PSYCH EOR 18%; 14%; 12%; 10%; 8%; 4%

Depressive Disorders; Bipolar 18%

Disorder About Criteria Treatment
Bipolar I/II •Mania: abnormal or persistently elevated, expansive or Bipolar I: •1st line-Lithium
irritable mood for at least 1 WEEK 1+ full manic or mixed episode and occasional •Others: Carbamazepine, Valproic Acid
depressive
•Hypomania: mania sx for 4 DAYS; no impairment
Bipolar II:
1+ MDD and 1+ hypomania episode
•Mixed: criteria for one and 3+ sx of other
•Rapid: 4+ ep/yr

Cyclothymi •Similar to bipolar II but less severe 2+ YEARS of hypomania and depressive symptoms •Mood stabilizers (Lithium) and
c •Gender: men=women (no more than 2 free consecutive months neuroepileptics

Major Risks: 2+ WEEKS of 5+ SX •Psychotherapy

Depressive •FHX, female, 20-40yo must include anhedonia or depressed mood •SSRI x3-6 weeks
Disorder
(MDD) Screen: •Somatic SX: constipation, HA, skin changes, chest or
•PhQ2  PhQ9 abdominal pain, cough, dyspnea
•Zung Self-Rated

Pathophys:
•Alteration in neurotransmitters serotonin, epi, norepi,
dopamine, ach, histamine
•Neuroendocrine dysfunction (adrenal, thyroid, GH)

Persistent •Patients are usually able to function Persistently depressed for 2+ YEARS with 2+ •SSRI and therapy
Depressive •No SX of hypomania, mania, or psychotic features symptoms (no more than 2 consecutive free months)
Disorder
(Dysthymia) •MC in women and teens/early adulthood

MDD Subtypes:
Seasonal: depressive sx at the same time each year, MC winter
- TX: SSRI, light therapy, Bupropion

Atypical: mood reactivity with depression (improve in response to positive events)

- TX: MAOI Inhibitors (A/B: Nardil, Parnate, Marplan; B only: Eldepryl)

Melancholia: anhedonia (inability to find pleasure in things), lack of mood reactivity, depression, severe weight loss/loss of appetite, excessive guilt, psychomotor agitation,
or retardation & sleep disturbance (increased REM time and reduced sleep). Sleep disturbances may lead to early morning awakening or mood that is worse in the morning

Catatonic: motor immobility, stupor, extreme withdrawal

Anxiety; Trauma; Stress 18%
Disorder About & Criteria Symptoms Treatment
General Excessive anxiety or worry a majority of days for •restless/on edge •irritable •SSRIs (Paroxetine, Escitalopram)
Anxiety 6+ months with 3+ symptoms •fatigue •sleep disturbance •SNRI (Venlafaine)
Disorder •difficulty concentrating •muscle tension •Benzos •Buspirone
(GAD) •CBT x6-12 months

Panic Panic Attacks: Physical Symptoms: Panic Attacks:

Attacks/ •Episode of intense fear or discomfort that develops •dizzy, trembling, choking, paresthesias, sweating, SOB, CP, •Benzos (Lorazepam, Alprazolam)
Disorder abruptly; usually peaks within 10min, last <60min chills, fear of losing control, fear of dying, palpitations,
tachycardia, nausea, depersonalization or derealization Panic Disorder
Panic Disorder Criteria: •SSRI (Paroxetine, Sertraline,
•Recurrent, unexpected panic attacks Panic Disorder Criteria Symptoms Fluoxetine)
•2+ attacks x1 month and 1+ criteria sx •persistent concern/worry of another attack •CBT
4/13 physical symptoms •worry of losing control during attack
•maladaptive behavior Acute Attacks: Benzos

Post- MC in young adults AVOIDANCE (1+): effort to avoid measure, effort to avoid 1st line-CBT with exposure
Traumatic •Men: combat experience, urban violence reminders
Stress •Women: rape or assault •SSRI/SNRI (Paroxetine, Sertraline,
Disorder EXPOSURE (1+): direct experience, witness, learn it happened Fluoxetine)
(PTSD) PTSD Criteria: to someone close, extreme/repeated exposure
1. Exposure to actual or threatened death, serious •Trazadone is good to use insomnia
injury, sexual violence INTRUSTION (1+): distressing memories, distressing dreams,
- Direct experience of the event feeling or reoccurrence, psych reaction or stress
- Witness the event
- Learn the event happened to someone close NEGATIVE CHANGE IN MOOD/COGNITIVE (2+):
- Experience extreme or repeat exposure to memory loss, exaggerated, distorted thoughts, negative state
details constantly, inability to be positive, decreased interest,
2. Presence of symptoms (avoidance, exposure, detachment
intrusion, negative change, arousal/reactivity)
3. ALL have to occur for ONE MONTH AROUSAL/REACTIVITY (2+): irritable, reckless, startled
easily, sleep disturbance, difficulty concentrating
Acute Stress Disorder: PTSD symptoms <1 month

Phobic •Symptoms 10-15min prior to specific stress event •out of proportion 1st line: CBT/exposure therapy
Disorder •6+ months of fear/anxiety about an •causes fear 2nd line: SSRI, Benzos
object/situation •actively avoided
•distress Specific, predictable trigger: Benzos
Agoraphobia: SSRI & CBT

Social 6+ months of intense fear of social situation or •CBT, SSRI/SNRI or both

Phobia/ performance where you can be scrutinized •Performance: Beta Blockers
Anxiety
Agoraphobi •Fear of going into places where you may not be Scenarios: •SSRI, CBT, or both
a able to escape •public transportation •open or closed spaces
•6+ months of fear/anxiety about 2+ scenarios •crowd/lines •outside home
Substance-Related Disorders 14%
Substanc About Intoxication Withdrawal Treatment
e
Alcohol Drink: Alcohol Intoxication: •uncomplicated (6-24h): increased CNS Withdrawal:
•12oz beer •8oz malt liquor •Slurred speech activity (tremors, anxiety, diaphoresis, •Benzos, Clonidine,
•5oz wine •1.3oz spirits •incoordination, unsteady gait palpitations, insomnia) Barbiturates, Anticonvulsants
•nystagmus •IV fluids
At-Risk Drinking: •impairment in memory or attention •withdrawal seizure (12-24h): •Thiamine & Magnesium
Continuous use of alcohol •coma or stupor MC tonic-clonic •Glucose
-men: 4 drinks/day or 14 drinks/week
-women: 3 drinks/day or 7 drinks/week Wernickes TRIAD: •alcoholic hallucinosis (48h): Chronic use TX:
confusion, ataxia, ophthalmalgia hallucinations with normal vital signs •Naltrexon
Moderate-Severe Drinking: •Campral
•Recurrent use of alcohol despite risks Karsakoff: •Thiamine
•delirium tremens (2-5d): delirium,
amnesia, aphasia, apraxia, agnosia •Antabuse (punishes you for
Tolerance: need for increased amounts
hallucinations, agitations, abnormal vitals
drinking)
of alcohol; diminished effect with
continued use of same amount S/S: sweating, tachycardia, increased hand
tremor, insomnia, N/V, hallucinations,
agitation, anxiety, seizure

Substance Intoxication Withdrawal Treatment

Marijuana •Takes effects in about 10-20 minutes Withdrawal *usually only with heavy use Urine drug test can detect for 4-6
•Cannabis binds to CB1/2 cannabinoid receptors •irritable days and up to 50d in chronic users
•insomnia & restless
Intoxication •diaphoresis Treatment:
Moderate dose: •diarrhea Symptomatic
•euphoria, giddiness •twitching
•dry mouth (cotton mouth)
•conjunctival erythema Complications of long-term use:
•tachycardia, hypotension •laryngitis & rhinitis
•low testosterone and low sperm count
High Dose: hallucinations, paranoia, delusions

Tobacco Withdrawal: (+) effects: decrease anxiety and appetite, increase mood, •Nicotine Replacement
•restless alertness, soling •Buproprion
•anxiety •Verenicline (Chantix)
•irritable (-) effects: CA, DM, COPD, asthma, dental, infection
•sleep abnormalities
•depression Tolerance due to UP REGULATION of receptors
•nicotine craving
•weight gain
Substance Intoxication Withdrawal Treatment
Hallucinogen PCP (NMDA receptor antagonist) *15-30 minutes PCP Labs: CK-MB, AKI, CBC, CMP.
PCP, LSD •S/S: euphoria, numbness, disorientation, physical S/S: depression, anxiety, irritable, restless, sleep urine drug test
detachment, body distortion, unusual strength, dilated disturbance
pupils, nystagmus Treatment:
LSD •Haloperidol
LSD (5-HT receptor) •no withdrawal because it does not affect dopamine •Benzos
•S/S: visual hallucination, see sound as color, dilated •Low stimulus environment
pupils, delusions

Inhalent Intoxication Common Chemicals Antipsychotics if severe aggression

Paint, Mild/moderate: euphoria, slurring speech, confused, •Toluene
petroleum, hallucinations, watery eyes, impaired vision, rash •Butane, Propane
toluene, glue, •Fluorocarbons
nail polish High dose: cardiopulm failure, liver, kidney, bone •Chlorinated hydrocarbons
marrow suppression *all organ failure •Acetone

Opioid MOA: mu receptor agonist Withdrawal Intoxiation:

heroin, •lacrimation Naltrexone (1st line)
oxycodone, Intoxication: •HTN, tachycardia Methadone,
morphine, •euphora •pruritic Buprenorphine
meperidine, •sedation & impaired memory •piloerections (goose bumps)
codeine •slurred speech •pupil dilation OD: Nalaxone
•impaired social function •flu-like symptoms
•pupil constriction •yawning Withdrawal:
•respiratory depression Methadone
Clonidine
•bradycardia & hypotension
Lofexidine
•nausea, vomit, flushing
Suboxone
Biots breathing: quick, shallow inspirations  apnea

Sedative/ GABAa channel-increased frequency of opening Withdrawal: Intoxication:

Hypnotic/ •rebound anxiety •Flumazenil (GABA antagonist)
Anxiolytic Intoxication: •seizures and tremors
Benzos •respiratory depression Withdrawal:
•hypotension •long acting benzo (Clonazepam)
•ataxia, amnesia (forget things), coma, death

Stimulants Intoxication: Withdrawal: Intoxication:

Cocaine •mydriasis (pupillary dilation) •depression and SI *do not restrain due to rhabdo risk
Amphetamine •hyperactivity, euphoria •hyperphagia •antipsychotics •benzos
Meth •perspiration •hypersomnolence & fatigue •antihypertensives (Labetolol)
•excessive talking  depression •craving •vitamin C
•weight loss, anorexia •vivid unpleasant dreams
•dry mouth Withdrawal:
 •nose bleeds and sepal perforation (COCAINE!) Kindling: hallucination and paranoia •Bupropion •Bromocriptine

Schizophrenia 12%
Disorder Criteria Notes Treatment
Delusional >1 delusion for >1 months WITHOUT other psychotic symptoms Antipsychotic
Disorder *usually non-bizarre

Brief Psychotic 1+ psychotic symptom with onset and remission in <1 month
Disorder
Schizophrenifor schizophrenia >1 MONTH but <6 MONTHS Antipsych
m
Schizoaffective Schizophrenia + mood disorder x2 WEEKS Antipsych
Disorder (psych continues w/o mood) (MDD worse)

Schizophrenia characteristic symptoms with social and/or occupational Risks: fhx, weed, immigrant, male, fetal hypoxia, preterm 2nd gen Anti-psych
dysfunction for 6 MONTHS labor, maternal infection. Maternal stress, winter birth; *positive symptoms
substance  Nicotine respond better
(+) symptoms: due to excess dopamine
hallucinations, delusions, disorganized speech & thinking, Onset: Women: late 20s Men: early 20s MOA: dopamine and
abnormal behavior serotonin antagonists
Brain: Less gray matter, increase in ventricular size, increased
(-) symptoms: due to dopamine dysfunction/decrease dopamine receptors, low glutamate function, decreased GABA
flat emotional affect, social withdrawal, lack of emotional
expression, avolition (lack of self-motivation) Metabolic: HTN, DM, HLD, insulin resistance

Psychosis: disturbance in the perception of reality (hallucinations, delusions, disorganized speech, catatonic behavior, abnormal emotions, cognitive difficulties)
Hallucinations: sensory perceptions in the absence of external stimuli
Illusions: sensory misperceptions of actual external stimuli
Delusions: fixed false beliefs that persist even with evidence to the contrary

Types of Disorganized Speech:

- Tangentiality: speech begins in a goal-directed manner, but deviates gradually and consistently off-topic such that answers to questions are not reached
- Circumstantiality: speech is goal-directed but full of unneeded detail and gets to the answer in a “roundabout” way
- Derailment: speech begins in a goal-directed manner, but topic shift rapidly between sentences with no logical connection to the topic previously discussed
- Neologisms: creation and use of new, nonsensical words
- Incoherence: incomprehensible speech due to loss of logical (severe-word salad)
- Clanging: words are used on how they sound rather than what they mean
- Concrete speech: inability to use abstract thinking
- Perseveration of ideas: consistently returning to one topic despite the conversation going in a different direction

Types of Delusions
- Persecutory: person or force is interfering with them, observing them or wishes harm to the patient
- Reference: Random events take on a personal significance (directed at them)
- Control: some agency takes control of patients thoughts, feelings, behaviors
- Nihilism: unrealistic belief in the futility of everything and catastrophic events
- Grandiose: unrealistic in one’s powers and beliefs
- Erotomanic: believes another person is in love with them
 - Jealousy: somebody is suspected of being unfaithful
- Doubles: believes a family member or close person has been replaced by an identical double
Disruptive, Impulse, Conduct, Neuro-Developmental 10%
Disorder About/Criteria Presentation Treatment
ADD/ADHD Symptoms usually onset before age 12 and Inattentiveness: easily distracted, difficulty focusing, miss 1st line 6yo+-Stimulant (Methylphenidate
occur in 2+ settings with 6+ symptoms from details, forget/lose things, becomes bored, can’t finish tasks (Ritalin), Amphetamine (Adderall), Focalin
either criteria
Hyperactive/Impulsive: fidgets, can’t sit long, constantly in 1st line preschool-behavioral therapy
motion, talks a lot, impatient, dashes around, interrupts

Oppositiona 6 MONTHS of 3 components Persistent pattern of negative, hostile, defiant behavior Behavioral therapy
l Defiant -angry/irritable mood towards adults *may progress to conduct disorder
Disorder -argumentative/defiant
(ODD) -vindictiveness

Conduct MC in <12yo, males, ADHD/ODD 4 areas: Violations of laws, aggression, destroy, deceitful, EARLY intervention
Disorder Violate societal norms/right for 12 MONTHS violate-hurts others/animals Risperidone, SRRI, anticonvulsant
Deviate sharply from age-appropriate norms 40% develop antisocial personality

Autism Spectrum of developmental disorders likely linked Social difficulties: emotional discomfort or detachment education, behavior, screening
to combination of prenatal viral exposure, immune (avoid eye contact, no response to affection)
system abnormalities and/or genetic factors -lacks empathy, does not imitate others, no interaction Medication:
Methylphenidate for hyperactivity,
MC in males Impaired communication: inability to communicate or Risperidone for maladaptive behavior
Onset about 2 years old chooses not to; difficulty understanding metaphors, jokes
-echolalia, pronoun reversal
Restrictive, repetitive, stereotyped behavior

Somatic Symptom; Nonadherence 8%

Disorder About Symptoms/Criteria Treatment
Factitious •Intentional falsification of exaggeration of signs Symptoms: Therapy
Disorder and symptoms of medical or psychiatric illness for •Creation of exaggeration of symptoms of illness
“primary gain” (sympathy) •May be willing or eager to undergo surgery repeatedly or painful tests
•may inject themselves with substances or make themselves sick; hospital jump
•Inners need to be seen as ill or injured, but NOT
for concrete personal gain (like malingering) Munchausen: predominance of physical sx, use of aliases, habitual lying
Malingering: intentional falsification of S/S for secondary gain

Illness •MC age 20-30 years old Criteria: Regularly scheduled

Anxiety •Frequently tested, “doctor shop” preoccupation w/ fear that one has or will contract illness for 6+ MONTHS visits to healthcare
(Hypo- excessive behaviors, maladaptive avoidance provider
chondriasis)

Somatic •MC in women <30 years old Criteria: sx in 1+ part of body with no cause for 6+ MONTHS Regularly scheduled
Symptom visits to healthcare
(Somatization •Physical symptoms involving 1+ body part but Symptoms: SOB, dysmenorrhea, burning in sexual organ, lump in throat, amnesia, provider
 Disorder) NO PHYSICAL CAUSE vomiting, painful extremities

Personality Disorder; Obsessive-Compulsive 8% *A=odd and eccentric, B=dramatic, emotional, erratic, C=anxious and fearful
Disorder About Presentation Treatment
Body •MC in females and teens; anxiety and depression •Commit repetitive acts in response to this preoccupation (mirror •SSRI (Fluoxetine)
Dysmorphic •pre-occupied with 1+ aspect of appearance checking, skin picking, seeking reassurance) or mental (compare) •TCA (Clomipramine)
*MC are hair, face, genitals, breasts •Psychotherapy

Paranoid • (+) fhx of schizophrenia •generalized distrust or suspicion  grudges, defensive, oversensitive Psychotherapy
*Type A •Begins in early adulthood, MC in males pre-occupation with doubt regarding others loyalty
+/- low dose antipsychotic,
Exam: poor eye contact or fixated antidep or psychostimulant

Schizoid •Long pattern of voluntary social withdrawal and •Detached, introverted, restricted emotion, doesn’t desire or enjoy Same as above
*Type A anhedonic introversion (“hermit-like” behavior) relationships, not distressed

Exam: falttened affect, quiet, stiff, difficult to engage

Schizotypal • (+) fhx schizophrenia •peculiar thoughts, speech, behavior, magical beliefs Same as above
*Type A •early adult onset •NO DELUSIONS OR HALLUCINATIONS

Exam: weird, off speech

Antisocial •>18yo; MC in men, prisoners, alcoholics •manipulative, selfish, no empathy, disregard and violation of rights Psychotherapy
*Type B •Often begins in childhood as conduct disorder and feelings of others Pharm NOT helpful
•Commonly drunk drive •Deviate sharply from the norms, values, and laws of society

Histrionic •MC in women •excessive, superficial emotional and sexually drawn to attention Psychotherapy
*Type B •Overly emotional, dramatic, seductive, attention dependent, insecure, seductive, center of attention
seeking
Exam: inappropriate, attention

Borderline •risks: sexual or physical abuse history •stormy relationships, labile mood, impulsive, self-injury, low self- Psychotherapy
Personality •Unstable, unpredictable mood and affect esteem, black and white thinking
*Type B
Narcissistic •Grandiose often excessive sense of self-importance •grandiosity, lack empathy, entitled, hypersensitive, arrogant, poor Psychotherapy
*Type B •MC in males response to criticism, inflated self-esteem
•Needs praise and admiration

Avoidant •Desires relationships but avoids due to intense •persistent avoidance due to anxiety  lifestyle decreased, introverted, •Psychotherapy
*Type C feelings of inadequacy anxious, withdrawn, shy, timid •+/- BB for anxiety, SSRI

Dependent •Dependent, submissive behavior •submissive, rely on other, agreeable, withhold info •Psychotherapy
*Type C •constantly needs reassurance, relies on others for decision making, will •+/- anxiolytics and antidep
not initiate things, intense discomfort with being alone

Obsessive- •Perfectionists who require a great deal of order •Rigid adherence to routines, inflexible, stubborn, perfectionist •Psychotherapy
 Compulsive and control •have rules, lists, details, “good patient” •+/- BB for anxiety, SSRI
*Type C •Preoccupied with minute details
Feeding 8%
Disorder About Presentation Findings Treatment
Anorexi •Refusal to maintain a minimally normal body LOW BMI (>17.5kg/m2) or body weight <85% ideal Labs: CBC, CMP, UA, 1st line-multimodal
a weight due to desire for thinness electrolytes, INR, EKG (therapy, SSRI,
Nervosa •Morbid fear of gaining weight Clinical findings: emancipation (thin), depressed, nutrition)
fatigue, bone pain, amenorrhea, abd pain, constipation, •Leukocytosis & leukopenia
Types: hair loss, brittle nails, Russel Sign (callous on hands), •Anemia Hospital:
hypothermia, decrease HR and BP, lanugo, petechial, •Hypokalemia •<75% ideal body wt
Restrictive: reduced calorie intake, dieting,
osteoporosis •Hypothyroidism •electrolyte imbalances
excessive exercise, diet pills
•Increased BUN (dehydration) •cardiac abnormalities
Purging: primarily engages in self-induced
vomiting, diuretic, laxative, enema

MC in women and mid-teens

Bulimia Purging (laxative, vomiting) v. non-purging NORMAL/HIGH BMI •Metabolic alkalosis 1st line-multimodal
Nervosa (exercise); Recurrent binging & compensation •Hypokalemia •therapy
ONCE WEEKLY x3 MONTHS Clinical findings: abdominal pain, constipation, hair •Hypomagnesemia •SSRI-Fluoxetine
loss, russel sign, teeth pitting or enamel erosion, •nutrition
MC in females and late-teens increased heart rate, puffy cheeks (parotid gland)

Paraphilic Disorder; Sexual 4%

Disorder About Criteria Treatment
Exhibitionisti Showing of one’s genitals to 6+ MONTHS-recurrent and intense sexual arousal from exposure of •Insight-oriented behavioral therapy
c an unsuspecting person ones genitals •SSRI (impulse control)
•Antiandrogens (paraphilic activity)

Female Sexual persistence or recurrent •Lack of, or significantly reduced, sexual interest/arousal with 3+ •Psychotherapy and couple's therapy
Interest/ inability to achieve sexual -Absent/reduced interest in sexual activity •Sildenafil/taldalfil *off-label
Arousal arousal -Absent/reduced sexual/erotic thoughts or fantasies •Testosterone *off-label
Disorder -No/reduced initiation of sexual activity, and unreceptive to attempts
•Absent/reduced sexual excitement/pleasure during sexual activity
•Absent/reduced sexual interest/arousal in response to stimuli
•Absent/reduced genital or non-genital sensations during sexual activity

Genito-Pelvic Pain/Penetration Disorder: SX above for 6+ months

Fetishistic Sexual arousal obtained by •6+ months recurrent and intense sexual arousal from either the use •Psychotherapy; Insight-oriented, behavioral therapy
Disorder specific objects of nonliving objects or a highly specific focus on non-genital parts •SSRI (impulse control)

Male lack or absence of sexual •6+ MONTHS •Psychotherapy/counseling is first line

Hypoactive fantasies and desire for •persistently or recurrently deficient (or absent) sexual/erotic thoughts or •Testosterone supplementation *short-term
Sexual Desire sexual activity fantasies and desire for sexual activity
Disorder

Disorder About Criteria Treatment

Pedophilic Sexual arousal by •6+ MONTHS •Psychotherapy
Disorder prepubecscent children •recurrent, intense sexually arousing fantasies, sexual urges, or behaviors •Insight-oriented, behavioral therapy
(generally ≤13 years) involving sexual activity with a prepubescent child or children •SSRI (impulse control)
• individual is at least 16yo and at least 5 years older than the child •Antiandrogens

Sexual Arousal from being •6+ MONTHS •Psychotherapy

Masochism threatened or hurt during •recurrent and intense sexual arousal from being humiliated, beaten, •Insight-oriented, behavioral therapy
Disorder sexual activities bound, or otherwise made to suffer •SSRI (impulse control)
•Antiandrogens

Voyeuristic Observing unsuspecting •6+ MONTHS •Anti-psychotics and antidepressants

Disorder persons naked or performing •recurrent and intense sexual arousal from observing an unsuspecting •therapy
sexual activities person who is naked, in the process of disrobing, or engaging in sexual •possible pornography as a treatment
activity, as manifested by fantasies, urges, or behaviors.
•at least 18 years old

BIPOLAR PHARM
Bipolar Labs/Indication Side effects DDI CI
Lithium Indication: Acute: GI, tremor, thirst, polyuria, weight •Diuretics •CKD, dehydration, sodium
•Acute mania/hypomania or gain, loose stools •NSAIDS depletion
maintenance •ACEIs •cardiovascular disease
Long term: •Tetracyclines •pregnancy
•Antidepressant *several wk LITH-PA •Metronidazole •Ebstein’s anaomly
onset •Leukocytosis, insipidus (renal), tremor, •theophylline •increased lithium toxicity
•Reduced SI risk & relapse risk hypothyroidism, parathyroid, arrhythmia

Valproate •Bipolar I/II N/V, HA, hair loss, bruising, weight gain, •TCAs •Allergy
*Depakote tremor, dizziness •anticonvulsants •Liver
enteric coated Labs: •Mitochondrial
*increase GABA •Serum drug Rare: hepatotoxicity, pancreatitis, •Pregnancy
•LFT thrombocytopenia

Lamotrigine •Bipolar I/II Nausea, rash, pruritis, drowsiness, MANY Allergy

*inhibit
glutamate Labs: Rare: *safest for pregnancy
•Serum drug •multiorgan hypersensitivity
•LFT, renal •SJS, TEN

Carbamazepine •Bipolar I/II Nausea, rash, pruritis, hyponatremia, fluid MANY •Allergy
retention, leukopenia •TCAs
Labs: •MAOI w/n 2 weeks
 •Serum drug levels Rare: bone marrow suppression, aplastic •Bone marrow suppression
•LFTs, CBC, sodium anemia, SJS, TEN •Pregnancy

SCHIZOPHRENIA PHARM
Side Effect Anti-Psychotics Symptoms
Hyperprolactinemia Typicals (1st generation) Gynecomastia Acne Typical (1st Gen; + sx)
Risperidone Galactorrhea Hirsutism Low Potency “Thor and Thio”
High dose Olanzapine or Ziprasidone Abnormal menses Infertility Chlorpromazine (Thorazine)
Sexual Dysfunction Thioridazine (Mellaril)
Anticholinergic Low-potency typicals Constipation Blurred vision High Potency “Halo’s Compromize”
Clozapine Urinary retention Cognitive impairment Haloperidol (Haldol)
Olanzapine, Quetiapine Dry mouth Prochlorperazine (Compazine”

Sedation Low-potency typicals Atypical (2nd Gen; +/-sx) “ABCC

Clozapine ROQZ”
Olanzapine, Quetiapine (“quiet”) Clozapine (Clozaril)
Olanzapine (Zyprexa)
Extrapyramidal High potency typicals-MC Psudoparkinsonism Dystonia Quetiapine (Seroquel)
Symptoms Akathisia Tardive Dyskinesia Ziprasidone (Geodon)
Hypotension Low-potency typicals Orthostatic hypotension *MC elderly, HTN, Risperidone (Risperidal)
Clozapine cardiovascular disease Aripiprazole (Abilify)
Risperidone, Quetiapine Brexipiprazole (Rexulti)
Agranulocytosis Clozapine Neutropenia *CBC weekly x6mo, Cariprazine (Vraylar)
Agranulocytosis biweekly x6mo, then
mo. “-pine, done, zole + Cariprazine”
Seizure Low-potency typicals *avoid depot Lower seizure threshold
Clozapine

Cardiac Arrhythmia Thioridazine Prolonged ventricular *dose dependent Positive s/s respond well to
Ziprasidone repolarization (long QT) antipsychotics
Negative s/s respond better to atypical

Weight Gain clozapine, olanzapine > Before treatment, screen for:

quetiapine, risperidone >  BMI, waist circumference, HR,
aripiprazole, ziprasidone brexpiprazole, BP, EKG, movement disorder,
cariprazine CBC, CMP, lipids, TFTs

Glycemic Clozapine Insulin resistance

Abnormalities olanzapine DKA
Increased glucose
Dyslipidemia Low-potency typicals Therapeutic lag of about 4-6 weeks ->
Quetiapine Especially elevated minimum of 6 weeks trial per drug as
Clozapine & Olanzapine triglycerides long as no adverse SE
-No high-dose therapy until 6wk
Overall Metabolic clozapine, olanzapine >
Syndrome quetiapine, low potency>
 aripiprazole, ziprasidone,
brexpiprazole, cariprazine, high
potency typicals
Side Effects:
- Neuroleptic Malignant Syndrome (NMS): life threatening disorder due to D2 inhibition in basal ganglia  mental status changes, extreme muscle rigidity, tremor,
autonomic instability (tachycardia, tachypnea, fever), diaphoresis, incontinence  Treatment: stop offending agent (MC with typical antipsychotics)

Typicals: Hyperprolactinemia
Olanzapine “all except SHEAA”
Low-potency Typicals (Halo and Compazine) “DASSH” *all except arrhythmia, extrapyramidal, hypotension, agranulocytosis, and
*intermediate for metabolic syndrome seizure
 Anticholinergic  Hyperprolactinemia
 Sedation  Anticholinergic
 Hypotension  Sedation
 Seizure  Weight gain
 Dyslipidemia  Glycemic abnormalities
 Dyslipidemia
High potency Typicals (Thorazine, Thioridazine) “EXTRA HIGH”  Overall metabolic syndrome
 Extrapyramidal Symptoms
Clozapine “all except HEAr” *only one to cause agranulocytosis
Risperidone (Atypical) *all except arrhythmia, hyperprolactinemia, and extrapyramidal
 Hyperprolactinemia & Hypotension
Quetiapine “DHS”
Cardiac arrhythmia “TZ” *intermediate for weight gain and metabolic syndrome
 thioridazine, ziprasidone  Sedation
 Hypotension
 Dyslipidemia
ANXIETY PHARM
Drug MOA Indication Side effects DDI CI
Benzodiazepines Enhance GABA •Anxiety, panic •Drowsiness •ETOH •Pregnancy
Short: at receptor •insomnia, •dizziness •Opioids •Allergy
-Midazolam •ETOH withdrawal •decreased motor coordination •CNS depressants •Myasthenia gravis
-Triazolam •agitation •decreased libido •Anticonvulsants •Glaucoma
Long: •seizure •disinhibition •antidepressants
-Diazepam •procedural sedation •rebound anxiety, SI •antifungal
-Flurazepame
-Chlordiazepoxide Rare: respiratory depression

Buspirone •5HT-1a Anxiety •Dizziness •Other Psych meds Allergy

receptor agonist •Drowsiness, nausea, HA •CNS depressants
•dopamine •Serotonin Syndrome
receptors

Hydroxyzine Histamine •Anxiety •Drowsiness •Potassium Allergy

(Vistaril, Atarax) receptor •muscle relax •dizziness •MAOIs 1st trimester prego
antagonist •antihistamine •dry mouth •CNS depressants *only use po route
 •antiemetic •rash
•insomnia •respiratory depression

DEPRESSION PHARM
Depression MOA CI Side effects Differences
SSRIs Selectively decreased •Allergy •N/D, anorexia •Sertraline: diarrhea, less QT, drowsy
FIRST LINE action of 5-HT reuptake •MOAI w/n 2 weeks •Sleep changes, HA, anxiety, dizziness •Citalopram/Escitalopram: more QT, least liver
*Fluoxetine 5wks •Decreased libido, anorgasmia, ED •Fluvoxamine: shorted t ½ and CYP
•Prolonged QT, WT gain, bleeding •Fluoxetine: long t ½ and don’t use with Tamoxifen
•Serotonin syndrome, increased SI •Paroxetine: anticholingeric SE, CYP, don’t use with
Tamoxifen *panic disorders 1st line

SNRIs Block reuptake of 5-HT •Allergy •N/D/V, constipation, dry mouth •Venlafaxine: high SE, elevated BP
2nd line if cant and NE (Milnacipran and •MOAI w/n 2 weeks •Sleep changes, HA, anxiety, dizziness •Desvenlafaxine: less HTN
tolerate SSRIs Levomilnacipran greater) •Angle closure •Decreased libido, anorgasmia, ED •Cymbalata: least associated with BP
glaucoma •Diaphoresis, HTN, SS syndrome •Milnacipran/Levomilnacipran: anticholinergic SE
•LESS SEX and NO WEIGHT GAIN!

Atypicals Buproprion: •Buproprion:, seizure, Buproprion: *NO WT GAIN OR SEX

Buproprion dopamine and NE reuptake anoremia, MAOI 2 weeks •dry mouth, insomnia, nausea
Remeron inhibitor •seizures, tobacco cessation
•Remeron: MAOI 2 wks
Remeron: antagonizes Remeron:
alpha-2 and 5-HT2/3 •dry mouth, drowsiness, sex dysfunction
•wt gain, increased appetite

Serotonin Nefazadone/Trazadone: •Allergy HA, N/D, SI risk, serotonin syndrome •Nefazadone: BBW-hepatotoxicity
Modulators Antagonize 5-HT •MOAI w/n 2 weeks  Drowsiness, xerostomia, hypotension
*with initiation and increase in dose •Trazadone: SEDATION, dry mouth, WT NEUTRAL
Vilazadone/ Vortioxetine:  Rare: priapism, cardiac arrhythmia
Partial agonist 5-HT •Vialazdone/Vortioxetine: N/V/C/D, sex dysfunction
 Faster onset and less sexual dysfunction

MAOIs MAOa: Break down •Allergy *MANY DDI INTERACTIONS Selegiline (Eldepryl): low doses for Parkinsons
serotonin and NE •Serotonin w/n 2 weeks •hypotension  Less CI than other MAOIs
Parnate •Cardiovascular •GI, urinary hesitancy  Less hypertensive crisis with transdermal
Nardil MAOb: •Pehochromocytoma •HA, myoclonic jerks
Marplan Break down dopamine •Hepatic/renal •edema
Eldepryl •Hypertensive crisis-foods with
tyramine

TCAs Inhibits reuatake of •Allergy •Anticholinergic, drowsiness, sweating Nortiptyline and Desipramine: highest tolerability
5-HT and NE •MOAI w/n 2 weeks •sexual dysfunction, wt gain & appetite
•Acute recovery of MI •tremor, OD fatality Tertiary(5-HT): Amitriptyline, Doxepin, Imipramine
•Cardiotoxicity (QT) Secondary (NE): Nortrip, Despiramine, Protriptyline
TeCAs •Ludiomil: •Less anticholinergic and more *have extra cyclic ring
block NE & 5-HT antihistaminic than TCAs *last resort, don’t ever really prescribe
Ludiomil •SI risk
Asendin •Asendin: blocks NE,
dopamine

SUBSTANCE ABUSE PHARM

Alcohol Chronic Use
Drug MOA Side Effects Dosing CI/DDI
Thiamine •Low BP Acute: 50-100mg IV/po
(B1) •Effect glucose metabolism
Wernicke: 100mg IV
500 BID x2d, qd x5d, then 100mg

Chronic: 50mg po daily

Naltrexone Blocks dopamine release, antagonizes mu BBW: hepatocellular 50mg daily CI: opioid dependency
1st LINE receptor  decreases craving and reward •N/V/D/C, abd pain
•dizzy, HA, anxiety, fatigue Vivitrol: 380mg IM monthly DDI: opioids

Acamprosate Restores glutamate •Diarrhea, nausea, abd pain 66mg TID (333 for renal) CI: renal (Cr <30)
(Campral)  Stops withdrawal S/S •fatigue, HA, amnesia, mood
1st LINE

Disulfiram Inhibits enzyme aldehyde dehydrogenase  •Metallic taste 500mg/d for 1-2wk, 250mg/d CI: heart or CAD, ethanol
(Antabuse) increases acetaldehyde  Fs you up
2nd Line •Effects of drug  sweating, HA, DI: “WAM”
dyspnea, low BP, flushing, palp warfarin, amitriptyline,
metronidazole

Opioid Overdose Treatment

Drug MOA Dose Side Effects
Naloxone Short-acting opioid antagonist Cardiorespiratory: 2mg
ventilations: 0.05mg IV
*titrate up every few minutes until RR
>12/min

Opioid Use Treatment

Drug MOA Dose Side Effects
Naltrexone Blocks dopamine release, antagonizes mu receptor 25-50mg daily BBW: hepatocellular
1st LINE  decreases craving and reward N/V/D/C, abd pain, dizzy, HA, anxiety, fatigue
*opioid antagonist, completely blocks effects Vivitrol (IV): 380mg IM/4wks
Methadone Long-acting opioid agonist 20-30mg po, titrate up (80-120mg) •Constipation, drowsiness, sweating
•peripheral edema, hyperalgesia
•reduced libido, ED
•QT prolongation, OVERDOSE

Buprenorphin Partial agonist *often in combo with Naloxone •HA, nausea, pain
e *take home therapy 4mg B/1mg N daily •insomnia
most stabile on 16-20mg/d B •withdrawal syndrome

Taper by reducing 2mg/1-2wk Rare: liver, necrosis, anaphylaxis

Tobacco Use Treatment

(Tobacco Replacement)
Drug Use Dose Side Effects
Transdermal Apply to skin once daily, avoid hair, change places >10 cig: 21 x6wk, 14 x2wk, 7 x2wk •Skin irritation
Patch each day •Insomnia, vivid dreams
10 or less cig: 14 x6wk, 7 x2wk

Oral DON’T CHEW Smoke w/n 30 min: 4mg •Mouth irritation

Nicotine •N/V/D
Lozenge All others: 2mg •palpitations
•HA, insomnia
Max: 5 every 6hrs or 20/day

Oral Diminishes withdrawal 25+ cigs: 4mg •N/V/D, HA

Nicotine “chew and park” method •excess salivation
Gum all others: 2mg •mouth irritation
*avoid TMJ, poor dentition, dental appliances

Nicotine Absorbs through mucosa 6-16 cartridges/d for 6-12 wk Oropharynx irritation, bronchospasm
Inhaler Satisfies behavioral & sensory cravings
*avoid RAD (asthma)

Nicotine Absorbed through nasal mucosa 1-2 sprays/3mo •Nasal and throat irritation
Nasal Spray Max: 10 sprays/hr or 80/day •sneezing, tearing

Tobacco Use Treatment

(Pharmacological)

Drug MOA Dose Side Effects

Buproprion Blocks dopamine and NE reuptake 150mg/d x3d, 150mg BID x12wk •Insomnia, agitation
(Wellbutrin) Antagonizes nicotinic rec. •dry mouth, HA
*start 1wk before quite date
•CI: Epilepsy, seizure, h/o anorexia/bulimia

Varenicline Partial agonist of nicotinic rec. 0.5mg x3d, 0.5mg BID x4d, 1mg BID •Vivid dreams
 (Chantix) -Decreases withdrawal x12wk •nausea, insomnia
-Interferes with reward *start 1wk before quite date •syncope

Serious: neuropsych (SI, mood, behavior)

ADHD PHARM
Stimulants MOA Route SE CI
Methylphenidate Blocks catecholamine reuptake IR and ER •less weight loss *don’t use within
(Ritalin, Focalin, *NE, dopamine  increases intrasynpatic levels Daytrana is a transdermal patch •priapism 14 days of MAOI
Concerta, Quillichew, *USE IN PRESCHOOLERS
Methylin)
Amphetamines Blocks catecholamine reuptake IR and ER •may be slightly more
(Vyvanse, Adderall) *NE, dopamine; increases dopamine release Vyvanse is a prodrug of dextroamphetamine effective
 increases intrasynpatic levels *activated from oral ingestion •more weight loss

Non-Stimulants MOA Route Uses Side Effects CI

Atomoxetine Selective NE PO, QD, BD •If stimulants can’t be used •GI: decreased appetite, N/V, abdominal pain, •Allergy
(Strattera) reuptake inhibitor Delay of 1-2wks *not first line dyspepsia, wt loss •2wk of MAOI
*not controlled for efficacy •Intolerable to stimulates, desire to •CV: rare, increased BP and HR •Glaucoma
avoid stimulants, h/o tic disorder, •Priapism •Liver injury •Pheochromocytoma
risk of abuse •Neuro/Psych: psychosis, SI thoughts, tics •CV Disease

XR Clonidine Stimulates alpha-2 PO, BID Fail to respond to or cannot •Sedating *helpful if agitate, aggressive, active Hypersensitivity
(Kapvay) adrenergic receptors *taper if DC tolerate stimulates or atomoxetine •offset of stimulant SE
a-Adrenergic •depression, HA
3rd line •bradycardia, low BP

XR Guanfacine PO, QD Improve ADHD symptoms •Sedation, fatigue Hypersensitivity

(Intuniv) *taper if DC Fewer SE than Clonidine •HA
a-Adrenergic •Abdominal pain

NON-PHARM
 Behavioral: preferred in preschool ADHD; adjunct for older children and teens; helps improve parent-child relationship
o Daily schedule, chart/checklists, minimal distractions, limiting choices for them, specific/logical storage places, reward, calm disciplines
 Cognitive Therapy: NOT recommended as monotherapy, may be an adjunct for pts with comorbid psych disorders
 Dietary Modifications (limited evidence): elimination diets, fatty acid sup; megavitamins, chelation, detox, herbal or mineral supplement

PHARMACOTHERAPY-STIMULANTS *FIRST LINE children 6yo+ with functional impairment; can use for all ages **SCHEDULE II-potential for abuse
 Dosing: start at low dose, gradually tirate up; adjust dosing schedule based on symptom and activing; dosing holidays for weekends/vacations
 Common SE: reduced appetite, insomnia/nightmares, on-edge or jittery, emotional, wt loss/decreased ht, tics; *mild and correctable
  Less common SE: increased HR and BP, palpitations, raynauds, priapism (RARE), HA, dizziness, N/V/D, psychotic, manic, diversion or misuse (BIGGEST!)
 CI: allergy, h/o substance abuse, hyperthyroidism, glaucoma, cardio disease, tics/Tourette, agitated, anxiety

ANTIDEPRESSANTS: *4th line therapy

TCAs:
 SE: cardiotoxicity (consult!)
 Helpful in children with comorbid mood disorders
Bupropion (Wellbutrin) *4th line therapy; not extensively studied
 MOA: Blocks reuptake of NE and dopamine
 Reduces aggressive, hyperactivity
 SE: insomnia, anorexia, tics, seizures