PANCE Blueprint Psychiatry (6%)

Lessons

1. Psychiatry Flashcards (Members Only)
2. Psychiatry Comprehensive Exam (Members Only)
3. 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.

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

   35 mins

   Joe Gilboy PA-C
5. 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)
        • CBT (relaxation, desensitization, examining behavior consequences)
   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
   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
6. Attention-Deficit/hyperactivity Disorder (ReelDx)

   Hyperactivity, impulsivity, or inattentiveness manifesting before age 7

   • > 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)
   • 1st line meds – caution: wt. loss & ↓ growth with stimulants!
     • methylphenidate (Ritalin, Concerta, Daytrana)
     • dexmethylphenidate (Focalin)
     • amphetamine/dextroamphetamine (Adderall, Dexedrine)
     • atomoxetine (Strattera) selective norepinephrine atomoxetine (Strattera) selective norepinephrine reuptake inhibitor (non-stimulant)
   • 2nd line/adjuncts
     • antidepressants (guanfacine, clonidine, imipramine, bupropion, venlafaxine)
     • Behavior modification, family, educational management
7. Autistic Disorder

   A spectrum of developmental disorders linked to a combination of prenatal viral exposure, immune system abnormality or genetic factors. > 6 symptoms from the following categories:

   • Impaired social interaction (at least 2)
     • problems with nonverbal behaviors (facial expression, gestures)
     • fail to develop peer relationships
     • does not seek sharing of interests/enjoyment
     • does not seek sharing of interests/enjoyment  with others
     • lacks reciprocal social/emotional interaction
   • Impaired communications (at least 1)
     • lack of or delayed speech
     • repetitive language use
     • lack of spontaneous, varied play activities
   • Repetitive stereotyped patterns of behavior & activities (at least 1)
     • inflexible rituals  intense, rigid commitment to maintaining routines
     • become agitated if routine is interrupted
     • sit in specific chair, dress in certain way, eat specific foods
     • preoccupation with parts of objects
8. Eating Disorders (PEARLS)

   1. Anorexia nervosa (ReelDx + Lecture)

      Two types of anorexia nervosa are recognized:

      • 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.

   2. Bulimia nervosa (Lecture)

      Binging followed by vomiting, laxative use, or extreme exercise in a normal weight patient

      • Scars on knuckles, swollen parotid glands, dental erosions, normal or overweight
      • Hypokalemia: Laboratory findings to support this diagnosis include hypochloremia with subsequent hypokalemia due to renal compensatory mechanisms, hypomagnesemia, and metabolic alkalosis
      • Treatment is with CBT and antidepressants
   3. Obesity and Binge Eating Disorder (ReelDx)

      Definition of obesity

      • Adults BMI = 30 kg/ m2 or, alternatively, 20% higher than suggested ideal body weight
      • Children and adolescents BMI at the 95th percentile or higher

      Binge eating disorder

      • Recurrent binge eating > 2 days/wk for 6 mos
      • Inappropriate weight control
      • >3 of following:
        • Eating rapidly, until very full, large amounts  when not hungry, alone out of embarrassment
        • Feeling disgusted/depressed/guilty afterward

      Bariatric surgery:  A body mass index of greater than 40 kg/ m2 or a body mass index of 35 kg/ m2 with an obesity-related comorbidity (e.g., diabetes, hypertension) are indications of bariatric surgery and are able to adhere to postoperative care.
9. Mood Disorders (PEARLS)
   1. Adjustment disorder

      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
   2. Bipolar disorder (Lecture)

      • Bipolar I: history of more mania than depression - Defined by the presence of at least one full-fledged (ie, disrupting normal social and occupational function) manic episode and usually depressive episodes
      • Bipolar II: history of depression and one episode of mania - Defined by the presence of major depressive episodes with at least one hypomanic episode but no full-fledged manic episodes
      • 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.
   3. 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
   4. Dysthymic disorder (Lecture)

      Mild chronic form of major depression lasting ≥ 2 years

10. 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.
11. Psychoses (PEARLS)
    1. Delusional disorder

       Non Bizarre delusions for > 1 month. Behavior not obviously odd; daily function not significantly impaired

       • Subtypes of delusions
         • erotomanic - another person in love with them
         • somatic - having a physical/medical condition* somatic - having a physical/medical condition
         • jealous - sexual partner’s infidelity
         • persecutory - mistreatment or persecution
         • grandiose - inflated self-worth, power, knowledge
       • Treatment – antipsychotics
    2. Schizophrenia (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
12. Somatoform Disorders

    • 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.
13. Substance Use Disorders (PEARLS)
    1. Abuse

       Substance abuse: hasn’t met criteria for dependence but causes impairment by >1 of the following in 1 year period:

       • Fails to meet home/school/work obligations
       • Repeatedly uses substance in hazardous situations
       • Recurrent substance-related legal problems
       • Continues use, even though results in interpersonal/social problems
    2. Dependence

       Dependence: using a substance to maintain normal psychological and/or somatic functioning. 

       • Physiologic addiction behaviors that include:
         • Tolerance
           • need to take larger amounts for the same desired effect
         • Withdrawal
         • Persistent desire or unsuccessful attempts to cut down
         • Disturbance of life function
           • significant energy spent obtaining, using, or recovering from substance
           • impaired control over substance use (work, school, relationships suffer and time spent doing these activities is reduced)
           • continued use in light of the problems caused by the drug
       • Disturbance of life function
         • Significant energy spent obtaining, using, or recovering from substance
         • Impaired control over substance use (work, school, relationships suffer and time spent doing these activities is reduced)
         • Continued use in light of the problems caused by the drug
    3. Withdrawal (ReelDx)

       • Marijuana:  Glassy, red eyes; loud talking and inappropriate laughter followed by sleepiness; a sweet burnt scent; loss of interest, motivation; weight gain or loss.
         • Withdrawal: irritability, depression, insomnia, nausea, anorexia. Most symptoms peak at 48 hours and last for 5 - 7 days.
         • Symptomatic treatment only.
       • Alcohol: Dilated pupils; clumsiness; difficulty walking; slurred speech; sleepiness; poor judgment.
         • Withdrawal: trembling, irritability, anxiety, headache, tachycardia, insomnia.
         • Thiamine, magnesium, multivitamin, dextrose (particularly if chronic alcoholism).
         • Benzodiazepines (if withdrawal). Disulfiram (Antabuse) - inhibits acetaldehyde dehydrogenase, aversive conditioning. Naltrexone - decreases desire.
       • Cocaine, Crack, Meth, and Other Stimulants: Dilated pupils; hyperactivity; euphoria; irritability; anxiety; excessive talking followed by depression or excessive sleeping at odd times; go long periods of time without eating or sleeping; weight loss; dry mouth and nose.
         • Withdrawal: severe depression and suicidality, hyperphagia, hypersomnolence, fatigue, malaise, severe psychological craving.
         • Treatment: bupropion, bromocriptine, SSRI's for depression. Antipsychotics (haloperidol), benzodiazepines, vitamin C (promotes excretion), antihypertensives, propranolol (BP + tachycardia control).
       • Opiates (morphine, heroin, methadone): Contracted pupils; needle marks; sleeping at unusual times; sweating; vomiting; coughing and sniffling; twitching; loss of appetite; no response of pupils to light.
         • Withdrawal: Anxiety, insomnia, anorexia, sweating, dilated pupils, piloerection ("cold turkey"). Fever, rhinorrhea, nausea, stomach cramps, diarrhea ("flulike" symptoms)
         • methadone, suboxone (buprenorphine + naloxone) long-acting oral administration with fewer withdrawal symptoms than methadone.
       • Depressants (including barbiturates and tranquilizers): Contracted pupils; seems drunk as if from alcohol but without the associated odor of alcohol; difficulty concentrating; clumsiness; poor judgment; slurred speech; and sleepiness.
         • Withdrawal: anxiety, seizures, delirium, similar to alcohol, life-threatening cardiovascular collapse.
         • Treatment: long-acting benzodiazepines with taper.
       • Inhalants (Glues, aerosols, and vapors): Watery eyes; impaired vision, memory and thought; secretions from the nose or rashes around the nose and mouth; headaches and nausea; appearance of intoxication; drowsiness; poor muscle control; anxiety; irritability.
         • Withdrawal: not well characterized, no treatment.
       • Hallucinogens (LSD, PCP): Dilated pupils; bizarre and irrational behavior including paranoia, aggression, hallucinations; mood swings; detachment from people; absorption with self or other objects, slurred speech; confusion.
         • Withdrawal: depression, anxiety, irritability, restlessness, anergia, disturbances of thought and sleep.
         • Treatment: symptomatic treatment only.
14. Other Behavior/Emotional Disorders (PEARLS)
    1. Acute reaction to stress

       Acute stress disorder is a brief period of intrusive recollections occurring within 4 weeks of witnessing or experiencing an overwhelming traumatic event. Symptoms last for a minimum of 3 days but, unlike posttraumatic stress disorder, last no more than 1 mo.

       • To meet the criteria for diagnosis, patients must have been exposed directly or indirectly to a traumatic event, and ≥ 9 of these criteria must be present for a period of 3 days up to 1 month.
    2. 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
    3. Conduct disorders

       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.
    4. Domestic violence

       Domestic violence includes physical, sexual, and psychological abuse between intimate partners.

       • The victim is usually a woman and more than 1 in 3 women has experienced domestic violence in their lifetime.
       • Physical injuries, psychological problems, social isolation, loss of a job, financial difficulties, and even death can result.
       • Domestic violence often begins or, if already present, increases during pregnancy and the postpartum period.
       • Domestic violence is much more common among black, Hispanic, and Native American women as compared with Caucasian women.
       • Keeping safe—for example, having a plan of escape—is the most important consideration.
       • Women are more likely to be assaulted or murdered when attempting to report the abuse or leave the abusive relationship; up to 75% of domestic assaults occur after separation.
    5. Grief reaction

       Grief Reaction: Normal grief in reaction to event + psychological symptoms + somatic symptoms. 

       • A normal grief reaction which combines psychological and somatic symptoms that result from extreme sorrow or loss.  Typically resolves in a few weeks or months up to 1 year.
    6. Suicide

       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 to19 yr, there may be 100 attempts to every 1 attempt among boys of the same age.
       • On average, primary care physicians encounter ≥ 6 potentially suicidal people in their practice each year. About 77% of people who die by suicide were seen by a physician within 1 yr before killing themselves, and about 32% had been under the care of a mental health care practitioner during the preceding year.