1. Skin lesion: shape
-Annular macules: drug eruptions, secondary syphilis, lupus.
2. Non Melanoma skin cancer
-Risk factors: >80% lifetime sun exposure before age 18 (single greatest risk factor). Other risk factors: (other than fair skin) smoking, psoralen/PUVA, coal-tar product use, M>>>F, chronic ulcers, burn scars, chronic draining sinus tracts. HPV.
3. Melanoma
-Nevi>6mm have increased risk of malignancy
-Cumulative sun exposure not a risk, or much less of a risk, compared to intermittent, intense sun exposure during childhood and adolescence-- i.e.blistering sunburns
-Other risk factors (in addition to fair skin): radiation exposure, immunosuppression, family history, familial atypical mole melanoma syndrome (FAMMS), lots of benign nevi, giant pigmented congenital nevi,
-1% of all skin cancers, 60% of all skin cancer deaths.
-Not always pigmented-- be wary of lesions that are slowly growing in size or bleed easily.
-In women, more than half of melanoma occur on legs.
4. Online tutorial of skin examination technique and findings:
http://www.logicalimages.com/educationalTools/learnDerm.htm
5. Squamous cell carcinoma
-Scaly and erythematous + raised base (vs actinic keratosis, no raised base)
-patch, plaque, or nodule, +/- scaling and/or an ulcerated center.
-Irregular borders, bleed easily
-Fleshy, heaped up edges (vs BCC: clear, heaped up edges)
-20% of all cases of skin cancer.
-Occurs on sun exposed areas, like extremities and face.
6. Basal cell carcinoma
-plaque-like or nodular. Waxy and translucent +/- ulcers or telangiectasia
-no associated itching or change in skin color.
-common on exposed skin surfaces but may occur anywhere.
-60% of primary skin cancers
-slow-growing lesions that invade local tissues but rarely metastasize.
7. Steroid vehicles & application:
-Cream: oil + water, drying effect with long-term use, good for acute inflammation.
-Ointment: oil-only base (i.e. petroleum jelly) with little water, excellent penetration (thus greater potency), good for dry skin
-Lotion: oil + water + alcohol, drying. Good for scalp, where it absorbs quickly without residue
-Gel: good for exudative lesions
-Apply 1-2 times a day. More frequent application does not lead to better results.
8. Steroid potency & side effects: (chart here)
-Psoriasis, lichen planus, hand eczema, alopecia need stronger steroids
-Atopic dermatitis, eczema, stasis dermatitis, seborrheic dermatitis need medium steroids
-Dermatitis on face, eyelids, diaper area - use weaker steroids.
-Side effects: skin atrophy (most common), hypopigmentation (more obvious in darker skinned people); however superpotent topical steroids can have the side effects of systemic steroids- HPA axis suppression, avascular necrosis of femoral head, HTN, hyperglycemia, glaucoma.
9. Tinea capitis: 
-Treat with systemic antifungals, as topical is unable to penetrate hair shaft.
-Griseofulvin is the only approved drug in the US
-20-25 mg/kg/day for 6-12 weeks using microsize formation
-10-15 mg/kg/day if ultramicrosize formation, as it is more easily absorbed.
10. Tinea unguium (onychomycosis):
-Treat with systemic antifungas, as topical cannot get into nail.
-Don't use griseofulvin, as it has low affinity for keratin and will take forever to work
-Treat with terbinafine 250 mg/day for 12 weeks (toenails) or 6 weeks (fingernails)
-Alternative: itraconazole pulses, 200mg BID, one week on, 3 weeks off. Fingernails need 2 rounds, toenails 3 rounds.

1. Treatment for ankle sprain: RICE
-Rest for 72 hours after injury, then begin gentle stretching. Do not be immobile for too long, it increases risk for chronic pain/instability/loss of ROM
-Ice for 10 minutes several times a day
-Compression: tape, ACE bandage, semi-rigid ankle support. The latter was purported to be the best by this Cochrane review, which was later withdrawn... for mysterious reasons.
-Elevation
2. Treatment for ankle sprain: preventing re-injury: 
-practice ankle strengthening exercises every day
-avoid sandals or flip flops
-protective ankle device when returning to sports
3. Causes of wheezing:
-Asthma
-COPD
-Persistent bronchitis
-Foreign body
-PE
-CHF
-Vocal cord dysfunction
-Upper airway cough syndrome
4. Comorbid conditions that may exacerbate asthma or render it more resistant to treatment:
-GERD
-Allergic rhinitis, sinusitis
-Anxiety/depression
-OSA, obesity
-Aspirin allergy: 21% of adults have aspirin-induced asthma and should avoid NSAIDs
5. Acute sinusitis: 
-Mucopurulent/opaque nasal discharge
-URI symptoms for at least 7-10 days before onset of sinusitis symptoms (pain in head, face, teeth; fever, congestion that doesn't respond to decongestants, pressure or fullness, loss of smell)
-Chronic sinusitis: same sx, for 12 weeks.
-Viral vs bacterial: consider bacterial if the symptoms don't resolve within 10 days or worsen.
6. Diagnosing asthma/RAD:
-Spirometry before and after bronchodilation
-FEV1 improvement >12% or FEV1 predicted improvement>10% after albuterol = diagnostic of asthma.
-Methacholine challenge only if the spirometry is normal-- trained administrators only
7. DDx asthma:
-COPD: sx will respond to albuterol, but spirometry findings will not change with albuterol.
-Vocal cord dysfunction: doesn't improve with albuterol, is associated with a flattening of inspiratory loop on spirometry
-Nonasthmatic eosinophilic bronchitis: spirometry and CXR normal, respond well to inhaled steroids. Dx with eosinophils on BAL or sputum.
-Silent GERD + aspiration: consider if they do not improve on asthma meds.
8. Asthma action plan
-Sample plan here
-Green: no symptoms, take controller meds daily and albuterol PRN before exercise
-Yellow: mild to moderate symptoms (night cough, SOB, wheeze) or exposure to known trigger (onset of viral illness, change in weather etc), mild loss of function. Controller meds plus rescue meds (i.e. albuterol 2 puffs q4-6) and call PCP.
-Red: severe symptoms: really struggling to breathe, struggling to walk/talk, rescue inhaler not working like normal, turning blue/dusky: rescue meds (i.e 4 puffs of rescue inhaler q 15 minutes for an hour) and go to the hospital.
9. Peak flows: 
-Based on age, sex, and height. Measure standing up, after a full breath; best of 3 trials.
-Determine someone's personal best peak flow by taking the best score during a 2 week period of doing peak flows BID (AM and afternoon/evening), during which asthma symptoms were optimally controlled.
-Correspondence to asthma action plan:
Green= peak flow >80% of personal best
Yellow= peak flow 50%-80% of personal best
Red = peak flow <50% of personal best.
10. Chronic sinusitis treatment:
-Aggressively manage allergic rhinitis with systemic antihistamines
-Nasal steroids
-Nasal saline irrigation
-Antibiotics do not help

1. Ankle anatomy

2. Common ankle injuries: Lateral ankle sprain-- from inversion injury. Most likely to damage anterior talofibular ligament. Sometimes calcaneofibular as well, which results in significant ankle instability. Rarely is the posterior talofibular ligament injured in inversion injuries. Swelling, erythema, pain, mild to moderate functional impairment, no deformity. Pain to palpation anterior of lateral malleolus. 

3. Common ankle injuries: peroneal tendon tear. From inversion injury, can happen concomitantly with lateral ankle sprain. There may or may not be swelling. Can also be due to repetitive trauma. 

4.  Common ankle injuries: fibular fracture usually from high-velocity/high-impact injuries, like fall or car accident. Severe pain, swelling, inability to ambulate, deformity. 

5.  Common ankle injuries: Talar dome fracture. may occur concomitantly with lateral ankle sprain. Presents with severe or persistent pain beyond normal lateral ankle sprain. Worry about this because it may compromise the blood supply and lead to avascular necrosis of the talus. 

6. Common ankle injuries: Subtalar dislocation. Can be either lateral or medial, will present with deformity. Talus subluxes off calcaneus/navicular bone 

7. Common ankle injuries: Medial sprain actually not super common, since it usually results from forced everson and dorsiflexion, and the deltoid ligament on the medial side of the ankle is a very strong ligament. 

8. Common ankle injuries: Syndesmotic sprain, generally involves anterior inferior tibofibular ligament and interosseus membrane. High impact injury. Pain and disability out of proportion. Positive ankle squeeze test: squeeze tibia and fibula together, then release; pain on release indicates sprain of anterior inferior tibulofibular ligament. 

9. Ankle sprain grades:

-Grade I: stretched tendon, minor tear. Mild pain, swelling. Little to no functional compromise, no mechanical instability. No excessive stretching of joint. 

-Grade II: incomplete tear. Pain to palpation over involved structure(s). Mild to moderate pain, swelling, ecchymosis. Moderate functional compromise. Loss of motor function, mild to moderate mechanical instability. Some stretching of joint with stress, but with stopping point. 

-Grade III: complete tear. Severe pain, swelling, ecchymosis, functional compromise. Inability to bear weight, mechanical instability. Stretching of joint with no stopping point. 

10. When to x-ray? The Ottowa ankle rules: 

Weight bearing=able to walk 4 steps unsupported. 

1. National education programs risk assessment tool for 10 year risk of MI (from framingham heart study data). 
High risk: >20%, start baby aspirin, get LDL<70-100, consider stress test
Intermediate risk: 10-20%, get high specificity CRP levels or electron-beam CT for coronary calcium to further stratify into high vs low risk.
Low risk:<10%
2. Various USPSTF recommendations:
-One time abdominal u/s to look at aorta in males age 65-75 with a history of smoking. 2005, (B)
-One or two small polyps found with tubular adenoma with low grade dysplasia: next screening colonoscopy in 5-19 years
3. CBT for primary insomnia in older adults:
-Sleep restriction: restrict sleep to actual number of hours patient has slept in past 2 weeks, gradually increase time in bed to optimal (15-20 minute increments every 5 days)
-Sleep compression: gradually decrease time spent in bed to total sleep times.
-Evidence for effectiveness; more effective when combined with pharmacotherapy (Zolpidem, avoid benzos and antihistamines in elderly)
4. Sleep hygiene handout
5. Organic depression:
-Dementia
-Endocrine: cushings, hypothyroid, addisons, diabetes, hypoglycemia, hyperparathyroid
-Rheum: lupus, RA, temporal arteritis
-CNS pathology: tumor, parkinsons, MS, stroke, cerebral arteriolosclerosis, temporal lobe epilepsy.-Cardiovascular: CHF, MI
-Liver pathology (hepatitis)
-Renal failure
-Electrolyte abnormalities
-Infectious: AIDS, syphilis
-Cancer, esp pancreas
-Micronutrient deficiencies: folate, B12, thiamine
-Porphyria
6. Mini-cog mental exam is faster, more sensitive and specific than MMSE. 
Mini-cog: repeat 3 words (apple, watch, penny)
Clock face drawing (45 min past 10)
Recall the 3 words
7. SSRI for depression with anxiety component: 
-Paxil has strong antianxiety effects, but worse SSRI discontinuation syndrome. It (and prozac) are most studied in children, it may cause significant weight gain.
-Escitalopram (lexapro) is approved for GAD, and is a "neutral" SSRI
8. Medications linked to (causing) depression:

Cardiovascular drugs	Clonidine (Catapres) Digitalis Guanethidine (Ismelin) Hydralazine (Apresoline) Methyldopa (Aldomet) Procainamide (Pronestyl) Propranolol (Inderal) Reserpine (Serpasil) Thiazide diuretics
Chemotherapeutics	6-Azauridine Asparaginase (Elspar) Azathioprine (Imuran) Bleomycin (Blenoxane) Cisplatin (Platinol) Cyclophosphamide (Cytoxan) Doxorubicin (Adriamycin) Mithramycin (Mithracin) Vinblastine (Velban) Vincristine
Antiparkinsonian drugs	Amantadine (Symmetrel) Bromocriptine (Parlodel) Levodopa (Larodopa)
Antipsychotic drugs	Fluphenazine (Prolixin) Haloperidol (Haldol)
Sedatives and antianxiety drugs	Barbiturates Benzodiazepines Chloral hydrate Ethanol
Anticonvulsants	Carbamazepine (Tegretol) Ethosuximide (Zarontin) Phenobarbital Phenytoin (Dilantin) Primidone (Mysoline)
Anti-inflammatory/anti-infective agents	Ampicillin Cycloserine (Seromycin) Dapsone Ethambutol (Myambutol) Griseofulvin (Grisactin) Isoniazid (INH) Metoclopramide (Reglan) Metronidazole (Flagyl) Nalidixic acid (NegGram) Nitrofurantoin (Furadantin) Nonsteroidal anti-inflammatory agents Penicillin G procaine Streptomycin Sulfonamides Tetracycline
Stimulants	Amphetamines (withdrawal) Caffeine Cocaine (withdrawal) Methylphenidate (Ritalin)
Hormones	Adrenocorticotropin Anabolic steroids Glucocorticoids Oral contraceptives
Other drugs	Choline Cimetidine (Tagamet) Disulfiram (Antabuse) Lecithin Methysergide (Sansert) Phenylephrine (Neo-Synephrine) Physostigmine (Antilirium) Ranitidine (Zantac)

9. Depression handout
10. Testing for gonorrhea-- NAAT/PCR on vaginal swab in women (more sensitive than urine). In men, urethral swab and urine test have same (high) sensitivity.

1. Differential for solitary ring-enhancing brain lesion on neuroimaging: MAGIC DR
-Mets
-Abscess
-Glioma/GBM
-Ischemia (subacute)
-Contusion
-Demyelinating
-Radiation necrosis
{video}
2. Neuroimaging findings of MS: 
-Dawson's fingers (hyperintense lesions in corona radiata),
-open ring sign (half circle, with the white matter half hyperintense and grey matter half hypointense)
3. Spinal cord ependymomas
-50% in c-spine, 25% c-t junction, 25% thoracic spine
-Arise from ependymal cells in central canal
-Frequently accompanied by syrinxes, hemosiderin cap from bleeding
-Hyperintense T2, iso/hypointense T1,
{video} {another video of lumbar MRI}
4. New guidelines for hyperlipidemia: no longer aiming for LDL cutoffs. Instead, there are 4 groups that should get statins:
-People with clinical atherosclerotic cardiovascular disease. => high intensity statin for goal of >50% reduction in LDL
-People with LDL >190 mg/dL (i.e. familial hypercholesterolemia) => high intensity statin for goal of >50% reduction
-People 40-75 years old, no evidence of atherosclerotic cardiovascular disease, who have diabetes and LDL between 70 and 189 mg/dL. => moderate intensity statin, for goal of 30-49% reduction
-People without evidence of cardiovascular disease or diabetes, but who have LDL between 70 and 189 mg/dL and a 10-year risk of atherosclerotic cardiovascular disease>7.5%. => moderate intensity statin, for goal of 30-49% reduction
{circulation} {medscape}
5. Statins:
-High intensity (shown to lower LDL >50%): Atorvastatin 80mg, Rosuvastatin 20-40mg,
-Moderate intensity (shown to lower LDL on avg 30-49%): Atorvastatin 10-20mg, Rosuvastatin 10mg, Simvastatin 20-40, Pravastatin 40,
-Low intensity (lowers LDL on avg <30%): Simvastatin 10mg, pravastatin 10-20, lovastatin 20

6. New hypertension guidelines (JNC 8/NHLBI) {JAMA} {AAFP summary} 

-Over 60: meds to lower BP below systolic 150 or diastolic 90 

-Under 60: meds to lower BP below systolic 140 or diastolic 90

-Over 18 with DM or CKD: meds to lower BP below systolic 140 or diastolic 90

-Non-black (+/- DM): start with thiazide diuretic, CCB, ARB/ACEI 

-Black (+/- DM): start with thiazide, CCB

-Over 18 with CKD & hypertension (+/- DM): should be on ARB/ACEI to protect kidneys

-Do not do both ARB and ACEI at same time. 

7. Do not aggressively treat older people with antihypertensives as it can lead to orthostatic hypotension, syncope, falls. 

8. Diabetes diagnosis & Screening: 

-Fasting glucose > 126 or random glucose > 200 

-Hb A1C > 6.5 (controversial, some say you need 2) 

Screening for: 

-Everyone over 45 years old

-Any age if they have a sustained BP > 135/80

-Any age if they are overweight & have 1+ risk factors (BP > 140/90, 1st degree relative with DM, HDL<35, triglyceride >250) 

9. Diabetes management:

-Microvascular complications (retinopathy, kidneys): manage hypertension, glycemia

-Macrovascular complications (PAD, CAD, cerebrovascular): manage lipids, BP, quit smoking

-Metabolic & neurovascular: manage glycemia

-First line is metformin

10. OTC antihistamine eye drops: {source}

-Pheniramine: rebound hyperemia & chemosis

-Ketotifen: less of the above

1. Competence to stand trial (all four required):
-Understand charges against them
-Able to work with lawyer
-Understand consequences on their life/values of the different outcomes
-Able to testify.
2. Not guilty by reason of  insanity criteria
-have mental illness
-not understand right from wrong
-not understand consequences of actions
at the time of action.
Then must meet one of the following criteria (depending on state): M'Naghten, American Law Institute Moral Penal Code
3. WBC & psychotropic drugs:
-Lithium: benign leukopenia
-Depakote: benign thrombocytopenia, agranulocytosis (rare)
-Carbamazepine: agranulocytosis
-All anti-psychotics: tranisent drop in leukopoesis, more common in clozapine
4. Schizotypal personality disorder: 
-Hallucinations rare
-May be confused with schizophrenia in remission
-Treat concomitant psychotic, mood, or anxiety symptoms with neuroleptics, SSRIs, and benzos respectively; these people do not have the insight and focus to benefit from therapy, esp if floridly psychotic.
-Vs paranoid personality disorder: both can have paranoia, withdrawal from people; however schizotypal's paranoias are a little more "magical" and odd, while paranoid personality disorders' suspicions are more grounded in reality.
5. Physiologic effects of alcoholism:
-Peripheral neuropathy (dietary micronutrient deficiencies, passing out drunk in bad positions)
-Decreased hematopoesis (thrombocytopenia, macrocytic anemia)
-Leukopenia/compromised T cell function
-Hepatitis/Cirrhosis (follow LFTs initially, PT-INR later)
6. Good tests to assess for delirium-- go-no-go and 1A2B.... counting, as they require high frontal lobe functioning.
7. Benzodiazepines can worsen lung function in those with chronic severe pulmonary disease.
8. Management of alcohol withdrawal:
-Good liver function: long-acting benzodiazepams, like cholordiazepoxide (librium) and diazepam (valium)
-Poor liver function, old person: shorter-acting benzos, like lorazepam, oxazepam
9. Panic attacks rarely lead to syncope- if a person is describing a panic attack like event and they syncopized, cardiovascular pathology is more likely and should be worked up.
10. Drug detox: 
-For opiate detox, try clonidine before methadone
-In suspected sedative overdose, give thiamine, dextrose, naloxone but not flumazenil unless you are sure they took benzodiazepines, as it can hypothetically decrease the seizure threshold.

1. Haldol is a good drug for delirium in older people because it has the least anticholinergic, least orthostatic hypotension, less QT-prolonging effect (at least when given IM or PO) than many other antipsychotics.
2. Pimozide causes bad QT-prolongation, as does IV haldol, clozapine, ziprasidone.
3. Mood stabilization & pregnancy: 
-Clonazepam is a mood stabilizer that doesn't have any teratogenic effects.
-Monitor lithium closely around the time of birth, given fluid shifts.
4. Things that increase lithium levels in the blood:
-Thiazide diuretics
-K sparing diuretics
-Dehydration
-Anything that compromises renal function: NSAIDs, ACE-I
-Metronidazole, tetracycline
5. Equivalent doses of benzodiazepines: 25mg librium = 5 mg valium/diazepam = 1 mg ativan/lorazepam
-Avoid benzos for sleep in someone with a history of alcoholism
6. Risperidone: 
-Less anticholinergic effects, more extrapyramidal effects
-Worst galactorrhea
-Good for negative symptoms
-Comes in a long acting depot injection, as does haldol, but has better side effect profile.
7. Treating the side effects of antipsychotics:
-Dystonia: benadryl, benztropine
-Akathesia: benzos, propanolol
-Bradykinesia/parkinsonism: amantadine, benztropine
-TD: clozapine
8. Treating the side effects of clozapine: 
-Sialorrhea: PTU (anticholinergic)
-Orthostatic hypotension and tachycardia (from significant alpha-blockage): selective b-blockers (a and b blockers like labetalol will exacerbate the problem)
9. Lamotrigine is very good for treating bipolar depression, and it's a good drug to use in people who have depression and a strong family history of bipolar disease.
10. Venlafaxine causes clinically significant increases in resting diastolic BP

1. Mature defense mechanisms: healthy and adaptive, seen in normal adults: 
-Altruism
-Humor
-Sublimation: channels impulses into productive tasks (taking out aggression in exercise)
-Suppression: put aside feelings temporarily to achieve a task.
2. Neurotic defense mechanisms: seen in OCD, hysteria, adults under stress. 
-Displacement: transferring negative emotions to someone else (someone upsets you, you take out your anger on someone else)
-Controlling: controlling events/situation around you to relieve anxiety
-Intellectualization: hide from the truth by burying yourself in facts/data, focusing on irrelevant details or inanimate objects.
-Rationalization
-Isolation of affect: unconsciously limiting feelings/distancing yourself from the event-- i.e. talking about a stressful event without emotion.
-Reaction formation: outwardly doing the opposite of what you actually feel-- i.e. insulting someone you're in love with, outwardly hating something that you think you are.
-Repression: relegating a feeling to the unconscious (suppression is a conscious act, repression is unconscious)
-Splitting
3. Immature defense mechansisms: used by children, adolescents, and psychotic people.
-Acting out-- throwing a tantrum, giving in to impulses
-Denial
-Regression-- regressing to a childish state
-Projection-- attributing your own unacceptable thoughts to others.
4. Psychoanalysis: bringing repressed thoughts and feelings to the surface. Freudian, patient on the couch with therapist out of view, "tell me about your mother". Sessions occur 4-5x a week for years. Techniques:
-Free association: patients says whatever comes to mind, to bring thoughts from unconscious
-Dream interpretation: dreams represent conflict between urges and fears.
-Transference: projection of unconscious feelings about important figures in your life onto the therapist, to interpret findings.
-Countertransference: therapist projects onto patient, must be wary of this.
5. Variants of psychoanalysis:
-Psychoanalytically oriented psychotherapy/brief dynamic psychotherapy: same as psychotherapy, but shorter, weekly sessions from 6-18 mos, face-to-face.
-Interpersonal therapy: work on developing social skills, weekly sessions for 3-6 months.
-Supportive psychotherapy: help patient feel better during a hard time, treatment focuses on empathy and understanding, builds up healthy defenses, dependency encouraged.
6. Behavioral therapy: treat psych illnesses by changing maladaptive behaviors and replacing them with better habits. Grounded in conditioning and deconditioning.
-Classical conditioning: stimulus can evoke a conditioned response (pavlov's dog)
-Operant conditioning: behaviors enforced with positive or negative reinforcement- pressing a lever for food.
-Systematic desensitization: slowly exposed to a increasing amounts of anxiety provoking stimulus with relaxation techniques
-Flooding and implosion: immediately fully exposed to anxiety provoking stimulus (flooding) or imagining being exposed to anxiety provoking stimulus (implosion) while teaching relaxation techniques and not allowing the patient to retreat. I.e making them get on a plane and not letting them off.
-Aversion therapy: pair addiction with negative stimulus
-Token economy: rewards for specific behaviors (i.e. showering for mentally retarded individuals)
-Biofeedback: giving patient feedback about HR and BP to facilitate patient control of VS; commonly used to treat migraines, chronic pain.
7. Cognitive therapy: used to correct faulty assumptions, destructive/maladaptive thought patterns. Used to treat anxiety and mood disorders. Can also be used for paranoid personality disorder, OCD, somatoform disorders, eating disorders.
8. Group therapy: 
-Can use any type of therapy. Can be done without a leader.
-Good for substance abuse, adjustment disorders, personality disorders.
9. Excessive daytime sleepiness vs fatigue: EDS involves falling asleep when you don't want to (while driving, etc), fatigue is being too tired to complete activities. EDS is common with OSA, narcolepsy
10. Competence and capacity: competence is a legal term that can only be used by a judge, capacity is a clinical diagnosis made by physicians. Decisional capacity is task specific-- someone may have it for one decision, but not for another.
Assessment of capacity: (patient must fulfill a 4 criteria)
-Can clearly and logically communicate their thoughts/wishes
-Understand the situation/intervention, indication, benefits, costs, alternatives, and can explain them back to you
-Understand the ramifications of the action/inaction on their life, their values.
-Can logically manipulate information and reach logical conclusions.

1. Enuresis:
-Continence usually develops by age 4.
-Subtypes: primary (never developed continence), secondary (learned continence and then lost it, usu between 5-8 years of age), nocturnal, diurnal
-DSM: >2 episodes of enuresis a week for at least 3 months in a child >5 years old.
-Tx: behavioral changes (alarm, no water 3 hours before bed, reward system for continence), DDAVP, imipramine
-DDx: diabetes, seizures, urethritis, small bladder.
-Encopresis: stool incontinence, >1 episode a month for 3 months in a child >5 years old. DDx: constipation with overflow, psychosocial stress, fissures/IBD.
2. Amnestic disorders
-Amnesia due to a medical condition= amnestic disorders. (Amnesia due to a psychological disorder= dissociative disorder)
-Differential:
-CNS pathology (herpes encephalitis, seizures, MS, space-occupying lesion, stroke)
-Head trauma
-Metabolic (hypoglycemia, CNS hypoxia, thiamine deficiency/wernicke-korsakoff)
-Substances: sedatives, alcohol.
3. Dissociative disorders: 
-Loss of memory, identity, sense of self 2/2 psychological trauma.
-Dissociative amnesia: patient temporarily and abruptly forgets who they are, but can remember other obscure facts, resolves after minutes or days. No other disassociative symptoms, usually aware of the memory deficit but not troubled by it. Treat by helping them retrieve memories, possibly with benzos under hypnosis.
-Dissociative fugue: patient abruptly leaves home and cannot remember their past; many assume a new identity. Predisposing factors: history of heavy alcohol use, seizures, head trauma, major depression; onset with stressful life event. Disease lasts hours to years, patients will sometimes go back to old life with no memory of the fugue.
-Dissociative identity disorder (multiple personality disorder): patient has 2+ personalities, which recurrently take control. Each personality is usually unaware of the personal information of the other. >90% female, usually history of childhood abuse, avg age of diagnosis 30 years, comorbid mood disorders and borderline personality. Treat with insight therapy, drug-assisted interview, drugs for comorbidities.
-Depersonaliziation disorder: recurrent feelings of detachment from self/environment, "out of body" experiences. People panic, feel they are going crazy, become anxious or depressed. Treat the anxiety/depression.
4. Somatization disorder:
-At least 4 pain symptoms, 2 GI symptoms, 1 neurological symptom, 1 sexual/reproductive symptom, plus onset before age 30.
-5-20x higher incidence in women
-30% concordance in identical twins, 10-20% concordance in female first degree relatives
-Increased incidence in lower SES
-Screen for other psych illnesses, commonly have comorbid anxiety/mood/personality disorders
-Tx: regular visits with PCP, since these people usually unwilling to see a psychiatrist. Medications rarely help, as they are consumed erratically.
5. Conversion disorder:
-One neurological symptom, non-pain/non-sexual. Common symptoms: blindness, shifting paralysis, mutism, paresthesias, seizures, globus hystericus (sensation of lump in throat)
-Symptom onset or exacerbation associated with psychological event.
-Patient is unconcerned-- la belle indifference
-Symptoms usually resolve in 1 month, although 25% of people will experience recurrence.
6. Other somatoform disorders:
-Hypochondriasis: >6 months of fear of serious medical condition, persists despite medical evaluation. 80% comorbid anxiety/depression
-Body dysmorphic disorder (with DSM-V now spectrum of OCD). 90% comorbid MDD, 70% comorbid anxiety, 30% comorbid psychotic. SSRIs reduce symptoms in 50% of patients.
-Pain disorder: prolonged severe pain, treat with SSRIs, transient nerve stimulation, biofeedback, hyponsis, psychotherapy.
-Factitious disorder/munchausen's syndrome: making up symptoms to play the sick role
-Malingering: making up symptoms for secondary gain (disability, a place to stay, narcotics)
7. Impulse control disorders: anxiety prior to impulse, relief on satisfaction, unable to resist impulse.
-Intermittent Explosive disorder: short bursts of aggressive behavior resulting in assault or property destruction, followed by remorse, treat with SSRIs, anticonvulsants, lithium, propanolol. Individual therapy doesn't work, group/family is better.
-Keptomania: unable to resist urge to steal, pleasure/relief assoc with stealing, occurs in <5% of shoplifters. Treat with insight-oriented psychotherapy, behavior therapy (aversive condition, systematic desensitization), SSRIs, naltrexone.
-Pyromania: >1 episode of intentional fire setting, more common in men and mentally retarded, kids recover adults don't. Treat with behavior therapy and SSRIs.
-Pathological gambling: predisposing factors- loss of parent during childhood, inappropriate parental discipline during childhood, ADHD. Treat with gamblers anonymous for 3 months, then insight-oriented psychotherapy.
-Trichotillomania: occurs usually during childhood/adolesence after stressful event, comorbid OCD, OCPD, borderline personalty. Treat with SSRIs, lithium, antipsychotics, hypnosis/relaxation, behavior therapy-- substitute another behavior for the hair pulling habit.
8. Eating disorder:
-Anorexia nervosa: BMI >15% below normal. Can be restrictive or binge/purge. Hospitalize when they are >20% below ideal body weight, or have bradycardia/electrolyte abnormalities. Treat with behavioral therapy, family therapy, weight-gaining antidepressants (mirtazapine, paroxetine)
-Bullemia: BMI normal or above normal, binge/purge occuring at least twice a week for 3 months. 50% recover fully, 50% chronic course with fluctuating symptoms. Treat with SSRIs.
-Binge eating: bingeing occurs at least 2 days a week for 6 months, no compensatory attempt to lose weight. Tx with psychotherapy and a diet/exercise program, as well as weight-loss drugs: stimulants, orlistat (inhibits panc lipase).
9. Dyssomnias: disturbances in amount/quality/timing of sleep
-Primary insomnia: difficulty initiating or maintaining sleep >3x/week for at least 1 month. Treat with sleep hygiene, short-term use of zolpidem/ambien, benadryl, zaleplon/sonata, trazodone
-Primary hypersomnia: excessive sleep, usually begins in adolescence. Treat with stimulants; SSRIs in others.
-Narcolepsy: repeated sudden daytime sleep attacks for at least 3 months, accompanied with cataplexy (70% of patients- collapse 2/2 sudden loss of muscle tone, associated with emotion), sleep paralysis upon awakening (50% of patients, resolves quickly) hypnagogic/hypnopompic hallucinations (30% of patients). Treat with timed daily naps plus stimulants (amphetamines or methyphenidate, SSRIs.
-OSA: treat with CPAP, central sleep apnea: treat with mechanical ventilation
-Melatonin for circadian rhythm disruptions: take 5.5 hours before bedtime.
10. Parasomnias: abnormal events during sleep
-Nightmare disorder: waking up with nightmares, usually in kids, worse in times of stress/illness, treat with tricyclics or other drugs that suppress REM
-Night terror: terror/fear during sleep, usually occur during first third of the night during stage 3 or 4 NREM sleep. Patients are not awake, do not remember the episodes, comorbid with sleepwalking, runs in families Tx with small dose of diazepam at bedtime.
-Sleepwalking: same as night terror.

1. Depression (pseudodementia) vs true dementia: 
-Depression is more acute onset, dysphoria, people emphasize failures, says "I don't know" when you ask them hard questions but when you press they often give the right answer, no sundowning, good insight
-True dementia is insidious onset, people "delight in accomplishments", confabulates (makes things up when they don't know), sundowning often present (confusion worse at night), poor insight.
2. Normal grief vs abnormal grief: 
-Normal grief: milder symptoms, minor illusions, no suicidal ideation, worst symptoms <2 mos, all symptoms <1 year
-Abnormal grief: severe, incapacitating symptoms (sleep, functionality, severe guilt'worthlessness), significant hallucinations, +Suicidal ideation, worst symptoms >2 mos, all symptoms >1 year
3. Insomnia in older person: 
-DDx: primary insomnia, medical/psych condition, behavioral problems: alcohol drinking, daytime naps, poor sleep hygiene.
-Tx: avoid benzos, use hydroxyzine (vistaril) or zolpidem (ambien). behavior modification first, better sleep hygiene, don't drink alcohol.
4. Conduct disorder:
-DSM criteria: >1 year of at least 3 acts of: aggression/violence towards people, animals, or things; stealing/lying; serious violations of rules
-Prevalence: 6-16% boys, 2-9% of girls
-40% risk of developing antisocial personality disorder as an adult
-Tx: disciplined environments with regularly enforced rules, behavior modification therapy, lithium/antipsychotics (for aggression),  and SSRIs for impulsivity, mood lability, irritability
5. Oppositional defiant disorder: 
-DSM criteria: >6 months of 4 of the following: displays of frequent loss of temper, arguments with adults, spitefulness, blaming others for things, defying rules, deliberately annoying others, being easily annoyed, harboring anger and resentment,
-Prevalence: 16 to 22% of children >6
-25% remission
-Tx: psychotherapy
6. ADHD:
-Triad of inattention, hyperactivity, impulsivity
-DSM: at least 6 symptoms of inattention, hyperactivity, or both, persisting for >6 months, onset before the age of 7 years
-Inattention: problems listening, completing tasks, loses things, easily distracted, forgetful
-Hyperactivity: problems sitting still, blurting out/interrupting, talking too much
-20% persist into adulthood
-most common comorbidities - ODD in boys, anxiety in girls
-Tx: Ritalin (methylphenidate), Concerta (methylphenidate extended release), Focalin (dexmethylphenidate-- the dextrorotary enantiomer), Adderall (dextroamphetamine/levoamphetamine),
-non stim tx: Strattera (atomoxetine) -not covered by Medicaid, Wellbutrin (norepinephrine helps w focus), tenex (clonidine and guanfacine)
-Theory of pathophysiology- mutation of dopamine R in prefrontal cortex, either increased reuptake or decreased excretion: "Placebo-controlled study examining effects of selegiline in children with attention-deficit/hyperactivity disorder."
7. Autism:
-DSM: at least 6 symptoms from the following three categories: at least 2 problems with social interaction (eye contact, empathy, interest in relationships, etc), at least 1 problem with communication (language development, grammar, vocabulary, repetitive language), at least 1 problem with stereotypy (stereotyped or repetitive movements, inflexible rituals).
-Usually begins before age 3
-Comorbid with tuberous sclerosis, fragile X, mental retardation, seizures
-36% concordance in monozygotic twins
-Tx: remedial education/behavioral therapy; antipsychotics for aggression/lability, SSRIs for stereotyped movements/language
8. Asperger's
-DSM: at least two symptoms of impaired social interaction (empathy, desire for relationships, impaired nonverbal behaviors-- expressions/gestures), at least 1 symptom of stereotypy (inflexible rituals, obsessions, repetitive movements)
9. Other childhood pervasive disorders:
-Rett's disorder- MECP2 gene on X chromosome. Only affects girls, normal development til 5 months, then decreasing head circumference, loss of hand skills (replaced by sterotyped hand movements), loss of social interaction, problems with gait/trunk movements, severely impaired language and psychomotor development (development never progresses beyond 1st year of life), seizures, cyanotic spells. Onset 5-48 months.
-Childhood disintegrative disorder: normal development in first 2 years, then loss of milestones in two of the following: language, social skills, bowel/bladder, motor skills, play.
10. Tic disorders: 
-Motor and verbal = tourette's. Motor or verbal only = motor or verbal tic disorder respectively.
-DSM for Tourettes: motor and verbal tics multiple times a day, every day for >1 year, with no tic-free period >3 months, onset before 18 years of age.
-Tx: haldol, pimozide, clondine, risperiodone

1. Panic disorder: 
-recurrent panic attack with no trigger plus >1 month worrying about having another panic attack
-associated with major depression > substance use > phobias > OCD.
-paroxetine and sertraline first line
-with agoraphobia: fear/avoidance of places where it would be bad to have a panic attack (crowded, no escape, no help) sometimes so bad that people wont leave their house
2. Paxil is FDA approved for social anxiety disorder
3. There is a genetic concordance between tourettes' and OCD
4. Four most common mental illnesses: phobias > substance abuse > major depression > OCD.
5. GAD: lifetime prevalence 45%
-excessive worry for 6 mos, plus 3 of the following
-Restlessness
-Fatigue
-Difficulty concentration
-Difficulty sleeping
-Irritability
-Muscle tension
6. Substances
-abuse: using it >1 year + any negative consequences (job, legal, relationships).
-dependence: using it > 1 year + tolerance/withdrawal + multiple negative consequences
7. Alcohol: 
-management of acute alcohol intoxication: thiamine, D50, nalxone
-wernicke: ataxia, altered mental status, nystagmus/gaze palsies
-korsakoff: anterograde and retrograde amnesia, confabulation
8. Differential for delirium:
-Alcohol
-Electrolytes
-Iatrogenic (all analgesics, benzos, anticholinergics, antiepileptics, steroids, BP meds, H2 blockers, antibiotics, parkinsons drugs)
-Oxygen - hypoxia
-Uremia/Ammonia
-Trauma
-Infection
-Poison
-Seizure (postictal)
9. Dementia vs delirium: 
-Dementia patients just have bad memories/cognition-- they are not altered mentally, they know what's happening, they are often A&O. It's slow onset, gradual fall, lose both recent and distant memory.
-Delirium patients have altered mental status, hallucinate, are not A&O, have no idea what's going on. Their course is rapid onset, waxing and waning, lose recent memory but retain distant memory.
10. Alzheimer's disease & vascular dementia
-Same DSM criteria: Memory slowing plus one of the following:
-Aphasia (loss of language-- incl speech and understanding)
-Apraxia (loss of ability to make purposeful movement)
-Agnosia (cannot interpret senses-- i.e. visual- can't recognize an object)
-Loss of executive function
It can also be accompanied by personality changes-- depression, anxiety, paranoia, agitation.
Vascular dementia is faster onset, stepwise progression, focal neurological findings, less loss of personality

1. SNRIs: 
-Desvenlafaxine (pristiq)

-Milnasaprine (sevena) - fda approved for fibromyalgia 

-Levomilnasaprine- FDA approved for depression 

-Venlafaxine (effexor) - causes clinically significant hypertension, better sexual side effects, worse somatic side ffects
-Duloxetine (cymbalta)- 60 cases of fulminant hepatic failure reported. Good for concomitant pain. 

2. Atypical antidepressants: Bupropion 
-dopamine and norepinephrine.

-Extended release formulas have much lower risk of seizures. In first trials for bullemia, 20% of the first 50 patients seized. 

-Can worsen anxiety in some people, esp those who are sensitive to caffeine. Some psychiatrists will not prescribe this in people who have depression with a significant anxiety component. 

-Does not cause sexual side effects. 

-Good for amotivational depression, seasonal affective disorder. 

3. Atypical antidepressants: Trazodone

-very sedating;  at low doses, hypnotic with no addiction. good as an add-on to treat depression-associated insomnia 

-Does not restore sleep architecture. 

4. Atypical antidepressants: Mirtazapine:
-restores sleep architecture so you get good restorative sleep (z-drugs and trazodone do not). 

-Potent antihistamine; the sedation and weight gain are significant. 

-Can cause leukopenia.
-More sedating at lower doses (~15) Less sedating at higher doses (>30), may be due to increased a2-antagonism at higher doses leading to norepi release  

5. Other strange antidepressants: 
-Nefazodone: black box warning for hepatic failure
-Velazadone (viibryd): has SSRI action and partial agonism of 5HT-1A, similar to buspar 

-Vortioxetine: also SSRI + 5HT-1A 

6. Stimulants: 

-worsen anxiety.
-contraindicated in structural heart dx.
-Work extremely will, if you fail one, 50% chance you'll respond to the other
-Monitor weight and height in kids.
-Prob do not cause heart problems
-Dexedrine - diet pill in 60s/70s
-Only sometimes exacerbate tic disorders, will sometimes bring out new ones 

7. Benzo: Clonazepam (klonopin)

-long half life (24 hrs) slow onset 

-good for long term treatment of panic disorders, short term treatment of anxiety (<2-3 mos; longer: choose SSRI)

8. Benzo: Diazepam (valium)

-Long half life (100 hrs 2/2 active metabolite oxazepam), rapid onset

-Good for alcohol detox: drops symptoms quickly, stays around to self wean

9. Benzo: Lorazepam (ativan)

-Medium half life (8-12 hrs), onset in ~30 minutes. 

-Good for panic attacks, short-term anxiety management, alcohol withdrawal. 

-Ativan + haldol: great combo for dealing with people going crazy in the ER

10. Benzo: Alprazolam (xanax)

-Short half life (3-4 hrs), very fast onset. 

-Addictive

-Highest street value 

1. SSRI: Fluoxetine 
-Perhaps more effective
-Worse for inducing mania

-One of the least selective SRI 

-4-7 day half life, no wean necessary
-More stimulating SSRI 

2. SSRI: Paroxetine 
-Most anticholinergic effects.
-Worst w/d 2/2 shortest half life.
-Increases risk of suicide in kids 

-Sedating
-Least likely to increase levels of carbamazepine 

3. SSRI: Sertraline: 

-Some dopamine effects?

-Doesn't have interactions, great for complex patients on a lot of meds. 

-Probably less effective. 

4. SSRI: Fluvoxamine 

-used less because it really hits cyp3A4, interacts with everything

5. SSRI: Escitalopram/Citalopram 

-Escitalopram: most selective SSRI 

-Citalopram: only 30% get better (STAR*D trial) 

6. SSRI side effects

-Sexual (impotence, low libido, anorgasmia)

-Diarrhea (initially only)

-Makes people tired

-Headaches 

-Constriction in range of emotion-- good for impulsive patients, less range of emotions so people seek out highs less

7. Serotonin syndrome:

-Autonomic changes

-Rigidity

-Diarrhea, flushing

-Myoclonic jerks (unique to SS, differs it from NMS)

8. TCA side effects:

-"HAM": antihistamine (sedating), anti-adrenergic (orthostatic hypotension- CI in people with bleeding risk), antimuscarinic (dry mouth, constipation, blurry vision) 

-Cardiotox: Inverts T waves, QRS widening (>100ms => TCA tox), can lead to torsades, can prolong QT

-Has all the side effects of SSRIs
-Weight gain
-nortriptyline has less orthostatic hypotension than some of the others.
-nortriptyline, desipramine act more on norepi
-imipramine, clomipramine act more on serotonin; (clomipramine has sexual side effects like an SSRI)
-amitriptyline is more balanced. 

9. TCA uses: 
-somatic pain, migraines, enuresis. OCD (clomipramine)
-not effective in treating depression in children, worse than placebo

10. MAOI 
-uses: better for atypical depression (i.e those who sleep and eat more, hypersensitive to rejection).
-orthostatic hypotension
-serotonin syndrome (combined with meperidine/demerol, linezolid)
-tyramine induced hypertensive crisis
-CI in pregnancy as it can worsen pregnancy-induced hypertension
-Need 2 week washout after d/c before starting another drug that increases serotonin levels to prevent serotonin syndrome 

1. Dementia w Lewy bodies can present like schizophrenia with hallucinations and flat affect, don't use haldol, use seroquel
2. Frontotemporal dementia: can present as dis-inhibition or as social withdrawal
3. Depression in the context of Alzheimer's:
-Sertraline 25, go to 50 in a week. GI side effects
-Citalopram well tolerated.
-SIADH as a side effect of SSRI more likely to occur in old people
4. Anxiety in the context of Alzheimer's: 
-NO BENZOS, avoid at all costs.
-Risperidone or seroquel (nice sedating effect, help them sleep)
5. Insomnia in the context of Alzheimer's:
-Trazodone: does not maintain sleep architecture.
-Seroquel
-Mirtazapine: maintains sleep architecture, grants refreshing sleep, increases appetite.
6. Diagnosing PTSD: 4 clusters of symptoms
-Reliving the experience (flashbacks, nightmares)
-Avoidance of things that remind of the experience
-Hyperarousal (hypersensitive to sound, light)
-Affect changes (irritability, etc)
-Sx can occur at any time after trauma, must last >4 weeks.
7. Schizotypy: 
-Impaired smooth pursuit (reflects problems with working memory): correlates with negative symptoms
-Negative symptoms correlate with brain mass loss
-General defects with auditory and tactile perception
-Defect of forming safe "personal space" in their head-- they feel like people who get close can invade into the deepest parts of them.
-Worsen with NMDA antagonists and D agonists.
8. Criteria for personality disorder: 2 or more of the following categories are compromised:
-Cognition (delusions, paranoia)
-Mood/affect
-Interpersonal relationships
-Impulsivity
9. Units of measure of alcohol (approx)
-Pint: 375 mL
-Fifth: 750 mL
-Handle: 1.75 L
10. Amount of alcohol in mouthwash: 0-27%. 

1. Lithium side effects: 
-25%-100% chance of getting hypothyroidism after taking it for 10 years, but not worrisome because you can just give synthroid. In fact, this is even better because it drops TSH and depressed people with TSH < 1 have fewer depressive sx.
-Mechanism of action is via gpcr, tsh, also iodine competition.

-10% get renal insufficiency at 10 years. 

-Tremor can develop with therapeutic doses, but worsens with higher levels.

-Nephrogenic DI: via effects on vasopressin. 

-3 labs you get for someone on lithium- Cr, TSH, Li levels. 

2. Lithium & pregnancy: 

-Li levels can vary a lot in pregnancy because of relatively rapid changes in total body water content 

-Corticosteroids given to accelerate fetal lung development can worsen psychosis (mania and depression)

-Risk of ebstein's anomaly and ASD are highest in first trimester; after that point, it can cause transient neonatal hypothyroid and goiter. 

-Absolute risk of ebstein's anomaly is very, very low
-Watch out for pre-eclampsia, because if you tank someone's kidneys they won't be able to clear the lithium and it can quickly accumulate to toxic levels 

3. Lithium Toxicity: get an EKG, Cr, Li level. 

-Tremor (correlates with level) 

-Altered mental status

-Diarrhea

-Kidneys can shut down-- problematic because lithium is 90% renally cleared (10% gi tract). 

-2nd/3rd deg heart block. Immediately check EKG in someone with suspected Li tox. 

-Levels normally 0.8 to 1.2. Toxicity can start at 1.5. 

-If its mildly toxic you give fluids, if its bad you have to dialyze. 

-Li levels remain higher, longer in the brain than elsewhere in the body so it takes longer to get over those effects. 

-Most common reason for lithium tox is inadvertent dehydration, causing mild renal impairment, or the addition of new meds-- NSAIDs and diuretics. 

4. Suicide risk is lower with people who take lithium, compared with other drugs. 

5. Valproate: 

-sedating

-a/symptomatic transaminitis

-elevated ammonia (can happen out of the blue even if you have been taking this drug for a long time) 

-pancreatitis. 

-Risk of birth defects is 10-15%. This drug is contraindicated in women of childbearing age who are not on a reliable birth control. Period, fullstop. 

6. Carbamazepine: 

-autoinducer, induces own destruction so the levels will drop over time. 

-Causes direct BM suppression

-Hepatotox

-Rash 

-Can cause ataxia, blurred vision, 

-Treats bipolar, trigeminal neuralgia, migraines. 

7. Lamotrigine 

-Works really well for depressed stage of bipolar, doesn't induce mania

-10% will get a rash, 1% of those people will get SJS. Rash risk proportional to rate of drug increase, so titrate 25mg slowly to 200. 

-First signs of SJS will be in mucosa, hands, feet; tell your patients to watch out for blisters in their mouth. 

8. Augmentation strategies for depression: 

-Lithium

-Abilify

-Synthroid 

-Stimulants (addictive; use only in refractory depression, or in terminal patients)

9. Risk factors for worsening QT prolongation: 

-Low K

-Low Mg

-Low Ca

-Replenish electrolytes aggressively in people taking meds that prolong QT... otherwise you will send them into torsades. Poor form. 

-Other meds that prolong QT (amiodarone, tramadol)

-IV haldol is the worst at this, definitely do not use in someone who's QT is >500

10. Antipsychotics: 

-Higher potency - worse EPS side effects, less Anticholinergic

-Lower potency - better EPS, worse anticholinergic 

1. Side effect of typical antipsychotics: NMS

-Lead pipe rigidity. 

-Fever

-Unstable vitals 

-CK can go high (when it gets >1,000,000, you may need to admit to dialyze) 

-Altered mental status. 

-Usually within the first week or two of taking the meds, but can happen idiosyncratically. Can eventually rechallenge with the same drug. 

2. Side effect of typical antipsychotics: Parkinsonism

-Classically Parkinson's develops unilaterally and med side effects present bilaterally. 

-Treat EPS with benztropine (ACh) rather than carbidopa/levodopa because it'll the latter will reverse the anti-dopamine effects and worsen psychosis 

-Bradykinesia, cogwheel rigidity, resting tremor

3. Side effect of typical antipsychotics: TD

-TD mostly presents orally, but can present in hands or feet or trunk. 

-People don't really notice they are doing it. 

-Irreversible. 

4. Side effect of typical antipsychotics: Dystonia

-oculogyric crisis

-laryngospasm

-torticollis (can treat w Botox since it's a large muscle you can inject). 

-Other treatments: antihistamines, benzos, benztropine. Can last hours or days. 

5. Side effect of typical antipsychotics: Akathesia

-Drug induced restlessness. People want to get up and walk/move around. 

-Feel anxious. 

-Most common w typical antipsychotics, but can happen with any psychotropic drug (even bupropion). -Can treat with benzos (first line), centrally acting b-blockers (second line)

-Persists with the duration of medicine, until  you change the meds or treat it. 

-Starts within weeks of taking the drug. 

6. Clozapine

-Clozapine works on serotonin receptors-- thus does not cause galactorrhea.
-It also works on dopamine, but hits D4 more than D2, which may explain why it is more effective than the other antipsychotics. 

-50-70% more effective than other antipsychotics. 

-People who partially or don't respond to other antipsychotics will respond to clozapine. 

-3% of white people get agranulocytosis -- may be lower in Asians (they use a lot of clozapine in china). 

-Black people have baseline WBC at 4-5, white people at 7-8. So black people can be hit harder. 

-Need weekly CBC at first 6 mos, then every 2 weeks, then monthly; you can't fill prescription without special form from doc and a lab white count. 

-5-10% of people who take it (>600mg/day dose) will develop seizures- best way to prevent is to use with valproate because it prevents seizures and boosts levels of clozapine. 

-Causes myocarditis. 

-Causes a lot of drooling, orthostatic hypotension.
-May treat tardive dyskinesia 

7. Antipsychotics that come in a immediate onset, short acting IM formulation:

-Haldol

-Ziprasidone (geodon) 

-Olanzapine (zyprexa): also very sedating, so a good choice to quickly take down a really crazy person. 

-Aripiprazole 

8. Antipsychotics that come in an long-acting IM formulation:

-Paliperidone (invega): monthly, derivative of haldol, medicare pays for it. 

-Risperidone 

-Haldol (should be q2 weeks, some people give it monthly)

-Fluphenazine (monthly)

-Olanzapine: nobody gives it though, bc the IM depot can cause life threatening hypotension. The instruction is to keep sb in your office for 3 hours to watch them after administration. 

9. Abilify:

-At low doses (~2mg) partial dopamine agonist, good for depression

-At high doses (~20-30mg) antagonist of dopamine, good for anti-psychotic. 

10. Seroquel:

-Low potency, doesn't bind D2 as tight, good for non-schizophrenics (i.e. organic or medication induced delirium)
-Only antipsychotic you'd use in diseases like MS or Lewy body dementia, where you don't want strong dopamine antagonism 

1. ECT & seizures: 
-Seizures necessary but not sufficient for treatment effectiveness
-Ect increases seizure threshold, has been used to treat epilepsy
-Epilepsy (endogenous) decreases seizure threshold: each seizure predicts future seizures. Epilepsy is also assoc w higher rate of depression than similarly impairing diseases.
2. ECT & Anesthesia: 
-Anesthesia plus sux, prevent fractures during seizures
-Methohexital: short acting barb. Cheap, long safety history. Fast wear off, compatible with inducing seizures since its less antiepileptic than most anesthetics. 

-Can also use thiopental, etomidate (least anticonvulsant so you can use if sb is hard to induce), propofol (most anticonvulsant, can't use in egg allergy), ketamine, remifentanil ($$$$)

-Use Sux if all possible: fast on, fast off, don't need to reverse. Only use nondepolarizing NM blockers if sux is CI (hyperK, hx of malignant hyperthermia, etc) 

3. ECT setup: 

-Bite block (since direct electrical stimulus to masseter)

-BP cuff on L leg (tourniquet) to monitor motor movements & make sure seizure is generalized.

-Also monitor with EEG. 

-Place electrodes on R unilateral side, fewer adverse effects than bitemporal placement. 

-Brief square wave is better than sine wave: reduces sx, since its believed that only the peak causes the seizure and the ramp up and down is just harmful. 0.1 to 0.4 ms pulse is enough. 

4. Perioperative adverse events

-Ect -> vagus -> bradycardia (10-15 sec). Can brady to asystole. Can use anticholinergic to protect against this. Atropine can be used but it crosses bbb (delirium) and can cause tachycardia. Glycopyrrolate doesn't cross bbb. 

-Sympathetic surge after ect for ~5 mins, most people can tolerate, can give b blocker. 

5. Indications: 
-Depression, bipolar, mania, schizophrenia/schizoaffective, catatonia (responds to benzos ESP Ativan and ECT)
-When to choose: severe or catatonic sx, hx of failure of drugs

6. Prognostic indicators:
-Predictive of good resp: severe, +psychosis, +catatonia
-Pred of poor resp: dep on dysthymia (cures acute depression not dysthymia baseline), depression due to medical condition, comorbid personality disorder or OCD
7. Contraindications: 

-space occupying lesion (ect and sux both increase ICP)

-hx recent MI-- usually wait 2 mos. 

-recent hemorrhagic stroke (rebleed risk w increased arterial pressures)

-severe heart disease like CHF with EF<30, severe valvular disease

-presence of aneurysm that may blow with increased arterial pressure 

8. Complications: 

-headache, myalgia, nausea likely due to sux and anaesthesia. 

-Postictal agitation or delirium in 10-25%. Responds to benzos. 

-Rarely: prolonged seizures >3 mins. 

-Treatment emergent mania (can give lithium, or more ect) 

-General anesthesia or seizures cause anterograde amnesia (can't make new memory) which induces a gradient retrograde deficit. Difficult to form memories during course of ect (2-4 weeks of ect 3x a week) so don't plan a wedding during this period. Anterograde memory will return to nl within a week. Retrograde deficit is days to weeks. 

9. Duration

-Will need maintenance psychotropic medications

-Most people will relapse without continued psychotropic meds

-Some people may need maintenance ECT on a weekly or monthly basis for the long-term 

10. Treatment of tic disorder in children: 

-Typical antipsychotics: pimozide, haldol 

-Clonidine

-Respiridone 

1. Psych H&P
-CC
-HPI
-Past psych history (hospitalizations, psychiatrists, diagnoses, meds)
-Substance use history
-Past medical/surgical history
-Meds/allergies
-Family psych history
-Social history (family structure, childhood, employment, school)
-Mental status exam
2. Mental status exam: 
-Appearance: dress, grooming, notable markings (tattoos, scars)
-Behavior: sitting calmly, tremors, abnormal movements. Cooperative or not.
-Mood: in their own words
-Affect: in/congruent with mood, quality (full, constricted, blunted, flat), lability (slow, labile)
-Speech: rate, quantity
-Thought process: linear, in/coherent, tangential/circumstantial, flight of ideas, word salad, neologisms, clanging, loosening of associations
-Thought content: delusions, hallucinations, preoccupations, obsessions/compulsions, phobias,
-Cognition: A&O x3, memory, attention/concentration (serial 7s, WORLD backwards), knowledge
-Insight: good/fair/poor
-Judgement: good/fair/poor
3. MMSE 
-A&Ox 3
-Memory: 3 words, short and long term memory
-Concentration: serial 7s, world backwards
-Language: naming, object recognition
-Visuospatial: clock face, draw 2 interlinking pentagons
-Writing: write a sentence
-Understanding: follow 2 step commands.
4. DSM-IV axes (now obsolete with DSM-V)
-Axis I: psych conditions incl substance abuse
-Axis II: personality disorders + mental disability
-Axis III: general medical conditions
-Axis IV: social conditions
-Axis V: global assessment of function
5. Schizophrenia diagnosis (DSM-V)
-2 or more of the following lasting for a month (less if treated): hallucinations, delusions, disorganized behavior, disorganized thought, negative symptoms
-Overall symptoms lasting > 6 mos
-Significantly affect life, not due to other reason
6. Schizophrenia epidemiology/genetics:
-1% prevalence
-12% risk if one first-degree family member has it
-40% risk if both parents have it
-50% concordance in monozygotic twins
7. Variations on a theme: 
-Delusional disorder: non-bizarre delusion for >1 month, normal functioning, doesn't meet schizophrenia criteria.
-Brief psychotic disorder: Schizophrenia symptoms<1 month
-Schizophreniform disorder: 1-6 mos
-Schizophrenia: >6 mos
-Schizoaffective: schizophrenia + mood disorder (major depression, bipolar); the mood sx occur only when the schizophrenia symptoms occur.
8. Major depression diagnostic criteria:
-Depressed mood
-S: sleep
-I: interest, loss (anhedonia)
-G: guilt/worthlessness/hopelessness
-E: energy down
-C: concentration down
-A: appetite up or down.
-P: psychomotor agitation/slowing
-S: suicidal thoughts
-Need 5/9 of the above, must include either depressed mood or anhedonia, for at least 2 weeks-- one of these is a "major depressive episode"
-To diagnose major depressive disorder, you need at least one major depressive episode, plus no episodes of mania or hypomania, and no other explanations, and cause major impairment.
9. Mania criteria: 
-Elevated/irritable mood plus:
-D: distractibility
-I: insomnia
-G: grandiosity
-F: flight of ideas
-A: activity
-S: speech (pressured)
-T: thoughtlessness
Need 3 out of the above, or 4 if irritable mood, lasting at least 7 days (mania) or 4 days (hypomania). Mania renders someone non-functional, hypomania does not.
10. Bipolar 
Bipolar I: One episode of mania (per DSM-V, no need for past depressive episode)
Bipolar II: One episode of hypomania
**Bipolar III: When a depressed person gets pushed into mania by SSRIs : not everyone believes this is a thing

1. Guidelines for choice of SSRI in depression. (abstract of similar paper from same group)
2. Bipolar vs borderline personality: diagnosis. & treatment
3. Adverse effects of antipsychotic medications
4. From wikipedia:

Millon's brief description of personality disorders[22]
Type of personality disorder	Description
Paranoid	Guarded, defensive, distrustful and suspiciousness. Hypervigilant to the motives of others to undermine or do harm. Always seeking confirmatory evidence of hidden schemes. Feels righteous, but persecuted.
Schizoid	Apathetic, indifferent, remote, solitary, distant, humorless. Neither desires nor needs human attachments. Withdrawal from relationships and prefer to be alone. Little interest in others, often seen as a loner. Minimal awareness of feelings of self or others. Few drives or ambitions, if any.
Schizotypal	Eccentric, self-estranged, bizarre, absent. Exhibits peculiar mannerisms and behaviors. Thinks can read thoughts of others. Preoccupied with odd daydreams and beliefs. Blurs line between reality and fantasy. Magical thinking and strange beliefs.
Antisocial	Impulsive, irresponsible, deviant, unruly. Acts without due consideration. Meets social obligations only when self-serving. Disrespects societal customs, rules, and standards. Sees self as free and independent.
Borderline	Unpredictable, manipulative, unstable. Frantically fears abandonment and isolation. Experiences rapidly fluctuating moods. Shifts rapidly between loving and hating. Sees self and others alternatively as all-good and all-bad. Unstable and frequently changing moods.
Histrionic	Dramatic, seductive, shallow, stimulus-seeking, vain. Overreacts to minor events. Exhibitionistic as a means of securing attention and favors. Sees self as attractive and charming. Constant seeking for others' attention.
Narcissistic	Egotistical, arrogant, grandiose, insouciant. Preoccupied with fantasies of success, beauty, or achievement. Sees self as admirable and superior, and therefore entitled to special treatment.
Avoidant	Hesitant, self-conscious, embarrassed, anxious. Tense in social situations due to fear of rejection. Plagued by constant performance anxiety. Sees self as inept, inferior, or unappealing. Feels alone and empty.
Dependent	Helpless, incompetent, submissive, immature. Withdraws from adult responsibilities. Sees self as weak or fragile. Seeks constant reassurance from stronger figures.
Obsessive–compulsive	Restrained, conscientious, respectful, rigid. Maintains a rule-bound lifestyle. Adheres closely to social conventions. Sees the world in terms of regulations and hierarchies. Sees self as devoted, reliable, efficient, and productive.
Depressive	Somber, discouraged, pessimistic, brooding, fatalistic. Presents self as vulnerable and abandoned. Feels valueless, guilty, and impotent. Judges self as worthy only of criticism and contempt.
Passive–aggressive (Negativistic)	Resentful, contrary, skeptical, discontented. Resists fulfilling others’ expectations. Deliberately inefficient. Vents anger indirectly by undermining others’ goals. Alternately moody and irritable, then sullen and withdrawn.
Sadistic	Explosively hostile, abrasive, cruel, dogmatic. Liable to sudden outbursts of rage. Feels selfsatisfied through dominating, intimidating and humiliating others. Is opinionated and close-minded.
Self-defeating (Masochistic)	Deferential, pleasure-phobic, servile, blameful, self-effacing. Encourages others to take advantage. Deliberately defeats own achievements. Seeks condemning or mistreatful partners.

5. Which psychotropics carry the greatest risk of QTc prolongation?
6. CIWA paper
7. Inpatient management of alcohol withdrawal
8. Evaluation and management of delirium in hospitalized older patients.
9. Delirium:
--Drugs that precipitate: opiates, steroids, GABAergics/benzos. Anticholinergics! (i.e. benadryl). Drugs with high anticholinergic potential, like theophylline, digoxin, furosemide, nifedepine. Some antibiotics.
--Can be precipitated by sleep deprivation, long term mechanical ventiliation, changes in immune function or endogenous cortisol levels.
--Dx: requires 1 AND 2, plus either 3 or 4: (1) acute & fluctuating course (collateral/serial MMSE),  (2) inattention, distracted, can't focus on conversation. (3) disorganized thinking: rambling, illogical flow of ideas (4) altered LOC: increased (hypervilgilant) or decreased (drowsy to comatose)
-Non-pharm tx: correct malnutrition, dehydration, electrolytes. Remove immobilizing devices/isolation, correct sensory deficits, promote normal circadian light rhythm.
-Pharm tx principles: no silver bullets, nothing FDA approved. Use one drug at a time, avoid sedatives (avoid benzos unless its w/d) and antipsychotics and tricyclics, tirate up, d/c 7-10 days after symptom resolution.
10. Drugs for delirium:
--Haldol: IVP (more reliable absorption, less EPS, peak effect 20 min). IM decanoate for chronic use. PO (peak in 4-6 hrs). Dose 0.25-10mg q2-12 hrs or PRN. No more than 20mg IM qd. No renal adjustment. Adjust in hepatic and elderly. CI in NMS, parkinson's, lewy body dementia. Highest EPS frequency (22% in RCT). IV haldol: relatively high risk of torsades and QTc compared to other drugs and compared to IM/PO, so follow QTc with baseline and daily EKG; measure QTc corrected for K and Mg. Avoid combining with other drugs that increase QTc (see below) or inhibit cyp3A4. D/c if QTc increases by 25% of baseline or is >500 msec.
--Olanzapine: IM, PO, ODT (zydis), long-acting IM (relprevv) for chronic use. Dose range: 2.5 to 10mg up to q2 hrs. Max dose 40 mg qd. No adjustment for renal impairment, not removed by dialysis, no adjustment for hepatic. Adjust for elderly. Most common side effects: orthostatic hypotension, somnolence (has antihistaminergic activity). Can also cause obesity and metabolic syndrome.
--Risperidone: PO, M-tab, oral solution. IM (Consta) depot, not for acute use. Dose range 0.25 to 1mg, q6 to q24. Max dose 8mg. Adjust down for renal, hepatic, elderly. Side effects: orthostatic hypotension, reflex tachycardia.
--Quetiapine (Seroquel): PO only. Seroquel XR for chronic use. Dose: 6.25 to 100 mg, qHS to TID, usually start dose at 25mg. No adjustment for renal, adjust for hepatic and elderly. Side effects: orthostatic hypotension, somnolence. Rarely QTc prolongation.
--Aripiprazole: possible role in hypoactive delirum
--Dont use clozapine or ziprazidone (high risk QTc)
--Excellent review paper of current trials of antipsychotics in the treatment of delirium (haldol vs resperidone vs olanzapine vs quetiapine: all about 70-80% response rate, quetiapine best)
--Drugs that increase QTc: class 1 (Na channel blockers) and 3 (K channel blockers- sotolol/amiodarone) antiarrhythmics, macrolide and quinolone antibiotics, antifungals, tamoxifen, furosemide.
--Non antipsychotics: acetycholinesterase inhibitors (donezepil, galantamine, rivastigmine), serotonin antagonist (zofran), trazodone (only uncontrolled studies, 25-100 mg qHS), valproic acid (250mg PO BID, plastma conc 50-100mg/L, case reports), benzos (go-to drug in ETOH and sedative-hypnotic w/d delirium, adjunct if people can't tolerate antipsychotics, palliative role)
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