Tricyclic/Tetracyclic medicationsAll tetracyclics/tricyclics

“Anti-HAM: histamine, adrenergic, muscarinic”

Block reuptake of NE and 5-HT

Antihistamine: SedationAntiadrenergic: Orthostatic hypotension, tachycardia, arrhythmiasAntimuscarinic/Anticholinergic: Dry mouth, constipation, urinary retention, blurred vision, tachycardiaWeight gainLethal in overdoseMajor complications: 3 C’s: Convulsions, coma, cardiotoxicity

Concerns/contraindications:- Risk of falling in elderly pts- Risk w/ pre-existing conduction

abnormalities

Tx: melancholic depression

Name Class Side effect CommentAmitriptyline (Elavil) Tertiary amine See above Highly anticholinergic, very sedatingDoxepin (Adapin, Sinequan) Tertiary amine ” Highly cholinergic, very sedatingImipramine Tertiary amine ” Highly anticholinergic

- used for bedwettingClomipramine (Anafranil) Tertiary amine

- most serotonin specific

” Highly anticholinergic, very sedating- OCD (2nd line, 1st line = SSRI)- Depression w/ marked obsessive features

Trimipramine (Surmontil) Tertiary amine ” Highly anticholinergic, very sedatingDesipramine (Norpramin) Secondary amine ” Least anticholinergic, NOT sedatingNortriptyline (Pamelor) Secondary amine ” Least anticholinergicProtriptyline (Vivactil) Secondary amine Psychomotor

stimulationLess anticholinergic, NOT sedating

Amoxapine (Asendin Asendas)

Tetracyclic May cause EPS and NMS

Less anticholinergic

SSRINearly all SSRI and SNRI Agitation, akathisia, anxiety,

panic, headache, insomniaGI distress, diarrheaSexual dysfunction: delayed ejaculation or impotence (male) anorgasmia (female)

Avoid Serotonin syndrome, should not be combined w/ MAOIWashout: SSRI 5 wks, MAOI: 2 wks

SS Sx: diarrhea, restlessness, extreme agitation, hyperreflexia, autonomic instability, myoclonus, seizures, hyperthermia, rigidity, delirium, coma, death

Fluoxetine (Prozac) Longest half life Beware of using in older pts (due to long ½ life)

Sertraline (Zoloft) GI symptoms (diarrhea)Paroxetine (Paxil) Shortest half life SSRI discontinuation syndrome (dizziness, N/V,

lethargy, flu-like sx: chills and aches, irritability, anxiety, crying spellsMildly anticholinergic

Fluvoxamine (Luvox) Nausea and vomiting more commonCitalopram (Celexa) Serotonin specific Possibly fewer sexual side effectsEscitalopram (Lexapro)Venlafaxine (Effexor) Anxiety, may increase BP at

higher dosages, headache, insomnia, sweating

SNRITx: GAD and social anxiety

Duloxetine (Cymbalta) SNRI:Tx: GAD and diabetic neuropathy

MAOIMAOI Orthostatic hypotension

SomnolenceWeight gain

Tx: atypical depression

All cheese, fermented or aged foods, wine and liver should be avoided (Hypertensive crisis end organ damage due to high BP)- Beware of pseudoephedrine (cough medicine)

Washout: SSRI 5 wks, MAOI: 2 wks

SS Sx: diarrhea, restlessness, extreme agitation, hyperreflexia, autonomic instability, myoclonus, seizures, hyperthermia, rigidity, delirium, coma, death

Phenelzine (Nardil) “ “Isocarboxazid (Marplan) “ “Tranylcypromine (Parnate) “ “Selegiline (Eldepryl) Irritation at site of patch Transdermal delivery available for depression, also

used to tx parkinsonism

AntidepressantsTrazodone/Desyrel↑5-HT

5-HT antagonist and SRI - Priapism: prolonged erection may lead to impotence

- Orthostatic hypotension- Sedation

Lower doses sleep problemsAvoid using w/ MAOI

Mirtazapine/Remeron↑NE and ↑5-HT

α2 blocker,5-HT2 & 5-HT3 blocker

- Weight gain- Sedation

No interference w/ sexual functionNo diarrhea or nausea Tx insomnia + depression

Buproprion/Wellbutrin↑NE and ↑DA

NE reuptake and DA reuptake inhibitor

- GI: nausea, anorexia- Risk of seizures at higher

doses- Less sexual dysfunction

Used for smoking cessationContraindicated in pts w/ eating d/o or seizure d/o (concurrent alcohol or BZD use due to predisposition to seizures)

Nefazodone/Serzone 5-HT2 antagonist and SRI - Sedation- Hepatotoxicity- Black box: liver failure

(reg monitor LFTs)

Decreased sexual dysfunction

Mood stabilizersLithium Inhibits adenylate

cyclase enzyme

- Psoriasis flares- Hair loss- Edema

Labs: thyroid fxn, renal fxn, hCG

LMNOP: Lithium –- Movement/tremors- Nephrogenic DI: thirst and

urination- Hypothyroidism- Pregnancy problems

(Ebstein’s anomaly atrialized right ventricle)

- Nausea- Cardiac dysrhythmias- Diarrhea- Weight gain- AcneToxic levels: alterations in consciousness, seizures, coma and death

WBC, electrolytes, TSH, Renal function tests (specific gravity, BUN, Cr), fasting blood glucose, pregnancy test, EKG

Lithium levels monitored at least 3 months once stabilized

Propranolol helps w/ tremor

Contraind: psoriasis

** ACEI and diuretics increase levels of lithium

**theophylline decreases lithium

Valproic acid/ Depakote

Opens chloride channels, unknown

Common: weight gain, GI distress- Thrombocytopenia- Hepatitis- Pancreatitis- Hair loss- Neural tube defects in

pregnancy (spina bifida)

CBC, LFT, pancreatic enzymes, hCG

Reconsider if alcoholic/has pancreatitis

Contraind: pregnancy

Carbamazepine/Tegretol

Inhibits kindling, inhibits repetitive firing of Aps by inactivating Na channels

- Nausea- Vomiting- Slurred speech- Dizziness- Drowsiness- Low WBC count

(agranulocytosis)- High LFTs/Liver toxicity- Teratogenesis- Stevens-Johnson syndrome- SIADH

CBC – assess for agranulocytosis – q2wks for first 2 mo, then q3monPlatelet, reticulocyte, iron levels yearlyLFTs – qmonth first 2 mon, then q3mon

Potent inducer of P450 system

Erythromycin can ↑Tegretol levels

Contraind: pregnancy

Lamotrigine/ Lamictal

Stevens-Johnson – prodrome of malaise + fever followed by rapid onset of erythematous/purpuric macules (oral, ocular, genital). Skin lesions progress to epidermal necrosis and sloughing

- Leukopenia- Stevens-Johnson syndrome- Hepatic failure- N/V- Diarrhea- Somnolence- Dizziness

CBC w/ plt countq6-12months

Dose increased slowly to avoid rash + Stevens-Johnson syndrome

Gabapentin/ Neurontin

- Somnolence- Ataxia- Dizziness, fatigue,

leukopenia, weight gain

Rash can be fatal No drug interactions

Typical AntipsychoticsMOA: D2 blockade, increases IC cAMP

1. Highly lipid soluble, stored in body fat, slow to be removed

2. EPS side effects3. Endocrine side effects (DA blocker

hyperprolactinemia galactorrhea)

4. Anti-HAMHistamine – sedationAdrenergic/alpha – hypotensionMuscarinic – dry mouth, constipation, urinary retention, blurry vision

5. NMS – FALTER Tx: dantrolene, DA agonists (bromocriptine)

6. Tardive dyskinesiaChlorpromazine/Thorazine Low - Sedation

- Orthostatic hypotension- Corneal deposits

Thioridazine/Mellaril Low - Higher incidence of cardiac disturbances- Retinitis pigmentosa

Mesoridazine/Serentil Low - Cardiac arrhythmias (torsades de pointes)Molindone/Lidone MediumLozapine/Loxitane MediumHaloperidol/Haldol High - Extrapyramidal syndrome

4 hours – acute dystonia (muscle spasm, stiffness, oculogyric crisis)4 days akinesia (parkinsonian sx) – Tx: propranolol4 weeks akathisia (restlessness)4 months tardive dyskinesia

- Tardive dyskinesia – stereotypic oral-face mvmt due to long term antipsychotic use (often irreversible)

Fluphenazine/Prolixin High “Trifluoperazine/Stelazine High “

Anxiiolytics/Sedative-HypnoticsBuspirone/BuSpar GAD - Headaches

- GI distress- Dizziness

Less efficacy after BZD use

Contraindicated w/ MAOIZolpidem/Ambien Insomnia - Headaches

- Drowsiness- Dizziness- Nausea- Diarrhea

Increased effect w/ EtOH or SSRI

Zalepolon/Sonata Insomnia - Headaches- Peripheral edema- Amnesia- Dizziness- Rash- Nausea- Tremor

Ramelteon/Rozerem Insomnia - Headache- Galactorrhea

Melatonin R agonist, no affinity for GABA R complex Contraindic: Severe

hepatic impairment, severe sleep apnea, severe COPD

Atypical AntipsychoticsClozapine/Clozaril 5-HT – DA antagonist - Agranulocytosis

- Anticholinergic side effects- Weight gain- Sedation- NMS

CBC + diff weekly or first 6 mo and biweekly

No hypotension PARKINSON’ s pts w/ psychotic sx

b/c spares nigrostriatal DA systems + anticholinergic effects (Parkinson’s ↑ACh ↓DA)

↑ risk for glucose abnormalitiesRisperidone/Risperdal 5-HT – DA antagonist - Extrapyramidal

- Postural hypotension- Hyperprolactinemia- Weight gain- Sedation- Decreased concentration

Present in breast milk

Olanzapine/Zyprexa 5-HT – DA antagonist - Hyperprolactinemia- Orthostatic hypotension- Anticholinergic SE- Weight gain- Somnolence

Alanine aminotransferase levels as drug affects the liver ↑ risk for glucose abnormalities

Quetiapine/Seroquel 5-HT – DA antagonist - Orthostatic hypotension- Somnolence- Transient increase in weight

Slit lamp eye exam at risk for developing cataracts

Ziprasidone/Geodon 5-HT – DA antagonist - QT prolongation- Postural hypotension- Sedation

Present in breast milkBaseline K and Mg measurements

NOT associated w/ weight gainAripiprazole/Abilify Partial DA, 5-HT1A

agonistAntagonist at 5-HT2A

- Headaches- Nausea- Anxiety- Insomnia- Somnolence

NONsedatingNo increased risk of weight gain or diabetes

NOT associated w/ weight gain

BenzodiazepinesChlordiazepoxide/Librium Long acting 1-3 days Alcohol detox

Presurg anxietyDiazepam/Valium Long acting Anxiety

Seizure controlRapid onset

Flurazepam/Dalmane Long acting Insomnia Rapid onsetAlprazolam/Xanax Intermed. 10-20 hrs Panic attacksClonazepam/Klonopin Intermed. Panic attacks

AnxietyLorazepam/Ativan Intermed. Panic attacks

Alcohol withdrawalNOT renally cleared

Oxazepam/Serax Short acting 3-8 hrs NOT renally clearedTriazolam/Halcion Short Insomnia

Important questions to be able to answer:

1) Which atypical antipsychotic does NOT cause weight gain?A: Ziprasidone/Geodon and Aripiprazole/Abilify

2) Which Antidepressant has black box warning for hepatitis and liver failure?A: Nefazodone

3) What are the different Axis?Axis I: Major psych d/o (schizo, GAD, MDD, bipolar), drug-related illness/abuse, pervasive learning d/oAxis II: MR or PDAxis III: Medical conditionsAxis IV: Psychosocial stressorsAxis V: GAF

4) What medication would you prescribe in alcoholic who has insomnia?A: Trazadone b/c other drugs overlap w/ EtOH in binding GABA (BZD, Zolpidem) and Zaplelon contraindicated with severe liver dysfxn, which is potential issue in pt w/ h/o alcohol abuse

5) If a patient gets an adverse side effect (acute dystonic reactions), how do you treat it?A: Anti-cholinergics: Benztropine 1-2 mg IM or diphenhydramine 50 mg IM or IV

6) What is the most likely atypical antipsychotic to cause EPS symptoms (anti-DA drugs)?A: Risperidone/Risperdol (dystonia akinesia/Parkinsonism akathisia TD)

7) If a patient has Parkinson’s dx and has psychotic sx, what medication is best to use?A: Clozapine/Clozaril

8) Patient is on risperidone and has accumulated EPS side effects, what should be done?A: replace with alternative, clozapine increased anti-cholinergic activity

9) How do you treat mania? Acutely and long term?A: Acutely: Haloperidol Long-term: 1st line: lithium, olazepine/zyprexa, lamotrigine/lamictal, quetiapine/Seroquel 2nd line: aripiprazole/Abilify, valproic acid/Depakote

Notes from USMLE World Step CK:

Anorexia nervosa:

Pregnancy complications (assoc. chronic deprivation of essential nutrition) ↑ risk:

o Premature, small for gestational age (2/2 intrauterine growth retardation)

o Miscarriageo Hyperemesis gravidarumo Cesarian deliveryo Postpartum depressiono Poor growth and intellectual impairment

Common findings in anorexic patients: Osteoporosis ↑ cholesterol and carotene levels Cardiac arrhythmias (prolonged QT) Euthyroid sick syndrome HPA axis dysfxn anovulation, amenorrhea, estrogen

deficiency Hyponatremia 2/2 excess water drinking

OCPD

Preoccupation w/ orderliness and perfectionism, negatively impacting function Too devoted to work, stubborn, “only one way” to do

things, over-attention to detail Diffiohncculty throwing out worn items Trouble w/ relationships – need for perfectionism Need to strictly follow rules Ego-syntonic No obsessions or compulsions

Compared to OCD:Obsessions + compulsions, not necessarily on “perfectionism”

Alzheimer’s dementia

Progressive cognitive decline characterized by one or more:Apraxia – difficulty carrying out activitiesAphasia – language difficultyAgnosia – recognizing objectsExecutive fxn – planning, abstraction, organization

Compared to: Multi-infarct- HTN and heart disease are risk factors BUT requires

presence of focal neurological sx

Compared to: Pick’s dx- Behavioral and personality changes more common

becoming apathetic or disinhibitted

Refractory mania despite mood stabilizer therapy:

Management:1) Urine toxicology screen2) Mood stabilizer drug levels (especially Lithium)

Types of disordered thought & speech:Disorganized speech = common in schizophrenics (i.e. circumstantial thought process)

Flight of ideas = loosely associated thoughts rapidly move from topic to topic

Tangentiality = abrupt, permanent deviation from current subject. New thought process minimally relevant at best and never returns to original subject (more severe = loose associations)

Loose associations = Lack of logical connection between

Trichotillomania = impulse-control d/oDSM-IV criteria:

1. Repeated episodes of hair pulling noticeable2. Anxiety right before or when trying to resist3. Sense of relief after hair pulling act4. Causes impairment or distress5. Inconsistent w/ other medical or dermatological

condition causing hair loss

Affected areas: scalp, eyebrows, eyelashes, facial hair, armpits, pubic hair

Compared to: alopecia areata

thoughts or ideas of individual (more severe form of tangentiality)

- Would have “patches devoid of hair” compared to trichotillomania: “broken hair of varying lengths” w/ alopecic patches

Antisocial PD- Pattern of disregard for & violation of rights of others- Onset: middle adolescence and continues to

adulthood- Routinely engage in illegal activities (drug use, assault,

theft), endanger well-being of others and freq. lie- Superficial charm allows for manipulation of others- Aggressive, impulsive, difficulty maintaining

employment- Conduct d/o (<18) Antisocial PD

Extrapyramidal sx: Acute dystonia= due to typical antipsychotics4 hr = acute dystonia: muscle spasms/stiffness, tongue protrusions, twistin, opisthotonus, oculogyric crisis (sustained elevation of eyes in upward position)Tx: Anticholinergics (benztropine or trihexyphenidyl) or antihistamines (diphenhydramine)

Compared to other tx:Akathisia (restlessness) propranolol or beta blockersNMS dantroleneParkinson’s dx Levodopa

Hypochondriasis- Occur during periods of stress- Misinterpretation of bodily sx and persistent fear of

fatal illness despite negative medical workupsTx: Initiate discussion about current emotional stressorsBrief psychotherapy

Neurotransmitters involved:

OCD Serotonin

Bipolar d/o genetics:- Strongest genetic components of all psychiatric d/o- 1st degree relative affected 5-10% risk of developing

in lifetime- Both parents affected 60% risk- Monozygotic twin 70% risk- General population 1%

Defense mechanisms:- Reaction formation transformation of unwanted

thought or feeling into opposite- Suppression intentionally postponing exploration of

anxiety-provoking thoughts by substituting other thoughts

- Sublimination unacceptable impulses channeled into more acceptable activities

Neuroleptic Malignant Syndrome:FeverAutonomic instabilityLeukocytosisTremorElevated enzymes CPK (rhabdomyolysis myoglobinuria ARF) Tx: alkaline diuresisRigidityTx: Dantrolene (muscle relaxant) or bromocriptine (DA agonist)- Supportive care: Aggressive cooling, antipyretics, fluid

and electrolyte repletion

Treatment for schizophrenia:

1) Positive or negative sx?o Positive = hallucinations, delusions,

disorganized speech/behavioro Tx: Typical antipsychotics

o Negative = flattened affect, poverty of speech, apathy (impaired grooming& hygiene, unwillingness to perform activities), asociality (few interests, impaired relationships) and inattentiveness/concentration

Tx: Atypical antipsychotics (risperidone = less EPS SE)

Neg sx = MORE serious Disorganized schizophrenia:

o Disorganized behavior/speech, flat or inappropriate affect, rambling speech, inapprop behavior (masturbation in public, laughing at strange times)

Depot antipsychotics for noncompliant pts:

Haloperidol deconoate once every 2 weeks to once a monthFluphenazine decanoate twice a month

Dysthymic d/o: (can also have double depression)Rule of 2’s:> 2 years, with no relief in sx > 2 months2 of the following “CHASES”Concentration, Hopelessness, Appetite

Risperidone depot twice a monthPaliperidone depot once a month

Self esteem, Energy, Sleep disturbances

Bereavement vs. MDDBereavement/complicated grief < 2 months

Symptoms > 2months antidepressants + psychotherapy

MDD + psychosis vs. Schizoaffective d/oMDD + psychosis= psychosis only occurs WITH depressed mood multiple episodes > 2 wks 5+ SIGECAPS

Schizophrenia- Family therapy = most important psychosocial

intervention- ↓ likelihood relapse by ↓ conflicts/stressors in home

environment

Increased ventricular size on CT scan

Clozapine least likely to cause EPS (parkinsonism “TRAP”)- Agranulocytosis- Lowers seizure thresholdRisperidone most likely atypical to cause EPS- Switch to clozapine if EPS SE occur

Panic d/o- 20-40 y/o- Sudden onset of “impeding doom”- Somatic complaints: CP, palpitations, nausea, SOB,

numbness, diaphoresis- Labs: drug screen + ECGTx:Acute BZD (alprazolam/Xanax) rapid reliefLong term SSRI, but effect takes weeks, CBT2nd line: TCA

ManiaDSM-IV:

> 1 wks abnormally and persistently elevated or expansive mood at least 3 of the following

o Distractabilityo Irritableo Grandiosityo Flight of ideaso Activity/agitationo Sleep disturbanceso Thoughtlessness

Diagnostic AssociationsKleptomania associa. w/ bulimia nervosaTourette syndrome assoc w/ ADHD or OCDPanic d/o assoc w/ depression, agoraphobia, GAD, substance abuse

ECT indications:- Severe depression- Depression in pregnancy- Refractory mania- NMS- Catatonic schizophreniaSide effects: amnesia (anterograde or retrograde), prolonged seizures, delirium, headache, nausea, skin burns

PyromaniaIntentional firesetting on more than 1 occasion w/ no obvious motive:- Deliberate firesetting on > 1 occasion- Feeling of tension or emotional arousal before setting- Fascination w/ fire or curiosity about situations

concerning fire- Feeling of relief or pleasure from setting fires &

witnessing aftermath- No motive- Not part of conduct d/o, antisocial PD, or manic epis.

“Schizo spectrum”

Brief psychotic d/o (< 1 months) Schizophreniform (<6 months) Schizophrenia (> 6 months)

Schizoaffective = depressive mood + psychosis (seen even w/o mood sx)Schizoid PD = prefers to be distant, does not obtain primary gain w/ relationships w/ others, do not have bizarre cognitionSchizotypal PD = magical thinking, odd thoughts/beliefs

Child abuse signs:PE: multiple fx or injuries in different healing stages, likely inflicted injuries (cigarette burn), poorly kept child, bruises on neck, abdomen or unusual sites, injury to genitalia, hands, back or buttocks

Steps for handing child abuse:1) Complete PE2) Radiographic skeletal survey (if necessary)3) Coagulation profile (if multiple bruises)4) Report to CPS5) Admittance to hospital

Hx: vague w/ no detail, or none given, inconsistent w/ injury, changing versions given by caregiver, sibling commits the injury, inconsistent w/ child’s developmental stage, implausible

Caregiver behavior: argumentative or rough, lack of emotional interaction w/ child, inapprop response to child injury, inapprop delay in seeking care, partial confession in causing injury, violent w/ staff

6) Consultation w/ psych and evaluation of family dynamics

Meningococcal meningitis/contagious diseases- Admit and isolate against wishes, and start tx- Due to complications & potential community outbreak

isolation, IV ABx and supportive care in ICU- Allowed to refust tx unless it would pose threat to

health and welfare of others

Somatization d/o (compare to below)- Multiple recurrent somatic complaints persisting for

years- < 30, female, functional impairment- Presents w/ at least 4 pain, 2 GI, 2 sexual or

reproductive, 1 pseudoneurological sx (blindness, deafness, weakness, seizures, LOC, impaired balance)

Note: Depressive sx & dx:Patient must experience IMPAIRMENT in FUNCTION in order to classify as any DSM-IV d/o- If feel “down”, but functional normal human

experience

Tx: Single episode of major depression6 months following patient’s response (maintenance therapy if multiple episodes)

Conversion d/o (compare to above)- One or more neurologic or general systemic sign- PPt by psychologic stressor- Not intentionally produced or feigned (vs. factitious

and malingering)- Impair social, occupational or daily fxn- Not explained by another mental d/o, limited to pain

or sexual dysfxn and do not exist w/ somatization d/o

Sx: la belle indifference (strangely indifferent) or hysterical, trigger = conflicts or stressor w/ emotional componentTx: hypnosis, relaxation, psychotherapy

SSRI side effects:Sexual side effects = impotence, delayed ejaculation, decreased libido

Circadian rhythm sleep d/o:- Traveling between time zones

Opioid withdrawal (ex. Heroin)- Rhinorrhea- Abdominal cramps, sweating- Lacrimation- Diarrhea- N/V- Muscle spasms- Joint painCan present w/in 24 hours

Anorexia nervosa:DSM-IV:

1) Body weight > 15% below normal weight accompanied by refusal to maintain body weight at normal levels

2) Amenorrhea for 3 months3) Distortion of body image4) Fear of gaining weight

Look for:1) Fast and/or exercising excessively (restricting

subtype)2) Bing eat followed by laxative use and purging

(binge and purge subtype)Hospitalization when evidence of dehydration, starvation, electrolyte disturbances, cardiac arrhythmias, physiologic instability or severe malnutrition (<75%)

Withdrawal:Cocaine suppression of stimulant effect – irritable, drowsy, fatigued, hungry, psychomotor agitation or retardationEtOH seizures, sweating, hyperreflexia, tremors, hallucinations, DTAmphetamine suppression of stimulant effects – irritability, fatigue, increased appetite, psychomotor disturbanceNicotine irritability, anxiety, depression, insomnia, restlessness, poor concentration, increased appetite, weight gain, bradycardia

Bulimia nervosa:DSM-IV:

1) Recurrent episodes of uncontrollable binge + disgust or guilt

2) Repeated compensatory behavior to prevent weight gain after binge

3) Binging episodes > 2x/wk over 3 month period4) Normal or slightly above normal BMI5) Dissatisfaction w/ weight and shape

** Compare to anorexia (NL BMI and not amoenorrheic

Dependent PD:- Clingy, submissive, crave protection and care of others- Avoid taking initiative b/c feelings of inadequacy- Fear of being left alone, inability to disagree w/ others,

willingness to stay in abusive relationships for fear of being left alone

Avoidant PD:- Hypersensitivity to criticism, social inhibition, feelings

of inadequacy, lacks self esteem- Want friendships, but avoid due to fear of ridicule

Intoxication:PCP aggression, agitation, impulsivity, impaired judgment, psychosis, paranoia, hallucinations- Nystagmus, HTN, tachycardia, ataxia, dysarthria,

muscle rigidity, seizures, comeAlcohol ataxia, nystagmus, aggression, impaired judgmentHeroin pinpoint pupils, drowsiness, CNS depression, constipationLSD hallucinogen, mood impairment, hallucinations, perceptual intesifications, depersonalization, illusionsCocaine anxiety, aggression, agitation, psychosis, delirium- High or low BP, tachy or bradycardia, sweating,

pupillary dilatation, N/V, insomnia- Cardiac arrhythmias, MI, seizures or stroke, “cocaine

bugs”Cannabis conjunctival injection, dry mouth, tachycardia, increased appetite

LSD vs. PCP- LSD = visual hallucinations, intensified perceptions- PCP = agitation, aggression (belligerence)

Treatments:o Depression + insomnia Mirtazapine/Remerono Anti-Psychotic (no weight gain)

ziprasadone/Geodon & aripiprazole/abilifyo Panic d/o acute (BZD), long term (SSRI)o Bipolar mood stabilizer Lithiumo Psychosis & agitiation haloperidolo OCD 1st line: SSRI, 2nd line: clomipramineo GAD 1st line: Buspirone, 2nd line: SSRIo Performance anxiety Propranololo Social phobia assertiveness training (CBT) and

paroxetine (SSRI)o Tourette’s Pimozide or haloperidolo Enuresis 1st line: Behav modif, desmopressin, 2nd

line: TCA (imipramine)o Specific or simple phobias BZDo NMS dantrolene and D2 agonists (bromocriptine)o EPS side effect benztropineo Alzheimer’s dementia reversible AChE inhibitors:

donepezil, rivastigmine, glantamine, tacrineo Mania acute sx: Haloperidol, LT maintenance: 1st

line: olanzapine, lithium, lamotrigine, quetiapine + psychotherapy, 2nd line: Depakote, Abilify

o Schizo atypical antipsych (risperidone clozapine)Consent/respecting patient’s wishes: Unless patient is putting themselves or other’s in harm

or danger (i.e. contagious disease like HIV or meningococcus meningitidis)

Physician must respect parent wishes (i.e. to not have children vaccinated)

Refusal of life-saving tx:- Discuss fully specific reasons for decision before

honoring itChild consent for tx:- Only need consent of one parent to proceed with tx of

minor- If parents refuse consent to tx for potentially fatal

medical condition pt seek court order mandating txLiving will:- If family disagrees w/ living will, discuss matters, then

hospital ethics committee should be consultedPregnant women: Have the right to refuse tx (baby is part

Defense mechanismsImmature Neurotic MatureIdealizationProjectionSomatizationDenialActing out

DisplacementDissociationRationalizationReaction formationRepression

AltruismSublimationSuppressionIntrojectionHumor

Reaction formation does complete opposite of what he/she feels or desiresSublimation unacceptable or negative impulses to be channeled into more acceptable or positive activitiesAltruism minimizing internal fears by serving others in positive manner- Ex: pt dx w/ cirrhosis & stop drinking due to complic.,

helps others/protect them from dangers of alcoholismPassive aggression expresses aggression w/ repeated, passive failures to meet other person’s needs

of their body) – even if harmful to fetusAdjustment d/o- Development of emotional or behavioral sx in

response to identifiable stressor that occurs w/in 3 months of stressor, causes significant impairment and disruption of daily activities

- Ex: Pt moves into 1st apartment by herself and is paranoid

Dissociative d/o: Dissociative identity d/o: multiple personality d/o. Two

or more distinct identities, amnesia regarding important personal infor about some of identities

Dissociative amnesia: inability to recall important personal information

Depersonalization d/o: persistent or recurrent feelings of detachment from physical or mental process (intact sense of reality)

Dissoc. Fugue: forgetfulness and dissociation, only one assoc w/ travel

Lithium side effects: Pregancy- Ebstein’s anomaly: malformed and inferiorly attached

tricuspid valve atrialization of RV and decrease size of functional RV

- Due to lithium exposure in first trimester of pregnancy

- Later trimesters = goiter, transient neonatal neuromuscular dysfunction

Lithium therapy guidelines:1) Single manic episode require LT maintenance at

least 1 yr2) 3 or more relapses require tx w/ lifelong

maintenance therapy

Side effects of medications: Olazepine = weight gain

o Check: fasting plasma glucose, weight BP and fasting lipid profile before beginning

Clozapine = agranulocytosis Ziprasadone/Geodone = QT prolongation, no weight

gain

Strongest indicator future suicide attempt:Hx of previous suicide attempt

Bereavement vs. MDDBereavement < 2 monthsMDD > 2 monthsAdjustment d/o- Psych sx response to stressor occurring previous 3

months, rarely last more than 6 mon after end of stressor. Tx: psychodynamic therapy

Cyclothymia vs. dysthymia:Cyclothymia: hypomania + chronic mood disturbance lasting > 2 years

Dysthymia: chronic depressed mood > 2 years

Antipsychotics SE:- DA blocker (normally DA inhibits prolactin and ACh)- Blockade hyperprolactinemia gynecomastia,

galactorrhea, menstrual dysfunction, decreased libido

- Excess DA blockade bradykinesia, masked facies, micropgraphia

TX: Benztropine

Sleep patterns/changes:

Elderly sleep less at night and nap during dayDeep sleep (Stage 4) becomes shorter and eventually disappears

Amphetamine vs. cocaine intoxication

Amphetamine=psychosis more prominent psych features (anxiety, aggression, agitation, psychosis)Hypo or hypertension, brady or tachycardia, cardiac arrhythmias, CP, respiratory depression, sweating, pupillary dilation, N/V, insomnia, weight loss, psychomotor agitation/retardation, muscular weakness, seizures, stroke,

Side effects: BZD withdrawal

Alprazolam/Xanax = short acting, used to tx: panic d/o- Abrupt cessation can cause severe withdrawal

(generalized tonic-clonic seizures and confusion)

coma

Childhood d/o:Childhood disintegrative d/o = nl development until 2 years of age loss of prev acquired skills in at least 2 of the following areas: expressive or receptive language, social skills, bowel or bladder control, play and motor skills, poor prognosis

Autism = males > females, onset before age three, impairments in communication and social interaction, repetitive, stereotyped behavior w/ strange preoccupations.

Rett syndrome nl development until around 5 months, loss of hand coordination, sterotyped hand mvmts, deceleration of head growth, poor coordination, seizures, ataxia, MR and diminished social interactions

Asperger syndrome qualitative impairment in social interaction + restricted, repetitive, stereotyped patterns of behavior, nl cognitive and language development

Types of Dyskinesia

DA:Mesolimbic pathway therapeutic effects of antipsychotics

Nigrostriatal pathway EPS Se assoc w/ antipsychotic use, signs and sx of Parkinson’s dx

Tuberoinfundibular pathway hyperprolactinemia

Clusters:

Cluster A odd and eccentricCluster B dramatic and emotionalCluster C anxious and fearful

Time lines:PTSD > 1 month vs. Acute stress d/o < 1 month

Postpartum blues < 10 days vs. postpartum depression 2 wks to 2 months

Oral and facial

Tongue protrusion and twistingLip smacking, pouting, puckeringRetraction of the corners of the mouthChewing mvmts

Limb Limb twisting and spreading“piano-playing” finger mvmtsFoot tappingDystonic extension of the toes

Neck and trunk

TorticollisShoulder shruggingRocking or swayingRotary hip mvmts

Respiratory Grunting noises