Sleep Disorders

Posted on 29 July، 2019 Tagged PsychiatryLeave a comment

Sleep Stages

NERM:

Stage	EEG Findings	Distribution
Stage 1	Disappearance of alpha wave and appearance of theta wave	5%
Stage 2	K complexes and sleep spindles	45%
Stage 3	Appearance of delta wave	12%
Stage 4	Continuation of delta wave	13%

REM:

Stage	EEG Findings	Distribution
REM	Bursts of sawtooth waves	25%

Stage	Facts
Stage 2	Longest of all sleep stages
Stage 3 and 4	Also called slow wave or delta sleep Hardest to arouse Tends to vanish in the elderly
REM	Easiest to arouse Lengthens in time as night progress Increased during the second half of the night

Sleep Latency: time to fall asleep (~15 min).
REM latency: time to reach REM (~90 min).

Chemical Effects on Sleep:

Tryptophan: Increases total sleep time.
Dopamine agonists: Produce arousal.
Dopamine antagonists: Decrease arousal, thus produce sleep.
Benzodiazepines: Suppress stage 4 and when used chronically increase sleep latency.
Alcohol intoxication: Suppresses REM.
Barbiturate intoxication: Suppresses REM.
Alcohol withdrawal: REM rebound.
Barbiturate withdrawal: REM rebound.
Major depression: Shorted REM latency, increased REM time, suppression of delta, multiple awakenings, and early morning awakening.

	Narcolepsy
Fx	hypocretin deficiency in lateral hypothalamus pt cant avoid falling asleep ⤵️ REM latency
S/S	• Sleep attacks: Most common symptom • Cataplexy: Pathognomonic , sudden loss of muscle tone. • Hypnagogic and hypnopompic Hallucinations that occur as the pt is going to sleep and is waking up from sleep, respectively. • Sleep paralysis: Most often occurs during awakening, when the patient is awake but unable to move. • Report falling asleep quickly at night
Dx	Clx Polysomnography
Tx	scheduled daily naps 💊: modafinil – psychostimulant (methylphenidate) If cataplexy: TCA

	Sleep Apnea
Fx	Central vs. Obstructive: both when u wake up, no more apnea What’s Central SA? no respiratory effort deriving from decreased CNS drive
S/S	Pt is not sleeping well, thus not refreshed from sleeping. chronic fatigue: similar to narcolepsy morning headache: specific to Central SA loud snoring: specific to OSA PEx: hypertension
Dx	Sleep studies (Polysomnography) ddx b/w Central vs. Obstructive CBC: polycythemia (2˚ to chronic hypoxia –> ⤴️ EPO)
Tx	Pediatrics: Weight reduction & adenotonsillectomy are the first line of management in appropriately selected children. Adults: Non-medical: weight loss / ⤵️ Alcohol intake / ❌ Smoking OSA: CPAP / Surgery: obstruction correction If central sleep apnea: BiPAP
📝	Complications: pulmonary HTN Arrhythmia –> cause of death

	Insomnia
S/S	Pt can’t sleep
Dx	Clx
Tx	Good sleep hygiene zolpidem, eszopiclone, or zaleplon

	Sleep Stage	Features	Tx
Nightmares (dream anxiety disorder)	REM	Memory of the event upon awakening Increases during times of stress Reported by 50% of the population	Usually none indicated, but may use REM suppressants such as TCAs
Night terror (sleep terror disorder)	Stages 3 and 4	Awakened by scream or intense anxiety No memory of the event the following day Seen more frequently in children More common in boys Runs in families	Treatment rarely required If medications is needed, consider benzodiazepines
Sleep-talking	All stages of sleep	Common in children Usually involves a few words May accompany night terrors and sleep-walking	No treatment is necessary
Sleep-walking	Stages 3 and 4	Sequence of behavers without full consciousness May preform perseverative behaviors Usually terminates in awaking followed by confusion May return to sleep without any memory of the event Begins at a young age More common in boys May find neurologic condition Sleep deprivation may exacerbate	Need to assure patient safety Use drugs to suppress stages 3 and 4 such as benzodiazepines Use drugs to suppress stages 3 and 4 such as such a

Sleep Terrors:

Characterized by recurrent episodes of intense fear and autonomic arousal during sleep
Occur during stages 3 and 4 (delta sleep)
Occur in children and usually benign
Occur typically during the first third of the night
Patients show a lack of responsiveness to others during an episode
Patients typically are unable to remember the sleep terror episode in the morning

Mini-mental State Examination

Posted on 29 July، 2019 Tagged PsychiatryLeave a comment

General Appearance	Appearance	grooming, poise,a clothes, body type (disheveled, neat, childlike, etc.)
	Behavior	patient’s motor behavior (restless, tics, etc.)
	Attitude	cooperative, frank, and seductive
Mood & Affect	Mood	What the pt think they feel (sad, adfds!)
	Affect	What they are showing u (flat, labile)
	Appropriate?	Is it appropriate?
Speech	The way pt speak
Perception	Hallucination
Perception	Illusion
Thought	Form	the way pt think (غير مترابط?(
Thought	Content	what is he/she thinking about? (Suicide?)

Sensorium and Cognition:

· Alertness and level of consciousness (awake, clouding of consciousness, etc..).

· Orientation: time, place, and person.

· Memory: recent, remote, recent past, and immediate retention and recall.

· Concentration and attention: serial sevens, ability to spell backwards.

· Capacity to read and write: ask patient to read a sentence and preform what it says.

· Visuospatial ability: copy a figure.

· Abstract thinking: similarities and proverb interpretation.

Defense Mechanisms

Posted on 29 July، 2019 Tagged PsychiatryLeave a comment

Projection ارم قشّك	A husband cheating –> says his wife is cheating A nurse avoids a pt –> says the pt wants to be alone vs Displacement?
Denial اجحد	You had huge stress, u can’t react to it, you deny.
Splitting خلك نصراوي	All good, all bad
Blocking مخك يهنق	You block
Regression تدحدر	you move from point B to point A
Somatization	psych –> physical sx
Introjection/identification	تاخذ أفكار/قيم أشخاص آخرين كما لو كانت أفكارك. Authority (parents) or someone you admire
Displacement	you displace your anger on others
Repression	unconscious forgetting. vs suppression (conscious forgetting)
Intellectualization	You mention the informtation only. Vs. Rationalization (التبرير): ماتبرر أنت، أنت تبحث عن المعلومات كوسيلة هرب
Isolation	جراح يصف لك العمليّة بتفاصيلها بدون مشاعر جندي يصف لك الحرب بدون مشاعر
Rationalization	تبرير
Reaction Formation	actions oppose feelings
Undoing	Someone has a very bad thought, but instead of doing it, he does the opposite. There has to be an act Example: you had a thought to hit that guy, instead, you went to him and become very nice vs Sublimation?
Acting out	tantrum
Humor	good one.
Sublimation	تحول الشيء السلبي لشيء إيجابي مثال: أبوك يضربك، فيك غضب، تروح تطلعه في الرياضة
Suppression	you suppress it until it’s time for it to come out
Repression	you involuntarily forget
Dissociation	تنفصل طفل عاش في بيئة قمع، ينفصل عن واقعه وذكرياته loses track of self / time
Fixation	stuck
Passive aggression	expression of angry feelings in a non-confrontational way

Key defense mechanisms:

Immature

· Acting out: Expressing unacceptable feelings through actions

· Denial: behaving as if an aspect of reality does not exist

· Displacement: transferring feelings to less threatening object/person

· Intellectualization: Focusing on non-emotional aspects to avoid distressing feelings

· Passive aggression: Avoiding conflict by expressing hostility covertly

· Projection: Attributing one’s own feelings to others

· Rationalization: Justifying behavior to avid difficult truths

· Reaction formation: Transforming unacceptable feelings/impulses into the opposite

· Regression: Riveting to earlier developmental stage

· Splitting: Experiencing a person/situation as either all positive or all negative

Mature

· Sublimation: Channeling impulses into socially acceptable behaviors

· Suppression: Putting unwanted feelings aside to cope with reality

Psychiatric Treatment Modalities

Posted on 29 July، 2019 Tagged PsychiatryLeave a comment

Modality	Primary Inductions	Features
CBT	Depression GAD PTSD Panic disorder OCD Eating disorders Negative thought patterns	· Combines cognitive and behavioral therapy · Challenges maladaptive cognitions · Targets avoidance with behavioral techniques (relaxation, exposure, behavior modification)
Interpersonal psychotherapy	Depression	· Links symptoms to current relationship conflicts and interpersonal skill deficits
Supportive psychotherapy	Lower functioning; psychotic disorders Patients in crisis	· Maintains hope; provides encouragement · Reinforces coping skills, adaptive defenses
Psychodynamic psychotherapy	Higher functioning Personality disorders	· Builds insight into unconscious conflicts and past relationships · Uses transference · Breaks down maladaptive defenses
Motivational interviewing	Substances use disorder	· Nonjudgmental; acknowledges ambivalence and resistance · Enhances intrinsic motivation to change
Dialectical behavioral therapy	Borderline personality disorder	· Improves emotion regulation, distress tolerance, mindfulness · Decreases self-harm; builds skills
Biofeedback	Prominent physical symptoms; pain disorders	· Improves control over physiological reactions to emotional stressor

Pediatric Psychiatry

Posted on 29 July، 2019 Tagged PsychiatryLeave a comment

Intellectual Disability
Features	IQ <70 in a <18 yo pt
S/S	Depends on IQ: 70-50: 6th grade can live independently <50: 2nd grade can do daily stuff, but they dont live alone <20: they are basically infants.
Dx	· Clx · IQ tests are not dxic. They just help to classify.
Tx	· Primary prevention includes genetic counseling, good prenatal care, and safe environments. · Special education.

Learning disorders
Features	Below expectation in learning certain material (math, reading, writing)
S/S	· Conduct disorder, oppositional defiant disorder, and ADHD · Poor self-esteem and social immaturity · School failure and behavioral disturbances
Dx	IQ testing and academic achievement tests are the major diagnostic tools.
Tx	Special education

Autism Spectrum Disorder
Features	ASD is a developmental disorder characterized by: · Impaired social relatedness · Deficits in verbal and nonverbal communication · Unusual responses to environment Clinical features of ASD include: · Failure to attach as an infant · Delayed or absent of social smile · Failure to anticipate interaction with the caretaker stereotypical movements · A need for sameness and routines ⤵️ Social communication · Approximately 30% of individuals with ASD become semi-independent in adulthood, but almost all have severe residual disabilities.
S/S	· Multiple sx of social dysfunction (lack of peer, empathy), and also behavioral (repetitive & bizzare). · PEx: self-injuries
Dx	Clx
Tx	· Family counseling, · special education, · antipsychotic medications to control episodes of severe agitation or self-destructive behavior.

Autism Spectrum Disorder
Clx	Deficits in social communication + interactions + starts in early development · Sharing of emotions · Nonverbal communication · Developing and understanding relationships · Restricted/repetitive patterns of behavior – · Repetitive movements or speech · Insists on routines · Intense fixated interests (Likes one toy only) · +/- language and intellectual impairment
Tx	· Comprehensive / multimodal Tx (speech, behavioral therapy, educational services) · Pharmacotherapy for psychiatric comorbidities (if pts has ADHD for example)

AHDH
Features	Inattention, hyperactivity, and impulsivity that interfere w/ social or academic Fxn.
S/S	· >6 months · <12 yo pt · Usually complian of a teacher.
Dx	Clx (to dx, sx has to be in 2 places)
Tx	· 1˚ Stimulants: methylphenidate and dextroamphetamine. · Non-stimulants such as atomoxetine. (if parents prefer that) · Effective in ⤵️ hyperactivity, inattention, and impulsivity.

ADHD
Clx	· Inattentive- ينسى كثير ، ما يسمع الكلام، ما يركز · Hyperactive- ما يجلس بهدوء · Impulsive- يعصب فجأة، ما يحب النقد · ≥6 months · Before age 12 · >2 settings (home-school) · Functional impairment
Tx	· Behavioral · 1° stimulants (methylphenidate, amphetamines) · If family prefers Nonstimulants (atomoxetine)

Enuresis

· It can be REGRESSION (defense mechanism!) → may be d/t ABUSE or New Brother.

TOURETTE Syndrome
Features	Motor and Vocal tics
S/S	Motor and Vocal tics. Associated w/ ADHD and obsessive-compulsive disorder ✳️
Dx	Clx
Tx	Antipsychotics: pimozide, haloperidol, olanzapine and risperidone

Conduct Disorder
Clx	· Pt has a pattern of violating major societal norms or rights of others · Time: over previous 12 months · Aggressive and cruel against ppl and animals · Destroys property · Serious violation of rules (run from school) · Deceitfulness and/or theft (lying, stealing) · Think of Joffrey Baratheon from GoT 😂
Tx	· CBT · Family therapy · Parent management training

Oppositional defiant disorder
Dx	Pattern of angry/irritable, argumentative/ vindictiveness for ≥months · On Adult, authority figures · Refuses to follow rules · Deliberately annoys others and blames them for own mistakes
Tx	· Parent management training · Psychotherapy (anger management, social skills training) · No pharmacotherapy for ODD but assess for comorbid ADHD and treat if present

Conduct disorder	Oppositional defiant
Oppose authority	Oppose authority
· Criminals (very bad violations) · Not cooporative w/ peers, actually they bully · Destructive	· Stupid Teens · COOPORATIVE w/ PEERs · Not destructive
Conduct disorder is a childhood/ adolescent disorder (patients must be younger than age 18 years) in which the basic rights of others are violated, which at least one of the following present in the past 6 months: · Destruction of property · Aggression to animals and people (this patient hit his classmate) · Deceitfulness or theft (he lied and was caught stealing) · Serious violations of rules	· They argue to annoy ppl, especially those w/ authority · they do not violate social norms, destroy property and so on · they dont steal, lie, or destroy or hit people.

Mood Disorders

Posted on 29 July، 2019 Tagged PsychiatryLeave a comment

1˚ Step ALWAYS IN ANY PT

Determine if pt is SUICIDAL.

If pt is suicidal –> HOSPITALIZE غصب عن أمه

Suicide Assessment & Tx of Suicidality
RF	SAD PERSONS · Sex (male) · Age · Depression · Previous attempt · EtOH or other substances use · Rational thoughts loss (psychosis) · Social support lacking · Organized plan · No spouse or significantly other · Sickness or injury
Assessment	Evaluate if pt has the idea: · Wish to die, not wake up (passive) · Thought of killing self (active) · Frequency, duration, intensity, controllability Evaluate if pt has intent: · Strength of intent to attempt suicide; ability to control impulsivity · Determine how close patient has come to acting on a plan (rehearsal, aborted attempts) Evaluate if pt has a plan: · Specific details: Method, time, place, access to means (e.g., weapons, pills), preparations (e.g., gathering pills, changing will) · Lethality of method Likelihood of rescue
Management	High imminent risk (ideation, intent and plan) · Ensure safety: Hospitalize immediately (involuntarily if necessary) · Remove personal belongings and objects in room that may present self-harm risk · Constant observation and security may be required to hold against will High non-imminent risk (ideation, intent and no plan to act near future) · Ensure close follow-up · Treat modifiable risk factors (underlying depression, psychosis, substance abuse, pain) · Recruit family or friends to support pt · Reduce access to potential means (secure firearms, medications)

Differential diagnosis of depressed mood:

MDD	· ≥2 weeks · ≥5 of 9 of the following symptoms; depressed mood and SIGECAPS o Loss of interest o Sleeping o Anhedonia o Suicidal o Low energy o Appetite o Concentration ❌ o Psychomotor agitation o No life-time history of mania o Significant functional impairment
Dysthymia	· Chronic depressed mood ≥2 years · ≥2 of the following: appetite disturbance, sleep disturbance, low energy, low self-esteem, poor concentration, hopelessness
Adjustment disorder w/ depressed mood	· Onset within 3 months of identifiable stressor · Marked distress/ functional impairment · Can be with depressed mood (but does not meet the criteria of MDD)
Normal stress response	· Not excessive or not out of proportion to severity of stressor · No significant functional impairment

Major Depression Disorder
Dx	· ≥5 of the following Sx for ≥2 weeks: o Depressed mood o Loss of interest or pleasure o Change in appetite or weight o Insomnia or hyperinsomnia o Psychomotor retardation or agitation o Low energy o Poor concentration or indecisiveness o Thoughts of worthlessness or inappropriate guilt o Recurrent thoughts of death or suicide · No hx of mania or hypomania · Not d/t substances or another medical conditions
Tx	· Psychotherapy · Antidepressant medication If partial response to antidepressant: § Add another💊w/ different MoA § 2^nd-gen antipsychotic § Psychotherapy § Lithium Bupropion (NDIR) § Appropriate for weight loss § No sexual SE Special uses: · Pt wants to sleep better: Trazodone · Pt wants to GAIN weight: Miratzapine · Pt wanna quit smoking: Bupropion
Electroconvulsive Therapy	Indications · Treatment resistance · Psychotic features · Emergency conditions o Pregnancy o Refusal to eat or drink o Imminent risk for suicide Safety · No absolute contraindication · Increased risk o Severe CV disease, recent MI o Space-occupying brain lesion o Recent stroke, unstable aneurysm

Anti-depressants 💊:

· Bupropion

o Is a NDRI

o It is associated with increased risk of SZ but less weight gain and sexual side effects than selective serotonin reuptake inhibitors (SSRIs)

· Mirtazapine

o In patients with depression characterized by insomnia and weight loss, mirtazapine is often preferred due to its sedating and appetite-stimulating properties.

· Trazodone

o Is a serotonin modulator that is highly sedating and commonly used lower doses to target insomnia

o It can cause orthostatic hypotension and is associated with the rare but serious side effect of priapism

· Duloxetine

o Serotonin and norepinephrine inhibitor (SNRI), has demonstrated efficacy in treating painful diabetic neuropathy.

o It can also be used as a first line treatment for depression

· SNRIs and TCA (Amitriptyline)

o Booth have been shown to have analgesic properties apart from their antidepressant effects and have a role in treating neuropathy and other chronic pain conditions

When to stop tx for MDD?

· MDD is a recurrent illness for most patients.

· If no recurrence → 6 months of free sx → discontinue tx.

· If ≥2 recurrence → maintainance therapy → longer than 6

· months

· If pt is young, persistant residual sx → maintainance

· therapy → longer than 6 months

However, patients with a hx of highly recurrent

illness (≥3 lifetime depressive episodes), chronic

episodes (≥2 years), severe ongoing psychosocial stressors,

or severe episodes (suicide attempts) are candidates

for maintaining antidepressant tx indefinitely (forever).

Antidepressant discontinuation syndrome:

Symptoms

· Dizziness

· Flu-like and GI symptoms

· Tremor

· Neurosensory disturbances (e.g., electric shock, rushing sensation in the head, paresthesia, hyper-responsivity to light and noise, vivid dreams)

The management approach

The best management approach is to re-institute in the same antidepressant and taper the dose gradually over 2-4 weeks or longer in severe cases

	Serotonin Syn	Neuroleptic Malignant Syn	Malignant Hyperthermia	MAOI crisis
Hx	SSRI / TCA	Antipsychotics	Post-op, use of anesthetic	Tyramine ingestion
BP	⤴️	⤴️	–	⤴️
T	⤴️	⤴️	⤴️	–
Muscle	Tremor, Myoclonus	RIGIDITY	RIGID	–
DTR	⤴️	N	N	–
Other Sx	GI Sx Dilated pupils	Confusion	–

	Serotonin Syndrome
features	· ⤴️ Serotonin Activity · Can happen w/: TCAs + SSRIs.
S/S	Vitals: · tachycardia · hypertension · hyperthermia, PEx: · agitation, · ocular clonus, · tremor, · akathisia, · hyperreflexia, · muscle rigidity, · dilated pupils.
Dx	Clx
Tx	1. withdrawal of the offending agent 2. benzodiazepines to tx agitation and tremor 3. Cyproheptadine as an antidote

Serotonin Syndrome
?	· Serotonergic medications, especially if combined (SSRI/SNRI, TCA, tramadol) · Drug interactions; Serotonergic medications and MAOI or linezolid ✳️ · Intentional overdose of serotonergic medications
Clx	· Mental status (Anxiety, agitation, delirium) · Autonomic dysregulation (diaphoresis, HTN, tachycardia, vomiting, diarrhea) · Neuromuscular hyperactivity (tremor, myoclonus, hyperreflexia)
Tx	· STOPP of all serotonergic medications · Supportive care, · sedation with benzos · If supportive measures fail: Serotonin antagonist (cyproheptadine)

Dysthymia (Chronic Depressed Mood)
Clx	· Chronic depressed mood ≥ 2 years · No Sx-free period >2 months · Presence of ≥ 2 of: o Appetite: Poor ⤵️ or overeating ⤴️ o Sleep: Insomnia ⤵️ or hypersomnia ⤴️ o Energy: ⤵️ o Self-esteem: ⤵️ o Poor concentration o Feeling hopeless (less severe than MDD)
Different Types	· Pure dysthymic syndrome: criteria for MDD episode are NEVER ⊕. · Dysthymia w/ intermittent MDD episodes · Dysthymia w/ persistent MDD episodes: criteria for MDD episode are ⊕ throughout previous 2 years

MDD	Grief (bereavement)
• 5 of 9 Sx – 2 Weeks Period: (Sleep disturbances, appetite (⤴️ or ⤵️), low energy, psychomotor retardation, anhedonia, low mood, feeling guilt, difficulty in concentration, suicidal ideation) • Low mood or anhedonia must be ⊕ • May occur in response to a variety of stressors, including loss of loved one • Pt has social & occupational dysfunction	• Normal reaction to loss • Feelings of loss & emptiness • Sx revolve around the lost one • Functional decline temporary (intensity ⤵️ over time) & less severe • “Waves” of grief at reminders • Less common sx of worthlessness, self-loathing, guilt & suicidality • Thoughts of dying involve joining the deceased

Postpartum mood disorder
⏰	Disorder	Sx	Mother’s Feelings Toward Baby	Tx
2 weeks	Postpartum blues or baby blues	Sadness, mood lability, tearfulness	No negative feelings	Supportive usually self-limited
During pregnancy or after 4 weeks	Depressive disorder with peripartum onset	Depressed mood, weight changes, sleep disturbances, and excessive anxiety	May have negative feelings toward baby	Antidepressant medications
During pregnancy or after 4 weeks	Bipolar disorder with prepartum onset Brief psychotic disorder with peripartum onset	Symptoms of depression, mania along with delusions, hallucinations and thoughts of harm	May have thoughts of harming baby	Antipsychotic medication, lithium, and possible antidepressant

Bipolar Disorder

Manic episode:

· Symptoms more sever

· 1 week unless hospitalized

· Marked impairment in social or occupational

functioning or hospitalization necessary

· May have psychotic features; makes episodes

manic by definition.

Hypomanic episode

· Symptoms are less severe

· ≥ consecutive days

· Unequivocal, observable change in functioning form

patient’s baseline.

· Symptoms not severe enough to cause marked impairment

Or necessitate hospitalization

· No psychotic features

Bipolar I:

· Manic episodes

· Depressive episodes common, but not required for diagnosis

Bipolar II:

· Hypomanic episodes

· ≥1 major depressive episodes required

Cyclothymic disorder:

· At least 2 years of fluctuating, mild hypomanic and depressive symptoms that do not meet criteria for hypomanic episodes

Or major depressive episodes

Bipolar
Nx	DSM-5?
S/S	· Mania + Depression
Dx	· Clx
Tx	1˚ ENSURE Pt SAFETY 2˚ Mood stablizer (Lithium)

Manic Episode
Clx	≥1 week of elevated or irritable mood and ⤴️ energy/activity ≥3 of the following sx: · Distractibility · Impulsivity/ indiscretion, risky behavior · Grandiosity · Flight of ideas/ racing thoughts · Increased need for sleep · Talkativeness/ pressured speech (DIGFAST mnemonic)
Severity	· Impaired psychosocial function · +/- psychosis (hallucinations, delusions) · May require hospitalization
Tx	· Antipsychotics (first-second-generation) · Lithium (avoid in renal disease) · Valproate (avoid in liver disease) · Combinations in severe mania (antipsychotic plus lithium or valproate) · Adjunctive benzodiazepines for insomnia, agitation

Dysthymia	Cyclothymia
light depression for 2 ys	· light bipolar for 2 ys · have mariatel issues · can be borderline
respond to psychotherapy	Respond to lithium & psychotherapy

Lithium Toxicity
?	· Overdose · Volume depletion (⤵️ GFR) · During interactions (ones that affect the kidney) o Thiazide o NSAIDs o ACE inhibitors
Sx	· Thyroid/ Nephrogenic DI · Acute o GI: N/V, diarrhea o Late neurologic sequelae · Chronic toxicity (neurologic) o Ataxia o Tremors/ fasciculations
Tx	1. Discontinuing: lithium is recommended 2. If you cannot: salt restriction and selected diuretics such as amiloride 3. When to hemodialysis? o Serum lithium level >4 o Lithium level >2.5 + signs of significant lithium toxicity (e.g., SZ,AMS) o Inability to excrete lithium (e.g., renal disease, decompensated heart failure.

Anxiety Disorders

Posted on 29 July، 2019 Tagged PsychiatryLeave a comment

DDx of DSM-5 anxiety disorders:

Social anxiety disorder	· Fear of negative evolution and embarrassment (social phobia) · Sx occurs only in specific performance situation · Avoids eye contact
Panic	· Recurrent, unexpected panic attacks
Specific phobia	· Excessive anxiety about a specific object or situation (phobic stimulus) (vs social phobia: fear of negative evolution)
GAD	· Chronic multiple worries, anxiety, tension

Generalized Anxiety Disorder
Clx	· Excessive anxiety · uncontrollable worry (multiple issues) ≥6 Months · ≥3 of the following sx: o Restlessness; feeling on edge o Difficulty concentrating o Muscle tension o Sleep disturbance
Tx	· CBT · 1° SSRIs or SNRIs · 2°Benzo · Use if SSRIs don’t work · Avoid if pt has hx of substance abuse · Risk of dependence, tolerance, and rebound effect when d/c · 2°Buspirone (FDA-approved – non-benzo anxiolytic) · Use if SSRI don’t work + you can’t use Benzo

Panic Disorder
Clx	· Rx and unexpected panic attacks w/ ≥4 of: o Chest pain, palpitations, SOB, choking (يحس أنه بيموت) o Trembling, sweating, nausea, chills o Dizziness, paresthesias o Derealization, depersonalization o Fear of losing control or dying · Worry about additional attacks, avoidance behavior
Tx	· 1°: SSRI/SNRI +/or CBT · During acute episode: benzodiazepine

Conversion Disorder
Clx	· Pt converts psychological stressor → Neurologic Sx · Not intentional · Normal PEx · Sx cause significant functional impairment
Tx	· Education · CBT · Physical therapy

Acute Stress Disorder/PTSD
Clx	· Exposure to acute or threatened trauma · Intrusive memories, nightmares, flashbacks with intense/ psychological reactions · Amnesia for event, detachment, avoidance of remainders · Negative mood · Arousal with sleep disturbance, irritability, hypervigilance, exaggerated startle, impaired concentration · Acute Stress Disorder: ≥3 days and ≤1 month · PTSD: >1 month
Tx	· Trauma-forced, brief CBT · Consider pharmacotherapy for insomnia, intense anxiety · Monitor for development of PTSD · Prazosin for nightmares

OCD
Clx	· Obsession o Recurrent, intrusive, anxiety-provoking thoughts, urges, or images · Compulsions o Response to obsessions with repeated behaviors or mental acts o Behaviors not connected realistically with preventing feared event · Time-consuming (>1hr/day) or causing significant distress or impairment
Tx	· SSRI · CBT (exposure and response prevention)

Specific Phobia
Clx	· Marked anxiety about a specific object or situation (the phobic stimulation) for >6 months · Common types: fear of flying ✈️, heights, animals, injections, blood · Avoidance behavior (e.g., avoiding brides and elevators, refusing work requiring travel) · Usually develops in childhood, often after traumatic event
Tx	· CBT with exposure (first-line) · Short-acting benzodiazepines

Social Anxiety Disorder (Social Phobia)
Dx	· Marked anxiety about ≥1 social situation for ≥6 months · Fear of humiliation, embarrassment · Avoids social situations or endured with intense distress · Marked impairment (Social, academic, occupational) · Subtype specifier; performance only
Tx	· SSRI/SNRI · CBT · BB or Benzodiazepine for performance-only subtype

Adjustment disorder
Features	Maladaptive response to an identifiable stressor w/i 3 months
S/S	=
Dx	The criteria of diagnosis: · Presence of an identifiable psychosocial stressor, or stressors · Maladaptive reaction to stressors · A time of within 3 months after onset of stressors · Symptoms that do not meet the criteria of any other psychiatric disorder
Tx	1˚ Remove Stressor 2˚ Psychotherapy –(failed?)–> Antidepressant / Anxiolytics

Body dysmorphic disorder
Clx	· Preoccupation with ≥1 physical defect · Not observable by others · Rx behavior or mental acts performed in response to the preoccupation · Significant distress or impairment · Variable insight (good, poor, absent/delusional beliefs)
Tx	· Antidepressant (SSRI) · CBT

Gender Dysphoria
Clx	· Experiences persistent (≥6 months) incongruence between assigned and felt gender · Desires to be other gender · Dislikes own anatomy, desires sexual traits of other gender · Believes feelings/reactions are of other gender
Tx	· Assessment of safety · Support; psychotherapy (individual, family) · Referral to specialist services (medical and mental health multidisciplinary)

Psychotic Disorders

Posted on 29 July، 2019 Tagged PsychiatryLeave a comment

DSM5: DDx Psychotic Disorder
Brief psychotic	≥1 day and <1 month Sudden onset, full return to function
Schizophreniform	≥1 month and <6 months Same symptoms as schizophrenia, functional decline not required
Schizophrenia	≥6 months (including ≥1 month of active symptoms, can include prodromal and residual periods), requires functional decline
Schizoaffective	Mood episode with concurrent active-phase symptoms of schizophrenia + ≥2 weeks of delusions or hallucinations in the absence of prominent mood symptoms
Delusional	≥1 delusions and ≥1 month, no other psychotic symptoms, normal functioning apart from impact of delusions

1˚ Step ALWAYS IN ANY PT

Determine if pt is SUICIDAL.

If pt is suicidal –> HOSPITALIZE غصب عن أمه

Schizophrenia
Clx	· Positive symptoms (delusions, hallucinations, disorganized speech/behavior) · Negative symptoms (flat affect, poverty of speech, lack of motivation, social withdrawal anhedonia) · Duration ≥6 months · Significant functional decline
Dx	· Dx is Clx. You need 6 months of 2 of the typical sx. Brain Imaging Findings · CT/MRI: · lateral and third ventricular enlargement, · ⤵️ cortical volume (associated w/ ⊖ sx) · PET: · hypoactivity of the frontal lobes · hyperactivity of the basal ganglia relative to the cerebral cortex Psychologic Tests · IQ tests: Will score lower on all IQ tests · Neuropsychologic: Tests usually are consistent with bilateral frontal and temporal lobe dysfunction
Tx	· Psychiatric consultation · Antipsychotic 💊 · If resistant schizophrenia → Clozapine (f/u CBC) · If agitated schizophrenia + in ER → Droperidol (sedative) · If pt has liver pathology → Paliperidone (metabolized in kidney not liver) · Ziprasidone: weight-neutral · Psychosocial interventions to augment antipsychotics (CBT, family therapy)

Breif Psychotic Disorder
Features	<1 month of schezophrenia
S/S	=
Dx	Clx
Tx	· Hospitalize the pt · both antipsychotics and benzodiazepines.

Schizophreniform disorder
Features	1-6 months of schezophrenia
S/S	=
Dx	Clx
Tx	Antipsychotic medication is indicated for a 3–6-month course.

Schizoaffective
Features	· Period of PURE mood · Period of PURE Psychosis
DSM-5	· Sx of MDD/Mania · Period where pt has psychosis but no mood sx · Lifetime history of delusions or hallucinations for ≥2 weeks in the absence of major depressive or manic episode · Mood episodes are prominent and recur throughout illness
Dx	Clx DDx: MDD or bipolar with psychotic features: Psychotic symptoms occur exclusively during mood episodes Schizophrenia: Mood symptoms may be present for relatively brief periods
Tx	Antidepressant –(failed?)–> Antipsychotic

Delusional disorder
Features	· ≥1 delusion in ≥1 month · *Nonbizarre* delusions · Bizzare (like the gov is watching me) is seen in schizophrenia · No impairment in level of functioning · No associated psychotic sx · Types include erotomanic, jealous, grandiose, somatic, mixed, unspecified.
Dx	Clx DDx: · Schizophrenia: dysfunctional + extra Sx · Alzheimer’s: psychosis/delusions occurs late in dz · Personality disorders: pervasive pattern of suspiciousness (paranoid), grandiosity (narcissistic), or odd beliefs (schizotypal), but no clear delusions.
Tx	· OP · Individual psychotherapy (CBT) · Antipsychotic

Catatonia
Clx	· Immobility or excessive purposeless activity · Mutism, stupor (decreased alertness and response to stimuli) · Negativism (resistant to instructions and movement) · Posturing (assuming positions against gravity) · Waxy flexibility (initial resistance, then maintenance of new posture) · Echolalia, echopraxia (mimicking speech and movements)
Tx	· Benzodiazepines (lorazepam) · Electroconvulsive therapy

Mood disorders with psychotic features vs primary psychotic disorders
MDD or bipolar disorder with psychotic features	· Psychotic symptoms occur exclusively during mood episodes
Schizophrenia	· Mood symptoms, if present, are brief and not prominent
Schizoaffective	· MDD or manic episode occur concurrent with symptoms of schizophrenia · Lifetime history of delusions or hallucinations for more than two weeks outside of mood episode is present · Mood episodes are prominent and recur throughout illness

Clozapine treatment guidelines
Indications	· Tx-resistant schizophrenia (They tried 2-3 meds with no response) · Schizophrenia + suicidality
SE	· Agranulocytosis · SZ · Myocarditis · Metabolic syndrome

Antipsychotic Med Effects (dopamine antagonism)
Pathway	?
Mesolimbic	Antipsychotic efficacy ⤵️
Nigrostriatal	Extrapyramidal sx: Acute dystonia, akathisias, parkinsonism
Tuberoinfundibular	Hyperprolactinemia

2^nd-gen antipsychotic SE:

	Metabolic	Extrapyramidal	⤴️ QTc
Aripiprazole	Low	Low	Low
Clozapine	Very high	Low	Medium
Lurasidone	Low	Medium	Low
Olanzapine	Very high	Low	Medium
Quetiapine	High	Low	Medium
Risperidone	High	High	Medium
Ziprasidone	Low	Low	High

2nd Gen Antipsychotics SE
Metabolic syndrome	· Weight gain · Dyslipidemia · Hyperglycemia (new-onset DM)
Highest-risk	· Clozapine · Olanzapine
Monitoring?	Baseline and regular F/U · BMI · Fasting glucose and lipids · BP · Waist circumference

Antipsychotic extrapyramidal effects
Dystonia	· Sudden, sustained contraction	· Benztropine · Diphenhydramine
Akathisia	· Subjective, restless, inability to sit still	· BB (propranolol) · Benzo (lorazepam) · Benztropine
Parkinsonism	· Gradual-onset tremor, rigidity, bradykinesia	· Benztropine · Amantadine
Tardive dyskinesia	· Gradual onset after prolonged therapy (>6months); Dyskinesia or mouth face, trunk and extremities	· Valbenazine

Neuroleptic Malignant Syndrome
S/S	· Fever >40 · Confusion · Muscle rigidity (generalization) · Autonomic instability (abnormal vital signs, sweating)
Tx	· 1° D/C antipsychotics or restart dopamine agents · 2°supportive care (hydration, cooling) + ICU · Dantrolene (muscle relaxant) or bromocriptine if refractory

Malignant Hyperthermia
#	· Genetic mutation alters control of intracellular calcium · Triggered by volatile anesthetics, succinylcholine, excessive heat
S/S	· Masseter muscle/generalized rigidity · Tachycardia · Hypercarbia resistant to increased minute ventilation · Rhabdomyolysis · Hyperkalemia · Hypothermia (late manifestation)
Tx	· Respiratory/ventilatory support · Immediate cessation of causative anesthetic · Dantrolene

Tardive dyskinesia –يتحرك كثير–
Clx	· 🆎 involuntary movements due to prolonged use of antipsychotics or metoclopramide · Orofacial dyskinesia (tongue protrusion, lip smacking, grimacing) · Limp dyskinesia (dystonic postures, foot tapping, chorea) · Trunk dyskinesia (rocking, thrusting, shoulder shrugging)
Tx	· Discontinue causative medication if feasible · Switch to 2^nd-gen antipsychotic (quetiapine, clozapine) if you need to continue antipsychotic · Tx w/ valbenazine or deutetrabenazine (NOT ANTI-PARKINSON)

Personality Disorders

Posted on 29 July، 2019 Tagged PsychiatryLeave a comment

DSM-5 personality disorders:

Cluster A (Odd/eccentric)

· Paranoid: suspicious, distrustful, hypervigilant

· Schizoid: prefers to be a loner; detached, unemotional

· Schizotypal: unusual thoughts, perceptions and behavior

Cluster B (Dramatic/ erratic)

· Antisocial: disregard and violation of the rights of others

· Borderline: chaotic relationships, abandonment fears, labile mood, impulsivity, inner emptiness, Self-harm

· Histrionic: superficial, مسرحية, attention-seeking

· Narcissistic: grandiosity, lack of empathy

Cluster C (Anxious/fearful)

· Avoidant: Avoidance due to fears of criticism and rejection

· Dependent: submissive, clingy, need to be taken care of

· Obsessive-compulsive: rigid, controlling, perfectionistic

Antisocial personality disorder المؤذي
Clx	· Age ≥ 18 yo · Violates rights of others, social norms, laws · Impulsive, irritable, aggressive (fight, assaults) · Consistently irresponsible, lies · Lack of remorse · Evidence of conduct disorder before age 15
Tx	Psychotherapy for milder forms (monitor for manipulation of therapeutic relationship) Treat comorbid psychiatric disorders (e.g., substance use, depression)

Borderline personality disorder

Diagnosis

§ Pervasive pattern of unstable relationships, self-image and affects and marked impulsivity,

§ ≥5of the following:

Frantic efforts to avoid abandonment
Unstable and intense interpersonal relationship
Markedly and persistently unstable self-image
Impulsivity in ≥2 areas that are potentially self-damaging
Recurrent suicidal behaviors or threats of self-mutilation (e.g., cutting)
Affective instability (marked mood reactivity)
Chronic feelings of emptiness
Inappropriate and intense anger
Transient stress-related paranoia or dissociation

Neurocognitive Disorders

Posted on 29 July، 2019 Tagged PsychiatryLeave a comment

Defenition

Cognition includes memory, language, orientation, judgment, problem solving, interpersonal relationships, and performance of actions.

Cognitive disorders have problems in these areas as well as behavioral symptoms.

	Dementia DDx
KEY SX	⤴️ disorientation, anxiety, depression, emotional lability, personality disturbances, hallucinations, and delusions.
Alzhiemer’s	MRI: Cortical atrophy, flattened sulci, and enlarged ventricles. Bx: plaques (amyloid deposits), neurofibrillary tangles, neuronal loss. ⤵️ NE + Ach First DEMENTIA (loss of spacial function) –> then they lose personality later or be inappropriate
Vascular dementia	Step-wise deterioration FND, Gait AN PEx: carotid bruits, fundoscopic abnormalities, and enlarged cardiac chambers. MRI: may show old infarctions Control RF + Tx U/C
FT dementia	Personality changes (pt suddenly is innappropriate) + dementia (hard to ddx from AD) Bx: Pick bodies (intraneuronal argentophilic inclusions) and Pick cells (swollen neurons).
Lewy body dementia	Hallucinations + Parkinsonism + extrapyramidal signs. Antipsychotic medications may worsen behavior. Patients typically have fluctuating cognition, as well as REM sleep behavior disorder.
Prion dz	EXTREMELY FAST Dementia myoclonus, visual and gait disturbances, choreoathetosis EEG abnormalities (e.g., sharp, triphasic, synchronous discharges and, later, periodic discharges)
Huntington	AD (⊕ FHx) choreoathetosis + Dementia They may be suicidal
Pseudodementia	depressed pt awares of dementia improves w/ antidepressants

Pseudodementia	Neurocognitive Disorder
Acute onset	Insidious onset
Family aware	Family unaware at first
Answers “I don’t know” when asked questions	Confabulates when asked questions
Will talk about deficits when asked	Will minimize deficits
Treat with antidepressants	Will not improve with antidepressants

Delirium	Neurocognitive Disorder
Acute onset	Insidious onset
Fluctuating course	Chronic course
Lasts days to weeks	Lasts months to years
Recent memory problems	Recent then remote memory problems
Disrupted sleep-wake cycle	Less disorientations at first
Disorientation	Normal sleep-wake cycle
Hallucinations common	Hallucinations, sundowning
Treat underlying condition	Supportive treatment

	Delirium
Features	ACUTE ⤵️ in Alertness & cognition Caused by acute metabolic or substance intoxication.
S/S	Hallucination is common Most common psychiatric illness on medical and surgical floors
Precipitate	Benzo / anticholinergic drugs Infections
Dx	Mainly Clx EEG may show slow of function, or focal abnormality, CT/MRI may show abnormality
Tx	Tx U/C Supportive Consider protective use of physical restraints and antipsychotic medications.

Dilirium
RF	· Advanced age · Neurologic disorder (e.g., dementia, stroke) · Sensory impairment (e.g., hearing loss)
?	· CNS insult (e.g., seizure, stroke) · Infection (e.g., pneumonia, UTI) · Medications (e.g., sedatives) · Metabolic disturbances (e.g., electrolytes, uremia)
Clx	· Acute-onset, fluctuating mental status · Disturbance in attention · Sleep-wake changes (e.g., sundowning)
Tx	· Avoid polypharmacy, physical restraints · Maintain normal sleep-wake cycle · Provide frequent reorientation · Treat U/C (antibiotics)

Fast HY Review

Tag: Psychiatry

Sleep Disorders

Sleep Stages

Mini-mental State Examination

Defense Mechanisms

Psychiatric Treatment Modalities

Pediatric Psychiatry

Mood Disorders

Anxiety Disorders

Psychotic Disorders

Personality Disorders

Neurocognitive Disorders