Psych: stuff looked up / learned

General Psych
Axes (DSM)

Axis I: Clinical syndromes

Axis II: Developmental (MR, etc) / Personality disorders (cluster A/B/C)
o Cluster A (the "weird"): paranoid, schizoid/schizotypal
o Cluster B (the "wild"): antisocial, borderline, histrionic, narcissitic
o Cluster C (the "worried"): avoidant, dependent, OCD
Axis III: Physical conditions (HIV, AIDs, brain injury, other med conditions that could be
contributing)
Axis IV: Psychosocial stressors
Axis V: Highest level of functioning in last year and level now (how is life affected)

Personality disorders
Cluster A
Schizoid: Loner, flat affect, restricted emotions, indifferent to interpersonal relationships, no
psychotic symptoms, not good with personal interaction, computer nerd. Use a low-key, technical
approach when discussing care.
Schizotypal: odd, eccentric, magical thinking, paranoid, not psychotic. Projection, regression,
fantasy are defenses. Stay nonjudgmental as therapist
Paranoid: distrustful / suspicious; constricted affect. Projection is defense. Try to form working
alliance with patient. No true delusions / hallucinations

Cluster B
Histrionic: excessively emotional, attention-seeking, theatrical, overblown speech, seductive
manner. Reaction formation is defense
Narcissistic: self-important, needs admiration, dismisses others' feelings, secretly low selfesteem. If they seek treatment, it's probably because they're angry that they're not getting the
credit that they deserve, etc.
Antisocial: no empathy, acting out, aggressive, conduct disorder as child, usually starts up
by age 15, need to be 18 y/o for dx

Conduct disorder: 3 sx in last 12 mo, 1 in last 6 mo of: aggression toward people /

animals, destruction of property, theft / deceitfulness, rule breaking (can have more than 1
in a category), need to be younger than age 18 generally
Can develop somatization disorders

Borderline: impulsive, unstable relationships, affective instability, can be transiently psychotic.

Splitting, projection are defenses. Dialectical behavioral therapy is specialized cognitive
therapy for BPD

Cluster C
OCPD: perfectionistic control freak, really into order, no obsessions or compulsions, may be really
into work. Reaction formation is defense
Avoidant: hypersensitive to criticism / rejection, socially uncomfortable, seeks interpersonal
relationships but uncomfortable doing so, maybe a very few close friends
Dependent: submissive, clingy, needs to be taken care of, wants others to make decisions
Ego Defenses

Projection: pt attributes their thoughts to another (angry with therapist? accuse therapist
of being angry at you!)
Reaction formation: deal with emotional conflict by substituting the opposite (e.g. angry
at husband? cook him a nice dinner!)
Somatization: express your problems as physical complaints (form of regression - e.g.
get headache when you're upset with therapist)
Idealization: attribute exaggerated positive qualities to others to deal with conflict
Devaluation: opposite of idealization; exaggerated negative qualities
Isolation of affect: separate ideas from feelings (lose touch with feelings about an event
but retain descriptive details)
Rationalization: deal with emotional conflict / stressors by concealing true motivations
Undoing: use words or behavior to negate / symbolically make amends for unacceptable
thoughts / feelings / actions (realistically or magically associated with conflict - e.g. don't
step on cracks to avoid "breaking mother's back")
Acting out: use actions rather than reflections / feelings to guard against stressors /
conflicts (e.g. angry? start a fight at a bar!)
Dissociation: deal with conflict / stressors by breakdown of normal consciousness splitting off (e.g. feel like events are being told to someone else after son killed in car
crash)
Repression: disturbing stuff gets pulled into unconscious (can't remember what troubling
things were said, etc)
Suppression: don't deal with feelings / ideas, but still in conscious awareness (actively
trying to forget)
Denial: don't acknowledge conflict / stressors - arguing that they don't exist instead of
dealing with them
Displacement: take out impulses on less threatening target (e.g. dad was alcoholic, dtr
now has conflict with boyfriends)
Sublimation: acting out impulses in socially acceptable way (e.g. aggressive? be a boxer!)

Mood Disorders

Depression
"SIG E CAPS" - Depression features

Sleep
Interest (decreased)
Guilt

Energy

Concentration
Appetite
Psychomotor retardation
Suicidal ideation

Suicide: "SAD PERSONS" (most at risk)

Sex (male)
Age less than 19 or greater than 45 years
Depression (patient admits to depression or decreased concentration, sleep, appetite
and/or libido)

Previous suicide attempt or psychiatric care

Excessive alcohol or drug use
Rational thinking loss: psychosis, organic brain syndrome
Separated, divorced, or widowed
Organized plan or serious attempt
No social support
Sickness, chronic disease

Bipolar Disorder
Mania: "DIG FAST"

Distractibility
Indiscretion (DSM-IV's "excessive involvement in pleasurable activities . . . ")
Grandiosity

Flight of ideas
Activity increase
Sleep deficit (decreased need for sleep)
Talkativeness (pressured speech)

AD / Dementia / etc

Dementia: multiple cognitive deficits with memory (often short-term lost 1st) and one
of aphasia / apraxia / agnosia / exec fxn with functional impairment
o Without the other cognitive deficits, it's just amnesia

AD

APOE4: associated with increased (2x?) risk of late-onset AD (>60 y/o)

APP (chr 21), presenilin 1-2: aut-dom forms, early onset AD
cortical atrophy, enlarged ventricles

Pick disease: frontotemporal, pick bodies, preferential frontotemporal atrophy

Vascular dementia: deep white-matter lacunar infarcts

Procedures
ECT:

Unilateral = less confusion / delirium afterwards; Bilateral = more powerful for sx but more
confusion / delirium
R. sided unilateral helps preserve language functioning afterwards
Hold meds beforehand: anticonvulsants (mechanistic) and anything that can contribute to
delirium

Meds
Old patients may need lower doses but similar blood levels for antidepressants (less metabolism)

In hepatic disease, use benzos metabolized outside the liver (oxazepam, temazepam,
lorazepam)
actually metabolized by the liver via glucuronidation, which isn't dependent on "liver function"
(takes a lot of liver fxn loss to lose glucuronidation capacity)

Sedation & the Agitated Patient

Physical restraints are bad: increased rate of sentinel events (death / harm / etc)
Chemical restraints: think B-52
o Benadryl 50 mg
o 5 mg Haldol
o 2 mg Ativan (lorazepam)

Bromocriptine = dopaminergic agonist. Can be used +/- dantrolene (muscle relaxant) in

treatment of NMS

Thioridazine (low potency typical antipsychotic) can cause retinitis pigmentosa (loss of night
vision)

Beta blockers (like Propranolol) can be used to treat akathisia, performance anxiety

Bradycardia, hypotension, asthma exacerbation can be side-effects

Buspirone (Buspar): selective serotonin type 1A receptor agonist. As effective as diazepam in

treating anxiety.

Anticholinergics (benztropine, trihexylphenidyl) used as 1st line in neuroleptic-induced

parkinsonism, acute dystonia.

Diphenhydramine (antihistamine with anticholinergic properties) - as above + nonspecific

sedation
These are CNS muscarinic antagonists; side effects (peripheral anticholinergic action) blurry vision (cycloplegia), constipation, urinary retention, (central action) - sedation,
delirium

Flumazenil is a benzo antagonist used in emergent benzo OD; can precipitate severe
withdrawal (dangerous)

Stimulants for ADHD: watch out for decreased appetite (incl. slowed growth), insomnia at
first, irritability, dysphoria, headache, tics sometimes; rapid action

Atomoxetine is a selective NE reuptake inhibitor, used in ADHD, especially

if substance abuse in family (not abusable) or tics (doesn't worsen tics) or comorbid
anxiety disorders

Pemoline has stimulant action too, but has rare heptatotoxicity (get baseline ALT,
q2wks)

Acetylcholinesterase inhibitors = donepezil, galantimine, rivistigmine, tacrine; all reversible

inhibitors.
GI upset, cholinomimetic effects (bradycardia, increased gastric acid secretion) can result.
Memantine used in AD too, NMDA antagonist (less neurotoxicity)
Use high potency antipsychotics in demented individuals to decrease agitation (low-potency
have more anticholinergic / orthostatic side effects)
Benzos
Short half-life (2-10 h)

Intermediate half-life (1015h)

Long half-life ( 1d+)

chlordiazepoxide (Librium)

temazepam* (Restoril)
diazepam (Valium)
triazolam (Halicon)

lorazepam* (Ativan)
clorazepale (Tranxene)

oxazepam* (Serax)

alprazolam (Xanax)
flurazepam (Dalmane)
halazepam (Panipam)
prazepam (Centrax)

Side Effects of neuroleptics

Dystonic rxn: hours - days, treat with anticholinergics / antihistamines

Parkinsonism: days - wks
Akathisia: days - wks
Tardive dyskinesia: years
NMS: anytime

Amphetamines: generally used for ADHD, narcolepsy, depressive disorders

Dexedrine (dextroamphetamine), Desoxyn (methamphetamine), Ritalin

(methylphenidate) affect dopaminergic system
Designer amphetamines (ecstasy, etc) have serotonergic effects too

Basic Science & Anatomy

Hypothalamic nuclei

Lateral = drive to eat

Venteromedial = satiety center (damaged in Prader-Willi)
Anterior = sex
Posterior = levels of arousal (lesion = lethargy, somnolence)
Paraventricular, supraoptic = vasopressin, oxytocin

Kluver-Bucy syndrome: bilateral amygdala damage (absence of fear, hyperorality,

hypersexuality, etc)

Neurotransmitters & stuff

Nuclei

Nucleus basalis - cognitive functions, memory; degenerates in Alz Dz

Substantia nigra (dopamine) - degenerates in PD
Raphe nuclei: serotonin, mood/pain/agression
Locus ceruleus: major noradrenergic nucleus; arousal / attention / autonomic tone,
connects to amygdala (threats)

Neurotransmitters:

Serotonin: depression, OCD

Dopamine: psychosis, EPS
Acetylcholine: cognitive fxn, memory
Norepi: anxiety disorders

Sleep:

Polysomnography: EEG, EOG, EMG.

Stage 1: theta waves, relaxed muscle tone, "nodding off"
Stage 2: K complexes, sleep spindles; no eye movements, nodding-off
Delta-sleep: Low frequency, high voltage EEG waves; stages 3-4 here
REM: low, fast EEG voltage; no muscle tone (cataplexy), very rapid eye movements

Sleep disorders:

Dyssomnia: too much / too little sleep (OSA, narcolepsy, poor hygeine)
Parasomnias: during sleep or on arousal (sleep terrors, sleep walking, rhythmic movement
disorder, etc)

Diagnostic tests

MMPI: personality test (minnesota multiphasic)

Projective tests: ambiguity
o Rorshach: ink blots
o Thematic apperception tests (TAT) - motivation (make a story about a picture)
o Sentence completion (My greatest fear is...)
Intelligence tests: WAIS (Weschelr Adult Intelligence Scale) is most common
Neuropsych tests
o Wisconsin card sorting: abstract reasoning, flexibility (sort cards) - abnl in frontal
lobe dysfxn
o Weschelr memory (various memory tests)

Visuomotor (Bender visual-motor gestalt)

Other medical conditions & psychiatry

Pancreatic cancer linked to depressive symptoms classically

Psychosis in deliria, dementias, severe hypothyroid, hyperCa, syphilis, substance abuse
(esp PCP)
Anxiety in Graves, PE, hyperthyroid, Sjogren, some seizures
o Sjogren: WBC attack moisture-producing glands. dry eyes + dry mouth + other
organs. 4M in USA/yr.
o Graves: up to 60% meet GAD criteria
o Pheochromocytoma: can mimic panic attacks
o Awaiting heart transplant: more noradrenergic tone; high incidence of panic
disorder
o Hypoglycemia can look like anxiety too
Mania-like states: corticosteroids, levodopa, cocaine.
PANDAS: Pediatric autommune neuropsych disorders a/w strep infections; includes OCDtype behavior
o Get antistrep Ab titer (antistreptolysin O - ASO - titer rises 3-6 wks after infection,
antistrep DNAase B - antiDNse-B - titer rises 6-8 wks later)
o Use SSRI + CBT for compulsive behaviors. ?Abx use to prevent recurrence?
Cardiac surgery is a big risk for delirium (90% of pts), also old age (60% nursing home
residents), hosp (10-30%)

DSM Junk, etc.

MDD: Most of the time for at least 2 wks, 5+ symptoms, 2+ episodes for recurrent

50-80% recurrence, 15% suicide rate, usually 6-12mo episodes

Vs normal bereavement: usually < 2mo after loss, diminishing with time, can even have
hallucinations of deceased person (children / adolescents) but reassuring / comforting vs
accusatory PMD hallucinations
Psychotic MD: taper antipsychotic when psychotic sx resolve, at least 6-9 mo or more of
antidepressant

Adjustment disorder: emotional response (mood sx) within 3 months of stressor, don't last
longer than 6 mo after stressor resolved

can be anxiety, depressed mood, conduct disturbance, mixes. Often somatic complaints
in kids / irritability in kids & adolescents
Treat with psychotherapy (group if possible, individual, generally not meds except actue
sleep help)

Postpartum blues: several days - a week, less severe than depression, present in 50-80% pts,
resolves in < 14d, no treatment
Postpartum depression: 65% of all women experience first MDD in 1st year after delivery.

Treat with SSRI, Can give antidepressant prophylaxis for next pregnancy (prior episode
is #1 risk factor for postpart depression)

Postpartum psychosis: confusion, extreme mood lability, 1-2/1000 deliveries, medical

emergency (hosp mom _ baby)

SSRI (generally safe) + antipsychotic, also consider ECT; TCAs not good

Dysthymic disorder: depressed for most of day, more days than not for at least 2 yrs (1 yr for
children /adolescents), not more than 2 mo without symptoms, no MDD
Cyclothymia: between dysthymia & hypomania over 2 yrs
Bipolar disorder, manic episode: need at least 1 wk of manic symptoms or hospitalization

70% MZ vs 20% DZ
Often psychotic features if manic in children. DDx vs ADHD + ODD or CDD
BP-I: full mania, BP-II: hypomania (don't meet full criteria; briefer; milder; 4d+)
Rapid-cycling: 4+ episodes in 12 mo

Schizophrenia: 2+ symptoms for 1 mo or one if bizarre delusions / commenting auditory

hallucinations / conversing voices, at least 6 mo with some sx (incl. negative symptoms)

1% lifetime prevalence, M=F, 20-40% attempt suicide, 10% complete, M present 18-25 yo,
F present 25-35 yo; women have better outcome
Thought-blocking: having one's train of thought curtailed absolutely, unpleasant
Ideas of reference: false beliefs that people talking about pt (often. via TV, radio, etc)

Schizoaffective disorder: psychotic symptoms like acute schiz, also must be around for 2 wks
without mood symptoms as well as with mood symptoms.

Treat with antipsychotics, often long-term (usually atypicals). Can use mood
stabilizers if manic manifestations.

Schizophreniform disorder: schizophrenia that doesn't last for 6 months and no social
withdrawal. Resolves or progresses to bipolar / schizophrenia
Delusional disorder: non-bizarre delusions, otherwise normal, at least 1 month, often mid-life,
F>M
Brief psychotic disorder: often after stress or postpartum, 1 day to 1 month
Panic disorder: panic attacks (4+ panic symptoms, out of the blue, episodic), recurrent, 1 mo
of behavior change / worry as result.

Treat with SSRIs / TCAs / MAOi + CBT; benzos short term only

GAD: more chronic anxiety, not attacks. A least 6 mo of symptoms for majority of the day.
Also irritable, fatigued, sleep disturbed. Need 3 sx. F>M

Treat with SSRIs/venlefaxine + CBT. Also buspirone, avoid benzos long-term.

Phobias are #1 common mental disorder in USA (5-10% population), specific > social,
women > men, late childhood / early adulthood, chronic.

Desensitization or exposure, SSRIs / benzos / venlafaxine / busipirone. Beta-blockers just

before (propanolol, atenolol)

Separation anxiety (a childhood disorder)

Hard to treat; often develop depression / psychotic disorders. 18-50% develop panic
disorder.
Use SSRIs for mood / anxiety + relaxation + graded separation. Earlier treatment better.
Don't homeschool (reinforces)
At least 4 wks, onset before age 18, inappropriate anxiety about separating from home /
care taker
Can have somatic sx, especially in kids.

OCD:

2-3% lifetime; 10% o/p psych visits, 20-30% have tic history (5% Tourette's).
Treat with behavioral therapy (Exposure-response prevention) and SSRIs
(clomipramine 2nd line, TCA mostly acting on serotonin, but side effects)

ADHD - needs to be present in more than one setting and start before 7 yrs old, 6+ sx

Inattentive, hyperactive, and combined types

Use simulants, atomoxetine (NE reuptake inhibitor, less tics associated), also
buproprion, imipramine / nortriptyline / pemoline
Comorbid ODD / CD is common; meds can only help if child wants to do the right thing!
70-80% respond to stimulants.
Tourette Disorder: both motor & vocal tics (don't have to be at same time), for at least 1
yr without 3 months free of tics, age < 18, causes disturbance

o
o
o

Coprolalia = potty mouth

4/5/10,000, more common in boys. Usually motor by age 7, vocal by age 11. Runs with
OCD / ADHD
Treat with alpha-adrenergic medicine (clonidine, guanfacine). If it doesn't work,
try atypical antipsychotic (esp risperidone)
Clonidine: alpha-2 agoniost, decrease NE by acting on locus ceruleus
Guanfacine: activates postsynaptic prefrontal alpha-adrenergic receptors
Both also used in ADHD to reduce sx - good for comorbid condition
PTSD: acute if < 3mo, chronic if > 3 mo. Acute often resolve on their own; if it lasts longer
than 3 mo, probably needs intervention.

Treat with SSRI (esp. sertraline, paroxetine) + psychotherapy (CBT), social interventions.
Can use alpha-2 agonists (clonidine, prazosin) for symptoms.
Benzos not helpful & risk for substance abuse.

Acute Stress Disorder (shortly after event; in first four weeks, lasting for at least 2 days) often resolves on its own

Have dissociative symptoms (3 of numbness / detatchment / lack of emotion, decreased

awareness of surroundings, derealization, dissociative amnesia) with avoidance
Major treatment is mobilizing social support
Beta-blockers can help sx, may help prevent progression to PTSD; can use short-term
hypnotic for insomnia

Somatiform disorders - take concerns seriously; regularly scheduled (not PRN) visits, no
inappropriate tests.

Hypochondriasis: all about the disease

Pain disorder: 1+ sites, primary complaint, psychological factors play role (initiate /
worsen pain), at least 6 months, may be triggered past trauma
o Validate pt experience, explain psych factors in pain, consider
antidepressants (TCAs / SSRIs) + biofeedback, pain is chronic so focus on
gradual improvement of function
o Analgesics usually don't help, really avoid narcotics
Somatization disorder: 4+ pain sx at different sites, 2 GI sx, one sex / repro problem,
one pseudoneurologic; all over course of illness, no explanation
o Needs to begin before age 30, last for several years, & cause impairment
Conversion disorder: 1+ sensory / motor deficits suggesting neuro / medical illness;
preceded by conflict / stress, not just pain / sex dysfxn, not part of somatiform disorder.
o La belle indifference: pt unconcerned about his symptoms
o Can recur; reassure that it will resolve on its own with time, pt not faking - tell pt
"body responds in unusual ways" to stress sometimes

Non-somatoform disorders (consciously doing stuff to self).

Factitious disorder: intentionally producing sx to assume sick role. Often borderline. Try
to develop therapeutic alliance
o Munchhausen is factitious disorder with repeated episodes, etc.; by proxy = induced
in children by parents
Malingering: intentionally producing sx for secondary gain

Bulimia Nervosa: 1% prevalence; brief purging in 5-10% young women, usually later onset
than AN, even adulthood

Danger: parotid glands / mouth / caries / esophageal / GI injury, dehydration from

laxatives, ipecac can cause hypotension, tachycardia, arrhythmias.
Check lytes (hypoCl / hypoK acidosis from emesis), amylase, mag.
Treat with nutritional rehab, CBT + group + family therapy, antidepressant (usually
SSRI). Mortality rate is up to 3%. Lots of relapses

Anorexia nervosa: high achievers (BN too), have to be underweight (85% ideal body
wt) and amenorrheic

Lanugo: fine body hair on prepubertal kids, pts with anorexia

Big contribution of society, family functioning
Albumin level canhelp follow nutritional status. Blood chem, ECG changes need to be
monitored.

Sleep Terrors:

Emotional / behavioral disorders, usually early in nightly sleep during arousal from delta
(slow-wave) sleep, no memory
Often in kids (3% vs 1% adults), can be increased by fever, sleep deprivation, CNS
depressants; generally self-limiting (use reassurance)
Often co-occur with restless leg syndrome and sleep-disordered breathing

Somnambulism: also during arousal from delta sleep (more common in kids, who have more
delta sleep, & first half of night)

Protect the kid from dangerous behaviors

Enuresis - tell the parents to be supportive, don't punish child, can use bell and pad to
retrain (alarm) - but only if after age 7, occasionally desmopressin or imipramine (need
ECG monitoring)

Primary: never a dry period

Secondary: usually UTI or psychological stressor (regression with new sib)

Insomnia

Primary: at least 1 month, causing distress. Bad sleep hygiene, so fix it. Stimulus control
(beds only for sleeping & sex, get up if can't fall asleep), relaxation therapy, take a hot
bath before bed. CBT can help; reassure anxiety
Ramelteon: meletonin receptor agonist, also benzos (don't use for > 2 wks), trazadone

Autism: Poor social reciprocity (verbal & non-verbal), sterotyped behaviors (purposeless,
repetitive - spin toys, hand flapping)

Need sx < 3 y/o; often dx'd when kids put in social situations like school.
40% have MR; some can have precocity.
A/w tuberous sclerosis, fragile x.
Language development is best predictor of outcome.
Multisystemic treatment: family education, behavior shaping, speech therapy, OT,
educational training
Focus on getting basic skills early so child can interact in school, etc.

Aspeberger: social impairment, restricted interests / stereotyped behavior but normal

language & cognition
Rett: developmental disorder: girls, normal early, then progressive encephalopathy, loss of
speech, gait problems, stereotyped movements, microcephaly, poor social interaction

Dissociative disorders: generally precipitated by trauma, DDx vs dementia in older pts

(more common, some past memory spared in dementia!)

Dissociative Fugue: usually brief (hours - days), can last for months, can be post-trauma /
conflict, usually rapid spontaneous recovery with no recurrence. Not aware of identity; may
create a new one.
Dissociative Amnesia: can't recall specific information (usually about identity) but intact
memory about general information; usually caused by trauma / stressful memory. no travel, no
new identity created. Hx of head trauma can predispose.
Dissociative identity disorder: "multiple personalities" to help deal with trauma, controversial,
2+ identities recurrently taking control
Gender Identity Disorder: persistent cross-gender identification; usually have to live as
opposite gender 3 mo before hormones, 1 yr before surgery
Intersex Stuff

Androgen Insensitivity Syndrome: intersex; chromosomally male but no androgen

response (develop external female genitalia)

Sexual dysfunction

Erectile: normal nocturnal erections means ED is probably psychogenic; can also be

medical (CRF, DM, malnutrition, cirrhosis, atherosclerosis, etc) and iatrogenic
(antidepressants - classically SSRIs, mood stabilizers, antipsychotics)
Vaginismus: involuntary muscle constriction of outer third of vagina, interferes with
sexual intercourse, causes distress

Mental Retardation

About 1% prevalence; see table below for degrees. Self-destructive behavior can be
response to painful med problems if child can't communicate
Down syndrome is #1 cause of moderate to severe MR in USA (facial features,
hypothonia, language + motor developmental delay, trisomy 21)
Fragile X: #2 common cause of mental retardation, #1 cause of heritable MR, Xq27.3
mutation, males are moderate to severe MR, females less so
PKU is another cause, can't break down phenylalanine; dietary restriction is treatment
Fetal alcohol exposure too
30-40% are unknown etiology

Severity

IQ

Characteristics

Function

50Usually not detected until

Mild (85%
55 to school; complete high
)
70
elementary school level

Can often live/work independently

w/ social support

30Moderate 40 to Socially isolated in

(10%)
50elementary school
55

Can be competent at occupational

tasks in supportive setting, need
high level of supervision

20Severe (3 25 to Minimal speech, poor

-4%)
35motor development
40

Not independent; can do some selfcare, need extensive supervision

Profound below Absent to minimal speech, Need constant nursing care

(1-2%)
20poor to absent motor skills throughout life

25
Learning Disorders: Specific deficits in math, reading, or written expression

Reading most common; all twice as prevalent in boys

Treat by addressing specific deficit

Substances

Dependence (substance): need 3+ of tolerance, withdrawal sx, increased use,

attempts / failure to cut down, lots of time spent getting it, less time spent doing other
stuff, still using despite knowing damage
Substance-induced mood disorders: If they don't resolve on their own, treat 'em like they're
not substance-induced (e.g. antipsychotics, mood stabilizers, antidepressants)
According to DSM, no cannibis-induced mood disorders

PCP intoxication

Phencyclidine, angel dust, horse tranq, happy leaf. piperidine like ketamine; originally
anesthetic (NMDA receptor blocker), long-acting (6h short-term effects, full effect can last
several days, variable behavioral changes, unpredictible), often with MJ
Dysarthria, nystagmus (vertical), belligerent, hyperacusis, ataxia, muscle
rigidity, can cause sz / coma, numbness, HTN / tachy
Treatment: treat HTN, can acidify urine to increase excretion, hospitalize in a quiet
dark room
Avoid restraints (more muscle breakdown), gastric lavage (emesis / aspiration), typical
antipsychotics (anticholinergic side effects make it worse). Benzos can delay excretion, so
avoid those too.

Alcohol dependence:

3-5% women, 10% men lifetime; a/w 50% homicides, 25% suicides
Lab tests: elevated liver transaminases (particularly gamma-glutamyl transferase, GGT)
and macrocytic anemia
Wernicke: acute, reversible encephalopathy from thiamine deficiency after chronic
ETOH use: delirium, opthalmoplegia (typically CN6), ataxia
o give thiamine before glucose
Korsakoff: usually irreversible amnesia, anterograde + retrograde with confabulation,
after chronic alcohol use (thiamine deficiency)

Alcohol withdrawal:

Typical stages: tremulousness / jitteriness (6-8h), psychosis / perceptual sx (8-12h),

seizures (12-24h), DTs (24-72h, up to 1 wk)
DTs: disorientation, tremors, elevated vital signs, fluctuating consciousness post-stoppage,
can be fatal!
DDx vs thyrotoxicosis, pheochromocytoma, inappropriate use of beta-agonist inhalers /
sympathomimetics.
Use long-acting benzos (chlordiazepoxide, diazepam). Oxazepam, lorazepam are
good if liver function may be compromised

Cocaine intoxication:

Behavioral: euphoria, bluted feelings, hypervigilance, hypersensitivity, anxiety, poor

judgment, anorexia
Physical: dilated pupils, autonomic instability, chills/sweating, n/v, PMA/R, chest pain /
arrhythmias, confusion / sz / stupor / coma, wt loss

Cocaine withdrawal: can last 2-4 days or longer, "crash" (dysphoria, irritibility, anxiety,
hypersomnia, depressive sx incl SI).

Intox - withdrawal during lifetime of addiction can mimic bipolar disorder in the history!

Amphetamine intoxication: causes adrenergic hyperactivity (tachy, pupils dilated,

hypertensive, perspiring, chills, nausea / vomiting, anorexia / wt loss, mm weakness, can
have hallucinations, resp depression chest pain, arrhythmias, confusion, sz, dyskinesia,
dystonia, coma can result)

Meth gives you bad dental problems (meth mouth) + paranoia, hallucination / tics /
aggression

Amphetamine withdrawal: the "crash" (anxiety, tremors, lethargy, fatigue, nightmares,

headache, extreme hunger)

Opioid intoxication: apathy, PMR, constricted pupils, drowsiness

Opioid withdrawal: nausea / vomiting, muscle aches, fluids from all orifices, autonomic
hyperactivity, fever, dilated pupils, depressed / anxious mood, rarely life-threatening

Generally, longer-acting substances give less withdrawal

Ibuprofen can help muscle aches
Can use clonidine for autonomic hyperactivity in acute-phase + methadone (long-acting
opiate)

Psychological theories

Freud: ego psychology: id (drives / instincts), superego (right / wrong, from societal /
parental morality), ego (resolves conflict / adapt to anxiety)
Drive psychiatry: oral / anal / phallic / latency / genital stages of development
Object relations: relationship to objects / people are more important than drives
Erikson: life cycle stages. Each part of life is conflict; progress / development throughout
o Trust vs mistrust (0-18mo, child depending on caretakers), autonomy vs shame
(18 mo - 3 yrs; bowel / bladder function, walking), initiative vs guilt (3-5 yrs,
more language / walking / explore the world), industry vs inferiority (5-13 yrs,
sense of self starts developing based on things created), identity vs role
confusion (13-21 yrs, adolescence, appearance to others important), intimacy vs
isolation (21-40 yrs, vulnerability of intimacy vs loneliness), generativity vs
stagnation (keep producing as member of society or not?), ego integrity vs
despair (60 - death, accepting life course or regretting)

Cognitive distortions (cognitive therapy)

o Arbitrary inference: don't have enough evidence

o Dichotomous thinking: all or none
o Overgeneralization: it was just one event!
o Magnification / minimization: just what it sounds like
Behavior theory
o Modeling: learn based on observing others, imitating actions / responses
o Classical conditioning: pair neutral stimulus, natural stimulus, response becomes
a/w neutral stimulus
o Operant conditioning: environmental events (contingencies) influence acquisition
of new behaviors, extinction of existing behaviors
Positive = give stimulus, negative = take stimulus away. Reinforce = make
repeat behavior, punish = make stop behavior
So "negative punishment" means you take a stimulus away to make
someone stop a behavior, for instance

Legal Issues

Malpractice: need negligence (broke standard of care), duty (had responsibility to pt),
direct causation (negligence caused pt problem), damages (pt had a problem as a
result)
Informed consent: need to inform (side effects, alternatives, outcome w/o treatment),
pt must be competent, and pt must give voluntary consent
Involuntary commitment: right to be treated & refuse treatment unless declared
incompetent
Tarasoff decisions: Tarasoff I: need to warn potential victims of patients who could do
them harm. Tarasoff II: need to take reasonable steps to prevent harm to 3rd party
M'Naughten Rule: 1843, England, mentally ill man tried to assassinate prime minister not held responsible if mentally ill / MR and didn't understand nature of act or realize that
it was wrong; controversial, basis of insanity defense.