Personality disorders have a lack of individual accountability results in a victim mentality and blaming others, society and t

Psychiatry Board Handouts
Panic disorders: Panic disorder is characterized by the spontaneous and
unexpected occurrence of panic attacks, the frequency of which can vary
from several attacks a day to only a few attacks a year. Patients present with
palpitations, pounding heart, accelerated heart rate sweating trembling or
shaking sense of shortness of breath or smothering feeling of choking or
faint fear of dying numbness or tingling sensations. Agoraphobia is defined
as anxiety toward places or situations in which escape may be difficult or
embarrassing which is a form of panic disorders. Precursors are phobias
Treatment:
Acute attacks:
 Alprazolam (Xanax)
 Clonazepam (Klonopin)
1st line therapy: (SSRIs, paroxetine, sertraline, fluoxetine)
Generalized anxiety disorder:
 Anxiety disorders appear to be caused by an interaction of biopsychosocial factors, including genetic vulnerability, which
interact with situations, stress, Post-traumatic stress syndrome is a
form of anxiety disorder (unable to cope)
 the major mediators of the symptoms of anxiety disorders appear to be norepinephrine and serotonin
 excessive uncontrollable worry about factors and circumstances in a patient’s life for a majority of the day for greater than 6 months.
Restlessness, fatigue, irritability, muscle tension, and insomnia.
 1st line therapy: SSRIs, paroxetine
 Lorazepam (Ativan®) the treatment of choice during acute attacks

Personality disorders is a collective term in which the patients have a lack of
individual accountability results in a victim mentality and blaming others,
society and the universe for their problems. Manipulative and exploitative
behavior and suffering from depression and other mood and anxiety disorders.
 Paranoid personality disorder (Delusions): suspiciousness, overall
delusions, and grandeur. Interrupt people’s actions as threatening.  Others are exploiting or deceiving the person.  Friends and associates are untrustworthy.
 Information confided to others will be used maliciously.
 The spouse or partner is unfaithful.
 Delusions are a type of psychotic symptom. Non-bizarre delusions are
fixed false beliefs examples include being followed or poisoned  They do not have hallucinations.
 They have long-term problems with employment and relationships
and friendships.
 Defensive, oversensitive, secretive, suspicious, hyperalert, with
limited emotional response
 Psychotherapy is the treatment of choice  SSRIs is the treatment of choice for long term therapy  Schizotypal personality disorder
 Symptoms include disturbances in thoughts (or cognitions), mood,  no close friends
 works alone
 solitary
 no sex
 detachment from social relationships
 restricted range of expression of emotions in interpersonal settings,
 odd speech
 beginning by early adulthood
 The hallmark symptoms of schizophrenia are auditory hallucinations
and delusions, which are fixed false beliefs. Impaired information
processing is a less vivid symptom that is highly disruptive.
 Schizophrenia is a chronic psychotic disorder with onset typically occurring in adolescence or young adulthood. Schizophrenia results in
fluctuating, gradually deteriorating, or relatively stable disturbances in
thinking, behavior, and perception.

 The syndrome must continue for at least 6 months=schizophrenia
 1-6 months=schizophreniform
 Schizoaffective=schizophrenia + major depression
 Schizoid=shy, introverted, withdrawn, avoids close relationships
 The hallmark symptom of schizophrenia is auditory hallucinations
 Treatment:
 1st line therapy agitation Haldol or chlorpromazine (Thorazine)
 1st line therapy outpatient=Olanzapine (Zyprexa®)
 Risperidone (Risperdal)
 Aripiprazole (Abilify®)
 Lorazepam (Ativan)
 Benztropine (Cogentin®)

Antisocial personality disorder - People sometimes use the term sociopath.
Symptoms typically appear in childhood. Before age 15 (Conduct disorder)
these individuals often display a pattern of lying, breaking the law and substance
abuse. As adults, people with this disorder may: Repeatedly break the law
Be unable to fulfill employment or financial obligations Display reckless
behavior Exhibit aggressive behavior Abuse alcohol and drugs
Selfish, callous, promiscuous, impulsive, unable to learn from experience,
has legal problems

Treatment: There's no specific treatment that's effective for this disorder.
Group counseling may help some people. Treatment of other conditions, such as
anxiety, depression and substance abuse, may improve symptoms.
Borderline personality disorder - Borderline Personality Disorder is
characterized by a pattern of unstable personal relationships, and poor
impulse control in areas such as spending, sexual conduct, driving, eating,
and substance abuse. There may be suicidal threats.
 Symptoms of BPD are usually present by late adolescence  Several researchers have proposed the existence of a constitutional incapacity to tolerate stress
 BPD rarely stands alone and commonly occurs simultaneously with other disorders, often preventing an accurate diagnosis.  These can include eating disorders, substance abuse, major depression
and bipolar disorder.
 increased impulsivity, cognitive inflexibility, and poor self-monitoring and perseveration, which may be indicators of frontal lobe dysfunction.  Treatment:
 1st line psychotherapy
 2nd line=Fluoxetine (Prozac) or any other SSRI
 Naltrexone (ReVia) (Opiate receptor antagonist)

Histrionic personality disorder overly dramatic. Minor situations can cause
wild swings in emotion. In relationships, they form bonds quickly, but the
relationships are often shallow, with the person demanding increasing amounts
of attention. They also tend to exaggerate friendships and relationships,
believing that everyone loves them. They are often manipulative.
Dependent, immature, seductive, egocentric, vain, emotionally labile
Treatment:
1st line Psychotherapy
2nd line SSRIs

Narcissistic personality disorder
Narcissistic patients are grandiose and require admiration from others. Particular
features of the disorder include the following:
 Exaggeration of their own talents or accomplishments
 Sense of entitlement
 Exploitation of others
 Lack of empathy
 Envy of others
 An arrogant, haughty attitude
 seek attention and praise
 exaggerate their achievements
 choosy about picking friends,
 difficulty maintaining long-lasting relationships.
 Lying is an integral part of the narcissist's behavior
Exhibitionist, grandiose, preoccupied with power, lacks interest in others,
with excessive demands for attention
Treatment:
 1st line Long-term psychodynamic therapy most effective
 2nd line SSRI
Avoidant personality disorder (social anxiety disorder)
 Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection.  feelings of inadequacy
 hypersensitivity to rejection
 Unlike patients with schizoid personality disorder, they actually desire
relationships with others but are paralyzed by their fear and sensitivity
 Shows restraint within intimate relationships because of the fear of
 Is preoccupied with being criticized or rejected in social situations.
 Views self as socially inept, personally unappealing, or inferior to
 Traumatic experiences
 parental overprotection, poor social skills, and parental anxiety have
been found to be related to social anxiety Fears rejection, hyperreacts to rejection and failure, with poor social
endeavors and low self-esteem
Treatment:
1st line psychotherapy
2nd line Paroxetine (Paxil)
3rd line Clonazepam (Klonopin) or beta blockers for performance anxiety

Obsessive-compulsive personality
 preoccupied with orderliness, perfectionism, and control.
 They lack flexibility or openness.
 Perfectionist, egocentric, indecisive, with rigid thought patterns and
need for control
 Their preoccupations interfere with their efficiency despite their focus on tasks. They are often scrupulous and inflexible about matters of morality,
ethics, and values to a point beyond cultural norms.
 They show perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met);
Treatment:
 1st line Psychotherapy
 2nd SSRIs


Bipolar Disorder: Bipolar disorder causes dramatic mood swings—from overly
"high" and/or irritable to sad and hopeless, and then back again, often with
periods of normal mood in between. Severe changes in energy and behavior go
along with these changes in mood. The periods of highs and lows are called
episodes of mania and depression.
Signs and symptoms of mania (or a manic episode) include:
 Increased energy, activity, and restlessness  Excessively "high," overly good, euphoric mood
 Racing thoughts and talking very fast, jumping from one idea to
 Distractibility, can't concentrate well  Unrealistic beliefs in one's abilities and powers
 Spending sprees
 A lasting period of behavior that is different from usual
 Increased sexual drive
 Abuse of drugs, particularly cocaine, alcohol, and sleeping medications  Provocative, intrusive, or aggressive behavior  Denial that anything is wrong
 DOWN SXS
 Sometimes, severe episodes of depression include symptoms of psychosis (or psychotic symptoms).
 Common psychotic symptoms are hallucinations and delusions
 suicide is common.
 Both children and adolescents can develop bipolar disorder.
 It is more likely to affect the children of parents who have the illness.

Treatment:
Depression: SSRIs are contraindicated
clozapine (Clozaril®), olanzapine (Zyprexa®), risperidone (Risperdal®), quetiapine
(Seroquel®), and ziprasidone (Geodon®)
"mood stabilizers/mania" Lithium valproate (Depakote®)gabapentin
(Neurontin®), carbamazepine (Tegretol®), and topiramate (Topamax®)
REMEMBER TO ORDER THE TSH WHEN PATIENTS OUR ON LITHIUM

Anorexia nervosa: is an eating disorder characterized by severe weight loss to
the point of significant physiologic consequences. Diagnostic criteria include an
intense fear of obesity despite slenderness, an overwhelming body-image
perception of being fat, weight loss of at least 25% from baseline or failure to
gain weight appropriately. Excessive physical activity, denial of hunger in the
face of starvation, academic success, asexual behavior, and a history of
extreme weight loss methods (eg, diuretics, laxatives, amphetamines,
emetics). Psychiatric characteristics include excessive dependency needs,
developmental immaturity, behavior favoring isolation, obsessive-compulsive
behavior, and constriction of affect. Cardiovascular effects include
supraventricular and ventricular dysrhythmias, long QT syndrome,
bradycardia, orthostatic hypotension, and shock due to congestive heart failure.
Renal disturbances include decreased glomerular filtration rate (GFR), elevated
BUN, edema, acidosis with dehydration, hypokalemia, hypochloremic
alkalosis with vomiting, and hyperaldosteronism
Treatment: extensive psychotherapy
Bulimia nervosa is an eating disorder characterized by eating binges. Binges
are frequently followed by self-induced vomiting, laxative and/or diuretic
abuse, prolonged fasting, or excessive exercise.
Teeth enamel destruction form severe vomiting
Some patients with anorexia nervosa also manifest bulimia. Many patients with
bulimia, however, are of normal weight or are overweight. Most commonly,
patients attempt to prevent weight gain by self-induced vomiting Laxative or
diuretic misuse is also common, although those substances almost exclusively
produce fluid rather than calorie loss. Individuals may display extreme caloric
restriction between episodes, may exhibit wide fluctuations in weight, or may
become obese. Menstrual irregularities may be caused by weight fluctuations,
nutritional deficiency, or emotional stress.
Remember this condition is the bipolar of eating disorders
Treatment: Psychotherapy and SSRIs and occasionally lithium


Adjustment Disorder: occurs when a person develops affective (emotional) or
behavioral symptoms in response to an identifiable stressor.
 Stressors can be natural disasters, retirement, divorce, or abuse. The
person displays either marked distress or unable to work or study.  last less than 6 months (after the stressor or its consequences end.
 If the symptoms last more than 6 months= depression.

Treatment: Psychotherapy
Depression: primarily serotonin neurotransmitter others include norepinephrine
(NE) and dopamine (DA) females>males
(b) Diminished interest or pleasure
(c) Significant weight loss or gain
(d) Insomnia or hypersomnia
(e) Psychomotor agitation or retardation
(f) Fatigue or loss of energy
(g) Feelings of worthlessness
(h) Diminished ability to think or concentrate; indecisiveness
(i) Recurrent thoughts of death, suicidal ideation, suicide attempt, or specific plan
for suicide
The symptoms persist for longer than 2 months

Need to rule out thyroid involvement TSH (hypothyroidism)
Need to rule out Addison’s, Cushing’s
Treatment:
1st line=SSRIs include fluoxetine (Prozac), paroxetine (Paxil), sertraline
(Zoloft), fluvoxamine (Luvox), citalopram (Celexa), and escitalopram (Lexapro).
Or
Selective serotonin and norepinephrine reuptake inhibitors include
venlafaxine (Effexor) and duloxetine (Cymbalta).
Atypical antidepressants include bupropion (Wellbutrin), nefazodone
(Serzone), mirtazapine (Remeron), and trazodone (Desyrel).
Tricyclic antidepressants (TCAs) include amitriptyline (Elavil), nortriptyline
(Pamelor), desipramine (Norpramin), clomipramine (Anafranil), doxepin
(Sinequan), protriptyline (Vivactil), trimipramine (Surmontil), and
imipramine (Tofranil).
MAOIs include phenelzine (Nardil) and tranylcypromine (Parnate)

THEY MUST BE TREATED FOR 1 YEAR AND MOST NOTE A CHANGE BY 2-
6 WEEKS OF THERAPY

Dysthymic disorder

By definition, this condition has a duration of at least 2 years in adults and 1 year
in adolescents and children. It is manifested as a depressed mood, or irritable
mood in children, for most of the day, occurring more days than not, and is
accompanied by at least 2 of the following symptoms:
 Poor appetite or overeating
 Insomnia or hypersomnia
 Low energy or fatigue
 Low self-esteem
 Poor concentration and/or difficulty making decisions
 Feelings of hopelessness
 persists for at least 2 years;
 less acute and severe than major depressive disorder
 low energy and drive, low self-esteem, and a low capacity for pleasure in
 may even withdraw from daily activities and isolate from society
 The rate of depression in the families of people with dysthymia is 50%
 Dysthymia is far more chronic than major depressive disorder
 SSRIs for dysthymia are fluoxetine, paroxetine, sertraline, and
fluvoxamine.

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