PSYCHIATRY & ETHICS TiKi TaKa

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. PSYCHOTIC DISORDERS:
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. Combination of positive &/or negative symptoms.
. POSITIVE SYMPTOMS (Associated e' DOPAMINE receptors):
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-> Delusions (Mostly bizarre).
-> Disorganized speech/behavior.
-> Hallucinations.
-> Agitation.
-> Impairment of baseline functions.
. NEGATIVE SYMPTOMS (Associated e' MUSCARINIC receptors):
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-> Flattened affect.
-> Social withdrawal.
-> Anhedonia.
-> Apathy.
-> Poverty of thought.
. N.B. Atypical anti-psychotics are the most effective ttt for -ve symptoms.
. N.B. The key differentiating feature is the DURATION of symptoms:
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. SCHIZO-PHRENIA: > 6 MONTHS.
. SCHIZO-PHRENI-FORM DISORDER: < 6 MONTHS BUT > 1 MONTH.
. BRIEF PSYCOTIC DISORDER: < 1 MONTH (Look for a stressful life event
precipitating it).
. SCIZO-AFFECTIVE DISORDER:
-> Distinguished from schizophrenia by the presence of mood symptoms
-> (mania or depression) during the course of the disease.
. N.B.
. Disorganized speech & CIRCUMSTANTIALITY is common in pts with schizophrenia;
. They deviate from the original subject but eventually returns to it !
. N.B.
. Schizophrenic pts have ++ ventricular size on CT !!

. N.B.
. When there is H/O of syms for many years e' NO IMPROVEMENT OF BASELINE
FUNCTIONING,
. think of:
* DELUSIONAL DISORDER:
-> Key is that delusions are NON-bizarre.
-> Delusions may occur normally in daily life.
-> Delusions are false beliefs in high functioning person.
* PERSONALITY DISORDERS (Especially SCHIZOTYPAL PERSONALITY DISORDER):
-> Prsents with peculiar thinking & social isolation.
-> No psychosis.
. The previous two types of pts (DELUSIONS & PERSONALTY DISORDERS):
-> Don't respond to anti-psychotics.
-> PSYCHOTHERAPY is the preferred therapy.
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N.B.
A DELUSION is a fixed, false belief not consistent with cultural norms.
Individuals with GRANDIOSE DELUSIONS typically believe they have
special powers extraordinary accomplishments or a special relationship e' god.

. RULE OUT other forms of psychosis that are NOT schizophrenia:

-> Get a DRUG SCREEN to rule our SUBSTANCE ABUSE.
-> Look for signs & symptoms of SEIZURE !
-> TEMPORAL LOBE EPILEPSY can present with hallucinations (Auditory &
Olfactory).
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N.B.
Watch out for SUICIDAL IDEATION in schizophrenia pts & schizophreniform pts.
50 % of them attempt suicide & 10 % are successful.
1st stepin management is always to HOSPITALIZE if there is risk of suicide.

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The 1st step in management of any acute psychiatric condition is:

to determine if the pt needs hospitalization !
Hospitalize if the pt at risk of harm to self or to others.
Hospitalize against the pt's will if the pt has suicidal or homicidal ideation.

. The greatest risk factor for progression to schizophrenia is SCHIZOFRENIFORM

DISORDER.
. Prognosis:
-> Females have a better prognosis & respond better to ttt than males.
-> Pts e' paranoid schizophrenia are more responsive to ttt.
. The prognosis is poor if there is:
-> Early age of onset.
-> Negative symptoms.
-> Poor premorbid functioning.

-> Family H/O of schizophrenia.

-> Disorganized or deficit subtype.
. Treatment:
-> If there is bizarre or paranoid syms -> HOSPITALIZE the pt.
-> Give BENZODIAZEPINES for agitation & start ANTI-PSYCHOTICS.
-> Anti-psychotic medications are given for 6 months.
-> They are most effective to prevent further episodes.
-> Long term anti-psychotics are ONLy given if there is H/O of REPEATED episodes.
-> Initiate log-term psychotherapy.
. ANTI-PSYCHOTICS:
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. Have an IMMEDIATE QUIETING EFFECT in acute atacks.
. Delay relapse.
. Used for sedation when benzodiazepines are cont'd or as an adjunct during
anesthesia.
. Used for ttt of movement disorders (Huntington's disease & Tourette $),
. to suppress tics & vocalization
. N.B. In ttt of Tourette $ -> We use TYPICAL antipsychotics (Haloperidol &
PIMOZIDE).
. N.B. Antipsychotics are chosen based on side effect profile, NOT efficacy !
. A . CONVENTIONAL (TYPICAL) ANTIPSYCHOTICS:
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(1) HIGH POTENCY {FLUPHENAZINE DECANOATE - HALOPERIDOL}:
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-> Less sedating - Fewer anticholinergic effects - Less hypotension.
-> Useful as depot injections (Haloperidol decanoate) for non-compliant pts.
-> Give IM route for acute psychosis when pt is unable or unwilling to take PO.
-> GREATEST ASSOCIATION WITH EXTRAPYRAMIDAL SYSTEMS (EPS).
-> ++ PROLACTIN.
(2) LOW POTENCY {THIORIDAZINE - CHLORPROMAZINE):
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-> Less likely to cause EPS.
-> Greater anticholinergic effects - More sedation - More postural hypotension.
. B . ATYPICAL ANTIPSYCHOTICS (RISPERIDONE - OLANZAPINE - QUETIAPINE CLOZAPINE):
___________________________________________________________________________________
-> OLANZAPINE is the best.
-> Drug of choice in initial therapy.
-> Greater effect on negative symptoms.
-> Little or no risk of EPS.

. N.B. SIDE EFFECTS of ATYPICAL ANTIPSYCHOTICS:

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. Clozapine -> Agranuloctosis (Order CBC before initiatin ttt & one week after).
. Quetiapine -> Cataracts.
. Olanzapine -> Weight gain - Hyperglycemia - Dyslipidemia.
. Respiredone -> Hyperprolactinemia.
. N.B. Anti-psychotic medications -> Dopamine receptor blockage ->
Hyperprolactinemia.
. ++ PRL > 200 ng/ml -> Gynecomastia - Galactorrhea - Menstrual dysfunction & -libido.
. N.B. Antipsychotics -- dopamine activity in the TUBERO-INFUNDIBULAR pathway.
. NOOOOOOOOTTTTTTTTT the mesolimbic pathway xxxxxxxx !
. LOW potency antipsychotics have the highest risk of causing ORTHOSTATIC
HYPOTENSION
. Due to (ALPHA BLOCKAGE).
. LOW potency antipsychotics have the highest risk of causing ANTICHOLINERGIC
SYMPTOMS
. Acute urine retention - Dry mouth - Blurry vision - Delirium.
. Thioridazine is associated with prolonged QT & arrhythmias.
. Order an EKG if there is chest pain - SOB - plapitations.
. Thioridazine is associated with abnormal retinal pigmentation.
. Routine eye exam is important.
. NONcompliance in males -> IMPOTENCE & INHIBITION OF EJACULATION.
. NONcompliance in females -> WEIGHT GAIN - HYPERPROLACTINEMIA GALACTORRHEA &AMENORRHEA
. Olanzapine - Quetiapine are 1st choice medications when INSOMNIA is a problem !
. RISPERIDONE is the 1st choice medication when SEDATION is a problem !
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. MOVEMENT DISORDERS:
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. Extra-pyramidal symptoms (EPS) are the most common reason for failure to
comply e' ttt.
. Acute dystonia - Bradykinesia - Tardive dyskinesia - Neuroleptic malignant $.
. Most common culprit atypical antipsychotic is RISPERIDONE -> Switch to
CLOZAPINE.

{1} ACUTE DYSTONIA:

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. Occurs in the 1st week.
. Muscle spasms (Torticollis) & difficulty swallowing.
. Young men are at higher risk.
. Tx -> Reduce the dose.
. Tx -> ANTICHOLINERGICS (Benztropine - Diphenhydramine - Trihexiphenidyl).
{2} BRADYKINESIA (PARKINSONISM):
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. Within weeks.
. Bradykinesia - tremors - rigidity & other signs of parkinsonism.
. Elderly are at higher risk.
. Tx -> Reduce the dose.
. Tx -> ANTICHOLINERGICS (Benztropine - Diphenhydramine - Trihexiphenidyl).
. Tx -> Amantadine (Dopamine agonist).
{3} AKATHISIA:
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. Weeks to chronic use.
. Motor restlessness (Do NOt nistake for anxiety or agitation).
. Tx -> Reduce the dose.
. Tx -> Add benzodiazepines or BBs (Propranolol).
{4} TARDIVE DYSKINESIA:
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. Months to years.
. Choreoathtosis & other involuntary movements after chronic use.
. Often irreversible.
. Circumoral movements.
. Tx -> Stop older antipsychotics.
. Tx -> Switch to newer antipsychotics (Clozapine).
. It can be ttt with BENZTROPINE.
. Symptoms commonly worsen after medication discontinuation.
. N.B.
. Chronic use of dopamine antagonists eg. antiemetics (Metoclopramide &
Prochlorperazine)
. can result in tardive dyskinesia.
{5} NEUROLEPTIC MALIGNANT $YNDROME:
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. Any time !
. Muscle rigidity - Hyperthermia - Volatile vital signs - Altered consciousness.
. ++ WBCs & ++ Creatinine kinase level.
. Tx -> Stop antipsychotics.
. Tx -> DANTROLENE (Muscle relaxant).
. Transfer to ICU for monitoring.
. Mortality rate 20 %.

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N.B.
CLOZAPINE is the most effective anti-psychotic for schizophrenia.
CLOZAPINE has NO incidence of movement disorders.
CLOZAPINE is a 2nd line therapy bec. of the risk of seizures & agranulocytosis.
Remember to monitor CBC to watch for bone marrow suppression.

. N.B.
. BENZTROPINE (Anticholinergic)
. is the 1st line ttt in management of acute dystonia & bradykinesia (parkinsonism).
. N.B.
. BBs (Propranlol) is the 1st line ttt of akathisia.
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. ANXIETY DISORDERS ( ):
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. Anxiety that interferes e' daytime functioning not due to any other identifiable
cause.
. Medical causes:
. Hyperthyroidism - Pheochromocytoma - Excess cortisol - Heart failure.
. Arrhythmia - Asthma - COPD.
. Drugs:
. Corticosterids - Cocaine - Amphetamines - Caffeine.
. Withdrawal from alcohol & sedatives.
{1} ADJUSTEMENT DISORDER ( ):
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. Normal psychological reaction (anxiety - depression - irritability).
. occurs soon after profound changes in a person's life.
. such as divorce - migration - birth of handicapped child.
. Symptoms are not severe enough to be classified in another category.
. It is NOT a true anxiety disorder.
. Tx -> Psychotherapy & counselling to help with the pt adjust to the life stressor.
. NO medications.
{2} PANIC DISORDER ( ):
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. Brief attacks of intense anxiety with autonomic symptoms;
. tachycardia - hyperventillation - dizziness - sweating.
. Episodes occur REGULARLY without an obvious precipitant.
. Absence of any other psychiatric ilness.
. Tx -> COGNITIVE BEHAVIORAL THERAPY.
. Tx -> Relaxation training & desensitization.
. Tx -> Acute panic attack -> Benzodiazepines (Alprazolam - Clonazepam).

. Tx -> Long term symptomatic relief -> SSRIs (Fluoxetine).

. Tx -> Imipramine & MAOIs (Phenelzine) may be used.
. N.B. Panic disorder pts have ++ risk of depression !
{3} PHOBIC DISORDERS ( ):
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. Persistent, unreasonable intense fear of situations, circumstances or objects.
. No known eliciting events in phobic disorders associated with the onset of
symptoms.
. D.D. -> Post-traumatic stress diorder (PTSD) & Acute stress diorder (AST);
. which have a HISTORY OF TRAUMATIC EVENT (Threat to life).
(a) AGORAPHOBIA ( ):
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. Fear of avoidance of places due to anxiety about non being able to escape;
. public spaces - being outside alone - public transportation - crowds.
. It is more common in women.
(b) SOCIAL PHOBIA ( ):
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. Fear of humiliation or embarrasement in either general or specific social
situations;
. public speaking - stage fright - Urinating in public restrooms.
. The pt knows that the response is excessive & unreasonable.
. D.D. AVOIDANT PERSONALITY DISORDER:
. The person does NOT believe the avoidance is excessive or unreasonable.
. Tx of generalized social anxiety disorder:
-> SSRIs (Paroxetine) & cognitive behavioral therapy.
(c) SPECIFIC PHOBIAS:
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. Most common type of phobias.
. Animals (Carnivores or spiders) - Natural environments (Storms).
. Injury (Injection - Blood) - Situations (Heights - Darkness).
. Tx -> Exposure therapy -> ++ exposure to stimulus to induce habituation & -anxiety.
. Benzodiazepenes & Beta blockers are helpful when given prior to exposure.
. BBs are useful in performance related anxiety.
{4} OBSESSIVE COMPULSIVE DISORDER (OCD) ( ):
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. Recurrent obsessions or compulsions.
. The pt recognizes that the behavior is unreasonable & excessive (there is insight).
. Obsessions are anxiety provoking; thoughts are intrusive.
. Related to contamination, doubt, guilt, aggression & sex.
. Compulsions are peculiar behaviors that reduce the anxiety.

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Most commonly habitual hand washing, organizing, checking, counting & praying.
Pts with Tourette $ often also have OCD !!
Depression & substance abuse are common.
Tx -> 1st line of ttt is SSRIs (Paroxetine & Sertaline).
SSRIs alter neurotransmitter serotonin level.
Behavioral therapy is useful.

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N.B.
Obsessive symptoms in psychotic disorders may be misdiagnosed as OCD.
You can differentiate psychosis from OCD by looking for:
a lack insight & loss of contact to reality.

. N.B.
. Pts with Tourette $ have a high risk of developing ADHD or OCD !
{5} ACUTE STRESS DISORDER (ASD) & POST-TRAUMATIC STRESS DISORDER
(PTSD):
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. ACUTE STRESS DISORDER (ASD) ->
. POST-TRAUMATIC STRESS DISORDER (PTSD) ->
. Anxiety symptoms that follow a life threatening event.
. ASD -> Symptoms last LESS THAN ONE MONTH & occur within 1 month of
stressor.
. PTSD -> Symptoms last MORE THAN ONE MONTH.
. Re-experiencing of the traumatic event: Dreams, flashbacks or intrusive
recollections.
. Avoidance of stimuli associated e' trauma or numbing of general responsiveness.
. Increased arousal: Anxiety, sleep disturbances, hypervigilance & impulsiveness.
. Tx -> Benzodiazepines acutely for anxiety symptoms.
. SSRIs & anti-depressants can be helpful for long term therapy.
. N.B.
. GROUP COUNSELING is the most effective to prevent PTSD following a traumatic
event.
{6} GENERALIZED ANXIETY DISORDER (GAD):
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. Excessive, poorly controlled anxiety that occurs daily for more than 6 months.
. No single event or focus is related to anxiety.
. It often coexists e' major depression, specific phobi, social phobia & panic
disorder.
. Tx -> SUPPORTIVE PSYCHOTHERAPY.
. Tx -> SSRIs, Venlafaxine, buspirone & benzodiazepenes may be used.
. N.B.
. Distinguish GAD from panic attack or social phobiaby what is causing the anxiety.

. If the question describes persistent worry of a panic attack or social encounter,

. then GAD is NOT the answer.
. In GAD, multiple life circumstances, not just one, are causing the anxiety.
. ANXIOLYTIC MEDICATIONS:
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. Adjustment disorder with anxious mood:
. Tx -> Benzodiazepines with brief psychotherapy.
. Rapid onset to therapy.
. Panic disorder:
. Tx -> SSRIs, Alprazolam & Clonazepam.
. They -- intensity & frequency of panic attacks.
. GAD: Tx -> Venlafaxine (-- overall anxiety).
. OCD: Tx -> SSRI (-- obsessional thinking).
. Social phobia -> SSRIs (-- fear ass. e' social situations).
. Benzodiazepines:
-> Don't change dosages abruptly.
-> Use the lowest dose in the elderly.
-> Advise against using machinery or driving.
-> Half life -> ALPRAZOLAM < LORAZEPAM < DIAZEPAM.
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N.B.
Abrupt cessation of Alprazolam (used in sleeping difficuties),
which is a short acting benzodiazepine lead to withdrawal symptoms;
in the form of generalized tonic clonic seizures.

. BUSPIRONE:
-> Therapeutic effect can take up to 1 week.
-> No sedation or cognitive impairment.
-> Best option for people with occupations where driving or machinery is involved.
-> No withdrawal syndrome.
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. MOOD DISORDERS ( ):
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{1} MAJOR DEPRESSIVE DISORDER ( ):
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. Depressed mood or anhedonia & depressive symptoms lasting at least 2 weeks.
. Major depressive disorder = Depressed mood + SIGECAPS.

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S -> changes in (S)leep.

I -> loss of (I)nterest.
G -> thoughts of worthlessness or (G)uilt.
E -> loss of (E)nergy.
C -> trouble (C)oncentrating.
A -> changes in (A)ppetite or weight.
P -> changes in (P)sychomotor activity.
S -> thoughts about death & (S)uicide.

. All depressed pts sh'd be asked about death or suicideal thoughts.

. Look for other causes of depression where the 1st step in management is
different:
-> Hypothyroidism (Check TSH).
-> Parkinson's disease.
-> Medications (Corticosteroids, BBs, antipsychotics).
-> Substance abuse (Alcohol - Amphetamines).
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Tx -> Admit the pt if there is suicidal/homicidal ideation or paranoia.

Begin antidepressant medications (SSRI is the 1st drug of choice).
Give benzodiazepines if agitated.
Electroconvulsive therapy (ECT) is the best choice if the pt is acutely suicidal.

. N.B.
. The antidepressant of choice for depressed pts who don't respond to 1st line ttt
. with an SSRI (e.g. Paroxetine) is another medication of the same class
(Citalopram).
. N.B.
. In management of single episode of major depression,
. the antidepressant sh'd be continued for a period of 6 months.
{2} DYSTHYMIC DISORDER ( ):
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. DYSTHYMIA = PERSISTENT DEPRESSIVE DISORDER.
. The pt is depressed over entire life.
. Low level depression symptoms on most days for at least 2 years.
. Superimposed acute major depressions may occur.
. Don't hospitalize the pt unless there's suicidal ideation.
. Tx -> Long term individual, insight oriented psychotherapy.
. Tx -> If failed, a trial of SSRIs may be done.
{3} SEASONAL AFFECTIVE DISORDER ( ):
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. Depressive symptoms in the winter months (Shorter daylight hours).
. Absence of depressive symptoms during summer months (Longer daylight hours).
. Tx -> Psychotherapy or sleep deprivation.
{4} BIPOLAR DISORDER ( : ):

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. Episodes of depression, mania or mixed symptoms for at least 1 week.
. H/O of both manic syms & depressive syms as well as periods of normal mood.
. RAPID CYCLIC BIPOLAR is indicated by > 4 episodes of mania per year.
. Risk of bipolar disorder in general population is 1 %.
. It is 10 % risk in those with 1st degree relative H/O.
. MANIA SYMPTOMS:
-> Grandiosity - Less need for sleep - Excessive talking - Pressured speech.
-> Racing thoughts - Flight of ideas - Distractability - Sexual promiscuity.
-> Goal focused activity at home or at work.
. MAJOR DEPRESSIVE SYMOTOMS:
-> Depressed mood - Loss of pressure or interest.
. BIPOLAR TYPE (1) DISORDER: MANIC episodes; pts may or may not 've depressive
episodes.
. BIPOLAR TYPE (2) DISORDER: Major depression + Hypomania.
. MANAGAEMENT:
*1* HOSPITALIZE (in case of severe manic symptoms despite mood stabilizer
therapy).
*2* Mood stabilizers are used to induce remission.
. Lithium is the drug of choice (takes 1 week for effect).
*3* Antipsychotics are used until acute mania is controlled.
. Risperidone is the drug of choice.
*4* Give IM depot phenothiazine in non-compliant severely manic patients.
*5* Give antidepressants only when there's a H/O of recurrent episodes of
depression,
. Given ONLY TOGETHER with mood stabilizers (to prevent including manic
episode).
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N.B.
The long term therapy of bipolar disorder is mood stabilizer (Lithium).
Lithium is NEPHROTOXIC.
If the pt has renal problems (++ urea & creat) -> Give VALPROIC ACID.

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N.B.
Lithium in the 1st trimester of pregnancy is very dangerous.
It causes cardiac malformations.
Septal defects & Ebstein's anomaly (Atrialization of right ventricle).
In 2nd & 3rd trimesters, it causes goiter & neuromuscular dysfunction.

. N.B.
. Choose electro-convulsive therapy (ECT) for 1st trimester pts with manic
episodes.
. LAMOTRIGENE may be used in 2nd or 3rd trimester.
. N.B.
. Pts who are extremely agitated, psychotic or manic, sh'd be initially managed with
. an antipsychotic medication such as "Haloperidol".
{5} CYCLOTHYMIA ( ):
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. H/O of recurrent episodes of depressed mood & hypomanic mood for at least 2
years.
. It is a mild form of bipolar affective disorder.
. Tx -> Psychotherapy is the 1st line of ttt.
. DIVALPROEX is used when functioning is impaired (More effective than Lithium).
{6} GRIEF & DEPRESSION ( ):
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.

< GRIEF >

< DEPRESSION >

. Sadness - Tearfulness - -- Sleep - -- Appetite - -- interest in the world.

. Symptoms wax & wane.
. Symptoms are pervasive & unremitting.
. Shame & guilt are less common.
. More common.
. Suicidal ideation is less common.
. More common.
. Symptoms can last up to 1 year.
. Symptoms continue for more than 1
year.
. Pt returns to normal functioning in 2 months . No return to base line functioning.
. Tx -> SUPPORTIVE therapy.
. Tx -> ANTI-DEPREESANTs.
. N.B.
. BEREAVEMENT is a normal reaction o the loss of beloved one !
. PERSISTENT COMPLEX BEREAVEMENT DISORDER -> Severe impairment >12
months after the loss!
. N.B.
. COMPLICATED GRIEF / EXTENDED BEREAVEMENT can present e' syms of major
depression.
. Bereaved pts who have at least 2 weeks of syms of depression,
. 6-8 weeks after a major loss, sh'd be considered for ttt with:
. BOTH PSYCHOTHERAPY & TRIAL OF ANTIDEPRESSANTs.
. N.B.
. Pts e' both mood & psychotic symptoms respond to both antidepressants &
antipsychotics.
. However, you must treat the worst symptoms first.
. N.B.

. Auditory hallucinations e'out other psychotic symptoms are normal in grief

reaction.
{7} POST-PARTUM DEPRESSION:
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. A . POSTPARTUM BLUES = BABY BLUES:
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. After any birth.
. Mother cares about the baby.
. Mild depressive symptoms.
. Self limited, no ttt necessary.
. B . POSTPARTUM DEPRESSION:
_____________________________
. Usually after 2nd birth.
. Many have thoughts about hurting the baby.
. Severe depressive symptoms.
. Tx -> Antidepressants.
. C . POSTPARTUM PSYCHOSIS:
____________________________
. Usually after 1st birth.
. Mothers have thoughts about hurting the baby.
. Psychotic symptoms along with severe depressive symptoms.
. Tx -> Mood stabilizers or antipsychotics & antidepressants.
. Avoid medications if the pt is breastfeeding; use ECT instead !
{8} SUICIDE & SUICIDAL IDEATION:
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* RISK FACTORS:
________________
. History of suicide threats & attempts is the most important predictor of suicide.
. Family H/O of suicide.
. Perceived hopelessness (Demoralization).
. Scizophrenia, borderline or antisocial personality.
. Drug use, especially alcohol.
. Males.
. Age > 65 ys.
. Socially isolated, recently divorced or widowed.
. Chronic physical illness.
. Low job satisfaction or unemployment.
* EMERGENCY ASSESSMENT:
________________________
. Take all suicide threats seriously.
. Detain & hospitalize (Usually 2 weeks).
. Never transport patient to emergency depratment without medically trained
personnel.

. Don't identify with the pt.

. Tx of choice -> PSYCHOTHERAPY + ANTIDEPRESSANTs (SSRIs are the 1st choice).
. For acute severe risk of self-harm -> Tx of choice is ECT.
. N.B.
. Minors with suicidal attempts must be admitted to hospital ,
. even against their parents will (Their consent is NOT mandatory).
* INDICATIONS FOR ELECTROCONVULSIVE THERAPY (ECT):
___________________________________________________
. Major depressive episodes that are unresponsive to medications.
. High risk of immediate suicide.
. Contraindications to using antidepressants.
. Good response to ECT in the past.
. The biggest complication of ECT is TRANSIENT MEMORY LOSS,
. which worsens with prolonged therapy & resolves after several weeks.
. Use of ECT is cautioned in pts with space occupying intracranial lesions.
. ECT ++ ICT.
* ANTIDEPRESSANTs & MOOD STABILIZERs:
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. SSRIs are the 1st line of therapy.
. TCAs are avoided bec. of risk of toxicity (U sh'd monitor BP).
. MAOIs are more helpful in atypical depressive disorders.
. Switch to another antidepressant if there is no response after 8 weeks.
. Treat the pt for 6 months then taper the dose gradually.
. SSRIs are the 1st line of therapy in the following disorders:
-> Major depressive disorder.
-> Bipolar disorder.
-> Anxiety disorders (Panic disorder - OCD - Social phobia - GAD).
-> Bulimia nervosa.
. When the Q. describes a pt concerned about weight gain or sexual side effects,
. Give Bupropion (causes modest weight loss).
. Bupropion is associated with SEIZURES !!
. When the Q. describes a pt who has poor appetite, loos of weight or insomnia,
. Give MIRTAZAPINE (Ass. e' weight gain).
. AMITRIPTYLINE is used to treat chronic pain (Neuropathic pain).
. Amitriptyline is ass. e' antichlinergic effects (If severe switch to SSIs).
. IMIPRAMINE is useful in noctunal enuresis (DESMOPRESSIN is the 1st choice).
. TRAZADONE is strongly sedating used in ttt of pts with insomnia.
. Trazadone causes PROLONGED ERECTION !

. SSRIs & TCAs are SAFE in pregnancy except for PAROXETINE !

. Seizures are common with TCAs & Bupropion.
. These medications sh'd be avoided in pts with seizures disorders.
. The best 1st line of ttt in pts with seizures is SSRIs.
. TCAs have anticholinergic effects & are an Alpha blocker,
. causing peripheral vasodilatation & hypotension.
. TCAs affect the sodium channels in the cardiac tissue.
. EKG is the single most important test to guide TCAs therapy.
. Watch out for prolonged QRS, QT & PR intervals.
. Most serious complication is ventricular tachycardia & fibrillation.
. SODIUM BICARBONATE Na HCO3 attenuates TCA cardiotoxicity by alkalinization of
blood,
. which uncouples TCA from myocardial sodium channels & ++ extracellular Na
concentration
. Lithium is the 1st line of ttt for BIPOLAR & SCHIZOAFFECTIVE disorders.
. Side effects:
-> Acne & weight gain are the most common problems.
-> Tremors, GI distress & headaches.
-> Hypothyroidism (Order TSH level).
-> Polyurea 2ry to lithium induced DI (Order Creinine level).
-> Fetal cardiac defects & Ebstein's anomaly if used in 1st trimester.
. DIVALPROEX is the 1st line of choice for rapid cyclic bipolar disorder.
. CARBAMAZEPINE is the SECOND line of ttt for bipolar disorder.
. Used when lithium is ineffective or contraindicated.
. Not used due to severe agranulocytosis & sedation side effects.
. Lithium for life time !!
. Pts who've experienced 2 episodes of acute mania sh'd be considered for long
time
. if previous manic episodes were severe or there is family H/O.
. Pts with 3 or more relapses are recomended to have life time lithium therapy.
. Q. What is the 1st assessment prior to prescribing antidepressants ?
. A. Suicidal ideation.
_____________________________________________________________________________________
_____
. MEDICATION OVERDOSES:
________________________
________________________
{1} LITHIUM TOXICITY:

______________________
. Elderly p who takes lithium with renal failure or hyponatremia.
. May be induced by diuretics, vomiting or dehydration.
. Nausea - vomiting - acute disorientation - tremors - ++ DTRs - seizures.
. Tx -> DIALYSIS.
{2} NEUROLEPTIC MALIGNANT $YNDROME:
____________________________________
. H/O of recent start with antipsychotics (Specially HALOPERIDOL).
. H/O of Parkinson's pt who has recently stopped Levo dopa.
. High fever - Tachycardia - Ms rigidity - Altered consciousness - Autonomic
dysfunction.
. It is unrelated to dosage or previous drug exposure.
. 20 % mortality rate.
. Tx -> Transfer to ICU.
. Tx -> Discontinue antipsychotic.
. Tx -> Bromocriptine to overcome dopamine receptor blockage.
. Tx -> Ms relaxants (DANTROLENE or DIAZEPAM) to reduce ms rigidity.
{3} SEROTONIN $YNDROME:
________________________
. H/O of SSRIs use or migraine medication (triptans) or MAOIs.
. Agitation - Hyperreflexia - Hyperthermia - Muscle rigidity.
. Volume contraction 2ry to sweating & insensible fluid loss.
. Tx -> IV fluids.
. Tx -> Cryptoheptadine to -- serotonin production.
. Tx -> Benzodiazepine to -- muscle rigidity.
{4} MAOIs INDUCED HYPERTENSIVE CRISIS:
_______________________________________
. H/O of MAOI use with acute hypertension.
. H/O of antihistaminics or nasal decongestants may be a cause.
. H/O of consumption of tyramine rich foods (Cheeses - Pickled foods).
. May also be seen in pts who take a MAOI (Phenelzine) & a TCA concurrently.
. Tx -> As hypertensive crisis.
_____________________________________________________________________________________
_____
. SOMATOFORM DISORDERS = :
______________________________________
. Physical symptoms without medical explanation.
. Severe enough to interfere with the pt's ability to function.
{1} SOMATIZATION DISORDER = :
_____________________________________
. 4 pain symptoms + 2 GIT symptoms + 1 Sexual symptom + 1 psudoneurologic
symptom
. Tx -> Maintain a single physician as the primary care giver.
. Tx -> Schedule brief monthly visits.

. Tx -> Avoid diagnosting tests or therapies.

. Tx -> Schedule individual psychotherapy.
. Tx -> Do NOT hospitalize the pt.
{2} CONVERSION DISORDER = :
___________________________________
. One or more neurological symptoms that,
. can't be explained by any medical or neurological disorder.
. Most common syms (Blindness - Mutism - Paralysis - Anesthesia - Paresthesia).
. Look for psychologic factors associated with the onset of syms.
. THE PATIENTS ARE UNCONCERNED ABOUT THEIR IMPAIRMENT (LA BELLE
INDIFFERENCE).
. You must first rule out other medical conditions.
. Tx -> Supportive physician-patient relationship.
. Tx -> Psychotherapy.
. N.B.
. Somatization disorder or conversion disorder are NEVER the correct diagnosis if:
. symptoms are produced intentionally or feigned.
{3} HYPOCHONDRIASIS = :
___________________________
. The pt has false belief that he has a specific disease,
. despite repeated negative medical tests & work up.
. Symptoms must have been present for at least 6 months.
. Physician's reassurance has failed to relief concerns.
. Tx -> Identify one primary care giver.
. Tx -> Schedule regular routine visits.
. Psychotherapy ( Initiate a discussion about current emotional stressors).
{4} FACTITIOUS & MALINGERING DISORDERS =
:
__________________________________________________________
. INTENTIONALLY FEIGNED SYMPTOMS !
. A pt that has seen many doctors & visited many hospitals.
. A pt that has large amount of medical knowledge (e.g. Health care workers).
. A pt who demands a treatment.
. Always agitated & threatens litigation if tests return -ve !!
. No secondary gain (Unlike malingering).
. Factitious disorder by proxy:
-> If the signs & syms are faked by another person.
-> As in a mother making up symptoms in her child.
-> The motivation is to assume the caretaker role.
. Malingering:
-> When obvious gain results from feigned symptoms.
-> Ex: Shelter - medications - disability insurance.
-> Pts are more occupied with rewards or gain than alleviation of presenting
symptoms.

. N.B.
. Factitious disorder -> The pt wants sick role.
. Malingering disorder -> The pt wants secondary gain.
. Tx -> Supportive psychotherapy.
. Do NOT confront or accuse the pt (The pt will become angry, more guarded &
suspicious).
. Only provide the minimum amount of treatment & work up needed.
_____________________________________________________________________________________
_____
. EATING DISORDERS = :
______________________________
______________________________
{1} ANOREXIA NERVOSA = :
_________________________________
. YOUNG FEMALE - UNDERWEIGHT.
. Food restriction & excessive exercise.
. No menstrual period for 3 months or more.
. H/O of purging ( ).
. N.B.
. REFEEDING $YNDROME:
-> Fluids & electrolytes shift -> Electrolyte depletion, arrhythmias & heart failure.
. N.B.
. ANOREXIA COMPLICATIONS:
-> Osteoporosis.
-> ++ Cholesterol & carotene levels.
-> Cardiac arrhythmias (Prolonged QT interval).
-> Euthyroid sick $.
-> Hypothalamic - pituitary axis dysfunction -> Anovulation.
-> Hyponatremia secondary to excess water intake.
-> Pregnants (Miscarriage - Hyperemesis gravidarum - postpartum depression C.S.).
-> Fetus (IUGR - Prematurity).
{2} BULIMIA NERVOSA = :
______________________________
. YOUNG FEMALE - NORMAL WEIGHT RANGE.
. Frequent episodes of binge eating follwed by guilt, anxiety.
. Self induced vomiting, laxative, diuretics or enema use.
. Food restriction is NOT a feature of bulimia nervosa.
. Painless parotid gland enlargement.
. Dental enamel erosions.
. Metabolic alkalosis with hypochloremia & hypokalemia caused by emesis.
. Metabolic acidosis caused by laxative abuse.

. Risk of cardiomyopathy with excessice syrup of epicac use.

. MANAGEMENT of ANOREXIA NERVOSA & BULIMIA NERVOSA:
____________________________________________________
. HOSPITALIZE for IV hydration if electrolyte disturbance are present.
. OLANZAPINE in anorexia nervosa helps with weight gain.
. SSRI antidepressants (esp. FLUOXETINE) prevent relapses.
. Behavioral therapy.
{3} BODY DYSMORPHIC DISORDER = :
__________________________________________
. YOUNG FEMALE - Preoccupied with an imagined or slight defect in appearance.
. causing an impaired ability to function in a social or occupational life.
. Distress is most commonly related to facial features.
. The pt is often isolated & housebound.
. Tx -> High doses of SSRIs are the 1st line of ttt.
. N.B.
. If the only concern is body shape & weight -> ANOREXIA NERVOSA is more
accurate Dx.
. If the only concern is sex characteristics -> GENDER IDENTITY DISORDER is more
acc.
_____________________________________________________________________________________
_____
. IMPULSE CONTROL DISORDERS = :
______________________________________________
______________________________________________
. People who are unable to resist impulses.
. Anxiety prior to the impulse that is relieved after the pt acts on it.
. Pts do NOT believe their actions or out of proportion.
. Pts lack insight (Unlike OCD).
{1} INTERMITTENT EXPLOSIVE DISORDER = :
_________________________________________________
. Episodes of aggression out of proportion to the stressor.
. H/O of head trauma.
. If there is a H/O of drug intake -> Intermittent explosive diorder is NOT the Dx !
. Tx -> SSRIs & mood stabilizers.
{2} KLEPTOMANIA = :
_________________________
. Individual who repeatedly steals items to relieve anxiety.
. The person doesn't steal because he needs the object.
. The person often secretely replaces the object after stealing it.
. Tx -> COGNITIVE BEHAVIORAL THERAPY.
{3} PYROMANIA = :

__________________________
. Individual who repeatedly lights fires.
. Pyromania is NOT the diagnosis if the motive is personal gain (insurance money),
. or when the motive is to show anger (Differenting it from CONDUCT DISORDER).
{4} PATHOLOGIC GAMBLING = :
___________________________________
. Obsession with gambling despite the consequences.
. Tx -> Group psychotherapy (GAMBLING ANONYMOUS).
{5} TRICHOTILLOMANIA:
______________________
. Uncontrollable urge to pull out the hair -> Alopecic areas.
. These areas still contain hair of varying lenghts.
_____________________________________________________________________________________
_____
. TYPES OF ABUSE:
__________________
__________________
{1} CHILD ABUSE:
_________________
. PHYSICAL is the most common.
. Look for bruises - burns - lacerations - broken bones.
. Shaken baby $ -> Do eye exam !!
. Neglect.
. Sexual exploitation (STDs).
. Mental cruelty.
. MANDATORY REPORTING UP TO AGE 18.
. You must report ALL suspected cases.
. Protect the child (Separate from parents) & consider admission to hospital.
. Those who are younger than 1 year are at risk.
. Step children, premature, very active & defective children are at risk.
. Be careful not to mistake BENIGN CULTURAL PRACTICES (Coining - Moxibustion) for
abuse.
. Treat FEMALE CIRCUMCISION as ABUSE !!
{2} ADULT MALTREATMENT = ELDER ABUSE:
______________________________________
. NEGLECT is the most common (50 % of all reported cases).
. Physical, psychological & financial are another forms.
. You must report ALL suspected cases.
. Protect pt from abuser & consider admission to hospital.

. Caretaker is the most likely source of abuse; spouses are often caretakers.
{3} SPOUSAL ABUSE:
___________________
. PHYSICAL is the most common.
. It is the number 1 cause of injury to American women.
. Psychological & financial are another forms.
. Reporting is NOOOOOTTTTT indicated !
. Provide information about local shelters & counseling.
. High risk categories:
-> More frequent in families with drug abuse, esp. Alcoholism.
-> Victim often grew up in a violent home (about 50 %).
-> Married at a young age.
-> Dependent personalities.
-> Pregnant, last trimester (Highest risk).
. MANAGEMENT OF ABUSE:
_______________________
1 - Complete physical examination.
2 - Radiographic skeletal survey.
3 - Coagulation profile (If multiple bruises).
4 - Report to child protective services.
5 - Admission of the child to hospital.
6 - Consultation with a psychiatrist & evaluation of family dynamics.
_____________________________________________________________________________________
_____
. PERSONALITY DISORDERS (PD):
______________________________
______________________________
{A} CLUSTER A -> Peculiar thought processes & Inappropriate affect !
_____________________________________________________________________
(1) PARANOID PD:
_________________
. Mistrustful & suspiciousness of the motivations & actions of others.
. Secretive & isolated.
. Emotionally cold & odd.
. Often take legal action against other people.
. Often confused with paranoid schizophrenia.
. Main defense mechanism is projection.
. Ex. 62 ys old man lives in an apartment,
. constantly acuses his neighbors of stealing his mail & prying into his apartment.

. He believes that all his neighbors are conspiring to have him removed from the
building
(2) SCHIZOID PD:
_________________
. Emotionally distant & fear intimacy with others.
. Absorbed in their own thoughts & feelings.
. Always disinterested.
. Main defense mechanism is projection.
. Ex. 68 ys old man lives in the country-side manning a lighthouse near a remote
village.
. He is seen in town 2-3 times a year to purchase supplies.
. He has no known friends or family.
(3) SCHIZOTYPAL PD:
____________________
. Like schizoid PD except they also have MAGICAL THINKING.
. They have clairvoyance, ideas of reference & paranoid ideation.
.
.
.
.

Ex. 28 ys old man lives in a small coastal town,

attempting to start his own internet herbal business.
He believes that the herbs have magical power of healing.
He believes that spirits are guiding him to wealth.

{B} CLUSTER B -> Mood lability, dissociative symptoms & preoccupation with
rejection:
_____________________________________________________________________________________
_
(1) HISTRIONIC PD:
___________________
. Colorful exagerrated behavior & excitable.
. Shallow expression of emotions.
. Use of physical appearance to draw attention to self.
. Sexually seductive.
. Discomfort in situatios where not the center of attention.
.
.
.
.

Ex. 30 ys old woman presents to the doctor's office,

dressed in a sexually seductive manner,
insisting taht the doctor comment on her appearance.
When the doctor refuses to do so, she becomes upset.

(2) BORDERLINE PD:

___________________
. Unstable affect, mood swings, marked impulsivity, unstable relationships.
. Recurrent suicidal behaviors, chronic feelings of emptiness & identity disturbance.
. Inappropriate anger (Become intensily angered if they feel abondened).
. Main defense mechanism is SPLITTING.

.
.
.
.
.
.

Ex. 30 ys old woman reports that she has been to many doctors,
They were all wonderful until they started ignoring her or cutting her visits short,
then she realized what terrible doctors they were.
She startes the visit saying that the assistant at the front desk is the worst ever,
because she didn't smile at her.
The other assistant was just wonderful according to her !

(3) ANTISOCIAL PD:

___________________
. Continous anti-social or criminal acts.
. Inability to conform to social rules, impulsivity & aggressiveness.
. Disregard for the rights of others.
. Lack of remorse & deceitfullness.
.
.
.
.
.

Ex. 26 ys old man is caught lighting forest fires during a recent spate.
H/O of legal problems since childhood.
He reports that his mother is to blame.
He denies feeling regret.
He has no friends & is found to be hostile to everyone at the police station.

(4) NARCISSISTIC PD:

_____________________
. Sense of self-importance, grandiosity & pre-occupation with fantasies of success.
. Belief of being special, requires excessive admiration.
. Reacts with rage when criticized.
. Lacks empathy, is envious of others & is interpersonally exploitative.
. Ex. Pt in hospital for chest pain & becomes very agitated,
. because he feels he is not getting enough attention.
. He reports that he is an important CEO.
. Demands a special VIP room, more consideration & a dedicated nurse to attend
his needs.
{C} CLUSTER C -> Anxiety, preoccupation with criticism or rigidity:
____________________________________________________________________
(1) AVOIDANT PD:
_________________
. Social inhibition, feelings of inadequacy & hypersensitivity to criticism.
. They shy away from starting anything new or attending social gatherings.
. Always fear of failure or rejection.
. They desire affection & acceptance.
. They are open about their isolation & inability to interact with others.
. Ex. 45 ys old singl man fears an upcoming social party being hosted by his
parents.
. He dreads having to meet other people & doesn't feel comfortable speaking e'
others.
. He is planning on staying at home to avoid speaking to others.

(2) DEPENDENT PD:

__________________
. Submissive & clinging behavior related to a need to be taken care of.
. They are always worry about abandonment.
. They feel inadquate & helpless & avoid disagreements with others.
. They usually focus dependency on a family member or a spouse.
. Ex. 28 ys old woman seeks counseling bec. of a recent relationship breakup.
. They were dating for 6 months.
. She continues to call her ex 15 - 20 times a day eventhough he doesn't pick up.
. She says she can't understand why they broke up bec. she never disagreed with
him.
. She never left the house without him & she always asked his opinion.
. She can't imagine life without him.
(3) OBSESSIVE COMPULSIVE PD:
_____________________________
. They are preoccupied with orderliness, perfectionism & control.
. They are always consumed by details of everything & lose their sense of overall
goals.
. They are strict & perfectionistic, overconscientious & inflexible.
. Associated with difficult interpersonal relationships.
. Ex. 38 ys old man presents with his wife for marital counseling.
. The wife reorts that he is inflexible & has unrealistic demands of orderliness.
. Both partners agree that his demands are causing marital problems.
_____________________________________________________________________________________
_____
. SUBSTANCE USE DISORDERS:
___________________________
___________________________
(1) ALCOHOL DEPENDENCE = ALCOHOLISM:
_____________________________________
. Frequent use of alcohol -> Tolerance & physical & psycholical dependence.
. Alcohol abuse -> Failure to fulfill obligations, legal troubles.
. Tolerance is NOT included in the diagnosis of alcohol abuse.
. Dx -> CAGE QUESTIONNAIRE (Lab tests are never included in the diagnosis).
. CAGE -> An
-> Have you
-> Have you
-> Have you
-> Have you
hangover ?

answer of YES to any 2 of the following Qs is suggestive of abuse:

ever felt that you should CUT down your drinking ?
ever felt ANNOYED by others who have criticized your drinking ?
ever felt GUILTY about your drinking ?
ever had an EYE-OPENER to steady your nerves or alleviate a

. Order toxicology to look for another drugs: breath, blood & urine drug screens.

. Look for 2ry effects of alcohol use: ++ GGTP, AST, ALT & LDH.
. If there is suggestion of IV drug use (treack marks) -> Order HIV, HBV, HCV & PPD.
. Management of abuse or prevention of relapse -> ALCOHICS ANONYMOUS (AA).
. ACUTE OUT-PATIENT MANAGEMENT OF ALCOHOL DEPENDENCE:
-> Prevent further ETOH intake.
-> Prevent individual from driving a car, operating machinery.
-> Sedate pt if he or she becomes agitated.
-> Transfer to inpatient.
. ACUTE IN-PATIENT MANAGEMENT PAERLS:
-> Look for withdrawal symptoms.
-> Prevent Wernicke-Korsakoff (ataxia - nystagmus - ophthalmoplegia - amnesia).
-> Give IV or IM thiamine & Mg ASAP plus vit. B12 & folate.
-> Benzodiazepine of choice is CHLORDIAZEPOXIDE or DIAZEPAM.
-> Choose short-acting benzodiazepam if there is H/O of severe liver disease:
LORAZEPAM
-> Do NOT give seizure prophylaxis; repaeted seizures sh'd be ttt e' diazepam.
-> Haldol is NEVER the answer (It reduces seizure threshold).
. CHRONIC MAINTENANCE MANAGEMENT:
-> Refer to inpatient rehabilitation or outpatient group therapy (AA).
-> Never give drug therapy without group psychotherapy.
-> Naloxone & acamprosate -- relapse rate only when given with psychotherapy.
-> Disulfiram has poor compliance and hasn't been shown to be effective.
. WITHDRAWAL $ MANIFESTATIONS:
_______________________________
(1) MINOR WITHDRAWAL SYMPTOMS:
_______________________________
-> Onset after last drink -> 6 hours.
-> Syms -> insomnia, tremulousness, mild anxiety, headache, diaphoresis &
palpitations.
-> Exam tips -> Give thiamine, folate, multivitamin & glucose.
(2) ALCOHOLIC HALLUCINOSIS:
____________________________
-> Onset after last drink -> 12 - 24 hours.
-> Symptoms -> Visual, auditory & tactile hallucinations.
-> Exam tips -> If there are hallucinations with disorientation & altered mental
status
-> then alcoholic hallucinosis is NOT the answer.
(3) WITHDRAWAL SEIZURES:
_________________________
-> Onset after last drink -> 48 hours.
-> Symptoms -> Tonic clonic seizures.
-> Exam tips -> Perform CT scan if repeated seizures to rule out structural causes.

(4) DELIRIUM TREMENS:

______________________
-> Onset after last drink -> 48 - 96 hours.
-> Symptoms -> Hallucinations, disorientation, tachycardia, hypertension.
-> Symptoms -> Low grade fever, agitation & diaphoresis.
-> Exam tips -> Time of onset is important.
-> This is the diagnosis if the case describes symptoms 2 DAYS after last drink.
_____________________________________________________________________________________
_____
. SUBSTANCE ABUSE:
___________________
___________________
{1} ALCOHOL:
_____________
. Intoxication syms -> Talkative, sullen, gregarious & moody.
. Intoxication ttt -> Mechanical ventillation if severe.
. Withdrawal syms -> Tremors, hallucinations, seizures & delirium.
. Withdrawal ttt -> Long acting benzodiazepeines (Chlordiazepoxide).
. No seizure prophylaxis.
. Disulfiram or naloxone for adjunct to supervised therapy after acute withdrawal.
{2} AMPHETAMINES & COCAINE:
____________________________
. Intoxication syms -> Euphoria, hypervigilance, autonomic hyperactivity & weight
loss.
. Intoxication syms -> Pupil dilatation, disturbed perception, stroke & MI !
. Intoxication syms -> -- appetite (Picky eater).
. Intoxication syms -> Erythema of turbinates & nasal septum.
. Intoxication ttt -> Antipsychotics, benzodiazepines, inderal & vit C to ++
excretion.
. Withdrawal syms -> Anxiety, tremors, headache, ++ appetite, depression &
suicide risk.
. Withdrawal ttt -> Antidepressants.
{3} CANNABIS:
______________
. Intoxication syms -> Impaired motor coordination, impaired time perception.
. Intoxication syms -> Social withdrawal, ++ appetite, dry mouth, tachycardia.
. Intoxication syms -> Conjunctival redness.
. Intoxication ttt -> NONE.
. Withdrawal syms -> NONE.
. Withdrawal ttt -> NONE.

{4} HALLUCINOGENS (LSD = LYSERGIC ACID):

_________________________________________
. Intoxication syms -> Visual hallucinations & intensified perception.
. Intoxication syms -> Ideas of reference, impaired judgment & dissociative syms.
. Intoxication syms -> Pupillary dilatation, panic, tremors & incoordination.
. Intoxication ttt -> Supportive counseling (talking down), antipsychotics & benzos.
. Withdrawal syms -> NONE.
. Withdrawal ttt -> NONE.
{5} INHALANTS:
_______________
. Intoxication syms -> Belligerence, apathy, assaultiveness & impaired judgement.
. Intoxication syms -> Blurred vision, stupor & coma.
. Intoxication ttt -> Antipsychotics if delirious or agitated.
. Withdrawal syms -> NONE.
. Withdrawal ttt -> NONE.
{6} OPIATES (HEROIN):
______________________
. Intoxication syms -> Respiratory depression, pin point pupils & CNS depression
(Coma).
. Intoxication syms -> Apathy, dysphoria, drowsiness, slurred speech.
. Intoxication syms -> Impaired memory, coma & death.
. Intoxication ttt -> NALOXONE.
. Withdrawal syms -> Fever, chills, lacrimation, runny nose, abdominal cramps.
. Withdrawal syms -> Muscle spasms, insomnia, yawning & secretions from all
openings !
. Withdrawal ttt -> METHADONE & clonidine.
{7} PHENYLCYCLIDINE (PCP):
___________________________
. Intoxication syms -> Panic reactions, assaultiveness & agitations.
. Intoxication syms -> Nystagmus, HTN, seizures, coma & hyperacusis.
. Intoxication ttt -> Talking down, benzodiazepines, antipsychotics & resp. support.
. Withdrawal syms -> NONE.
. Withdrawal ttt -> NONE.
{8} BARBITURATES & BENZODIAZEPINES:
____________________________________
. Intoxication syms -> Inappropriate sexual or aggressive behavior.
. Intoxication syms -> Impaired memory & concentrations.
. Intoxication ttt -> FLUMAZENIL.
. Withdrawal syms -> Autonomic hyperactivity, tremors, insomnia, seizures &
anxiety.

. Withdrawal ttt -> Substitute short with long acting barbiturates

(chlordiazepoxide).
_____________________________________________________________________________________
_____
. HUMAN SEXUALITY:
___________________
___________________
{1} HOMOSEXUALITY:
___________________
. It is NOT a mental illness.
{2} GENDER IDENTITY DISORDER & TRANS-SEXUALISM:
________________________________________________
. An individual who insists that he/she is the opposite gender.
. Intense discomfort about his or her sex.
. It is NOT the Dx when the Q. describes an individual who desires to be another
gender
. because of the perceived advantages of the other sex.
. e.g. a boy who wants to be a girl so that he will receive the same special ttt as his
younger sister.
{3} PARAPHILIAS:
_________________
. Recurrent, sexually arousing preoccupations which are usually focused on
humiliation,
. The use of non-living objects & non-consenting partners.
. Occurs for more than 6 months & causes impairment in pt's level of functioning.
. Tx -> Individual psychotherapy & averse conditioning.
. If severe impairment -> Give antiandrogens or SSRIs to help reduce pt's sexual
drive.
. TYPES OF PARAPHILIAS:
________________________
________________________
.1. VOYEURISM:
_______________
. Recurrent urges to observe an unsuspecting person who is engaging in sexual
activity or disrobing.
. This is the earliest paraphilia to develop.
.2. PEDOPHILIA:
________________
. Recurrent urges or arousal toward prepubescent children.
. This is the most common paraphilia.

.3. EXHIBITIONISM:
___________________
. Recurrent urge to expose oneself to strangers.
.4. FETISHISM:
_______________
. Use of non-living objects usually associated with the human body.
.5. FROTTEURISM:
_________________
. Recurrent urge involving touching or rubbing against a non-consenting partner.
.6. MASOCHISM:
_______________
. Recurrent urge or behavior involving the act of humiliation.
.7. SADISM:
____________
. Recurrent urge or behavior involving acts in which ..
. physical or psychological suffering of a victim is exciting to the patient.
. PHARMACOLOGICAL AGENTS THAT CAUSE SEXUAL DYSFUNCTION:
________________________________________________________
________________________________________________________
.
.
.
.
.
.

Alpha 1 blockers -> Impaired ejaculation.

Beta blockers -> Erectile dysfunction.
Neuroleptics -> Erectile dysfunction.
SSRIs -> Inhibited orgasm.
Trazodone -> Priapism.
Dopamine agonists -> ++ Erection & libido.

. N.B. POOR SLEEP HYGIENE:

___________________________
-> can be associated with insomnia.
-> Due to performance of bad daily living activities.
-> that are inconsistent with maintainance of sleep.
-> Poor sleep scheduling with variable wake & sleep times.
-> Frequent day time naping.
-> Routine use of caffeine, Alcohol, Nicotine in period preceiding sleep.
-> Engaging in mentally or physically stimulating activities too close to bed time.
-> Frequent use of the bed for activities other than sleep.
. N.B. DELAYED SLEEP PHASE $YNDROME:
_____________________________________
-> Circadian rhythm disorder.
-> Inability to fall asleep at normal bed times such as 10 p.m. to midnight.
-> These pts often can't fall asleep until 4-5 a.m. BUTTTTTT ..

-> their sleep is normal if they are allowed to sleep until late morning.
==================================================
========================================
==================================================
========================================
ETHICS TiKi TaKa
__________________
. AUTONOMY:
____________
. An adult e' capacity to understand his/her medical problems can refuse any ttt or
test
. It doesn't matter if the ttt or test is simple, safe & risk free.
. It doesn't matter if the person will die without the ttt or the test.
. Respecting autonomy is MORE IMPORTANT to do the right thing for a pt !
.
.
.
.

Even though an adult pt e' capacity can refuse anything,

USMLE wants u to discuss things 1st.
Eventhough u may eventually honor his wishes,
if an answer says "meet", "confer", or "discuss", the do that first !

. CAPACITY:
____________
. Capacity is determined by physicians.
. Competence is a legal term & is determined by courts & judges.
. An adult who is alert & not mentally handicapped is deemed to have capacity.
. PSYCHIATRY CONSULTATION:
___________________________
. is the answer when a pt's capacity to understand is NOT clear.
. It is NOT necessary if the pt is clearly competent or clearly in coma !
_____________________________________________________________________________________
_____
. MINORS:
__________
. Minors aren't determined to have the capacity to understand their medical
problems,
. until the age of 18.
. Emancipation means that although the pt is under 18, he can make his own
decisions.
. Emancipated minors are living independently & self supporting, married or in
military.
. Partial emancipation is considered for (Sex - Reproductive health - Substance
abuse).
. If the pt is a minor & seeks ttt for contraception, STDs, HIV or prenatal care,

. she is partially emancipated.

. i.e. she can make these decisions on her own,
. her privacy sh'd be resprected like that of an adult.
. An exception is ABORTION: 36 states have parental notification laws for abortion.
.

.
.
.
.

MINOR STATUS
|
______________________________________________
|
|
UN-emancipated
Emancipated
|
(Can consent for care)
|
|
. Age < 17 ys & must have consent
. Married
from parent or legal guardian
. In the military
. Lives separately from parents
& manages own financies.
N.B. Parents can NOT refuse lifesaving therapy for minors.
Ex. If a blood transfusion w'd be lifesaving, the parents can't refuse.
Doing so w'd be considered child abuse.
JEHOVAH's WITNESSES may refuse therapy for themselves but not for a child.

. In an emergency, family members or friends of a Jehovah's witness who suggest

that a pt
. would not accept blood transfusion should be asked to provide documentary
evidence,
. such as an advance directive.
. Without this documentation or when uncertainity remains,
. it is advisable NOT to withhold blood in life threatening conditions.
_____________________________________________________________________________________
_____
. INFORMED CONSENT:
____________________
. It is based on autonomy.
. Only a fully informed pt e' the capacity to understand the issues can grant it.
. The pt must be informed of the benifits & the risks of the procedure.
. Alternatives of the procedure must be given.
. The information is in a language the pt can understand.
. The informed consent must be given for each procedure.
.
.
.
.
.
.

For emergency procedures, consent is implied in an emergency,

when there isn't suffecient time to determine capacity or prior wishes.
If prior wishes are fully known, then this information takes precedence.
Consent obtained via telephone is considered valid.
If the pt's proxy isn't present at the time of the procedure, then,
consent via telephone counts.

. Pregnant women can refuse therapy, even if the life of the fetus is at risk !!
. Until the fetus comes out of the body, it is considered part of the woman's body.
. Ex. A woman can refuse a blood transfusion while pregnant.
. She can refuse antiretroviral ttt during prgnancy, even if the fetal's life is at risk.
. Once the baby comes out, she can't refuse ttt for the baby.
_____________________________________________________________________________________
_____
. CONFIDENTIALITY:
___________________
. The pt has an absolute right to privacy concerning his own medical information.
. The following persons do NOT have a right to any of the medical information of
the pt:
-> Relatives, employers, friends & spouses.
-> Other physicians -> U can't release it without the express consent of the pt.
-> Members of law enforcement: U can't release medical information to courts or
police without a court order or subpoena.
. BREAKING CONFIDENTIALITY TO PREVENT HARM TO OTHERS:
______________________________________________________
. If a pt has a TRANSMISSIBLE disease, such as T.B. or HIV,
. the physician can violate the pt's confidentiality to protect innocent 3rd parties.
. If u have T.B., your doctr can contact your close associates with OUT your consent.
. If u have $, HIV or gonorrhea, your doctor can safely inform others e'OUT your
consent.
. The classic ex. is of a pt e' a psychiatric illness who may be planning to harm
others.
. The physician has the right to alert the person at risk to prevent harm.
_____________________________________________________________________________________
_____
. END OF LIDE ISSUES:
______________________
______________________
. An adult with capacity can withhold or withdraw any form of therapy.
. If the pt begins ttt, he or she has the right to withdraw any form of ttt.
. The reasons for the withdrawal or withholding of care are not important.
. An advice directive is a set of instructions from an adult pt.
. with capacity directing the care of himself or herslf prior to losing capacity.
. HEALTH CARE PROXY:
_____________________
. The strongest advance directive is a health care proxy.
. The proxy is both a document describing the care the person desire,
. as well as the appointment of an agent to be the decision maker.
. The agent as a decision maker doesn't take hold until the pt loses the capacity.
. If I appoint a proxy but I'm still here, alert & communicative,
. you can't ask the agent for consent for my procedures.

. LIVING WILL:
_______________
. It is a writen document outlining the care desired by the patient.
. If a pt doesn't have a health care proxy, the living will can be very useful.
. If the pt writes out "I never want to be intubated", this is valid.
. If he writes "No heroic measures", this is not valid.
. To be useful, a living will must be clear & precise.
. If a pt's family members disagree with a living will,
. and demand care that contradicts the pt's written wishes,
. the best initial step is -> DISCUSS THE MATTER WITH THEM.
. If discussion fails o resolve the condition -> consult the hospital's ETHICS
COMMITTEE.
. DO NOT RESUSCITATE (DNR) ORDERS:
___________________________________
. It means the refusal of endotracheal intubation & cardiopulmonary resuscitation,
. in the event of the loss of the ability to breathe or the heart stopping.
. A DNR doesn't mean the elimination of testing or medical therapy.
. PATIENT WITH NO CAPACITY & NO ADVANCE DIRECTIVE (PROXY OR LIVING WILL):
__________________________________________________________________________
. This is the most complex & the most common circumstance.
. The care is based on the best understanding of the pt's wishes for himself.
. Family & friends attempt to outline what they heard the pt say he wanted.
. This is not the same as saying "This is what is best for the pt".
. Decisions are based on the best possible understanding of clearly expressed
wishes.
. If there is no clear expression of wishes,
. the the weakest basis on which to act is the "best interests of the pt".
. ETHICS COMMITTEE:
____________________
. The ethics committee is used for cases in which the following are true:
-> The pt is not an adult with capacity.
-> There are no clearly stated wishes on the part of the pt.
. Also, the ethics committee is the answer if:
-> the caregivers, such as family, are split or in disagreement about the nature of
care.
-> If some family members say "He never wanted to be on a ventilator, ever".
-> and some family members say "He might have wanted a ventilator sometime",
-> then this a case for an ethics committee.
. COURT ORDER:
_______________
. It is the option when all the other options haven't given clarity.
. If their is disagreement after all the other steps, including an ethics committee.

. You don't need a court order if the proxy clearly states wishes or family in
agreement.
. If parents refuse to consent to ttt of their child for a non-emergent but ..
. potentially fatal medical case, the physician sh'd seek a court order mandating ttt.
. FLUID & NUTRITION ISSUES:
____________________________
. An adult pt with capacity may refuse all forms of nutrition.
. There is no ethical basis for forcing fluids or nutrition upon a pt.
. If the pt is not an adult with the capacity to understand,
. the proxy or living will can direct the removal of fluid & nutrition,
. provided the pt's clearly expressed wishes while competent stated that:
. "No artificial nutrition be started".
. In absence of clearly stated wishes on the issue fluids & nutrition, they sh'd be
given
. PHYSICIAN-ASSISTED SUICIDE & EUTHANASIA:
___________________________________________
. It means providing the pt with the means to end his own life.
. THIS IS ALWAYS WRONG !
. Euthanasia means the physician directly administers the means of ending the pt's
life.
. THIS IS ALWAYS WRONG !
. These are not the same as providing pain medications that may end the pt's life.
. It is ethical to give pain medication, even if the only way to relieve pain,
. may result in shortenening of life !
. The primary difference is clear:
-> In physician assisted suicide, the 1ry intent is to end life.
-> With a life shortened by pain medication, the 1ry intent is to relieve suffering.
. FUTILE CARE:
_______________
. There is NO obligation on the part of the physician to provide care that won't work
!
. There is NO obligation to provide treatment without possible benifit.
. Ex. A pt with widely metastatic cervical cancer develops renal failure,
. the family members insist that dialysis be started. What do u tell them ??!
-> You don't have to provide dialysis to a person who will certainly die !!
. BRAIN DEATH:
_______________
. You are NOT obliged to provide care for a brain-dead patient.
. Brain death = Dead.
_____________________________________________________________________________________
_____

. REPRODUCTIVE ISSUES:
_______________________
_______________________
. 1 . ABORTION:
________________
. A woman's right to an abortion varies by trimester of pregnancy:
-> 1st trimester -> A woman has UNRESTRICTED right to an abortion.
-> 2nd trimester -> A woman has access, but her rights are LESS CLEAR.
-> 3rd trimester -> NO CLEAR ACCESS to abortion (The fetus is potentially viable).
. N.B. YOU DO NOT NEED THE CONSENT OF THE FATHER FOR THE ABORTION.
. 2 . DONATION OF GAMETES:
___________________________
. Pts have UNRESTRICTED RIGHT to donate sperm & eggs.
. There is no ethical problem with being a PAID DONOR for sperm & eggs.
. Note that one can't be a paid donor for organs, such as the kidneys or the cornea.
_____________________________________________________________________________________
_____
. HIV ISSUES:
______________
. A pt has a right to confidentiality of his HIV status.
. However, this confidentiality can be broken to prtect the uninfected,
. such as sexual & needle-sharing partners.
. No obligation for HIV +ve health care workers to disclose their HIV status.
. This include surgeons.
. A surgeon doesn't have to disclose her HIV status to patient.
. Physicians have the legal right to refuse to treat any patient.
. It is not legal to refuse to take care of HIV +ve persons.
. It is unethical to refuse care to HIV +ve pts simply as they are HIV +ve, BUT .....
. It is legal to do so !
_____________________________________________________________________________________
_____
. DOCTOR PATIENT RELATIONSHIP:
_______________________________
_______________________________
. ACCEPTING A PATIENT:
_______________________
. A physician doesn't have an obligation to accept a patient.
. The need of a person doesn't compel the physician to accept that person as a pt.
. Ex. if there is only 1 neurosurgeon at a hospital & a pt needs neurosurgery,
. this situation does NOT compel the physician to accept the pt.

. Once having accepted a pt, however, the physician can NOT simply abandon the
pt.
. The physician has an obligation to inform the pt that he must find another
physician,
. and the physician must render care until a substitute caregiver can be identified.
. GIFTS:
_________
. Ethically acceptable -> Small gifts not tied to specific ttt or tests.
. Ethically UNacceptable -> Gifts given e' intention of getting a specific prescription.
. SEXUAL CONTACT:
__________________
. Psychiatrists -> NEVER acceptable.
. Other physicians -> They must end the doctor-patient relationship FIRST !
. ELDER ABUSE:
_______________
. Can be reported even against the will of the patient.
. Doesn't imply a specific age; it has to do e' the FRAGILITY of the pt.
. If the pt is frail & vulnerable, the abuse can be reported even against the pt's will.
. IMPAIRED DRIVERS:
____________________
. Such as pts suffering from a seizure disorder,
. can NOT have their license taken away by a physician.
. Only the department of motor vehicles can remove or restrict a license.
. TORTURE:
___________
. Physician participation in torture, on any level, is always WRONG.
. You can't even agree to certify the patient dead !
_____________________________________________________________________________________
_____
. IMPAIRED PHYSICIANS:
_______________________
. Must be reported to an authority figure.
-> Physicians in training -> Reported to program director ar department chair.
-> Faculty -> Reported to the department chair or the dean of the medical school.
-> Those in practice -> Reported to the state medical board.
. The impairment must involve potential danger to medical care.
. If u c a physician stealing a car, behavior is NOT reportable to the department
chair.
. If u c a physician at a bar dancing naked on the table top,
. but her medical performance is not impaired, this is NOT reportable.
_____________________________________________________________________________________
_____

. TIPS & TRICKS:

_________________
_________________
. Tx of Alzheimer's dementia -> Acetylcholinesterase inhibitors (Donepezil,
Rivostigmine)
. Pts with homicidal thoughts sh'd be admitted at the psychiatric ward.
. Pt with meningitis -> Admit him against his will & start ttt.
. PASSIVE AGGRESSIVE BEHAVIOR:
. Individual expresses his aggression toward another person,
. with repeated passive failures to meet the other person's needs.
. When dealing with an angry pt, the most appropriate response is to:
. encourage a discussion about the source of feelings.
. ex. You seem to be angry about something, May I ask what is bothering u so I can
help?!
. If a pt is interested in alternative therapy, the physician sh'd 1st inquire as to
why?
. If a pt refuses ttt after being informed about cancer, he sh'd be asked why u
refuse ?
. DISPLACEMENT DEFENSE MECHANISM:
-> Shifting of emotions associated with an upsetting person to a safer alternate
object,
-> that represent the original.
-> Ex. Husband angry with his wife, breaks the car she gave to him !
. INTELLECTUALIZATION DEFENSE MECHANISM:
-> Transformation of an unpleasant event into a purely intellectual problem - No
emotions -> Ex. A doctor received the results of his investigations & discovered
that has cancer,
-> He went home & surfed the net for the most recent ways of ttt of cancer.
. REACTION FORMATION DEFENSE MECHANISM:
-> Transformation of unwanted thought or feeling into its opposite.
-> REACTION FORMATION is NEITHER a splitting, NOR a dissociation.
. Genito-pelvic pain (Vaginismus) -> Pain with intercourse or attempted
penetration.
. Treatment response
-> When a pt demonstrates significant improvement with or without remission.
-> Generally defined as a 50 % reduction in base line of severity.

Dr. Wael Tawfic Mohamed

_________________________