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Linezolid + SSRI = serotonin syndrome

Minocycline (chronic acne) chronic use = bluish tint to skin


Aminoglycosides + beta lactam antibiotics (synergy)
Ampicillin + gentamicin (neonatal)
Babies lack UDP-glucoronyl-transferase (metabolizes chloramphenicol
causes gray baby syndrome)
GBS vomiting, ashen gray color, poor muscle tone, CV collapse,
cyanosis
- can use phenobarbital to induce enzyme
hypnagogic (going to sleep) hallucinations
hypnapompic hallucinations
Schizophrenic bains
Smaller
Enlarged ventricles
Thin cortex
Damage to areas in brain related to language/auditory function
Genetic predisposition
- monozygotic twins
in utero viral infection, toxin exposures, birth trauma
exposure to psychoactive substances young (LSD, cocaine,
amphetamines, marijuana)
psychosis + decline in functioning > 6 mo
Positive sx:
Adding something that normally isnt present
Delusions
Hallucinations
Disorganized speech (disorganized, loose assoc.)
Grossly disorganized or catatonic behavior
- one of first three must be present
autonotisms repetitive purposeless movements
negative subtracting parts of normal personality/behavior
flat affect
social withdrawal
avolition (no motivation)
alogia (poverty of speech)

thought blocking (train of thought blocked)


poor grooming
mesolimbic pathway: increased dopamine causes positive sx
mesocortical tract: less dopamine causes negative sx
increased risk of suicide, earlier onset in men
2+ sx for > 6 mo
brief psychotic disorder: <1 mo
schizophreniform: 1-6mo
schizo then affective disorder
psychotic sx for at least 2 wks in absence of mood disorder
then time period with psychosis + major mood disorder episode at the
same time (major depressive or manic)
- dominant feature is psychosis
(vs dominant feature of mood disorder = major depressive disorder +
psychotic features)
schizoid personality disorder is separate from schizotypal
schizoids avoid (avoid social interaction)
schizotypal personality is odd thinking and strange behavior
delusional disorder: fixed persistent delusional belief system lasting >
1 mo
- functioning is NOT impaired
- behavior is NOT bizarre
- can hold down a job
- can be a shared delusion (Folie a deux madness shared by two)
Treatment for:
Alcohol OD: IVF, wait
Alcohol withdrawal: benzo
Alcohol abuse: alcoholics anonymous (naltrexone, disulfiram,
topiramate, acamprosate)
Opioid OD: naloxone, naltrexone
Opioid withdrawal: methadone, naltrexone
Amphetamine, cocaine OD: benzo
PCP OD: benzo
Nicotine withdrawal: nicotine replacement, bupropion, varenicline
PCP = NMDA receptor antagonist

Inhibits nicotinic Ach R


Dopamine reuptake inhibitor
Easier to get rid of positive sx (antipsychotics generally work by
blocking dopamine)
Atypicals work better on negatives than typicals
Psychosis
Acute mania
Tourette syndrome
1. Fluphenazine
2. Pimozide
3. Tetrabenazine (degrade DA)
Agitation (haloperidol acute agitation)
Neuroleptic SE
- anticholinergic
- EPS
- Tardive dyskinesia
- Neuroleptic malignant syndrome
- Amenorrhea/galactorrhea
High potency
First few days
Acute dystonia (want more anticholinergic, add a drug with more
anticholinergic SE benztropine, diphenhydramine)
Torticollis
First month
Parkinsonism
- bradykinesia
- akinesia
several months
akathisia (restlessness)
(retardation) tardive dyskinesia not an EPS side effect
its a movement disorder
- late manifestation
- stereotypical oral-facial, lip smacking movements (think of the
Joker)
IRREVERSIBLE
Neuroleptic Malignant syndrome
- delirium and altered MS (being on neuroleptic for long)
autonomic instability

muscle rigidity
myoglobinuria
hyperpyrexia
excess muscle contraction = breakdown muscle tissue, myoglobin
goes out into blood, clogs up kidneys
- raises body temp
Tx: dantrolene (also treats malignant hyperthermia from inhaled
anesthetics), DA agonist (bromocriptine)
Atypical antipsychotics
- olanzapine, quetiapine, risperidone, aripriprazole, clozapine
block dopamine AND serotonin receptors (fewer SE)
but also block alpha (hypotension) and histamine (sedation, wt gain)
olanzapine = wt gain, diabetes (metabolic syndrome)
clozapine = strongest, most effective atypical
AGRANULOCYTOSIS (STOP MAKING GRANULOCYTES LIKE
NEUTROPHILS, EOSINOPHILS)
- monitor CBC 1x/wk
quetiapine = tx for psychosis from Parkinson meds (lowest risk EPS
side effects)
Virchow = left supraclavicular lymph node
Marked impairment in social/occupational functioning
Mania >/= 1 week
3 of 7 sx
Distractability
Irresponsibility
Grandiosity (inflated sense of self-esteem)
Flight of ideas (loose associations, cant slow down brain)
Activity & Agitation (energy to spare, productive or agitation/antsy,
over the top, larger than life)
Sleep decrease (less need)
Talkativeness (pressured speech, louder)
Hypomanic episode
Less severe sx, shorter duration (>/= 4 days)
No impairments in social or occupational functioning
Bipolar I

- manic episode (not required to have depression, but will have


depression eventually)
Bipolar II
- hypomanic episode + episode of major depression
Depression
- decreased dopamine, serotonin, norepinephrine
Cyclothymic disorder (at least 2 years)
- milder form of bipolar
mild hypomanic and mild depressive sx
periods of normal mood (<2 mo)
Lithium
- may inhibit PIP2 second messenger system
- narrow TI
SE:
Sedation, dizziness
Tremors
Sick sinus syndrome (arrhythmia)
Bradycardia/heart block (arrhythmia)
Hypothyroidism or goiter
Polyuria (block effects of ADH in kidneys)
- nephrogenic DI
Lithium = TERATOGEN (EBSTEINS ANOMALY)
Dissociative Disorder
- DID = multiple personality
- depersonalization/derealization (detachment from own
body/thoughts, outsider observer, seems like a dream)
dissociative amnesia (specific event, specific series of events, or
generalized amnesia of identity/personal life history)
Recurrent Neisseria infections
- deficiency in any of MAC complex proteins
C5, C6, C7, C8, C9
Acute gout flare: NSAIDs (Indomethacin), Colchicine, Corticosteroids
Postpartum psychosis risk of harming themselves/child/others
MDD w psychotic features
MDD w seasonal pattern (typically fall/winter)
- decreased exposure to sunlight
- at least 2 years
- no MDD outside of seasonal pattern

- exposure to light therapy


persistent depressive disorder
- chronic depression at least 2 yrs
- within 2 yrs, no more than 2 mo without depressive sx (could be MDD
or mild depression)
Premenstrual Dysphoric Disorder
- anxiety, mood swings, depression, tied to menstrual cycles
- severe enough to interfere with work, school, social activities
(impairment of function) as opposed to PMS
IL-12 deficiency = Mycobacterial infections
Chronic gout: allopurinol
Probenecid, colchicine, NSAIDs
Anti-depressants also for Anxiety, OCD, PTSD, bulimia, etc
Know MOE and SE
SSRI: fluoxetine, sertraline, paroxetine, citalopram
3-4 wks to kick in
have eliminated use of TCAs for first line depression therapy
sexual dysfunction (loss of libido, anorgasmia)
serotonin syndrome (SSRI + MAOi, tryptan migraine drug)
tachycardia can lead to CV collapse
MS changes, autonomic instability, NM abnormalities (hyperreflexia,
myoclonus)
SNRI: venlafaxine, desvenlafaxine, duloxetine, milnacipran
(fibromyalgia)
Tx for depression, GAD, chronic pain conditions (duloxetine painful
fibromyalgias, diabetic neuropathy), fibromyalgia (milnacipran not for
depression)
TCA: amitriptyline, nortriptyline, clomipramine, desipramine,
imipramine
Amoxapine, doxepin
- chemical structure is different, can cause anticholinergic, alpha
blocking sx
depression, enuresis (imipramine), OCD (clomipramine), fibromyalgia
(amitriptyline), neuropathic pain (amitryptaline)
SE:

Sedation
Hypotension/sedation/dizziness (anti alpha)
Anticholinergic (hot as a hare, dry as a bone, mad as a hatter, etc)
HIGH DOSE = prolong QT interval
TCA OD (3 Cs of TCA ODs)
Cardiotoxicity (tachycardia, hypotension, conduction abnormalities,
arrhythmias)
CNS toxicity (sedated, obtunded, coma, seizure)
anticholinergic sx (mydriasis, dry mouth, ileus, urinary retention,
hyperpyrexia, confusion)
OR: convulsions, coma, cardiotoxicity
use sodium bicarbonate (TCA are weak acids)
MAOi (never used anymore)
Not breaking down serotonin, norepinephrine, dopamine, etc
Tranylcypromine, Phenelzine, Selegiline, Rasagiline
Selegiline, rasagiline selectively inhibit MAOi B inhibits dopamine
breakdown selectively (used for tx of Parkinson)
Serotonin syndrome
Hypertensive crisis with ingestion of tyramine (aging foods)
- these foods trigger migraines
brown bananas, wine, aged cheese, soy sauce, aged beef
- stimulates NE release
normally MAOi in gut will breakdown tyramine in foods
Atypical antidepressants
Bupropion NE/DA RI
Mirtazapine alpha 2 antagonist
Trazodone serotonin modulator
Nefazodone serotonin modulator
Bupropion works with SSRI (increases NE and DA, SSRI increases
serotonin)
- stimulant effect
smoking cessation
lowers seizure threshold
NO sexual dysfunction (unlike SSRI)
Mirtazapine
Remember, alpha 2 is on PRESYNAPTIC nerve terminal

- stimulation INHIBITS RELEASE OF NE


BLOCKING = increased release
Serotonin 2/3 receptor antagonist
Trazodone inhibits serotonin reuptake
- treats insomnia
KNOW SE = priapism
ECT can be effective, works quickly
Anesthetize pt, electrical conduction to brain = controlled seizure in
brain
REFRACTORY DEPRESSION
SE: disorientation, amnesia
Alcohol/large meals = gout flare
Parietal cell receptors:
H2 histamine
CCKB
M3
PG
SST
Panic disorder
Tx: CBT
SSRIs
TCAs
Benzodiazepines
Beta blockers (decrease sympathetic tone of ANS)
Phobia:
Systematic desensitization
Social Anxiety Disorder
SSRIs
Beta blockers (e.g. public speaking)
Agoraphobia
- fear of open spaces or public situations (agora = public gathering
location)
OCD
Excessive handwashing
Repetitive rituals, compulsions

Obsession: intrusive thought that cant be controlled


Compulsion: performance of action/task to relieve the obsession
Tx:
SSRIs
Clomipramine (TCA)
PTSD
Persistent re-experiencing of a previous traumatic event
Hypervigilance
Intense fear
Disturbance longer than 1 month
(less than 1 month = acute stress disorder or normal bereavement)
more likely to have somatization
Tx:
Psychotherapy
SSRIs
Generalized Anxiety Disorder
Uncontrollable anxiety and worry for greater than 6 months
Adjustment disorder
- similar sx but identifiable psychosocial stressor (divorce, illness,
death in family etc)
lasts less than 6 mo after stressor is gone
Tx for GAD:
Benzo
SSRIs
SNRIs
Buspirone
Buspirone:
Stimulates serotonin receptors
- ONLY USED FOR GENERALIZED ANXIETY DISORDER
NO ADDICTION, SEDATION, ETC
NO INTERACTION W ALCOHOL
NOT MANY SE
Malingering disorder
- conscious faking
- avoiding work, obtaining drugs, money etc
- needs to get something
Factitious disorder
- no other incentive other than being perceived as sick
- exaggerate physical sx

Munchausen syndrome
- more self-harm
- multiple invasive procedures (long distances)
- risk to life
Munchausen by Proxy (factitious disorder imposed on another)
illness in child caused by caregiver
mental disorder in caregiver not child, they get to achieve sick role by
proxy
Somatization
Somatic Symptom disorder
(w predominant pain = pain disorder)
illness anxiety disorder = hypochondriasis
- no physical symptoms
- actually worried, not faking
conversion = stress converted to disorder
Immature defense mechanisms
isolation what we do as physicians to protect our emotions
rationalization convenient excuse (I didnt get that job but I didnt
really want it)
reaction formation overcompensating in the opposite direction
repression = unconscious forgetting of negative things
splitting = BPD
Mature defense mechanisms
Sublimation anxiety about an exam transformed into vigorous
exercise/study
Suppression conscious and deliberate attempt to stop thinking about
negative or stressful things
Personality Disorders
Trait vs disorder (cause problems, impaired functioning)
Disorder = stable by early adulthood
- educate people around them
- people dont recognize they have them

Cluster A = Weird, Odd, Eccentric (no psychosis, difficulty forming


relationships)
Paranoid distrust of others, projection
Schizoid avoid, voluntary social withdrawal, limited emotional
expressions
Schizotypal dress like a pickle, eccentric appearance, odd beliefs,
magical thinking (comic book convention)
Cluster B = drama (B movies, emotional, dramatic, scary)
Antisocial disregard for and violation of rights of others
- lack empathy (Males>females)
- conduct disorder (<18 yo)
- world conquerors
Borderline unusual variability and depth of moods
- unstable moods
- chaotic relationships
- manipulative, impulsive
- females, splitting
- wont remember many of damaging behaviors (all good/all bad)
HIGH SUICIDE RATE
Histrionic excessive emotions
Attention seeking
Seductive behavior
Exaggerated
Narcissistic
- excessive preoccupation w personal prestige, power, and vanity
lack empathy
require excessive admiration
react to criticism with rage
Cluster C: anxious, fearful, cowardly, compulsive, clean
Avoidant hypersensitive to rejection
- socially inhibited, timid, inadequacy
- NOT SCHIZOID want relationships w others
Obsessive-compulsive
- preoccupied with order, perfectionism, and control
- not aware of abnormalities, perfectionists
NOT OCD THESE PEOPLE DONT LIKE THIS AND ARE AWARE THIS IS A
PROBLEM
OCPD ITS PERFECTLY FINE TO THINK THIS WAY
Dependent low self-esteem
Psychologically dependent