Psychiatry and Behavioral Health Rotation

Lessons

1. Psychiatry and Behavioral Health Rotation (EOR) Exam Topic List
2. Psychiatry Rotation Exam

3. Psychiatry EOR: Depressive Disorders and Bipolar Related Disorders (PEARLS)
   1. Psychiatry EOR: Bipolar I disorder (Lecture)

      Bipolar I Disorder is a mood disorder characterized by at least one manic episode, with or without depressive episodes, causing marked impairment in functioning.

      • Bipolar I = Mania (with or without depression)
      • Manic episodes involve elevated, expansive, or irritable mood lasting ≥1 week (or any duration if hospitalization is required), with symptoms like grandiosity, decreased need for sleep, pressured speech, flight of ideas, distractibility, increased goal-directed activity, and risky behaviors
      • May alternate with major depressive episodes, but depression is not required for diagnosis
      • Impairment may include hospitalization, psychosis, or occupational and social dysfunction
      • Diagnosis is clinical, based on DSM-5 criteria; rule out substance use and medical causes
      • Treatment involves mood stabilizers (e.g., lithium, valproate) or atypical antipsychotics (e.g., quetiapine, olanzapine)
      • Antidepressants should be used cautiously and only in combination with a mood stabilizer to avoid triggering mania
      • Psychotherapy and psychoeducation are important adjuncts for long-term management
      • Hospitalization may be necessary during acute manic or mixed episodes, especially if there is a risk of harm to self or others
   2. Psychiatry EOR: Bipolar II disorder

      Bipolar II Disorder is a mood disorder characterized by recurrent episodes of major depression and hypomania, without any full manic episodes.

      • Low-level mania with profound depression; no psychosis
      • Remember that bipolar II is depression > mania because depression is twice as big a word as mania
      • Hypomania involves elevated or irritable mood, increased energy, and goal-directed activity lasting at least 4 consecutive days, but without psychosis or severe impairment
      • Major depressive episodes are often more frequent and disabling than in Bipolar I, with symptoms such as sadness, anhedonia, fatigue, sleep/appetite changes, and suicidal ideation
      • Patients never experience full manic episodes—this differentiates Bipolar II from Bipolar I
      • Often misdiagnosed as major depressive disorder, especially if hypomanic episodes are not reported
      • Diagnosis is clinical, based on DSM-5 criteria, and requires at least one hypomanic and one major depressive episode
      • Mood stabilizers (e.g., lithium, lamotrigine, valproate) are first-line treatment; antidepressants should be used cautiously due to the risk of triggering hypomania
      • Psychotherapy (especially CBT and psychoeducation) improves medication adherence and helps with mood regulation
      • Suicide risk is elevated—monitor closely, especially during depressive episodes
   3. Psychiatry EOR: Cyclothymic disorder

      Cyclothymic Disorder is a chronic mood disorder characterized by recurrent periods of mild hypomanic symptoms and mild depressive symptoms that do not meet full criteria for hypomania or major depression.

      • Symptoms must be present for at least 2 years (1 year in children/adolescents), with numerous episodes of subthreshold mood swings
      • Patients are symptom-free for no more than 2 months at a time
      • Mood shifts are persistent, causing social or occupational impairment, but not severe enough to qualify as bipolar I or II
      • Diagnosis is clinical, based on history and exclusion of other mood disorders, substance use, or medical causes
      • Treatment includes mood stabilizers (e.g., lithium, lamotrigine), anticonvulsants, and psychotherapy, particularly CBT for improving coping strategies
      • Early identification is important to prevent progression to full bipolar disorder
      • Differential diagnoses include bipolar I/II disorder, borderline personality disorder, and substance-induced mood disorder
   4. Psychiatry EOR: Major depressive disorder (Lecture)

      Major Depressive Disorder (MDD) is a mood disorder characterized by persistent low mood, loss of interest or pleasure, and functional impairment

      • Depressed mood or anhedonia + SIGECAPS ≥2 weeks
      • Diagnosis requires ≥2 weeks of depressed mood or anhedonia, PLUS at least five total symptoms from: sleep disturbance, interest loss, guilt/worthlessness, energy loss, concentration problems, appetite changes, psychomotor changes, or suicidal ideation (SIGECAPS)
      • Symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
      • Risk factors include family history, prior episodes, chronic illness, substance use, and psychosocial stressors
      • Screening tools include the PHQ-9 and Beck Depression Inventory
      • First-line treatment includes SSRIs (e.g., sertraline, fluoxetine), SNRIs, or psychotherapy (CBT)
      • Combination therapy (medication + psychotherapy) is often more effective for moderate to severe cases
      • Treatment-resistant depression may require augmentation with atypical antipsychotics, electroconvulsive therapy (ECT), or newer options like ketamine/esketamine
      • Monitoring for suicide risk is critical, especially in early treatment stages
      • Prognosis is good with treatment, though relapse is common; maintenance therapy may be needed after multiple episodes
   5. Psychiatry EOR: Persistent depressive disorder (dysthymia) (Lecture)

      Persistent Depressive Disorder (PDD) is a chronic form of depression characterized by a depressed mood lasting at least 2 years in adults (1 year in children/adolescents).

      • Symptoms are milder but more persistent than major depressive disorder (MDD), and may include low energy, poor concentration, low self-esteem, hopelessness, poor appetite or overeating, and sleep disturbances
      • Patients often describe themselves as being “down most of the time”, with symptoms present most days for at least 2 years, without a symptom-free period longer than 2 months
      • Frequently underdiagnosed due to the insidious, long-standing nature of symptoms
      • Can be comorbid with MDD (called "double depression") or anxiety disorders
      • Diagnosis is clinical, based on DSM-5 criteria; important to rule out bipolar disorder, substance use, or medical causes
      • First-line treatment includes psychotherapy (especially CBT) and antidepressants (SSRIs or SNRIs)
      • Long-term follow-up and support are crucial due to the chronic nature of the illness

4. Psychiatry EOR: Anxiety Disorders; Trauma and Stress Related Disorders (Pearls)

   1. Psychiatry EOR: Generalized anxiety disorder (Lecture)

      Generalized Anxiety Disorder (GAD) is a chronic mental health condition characterized by excessive, persistent worry about various aspects of daily life.

      • Symptoms include restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbances lasting ≥6 months
      • The anxiety is difficult to control and occurs on most days about multiple events or activities
      • Often coexists with depression, other anxiety disorders, or substance use
      • Diagnosis is clinical and based on DSM-5 criteria; screening tools like the GAD-7 questionnaire may assist in assessment
      • First-line treatment includes cognitive behavioral therapy (CBT) and/or SSRIs (e.g., sertraline, escitalopram) or SNRIs (e.g., venlafaxine)
      • Buspirone may be used as an alternative or adjunct; benzodiazepines are effective short-term but not recommended for long-term use due to dependency risk
      • Lifestyle modifications, including exercise, mindfulness, stress management, and adequate sleep, play a supportive role in treatment
      • Prognosis is favorable with appropriate treatment, but symptoms may wax and wane over time
   2. Psychiatry EOR: Panic disorder (Lecture)

      Panic Disorder is a psychiatric condition characterized by recurrent, unexpected panic attacks and persistent concern about having additional attacks or their consequences.

      • Panic attacks are sudden episodes of intense fear or discomfort that peak within minutes and include symptoms such as palpitations, chest pain, shortness of breath, dizziness, sweating, trembling, nausea, and fear of losing control or dying
      • Attacks occur unexpectedly, not triggered by a specific stimulus (unlike phobias)
      • Diagnosis requires recurrent unexpected panic attacks (≥1) followed by at least 1 month of persistent concern about additional attacks, worry about implications, or significant maladaptive behavioral change
      • Often associated with agoraphobia (fear of situations where escape might be difficult), though not always present
      • Rule out medical causes (e.g., myocardial infarction, hyperthyroidism, arrhythmias) with appropriate workup before diagnosis
      • First-line treatment includes cognitive-behavioral therapy (CBT) and SSRIs (e.g., sertraline, paroxetine)
      • Benzodiazepines (e.g., lorazepam, clonazepam) may be used short-term for acute relief, but long-term use is discouraged due to dependency risk
      • Prognosis is favorable with proper treatment, though recurrence is common without ongoing therapy
   3. Psychiatry EOR: Phobic disorders

      Phobic Disorders are a type of anxiety disorder characterized by an excessive, persistent, and irrational fear of specific objects, situations, or activities, leading to avoidance behavior.

      • Specific Phobia: Fear is triggered by a particular object or situation (e.g., heights, animals, flying, injections)
      • Social Anxiety Disorder (Social Phobia): Fear of social or performance situations where the individual fears embarrassment or judgment
      • Agoraphobia: Fear of being in places where escape might be difficult (e.g., public transportation, open spaces, crowds), often associated with panic disorder
      • Symptoms include intense fear or anxiety, physical symptoms (e.g., palpitations, sweating, nausea), and avoidance behavior that interferes with daily functioning
      • Diagnosis is clinical, based on DSM-5 criteria, requiring symptoms to persist for 6 months or more and cause significant impairment
      • Treatment:
        • First-line: Cognitive Behavioral Therapy (CBT) with exposure therapy
        • Pharmacologic options: SSRIs or SNRIs for social anxiety and agoraphobia; beta-blockers (e.g., propranolol) may be used for performance anxiety
      • Prognosis is good with treatment, but without intervention, symptoms often persist or worsen over time

      1. Psychiatry EOR: Specific phobias

         Specific Phobias are intense, irrational fears of a specific object, situation, or activity that is actively avoided or endured with significant distress.

         • Common subtypes include fear of animals (e.g., spiders, dogs), natural environment (e.g., storms, heights), blood/injection/injury, situational (e.g., flying, elevators), and others (e.g., choking, loud sounds)
         • Onset is usually in childhood or adolescence, and the fear is out of proportion to actual danger
         • Exposure triggers an immediate anxiety response, which may include panic symptoms
         • The fear leads to avoidance behavior, causing functional impairment or significant distress
         • Diagnosis is clinical, based on DSM-5 criteria, requiring symptoms to persist for 6 months or more
         • Treatment of choice is exposure-based cognitive behavioral therapy (CBT), which involves systematic desensitization
         • Pharmacotherapy (e.g., benzodiazepines or beta-blockers) may be used short-term for situational triggers (e.g., fear of flying), but not first-line
         • Prognosis is excellent with proper therapy; early intervention improves outcomes
   4. Psychiatry EOR: Post-traumatic stress disorder

      Post-Traumatic Stress Disorder (PTSD) is a psychiatric condition that develops after exposure to a traumatic event involving actual or threatened death, serious injury, or sexual violence.

      • 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)
        • Acute Stress Disorder (ASD) occurs within one month of the traumatic event and lasts from three days up to one month, whereas PTSD symptoms must last more than one month!

      • Common causes include military combat, physical or sexual assault, accidents, natural disasters, and witnessing traumatic events
      • Core symptom clusters:
        • Intrusion: Recurrent, involuntary flashbacks, nightmares, and distressing memories
        • Avoidance: Efforts to avoid reminders of the trauma, including thoughts, feelings, people, or places
        • Negative mood and cognition changes: Emotional numbness, guilt, detachment, or distorted blame
        • Hyperarousal: Irritability, insomnia, exaggerated startle response, hypervigilance
      • Symptoms must persist for more than 1 month and cause significant functional impairment
      • Diagnosis is clinical, based on DSM-5 criteria; screening tools like the PCL-5 are often used
      • First-line treatment includes trauma-focused cognitive behavioral therapy (CBT) and SSRIs (e.g., sertraline, paroxetine)
      • Other options include EMDR (eye movement desensitization and reprocessing) and prazosin for nightmares
      • Avoid benzodiazepines, as they can worsen symptoms and increase risk of dependence
      • Early intervention, social support, and ongoing therapy improve outcomes and reduce long-term disability
5. Psychiatry EOR: Substance-Related Disorders (Pearls)

   1. Psychiatry EOR: Alcohol-related disorders (ReelDx)

      Alcohol-Related Disorders encompass a spectrum of conditions caused by excessive alcohol use, including acute intoxication, withdrawal, dependence, and alcohol-related organ damage.

      • Alcohol use disorder (AUD) is diagnosed based on impaired control, social impairment, risky use, and physiologic dependence; severity is determined by the number of criteria met (DSM-5)
      • Alcohol intoxication presents with slurred speech, incoordination, unsteady gait, nystagmus, and impaired judgment
      • Alcohol withdrawal symptoms begin within 6–24 hours after last drink and can progress from tremors, anxiety, tachycardia to seizures, hallucinations, and delirium tremens (DTs)—a medical emergency
      • Delirium tremens occurs 48–96 hours after cessation and presents with confusion, agitation, autonomic instability, and hallucinations; treated with IV benzodiazepines and supportive care
      • Chronic alcohol use is associated with liver disease (e.g., cirrhosis), pancreatitis, gastritis, cardiomyopathy, neuropathy, and Wernicke-Korsakoff syndrome (thiamine deficiency)
      • Screening tools include AUDIT and CAGE questionnaire
      • Treatment of AUD includes motivational interviewing, cognitive behavioral therapy, and pharmacotherapy (e.g., naltrexone, acamprosate, disulfiram)
      • Thiamine should always be given before glucose in suspected Wernicke's encephalopathy to prevent worsening symptoms
   2. Psychiatry EOR: Cannabis-related disorders

      Cannabis-Related Disorders refer to problematic patterns of cannabis use that lead to clinical impairment or distress, including intoxication, withdrawal, and cannabis use disorder.

      • Cannabis Use Disorder involves compulsive use, craving, tolerance, and continued use despite harm; associated with impaired social, occupational, or academic performance
      • Cannabis intoxication presents with euphoria, relaxation, dry mouth, increased appetite, impaired coordination and short-term memory, and tachycardia
      • High doses can cause paranoia, anxiety, hallucinations, or psychosis, especially in susceptible individuals
      • Cannabis withdrawal includes irritability, anxiety, sleep disturbances, decreased appetite, and depressed mood; symptoms peak within 1 week of cessation
      • Long-term use is associated with amotivational syndrome, cognitive impairment, and in adolescents, increased risk of psychosis
      • Diagnosis is clinical, based on DSM-5 criteria for cannabis use disorder or related syndromes
      • Treatment includes motivational interviewing, cognitive-behavioral therapy, and supportive care; no FDA-approved medications, but symptom-targeted treatment (e.g., sleep aids, anxiolytics) may help during withdrawal
      • Urine drug screen can detect THC metabolites for up to 30 days in chronic users
   3. Psychiatry EOR: Hallucinogen-related disorders

      Hallucinogen-Related Disorders are psychiatric conditions caused by the use of substances that alter perception, mood, and cognition, most commonly LSD, psilocybin (magic mushrooms), PCP, and mescaline.

      • Symptoms include visual and auditory hallucinations, distorted time perception, euphoria, paranoia, depersonalization, and anxiety
      • PCP (phencyclidine) is associated with violent behavior, nystagmus, hypertension, muscle rigidity, and dissociation
      • "Bad trips" can lead to acute panic, psychosis, or dangerous behavior
      • Hallucinogen Persisting Perception Disorder (HPPD) involves flashbacks or perceptual disturbances long after drug use
      • Diagnosis is clinical and based on history of use, with urine toxicology sometimes useful (especially for PCP)
      • Management includes supportive care in a calm, low-stimulation environment; benzodiazepines may be used for severe agitation or anxiety
      • Antipsychotics are avoided with PCP, as they may lower seizure threshold or worsen symptoms
      • Long-term complications include persistent mood disorders, psychosis, or cognitive impairment in chronic users
   4. Psychiatry EOR: Inhalant-related disorders

      Inhalant-Related Disorders involve the intentional inhalation of volatile substances to achieve euphoria, leading to acute and chronic neurotoxic effects.

      • Common inhalants include glue, paint thinners, aerosol sprays, gasoline, nitrous oxide, and cleaning agents
      • Most often affects adolescents and young adults, especially those in low-resource environments
      • Acute effects include euphoria, dizziness, slurred speech, hallucinations, ataxia, and disinhibition; can progress to loss of consciousness or sudden sniffing death due to cardiac arrhythmias
      • Chronic use leads to cognitive impairment, peripheral neuropathy, liver and kidney damage, hearing loss, and bone marrow suppression
      • Signs of use may include chemical odors, paint stains around mouth or nose, perinasal rash, and mood/behavioral changes
      • Diagnosis is clinical, based on history, symptoms, and physical findings; standard drug screens may not detect many inhalants
      • Management includes supportive care, oxygen therapy, and cardiac monitoring in acute intoxication; long-term treatment involves behavioral therapy, counseling, and addressing psychosocial factors
      • No FDA-approved medications for treatment; relapse prevention focuses on psychosocial support and substance use counseling
      • Complications include sudden death, brain atrophy, and long-term neurocognitive deficits
   5. Psychiatry EOR: Opioid-related disorders

      Opioid-Related Disorders encompass a spectrum of conditions resulting from the misuse, dependence, or withdrawal from opioid medications or illicit opioids.

      • Common opioids include heroin, morphine, oxycodone, fentanyl, hydrocodone, and methadone
      • Opioid use disorder (OUD) is characterized by compulsive use, loss of control, and continued use despite harm
      • Clinical features of intoxication include euphoria, miosis (pinpoint pupils), respiratory depression, bradycardia, and decreased level of consciousness
      • Overdose is a medical emergency—marked by respiratory depression, unconsciousness, and constricted pupils; can be reversed with naloxone (Narcan)
      • Withdrawal symptoms include anxiety, lacrimation, rhinorrhea, yawning, sweating, abdominal cramps, diarrhea, piloerection, and mydriasis
      • Diagnosis is clinical, based on history, physical exam, and urine toxicology screening
      • Treatment of OUD includes:
        • Medication-Assisted Treatment (MAT) with buprenorphine-naloxone (Suboxone), methadone, or naltrexone
        • Behavioral therapy, support groups, and psychosocial support
      • Harm reduction strategies include needle exchange programs, naloxone distribution, and safe consumption sites
      • Complications include infective endocarditis, HIV, hepatitis C, and overdose death if untreated
   6. Psychiatry EOR: Sedative, Hypnotic, or anxiolytic-related disorders

      Sedative, Hypnotic, or Anxiolytic-Related Disorders involve problematic use of substances like benzodiazepines, barbiturates, and sleep aids, leading to intoxication, dependence, or withdrawal.

      • Common agents: Benzodiazepines (e.g., diazepam, alprazolam), barbiturates, and Z-drugs (e.g., zolpidem)
      • Symptoms of intoxication: Drowsiness, slurred speech, ataxia, impaired judgment, and respiratory depression; symptoms may resemble alcohol intoxication
      • Withdrawal symptoms include anxiety, tremors, insomnia, diaphoresis, seizures, and delirium, especially with abrupt discontinuation after prolonged use
      • Diagnosis is clinical but may be supported by urine drug screening
      • Management of intoxication includes airway protection and supportive care; flumazenil is a benzodiazepine antagonist but is rarely used due to seizure risk
      • Withdrawal treatment involves gradual tapering of the drug, often using a long-acting benzodiazepine (e.g., diazepam or clonazepam) to prevent complications
      • Chronic use may be associated with cognitive impairment, falls (especially in elderly), and substance use disorder
      • Behavioral therapy and addiction support programs are essential for long-term management
   7. Psychiatry EOR: Stimulant-related disorders

      Stimulant-Related Disorders refer to the problematic use of stimulant substances such as amphetamines, methamphetamine, cocaine, or prescription stimulants (e.g., methylphenidate) that lead to clinically significant impairment or distress.

      • Acute intoxication presents with euphoria, hyperactivity, agitation, tachycardia, hypertension, mydriasis, and paranoia; severe cases may include cardiac arrhythmias, seizures, or psychosis
      • Chronic use can lead to weight loss, insomnia, mood disturbances, anxiety, and formication (sensation of bugs crawling on the skin)
      • Cocaine is a potent dopamine reuptake inhibitor, associated with myocardial infarction, stroke, and sudden death
      • Methamphetamine use is associated with violent behavior, severe dental decay (“meth mouth”), and long-term cognitive impairment
      • Withdrawal symptoms include fatigue, depression, hypersomnia, increased appetite, and cravings, but are not life-threatening
      • Diagnosis is clinical, supported by toxicology screening in urine or blood
      • Management of acute intoxication includes benzodiazepines for agitation, cooling measures for hyperthermia, and cardiac monitoring for arrhythmias
      • Treatment of stimulant use disorder involves behavioral therapy (CBT), motivational interviewing, and contingency management; no FDA-approved medications currently exist for stimulant dependence
      • Complications include psychosis, cardiovascular events, legal and occupational issues, and co-occurring psychiatric disorders
   8. Psychiatry EOR: Tobacco-related disorders

      Tobacco-Related Disorders refer to a broad range of health conditions caused or worsened by tobacco use, particularly cigarette smoking.

      • Leading preventable cause of death worldwide, associated with cardiovascular disease, chronic obstructive pulmonary disease (COPD), and multiple cancers (especially lung, esophageal, bladder, and pancreatic)
      • Nicotine dependence is the primary driver of continued tobacco use, contributing to physical addiction and behavioral reinforcement
      • Symptoms may include chronic cough, dyspnea, fatigue, weight loss, or chest pain, depending on the system affected
      • Pulmonary complications include chronic bronchitis, emphysema, and increased risk of lung infections
      • Cardiovascular effects include atherosclerosis, myocardial infarction, stroke, and peripheral artery disease
      • Cancers associated with tobacco involve the respiratory tract, gastrointestinal tract, genitourinary system, and hematologic system (e.g., leukemia)
      • Diagnosis is based on history and screening for related diseases; spirometry is essential in suspected COPD; low-dose chest CT is used for lung cancer screening in high-risk individuals (ages 50–80 with 20+ pack-year history who currently smoke or quit <15 years ago)
      • Treatment focuses on smoking cessation, which significantly reduces risk of morbidity and mortality
        • Options include nicotine replacement therapy (NRT), bupropion, and varenicline
        • Behavioral therapy and support groups increase cessation success
      • Long-term management includes monitoring for relapse, screening for associated diseases, and preventive care
6. Psychiatry EOR: Schizophrenia Spectrum and Other Psychotic Disorders (Pearls)
   1. Psychiatry EOR: Delusional disorder

      Delusional Disorder is a psychiatric condition characterized by the presence of one or more non-bizarre, fixed delusions lasting at least one month, without other features of schizophrenia.

      • Delusions are non-bizarre, meaning they involve situations that could occur in real life (e.g., being followed, poisoned, loved from afar)
      • Subtypes include persecutory, erotomanic, grandiose, jealous, and somatic
      • Functioning is typically preserved outside of the delusional belief, and behavior is not obviously odd or bizarre
      • No prominent hallucinations, disorganized speech, or negative symptoms, which distinguishes it from schizophrenia
      • Diagnosis is clinical, based on DSM-5 criteria, and requires exclusion of substance use, medical conditions, or other psychotic disorders
      • Treatment involves antipsychotic medications (e.g., risperidone, olanzapine), although insight is often limited, making engagement difficult
      • Cognitive behavioral therapy (CBT) may help with insight and coping
      • Prognosis varies; some patients maintain stable functioning, while others may develop more severe psychotic disorders over time
   2. Psychiatry EOR: Schizoaffective disorder

      Schizoaffective Disorder is a chronic psychiatric condition characterized by symptoms of schizophrenia (e.g., delusions, hallucinations) along with mood disturbances (depression or mania).

      • Core feature is the presence of psychotic symptoms for at least 2 weeks WITHOUT mood symptoms, distinguishing it from mood disorders with psychotic features
      • Also includes periods where mood symptoms (major depression or mania) occur concurrently with psychotic features
      • Symptoms may include paranoia, disorganized thinking, flat affect, along with depressive episodes or manic behavior
      • Diagnosis is clinical and based on DSM-5 criteria; must rule out schizophrenia and bipolar disorder
      • Treatment involves antipsychotic medications (e.g., paliperidone is FDA-approved), often combined with mood stabilizers (e.g., lithium, valproate) or antidepressants, depending on the mood component
      • Psychotherapy, social support, and psychiatric follow-up are important for long-term management
      • Prognosis is typically better than schizophrenia but worse than mood disorders alone; early treatment improves functional outcomes
   3. Psychiatry EOR: Schizophrenia (Lecture)

      Schizophrenia is a chronic psychiatric disorder characterized by disorganized thinking, hallucinations, delusions, and functional decline lasting ≥6 months.

      • Positive symptoms: Delusions, hallucinations, disorganized speech and behavior
      • Negative symptoms: Flat affect, social withdrawal, anhedonia, avolition, and poverty of speech
      • Onset typically occurs in late adolescence or early adulthood, often earlier in males than females
      • Risk factors include family history, prenatal complications, and substance use (especially cannabis)
      • Diagnosis is clinical, based on DSM-5 criteria: two or more symptoms (at least one positive) present for 1 month, with continuous signs for ≥6 months
      • Brain imaging may show enlarged ventricles, reduced cortical volume, and decreased hippocampal size
      • Treatment involves antipsychotic medications:
        • First-line: Second-generation (atypical) antipsychotics (e.g., risperidone, olanzapine, aripiprazole)
        • Clozapine is reserved for treatment-resistant schizophrenia
      • Psychosocial interventions, including cognitive behavioral therapy (CBT) and supported employment, improve functional outcomes
      • Prognosis varies, with many patients experiencing relapses and chronic impairment, but early intervention and adherence to treatment improve outcomes
      • Monitoring for metabolic and extrapyramidal side effects of antipsychotics is essential
   4. Psychiatry EOR: Schizophreniform disorder

      Schizophreniform Disorder is a psychiatric condition characterized by symptoms of schizophrenia lasting more than 1 month but less than 6 months.

      • Schizophreniform = schizophrenia “lite” (shorter duration, possible full recovery)
      • Core features include delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, and negative symptoms (e.g., flat affect, avolition)
      • Functional decline may be present, but is not required for diagnosis (unlike schizophrenia)
      • Often considered a transitional diagnosis between brief psychotic disorder and schizophrenia
      • Diagnosis is clinical, based on DSM-5 criteria: at least 2 psychotic symptoms (one must be delusions, hallucinations, or disorganized speech), lasting 1–6 months
      • Rule out substance use, medical conditions, and mood disorders with psychotic features
      • Treatment includes antipsychotic medications (e.g., risperidone, olanzapine) and psychosocial support
      • Prognosis varies: about ⅓ recover fully, while others may go on to develop schizophrenia or schizoaffective disorder
      • Early treatment and good premorbid functioning are associated with better outcomes

7. Psychiatry EOR: Disruptive, Impulse Control and Conduct Disorders; Neurodevelopmental Disorders (Pearls)
   1. Psychiatry EOR: Attention-deficit/hyperactivity disorders

      Attention-Deficit/Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder characterized by persistent inattention, hyperactivity, and impulsivity that interferes with functioning or development.

      • Symptoms must be present before age 12 and occur in multiple settings (e.g., home, school, work)
      • Two core presentations:
        • Inattentive type: Difficulty sustaining attention, forgetfulness, disorganization, distractibility
        • Hyperactive-impulsive type: Fidgeting, restlessness, interrupting, excessive talking, difficulty waiting turns
      • Combined type is the most common presentation
      • Diagnosis is clinical, based on DSM-5 criteria, and often includes teacher/parent behavior rating scales
      • More common in boys, with symptoms often persisting into adolescence and adulthood
      • Management includes:
        • Behavioral therapy (especially in younger children)
        • Pharmacologic treatment: Stimulants (e.g., methylphenidate, amphetamines) are first-line; non-stimulants (e.g., atomoxetine, guanfacine) are alternatives
      • Comorbidities include learning disorders, anxiety, oppositional defiant disorder, and depression
      • Early diagnosis and intervention are key to improving academic performance, social relationships, and self-esteem
   2. Psychiatry EOR: Autism spectrum disorder

      Autism Spectrum Disorder (ASD) is a neurodevelopmental condition characterized by deficits in social communication and the presence of restricted, repetitive patterns of behavior or interests.

      • Symptoms typically appear in early childhood, often before age 3
      • Core features include difficulty with social interactions, delayed language development, and repetitive behaviors (e.g., hand-flapping, strict routines, intense focus on specific interests)
      • May have hypersensitivity or hyposensitivity to sensory input (e.g., sounds, textures, lights)
      • Diagnosis is clinical, based on DSM-5 criteria and comprehensive developmental evaluation; screening tools include the M-CHAT (Modified Checklist for Autism in Toddlers)
      • Intellectual ability varies widely—from profound impairment to above-average intelligence (high-functioning autism)
      • Associated conditions include ADHD, anxiety, seizures, and GI disturbances
      • Early intervention with behavioral therapies (e.g., Applied Behavior Analysis), speech and occupational therapy, and educational support improves outcomes
      • No cure, but early diagnosis and comprehensive support can significantly enhance social and functional skills
      • Pharmacologic treatment (e.g., risperidone or aripiprazole) may be used for irritability, aggression, or severe behavioral issues

   3. Psychiatry EOR: Conduct disorder

      Conduct Disorder is a behavioral disorder in children and adolescents characterized by a persistent pattern of violating the rights of others or major societal norms.

      • CD = "Troubled teen" → violates rules and others' rights
      • Core features include aggression toward people or animals, destruction of property, deceitfulness or theft, and serious rule violations
      • Commonly presents with bullying, fighting, cruelty to animals, setting fires, lying, and truancy or running away
      • More common in males, with symptoms typically emerging in late childhood or early adolescence
      • Associated with increased risk of substance use, school failure, and progression to antisocial personality disorder (ASPD) in adulthood
      • Diagnosis of ASPD requires age ≥18 years old and a history of conduct disorder before age 15
      • Diagnosis is clinical, based on DSM-5 criteria, requiring at least 3 behaviors from the above categories in the past 12 months, with at least one in the past 6 months
      • Subtypes include childhood-onset, adolescent-onset, and unspecified onset
      • Management includes individual and family therapy, behavioral interventions, and addressing comorbidities such as ADHD or depression
      • Early intervention and stable home environment are key to improving outcomes

   4. Psychiatry EOR: Oppositional defiant disorder

      Oppositional Defiant Disorder (ODD) is a behavioral disorder characterized by a persistent pattern of angry, irritable mood, argumentative behavior, and defiance toward authority figures, typically beginning in childhood.

      • ODD = "Angry kid" → defiant but not dangerous 
      • Can progress to conduct disorder if untreated
      • Symptoms include frequent temper tantrums, refusal to follow rules, deliberately annoying others, and blaming others for mistakes
      • Behavior must last for at least 6 months and cause impairment in social, academic, or occupational functioning
      • More common in boys before puberty, with prevalence balancing out in adolescence
      • Often coexists with ADHD, learning disorders, and mood or anxiety disorders
      • Diagnosis is clinical, based on criteria from the DSM-5; must differentiate from normal childhood behavior, conduct disorder, and disruptive mood dysregulation disorder
      • Treatment involves behavioral therapy, especially parent management training and family therapy
      • Medications are not first-line, but may be used to manage comorbid conditions like ADHD
      • Early intervention is crucial to reduce the risk of progression to conduct disorder or antisocial behavior in adolescence and adulthood

8. Psychiatry EOR: Somatic Symptom and Related Disorders; Nonadherence to Medical Treatment (Pearls)

   1. Psychiatry EOR: Factitious disorder

      Factitious Disorder is a psychiatric condition in which a person deliberately produces, feigns, or exaggerates symptoms of illness with no obvious external gain.

      • Also known as Munchausen syndrome when severe and chronic
      • Motivation is to assume the sick role, not for financial gain, drugs, or avoidance of responsibility (which distinguishes it from malingering)
      • Common behaviors include falsifying medical history, tampering with lab results, or inducing illness (e.g., injecting insulin to cause hypoglycemia)
      • Patients often have extensive medical knowledge and may be frequent hospital visitors with dramatic or inconsistent histories
      • Diagnosis is clinical, based on suspicion and exclusion of true medical conditions; may involve reviewing medical records and observing discrepancies between reported and observed symptoms
      • Confrontation should be nonjudgmental and handled carefully, often with psychiatric consultation
      • Treatment involves psychotherapy, particularly cognitive behavioral therapy (CBT); outcomes vary and long-term follow-up is often needed
      • Factitious disorder imposed on another (previously Munchausen by proxy) is a form of abuse where a caregiver induces illness in another person, often a child

   2. Psychiatry EOR: Illness anxiety disorder

      Illness Anxiety Disorder is a psychiatric condition characterized by excessive preoccupation with having or acquiring a serious illness, despite minimal or no somatic symptoms.

      • Previously known as hypochondriasis
      • Patients often misinterpret normal bodily sensations as signs of serious disease and have high health-related anxiety
      • Minimal or absent physical symptoms, but persistent worry about health for ≥6 months
      • Frequently seek reassurance from providers, request multiple medical evaluations, or may avoid medical care altogether due to fear of diagnosis
      • Physical exams and diagnostic tests are typically normal
      • Diagnosis is clinical and requires ruling out other medical or psychiatric conditions (e.g., somatic symptom disorder, OCD)
      • Management includes regularly scheduled outpatient visits, psychotherapy (especially cognitive behavioral therapy - CBT), and possibly SSRIs if anxiety is severe
      • Avoid excessive testing, as it can reinforce anxiety and perpetuate the cycle
      • Prognosis is variable—some improve with treatment, while others experience chronic symptoms

   3. Psychiatry: Somatic symptom disorder

      Somatic Symptom Disorder is a psychiatric condition characterized by excessive focus on physical symptoms that cause significant distress or impairment, without an identifiable medical cause.

      • Patients present with one or more physical symptoms (e.g., pain, fatigue, GI complaints) that are disproportionate in severity and impact to any underlying medical findings
      • Preoccupation with symptoms leads to frequent healthcare visits, anxiety about health, and interference with daily functioning
      • Symptoms are not intentionally produced or faked (distinguishing it from factitious disorder or malingering)
      • Diagnosis is clinical, based on persistent (typically >6 months) physical complaints and excessive thoughts, feelings, or behaviors related to the symptoms
      • Common in women <30 years old, especially those with a history of childhood trauma, anxiety, or depression
      • Management includes regular follow-up with a single primary care provider, cognitive behavioral therapy (CBT), and treatment of comorbid psychiatric conditions (e.g., SSRIs for anxiety or depression)
      • Avoid unnecessary tests and procedures, which can reinforce the patient’s health anxiety
      • Prognosis improves with coordinated care, empathy, and a therapeutic alliance that emphasizes coping rather than cure
9. Psychiatry EOR: Personality Disorders; Obsessive-Compulsive and Related Disorders (Pearls)
   1. Psychiatry EOR: Antisocial personality disorder (Lecture)

      Antisocial Personality Disorder (ASPD) is a chronic mental health condition marked by a persistent disregard for the rights of others and violation of social norms.

      • More common in men, often with a history of conduct disorder before age 15
      • Core features include deceitfulness, impulsivity, irritability, aggression, repeated unlawful acts, and lack of remorse
      • Individuals often manipulate, exploit, or violate others’ rights without guilt or empathy
      • Frequently associated with substance use disorders, criminal behavior, and poor occupational or relationship functioning
      • Diagnosis is clinical, based on DSM-5 criteria, with symptoms persisting from age 18 and evidence of conduct disorder before age 15
      • Differentiated from conduct disorder (in children) and narcissistic or borderline personality disorders by the presence of pervasive criminal and exploitative behavior
      • Treatment is challenging; patients often lack insight and rarely seek help unless legally required
      • Cognitive behavioral therapy (CBT) may have limited benefit; long-term structure and monitoring are often needed
      • Prognosis is poor, but some symptoms may lessen with age
   2. Psychiatry EOR: Avoidant personality disorder (Lecture)

      Avoidant Personality Disorder (AVPD) is a Cluster C personality disorder characterized by extreme social inhibition, feelings of inadequacy, and hypersensitivity to criticism or rejection.

      • Individuals are socially withdrawn, yet desire close relationships, unlike those with schizoid personality disorder
      • Marked by intense fear of embarrassment, low self-esteem, and avoidance of social or occupational activities that involve interpersonal contact
      • Commonly described as "shy, timid, or inhibited", even in familiar settings
      • Frequently comorbid with social anxiety disorder, depression, and other personality disorders
      • Diagnosis is clinical and based on DSM-5 criteria, including a pattern of social inhibition and sensitivity to negative evaluation beginning by early adulthood
      • Differentiated from social anxiety disorder by the pervasiveness of avoidance across most situations and settings
      • Treatment includes psychotherapy, particularly cognitive-behavioral therapy (CBT) aimed at building social skills and addressing maladaptive beliefs
      • Pharmacologic treatment may include SSRIs or SNRIs for comorbid anxiety or depression, though medications are not first-line for personality change
      • Prognosis improves with long-term therapy and patient motivation, though symptoms may persist without consistent intervention
   3. Psychiatry: Body dysmorphic disorder

      Body Dysmorphic Disorder (BDD) is a psychiatric condition characterized by obsessive preoccupation with one or more perceived flaws in physical appearance that are not observable or appear minor to others.

      • Most commonly involves the face, skin, hair, nose, or body shape
      • Patients experience significant distress and impairment, often spending hours daily checking, comparing, or attempting to hide the perceived defect
      • May lead to social withdrawal, depression, anxiety, or repetitive behaviors such as mirror checking or skin picking
      • Diagnosis is clinical, based on DSM-5 criteria; the concern must cause functional impairment and is not better explained by an eating disorder
      • Frequently co-occurs with other mental health conditions like major depression, OCD, and social anxiety
      • Treatment includes cognitive-behavioral therapy (CBT) focused on exposure and response prevention and SSRIs (e.g., fluoxetine) as first-line pharmacologic therapy
      • Surgical or cosmetic procedures are contraindicated, as they rarely improve symptoms and may worsen the obsession
      • Early recognition and psychiatric referral are key to preventing chronic impairment and suicide risk
   4. Psychiatry EOR: Borderline personality disorder (Lecture)

      Borderline Personality Disorder (BPD) is a Cluster B personality disorder characterized by instability in mood, relationships, self-image, and behavior, often beginning in early adulthood.

      • Core features include emotional instability, intense interpersonal relationships, impulsivity, and chronic feelings of emptiness
      • Patients may exhibit fear of abandonment, identity disturbance, and self-injurious behaviors or suicidal threats
      • Mood swings are rapid and reactive, often triggered by perceived interpersonal slights
      • Splitting (viewing people as all good or all bad) is a common defense mechanism
      • High rates of co-occurring disorders, including depression, anxiety, PTSD, and substance use disorders
      • Diagnosis is clinical, based on DSM-5 criteria; symptoms must be persistent and pervasive across contexts
      • First-line treatment is dialectical behavior therapy (DBT), a form of cognitive behavioral therapy specifically designed for BPD
      • Medications may be used to target mood symptoms or comorbid conditions, but no pharmacologic cure exists
      • Prognosis improves with long-term therapy, structure, and social support, though risk of suicide is significantly elevated
   5. Psychiatry EOR: Dependent personality disorder

      Dependent Personality Disorder is a Cluster C personality disorder characterized by an excessive need to be taken care of, leading to submissive and clingy behavior and fear of separation.

      • Core features include difficulty making everyday decisions without excessive reassurance, avoidance of personal responsibility, and fear of being alone or abandoned
      • Individuals often go to great lengths to seek approval, tolerate mistreatment, and have difficulty expressing disagreement out of fear of losing support
      • Commonly begins in early adulthood, more frequent in women, and often associated with low self-esteem and passive behavior
      • Diagnosis is clinical, based on DSM-5 criteria, requiring a pervasive and excessive need to be taken care of that leads to dependency and submissive behavior in multiple contexts
      • May co-occur with other disorders, especially depression, anxiety disorders, and other personality disorders
      • Treatment includes psychotherapy, particularly cognitive-behavioral therapy (CBT) to improve autonomy, assertiveness, and coping skills
      • Pharmacologic treatment may be used to manage associated symptoms like anxiety or depression, but is not curative
      • Prognosis is variable, but with therapy, many patients can improve their interpersonal functioning and independence
   6. Psychiatry EOR: Histrionic Personality Disorder (Lecture)

      Histrionic Personality Disorder (HPD) is a Cluster B personality disorder characterized by excessive emotionality and attention-seeking behavior.

      • More common in females and often evident by early adulthood
      • Core features include being dramatic, theatrical, flirtatious, and displaying rapidly shifting and shallow emotions
      • Constantly seeks reassurance, approval, and praise, often using physical appearance or provocative behavior to draw attention
      • May perceive relationships as more intimate than they truly are
      • Speech is often impressionistic, lacking in detail but high in emotional expression
      • Diagnosis is clinical, based on DSM-5 criteria and comprehensive psychiatric evaluation
      • Often co-occurs with depression, anxiety, or other personality disorders (especially borderline or narcissistic)
      • Treatment focuses on psychotherapy, especially cognitive-behavioral therapy (CBT) to improve self-esteem and interpersonal functioning
      • Pharmacotherapy is not primary but may be used to manage comorbid mood or anxiety symptoms

   7. Psychiatry EOR: Narcissistic personality disorder (Lecture)

      Narcissistic Personality Disorder (NPD) is a Cluster B personality disorder characterized by a pervasive pattern of grandiosity, need for admiration, and lack of empathy.

      • Core features include an inflated sense of self-importance, preoccupation with fantasies of success or power, and belief in being special or unique
      • Individuals often exhibit arrogant behavior, exploit others for personal gain, and have difficulty handling criticism
      • May appear charming and confident, but underlying fragile self-esteem leads to hypersensitivity to perceived slights or failures
      • Commonly associated with interpersonal conflict, impaired relationships, and occupational difficulties
      • Diagnosis is clinical, based on DSM-5 criteria, requiring at least five or more characteristic features
      • Comorbidities may include depression, substance use disorders, or other personality disorders (e.g., antisocial or borderline)
      • Treatment involves psychotherapy (particularly cognitive behavioral therapy) to improve insight, interpersonal functioning, and emotional regulation
      • Pharmacologic therapy is not curative but may be used to treat coexisting conditions like depression or anxiety

   8. Psychiatry EOR: Obsessive-compulsive disorder

      Obsessive-Compulsive Disorder (OCD) is a chronic psychiatric condition characterized by recurrent obsessions (intrusive, unwanted thoughts) and compulsions (repetitive behaviors or mental acts performed to reduce anxiety).

      • Obsessive-Compulsive and Related Disorders (DSM-5)
      • Common obsessions include fears of contamination, harm, symmetry, or intrusive violent or sexual thoughts
      • Common compulsions include washing, checking, counting, or repeating behaviors

      • Ego-dystonic obsessions and compulsions (intrusive, unwanted)

      • Patients usually recognize the irrational nature of their thoughts and behaviors but feel driven to perform them to relieve distress
      • Symptoms often cause significant distress, functional impairment, and consume >1 hour/day
      • Diagnosis is clinical, based on criteria from the DSM-5
      • First-line treatment includes cognitive-behavioral therapy (CBT), particularly exposure and response prevention (ERP)
      • SSRIs (e.g., fluoxetine, fluvoxamine, sertraline) are first-line pharmacologic treatments; higher doses and longer duration may be needed compared to depression
      • Clomipramine, a tricyclic antidepressant, may be effective in treatment-resistant cases
      • Severe or refractory cases may benefit from augmentation with antipsychotics or referral for deep brain stimulation (DBS)
      • Prognosis varies—many achieve partial control with therapy, but relapse is common without maintenance treatment
   9. Psychiatry EOR: Obsessive-compulsive personality disorder (Lecture)

      Obsessive-Compulsive Personality Disorder (OCPD) is a Cluster C personality disorder characterized by a pervasive pattern of preoccupation with orderliness, perfectionism, and control, at the expense of flexibility and efficiency.

      • Cluster C personality disorder
      • Patients are ego-syntonic, meaning they see their behaviors as appropriate and do not view them as problematic (unlike OCD)
      • Ego-syntonic perfectionism and control (they think it’s normal) - lacks insight; sees behaviors as appropriate
      • Presents with rigid adherence to rules, excessive devotion to work, reluctance to delegate, and inflexibility about morals or values
      • Often described as "perfectionistic, controlling, and detail-oriented", which can interfere with social and occupational functioning
      • Common features include hoarding behavior, indecisiveness, and hyperfocus on productivity
      • Diagnosis is clinical and based on DSM-5 criteria, requiring persistent traits that impair functioning or cause distress to others
      • Distinguished from OCD by the absence of true obsessions and compulsions
      • Treatment includes psychotherapy (especially cognitive-behavioral therapy) as first-line; SSRIs may help in patients with overlapping anxiety or depression
      • Patients may resist treatment due to limited insight and pride in their behavior

   10. Psychiatry EOR: Paranoid personality disorder (Lecture)

       Paranoid Personality Disorder is a Cluster A personality disorder characterized by pervasive distrust and suspicion of others without sufficient basis.

       • Patients exhibit persistent suspicion, believing others are exploiting, harming, or deceiving them, even without evidence
       • Common behaviors include reluctance to confide in others, reading hidden threats into benign remarks, holding grudges, and quickly perceiving attacks on character
       • More common in males, and often begins in early adulthood
       • Differentiated from delusional disorder or schizophrenia by the absence of fixed delusions or hallucinations
       • Diagnosis is clinical and based on DSM-5 criteria, typically requiring long-term patterns of mistrust across multiple contexts
       • Insight is limited; individuals rarely seek treatment unless under duress (e.g., legal trouble, relationship loss)
       • Psychotherapy, especially cognitive behavioral therapy (CBT), is the mainstay of treatment, aimed at improving trust, coping mechanisms, and interpersonal skills
       • Medications (e.g., antipsychotics or anxiolytics) may be used short-term for severe anxiety or transient psychotic symptoms, but pharmacotherapy is not primary treatment

   11. Psychiatry EOR: Schizoid personality disorder

       Schizoid Personality Disorder is a Cluster A personality disorder characterized by lifelong detachment from social relationships and a limited range of emotional expression.

       • Individuals appear emotionally cold, aloof, and prefer solitary activities
       • They have little interest in close relationships, including with family, and often choose jobs or hobbies that require minimal social interaction
       • Typically indifferent to praise or criticism and show minimal interest in sexual experiences
       • Unlike avoidant personality disorder, social withdrawal is due to lack of desire, not fear of rejection
       • Diagnosis is clinical, based on DSM-5 criteria, which includes a pattern of detachment and restricted emotional expression beginning in early adulthood
       • Treatment is often challenging, as patients rarely seek help; psychotherapy (particularly supportive therapy) may help improve social functioning if the patient is open to it
       • Pharmacologic treatment is not routinely indicated but may be used if comorbid depression or anxiety is present
       • Patients are not psychotic but may have a flat affect and be mistaken for having a prodromal psychotic disorder
   12. Psychiatry EOR: Schizotypal personality disorder (Lecture)

       Schizotypal Personality Disorder is a Cluster A personality disorder characterized by eccentric behavior, odd beliefs, and social anxiety, often with interpersonal deficits.

       • Patients may exhibit magical thinking, paranoia, odd speech patterns, and unusual perceptual experiences
       • Often described as "socially awkward" or "strange", but not overtly psychotic or delusional
       • Unlike schizophrenia, they do not have frank hallucinations or delusions, though they may have ideas of reference and odd beliefs (e.g., belief in telepathy or superstitions)
       • Social anxiety is prominent, often related to paranoid fears rather than negative self-judgment
       • Diagnosis is clinical, based on DSM-5 criteria involving persistent pattern of discomfort in close relationships and cognitive/perceptual distortions
       • Treatment includes psychotherapy focused on improving social skills and cognitive distortions
       • Antipsychotics may be used short-term for severe symptoms, such as paranoid ideation or transient psychosis
       • Patients are at increased risk of developing schizophrenia, and early identification and monitoring are essential

10. Psychiatry: Feeding or Eating Disorders (Pearls)
    1. Psychiatry EOR: Anorexia nervosa (ReelDx + Lecture)

       Anorexia Nervosa is a psychiatric eating disorder characterized by self-induced weight loss, intense fear of gaining weight, and a distorted body image.

       • Primarily affects adolescent girls and young women, but can occur in all genders and age groups
       • Subtypes include restricting type (weight loss through dieting/fasting) and binge-eating/purging type (includes episodes of binge eating or purging behaviors)
       • Symptoms include extreme caloric restriction, excessive exercise, amenorrhea, bradycardia, hypotension, hypothermia, and lanugo (fine body hair)
       • Medical complications include electrolyte imbalances (hypokalemia), osteoporosis, cardiac arrhythmias, gastroparesis, and infertility
       • Labs may show low T3, high cholesterol, elevated liver enzymes, and leukopenia; EKG may reveal QT prolongation
       • Diagnosis is clinical and based on DSM-5 criteria, including significantly low body weight and intense fear of gaining weight or becoming fat
       • Treatment requires a multidisciplinary approach with nutritional rehabilitation, psychotherapy (CBT), and medical monitoring
       • Hospitalization is indicated for severe malnutrition, bradycardia (<40 bpm), electrolyte abnormalities, or cardiac instability
       • Complication to monitor for during refeeding is refeeding syndrome, characterized by hypophosphatemia and fluid/electrolyte shifts

    2. Psychiatry EOR: Bulimia nervosa (Lecture)

       Bulimia Nervosa is an eating disorder characterized by recurrent episodes of binge eating followed by compensatory behaviors such as vomiting, laxative use, fasting, or excessive exercise to prevent weight gain.

       • Most common in adolescent and young adult females, often with normal or slightly overweight BMI
       • Core features include loss of control during binge episodes and preoccupation with body image and weight
       • Physical findings may include parotid gland enlargement, dental enamel erosion, Russell’s sign (calluses on knuckles from self-induced vomiting), and hypokalemia
       • Electrolyte abnormalities (especially hypokalemia, metabolic alkalosis) are common due to vomiting or diuretic use
       • Diagnosis is clinical, based on DSM-5 criteria: binge eating and compensatory behaviors occurring at least once a week for 3 months
       • Management includes cognitive behavioral therapy (CBT) as first-line treatment; SSRIs, especially fluoxetine, are effective for reducing binge-purge cycles
       • Medical monitoring is important to manage cardiac risks (arrhythmias) and metabolic disturbances
       • Prognosis improves with early intervention, but relapse is common without continued support and therapy

11. Psychiatry EOR: Paraphilic Disorders; Sexual Dysfunctions (Pearls)
    1. Psychiatry EOR: Exhibitionistic disorder

       Exhibitionistic Disorder is a paraphilic disorder characterized by intense urges or behaviors involving the exposure of one’s genitals to an unsuspecting person.

       • Most common in males, typically beginning in adolescence or early adulthood
       • Individuals experience sexual arousal from the act of exposing themselves to strangers, often followed by masturbation, but no attempt at sexual contact
       • Must cause clinically significant distress or impairment in functioning, or involve non-consenting individuals, to meet diagnostic criteria
       • Diagnosis is clinical, based on persistent behaviors or fantasies for ≥6 months involving exposure to a non-consenting person
       • May be associated with social isolation, impulsivity, or other paraphilic disorders
       • Treatment includes cognitive-behavioral therapy (CBT) focused on impulse control and relapse prevention, and SSRIs for individuals with high levels of sexual preoccupation or comorbid depression/anxiety
       • Anti-androgen therapy (e.g., medroxyprogesterone acetate) may be used in severe or refractory cases
       • Legal issues may arise, as behavior is often criminalized as indecent exposure
    2. Psychiatry EOR: Female sexual interest/arousal disorder

       Female Sexual Interest/Arousal Disorder (FSIAD) is characterized by a persistent lack of sexual interest or arousal that causes personal distress or relationship difficulties.

       • Defined by reduced or absent sexual thoughts, desire, initiation of sexual activity, and pleasure or arousal during sexual encounters, lasting 6 months or more
       • Must cause significant distress to the individual to meet diagnostic criteria
       • Risk factors include menopause, chronic illness, psychiatric conditions (e.g., depression, anxiety), relationship issues, hormonal changes, and certain medications (e.g., SSRIs)
       • Diagnosis is clinical, based on detailed sexual history, symptom duration, distress level, and exclusion of medical or psychiatric causes
       • Important to assess for genitourinary syndrome of menopause (GSM), vaginal dryness or dyspareunia, and hormonal or psychosocial contributors
       • Management includes education, counseling, and addressing underlying causes; options may include psychotherapy, sex therapy, or couples therapy
       • Pharmacologic treatments include flibanserin (a serotonin receptor modulator) or bremelanotide for premenopausal women with acquired FSIAD
       • Hormone therapy (e.g., vaginal estrogen, systemic estrogen with/without testosterone) may be used in postmenopausal women if GSM is a contributing factor
    3. Psychiatry EOR: Fetishistic disorder

       Fetishistic Disorder is a paraphilic disorder characterized by intense sexual arousal from nonliving objects or specific non-genital body parts, causing significant distress or impairment.

       • Common fetishes include shoes, underwear, leather, or feet
       • The fetish object is required for sexual arousal and is not limited to cross-dressing items or sex toys
       • Diagnosis requires recurrent and intense sexual urges, fantasies, or behaviors for at least 6 months that cause clinically significant distress or functional impairment
       • Most individuals are male, and onset typically occurs in adolescence
       • Differentiated from normative sexual interests by the presence of impairment, distress, or compulsive behavior
       • Treatment options include cognitive behavioral therapy (CBT), psychotherapy, and sometimes SSRIs or antiandrogen medications for severe or compulsive cases
       • May co-occur with other paraphilic disorders or obsessive-compulsive traits
       • Does not require treatment unless the individual experiences distress, interpersonal difficulties, or legal/occupational impairment
    4. Psychiatry EOR: Male hypoactive sexual desire disorder

       Male Hypoactive Sexual Desire Disorder (MHSDD) is characterized by a persistent or recurrent deficiency or absence of sexual thoughts, fantasies, and desire for sexual activity, causing significant distress or interpersonal difficulty.

       • Must be present for at least 6 months and not better explained by another medical or psychiatric condition, substance use, or relationship issues
       • Often associated with depression, anxiety, relationship problems, hormonal imbalances (e.g., low testosterone), or chronic illness
       • Assessment includes a thorough history, psychosocial evaluation, and hormonal testing (e.g., serum testosterone levels) to rule out underlying causes
       • Treatment involves addressing underlying contributors:
         • Psychotherapy (especially cognitive behavioral therapy or sex therapy) for psychological or relationship-related causes
         • Testosterone replacement therapy may be considered if there is confirmed hypogonadism
         • Management of comorbid conditions such as depression or anxiety with appropriate pharmacologic and non-pharmacologic interventions
       • Education and counseling are key components, including normalizing sexual concerns and improving communication with partners
       • Prognosis depends on identifying and treating contributing factors; many cases improve with targeted intervention
    5. Psychiatry EOR: Pedophilic disorder

       Pedophilic Disorder is a psychiatric condition characterized by recurrent, intense sexual urges, fantasies, or behaviors involving sexual activity with prepubescent children, typically age 13 or younger, over a period of at least 6 months.

       • To meet diagnostic criteria, the individual must be at least 16 years old and at least 5 years older than the child involved
       • May involve fantasies only, or actual behaviors; distress, interpersonal difficulty, or acting on these urges is required for diagnosis
       • Excludes consensual sexual activity with individuals in late adolescence
       • More common in males, and may be associated with other paraphilic disorders or antisocial traits
       • Diagnosis is clinical, based on a detailed psychiatric history and behavioral assessment
       • Treatment includes cognitive-behavioral therapy (CBT) focused on impulse control and relapse prevention; SSRIs or antiandrogen therapy (e.g., medroxyprogesterone acetate) may be used to reduce sexual drive in some cases
       • Mandatory reporting and legal involvement are often necessary if the individual has engaged in illegal or harmful behavior
       • Important to distinguish pedophilic disorder from child sexual abuse, which refers to the criminal act, while the disorder refers to psychiatric criteria
    6. Psychiatry EOR: Sexual masochism disorder

       Sexual Masochism Disorder is a paraphilic disorder characterized by intense sexual arousal from being humiliated, beaten, bound, or otherwise made to suffer, causing significant distress or impairment.

       • Diagnosis requires recurrent and intense sexually arousing fantasies, urges, or behaviors involving acts of being humiliated or made to suffer, occurring for at least 6 months
       • The behavior must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
       • May involve asphyxiophilia (sexual arousal from restriction of breathing), which carries a risk of accidental death
       • Distinct from consensual BDSM unless the individual experiences distress, impairment, or engages in non-consensual acts
       • More commonly seen in males, often beginning in adolescence or early adulthood
       • Assessment includes a thorough psychiatric evaluation, often revealing comorbid conditions like depression, anxiety, or other paraphilic disorders
       • Treatment options include cognitive-behavioral therapy (CBT), psychodynamic psychotherapy, and sometimes SSRIs or antiandrogen medications if behavior is compulsive or dangerous
       • Prognosis depends on the degree of insight, motivation for treatment, and presence of comorbid psychiatric conditions
    7. Psychiatry EOR: Voyeuristic disorder

       Voyeuristic Disorder is a paraphilic disorder characterized by recurrent, intense sexual arousal from observing an unsuspecting person who is naked, undressing, or engaging in sexual activity.

       • To meet diagnostic criteria, the behavior must occur for at least 6 months and cause clinically significant distress or impairment, or be acted upon with a nonconsenting person
       • Most commonly affects males, with onset typically in adolescence
       • May involve secretive behavior, such as using mirrors, hidden cameras, or surveillance to observe individuals without their knowledge
       • Differentiated from normal sexual curiosity by its compulsive nature and the presence of distress or functional impairment
       • Diagnosis is clinical, based on DSM-5 criteria, and may be uncovered through self-report, legal involvement, or partner concern
       • Treatment options include cognitive-behavioral therapy (CBT) focused on relapse prevention, psychotherapy, and in some cases, SSRIs to reduce obsessive-compulsive features or paraphilic urges
       • Legal consequences (e.g., arrest for invasion of privacy) may occur if the behavior is acted upon, especially involving nonconsenting individuals
       • May co-occur with other paraphilic disorders, anxiety, depression, or impulse-control disorders