PANCE Blueprint Psychiatry (6%)

Lessons

1. 2019 PANCE Psychiatry and Behavioral Science Content Blueprint
2. Psychiatry Flashcards (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 Comprehensive Exam (Members Only)

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

   35 mins

   Joe Gilboy PA-C
6. 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. 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.
   3. Sexual abuse
7. 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
8. 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.
9. 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)

      A disorder marked by repeated episodes of significant depression and related symptoms during the week before menstruation
   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 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.

10. 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.
11. Dissociative disorders

    Dissociative identity disorder

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

    Dissociative amnesia

    • An abrupt change in geographic location with an inability to recall past and loss of identity

    Depersonalization/derealization disorder

    • Persistent feelings of detachment or estrangement from oneself
12. 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

13. Human sexuality (PEARLS)

    Exhibitionistic disorder

    • Sexual gratification attained by exposing genitals to unsuspecting strangers

    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

    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

    Male hypoactive sexual desire disorder

    • A male dysfunction marked by a persistent reduction or lack of interest in sex and hence a low level of sexual activity

    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

    Sexual masochism disorder

    • A paraphilic disorder characterized by repeated and intense sexual urges, fantasies, or behaviors that involve being humiliated, beaten, bound, or otherwise made to suffer.

    Voyeuristic disorder

    • A paraphilic disorder in which sexual arousal is derived from observing unsuspecting individuals undressing or naked
14. 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

     
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. 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.
17. 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

18. 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
19. 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.
20. Substance-related and addictive disorders (ReelDx)

21. Trauma and stressor-related disorders (PEARLS)
    1. 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
    2. 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