Alhamar Notes

Psychiatry notes
Psychotic disorders

Psychosis

- Definition: distorted perception of reality which may be accompanied by:

o Delusion: fixed false beliefs unrelated to culture or religion – can be bizarre (impossible)
or non-bizarre (plausible):
▪ Delusion of persecution (paranoid delusions); one is being persecuted
▪ Ideas of reference; “TV characters are talking to me”
▪ Thought broadcasting; “own thoughts can be heard by others”
▪ Delusion of grandeur ▪ Delusion of guilt ▪ Somatic Delusion
o Perceptual disturbances → illusion, hallucinations
▪ Illusion: false perception of a present sensory stimuli (sees cat as monster)
▪ Hallucination: perception without stimulus (no cat, but pt. sees a cat)
• Auditory: most commonly in schizophrenic patient
• Visual: drug intoxication, drug & alcohol withdrawal
• Olfactory: usually associated with epilepsy (an aura)
• Tactile: usually secondary to drug use / alcohol withdrawal
o Disorganized thinking/behavior
- It can be a symptom of schizophrenia, mania, depression, delirium and dementia
- DDx of psychosis:
o Due to another medical condition:
Sx DO NOT occur ▪ CNS disease (MS, AD, PD, epilepsy, encephalitis, neoplasm…etc.)
only during
delirium (acute
▪ Endocrinopathies (hypo/hyper-thyroidism, Addison/Cushing)
confusional state) ▪ B12, folate or niacin deficiency
o Substance/Medication-induced psychotic disorder → E.g.: anesthetics, antiparkinsonian agents,
anticonvulsants, NSAIDs, alcohol, cocaine,
o Delirium/Dementia LSD, benzodiazepine, phencyclidine (PCP)
o Bipolar disorder
o Major depression with psychotic features
o Schizophrenia + Schizophreniform disorder + Schizoaffective disorder
o Brief psychotic disorder (postpartum psychosis): 1day – 1 month
o Delusional disorder: non-bizarre delusion + no impairment + no 1,2 or 3 of schizophrenia

Schizophrenia (life-long disorder)

- Psychiatric thought disorder → abnormalities in thinking, emotion & behavior

- Epidemiology:
o Affect 0.3%-0.7% of people – M=F but M tend to have more -ve Sx
o It has strong genetic predisposition (50% concordance rate among monozygotic twins)
- Symptoms come in 3 categories: ▪ +ve Sx due to high
o Positive Sx: hallucination, delusions, bizarre behavior, disorganized speech dopamine
o Negative Sx (5 As): Anhedonia, Affect (flat), Alogia (poverty of speech), Apathy, (mesolimbic)
▪ -ve Sx due to high
Attention (poor)
serotonin & low
o Cognitive Sx: impairment in attention, executive function & working memory dopamine
(prefrontal cortical)
Alhamar Notes
- Dx:
o ≥2 of the following present for ≥1 month:
One of the 2 should
1. Delusion (persecution – grandiosity) be 1,2 or 3: delusion
2. Hallucination (generally auditory) or hallucination or
3. Disorganized speech disorganized speech
4. Disorganized behavior
5. Negative symptoms (the 5 As) Typical finding of schizophrenia are flat
affect, intact procedural memory &
o Duration of illness for ≥6 months
concentration, auditory hallucinations,
o Must cause social, occupational or self-care functional paranoid delusions, ideas of reference & lack
deterioration of insight into their disease
o Sx not due to substance or medical condition
- Prognosis:
o Better → later onset – good social support - +ve Sx – acute onset – female
o Worse → early onset – poor social support - -ve Sx – gradual onset – male
- Tx by antipsychotics – lifelong
o Types:
▪ Typical (1st generation):
• Work on dopamine receptors → prevent +ve Sx
• Examples → chlorpromazine – haloperidol
• Severe S/E (extrapyramidal) → tardive dyskinesia – acute dystonia
▪ Atypical (2nd generation):
• Work on dopamine & serotonin → prevent both +ve & -ve Sx
• Examples → quetiapine – risperidone - clozapine
• Safer S/E (metabolic syndrome) → need lipid, BP & BG monitoring
o Pathways other than prefrontal (-ve Sx) & mesolimbic (+ve Sx) blocked by antipsychotics
▪ Tuberoinfundibular → hyperprolactinemia (gynecomastia, irregular menses)
▪ Nigrostriatal → parkinsonism/extrapyramidal S/E (tremor, rigidity, slurred
speech, akathisia, dystonia)
o Neuroleptic malignant syndrome (S/E of high-potency 1st generation antipsychotics)
▪ Pt. taking typical antipsychotics and developed fever + rigidity + elevated CK
▪ Treated with dantrolene & immediate stopping of antipsychotics
o What to give (a little details):
▪ Compliant → atypical (quetiapine, olanzapine)
▪ Combative (ER) → typical (haloperidol) IM
▪ Non-compliant → IM depot haloperidol
▪ All else fails → clozapine but risk of agranulocytosis (monitor WBC)
- Comparison to similar things:
o Brief psychotic disorder: Sx lasts from 1 day to 1 month
o Schizophreniform disorder: Sx lasted >1 month but <6 months
o Schizoaffective disorder: psychosis + mood disorder (depression/mania)
▪ Delusion/Hallucinations for 2 wks with no mood disorder Sx
▪ Mood treated first (mood stabilizers) + atypical antipsychotics
o Schizotypal (personality disorder): paranoid, social anxiety
o Schizoid (personality disorder): lack of enjoyment from social activities
 Alhamar Notes
Mood disorders

Introduction

- Mood: description of one’s internal emotional state (sad, happy, irritable ..etc.)
- Mood episodes: distinct periods of time in which an abnormal mood is present
- Mood disorders: defined by their patterns of mood episodes (MDD, bipolar) – chronic course
- Remember that Sx should not be due to substance or medical illness + cause significant
distress or social/occupational impairment
- Medical conditions that can cause mood disorders:
o Depressive episode: stroke, MI, DM, Cushing, Addison, Parkinson’s, cancer, viral illness
o Manic episode: hyperthyroidism, temporal lobe seizure, MS, HIV
- Medications/Substances-induced mood disorders:
o Depressive disorder: alcohol, anticonvulsants, antipsychotics, stimulants withdrawal
o Bipolar disorder: antidepressants, sympathomimetics, stimulants (cocaine)
- Bereavement (simple grief): reaction to major loss (loved one), not a mental illness
o Should not include psychotic Sx, disorganization or active suicidality

Mood episodes

- Major depressive episode – must have 5/9 for ≥2 wks (SIG E CAPS):
1. Depressed mood most the time 2. Insomnia/hypersomnia 3. Anhedonia (no interest)
4. Guilt/worthlessness 5. Loss of energy/Fatigue 6. ↓ Concentration
7. Appetite/Weight (↑/↓) 8. Psychomotor agitation or retardation 9. Suicidal ideation

- Manic episode: period of abnormally & persistently elevated, expansive or irritable mood ≥1 wk
+ at least 3/7 (DIG FAST):
1. Distractibility 2. Insomnia
3. Grandiosity 4. Flight of ideas (racing thoughts)
5. Activity/Agitation 6. Speech (pressured; interruptible)
7. Thoughtlessness (shopping spree, sexual indiscretion)

- Hypomanic episode: same as mania BUT lasts ≥4 days (not 1 wk) & there is no marked
impairment in social or occupational functioning

Mood disorders

- Major depressive disorder (MDD):

o Depressed mood/anhedonia (loss of interest) for ≥2 wks with 5/9 criteria (SIGECAPS)
▪ Patients may express vague somatic complaints (fatigue, headache, ABD pain)
o Heterogenous disease (biological, genetic, environmental & psychosocial)
▪ Antidepressants exert their therapeutic effect by raising catecholamines
▪ High cortisol & thyroid disorders associated with depressive symptoms
o 12% worldwide & considered the MC disorder among those who complete suicide
o Sleep problems:
▪ Multiple awakenings → ↓ deep sleep + ↑ REM
▪ MC types of disturbances: difficulty falling asleep & early morning awakenings
 Alhamar Notes
o Atypical depression features → hypersomnia, hyperphagia, leaden paralysis
o Tx:
▪ Hospitalization if pt. at risk for suicide or homicide or unable to care for himself
▪ Antidepressant:
• SSRI (safer S/E): fluoxetine, paroxetine (headache, N/V)
• TCA: amitriptyline, S/E: arrhythmia & prolonged QT, weight gain
• MAOI: phenelzine, S/E: orthostatic hypotension, hypertensive crisis if
taken with tyramine-rich food
▪ Psychotherapy (CBT)
▪ Electroconvulsive therapy → if pt. unresponsive to meds or cannot tolerate
them (pregnant) – extremely safe method (primary risk is from anesthesia)
▪ Depression + psychotic features → antidepressant & antipsychotic
- Bipolar I disorder (into everything but finishes nothing):
o Occurrence of manic episode for ≥ 1 wk
▪ Episodes of major depression not required for diagnosis (AKA manic-depression)
o Has the highest genetic link of all major psychiatric disorders
o R/O stimulants (cocaine, amphetamines)
S/E of lithium: weight gain,
o Tx: tremor, N/V, polyuria
▪ Agitated in ER → benzodiazepine to calm patient (nephrogenic DI), polydipsia,
Rapid cycling: ≥4
▪ Chronically → mood stabilizer (lithium) – valproic acid alopecia, metallic taste,
mood episodes hypothyroidism, seizures
in 1 year ▪ Antipsychotic as adjunct → quetiapine
▪ Psychotherapy (family therapy, group therapy) & ECT (e.g. pregnant)
- Bipolar II disorder:
o Hypomania (4 days) + major depressive episode
▪ If it is a full maniac episode then it is bipolar I
o Rule out psychosis or catatonia (any of them is present then it is bipolar I)
o Treated with mood stabilizer (lithium)
- Dysthymia; persistent depressive disorder (Indolent MDD):
o Depressed mood ≥ 2 yrs + never without Sx for 2 months during those 2 yrs + ≥ 2 of:
▪ Poor concentration ▪ Feeling of hopelessness ▪ Poor appetite/overeating
▪ Insomnia/hypersomnia ▪ Low energy/fatigue ▪ Low self-esteem

o Tx → combination of psychotherapy & pharmacotherapy; SSRI)

- Cyclothymia:
o Lesser version of bipolar II
o Not a full hypomanic episode neither full MDE for ≥ 2 yrs & never Sx-free for >2 months
o Basically they are the people you hate in medical school: study 16 hrs/day and get all A’s
and always have energy and they never have any depression Sx
- Premenstrual dysphoric disorder:
o Mood liability, irritability, depressed & anxiety during premenstrual days
o Improve within few days of menses & absent in week post-menses
o Sx not an exacerbation of other disorder (MDD, dysthymia) & not due to substance or
medical condition
o Tx → SSRI
Alhamar Notes
- Disruptive mood dysregulation disorder (DMDD):
o Chronic severe perseistent irritability occurring in childhood & adolescence
o Outbursts ≥ 3/wk & mood btw outbursts is persistently angry most of the day
o Sx should be in ≥ 2 settings (school, home) & for ≥ 1 yr (no 3 months without Sx)
o Sx not explained by other mental disorder & not due to substance
o Tx → psychotherapy; parent management training

Anxiety, Obsessive-Compulsive, Trauma, & Stressor-related Disorders

Introduction

- Anxiety → individual’s emotional & physical fear response to perceived threat

o Considered pathologic when Sx are excessive, irrational, out of proportion to trigger OR
Sx without an identifiable trigger
o S&S:
▪ Constitutional → fatigue, diaphoresis, shivering
▪ Cardiac → chest pain, palpitations, tachycardia, hypertension
▪ Pulmonary → SOB, hyperventilation
▪ Neurologic/Musculoskeletal → vertigo, lightheadedness, tremor, insomnia
▪ GI → nausea, emesis, diarrhea, constipation, anorexia
o S&S should not be caused by substances or medical conditions:
Alcohol intoxication/withdrawal CNS → epilepsy, brain tumor, migraines, MS
Sedative/anxiolytics withdrawal Endocrine → hyperthyroidism, thyrotoxicosis, hypoglycemia
Stimulants intoxication/withdrawal Metabolic → B12 deficiency, electrolyte abnormalities
Caffeine intoxication Respiratory → asthma, COPD, PE, pneumonia
Tobacco intoxication/withdrawal Cardiovascular → CHF, angina, MI, arrhythmia
Opioids withdrawal
o MC form of psychopathology & mostly in women (2:1 ratio) – late adolescence
o General Tx guidelines → psychotherapy for mild & pharmacotherapy (mod-severe)
- Pharmacotherapy:
o First line → SSRI (sertraline); effective in 4-6 wks or SNRI (venlafaxine)
o Benzodiazepines (diazepam); quick effect but may worsen depression + addictive
o Buspirone (Non-benzodiazepine anxiolytic) – only for augmentation
o β-blockers (propranolol): control autonomic Sx; for panic attacks & performance anxiety
- Psychotherapy: cognitive behavioral therapy (CBT) & psychodynamic psychotherapy
- Panic attacks:
o Fear response; abrupt surge of intense anxiety, peak within mins & resolve within ½ hr
o Sx of panic attacks; at least 4/13 (STUDENTS PANIC):
S → SOB T → trembling U → unsteady D → depersonalization
E → excessive HR N → numbness T → tingling S → sweating
P → palpitations A → ABD pain N → nausea I → intense fear of dying
C → chest pain

o Smoking is a risk factor for panic attacks

Alhamar Notes
Anxiety disorders

General rule in anxiety disorders: anxiety/fear + excessive + avoidance/endured with severe

anxiety + causing functional impairment + not due to substance or medical illness
- Panic disorder (acute & overt amount of anxiety):
o Associated with genetic & psychosocial factors (stressors)
o Criteria → Recurrent panic attacks w/o trigger + 1 month of worry after panic attack
o 1st thing to do R/O ACS (ECG, troponins), hyperthyroidism (TSH) & asthma
o Tx → SSRI & CBT – benzodiazepines for acute attacks (PRN)
- Agoraphobia (often develops with panic disorder):
o Fear of going outside alone where escape or getting help is difficult
o Criteria → >2 situations (bridges, crowds, buses, trains, stores, outside alone) + Sx
lasting ≥ 6 months + causing social/occupational dysfunction
o Tx → CBT & SSRI
- Specific phobias & social anxiety disorder (social phobia; embarrassment/humiliation):
o Exaggerated & irrational fear against specific thing or situation (≥6 months)
Phobias are MC
o Specific phobias → heights, flying, animals (snakes, spiders), blood, injections psychiatric disorder
▪ Patients with blood-injury-injection specific phobia may experience in women & 2nd MC
bradycardia & hypotension ➔ vasovagal fainting in men (substance-
o Social phobia → public speaking, eating in public, using public restrooms related is 1st)
o Tx:
▪ Specific phobia → CBT
▪ Social anxiety disorder → CBT & SSRI (BB for performance anxiety)
- Selective mutism:
o Failure to speak in specific situation for ≥ 1 month – typically starts in childhood
o Criteria → consistent failure to speak in specific situations (school) with no language
difficulty or communication disorder causing significant impairment + Sx > 1 month
o Tx → CBT & family therapy + SSRI for anxiety
- Separation anxiety disorder:
o It begins by 1 year & peaks by 18 months
▪ Stranger anxiety begins around 6 months, peaks at 9 months
o Criteria → excessive inappropriate fear/anxiety regarding separation with ≥ 3 of:
▪ Separation leads to extreme distress
▪ Worry about loss of OR harm to attachment figures
▪ Worry about experiencing an event that leads to separation
▪ Reluctance to be alone / reluctance to leave home / reluctance to sleep alone
▪ Lasts ≥4 wks in children & ≥6 months in adults
- Generalized anxiety disorder (GAD; chronic low-level insidious amount of anxiety):
Worry WARTS
o Criteria (not due to substance or medical condition & causing impairment): Worried
▪ Constant state of worry about most things in most days for ≥ 6 months Worn-out
▪ With ≥ 3 somatic complaints (sleep, weight, irritability & concentration) Absent-minded
o Tx → psychotherapy (CBT) & SSRI Restless
Tense
Sleepless
Alhamar Notes
Obsessive-Compulsive & related disorders (should not be due to substance or medical illness)

- Obsessive-Compulsive disorder (OCD)

o Obsessions → anxiety-provoking, internal, intrusive, unwanted thoughts
o Compulsions → anxiety-reducing, repetitive behavior/ritual
o Patterns (obsession → compulsion):
▪ Safety → frequent checking
▪ Contamination → washing/cleaning
▪ Symmetry → order/counting
o Criteria → time-consuming (>1hr/daily) or impairs function (socially – occupationally)
o Tx → psychotherapy (CBT; exposure & response prevention) + SSRI (sertraline), TCA (2nd)
- Body Dysmorphic disorder (female disease)
o Preoccupation of part of body (skin, hair, nose, breast) perceived as defective → check
appearance (makeup) & unnecessary surgeries
o To diagnose it, also should causes impairment in functioning (mean age is 15)
o Tx → SSRI &/or CBT
- Hoarding disorder
o Difficulty to throw things away → accumulation of these items (trash)
o Leads to unsafe environment & no one could know as items hidden in home
o Tx → CBT but difficult to treat
- Trichotillomania (hair-pulling disorder)
o Compulsion by pulling hair (scalp, eyebrows) leading to alopecia/varying length hair
o More common in women Tx → SSRI & CBT + Need to R/O fungal cause of hair loss
- Excoriation (skin-picking) disorder
o Recurrent skin picking → lesions (mostly in women)
o Tx → CBT (habit-reversal training) +/- SSRI

Trauma & Stressor-related disorders (as always; Sx causing impairment + not due to substance or illness)

- Post-traumatic stress disorder (PTSD) & Acute stress disorder

o Life-threatening severe stressor (actual death/threatened death, combat, sexual assault)
o The event could be experienced, witnessed or just learned (know about loved one)
o Criteria (post-exposure to event): intrusions (flashbacks, nightmares), avoidance (not
talking, avoiding people/place), ↓ mood & ↑ arousal (impaired concentration,
insomnia) TRAUMA
o Duration: T: traumatic event
▪ >3 days but <1 month → acute stress disorder R: re-experience
A: avoidance
• It is normal to be afraid in 1 3 days after life-threatening event
st
U: unable to
▪ Sx for >1 month → PTSD function
o Tx → psychotherapy (group therapy) & SSRI M: month or more
▪ PrazoSiN (α1-antagonist) → Stop Nightmares of Sx
▪ They may fall into substance abuse as they try to treat themselves A: arousal
increased
- Adjustment disorders (divorce – loss of job)
o Non-life-threatening stressor → mood change but not enough to be mood disorder
o Onset of event must be within 3 months & duration <6 months
o Tx is supportive psychotherapy – group therapy
 Alhamar Notes
Personality disorders

Introduction

- Personality disorder criteria:

o Enduring pattern of behavior that deviates from person’s culture & manifested in ≥2 of:
▪ Cognition ▪ Affect CAPRI
▪ Personal relations ▪ Impulse control
o The pattern is pervasive (in group of people), inflexible
o Pattern is stable with an onset in adolescence or early adulthood
o As ALWAYS should lead to distress in functioning
o As ALWAYS not related to substance or another mental/medical illness
- Clusters:
o Cluster A (WEIRD) → paranoid, schizoid & schizotypal Schizoid & schizotypal have no
▪ Patients seem eccentric, peculiar or withdrawn delusions to be schizophrenic
▪ Familial association with psychotic disorders
o Cluster B (WILD; bad boys) → antisocial, borderline, histrionic & narcissistic
▪ Patients seem emotional, dramatic or inconsistent
▪ Familial association with mood disorders
o Cluster C (WIMPY) → avoidant, dependent & obsessive-compulsive
▪ Patients seem anxious or fearful
▪ Familial association with anxiety disorders
- Usually Tx is difficult (few patients aware that they need help) – most helpful is psychotherapy

Drug Description How to handle them

Paranoid Distrustful, suspicious, interpret other are malicious Clear, honest, nonthreatening
Loners, have no relationships but also are happy not
Schizoid You won’t see them
A having any relationships
Magical Thinking, borders on psychosis, Bizarre Thoughts, Brief psychotic episodes, clear, honest,
Schizotypal
Behavior or Dress nonthreatening
Unstable, impulsive, promiscuous, emotional emptiness, Suicidal gestures may be successful.
Borderline unable to control rapid changes in mood, suicidal Splitting (others are all good or all bad),
gestures (I will kill myself if u don’t come now) Dialectic Behavioral Therapy is TOC
Theatrical, attention-seeking, hypersexual, use of physical
Histrionic appearance, dramatic. Exaggerated but superfluous Set rules, insist they are followed
B emotions (unable to form meaningful relationship)
Inflated sense of worth or talent, self-centered, fragile
Narcissistic ego, use eccentric dress to draw attention, demand Set rules, insist they are followed
special treatment
Criminal, no regards for rights of others, impulsive, lack
Anti-Social Jail Set rules, insist they are followed
remorse, manipulative. Must be >18yrs (conduct disorder)
Fears rejection & criticism, wants relationships but does Avoid power struggles, make patients
Avoidant
not pursue them, passes on promotions choose
Unable to assume responsibility, submissive, clingy, fear Give clear advice, patient may try to
C Dependent
being alone sabotage their own treatment
Obsessive- Rigid, orderly perfectionist. Order, Control. Perfection at
Compulsive the expense of efficacy
 Alhamar Notes
Substance-Related & Addictive Disorders

Introduction

- Criteria: problematic pattern of substance use leading to impairment manifested by ≥2 of the

following within 12 months:
o Using substance more than originally intended
o Unsuccessful efforts to cut down on use
Control
o Significant time spent on obtaining, using or recovering from substance
o Craving to use substance (must do the substance)
o Failure to fulfil obligation at work, school or home
Social impairment o Continued use despite social or interpersonal problems due to substance use
o Reduced social, occupational or recreational activities because of substance use
o Use in dangerous situations (driving car)
Risk
o Continued use despite subsequent physical/psychological problem (liver & alcohol)
o Tolerance → need for higher amounts to reach the desired effect
Pharmacological
o Withdrawal → Sx due to cessation of substance use that has been heavy & prolonged
- Alcohol & nicotine are most commonly used substances
- Substance-induced Sx improve during abstinence whereas primary mood Sx persist
- Testing of substance use:
o Alcohol → Breathalyzer test (police) – blood/urine more accurate
o Cocaine → urine drug screen (+ve for 2-4 days)
o Amphetamines → urine drug screen (+ve for 1-3 days)
o Phencyclidine (PCP) → urine drug screen (+ve for 5-7 days) + elevated CPK & AST (LFT)
o Sedative-Hypnotics → urine & blood (Barbiturates 24 hrs – 3 wks // BZN 5 – 30 days)
o Opioids → urine drug screen (+ve for 1-3 days) – methadone need separate panel
o Marijuana → urine detection
- Tx → behavioral counseling – motivational intervention (MI) – CBT – group therapy +/- meds

Alcohol (VERY IMPORTANT) – MC co-ingestant in drug overdoses

- Alcohol activates GABA (inhibitory to brain activity), dopamine & serotonin receptors & inhibits
glutamate receptors (excitatory to brain activity) → CNS depression
- Intoxication:
o Effects → ↓ fine motor control - altered mental status – disinhibition – slurred speech –
cerebellar dysfunction (ataxia) – N/V – coma & death (life-threatening)
o Chronic use impacts:
▪ Brain → Wernicke encephalopathy (B1 deficiency) – Korsakoff dementia
▪ Liver → cirrhosis
▪ GI → GI bleeds & gastritis
o Tx → ABC, glucose, electrolytes & acid-base status (group therapy is for chronic)
▪ Thiamine to prevent or treat Wernicke’s encephalopathy – +/- gastric lavage
- Withdrawal (same as BZN withdrawal → increased activity of brain; seizures):
o Diastolic HTN & tachycardia – tremor – diaphoresis – agitation – confusion – seizure
o Delirium Tremens (DT): visual hallucination, gross tremor (emergency; Tx with BZN)
o Tx → long-acting BZN taper (lorazepam) + rapid-acting BZN PRN
Sx of withdrawal begin
after 6-24 hrs of last drink
Alhamar Notes
↑LFT (AST:ALT 2:1 & ↑ GGT) & ↑ MCV
- Alcohol use disorder:
o Most commonly used biomarkers to detect prolonged drinking are BAL, LFT & MCV
o Medications for alcohol use disorder:
▪ Naltrexone (opioid receptor blocker) → ↓ desire for alcohol
▪ Acamprostate: can be used in pt. with liver disease but CI in renal disease

Cocaine

- Blocks reuptake of dopamine (reward system), Epi & NEpi in synaptic cleft → stimulant effect
- Intoxication → psychomotor agitation, HTN, tachycardia, psychosis, dilated pupils, angina
o Can lead to cardiac arrhythmia, respiratory depression, MI or stroke (DEADLY)
o Tx → mild-moderate (reassurance & BZN), severe (antipsychotics; haloperidol)
- Withdrawal → depression (hunger, fatigue, anhedonia), “cocaine bugs”
o Not life-threatening, just supportive Tx (Sx resolve within 72 hrs or if heavy 1-2wks)

Amphetamine (used in treatment of ADHD & narcolepsy)

- Blocks reuptake & facilitate release of dopamine & NEpi → stimulant effect
- Intoxication → dilated pupils, psychosis, overheating (fever, tachycardia), water intoxication
o Chronic use → accelerated tooth decay (meth mouth)
- Withdrawal → crash, depression - Tx → supportive care

Phencyclidine (PCP)

- Intoxication → aggressive psychosis, vertical/horizontal nystagmus, impossible strength,

blunted senses, dilated pupils
- Withdrawal → severe random violence
- Tx → BZN for agitation, haloperidol to subdue them – acidify urine to increase excretion

Sedative-Hypnotics

- Include BZN (used for anxiety disorders) & barbiturates (for epilepsy & as anesthetics)
- Intoxication: delirium – respiratory depression & coma (need large dose to happen) – amnesia
o Tx → flumazenil (for BZN only) – activated charcoal & gastric lavage – alkalinize urine
with NaHCO3 to promote renal excretion (for barbiturates only)
- Withdrawal same as alcohol (note that barbiturates withdrawal has highest mortality rate)

Opioids (VERY IMPORTANT)

- Involved in analgesia & sedation – examples: heroin, codeine, morphine, methadone

- They start with prescription pills & end up with heroin (IV use; HIV, Hepatitis C & IE)
o Behaviors such as losing meds, doctor shopping & running out of medication early
- Intoxication: euphoria – coma – constricted pupils & decreased RR – constipation – N/V
o Tx → naloxone (opioid antagonist)
- Opiate use disorder Tx:
o Methadone (opioid-R-agonist): gold-standard Tx in pregnant opioid-dependent women
o Buprenorphine (partial-R-agonist): sublingual; prevents intoxication by IV injection)
o Naltrexone (competitive antagonist): daily oral OR monthly injection (needs compliance)
- Withdrawal (non-life-threatening): pain, N/V, diarrhea, ABD cramps, irritable, lacrimation
 Alhamar Notes
Hallucinogens (LSD)

- Intoxication → hallucinations, flashbacks, enhanced senses Withdrawal → flashbacks

Caffeine

- Adenosine antagonist → ↑cAMP → release of excitatory neurotransmitters

- > 250mg (2 cups) → anxiety, insomnia, muscle twitching, diuresis, GI disturbance

Nicotine

- Intoxication → anxiety, insomnia, if very high can lead to ventricular tachycardia

- Withdrawal → craving, increased appetite, weight gain, restlessness
- Tx → transdermal patch, gum

Neurocognitive Disorders (NCD)

Definition: group of conditions defined by decline from a previous level of cognitive function

Delirium (think of this as acute brain failure)

- Medical emergency, reversible but can advance to coma, seizures or death

- RF:
o Polypharmacy (esp. BZN & anticholinergic drugs) o Preexisting cognitive impairment or depression
o Advanced age o Prior history of delirium
o Severe illness o Alcohol use
o Impaired mobility o Hearing/Vision impairment
- Causes:
MC precipitant of
o Substance intoxication/withdrawal delirium
delirium in children o Medication-induced delirium (TCA – anticholinergic – BZN – CS – H2 blockers)
are febrile illness & o Delirium due to medical condition (CVA – meningitis – thyrotoxicosis)
medications
o Delirium due to multiple etiologies
- Clinical features develop acutely over hrs to days & fluctuate throughout day (worse at night)
o Disorder of attention & awareness (disorientation)
o Deficit in recent memory OR perceptual disturbances (visual illusions/hallucinations)
o Circadian rhythm disruption & emotional symptoms
- Types of delirium (based on psychomotor activity):
o Mixed type – MC
o Hypoactive “quiet” type – more likely to go undetected
o Hyperactive type “ICU psychosis” – more common in drug withdrawal or toxicity
- Diagnosis (DSM-5):
o Disturbance in attention & awareness
o Disturbance in an additional cognitive behavior (thinking – conscious)
o Develops acutely (hrs-days), represents a change from baseline & fluctuates
o Not accounted by another NCD & not occurring during coma
o Evidence from Hx, physical or labs that it is a direct consequence of a cause
▪ Check BG, ABG, ECG, CBC, LFT, blood alcohol, urine screening, head CT, LP
- Tx → treat underlying cause – antipsychotics (haloperidol) for agitation

Unless treating delirium due to BZN or Alcohol

withdrawal, do not use BZN as they may
worsen or prolong delirium
Alhamar Notes
Mild & Major Neurodegenerative Disorders IADLs; feeding
toileting,
- Chronic cognitive decline that impacts functioning in daily activities (NOT acute) bathing, paying
o Mild NCDs; difficulty in complex activities but able to maintain their independence bills, shopping
o Major NCDs; need assistance with independent activities of daily living (IADL) for groceries
- DSM-5 criteria:
Criterion Mild NCDs Major NCDs
Functional decline in at least 1 cognitive domain (thinking, consciousness)
Concern (expressed by pt. or someone Mild decline Significant decline
who knows them)
Objective findings on cognitive testing Modest impairment Substantial impairment
Effect on functioning in daily life Ability to perform Impaired performance of
IADLs preserved IADLs
Deficits do not occur exclusively in the context of delirium
Deficits are not better explained by another mental disorder
- MMSE is a screening tool – perfect is 30 & <25 indicates dysfunction
o Orientation – Registration – Attention – Recall – Language
o Another screening tool is Mini-Cog; 3 item recall & clock-drawing tasks
- Alzheimer’s Disease (AD) - MCC of major NCDs (dementias)
o Gradual progressive decline in cognitive functions (memory, learning & language)
o Accumulation of extra-neuronal senile plaques & intraneuronal tau protein tangles
o Tx → cholinesterase inhibitors (donepezil) & NMDA-R antagonist (memantine)
- Vascular disease (vascular cognitive impairment) – 2nd MCC of major NCD
o Cognitive decline occurs as a result of strokes (large/small vessels)
▪ Loss of function is corresponding with occurrence of micro-infarcts
▪ Complex attention & executive function affected in small vessel disease
o RF → HTN, DM, smoking, obesity, hyperlipidemia, A fib, old age
o Tx → manage RF & symptomatic treatment
- Lewy body disease (LBD) – accumulation of α-synuclein & Lewy neurites in brain (basal ganglia)
o Progressive cognitive decline – core features:
▪ Waxing & waning of cognition (esp. attention & alertness)
▪ Visual hallucinations – vivid, colorful, well-formed images of animals/people
▪ Extrapyramidal signs after 1yr of cognitive decline
o Tx → cholinesterase inhibitor for cognition & clozapine for psychotic Sx
- HIV is the MC infectious agent known to cause cognitive impairment (major NCD)
- Normal pressure hydrocephalus (reversible cause of cognitive dysfunction)
o Etiology → idiopathic or 2ndry to meningitis & hemorrhage
o Clinical features:
▪ Wobbly (gait)
▪ Wacky (cognition; apathy, psychomotor retardation)
▪ Wet (urinary incontinence)
o Tx → ventriculoperitoneal shunt
▪ Gait is most responsive to Tx & cognition is least likely to improve
 Alhamar Notes
Psychiatric Disorders in Children

Intellectual Disability (ID; replaces mental retardation)

- Severely impaired cognitive (reasoning, learning) & adaptive/social functioning (independent

living)
- Causes (50% is idiopathic):
o Genetic → Down syndrome, Fragile X (MC inherited form of ID)
o Acquired → hypothyroidism, TORCH, drinking in pregnancy, prematurity, jaundice
- Tx → special education & social care

Specific Learning Disability

- Delayed cognitive development in a particular academic domain (reading, writing ..etc.)

o Poor performer – consider ID, ADHD, ASD
- Don’t forget about usual things – kid need glasses? hearing problems? Native language of kid?

Attention Deficit/Hyperactivity Disorder (ADHD) – idiopathic

- Impulsivity → blurt answers before Qs done, interrupts people, fidgets, can’t wait for their turn
- Inattention → talks fast, easily distracted, fails to complete tasks, lose things
DSM-5
- Present in ≥2 settings (home, school, work) & the onset is between 7 & 12 yrs
criteria
- Duration of symptoms ≥ 6 months
- It should be frequent & impair the kid’s functioning (learning, socializing, academic)
- Tx → stimulants (amphetamine) & special education + training parents
o Follow up for absence seizures (ethosuximide)

Autism Spectrum Disorder (ASD)

- Decreased social communication (NOT ASSOCIATED WITH VACCINES)

- Dx:
o Impaired social communication → social reciprocity (can’t understand others emotions)
+ – social relationships – non-verbal communication – joint attending
o Restricted/repetitive behavior → stereotypy – sameness (rigid thought patterns) –
restricted interests – change in sensory perception
- R/O learning disability & intellectual disability
- Tx → special education & social interaction

Tic Disorders: sudden, rapid, repetitive, stereotyped movements or vocalizations

- Association with OCD & ADHD – should diagnosed <18 yrs & duration of Sx >1yr
- Either physical or vocal tic (same physical movement – same grunts/coughs)
o Echolalia → repeating others’ words
- Tourette’s disorder is the most severe of the tic disorder
- Tx → CBT (habit reversal therapy) + meds (dopamine antagonist OR α2-agonist (guanfacine))
Alhamar Notes
Disruptive & Conduct Disorders

- Oppositional defiant disorder (ODD) – lie, cheat, steal)

o Irritability/anger, defiance or vindictiveness causing dysfunction
o Criteria: one individual involved (not a sibling) & ≥4 Sx for ≥6 months:
▪ Anger/irritable mood – loses temper, easily annoyed, often angry
▪ Argumentative/Defiant behavior – breaks rules, blames others
▪ Vindictiveness; at least 2 times in past 6 months
o Does not involve physical aggression or violating others’ basic rights (no bullying or
animal hurting)
o Tx → behavior modification & parent management training
- Conduct disorder (anti-social for children)
o Most serious disruptive behaviors which violates rights of other humans & animals
▪ Lack remorse for committing crimes or lack empathy to their victims
o Theft → broken into house, car
o Serious violation of rules → runs away from home overnight twice, truant from school
o Tx → behavior modification & parent management training

Elimination Disorders – developmentally inappropriate elimination of urine or feces

- Can be primary (never established continence) or secondary (continence developed then lost)
- Enuresis → recurrent urination into clothes (bed-witting) in ≥5 yrs developmentally
o Occurs 2 times/wk for ≥3 consecutive months resulting in impairment
o Can be nocturnal or diurnal (waking hours) or both
- Encopresis → recurrent defecation into inappropriate places (clothes, floor)
o Occurs ≥ 1 time/month for ≥3 months in ≥4 yrs developmentally
o Should not be due to substance (laxatives) or medical illness (hypothyroidism, fissures)
- Tx → psychoeducation
o Enuresis → limit fluid & caffeine intake – “urine alarm” – desmopressin (last option)
o Encopresis:
▪ Without constipation → behavioral program “bowel retraining”
▪ Due to constipation → bowel cleaning followed by stool softeners & fiber-diet

Child Abuse includes physical abuse, sexual abuse, emotional abuse & neglect

Dissociative Disorders: disruption in the integrated sense of self (separation of mental functions which
are normally connected; thought, memory & identity) – usually after significant prolonged stressor

Dissociative Amnesia

- Unable to remember important personal information while procedural memory is preserved

- Amnesia without travel (without fugue) – if with sudden unexpected travel (with fugue)
o Amnesia of stressor or event (women gets raped but can’t remember the rape)
o Loss of everyday routines (doesn’t remember favorite Jasmis meal)
o Can progress to the entire autobiography (can’t remember who they are)
- Should not be due to substance or medical/psychiatric illness
- Tx → establish pt. safety & psychotherapy (supportive, CBT)
Alhamar Notes
Depersonalization/Derealization Disorder (should be repeated experiences)

- Depersonalization → detachment from the body (watching yourself; out-of-body experience)

- Derealization → detachment from the environment (as if they are in a dream)
- Intact reality testing (not psychotic)
- Should not be due to substance or medical/psychiatric illness
- Usually they occur in a non-severe trauma (stressor) in adolescent
- Tx → CBT, hypnotherapy & supportive therapy

Dissociative Identity Disorder (Multiple Personality Disorder)

- ≥2 distinct identity states (so that primary self does not experience the trauma)
- Self → memory gaps (blackouts) – Hx of severe trauma – might have other dissociative Sx
- Others → paradoxical behaviors – appearance change
- Should not be due to substance (alcohol) or another medical condition
- Tx → psychotherapy +/- SSRI if depression is there or Sx of PTSD

Somatic Symptom & Factitious Disorders:

Introduction

- Real Sx or distress about a disease without an organic cause (not finding cause for Sx worsen it)
- Patients usually go from one doctor to another & do many tests & procedures
o Usually they have some sort of anxiety or depression
- The first thing is to R/O organic disease, factitious disorder & malingering
- Tx would be psychotherapy (CBT) & setting boundaries (one doctor to deal with them)

Somatic Symptom Disorder

- Pt. has somatic Sx (pain, fatigue), & they will be preoccupied about these Sx & they don’t want
to feel these symptoms (Sx ≥6 months)
o They may have a real medical problem but it will be disproportionate (Sx not related to
the illness he got)

Conversion Disorder (Functional Neurological Symptom Disorder)

- Pt. has neurologic complaints (blindness, paralysis) but there is no preoccupation (also won’t
hurt themselves) & they want to get rid of the problem
o Often associated with acute stressor & the neurologic defect is proportional to stressor
(kick a dog but you have never done it & suddenly your leg is paralyzed)

Illness Anxiety Disorder: No Sx but preoccupied about getting an illness despite repeated assurance &
they don’t want to feel these feeling & having these thoughts (≥6 months) – Tx by CBT & just 1 Dr

Psychological Factors Affecting Other Medical Conditions: anxiety worsening asthma

Factitious Disorder: falsification of physical or psychosocial Sx → could have any Sx, but Sx done Sx in both
intentionally to deceive & achieve attention (emotional gain; internal) depend on
whatever
Malingering → could have any Sx, but Sx done intentionally to deceive & get money or freedom they done to
themselves
from jail (personal gain; external)
Alhamar Notes
Eating Disorders: mostly in teens to twenties & in females (10:1)

Anorexia Nervosa Bulimia Nervosa

Bodyweight Underweight Normal
Self-image Very disturbed Disturbed
Fearing becoming or being fat + About the binge (uncontrolled eating) + there is
Anxiety
there is no insight insight
Restriction; ↓ caloric intake Purge (emesis or laxative abuse)
Method (diet, fast) & ↑ caloric
expenditure (exercise)
Malnourished (hypothyroid pt. Normal pt. but S&S of purge:
but thin; amenorrhea, cold - Emesis: dental erosions, dorsal hand
intolerance, orthostatic scars “Russell’s sign”, parotid swelling,
S&S
hypotension, bradycardia, ↓ K & Mg, metabolic alkalosis
arrhythmia) - Laxative abuse: diarrhea & metabolic
acidosis (loss of HCO3)
If anorexia is extreme (BMI <16) Rarely needed
Hospitalization
or electrolyte imbalance
In hospital: force feed & IV fluids SSRI (fluoxetine) + CBT
Tx
Outpatient: antipsychotic + CBT
Follow up for OCD, MDD (maybe needs SSRI) Never use bupropion (increased risk of seizure)
Appetite in MDD is poor while in anorexia nervosa the appetite is good but they starve themselves

Binge-Eating Disorder

- Binge (uncontrolled eating for 2-hour period) without the purge → obese patients
- Patients usually suffer from medical problems related to obesity (T2D, cardiovascular disease)
- Tx → CBT with strict diet & exercise & anti-obesity meds (orlistat) – stimulants can help

Psychopharmacology

Side Effects Overview

- HAM side effects – found in TCA & low-potency typical antipsychotics:

o Anti-Histamine → sedation, weight gain
o Anti-Adrenergic → hypotension
o Anti-Muscarinic (anticholinergic) → dry mouth, blurred vision, urinary retention, constipation
- Serotonin syndrome → flushing, diaphoresis, tremor, myoclonic jerks, hyperthermia,
rhabdomyolysis, renal failure & death
- Hypertensive crisis → MAOI with tyramine-rich food (cheese, chicken liver, cured meats)
- Extra-pyramidal side effects (EPS) → occurs with high-potency typical antipsychotics:
o Parkinsonism: masklike face, cogwheel rigidity, bradykinesia, pill-rolling tremor
o Akathisia: restlessness, need to move
o Dystonia: sustained painful contraction of muscles of neck, tongue, eyes & diaphragm
- Hyperprolactinemia – occurs with high-potency typical antipsychotics & risperidone
- Tardive dyskinesia: prolonged use of high-potency typical antipsychotics – usually irreversible
- Neuroleptic malignant syndrome (NMS): mental status changes, fever, tachycardia, HTN,
tremor, ↑ CPK, “lead pipe” rigidity – occurs due to antipsychotics
 Alhamar Notes
Antidepressants → SSRI, TCA, MAOI, miscellaneous Plasticity
of neurons
- All have same efficacy but differ in safety & side effects
- Usually a pt. needs a 6 wks of full dose of a specific type before considering changing medication
- Withdrawal phenomenon → dizziness, headaches, nausea, insomnia & malaise // need tapering
- Selective serotonin reuptake inhibitor (SSRI) – most commonly used:
o Inhibit presynaptic serotonin pumps → ↑ availability of serotonin in synaptic cleft 6 wks before
o Most SSRI dosed daily – fluoxetine has a weekly dosing form available as well changing
o Examples include: fluoxetine, sertraline, paroxetine 6 wks treatment
duration
▪ Fluoxetine – longest half-life, safe in pregnancy, S/E: insomnia, sexual
6 wks of washout
dysfunction, elevate levels of antipsychotics; ↑ their S/E
▪ Paroxetine – highly protein bound leading to several drug interactions, sedation,
constipation, weight gain & sexual dysfunction
o S/E → nausea, diarrhea, insomnia, headache, anorexia, ↓libido & prolonged ejaculation
▪ Serotonin syndrome (taking 2 meds increasing serotonin); triptan for migraine
& SSRI
- Serotonin-Norepinephrine Reuptake Inhibitor (SNRI) – cost more money than SSRI
o Venlafaxine: used for depression & GAD – similar S/E of SSRI + raises BP
o Duloxetine: depression & neuropathic pain – similar S/E of SSRI but more dry mouth &
constipation
- Norepinephrine-Dopamine Reuptake Inhibitors – Bupropion
o Used in treatment of adult ADHD & quitting smoking, S/E → increases anxiety, increase
risk of seizures (not used in bulimia) and increases psychosis at high doses
o Lacks sexual S/E as compared to SSRI
- Alpha2-Adrenergic Receptor Antagonists – Mirtazapine
o Used for major depression especially if pt. has weight loss &/or insomnia
o S/E → sedation (sleep) & weight gain (appetite); which is useful for the above patients
- Tricyclic Antidepressants (TCA) – rarely used for depression
o Inhibit reuptake of NEpi & serotonin → ↑ availability of monoamines in synapse
o S/E → highly anticholinergic (dry mouth, blurred vision), antihistaminergic (sedation,
weight gain) & antiadrenergic (hypotension, arrhythmia)
▪ Rarely used as it is lethal in overdose → Tx of TCA overdose is IV NaHCO3
▪ Major complications → Cardiotoxicity, Convulsions & Coma
o Examples → Amitriptyline (chronic pain), Imipramine (enuresis), Clomipramine (OCD)
- Monoamine Oxidase Inhibitor (MAOI)
o Prevent the inactivation of NEpi, serotonin, dopamine & tyramine by reversibly
inhibiting the enzymes MAO-A & MAO-B
o Phenelzine used in refractory depression
o S/E → serotonin syndrome (if taking SSRI & MAOI together), hypertensive crisis (MAOI
+ tyramine-rich food), orthostatic hypotension (MC), drowsiness, sexual dysfunction
- Uses of Antidepressants in other disorders (other than depression):
o OCD → SSRI (high dose) o Panic disorder → SSRI, TCA o Eating disorder → SSRI (high dose)
o Dysthymia → SSRI o Social phobia → SSRI o GAD → SSRI
o PTSD → SSRI o Enuresis → TCA (imipramine) o Migraine → TCA (amitriptyline)
o IBS → SSRI, TCA o Insomnia → Mirtazapine o Smoking cessation → bupropion
Alhamar Notes
Antipsychotics

- Used to treat psychotic disorders + psychotic Sx associated with other psychiatric illnesses
- Both 1st & 2nd generation have same efficacy in treating +ve psychotic Sx (hallucinations &
delusions) while atypical antipsychotics are more effective in treating -ve Sx (flattened affect &
social withdrawal)
EPS due to blockage of dopamine in
o Positive Sx → mesolimbic pathway high dopamine nigrostriatal pathway & high prolactin due to
o Negative Sx → mesocortical pathway low dopamine dopamine blockage in tuberoinfundibular area
- Typical (1st generation) antipsychotics:
o Classified according to potency & act by blocking dopamine (D2) receptors (+ve Sx)
▪ Low-potency → chlorpromazine (orthostatic hypotension & blue-gray skin
discoloration) & thioridazine (retinitis pigmentosa)
▪ Mid-potency → loxapine (seizures) thiothixene (ocular pigment changes)
▪ High-potency → haloperidol (PO/IM/IV & long-acting IM form)
o S/E:
▪ Antidopaminergic effects (giving anticholinergic “benztropine” can help)
• Extrapyramidal symptoms (EPS) → parkinsonism, akathisia, dystonia
• Hyperprolactinemia → ↓ libido, galactorrhea, gynecomastia
▪ Anti-HAM effects (Histaminic, Adrenergic, Muscarinic)
• Antihistamine → sedation, weight gain
• Antiadrenergic → orthostatic hypotension, cardiac abnormalities &
sexual dysfunction
• Antimuscarinic (anticholinergic) → dry mouth, urinary retention, blurry
vision, constipation, tachycardia
▪ Tardive dyskinesia → writhing movement of mouth & tongue if used >6 months
▪ Neuroleptic malignant syndrome (NMS) – emergency, but rare: FALTERED
• Fever • Autonomic instability (tachycardia)
• Leukocytosis • Tremor
• Elevated CPK • Rigidity “lead pipe”
• Excessive sweating • Delirium
▪ Elevated LFT, jaundice
- Atypical (2nd generation) antipsychotics:
o Act by blocking both dopamine (D2) & serotonin (2A) receptors (+ve & -ve Sx)
o Increased risk of mortality & stroke when used in elderly
o Used to treat acute mania, bipolar disorder, borderline personality disorder, PTSD
o Examples:
▪ Clozapine → used for refractory schizophrenia – ↓ risk of suicide
• Associated with agranulocytosis - Needs WBC & ANC monitoring
▪ Risperidone → can cause increased prolactin & EPS
▪ Olanzapine (good for non-compliant) → can cause weight gain & sedation
o S/E: Quetiapine causes
▪ Metabolic syndrome: weight gain, hyperlipidemia & hyperglycemia somnolence – can be
• Monitor weight, BP, fasting glucose & lipids used in insomnia &
▪ Some anti-HAM effects (dry mouth, urinary retentions ... etc.) bipolar/mania
▪ Elevated LFT & QTc prolongation
 Alhamar Notes
Mood stabilizers (for mania you also need antipsychotic with the mood stabilizer)

- Used to treat acute mania & to prevent relapse of manic episodes in bipolar & schizoaffective
- Lithium:
o DOC in acute mania & as prophylaxis for both manic & depressive episodes in bipolar
o Metabolized by kidney – careful when dealing with patient with renal problems
o Before prescribing, pt. need to have ECG, RFT, CBC, TFT & pregnancy test
o Very narrow therapeutic index (0.6 – 1.2), toxic >1.5 & lethal >2
o S/E:
Valproic acid, ▪ Toxic levels → AMS, coarse tremors, convulsions, delirium, coma & death
carbamazepine & ▪ Nephrogenic DI
lamotrigine also ▪ Weight gain & sedation
can be used as
▪ Hypothyroidism
mood stabilizers
▪ Ebstein’s anomaly – cardiac defect in babies (teratogen)
o NSAID, aspirin & thiazide diuretics increase lithium level in blood (be careful)

Anticonvulsants

- Carbamazepine:
o Acts by blocking Na-channels / CBC & LFT must be obtained
o S/E → GI, CNS, skin rash (SJS), leukopenia, agranulocytosis, hepatitis, NTD (preg. X)
- Valproic acid (depakene) – 2nd option after lithium
o For treating acute mania, mania with mixed features & rapid cycling
o Blocks Na-channels & increase GABA concentration in brain (monitor CBC & LFT)
o CI in pregnancy → NTD
- Lamotrigine → for bipolar depression, most serious S/E is SJS (pregnancy category C)

Anxiolytics/Hypnotics → anxiety disorders, muscle spasm, seizure, sleep disorders, alcohol withdrawal

- Benzodiazepines (BDZ):
o Act by potentiating the effect of GABA to help patients with acute panic to abort attack
o Many patients develop tolerance & dependence
o Long-acting → diazepam (valium) – has rapid onset, used for detoxification from alcohol
or sedative-hypnotic anxiolytic (withdrawal) & for seizures
o Intermediate-acting → lorazepam – panic attacks, agitation, not metabolized by liver
o S/E → drowsiness, reduced motor coordination, ante-retrograde amnesia Can be used in
▪ Withdrawal is life-threatening & can case seizures chronic alcoholics
▪ Toxicity → respiratory depression, especially if combined with alcohol or those with liver
disease
▪ For BZN overdose → flumazenil
- Non-BDZ anxiolytics
o Buspirone: can be used in combination with SSRI for treatment of GAD
o Barbiturates (phenobarbital): potential for abuse & side effect profile
o Propranolol (β-blocker): for treating autonomic effects of panic attacks or social phobia
such as palpitations, sweating & tachycardia + akathisia (S/E of antipsychotics)

Psychostimulants (dextroamphetamine) for ADHD & refractory depression

Alhamar Notes
Other Treatments

- Acetylcholinesterase inhibitors (donepezil) for major NCD (dementia)

- NMDA receptor antagonist (memantine) for dementia
- Electroconvulsive therapy (ECT) is the most effective treatment for MDD especially with
psychotic features
- Dialectical Behavioral Therapy (DBT) is effective with borderline personality disorders