Benzodiazepine overdose: altered mental status, ataxia, slurred speech. Normal vital signs.

When vital sign derangement or respiratory depression are seen, co-ingestion with other
sedate-hypnotics/CNS depressants should be suspected
- With opioid, you would see constricted pupils, slow bowel sounds, altered
consciousness, respiratory depression

Obsessive compulsive personality disorder: eg-synotic beliefs and comfortable with the
behaviors (thinks his system is superior)
- Obsessive compulsive disorder: ego-dystonic beliefs BUT are distressed by their
symptoms

Narcolepsy. What drug sjould be considered? Besides sleep hygiene, scheduled naps,
avoidance of alcohol/drugs that cause drowsiness
- Modafinil - “moda” de to the guy with narcolepsy
- Also amphetamines, methylphenidate as second line

Patient is depressed. Failed a couple attempts from two SSRIs. Gained weight. Been sleeping a
lot. What drug to give?
- Bupropion
- NDRI (Norepi and dopamine reputake inhibitor)
- Cant give mirtazapine BECUASE OF SEDATION AND WEIGHT GAIN
- BUSpirone is for generalized anxiety disorder. DIFFERENT!! Anxious from bus
- Bu (boo) helps with depression

Anorexia nervosa vs bulimia nervosa vs binge-eating disorder

- AN: LOW WEIGHT, fear of weight gain, ditorted views of body weight and shape
- BN: recurrent episode of binge eating, COMPENSATORY BEHAVIOR (vomiting,
exersive) to prevent weight gain, excessive worry about weight and hsape, MAINTAINS
NORMAL WEIGHT
- BED: recurrent binge eating, NO COMPENSATORY BEHAVIORS
- Treatment for bulimua: nutritional rehab, CBT, pharmacotherapy with fluoxteine

Sleep terrors. Treatment?

- REASSURANCE
- Low dose benzo at bedtime if episodes frequent, perisstent and distressing

What to do in a shared psychotic disorder (folie a deuz), where the dominant person’s delusion
is transmferred to a more submissive partner
- Seprate the individuals to determine the degree of impairment in each
- The dominant indicudual usually requires psychotic treatment

Delusions, hallucinatins, disorganized speech and behabior, and negative symptoms f >6
months duration
- Schizophrenia
Unexplained abdominal pain, new onset neuropsychiatric symtoms, including neuropathies,
anxiety, mood changes, psychosis. Diagnosis?
- Acute intermittent porphyria
- Urinary prophobilinogen is elevated

Wilson disease
- Hepatic, psychiatric, neurologic dysfunction
- Dysarthria, dystonia, tremor, parkinsonism, copper cornea deposits
- Depression is the most common psychiatric manifestation

Muscle sitffness, fever (103,104, hight!), confusion, delirium, rhabdo. Diagnosis and treatment
- Neuroleptic malignant syndrome
- Treatment: stop antipsychotics or setart dopamine agents
- Hydration, cooling, ICU
- Dantrolene or bromocriptine if refractory
- Patient was recently start on antipsychodic resperidone…
Serotonin syndrome
- Interaction of serotonergic medications and monoamine oxidase inhibitors
- Neuromuscular irritability (treamor, hyperreflexia, myoclonis), NO RIGIDITY, fever not as
high as NMS, GI symptoms (vomiting, diarrhea)
- Wait two weeks between discontinuation of an MAOI and start of serotonergic
antidepressant
Malignant hyperthermia - hypercarbia, muscle rigidity, hyperthermia - when exposed to volatile
anesthetics or succinylcholine. MORE RAPID THAN NMS

Dementia with lewy bodies VS parkinson disease dementia

- PDD: parkinsonism predates cognitive impairment by >1 year
- Executive and visuospatial dysfunction: impaired attention and planning, inability
to recognize grandchilder, getting lost in familiar locations
- DLB: cognitive impairment before or at same time as parkinsonism

Vascular dementia - mild memory impairments, prominent executive dysfunction, docal

neurologic deficits
Alzheimer’s: early prominent memory impairment accompanied by executive and visuospatial
dysfunction. Motor symptoms are rare early in the disease process

Generalized anxiety disorder. Treatment?

- CBT
- SSRI/SNRI

An old patient on terazosin and alprazolam. An hour after taking his medications, he was
agitated, irritable and confused. Has been more stressed because of stock loss. What to do?
- Taper and discontinue the BENZO. Alprazolam
 - In elderly - increased risk of adverse effects. COgnitive impairment, falls,
paradoxical agitation

Dream enactment that occurs during REM sleep if muscle atonia is absemnt. If awakened,
patients become gully alert and recall their dreams. DIagnosis
- REM sleep behabior disorder
- In older patients, these behaviors may be sign of neurodegenration

Obsessive-compulsive disorder treatment

- CBT and/or SSRI!!!

Dialectival behavioral therapy - type of psychotherapy for borderline personality disorder that
integrates standart CBT with principles of mindfulness, distress tolerance, and emotion
regulation

Psychodynamic psychotherapy - traces problems back to their origins in childhood and

unconscious conflict

Bloating, fatigue, headaches, breast tenderness. Mood swings, anxiety, diffculty concentrating.
A detailed menstrual history is used to confirm
- Mild PMS managed with exercise and stress reduction. SSRIs (fluoxetine) - first line for
moderate to severe PMS/PMDD

Toxicity of lithium in nonpregnant patient

- Nephrogenic diabetes insipidus, chronic kidney disease, hyperparathyroidism with
hypercalcemia, thyroid dysfunction (hypothyroidism)
- Contraindicated in patient with significant renal or cardiovascular disease.
- ECG in patient with coronary artery disease risk factors (diabetes, hypertension,
smoking)

Major depressive episode has to be greater than what in length?

- >2 weeks

Treatment for delusional disorder

- antipsychotic/CBT

Single episode of major depressive disorder: continue antidepressants for an additinal 6 months
following acute response to reduce risk of relapse. Patients with recurrent, chronic, or severe
episodes should e considered for maintenance treatment (1-3 years or indefinitely)

Metaboilic syndrome drugs (weight gain, dyslipidemia, hyperglycemia)

- Clozapine, Olanzapine
If given opioids, query the prescription drug monitoring database at each visit to reduce risk of
prescription misuse (check data for undisclosed co-prescriptions)
- Also can perdorm random random urine drug screens, and scheduling frequent follow
ups

Abnormal involuntary movements of the mouth, tongue, face, extremeties. What is this? How do
you get it? Cant discontinue antipsychotic, so what do you do
- Tardive dyskinesia, Switching to clozapine is preferred
- Management of tardive dyskinesia
- Discontinue causative medication if feasible
- Switch (cross taper) to secnd generation antipsychotic (quetiapine, clozapine) if
continue antipsychotic is requred
- Treat with valbenazine (reversible inhibitor of vesicular monamine transporter 2
(VMAT 2))
- In addition to TD, first and second antipsychotics can cause other extrapyramidal
symptoms - acute dystonias, parkinsonisms, akathisia
- Treat with anticholinergics(benztropine and diphenhydramine) and beta blockers
(for akasthisia). These don't treat TD

Dysthymia - duration?
- Depressed mood for >2 years
- Presence of >2 of following
- Poor appetitie or overeating
- Insomnia or hypersomnia
- Low energy or fatigue
- Low self esteem
- Poor concentration or difficulty making decisions
- Feelings of hopelessness

Difference between bipolar I vs bipolar II vs cyclothymic disorder

- Cyclothymic: >2 years of nymerous episodes of hypomanic and depressive symtoms
that are subthreshold for diagnosing major depressive or hypomanic/manic episodes

Post traumatic stress disorder - symptoms greater than?

- 4 weeks
- If less, then its acute stress disorder

Poststroke depression
- Treat with antidepressants and/or psychotherapy

Amphetamine intoxication
- Irritability, agitation, psychosis. Physical signs: tachycardia, hypertension, hyperthermia,
diaphoresis, mydriasis
Hoarding disorder treatment
- CBT!!

Treatment for PTSD

- Trauma focused CBT
- Antiepressants (SSRI, SNRIs)
- Prazosin for nightmares

AUtism spectrum disorder in kids: language communication delay, fixed intrest in one toy, lack
of social interaction, poor eye contact
- Early intervention starting at age 2 or 3, in the form of educational and behavioral
sevices

POSTPARTUM

Depressed, patient not eating, losing weight, and not sleeping well. Best treatment
- Mirtazapine and psychotherapy

SCHIZOAFFECTIVE

If modd symtpms occur in schizophrenia, they are typically present for a small portion of the
illness. In contrast, if they presist for a significant portion of the illness, ITS SCHIZOAFFECTIVE

If a patient has dementia with lewy bodies, and is given risperidone, higher chances of
developing confusion, parkinsonism, and autonomic dysfunction, rigidity

Different therapies

Erythema of the turbinates and nasal septum

- snorting cocaine

Treatment-resistant schizophrenia or schizophrenia with suicidality. Treatment?

- COZAPINE

CLOZAPINE adverse effects?

- Agranulocytosis, seizures, myocarditis, metabolic syndrome
HIV associated dementia is a severe form of dementia in patients with untreated and/or long
standing HIV disease and a CD4 count of <200. Characterized by subcortical symtoms early in
the course of illness

BIPOLAR DISORDERS

Schizophrenia. What neuroimaging findings?

- Loss of cortical tissue volume with ventricular enlargement, with lateral ventricular
enlargement being the most widely replicated

Obessive compulsive disorder. Neuroimaging findings

- Structural abnormalities in orbitofrontal cortex and basal ganglia

Patient with disorganized speech and behavior, probable hallucinations. What is it and what do
you give?
- Psychosis
- Second genetation antipsychotics (Risperidone)...first generation...benzo for agitation
- Special population
- Nonadherence? Consider long acting injectable
- Treatment resistance (2 failed trials): Clozapine
- Flashcard

Depressed mood

Patient was taking medication for anxiety and stopped it 2 days ago which resulted in a seizure.
Which medication
- A short acting benzo, alprazolam

WITHDRAWL SYMPTOMS/FINDINGS

Drug intoxication

Abrupt discontinuation of short acting antidepressants (paroxetine, venlafaxine, duloxetine) may

lead to discontuation syndrome - dizziness, fatigue, headaches, and myalgias. Neurological
symptoms such as perceptual changes, paresthesias, and “electric shock” sensations

Bulimia nervosa signs

 - Tachycardia, hypotension, dry skin, painless bilateral parotid gland swelling, calluses or
scarring on dorsum of hand (Russell sign), and erosion of dental enamel
- Electrolyte disturbances: metabolic alkalosis with hypokalemia and hypocholeemia

Immobility or excessive purposeless activity, mutism, negativism (resistance to instructions).

What is it and whats the treatment
- Catatonia. Treat with benzos and/or electroconvulsive therapy. Lorazepam challenge
test

Over the counter cold and cough preparations contain ingreients that can have unwanted side
effects, including confusion and hallucinations. Be cautious with young children. Over the
counter cold preparations contain antihistaines (diphenhydramine, doxylamine) that decrease
nasal dischage but also have anticholinergic properties that can cause confusion and
hallucinations

Alcohol Withdrawl

Immediate and Long term treatments for panic disorders

- Immediate: bezos
- Long term: ssri/snri and/or CBT

A slight increased risk of antidepressant-related suicidality in child and adolescent patient must
be weighted against the established efficacy of antidepressants.

Dissociative disorders
- Depersonalization/derelaization disorder
- persistent /recurrent experiences of 1 or both:
- Depersonalization: feelings of detachement from, or being an outside
observer
- Derelaization: experiencing surroundings as unreal
- Intact reality testing
- Dissociative Amnesia
- Inability to recall important perosnal info, usually of a traumatic or stressful nature
- Not explained by another disorder like substance use or PTSD
- Dissociative identity disorder
- Marked discontunutiy in identity and loss of personal agency with fragmentation
into >= 2 distinct personality states
- Associated with severe trauma/abuse
- Often have chronic auditory hallucinations that have been present since
childhood
- Treatment: long term, trauma focused psychotherapy
GAD - does not have unexpected panic attacks

Narcolepsy: hypnagogic or hypnopompic hallucinations, sleep paralysis. Recurrent lapses into

sleep or naps. Cataplexy, low cerebospinal fluid levels of hypocretin-1, shortened REMP sleep
altency

Rash around mouth, liver shit elevated, decreased sensation in lower extremities. What drug
used
- Inhalant
- Nitric oxide associated with b12 deficiency leading to polyneuropathy
- Boys 14-17 at higher risk

First line for alcohol abuse disorder

- Naltrexone, a mu opioid receptor antagonist, and acamprosate, a glutamate modulator
- Naltrexone resudes alcohol craving. Contraindicated in patients taking opioids
- Acamprosate - used to maintain abstinence
- Avoid in renal impairment
- Disulfiram can only be used in abditent patient and not in patient who is actively
drinking. Candidates have to be highly motivated or take medication in
supervised setting. Second line

A mild rash after patient given medication for a depressive episode with suicidal ideation. What
drug
- Lamotrigine. Mood stabilzier in bipolar disorder
- Sever form: stevens-johnson
- Discontinue if rash seen

Patient comes in with worsening insomnia, dysphoria, and anxiety after discontinuing fluoxetine
and lorazepam
- Benzodiazepine withdrawl. Worseining anxiety, insomnia, tremor, psychomotor agitation,
and dysphoria. Can also present with PSYCHOSIS AND SEIZURES.
- Fluoxetine’s half life (4-6 days). LONG! So less likely

Side effect of phenelzine? When mixed with what?

- Its a MAOI. Hypertensive crisis (headches, can lead to intracranial bleeding, stroke and
death). When mixed with wine, cheese, aged or cured meats, overripe fruits, aged or
fermented soy products (tyramine)
- MAOI - used primary for treatment for refractory and atypical depression

TIme range for an adequate antidepressant trial

- 4-6 weeks

Which benzodiazepines are okay to use if liver issues

- Oxazepam, Temazepam, Lorazepam
 - “Outside the Liver”

Fever, confusion, muscle rigidity, abnormal vital signs, sweating. What is it and what do you
give
- Stop antipsychotics or restart dopamine agents (bromocriptine, amantadine)
- Supportive care (hydration, cooling); ICU
- Dantrolene or bromocriptine if refractory

PCP intoxication. PCP symptoms? What do you give? Patient screaming, trying to fight. Patient
has a history of seizures
- Symptoms: agitation, psychosis, disorientationn, nystagmus
- Benzos
- Haloperidol is contraindicated if seizure history. Lowers threshold

Medication-induced PSYCHOSIS disorder - delusions and/or hallucinations

- Glucocorticoids often implicated in new onset psychotic symptoms
- Not medication induced delirium: where you have fluctuating impairment, such as poor
attention and disorientation. Patient didn’t have lack od disorientation and normal
cognitive examination in office

What the receptor pathology of tardive dykinesia. Also what drugs can cause TD?
- Can occur with both generation of antipsychotics. Common with first generation
- Due to dopamine D2 receptor UPREGULATION and SUPERSENSITIVITY
- Other hypotheses: imbalance between dopamine D1 and D2 receptor effect in basal
ganglia, excitotoxic destruction of GABA neurons in striatum

In depersonalization/derealization disorder, patient has INTACT AUTOBIOGRAPHICAL

MEMORY but experiences repeated or chronic feelings of unreality or detachment

You can derealization and depersonalization shit with panic disorder. DIAGNOSIS is panic
diorder
Can’t diagnose adjustment disorder if symptoms have persisted >6 months after stressor

If a patient has a partial response to a first line reatment for depression, add another
antidepressant with a different mechanism of action, a second generation antipsychotic
(apoprazole), lithium, trioodothyronine, or psychotherapy

What are the side effects of bupronion

- No weight gain or sexual side effects

Narcisistic personality disorder people don’t engage in violent activities or break laws

BORDERLINE PERSONALITY DISORDER

TREATMENT OF CHOICE: PSYCHOTHERAPY (dialectical behavior therapy)

Antipsychotic medication effects in dopamine pathway

Mesolimbic: antipsychotic efiicacy
Nigrastriatal: extrapyramidal symtoms (Acute dystonia, akathisia, parkinsonism)
Tuberoinfundibular: Hyperprolactinemia (sexual dysfunction and gynecomastia in men).
Amenorrhea, galactorrhea
Dysthymia
- Pchronic depressed mood >= 2 years (1 year in children/adolescents)
- No symtom free period for >2 months
- Present of >=2 of following
- Poor appetitie or overeating
- Insomnia or hypersomnia
- Low energy or fatigue
- Low self esteem
- Poor concentration or difficulty making decisions
- Feeling of hopelessness

When should olanzapine be avoidided

- In motherfuckin metabolic syndrome shit
- Weight gain, diabetes, hyperlipidemia

Use clozapine for patient who have FAILED AT LEAST 2 ANTIPSYCHOTIC TRIALS due to risk
of agranulocytosis

First line treatment for major depressive disorder with seasonal pattern (seasonal affective
disorder, fall-winter onset and spring-summer remission)
- Antidepressants and bright light therapy

Schizotypal personality disorder - long standing pattern of eccentric behaviors and social
anxiety despite familarity. Magical thinking and odd perceptual disturbances
Delusional: nonbizarre delusions without any other positive or negative symptoms

Childhood trauma → borderline personality disorder

ECT for depression indications

- Treatment resistance
- Psychotic features
- Emergency conditions
- Pregnancy
- Refusal to eat or drink
- Imminent risk for suicide
- No absolute contraindications
- Increased risk
 - Severe cardiovascular disease, recent myocardial infarctions
- Space occupying brain lesion
- Recent stroke, unstable aneurysm

Management for acute mania

- Antipsychotics (1st and 2nd generation)
- Lithium (avoid in renal disease)
- Valproate (avoid in liver disease)
- Combination
- Abdinctive benzos for insomnia, agitation

Depression
- Decreased rem sleep latency, decreased slow-wave sleep
- Increased cortisol levels from hyperactivity of hypothalamic-pituitary adrenal axis
- Decreased hippocampal and fronal lobe volumes

Delirium-induced psychosis is differentiated from primary psychotic disorders by fluctuating

levels of consiousness, acute onset, and association with an underlying condirtion and/or
offending medications. Could be postoperatively or in setting of new or worseinging infections

Duration of brief psychotic disorder, schizophreniform disorder, and schizophrenia

Brief psychotic: >1 day and <1 month
Schizophreniform disorder:>1 month and <6 months
Schizophrenia: >=6 months

Delusional disorder: >= 1 delusion >1 month, NO OTHER PSYCHOTIC SYMPTOMS

Treatment of oppositional defiant disorder
- Parent management training
- Psychotherapy (anger management, social training)
- NO PHARMACOTHERAPY for ODD but assess for comorbit ADHD

Nystagmus. What drug?

- Phencyclidine (PCP)

ADHD
- First line: methylphenidate, amphetamines (stimulants)
- Nonstimulant options: norepinephrine reuptake inhibitor ATOMOXETINE and alpha-2
adrenergic agonists (guanfacine, clonidine)
- Atomoxetine appropriate for patient with a history of illicit substance use
- Alpha 2 agonists used when there is a poor respone to or intolerable side effects
doem stimulants or coexisting conditions (tic disorders)
FDA approved first line for smoking sessation
- Nicotine replacement therapy, bupropion, varenicline

Delusions, tactile hallucinations, aggressive, severe insomnia, poor dentition. What drug
- Methamphetamine abuse
- Excoritations due to chronic skin picking

Adjustment disorder with depressed mood

- onset within 3 months of identifiable stressor
- Does not meet criteria for another disorder
- PSYCHOTHERAPY

Bupropion
- No sexual side effects
- Can be activating and worsen insomnia

Malingering
- MAL mangdi
- Secondary gain

Medications for acute bipolar depression

- Second generation antipsychotics
- Quetipapine and lurasidone
- Anticonvulsant lamotrigine
- Lithium, valproate and combination of olanzapine and fluoxtenine have also
demonstrated efficacy

MDMA (ecstasy or molly): increases synaptic norepi, dopamine and serotonin. Can cause
serotonin syndrome. May not show up in urine toxicology screen. Also can cause hyponatremia
(drug induced ADH)

Cocaine withdrawl: fatifue, hypersomnia, increased dreaming, hyperphagia, impaired

concentration, intense drug cracving. Can cause acute depression with suicidal ideation