1. Psychiatry Review for Step II
Glenn Catalano, M.D.
Chief, Mental Health and Behavioral Sciences Service
James A. Haley Veterans Hospital

2. Classification Scheme
Axis I through Axis V
Mental retardation
Personality change secondary to GMC

3. Assessment Psychological Testing WAIS/WISC Rorschach/TAT MMPI
Bender-Gestalt

4. Assessment EEG Amobarbital Interview Temporal Lobe Diffuse Slowing
Fugue and Amnesia
Catatonic Schizophrenia vs. Organicity

5. Schizophrenia Overview Cause: Time course: At least 6 months
Not due to mood, organic or substance use disorder
Time course: At least 6 months
Post psychotic Depression
Brief Psychotic Disorder < 30 days
Schizophreniform Disorder 30< but <180 days
Schizophrenia > 180 days

6. Schizophrenia Symptoms Neurotransmitters Positive Negative
Positive = Dopamine (D2)
Negative = Serotonin (5HT-2A)

7. Schizophrenia Five Subtypes Paranoid (best prognosis)
Catatonic (catatonic excitement)
Undifferentiated
Residual
Disorganized (worst prognosis)

8. Schizophrenia: Definitions
Neologism
Word salad
Thought blocking
Idea of influence
Idea of reference
Catalepsy

9. Schizophrenia: Prognosis
Rapid onset
Late onset
Good premorbid functioning
Confusion at diagnosis (affective disorder?)
Precipitating stress
Female sex
Paranoid subtype

10. Schizophrenia: Concepts
Downward drift
Medication is forever

11. Schizophrenia: Genetics
1% general population
30% - 40% if two schizophrenic parents
40% - 50% if mono-zygotic twins

12. Schizophrenia: Variations
Brief psychotic disorder
Schizophreniform
Schizoaffective disorder
Delusional disorder
Psychosis secondary to GMC
Shared psychotic disorder
Substance induced psychotic disorder

13. Schizophrenia: Vignette

14. Mood Disorders Major Depression Dysthymia
Mood disorder secondary to GMC
Pancreatic carcinoma
Hypothyroidism
Bipolar Disorder
Cyclothymia
Substance induced mood disorder

15. Mood Disorders Major Depression Cause: Imbalance of Time Course
Serotonin (SSRIs)
Norepinephrine (TCAs)
Both (venlafaxine, mirtazapine, duloxetine)
Time Course
A minimum of 14 days
Versus adjustment disorder

16. Mood Disorders: Depression
Dysthymia
Any non-psychotic depressive symptom
2 year duration
Pseudodementia
Older , more somatic patients
“I don’t know”
Memory impairment
Time Course

17. Mood Disorders: Depression
Post-Partum Depression
Usually 2nd child
Versus “baby blues”
Atypical Depression
MAOIs
Hypersomnia, hyperphagia, weight gain, reverse diurnal variation
15% of depressions

18. Mood Disorders: Depression
Tests:
DST
Decreased REM latency in sleep studies
Scales
BDI
HAM-D
MADRS

19. Mood Disorders: Mania Bipolar I Disorder Bipolar II Disorder
Cyclothymia
Rapid Cycling Bipolar Disorder
Substance induced mood disorder, bipolar type
Mood Disorder 2o to GMC

20. Mood Disorders: Mania Bipolar I Disorder
Depressive episodes and manic episodes
Lithium, VPA, carbamazepine, lamotrigine
1% rule
Does not need to sleep

21. Mood Disorders: Mania Bipolar II Disorder
Depressive episodes and hypomanic episodes
Lithium, VPA, carbamazepine, lamotrigine
1% rule
Does not get psychotically manic

22. Mood Disorders: Mania Rapid cycling Bipolar Disorder
Four or greater deviations from baseline; remember an up/down sine wave counts as two episodes
VPA/carbamazepine superior to lithium
Time course of symptom control with mood stabilizers

23. Mood Disorders: Mania
Tests:
Urine drug screen

24. Mood Disorders: Mania
Concepts
Teratogenicity
Time course of treatment

25. Mood Disorders: Vignettes

26. Delirium and Dementia Delirium
Visual hallucinations, illusions most common
Fluctuating level of consciousness; “Waxing and Waning” course
EEG reveals “Diffuse Slowing”
Medical condition so severe that there are mental status changes
I WATCH DEATH
Delirium

27. Delirium and Dementia Delirium UTIs
Opioids, H2 Blockers, Anticholinergics
CHECK ALL LEVELS
Usually reversible
Delirium

28. Delirium and Dementia Dementia Normal level of consciousness
Most common is Alzheimer’s Dementia
Vascular dementia also common
Usually irreversible
Dementia

29. Delirium and Dementia Dementia Memory impairment Aphasia Apraxia
Agnosia
Disturbance in executive function
Dementia

30. Delirium and Dementia Dementia Alzheimer’s Dementia Vascular Dementia
Slow, steady decline
Vascular Dementia
Step wise decline
Normal pressure hydrocephalus
Urinary incontinence, dementia, ataxia
Dementia

31. Delirium and Dementia
Vignettes

32. Suicide and Assault Mood disorder associated with over 50% of suicides
Alcohol Dependent patients have a rate 50X the general population
Males complete more than females
3:1
Females attempt more than males

33. Suicide and Assault Beware the anniversary reaction High risk groups:
Adolescents and geriatrics
Divorced, separated, single or alone
Giving away possessions
Gender identity issues
Family history of suicide, cultural sanction of suicide
Early loss of parents
Impulsive

34. Suicide and Assault SSRIs vs TCAs & MAOIs High risk groups: Males
Physical illness
Previous serious attempts
Non-religious
White
Unemployed
Suicide epidemics

35. Suicide and Assault Cause of violence directs treatment
Psychotic = Hospitalize
Tarasoff decision
Predictors of violence
Excessive alcohol intake
History of violent acts
History of childhood abuse

36. Suicide and Assault Signs of impending violence
Recent acts of violence
Verbal or physical threats
Intoxication
Frontal lobe disease
Personality disorders
Command auditory hallucinations
Paranoid delusions

37. Suicide and Assault Intermittent explosive disorder
Directed violence
Neurologic soft signs
Temporal lobe epilepsy
NP leads
Incidental violence
Pharmacologic strategies
Lithium, carbamazepine, beta blockers

38. Suicide and Assault: Vignettes

39. Anxiety Panic disorder Generalized anxiety disorder Specific phobia
Social phobia
Obsessive-compulsive disorder
Post traumatic stress disorder
Acute stress disorder
Anxiety disorder secondary to GMC
Substance induced anxiety disorder

40. Anxiety: Concepts Panic disorder vs. GAD Ego-dystonic Agoraphobia
Flooding, implosion, systematic desensitization
Serotonin

41. Anxiety GAD Benzodiazepines Paroxetine, buspirone, venlafaxine
Muscle tension
“Worry disease”

42. Anxiety Panic Disorder
Often mistaken for MI; must be ruled out for MI in many cases
SSRIs, TCAs, MAOIs have efficacy
Buspirone and bupropion do not
Phobic avoidance
Anticipatory anxiety

43. Anxiety Anxiety disorder 2o to GMC Mitral valve prolapse
Acute intermittent porphyria
Abdominal pain
Psychosis
Motor polyneuropathy
Barbiturates precipitate attacks
Pheochromocytoma
Meniere’s disease

44. Anxiety Obsessive Compulsive Disorder Obsessions = thoughts
Compulsions = actions
Serotonin based medications
Compulsions include checking, hoarding, counting, hand washing, ordering, praying

45. Anxiety Post traumatic stress disorder Traumatic event
Reliving: nightmares, flashbacks, physiological arousal, recurrent intrusive thoughts, psychological distress (elephant pen)
Avoidance: numbing, amnesia, detachment, foreshortened future
Increased arousal: irritable, hypervigilance, exaggerated startle response
Carbamazepine/SSRIs

46. Anxiety Trichotillomania Related to OCD Associated with red hair
Chronic hair pulling
Hair may be eaten (trichophagia); beware of the bezoar
May respond to SSRIs

47. Anxiety: Vignettes PTSD OCD Panic Anxiety disorder secondary to GMC
Social phobia

48. Grief
Normal reaction to loss
DABDA
Kubler-Ross

49. Dissociation Dissociative fugue DID Dissociative amnesia
Sudden, unexpected travel away from home, often with inability to recall identity
Common in wartime or natural disasters
Associated with ETOH use
DID
Dissociative amnesia

50. Dissociation Dissociative fugue DID Dissociative amnesia
Two or more distinct identities that take control of an individual’s behavior
Associated with childhood sexual abuse
Overwhelmingly female (9:1)
Dissociative amnesia

51. Dissociation Dissociative fugue DID Dissociative amnesia
Episodes of inability to recall important information
Associated emotional trauma
Amytal interview

52. Dissociation
Vignettes

53. Somatoform/psychosomatic disorders
Conversion disorder
Neurologic symptoms only
Good correlation between emotional input and physical symptoms (burned baby)
Astasia abasia
Globus hystericus
Rule out medical problems first
La belle indifference

54. Somatoform/psychosomatic disorders
Somatization disorder
Symptoms from multiple organ systems
4 pain symptoms
2 GI symptoms
1 sexual symptom
1 pseudoneuroloic symptom
Onset prior to age 30
Female predominance

55. Somatoform/psychosomatic disorders
Pain disorder
Pain in one or more anatomic sites
Associated with psychological factors
Associated with both psychological factors and a GMC

56. Somatoform/psychosomatic disorders
Factitious Disorder
Aware of what they are doing, but unsure of reason
Malingering
Totally conscious
Somatoform disorders
Totally unconscious

57. Somatoform/psychosomatic disorders
Factitious Disorder
By proxy
Associated with medical field
Symptoms intentionally feigned to assume sick role
“gridiron abdomen”
Prolonged childhood hospitalization 
“Pseudologia fantastica”

58. Somatoform/psychosomatic disorders
Vignettes

59. Eating disorders Anorexia nervosa
Willful and purposeful behavior directed towards losing weight
Fear of becoming fat
Less than 85% of IBW
Body image disturbance
Missing at least 3 consecutive menstrual cycles

60. Eating disorders Anorexia nervosa More prevalent in females
Upper middle class illness
Carotenemia
Medical effects include:
Hypothermia, hypotension
Bradycardia, lanugo
Potassium loss can lead to death

61. Eating disorders Bulimia nervosa Recurrent episodes of binge eating
Eating large amounts of food quickly
Lack of control during binge
Recurrent inappropriate behavior to avoid weight gain
Vomiting, laxative abuse
Excessive exercise
Misuse of enemas, diuretics

62. Eating disorders Bulimia nervosa 10:1 female:male ratio High achievers
Normal or slightly increased weight
Bad teeth “moth eaten”
Swollen parotid glands
Scars on dorsum of hands

63. Medical mimics Pellagra Anticholinergic syndrome
Diarrhea, dermatitis, depression, dementia, death
Niacin deficiency
Anticholinergic syndrome
Delirium due to anticholinergic overload
Reverse with physostigmine (crosses BBB)
Depression can be caused by
Rauwolfia alkaloids (reserpine)
Beta blockers (great temporal relationship)
Pancreatic carcinoma (false neurotransmitter)

64. Neurological issues Kluver-Bucy syndrome often seen after TBI
Hypersexuality, hyperphagia, placidity
Klein-Levin Syndrome
Hypersexuality, hyperphagia, hypersomnia
A CVA places a patient at increased risk for depression for 2 years
L-frontal lobe 75% chance
Anywhere else 50%

65. Neurological issues Tourette’s syndrome
Syndrome of multiple motor and phonic tics
Coprolalia
Associated with ADHD and OCD
More common in males
Onset before age 18
Often treated with haloperidol, pimozide, clonidine

66. Alcohol Use Withdrawal is frequently fatal
15% of those going through DTs untreated will die
Symptoms include autonomic hyperarousal, increased hand tremor, insomnia, nausea, vomiting, transient hallucinations or illusions, seizures, psychomotor agitation and anxiety
Screening tests: MAST & CAGE
Thiamine deficiency
Wernicke’s and Korsakoff’s

67. Alcohol Use Fetal alcohol syndrome Best Treatment?
Medications for withdrawal
Commonly used aversive medication is disulfiram
Ataxia and a metallic taste in the mouth
Causes nausea and vomiting if patient uses ETOH while on disulfiram
Blocks aldehyde dehydrogenase; leads to a toxic acetaldehyde build-up

68. Drug Use
Opioid Use
Intoxication: pupillary constriction, drowsiness, slurred speech, impairment in attention (SLOW DOWN)
Withdrawal: dysphoric mood, nausea, muscle aches, rhinorrhea, pupillary dilation, piloerection, diarrhea, yawning, fever, insomnia (SPEED UP)

69. Drug Use Opioid Use: Factoids Methadone vs meperidine vs heroin
Mu receptors
How do heroin addicts die?

70. Drug Use: Other Drug Factoids
THC and eating
Synesthesias and hallucinogens
Vision quests (Mescaline)
Paranoid schizophrenia mimics
Amphetamine and PCP intoxication
Angel dust (PCP)
Decreased pain sensitivity
Superhuman strength
Rotatory nystagmus

71. Drug Use: Other Drug Factoids
Huffing of inhalants
Usually done in children (groups)
Latency aged kids
Can be fatal if child suffocates
First substance abused by kids
May have odor of paints or solvents.
“glue sniffer’s rash”

72. Personality Disorders
Cluster A, B, C
Antisocial: Majority of inmates
OCD vs OCPD
Transient psychosis
Borderline and histrionic
Schizoid vs schizotypal vs avoidant

73. Sex and sleep: Factoids
Sexual excitement stages
The “stamp test”
Vaginismus/dyspareunia
Premature ejaculation
30% of men
Highest in college educated

74. Sex and sleep: Factoids
Paraphilias are ego syntonic
Sexual excitement from “bizarre or unusual” stimuli
Pedophilia highly recidivistic
Aversive treatment
“Chicken hawks”
Sadism/masochism
Frotteurism/voyeurism

75. Sex and sleep: Factoids
Sleep stages:
Stage I
Stage II
Stage III deepest portion of sleep
Stage IV deepest portion of sleep
Sleepwalking, night terrors, good muscle tone
REM
Decreased muscle tone, nightmares

76. Sex and sleep: Factoids
Narcoleptic tetrad
Hypnogogic or hypnopompic hallucinations
Sleep paralysis
Sleep attacks,
cataplexy
Treated with sodium oxybate (GHB)

77. Mental retardation Mild (50-70 IQ) 85 % those affected
Moderate (35-50 IQ) 10%
Severe (20-35 IQ) 4%
Profound (Less than 20 IQ)

78. Medication Factoids SSRIs TCAs MAOIs Other antidepressants
Dextromethorophan
SSRIs, meperidine
Pizza
Other antidepressants
Psychostimulants
Atypical antipsychotics
Conventional antipsychotics
Mood stabilizers
Benzodiazepines
Anticholinergics

79. Medication Factoids Oculogyric crisis EPS Akathisia NMS
Rigid, increased CPK, fever, HTN
Tardive dyskinesia
Priapism
Manic overshoot
Teratogenicity of mood stabilizers
Therapeutic window
TCA overdose
TCA hypotension
Lithium range
Thyroid, bone, kidney

80. Medication Factoids Skin color changes Retinitis pigmentosa
Amoxapine and TD
Carbamazepine
Diplopia, induction of own metabolism
Leukopenia
PTSD
Serotonin syndrome
Tremor, hypertonia, myoclonus, autonomic signs, hallucinosis, hyperthermia, death

81. Medication Factoids ETOH withdrawal benzodiazepines
Panic disorder benzodiazepines
SSRIs by the pound!
ECT
Uni vs bilateral
indications
Pre-medication:
Stop lithium, reserpine
Remove dentures
Atropine for secretions
Methohexital for sleep
Succinylcholine for muscle relaxation

82. Legal stuff Tarasoff Decision Capacity decisions M’Naughton rule
Informed consent