05-10-2009, 07:48 PM
USMLE Step 2 ” Lesson 1:Child Psychiatry
Psychiatry Highlights for USMLE Step 2
Alina Gonzalez-Mayo, MD
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Child Psychiatry
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Mental Retardation
¢ Present before age 18
¢ Consisting of below-average intellectual functioning with an impairment in social adaptive functioning
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Characteristics:
Mental Retardation
Degree IQ Range Characteristics
Mild 55 - 69 6th gr level, can handle own affairs
& live on his own
Moderate 35 - 54 2nd gr. level, benefit from vocational
trainng, sheltered workshop
Severe 20 - 34 Can communicate, training not help-
ful, can be taught basic health habits.
Profound 6 months, < 7 years
¢ Increased incidence among school age
¢ Boys have a greater incidence than girls
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Clinical features:
ADHD
¢ Symptoms must be present in at least 2 situations e.g., home, school or work
¢ Symptoms may persist into adult life
¢ Increased incidence of conduct disorders
¢ Antisocial personality & substance-related disorders
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Management
ADHD
¢ Psychostimulants
o - methylphenidate
o - dextroamphetamine
o - pemoline
¢ Methylphenidate side effect - GH suppression
¢ Consider drug holiday
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Case Study
Johnny is an 8-year-old child being evaluated for various behaviors, such as staying to himself, as well as self-abusive and aggressive behaviors. He does not play with the other children and tends to act out aggressively when things are changed around at home. He has been in foster care since an early age and has not attended regular classes due to his behavior.
At the time of admission into foster care, he had an abnormal EEG but no seizures. When last given IQ tests, he scored 55, with comparable deficits in adaptive behavior. During the evaluation, Johnny spends most of his time reading a book he found in the waiting room. When asked about the book, he becomes angry and begins to rock back and forth. When called, he does not respond and does not make any eye contact.
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Characteristics:
Tourette's Disorder
¢ Multiple motor and vocal tics present for over 1 year, must occur before age 18
¢ Three times more common in boys than in girls
¢ Association between ADHD (50%) & OCD (40%)
¢ Abnormalities in the dopaminergic and adrenergic systems
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Clinical features:
Tourette's Disorder
¢ Initial tics are in the face & neck, progress down
¢ Coprolalia
o - begins in early adolescence
o - occurs in 1/3 of all cases
¢ Chronic, with remissions and exacerbations
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Management
Tourette's Disorder
¢ Antipsychotic drugs - haloperidol & pimozide
¢ Noradrenergic antagonist such as clonidine ________________________________________
USMLE Step 2 ” Lesson 2: Eating Disorders
Eating Disorders
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Characteristics:
Anorexia Nervosa
¢ Disturbance of body image, losing more than 15% body weight and amenorrhea
¢ Girls > boys, early teenage years
¢ All socioeconomic status
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Clinical Features:
Anorexia Nervosa
¢ Refuse to eat with others, disposes of food
¢ Constant thoughts of food - collect recipes & prepare meals
¢ Binge eating when alone, leads to self-induced vomiting
¢ Abuse laxatives, diuretics, exercising
¢ Medical complications
¢ Mortality rates are 5% to 18%
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Management:
Anorexia Nervosa
¢ Hospitalization
¢ Psychotherapy
¢ Pharmacotherapy (cyproheptadine)
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Characteristics:
Bulimia Nervosa
¢ More common than anorexia, girls > boys
¢ Binging and purging
¢ Recurrent behaviors - fasting, laxatives, diuretics
¢ Usually maintain a normal body weight
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Clinical Features:
Bulimia Nervosa
¢ Later onset, obesity predisposing factor
¢ Usually eat food high in calories during binge
¢ Food eaten secretly & rapidly, & at times not chewed
¢ Medical complications
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Management:
Bulimia Nervosa
¢ Psychotherapy
¢ Behavioral modification
¢ Pharmacotherapy ( SSRI™s)
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Case Study
A 23-year-old female (5™6™™, 90 lbs.) was seen in a clinic for œabdominal problems. The problem began as an adolescent when she started using laxatives to lose weight and would mostly drink water and eat some food during the day. At times, she would not eat for days and when overcome by hunger, would eat large quantities of food followed by vomiting. Despite this, she continued to lose weight. œThe more I lost, the more I was concerned that I would be getting fat, she said.
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USMLE Step 2 ” Lesson 3: Anxiety Disorders
Anxiety Disorders
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Anxiety Disorders
Disorders characterized by a diffuse, unpleasant, and often vague sense of apprehension, accompanied by one or more bodily sensations (autonomic hyperactivity), such as palpitations, diaphoresis, shortness of breath, stomach discomfort, etc..
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Characteristics:
Panic Disorder (with or without agoraphibia)
¢ Women > men, 2-3:1
¢ Most commonly develops in young adulthood (mean age is 25)
¢ Has a genetic component
¢ Associated with depressive symptoms
¢ Suicide is a risk
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Clinical Features:
Panic Disorder (with or without agoraphibia)
¢ Unexpected panic attacks (a panic attack is a short lived period of massive anxiety which may be accompanied by fear of impending doom or dread as well as symptoms of autonomic hyperactivity)
¢ Must have at least one attack followed by a one-month long period of concern about a recurrent panic attack
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Panicogens:
Panic Disorder (with or without agoraphibia)
¢ Induce panic attacks: e.g., CO2, sodium lactate, yohimbine, caffeine, flumazenil
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Management:
Panic Disorder (with or without agoraphibia)
¢ Pharmacotherapy (SSRI™s, TCA™s, MAOI™s, benzodiazapines)
¢ Behavior therapy
¢ Psychotherapy
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Characteristics:
Phobias
Definition
o Irrational fear of an object and the need to avoid it
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Clinical Features:
Phobias
Types of Phobias
o Specific phobias:
 involve fear of any object
o Social phobias:
 involve excessive fear of humiliation or embarrassment in social settings
 more common among women
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Management:
Phobias
¢ Psychotherapy
¢ Behavioral therapy (systematic desensitization)
¢ Pharmacotherapy (if stage fright - beta blockers)
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Characteristics:
Obsessive-Compulsive Disorder (OCD)
¢ Ego-dystonic, men = women, mean age = 20
¢ Obsessions are recurring & intrusive thoughts that the patient realizes are a part of his own mind
¢ Compulsion is a recurring & time-consuming act performed to reduce the distress
¢ Suicide is a risk
¢ Genetic, serotonergic system
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Clinical Features:
Obsessive-Compulsive Disorder
¢ Most common symptom patterns
o Obsession of contamination followed by washing or compulsive avoidance of contaminated object
o Obsession of doubt followed by a compulsion of checking
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Management:
Obsessive-Compulsive Disorder
¢ Pharmacotherapy (TCA™s or SSRI™s)
¢ Behavior therapy
¢ Psychotherapy
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Characteristics:
Post-Traumatic Stress Disorder (PTSD)
¢ Emotional stressor that would be stressful to anyone
¢ Stressor involved actual or threatened death or serious injury
¢ Women > men, young adults, genetic predisposition
¢ Trauma for men is usually combat experience
¢ Trauma for women is usually assault or rape
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Clinical Features:
Post-Traumatic Stress Disorder
¢ Patient™s response to stressor involved fear, helplessness, or horror
¢ After stressor event, there is phobic avoidance and persistent hyperarousal
¢ The event will usually be re-experienced in many ways, including nightmares, flashbacks, etc.
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Management
Post-Traumatic Stress Disorder
¢ Pharmacotherapy (TCA™s, MAOI™s, SSRI™s, benzodiazapines)
¢ Psychotherapy
¢ Behavioral therapy
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Case Study
Marty is a 30-year-old male who lives with his mother. He works as a night-time cleaner in a large store since he dropped out of college many years ago. He complains of being œnervous all of the time and would like to œget his life back. He stated that he would like to change jobs but prefers his current job because he does not have any contact with other employees.
He did not have many friends in high school or in college, mostly due to his feeling œself-conscious. When among strangers, he would feel nervous and would œbreak out in a sweat. He had what he described as œnervous attacks, which came on suddenly and lasted for a few seconds to minutes. These attacks only came on when in the presence of strangers. Since these episodes increased in intensity and frequency, he dropped out of college.
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USMLE Step 2 ” Lesson 4: Psychotic Disorders
Psychotic Disorders
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Schizophrenia
¢ Thought disorder that impairs judgment, behavior, and ability to interpret reality
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Characteristics:
Schizophrenia
¢ Lifetime prevalence of 1 to 1.5 %
¢ Equal incidence in men and women
¢ Peak age of onset: men 15-25, women 25-35
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Brain Imaging Findings:
Schizophrenia
¢ CT: lateral and third ventricular enlargement, reduction in cortical volume
¢ MRI: increased cerebral ventricles
¢ PET: hypoactivity of the frontal lobes
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Types:
Schizophrenia
¢ Paranoid: presence of delusions of grandeur or persecution, best prognosis, late onset
¢ Disorganized: marked regression to primitive, disinherited, and disorganized behavior, worst prognosis, early onset
¢ Catatonic: psychomotor disturbance involving rigidity, stupor, posturing, negativism, good prognosis, œwaxy flexibility
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Types:
Schizophrenia
¢ Undifferentiated: those who do not meet other criteria
¢ Residual: continuing evidence of schizophrenia without overt psychotic symptoms
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Other Types:
Schizophrenia
¢ Type I (positive symptoms): loose associations, hallucinations, bizarre behavior, and increased speech
¢ Type II (negative symptoms): changes in affect, poverty of speech, poor grooming, anhedonia, social withdrawal, cognitive defects, attention deficits
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Clinical Features:
Schizophrenia
¢ Symptoms > 6 months
¢ Prodromal signs and symptoms
¢ Perceptual disturbances
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Management:
Schizophrenia
¢ Dopamine receptor antagonists
¢ Clozapine
¢ Other atypicals (risperidone, olanzapine, quetiapine
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Other Psychotic Disorders
¢ Schizophreniform disorder
o Symptoms less than 6 months
¢ Delusional disorder
o Non-bizarre delusions
¢ Brief psychotic disorder
o Associated with stressor
o Symptoms > one day and < one month
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Case Study
A 45-year-old male is brought to the emergency room by his mother because she is afraid of him. He is wearing a wool coat, several sweaters, a wool cap, and mittens on the hottest day of the year. His affect ranges from anger to laughter. His speech and behavior are childlike and when asked what is wrong, he replied, œThe medicine is badtomorrow is mad.
His mother also reports she has heard him talking to himself in his bedroom. When she questioned him, he denied that he was speaking, but then continued to speak when she left the room. His mother stated that his problems have escalated since he stopped taking his medication several months ago. His first hospitalization occurred at the age of 18 and he has been hospitalized more than 20 times since then.
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USMLE Step 2 ” Lesson 5: Sleep Disorders
Sleep Disorders
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Characteristics:
Narcolepsy
¢ Excessive daytime sleepiness and abnormalities of REM sleep for a period of greater than 3 months
¢ REM sleep occurs in less than 10 minutes
¢ Patients will feel refreshed upon awakening
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Clinical Features:
Narcolepsy
¢ Sleep attacks
¢ Cataplexy
¢ Hypnagogic and hypnopompic hallucinations
¢ Sleep paralysis
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Management:
Narcolepsy
¢ Pharmacotherapy (psychostimulants for sleep attacks and imipramine for cataplexy)
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Characteristics:
Sleep Apnea
¢ Cessation of air flow at the nose or mouth during sleep
¢ Apneic episodes usually last greater than 10 seconds each
¢ Loud snore followed by a heavy pause
¢ Usually seen in obese, middle aged males, who complain of being tired during the day
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Clinical Features:
Sleep Apnea
¢ Types
o obstructive
o central
o mixed
¢ Complications
o arrhythmias
o pulmonary hypertension
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Management:
Sleep Apnea
¢ Nasal continuous positive airway pressure
¢ Weight loss
¢ Surgery
¢ Treat the underlying condition
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Case Study
Case #1 A 45-year-old housewife is being seen at a sleep clinic for the first time. She claims that she has been unable to sleep for the last few years. According to the patient, her obese, middle-aged husband™s œsnoring keeps her up all night and interferes with her sleep.
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Case Study
Case #2 A 50-year-old businessman is seeking help to overcome his being œtired during the day. He has taken vitamins during the last few months since he thought they œmight help. He is 54 and weighs 200 pounds.
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USMLE Step 2 ” Lesson 6: Mood Disorders
Mood Disorders
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Characteristics:
Major Depression
¢ Women > men 2:1
¢ Biological factors
o Norepinephrine, serotonin, 5-HIAA
¢ Sleep
o Shortened REM latency, etc.
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Clinical Features:
Major Depression
¢ Symptoms > 2 weeks
¢ Vegetative changes, anxiety
¢ Psychomotor disturbances, somatic complaints
¢ Decreased concentration, guilt, suicidal
¢ Decreased libido
¢ With psychotic features: worse prognosis
¢ With atypical features: increased weight, appetite, and sleep
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Management:
Major Depression
Pharmacotherapy
¢ Tricyclic antidepressants (TCA™s)
¢ Serotonin selective reuptake inhibitors (SSRI's)
¢ Monoamine oxidase inhibitors (MAOI's)
¢ Electroconvulsive therapy (ECT)
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Characteristics:
Bipolar I Disorder
¢ Lifetime prevalence of 1%
¢ Equal prevalence in men and women
¢ Mean age of onset is 30
¢ More prevalent among high socioeconomic status and those that did not finish college
¢ Sleep
o Perceived decrease need for sleep
o Decrease in total sleep time
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Clinical Features:
Bipolar I Disorder
¢ Symptoms > 1 week
¢ Increased self-esteem or grandiosity
¢ Distractibility, flight of ideas
¢ Excessive involvement in activities
¢ More talkative than usual
¢ Psychomotor agitation
¢ Increased sexual activity
¢ Increase in goal-directed activity
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Course and Prognosis:
Bipolar I Disorder
¢ Most often starts with depression
¢ Most experience both manic and depressive symptoms
¢ Untreated manic episode lasts 3 months
¢ Worse prognosis than major depressive disorder
¢ If depression and hypomania: called bipolar II disorder
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Management:
Bipolar I Disorder
¢ Pharmacotherapy: mood stabilizers, benzodiazepines, neuroleptics
¢ Psychotherapy
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Dysthymic Disorder
¢ Chronic disorder characterized by a depressed mood that lasts most of the time during the day and is present on most days for at least 2 years
¢ Treatment: SSRI™s, TCA™s, or MAOI™s
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Cyclothymic Disorder
¢ Chronic disorder characterized by many periods of depressed mood and many periods of hypomanic mood for at least 2 years; a milder form of bipolar II disorder
¢ Treatment: antimanic drugs such as lithium, carbamazepine, and valproic acid
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Seasonal Affective Disorder
¢ Disorder characterized by depressive symptoms found during winter months and absent during summer months; believed to be caused by abnormal melatonin metabolism (decreased MSH)
¢ Treatment: phototherapy or sleep deprivation
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Adjustment Disorder
¢ Disorder characterized by the development of symptoms in response to an identifiable stressor occurring within 3 months of the onset of the stressor
¢ Treatment: usually require supportive psychotherapy
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Differences:
Grief
¢ Normal identification with deceased
¢ Crying, decreased libido, weight changes
¢ Self-limited, lasts 6 months - 1 year
¢ Antidepressants not helpful
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Differences:
Depression
¢ Abnormal identification with deceased
¢ Sleep disturbance, depressed mood, appetite disturbance
¢ Suicidal ideation rare
¢ Suicidal ideation common
¢ Symptoms persist greater than 1 year
¢ Antidepressants helpful
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Case Study
Case #1
A 30-year-old female was fired from her job about 1 month ago. Since then, she has complained of depressed mood and sleep problems. She denies any appetite or weight problems. She denies any suicidal ideation or plan. Her concentration is good and her memory is intact.
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Case Study
Case #2
A 28-year-old female has had a 9-year history of periods of œfeeling great and feeling lousy. During the œfeeling great periods, she reported increased libido and decreased sleep. During her œfeeling lousy periods, she reported decreased concentration and tearfulness.
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USMLE Step 2 ” Lesson 7: Substance Disorders
Substance Disorders
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Buzz Words.
¢ Paranoia - cocaine/amphetamine intoxication
¢ Arrhythmia - cocaine intoxication
¢ Depression - cocaine withdrawal
¢ Flashback - LSD
¢ Severe violence - PCP
¢ Pin-point pupils - opiate overdose
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Buzz Words..
¢ Flu-like symptoms - opiate withdrawal
¢ Lack of motivation - marijuana
¢ Tremors - alcohol
¢ Seizures - benzodiazepines
¢ Death - barbiturates ________________________________________
USMLE Step 2 ” Lesson 8: Somatoform Disorders
Somatoform Disorders
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Somatoform Disorders
A group of disorders characterized by the presentation of physical symptoms without any medical explanation. The symptoms will be severe enough to interfere with the patient™s ability to function in social or occupational activities. Typically, patients are females of low socioeconomic status.
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Clinical Features:
Somatization Disorder
¢ Presentation of many physical symptoms affecting many organ systems without any medical explanation
¢ Need at least 8+ symptoms in order to make a diagnosis:
o 2 gastrointestinal symptoms
o 1 sexual symptom
o 1 pseudo-neurological symptom
o 4 pain symptoms
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Management:
Somatization Disorder
¢ Must have a single identified physician as the primary caretaker
¢ Regularly scheduled brief monthly visits
¢ Increase the patient™s awareness of the possibility that the symptoms are psychological in nature
¢ Psychotherapy
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Characteristics:
Conversion Disorder
¢ One or two neurological symptoms affecting voluntary or sensory function that cannot be explained by any known neurological disorder
¢ Must have psychological factors associated with the onset or exacerbation of the symptoms
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Clinical Features:
Conversion Disorder
¢ Primary gain
¢ Secondary gain
¢ La belle indifference
¢ Identification
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Management
Conversion Disorder
¢ Psycotherapy
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Hypochondriasis
¢ Patient believes that he or she has some specific disease
¢ Despite constant reassurance, the patient™s belief remains the same
¢ Treatment
o Psychotherapy
o Frequent, regular visits to their MDs
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Body Dysmorphic Disorder
¢ Patients believes a body part is abnormal, defective, or misshapen
¢ May involve serotonergic systems
¢ Treatment:
o Psychotherapy
o Pharmacotherapy (SSRI™s, TCA™s, MAOI™s)
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Factitious Disorder
¢ Conscious production of signs and symptoms of both medical and mental disorders
¢ Assume sick role and hospitalization
¢ Usually diagnosed with physical or psychological symptoms or both
¢ Men > women
¢ Hospital and health care workers
¢ Treatment: usually involves management rather than cure
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Malingering
Conscious production of signs and symptoms for an obvious gain (money, avoid work, free bed and board, etc.). It is not a mental disorder.
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Case Study
A 50-year-old woman was referred by her husband™s psychiatrist because of œattacks of dizziness that have been occurring for more than 10 years. Every day, at about 3pm, the attacks occur. They leave her helpless and, when her husband arrives, she is unable to attend to him. She remains in bed until 8pm when the attacks subsided, and she would watch TV and fall asleep.
When questioned, she described her husband as abusive and not caring about her well-being. He has repeatedly abused her and their children, which resulted in their leaving home at an early age, and moving in with their grandmother. She stated that she hated when he came home and would make comments about the house, dinner, etc. Many times, these verbal comments were followed by actual episodes of violence, several of which have resulted in her hospitalization.
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USMLE Step 2 ” Lesson 9: Personality Disorders
Personality Disorders
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Personality Disorders
¢ Ego-syntonic maladaptive patterns of behavior
¢ These individuals rarely seek treatment by themselves and are regarded as unmotivated for treatment
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Personality Disorders
¢ Odd, eccentric type (Cluster A): paranoid, schizoid, schizotypal
¢ Dramatic, emotional type (Cluster B): histrionic, borderline, antisocial, narcissistic
¢ Anxious, fearful type (Cluster C): avoidant, obsessive-compulsive, dependent
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Paranoid Personality Disorders
¢ Pervasive distrust & suspiciousness of others
¢ Reluctance to confide in others
¢ Recurrent suspicions
¢ Persistently bears grudges
¢ Questions the loyalty of others
¢ Reads demeaning meaning into benign remarks
¢ Main defense mechanism is projection
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Schizoid Personality Disorder
¢ Lifelong pattern of social withdrawal
¢ No desire for close interpersonal relationships
¢ No interest in sexual activities
¢ Appears indifferent to criticism
¢ Emotional coldness
¢ Lacks close friends
¢ Almost always chooses solitary activities
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Schizotypal Personality Disorder
¢ Magical thinking
¢ Ideas of reference
¢ Illusions
¢ Inappropriate affect
¢ Paranoid ideation
¢ Odd appearance
¢ Excessive social anxiety
¢ If stress, may become psychotic
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Histrionic Personality Disorder
¢ Usually characterized by colorful, exaggerated behavior
¢ Excitable, shallow expression of emotions
¢ Uses physical appearance to draw attention to self
¢ Sexually seductive
¢ Uncomfortable in situations where they are not the center of attention
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Borderline Personality Disorder
¢ Unstable affect, mood swings, marked impulsivity
¢ Unstable relationships, identity disturbance
¢ Recurrent suicidal behaviors
¢ Chronic feelings of emptiness or boredom
¢ Inappropriate anger
¢ If stressed, may become psychotic
¢ Main defense mechanism is splitting
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Antisocial Personality Disorder
¢ Continuous antisocial or criminal acts
¢ Inability to conform to social rules
¢ Impulsivity
¢ Disregard for the rights of others
¢ Aggressiveness
¢ Lack of remorse and deceitfulness
¢ Symptoms before 15 and patient > 18
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Narcissistic Personality Disorder
¢ Sense of self-importance and grandiosity
¢ Preoccupied with fantasies of success
¢ Believe they are special
¢ Require excessive admiration
¢ React with rage when criticized
¢ Lack empathy, envious of others
¢ Interpersonally exploitative
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Avoidant Personality Disorder
¢ Extreme sensitivity to rejection
¢ Shy, social inhibition, few friends
¢ Feelings of inadequacy
¢ Reluctant to take personal risks
¢ Hypersensitive to criticism
¢ Shows restraint within intimate relationships
¢ High incidence of social phobias
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Dependant Personality Disorder
¢ Lacking self-confidence
¢ Subordinate their needs for those of others
¢ Difficulty making decision
¢ Unable to assume responsibilities
¢ Feeling uncomfortable or helpless when alone
¢ Need support from others and urgently seek relationships as a source of care and support
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Obsessive-Compulsive Personality Disorder
¢ Orderliness, stubbornness, inefficiency, perfectionistic
¢ Preoccupied with details, rules, lists
¢ Excessively devoted to work
¢ Unable to discard worn out objects
¢ Rigid, cheap, and over conscientious
¢ Described as being fixated at the anal stage of development ________________________________________
USMLE Step 2 ” Lesson 10: Psychopharmacology
Psychopharmacology
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Mechanism of Action
Dopamine Receptor Antagonists (Antipsychotics)
¢ Act primarily by dopamine blockade, D2
¢ Produce alpha-blockade (hypotension)
¢ Block muscarinic receptors (anticholinergic side effects)
¢ Block NE reuptake and block serotonin and histamine receptors
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Dopamine Tracts:
Dopamine Receptor Antagonists (Antipsychotics)
¢ Mesolimbic and mesocortical (psychosis)
¢ Nigrostriatal (movement disorders)
¢ Tuberoinfundibular (prolactin)
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Acute Dystonia
Dopamine Receptor Antagonists (Antipsychotics)
¢ Usually within a few hours to few days of initiating treatment
¢ Greater incidence among young males
¢ Muscular rigidity and cramping
¢ Treat with anticholinergic medication
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Drug-Induced Parkinsonism
Dopamine Receptor Antagonists (Antipsychotics)
¢ Onset within several weeks of therapy
¢ Greater incidence among the elderly
¢ Characterized by bradykinesia, rigidity, cogwheel tremor, masked facies, etc.
¢ Treatment consists of anti-parkinsonism medication and decreased antipsychotic medications
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Akathisia
Dopamine Receptor Antagonists (Antipsychotics)
¢ Onset after many weeks of therapy
¢ Characterized by restlessness and symptoms of anxiety
¢ Treatment consists of decreasing the antipsychotic medication, Beta-blockers, or benzodiazepines
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Neuroleptic Malignant Syndrome
Dopamine Receptor Antagonists (Antipsychotics)
¢ Fever, rigidity, and autonomic instability
¢ Greater incidence with high-potency neuroleptics and lithium
¢ Medical emergency
¢ Treatment consists of dantrolene or bromocriptine
¢ Obtain CPK
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Tardive Dyskinesia
Dopamine Receptor Antagonists (Antipsychotics)
¢ Onset after long term use > 3-6 months
¢ Greater incidence among elderly females
¢ Characterized by involuntary movements of the tongue, face, neck, and upper extremities
¢ Treatment consists of prevention, risks vs. benefits, vitamin E?, consider clozapine
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Differences Between Typical and Atypical Antipsychotics
Typical Atypical
Dopamine receptors Dopamine & serotonin
receptors
Treat (+) symptoms Treat (+) and (-)
symptoms
Many side effects Less side effects
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Clozapine
¢ Weak D2 receptor antagonist
¢ Blocks the mesolimbic and mesocortical dopamine tracts
¢ Adverse effects include agranulocytosis (1-2%), seizures, and drooling
¢ Weekly WBC™s
¢ Never use as first line
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Risperidone/Olanzapine/Quetiapine
¢ Sedation
¢ Less side effects
¢ May use as first line
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Antidepressants
¢ Mechanism of action
o Block the reuptake of the neurotransmitters
o Down-regulation of receptors
o Increase endogenous opiates & pain threshold
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Antidepressants
¢ Adverse effects
o Sedation, weight gain, orthostatic hypotension
o Dry mouth, blurry vision, urinary retention
o Increased heart rate and EKG changes
o Sexual dysfunctions
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SSRI's & SSRI-Like Drugs
¢ Fluoxetine
¢ Sertraline
¢ Paroxetine
¢ Fluvoxamine (for the treatment of OCD)
¢ Nefazodone
¢ Citalopram
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SSRI's & SSRI-Like Drugs
¢ Most common adverse effects include GI (N/V)
¢ Headache, sedation, or restlessness
¢ Anorgasmia, retarded ejaculation
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MAOI's
¢ Phenelzine
¢ Tranylcypromine
¢ Selegiline
¢ Must have strict dietary restrictions due to tyramine reaction
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Mood Stabilizing Agents: Lithium
¢ Mechanism of action - blocks inositol-1-phosphatase
¢ Adverse effects
o N/V, anorexia, diarrhea, abdominal pain
o Polyuria and polydypsia
o Tremors
o Hypothyroidism
o Teratogenic - Ebstein™s anomaly
¢ Others - carbamazepine, valproic acid, gabapentin
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Antianxiety Agents (Benzodiazepines)
¢ Mechanism of action
o Facilitate GABA-ergic synaptic transmission
o Alter membrane permeability to chloride ions (facilitate GABA effects)
o All undergo hepatic microsomal oxidation except lorazepam, oxazepam, and temazepam, which undergo glucoronidation
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Antianxiety Agents (Benzodiazepines)
¢ Adverse effects
o Sedation and impairment of performance
o Memory impairments
¢ Disinhibition
¢ Depression
¢ Addiction ________________________________________
Psychiatry Highlights for USMLE Step 2
Alina Gonzalez-Mayo, MD
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Child Psychiatry
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Mental Retardation
¢ Present before age 18
¢ Consisting of below-average intellectual functioning with an impairment in social adaptive functioning
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Characteristics:
Mental Retardation
Degree IQ Range Characteristics
Mild 55 - 69 6th gr level, can handle own affairs
& live on his own
Moderate 35 - 54 2nd gr. level, benefit from vocational
trainng, sheltered workshop
Severe 20 - 34 Can communicate, training not help-
ful, can be taught basic health habits.
Profound 6 months, < 7 years
¢ Increased incidence among school age
¢ Boys have a greater incidence than girls
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Clinical features:
ADHD
¢ Symptoms must be present in at least 2 situations e.g., home, school or work
¢ Symptoms may persist into adult life
¢ Increased incidence of conduct disorders
¢ Antisocial personality & substance-related disorders
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Management
ADHD
¢ Psychostimulants
o - methylphenidate
o - dextroamphetamine
o - pemoline
¢ Methylphenidate side effect - GH suppression
¢ Consider drug holiday
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Case Study
Johnny is an 8-year-old child being evaluated for various behaviors, such as staying to himself, as well as self-abusive and aggressive behaviors. He does not play with the other children and tends to act out aggressively when things are changed around at home. He has been in foster care since an early age and has not attended regular classes due to his behavior.
At the time of admission into foster care, he had an abnormal EEG but no seizures. When last given IQ tests, he scored 55, with comparable deficits in adaptive behavior. During the evaluation, Johnny spends most of his time reading a book he found in the waiting room. When asked about the book, he becomes angry and begins to rock back and forth. When called, he does not respond and does not make any eye contact.
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Characteristics:
Tourette's Disorder
¢ Multiple motor and vocal tics present for over 1 year, must occur before age 18
¢ Three times more common in boys than in girls
¢ Association between ADHD (50%) & OCD (40%)
¢ Abnormalities in the dopaminergic and adrenergic systems
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Clinical features:
Tourette's Disorder
¢ Initial tics are in the face & neck, progress down
¢ Coprolalia
o - begins in early adolescence
o - occurs in 1/3 of all cases
¢ Chronic, with remissions and exacerbations
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Management
Tourette's Disorder
¢ Antipsychotic drugs - haloperidol & pimozide
¢ Noradrenergic antagonist such as clonidine ________________________________________
USMLE Step 2 ” Lesson 2: Eating Disorders
Eating Disorders
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Characteristics:
Anorexia Nervosa
¢ Disturbance of body image, losing more than 15% body weight and amenorrhea
¢ Girls > boys, early teenage years
¢ All socioeconomic status
________________________________________
Clinical Features:
Anorexia Nervosa
¢ Refuse to eat with others, disposes of food
¢ Constant thoughts of food - collect recipes & prepare meals
¢ Binge eating when alone, leads to self-induced vomiting
¢ Abuse laxatives, diuretics, exercising
¢ Medical complications
¢ Mortality rates are 5% to 18%
________________________________________
Management:
Anorexia Nervosa
¢ Hospitalization
¢ Psychotherapy
¢ Pharmacotherapy (cyproheptadine)
________________________________________
Characteristics:
Bulimia Nervosa
¢ More common than anorexia, girls > boys
¢ Binging and purging
¢ Recurrent behaviors - fasting, laxatives, diuretics
¢ Usually maintain a normal body weight
________________________________________
Clinical Features:
Bulimia Nervosa
¢ Later onset, obesity predisposing factor
¢ Usually eat food high in calories during binge
¢ Food eaten secretly & rapidly, & at times not chewed
¢ Medical complications
________________________________________
Management:
Bulimia Nervosa
¢ Psychotherapy
¢ Behavioral modification
¢ Pharmacotherapy ( SSRI™s)
________________________________________
Case Study
A 23-year-old female (5™6™™, 90 lbs.) was seen in a clinic for œabdominal problems. The problem began as an adolescent when she started using laxatives to lose weight and would mostly drink water and eat some food during the day. At times, she would not eat for days and when overcome by hunger, would eat large quantities of food followed by vomiting. Despite this, she continued to lose weight. œThe more I lost, the more I was concerned that I would be getting fat, she said.
________________________________________
USMLE Step 2 ” Lesson 3: Anxiety Disorders
Anxiety Disorders
________________________________________
Anxiety Disorders
Disorders characterized by a diffuse, unpleasant, and often vague sense of apprehension, accompanied by one or more bodily sensations (autonomic hyperactivity), such as palpitations, diaphoresis, shortness of breath, stomach discomfort, etc..
________________________________________
Characteristics:
Panic Disorder (with or without agoraphibia)
¢ Women > men, 2-3:1
¢ Most commonly develops in young adulthood (mean age is 25)
¢ Has a genetic component
¢ Associated with depressive symptoms
¢ Suicide is a risk
________________________________________
Clinical Features:
Panic Disorder (with or without agoraphibia)
¢ Unexpected panic attacks (a panic attack is a short lived period of massive anxiety which may be accompanied by fear of impending doom or dread as well as symptoms of autonomic hyperactivity)
¢ Must have at least one attack followed by a one-month long period of concern about a recurrent panic attack
________________________________________
Panicogens:
Panic Disorder (with or without agoraphibia)
¢ Induce panic attacks: e.g., CO2, sodium lactate, yohimbine, caffeine, flumazenil
________________________________________
Management:
Panic Disorder (with or without agoraphibia)
¢ Pharmacotherapy (SSRI™s, TCA™s, MAOI™s, benzodiazapines)
¢ Behavior therapy
¢ Psychotherapy
________________________________________
Characteristics:
Phobias
Definition
o Irrational fear of an object and the need to avoid it
________________________________________
Clinical Features:
Phobias
Types of Phobias
o Specific phobias:
 involve fear of any object
o Social phobias:
 involve excessive fear of humiliation or embarrassment in social settings
 more common among women
________________________________________
Management:
Phobias
¢ Psychotherapy
¢ Behavioral therapy (systematic desensitization)
¢ Pharmacotherapy (if stage fright - beta blockers)
________________________________________
Characteristics:
Obsessive-Compulsive Disorder (OCD)
¢ Ego-dystonic, men = women, mean age = 20
¢ Obsessions are recurring & intrusive thoughts that the patient realizes are a part of his own mind
¢ Compulsion is a recurring & time-consuming act performed to reduce the distress
¢ Suicide is a risk
¢ Genetic, serotonergic system
________________________________________
Clinical Features:
Obsessive-Compulsive Disorder
¢ Most common symptom patterns
o Obsession of contamination followed by washing or compulsive avoidance of contaminated object
o Obsession of doubt followed by a compulsion of checking
________________________________________
Management:
Obsessive-Compulsive Disorder
¢ Pharmacotherapy (TCA™s or SSRI™s)
¢ Behavior therapy
¢ Psychotherapy
________________________________________
Characteristics:
Post-Traumatic Stress Disorder (PTSD)
¢ Emotional stressor that would be stressful to anyone
¢ Stressor involved actual or threatened death or serious injury
¢ Women > men, young adults, genetic predisposition
¢ Trauma for men is usually combat experience
¢ Trauma for women is usually assault or rape
________________________________________
Clinical Features:
Post-Traumatic Stress Disorder
¢ Patient™s response to stressor involved fear, helplessness, or horror
¢ After stressor event, there is phobic avoidance and persistent hyperarousal
¢ The event will usually be re-experienced in many ways, including nightmares, flashbacks, etc.
________________________________________
Management
Post-Traumatic Stress Disorder
¢ Pharmacotherapy (TCA™s, MAOI™s, SSRI™s, benzodiazapines)
¢ Psychotherapy
¢ Behavioral therapy
________________________________________
Case Study
Marty is a 30-year-old male who lives with his mother. He works as a night-time cleaner in a large store since he dropped out of college many years ago. He complains of being œnervous all of the time and would like to œget his life back. He stated that he would like to change jobs but prefers his current job because he does not have any contact with other employees.
He did not have many friends in high school or in college, mostly due to his feeling œself-conscious. When among strangers, he would feel nervous and would œbreak out in a sweat. He had what he described as œnervous attacks, which came on suddenly and lasted for a few seconds to minutes. These attacks only came on when in the presence of strangers. Since these episodes increased in intensity and frequency, he dropped out of college.
________________________________________
USMLE Step 2 ” Lesson 4: Psychotic Disorders
Psychotic Disorders
________________________________________
Schizophrenia
¢ Thought disorder that impairs judgment, behavior, and ability to interpret reality
________________________________________
Characteristics:
Schizophrenia
¢ Lifetime prevalence of 1 to 1.5 %
¢ Equal incidence in men and women
¢ Peak age of onset: men 15-25, women 25-35
________________________________________
Brain Imaging Findings:
Schizophrenia
¢ CT: lateral and third ventricular enlargement, reduction in cortical volume
¢ MRI: increased cerebral ventricles
¢ PET: hypoactivity of the frontal lobes
________________________________________
Types:
Schizophrenia
¢ Paranoid: presence of delusions of grandeur or persecution, best prognosis, late onset
¢ Disorganized: marked regression to primitive, disinherited, and disorganized behavior, worst prognosis, early onset
¢ Catatonic: psychomotor disturbance involving rigidity, stupor, posturing, negativism, good prognosis, œwaxy flexibility
________________________________________
Types:
Schizophrenia
¢ Undifferentiated: those who do not meet other criteria
¢ Residual: continuing evidence of schizophrenia without overt psychotic symptoms
________________________________________
Other Types:
Schizophrenia
¢ Type I (positive symptoms): loose associations, hallucinations, bizarre behavior, and increased speech
¢ Type II (negative symptoms): changes in affect, poverty of speech, poor grooming, anhedonia, social withdrawal, cognitive defects, attention deficits
________________________________________
Clinical Features:
Schizophrenia
¢ Symptoms > 6 months
¢ Prodromal signs and symptoms
¢ Perceptual disturbances
________________________________________
Management:
Schizophrenia
¢ Dopamine receptor antagonists
¢ Clozapine
¢ Other atypicals (risperidone, olanzapine, quetiapine
________________________________________
Other Psychotic Disorders
¢ Schizophreniform disorder
o Symptoms less than 6 months
¢ Delusional disorder
o Non-bizarre delusions
¢ Brief psychotic disorder
o Associated with stressor
o Symptoms > one day and < one month
________________________________________
Case Study
A 45-year-old male is brought to the emergency room by his mother because she is afraid of him. He is wearing a wool coat, several sweaters, a wool cap, and mittens on the hottest day of the year. His affect ranges from anger to laughter. His speech and behavior are childlike and when asked what is wrong, he replied, œThe medicine is badtomorrow is mad.
His mother also reports she has heard him talking to himself in his bedroom. When she questioned him, he denied that he was speaking, but then continued to speak when she left the room. His mother stated that his problems have escalated since he stopped taking his medication several months ago. His first hospitalization occurred at the age of 18 and he has been hospitalized more than 20 times since then.
________________________________________
USMLE Step 2 ” Lesson 5: Sleep Disorders
Sleep Disorders
________________________________________
Characteristics:
Narcolepsy
¢ Excessive daytime sleepiness and abnormalities of REM sleep for a period of greater than 3 months
¢ REM sleep occurs in less than 10 minutes
¢ Patients will feel refreshed upon awakening
________________________________________
Clinical Features:
Narcolepsy
¢ Sleep attacks
¢ Cataplexy
¢ Hypnagogic and hypnopompic hallucinations
¢ Sleep paralysis
________________________________________
Management:
Narcolepsy
¢ Pharmacotherapy (psychostimulants for sleep attacks and imipramine for cataplexy)
________________________________________
Characteristics:
Sleep Apnea
¢ Cessation of air flow at the nose or mouth during sleep
¢ Apneic episodes usually last greater than 10 seconds each
¢ Loud snore followed by a heavy pause
¢ Usually seen in obese, middle aged males, who complain of being tired during the day
________________________________________
Clinical Features:
Sleep Apnea
¢ Types
o obstructive
o central
o mixed
¢ Complications
o arrhythmias
o pulmonary hypertension
________________________________________
Management:
Sleep Apnea
¢ Nasal continuous positive airway pressure
¢ Weight loss
¢ Surgery
¢ Treat the underlying condition
________________________________________
Case Study
Case #1 A 45-year-old housewife is being seen at a sleep clinic for the first time. She claims that she has been unable to sleep for the last few years. According to the patient, her obese, middle-aged husband™s œsnoring keeps her up all night and interferes with her sleep.
________________________________________
Case Study
Case #2 A 50-year-old businessman is seeking help to overcome his being œtired during the day. He has taken vitamins during the last few months since he thought they œmight help. He is 54 and weighs 200 pounds.
________________________________________
USMLE Step 2 ” Lesson 6: Mood Disorders
Mood Disorders
________________________________________
Characteristics:
Major Depression
¢ Women > men 2:1
¢ Biological factors
o Norepinephrine, serotonin, 5-HIAA
¢ Sleep
o Shortened REM latency, etc.
________________________________________
Clinical Features:
Major Depression
¢ Symptoms > 2 weeks
¢ Vegetative changes, anxiety
¢ Psychomotor disturbances, somatic complaints
¢ Decreased concentration, guilt, suicidal
¢ Decreased libido
¢ With psychotic features: worse prognosis
¢ With atypical features: increased weight, appetite, and sleep
________________________________________
Management:
Major Depression
Pharmacotherapy
¢ Tricyclic antidepressants (TCA™s)
¢ Serotonin selective reuptake inhibitors (SSRI's)
¢ Monoamine oxidase inhibitors (MAOI's)
¢ Electroconvulsive therapy (ECT)
________________________________________
Characteristics:
Bipolar I Disorder
¢ Lifetime prevalence of 1%
¢ Equal prevalence in men and women
¢ Mean age of onset is 30
¢ More prevalent among high socioeconomic status and those that did not finish college
¢ Sleep
o Perceived decrease need for sleep
o Decrease in total sleep time
________________________________________
Clinical Features:
Bipolar I Disorder
¢ Symptoms > 1 week
¢ Increased self-esteem or grandiosity
¢ Distractibility, flight of ideas
¢ Excessive involvement in activities
¢ More talkative than usual
¢ Psychomotor agitation
¢ Increased sexual activity
¢ Increase in goal-directed activity
________________________________________
Course and Prognosis:
Bipolar I Disorder
¢ Most often starts with depression
¢ Most experience both manic and depressive symptoms
¢ Untreated manic episode lasts 3 months
¢ Worse prognosis than major depressive disorder
¢ If depression and hypomania: called bipolar II disorder
________________________________________
Management:
Bipolar I Disorder
¢ Pharmacotherapy: mood stabilizers, benzodiazepines, neuroleptics
¢ Psychotherapy
________________________________________
Dysthymic Disorder
¢ Chronic disorder characterized by a depressed mood that lasts most of the time during the day and is present on most days for at least 2 years
¢ Treatment: SSRI™s, TCA™s, or MAOI™s
________________________________________
Cyclothymic Disorder
¢ Chronic disorder characterized by many periods of depressed mood and many periods of hypomanic mood for at least 2 years; a milder form of bipolar II disorder
¢ Treatment: antimanic drugs such as lithium, carbamazepine, and valproic acid
________________________________________
Seasonal Affective Disorder
¢ Disorder characterized by depressive symptoms found during winter months and absent during summer months; believed to be caused by abnormal melatonin metabolism (decreased MSH)
¢ Treatment: phototherapy or sleep deprivation
________________________________________
Adjustment Disorder
¢ Disorder characterized by the development of symptoms in response to an identifiable stressor occurring within 3 months of the onset of the stressor
¢ Treatment: usually require supportive psychotherapy
________________________________________
Differences:
Grief
¢ Normal identification with deceased
¢ Crying, decreased libido, weight changes
¢ Self-limited, lasts 6 months - 1 year
¢ Antidepressants not helpful
________________________________________
Differences:
Depression
¢ Abnormal identification with deceased
¢ Sleep disturbance, depressed mood, appetite disturbance
¢ Suicidal ideation rare
¢ Suicidal ideation common
¢ Symptoms persist greater than 1 year
¢ Antidepressants helpful
________________________________________
Case Study
Case #1
A 30-year-old female was fired from her job about 1 month ago. Since then, she has complained of depressed mood and sleep problems. She denies any appetite or weight problems. She denies any suicidal ideation or plan. Her concentration is good and her memory is intact.
________________________________________
Case Study
Case #2
A 28-year-old female has had a 9-year history of periods of œfeeling great and feeling lousy. During the œfeeling great periods, she reported increased libido and decreased sleep. During her œfeeling lousy periods, she reported decreased concentration and tearfulness.
________________________________________
USMLE Step 2 ” Lesson 7: Substance Disorders
Substance Disorders
________________________________________
Buzz Words.
¢ Paranoia - cocaine/amphetamine intoxication
¢ Arrhythmia - cocaine intoxication
¢ Depression - cocaine withdrawal
¢ Flashback - LSD
¢ Severe violence - PCP
¢ Pin-point pupils - opiate overdose
________________________________________
Buzz Words..
¢ Flu-like symptoms - opiate withdrawal
¢ Lack of motivation - marijuana
¢ Tremors - alcohol
¢ Seizures - benzodiazepines
¢ Death - barbiturates ________________________________________
USMLE Step 2 ” Lesson 8: Somatoform Disorders
Somatoform Disorders
________________________________________
Somatoform Disorders
A group of disorders characterized by the presentation of physical symptoms without any medical explanation. The symptoms will be severe enough to interfere with the patient™s ability to function in social or occupational activities. Typically, patients are females of low socioeconomic status.
________________________________________
Clinical Features:
Somatization Disorder
¢ Presentation of many physical symptoms affecting many organ systems without any medical explanation
¢ Need at least 8+ symptoms in order to make a diagnosis:
o 2 gastrointestinal symptoms
o 1 sexual symptom
o 1 pseudo-neurological symptom
o 4 pain symptoms
________________________________________
Management:
Somatization Disorder
¢ Must have a single identified physician as the primary caretaker
¢ Regularly scheduled brief monthly visits
¢ Increase the patient™s awareness of the possibility that the symptoms are psychological in nature
¢ Psychotherapy
________________________________________
Characteristics:
Conversion Disorder
¢ One or two neurological symptoms affecting voluntary or sensory function that cannot be explained by any known neurological disorder
¢ Must have psychological factors associated with the onset or exacerbation of the symptoms
________________________________________
Clinical Features:
Conversion Disorder
¢ Primary gain
¢ Secondary gain
¢ La belle indifference
¢ Identification
________________________________________
Management
Conversion Disorder
¢ Psycotherapy
________________________________________
Hypochondriasis
¢ Patient believes that he or she has some specific disease
¢ Despite constant reassurance, the patient™s belief remains the same
¢ Treatment
o Psychotherapy
o Frequent, regular visits to their MDs
________________________________________
Body Dysmorphic Disorder
¢ Patients believes a body part is abnormal, defective, or misshapen
¢ May involve serotonergic systems
¢ Treatment:
o Psychotherapy
o Pharmacotherapy (SSRI™s, TCA™s, MAOI™s)
________________________________________
Factitious Disorder
¢ Conscious production of signs and symptoms of both medical and mental disorders
¢ Assume sick role and hospitalization
¢ Usually diagnosed with physical or psychological symptoms or both
¢ Men > women
¢ Hospital and health care workers
¢ Treatment: usually involves management rather than cure
________________________________________
Malingering
Conscious production of signs and symptoms for an obvious gain (money, avoid work, free bed and board, etc.). It is not a mental disorder.
________________________________________
Case Study
A 50-year-old woman was referred by her husband™s psychiatrist because of œattacks of dizziness that have been occurring for more than 10 years. Every day, at about 3pm, the attacks occur. They leave her helpless and, when her husband arrives, she is unable to attend to him. She remains in bed until 8pm when the attacks subsided, and she would watch TV and fall asleep.
When questioned, she described her husband as abusive and not caring about her well-being. He has repeatedly abused her and their children, which resulted in their leaving home at an early age, and moving in with their grandmother. She stated that she hated when he came home and would make comments about the house, dinner, etc. Many times, these verbal comments were followed by actual episodes of violence, several of which have resulted in her hospitalization.
________________________________________
USMLE Step 2 ” Lesson 9: Personality Disorders
Personality Disorders
________________________________________
Personality Disorders
¢ Ego-syntonic maladaptive patterns of behavior
¢ These individuals rarely seek treatment by themselves and are regarded as unmotivated for treatment
________________________________________
Personality Disorders
¢ Odd, eccentric type (Cluster A): paranoid, schizoid, schizotypal
¢ Dramatic, emotional type (Cluster B): histrionic, borderline, antisocial, narcissistic
¢ Anxious, fearful type (Cluster C): avoidant, obsessive-compulsive, dependent
________________________________________
Paranoid Personality Disorders
¢ Pervasive distrust & suspiciousness of others
¢ Reluctance to confide in others
¢ Recurrent suspicions
¢ Persistently bears grudges
¢ Questions the loyalty of others
¢ Reads demeaning meaning into benign remarks
¢ Main defense mechanism is projection
________________________________________
Schizoid Personality Disorder
¢ Lifelong pattern of social withdrawal
¢ No desire for close interpersonal relationships
¢ No interest in sexual activities
¢ Appears indifferent to criticism
¢ Emotional coldness
¢ Lacks close friends
¢ Almost always chooses solitary activities
________________________________________
Schizotypal Personality Disorder
¢ Magical thinking
¢ Ideas of reference
¢ Illusions
¢ Inappropriate affect
¢ Paranoid ideation
¢ Odd appearance
¢ Excessive social anxiety
¢ If stress, may become psychotic
________________________________________
Histrionic Personality Disorder
¢ Usually characterized by colorful, exaggerated behavior
¢ Excitable, shallow expression of emotions
¢ Uses physical appearance to draw attention to self
¢ Sexually seductive
¢ Uncomfortable in situations where they are not the center of attention
________________________________________
Borderline Personality Disorder
¢ Unstable affect, mood swings, marked impulsivity
¢ Unstable relationships, identity disturbance
¢ Recurrent suicidal behaviors
¢ Chronic feelings of emptiness or boredom
¢ Inappropriate anger
¢ If stressed, may become psychotic
¢ Main defense mechanism is splitting
________________________________________
Antisocial Personality Disorder
¢ Continuous antisocial or criminal acts
¢ Inability to conform to social rules
¢ Impulsivity
¢ Disregard for the rights of others
¢ Aggressiveness
¢ Lack of remorse and deceitfulness
¢ Symptoms before 15 and patient > 18
________________________________________
Narcissistic Personality Disorder
¢ Sense of self-importance and grandiosity
¢ Preoccupied with fantasies of success
¢ Believe they are special
¢ Require excessive admiration
¢ React with rage when criticized
¢ Lack empathy, envious of others
¢ Interpersonally exploitative
________________________________________
Avoidant Personality Disorder
¢ Extreme sensitivity to rejection
¢ Shy, social inhibition, few friends
¢ Feelings of inadequacy
¢ Reluctant to take personal risks
¢ Hypersensitive to criticism
¢ Shows restraint within intimate relationships
¢ High incidence of social phobias
________________________________________
Dependant Personality Disorder
¢ Lacking self-confidence
¢ Subordinate their needs for those of others
¢ Difficulty making decision
¢ Unable to assume responsibilities
¢ Feeling uncomfortable or helpless when alone
¢ Need support from others and urgently seek relationships as a source of care and support
________________________________________
Obsessive-Compulsive Personality Disorder
¢ Orderliness, stubbornness, inefficiency, perfectionistic
¢ Preoccupied with details, rules, lists
¢ Excessively devoted to work
¢ Unable to discard worn out objects
¢ Rigid, cheap, and over conscientious
¢ Described as being fixated at the anal stage of development ________________________________________
USMLE Step 2 ” Lesson 10: Psychopharmacology
Psychopharmacology
________________________________________
Mechanism of Action
Dopamine Receptor Antagonists (Antipsychotics)
¢ Act primarily by dopamine blockade, D2
¢ Produce alpha-blockade (hypotension)
¢ Block muscarinic receptors (anticholinergic side effects)
¢ Block NE reuptake and block serotonin and histamine receptors
________________________________________
Dopamine Tracts:
Dopamine Receptor Antagonists (Antipsychotics)
¢ Mesolimbic and mesocortical (psychosis)
¢ Nigrostriatal (movement disorders)
¢ Tuberoinfundibular (prolactin)
________________________________________
Acute Dystonia
Dopamine Receptor Antagonists (Antipsychotics)
¢ Usually within a few hours to few days of initiating treatment
¢ Greater incidence among young males
¢ Muscular rigidity and cramping
¢ Treat with anticholinergic medication
________________________________________
Drug-Induced Parkinsonism
Dopamine Receptor Antagonists (Antipsychotics)
¢ Onset within several weeks of therapy
¢ Greater incidence among the elderly
¢ Characterized by bradykinesia, rigidity, cogwheel tremor, masked facies, etc.
¢ Treatment consists of anti-parkinsonism medication and decreased antipsychotic medications
________________________________________
Akathisia
Dopamine Receptor Antagonists (Antipsychotics)
¢ Onset after many weeks of therapy
¢ Characterized by restlessness and symptoms of anxiety
¢ Treatment consists of decreasing the antipsychotic medication, Beta-blockers, or benzodiazepines
________________________________________
Neuroleptic Malignant Syndrome
Dopamine Receptor Antagonists (Antipsychotics)
¢ Fever, rigidity, and autonomic instability
¢ Greater incidence with high-potency neuroleptics and lithium
¢ Medical emergency
¢ Treatment consists of dantrolene or bromocriptine
¢ Obtain CPK
________________________________________
Tardive Dyskinesia
Dopamine Receptor Antagonists (Antipsychotics)
¢ Onset after long term use > 3-6 months
¢ Greater incidence among elderly females
¢ Characterized by involuntary movements of the tongue, face, neck, and upper extremities
¢ Treatment consists of prevention, risks vs. benefits, vitamin E?, consider clozapine
________________________________________
Differences Between Typical and Atypical Antipsychotics
Typical Atypical
Dopamine receptors Dopamine & serotonin
receptors
Treat (+) symptoms Treat (+) and (-)
symptoms
Many side effects Less side effects
________________________________________
Clozapine
¢ Weak D2 receptor antagonist
¢ Blocks the mesolimbic and mesocortical dopamine tracts
¢ Adverse effects include agranulocytosis (1-2%), seizures, and drooling
¢ Weekly WBC™s
¢ Never use as first line
________________________________________
Risperidone/Olanzapine/Quetiapine
¢ Sedation
¢ Less side effects
¢ May use as first line
________________________________________
Antidepressants
¢ Mechanism of action
o Block the reuptake of the neurotransmitters
o Down-regulation of receptors
o Increase endogenous opiates & pain threshold
________________________________________
Antidepressants
¢ Adverse effects
o Sedation, weight gain, orthostatic hypotension
o Dry mouth, blurry vision, urinary retention
o Increased heart rate and EKG changes
o Sexual dysfunctions
________________________________________
SSRI's & SSRI-Like Drugs
¢ Fluoxetine
¢ Sertraline
¢ Paroxetine
¢ Fluvoxamine (for the treatment of OCD)
¢ Nefazodone
¢ Citalopram
________________________________________
SSRI's & SSRI-Like Drugs
¢ Most common adverse effects include GI (N/V)
¢ Headache, sedation, or restlessness
¢ Anorgasmia, retarded ejaculation
________________________________________
MAOI's
¢ Phenelzine
¢ Tranylcypromine
¢ Selegiline
¢ Must have strict dietary restrictions due to tyramine reaction
________________________________________
Mood Stabilizing Agents: Lithium
¢ Mechanism of action - blocks inositol-1-phosphatase
¢ Adverse effects
o N/V, anorexia, diarrhea, abdominal pain
o Polyuria and polydypsia
o Tremors
o Hypothyroidism
o Teratogenic - Ebstein™s anomaly
¢ Others - carbamazepine, valproic acid, gabapentin
________________________________________
Antianxiety Agents (Benzodiazepines)
¢ Mechanism of action
o Facilitate GABA-ergic synaptic transmission
o Alter membrane permeability to chloride ions (facilitate GABA effects)
o All undergo hepatic microsomal oxidation except lorazepam, oxazepam, and temazepam, which undergo glucoronidation
________________________________________
Antianxiety Agents (Benzodiazepines)
¢ Adverse effects
o Sedation and impairment of performance
o Memory impairments
¢ Disinhibition
¢ Depression
¢ Addiction ________________________________________