Psychiatry

• Pavlov's dog: ringing bell provokes salivation
• Learning in which a natural response (salivation) is elicited by a conditioned, or learned stimulus (bell) that previously was presented in conjunction with an unconditional stimulus (food)

• Learning in which a particular action is elicited because it produces a reward
• Positive reinforcement: Desired reward produces action (mouse presses button to get food)
• Negative reinforcement: Target behavior (response) is followed by removal of aversive stimulus (mouse presses button to turn off continuous loud noise)
• Punishment: Repeated application of aversive stimulus extinguishes unwanted behavior
• Extinction: Discontinuation of reinforcement (positive or negative) eventually eliminates behavior

Transference: Patient projects feelings about formative or other important person onto physician (e.g., psychiatrist is seen as parent)

Contertransference: Doctor projects feelings about formative or other important persons onto patient

Unconscious mental processes used to resolve conflict and prevent undesirable feelings (e.g., anxiety, depression)

• Acting out
• Dissociation
• Denial
• Displacement
• Fixation
• Identification
• Isolation (of affect)
• Projection
• Rationalization
• Reaction formation
• Regression
• Repression
• Splitting

• Unacceptable feelings and thoughts are expressed through action
• Tantrums

• Temporary, drastic change in personality, memory, consciousness, or motor behavior to avoid emotional stress
• Extreme form: dissociative identity disorder

• Avoidance of awareness of some painful reality
• Common reaction in newly diagnosed AIDS and cancer patients

• Process whereby avoided ideas and feelings are transferred to some neutral person or object (vs. projection)
• Example: mother yells at her child, bc her husband yells at her

Partially remaining at a more childish level of development (vs. regression)

• Modeling behavior after another person who is more powerful (though not necessarily admired)
• Abused child identifies himself/herself with an abuser

• Separation of feelings from ideas and events
• Describing murder in graphic detail with no emotional response

• An unacceptable internal impulse is attributed to an external source (vs. displacement)
• A man who wants another woman thinks his wife is cheating on him

• Prolcaiming logical reasons for actions actually performed for other reasons, usually to avoid self-blame
• After getting fired, claiming that the job was not important anyway

• Process whereby a warded-off idea or feeling is replaced by an (unconsciously derived) emphasis on its opposite (vs. sublimation)
• A patient with libidinous thoughts enters a monastery

• Turning back the maturational clock and going back to earlier modes of dealing with the world (vs. fixation)
• Seen in children under stress as illness, punishment, or birth of a new sibling

• Involuntary withholding of an idea or feeling from conscious awareness (vs. suppression)
• Not remembering a conflictual or traumatic experience; pressing bad thoughts into the unconscious

• Belief that people are either all good or all bad at different times due to intolerance of ambiguity
• Seen in borderline personality disorder
• A patient says that all the nurses are cold and insensitive but that the doctors are warm and friendly

• Sublimation
• Altruism
• Suppression
• Humor
• *Mature adults wear a SASH

• Guilty feelings alleviated by unsolicited generosity toward others
• Mafia boss makes large donation to charity

• Appreciating the amusing nature of an anxiety-provoking or adverse situation
• Nervous medical students jokes about boards

• Process whereby one replaces an unacceptable wish with a course of action that is similar to the wish but does not conflict with one's value system (vs. reaction formation)
• Teenager's aggression toward his father is redirected to perform well in sports

• Voluntary withholding of an idea or feeling from conscious awareness (vs. repression)
• Choosing not to think about USMLE until the week of the exam

• Long-term deprivation of affection results in:
• -↓ muscle tone
• -Poor language skills
• -Poor socialization skills
• -Lack of basic trust
• -Anaclitic depression (infant withdrawn/unresponsiveness)
• -Weight loss
• -Physical illness

• *The 4 W's: Weak, Wordless, Wanting (socially), Wary
• *Deprivation > 6 months → irreversible changes
• *Severe deprivation can result in infant death

• Evidence:
• -Healed fractures on x-ray
• -burns,
• -subdural hematomas,
• -multiple bruises,
• -retinal hemorrhage or detachment

Abuser: usually male caregiver

• Epidemiology: ~3000 deaths/yr in US
• -80% < 3 yr of age

• Evidence:
• -Genital, anal, or oral trauma
• -STI
• -UTI

Abuser: Known to victim, usually male

Epidemiology: Peak incidence 9-12 years of age

• Failure to provide a child with adequate food, shelter, supervision, education, and/or affection
• Most common form of child maltreatment
• Evidence: poor hygiene, malnutrition, withdrawal, impaired social/emotional development, failure to thrive

• Attention-deficit hyperactivity disorder (ADHD)
• Conduct disorder
• Oppositional defiant disorder
• Tourette's syndrome
• Separation anxiety disorder

• Onset < age 7
• Limited attention span or poor impulse control
• Characteristics: hyperactivity, impulsivity, inattention in multiple settings (school, home, place of worship)
• Normal intelligence, but commonly coexist with difficulties in school
• Can continue into adulthood: as many as 50% of individuals
• Associated with: decrease frontal lobe volumes
• Tx: methylphenidate, amphetamines, atomoxetine, behavioral interventions (reinforcement, reward)

• Repetitive and pervasive behavior violating the basic rights of others
• (physical aggression, destruction of property, theft)
• After age 18 → antisocial personality disorder (many, not all)

Enduring pattern of hostile, defiant behavior toward authority figures in the absence of serious violations of social norms

• Onset before age 18
• Characterized by sudden, rapid, recurrent, nonrhythmic, stereotyped motor and vocal tics that persist for >1 year
• Lifetime prevalence: 0.1-1.0% in general population
• Coprolalia: found in only 10-20% of patients
• Association with OCD
• Tx: antipsychotics and behavioral therapy

• Age of onset: 7-9 years
• Overwhelming fear of separation from home or loss of attachment figure
• May lead to factitious physical complaints to avoid going to or staying at school
• Tx: SSRIs, relaxation techniques/behavioral interventions

• Characterized by difficulties with language and failure to acquire (or early loss of) social skills
• -Austistic disorder
• -Asperger's disorder
• -Rett's disorder
• -Childhood disintegrative disorder

• Severe language impairment and poor social interactions
• Greater focus on objects than on people
• Features: repetitive behavior, below-normal intelligence (usual), unusual abilities (savants; rare)
• Boys > males
• Tx: behavioral and supportive therapy to improve communication and social skills

• Milder form of autism
• Features: all-absorbing interests, repetitive behavior, problems with social relationships
• Language is normal; normal intelligence

• X-linked disorder seen almost exclusively in girls (affected males die in utero or shortly after birth)
• Sx: begin by age 1-4, regression, loss of verbal skills, mental retardation, ataxia, stereotyped hand-wringing

• Age of onset: 3-4 years
• Marked regression in multiple areas of function after >2 years of normal development
• Loss of: expressive or receptive language skills, social skills or adaptive behavior, bowel or bladder control, play or motor skills
• Boys more common

• ↑ NE
• ↓ GABA
• ↓ serotonin (5-HT)

• ↓ NE
• ↓ serotonin (5-HT)
• ↓ dopamine

↓ ACh

• ↓ GABA
• ↓ ACh
• ↑ dopamine

↑ dopamine

• ↓ dopamine
• ↑ serotonin (5-HT)
• ↑ ACh

• Patient's ability to know who he or she is, where she or he is, and the date and time
• Loss of orientation: alcohol, drugs, fluid/electrolyte imbalance, head trauma, hypoglycemia, nutritional deficiencies

• Retrograde amnesia: inability to remember things that occurred before a CNS insult
• Anterograde amnesia: inability to remember things that occurred after a CNS insult (no new memory)
• Korsakoff's amnesia: Classic anterograde amnesia caused by thiamine deficiency and the associated destruction of mammillary bodies
• - may also include some retrograde amnesia
• - alcoholics; associated with confabulations
• Dissociative amnesia: inability to recall important personal information, usually subsequent to severe trauma or stress

• Significant change in cognition (memory, attention, language, judgment)
• Associated with abnormalities in CNS, general medical condition, medications, or substance use
• Includes delirium and dementia

• "Waxing and waning" level of consciousness with acute onset
• -Rapid ↓ in attention span and level of arousal

• Features:
• disorganized thinking, hallucination (often visual), illusions, misperceptions, disturbance in sleep-wake cycles, cognitive dysfunction
• *Usually secondary to other illness (CNS disease, infection, trauma, substance abuse/withdrawal

*Most common presentation of altered mental status in the hospital

• Abnormal EEG
• Tx:
• -Identify and address underlying cause
• -Optimize brain condition (O2, hydration, pain)
• -Antipsychotics (mainly haloperidol)
• *T-A-DA approach (Tolerate, Anticipate, Don't Agitate

• Gradual ↓ in intellectual ability or "cognition" without affecting level of consciousness
• *"Dementia" is characterized by memory loss

• Characteristics: usually irreversible
• -memory deficits
• -aphasia
• -apraxia
• -agnosia
• -loss of abstract thought
• -behavioral/personality changes
• -impaired judgement
• -pt with dementia can develop delirium

• Cause:
• -Alzheimer's disease
• -cerebral vascular infarcts
• -HIV
• -Pick's disease
• -Chronic substance abuse
• -Creutzfeldt-Jakob disease
• -NPH
• -others

• Presentation:
• -↑ incidence with age. EEG usually normal
• -elderly patients with depression may be present like dementia

Distorted perception of reality (psychosis) or reality testing

• Characterized by:
• -delusions
• -hallucinations
• -disorganized thinking

Can occur in pts with medical illness, psychiatric illness, or both

• Hallucination: Perceptions in the absence of external stimuli
• Delusions: False beliefs about oneself or others that persist despite the facts
• Disorganized speech: words or ideas are strung together based on sounds, puns, or 'loose association'

• Visual: more common in medical illness (drug intoxication) than psychiatric illness
• Auditory: more commonly a feature of psychiatric illness that medical
• Olfactory: aura of psychomotor epilepsy and in brain tumors
• Gustatory: rare
• Tactile: Common in alcohol withdrawal; cocaine abusers
• HypnaGOgic: occurs while GOing to sleep
• HypnoPOMPic: Occurs while waking from sleep ("POMPous upon awakening")

• Chronic mental disorder with periods of psychosis
• disturbed behavior and thought
• decline in functioning that lasts > 6 months
• Associated with ↑ dopaminergic activity, ↓ dendritic branching
• ↑ risk for suicide

• Paranoid (delusions)
• Disorganized (with regard to speech, behavior, and effect)
• Catatonic (automatisms)
• Undifferentiated (elements of all types)
• Residual

• Diagnosis requires 2 or more of the following (fist 4 are "positive symptoms")
• -Delusions
• -Hallucinations: often auditory
• -Disorganized speech (loose associations)
• -Disorganized or catatonic behavior
• -"negative symptoms" - flat affect, social withdrawal, lack of motivation, lack of speech or thought

• Etiology: genetics and environment
• Associated with frequent cannabis use in teens

• Lifetimes prevalence: 1.5%
• -males = females (earlier in men)
• -blacks = whites

• <1 month
• usually stress related

1-6 months

• > 2 weeks of stable mood with psychotic symptoms
• major depressive
• manic
• or mixed
• Subtypes: bipolar, depressive

• Fixed, persistent, nonbizarre belief system lasting > 1 month
• Functioning otherwise not impaired
• Examples: woman who believes she's married to a celebrity
• Shared psychotic disorder: development of delusions in a person in a close relationship. Often resolves upon separation

• Dissociative identity disorder
• Depersonalization disorder
• Dissociative fugue

• Formerly known as multiple personality disorder
• Presence of 2 or more distinct identities or personality states
• More common in women
• Associated with history of sexual abuse

Persistent feelings of detachment or estrangement from one's own body, social situation, or environment

• Abrupt change in geographic location with inability to recall the past, confusion about personal identity, assumption of a new identity
• Associated with traumatic circumstances
• Leads to significant distress or impairment
• Not the result of substance abuse or general medical condition

• Characterized by an abnormal range of moods or internal emotional states and loss of control over them
• Impairs social and/or occupational functioning
• -Major depressive disorder
• -Bipolar disorder
• -Dysthymic disorder
• -Cyclothymic disorder
• *Psychotic features may be present

• Distinct period of abnormally and persistently elevated, expansive, or irritable mood
• Abnormal and persistent increased activity or energy lasting at least 1 week
• Diagnosis: 3 or more of the following (DIG FAST)
• -Distractibility
• -Irresponsiblility - seeks pleasure without regard to consequences
• -Grandiosity
• -Flight of ideas
• -Agitation/ ↑ goal-directed Activity
• -↓ need for Sleep
• -Talkativeness or pressured speech

• Like manic episode except mood disturbance is not severe enough to cause marked impairment in social/occupational functioning or need hospitalization
• No psychotic features

• ≥1 manic (bipolar I) or hypomanic (bipolar II) episode
• Depressive symptoms always occur eventually
• Functioning, mood return to normal between episodes
• Caution: antidepressants can lead to ↑ mania
• High suicide risk
• Tx: mood stabilizers (lithium, valproic acid, carbamazepine), atypical antipsychotics

• Dysthymia and hypomania
• milder form of bipolar disorder lasting at least 2 years

• Self-limited disorder, with major depressive episodes usually lasting 6-12 months
• Dx: >5 of the following for 2 or more weeks:
• -Sleep disturbance
• -Loss of Interest (anhedonia)
• -Guilt or feelings of worthlessness
• -Loss of Energy
• -Loss of Concentration
• -Appetitie/weight changes
• -Psychomotor retardation or agitation
• -Suicidal ideations
• -Depressed mood
• *SIG E CAPS

Prevalence: 5-12% in males; 10-25% in females

Milder form of depression lasting > 2 years

• Symptoms associated with winter season
• improves in response to full-spectrum bright-light exposure

• Mood reactivity: being able to experience improved mood in response to positive events
• "Reversed" vegetative symptoms (hypersomnia and weight gain)
• Leaden paralysis (heavy feeling in arms and legs)
• Long-standing interpersonal rejection sensitivity
• *Most common subtype of depression
• Treatment: MAO inhibitors; SSRIs

• Maternal (postpartum) "blues"
• Postpartum depression
• Postpartum psychosis

• Incidence rage: 50-85%
• Features: depressed affect, tearfulness, fatigue starting 2-3 days after delivery
• Usually resolves within 10-14 days
• Tx: supportive

• Incidence rate: 10-15%
• Features: depressed affect, anxiety, poor concentration starting within 4 weeks after delivery
• Lasts 2 weeks to a year or more
• Treatment: antidepressants, psychotherapy

• Incidence rate: 0.1-0.2%
• Features: delusions, hallucinations, confusion, unusual behavior, possible homicidal/suicidal ideations or attempts
• Usually lasts 4-6 weeks
• Treatment: antipsychotics, antidepressants, possible inpatient hospitalization

• Treatment option for major depressive disorder refractory to other treatment
• Also for pregnant women with depressive disorder
• Painless seizure in an anesthetized patient
• AEs: disorientation, temporary anterograde/retrograde amnesia (usually recovers in 6 months)

• Sex
• Age
• Depression
• Previous attempt
• Ethanol or drug use
• Loss of Rational thinking
• Sickness
• Organized plan
• No spouse
• Social support lacking
• Women try more; men are more often successful
• *SAD PERSONS are more likely to complete suicide

• Inappropriate experience of fear/worry and its physical manifestation when the source of fear/worry is either not real or insufficient to account for severity of sx
• Sx interfere with daily function
• Lifetime prevalence: 30% in women; 19% in men
• Includes: panic disorder, phobias, OCD, PTSD, generalized anxiety disorder

Recurrent periods of intense fear and discomfort

• Peaking in 10 minutes; at least 4 of the following: PANICS
• -Palpitations
• -Paresthesias
• -Abdominal distress
• -Nausea
• -Intense fer of dying or losing control
• -LIght-headedness
• -Chest pain
• -Chills
• -Choking
• -DisConnectedness
• -Sweating
• -Shaking
• -Shortness of breath

• Strong genetic component
• Persistent fear of having another attack

• Treatment:
• -Cognitive behavioral therapy (CBT)
• -SSRIs
• -Venlafaxine
• -Benzodiazepines (risk of tolerance, physical dependence

• Fear that is excessive or unreasonable and interferes with normal function
• Cued by presence or anticipation of specific object or situation
• Person recognizes that fear is excessive
• Tx: systematic desensitization; SSRIs
• Social phobia: exaggerated fear of embarrassment in social situation

• Recurring intrusive thoughts, feelings, or sensations that cause severe distress
• Relieved (partly) by performing repetitive action
• Ego dystonic: behavior inconsistent with one's own beliefs and attitudes (vs. Obsessive-compulsive personality disorder)
• Associated with Tourette's disorder
• Tx: SSRIs, clomipramine

• Persistent reexperiencing of a previous traumatic event
• Nighmares, flashbacks, intense fear, helplessness, or horror
• Leads to avoidance
• Disturbance lasts > 1 month
• Cause significant distress or impairment of function
• Tx: psychotherapy, SSRIs
• Acute stress disorder: lasts between 2 days and 1 month

• Pattern of uncontrollable anxiety for at least 6 months that is unrelated to a specific person, situation, or event
• Associated with sleep disturbance, fatigue, GI disturbance, and difficulty concentrating
• Tx: SSRI, SNRI

Emotional symptoms (anxiety, depression) causing impairment following an identifiable psychosocial stressor (divorce, illness) and lasting < 6 months (>6 months in presence of chronic stressor)

• Patient consciously fakes or claims to have a disorder in order to attain a specific 2° gain (avoiding work, obtaining drugs)
• Poor compliance with treatment or follow-up of diagnostic tests
• Complaints cease after gain (vs. factitious disorder)

Patient consciously creates physical and/or psychological symptoms in order to assume "sick role" and to get medical attention (1° gain)

• Chronic factitious disorder with predominantly physical signs and symptoms
• Characterized by a history of multiple hospital admissions and willingness to receive invasive procedures

• When illness in a child or elderly patient is caused by the caregiver
• Motivation is to assume a sick role by proxy
• Form of child/elder abuse

Category of disorders characterized by physical symptoms (at least 4 pain, 2 GI, 1 sexual, 1 pseudoneurologic) over a period of years, developing before age 30

• Sudden loss of sensory or motor function (paralysis, blindness, mutism), often following acut stressor
• patient is aware of sx, but sometimes indifferent toward symptoms
• Females, adolescents, young adults

Preoccupation with and fear of having a serious illness despite medical evaluation and reassurance

• Preoccupation with minor or imagined defect in appearance, leading to significant emotional distress or impaired functioning
• Patients often repeatedly seek cosmetic surgery

• Prolonged pain with no physical findings
• Pain is the predominant focus of clinical presentation and psychological factors play an important role in severity, exacerbation, or maintenance of the pain

An enduring, repetitive pattern of perceiving, relating to, and thinking about the environment and oneself

• Inflexible, maladaptive, and rigidly pervasive pattern of behavior causing subjective distress and/or impaired functioning
• Person is usually not aware of problem
• Usually presents by early adulthood

• Weird (Accusatory, Aloof, Awkward)
• Odd or eccentric
• inability to develop meaningful social relationship
• No psychosis
• genetic association with schizophrenia
• -Paranoid
• -Schizoid
• -Schizotypal

• Pervasive distrust and suspiciousness
• projection is the major defense mechanism

• Voluntary social withdrawal, limited emotional expression, content with social isolation (vs. avoidant)
• Schizoid = distant

• Eccentric appearance, odd beliefs or magical thinking, interpersonal awkwardness
• Schizotypal = magical thinking

• Dramatic, emotional, or erratic
• Genetic association with mood disorders and substance abuse
• Wild (Bad to the Bone)
• -Antisocial
• -Borderline
• -Histrionic
• -Narcissistic

• Disregard for and violation of rights of others, criminality
• Males > females
• Conduct disorder if <18 years
• Antisocial = sociopath

• Unstable mood and interpersonal relationships, impulsiveness, self-mutilation, boredom, sense of emptiness
• Females > males
• splitting is a major defense mechanism

• Excessive emotionality and excitability
• Attention seeking
• sexual provocative
• overly concerned with appearance

• Grandiosity, sense of entitlement
• Lacks empathy and requires excessive admiration
• often demands the "best" and reacts to criticism with rage

• Anxious or fearful
• Genetic association with anxiety disorders
• Worried (Cowardly, Compulsive, Clingy)
• -Avoidant
• -OBsessive-compulsive
• -Dependent

• Hypersensitive to rejection,
• socially inhibited,
• timid,
• feelings of inadequacy,
• desires relationships with others
• (vs. schizoid)

• Preoccupation with order, perfectionism, and control
• Ego-syntonic: behavior consistent with one's own beliefs and attitudes
• (vs. OCD)

• Submissive and clinging
• excessive need to be taken care of
• low self-confidence

• Schizotypal: (schizoid + odd thinking)
• Schizophrenic: (greater odd thinking than schizotypal)
• Schizoaffective: (schizophrenic psychotic symptoms + bipolar or depressive mood disorder)

• <1 mo: breif psychotic disorder, usually stress related
• 1-6 mo: schizophreniform disorder
• >6 mo: schizophrenia

• Anorexia nervosa
• Bulimia nervosa

• Excessive dieting +/- purging
• intense fear of gaining weight, body image distortion, ↑ exercise
• body weight 85% of ideal body weight
• Associated with ↓ bone density
• Clinical features: severe weight loss, metartasal stress fractures, amenorrhea, anemia, electrolyte distrubances
• Can coexist with depression

• Strong, persistent cross-gender identification
• Characteriezed by persistent discomfort with one's sex → significant distress, impairs function
• Transsexualism: desire to live as the opposite sex, often through surgery or hormone treatment
• Transvestism: paraphilia; wearing clothes (e.g., vest) of the opposite sex

• Maladaptive pattern of substance use defined as 3 or more of the following signs in 1 year:
• -Tolerance: need more to achieve same effect
• -Withdrawal
• -Substance taken in larger amounts, over longer time, than desired
• -Persistent desire or unsuccessful attempts to cut down
• -Significant energy spent obtaining, using, or recovering from substance
• -Important social, occupational, or recreational activities reduced because of substance use
• -Continued use in spite of knowing the problems that it causes

• Maladaptive pattern leading to clinically significant impairment or distress
• -Recurrent use results in failure to fulfill obligations
• -recurrent use in physically hazardous situations
• -recurrent substance-related legal problems
• -Continued use in spite of persistent problems caused by use

• 1. Precontemplation: not yet acknowledging that there is a problem
• 2. Contemplation: knows there's a problem, not ready to make change
• 3. Preparation/determination: getting ready to make change
• 4. Action/willpower: changing behaviors
• 5. Maintenance: maintaining the behavior change
• 6. Relapse: returning to old behaviors and abandoning new changes

• Intoxication:
• -nonspecific
• -mood elevation, 
• -↓ anxiety
• -sedation
• -behavioral disinhibition
• -respiratory depression

• Withdrawal:
• -Nonspecific
• -Anxiety
• -tremor
• -seizures
• -insomnia

• Drugs:
• -Alcohol
• -Opiods (morphine, heroin, methadone)
• -Barbiturates
• -Benzodiazepines

• Intoxication:
• -Emotional lability
• -slurred speech
• -ataxia
• -coma
• -blackouts
• -Serum γ-glutamyltransferase (GGT): sensitive indicator of alcohol use
• -Labs: AST > ALT (~2:1)

• Withdrawal:
• -Mild withdrawal: similar to other depressants
• -Severe withdrawal: autonomic hyperactivity, delirium tremors
• -Tx: benzodiazepines (for DTs)

• Intoxication:
• -Euphoria
• -Respiratory and CNS depression
• -↓ gag reflex
• -pupillary constriction (pinpoint pupils)
• -Seizures (OD)
• Tx: naloxone, naltrexone

• Withdrawal:
• -Sweating
• -dilated pupils
• -piloerection ("cold turkey")
• -fever
• -rhinorrhea
• -yawning
• -nausea, stomach cramps, diarrhea ("flu-like" symptoms)
• Tx: long-term support, methadone, buprenorphine

• Intoxification:
• -Low safety margin
• -Marked respiratory depression
• Tx: symptom management (assist respiration, ↑BP)

• Withdrawal:
• -Delerium
• -Life-threatening cardiovascular collapse

• Intoxication:
• -Greater safety margin
• -Ataxia
• -minor respiratory depression
• Tx: flumazenil (competitive benzodiazepine antagonist)

• Withdrawal:
• -Sleep disturbance,
• -depression,
• -rebound anxiety,
• -seizures (severe)

• Intoxication:
• Nonspecific: mood elevation
• -psychomotor agitation
• -insomnia
• -cardiac arrhythmias
• -tachycardia
• -anxiety

• Withdrawal:
• Nonspecific: post use "crash"
• -depression
• -lethargy
• -weight gain
• -headache

• Drugs:
• -Amphetamines
• -Cocaine
• -Caffeine
• -Nicotine

• Intoxication:
• -Euphoria
• -grandiosity
• -pupillary dilation
• -prolonged wakefulness and attention
• -hypertension
• -tachycardia
• -anorexia
• -paranoia
• -fever
• -Severe: cardiac arrest, seizure

• Withdrawal:
• -Anhedonia
• -increased appetite
• -hypersomnolence
• -existential crisis

• Intoxication:
• -impaired judgement
• -pupillary dilation
• -hallucinations (including tactile)
• -paranoid ideations
• -angina
• -sudden cardiac death
• Tx: benzodiazepines

• Withdrawal:
• -Hypersomnolence
• -malaise
• -severe psychological craving
• -depression/suicidality

• Intoxication:
• -Restlessness
• -↑ diuresis
• -Muscle twitching

• Withdrawal:
• -Lack of concentration
• -Headache

• Intoxication:
• -Restlessness

• Withdrawal:
• -Irritability
• -anxiety
• -craving
• Tx: nicotine patch, gum, lozenges; bupropion/varenicline

• PCP
• LSD
• Marijuana (cannabinoid)

• Intoxication:
• -Belligerence
• -impulsiveness
• -fever
• -psychomotor agitation
• -analgesia
• -vertical and horizontal nystagmus
• -tachycardia
• -homicidality
• -psychoisis, delirium, seizures
• Tx: benzodiazepines, rapid-acting antipsychotic

• Withdrawal:
• -Depression, anxiety
• -Irritability, restlessness
• -anergia
• -disturbances of thought and sleep

• Intoxication:
• -Perceptual distortion (visual, auditory)
• -depersonalization
• -Anxiety
• -Paranoia
• -Psychosis
• -possible flashbacks

• Intoxication:
• -Euphoria, anxiety, paranoid delusions
• -Perception of slowed time
• -impaired judgment
• -social withdrawal
• -↑ appetitie, dry mouth
• -conjunctival injection
• -hallucinations
• Rx: dronabinol - used as antiemetic, appetite stimulant

• Withdrawal:
• -Irritability, depression, insomnia, nausea, anorexia
• -Most sx peak in 48 hours, lasts 5-7 days
• -Generally detectable in urine for 4-10 days

• Risks:
• -Hepatitis
• -Abscesses
• -Overdose
• -Hemorrhoids
• -AIDS
• -right-sided endocarditis

• Methadone: long-acting oral opiate; used for heroin detoxification or long-term maintenance
• Naloxone + buprenorphine: partial agonist; long acting with fewer withdrawal sx than methadone
• -Naloxone is not active orally; withdrawal sx only occur if injected

• Physiologic tolerance and dependence with sx of withdrawal (tremor, tachycardia, HTN, malaise, nausea, DTs) when intake is interrupted
• Complications:
• -alcoholic cirrhosis, hepatitis
• -pancreatitis
• -peripheral neuropathy
• -testicular atrophy

• Treatment:
• -Disulfiram (condition the pt to abstain from alcohol use)
• -supportive care (AA)

• Thiamine deficiency
• Presentation:
• -Triad: confusion, opthalmoplegia, ataxia (Wernicke's encephalopathy)
• -May progress to irreversible memory loss, confabulation, personality change (Korsakoff's psychosis)
• -Associated with periventricular hemorrhage/necrosis of mammillary bodies

Tx: IV vitamin B1 (thiamine)

• Longitudinal laceration at the GE junction caused by excessive vomiting
• Presentation: hematemesis
• Associated with pain (vs. esophageal varices)

• Life-threatening alcohol withdrawal syndrome that peaks 2-5 days after last drink
• Presentation: in order of appearance
• -autonomic system hyperactivity (tachycardia, tremors, anxiety, seizures)
• -psychotic symptoms (hallucinations, delusions)
• -Confusion

Treatment: benzodiazepines