hello once again in this audio lecture

we're going to be discussing psychiatry

for the USMLE step to seek a exam this
is specifically my you world notes that
I am gonna be dictating this covers
everything that I was able to gather
from you world and it makes a pretty
good review especially if you're out on
the road or in a situation where you're
not able to be reading something you
still want to be studying this is a good
tool for that so let's start her off so
psychiatry we're gonna start off with
the assessment of decision-making
capacity so the assessment at the
decision-making capacity it depends on
the criteria and what the patient's task
is so if the criteria means that that
the person has to communicate a choice
that means that the patient's able to
clearly indicate a preferred treatment
option that's the criteria for that
decision-making capacity if the patient
understands a condition and the
treatment options that means that the
patient understands the information
provided if the patient acknowledges
having a condition and likely
consequences of treatment options
including no treatment that means that
he appreciates the consequences behind
that decision and if a patient's able to
weigh that risks and benefits and offers
a reason for their decision that's a
rationale given for the decision so all
those are assessments of a good
decision-making capacity next topic
would be defense mechanisms so he
defense mechanisms are divided into
immature defense mechanisms versus
mature the immature defense mechanisms
include primitive and neurotic
mechanisms and they're the majority of
the ones so for example acting out means
expressing unacceptable feelings through
their action denial is behaving as if an
aspect of reality doesn't exist
displacement would be
transferring someone's feelings to a
more acceptable object as displacement
intellectualization means using
someone's intellect to avoid an
uncomfortable feeling passive aggression
means to avoid a conflict by expressing
hostility covertly projection means that
tributing one's own feelings unto other
kind of like you're projecting your
voice I always have a problem
remembering this one but it's bright
like projecting your voice in order for
somebody to be heard this is projection
you're projecting your own feelings unto
others rationalization means
justification of someone's behavior to
avoid a difficult truth
there's reaction for formation which
means responding in a matter opposite to
one's actual feelings regression would
be reverting to an earlier developmental
stage and then splitting would be seeing
others as either all good or all bad so
all of those are immature defense
mechanisms the mature mechanisms there's
only two there's sublimation and
suppression so they both start with the
letter S so sublimation means channeling
someone's impulses into a socially
acceptable behavior
the classic example there is someone who
likes to start fires and becomes a fire
fighter that is a sublimation and then
suppression would be putting unwanted
feelings aside to cope with reality
you can tell those two are going to be
more mature ways of dealing with an
issue in life versus all the other ones
are kind of a childish very image well
and a mature way of dealing with things
so if he's just that's a good way of
categorizing him altruism is a mature
defense mechanism in which a person
manages unpleasant emotions through
services to others
this service is going to provide
gratification unlike in reaction
formation in which a true sense of the
internal pleasure is going to be lacking
so the neural imaging in psychiatry
disorders would be the following so in
autism you'll have an increased volume
total brain volume obsessive-compulsive
disorder means that the abnormalities in
the orbital cortex and the striatum so
obsessive compulsive disorder the oh and
obsessive is the oh and orbital cortex
panic disorder is decreased volume of
the amygdala so that a and panic you can
remember it as the a and amygdala but it
also affects that the left temporal lobe
also post traumatic stress disorder
means that you'll have a decreased
volume in the hippocampal region and
then gets afrien iya has enlargement of
the cerebral ventricles in clinical
patient and clinical practice there's
structural neural imaging like CT s or
MRIs and that's often done as part of a
diagnostic workup for patients with new
onset of psychosis --is to rule out any
type of non psychiatric disorders so
that's why you do a CT or MRI when you
have a new diagnostic workup you want to
see if there's increase in brain volume
if there's any kind of abnormality and
the cortex in the amygdala is and so on
any type of cerebral ventricle
enlargement so routine neuro imaging is
not indicated in patients with unknown
psyche out a psychotic disorder this is
just done to evaluate first off to see
if the diagnosis could be made through a
CT but once it's not then you can just
forget about doing any more neuroimaging
functional neuroimaging techniques like
a PET scan or a functional MRI and an
MRI mr spectroscopy are important
research tools in psychiatry and those
are used to studying neural
p'tee and brain pathways involved in
psychiatric disorders however they're
not routinely used in clinical practice
and then we have selective mutism which
is a condition in which children have a
fear of a situation that call for them
to speak like a school or social
gathering as well as social phobia
that's also called social anxiety
disorder it's often a core morbid
condition and children suffering from
selective mutism with anxiety and
avoidance commonly occurring the dsm-5
criteria for selective mutism is gonna
be either consistent failure to speak in
some specific situation like at home or
at school but not others in which a
person is expected to speak so these are
all selective mutism is always a is
always an alternative to some type of
autism spectrum so be sure to
differentiate these so the other one
would be a duration of at least one
month so mutism would be at least for
one month there's interference with
educational or other expected
achievement or social communication it's
not a tribunal attributable to lack of
knowledge or comfort with a spoken
language it's just them deciding to not
speak other communication or optimism
spectrum spectrum disorder or psychosis
do not account for the presentation so
that's what I was saying in these cases
they only speak in specific situations
either at home or at school but versus
autism they just won't speak at all if
that's what they don't if that's what
they want to do so it's not it's not
geared towards a specific situation or
condition
so continuing on with attention deficit
hyperactivity disorder clinical features
would be like inattentive or
hyperactive-impulsive symptoms that last
for more than a month more than six
months so sorry inattentive symptoms
would be difficulty focusing they're
very distractible does not listen or
follow instructions very disorganized
forgetful and loses and miss places
objects versus hyperactive-impulsive
symptoms would be as if they would be
fidgety or unable to sit still like if
they were be like if they're driven by a
motor is what it's what it's a an
example would be hyper talkative
interrupts blurts out answers symptoms
would be severe if they present before
age 12 and symptoms occur in at least
two settings either at home or at school
and cause functional impairment there
are subtypes that are predominantly
inattentive predominantly hyperactive or
impulsive or combined inattentive
impulsive and then the treatment for
ADHD would be stimulants like
methylphenidate or other amphetamines
also non stimulants such as atomoxetine
and alpha-2 adrenergic agonists as well
as behavioral therapy adverse effects of
methylphenidate would be like
nervousness loss of appetite nausea
abdominal pain insomnia and tachycardia
the loss of appetite is the one that's
most commonly associated in the
nervousness and there's also a prolonged
therapy has been shown to cause mild
growth retardation with mild with weight
loss methylphenidate should not be used
in children younger than 6 years old
because of safety and efficacy xand
within this age group it just hasn't
been evaluated
so the dsm-5 criteria for ADHD would be
more than six inattentive or more than
six hyperactive or impulsive symptoms
for more than six months
there's several symptoms present before
age 12 and symptoms do occur in at least
two settings either at home school or in
peer relations there can be functional
impairment like social or academic
impairment and there's predominant
predominantly there's various subtypes
so you have predominantly inattentive
predominantly hyperactive-impulsive or
combined inattentive impulsive type 4
inattention Cinch symptoms
there is no attention to detail in
patients with ADHD and they make
careless mistakes it's there's
difficulty focusing on things like games
and tasks reading and lectures make it
difficult they don't appear to listen
when you speak to them they cannot
follow instructions because of that and
they get sidetracked easily they're
unable to finish tasks they have also
difficulty organizing tasks such as
disorganized work poor time management
and they avoid tasks you need to avoid
tasks requiring sustained concentration
for them they can easily lose or
misplace objects requiring to perform
tasks like books phones keys they can
all misplace that they're easily
distracted by extraneous stimuli and
chores and appointments can then be
forgetful to them they also have
hyperactivity or impulsivity symptoms so
characteristics would be they fidget a
lot they have difficulty staying seated
they run or climb inappropriately they
cannot perform activities quietly
they're physically active all the time
as if they're driven by some kind of
motor that constantly working they
talk consistently and constantly and
they blurt out answers and complete
other people's sentences they also have
difficulty awaiting someone's turn so
like Anne they were in the line or
something they have difficulty awaiting
their turn and they're constantly
interrupting and intruding when others
are also busy or speaking so patients
with ADHD are at higher risk of
developing a conduct disorder in
adolescence and one of the vignettes do
describe a patient who has ADHD and they
ask you what is the what are they more
likely going to develop and it is
conduct disorder when they reach
adolescence now conduct disorder by the
dsm-5 is categorized by a aggression
towards other people and animals
destruction of property serious
violation of rules decide fulness or
theft
so aggression towards people and animals
would be that they would initiate
physical fights they're bullies they
threaten intimidate other people they
use weapons to cause serious harm to
others it can also be physically cruel
to people physically cruel to animals
they can steal while confront
confronting a victim and they can also
force someone into a sexual activity
just they can also be caught they can
also cause destruction of property -
such as setting fires so watch out with
pyromania in these differentials also
they can have intention they can
intentionally destroy properties of
others and they also have serious
violation of rules so they'll run
they'll be running away overnight at
least twice or once without returning
for a lengthy period being truant from
school often starting before age 13 and
they frequently are staying out at night
despite prenup is despite parental
prohibitions starting before age 13 so
that won't they really won't listen to
their
even at an early age and just do
whatever they want to do they frequently
are lying to obtain goods for favors and
they break into cars or buildings and
steal items of non trivial value without
confronting the victim so this is
diagnosed at least when they have three
behaviors and they have been present
within the last year or within the past
12 months with at least one present in
the past six months so they can also be
at risk of developing antisocial
personality disorder as adults and the
diagnosis of antisocial is not given to
patients less than 18 years of age
before they're 18 years old anti
antisocial personality disorders
basically conduct disorder next is
kleptomania clinical features would be
rare impulsive control disorders of
typical onset in adolescence the
repetitive failures to resist
impulsiveness to steal stealing objects
have little value they just basically
want to steal things for the for the
purpose of just stealing they can also
be a differential diagnosis would be
shoplifting but in this case shoplifting
would be theft for a personal gain and
kleptomania there is no personal gain in
anti person antisocial personality
disorder it's a general pattern of
antisocial behavior whereas in
kleptomania and there could be a
completely fine normal individual they
just require themselves to steal for
some reason bipolar disorder would be
another differential manic with a manic
episode such as a person who has
impulsivity or an impaired judgment as
well as other psychotic disorders like
stealing in response to delusions or
hallucinations like saying oh the devil
made me steal this or break into this
place to steal that with kleptomania
there is no psychotic behavior or
deceitfulness behind that so kleptomania
can be treated with psychotherapy as
well as medications psychotherapy is
going to involve cognitive behavioral
therapy orientation focusing on
techniques to resist and manage urges
and anxiety as well as medications that
have been used in for this would include
SSRIs opioid antagonists lithium and
then ty convulsive pyromania is the next
topic that dsm-5 describes this as a
deliberate fire setting on more than one
occasion with tension and arousal prior
to the act
there's fascination with fires and its
consequences there's a pleasure behind
setting fires and relief when setting or
witnessing a fire there is no external
gain there's no revenge or political
motivation there's nothing of that sort
it's just the primal urge I would say to
just set a fire and it's not better
explained by conduct disorder manic
episode psychosis antisocial personality
disorder impaired judgement none of that
they just like setting fires ok
tourettes disorder is the next topic the
dsm-5 states that this is in both
multiple motor and one or more vocal
tics involved it's not necessarily
concurrent but it does happen more than
once a year
the motor findings would be fit facial
grimacing facial blinking head or neck
jerking with shoulder shrugging there
could be tongue protrusion and sniffing
vocal tics would be like grunts or
snorting throat clearing barking yelling
or yelling obscenities also known as
coprolalia the onset of this happens
before age 18 and the treatments for
Tourette's would be antipsychotics which
is a very known question answer to a
question alpha adrenergic agonists like
clonidine and wolf Ineson
and behavioral therapies that can have
it reverse themselves so it's an in
forms of training themselves to not do
this or suppress these tics if the tics
occur many times a day frequently in
bouts nearly every day or at erect or at
regular intervals the tics can wax and
wane but they must persist for more than
a year after the initial onset and they
must occur before the age of 18 in order
to be properly diagnosed there's an
exacerbation and stress and fatigue and
it's also relieved during sleep comorbid
conditions there could be an association
with ADHD and 60% of patients or an OCD
with 27% of patients and it can develop
within 3 to 6 years after the tics first
appear it may peak and leak and in late
adolescence or in early adulthood at a
time when the tics are waning and less
common core' morbid conditions include
anxiety depression and impulse control
disorders now their management would be
pharmacotherapy if that's given it
interferes with social academic or
occupational functioning so it's based
on older trials first generation
antipsychotics like holo paradol can
maza Dean these are the only
fda-approved medications for Tourette's
disorder however due to the side effects
of first generation antipsychotics and
prolongation of the QT C interval it's
also that's associated with pema's I'd
2nd generation antipsychotics would then
be generally preferred and among the
second generations antipsychotics you
have your risperidone which is going to
be the best one because that's the one
that's been mostly studied alright so
next topic is autism spectrum disorders
so some of the features of autism
spectrum is multiple or persistent
deficits in social communication and
action and it's currently or by the
history of involving either social
emotional reciprocity nonverbal
communicative de behaviors developing or
maintaining and understanding
relationships there's a restricted or
repetitive pattern of behavior currently
or by a history of either repetitive
motor movements insistence on the
sameness or inflexible adherence to
routines fixated on interests of
abnormal intensity or focus
there's adverse responses to sensory
input and the onset is in early
developmental period and may occur with
or without any kind of language or
intellectual impairment
now assessment and management of
principles the early diagnosis is better
for early intervention there can be a
comprehensive assessment multimodal
treatment such as speech treatment
behavioral therapy and educational
services provided as was adjunctive
pharmacotherapy for psychiatric
comorbidities the second-generation
antipsychotics
risperidone has been shown to improve
the aggression seen in autism spectrum
disorder patients but after other
therapies are done it's not first-line
the dsm-5 diagnosis of autism spectrum
disorder encompasses high-functioning
autism z' like previously known as
Asperger syndrome or I believe it's it
was just reintroduced recently the
diagnosis of Asperger's so that would be
a higher functioning autism spectrum
disorder
there's also childhood disintegrative
disorder and any pervasive developmental
disorder not otherwise specified
diagnosis is going to be based on the
history and behavioral observations that
we just talked about and the physician
should empathically listen to the
parents concerns and a complete
comprehensive evaluation should be done
before making any type of Defense
of diagnosis this evaluation is going to
include structured assessments of social
language and intellectual development in
addition to hearing vision and genetic
testing such as fragile X syndrome
alright so sexual behavior in pre
adolescence so what's normal what's
abnormal so when a toddler what's normal
is exploring their own or others
genitals the movements of masturbatory
movements undressing themselves or
addressing others that's completely
normal and a toddler in school-aged
children there's increased interest for
sexual words and play there's asking
questions about sex and reproduction as
well as masturbatory movements that can
become more sophisticated now abnormal
sexual behaviors and pre-adolescents
would be repeated objects of insertions
into the vagina or anus sex play
involving the genital oral or anal
region or contact any use of force
threats or bribes and agent appropriate
sexual knowledge that is all abnormal if
you see that that is then going to be
considered grounds for child abuse next
would be psychotic disorders so the
dsm-5 has certain criterias of the
differential diagnosis of psychotic
disorders there's several so brief
psychotic disorders schizophrenic form
it's good so Freni a-- schizoaffective
and delusional disorders so brief
psychotic disorders means that you will
have psychotic symptoms that are more
than a day but less than a month their
sudden an onset and they have full
return to function after the month is
over so that's a brief psychotic
disorder versus schizophrenia is at
least six months and that includes at
least one month of active symptoms and
can include prodromal or residual pair
and that requires functional decline so
at least six months is schizophrenia
versus psychotic disorders at last less
than a month is brief psychotic
disorders but what if you have a period
that's between one month to six months
that's called schizophrenia form
disorders so if it lasts less than six
months but more than a month you're in
the schizophreniform category and those
are the same symptoms of schizophrenia
just with a shorter time period and
because it's a shorter time period there
is no functional decline required to
make the diagnosis of schizophrenia also
you have schizoaffective disorder which
is basically schizophrenia with mood
episodes which is an active phase of
schizophrenia with at least two week
life time histories of delusions or
hallucinations in the absence of
prominent mood symptoms so you'll have
mood with schizophrenia it's the best
way of describing it so you they'll
present you with somebody who has signs
and symptoms of maybe mania or major
depressive disorder and then at the same
time they'll have psychotic episodes
like they'll see things or hear voices
okay delusional disorder would be more
than one delusion in more than one month
with no other psychotic symptoms they're
actually normal functioning apart from
direct impact impaction of the delusions
so a prior prior to the diagnosis it
would be appropriate to rule out any
type of substance induced psychosis or
psychosis that's secondary to a general
medication medical condition because in
that case it would be kind of easy to
misdiagnosed someone with a brief
psychotic disorder or a schizophreniform
disorder if in in fact they are just
under the influence of some kind of
substance induced psychosis
so some of the symptoms of schizophrenia
include the presence of either two or
more of the following so they'll can
have delusions hallucinations
disorganized speech frequent derailment
of ink or incoherence that can be
grossly disorganized or catatonic
behavior involved with negative symptoms
affecting like a flat effect or some are
a Society ality so somebody who doesn't
want to be a part of society or a loggia
no schizoaffective disorder is basically
myth like we said it's major depressive
disorder or a manic episode with skits
with symptoms of schizophrenia so some
type of mood disorder with schizophrenia
there is a lifetime history of delusions
or hallucinations for more than two
weeks in the absence of major depressive
or manic episodes the mood symptoms are
present for the majority of the illness
and it's not due to a substance or any
other medical condition so again it's
very important to distinguish substance
abuse versus psych psychosis get so
effective or other types of psychotic
disorders the differential diagnosis for
schizoaffective disorder would be like a
major depressive disorder or bipolar
disorder like we mentioned earlier with
psychotic features and that can occur
exclusively during those mood episodes
as well as schizophrenia would be the
mood symptoms present for relatively
brief periods then you have your
delusional disorder and clinical
features of delusional disorder would be
more than one delusion for more than one
month other psychotic symptoms can be
absent and not prominent there could be
ability to function apart from a
delusion and that's a behavior that's
it's not obviously bizarre or odd
subtypes of delusional disorders would
be erato manic disorders grandiose
disorders jealousy can be a delusional
disorder as well as persecutory or
and somatic symptoms can be delusional
as well differential diagnosis is for
delusional disorder could be
schizophrenia other psychotic symptoms
can present like hallucinations
disorganized Asur ghen ization negative
symptoms and they can have a greater
functional impairment as well as another
differential would be personality
disorders like pervasive patterns of
suspiciousness such as in patients that
have paranoia or narcissism showing
grandiosity or odd beliefs like skips a
tipple patients but no clear delusions
and the treatment for delusional
disorder would be again antipsychotics
or cognitive behavioral therapy or a
combination of both is always a correct
answer there's also a classification of
psychotic disorders called shared
psychotic disorders which is a very rare
form of delusional disorder some
delusions are present and individuals
who share a close relationship so it's
this is very strange
if a person is completely normal yet
they're very close let's say a husband
or a wife or a sister or brother and
they share the same relationship and one
of them has psychotic disorders that
disorder can actually spill on to the
other person who was normally not
supposed to have them but because of
that close relationship they now have a
form of delusion null psychotic disorder
and that's called a shared psychotic
disorder that's the same delusion as
present in the individuals who share the
close relationship like we mentioned
it's usually the dominant individual and
the pair that becomes delusional and
transfers their delusions onto the
second one the management in these cases
is most our appropriate courses first of
all is to separate them you basically
break the chain of reinforcing each
other's beliefs but usually they're the
dominant one requires psychiatric
treatments sometimes they'll require
inpatient treatments whereas the other
person will require treatment only in
some cases like the first assess so
first you want to assess the other one
by separating the two and what are some
of the indications for hospitalization
would be the inability to function or
obtain any type of outpatient treatment
on their own or if they're being a
threat to themselves or others and that
just doesn't fall under this category
that's basically a generalized rule for
indications of hospitalization if you
cannot function or obtain any type of
treatment on your own as an outpatient
or if you're seen as a threat to
yourself as two or as two others that's
an indication for a hospitalization
if both patients require the inpatient
treatment preferably you want to admit
them in two different units remember
separate the parents and if psychotic
disorders are confirmed in an
anti-psychotic Anna cognitive behavioral
therapy in combination is recommended
now the next topic is secondary causes
of psychosis and children and
adolescents so it could be either due to
medical disorders like CNS injury or
dysfunction trauma space-occupying
lesion infection stroke epilepsy
cerebral hypoxia could also be due to
metabolic or electrolyte disturbances
such as urea cycle disorders acute
intermittent porphyria swil syns disease
renal failure liver failure hypoglycemia
or any kind of electrolyte disorders
like sodium calcium or magnesium and
then systemic disorders such as systemic
lupus and thyroiditis as well also how
those citizens like PCP LSD and ketamine
marijuana sympathy um and medics such as
cocaine or amphetamines and alcohol
withdrawal and the new one is bath salts
those are all illicit substance use
causes of psychosis and children and
adolescents and then finally medications
that can cause this would be anakata
intoxication with anticholinergics like
diphenhydramine scopolamine serotonin
syndrome amoxicillin erythromycin
clarithromycin can cause it
anticonvulsant steroids and inh and
actually if you withdrawal from either
baclofen or benzodiazepines it can cause
a psychosis so how would you go ahead
and manage them
pharmacological management and treatment
would be second generation
antipsychotics are always good
risperidone olanzapine quetiapine arab
pepper is all supras adone and poly
perdón also first generation
antipsychotics can be used but they're
obviously not preferred due to high risk
of extrapyramidal side effects like
tardive dyskinesia and benzodiazepines
can be added to the treatment so that
you can treat the any kind of agitation
involved also special populations like
chronic non-compliance populations you
want to consider long-acting injectable
in these patients as well as if they've
had any type of treatment resistance
such as they've tried two trials of
medications and they didn't it failed
you want to consider in those cases
clozapine so clozapine has always been
the answer to when haloperidol isn't
isn't working or any type of first
generation isn't working you want to do
ace the second line it would be
clozapine so although antipsychotic
medications is primary is the primary
treatment for schizophrenia integrating
both psychosocial interventions into a
broader treatment program can improve
the outcomes family counseling and
psycho in have proven to be high-yield
interventions in schizophrenia
for example educating the patient's
father about symptoms of schizophrenia
her social isolation and declining
grades are not laziness
can't help produce family stress but
that's reduce not produce a family
stress patients with schizophrenia who
have critical hostile or over-involved
family members such as higher risk
relapse while if they're in the home
atmosphere if they're stable and the
family stressors are kept to a minimum
you want to decrease the risk of real
that decreases the risk of relapse so
that is another test question where they
ask what would you want to recommend to
the family and it would be to stop
arguing have a peaceful home environment
keep family stress stress to a minimum
antipsychotics such as long acting
injectables you want to administer every
two to four weeks both first generation
and second generation antipsychotics can
be long-acting so first generations are
your haloperidol and your flu phenazine
second generations we said earlier like
risperidone and pellet perdón allows of
pain and era pip result these are
available along as is long-acting
injectable and then suitable candidates
would be unstable patients who let's say
they'll at home have poor social support
systems poor insight frequent medication
non-compliance or or patients who have
had a good response to oral medication
alright so what are some of the
anti-psychotic medication effects in the
dopamine pathways and so we're gonna
distinguish this into mesolimbic pathway
the Niagra straddle pathway and the
tubular and to burrow in from dibbler
pathway so let's say for them as a
limbic pathway antipsychotics have and a
higher efficacy in the mesolimbic
pathway whereas in the Niagra Nigro
straddle pathway would be extrapyramidal
symptoms like acute dystonia and
Teesha and parkinsonism and then you
have your two borough infundibular
pathway which can cause
hyperprolactinemia so mesolimbic would
give you the efficacy of antipsychotics
then micro straddle would be the
extrapyramidal symptoms and the two
burro infundibular will give you
hyperprolactinemia so you can get things
like a materia again akka mastiha dr.
Arya decrease in libido resulting from
an increase in prolactin that's more
common with the high potency first
generation antipsychotics like
haloperidol and of phenazine and then
second generation antipsychotics like
palak para Doane which is a metabolite
of risperidone and risperidone as well
can cause those side effects prolactin
Ouma's can cause a very high prolactin
levels so you're looking at prolactin
levels of more than 200 nanograms
whereas medication related
hyperprolactinemia is typically 25 to
100 nanograms with levels that seldom
raise above 200 so some of these
antihypertensives are associated with
hyperprolactinemia and those include
risperidone alpha methyl dopa and
verapamil okay so moving on we have
antipsychotic extrapyramidal effects so
you have your extrapyramidal symptoms
and their treatments so for acute
dystonia this happens between four hours
to four days these are sudden sustained
contractions of the neck mouth tongue
and eye muscles treatment would be Ben's
atropine or diphenhydramine for acute
dystonia akathisia can happen at any
time akathisia is subjective
restlessness or an inability to stand
still or sit still and you treat
akathisia with beta blockers like
propranolol
or benzodiazepines like lorazepam
parkinsonism occurs four days to four
months afterwards after an
anti-psychotic is given and these
usually have gradual onset of tremors
rigidity and bradykinesia which is slow
movement
and some of these and the way you would
treat that would be with a benzo with
been stripping or amantadine and then
you have tardive dyskinesia which occurs
later on at 1 to 6 months of use and
these are gradual this happens as a
gradual onset after a prolonged therapy
that usually lasts more than six months
dyskinesia of the mouth dyskinesia of
the face the trunk and the extremities
and there's no definitive treatment
unfortunately but clozapine can help
with tardive dyskinesia so types of
dyskinesia you have oral and facial
dyskinesia limb neck and trunk and
respiratory dyskinesia so the oral and
facial are gonna be your tongue
protrusions tongue twisting lip smacking
lip and puckering retraction of the
corners of the mouth and chewing
movements if the limbs are affected
you'll see limb twisting and spreading
piano playing finger movements and foot
tapping as well as dystonic extension of
the toes neck and trunk you'll see
torticollis shoulder struggling or
muster I'm sorry shrugging the shoulders
shrugging rocking and swaying rotary hip
movements and for respiratory symptoms
you'll see grunting noises so
extrapyramidal side effects are more
common again with first generation
antipsychotics compared to the
second-generation ones out of the
second-generation antipsychotics
risperidone is going to be the one
that's most likely going to cause the
extrapyramidal symptoms so remember that
and that's going to be obviously at a
higher dose and if the dose reduction is
not even feasible with these patients
then you would want to give medication
associated with whatever it is that
they're suffering from that we've listed
moving on we have our next topic is
neuroleptic malignant syndrome
and this is a highly tested question so
signs and symptoms would be sometimes
they'll have severe feet fever so you're
looking at over 40 degrees Celsius and
that can develop within one to three
days associated with delirium often as
its first manifestation so high fever
you can have mental status changes
muscle rigidity autonomic instability
tachyarrhythmias and dis arrhythmias
labile blood pressure so rhabdomyolysis
is followed by a mile globulin urea
which can cause acute renal failure and
that's a common complication and as well
as leukocytosis also tachypneic and
diaphoresis those are all signs of
symptoms of neuroleptics malignant
syndrome i remember them rhabdomyolysis
that's a big one precipitating factors
would be antipsychotics typical or
atypical remember risperidone if it's
the atypical one is the one that's gonna
cause it and clozapine is gonna be your
go-to drug for that for that treatment
antiemetics like promethazine and
metoclopramide but that's associated
with meds that block dopamine
transmission and that can occur at any
time after treatment anti Parkinson
drugs such as dopamine agonists
and medication withdrawal can cause this
and infections and surgeries and you
would the way you would treat it is to
first stop the neuroleptic or restart
dopamine agents if they've done the
withdrawal you want to restart them or
if they're on a medication you want to
stop the neuroleptic supportive care
like hydration and cooling if they're
having the fever so antipyretics
alkaline the diarist diuresis and cases
of rhabdomyolysis
and also the big ones here are
dantrolene and bromocriptine and
amantadine so you can give either either
one of those three dant redeem
dantrolene bromocriptine or amantadine
will treat neuroleptics malignant
syndrome and you want to monitor these
patients in the ICU so if they ask you
typical a psychotic patient that's under
medical management with an
anti-psychotic and they present to you
with a fever mental status changes
rigidity and such and then you they ask
you where would you want to monitor
these patients in do you want to
discharge them home after they're being
treated and everything is fine it's the
answer is no you want to take them into
the ICU so what's the difference between
neuroleptic malignant syndrome and
serotonin syndrome is that in serotonin
syndrome that begins with vomiting
diarrhea restlessness and autonomic
instability and that's characterized by
neuromuscular irritability but not
rigidity so they'll have tremors and
hyperreflexia and myoclonus but they
won't have muscle rigidity fever isn't
really as high even though it may be
present they'll give you a patient
that's is is febrile so you'll see 101
maybe 102
as their fever but here with these
patients they're suffering fevers more
than 104 and also waiting two weeks
between the discs it's the
discontinuation of an MAOI like
phenelzine and the start of a ceratin
genic antidepressant like psych tala
pram is deemed sufficient enough to
avoid the risk of a developing serotonin
syndrome
so again neuroleptic malignant syndrome
just remember it causes sweating to Kip
Nia hypertension tachycardia you can
have dis arrhythmia muscle rigidity is
the big one fever and altered mental
status so what are going on to the next
topic what are some of the metabolic
effects of second-generation
antipsychotics so we know what first
generations can do what is second
generations do and one of them would be
metabolic syndrome like weight gain this
epidemia hyperglycemia including new
onset of diabetes highest drug the
highest risk drugs that can cause these
metabolic effects would be clozapine and
olanzapine remember Alonza pain causes
weight gain the Oh remember the Oh think
of a big oh as a big body and a person a
big round belly or something
it's olanzapine and that is associated
with weight gain and monitoring
guidelines would be a baseline and
regular follow-ups such as body mass
index cuz these drugs cause weight gain
fasting glucose and lipids blood
pressure and waist circumference and the
BMI is measured monthly the rest is
measured at baseline then three months
and then annually the earlier and the
more frequent the monitoring needed in
those with diabetes or those who have
gained more than 50 percent of their
initial weight gain so you just want to
closely monitor them if they are gaining
weight Alonza pain is a serotonin and
dopamine blocker but it also has
affinity for the histamine receptors
alpha one adrenergic receptors and
muscular Inuk receptors allows apenas
most common side effect is going to be
weight gain and sedation like we said
the weight gain is due to the antagonism
of histamine 1 and serotonin receptors
and the sedation is due to the blocking
of the histamine receptors
next is clozapine treatment guidelines
so we said earlier that the indications
for clozapine would be for a treatment
resistant schizophrenia so if they're
resistant at some type of treatment
they're the go-to drug next in line
would be clozapine and in schizophrenia
associated with suicidality you also
want to give clozapine so if they're
suicidal
clozapine is a good treatment and an
indication to give adverse effects would
be a granulocyte ptosis so you'll see a
very low white blood cell count and all
the granulocytes would be low seizures
myocarditis metabolic syndrome as well
as aliases and hypotension can all be
adverse effects of clozapine so adverse
effects so with the exception of
clozapine no ins like psychotic is
superior to another the least it's least
likely cause of extrapyramidal side
effects and it hasn't been shown to
cause tardive dyskinesia so that's why
it can be a treatment for tardive
dyskinesia because it's maybe it's not
necessarily treating the tardive
dyskinesia but it can it just hasn't
been shown to cause tardive dyskinesia
okay also
clozapine is associated with treatment
resistance so any poor response are
these two anti-psychotic trials will
require regular monitoring of the white
blood cell counts as well because of the
agranulocytosis and absolute neutrophil
counts to two risk of leukopenia and
neutropenia as well as the
agranulocytosis which we mentioned also
weekly blood blood counts should be done
within the first six months of treatment
to look out for that so just remember
that about clozapine
what else oh just one of my professors
said that clozapine sounds like a clown
clozapine clown of pain or whatever and
clowns are kind of weird and wacky so a
closet pain can cause seizures
so maybe because it causes seizures and
makes you look kind of wacky when you're
having a seizure that's a like a clown
clozapine maybe that'll help you it did
help me so why not wacky little things
like that help sometimes
next would be error pip resolve that's
another second-generation antipsychotic
is both antagonist and partial agonist
of the dopamine d2 receptors and that's
less likely to cause hyperprolactinemia
so if you're asked most likely you'll be
asked for era papers all the only
question would be this patient has
hyperprolactinemia as a side effect what
medication would you like to switch them
to and it would be err pippers all
ziprasidone is associated with QT
prolongation at higher doses so just
remember that ziprasidone starts with
the letter Z and the letters QT are all
end of the alphabet letters so make
that'll help as well so prolongation of
the QT and ziprasidone all right moving
on we have anxiety disorders so some of
the differential diagnosis is of the dnc
dsm-5 for anxiety disorders would be
social anxiety disorders like social
phobia and that would be an anxiety
that's restricted to social and
performance situations or fear of
scrutiny and embarrassment so they'll
give you a patient that only has anxiety
when they're put in a specific situation
so in that case that would be social
anxiety disorder
panic disorder would be if they have
recurrent unexpected panic attacks
versus specific phobia which is an
excessive anxiety about one specific
object or a situation so try to remember
try to differentiate between specific
phobia and social anxiety and a specific
phobia it could be anything but it's a
it's usually an object versus social
anxiety disorder would be anxiety
because of a fear of scrutiny or an
embarrassment in a specific situation
so I guess anxiety social anxiety would
be according to the situation where a
specific fody phobia would be according
to a specific object or a situation but
if in the exam they'll probably point
you in the direction of a specific
object all right and generalized anxiety
disorder would be chronic multiple
worrying anxiety and tension I know
people that are constantly chronic
worriers they're worried about this
worried about that gives them anxiety
and tension and if that's actually
impeding on your daily life that would
be given a category of generalized
anxiety disorder so moving on we have
we're gonna 12 into this a little bit
more in detail so let's start off with
social anxiety disorder or social
phobias it's also known as the diagnosis
is marked anxiety about more than one
social situation for more than six
months there you have your six month
bracketing that these like these
psychiatric conditions are based off of
more than six months at about more than
one social situation fear of scrutiny by
others in humiliation and embarrassment
social situations are then avoided or
endured with very extreme intense
de-stress and then marked impairment of
social academic and occupational
situations because you just don't want
to deal with life at that point whatever
it is that you're you have a phobia too
as well as subtypes specifier so
performance only such as if you are
gonna go on stage or give a speech in
front of hundreds of people that's some
type of performance anxiety
which is a specific social phobia or not
specific phobia I'm sorry it would be a
social anxiety disorder or social phobia
okay a treatment would be in the in
these situations an SSRI or SNRI as well
as cognitive behavioral therapy again if
you ever get the option of having both a
treatment a medical treatment plus
cognitive behavioral therapy always pick
both beta-blockers or benzodiazepines
are used for the performance subtype of
this disorder so the beta blockers are
preferred benzos because benzos can
cause sedation or effects in cognition
so you want to kind of avoid that
because you don't want to actually make
a fool out of yourself if you're sedated
or or something on stage you just want
to calm yourself down and it'll help you
perform better on stage and avoid
substance avoid benzos in substance
abuse patients because benzos again are
highly addictive cognitive behavioral
therapy techniques include social skills
training cognitive reframing of anxious
thoughts and systemic de sensitization
all right moving on we have panic
disorders panic disorders are recurrent
and unexpected attacks with more than
four of the following so they can have
chest pains palpitations shortness of
breath trembling and sweating nausea
dizziness paresthesias D realization or
deep personalization
fear of losing control or dying and
worry about additional attacks and
avoidance of behaviors so how do you
treat panic disorder immediately you
want to give benzodiazepine to just calm
them down and then long term you calm
them down how do you want to treat them
long term is with an SSRI or SNRI or you
can combined that with the cognitive
behavioral therapy
alright panic disorder the R is
recurrent and unexpected panic attacks
with more than four of the following so
they can get palpitations and sweating
trembling or shaking shortness of breath
choking sensations that's a common one
chest pain and discomfort so I can mimic
an mi right nausea abdominal distress
dizziness and lightheadedness chills or
heat sensations paresthesias a
derealization or depersonalization
disorder fear of losing control or going
crazy or the fear of dying these are all
symptoms of panic disorders and this
will happen very commonly at least one
attack followed by one or both of the
following for more than a month so they
can have worry about additional panic
attacks or Consequences and changes in
behavior related to the attacks like
avoidance the panic attacks are not
attributable to other mental illnesses
or substance abuse so how would you
treat panic disorder you would treat it
exactly the same as what we said earlier
with benzodiazepine and long term with
SSRIs and cognitive behavioral therapy
you can also do a benzo like lorazepam
well that's not all so you immediately
you want to give benzodiazepines an
example would be lorazepam and once the
symptoms are controlled benzos should
then be tapered off due to risk of
dependent
and then the diagnosis is mainly
clinical but drug screening monitoring
of vitals
EKGs cardiac enzymes should all be
performed to rule out any type of MI
because again panic disorder does look
like an mi core morbidities of panic
disorder would be they could be
associated with major depression studies
have shown that about 60% of patients
with panic disorder
have at least one lifetime episode of
major depression bipolar disorder is
also a sort of ciated with panic
disorder agoraphobia which is the fear
of public places an approximately 40% of
patients meet that criteria of
agoraphobia and substance abuse and
there's also a higher risk of suicide
attempts and suicidal ideations now we
can move on to specific phobia and that
would be a marked anxiety about a
specific object or a situation for more
than six months again you have that six
months time period common types of
phobias would be phobias of flying
phobias of heights
animals injections or seeing blood those
are all examples so avoidance behaviors
like bridges and elevators refusing to
work requiring travel like on an
airplane or a boat or whatever their
phobic to the object of their and they
have phobia too and it's common around
10% of the population does have some
type of specific phobia and usually it
develops in childhood and can develop
after a traumatic event so treatment for
a specific phobia here you want to do
behavioral therapy first such as
exposure therapy like flooding I believe
is the term right flooding a systemic
desensitization as well and those are
the treatment of choices short acting
benzos can help acutely so if a
therapist is unavailable
there's just insufficient time
benzodiazepines can be given if if
there's something going on at this
moment but since this is a specific
phobia they're coming to you because
they need help dealing with a folk with
a phobia that just means that they need
therapy at that time okay not not
medical therapy okay or pharmacological
therapy I'm sorry generalized anxiety
disorder is the next one and this is
excessive worrying or anxiety about
multiple issues and that occurs more
than six months they're difficult to
control there's more than three of the
following symptoms they can have
restlessness or feeling on edge they can
have fatigue difficulty concentrating
irritability muscle tension and sleep
disturbances as well as significant
distress or impairment and it's not due
to substances or any other type of
mental disorder or medical condition and
treatment for generalized anxiety
disorder first line would be cognitive
behavioral therapy with an SSRI or an
SNRI
and if those don't work second line
would be to give them benzos or
buspirone
and be spur on is used in non depressed
patients as well and in the absence of
panic symptoms so it it if they have
signs of panic symptoms you don't want
to give them booster perón you actually
want to give them a benzo to calm them
down first and then again and then send
them home on an SSRI or SNRI
with cognitive behavioral therapy I
think you're getting the point
so benzodiazepines should not be used in
patients with comorbid depression
substance abuse because they're what
they called Downers they should be used
sparingly in elderlies due to slow
metabolism
and accumulation so remember that
elderly patients have a slower rate of
metabolism so any type of drug that you
give them has to be titrated at a
perfect amount because they have a very
slow metabolism and can linger around
their body causing toxic levels to
accumulate so remember that about
elderly patients and that slow
metabolism and accumulation of the drug
in elderly patients can cause confusion
and an increased risk of Falls another
adverse effect of benzodiazepine is
paradoxical agitation now paradoxical
agitation is gonna be characterized by
increased agitation confusion and
aggression as well as this inhibition
and it's typically within an hour of
administration although paradoxical
reactions of benzodiazepines are
relatively uncommon less than 1% they
are important to recognize as increasing
the doses of benzodiazepines will only
worsen the patient's condition and
discontinuing is going to be the most
appropriate next step in the management
if a patient starts developing
paradoxical agitation
okay the next topic is OCD or obsessive
compulsive disorder and diagnostic
criteria would be obsessions that are
recurrent or intrusive obsessions
anxiety provoking thoughts urges or
images and there's attempts to suppress
or neutralize them with other thoughts
of actions like compulsions and it has
no relation to other mental or substance
use disorders so these are just straight
obsessions compulsions are another
diagnostic criteria which are responses
to the obsessive thoughts and repeated
behaviors or mental acts they have
excessive behaviors that are intended to
reduce the anxiety or to avoid any kind
of outcome so their behaviors are not
connected realistically with preventing
anxiety or the feared event obsessions
or compulsions they consume more than an
hour's worth of your day and that causes
significant distress and it interferes
with a daily routine or social
functioning whenever you see that phrase
by the way as a general rule that it
interferes with daily routine or social
functioning that is a hint for a
psychiatric condition if it doesn't have
that it might just be counseling or
whatnot but if you see that someone's
daily routines or social functioning has
been compromised then you're more look
you're looking more into a psychiatric
condition so be aware of that
okay treatment options for OCD would be
cognitive behavioral therapy exposure
and response prevention and/or a high
dose selective SSRI you can also give
Kalama fene or an anti-psychotic for
people who do not respond to that
treatment that don't respond to SSRIs
you can give them clear amine or
antipsychotics and also deep brain
stimulation for treatment of severe or
refractory cases so I mean if nothing
works the last case scenario
would be to stimulate your brain that
would be pretty much anybody's last
resort is to actually get into the brain
and do some kind of stimulation there
all right next topic would be
trichotillomania
and that's basically hair pulling so
dsm-5 criteria states that these are
recurrent hair pulling causing hair loss
with repeated attempts to decrease or
stop the hair pulling they don't want to
be doing this but they're just doing it
causes significant distress in their
lives again you have your that it
affects their daily life that's an issue
it's not due to a medical or
dermatological conditions such as
alopecia this is just them pulling out
their hair and it's not due to any other
mental disorders like body dysmorphic
disorder so it's not it's not a symptom
of something else this is it it's a it's
a diagnosis in itself how you treated is
with cognitive behavioral therapy to
reverse their habits so it's like a
training form of reversing that habit of
hair pulling the dsm-5 classifies it as
an OCD related disorder to reflect the
increasing evidence of shared features
that they have with OCD and because of
their higher rates of core morbidity in
patients with a personal or family
history of OCD and commonly it affects
areas such as the scalp the eyebrows and
the eyelids more common in girls and
women and they have something also
called trick aphasia which means when
they pull out their hair they'll eat it
and subsequently they can actually form
a trick Oh bezoar which remember was
like a ball of hairs in the intestines
or in the stomach that was from step one
a bezoar so that can lead to abdominal
pain and even bowel obstruction if it
gets too bad next one would be hoarding
syndrome and this is a new disorder in
the dsm-5 it's distinct from OCD in that
it is characterized by the accumulation
of large numbers of
questions that make clutter the living
spaces to the point that they are the
living spaces are not are not usable
patients experience intense distress
when they try to attempt to discard any
of their possessions regarding to their
actual value regarding of their actual
value so it could be somebody collecting
newspapers that have no significant
value or no newspaper clippings I really
have no significant value and yet it's
so many of them that it's impeding their
walkway to get into their bedroom and if
you try to remove that they are
extremely held on to this clippings in
this example so they don't want you to
get rid of it so that is a problem it
can also become caitiff it's extreme it
can cause associations with unsanitary
conditions fire risks basically because
of the blocked exits and then cognitive
behavioral therapy would be the
treatment specifically targeted to the
hoarding behaviors that's the most
effective treatment and their specific
techniques to educate the patient as
well as motivational interviewing skills
skills training and organization and
decision-making capacities also can
cognitive reconstruction or
restructuring of dysfunctional thoughts
an actual gradual exposure to discarding
possessions so you can say well we'll
get rid of these little five clippings
you don't really need that and so on and
so forth
until they're cured or at least they're
stable all those SSRIs are often tried
based on the efficacy in treating the
OCD their efficacy in treating this
disorder the hoarding behavior without
obsessive-compulsive disorder is going
to be limited so SSRIs can be considered
as an adjunct to cognitive behavioral
therapy and then it can be helpful in
treating core morbid depressions and
anxiety disorders but cognitive
behavioral therapy in itself is
basically
first line also I'd like to add a side
note that most of these disorders they
require the patient to to basically tell
you that there's a problem they have to
admit there's a problem you can't just
go out of your way because a family
member brought them in and expect the
patient to be compliant with any type of
treatment that you give them because
they're they think them themselves that
this is perfectly fine behavior unless
they come to you and say doc this is a
problem then the treatment is always
gonna be better versus if they don't
then no amount of treatment is gonna
help them because they're not gonna
comply with anything you tell them to
because in themselves they really think
there's nothing wrong with them okay so
just just a little adjuvant there
so next disorder would be PTSD or
post-traumatic stress disorder and the
clinical features would be exposures to
a life-threatening trauma as well as
nightmares flashbacks intrusive memories
there's avoidance of reminders amnesia
of the event there's emotional
detachment and a negative mood towards
it with decrease interest in activities
sleep disturbance hyper vigilance
irritability and this is gonna be
lasting more than one more than one
month so again this is the that it
affects their daily life treatment would
be a trauma focused cognitive behavioral
therapy like what is it that caused you
to have the post traumatic stress
disorder what traumatic experience were
you exposed to and then the cognitive
behavioral therapy will be geared
towards that and you can also add an
antidepressant to help out with the
cognitive behavioral therapy such as
SSRIs or SNR ice sexual assault patients
and also military veterans are at
increased risk of PTSD along with the
risk of developing major depression
and a contemplation of suicide attempts
also there's an increased risk for
medical problems including sexual
transmitted diseases pelvic pains
fibromyalgia functional gastric
gastrointestinal disorders and cervical
cancer those can all be linked to an
avoidance of pelvic examinations some
PTSD symptoms may appear immediately
after a trauma however sometimes it's
often delayed months or even years
before you actually start seeing any
kind of criteria for the diagnosis all
right next topic is depression
so we're gonna have differential
diagnosis of depression specifically
differentials of that depressed mood so
you'll have your category of major
depression adjustment disorder with a
depressed mood and normal stress
responses so that's category ISM so in
major depressive disorder you're looking
at something that's gonna be occurring
more than two weeks there's gonna have
more than five of the nine symptoms of
ciggy caps there's gonna be a
significant functional impairment
there's no lifetime history of mania and
there's it's not due to drugs or any
kind of other medical conditions so it's
just think about a significant
functional impairment again with their
daily lives with more than five of the
symptoms of ciggy caps now the mnemonic
ciggy caps you probably already know
this but the S stands for sleep
disturbance I stands for interest or
loss of interest G is for excessive
guilt use for energy so low energy that
the seein caps is impaired concentration
the a is appetite disturbance so they
won't have an appetite or they will
excessively or under appetite or low
appetite of the P is for psychomotor
agitation or retardation and the essence
Iggy caps is suicidal ideation so if
they have five of those nine symptoms
and that
is the criteria for major depressive
disorder now adjustment disorder with
depressed mood would be you can actually
pinpoint the identifiable stressor the
onset is going to be within three months
of that stressor so it's more of an
acute kind of thing it's mark there's
mark distress in the patient there's
significant functional impairment again
with their daily lives but it doesn't
meet any criteria for other dsm-5
disorders so here they have an
identifiable stressor that happened
within the last three months
specifically these could be like an
automobile accident or witnessing
somebody being killed or or something
very traumatic and it happened fairly
recently within the last three months
and that is significantly causing them
to stress an impairment so that is
adjustment disorder with a depressed
mood and then you have your normal
stress response and that is not
excessive or out of proportion to
severity of the stressor there's no
significant functional impairment these
people can actually go about doing their
daily lives they may be thinking about
the event or thinking about the stressor
but they're still able to go to work
they're still go to go to school study
do their normal daily lives this is just
a normal stress response okay so for
adjustment disorder the symptoms rarely
last more than six months after the
stressor ends and the stressors can be
either single or multiple stressors and
it involves emotional or behavioral
symptoms such as anxiety depression
disturbance of conduct and you want to
treat with psychotherapy that that's
focused on developing coping mechanisms
and improving individuals and responses
to and an attitude about stressful
situations so psychotherapy is going to
be your treatment in adjustment disorder
for major depression there's signs and
symptoms of major depressions we already
said a ciggy cab sleep lack of sleep
increased or lack
of theirs anhedonia decreased interest
guilt so they have feelings of
worthlessness or hopelessness their
deficient and energy they've just
they're not energetic they have a
difficulty concentrating their appetite
can either be increased or decreased
they can have a psychomotor retardation
or agitation and actually suicidal
ideations so so some what are the
differences between major depression and
a grief reaction so a major depressive
episode is basically five of the
following nine symptoms so this the nine
siggy caps I'm not gonna keep going over
them but there's low solo mood or
anhedonia must be present it has it
can't occur in response to a variety of
stressors including a loss of a loved
one the duration here has to be at least
more than two weeks and there can be
social or occupational dysfunction and
suicidality is really this is gonna be
related to hopelessness they feel
hopeless and worthless maybe the stock
market crashed and they lost all their
money and now they feel suicidal and
they can't even function in life and
right there and then that's the
diagnosis for major depression a grief
reaction or bereavement is going to be a
normal reaction to the loss feelings of
loss or emptiness the symptoms are going
to resolve around they're not gonna
they're gonna revolve around the
deceased person functional decline is
gonna be less severe the the grief is
gonna occur in waves there's also going
to be feelings of worthlessness
self-loathing guilt but there's not
really a feeling of suicidal tendency
there that's that's not as common but
they do feel extremely sad
but it's more specific towards the
deceased person that's what's why
they're grieving thoughts of dying
involved joining the deceased person oh
they they had a strong connection to
their loved one they just want to join
the deceased
there's also intensity is gonna the
intensity is gonna decrease over time so
the timeframe there would be weeks two
months now there's also sub
classifications of depression you have
melancholic depression atypical
depression and depression with psychotic
features so a melancholic depression
would be a subtype of major depression
that's characterized by anhedonia absent
mood reactivity a depressed mood and
that's typically worse in the morning
you have insomnia or early morning
awakenings they get up early early in
the morning with loss of appetite so
they have weight loss they are typically
they feel guilty excessively with
psychomotor agitation or retardation and
that subtype is and it's psychomotor
changes are more common in older adults
so that would be a melancholic
depression older adults but if you see
something that involves hypersomnia they
constantly sleeping with an increase in
appetite and they basically are not very
sensitive to anything anymore and now
they have physiological feelings of
heaviness in their limbs
that's an atypical depression and then
versus major depression with psychotic
features that is gonna be basically an
elderly patient who has depression to
the point of suicidal ideations so in
those cases you want to treat with
electro convulsive therapy the reason
again is because remember we said
earlier that in the elderly population
their metabolic their metabolism is
slowly reduced so they're going to have
an increase of the concentration of
whatever drug you give them in there
system so it's gonna take them longer to
eliminate psychotic antipsychotic drugs
antidepressants any type of medication
they're slower renal function they have
a decline in renal function normally so
you want to avoid any of these heavy
heavy medications so just go straight
into electrical fall severe apibe II cuz
it is a rapid response it's a very quick
procedure as very low side effects if
not any and it's just preferred
over the medical pharmacological therapy
all right next topic would be dysthymia
which is a persistent depressive
disorder the dsm-5 categorizes as a
chronic depressed mood that lasts more
than two years when and one year in
children or adolescents there is no
symptom free period for at least two
months so this is happening more than
two months the presence of at least two
of the following so they'll have poor
appetite or overeating insomnia or
hypersomnia low-energy or fatigue low
self-esteem poor concentration or
difficulty making decisions
there could be feeling of hopelessness
and with a peer dislike the Stimac
syndrome it's a criteria for major
depressive episodes that's never been
met with intermittent major depressive
episodes and they can also be with
persistent major depressive episodes and
that criteria is for major depressive
episodes that's met previously for the
previous two years okay so moving along
we have antidepressants and there's
several classifications of
antidepressants first you have your
SSRIs SNRIs your nd our eyes TCAs
mao eyes and other medications so let's
start off with SSRIs these are a
selective serotonin reuptake inhibitor
that's what it stands for
you have your fluoxetine paroxetine
sertraline citalopram escitalopram and
fluvoxamine be careful with citalopram
and escitalopram because that sounds
like a benzo but it's actually an SSRI
citalopram escitalopram SNR eyes would
be your serotonin and norepinephrine
reuptake inhibitors
those are your venlafaxine dest
venlafaxine and duloxetine you have your
and DRI which is norepinephrine and
dopamine reuptake inhibitors the end DRI
the one that we should know is if you
Pro prion and
though that bupropion it helps with
smoking association so that's a big one
no weight gain so there's no weight gain
involved no hypersomnia so that's good
and no sexual dysfunction as well so
that is those are really good benefits
for the appropriate and they will be
tested on they'll have which of the
following helps with will help with this
patient and they'll give you a patient
who wants to stop smoking be appropriate
they'll give you a patient who says that
he really doesn't want to gain weight
anymore so it's something appropriate
contraindications however would be
seizure disorders because they do cause
seizures it's known to cause seizures so
if they are suffering from seizure
disorder that's contraindicated also
patients who are bulimic because this
medication does not cause weight gain
and we want patients with bulimia
nervosa anorexia nervosa to actually
gain weight so that would be a
contraindication and if they've had any
type of maoi use within the past two
weeks if they've been on like phenelzine
or tripe trial super-mean within the
past two weeks and you want to change
them this would be a contraindication so
you would not want to give be
appropriate in those cases so caution
needed when there is an abrupt
withdrawal of sedative hypnotics and
co-administration with other drugs that
lower the seizure threshold because
again this medication is known to cause
seizures
TCAs are your tricyclic antidepressants
your amitriptyline nortriptyline you'll
see later on that these tricyclic
antidepressants and although they are
classified as antidepressants are
usually used as pain management so go
figure but that's what it is and you
have your mao eyes which are your
monoamine oxidase inhibitors again your
phenelzine trials if I mean and both
TCAs and mio is our never first line
because they have the greatest
side-effect profile you want to give
them five weeks after a washout period
when you've taken fluoxetine and before
starting at mio I basically to avoid
serotonin syndrome other antidepressants
would be mirtazapine
trazodone and wart ty oxy teen alright
so parents of adolescents patients
should always be notified when the
patient is at risk to themselves or to
others or when starting a psychotropic
medication if patient the patients are
not suicidal and they simply just want
to discuss his or her depression or
obtain psychotherapy referrals and his
request for confidentiality should be
respected patients with a single episode
of major depressive disorder who do
respond to actual treatment should
continue the anti-depressive medication
for an additional four to nine months
and that would be a continuation phase
treatment there is a significantly
increased risk of a depressive relapse
in patients who suddenly discontinue
their antidepressants earlier than four
to nine months so if you have a patient
who says thanks doc this has been
working great and it's only been two
months of treatment or three months what
would be the next thing do you want to
wean them off or what no you actually
want to continue them on for at least
nine months four to nine months the dose
should be maintained at the level that
was that achieved remission and it
shouldn't be reduced the dose that gets
the patient well keeps the patient well
is what you should know so the
maintenance phase treatment is going to
be defined as continuing the
antidepressant medication past the
initial continuation phase treatment
maintenance therapy is about 1 to 3 1 to
3 years that would be appropriate for
patients with a history of multiple
episodes like recurrent major depressive
disorder and for chronic episodes that
lasts more than like two years with a
strong family history or if they've had
severe episodes like
that suicide is attempted that would be
an indication patients with a history of
highly recurrent lifetime episodes more
than three lifetime episodes and very
severe episodes chronic major depressive
episodes those all should be continuing
on with maintenance treatment
indefinitely so in those patients no
matter how much they want to ask you can
we be weaned off because of their past
history and risks you do you just want
to continuing them you want to continue
them on indefinitely when should you
taper or discontinue when there's
failure of initial SSRI treatment so
you'd want to increase the dose to its
maximum therapeutic dose then you'd want
to do adequate duration of more than six
weeks where you'll see minimal or no
improvement then you want to switch to
another first-line antidepressant with a
different like let's say into Mayo I are
in Smar SNRI
and other options would include adding a
second agent especially in those with
that have some benefit but not complete
improvement with either adding or
switching that pharmacotherapy so it's
all this is all tailored therapy in
other words so you kind of want to see
where the patients at have they been
doing better with it or minimally better
if not do you want to switch them to the
same class of maybe a different class
you want to add to a different class and
maintain them on a current one because
it's having a little bit of benefit here
but not enough there so you want to add
another medication everything is
tailored in this case so patients
undergoing chemotherapy also that have a
low threshold of depression and starting
SSRIs the first step in management would
be pain control obviously because
chronic pain can lead to depression
mirtazapine side-effect
that's weight gain and sedation and
trazodone is very sedating and it's used
in insomnia related to depression so if
there's depression with insomnia
trazadone would be a good treatment now
coming back to the topic of electro
convulsive therapy or a CT when would
these be a good condition like we said
in in well first of all in elderly
patients with major depression or with
unipolar and bipolar depression
catatonic patients and patients that
have bipolar mania so what are some of
the specific indications if there's
treatment resistance to other
medications if it just didn't work or if
they have psychotic features present or
any type of emergency condition such as
in pregnancy that's a good one
refusal to eat or drink or imminent risk
of suicide you want to treat them ASAP
with a very quick treatment minimal side
effect profile profile electroconvulsive
therapy and then pharmacotherapy is
contraindicated due to the core morbid
medical illnesses and poor tolerability
and also if they've had a history of
response to electro convulsive therapy
that would be in also a good indication
to continue on doing that treatment
because again that would be last resort
anyway
the safety is that there's no absolute
contraindications to electric electro
convulsive therapy there is an increased
risk of severe cardiovascular disease or
if patients have had severe recent MI or
if they have a space occupying brain
lesion or a recent stroke or they have
some type of unstable aneurysm then that
will make a contraindication so you want
to perform it's performed under general
anesthesia and it's one of the most
common and one of the most common side
effects of ECT would be amnesia it can't
be a retrograde amnesia
so like forgetting me recent memories
that tends to last longer especially of
events occurring during the ECT or it
could be anterograde amnesia such as
retaining new memories but that resolves
rapidly there's an increased risk of
fractures especially in osteoporotic
patients but not as common as a boniva
you want to do close monitoring of
muscle relaxation with succinylcholine
and that has decreased the incidence of
bone fractures if they do have an
increased risk of osteoporosis all right
next topic would be postpartum blues
depression and psychosis so postpartum
blues the prevalence of that is 40 to 80
percent so this is fairly common the
onset occurs within two to three days
and it resolves within 10 days symptoms
would be mild depression tearfulness
irritability and basically you just want
to reassure these patients and monitor
them because it does go away in ten days
and it's fairly common versus postpartum
depression that is actually least common
or less common only eight to 15% of the
population has this usually happens
within four weeks their symptoms are
moderate to severe depression
they'll have sleep or appetite
disturbance low energy they can have
psychomotor changes they can feel guilty
lack of concentration or they can even
go as far as to having suicidal ideation
and treatment for postpartum depression
would be antidepressants and
psychotherapy and then finally you have
your postpartum psychosis which
thankfully it's the least prevalent at
only 0.1 to 0.2% of the population this
occurs it's onset is variable it can
happen within days to weeks symptoms
would be delusions or hallucinations fot
dis organizations and bizarre behavior
so all the symptoms of standard
psychosis is just happening postpartum
and their treatment would be
antipsychotics and antidepressants and
you don't want to leave the mother alone
with the infant because there's a risk
that the mother can kill the infant so
if you see a vignette that says that
she's doing something for Rita
she's seeing things or voices are
telling her to kill herself and the baby
or something like that those are
obviously red flags and that is not
normal by any means so you want to admit
the patient and don't leave the mother
alone with the patient you don't want to
discharge these patients and you want to
treat them with antipsychotics and
antidepressants immediately okay next
would be bipolar disorder and that is
bipolar disorder and it's related
disorder so we can classify these first
of all as either manic episodes or
hypomanic episodes and then we'll go
into bipolar one bipolar two and
cyclothymic disorder so bipolar disorder
that it's manic episodes or symptoms
that are more severe it's usually one
week long and less hospitalized
they'll have marked impairment and
social or occupational functioning or
hospitalization necessary it may lead to
psychotic features and that makes the
episodic makes the episodes manic by
definition so those psychotic features
are basically a manic episode then you
have your hypomanic episode which are
less severe symptoms that occur more
than four consecutive days long so a
little bit less than a week there though
it'll be unequivocal with observable
changes in functioning from the
patient's baseline so symptoms are not
going to be severe enough to cause
marked impairment or necessitate
hospitalization with these patients and
their key here is that there are no
psychotic features so it'll be
very very very less very low less severe
symptoms of mania but with no psychotic
features so then you have your bipolar
one and bipolar one is basically defined
as manic episodes they have depressive
episodes
that's pomander it's not required for
the diagnosis the diagnosis of bipolar
one are basically manic episodes versus
bipolar two are hypomanic episodes
there's episodes of mania but there's
more than one major depressive episode
required so they'll have mania and
depression at some point in time that
would be bipolar - just think of it as
two episodes manic and depressive
bipolar - bipolar one only manic they
could have a depressive episodes but
that's not common and it isn't required
so bipolar one only manic bipolar two
hypomanic episodes with at least one or
more major depressive episodes and then
finally you have your cyclothymic
disorders which is at least two years of
fluctuating in and out of mild hypomania
and depressive symptoms that do not
really meet criteria for hypomanic
episodes or major depressive episodes
it's just a waxing and waning kind of
deal but it's lasting for more than two
years and that would be cyclothymic
disorder so let's break these down a
little bit more in detail so acute mania
its clinical features would be elevated
arrabal and labile mood
they'll have increased energy increased
activity they'll have a decreased need
for sleep
they have pressured speech and racing
thoughts and distractibility almost like
like like ADHD but less severe or more
severe sorry grandiosity risk of risky
behavior they'll have pressured speech
Martin
pyramid and they could have psychotic
symptoms as well and how would you
manage acute mania first line would be
yours antipsychotics it could be either
first or second generation second
generation again risperidone because of
its more rapid onset of action and you
always kind of want to give second
generation antipsychotics before you
give first generations kind of contra
country intuitive there but second
generations have less side effects
profile like we already mentioned and
out of all of them risperidone is the
treatment of choice although it does
have the highest side-effect profile of
all the second-generation ones it is
more rapid onset of action so you want
to kind of give that first for acute
mania you can also give lithium but you
want to avoid in patients that do have
renal disease because lithium does cause
a renal failure without pro8 can also be
used but you want to avoid valproate
in patients with liver diseases
carbamazepine lithium valproate they all
require gradual titration over several
days so yeah you don't want to give them
for patients with liver disease because
these are metabolized in the liver and
not in the kidney also combinations in
severe mania you can give antipsychotics
with lithium or valproate and you can
also give as an adjuvant benzodiazepines
for patients that have insomnia or if
they are agitated you can give the
benzos so some of these manic episodes
are classified as more than one week
unless they're hospitalized so more than
one week of persistently elevated or
irritable moods and increase energy or
activity and as well as more than three
of the following symptoms so four of
these if there's a mood or they're just
irritable so more than a
than three of the following so a
decreased need for sleep symptoms of
grandiosity pressured speech racing
thoughts like flight of ideas
distractibility hyperactive or
psychomotor agitation and risky
behaviors like spending a lot of money
having lots and lots of investments and
sexual indiscretions these are all
symptoms of manic episodes and you only
need more than a little three or more to
make the diagnosis there's also a marked
impairment of typically necessity that
are typically necessitates
hospitalization and psychotic features
can also be present so there's a
mnemonic called dig fast and that stands
for a distractibility distractibility
impulsivity or indiscretion the G is for
grandiosity or the F is flight of ideas
a is for increase in activity S is for
sleep so there's a decrease in sleep and
also talkativeness or T okay so moving
on we have guidelines for lithium
therapy so what are some of these
indications for giving them lithium so
mania due to a bipolar disorder that's
an indication but contraindications
remember chronic kidney disease you
shouldn't give lithium also in patients
with heart disease or if they have
hyponatremia or diuretic use you should
avoid lithium baseline studies before
giving lithium would be to check their B
when their creatinine calcium levels and
your analysis because again these can
cause renal failure
the lithium can cause renal failure and
thyroid function tests as well and you
want to do an EKG in patients with
coronary risk factors because heart
disease is a contraindication adverse
affects acutely you'll they'll have
tremors a taxi and weakness polyuria
polydipsia vomiting diarrhea
they'll have weight gain
cognitive impairment and then chronic
adverse effects would be nephrogenic
diabetes insipidus that can also cause
chronic to below interstitial
nephropathy that rarely progresses to
end-stage renal disease but that's what
it can cause and if Radek diabetes
insipidus also thyroid dysfunction
that's why you also want to check their
thyroid function tests and
hyperparathyroidism because it does
cause an accumulation of calcium all
right and pregnant women should either
avoid lithium or adjust the dose during
pregnancy because that can cause
complications within the first trimester
as most complications occur within the
first trimester like Epstein's anomaly
and in the later stages they can get
polyhydramnios diabetes insipidus floppy
infant syndrome which is a transient
neonatal neuromuscular dysfunction as
well as a goiter and the lithium has a
narrow therapeutic index and can easily
cause toxicity so those drug levels
should be monitored every six to twelve
months and five to seven days after any
dose changes or after starting other
medications that can interact with
lithium so what are some of the common
drug interact fm sorry what are the
common drugs effecting lithium levels
diuretics can do it can affect lithium
levels NSAIDs
except for aspirin SSRIs can affect
lithium levels angiotensin converting
enzyme inhibitors ACE inhibitors and
ARBs angiotensin receptor blockers and
anti-epileptics like carbamazepine and
phenytoin because they can rev up the
p450 system so that's that's a lithium
can affect my anti the lithium can
affect be affected by anti-epileptics so
if a patient has an increase in
creatinine level then you'd want to give
them valproate remember you don't want
to give them lithium so you
Duvall Pro with periodic liver function
tests because again valproate does this
cause changes with within your liver
enzymes and you want up so you want to
monitor the liver function tests and
platelet count needed due to a rare side
effect profile of hepatic toxicity and
thrombocytopenia because again your
platelet and your coagulation factors
are made in the liver management of
acute bipolar depression commonly used
medications would be your
second-generation antipsychotics those
would be quetiapine or Laura's adone and
anticonvulsant like lamotrigine lithium
valproate and the combination of ola
subpoena fluoxetine also have been shown
to have some efficacy and then
anti-depressive monitor mono therapy you
want to avoid that because there is a
risk of precipitating mania so you just
you don't want it in a patient with
bipolar you don't want to give them just
an antidepressant because you're just
you're making the mania worse if
necessary you can use in a combination
with mood stabilizers like lithium or
valproate second-generation
antipsychotics those decrease the risks
and decrease the risk to switch to mania
so lamotrigine has the greatest efficacy
for bipolar depressive episodes and can
cause Sjogren's syndrome and one but in
very low prevalence and only 0.1% of
patients so that's a good medication the
motor gene but it can cause it's even
johnson syndrome not Sjogren's syndrome
I'm sorry Steven Johnson syndrome
maintenance therapy so for lifelong
illnesses this is gonna require
maintenance to decrease the risk of
recurrence most require maintenance is
for many years but lifetime lifetime
maintenance is indicated for those with
severe courses like highly recurrent
episodes suicide attempts severe symptom
impairments requiring hospitalizations
and that can lead to let's say if the
patient wants to stop the medication
because of a strong therapeutic alliance
there's a psychoeducation involved and
adjunctive psychotherapy can also help
the patient's accept the chronic nature
of that illness and enhance their
adherence so if the patient still
insists on stopping the medication you
want to slowly taper over weeks to
months and frequently monitor them to
identify any type of early signs and
symptoms of recurrence so basically you
just basically want to maintain them
lifelong with these medications unless
they really truly want to stop doing it
slowly taper them off and then just
observe them monitor them for any type
of signs of recurrence maintenance
treatment typically is going to involve
continuation of the mood stabilizer and
that's used to treat any kind of acute
mood episodes and evidence-based options
are gonna include lithium valproate
quetiapine and lamotrigine patients with
inadequate responses to these mono
therapies or severe episodes like
psychotic features or they get
aggression or if they have a higher risk
of suicide or frequent episodes with
marked impairment of requirement
requiring hospitalization that will
often then require a combination therapy
of lithium or valproate combined with
any type of site the second-generation
antipsychotics like quetiapine
preferably over risperidone because of
its higher side effect profile and
that's recommended his first line to do
a combination if the antidepressant is
used in acute depression it should be
tapered slowly and it should be
discontinued in maintenance treatment
now disruptive mood dysregulation
disorder this is an individual with
disruptive mood dysregulation and that
can display with severity
by the severity so severe pervasive
irritability and poor frustration
tolerance so they're very frustrated
very irritable individuals and that
results in frequent temper tantrums or
temper outbursts
that's called disruptive mood
dysregulation disorder so somebody who's
just think see is in a vignette somebody
who has just it is always irritable
always frustrated has temper tantrums
attractive dysregulation mood disorder
that's what that is okay now for sleep
disorders you have poor sleep hygiene
and that would be inadequate sleep
hygiene that is the next topic so
inadequate sleep hygiene is a sleep
disorder due to performance of daily
living activities that are inconsistent
with a maintenance of a good quality
sleep and full daytime alertness
examples of poor sleep hygiene practices
include poor sleeps scheduling with
variable wake and sleep times and
frequent daytime napping there's a
routine use of caffeine alcohol or
nicotine especially in the periods that
precede the sleep so engaging in
mentally or physical stimuli activities
that are too close to bedtime all can
give you a poor sleep hygiene as well as
frequent use of the bed for activities
other than sleep intent so all these are
types of poor sleep hygiene
okay so insomnia disorder would be
insomnia for more than three nights a
week or for more than three months that
would give you an insomnia disorder
narcolepsy is that patients are advised
to maintain poor sleep habits minimize
alcohol and avoid medications that can
cause drowsiness and worsen the symptoms
in addition a number of medications can
be used to treat the symptoms of
narcolepsy so some of these symptoms the
ones used on you world would be
modafinil and our modafinil
those are the daffodils those are for
narcolepsy
these are Jurassic s-- excessive
uncontrollable daytime sleepiness that's
considered chemically to be a novel
stimulant and it's preferred as the
preferred treatment for not NorCal epsy
because it's a very mild stimulant
amphetamines simulants would be like
your methylphenidate your
dextromethorphan x' Dexter
methamphetamine sorry sorry
[Music]
methamphetamines these have been
traditionally used but an hour aren't
currently considered first-line
treatment anymore because of their high
risk of abuse there's a potential
tolerance with these medications and
there's significant side of side effects
with them so for instance if a patient
can become tolerant to their dosages in
time and by the time they reach maximum
doses dosages then it could potentially
not even be beneficial to them anymore
but they're still hooked on it so that's
why it's not first-line anymore so then
you have sodium oxide bait and this
reduces cataplexy due to the potential
for abuse and illicit use both sodium
oxide bait and amphetamines are
regulated as controlled substances in
the United States so so for narcolepsy
just remember mow daffodils or armload
daffodils are all the ones that say
daffodil for a narcolepsy then you have
something called advanced sleep phase
syndrome and what this is is that it's a
circadian rhythm disorder characterized
by the inability to stay awake in the
evening that's usually after 7:00 p.m.
you can't stay awake it makes it make
social functioning very difficult these
patients frequently complain of
early-morning insomnia due to their
early bedtime the next one would be
delayed sleep phase syndrome and this is
another circadian rhythm disorder that's
characterized by the inability to fall
asleep at normal bedtimes normal
bedtimes being 10:00 p.m. to midnight
so remember in this exam it's
everything's very generalized so this
may not be a normal time for you but for
the majority of the population normal
bedtimes are 10 p.m. to midnight so this
is a sleep onset insomnia and excessive
morning sleep sleepiness of these
patients cannot often cannot fall asleep
until almost about 4 to 5 a.m. but their
sleep is normal if they're allowed to
sleep until late morning unfortunately
society and their and the pressures in
society make this kind of treatment
impossible who's gonna explain to their
boss say I can't come into work at 8
a.m. because I have delayed sleep phase
syndrome so you're just gonna have to
come in around noon yeah it's not gonna
fly so sleep is normal when they are
allowed to set their own schedules they
describe themselves as night owls and
the onset is usually in adolescence and
they may respond to treatments such as
light or behavioral therapy and an
accurate history and sleep diary are
essential for making the diagnosis so
that's called delayed sleep phase
syndrome easy enough because it's
delayed now the other ones called shift
work sleep disorder shift work sleep
disorder involves a recurrent pattern of
sleep interruptions due to due to a
shift work causing it difficulty in
initiating and maintaining sleep at
daytime sleepiness this disorder is
usually due to a work schedule that is
incongruent with normal circadian clock
so this could be a patient who was who
has been working a normal shift from
9:00 to 5:00 and suddenly they've been
asked to take the overnight shift
so another working from 5:00 p.m. to
8:00 a.m. or something like that
or that's actually kind of crazy maybe a
p.m. to 8:00 a.m. or something like that
where they're sleeping now during the
day and having to work at night
this can cause a transient inability to
fall asleep at normal at their new
normal times so this is called Metis
Tuna their their work situation so it's
their shift work sleep disorder well so
these are pretty pretty easy to remember
because of the the way they're described
you have shift work sleep disorder
delayed sleep phase syndrome disorder
advance sleep phase syndrome disorder so
delayed advanced shift work that's
pretty easy to remember example would be
like the next one age-related sleep
changes these are sleep patterns that
tend to change in older individuals or
as the people age they typically sleep
less at night and they nap during the
day the periods of deep sleep which is
stage 4 sleep becomes very short and
eventually it disappears so older people
often are more often awakened more
during all stages of sleep these changes
are normal and are usually not
indication of a sleep disorder this is
just very normal behavior the next one
would be night terrors these occur in
specifically a non REM sleep the child
it's usually fine in children you'll
have you get a child that cannot be
fully awakened or I'm sorry
the child cannot be fully awakened
during the episode and it lasts for a
few minutes
but here's the the clue here is when
they wake up they have no memory of the
event that's a night terror means a
child that's having it looks like he's
having a nightmare but it's not a
nightmare it's a night terror because
when you ask him so what happened and
they have no idea most common in
children is 2 to 12 and it peaks at 5 to
7 years of age and it's usually resolves
spontaneously as a child ages and this
can be triggered by acute stress or
sleep deprivation or illnesses or meds
that affect the CNS then vs. nightmare
disorder which this occurs during REM
sleep so what we said earlier night
terrors are non REM nightmare is during
REM and it's usually in the middle of
the night and early morning the child is
fully asleep during a nightmare and
doesn't scream or cry or become
tachycardic such as in night terrors
they do and they're fully alert when
they wake up and but and when you ask
them in so what happened I just had a
nightmare that what they all tell you
because they can recall the nightmare so
in a nightmare the child can tell you
what happened they can recall the
nightmare and a night air they cannot in
the nightmare the child is fully asleep
wakes up when you shake them up to wake
up they can wake up in a night terror a
child cannot be fully awakened during an
episode and
and then they tear they do scream and
cry and all that okay so next one next
topics would be eating disorders so
eating disorders can be classified as
either as either anorexia nervosa
bulimia nervosa or a binge eating
disorder so in anorexia nervosa the BMI
is going to be less than eighteen point
five they're gonna have intense fear of
gaining weight and they have a distorted
views of their own body their their
weight and shape and how do you treat
anorexia with cognitive behavioral
therapy you treat them with nutritional
rehabilitation and often if they do not
respond to cognitive behavioral therapy
or nutritional rehabilitation then you
start them on medications such as
olanzapine remember olanzapine was the
antipsychotic that causes weight gain
because it's that shape the the first
letter is an O so you want it causes
weight gain there you go it's given to
anorexia nervosa now for bulimia nervosa
these are recurrent episodes of binge
eating but a binge eating can be seen in
all the eating disorders but they do
have recurrent episodes of binge eating
[Music]
binge eating is then followed by a
compensatory behavior to prevent weight
gains so they'll try to vomit for
instance but then again anorexia nervosa
also vomits that doesn't tell you much
either in bulimia nervosa they have
excessive worrying about their own body
weight and shape that doesn't tell me
much either but here is the difference
between bulimia and anorexia and bulimia
their body weight is normal so their BMI
is between eighteen point five to thirty
versus anorexia nervosa their BMI is
less than eighteen point five now the
treatment for bulimia nervosa again is
the same it's cognitive behavioral
therapy and nutritional rehabilitation
but since they do not need to gain
weight since their body weight is normal
you can give them an SSRI like
fluoxetine and that often isn't given in
combination with the cognitive
behavioral therapy and the nutritional
rehabilitation so in bulimia nervosa
remember that their their treatment is
going to be an SSRI not an
anti-psychotic and that their body
weight is gonna be normal versus and nrx
the other body weight is gonna be a less
than eighteen point five for BMI okay
and then you have binge eating disorder
and these would be recurrent episodes of
binge eating with no compensatory
behaviors and they have a lack of
control during eating so in this case
binge eating disorders they don't have a
problem with their with their image per
se they just have control AK of control
of their meals they have to be eating
eating eating constantly so again you
want to start them off with cognitive
behavioral therapy behavioral
weight-loss therapy if they're well are
probably going to be gaining weight and
pharmacological treatments would be like
topiramate and something called I'm
gonna try to pronounce this list Dex
some feta mean
so let's dexon feta mean is I'm assuming
I've never seen this one before it's I'm
guessing it's an amphetamine
and amphetamines are a stimulant that
cause weight loss so that would be a
pretty good treatment for binge eating
disorder in these patients who doesn't
say here but it's pretty obvious that
they're gonna be having weight gain so
to go into detail with these eating
disorders in anorexia nervosa they could
have binge eating or purging subtypes
like we said earlier but the main
difference here is in the weight they
have a restrictive sub there's there
could be a restrictive subtype meaning
that they have fasting or hyper
exercising they could be exercising a
lot of times a day taking a lot of
classes at the gym
or something like that and then
hospitalization and acute stabilization
it's highly recommended due to
dehydration and electrolyte disturbances
such as hypokalemia or hypophosphatemia
they can have bradycardia or severe
weight loss
remember that anybody that has a very
very low BMI may require hospitalization
and by a low BMI we're talking less than
18 point 18 less than 18 there's a new
question somewhere in your world that I
forgot I have to look it up but I it it
tells you this patient it has basically
anorexia nervosa and they're telling you
that their their BMI is eighteen point
five what would you do next but since
they were normal they didn't have any
symptoms of dehydration
in this case what you do is you just
send them home it's not to hospitalize
them so also look for blood pressure
readings if their blood pressure is less
than 80 over 60 you don't want a
hospitalized but if it's 90 over 70 you
don't hospitalized so that can be tricky
you want to also supervise their meals
and some patients will require nasal
gastric tube feedings during the onset
of anabolism which is the it's the
opposite of cata and catabolism which is
the breakdown this is basically the
gaining of weight patients will require
close monitoring and refeeding syndrome
refeeding syndrome is when you have is
when you have electrolyte depletions and
arrhythmias and heart failure and that's
due to fluid and electrolyte shift
imbalances so I mean think about it this
patient hasn't been eating normally and
suddenly you're introducing to them all
these nutrients and electrolytes and
those electrolytes that rush of
potassium and calcium and sodium can
cause arrhythmias and it can cause a
leak to heart failure very quickly so
that can result from those electrolyte
light and balances there could be also
vitamin deficiencies and that should be
assessed and supplemented if there is
any type of deficiency that you are
identified you'd want to correct that
all right next topics the next topic is
bulimia nervosa these is another binge
eating and inappropriate compensatory
behaviors that occur once a week or
three times a month or for three I'm
sorry not three times a month but for
three months in order for the diagnosis
to be made so you have signs of
sorry you have signs of bulimia which
would be hypotension tachycardia dry
skin menstrual abnormalities and
electrolyte abnormalities as well
connect hypokalemia hypochlorite
metabolic alkalosis
there could be erosions of dental enamel
and parotid hypertrophy and patients who
vomited Lee alright so the next topic is
body dysmorphic disorder okay so I'm
body dysmorphic disorder the clinical
features are they have a preoccupation
with more than one perceived physical
defect the defects are not observable or
appear slight to others they appear
slightly different to other people
there's a repetitive behavior or mental
acts that are performed in response to
the preoccupation and there can be
significant distress or impairment
there's a significant or a specific
insight of either good poor or absent
delusional beliefs and again body
dysmorphic disorder can be found in both
anorexia and bulimia and their
management is with antidepressants so
you give them SSRIs cognitive behavioral
therapy also you always want to do CBT
or cognitive behavioral therapy in
conjunction with
pharmacological treatments such as
antidepressants alright so the next
group of disorders that we're going to
speak about is dissociative disorders so
in dissociative disorders you have three
types you have depersonalization or
derealization disorder you have
dissociative amnesia and you have a
dissociative identity disorder
so for depersonalization derealization
disorder this means that the patient has
persistent or recurrent episodes of
either one or both of the following so
they can have persistent and recurrent
experiences of either deep personal is
which is feelings of detachment from or
being outside an observer of oneself so
you're like detached from your your own
body kind of view oh and then there's or
they can have D realization which is
experiencing surroundings as being
unreal so they'll be in a room but they
don't think that room is very is real or
they can have both being a sense of
detachment with experiencing as their
surroundings being unreal so thats
depersonalization derealization disorder
but they have intact reality testing
okay then you have something called
dissociative amnesia this is the
inability to recall important personal
information usually of a traumatic or
stressful nature it's not explained by
any other disorder like substance use or
post-traumatic stress disorder this is
somebody who just forgot personal
information that you should always
remember like your address your
telephone number versus the associative
identity disorder means that this is
marked discontinuity discontinuity in
identity or the loss of personal agency
with fragmentation into more than two
distinct personality states it's
associated with severe trauma or abuse
this can be like your multiple
personality disorder it's now called
dissociative identity disorder alright
then you have so for dissociative
amnesia
the specifier with its with dissociative
fugue is used when amnesia is associated
with seemingly purposeful travel or
bewildered wandering okay so like they
are in an airport and they don't know
how they got there next one would be
somatic and somatic symptom and
related disorders so here you have
somatic symptom disorder x' you have an
illness anxiety disorders conversion
disorder which is also known as
functional neurological symptom disorder
there's also a factitious disorder and
malingering so for somatic symptom
disorder this is basically excessive
anxiety or a preoccupation with more
than one unexplained symptom an illness
anxiety disorder however you have fear
of having a serious illness despite few
or no symptoms of consistently negative
evaluations okay so what's the what's
the difference with these two and the
somatic symptoms you have excessive
anxiety with more than one unexplained
symptom I'll have a I'll have gi pains
but you do you do all testings for gi
and there's nothing that'll explain your
stomach pains versus illness anxiety
disorder is a fear of having serious
illnesses it's despite having either few
or no symptoms at all and they're
consistently negative evaluations so
fearing fearing of having the
consequence of an illness is called
illness anxiety disorder versus the
preoccupation of excessive anxiety due
to a symptom is a specific thing that's
a specific somatic symptom disorder it's
a little confusing but I think we broke
it down fairly easy then you have
conversion disorder which is also known
as functional neurological symptom
disorder and that is basically
neurological symptoms that are in kit
incompatible with any known neurological
disease and it's often acute onset
associated with stress okay and then you
have fictitious disorder and in fact
Isha's disorder there's an intentional
falsification or inducement of symptoms
with a goal to assume the sick role so
these patients
they are going to make believe that
they're sick just because they want to
feel sick kind of like if you like it
when they bring you ice cream in bed
because you got sick so you lay the sick
role so that you keep getting ice cream
in bed kind of that's a simple way of
seeing it but that's what it is
you're falsifying your disorder in order
to get a to get something out of it a
reward
alright so malingering is your next
topic that is falsification or
exaggeration of symptoms to obtain
external as incentives or a secondary
game so be careful here with factitious
disorder versus malingering so in fact
Isha's disorder
you're just you're actually not doing it
for the ice cream you're just doing it
because you want to be sick you want to
look like you're sick but for
malingering you're doing it for the ice
cream you're doing it because you want
to not go into work that day and you
call in sick
so that's malingering alright next topic
in more detail would be somatic symptom
disorder we said the somatic symptom
it's clinical features was more than one
somatic symptom causing distress and
functional impairment the thoughts are
excess the thoughts are going to be
excessive we're behaviors are going to
be related to the somatic symptoms
symptoms are going to be unwarranted
persistent thoughts about seriousness of
symptoms that don't really exist and
they can have persistent anxiety about
it about their health or other symptoms
and they can have excessive times and
energy devoted to those symptoms and
that can lead and that can last more
than six months back again to our rule
of six months with psychiatry disorders
so again these patients are worried
about specific symptoms
and how do you manage them is with
regularly scheduled visits with the same
provider so usually in the test question
they'll ask you what would you do next
and it would be to reschedule and
reevaluate them and like a month or a
week or two weeks you want to limit
unnecessary types of work ups and
specialist referrals you never want to
refer anyone on the boards anyway so and
you don't want to do a lot of working up
on these people even though they may ask
you to your response would be let's
let's see what happens in two weeks you
want to legitimize symptoms but make
functional improvements to the goal and
you want to focus on stress reducing and
improving on coping on their coping
strategies mental health referral is
patient is if the patient will accept it
all right next topic is going to be
conversion disorder and this is a
functional neurological symptom disorder
common presenting symptoms would be
weakness or paralysis not epileptic
seizures and movement disorders that are
also present with speech or visual
impairment as well as swallowing
difficulties and sensory disturbances as
well as cognitive symptoms so what are
some of the diagnostic criteria for
conversion disorder you have symptoms of
altered neurological function as well as
voluntary motor or sensory function it's
gonna be altered there's often a
precipitated it's often precipitated by
psychological stressors it's not fiend
or intentionally produced as a
fictitious disorder and mulignan
malingering but findings are
incompatible with a recognized
neurological condition symptoms can
cause a significant social or
occupational impairment and there's
treatment options which are usually
stepwise so first you want to educate
the patient with self-help techniques
then second line would be cognitive
behavioral therapy if education and
self-help techniques don't work
and finally physical therapy for motor
symptoms and then patients can be
hysterical or strangely indifferent to
their symptoms differential diagnosis is
require extensive workup to rule out
other possible underlying medical causes
there's also another condition called
pseudo cc's and this is a fairly an
uncommon condition and it's basically
when a woman presents with many signs
and symptoms of pregnancy she'll present
with amenorrhea they'll have
enlargements of her breast and the
abdomen she'll even present with morning
sickness weight gain sensations of fetal
movement and reportedly she couldn't
they've even reported positive urine
pregnancy tests per the patient
how Strange's us and then ultrasound
however is going to reveal that there is
a normal and de metrio stripe and that
the pregnancy tests in the office will
be negative so there your in pregnancy
test will be positive at home but
obviously the one done in the office
will be negative so this is usually seen
in women who have a very very strong
desire to become pregnant it's also been
suggested that the depression can cause
by this need is behind the occurrence of
some hormonal changes that can mimic
those of pregnancy this is a form of
conversion disorder it's management does
require psychiatric evaluation and
treatment so in these patients they
present to you like if they're pregnant
they might even have signs and symptoms
of pregnancy but ultrasound however
reveals otherwise and the office
pregnancy test is negative
all right then there's another condition
called pathological gambling more common
in males that's defined as a persistent
and maladaptive gambling behavior that
usually it's going to result in a
preoccupation with gambling an
arrangement for means to indulge in it
so these patients might gamble
increasing amounts of money to achieve
the desired excitement and can result to
a legal behavior to finance their
activities attempts to reduce gambling
behavior are typically unsuccessful and
they result in a jeopardized
relationship and financial instability
when confronted about this issue
pathological gamblers are usually very
dishonest and evasive towards those
questions so gambling can also be used
as a mean of escaping from problems or
relieving unhappiness so these are
pretty straightforward not too difficult
now we're going to go into the
psychotherapy
so there's different types of
psychotherapy there's interpersonal
psychotherapy supportive psychodynamic
motivational cognitive behavioral
therapy there's dialectical behavioral
therapy
be in biofeedback so let's go one by one
so interpersonal psychotherapy is its
duration is time limited typical patient
will have relationship conflicts
they'll have life role transitions as
well as grief and their focus here is on
the here and the now there's current
relationships and conflicts with
interpersonal psychotherapy the next one
would be supportive psychotherapy it
this would be something ongoing this is
a lifetime of treatment a typical
patient here has a lower functioning
they're in crisis there they can be
psychotic and they can be cognitively
impaired some supportive psychotherapy
focus is a therapist it is used as the
guide it's to reinforce coping skills is
to listen and foster understandings and
build up an adaptive defense mechanism
so that's the key here is to build up a
defense mechanism for for these patients
undergoing supportive psychotherapy
versus psychodynamic psychotherapy this
again is on an ongoing duration the
typical patient is a higher functioning
patient with persistent patterns of
dysfunction and they're a little bit
more neurotic patients so their focus
the focus here is an unconscious
conflict causing the symptoms there's an
exploration of past relationships and
conflicts it the utilized transference
and the breakdown of defense mechanism
so in this the difference between these
two types of therapy supportive and
psychodynamic remember that this would
be psychodynamic would be in a more
higher functioning individual we're in
support of that psychotherapy there
would be a lower functioning individual
and psychodynamic psychotherapy has to
do with past relationships and conflicts
what has bothered you in the past
you do have a problem with your mother
did you have a problem with your father
husband wife the things like that so
motivational interviewing is the next
one and this duration is variable
because it's to deal with motivations
it's it's basically the typical patient
for motivational interviewing as a
substance use disorder patient and he
here is to address ambivalence it's to
change
it's a non-judgmental focus there's an
enhancement of motivation to change and
there's an acknowledgement of resistance
here next one is cognitive behavioral
therapy and this one's time limited its
persistent the the typical patient is a
persistent maladaptive thoughts a
patient that comes in with persistent
thoughts that are bad there's an
avoidance behavior or the ability to
participate in homework would be one of
them the key focus here is to identify
and challenge the maladaptive thoughts
it's also to change their behaviors to
change their emotions coming from those
thoughts and to focus on behavioral
techniques such as breathing exercises
exposure goal-setting visualization eye
on the prize kind of deal
that's cognitive behavioral therapy and
this is time limited this isn't
something on going like psychodynamic or
supportive then you have biofeedback
which is also a variable duration and
the typical patient here is a prominent
physical relation with prominent
physical responses that accompany
psychiatric symptoms and here the goal
of treatment is to improve awareness and
control over psychological reactions
it's also used to lower the stress
levels and integrate mind and body
techniques and that would be the role of
biofeedback alright so moving along the
next topic here is suicide there's a
suicide risk and protective factors some
of the risk factors for suicide would be
a pre-existing psychiatric disorder
feelings of hope
this impulsivity previous suicide
attempts or threats a divorce or a
separated couple an elderly white man
unemployed or unskilled patient physical
illness family history of suicide family
discord access to firearms is a big one
and substance abuse and then protective
factors would be a social support family
connectedness you want to actually
promote this pregnancy Parenthood
religion and participation and religious
activities these are all things that
help support and prevent suicide so how
would you assess suicide so suicide
assessment is basically on evaluation of
three things ideation intent and plan
so for ideation it would be the wishing
of to die not to wake up this would be a
passive assessment thoughts of killing
themselves I would be active and
frequency duration intensity and
controllability are also evaluated with
ideation for evaluating intent the
strength of the intent to attempt the
suicide and the ability to control
impulsivity and also to determine how
close the patient has come to acting on
a plan so if they've had any type of
rehearsals or any type of failed
attempts
those are evaluations of a intent and
then evaluation of plans would be
specific details on how they're going to
do it the method the time the place
access to the means like weapons and
pills here we have weapons again these
are all high-yield keywords preparations
like gathering pills changing one's will
and you'd also want to evaluate the
lethality of the method is a very lethal
method that they're going to be choosing
or the likelihood of rescue and then you
always want to hospitalize these
patients to maintain safety and that's
indicated for patients with
active suicidal ideation that includes a
plan and an intent to act patients with
suicidal ideations but not specific
plans or intent need intensive
outpatient treatment but not necessarily
hospitalization if they're just sloppy
about it but remember key thing here for
the exam is suicide is a big topic and
if you see any subtype of suicidal
ideation and hospitalized as part of the
option choices I would always put
hospitalization so I would I have rarely
have ever seen
intensive outpatient treatment as an
answer choice okay
now you want to assess and manage this
item suicidality so the assessment is
the mnemonic called sad person's sad
person stands for sex age depression
previous attempts EtOH which means
alcohol or other substance use also
rational thought loss like psychosis a
social support or a lack of social
support an organized plan if there's no
spouse or a significant other or a
sickness or an injury these are all the
mnemonics for sad persons and how would
you manage this so for an hi imminent
risk patient meaning a patient who has
ideation or an intent and a plan you
want to first ensure their safety
hospitalized immediately you want to
hospitalized and voluntarily if
necessary like I said before you want to
remove the personal belongings and
objects in a room that can harm
themselves so they have any kind of
access to guns this doesn't mean putting
locks on them or putting in a safe and
it just remove them outside of any reach
that they can be in so out of the house
number one also constant observation and
security can be need to be required to
hold against their will
how would you manage high non imminent
risk of ideation or intent
this would be if they have no plan to
act in the future these are you want to
just treat the modifiable risk factors
like underlying depression or a
psychosis or if they're under the
influence of any kind of substance abuse
you also want to go ahead and recruit
family members or friends as a support
for the patient and you also want to
reduce access to potential means such as
firearms and medication and there you
have your firearms again I can't stress
enough how important removing firearms
and hospitalization for suicide is all
right next topic would be firearm injury
so for a firearm injury the risk factors
would be a male adolescent there's
behaviors of psychiatric problems an
impulsive patient a violent patient or
some patient with a history of criminal
behavior and also low socioeconomic
status how would you prevent a firearm
injury easy you want to remove all the
firearms from the house that's not
rocket science there you want to store
the firearms unloaded and you want to
lock firearms and ammunition and
separate containers but on the exam
remove all firearms from the house is
always the correct answer now so what
are some of the homicide risk factors a
young male an unemployed person if they
have access to firearms substance abuse
antisocial personality disorder or
history of violence or criminality as
well as history of child abuse and
impulsivity okay so now we're going to
go into the topic of personality
disorders which is very fun and it could
be a little bit confusing but we're
gonna try to set this straight here oh
here we go all right so some of the key
features here on the dsm-5 for the
personality disorders would be paranoid
and this is a suspicious or distrustful
person that's hyper vigilant so paranoid
is a very hyper vigilant person versus a
schizoid patient this prisoner presents
as a loner someone who is detached and
emotional schizotypal would be somebody
has odd thoughts they're eccentric they
have perceptions and behaviors that are
odds that are odd there's a old mnemonic
that says dressed like a pickle is
someone who skits a tipple so dressed
like a pic the pickle would be someone
who's odd eccentric weird behaviors okay
antisocial is any person who has total
disregard and violations the rights of
others
you have borderline which is somebody
who has chaotic relationships
sensitivity to abandonment a labile mood
impulsivity and inner emptiness with
self-harm as part of their as part of
their characteristics next one would be
histrionic this is your typical dramatic
person their superficial
attention-seeking you'll probably have a
very dramatic woman as part of your
vignette somebody who's wearing very
exotic clothing or something and they're
very superficial always attending to
themselves in the mirror or something
this is your histrionic versus
narcissistic which is somebody who has
grandiosity about themselves with lack
of empathy so don't get those two
confused what you would think
narcissistic is normally or what I would
think is actually a histrionic person a
narcissistic would be somebody who is
completely into themselves in in in
terms of grandiosity and lack of empathy
is a big one you have a void n't person
and avoidance is obviously one who
avoids due to fear of criticism and
rejection they might give you a
situation where they had just they miss
to mess you up they have a their job
requires them to give a presentation or
something and they're trying to avoid
going there and you're thinking it's
because of a situation and it's not the
situation
is that they really are avoiding the
whole interaction just due to fear of
criticism and rejection so keep an eye
on those little details dependent is
somebody who's very clingy they needs to
be taken care of submissive they're just
usually it's somebody who is an abusive
in an abusive relationship and just
can't leave the other person because
they just need to be with them that's
dependent and then you have obsessive
compulsive behavior and this would be a
perfectionist
someone who's controlling or very rigid
alright so moving on with anteye
personality disorders or antisocial
personality disorder sorry clinical
features would be someone who have
violates the rights of others social
norms and laws they're impulsive they're
irritable they're very aggressive they
fight a lot they are accused of assault
they're consistently and responsible
they lie and they're very deceitful
there's lack of any type of remorse they
don't feel bad about anything they do
and here the key thing is age is greater
than 18 years of old so of age so this
is an adult so in a versus in a minor
less than 18 years of age it's not
antisocial personality disorder it's
it's a conduct disorder
okay so management here how would you
manage anti-personnel antisocial
personality disorder is with
psychotherapy you always want to try
psychotherapy first for their ma if
they're mild so you just want to monitor
or manipulate them with some type of
therapeutic techniques such as
therapeutic relationships and you also
want to treat any kind of comorbid
psychiatric disorders that they might
have such as substance abuse or
depression if that's also found in them
but I think that they might try to
that's two conflicting and too many
details for the exam so just just say
there's somebody who just likes to
hurt other people for no particular
reason violate the laws and if there are
there an adult that's antisocial
personality disorder if they're a minor
its conduct disorder so basically again
it's failure to sustain consistent
employment self appraisal and a very
irresponsible work behavior I think he
gets a picture next would be borderline
personality disorder in borderline
personality disorder the diagnostic
criteria would require percent per
vasive patterns of unstable
relationships a self-image and effects
of marked impulsivity with more more
than five of the following features so
they have frantic efforts to avoid
abandonment
there's unstable and intense
interpersonal relationships markedly and
persistently unstable self-image as well
as impulsivity in more than two areas
that are potentially self damaging
there's recurrent suicidal behaviors or
threats of self-mutilation like cutting
and there's affective instability like a
marked mood reactivity chronic feelings
of emptiness and an appropriateness of
an intense anger there's a transient
stress-related paranoia or
disassociation with borderline so how
would you treat borderline personality
disorders this would be a primary
treatment is going to be psychotherapy
and the types of psychotherapy or
several types can be effective such as
dialectical behavioral therapy that
tends to be the best one there's a
adjunctive pharmacotherapy also with
psychotherapy to target mood instability
and transient psychosis so in other
words you want to combine primary or the
you want to combine psychotherapy with
second-generation antipsychotics and
with mood stabilizers and then
antidepressants if there's any type of
comorbid mood or anxiety disorders now
you have acute drug toxicities so these
are some this is another highly
tested topic is a pharmacal pharmacology
in psychiatry so let's start with all
the substance abuse drug toxicity so
first of all we have PCP or
phencyclidine it's a loose intogen that
patients present with a violent behavior
there's disassociation hallucinations
amnesia there's vertical or horizontal
nystagmus as well as ataxia and high
doses can actually cause severe
hypertension so you'll see very severe
hypertension and these people seizures
and life-threatening hyperthermia with
benzos and that's used for severe
psychomotor agitation so just a crazy
person that comes in to the ER starts
flipping over Gurney's and and just
causing mild hysteria and there's just a
bp's sky high and they're just very very
violent you're thinking PCP and first of
all you just want to give them a
benzodiazepine to just calm their
psychomotor agitation down
next would be LSD this is another
hallucinogen it's the it causes visual
hallucinations euphoria dysphoria and
panic attacks as well as tachycardia and
hypertension but the visual
hallucinations is gonna be the one for
Alice do you think we all know that next
one is cocaine that's a stimulant which
causes euphoria agitation but the big
one here would just be seizures and
chest pain chest pain particularly as
well as teki cardia hypertension and
mydriasis now this can cause bradycardia
or low blood pressure as well as anxiety
and psychosis they can have sweating
nausea and vomiting and an overdose can
actually cause an MI and cardiac
arrhythmias seizure or a stroke in these
patients so if you're seeing a patient
that has signs and symptoms of an MI but
also has some type of euphoria or
agitation involved and
businessmen usually in their 20s or 30s
I think a cocaine okay
methamphetamines is a stimulant and this
is associated with violent behaviors and
psychosis there also have diaphoresis
tachycardia hypertension and they also
have core form movements of their hands
and fingers as well as tooth decay the
next one would be marijuana or tetra
hydro cannabis or canta canta ball or
cannabis and this is a psychoactive drug
it's it's it causes an increase in
appetite euphoria dysphoria with panik's
impaired time perception a dry mouth and
conjunctival injection that's pretty
easy to figure out you'll see somebody
in their teens come in and they come in
with euphoria dry mouth it just look
very low and their conjunctive they'll
have a conjunctival injection and that's
the key heroin is the last one and
that's an opioid again causing euphoria
but this time it causes heroines
associated with a depressed mental
status so associated with meiosis
respiratory depression and constipation
since it's an opiate it's gonna cause
respiratory depression and constipation
okay then you have inhalants so inhalant
abuse is commonly abused some of the
inhalants that are commonly abused would
be glues nitrous oxide or whippets is
what they call them amyl nitrate which
are called poppers and spray paints
there's a way of abuse such as sniffing
you're huffing which is an inhaled form
when they inhaled from us very from a
very saturated cloth bagging over the
mouth or nose very very weird but that's
what it is signs of an acute
intoxication you're gonna have brief
transient euphoria loss of consciousness
there's a very
there's loss of consciousness that
varies depending on a specific chemical
and hild
these are highly related soluble agents
that produce immediate effects and since
it's lipid soluble it lasts up to 45
minutes 15 to 45 minutes and it's
rapidly eliminated from the body it's
also not commonly included in toxicology
screens so they might present you with a
negative toxicology screen or you won't
even do one because it's pretty obvious
what they did they act as CNS
depressants and cot and can cause death
there's dermatitis associated with glue
sniffers rash and let's do two a
chemical exposure around the mouth and
the nostrils their liver function tests
can be elevated so look for that in the
vignette as well as boys around the age
of 14 to 17 those are the ones that are
at the highest risk and they can go
unnoticed as common Hospital products
are used all right the next topic is and
fetta mean intoxication and these are
commonly exhibit these commonly an
exhibit agitation irritability paranoia
and delirium other side effects would be
Chiapas other symptoms would be chest
pains and palpitations as well as
tachycardia hypertension diaphoresis and
mydriasis other complications such as
cardiac arrhythmias seizures
hyperthermia and interest or ebrill
hemorrhages are also found diagnosis is
based on clinical is based clinically as
well as laboratory tests and it's beyond
the qualitative toxicology screen and
these are of limited utility so one big
one and a new one would be bath salt
feta mean intoxication bath salts are
and feta mean analog that can cause
severe agitation and combativeness so
they can present with hyperthermia as
well as
psychosis and the hyperthermia is due to
the physical exertion but it's not as
severe as other types of psychosis like
PCP intoxication so this one is going to
be kind of different from PCP and we'll
see why so in bath salts these are
synthetic cations which consists of a
large family of amphetamine analogues so
their mechanism of action is that they
increase the release or they inhibit the
reuptake of norepinephrine and dopamine
as well as serotonin and they can cause
myoclonus and rarely they can cause
seizures but the most distinguishing
feature of bath salts intoxication is
going to be prolonged duration of effect
these patients have delirium and
psychosis that last days to weeks
whereas the effects of intoxication with
other in front of means like piece of
peak PCP are very short duration so
that's a good way of remembering the
differences bath salts are gonna take
longer PCP is gonna be short duration
bath salts are usually sold as a white
powder and small packages labeled as
food as plant food as cleaners or other
substances and may be ingested orally
they could be inhaled or injected and
it's not related to any products like
epsom salts or other substances that are
used in bathing routine toxicology
screens do not test for bath salts
unfortunately so here you're gonna have
to just see the effects of the drug used
okay the next drug would be MDMA ecstasy
or something called Molly this is a
three it's called three four methyl and
deoxy methamphetamines or MDMA it's a
synthetic and fed amine with a mild
hallucinogenic property there's
increased synaptic norepinephrine and
dopamine as well as cert tonin
concentrations it can lead to
neurotoxicity with long-term use MDMA is
austin you
used by college students during raves
and large dance parties to enhance
euphoria and also to increase social
ability to increase empathy and sexual
desire but they don't have any type of
combative behavior the intoxication here
can lead to a form of hypertension
tachycardia they can present with
hyperthermia and serotonin syndrome
which we can remember as an autonomic
dysregulation causing high fever altered
Mental Status a neuromuscular
irritability and seizures and here they
can cause hyponatremia and death there's
a combination of MDMA with other certs
and the genetic drugs such as serotonin
genic antidepressants it can increase
the risk of serotonin syndrome but it's
not detected again by routine toxicology
screens with these patients just
remember somebody who went to a party
and they're presenting with some signs
of serotonin sand syndrome but they're
also extremely hyperthermic and very
thirsty very very thirsty so that is the
behavioral pattern that you should look
out for on the vignettes next topic is
your marijuana intoxication it's pretty
easy again cognitive effects that
include slow reaction time and
coordination there's impaired short-term
memory poor concentration some some
patients experience dysphoria they have
anxiety paranoia
they have perceptual disturbances like
auditory original hallucinations can
also occur but remember these patients
aren't psychotic they're just under the
influence of marijuana there's also a
psycho motor impairment that lasts
beyond the timeframe of euphoria and
campers it persists for up to a day and
that can result in a high risk of injury
or death and motor vehicle accidents and
chronic abuse is also associated with
gynecomastia in men so that's a good way
of stopping to use the drug
withdrawal syndromes so we're gonna talk
about now the withdrawal common
withdrawal syndromes associated with
substances so let's start off by alcohol
withdrawal symptoms of alcohol would
give you tremors agitation anxiety
delirium or delirium tremens is what
it's called as well as psychosis and
their examination findings are seizures
they can personally can present with
seizures tachycardia and palpitations as
well as benzodiazepines can also have
seizures tachycardia and palpitations
but here their symptoms are going to be
actual perceptual disturbances and
insomnia you can also add the tremors
agitation and anxiety psychosis seen
with alcohol withdrawal but the insomnia
would also be part of a benzo and
withdrawal for heroin withdrawal they
present with nausea vomiting abdominal
cramping with muscle aches they're also
on exam you'll see dilated pupils so
you'll see a mydriasis yawning pile of
erection lacrimation there's hyperactive
bowel sounds and that's pretty much it
now with stimulants like cocaine and
amphetamines their symptoms are increase
in appetite hypersomnia intense
psychomotor retardation and severe
depressions like a symptom of crashing
that's what their withdrawal symptoms
would be there's no significant findings
on exam it's just basically the symptoms
as well as nicotine there's no
significant findings but their
withdrawal symptoms would be dysphoria
and irritability state anxiety and
increase in appetite because nicotine is
an appetite suppressant
alright so alcohol withdrawal syndrome
so this can be so classified with mild
withdrawal seizures alcoholic
hallucinosis and other delivery
tremens so basically a wacom mild
withdrawal their symptoms would be just
anxiety insomnia they can have tremors
diaphoresis palpitations they can have
intact orientation and usually that's
basically within 6 to 24 hours since
their last drink
that's a mild withdrawal versus seizures
seizures are basically going to occur
within a timeframe of 12 to 48 hours of
withdrawal seizures can be single they
can be multiple and they're generalized
tonic-clonic seizures versus alcoholic
hallucinosis is when you actually see
visual auditory or tactile
hallucinations as well as and but they
do have intact orientations and their
vital signs are stable and again this
happens between 12 to 48 hours but it
usually develops with between 24 hours
and resolves at 48 hours so at past two
days there they're gonna be fine but the
most complicated one would be delirium
tremens which is a patient that presents
with confusion agitation fever
tachycardia hypertension diaphoresis and
hallucinations and this is gonna happen
48 to 96 hours of withdrawal typically
it Peaks during the second day following
the cessation of alcohol in any
hospitalized patients with a suspected
suspected hype history of alcoholism
there's gonna be precautions taken to
prevent symptoms of withdrawal but due
to the serious potential complications
of alcohol withdrawal those patients
should be placed on proactive treatment
or protective treatment and be treated
with benzodiazepines which are basically
CNS depressants that will limit the
effects of alcohol withdrawal there's
clora dioxide POC side which is called
Librium that's a benzodiazepine
and that's the most common choice of
treatment for alcohol withdrawal
symptoms so if you see a patient that
has
type of alcohol withdrawal and they're
just asking you what would you give them
as a treatment oh is it's a
benzodiazepine so what are some of the
management of alcohol withdrawal
seizures first you want to rule out
other possible causes of seizures you
just don't want to blame it on the
alcohol you want to check for infections
you want to check for hypoxia bleeding
metabolic derangements persistent
seizure disorders or pre-existing
seizure disorders or any type of
confirmed seizures that was happening
beforehand then you want to treat with a
benzo especially intermediate benzos
such as IV lorazepam that's going to be
the preferred in hospital setting to
control the symptoms and prevent the
progression to delirium tremens and it's
also safe in possible liver disease so
that's a big one
alcoholics have to tend to have liver
problems so um in this lorazepam would
be safer in these patients because
there's no active metabolites with
lorazepam versus Clorox epoxide this is
very long acting and it's not preferred
in the hospital setting and the patients
and patients with possible liver disease
because of their metabolic side effects
and their metabolites then you have
adjunctive therapy that you give with
the benzo like you're obviously going to
go on IV fluids
you're gonna frequently monitor their
vitals you're gonna give them five
meeting folate and nutritional support
you can also give them phenobarbital
which can be used as an adjunct to the
benzo if they have any type of
refractory alcohol withdrawal and
withdrawal or two related seizures then
we have heroin withdrawal now heroin
withdrawal presents six to 12 hours and
it Peaks 36 to 72 hours and it could
continue on for several days it's very
distressing but however it's not
life-threatening
this is a big one it's they present with
restlessness elevated pulse and blood
pressure
all those usually not as elevated as
alcohol withdrawal so it's actually it's
interesting because it's actually more
lethal to you can actually die from
alcohol withdrawal but you cannot die
from heroin withdrawal
although heroin withdrawal would
probably way more painful and obviously
that's important to treat the pain but
Harun Lu withdrawal is not
life-threatening
then there's neonatal abstinence
syndrome which is neonates frequently
exposed to heroin and methadone such as
in from the mother methadone is given to
heroin addicts and mothers to prevent
uncontrollable withdrawal in infants and
heroin does not cause this morphic feces
but can cause intrauterine growth
restriction so that's a very important
one as well as microcephaly sudden
infant death syndrome and neonatal
abstinence syndrome signs of neonatal
abstinence syndrome would be
irritability a high-pitched cry poor
sleeping tremors seizures sweating
sneezing - kit Nia's poor feeding
vomiting and diarrhea and they usually
present within 48 hours after birth for
heroin withdrawal and that happens
between 48 to 72 hours for the methadone
withdrawal it can't be a delayed up to
it for weeks and treatment for neonatal
abstinence syndrome includes symptomatic
care to calm the infant down and help
the infant go to sleep you want to such
as swaddling and provide small frequent
meals to the infant you want to keep the
infant in a very low stimulated
environment pharmacological treatment
should be used only when supportive
treatment does not control the infant's
withdrawal symptoms remember always try
first supportive treatment cheap is best
on the boards and then you can move on
to pharmacological treatments and
morphine finally can be administered and
systemically weaned off to help control
the opiate withdrawal symptoms
although also another type of withdrawal
symptoms would be smoking cessation in
addition to counseling
several medications are going to be used
to promote the short and long term of
quitting to quit smoking bupropion is
going to be the most commonly used it
has modestly it's modestly effective it
has an increasing quit rate so that's
really good it's oh it's always going to
be the answer if you have a patient who
wants to stop smoking what kind of
treatment you want to give them be pro
prion is a good one
TCAs are also moderately effective but
they're not approved for this there's
also variance cycling which is a partial
agonist of the nicotinic acetylcholine
receptor that's more effective than
appropriate at increasing short and long
term quitting and there's efficacy of
all medications to enhance the nicotine
replacement therapy and appropriate
patients next some of the steroids like
corticoids can induce manic or
depressive psychotic episodes if a child
or adolescence is going to present with
recent changes in behavior emotions and
a social circle then you want to suspect
a substance abuse even if the patient
denies it you want to perform urine
toxicology screens but keep in mind that
the patient may be using a substance
that's not detected on urine or your
routine toxicology screens so bath salts
as we said k2 is another one salvia and
household inhalants all those are not
routinely detect they're not done when
they don't they're not very detectable
on toxicology screen so here you have to
you have to actually go on see the
symptoms of the patient in addition to
substance use other considerations of
adolescent patients presenting what
behavioral changes are going to include
the partners if they are violent date
rapes it's like a physical physical or
sexual abuse and finally pregnancy and
that is
you
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