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USMLE Step 2 (Fach) / Psychiatry (Lektion)

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• Depression subtypes Depression with seasonal pattern- Occurs yearly in fall and winter- Patients suffer from the usual symptoms of MDD along with atypical ones, such as weight gain and requiring more sleep.- Light therapy has been shown to improve symptoms. Atypical depression- Mood reactivity: brightening of mood in response to positive events, which is usually not the case in classical MDD- ≥ 2 of the following features→ Increased appetite or weight gain→ Increased sleep→ Leaden paralysis (weighing down of arms and legs)
• Postpartum depression Depression occurring during pregnancy or within the first four weeks after delivery. Treatment:- During pregnancy: Most antidepressants cross the placenta and should, therefore, be avoided unless the patient has severe or relapsing depression.- After delivery: generally the same as for depression unrelated to pregnancy- For lactating patients: Psychotherapy may be attempted before initiating drug therapy to avoid exposing the baby to antidepressants via breastmilk. Differential diagnosis: postpartum blues- Incidence: up to 80% of pregnancies- Clinical features: mild depressive symptoms that resolve spontaneously within 2 weeks after delivery- Treatment: Reassurance
• Persistent complex bereavement disorder Refers to a pathological grieving process. Diagnostic features:- Death of a close other- Clinical significant yearning for the deceased persist for at least > 12 months- Difficulty adjusting to a life without the deceased- Disturbance impairs daily life (socially, occupational)- Yearning is inconsistent with cultural norms- NOT pervasive into all elements of a patient's life Additional features:- Hallucinations of deceased- Somatic complaints
• Psychotic disorders - Differential Schizophrenia: Psychotic symptoms lasting > 6 months Brief psychotic disorder:- Psychotic symptoms lasting > 1 day but ≤ 1 month- Triggered by stressful situations Schizophreniform disorder: Psychotic and residual symptoms lasting 1–6 months Schizoaffective disorder:- Features of schizophrenia AND a major mood disorder (depression or bipolar disorder)- Psychosis must have been present for at least 2 weeks in the absence of any mood disturbance.- Mood symptoms do not appear in the absence of psychosis Delusional disorder:- ≥ 1 delusion with a duration of ≥ 1 month and no other psychotic symptoms - Functioning is not markedly impaired and behavior is not obviously bizarre or odd- Common central themes of the delusions are grandiosity, jealousy, and persecution Delusional symptoms in partner of individual with delusional disorder:- Formerly known as shared psychotic disorder or folie à deux- One person's delusion is transferred to another person- Management: Assess both individuals separately to determine the degree of delusions in each- First-line therapy: cognitive-behavioral therapy and atypical antipsychotics (e.g., ziprasidone, aripiprazole) Mood disorder with psychotic features:- Meets criteria for a mood disorder (e.g., depression or manic phase of bipolar mood disorder)- Psychotic features appear exclusively during manic or depressive episodes.- Mood symptoms may be present in the absence of psychosis.
• Binge eating disorder Epidemiology:- Sex: ♀ > ♂- Peak incidence: late teens to early 20s Diagnostic criteria:- Recurrent binge eating: eating a portion of food larger than average within 2 hours- Feeling of lack of control over amount of food consumed with at least three of the following properties:→ Eating faster than normal→ Eating until uncomfortably full→ Eating large amounts when not hungry→ Eating alone because of embarrassment regarding eating habits→ Feeling of disgust and/or guilt after eating- Symptoms present at least 1/week for 3 months Treatment:- Psychotherapy (first-line): cognitive behavioral therapy (CBT) - Pharmacological therapy: May be added if CBT alone is ineffective→ SSRI: helps to reduce binge eating impulse→ Lisdexamfetamine or topiramate (for patients who do not respond to treatment with SSRIs): reduces weight gain from binge eating and impulsive behavior
• Dissociative amnesia Epidemiology: - Most common dissociative disorder (lifetime prevalence ∼ 7%); more common in women than in men Diagnostic criteria:1. Inability to recall autobiographical information, typically of a traumatic or stressful event, that is distinct from ordinary forgetting 2. Can be described as localized (i.e. amnesia of a single event or time period), selective (i.e. amnesia of a specific aspect of an occurrence), or generalized (i.e. amnesia of personal history and identity)3. Symptoms cause significant social or occupational impairment.4. Symptoms are not due to substance use or another medical condition.5. Symptoms cannot be explained better by another psychiatric disorder (e.g., dissociative identity disorder, acute stress disorder, or posttraumatic stress disorder).6. May present with dissociative fugue: wandering or purposeful travel; associated with amnesia of identity or autobiographical information Treatment: - Psychotherapy; no effective pharmacotherapy available 
• Depersonalization/Derealization disorder Epidemiology: - Lifetime prevalence ∼ 2%- Average age at onset 16 years Diagnostic criteria:1. Recurrent or persistent episodes of depersonalization and/or derealization→ Depersonalization: sense of unreality with detachment from oneself (e.g., body perception, feelings, thoughts, actions)→ Derealization: sense of unreality with detachment from one's environment2. Reality testing is intact during these episodes.3. Symptoms cause significant social or occupational impairment.4. Symptoms are not due to substance use or another medical condition. Treatment: Cognitive behavioral therapy, hypnotherapy, psychodynamic therapy
• Dissociative identity disorder Epidemiology:- Rare (prevalence < 1%)- May manifest at any age- Very common in patients with a history of physical/sexual abuse and/or neglect during childhood (90% of patients) Diagnostic criteria:1. Alternation of at least two separate personality states that cause identity disruption and dominate at different times2. Involves discontinuity in sense of self (depersonalization) and agency; altered affect, memory, behavior, perception, consciousness, cognition and/or sensory-motor functioning (derealization)3. Frequent gaps in recall ("blackouts") of normal daily events or personal information that are significantly different from ordinary forgetfulness4. Symptoms cause the patient significant social or occupational impairment.5. Symptoms are not related to substance use, another medical condition, or a broadly accepted religious or cultural practice. Treatment: psychotherapy; hypnosis; SSRIs for comorbid conditions (depression, PTSD)
• Catatonia A behavioral syndrome characterized by abnormal movements and reactivity to the environment Defined by at least 3 of the following:- Stupor: ↓ alertness and ↓ response to stimuli- Catalepsy: patient can be put in any position- Waxy flexibility: slight, even no resistance to positioning (and holding)- Mutism: no verbal response when once there was- Negativism: motiveless resistance to instructions- Stereotypy: repetitive, non-goal directed movements- Agitation or grimacing- Echolalia: mimicking speech- Echopraxia: mimicking movements Treatment: Lorazepam- Refractory cases: Electroconvulsive therapy
• Neuroleptic malignant syndrome Life-threatening neurological disorder usually associated with antipsychotics. Etiology- Reaction to antipsychotic drugs (especially high-potency antipsychotics such as haloperidol), other agents that affect the CNS (e.g. carbamazepine, lithium, venlafaxine), or certain antiemetics (e.g., metoclopramide, promethazine) Clinical features: - Onset usually within 2 weeks of the first dose- Psychiatric symptoms: reduced vigilance, stupor, mental confusion, mutism- Vegetative symptoms: high fever, tachycardia, tachypnea, diaphoresis- Extrapyramidal symptoms: akinesia, tremor, rigor Diagnostics:- ↑↑ Creatinine kinase- ↑ Transaminases- Leukocytosis- Metabolic acidosis- Myoglobinuria Treatment:- Discontinuation of the antipsychotic drug!- Supportive measures (e.g., ICU care)- First line: Dantrolene (ryanodine receptor antagonist): reduces muscular activity- Alternatives: bromocriptine, apomorphine, or amantadine
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• Serotonin syndrome Life-threatening condition caused by serotonergic overactivity. Trigger: ingestion of two or more serotonergic drugs; rapid switching from one serotonergic drug to another Clinical features- Fever, sweating- Hypertension, tachycardia, hypotension (if caused by MAOI)- Nausea, vomiting, diarrhea- Delirium, psychomotor agitation, anxiety- Hyperreflexia, myoclonus, tremor, ataxia, mydriasis Differential diagnoses- Neuroleptic malignant syndrome: Patients are rigid and do not have hyperreflexia or myoclonus- Malignant hyperthermia: Occurs almost exclusively after exposure to certain trigger substances (e.g., volatile anesthetics or succinylcholine) Treatment:- Discontinue serotonergic drugs immediately- Antihypertensives, fluid replacement- Benzodiazepines for sedation- Cyproheptadine: H1-, 5-HT1A-, and 5-HT2A-receptor antagonist→ Used for cases of serotonin syndrome that do not respond to supportive care- Cooling measures: ice-packs and cold compresses
• Asperger's syndrome - Normal language and cognitive development (normal or high IQ)→ For this reason, children with Asperger's syndrome are often not diagnosed until age > 4 years.- Exceptional skills/interests in specific areas- Reduced ability or inability to empathize- Impaired emotional expression and emotional intelligence- Stereotyped repetitive behavior patterns- Increased risk of ADHS, obsessive compulsory disorder, anxiety disorders, schizophrenia
• Tic disorder Sporadic transient tic disorder (occurs in up to 25% of normal children):- Motor and/or vocal tics- Onset before 18 years of age- Symptoms occur for less than 1 year (resolve spontaneously)- Not explained by any other medical conditions or substance abuse- Do not meet the criteria for Tourette's syndrome Persistent motor tic disorder or persistent vocal tic disorder:- Motor or vocal tics (not both)- Onset before 18 years of age- Persist > 1 year- Not explained by any other medical conditions or substance abuse- Do not meet the criteria for Tourette's syndrome
• Enuresis Repeated involuntary elimination of urine that is inappropriate for developmental age (e.g., pants- or bed-wetting) Epidemiology: - Affects 5-10% of 5-year-olds; prevalence decreases with age Risk factors: - Psychosocial stressors (e.g., recent move, sexual abuse, conflicts in the family)- Positive family history- Associations: other psychiatric disorders, e.g., ADHD, conduct disorders, autism Diagnostic criteria:- Occurs 2x/week for ≥ 3 months or causes clinical distress- Patient's developmental age must be ≥ 5 years- Symptoms not caused by a medication or another medical condition Therapy:- Organic causes (e.g., urinary tract infections, urinary tract abnormalities, renal disorders) must be excluded before any treatment is started.- First-line: → Psychoeducation→ Parent management training→ Fluid restriction at night→ Behavioral training with a urine alarm- Second-line: pharmacological treatment (e.g., desmopressin, imipramine)Treatment of enuresis is not indicated before 5 years of age! Most cases resolve spontaneously!
• Encopresis Repeated involuntary or intentional elimination of feces inappropriate for developmental age (e.g., into clothes or on the floor). Epidemiology:- ♂ > ♀- Approx. 1% of 5-year-olds affected- 80% of cases are due to underlying constipation Risk factors: psychosocial stressors, positive family historyAssociations: other psychiatric disorders, e.g., ADHD, conduct disorders, autism Diagnostic criteria:- Occurs ≥ 1/month for ≥ 3 months- Patient's developmental age must be ≥ 4 years- Symptoms not caused by a medication or another medical condition Therapy:- Behavioral training with operant conditioning (e.g., rewarded scheduled toilet visits) - If encopresis is due to constipation, treat the underlying constipation with stool softeners and dietary changes.
• SSRIs Drugs:- Fluoxetine- Paroxetine- Sertraline- Citalopram- Escitalopram Side effects:- Sexual disorders (anorgasmia, erectile or ejaculatory dysfunction, ↓ libido)- Diarrhea, nausea, vomiting- Sleep disorders- Headache- Increased risk of bleeding- Serotonin syndrome Additional information: must usually be taken for 4-6 weeks before symptom reduction is seen
• SNRIs Drugs:- Venlafaxine- Duloxetine Side effects:- Similar profile to SSRIs - Increased blood pressure Additional information: Blood pressure should be controlled before initiating SNRI therapy.
• Serotonin antagonist and reuptake inhibitor Drugs:- Trazodone- Nefazodone Side effects:- Priapism- Sedation (due to H1 antagonism)- Orthostatic hypotension
• Mirtazapine Atypical antidepressant Side effects:- ↑ appetite and weight gain- Sedation (due to H1 antagonism)
• Buproprion Indications:- Smoking cessation: used in conjunction with counseling and nicotine replacement- Major depressive disorder- Depressive disorders with seasonal pattern Side effects- Reduction of seizure threshold- Tachycardia, mild hypertension, palpitations, agitation- Weight loss- Neuropsychiatric symptoms (including depression, mania, psychosis, and paranoia) Contraindications: Patients with ↑ risk for seizure (epilepsy, anorexia/bulimia, alcohol or benzodiazepine withdrawal, etc.) Additional information: Bupropion has no sexual side effects, which makes it a viable alternative to SSRIs or SNRIs for patients who experience sexual dysfunction.
• Monoamine oxidase inhibitors Drugs:- Tranylcypromine- Phenelzine- Selegiline- Isocarboxazid Side effects:- Hypertensive crisis with ingestion of foods containing tyramine (e.g. aged cheeses, smoked/cured meats, alcoholic beverages, dried fruits)- Serotonin syndrome Additional information:- Rarely used as a first- or second-line antidepressant today due to its potentially severe side effects, interaction with foods containing tyramine, and numerous drug interactions- For the treatment of depression, selegiline is available as a transdermal patch (oral form is only used for Parkinson's disease)
• Tricyclic antidepressants Drugs- Amitriptyline- Clomipramine- Doxepin- Imipramine- Trimipramine- Nortriptyline- Desipramine- Protriptyline Side effects:- Orthostatic hypotension- Sedation and delirium- Changes in cardiac conductivity velocity, arrhythmias, prolongation of the QT interval (predisposes to Torsade-de-pointes)- Anticholinergic symptoms:→ Cardiovascular symptoms: wide QRS complex, tachycardia, arrhythmia (including ventricular fibrillation), hypotension→ CNS symptoms: confusion, hallucinations, sedation, coma, seizures→ Gastrointestinal symptoms: intestinal ileus, constipation→ Genitourinary symptoms: urinary retention→ General: xerostomia, mydriasis, hyperthermia/dry skin Management:- Secure airways, oxygenation, monitoring, fluid resuscitation- Activated carbon in first 2 hours after ingestion as soon as the airways are secured- Sodium bicarbonate for cardiac arrythmias
• Lithium toxicity Etiology:- Overdose- Volume depletion (↓ GFR)- Drug interactions: Thiazide diuretics, NSAIDs (not aspirin), ACE inhibitors, tetracyclines, metronidazole Side effects:- Gastrointestinal: Nausea/vomiting, diarrhea, abdominal pain- CNS and peripheral nervous system: Fine tremors, hyperreflexia, decreases the seizure threshold (esp. if predisposing lesions exist), weight gain- Thyroid: Hypothyroidism, goiter- Lithium nephropathy→ Definition: nephrogenic diabetes insipidus triggered by lithium→ Pathophysiology: lithium interferes with ADH signaling → reduces aquaporins (water channels) on the collecting duct cell's surface → Clinical features: polyuria, nocturia, and polydipsia → increased risk of dehydration→ Treatment: amiloride- Chronic kidney disease- Cardiovascular: Prolonged QT intervals, arrhythmias, bradycardia- Skin: Lithium acne, triggering and exacerbations of psoriasis Intoxication:- Etiology: serum lithium levels > 1.5 mEq/L / 1.5–2.0 mmol/L→ Overdosage due to frequent intake→ Renal impairment→ Low sodium diet or increased perspiration→ Diuretic therapy (e.g., loop or thiazide diuretics)- Neurological (earliest and predominant feature): dysarthria, vertigo, ataxia, nystagmus (especially downbeat nystagmus), dysdiadochokinesia, tremor, somnolence, delirium. - Neuromuscular: fine tremors, fasciculations- Gastrointestinal: vomiting, diarrhea, abdominal pain- Psychiatric: apathy, psychomotor impairment Management: Hemodialysis for severe cases
• Benzodiazepines Short-acting:- Midazolam- Triazolam- AlprazolamIndications:- Procedural sedation and anaesthesia induction- Sleep-onset insomnia Intermediate-acting:- Oxazepam- Temazepam- LormetazepamIndications:- Sleep-onset as well as sleep-maintenance insomnia- Anxiety disorders Long-acting:- Lorazepam- Diazepam- Clonazepam- ChlordiazepoxideIndications:- Anxiety and panic attacks- Stress disorders- Acute episodes of paranoia- Muscle relaxation- Epilepsy- Alcohol withdrawal syndrome
• Antipsychotics First-generation antipsychotics:- Haloperidol- Fluphenazine- Chlorpromazine- Promethazine Second-generation antipsychotics:- Clozapine→ Agranulocytosis (usually within the first 4 months of therapy)→ Metabolic syndrome, hyperglycemia, hypercholesterolemia, weight gain- Olanzapine→ Metabolic syndrome, hyperglycemia, dyslipidemia, weight gain, asymptomatic increase of liver enzymes- Risperidone→ Elevated prolactin levels- Quetiapine→ Sedation→ Metabolic syndrome, hyperglycemia, hypercholesterolemia, weight gain- Amisulpride→ Elevated prolactin levels- Ziprasidone- Aripiprazole
• Extrapyramidal symptoms Acute dystonia- Hours to days- Painful and lasting muscle spasms predominantly affecting the head, neck, and tongue→ Oculogyric crisis (upward deviation of the eyes)→ Tongue protrusion or twisting→ Facial grimacing, torticollis→ Opisthotonus of the back- Acute treatment: anticholinergics or antihistamines→ Common first-line: benztropine→ Alternatives: Diphenhydramine; Benzodiazepines (e.g., diazepam) Pseudoparkinsonism- Week 1- Cogwheel rigidity, stiff gait, tremor- Treatment: → Anticholinergic (e.g., benztropine) or a dopamine agonist (e.g., amantadine)→ Dose reduction or discontinuation of antipsychotic drug Akathisia- Week 1-8- Restlessness/compelling urge to move- Inability to sit or stand still- Treatment:→ Discontinuation or dose reduction of antipsychotic drug→ Propranolol Tardive dyskinesia- Months – years- Repetitive chewing and lip smacking- Choreic movements- Treatment:→ Discontinuation of antipsychotic drug→ Switch to atypical antipsychotic (less EPS)
• Substance use disorder Epidemiology:- Sex: ♂ > ♀- Alcohol and nicotine use is most common Criteria:1. Impaired control2. Social impairment3. Risky use4. Pharmacologic indicators- Drug tolerance- Drug withdrawal
• Sleepwalking disorder Non-REM sleep arousal disorder (no memory of dream) Epidemiology:- Discrete episodes are common (up to 7% of adults and 30% of children), but the disorder is rare.- Associated with sleep deprivation, irregular sleep schedules, some medications Etiology: idiopathic or genetic (inherited in 80% of cases) Risk factors:- Stress or fatigue- Obstructive sleep apnea- Nocturnal seizures- Fever- Drugs (e.g., lithium) Clinical features:- Recurrent episodes during the first third of the sleep cycle, including sitting up, walking, or eating- Blank stare and difficulty arousing patient during the episode- Followed by amnesia of the event Treatment:- Education and reassurance- Ensuring safe sleep environment to reduce the risk of physical harm or wandering outdoors- In refractory cases, benzodiazepines
• Sleep terror disorder Non-REM sleep arousal disorder (no memory of dream) Epidemiology: Discrete episodes of sleep terrors are relatively common (up to 2% of adults and 20% of children), but the disorder is rare. Risk factors:- Stress or fatigue- Obstructive sleep apnea- Nocturnal seizures- Fever- Drugs (e.g., lithium) Clinical features:- Screaming or crying suddenly upon awakening- Intense fear and agitation- Tachypnea, diaphoresis, tachycardia during episodes- Difficulty arousing patients during episodes; patients will often return to sleep and not remember the episode the next day Treatment:- Education and reassurance (disorder is usually self-limited)- Remove dangerous objects from bedroom to reduce risk of self-injury- In refractory cases, benzodiazepines
• Central sleep apnea Breathing-related sleep disorder characterized by repetitive cessation or decrease of respiratory effort during sleep due to impaired function of the respiratory center. Airway obstruction is absent. Risk factors:- Age > 65 years- Male sex- Heart failure- Central nervous system disease (e.g., brainstem tumor, stroke) Pathophysiology: lack of stimulation to the respiratory center with patent upper airways → periodic lack of respiratory muscle innervation → interruption of thoracic and/or abdominal respiratory movements Clinical features:- Morning headaches- Repeated waking at night- Daytime sleepiness- Snoring- Association with OSA is very common Diagnosis:- Based on clinical history (e.g., underlying conditions such as heart failure or stroke)- Polysomnography Treatment:- Treat underlying disorder (if present)- BiPAP
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• Obstructive sleep apnea Breathing-related sleep disorder in which airflow significantly decreases or ceases because of upper airway obstruction (typically the oropharynx) Risk factors:- Obesity, especially around the neck (short, wide “bull neck”)- Structural abnormalities that impair respiratory flow: tonsillar hyperplasia, nasal septum deviation, enlarged uvula, tongue, or soft palate; nasal polyps; overbite with a small chin; hypertrophied pharyngeal muscles- Alcohol consumption before sleep- Intake of sedatives and/or beta-blockers before sleep- Smoking Clinical features:- Restless sleep with waking, gasping, or choking- Loud, irregular snoring with apneic episodes (third-party reports)- Excessive daytime sleepiness (e.g., patient falls asleep, microsleep during meetings or while watching TV)- Impaired cognitive function (e.g., impaired concentration, memory loss)- Depression, decreased libido Diagnostics:- Initial assessment: standardized questionnaires and third-party reports- Lab tests: Polycythemia, TSH (rule out hypothyroidism)- Polysomnography: first-line method  Treatment:- Mild to moderate OSA (mild symptoms and < 20 apneic episodes)→ Weight loss → Reduce and/or avoid risk factors: alcohol, nicotine, sedatives (e.g., benzodiazepines)→ Sleep hygiene: regular and sufficient sleep→ Lateral as opposed to supine sleeping position→ Blood pressure control→ Oral appliances- Severe OSA (> 20 apneic episodes and alterations in arterial oxygen saturation)→ Surgery (uvulopalatopharyngoplasty) → Bilevel positive airway pressure (BPAP)→ Continuous positive airway pressure (CPAP)
• Somatic symptom disorder Patients with somatic symptom disorder often have multiple physical symptoms that cause significant distress and have a history of extensive (and fruitless) diagnostic testing and medical procedures. Affected patients maintain a preoccupation with their symptoms and health concerns over an extended period. Epidemiology:- ♀ > ♂- Prevalence in adults: ∼ 5–7% Diagnostic criteria: - ≥ 1 somatic symptom that causes significant distress or impairment- The patient exhibits excessive thoughts, feelings, or behaviors related to the somatic symptoms or health manifested by ≥ 1 of the following:→ Disproportionate and constant thinking about the severity of symptoms→ Constant anxiety about symptoms or general health→ Excessive amounts of time and energy attending to symptoms or health concerns- Duration: ≥ 6 months Management:- Establish regular visits with a single primary care physician in order to minimize unnecessary testing and procedures.- Gradually begin to address psychological issues with psychotherapy.
• Conversion disorder Patients with conversion disorder (also known as functional neurological symptom disorder) present with neurological symptoms that cannot be fully explained by a neurological condition. Epidemiology:- ♀ > ♂- Age of onset: ∼ 10-35 years- Strongly associated with comorbid psychiatric or neurological disorders Diagnostic criteria:- ≥ 1 neurological symptom (altered motor or sensory function)- Reported symptoms must be incompatible with recognized neurological or medical conditions.- Reported symptoms are not explained better by another medical disorder.- Symptoms cause significant distress or psychosocial impairment. Management:- Patient education- Cognitive behavioral therapy
• Illness anxiety disorder Patients present with a persistent preoccupation with having or developing a serious illness. Somatic symptoms are usually absent or mild, but patients spend large amounts of time and energy obsessing over their health and over the possibility of developing a disease. Epidemiology:- ♀ = ♂- Age of onset: usually early adulthood- Strongly associated with comorbid anxiety or depressive disorders Diagnostic criteria:- Preoccupation with having or acquiring an illness- Somatic symptoms absent or mild- Significant anxiety over health- Excessive health-related behaviors (e.g., constantly checking for minor signs of illness) or maladaptive avoidance (e.g., frequently switching doctors)- Duration: ≥ 6 months- Not better explained by another mental disorder Management:- Cognitive behavioral therapy- Schedule regular visits to one primary care physician.- Treat comorbid disorders (e.g., depression), if present.
• Factitious disorder Previously known as Münchhausen syndrome.Patients intentionally falsify signs and symptoms, even through self-harm (e.g., injecting insulin), to assume the role of a patient. Epidemiology:- ♀ > ♂- Associated with history of significant exposure to health care and personality disorders (e.g., narcissistic, borderline, or antisocial personality disorder) Diagnostic criteria:- Intentionally deceptive falsification of disease signs or symptoms, inducing injury, or promoting disease in self - Presents himself, herself to others as ill, impaired, or injured- Even occurs in the absence of external rewards- Behavior is not better explained by another mental disorder. Management- Confront the patient in a non-threatening manner.- Avoid unnecessary referral to avoid unnecessary procedures.- Treat the perpetrator (if imposed on self or on another).→ Psychotherapy and/or parenting classes→ Assess for comorbid conditions.→ Monitor pharmacotherapy intake.- Treat the victim (if imposed on another).→ Provide a safe place from the perpetrator (e.g., call child protective services).→ Psychotherapy, depending on the child's age→ Exclude other forms of abuse or neglect if suspected.
• Malingering Individuals displaying malingering behavior present with vague complaints, either false or grossly exaggerated, that do not conform to a known medical condition. This is an intentional behavior motivated by an external reward (e.g., avoiding the police; obtaining narcotics, insurance money, sympathy from others, time off work, etc.). Malingering individuals are typically uncooperative and insist on undergoing an extensive medical evaluation. Epidemiology: ♂ > ♀ Diagnostics: Any combination of the following are suggestive of the condition.- The individual presents under medicolegal circumstances (e.g., self-referral while criminal charges are pending).- Clinical findings do not match up with the individual's complaints.- Lack of patient cooperation during diagnostic evaluation and/or treatment- Features of antisocial personality disorder Management:- Confront the patient in a nonthreatening manner (give the patient the opportunity to be honest).- Avoid unnecessary referral (which perpetuates malingering).
• Frotteuristic disorder - Treatment SSRI + CBT
• Delusional disorder Clinical features:- ≥1 delusions for ≥1 months- Other psychotic symptoms absent or not prominent- Behavior not obviously odd/bizarre; ability to function apart from delusion's impact- Subtypes: Erotomanic, grandiose, jealous, persecutory, somatic Differential diagnosis:- Schizophrenia: Other psychotic symptoms present (eg, hallucinations, disorganization, negative symptoms); greater functional impairment- Personality disorders: Pervasive pattern of suspiciousness (paranoid), grandiosity (narcissistic), or odd beliefs (schizotypal), but no clear delusions Treatment:- Antipsychotics- CBT
• Electroconvulsive therapy for depression Indication:- Treatment resistance- Psychotic features- Emergency conditions→ Pregnancy→ Refusal to eat or drink→ Imminent risk for suicide Safety:- No absolute contraindications- Increased risk→ Severe cardiovascular disease, recent myocardial infarction→ Space-occupying brain lesion→ Recent stroke, unstable aneurysm
• Urine drug screen Amphetamine:- Duration of positive test (short-term use): ≤ 2 days- Duration of positive test (long-term use): ≤ 4 days- False positives: Atenolol, propanolol, bupropion, nasal congestants Cocain:- Duration of positive test (short-term use): ≤ 2 days- Duration of positive test (long-term use): ≤ 7 days- False positives: High specificity Cannabis:- Duration of positive test (short-term use): ≤ 3 days- Duration of of positive test (long-term use): 1-2 months- False positives: Hemp-containing foods Opioids:- Duration of positive test (short-term use): ≤ 3 days- Duration of positive test (long-term use): ≤ days- False positives: Poppy seedsStandard urine drug tests do not detect semisynthetic (eg, hydrocodon, hydromorphone, oxycodone) or synthetic (e.g., fentanyl, meperidine, methadone, tramadol) opioids. Phencyclidine:- Duration of positive test (short-term use): ≤ 7 days- Duration of positive test (long-term use): ≤ 7 days- False positives: Diphenhydramine, doxylamine, ketamine, tramadol, venlaflaxine
• Substance abuse - Bath salts Synthetic cathinones, which consist of a large family of amphetamine analogues.Increase the release, or inhibit the reuptake, of norepinephrine, dopamine, and serotonin. Usually sold as white powder in small packages labeled as "bath salts," "plant food," "cleaners."May be ingested orally, inhaled, or injected. Symptoms of intoxication:- Severe agitation- Combativeness- Psychosis- Delirium- Myoclonus- Seizures- Increased blood pressure and heart rate Most distinguishing feature of bath salts intoxication is the prolonged duration of effect (up to a week). Not in routine toxicology screens.
• Dhat syndrome Culture-bound syndrome found in South Asian cultures in which sufferers attribute a range of psychological and somatic complaints to the loss of semen via various methods (eg, loss in urine, excess masturbation)
• Causes of stridor in infants & toddlers Acute:Croup:- Parainfluenza virus, most cases in fall/winter- Inspiratory or biphasic stridor, "barky" cough, infectious symptoms Foreign body aspiration:- ± Choking episode- Inspiratory stridor &/or wheeze, focally diminished breath sounds Chronic:Larnygomalacia:- "Floppy" supraglottis, prominent age 4-8 months- Inspiratory stridor worsens when feeding, crying, or supine; improves when prone Vascular ring:- Great vessels encircle & compress trachea- Biphasic stridor that improves with neck extension Airway hemangioma:- Hemangiomas enlarge in the first few weeks of life- Worsening biphasic stridor, concurrent skin hemangiomas ("beard distribution")
• Tardive dyskinesia Clinical features:- Abnormal involuntary movements due to prolonged use of antipsychotics or metoclopramide- Orofacial dyskinesia (tongue protrusion, lip smacking, grimacing)- Limb dyskinesia (dystonic postures, foot tapping, chorea)- Trunk dyskinesia (rocking, thrusting, shoulder shrugging)- Greater risk with first-generation antipsychotics Management:- Discontinue causative medication if feasible- Switch to second-generation antipsychotic (quetiapine, clozapine) if continued antipsychotic is required- Treat with valbenazine or deutetrabenazine (reversible VMAT2 inhibitors)
• Substance abuse - Beta blockers Clinical features:- Bradycardia/bradyarrhythmia- Cardiogenic shock (hypotension; cold, clammy extremities)- Hypoglycemia- Hyperkalemia- Wheezing (bronchoconstriction)- Neurological symptoms (seizure, delirium, coma) Management:- Secure airway- Correct hypotension: IV fluids and vasopressors (epinephrine)- Correct bradycardia: atropine- Treat cardiogenic shock: IV glucagon (↑ cAMP → ↑ cardiac contractility); IV calcium salts- Correct hypoglycemia: IV high-dose insulin with glucose
• Intermittent explosive disorder An impulse control disorder characterized by recurrent outbursts of physical and/or verbal aggression against people and/or property. Clinical features:- Occur after the age of 6 years- Not pre-meditated- Grossly out of proportion to the triggering event- Associated with marked distress or impairment of interpersonal or occupational functioning- After the act the patient is calm, relaxed, and without remorse Treatment:- SSRIs- Group therapy oriented at self-reflection
• Muscle dysmorphia Diagnotic criteria:- Patients preoccupied with insuffienct musculature- Use of anabolic steroids or excessive weightlifting and exercising Complications:- Rhabdomyolysis- Roid rage (uncontrollable anger or violent behavior resulting from the usage of anabolic steroids)
• Acute stress disorder Characteristic symptoms that last between 3 days to 1 month following ≥ 1 traumatic event(s) Epidemiology:- Presents in up to ∼ 50% of individuals suffering interpersonal traumatic events- Occurs in up to ∼ 13% of individuals in motor vehicle accidents Risk factors:- Preexisting mental disorder- Poor social support- Witnessing a traumatic event (e.g., rape, assault)- Significant physical injury from a traumatic event Diagnostic criteria:- Intrusion: Nightmares, flashbacks, memories- Negative mood: Depression- Dissociation: Depersonalization, amnesia- Avoidance: Symbols, locations, memories- Arousal: Hyperviligance, irritability, easily startled, changes in concentration Treatment:- Cognitive behavioral therapy is first-line treatment.- Benzodiazepines can be administered to reduce agitation or sleep disturbances.
• Depression with suicidal ideation If there are suicidal ideations AND a plan, hospitalize. If there are suicidal ideations but no plan, safety contract. If there are no suicidal ideations, use SSRI, SNRI.
• Disruptive mood dysregulation disorder Condition of extreme irritability, anger, and severe recurrent outbursts of temper (verbal or behavioral) for ≥ 12 months (without interruption > 3 months). Epidemiology:- ♂ > ♀- Age at onset < 10 years Diagnostic criteria:- Severe temper outbursts (verbal or behavioral) at an average of ≥ 3 times/week that are grossly disproportionate in intensity or duration to the situation and the child's developmental level- Persistent angry or irritable mood in between outbursts; observable by others (e.g., parents, teachers, peers)- Trouble functioning due to irritability in various situations (e.g., home, school, with peers) Treatment:- Psychotherapy (individual and family), parent management training- Pharmacotherapy to address irritability and mood problems Prognosis: children may develop major depressive disorder or anxiety disorders in adulthood

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