shown to be at increased risk. The suicide rate for adolescents and young adults (age 15-24) also remains high, with impulsivity, hopelessness, substance use, and suicide contagion contributing largely to the rate. Thus, patient age is considered to be a less attributable risk factor than a history of previous suicide attempts. All depressed patients should be screened for suicidal ideation. Actively suicidal patients will often need to be hospitalized for stabilization and to maintain their safety.

Patients who are an acute threat to themselves should be hospitalized (involuntarily. if necessary) for treatment and stabilization. This principle also applies to minors, even without parental or guardian consent. Patients with depression and comorbid medical conditions, including terminal illnesses, can benefit from treatment with antidepressant medications to improve their quality of life. It is considered normal for patients with advanced cancer to have feelings of sadness. However, differentiating bereavement from major depression is important as patients with major depression will often have decreased quality of life. Antidepressants can largely be classified as the following: Selective serotonin reuptake inhibitors (SSRis) • • • •

Citalopram ( Celexa) Fluoxetine (Prozac) Paroxetine (Paxil) Sertraline (Zoloft)

Serotonin norepinephrine reuptake inhibitors (SNRis) • Duloxetine (Cymba Ita) • Venlafaxine (Effexor. Effexor XR) • Desvenlafaxine (Pristiq) Tricyclic and heterocyclic antidepressants (TCAs) • • • •

Amitriptyline (Eiavil) Clomipramine (Anafranil) Doxepin (Sinequan) Nortriptyline (Pamelor)

Monoamine oxidase inhibitors (MAOis) • Phenelzine (Nardil) • Tranylcypromine (Parnate) Other or atypical antidepressants • Bupropion (Wellbutrin) • Mirtazapine (Remeron) • Trazodone (Desyrel)

Sertraline is an SSRI that works by blocking the reuptake of serotonin at the presynaptic nerve terminal, thereby increasing the concentration of available serotonin in the brain. Important side effects of SSRis include anorexia and sexual dysfunction ( eg. decreased libido, delayed/retrograde ejaculation, erectile dysfunction). SSRI medications are generally considered the first-line treatment for patients with moderate-to-severe depression. If there is no improvement and/or side effects, Treatment guidelines recommend switching to a different medication in same class. If there is no improvement and/or side effects after 2 trials, switching to a different class of antidepressants is indicated. When choosing between medications for depression, consider treatment guidelines as well as the safety and side effect profiles. Also, consider a medication that may be effective for more than one condition. Bupropion is an example of a medication with two uses, as it is an antidepressant and a smoking cessation aid. Mirtazapine is an effective antidepressant for the treatment of depression; however, weight gain can be a fairly common side effect with its use. Dysthymia - A mood disorder characterized by the diagnostic criteria defined in the table below. Patients with dysthymia will often say that they have felt depressed their entire life, although the symptoms of dysthymia are less severe than those seen in major depressive disorder.

SSRis such as fluoxetine are the first-line treatment for depression and may take 4-6 weeks before a beneficial effect is noticed. Therefore, as long as the patient is tolerating the medication without significant side effects, he should be advised to continue fluoxetine for at least another 2 weeks (when he comes after only 2 weeks of usage) before a change is considered. Primary insomnia is characterized by the isolated symptom of having difficulty in falling or staying asleep. Given Panic Disorder – Panic disorder occurs most commonly in women between 20-40 years old. The condition is characterized by sudden-onset of episodes in which the patient experiences extreme anxiety, a sense of "impending doom," and somatic complaints such as chest pain, palpitations, nausea, shortness of breath, numbness in extremities, and diaphoresis. The diagnosis is typically made based on the clinical presentation, but drug screening and an EKG should be performed to rule out more serious conditions. Acute treatment of panic disorder includes the administration of benzodiazepines (e.g. alprazolam) for rapid relief of symptoms. A selective serotonin reuptake inhibitor (SSRI) should also be started for longterm symptom relief, but this won't take effect for a few weeks. Once symptoms are controlled, the benzodiazepines should be tapered off due to risks of dependence. Cognitive/behavioral therapy may also be of benefit.

Problems commonly associated with panic disorder include depression, bipolar disorder, agoraphobia, and substance abuse. Observational studies have shown that 1/3 to 1/2 of patients meet DSM-IV criteria for major depression at initial presentation and >60% have had 1 or more lifetime episodes of major depression. Approximately 40% of patients meet the criteria for agoraphobia. Pyromania is characterized by intentional and repeated firesetting with no obvious motive. Conduct disorder can also have a history of fire setting, but other features (e.g .. lying. theft. and cruelty to others) are also present.

Bipolar Disorder – Patient’s grandiose delusions, racing thoughts, distractibility, increased energy, and irritability are highly suggestive of a manic episode. The history of depression and now manic symptoms, with apparent good functioning between episodes, support a diagnosis of bipolar disorder. The key difference between DSM-IV-TR and DSM-5 is that patients with bipolar I disorder are, now, by definition, not required to have had a depressive episode. For the general population, the lifetime risk of developing bipolar disorder is 1%. However, an individual with a first-degree relative (eg, parent, sibling, or dizygotic twin) who suffers from bipolar disorder has a 5-10% risk of developing the condition in his lifetime.

Bipolar II disorder is characterized by episodes of major depression and hypomania (manic-like symptoms that are milder, do not require hospitalization, and do not cause psychosis). The diagnosis of bipolar I disorder is differentiated from bipolar II disorder by whether there have been any previous episodes of mania. First-line pharmacologic treatment for bipolar disorder includes the following: 1. Atypical antipsychotics ( eg, risperidone, aripiprazole, olanzapine) 2. Lithium 3. Valproic acid Monotherapy with atypical antipsychotics is preferred for mild to moderately ill patients. Monotherapy with lithium or valproic acid can be used as alternate therapy. For more severe episodes, combination therapy with lithium or valproate plus atypical antipsychotics is usually preferred over monotherapy. Combination therapy (compared to lithium or valproate monotherapy) has a more rapid onset of action. In patients with severe acute mania, psychosis, or extreme agitation, an antipsychotic is often required. In this case, haloperidol should be given immediately because of its acute onset of action in order to decrease this patient's increasing agitation.

The long-term treatment of choice for bipolar disorder is either lithium carbonate or valproic acid. The therapeutic effects of lithium carbonate are attributed to its ability to inhibit inositol-1-phosphatase in neurons. Because the margin of safety for lithium is very low, frequent monitoring is required to avoid toxicity. The potential adverse effects associated with lithium usage include gastrointestinal distress (e.g. nausea, vomiting, diarrhea, or abdominal pain), nephrotoxicity (resulting in polyuria and polydipsia, ultimately leading to nephrogenic diabetes insipidus), hypothyroidism, leukocytosis, tremors, acne, psoriasis flares, hair loss, and edema. Lithium is also a teratogen that is associated with Ebstein's anomaly (a cardiac defect). In a young woman, it is therefore important to evaluate thyroid function, renal function, and human chorionic gonadotropin levels before prescribing lithium. Lithium is a first-line medication for bipolar disorder. However, it is contraindicated in renal diseases. If the patient is on lithium for sometime & still experiences a manic episode, it is important to first obtain a urine toxicology screen to ensure he has not recently taken cocaine or amphetamine, as usage of either stimulant can result in a manic presentation. In the presence of a negative toxicology screen, lithium levels should be evaluated to determine if noncompliance or insufficient drug levels could be responsible for this man's manic episode. Patient with Hx of Manic episodes presents with mania despite on medication, the possible explanations are 1. He is taking Stimulants like Cocaine or Amphetamines (Do urine tox) 2. He is non compliant with his meds (Do blood lithium levels) The mood stabilizers such as lithium and valproate are the mainstays of treatment for bipolar disorder. For a bipolar patient on lithium, maintenance therapy should be continued for at least one year following an acute episode. If there are no relapses and the patient has attained good symptomatic control, then the lithium can be gradually tapered off and ultimately discontinued. Because abrupt cessation of lithium increases the risk of suicide and relapse, tapering the medication is always recommended.

Specific Phobias Treatment - The first-line treatment for specific phobia is cognitive behavioral therapy (CBT). CBT has been shown to be effective even with a relatively short number of sessions (ie .1-5). Medication is considered second-line treatment for specific phobias. If medication is needed, beta blockers and selective serotonin reuptake inhibitors are the best initial pharmacologic choices.

Generalized Anxiety Disorder - According to the DSM-IV, GAD is characterized by excessive anxiety and concern regarding multiple events or activities for a minimum of 6 months. Three or more of the following symptoms must also be present sleep impairment, easy fatigability, restlessness, muscle tension, poor concentration, and irritability. First-line medications for GAD are selective-serotonin reuptake inhibitors (SSRis), such as citalopram, or serotonin-norepinephrine reuptake inhibitors (SNRis). These medications are highly effective in combination with cognitivebehavioral psychotherapy. Treatment of Anxiety Disorders –

Social Phobia - These patients have extreme fear and avoidance of settings that require socialization. Patients stricken with this condition tend to view themselves as inferior and will blame themselves for any failures or negative outcomes in social situations. Functional impairment is common. An effective treatment regimen for social phobia is the combination of assertiveness training and an SSRI such as paroxetine. Assertiveness training is a subset of cognitive-behavioral psychotherapy that involves social skills training and the exploration and elimination of fearful thoughts that arise because of faulty cognitive processing. SSRis are also of help and

are considered first-line drugs in the management of social phobia. Therefore, a combination of these two therapies would be most effective for this patient. Specific Phobia of Public Speaking - Beta-blockers such as propranolol are excellent medications for prophylaxis against anxiety for this patient population when public speaking is unavoidable. They can be used on an as needed basis to help control much of the trembling, tachycardia, and other sympathetic symptoms associated with anxiety. Specific phobias can also benefit from behavioral therapy such as flooding, biofeedback, relaxation therapy, and exposure desensitization. Selective serotonin reuptake inhibitors (SSRIs) are used in the treatment of a variety of anxiety disorders. Since the patient's anxiety is only situational, it would be inappropriate to prescribe a daily medication. Hypochondriasis - a condition characterized by the misinterpretation of bodily symptoms and a persistent fear of fatal illness despite negative medical workups. Hypochondriacal symptoms become more prominent during periods of psychological stress. Therefore, it is always helpful to inquire about current emotional stressors with these patients. This discussion should be followed up with brief psychotherapy, which often resolves the symptoms.

Adjustment disorder requires the development of emotional or behavioral symptoms in response to an identifiable stressor within 3 months of the onset of the stressor. These symptoms cause impairment in the patient's life, but do not meet criteria for other psychiatric illnesses. Even moving away from home & living alone for the first time can cause symptoms of tension and insomnia leading to Adjustment Disorder. The treatment of choice for adjustment disorder is cognitive or psychodynamic psychotherapy. Grief is the specific emotional response to a loss and includes pain, distress, and physical and emotional suffering. Bereavement is a person's response to the loss of a close relationship and is many times interchangeably used with grief. A normal grief reaction typically subsides by 6 months after the initial loss, and the bereaved individual usually starts moving on with their usual daily activities. Although the symptoms can recur for up to 1 year and on

particular days, such as anniversaries, the patient generally has overall improvement. Abnormal bereavement/complicated grief reactions are characterized by difficulty moving on with life, bitterness, empty feelings, trouble accepting death, and social withdrawal. This can many times overlap with the symptoms of major depression, listed below using the "SIGECAPS" mnemonic. These symptoms can present in a 2-week period with depressed mood. In other words, its okay to have symptoms of depression for the 1st 2 months after the loss of a loved one. Bereaved patients who have at least 2 weeks of symptoms of depression 6-8 weeks after a major loss should be considered for treatment with both psychotherapy and a trial of antidepressants. This patient satisfies the criteria for major depression because he has experienced depressed mood, insomnia, guilt, energy deficit, decreased appetite, and suicidality. If the patient is not acutely suicidal, they can be started on first-line treatment for major depression with a selective serotonin reuptake inhibitor (SSRI), such as sertraline, and continue psychotherapy.

Obsessive-Compulsive Personality Disorder - Those with this condition develop a need for order and perfection and carry out activities in an extremely methodical way beginning before adulthood. They frequently do not complete tasks in a timely manner due to being extremely rigid, meticulous, and focused on the need for perfection. These patients often have anxiety, indecisiveness, and perseveration on assignments. These patients do well in school because they have little to do in school. However, when they enter college, they have a lot of work & Study & assignments to do and this is when they frequently end up finishing their work after the allotted time. They have limited insight and are ego-syntonic. Obsessive-Compulsive Anxiety Disorder - According to the DSM-IV, OCD is characterized by the presence of persistent, intrusive thoughts that lead to the performance of compulsive acts in order to allay inherent anxieties. Individuals suffering from this disorder often perform multiple time-wasting rituals and recognize the absurdity of their behavior but feel unable to stop. They suffer from significant functional impairment. They are ego-dystonic. This disorder results from altered levels of serotonin, a neurotransmitter that regulates mood, aggression, and impulsivity. The treatment of choice for

OCD is a selective serotonin reuptake inhibitor (SSRI), such as paroxetine & TCAs like Clomipramine. Alzheimer’s Dementia - Although the etiology of Alzheimer's dementia is not well understood, histopathologic examination of brain tissue in affected patients clearly indicates a selective loss of cholinergic neurons. The first-line treatments for cognitive symptoms of Alzheimer's dementia are cholinesterase inhibitors. The cholinesterase inhibitors donepezil (Aricept), galantamine (Razadyne), galantamine ER (Razadyne ER), and rivastigmine (Exelon) have been shown to be effective in patients with mild-to-moderate dementia. Cholinesterase inhibitors may improve quality of life and cognitive functions, including memory, language, thought, and reasoning. Donepezil is approved for all stages of Alzheimer's dementia. Memantine, an N-methyl-D-aspartate receptor antagonist, is approved for moderate-to-severe dementia.

Dissociative Disorders – Dissociative Fugue - The dissociative disorders are characterized by forgetfulness and dissociation. Dissociative fugue is the only condition within this group that is associated with travel. Dissociative amnesia is characterized by the presence of one or more episodes of inability to recall important personal information. The memory disturbance is usually related to a traumatic or stressful event and is too extensive to be considered ordinary forgetfulness. Depersonalization disorder is characterized by persistent or recurrent feelings of detachment from one's own physical or mental processes in the context of an intact sense of reality. These patients tend to feel they are observing their body and thoughts from afar, as if they are living in a dream. This condition usually results in significant occupational or functional impairment. Derealization disorder describes the state of experiencing familiar persons and surroundings as if they were strange or unreal. Dissociative identity disorder, formerly known as multiple personality disorder, is characterized by the presence of two or more distinct identities that alternatively assume control of the person's behavior. Amnesia regarding important personal information about some of the identities is observed.

Physical/Sexual Abuse - Always have a high index of suspicion for physical/sexual abuse in children (especially females) with sudden behavioral problems, families with unstable economic backgrounds, or parents with a history of drug/alcohol abuse.

Anorexia nervosa is most common in adolescent girls from affluent families. The DSM-IV criteria for the diagnosis of anorexia nervosa include: 1) Body weight at least 15% below normal weight accompanied by a refusal to maintain body weight at normal levels (Still want to lose weight); 2) Amenorrhea for three months; 3) Distortion of body image in which the individual views herself as obese when she is in fact thin; and 4) Fear of gaining weight or becoming fat despite being underweight. To continue to lose weight, individuals suffering from anorexia nervosa will either: 1) Fast and/or exercise excessively (the restricting subtype), or 2) Binge eat followed by laxative usage or induced vomiting (the binge and purging subtype). Hospitalization is highly recommended for patients with anorexia nervosa when there is evidence of dehydration, starvation, electrolyte disturbances (i.e. hyponatremia, hypokalemia, or hypophosphatemia), cardiac arrhythmias, physiologic instability, or severe malnutrition (i.e. weight< 75% of average body weight for age, sex, and height). The goals of hospitalization include weight gain as well as prevention and management of the medical complications caused by anorexia nervosa. Although patients with anorexia may have thyroid dysfunction, meaning they will feel cold & have dry skin & bradycardia, low BP & low pulse. The primary illness needs to be managed first. On physical examination, the most striking finding is emaciation. Some individuals develop lanugo (a fine downy body hair) on the back and abdomen. Other common findings include bradycardia, hypotension, hypothermia, hair loss, and dry skin. Those who induce vomiting may have "puffy cheeks" from parotid gland hypertrophy, dental caries,

halitosis, and scars or calluses on the hand from contact with the teeth ("Russell's sign”) Electrolyte derangements can result from vomiting.

Although a woman with eating disorder has corrected her eating disorder, she remains at increased risk for developing pregnancy complications associated with the chronic deprivation of essential nutrition. Patients with a current or previous diagnosis of anorexia nervosa are at higher risk for giving birth to infants that are premature, small for gestational age (secondary to intrauterine growth retardation) or both. Other potential complications include miscarriage, hyperemesis gravidarum, cesarean delivery, and postpartum DEPRESSION (Not psychosis). Children born to anorexic mothers often suffer from poor growth and intellectual impairment. Remember the other common findings seen in anorexic patients (important for USMLE): 1. Osteoporosis 2. Elevated cholesterol and carotene levels 3. Cardiac arrhythmias (prolonged QT interval) 4. Euthyroid sick syndrome 5. Hypothalamic-pituitary axis dysfunction resulting in anovulation, amenorrhea and estrogen deficiency 6. Hyponatremia secondary to excess water drinking is often the only electrolyte abnormality, but the presence of other electrolyte abnormalities indicates purging behavior.

Conversion disorder requires the following diagnostic criteria:

Common triggers include relationship conflicts or other stressors with an intense emotional component. But the symptoms are not feigned or purposefully produced. Patients with conversion disorder can be hysterical or strangely indifferent (i.e .. "Ia belle indifference") to their symptoms. Definitive diagnosis of conversion disorder requires an extensive workup to rule out possible underlying medical causes. Treatment options include hypnosis and relaxation techniques in the acute setting, while psychotherapy offers the best long-term results. Delusional disorder is characterized by non-bizarre (i.e., can occur in real life) false beliefs in an otherwise high-functioning individual. Common types of delusions include: erotomanic (false belief that a person of higher social status is in love with them, such as a movie star); persecutory (false belief that someone is out to harm them or someone close to them); jealous (false belief that their spouse is cheating when the evidence shows that they have remained faithful). Delusional disorder involves one or more non-bizarre delusions in an otherwise high-functioning individual – meaning, they have a normal functioning life…but they have this one delusion. Grandiose Delusion - A delusion is a fixed, false belief not consistent with cultural norms. Individuals with grandiose delusions typically believe they have special powers, extraordinary accomplishments or a special relationship with God. Grandiosity is defined as a grossly inflated sense of selfimportance. Vs

Magical thinking is the belief that one's thoughts can control events in a manner not explained by natural cause and effect. It also includes the attribution of casual incidents to supernatural forces. Folie a deux – In this disorder, a delusion or set of delusions is shared simultaneously by individuals who share a close relationship. Usually, the dominant individual in the pair becomes delusional and transfers the delusion onto the second person. Treatment includes separating the pair to break the chain of reinforcing each other's beliefs. The individual who first had the delusion, always requires psychiatric treatment (sometimes in an inpatient setting), whereas the other individual only requires treatment in some cases. It is important to assess both individuals separately to determine the degree of impairment in each. Selective Mutism – These individuals demonstrates poor communication and reduced verbal expression in a specific social setting (school) but behaves normally at home because she feels comfortable and relaxed there. This supports the diagnosis of selective mutism, a condition in which people have a fear of situations in which they are expected to talk ( eg. school or a formal social gathering). They may "freeze up" and become expressionless. To establish the diagnosis, symptoms must be present for at least one month. Cause significant functional impairment, and not be caused by another communication or learning disorder.

Child Abuse - The table below summarizes the history, physical examination findings, and caregiver behaviors that increase the likelihood that abuse is the cause of an injury.

The first step is to perform a more complete and thorough examination with the clothes completely removed because sometimes the initial cursory examination can miss some of the findings noted in the above table. Injuries that are suggestive of a cigarette burn (e.g .. circular punched-out lesions) or immersion in scalding hot water (e.g .. clear line of demarcation with no splash marks) are very concerning for child abuse. If there are physical examination findings suggestive of current or past abuse/injury, appropriate laboratory (e.g .. liver function tests to evaluate for abdominal injury) and radiologic (e.g .. skeletal survey x-rays to document fracture) studies should be done. Once this investigation is complete, a physician can determine if there are data to suggest abuse and consult Child Protective Services (CPS), perform an evaluation of family dynamics, or admit the patient to the hospital for further care if necessary. When child abuse is suspected, the following steps should be performed: 1. 2. 3. 4. 5.

Complete physical examination Radiographic skeletal survey (if necessary) Coagulation profile (if multiple bruises are present) Report to Child Protective Services Admittance to the hospital (if necessary) 6. Consultation with a psychiatrist and evaluation of family dynamics Domestic Abuse - Physicians should be alert to clues suggestive of physical abuse as patients will rarely report such abuse on their own. Multiple ecchymoses, fractures, or repeated visits to the physician with different injuries are all signs of possible physical abuse. The initial statement in such cases should be made delicately. Open-ended questions and general

statements of observation often provide the best introduction to such a discussion. Therefore, encouraging the patient to say a little more about the bruises is a good start as it encourages an open dialogue. The fact that the patient cried at mention of the bruises suggests that she indeed has something to say. She should also be reminded that this conversation is confidential. Physical abuse should be suspected in a woman with multiple bruises and frequent injuries. In these cases, the following steps should be carried out 1. 2. 3. 4. 5. 6. 7.

Confront the patient gently, in a nonjudgmental way. Assure the patient of confidentiality and any limitations. Emphasize that the abuse is not acceptable. Suggest informing the police. Ensure safety of the patient and any children. Ask the patient if she has an escape plan. Suggest talking to a support group or agency dealing with these issues. 8. Assure the patient of continuing support. Pathologic gambling is more common in males and defined as a persistent and maladaptive gambling behavior that usually results in a preoccupation with gambling and arranging for the means to indulge in it. These patients might gamble increasing amounts of money to achieve the desired excitement and can resort to illegal behavior to finance their activities. Attempts to reduce gambling behavior are typically unsuccessful and result in jeopardized relationships and financial instability. When confronted about the issue, pathologic gamblers are usually dishonest and evasive. The gambling can also be used as a means of escaping from problems or relieving unhappiness. Bereavement is a normal reaction to the loss of a loved one. Normal bereavement rarely lasts longer than a few months and is distinguished from PCBD by duration and degree of impairment. However, Persistent Complex Bereavement Disorder can occur in patients experiencing significant impairment and other symptoms more than 12 months following the loss.

Imaginary Friends - Parents often become concerned and puzzled when their children acquire imaginary friends, but this phenomenon is generally considered an indication that the child has found creative ways to deal with being alone. Children between the ages of two and six years are most likely to develop imaginary friends, typically in response to times of change or stress. Most children abandon this behavior within the first few years of elementary school. Autism - Autism presents early in childhood, becoming evident before three years of age. The autistic child fails to develop normal interactions with others and has impaired verbal and non-verbal communication. These children often indulge in repetitive, stereotyped behavior and may babble and use strange words. They avoid eye contact and have restricted interests.

Vs Hearing impairment in children can mimic the communication and social abnormalities evident in autism spectrum disorder. However, patients with hearing impairment are unlikely to demonstrate the abnormal motor and sensory responses Vs Attention deficit hyperactivity disorder in DSM-5 presents before age 12 and is characterized by inattention, impulsiveness, overactivity, forgetfulness, poor organization, and short attention span.

Trichotillomania - By definition. trichotillomania is an impulse-control disorder. According to the DSM-IV diagnostic criteria. The patient must have the following characteristics: 1. 1 . Repeated episodes of pulling out one's hair resulting in hair loss that is noticeable 2. Experiencing anxiety right before the act of pulling out the hair or when trying to resist the temptation 3. A sense of relief after the hair has been pulled out 4. This behavior causes impairment or distress

5. Features inconsistent with any other medical or dermatological condition causing hair loss These individuals most commonly pull out hair from the scalp. However, other areas can also be affected (e.g .. eyebrows, eyelashes, facial hair, armpits and even pubic hair). The act is usually triggered by a stressful event and is often associated with other disorders (e.g .. obsessive compulsive disorder (OCD), anxiety disorders, Tourette's, eating disorders. etc.) Sleep Disorders – Sleep hygiene Inadequate sleep hygiene is a sleep disorder due to performance of daily living activities that are inconsistent with the maintenance of good-quality sleep and full daytime alertness. Poor sleep hygiene can be associated with insomnia. Examples of poor sleep hygiene practices include poor sleep scheduling with variable wake and sleep times and frequent daytime napping; routine use of caffeine. alcohol. or nicotine especially in the period preceding sleep; engaging in mentally or physically stimulating activities too close to bedtime; and frequent use of the bed for activities other than sleep. It is typically seen in people who have a very hectic job & have lot more activities. They have a delayed sleeping phase due to anxiety of work.

Delayed sleep phase syndrome is a circadian rhythm disorder characterized by inability to fall asleep at "normal" bedtimes such as 10 PMmidnight. These patients often cannot fall asleep until 4-5 AM, but their sleep is normal if they are allowed to sleep until late morning. They present with complaints of insomnia and excessive daytime sleepiness. An accurate history and/or a sleep diary are essential in making the diagnosis. Advanced sleep phase disorder is also a circadian rhythm disorder and is characterized by an inability to stay awake in the evening (usually after 7 PM), making social functioning difficult. These patients frequently complain of early-morning insomnia because of their early bedtime.

Age Related Changes - Sleep patterns tend to change in older individuals. As people age, they typically sleep less at night and nap during the day. The period of deep sleep (Stage 4 sleep) becomes shorter and eventually disappears. Older people also awaken more during all stages of sleep. These changes are normal and usually do not indicate a sleep disorder.

Age Dependent Changes - changes that are inevitable with age. Auditory - Presbycusis: sensorineural hearing loss, particularly at high frequency, Otosclerosis: fusion of ear ossicles producing conductive hearing loss Body composition - Total body fat increases while total body water and lean body mass decrease: watersoluble medications (e.g., cimetidine, digoxin, ethanol) have decreased volume of distribution causing higher levels in the plasma. Fat-soluble drugs (e.g., chlordiazepoxide) have a larger volume of distribution causing a decreased plasma concentration; excretion from the body is at a slower rate, which increases half-life and extends pharmacologic effects. Cardiovascular - Blunted maximal cardiovascular responses to exercise Central nervous - Cerebral atrophy with mild forgetfulness, Impaired sleep patterns such as insomnia, early wakening, Decreased dopaminergic synthesis: parkinsonian-like gait Decrease in cerebral blood flow and increase in blood-brain barrier permeability: increases sensitivity to medications that affect CNS Female reproductive- Breast and vulvar atrophy, Decreased estrogen and progesterone: ↑FSH and LH, respectively Gastrointestinal- Decreased gastric acidity: predisposes to Helicobacter pylori infection Decreased colonic motility: constipation predisposing to diverticulosis General Increased body fat- decreased number insulin receptors (glucose intolerance) Hepatobiliary Liver mass decreases 25%−35% with increasing age: liver blood flow decreases 35%−45%; hence, medications have a longer duration of effect Immune Decreased skin response to antigens (called anergy) Male reproductive - Prostate hyperplasia: predisposes to urinary retention, Prostate cancer: most common cancer in men Musculoskeletal - Osteoarthritis in weight-bearing joints: wearing down of articular cartilage in the femoral head Renal - Kidney loses 20%-25% of renal mass as people age from 30 to 80 years, Decreased GFR (↓10% per decade from the age of 30 years): increased risk of drug, toxicity from slow clearance of drugs

Respiratory - Mild obstructive pattern in pulmonary function tests: e.g., ↑TLC, ↓vital capacity, Mild hypoxemia and increased A-a gradient Skin - Decreased skin elasticity due to increased crossbridge formation between collagen fibers Senile purpura over the dorsum of the hands and lower legs Visual Cataracts - visual impairment, increased risk for falls, Presbyopia: inability to focus on near objects Age Related Changes - changes that have a greater incidence with age but are not inevitable with age. Cardiovascular Atherosclerosis: increased risk for coronary artery disease, heart failure, peripheral vascular disease, strokes, Aortic stenosis: most common valvular abnormality in the elderly, Systolic hypertension: due to loss of aortic elasticity, Giant cell arteritis: large vessel vasculitis involving aortic arch vessels Central nervous Alzheimer disease: most common cause of dementia in people >65 years Parkinson disease, Subdural hematomas: due to falls. Endocrine Type 2 diabetes mellitus Female reproductive Increased incidence of cancers of the breast, endometrium, ovary Gastrointestinal Increased incidence of colorectal cancer Immune MGUS: most common cause of monoclonal gammopathy Musculoskeletal Osteoporosis: vertebral column in females and femoral head in males Polymyalgia rheumatica: muscle and joint pain associated with an increased erythrocyte sedimentation rate Renal/lower urinary tract Renovascular hypertension secondary to atherosclerosis Urinary incontinence Respiratory Pneumonia: usually Streptococcus pneumonia Primary lung cancer: particularly in smokers

Skin UVB-induced cancers: e.g., basal cell carcinoma (most common), Actinic (solar) keratosis: precursor for squamous cell carcinoma, Pressure sores: pressure on capillaries is the most important risk factor Visual Macular degeneration: most common cause of blindness in the elderly