H I G H - YI E LD F A C T S I N

PSYCHIATRY
Childhood and Adolescent Disorders

422

ATTENTIo N-d EFIc IT HYPERAc TIVITY d ISo Rd ER

422

MAJo R d EPRESSIVE d ISo Rd ER

432

AUTISM SPEc TRUM d ISo Rd ER

422

BIPo LAR d ISo Rd ER

434

d ISRUPTIVE BEHAVIo RAL d ISo Rd ERS

423

INTELLEc TUAL d EVELo PMENTAL d ISo Rd ER

423

Personality Disorders

436

To URETTE SYNd Ro ME

423

Substance Use Disorders

438

ALc o Ho L USE d ISo Rd ER

438

Psychotic Disorders
Sc HIZo PHRENIA

Anxiety Disorders

424
424

425

GENERALIZEd ANXIETY d ISo Rd ER

425

PANIc d ISo Rd ER

426

PHo BIAS (So c IAL ANd SPEc IFIc )

427

Obsessive-Compulsive Disorder and Related Disorders

428

o BSESSIVE-c o MPULSIVE d ISo Rd ER

428

Bo d Y d YSMo RPHIc d ISo Rd ER

429

Trauma and Stressor-Related Disorders

429

Po STTRAUMATIc STRESS d ISo Rd ER

429

Ad JUSTMENT d ISo Rd ER

430

Neurocognitive Disorders

Mood Disorders

Eating Disorders

432

440

ANo REXIA NERVo SA

440

BULIMIA NERVo SA

442

Miscellaneous Disorders

442

SEXUAL d ISo Rd ERS

442

SLEEP d ISo Rd ERS

443

So MATIc SYMPTo M ANd RELATEd d ISo Rd ERS

445

FAc TITIo US d ISo Rd ERS ANd MALINGERING

445

SEXUAL ANd PHYSIc AL ABUSE

446

SUIc Id ALITY

446

430

d EMENTIA (AKA MAJo R NEURo c o GNITIVE d ISo Rd ER)

430

d ELIRIUM

431

421

422

HIGH-YIELD FACTS IN

PSYCHIATRY

Childhood and Adolescent Disorders

ATTENTION-DEFICIT HYPERACTIVITY DISORDER

KEYFACT
Children must exhibit ADHD symptoms
in two or more settings (eg, home and
school).

A persistent pattern of excessive inattention (mostly girls) and/or hyperactivity/impulsivity (mostly boys); typically presents between ages 3 and 13. Often
shows a familial pattern.
His To r y /Pe
Diagnosis requires ve or more symptoms from each category listed below for
6 or more months in at least two settings, leading to signi cant social and
academic impairment. Symptoms must be present in patients before age 12.
Inattention: Exhibits a poor attention span in schoolwork/play; displays
poor attention to detail or careless mistakes; has dif culty following
instructions or nishing tasks; is forgetful and easily distracted.
Hyperactivity/impulsivity: Fidgets; leaves seat in classroom; runs around
inappropriately; cannot play quietly; talks excessively; does not wait for
his or her turn; interrupts others.
Tr ea Tmen T
Initial treatment may be nonpharmacologic (eg, behavior modi cation).
Sugar and food additives are not considered etiologic factors.
Pharmacologic treatment includes the following:
Psychostimulants: Methylphenidate (Ritalin), dextroamphetamine
(Dexedrine), mixed salts of dextroamphetamine and amphetamine
(Adderall). Adverse effects include insomnia, irritability, appetite, tic
exacerbation, and growth velocity (normalizes when medication is
stopped).
Nonstimulants (eg, SSRIs, nortriptyline, bupropion) and 2-agonists
(eg, clonidine), and atomoxetine (Strattera).
AUTISM SPECTRUM DISORDER

Persistent impairment in socialization, communication, and behavior. More

common in males. Symptom severity and IQ vary widely. DSM 5 does not
distinguish between the pervasive developmental disorders; severity is based
on the level of support needed in the psychopathologic domains of social
communication and restricted/repetitive behaviors.
KEYFACT
I you see ASD, think about associated
congenital conditions such as Rett
syndrome, tuberous sclerosis, and
ragile X syndrome.

His To r y /Pe
Characterized by abnormal or impaired social interaction and communication together with restricted activities and interests, evident before age 3.
Patients fail to develop normal social behaviors (eg, social smile, eye contact) and lack interest in relationships.
Development of spoken language is delayed or absent.
Children show stereotyped speech and behavior (eg, hand apping) and
restricted interests (eg, preoccupation with parts of objects).
Tr ea Tmen T
Intensive special education, behavioral management, and symptomtargeted medications (eg, neuroleptics for aggression; SSRIs for stereotyped behavior).
Family support and counseling are crucial.

PSYCHIATRY

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423

DISRUPTIVE BEHAVIORAL DISORDERS

Include conduct disorder and oppositional de ant disorder. More common

among men or boys and in patients with a history of abuse.
His To r y /Pe
Oppositional de ant disorder: A pattern of negativistic, de ant, disobedient, and hostile behavior toward authority gures (eg, losing ones temper, arguing) for 6 or more months. May progress to conduct disorder.
Conduct disorder: A repetitive, persistent pattern of violating the basic
rights of others or age-appropriate societal norms or rules for 1 year or
more. Behaviors may be aggressive (eg, rape, robbery, animal cruelty) or
nonaggressive (eg, stealing, lying, deliberately annoying people). May
progress to antisocial personality disorder in adulthood.

KEYFACT
Conduct disorder is seen in Children.
Antisocial personality disorder is seen
in Adults.

Tr ea Tmen T
Individual and family therapy.
INTELLECTUAL DEVELOPMENTAL DISORDER

Associated with male gender, chromosomal abnormalities, congenital infections, teratogens (including alcohol/illicit substances), and inborn errors of
metabolism.
His To r y /Pe
Patients have impaired intellectual functioning (IQ < 70) with de cits in
adaptive functioning (eg, hygiene, social skills); onset is before age 18.
Levels of severity are mild (IQ 5070; 85% of cases), moderate (IQ
3549), severe (IQ 2034), and profound (IQ < 20).

KEYFACT
Fetal alcohol syndrome is the most
common avoidable cause o intellectual
disability.

Tr ea Tmen T
1 prevention consists of educating the general public about possible
causes of intellectual disability and providing optimal prenatal screening
to mothers.
Treatment measures include family counseling and support; speech and
language therapy; occupational/physical therapy; behavioral intervention;
educational assistance; and social skills training.
TOURETTE SYNDROME

More common in men and boys; shows a genetic predisposition. Associated

with ADHD, learning disorders, and OCD.
His To r y /Pe
Begins before age 18.
Characterized by multiple motor tics (eg, blinking, grimacing) and vocal
tics (eg, grunting, coprolalia) occurring many times per day, recurrently,
for > 1 year with social or occupational impairment.
Tr ea Tmen T
Treatment includes dopamine receptor antagonists (haloperidol, pimozide) or clonidine.
Behavioral therapy may be of bene t, and counseling can aid in social
adjustment and coping. Stimulants can worsen or precipitate tics.

KEYFACT
Coprolalia = repetition o obscene
words.

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HIGH-YIELD FACTS IN

PSYCHIATRY

Psychotic Disorders
SCHIZOPHRENIA

KEYFACT
Psychosis (hallucinations and/
or delusions without insight)
schizophrenia. Di erential diagnosis
must also include medical diseases,
other psychiatric illnesses, and
substance-induced psychosis.

KEYFACT
Terms used to describe components o
psychosis:
Delusion: A xed alse idiosyncratic
belie .
Hallucination: Perception without
an existing external stimulus.
Illusion: Misperception o an actual
external stimulus.

Characterized by psychotic symptoms (hallucinations, bizarre delusions), disorganization (thought disorder, behavioral disturbances), and negative symptoms (poverty of affect, thought, and social interaction).
Epidemiology: Prevalence is approximately 1%; men and women are
affected equally. Peak onset is earlier in men (ages 1825) than in
women (ages 2535). Schizophrenia in rst-degree relatives also risk.
Up to 50% of patients attempt suicide, and 10% of those affected successfully commit suicide.
Etiology: Etiologic theories focus on neurotransmitter abnormalities such
as dopamine dysregulation (frontal hypoactivity and limbic hyperactivity)
and brain abnormalities on CT and MRI (enlarged ventricles and cortical volume).
His To r y /Pe
Two or more of the following are present continuously for 6 or more
months with social or occupational dysfunction:
Positive symptoms: Hallucinations (most often auditory), delusions,
disorganized speech, bizarre behavior, and thought disorder.
Negative symptoms: Flat affect, emotional reactivity, poverty of
speech, lack of purposeful actions, and anhedonia.
See Table 2.14-1 for the differential diagnosis of psychosis.
TA B L E 2 . 1 4 - 1 .

Dif erential Diagnosis of Psychosis

d iSo r d er
Psychotic disorders

d u r at io n /c h a r a c t er iSt ic S
Brief psychotic disorder: > 1 day and < 1 month.
Schizophreniform disorder: > 1 month and < 6 months.
Note: Both have same presentation as schizophrenia, but are usually
preceded by stressors, have no prior episodes, are less likely to
have negative symptoms, and have better lifetime prognosis.
Schizophrenia: > 6 months.
Schizoaf ective disorder: Schizophrenia + major a ective disorder
(major depressive disorder or bipolar a ective disorder).

Personality disorders

Schizotypal: Magical thinking.

Schizoid: Loners.

Delusional disorder

Persistent nonbizarre fi ed delusions without disorganized

thought process, hallucinations, or negative symptoms of
schizophrenia; subtypes are jealous, paranoid, somatic, erotomanic,
or grandiose. Day-to-day functioning mostly unaf ected.

PSYCHIATRY

Tr ea Tmen T
Antipsychotics (see Table 2.14-2); long-term follow-up.
Supportive psychotherapy, training in social skills, vocational rehabilitation, and illness education may help.
Negative symptoms may be more dif cult to treat than positive symptoms;
atypical antipsychotics are drug of choice.

Anxiety Disorders

HIGH-YIELD FACTS IN

425

MNEMONIC
Evolution of EPS

4 and A
4 hours: Acute dystonia.
4 days: Akinesia.
4 weeks: Akathisia.
4 months: Tardive dyskinesia (often
permanent).

GENERALIZED ANXIETY DISORDER

Uncontrollable, excessive anxiety or worry about multiple activities or

events that leads to signi cant impairment or distress. The male-to-female
ratio is 1:2; clinical onset is usually in the early 20s.
TA B L E 2 . 1 4 - 2 .

Antipsychotic Medications

d r u g c l a SS
Typical

e x a Mpl eS
High potency.

Haloperidol, fluphenazin .

antipsychotics

in d ic at io n S
Psychotic disorders, acute

Sid e e FFec t S
EPS (see Table 2.14-3)

agitation, acute mania,

> anticholinergic symptoms

Tourette syndrome.

(dry mouth, urinary retention,

Thought to be more e ective

for positive symptoms of
schizophrenia; primarily block
D2 dopamine receptors.
For patients in whom

constipation).
QTc prolongation and torsades,
especially IV haloperidol.
Neuroleptic malignant
syndrome (see Table 2.14-3).

compliance is a major issue,

consider antipsychotics that
come in depot forms (eg,
haloperidol, fluphenazine)
Low potency.

Thioridazine, chlorpromazine.

Same as high potency.

Anticholinergic > EPS.

More sedative.
Greater risk of orthostatic
hypotension.
Thioridazine causes dosedependent QTc prolongation
and irreversible retinal
pigmentation.

Atypical

Risperidone (also available in

antipsychotics

long-acting depot injection),

for schizophrenia given fewer

mellitus, somnolence,

quetiapine, olanzapine,

EPS and anticholinergic

sedation, and QTc

ziprasidone, aripiprazole,

e ects.

prolongation.

clozapine.

Currently firs -line treatment

Clozapine is reserved for severe

Weight gain, type 2 diabetes

Clozapine can cause

treatment resistance and

agranulocytosis, requiring

severe tardive dyskinesia.

weekly CBC monitoring

during first 6 mo ths.

426

HIGH-YIELD FACTS IN

TA B L E 2 . 1 4 - 3 .

EPS and Treatment

Su bt ype
Acute dystonia

PSYCHIATRY

d eSc r ipt io n
Prolonged, painful tonic muscle contraction or

t iMe
o F o n Set
Hours

spasm (eg, torticollis, oculogyric crisis).

t r eat Men t
Anticholinergics (benztropine or diphenhydramine)
are acute therapy; some patients on antipsychotics
who are prone to dystonic reactions may need regular
prophylactic dosing (eg, benztropine).

Dyskinesia

Pseudoparkinsonism (eg, shuffling ga ,

Days

cogwheel rigidity).

Give an anticholinergic (benztropine) or a dopamine

agonist (amantadine). the dose of neuroleptic or
discontinue (if tolerated).

Akathisia

Subjective/objective restlessness that is

Weeks

perceived as being distressing.

neuroleptic and try -blockers (propranolol).

Benzodiazepines or anticholinergics may help.

Tardive

Stereotypic, involuntary, painless oral-facial

Months

Discontinue or the dose of neuroleptic; attempt

dyskinesia

movements. Probably from dopamine receptor

treatment with more appropriate drugs; and consider

sensitization from chronic dopamine blockade.

changing neuroleptic (eg, to clozapine or risperidone).

Often irreversible (50%).

Giving anticholinergics or decreasing neuroleptics

may initially worsen tardive dyskinesia.

Neuroleptic

Fever, muscle rigidity, autonomic instability,

malignant

elevated CK and WBC, clouded consciousness.

Anytime

Stop medication; provide supportive care in the ICU;

administer dantrolene or bromocriptine.

syndrome

His To r y /Pe
Presents with anxiety on most days (6 or more months) and with three or
more somatic symptoms (restlessness, fatigue, dif culty concentrating, irritability, muscle tension, disturbed sleep).

KEYFACT
Buspirone is another drug, in addition
to SSRIs, that should not be used in
conjunction with MAOIs.

Tr ea Tmen T
Short-term therapy:
Benzodiazepines may be used for immediate symptom relief.
Taper benzodiazepines as soon as long-term treatment is established
(eg, with SSRIs) in view of the high risk of tolerance and dependence.
Do not stop benzodiazepines cold turkey, as patients may develop
potentially lethal withdrawal symptoms similar to those of alcohol withdrawal.
Long-term therapy:
Lifestyle changes.
Psychotherapy.
Medications (see Table 2.14-4): SSRIs ( rst-line treatment), venlafaxine, buspirone. Patient education is essential.
PANIC DISORDER

Characterized by recurrent, unexpected panic attacks. Two to three times

more common in women than in men. Agoraphobia is present in 3050% of
cases. The average age of onset is 25, but may occur at any age.

PSYCHIATRY

TA B L E 2 . 1 4 - 4 .

HIGH-YIELD FACTS IN

427

Anxiolytic Medications

d r u g c l a SS
SSRIs (flu xetine, sertraline,

in d ic at io n S
GAD, OCD, panic disorder.

Sid e e FFec t S
Nausea, GI upset,

paroxetine, citalopram,

somnolence, sexual

escitalopram)

dysfunction, agitation.

Buspirone

GAD, social phobia. No

Seizures with chronic use.

tolerance, dependence, or
withdrawal.
-blockers

Phobic disorders (best when

Bradycardia, hypotension.

given prior to exposure).

Benzodiazepines

Anxiety, insomnia, alcohol

sleep duration; risk of

withdrawal, muscle spasm,

abuse, tolerance, and

night terrors, sleepwalking.

dependence; disinhibition
in young or old patients;
confusion.

His To r y /Pe
Panic attacks are de ned as discrete periods of intense fear or discomfort in which at least four of the following symptoms develop abruptly and
peak within 10 minutes: tachypnea, chest pain, palpitations, diaphoresis,
nausea, trembling, dizziness, fear of dying or going crazy, depersonalization, or hot ashes.
Perioral and/or acral paresthesias, when present, are fairly speci c to panic
attacks, which produce hyperventilation and low O 2 saturation.
Patients present with 1 or more months of concern about having additional attacks or signi cant behavior change as a result of the attackseg,
avoiding situations that may precipitate attacks.
Determine whether a patient has panic disorder with or without agoraphobia so that agoraphobia can also be addressed in the treatment plan.

KEYFACT
Walks like a chicken, talks like a chicken
its a bear. Di erential diagnosis or
panic disorders:
Medical conditions: Angina,
MI, arrhythmias, hyperthyroidism,
pheochromocytoma.
Psychiatric conditions:
Substance-induced anxiety, GAD,
PTSD.

Tr ea Tmen T
Short-term therapy: Benzodiazepines (eg, clonazepam) may be used
for immediate relief, but long-term use should be avoided in light of the
potential for addiction and tolerance (see Table 2.14-4). Taper benzodiazepines as soon as long-term treatment is initiated (eg, SSRIs).
Long-term therapy:
CBT.
Medications: SSRIs ( rst-line therapy), TCAs.
PHOBIAS (SOCIAL AND SPECIFIC)

Distinguished as follows:
Social phobia: Characterized by marked fear provoked by social or performance situations in which embarrassment may occur. It may be speci c (eg, public speaking, urinating in public) or general (eg, social interaction) and often begins in adolescence.

A 26-year-old woman has been

hearing voicesand has isolated
hersel rom her riends and amily.
Within the past 2 months, she has
also been sleeping poorly and has
reported eeling sad. What is her most
likely diagnosis?

428

HIGH-YIELD FACTS IN

PSYCHIATRY

Speci c phobia: Anxiety is provoked by exposure to a feared object or

situation (eg, animals, heights, airplanes). Most cases begin in childhood.

KEYFACT
Agoraphobia is de ned as ear o
being alone in public places. Literally
translated, it means ear o the
marketplace.

His To r y /Pe
Presents with excessive or unreasonable fear and/or avoidance of an object or
situation that is persistent and leads to signi cant distress or impairment in
function. Patients recognize that their fear is excessive.
Tr ea Tmen T
Speci c phobias: CBT involving desensitization through incremental
exposure to the feared object or situation along with relaxation techniques.
Other options include supportive, family, and insight-oriented psychotherapy.
Social phobias: CBT, SSRIs, low-dose benzodiazepines, or -blockers (for
performance anxiety) may be used (see Table 2.14-4).

Obsessive-Compulsive Disorder
and Related Disorders
OBSESSIVE-COMPULSIVE DISORDER

KEYFACT
Many OCD patients initially present to a
nonpsychiatristeg, they may consult
a dermatologist with a skin complaint
2 to overwashing hands.

Characterized by obsessions and/or compulsions that lead to signi cant distress and dysfunction in social or personal areas. Typically presents in late
adolescence or early adulthood; prevalence is equal in male and female
patients. Often chronic and dif cult to treat.
His To r y /Pe
Obsessions: Persistent, unwanted, and intrusive ideas, thoughts,
impulses, or images that lead to marked anxiety or distress (eg, fear of
contamination, fear of harm to oneself or to loved ones).
Compulsions: Repeated mental acts or behaviors that neutralize anxiety from obsessions (eg, handwashing, elaborate rituals for ordinary tasks,
counting, excessive checking).
Patients recognize these behaviors as excessive and irrational products
of their own minds (vs obsessive-compulsive personality disorder, or
OCPD; see Table 2.14-5).
Patients wish they could get rid of the obsessions and/or compulsions.
TA B L E 2 . 1 4 - 5 .

OCD vs OCPD

o cd

Schizoa ective disorder causes

symptoms o schizophrenia with
mood symptoms, with at least 2
weeks when psychotic symptoms
were present without any mood
symptoms. Patients o ten have
chronic psychotic symptoms, even
a ter mood symptoms have resolved.

o c pd

Characterized by obsessions and/or

Patients are excessively conscientious and

compulsions.

infl xible.

Patients recognize the obsessions/

Patients do not recognize their behavior as

compulsions and want to be rid of them

problematic (ego syntonic).

(ego dystonic).

PSYCHIATRY

HIGH-YIELD FACTS IN

429

Tr ea Tmen T
Pharmacotherapy (SSRIs are rst-line pharmacologic treatment).
CBT using exposure and desensitization relaxation techniques.
Patient education is imperative.
BODY DYSMORPHIC DISORDER

Characterized by preoccupation with imagined or slight defects in physical

appearance that are usually imperceptible to others, leading to signi cant distress/impairment. Actions and behaviors are obsessive and repetitive (ie, mirror checks, comparisons) in response to concerns of appearance.
Tr ea Tmen T
SSRIs.

Trauma and Stressor-Related Disorders

POSTTRAUMATIC STRESS DISORDER

Clinically signi cant stress or impairment in day-to-day social/work interactions as a result of direct exposure to an extreme, life-threatening traumatic
event (eg, assault, combat, injury, rape, accident, violent crime), witnessing a
traumatic event, indirect exposure through learning of a life-threatening event
involving a close family member or friend, or reexposure to trauma-related
events through occupation.

KEYFACT
Top causes o PTSD in male patients
are (1) sexual assault and (2) combat.
Top causes o PTSD in emale patients
are (1) childhood abuse and (2) sexual
assault.

His To r y /Pe
Characterized by the following four symptom clusters:
Intrusion: Reexperiencing of the event through nightmares, ashbacks, intrusive memories.
Avoidance of stimuli associated with the trauma.
Negative alterations in mood and cognitions: Numbed responsiveness (eg, detachment, anhedonia), guilt, self-blame.
Changes in arousal and reactivity: arousal (eg, hypervigilance, exaggerated startle), sleep disturbances, aggression/irritability, and poor
concentration that leads to signi cant distress or impairment in functioning.
Symptoms must persist for > 1 month; the same symptoms present for 3
days to 1 month characterize acute stress disorder.
t r ea Tmen T
Short-term therapy: To target anxiety; includes -blockers and 2-agonists
(eg, clonidine).
Long-term therapy:
Medications: SSRIs are rst line; buspirone, TCAs, and MAOIs may
be helpful. Benzodiazepines are also used but should be avoided in
light of their addictive potential, as there is a high incidence of substance abuse among patients with PTSD.
Psychotherapy and support groups are useful.

KEYFACT
In patients with a history o substance
abuse, benzodiazepines should be
avoided in view o their high addictive
potential.

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HIGH-YIELD FACTS IN

PSYCHIATRY

ADJUSTMENT DISORDER

Clinically signi cant distress following a profound life change (eg, divorce,
unemployment, nancial issues, romantic breakup), not severe enough to
meet criteria for another mental disorder.
His To r y /Pe
Occurs within 3 months after onset of the stressor, can place person at
higher risk for suicidality. Symptoms can be further characterized by anxiety, depressed mood, or issues in conduct. Usually resolves with 6 months of
onset.
Tr ea Tmen T
No pharmacologic treatment! Treat adjustment disorder with supportive
counseling.

Neurocognitive Disorders
Affect memory, orientation, judgment, and attention.
DEMENTIA (AKA MAJOR NEUROCOGNITIVE DISORDER)

MNEMONIC
Ca uses of dementia

DEMENTIASS
Degenerative diseases (Parkinson,
Huntington)
Endocrine (thyroid, parathyroid, pituitary,
adrenal)
Metabolic (alcohol, electrolytes, vitamin
B12 deficien y, glucose, hepatic, renal,
Wilson disease)
Exogenous (heavy metals, carbon
monoxide, drugs)
Neoplasia
Trauma (subdural hematoma)
Infection (meningitis, encephalitis,
endocarditis, syphilis, HIV, prion
diseases, Lyme disease)
A ective disorders (pseudodementia)
Stroke/Structure (vascular dementia,
ischemia, vasculitis, normal-pressure
hydrocephalus)

A decline in cognitive functioning with global de cits. Level of consciousness is stable (vs delirium). Prevalence is highest among those > 85 years of
age. The course is persistent and progressive. The most common causes are
Alzheimer disease (65%) and vascular dementia (20%). Other causes are
outlined in the mnemonic DEMENTIASS.
His To r y /Pe
Diagnostic criteria include memory impairment and one or more of the following:
The four As of dementia (the progression of cognitive impairment follows this order): Amnesia (partial or total memory loss), Aphasia (language
impairment), Apraxia (inability to perform motor activities), Agnosia
(inability to recognize previously known objects/places/people).
Impaired executive function (problems with planning, organizing, and
abstracting) in the presence of a clear sensorium.
Personality, mood, and behavior changes are common (eg, wandering and
aggression).
Dia g n o s is
A careful history and physical is critical. Serial mini-mental state exams
should be performed.
Rule out treatable causes of dementia; obtain CBC, RPR, CMP, TFTs,
HIV, B12/folate, ESR, UA, and a head CT or MRI.
Table 2.14-6 outlines key characteristics distinguishing dementia from
delirium.
Tr ea Tmen T
Provide environmental cues and a rigid structure for the patients daily
life.

PSYCHIATRY

TA B L E 2 . 1 4 - 6 .

Delirium vs Dementia

Va r ia bl e
Level of

HIGH-YIELD FACTS IN

d el ir iu M

d eMen t ia

Impaired (flu tuating).

Usually alert.

Onset

Acute.

Gradual.

Course

Fluctuating from hour to hour,

Progressive deterioration.

attention

sundowning.
Consciousness

Clouded.

Intact.

Hallucinations

Present (often visual or tactile).

Occur in approximately 30%

of patients in highly advanced
disease.

Prognosis

Reversible.

Largely irreversible, but up to 15%

of cases are due to treatable causes
and are reversible.

Treatment

Treat underlying causes.

Cholinesterase inhibitors; low-

Low-dose antipsychotics;

dose antipsychotics (primarily

environmental changes (ie, low-

for behavior disturbances).

stimulus environment, frequent

Environmental changes.

orientation to day and time,

shades up during daytime to
reestablish circadian rhythm).

Cholinesterase inhibitors are used to treat. Low-dose antipsychotics may

be used for psychotic symptoms and sometimes for aggression, but with
the added risk of cardiovascular events in elderly patients. Avoid benzodiazepines, which may exacerbate disinhibition and confusion.
Family, caregiver, and patient education and support are imperative.
DELIRIUM

An acute disturbance of consciousness with altered cognition that develops

over a short period of time (usually hours to days). Children, the elderly, and
hospitalized patients (eg, ICU psychosis) are particularly susceptible. Major
causes are outlined in the mnemonic I WATCH DEATH. Symptoms are
potentially reversible if the underlying cause can be treated.
His To r y /Pe
Presents with acute onset of waxing and waning consciousness with lucid
intervals and perceptual disturbances (hallucinations, illusions, delusions).
Patients may be combative, anxious, paranoid, or stuporous.
Also characterized by a attention span and short-term memory, a
reversed sleep-wake cycle, and symptoms at night (sundowning).

MNEMONIC
Ma jor ca uses of delirium

I WATCH DEATH
Infection
Withdrawal
Acute metabolic/substance Abuse
Trauma
CNS pathology
Hypoxia
Deficiencie
Endocrine
Acute vascular/MI
Toxins/drugs
Heavy metals

431

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HIGH-YIELD FACTS IN

KEYFACT
It is common or delirium to be
superimposed on dementia.

KEYFACT
MDEs can be present in major
depressive disorder or in bipolar
disorder types I and II.

PSYCHIATRY

Dia g n o s is
Check vital signs, utilize pulse oximetry, and provide glucose; perform
physical and neurologic examinations.
Note recent medications (narcotics, anticholinergics, steroids, or benzodiazepines), substance use, prior episodes, medical problems, signs of
organ failure (kidney, liver), and infection (occult UTI is common in the
elderly; check UA).
Order lab and radiologic studies to identify a possible underlying cause.
Tr ea Tmen T
Treat underlying causes (delirium is often reversible).
Normalize uids and electrolytes.
Optimize the sensory environment, and provide necessary visual and
hearing aids.
Use low-dose antipsychotics (eg, haloperidol) for agitation and psychotic
symptoms.
Conservative use of physical restraints may be necessary to prevent harm
to the patient or others.

Mood Disorders
Also known as affective disorders.
MAJOR DEPRESSIVE DISORDER

MNEMONIC
Symptoms of a depressive
episode

SIG E CAPS
Sleep (hypersomnia or insomnia)
Interest (loss of interest or pleasure in
activities)
Guilt (feelings of worthlessness or
inappropriate guilt)
Energy () or fatigue
Concentration ( )
Appetite ( or ) or weight ( or )
Psychomotor agitation or retardation
Suicidal ideation

MNEMONIC
TCA toxicity

Tri-Cs
Convulsions
Coma
Cardiac arrhythmias

A mood disorder characterized by one or more major depressive episodes

(MDEs). The male-to-female ratio is 1:2; lifetime prevalence ranges from
15% to 25%. Onset is usually in the mid-20s; in the elderly, prevalence
with age. Chronic illness and stress risk. Approximately 29% of patients
die by suicide.
His To r y /Pe
Diagnosis requires depressed mood or anhedonia (loss of interest/pleasure)
and ve or more signs/symptoms from the SIG E CAPS mnemonic for a
2-week period (you should be sure to learn this mnemonic to ace the MDD
questions). Table 2.14-7 outlines the differential diagnosis of conditions that can
be mistaken for depression. Selected depression subtypes include the following:
Psychotic features: Typically mood-congruent delusions/hallucinations.
Postpartum: Occurs within 1 month postpartum; has a 10% incidence
and a high risk of recurrence. Psychotic symptoms are common (see Table
2.14-8).
Atypical: Characterized by weight gain, hypersomnia, and rejection sensitivity.
Seasonal: Depressive episodes tend to occur during a particular season,
most commonly winter. Responds well to light therapy with or without
antidepressants.
Double depression: Major depressive episode (MDE) in a patient with
dysthymia. Has a poorer prognosis than MDE alone.
Tr ea Tmen T
Pharmacotherapy:
Effective in 5070% of patients.
Allow 26 weeks to take effect; treat for 6 or more months (see Table
2.14-9).

PSYCHIATRY

TA B L E 2 . 1 4 - 7 .

HIGH-YIELD FACTS IN

433

Dif erential Diagnosis of Major Depression

d iSo r d er

d eSc r ipt io n a n d e x a Mpl eS

Mood disorder due to a

Hypothyroidism, Parkinson disease, CNS neoplasm, other

medical condition

neoplasms (eg, pancreatic cancer), stroke (especially ACA stroke),

dementias, parathyroid disorders.

Substance-induced

Illicit drugs, alcohol, antihypertensives, corticosteroids, OCPs.

mood disorder
Adjustment disorder

A constellation of symptoms that resemble an MDE but do

with depressed mood

not meet the criteria for MDE. Occurs within 3 months of an

identifiable st essor.

Normal bereavement

Occurs after the loss of a loved one. Involves no severe

impairment/suicidality. Usually lasts < 6 months; should resolve
within 1 year. May lead to MDD that requires treatment.
Illusions/hallucinations of the deceased can be normal as long as
the person recognizes them as such.

Dysthymia

Milder, chronic depression with depressed mood present most of

the time for at least 2 years; often resistant to treatment.

Psychotherapy: Psychotherapy combined with antidepressants is more

effective than either treatment alone.
Electroconvulsive therapy (ECT):
Safe, highly effective, and often lifesaving therapy that is reserved for
refractory depression or psychotic depression, if rapid improvement in
mood is needed (severe suicidality), or intractable mania and psychosis. Also safe during pregnancy.
Usually requires two to three times per week treatment for a total of
612 treatments.
Adverse effects include postictal confusion, arrhythmias, headache,
and anterograde amnesia.
No absolute contraindications. Relative contraindications include
recent MI/stroke, intracranial mass, and high anesthetic risk.
TA B L E 2 . 1 4 - 8 .

KEYFACT
Discontinue SSRIs at least 2 weeks
be ore starting an MAOI. Wait 5 weeks i
the patient was on uoxetine.

Dif erential Diagnosis of Postpartum Disorders

Su bt ype
Postpartum blues

Postpartum psychosis

t iMe o F o n Set

SyMpt o MS

Within 2 weeks of

Sadness, moodiness, emotional lability.

delivery.

No thoughts about hurting baby.

23 weeks postdelivery.

Delusions and depression.

May have thoughts about hurting baby.

Postpartum

13 months

depression

postdelivery.

Same as above plus sleep disturbances

and anxiety.
Thoughts about hurting baby.

A 23-year-old woman complains o

dif culty alling asleep and worsening
anxiety that began 2 months earlier,
a ter she was involved in a minor
biking accident (bike vs car) in which
she did not su er any injuries. Since
the accident, she has re used to
participate in any outdoor activities.
What is her most likely diagnosis?

434

HIGH-YIELD FACTS IN

TA B L E 2 . 1 4 - 9 .

d r u g c l a SS
SSRIs

PSYCHIATRY

Indications and Side Ef ects of Common Antidepressants

e x a Mpl eS
Fluoxetine, sertraline,

in d ic at io n S
Depression, anxiety.

paroxetine, citalopram,

Sid e e FFec t S
Sexual side e ects, GI distress, agitation, insomnia, tremor, diarrhea.
Serotonin syndrome (fever, myoclonus, mental status changes,

flu oxamine.

cardiovascular collapse) can occur if SSRIs are used with MAOIs, illicit
drugs, or herbal medications.
Paroxetine can cause pulmonary hypertension in the fetus. Avoid in
pregnancy.

Atypicals

Bupropion, mirtazapine,

Depression, anxiety.

Bupropion: seizure threshold; minimal sexual side e ects.

trazodone.

Contraindicated in patients with eating disorders as well as in seizure

patients.
Mirtazapine: Weight gain, sedation.
Trazodone: Highly sedating; priapism.

SNRIs

Venlafaxine, duloxetine.

Depression, anxiety,

Venlafaxine: Diastolic hypertension.

chronic pain.
TCAs

Nortriptyline,

Depression, anxiety

desipramine,

disorder, chronic pain,

(eg, prolonged conduction through the AV node, long QRS). Monitor

amitriptyline, imipramine.

migraine headaches,

in the ICU for 34 days following an overdose.

enuresis (imipramine).

Lethal with overdose resulting from cardiac conduction arrhythmias

Anticholinergic e ects (dry mouth, constipation, urinary retention,

sedation).

MAOIs

Phenelzine,

Depression, especially

tranylcypromine,

atypical.

selegiline (a patch form is

Hypertensive crisis if taken with high-tyramine foods (aged cheese, red

wine).
Sexual side e ects, orthostatic hypotension, weight gain.

available).

KEYFACT
SIG E CAPS = MDD. DIG FAST = BPD.

Phototherapy: Effective for patients whose depression has a seasonal pattern.

Transcranial magnetic stimulation (TMS): Now approved for the treatment of major depression. TMS is about as effective as medications for
some patients but is not as effective as ECT.
BIPOLAR DISORDER

Prevalence is approximately 1% for type I and an additional 3% for type II;

male and female patients are affected equally. A family history of bipolar illness signi cantly risk. The average age of onset is 20, and the frequency of
mood episodes tends to with age. Up to 1015% of those affected die by suicide. Subtypes are as follows:

Adjustment disorder, which consists

o emotional and behavioral
symptoms that develop in response
to an identi able stressor, lasts > 1
month and < 6 months, and does not
have ve or more symptoms o MDD.

Bipolar I: Involves at least one manic or mixed episode (usually requiring hospitalization).
Bipolar II: Involves at least one MDE and one hypomanic episode (less
intense than mania). Patients do not meet the criteria for full manic or
mixed episodes. Characterized predominantly by depression with occasional hypomanic episodes.
Rapid cycling: Involves four or more episodes (MDE, manic, mixed, or
hypomanic) in 1 year.
Cyclothymic: Chronic and less severe, with alternating periods of hypomania and moderate depression for > 2 years.

PSYCHIATRY

His To r y /Pe
The mnemonic DIG FAST outlines the clinical presentation of mania.
Patients may report excessive engagement in pleasurable activities (eg,
excessive spending or sexual activity), reckless behaviors, and/or psychotic
features.
Antidepressant use without a mood stabilizer may trigger manic episodes.
Dia g n o s is
A manic episode is 1 week or more of persistently elevated, expansive,
or irritable mood plus three DIG FAST symptoms. Psychotic symptoms
are common in mania.
Symptoms are not due to a substance or medical condition and lead to signi cant impairment socially, occupationally, or familially.
Hypomania is similar but does not involve marked functional impairment
or psychotic symptoms and does not require hospitalization.

HIGH-YIELD FACTS IN

435

MNEMONIC
Symptoms of ma nia

DIG FAST
Distractibility
Insomnia ( need for sleep)
Grandiosity ( self-esteem)/more Goal
directed
Flight of ideas (or racing thoughts)
Activities/psychomotor Agitation
Sexual indiscretions/other pleasurable
activities
Talkativeness/pressured speech

Tr ea Tmen T
Bipolar mania: Mania is considered a psychiatric emergency because of
the impaired judgment and great risk of harm to self and others.
Acute therapy: Antipsychotics, lithium, valproate.
Maintenance therapy: Mood stabilizers (see Table 2.14-10).
Use benzodiazepines for refractory agitation.
Bipolar depression: Mood stabilizers with or without antidepressants.
Start mood stabilizers rst (see Table 2.14-10) to avoid inducing mania.
ECT may be used to treat refractory cases.
TA B L E 2 . 1 4 - 1 0 .

Mood Stabilizers

d r u g c l a SS
Lithium

in d ic at io n S
First-line mood stabilizer. Used for acute mania (in

Sid e e FFec t S
Thirst, polyuria, diabetes insipidus, tremor, weight

combination with antipsychotics), for prophylaxis in BPD,

gain, hypothyroidism, nausea, diarrhea, seizures,

and for augmentation in depression treatment. Also

teratogenicity (if used in the first t imester, 0.1% risk of

decreases suicide risk.

Ebstein anomaly), acne, vomiting.

Narrow therapeutic window (but blood level can be
monitored).
Lithium toxicity: blood level > 1.5 mEq/L; presents with
ataxia, dysarthria, delirium, and acute renal failure.
Avoid lithium in patients with renal function.

Carbamazepine

Second-line mood stabilizer; anticonvulsant; trigeminal

neuralgia.

Nausea, skin rash, leukopenia, AV block. Teratogenicity

(0.51% neural tube defect).
Rarely, aplastic anemia (monitor CBC biweekly). SJS.

Valproic acid

BPD; anticonvulsant.

GI side e ects (nausea, vomiting), tremor, sedation,

alopecia, weight gain, teratogenicity (35% risk of
neural tube defect).
Rarely, pancreatitis, thrombocytopenia, fatal
hepatotoxicity, and agranulocytosis.

Lamotrigine

Second-line mood stabilizer; anticonvulsant.

Blurred vision, GI distress, SJS. dose slowly to monitor

for rashes.

436

HIGH-YIELD FACTS IN

PSYCHIATRY

In patients with severe depression or bipolar II with predominantly

depressive features, antidepressant treatment can be augmented with lowdose lithiumeg, at blood levels of 0.40.6 mEq/L.

MNEMONIC
Cha ra cteristics of persona lity
disorders

MEDIC
Maladaptive
Enduring
Deviate from cultural norms
Infl xible
Cause impairment in social or occupational
functioning

TA B L E 2 . 1 4 - 1 1 .

Personality Disorders
Personality can be de ned as an individuals set of emotional and behavioral traits, which are generally stable and predictable. Personality disorders
are de ned when ones traits become chronically rigid and maladaptive, and
affect most aspects of ones life (see the mnemonic MEDIC). Onset occurs
by early adulthood. Speci c disorders are outlined in Table 2.14-11.

Signs and Symptoms of Personality Disorders

d iSo r d er

c h a r a c t er iSt ic S

c l in ic a l pr eSen t at io n
c l u St er a : Weir d

Paranoid

Distrustful, suspicious; interpret othersmotives as

59-year-old man who lives alone constantly feels that his

malevolent.

neighbors children are spying on him and plotting to break

into his home. He has installed security cameras all around his
property to obtain proof. He feels he cannot trust the police to
do a good job because they will probably take the side of his
neighbors.

Schizoid

Isolated, detached loners. Restricted emotional

66-year-old man who moves to Thailand alone after

expression.

retirement, has no desire to remain in contact with his family,

and is very distant in his interactions. He stays in his remote
accommodations without unnecessary travel and does not
crave interaction with the locals.

Schizotypal

Odd behavior, perceptions, and appearance. Magical

thinking; ideas of reference.

35-year-old man with very strange ideas regarding the

importance of crystals and their e ect on health. He

Note: These patients may have eccentric/disorganized

thoughts and behavior; however, they lack delusions and

meticulously mines and collects crystals, feeling that they will

one day prevent him from acquiring cancer.

hallucinations that would classify them as schizophrenic.

c l u St er b: Wil d
Borderline

Unstable mood, relationships, and self-image; feelings of

28-year-old woman presents to clinic after having praised her

emptiness. Impulsive. History of suicidal ideation or self-

new clinician as better than all the others. She reveals that she

harm.

fi ed her last therapist, as he was not really helping. You notice

Note: These patients will use splitting as a defense

she has fresh cuts in a row on her forearm.

mechanism.
Histrionic

Excessively emotional and attention seeking. Sexually

35-year-old woman presents to clinic wearing a very low-cut

provocative; theatrical.

blouse, adjusting her position to draw attention to herself.

When she does not get attention, she breaks into tears, saying
that no one notices her, not even her friends.
(continues)

PSYCHIATRY

TA B L E 2 . 1 4 - 1 1 .

HIGH-YIELD FACTS IN

437

Signs and Symptoms of Personality Disorders (continued)

d iSo r d er

c h a r a c t er iSt ic S

c l in ic a l pr eSen t at io n
c l u St er b: Wil d

Narcissistic

Grandiose; need admiration; have sense of entitlement.

45-year-old man sits impatiently tapping his foot in the waiting

Lack empathy.

room of your of ce. He approaches the receptionist, demands

to know where the doctor is, and tells her that he will have her
fi ed and the doctor reported if he is not seen shortly. You are
all wasting his time.

Antisocial

Violate rights of others, social norms, and laws. Impulsive;

22-year-old man who was in juvenile detention for theft as a

lack remorse. Must have a prior diagnosis of conduct

teenager and presents to your of ce now via court order after

disorder.

a brutal assault. He says that he doesnt need to be seen by

a shrink and that the victim o ended him and deserved the
assault.

c l u St er c : Wo r r ied
Obsessivecompulsive

Preoccupied with perfectionism, order, and control at the

expense of efficie

y. Infl xible morals and values.

Note: Remember, in contrast to OCD, these patients dont

feel their behavior is problematic.

and

WiMpy

35-year-old woman presents to your of ce at the request of

her boss, who feels she is too focused on minute details on
team projects and doesnt allow others to participate for fear
of unwanted errors. She doesnt see anything wrong with this
style of work, as she believes her coworkers cant be trusted to
pay adequate attention to detail.

Avoidant

Socially inhibited; rejection sensitive. Fear of being

33-year-old man stays at home to avoid an of ce Christmas

disliked or ridiculed, yet desires to have friends and

party, as he fears having to make small talk. He wants to go,

social interactions.

though is more afraid that he will be inadequate or rejected by

others.

Dependent

Submissive, clingy; have a need to be taken care of. Have

30-year-old woman presents to your of ce in crisis, saying

difficu y making decisions. Feel helpless.

that her parents just kicked her out of their house and she is
struggling to survive on her own. She says she is too weak to
even make choices at the grocery, as her mother would always
care for her and now these decisions are overwhelming. She
has been sitting outside of their house daily, hoping they will
let her live there again.

Dia g n o s is
Ask about attitudes, mood variability, activities, and reaction to stress.
Patients have chronic problems dealing with responsibilities, roles, and
stressors. They may also deny their behavior, have dif culty changing their
behavior patterns, and frequently refuse psychiatric care.
Tr ea Tmen T
Psychotherapy is the mainstay of therapy.
Pharmacotherapy is reserved for cases with comorbid mood, anxiety, or
psychotic signs/symptoms.

A 22-year-old man requently washes

his hands, re uses to sit on chairs in
public places, and will not use public
transportation or ear o contracting
diseases. He does not think his
behaviors are abnormal, nor does he
think his behaviors inter ere with his
daily activities. What is the diagnosis?

438

HIGH-YIELD FACTS IN

PSYCHIATRY

Substance Use Disorders

Substance use disorder is a maladaptive pattern of substance use that leads
to clinically signi cant impairment. It can be applied to most substances of
abuse, except caffeine. The patient must meet 2 of the 11 criteria within a
1-year period for diagnosis. The criteria can be grouped into four categories of
symptoms and are as follows:
Impaired control:
Consumption of greater amounts of the substance than intended.
Failed attempts to cut down use or abstain from the substance.
Increased amount of time spent acquiring, using, or recovering from
effects.
Craving.
Social impairment:
Failure to ful ll responsibilities at work, school, or home.
Continued substance use despite recurrent social or interpersonal
problems 2 to the effects of such use (eg, frequent arguments with
spouse over the substance use).
Isolation from life activities.
Risky use:
Use of substances in physically hazardous situations (eg, driving while
intoxicated).
Continued substance abuse despite recurrent physical or psychological
problems 2 to the effect of the substance use.
Pharmacologic:
Tolerance and use of progressively larger amounts to obtain the same
desired effect.
Withdrawal symptoms when not taking the substance.
Note: Tolerance and withdrawal are not needed to make the diagnosis.
KEYFACT
Pinpoint pupils are not always a reliable
sign o opioid ingestion, because
coingestions can lead to normal
or enlarged pupils. Also look or a
respiratory rate, track marks, and
breath sounds.

Dia g n o s is /Tr ea Tmen T

Substance use is often denied or underreported, so seek out collateral
information from family and friends.
Severity is determined by number of symptoms present: mild, two to three;
moderate, four to ve; severe, more than six.
Check urine and blood toxicology screens, LFTs, and serum EtOH level.
The management of intoxication for selected drugs is described in Table
2.14-12.
ALCOHOL USE DISORDER

Occurs more often in men (4:1) and in those 2134 years of age, although the
incidence in women is rising. Also associated with a family history.

This person su ers rom obsessivecompulsive personality disorder

(OCPD). These patients are
per ectionists, are preoccupied
with rules and order, and are o ten
in exible. Unlike patients with
obsessive-compulsive disorder, those
with OCPD typically are not disturbed
by their disease.

His To r y /Pe
See Table 2.14-12 for the symptoms of intoxication and withdrawal. Look for
palmar erythema or telangiectasias as well as for other signs and symptoms of
end-organ complications.
Dia g n o s is
Screen with the CAGE questionnaire. Monitor vital signs for evidence of
withdrawal. Labs may reveal LFTs, LDH, and mean corpuscular volume.

PSYCHIATRY

TA B L E 2 . 1 4 - 1 2 .

439

Signs and Symptoms of Substance Abuse

d rug
Alcohol

HIGH-YIELD FACTS IN

in t o x ic at io n

Wit h d r aWa l

Disinhibition, emotional lability, slurred speech, ataxia,

Tremor, tachycardia, hypertension, malaise, nausea,

aggression, blackouts, hallucinations, memory impairment,

seizures, DTs, agitation.

impaired judgment, coma.

Opioids

Euphoria leading to apathy, CNS depression, constipation,

Dysphoria, insomnia, anorexia, myalgias, fever,

pupillary constriction, and respiratory depression (life-

lacrimation, diaphoresis, dilated pupils, rhinorrhea,

threatening in overdose).

piloerection, nausea, vomiting, stomach cramps,

Naloxone and naltrexone block opioid receptors and

reverse e ects, but beware of the antagonist clearing
before the opioids, particularly with long-acting opioids

diarrhea, yawning.
Opioid withdrawal is not life-threatening, hurts all over,
and does not cause seizures.

such as methadone.
Amphetamines

Psychomotor agitation, impaired judgment, hypertension,

Postuse crash with anxiety, lethargy, headache, stomach

pupillary dilation, tachycardia, fever, diaphoresis,

cramps, hunger, fatigue, depression/dysphoria, sleep

anxiety, angina, euphoria, prolonged wakefulness/

disturbance, nightmares.

attention, arrhythmias, delusions, seizures, hallucinations.

Haloperidol can be given for severe agitation and
symptom-targeted medications (eg, antiemetics, NSAIDs).
Cocaine

Psychomotor agitation, euphoria, impaired judgment,

Postuse crash with hypersomnolence, depression,

tachycardia, pupillary dilation, hypertension, paranoia,

malaise, severe craving, angina, suicidality, appetite,

hallucinations, cocaine bugs (the feeling of bugs

nightmares.

crawling under ones skin), sudden death. ECG changes

from ischemia are often seen (cocaine chest pain).
Treat with haloperidol for severe agitation along
with symptom-specific medic tions (eg, to control
hypertension).
Phencyclidine

Assaultiveness, belligerence, psychosis, violence,

hydrochloride

impulsiveness, psychomotor agitation, fever, tachycardia,

(PCP)

vertical/horizontal nystagmus, hypertension, impaired

Recurrence of intoxication symptoms due to reabsorption

in the GI tract; sudden onset of severe, random violence.

judgment, ataxia, seizures, delirium.

Give benzodiazepines or haloperidol for severe symptoms;
otherwise reassure. Acidific tion of urine or gastric lavage
can help eliminate the drug.
LSD

Marked anxiety or depression, delusions, visual

None.

hallucinations, flashback , pupillary dilation, impaired

judgment, diaphoresis, tachycardia, hypertension,
heightened senses (eg, colors become more intense).
Supportive counseling; traditional antipsychotics for
psychotic symptoms; benzodiazepines for anxiety.
Marijuana

Euphoria, slowed sense of time, impaired judgment, social

None.

withdrawal, appetite, dry mouth, conjunctival injection,

hallucinations, anxiety, paranoia, amotivational syndrome.
(continues)

440

HIGH-YIELD FACTS IN

TA B L E 2 . 1 4 - 1 2 .

PSYCHIATRY

Signs and Symptoms of Substance Abuse (continued)

d rug

in t o x ic at io n

Barbiturates

Low safety margin; respiratory depression.

Wit h d r aWa l
Anxiety, seizures, delirium, life-threatening cardiovascular
collapse.

Benzodiazepines

Interactions with alcohol, amnesia, ataxia, somnolence, mild

Rebound anxiety, seizures, tremor, insomnia,

respiratory depression. (Avoid using for insomnia in the

hypertension, tachycardia, death.

elderly; can cause paradoxic agitation even in relatively low

doses.)
Ca eine

Restlessness, insomnia, diuresis, muscle twitching,

Headache, lethargy, depression, weight gain, irritability,

arrhythmias, tachycardia, flushed fa e, psychomotor

craving.

agitation.
Nicotine

Restlessness, insomnia, anxiety, arrhythmias.

Irritability, headache, anxiety, weight gain, craving,

bradycardia, difficu y concentrating, insomnia.

MNEMONIC
CAGE questionna ire:
1. Have you ever felt the need to Cut
down on your drinking?
2. Have you ever felt Annoyed by
criticism of your drinking?
3. Have you ever felt Guilty about
drinking?
4. Have you ever had to take a morning
Eye opener?
More than one yesanswer makes
alcoholism likely.

Tr ea Tmen T
Rule out medical complications; correct electrolyte abnormalities.
Start a benzodiazepine taper for withdrawal symptoms. Add haloperidol
for hallucinations and psychotic symptoms.
Give multivitamins and folic acid; administer thiamine before glucose
(which depletes thiamine) to prevent Wernicke encephalopathy.
Give anticonvulsants to patients with a seizure history.
Group therapy, disul ram, or naltrexone can aid patients with dependence.
Long-term rehabilitative therapy (eg, Alcoholic Anonymous).
Co mPl iCa Tio n s
GI bleeding from gastritis, ulcers, varices, or Mallory-Weiss tears.
Pancreatitis, liver disease, DTs, alcoholic hallucinosis, peripheral neuropathy, Wernicke encephalopathy, Korsakoff psychosis, fetal alcohol syndrome, cardiomyopathy, anemia, aspiration pneumonia, risk of sustaining trauma (eg, subdural hematoma).

Eating Disorders
ANOREXIA NERVOSA

Risk factors include female gender, low self-esteem, and high socioeconomic
status. Also associated with OCD, MDD, anxiety, and careers/hobbies such as
modeling, gymnastics, ballet, and running.
His To r y /Pe
Patients restrict (eg, severely restricting caloric intake by fasting or by
excessively exercising) or binge and purge (through vomiting, laxatives,
and diuretics).
Signs and symptoms include cachexia, a body mass index (BMI) < 18,
lanugo, dry skin, bradycardia, lethargy, hypotension, cold intolerance, and
hypothermia (as low as 35C [95F]).
See Table 2.14-13.

PSYCHIATRY

TA B L E 2 . 1 4 - 1 3 .

HIGH-YIELD FACTS IN

441

Anorexia vs Bulimia

Va r ia bl e

a n o r ex ia n er Vo Sa

Presentation

b u l iMia n er Vo Sa

Persistent restriction of caloric

For at least once a week for 3

intake resulting in low body

or more months, patients have

weight, an intense fear of weight

episodes of binge eating and

gain, a distorted body image

compensatory behaviors that

(patients perceive themselves

include purging or fasting.

as fat).
Weight

Patients are underweight

Patients are of normal weight or

( 15% below expected weight).

are overweight.

Attitude toward

Patients are typically not

Patients are typically distressed

illness

distressed by their illness

about their symptoms and are

and may thus be resistant to

thus easier to treat.

treatment.
Treatment

Monitor calorie intake and

weight gain; hospitalize if

Psychotherapy
antidepressants.

necessary.
Psychotherapy.
Treat comorbidities.

Dia g n o s is
Measure height and weight; check BMI; check CBC, electrolytes, endocrine
levels, and ECG. Perform a psychiatric evaluation to screen patients for
comorbid conditions.
Tr ea Tmen T
See Table 2.14-13.

KEYFACT
There are two types o anorexia
nervosa:
Restricting type
Binging/purge-eating type

Co mPl iCa Tio n s

See Table 2.14-14.
Mortality from suicide or medical complications is > 10%.
TA B L E 2 . 1 4 - 1 4 .

Medical Complications of Eating Disorders

c o n St it u t io n a l

c a r d ia c

gi

gu

o t h er

Dental erosions and

Amenorrhea

Dermatologic: Lanugo

Nephrolithiasis

Hematologic:

Cachexia

Arrhythmias

Hypothermia

Sudden death

Fatigue

Hypotension

Abdominal pain

Electrolyte abnormalities

Bradycardia

Delayed gastric

(hypokalemia, pH
abnormalities)

Prolonged QT interval

decay

emptying

Leukopenia
Neurologic: Seizures
Musculoskeletal:
Osteoporosis, stress
fractures

442

HIGH-YIELD FACTS IN

PSYCHIATRY

BULIMIA NERVOSA

KEYFACT
Bulimic patients tend to be more
disturbed by their behavior than
anorexics and are more easily engaged
in therapy. Anorexic patients deny
health risks associated with their
behavior, making them resistant to
treatment.

KEYFACT
Bupropion should be avoided in the
treatment o patients with eating
disorders, as it is associated with a
seizure threshold.

More common among women; associated with low self-esteem, mood disorders, and OCD.
His To r y /Pe
See Table 2.14-13.
Signs include dental enamel erosion, enlarged parotid glands, and scars
on the dorsal hand surfaces (if there is a history of repeated induced vomiting).
Tr ea Tmen T
See Table 2.14-13.
Co mPl iCa Tio n s
See Table 2.14-14.

Miscellaneous Disorders
SEXUAL DISORDERS

Sexual Changes With Aging

Interest in sexual activity usually does not with aging.

Men usually require stimulation of the genitalia for longer periods of
time to reach orgasm; intensity of orgasm , and the length of the refractory period before the next orgasm .
In women, estrogen levels after menopause, leading to vaginal dryness and thinning, which may result in discomfort during coitus. May be
treated with hormone replacement therapy, estrogen vaginal suppositories,
or other vaginal creams.
Paraphilic Disorders

Preoccupation with or engagement in unusual sexual fantasies, urges, or

behaviors for > 6 months with clinically signi cant impairment in ones life.
There are eight classi ed disorders, characterized by disordered courtship
(voyeurism, exhibitionism, and frotteurism), disordered preferences (pedophilia, transvestic fetishism, fetishism), and pleasure in in icting/receiving
pain (sadism, masochism). See Table 2.14-15.
Treatment includes insight-oriented psychotherapy and behavioral therapy.
Antiandrogens (eg, Depo-Provera) have been used for hypersexual paraphilic
activity.
Gender Dysphoria

Strong, persistent cross-gender identi cation and discomfort with ones

assigned sex or gender role of the assigned sex in the absence of intersexual disorders. Patients may have a history of dressing like the opposite
sex, taking sex hormones, or pursuing surgeries to reassign their sex.
More common in men than in women. Associated with depression, anxiety, substance abuse, and personality disorders.
Tx: Treatment is complex and includes educating the patient about culturally acceptable behavior patterns and addressing comorbidities. Other

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TA B L E 2 . 1 4 - 1 5 .

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Features of Common Paraphilic Disorders

d iSo r d er

c l in ic a l Ma n iFeSt at io n S

Exhibitionistic

Sexual arousal from exposing ones genitals to a stranger.

Pedophilic

Urges or behaviors involving sexual activities with children.

Voyeuristic

Observing unsuspecting persons unclothed or involved in sex.

Fetishistic

Use of nonliving objects (often clothing) for sexual arousal.

Transvestic

Cross-dressing for sexual arousal.

Frotteuristic

Touching or rubbing ones genitalia against a nonconsenting person

(common in subways).

Sexual sadism

Sexual arousal from infli ting su ering on sexual partner.

Sexual masochism

Sexual arousal from being hurt, humiliated, bound, or threatened.

options include sex-reassignment surgery or hormonal treatment (eg, estrogen for men, testosterone for women). Supportive psychotherapy is helpful.
Sexual Dysfunction

Problems in sexual arousal, desire, or orgasm, or pain with sexual intercourse.

Prevalence is 30%; one-third of cases are attributable to biologic factors
and another third to psychological factors.
Tx: Treatment depends on the particular condition. Pharmacologic strategies include sildena l (Viagra) and bupropion (Wellbutrin). Psychotherapeutic strategies include sensate focusing.
SLEEP DISORDERS

Up to one-third of all American adults suffer from some type of sleep disorder
during their lives. The term dyssomnia describes any condition that leads to
a disturbance in the normal rhythm or pattern of sleep. Insomnia is the most
common example. Risk factors include female gender, the presence of mental and medical disorders, substance abuse, and advanced age.
1 Insomnia

Affects up to 30% of the general population; causes sleep disturbance

that is not attributable to physical or mental conditions. Often exacerbated
by anxiety, and patients may become preoccupied with getting enough
sleep.
Dx: Patients present with a history of nonrestorative sleep or dif culty
initiating or maintaining sleep that is present at least three times per
week for 1 month.
Tx:
First-line therapy includes the initiation of good sleep hygiene measures.
Pharmacotherapy is considered second-line therapy and should be initiated with care for short periods of time (< 2 weeks). Pharmacologic

KEYFACT
Recommended sleep hygiene
measures: Stimulus control therapy
to reestablish a circadian (24-hour)
sleep/wake cycle.
Establishment o a regular sleep
schedule
Limiting o ca eine intake
Avoidance o daytime naps
Warm baths in the evening
Use o the bedroom or sleep and
sexual activity only
Exercising early in the day
Relaxation techniques
Avoidance o large meals near
bedtime

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PSYCHIATRY

agents include diphenhydramine (Benadryl), zolpidem (Ambien),

zaleplon (Sonata), and trazodone (Desyrel).
1 Hypersomnia

Dx: Diagnosed when a patient complains of excessive daytime sleepiness

or nighttime sleep that occurs for > 1 month. The excessive somnolence
cannot be attributable to medical or mental illness, medications, poor
sleep hygiene, insuf cient sleep, or narcolepsy.
Tx:
First-line therapy includes stimulant drugs such as amphetamines.
Antidepressants such as SSRIs may be useful in some patients.
Narcolepsy

May affect up to 0.16% of the population. Onset typically occurs by young

adulthood, generally before age 30. Some forms of narcolepsy may have a
genetic component.
Dx:
Manifestations include excessive daytime somnolence and REM
sleep latency on a daily basis for at least 3 months. Sleep attacks are
the classic symptom; patients cannot avoid falling asleep.
The characteristic excessive sleepiness may be associated with the following:
Cataplexy: Sudden loss of muscle tone that leads to collapse.
Hypnagogic hallucinations: Occur as the patient is falling asleep.
Hypnopompic hallucinations: Occur as the patient awakens.
Sleep paralysis: Brief paralysis upon awakening.
Tx: Treat with a regimen of scheduled daily naps plus stimulant drugs
such as amphetamines; give SSRIs for cataplexy.
Sleep Apnea

Occurs 2 to disturbances in breathing during sleep that lead to excessive

daytime somnolence and sleep disruption. Etiologies can be either central or peripheral.
Central sleep apnea (CSA): A condition in which both air ow and
respiratory effort cease. CSA is linked to morning headaches, mood
changes, and repeated awakenings during the night.
Obstructive sleep apnea (OSA): A condition in which air ow ceases
as a result of obstruction along the respiratory passages. OSA is strongly
associated with snoring. Risk factors include male gender, obesity,
prior upper airway surgeries, a deviated nasal septum, a large uvula or
tongue, and retrognathia (recession of the mandible).
In both forms, arousal results in cessation of the apneic event.
Associated with sudden death in infants and the elderly, headaches,
depression, systolic BP, and pulmonary hypertension.
Dx: Sleep studies (polysomnography) document the number of arousals,
obstructions, and episodes of O 2 saturation; distinguish OSA from CSA;
and identify possible movement disorders, seizures, or other sleep disorders.
Tx:
OSA: Nasal continuous positive airway pressure (CPAP). Weight loss if
obese. In children, most cases are due to tonsillar/adenoidal hypertrophy, which is corrected surgically.
CSA: Mechanical ventilation (eg, BiPAP) with a backup rate for severe
cases.

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Circadian Rhythm Sleep Disorder

A spectrum of disorders characterized by a misalignment between desired

and actual sleep periods. Subtypes include jet-lag type, shift-work type,
delayed sleep-phase type, and unspeci ed.
Tx:
The jet-lag type usually resolves within 27 days without speci c treatment.
The shift-work type may respond to light therapy.
Oral melatonin may be useful if given 5 hours before the desired
bedtime.

KEYFACT
Factitious disorders and malingering
are distinct rom somato orm disorders
in that they involve conscious and
intentional processes.

SOMATIC SYMPTOM AND RELATED DISORDERS

Somatic Symptom Disorder

Patients often present with excessive thoughts, anxiety, and behaviors driven
by presence of somatic symptoms that is distressing and negatively affects
daily life. This may occur with or without any medical illness present. High
health care utilization is often present.
Tr ea Tmen T
Regularly scheduled appointments with one clinician as 1 caregiver.
Avoid unnecessary diagnostics.
Psychotherapy.
Conversion Disorder

Characterized by symptoms or de cits of voluntary motor or sensory function

(eg, blindness, seizurelike movements, paralysis) incompatible with medical
processes. Close temporal relationship to stress or intense emotion.
Dia g n o s is
Symptoms unexplained by other medical or neurologic causes.
Physical exam signs suggesting nonorganic cause of symptoms:
Presence of Hoover sign (extension of affected leg when asked to raise
the unaffected contralateral leg) when attempting to rule out leg paralysis.
Eyes closed and resistant to opening during seizure, negative simultaneous EEG.
Tremor disappears with distraction.
Tr ea Tmen T
Psychotherapy.

KEYFACT
In malingering, patients intentionally
simulate illness or personal gain.

FACTITIOUS DISORDERS AND MALINGERING

Characterized by the fabrication of symptoms or self-injury to assume the

sick role (1 gain). Referred to as factitious disorder imposed on another
(formerly Munchausen by proxy) when a caregiver makes someone else ill
and enjoys taking on the role of concerned caregiver.
In malingering, patients intentionally cause or feign symptoms for 2 gain of
nancial bene t or housing.

A 57-year-old morbidly obese

man presents to his physician with
concerns about daytime sleepiness
and work productivity. He recently
received multiple divorce threats
rom his wi e or excessive snoring
that sounds like the snort o a steam
engine.What long-term complications
are o concern or this patient?

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Tr ea Tmen T
Psychotherapy.
Minimal diagnostics and treatment to avoid reinforcement of behaviors.
KEYFACT
Sexual abusers are usually male and
are o ten known to the victim (and are
o ten amily members).

MNEMONIC
Risk fa ctors for suicide

SAD PERSONS
Sex (male)
Age (older)
Depression
Previous attempt
Ethanol/substance abuse
Rational thought
Sickness (chronic illness)
Organized plan/access to weapons
No spouse
Social support lacking

KEYFACT
Suicide is the third leading cause o
death (a ter homicide and accidents)
among 15- to 24-year-olds in the
United States.

KEYFACT
Emergent inpatient hospitalization
is required or patients with suicidal
intentions.

This patient has obstructive sleep

apnea. Serious consequences
include leg swelling, hypertension,
cor pulmonale, stroke, and clinical
depression.

SEXUAL AND PHYSICAL ABUSE

Most frequently affects women < 35 years of age who:

Are experiencing marital discord and are substance abusers or have a
partner who is a substance abuser; or
Are pregnant, have low socioeconomic status, or have obtained a
restraining order.
Victims of childhood abuse are more likely to become adult victims of
abuse.
Hx/PE:
Patients typically have multiple somatic complaints, frequent ER visits, and unexplained injuries with delayed medical treatment. They
may also avoid eye contact or act afraid or hostile.
Children may exhibit precocious sexual behavior, genital or anal
trauma, STDs, UTIs, and psychiatric problems.
Other clues include a partner who answers questions for the patient or
refuses to leave the examination room.
Tx: Perform a screening assessment of the patients safety domestically and
in her/his close personal relationships. Provide medical care, emotional
support, and counseling; educate the patient about support services, and
refer appropriately. Documentation is crucial.
SUICIDALITY

Accounts for 30,000 deaths per year in the United States; the eighth overall cause of death in the United States. One suicide occurs every 1720
minutes.
Risk factors include male gender, age > 45 years, psychiatric disorders
(major depression, presence of psychotic symptoms), a history of an admission to a psychiatric institution, a previous suicide attempt, a history of
violent behavior, ethanol or substance abuse, recent severe stressors, and a
family suicide history (see the mnemonic SAD PERSONS).
Women are more likely to attempt suicide, whereas men are more likely
to succeed by virtue of their use of more lethal methods.
Dx:
Perform a comprehensive psychiatric evaluation.
Ask about family history, previous attempts, ambivalence toward death,
and hopelessness.
Ask directly about suicidal ideation, intent, and plan, and look for
available means.
Tx: A patient who endorses suicidality requires emergent inpatient hospitalization even against his/her will. Suicide risk may after antidepressant
therapy is initiated because a patients energy to act on suicidal thoughts
can return before the depressed mood lifts.