PANCE Blueprint Psychiatry (7%)

Lessons

1. PANCE Psychiatry and Behavioral Science Content Blueprint

2. PANRE & PANRE-LA Psychiatry/Behavioral Science Content Blueprint

3. Psychiatry and Behavioral Science With Joe Gilboy PA-C (Video Lecture)

   35 mins

   Joe Gilboy PA-C
4. Psychiatry 75 Question Comprehensive Exam

   Comprehensive PANCE/PANRE Psychiatry and Behavioral Science Blueprint Exam
5. Smarty PANCE Psychiatry Flashcards and Cheat Sheet

   Flashcards covering all Psychiatry and Behavioral Science PANCE/PANRE NCCPA Content Blueprint topics. Download and print the flashcard cheat sheet and access our premium Quizlet flashcard sets.
   1. Additional Psychiatry Flashcards
6. Pediatric Developmental Milestones

   • NEONATE (0-3 mos)
     • 0-1 mo Moro and grasp reflex, visual tracking, crying minimal.
     • 2 mos holds head up, swipes at objects, cooing, social smile.
   • INFANT (3-12 mos)
     • 3 mos lifting head and chest, Moro reflex disappears.
     • 4 mos rolls from prone to supine, grasp objects, orients to voice, colic resolves in most babies by this age.
     • 6 mos sits upright, babbles, stranger anxiety.
     • 9 mos crawls, pull-to-stand, pincer grasp, eats with fingers mama-dada(nonspecific), waves bye-bye, responds to name.
   • TODDLER (12-24 mos)
     • 12 mos stands, mama-dada (specific), picture book.
     • 15 mos walks, uses a cup, several words, temper tantrums.
     • 18 mos walks up stairs, throws a ball, names objects, toilet-training begins.
     • 24 mos runs, 2-word sentences, several hundred word vocabulary, follows 2-step commands.
   • PRESCHOOL (3-6 years)
     • 36 mos rides a tricycle (3yrs), eats with utensils, 3-word sentences, knows first and last name.
   • SCHOOL AGE (6-11 years)
     • Development of conscience (super-ego), has same-sex friends.
   • ADOLESCENCE (Girls-11yrs, Boys-13 yrs)
     • Abstract reasoning, the formation of personality, may have friends of opposite sex.
7. Abuse and Neglect (PEARLS)
   1. Child/elder abuse

      • Child Abuse: Injury not adequately explained or inconsistent with the history given.
        • Bruises/lacerations/soft-tissue swelling, dislocations/fractures, spiral fractures
        • Burns (doughnut-shaped, stocking-glove, symmetrically round)
        • Bruises or injuries with regular patterns on the face, back, buttocks, thighs.
        • Internal hemorrhages, abdominal injuries, bite marks,  injury with shape of instrument used
      • Child Sexual Abuse: Common ages 9-12 and often by male known to child.
        • Evidence of sexually transmitted infection
        • Knowledge about sexual acts inappropriate for age
        • Initiates sexual acts with others, peers
        • Exhibits sexual knowledge through play
      • Elder abuse
        • Physical or sexual abuse
        • Psychological
        • Financial
        • Neglect
   2. Intimate partner violence

      Intimate Partner Violence (IPV) is a pattern of abusive behavior by a current or former partner that can include physical, emotional, sexual, or financial abuse.

      • Common presentations include unexplained injuries, delayed care, frequent ED visits, and partner who is overly controlling or refuses to leave the room
      • Victims may report vague complaints such as chronic pain, anxiety, depression, or sleep disturbances
      • High-risk populations include pregnant women, LGBTQ+ individuals, the elderly, and those with low socioeconomic status
      • Screening is essential and should be conducted privately and nonjudgmentally using validated tools (e.g., HITS or SAFE questions)
      • Healthcare providers are mandated reporters in many states if there is suspicion of abuse, especially if children or vulnerable adults are involved
      • Documentation should be objective and detailed, including quotes from the patient, injury patterns, and photographs (if allowed)
      • Management includes ensuring patient safety, providing resources (e.g., shelters, counseling, legal aid), and making appropriate referrals to social work or advocacy services
      • Discharge planning should prioritize safety, including discussing a safety plan and avoiding sending the patient home with the suspected abuser

   3. Physical abuse

      Physical Abuse is the intentional infliction of physical harm on another person, often seen in vulnerable populations such as children, the elderly, and intimate partners

      • Common signs include unexplained bruises, burns, fractures, bite marks, or injuries in various stages of healing
      • Injuries may be inconsistent with the history provided, especially in non-ambulatory children or elderly patients
      • Suspicious injury patterns:
        • Posterior rib fractures, long bone fractures, retinal hemorrhages, and subdural hematomas in infants (raise concern for shaken baby syndrome)
        • Patterned injuries such as belt marks, handprints, or immersion burns
      • Behavioral red flags: Delayed care, fearful behavior, avoidance of eye contact, or overprotective caregivers
      • Diagnosis involves a careful history and physical exam, skeletal survey (in children), CT/MRI, and appropriate lab work; photographic documentation may be needed
      • Mandatory reporting laws require clinicians to report suspected abuse to child protective services (CPS) or adult protective services (APS) based on the patient’s age and situation
      • Management includes ensuring the safety of the patient, providing medical and psychological support, and involving social services, law enforcement, or legal intervention when necessary
      • Failure to recognize and intervene can result in continued abuse, permanent injury, or death
   4. Psychological abuse

      Psychological Abuse is a form of emotional maltreatment involving verbal or nonverbal behaviors that inflict mental harm, undermine self-worth, or control and isolate a person.

      • Common in intimate partner violence, child abuse, and elder abuse contexts
      • Behaviors include: verbal insults, threats, intimidation, gaslighting, humiliation, and controlling or isolating actions
      • Victims may present with anxiety, depression, low self-esteem, sleep disturbances, or somatic complaints without a clear physical cause
      • Red flags include fearfulness, reluctance to speak, inconsistent stories, or a partner/family member who answers for the patient or refuses to leave the room
      • Screening is crucial and should be done in a safe, private setting, using validated tools like HITS (Hurt, Insult, Threaten, Scream) or psychosocial assessment questions
      • Documentation should be clear, objective, and include direct quotes, observed behavior, and findings
      • Management involves ensuring the patient’s immediate safety, providing psychological support (trauma-focused therapy, such as CBT or EMDR), and connecting them with social services or mental health professionals
      • Mandatory reporting may be required in cases involving children, elders, or vulnerable adults, depending on state laws
   5. Sexual abuse

      Forced or otherwise inappropriate (e.g. in age difference) sexual behavior with others

      • Fear of or anxiety towards sexual activity, increased risk of suicide
      • Physical symptoms (e.g. physical trauma, STIs, UTIs)
      • Diagnosis is based on individual history and presence of above symptoms
      • May require emergency contraceptives or STD prophylactics, referral to protective services for legal/social support
8. Anxiety Disorders (Pearls)
   1. General anxiety disorder (Lecture)

      Generalized anxiety disorder (GAD) involves persistent and excessive worry pertaining to multiple events or domains that continues for 6 months or more

      • SSRIs: Paroxetine and escitalopram; SNRIs: Venlafaxine
      • Buspirone is also effective; the starting dose is 5 mg PO bid or tid. However, buspirone can take at least 2 wk before it begins to help.
      • Benzodiazepines (short-term use), beta blockers
      • Psychotherapy

   2. Panic disorder (ReelDx + Lecture)

      Panic disorder is characterized by recurrent, unexpected panic attacks with at least a month or more of worry or avoidant behavior. Panic disorder can occur with or without agoraphobia.  Symptoms develop abruptly and reach a peak within 10 minutes.

      • Palpitations, chest pain, sweating, SOB, etc. etc.
      • SSRIs: Paroxetine, Sertraline, Fluoxetine
        • Benzodiazepines: for acute attacks (watch for abuse)
        • Cognitive-behavioral therapy (CBT) (relaxation, desensitization, examining behavior consequences) - a good choice when medication safety is a concern (ex. pregnancy) 
   3. Phobias

      Same as panic disorder – symptoms begin 10-15 minutes prior to stress event except in this case it is a specific stress event (i.e flying, blood, social situations, spiders etc. etc.)

      • Treat with exposure therapy (first line), teach to relax and try to understand/overcome the fear
      • Medications may be used
        • SSRI + CBT
        • Benzodiazepines (i.e prior to flying)
        • Treat agoraphobia just as GAD with SSRIs and CBT
9. Bipolar and related disorders (Lecture)

   Bipolar I disorder A manic episode with or without a major depressive episodes Bipolar II disorder At least one hypomanic episode and at least one major depressive episode

   • There has never been a manic episode

   Cyclothymic disorder A chronic mood disorder characterized by episodes of depression and hypomania for at least 2 years.

   • This is a less intense but often longer lasting version of bipolar disorder.
   • A person with cyclothymia has both high and low mood, but never as severe as either mania or major depression.

   Treatment depends on the manifestations and their severity

   • Mood stabilizers: lithium, valproate, carbamazepine, lamotrigine
   • 2nd-generation antipsychotics: aripiprazole, lurasidone, olanzapine, quetiapine, risperidone, ziprasidone
   • TSH should be followed routinely every 6-12 months in patients taking lithium.

10. Depressive disorders (Pearls)
    1. Major depressive disorder (ReelDx + Lecture)

       5 or more SIEGECAPS for ≥ 2 weeks nearly every day and at least one of the symptoms is depressed mood or anhedonia

       • SIGECAPS: Sadness, Interest/anhedonia, Guilt, Energy, Concentration, Appetite, Psychomotor activity, Suicidal
       • Continue to increase dosage q3–4wk until symptoms in remission. Full medication effect is complete in 4–6 weeks. Augmentation with 2nd medication may be necessary.
       • See within 2–4 weeks of starting medication and q2wk until improvement, then monthly to monitor medication changes
    2. Persistent depressive disorder (dysthymia) Lecture

       Mild chronic form of major depression lasting ≥ 2 years

    3. Premenstrual dysphoric disorder (PMDD)

       Premenstrual Dysphoric Disorder (PMDD) is a severe form of premenstrual syndrome (PMS) characterized by significant emotional and physical symptoms during the week before menstruation

       • Severe mood swings, irritability, and depression occurring in the luteal phase of the menstrual cycle
       • Anxiety, tension, and anger are common emotional symptoms
       • Physical symptoms include bloating, breast tenderness, headache, and joint/muscle pain
       • Symptoms significantly impair daily functioning and relationships
       • Diagnosed based on symptom diary tracking for at least two menstrual cycles, showing symptom-free follicular phase
       • Manifestations are similar to those of premenstrual syndrome (PMS) but are more severe, causing clinically significant distress and/or marked impairment of social or occupational functioning
       • Treated with SSRIs (e.g., fluoxetine, sertraline) as first-line therapy; other options include oral contraceptives, GnRH agonists, and lifestyle modifications (e.g., diet, exercise, stress management)
    4. Suicidal/homicidal behaviors

       Suicide is the 8th leading cause of death in the United States and the 3rd leading cause of death in ages 15-24 years.

       • In all age groups, male deaths by suicide outnumber female deaths 4 to 1.
       • Women attempt suicide 2 to 3 times more often than men; among girls aged 15 to 19 yr, there may be 100 attempts to every 1 attempt among boys of the same age.
       • On average, primary care providers encounter ≥ 6 potentially suicidal people in their practice each year. About 77% of people who die by suicide were seen by a healthcare provider within 1 yr before killing themselves, and about 32% had been under the care of a mental health care practitioner during the preceding year.

    5. Major depressive disorder with seasonal pattern (seasonal affective disorder)

       Major Depressive Disorder with Seasonal Pattern (seasonal affective disorder) is recurrent MDD in which episodes begin and fully remit at characteristic times of year — most commonly fall/winter onset with spring remission

       • Requires 2 consecutive years of seasonal episodes with no nonseasonal episodes, and seasonal episodes substantially outnumbering nonseasonal ones lifetime
       • Episodes show atypical features: hypersomnia, carbohydrate craving, and weight gain; more common in women and at higher latitudes
       • A specifier of MDD (or bipolar disorder) — not a standalone diagnosis; screen for bipolar before treating
       • Treatment: morning bright light therapy (10,000 lux) first-line; SSRIs and seasonal CBT equally effective; bupropion XL FDA-approved for prevention starting in early fall
       • Differential diagnoses include persistent depressive disorder with winter worsening, bipolar disorder with seasonal pattern, and hypothyroidism

11. Disruptive, impulse-control, and conduct disorders (PEARLS)
    1. Conduct disorder

       Conduct Disorder is diagnosed in children or adolescents who have demonstrated ≥ 3 of the following behaviors in the previous 12 mo plus at least 1 in the previous 6 mo:

       • Aggression toward people and animals
       • Destruction of property
       • Deceitfulness, lying, or stealing
       • Serious violations of parental rules
       • Symptoms or behaviors must be significant enough to impair functioning in relationships, at school, or at work.

       Oppositional Defiant Disorder (ODD) is diagnosed if children have had ≥ 4 of the following symptoms for at least 6 mo. Symptoms must also be severe and disruptive.

       • Lose their temper easily and repeatedly
       • Argue with adults
       • Defy adults
       • Refuse to obey rules
       • Deliberately annoy people
       • Blame others for their own mistakes or misbehavior
       • Be easily annoyed and angered
       • Be spiteful or vindictive
       • Many affected children also lack social skills.
12. Dissociative disorders

    Dissociative identity disorder

    • Presence of two or more distinct identities or personality states that recurrently take control of behavior

    Dissociative amnesia

    • Sudden and extensive inability to recall important personal and autobiographical information, usually of a traumatic or stressful nature

    Depersonalization/derealization disorder

    • Persistent feelings of detachment or estrangement from oneself
    1. Depersonalization/Derealization Disorder

       Depersonalization/Derealization Disorder is persistent or recurrent detachment from self ("outside observer") or surroundings ("flat, dreamlike, unreal") with intact reality testing

       • Intact reality testing — the patient knows it isn't real — is the discriminator from psychosis
       • Triggers: severe stress, panic, depression, and drugs (cannabis, hallucinogens, ketamine)
       • Transient symptoms are common and normal — the disorder requires persistence, distress, and impairment
       • Rule out temporal lobe epilepsy and substance effects
       • Treatment: CBT with grounding techniques first-line; treat comorbid anxiety/depression — no FDA-approved medication for the dissociation itself
       • Differential diagnoses include psychotic disorders, panic disorder, temporal lobe epilepsy, and substance intoxication
    2. Dissociative Amnesia

       Dissociative Amnesia is inability to recall important autobiographical information — usually traumatic — beyond ordinary forgetting, with preserved new learning

       • Dissociative fugue is a subtype specifier (travel or wandering with identity amnesia), not a separate diagnosis
       • Patterns: localized (most common) > selective > generalized (identity + life history — rare)
       • vs transient global amnesia: older patients, anterograde repetitive questioning, resolves < 24 h, no identity loss
       • Memory often returns spontaneously once the person is safe
       • Treatment: safety + supportive care, then trauma-focused psychotherapy; avoid suggestive "memory recovery" techniques (false-memory risk)
       • Differential diagnoses include TBI, seizures, transient global amnesia, substance blackouts, and malingering
    3. Dissociative Identity Disorder

       Dissociative Identity Disorder is disruption of identity with ≥ 2 distinct personality states plus recurrent amnesia gaps ("losing time") beyond ordinary forgetting

       • Near-universal severe childhood trauma — DID is a disorder of developmental trauma
       • Voices are internal with intact reality testing — the classic reason DID is misdiagnosed as schizophrenia (and why antipsychotics fail)
       • High comorbidity: PTSD, depression, self-harm — > 70% attempt suicide
       • Diagnosis is clinical; exclude substances, seizures, and cultural/religious practice
       • Treatment: phased trauma-focused psychotherapy (safety → trauma processing → integration) — long-term; medication only for comorbid symptoms
       • Differential diagnoses include PTSD, borderline personality disorder, schizophrenia, seizures, and malingering
13. Feeding and eating disorders (Lecture + ReelDx)

    Anorexia nervosa

    • Restricting type: Patients restrict food intake but do not regularly engage in binge eating or purging behavior; some patients exercise excessively.
    • Binge-eating/purging type: Patients regularly binge eat and then induce vomiting and/or misuse laxatives, diuretics, or enemas.
    • Anorexia nervosa can be distinguished from bulimia nervosa by BMI < 17 or body weight < 85% of ideal body weight.

    Bulimia nervosa

    • Frequent binge eating with or without purging
    • Purging commonly performed by self-induced vomiting resulting in metabolic alkalosis, urinary chloride < 20 mEq, and volume depletion
    • May abuse laxatives/diuretics  or exercise excessively
    • Patients are disturbed by their behavior
    • Binging and compensatory behaviors occur at least once a week for 3 months
    • On the exam look for these classic physical findings: scars on knuckles, swollen parotid glands + dental erosions + normal weight +hypokalemia

    Binge Eating Disorder

    • Recurrent binge eating at least once per week for 3 months
    • Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most people would eat in a similar period of time under similar circumstances.
    • A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
    • Binge eating episodes associated with three (or more) of following:
      • Eating rapidly, until uncomfortably full, large amounts when not hungry, alone out of embarrassment
      • Feeling disgusted/depressed/guilty afterward
    1. Other specified feeding or eating disorder (OSFED)

       Other Specified Feeding or Eating Disorder (OSFED) is clinically significant eating disorder symptomatology that does not meet full criteria for anorexia nervosa, bulimia nervosa, binge-eating disorder, or ARFID — among the most common eating disorder diagnoses in practice

       • Named presentations: atypical anorexia nervosa (all AN criteria at normal or above-normal weight), low-frequency/limited-duration bulimia or binge-eating disorder, purging disorder (purging without binges), and night eating syndrome
       • ⚠️ A normal BMI never rules out a dangerous eating disorder — bradycardia, electrolyte derangement, and amenorrhea follow rapid weight loss at any weight
       • Treatment: treat to the nearest full-criteria counterpart — CBT-E for adults, family-based treatment for adolescents, nutritional rehabilitation, and medical monitoring with refeeding precautions
       • Differential diagnoses include anorexia nervosa, bulimia nervosa, binge-eating disorder, ARFID, and medical causes of weight loss

14. Human sexuality (PEARLS)

    Sexual dysfunctions:

    • Delayed ejaculation
      • Marked delay, infrequency, or absence of ejaculation on almost all or all occasions (approximately 75%-100%) of partnered sexual activityand without the individual desiring delay for a minimum duration of approximately 6 months
    • Erectile disorder
      • Marked difficulty in obtaining or maintaining an erection until completion of sexual activity or a marked decrease in erectile rigidity on almost all or all (approximately 75%-100%) occasions of sexual activity for a minimum duration of approximately 6 months.
    • Female orgasmic disorder
      • Marked delay, infrequency, or absence of orgasm, or reduced intensity of orgasmic sensations on almost all or all (ap­proximately 75%-100%) occasions of sexual activity for a minimum duration of approximately 6 months.
    • Female sexual interest/arousal disorder
      • A female dysfunction marked by a persistent reduction or lack of interest in sex and low sexual activity, as well as, in some cases, limited excitement and few sexual sensations during sexual activity
    • Genito-pelvic pain/penetration disorder
      • A persistent condition, it's diagnosed by extreme pain or ongoing discomfort, usually while trying to have sex.
    • Male hypoactive sexual desire disorder
      • Persistently or recurrently deficient (or absent) sexual/erotic thoughts or fantasies and desire for sexual activity for a minimum duration of approximately 6 months
    • Premature (early) ejaculation
      • A persistent or recurrent pattern of ejaculation occurring during partnered sexual activ­ity within approximately 1 minute following vaginal penetration and before the individ­ual wishes it. It is experienced on almost all or all occasions (approximately 75%-100%) of partnered sexual activity and without the individual desiring delay for a minimum duration of approximately 6 months.
    • Substance/medication-induced sexual dysfunction
      • Substance-induced sexual dysfunction refers to a condition in both men and women in which patients have difficulties with sexual desire, arousal, and/or orgasm due to a side effect of certain medications(legal or illicit)

    Paraphilic disorders:

    • Voyeuristic disorder
      • A paraphilic disorder in which sexual arousal is derived from observing unsuspecting individuals undressing or naked
    • Exhibitionistic disorder
      • Sexual gratification attained by exposing genitals to unsuspecting strangers
    • Frotteuristic disorder
      • Sexual gratification attained by touching or rubbing against a nonconsenting individual
    • Sexual masochism disorder
      • Sexual gratification in response to undergoing humiliation, bondage, or suffering
    • Sexual sadism disorder
      • Sexual gratification in response to inflicting humiliation, bondage, or suffering
    • Pedophilic disorder
      • A paraphilic disorder in which a person has repeated and intense sexual urges or fantasies about watching, touching, or engaging in sexual acts with children, and either acts on these urges or experiences clinically significant distress or impairment
    • Fetishistic disorder
      • A paraphilic disorder consisting of recurrent and intense sexual urges, fantasies, or behaviors that involve the use of a nonliving object or nongenital part, often to the exclusion of all other stimuli, accompanied by clinically significant distress or impairment
    • Transvestic disorder
      • A condition in which there is persistent (at least 6 months), recurrent, and intense sexual arousal from wearing clothes associated with the opposite gender as evidenced by fantasies, urges, or behaviors

    1. Gender Dysphoria

       Gender Dysphoria is clinically significant distress from the incongruence between experienced gender and assigned sex — the identity itself is not a disorder

       • DSM-5 (adolescents/adults): incongruence ≥ 6 months with ≥ 2 of 6 manifestations plus distress or impairment
       • High comorbid depression, anxiety, and suicidality — driven substantially by minority stress; family acceptance is strongly protective
       • PA role: affirming primary care — chosen name/pronouns, comorbidity and safety screening, coordinated specialty referral (WPATH)
       • Medical interventions are individualized through multidisciplinary gender care teams
       • "Conversion" efforts are harmful and unethical — opposed by every major medical organization

    2. Gender Identity

       Gender Identity is a person's internal sense of gender — distinct from sex assigned at birth, gender expression, and sexual orientation (four independent concepts)

       • Terms: transgender (identity differs from assigned sex), cisgender (matches), nonbinary; core identity typically established by ages 3–4
       • Identity is not a mental disorder — only distress from incongruence (gender dysphoria) is diagnosable
       • Screen by anatomy present, not gender marker — cervical screening if a cervix, prostate remains in transgender women ("organ inventory")
       • Two-step intake (identity + sex assigned at birth) and consistent chosen name/pronoun use improve engagement and mental health
       • Know the disparities: elevated depression, suicidality, substance use, violence, and care avoidance after negative experiences
15. Neurodevelopmental disorders (PEARLS)
    1. Attention-Deficit/hyperactivity Disorder (ReelDx)

       Characterized by problems paying attention, excessive activity, or difficulty controlling behavior which is not appropriate for a person's age.

       • Hyperactivity, impulsivity, or inattentiveness manifesting prior to age 12 years.
       • > 6 symptoms of inattention, hyperactivity-impulsivity, developmentally inappropriate and duration of symptoms > 6 months
       • Symptoms must occur in more than one setting (example school and home)

       Treatment: Stimulants (methylphenidate, mixed amphetamine salts)
    2. Autism spectrum disorder

       Developmental delay in socialization, language, and cognition. Autism spectrum disorders (ASD) encompasses:

       • Autistic disorder - Disruption of social interaction and language at age 3 or earlier
       • Childhood disintegrative disorder
       • Pervasive developmental disorder-not otherwise specified
       • Asperger disorder - A child has normal cognitive development, poor relationships and does not spontaneously seek activities with others - Asperger disorder

       DSM V criteria

       • Social communication and social interaction deficit in many contexts such as
         • Lack of social-emotional reciprocity
         • Lack of nonverbal communicative behaviors
         • Impairment in developing, maintaining, and understanding relationships
       • Restricted and repetitive patterns of behavior, interests, or activities such as
         • Motor movements that are stereotyped or repetitive (e.g., flipping objects)
         • Inflexibility to change
         • Restricted and fixated interests - these are typically with abnormal intensity or focus
         • Hyper- or hyporeactivity or unusual interest in a sensory stimulus (e.g., fascination with lights)
       • These symptoms must be present in the patient's early developmental period in the absence of an organic etiology (e.g., hearing dysfunction)
       • These symptoms cannot be better explained by other conditions (e.g., intellectual developmental disorder)

       Treatment:

       • Refer – autism specialists, speech & language pathologist
       • Second generation antipsychotics(risperidone, aripiprazole) for aggression/hyperactivity, mood lability; can also use haloperidol, carbamazepine
       • SSRIs for stereotyped/repetitive behavior
16. Obsessive-compulsive and related disorders (PEARLS)

    Obsessive-compulsive disorder

    • Repetitive thoughts (obsessions) or behaviors (compulsions) that are disabling and cause anxiety or distress

    Body Dysmorphic Disorder

    • Obsession with some perceived/imagined flaw or flaws in one's appearance

    Hoarding Disorder

    • Persistent difficulty discarding or parting with possessions, regardless of their actual value

    Trichotillomania (Hair-Pulling Disorder)

    • An impulse-control disorder involving the compulsive, persistent urge to pull out one's own hair

    Excoriation (Skin-Picking) Disorder

    • Distressing and recurrent compulsive picking of the skin resulting in skin lesions

     

17. Personality Disorders (Lecture)

    • Histrionic: Attention seeker, overly emotional.
    • Schizotypal: Discomfort with social and interpersonal relationships. Odd, eccentric behavior.
    • Schizoid: Inability to form and maintain meaningful personal relationships. Neither desires nor enjoys close relationships, including being part of a family.
    • Borderline: Poor impulse control, poor self-image, unstable interpersonal relationships.
    • Narcissistic: Need for admiration, grandiose thoughts, concerned about what others think yet lack empathy.
    • Anti-social: No concern for others, neglect of dependents, lack of remorse, morals or empathy.
    • Obsessive-Compulsive: Preoccupation with perfectionism attempts to control interpersonal relationships, obsessive thought and performance of compulsions impede daily functioning.
    • Paranoid: Persistent feelings of suspiciousness and mistrust of other people.
    • Dependent: Characterized by behaviors demonstrating an excessive need to be taken care of.
    • Avoidant: A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts.
18. Psychogenic nonepileptic seizure
19. Schizophrenia spectrum and other psychotic disorders (Lecture)

    > 2 of the following in a 1 month period and continuous signs for >6 months; hallucinations/delusions not needed for dx

    • Delusions
    • Hallucinations - auditory (most common), tactile olfactory visual
    • Disorganized speech/thought processes unable to stay on topic (loose associations) unable to provide answer related to questions (tangential response)
    • Symptoms impair daily functioning
    • Disorganized behavior - unpredictable agitation, inappropriate sexual behavior, child-like silliness, catatonic motor behavior, lacking self-care/hygiene
    • Negative symptoms - blunted affect, poor posture, lack goal-directed activities/initiative
    • Impairment inability to hold job or maintain relationships

    Treatment: Hospitalize if suicidal, unable to care for self, pose threat to self/others

    • 1st line- serotonin & dopamine antagonists (SDAs); (risperidone, olanzapine, aripiprazole, ziprasidone, quetiapine, asenapine, paliperidone) for negative symptoms & fewer side effects

20. Sleep-wake disorders (Pearls)
    1. Narcolepsy

       • Presents with a classic tetrad:
         • Excessive daytime sleepiness: naps can be refreshing
         • Hallucination: Hypnagogic (just before sleep) and Hypnopompic (just before waking)
         • Cataplexy: loss of muscle tone following strong emotional stimulus
         • Sleep paralysis: short paralysis with awakening.
       • Caused by: hypocretin deficiency in lateral hypothalamus (per DSM-V)
       • Diagnosed with polysomnography 
       • Treatment: modafinil (Provigil), methylphenidate (Ritalin), or amphetamines
    2. Parasomnias

       Parasomnias are characterized by NREM sleep arousal disorder, nightmare sleep disorder, and REM sleep behavior disorder. Characterized by abnormal behaviors, experiences, or feelings while sleeping, during specific sleep stages, or as individuals wake up

       • NREM Sleep Arousal Disorders (sleepwalking and sleep terrors):
         • Sleepwalking: A phenomenon primarily occurring in non-REM sleep in which people walk while asleep
         • Sleep Terrors: frightening dreamlike experiences that occur during the first third stage of deep slow-wave non-REM sleep, shortly after the child has gone to sleep
       • Nightmare disorder: a type of sleep-wake disorder involving a pattern of frequent, disturbing nightmares  occurring in the last third of REM sleep
       • REM sleep behavior disorders: move a lot while sleeping and reenacting violent nightmares with the possibility of hurting themselves (falling out of bed)
         • Polysomnographic evidence of episodes of arousal or stimulation during sleep, vocalization (talking, screaming), or movement (hitting, kicking)
         • Episodes happen during REM sleep
         • When individuals awaken they feel alert and well oriented
         • During polysomnography recordings muscles don't have atonia during REM sleep or if atonia it is due to neurodegenerative disease (e.g. Parkinson's)
    3. Circadian Rhythm Sleep-Wake Disorders

       Circadian Rhythm Sleep-Wake Disorders are misalignment between the internal clock and the required schedule — sleep is normal and refreshing on the patient's own preferred timing

       • Types: delayed phase (adolescent night owl), advanced phase (older early risers), shift work, jet lag, non-24 (totally blind), irregular (neurodegeneration)
       • Diagnosis: sleep diary + actigraphy for 7–14 days — polysomnography not routinely needed
       • Treatment: timed low-dose evening melatonin + morning bright light for delayed phase; evening light for advanced phase
       • Shift work: strategic naps, light management; modafinil FDA-approved for severe residual sleepiness; tasimelteon for non-24
       • Differential diagnoses include insomnia disorder, hypersomnolence, obstructive sleep apnea, and poor sleep hygiene
    4. Hypersomnolence Disorder

       Hypersomnolence Disorder is excessive sleepiness despite ≥ 7 hours of sleep — long, unrefreshing sleep with "sleep drunkenness" on waking, ≥ 3×/week for ≥ 3 months

       • Unrefreshing naps + no cataplexy + < 2 SOREMPs on MSLT separates it from narcolepsy (short refreshing naps, cataplexy, ≥ 2 SOREMPs)
       • Exclude first: insufficient sleep, OSA, depression, sedating medications, substances
       • Workup: Epworth scale → polysomnography + MSLT (mean latency ≤ 8 min, < 2 SOREMPs)
       • Treatment: modafinil first-line; low-sodium oxybate FDA-approved (2021) for idiopathic hypersomnia; stimulants alternative; scheduled naps do NOT refresh
       • Differential diagnoses include narcolepsy, OSA, insufficient sleep syndrome, depression, and circadian rhythm disorders
    5. Insomnia Disorder

       Insomnia Disorder is dissatisfaction with sleep — difficulty initiating, maintaining, or early-morning waking — ≥ 3 nights/week for ≥ 3 months despite adequate opportunity, with daytime impairment

       • Diagnosis is clinical (history + sleep diary) — polysomnography is NOT routine, reserved for suspected OSA or PLMD
       • Screen for drivers: OSA, depression/anxiety, caffeine/alcohol/stimulants, restless legs, circadian misalignment
       • CBT-I is first-line — before any medication: stimulus control, sleep restriction, cognitive restructuring
       • If medication is added: low-dose doxepin, ramelteon, or a dual orexin receptor antagonist (suvorexant, lemborexant, daridorexant); avoid chronic benzodiazepines/Z-drugs in older adults (Beers)
       • Differential diagnoses include OSA, circadian rhythm disorders, restless legs syndrome, depression, and substance-induced sleep disturbance
21. Somatic symptom and related disorders (PEARLS)

    • Somatization disorder: Vague physical complaints involving many organ systems not explained by a medical condition or substance use.
    • Conversion disorder: >1 neurological complaints not explained by medical/neuro disorder.
    • Hypochondriasis: Preoccupation with belief/fear of having/contracting a serious disease.
    • Body dysmorphic disorder: Preoccupation with an imagined defect in physical appearance/exaggerated distortion of a minor flaw.
    • Pain disorder: Pain in >1 areas with no known cause.
22. Substance-related and addictive disorders (ReelDx)

    Substance-Related and Addictive Disorders involve the compulsive use of substances despite harmful consequences, resulting in significant impairment, distress, or both. They include substance dependence (tolerance and withdrawal) and substance abuse (harmful use without dependence).

    • Alcohol-Related Disorders
      • Alcohol Use Disorder is a problematic pattern of alcohol use causing clinically significant impairment or distress, typically over a 12-month period.

    • • Symptoms include craving, loss of control, continued use despite problems, tolerance, and withdrawal
      • Withdrawal symptoms: tremors, anxiety, seizures, delirium tremens (DTs)
      • Treatment: Benzodiazepines for withdrawal, naltrexone or acamprosate for maintenance; disulfiram for aversion therapy
    • Cannabis-Related Disorders
      • Cannabis Use Disorder involves recurrent use causing impairment or distress, with features such as:
      • Impaired coordination, anxiety, social withdrawal, and amotivational syndrome
      • Withdrawal symptoms: irritability, sleep disturbance, decreased appetite, anxiety
      • Treatment is primarily supportive, with behavioral therapies
    • Hallucinogen-Related Disorders
      • Includes PCP (phencyclidine) and LSD (lysergic acid diethylamide)
      • PCP: dissociation, violent behavior, nystagmus, hallucinations, psychosis; may lead to dangerous agitation
      • LSD: visual hallucinations, synesthesia, anxiety, panic attacks
      • No physical dependence, but psychological dependence can occur
      • Treatment: benzodiazepines for agitation, antipsychotics if needed for severe psychosis
    • Inhalant-Related Disorders
      • Result from inhaling volatile solvents like glues, paint thinners, toluene, or nail polish remover
      • Effects mimic CNS depressants: euphoria, dizziness, slurred speech, ataxia
      • High risk in adolescents due to ease of access
      • Sudden sniffing death syndrome from cardiac arrhythmias is a fatal complication
      • Treatment is primarily supportive, with long-term psychosocial intervention
    • Opioid-Related Disorders
      • Includes heroin, morphine, codeine, methadone, and prescription opioids
      • Effects: euphoria, respiratory depression, miosis, drowsiness
      • Withdrawal symptoms: yawning, lacrimation, rhinorrhea, diarrhea, myalgias—not life-threatening but intensely uncomfortable
      • Treatment:
        • Acute overdose: naloxone
        • Long-term: methadone, buprenorphine, or naltrexone for maintenance
    • Sedative, Hypnotic, or Anxiolytic-Related Disorders
      • Includes benzodiazepines and barbiturates
      • Effects: CNS depression, drowsiness, confusion, slurred speech
      • Withdrawal can be life-threatening: seizures, tremors, agitation, insomnia
      • Treatment: Gradual tapering with long-acting benzodiazepines (e.g., clonazepam)
    • Stimulant-Related Disorders
      • Includes cocaine, methamphetamines, MDMA (Ecstasy), methylphenidate
      • Cocaine: euphoria, increased energy, mydriasis, chest pain, paranoia, risk of MI or stroke
      • MDMA: empathy, euphoria, hyperthermia, hyponatremia, serotonin syndrome
      • Amphetamines: alertness, decreased appetite, insomnia, agitation, psychosis
      • Withdrawal: fatigue, hypersomnia, depression, increased appetite (not life-threatening)
      • Treatment: supportive care, antipsychotics if needed, behavioral therapy for dependence
    • Tobacco-Related Disorders
      • Nicotine Use Disorder is marked by dependence on tobacco, most commonly through smoking
      • Withdrawal: irritability, anxiety, increased appetite, difficulty concentrating
      • Treatment includes:
        • Nicotine replacement therapy (NRT) (patch, gum, lozenges)
        • Bupropion (also helps with depression)
        • Varenicline (Chantix): partial nicotine receptor agonist

    1. Non-substance-related addictive disorders (PANRE) (Lecture)

       Non-substance-related addictive disorders (also known as behavioral addictions) include conditions like gambling disorder, internet gaming disorder, and compulsive shopping

       • Etiology: Multifactorial, involving genetic, neurobiological, and environmental factors
       • Symptoms include compulsive engagement, loss of control, withdrawal symptoms, and negative consequences
       • Diagnosis is based on clinical evaluation and DSM-5 criteria—include persistent and recurrent problematic behavior, significant impairment or distress, and at least four of eight diagnostic criterion
       • Treatment involves CBT, motivational interviewing, support groups, and sometimes pharmacotherapy for comorbid conditions

23. Trauma and stressor-related disorders (PEARLS)
    1. Acute stress disorder (ASD) (PANRE) (Lecture)

       Acute Stress Disorder (ASD) is a period of intrusive recollections that occurs after witnessing or experiencing a traumatic event

       • Occurs within one month of the traumatic event and lasts from three days up to one month
       • Symptoms include intrusive memories, flashbacks, nightmares, and severe anxiety
       • Avoidance of reminders of the trauma and hyperarousal (e.g., difficulty sleeping, irritability)
       • Dissociative symptoms such as feeling detached from oneself or reality
       • Differentiates from Posttraumatic Stress Disorder (PTSD), which has similar symptoms but lasts MORE than one month
       • Diagnosis is clinical, based on history and symptom criteria
       • Treatment includes cognitive-behavioral therapy (CBT), supportive counseling, and in some cases, short-term pharmacotherapy (e.g., benzodiazepines for acute anxiety)
    2. Adjustment disorders

       Disproportionate response to a stressor than would normally be expected (ex. job loss, physical illness) which begins within 3 months of the stressful event. Remission of symptoms usually within 6 months

       • Stressors:
         • Marital conflict
         • Financial conflict
         • Family conflict/parental separation
         • School problems/changing schools
         • Sexuality issues
         • Death/illness in the family
       • Treatment is psychotherapy
    3. Bereavement/Grief reaction

       Bereavement refers to the normal process of grieving and coping with the loss of a loved one, distinguished from pathological grief or depressive disorders

       • Symptoms include intense sadness, crying, difficulty concentrating, loss of appetite, insomnia, and feelings of emptiness or yearning for the deceased
       • Typically peaks within the first 6 months but can vary in duration; most individuals adapt over time without clinical intervention
       • Complicated grief (Prolonged Grief Disorder) is characterized by persistent, intense longing, preoccupation with the deceased, AND functional impairment lasting >12 months
       • Differentiation from Major Depressive Disorder (MDD): Bereavement-related grief may involve transient guilt, self-esteem preservation, and ability to feel joy, unlike MDD, which includes persistent worthlessness, hopelessness, and anhedonia
       • Risk factors for complicated grief include sudden or traumatic loss, lack of social support, history of mental health disorders, or dependence on the deceased

       TX:

       • Normal grief: Supportive care, including empathy, active listening, and encouraging healthy coping mechanisms (e.g., journaling, therapy)
       • Complicated grief: Grief-specific psychotherapy (e.g., Cognitive Behavioral Therapy), and in severe cases, antidepressants (e.g., SSRIs) may be considered for co-occurring depression or anxiety

       Prognosis: Most individuals recover without long-term complications, but untreated complicated grief can lead to depression, substance use disorders, or impaired functioning
    4. Post-traumatic stress disorder

       The patient has experienced a traumatic event which causes an acute stress reaction. Once the symptoms persist past 1 month it is now considered post-traumatic stress disorder (PTSD)

       • SSRIs are first line
       • Cognitive Behavioral Therapy (CBT)
       • Prazosin for nightmares
       • Benzodiazepines, if used, should not be continued more than 2 weeks after a traumatic event