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. Anxiety Disorders (Pearls)
   1. General anxiety disorder

      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)

      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
5. 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
6. 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
7. Eating Disorders (PEARLS)

   1. Anorexia nervosa (ReelDx)

      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

      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.
8. 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

      • 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)

      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 (Persistent Depressive Disorder)

      Mild chronic form of major depression lasting ≥ 2 years

9. Personality Disorders

   • 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.
10. 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

       > 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
11. 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.
12. 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.
13. 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.