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PSYCHIATRY (Psychiatric Disorders (Childhood and Adolescent Psych…

- - - - MDD Treatment
        
        1st line = SSRIs and SNRIs
        
        2nd lines = TCAs, MAOS
        
        3rd line = refractory MDD = ECT = electrical convulsive therapy
        
        note you MUST ALWAYS screen anyone you consider for depression for MANIC episodes to rule out BIPOLAR DISORDER
        --> this is important since if you give them SSRIs they can precipitate a manic episode
        
        BIPOLAR people may present with depression if they are in the depressed cycle
        
        *ECT = Electroconvulsive Therapy
        
        can be used as last resort for refractory depression anfter CBT and drugs
        
        causes grand mal seizure under anesthetic
        --> S/E of amnesia etc. resolve after 6 months
      - MDD Diagnosis and Differential for Depressed Mood
        
        Depression = SIG E CAPS
        --> MUST have 5 of the 9 for Dx of MDD
        
        of the 9 symptoms for depression the MOST important one is loss of interest or ANHEDONIA
        
        Anhedonia = loss of pleasure in things you would enjoy before
        --> this is especially important when trying to rule out other things with MDD like normal grief
        
        ALWAYS in diagnosing MDD, have to RULE OUT MANIAs
      - *Atypical MDD disorders
        
        Postpartum MDD
        
        Dysthymia = Persistent DD = PDD
        
        MDD with Psychotic Features
        
        MDD with Psychotic Features
        
        very serious form of MDD
        
        important to differentiate MDD with psychotic features from schizoaffective disorder
        --> key is that schizoaffetive has the psychotic features NOT associated witht he depressed mood
        --> MDD with psychotic features the psychosis goes with the depressed mood
        
        Atypical MDD and MAO Inhibiotrss
        
        MAOs are used for atypical MDD and also for refractory MDD to first line SSRIs and SNRIs
        
        in normal MDD weight loss and sleep loss can be reversed in atypical MDD
        
        *PPD = Post-partum Depression
        
        3 varying levels of PPD
        --> blues, depression and psychosis
        
        *Dysthymia = PDD = Persistent Depressive Disorder
        
        "2 2 2 rule" for Dysthymia Persistent Depression
        --> 2 years = chronic depressed mood
        --> 2 months = no loss of depressed mood for > 2 months at a time
        --> more than > 2 symptoms
        
        3 subtypes of Dysthymia
        --> PURE PDD
        --> PDD with intermittent MDD
        --> PDD with Constant MDD
      - MDD has double "DD SIZE CUPS" = "SIG E CAPS"
        --> 5 of 9 of SIG E CAPS
        --> atleast one of these MUST be depressed mood or ANHEDONIA
        --> symptoms go from MDD specific = suicide and andhedonia to less specific = sleep
        
        S = suicide
        
        I = Interests gone = ANDHEDONIA
        
        G = guilt / worthless feelings
        
        E = energy fatigue
        
        C = concentration
        
        A = appetite
        
        P = psychomotor symptoms
        
        S = sleep
  - - - *ASD
        
        ASD = Acute Stress DIsorder
        
        symptoms directly related to traumatic event
        
        symptoms < 1 month
        
        Clinical Cases
        
        ASD = Acute
        Stress Disorder
        
        Notes:
        
        ASD and PTSD are the same condition and ONLY differ in their duration
        
        ASD lasts between 3 days < ASD < 1 month
        
        PTSD > 1 month
        
        Clinical Case
        
        Clinical Case
        
        Notes:
        
        note that
      - *PTSD
        
        PTSD = Post traumatic stress disorder
        
        think of PTSD as a very GENERAL diagnosis related to 1 traumatic event
        --> requires ONLY 1 month vs 6 months for most other Dx
        --> catch all for agoraphobia and depersonalization disorder
        --> KEY is that it is related to a TRAUMATIC event
        
        symptoms directly related to traumatic event
        
        symptoms > 1 month
        
        Clinical Cases
        
        Clinical Case
        
        Notes:
        
        note that
        
        Clinical Case
        
        PTSD Treatment
        
        first line = SSRI / SNRI with trauma-specific CBT
        
        prazosin can be used for PTSD specific nightmare
        --> for PTSD, I PRAZOS IN bed I don't get nightmares
  - - - Notes:
        
        the main differentiating factors are:
        --> number of delusions
        --> functional decline
        --> duration of the symptoms is the biggest factor
        
        ""schizophrenia AFFECTS your FRIENDLY FORM""
        --> schizoaffective disorder : >= 2 wks schizo symptoms
        --> schizophreniform disorder : >= 1 month schizo symptoms
        --> schizophrenia disorder : >= 6 months schizo symptoms
      - Schizophrenia related symptoms
        
        *Psychosis
      - Saving SCHIZOS is EAZY...
        "BE a FRIEND, make a FRIEND, bring AFFRIEND to Christ"
        
        BE = brief psychotic episode
        (< 1 month)
        
        FRIEND = Phreniform
        (< 6 month)
        
        make a FRIEND = Phrenia
        (> 6 month)
        
        AFRIEND to CHRIST = Schizo AFFECTIVE disorder is CONSTANT mood history vs. CONCURRENT
        (CONCURRENT mood / psychotic)
        ( THEN > 2 weeks of psychosis ONLY / NO MOOD)
        
        Affective = mix of bipolar / Schizo with specific concurrent symptoms and then break in mood, but continued psychosis
        --> long history of MANIC / DEPRESSIVE moods
        --> KEY is Affective has WIHTOUT the moods
        --> this is opposite to depression/bipolar with psychotic features that have their moods WITH the psychosis
        
        *DIRTY USMLE
        SCHIZO family
        
        schizotypal
        most likely of all PDs to turn into an actual psychotic disorder
        
        1 more item...
      - schizophreniform vs.
        schizophrenia
        
        1 month vs 6 months
        
        +/- functional decline vs. definite functional decline
        
        *SCHIZOAFFECTIVE disorder
        
        AFRIEND to CHRIST = Schizo AFFECTIVE disorder is CONSTANT mood history vs. CONCURRENT
        (CONCURRENT mood / psychotic)
        ( THEN > 2 weeks of psychosis ONLY / NO MOOD)
        
        Affective = mix of bipolar / Schizo with specific concurrent symptoms and then break in mood, but continued psychosis
        --> long history of MANIC / DEPRESSIVE moods
        --> KEY is Affective has WIHTOUT the moods
        --> this is opposite to depression/bipolar with psychotic features that have their moods WITH the psychosis
  - - - Clinical Cases
        
        Clinical Case
        
        Notes:
        
        note that
        
        Clinical Case
        
        Delusional Disorder Case
        
        Case presentation:
        
        Notes:
        
        note that similar to diagnosing schizo family disorders according to length of time in months
        --> schizotypal < 1 month
        --> schizophreniforml - 1 month < symptoms < 6 months
        --> schizotypal > 6 months
        
        delusional disorder has to be >= 1 delusion and has to last >= 1 month
        
        for delusional disorder key to diagnosing is also that schizo and other symptoms are not present
        --> also they have to be holding delusion to be true and able to function in their normal lives to a certain degree, as the person above is able to still hold a job as a teacher and maintaining the delusion
  - - - SAD = *Social Anxiety Disorder
        
        Clinical Cases
        
        Clinical Case
        
        Clinical Case
        
        Clinical Case
        
        Clinical Case
        
        Notes:
        
        note that
        
        Notes:
        
        SAD is often self treated with alcohol and other abuse substances
        
        if untreated can lead to depression
      - *GAD= General Anxiety Disorder
        
        Tx = CBT SSRIs and SNRIs 1st line
        
        2nd line = busprione, TCAs
        
        GAD requires > 6 months
        --> starts as AAD = adjustment anxiety disorder
        --> AAD = Adjustment anxiety disorder is < 6 months with a specific trigger (divorce)
        --> AAD turns into GAD after 6 months duration
      - *Panic Disorder
        
        present similar to MI symptoms
        (must rule this out)
        
        key to diagnosis is the attacks
        --> cardio neurological
        --> they reach their peak intensity at 10 minutes or less
        
        panic attacks are often parts of other anxiety conditions
        --> key to Panic Disorder is that there is no obvious trigger
        --> can even get panic attacks while relaxing
        
        think of Panic attacks as like GAD and ASD that only require 1 month for them to be diagnosed
        --> vs most other psych disorders require > 6 months for diagnosis
        
        *Panic attacks
        
        mainly hyperventilation
        
        hyperventilation gets rid of CO2 = hypocapnea
        
        hypocapnea --> brain vasoconstriction
        --> light headed, confusion, muscle weakness, etc.
        
        treat acute panic attacks with BEnzos
        --> increase GABAa frequency and calms them down
        
        Clinical Cases
        
        2 more items...
        
        Panic Attack Tx
        
        acute Tx = Benzos
        
        chronic Tx = SSRIs and SNRIs
        
        2 more items...
        
        *Agoraphobia secondary to panic disorder
        
        it is common to get agoraphobia after having panic disorder
        
        this is where they avoid situations where they may feel trapped if they were to have a panic attack there
        
        note this is a distinct disease and does not require a panic disorder to diagnose
      - *Separation Anxiety Disorder = SAD
        
        actually get physical symptoms from the anxiety
        -> GI problems, nausea, headaches
        --> symptoms occur whenever separate from mother, etc. for a long period of time
        
        Dx in children = symptoms present for > 1 month
        
        Dx in adults = symptoms present for > 6 months
        --> regularly time for all adult psych disorders
      - Medical conditions and drug caused Anxiety
        
        ALWAYS need to rule out common underlying diseases that can cause Anxiety disorders
        --> secondary anxiety disorder
        
        common disease that cause anxiety
        --> hyperhypothyroidism,
  - - - *ADHD
        
        attention deficit hyperactivity Disorder
        
        2 LOCATIONS (home + school) needed for Dx
        
        affects life dramatically (school, relationships)
        
        present for > 6 months
        
        MUST start in childhood
        --> mot > 50% stay active right through adulthood
        --> can't Dx it later in life
        
        treatment = methylphenidate = Ridalin
        
        ADHD Treatment
        
        Methylphenidate
        
        amphetamines
        
        Conduct Disorder vs. Oppositional Disorder
        
        conduct leads to serious rejection of socieety and crime
        --> aggression and violence
        --> after age 18 conduct disorder turns into ASD = Anti-social disorder = sociopaths
        
        oppositional is mainly DEFIANT to authority figures
        --> BUT doesn't leads to anything too serious
        
        Conduct Disorder
        
        conduct leads to serious rejection of socieety and crime
        --> after age 18 conduct disorder turns into ASD = Anti-social disorder = sociopaths
        
        Oppositional Disorder
        
        oppositional is mainly DEFIANT to authority figures
        --> BUT doesn't leads to anything too serious
        
        *Autism Spectrum Disorder = ASD
        
        decreased social interaction
        
        almost always presents before the age of 2
        --> BUT Autism is a SPECTRUM
        --> the less impaired can present later
        
        can be with or without language or intelligence losses
        
        repetitive play and intense fixated interests on certain things
        
        AUTISM is an ODD - ISM
        
        I = intense INTERESTS and INSISTENT on their own ways
        S = SOCIAL problems and relationships
        
        M = Many MAYs and differences
        --> MAY be on a Spectrum
        --> MAY present early is serious and
        --> MAY present late if high functioning
        --> MAY or MAY not have speech and language difficulties
    - - *Eating Disorders and Body Image
        
        annorexia nervosa
        
        bulemia nervosa
        
        binge eating disorder
        
        Anorexia vs Bulemia
        
        key difference between anorexia and bulemia is
        
        BULEMIA has NORMAL weight
        --> BMI > 18.5
        
        ANOREXIA has LOW weight
        --> BMI < 18.5
        
        *Bulemia
        
        key difference between anorexia and bulemia is
        
        BULEMIA has NORMAL weight
        --> BMI > 18.5
        
        Bulemia will have signs of forced and chronic emesis
        --> hypokalemia and metabolic alkylosis are the biggest signs
        --> enlarged parotid glands
        
        Russell's Sign = calluses on dorsum of the hands from excessive vomitting
        
        1 more item...
        
        *Body Image Disorders
        
        BDD = body dysmorphic disorder
        
        *BDD = body dysmorphic disorder
        
        BDD is a mix of 3 major mental illnesses
        --> but applies eah of these 3 especially to body appearance
        
        1 = delusional disorder
        --> BDD have delusions, but they are specific to their body image
        --> fixed, false beliefs about their body, clearly not true and apparant to others
        
        2 = eating disorders
        --> BDD has same DISORTED self image of their body
        --> they DO NOT have binge, purge, or compensation
        --> BDD have NORMAL WEIGHT
        
        3 = OCD
        --> BDD same obsessive behaviours = constantly staring in mirrors
        --> BDD same compulsive behaviours = repetitive actions to try and improve their body image = constant grooming, etc.
      - *Adolescent mood Disorders
        --> must rule out NORMAL adolescent behaviour and mood changes first
        --> consistentn with normal adolescent development
        
        Normal adolescent development
        
        note that it is normal and a good thing for young people to start detaching from their parents
        
        they have many mood swings getting used to puberty and new bodies
  - - - DX of OCD
        
        the behaviours have to be time consuming
        --> for DX usually > 1 hr per day
        
        note that OC personality disorder is NOT DX until after age 18
        --> this is true for ALL PDs
        --> OCD is DX more early usually before age 18
  - - - *Paraphilia vs Paraphyllic Disorders
        
        paraphyllia Dx
        --> needs to be more than 6 months
        
        paraphilias lead to paraphillic disorders
        --> if you act on paraphylias they become paraphyllic disorder?
      - *Premature Ejaculation Disorder
        
        actually only diagnosed in 4% of people who think they have it
        
        has to be < 1 minute of penetration in ACTUAL sex
        --> masturbation ejaculation is NOT counted
        
        Clinical Cases
        
        Clinical Case
        
        Notes:
        
        note that
        
        Clinical Case
  - - - *Illness Anxiety Disorder
        
        NO or few symptoms
        
        compared with somatic where there are actual symptoms
      - *Factitious Disorder
        
        going to great lengths to fake an illness to "assume the sick role"
        
        note that in factitious disorder they may actually have an illness, but they have caused it in some way
        
        you can also diagnose factitious disorder for someone who induces illness in someone else so that they are in the "sick role"
        --> ex: the mother in the 6th sense who is poisoning her kids
        
        Clinical Cases
        
        Clinical Case
        
        Notes:
        
        note that
        
        Clinical Case
      - *Somatic Symptoms Disorder
        
        anxiety related to symptoms from illness
        
        may or may not have an illness
        
        the best management for somatic disorder is to schedule REGULAR VISITS with the patient
        --> goal for regulaar visits should not be to focus on somatic symptoms but being proactive and trying to help them get better coping mechanisms, etc.
        
        make them feel like they are not lying, but reassure them when test are negative that they are healthy
      - *Coversion Disorder
        
        think of CARDIOVERSION = neurological shock
        
        neuro symptoms (weakness, paralysis, etc.)
        --> but not from any known neuro or psychiatric condition
        
        the patient is also not making the symptoms up and can be present on examination
  - - - Clinical Cases
        
        Clinical Case
        
        Clinical Case
        
        Notes:
        
        note that
  - - - *Bipolar Disorder Type 2
        
        Type 2 = depressive episode and possible hypomanic, but NO MANIC
        --> "Bipolar TYPE 2s have the BLUES"
        
        *Bipolar Disorder Type 1
        
        Types 1 = manic episode +/- depressive
        
        BIPOLAR manics DIG FAST
        
        BIPOLAR manics DIG FAST
        
        D = distracted
        
        I = irritable / irresponsible
        --> quit job, etc.
        
        G = grandiose ideas
        --> thinking they can save the world
        
        F = Flight of ideas
        --> write manifestos, etc.
        
        A = agitated
        
        S = don't SLEEP for a week
        
        T = talkative / pressured speech
        
        *Manic Depressive Disorders
        
        periods are DISTINCT and last > 1 week
- - - - OCD vs OC personality disorder
        
        the Personality PD does NOT bother the person where OCD does
  - - - Schizo AFFECTIVE DISORDER
        AFFECTIVE = means the PSYCHOTIC symptoms are only AFFECTIVE for 2 weeks ALONE = without any mood changes
        --> then they have +/- either
        --> MANIC or DEPRESSIVE MOOD after this
  - - - *Grief
        
        note that visual hallucinations of a close dead relative is a NORMAL thing
        
        Grief is normal to last up to a year after
        
        Adjustment disorder = half the time of Grief
  - - - EPS ADAPT with anti-psychotics
- - - - Suppression
        
        putting unwanted feelings to the side in order to deal with reality
      - Sublimation
        
        taking out negative feelings in socially acceptable ways
        --> anger taken out in sports
        --> SOCKING someone in soccer/rugby is SUBLIME
        --> rather than in public
    - - Notes:
        
        note that intellectualization of a medical condition is a defense mechanism that is detached and takes a purely logical approach to the disease with out an feelings
    - - DENIAL = unhealthy
        vs
        SUPRESSION = healthy
        
        SUPS are both good
        SUBLIMATION
        SUPPRESSION
        
        think of the water boy
        = SUB him IN
        
        take out his aggression
        
        Suppression is the healthy form of denial
        --> you awknoledge the truth
        --> but you are purposefully not thinking about it
        
        DENIAL = unhealthy
        vs
        SUPRESSION = healthy
        
        DISPLACEMENT -= GAME OF THRONES
        
        more to do with anger that is completely unrelated to your own actions
        
        vs projection
        --> classic example
        --> you want to cheat on your wife and instead accuse her
- - - - Clinical Case
        
        Notes:
        
        note that
        
        Clinical Case
- - - - Clinical Case
        
        Clinical Case
        
        Notes:
        
        note that