The Kaufman
Courses

Carbamazepine, phenytoin, phenobarbital all induce CYP 450 3A4 enzymes, leading to decreased levels of co-administered drugs that are degraded by this enzyme.  Important substrates are oral contraceptives, Warfarin, atypical antipsychotics, imipramine, methadone, statins, and some antineoplastic agents. In addition, since carbamazepine is also metabolized by 3A4, it can “auto-induce” its own metabolism, leading to its own decreased serum levels. Valproic acid can increase the levels of several co-administered drugs through a variety of metabolic pathways; however, it has no induction properties. Of most significance in psychiatry, valproic acid can increase levels of lamotrigine (thereby increasing the risk of developing a rash), carbamazepine, and amitriptyline.

Johannessen SI, Landmark C:  Antiepileptic drug interactions – principles and clinical implications. Current Neuropharmacol 2010; 8; 254-267

Ciraulo D, Shader I, et al:  Drug Interactions in Psychiatry, 3^rd ed.  Lippincott Williams &Wilkins 2006

PCP intoxication is characterized by unpredictable and violent behavior. Dissociative and psychotic symptoms can occur. Individuals frequently are agitated, impulsive, and exhibit decreased sensitivity to pain.  Physical findings include autonomic hyperactivity, muscle rigidity, and ataxia. Although rotary or horizontal nystagmus may be observed, vertical nystagmus is virtually pathognomonic of PCP intoxication. It is not seen with any other drugs of abuse. Treatment includes placing the patient in a quiet area with low stimulation.  Acidification of the urine with ammonium chloride or ascorbic acid can expedite drug excretion. Haloperidol and/or a benzodiazepine may be useful for agitation and psychosis.

Leamon MH, Wright T, Myrick, H:  Chapter 9. Substance-Related Disorders, (in) Hales R, et.al.  The American Psychiatric Publishing Textbook of Psychiatry, 5^th ed.  American Psychiatric Publishing, 2008

Weaver M, Schnoll SH: Chapter 14. Hallucinogens and Club Drugs (in) Galanter M. et. al. The American Psychiatric Publishing Textbook of Substance Abuse Treatment, 4^th ed.  American Psychiatric Publishing, 2008

Psychiatric symptoms may be the first or most prominent manifestation of NMDA-receptor encephalitis – a recently described cause of delirium. In addition to mood and thought disturbances, seizures and involuntary movements, which mimic myoclonus, occur regularly. Ovarian teratomas frequently give rise to the disorder. Removing a teratoma, if present, will reverse it. Conditions with similar symptoms include infectious encephalitis, non-infectious inflammatory encephalitis, such as lupus, and abuse of PCP or ketamine. NMDA-receptor encephalitis may develop in children as well as individuals, predominantly males, older than 45 years.

Chapman MR, Vause HE: Anti-NMDA receptor encephalitis: Diagnosis, psychiatric presentation, and treatment. Am J Psychiatry 2011; 168: 245-51

Dalmau J, Lancaster E, Martinez-Hernandez E, Rosendeld MR, Balice-Gordon R: Clinical experience and laboratory investigations in patients with anti-NMDAR encephalitis. Lancet Neurol 2011; 10: 63-74

Kayser MS, Titulaer MJ, Gresa-Arribas N, Dalmau J: Frequency and characteristics of isolated psychiatric episodes in anti-N-methyl-D-aspartate receptor encephalitis. 2013; 70: 1133-1139

Sarin is an organophosphate – a group of chemicals that constitute the active elements of insecticides and pesticides as well as poison gases. Organophosphates inhibit acetylcholinesterase and thereby allow acetylcholine to accumulate, precipitating a cholinergic crisis.

Okumura T, Takasu N, Ishimatsu S, et al: Report on 640 victims of the Tokyo subway sarin attack. Ann Emerg Med 1996; 28 (2): 129-135

Sidell FR, Borak J: Chemical warfare agents: II Nerve agents. Ann Emerg Med 1992; 21 (7): 865-871

Suchard JR: Chemical weapons (in) Goldfrank LR et al: Goldfrank’s Toxicologic Emergencies, 8^th edition, McGraw-Hill, New York, 2006, pps 1775-179

Salient features of this case are dementia and parkinsonism as well as the visual hallucinations. These three symptoms constitute the core features of dementia with Lewy body disease. Suggestive features are rapid eye movement (REM) disorder and hypersensitivity to antipsychotic agents. In contrast, dementia usually does not complicate Parkinson disease until it has been present for five or more years. Parkinsonism does not complicate Alzheimer disease. Unlike dopaminergic substances, such as cocaine, dopamine-blocking substances do not produce euphoria and are unlikely to be taken surreptitiously.

McKeith IG: Dickson DW, Lowe J, et al: Diagnosis and management of dementia with Lewy bodies: Third report of the DLB consortium. Neurology 2005; 65: 1863-1872

Because SSRIs have a flat dose response curve, higher doses of SSRIs will not necessarily offer additional therapeutic benefit, although some patients may show a response to higher doses.  Premature dose increases can also increase the risk of side effects.  Therefore when treating depression, “we recommend maintaining the usual therapeutic dose for at least 4 weeks.  If no improvement is seen after 4 weeks, a trial of a higher dose may be warranted.  If a partial response is evident after 4 weeks of therapy, the dose should remain constant for an additional two weeks…”

Martinez M, Marangell L et al: Chapter 26. Psychopharmacology, (in) Hales R et al The American Psychiatric Publishing Textbook of Psychiatry, 5^th ed.  American Psychiatric Publishing, 2008

This man had a several hour period of almost entirely anterograde amnesia that developed after vigorous exercise. During that time, he retained personal, well-learned information. This is the well-known syndrome of transient global amnesia (TGA). Physically stressful activities, including sexual intercourse, and exposure to cold may precipitate an episode of TGA, but episodes rarely recur. Postulated mechanisms have included transient ischemia, cerebral venous insufficiency, and partial complex seizures. Although research has not identified a specific cause, the consensus has always been that TGA is a physiologic disorder. In contrast to TGA, the diagnostic criteria for dissociative amnesia require loss of important autobiographical information, even if only for a specific event. Dissociative identity disorder’s criteria essentially require two or more personalities as well as amnesia for autobiographical information or traumatic events. Because he was fully alert and attentive, he could not have been having a partial complex seizure.

Bartsch T, Deuschl G: Transient global amnesia: Functional anatomy and clinical implications. Lancet Neurol 2010; 9: 205-14.

Hunter G: Transient global amnesia 2011; 29: 1045-54.

Quinette P, Guillery-Girard B, Dayan J, et al: What does transient global amnesia really mean? Review of the literature and thorough study of 142 cases. Brain 2006; 129: 1640-58.

When doctors go to court for medication over objection they need to demonstrate that the patient lacks the capacity to make a refusal and that the treatment is in the patient’s best interests. Involuntary hospitalization does not negate the presumption that a patient is competent to refuse medication. If the patient represents an acute danger to self or others it constitutes an emergency and medication can be given over a patient’s objection without going to court. Even if the patient were willing to contract for safety, the contract would not resolve the issue of her refusal to take medication.

Sadock, Benjamin J, Sadock, Virginia A, Ruiz, Pedro: Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Lippincot Williams & Wilkins. Philadelphia, 2009. Ch. 57.1 pp. 4435.

Appelbaum PS, Gutheil TG: Clinical Handbook of Psychiatry and the Law. 4th ed. Lippincott Williams & Wilkins. 2007. pp. 81-6

Some of the most common reasons for psychiatric malpractice suits include suicide attempt or completion by a patient (most common), incorrect or negligent treatment, medication error or drug reaction, and incorrect diagnosis. Less common causes for psychiatric malpractice suits include boundary violations, negligent supervision, improper commitment, injury to a third party (Tarasoff cases), and breach of confidentiality.

Sadock, Benjamin J, Sadock, Virginia A, Ruiz, Pedro: Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Lippincot Williams & Wilkins. Philadelphia, 2009. Ch. 58 pp. 1371-1382.
Appelbaum PS, Gutheil TG: Clinical Handbook of Psychiatry and the Law. 4th ed. Lippincott Williams & Wilkins. 2007. pp. 118-25.

. A socially harmful act is not enough to have committed a crime. To be found guilty, the accused must also have mens rea (evil intent) and actus reus (voluntary conduct). Because Mr. Newell is psychotic, he could be found not responsible for his crime because he was lacking both of these elements. Respondeat superior holds that a person occupying a high position in a hierarchy is responsible for those in lower positions. Nonmalfeasance is the duty of physicians to do no harm. Parens patriae is a doctrine that allows the state to intervene and act as a surrogate parent for those who are unable to care for themselves.

Sadock, Benjamin J, Sadock, Virginia A, Ruiz, Pedro: Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Lippincot Williams & Wilkins. Philadelphia, 2009. Ch. 58 pp. 1371-1382, Ch. 59 pp.1383-1392.
Appelbaum PS, Gutheil TG: Clinical Handbook of Psychiatry and the Law. 4th ed. Lippincott Williams & Wilkins. 2007. pp. 221-31.

Society has deemed that sexual behavior, which is not “healthy and non-harming,” can be punished by serious legal and societal consequences. The paraphilias that most commonly lead to legal consequences include pedophilia, exhibitionism, and sexual sadism resulting in rape or murder.

Sadock, Benjamin J, Sadock, Virginia A, Ruiz, Pedro: Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Lippincot Williams & Wilkins. Philadelphia, 2009. Ch .18.2 pp. 2090-9.

The McGarry instrument is a clinical guide that evaluates 13 areas of functioning in order to determine a patient’s competence to stand trial. The McNaughton rule states that people are not guilty by reason of insanity if they have a mental disease such that they are unaware of the nature, quality and consequences of the actions, or if they are incapable of realizing that their acts are wrong. The McGann instrument and the McInnis instrument are not real and are just distractors.

Sadock, Benjamin J, Sadock, Virginia A, Ruiz, Pedro: Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Lippincot Williams & Wilkins. Philadelphia, 2009. Ch. 58 pp. 1371-1382, Ch. 59 pp.1371-82.
Appelbaum PS, Gutheil TG: Clinical Handbook of Psychiatry and the Law. 4th ed. Lippincott Williams & Wilkins. 2007. pp. 221-31.

Iloperidone (Fanapt) is metabolized by CYP 2D6 and CYP 3A4 P450 enzymes. It is necessary to reduce the dosage of iloperidone by 50% if it is given concomitantly with a strong inhibitor of either enzyme. Paroxetine is a strong inhibitor of 2D6. When the inhibitor is discontinued, the dosage should be returned to its previous level. Side effects of iloperidone include sedation, orthostatic hypotension , dizziness and tachycardia. Iloperidone can also cause QTC prolongation and EPS. The usual starting dose is 1 mg. BID with a gradual titration to a 6-12 mg. BID.

Drugs.com http://www.drugs.com/ppa/iloperidone.html

MRI studies in patients with PTSD show decreased hippocampal volume. The answer choice involving the putamen and caudate is a distractor. Increased size of the lateral ventricles is seen in schizophrenia. Decreased metabolic activity in the prefrontal cortex is seen in schizophrenia, not PTSD. In addition metabolic activity is evaluated using fMRI or PET, not a standard MRI.

Gilbertson MW, Shenton ME, Ciszewski A, et al: Smaller hippocampal volume predicts pathologic vulnerability to psychological trauma. Nat Neurosci 2002; 5: 1242-47.

. B.F. Skinner is associated with operant conditioning. In operant conditioning voluntary behavior is modified using positive and negative reinforcement to shape the desired behavior. Ivan Pavlov is associated with classical conditioning. In classical conditioning a neutral (conditioned) stimulus is paired with a stimulus that evokes a response (unconditioned) such that the neutral stimulus eventually comes to evoke the same response. Martin Seligman is associated with learned helplessness, which is a model of depression in which an individual repetitively fails at tasks and eventually stops trying, adopting a hopeless apathetic position. Salvador Minuchin is associated with structural family therapy. Structural family therapy focuses on the organization of the family and how that organization promotes or impedes the family from functioning successfully.

Sadock, Benjamin J, Sadock, Virginia A, Ruiz, Pedro: Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Lippincot Williams & Wilkins. Philadelphia, 2009. Ch. 30.3 pp. 2781.

CBT has been well studied and shown to be very effective for panic disorder. It often includes psychoeducation, continuous panic monitoring, breathing retraining, cognitive restructuring, and exposure to fear cues. Developing discrepancy between the patient’s goals and current behavior is an important element of Motivational Interviewing, which is used in substance abuse treatment; however, it is not considered a central element of CBT.

Kristin M: A meta-analysis of the efficacy of psycho- and pharmacotherapy in panic disorder with and without agoraphobia. J Affect Dis 2005; 88: 27-45.

In the treatment guidelines for children with ADHD and moderate tic disorders, guanfacine and clonidine are considered first line treatments. These medications are effective both for tic control and decrease in impulsivity and hyperactivity while having a favorable safety margin compared with the antipsychotic medications.

Scahill L, Chappell PB, Kim YS, et al: Guanfacine in the treatment of children with tic disorders and ADHD: a placebo-controlled study, Amer J Psych 2001; 158; 1067-1074.

Biederman J, Melmed RD, Patel A, et al. A randomized, double-blind, placebo-controlled study of guanfacine extended release in children and adolescents with attention deficit hyperactivity disorder. Pediatrics 2008; 121: e73-e84.

The most important first intervention in a child who presents with language delay is a full hearing evaluation.
Practice Parameter for the Assessment and Treatment of Children and Adolescents with Language and Learning Disorders, J Amer Acad Child Adol Psychiatry 1998 suppl; 37: 10.

Problems with attention and behavior typically occur in several settings, and may vary depending on the level of structure and supervision provided, the interest in and/or novelty of an activity or setting, as well as the level of concentration and effort required. Therefore, in order to make the diagnosis of ADHD, the patient must exhibit symptoms in at least two settings.

Practice Parameter for the Assessment and Treatment of Children and Adolescents with Attention Deficit Hyperactivity Disorder, J Amer Acad Child Adol Psychiatry 2007; 46: 894-921.

Velocardiofacial Syndrome (VCFS, Shprintzen syndrome, DiGeorge syndrome) is caused by microdeletion in the long arm of chromosome 22 at band 22q11.2. The phenotypic spectrum of VCFS is extremely wide and includes congenital cardiac anomalies, abnormal facies, palatal abnormalities, hypocalcemia and T-cell immunodeficiencies, cognitive deficits and psychiatric manifestations including schizophrenia.

Gothelf D. Velocardiofacial Syndrome. Child Adol Clin North Amer 2007; 16: 677-93.

When patients treated with nonreversible MAOIs ingest tyramine containing foods, they are at risk to develop a hypertensive crisis. Foods with high tyramine content should be avoided and include aged cheeses, aged or fermented meats, fava beans and other broad beans, sauerkraut, overripe or spoiled foods,, soy sauce, and yeast extracts (marmite). Both alcoholic and non-alcoholic tap beer, and chianti wine should also be avoided . Foods that are safe to ingest include fresh cheeses, fresh yogurt, other alcoholic beverages and smoked fish. Chocolate and caffeine can be a problem if ingested in large amounts, but are acceptable if used in moderation.

Hales RF, Yudofsky SC, Gabbard GO (eds.):The American Psychiatric PublishingTextbook of Psychiatry: 5th ed. American Psychiatric Publishing, Inc. 2008
Labbate LA, Fava M, et al: Handbook of Psychiatric Drug Therapy, 6th ed. Lippincott Williams & Williams, 2010.

Schizoid personality disorder is characterized by social detachment, isolation and constricted affect. Affected individuals lack close friends, do not take pleasure in activities, and appear cold, aloof and indifferent to others. Suspiciousness and mistrust is a core feature of paranoid personality disorder.

Hales RF, Yudofsky SC, Gabbard GO (eds.) The American Psychiatric PublishingTextbook of Psychiatry: 5th ed. American Psychiatric Publishing, Inc, 2008
Saddock BJ, Kaplan VA: Kaplan and Saddock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry 10th ed. Lippincott Williams & Wilkins, 2007

According to the APA practice guidelines for treating Borderline Personality Disorder, the initial medication treatment for patients who have symptoms of affective dysregulation (mood lability, inappropriate intense anger, depressive mood crashes, or outbursts of temper), is an SSRI or similar antidepressant. In the recommended treatment algorithm, the next step would be to try a different SSRI or other related antidepressant. If this continues to be ineffective or only partially effective, then a low dose of neuroleptic should be added for symptoms of anger, and or clonazepam for anxiety. If the patient is still symptomatic, then a trial of an MAOI should be utilized. The last step in the algorithm, if the patient remains symptomatic, is a trial of a mood stabilizer.
APA Practice Guidelines for the Treatment of Borderline Personality Disorder. (originally published in 2001)

Due to its long half-life, when switching from fluoxetine to an MAOI, a 5-week washout period is advised, in order to reduce the risk of developing serotonin syndrome. When transitioning from an MAOI to fluoxetine, the recommended washout period is two weeks. When switching between an MAOI and other SSRIs, the washout period is two weeks.
Schatzberg AF, Cole JO, DeBattista, C. Manual of Clinical Psychopharmacology 5th ed. American Psychiatric Publishing, 2005, pp. 122-3.

According to data published in 2004 by the American Association of Suicidology, firearms account for 51.6% of completed suicides. Suffocation or hanging accounts for 22.6% and poisoning resulted in 17.9 % of suicides. However worldwide, hanging is cited as the most common method of suicide.

Hales RF, Yudofsky SC, Gabbard GO (eds.) The American Psychiatric PublishingTextbook of Psychiatry: 5th ed. American Psychiatric Publishing, 2008
Saddock BJ, Kaplan VA: Kaplan and Saddock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry 10th ed. Lippincott Williams & Wilkins, 2007

Serotonin syndrome can present with a wide array of symptoms that vary in severity. The neuromuscular findings of hyperreflexia, myoclonus, and tremor are highly suggestive of the disorder, in a patient who has recently received serotonergic agents, or has had a dosage adjustment. Other symptoms include diarrhea, tachycardia, elevated temperature, diaphoresis, shivering, elevated BP, and muscular rigidity (which can mask the other neuromuscular symptoms). Mental status changes ranging from agitation and confusion to frank delirium can also occur. Lithium toxicity would be unlikely to occur at a level of 0.7. In neuroleptic malignant syndrome, symptoms of severe muscle rigidity (“lead pipe rigidity”), mutism, and decreased bowel sounds would be seen. Anticholinergic toxicity is characterized by hyperthermia, tachycardia, dry mouth, decreased or absent bowel sounds, agitation and delirium, normal neuromuscular tone and normal reflexes.
Boyer EW; Shannon M: The serotonin syndrome, N Engl J Med 2005; 352: 1112-20.

Pharmacological management strategies for serotonin syndrome include the use of benzodiazepines for control of agitation, and 5-HT2A antagonists such as cyproheptadine. In severe cases, if the excessive muscular activity is not suppressed by a benzodiazepine, the use of a non-depolarizing agent, such as vecuronium (with appropriate supportive measures), may be necessary to control hyperthermia. Since the hyperthermia is a direct result of muscular hyperactivity, antipyretics such as acetaminophen have no effect.
Boyer EW; Shannon M: The serotonin syndrome, N Engl J Med 2005; 352: 1112-20.

Valproic acid can double serum levels of lamotrigine. This is of particular concern because of the increased risk of rash that occurs in patients taking lamotrigine. While most often the rash is benign, it can herald the beginning of Steven’s Johnson syndrome, a potentially fatal reaction. Lamotrigine should be discontinued in any patient who develops a rash. The risk of developing a rash is increased by rate of titration and starting dosage. Therefore, lower dosage and slower titration of lamotrigine is recommended if valproic acid is used together with lamotrigine. . Paroxetine, a 2D6 inhibitor does not affect lamotrigine levels, nor does iloperidone.

Labbate LA, Fava M, et al: Handbook of Psychiatric Drug Therapy, 6th ed. Lippincott Williams & Williams, 2010.

The long acting injectable formulation of olanzapine has a black box warning because it is associated with the development of post-sedation delirium syndrome (PDSS). Symptoms can range from sedation, which may be severe, to delirium or coma. This formulation of olanzapine can only be administered in a registered health care facility, and patients must be observed for at least 3 hours before they can be sent home.
Saddock B, Saddock V, Sussman N: Pocket Handbook of Psychiatric Drug Treatment 5th ed. 2011. Lippincott Williams &Wilkins, p225.

The Teva Clozapine Patient Registry has established guidelines for monitoring patients on clozapine to reduce the risk of agranulocytosis. Physicians must monitor both WBC and ANC. WBC should remain  3500 and the ANC 2000. Monitoring is done weekly for the first 6 months, and then every two weeks for the next 6 months. If the blood counts remain acceptable after 12 months of treatment, monitoring can be decreased to monthly. If the WBC falls between 3000 and 3500,(and/or the ANC falls between 2000 and 1500), clozapine can be continued, but monitoring should be increased to twice weekly until the WBC returns to  3500, then previous monitoring frequency can be resumed. If WBC or ANC fall below 3000, and 1500 respectively, then clozapine should be temporarily discontinued and monitoring substantially increased in frequency (consult registry for details.) Clozapine should be permanently discontinued in any patient in which WBC falls below 2000 or ANC falls below 1000, and continued monitoring is required until blood counts return to normal. Decreasing the dose of clozapine will not be helpful, as agranulocytosis is not dose dependent. Agranulocytosis occurs in about 1% of patients on clozapine. It occurs early in treatment with the highest risk period between 4 and 18 weeks after starting treatment.

For monitoring guidelines go to http://www.clozapineregistry.com/Table1.pdf.ashx
Labbate LA, Fava M, et al: Handbook of Psychiatric Drug Therapy, 6th ed. Lippincott Williams & Williams, 2010

Anticholinergic agents do not improve and in some cases may exacerbate symptoms of tardive dyskinesia, and should be discontinued or avoided. Switching to clozapine or a second generation antipsychotic agent may be helpful in decreasing symptoms of tardive dyskinesia. Lowering the dose of a medication may also be effective, but initially the symptoms may appear to worsen, as a result of withdrawal emergent dyskinesias. Benzodiazepines may offer some partial or temporary relief.

Brasic, JR: Tardive Dyskinesia. Medscape, Updated 2/9/12
emedicine.medscape.com/article/1151826-overview

Woo TW et al: Treatment of Schizophrenia, Chapter 55, (in) Schatzberg AF et al: The American Psychiatric Publishing Textbook of Psychopharmacology, 4th ed, 2009.
Kaufman D, Milstein M: Kaufman’s Clinical Neurology for Psychiatrists, 7th ed, Elsevier, 2013.

There is an increased risk of schizotypal personality disorder in the relatives of people diagnosed with schizophrenia, providing some of the support for the concept that schizoptypal personality disorder and schizophrenia are spectrum disorders. In addition, an increased risk for developing schizophrenia occurs in the relatives of people with schizotypal personality disorder. Paranoid personality disorder can also be found in relatives of people with schizophrenia, but it is not as common as schizotypal personality disorder.

Hales RF, Yudofsky SC, Gabbard GO (eds.) The American Psychiatric PublishingTextbook of Psychiatry: 5th ed. American Psychiatric Publishing, 2008

Carbamazepine is both a substrate and an inducer at CYP 450 3A4, and can induce its own metabolism, leading to decreased plasma levels, even though dosing remains constant.
Schatzberg AF, Cole JO, DeBattista, C. Manual of Clinical Psychopharmacology 5th ed. American Psychiatric Publishing, 2005, pp277-9.

Fluoxetine is a strong CYP 450 2D6 inhibitor and risperidone is a substrate at 2D6. The

metabolism of risperidone has been inhibited by the addition of fluoxetine, and the patient likely

now has elevated plasma levels of risperidone, despite taking the same oral dose. Thus he has

developed EPS.

Labbate LA, Fava M, et al: Handbook of Psychiatric Drug Therapy, 6th ed. Lippincott Williams &

Wilkins. 2010

Sedation is the most common side effect of trazodone. Orthostatic hypotension and dizziness also frequently occur. Priapism and cardiac arrhythmias are uncommon events associated with trazodone use.

Hales RF, Yudofsky SC, Gabbard GO (eds.) The American Psychiatric PublishingTextbook of Psychiatry: 5th ed. American Psychiatric Publishing, 2008

Psychotic symptoms are seen in patients experiencing a manic episode but not in hypomania. All of the other symptoms are consistent with both mania and hypomania. Another distinction between hypomania and mania is that social and occupational functioning is not significantly impaired in the former.

APA Diagnostic and Statistical Manual of Mental Disorders 5th ed. American Psychiatric Publishing, 2013.

Fetal Alcohol Syndrome, caused by maternal excessive alcohol consumption, is considered to be the most common acquired, therefore potentially preventable, cause of intellectual disability. Fetal Alcohol Syndrome is caused by excessive alcohol consumption late in pregnancy (3>2>1 trimester). Down’s syndrome is the most common genetic cause of intellectual disability but is not heritable, as it is not present in either parent. Fragile X is probably the most common heritable rather than acquired cause of intellectual disability. The mutation is often present in parents, but in small enough size that symptoms occur but in milder forms. When the mutation, and number of trinucleotide repeats, increase, children are at risk for the full-blown illness. Autism (DSMIVTR) is associated in 65-70% of cases with intellectual disability but is not a cause of intellectual disability.

Sadock BJ, Sadock VA, Ruiz P: Kaplan & Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. 2009, Vol I. Lippincott Williams & Wilkins, p83.
Roussotte FF et al.: Regional brain volume reductions relate to facial dysmorphology and neurocognitive function in fetal alcohol spectrum disorders. Human Brain Mapping 2012; 33(4): 920-37.

VCFS is best known for its association with psychiatric disorders, and is particularly well-known for representing a genetic risk for schizophrenia. Early loss of temporal grey matter seems to predict the early signs of significant psychiatric problems. Except for having two parents with schizophrenia or being the monozygotic twin of someone with schizophrenia, VCFS is the highest risk factor for developing the disorder. VCFS is also associated with autism, ADHD, mood disorders and phobias. In the very young, management is related to treatment of heart, immune, palatal difficulties along with developmental delays. In the school years, cognitive difficulties are prominent. In young adulthood, psychiatric difficulties may develop. Answer a refers to tuberous sclerosis, which presents with nodules seen on the malar surface of the face, progressive intellectual disability and is associated with autism, epilepsy and cerebral tumors. VCFS is not a sex-linked condition; it is caused by a micro-deletion at 22.11.2. The microdeletion syndromes at 15Q are Prader-Willi (paternal deletion) and Angelman (maternal). In general, abnormal sex chromosomes produce physical findings and not necessarily intellectual dysfunction, whereas abnormal autosomal chromosomes are usually associated with intellectual disability.

Kates et al.: Neuroanatomic predictors to prodromal psychosis in velo-cardio-facial syndrome (22q11.2 deletion syndrome): a longitudinal study. Biol Psychiatry 2011; 69: 945-52.
Murphy, KC: Schizophrenia and velo-cardio-facial syndrome. The Lancet 2002; 359: 426-30.
Sadock BJ, Kaplan HI, Sadock VA: Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. 2007. Lippincott Williams & Wilkins: Philadelphia, p. 1141.

The vast majority of paraphilias occur in men. Close to 100% of exhibitionists are males exposing themselves to women. Fetishism, a disorder in which sexual arousal involves the use of inanimate objects that are typically associated with the body e.g. shoes, gloves, undergarments, etc.,also almost always occurs in men. 95% of pedophiles are heterosexual. Most pedophiles also have engaged in voyeurism, exhibitionism and rape.

Saddock BJ, Kaplan VA: Kaplan and Saddock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry 10th ed. Lippincott Williams & Wilkins, 2007.

Angelman Syndrome is a heritable cause of intellectual disability that occurs when the deletion at 15q is maternally inherited. It occurs in boys and girls and is comprised of profound intellectual disability, microcephaly, paroxysms of laughter, ataxia and autistic features. Rett syndrome is heritable, but is present exclusively in girls (and XXY boys) so this is incorrect as a diagnosis. Young girls with Rett have characteristic hand stereotypies and they do have microcephaly but not bursts of laughter and ataxia. Prader-Willi is a heritable cause of intellectual disability (paternal deletion at 15q) but classically has hyperphagia, obesity, non food-related obsessions and severe behavior problems. In Williams one sees “elfin” facies and “cocktail party chatter” and some level of intellectual disability.Sadock BJ Kaplan HI Sadock VA: Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. 2007. Lippincott Williams & Wilkins: Philadelphia, pp 1138-57.

Mild elevations of pulse and blood pressure are a common side effect of stimulants. A recommendation for pediatric or cardiology consultation and EKG or further work-up is indicated if there is a family history of early/sudden death or congenital cardiac condition or dysrhythmia in the child. Stimulants do not cause evening sedation (and can cause insomnia.) Lithium is known to cause increased thirst. SSRIs and antipsychotics are known to increase appetite (stimulants typically decrease appetite.)

Spencer T et al: Assessment and Treatment of Attention-Deficit Hyperactivity Disorder in Martin A et al. (Eds.) Pediatric Psychopharmacology: Principles and Practice, 2001. Oxford University Press, New York, pp 437-52.

This woman suffers from Social Anxiety Disorder Generalized type. Paroxetine, sertraline and venlafaxine have FDA approval for the treatment. Off label, all SSRIS, MAOIs, and benzodiazepines have demonstrated efficacy. B-blockers are effective off label treatments for performance anxiety, but are not useful in generalized social anxiety. Tricyclic antidepressants, which are effective in the treatment of both GAD and panic disorder, have not been shown to be helpful in the treatment of social anxiety disorder.
Labbate LA, Fava M, et al: Handbook of Psychiatric Drug Therapy, 6th ed. Lippincott Williams & Williams, 2010. p175-179.

Guanfacine (and extended-release Guanfacine) as well as clonidine, both alpha 2-adrenergic agonists, commonly present with side effects of drowsiness, dizziness and dry mouth. Increased urination is seen with lithium treatment, not guanfacine.
Labbate LA et al: Handbook of Psychiatric Drug Therapy. 2010. Lippincott, Williams & Wilkins: Philadelphia. p. 281.

Bupropion acts to enhance transmission of dopamine and norepinephrine and does not exert influence on serotonin receptors. Common side effects include headache, anxiety, insomnia, GI upset and sweating.. Tremor and akathisia can also occur. Bupropion is not associated with weight gain (and may cause weight loss , sexual dysfunction or cardiac conduction problems. It does not cause daytime sedation or orthostatic hypotension. Bupropion is not associated with anticholinergic side effects. Daily dose should not exceed 450 mg. as dose dependent seizures can occur when this level is exceeded. Because it facilitates dopamine transmission, it may be a good choice for use in patients with Parkinson’s disease.

Hales RF, Yudofsky SC, Gabbard GO (eds.) The American Psychiatric PublishingTextbook of Psychiatry: 5th ed. American Psychiatric Publishing, 2008
Labbate LA, Fava M, et al: Handbook of Psychiatric Drug Therapy, 6th ed. Lippincott Williams & Williams, 2010

Since 2007, the FDA has approved 3 medications for the treatment of fibromyalgia: pregabalin (Lyrica), duloxetine (Cymbalta), and milnacipran (Savella). Pregabalin acts as a Alpha2-delta ligand, while the latter two are serotonin-norepinephrine reuptake inhibitors (SNRI). Venlafaxine is also an SNRI, but has not been FDA-approved for fibromyalgia. Tricyclic antidepressants have been shown to be helpful as well.

Nickerson B: Recent Advances in the Treatment of Pain Associated with Fibromyalgia. US Pharmacist. 2009;34(9):49-55

The use of antipsychotics have been recognized to increase the risk for markers of cardiac dysfunction (e.g. prolonged QTc), ventricular arrhythmias (including torsade de pointe), and even sudden cardiac death. The association may be more common in elderly patients and with the use of typical antipsychotic agents. Leonard CE, Freeman CP, Newcomb CW, et al: antipsychotics and the risks of sudden cardiac death and all-cause death: Cohort studies in Medicaid and dually-eligible Medicaid-Medicare beneficiaries of five states. J Clin Exp Cardiolog. 2013; Suppl 10(6): 1–9.

Adrenal insufficiency or Addison's Disease is an often overlooked endocrine condition with prominent fatigue that can mimic depression. Other common symptoms include nausea, vomiting, diarrhea, muscle pain, and sweating, Weight loss and postural hypotension are common signs. The treatment involves replacement corticosteroids.

Margolin L, Cope DK, Bakst-Sisser R, et al: The steroid withdrawal syndrome: A review of the implications, etiology, and treatments. J Pain Sympt Management 2007: 33(2):224-8.
Ten S, New M, MacClaren N: Addison’s disease 2001. J Clin Endocrinol Metab 2001. 86: 2909–

Bupropion doses should not exceed 450mg. daily due to increased risk of seizures at higher doses. Bupropion use is contraindicated in patients with bulimia and anorexia, as these patients demonstrated an increased susceptibility to seizures in premarketing trials. Bupropion has been shown to be effective in treating patients with seasonal affective disorder, and is a second line treatment for ADHD. Marketed under the name Zyban, it is an approved treatment for smoking cessation. Bupropion may be useful in the treatment of depression in bipolar disorder, because it is less likely to induce a switch to mania. Bupropion may exacerbate anxiety symptoms in patients with panic disorder or other anxiety disorders.

Saddock B, Saddock V, Sussman N: Pocket Handbook of Psychiatric Drug Treatment 5th ed. Lippincott Williams &Wilkins, 2011.
Labbate LA, Fava M, et al: Handbook of Psychiatric Drug Therapy, 6th ed. Lippincott Williams & Williams, 2010

Saddock B, Saddock V, Sussman N: Pocket Handbook of Psychiatric Drug Treatment 5th ed. Lippincott Williams &Wilkins, 2011

Compared to those with bulimia, patients with anorexia nervosa have a lower nutrition status and thus higher rates of medical complications including effects on thyroid (euthyroid sick syndrome) and sex hormones (including decreased LH and FSH), amenorrhea, electrolyte abnormalities, osteoporosis, cardiac malfunction (including bradycardia and arrhythmia), and overall mortality. An elevated amylase is associated with purging in either condition. In this case the bulimic patient who purges is more likely to have an elevated amylase than a non-purging anorexic patient.Maine M, McGilley BH, Bunnell, DW: Medical Assessment of Eating Disorders, Chapter 6, 89-110, in Treatment of Eating Disorders, edited by Maine M, McGilley BH, Bunnell, DW, 2010, London, Elsevier Inc.

Obstructive sleep apnea (OSA) is common occurring in up to 17% of men. OSA can lead to symptoms that mimic depression: fatigue, lack of energy, and poor concentration. Sufferers are more likely to be involved in car accidents. Medications may be used to increase alertness or to treat associated depressive symptoms, but continuous positive airway pressure (CPAP) has been shown to decrease somnolence and to improve the quality of life, mood, and alertness in patients with OSA. First, however, patients must be evaluated with polysomnography. Morning cortisol should be checked in patients with presentations suspicious for adrenal insufficiency, which would include those with prominent fatigue, nausea/anorexia, weight loss, and hypotension.

Myers KA, Mrkobrada M, Simel DL: Does this patient have obstructive sleep apnea? The Rational Clinical Examination Systematic Review. JAMA. 2013;310(7):731-41.
Flemons WW: Obstructive sleep apnea. N Engl J Med 2002; 347:498-504.

The SSRIs and SNRIs can all cause sexual dysfunction. Mirtazipine and bupropion are notable for their lack of association with sexual dysfunction. Common side effects of mirtazipine include weight gain, sedation, and dizziness.

Hales RF, Yudofsky SC, Gabbard GO (eds.) The American Psychiatric PublishingTextbook of Psychiatry: 5th ed. American Psychiatric Publishing, 2008

Psoriasis is a chronic, relapsing skin disease presenting with erythematous, scaling papules, and indurated plaques, arising preferentially on the elbows, knees, and scalp. Common trigger factors include psychological stress, physical trauma, infections, certain drugs (lithium, antimalarials, interferon, β-blockers), corticosteroid withdrawal, and alcohol use.

Gupta, AK: Psychocutaneous Disorders, in Kaplan & Sadock’s Comprehensive Textbook of Psychiatry, 9th edition. Sadock BJ, Sadock VA, Ruiz P(eds). (2009). Philadelphia. Lippincott Williams & Wilkins.

HIV-associated dementia (HAD) is one of the leading causes of dementia in those under 60 years of age. Risk factors include higher viral load, lower educational level, anemia, older age and female sex. The incidence of HAD has decreased significantly since the advent of antiretroviral medication, including zidovudine.

Tozzi V, Balestra P, Libertone R, et al: Cognitive function in treated HIV patients. Neurobehavioral HIV Medicine 2010; 2: 95–113.

Major Depressive Disorder is twice as common in women and tends to have a later age of onset than bipolar disorder. Bipolar disorder occurs with equal frequency in men and women. Rapid cycling is occurs much more frequently in women than men.
Saddock BJ, Kaplan VA: Kaplan and Saddock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry 10th ed. Lippincott Williams & Wilkins, 2007.

Medications that are FDA approved for nicotine dependence include Varenicline (Chantix), bupropion SR (Zyban), and nicotine replacement therapy. Physician advice has been shown to be effective as part of the “5 A’s” (Ask, Advise, Assess, Assist, Arrange). Acupuncture has not been shown to demonstrate efficacy.
Textbook of Substance Abuse Treatment: APA Press, 4th Ed, Galanter, Kleber, 2008.

The most likely cause of her delirium is MDMA (Ecstasy, Molly), which can cause agitation and paranoia; however, the greatest concern is the hypertension and hyperthermia that can lead to cardiovascular collapse. The other drugs do not produce this combination of symptoms.

Lowinson and Ruiz’s Substance Abuse: A Comprehensive Textbook, 5th Edition, Ed: Ruiz, Strain 2011

When benzodiazepines are used in patients with cirrhosis, those with shorter half lives and without active metabolites like lorazepam and oxazepam are preferred. Benzodiazepines which undergo oxidative metabolism in the liver, can accumulate to toxic levels in patients with cirrhosis. Despite its short half life, levels of alprazolam, which also undergoes oxidation, can accumulate to dangerous levels in a patients with a cirrhotic liver.

Labbate LA, Fava M, et al: Handbook of Psychiatric Drug Therapy, 6th ed. Lippincott Williams & Williams, 2010.
Saddock B, Saddock V, Sussman N: Pocket Handbook of Psychiatric Drug Treatment 5th ed. Lippincott Williams &Wilkins, 2011.

Conduct disorder both precedes and predicts substance abuse in adolescents. Its risk is greater than for ADHD, PTSD and Bipolar Disorder.
Lowinson and Ruiz’s Substance Abuse: A Comprehensive Textbook, 5th Edition, Ed: Ruiz, Strain 2011.

Patients with co-occurring disorders my benefit from self-help groups (e.g., “Double Trouble”). Clinicians should treat psychosis, irrespective of etiology, with neuroleptics. No medications have proven to be effective for cocaine use. Benzodiazepines may be effective in anxiety disorders where patients have not responded to SSRIs, buspirone, etc, where they are stable in an Methadone Maintenance Treatment Program (MMTP) with a good therapeutic alliance.Reference: Textbook of Substance Abuse Treatment: APA Press, 4th Ed, Galanter, Kleber, 2008
Lowinson and Ruiz’s Substance Abuse: A Comprehensive Textbook, 5th Edition, Ed: Ruiz, Strain 2011

Her dementia, accompanied by myoclonus and an EEG showing periodic complexes, progressing to death in 6 months characterizes Creutzfeldt-Jakob disease. Finding a 14-3-3 protein in her CSF would have given further diagnostic support. A brain biopsy would have shown spongiform changes, but clinicians do not routinely perform biopsies in suspected Creutzfeldt-Jakob disease cases because the material, which is infectious, would contaminate the surgical instruments and expose the surgical and pathology teams. Another reason for not performing a biopsy is that the illness remains untreatable. Creutzfeldt-Jakob disease is a frequently occurring neurodegenerative cause of dementia that follows a rapid, fatal course. As Dr. Stanely Prusiner, the Nobel-prize winning discoverer of the mechanism underlying Creutzfeldt-Jakob disease and related illnesses, explained at the American Psychiatric Association’s 2013 meeting, prions cause these illnesses by conformational conversion of prion proteins.

Prusiner SB: Cell biology. A unifying role for prions in neurodegenerative disease. Science 2012; 336: 1511-3.

ADHD is always more impairing than tics when the two are co-morbid. The severity of ADHD, not tics, is a good predictor of social difficulties, particularly with peers. Methylphenidate and clonidine can be used either alone or in combination when patients have comorbid tics/Tourette’s and ADHD, no matter which condition is worse. By history, ADHD will precede tics, usually by 2-3 years.

Bloch MH et al. Meta-Analysis: Treatment of attention-deficit/hyperactivity disorder in children with comorbid tic disorders. J Amer Acad Child Adol Psychiatry 2009; 48: 884-93.

While methadone and buprenorphine have both been demonstrated to be safe during pregnancy for the mother and fetus, the National Institute of Drug Abuse (NIDA)–sponsored MOTHER study showed milder neonatal abstinence with buprenorphine compared to methadone.

Jones ME, et al: Neonatal abstinence syndrome after methadone or buprenorphine exposure. N Engl J Med 2010; 363: 24: 2330-32.

Frontotemporal dementia, a neurodegenerative illness, causes dementia that is initially overshadowed by personality changes and behavioral disturbances. The diagnostic criteria require 3 of 6 disturbances: disinhibition, apathy, loss of sympathy, perseveration or compulsive behaviors, hyperorality, and impaired executive ability. Physicians might easily misdiagnosis frontotemporal dementia for bipolar disorder or late-life depression. Frontotemporal dementia is a common cause of dementia that characteristically has a relatively young age of onset (53 years), follows a rapidly fatal course (4 years), develops in men more than women, and occurs in multiple family members.

Forman MS, Farmer J, Johnson JK, et al: Frontotemporal dementia. Ann Neurol 2006; 59: 952-62.
Kertesz A, Blair M, McMonagle P, et al: The diagnosis and course of frontotemporal dementia. Alzheimer Dis Assoc Disord 2007; 21: 155-63.

There is a large body of literature on the gender differences in the somatoform disorders. The evidence points to a higher prevalence of these diagnoses in women except for hypochondriasis which is found equally in men and women.

Barsky AJ, Peekna HM, Borus JF: Somatic symptom reporting in women and men. J Gen Int Med 2001;16:266-75.

Down's syndrome is caused by a trisomy at chromosome 21 and includes intellectual disability of mild-moderate level, characteristic physical findings including stunted growth, low tone, small genitalia and facial dysmorphia and risk of dementia in later life. This risk is of more concern now that people with Down's have a greater life expectancy. The intellectual decline in the 40s and 50s is associated with an excess of beta amyloid. Down's syndrome is negatively associated with autism. Prader-Willi is caused by a paternally-inherited translocation at 15Q. It is comprised of hyperphagia, non food-related compulsive behavior and borderline-moderate intellectual disability. Fragile X is caused by a mutation at the “fragile” site of the X chromosome (Xq27.3). Fragile X is the most common inherited cause of intellectual disability, causes moderate to severe disability and, besides a long face and large ears, is also associated with macro-orchidism, ADHD, autism and social anxiety.

Sadock BJ, Kaplan HI, Sadock VA: Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. 2007 Lippincott Williams & Wilkins: Philadelphia pp 1138-57.
Car J: Six weeks to 45 Years: A longitudinal study of a population with Down syndrome. J Applied Res Intellect Disabil 2012; 25: 414-22.

This is an example of the concept of operational thought described by Piaget and typically emerging between the ages of 7-11 years. Normally-developing children in this developmental stage are able to use logical thought to order, seriate and group objects based on common characteristics. The concept of conservation attained in this developmental phase refers to the ability to recognize that even when the shape of an object changes, the amount of matter is conserved.

High potency conventional antipsychotics, like haloperidol, are most likely to cause extrapyramidal side effects, while low potency agents, like thioridazine, are more likely to cause anticholinergic side effects (blurred vision, dry mouth, urinary hesitancy, constipation, tachycardia), alpha adrenergic side effects (orthostasis) as well as weight gain and sedation (mediated by histamine and alpha adrenergic receptors). Perphenazine and thiothixene are both midrange in potency, and less likely to cause anticholinergic side effects. Labbate LA, Fava M, et al: Handbook of Psychiatric Drug Therapy, 6th ed. Lippincott Williams & Williams, 2010.

Hemorrhagic changes at the base of the frontal and temporal lobes characterize herpes simplex encephalitis. The incidence of SSPE, which had been the most common cause of dementia of childhood, has dramatically fallen with widespread, complete measles immunization.

Gutierrez J, Issacson RS, Koppel BS: Subacute sclerosing panencephalitis: An update. Dev Med Child Neurol 2010; 52: 901-7.

This patient is most likely using crystal methamphetamine. The presentation is similar to cocaine, but with cocaine use, the urine would be positive for benzoylecgonine, which is the metabolite of cocaine. PCP does not cause dilated pupils. Schizophrenia in and of itself would not cause increased heart rate or dilated pupils, but otherwise may be similar.

Principles of Addiction Medicine 47th Edition ed. Reis, Fiellin, et al 2009.
Textbook of Substance Abuse Treatment, APA Press 4th Edition, ed Galantar, Kleber, 2008

At one to six months after bariatric surgery, particularly when they have vomiting, patients are at risk for Wernicke encephalopathy and other nutritional deficiencies. In this case, she had the classic signs of Wernicke encephalopathy. In many cases, atypical features are also present. Surprisingly, Wernicke encephalopathy rarely develops in patients with anorexia with or without bulimia.

Aasheim ET: Wernicke encephalopathy after obesity surgery: A systemic review. Ann Surg 2008; 248; 718-20.

Singh S, Kumar A: Wernicke encephalopathy after obesity surgery: A systemic review. Neurology 2007; 68: 807-11.

Prescription drug abuse is a major epidemic resulting in loss of life now exceeding motor vehicle accidents. Its use is enhanced by its perceived safety and increased availability. Because of prescription opiates’ greater expense, people transition to heroin.
Substance Abuse and Mental Health Services Administration (SAMHSA) Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings. NSDUH Series H-41, HHS Publication No. (SMA) 11-4658, Rockville, Md, 2011.

McCabe, SE, Boyd CJ, and Teter CJ: Subtypes of nonmedical prescription drug misuse. Drug Alcohol Dependence: 2009; 63-70.

His physical outbursts during REM periods indicates REM sleep behavior disturbance. Seizures would have been reflected in paroxysmal EEG activity, such as bursts of spike-and-wave activity.

Fantini ML, Ferini-Strambi L, Montplaisir J. Idiopathic REM sleep behavior disorder. Neurology 2005; 64: 780-86
Frenette E: REM sleep behavior disorder. Med Clin North Am 2010; 94: 593-614.

The most consistent PSG changes in depression are decreased REM latency, increased total REM sleep time, and decreased slow wave sleep. Even with remission of symptoms, these changes may persist. If so, they are a risk factor for recurrence of depression.

Palagini L, Baglioni C, Ciapparelli, et al: REM sleep dysregulation: State of the art. Sleep Med Rev 2013;

Ataxia, confusion and ocular abnormalities are the hallmarks of acute thiamine deficiency (Wernicke’s Disease). In contrast, anterograde amnesia is a defining symptom of chronic thiamine deficiency (Korsakoff’s Dementia).

Textbook of Substance Abuse Treatment, APA Press, 4th Edition, ed: Galanter, Kleber, 2008.

In Piaget’s cognitive development theory, the period from 7 years to puberty coincides with the concrete operational stage. Piaget defines this as the stage during which egocentric thought is replaced by operational thought and a large amount of information is dealt with using logical thinking. This is also the stage during which the child can take another’s perspective according to Piaget. In the psychodynamically-informed developmental stage theory of Erik Erikson, the stage of Industry versus Inferiority is described as extending from age 5 years -adolescence, coinciding with the onset of latency. During this phase, the child learns new skills, enters systematic instruction and discovers the joy of productivity.

Kaplan and Sadock’s Synopsis of Psychiatry, 10th edition, 2007.

Sublimation is a mature defense mechanism in which an individual channels unacceptable impulses into socially acceptable alternatives. In this case, the man’s unacceptable aggressive behavior has been redirected into sports, which allows him to discharge his aggressive impulses in this socially acceptable context. Displacement is a defense mechanism in which unacceptable feelings or impulses are redirected towards a less threatening object. Reaction formation is when an unacceptable thought or feeling is converted into its opposite. Projection is when one’s own unwanted or unacceptable thoughts or impulses are attributed to someone else.

Hales RE, Yudofsky SC. American Psychiatric Publishing Textbook of Clinical Psychiatry 4th ed. 2003. pp.120-124.

The patient is in the locked-in syndrome or state. He characteristically can communicate with eye movements and eyelid blinks. Most important, his cognitive function is preserved. Because he is in the locked-in syndrome, he retains his autonomy and decisional capacity. Most cases of locked-in syndrome result from a brainstem stroke due to an occlusion of the basilar artery. Other causes are brainstem trauma, amyotrophic lateral sclerosis (ALS), and, at least temporarily, Guillain-Barré syndrome.

Cardwell MS: Locked-in syndrome. Tex Med 2013; 109: el.
Kuehlmeyer K, Racine E, Palmour N, et al: Diagnostic and ethical challenges in disorders of consciousness and locked-in syndrome. J Neurol 2012; 259: 2076-89.

REM sleep behavior disorder often develops along with or up to 15 years before the onset of either Parkinson disease or dementia with Lewy bodies. It ultimately affects almost one-third of Parkinson disease patients. In both of these illnesses, which neurologists classify as synucleinopathies, REM sleep behavior disorder correlates with cognitive impairment.

Clasassen DO, Josephs KA, Ahlskog JE, et al: REM sleep behavior disorder preceding other aspects of synucleinopathies by up to half a century. Neurology 2010; 75: 494-500.
Sixel-Doring F, Trautmann E, Mollenhauer B, et al: Associated factors for REM sleep behavior disorder in Parkinson disease. Neurology 2011; 77: 1048-54.

This boy has the presumptive diagnosis of Fragile X, which is associated with ADHD, learning problems, some language dysfluency and social anxiety. There may be a history of infertility or autism spectrum disorder in the family. Physically, as the child grows, there is progressive elongation of the head and ears. DNA testing will reveal between 230 and >1000 trinucleotide repeats when the syndrome is present with fragility at Xq27.3. Rett Syndrome is an X-linked dominant disorder with a mutation at MECP2 and is seen in girls only – and in XXY boys – so would not likely be seen in this teenage boy. An ADOS evaluation would not be specific for Rett but the patient could score in the autistic range if she was evaluated during that part of her clinical course. Uric acid testing might help diagnose Lesch Nyhan syndrome, but the boy would have characteristic self-mutilation, spasticity and psychomotor retardation. The patient with tuberous sclerosis can present with CNS tubers; tubers are characteristically seen across the malar surface of the face and the syndrome is associated with autism, epilepsy and worsening dementia.

Chonchaiya W Schneider A Hagerman RJ (2009). Fragile X: A family of disorders. Adv Ped 2009;  56: 165-86.

Sadock BJ, Kaplan HI, Sadock VA: Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. 2007. Lippincott Williams & Wilkins: Philadelphia, p. 1142.

Warren ST Nelson DL (1994). Advances in molecular analysis of Fragile X syndrome. JAMA 1994; 21: 536-42.

Approximately 50% of children diagnosed with ADHD will continue into adulthood with the diagnosis. Typically, as children age into adolescence and adulthood, the gross manifestations of hyperactivity become less prominent, though restlessness can still remain as a residual symptom. Whereas DSM-IV-TR required that symptoms be present prior to the age of 7, DSM-5 only requires that symptoms (“several”) be present prior to the age of 12. In childhood, the diagnosis of ADHD is made far more often in boys than girls; adult men with ADHD seem to still outnumber women, though previously the ratio had thought to be equal; women are likely oversampled in treatment groups as they seem to preferentially seek help, making these statistics variable from study to study.

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5^th Ed. 2013. American Psychiatric Association Press: Washington, D.C. pp. 59-66.

Kessler RC: The prevalence and correlates of adult ADHD in the United States: results from the national comorbidity survey replication. Am J Psychiatry 2006; 163: 716-23.

The vignette describes a patient with classic symptoms of somatization disorder (according to DSM-IV TR):  She has four pain symptom (abdominal, head, pelvic and back),  two gastrointestinal complaints (N/V), a psuedoneurologic problem (memory difficulty) and a sexual complaint (anorgasmia). Since her symptoms are already chronic at the age of 32, she meets the DSM-IV TR requirement that the symptoms begin before the age of 30.  In his 2007 review of treatments for somatoform disorders, Kroenke found a total of 34 randomized controlled trials.  Most of the studies involved patients with somatization disorder or similar lower threshold variants. Cognitive behavioral therapy (CBT) was effective in 11 of 13 studies, while antidepressants were helpful in 4 of 5 of studies. Only 1 of 3 RCTs for conversion disorder showed benefit.  There were no studies of pain disorder.

Kroenke K: Efficacy of treatment for somatoform disorders: A review of randomized controlled trials. Psychosomatic Med 2007; 69:881–8.

Learning Disorders are defined as persistent difficulties learning keystone academic skills that are chronic, well below average for age, and not attributable to intellectual disability. The full assessment of such a learning disability requires IQ testing  (such as the WISC or Stanford Binet) and psychoeducational testing of the relevant learning area, for example reading (Kaufman), mathematics (standardized mathematics examination) or writing( Test of Written Language/ TOWL).

Kaplan and Sadock’s Synopsis of Psychiatry, 10th edition, 2007.

Practice Parameter for the Assessment and Treatment of Children and Adolescents with Language and Learning Disorders, J Amer Acad Child Adol Psychiatry 1998 suppl; 37: 10.

The following medications are approved by the U.S. Food and Drug Administration (FDA) for the treatment of ADHD: dextroamphetamine, D- and D, L-methylphenidate, mixed salts amphetamine, and atomoxetine. The American Academy of Pediatrics (AAP) and the American Academy of Child and Adolescent Psychiatry (AACAP) have recommended stimulants as the first line of treatment for ADHD. After two failed trials of each of the two stimulant classes, it is recommended that the third line choice for ADHD treatment is atomoxetine. However atomoxetine, a noradrenergic reuptake inhibitor, can be considered as the first line medication for ADHD in individuals with an active substance abuse problem, comorbid anxiety, or tics.

Practice Parameter for the Assessment and Treatment of Children and Adolescents with Attention Deficit Hyperactivity Disorder, J Amer Acad Child Adol Psychiatry 2007; 46: 894-921.

Use in physically hazardous situations and persistent desire or unsuccessful effort to cut down have been retained from DSM-IV-TR to DSM-5.  Recurrent legal problems have been deleted.  The only new criteria is craving or a strong desire or urge to use the substance and can even persist in remission.

Reference: DSM IV and DSM-5.

The neural tube forms in the first trimester of gestation. If the lower (caudal) end of the neural tube fails to close, the failure will cause a meningomyelocele, meningocele, or spina bifida. If the upper (cephalad) end fails to close, the failure will cause anencephaly, encephalocele, or similar defect. Supplementing breakfast cereals with folic acid or taking prenatal vitamins with folic acid has significantly lowered the incidence of neural tube defects. Nevertheless, the mother’s taking folic acid while taking medicines associated with the defect remains unsafe. Neural tube defects are readily detectable with MRI or ultrasound. Elevated levels of maternal serum alpha-fetoprotein indicate the presence of a neural tube defect. Not all mood stabilizers taken during pregnancy have been associated with neural tube defects. Valproate and, to a less extent, carbamazepine have been linked to neural tube defect. Other medical teratogens and genetic mutations have also been linked to the defect.

Rose, N, Mennuti, M, Glob. Fetal Neural Tube Defects: Diagnosis, Management, and Treatment libr. women’s med., (ISSN: 1756-2228) 2009; DOI 10.3843/GLOWM.10224

Of the choices, oxcarbazepine (most closely) and carbamazepine (second most closely) are linked with hyponatremia. One study (Dong) found serum sodium levels <128 mEq/L in 12% of patients taking oxcarbazepine and 3% of ones taking carbamazepine. The mechanism of hyponatremia probably involves renal dysfunction rather than either pituitary insufficiency or inappropriate secretion of antidiuretic hormone (ADH). Risk factors include high doses of the medicine, concurrent use of other medicines, and advanced age.
Pimozide is a classic antipsychotic agent that blocks D2 dopamine receptors. Its distinguishing features are that it has an indication for treatment of Tourette’s disorder, for which it is still used, and its half-life is one of the longest of all of the antipsychotics (55 hours). As with other D2 dopamine receptor antagonists, pimozide use may be complicated by acute dystonic reactions, other extrapyramidal side effects, and the neuroleptic malignant syndrome. Likewise, it may also dangerously prolong the QTc interval.
Lithium itself does not induce hyponatremia. However, if patients taking lithium or the other medicines develop psychogenic polydipsia or take diuretic, they may develop hyponatremia.

Brunton L, Parker K, Blumenthal D, et al: Goodman & Gilman’s Manual of Pharmacology and Therapeutics. McGraw Medical, New York, 2008, p307, 315

Dong X, Leppik IE, White J, et al: Hyponatremia from oxcarbazepine and carbamazepine. Neurology 2005; 65: 1976-1978

Lin CH, Lu CH, Wang FJ, et al: Risk factors of oxcarbazepine-induced hyponatremia inpatients with epilepsy. Clin Neuropharmacol 2010; 3: 293-296

Pringsheim T, Marras C. Pimozide for tics in Tourette’s syndrome. Cochrane Database System Rev 2009 (2) :CD006996

Sachedo RC, Wasserstein A, Mesenbrink PJ, et al: Effects of oxcarbazepine on sodium concentration and water handling. Ann Neurol 2002; 51: 613-620

Behavioral Signs and symptoms of amphetamine intoxication include initial euphoria or affective blunting that gives way to changes in sociability, hypervigilance, and interpersonal sensitivity in which individuals can become easily angered. Anxiety, tension and stereotyped behaviors can also occur. Impairment in judgment and function frequently result. Individuals can exhibit psychomotor agitation or retardation. Other clinical manifestations may include changes in heart rate and blood pressure, nausea and vomiting, and/or dilated pupils. Individuals may also present with respiratory depression, muscular weakness and/or chest pain. Weight loss is common. Confusion, seizures, dyskinesia, cardiac arrhythmias and coma can occur.
Reference: Fauman, MA, Study Guide to DSM IV TR. American Psychiatric Publishing, Inc. 2002

Signs and symptoms of opiate withdrawal can occur within minutes to several days after cessation following heavy or prolonged use, or receiving an opiate antagonist. They include stomach cramps, nausea, vomiting, and /or diarrhea. Individuals may report dysphoria, muscle aches and difficulty sleeping. Yawning, lacrimation, rhinorrhea can occur, as does pupillary dilation, piloerection, diaphoresis and elevated temperature. On PE, needle “tracks” may be visible. Seizures can occur during withdrawal from sedatives, hypnotics or alcohol.

Reference: Fauman, MA, Study Guide to DSM IV TR. American Psychiatric Publishing, Inc. 2002