Psychiatry and Behavioral Health Rotation

A manic episode (≥ 1 week of elevated/irritable mood + ↑ energy, or any duration if hospitalized) with or without major depressive episodes

• Mania alone is sufficient for the diagnosis
• Treatment: lithium or valproate or a second-generation antipsychotic — check pregnancy status before valproate; monitor lithium levels and renal/thyroid function

Chronic depression - depressive symptoms for > 2 years (never symptom-free > 2 months)

• Treatment: psychotherapy + SSRI — combination beats either alone

At least one hypomanic episode (≥ 4 days, no marked impairment) and at least one major depressive episode

• There has never been a manic episode
• ⚠️ Screen every "depressed" patient for prior mania/hypomania before starting an antidepressant — unopposed antidepressants can precipitate mania

Severe mood swings, irritability, and depressed mood in the week before menses that resolve within days of onset of menses

• ≥ 5 symptoms in the final week before menses, with at least one core mood symptom (lability, irritability, depressed mood, or anxiety)
• Confirm with prospective daily symptom ratings across ≥ 2 cycles — retrospective recall alone is unreliable
• Treatment: SSRIs first-line (fluoxetine, sertraline) — effective continuously or luteal-phase only; drospirenone-containing OCPs are an alternative

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.

A prior suicide attempt is the single strongest predictor of completed suicide

• Highest-risk profile: older white male, lives alone, substance use, chronic illness, access to firearms; women attempt more, men complete more
• Ask directly about suicidal ideation, plan, intent, and means — asking does not increase risk
• Management: safety planning + lethal-means counseling (firearms, medication stockpiles); hospitalize (involuntarily if needed) for imminent risk — a plan with intent and access to means
• Ketamine/esketamine can rapidly reduce suicidal ideation in depression while first-line therapy takes effect

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

• Sadness
• Interest/anhedonia
• Guilt
• Energy
• Concentration
• Appetite
• Psychomotor activity
• Suicidal

Treatment: SSRI first-line + psychotherapy (CBT) — combination beats either alone

• Allow 4–6 weeks at therapeutic dose before calling a medication a failure; screen with PHQ-9 and reassess with it
• ECT for refractory, psychotic, or catatonic depression, or when rapid response is needed (pregnancy, refusal to eat/drink)

Alcohol is a depressant - it increases GABAa channel opening. Long-term use leads to downregulation of GABA channels (inhibitory) and upregulation of NMDA (excitatory)

• Intoxication:
  • Dilated pupils; clumsiness; difficulty walking; slurred speech; sleepiness; poor judgment. Talkative, flirtatious, aggressive, moody, disinhibited
• Treatment:
  • Thiamine, folate, MVI, dextrose (particularly if chronic alcoholism), and IV fluids. Benzodiazepines (CIWA-driven dosing) for withdrawal.
  • Give thiamine before dextrose — prevents precipitating Wernicke encephalopathy

Delirium Tremens (48 - 96 hours): autonomic instability, disorientation, hallucinations, agitation.

• Suspect in a patient with an unknown history followed by DT symptoms 2 days later
• IV benzodiazepines, preferably in an ICU.

Addiction medications

• Naltrexone - first-line, decreases craving — avoid in patients on opioids or with acute hepatitis
• Acamprosate - first-line alternative for maintaining abstinence — safe in liver disease, avoid in severe renal impairment
• Disulfiram - inhibits acetaldehyde dehydrogenase, aversive conditioning - second-line, requires motivated patient
• Gabapentin/topiramate - alternatives that decrease desire

Gambling disorder — the only behavioral addiction with its own DSM-5 diagnosis

• ≥ 4 criteria in 12 months: preoccupation, needing to bet more (tolerance), restless/irritable when cutting back, "chasing losses," lying about gambling, jeopardizing relationships/job, relying on others for bailout money
• Highly comorbid with mood disorders, substance use, and suicidality — screen for all three
• Treatment: CBT and Gamblers Anonymous first-line; naltrexone has the best medication evidence

Headache is the hallmark of caffeine withdrawal

• Intoxication (> 250 mg, roughly 2–3 cups of coffee): restlessness, insomnia, flushed face, diuresis, GI upset, muscle twitching, tachycardia/arrhythmia, psychomotor agitation
• Withdrawal: headache, fatigue, drowsiness, irritability, difficulty concentrating — begins 12–24 hours after last dose, peaks at 1–2 days, resolves within about a week
• Treatment: supportive — analgesics for headache and a gradual taper rather than abrupt cessation

• Mechanism: mu receptor agonist
• Examples: morphine, heroin, methadone, fentanyl

Intoxication

• Constipation - no tolerance to this side effect
• Respiratory depression - life-threatening
• Pupillary constriction (pinpoint pupils)
• Seizures (overdose is life-threatening)
• For heroin use, look for track marks (needle injections)

Overdose treatment

• Naloxone — opioid receptor antagonist; repeat dosing may be needed with fentanyl and long-acting opioids (naloxone wears off first)
• Supportive care/airway management

Withdrawal

• Presentation
  • Anxiety, insomnia, anorexia, sweating, dilated pupils, piloerection ("cold turkey"),
  • Fever, rhinorrhea, nausea, stomach cramps, diarrhea ("flulike" symptoms)
  • Yawning
  • Unpleasant but not life-threatening
• Treatment of withdrawal
  • Clonidine/Guanfacine
    • α2 agonist that decreases NE and sympathetic output, making autonomic symptoms less intense
  • Methadone (long-acting)
  • Buprenorphine + naloxone
    • Can precipitate withdrawal if given too soon (partial mu agonist)

• Treatment of addiction — medication for opioid use disorder (MOUD) is standard of care
  • Buprenorphine/Suboxone (buprenorphine + naloxone)
    • Partial mu agonist; office-based prescribing (no special waiver required)
    • Naloxone is not active when taken orally, so withdrawal symptoms occur only if injected — intended to deter injection misuse
  • Methadone
    • Full agonist, long-acting; dispensed through opioid treatment programs for maintenance
  • Extended-release naltrexone — antagonist option; requires 7–10 days opioid-free before starting

Binds to CB1/CB2 cannabinoid receptors

• Intoxication
  • Euphoria, anxiety, disinhibition, paranoid delusions, perception of slowed time, conjunctival injection, impaired judgment, social withdrawal, ↑ appetite, dry mouth, hallucinations
  • Amotivational syndrome
  • Treatment:
    • No specific treatment
    • Symptomatic treatment only
• Withdrawal
  • Irritability, depression, insomnia, nausea, anorexia
  • Most symptoms peak in 48 hours and last for 5 - 7 days
  • Can be detected in urine up to 1 month after last use
  • Hyperemesis syndrome
    • In chronic cannabis users, individuals can experience chronic severe emesis; classically relieved by hot showers
    • Treatment: stop cannabis use (definitive), anti-emetics; topical capsaicin and haloperidol/droperidol often work when ondansetron fails
  • Treatment
    • No specific treatment
    • Symptomatic treatment only

Patient with CNS depression and a history of anxiety or panic disorder

Anxiolytics are medications such as benzodiazepines used for the treatment of anxiety disorders. They have additive effects with alcohol and tend to have a cumulative effect if doses are repeated indiscriminately.

• The mechanism is through GABAa channel-increased frequency of opening.
• Intoxication: respiratory depression, hypotension, amnesia, ataxia, stupor/somnolence, coma, death.
• Withdrawal: rebound anxiety, seizures (life-threatening) and tremor-most commonly found in short-acting benzos such as alprazolam.

TX: Treat life-threatening intoxication with flumazenil, a competitive benzodiazepine-receptor antagonist — use cautiously; can precipitate seizures in chronic users

• Treat withdrawal with a long-acting benzodiazepine such as clonazepam with an appropriate taper.

PCP
A patient who is extremely aggressive and becomes enraged when sudden movements or loud sounds are made.

• Mechanism: NMDA receptor antagonist - Ketamine is a similar drug
• Intoxication
  • Belligerence, impulsiveness, fear, homicidality, psychosis, delirium, seizures, psychomotor agitation, vertical and horizontal nystagmus, tachycardia, ataxia
  • Treatment
    • Pharmacologic
      • Benzodiazepines
      • Antipsychotics (haloperidol)
    • Further management
      • Low stimulus environment
      • Restraints, if needed, to prevent the patient from hurting self/others
• Withdrawal
  • Depression, anxiety, irritability, restlessness, anergia, disturbances of thought and sleep
  • Treatment: no specific treatment - symptomatic treatment only

LSD
Patient wants to hurt himself. They say that he has "been freaking out" and seeing things that are not there.

• Mechanism: action at the 5-HT receptor
• Intoxication
  • Visual hallucinations and synesthesias (e.g., seeing sound as color)
  • Marked anxiety or depression, delusions, pupillary dilation
  • "bad trip" panic
• Treatment
  • Pharmacologic
    • Benzodiazepines
    • Antipsychotics (e.g., haloperidol) if severe
    • Talking down, supportive counseling
• Withdrawal
  • Largely no withdrawal because it does not affect dopamine
  • Flashbacks can occur years later
• Treatment: no specific treatment - symptomatic treatment only

Cocaine: blocks biogenic amine (Dopamine (DA), norepinephrine (NE), and Serotonin (5-hydroxytryptamine; 5-HT)) reuptake

• Intoxication:
  • Mental status changes
    • Euphoria, psychomotor agitation, grandiosity, hallucinations (including tactile), paranoid ideations
  • Sympathetic activation
    • ↓ appetite, tachycardia, pupillary dilation, hypertension, angina
    • Can cause severe vasospasm
      • MI - coronary vasospasm
      • Placental infarction - vasospasm of placental vessels
      • Nasal septum perforation - Kiesselbach's plexus vasospasm
      • Stroke - CVA
  • Stereotyped behavior
    • Repetitive motions (eg, digging through trash)
  • Treatment
    • Pharmacologic
      • Benzodiazepines first-line for agitation, hypertension, and chest pain
      • Antipsychotics (haloperidol) for psychosis
      • Antihypertensives (labetalol - need alpha-1 blockade; avoid pure beta-blockade)
    • Non-pharmacologic
      • Do not restrain patients - may result in rhabdomyolysis
• Withdrawal
  • Severe depression and suicidality
  • Hyperphagia, hypersomnolence, fatigue, malaise
  • Severe psychological craving
  • Treatment
    • Supportive; treat depression if it persists (SSRIs); monitor for suicidality during the "crash"

Amphetamines: methamphetamine, dextroamphetamine (Dexedrine), methylphenidate (Concerta).
Stimulates biogenic amine (Dopamine (DA), norepinephrine (NE), and Serotonin (5-hydroxytryptamine; 5-HT) release + decreases reuptake (high dose)

• Intoxication
  • Mental status changes
    • Euphoria, impaired judgment, delusions, hallucinations, prolonged wakefulness/attention
  • Sympathetic activation
    • Psychomotor agitation, pupillary dilation, hypertension, tachycardia, fever, cardiac arrhythmias
  • Treatment
    • Pharmacologic
      • Benzodiazepines first-line
      • Antipsychotics (haloperidol) for psychosis
      • Antihypertensives as needed
    • Non-pharmacologic
      • Do not restrain patients - may result in rhabdomyolysis; active cooling for hyperthermia

Mechanism: unknown

• Intoxication
  • Belligerence, assaultiveness
  • Apathy, impaired judgment
  • Blurred vision, coma
  • Look for a perioral or perinasal rash ("glue-sniffer's rash") in an adolescent with brief episodes of intoxication
  • "Sudden sniffing death" — fatal arrhythmia can occur with first use
• Treatment
  • No specific treatment - supportive
  • Antipsychotics (haloperidol) if severe aggression
• Withdrawal
  • Not well characterized, no treatment
  • Abuse of other drugs is commonly seen in these patients

Cigarette smoking is the leading preventable cause of death in the United States.

• Cigarette smoking causes more than 480,000 deaths each year in the United States. This is nearly one in five deaths.
• Intoxication: restlessness, insomnia, anxiety, arrhythmias
• Withdrawal: irritability, headache, anxiety, weight gain, craving

Treatment for cessation — every patient, every visit: ask + advise + offer treatment

• Varenicline: partial nicotine receptor agonist — most effective single agent, especially combined with nicotine replacement
• Combination nicotine replacement (patch + short-acting gum/lozenge) — first-line alternative
• Bupropion — useful with comorbid depression; avoid in seizure disorders and eating disorders
• Pair every medication with behavioral counseling/quitline support — combination beats either alone

Same symptoms as PTSD, but lasting 3 days to 1 month after the trauma

• Intrusion, negative mood, dissociation, avoidance, and arousal symptoms following a traumatic event
• Symptoms beyond 1 month → rediagnose as PTSD
• Treatment: trauma-focused CBT — reduces progression to PTSD; benzodiazepines are not recommended and may worsen outcomes

The patient has experienced a traumatic event and has intrusion (flashbacks, nightmares), avoidance, negative mood/cognition, and hyperarousal symptoms

• Symptoms persist past 1 month — before 1 month, the diagnosis is acute stress disorder
• Treatment: trauma-focused psychotherapy first-line (CPT, prolonged exposure, EMDR) and/or SSRIs/SNRIs (sertraline, paroxetine, venlafaxine)
• Prazosin for trauma-related nightmares; benzodiazepines are not recommended in PTSD

Out-of-proportion distress within 3 months of an identifiable stressor (divorce, job loss, diagnosis) that does not meet criteria for another disorder

• Symptoms begin within 3 months of the stressor and resolve within 6 months once the stressor ends
• Specifiers: with depressed mood, with anxiety, with disturbance of conduct, or mixed
• Treatment: psychotherapy first-line; short-term symptom-targeted medication only if needed

Intense yearning or preoccupation with the deceased, nearly every day, ≥ 12 months after the death (≥ 6 months in children)

• Newest DSM diagnosis in this category (added in DSM-5-TR) — grief that exceeds cultural norms and impairs functioning
• Features: identity disruption ("part of me died"), disbelief, avoidance of reminders, emotional numbness, feeling life is meaningless
• Treatment: grief-targeted psychotherapy (complicated grief therapy) — more effective than antidepressants for the grief itself; treat comorbid MDD if present

Normal grief after a loss — comes in waves triggered by reminders, with preserved self-esteem

• Can normally include transient hallucinations of the deceased (hearing their voice) with intact insight
• vs MDD: pervasive depressed mood, worthlessness, guilt unrelated to the deceased, suicidal ideation — a major depressive episode can be diagnosed during bereavement when criteria are met
• Treatment: support and time — no medication for normal grief

Nonphysical abuse — intimidation, humiliation, isolation from friends/family, threats, and control of money or daily activities

• Often precedes and accompanies physical violence; commonly the most long-lasting harm in intimate partner violence and elder abuse
• Clues: partner or caregiver who answers all questions and won't leave the room, patient who is withdrawn, anxious, or "checks in" before answering
• Management: interview the patient alone, validate, assess safety, document, and offer resources — same framework as other abuse

"Those who don't cruise rarely bruise" — any bruising in a non-mobile infant is abuse until proven otherwise

• Red flags: injury inconsistent with the history or developmental stage, changing story, delay in seeking care
• High-specificity injuries: posterior rib fractures, metaphyseal "corner" fractures, fractures in various stages of healing, patterned bruises/burns, stocking-glove immersion burns
• TEN-4 rule: bruising of Torso, Ear, or Neck in a child ≤ 4, or any bruising < 4 months old → evaluate for abuse
• Workup: skeletal survey in children < 2 years; consider head CT and dilated eye exam (retinal hemorrhages) in infants
• Clinicians are mandatory reporters — report suspicion to CPS; certainty is not required; neglect is the most common form of child maltreatment

A child with a history of severe neglect who is emotionally withdrawn and rarely seeks or responds to comfort when distressed

• Requires a history of grossly insufficient care (neglect, repeated changes of caregivers, institutional rearing); evident before age 5, developmental age ≥ 9 months
• Minimal social-emotional responsiveness, limited positive affect, unexplained irritability or fearfulness with caregivers
• Contrast: disinhibited social engagement disorder — same neglect history but overly familiar with strangers, will wander off with unfamiliar adults
• Treatment: establish one consistent, emotionally available caregiver + caregiver-child therapy — no medication treats RAD itself

Most common abuser = a caregiver the patient knows, most often an adult child or spouse; neglect is the most common form

• Clues: unexplained bruises in various stages, pressure ulcers, dehydration/malnutrition, poor hygiene, missing medications or missed appointments, sudden financial changes
• Interview the patient alone; screening tools such as the EASI (Elder Abuse Suspicion Index) can help
• Report suspected elder abuse to Adult Protective Services — mandatory for clinicians in nearly every state

• Acute assault: refer to a trained forensic examiner (SANE) — evidence collection ideally within 72–120 hours; do not "pre-examine" and contaminate evidence
• Offer STI prophylaxis, HIV post-exposure prophylaxis, and emergency contraception; provide trauma-informed support and follow-up
• A normal genital exam does NOT rule out sexual abuse — most examinations of abused children are normal
• Mandatory reporting for minors; any STI in a prepubertal child (beyond the perinatal period) should prompt an abuse evaluation

Screen all women of reproductive age (USPSTF) — always privately, never with the partner in the room

• Clues: injuries in various stages of healing, central/defensive-pattern injuries, partner who won't leave, vague or inconsistent explanations, frequent visits
• Validated screens: HITS, HARK; pregnancy is a period of increased risk
• The most dangerous time is when the patient attempts to leave the relationship — safety planning comes before any push to leave
• Management: validate, document objectively (photos, quotes), safety plan, resources — reporting for competent adults is generally NOT mandatory without consent (state laws vary; injuries from weapons often are reportable)

• Suspect with patterned injuries (loop/cord marks, cigarette burns, immersion burns with sharp demarcation), injuries in multiple stages of healing, or central injuries (torso, neck, face)
• History inconsistent with the injury, story that changes between tellings, or delay in seeking care
• Document precisely (body diagrams, photographs, patient's own words in quotes) — the chart is a legal document
• Report per population: children and elders/dependent adults → mandatory; competent adults → support and safety planning, report only per state law/consent

Patient consciously reports false symptoms, or induces symptoms, with the goal of playing the "sick role.

A condition in which a person, without a motive for external reward, acts as if they have an illness by deliberately producing, feigning, or exaggerating symptoms, purely to attain (for themselves or for another) a patient's role.

• vs malingering: symptoms are feigned for external gain (money, work excuse, drugs) — malingering is not a mental disorder

Factitious disorder imposed on self (Munchausen syndrome)

• The patient falsifies physical or psychological symptoms or induces injury or disease to themselves
• When in another person (e.g., a child) it is termed factitious disorder imposed on another (Munchausen syndrome by proxy)

Treatment:

• Nonconfrontational, supportive approach coordinated between the PCP and the psychiatrist; minimize unnecessary procedures
• In factitious disorder imposed on another (e.g., in a child)
  • This is child abuse — report and ensure the child's safety via child protective services

A school-age child with recurrent stomachaches every school morning that vanish on weekends

• Developmentally excessive fear of separation from attachment figures — worry about harm to caregivers, refusal to sleep alone or attend school, somatic complaints on separation
• Duration: ≥ 4 weeks in children/adolescents, ≥ 6 months in adults — no longer a childhood-only diagnosis
• Treatment: CBT first-line (graded exposure, parent coaching); add an SSRI for moderate-severe cases; prompt return to school beats avoidance

Neurologic symptoms (weakness, nonepileptic spells, blindness) incompatible with recognized disease — diagnosed by positive rule-in signs, not by exclusion

• Rule-in findings: Hoover sign (hip extension weakness that normalizes with contralateral hip flexion), tremor entrainment, eyes-closed resistance during a "seizure"
• Often follows an acute stressor; "la belle indifférence" is classic but not reliable for diagnosis
• Treatment: explain the diagnosis positively (real, common, reversible), then CBT and physical therapy; treat comorbid depression/anxiety

Marked fear of scrutiny by others — public speaking, eating in public, meeting strangers — lasting ≥ 6 months

• Fear of acting in a way that will be negatively evaluated (humiliating, embarrassing); situations are avoided or endured with intense distress
• May coexist with avoidant personality disorder
• Treatment: SSRI/SNRI + CBT first-line
• Performance-only subtype: propranolol (or a benzodiazepine) as needed before events — the classic board answer

Excessive anxiety and worry about multiple domains occurring more days than not for at least 6 months, with ≥ 3 of: restlessness, fatigue, poor concentration, irritability, muscle tension, sleep disturbance

• Treatment: SSRI or SNRI first-line + CBT
• Buspirone is a non-sedating, non-habit-forming adjunct; avoid long-term benzodiazepines

≥ 1 distressing physical symptom + excessive thoughts, feelings, or behaviors about it

• More than 1 somatic symptom(s) which are distressing to the patient or lead to significant disruption in the patient's life
• The patient experiences excessive thoughts, feelings, and behaviors in relation to their somatic symptoms or their health concerns
• Persistently symptomatic state typically > 6 months (the symptom focus may shift)
• vs illness anxiety disorder: there the anxiety is about having a disease with minimal or no somatic symptoms

Treatment

• Have a single clinician as the designated primary caretaker
  • Schedule regular short visits and CBT
  • Avoid unnecessary diagnostic testing unless indicated

Obsession with the idea of having a serious but undiagnosed medical condition — with few or no actual somatic symptoms

• Patients are worried about having or developing a serious illness and
• This preoccupation has been present for at least 6 months and
• Is not better explained by another mental disorder (e.g., obsessive-compulsive disorder and somatic symptom disorder)

Treatment:

• Regular scheduled appointments with a single provider for reassurance
• CBT; SSRIs if concurrent/underlying anxiety or major depressive disorder

Recurrent UNEXPECTED panic attacks + ≥ 1 month of worry about further attacks or maladaptive behavior change

• Attacks peak within minutes: palpitations, sweating, trembling, dyspnea, chest pain, paresthesias, fear of dying or losing control — rule out cardiac, thyroid, and stimulant causes first
• At least one attack is followed by 1 month (or more) of one or both of the following:
  • Persistent concern or worry about additional panic attacks or their consequences
  • A significant maladaptive change in behavior related to the attacks (agoraphobic avoidance)
• Treatment: SSRI first-line + CBT; benzodiazepines only as a short-term bridge while the SSRI takes effect

Psychosis lasting ≥ 1 day but < 1 month with FULL return to baseline functioning

• ≥ 1 of: delusions, hallucinations, disorganized speech, or grossly disorganized/catatonic behavior — often after an acute stressor
• Classic setting: postpartum onset — postpartum psychosis is an emergency (infanticide/suicide risk) — hospitalize
• Duration ladder: < 1 month = brief psychotic → 1–6 months = schizophreniform → ≥ 6 months = schizophrenia
• Treatment: short-course second-generation antipsychotic + safety monitoring

A mental health condition, including schizophrenia and mood disorder symptoms.

Schizoaffective disorder is a combination of symptoms of schizophrenia and mood disorder, such as depression or bipolar disorder. Symptoms may occur at the same time or at different times.

• Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode (depressive or manic) during the lifetime duration of the illness.
• Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of the illness.

Treatment:

• Psychotherapy
• Pharmacologic - atypical antipsychotic agents, mood stabilizers, and Selective Serotonin Reuptake Inhibitors (SSRI) depending on the mood component

Mute, immobile patient who holds any posture you place them in (waxy flexibility) — give lorazepam and watch them "wake up"

• ≥ 3 of 12 features: stupor, catalepsy, waxy flexibility, mutism, negativism, posturing, mannerisms, stereotypies, agitation, grimacing, echolalia, echopraxia
• Occurs more often with mood disorders (depression, bipolar) than with schizophrenia; also seen with medical illness
• DX: lorazepam challenge — rapid improvement supports the diagnosis
• Treatment: benzodiazepines (lorazepam) first-line → ECT if refractory
• ⚠️ Malignant catatonia (fever + autonomic instability) is life-threatening — stop antipsychotics (overlaps with NMS) and move to ECT early

Major psychosis for greater than 6 months + difficulty functioning

• Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3):
  1. Delusions
  2. Hallucinations - auditory (most common), tactile, olfactory, visual
  3. Disorganized speech/thought processes - unable to stay on topic (loose associations), unable to provide answers related to questions (tangential response)
  4. Grossly disorganized or catatonic behavior - unpredictable agitation, child-like silliness, lacking self-care/hygiene
  5. Negative symptoms - blunted affect, avolition, alogia, asociality, anhedonia
• Continuous signs of the disturbance persist for at least 6 months with functional decline (work, relationships, self-care)

Treatment:

• Second-generation (atypical) antipsychotics first-line: (risperidone, olanzapine, aripiprazole, ziprasidone, quetiapine, paliperidone, lurasidone) — fewer extrapyramidal side effects; monitor for metabolic syndrome (weight, glucose, lipids)
• First-generation (typical) antipsychotics (haloperidol, fluphenazine, chlorpromazine) — effective for positive symptoms; higher risk of EPS/tardive dyskinesia
• Clozapine for treatment-resistant schizophrenia (failure of 2 adequate antipsychotic trials) and for persistent suicidality — requires ANC monitoring for severe neutropenia
• Long-acting injectables for nonadherence; behavior-oriented/group/family therapy and supported employment improve outcomes
• Watch for side effects: extrapyramidal symptoms, neuroleptic malignant syndrome, tardive dyskinesia (more likely with typicals); metabolic syndrome (more likely with atypicals)

Otherwise normally functioning person with a fixed false belief lasting more than 1 month

One or more delusions—such as beliefs that occur in real life, such as being poisoned, being stalked, being loved or deceived, or having an illness, provided no other symptoms of schizophrenia are exhibited.

• No accompanying prominent hallucinations, thought disorder, mood disorder, or significant flattening of affect.
• Beliefs lasting > 1-month
• Functioning is otherwise unimpaired — behavior is not obviously bizarre outside the delusion's scope

Treatment

• Psychotherapy — build alliance without directly confronting the delusion
• Pharmacologic - atypical antipsychotic agents (often only partially effective)

Schizophrenia-criteria symptoms lasting ≥ 1 month but < 6 months

• Same criterion-A symptoms as schizophrenia — the difference is duration: at least 1 month but less than 6 months
• Functional decline is not required for the diagnosis (unlike schizophrenia)
• About two-thirds progress to schizophrenia once symptoms pass 6 months — re-evaluate at the 6-month mark

Treatment:

• Second-generation antipsychotic is the usual drug of choice + psychotherapy
• Non-responders: switch antipsychotics or add a mood stabilizer; monitor closely for progression

Patient who refuses to eat due to fear of being overweight

• Significantly low body weight + intense fear of gaining weight + disturbed body image with denial of the seriousness of low weight
• Severity tracks with BMI (mild ≥ 17 → extreme < 15); amenorrhea is common but no longer required for the diagnosis
• Distinguished from bulimia by low weight — bulimia patients are typically normal weight or overweight
• The highest mortality of any psychiatric disorder (starvation + suicide)

Two types

• Binge-eating/purging
  • Laxatives/diuretics abuse
  • Self-induced vomiting
• Restricting
  • Eat very little
  • Exercise to excess

Treatment:

• Restore nutritional state — ⚠️ refeed slowly and monitor phosphorus: refeeding syndrome (hypophosphatemia, arrhythmias) kills
• Hospitalize for < 70–75% expected body weight, bradycardia < 40, hypotension, hypothermia, electrolyte derangement, or arrhythmia
• Psychotherapy is the core treatment — CBT for adults; family-based treatment (Maudsley) for adolescents
• Pharmacologic: no medication reliably treats anorexia itself — olanzapine has modest evidence for weight restoration; avoid bupropion in any purging patient (seizure risk)

Patient who has episodes of mass eating followed by self-induced vomiting or intense exercise

Frequent binge eating with recurrent compensatory behavior (purging, laxatives, fasting, exercise)

• Purging is commonly performed by self-induced vomiting, resulting in hypokalemic metabolic alkalosis, urinary chloride < 20mEq, and volume depletion
  • May abuse laxatives/diuretics
  • May 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 (Russell sign), swollen parotid glands + dental erosions + normal weight + hypokalemia

Treatment:

• CBT + nutritional rehabilitation is first-line
• Fluoxetine 60 mg PO once/day is the FDA-approved medication (higher than the usual depression dose) — reduces binge/purge frequency
• Bupropion is contraindicated — seizure risk in purging patients

Severe food restriction WITHOUT any body-image disturbance or fear of weight gain — that's the whole distinction from anorexia

• Restriction driven by sensory aversion (textures, smells), fear of a bad outcome (choking, vomiting after an aversive event), or simple lack of interest in eating
• Consequences define the diagnosis: weight loss or faltering growth, nutritional deficiency, dependence on supplements/tube feeds, or impaired functioning
• Typically begins in childhood; common in autism spectrum disorder
• Treatment: nutritional rehabilitation + CBT-AR (graded food exposure); treat deficiencies (iron, vitamins)

Recurrent binges with loss of control and marked distress — but NO compensatory purging, fasting, or excessive exercise

• ≥ 1 binge/week for 3 months: eating rapidly, until uncomfortably full, when not hungry, alone out of embarrassment, followed by guilt/disgust
• The most common eating disorder in the US; patients are typically overweight or obese
• vs bulimia: no compensatory behavior — that single feature separates the two
• Treatment: CBT first-line; lisdexamfetamine (Vyvanse) is FDA-approved; SSRIs and topiramate are alternatives

An 8-year-old who is disruptive in class, constantly fidgeting, has difficulty concentrating, and does not complete assignments.

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

• Hyperactivity, impulsivity, or inattentiveness with several symptoms manifesting prior to age 12 years.
• ≥ 6 symptoms of inattention and/or hyperactivity-impulsivity (≥ 5 for age ≥ 17), developmentally inappropriate, for > 6 months
• Symptoms must occur in more than one setting (for example, school and home)

Treatment:

• Age 4–5: parent training in behavior management first-line before medication
• Age ≥ 6: stimulants first-line (methylphenidate, mixed amphetamine salts) + behavioral therapy
• Nonstimulant alternatives: atomoxetine, guanfacine ER, clonidine ER (comorbid tics, substance-use concerns, or stimulant intolerance)

Two or more distinct personality states with recurrent gaps in memory for everyday events — strongly linked to severe childhood trauma

• Disruption of identity with marked discontinuity in sense of self, plus amnesia beyond ordinary forgetting (lost time, unexplained purchases)
• Highest association with chronic childhood abuse of any psychiatric disorder; high comorbid PTSD and suicidality
• Treatment: trauma-focused, phased psychotherapy; medications only for comorbid conditions

A neurodevelopmental disorder with a developmental delay in socialization, language, and cognition

• DSM-5 folded the former subtypes (autistic disorder, Asperger disorder, childhood disintegrative disorder, PDD-NOS) into the single diagnosis of ASD, graded by support needs (levels 1–3)

DSM-5 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)
• Screen all children with the M-CHAT-R at 18 and 24 months (AAP)

Treatment:

• Early intensive behavioral intervention (e.g., ABA-based), speech & language therapy, occupational therapy
• Audiology evaluation to exclude hearing loss; genetic testing (fragile X, chromosomal microarray) is standard of care
• Medications treat targets, not autism itself:
  • Risperidone or aripiprazole — FDA-approved for irritability/aggression in ASD
  • SSRIs sometimes used for repetitive behavior/anxiety (evidence modest)

Deficits in BOTH intellectual functioning AND adaptive functioning, with onset during the developmental period

• Severity (mild → profound) is graded by adaptive functioning (conceptual, social, practical skills), not by IQ score alone
• Most common genetic cause: Down syndrome; most common inherited cause: fragile X syndrome; most common preventable cause: fetal alcohol exposure
• Workup: hearing and vision testing, chromosomal microarray + fragile X testing, metabolic screening as indicated
• Management: early intervention services, individualized education plan (IEP), family support; treat comorbid conditions

"I feel like I'm watching myself from outside my body" — with reality testing INTACT

• Depersonalization: detachment from one's own body, thoughts, or actions (an outside observer)
• Derealization: surroundings feel unreal, dreamlike, foggy, or distorted
• Intact reality testing separates this from psychosis — the patient knows the experience is "not real"
• Rule out substances (cannabis, hallucinogens, ketamine), seizures, and panic attacks
• Treatment: psychotherapy (CBT, grounding techniques); treat comorbid anxiety/depression

Rhythmic, purposeless, PATTERNED movements (hand flapping, body rocking, head banging) starting in early childhood

• Onset in the early developmental period (typically < 3 years); movements are fixed in form and can cause self-injury
• vs tics: stereotypies start earlier, are rhythmic and prolonged, and stop with distraction; tics are brief, variable, preceded by an urge, and suppressible
• Common in intellectual disability and autism; specify with or without self-injurious behavior
• Treatment: behavioral interventions (habit reversal, environmental modification); protect from self-injury

Sudden inability to recall important autobiographical information — usually traumatic or stressful — beyond ordinary forgetting

• Memory for personal identity/events is lost while general knowledge and new learning remain intact
• May include dissociative fugue: sudden, purposeful travel or wandering with amnesia for identity
• Rule out head injury, seizures, substances, and transient global amnesia
• Treatment: safe environment + psychotherapy; memory typically returns — avoid pressured "memory recovery" techniques

Tourette disorder = BOTH multiple motor tics AND ≥ 1 vocal tic for > 1 year, onset before age 18

• Tics: sudden, rapid, nonrhythmic movements or vocalizations — preceded by a premonitory urge, briefly suppressible, wax and wane, worsen with stress
• Persistent (chronic) motor OR vocal tic disorder = one type only for > 1 year; provisional tic disorder = < 1 year
• Highly comorbid with ADHD and OCD — screen for both
• Treatment: reassurance for mild tics; CBIT (Comprehensive Behavioral Intervention for Tics) first-line; then alpha-2 agonists (guanfacine, clonidine), especially with comorbid ADHD; antipsychotics/VMAT2 inhibitors for refractory, impairing tics

Normal sleep at the WRONG time — the sleep itself is fine once it happens

• Delayed sleep phase (the classic teenage "night owl" — can't fall asleep or wake early), advanced sleep phase (older adults — early to bed, 3 a.m. waking), shift work, and jet lag types
• DX: sleep diary ± actigraphy for 1–2 weeks — no polysomnography needed unless another disorder is suspected
• Treatment: timed bright-light exposure + timed low-dose melatonin and consistent scheduling — light in the morning and evening melatonin for delayed phase (reverse for advanced phase)

Irresistible "sleep attacks" + cataplexy — sudden loss of muscle tone triggered by laughter or strong emotion

Classic tetrad:

• Excessive daytime sleepiness — naps are short and refreshing
• Cataplexy — emotion-triggered loss of tone with preserved consciousness (type 1)
• Hypnagogic (falling asleep) and hypnopompic (on waking) hallucinations
• Sleep paralysis — brief inability to move on waking

Caused by loss of hypothalamic hypocretin (orexin) neurons in type 1; onset typically in adolescence/young adulthood

• DX: overnight polysomnography + next-day multiple sleep latency test (MSLT) — mean sleep latency ≤ 8 minutes with ≥ 2 sleep-onset REM periods; low CSF hypocretin-1 is diagnostic for type 1
• Treatment: modafinil first-line for sleepiness + scheduled naps; sodium oxybate treats both sleepiness and cataplexy; pitolisant or SNRIs/SSRIs for cataplexy; traditional stimulants (methylphenidate, amphetamines) remain options

Excessive daytime sleepiness DESPITE ≥ 7 hours of sleep — with long unrefreshing naps and severe sleep inertia ("sleep drunkenness")

• Recurrent daytime sleep episodes or prolonged nonrestorative nighttime sleep, ≥ 3×/week for ≥ 3 months with impairment
• vs narcolepsy: naps are long and unrefreshing, no cataplexy, no sleep-onset REM on MSLT
• Rule out obstructive sleep apnea, insufficient sleep, medications, and depression first
• Treatment: modafinil first-line; methylphenidate/amphetamines are alternatives

NREM events (sleepwalking, sleep terrors) = first third of the night, no recall; nightmares = second half, vivid recall

NREM arousal disorders (children, first third of night, amnesia for the event)

• Sleepwalking — blank stare, unresponsive, no memory; treatment is safety measures + reassurance (locks, alarms, clear floors)
• Sleep terrors — abrupt scream, intense autonomic arousal (tachycardia, sweating, mydriasis), inconsolable, no recall — vs nightmares, which are remembered

REM parasomnias

• Nightmare disorder — dysphoric, well-remembered dreams in the second half of the night; image rehearsal therapy; prazosin when trauma-related
• REM sleep behavior disorder — loss of REM atonia with dream enactment (punching, yelling), typically older men; ⚠️ strong association with Parkinson disease and other α-synucleinopathies — often precedes them by years; treatment: bedroom safety + melatonin or clonazepam

CBT-I — not medication — is first-line for chronic insomnia

• Difficulty initiating or maintaining sleep, or early waking, ≥ 3 nights/week for ≥ 3 months with daytime impairment despite adequate opportunity to sleep
• Treatment: cognitive behavioral therapy for insomnia (CBT-I) — stimulus control, sleep restriction, sleep hygiene, relaxation
• If medication is needed: orexin receptor antagonists (suvorexant, lemborexant, daridorexant), ramelteon, or low-dose doxepin; z-drugs (zolpidem) only short-term
• ⚠️ Avoid benzodiazepines and z-drugs in older adults (Beers criteria) — falls, fractures, confusion

The diagnosis requires marked incongruence between experienced and assigned gender for ≥ 6 months PLUS clinically significant distress or impairment

• Incongruence alone is not a disorder — the distress is what defines gender dysphoria
• High rates of comorbid depression, anxiety, and suicidality, driven substantially by stigma and lack of support — screen and treat actively
• Management: gender-affirming, multidisciplinary care — psychosocial support first for all ages; puberty suppression, hormone therapy, and surgical options are individualized by specialty teams per current standards of care
• A supportive clinical environment (correct name/pronouns, nonjudgmental history-taking) measurably improves mental health outcomes

Umbrella for paraphilic disorders and sexual dysfunctions

• Paraphilic disorders (exhibitionistic, voyeuristic, fetishistic, sexual masochism, pedophilic): an atypical arousal pattern becomes a disorder only when it is acted on with a nonconsenting person or causes clinically significant distress/impairment, over ≥ 6 months
• Sexual dysfunctions (female sexual interest/arousal disorder, male hypoactive sexual desire disorder, erectile disorder, genito-pelvic pain/penetration disorder): symptoms ≥ 6 months causing distress
• Always rule out medical causes, medications (SSRIs, antihypertensives), substances, and relationship factors before diagnosing a primary sexual dysfunction
• Treatment: psychotherapy/sex therapy for most; SSRIs (+ CBT) for paraphilic disorders with compulsive features; address the offending medication or medical cause in dysfunctions

A person's internal sense of their own gender — distinct from sex assigned at birth and from sexual orientation (who a person is attracted to)

• Gender identity that differs from assigned sex is not itself a mental disorder — only dysphoria (distress) is diagnosed and treated
• Take an inclusive history: ask name/pronouns, use an organ inventory to guide screening (e.g., cervical cancer screening for anyone with a cervix)
• Terms to know for the exam: cisgender, transgender, nonbinary; a transgender man is a man who was assigned female at birth

Sociopath - a lack of remorse and no concern for others

A disregard for and violation of the rights of others, with a lack of remorse, which commonly results in criminality

• males > females
• Conduct disorder if < 18 years
  • rule out substance use, sexual abuse, and possible normal behavior
• Classic triad: set fires, torture animals, bedwetting

Concerned about what others think of them and need admiration

Need for admiration, grandiose thoughts, concerned about what others think, yet lack empathy

• Sense of entitlement
• Lacks empathy
• Reacts to criticism with rage

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.

• Patients tend to be hypersensitive to rejection and socially inhibited, resulting from feelings of inadequacy
• Desires relationships with others (vs. schizoid)

Focus on obsessions - repetition of compulsive behaviors

Two components

• Obsessions: Recurring, intrusive thoughts that cause severe distress and impairment
• Compulsions: Performance of repetitive actions (rituals) in an attempt to neutralize the obsessions
  • e.g., hand washing, checking - the primary goal is to not lose control
  • The disorder is ego-dystonic: behavior inconsistent with one's own beliefs and attitudes - separates OCD from obsessive compulsive personality disorder
• Associated conditions - Tourette's disorder
• Treatment: SSRI (often high-dose) + exposure and response prevention (ERP); clomipramine second-line

A beautiful woman is noted to complain that her hands are too big, yet they appear well-formed and appropriate.

Preoccupation with an imagined defect in physical appearance/exaggerated distortion of a minor flaw

• Common concerns – face/hair/skin/breasts/genitalia
• High comorbidity with depressive/anxiety disorders; linked to psychotic disorder & OCD
• Repetitive behaviors (mirror checking, grooming, reassurance seeking) in response to the concern
• Treatment: SSRI + CBT — cosmetic procedures do not help and should be discouraged

Patients tend to be preoccupied with order, perfectionism, and control

• Ego-syntonic: the patient is not aware of their behavior causing issues, vs. OCD, which is ego dystonic

Black and white perception unstable interpersonal relationship

Borderline personality disorder presents with emotional instability, unstable relationships, and self-harming behavior

• Females > Males
• Splitting is a major defense mechanism
  • Relationships are either all good ("my boyfriend is a perfect angel") or all bad ("my boyfriend is evil and I hate him")
• Treatment: dialectical behavior therapy (DBT) is the best-validated treatment

Paranoid personality disorder is characterized by persistent feelings of suspiciousness and mistrust of other people.

• Excessive distrust and suspicion
• Higher incidence in families with schizophrenia

Submissive and clingy with an excessive need to be taken care of resulting from a low self-esteem

Patients tend to have emotional aloofness, indifferent to praise or criticism, without bizarre or idiosyncratic thinking

• Exhibit voluntary social withdrawal
• Content with social isolation (vs avoidant)
• Limited emotional expression
• No association with schizophrenia

Attention-seeking, dramatic, seductive behaviors

Needs to be the center of attention. Very dramatic. Dresses for attention. Very shallow. Seductive and flirtatious.

• A large concern with appearance

Odd eccentric behavior and discomfort with social relationships

A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships

• Presents with eccentric behavior, magical thoughts, odd beliefs, and perceptual distortion
• These patients are able to function in society, though they struggle to maintain social relationships
• Patients may develop schizophrenia