psych clinical stuff goes on...

one can stop valproate right away, no taper is needed.

"much easier to use none than one" - heard on addiction rounds in reference to making a case for abstinence over controlled use

brain reward system prefers immediate gratification- overweighting the immediate reward is called delayed discounting.

Age of onset of schizophrenia in habitual marijuana users is 3 years earlier.

"imagination is more important than knowledge" - einstein

"conscious mind is but the neck of the bottle" -psychoanalyst making his case for his practice

"neocortex is the thin condom covering the limbic system" - heard in seminar

Semmelweis who single-handedly did more to reduce hospital mortality than anyone or thing since the modern era died in an asylum a madman.

"marriage is diagnostic, not therapeutic" - heard in seminar

4 major side effects of the typical antipsychotics

1. EPS

2. anti-cholinergic

3. sedation

4. orthostatic hypotension

-be sure to ask yourself, is it potent or not?

think of the high and low potency typical antipsychotics in this way

the high potency- turn you into a walking zombie, drooling because less anticholinergic

the low potency - put you out cold because they're very sedating, completely knocks you out very sedating and anticholinergic so no drooling, nurses love giving the low potency antipsychotics

the first antipsychotic was chlorpromazine in the 50's, aka Thorazine. it takes about 300-350mg of thorazine to put someone out cold. this was a low potency antipsychotic and all other antipsychotics from that day have been measured in thorazine equivalents. the other low potency antipsychotics are 1:1 with thorazine (thioridazine etc...)

there are middle of the road antipsychotics that are somewhere between high and low potency-

perphenazine - 12:1 thorazine equivalents

thiothixene and stelazine: 20:1 thorazine equivalents

big dog haldol (haloperidol) is high potency antipsychotic with 50:1 thorazine equivalents (300mg thorazine = 6 mg haloperidol)

calm someone down with this: 5:2:1, 5mg haldol, 2mg ativan (lorazepam), 1mg cogentin (benztropine)

difference between psychiatry and medicine - in medicine dropping in on your patients on the weekend makes them feel cared for and they may think you're a good doctor. "drop in" on your psych patients on the weekend and you risk confusing them by blurring boundaries, ESPECIALLY with borderline persons

nortriptyline is a "window" drug- meaning there is a plasma concentration range that is its therapeutic window if you are too high or low the drug looses its efficacy, nortriptyline has low ortho/low anticholinergic side effects good for geriatric

45 minutes is most time you want to spend in family meetings, after that there is no payoff and only risk

"these are new year's resolutions" -in regard to the promises heard on the wards about future adherence

the narcissistic injury leads to suicidality

4 types of emotional attachment in this life

1. secure

2. avoidant

3. anxious

4. chaotic

"he who has never read the greeks is bound to make a lot of discoveries" - heard in seminar

Notes on Freud:

masculine protest- striving to be a real man, genesis behind narcissism

neurotics - will trade everything for safety

oral phase - wish for dependency/gratification

anal - time dirt money (anal trilogy), compliance v defiance, autonomy v doubt

phallic/oedipal - exhibition/woo the world

genital phase- typified by cougar in top gun - turn in your wings

anal phase - comply until resent, defy until guilty and go around in neurotic circle, men become dependent on mothers, passive aggressive

misc notes...

borderlines have affective storms

don't know where to go in an interview? hunt for the affect, follow the affect.

patient's advice on marriage:

"respect and believe what they are saying. believe the other person if they say you hurt them, feel the genuine of your heart, and do things together, work on being buddies from the start"

when someone has has axis i disorder its impossible to diagnose an axis ii b/c coping with diseases regresses our defenses

and the final pearl for the psychiatry rotation-

"why have a tantrum about taking your medication? isn't that cutting your nose off to spite your face?" - heard in rounds

Violence on the psych ward

notes from case conference on violence

-50% of psych residents have been assaulted sometime during there residency

many times patients are frightened by their own lack of control, and end up thanking provider for any interventions. trust your gut, if you get that uncomfortable feeling, its for a reason.

types of interventions...

what do you do when patient is verbal, agitated, complaining-

ask the patient to room or quiet spot, dining area maybe to sit and talk, respect personal space. also your behavioral style is important so speak softly and move slowly. tell them their actions are frightening others- its all how you say it, use a small posture, hunch a lower in a nonthreatening way, don't hide your hands or turn your back. Sometimes sitting at a 45degree angle helps calm, others have said sit side by side so you both are "looking out at the crazy world like a pair of lost truckers". Be sure to leave an exit for both you and the patient, listen empathetically and hear them out. Offer food or drink, these are culturally universal symbols of nurturance. Then you want to assess the possibility of violence. Aske, are your worried you'll lose control? Can you control yourself? Is there someone you feel like hurting right now? Who? Don' use negatives, instead of saying "you can't shout" say "show me you in control". btw this is good for kids too.

PRN Meds can be PO or IM- the point is these are her for "helping the patient maintain control of himself/herself". If agitated to the point where its warranted introduce the meds by saying, "the staff doesn't want anyone to get hurt"

if you have to think about whether the patient needs stat prn meds, or you need to mobilize the "show of force" - say to the patient, "i have a call to make, i'll come back"

major point - if you decide the patient needs STAT PRN you have to go all the way, no conditions, arguing, or bartering can be allowed, do not change your mind. At this point you will need to mobilize a show of force -psychotic patients will respond to a show of force most times by agreeing to take the meds, allow them to submit without them losing face, organic person (encephalitis, meningitis, neoplasm) will not respond to show of force.

You need:

1. a leader (does all the talking)

2. someone to clear the decks, put patients back to their rooms

3. one nurse to get the seclusion and restraints ready

4. one nurse to ready the stat meds, don't forget IM,

5. one person to call security

6. five people to hold patient, more is better,

remember -never establish a show of force w/PO meds only, need to bring only IM

1 staff for each limb, 1 staff for head, neck, airway control

only the leader talks, "i need to talk to the patient alone"

when security arrives if it looks like you don't have things under control, they will take control from you, so greet security w/two sentences stating succintly what is going on.

the leader talks to the patient and gives the need and reason:

"your behavior has escalated and this medicine will help and you NEED it"

patient may dispute, bargain, question, threaten to sue, call lawyer - you have set conditions you can never back down - repeat the need for meds and give them a choice- IM or PO

restraints vs. seclusion- many patients have harmed themselves in seclusion (padded room) by scratching themselves or banging their heads, makes the case for using restraints, with mentally retarded patients go for using the restraints.

Psychiatry clinical continued

Mental retardation is defined by a greater than two SD deviation below the mean in IQ + an impairment in function that is clinically significant

IQ 55-70 Mild (educable)

IQ 35-55 Moderate (trainable)

IQ 20-35 Severe (must be cleaned after)

-reading has been around for 10,000 years

ADHD in adulthood - no impulsivity, relationship problems, forgetfulness

Vyvanse - new ADHD prodrug, can't be snorted (abused) as Adderall/Ritalin

Current meta-analyses reveal ADHD to be 50% heritable

ADHD prevalence in school age children ~5-11%

Children, ADHD & China

sDiagnosis of mental retardation = IQ >2 Standard Deviations below the mean + impairment of function.

To get a sense of patitent’s IQ, ask about their education, ask about their parents education.

“socializing is like skiing, the better you get the better it gets”

average attention span 22 minutes.

ADHD is the #1 reason for pediatric outpatient referrals!!!!

Referrals – school, parents, pediatricians in that order

30-50% of cases of ADHD are co-morbid w/LD

First thing to do when kid has delayed language development – hearing test.

FAQ – Is my kid manipulative because s/he won't sit still for math homework but has perfect attention for the Xbox/nintendo video game?

No - ADHD kids are understimulated. Paper and pencil mathhomework sitting stil is not stimulating enough, but the lights and colors of video games are far more stimulating. This also underlies the reason the stimulant is given as treatment.

Children manifest psychological disorders uniquely to adults. School is normally the major stress in a child's life. When you think about what is going on with a kid, you have to always think in developmental terms as the kids change so rapidly, also think Family Context!! Family Context!! It effects children much more significantly. A child can either internalize or externalize a trauma/mental illness/medical condition. Internalizing results in depression and anxiety and is egodystonic whereas externalizing disorders manifest as conduct disorders and tend to be egosyntonic. The major externalizing disorders are:

ADHD, conduct disorder (this is typified by an absence of remorse), oppositional defiant disorder

Pediatrics can commit suicide, it has been found that the single greatest risk factor for suicide in a depressed child is a feeling of hopelessness.

From the mouth of a borderline, "I came here depressed and I'll be leaving suicidal" -individuals with borderline personality disorder often threaten suicide as way of leveraging, have to set limits!! w/borderline

ZyprexaZydis - an olanzapine wafer that dissolves instantly in your mouth, helps with compliance.

Suicide in Chinese vs US

US suicide rate 11.5/10^6, in '07 ~35,900 completed suicides

• males 4x females for successful suicides
• females 3x males for attempts
• 3rd leading cause of death for 15-24 year old, most common means FIREARM
• 90% of those who have committed suicide have some sort of psychological disorder

Risk Factors for suicide: past suicide attempt, having a specific plan, making an attempt without others being able to know (doing it in secret)

Chinese suicide statistics

• China has 1/3 of global suicides. Rate is 23/10^6 people.
• there are decreased rates of mental illness in China
• Chinese male suicides much much more common than female suicide
• Rural citizen has 3x the suicide rate than urban citizen
• low plan suicides (impulsive) more common among the young
• most frequent means, pesticide poisoning
• risk factors: low social status, lack of social support

Notes

Psychoanalysis

1. Connect (anyway, find anything to agree on, even agreeing on nothing)

2. Listen!

3. Have list of diagnosis in head - Achilles heel is not having a framework in place to pull from.

Do not interrupt!!! If you interrupt to clarify, sure you get your answers, but you won't see how they think!!

Psychoanalysis Metaphor:

Anatomy is what the person thinks

Physiology is how the person thinks

Hallucination- real sensory event in absence of stimuli

Hallucinosis - patient hallucinating but knows it, almost always a form of organic brain injury. Acute!! probably an emergency

Illusion - incorrect conclusion about real sensory stimulus, the chair in the dark looks like a monster

Attitude- a persons attitude is a reflection of their way of organizing social information into a theme.

Psychosis - loss of reality testing involves two categories

-ideas (reference, religiosity, grandeur...)

-sensations (bugs crawling on skin)

Near delusion - almost completely fixed false belief, a little room for doubt (e.g. - i am willing to entertain the notion that the CIA may not be controlling my mind from my microwave)

Overvalued idea - on the same spectrum as a near delusion, a little less fixed.

Somatic delusion - a healthy body w/subjective pain symptoms (back pain w/no medical explanation)

Panic disorder - SSRI 1st line treatment, can have paradoxical response so start extra low and uptitrate, if you're gonna prescribe meds for panic disorder patient will have to be on them longer, clinically looking for "1 year of feeling good"

Panic disorder - cognitive behavior therapy, psychodynamic therapy - just don't harp on physical symptoms (if present)

Buspirone: non benzo anxiolytic, an adjunct - big plus: NO SIDE F/X, takes time to work

Tricyclics can be very sedating, start low. They can also create a conduction block so clear an EKG. The most sedating is amitriptyline (Elavil), lots of anticholinergic side F/X, dry mouth, constipation, urinary retention, vision problems

Tardive Dyskinesia

TARDIVE DYSKINESIA BULLETS

ü TD hyperkinetic movement disorder from prolonged dopamine block

o Caused by antipsychotics and metoclopramide

o “Tardive” latin tardus –slow (delayed onset) history of >3months don’t confuse w/acute and EPS (although associated)

o Involuntary movements –

§ Choreiform (greek khoreia: to dance– rapid, jerky, nonrepetitive

§ Athetoid (greek athetos: without position)– slow, sinuous

§ Rhythmic (stereotypies)

ü TD manifestations

o Oral, facial, lingual dyskinesia (3/4 of patients, typical in older patients)– protruding/twisting tongue, pouting, puckering, smacking, bulging of cheeks, chewing, blepharospasm

o Limb dyskinesia (~1/2 of patients, more typical in younger patients) – “piano playing” finger movements, foot tapping, toe extension, akathisia (subjective motor restlessness; occur both early and late in AP tx)

§ Tardive akathisia – inability to sit still, crossing/uncrossing, marching in place, rubbing hair or face w/hand

o Neck/trunk dyskinesia (Tardive dystonia) (~1/4 of patients)– torticollis, shoulder shrugging, rocking/swaying, arching

o Respiratory dyskinesia – cause tachypnea, grunting

o Tremor/tics/myoclonus – uncommon

ü SUBTYPES

o Transient TD – brief, limited only during treatment

o Withdrawal Emergent TD – described in pediatrics following discontinuation! Common for TD to appear after a reduction in dose or switch to less potent AP. Called “unmasking”. Withdrawal TD normally resolves within several weeks.

o Persistent TD – permanent. Most feared!

§ Classic tardive – “fly-catcher tongue”, trunk flexion/extension, “piano playing” (prevalence increases with age, elderly women)

§ Manifested by reducing dose or coming off drug which unmask the disorders (in fact last resort treatment to resume AP)

ü Pathophysiology

o Unknown – working theories include

§ Dopamine receptor supersensitivity (evidence of striatal dopamine receptor upregulation)

§ Decreased GABA inhibitory interneuron firing in basal ganglia leads to excitotoxicity (ev -chronic AP treatment in primates leads to reduced GABA/glutamic decarboxylase)

· D2 block (inhibitory) increase glutamate firing in striatum and subthalamic nucleus

o Leading theory – imbalance between D1/D2 firing b/c of preferential block of D2 (supported by increased atypical EPS threshold)

ü Prevalance – AIMS (12 item inventory) difficult to assess accurately b/c AP both cause and mask the clinical manifest, fluctuates based on emotional arousal, orofacial dyskinesia common in age 65

o Thus, current point prevalence has range from 3-77%

o DSM-IV – 20-30%

ü 1^st Generation -1982 analysis of 35K cases put prevalence @ 20%

o controls had prevalence of spont dyskinesias @5%

§ therefore – estimated prevalence at 15%

ü 2^nd Generation – less D2 block, more 5-HT2A block

o Case reports -Clozapine – almost no risk of EPS

o Case reports – risp/olanz have greater risk for TD than other atypical

o associated w/akathisia and NMS

o still better than 1^st gen, but not as safe as previously thought

§ short term studies

§ very few patients are AP naïve, this is a risk factor for TD

§ In reviews earlier patients had schizo later had dementia

ü Risk factors -

o Older age, length of exposure, female, brain damage, affective disorder, history of ECT, use of anti-cholinergics, African American ethnicity

ü PREVENTION – early detection!

o >3months treatment should be limited

o metoclopramide should not be used >12months

o should inform patient of risk, possibly obtain consent given medicolegal implications

ü Treatment guidelines – only give when absolutely necessary, if the psychosis is controlled, attempt to reduce dosage or eliminate

o Long term use is discouraged in neurosis, anxiety, Axis II, chronic pain

o Monitor patient using AIMS scale (abnormal involuntary movement)

ü TREATING TD – few therapies (lower, change, stop)

o Discontinue drug – within 3 months ~1/3 remit, 12-18months 50%, as late as 3 years

o switch to atypical antipsychotic – may just be masking, or gradual improvement w/weaker drug

§ clozapine - @least 8 studies since 1991, all uncontrolled, effective at reducing tardive dystonia

o Benzodiazepine- mixed results in trials: DBRCT 19 patients: clonazepam- start 0.5mg and titrate max 3-4mg/day

o Botulinum: multicenter 29/34 shown to help cervical dystonia/blepharospasm

§ Contraindicated in Myasthenia Gravis

o Tetrabenazine (approved Aug08 for HD)/mirtazapine – deplete dopamine storage used for Huntington’s chorea and debilitating TD

o Anticholinergics - benztropine (*anticholinergics exacerbate choreiform disorders but good for acute/tardive dystonias/EPS)

§ Contraindicated: narrow angle glaucoma, confusion, dementia.

§ Use with caution: >60yrs, BPH, obstructive GI,

o Last resort: resumption of anti-psychotics! Usually SGA.

o Misc treatments: bblock, calcium block, 5-HT antagonist, buspirone, B6, amantadine, lithium, levetiracetam

o Deep brain stim: bilateral internal globus pallidus

§ 10 patient prospectus – all ten had result – mean decrease in EPS rating scale of 50% when stimulation was on

o Vitamin E (via anti-oxidant) – not found to be beneficial in 6 placebo controlled clinical trials

ü CLINICAL TRIALS – HAND OUT PAPERS w/STUDIES STARTING

Psych pretest items worth remembering

Auras of an unpleasant odor can indicate a temporal lobe partial complex seizure.

Prepubescent kid suddenly becomes OCD, anxious, oppositional?

PANDAS - pediatric autoimmune neuropsychiatric disorder associated w/strep A

Bedwetting aka nocturnal enuresis most likely to happen in first third of the night

Garlic breath - could also be arsenic poisoning

Lifetime prevalence of psych disorders (chiefly anxiety and depression) in epileptic patients - 20-30%

How to differentiate a generalized tonic-clonic from a non epileptic seizure?

check prolactin levels - they are elevated in the epileptic form, but have to get sample within 20minutes

postcardiotomy delirium is differentiate from delirium tremens of alcohol withdrawal because the former does not have the autonomic activation. The prevalence of postcardiotomy delirium has remained constant at 32% over the years!!!!

Mental retardation

IQ:

50-70 mild retardation - 90% (6th grade level)

35-55 moderate ret... - 7% (preschool level)

25-40 severely ret... - 3%

20-25 profoundly ret - less than 1% (death in early 20's)

prevalence of schizophrenia in siblings - 10%

which antipsychotics treat negative symptoms of schiz? olanzepine/clozapine

uneven pigmentation after exposure to sun - which antipsychotic? chlorpromazine

delusions -fixed false belief not culturally shared is a dysfunction of thought content

suicide rate for schizophrenic patients- 10%

concordance rate in homozygotic twins for mood disorders - 70%!!!

which cancer most likely to manifest w/depressive symptoms? pancreatic adenocarcinoma

prevalence of depression in post stroke patients estimated to be 30-50%

post stroke depression risk extends for approximately 2 years

Heinz Kohut - his theory was all psychopathology comes from bad parenting. neglectful, unempathetic

Beck - depression results from cognitive distortions in depression prone people

Bowlby - attachment

Mahler - separation/individuation (rapprochement - kid comes back to mom for check in supports)

ECT improves motor symptoms associated with Parkinson's

Lithium, thyroid, stimulants, estrogens can all augment anti-depressants

Prevalence of alcoholism in bipolar is 60%

REM latency is shortened in depression and narcolepsy

Treatments for panic disorder - SSRI, TCA, benzos

OCD tx - ssri, clomipramine,

GAD tx - buspirone, SSRI, imipramine

Causes of restless leg syndrome - pregnancy, anemia, renal failure

Symptoms of meperidine intoxication - resp. depression, stupor, coma and seizure!

Hypnosis is contraindicated in paranoid personality disorder (it just won't work)

Important to remember that when living with a schizophrenic the emotional environment of the home is very important- keep fights, arguing etc to a minimum

Freudian concept of abstinence -refrain from making an major life decisions while receiving psychoanalytic treatment.

Akathisia occurs early during neuroleptic treatment, treat it w/beta blocker

Want to knock down both ADHD and depression in a 16 year old? tx with bupropion

Trazodone priapism risk is highest with LOW doses (50-150mg/day)

How to treat sexual side effects of SSRI (decreased libido, anorgasmia) without changing medication? add cyproheptadine

treatment for involuntary tics, grunts, and coproalia (obscene outbursts) - haloperidol

Person being treated with disulfiram presents with facial flushing, tachycardia, hypotension, N?V - denies alcohol use what else could do it? Cough syrup has 40% alcohol.

Lithium treatment begins to work after roughly 7-14 days.

treatment of cataplexy? SSRI, MAOi, TCA

The drug of choice to knock down both bedwetting and ADHD is imipramine.

Going to be sued for malpractice? Plaintiff has to prove the 4 D's

Duty - you had a duty to act and didn't

Deviation from the standard of care

Direct - harm was directly caused by physician's actions

Damages - there were actual damages as a result

Tarasoff v. Regents of California - provider has to warn the potential victim of a violent patient if identity becomes known

Two most common cause of malpractice claims?

1. maltreatment

2. suicide

Principles

Beneficence - promote well being

Nonmaleficence - do no harm

mens rea - state of mind that indicates criminal intent at the time of the crime

Durham rule - defendant is criminally liable if it can be shown the unlawful act was a result of mental disease

psychiatry clerkship continues in bullet points

Who am I?

Olanzapine!! A commonly used antipsychotic that is commercially known as Zyprexa. This compound can eliminate psychotic symptoms by competitively blocking overactive serotonin receptors in the basal forebrain in psychotic individuals. However significant side effects to this medication are metabolic derangements, obesity, and edema. Instances of extrapyramidal symptoms are rare with Zyprexa because it is not a strong blocker of dopamine.

Here is my mnemonic for the DSM criteria for diagnosing substance dependence"

L U/R Ng Q W T Time

aka "learning quit time"

L- longer/larger periods using substance than originally planned

U/R - use despite repercussions

Ng - neglect of obligations, work, relationships...

Q - unsuccessful attempts at quitting

W - withdrawal

T - tolerance

Time - inordinate amount of time/energy/expense used to acquire substance

in psychotherapy here are three things to say when you don't know what to say next-

1. that must have been hard

2. tell me more

3. how are you feeling?

The full-proof parenting algorithm:

1. Hungry? Feed em

2. Wet? Change em

3. Upset? Soothe em

When inquiring about history of trauma or abuse during an interview one way to ask is, "Do you have any history of trauma or abuse?"

The signs and symptoms of PTSD revolve around three primary clusters:

1. Reliving the experience in some way

2. Hyperarousal/hypervigilance

3. Avoidance, numbing, shutting out/down/off

Substance abuse clinical points-

ethanol disinhibits the behavior regulating prefrontal cortex- it inhibits the inhibitor, most drugs don't do this. -"Have you ever heard of a crack house brawl?"

Heard in rounds- "when the going gets tough, the borderlines get using"

-substance abusers are ambivalent about change, remember- ITS DOING SOMETHING GOOD FOR THEM!!! - so don't finger wag, it will get you nowhere, instead try asking about their goals? do they want to control their using, cut down, switch whatever but find out- this can reveal flawed thinking and assumptions. And if you feel as though whatever reasons are not in line with treatment, reality or your own moral compass simply state - , "I can't join you in that goal"

Think a person in a hospital for detox is lying about use? Ask him/her what are their goals? What are you hoping to get out of this hospital visit?

Heard in rounds regarding borderline personality - "They love beyond measure whom they will soon hate without reason."

"what is learned with pleasure is learned full measure"

the key to motivational interviewing is get the patient to tell you why they should quit

Food for thought:

During a discharge plan one day we were discussing the private psychiatrist fees for an office in a suburb of Washington, DC. The office does not take insurance and the following rates are out-of-pocket.

Initial consult - $350

20 minute med check - $135

1 hour psychotherapy - $270

Child psychiatry pearls

Kids deal with trauma by either internalizing or externalizing.

IF they internalize there are two chief symptoms: depression and anxiety. This is ego-dystonic, i.e. - it causes conflict with the child's sense of self or ego.

IF they externalize then you get conduct disorder, oppositional defiant disorder, disruptive behavior disorder. Conduct disorder presents with two chief behaviors - fire setting and animal harming. It is oftentimes a prelude to antisocial personality disorder as an adult.

The 4 P's for diagnosing and understanding psychological illness

Predisposing factors - family history, genetics, environment

Precipitating events - trauma, deaths, life events

Perpetuating circumstances - psychosocial issues, persons, places, things

Protective factors - supportive family, financial stability, treatment

Atypical antipsychotic receptor blockade profiles:

here is another source comparing first generation antipsychotic and atypical - notice the reduction in dopamine blockade

for billing and insurance be sure to include two GAF scores, the most recent GAF and the highest that the patient has experienced in the past year.

the proper order of a presentation for morning rounds on psych

-ID 1-2 sentences

-reason for presentation, why on psych now?

-Axis dx

-meds + doses, organize the polypharmacy, don't care about prn

-clinical update on case, what's new

don't discharge anyone without a follow up appointment

getting a parallel history is crucial for establishing the history of present illness, but many patients don't want anyone talking to their families. in order to get consent try asking in this way, "who would you like us to contact?", in this way you kind of "assume" talking to family is part of the care, if patient still refuses, well then the trick didn't work

heard on the floor - "for now, she's going to marinate in zyprexa"

heard on the floor - "we once had a fireman try and crawl through the ceiling in an attempt to elope from the ward, patients can be inventive"

many personality defenses arise in psychotherapy, regarding anger vs. apathy - "it is easier to calm the wild than raise the dead"

in psychotherapy don't interrupt - goal is not to get the answers but to see how patient thinks, if you interrupt - sure you'll get the answers but you won't see how they think!

the act of worrying about having a panic attack strongly suggests panic disorder

SSRI first line treatment for panic disorder

buspirone - non benzo anxiolytic, takes time to work but no side f/x!

thinking about using tricyclic antidepressant? don't forget to get an ekg, these drugs can cause conduction blocks

end point of using meds for panic disorder? "1 year of feeling good"

not getting better on an SSRI?

1. increase the dose

2. switch to another class

3. augment - (buspirone, lithium, thyroid, atypical antipsychotic)

clomipramine is the only TCA that can be used for OCD

patient comes in with major depression, you treat with antidepressants, patient gets better with a very quick response - you should start to suspect bipolar disorder

sleep deprivation can trigger manic episode

patient on lithium sudden develops polyuria? check levels, they may have taken NSAIDS decrease renal clearance of lithium

"even if you don't go into psychiatry, you will be treating depression, in fact most provider's that treat depression are not pscyhiatrists. but if you see these 3 things you need to get a pscyh eval, 1. suicide/homicide 2. psychosis 3. mania

transference - displacement of emotions, thoughts, behaviors toward the therapist derived from earlier emotionally significant relationships

e.g. - patient comes in late, therapist asks "what's the deal?" patient says - "stop treating me like a child!"

countertransference (two types)

- true: thoughts feelings behavior directed toward patient from therapist that come from significant emotional relationships in past

- general: the ability of a patient to call out a similar response from all persons he/she interacts with,

how do you tell if its just you who has a problem w/patient? ask around about how others feel

are you a highly sensitive person? do you want to find out?

PTSD patients have different neurobiology -

hippocampus is decreased in size

emotion responsive areas (insula etc) are hyperactive

prefrontal executive dampening is decreased

PTSD - use of morphine good because lessens memory formation

beta blockers were a bust for treating autonomic hyperarousal in PTSD

psych inpatient clinical things

-when taking an interview in the ER, for the HPI try to find out why now? why here? what happened this time that brought patient to ER

-unless absolutely necessary never use family member as interpreter, especially children

-patient on edge? glance over the EMS report before doing the interview to get a better sense of whats up

remember you need patient consent to give the family details about the patient, but you don't need consent to get details from the family

while getting a parallel history, if the family etc start to inquire about patient, just reply, "there in a safe place"

tremor and tongue fasciculations? could be EtOH withdrawal

mental health therapy aides, "nurses aides", have been around the longest and have the best subjective sense about patients

stress comes from emotionally draining patients.

whats a delusion? fixed, false belief not culturally shared.

an arkow pearl: limit setting with a borderline patient is imperative, "i don't care if you have the chainsaw gassed up and ready to kill yourself if you have to leave, than we can just go the state hospital and you can figure it out over the next few months"

the pronouns are screwed up with borderline patients, you should be I, (patient)- I have the problem, I have issue, its my fault

clozapine is different - it never crosses the threshold for extrapyramidal symptoms, good for negative symptoms

axis I diagnosis will trump adjustment disorder

fluoxetine takes ~5 weeks to washout, paroxetine has the most DDI

when diagnosing depression, don't say "major depressive episode, or major depression", instead say you have "a depression", educate about symptoms

SSRI side effects

1. anorgasmia

2. tend to be activating

3. loose bowel movements/GI symptomes

4. black box for under 25yo

end point with SSRI's is "six months of feeling good"

stay away from benadryl and anti-cholinergic

help projecting complainer i.e. - gimme help please, no thanks don't need it.

when choosing residency don't go to a place where you have to drive far to work

check and see if the residency is unionized

risperdal consta can lead to retrograde ejaculation in young men

-regarding psychopathology - "if its not affecting you, its affecting someone else..."

-arkow pearl: "we once had a patient who was a fireman try to crawl through the ceiling tile trying to escape out of here"

-is there a giant fight going on over a patient in the nurses station? look for the patient quietly reading a magazine nearby, that's who there fighting over