Psychiatry is covered on both the RITE® exam and the neurology boards, so it is important to stay up-to-date on the basics of psychiatry. The level of knowledge required as a neurologist in the realm of psychiatry is somewhat limited. You should be able to identify common psychiatric disorders, understand the first-line treatment, and know the side effects of medications. Here you will find the high-yield psychiatry material you should know.

Authors: Kyle Rodenbach MD, Brian Hanrahan MD

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Goals

  1. Differentiate between volitional and non-volitional Disorders.
  2. Identify major depressive disorder, dysthymia, bereavement, and bipolar disease.
  3. Differentiate between different Cluster B personality disorders.
  4. Understand basic panic disorders.
  5. Be able to identify psychotropic drugs, their mechanism of action, and adverse side effects.

Volitional and non-volitional psychiatric diseases

Factitious disorder

  • In an effort to assume the sick role, patients will intentionally produce symptoms in the absence of external incentives. Patients place value on the emotional comfort that comes from being cared for, and may not have insight into their actions.
  • Common comorbidities: Borderline personality disorder, antisocial personality disorder, and history of trauma (sexual, verbal, and/or emotional).

Malingering

  • The performance of certain behaviors for external secondary gain.
  • Example: Patient with opioid addiction complains of abdominal pain in order to receive pain medication.

Conversion disorder

  • Presents with motor or sensory dysfunction that causes significant distress to the patient that can’t be explained by any neurological/medical disorder. 
  • Onset is often preceded by conflicts, abuse, or other stressors but is not required for diagnosis.
  • Symptoms are produced subconsciously and not intentionally.
  • Example: A patient whose mother just passed away who now can no longer walk. Her examination shows no effort with individual muscle strength testing and she has negative imaging/diagnostic studies. Additionally, the patient will withdraw to pain when pinched on the leg.

Somatic symptom disorder/somatoform disorder

  • Presents before the age of 30 years with recurrent and multiple somatic complaints not due to any physical disorder.
  • Diagnosis (each of the following must be met, based on DSM-IV criteria):
    1. Four pain symptoms
    2. Two gastrointestinal symptoms
    3. One sexual symptom
    4. At least one symptom or deficit suggesting a neurologic condition not limited to pain (pseudo-neurologic)

Dissociative disorders

  • Dissociate disorders present with a disruption of normally integrated functions of consciousness, environmental perception, memory, and identity.

Dissociative identity disorder (multiple personality disorder)

  • The patient will present with two or more distinct personalities.
  • Etiology is usually related to a severe physical and/or sexual abuse event(s) in childhood.

Depersonalization disorder

  • The patient will present with detachment or estrangement from one’s own body or the environment.

Dissociative fugue

  • Patients will present in a new geographic location with amnesia and possibly a new identity. Can be associated with traumatic circumstances.

Depression and related diseases

Major depressive disorder (MDD)

  • Symptoms: SIGECAPS (Sleep, loss of interest, guilt, loss of energy, loss of concentration, appetite/weight changes, psychomotor retardation, suicidal ideations).
    • Symptoms need to be longer than 2 weeks.
  • Associated with low serotonin levels in the brain.
  • If someone makes a vague suicidal statement during history gathering, it is important to try to ascertain intent and degree of risk.
  • Suicide risk factors: Severe depression, widowed/divorced, male gender, age over 45, white ethnicity, past suicide attempts.
  • Neurologic diseases with a higher risk of depression and suicide include Parkinson’s disease, stroke, epilepsy, Huntington’s disease, and multiple sclerosis.
  • Electroconvulsive therapy (ECT) should be considered in patients with medically refractory MDD or those who are pregnant due to the teratogenic effects of psychotropic medications.
    • Contraindications include a recent stroke or myocardial infarction, increased intracranial pressure, and having an intracranial space-occupying lesion.

Dysthymia/Persistent depressive disorder (PDD)

  • Presents with mild depression for 2 years or longer.

Bipolar disorder

  • Presents with depression and recurrent episodes of hypomania/mania.
  • Manic episodes can be severe enough to seriously interfere with daily functioning or lead to hospitalization but functioning usually returns back to baseline between episodes.
  • Can also present with…

Catatonia

    • Presents with akinetic mutism, waxy flexibility, echopraxia/echolalia, utilization behavior, and automatic obedient behavior.
    • Treatment: Electroconvulsive therapy (ECT) is the treatment of choice. Benzodiazepines may also be beneficial.
    • Dopamine antagonists, as well as baclofen, may worsen the condition.
    • Can be seen with other mood disorders, not only bipolar disease.

Bereavement

  • A non-pathologic emotional response to a stressful event such as a family death.

Personality disorders

Cluster A

  • Paranoid:
    • Excessive suspicion and distrust of others.
  • Schizoid:
    • Blunted affect and emotion. Prefers to be alone.
  • Schizotypal:
    • Magical thinking, odd and eccentric behavior. Paranoid ideation.

Cluster B

  • Borderline:
    • Presents with splitting/dichotomous thinking. Can also have Impulsive outbursts of anger, suicidal gestures, self-mutilation, and dissociative states. Patients often have unstable mood and interpersonal relationships
  • Histrionic:
    • Presents with an excessive pattern of emotionality and attention-seeking behavior.
    • Individuals are usually lively, dramatic, enthusiastic, and flirtatious. They may be inappropriately sexually provocative and overly concerned about their appearance.
  • Antisocial:
    • Patients will have disregard for authority and violation of the rights of others. Seen more in men than women. Patients tend to have a history of substance abuse.
  • Narcissistic:
    • Presents with grandiosity, a sense of entitlement, and a lack of empathy.

Cluster C

  • Avoidant:
    • Avoids social interactions with others.
  • Obsessive-compulsive:
    • Heightened focus on organization and intricacies, but does not have pervasive compulsions that impair functioning, as is seen with obsessive-compulsive disorder.
  • Dependent:
    • Excessive reliance on others. Often described as someone who is always in a relationship and described as needy.

Anxiety Disorders

Panic disorder

  • Presents with recurrent panic attacks.
  • Fears center around the possibility of having a panic attack which impairs functioning.

Phobias

  • Strong emotionally charged aversion and anxiety to specific activities, places, or things.
  • Examples:
    • Social phobia/Social anxiety disorder: Presents with extreme self-consciousness leading to impaired ability to function in daily life.
    • Agoraphobia: fear of being unable to escape a situation, usually in the setting of large groups of people.
    • Claustrophobia: the fear of confined spaces
    • Amaxophobia: A fear of being inside a vehicle
    • Neurophobia: fear of neurological diseases

Post-traumatic Stress Disorder (PTSD)

  • Presents in those who have personally experienced, or have been witness to, a traumatic event (death, serious injury, sexual violence).
  • Symptoms include involuntary distressing memories, flashbacks, and the avoidance of reminders that arouse these symptoms.
    • Chronically increased sympathetic tone related to PTSD can lead to co-morbid anxiety and hypervigilance.
  • Symptoms must continue for more than a month from the traumatic event.
  • Treatment:
    • Trauma-based cognitive behavioral therapy (CBT) (First-line) 
    • SSRIs can lead to remission and reduce recurrence rates.
      • SNRIs, trazodone, and mirtazapine can also be considered.
    • Alpha-1 adrenergic receptor antagonist, prazosin, can be used to treat PTSD-related nightmares.

Obsessive-compulsive disorder

  • Characterized by the presence of intrusive, distressing, and repetitive thoughts, images, or urges (obsessions) and repetitive behaviors or mental acts aimed at reducing distress associated with obsessions (compulsions).
  • Patients spend over an hour on obsessions and compulsions a day.
  • Associated with dysfunction of the frontal lobe and its associated network connections.

Psychotic related disorders

Schizophrenia

  • Presents with bizarre delusions, hallucinations (auditory>visual), disorganized speech/behavior, and “negative symptoms” with flat affect or social withdrawal. These issues lead to significant impairment in psychosocial functioning.
    • Patients can also have cognitive deficits in executive function, processing speed, attention, and working memory.
  • A positive family history of schizophrenia, schizoid personality, or schizotypal personality is often present in schizophrenia
  • Symptoms must be present for ≥6 months.
    • If present for <1 month, it is called “brief psychotic disorder“
    • If present for 1-6 months, it is called “schizophreniform disorder“

Schizoaffective disorder

  • Patients have symptoms of schizophrenia, but they also have the presence of a concurrent mood disorder.
  • There must be a period of psychotic symptoms for at least two weeks without mood symptoms present to make the diagnosis. 
    • If there is never a period where the psychosis is present without the symptoms of the mood disorder, this is given the nomenclature “with psychotic features.” Such as “Depression with psychotic features.”

Delusional disorder

  • Fixed, false beliefs but lack prominent auditory/visual hallucinations.
  • These false beliefs do not impair psychosocial functioning.

Pediatric-specific disorders

Autism

  • Part of a spectrum of pervasive developmental disorders .
  • Presents with impaired socialization, poor verbal and non-verbal communication with others, and stereotypic patterns of behavior.
  • Typically diagnosed at 6 years of age, but symptoms often are appreciated much earlier by family.
  • Chromosomal microarray is the recommended genetic workup.
    • Testing for Fragile X, if male, and Rett syndrome, if female, should also be considered.

Rett syndrome

  • Occurs due to an X-linked dominant mutation in MECP2 gene.
    • Only seen in females due to lethality in males.
  • Presents with symptoms comparable to autism (stereotypies), loss of speech, and motor skills. 
  • Between 60-80% of patients will also have epilepsy.

Attention deficit hyperactivity disorder (ADHD)

  • Presents with issues of attention and impulse control in at least two different settings.
  • Onset is during childhood and male predominant.
  • Overdiagnosis is common.
  • Treatment:
    • Methylphenidate:
      • Mechanism of action: Stimulant. Norepinephrine-Dopamine re-uptake inhibitor.
      • Side effects: Can make tics worse if the patient has concurrent Tourette’s or tic disorder.
      • Could also be used in mesial frontal syndrome.
    • Atomoxetine:
      • Mechanism of action: Non-stimulant. Norepinephrine reuptake inhibitor.
      • Will not make tics worse like methylphenidate.
    • Guanfacine:
      • Mechanism of action: Non-stimulant. a2-agonist.
      • Will not make tics worse like methylphenidate.
    • Clonidine:
      • Mechanism of action: Non-stimulant. a2-agonist.
      • Will not make tics worse like methylphenidate. May cause night terrors.

Williams syndrome

  • Microdeletion syndrome of chromosome 7.
  • Presents with developmental delay, congenital heart defects (i.e. aortic stenosis), hypercalcemia, and characteristic facial features (microcephaly, large mouth, and epicanthal folds).
  • Usually have excellent social and language skills in relation to other deficits.

Psychopharmacology

Antidepressants

Selective Serotonin Reuptake Inhibitors (SSRI)

  • Fluoxetine, paroxetine, sertraline, citalopram, and escitalopram
  • Side effects: Sexual dysfunction, drowsiness, weight gain, insomnia

Citalopram: High doses can lead to QT prolongation.

  • May also be used for obsessive-compulsive disorder and frontotemporal dementia (even without depression).

Serotonin-Norepinephrine Reuptake Inhibitors (SNRI)

  • Venlafaxine, Duloxetine
  • Side effects: Less sexual dysfunction and weight gain than SSRIs.
  • Duloxetine may also be used for diabetic peripheral neuropathy.

Tricyclic antidepressants (TCA)

  • Imipramine, Amitriptyline, Nortriptyline
  • Side effects: anticholinergic effects (dry mouth), anti-histaminergic effect (sedation, weight gain), insomnia, QT prolongation, and sexual dysfunction.
  • Nortriptyline is the least likely to cause weight gain and sedation due to its relatively weak H1 receptor blockade. Thus, it is better tolerated by elderly patients.

Atypical antidepressants

  • Bupropion
    • Side effects: Insomnia, headache, tremor, weight loss.
    • Lower incidence of sexual dysfunction than SSRIs/SNRIs.
    • Patients have an increased risk of seizures
    • May also be used for smoking cessation.
    • Due to the risk of abuse, it should be avoided in those with a history of substance abuse.
  • Trazodone
    • Side effects: Drowsiness, dizziness with minimal anticholinergic effects.
    • May also be used for insomnia.
  • Mirtazapine:
    • Defined as a noradrenergic and specific serotonergic antidepressant (NaSSA).
    • Side effects: Weight gain and drowsiness
      • May be helpful for those with insomnia. 

Bipolar Medications

  • Lithium
    • Mechanism of action is unknown
    • Side effects: Tremor, sedation, weight gain, acne, heart block, polyuria, decreased cognition and incoordination.
    • Lithium has a very narrow therapeutic window which makes it easy for someone to become toxic.
      • Dehydration, high salt diet, and certain medications (NSAIDs, thiazides, ACE inhibitors, etc.) can increase the risk of lithium toxicity.
      • Toxicity will present with altered mental status, seizures, and acute renal failure.
  • Anticonvulsants: Valproate and carbamazepine (see Epilepsy Syndromes chapter for more information).
  • Atypical antipsychotics (see below)

Antipsychotics

Typicals

  • Haloperidol, thioridazine, fluphenazine, chlorpromazine
  • Mechanism of action: Antagonism of the D2 receptor in the mesolimbic pathway. Also acts on a1 adrenergic, cholinergic and histaminergic receptors.
  • Side effects:
    • Hypotension, dizziness and drowsiness, dry mouth, constipation, and weight gain.
    • Patients on typical antipsychotics are at a higher risk of developing extrapyramidal symptoms (EPS) than those on atypicals.

Atypicals

  • Olanzapine, clozapine, quetiapine, risperidone, ziprasidone
  • Side effects:
    • Fewer EPS and anticholinergic side effects than typical antipsychotics.
    • Olanzapine: Weight gain, metabolic syndrome
    • Clozapine: Seizures and agranulocytosis.
    • Ziprasidone: Prolonged QT

Other Psychotropic Drugs

  • Pimavanserin
    • The only FDA approved medication specifically for Parkinson’s disease psychosis.
    • Mechanism of action: Serotonin 5-HT2A receptor inverse agonist and antagonist.

Serotonin Syndrome

  • Due to increased serotonin activity by either decreased breakdown or overproduction.
  • Common causes: MAOIs, SSRIs/SNRIs, TCAs, and dextromethorphan
  • Presents with hypertension, diaphoresis, hyperthermia, tachycardia, tremor and altered mental status
  • Shivering and myoclonus are seen with serotonin syndrome and NOT NMS
  • Treatment: Removal of offending agent(s). Primarily symptomatic management and benzodiazepines for agitation. Can try cyproheptadine (a serotonin antagonist) if the patient is not responsive to supportive care.

Neuroleptic Malignant Syndrome (NMS)

  • Due to decreased CNS dopamine activity.
  • Presents with hyperthermia, muscle rigidity, altered mental status.
  • Common causes: Antipsychotics or withdrawal of dopaminergic medications
  • Treatment: Removal of the offending agent(s). Use bromocriptine (dopamine agonist), amantadine, and/or dantrolene for severe cases.

References

  1. Biskin, R. S., and J. Paris. “Diagnosing Borderline Personality Disorder.” Canadian Medical Association Journal, vol. 184, no. 16, 2012, pp. 1789–1794., doi:10.1503/cmaj.090618.

  2. Casey DE, Zorn SH, The Pharmacology of Weight Gain with Antipsychotics, The Journal of Clinical Psychiatry, vol 62, pp 4-10, 2001.

  3. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. CBS Publishers & Distributors, Pvt. Ltd., 2017.
  4. Katzung, Bertram G. Basic & Clinical Pharmacology. Lange Medical Books/McGraw-Hill, 2001.
  5. Operto FF, Mazza R, Pastorino GMG, Verrotti A, Coppola G. Epilepsy and genetic in Rett syndrome: A review. Brain Behav. 2019;9(5):e01250. doi:10.1002/brb3.1250

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