Tricyclic/Tetracyclic medications Antihistamine: Sedation Concerns/contraindications: Antiadrenergic: Orthostatic hypotension, - Risk of falling in elderly pts Anti-HAM: histamine, tachycardia,

arrhythmias - Risk w/ pre-existing conduction adrenergic, muscarinic Antimuscarinic/Anticholinergic: Dry mouth, abnormalities constipation, urinary retention, blurred vision, Block reuptake of NE and tachycardia 5-HT Weight gain Tx: melancholic depression Lethal in overdose Major complications: 3 Cs: Convulsions, coma, cardiotoxicity Name Class Side effect Comment Amitriptyline (Elavil) Tertiary amine See above Highly anticholinergic, very sedating Doxepin (Adapin, Sinequan) Tertiary amine Highly cholinergic, very sedating Imipramine Tertiary amine Highly anticholinergic - used for bedwetting Clomipramine (Anafranil) Tertiary amine Highly anticholinergic, very sedating - most serotonin - OCD (2nd line, 1st line = SSRI) specific - Depression w/ marked obsessive features Trimipramine (Surmontil) Tertiary amine Highly anticholinergic, very sedating Desipramine (Norpramin) Secondary amine Least anticholinergic, NOT sedating Nortriptyline (Pamelor) Secondary amine Least anticholinergic Protriptyline (Vivactil) Secondary amine Psychomotor Less anticholinergic, NOT sedating stimulation Amoxapine (Asendin Tetracyclic May cause Less anticholinergic Asendas) EPS and NMS All tetracyclics/tricyclics

SSRI Nearly all SSRI and SNRI Agitation, akathisia, anxiety, panic, headache, insomnia GI distress, diarrhea Sexual dysfunction: delayed ejaculation or impotence (male) anorgasmia (female) Longest half life Avoid Serotonin syndrome, should not be combined w/ MAOI Washout: SSRI 5 wks, MAOI: 2 wks SS Sx: diarrhea, restlessness, extreme agitation, hyperreflexia, autonomic instability, myoclonus, seizures, hyperthermia, rigidity, delirium, coma, death Beware of using in older pts (due to long life) GI symptoms (diarrhea) SSRI discontinuation syndrome (dizziness, N/V, lethargy, flu-like sx: chills and aches, irritability, anxiety, crying spells Mildly anticholinergic Nausea and vomiting more common Possibly fewer sexual side effects SNRI Tx: GAD and social anxiety SNRI: Tx: GAD and diabetic neuropathy

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

Shortest half life

Fluvoxamine (Luvox) Citalopram (Celexa) Escitalopram (Lexapro) Venlafaxine (Effexor)

Serotonin specific Anxiety, may increase BP at higher dosages, headache, insomnia, sweating

Duloxetine (Cymbalta)

MAOI MAOI Orthostatic hypotension Somnolence Weight gain Tx: atypical depression Washout: SSRI 5 wks, MAOI: 2 wks SS Sx: diarrhea, restlessness, extreme agitation, hyperreflexia, autonomic instability, myoclonus, seizures, hyperthermia, rigidity, delirium, coma, death Transdermal delivery available for depression, also used to tx parkinsonism All cheese, fermented or aged foods, wine and liver should be avoided (Hypertensive crisis end organ damage due to high BP) - Beware of pseudoephedrine (cough medicine)

Phenelzine (Nardil) Isocarboxazid (Marplan) Tranylcypromine (Parnate) Selegiline (Eldepryl)

Irritation at site of patch

Trazodone/Desyrel 5-HT

Mirtazapine/Remeron NE and 5-HT

Antidepressants 5-HT antagonist and SRI - Priapism: prolonged erection may lead to impotence - Orthostatic hypotension - Sedation 2 blocker, - Weight gain 5-HT2 & 5-HT3 blocker - Sedation

Lower doses sleep problems Avoid using w/ MAOI

Buproprion/Wellbutrin NE and DA

NE reuptake and DA reuptake inhibitor

GI: nausea, anorexia Risk of seizures at higher doses Less sexual dysfunction

Nefazodone/Serzone

5-HT2 antagonist and SRI

Sedation Hepatotoxicity Black box: liver failure (reg monitor LFTs)

No interference w/ sexual function No diarrhea or nausea Tx insomnia + depression Used for smoking cessation Contraindicated in pts w/ eating d/o or seizure d/o (concurrent alcohol or BZD use due to predisposition to seizures) Decreased sexual dysfunction

Lithium

Inhibits adenylate cyclase enzyme

Psoriasis flares Hair loss Edema

Labs: thyroid fxn, renal fxn, hCG

Valproic acid/ Depakote

Opens chloride channels, unknown

Carbamazepine /Tegretol

Inhibits kindling, inhibits repetitive firing of Aps by inactivating Na channels

Lamotrigine/ Lamictal

Stevens-Johnson prodrome of malaise + fever followed by rapid onset of erythematous/purpuric macules (oral, ocular, genital). Skin lesions progress to epidermal necrosis and sloughing

Mood stabilizers LMNOP: Lithium - Movement/tremors - Nephrogenic DI: thirst and urination - Hypothyroidism - Pregnancy problems (Ebsteins anomaly atrialized right ventricle) - Nausea - Cardiac dysrhythmias - Diarrhea - Weight gain - Acne Toxic levels: alterations in consciousness, seizures, coma and death Common: weight gain, GI distress - Thrombocytopenia - Hepatitis - Pancreatitis - Hair loss - Neural tube defects in pregnancy (spina bifida) - Nausea - Vomiting - Slurred speech - Dizziness - Drowsiness - Low WBC count (agranulocytosis) - High LFTs/Liver toxicity - Teratogenesis - Stevens-Johnson syndrome - SIADH - Leukopenia - Stevens-Johnson syndrome - Hepatic failure - N/V - Diarrhea - Somnolence - Dizziness

WBC, electrolytes, TSH, Renal function tests (specific gravity, BUN, Cr), fasting blood glucose, pregnancy test, EKG Lithium levels monitored at least 3 months once stabilized

Propranolol helps w/ tremor Contraind: psoriasis ** ACEI and diuretics increase levels of lithium **theophylline decreases lithium

CBC, LFT, pancreatic enzymes, hCG

Reconsider if alcoholic/has pancreatitis Contraind: pregnancy

CBC assess for agranulocytosis q2wks for first 2 mo, then q3mon Platelet, reticulocyte, iron levels yearly LFTs qmonth first 2 mon, then q3mon

Potent inducer of P450 system Erythromycin can Tegretol levels Contraind: pregnancy

CBC w/ plt count q6-12months

Dose increased slowly to avoid rash + StevensJohnson syndrome

Gabapentin/ Neurontin

Somnolence Ataxia Dizziness, fatigue, leukopenia, weight gain

Rash can be fatal

No drug interactions

Typical Antipsychotics MOA: D2 blockade, increases IC cAMP 4. Anti-HAM 1. Highly lipid soluble, stored in body fat, slow to be Histamine sedation removed Adrenergic/alpha hypotension 2. EPS side effects Muscarinic dry mouth, constipation, urinary retention, 3. Endocrine side effects (DA blocker blurry vision hyperprolactinemia galactorrhea) 5. NMS FALTER Tx: dantrolene, DA agonists (bromocriptine) 6. Tardive dyskinesia Chlorpromazine/Thorazine Low Sedation Orthostatic hypotension Corneal deposits Thioridazine/Mellaril Low Higher incidence of cardiac disturbances Retinitis pigmentosa Mesoridazine/Serentil Low Cardiac arrhythmias (torsades de pointes) Molindone/Lidone Medium Lozapine/Loxitane Medium Haloperidol/Haldol High Extrapyramidal syndrome 4 hours acute dystonia (muscle spasm, stiffness, oculogyric crisis) 4 days akinesia (parkinsonian sx) Tx: propranolol 4 weeks akathisia (restlessness) 4 months tardive dyskinesia Tardive dyskinesia stereotypic oral-face mvmt due to long term antipsychotic use (often irreversible) Fluphenazine/Prolixin High Trifluoperazine/Stelazine High

Buspirone/BuSpar

GAD

Zolpidem/Ambien

Insomnia

Zalepolon/Sonata

Insomnia

Ramelteon/Rozerem

Insomnia

Anxiiolytics/Sedative-Hypnotics - Headaches - GI distress - Dizziness - Headaches - Drowsiness - Dizziness - Nausea - Diarrhea - Headaches - Peripheral edema - Amnesia - Dizziness - Rash - Nausea - Tremor - Headache - Galactorrhea

Less efficacy after BZD use Contraindicated w/ MAOI Increased effect w/ EtOH or SSRI

Melatonin R agonist, no affinity for GABA R complex Contraindic: Severe hepatic impairment, severe sleep apnea, severe COPD

Clozapine/Clozaril

5-HT DA antagonist

Atypical Antipsychotics Agranulocytosis Anticholinergic side effects Weight gain Sedation NMS

CBC + diff weekly or first 6 mo and biweekly No hypotension PARKINSONs pts w/ psychotic sx b/c spares nigrostriatal DA systems + anticholinergic effects (Parkinsons ACh DA) risk for glucose abnormalities Present in breast milk

Risperidone/Risperdal

5-HT DA antagonist

Olanzapine/Zyprexa

5-HT DA antagonist

Quetiapine/Seroquel

5-HT DA antagonist

Extrapyramidal Postural hypotension Hyperprolactinemia Weight gain Sedation Decreased concentration Hyperprolactinemia Orthostatic hypotension Anticholinergic SE Weight gain Somnolence Orthostatic hypotension Somnolence Transient increase in weight QT prolongation Postural hypotension Sedation Headaches Nausea Anxiety Insomnia Somnolence

Alanine aminotransferase levels as drug affects the liver risk for glucose abnormalities

Slit lamp eye exam at risk for developing cataracts

Ziprasidone/Geodon

5-HT DA antagonist

Present in breast milk Baseline K and Mg measurements NOT associated w/ weight gain NONsedating No increased risk of weight gain or diabetes NOT associated w/ weight gain

Aripiprazole/Abilify

Partial DA, 5-HT1A agonist Antagonist at 5-HT2A

Chlordiazepoxide/Librium Diazepam/Valium Flurazepam/Dalmane Alprazolam/Xanax Clonazepam/Klonopin Lorazepam/Ativan Oxazepam/Serax Triazolam/Halcion

Long acting 1-3 days Long acting Long acting Intermed. 10-20 hrs Intermed. Intermed. Short acting 3-8 hrs Short

Benzodiazepines Alcohol detox Presurg anxiety Anxiety Seizure control Insomnia Panic attacks Panic attacks Anxiety Panic attacks Alcohol withdrawal Insomnia

Rapid onset Rapid onset

NOT renally cleared NOT renally cleared

Important questions to be able to answer: 1) Which atypical antipsychotic does NOT cause weight gain? A: Ziprasidone/Geodon and Aripiprazole/Abilify 2) Which Antidepressant has black box warning for hepatitis and liver failure? A: Nefazodone 3) What are the different Axis? Axis I: Major psych d/o (schizo, GAD, MDD, bipolar), drug-related illness/abuse, pervasive learning d/o Axis II: MR or PD Axis III: Medical conditions Axis IV: Psychosocial stressors Axis V: GAF 4) What medication would you prescribe in alcoholic who has insomnia? A: Trazadone b/c other drugs overlap w/ EtOH in binding GABA (BZD, Zolpidem) and Zaplelon contraindicated with severe liver dysfxn, which is potential issue in pt w/ h/o alcohol abuse 5) If a patient gets an adverse side effect (acute dystonic reactions), how do you treat it? A: Anti-cholinergics: Benztropine 1-2 mg IM or diphenhydramine 50 mg IM or IV 6) What is the most likely atypical antipsychotic to cause EPS symptoms (anti-DA drugs)? A: Risperidone/Risperdol (dystonia akinesia/Parkinsonism akathisia TD) 7) If a patient has Parkinsons dx and has psychotic sx, what medication is best to use? A: Clozapine/Clozaril 8) Patient is on risperidone and has accumulated EPS side effects, what should be done? A: replace with alternative, clozapine increased anti-cholinergic activity 9) How do you treat mania? Acutely and long term? A: Acutely: Haloperidol Long-term: 1st line: lithium, olazepine/zyprexa, lamotrigine/lamictal, quetiapine/Seroquel 2nd line: aripiprazole/Abilify, valproic acid/Depakote

Notes from USMLE World Step CK:

Anorexia nervosa: Pregnancy complications (assoc. chronic deprivation of essential nutrition) risk: o Premature, small for gestational age (2/2 intrauterine growth retardation) o Miscarriage o Hyperemesis gravidarum o Cesarian delivery o Postpartum depression o Poor growth and intellectual impairment Common findings in anorexic patients: Osteoporosis cholesterol and carotene levels Cardiac arrhythmias (prolonged QT) Euthyroid sick syndrome HPA axis dysfxn anovulation, amenorrhea, estrogen deficiency Hyponatremia 2/2 excess water drinking Alzheimers dementia Progressive cognitive decline characterized by one or more: Apraxia difficulty carrying out activities Aphasia language difficulty Agnosia recognizing objects Executive fxn planning, abstraction, organization Compared to: Multi-infarct - HTN and heart disease are risk factors BUT requires presence of focal neurological sx Compared to: Picks dx - Behavioral and personality changes more common becoming apathetic or disinhibitted Types of disordered thought & speech: Disorganized speech = common in schizophrenics (i.e. circumstantial thought process) Flight of ideas = loosely associated thoughts rapidly move from topic to topic Tangentiality = abrupt, permanent deviation from current subject. New thought process minimally relevant at best and never returns to original subject (more severe = loose associations) Loose associations = Lack of logical connection between

OCPD Preoccupation w/ orderliness and perfectionism, negatively impacting function Too devoted to work, stubborn, only one way to do things, over-attention to detail Diffiohncculty throwing out worn items Trouble w/ relationships need for perfectionism Need to strictly follow rules Ego-syntonic No obsessions or compulsions Compared to OCD: Obsessions + compulsions, not necessarily on perfectionism

Refractory mania despite mood stabilizer therapy: Management: 1) Urine toxicology screen 2) Mood stabilizer drug levels (especially Lithium)

Trichotillomania = impulse-control d/o DSM-IV criteria: 1. Repeated episodes of hair pulling noticeable 2. Anxiety right before or when trying to resist 3. Sense of relief after hair pulling act 4. Causes impairment or distress 5. Inconsistent w/ other medical or dermatological condition causing hair loss Affected areas: scalp, eyebrows, eyelashes, facial hair, armpits, pubic hair Compared to: alopecia areata

thoughts or ideas of individual (more severe form of tangentiality) Antisocial PD - Pattern of disregard for & violation of rights of others - Onset: middle adolescence and continues to adulthood - Routinely engage in illegal activities (drug use, assault, theft), endanger well-being of others and freq. lie - Superficial charm allows for manipulation of others - Aggressive, impulsive, difficulty maintaining employment - Conduct d/o (<18) Antisocial PD

Would have patches devoid of hair compared to trichotillomania: broken hair of varying lengths w/ alopecic patches Extrapyramidal sx: Acute dystonia = due to typical antipsychotics 4 hr = acute dystonia: muscle spasms/stiffness, tongue protrusions, twistin, opisthotonus, oculogyric crisis (sustained elevation of eyes in upward position) Tx: Anticholinergics (benztropine or trihexyphenidyl) or antihistamines (diphenhydramine) Compared to other tx: Akathisia (restlessness) propranolol or beta blockers NMS dantrolene Parkinsons dx Levodopa Neurotransmitters involved: OCD Serotonin

Hypochondriasis - Occur during periods of stress - Misinterpretation of bodily sx and persistent fear of fatal illness despite negative medical workups Tx: Initiate discussion about current emotional stressors Brief psychotherapy Bipolar d/o genetics: - Strongest genetic components of all psychiatric d/o - 1st degree relative affected 5-10% risk of developing in lifetime - Both parents affected 60% risk - Monozygotic twin 70% risk - General population 1% Neuroleptic Malignant Syndrome: Fever Autonomic instability Leukocytosis Tremor Elevated enzymes CPK (rhabdomyolysis myoglobinuria ARF) Tx: alkaline diuresis Rigidity Tx: Dantrolene (muscle relaxant) or bromocriptine (DA agonist) - Supportive care: Aggressive cooling, antipyretics, fluid and electrolyte repletion

Defense mechanisms: - Reaction formation transformation of unwanted thought or feeling into opposite - Suppression intentionally postponing exploration of anxiety-provoking thoughts by substituting other thoughts - Sublimination unacceptable impulses channeled into more acceptable activities Treatment for schizophrenia: 1) Positive or negative sx? o Positive = hallucinations, delusions, disorganized speech/behavior o Tx: Typical antipsychotics o Negative = flattened affect, poverty of speech, apathy (impaired grooming& hygiene, unwillingness to perform activities), asociality (few interests, impaired relationships) and inattentiveness/concentration Tx: Atypical antipsychotics (risperidone = less EPS SE) Neg sx = MORE serious Disorganized schizophrenia: o Disorganized behavior/speech, flat or inappropriate affect, rambling speech, inapprop behavior (masturbation in public, laughing at strange times)

Depot antipsychotics for noncompliant pts: Haloperidol deconoate once every 2 weeks to once a month Fluphenazine decanoate twice a month Risperidone depot twice a month Paliperidone depot once a month Bereavement vs. MDD Bereavement/complicated grief < 2 months Symptoms > 2months antidepressants + psychotherapy

Dysthymic d/o: (can also have double depression) Rule of 2s: > 2 years, with no relief in sx > 2 months 2 of the following CHASES Concentration, Hopelessness, Appetite Self esteem, Energy, Sleep disturbances MDD + psychosis vs. Schizoaffective d/o MDD + psychosis = psychosis only occurs WITH depressed mood multiple episodes > 2 wks 5+ SIGECAPS Clozapine least likely to cause EPS (parkinsonism TRAP) - Agranulocytosis - Lowers seizure threshold Risperidone most likely atypical to cause EPS - Switch to clozapine if EPS SE occur Mania DSM-IV: > 1 wks abnormally and persistently elevated or expansive mood at least 3 of the following o Distractability o Irritable o Grandiosity o Flight of ideas o Activity/agitation o Sleep disturbances o Thoughtlessness ECT indications: - Severe depression - Depression in pregnancy - Refractory mania - NMS - Catatonic schizophrenia Side effects: amnesia (anterograde or retrograde), prolonged seizures, delirium, headache, nausea, skin burns Schizo spectrum Brief psychotic d/o (< 1 months) Schizophreniform (<6 months) Schizophrenia (> 6 months) Schizoaffective = depressive mood + psychosis (seen even w/o mood sx) Schizoid PD = prefers to be distant, does not obtain primary gain w/ relationships w/ others, do not have bizarre cognition Schizotypal PD = magical thinking, odd thoughts/beliefs

Schizophrenia - Family therapy = most important psychosocial intervention - likelihood relapse by conflicts/stressors in home environment Increased ventricular size on CT scan Panic d/o - 20-40 y/o - Sudden onset of impeding doom - Somatic complaints: CP, palpitations, nausea, SOB, numbness, diaphoresis - Labs: drug screen + ECG Tx: Acute BZD (alprazolam/Xanax) rapid relief Long term SSRI, but effect takes weeks, CBT 2nd line: TCA Diagnostic Associations Kleptomania associa. w/ bulimia nervosa Tourette syndrome assoc w/ ADHD or OCD Panic d/o assoc w/ depression, agoraphobia, GAD, substance abuse

Pyromania Intentional firesetting on more than 1 occasion w/ no obvious motive: - Deliberate firesetting on > 1 occasion - Feeling of tension or emotional arousal before setting - Fascination w/ fire or curiosity about situations concerning fire - Feeling of relief or pleasure from setting fires & witnessing aftermath - No motive - Not part of conduct d/o, antisocial PD, or manic epis.

Child abuse signs: PE: multiple fx or injuries in different healing stages, likely inflicted injuries (cigarette burn), poorly kept child, bruises on neck, abdomen or unusual sites, injury to genitalia, hands, back or buttocks Hx: vague w/ no detail, or none given, inconsistent w/ injury, changing versions given by caregiver, sibling commits the injury, inconsistent w/ childs developmental stage, implausible Caregiver behavior: argumentative or rough, lack of emotional interaction w/ child, inapprop response to child injury, inapprop delay in seeking care, partial confession in causing injury, violent w/ staff Meningococcal meningitis/contagious diseases - Admit and isolate against wishes, and start tx - Due to complications & potential community outbreak isolation, IV ABx and supportive care in ICU - Allowed to refust tx unless it would pose threat to health and welfare of others Note: Depressive sx & dx: Patient must experience IMPAIRMENT in FUNCTION in order to classify as any DSM-IV d/o - If feel down, but functional normal human experience Tx: Single episode of major depression 6 months following patients response (maintenance therapy if multiple episodes)

Steps for handing child abuse: 1) Complete PE 2) Radiographic skeletal survey (if necessary) 3) Coagulation profile (if multiple bruises) 4) Report to CPS 5) Admittance to hospital 6) Consultation w/ psych and evaluation of family dynamics

Somatization d/o (compare to below) - Multiple recurrent somatic complaints persisting for years - < 30, female, functional impairment - Presents w/ at least 4 pain, 2 GI, 2 sexual or reproductive, 1 pseudoneurological sx (blindness, deafness, weakness, seizures, LOC, impaired balance) Conversion d/o (compare to above) - One or more neurologic or general systemic sign - PPt by psychologic stressor - Not intentionally produced or feigned (vs. factitious and malingering) - Impair social, occupational or daily fxn - Not explained by another mental d/o, limited to pain or sexual dysfxn and do not exist w/ somatization d/o Sx: la belle indifference (strangely indifferent) or hysterical, trigger = conflicts or stressor w/ emotional component Tx: hypnosis, relaxation, psychotherapy Opioid withdrawal (ex. Heroin) - Rhinorrhea - Abdominal cramps, sweating - Lacrimation - Diarrhea - N/V - Muscle spasms - Joint pain Can present w/in 24 hours Withdrawal: Cocaine suppression of stimulant effect irritable, drowsy, fatigued, hungry, psychomotor agitation or retardation EtOH seizures, sweating, hyperreflexia, tremors, hallucinations, DT Amphetamine suppression of stimulant effects irritability, fatigue, increased appetite, psychomotor disturbance Nicotine irritability, anxiety, depression, insomnia,

SSRI side effects: Sexual side effects = impotence, delayed ejaculation, decreased libido Circadian rhythm sleep d/o: - Traveling between time zones

Anorexia nervosa: DSM-IV: 1) Body weight > 15% below normal weight accompanied by refusal to maintain body weight at normal levels 2) Amenorrhea for 3 months 3) Distortion of body image 4) Fear of gaining weight Look for: 1) Fast and/or exercising excessively (restricting

subtype) 2) Bing eat followed by laxative use and purging (binge and purge subtype) Hospitalization when evidence of dehydration, starvation, electrolyte disturbances, cardiac arrhythmias, physiologic instability or severe malnutrition (<75%) Bulimia nervosa: DSM-IV: 1) Recurrent episodes of uncontrollable binge + disgust or guilt 2) Repeated compensatory behavior to prevent weight gain after binge 3) Binging episodes > 2x/wk over 3 month period 4) Normal or slightly above normal BMI 5) Dissatisfaction w/ weight and shape ** Compare to anorexia (NL BMI and not amoenorrheic Intoxication: PCP aggression, agitation, impulsivity, impaired judgment, psychosis, paranoia, hallucinations - Nystagmus, HTN, tachycardia, ataxia, dysarthria, muscle rigidity, seizures, come Alcohol ataxia, nystagmus, aggression, impaired judgment Heroin pinpoint pupils, drowsiness, CNS depression, constipation LSD hallucinogen, mood impairment, hallucinations, perceptual intesifications, depersonalization, illusions Cocaine anxiety, aggression, agitation, psychosis, delirium - High or low BP, tachy or bradycardia, sweating, pupillary dilatation, N/V, insomnia - Cardiac arrhythmias, MI, seizures or stroke, cocaine bugs Cannabis conjunctival injection, dry mouth, tachycardia, increased appetite LSD vs. PCP - LSD = visual hallucinations, intensified perceptions - PCP = agitation, aggression (belligerence) Consent/respecting patients wishes: Unless patient is putting themselves or others in harm or danger (i.e. contagious disease like HIV or meningococcus meningitidis) Physician must respect parent wishes (i.e. to not have children vaccinated) Refusal of life-saving tx: - Discuss fully specific reasons for decision before honoring it Child consent for tx: - Only need consent of one parent to proceed with tx of minor - If parents refuse consent to tx for potentially fatal

restlessness, poor concentration, increased appetite, weight gain, bradycardia

Dependent PD: - Clingy, submissive, crave protection and care of others - Avoid taking initiative b/c feelings of inadequacy - Fear of being left alone, inability to disagree w/ others, willingness to stay in abusive relationships for fear of being left alone Avoidant PD: - Hypersensitivity to criticism, social inhibition, feelings of inadequacy, lacks self esteem - Want friendships, but avoid due to fear of ridicule Treatments: o Depression + insomnia Mirtazapine/Remeron o Anti-Psychotic (no weight gain) ziprasadone/Geodon & aripiprazole/abilify o Panic d/o acute (BZD), long term (SSRI) o Bipolar mood stabilizer Lithium o Psychosis & agitiation haloperidol o OCD 1st line: SSRI, 2nd line: clomipramine o GAD 1st line: Buspirone, 2nd line: SSRI o Performance anxiety Propranolol o Social phobia assertiveness training (CBT) and paroxetine (SSRI) o Tourettes Pimozide or haloperidol o Enuresis 1st line: Behav modif, desmopressin, 2nd line: TCA (imipramine) o Specific or simple phobias BZD o NMS dantrolene and D2 agonists (bromocriptine) o EPS side effect benztropine o Alzheimers dementia reversible AChE inhibitors: donepezil, rivastigmine, glantamine, tacrine o Mania acute sx: Haloperidol, LT maintenance: 1st line: olanzapine, lithium, lamotrigine, quetiapine + psychotherapy, 2nd line: Depakote, Abilify o Schizo atypical antipsych (risperidone clozapine) Defense mechanisms Immature Neurotic Mature Idealization Displacement Altruism Projection Dissociation Sublimation Somatization Rationalization Suppression Denial Reaction Introjection Acting out formation Humor Repression Reaction formation does complete opposite of what he/she feels or desires Sublimation unacceptable or negative impulses to be channeled into more acceptable or positive activities Altruism minimizing internal fears by serving others in

medical condition pt seek court order mandating tx Living will: - If family disagrees w/ living will, discuss matters, then hospital ethics committee should be consulted Pregnant women: Have the right to refuse tx (baby is part of their body) even if harmful to fetus Adjustment d/o - Development of emotional or behavioral sx in response to identifiable stressor that occurs w/in 3 months of stressor, causes significant impairment and disruption of daily activities - Ex: Pt moves into 1st apartment by herself and is paranoid

positive manner - Ex: pt dx w/ cirrhosis & stop drinking due to complic., helps others/protect them from dangers of alcoholism Passive aggression expresses aggression w/ repeated, passive failures to meet other persons needs Dissociative d/o: Dissociative identity d/o: multiple personality d/o. Two or more distinct identities, amnesia regarding important personal infor about some of identities Dissociative amnesia: inability to recall important personal information Depersonalization d/o: persistent or recurrent feelings of detachment from physical or mental process (intact sense of reality) Dissoc. Fugue: forgetfulness and dissociation, only one assoc w/ travel Lithium therapy guidelines: 1) Single manic episode require LT maintenance at least 1 yr 2) 3 or more relapses require tx w/ lifelong maintenance therapy

Lithium side effects: Pregancy - Ebsteins anomaly: malformed and inferiorly attached tricuspid valve atrialization of RV and decrease size of functional RV - Due to lithium exposure in first trimester of pregnancy Later trimesters = goiter, transient neonatal neuromuscular dysfunction Side effects of medications: Olazepine = weight gain o Check: fasting plasma glucose, weight BP and fasting lipid profile before beginning Clozapine = agranulocytosis Ziprasadone/Geodone = QT prolongation, no weight gain Bereavement vs. MDD Bereavement < 2 months MDD > 2 months Adjustment d/o - Psych sx response to stressor occurring previous 3 months, rarely last more than 6 mon after end of stressor. Tx: psychodynamic therapy Antipsychotics SE: - DA blocker (normally DA inhibits prolactin and ACh) - Blockade hyperprolactinemia gynecomastia, galactorrhea, menstrual dysfunction, decreased libido Excess DA blockade bradykinesia, masked facies, micropgraphia TX: Benztropine -

Strongest indicator future suicide attempt: Hx of previous suicide attempt

Cyclothymia vs. dysthymia: Cyclothymia: hypomania + chronic mood disturbance lasting > 2 years Dysthymia: chronic depressed mood > 2 years

Sleep patterns/changes: Elderly sleep less at night and nap during day Deep sleep (Stage 4) becomes shorter and eventually disappears

Amphetamine vs. cocaine intoxication

Side effects: BZD withdrawal

Amphetamine=psychosis more prominent psych Alprazolam/Xanax = short acting, used to tx: panic d/o features (anxiety, aggression, agitation, psychosis) - Abrupt cessation can cause severe withdrawal Hypo or hypertension, brady or tachycardia, cardiac (generalized tonic-clonic seizures and confusion) arrhythmias, CP, respiratory depression, sweating, pupillary dilation, N/V, insomnia, weight loss, psychomotor agitation/retardation, muscular weakness, seizures, stroke, coma Childhood d/o: Childhood disintegrative d/o = nl development until 2 years of age loss of prev acquired skills in at least 2 of the following areas: expressive or receptive language, social skills, bowel or bladder control, play and motor skills, poor prognosis Autism = males > females, onset before age three, impairments in communication and social interaction, repetitive, stereotyped behavior w/ strange preoccupations. Rett syndrome nl development until around 5 months, loss of hand coordination, sterotyped hand mvmts, deceleration of head growth, poor coordination, seizures, ataxia, MR and diminished social interactions Asperger syndrome qualitative impairment in social interaction + restricted, repetitive, stereotyped patterns of behavior, nl cognitive and language development DA: Mesolimbic pathway therapeutic effects of antipsychotics Nigrostriatal pathway EPS Se assoc w/ antipsychotic use, signs and sx of Parkinsons dx Tuberoinfundibular pathway hyperprolactinemia Time lines: PTSD > 1 month vs. Acute stress d/o < 1 month Postpartum blues < 10 days vs. postpartum depression 2 wks to 2 months

Types of Dyskinesia Oral and facial Tongue protrusion and twisting Lip smacking, pouting, puckering Retraction of the corners of the mouth Chewing mvmts Limb twisting and spreading piano-playing finger mvmts Foot tapping Dystonic extension of the toes Torticollis Shoulder shrugging Rocking or swaying Rotary hip mvmts Grunting noises

Limb

Neck and trunk

Respiratory

Clusters: Cluster A odd and eccentric Cluster B dramatic and emotional Cluster C anxious and fearful