Psychiatry

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Schizophrenia;

1. The diagnostic criteria provide clues: delusions, hallucinations, disorganized speech, grossly disorganized/catatonic behavior, and negative symptoms (flat affect, refusal to talk, avolition, apathy).

2. Time period important: < 1 month — acute psychotic disorder, 1—6 months = schizophreniform disorder, > 6 months = schizophrenia.

3. Positive symptoms: delusions, hallucinations, bizarre behavior, thought disorder (e.g., tangentiality, clanging).These symptoms respond to traditional antipsychotics (lialoperi-dol, cblorpromazme).

4. Negative symptoms ~ flat affect, alogia (no speech), avolition (apathy), anhedonia, poor attention.These symptoms respond poorly to traditional antipsychotics but may respond to clozapine or risperidone.

5. Good prognosis features: good premorbid functioning (most important); late onset; obvious precipitating factors; married; family history of mood disorders; positive symptoms; good support system.

6. Poor prognosis features: poor premorbid functioning (most important); early onset; no precipitating factors; single, divorced, or widowed; family history of schizophrenia; negative symptoms; poor support system.

7. Typical age of onset: 15-25 years for men (look for someone going to college and deteriorating); 2.5-35 years for women.

8. Roughly 1% of people have schizophrenia (in. all cultures).

9. In the U.S., most schizophrenic patients are born in the winter (not known why).

10. Up to 10% of schizophrenics eventually commit suicide (past attempt is best predictor of eventual success).

11. Antipsychotic medications are the mainstay of therapy, but psychosocial treatment has. been shown to improve outcome. Medications are used first, but the best treatment (as in most of psychiatry) is medications plus therapy.

Antipsychotic medications (see table, top of next page)

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Extrapyramidal side effects:

1. Acute dystonia: first few hours or days of treatment. The patient has muscle spasms or stiffness (e.g., torticollis, trismus), tongue protrusions and twisting, opisthotonos, and oculogyric crisis (forced sustained deviation of the head and eyes). Acute dystonia is most common in young men.Treat by giving antihistamines (diphenhydramine) or anticholinergics (benztropine, trihexyphenidyl).

2. Akathisia: first few days of treatment. The patient Iras a subjective feeling of restlessness. Look for constant pacing, alternate sitting and standing, and inability to sit still. Beta blockers can be tried for treatment.

3. Parkinsonism: first few months of treatment. The patient has stiffness, cogwheel rigidity, shuffling gait, mask-like facies, and drooling. Parkinsonism is most common in older women. Treat by giving antihistamines (diphenhydramine) or anticholinergics (benztropine, trihexyphenidyl).

4. Tardive dyskinesia: after years of treatment. Most commonly, the patient has perioral movements (darting, protruding movements of the tongue, chewing, grimacing, puckering). The patient also may have involuntary, choreoathetoid movements of head, limbs, and trunk. There is no known treatment for tardive dyskinesia. If you have to make a choice when the patient develops tardive dyskinesia, discontinue the antipsychotic and consider switching to clozapine.

5. Neuroleptic malignant syndrome: life-threatening condition that can develop at any time during treatment. The patient has rigidity, mutism, obtundation, agitation, high fever (up to 107°F), high creatine phosphokinase (often > 5000), sweating, and myoglobinuria. Treatment: first discontinue antipsychotic; then provide supportive care for fever and renal shutdown due to myoglobinuria; finally, administer dantrolene (just as in malignant hyperthermia).

Other antipsychotic medication pearls:

1. Dopamine blockade causes increases in prolactin (dopamine is a prolactin-inhi biting factor in the tuberoinfundibular tract), which may cause galactorrhea, impotence, menstrual dysfunction, and decreased libido.

2. Individual antipsychotic side effects: thioridazine causes retinal pigment deposits; clozapine causes agranulocytosis (white blood cells counts must be monitored); chlorpro-mazine causes jaundice and photosensitivity.

Bipolar disorder:

1. Mania is the only symptom required for a diagnosis of bipolar disorder, but a history of depression is common.

2. Look for classic symptoms such as decreased need for sleep, pressured speech, sexual promiscuity, shopping sprees, and exaggerated sell importance or delusions of grandeur.

3. Look for initial onset between 16-30 years old.

4. Lithium and valproic acid are first-line treatments. Choose lithium if both are options; choose carbamazepine if lithium fails. If valproic acid is a choice, choose valproic acid over carbamazepine.

Si. Antipsychotics may be needed if the patient becomes psychotic; use at the same time as mood stabilizer.

6. Bipolar II disorder is hypomania (mild mania without psychosis that does not cause occupational dysfunction) plus major depression.

7. Cyclothymia is at least 2 years of hypomania alternating with depressed mood (no full blown mania or depression),

8. Lithium causes renal dysfunction (diabetes insipidus), thyroid dysfunction, tremor, and central nervous system effects at toxic levels. Valproic acid causes liver dysfunction, and carbamazepine may cause bone marrow depression.

Suicide:

1. The major risk factors are age > 45 years, alcohol or substance abuse, history of rage or violence, prior suicide attempts, male sex (men commit suicide 3 times more often than women, but women attempt it 4 times more often than men), prior psychiatric history depression, recent loss or separation, loss of health, unemployment or retirement, and single, widowed, or divorced status.

2. If you have to choose, the best predictor of future suicide is a past attempt.

3. Always ask patients about suicide (it does not make them more likely to commit suicide). If you need to do so, hospitalize acutely suicidal patients against their will.

4. When patients come out of a deep depression, they are at increased risk of suicide. The antidepressant may begin to work, and the patient gets more energy—just enough to carry out suicide plans.

5. Suicide rates are rising the fastest in 15-24-year~olds, but the greatest risk is in people over age 65.

Depression:

1. Patients may not directly say,"I'm depressed," You have to watch for clues: change in sleep habits (classically, insomnia), vague somatic complaints, anxiety, low energy or fatigue, change in appetite (classically, decreased appetite), poor concentration, psychomotor retardation, and/or anhedonia (loss of pleasure).

2. Patients may or may not have obvious precipitating factors in history, such as loss of loved one, divorce or separation, unemployment or retirement, chronic or debilitating disease.

3. Depression is more common in females.

4. Treat with both antidepressants and psychotherapy (combination works better than medications alone).

5. Adjustment disorder with depressed mood; when a bad situation occurs, the patient does not handle it well and feels "bummed out" for < 6 months, but does not meet criteria for full-blown depression. For example, the patient gets a divorce, seems to cry a lot for the next few weeks, and leaves work early on most days.

6. Dystbymia: depressed mood on most days for more than 2 years, but no episodes of major depression, mania, hypomania, or psychosis.

7. Antidepressants can trigger mania or hypomania, especially in bipolar patients.

8. Tricyclic antidepressants (TCAs; e.g., nortriptyline, amitriptyline) prevent reuptake of norepinephrine and serotonin. They also block alpha-adreuergic receptors (watch for orthostatic hypotension, dizziness, and falls) and muscarinic receptors as well as cause sedation and lower the seizure threshold (especially bupropion, which technically is not a tricyclic). TCAs are dangerous in overdose primarily because of cardiac arrhythmias, which may respond to bicarbonate.

9. Selective serotonin reuptake inhibitors (SSRls; e.g., fluoxetine, paroxetine) prevent reuptake of serotonin only and have less serious side effects (insomnia, anorexia, sexual dysfunction).

10. Monoamine oxidase inhibitors (MAOIs; e.g., phenelzine, tranylcypromine) are older medications and not first-line agents.They may be good for atypical depression (look for hypersomnia and hyperphagia, the opposite of classic depression). When patients eat tyramine-containmg foods (especially wine and cheese), they may get a hypertensive crisis. Do not give MAOI at the .same time as SSRIs or meperidine; severe reactions may occur, possibly death.

11. Trazodone is famous because it can cause priapism (persistent, painful erection without sexual arousal or desire).

Normal vs. pathologic grief, mourning, bereavement:

1. Initial grief after a loss (e.g., death of a loved one) may include a state of shock, feeling of numbness or bewilderment, distress, crying, sleep disturbances, decreased appetite, difficulty with concentrating, weight loss, and guilt (survivor guilt) for up to I year—in other words, the same symptoms as depression.

2. It is normal to have an illusion or hallucination about the deceased, but a normal grieving person knows that it is an illusion or hallucination, whereas a depressed person believes that the illusion or hallucination is real.

3. Intense yearning (even years after the death) and even searching for the deceased are normal.

4. Feelings of worihlessness, psychomotor retardation, and. suicidal ideation are not normal expressions of grief; they are signs of depression.

Panic disorder: Look for ?,0-40~year-old patient who thinks that he or she is dying or having a heart attack but is healthy and has a negative work-up for organic disease. Patients often hyperventilate and are extremely anxious. A common association is agoraphobia (fear of leaving the house).Treat with SSRIs (e.g., fluoxetine).

Generalized anxiety disorder: patients worry about everything (e.g., career, family, future, relationships, money) at the same time. Symptoms are not as dramatic as in panic disorder; patients are just severe worriers. Treat with buspirone (nonaddicti.ve, nonsedating) or benzodiazepines (addictive, sedating).

Simple phobias: for example, to needles, blood products, animals, or heights. Treat with behavioral therapy (flooding, systematic desensitizatlon, biofeedback, mental imagery—know what these terms mean).

Social phobia: a specific simple phobia that is best treated with behavioral therapy. Beta blockers may be used, to reduce symptoms before a public appearance that cannot be avoided.

Posttraumatic stress disorder: look for someone who has been through a life-threatening event (Vietnam veteran, victim of severe accident or rape) who recurrently experiences the event in nightmares or flashbacks, tries to avoid thinking about it, and has depression or poor concentration as a result. Treat with group therapy, if you have to choose a medication, use imipramine or phenelzine (MAOI).

Homosexuality and homosexual experimentation are not considered a disease at any age; they are normal variants. Kinky fantasies or occasional kinky activities (a man wearing women's underwear, mild foot fetish) are normal.

Somatoform disorders: patients do not behave inappropriately on purpose. Treat with frequent return clinic visits and/or psychotherapy.

1. Somatization disorder: multiple difieren! complaints in multiple different organ systems over many years with extensive work-ups in the past.

2. Conversion disorder: obvious precipitating factor (figl.it with boyfriend) followed by un-explainable neurologic symptoms (blindness, stocking-and-glove numbness).

3. Hypochondriasis: patients keep believing that they have the same disease despite extensive negative work-up.

4. Body dysmorphic disorder: preoccupation with imagined physical defect (e.g., a teenager who thinks that his or her nose is too big when it is of normal size).

Somatoform disorders vs. factitious disorder vs. malingering:

1. Somatoform disorders: patients do not intentionally create symptoms.

2. Factitious disorders: patients intentionally create their illness or symptoms (e.g., inject: themselves with insulin to provoke hypoglycemia) and subject themselves to procedures to assume the role of a patient, (no financial or other secondary gain).

3. Malingering: patients intentionally create their illness for secondary gain (e.g., money, to get out of work).

Dissociative fugue/psychogenic fugue: the patient has amnesia and travels, assuming new identity.

Multiple personality disorder: most likely to be associated with childhood sexual abuse.

Adjustment disorder: normal life experience (e.g., relationship break-up, failing grade, loss of job) is not handled well. Patients often are depressed (adjustment disorder with depressed mood) but do not meet the criteria for full-blown depression. For example, a high-school girl who breaks up with her boyfriend may mope around the house, crying and not wanting to attend school or go out with her friends for I week.

Personality disorders are lifelong disorders with no real treatment, although psychotherapy may be tried:

1. Paranoid: patients think that everyone is out to get them (friends, too) and often start law-suits.

2. Schizoid: the classic loner; no friends and no interest in having friends.

3. Schizotypal: bizarre beliefs (extrasensory perception, cults, superstition, illusions) and manner of speaking but no psychosis.

4. Avoidant: patients have no friends but want them; they are afraid of criticism or rejection and avoid others (inferiority complex).

5. Histrionic: overly dramatic, attention-seeking, and inappropriately seductive; the patient must be the center of attention.

6. Narcissistic: egocentric and lacking empathy; patients use others for their own gain or have a sense of entitlement.

7. Antisocial: most frequently tested personality disorder. Patients have long criminal record (con-men) and torture animals or set fires as children (a history of conduct disorder is required for this diagnosis).They are aggressive, do not pay bills or support children, often lie, and have no remorse or conscience. Strong association with alcoholism or drug abuse and somatization disorder. Most patients are male.

8. Borderline: unstable mood, behavior, relationships (many bisexual), and self-image. Look for splitting (people are all good or all bad and may frequently change categories), suicide attempts, micropsychotic episodes (2 minutes of psychosis), impulsiveness and constant crisis (see Gienn Close in Fatal Attraction).

9. Dependent: patients cannot be (or do anything) alone; a wife stays with an abusive husband; highly dependent on others.

10. Obsessive-compulsive: anal-retentive, stubborn; rules more important than objectives; restricted affect, cheap.

Obsessive-compulsive disorder: patients have recurrent thoughts or impulses (obsessions) and/or recurrent behaviors/acts (compulsions) that cause marked dysfunction in occupational and/or interpersonal lives. Look for washing (wash hands 30 times a day) and/or checking rituals (check to see if door is locked 30 times a day). Onset usually is in adolescence or early adulthood.Treat with SSRIs or clomipramine. Behavioral therapy also may be effective (e.g., flooding).

Narcolepsy: daytime sleepiness; decreased rapid-eye-movement (REM) latency (patients go into REM as soon as they fall asleep); cataplexy (loss of muscle tone, falls); hypnopompic (as patient wakes up) and hypnagogic (as patient falls asleep) hallucinations.Treat with amphetamines.

Note: Patients can be hospitalized against their will if they are a danger to themselves (suicidal or unable to take care of themselves) or others (homicidal).

Many different psychological tests are available to aid in a difficult diagnosis; they are not used for a straightforward case. There are two types of tests: objective (multiple choice, scored by a computer) and subjective (no right answer, scored by test giver):

1. Stanford-Binet: objective IQ test for adults.

2. Wechsler Intelligence Scale for Children: objective IQ test for children (4-1 / years old).

3. Rorschach test: subjective test in which patients describe what they see in an inkblot.

4. Thematic Apperception Test: subjective test in which the patients describes what is going on in a cartoon drawing of people.

5. Beck Depression Inventory: objective test to screen for depression.

0. Minnesota Multiphasic Personality Inventory: objective test designed to measure personality type.

1. Halstead-Reitan Battery: used to determine the location and effects of specific brain lesions.

8. Luria-Nebraska Neuropsychological Battery: assesses a wide range of cognitive functions and tells you the patient's cerebral dominance (left or right).

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