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Here you will find the template and cited resources for the podcast episode covering the highest yield psychiatry concepts based on the EOR Topic Blueprint
Hello and Welcome to PASPAC, Your Audio Passport from Physician Assistant Student to Certified - And Beyond - With your host, Rebecca Harrell, MPA, PA-C
Today our destination is High Yield Psychiatry and Behavioral Health
So, sit back, relax, and let’s get to it
Before we get into today’s episode, I would like to provide a trigger warning that we will be discussing things like suicide and homicidal ideation, substance abuse, domestic violence, and other hard topics we must cover when reviewing Psychiatry. Please know, patients with psychiatric diagnoses can present in a variety of ways, but the high yield we cover will either be directly taken from criteria needed to make a DSM-5 diagnosis or the buzzwords associated with a psychiatric diagnosis. If you or someone you love are experiencing thoughts of suicide or emotional crisis, call 988 to talk to someone 24/7 toll-free. The National Domestic Violence Hotline is also available 24/7 at 800-799-7233. Thank you and lets begin the show.
Hey everyone, it’s Becca
Today we are going to be covering the highest yield topics incorporated in the Psych EOR going in descending order of content covered on the blueprint starting with Mood Disorders which makes up 18% of the EOR
Mood Disorders: Depression, Bipolar, and Related Disorders
Your patient is a 22 year old female who presents to primary care due multiple episodes this year of anhedonia and lack of motivation for at least 2 weeks. When questioning her further, she reveals there are some instances when she is extremely elevated and happy and she doesn’t know why she gets so depressed sometimes. She states her periods of elevated mood last about 4 days to 1 week and she feels on top of the world and has a lot of motivation to complete tasks without even feeling she needs to sleep. Given her presentation, what is your top differential?
Bipolar II Disorder (BPAD II)
Bipolar II differs from Bipolar I by duration of HYPOMANIA and at least one clear historical account of Major Depressive Disorder (MDD).
Overall, you can think of Bipolar II as less severe than Bipolar I because it does not have the criteria that hit the severe level seen in BPADI and also must have a component of at least 1 episode of MDD, whereas BPADI does not require an MDD episode.
However, remember that anytime psychotic features are present during manic episode, regardless of the duration, the diagnosis is considered BPAD1.
Additionally, BPADII should never lead to hospitalization or major impairments. If this occurs, the diagnosis will also be BPADI.
Treatment of BPADII is going to be same as the treatments for BPADI, which is first line maintenance with Lithium or Quetiapine.
MDD can be treated with antidepressants WITH antipsychotics.
Antidepressant MONOTHERAPY is contraindicated in patients with history of mania or hypomania because they can induce mania without the buffer of the antipsychotic.
First line treatment for BPADI is essentially whatever stabilized the acute manic episode, ex. lithium, antipsychotics, anticonvulsants, or a combination.
If malignant catatonia exists in BPADI with MDD (immobility or waxy flexibility with fever/rigidity/ signs of autonomic instability ) then 1st line is ECT
Remember, mania and hypomania criteria is met when 3+ DIGFAST components exist (for 7 days in BPAD1 or at least 4 days for BPADII) – do you recall what it stands for?
Distractibility
Impulsivity – poor judgement (ex. reckless driving, risky sex, spending money)
Grandiosity – inflated self-esteem
Flight of Ideas – racing thoughts
Activities – psychomotor agitation
Sleep – decreased NEED (not just wanting to sleep but can’t, they truly feel they do not need to sleep and still have expansive energy despite not needing to sleep)
Talkativeness – pressured speech
Your 18 year old male presents to your office due to persistent feelings of worthlessness over the past couple weeks. He has had no interest in any of the things that used to make him happy and he has been having difficulty sleeping, despite feeling completely worn out. His mom urged him to come in because she has a history of depression and felt this was similar to what she experienced in the past. He denies any known trigger to his mood change and denies any periods of expansive elevation. What is considered 1st line treatment for your top differential?
SSRIs + Psychotherapy
Psychotherapy is first line in mild to moderate depression that does not have any features of psychosis or appears chronic/ recurrent.
Otherwise, or if asked specifically for first line pharmacotherapy, the answer is SSRIs like Fluoxetine, Paroxetine, Citalopram, Escitalopram, or Sertraline.
Typically, if the patient does not respond to the first choice SSRI after 4-8 weeks, you would do a trial of another SSRI before choosing an SNRI, however SNRIs are increasingly becoming more common as first line.
Positive family history, substance abuse, chronic pain or illness, and severe stress are all risk factors for developing MDD
Screening should be performed with either the PHQ-9 or Beck Depression Inventory for Primary Care
Diagnosis can be made if the patient experiences at least 2 weeks of depressed mood OR loss of interest in addition 4 of the following:
Significant weight change
Insomnia/hypersomnia
Psychomotor agitation or retardation
Feelings of worthlessness/guilt
Decreased concentration/ indecisiveness
Recurring thoughts of death or suicide
Decreased energy and fatigue
This criteria can be summarized by the mnemonic SIGECAPS – what does SIGECAPS stand for?
Sleep, interest, guilt, energy, concentration, appetite, psychomotor, suicidality
FYI - If the patient has had persistent or recurrent episodes of MDD for two years or longer without any remission longer than 2 months during that time, the diagnosis is DYSTHYMIC disorder aka Persistent Depressive Disorder
First line remains the same as MDD which is Psychotherapy & SSRIs
What is the difference between Postpartum Unipolar MDD and Postpartum Depression?
PP Unipolar MDD begins within 4 weeks of delivery
PP Depression is persistent depression that occurs anytime within 12 months of delivery which interferes with daily living – treatment for this is also Therapy & SSRIs
Okay, we’ll touch on some more mood disorders at the end of the episode during the rapid review, for now let’s move onto Anxiety Disorders which also make up 18% of the EOR
Anxiety Disorders
Your 45 year old female patient is referred to your psychiatry clinic due to excessive overthinking and worry that has been predominating her thoughts for the past 6 months. She states she worries about nearly everything, from her children, to finances, to driving, and everything in between. She has had difficulty concentrating on much else and her anxiousness has made her irritable and tense. All labs return within normal limits. What is considered first line pharmacotherapy for suspected diagnosis?
SSRIs – dosed half of dosing for MDD – is first line for treatment of generalized anxiety disorder.
GAD is the most common psychiatric disorder seen in the elderly and is defined by a persistent anxious state that occurs most days in a 6 month period about a variety of things and is not specific to one worry.
For this diagnosis, patients must find it difficulty to control worry and 3+ of the following should be present
Restlessness
Fatigue
Difficulty Concentrating
Irritability
Muscle Tension
Sleep Disturbances
First line pharmacotherapy for GAD is SSRIs in combination with Cognitive Behavioral Therapy.
Venlafaxine is an SNRI that also has FDA approval for long term treatment of GAD, but first line is still SSRIs
Your 22 year old female patient arrives to the ER an hour after experiencing episode of chest pain and shortness of breath earlier today associated with nausea, palpitations, and sensation of doom which occurred abruptly for about 10 minutes. EKG is WNL and all her lab work is normal. She has never experienced this before states it all seemed triggered after getting laid off from her job. What is she describing?
Panic Attack
This is not a disorder by itself unless it occurs repeatedly and unexpectedly leading to accompanying behavior modifications to avoid future panic attacks or worrying about panic attacks for at least 1 month, which in that case the diagnosis of Panic Disorder.
The patient in the stem does NOT meet the requirements for a diagnosis of Panic Disorder tat this time.
Because differentials for panic attacks and panic disorder include life threatening disorders, you must rule out conditions which can present this way such as
Hyperthyroidism
Hypoglycemia
Electrolyte Imbalances
Anemias
Infections, etc.
Work up should include labs to rule out physiological causes of symptoms including an ECG or Halter to rule out cardiac causes
Your patient has an overwhelming fear of driving over bridges and it is beginning to interfere with her work as a regional manager requiring her to travel frequently. What is a long term treatment option for her diagnosis?
Specific Phobia
This is the most common psychiatric disorder and most commonly occurs in women starting in childhood in which the fear to object or situation leads to anxiety and avoidance that causes distress or impairs function
In phobic disorders, 1st line treatment is exposure therapy and long term pharmacotherapy can be discussed, which includes SSRIs along with CBT.
Short term therapy like short acting BZDs or BBs are useful in initial short term treatment, especially if used 1-2 hours before a known exposure in case where the exposure cannot be avoided or infrequently encountered. However, long term pharmacotherapy option remains SSRI with CBT.
Diagnosis of a specific phobia should only be considered if the patient as experienced symptoms for at least 6 months
Your 45 year old male patient has been experiencing a lot of sadness and anxiety following his recent divorce 2 months ago and he has been having a hard time sleeping and staying on task at work because he is constantly thinking about how things could be different . What is his diagnosis at this time?
Adjustment Disorder
Adjustment Disorder when a person as a difficult time coping with a stressor, not a trauma.
A stressor would be something like a life-change, including but not limited to, divorce, moving, break up, new job, laid off, etc.
In order to dx adjustment disorder, the emotional response must develop WITHIN 3 months of the onset of stressor that is considered in excess of what would be normally expected
Adjustment disorder can be later subtyped as predominantly symptoms involving mood, anxiety, or disturbance of conduct
Acute Adjustment disorder resolves within 6 months.
Chronic Adjustment Disorder is when the behavior last longer than 6 months, but the stressor itself must be ongoing (ex. loss of job and still out of work)
Treatment is psychotherapy
*Don’t confuse Adjustment disorder with Acute Stress Disorder or PTSD in which the stressor involved is much more severe, and more consistent with a trauma rather than a response to stressful life phase.*
Your 29 year old female patient is referred to your psychiatry clinic due to distressing nightmares and intrusive thoughts about her combat deployment which she returned home from a few months ago. She states she did not get hurt herself but witnessed the death of one of her friends and keeps replaying the memory over and over, sometimes feeling like she is living it again. Her partner says she is more irritable than normal and jumps at the slightest sounds. What is the first line treatment for your top differential?
SSRIs like Sertraline are considered as first line pharmacotherapy for PTSD.
Nightmares specifically can be treated with Prazosin, which is an alpha adrenergic blocker.
First line therapy for PTSD is Trauma Focused Therapy.
The most common group who experiences PTSD is young adults.
Although this patient is female, remember the most common trauma for men results from combat and the most common trauma for women is from assault or rape.
Screening for PTSD can be done with PCL-5 and criteria to meet diagnosis include directly experiencing or witnessing a traumatic event.
Unlike Adjustment Disorder, the stressor must be an exposure to actual or threatened death, serious injury, or sexual violation in addition to presence of persistently re-experiencing the trauma for over 1 month with avoidance of reminders and 2+ symptoms of hyperarousal.
Remember, while benzos are relatively contraindicated as treatment for PTSD due to substance abuse potential, there have been some studies that suggest using BZD immediately after a trauma for sleep and help processing the event can help improve anxiety and stress responses.
The above patient meets criteria for PTSD because her symptoms have persisted longer than 1 month. If symptoms resolved within 1 month, her diagnosis would be Acute Stress Disorder.
We will touch on more anxiety high yields later, but now let’s get into Substance-Related Disorders which make up 14% of the EOR
Substance-Related Disorders
Your patient is a 26 year old male who arrives to your psych clinic after his girlfriend told him he has an alcohol problem. During your evaluation, you find that since he was about 24, he has been drinking 1-2 beers a night and likes to party on the weekend with his friends and can drink up to 8-12 beers during those nights. He has never been arrested or gotten in trouble for his drinking but admits he has occasionally driven home on nights he has had a little too much to drink - leading to arguments with his girlfriend which causes him a lot of distress. He has tried to cut back in the past, but states he has difficulty sleeping without his nightly beers and thus starts drinking again. Given suspected diagnosis, how should you initiate your treatment?
Motivational interviewing or some other form of psychosocial treatment like AA or CBT should be provided to all patients with alcohol use disorder.
AUD is the 3rd leading cause of preventable death in the US can be diagnosed in anyone with at least 2+ AUD criteria in a 12 month period which leads to significant impairment/distress. You can remember the criteria with the Mnemonic I found on PsychDB - WILD ADDICCT’D
W – Work, school, home obligation failure
I L – Interpersonal or social consequences
D – Dangerous Use
A – Activities Given Up/Reduced
D – Dependence (tolerance)
D – Dependence (withdrawal)
I – Internal Consequences (physical or psychological)
C – Cannot cut down or control
T – Time Consuming Use
D – Duration or amount is greater than intended
About 2 days after discontinuing excessive and long term alcohol use, your patient arrives to the ER altered with nausea, vomiting, and diaphoresis. Vitals reveal HR 112, temperature of 100.4 F, and BP 190/100. What is his diagnosis ?
Delirium Tremens
This is the most severe form of withdrawal and considered a medical emergency.
DT typically is seen after ~48 hours from the last drink in which the patient experiences autonomic hyperactivity and altered mental status.
Treatment for DT or prevention if patient has a high risk of DT is with high dose paternal BZD like Diazepam
Criteria for withdrawal does not need to meet criteria for DT, but instead is at least 2 symptoms of withdrawal criteria which includes hand tremors, transient tactile or visual hallucinations, insomnia, nausea, vomiting, anxiety, psychomotor agitation, or your heavy hitters like seizure and autonomic hyperactivity.
Your 17 year old male patient is brought into your clinic due to his odd behaviors. She states he has been excessively giggling and not concentrating on any of his chores. When questioning the patient, he states he feels totally fine and relaxed, but sometimes just loses track of time. Physical reveals injection of bilateral eyes. What complications are associated with your suspected diagnosis?
Complications of cannabinoid intoxication include decreased memory, attention, concentration, and transient psychosis. While overdose of cannabis itself is not commonly seen, aside from perhaps cannabinoid hyperemesis syndromes, synthetic marijuana like spice or K2 can be deadly.
Cannabis is the most widely used illegal psychoactive substance in the world and can lead to abuse potential given the activation of the body’s reward system aka Dopamine Mesolimbic Brain Circuit.
Symptoms of intoxication include euphoric affect, increased perception of external and internal stimuli, somatic sensation of floating or sinking, and cognitive distortion of time perception, memory lapses, and difficulty concentration.
In patients with moderate to heavy use, UDS can remain positive for up to 1 month, while mild use may only be detected for 1-7 days.
What substance use disorder should be suspected in a patient with erythematous rash around the mouth, history of mood swings, facial flushing, and unusual odor of both breath and body?
Inhalant related disorder with sniffing, huffing, or bagging of solvents
Acute treatment is supportive, but if severe aggression is seen you may need to give Haloperidol or treat any medical complications as high doses can lead to cardiopulmonary failure, liver/kidney disease, and bone marrow suppression
However, prolonged abuse itself can essentially damage nearly every organ.
What are some signs and symptoms of Opioid Intoxication and Overdose and how do you treat?
Patients will first experience euphoria which can later turn to apathy. Physical findings include pinpoint pupils, slurred speech, and impaired memory. Patient’s also will experience constipation which will not improve even when tolerance is built.
The most common vital sign abnormality in overdose is hypoventilation which will lead to both respiratory and CNS compromise.
Treatment for overdose first consists of supporting the airway and breathing with oxygen and bag-valve mask.
Next is Naloxone, which is a pure opioid antagonist, and should be given to all patients with opioid overdose or suspicion for opioid overdose.
Don’t forget patient’s should be discharged WITH naloxone and patients with OUD or those on opioid therapy for medical reasons can be given prescriptions of naloxone outpatient as well.
Your patient is brought into the ER by his parents due to strange behavior and high fever after returning home from a concert. Physical reveals dilated pupils, BP of 160/90, HR 133, and temperature of 101.3 F. What substance do you suspect as the cause of his presentation?
MDMA – leads to signs and symptoms of sympathomimetic toxidrome including hypertension, tachycardia, and hyperthermia.
The sympathomimetic toxidrome, as also seen with cocaine and amphetamines results from adrenergic stimulation of norepinephrine and epinephrine which leads to the symptoms present in the stem.
MDMA use is part of the overall diagnosis of Stimulant Use Disorders, including cocaine and methamphetamines.
In all of these conditions, pupils will be dilated, vs. opioid use disorder where miosis or pin-point pupils are seen.
Don’t forget that beta blockers should be avoided in patients with sympathomimetic toxidrome suspected due to unopposed alpha potentially leading to cardiovascular collapse.
Okay, that was a lot of substance use disorders and we’ll hit on even more high yields later. For now, lets go onto Schizophrenia and Other Psychotic Disorders which make up 12% of the EOR
Schizophrenia and Other Psychotic Disorders
Your patient arrives to his annual follow up and is in generally good health with no new complaints. Social history reveals he has been having difficulty with his marriage because he believes his wife is cheating on him. He states despite her denying this and not being able to find any proof of it for the past month he’s had this belief, he continues to have this gut feeling she’s being unfaithful that he cannot shake. Given suspected diagnosis what is the number one goal of treating his persistent fixed false beliefs?
Establishing a therapeutic alliance is the first line goal of treatment for the diagnosis of Delusional Disorder
Delusional Disorder occurs when a patient has one or more persistent fixed false beliefs for at least 1 month WITHOUT hallucinations or major functional impairment.
In fact, you may never even know a patient has delusional disorder without directly asking them about it during an interview.
Additionally, patients often have such belief in the delusion, they can be resistant to this psychiatric diagnosis at all, especially because in other areas of life, they are generally well functioning without overt bizarre behaviors
The most common subtype is persecutory delusional disorder in which a person believes they are being attacked or harmed in some way, other subtypes include jealous (like in our stem), grandiose (feelings of inflated self-importance), erotomaniac (belief celebrity or person of unattainable social status is in love with them), or Somatic which is the belief something awful is happening inside their body
If the somatic belief is believing parasites are living in their body, consider diagnosis of Delusions of Parasitosis which may also be accompanied by the Match Box Sign in which the patient brings samples of debris or dead skin in a container to "prove" their infestation.
The initial management is the same as delusional disorder with establishing a strong therapeutic alliance and fully respecting a patient’s autonomy in all encounters.
If the patient is amenable to therapy, 2nd gen antipsychotics with a low side effect profile, like Aripiprazole, is considered first line for pharmacotherapy.
Remember to rule out systemic differentials for somatic delusions, including scabies and uremia/cirrhosis, and SUD, in patients with delusional parasitosis.
What criteria differentiates Schizoaffective Disorder from Schizophreniform or Schizophrenia?
Remember, affect is similar to a patients mood or how they present their mood, so Schizoaffective Disorder should be suspected with a patient who meets the diagnostic criteria of a mood disorder, like depression or mania, and also meets diagnostic criteria for Schizophrenia.
However, the patient must have at LEAST one 2 week period of time in which the patient continues to have schizophrenic symptoms, like delusions or hallucinations, in the absence of the mood disorder.
Schizophreniform meets criteria for Schizophrenia, but the duration of symptoms only persists between 1-6 months and no social or occupational impairment results from their symptoms. They should be closely monitored for development of Schizophrenia.
Schizophrenia is diagnoses if symptoms last for at least 6 months with at least one month of 2+ criteria and at least one criteria being presence of delusions, hallucinations, or disorganized speech which are all considered positive symptoms.
Catatonia may also be seen in Schizophrenia in which a patient has decreased reactivity to their environment which is secondary to profound neurocognitive decrease in motivation, leading to negativism (or resistance to instructions), bizarre posturing, mutism, or purposeless movement
Finally, other symptom components of Schizophrenia include negative symptoms which include flat affect, decreased fluency of speech or productivity of thought, and a bunch of words starting with A –
Alogia – diminished speech
Avolition – Decrease in self-initiated purposeful activities
Anhedonia – Lack of finding pleasure in previously enjoyed activities
Asociality – Lack of interest in social activities
In Schizophrenia, there must be a diminished level of functioning that affects at least one area of life – ex. Relationships, work, school.
Treatment of Schizophrenia is with 2nd Gen Antipsychotics, like Risperidone, Olanzapine, and Aripiprazole, which are most useful for treating the negative symptoms and have fewer side effects than 1st gen antipsychotics
Positive symptoms are usually attacked with dopamine antagonists aka typical neuroleptics like haloperidol.
That was a lot about Schizophrenia and Ill touch a tiny bit more on it later, but lets get to Disruptive/Impulse Disorders and Neurodevelopmental Disorders which make up 10% of your EOR
Disruptive/Impulse Disorders and Neurodevelopmental Disorders
Your 3 year old male patient is brought into see you by his parents because of his speech delays. They say he seems to be uninterested in trying to communicate with them or even look at them. They state he hit his walking milestone on time even though he repetitively likes to walk on tip toes. At daycare he has little interest playing with the other kids and instead likes to sit by himself putting all the toy cars in straight line. What is your suspected diagnosis?
Autism Spectrum Disorder
This is seen with repetitive behaviors and difficulties with social interaction and communication, as evident by speech and language delays, and poor eye contact.
Occasionally, aggression may be present - FDA approval treatment for aggression in ASD is with Risperidone or Aripiprazole.
Your 10 year old patient is brought into your psychiatry office by his parents due to his aggressive behaviors this past year. He has been getting in trouble for bullying at school, has been setting fires in his backyard, and was caught kicking his family’s cat multiple times. Even when caught, he lies and blames his sister or classmates for his behaviors and does not seem to have any remorse when confronted. What is the first line treatment for suspected diagnosis?
Multisystemic Treatment is the program recommended for patients with conduct disorder which is an intensive integrative program emphasizing correct behaviors
The best medication to use in patients with both CD and ADHD is with methylphenidate
Criteria for conduct disorder is met when a patient violates the rights of others for at least 12 months by either acting aggressive or violent to people or animals, destroying property, deceit or theft, or seriously violation of home/school rules like running away overnight at least 2x or being truant from school.
Conduct disorder is currently the best predictor of antisocial personality disorder, which cannot be diagnosed until a person is 18 and conduct disorder criteria was evident prior to 15 years old.
Don’t confused conduct disorder with oppositional defiant disorder which occurs when pediatric patient has a pattern of disobedience or defiance toward authority for at least 6 months, but though vindictive does not actually violate the rights of others. Treatment for ODD is psychotherapy and parent management training.
Okay, lets move onto personality disorders and OCD related disorders which make up 8% of the EOR
Personality Disorders and OCD Related Disorders
Your new 30 year old female patient comes to your psychiatric clinic to address her new onset issues with anxiety. She states she is usually in tune with her body and typically uses crystals to heal her ailments but has felt her energies are blocked off and has not been able to connect with nature and guardian angels as she typically has which has left her lonely since she does not have many friends. She tells you her aura has been feeling dulled and she has been seeing an excessive amount of crows around which makes her feel something awful is coming. What personality disorder best fits this patient?
Schizotypal Personality Disorder
These patients have longstanding “magical” thinking and beliefs that may be considered odd, but do not actually represent real delusions or hallucinations.
They may avoid close personal relationships and social situations with some distortions in thought and perception with odd behavior, which typically begins in early childhood with at least 5 of the following criteria
1. Ideas of reference – thinking things based in reality (aka seeing crows) have a specific relation to you
2. Odd Beliefs or Magical thinking – these beliefs influence behavior and are not considered consistent with subcultural norms, like her crystal practices, though can also be things like superstitiousness, clairvoyance, telepathy, or someone having bizarre fantasies
3. Unusual perceptual experiences – including bodily illusions, like auras
4. Suspiciousness and paranoid ideation – something bad may happen or bad omens
5. Inappropriate or constricted affect – may be so caught up in their thinking they blunt the experience as connecting with others and seem hesitant to accept other ideas as based in reality
6. Behavior or appearance is considered odd, eccentric, or peculiar – ex. flowy movements, dress may be over exaggerated and inconsistent with societal norms
7. Lack of close friends - this is typically due to discomfort and avoiding closer personal relationships, not something like antisocial where they don’t care or borderline where interpersonal relationships can be explosive and rocky
8. Excessive social anxiety that doesn’t diminish with familiarity – paranoid fears, not due to negative judgements about oneself.
Their personality and criteria will not be exclusively during any sort of schizophrenia or mood disorder with psychotic features, but instead a baseline personality
Treatment is with psychotherapy and antipsychotics, but most patients with personality disorders are resistant to treatment because their entire belief system is typically based in their underlying personality.
*Remember, most people exhibit one or more traits that make up various personality disorders - but that does not mean they have a personality disorder unless full criteria is met. For example, I totally believe in clairvoyance and mediumship, as do many others, but if they’re still functioning within society and not overtaken so much by their magical beliefs that it is difficult for them to trust or interact with the world, its just a trait and not an actual personality disorder.*
Your patient is a 27 year old female who was brought to the ED after threatening to commit suicide when her partner was trying to leave to hang out with his friends tonight. Records show this is the 6th time this year she has been involuntarily admitted after threatening to commit suicide. Thought she has not made any attempts; she has a history of self-harm behaviors which she says are triggered by others not caring about her enough. What are other common traits of her suspected personality disorder?
Splitting – you’re either all good or all bad depending on how they interpret or perceive your actions. You may see this in the stem as a history of “firing” multiple health care workers, despite “loving” you or another coworker.
These patients will have very intense interpersonal relationships and lability of mood which occasionally can look like mania or hypomania, but mood swings are a lot quicker than will be seen in a mood disorder like BPAD
They typically perceive their lives as being in constant crisis and will have a longstanding history of suicide threats or attempts, typically when feeling rejected by someone or something.
Despite their rocky interpersonal relationships, a lot of their mood swings are resulting around an intense fear of rejection.
Validating distress is a very useful way to engage patients and the most promising psychological therapy for them is Dialectic Behavioral Therapy which teaches others emotional regulation and coping mechanisms after identifying triggers and relearning how to react to certain emotional triggers.
Your patient is referred to you from their PCP due to their treatment resistant depression. During your interview, they get teary eyed that they are disappointing their PCP because they can’t seem to “get better” and feel like they’re failing them. They state they have been overwhelmingly lonely and are longing for more friends or relationships with others but were bullied so much in high school that they have extremely low self esteem and fear others will not like them – so they stay at home all day instead – which has added to their depressed state. Which personality disorder is best represented by this patient?
Avoidant Personality Disorder
This is part of the Cluster C personality disorders and is evident by a similar problem with interpersonal relationships, as we see in a lot of these personality disorders, but the difference here is these patients have a strong desire to make friends or have relationships, but their self-esteem and fear of rejection keeps them from achieving this.
They may be extremely hypersensitive to criticism and failure which might appear in the stem as an inability to hold onto jobs for a long period of time or maintain relationships
First line is Cognitive Behavioral Therapy
While working at a Plastic Surgery Suite, you meet a patient who is asking for their third calf muscle augmentation due to perceived defects from their last surgery, which are not evident to you during exam. His chart reveals he has had 16 cosmetic surgeries in the past 5 years. What do you expect is his underlying diagnosis?
Body Dysmorphic Disorder
These patients will have an intense preoccupation around their physical appearance and perceived defects, regardless of if they are something others notice or not.
This is seen in many patients with comorbid SUD, OCD, Eating Disorders, etc.
The stems usually present with patients who repeatedly see dermatologists or plastics for cosmetic procedures and they will have repetitive behaviors like checking the mirror or excessively grooming or seeking reassurance.
First line therapy is SSRI, like Fluoxetine and CBT
We’ll get into more of those later, now lets move onto Somatic Symptom and Related Disorders which makes up 8% of EOR
Somatic Symptom and Related Disorders
Your patient is a 41 year old male who arrived to the hospital with signs and symptoms of intestinal perforation without any known cause and has to undergo hours of surgery to save his life. While in the surgical suite, you find multiple batteries corroding his GIT tract. His records show this is the second time he has had to undergo surgery secondary to feigning an illness. Which diagnosis do you suspect?
Factitious Disorder, formerly known as Munchausen Syndrome
These patients will feign illness and play the sick role in order to gain attention and sympathy from others – NOT for external rewards (ex. medication or financial gain) as is seen in malingering.
Any objective findings are from self-harm in order to maintain the sick role and they will often be willing to undergo dangerous procedures or take risking medications to maintain their role
The most commonly falsified objective sign in these patients is hypoglycemia secondary to taking insulin
You will need to routinely assess suicide risk and monitor self-injurious behaviors
In order to make this diagnosis, you must have objective identification of illness falsification behaviors and evidence of deception – cannot just assume a patient is feigning an illness based on a suspicion.
What is the difference between Illness Anxiety Disorder and Somatic Symptom Disorder (aka Somatoform Disorder)?
Illness Anxiety Disorder
This occurs when there is a chronic excessive preoccupation for at least 6 months about a possible disease a patient has in which they may perform excessive health-related behaviors, like repeatedly checking their vital signs, or exhibits maladaptive avoidance, like avoiding hospitals and annual physicals due to an intense fear they have some serious undiagnosed medical illness.
Most of their symptoms are based on fear surrounding a disease itself.
Somatoform Disorder
This focuses on preoccupation with physical sensations and interpreting normal body functions and physical symptoms. They won’t be focused on a particular illness, but instead on the actual bodily sensation.
You should be scheduling regular outpatient visits with them and refer to psychiatric evaluation
Another differential to keep in mind is Functional Neurological Symptom Disorder (formerly known as Conversion Disorder) in which the patient is not intentionally producing symptoms or misinterpreting physical sensations, but instead has actual somatic signs secondary to a significant stressor, such as paralysis, involuntary movements, or seizures.
The first line treatment is developing a therapeutic alliance and first line therapy includes insight oriented or behavioral therapy, physical therapy, and CBT.
95% of these patients will have symptoms spontaneously resolve in 2 weeks
Okay, we’re moving along to Feeding and Eating Disorders now which make up 8% of your EOR
Feeding and Eating Disorders
Your 17 year old male patient has dropped a significant amount of weight since his last visit and is weighting in at 17.5% BMI. He reports he has been trying to “get fit” for Summer and still sees excesses stomach fat when he looks in the mirror. He states he is eating one meal daily, which typically consists of a single piece of fruit or a protein shake. Given suspected dx, What might labs show?
Increased LFTs
Decreased Renal Function
Decreased Secretion of hypothalamic-pituitary hormones
Decreased Bone density
Increased Total Cholesterol due to increased HLD, not LDL.
This patient has Anorexia Nervosa, which is differentiated from Bulimia by the low BMI, whereas Bulimic patients will have a normal or elevated BMI.
Both of these disorders are secondary to obsession with weight loss or fear of weight gain.
Physical signs in anorexia tend to be things like stress fractures, amenorrhea, lanugo, and muscle wasting
Physical signs in bulimia may be secondary to purging behaviors, such as eroded tooth enamel or dental caries of posterior molars, tenderness of bilateral parotid glands, or presence of Russell Sign, which is visualization of calluses over the knuckles.
In patients with Bulimia Nervosa, labs will typically show hypochloremia from vomiting and hypokalemia due to renal compensation along with hypomagnesemia and metabolic alkalosis.
I like to remember the acid base dysfunction for vomiting as Metabolic Alkalosis because you’re vomiting out all your stomach ACID aka hydrochloric acid, whereas with Diarrhea, you’re “pooping out your bicarb” leading to a Metabolic Acidosis – this is not the actual mechanisms of bicarb decreasing here, but it helps me to visualize the difference.
Lastly before our rapid review, lets quickly touch on some Paraphilic and Sexual Dysfunctions making up 4% of the EOR
Paraphilic and Sexual Dysfunctions
Which paraphilic disorder is characterized on having clinically significant urges or fantasies to specific objects or non-genital body parts?
Fetishistic Disorder
These patients will be aroused by things that aren’t considered sexual in nature and need to cause clinically significant distress or impaired function to be considered a disorder aka causing disruptions in their daily life or relationships
Your patient comes to your psychiatry office due to intense fear regarding his overwhelming sexual urges to hurt or torture his partners during sex. He states imaging these things is the only way he can achieve orgasm and he is fearful one day he will act on these urges. What paraphilic disorder does he exhibit?
Sexual Sadism
This is represented by either behaviors or fantasies about harming or causing psychological torment to others in order to achieve sexual arousal which leads to distress or impairment in function.
Don’t confuse this with Sexual Masochism disorder in which the person has distressing desires for someone else to harm them, either physically or psychologically, in order to achieve arousal.
RAPID REVIEW
1. What is the end metabolite of Ethanol?
Acetate (alcohol dehydrogenase converts alcohol to acetaldehyde which then converts into acetate) I’m sure it comes as no surprise that the liver is the primary site of oxidation of alcohol.
The primary metabolite of ethanol oxidation is acetaldehyde which is toxic to the body leads to a lot of the affects you may feel if you drink too much too quickly, like nausea and facial flushing, or when you drink so much the metabolites build to give you a hangover, leading to headaches, rapid heart rate, nausea, and vomiting.
The liver then converts the acetaldehyde to acetic acid which is an inactive metabolite that is later converted into carbon dioxide and water.
2. What comorbidity is commonly seen in Binge Eating Disorder?
Diabetes Type II
3. What is the first line treatment for Pedophilic Disorder?
Libido Reduction with medroxyprogesterone IM, leading to testosterone synthesis blockade
4. What presentation is seen in pediatric patients with Separation Anxiety Disorder?
Fear of leaving home, refusing to attend school, or overall excessive anxiety/fear regarding separation from attachment figures persisting for at least 4 weeks
In adults, Separation Anxiety Disorder tends to present with dependency or overprotective behavior surrounding possibility of separation from attachment figures for at least 6 months or longer
5. What is the criteria for a diagnosis of ADHD?
Symptoms of hyperactivity, impulsivity, and/or inattention that present in at least 2 areas of interaction for at least 6 months and beginning before age 12
6. Which cluster A personality disorder is represented by lack of desire for close relationships and preference for solitary activities?
Schizoid Personality Disorder
7. What is the “Female Athlete Triad”?
Weight loss, irregular periods, osteopenia
Their bone mineral density is adversely affected by their menstrual dysfunction, thus treatment with HRT, like OCPs, is useful in addition to restoration of normal caloric intake and increasing intake of calcium and vitamin D.
8. What are some symptoms of PCP intoxication?
PCP is a NMDA-R antagonist, similar to ketamine, leading to symptoms of euphoria, numbness, agitation, unusual strength, dilated pupils with vertical and horizontal nystagmus, with high doses leading to possible coma, seizure, severe hypertension, and psychosis.
9. What are the components of residual symptoms seen in Schizophrenia, even between episodes of psychosis?
Flat affect and auditory hallucinations
10. What is the most common time a patient suffering from intimate partner violence is assaulted?
When attempting to leave abuser
11. What is first line pharmacotherapy for OCD?
SSRIs – ex. fluvoxamine, sertraline, paroxetine – 2x dose as used for depression
2nd line is Clomipramine which is a TCA
First line pharmacotherapy should be combined with Cognitive Behavioral Therapy which focuses on Exposure and Response Prevention
12. What is the difference between Social Anxiety Disorder and Agoraphobia?
Social Anxiety encompasses fear around embarrassment or ridicule
Agoraphobia involves fear around things outside of the home, such as public transportation or open spaces, that is out of proportion to any real danger and leads to avoidant behaviors.
13. What are Screening Tools used in Alcohol Use Disorder?
CAGE and AUDIT-C which can determine mild, moderate, or excessive use
14. What part of the limbic system is hyperactive in specific phobias and PTSD?
Amygdala
This part of the brain is what will assign a particular emotional significance to external stimuli and then modifies behaviors in response
15. Which Cluster B personality disorder is characterized by grandiosity and attention seeking behavior with belief they are entitled special treatment with a need for admiration all while lacking empathy for others?
Narcissistic personality disorder
Unlike the short or sudden bursts of grandiosity one might see in psychosis or mania, patients with NPD will have a persistent belief of entitlement and grandiosity that is stable among time and situations and will likely get angry when they feel others aren’t treating them as they belief they should be treated.
16. What ocular finding is commonly associated with Shaken Baby Syndrome?
Retinal Petechiae
17. What is the mechanism of action for first line treatment of ADHD?
Methylphenidate non-competitively blocks the reuptake of dopamine and noradrenaline by blockade of the transporters for both, which lead to increased dopamine and noradrenaline in synaptic cleft.
18. What labs may support a diagnosis of Alcohol Use Disorder?
Elevated AST > ALT 2:1
Macrocytosis (ex. Folate or B12 deficiency)
Elevated GGT
19. What is the duration of Brief Psychotic Disorder?
Symptoms of schizophrenia for less than 1 month
20. What is the timeframe of criteria meeting Acute Stress Disorder?
Sx begin at least 3 days after trigger and must resolve within 1 month of onset
If persisting symptoms over 1 month, diagnosis is considered PTSD
21. What are some high yield physical findings for Opioid Withdrawal?
Piloerection (goosebumps)
Yawning
Rhinorrhea
Lacrimation
Unlike withdrawal from AUD or BZD, withdrawal from opiates is NOT life-threatening
Can also differentiate pupils in withdrawal vs. intoxication, in which withdrawal leads to dilated pupils (Mydriasis) and use/overdose leads to miosis (pinpoint)
22. What is the triad for Wernicke Encephalopathy?
Memory impairment, Gait disturbance, and Oculomotor Dysfunction (like Nystagmus)
Secondary to thiamine deficiency
If not treated, can progress to irreversible diagnosis of Wernicke-Korsakoff Syndrome which is characterized by anterograde amnesia and confabulation, in which brain makes up new memories
23. What personality disorder is characterized by flirtatious behaviors and impressionistic speech?
Histrionic Personality Disorder, Cluster B
24. What disorder can lead to “chocolate brown blood”
Methemoglobinemia leading to dark discoloration of blood
Can be associated with genetic conditions or exposure to drugs like Amyl Nitrate
Treat with IV Methylene Blue, supplemental O2, and exchange transfusion
25. What are two common over the counter pain meds which can lead to false positives on drug testing?
Ibuprofen and Naproxen
26. Which psychiatric medication can induce hypothyroidism?
Lithium
Can also lead to teratogenicity and Nephrogenic Diabetes Insipidus
27. How do pupils appear in someone on cocaine?
Dilated and reactive
28. What is the considered first line treatment for Extrapyramidal Syndromes?
Anticholinergics like Diphenhydramine and Benztropine
29. When is use of bupropion contraindicated?
Seizure disorder of use of MAOIs in previous 14 days
30. What is Dissociative Fugue?
Subset of Dissociative Amnesia in which the patient travels or wanders while in a dissociative state
31. What is the treatment for Benzodiazepine Withdrawal?
Long acting benzodiazepines or IV BZD to slow taper
Similar to AUD, withdrawal from benzodiazepines can lead to seizure and death.
32. Where does morphine and codeine come from?
Poppy plant – these are considered naturally occurring opioids whereas others are classified as either semi-synthetic or synthetic
33. What is the mechanism of action for second generation antipsychotics?
Blockade of dopamine and serotonin receptors
Some action on A1 and H1 receptors too which all lead to the high yield adverse effects like EPS, QTC prolongation, sedation, orthostatic hypotension, etc.
34. What is Depersonalization?
Feelings of detachment from one’s own self and perception of your body vs. Derealization which is feelings of detachment to surroundings as if the world or events occurring are not real.
35. What is the most common personality disorder?
Obsessive Compulsive Personality Disorder
Perfectionistic behavior that is egosyntonic (aka their perfectionism does not bother them). Unlike actual OCD, which is egodystonic (aka they recognize their obsessions and compulsions as something disabling)
In OCPD, pharmacotherapy is only used if there are comorbidities like depression or anxiety, but not for the actual OCPD itself.
36. Which 1st generation antipsychotic has the highest risk for Tardive Dyskinesia?
Haloperidol
2nd generation A/Ps with high risk include Risperidone and Olanzapine
Familiarize yourself with the signs and symptoms of TD, which include involuntary hyperkinetic movements such as facial grimacing and lip smoking, tics, akathisia, dystonia, and chorea.
TD is considered chronic and typically irreversible – requiring early recognition and discontinuation of causative agent asap
37. Which 2nd generation antipsychotic requires monitoring of WBCs and ANC due to the black box warning for severe neutropenia?
Clozapine
This can lead to life threatening agranulocytosis
38. What can be used as both prevention and treatment for Delirium Tremens?
Paternal Benzos (ex. Diazepam) in high doses
Don’t forget DT is the most severe for of alcohol withdrawal and has a high mortality rate secondary to respiratory failure and cardiac dysrhythmias
39. What is the treatment for Neuroleptic Malignant Syndrome?
Dantrolene and Bromocriptine
Discontinue causative agent and provide supportive treatment as well
40. What is the most common psychiatric comorbidity in ADHD?
Oppositional Defiant Disorder – up to 50% of patients have both
41. What are some high yield adverse effects of Olanzapine?
Weight gain leading to Metabolic Syndrome and T2DM
42. What is a contraindication of Naltrexone?
Hepatic Failure due to risk of increased LFTs
Oh my gosh,
That was a lot of psychiatric high yields. This episode was a doozy, but psychiatry and behavioral health is one of my favorite topics and also was one of my favorite rotations. I hope you all got a lot out of this episode and I really want to remind you all of just how many medical diagnoses can present with psychiatric symptoms, such as psychosis, so it is always important to consider non-psychiatric causes of apparent psychiatric diagnoses.
As always you can go to my website www.paspacpodcast.com for today's transcript and the cited resources from today's questions. Also, be sure to follow PASPAC on Instagram (@paspac_passport) for near daily questions, mini quizzes on the stories, weekly updates in healthcare, and more.
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Safe travels.
As a responsible disclaimer, PASPAC Podcast is not intended to be used for medical or legal advice and though we always try to keep it educational and evidenced-based, any opinions or viewpoints we do share are ours alone and do not represent our employer or the profession at large.
RESOURCES
4.https://smartypance.com/lessons/psychiatry-substance-related-disorders-pearls-reeldx840/ref/ixemn/
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