Psych Notes

ANXIETY DISORDERS egodystonic (they dont want to do it)

GAD
o what: constant state of worry about most things on most days of the
month for more than 6 months + at least 3 somatic complaints
(irritability, weight changes, sleep changes, concentration loss)
o tx: psychotherapy + SSRIs, anxiolytics such as benzos to abort panic
attacks do not work
Phobia
o what: irrational/exaggerated learned fear response, people know its
irrational so they avoid what causes phobia
o types:
specific= spiders, heights, clowns
tx= CBT + med to control anxiety
o flooding - works less well but faster (stimulus dump)
o desensitization slower but better
social = peeing in public restroom, public speaking
tx= CBT, beta blockade with public speaking
Panic Attacks
o what: PANICS (palpitations/paresthesias, abdominal distress, nausea,
intense fear of death, chest pain/tightness, shortness of breath)
happens out of the blue with no trigger person looks dying
o who: female in 20s without comorbidities
o tx:
1. rule out medical disease EKG /troponins to r/o MI, TSH
(hypothyroid), urine tox (drugs)
2. abort with benzos
3. long term control with SSRIs +- psychotherapy
4. f/u for agoraphobia due to spontaneous onset of panic attacks (ie
afraid to go out in public bc panic attacks)
OCD
o what: patient knows that they obsessions (intrusive and unwanted
thoughts that provoke anxiety, occur throughout the day) and
compulsions (actions that reduce anxiety) egodystonic and function
impairment
contamination, safety
o tx: SSRIs + densensitization
PTSD sx greater than 1 month
o what: exposure to extreme stimulus (experience or witness lifethreatening
event) + anhedonia + hypervigilance + avoidance + flashbacks
o tx: psychotherapy + SSRIs + abortive benzos if panic attacks

Acute stress Disorder if sx less than 1 month - better prognosis b/c earlier
access to psychotherapy + SSRIs + abortive benzos if panic attacks

IMPULSE CONTROL anxiety disorders that are egosyntonic (pt commits acts b/c it
makes them feel good.. they want to)

Intermittent Explosive Disorder

o what: normal person has sudden inappropriate and violent act out of
proportion to the stressor road rage
o who: men, more violent in younger males bc sx decrease with age
o tx: SSRIs or mood stabilizers + group therapy
Pyromania
o what: fire starters bc of pleasure or anxiety reduction or sexual arousal
o who: males
o dx: r/o arson and intermittent explosive disorder (revenge)
o tx: drugs dont work, most likely jail
Kleptomania
o what: steal things (the exact same object, ie salt shkers) that reduce
anxiety,
o who: females, linked with bulimia and OCD
o r/o petty theft
o tx: SSRIs and CBT
Trichotillomania
o what: pulls our hait ro reduce anxiety
o who: female in 20s with hair in varying lengths
o r/o fungus (KOH prep) and alopecia (patchy hair loss)
o tx: SSRIs
o f/u bezoar (hair ball SBO get KUB)

MOOD DISORDERS

MAJOR DEPRESSION
o what: depressed mood and LOF 5/9 SIGECAPS (sleep, interest, guilt,
energy, concentration, appetite, psychomotor, suicidality*) - 2 weeks or
more
o tx:
if SI and plan hospitalize
if SI and NO plan safety contract
ECT- amnesia and stigma
therapy (group)
antidepressants:
typical everything slows down insomnia and dont eat
SSRIs

atypical sleep more and eat more SNRIs

o r/o: hypothyroid, chronic pain syndromes, rheum disorders, anemia,
chronic fatigue disorder
DYSTHMIA
o what: depressed mood w/o LOF, chronic (2 years)
o r/o Major Dep Episode
o tx: SSRIs
BIPOLAR
o Type 1 = mania DIGFAST (distractible, insomnia, grandiosity, flight of
ideas, agitated, sexual exploits, talkative)
o Type 2 = hypomania + major depressive episodes
o tx: mood stabilization (Lithium, Lamotrigine, Valproate), benzo to calm
down for interview
o ro =if you think MD and if give SSRI and it illicits mania then BP
CYCLOTHYMIA
o what: hypomania, episodes of dysthymia, w/o LOF
o r/o BP disorder
o tx: mood stabilizers

GRIEF v. Depression (timing, psychotic features, impaired function)

o grief follows an event leading to SIGECAPS but no SI (Verus depression
which has SI), grief comes and goes while depression is persistent, lasts
less than a year and spontaneously resolves while depression lasts for
more than a year, both grief and depression can have psychotic features
involving dead loved one but grief involves the patient recognizing that is
not possible versus depression involves patient that lacks insight and
talks to dead person
o tx: grief requires reassurance versus depression needs SSRI b/c LOF
Stages of Dying these happen in any order and patients can go back and forth
o denial
o anger
o bargaining
o depression
o acceptance
Baby blues
PP depression PP Psychosis
# baby
With first
After first baby
After first baby
baby
Timing, onset,
Starts and
Within 1st
Within 1st month, can be
duration
ends within 2 month, can be
ongoing
weeks
ongoing
Depression
Dysthymic
MDE
MDE
Risk to baby
NO
YES, neglect
YES, abuse (mom fears
(mom doesnt
baby)
care)

Mom cares about

baby
Psychotic sx
Tx:

YES

NO

NO

NO
Reassurance

NO
SSRI + other
caregiver

YES
Mood stabilizers or
antipsychotics depending on
predominating depression v.
psychosis

POSTPARTUM DISEASES in new mom

DELUSIONAL DISORDERS
delusion fixed firm belief to patient but to nobody else, dont bother to tell them
its not real

SCHIZOPHRENIA
o what: thought disorder associated with delusions, genetic component,
dysfunction of DA (too much- positive sx), and 5HT (too much negative
sx)
positive sx:
bizarre delusions
auditory hallucinations
negative sx:
flat affect
poverty speech
anhedonia
cognitive defects
o who: young teenager after a major stressor (ex: college kid who goes to
college for first time)
psychotic break: level of function decreases with each break that a
person has.. they never regain baseline of function but can only get
worse especially if doesnt take meds over time
o r/o: cocaine (urine tox),
o types:
Paranoid delusions dominate grandiose or persecution
Catatonic visually impressive b/c immobility and waxy flexibility,
echolalia /echopraxia (repeat words or sounds), hypermotile
(running all over the place)
Disorganized no contact with reality, terrible prognosis
homeless people
o tx: acute catatonic state (benzos to get out of that state), but all others
will get typical or atypical antipsychotics, duration tx depends on duration
sx

NON
o
o
o

typical positive (DA based)

atypical negative (5HT based)
separate between:
acute psychotic disorder- < 1month
tx: wait and watch
schizophreniform- <6 months
tx: 3-6 weeks b/c can recover to baseline
schizophrenia- >6 months or more
tx: lifelong if sx persist
schizoaffective - schizophrenia + any mood sx (rather than
psychotic sx only during time of depressive episodes)
tx: lifelong, delusions tx first then mood
BIZARRE DEULSIONAL DISORDER
what: believable, logical delusions that are rational and believable, no
LOF, doesnt come to light unless some sort of strife happens
r/o actual truth
tx: gentle confrontation, no medications for this social fix only

PERSONALITY DISORDERS rigid, permanent, maladaptive traits that define the

way a person behaves and interferes with functionality, egosyntonic so almost
impossible to treat the patients cannot diagnose adolescent b/c might grow out of
it cluster traits if doesnt involve LOF
A = absurd / weird
B= bad boys
C=criticism and control
PD

description

defense

example

Paranoid

Distrustful, suspicious,
interprets others as
malicious
Loners, have no relationships
and are happy being alone
dont want to see people and
dont get in trouble ever
Magical thinking / bizarre
thoughts and dress, almost
schizophrenia but no
hallucinations or internal
stimuli,
Unstable, impulsive,
promiscuous, unable to
control rapid changes in
mood/emotions/emptiness,
suicidal gestures - flip on a
dime
Theatrical, attention seeking,
superficial emotions,

projection

Michael Douglas in
enemy of the state

Schizoid

Schizotypal

Borderline

Histrionic

Splitting
(perfect or
terrible,
black or
white)

How to
handle
Clear, honest,
nonthreatening

Night shift toll booth

operators or the IBM
clandestine analyst

You wont see

them

Lady gaga in one of

weird dresses fully
functional

Clear, honest,
nonthreatening

Women have cries

for help bc want the
attention
girl interrupted

Patients will try

to change the
rules, be
manipulative
and
demanding
you need to
make sure they

Women- with no
deep meaningful

hypersexual

Narcissistic

Anti Social

Avoidant

Dependent

Obsessive
Compulsive

Self centered, inflate sense

of worth or talent, exploitive,
demands the best, entitled,
not necessarily attention
seeking
Criminals, no regard for
rights of others, impulsive,
lack remorse, not necessarily
sociopaths b/c can have
remorse, but think they can
live outside the law
Shy, fear criticism and
rejection, consumed with
feelings of inadequacy,
wants relationships but does
not pursue them bc scared

Submissive and clingy, need

to be taken care of, also
have unrealistic fear of
rejection
Order, control, and
perfection at the expense of
efficacy (not OCDegodystonic vs this is
egosyntonic)

relationships
dependent on looks /
personality
Marilyn Monroe
Men who are self
centered and
entitled
zoolander

follow the rules

and do not
deviate from
them, be firm
but
nonaccusatory

The teenagers who

had conduct
disorder but werent
fixed tony
soprano

Jail , cannot
treat b/c only
makes them
better liars

Really shy, people

that pass up on
promotions,
napoleon dynamite
or hot librarian

Avoid power
struggles and
make the
patients choose
bc they will
literally do
whatever you
want them to
Give clear
advice, patient
may try and
sabotage their
own treatment

Stay at home mom

in abusive
relationship bc afraid
to leave
Student who has to
re-write notes a
million times b/c not
right pen colors
monk

EATING DISORDERS

ANOREXIA
o what: body dysmorphic disorder, anxiety provoked by being fat though
she really isnt, will either restrict or binge/purgethese people wont
come to find you
o who: <85% IBW, sx bradycardia, lethargy, cold intolerance, maybe
hypotension if very severe - ie underweight girl that looks like she has
hypothyroid
o tx:
<85% IBW = hospitalize, forced feed, nutritional status up, antidepressants, psychotherapy
outpatient if >85% IBW = anti-depressants, psychotherapy
BULIMIA
o what: correct body image, anxiety provoked bc doesnt like being fat,
doesnt like to binge and purge but does it anyways, may also restrict in
betweenthese people will come and find you

o who: weight normal or elevated, will abuse laxatives, induces vomiting

(dental erosions, parotid swelling, dorsal scars on hands)
o tx: antidepressants and psychotherapy, NEVER GIVE WELLBUTYRIN
(increased seizures in bulimics)
PEDIATRIC PSYCHIATRITY
MENTAL RETARDATION
o what: IQ <70, onset prior to age 18, impair functioning
o who
genetic: down syndrome, fragile x, cri-du-chat
acquired: maternal substance abuse, lead poisoning
o characterization:
severity
IQ
live
work
Mild MR
50-69
Group home
Independent
Moderate
35-49
Group home
Supervised
MR
Severe MR
20-34
Institutionalize Barely daily fxns
d
Profound
<20
Institutionalize Dependent on others
d
completely

education
6th grade
3rd grade
None
None

AUTISM
o what: speech and social interaction problems, though mental function is
preserved, dont know the cause does not develop social smile or
parent bonding
**hand flapping, lining up objects, rocking back and forth
o who: 3yo, failure of milestone development
o tx: none, behavioral therapy
aspergers = speech is preserved but still social interaction
problems
rhetts= girls, normal until 5 months and then regress to death,
parents need genetic counseling
ADHD
o what: kid cant focus
o who: disruptive student with bad grades
o dx:
1. Timing child between 6 months 7 years old, issues in more
than 1 setting
2. Attention Deficit = decreased attention, inability to complete
tasks, easily distracted
3. Hyperactivity = inability to wait in line, cant wait turn, constantly
interrupting, fidgeting in seat

o tx: stimulants (methylphenidate, dextroamphetamine) in the morning,

parental education, special education
CONDUCT DISORDER
o what: antisocial personality disorder in kid 18yo or less, can take this
opportunity to change this childs life direction, total disregard for others
(lie, cheat, steal, defy authorities), will often bully /start fights / hurt other
playmates, can break law
**killing small animals
o tx: rehabilitation with big brother / big sister program and juvenile
detention
OPPOSITION DEFIANT DISORDER
o what: disregard for authority (parents, teachers) so can lie/cheat/steal,
but no bullying / fighting / no hurting of others (obey peer social
interactions)
o tx: parental education, b/c the cause is inconsistent parenting (especially
divorced)
LEARNING DISBAILITY
o what: kid scores poorly on tests in school
o r/o: hearing, vision, fluent English speaking, able to read, MR
o tx: correct sensory problem if able to find one, remediation if no problems
found (repeat grade), also need to r/o absence seizures and ADHD
TOURETTES SYNDROME
o what: largely associated with OCD, anxiety, ADHD.. vocals that are NOT
swears or hair flicks / blinks / tongue protrusion
o who: less than 18yo with impulses (impulses related to anxiety while
action reduces anxiety.. like OCD)
o tx: DA antagonists (not SSRIs like OCD)
ENURESIS
o what: bed wetting assess age and whether they have ever been dry
before
older than 4 and have been dry before
assess for medical disease with u/a and u/s to look for mass /
hematuria (cancer bx and resect)
leukocytosis (UTI abx and education)
regression especially if new baby in household, need to r/o
abuse
never been dry and less than 7yo normal variant need to potty
train, never use negative reinforcement (yelling), only positive
reinforcement (good job) as well as bed alarms / fluid restriction /
DDAVP

DISSOCIATIVE DISORDERS
dissaccoiation: things are happening to us but we dont know it..
MULTIPLE PERSONALITY DISORDER / DISSOCIATIVE IDENTITY

o what: multiple personalities so that person can shield true self from
extreme stressor, personalities dont know that others exist
o who: patient complaining of blackouts, memory gaps, behavioral changes
(sex and drugs), appearance can change in visually striking ways
(expression, posture, clothes, etc) in response to prolonged and intense
stressor
o tx: hypnosis and intense psychotherapy to bring primary personality back
to light and confront original stressor
DISSOCIATIVE AMNESIA
o what: major stressor precedes amnesia of the event or a person,
eventually memory will recover
o dx: amital interview to r/o malingering
o tx: psychotherapy to get personality back and confront stressor so doesnt
slip into acute stress or psychotic disorder
DISSOCIATIVE FUGUE
o what: stressor brings amnesia of old life.. patient will travel to new place
and presume new identity and can last months / years until stressor
confronted. person can forget entire new life
o dx: amital interview to r/o malingering
o tx: psychotherapy to maintain memories from both lives
DEPERSONALIZATION
o what: out of body experience, sensation of de-ja-vu, usually in teenagers
following minor stressor
o tx: psychotherapy

ADDICTION
abuse using a drug / medication / alcohol in anyother way from how it should
be used
o ex: legal troubles bc of use, risky situations, failure to fulfill
responsibilities, continue to use despite these issues
dependence - having body get used to it
o ex: tolerance, withdrawal, isolation, spend too much time trying to get it,
risk for OD
ADDICTION PATHOLOGY
o what: genetic predisposition to the disease, addict will continue to use so
that they feel normal
ACUTE SIGNS OF INTOXICATION / WITHDRAWAL
o ALCOHOL
CAGE questionnaire (cut down, are people angry about your alcohol
use, feel guilty about drinking, do you need an eye opener)
acute intoxication slurred speech, ataxic gait, cerebellar
dysfunction, BAC>0.08 (legal limit) dangerous at 0.2

pt can also be found down give IVF and monitor for

aspiration.. or even naloxone (opiate reversal)/ thiamine +
D50 (reverses hypoglycemia)
withdrawal HTN, tachycardia, diaphoretic, anxious, delirius,
seizure
tx: BZD taper and then BZD prn
f/u: Wernickes encephalopathy (reversible cerebellar dysfunction, tx
with thiaimine), Korsakoffs (irreversible, confabulation), Cirrhosis
(ascites, varices, hepatic encephalopathy).
tx: AA group thearpy, antibuse (disulfram medication) though
doesnt really work
o OTHER DRUGS:
DRUG
Alcohol

BZD

Opiates
(downer)

ACUTE
INTOXICATION
Slurred speech,
disinhibition, ataxia,
blackout, impaired
judgment
Delirium in elderly,
decrease respiratory
drive, coma, amnesia

Euphoria, pupil
constriction, decrease
resp drive, tracks
marks
Cocaine
Psychomotor
(vasoconstricto agitation, HTN,
r and upper)
tachycardia,
psychosis, dilated
pupils, angina, HTN
crisis
Amphetamin
Dilated pupils,
es
psychosis,
overheating (fever,
tachycardia), water
intoxication
PCP
Aggressive psychosis,
vertical and horizontal
nystagmus,
impossible strength,
blunted senses
LSD
Rare hallucinations,
flashbacks,
heightened senses
Marijuana /
Conjunctivitis,
THC
munchies, paranoia,
tired, slow reflexes
Barbiturates
Decreased safety
margin, resp drive
decrease, coma
Nicotine
None, jittery and
stimulated, vtach

WITHDRAWAL

TX

HTN, tachycardia,
delirium, seizures,
psychosis,

BZD taper acutely

Same as alcohol

BZD taper,
Flumazenil if OD
(lower seizure
threshold)
Naloxone if OD
(no side effects),
methadone for
withdrawal
A blockade
before B blockade
if OD to control
HTN crisis

Yawning,
lacrimation,
sweating, itching,
all over body pain
Depression, bugs
crawling

Crash, depression

Supportive care

Severe random
violence

Haldol to subdue,
acidify urine to
increase excretion

Flashbacks

Supportive

none

Supportive

Redistributes into
fat so take long
time to wear off
cravings

Low-yield
Patch, gum,
wellbutyrin,
chantix

SLEEP PHYSIOLOGY:
stages:
o I = easy to arouse, theta waves and absent alpha waves
o II = easy to arouse, k-complexes and sleep spindles
o III=difficult to arouse, delta waves
o IV= difficult to arouse, delta waves
o REM= where you dream, longer you are asleep, the more you will have
REM (becomes longer in proportion to other stages) same alpha waves
as being awake, tone loss, rapid eye movements, erections in men and
women, easiest to arouse
sleep latency = time from head on pillow to actually asleep
o insomnia = increased latency
o deprivation = decreased latency
REM latency = time it takes to fall asleep to get to REM typically 40 minutes.
o decreased REM latency in narcolepsy as well as sleep deprivation (sleep
apnea or alcoholics)
NT involved:
o SAND (GD)
serotonin elevated 5HT puts you to sleep --> why SSRIs put you
to sleep
Ach- elevated Ach increases dreams
NE increased NE means more awake
DA increased DA means more awake why cocaine makes you
hyper
GABA decreases sleep latency and stage 4 (BZDs help people fall
asleep)
Drugs- barbituates and alcohol decreases sleep latency and REM (ie
dont get restful sleep)
NIGHTMARES
o what: dreams gone bad, patient in REM sleep, patient awakes and
remembers dream
o patient: any age
o tx: treat PTSD only in adults if flashbacks occurring, generally can
decrease REM to decrease nightmares by drinking alcohol, also TCAs
real tx is to remove stress
NIGHTTERRORS
o what: product of stage

o who: kid 4-10years old who wakes up and screams head off, parents care
more about this then the kids b/c the kids dont even know that they are
doing it
o tx: none, but could give benzos to shorten stage , reassurance
Sleep TALKING not during REM, meaningless talk
Sleep WALKING patient moves about house and seems to be awake but isnt,
side effects of BZD1

SLEEP DISORDERS
OSA
o what: obstructed upper airway, generally a product of obesity
decreased ventilation and oxygenation, patient gets apneic and wakes up.
increases pulmonary HTN
o who: obesity, HTN, DM, snorer, daytime somnolence (not getting restful
sleep because not making it to REM)
o dx: sleep study (polysomnography)
o tx: CPAP and weight loss
o r/o central sleep apnea due to brainstem lesion, which are treated with
bipap
NARCOLEPSY
o what: response to stress or loud noise daytime somnolence and sleep
attacks during which they experience cataplexy (loss of muscle tone),
decreased REM latency, hypnoGogic (going to sleep) or hypnopompic
(waking) hallucinations (these can happen in normal people), as well as
paralysis upon waking
eye movement all around can help distinguish from syncope, as well
as hallucinations and paralysis on waking, will feel refreshed rather
than confused
o dx: clinical or decreased REM latency on EEG
o tx: schedule naps, stimulants (amphetamines)
INSOMNIA
o what: psychiatric illness in people with poor sleep hygiene, patient
complains that they have trouble falling asleep or staying asleep, must
have less than 6 hours of sleep / day,
how many hours do they sleep a day?
o r/o major depressive episode with SIGECAPS, BP 2 with DIGFAST
o tx: assess sleep hygiene to address lifestyle modifications
1. lifestyle modifications
avoid stimulants 5 hours before sleep, no stimulants after
noon if trouble sleeping, avoid exercise / napping late in the
day
bed for sex/ sleep only, lights out time scheduled (Get out of
bed if tossing and turning)
2. meds:

1. Benadryl (s/e drowsiness)

2. trazodone (s/e priapism)
3. Seroquel or quietapine
4. BZD1 (s/e addicting after 2 or more weeks, sleep
talking/walking)

JET LAG
o what: insomnia + travel = use melatonin