Case 1: Major Depression, recurrent

 Tx: SSRI (sertraline, paroxetine, citalopram, fluoxetine or fluvoxamine) are first-line and
SNRIs (venlafaxine, duloxetine). Other options buproprion and mirtazapine.
 Buproprion does not cause any sexual side effects.
 TCAs cause cardiac arrhythmias.
 Sx at least for 2 weeks.
 ECT if psychotic sx present.
 Pharm and psychotherapy tx together the best.
Case 2: Schizophrenia, Paranoid
 Bizarre delusions and auditory hallucinations for 1 month and should last for 6 months.
 R/o medical conditions: hypothyroidism, hypercalcemia, syphilis
 Tx: atypical antipsychotics (risperidone, olanzapine, quetiapine, aripiprazole).
 Parkinsonian sx treat with reducing dose or anticholinergic (benztropine)
 Akathisia (can’t stay still) tx with BZD or BB (propranolol)
 Tx for NMS is dantrolene and bromocriptine.
 Schizoaffective has mania
Case 3: Panic Disorder
 Tx: CBT and SSRI. Also, SNRIs (venlafaxine) and TCAs. Short-term anxiety can use a BZD
(alprazolam).
 Unexpected
Case 4: Hypothyroid with Depression
 Meds that cause depression: Metoclopramide, Corticosteroids, OCPs, Propranolol,
Opiates, ampicillin, antineoplastic agents, ranitidine, BZDs
Case 5: Bipolar (Adolescent)
 Tx: Mood stabilizer (valproate or lithium) and atypical antipsychotic agent (olanzapine,
quetiapine, risperidone) if psychosis present.. Monotherapy includes lithium, divalproex
and CBZ or the atypical antipsychotics if no psychosis. Lithium (older than 12) and
divalproex (younger than 12) are first choice.
 Increased energy, lack of sleep, grandiosity, flight of ideas lasting at least 1 week
 Antidepressants unmask mania.
Case 6: Schizoid
 Tx: Psychotherapy long-term, but best is to seek job where low levels of interaction.
 Cluster A: Odd and eccentric (Schizoid, schizotypal, paranoid)
Case 7: Major Depression in Elderly
 Tx in geriatric patients is ECT. Use if patient is suicidal, catatonic or refusing food or
liquids. Can also use SSRIs, SNRIs, TCAs, and MAOIs. Start low and go slow.
 No ECT if elevated ICP, unstable angina, recent MI, and electrolyte imbalances.
Case 8: Social Phobia (Public Speaking)
 Tx: Behavioral or CBT is the best choice. Short term tx includes BZDs and beta-blockers
(atenolol and propranolol). Long term tx includes SSRIs (sertraline or fluoxetine) and
SNRI (venlafaxine). Also, buspirone in conjunction with SSRIs.
 Tx for specific phobias include slowly desensitization.
 More activity in amygdala and insula in patients with social phobia.
Case 9: PCP Intoxication
 PCP intoxication symptoms include: violent, slurred speech (dysarthria), vertical
nystagmus, HTN, tachycardia, numbness, ataxia, muscle rigidity, seizures or coma and
hyperacusis (hearing sensitivity).
 Tx: In non-psychotic patients use BZDs to prevent muscle spasms, seizures and sedation.
In psychotic patients, use haloperidol (typical antipsychotic) or atypical antipsychotics,
but beware of induced hyperthermia, dystonia, anticholinergic rxns and lowering the
seizure threshold. Treat HTN with IV antihypertensive medications.
Case 10: Dependent Personality Disorder
 Tx: Behavioral therapy, assertiveness training, family therapy and group therapy.
 Cluster C: “sad” anxious and timid (OC, Avoidant, Dependent)
Case 11: Generalized Anxiety Disorder
 Tx: SSRI/SNRI with CBT or can use buspirone. Use BZDs for short term.
 Anxiety for 3 months.
Case 12: Bipolar Disorder, Manic
 Tx; Mood stabilizer (lithium, CBZ, valproate) and antipsychotics (risperidone).
 Bipolar I: depression and mania
 Bipolar II: depression and hypomania
 4 episodes in 12 months
 Mania or hypomania less than 1 week duration
 Corticosteroids, levodopa and cocaine can cause mania.
Case 13: OCD
 Tx: Psychotherapy (exposure/response prevention) and SSRI (fluoxetine, sertraline,
fluvoxamine)
 Obsessions and compulsions.
 Fluoxetine can cause suicidal ideation in children.
Case 14: Alcohol Dependence
 Tx: Abstinence. AA groups. Medications
 Disulfiram (Antabuse): blocks ADH
 Naltrexone: opioid antagonist that reduces cravings for alcohol by blocking
dopaminergic pathway
 Acamprosate (Campral): stabilize glutamatergic functioning
Case 15: Schizotypal Personality Disorder
 Tx: Pyschotherapy
Case 16: Cocaine Use
 Euphoria, dilated pupils, sweating, weight loss, agitation
Case 17: Delirium
 Onset short
Case 18: Major Depression with Psychotic features
 Tx: SSRI (continue for 6-12 months and taper over 2-3 months) and anti-psychotic (taper
off after 3 months)
Case 19: Conduct disorder
 Tx; multisystem treatment
Case 20: Obsessive-Compulsive personality
 Inflexible in thinking or behavior
 Blames others
 Perfectionism and inflexible
Case 21: PTSD
 Acute if less than 3 months; Chronic if more than 3 months
 Tx: Psychotherapy, pharmacotherapy and social intervention.
 SSRIs (sertraline and paroxetine), SNRIs, TCAs and MAOIs. Also, prazosin.
Case 22: Dysthymic Disorder
 Tx: SSRIs, SNRIs, and buproprion plus CBT.
 Depressed mood for 2 years at least.
 Children at least 1 year.
Case 23: Dementia
 R/o reversible causes of dementia first
 Memory impairment plus either agnosia, apraxia, or aphasia.
 Tx: acetylcholinesterase inhibitors (GDR). Also, memantine (NMDA receptor antagonist)
 Give low dose antipsychotic for violence or aggressive behavior. EPS likely with
Parkinson and LBD.
Case 24: Hypochondriac
 Schedule frequent visits with primary care provider
 Duration is 6 months
Case 25: Antisocial
 Over 18
 No remorse for others
 Tx: SSRIs and mood stabilizers for aggressive behavior
Case 26: Schizoaffective Disorder
 Paranoia with mood symptoms, but mood not always during paranoia
 Tx: Antipsychotic (haloperidol or risperidone) or antidepressant SSRI. Mood stabilizers
(lithium, CBZ, valproate) used for manic symptoms.
Case 27: Psychosis from medical condition
 Olfactory or gustatory hallucinations with seizure (medical condition)
 Psychotic disorder in axis I
 Medical condition causing the psychotic disorder on axis II
Case 28: ADHD
 Tx: Pyschostimulants or atomoxetine
 Sx for 6 months before age 7
Case 29: Bulimia nervosa
 Tx: Nutrition, CBT and SSRI (fluoxetine and sertraline)
 Anorexia before bulimia onset
Case 30: Acute Stress Disorder
 Sx duration less than 4 weeks
Case 31: Opioid Withdrawal
  Tx: Methadone or clonidine
 Withdrawal sx: N/V, diarrhea, diaphoresis, F/C, lacrimation, rhinorrhea, muscle aches
and dilated pupils.
Case 32: Pain Disorder
 Tx: pain clinic or biofeedback
Case 33: Histrionic Personality Disorder
 Tx: Psychotherapy
 Use repression and dissociation defense mechanisms
Case 34: Adjustment Disorder
 Somatic complaints with mood (anxiety, depression)
 Emotional response to a specific stressor
 Tx: psychotherapy
 Children present with irritability rather than saying they are depressed
Case 35: Factitious Disorder
 Seen with borderline
 Assume sick role
Case 36: Sleep Terror
 Tx: do nothing except protect child from injury
 Occur during delta sleep wave
 Enuresis tx includes desmopressin and imipramine
 Occur with restless leg syndrome or sleep-disordered breathing
Case 37: Primary Insomnia
 Tx: sleep hygiene, CBT, relaxation, meds (ramelteon, trazodone, and BZDs)
 Sleep problems for 1 month
Case 38: Somatization Disorder
 Tx: frequent visits for reassurance or psychotherapy
Case 39: Psychotic disorder
 Delusions and hallucinations with depressed mood and labile affect.
 Tx: antipsychotic and mood stabilizer. Hospitalization. ECT.
Case 40: Extrapyramidal Symptoms (Acute Dystonic Reaction)
 Tx: Benztropine 2 mg IM or diphenhydramine
 Due to antipsychotics (block dopamine receptors in mesolimbic and mesocortical areas
and nigrostriatal pathway)
 Akathisia tx is BB or BZD
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Cluster B: Bad (Histrionic, narcissistic, antisocial, borderline)