block D2-R

FGAs → D1+D2

SGAs → D2 (selective → less SE)

(Clozapine → D4)

1. ⚙️ Extrapyramidal

→ Acathisia (restlessness) → benzos, BB or switch to 2nd gen

→ Parkinsonims → ↓dose, switch to 2nd gen or anticholinergics

→ acute dystonia (torticolis, spasm, grimaces) → give anticholinergics

→ tardive dyskinesia (irreversible extrapyramidal; the ones above are reversible) → switch to 2nd gen

2. 🍼 ↑PRL → amenorrhea, gynecomastia
3. ❤️ CV
1. ↓BP
2. ventricular arrhythmias (torsades)
4. ⚡ Seizures
5. 💤 M-cholinolytic effect → Sedation
6. ⌛ Agranulocytosis (clozapine)
7. 👨🏽‍🌾 NMS 📷→ give muscle relexants, stop antipsychotic → switch to 2nd gen after 2w

SGAS:

• also ↓negative symptoms (FGAs only positive)
• ↓ extrapyramidal symptoms, PRL, NMS
• ↓anti-cholinergic SE
• ↓Seizures
• ↓Relapse

⇒ BUT SGA → ↑ metabolic SE

bipolar mood disorder (manic episodes)

• 🏂🏽 Lithium #1
• ⚡ valproic acid, lamotrigin, carbamazepin

→ pregnancy = #1 lamotrigine

• lamitrigine
• Antipsychotics (halo)

*MDD = Major depressive disorder

F - more common in woman

False statement

⇒ M=F (equally distributed)

childhood → somatic, irritability, social withdrawal

adolescents → “ATYPICAL” ⇒ ↑eating + ↑sleep (see below)

elderly → “TYPICAL”/ MELANCHOLIC features ⇒ ANHEDONIA = ↓ interest + pleasure ⇒ ↓eat+sleep

‣

💬

PLUS ≥3 OTHER CRITERIA MET (see “DIG FAST” below)

• Secondary to other PSYCHIATRIC CAUSES
💡
depression has to be differentiated from normal sadness / grief !

• Antidepressant (SSRI or other) → mainly Fluoxetine (Prozac)

⇒more details: see Tx-approach above!

• Psychotherapy

⇒ See psychotherapy types above!

• ECT

• Chronic ⇒ Mood stabilizers ⇒ see above

#1 Lithitium

#2 Valproic acid, Carbamazepin, Lamotrigin

• Agitated ⇒ Antipsychotic (quetiapine, olanzapine)
• in depressive episodes there might be an anti-depressant added, but usually not used in bipolar!
• Psychotherapy
• ECT

Case 1: Major Depressive Disorder Case 2: Bipolar I Disorder Case 3: Dysthymic Disorder Case 4: Cyclothymic Disorder Case 5: Bipolar II Disorder

Case 1: Agoraphobia Case 2: Obsessive-Compulsive Disorder (OCD) Case 3: Generalized Anxiety Disorder (GAD) Case 4: Acute Stress Disorder (ASD) Case 5: PTSD Case 6: Adjustment Disorder Case 7: Social Anxiety Disorder (Social Phobia) Case 8: Panic Disorder

1. Catatonic type
2. Disorganized type (worst Prognosis)
3. Paranoid type 🥇 (most common, best Prognosis)
4. Undifferentiated type

1. Premorbid
2. Prodromal
3. Syndromal
4. Chronic / Residual

• Cluster A (Weird)
• types: Paranoid, schizoid, schizotypal
• Odd and eccentric behavior
• ⇒ associated with SCHIZOPHRENIA
• Cluster B (Wild)
• types: Antisocial, borderline, histrionic, narcissistic
• Dramatic, erratic behavior
• ⇒ assoc. with MOOD DISORDERS & SUBSTANCE ABUSE
• Cluster C (Worried)
• types: Avoidant, obsessive-compulsive, dependent
• Anxious, fearful behavior
• ⇒ assoc. with ANXIETY DISORDERS

Key differences: Schizoid vs Schizotypal vs Schizophrenia

• Thought Form:
• Schizoid: Organized thoughts.
• Schizotypal: Thoughts are organized but can be vague and circumstantial.
• Schizophrenia: Disorganized thinking pattern, often tangent, with loosening of associations.
• Thought Content:
• Schizoid: No evidence of psychosis.
• Schizotypal: While no psychosis, there may be ideas of reference, paranoid ideation, odd beliefs, and magical thinking.
• Schizophrenia: Characterized by psychosis and hallucinations.
• Relationships:
• Schizoid: Prefers solitude, lacking the desire for social relationships.
• Schizotypal: Has an interest in relationships but struggles socially, lacking close ties.
• Schizophrenia: Socially marginalized, not by choice, but due to symptoms.

1. A 54-year-old woman with a history of alcohol abuse has been drinking heavily for the past 10 years. She reports experiencing tremors, anxiety, sweating, and insomnia since she stopped drinking two days ago.
2. A 35-year-old man has been drinking heavily for the past 5 years. He reports drinking every day, often starting in the morning and continuing until he passes out at night. He has lost interest in hobbies and has strained relationships with friends and family due to his alcohol use.
3. A 42-year-old man presents to the emergency department with confusion, slurred speech, unsteady gait, and nystagmus. His breath smells of alcohol, and his blood alcohol level is found to be 250 mg/dL.

INTOXICATION

‣

💬 *

Angina:

WITHDRAWAL

Q. Which statements are true for opiod withdrawal syndrome: A. The appropriate management ist with alpha 2 adrenergic agonists B. The appropriate management is with antipsychotics C. Characteristic symptoms are autonomic instability, insomnia, drug-craving D. The onset is 24-48h E. The duration is 5-10days

1. A 32-year-old man presents to the emergency department with chest pain, dilated pupils, sweating, and agitation. He reports using cocaine earlier in the day.
2. A 25-year-old woman reports feeling anxious, irritable, and experiencing muscle aches, runny nose, and watery eyes since she stopped using opioids two days ago.
3. A 26-year-old man presents to the emergency department with confusion, paranoia, and visual hallucinations. He reports taking LSD earlier in the day.
4. A 35-year-old woman reports feeling euphoric and having increased energy and talkativeness after using MDMA at a party.
5. A 28-year-old man presents to the emergency department with chest pain and shortness of breath. He reports using marijuana earlier in the day.
6. A 40-year-old man reports feeling irritable, restless, and experiencing insomnia since he stopped using cocaine two days ago.
7. A 24-year-old woman presents to the emergency department with drowsiness and confusion. She reports taking opioids earlier in the day.
8. A 30-year-old man reports feeling anxious and paranoid after using marijuana at a concert.

• 👁️ ATTENTION + AWARENESS disturbance → distractibility → disorientation (time, place, rarely person)

PLUS

• 🧠 COGNITION disturbance (memory, language, perception etc. → see dementia)

⇒ develops RAPIDLY ⏱️

⇒ FLUCTUATE over a day

⇒ EVIDENCE for CAUSE (med. condition, intox/ withdrawal) ⇒ exclusion DDx (other neuro or psych causes)

OTHER FEATURES:

• 🎭 AFFECTIVE disturbances (anxiety, fear, depression, irritability, anger, euphoria, apathy)
• 😵‍💫 PSYCHOTIC-LIKE symptoms delusions, misinterpretations, illusions, and hallucinations (visual hallucinations are organic until proven otherwise)
• 🕺🏽 PSYCHO-MOTOR ACTIVITY disturb. groping/picking at clothes, attempts to get out of bed when unsafe, sudden movements, sluggishness, lethargy
• 😴 SLEEP/WAKE disturbance

“I WATCH DEATH” ⇒ 📷

1) Treat UNDERLYING CONDITION

2)🥇 HALOPERIDOL

#2 atypical antipsychotics, Tiapride

‣

💬

Øbenzos → aggrevate confusion+cognitive funcction

A 75-year-old man is brought to the emergency room by his family after they noticed changes in his behavior. He has been confused, disoriented, and easily agitated over the past few days. Upon examination, the patient is found to have a fever and an elevated heart rate. He is also experiencing difficulty sleeping and has been seeing and hearing things that are not there. The emergency room physician suspects that the patient is experiencing delirium, a sudden and severe change in mental function that can be caused by a medical condition or medication use.

Further evaluation reveals that the patient has a urinary tract infection, which is causing the fever and delirium. He is started on antibiotics to treat the infection, as well as medications to manage his symptoms of confusion, agitation, and sleep disturbances. The patient's delirium improves over the next few days as the infection is treated and his body begins to recover. He is then transferred to a rehabilitation center for further treatment and recovery.

1)

Patient: Mr. John Doe, 68 years old Medical history: smoking, hypertension, stroke

Presenting complaint: Mr. Doe was brought to the clinic by his wife, who noticed that he was having difficulty with planning and organizing daily tasks, as well as with memory recall. He also showed signs of confusion and disorientation.

Examination: Upon evaluation, Mr. Doe was found to have trouble with coordination and balance, as well as difficulty with understanding spoken language and expressing his thoughts. Neurological examination revealed mild weakness in the right arm and leg, and imaging tests showed evidence of multiple small strokes.

2) Patient: Mrs. Jane Smith, 76 years old Medical history: hypertension, diabetes, mild cognitive impairment

Presenting complaint: Mrs. Smith was brought to the clinic by her daughter, who noticed her memory loss and confusion. The patient was also having trouble performing daily activities such as cooking and taking care of herself.

Examination: Upon evaluation, Mrs. Smith was disoriented to time and place. She had difficulty recalling recent events and recognizing familiar faces. She also showed signs of forgetfulness, repeating the same questions multiple times. Neurological examination revealed mild difficulty with coordination and imbalance.

❓ unknown, multifactoral → neurodevelopmental disorder

M>F

+/- 🧠 ↓INTELLECTUAL ABILITY

Some skills weak (i.e. verbal communication, reasoning)

⇒ Do Ø REACH MILESTONES

‣

💬

+/- 🏝️ ↑ABILITY IN SPECIFIC SKILLS =  SAVANTS

Some patients have special skills in one area Memory, music, art, math Classic example: determining day of week for given date

1. 🕺🏽 Early behavioral / educational intervention
2. 💊  SYMPTOMATIC drugs
1. 😵‍💫 Atypical Antipsychotics ⇒🍓 RISPERIDONE,🤫 ARIPRIPRAZOL
1. ❄️ Stimulants (if ADHD features)
2. 🙂 SSRIs (if anxiety, OC-features)
‣
💬

3. 💤  Melatonin (if insomnia)
4. ⚡ anti-epileptics (if seizure)
‣
💬

Alice is a 6-year-old girl. She was diagnosed with ASD at age 4 after her parents noticed that she was having difficulty developing language skills and engaging in social interactions. She has difficulty with social communication and impaired social interaction. She rarely makes eye contact and has difficulty engaging in back-and-forth conversations. She often appears distant and prefers to be alone. Alice tends to become overwhelmed and upset when faced with changes in her routine and has difficulty transitioning from one activity to another. She also has repetitive behaviors, such as hand-flapping, spinning, and rocking.

Enduring pattern of anger and irritability with argumentative, vindictive, and defiant behavior toward authority figures. Treatment: psychotherapy (eg, CBT).

>6m

Onset before age 10. Severe, recurrent temper outbursts out of proportion to situation. Child is constantly angry and irritable between outbursts. Treatment: CBT, stimulants, antipsychotics.

>1y

Onset before age 5.

Anxiety disorder lasting ≥ 1 month

involving refraining from speech in certain situations despite speaking in other, usually more comfortable situations.

Development (eg, speech and language) not typically impaired.

Interferes with social, academic, and occupational tasks.

Commonly coexists with social anxiety disorder.

Treatment: behavioral, family, and play therapy; SSRIs.

Overwhelming fear of separation from home or attachment figure lasting ≥ 4 weeks(1m). (Can be normal behavior up to age 3–4.) → May lead to factitious physical complaints to avoid school.

Treatment: CBT, play therapy, family therapy.

Global cognitive deficits (vs specific learning disorder) that affect reasoning, memory, abstract thinking, judgment, language, learning.

→ Adaptive functioning is impaired, leading to major difficulties with education, employment, communication, socialization, independence.

Treatment: psychotherapy, occupational therapy, special education.

Onset during school-age years.

Inability to acquire or use information from a specific subject (eg, math, reading, writing) near age-expected proficiency for ≥ 6 months despite focused intervention.

General functioning and intelligence are normal (vs intellectual disability).

Treatment: academic support, counseling, extracurricular activities.