27

Psychiatry
776 Chapter 27 Psychiatry

27-1 Diagnosis of Psychiatric Concerns

Psychosis: Neurological:
Schizophrenia, Psychiatric Complaint Dementia, Delirium,
schizoaffective, Stroke, Seizure,
delusional Multiple Sclerosis

Endocrine:
Mood: Depression, Hypothyroidism,
bipolar, adjustment Cushing’s,
Pheochromocytoma

Primary psychiatric Substance-induced Medical

Anxiety:
Generalized, panic, Infectious: UTI,
phobia, OCD, HIV, Lyme, Syphilis
PTSD, adjustment

Intoxication Withdrawal
Other: Personality, Other: Electrolytes,
eating, sexual, Porphyria, Uremia,
sleep, movement, Cardiac/liver, Lupus,
psychosomatic Fe Deficiency, OSA

When presented with a patient complaining of psychiatric issues, the vignette will help to point you toward the set of diseases that should be considered.
While this chapter will primarily deal with primary psychiatric pathologies, it is important to rule out substance-induced presentations (both intoxication
and withdrawal) and also consider a medical cause. Some clues for substance/medication-induced cases include an acute onset (symptoms develop
during or soon after exposure to and/or withdrawal from offending agent) and features that point more toward an “organic” origin (eg, visual and tactile
hallucinations). The relevant algorithms for these diagnoses are present in the corresponding chapter. Among psychiatric causes, it is generally possible
to decide whether the question is describing acute or chronic illness, which can narrow your differential based on DSM-5 timeline criteria. Demographic
information such as age, gender, family history, and other pertinent risk factors may clue you into the correct diagnosis or treatment plan. Finally,
pharmacology is heavily tested, so it is essential to not only know the indications for the psychotropics, but also medical monitoring, contraindications,
and complications that may arise. There will be medication decision trees grouped with the disorders they are treating for antipsychotics, antidepressants,
mood stabilizers, and anxiolytics/sedatives to detail these considerations.

Disorders by Symptom Duration

Anxiety Disorders Acute stress <1 mo Post-traumatic stress >1mo
Adjustment <6 mo Generalized anxiety >6 mo
Psychotic Disorders Brief psychotic <1 mo Schizophreniform 1–6 mo Schizophrenia >6 mo
Mood Disorders Hypomania >4 days Mania >7 days Cyclothymia >2 years
Major depression >2 weeks Dysthymia >2 years

FIGURE 27.1
Chapter 27 Psychiatry 777

27-2 Psychology, Psychodynamic & Behavioral Factors

Psychological
or Behavorial
Reaction to
Stress

In context of
psychotherapy

Projection onto
Ego threat
provider

Projection onto Harmful/

Healthy
patient unhealthy

Counter- Maladaptive Immature Adaptive Mature Ego

Transference transference Coping Skills Ego Defense Coping Skills Defense

Behavioral Instrumental Emotional

Substance use Denial Acceptance
disengagement support support

FIGURE 27.2
 778 Chapter 27 Psychiatry

27-2 Psychology, Psychodynamic & Behavioral Factors

TRANSFERENCE AND EGO DEFENSES
COUNTERTRANSFERENCE A 17-year-old F does not perform as well on a test as she thought
A 45-year-old F is seen in her psychotherapist’s office. When dis- she would. She makes a self-deprecating joke about needing to
cussing her relationship with her father, she becomes angry at the study more in the future.
therapist, as she feels he is treating her the same way as her father
did, and she recognizes this as transference. Her psychotherapist HYF:
then experiences countertransference when he becomes quiet, as • Initially described by Sigmund Freud and then enumerated by
her angry shouting reminds him of his mother yelling in anger. Anna Freud.
• George Eman Vailant introduced a 4-level classification.
HYF: ■ Level 1: Pathological
• Transference = redirection of a patient’s feelings for a significant ■ Level 2: Immature
person to the therapist. ■ Level 3: Neurotic
• Countertransference = redirection of a therapist’s feelings
■ Level 4: Mature
toward a patient, or more generally, a therapist’s emotional
entanglement with a patient. • More defenses have since been added, including conversion and
splitting.

COPING SKILLS
A 31-year-old M was recently fired from his job. He is upset about
Pathologic Immature Neurotic Mature
this and drinks several alcoholic drinks until he passes out.
Delusion Acting out Displacement Altruism
HYF: Denial Hypochondriasis Dissociation Humor
• Conscious or unconscious strategies used to reduce unpleasant Distortion Passive aggression Intellectualization Suppression
emotions.
Projection Reaction Sublimation
• Adaptive or maladaptive. Adaptive techniques are further formation
divided:
Fantasy Repression Anticipation
■ Appraisal-focused.
■ Adaptive behavioral.
■ Emotion-focused. • Displacement: Redirecting a negative emotion from its original
source to a less-threatening recipient.
• Projection: Unwanted feelings are ascribed to another person.
Adaptive Maladaptive
• Fixation: Stuck at a particular point in psychosexual
Active coping Denial development.
Positive reframing Self-distraction • Regression: Reversion to patterns of behavior used earlier in
Planning Substance use development.
Acceptance Behavioral disengagement • Reaction formation: Taking up the opposition feeling, impulse,
or behavior.
Religion Venting
• Sublimation: Converting behaviors into a more acceptable form.
Emotional support Self-blame • Repression: Unconsciously stopping information from rising to
Instrumental support level of consciousness.
Humor • Suppression: Consciously pushing information from
consciousness.
Chapter 27 Psychiatry 779

27-3 Personality Disorders

Distrustful, suspicious; Psychotherapy, focus on

interpret others’ motives Paranoid trust, empathy (often don’t
as malevolent seek treatment)

Isolated, detached Psychotherapy, group

Cluster A “Weird” “loners.” Restricted Schizoid therapy (often don’t
emotional expression seek treatment)

Odd behavior, perceptions,

Psychotherapy, group
appearance. Magical
thinking; ideas
Schizotypal therapy (often don’t
seek treatment)
of reference

Unstable mood,
relationships, self-image; Dialectical behavioral
feelings of emptiness. Borderline therapy; ±
Impulsive. Suicidal, SGA1/mood stabilizer
self-harm. Splitting

Excessively emotional,
attention seeking. Psychotherapy,
Sexually provocative;
Histrionic interpersonal focus
theatrical

Cluster B “Wild”

Grandiose, need Psychotherapy;

admiration; sense supportive (high
of entitlement;
Narcissistic resistance to tx; high
lack empathy drop out rate)

Violates rights of others,

social norms, and laws; CBT2 for mild cases;
impulsive, lack remorse. Antisocial other therapies and
Begins in childhood as meds have not
conduct disorder shown efficacy

Preoccupied with
CBT, psychodynamic
perfection, order, and
Obsessive- psychotherapy,
control at the expense
of efficiency. Inflexible Compulsive relaxation
techniques
morals, values

Socially inhibited; rejection

sensitive. Fear of being CBT ± SSRIs3 for
Cluster C “Worried” disliked, ridiculed. Avoidant comorbid
Ego-dystonic (wishes anxiety/depression
that they had friends)
Footnotes
1. SGA: Second-generation
antipsychotic. Submissive, clingy;
2. CBT: Cognitive behavioral
need to be taken care CBT, psychodynamic
therapy.
of. Difficulty making
Dependent psychotherapy
3. SSRI: Selective serotonin
reuptake inhibitor. decisions

FIGURE 27.3
 780 Chapter 27 Psychiatry

27-3 Personality Disorders

CLUSTER A: “WEIRD” (PARANOID, 1. Frantic efforts to avoid abandonment.
SCHIZOID, SCHIZOTYPAL) 2. Unstable personal relationships; alternating between extremes
(splitting).
Individuals can appear odd and eccentric.
3. Persistent unstable self-image.
4. Impulsivity.
PARANOID 5. Recurrent suicidal behavior.
A 45-year-old M has persistent beliefs that his wife is cheating on 6. Marked mood reactivity.
him and that his boss is out to get him. He does not demonstrate
7. Chronic feelings of emptiness.
other psychiatric symptoms.
8. Inappropriate intense anger.
Management: 9. Stress-related paranoia/dissociation.
1. Early referral to mental health provider.
2. CBT can help recognize destructive thought patterns and ANTISOCIAL
behaviors. A 25-year-old M presents on court-ordered visit for assault/battery.
He has a history of violence toward animals as a child. He displays
HYF: Projection is a common defense mechanism. no guilt for his actions.

SCHIZOID Management:
A 60-year-old M, unpartnered, lives in an isolated village with his 1. Treatment-resistant; patients often lack insight. Extreme cases
computer as his sole companion and does not desire to make close often end with jail.
relationships with others.
HYF: Often presents with evidence of conduct disorder before age
Management: 15. Must be >18 for this diagnosis (<18 usually meets criteria for
conduct disorder).
1. CBT/psychotherapy.
2. Treat for anxiety/depression if indicated.
CLUSTER C: “WORRIED” (OBSESSIVE-
SCHIZOTYPAL COMPULSIVE, AVOIDANT, DEPENDENT)
A 35-year-old M exhibits eccentric clothing, odd speech, and ideas Individuals appear anxious, fearful.
of reference but without delusions or hallucinations.
OBSESSIVE-COMPULSIVE
Management: A 34-year-old M was recently fired from work for not making pro-
1. Rarely seek treatment; CBT/psychotherapy. duction quotas at his factory job because he was consumed with
making every widget perfect before moving on to the next.
HYF: Both schizotypal and schizoid share the inability to main-
tain relationships; schizotypals avoid because of deep-seated fear Management:
of people vs. schizoids, who see no point in forming relationships. 1. CBT/psychotherapy.

CLUSTER B: “WILD” (BORDERLINE, HYF: Similar to obsessive-compulsive disorder (OCD), obsessive-

HISTRIONIC, NARCISSISTIC, ANTISOCIAL) compulsive personality disorder (OCPD) exhibits rigid behaviors,
but patients do not generally feel compelled to repeatedly perform
Individuals appear dramatic, emotional, erratic.
ritualistic actions. They also find pleasure in perfecting a task,
whereas people with OCD are often more distressed after their
BORDERLINE actions. OCPD is egosyntonic. OCD is egodystonic.
A 25-year-old F presents with history of non-suicidal self-injury
due to a relationship with her partner, with whom she is either
infatuated with or cannot stand. She has a history of 5 prior non- AVOIDANT
lethal suicide attempts immediately after a break-up. A 22-year-old M complains of low self-esteem, loneliness, a sense
of emptiness, social isolation, substance abuse, and general unhap-
Management: piness with life.
1. Psychotherapy, specifically dialectical behavioral therapy
(DBT).
Management:
2. Adjunctive pharmacotherapy to target mood instability and 1. CBT/psychotherapy
transient psychosis (eg, 2nd-generation antipsychotics, mood
stabilizers)
HYF: People with avoidant PD desire to have friends, unlike those
with schizoid PD.
HYF: For diagnosis, must have a pervasive pattern of unstable
relationships, self-image, impulsivity, and ≥5 of the following:
Chapter 27 Psychiatry 781

27-4 Psychotic Disorders

Psychotic Symptoms1

RPR, B12, folate, TSH

No medical cause.
Prominent mood
Mood symptoms
symptoms
not prominent

Psychotic symptoms Psychotic symptoms

Symptoms Symptoms Symptoms
present ONLY in the present for at least
present present present
context of mood 2 weeks without
<1 month 1–6 months >6 months
symptoms mood symptoms

Mood Disorder Brief

Schizoaffective Schizophreniform
With Psychotic Psychotic Schizophrenia
Disorder Disorder
Features Disorder

Antidepressants or Antipsychotics ± Antipsychotics ±

mood stabilizers antidepressants or behavioral
± antipsychotics mood stabilizers therapy

Psychosis related
to substance use
or other medical
condition

Lab work Medical cause of

Symptoms of Only delusions present.
and physical psychosis
delirium3 Hallucinations absent
exam2 diagnosed

Substance- Psychotic
Induced Disorder Due to Delusional
Delirium
Psychotic Another Medical Disorder
Disorder Condition Footnotes
1. Auditory or visual hallucinations,
delusions, and thought or behavioral
disorganization.
Cessation of Treat underlying 2. Utox, blood alcohol level (not required
Treat underlying Difficult to treat; ± for diagnosis), hx drug use, pupil &
substance use, condition ±
medical condition antipsychotics ± skin exam.
substance use antipsychotics for
± antipsychotics supportive therapy 3. Waxing/waning attention, confusion,
treatment psychosis/agitation paranoia, hallucinations, elderly patient.

FIGURE 27.4
 782 Chapter 27 Psychiatry

27-4 Psychotic Disorders

SCHIZOAFFECTIVE DISORDER Complications:
A 41-year-old presents with auditory hallucinations and grossly dis- • Severe agitation and violence.
organized behavior along with 1–2 hours sleep per night for 7 days, • Withdrawal syndrome: Dysphoria, fatigue, anxiety, etc.
grandiosity, distractibility, increased talkativeness, and risk-taking
behavior. HYF: Drugs that can present with psychosis: adrenergic, alcohol/
benzo/barbiturate withdrawal, antiarrhythmics, antibiotics,
Management: anticholinergics, antihistamines, cannabis, ketamine, cocaine,
1. Antipsychotic medication. MDMA, corticosteroids, dextromethorphan, antiparkinsonian
2. Mood stabilizers. medications, heavy metals, organophosphates, thyroid hormones.
3. Consider inpatient hospitalization.
PSYCHOTIC DISORDER DUE TO ANOTHER
HYF: Differentiate schizoaffective disorder (delusions or hallu- MEDICAL CONDITION
cinations present for 2 weeks in the absence of mood symptoms) A 68-year-old M with history of shuffling gait, resting tremors, and
from mood disorder with psychotic symptoms (psychotic symp- cogwheel rigidity presents with visual hallucinations and paranoia
toms ONLY present during mood episode) by time course. on exam.

Management:
SCHIZOPHRENIA
1. Assess for delirium, dementia, adverse effect of anti-Parkinson
A 25-year-old M presents with 4 months of flat affect, anhedonia,
drug.
and apathy on exam he has auditory hallucinations and disorga-
nized speech. 2. May need to lower dopamine agonist drugs.
3. Last resort: Antipsychotic medication (should be used with
Management: extreme caution in patients with Parkinson’s disease. Prioritize
1. Antipsychotic medications. quetiapine or clozapine over other anti-psychotics.).

HYF: HYF: Many non-psychiatric disorders can present with psychosis:

• For diagnosis, 2 of the following criteria must be present for ≥1 • CNS disease: Parkinson’s, MS, Alzheimer’s, encephalitis, etc.
month: • Endocrinopathies: Addison’s/Cushing’s disease, hypo/
hyperthyroidism, etc.
■ Delusions.
• Nutritional: B12/folate deficiency, etc.
■ Hallucinations.
• Other: Lupus, porphyria, etc.
■ Disorganized speech.
■ Grossly disorganized or catatonic behavior. DELUSIONAL DISORDER
■ Negative symptoms: Flat affect, alogia, avolition. A 52-year-old M presents with a 6-month history of fixed belief
• Neuroimaging may find enlargement of 3rd and lateral ventricles. that the government is monitoring his every move. No hallucina-
• Brief psychotic disorder (<1 month), schizophreniform disor- tions are present. He has a reactive affect and linear thought process
der (1–6 months), and schizophrenia (>6 months) have similar on exam.
diagnostic criteria but differ based on duration.
Management:
• Schizoid and schizotypal personality disorder have intact reality.
1. Difficult to treat; antipsychotics are recommended though
efficacy is unclear.
SUBSTANCE-INDUCED PSYCHOTIC 2. Supportive therapy.
DISORDER
A 26-year-old M with strong substance abuse history and no his-
Complications:
tory of psychosis presents with agitation, dilated pupils, HR 125, • ~50% of people have a full recovery.
BP 170/110, and prominent paranoid delusions on exam. Labs are
notable for methamphetamine on urine toxicology.
HYF: Types of delusions:
• Erotomanic type: Delusion that someone is in love with them.
Management: • Grandiose type: Delusions of great talent.
1. Benzodiazepines. • Somatic type: Physical delusions.
2. Antipsychotics, PRN agitation. • Persecutory: Delusions of being persecuted.
3. Fluids if dehydrated. • Jealous: delusions of unfaithfulness.
4. Substance-use treatment.
Delirium: See p. 737.
Chapter 27 Psychiatry 783

27-5 Antipsychotics
Psychotic Symptoms Mood Symptoms
Predominant Predominant

Brief Bipolar Treatment-

Schizophreniform Delusional Bipolar
Schizophrenia Psychotic Depression Refractory
Disorder Disorder Mania
Episode Depression

Antidepressant
Antipsychotics
Quetiapine, augmentation with
First- or second- Antipsychotics (acute agitation)
lurasidone, aripiprazole,
generation may have + mood
olanzapine + seroquel,
antipsychotics some efficacy stabilizers
fluoxetine olanzapine
(maintenance)
(+ fluoxetine)

Mood D/O
2+ failed trials of Schizoaffective
With Psychotic
antipsychotics Disorder
Features

Antipsychotics ± MDD With Bipolar D/O

Clozapine antidepressants Psychotic With Psychotic
± mood stabilizers Features Features

Antidepressants,
Other medical Antidepressants or mood stabilizers,
illness is mood stabilizers antipsychotics
predominant ± antipsychotics (aripiprazole,
olanzapine)

Psychotic D/O
Due to Another Delirium
Medical Condition Contraindications of Antipsychotics
1. Prolonged QTc: Avoid ziprasidone, clozapine, haloperidol, any IV
formulations. Aripiprazole and lurasidone have some evidence for neutral
or beneficial effect.
2. History of diabetes: Tend toward first-generation antipsychotics; avoid
clozapine, olanzapine, seroquel.
Antipsychotics Only use antipsychotics 3. History of dystonia/EPS: Avoid high-potency first-generation antipsychotics.
can be used if behavior is dangerous or 4. Hyperprolactinemia: Avoid first-generation antipsychotics and risperidone.
while treating interfering significantly with 5. History of orthostatic hypotension: Avoid thioridazine, chlorpromazine,
underlying medical care and not improving with clozapine, and iloperidone.
condition non-pharm measures
*Side effects are discussed in more detail in the high yield facts page.

FIGURE 27.5
 784 Chapter 27 Psychiatry

27-5 Antipsychotics
Indications: Psychotic spectrum disorders, mood disorders pimavanserin (5HT2A-inverse agonist and antagonist with no
with psychotic features, bipolar disorder, augmentation for antide- dopamine D2 affinity).
pressants, and behavioral management. Generally, SGAs carry lower risk of EPS than FGAs. These should
The decision tree for this topic lists the most common agents used still be monitored for anyone on antipsychotics.
in each disorder. This page will mainly discuss side effects, which Clozapine, though the most effective antipsychotic, comes with
also weigh heavily in picking an agent. unique side effects, and use must be monitored. Potential side
effects include:
FIRST-GENERATION (TYPICAL) • Myocarditis and cardiomyopathy.
ANTIPSYCHOTICS (FGAs) • Agranulocytosis/neutropenia.
• QTc prolongation, PE, metabolic syndrome, seizures, excessive
Mechanism: Postsynaptic blockade of D2 receptors. salivation, constipation.
• Monitoring: CBC and ANC (regularly), weight, height, BMI,
High-potency FGAs: Fluphenazine, haloperidol, loxapine,
fasting glucose and HbA1c, lipids, EKG.
perphenazine, pimozide, thiothixene, trifluoperazine.
• Low activity at histaminic (low sedation) and muscarinic recep- OTHER SIDE EFFECTS
tors (low anticholinergic activity), but higher risk for extrapyra-
midal symptoms (EPS). Metabolic syndrome: Weight gain, diabetes, dyslipidemia.
• Generally attributed to SGAs, but chlorpromazine carries rela-
Low-potency FGAs: Chlorpromazine, thioridazine. tively high risk. Fluphenazine, haloperidol, and pimozide show
• High activity at histaminic (sedating) and muscarinic (anticho- the lowest risk.
linergic) receptors, but low risk of EPS. • SGAs: Most common among clozapine and olanzapine; queti-
• Adverse effects: Blurred vision, ocular toxicity, orthostatic apine also relatively high-risk.
hypotension, QTc prolongation, urinary retention, retinopathy • Management: Routine monitoring of weight, BP, glucose and
(thioridazine, specifically); not often used. HbA1c, lipid profile.
Extrapyramidal symptoms include akathisia, rigidity, bradykine- Anticholinergic effects (dry mouth, constipation, less commonly
sia, tremor, acute dystonia. urinary retention and blurred vision).
• More common with high-potency agents. • FGAs: Most prominent with low-potency agents, chlorpro-
• Treatment: Anticholinergic agents. mazine, and thioridazine.
Tardive dyskinesia: Involuntary choreoathetoid movements of • SGAs: Most common with clozapine; intermediate risk with
mouth, tongue, face, extremities, trunk (lip-smacking, tongue quetiapine and olanzapine.
writhing, jaw movements, facial grimacing, trunk writhing). QT prolongation:
• More common among FGAs, even more so among high-potency • Sudden cardiac death is reported in 1.5 to 1.8 people per 1000
agents. years’ exposure to antipsychotic medication. This is thought to
• Treatment: Benzodiazepines, VMAT2 inhibitors. be secondary to QT prolongation leading to torsades de pointes.
Neuroleptic malignant syndrome: Fever, muscle rigidity, mental • FGAs: Most with chlorpromazine, thioridazine, IV haloperidol.
status change, autonomic instability, rhabdomyolysis often with ele- • SGAs: Most with ziprasidone; less with clozapine, olanzapine,
vated CK. quetiapine, and risperidone; least with aripiprazole, brexpipra-
• No differences demonstrated between FGAs. zole, cariprazine, and lurasidone.
Prolactin elevation among all FGAs via blockade of tuberoinfun- Orthostatic hypotension:
dibular dopamine. • Caused by adrenergic blockade.
• FGAs: Most common with thioridazine and chlorpromazine;
SECOND-GENERATION (ATYPICAL) least common with fluphenazine, haloperidol, and perphenazine.
ANTIPSYCHOTICS (SGAs) • SGAs: Most common with clozapine and iloperidone

Mechanism: Generally, blockade of D2 receptors. Also with ∗All antipsychotics carry a “black box” warning from the FDA of a 1.6- to
5HT2a antagonism. 1.7-fold increase in mortality from all causes for older adult patients with
dementia-related psychosis.
Examples: Olanzapine, quetiapine, risperidone. Drugs with
different mechanisms include aripiprazole and brexpiprazole
(D2-partial agonist), cariprazine (D3-preferring partial agonist),
Chapter 27 Psychiatry 785

27-6 Psychotropic-Induced Movement Disorders

Abnormal
Movements

Progressive, memory
History of
changes and not Neurodegenerative
psychotropic
attributable to (pp. 742–743)
medication
medications

Vital sign changes,

altered mental
↑ Movement ↓ Movement
status, autonomic
dysfunction

Repetitive Rigidity, bradykinesia,

Feeling of Painful muscle Fever, sweating, Myoclonus,
involuntary muscle tremor, masked
restlessness spasms rigidity hyperreflexia
movement facies, shuffling gait

Neuroleptic
Tardive Serotonin
Akathisia Parkinsonism Dystonia Malignant
Dyskinesia Syndrome
Syndrome

↓ or stop Stop neuroleptics. Stop serotonergic

↓ or stop ↓ or stop agents. Tx:
↓ or stop antipsychotic. Tx: Tx: Supportive
antipsychotic. Tx: antipsychotic. Tx: Supportive care,
antipsychotic. Tx: VMAT-2 inhibitors, care, dantrolene,
Anticholinergics, Anticholinergics, cyproheptadine
Beta-blockers botulinum toxin bromocriptine
amantadine benzodiazepines (serotonin antagonist)
injections (D2 agonist)

FIGURE 27.6
 786 Chapter 27 Psychiatry

27-6 Psychotropic-Induced Movement Disorders

EXTRAPYRAMIDAL SYMPTOMS (EPS) Management:
A 66-year-old F is started on a new antipsychotic after she had 1. Stop neuroleptics.
intolerable side effects from her last medication. A few days later, 2. Rapid cooling.
she complains of extreme restlessness and feels like she must con- 3. Supportive care.
stantly move around. 4. Pharmacologic:
a. Dantrolene.
Management:
b. Bromocriptine.
1. Decrease dose of neuroleptic. c. Benzodiazepines.
2. Switch to lower-potency neuroleptic.
3. Pharmacologic: HYF:
a. Anticholinergics. • Typical antipsychotics are more likely to cause NMS than
b. Beta-blockers. atypicals.
c. Vesicular monoamine transporter 2 inhibitors. • Catatonia is a risk factor for NMS.

HYF: SEROTONIN SYNDROME (SS)

• Includes akathisia, dystonia, pseudoparkinsonism (drug-induced A 40-year-old F presents to the emergency department with palpi-
parkinsonism), and tardive dyskinesia. tations. She is found to have elevated blood pressure, elevated heart
• Oculogyric crisis is a kind of acute dystonic reaction that involves rate, fever, hyperreflexia, and myoclonus on exam. She reports that
the prolonged involuntary upward deviation of the eyes. she is cross-titrating from an SSRI to an MAOI.

Management:
Domain Symptoms Treatment 1. Stop serotonergic agents.
Dystonia Continuous spasms and Anticholinergics PO or 2. Supportive care.
muscle contractions IM 3. Pharmacologic:
Akathisia Internal motor Beta-blockers, a. Cyproheptadine.
restlessness benzodiazepines, b. Benzodiazepines.
clonidine, mirtazapine
Parkinsonism Rigidity, bradykinesia, Anticholinergics, HYF:
tremor amantadine • Typically caused by the use of 2 or more serotonergic medications.
Tardive Involuntary muscle Vesicular monoamine • Serotonergic agents include not only antidepressants, but also
dyskinesia movements in the transporter 2 inhibitors opioids, CNS stimulants, 5-HT1 agonists, psychedelics, some
lower face and distal antipsychotics, and some antibiotics.
extremities
Characteristics of NMS versus Serotonin Syndrome
NMS Serotonin Syndrome
NEUROLEPTIC MALIGNANT
SYNDROME (NMS) Autonomic dysfunction Autonomic dysfunction
Rigidity No rigidity
A 25-year-old M is started on haloperidol to treat psychosis in the
inpatient psychiatric unit. A few days later, he develops high fever, No myoclonus Myoclonus
confusion, rigid muscles, variable blood pressure, sweating, and No hyperreflexia Hyperreflexia
elevated heart rate on exam. Fever Fever less prominent
Chapter 27 Psychiatry 787

27-7 Mood Disorders

Abnormal Mood

Substance or
Medical condition
medication
inducing mood
inducing mood
disorder
disorder

Substance- Mood D/O

Mania1 or
Induced 2/2 Medical
hypomania2
Mood D/O Condition

Stop Hypomanic and Meets criteria for

Manic Treat underlying
substance or hx of depressive major depressive
episode medical condition
medication episode episode

Psychotic
Bipolar I Bipolar II Bereavement
symptoms

Mood stabilizers, Mood stabilizers, MDD3 With MDD Without

Symptoms
antipsychotics, antidepressants,
≥2 years Grief Psychotic Psychotic
psychotherapy psychotherapy
Features Features

Hypomanic Antidepressants4–6,
experiences Adjustment psychotherapy, SSRIs/SNRIs,
Time,
that do not D/O psychotherapy antipsychotics, TCAs, MAOIs,
meet criteria consider psychotherapy
hospitalization

Persistent Footnotes
Psychotherapy,
Depressive Cyclothymia SSRIs/SNRIs
1. Mania: ≥7 days, may have psychotic features,
functional impairment.
Disorder 2. Hypomania: ≥4 days, no psychotic features, no
functional impairment.
3. MDD: Major depressive disorder.
4. SSRI/SNRI: Selective serotonin/norepinephrine
reuptake inhibitor.
Psychotherapy, Mood stabilizers, 5. TCA: Tricyclic antidepressant.
SSRIs/SNRIs psychotherapy 6. MAOI: Monoamine oxidase inhibitor.

FIGURE 27.7
 788 Chapter 27 Psychiatry

27-7 Mood Disorders

MAJOR DEPRESSIVE DISORDER (MDD) HYF: Diagnosis only requires 1 episode of mania.
A 50-year-old F presents to the outpatient office with 1 month of
low mood, anhedonia, fatigue, poor appetite and sleep, and passive D Distractibility
death wish. She has had similar episodes in the past. I Indiscretion/impulsivity: Spending money, sexual
promiscuity
Management
G Grandiosity: Feeling on top of the world
1. Risk assessment.
F Flight of ideas: Racing thoughts
2. Psychotherapy.
3. Pharmacologic: A Activity increase in goal-directed behavior
a. SSRI/SNRI, bupropion or mirtazapine. S Sleep deficit: Decreased need for sleep
b. TCA. T Talkative: Pressured speech
c. MAOI.
4. For treatment refractory consider augmentation versus BIPOLAR DISORDER II
interventional treatments (TMS, ketamine, ECT). A 28-year-old F presents to the outpatient office with a recurrent
HYF: depressive episode. She reports that before the current episode, she
had a week-long period where she felt “on top of the world” and
• Major depressive episode defined by low mood and 5 SIGECAPS could accomplish anything, felt less need for sleep, and completed
symptoms for at least 2 weeks. all her projects at work. Her partner commented that she was talk-
ing more at that time.
S Sleep: Either increase or decrease
Management:
I Interest: Loss of interest in activities
1. Risk assessment.
G Guilt: Excessive guilt
2. Psychotherapy.
E Energy: Lack of energy, fatigue 3. Pharmacologic:
C Concentration: Difficulty concentrating a. Mood stabilizers.
A Appetite: Either increase or decrease b. Antidepressants (combine with mood stabilizer to prevent
P Psychomotor agitation/retardation manic switch).
S Suicidal ideation HYF: Diagnosis requires ≥1 episode of hypomania and 1 episode
of depression.
BIPOLAR DISORDER I
A 25-year-old M is brought to ED by his girlfriend. For the past
Mania Hypomania
week, he has been sleeping 2 hours per night, quit his job to start his
own business, and spent $10,000 on sports equipment. On exam, Elevated or irritable mood + Elevated or irritable mood + 3/7
he talks quickly and jumps from one topic to another, sharing his 3/7 (4 for irritable mood) (4 for irritable mood) DIGFAST
plans to cure cancer and end world hunger. DIGFAST symptoms symptoms
≥7 days ≥4 days
Management:
Psychotic features No psychotic features
1. Risk assessment.
Hospitalization No hospitalization
2. Pharmacologic:
Functional impairment No functional impairment
a. Mood stabilizers (lithium, valproic acid, carbamazepine,
lamotrigine).
b. 2nd-generation antipsychotics. Substance-Induced Mood Disorder: See p. 782.
3. ECT for treatment of refractory cases.
Mood Disorder 2/2 Medical Condition: See p. 782.
Adjustment Disorder: See p. 795.
Chapter 27 Psychiatry 789

27-8 Antidepressants

Unipolar
Depression

Urgent need for ECT

Actively suicidal, Consider ECT
psychotic features,
treatment-refractory

SSRIs + CBT

Tolerating SSRI and Continue

adequate response treatment
after 6–8 week trial ∼1–3 years1

Try different SSRI,

SNRI, atypical
antidepressant2

Chronic pain Weight gain, fatigue Weight loss, insomnia

SNRI Bupropion Mirtazapine

Tolerating 2nd
Continue
antidepressant and
treatment
adequate response
∼1–3 years1
after 6–8 weeks

Try different SSRI,

SNRI, atypical
antidepressant2

Footnotes
1. Treat indefinitely if recurrent, chronic,
Chronic pain Atypical features3 or severe episodes.
2. Taper previous antidepressant to
prevent serotonin syndrome.
3. ↑ sleep, appetite, or weight;
reactive to pleasurable events;
heaviness in limbs; hypersensitivity
TCA, another SNRI MAOI to interpersonal rejection.

FIGURE 27.8
 790 Chapter 27 Psychiatry

27-8 Antidepressants
SSRI (FLUOXETINE, SERTRALINE, Indications:
PAROXETINE, CITALOPRAM, 1. Depression with inadequate response to SSRI, especially in
ESCITALOPRAM, FLUVOXAMINE) those who are underweight or have insomnia.
2. Anxiety.
Mechanism: Presynaptic serotonin reuptake inhibitor. 3. Insomnia.

Indications: Side Effects:

1. Anxiety, OCD, social anxiety, panic disorder (long-term), • Increased appetite and weight gain.
PTSD, selective mutism. • Sedation.
2. Depression, adjustment disorder, persistent dysthymic disorder, • Dry mouth.
pseudodementia, complex grief.
3. Premenstrual dysphoric disorder. ATYPICAL ANTIDEPRESSANT:
4. Bulimia, binge-eating disorder, body dysmorphic disorder. TRAZODONE
5. Kleptomania, somatic symptom disorder.
Mechanism: 5-HT2 receptor, alpha-1, H1 antagonist.
Side Effects:
• Sexual side effects, GI distress, agitation, insomnia, tremor.
Indications:
• Citalopram: Contraindicated in post-MI patients due to dose- 1. Depression with inadequate response to SSRI, especially for
dependent QT prolongation; choose sertraline or escitalopram. patient with insomnia.
• Paroxetine: Contraindicated in pregnancy due to fetal cardiac 2. Anxiety, insomnia
defects (1st trimester), pulmonary hypertension (3rd trimester).
Side Effects:
HYF: • Highly sedating.
• SSRIs should be trialed for 6 weeks at full dose; change to a dif- • Priapism.
ferent SSRI or SNRI if inadequate response. • Antiadrenergic: Orthostatic hypotension.
• Abrupt cessation: Discontinuation syndrome (flu-like symptoms,
nausea, insomnia, brain zaps). SNRI (DULOXETINE, VENLAFAXINE,
• Interactions with other serotonergic drugs and herbs (St. John’s DESVENLAFAXINE, MILNACIPRAN,
wort): Serotonin syndrome risk. LEVOMILNACIPRAN)
ATYPICAL ANTIDEPRESSANT: Mechanism: Presynaptic serotonin and norepinephrine
BUPROPION reuptake inhibitor.
A 27-year-old F with MDD has only a partial response to SSRI ther-
Indications:
apy and complains of weight gain, fatigue, hypersomnia, and sexual
side effects. She is requesting an alternative agent. 1. Anxiety, panic disorder (long-term), PTSD.
2. Depression.
Mechanism: Presynaptic dopamine and norepinephrine 3. Neuropathic pain, fibromyalgia.
reuptake inhibitor (mild stimulant effect).
Side Effects: Venlafaxine: Diastolic hypertension at higher doses.
Indications: Venlafaxine is also commonly associated with discontinuation syn-
drome when stopped abruptly. Rare hepatotoxicity with duloxetine.
1. Depression with inadequate response to SSRI, especially those
with weight gain, fatigue, difficulty concentrating.
2. Nicotine withdrawal.
TRICYCLIC ANTIDEPRESSANTS
(NORTRIPTYLINE, DESIPRAMINE,
Side Effects: Decreased seizure threshold in patients with elec- IMIPRAMINE, CLOMIPRAMINE)
trolyte abnormalities (anorexia or bulimia).
Mechanism: Presynaptic serotonin and norepinephrine
HYF: Contraindicated in seizure or eating disorder history. Can reuptake inhibitor.
also be used for nicotine cessation or off-label for ADHD.
Indications:
ATYPICAL ANTIDEPRESSANT: 1. Anxiety.
MIRTAZAPINE 2. Depression with inadequate response to SSRI.
3. Migraine.
Mechanism: 5-HT2, 5-HT3 receptor, alpha-2, H1 antagonist. 4. Enuresis.
5. OCD (clomipramine).
Chapter 27 Psychiatry 791

27-8 Antidepressants
Side Effects: Indications:
• Antihistamine effect: Sedation, weight gain. 1. Treatment-resistant depression.
• Anticholinergic: Dry mouth, tachycardia, urinary retention. 2. Atypical depression.
• Antiadrenergic: Orthostatic hypotension, dizziness.
Side Effects: Sexual side effects, orthostatic hypotension,
HYF: weight gain.
• Overdose can be lethal: Convulsion (seizure), coma, cardiotox-
icity, respiratory depression, hyperpyrexia. HYF:
• Treat with sodium bicarbonate if QRS >100 msec, hypotensive, • Hypertensive crisis with high-tyramine foods (aged cheese, red
or arrhythmic. wine).
• Serotonin syndrome risk.
MAOI (PHENELZINE, TRANYLCYPROMINE,
SELEGILINE)
Mechanism: Inhibit monoamine oxidase, which leads to
increased serotonin, dopamine, norepinephrine.
792 Chapter 27 Psychiatry

27-9 Mood Stabilizers

Bipolar
Mania

Assess medical,
substance use

Meet criteria for

manic episode1

On
Taper, stop
antidepressants?

Benzodiazepine
Severe agitation?
± antipsychotic

On mood Switch or try

stabilizers? antipsychotic

Pregnancy? Consider haloperidol

Psychosis? Add antipsychotic

Renal disease? Try valproate

Footnote
1. Diagnostic criteria for
manic episode.
Start lithium a. Expansive mood ≥1
week AND ≥3 of
DIGFAST (≥4 if
mood is only irritable):
Distractibility, easily
Switch mood stabilizer frustrated
Refractory?
or add antipsychotic Irresponsibility & erratic
uninhibited behavior
Grandiosity
Flight of ideas
Activity ↑
Sleep ↓
Refractory? ECT Talkativeness

FIGURE 27.9
Chapter 27 Psychiatry 793

27-9 Mood Stabilizers

LITHIUM Indications:
Toxicity: A 65-year-old M with PMH of mania and severe aggres- 1. 2nd line in acute mania.
sion presents to the ER with confusion, tremors, ataxia, and seizures 2. 1st-line maintenance treatment in bipolar disorder.
on exam after starting thiazide diuretics. 3. Combined with valproate or lithium for maintenance therapy
in bipolar disorder.
Mechanism: Possibly related to inhibition of phosphoinosi-
tol-signaling pathway. Side Effects: See “Antipsychotics,” pp. 783–784.
Indications: HYF: Quetiapine dosed at nighttime helps with sleep. Other
atypicals approved for bipolar maintenance include: Risperidone,
1. 1st-line mood stabilizer for acute mania (in combination with
Aripiprazole, Cariprazine, Lurasidone, Asenapine.
antipsychotics if severe).
2. Maintenance therapy in bipolar disorder. LAMOTRIGINE
3. Reduces suicide risk.
4. Augmentation in depression treatment. Mechanism: Sodium channel blockade, inhibits glutamate release.

Side Effects: Indications:

• Nephrogenic diabetes insipidus. 1. 2nd-line mood stabilizer for acute mania.
• Hypothyroidism. 2. 1st line for maintenance treatment in bipolar disorder.
• Hyperparathyroidism. Side Effects: Blurred vision, GI distress, Stevens-Johnson
• Lithium toxicity (blood level >1.5 mEq/L). syndrome. ↑ dose slowly to monitor for rashes.
• Acute toxicity: GI distress, nausea, diarrhea, vomiting.
• Chronic toxicity: Confusion, agitation, ataxia, tremors, seizures. HYF: Primarily an anticonvulsant. If using with valproate, halve
the dose of lamotrigine as valproate can double lamotrigine levels.
HYF:
• Contraindicated in patients with ↓ renal function. CARBAMAZEPINE
• Narrow therapeutic window (0.8–1.2 mEq/L). Mechanism: Sodium channel blocker.
• Dialysis indicated for lithium toxicity >4.
• Risk to fetus if used in pregnancy (Ebstein anomaly in 1st trimester). Indications:
• Drug interactions with thiazide diuretics, NSAIDs (except aspi- 1. 3rd line for acute mania.
rin), ACE inhibitors, tetracyclines, metronidazole.
Side Effects:
VALPROATE • Nausea, skin rash, agranulocytosis, AV block. Teratogenicity
A 35-year-old M with PMH of kidney disease presents to the ER (0.5–1% neural tube defect).
with mania and severe aggression. • Blood dyscrasias like aplastic anemia.
• DRESS, Stevens-Johnson syndrome (rare).
Mechanism: Sodium, calcium channel blocker, GABA agonist.
HYF: Cytochrome P450 inducer.
Indications:
1. 1st-line mood stabilizer. ECT
2. 1st-line maintenance therapy for bipolar disorder. Mechanism: Neurophysiological and neurochemical change in
3. Combine with antipsychotic in severe mania (psychotic the brain modeling and perfusion.
features, aggression, DTS, DTO).
Indications:
Side Effects: • Refractory manic episode, mixed episode in bipolar disorder.
• GI (nausea, vomiting), tremor, sedation, alopecia, weight • Schizoaffective disorder.
gain, teratogenicity (3–5% risk for neural tube defect), • Schizophrenia with catatonia.
hyperammonemia. • Highly suicidal patients.
• Pancreatitis, thrombocytopenia, fatal hepatotoxicity, and agran- • Treatment-refractory depression.
ulocytosis (rare). • MDD with psychotic features.
HYF: Avoid in liver disease, thrombocytopenia and pregnancy. Side Effects:
• Reversible retrograde or anterograde memory loss.
ATYPICAL ANTIPSYCHOTICS • Tension headache.
(QUETIAPINE, OLANZAPINE) • Transient muscle loss.
Mechanism: Antagonize both 5-HT2A and D2 receptors. HYF: Generally safe in all populations, including pregnancy.
794 Chapter 27 Psychiatry

27-10 Anxiety Disorders

Abbreviation Anxiety
BDD: Body dysmorphic disorder
D/O: Disorder
GAD: Generalized anxiety disorder
OCD: Obsessive-compulsive disorder
PTSD: Post-traumatic stress disorder Depression Treat depression

Predominant symptom
focus

Uncontrollable Obsessions and/or Trauma + intrusions Fear of objects Panic attacks;

pervasive worries compulsions + avoidance or situations avoidance

Related Social Anxiety D/O Specific Panic D/O é

GAD OCD
D/Os (Social Phobia) Phobias Agoraphobia

CBT, SSRI/SNRI, CBT, SSRI/SNRI,

CBT, CBT, SSRI CBT,
propranolol benzodiazepine
SSRI/SNRI (high-dose) SSRI/SNRI
(performance) (short-term)

Acute Stress PTSD

D/O (<1 Month) (>1 Month)

CBT,
CBT
SSRI/SNRI

Difficulty Recurrent
Preoccupation discarding Recurrent picking of
with physical possessions pulling of one’s skin
appearance regardless of one’s own hair resulting in
value lesions

BDD Hoarding Trichotillomania Excoriation

D/O D/O

CBT, SSRI CBT, SSRI CBT, SSRI CBT, SSRI

FIGURE 27.10
Chapter 27 Psychiatry 795

27-10 Anxiety Disorders

ANXIETY DISORDERS Complications: Vasovagal syncope in needle injections.
1. Significant functional impairment.
HYF: Panic disorder may present with agoraphobia (fear of being
2. R/O medical condition- or substance/medication-induced.
in public where escape may be hard).
If indicated (eg, catatonia, panic), benzodiazepines for short-term
use only; monitor for withdrawal; avoid in substance use
PANIC DISORDER ± AGORAPHOBIA
GENERALIZED ANXIETY DISORDER (GAD) A 25-year-old M presents with recurrent unexpected panic attacks.
A 30-year-old F presents with 6+ months of uncontrollable worry 1+ month of fear of additional panic attacks and/or avoidance of
about multiple issues and 3+ symptoms (1 in children): Restless- panic attack triggers.
ness/on edge, irritability, disturbed sleep, fatigue, difficulty concen-
Management:
trating, muscle tension.
1. CBT (graded exposure), SSRI/SNRIs.
Management: 2. TCAs (imipramine, clomipramine), benzodiazepines.
1. CBT, SSRI/SNRI.
HYF: Decreased amygdala volume.
2. Buspirone, benzodiazepines.

ACUTE STRESS DISORDER

OBSESSIVE-COMPULSIVE DISORDER 1. Trauma occurred <1 month ago.
A 30-year-old F with obsessions and/or compulsions, eg, 2. PTSD symptoms last between 3 days and 1 month.
contamination/cleaning, safety/checking, symmetry/ordering, intru-
sive sexual/violent thoughts. She spends several hours per day per- Management: Same as PTSD management.
forming her compulsions and is significantly distressed by them.

Management: ADJUSTMENT DISORDER

1. CBT (exposure & response prevention), SSRI. 1. Onset of depressed mood, anxiety, and/or disturbance of
conduct within 3 months of stressor.
2. TCA (clomipramine).
2. Resolution within 6 months of stressor termination
3. Deep brain stimulation for severe or refractory cases.

HYF: Abnormal orbitofrontal cortex and striatum. OCD is ego- Management: Supportive therapy only.
dystonic versus OCPD which is ego-syntonic.
POST-TRAUMATIC STRESS DISORDER
(PTSD)
SOCIAL ANXIETY DISORDER A 20-year-old M presents with direct or witnessed exposure to
(SOCIAL PHOBIA) death, serious injury or sexual violence and 1+ month of intrusions,
A 30-year-old F presents with 6+ months of irrational fear of public avoidance, negative thoughts/mood, hyperarousal.
scrutiny/humiliation in social situations, leading to intense anxi-
ety/avoidance of social situations. Performance-only subtype: Fear Management:
of public speaking/presentations. 1. CBT (exposure therapy, cognitive processing therapy), SSRI/
SNRI.
Management: 2. Alpha-1 receptor antagonist (prazosin, doxazosin) for nightmares.
1. CBT, SSRI/SNRIs.
2. Beta-blockers (propranolol for performance subtype; avoid in HYF: Decreased hippocampal volume.
asthma).
BODY DYSMORPHIC DISORDER (BDD)
SPECIFIC PHOBIAS Preoccupation with imagined defect in physical appearance
A 30-year-old F presents with 6+ months of irrational fear of a cer- → repetitive behaviors to fix appearance concerns.
tain object/situation, leading to intense anxiety/avoidance of feared
object/situation, eg, needles, elevators, snakes, heights.
Management: CBT, SSRIs; avoid surgery.

Management: HOARDING DISORDER

1. CBT (exposure techniques/systematic desensitization). Difficulty discarding possessions regardless of value/distress asso-
2. SSRI/SNRIs, benzodiazepines. ciated with discarding.
796 Chapter 27 Psychiatry

27-11 Anxiolytics

Predominant
Symptom Focus

Alcohol withdrawal and

Anxiety Trauma
status epilepticus

Primary Symptoms 1+ Benzodiazepines,

month(s) barbiturates,
Anxiety D/O1 anti-epileptics (refer to
psychiatry substance
dependency section
and neurology epilepsy
section, respectively)

Acute Stress PTSD

D/O

CBT

CBT + SSRI/SNRIs

TCAs,
buspirone (GAD)

Sympatholytics,
ie, propranolol
(performance-only
social anxiety
disorder)

Footnotes
Benzodiazepines 1. Primary anxiety disorder(s): Generalized
for short-term use; anxiety disorder, social anxiety disorder,
avoid in substance panic disorder, specific phobias, obsessive-
compulsive disorder.
use disorder; use 2. LOT: Lorazepam, oxazepam, temazepam.
LOT2 in ESLD3 3. ESLD: End-stage liver disease.

FIGURE 27.11
Chapter 27 Psychiatry 797

27-11 Anxiolytics & Hypnotics

BENZODIAZEPINES Indication(s): Primary insomnia, circadian rhythm disorders,
jet lag.
Mechanism: GABA-A receptor agonists act by increasing bind-
ing frequency of the Cl– channel opening. Side Effects: Headache, dizziness, nausea, fatigue, arthralgias,
angioedema (rare). Examples include: Ramelteon, agomelatine.
Indication(s): Anxiety, agitation, panic attacks, performance-
only social anxiety disorder (SAD), alcohol withdrawal, catatonia. DUAL OREXIN RECEPTOR ANTAGONISTS
Side Effects: Anterograde amnesia, drowsiness, dizziness, Mechanism: Antagonism of orexin (hypocretin) receptors.
confusion, hangover effect, habit-forming potential, paradoxical
agitation. Indication(s): Primary maintenance or mixed insomnia.
HYF: Antidote for overdose is flumazenil; death from overdose Side Effects: Sleep disturbances, suicidal thoughts, headache,
rare without concurrent use of CNS depressant; LOT (lorazepam, somnolence, habit-forming potential (low risk). Examples include:
oxazepam, temazepam) are NOT metabolized by the liver; suvorexant, lemborexant, daridorexant).
ATOM (alprazolam, triazolam, oxazepam, midazolam) have short
half-lives.
PROPRANOLOL
BENZODIAZEPINE-LIKE SUBSTANCES Mechanism: Non-selective beta-blocker.
(Z-DRUGS)
Indication(s): Performance-only SAD, essential tremor,
Mechanism: Selective for GABA-A receptors with onset or migraine prophylaxis, akathisia.
maintenance α1 subunits.
Side Effects: Decrease heart rate and blood pressure,
Indication(s): Primary insomnia. bronchoconstriction.

Side Effects: Ataxia, headaches, confusion, hangover effect,

habit-forming potential (lower risk than benzodiazepines).
PRAZOSIN

HYF: Antidote for overdose is flumazenil. Examples includes: Mechanism: Selective α1 antagonist.
zaleplon, eszopiclone, zolpidem.
Indication(s): PTSD-related nightmares.
BARBITURATES Side Effects: Orthostatic hypotension, syncope, priapism.
Mechanism: GABA-A receptor agonists (binding site different
from that of benzodiazepines) by increasing binding duration Cl–
BUSPIRONE
channel opening.
Mechanism: 5-HT1A receptor stimulation.
Indication(s): Seizures/status epilepticus, alcohol withdrawal,
general anesthesia.
Indication(s): GAD.

Side Effects: Hypotension, respiratory depression, habit-forming Side Effects: Nausea, dizziness, headache, somnolence, MI
(rare), CVA (rare).
potential. Examples include: Phenobarbital, primidone.

MELATONIN AGONISTS Typical/Atypical Antidepressants: See pp. 789–791.

Mechanism: Activation of MT1 and MT2 receptors in the

suprachiasmatic nuclei of the hypothalamus.
798 Chapter 27 Psychiatry

27-12 Substance Use Disorders

ALOC1 + Suspected
Substance Use2

Psychomotor
slowing

Respiratory
↑ Appetite
depression

Conjunctival Somnolence,
Hypothermia Miosis
injection, dry mouth irritability

Sedative3 Opiate THC Stimulant Footnotes

Intoxication Intoxication Intoxication Withdrawal 1. ALOC: Altered level of consciousness.
2. Diagnosis of substance intoxication/
withdrawal is typically clinical; however,
urine and blood toxicology screens can
be used to confirm the presence of
Supportive; ± Supportive (O2), many common drugs.
flumazenil naloxone Supportive Supportive 3. Sedatives: Barbiturates, tranquilizers
(for benzo intox) (overdose) (zolpidem, benzodiazepines).

Psychomotor
agitation

Thought: Thought:
Organized Disorganized

GI distress, Tremor, Mydriasis, Mydriasis,

Restlessness, Rotary or vertical
diaphoresis, diaphoresis perceptual psychomotor
arrhythmias nystagmus
mydriasis ± seizure distortions agitation

(Caffe/
Opiate Benzo/Alcohol PCP Psychedelic Stimulant
Nicot)-ine
Withdrawal Withdrawal Intoxication Intoxication Intoxication
Intoxication

Supportive ± Methadone, Benzos Benzodiazepines,

Supportive
antiarrhythmics/ buprenorphine, (eg, diazepam, Supportive consider
± benzos
beta-blockers clonidine chlordiazepoxide) antipsychotics

FIGURE 27.12
Chapter 27 Psychiatry 799

27-12 Substance Use Disorders

ALCOHOL WITHDRAWAL – ACUTE Management:
(DELIRIUM TREMENS) 1. Stabilize vitals, fluids.
A 55-year-old M presents to the ED with BP 180/110, HR 130, 2. Benzodiazepines.
disorientation, tremors, and auditory hallucinations on exam. Blood 3. Antipsychotics as needed for agitation.
alcohol concentration >0.3. Last known drink was 72 hours ago. 4. Long term: Substance-use treatment.

Management: Complications:
1. Stabilize electrolytes, vitals. • Agitation, seizures, acute coronary syndrome, stroke.
2. Thiamine (to prevent Wernicke’s encephalopathy), glucose, • Withdrawal syndrome: Dysphoria, somnolence, anxiety.
folic acid.
3. Benzodiazepines (eg, lorazepam, chlordiazepoxide if no liver HYF: Commonly abused common stimulants that can present
failure) or phenobarbital. with psychosis: Methamphetamine, phencyclidine (PCP), cocaine.
4. Antipsychotics as needed for agitation.
5. Long term: Substance-use treatment. PCP INTOXICATION
A 21-year-old M is brought in by police for assault and hallucina-
Complications: tions. On exam, he is noted to have hypertension, tachycardia, and
• Severe agitation and violence. vertical nystagmus.
• Seizures, arrhythmias.
Management:
HYF: Delirium tremens onset 48–96 hours after last drink vs. 1. Stabilize vitals, fluids.
alcoholic hallucinosis 12–24 hours.
2. Benzodiazepines.
3. Antipsychotics as needed for agitation.
CHRONIC ALCOHOL USE DISORDER 4. Decontamination with activated charcoal in cases of massive
A 60-year-old M with history of chronic alcohol use presents with ingestion.
abdominal pain and ataxia. On exam they have palmar erythema,
telangiectasias and horizontal nystagmus. HYF: Overdose can be life-threatening. Symptoms can recur after
reabsorption of the drug in the GI tract.
Management:
1. Electrolyte repletion, glucose, parenteral thiamine, folic acid, BENZODIAZEPINE INTOXICATION
multivitamins. A 44-year-old F with a history of panic attacks is brought in by
2. Long term treatment for AUD includes pharmacological and her husband as she has been stuporous, minimally responsive, and
psychosocial interventions. drowsy.
3. Pharmacological: Naltrexone for cravings, acamprosate,
disulfiram, topiramate. Management:
4. Psychosocial: Motivational interviewing, cognitive behavioral 1. Supportive care. Monitor respiratory status. Naloxone for
therapy, 12-step programs, psychoeducation, contingency possible concomitant opioid intoxication.
management. 2. Flumanezil in select patient populations (no seizure hx, no
chronic benzo use, requiring intubation).
Complications:
• GI bleeds, ulcers, varices, Mallory-Weiss tears. HYF: In general, benzodiazepine intoxication is benign, and
• Pancreatitis, liver failure. patients can “sleep off ” the overdose. Benzodiazepine withdrawal,
• Fetal alcohol syndrome. on the other hand, can be life-threatening (seizures) and necessi-
• Cardiomyopathy, anemia. tates treatment with long-acting benzodiazepines (eg, clonazepam,
diazepam) to taper off dose.
• Wernicke-Korsakoff syndrome.

HYF: Naltrexone blocks the mu-opioid receptor and helps reduce

the craving for alcohol. Patients who continue drinking can still use
it. CAGE questionnaire: Cut down, Annoyed, Guilty, Eye opener.

STIMULANT INTOXICATION
A 30-year-old M with polysubstance abuse history and no his-
tory of psychosis presents with exam findings of agitation, dilated
pupils, elevated HR and BP, and delusions of grandeur. Labs are
notable for + amphetamine.
 800 Chapter 27 Psychiatry

27-13 Somatoform, Factitious & Related Disorders

SOMATIC SYMPTOM DISORDER 2. Psychotherapy: CBT, ACT or mindfulness therapy.
3. If refractory, SSRIs/SNRIs.
A 23-year-old M presents with 2 years of multiple chronic com-
plaints including fatigue, nausea, and headache. He spends much of Complications: Excessive invasive diagnostic tests and inap-
the day worrying about his symptoms and researching them online. propriate medical or surgical treatments.
Extensive medical/neurological workup is negative.
Management: HYF:
• Differs from somatic symptoms disorder in that minimal or no
1. Establishment with a single provider as designated point of
symptoms are present in illness anxiety disorder.
contact (primary team while admitted to hospital, PCP on an
outpatient basis) with frequent communication. • The anxiety may resemble obsessions but differs from OCD
because no anxiety-relieving compulsions are present.
2. Setting clear boundaries for not pursuing unnecessary tests or
inappropriate medical/surgical treatments. • Patients may perform excessive health-related behaviors
(eg, weighing self daily to ensure no abnormal weight loss) or
3. CBT, mindfulness-based therapy, consider SSRIs, TCAs.
develop maladaptive avoidance patterns (eg, avoiding doctors’
Complications: Excessive invasive diagnostic tests and inap- appointments for fear of bad health news).
propriate medical or surgical treatments.
FACTITIOUS DISORDER
HYF: One or more symptom(s) must be present for ≥6 months.
However, the same symptoms do not have to be constantly present A 25-year-old F in nursing school presents via EMS after a witnessed
during this period. Associated with excessive thoughts and anxiety seizure at the mall. She is hospitalized and started on levetiracetam
and cause significant time and energy devoted to the symptoms. (Keppra). EEG and brain MRI are unremarkable. She is stable
throughout admission. On day of discharge, patient has a tonic-
CONVERSION DISORDER clonic seizure. An empty insulin syringe is found in her bed. Insulin
to C-peptide ratio is >1.
A 28-year-old F presents with bilateral upper extremity weakness.
She reports frequently dropping items. On exam, she has 3/5 strength Management:
and give-way weakness in her upper extremities. When she is asked 1. Sitter to observe patient behavior and intervene if potentially
to hold arms outstretched with palms up, her arms drift downward harmful behavior is observed.
while palms remain face up in supination. She is observed opening 2. If factitious disorder is imposed on another, legal services (eg,
and closing doors and using her phone without difficulty. child protective services) may need to be involved.
Management: 3. Psychotherapy is the only known treatment, though
1. Psychotherapy and physical therapy with a focus on regaining engagement is often poor.
function even if symptoms persist. Complications: Significant bodily harm or death from induced
Complications: Excessive invasive diagnostic tests and inap- symptoms.
propriate medical or surgical treatments.
HYF:
HYF: • Higher frequency in individuals who work in healthcare.
• Defined as motor or sensory symptoms with clinical findings • Driven by primary gain of taking the sick role.
incompatible with recognized medical conditions. Can occur in • Can be imposed on self or another (Munchausen by proxy).
tandem with real neurological disease (ie. patient with real sei-
zures and PNES). MALINGERING
• Seizure-like spells = psychogenic non-epileptic spells (PNES). A 38-year-old M presents with depression and suicidal ideation
• Other neurologic symptoms = functional neurological disorder with plan to jump off a bridge. He is unhoused and unemployed.
(FND). He is admitted to the inpatient psychiatric unit where he declines
• La belle indifference: Patients seem unconcerned by their symptoms. medications. He is pleasant euthymic and engaged on the unit. The
treatment team discusses his positive progress and suggests dis-
ILLNESS ANXIETY DISORDER charge the following day. Later that day, he attempts to cut his wrist
A 38-year-old M presents to his PCP with concerns that he may with a plastic knife in front of the nursing station.
have cancer for the past 12 months. His uncle died of pancreatic
Management:
cancer 2 years ago. He frequently worries that he has undetected
cancer and spends many hours each week looking up symptoms 1. Avoid reinforcement of behavior. Careful and thorough risk
of cancer. He denies any symptoms. Exam and screening labs are assesment and documentation.
normal. He requests a full body CT to look for occult cancer. Complications: Misuse of medical system for secondary gain.
Management: HYF: Examples of secondary gain: Time off from work, gifts,
1. Regular follow up and therapeutic alliance. Limit diagnostic housing, disability benefits, improved chances of success in a law-
testing and referrals. suit, avoidance of incarceration, shelter.
Chapter 27 Psychiatry 801

27-14 Eating Disorders

Dysregulated
Eating Behaviors

BMI <18.5 Normal BMI Normal BMI or BMI >30

Body image Recurrent binge

Body image
disturbance + recurrent eating + absence of
disturbance + fear of
binging + compensatory purging + loss of
weight gain + deliberate
behavior to counteract control over food
weight loss
weight gain intake

Anorexia Bulimia Binge Eating

Nervosa Nervosa Disorder

Binge eating +
Counting calories,
compensatory
fasting, restricting CBT + nutritional CBT + nutritional
behaviors (ie,
intake of certain support support
vomiting, use
foods
of laxatives)

Restrictive Binge/Purge SSRIs SSRIs, topiramate

Subtype Subtype

Assess need for

hospitalization1

Psychotherapy +
nutritional support Footnote
1. Criteria for hospitalization in anorexia:
BMI ≤15, unstable vitals (HR<40, BP
<80/60, T<35°C), electrolyte derangements,
marked dehydration, hypovolemia/orthostatic,
Consider organ injury (renal, hepatic, cardiac), acute
olanzapine medical complications.

FIGURE 27.14
 802 Chapter 27 Psychiatry

27-14 Eating Disorders

ANOREXIA NERVOSA BINGE EATING DISORDER
A 20-year-old F with BMI <18.5, body image disturbance/fear of A 30-year-old obese M presents with recurrent binge eating without
weight gain, deliberate reduction in body mass. purging behavior, loss of control over food intake with 3+ symp-
• Restricting subtype: Counting calories, fasting, restricting intake toms: Faster-than-normal eating, eating until uncomfortably full,
of certain foods. eating large amounts when not hungry, eating alone due to shame,
• Binge/purge subtype: Binge eating or purging behaviors such as feeling of disgust/guilt after eating.
vomiting, use of laxatives.
Management:
Management: 1. 1st line: Guided self-help (CBT-based), interpersonal
1. Hospitalize if needed. psychotherapy, nutritional support.
2. 1st line: CBT + nutritional support. 2. Adjunctive pharmacotherapy: SSRIs, topiramate, can consider
3. Adjunctive pharmacotherapy (olanzapine, treat comorbid lisdexamfetamine, methylphenidate.
diagnoses).
Complications:
Complications: • Metabolic syndrome (HTN, HLD, DM2).
• Secondary amenorrhea. • Cardiovascular disease.
• Secondary osteoporosis.
HYF: Emotional distress centers around binge eating but not
• Euthyroid sick syndrome. about weight/physical appearance.
• Lanugo body hair.
• Cardiovascular remodeling, gastroparesis, Wernicke-Korsakoff
syndrome. PICA
• Russell sign/dental caries/metabolic alkalosis (binge/purge A 30-year-old pregnant F presents with 1+ month of appetite for
subtype). and ingestion of non-nutritive substances (ie, hair, ice, clay, paint).

HYF: Management:
• Refeeding syndrome (increase in glucose intake → excessive 1. CBC, ferritin.
insulin release → hypomagnesemia, hypokalemia, hypophos- 2. Harm reduction strategies, behavioral interventions, nutritional
phatemia → arrhythmias, seizures). support.
• Antidepressant bupropion lowers seizure threshold and is 3. Consider SSRIs.
contraindicated.
Complications:
BULIMIA NERVOSA • Lead poisoning 2/2 ingested paint.
A 20-year-old M with normal BMI, presents with recurrent binge • GI infections/obstruction/perforation.
eating and compulsive exercise and laxative use to counteract
weight gain. AVOIDANT RESTRICTIVE FOOD INTAKE
DISORDER (ARFID)
Management: A 10-year-old F with disinterest in eating/avoidance of food (ie,
1. 1st line: CBT + nutritional support. dislikes texture of food), resulting in persistent failure to meet
2. SSRIs. nutritional needs (significant weight loss, nutritional deficiency,
dependence on enteral feeding or oral nutritional supplementation).
Complications:
• Cardiac arrhythmias. RUMINATION DISORDER
• Seizures. A 20-year-old F with 1+ month of repeated regurgitation of ingested
• Hypotension. food during/after meal (regurgitated food can be rechewed/
• Sialadenosis. swallowed or spit out).
• Esophagitis/gastritis.
• Mallory-Weiss syndrome. OTHER SPECIFIED FEEDING AND EATING
• Russell sign/dental caries/metabolic alkalosis. DISORDER (OSFED)
A 20-year-old M with eating disorder characteristics (ie, body
image disturbances, dysregulated eating behaviors) NOT meeting
DSM criteria for other eating disorders.
Chapter 27 Psychiatry 803

27-15 Sleep Disorders

Difficulty Initiating or
Maintaining Sleep With
Impaired Daytime
Functioning

Adequate sleep opportunities Sleep hygiene

Sleep onset Sleep maintenance Excessive daytime

difficulty difficulty sleepiness

Total sleep time Snoring, apnea Morning HA, mood Cataplexy, sleep
Urge to move
normal if left to Parasomnias with respiratory changes, apnea paralysis,
legs, iron low
sleep effort w/o respiratory effort dysfunction

Delayed Terrors, Nightmares,

Polysomnography
RLS Sleep-Wake (dec sleep
walking, event remember Polysomnography
latency), multiple
Phase D/O amnesia event
sleep latency test

Ropinirole, Non-REM REM Sleep

Light therapy,
pramipexole, OSA CSA Narcolepsy
gabapentin
melatonin Sleep D/O D/O

Clonazepam,
CBT, CPAP, weight Scheduled naps,
high dose BiPAP
melatonin loss stimulants/modafinil
melatonin

Primary Abbreviations Primary

Insomnia CBT-I: Cognitive behavioral Hypersomnia
therapy for insomnia
CSA: Central sleep apnea
D/O: Disorder
OSA: Obstructive sleep apnea
REM: Rapid eye movement
CBTi ± RLS: Restless leg syndrome Stimulants,
pharmacotherapy Z-drugs: eg, zolpidem, SSRIs
eszopiclone

FIGURE 27.15
 804 Chapter 27 Psychiatry

27-15 Sleep Disorders

RESTLESS LEGS SYNDROME (RLS) PRIMARY INSOMNIA
A 67-year-old M presents with intolerable sensation of restlessness A 45-year-old F presents with trouble falling asleep and staying
in legs, especially when lying down for sleep. Symptoms resolve asleep, causing functional impairment at work. Polysomnography
when he stands up or takes a few steps. His wife also complains that is negative. Other medical issues are ruled out.
he often kicks her during sleep.
Management:
Management: 1. CBT for insomnia, sleep hygiene, treat comorbid psychiatric
1. Replete iron if deficient. disorders.
2. Dopamine agonists (eg, ropinirole, pramipexole), pregabalin, 2. Isolated onset insomnia: Non-benzo hypnotics, ramelteon,
gabapentin 1st generation antihistamines, trazodone, mirtazapine.
3. Avoid caffeine, antihistamines, antidepressants, dopamine 3. Maintenance or mixed insomnia: Dual orexin receptor
antagonists (eg, antipsychotics). antagonists, low dose doxepin, non-benzo hypnotics,
trazodone, mirtazapine.
Complications:
• Insomnia. Complications:
• Excessive daytime sleepiness. • Depression, anxiety, substance use.
• Caution: Can develop high dependence on sleep aids.
HYF: Always check iron studies first when suspecting RLS!
HYF: Sleep hygiene measures: ASLEEP
OBSTRUCTIVE SLEEP APNEA (OSA) A: Alcohol, caffeine, nicotine avoidance
S: Sleep and sex only in bed
A 50-year-old M with BMI 36 presents with depression and day-
L: Leave electronics out of bedroom
time sleepiness. His wife complains that he snores loudly.
E: Exercise early in the day
Management: E: Early rise rather than sleeping in, avoid naps.
P: Plan a regular sleep schedule and routine (bath, meditate,
1. Polysomnography, CPAP.
sleep only when tired)
2. Self-care (side sleep, weight loss).
3. Surgery (eg, tonsillectomy).
NIGHT TERRORS (NON-REM SLEEP
Complications: DISORDER)
• Hypertension. A 6-year-old M presents with parents who remark he has several
• Pulmonary hypertension. episodes of aggressive thrashing while sleeping, occasionally yell-
• Sudden death 2/2 cardiac arrhythmias. ing or even walking in his sleep. He is inconsolable upon awakening
but does not remember the events the next day.
HYF: Differentiate OSA: Upper airway blocked during sleep
vs. central sleep apnea (cessation of respiratory drive → lack of Management:
respiration). 1. Reduce stress.
2. Anticipatory awakening.
NARCOLEPSY 3. Strong bedtime routine.
A 25-year-old M presents with irresistible attacks of sleep during Complications:
the day. On intense emotion, he loses muscle tone (cataplexy).
• Injury to self or others.
Management: • Daytime sleepiness.
1. Scheduled naps. HYF: Sleep/night terror: Non-REM, non-REMembered, boys >
2. Stimulants (modafinil, amphetamines). girls, 3–12 years.
3. SSRIs, SNRIs, TCAs, or sodium oxybate for cataplexy. Nightmare: REM, REMembered, boys = girls, 2 years–adolescence.
HYF:
• HypnaGOgic hallucinations occur when you GO to sleep.
• HypnoPOMPic hallucinations occur when you are getting up
and POMPed in the morning.
• Caused by Low Hypocretin (orexin) in Lateral Hypothalamus.
Chapter 27 Psychiatry 805

27-16 Sexual & Gender Identity Disorders

Sexual Dysfunction

Rule out medial causes1

Patient is male Patient is female

or has a penis or has a vagina

Difficulty in Related to
Reduced
obtaining or Issues with substance
sexual/erotic
maintaining an ejaculation intoxication
thoughts/desires
erection withdrawal

Male Delay in or Ejaculation Substance/

Erectile absence of earlier Medication-
Hypoactive Sexual
Disorder ejaculation than desired Induced Sexual
Desire Disorder
Dysfunction

PDE-5 Inhibitors
Low-dose Delayed Premature
(sildenafil); (Early)
vacuum-assisted
testosterone if Ejaculation Cessation of
erection devices,
hypogonadism Ejaculation substance use
present
occlusive rings, etc

Incongruence SSRIs
between one’s “squeeze” or
experienced and “stop-start”
assigned gender technique2

Delay of, Difficulties with

Associated with Not associated Absent/reduced
infrequency of, vaginal penetration
significant with significant interest in sexual
or reduced related to pain or
distress distress activity/thoughts
intensity of orgasm fear/anxiety

Female Female Sexual Genito-Pelvic

Gender
No Pathology Orgasmic Interest/Arousal Pain/Penetration
Dysphoria
Disorder Disorder Disorder

Lifestyle
Gradual
Directed interventions,
desensitization;
masturbation consider hormonal
Treatment is muscle relaxation
therapy
tailored to
individual3
Footnotes
1. Consider hormonal, vascular, neurogenic, causes.
2. Sex therapy and CBT can be used for premature ejaculation and for all sexual dysfunctions.
3. Treatment may involve therapy, hormone replacement, surgical reassignment,
binders, packing.

FIGURE 27.16
 806 Chapter 27 Psychiatry

27-16 Sexual & Gender Identity Disorders

ERECTILE DISORDER Management:
A 56-year-old M with PMH of HTN and HLD presents to his PCP 1. Highly personalized: Can range from no treatment to changes
complaining of difficulty achieving erection, which has caused sig- in clothing, hormones, and/or surgery.
nificant strain on his sex life and relationship.
FEMALE SEXUAL INTEREST/AROUSAL
Management:
DISORDER
1. PDE-5 inhibitors (eg, sildenafil).
A 53-year-old F presents around 4 years after menopause with sig-
2. Vacuum-assisted erection devices. nificantly decreased interest in sexual intercourse, which is causing
3. Occlusive rings. a strain on her relationship with her partner.
HYF: Management:
• This should be contrasted with performance anxiety. This can Multifaceted and can include: Lifestyle changes, couples therapy,
lead to decreased libido, decreased ability to obtain or maintain individual psychotherapy, pelvic physical therapy, hormone therapy.
an erection, or issues with ejaculation. Patients who experience
sexual dysfunction secondary to performance anxiety often typ- GENITO-PELVIC PAIN/PENETRATION
ically continue to experience nocturnal tumescence. Patients
with erectile disorder, on the other hand, do not have erections
DISORDER
during the night. A 22-year-old F comes into the office several years after her first
• Concomitant urinary symptoms (such as polyuria, dribbling, or sexual encounter, which was very painful. She tried several other
incomplete bladder emptying) may suggest a diagnosis of BPH. times, which also caused significant pain. The last time she tried to
engage in sexual intercourse, she was in so much pain that she now
has marked fear and anxiety just thinking about vaginal penetration.
PREMATURE EJACULATION
A 35-year-old M comes to his PCP complaining of dissatisfaction Management:
with his sex life. He will often ejaculate in one minute or less after 1. Gradual desensitization.
initiating intercourse and has been unsuccesful at multiple attempts
2. Muscle relaxation techniques.
to delay ejaculation.
3. Sexual therapy can be helpful.
Management:
1. SSRIs/TCAs (clomipramine), topical anesthetics. PARAPHILIC DISORDERS (ATYPICAL
2. “Squeeze” or “stop/start technique.” SEXUAL INTEREST)
Voyeuristic Disorder: Observing as an unsuspecting person
SUBSTANCE-INDUCED SEXUAL is naked, disrobing, or engaging in sexual activity.
DYSFUNCTION
A 61-year-old M with alcohol use disorder presents with inability Exhibitionistic Disorder: Exposure of one’s genitals to an
to achieve erection. He notes that he is often intoxicated when unsuspecting person.
attempting sexual intercourse with this wife.
Frotteuristic Disorder: Touching or rubbing against a non-
Management: consenting person.
1. Treat underlying substance use disorder Sexual Masochism Disorder: Being humiliated, beaten,
HYF: Many medications (both recreational and prescription) can bound, or otherwise made to suffer.
interfere with sexual function:
Sexual Sadism Disorder: Physical or psychological suffering
• Psychiatric: SSRIs, TCAs, MAOIs, benzodiazepines, antipsychotics. of another person.
• Antihypertensives.
• Hormonal drugs and chemotherapeutics. Pedophilic Disorder: Prepubescent children.
• Recreational: Alcohol, amphetamines, barbiturates, cocaine,
marijuana, opioids, nicotine.
Fetishistic Disorder: Non-living objects or non-genital body
parts.
• Antihistamines.

GENDER DYSPHORIA
A 19-year-old who grew up as M comes in after 4 years identifying
as F only to close friends. This identity is causing her significant
distress and fear of being in public.
Chapter 27 Psychiatry 807

27-17 Self-Harm/Suicide
Protective Factors
Assess Suicidal
Coping skills
Ideation in Patient
Religion or cultural beliefs
With Depressive Social support
Symptoms; Weigh Connection to mental health provider
Acute/Chronic Risk Limited access to lethal means
vs. Protective Factors

Acute Risk Factors

Acute symptoms of mental disorder
Hopelessness, lack of purpose or meaning
Suicide plan? Impulsivity
Recent loss or disruption of relationships
Anniversary of loss of relationships
Preparation for suicide (giving away possessions)

Suicide intent?
Chronic Risk Factors
S Sex – females attempt more, males succeed more
A Age – <19 or >45 years
D Depression, hopelessness, other mental illness
Hospitalize and stabilize; P Previous attempts
remove lethal means1 E Ethanol/substance use
R Rational thinking loss (psychosis)
S Separated/divorced/widowed
O Organized or serious attempt
N No social support
Medication, counseling, S Stated future intent/Sickness (chronic or terminal)
long-term outpatient
follow-up, frequent safety
assessments Footnote
1. Lethal means: Guns, sharp objects,
medications that patient could
overdose on, supplies for hanging.

FIGURE 27.17
 808 Chapter 27 Psychiatry

27-17 Self-Harm/Suicide
SUICIDAL IDEATION AND BEHAVIOR Management:
1. High acute risk.
Overall Management: 2. Consider voluntary or involuntary hospitalization
1. Conduct suicide risk assessment and assure immediate safety. 3. Antipsychotic, mood stabilizer and connection with social
a. Assess suicide ideation, intent, and lethality of plan. support and long-term outpatient psychiatric care.
b. Assess acute risk factors.
c. Assess chronic risk factors. ACTIVE SUICIDALITY WITH NO INTENT OR
d. Coach/Sitter in room at all times for elevated risk. NO PLAN
2. Determine level of care: A 50-year-old F with chronic suicidality, past amphetamine use,
a. Voluntary or involuntary hospitalization. and recent loss of her boyfriend presents and states, “I want to join
b. Partial hospitalization, intensive outpatient program. him in heaven,” but doesn’t think she will follow through with the
c. Outpatient clinic plan due to her morals and her family’s support.
3. Address modifiable risk factors:
a. Non-pharmacologic: Management:
i. Counseling and therapy, social interventions (housing, 1. Intermediate acute risk.
basic income and access to food). 2. Consider partial hospitalization or day program.
ii. Electroconvulsive therapy. 3. Consider addressing risk factor of substance use,
b. Pharmacologic: Treat underlying disorder. psychotherapy for chronic suicidality, and long-term outpatient
i. Antidepressants. care.
ii. Antipsychotics.
iii. Mood stabilizers (eg, lithium). PASSIVE SUICIDALITY
A 53-year-old M with depression with psychotic features self-
HYF: presents to the inpatient service, stating, “I’m better off dead. I’m
• 2nd leading cause of death in 15–24-year-olds. hopeless and just gonna rot away because I’m a horrible person.” He
• Most suicides in the United States involve firearms. lives alone and has an outpatient psychiatrist, but his medications
• Major risk factors for suicide: Prior suicide attempts, prior psy- aren’t helping.
chiatric illness, hopelessness, male gender.
Management:
ACTIVE SUICIDALITY WITH PLAN AND 1. High acute risk.
2. Consider inpatient hospitalization.
INTENT
3. Address refractory depression (consider ECT) and connect him
A 25-year-old M with amphetamine use, schizoaffectice disorder, with social support and outpatient psychiatric care.
and homelessness presents with command auditory hallucinations
and plan with intent to jump off of a bridge.
Chapter 27 Psychiatry 809

27-18 Pediatric Psychiatry

Psychiatric Complaint Anxiety: separation
Genetic Syndromes:
Down, Fragile X,
Not Within Normal anxiety d/o, selective
Development mutism
Williams, DiGeorge

Mood and disruptive

behavioral: ODD,
conduct d/o
Acquired: Fetal Alcohol Neuro- Substance- Other primary
Syndrome developmental induced psychiatric

Eating disorders

DSM-5: intellectual
Intoxication: Cough Withdrawal: Neonatal Child Abuse
disability, ASD,
medicine, inhalants Abstinence Syndrome and Neglect
ADHD, Tourette’s

When a child or adolescent has a psychiatric complaint, always do a quick check and ask if it is within
Abbreviation
normal developmental stages. If mere reassurance to parents is not appropriate, look for clues in the
ADHD: Attention-deficit/hyperactivity vignette about some genetic or medical causes. Genetic syndromes will often have clues present at
disorder birth, such as dysmorphic facial features. Down syndrome and fetal alcohol syndrome are commonly
ASD: Autism spectrum disorder tested causes of intellectual disability, which can be reviewed in the pediatrics section. While the
D/O: Disorder following algorithm will mainly deal with primary psychiatric pathologies that uniquely arise before
ODD: Oppositional defiant disorder adulthood, it is important to screen for common conditions such as general anxiety disorder and major
depressive disorder. One should also rule out substance-induced presentations (both intoxication and
withdrawal). Some clues for substance/medication-induced cases include an acute onset (symptoms
develop during or soon after exposure to and/or withdrawal from offending agent) and features that
point more toward an “organic” origin (eg, visual and tactile hallucinations). Keep in mind that pediatric
depression may mask as irritable instead of ↓ mood. Although pharmacology is heavily tested, it is
equally if not more important to know when to combine non-medication options (eg, cognitive behavioral
therapy, parental psychoeducation) with pharmacological treatment. Finally, don’t forget about child
abuse, and if suspected, contact child protective services immediately.

FIGURE 27.18
810 Chapter 27 Psychiatry

27-19 Pediatric Psychiatry Presentations

Emotional or Behavioral
Disturbance in Someone
<18 Years Old

Isolated Difficulty with

Developmental
language academic demands
delay
deficits of school

Difficulty with Difficulties

Incontinence Language attachments extend to home
Disorder

Bladder Bowel Speech and Specific

incontinence incontinence
Difficulty Attention-
language therapy,
following rules Learning
>5 years >4 years psychotherapy Deficit/
Disorder
Hyperactivity
(Includes
Disorder
Dyslexia)

Difficulty forming Behavior therapy,

Serious norm Individual
Enuresis Encopresis emotional stimulants1,
violations education plan
attachments non-stimulants2

Psychotherapy, Behavior Reactive Oppositional

alarms, modification, Conduct
Attachment Defiant
desmopressin laxatives Disorder
Disorder Disorder

Social deficits Psychotherapy,

Psychotherapy3, Psychotherapy,
and repetitive Cognitive deficits natural
parent education parent education
behaviors consequences

Autism
Spectrum Intellectual
Disorder Disability
Footnotes
1. Stimulants: Amphetamine
salts, methylphenidate.
2. Non-stimulants: Atomoxetine,
Early intervention, Early intervention,
guanfacine, clonidine.
applied behavioral special education, 3. Psychotherapy: Play therapy,
analysis community services art therapy, EMDR.

FIGURE 27.19
Chapter 27 Psychiatry 811

27-19 Pediatric Psychiatry Presentations

AUTISM SPECTRUM DISORDER (ASD) Inattentive Hyperactive
A 2-year-old M presents to the pediatrician’s office after his mother Poor listening skills Squirms or fidgets
noticed that he had delays in social communication skills, lack of
Loses or misplaces items Restlessness
conversational speech, poor eye contact, and repetitive and stereo-
typed behaviors, including hand flapping and toe walking. Sidetracked by stimuli Driven by a motor
Forget daily activities Overly talkative
Management Diminished attention span Unable to stay seated
1. Autism diagnostic observation schedule (ADOS). No follow-through Difficulty waiting turn
2. Early intervention.
Avoids tasks with concentration Intrudes on others
3. Behavior and communication approaches:
Thoughtless mistakes Impulsively blurts answers
a. Applied behavioral analysis (ABA).
4. Assistive technology.
5. Developmental, individual differences, relationship-based
approach. OPPOSITIONAL DEFIANT DISORDER
6. Occupational therapy. (ODD)
7. Social skills therapy. A 10-year-old M is brought to the counselor’s office because par-
8. Speech therapy. ents have noticed that he has been more angry and that he becomes
9. Pharmacology for comorbid disorders. argumentative or defiant when they are imposing limitations or
boundaries.
HYF:
• ASD is frequently comorbid with other psychiatric conditions Management:
such as ADHD, mood disorders, and anxiety disorders. 1. Psychotherapy:
• ASD and intellectual disability (ID) are sometimes comorbid a. Parent training.
but are distinct disorders with distinct symptoms. b. Parent-child interaction therapy (PCIT).
c. Family therapy.
ATTENTION-DEFICIT/HYPERACTIVITY d. Cognitive problem-solving training.
DISORDER (ADHD) e. Social skills training.
An 8-year-old M is brought to the pediatrician by his mother. Both 2. Pharmacology for comorbid disorders.
at home and at school, he has been restless, overly talkative, unable
to stay seated, intruding on conversations, impulsively blurting HYF: ODD is frequently comorbid with other psychiatric con-
answers, and seems to “be driven by a motor.” ditions such as ADHD, mood disorders, and anxiety disorders.
Differentiate from conduct disorder, adjustment disorder, ADHD
Management: and trauma reaction.
1. Vanderbilt assessment, Conners assessment, SNAP assessment.
2. Behavioral therapy. ODD Conduct Disorder
3. Pharmacologic: Angry or Irritable mood, Aggression, destruction,
a. Stimulants (methylphenidate, amphetamine salts). argumentative or defiant, and deceitfulness/theft, serious rule
b. Non-stimulants (guanfacine, clonidine). vindictiveness violations
Less physical violence More physical violence
HYF:
≥ 6 months ≥ 12 months
• Symptoms must be present age <12.
Severity = number of settings Severity = frequency and extent
• Inattentive type, hyperactive type, or combined type.
of misconduct
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