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Tx: SSRI (sertraline, paroxetine, citalopram, fluoxetine or fluvoxamine) are first-line and
SNRIs (venlafaxine, duloxetine). Other options buproprion and mirtazapine.
Buproprion does not cause any sexual side effects.
TCAs cause cardiac arrhythmias.
Sx at least for 2 weeks.
ECT if psychotic sx present.
Pharm and psychotherapy tx together the best.
Case 2: Schizophrenia, Paranoid
Bizarre delusions and auditory hallucinations for 1 month and should last for 6 months.
R/o medical conditions: hypothyroidism, hypercalcemia, syphilis
Tx: atypical antipsychotics (risperidone, olanzapine, quetiapine, aripiprazole).
Parkinsonian sx treat with reducing dose or anticholinergic (benztropine)
Akathisia (can’t stay still) tx with BZD or BB (propranolol)
Tx for NMS is dantrolene and bromocriptine.
Schizoaffective has mania
Case 3: Panic Disorder
Tx: CBT and SSRI. Also, SNRIs (venlafaxine) and TCAs. Short-term anxiety can use a BZD
(alprazolam).
Unexpected
Case 4: Hypothyroid with Depression
Meds that cause depression: Metoclopramide, Corticosteroids, OCPs, Propranolol,
Opiates, ampicillin, antineoplastic agents, ranitidine, BZDs
Case 5: Bipolar (Adolescent)
Tx: Mood stabilizer (valproate or lithium) and atypical antipsychotic agent (olanzapine,
quetiapine, risperidone) if psychosis present.. Monotherapy includes lithium, divalproex
and CBZ or the atypical antipsychotics if no psychosis. Lithium (older than 12) and
divalproex (younger than 12) are first choice.
Increased energy, lack of sleep, grandiosity, flight of ideas lasting at least 1 week
Antidepressants unmask mania.
Case 6: Schizoid
Tx: Psychotherapy long-term, but best is to seek job where low levels of interaction.
Cluster A: Odd and eccentric (Schizoid, schizotypal, paranoid)
Case 7: Major Depression in Elderly
Tx in geriatric patients is ECT. Use if patient is suicidal, catatonic or refusing food or
liquids. Can also use SSRIs, SNRIs, TCAs, and MAOIs. Start low and go slow.
No ECT if elevated ICP, unstable angina, recent MI, and electrolyte imbalances.
Case 8: Social Phobia (Public Speaking)
Tx: Behavioral or CBT is the best choice. Short term tx includes BZDs and beta-blockers
(atenolol and propranolol). Long term tx includes SSRIs (sertraline or fluoxetine) and
SNRI (venlafaxine). Also, buspirone in conjunction with SSRIs.
Tx for specific phobias include slowly desensitization.
More activity in amygdala and insula in patients with social phobia.
Case 9: PCP Intoxication
PCP intoxication symptoms include: violent, slurred speech (dysarthria), vertical
nystagmus, HTN, tachycardia, numbness, ataxia, muscle rigidity, seizures or coma and
hyperacusis (hearing sensitivity).
Tx: In non-psychotic patients use BZDs to prevent muscle spasms, seizures and sedation.
In psychotic patients, use haloperidol (typical antipsychotic) or atypical antipsychotics,
but beware of induced hyperthermia, dystonia, anticholinergic rxns and lowering the
seizure threshold. Treat HTN with IV antihypertensive medications.
Case 10: Dependent Personality Disorder
Tx: Behavioral therapy, assertiveness training, family therapy and group therapy.
Cluster C: “sad” anxious and timid (OC, Avoidant, Dependent)
Case 11: Generalized Anxiety Disorder
Tx: SSRI/SNRI with CBT or can use buspirone. Use BZDs for short term.
Anxiety for 3 months.
Case 12: Bipolar Disorder, Manic
Tx; Mood stabilizer (lithium, CBZ, valproate) and antipsychotics (risperidone).
Bipolar I: depression and mania
Bipolar II: depression and hypomania
4 episodes in 12 months
Mania or hypomania less than 1 week duration
Corticosteroids, levodopa and cocaine can cause mania.
Case 13: OCD
Tx: Psychotherapy (exposure/response prevention) and SSRI (fluoxetine, sertraline,
fluvoxamine)
Obsessions and compulsions.
Fluoxetine can cause suicidal ideation in children.
Case 14: Alcohol Dependence
Tx: Abstinence. AA groups. Medications
Disulfiram (Antabuse): blocks ADH
Naltrexone: opioid antagonist that reduces cravings for alcohol by blocking
dopaminergic pathway
Acamprosate (Campral): stabilize glutamatergic functioning
Case 15: Schizotypal Personality Disorder
Tx: Pyschotherapy
Case 16: Cocaine Use
Euphoria, dilated pupils, sweating, weight loss, agitation
Case 17: Delirium
Onset short
Case 18: Major Depression with Psychotic features
Tx: SSRI (continue for 6-12 months and taper over 2-3 months) and anti-psychotic (taper
off after 3 months)
Case 19: Conduct disorder
Tx; multisystem treatment
Case 20: Obsessive-Compulsive personality
Inflexible in thinking or behavior
Blames others
Perfectionism and inflexible
Case 21: PTSD
Acute if less than 3 months; Chronic if more than 3 months
Tx: Psychotherapy, pharmacotherapy and social intervention.
SSRIs (sertraline and paroxetine), SNRIs, TCAs and MAOIs. Also, prazosin.
Case 22: Dysthymic Disorder
Tx: SSRIs, SNRIs, and buproprion plus CBT.
Depressed mood for 2 years at least.
Children at least 1 year.
Case 23: Dementia
R/o reversible causes of dementia first
Memory impairment plus either agnosia, apraxia, or aphasia.
Tx: acetylcholinesterase inhibitors (GDR). Also, memantine (NMDA receptor antagonist)
Give low dose antipsychotic for violence or aggressive behavior. EPS likely with
Parkinson and LBD.
Case 24: Hypochondriac
Schedule frequent visits with primary care provider
Duration is 6 months
Case 25: Antisocial
Over 18
No remorse for others
Tx: SSRIs and mood stabilizers for aggressive behavior
Case 26: Schizoaffective Disorder
Paranoia with mood symptoms, but mood not always during paranoia
Tx: Antipsychotic (haloperidol or risperidone) or antidepressant SSRI. Mood stabilizers
(lithium, CBZ, valproate) used for manic symptoms.
Case 27: Psychosis from medical condition
Olfactory or gustatory hallucinations with seizure (medical condition)
Psychotic disorder in axis I
Medical condition causing the psychotic disorder on axis II
Case 28: ADHD
Tx: Pyschostimulants or atomoxetine
Sx for 6 months before age 7
Case 29: Bulimia nervosa
Tx: Nutrition, CBT and SSRI (fluoxetine and sertraline)
Anorexia before bulimia onset
Case 30: Acute Stress Disorder
Sx duration less than 4 weeks
Case 31: Opioid Withdrawal
Tx: Methadone or clonidine
Withdrawal sx: N/V, diarrhea, diaphoresis, F/C, lacrimation, rhinorrhea, muscle aches
and dilated pupils.
Case 32: Pain Disorder
Tx: pain clinic or biofeedback
Case 33: Histrionic Personality Disorder
Tx: Psychotherapy
Use repression and dissociation defense mechanisms
Case 34: Adjustment Disorder
Somatic complaints with mood (anxiety, depression)
Emotional response to a specific stressor
Tx: psychotherapy
Children present with irritability rather than saying they are depressed
Case 35: Factitious Disorder
Seen with borderline
Assume sick role
Case 36: Sleep Terror
Tx: do nothing except protect child from injury
Occur during delta sleep wave
Enuresis tx includes desmopressin and imipramine
Occur with restless leg syndrome or sleep-disordered breathing
Case 37: Primary Insomnia
Tx: sleep hygiene, CBT, relaxation, meds (ramelteon, trazodone, and BZDs)
Sleep problems for 1 month
Case 38: Somatization Disorder
Tx: frequent visits for reassurance or psychotherapy
Case 39: Psychotic disorder
Delusions and hallucinations with depressed mood and labile affect.
Tx: antipsychotic and mood stabilizer. Hospitalization. ECT.
Case 40: Extrapyramidal Symptoms (Acute Dystonic Reaction)
Tx: Benztropine 2 mg IM or diphenhydramine
Due to antipsychotics (block dopamine receptors in mesolimbic and mesocortical areas
and nigrostriatal pathway)
Akathisia tx is BB or BZD
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