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USMLE Step 2 (Fach) / Psychiatry (Lektion)

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• Paranoid personality disorder Cluster A - Distrustful, suspicious- Interpret others' motives as malevolent- Ensue loyalty of friends & family- React severely if feel they've been lied to- Hold grudges - Use projection as a defense mechanism. How to handle them: Clear honest, nonthreatening
• Schizoid personality disorder Cluster A - Emotional coldness- Preoccupation with fantasy- Restricted emotional expression and anhedonia- Voluntary social withdrawal
• Schizotypal personality disorder Cluster A - Odd behaviour, perceptions, and appearance- Magical thinking (inventing causal relationships between behaviors and events with no evidence) that is inconsistent with patient's cultural norms- Ideas of reference (everything relates to their destiny) How to handle them: Clear, honest, nonthreatening
• Borderline personality disorder Cluster B Diagnostic criteria:- Pervasive pattern of unstable relationships, self-image & affects & marked impulsivity, with ≥ 5 of the following features:→ Franctic efforts to avoid abandonment→ Unstable & intense interpersonal relationships→ Markedly & persistently unstable self-image→ Impuslivity in ≥ 2 areas that are potentially self-damaging→ Recurrent suicidal behaviors or threats of self-mutilation (eg, cutting)→ Mood instability (marked mood reactivity)→ Chronic feelings of emptiness→ Inappropriate & intense anger→ Transient stress-relatied paranoia or dissociation Treatment:- Psychotherapy: Several types effective; best evidence for dialectical behavior therapy- Adjunctive pharmacotherapy to target mood instabilits & transient psychosis (second-generation antipsychotics, mood stabiliizers)- Antidepressants if comorbid mood or anxiety disorder
• Histrionic personality disorder Cluster B - Attention-seeking, excessively emotional behavior- Often exhibits inappropriately sexually provocative and/or seductive behavior- Draws attention to self by way of physical appearance- Overestimates the degree of intimacy in relationships- Becomes uncomfortable when not the center of attention How to handle them: Set rules, insist they are followed
• Narcissistic personality disorder Cluster B - Attention seeking, grandiosity, and need for admiration- Difficulty dealing with criticism- Lack of empathy How to handle them: Set rules, insist they are followed
• Antisocial personality disorder Cluster B - A history of a conduct disorder- ≥ 3 of the following 7 criteria after the age of 15 years:→ Repeatedly engaging activities that are grounds for arrest→ Deceitfulness→ Impulsivity/failure to plan ahead→ A history of repeated aggression→ Reckless disregard for one's own safety or the safety of others→ A failure to fulfill work-related or financial obligations→ A lack of remorse or emotional indifference to the plight of others How to handle them: Set rules, insist they are followed
• Obsessive-compulsive personality disorder Cluster C - Obsession with control and perfectionism that is often ego-syntonic (in contrast to obsessive-compulsive disorder!)- Rigid routines- Unwanted thoughts and compulsions Features of obsessive-compulsive personality disorder often occur at the expense of occupational success (e.g., missing deadlines), social relationships (e.g., excluding social activities to complete tasks), and pleasurable activities (e.g., not taking vacation)!
• Avoidant personality disorder Cluster C - Socially inhibited- Fear of rejection- Feelings of inadequacy- Fear of being disliked or ridiculed, yet desires to have friends and social interactions
• Dependent personality disorder Cluster C - Difficulty making everyday decisions often requiring others to assume responsibility- Difficulty initiating projects (e.g., applying for jobs) due to lack of self-confidence- Feelings of helplessness when alone, and urgently seeking new relationships once one fails How to handle them: Give clear advice; patient may try to sabotage their own treatment
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• Schizophrenia Epidemiology: - Prevalence is approximately 1%- W=M- Peak onset is earlier in men (18-25 years) than in women (25-35 years) Clinical features:- Positive symptoms: Hallucinations, delusions, disorganized speech, bizarre behaviour, thought disorder- Negative symptoms: Flat affect, avolition, alogia (poverty of speech), anhedonia, apathy- Catatonia Diagnostics:- ≥ 2 of the following symptoms for ≥ 1 month (at least one of the symptoms must be from the group that is bolded)1. Delusions2. Hallucinations3. Disorganized speech4. Grossly disorganized or catatonic behavior5. Negative symptoms- Symptoms must cause social, occupational, or personal functional impairment.- Some sign of illness must persist for at least 6 months. Treatment: - Acute psychotic episodes: short-acting antipsychotics (e.g., olanzapine) ± mood stabilizer for acute mania (e.g., lithium, valproate, carbamazepine)- First-line treatment: second-generation antipsychotics (atypical antipsychotics; e.g., olanzapine, risperidone, quetiapine)- Alternatively, first-generation antipsychotics (typical antipsychotics) in depot form for those at risk of poor adherence (e.g., fluphenazine, haloperidol, chlorpromazine)- Clozapine for treatment-resistant schizophrenia: persistent positive symptoms (i.e., delusions, hallucinations, and/or disorganized speech) despite trials of ≥ 6 weeks of 2 different antipsychotics at their maximum doses- Psychoeducation (used as an adjunct to avoid relapse)→ Patient, family, and group psychosocial therapy and education→ Cognitive behavioral therapy→ Supportive social measures
• Obsessive-compulsive disorder Obsessive-compulsive disorder (OCD) is characterized by persistent and recurring thoughts, urges, or images (obsessions) that lead to repetitive behaviors or mental acts (compulsions). Epidemiology:- Sex: ♀ ≥ ♂- Age of onset: average is 20 years of age- Lifetime prevalence: approx. 2% Clinical features:- Obsessions: recurring and intrusive thoughts- Compulsions: repetitive actions to provide relief from anxiety caused by obsessions- Can be egosyntonic or egodystonic Comorbidities:- Anxiety disorders- Depressive disorders- Bipolar disorders- Tic disorders- Personality disorders- Schizophrenia or schizoaffective disorder Diagnostics:- Obsessions (e.g., thoughts about contamination, harm, or symmetry) defined by both: → Recurrent/persistent, intrusive thoughts, or urges that cause anxiety or distress→ Attempts to suppress these thoughts or urges- Compulsions (e.g., repeatedly washing hands, opening and closing a door multiple times, or rearranging objects on a desk) defined by both: → Repetitive behaviors or mental actions (e.g., counting, repeating words) that the individual feels compelled to perform, in order to relieve anxiety brought upon by the obsessions.- These behaviors or mental actions may be performed in an attempt to prevent some perceived dreaded event, though they tend to be excessive and not connected in any realistic way to the event.- Time-consuming (E.g., ≥ 1 hour/day), or result in significant distress/impairment (school, work) Treatment:- CBT using exposure and desensitization relaxation techniques (e.g., exposure and response prevention [ERP])- SSRIs, e.g., sertraline, paroxetine, fluoxetine, fluvoxamine- Clomipramine is the TCA of choice
• Generalized anxiety disorder Prolonged and excessive anxiety that is either unspecific or revolves around certain themes (e.g., health, work); not focused on a single specific fear. Epidemiology:- Most common anxiety disorder among the elderly population- Lifetime prevalence: 5-10%- ♀ > ♂ (2:1) Clinical features:- Prolonged (≥ 6 months, occurring more days than not) and excessive anxiety- Anxiety causes clinically significant distress- Not caused by substance use, medication, or underlying medical condition- Fatigue and muscle tension- Restlessness and irritability- Sleep disturbances and difficulty concentrating Treatment:- First-line: psychotherapy, pharmacotherapy, or both→ CBT→ SNRI/SSRIs- Buspirone: Requires consistent, daily intake for at least two weeks due to a delayed onset of action. Favorable in patients with sexual dysfunction.- Benzodiazepines can be used until SSRIs take effect 
• Panic disorder Recurrent spontaneous panic attacks without a known trigger. Epidemiology- Lifetime prevalence: approx. 5%- Most common in patients of age 20-30- ♀ > ♂ (2:1) Associations:- Depression- Bipolar disorder- Agoraphobia- Substance use Clinical features:- Episodes of intense fear and discomfort- Fear of dying- Sympathetic overstimulation (sweating, palpitations)- Panic attacks that last for several minutes- Also: Paraesthesias, abdominal pain, nausea, light-headedness, chest pain, shortness of breath, choking sensation Treatment:- SSRIs- CBT- Benzodiazepines may be used until SSRIs take effect
• Specific phobia Persistent and intense fears of one or more specific situations or objects (phobic stimuli); always occur during encounters with the phobic stimulus, but may already surge in its anticipation. Epidemiology:- Lifetime prevalence: approx. 5-10%- Average age of onset depends on the specific phobia (e.g., animal phobias more commonly develop in early childhood)- ♀ > ♂ (2:1) Common phobias:- Animal: spiders (arachnophobia), insects (entomophobia), dogs (cynophobia)- Natural environment: heights (acrophobia), storms (astraphobia)- Blood-injection-injury: blood (hematophobia), needles (blenophobia), dental procedures (odontophobia), fear of injury (traumatophobia)- Situational: enclosed places (claustrophobia), flying (aviophobia) Treatment:- Systemic desensitization: Slower but longer duration of success- Flooding: Faster but less effective over time- Alternative: benzodiazepine or SSRI
• Post-traumatic stress disorder (PTSD) Characteristic symptoms that last > 1 month following ≥ 1 traumatic event(s). Epidemiology:- Lifetime prevalence: ∼ 9%- Duration of combat exposure directly proportional to risk of developing PTSD Clinical features:- Intrusion: Reexperiencing of the event through nightmares, flashbacks, intrusive memories- Avoidance of stimuli - Negative alterations in mood and cognition: Numbed responsiveness, guilt, self-blame- Changes in arousal and reactivity: ↑ arousal, sleep disturbances, aggression/irritability- Common comorbidities: depression, suicidality, addictive disorders, somatic symptom disorder Treatment:- Cognitive behavioral therapy→ Group therapy→ Trauma-focused→ Exposure therapy (e.g., showing war veterans images of war, returning to the scene of an accident)- Cognitive processing therapy- Eye movement desensitization and reprocessing (EMDR): The patient, who is under the guidance of a therapist, recalls traumatic images and simultaneously follows the therapist's fingers with their eyes, which move from left to right.- SSRI, SNRI- Nightmares: Prazosin is effective for improving sleep
• Adjustment disorder A maladaptive emotional or behavioral response to a stressor that lasts ≤ 6 months following termination of the stressor. Epidemiology:- Presents in ∼ 5-20% of individuals undergoing outpatient mental health care- Up to one-third of patients with a cancer diagnosis develop this disorder Diagnostic criteria:- Emotions or behaviors in response to a stressor within 3 months of onset- Clinically significant responses, including ≥ 1 of the following:→ Inappropriate subjective distress (not in relation to the nature of the event)→ Impaired functioning (social, occupational, or other important areas)- Not explained by another mental disorder- Not due to normal bereavement- Symptoms last ≤ 6 months following termination of the stressor Treatment:- First-line treatment: cognitive behavioral therapy or psychodynamic psychotherapy- Group therapy- Interpersonal psychotherapy- For depressed mood: SSRIs- For anxiety or panic attacks: benzodiazepines- For insomnia: benzodiazepines or other hypnotic agents (e.g., zolpidem)
• Bipolar disorder Epidemiology:- Sex: ♀ = ♂Lifetime prevalence: 1-3% Bipolar I disorder: One or more manic episodes (lasting ≥ 1 week) with or without major depressive episodesBipolar II disorder: One episode of hypomania + one episode of major depressive episode + no episodes of mania (distinguishing feature from bipolar I)Rapid cycling: ≥ 4 manic/hypomanic episodes or major depressive episodes per yearCyclothymic: Chronic and less severe, with alternating periods of hypomania and moderate depression for > 2 years Clinical features:- Increased goal-directed activity (sexually, at work, and/or socially) or psychomotor agitation- Increased talkativeness or pressure of speech- Flight of ideas or racing thoughts- Loss of social inhibitions, socially inappropriate and reckless behavior, aggressiveness, and hostility- Decreased need for sleep- Overconfidence- Easily distracted Diagnostics:- Manic episode: Lasts most of the day for at least 1 week- Hypomanic episode: Lasts most of the day for at least 4 consecutive days Acute treatment:- General measures:→ Reduction of external stimuli→ Assessment for possible offending substances (e.g., cocaine, alcohol, PCP, etc.)→ Limit access to cars, bank accounts/credit cards, cell phones, etc., due to reckless behavior - Medication:→ Depressed: Quetiapine, lurasidone, olanzapine-fluoxetine→ Lithium, valproate, carbamazepine→ Antipsychotics: Olanzapine, aripiprazole, risperidone, ziprasidone, chlorpromazine→ Benzodiazepines Long-term treatment- Duration of therapy:→ Treat for at least 1 year following an acute manic episode.→ Patients who experience 2 or more episodes should be considered for long-term or lifetime therapy.- Medication:→ First-line: Valproic acid, lithium→ Antipsychotics: Olanzapine, aripiprazole, risperidone, ziprasidone, chlorpromazine
• Delirium 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.  History/PE:- 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) Diagnosis:- Check vital signs, pulse oxymetry, provide glucose, psysical and neurologic examinations- Note recent medications, substance use, prior episdes, signs of organ failure, and infection (occult UTI is common in the elderly)- order lab and radiologic studies to identify a possible underlying cause Treatment:- Treat underlying cause- Normalize fluids and electrolytes- Optimize the sensory environment, provide necessary visual and hearing aides
• Obesity hypoventilation syndrome (Pickwickian syndrome) Breathing disorder that only affects morbidly obese individuals; frequently accompanied by OSA, it is characterized by diurnal hypercapnia. Etiology: morbid obesity Pathophysiology: ↑ production of CO2 + sleep disordered breathing (e.g., OSA) + failure of ventilatory compensatory mechanisms → alveolar hypoventilation Clinical features: Same symptoms as those of OSA- Headaches and severe sleepiness Diagnostic criteria: - BMI ≥ 30 kg/m2- Arterial blood gasses showing diurnal hypercapnia (PaCO2 > 45 mm Hg) that cannot not be explained by another condition- Polysomnography shows hypoventilation during sleep with or without obstructive apnea events. Treatment:- Weight loss- Nasal intermittent positive pressure ventilation
• Insomnia Epidemiology:- Prevalence: ∼ 10% (most common sleep-wake disorder) Etiology:- Poor sleep hygiene- Subclinical mood or anxiety disorders DSM-5 diagnostic criteria (primary insomnia is a diagnosis of exclusion):- Problems initiating or maintaining sleep, or awakening in the early morning and being unable to return to sleep- Symptoms occur ≥ 3 days/week for ≥ 3 months- Symptoms cause functional impairment or distress- Symptoms are not caused by an underlying substance or medication use- Symptoms occur despite having enough time to sleep- No underlying or coexisting psychiatric or medical disorder that explains symptoms Treatment:1. Improve sleep hygiene- No alcohol 4-6 hours preceding sleep- No stimulants (caffeinated drinks and nicotine should be avoided 3–4 hours before bedtime)- Quiet, dark, pleasantly cool bedroom and a comfortable bed- No large meals before bedtime- Regular exercise is beneficial but should be avoided 6 hours before bedtime.2. Stimulus control therapy- Advise waking up at regular times (also during the weekend and holidays).- Discourage engaging in other activities in bed such as working or reading.- Leave the bedroom when unable to fall asleep within 20 minutes (e.g., to read or listen to music) and return only when sleepy.- Advise against afternoon naps; if taken, this should not take place after 3 pm and naps should be no longer than 1 hour.3. Cognitive-behavioral therapy (CBT): preferred treatment for chronic insomnia4. Pharmacotherapy (use sparingly and short-term)- Benzodiazepines: ↓ Sleep latency; ↓ awakenings during sleep- For sleep onset insomnia: short-acting agent, e.g., triazolam, lorazepam- Antidepressants: trazodone (most commonly prescribed antidepressant for chronic insomnia and depressive symptoms) or amitriptyline- Non-benzodiazepine sedatives: Zolpidem, eszopiclone, zaleplon→ Lower risk of daytime sleepiness, although falls and cognitive impairment are still a concern
• Narcolepsy Epidemiology:- Sex: ♂ > ♀- Bimodal distribution: teens and early twenties; another smaller peak at around age 35 Clinical features:- Excessive daytime sleepiness: patients experience an irresistible urge to sleep → sudden, short sleep attacks (< 30 minutes), often at inappropriate times or in inappropriate situations (e.g., while driving a car) - Cataplexy (in ∼ 80% of cases): sudden muscle weakness in a fully conscious patient, triggered by strong emotions (e.g., patients may experience buckling of the knees upon laughing. → Cataplexy usually resolves within a few seconds, at most two minutes.→ Often as partial cataplexy: isolated weakness of distinct muscle groups (e.g., neck muscles → head tilts forward involuntarily, leg muscles → patient falls down)- Sleep paralysis (in ∼ 50% of cases): complete paralysis occurring for 1-2 minutes after waking or before falling asleep. External stimuli (e.g., stirring or addressing the patient) can release the patient from this condition. - Hypnagogic hallucinations (in ∼ 50% of cases): vivid, often frightening visual or auditory hallucinations occurring as the patient falls asleep. Hallucinations experienced while waking up (hypnopompic hallucinations) are less common. - Automatic behavior: During narcoleptic attacks, patients often start or continue routine, dull, or repetitive tasks automatically without conscious awareness, perception of their environment, or memory. Diagnostic criteria:- Daily irresistible urge to sleep, which lasts for ≥ 3 months- At least one of the following:→ Cataplexy plus specific findings on a multiple sleep latency test and polysomnography→ Abnormal CSF orexin-A (hypocretin-1) levels Treatment:- Sleep hygiene- Avoid substances that disturb the sleep-wake rhythm (e.g., alcohol, antipsychotics, opiates)- Psychosocial counseling with family and employer (narcoleptics require a place to sleep at their workplace)- For diurnal sleepiness: Modafinil→ Alternatives: methylphenidate and amphetamines- For cataplexy, sleep paralysis, and sleep hallucinations: Sodium oxybate→ Alternative: SSRIs (e.g, citalopram) or SNRIs (e.g., venlafaxine)
• Attention deficit hyperactivity disorder Epidemiology:- Sex: ♂ > ♀- Age of onset: usually before age 6- Prevalence: estimated to be 8-11% Comorbidities:- Oppositional defiant disorder- Conduct disorder- Depression- Anxiety Disorder- Learning disabilities Diagnostic criteria: ≥ 5 of the following for 6 or more months in at least 2 settings, leading to significant social and academic impairment. Symptoms must be present in patients before age 12.- Inattention- Hyperactivity- Impulsivity Treatment:- Initial treatment: Behavioral interventions→ Socio-educational measures: Creation of a low-stimulus environment, support of learning disabilities→ Behavioral parent training (BPT)→ Operant conditioning- Methylphenidate (Ritalin®)→ Indication: first-line therapy for patients ≥ 6 years of age- Atomoxetine (NRI)→ Indications: second-line therapy for patients ≥ 6 years of age; preferred in cases of substance abuse (patient or family member) Prognosis:- In 35-65% of patients, symptoms of ADHD will persist into adulthood.- Patients with ADHD are at higher risk of injury (both unintentional and self-injury), substance use disorder, and antisocial personality disorder.
• Autism spectrum disorder Epidemiology:- Sex: ♂ > ♀ (4:1)- Age: symptoms typically evident before 2-3 years of age Clinical features:- Persistent impairment in communication and social interaction- Restricted, stereotyped patterns of behavior, interests, and activities- Intellectual impairment- Language impairment- Associated conditions: → Epilepsy→ Pica: eating of non-nutritive substances (e.g., stones, clay, lime, feces)→ ADHD→ Anxiety disorder→ Genetic disorders, e.g., tuberous sclerosis, fragile X syndrome, Rett's syndrome Treatment:- Competence training: social skills, communication skills- Establishing clear and consistent structures- Family support and counseling: e.g., parental education on interaction with the child and acceptance of his/her behavior.- SSRIs: repetitive stereotyped behavior, anxiety- Antipsychotic drugs: aggression, self-injury- Methylphenidate: ADHD
• Tourette syndrome Epidemiology:- Sex: ♂ > ♀- Age of onset: usually 2-15 years of age- Associated with ADHD and/or OCD Diagnostic criteria:- Multiple motor tics and at least 1 vocal tic with a variable anatomical location, frequency, number, frequency, complexity, type, or severity over time- Onset before 18 years of age- Lasting > 1 year Treatment:- Behavioral therapy:→ Indicated for mild, nondisabling symptoms→ Involves habit reversal training or Comprehensive Behavioral Intervention for Tics (CBIT)- Medical therapy→ Alpha-adrenergic agonists: guanfacine (often first-line therapy), clonidine (very sedating) - Typical neuroleptic drugs: pimozide or haloperidol (FDA-approved but may cause tardive dyskinesia) - Atypical neuroleptic drugs: risperidone (increasingly preferred because of fewer side effects)- Dopamine depleting drugs: tetrabenazine (may be used as first-line therapy to avoid side effects of neuroleptic drugs i.e., dopamine blockade)
• Major depressive disorder Episodic mood disorder primarily characterized by depressed mood and anhedonia that lasts for at least 2 weeks. Epidemiology:- Sex: ♀ > ♂- Lifetime prevalence: 15-25%- The peak age of onset is in the 20s. Diagnostics: ≥ 5 symptoms, for at least 2 weeks- Depressed mood present most of the day, almost every day- Sleep disturbance (insomnia or hypersomnia)- Loss of interest or anhedonia- Feelings of worthlessness or guilt- Fatigue or loss of energy- Diminished concentration, ability to think, or make decisions - Weight change due to appetite change- Psychomotor changes- Suicidal ideation- Clinically significant distress or impaired functioning in important areas of life (e.g., work, school)- No history of a manic or hypomanic episode - Suicide screening and assessment: indicated for all patients- Polysomnography: indicated in sleep-onset insomnia (the patient is unable to fall asleep) and sleep-maintenance insomnia (the patient falls asleep but wakes up often)- Thyroid function tests: to rule out hypothyroidism Treatment:- Single episode: Continue medication for ≥ 6 months- Multiple episodes: Continue medication for ≥ 2 years- If the patient is in remission: Continue antidepressants for at least 4-9 months- First-line: SSRIs- SNRIs- Bupropion: lowers seizure threshold, less sexual dysfunction compared to SSRIs, and can also treat tobacco dependence- Mirtazapine: significant weight gain- Suicidal patients: Lithium should be combined with an antidepressant as prophylaxis to prevent recurrence.- Psychotherapy: Cognitive-behavioral therapy; Interpersonal therapy; Psychodynamic psychotherapy; Family and couples therapy
• Substance Abuse - Alcohol Epidemiology:- Prevalence: 13.9%; more common in Native Americans- Sex: ♂ > ♀=  2:1- Peak incidence: 21-34 years Intoxication:- Disinhibition, emotional lability, slurred speech, ataxia, aggression, blackouts, hallucinations, memory impairment, impaired judgement, coma Minor withdrawal- Onset: 6-24 hours after last drink- Tremor, insomnia, anxiety, palpations, and sweating, gastrointestinal upset, headache Withdrawal seizures- Onset: 12-48 hours after last drink- Brief, generalized tonic-clonic seizures (usually singular)- If left untreated, risk of delirium tremens Alcoholic hallucinosis- Onset: 12-48 hours after last drink- Intact orientation- Normal vital signs- Auditory and/or visual hallucinations are common, tactile hallucinations are also possible- Delusions Delirium tremens- Occurs within 48-96 hours after last drink- Impaired consciousness, disorientation- Visual hallucinations (usually small, moving objects, e.g., white mice)- Increased suggestibility- Rest and intention tremor (first high-frequency → low-frequency), sweating, nausea- Tachycardia, hypertension- Generalized tonic-clonic seizures- Hyperreflexia- Possible death- Persists for 1-5 days Management withdrawal:- IV benzodiazepines: Lorazepam, diazepam (especially for patients with hepatic disease), and chlordiazepoxide (also useful as prophylaxis) Pharmacology to promote alcohol cessation:- Blocks positive effects of alcohol: Naltrexone (first-line) (blocks mu-opioid receptor), acamprosate (blocks central glutamate receptors to reduce craivngs), topiramate- Ongoing vitamin supplementation: Vitamin B1 (thiamine), B6 (pyridoxine), B12, folate 
• Substance abuse - Opioids Intoxication:- Euphoria leading to apathy, CNS depression, constipation, pupillary constriction, and respiratory depression- Naloxone and naltrexone block opioid receptors and can revrse effects Withdrawal:- Gastrointestinal: nausea, vomiting, diarrhea, cramping, ↑ bowel sounds- Cardiac: ↑ pulse, ↑ blood pressure, diaphoresis- Psychological: insomnia, yawning, dysphoric mood- Other: myalgias, arthralgias, lacrimation, rhinorrhea, piloerection, mydriasis - Opioid withdrawal is not life-threatening, "hurts all over", and does not cause seizures Treatment:- Methadone (preferred) or buprenorphine- Pharmacological treatment should be accompanied by psychosocial treatment (e.g., cognitive behavioral therapy).- Clonidine (α2-antagonist): Alleviates autonomic symptoms (e.g., lacrimation, sweating, diarrhea, nausea)
• Substance abuse - Amphetamines Intoxication:- ↑ libido, constipation, tachycardia with arrhythmias, mydriasis, ↑ body temperature, ↑ perspiration, ↓ appetite, weight loss, grinding teeth- Neuropsychiatric symptoms: sleep disorders, megalomania, seizures, delusional parasitosis (delusion that body is infested with parasites or bugs)- Hyponatremia (MDMA): dry mouth and diaphoresis → extreme thirst → ↑ water intake without electrolyte repletion → hyponatremia → seizures and life-threatening cerebral and pulmonary edema- Overdose → serotonin syndrome- Haloperidol can be given for severe agitation Withdrawal:- Postuse "crash" with anxiety, lethargy, headache, stomach cramps, hunger, fatigue, sleep disturbance, nightmares
• Substance abuse - Cocaine Intoxication:- Psychomotor agitation, euphoria, impaired judgement, tachycardia, pupillary dilation, hypertension, paranoia, hallucinations, "cocaine bugs", sudden death. ECG changes from ischemia are often seen ("cocain chest pain")- Treat with haloperidol for severe agitation Withdrawal:- Postuse "crash" with hypersomnolence, depression, malaise, severe craving, angina, suicidality, ↑ appetite, nightmares
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• Substance abuse - Phencyclidine hydrochloride (PCP) Intoxication:- Assaultiveness, belligerence, psychosis, violence, impulsiveness, fever, tachycardia, vertical/horizontal nystagmus, hypertension, impaired judgement, ataxia, seizures, delirium Withdrawal:- Recurrence of intoxication symptoms due to reabsorption in the GI tract, sudden onset of severe, random violence Treatment:- Benzodiazepines- Haloperidol (cave: lowers seizure threshold)
• Substance abuse - LSD Intoxication:- Marked anxiety or depression, delusions, visual hallucinations, flashbacks, pupillary dilation, impaired judgement, diaphoresis, tachycardia, hypertension, heightened senses (eg, colors become more intesne) Withdrawal: none
• Substance abuse - Marijuana Intoxication:- Euphoria, slowed sense of time, impaired judgement, social withdrawal, ↑ appetite, dry mouth, conjunctival injection, hallucinations, anxiety, paranoia Withdrawal: none
• Substance abuse - Barbiturates Intoxication: - Low safety margin; respiratory depression Withdrawal:- Anxiety, seizures, delirium, life-threatening cardiovascular collapse
• Substance abuse - Benzodiazepines Intoxication:- Interactions with alcohol, amnesia, ataxia, somnolence, mild respiratory dpression Withdrawal:- Rebound anxiety, seizures, tremor, insomnia, hypertension, tachycardia
• Substance abuse - Nicotine Intoxication:- Restlessness, insomnia, anxiety, arrhythmias Withdrawal:- Irritability, headache, anxiety, weight gain, craving, bradycardia
• Anorexia nervosa Epidemiology:- Sex: ♀ > ♂ (10:1)- Age of onset: 10-25 years Diagnostic criteria:- Significant deliberate reduction in body mass (as measured by BMI) using strategies that include restrictive eating, purging, and excessive exercise.- Fear of weight gain motivates compensatory behavior that promotes weight loss, even if the patient already has low body weight.- Excessive concern about weight and body shape, despite being considerably underweight- Lack of awareness of the seriousness of low body weight Subtypes- Restricting type:→ No binge eating or purging over a 3-month period→ Suggests weight loss achieved by excessive dieting, exercise, or fasting- Binge-eating/purging type→ Presence of binge eating or purging over a 3-month period→ Suggests weight loss achieved by vomiting, laxative abuse, or enemas Diagnostics:- BMI < 18.5- Electrolyte imbalances: ↓ potassium, ↓ sodium, ↓ chloride, ↑ bicarbonate (metabolic alkalosis)- ↓ Glucose, pathological tolerance of low glucose levels- ↑ AST/ALT, ↑ serum α-amylase, ↑ cholesterol, hypoproteinemia, hypoalbuminemia- Blood count: pancytopenia Treatment:- Psychotherapy (first-line):→ Cognitive behavioral therapy→ Psychodynamic psychotherapy- Nutritional support- Olanzapine if not response to above- Indications for hospitalization:→ < 70% ideal body weight or BMI < 15 kg/m2→ Unstable vital signs: Hypothermia (< 35.5°C), bradycardia (< 40 bpm), hypotension (< 80/60 mmHg)→ Acute medical complications (e.g., syncope, seizures, pancreatitis, liver failure)→ Arrhythmia→ Hypoglycemia→ Electrolyte disturbances Complications:- Cardiovascular: myocardial atrophy, bradycardia, hypotension, arrhythmias- Renal: Poor urinary concentration, dehydration- Neurological: Seizures, cognitive impairment- Dermatological: Dry skin, lanugo- Gynecological: Infertility, amenorrhea- Gastrointestinal: Gastroparesis, constipation- Hematological: Cytopenia- Other: Electrolyte depletion, osteopenia, hypercholesterolemia, hypercarotenemia
• Bulimia nervosa Epidemiology:- Sex: ♀ > ♂ (> 90% of affected individuals are young women)- Peak age: 20-24 years of age (late adolescence to early adulthood) Diagnostic criteria: All five criteria must be met for diagnosis:1. Recurrent binge eating2. Recurrent compulsive compensatory behavior to counteract weight gain→ Most frequent: self-induced vomiting after binge eating→ Laxative abuse→ Transient starvation periods3. Binge eating and inappropriate compensatory behavior both occur at least once a week over a 3-month period.4. Sense of self-worth pathologically influenced by perception of physical appearance (body weight and shape)5. Symptoms do not exclusively occur during an episode of anorexia nervosa Clinical features:- By definition, the BMI in individuals with bulimia is normal or elevated (≥ 18.5 kg/m2 or ≥ 10th percentile for pediatric patients)- Esophagitis and/or gastritis- Poor dental status (e.g., perimylolysis) - Salivary gland swelling (parotitis)- Metabolic imbalances: ↓ Potassium, ↓ sodium, ↓ chloride, and ↓ calcium, ↑ blood pH- Calluses on the knuckles (Russell's sign)- Dry skin and brittle nails- Cardiac arrhythmias, hypotension Treatment:- Psychotherapy (first-line): cognitive behavioral therapy- Nutritional rehabilitation- Pharmacotherapy: treatment with SSRIs (e.g., fluoxetine) may help decrease binging/purging cycles.
• Social anxiety disorder Pronounced anxiety of social situations that may involve scrutiny by others and lasts ≥ 6 months. Epidemiology:- One of the most common mental disorders- Lifetime prevalence: approx. 5-10%- Peak incidence: adolescence and early adulthood- ♀ > ♂ (2:1) Clinical features:- Blushing, palpitations, sweating during a social interaction- Anticipatory anxiety- Anxiety driven by fear of embarrassment and others noticing the reaction- Avoidance of the aforementioned triggers- In children: refusing to speak at a social event, crying/throwing a tantrum, clinging to the care giver Treatment:- Cognitive behavioral therapy- First line pharmacotherapy: SSRI/SNRI- No/partial response to SSRI and no history of a substance use disorder: clonazepam (long-acting benzodiazepine) - No/partial response to SSRI and a history of a substance abuse disorder: phenelzine (monoamine-oxidase inhibitors)- Performance-only SAD: propranolol (beta blockers) or clonazepam on an as-needed basis
• Agoraphobia Inordinate fear or anxiety of being in situations that are perceived as difficult to escape from, or situations in which it might be difficult to seek help. Epidemiology:- ♀ > ♂ (2:1)- Age of onset: < 35 years (60-70% of cases) Clinical features:- Fear, anxiety, or even panic attacks over a period of ≥ 6 months in ≥ 2 of the following 5 situations:1. Using public transportation2. Being in open spaces3. Being in enclosed places4. Standing in line or being in a crowd5. Being outside of the home alone- Active avoidance of these settings unless a companion is present- Some patients can have a comorbid panic disorder Treatment:- Cognitive behavioral therapy- SSRIs
• Pyromania Rare impulse control disorder more commonly found in males. Features:- Deliberate fire setting on ≥ 1 occasions- Tension, arousal prior to act; pleasure/relief when setting/witnessing fire- No external gain, revenge, or political motivation; not done to attract attention- Tend to be fascinated by fire and anything related to it (eg, fire stations, firefighters) Treatment:- No successful therapy- Incarceration may be required Differential: Arson – setting fire for monetary gain (not for anxiety relief or pleasure)
• Kleptomania Recurrent failure to resist impulses to steal objects that are not needed for personal use or for their monetary value. Diagnotics:- Increasing internal tension before committing the theft and pleasure, gratification, or relief at the time of committing the theft- Items often have no value to the patient, can be purchased- Thefts occur spontaneously and unplanned- Patient feels intense guilt after the face, and may often gift the object or stash it away, never to be used Treatment: - CBT- SSRIs
• Conduct disorder A repetitive and persistent pattern of disruptive behavior for ≥ 12 months that violates basic rights of others or age-appropriate societal norms or rules. Epidemiology:- Onset during childhood or adolescence; the diagnosis is only applied to patients < 18 years.- ♂ > ♀ Diagnostic criteria:- Aggression to people and animals: bullying, threatening, fighting, using weapons, cruelty, forced sexual activity- Destruction of property- Deceitfulness or theft- Serious rule violation: Truancy or disobeying family rules - staying out at night before age 13- The disturbance in behavior significantly impairs social, academic, and/or occupational functioning.- Many patients also have ADHD Treatment:- CBT, parent management training- Juvenile detention, big brother programs- Pharmacotherapy (e.g., psychostimulants in comorbid ADHD, antipsychotic medications or mood stabilizers in cases of severe aggression) Prognosis: Patients with CD are at increased risk of developing antisocial personality disorder in adulthood
• Oppositional defiant disorder Anger, irritable mood, and defiant behavior towards figures of authority lasting ≥ 6 months. Significantly impairs social and/or academic functioning. Epidemiology:- Usually appears in late preschool or elementary school- ♂ > ♀ at onset; equal incidence after puberty Diagnostic criteria: ≥ 4 of the following symptoms for ≥ 6 months with ≥ 1 individual who is not a sibling (e.g., teachers, parents)- Losing temper frequently- Easily annoyed- Resentful or angry mood- Argumentative with authority figures- Defiant or refusal to comply with requests from authority figures- Deliberately annoying- Blaming others for one's own mistakes- ≥ 2 episodes of vindictive or spiteful behavior in the past 6 months Treatment: psychotherapy (individual and family), parent management training, social-skills programs Prognosis: often precedes conduct disorder
• Hoarding disorder Epidemiology:- Point prevalence: ∼ 2-6%- ♂ > ♀ Diagnostic criteria:- Persistent urge to keep items; distress associated with getting rid of items- Difficulty discarding belongings- Accumulation of belongings → intended use of belongings is compromised and living areas are cluttered- Clinically relevant impairment in functioning and/or clinically relevant distress- Not explained by other medical conditions (e.g., brain injuries) or mental illness (e.g., OCD) Treatment:- CBT- If CBT fails: trial of SSRI (off-label use)
• Body dysmorphic disorder Epidemiology:- Point prevalence: ∼ 2%- ♂ ≈ ♀- Mean age of onset: ∼ 17 years Diagnostic criteria:- Persistent preoccupation with a perceived flaw in one's physical appearance- Flaws are mild or not observable by others- Repetitive behaviors (e.g., skin scratching) or thoughts (e.g., comparing oneself to others)- Clinically relevant impairments in functioning and/or clinically relevant distress- Patients excessively check their appearance in a mirror, engage in repetitive grooming, make comparisons or seek reassurance about their appearance- In order to diagnose BDD, an eating disorder that might also explain the symptoms should be ruled out. Treatment: CBT, SSRIs
• Trichotillomania Epidemiology:- Lifetime prevalence: ∼ 2%- ♀ >> ♂- Onset usually in puberty following a stressful event- ↑ Incidence of comorbid major depressive disorder, OCD, and excoriation disorder Clinical features: - Hair loss, most commonly involving the scalp, eyebrows, or eyelashes Diagnostic criteria:- Hair loss due to recurrent pulling out of one's hair- Repeated attempts to stop this behavior- Results in significant distress/impairment (school, work)- Not due to another medical or mental disorder (e.g., skin disease, body dysmorphic disorder) Treatment: CBT, SSRIs
• Reactive attachment disorder Attachment disorder that is due to abuse and neglect (deprivation) and may be associated with signs of physical maltreatment, undernutrition, excessive appetite/food hoarding, or, if the disorder is severe, growth retardation. In contrast to separation anxiety disorders, symptoms occur in a variety of situations, even with strangers, and may be associated with aggressive behavior. Diagnostic criteria:- At least 9 months of age developmentally and onset before 5 years of age- Consistent pattern of inhibited, emotionally withdrawn behavior towards caretakers without seeking comfort when distressed, minimal emotional expression to others, and inadequate care- Hoarding- Rule out autistic spectrum disorder Treatment: - Behavioral modification for primary caretakers (provision of security, stability, sensitivity)- Referral to mental health professionals- Medication for comorbid disorders (e.g., depression) if needed RAD is an internalizing disorder (depressive symptoms, withdrawn behavior), whereas disinhibited social engagement disorder (DSED) is an externalizing disorder (disinhibition, overfamiliarity with strangers)!
• Separation anxiety disorder Fear, anxiety, or avoidance of separation from major attachment figures.  Age of onset: childhood, with mean onset at 7.5 years Diagnostic criteria:- Duration: at least 1 month- Developmentally inappropriate and excessive fear about separation from major attachment figures (e.g., parents)- Characterized by persistent worrying about losing attachment figures or being without them, with possible complaints of physical symptoms (headaches, nausea/vomiting) and/or nightmares about separation - Significantly impairs academic and/or social life- Not attributable to other psychiatric disorders (e.g., autism spectrum, psychotic, or anxiety disorders) Treatment:- Psychotherapy (cognitive behavioral therapy, exposure therapy), play therapy, family therapy- Medications (e.g., fluoxetine) are indicated as an adjunct to psychotherapy if there is moderate to severe functional impairment. Complications:- Often a precursor to school refusal behavior- Complications later on in life include depression and substance use disorder.
• Selective mutism Relatively uncommon disorder in which children do not speak in situations when speech is expected. It may coexist with social anxiety disorder and/or result in school refusal. Age of onset: generally occurs by 5 years of age, although usually not diagnosed until the child starts school Diagnostic criteria:- Duration: at least 1 month- Child consistently fails to speak in specific situations- Interferes with normal life (e.g., social interactions, school)- Not attributable to language difficulties or other disorders Treatment: SSRIs (fluoxetine) and cognitive behavioral therapy

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