Psychiatry Rotation

2.
1.
1. Psychotic
Disorders

Normal development

:
:

:
:
:

AntiPsychotics

4.

3.

3. Anxiety and Adjustment Disorders

2. Mood Disorders

Anxiolytics

Treatment:

Antidepressants

Mood Stabilizers

Treatment:

5.

6.

9. Dissociative Disorders
Dissociative Disorders in general involve memory loss, loss of identity or sense of self.

Ab-reaction = the strong reaction patients often

get when retrieving traumatic memories

Etiology: usually stress, trauma, abuse

De-realization = detachement from

ones self, environment or social situation

DDx: forget name, remember specifics (Jason Borne)

(Multiple Personality Disorder)

Amnesia is the only dissociative symptom present.

Patients are aware but not concerned
Epi: MC dissociative D/O, W > M, Young > Old

Definition: Have 2+ more distinct personalities that alternately control their behaviors and thoughts

ECCENTRIC
PECULIAR
WITHDRAWN

Associated: MDD, Anxiety d/o, Borderline, SA

Prognosis: Worst of all Dissociative D/Os
Chronic, 33% attempt to commit suicide
Tx:
Hypnosis, drug-assisted interviewing,
Insight-oriented psychotherapy
Pharmacotherapy for comorbid D/Os

2. DISSOCIATIVE FUGUE:

4. DEPERSONALIZATION DISORDER:

Truth Serums

DDx: unaware they forgot (vs dissociative amnesia)

DDx: only DD w/o amnesia

Ethanol
Scopolamine
3-Quinuclidinyl Benzilate,
Benzos:
Midazolam (Versed)
Flunitrazepam (Rohypnol)
Temazepam (Restoril)
Barbs:
Sodium Thiopental (Na-Pentothal)
Sodium Amobarbital (Na-Amytal)

Associated with: EtOH abuse, MDD, TBI, Epilepsy

Prognosis: usually lasts a few hours to several days but may last longer.
**Ptns are unaware of amnesia and new identity
they never recall the period of the fugue
Criteria

Associated with MDD, depression, and severe stress

DDx Dementia:
AEIOU TIPS

6. Cognitive
Disorders

Alcohol
Electrolytes
Iatrogenic

Anticholinergics
Benzodiazepines
Antiepileptics
Blood Pressure Medicines
Insulin
Hypoglycemics
Narcotics
Steroids
H2 Receptor Blockers
Nsaids
Antibiotics
Antiparkinsonians

DDx: Dementia

Most common causes of dementia are:

1. Psychiatric

Depression (pseudodementia)
Delirium
Schizophrenia
Malingering

Cortical dementias

2. Structural:
Normal aging,
PD
HNT
Downs
TBI
CNS Tumor
NPH
MS
SDH

3. Metabolic

Hypothyroidism
Hypoxia
Malnutrition (B12, Folate, Thiamine Df)
Wilsons
Lead Tox

4. Infectious:
Lyme Disease
HIV Dementia,
CJD
Neurosyphilis
Meningitis
Encephalitis

5. Drugs

Alcohol (chronic and acute)

Phenothiazines
Anticholinergics
Sedatives

Oxygen = Hypoxia
Bleeding
Central Venous
Pulmonary)

Subcortical dementias
(#1 affective and movement symptoms)

Uremia/Hepatic Encephalopathy

(#1 decline in intellectual functioning)

h. Normal Pressure Hydrocephalus (NPH)

NPH
Vascular Dementia

CJD

LC Brainstem

AD (Alzheimers Dz)

Picks / FTD

Vascular Dementia

PD
Prognosis: 30% develop dementia, 50% suffer from MDD
Etiology: Idiopathic (MC), Traumatic (Ali), Drug-induced, Encephalitic, Familial (rare)
PD S/s:

CJD, BSE,

DDx vs AD
stepwise
focal neurological dfs (hyperreflexia or paresthesias)
onset = more abrupt
personality changes more pronounced

S/s: Aphasia, apraxia, agnosia

Path: Diffuse atrophy + enlarged ventricles + flattened sulci

of Meynert @ Midbrain

ACh

NE
of Meynert @ Midbrain

Dx: Autopsy is only confirmatory

Prognosis: average live 8 years after Dx
Tx:
1. NMDA Glu antagonists (Memantidine / Amantidine)
2. AChEi's: Tacrine (Cognex), Donepezil (Aricept), Rivastigmine (Exelon)
improve S/s in 25% of patients
+: Xanax / Ativan for Anxiety
+: Seroquell for agitation / psychosis
+: SSRI if the patient meets criteria for MDD

Trauma
Infection
Poisons
Seizures (Post Ictal)

S/s: progressive dementia 6 to 12 months, 90% myoclonus, EPS, Ataxia, LMN signs
Path: spongiform cerebral cortex, neuronal loss, and hypertrophy of glial cells
Prognosis: death within 1yr
Dx Definitive: Pathological @ autopsy
Dx Probably: rapidly progressive dementia + sharp waves on (EEG) + 2/6 of

1. Bradykinesia
2. Cogwheel rigidity
4. Masklike facial expression
5. Shuffling gait
6. Dysarthria (abnormal speech)

Dx: MRI

PD Drugs

HNT Dz

Onset @ 35-50, death in 15 years,

Dx: MRI shows atrophy of caudate atrophy, Genetic test

S/s: dementia, chorea, hypertonicity, depression, psychosis

AD DSM Criteria:
AAA + personality, cognitive functioning
Aphasia: scanning, word finding)
A. -Amyloid plaques in AD

DfDx: do not have any fixed delusions, are not frankly psychotic
Tx: Therapy > Anxiolytics or Antipsychotics (briefely)

B. NFT (tau) in AD

Tx: none really very effective

Tetrabenazine
Neuroleptics
Benzodiazepines
Amantadine
Remacemide
Antiparkinsonian Drugs
Valproic Acid
SSRIs

NPH

Path: reversible, enlarged ventricles, increased CSF pressure

S/s: Triad: Wacky, Wobbly, Wet
Tx: Shunt, dementia is last to improve

Multi-infarct Dementia Dementia + Stepwise increase in severity + focal neuro dfs

Dx: CT-MRI
Lewy body Dementia Dementia + Cogwheel rigidity + Resting tremor
Dx: Clinical
Parkinsons Disease Dementia + Cogwheel rigidity + Resting tremor
Dx: Clinical
NPH Dementia + ataxia + urinary incontinence, dialated ventricles
Dx: CT-MRI
Hypothyroidism Dementia + obesity + coarse hair + constipation + cold intol
Dx: TSH + T4
Vit-B12 df Dementia + decreased vibratory & proprioception + Megaloblastic anemia
Dx: Serum B12
Wilsons Disease Dementia + tremor, increase LFTs, Kayser Fleischer rings
Dx: serum Seruloplasmin
Neurosyphillis Dementia + decreased proprioception and vibration, Argyl-Robertson
Dx: CSF-FTA-ABS or CSF-VDRL

Etiologies of Delerium
CNS injury or disease
Systemic illness
Drug abuse/withdrawal
Hypoxia
Fever
Sensory deprivation
Medications (anticholinergics, steroids, antipsychotics, antihypertensives, insulin)
Postop anesthesia
Electrolyte imbalances

DDx Delerium
CVA Delerium + hemiparesis / FND
Dx: CT/MRI
Hypertensive Encephalopathy Delerium + elevated BP + papilledema
Dx: CT/MRI
Drug Intoxication Delerium + dialated pupils + tachycardia
Dx: UDS
Meningitis Delerium + fever + nucal rigidity + photophobia
Dx: Lumbar puncture
Thyrotoxicosis Delerium + tachycardia + tremor + thyromegaly
Dx: T4 + TSH

DDx delirium:
IM DELIRIOUS

Impaired delivery (stroke)

Metabolic
Drugs
Endocrinopathy
Liver disease
Infrastructure (structural disease of cortical neurons)
Renal failure
Infection
Oxygen
UTI
Sensory deprivation

Preoccupation with details, rules, lists

Detrimental Perfectionism that misses the point
XS devotion to work
XS conscientiousness
Scrupulousness about morals and ethics
Will not delegate tasks

Regression defense mechanism: revert to childlike behaviors

4. NARCISSISTIC ( < 1%)

Feeling of superiority, grandiosity, special
DDx: Antisocial-PD exploits for direct gain
DDx: N-PD exploits so they look good

XS sense of self-importance & entitlement

Fantasies of unlimited $$$, success, brilliance
Are special or unique and can only associate with the best
Needs XS admiration
Takes advantage of others for self-gain
Lacks empathy, Arrogant, haughty
Envious of others
believes others are envious of them

-DDx: NPD patients are motivated by status

-DDx: OCPD patients are motivated by the work itself
-Prognosis: some develop OCD, Schizophrenia, MDD, others improve
-Tx: psychotherapy, group therapy, pharmaco (anxiety)

D) Personality disorder not otherwise specified (NOS)

stubborn, inefficient procrastinators. Alternate between compliance
and defiance and passively resist fulfillment of tasks.
make excuses for themselves and lack assertiveness

Tx: Psychotherapy > Antidepressants or lithium

2. Depressive Personality Disorder

3. Sadomasochistic Personality Disorder
4. Sadistic Personality Disorder

SOURCES OF INFO

Child is the source for EMOTIONAL STATES

Parent is the source for CONDUCT, DEVELOPMENTAL Hx
Teachers: collateral

a. MENTAL RETARDATION (MR)

K-ABC: IQ 2.5-12yo

68-95-99.7 Rule:
Etiology

PIAT = peabody acedemic achievement test

36% Chromosomal:
Downs (1/700) > FXS (1/4000)
Kleinfelters (1:700) not always have MR

20% Congenital MFU

8% Intrapartum Asphyxia
8% Prenatal/Intrapatum
7% Metabolic/Postnatal
6% TORCHES
15% Other

18yo

WISC-R: IQ 6-16

2DSs = 95% of the population, -2.5% thats gifted

b. LEARNING DISORDERS
2. Math
3. Writing
4. NOS

5%
5%

Epi: 4% of school aged children, 4:1 male

DDx: hearing or visual df
Often due to deficits in cognitive processing
Ex: abnormal attention, memory, visual perception...etc
Ex: Genetic, Development, Trauma, Neurological, GMC
Tx: Remedial education

d. ADHD
c. DISRUPTIVE BEHAVIORAL DISORDERS
1. Conduct Disorder

2. Oppositional Defiant Disorder (ODD)

= violation of the basic rights of others or of social norms and rules

Etiology: bio-psycho-social
Prognosis: 30-40% risk of developing antisocial personality D/O

3 out of 4 within the year

1. Aggression toward ppl or animals
2. Destruction of property
3. Deceitfulness
4. Serious violation of rules

Epi: 18% > 6yo, before puberty in boys

PrognosisAssociated with: SA, Affective d/o, ADHD
Can remit in 25%, can progress to Conduct d/o
Tx: psychotherapy, behavior modification, parenting
4 out of 8 for 6 months
1. Frequent loss of temper
2. Arguments w/ Adults
3. Defying adults rules
4. Deliberatly annoying ppl
5. Easily annoyed
6. Anger & Resentment
7. Spitefulness
8. Blaming other

Tx for Conduct D/O

-Structured environment
-Firm rules that are consistently enforced
-Individual dynamic psychotherapy
+behavior modification
-Rx: ANTIPSYCHOTICS, LITHIUM, SSRI

Epi: 4% of school aged kids, onset of S/s before 7, 3x Male

Prognosis: 66% have ODD

3. AMNESTIC DISORDERS
CAUSES
Hypoglycemia
Systemic illness (such as thiamine deficiency)
Hypoxia
Head trauma
Brain tumor
CVA
Seizures
Multiple sclerosis
Herpes simplex encephalitis
Substance use (alcohol, benzodiazepines, medications)

PROGNOSIS:
a. Full recovery: seizures, drug induced, metabolic, nutritional
b. Permanent: hypoxia, trauma, HSV, CVA

Types of ADHD:

Dx ADHD

-Inattentive ADHD
-Hyperactive impulsive ADHD
-Combined ADHD

1. Onset before age 7

2. Behavior inconsistent with age and development
3. Six S/s of the following for 6 months:
A. Inattention:

Problems Listening
Concentrating
Paying Attention To Details
Organizing Tasks
Easily Distracted
Often Forgetful

Etiology of ADHD is multifactorial

B. Hyperactivity / Impulsivity
Blurting Out
Interrupting
Fidgeting,
Leaving Seat
Talking Excessively

Genetic factors: Mz > Dz

Prenatal trauma/toxin (FAS, Lead)
Neurochemical factors (df @ NE)
Neurophysiological
EEG signature
PET signature

Psychosocial factors (neglect)

PERVASIVE DEVELOPMENTAL DISORDERS

Epi: Girls >> Boys (dealth in utero)
Etiology: MECP2 gene mutation on X chromosome
Tx: supportive
Course:

Incidence = 1/100
Etiology: Genetic, Familial, Prenatal insults, Immuno
Associate with: FXS, TS, MR, Seizure d/o

2. DELERIUM

Rapid Onset
Periods of Altered Levels of Consciousness
Perceptual Disturbances (Hallucinations / Illusions)
Fluctuating Course w/ Lucid Intervals
Potential Reversal
Stuporous or Agitated
Anxious, Incoherent
Disrupted Sleep

-Detrimental trivial perfectionism, ego-syntonic

-Successful professionally, poor interpersonal skills

OC-PD

Narcissistic PD

1. Autistic Disorder: 0.03% of children under 12

Hallmarks:

3. OBSESSIVE COMPULSIVE-PD (?) M > F

Tx: improves with age, therapy, symptomatic relief with drugs

8. Psychiatric
Disorders
in Children

e. PDD =

Tx: underlying cause, cut polypharmacy, low dose antipsychotics, sedative hypnotic to correct sleep
Avoid using BENZOS in delirious patients, as they will often exacerbate the delirium.
FEUD: Fluids/Nutrition + Environment + Underlying cause + Drug withdrawal

= poor self-confidence, fear of separation, submissive

feel helpless when left alone, need to be taken care of
DDx: BorPD/HPD: dependents have long lasting dependent relationships
Patients are prone to depression
Tx: S/s decrease with Age and Therapy
+ symptomatic Rx of MDD or Anxiety

Tx: Ritalin, Dexedrine, Pemoline (Cylert), SSRI, TCA, Therapy

DDx Dementia
C. Lewy bodies (-synuclein) in PD D. TDP-43 inclusions in MNs in ALS

= intense fear of social rejection, hypersensitivity, inadequacy

desire companionship, extremely shy and easily injured,
difficult during adolescence, when attractiveness and socialization are important
DDx: Schizoids are content
DDx: Social Phobia: fear of embarrassment + later onset
DDx: Avoidant PD have fear of rejection
DDx: Dependent PD are quick to get into a relationship
Associated: with anxiety and depressive disorders
Tx: #1 = Psychotherapy (asertivness training) + BBs, SSRIs

2. DEPENDENT: (1%) F > M

Difficulty making everyday decisions

Needs reassurance from others
Needs others to assume their responsibilities
Always agrees
Lacks confidence, won't initiate projects
Must obtain support from others
Feels helpless when alone
Seeks another relationship when one ends
Preoccupied with fears not being taken care of

3. HISTRIONIC-PD

Needs to be the center of attention

Seductive or provocative behavior
Sexually suggestive
Melodramatic
Caves with Peer Pressure
Misreads intamacy

8.

Dependent PD

*Drugs more useful in Borderline-PD

than in any other personality disorder

Thalamotomy or Pallidotomy may be performed if no longer responsive to pharmacotherapy

Depression, anxiety, anger, suspiciousness

MMSE scoring:
Perfect score: 30
Passing = 25
Dysfunction: < 25

3. PARANOID = PPD (2%) M > W

(of neuroticism (stress) and psychosis)

Anticholinergics (Benztropine = Cogentin): help relieve tremor

Dopamine agonists (bromocriptine, etc.)

PD Sx:

Avoids social occupation

Preoccupied / Fear of criticism and rejection
Interact only if certain of being liked
Cautious of intrapersonal relationships
Feels socially inadequate, inept and inferior
Fear of embarrassment

SPLITTING
Instability @ relationships, affect,
behavior, self image, Impulsivity
10% suicide rate (often a gesture that goes wrong)
Associated: MDD, Drugs, Suicide
Tx: Therapy > Pharmacotherapy

Avoid real or imagined abandonment

Unstable, intense interpersonal relationships
Unstable self-image
Impulsivity x2 (spending, sexual activity, drugs)
Recurrent suicidal threats or attempts or self-mutilation
Unstable mood/affect
General feeling of emptiness
Difficulty controlling anger
Transient, stress-related paranoid ideation
or dissociative symptoms

Histronic PD

Tx: Chronic with intermittent course, may remit without treatment

Pharmacological: SSRIs for comorbid GAD and MDD

Personality changes

Nuc of Meynert @ Midbrain

2. BORDERLINE
Borderline PD

Etiology: Precipitated by stress

3. Causes social/occupational impairment

R/O other mental or physical disorder

Hx of abuse (physically or sexually),

Hx of hurting animals, starting fires
Hx of violations of the law

Tx: Psychotherapy > Drugs (addictive personality)

Patient remains consciousness, just out of body

3. Confusion about personal identity or assumption of new identity

R/O dissociative identity disorder, SA, GMC

Epi: 20% > 80

S/s

peculiar thought patterns

MZ > DZ concordance = some heritability
Chronic, can progress to schizophrenia
Tx: Psychotheraly > Antipsychotics

Suspicion (without evidence)

Preocupation with trustworthiness of aquaintances
Reluctance to work with others
Interpret benign remarks as threatening
Hold persistent grudges

Avoidand PD

Associated with poor urban areas and in prisoner

2. SCHIZOTYPAL PD (3%), MAGICAL

1. must be recurrent
2. patient can always recall details about event

1. Sudden, unexpected travel away from home or work

1. DEMENTIA

Abnormal violation of the law

Deceitfulness, lying, manipulating others for personal gain
Impulsivity + failure to plan ahead
Irritability and aggressiveness (repeated fights or assaults)
Recklessness and disregard for safety of self or others
Irresponsibility + failure to sustain work
Failure to honor financial obligations
Lack of remorse for actions

PPD Criteria

Patients feel separated from their bodies and mental process

Aware of S/s, feel like going crazy
Criteria:

Etiology: APD begins in childhood as Conduct Disorder

Antisocial PD

Tx: Therapy (group)

transient low dose antipsychotics, antidepressants

Ideas of reference ( delusions of reference)

Odd beliefs or magical thinking
Clairvoyance, Telepathy, Superstitions
Cults or Strange religious practices
Suspiciousness
Inappropriate or restricted affect
Odd or eccentric appearance or behavior
Few close friends or confidants
Odd thinking or speech
XS social anxiety

Genetic association with ANXIETY disorders

1. AVOIDANT (1-10%?)

weird, prefer to be alone DfDx Avoidant PD

No close relationships, (totally OK with that)

No sex
Indifference to Praise or Criticism
Emotional coldness & Detachment
Flattened affect

C) CLUSTER C = Weak, anxious and fearful

Genetic association with MOOD disorders

1. SCHIZOID PD (7%) eccentric, reclusive,

Schizoid PD

C:

AVOIDANT
DEPENDENT
OBSESSIVECOMPULSIVE

B) CLUSTER B = Wicked

A) CLUSTER A = Wacky

Schizotypal PD

b. Vascular dementia (10 to 20%)

B:

EMOTIONAL
DRAMATIC
INCONSISTENT

Genetic association with PSYCHOTIC disorders

Criteria: at least one episode of forgetting important personal info

usually associated with trauma, R/O forgetfulness
S/s cause stress, impair ADLs, R/O GMC
Prognosis: patients usually snap out of it from minuted to days

7.

Stable, persistant, inflexible emotional, MALADAPTIVE PATTERN of behavioral traits that are EGO-SYNTONIC
EPI: each personality disorder is present in 1% of the population
Etiology: Bio-Psycho-Social

Cognition,
Affect
Personal Relations
Impulse control

A:

3. DISSOCIATIVE IDENTITY DISORDER

1. DISSOCIATIVE AMNESIA:

4. Personality Disorders

PERSONALITY DISORDER CRITERIA

CAPRI

Dx Autistic d/o
1. Problems with social interaction,
2. Impairments in communication

Tx: Remedial education, BT, Antipsychptics Pimozine, SSRI, Stimulants

3. loss of milestones
4. Hand writhing
5. Seizures

4. Childhood Disintegrative Disorder

Epi: ??? M > F
Etiology: ?? like autism
Tx: CBT
Dx Aspergers d/o
1. Impaired social interaction
2. Restricted or stereotyped behaviors, interests, or activities

Epi: onset 2-10, M > F, rare

Etiology: unknown
Tx: supportive
Definition
1. NL development for first 2 yrs
2. Loss of milestone in
(language, social, bladder, play, motor)
3. Impaired social interaction, Autism like

Guaifenesin = Mucinex, a mucolytic and expectorant

Guanfacine = Tenex, A2-agonist, for ADHD and hypertension
Primidone = Mysoline, for ET (tremor) and seizures
Pimozide = Orap, antipsychotic for tourettes and autism

+ TIC DISORDERS
Epi: 1/2000 children, 3B : 1G, onset @ 7-8
Association with OCD and ADHD
Rx: Haldol, Pimozide (Orap)
Etiology = Genetic: HI = 46
Neuro: df of DA @ Caudate Nucleas
Df endoopiates, df NE
Definition:
The most severe tic disorder
Characterized by multiple daily motor or vocal tics
Onset before age 18
Dx:
1. Multiple motor and vocal tics (both must be present)
3. Onset < 18
4. Distress
DDx: Motor Tic Disorder or Vocal Tic Disorder

h. OTHER
1. Selective Mutism: F > M

g. ELIMINATION DISORDERS
1. Enuresis, MC: Secondary Nocturnal
Epi: 7% of 5yo
Etiology: genetic, small bladder, ADH dysregulation
Primary: never established
Secondary: between 5-8
Diurnal: daytime episodes
Nocturnal: nighttime

Tx: therapy

2. Separation Anxiety Disorder

Epi: 4% of school-age children, M = F, Onset @ 7
Etiology:
1. Preceded by a stressful life event
2. Parents with anxiety disorders
Tx: Therapy, low-dose antidepressants

Tx: buzzer, DDAVP, TCAs (Imipramine)

2. Encopresis
Dx: >4yo, once/month for 3months, inappropriate shitting
Epi: 1% of 5yo
DDx: R/O GMCs
-Metabolic abnormalities (hypothyroidism)
-Lower GI problems (anal fissure, IBS)
-Dietary factors

3. Child Abuse
MDs are mandated to report all cases suspected
Associated: with children of abuse, all axis 1 disorders
Sexual Abuse
Usually a Male who knows the child
25% of women, 12% of men
MC @ 9-12 yo

10.

9.

15. Psychotherapies

5. Substance-Related Disorders

7. Geriatric Psychiatry
NORMAL AGING

11.

ER: MS? Thiamine, Glucose, Naloxone Folate

NORMAL AGING:
Criteria = 1 or more of: Failure to fulfill obligations, Dangerous Use, Legal Consequences, Social Consequences
Tolerance, Withdrawal, Loss of control, Effort, $$$, other Interests, Continued use despite physical consequences
substance specific syndrome due to the cessation from prolonged use

-Need for amounts of the substance to achieve the desired effect

-Diminished effect if using the same amount of the substance

SEC = 400 mg/dL

BAL = 0.400%

SEC = 300 mg/dL

BAL = 0.300%

DDx Pseudodementia vs Dementia

SEC = 150250 mg/dL

BAL = 0.150 - 0.250%

-More Acute
-Emphasis On Failure
-No Sundowning
-No Confabulation
-Patient Is Aware

SEC =100150 mg/dL

BAL = 0.10 - 0.150%
SEC = 50100 mg/dL
BAL = 0.050 - 0.100%

DDx: Sleep Disturbances in the Elderly

SEC = 2050 mg/dL

BAL = 0.020 - 0.050%

-Primary (idiopathic, MC) Insomnia

-Axis 1 disorders
-Substance Abuse (EtOH)
-Axis 3 (GMC) disorders
-Axis 4 disorders (stressors)

123

10

Serotonin Syndrome:
To convert Serum Ethanol Level to BAC
1. move the decimal point 3 places to the left.
EX (100 mg/dL serum ethanol level = a 0.10 (g/dL) BAC, or 0.10% (weight/volume)
This means that one tenth of a percent of a person's blood volume is alcohol
That a person has 1 part alcohol per 1000 parts blood

Rum Fits = General Withdrawl

3. Non-Benzo/Non-Barb Sedative-hypnotics
Glutethimide
Chloral Hydrate
Meprobamate
Methaqualone
Methyprylon
Carisoprodol
GHB / GBL
Vistaril = Hydroxyzine

Rebound excitation, Begins between 6 -24hrs post last drink

Mild = irritable, insomnia, Severe = fever, disorientation, seizures, hallucinations

Alcohol Withdrawal Syndrome

S/s = insomnia, anxiety, tremor, irritability, anorexia, tachycardia,

hyperreflexia, hypertension, fever, seizures, hallucinations, delirium

Delirium tremens (DTs)

Most serious form of EtOH withdrawal, begins within 72hrs post cessation
5% of patients hospitalized for EtOH withdrawal develop DTs, 20% untreated mortality
S/s = delirium, visual or tactile hallucinations, gross tremor, autonomic instability
DDx: SDH, EDH, SAH, Look for signs of Cirrosis (ascites, jaundice, caput, coagulopathy)
Rx: Tapering doses of benzodiazepines (chlordiazepoxide, lorazepam)
+ Thiamine, folic acid, multivitamin
+ MgSO4 for postwithdrawal seizures

Wernicke Encephalopathy:
Korsokoffs Syndrome:

12.

50mg: 1 Cup Of Tea

125mg: 1 Cup Of Coffee
250mg: Anxiety, Insomnia, Twitching, Rambling Speech,
Flushed Face, Diuresis, Gi-df, Restlessness

1g: Tinnitus, Severe Agitation, Cardiac Arrhythmias

10g: Death Due To Seizures And Respiratory Failure

10. Somatoform Disorders

Consciously

Uncousciously
Faking

Primary Gain

Factitious D/O
Gain

(attention)

Secondary Gain

Avoiding The Police

Receiving Room And Board
Obtaining Narcotics
$$$

Malingering

Munchausen

13.

12. Eating Disorders

13. Sleep Disorders

Etiologies of Sleep Disorders

Medical conditions
Physical conditions
Sedative withdrawal
Caffeine, amphetamines
Major depression
Mania or anxiety
Neurotransmitter abnormalities:
DA or NE = total sleep time
ACh = total sleep time & REM
5HT = total sleep time & delta wave sleep

Medical complications of anorexia nervosa

Constitution/whole body

Cachexia and low body mass index

Arrested growth
Hypothermia

Cardiovascular

Myocardial atrophy
Mitral valve prolapse
Pericardial effusion
Brachycardia
Arrhythmia, which may cause sudden death
Electrocardiogram (ECG) changes
Long QT syndrome (QTc prolongation)
Increased PR interval
First-degree heart block
ST-T wave abnormalities
Hypotension
Acrocyanosis

Wake

Gynecologic and reproductive

Amenorrhea
Infertility
Pregnancy and neonatal complications

REM

Endocrine

Osteoporosis and pathologic stress fractures

Euthyroid hypothyroxinemia
Hypercortisolemia
Hypoglycemia
Neurogenic diabetes insipidus

NREM

Gastrointestinal

Gastroparesis (delayed gastric emptying)

Constipation
Gastric dilatation
Increased colonic transit time
Hepatitis
Superior mesenteric artery syndrome
Muscle wasting
Vitamin deficiencies
Refeeding syndrome

Primary Sleep Disorders

14.

2.= abnormal
Parasomnias
events in behavior or physiology during sleep

1.= disturbances
Dyssomnias
in the amount, quality, or timing of sleep
a. Insomnia: 30% general population

a. Nightmare Disorder

Tx: 1. Behavioral,
Tx: 2. Benadryl, Ambien (zolpidem), Sonata (zaleplon), Desyrel (trazodone)

b. Night Terror Disorder

b. Hypersomnia:

Tx: diazepam
Associated with Somnambulism

Tx: amphetamines, SSRIs, R/O other causes

c. Narcolepsy:

Epi: rare, M = F
= sudden attacks of sleep in the daytime for at least 3 months
-Cataplexy (loss of all muscle tone) in 70%
-Decreased REM latency, sleep paralysis, Hypnogogic, Hypnopompic
Rx: Ritalin, Amphetamines, Modafinil (Provigil), SSRIs, Na-Oxalate for Cataplexy

d. Breathing-Related Disorders:

Cause EDS (XS daytime sleepiness) Fatigue

Associated: HA, MDD, pHTN, SUNDS, SIDS
1. Obstructive sleep apnea (OSA):

Strong correlation with snoring

Tx: OSA: Nasal continuous positive airway pressure (nCPAP)
+ weight loss, nasal surgery, or uvulopalatoplasty

2. Central sleep apnea (CSA)

OSA RFs

Male gender
Obesity
Male shirt collar size 17
Prior upper airway surgeries
Deviated nasal septum
Kissing tonsils
Large uvula, tongue
Retrognathia

correlated with heart failure

Tx: CSA: Mechanical ventilation (such as b-PAP) with a backup rate

e. Circadian Rhythm Sleep Disorder

1. Jet Lag Type Sleep Disorder

2. Shift Work Type Sleep Disorder
3. Delayed Sleep Phase Type Sleep Disorder
4. Advanced Sleep Phase Type Sleep Disorder

Epi: childhood, associated with stress, TCAs

c. Sleepwalking Disorder (Somnambulism)

-Onset: 4-8yo; peak prevalence at age 12
-M > F, runs in families

Renal and electrolytes

Decreased glomerular filtration rate

Renal calculi
Impaired concentration of urine
Dehydration
Hypokalemia
Hypomagnesemia
Hypophosphatemia
Hypokalemic nephropathy
Hypovolemic nephropathy

Pulmonary

Pulmonary muscle wasting

Decreased pulmonary capacity
Respiratory failure
Spontaneous pneumothorax and pneumomediastinum
Enlargement of peripheral lung units without alveolar septa destruction

Hematologic

Anemia (normocytic, microcytic, or macrocytic)

Leukopenia
Thrombycytopenia

Neurologic

Cerebral atrophy (decreased gray and white matter)

Enlarged ventricles
Cognitive impairment
Peripheral neuropathy
Seizures

Dermatologic

Xerosis (dry skin)

Lanugo hair (fine, downy, dark hair)
Telogen effluvium (hair loss)
Carotenoderma (yellowing)
Scars from self-injurious behavior (cuts and burns)

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15.

11. Impulse Control Disorders

a. INTERMITTENT EXPLOSIVE DISORDER
Low levels of serotonin have been shown to be associated with impulsiveness and aggression
M > W, younger, feel remorseful
Tx: SSRI, Anticonvulsants, Li, Propanolol
Group > Individual therapy

b. KLEPTOMANIA

Kleptomana

25%
Kelptomania
+ Bulemia

Bulemia Nervosa

= Compulsive stealing for pleasure

W > M, less than 5% of thefts
Associated with stress, mood, eating, OCD
R/O acting out, gain, anger, hallucination, delusion
Tx: therapy, CBT (systematic desensitization and adversive conditioning)
SSRIs, Naltrexone

c. PYROMANIA
Epi: men and mentally retarded, earlier is better prognosis

d. PATHOLOGICAL GAMBLING
Lithium

= a gambling addiction, common, M > W

Tx: Gamblers anonymous (12 step)

e. TRICHOTILLOMANIA
Associated with OCD, OCPD, Relief, SSRIs, Antipsychotics, Lithium, Hypnosis
Substitution, break the habit

16.

14. Sexual Disorders

Dopamine enhances libido
Serotonin inhibits libido
a. SEXUAL RESPONSE CYCLE:
Desire > Excitement > Plateau > Orgasm > Resolution
b. SEXUAL CHANGES WITH AGING
c. DDX OF SEXUAL DYSFUNCTION
d. SEXUAL DISORDERS
Disorders of Desire
Disorders of Arousal (Excitement and Plateau)
Disorders of Orgasm
Sexual Pain Disorders
e. TREATMENT OF SEXUAL DISORDERS
Dual Sex Therapy
Behavior Therapy
Hypnosis
Group Therapy
Analytically Oriented Psychotherapy
Others
f. PARAPHILIAS
1. PEDOPHILIA: Sexual gratification from fantasies or behaviors involving sexual acts with children (most common paraphilia)
2. VOYEURISM: Watching unsuspecting nude individuals (often with binoculars) in order to obtain sexual pleasure
4. FETISHISM: Sexual preference for inanimate objects (e.g., shoes or pantyhose)
6. FROTTEURISM: Sexual pleasure in men from rubbing their genitals against unsuspecting women; usually occurs in a crowded area (such as subway)
7. MASOCHISM: Sexual excitement from being humiliated or beaten
8. SADISM: Sexual excitement from hurting or humiliating another
9. NECROPHILIA: Sexual pleasure from engaging in sexual activity with dead people
10. TELEPHONE SCATOLOGIA: Sexual excitement from calling unsuspecting women and engaging in sexual conversations with them
g. GENDER IDENTITY DISORDER
h. HOMOSEXUALITY